hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|TX,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Val Verde Regional Medical Center,2/28/2025,2.0.0,Val Verde Regional Medical Center,"801 N Bedell Ave, Del Rio, TX 78840",1891124640,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,modifiers,standard_charge|90_DEGREES|MEDICARE|negotiated_dollar,standard_charge|90_DEGREES|MEDICARE|negotiated_percentage,standard_charge|90_DEGREES|MEDICARE|negotiated_algorithm,estimated_amount|90_DEGREES|MEDICARE,standard_charge|90_DEGREES|MEDICARE|methodology,additional_payer_notes|90_DEGREES|MEDICARE,standard_charge|AETNA|COMMERCIAL|negotiated_dollar,standard_charge|AETNA|COMMERCIAL|negotiated_percentage,standard_charge|AETNA|COMMERCIAL|negotiated_algorithm,estimated_amount|AETNA|COMMERCIAL,standard_charge|AETNA|COMMERCIAL|methodology,additional_payer_notes|AETNA|COMMERCIAL,standard_charge|AETNA_CLINIC|COMMERCIAL|negotiated_dollar,standard_charge|AETNA_CLINIC|COMMERCIAL|negotiated_percentage,standard_charge|AETNA_CLINIC|COMMERCIAL|negotiated_algorithm,estimated_amount|AETNA_CLINIC|COMMERCIAL,standard_charge|AETNA_CLINIC|COMMERCIAL|methodology,additional_payer_notes|AETNA_CLINIC|COMMERCIAL,standard_charge|BCBC_OF_DEL_RIO|COMMERCIAL|negotiated_dollar,standard_charge|BCBC_OF_DEL_RIO|COMMERCIAL|negotiated_percentage,standard_charge|BCBC_OF_DEL_RIO|COMMERCIAL|negotiated_algorithm,estimated_amount|BCBC_OF_DEL_RIO|COMMERCIAL,standard_charge|BCBC_OF_DEL_RIO|COMMERCIAL|methodology,additional_payer_notes|BCBC_OF_DEL_RIO|COMMERCIAL,standard_charge|BCBS|COMMERCIAL|negotiated_dollar,standard_charge|BCBS|COMMERCIAL|negotiated_percentage,standard_charge|BCBS|COMMERCIAL|negotiated_algorithm,estimated_amount|BCBS|COMMERCIAL,standard_charge|BCBS|COMMERCIAL|methodology,additional_payer_notes|BCBS|COMMERCIAL,standard_charge|BCBS_MEDICARE|MEDICARE|negotiated_dollar,standard_charge|BCBS_MEDICARE|MEDICARE|negotiated_percentage,standard_charge|BCBS_MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|BCBS_MEDICARE|MEDICARE,standard_charge|BCBS_MEDICARE|MEDICARE|methodology,additional_payer_notes|BCBS_MEDICARE|MEDICARE,standard_charge|BCBS_PPO|COMMERCIAL|negotiated_dollar,standard_charge|BCBS_PPO|COMMERCIAL|negotiated_percentage,standard_charge|BCBS_PPO|COMMERCIAL|negotiated_algorithm,estimated_amount|BCBS_PPO|COMMERCIAL,standard_charge|BCBS_PPO|COMMERCIAL|methodology,additional_payer_notes|BCBS_PPO|COMMERCIAL,standard_charge|BLUE_ADV_HMO|COMMERCIAL|negotiated_dollar,standard_charge|BLUE_ADV_HMO|COMMERCIAL|negotiated_percentage,standard_charge|BLUE_ADV_HMO|COMMERCIAL|negotiated_algorithm,estimated_amount|BLUE_ADV_HMO|COMMERCIAL,standard_charge|BLUE_ADV_HMO|COMMERCIAL|methodology,additional_payer_notes|BLUE_ADV_HMO|COMMERCIAL,standard_charge|CIGNA|COMMERCIAL|negotiated_dollar,standard_charge|CIGNA|COMMERCIAL|negotiated_percentage,standard_charge|CIGNA|COMMERCIAL|negotiated_algorithm,estimated_amount|CIGNA|COMMERCIAL,standard_charge|CIGNA|COMMERCIAL|methodology,additional_payer_notes|CIGNA|COMMERCIAL,standard_charge|FIRST_CARE|MEDICAID|negotiated_dollar,standard_charge|FIRST_CARE|MEDICAID|negotiated_percentage,standard_charge|FIRST_CARE|MEDICAID|negotiated_algorithm,estimated_amount|FIRST_CARE|MEDICAID,standard_charge|FIRST_CARE|MEDICAID|methodology,additional_payer_notes|FIRST_CARE|MEDICAID,standard_charge|HUMANA|COMMERCIAL|negotiated_dollar,standard_charge|HUMANA|COMMERCIAL|negotiated_percentage,standard_charge|HUMANA|COMMERCIAL|negotiated_algorithm,estimated_amount|HUMANA|COMMERCIAL,standard_charge|HUMANA|COMMERCIAL|methodology,additional_payer_notes|HUMANA|COMMERCIAL,standard_charge|HUMANA_MEDICARE|MEDICARE|negotiated_dollar,standard_charge|HUMANA_MEDICARE|MEDICARE|negotiated_percentage,standard_charge|HUMANA_MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|HUMANA_MEDICARE|MEDICARE,standard_charge|HUMANA_MEDICARE|MEDICARE|methodology,additional_payer_notes|HUMANA_MEDICARE|MEDICARE,standard_charge|HUMANA_MILITARY|MEDICARE|negotiated_dollar,standard_charge|HUMANA_MILITARY|MEDICARE|negotiated_percentage,standard_charge|HUMANA_MILITARY|MEDICARE|negotiated_algorithm,estimated_amount|HUMANA_MILITARY|MEDICARE,standard_charge|HUMANA_MILITARY|MEDICARE|methodology,additional_payer_notes|HUMANA_MILITARY|MEDICARE,standard_charge|MEDICARE|MEDICARE|negotiated_dollar,standard_charge|MEDICARE|MEDICARE|negotiated_percentage,standard_charge|MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|MEDICARE|MEDICARE,standard_charge|MEDICARE|MEDICARE|methodology,additional_payer_notes|MEDICARE|MEDICARE,standard_charge|SAN_FELIPE_DEL_RIO|MEDICARE|negotiated_dollar,standard_charge|SAN_FELIPE_DEL_RIO|MEDICARE|negotiated_percentage,standard_charge|SAN_FELIPE_DEL_RIO|MEDICARE|negotiated_algorithm,estimated_amount|SAN_FELIPE_DEL_RIO|MEDICARE,standard_charge|SAN_FELIPE_DEL_RIO|MEDICARE|methodology,additional_payer_notes|SAN_FELIPE_DEL_RIO|MEDICARE,standard_charge|TEXAS_MEDICAID|MEDICAID|negotiated_dollar,standard_charge|TEXAS_MEDICAID|MEDICAID|negotiated_percentage,standard_charge|TEXAS_MEDICAID|MEDICAID|negotiated_algorithm,estimated_amount|TEXAS_MEDICAID|MEDICAID,standard_charge|TEXAS_MEDICAID|MEDICAID|methodology,additional_payer_notes|TEXAS_MEDICAID|MEDICAID,standard_charge|TML|COMMERCIAL|negotiated_dollar,standard_charge|TML|COMMERCIAL|negotiated_percentage,standard_charge|TML|COMMERCIAL|negotiated_algorithm,estimated_amount|TML|COMMERCIAL,standard_charge|TML|COMMERCIAL|methodology,additional_payer_notes|TML|COMMERCIAL,standard_charge|TRICARE|MEDICARE|negotiated_dollar,standard_charge|TRICARE|MEDICARE|negotiated_percentage,standard_charge|TRICARE|MEDICARE|negotiated_algorithm,estimated_amount|TRICARE|MEDICARE,standard_charge|TRICARE|MEDICARE|methodology,additional_payer_notes|TRICARE|MEDICARE,standard_charge|UHC|COMMERCIAL|negotiated_dollar,standard_charge|UHC|COMMERCIAL|negotiated_percentage,standard_charge|UHC|COMMERCIAL|negotiated_algorithm,estimated_amount|UHC|COMMERCIAL,standard_charge|UHC|COMMERCIAL|methodology,additional_payer_notes|UHC|COMMERCIAL,standard_charge|UNICARE|COMMERCIAL|negotiated_dollar,standard_charge|UNICARE|COMMERCIAL|negotiated_percentage,standard_charge|UNICARE|COMMERCIAL|negotiated_algorithm,estimated_amount|UNICARE|COMMERCIAL,standard_charge|UNICARE|COMMERCIAL|methodology,additional_payer_notes|UNICARE|COMMERCIAL,standard_charge|min,standard_charge|max,additional_generic_notes
Swing Bed Rm chg,22000000,CDM,120,RC,,,Inpatient,,,1139.00,740.35,,1139,125,MS-DRG,911.2,Case Rate,125% of CMS IPPS Rate,865.64,76,,692.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,820.08,72,,656.064,Percent of Total Billed Charges,72% of Total Billed Charges,854.25,75,,683.4,Percent of Total Billed charges,75% of Total Billed Charges,1139,100,MS-DRG,911.2,Case Rate,100% of CMS IPPS Rate,820.08,72,,656.064,Percent of Total Billed Charges,72% of Total Billed Charges,683.4,60,,546.72,Percent of Total Billed Charges,60% of Total Billed Charges,1025.1,90,,820.08,Percent of Total Billed Charges,90% of Total Billed Charges,318.92,28,,255.136,Percent of Total Billed Charges,28% of Total Billed Charges,1025.1,90,,820.08,Percent of Total Billed Charges,90% of Total billed Charges,1139,100,MS-DRG,911.2,Case Rate,100% of CMS IPPS Rate,1139,100,MS-DRG,911.2,Case Rate,100% of CMS IPPS Rate,1139,100,MS-DRG,911.2,Case Rate,100% of CMS IPPS Rate,740.35,65,,592.28,Percent of total Billed Charges,65% of Total Billed Charges,307.53,27,,246.024,Percent of Total Billed Charges,27% of Total Billed Charges,1082.05,95,,865.64,Percent of Total Billed Charges,95% of Total Billed Charges,255.76,22.455,,204.608,Percent of Total billed Charges,22.455% of Total Billed Charges,1002.32,88,,801.856,Percent of Total Billed Charges,88% of Total Billed Charges,1025.1,90,,820.08,Percent of Total Billed charges,90% of Total Billed Charges,255.76,1139,
COVID STEP DOWN PEDIATRICS,1100000000,CDM,110,RC,,,Inpatient,,,1421.00,923.65,,1421,125,MS-DRG,1136.8,Case Rate,125% of CMS IPPS Rate,1079.96,76,,863.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1023.12,72,,818.496,Percent of Total Billed Charges,72% of Total Billed Charges,1065.75,75,,852.6,Percent of Total Billed charges,75% of Total Billed Charges,1421,100,MS-DRG,1136.8,Case Rate,100% of CMS IPPS Rate,1023.12,72,,818.496,Percent of Total Billed Charges,72% of Total Billed Charges,852.6,60,,682.08,Percent of Total Billed Charges,60% of Total Billed Charges,1278.9,90,,1023.12,Percent of Total Billed Charges,90% of Total Billed Charges,397.88,28,,318.304,Percent of Total Billed Charges,28% of Total Billed Charges,1278.9,90,,1023.12,Percent of Total Billed Charges,90% of Total billed Charges,1421,100,MS-DRG,1136.8,Case Rate,100% of CMS IPPS Rate,1421,100,MS-DRG,1136.8,Case Rate,100% of CMS IPPS Rate,1421,100,MS-DRG,1136.8,Case Rate,100% of CMS IPPS Rate,923.65,65,,738.92,Percent of total Billed Charges,65% of Total Billed Charges,383.67,27,,306.936,Percent of Total Billed Charges,27% of Total Billed Charges,1349.95,95,,1079.96,Percent of Total Billed Charges,95% of Total Billed Charges,319.09,22.455,,255.272,Percent of Total billed Charges,22.455% of Total Billed Charges,1250.48,88,,1000.384,Percent of Total Billed Charges,88% of Total Billed Charges,1278.9,90,,1023.12,Percent of Total Billed charges,90% of Total Billed Charges,319.09,1421,
COVID STEPDOWN SPECIAL PROCEDU,1100000002,CDM,110,RC,,,Inpatient,,,1350.00,877.50,,1350,125,MS-DRG,1080,Case Rate,125% of CMS IPPS Rate,1026,76,,820.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,972,72,,777.6,Percent of Total Billed Charges,72% of Total Billed Charges,1012.5,75,,810,Percent of Total Billed charges,75% of Total Billed Charges,1350,100,MS-DRG,1080,Case Rate,100% of CMS IPPS Rate,972,72,,777.6,Percent of Total Billed Charges,72% of Total Billed Charges,810,60,,648,Percent of Total Billed Charges,60% of Total Billed Charges,1215,90,,972,Percent of Total Billed Charges,90% of Total Billed Charges,378,28,,302.4,Percent of Total Billed Charges,28% of Total Billed Charges,1215,90,,972,Percent of Total Billed Charges,90% of Total billed Charges,1350,100,MS-DRG,1080,Case Rate,100% of CMS IPPS Rate,1350,100,MS-DRG,1080,Case Rate,100% of CMS IPPS Rate,1350,100,MS-DRG,1080,Case Rate,100% of CMS IPPS Rate,877.5,65,,702,Percent of total Billed Charges,65% of Total Billed Charges,364.5,27,,291.6,Percent of Total Billed Charges,27% of Total Billed Charges,1282.5,95,,1026,Percent of Total Billed Charges,95% of Total Billed Charges,303.14,22.455,,242.512,Percent of Total billed Charges,22.455% of Total Billed Charges,1188,88,,950.4,Percent of Total Billed Charges,88% of Total Billed Charges,1215,90,,972,Percent of Total Billed charges,90% of Total Billed Charges,303.14,1350,
COVID STEP DOWN ICU,1100000003,CDM,110,RC,,,Inpatient,,,3146.00,2044.90,,3146,125,MS-DRG,2516.8,Case Rate,125% of CMS IPPS Rate,2390.96,76,,1912.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2265.12,72,,1812.096,Percent of Total Billed Charges,72% of Total Billed Charges,2359.5,75,,1887.6,Percent of Total Billed charges,75% of Total Billed Charges,3146,100,MS-DRG,2516.8,Case Rate,100% of CMS IPPS Rate,2265.12,72,,1812.096,Percent of Total Billed Charges,72% of Total Billed Charges,1887.6,60,,1510.08,Percent of Total Billed Charges,60% of Total Billed Charges,2831.4,90,,2265.12,Percent of Total Billed Charges,90% of Total Billed Charges,880.88,28,,704.704,Percent of Total Billed Charges,28% of Total Billed Charges,2831.4,90,,2265.12,Percent of Total Billed Charges,90% of Total billed Charges,3146,100,MS-DRG,2516.8,Case Rate,100% of CMS IPPS Rate,3146,100,MS-DRG,2516.8,Case Rate,100% of CMS IPPS Rate,3146,100,MS-DRG,2516.8,Case Rate,100% of CMS IPPS Rate,2044.9,65,,1635.92,Percent of total Billed Charges,65% of Total Billed Charges,849.42,27,,679.536,Percent of Total Billed Charges,27% of Total Billed Charges,2988.7,95,,2390.96,Percent of Total Billed Charges,95% of Total Billed Charges,706.43,22.455,,565.144,Percent of Total billed Charges,22.455% of Total Billed Charges,2768.48,88,,2214.784,Percent of Total Billed Charges,88% of Total Billed Charges,2831.4,90,,2265.12,Percent of Total Billed charges,90% of Total Billed Charges,706.43,3146,
COVID ISOLATION PEDIATRICS,1100000004,CDM,110,RC,,,Inpatient,,,1421.00,923.65,,1421,125,MS-DRG,1136.8,Case Rate,125% of CMS IPPS Rate,1079.96,76,,863.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1023.12,72,,818.496,Percent of Total Billed Charges,72% of Total Billed Charges,1065.75,75,,852.6,Percent of Total Billed charges,75% of Total Billed Charges,1421,100,MS-DRG,1136.8,Case Rate,100% of CMS IPPS Rate,1023.12,72,,818.496,Percent of Total Billed Charges,72% of Total Billed Charges,852.6,60,,682.08,Percent of Total Billed Charges,60% of Total Billed Charges,1278.9,90,,1023.12,Percent of Total Billed Charges,90% of Total Billed Charges,397.88,28,,318.304,Percent of Total Billed Charges,28% of Total Billed Charges,1278.9,90,,1023.12,Percent of Total Billed Charges,90% of Total billed Charges,1421,100,MS-DRG,1136.8,Case Rate,100% of CMS IPPS Rate,1421,100,MS-DRG,1136.8,Case Rate,100% of CMS IPPS Rate,1421,100,MS-DRG,1136.8,Case Rate,100% of CMS IPPS Rate,923.65,65,,738.92,Percent of total Billed Charges,65% of Total Billed Charges,383.67,27,,306.936,Percent of Total Billed Charges,27% of Total Billed Charges,1349.95,95,,1079.96,Percent of Total Billed Charges,95% of Total Billed Charges,319.09,22.455,,255.272,Percent of Total billed Charges,22.455% of Total Billed Charges,1250.48,88,,1000.384,Percent of Total Billed Charges,88% of Total Billed Charges,1278.9,90,,1023.12,Percent of Total Billed charges,90% of Total Billed Charges,319.09,1421,
COVID ISOLATION SPECIAL PROCED,1100000005,CDM,110,RC,,,Inpatient,,,1350.00,877.50,,1350,125,MS-DRG,1080,Case Rate,125% of CMS IPPS Rate,1026,76,,820.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,972,72,,777.6,Percent of Total Billed Charges,72% of Total Billed Charges,1012.5,75,,810,Percent of Total Billed charges,75% of Total Billed Charges,1350,100,MS-DRG,1080,Case Rate,100% of CMS IPPS Rate,972,72,,777.6,Percent of Total Billed Charges,72% of Total Billed Charges,810,60,,648,Percent of Total Billed Charges,60% of Total Billed Charges,1215,90,,972,Percent of Total Billed Charges,90% of Total Billed Charges,378,28,,302.4,Percent of Total Billed Charges,28% of Total Billed Charges,1215,90,,972,Percent of Total Billed Charges,90% of Total billed Charges,1350,100,MS-DRG,1080,Case Rate,100% of CMS IPPS Rate,1350,100,MS-DRG,1080,Case Rate,100% of CMS IPPS Rate,1350,100,MS-DRG,1080,Case Rate,100% of CMS IPPS Rate,877.5,65,,702,Percent of total Billed Charges,65% of Total Billed Charges,364.5,27,,291.6,Percent of Total Billed Charges,27% of Total Billed Charges,1282.5,95,,1026,Percent of Total Billed Charges,95% of Total Billed Charges,303.14,22.455,,242.512,Percent of Total billed Charges,22.455% of Total Billed Charges,1188,88,,950.4,Percent of Total Billed Charges,88% of Total Billed Charges,1215,90,,972,Percent of Total Billed charges,90% of Total Billed Charges,303.14,1350,
COVID ISOLATION ICU,1100000006,CDM,110,RC,,,Inpatient,,,3146.00,2044.90,,3146,125,MS-DRG,2516.8,Case Rate,125% of CMS IPPS Rate,2390.96,76,,1912.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2265.12,72,,1812.096,Percent of Total Billed Charges,72% of Total Billed Charges,2359.5,75,,1887.6,Percent of Total Billed charges,75% of Total Billed Charges,3146,100,MS-DRG,2516.8,Case Rate,100% of CMS IPPS Rate,2265.12,72,,1812.096,Percent of Total Billed Charges,72% of Total Billed Charges,1887.6,60,,1510.08,Percent of Total Billed Charges,60% of Total Billed Charges,2831.4,90,,2265.12,Percent of Total Billed Charges,90% of Total Billed Charges,880.88,28,,704.704,Percent of Total Billed Charges,28% of Total Billed Charges,2831.4,90,,2265.12,Percent of Total Billed Charges,90% of Total billed Charges,3146,100,MS-DRG,2516.8,Case Rate,100% of CMS IPPS Rate,3146,100,MS-DRG,2516.8,Case Rate,100% of CMS IPPS Rate,3146,100,MS-DRG,2516.8,Case Rate,100% of CMS IPPS Rate,2044.9,65,,1635.92,Percent of total Billed Charges,65% of Total Billed Charges,849.42,27,,679.536,Percent of Total Billed Charges,27% of Total Billed Charges,2988.7,95,,2390.96,Percent of Total Billed Charges,95% of Total Billed Charges,706.43,22.455,,565.144,Percent of Total billed Charges,22.455% of Total Billed Charges,2768.48,88,,2214.784,Percent of Total Billed Charges,88% of Total Billed Charges,2831.4,90,,2265.12,Percent of Total Billed charges,90% of Total Billed Charges,706.43,3146,
COVID ISOLATION ED,1100000007,CDM,110,RC,,,Inpatient,,,1421.00,923.65,,1421,125,MS-DRG,1136.8,Case Rate,125% of CMS IPPS Rate,1079.96,76,,863.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1023.12,72,,818.496,Percent of Total Billed Charges,72% of Total Billed Charges,1065.75,75,,852.6,Percent of Total Billed charges,75% of Total Billed Charges,1421,100,MS-DRG,1136.8,Case Rate,100% of CMS IPPS Rate,1023.12,72,,818.496,Percent of Total Billed Charges,72% of Total Billed Charges,852.6,60,,682.08,Percent of Total Billed Charges,60% of Total Billed Charges,1278.9,90,,1023.12,Percent of Total Billed Charges,90% of Total Billed Charges,397.88,28,,318.304,Percent of Total Billed Charges,28% of Total Billed Charges,1278.9,90,,1023.12,Percent of Total Billed Charges,90% of Total billed Charges,1421,100,MS-DRG,1136.8,Case Rate,100% of CMS IPPS Rate,1421,100,MS-DRG,1136.8,Case Rate,100% of CMS IPPS Rate,1421,100,MS-DRG,1136.8,Case Rate,100% of CMS IPPS Rate,923.65,65,,738.92,Percent of total Billed Charges,65% of Total Billed Charges,383.67,27,,306.936,Percent of Total Billed Charges,27% of Total Billed Charges,1349.95,95,,1079.96,Percent of Total Billed Charges,95% of Total Billed Charges,319.09,22.455,,255.272,Percent of Total billed Charges,22.455% of Total Billed Charges,1250.48,88,,1000.384,Percent of Total Billed Charges,88% of Total Billed Charges,1278.9,90,,1023.12,Percent of Total Billed charges,90% of Total Billed Charges,319.09,1421,
COVID STEP DOWN ED,1100000008,CDM,110,RC,,,Inpatient,,,1421.00,923.65,,1421,125,MS-DRG,1136.8,Case Rate,125% of CMS IPPS Rate,1079.96,76,,863.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1023.12,72,,818.496,Percent of Total Billed Charges,72% of Total Billed Charges,1065.75,75,,852.6,Percent of Total Billed charges,75% of Total Billed Charges,1421,100,MS-DRG,1136.8,Case Rate,100% of CMS IPPS Rate,1023.12,72,,818.496,Percent of Total Billed Charges,72% of Total Billed Charges,852.6,60,,682.08,Percent of Total Billed Charges,60% of Total Billed Charges,1278.9,90,,1023.12,Percent of Total Billed Charges,90% of Total Billed Charges,397.88,28,,318.304,Percent of Total Billed Charges,28% of Total Billed Charges,1278.9,90,,1023.12,Percent of Total Billed Charges,90% of Total billed Charges,1421,100,MS-DRG,1136.8,Case Rate,100% of CMS IPPS Rate,1421,100,MS-DRG,1136.8,Case Rate,100% of CMS IPPS Rate,1421,100,MS-DRG,1136.8,Case Rate,100% of CMS IPPS Rate,923.65,65,,738.92,Percent of total Billed Charges,65% of Total Billed Charges,383.67,27,,306.936,Percent of Total Billed Charges,27% of Total Billed Charges,1349.95,95,,1079.96,Percent of Total Billed Charges,95% of Total Billed Charges,319.09,22.455,,255.272,Percent of Total billed Charges,22.455% of Total Billed Charges,1250.48,88,,1000.384,Percent of Total Billed Charges,88% of Total Billed Charges,1278.9,90,,1023.12,Percent of Total Billed charges,90% of Total Billed Charges,319.09,1421,
PEDIATRIC ROOM&BOARD PRIVATE,1130000001,CDM,113,RC,,,Inpatient,,,772.85,502.35,,772.85,125,MS-DRG,618.28,Case Rate,125% of CMS IPPS Rate,587.37,76,,469.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,556.45,72,,445.16,Percent of Total Billed Charges,72% of Total Billed Charges,579.64,75,,463.712,Percent of Total Billed charges,75% of Total Billed Charges,772.85,100,MS-DRG,618.28,Case Rate,100% of CMS IPPS Rate,556.45,72,,445.16,Percent of Total Billed Charges,72% of Total Billed Charges,463.71,60,,370.968,Percent of Total Billed Charges,60% of Total Billed Charges,695.57,90,,556.456,Percent of Total Billed Charges,90% of Total Billed Charges,216.4,28,,173.12,Percent of Total Billed Charges,28% of Total Billed Charges,695.57,90,,556.456,Percent of Total Billed Charges,90% of Total billed Charges,772.85,100,MS-DRG,618.28,Case Rate,100% of CMS IPPS Rate,772.85,100,MS-DRG,618.28,Case Rate,100% of CMS IPPS Rate,772.85,100,MS-DRG,618.28,Case Rate,100% of CMS IPPS Rate,502.35,65,,401.88,Percent of total Billed Charges,65% of Total Billed Charges,208.67,27,,166.936,Percent of Total Billed Charges,27% of Total Billed Charges,734.21,95,,587.368,Percent of Total Billed Charges,95% of Total Billed Charges,173.54,22.455,,138.832,Percent of Total billed Charges,22.455% of Total Billed Charges,680.11,88,,544.088,Percent of Total Billed Charges,88% of Total Billed Charges,695.57,90,,556.456,Percent of Total Billed charges,90% of Total Billed Charges,173.54,772.85,
MED/SURG RESPITE ROOM & BOARD,1150000001,CDM,115,RC,,,Inpatient,,,772.85,502.35,,772.85,125,MS-DRG,618.28,Case Rate,125% of CMS IPPS Rate,587.37,76,,469.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,556.45,72,,445.16,Percent of Total Billed Charges,72% of Total Billed Charges,579.64,75,,463.712,Percent of Total Billed charges,75% of Total Billed Charges,772.85,100,MS-DRG,618.28,Case Rate,100% of CMS IPPS Rate,556.45,72,,445.16,Percent of Total Billed Charges,72% of Total Billed Charges,463.71,60,,370.968,Percent of Total Billed Charges,60% of Total Billed Charges,695.57,90,,556.456,Percent of Total Billed Charges,90% of Total Billed Charges,216.4,28,,173.12,Percent of Total Billed Charges,28% of Total Billed Charges,695.57,90,,556.456,Percent of Total Billed Charges,90% of Total billed Charges,772.85,100,MS-DRG,618.28,Case Rate,100% of CMS IPPS Rate,772.85,100,MS-DRG,618.28,Case Rate,100% of CMS IPPS Rate,772.85,100,MS-DRG,618.28,Case Rate,100% of CMS IPPS Rate,502.35,65,,401.88,Percent of total Billed Charges,65% of Total Billed Charges,208.67,27,,166.936,Percent of Total Billed Charges,27% of Total Billed Charges,734.21,95,,587.368,Percent of Total Billed Charges,95% of Total Billed Charges,173.54,22.455,,138.832,Percent of Total billed Charges,22.455% of Total Billed Charges,680.11,88,,544.088,Percent of Total Billed Charges,88% of Total Billed Charges,695.57,90,,556.456,Percent of Total Billed charges,90% of Total Billed Charges,173.54,772.85,
PEDIATRIC ROOM&BOARD TELEMETRY,1200000001,CDM,120,RC,,,Inpatient,,,1065.02,692.26,,1065.02,125,MS-DRG,852.016,Case Rate,125% of CMS IPPS Rate,809.42,76,,647.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,766.81,72,,613.448,Percent of Total Billed Charges,72% of Total Billed Charges,798.77,75,,639.016,Percent of Total Billed charges,75% of Total Billed Charges,1065.02,100,MS-DRG,852.016,Case Rate,100% of CMS IPPS Rate,766.81,72,,613.448,Percent of Total Billed Charges,72% of Total Billed Charges,639.01,60,,511.208,Percent of Total Billed Charges,60% of Total Billed Charges,958.52,90,,766.816,Percent of Total Billed Charges,90% of Total Billed Charges,298.21,28,,238.568,Percent of Total Billed Charges,28% of Total Billed Charges,958.52,90,,766.816,Percent of Total Billed Charges,90% of Total billed Charges,1065.02,100,MS-DRG,852.016,Case Rate,100% of CMS IPPS Rate,1065.02,100,MS-DRG,852.016,Case Rate,100% of CMS IPPS Rate,1065.02,100,MS-DRG,852.016,Case Rate,100% of CMS IPPS Rate,692.26,65,,553.808,Percent of total Billed Charges,65% of Total Billed Charges,287.56,27,,230.048,Percent of Total Billed Charges,27% of Total Billed Charges,1011.77,95,,809.416,Percent of Total Billed Charges,95% of Total Billed Charges,239.15,22.455,,191.32,Percent of Total billed Charges,22.455% of Total Billed Charges,937.22,88,,749.776,Percent of Total Billed Charges,88% of Total Billed Charges,958.52,90,,766.816,Percent of Total Billed charges,90% of Total Billed Charges,239.15,1065.02,
MED/SURG ROOM&BOARD SEMI-PVT,1200000002,CDM,120,RC,,,Inpatient,,,1139.00,740.35,,1139,125,MS-DRG,911.2,Case Rate,125% of CMS IPPS Rate,865.64,76,,692.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,820.08,72,,656.064,Percent of Total Billed Charges,72% of Total Billed Charges,854.25,75,,683.4,Percent of Total Billed charges,75% of Total Billed Charges,1139,100,MS-DRG,911.2,Case Rate,100% of CMS IPPS Rate,820.08,72,,656.064,Percent of Total Billed Charges,72% of Total Billed Charges,683.4,60,,546.72,Percent of Total Billed Charges,60% of Total Billed Charges,1025.1,90,,820.08,Percent of Total Billed Charges,90% of Total Billed Charges,318.92,28,,255.136,Percent of Total Billed Charges,28% of Total Billed Charges,1025.1,90,,820.08,Percent of Total Billed Charges,90% of Total billed Charges,1139,100,MS-DRG,911.2,Case Rate,100% of CMS IPPS Rate,1139,100,MS-DRG,911.2,Case Rate,100% of CMS IPPS Rate,1139,100,MS-DRG,911.2,Case Rate,100% of CMS IPPS Rate,740.35,65,,592.28,Percent of total Billed Charges,65% of Total Billed Charges,307.53,27,,246.024,Percent of Total Billed Charges,27% of Total Billed Charges,1082.05,95,,865.64,Percent of Total Billed Charges,95% of Total Billed Charges,255.76,22.455,,204.608,Percent of Total billed Charges,22.455% of Total Billed Charges,1002.32,88,,801.856,Percent of Total Billed Charges,88% of Total Billed Charges,1025.1,90,,820.08,Percent of Total Billed charges,90% of Total Billed Charges,255.76,1139,
MED/SURG ROOM&BOARD TELEMETRY,1200000003,CDM,120,RC,,,Inpatient,,,1012.00,657.80,,1012,125,MS-DRG,809.6,Case Rate,125% of CMS IPPS Rate,769.12,76,,615.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,728.64,72,,582.912,Percent of Total Billed Charges,72% of Total Billed Charges,759,75,,607.2,Percent of Total Billed charges,75% of Total Billed Charges,1012,100,MS-DRG,809.6,Case Rate,100% of CMS IPPS Rate,728.64,72,,582.912,Percent of Total Billed Charges,72% of Total Billed Charges,607.2,60,,485.76,Percent of Total Billed Charges,60% of Total Billed Charges,910.8,90,,728.64,Percent of Total Billed Charges,90% of Total Billed Charges,283.36,28,,226.688,Percent of Total Billed Charges,28% of Total Billed Charges,910.8,90,,728.64,Percent of Total Billed Charges,90% of Total billed Charges,1012,100,MS-DRG,809.6,Case Rate,100% of CMS IPPS Rate,1012,100,MS-DRG,809.6,Case Rate,100% of CMS IPPS Rate,1012,100,MS-DRG,809.6,Case Rate,100% of CMS IPPS Rate,657.8,65,,526.24,Percent of total Billed Charges,65% of Total Billed Charges,273.24,27,,218.592,Percent of Total Billed Charges,27% of Total Billed Charges,961.4,95,,769.12,Percent of Total Billed Charges,95% of Total Billed Charges,227.24,22.455,,181.792,Percent of Total billed Charges,22.455% of Total Billed Charges,890.56,88,,712.448,Percent of Total Billed Charges,88% of Total Billed Charges,910.8,90,,728.64,Percent of Total Billed charges,90% of Total Billed Charges,227.24,1012,
LABOR & DELIVERY ROOM & BOARD,1200000004,CDM,120,RC,,,Inpatient,,,1139.00,740.35,,1139,125,MS-DRG,911.2,Case Rate,125% of CMS IPPS Rate,865.64,76,,692.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,820.08,72,,656.064,Percent of Total Billed Charges,72% of Total Billed Charges,854.25,75,,683.4,Percent of Total Billed charges,75% of Total Billed Charges,1139,100,MS-DRG,911.2,Case Rate,100% of CMS IPPS Rate,820.08,72,,656.064,Percent of Total Billed Charges,72% of Total Billed Charges,683.4,60,,546.72,Percent of Total Billed Charges,60% of Total Billed Charges,1025.1,90,,820.08,Percent of Total Billed Charges,90% of Total Billed Charges,318.92,28,,255.136,Percent of Total Billed Charges,28% of Total Billed Charges,1025.1,90,,820.08,Percent of Total Billed Charges,90% of Total billed Charges,1139,100,MS-DRG,911.2,Case Rate,100% of CMS IPPS Rate,1139,100,MS-DRG,911.2,Case Rate,100% of CMS IPPS Rate,1139,100,MS-DRG,911.2,Case Rate,100% of CMS IPPS Rate,740.35,65,,592.28,Percent of total Billed Charges,65% of Total Billed Charges,307.53,27,,246.024,Percent of Total Billed Charges,27% of Total Billed Charges,1082.05,95,,865.64,Percent of Total Billed Charges,95% of Total Billed Charges,255.76,22.455,,204.608,Percent of Total billed Charges,22.455% of Total Billed Charges,1002.32,88,,801.856,Percent of Total Billed Charges,88% of Total Billed Charges,1025.1,90,,820.08,Percent of Total Billed charges,90% of Total Billed Charges,255.76,1139,
POST PARTUM ROOM & BOARD,1200000005,CDM,120,RC,,,Inpatient,,,1139.00,740.35,,1139,125,MS-DRG,911.2,Case Rate,125% of CMS IPPS Rate,865.64,76,,692.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,820.08,72,,656.064,Percent of Total Billed Charges,72% of Total Billed Charges,854.25,75,,683.4,Percent of Total Billed charges,75% of Total Billed Charges,1139,100,MS-DRG,911.2,Case Rate,100% of CMS IPPS Rate,820.08,72,,656.064,Percent of Total Billed Charges,72% of Total Billed Charges,683.4,60,,546.72,Percent of Total Billed Charges,60% of Total Billed Charges,1025.1,90,,820.08,Percent of Total Billed Charges,90% of Total Billed Charges,318.92,28,,255.136,Percent of Total Billed Charges,28% of Total Billed Charges,1025.1,90,,820.08,Percent of Total Billed Charges,90% of Total billed Charges,1139,100,MS-DRG,911.2,Case Rate,100% of CMS IPPS Rate,1139,100,MS-DRG,911.2,Case Rate,100% of CMS IPPS Rate,1139,100,MS-DRG,911.2,Case Rate,100% of CMS IPPS Rate,740.35,65,,592.28,Percent of total Billed Charges,65% of Total Billed Charges,307.53,27,,246.024,Percent of Total Billed Charges,27% of Total Billed Charges,1082.05,95,,865.64,Percent of Total Billed Charges,95% of Total Billed Charges,255.76,22.455,,204.608,Percent of Total billed Charges,22.455% of Total Billed Charges,1002.32,88,,801.856,Percent of Total Billed Charges,88% of Total Billed Charges,1025.1,90,,820.08,Percent of Total Billed charges,90% of Total Billed Charges,255.76,1139,
PEDIATRIC ROOM&BOARD SEMI-PVT,1230000001,CDM,123,RC,,,Inpatient,,,1087.00,706.55,,1087,125,MS-DRG,869.6,Case Rate,125% of CMS IPPS Rate,826.12,76,,660.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,782.64,72,,626.112,Percent of Total Billed Charges,72% of Total Billed Charges,815.25,75,,652.2,Percent of Total Billed charges,75% of Total Billed Charges,1087,100,MS-DRG,869.6,Case Rate,100% of CMS IPPS Rate,782.64,72,,626.112,Percent of Total Billed Charges,72% of Total Billed Charges,652.2,60,,521.76,Percent of Total Billed Charges,60% of Total Billed Charges,978.3,90,,782.64,Percent of Total Billed Charges,90% of Total Billed Charges,304.36,28,,243.488,Percent of Total Billed Charges,28% of Total Billed Charges,978.3,90,,782.64,Percent of Total Billed Charges,90% of Total billed Charges,1087,100,MS-DRG,869.6,Case Rate,100% of CMS IPPS Rate,1087,100,MS-DRG,869.6,Case Rate,100% of CMS IPPS Rate,1087,100,MS-DRG,869.6,Case Rate,100% of CMS IPPS Rate,706.55,65,,565.24,Percent of total Billed Charges,65% of Total Billed Charges,293.49,27,,234.792,Percent of Total Billed Charges,27% of Total Billed Charges,1032.65,95,,826.12,Percent of Total Billed Charges,95% of Total Billed Charges,244.09,22.455,,195.272,Percent of Total billed Charges,22.455% of Total Billed Charges,956.56,88,,765.248,Percent of Total Billed Charges,88% of Total Billed Charges,978.3,90,,782.64,Percent of Total Billed charges,90% of Total Billed Charges,244.09,1087,
NURSERY LEVEL 1,1710000001,CDM,171,RC,,,Inpatient,,,384.00,249.60,,384,125,MS-DRG,307.2,Case Rate,125% of CMS IPPS Rate,291.84,76,,233.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,276.48,72,,221.184,Percent of Total Billed Charges,72% of Total Billed Charges,288,75,,230.4,Percent of Total Billed charges,75% of Total Billed Charges,384,100,MS-DRG,307.2,Case Rate,100% of CMS IPPS Rate,276.48,72,,221.184,Percent of Total Billed Charges,72% of Total Billed Charges,230.4,60,,184.32,Percent of Total Billed Charges,60% of Total Billed Charges,345.6,90,,276.48,Percent of Total Billed Charges,90% of Total Billed Charges,107.52,28,,86.016,Percent of Total Billed Charges,28% of Total Billed Charges,345.6,90,,276.48,Percent of Total Billed Charges,90% of Total billed Charges,384,100,MS-DRG,307.2,Case Rate,100% of CMS IPPS Rate,384,100,MS-DRG,307.2,Case Rate,100% of CMS IPPS Rate,384,100,MS-DRG,307.2,Case Rate,100% of CMS IPPS Rate,249.6,65,,199.68,Percent of total Billed Charges,65% of Total Billed Charges,103.68,27,,82.944,Percent of Total Billed Charges,27% of Total Billed Charges,364.8,95,,291.84,Percent of Total Billed Charges,95% of Total Billed Charges,86.23,22.455,,68.984,Percent of Total billed Charges,22.455% of Total Billed Charges,337.92,88,,270.336,Percent of Total Billed Charges,88% of Total Billed Charges,345.6,90,,276.48,Percent of Total Billed charges,90% of Total Billed Charges,86.23,384,
NURSERY LEVEL 2,1720000001,CDM,172,RC,,,Inpatient,,,2323.00,1509.95,,2323,125,MS-DRG,1858.4,Case Rate,125% of CMS IPPS Rate,1765.48,76,,1412.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1672.56,72,,1338.048,Percent of Total Billed Charges,72% of Total Billed Charges,1742.25,75,,1393.8,Percent of Total Billed charges,75% of Total Billed Charges,2323,100,MS-DRG,1858.4,Case Rate,100% of CMS IPPS Rate,1672.56,72,,1338.048,Percent of Total Billed Charges,72% of Total Billed Charges,1393.8,60,,1115.04,Percent of Total Billed Charges,60% of Total Billed Charges,2090.7,90,,1672.56,Percent of Total Billed Charges,90% of Total Billed Charges,650.44,28,,520.352,Percent of Total Billed Charges,28% of Total Billed Charges,2090.7,90,,1672.56,Percent of Total Billed Charges,90% of Total billed Charges,2323,100,MS-DRG,1858.4,Case Rate,100% of CMS IPPS Rate,2323,100,MS-DRG,1858.4,Case Rate,100% of CMS IPPS Rate,2323,100,MS-DRG,1858.4,Case Rate,100% of CMS IPPS Rate,1509.95,65,,1207.96,Percent of total Billed Charges,65% of Total Billed Charges,627.21,27,,501.768,Percent of Total Billed Charges,27% of Total Billed Charges,2206.85,95,,1765.48,Percent of Total Billed Charges,95% of Total Billed Charges,521.63,22.455,,417.304,Percent of Total billed Charges,22.455% of Total Billed Charges,2044.24,88,,1635.392,Percent of Total Billed Charges,88% of Total Billed Charges,2090.7,90,,1672.56,Percent of Total Billed charges,90% of Total Billed Charges,521.63,2323,
NURSERY LEVEL 3,1730000001,CDM,173,RC,,,Inpatient,,,706.70,459.36,,706.7,125,MS-DRG,565.36,Case Rate,125% of CMS IPPS Rate,537.09,76,,429.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,508.82,72,,407.056,Percent of Total Billed Charges,72% of Total Billed Charges,530.03,75,,424.024,Percent of Total Billed charges,75% of Total Billed Charges,706.7,100,MS-DRG,565.36,Case Rate,100% of CMS IPPS Rate,508.82,72,,407.056,Percent of Total Billed Charges,72% of Total Billed Charges,424.02,60,,339.216,Percent of Total Billed Charges,60% of Total Billed Charges,636.03,90,,508.824,Percent of Total Billed Charges,90% of Total Billed Charges,197.88,28,,158.304,Percent of Total Billed Charges,28% of Total Billed Charges,636.03,90,,508.824,Percent of Total Billed Charges,90% of Total billed Charges,706.7,100,MS-DRG,565.36,Case Rate,100% of CMS IPPS Rate,706.7,100,MS-DRG,565.36,Case Rate,100% of CMS IPPS Rate,706.7,100,MS-DRG,565.36,Case Rate,100% of CMS IPPS Rate,459.36,65,,367.488,Percent of total Billed Charges,65% of Total Billed Charges,190.81,27,,152.648,Percent of Total Billed Charges,27% of Total Billed Charges,671.37,95,,537.096,Percent of Total Billed Charges,95% of Total Billed Charges,158.69,22.455,,126.952,Percent of Total billed Charges,22.455% of Total Billed Charges,621.9,88,,497.52,Percent of Total Billed Charges,88% of Total Billed Charges,636.03,90,,508.824,Percent of Total Billed charges,90% of Total Billed Charges,158.69,706.7,
ICU ROOM & BOARD,2000000001,CDM,200,RC,,,Inpatient,,,2259.00,1468.35,,2259,125,MS-DRG,1807.2,Case Rate,125% of CMS IPPS Rate,1716.84,76,,1373.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1626.48,72,,1301.184,Percent of Total Billed Charges,72% of Total Billed Charges,1694.25,75,,1355.4,Percent of Total Billed charges,75% of Total Billed Charges,2259,100,MS-DRG,1807.2,Case Rate,100% of CMS IPPS Rate,1626.48,72,,1301.184,Percent of Total Billed Charges,72% of Total Billed Charges,1355.4,60,,1084.32,Percent of Total Billed Charges,60% of Total Billed Charges,2033.1,90,,1626.48,Percent of Total Billed Charges,90% of Total Billed Charges,632.52,28,,506.016,Percent of Total Billed Charges,28% of Total Billed Charges,2033.1,90,,1626.48,Percent of Total Billed Charges,90% of Total billed Charges,2259,100,MS-DRG,1807.2,Case Rate,100% of CMS IPPS Rate,2259,100,MS-DRG,1807.2,Case Rate,100% of CMS IPPS Rate,2259,100,MS-DRG,1807.2,Case Rate,100% of CMS IPPS Rate,1468.35,65,,1174.68,Percent of total Billed Charges,65% of Total Billed Charges,609.93,27,,487.944,Percent of Total Billed Charges,27% of Total Billed Charges,2146.05,95,,1716.84,Percent of Total Billed Charges,95% of Total Billed Charges,507.26,22.455,,405.808,Percent of Total billed Charges,22.455% of Total Billed Charges,1987.92,88,,1590.336,Percent of Total Billed Charges,88% of Total Billed Charges,2033.1,90,,1626.48,Percent of Total Billed charges,90% of Total Billed Charges,507.26,2259,
ACET 200MG/ML 6G/30ML 30ML VIA,2500000001,CDM,250,RC,J0132,HCPCS,Outpatient,200,GM,950.36,617.73,,950.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,722.27,76,,577.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.6,350,,53.976,Fee Schedule,350% of BCBS fee schedule,7.6,350,,56.224,Fee Schedule,350% of BCBS fee schedule,950.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.6,350,,53.976,Fee Schedule,350% of BCBS PPO fee schedule,2.17,100,,44.984,Fee Schedule,100% of Blue ADV HMO fee schedule,855.32,90,,684.256,Percent of Total Billed Charges,90% of Total Billed Charges,427.66,45,,342.128,Percent of Total Billed Charges,45% of Total Billed Charges,855.32,90,,684.256,Percent of Total Billed Charges,90% of Total billed Charges,950.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,950.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,950.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,617.73,65,,494.184,Percent of total Billed Charges,65% of Total Billed Charges,419.11,44.1,,335.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,902.84,95,,722.272,Percent of Total Billed Charges,95% of Total Billed Charges,950.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,836.32,88,,669.056,Percent of Total Billed Charges,88% of Total Billed Charges,855.32,90,,684.256,Percent of Total Billed charges,90% of Total Billed Charges,2.17,950.36,
ALBUT SUL 0.021% 0.63MG/3ML NE,2500000003,CDM,250,RC,J7613,HCPCS,Outpatient,0.63,GM,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,56.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.28,350,,1.272,Fee Schedule,350% of BCBS fee schedule,0.28,350,,1.328,Fee Schedule,350% of BCBS fee schedule,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.28,350,,1.272,Fee Schedule,350% of BCBS PPO fee schedule,0.08,100,,1.064,Fee Schedule,100% of Blue ADV HMO fee schedule,8.93,90,,67.472,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,33.736,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,67.472,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,48.728,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,33.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,71.216,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,65.968,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,67.472,Percent of Total Billed charges,90% of Total Billed Charges,0.08,9.92,
AMOX/CLAV 200MG/5ML SUS 75ML S,2500000005,CDM,250,RC,,,Outpatient,200,GM,93.71,60.91,,93.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,71.22,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,67.47,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,70.28,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,93.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.47,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,56.23,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,84.34,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,42.17,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,84.34,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,93.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.91,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,41.33,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,89.02,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,93.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.46,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,84.34,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,41.33,93.71,
AMOX/CLAV 600MG/5ML SUS 75ML S,2500000006,CDM,250,RC,,,Outpatient,600,GM,146.63,95.31,,146.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,111.44,76,,42.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,105.57,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,109.97,75,,10.584,Percent of Total Billed charges,75% of Total Billed Charges,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.57,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,87.98,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,131.97,90,,49.864,Percent of Total Billed Charges,90% of Total Billed Charges,65.98,45,,24.928,Percent of Total Billed Charges,45% of Total Billed Charges,131.97,90,,49.864,Percent of Total Billed Charges,90% of Total billed Charges,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.31,65,,36.008,Percent of total Billed Charges,65% of Total Billed Charges,64.66,44.1,,24.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,139.3,95,,52.632,Percent of Total Billed Charges,95% of Total Billed Charges,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.03,88,,48.752,Percent of Total Billed Charges,88% of Total Billed Charges,131.97,90,,49.864,Percent of Total Billed charges,90% of Total Billed Charges,64.66,146.63,
AUGMENTN 200MG/28.5MG/5ML SUSP,2500000010,CDM,250,RC,,,Outpatient,200,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
CAFF/ SOD BENZOATE 250MG/2ML,2500000013,CDM,250,RC,,,Outpatient,250,GM,69.25,45.01,,69.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.63,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49.86,72,,80.648,Percent of Total Billed Charges,72% of Total Billed Charges,51.94,75,,84.016,Percent of Total Billed charges,75% of Total Billed Charges,69.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.86,72,,80.648,Percent of Total Billed Charges,72% of Total Billed Charges,41.55,60,,67.208,Percent of Total Billed Charges,60% of Total Billed Charges,62.33,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,31.16,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,62.33,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,69.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.01,65,,6.88,Percent of total Billed Charges,65% of Total Billed Charges,30.54,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.79,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,69.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.94,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,62.33,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,30.54,69.25,
CIPROFLXA CM 0.3 OPHTH SOL 5ML,2500000016,CDM,250,RC,,,Outpatient,5,ML,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,46.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,7.2,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,54.768,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,27.384,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,54.768,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,39.56,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,26.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,57.816,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,53.552,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,54.768,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
GLUC 1.5 237 MLS KCAL 356 LIQD,2500000021,CDM,250,RC,,,Outpatient,,,17.64,11.47,,17.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.41,76,,28.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.7,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,75,,26.464,Percent of Total Billed charges,75% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.7,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,10.58,60,,21.168,Percent of Total Billed Charges,60% of Total Billed Charges,15.88,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,7.94,45,,16.92,Percent of Total Billed Charges,45% of Total Billed Charges,15.88,90,,33.84,Percent of Total Billed Charges,90% of Total billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.47,65,,24.44,Percent of total Billed Charges,65% of Total Billed Charges,7.78,44.1,,16.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.76,95,,35.72,Percent of Total Billed Charges,95% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.52,88,,33.088,Percent of Total Billed Charges,88% of Total Billed Charges,15.88,90,,33.84,Percent of Total Billed charges,90% of Total Billed Charges,7.78,17.64,
LACTULOSE 100GR/150 ML ORL SOL,2500000024,CDM,250,RC,,,Outpatient,150,ML,7.75,5.04,,7.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.89,76,,66.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.58,72,,14.688,Percent of Total Billed Charges,72% of Total Billed Charges,5.81,75,,15.304,Percent of Total Billed charges,75% of Total Billed Charges,7.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.58,72,,14.688,Percent of Total Billed Charges,72% of Total Billed Charges,4.65,60,,12.24,Percent of Total Billed Charges,60% of Total Billed Charges,6.98,90,,78.592,Percent of Total Billed Charges,90% of Total Billed Charges,3.49,45,,39.296,Percent of Total Billed Charges,45% of Total Billed Charges,6.98,90,,78.592,Percent of Total Billed Charges,90% of Total billed Charges,7.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.04,65,,56.76,Percent of total Billed Charges,65% of Total Billed Charges,3.42,44.1,,38.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.36,95,,82.952,Percent of Total Billed Charges,95% of Total Billed Charges,7.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.82,88,,76.84,Percent of Total Billed Charges,88% of Total Billed Charges,6.98,90,,78.592,Percent of Total Billed charges,90% of Total Billed Charges,3.42,7.75,
"LIDOC 2%  1:100,000 INJ 20ML",2500000025,CDM,250,RC,,,Outpatient,20,ML,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,7.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,5.952,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,4.76,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,9,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,4.504,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,9,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,6.504,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,4.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,9.504,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,8.8,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,9,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
NEO/POLY B/BACI ZN/HC 1% OINT,2500000027,CDM,250,RC,,,Outpatient,,,86.00,55.90,,86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,65.36,76,,10.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.92,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,75,,7.2,Percent of Total Billed charges,75% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.92,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,51.6,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,77.4,90,,12.544,Percent of Total Billed Charges,90% of Total Billed Charges,38.7,45,,6.272,Percent of Total Billed Charges,45% of Total Billed Charges,77.4,90,,12.544,Percent of Total Billed Charges,90% of Total billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.9,65,,9.056,Percent of total Billed Charges,65% of Total Billed Charges,37.93,44.1,,6.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,81.7,95,,13.24,Percent of Total Billed Charges,95% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.68,88,,12.264,Percent of Total Billed Charges,88% of Total Billed Charges,77.4,90,,12.544,Percent of Total Billed charges,90% of Total Billed Charges,37.93,86,
NEOMYCIN  BACITRAICN POLYMYCN,2500000028,CDM,250,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,15.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,69.456,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,55.568,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,18.256,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,9.128,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,18.256,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,13.184,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,8.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,19.272,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,17.856,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,18.256,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
NYSTATIN/TRIAMCINOLONE CRM 15G,2500000029,CDM,250,RC,,,Outpatient,,,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,154.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,87.552,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,91.2,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,87.552,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,72.96,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,182.576,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,91.288,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,182.576,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,131.864,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,89.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,192.72,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,178.52,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,182.576,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
PENICLN V POTASIUM 250/5 200ML,2500000030,CDM,250,RC,,,Outpatient,200,ML,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,56.88,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,59.248,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,56.88,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,47.4,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,6.24,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
PHENYLEPHRINE 0.5% NASAL SOLUT,2500000032,CDM,250,RC,,,Outpatient,,,140.02,91.01,,140.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.42,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.81,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,105.02,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,140.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.81,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,84.01,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,126.02,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,63.01,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,126.02,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,140.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.01,65,,6.24,Percent of total Billed Charges,65% of Total Billed Charges,61.75,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,133.02,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,140.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.22,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,126.02,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,61.75,140.02,
POTASSCHLORI 10 MEG / 50ML INJ,2500000034,CDM,250,RC,,,Outpatient,50,ML,76.07,49.45,,76.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,57.81,76,,9.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,54.77,72,,78.112,Percent of Total Billed Charges,72% of Total Billed Charges,57.05,75,,81.368,Percent of Total Billed charges,75% of Total Billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.77,72,,78.112,Percent of Total Billed Charges,72% of Total Billed Charges,45.64,60,,65.096,Percent of Total Billed Charges,60% of Total Billed Charges,68.46,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,34.23,45,,5.76,Percent of Total Billed Charges,45% of Total Billed Charges,68.46,90,,11.52,Percent of Total Billed Charges,90% of Total billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.45,65,,8.32,Percent of total Billed Charges,65% of Total Billed Charges,33.55,44.1,,5.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,72.27,95,,12.16,Percent of Total Billed Charges,95% of Total Billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.94,88,,11.264,Percent of Total Billed Charges,88% of Total Billed Charges,68.46,90,,11.52,Percent of Total Billed charges,90% of Total Billed Charges,33.55,76.07,
SOD BICARBONATE 8.4% 10ML INJ,2500000035,CDM,250,RC,,,Outpatient,10,ML,49.61,32.25,,49.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,37.7,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,35.72,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,37.21,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.72,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,29.77,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,44.65,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,22.32,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,44.65,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.25,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,21.88,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,47.13,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,44.65,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,21.88,49.61,
SOD CHL BACTERIOSTA F INJ 10ML,2500000036,CDM,250,RC,,,Outpatient,10,ML,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.64,72,,152.408,Percent of Total Billed Charges,72% of Total Billed Charges,9,75,,158.76,Percent of Total Billed charges,75% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.64,72,,152.408,Percent of Total Billed Charges,72% of Total Billed Charges,7.2,60,,127.008,Percent of Total Billed Charges,60% of Total Billed Charges,10.8,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,5.29,12,
SODIUM PHOSPHTE 3MM/ML 5ML INJ,2500000037,CDM,250,RC,,,Outpatient,5,ML,59.25,38.51,,59.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.03,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.66,72,,52.08,Percent of Total Billed Charges,72% of Total Billed Charges,44.44,75,,54.248,Percent of Total Billed charges,75% of Total Billed Charges,59.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.66,72,,52.08,Percent of Total Billed Charges,72% of Total Billed Charges,35.55,60,,43.4,Percent of Total Billed Charges,60% of Total Billed Charges,53.33,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,26.66,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,53.33,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,59.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.51,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,26.13,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,56.29,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,59.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.14,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,53.33,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,26.13,59.25,
STER WTR IRR W/SET PORT 1000ML,2500000038,CDM,250,RC,,,Outpatient,1000,ML,47.00,30.55,,47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.72,76,,15.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.84,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,35.25,75,,16.536,Percent of Total Billed charges,75% of Total Billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.84,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,28.2,60,,13.232,Percent of Total Billed Charges,60% of Total Billed Charges,42.3,90,,18.256,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,45,,9.128,Percent of Total Billed Charges,45% of Total Billed Charges,42.3,90,,18.256,Percent of Total Billed Charges,90% of Total billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.55,65,,13.184,Percent of total Billed Charges,65% of Total Billed Charges,20.73,44.1,,8.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.65,95,,19.272,Percent of Total Billed Charges,95% of Total Billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.36,88,,17.856,Percent of Total Billed Charges,88% of Total Billed Charges,42.3,90,,18.256,Percent of Total Billed charges,90% of Total Billed Charges,20.73,47,
STER WTR IRR W/SET PORT 500ML,2500000039,CDM,250,RC,,,Outpatient,500,ML,47.00,30.55,,47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.72,76,,15.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.84,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,35.25,75,,7.936,Percent of Total Billed charges,75% of Total Billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.84,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,28.2,60,,6.352,Percent of Total Billed Charges,60% of Total Billed Charges,42.3,90,,18.36,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,45,,9.184,Percent of Total Billed Charges,45% of Total Billed Charges,42.3,90,,18.36,Percent of Total Billed Charges,90% of Total billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.55,65,,13.264,Percent of total Billed Charges,65% of Total Billed Charges,20.73,44.1,,9,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.65,95,,19.384,Percent of Total Billed Charges,95% of Total Billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.36,88,,17.952,Percent of Total Billed Charges,88% of Total Billed Charges,42.3,90,,18.36,Percent of Total Billed charges,90% of Total Billed Charges,20.73,47,
TETRACAINE 0.5% OPHTH SOL 15ML,2500000041,CDM,250,RC,,,Outpatient,15,ML,125.96,81.87,,125.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95.73,76,,135.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90.69,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,94.47,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,125.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.69,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,75.58,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,113.36,90,,160.352,Percent of Total Billed Charges,90% of Total Billed Charges,56.68,45,,80.176,Percent of Total Billed Charges,45% of Total Billed Charges,113.36,90,,160.352,Percent of Total Billed Charges,90% of Total billed Charges,125.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.87,65,,115.808,Percent of total Billed Charges,65% of Total Billed Charges,55.55,44.1,,78.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,119.66,95,,169.256,Percent of Total Billed Charges,95% of Total Billed Charges,125.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.84,88,,156.784,Percent of Total Billed Charges,88% of Total Billed Charges,113.36,90,,160.352,Percent of Total Billed charges,90% of Total Billed Charges,55.55,125.96,
XYLOC MPF 2% 10MLW/EPI INJ10ML,2500000045,CDM,250,RC,,,Outpatient,10,ML,44.10,28.67,,44.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33.52,76,,60.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,31.75,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.75,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,39.69,90,,71.104,Percent of Total Billed Charges,90% of Total Billed Charges,19.85,45,,35.552,Percent of Total Billed Charges,45% of Total Billed Charges,39.69,90,,71.104,Percent of Total Billed Charges,90% of Total billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,65,,51.352,Percent of total Billed Charges,65% of Total Billed Charges,19.45,44.1,,34.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.9,95,,75.048,Percent of Total Billed Charges,95% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.81,88,,69.52,Percent of Total Billed Charges,88% of Total Billed Charges,39.69,90,,71.104,Percent of Total Billed charges,90% of Total Billed Charges,19.45,44.1,
MAXIPIME 2 GRAM VIAL INJ,2500000047,CDM,250,RC,J0692,HCPCS,Outpatient,,,109.15,70.95,,109.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.95,76,,155.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.58,350,,291.488,Fee Schedule,350% of BCBS fee schedule,8.58,350,,303.632,Fee Schedule,350% of BCBS fee schedule,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.58,350,,291.488,Fee Schedule,350% of BCBS PPO fee schedule,2.45,100,,242.904,Fee Schedule,100% of Blue ADV HMO fee schedule,98.24,90,,184.32,Percent of Total Billed Charges,90% of Total Billed Charges,49.12,45,,92.16,Percent of Total Billed Charges,45% of Total Billed Charges,98.24,90,,184.32,Percent of Total Billed Charges,90% of Total billed Charges,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.95,65,,133.12,Percent of total Billed Charges,65% of Total Billed Charges,48.14,44.1,,90.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,103.69,95,,194.56,Percent of Total Billed Charges,95% of Total Billed Charges,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.05,88,,180.224,Percent of Total Billed Charges,88% of Total Billed Charges,98.24,90,,184.32,Percent of Total Billed charges,90% of Total Billed Charges,2.45,109.15,
DIPHENYDRAMINE 50MG/ML VIAL,2500000048,CDM,250,RC,J1200,HCPCS,Outpatient,50,GM,12.50,8.13,,12.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.5,76,,32.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.91,350,,3.816,Fee Schedule,350% of BCBS fee schedule,2.91,350,,3.976,Fee Schedule,350% of BCBS fee schedule,12.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,350,,3.816,Fee Schedule,350% of BCBS PPO fee schedule,0.83,100,,3.176,Fee Schedule,100% of Blue ADV HMO fee schedule,11.25,90,,38.104,Percent of Total Billed Charges,90% of Total Billed Charges,5.63,45,,19.048,Percent of Total Billed Charges,45% of Total Billed Charges,11.25,90,,38.104,Percent of Total Billed Charges,90% of Total billed Charges,12.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.13,65,,27.52,Percent of total Billed Charges,65% of Total Billed Charges,5.51,44.1,,18.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.88,95,,40.216,Percent of Total Billed Charges,95% of Total Billed Charges,12.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11,88,,37.256,Percent of Total Billed Charges,88% of Total Billed Charges,11.25,90,,38.104,Percent of Total Billed charges,90% of Total Billed Charges,0.83,12.5,
HEPARIN DRIP 25 000/250ML INJ,2500000050,CDM,250,RC,J1644,HCPCS,Outpatient,250,ML,57.33,37.26,,57.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.57,76,,29.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.67,350,,4.448,Fee Schedule,350% of BCBS fee schedule,0.67,350,,4.632,Fee Schedule,350% of BCBS fee schedule,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.67,350,,4.448,Fee Schedule,350% of BCBS PPO fee schedule,0.19,100,,3.704,Fee Schedule,100% of Blue ADV HMO fee schedule,51.6,90,,34.56,Percent of Total Billed Charges,90% of Total Billed Charges,25.8,45,,17.28,Percent of Total Billed Charges,45% of Total Billed Charges,51.6,90,,34.56,Percent of Total Billed Charges,90% of Total billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.26,65,,24.96,Percent of total Billed Charges,65% of Total Billed Charges,25.28,44.1,,16.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.46,95,,36.48,Percent of Total Billed Charges,95% of Total Billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.45,88,,33.792,Percent of Total Billed Charges,88% of Total Billed Charges,51.6,90,,34.56,Percent of Total Billed charges,90% of Total Billed Charges,0.19,57.33,
HEPARIN SOD 1000UN INJ,2500000051,CDM,250,RC,J1644,HCPCS,Outpatient,,,17.42,11.32,,17.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.24,76,,298.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.67,350,,3.816,Fee Schedule,350% of BCBS fee schedule,0.67,350,,3.976,Fee Schedule,350% of BCBS fee schedule,17.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.67,350,,3.816,Fee Schedule,350% of BCBS PPO fee schedule,0.19,100,,3.176,Fee Schedule,100% of Blue ADV HMO fee schedule,15.68,90,,353.24,Percent of Total Billed Charges,90% of Total Billed Charges,7.84,45,,176.616,Percent of Total Billed Charges,45% of Total Billed Charges,15.68,90,,353.24,Percent of Total Billed Charges,90% of Total billed Charges,17.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.32,65,,255.12,Percent of total Billed Charges,65% of Total Billed Charges,7.68,44.1,,173.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.55,95,,372.864,Percent of Total Billed Charges,95% of Total Billed Charges,17.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.33,88,,345.392,Percent of Total Billed Charges,88% of Total Billed Charges,15.68,90,,353.24,Percent of Total Billed charges,90% of Total Billed Charges,0.19,17.42,
HEPARIN 5000UN INJ,2500000052,CDM,250,RC,J1644,HCPCS,Outpatient,,,25.36,16.48,,25.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.27,76,,23.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.67,350,,217.824,Fee Schedule,350% of BCBS fee schedule,0.67,350,,226.896,Fee Schedule,350% of BCBS fee schedule,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.67,350,,217.824,Fee Schedule,350% of BCBS PPO fee schedule,0.19,100,,181.52,Fee Schedule,100% of Blue ADV HMO fee schedule,22.82,90,,27.784,Percent of Total Billed Charges,90% of Total Billed Charges,11.41,45,,13.896,Percent of Total Billed Charges,45% of Total Billed Charges,22.82,90,,27.784,Percent of Total Billed Charges,90% of Total billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,65,,20.064,Percent of total Billed Charges,65% of Total Billed Charges,11.18,44.1,,13.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.09,95,,29.328,Percent of Total Billed Charges,95% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,88,,27.168,Percent of Total Billed Charges,88% of Total Billed Charges,22.82,90,,27.784,Percent of Total Billed charges,90% of Total Billed Charges,0.19,25.36,
LEVOFLOXACIN 500MG/100ML INJ,2500000055,CDM,250,RC,J1956,HCPCS,Outpatient,500,GM,253.58,164.83,,253.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,192.72,76,,38.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.02,350,,153.68,Fee Schedule,350% of BCBS fee schedule,6.02,350,,160.088,Fee Schedule,350% of BCBS fee schedule,253.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.02,350,,153.68,Fee Schedule,350% of BCBS PPO fee schedule,1.72,100,,128.072,Fee Schedule,100% of Blue ADV HMO fee schedule,228.22,90,,45.248,Percent of Total Billed Charges,90% of Total Billed Charges,114.11,45,,22.624,Percent of Total Billed Charges,45% of Total Billed Charges,228.22,90,,45.248,Percent of Total Billed Charges,90% of Total billed Charges,253.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,253.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,253.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.83,65,,32.68,Percent of total Billed Charges,65% of Total Billed Charges,111.83,44.1,,22.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,240.9,95,,47.76,Percent of Total Billed Charges,95% of Total Billed Charges,253.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,223.15,88,,44.24,Percent of Total Billed Charges,88% of Total Billed Charges,228.22,90,,45.248,Percent of Total Billed charges,90% of Total Billed Charges,1.72,253.58,
LIDOCAINE HCL 2% 10 ML INJ,2500000056,CDM,250,RC,J2003,HCPCS,Outpatient,10,ML,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.64,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,9,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.64,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,7.2,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,10.8,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,5.29,12,
ATIVAN 2MG/ML INJ,2500000057,CDM,250,RC,J2060,HCPCS,Outpatient,2,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.12,350,,5.08,Fee Schedule,350% of BCBS fee schedule,1.12,350,,5.296,Fee Schedule,350% of BCBS fee schedule,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.12,350,,5.08,Fee Schedule,350% of BCBS PPO fee schedule,0.32,100,,4.232,Fee Schedule,100% of Blue ADV HMO fee schedule,9.93,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.32,11.03,
DEMEROL 25MG INJ SLI INJ,2500000058,CDM,250,RC,J2175,HCPCS,Outpatient,25,GM,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,82.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.29,350,,0.632,Fee Schedule,350% of BCBS fee schedule,3.29,350,,0.664,Fee Schedule,350% of BCBS fee schedule,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.29,350,,0.632,Fee Schedule,350% of BCBS PPO fee schedule,0.94,100,,0.528,Fee Schedule,100% of Blue ADV HMO fee schedule,10.8,90,,97.64,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,48.816,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,97.64,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,70.52,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,47.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,103.064,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,95.472,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,97.64,Percent of Total Billed charges,90% of Total Billed Charges,0.94,12,
DEMEROL 50MG INJ SLI INJ,2500000059,CDM,250,RC,J2175,HCPCS,Outpatient,50,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.29,350,,1.904,Fee Schedule,350% of BCBS fee schedule,3.29,350,,1.984,Fee Schedule,350% of BCBS fee schedule,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.29,350,,1.904,Fee Schedule,350% of BCBS PPO fee schedule,0.94,100,,1.592,Fee Schedule,100% of Blue ADV HMO fee schedule,9.93,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.94,11.03,
DEMEROL 100MG INJ,2500000060,CDM,250,RC,J2175,HCPCS,Outpatient,100,GM,16.00,10.40,,16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.16,76,,160.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.29,350,,1.904,Fee Schedule,350% of BCBS fee schedule,3.29,350,,1.984,Fee Schedule,350% of BCBS fee schedule,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.29,350,,1.904,Fee Schedule,350% of BCBS PPO fee schedule,0.94,100,,1.592,Fee Schedule,100% of Blue ADV HMO fee schedule,14.4,90,,190.512,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,45,,95.256,Percent of Total Billed Charges,45% of Total Billed Charges,14.4,90,,190.512,Percent of Total Billed Charges,90% of Total billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,65,,137.592,Percent of total Billed Charges,65% of Total Billed Charges,7.06,44.1,,93.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.2,95,,201.096,Percent of Total Billed Charges,95% of Total Billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.08,88,,186.28,Percent of Total Billed Charges,88% of Total Billed Charges,14.4,90,,190.512,Percent of Total Billed charges,90% of Total Billed Charges,0.94,16,
MORPHINE SULFATE 2MG INJ,2500000061,CDM,250,RC,J2270,HCPCS,Outpatient,2,GM,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,24.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.25,350,,4.448,Fee Schedule,350% of BCBS fee schedule,0.25,350,,4.632,Fee Schedule,350% of BCBS fee schedule,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.25,350,,4.448,Fee Schedule,350% of BCBS PPO fee schedule,0.07,100,,3.704,Fee Schedule,100% of Blue ADV HMO fee schedule,8.93,90,,29.368,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,14.688,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,29.368,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,21.208,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,14.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,31,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,28.72,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,29.368,Percent of Total Billed charges,90% of Total Billed Charges,0.07,9.92,
ZOFRAN 1MG INJ,2500000062,CDM,636,RC,J2405,HCPCS,Outpatient,1,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,54.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.07,350,,2.544,Fee Schedule,350% of BCBS fee schedule,2.07,350,,2.648,Fee Schedule,350% of BCBS fee schedule,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.07,350,,2.544,Fee Schedule,350% of BCBS PPO fee schedule,0.59,100,,2.12,Fee Schedule,100% of Blue ADV HMO fee schedule,4.96,90,,65.096,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,32.544,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,65.096,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,47.016,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,31.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,68.712,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,63.648,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,65.096,Percent of Total Billed charges,90% of Total Billed Charges,0.59,5.51,
PHENERGAN 25MG INJ,2500000063,CDM,250,RC,J2550,HCPCS,Outpatient,25,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,16.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.48,350,,4.448,Fee Schedule,350% of BCBS fee schedule,4.48,350,,4.632,Fee Schedule,350% of BCBS fee schedule,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.48,350,,4.448,Fee Schedule,350% of BCBS PPO fee schedule,1.28,100,,3.704,Fee Schedule,100% of Blue ADV HMO fee schedule,5.96,90,,19.84,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,9.92,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,19.84,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,14.328,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,9.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,20.944,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,19.4,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,19.84,Percent of Total Billed charges,90% of Total Billed Charges,1.28,6.62,
ULORIC 40MG TAB,2500000064,CDM,250,RC,J3490,HCPCS,Outpatient,40,GM,25.36,16.48,,25.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.27,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.26,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,19.02,75,,36.384,Percent of Total Billed charges,75% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.26,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,15.22,60,,29.104,Percent of Total Billed Charges,60% of Total Billed Charges,22.82,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,11.41,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,22.82,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,65,,6.88,Percent of total Billed Charges,65% of Total Billed Charges,11.18,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.09,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,22.82,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,11.18,25.36,
KETAMINE 500MG/10ML INJ,2500000065,CDM,250,RC,J3490,HCPCS,Outpatient,500,GM,25.50,16.58,,25.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.38,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.36,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,19.13,75,,9.928,Percent of Total Billed charges,75% of Total Billed Charges,25.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.36,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,15.3,60,,7.936,Percent of Total Billed Charges,60% of Total Billed Charges,22.95,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,11.48,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,22.95,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,25.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.58,65,,6.88,Percent of total Billed Charges,65% of Total Billed Charges,11.25,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.23,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,25.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.44,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,22.95,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,11.25,25.5,
ROBINUL 0.2MG/ML INJ,2500000066,CDM,250,RC,J3490,HCPCS,Outpatient,0.2,GM,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,5.95,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,8.93,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,4.37,9.92,
ROCURONIUM 100MG/10ML INJ,2500000067,CDM,250,RC,J3490,HCPCS,Outpatient,100,GM,222.71,144.76,,222.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,169.26,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,160.35,72,,152.408,Percent of Total Billed Charges,72% of Total Billed Charges,167.03,75,,158.76,Percent of Total Billed charges,75% of Total Billed Charges,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.35,72,,152.408,Percent of Total Billed Charges,72% of Total Billed Charges,133.63,60,,127.008,Percent of Total Billed Charges,60% of Total Billed Charges,200.44,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,100.22,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,200.44,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.76,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,98.22,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,211.57,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.98,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,200.44,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,98.22,222.71,
PEPCID INJ 20MG/2ML INJ,2500000068,CDM,250,RC,,,Outpatient,20,GM,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.64,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,9,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.64,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,7.2,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,10.8,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,5.29,12,
ROCURONIUM 50MG/5ML VIAL,2500000069,CDM,250,RC,J3490,HCPCS,Outpatient,50,GM,115.76,75.24,,115.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.98,76,,427.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,83.35,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,86.82,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.35,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,69.46,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,104.18,90,,506.448,Percent of Total Billed Charges,90% of Total Billed Charges,52.09,45,,253.224,Percent of Total Billed Charges,45% of Total Billed Charges,104.18,90,,506.448,Percent of Total Billed Charges,90% of Total billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.24,65,,365.768,Percent of total Billed Charges,65% of Total Billed Charges,51.05,44.1,,248.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,109.97,95,,534.584,Percent of Total Billed Charges,95% of Total Billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.87,88,,495.192,Percent of Total Billed Charges,88% of Total Billed Charges,104.18,90,,506.448,Percent of Total Billed charges,90% of Total Billed Charges,51.05,115.76,
CEFOTETAN 2 G INJ,2500000072,CDM,250,RC,J3490,HCPCS,Outpatient,,,152.00,98.80,,152,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,115.52,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,109.44,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,114,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,152,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.44,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,91.2,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,136.8,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,68.4,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,136.8,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,152,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.8,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,67.03,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,144.4,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,152,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.76,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,136.8,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,67.03,152,
LABETALOL INJ 5MG/ML INJ 40ML,2500000073,CDM,250,RC,J3490,HCPCS,Outpatient,5,GM,98.75,64.19,,98.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.05,76,,307.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71.1,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,74.06,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,98.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.1,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,59.25,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,88.88,90,,364.36,Percent of Total Billed Charges,90% of Total Billed Charges,44.44,45,,182.176,Percent of Total Billed Charges,45% of Total Billed Charges,88.88,90,,364.36,Percent of Total Billed Charges,90% of Total billed Charges,98.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.19,65,,263.144,Percent of total Billed Charges,65% of Total Billed Charges,43.55,44.1,,178.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,93.81,95,,384.6,Percent of Total Billed Charges,95% of Total Billed Charges,98.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.9,88,,356.256,Percent of Total Billed Charges,88% of Total Billed Charges,88.88,90,,364.36,Percent of Total Billed charges,90% of Total Billed Charges,43.55,98.75,
XOPENEX HFA 45MCG,2500000074,CDM,250,RC,J3535,HCPCS,Outpatient,45,GM,256.00,166.40,,256,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,194.56,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,184.32,72,,48.896,Percent of Total Billed Charges,72% of Total Billed Charges,192,75,,50.936,Percent of Total Billed charges,75% of Total Billed Charges,256,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.32,72,,48.896,Percent of Total Billed Charges,72% of Total Billed Charges,153.6,60,,40.744,Percent of Total Billed Charges,60% of Total Billed Charges,230.4,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,115.2,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,230.4,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,256,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.4,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,112.9,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,243.2,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,256,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.28,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,230.4,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,112.9,256,
250CC D5W IV,2500000075,CDM,250,RC,J7060,HCPCS,Outpatient,,,52.92,34.40,,52.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.22,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.41,350,,47.632,Fee Schedule,350% of BCBS fee schedule,25.41,350,,49.616,Fee Schedule,350% of BCBS fee schedule,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.41,350,,47.632,Fee Schedule,350% of BCBS PPO fee schedule,7.26,100,,39.688,Fee Schedule,100% of Blue ADV HMO fee schedule,47.63,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,23.81,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,47.63,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.4,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,23.34,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.27,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.57,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,47.63,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,7.26,52.92,
ACETYLCYSTEINE 20% 4ML,2500000076,CDM,250,RC,J7608,HCPCS,Outpatient,4,ML,48.00,31.20,,48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.48,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.7,350,,21.592,Fee Schedule,350% of BCBS fee schedule,14.7,350,,22.496,Fee Schedule,350% of BCBS fee schedule,48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.7,350,,21.592,Fee Schedule,350% of BCBS PPO fee schedule,4.2,100,,17.992,Fee Schedule,100% of Blue ADV HMO fee schedule,43.2,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,21.6,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,43.2,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.2,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,21.17,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.6,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.24,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,43.2,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,4.2,48,
BLEOMYCIN 30 UNIT INJ,2500000077,CDM,250,RC,J9040,HCPCS,Outpatient,,,490.61,318.90,,490.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.86,76,,229.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.58,350,,3.176,Fee Schedule,350% of BCBS fee schedule,111.58,350,,3.304,Fee Schedule,350% of BCBS fee schedule,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.58,350,,3.176,Fee Schedule,350% of BCBS PPO fee schedule,31.88,100,,2.648,Fee Schedule,100% of Blue ADV HMO fee schedule,441.55,90,,272.272,Percent of Total Billed Charges,90% of Total Billed Charges,220.77,45,,136.136,Percent of Total Billed Charges,45% of Total Billed Charges,441.55,90,,272.272,Percent of Total Billed Charges,90% of Total billed Charges,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.9,65,,196.64,Percent of total Billed Charges,65% of Total Billed Charges,216.36,44.1,,133.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,466.08,95,,287.4,Percent of Total Billed Charges,95% of Total Billed Charges,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,431.74,88,,266.224,Percent of Total Billed Charges,88% of Total Billed Charges,441.55,90,,272.272,Percent of Total Billed charges,90% of Total Billed Charges,31.88,490.61,
SULFA TRIM 400MG/80MG 10ML INJ,2500000078,CDM,250,RC,S0039,HCPCS,Outpatient,400,GM,38.59,25.08,,38.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.33,76,,162.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.35,350,,1.904,Fee Schedule,350% of BCBS fee schedule,30.35,350,,1.984,Fee Schedule,350% of BCBS fee schedule,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.35,350,,1.904,Fee Schedule,350% of BCBS PPO fee schedule,8.67,100,,1.592,Fee Schedule,100% of Blue ADV HMO fee schedule,34.73,90,,192.104,Percent of Total Billed Charges,90% of Total Billed Charges,17.37,45,,96.048,Percent of Total Billed Charges,45% of Total Billed Charges,34.73,90,,192.104,Percent of Total Billed Charges,90% of Total billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.08,65,,138.744,Percent of total Billed Charges,65% of Total Billed Charges,17.02,44.1,,94.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.66,95,,202.776,Percent of Total Billed Charges,95% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.96,88,,187.832,Percent of Total Billed Charges,88% of Total Billed Charges,34.73,90,,192.104,Percent of Total Billed charges,90% of Total Billed Charges,8.67,38.59,
CEFOTETAN 1G INJ,2500000079,CDM,250,RC,S0074,HCPCS,Outpatient,,,62.84,40.85,,62.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.76,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.03,350,,26.032,Fee Schedule,350% of BCBS fee schedule,23.03,350,,27.12,Fee Schedule,350% of BCBS fee schedule,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.03,350,,26.032,Fee Schedule,350% of BCBS PPO fee schedule,6.58,100,,21.696,Fee Schedule,100% of Blue ADV HMO fee schedule,56.56,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,28.28,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,56.56,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.85,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,27.71,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.7,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.3,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,56.56,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,6.58,62.84,
GEOCILLIN 500 MG TAB,2500000082,CDM,250,RC,,,Outpatient,500,GM,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
NOVOLOG 70/30 INSULIN INJ,2500000083,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
HYDASE 150 UNITS/ML INJ,2500000085,CDM,250,RC,,,Outpatient,1,ML,135.61,88.15,,135.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,103.06,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,97.64,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,101.71,75,,14.56,Percent of Total Billed charges,75% of Total Billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.64,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,81.37,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,122.05,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,61.02,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,122.05,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.15,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,59.8,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,128.83,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.34,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,122.05,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,59.8,135.61,
LEVEMIR INSULIN 1CC INJ,2500000086,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,7.936,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,6.352,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
PLAIN SHUGARCANIE MIX INJ,2500000087,CDM,250,RC,,,Outpatient,,,264.60,171.99,,264.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,201.1,76,,36.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,190.51,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,198.45,75,,9.264,Percent of Total Billed charges,75% of Total Billed Charges,264.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.51,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,158.76,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,238.14,90,,43.664,Percent of Total Billed Charges,90% of Total Billed Charges,119.07,45,,21.832,Percent of Total Billed Charges,45% of Total Billed Charges,238.14,90,,43.664,Percent of Total Billed Charges,90% of Total billed Charges,264.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,65,,31.536,Percent of total Billed Charges,65% of Total Billed Charges,116.69,44.1,,21.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,251.37,95,,46.088,Percent of Total Billed Charges,95% of Total Billed Charges,264.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.85,88,,42.688,Percent of Total Billed Charges,88% of Total Billed Charges,238.14,90,,43.664,Percent of Total Billed charges,90% of Total Billed Charges,116.69,264.6,
XOPENEX 0.63MG/3ML NEB,2500000088,CDM,250,RC,J7614,HCPCS,Outpatient,0.63,GM,40.79,26.51,,40.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.18,350,,8.256,Fee Schedule,350% of BCBS fee schedule,5.18,350,,8.6,Fee Schedule,350% of BCBS fee schedule,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.18,350,,8.256,Fee Schedule,350% of BCBS PPO fee schedule,1.48,100,,6.88,Fee Schedule,100% of Blue ADV HMO fee schedule,36.71,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,18.36,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,36.71,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.51,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,17.99,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.75,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.9,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,36.71,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,1.48,40.79,
GLYCINE 1.5PCT 300ML SOLN,2500000089,CDM,250,RC,,,Outpatient,300,ML,90.41,58.77,,90.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.71,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.1,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,67.81,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.1,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,54.25,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,81.37,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,40.68,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,81.37,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.77,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,39.87,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.89,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.56,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,81.37,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,39.87,90.41,
ZITHROMAX 250MG CAP,2500000090,CDM,250,RC,,,Outpatient,250,GM,27.56,17.91,,27.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.95,76,,160.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.84,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,20.67,75,,21.168,Percent of Total Billed charges,75% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.84,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,60,,16.936,Percent of Total Billed Charges,60% of Total Billed Charges,24.8,90,,190.512,Percent of Total Billed Charges,90% of Total Billed Charges,12.4,45,,95.256,Percent of Total Billed Charges,45% of Total Billed Charges,24.8,90,,190.512,Percent of Total Billed Charges,90% of Total billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.91,65,,137.592,Percent of total Billed Charges,65% of Total Billed Charges,12.15,44.1,,93.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.18,95,,201.096,Percent of Total Billed Charges,95% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,88,,186.28,Percent of Total Billed Charges,88% of Total Billed Charges,24.8,90,,190.512,Percent of Total Billed charges,90% of Total Billed Charges,12.15,27.56,
DITROPAN XL 5MG TAB,2500000091,CDM,250,RC,,,Outpatient,5,GM,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,21.832,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,17.464,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
CELEBREX 100MG CAP,2500000092,CDM,250,RC,,,Outpatient,100,GM,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,57.16,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,59.536,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,57.16,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,47.632,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
AUGMENTIN 875/125MG TAB,2500000093,CDM,250,RC,,,Outpatient,125,GM,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
DEPAKOTE 500 EC TAB,2500000094,CDM,250,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,18.52,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,14.816,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
MS CONTIN 15MG TAB,2500000095,CDM,250,RC,,,Outpatient,15,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,51.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,61.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,30.56,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,61.12,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,44.144,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,29.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,64.52,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,59.76,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,61.12,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
PREMARIN 0.625MG CREAM,2500000096,CDM,250,RC,,,Outpatient,0.625,GM,703.40,457.21,,703.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,534.58,76,,50.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,506.45,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,527.55,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,703.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.45,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,422.04,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,633.06,90,,59.536,Percent of Total Billed Charges,90% of Total Billed Charges,316.53,45,,29.768,Percent of Total Billed Charges,45% of Total Billed Charges,633.06,90,,59.536,Percent of Total Billed Charges,90% of Total billed Charges,703.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,703.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,703.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,457.21,65,,43,Percent of total Billed Charges,65% of Total Billed Charges,310.2,44.1,,29.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,668.23,95,,62.848,Percent of Total Billed Charges,95% of Total Billed Charges,703.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618.99,88,,58.216,Percent of Total Billed Charges,88% of Total Billed Charges,633.06,90,,59.536,Percent of Total Billed charges,90% of Total Billed Charges,310.2,703.4,
SINEMET CR 25/100 TAB,2500000097,CDM,250,RC,,,Outpatient,,,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,22.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,26.992,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,13.496,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,26.992,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,19.496,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,13.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,28.496,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,26.392,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,26.992,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
BECLOMETHA 84MCG INHALER,2500000098,CDM,250,RC,,,Outpatient,84,GM,506.05,328.93,,506.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,384.6,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,364.36,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,379.54,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,506.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.36,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,303.63,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,455.45,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,227.72,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,455.45,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,506.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.93,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,223.17,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,480.75,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,506.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,445.32,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,455.45,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,223.17,506.05,
VICOPROFEN TAB,2500000099,CDM,250,RC,,,Outpatient,,,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,95.256,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,76.208,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
ZYBAN 150MG TAB,2500000100,CDM,250,RC,,,Outpatient,150,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,27.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,32.544,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,16.272,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,32.544,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,23.504,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,15.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,34.352,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,31.824,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,32.544,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
TOPROL XL 25MG TAB,2500000101,CDM,250,RC,,,Outpatient,25,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,63.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,74.624,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,37.312,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,74.624,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,53.896,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,36.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,78.768,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,72.96,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,74.624,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
QVAR 40MCG INHALER,2500000102,CDM,250,RC,,,Outpatient,40,GM,378.16,245.80,,378.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,287.4,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,272.28,72,,21.592,Percent of Total Billed Charges,72% of Total Billed Charges,283.62,75,,22.496,Percent of Total Billed charges,75% of Total Billed Charges,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.28,72,,21.592,Percent of Total Billed Charges,72% of Total Billed Charges,226.9,60,,17.992,Percent of Total Billed Charges,60% of Total Billed Charges,340.34,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,170.17,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,340.34,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.8,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,166.77,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,359.25,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.78,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,340.34,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,166.77,378.16,
CLEOCIN 75MG/5ML SYRUP,2500000103,CDM,250,RC,,,Outpatient,75,GM,266.81,173.43,,266.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,202.78,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,192.1,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,200.11,75,,18.52,Percent of Total Billed charges,75% of Total Billed Charges,266.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.1,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,160.09,60,,14.816,Percent of Total Billed Charges,60% of Total Billed Charges,240.13,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,120.06,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,240.13,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,266.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.43,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,117.66,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,253.47,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,266.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.79,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,240.13,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,117.66,266.81,
ZITHROMAX 200MG/5ML SUSP E,2500000104,CDM,250,RC,,,Outpatient,200,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
ZITHROMAX 200MG/5ML SUSP S,2500000105,CDM,250,RC,,,Outpatient,200,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,13.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,15.88,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,7.936,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,15.88,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,11.464,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,16.76,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,15.52,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,15.88,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
PHENOBARBITAL 32.4 MG TAB,2500000106,CDM,250,RC,,,Outpatient,32.4,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
PROPARACAINE 0.5% 15ML OPHTH,2500000107,CDM,250,RC,,,Outpatient,15,ML,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,6.88,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
ACETAMIN 120MG SUPP,2500000108,CDM,250,RC,,,Outpatient,120,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,7.936,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,6.352,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
DICLOFENAC 50MG XL TAB,2500000109,CDM,250,RC,,,Outpatient,50,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,8.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,10.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,10.32,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,7.448,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,10.888,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,10.088,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,10.32,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
KEPPRA 500 MG TAB,2500000110,CDM,250,RC,,,Outpatient,500,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
LOVAZA 1 GRAM CAP,2500000111,CDM,250,RC,,,Outpatient,,,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,21.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,25.4,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,12.704,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,25.4,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,18.344,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,12.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,26.816,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,24.84,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,25.4,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
MESALAMINE RECTAL ENEMA,2500000112,CDM,250,RC,,,Outpatient,,,60.64,39.42,,60.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.09,76,,22.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.66,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,45.48,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,54.58,90,,26.192,Percent of Total Billed Charges,90% of Total Billed Charges,27.29,45,,13.096,Percent of Total Billed Charges,45% of Total Billed Charges,54.58,90,,26.192,Percent of Total Billed Charges,90% of Total billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.42,65,,18.92,Percent of total Billed Charges,65% of Total Billed Charges,26.74,44.1,,12.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.61,95,,27.648,Percent of Total Billed Charges,95% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.36,88,,25.608,Percent of Total Billed Charges,88% of Total Billed Charges,54.58,90,,26.192,Percent of Total Billed charges,90% of Total Billed Charges,26.74,60.64,
LORTAB ELIXIR 7.5MG/15ML ORAL,2500000113,CDM,250,RC,,,Outpatient,7.5,GM,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,60.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,71.448,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,35.72,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,71.448,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,51.6,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,35.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,75.416,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,69.856,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,71.448,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
PORSTIGMIN B 15MGTAB,2500000114,CDM,250,RC,,,Outpatient,15,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,26.464,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,21.168,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
HALF LYTELY 2 LITER,2500000115,CDM,250,RC,,,Outpatient,,,264.60,171.99,,264.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,201.1,76,,18.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,190.51,72,,33.656,Percent of Total Billed Charges,72% of Total Billed Charges,198.45,75,,35.056,Percent of Total Billed charges,75% of Total Billed Charges,264.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.51,72,,33.656,Percent of Total Billed Charges,72% of Total Billed Charges,158.76,60,,28.048,Percent of Total Billed Charges,60% of Total Billed Charges,238.14,90,,22.224,Percent of Total Billed Charges,90% of Total Billed Charges,119.07,45,,11.112,Percent of Total Billed Charges,45% of Total Billed Charges,238.14,90,,22.224,Percent of Total Billed Charges,90% of Total billed Charges,264.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,65,,16.056,Percent of total Billed Charges,65% of Total Billed Charges,116.69,44.1,,10.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,251.37,95,,23.464,Percent of Total Billed Charges,95% of Total Billed Charges,264.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.85,88,,21.736,Percent of Total Billed Charges,88% of Total Billed Charges,238.14,90,,22.224,Percent of Total Billed charges,90% of Total Billed Charges,116.69,264.6,
ACETAMIN 650MG SUPP,2500000116,CDM,250,RC,,,Outpatient,650,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
DOXEPIN 25MG CAP,2500000117,CDM,250,RC,,,Outpatient,25,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
ZONISAMIDE 100MG CAP,2500000118,CDM,250,RC,,,Outpatient,100,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
VOLTAREN 75MG DR TAB,2500000119,CDM,250,RC,,,Outpatient,75,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
QUIXIN 0.5% OPHTH SOLN,2500000120,CDM,250,RC,,,Outpatient,,,84.89,55.18,,84.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,64.52,76,,96.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.12,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,63.67,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,50.93,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,76.4,90,,114.304,Percent of Total Billed Charges,90% of Total Billed Charges,38.2,45,,57.152,Percent of Total Billed Charges,45% of Total Billed Charges,76.4,90,,114.304,Percent of Total Billed Charges,90% of Total billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.18,65,,82.552,Percent of total Billed Charges,65% of Total Billed Charges,37.44,44.1,,56.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,80.65,95,,120.656,Percent of Total Billed Charges,95% of Total Billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.7,88,,111.768,Percent of Total Billed Charges,88% of Total Billed Charges,76.4,90,,114.304,Percent of Total Billed charges,90% of Total Billed Charges,37.44,84.89,
DICOLOFENAC 0.1% OPHTH SOLN,2500000121,CDM,250,RC,,,Outpatient,,,82.69,53.75,,82.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.84,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.54,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,62.02,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,49.61,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,74.42,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,37.21,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,74.42,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.75,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,36.47,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,78.56,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,74.42,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,36.47,82.69,
VESICARE 5MG TAB,2500000122,CDM,250,RC,,,Outpatient,5,GM,37.49,24.37,,37.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.49,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.99,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,28.12,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,37.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.99,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,22.49,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,33.74,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,16.87,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,33.74,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,37.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.37,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,16.53,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.62,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,37.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.99,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,33.74,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,16.53,37.49,
FIORNAL TAB,2500000123,CDM,250,RC,,,Outpatient,,,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,22.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,26.992,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,13.496,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,26.992,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,19.496,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,13.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,28.496,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,26.392,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,26.992,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
MUCINEX D 600/60 TAB,2500000124,CDM,250,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,18.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,22.224,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,11.112,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,22.224,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,16.056,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,10.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,23.464,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,21.736,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,22.224,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
ORAPRED 15MG TAB,2500000125,CDM,250,RC,,,Outpatient,15,GM,45.20,29.38,,45.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.35,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.54,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,33.9,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.54,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,27.12,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,40.68,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,20.34,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,40.68,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.38,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,19.93,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.94,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.78,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,40.68,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,19.93,45.2,
IMITREX 25MG TAB,2500000126,CDM,250,RC,,,Outpatient,25,GM,103.64,67.37,,103.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,78.77,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,74.62,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,77.73,75,,46.968,Percent of Total Billed charges,75% of Total Billed Charges,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.62,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,62.18,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,93.28,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,46.64,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,93.28,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.37,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,45.71,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,98.46,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.2,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,93.28,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,45.71,103.64,
DIOVAN 160MG TAB,2500000127,CDM,250,RC,,,Outpatient,160,GM,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,9.264,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
A&D OINTMENT TUBE,2500000128,CDM,250,RC,,,Outpatient,,,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,358.8,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,373.744,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,358.8,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,299,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
BACTRIM SUSP 60ML (S),2500000129,CDM,250,RC,,,Outpatient,60,ML,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,55.88,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,58.216,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,55.88,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,46.568,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,6.88,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
BACTRIM SUSP 60ML (E),2500000130,CDM,250,RC,,,Outpatient,60,ML,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.88,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.88,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.05,
OMNICEF 300MG CAP,2500000131,CDM,250,RC,,,Outpatient,300,GM,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
LYRICA 25MG CAP,2500000132,CDM,250,RC,,,Outpatient,25,GM,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,62.24,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,64.832,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,62.24,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,51.864,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
LYRICA 50MG CAP,2500000133,CDM,250,RC,,,Outpatient,50,GM,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,220.944,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,176.752,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
LANOLIN 2CC UD,2500000134,CDM,250,RC,,,Outpatient,,,14.33,9.31,,14.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.89,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.32,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,10.75,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,8.6,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,12.9,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,12.9,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.31,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.61,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.61,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,12.9,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,6.32,14.33,
RENVELA 800MG TAB,2500000135,CDM,250,RC,,,Outpatient,800,GM,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,26.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,16.536,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,13.232,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,31.752,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,15.88,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,31.752,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,22.936,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,15.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,33.52,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,31.048,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,31.752,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
FOSRENOL 500MG TAB,2500000136,CDM,250,RC,,,Outpatient,500,GM,35.28,22.93,,35.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.81,76,,35.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.4,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.4,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,21.17,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,31.75,90,,42.072,Percent of Total Billed Charges,90% of Total Billed Charges,15.88,45,,21.032,Percent of Total Billed Charges,45% of Total Billed Charges,31.75,90,,42.072,Percent of Total Billed Charges,90% of Total billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.93,65,,30.384,Percent of total Billed Charges,65% of Total Billed Charges,15.56,44.1,,20.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.52,95,,44.408,Percent of Total Billed Charges,95% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.05,88,,41.136,Percent of Total Billed Charges,88% of Total Billed Charges,31.75,90,,42.072,Percent of Total Billed charges,90% of Total Billed Charges,15.56,35.28,
HECTEROL 0.5MCG CAP,2500000137,CDM,250,RC,,,Outpatient,0.5,GM,36.38,23.65,,36.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.65,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.19,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,27.29,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.19,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,21.83,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,32.74,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,16.37,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,32.74,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.65,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,16.04,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.56,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.01,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,32.74,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,16.04,36.38,
HECTEROL 2.5MCG CAP,2500000138,CDM,250,RC,,,Outpatient,2.5,GM,99.23,64.50,,99.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.41,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71.45,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,74.42,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.45,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,59.54,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,89.31,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,44.65,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,89.31,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.5,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,43.76,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,94.27,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.32,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,89.31,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,43.76,99.23,
VOLTAREN 1% GEL 100G,2500000139,CDM,250,RC,,,Outpatient,,,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
AFRIN NASAL SOL 15CC,2500000140,CDM,250,RC,,,Outpatient,,,30.87,20.07,,30.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.46,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.23,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.23,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,18.52,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,27.78,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,13.89,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,27.78,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.07,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,13.61,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.33,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.17,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,27.78,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,13.61,30.87,
ALDACTONE 25MG TAB,2500000141,CDM,250,RC,,,Outpatient,25,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
ATARAX 25MG TAB,2500000142,CDM,250,RC,,,Outpatient,25,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
ALDOMET 250MG TAB,2500000143,CDM,250,RC,,,Outpatient,250,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
ALLBEE/VIT C CAP,2500000144,CDM,250,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
ALPHAGAN 0.2% OPHTH SOLN,2500000145,CDM,250,RC,,,Outpatient,,,158.76,103.19,,158.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.66,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.31,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,119.07,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.31,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,95.26,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,142.88,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,71.44,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,142.88,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.19,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,70.01,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,150.82,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.71,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,142.88,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,70.01,158.76,
AMARYL 2MG TAB,2500000146,CDM,250,RC,,,Outpatient,2,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
HYDROCOD APAP 10/500MG TAB,2500000147,CDM,250,RC,,,Outpatient,500,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
NIMOTOP 30MG CAP,2500000148,CDM,250,RC,,,Outpatient,30,GM,37.49,24.37,,37.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.49,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.99,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,28.12,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,37.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.99,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,22.49,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,33.74,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,16.87,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,33.74,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,37.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.37,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,16.53,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.62,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,37.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.99,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,33.74,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,16.53,37.49,
PREVACID 30MG SOLUTAB,2500000149,CDM,250,RC,,,Outpatient,30,GM,30.87,20.07,,30.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.46,76,,378.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.23,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.23,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,18.52,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,27.78,90,,448.496,Percent of Total Billed Charges,90% of Total Billed Charges,13.89,45,,224.248,Percent of Total Billed Charges,45% of Total Billed Charges,27.78,90,,448.496,Percent of Total Billed Charges,90% of Total billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.07,65,,323.912,Percent of total Billed Charges,65% of Total Billed Charges,13.61,44.1,,219.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.33,95,,473.408,Percent of Total Billed Charges,95% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.17,88,,438.528,Percent of Total Billed Charges,88% of Total Billed Charges,27.78,90,,448.496,Percent of Total Billed charges,90% of Total Billed Charges,13.61,30.87,
SKELAXIN 800MG TAB,2500000150,CDM,250,RC,,,Outpatient,800,GM,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,58.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,69.856,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,34.928,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,69.856,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,50.448,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,34.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,73.736,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,68.304,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,69.856,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
AMMONIA INHAL SNAPS,2500000151,CDM,250,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
AMOXIL 500MG CAP,2500000152,CDM,250,RC,,,Outpatient,500,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
AMOXIL 250MG CAP,2500000153,CDM,250,RC,,,Outpatient,250,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,65.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,77.8,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,38.896,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,77.8,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,56.184,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,38.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,82.12,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,76.064,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,77.8,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
AMOXIL SUSP 125MG/5ML,2500000154,CDM,250,RC,,,Outpatient,125,GM,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,223.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,265.136,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,132.568,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,265.136,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,191.488,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,129.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,279.864,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,259.24,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,265.136,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
ANTIVERT 25MG TAB,2500000155,CDM,250,RC,,,Outpatient,25,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
ANUSOL PLAIN SUPP,2500000156,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,16.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,19.84,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,9.92,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,19.84,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,14.328,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,9.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,20.944,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,19.4,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,19.84,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
ANUSOL HC SUPP,2500000157,CDM,250,RC,,,Outpatient,,,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
APRESOLINE 10MG TAB,2500000158,CDM,250,RC,,,Outpatient,10,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
APRESOLINE 25MG TAB,2500000160,CDM,250,RC,,,Outpatient,25,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
ARICEPT 5MG TAB,2500000161,CDM,250,RC,,,Outpatient,5,GM,44.10,28.67,,44.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33.52,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,31.75,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.75,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,39.69,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,19.85,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,39.69,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,19.45,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.9,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.81,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,39.69,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,19.45,44.1,
TRIAMCINOLONE 0.5% CREAM,2500000162,CDM,250,RC,,,Outpatient,,,58.43,37.98,,58.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,44.41,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.07,72,,600.752,Percent of Total Billed Charges,72% of Total Billed Charges,43.82,75,,625.784,Percent of Total Billed charges,75% of Total Billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.07,72,,600.752,Percent of Total Billed Charges,72% of Total Billed Charges,35.06,60,,500.624,Percent of Total Billed Charges,60% of Total Billed Charges,52.59,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,26.29,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,52.59,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.98,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,25.77,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,55.51,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.42,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,52.59,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,25.77,58.43,
ARTANE 2MG TAB,2500000163,CDM,250,RC,,,Outpatient,2,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
ASPIRIN 325MG TAB,2500000164,CDM,250,RC,,,Outpatient,325,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
ASPIRIN EC 81MG TAB,2500000165,CDM,250,RC,,,Outpatient,81,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
ASA 10 GRS SUPP,2500000166,CDM,250,RC,,,Outpatient,,,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
ASA 5GRS SUPP,2500000167,CDM,250,RC,,,Outpatient,,,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,9.928,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,7.936,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
ASA 81MG CHEW TAB,2500000168,CDM,250,RC,,,Outpatient,81,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
ATARAX 10MG TAB,2500000169,CDM,250,RC,,,Outpatient,10,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,28.448,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,22.76,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
ATARAX 10MG/5ML SYRUP,2500000170,CDM,250,RC,,,Outpatient,10,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,219.728,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,228.88,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,219.728,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,183.104,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
ATIVAN 1MG TABLET,2500000171,CDM,250,RC,,,Outpatient,1,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,78.744,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,82.024,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,78.744,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,65.624,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
ATROVENT 0.02% 0.5MG/2.5ML NEB,2500000172,CDM,250,RC,,,Outpatient,0.5,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,267.352,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,278.488,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,267.352,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,222.792,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
ATROPISOL 1% OPHTH SOLN,2500000173,CDM,250,RC,,,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,58.71,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
AUGMENTIN 500MG TAB,2500000174,CDM,250,RC,,,Outpatient,500,GM,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
AVC VAGINAL CREAM 15% 120 GM,2500000175,CDM,250,RC,,,Outpatient,120,gm,622.91,404.89,,622.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,473.41,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,448.5,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,467.18,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,622.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,448.5,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,373.75,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,560.62,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,280.31,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,560.62,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,622.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,622.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,622.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404.89,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,274.7,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,591.76,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,622.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,548.16,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,560.62,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,274.7,622.91,
PAMELOR 25MG CAP,2500000176,CDM,250,RC,,,Outpatient,25,GM,97.02,63.06,,97.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.74,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.85,72,,50.168,Percent of Total Billed Charges,72% of Total Billed Charges,72.77,75,,52.264,Percent of Total Billed charges,75% of Total Billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.85,72,,50.168,Percent of Total Billed Charges,72% of Total Billed Charges,58.21,60,,41.808,Percent of Total Billed Charges,60% of Total Billed Charges,87.32,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,43.66,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,87.32,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,42.79,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,92.17,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.38,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,87.32,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,42.79,97.02,
AZULFIDINE 500MG TAB,2500000177,CDM,250,RC,,,Outpatient,500,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
B&O SUPP 30MG,2500000178,CDM,250,RC,,,Outpatient,30,GM,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,37.472,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,39.032,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,37.472,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,31.224,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
B&O SUPP 60MG,2500000179,CDM,250,RC,,,Outpatient,60,GM,108.05,70.23,,108.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.12,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.8,72,,24.136,Percent of Total Billed Charges,72% of Total Billed Charges,81.04,75,,25.144,Percent of Total Billed charges,75% of Total Billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.8,72,,24.136,Percent of Total Billed Charges,72% of Total Billed Charges,64.83,60,,20.112,Percent of Total Billed Charges,60% of Total Billed Charges,97.25,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,48.62,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,97.25,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.23,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,47.65,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.65,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.08,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,97.25,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,47.65,108.05,
BACITRACIN OINT .5OZ,2500000180,CDM,250,RC,,,Outpatient,,,368.24,239.36,,368.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,279.86,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,265.13,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,276.18,75,,21.168,Percent of Total Billed charges,75% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.13,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,220.94,60,,16.936,Percent of Total Billed Charges,60% of Total Billed Charges,331.42,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,165.71,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,331.42,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.36,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,162.39,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,349.83,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.05,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,331.42,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,162.39,368.24,
BACTRIM DS TAB,2500000181,CDM,250,RC,,,Outpatient,,,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
BENADRYL CREAM,2500000182,CDM,250,RC,,,Outpatient,,,27.56,17.91,,27.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.95,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.84,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,20.67,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.84,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,24.8,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,12.4,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,24.8,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.91,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,12.15,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.18,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,24.8,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,12.15,27.56,
BENADRYL 25MG TAB,2500000183,CDM,250,RC,,,Outpatient,25,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,634.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,750.936,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,375.472,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,750.936,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,542.344,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,367.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,792.656,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,734.248,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,750.936,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
BENTYL 10MG CAP,2500000184,CDM,250,RC,,,Outpatient,10,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
SOD BICARBONATE 650MG TAB,2500000185,CDM,250,RC,,,Outpatient,650,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,9.264,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
BRETHINE 5MG TAB,2500000186,CDM,250,RC,,,Outpatient,5,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
BRETHINE 2.5MG TAB,2500000187,CDM,250,RC,,,Outpatient,2.5,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
VITAMIN B6 50MG TAB,2500000188,CDM,250,RC,,,Outpatient,50,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
VITAMIN C 500MG TAB,2500000189,CDM,250,RC,,,Outpatient,500,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
CALAN SR 180MG,2500000190,CDM,250,RC,,,Outpatient,180,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,28.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,9.264,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,34.136,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,17.064,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,34.136,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,24.656,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,16.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,36.032,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,33.376,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,34.136,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
CAPOTEN 12.5MG TAB,2500000191,CDM,250,RC,,,Outpatient,12.5,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,231.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,274.656,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,137.328,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,274.656,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,198.368,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,134.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,289.92,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,268.552,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,274.656,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
CAPOTEN 25MG TAB,2500000192,CDM,250,RC,,,Outpatient,25,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,83.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,98.432,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,49.216,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,98.432,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,71.088,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,48.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,103.896,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,96.24,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,98.432,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
CARDIZEM CD 120 CAP,2500000193,CDM,250,RC,,,Outpatient,,,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,282.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,334.192,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,167.096,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,334.192,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,241.36,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,163.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,352.752,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,326.76,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,334.192,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
CARDIZEM CD 180 CAP,2500000194,CDM,250,RC,,,Outpatient,,,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
CARDIZEM CD 240 CAP,2500000195,CDM,250,RC,,,Outpatient,,,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
CARAFATE 1 GRAM TAB,2500000196,CDM,250,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
CARDIZEM TAB 60MG,2500000197,CDM,250,RC,,,Outpatient,60,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,52.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,62.712,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,31.36,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,62.712,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,45.296,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,30.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,66.2,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,61.32,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,62.712,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
CATAPRES 0.1MG TAB,2500000198,CDM,250,RC,,,Outpatient,0.1,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
CEFOL TAB,2500000199,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,39.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,13.232,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,10.584,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,46.84,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,23.416,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,46.84,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,33.824,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,22.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,49.44,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,45.792,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,46.84,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
CHLORASEPTIC SPRAY,2500000200,CDM,250,RC,,,Outpatient,,,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,25.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,30.168,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,15.088,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,30.168,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,21.792,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,14.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,31.848,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,29.496,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,30.168,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
CHLORTHALIDONE 25MG,2500000201,CDM,250,RC,,,Outpatient,25,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,21.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,25.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,12.704,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,25.4,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,18.344,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,12.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,26.816,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,24.84,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,25.4,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
CITRATE OF MAGNESIA 10OZ,2500000202,CDM,250,RC,,,Outpatient,,,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
CLEOCIN 150MG CAP,2500000203,CDM,250,RC,,,Outpatient,150,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
CLINORIL 200MG TAB,2500000204,CDM,250,RC,,,Outpatient,200,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
COLACE 100MG CAP,2500000205,CDM,250,RC,,,Outpatient,100,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
COLACE 100MG/25ML UD LIQUID,2500000206,CDM,250,RC,,,Outpatient,100,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,52.712,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,54.904,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,52.712,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,43.928,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
COUMADIN 1MG TAB,2500000207,CDM,250,RC,,,Outpatient,1,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
COMBIVENT INHALER,2500000208,CDM,250,RC,,,Outpatient,,,1042.97,677.93,,1042.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,792.66,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,750.94,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,782.23,75,,43,Percent of Total Billed charges,75% of Total Billed Charges,1042.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,750.94,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,625.78,60,,34.4,Percent of Total Billed Charges,60% of Total Billed Charges,938.67,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,469.34,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,938.67,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,1042.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1042.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1042.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.93,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,459.95,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,990.82,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,1042.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,917.81,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,938.67,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,459.95,1042.97,
CARDIZEM CD 300MG CAP,2500000209,CDM,250,RC,,,Outpatient,300,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
GLUCOTROL XL 5MG TAB,2500000210,CDM,250,RC,,,Outpatient,5,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
COREG 3.125MG TAB,2500000211,CDM,250,RC,,,Outpatient,3.125,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
COREG 6.25 MG TAB,2500000212,CDM,250,RC,,,Outpatient,6.25,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
CORGARD 40MG TAB,2500000213,CDM,250,RC,,,Outpatient,40,GM,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
COREA 12.5MG TAB,2500000214,CDM,250,RC,,,Outpatient,12.5,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
CORTENEMA 60ML,2500000215,CDM,250,RC,,,Outpatient,60,ML,47.41,30.82,,47.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.03,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.14,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,35.56,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.14,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,28.45,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,42.67,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,21.33,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,42.67,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.82,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,20.91,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.04,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.72,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,42.67,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,20.91,47.41,
CORTISPORIN OTIC SOLN,2500000216,CDM,250,RC,,,Outpatient,,,381.47,247.96,,381.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,289.92,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,274.66,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,286.1,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,381.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.66,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,228.88,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,343.32,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,171.66,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,343.32,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,381.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.96,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,168.23,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,362.4,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,381.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,335.69,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,343.32,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,168.23,381.47,
CORTISPORIN OTIC SUSP,2500000217,CDM,250,RC,,,Outpatient,,,136.71,88.86,,136.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,103.9,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,98.43,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,102.53,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,136.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.43,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,82.03,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,123.04,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,61.52,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,123.04,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,136.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.86,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,60.29,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,129.87,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,136.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.3,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,123.04,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,60.29,136.71,
CORTISPORIN OPHTH SUSP,2500000218,CDM,250,RC,,,Outpatient,,,464.15,301.70,,464.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,352.75,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,334.19,72,,114.304,Percent of Total Billed Charges,72% of Total Billed Charges,348.11,75,,119.072,Percent of Total Billed charges,75% of Total Billed Charges,464.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.19,72,,114.304,Percent of Total Billed Charges,72% of Total Billed Charges,278.49,60,,95.256,Percent of Total Billed Charges,60% of Total Billed Charges,417.74,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,208.87,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,417.74,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,464.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,464.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,464.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.7,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,204.69,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,440.94,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,464.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,408.45,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,417.74,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,204.69,464.15,
COUMADIN 2MG,2500000219,CDM,250,RC,,,Outpatient,2,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,33.024,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,34.4,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,33.024,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,27.52,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
COUMADIN 5MG TAB,2500000220,CDM,250,RC,,,Outpatient,5,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,13.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,15.88,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,7.936,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,15.88,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,11.464,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,16.76,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,15.52,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,15.88,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
COZAAR 50MG TAB,2500000221,CDM,250,RC,,,Outpatient,50,GM,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
CYCLOGYL 1% OPHTH SOLN,2500000222,CDM,250,RC,,,Outpatient,,,87.10,56.62,,87.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.2,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.71,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,65.33,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.71,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,52.26,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,78.39,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,39.2,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,78.39,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.62,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,38.41,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.75,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.65,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,78.39,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,38.41,87.1,
DALMANE 15MG CAP,2500000223,CDM,250,RC,,,Outpatient,15,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
DECLOMYCIN 300MG TAB,2500000224,CDM,250,RC,,,Outpatient,300,GM,65.05,42.28,,65.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.44,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.84,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,48.79,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.84,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,39.03,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,58.55,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,29.27,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,58.55,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.28,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,28.69,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,61.8,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.24,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,58.55,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,28.69,65.05,
DERMOPLAST CAN,2500000225,CDM,250,RC,,,Outpatient,,,41.90,27.24,,41.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31.84,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.17,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,31.43,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.17,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,25.14,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,37.71,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,18.86,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,37.71,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.24,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,18.48,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,39.81,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.87,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,37.71,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,18.48,41.9,
DESITIN OINT 1.24 OZ,2500000226,CDM,250,RC,,,Outpatient,,,35.28,22.93,,35.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.81,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.4,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,75,,9.264,Percent of Total Billed charges,75% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.4,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,21.17,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,31.75,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,15.88,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,31.75,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.93,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,15.56,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.52,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.05,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,31.75,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,15.56,35.28,
DESYREL 50MG TAB,2500000227,CDM,250,RC,,,Outpatient,50,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,55.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,65.888,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,32.944,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,65.888,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,47.584,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,32.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,69.544,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,64.424,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,65.888,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
DIAMOX 250MG TAB,2500000228,CDM,250,RC,,,Outpatient,250,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
DILANTIN 100MG CAP,2500000229,CDM,250,RC,,,Outpatient,100,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,43.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,51.592,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,25.8,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,51.592,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,37.264,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,25.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,54.464,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,50.448,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,51.592,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
DILANTIN 125/5ML SUSP UD,2500000230,CDM,250,RC,,,Outpatient,5,ML,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
DIOVAN 80MG CAP,2500000231,CDM,250,RC,,,Outpatient,80,GM,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
DITROPAN 5MG TABS,2500000232,CDM,250,RC,,,Outpatient,5,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
DONNATAL ELIXIR 5ML UD,2500000233,CDM,250,RC,,,Outpatient,5,ML,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
DUCOLAX 5MG TAB,2500000234,CDM,250,RC,,,Outpatient,5,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
DUCOLAX 10MG SUPP,2500000235,CDM,250,RC,,,Outpatient,10,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,43,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,34.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
DURICEF 500MG CAP,2500000236,CDM,250,RC,,,Outpatient,500,GM,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,19.848,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,15.88,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
DYNACIRC 5MG CAP,2500000237,CDM,250,RC,,,Outpatient,5,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,43.664,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,34.928,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
ECOTRIN 325MG TAB,2500000238,CDM,250,RC,,,Outpatient,325,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,18.52,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,14.816,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
ELAVIL 10MG TAB,2500000239,CDM,250,RC,,,Outpatient,10,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,120.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,142.888,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,71.44,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,142.888,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,103.192,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,70.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,150.824,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,139.712,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,142.888,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
ELAVIL 25MG TAB,2500000240,CDM,250,RC,,,Outpatient,25,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,34.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,41.28,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,20.64,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,41.28,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,29.808,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,20.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,43.568,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,40.36,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,41.28,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
ERYC 250MG CAP,2500000242,CDM,250,RC,,,Outpatient,250,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,334.032,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,347.952,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,334.032,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,278.36,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
VITAMIN E 400 UNIT CAP,2500000243,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,319.424,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,332.736,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,319.424,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,266.192,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
FELDENE 20MG CAP,2500000244,CDM,250,RC,,,Outpatient,20,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
FEOSOL LIQ 2OZ,2500000245,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
FER IN SOL DROPS BTL,2500000246,CDM,250,RC,,,Outpatient,,,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.88,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.88,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.05,
FERROUS SULFATE 325MG TAB,2500000247,CDM,250,RC,,,Outpatient,325,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,38.104,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,39.688,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,38.104,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,31.752,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
FLAGYL 250MG TAB,2500000248,CDM,250,RC,,,Outpatient,250,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
FLEXERIL 10MG TAB,2500000249,CDM,250,RC,,,Outpatient,10,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
FLORINEF 0.1MG TAB,2500000250,CDM,250,RC,,,Outpatient,0.1,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
FOLIC ACID 1MG TAB,2500000251,CDM,250,RC,,,Outpatient,1,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
DYAZIDE 50/25 CAP,2500000252,CDM,250,RC,,,Outpatient,,,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
GENTAMICIN OPHTH OINT,2500000253,CDM,250,RC,,,Outpatient,,,91.51,59.48,,91.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,69.55,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.89,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,68.63,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.89,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,54.91,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,82.36,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,41.18,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,82.36,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.48,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,40.36,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,86.93,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.53,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,82.36,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,40.36,91.51,
GENTAMICIN 0.3% OPH SOL 5 ML,2500000254,CDM,250,RC,,,Outpatient,5,ML,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
GENTAMICIN 0.1% CREAM,2500000255,CDM,250,RC,,,Outpatient,,,71.66,46.58,,71.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.46,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.6,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,53.75,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,43,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,64.49,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,32.25,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,64.49,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.58,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,31.6,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.08,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,64.49,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,31.6,71.66,
GAVISCON LIQUID 1OZ,2500000256,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
GERITONIC LIQUID 30ML,2500000257,CDM,250,RC,,,Outpatient,30,ML,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,43.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,51.592,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,25.8,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,51.592,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,37.264,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,25.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,54.464,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,50.448,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,51.592,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
GOLYTELY 4L,2500000258,CDM,250,RC,,,Outpatient,,,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,20.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,23.816,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,11.912,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,23.816,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,17.2,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,11.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,25.144,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,23.288,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,23.816,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
GLUCOTROL XL 10MG TAB,2500000259,CDM,250,RC,,,Outpatient,10,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,44.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,52.392,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,26.2,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,52.392,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,37.84,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,25.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,55.304,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,51.232,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,52.392,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
GLUCOTROL 5MG TAB,2500000260,CDM,250,RC,,,Outpatient,5,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,18.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,22.224,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,11.112,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,22.224,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,16.056,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,10.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,23.464,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,21.736,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,22.224,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
HALCION 0.25MG TAB,2500000261,CDM,250,RC,,,Outpatient,0.25,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,26.672,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,27.784,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,26.672,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,22.232,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
HALDOL 1MG TAB,2500000262,CDM,250,RC,,,Outpatient,1,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,93.984,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,97.904,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,93.984,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,78.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
HALDOL 5MG TAB,2500000263,CDM,250,RC,,,Outpatient,5,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,352.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,417.544,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,208.768,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,417.544,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,301.56,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,204.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,440.736,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,408.264,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,417.544,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
GLYNASE 3MG PRESTAB,2500000264,CDM,250,RC,,,Outpatient,3,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,337.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,399.28,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,199.64,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,399.28,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,288.368,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,195.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,421.464,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,390.408,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,399.28,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
HURRICANE SPRAY,2500000265,CDM,250,RC,,,Outpatient,,,198.45,128.99,,198.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,150.82,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,142.88,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,148.84,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.88,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,119.07,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,178.61,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,89.3,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,178.61,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.99,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,87.52,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,188.53,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.64,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,178.61,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,87.52,198.45,
HYDROCORTISONE 2.5% CREAM,2500000266,CDM,250,RC,,,Outpatient,,,57.33,37.26,,57.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.57,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.28,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,43,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.28,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,34.4,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,51.6,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,25.8,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,51.6,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.26,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,25.28,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.46,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.45,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,51.6,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,25.28,57.33,
ILOTYCIN OPHTH OINT,2500000267,CDM,250,RC,,,Outpatient,,,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,9.264,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
IMDUR 30 MG TAB,2500000268,CDM,250,RC,,,Outpatient,30,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,40.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,47.632,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,23.816,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,47.632,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,34.4,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,23.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,50.272,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,46.568,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,47.632,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
IMODIUM 2MG CAP,2500000269,CDM,250,RC,,,Outpatient,2,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,23.152,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,18.52,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
INDERAL 10MG TAB,2500000270,CDM,250,RC,,,Outpatient,10,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
INDERAL 20MG TAB,2500000271,CDM,250,RC,,,Outpatient,20,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
INDOCIN 25MG CAP,2500000272,CDM,250,RC,,,Outpatient,25,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
INSTAGLUCOSE TUBE,2500000273,CDM,250,RC,,,Outpatient,,,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
ISOPTIN 80MG TAB,2500000274,CDM,250,RC,,,Outpatient,80,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
ISOPTIN 120MG TAB,2500000275,CDM,250,RC,,,Outpatient,120,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
ISORDIL 10MG TAB,2500000276,CDM,250,RC,,,Outpatient,10,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
ISORDIL 20MG TAB,2500000277,CDM,250,RC,,,Outpatient,20,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,7.936,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,6.352,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
KAOCHLOR LIQUID 40MEQ/30ML,2500000278,CDM,250,RC,,,Outpatient,30,ML,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,69.456,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,55.568,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
KLORCON 20MEQ PKT,2500000279,CDM,250,RC,,,Outpatient,,,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
KEFLEX 250MG CAP,2500000280,CDM,250,RC,,,Outpatient,250,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
KEFLEX 500MG CAP,2500000281,CDM,250,RC,,,Outpatient,500,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
KEFLEX 250MG 100ML,2500000282,CDM,250,RC,,,Outpatient,250,GM,71.66,46.58,,71.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.46,76,,28.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.6,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,53.75,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,43,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,64.49,90,,33.344,Percent of Total Billed Charges,90% of Total Billed Charges,32.25,45,,16.672,Percent of Total Billed Charges,45% of Total Billed Charges,64.49,90,,33.344,Percent of Total Billed Charges,90% of Total billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.58,65,,24.08,Percent of total Billed Charges,65% of Total Billed Charges,31.6,44.1,,16.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.08,95,,35.192,Percent of Total Billed Charges,95% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,88,,32.6,Percent of Total Billed Charges,88% of Total Billed Charges,64.49,90,,33.344,Percent of Total Billed charges,90% of Total Billed Charges,31.6,71.66,
KAYEXALATE 15G SUSP,2500000283,CDM,250,RC,,,Outpatient,,,33.08,21.50,,33.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.14,76,,99.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.82,72,,22.864,Percent of Total Billed Charges,72% of Total Billed Charges,24.81,75,,23.816,Percent of Total Billed charges,75% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.82,72,,22.864,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,60,,19.048,Percent of Total Billed Charges,60% of Total Billed Charges,29.77,90,,117.48,Percent of Total Billed Charges,90% of Total Billed Charges,14.89,45,,58.744,Percent of Total Billed Charges,45% of Total Billed Charges,29.77,90,,117.48,Percent of Total Billed Charges,90% of Total billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.5,65,,84.848,Percent of total Billed Charges,65% of Total Billed Charges,14.59,44.1,,57.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.43,95,,124.008,Percent of Total Billed Charges,95% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.11,88,,114.872,Percent of Total Billed Charges,88% of Total Billed Charges,29.77,90,,117.48,Percent of Total Billed charges,90% of Total Billed Charges,14.59,33.08,
KENALOG CR .1% 60GM,2500000284,CDM,250,RC,,,Outpatient,60,gm,72.77,47.30,,72.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.31,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.39,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,54.58,75,,33.08,Percent of Total Billed charges,75% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.39,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,65.49,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,32.75,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,65.49,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.3,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,32.09,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,69.13,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.04,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,65.49,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,32.09,72.77,
KENALOG CR .1% 15GM,2500000285,CDM,250,RC,,,Outpatient,15,gm,30.87,20.07,,30.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.46,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.23,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.23,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,18.52,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,27.78,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,13.89,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,27.78,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.07,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,13.61,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.33,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.17,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,27.78,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,13.61,30.87,
KLONOPIN 0.5MG TAB,2500000286,CDM,250,RC,,,Outpatient,0.5,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,48.896,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,50.936,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,48.896,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,40.744,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
KLYTE 25MEQ EFF TAB,2500000287,CDM,250,RC,,,Outpatient,,,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
KWELL LOTION 2OZ,2500000288,CDM,250,RC,,,Outpatient,,,579.92,376.95,,579.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,440.74,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,417.54,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,434.94,75,,73.432,Percent of Total Billed charges,75% of Total Billed Charges,579.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.54,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,347.95,60,,58.744,Percent of Total Billed Charges,60% of Total Billed Charges,521.93,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,260.96,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,521.93,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,579.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.95,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,255.74,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,550.92,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,579.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,510.33,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,521.93,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,255.74,579.92,
KWELL SHAMPOO 2OZ,2500000289,CDM,250,RC,,,Outpatient,,,554.56,360.46,,554.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,421.47,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.28,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,415.92,75,,46.968,Percent of Total Billed charges,75% of Total Billed Charges,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.28,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,332.74,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,499.1,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,249.55,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,499.1,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360.46,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,244.56,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,526.83,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.01,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,499.1,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,244.56,554.56,
LACTINEX TAB,2500000290,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,23.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,27.784,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,13.896,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,27.784,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,20.064,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,13.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,29.328,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,27.168,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,27.784,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
LANOXIN 0.25 MG TAB,2500000291,CDM,250,RC,,,Outpatient,0.25,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
LANOXIN 0.125MG TAB,2500000292,CDM,250,RC,,,Outpatient,0.125,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
LAMISIL CREAM,2500000293,CDM,250,RC,,,Outpatient,,,66.15,43.00,,66.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,50.27,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47.63,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,49.61,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.63,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,39.69,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,59.54,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,29.77,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,59.54,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,29.17,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.84,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.21,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,59.54,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,29.17,66.15,
LAMACTIL 100MG TAB,2500000294,CDM,250,RC,,,Outpatient,100,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,28.576,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,29.768,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,28.576,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,23.816,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
LASIX 20MG TAB,2500000295,CDM,250,RC,,,Outpatient,20,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
LASIX 40MG TAB,2500000296,CDM,250,RC,,,Outpatient,40,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
LIBRAX CAP,2500000297,CDM,250,RC,,,Outpatient,,,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,102.88,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,107.168,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,102.88,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,85.736,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
LIBRIUM 5MG TAB,2500000298,CDM,250,RC,,,Outpatient,5,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,52.712,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,54.904,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,52.712,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,43.928,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,6.88,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
LIBRIUM 10MG TAB,2500000299,CDM,250,RC,,,Outpatient,10,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,70.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,83.344,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,41.672,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,83.344,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,60.192,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,40.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,87.976,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,81.496,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,83.344,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
LIBRIUM 25MG CAP,2500000300,CDM,250,RC,,,Outpatient,25,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
ISORDIL 40MG TAB,2500000301,CDM,250,RC,,,Outpatient,40,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
LIORESAL 10MG TAB,2500000302,CDM,250,RC,,,Outpatient,10,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,16.512,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,17.2,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,16.512,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,13.76,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
LONITEN 2.5MG TAB,2500000304,CDM,250,RC,,,Outpatient,2.5,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,24.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,28.576,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,14.288,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,28.576,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,20.64,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,14,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,30.168,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,27.944,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,28.576,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
LOMOTIL TAB,2500000305,CDM,250,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,83.824,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,87.32,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,83.824,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,69.856,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
LOPRESSOR 50MG TAB,2500000306,CDM,250,RC,,,Outpatient,50,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
LOPRESSOR 100MG TAB,2500000307,CDM,250,RC,,,Outpatient,100,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,51.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,61.12,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,30.56,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,61.12,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,44.144,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,29.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,64.52,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,59.76,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,61.12,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
LOTRIMIN 1% CR 30GM,2500000308,CDM,250,RC,,,Outpatient,30,gm,46.31,30.10,,46.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.2,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.34,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,34.73,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.34,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,27.79,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,41.68,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,20.84,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,41.68,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.1,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,20.42,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,43.99,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.75,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,41.68,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,20.42,46.31,
LOTRISONE CR 15GM,2500000309,CDM,250,RC,,,Outpatient,15,gm,163.17,106.06,,163.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.01,76,,74.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,117.48,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,122.38,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.48,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,97.9,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,146.85,90,,88.112,Percent of Total Billed Charges,90% of Total Billed Charges,73.43,45,,44.056,Percent of Total Billed Charges,45% of Total Billed Charges,146.85,90,,88.112,Percent of Total Billed Charges,90% of Total billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.06,65,,63.64,Percent of total Billed Charges,65% of Total Billed Charges,71.96,44.1,,43.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,155.01,95,,93.008,Percent of Total Billed Charges,95% of Total Billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.59,88,,86.152,Percent of Total Billed Charges,88% of Total Billed Charges,146.85,90,,88.112,Percent of Total Billed charges,90% of Total Billed Charges,71.96,163.17,
LOZOL 2.5MG TAB,2500000310,CDM,250,RC,,,Outpatient,2.5,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,33.08,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
MAALOX 30ML,2500000311,CDM,250,RC,,,Outpatient,30,ML,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,33.08,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
MACRODANTIN 50MG CAP,2500000312,CDM,250,RC,,,Outpatient,50,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,33.08,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
MACRODANTIN 100MG CAP,2500000313,CDM,250,RC,,,Outpatient,100,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,61.6,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,64.168,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,61.6,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,51.328,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
MACROBID 100MG CAP,2500000314,CDM,250,RC,,,Outpatient,100,GM,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,7.936,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,6.352,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
MEGACE 40MG TAB,2500000315,CDM,250,RC,,,Outpatient,40,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,30.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,35.72,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,17.856,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,35.72,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,25.8,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,17.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,37.704,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,34.928,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,35.72,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
MEPHYTON 5MG TAB,2500000316,CDM,250,RC,,,Outpatient,5,GM,38.59,25.08,,38.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.33,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.78,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,28.94,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.78,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,34.73,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,17.37,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,34.73,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.08,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,17.02,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.66,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.96,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,34.73,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,17.02,38.59,
METHADONE 10 MG TAB,2500000317,CDM,250,RC,,,Outpatient,10,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
METAMUCIL PKT,2500000318,CDM,250,RC,,,Outpatient,,,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,108.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,128.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,64.296,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,128.6,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,92.88,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,63.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,135.744,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,125.744,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,128.6,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
METHERGINE 0.2MG TAB,2500000319,CDM,250,RC,,,Outpatient,0.2,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,55.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,65.888,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,32.944,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,65.888,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,47.584,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,32.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,69.544,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,64.424,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,65.888,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
MICRONASE 2.5MG TAB,2500000320,CDM,250,RC,,,Outpatient,2.5,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
MICRONASE 5MG TAB,2500000321,CDM,250,RC,,,Outpatient,5,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,8.6,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,6.88,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
MILK OF MAGNESIA 30ML,2500000322,CDM,250,RC,,,Outpatient,30,ML,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
MINERAL OIL 30ML,2500000323,CDM,250,RC,,,Outpatient,30,ML,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,17.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,52.08,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,54.248,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,52.08,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,43.4,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,20.64,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,10.32,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,20.64,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,14.912,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,10.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,21.792,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,20.184,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,20.64,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
MINOCIN 100MG CAP,2500000324,CDM,250,RC,,,Outpatient,100,GM,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,17.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,11.248,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,8.992,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,20.64,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,10.32,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,20.64,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,14.912,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,10.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,21.792,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,20.184,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,20.64,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
MONISTAT DERM 2% CR,2500000325,CDM,250,RC,,,Outpatient,,,115.76,75.24,,115.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.98,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,83.35,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,86.82,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.35,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,69.46,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,104.18,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,52.09,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,104.18,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.24,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,51.05,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,109.97,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.87,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,104.18,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,51.05,115.76,
MONOPRIL 10MG TAB,2500000326,CDM,250,RC,,,Outpatient,10,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,88.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,104.784,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,52.392,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,104.784,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,75.672,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,51.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,110.6,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,102.456,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,104.784,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
MOTRIN 800MG TAB,2500000327,CDM,250,RC,,,Outpatient,800,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
MOTRIN 400MG TAB,2500000328,CDM,250,RC,,,Outpatient,400,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
MOTRIN 600MG TAB,2500000329,CDM,250,RC,,,Outpatient,600,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,9.264,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
MUCOMYST INH SOLN 30ML,2500000330,CDM,250,RC,J7604,HCPCS,Outpatient,30,ML,39.69,25.80,,39.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,30.16,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.58,72,,151.144,Percent of Total Billed Charges,72% of Total Billed Charges,29.77,75,,157.44,Percent of Total Billed charges,75% of Total Billed Charges,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.58,72,,151.144,Percent of Total Billed Charges,72% of Total Billed Charges,23.81,60,,125.952,Percent of Total Billed Charges,60% of Total Billed Charges,35.72,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,17.86,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,35.72,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.8,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,17.5,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.71,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,35.72,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,17.5,39.69,
MUCOMYST SOL 30ML,2500000331,CDM,250,RC,,,Outpatient,30,ML,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,154.32,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,160.744,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,154.32,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,128.6,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
MYAMBUTOL 400MG TAB,2500000332,CDM,250,RC,,,Outpatient,400,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,18.52,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,14.816,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
PLAVIX 300MG TABLET,2500000333,CDM,250,RC,,,Outpatient,300,GM,84.89,55.18,,84.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,64.52,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.12,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,63.67,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,50.93,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,76.4,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,38.2,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,76.4,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.18,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,37.44,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,80.65,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.7,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,76.4,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,37.44,84.89,
CAMPRAL 333MG TAB,2500000334,CDM,250,RC,,,Outpatient,333,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,65.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,77,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,38.496,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,77,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,55.608,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,37.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,81.272,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,75.288,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,77,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
MYCOSTATIN TOPICAL POWDER,2500000335,CDM,250,RC,,,Outpatient,,,122.38,79.55,,122.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.01,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.11,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,91.79,75,,33.08,Percent of Total Billed charges,75% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.11,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,73.43,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,110.14,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,55.07,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,110.14,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.55,65,,6.88,Percent of total Billed Charges,65% of Total Billed Charges,53.97,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.26,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.69,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,110.14,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,53.97,122.38,
MYDRIACYL 1 0/0 OPTH SOLN,2500000336,CDM,250,RC,,,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,58.71,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
MYLANTA SUSP 30ML,2500000337,CDM,250,RC,,,Outpatient,30,ML,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
MYLICON 80MG TAB,2500000338,CDM,250,RC,,,Outpatient,80,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,12.568,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,10.056,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
MYLICON DROPS 40MG/0.6ML 30ML,2500000339,CDM,250,RC,,,Outpatient,40,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,110.496,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,115.104,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,110.496,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,92.08,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
MYSOLINE 250MG TAB,2500000340,CDM,250,RC,,,Outpatient,250,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
NAPHCON A OPHTH SOLN,2500000341,CDM,250,RC,,,Outpatient,,,49.61,32.25,,49.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,37.7,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,35.72,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,37.21,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.72,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,29.77,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,44.65,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,22.32,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,44.65,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.25,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,21.88,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,47.13,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,44.65,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,21.88,49.61,
NAPROSYN 250MG TAB,2500000342,CDM,250,RC,,,Outpatient,250,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,8.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,10.32,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,10.32,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,7.448,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,10.888,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,10.088,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,10.32,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
NAPROSYN 375MG TAB,2500000343,CDM,250,RC,,,Outpatient,375,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
MAXITROL OPHTH OINT,2500000344,CDM,250,RC,,,Outpatient,,,178.61,116.10,,178.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,135.74,76,,54.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,128.6,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,133.96,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.6,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,107.17,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,160.75,90,,65.096,Percent of Total Billed Charges,90% of Total Billed Charges,80.37,45,,32.544,Percent of Total Billed Charges,45% of Total Billed Charges,160.75,90,,65.096,Percent of Total Billed Charges,90% of Total billed Charges,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.1,65,,47.016,Percent of total Billed Charges,65% of Total Billed Charges,78.77,44.1,,31.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,169.68,95,,68.712,Percent of Total Billed Charges,95% of Total Billed Charges,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.18,88,,63.648,Percent of Total Billed Charges,88% of Total Billed Charges,160.75,90,,65.096,Percent of Total Billed charges,90% of Total Billed Charges,78.77,178.61,
NEODECADRON OPHTH SUSP,2500000345,CDM,250,RC,,,Outpatient,,,91.51,59.48,,91.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,69.55,76,,11.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.89,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,68.63,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.89,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,54.91,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,82.36,90,,13.496,Percent of Total Billed Charges,90% of Total Billed Charges,41.18,45,,6.744,Percent of Total Billed Charges,45% of Total Billed Charges,82.36,90,,13.496,Percent of Total Billed Charges,90% of Total billed Charges,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.48,65,,9.744,Percent of total Billed Charges,65% of Total Billed Charges,40.36,44.1,,6.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,86.93,95,,14.24,Percent of Total Billed Charges,95% of Total Billed Charges,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.53,88,,13.192,Percent of Total Billed Charges,88% of Total Billed Charges,82.36,90,,13.496,Percent of Total Billed charges,90% of Total Billed Charges,40.36,91.51,
NEOMYCIN 500MG TAB,2500000346,CDM,250,RC,,,Outpatient,500,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
NEURONTIN 100MG CAP,2500000347,CDM,250,RC,,,Outpatient,100,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
NEURONTIN 300MG CAP,2500000348,CDM,250,RC,,,Outpatient,300,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,114.944,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,119.728,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,114.944,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,95.784,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
TRIPLE ANTIBIOTIC 28.4 GM,2500000349,CDM,250,RC,,,Outpatient,28.4,gm,28.67,18.64,,28.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21.79,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.64,72,,186.064,Percent of Total Billed Charges,72% of Total Billed Charges,21.5,75,,193.816,Percent of Total Billed charges,75% of Total Billed Charges,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.64,72,,186.064,Percent of Total Billed Charges,72% of Total Billed Charges,17.2,60,,155.056,Percent of Total Billed Charges,60% of Total Billed Charges,25.8,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,12.9,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,25.8,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.64,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,12.64,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,27.24,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.23,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,25.8,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,12.64,28.67,
NEOSYNEPHNE 0.25% NASAL SOLN,2500000350,CDM,250,RC,,,Outpatient,,,28.67,18.64,,28.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21.79,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.64,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,21.5,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.64,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,17.2,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,25.8,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,12.9,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,25.8,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.64,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,12.64,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,27.24,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.23,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,25.8,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,12.64,28.67,
NITROGLY 1/150GR TAB,2500000351,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,159.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,188.928,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,94.464,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,188.928,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,136.448,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,92.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,199.424,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,184.728,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,188.928,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
NITROLINGUAL SPRAY 4.9GM,2500000352,CDM,250,RC,,,Outpatient,4.9,gm,145.53,94.59,,145.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.6,76,,162.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,104.78,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,109.15,75,,15.88,Percent of Total Billed charges,75% of Total Billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.78,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,87.32,60,,12.704,Percent of Total Billed Charges,60% of Total Billed Charges,130.98,90,,192.896,Percent of Total Billed Charges,90% of Total Billed Charges,65.49,45,,96.448,Percent of Total Billed Charges,45% of Total Billed Charges,130.98,90,,192.896,Percent of Total Billed Charges,90% of Total billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.59,65,,139.312,Percent of total Billed Charges,65% of Total Billed Charges,64.18,44.1,,94.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,138.25,95,,203.608,Percent of Total Billed Charges,95% of Total Billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.07,88,,188.608,Percent of Total Billed Charges,88% of Total Billed Charges,130.98,90,,192.896,Percent of Total Billed charges,90% of Total Billed Charges,64.18,145.53,
NOLVADEX 10MG PO,2500000353,CDM,250,RC,,,Outpatient,10,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,18.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,7.936,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,6.352,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,22.224,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,11.112,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,22.224,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,16.056,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,10.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,23.464,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,21.736,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,22.224,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
NORMODYNE 200MG TAB,2500000354,CDM,250,RC,,,Outpatient,200,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
NORVASC 5MG TAB,2500000355,CDM,250,RC,,,Outpatient,5,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
NORVASC 10MG TAB,2500000356,CDM,250,RC,,,Outpatient,10,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
NU GUAZE .25 IN,2500000357,CDM,250,RC,,,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
NU GUAZE .5 IN,2500000358,CDM,250,RC,,,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
NU GUAZE 1IN,2500000359,CDM,250,RC,,,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
NYSTATIN CREAM 30G,2500000360,CDM,250,RC,,,Outpatient,,,106.94,69.51,,106.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.27,76,,116.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,80.21,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,64.16,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,96.25,90,,138.128,Percent of Total Billed Charges,90% of Total Billed Charges,48.12,45,,69.064,Percent of Total Billed Charges,45% of Total Billed Charges,96.25,90,,138.128,Percent of Total Billed Charges,90% of Total billed Charges,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.51,65,,99.76,Percent of total Billed Charges,65% of Total Billed Charges,47.16,44.1,,67.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,101.59,95,,145.8,Percent of Total Billed Charges,95% of Total Billed Charges,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.11,88,,135.056,Percent of Total Billed Charges,88% of Total Billed Charges,96.25,90,,138.128,Percent of Total Billed charges,90% of Total Billed Charges,47.16,106.94,
KETOCONAZOLE 200MG TAB,2500000361,CDM,250,RC,,,Outpatient,200,GM,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
CALCIUM + D 250/125 TAB,2500000362,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
CALCIUM + D 500/200 TAB,2500000363,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
PANCREASE 5000 UNIT CAP,2500000364,CDM,250,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,151.776,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,158.104,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,151.776,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,126.48,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
PARLODEL 2.5MG TAB,2500000365,CDM,250,RC,,,Outpatient,2.5,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
PAVABID 150MG CAP,2500000366,CDM,250,RC,,,Outpatient,150,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
PENVEE K 250MG,2500000367,CDM,250,RC,,,Outpatient,250,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,90.176,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,93.936,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,90.176,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,75.152,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
PEPTO BISMOL 4OZ,2500000368,CDM,250,RC,,,Outpatient,,,14.33,9.31,,14.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.89,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.32,72,,28.576,Percent of Total Billed Charges,72% of Total Billed Charges,10.75,75,,29.768,Percent of Total Billed charges,75% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,72,,28.576,Percent of Total Billed Charges,72% of Total Billed Charges,8.6,60,,23.816,Percent of Total Billed Charges,60% of Total Billed Charges,12.9,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,12.9,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.31,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.61,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.61,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,12.9,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,6.32,14.33,
PERIACTIN 4MG TAB,2500000369,CDM,250,RC,,,Outpatient,4,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,121.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,143.68,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,71.84,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,143.68,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,103.768,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,70.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,151.656,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,140.48,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,143.68,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
LEVAQUIN 500MG TAB,2500000370,CDM,250,RC,,,Outpatient,500,GM,90.41,58.77,,90.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.71,76,,196.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.1,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,67.81,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.1,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,54.25,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,81.37,90,,232.584,Percent of Total Billed Charges,90% of Total Billed Charges,40.68,45,,116.288,Percent of Total Billed Charges,45% of Total Billed Charges,81.37,90,,232.584,Percent of Total Billed Charges,90% of Total billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.77,65,,167.976,Percent of total Billed Charges,65% of Total Billed Charges,39.87,44.1,,113.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.89,95,,245.504,Percent of Total Billed Charges,95% of Total Billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.56,88,,227.416,Percent of Total Billed Charges,88% of Total Billed Charges,81.37,90,,232.584,Percent of Total Billed charges,90% of Total Billed Charges,39.87,90.41,
LIPITOR 10MG TAB,2500000371,CDM,250,RC,,,Outpatient,10,GM,18.74,12.18,,18.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.24,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.49,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,14.06,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.49,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,11.24,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,16.87,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,8.43,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,16.87,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.18,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,8.26,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.8,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,16.87,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,8.26,18.74,
PERICOLACE CAP,2500000372,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
PERSANTINE 25MG TAB,2500000373,CDM,250,RC,,,Outpatient,25,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,16.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,19.048,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,9.528,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,19.048,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,13.76,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,9.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,20.112,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,18.624,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,19.048,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
PHENOBARB 30MG TAB,2500000374,CDM,250,RC,,,Outpatient,30,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,6.88,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
PHENERGAN 25MG TAB,2500000375,CDM,250,RC,,,Outpatient,25,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
PHENERGAN 12.5 SUPP,2500000376,CDM,250,RC,,,Outpatient,,,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
PILOCAR 1% OPHTH SOLN,2500000377,CDM,250,RC,,,Outpatient,,,262.40,170.56,,262.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,199.42,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,188.93,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,196.8,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,262.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.93,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,157.44,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,236.16,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,118.08,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,236.16,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,262.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.56,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,115.72,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,249.28,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,262.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.91,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,236.16,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,115.72,262.4,
PILOCAR 2% OPHTH SOLN,2500000378,CDM,250,RC,,,Outpatient,,,267.91,174.14,,267.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,203.61,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,192.9,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,200.93,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,267.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.9,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,160.75,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,241.12,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,120.56,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,241.12,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,267.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.14,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,118.15,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,254.51,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,267.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.76,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,241.12,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,118.15,267.91,
PLAVIX 75MG TAB,2500000379,CDM,250,RC,,,Outpatient,75,GM,30.87,20.07,,30.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.46,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.23,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.23,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,18.52,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,27.78,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,13.89,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,27.78,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.07,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,13.61,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.33,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.17,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,27.78,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,13.61,30.87,
PLAQUENIL 200MG TAB,2500000380,CDM,250,RC,,,Outpatient,200,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
PLENDIL 5MG TAB,2500000381,CDM,250,RC,,,Outpatient,5,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
POLYCIL 250/5 SUSP 100ML,2500000382,CDM,250,RC,,,Outpatient,100,ML,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
POLYCILLIN 250 CAP,2500000383,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
POLYCILLIN 500 CAP,2500000384,CDM,250,RC,,,Outpatient,,,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
AMOXICILN 250MG/5ML SUSP 80ML,2500000385,CDM,250,RC,,,Outpatient,250,GM,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,160.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,15.71,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,189.72,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,94.864,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,189.72,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,137.024,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,92.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,200.264,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,185.504,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,189.72,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
PRED FORTE 1% OPTH SOLN,2500000386,CDM,250,RC,,,Outpatient,,,191.84,124.70,,191.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,145.8,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,138.12,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,143.88,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.12,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,115.1,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,172.66,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,86.33,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,172.66,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.7,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,84.6,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,182.25,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.82,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,172.66,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,84.6,191.84,
PREDNISONE 1MG TAB,2500000387,CDM,250,RC,,,Outpatient,1,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
PREDNISONE 5MG TAB,2500000388,CDM,250,RC,,,Outpatient,5,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,95.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,112.72,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,56.36,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,112.72,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,81.408,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,55.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,118.984,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,110.216,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,112.72,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
PREDNISONE 10MG TAB,2500000389,CDM,250,RC,,,Outpatient,10,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,30.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,35.72,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,17.856,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,35.72,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,25.8,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,17.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,37.704,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,34.928,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,35.72,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
PREDNISONE 20MG TAB,2500000390,CDM,250,RC,,,Outpatient,20,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
PREMARIN 0.3MG TAB,2500000391,CDM,250,RC,,,Outpatient,0.3,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
PREMARIN .625MG TAB,2500000392,CDM,250,RC,,,Outpatient,0.625,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,7.936,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,6.352,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
PROCARDIA 10MG CAP,2500000393,CDM,250,RC,,,Outpatient,10,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,19.688,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,20.512,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,19.688,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,16.408,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
PROCARDIA 60MG XL TAB,2500000394,CDM,250,RC,,,Outpatient,60,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
PROCTOFOAM 15G,2500000395,CDM,250,RC,,,Outpatient,,,199.55,129.71,,199.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,151.66,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,143.68,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,149.66,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,199.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.68,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,119.73,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,179.6,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,89.8,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,179.6,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,199.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.71,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,88,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,189.57,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,199.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.6,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,179.6,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,88,199.55,
PROCTOFOAM HC 15MG,2500000396,CDM,250,RC,,,Outpatient,15,GM,323.03,209.97,,323.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,245.5,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,232.58,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,242.27,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.58,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,193.82,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,290.73,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,145.36,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,290.73,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.97,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,142.46,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,306.88,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.27,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,290.73,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,142.46,323.03,
ALTACE 5MG CAP,2500000397,CDM,250,RC,,,Outpatient,5,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
IMDUR 60MG TAB,2500000398,CDM,250,RC,,,Outpatient,60,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,11.248,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,8.992,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
SEREVENT INHALER,2500000399,CDM,250,RC,,,Outpatient,,,26.46,17.20,,26.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.11,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.05,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.05,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,15.88,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,23.81,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,11.91,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,23.81,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,11.67,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.14,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.28,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,23.81,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,11.67,26.46,
PROSCAR 5MG TAB,2500000400,CDM,250,RC,,,Outpatient,5,GM,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
PROVERA 10MG TAB,2500000401,CDM,250,RC,,,Outpatient,10,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,46.968,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
PYRIDIUM 100MG TAB,2500000402,CDM,250,RC,,,Outpatient,100,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,118.752,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,123.704,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,118.752,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,98.96,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
QUESTRAN 9GM POWDER,2500000403,CDM,250,RC,,,Outpatient,9,gm,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,97.8,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,101.872,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,97.8,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,81.496,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
NABUMETONE 500MG TAB,2500000404,CDM,250,RC,,,Outpatient,500,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,154.952,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,161.408,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,154.952,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,129.128,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
REGLAN 10MG TAB,2500000405,CDM,250,RC,,,Outpatient,10,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,95.256,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,76.208,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
RESTORIL 15MG CAP,2500000406,CDM,250,RC,,,Outpatient,15,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
RIFADIN 300MG CAP,2500000407,CDM,250,RC,,,Outpatient,300,GM,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,22.864,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,23.816,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,22.864,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,19.048,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
ROBAXIN 500MG TAB,2500000408,CDM,250,RC,,,Outpatient,500,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
ROBINUL 1MG TAB,2500000409,CDM,250,RC,,,Outpatient,1,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,15.216,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,12.176,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
ROBITUSSIN AC SYRUP 5ML UD,2500000410,CDM,250,RC,,,Outpatient,5,ML,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,7.936,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,6.352,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
SANTYL OINT COL 30G,2500000411,CDM,250,RC,,,Outpatient,,,263.50,171.28,,263.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,200.26,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,189.72,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,197.63,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,263.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.72,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,158.1,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,237.15,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,118.58,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,237.15,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,263.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.28,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,116.2,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,250.33,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,263.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.88,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,237.15,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,116.2,263.5,
SENOKOT TABLET,2500000412,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,7.936,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,6.352,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
SEPTRA 200  40MG / 5ML,2500000413,CDM,250,RC,,,Outpatient,40,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,6.88,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
SILVADENE CREAM JAR 400G,2500000414,CDM,250,RC,,,Outpatient,,,156.56,101.76,,156.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,118.99,76,,20.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,112.72,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,117.42,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.72,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,93.94,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,140.9,90,,24.608,Percent of Total Billed Charges,90% of Total Billed Charges,70.45,45,,12.304,Percent of Total Billed Charges,45% of Total Billed Charges,140.9,90,,24.608,Percent of Total Billed Charges,90% of Total billed Charges,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.76,65,,17.776,Percent of total Billed Charges,65% of Total Billed Charges,69.04,44.1,,12.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,148.73,95,,25.976,Percent of Total Billed Charges,95% of Total Billed Charges,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.77,88,,24.064,Percent of Total Billed Charges,88% of Total Billed Charges,140.9,90,,24.608,Percent of Total Billed charges,90% of Total Billed Charges,69.04,156.56,
SILVADENE CREAM TUBE 25G,2500000415,CDM,250,RC,,,Outpatient,,,49.61,32.25,,49.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,37.7,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,35.72,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,37.21,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.72,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,29.77,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,44.65,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,22.32,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,44.65,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.25,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,21.88,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,47.13,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,44.65,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,21.88,49.61,
SINEQUAN 10MG TAB,2500000416,CDM,250,RC,,,Outpatient,10,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
SINEMET 10/100 TAB,2500000417,CDM,250,RC,,,Outpatient,,,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,24.624,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,25.648,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,24.624,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,20.52,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
SINEMET 25/100 TAB,2500000418,CDM,250,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
SINEMET 25/250 TAB,2500000419,CDM,250,RC,,,Outpatient,,,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,11.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,13.496,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,6.744,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,13.496,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,9.744,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,6.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,14.24,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,13.192,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,13.496,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
SOMA 350MG TAB,2500000420,CDM,250,RC,,,Outpatient,350,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
STRESSTAB W/ZN TAB,2500000421,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
SUMYCIN 250MG CAPS,2500000422,CDM,250,RC,,,Outpatient,250,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
SYNTHROID 25MCG TAB,2500000423,CDM,250,RC,,,Outpatient,25,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,125.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,267.352,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,278.488,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,267.352,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,222.792,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,148.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,74.224,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,148.44,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,107.208,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,72.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,156.688,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,145.144,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,148.44,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
TENORMIN 50MG TAB,2500000424,CDM,250,RC,,,Outpatient,50,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,103.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,122.248,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,61.128,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,122.248,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,88.288,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,59.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,129.04,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,119.536,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,122.248,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
TESSALON 100MG CAP,2500000425,CDM,250,RC,,,Outpatient,100,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,163.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,193.688,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,96.84,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,193.688,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,139.888,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,94.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,204.448,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,189.384,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,193.688,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
THERAGRAN M TAB,2500000426,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,96.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,114.304,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,57.152,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,114.304,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,82.552,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,56.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,120.656,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,111.768,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,114.304,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
THORAZINE 25MG TAB,2500000427,CDM,250,RC,,,Outpatient,25,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,27.12,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,21.696,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
THYROID 1GR TAB,2500000428,CDM,250,RC,,,Outpatient,,,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,24.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,46.312,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,37.048,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,28.576,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,14.288,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,28.576,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,20.64,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,14,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,30.168,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,27.944,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,28.576,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
SUDAFED TAB 30MG,2500000429,CDM,250,RC,,,Outpatient,30,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
SURFAK 240MG CAP,2500000430,CDM,250,RC,,,Outpatient,240,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,15.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,18.256,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,9.128,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,18.256,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,13.184,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,8.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,19.272,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,17.856,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,18.256,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
SYMMETREL 100MG TAB,2500000431,CDM,250,RC,,,Outpatient,100,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,6.88,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
SYNTHROID 0.1MG CAP,2500000432,CDM,250,RC,,,Outpatient,0.1,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,55.248,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,57.552,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,55.248,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,46.04,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
SYNTHROID 0.15MG TAB,2500000433,CDM,250,RC,,,Outpatient,0.15,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,6.88,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
SLOWMAG TAB,2500000434,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
HUMIBID LA TAB,2500000435,CDM,250,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,12.568,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,10.056,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
TOPROL XL 50MG TAB,2500000436,CDM,250,RC,,,Outpatient,50,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,36.832,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,38.368,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,36.832,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,30.696,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
TOPROL XL 100MG TAB,2500000437,CDM,250,RC,,,Outpatient,100,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,29.104,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,23.288,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
ULTRAM 50MG TAB,2500000438,CDM,250,RC,,,Outpatient,50,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,25.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,30.784,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,15.392,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,30.784,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,22.232,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,15.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,32.488,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,30.096,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,30.784,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
FOSAMAX 10MG TAB,2500000439,CDM,250,RC,,,Outpatient,10,GM,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,14.56,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
TEARS NATURALE 15ML OPHTH SOLN,2500000440,CDM,250,RC,,,Outpatient,15,ML,34.18,22.22,,34.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.98,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.61,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,25.64,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.61,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,20.51,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,30.76,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,15.38,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,30.76,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.22,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,15.07,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.47,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.08,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,30.76,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,15.07,34.18,
GLUCOPHAGE 500MG TAB,2500000441,CDM,250,RC,,,Outpatient,500,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
ZINC 220MG TAB,2500000442,CDM,250,RC,,,Outpatient,220,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
DEPAKOTE 250MG TAB,2500000443,CDM,250,RC,,,Outpatient,250,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
SINEMET 50/200CR TAB,2500000444,CDM,250,RC,,,Outpatient,,,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,282.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,37.704,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,30.16,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,334.192,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,167.096,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,334.192,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,241.36,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,163.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,352.752,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,326.76,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,334.192,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
RISPERDOL 1MG TAB,2500000445,CDM,250,RC,,,Outpatient,1,GM,18.74,12.18,,18.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.24,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.49,72,,54.616,Percent of Total Billed Charges,72% of Total Billed Charges,14.06,75,,56.896,Percent of Total Billed charges,75% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.49,72,,54.616,Percent of Total Billed Charges,72% of Total Billed Charges,11.24,60,,45.512,Percent of Total Billed Charges,60% of Total Billed Charges,16.87,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,8.43,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,16.87,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.18,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,8.26,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.8,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,16.87,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,8.26,18.74,
TEGRETOL 200MG TAB,2500000446,CDM,250,RC,,,Outpatient,200,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,144.792,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,150.824,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,144.792,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,120.656,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
THIAMINE 100MG TAB,2500000447,CDM,250,RC,,,Outpatient,100,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
TIMOPTIC .25% 5ML OPHTH SOLN,2500000448,CDM,250,RC,,,Outpatient,5,ML,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,27.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,58.71,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,32.544,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,16.272,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,32.544,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,23.504,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,15.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,34.352,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,31.824,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,32.544,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
TIMOPTIC 0.5% 5ML OPHTH SOLN,2500000449,CDM,250,RC,,,Outpatient,5,ML,206.17,134.01,,206.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,156.69,76,,46.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,148.44,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,154.63,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,206.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.44,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,123.7,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,185.55,90,,55.568,Percent of Total Billed Charges,90% of Total Billed Charges,92.78,45,,27.784,Percent of Total Billed Charges,45% of Total Billed Charges,185.55,90,,55.568,Percent of Total Billed Charges,90% of Total billed Charges,206.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.01,65,,40.136,Percent of total Billed Charges,65% of Total Billed Charges,90.92,44.1,,27.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,195.86,95,,58.656,Percent of Total Billed Charges,95% of Total Billed Charges,206.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.43,88,,54.336,Percent of Total Billed Charges,88% of Total Billed Charges,185.55,90,,55.568,Percent of Total Billed charges,90% of Total Billed Charges,90.92,206.17,
TRUSOPT OPHTH SOLN,2500000450,CDM,250,RC,,,Outpatient,,,169.79,110.36,,169.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.04,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,122.25,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,127.34,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,169.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.25,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,101.87,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,152.81,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,76.41,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,152.81,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,169.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.36,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,74.88,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,161.3,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,169.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.42,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,152.81,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,74.88,169.79,
TOBRADEX OPHTH SUSP,2500000451,CDM,250,RC,,,Outpatient,,,269.01,174.86,,269.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,204.45,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,193.69,72,,159.4,Percent of Total Billed Charges,72% of Total Billed Charges,201.76,75,,166.04,Percent of Total Billed charges,75% of Total Billed Charges,269.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.69,72,,159.4,Percent of Total Billed Charges,72% of Total Billed Charges,161.41,60,,132.832,Percent of Total Billed Charges,60% of Total Billed Charges,242.11,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,121.05,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,242.11,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,269.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.86,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,118.63,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,255.56,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,269.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.73,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,242.11,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,118.63,269.01,
TOBREX OPTH 0.3% 5ML OINT,2500000452,CDM,250,RC,,,Outpatient,5,ML,158.76,103.19,,158.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.66,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.31,72,,220.992,Percent of Total Billed Charges,72% of Total Billed Charges,119.07,75,,230.2,Percent of Total Billed charges,75% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.31,72,,220.992,Percent of Total Billed Charges,72% of Total Billed Charges,95.26,60,,184.16,Percent of Total Billed Charges,60% of Total Billed Charges,142.88,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,71.44,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,142.88,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.19,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,70.01,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,150.82,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.71,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,142.88,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,70.01,158.76,
TOFRANIL 25MG TAB,2500000453,CDM,250,RC,,,Outpatient,25,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,58.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,69.064,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,34.528,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,69.064,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,49.88,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,33.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,72.896,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,67.528,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,69.064,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
TOPAMAX XL 100MG TAB,2500000454,CDM,250,RC,,,Outpatient,100,GM,39.69,25.80,,39.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,30.16,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.58,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,29.77,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.58,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,23.81,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,35.72,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,17.86,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,35.72,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.8,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,17.5,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.71,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,35.72,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,17.5,39.69,
TRANSDERMNITRO 0.2MG/HR PATCH,2500000455,CDM,250,RC,,,Outpatient,0.2,GM,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
TRANSDERM NITRO 0.4MG/HR PATCH,2500000456,CDM,250,RC,,,Outpatient,0.4,GM,25.36,16.48,,25.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.27,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.26,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,19.02,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.26,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,15.22,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,22.82,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,11.41,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,22.82,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,11.18,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.09,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,22.82,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,11.18,25.36,
TRANXENE 3.75MG CAP,2500000457,CDM,250,RC,,,Outpatient,3.75,GM,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,38.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,46.048,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,23.024,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,46.048,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,33.256,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,22.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,48.6,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,45.024,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,46.048,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
TRENTAL 400MG TAB,2500000458,CDM,250,RC,,,Outpatient,400,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,29.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,34.928,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,17.464,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,34.928,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,25.224,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,17.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,36.864,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,34.152,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,34.928,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
TRANSDERM NITRO 0.6MG/HR PATCH,2500000459,CDM,250,RC,,,Outpatient,0.6,GM,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,12.568,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,10.056,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
TUSSIONEX SUSP UD 5ML,2500000460,CDM,250,RC,,,Outpatient,5,ML,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
TYLENOL 325MG TAB,2500000461,CDM,250,RC,,,Outpatient,325,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,8.6,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,6.88,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
TYLENOL 500MG TAB,2500000462,CDM,250,RC,,,Outpatient,500,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
TYLENOL W/CODEINE #3 TAB,2500000463,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
JANUVIA 50MG TAB,2500000464,CDM,250,RC,,,Outpatient,50,GM,42.75,27.79,,42.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,32.49,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.78,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,32.06,75,,10.584,Percent of Total Billed charges,75% of Total Billed Charges,42.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.78,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,25.65,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,38.48,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,19.24,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,38.48,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,42.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.79,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,18.85,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,40.61,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,42.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.62,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,38.48,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,18.85,42.75,
URECHOLINE 25MG TAB,2500000465,CDM,250,RC,,,Outpatient,25,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,38.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,13.232,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,10.584,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,45.248,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,22.624,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,45.248,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,32.68,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,22.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,47.76,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,44.24,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,45.248,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
VALIUM 2MG TAB,2500000466,CDM,250,RC,,,Outpatient,2,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,57.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,68.272,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,34.136,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,68.272,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,49.304,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,33.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,72.064,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,66.752,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,68.272,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
VALIUM 5MG TAB,2500000467,CDM,250,RC,,,Outpatient,5,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,152.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,180.984,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,90.496,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,180.984,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,130.712,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,88.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,191.04,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,176.968,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,180.984,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
VICODIN TAB,2500000468,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,556.296,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,579.472,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,556.296,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,463.576,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
VIBRAMYCIN 100MG CAP,2500000469,CDM,250,RC,,,Outpatient,100,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
XALATAN OPHT SOL,2500000470,CDM,250,RC,,,Outpatient,,,464.15,301.70,,464.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,352.75,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,334.19,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,348.11,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,464.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.19,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,278.49,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,417.74,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,208.87,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,417.74,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,464.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,464.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,464.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.7,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,204.69,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,440.94,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,464.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,408.45,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,417.74,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,204.69,464.15,
XANAX 0.25MG TAB,2500000471,CDM,250,RC,,,Outpatient,0.25,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,13.336,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,13.888,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,13.336,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,11.112,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
XANAX 0.5MG TAB,2500000472,CDM,250,RC,,,Outpatient,0.5,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,168.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,199.248,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,99.624,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,199.248,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,143.896,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,97.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,210.312,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,194.816,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,199.248,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
XANAX 1MG TAB,2500000473,CDM,250,RC,,,Outpatient,1,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,233.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,276.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,138.12,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,276.24,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,199.512,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,135.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,291.592,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,270.104,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,276.24,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
XYLOCAINE JELLY 2% 5ML,2500000474,CDM,250,RC,,,Outpatient,5,ML,45.20,29.38,,45.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.35,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.54,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,33.9,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.54,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,27.12,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,40.68,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,20.34,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,40.68,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.38,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,19.93,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.94,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.78,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,40.68,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,19.93,45.2,
XYLOCAIN JEL 2% 30CC,2500000475,CDM,250,RC,,,Outpatient,,,77.18,50.17,,77.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.66,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.57,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,57.89,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.57,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,69.46,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,34.73,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,69.46,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.17,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,34.04,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.32,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.92,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,69.46,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,34.04,77.18,
ZANTAC 150MG TAB,2500000476,CDM,250,RC,,,Outpatient,150,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
ZAROXOLYN 5MG TAB,2500000477,CDM,250,RC,,,Outpatient,5,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
ZOLOFT 50MG TAB,2500000478,CDM,250,RC,,,Outpatient,50,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
ZOFRAN 4MG TAB,2500000479,CDM,250,RC,,,Outpatient,4,GM,95.92,62.35,,95.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.9,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.06,72,,24.136,Percent of Total Billed Charges,72% of Total Billed Charges,71.94,75,,25.144,Percent of Total Billed charges,75% of Total Billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.06,72,,24.136,Percent of Total Billed Charges,72% of Total Billed Charges,57.55,60,,20.112,Percent of Total Billed Charges,60% of Total Billed Charges,86.33,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,43.16,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,86.33,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.35,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,42.3,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.12,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.41,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,86.33,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,42.3,95.92,
ZYLOPRIM 100MG TAB,2500000480,CDM,250,RC,,,Outpatient,100,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,164.48,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,171.328,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,164.48,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,137.064,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
ZYLOPRIM 300MG TAB,2500000481,CDM,250,RC,,,Outpatient,300,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,13.336,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,13.888,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,13.336,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,11.112,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
ZYRETEC 10MG TAB,2500000482,CDM,250,RC,,,Outpatient,10,GM,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,8.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,15.71,75,,8.6,Percent of Total Billed charges,75% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,6.88,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,10.32,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,10.32,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,7.448,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,10.888,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,10.088,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,10.32,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
ACTIDOSEAQUA 120ML,2500000483,CDM,250,RC,,,Outpatient,120,ML,63.95,41.57,,63.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,48.6,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.04,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,47.96,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.04,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,38.37,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,57.56,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,28.78,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,57.56,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.57,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,28.2,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,60.75,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.28,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,57.56,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,28.2,63.95,
CLOTRIMAZOLE 1% CREAM,2500000484,CDM,250,RC,,,Outpatient,,,48.51,31.53,,48.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.87,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.93,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,29.11,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,43.66,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,21.83,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,43.66,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.53,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,21.39,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.08,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.69,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,43.66,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,21.39,48.51,
ZOCOR 10MG TAB,2500000485,CDM,250,RC,,,Outpatient,10,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,10.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,12.704,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,6.352,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,12.704,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,9.176,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,6.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,13.408,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,12.416,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,12.704,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
NEOSYNEPHRINE 1% NASAL SOLN,2500000486,CDM,250,RC,,,Outpatient,,,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,13.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,10.584,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,15.88,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,7.936,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,15.88,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,11.464,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,16.76,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,15.52,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,15.88,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
COUMADIN 2.5MG TAB,2500000487,CDM,250,RC,,,Outpatient,2.5,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
BUMEX 1MG TAB,2500000488,CDM,250,RC,,,Outpatient,1,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,43.664,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,34.928,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
FLAGYL 500MG TAB,2500000489,CDM,250,RC,,,Outpatient,500,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,587.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,695.368,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,347.688,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,695.368,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,502.208,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,340.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,734,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,679.92,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,695.368,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
THEOPHYLL 200MG TAB,2500000490,CDM,250,RC,,,Outpatient,200,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
LANOLIN OINT,2500000491,CDM,250,RC,,,Outpatient,,,62.84,40.85,,62.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.76,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.24,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,47.13,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.24,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,37.7,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,56.56,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,28.28,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,56.56,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.85,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,27.71,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.7,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.3,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,56.56,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,27.71,62.84,
SILVER NITRATE 1GM,2500000492,CDM,250,RC,,,Outpatient,1,gm,94.82,61.63,,94.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.06,76,,14.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,68.27,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,71.12,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.27,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,56.89,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,85.34,90,,16.672,Percent of Total Billed Charges,90% of Total Billed Charges,42.67,45,,8.336,Percent of Total Billed Charges,45% of Total Billed Charges,85.34,90,,16.672,Percent of Total Billed Charges,90% of Total billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.63,65,,12.04,Percent of total Billed Charges,65% of Total Billed Charges,41.82,44.1,,8.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,90.08,95,,17.592,Percent of Total Billed Charges,95% of Total Billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.44,88,,16.296,Percent of Total Billed Charges,88% of Total Billed Charges,85.34,90,,16.672,Percent of Total Billed charges,90% of Total Billed Charges,41.82,94.82,
CATAPRESS TTS1 PATCH,2500000493,CDM,250,RC,,,Outpatient,,,251.37,163.39,,251.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,191.04,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,180.99,72,,52.712,Percent of Total Billed Charges,72% of Total Billed Charges,188.53,75,,54.904,Percent of Total Billed charges,75% of Total Billed Charges,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.99,72,,52.712,Percent of Total Billed Charges,72% of Total Billed Charges,150.82,60,,43.928,Percent of Total Billed Charges,60% of Total Billed Charges,226.23,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,113.12,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,226.23,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.39,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,110.85,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,238.8,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.21,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,226.23,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,110.85,251.37,
PERCOCET TAB,2500000494,CDM,250,RC,,,Outpatient,,,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
VASOTEC 5MG TAB,2500000495,CDM,250,RC,,,Outpatient,5,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,12.568,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,10.056,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
DIMETANE DX,2500000496,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,14.56,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
RONDEC DROPS 30ML,2500000497,CDM,250,RC,,,Outpatient,30,ML,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,80.016,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,83.352,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,80.016,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,66.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
CATAPRESS TTS2 PATCH,2500000499,CDM,250,RC,,,Outpatient,,,276.73,179.87,,276.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,210.31,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,199.25,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,207.55,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,276.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.25,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,166.04,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,249.06,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,124.53,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,249.06,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,276.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.87,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,122.04,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,262.89,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,276.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.52,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,249.06,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,122.04,276.73,
CATAPRESS TTS3 PATCH,2500000500,CDM,250,RC,,,Outpatient,,,383.67,249.39,,383.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,291.59,76,,25.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,276.24,72,,0.792,Percent of Total Billed Charges,72% of Total Billed Charges,287.75,75,,0.832,Percent of Total Billed charges,75% of Total Billed Charges,383.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.24,72,,0.792,Percent of Total Billed Charges,72% of Total Billed Charges,230.2,60,,0.664,Percent of Total Billed Charges,60% of Total Billed Charges,345.3,90,,30.168,Percent of Total Billed Charges,90% of Total Billed Charges,172.65,45,,15.088,Percent of Total Billed Charges,45% of Total Billed Charges,345.3,90,,30.168,Percent of Total Billed Charges,90% of Total billed Charges,383.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,383.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,383.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.39,65,,21.792,Percent of total Billed Charges,65% of Total Billed Charges,169.2,44.1,,14.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,364.49,95,,31.848,Percent of Total Billed Charges,95% of Total Billed Charges,383.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.63,88,,29.496,Percent of Total Billed Charges,88% of Total Billed Charges,345.3,90,,30.168,Percent of Total Billed charges,90% of Total Billed Charges,169.2,383.67,
ATIVAN 05MG TAB,2500000501,CDM,250,RC,,,Outpatient,5,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,173.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,28.448,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,22.76,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,205.6,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,102.8,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,205.6,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,148.488,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,100.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,217.016,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,201.024,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,205.6,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
LOPID 600MG TAB,2500000502,CDM,250,RC,,,Outpatient,600,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,14.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,18.416,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,19.184,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,18.416,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,15.344,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,16.672,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,8.336,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,16.672,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,12.04,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,8.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,17.592,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,16.296,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,16.672,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
CALAN SR 240MG TAB,2500000503,CDM,250,RC,,,Outpatient,240,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,8.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,104.784,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,109.144,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,104.784,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,87.32,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,10.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,10.32,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,7.448,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,10.888,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,10.088,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,10.32,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
BUSPAR 10MG TAB,2500000504,CDM,250,RC,,,Outpatient,10,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
ROCALTROL 0.25MCG CAP,2500000505,CDM,250,RC,,,Outpatient,0.25,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
DEEP SEA NASAL SPRAY 45ML,2500000506,CDM,250,RC,,,Outpatient,45,ML,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
MICROK 10 CAP,2500000507,CDM,250,RC,,,Outpatient,,,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,10.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,15.71,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,12.704,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,6.352,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,12.704,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,9.176,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,6.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,13.408,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,12.416,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,12.704,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
CALAMINE LOT 60ML,2500000508,CDM,250,RC,,,Outpatient,60,ML,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
AURO EAR SOLN 15ML,2500000509,CDM,250,RC,,,Outpatient,15,ML,14.33,9.31,,14.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.89,76,,44.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.32,72,,182.888,Percent of Total Billed Charges,72% of Total Billed Charges,10.75,75,,190.512,Percent of Total Billed charges,75% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,72,,182.888,Percent of Total Billed Charges,72% of Total Billed Charges,8.6,60,,152.408,Percent of Total Billed Charges,60% of Total Billed Charges,12.9,90,,52.392,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,26.2,Percent of Total Billed Charges,45% of Total Billed Charges,12.9,90,,52.392,Percent of Total Billed Charges,90% of Total billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.31,65,,37.84,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,25.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.61,95,,55.304,Percent of Total Billed Charges,95% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.61,88,,51.232,Percent of Total Billed Charges,88% of Total Billed Charges,12.9,90,,52.392,Percent of Total Billed charges,90% of Total Billed Charges,6.32,14.33,
LEVSIN 0.125MG TAB,2500000510,CDM,250,RC,,,Outpatient,0.125,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
DEPAKENE 250/5 SUSP,2500000511,CDM,250,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
PHENERGAN SUPP 25MG,2500000513,CDM,250,RC,,,Outpatient,25,GM,17.64,11.47,,17.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.41,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.7,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.7,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,10.58,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,15.88,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,7.94,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,15.88,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.47,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,7.78,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.76,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.52,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,15.88,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,7.78,17.64,
IMODIUM LIQ 4OZ,2500000514,CDM,250,RC,,,Outpatient,,,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.88,72,,19.688,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,75,,20.512,Percent of Total Billed charges,75% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.88,72,,19.688,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,60,,16.408,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.05,
MS CONTIN 30MG TAB,2500000515,CDM,250,RC,,,Outpatient,30,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,55.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,65.888,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,32.944,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,65.888,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,47.584,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,32.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,69.544,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,64.424,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,65.888,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
MYCELEX TROCHE 10MG TAB,2500000516,CDM,250,RC,,,Outpatient,10,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,18.52,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,14.816,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
ATROVENT INHALER,2500000517,CDM,250,RC,,,Outpatient,,,965.79,627.76,,965.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,734,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,695.37,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,724.34,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,965.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.37,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,579.47,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,869.21,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,434.61,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,869.21,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,965.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,965.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,965.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,627.76,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,425.91,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,917.5,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,965.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,849.9,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,869.21,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,425.91,965.79,
MOTRIN 200MG TAB,2500000518,CDM,250,RC,,,Outpatient,200,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,29.216,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,30.432,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,29.216,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,24.344,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
SORBITOL 70% 2OZ,2500000519,CDM,250,RC,,,Outpatient,,,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,84.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,100.024,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,50.008,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,100.024,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,72.24,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,49.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,105.576,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,97.8,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,100.024,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
MARINOL 2.5MG CAP,2500000520,CDM,250,RC,,,Outpatient,2.5,GM,23.15,15.05,,23.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.59,76,,115.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.67,72,,57.16,Percent of Total Billed Charges,72% of Total Billed Charges,17.36,75,,59.536,Percent of Total Billed charges,75% of Total Billed Charges,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.67,72,,57.16,Percent of Total Billed Charges,72% of Total Billed Charges,13.89,60,,47.632,Percent of Total Billed Charges,60% of Total Billed Charges,20.84,90,,136.536,Percent of Total Billed Charges,90% of Total Billed Charges,10.42,45,,68.264,Percent of Total Billed Charges,45% of Total Billed Charges,20.84,90,,136.536,Percent of Total Billed Charges,90% of Total billed Charges,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.05,65,,98.608,Percent of total Billed Charges,65% of Total Billed Charges,10.21,44.1,,66.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.99,95,,144.12,Percent of Total Billed Charges,95% of Total Billed Charges,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.37,88,,133.496,Percent of Total Billed Charges,88% of Total Billed Charges,20.84,90,,136.536,Percent of Total Billed charges,90% of Total Billed Charges,10.21,23.15,
TEGRETOL 100MG TAB,2500000521,CDM,250,RC,,,Outpatient,100,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,166.384,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,173.32,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,166.384,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,138.656,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
SYNTHOID 0.125MG TAB,2500000522,CDM,250,RC,,,Outpatient,0.125,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,0.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,0.992,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,0.496,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,0.992,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,0.72,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,0.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,1.048,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,0.968,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,0.992,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
GLYCERIN PEDI SUPP,2500000523,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,28.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,34.136,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,17.064,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,34.136,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,24.656,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,16.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,36.032,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,33.376,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,34.136,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
RYTHMOL 150MG TAB,2500000524,CDM,250,RC,,,Outpatient,150,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,19.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,23.016,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,11.512,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,23.016,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,16.624,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,11.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,24.296,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,22.504,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,23.016,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
LEVOTHROID 50MCG TAB,2500000525,CDM,250,RC,,,Outpatient,50,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,110.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,130.976,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,65.488,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,130.976,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,94.592,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,64.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,138.248,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,128.064,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,130.976,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
PROZAC 20MG CAP,2500000526,CDM,250,RC,,,Outpatient,20,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
SYNTHROID 0.112 MG TAB,2500000527,CDM,250,RC,,,Outpatient,0.112,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
EUCERIN CREAM 30GM,2500000528,CDM,250,RC,,,Outpatient,30,gm,41.90,27.24,,41.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31.84,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.17,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,31.43,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.17,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,25.14,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,37.71,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,18.86,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,37.71,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.24,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,18.48,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,39.81,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.87,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,37.71,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,18.48,41.9,
CETACAINE SPRAY,2500000529,CDM,250,RC,,,Outpatient,,,285.55,185.61,,285.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,217.02,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,205.6,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,214.16,75,,49.616,Percent of Total Billed charges,75% of Total Billed Charges,285.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.6,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,171.33,60,,39.688,Percent of Total Billed Charges,60% of Total Billed Charges,257,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,128.5,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,257,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,285.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.61,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,125.93,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,271.27,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,285.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.28,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,257,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,125.93,285.55,
TUCKS MOISTENED PADS,2500000530,CDM,250,RC,,,Outpatient,,,23.15,15.05,,23.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.59,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.67,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,17.36,75,,5.952,Percent of Total Billed charges,75% of Total Billed Charges,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.67,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,13.89,60,,4.76,Percent of Total Billed Charges,60% of Total Billed Charges,20.84,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,10.42,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,20.84,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.05,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,10.21,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.99,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.37,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,20.84,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,10.21,23.15,
PACERONE 200MG TAB,2500000531,CDM,250,RC,,,Outpatient,200,GM,14.33,9.31,,14.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.89,76,,193.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.32,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,10.75,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,8.6,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,12.9,90,,228.616,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,114.304,Percent of Total Billed Charges,45% of Total Billed Charges,12.9,90,,228.616,Percent of Total Billed Charges,90% of Total billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.31,65,,165.112,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,112.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.61,95,,241.312,Percent of Total Billed Charges,95% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.61,88,,223.536,Percent of Total Billed Charges,88% of Total Billed Charges,12.9,90,,228.616,Percent of Total Billed charges,90% of Total Billed Charges,6.32,14.33,
KPHOS 500MG TAB,2500000532,CDM,250,RC,,,Outpatient,500,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
CARDIZEM SR 60 CAP,2500000533,CDM,250,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
NEPTAZANE 50MG TAB,2500000534,CDM,250,RC,,,Outpatient,50,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
CEFTIN 250MG TAB,2500000535,CDM,250,RC,,,Outpatient,250,GM,17.64,11.47,,17.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.41,76,,20.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.7,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.7,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,10.58,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,15.88,90,,24.608,Percent of Total Billed Charges,90% of Total Billed Charges,7.94,45,,12.304,Percent of Total Billed Charges,45% of Total Billed Charges,15.88,90,,24.608,Percent of Total Billed Charges,90% of Total billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.47,65,,17.776,Percent of total Billed Charges,65% of Total Billed Charges,7.78,44.1,,12.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.76,95,,25.976,Percent of Total Billed Charges,95% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.52,88,,24.064,Percent of Total Billed Charges,88% of Total Billed Charges,15.88,90,,24.608,Percent of Total Billed charges,90% of Total Billed Charges,7.78,17.64,
TEGRETOL SUSP 100MG/5ML,2500000536,CDM,250,RC,,,Outpatient,100,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
LACHYDRIN 12% 5OZ,2500000537,CDM,250,RC,,,Outpatient,,,72.77,47.30,,72.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.31,76,,18.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.39,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,54.58,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.39,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,65.49,90,,22.224,Percent of Total Billed Charges,90% of Total Billed Charges,32.75,45,,11.112,Percent of Total Billed Charges,45% of Total Billed Charges,65.49,90,,22.224,Percent of Total Billed Charges,90% of Total billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.3,65,,16.056,Percent of total Billed Charges,65% of Total Billed Charges,32.09,44.1,,10.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,69.13,95,,23.464,Percent of Total Billed Charges,95% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.04,88,,21.736,Percent of Total Billed Charges,88% of Total Billed Charges,65.49,90,,22.224,Percent of Total Billed charges,90% of Total Billed Charges,32.09,72.77,
PRINIVIL 10MG TAB,2500000538,CDM,250,RC,,,Outpatient,10,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,9.928,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,7.936,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
HYDROXYUREA 500MG TAB,2500000539,CDM,250,RC,,,Outpatient,500,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,30.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,36.52,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,18.256,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,36.52,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,26.376,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,17.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,38.544,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,35.704,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,36.52,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
KDUR 20MEQ TAB,2500000540,CDM,250,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
PROVENTIL 3ML U/D NEB 2.5MG,2500000541,CDM,250,RC,,,Outpatient,2.5,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,60.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,71.448,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,35.72,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,71.448,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,51.6,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,35.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,75.416,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,69.856,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,71.448,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
NEOSYNEPHRINE 2.5% OPHTH SOLN,2500000542,CDM,250,RC,,,Outpatient,,,91.51,59.48,,91.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,69.55,76,,175.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.89,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,68.63,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.89,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,54.91,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,82.36,90,,207.976,Percent of Total Billed Charges,90% of Total Billed Charges,41.18,45,,103.992,Percent of Total Billed Charges,45% of Total Billed Charges,82.36,90,,207.976,Percent of Total Billed Charges,90% of Total billed Charges,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.48,65,,150.208,Percent of total Billed Charges,65% of Total Billed Charges,40.36,44.1,,101.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,86.93,95,,219.536,Percent of Total Billed Charges,95% of Total Billed Charges,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.53,88,,203.36,Percent of Total Billed Charges,88% of Total Billed Charges,82.36,90,,207.976,Percent of Total Billed charges,90% of Total Billed Charges,40.36,91.51,
ROBITUSSIN 5CC,2500000543,CDM,250,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,104.784,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,109.144,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,104.784,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,87.32,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
CIPRO 250MG TAB,2500000544,CDM,250,RC,,,Outpatient,250,GM,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,15.71,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
CIPRO 500MG TAB,2500000545,CDM,250,RC,,,Outpatient,500,GM,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
MIOSTAT OPHTH SOLN,2500000546,CDM,250,RC,,,Outpatient,,,138.92,90.30,,138.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,105.58,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.02,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,104.19,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.02,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,83.35,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,125.03,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,62.51,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,125.03,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.3,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,61.26,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,131.97,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.25,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,125.03,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,61.26,138.92,
FLUORISTRIP,2500000547,CDM,250,RC,,,Outpatient,,,189.63,123.26,,189.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.12,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,136.53,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,142.22,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.53,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,113.78,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,170.67,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,85.33,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,170.67,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.26,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,83.63,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,180.15,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.87,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,170.67,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,83.63,189.63,
TORADOL 10MG TAB,2500000548,CDM,250,RC,,,Outpatient,10,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,17.864,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
PEPCID 20MG TAB,2500000549,CDM,250,RC,,,Outpatient,20,GM,1.38,0.90,,1.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.05,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.99,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.04,75,,49.616,Percent of Total Billed charges,75% of Total Billed Charges,1.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.99,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,60,,39.688,Percent of Total Billed Charges,60% of Total Billed Charges,1.24,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,0.62,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,1.24,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,1.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.9,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,0.61,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.31,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,1.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.21,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,1.24,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,0.61,1.38,
SILVADENE CREAM 400G,2500000550,CDM,250,RC,,,Outpatient,,,47.41,30.82,,47.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.03,76,,50.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.14,72,,24.136,Percent of Total Billed Charges,72% of Total Billed Charges,35.56,75,,25.144,Percent of Total Billed charges,75% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.14,72,,24.136,Percent of Total Billed Charges,72% of Total Billed Charges,28.45,60,,20.112,Percent of Total Billed Charges,60% of Total Billed Charges,42.67,90,,59.536,Percent of Total Billed Charges,90% of Total Billed Charges,21.33,45,,29.768,Percent of Total Billed Charges,45% of Total Billed Charges,42.67,90,,59.536,Percent of Total Billed Charges,90% of Total billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.82,65,,43,Percent of total Billed Charges,65% of Total Billed Charges,20.91,44.1,,29.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.04,95,,62.848,Percent of Total Billed Charges,95% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.72,88,,58.216,Percent of Total Billed Charges,88% of Total Billed Charges,42.67,90,,59.536,Percent of Total Billed charges,90% of Total Billed Charges,20.91,47.41,
MUCOMYST 10% 4ML,2500000551,CDM,250,RC,,,Outpatient,4,ML,31.97,20.78,,31.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.3,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.02,72,,52.08,Percent of Total Billed Charges,72% of Total Billed Charges,23.98,75,,54.248,Percent of Total Billed charges,75% of Total Billed Charges,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.02,72,,52.08,Percent of Total Billed Charges,72% of Total Billed Charges,19.18,60,,43.4,Percent of Total Billed Charges,60% of Total Billed Charges,28.77,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,14.39,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,28.77,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.78,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,14.1,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.37,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.13,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,28.77,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,14.1,31.97,
TERAZOL 7 VAG CREAM,2500000552,CDM,250,RC,,,Outpatient,,,181.91,118.24,,181.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,138.25,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,130.98,72,,66.048,Percent of Total Billed Charges,72% of Total Billed Charges,136.43,75,,68.8,Percent of Total Billed charges,75% of Total Billed Charges,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.98,72,,66.048,Percent of Total Billed Charges,72% of Total Billed Charges,109.15,60,,55.04,Percent of Total Billed Charges,60% of Total Billed Charges,163.72,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,81.86,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,163.72,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.24,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,80.22,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,172.81,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.08,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,163.72,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,80.22,181.91,
TYLENOL ELIXIR 5CC,2500000553,CDM,250,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
TUMS,2500000554,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,9.264,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
TYLENOL W/CODEINE 5ML SYRUP,2500000555,CDM,250,RC,,,Outpatient,5,ML,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,27.12,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,21.696,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
COLCHICINE 0.6MG TAB,2500000556,CDM,250,RC,,,Outpatient,0.6,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
VASOTEC 10MG TAB,2500000557,CDM,250,RC,,,Outpatient,10,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
BACTROBAN 2% UNG 15G,2500000558,CDM,250,RC,,,Outpatient,,,317.52,206.39,,317.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,241.32,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,228.61,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,238.14,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,317.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.61,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,190.51,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,285.77,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,142.88,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,285.77,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,317.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,317.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,317.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.39,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,140.03,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,301.64,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,317.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279.42,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,285.77,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,140.03,317.52,
PROCARDIA XL 30MG TAB,2500000559,CDM,250,RC,,,Outpatient,30,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
HYTRIN 1MG TAB,2500000560,CDM,250,RC,,,Outpatient,1,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,8.6,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,6.88,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
HYTRIN 5MG TAB,2500000561,CDM,250,RC,,,Outpatient,5,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
DIFLUCAN 100MG TAB,2500000562,CDM,250,RC,,,Outpatient,100,GM,34.18,22.22,,34.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.98,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.61,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,25.64,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.61,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,20.51,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,30.76,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,15.38,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,30.76,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.22,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,15.07,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.47,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.08,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,30.76,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,15.07,34.18,
PEPTOBISMOL TAB,2500000563,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
AMBIEN 5MG TAB,2500000564,CDM,250,RC,,,Outpatient,5,GM,30.87,20.07,,30.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.46,76,,110.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.23,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.23,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,18.52,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,27.78,90,,130.976,Percent of Total Billed Charges,90% of Total Billed Charges,13.89,45,,65.488,Percent of Total Billed Charges,45% of Total Billed Charges,27.78,90,,130.976,Percent of Total Billed Charges,90% of Total billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.07,65,,94.592,Percent of total Billed Charges,65% of Total Billed Charges,13.61,44.1,,64.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.33,95,,138.248,Percent of Total Billed Charges,95% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.17,88,,128.064,Percent of Total Billed Charges,88% of Total Billed Charges,27.78,90,,130.976,Percent of Total Billed charges,90% of Total Billed Charges,13.61,30.87,
IBUPROFEN 100MG/5ML SUSP,2500000565,CDM,250,RC,,,Outpatient,100,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,5.952,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,4.76,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
TETRACAINE 0.5% OPHTH SOLN,2500000566,CDM,250,RC,,,Outpatient,,,50.72,32.97,,50.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38.55,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36.52,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,38.04,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.52,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,30.43,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,45.65,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,22.82,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,45.65,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.97,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,22.37,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.18,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.63,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,45.65,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,22.37,50.72,
MAGOX 400 TAB,2500000567,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
DURAGESIC25 PATCH,2500000568,CDM,250,RC,,,Outpatient,,,99.23,64.50,,99.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.41,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71.45,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,74.42,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.45,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,59.54,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,89.31,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,44.65,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,89.31,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.5,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,43.76,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,94.27,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.32,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,89.31,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,43.76,99.23,
DURAGESIC 50MCG PATCH,2500000569,CDM,250,RC,,,Outpatient,50,GM,288.86,187.76,,288.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,219.53,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,207.98,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,216.65,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,288.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.98,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,173.32,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,259.97,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,129.99,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,259.97,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,288.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.76,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,127.39,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,274.42,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,288.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,254.2,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,259.97,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,127.39,288.86,
JEVITY 8OZ,2500000570,CDM,250,RC,,,Outpatient,,,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,50.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,36.832,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,38.368,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,36.832,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,30.696,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,59.536,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,29.768,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,59.536,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,43,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,29.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,62.848,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,58.216,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,59.536,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
BIAXIN 500MG TAB,2500000571,CDM,250,RC,,,Outpatient,500,GM,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,25.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,16.536,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,13.232,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,30.168,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,15.088,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,30.168,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,21.792,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,14.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,31.848,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,29.496,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,30.168,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
MAXZIDE 25 TAB,2500000572,CDM,250,RC,,,Outpatient,,,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,54.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,39.376,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,41.016,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,39.376,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,32.816,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,65.096,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,32.544,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,65.096,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,47.016,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,31.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,68.712,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,63.648,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,65.096,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
LORTAB 7.5 MG TAB,2500000573,CDM,250,RC,,,Outpatient,7.5,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,69.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,82.552,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,41.28,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,82.552,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,59.624,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,40.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,87.144,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,80.72,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,82.552,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
LOTENSIN 10MG TAB,2500000574,CDM,250,RC,,,Outpatient,10,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,43.664,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,34.928,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
NIFEREX  150 CAP,2500000575,CDM,250,RC,,,Outpatient,,,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
DICLOXACILLIN 250MG CAP,2500000576,CDM,250,RC,,,Outpatient,250,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,27.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,32.544,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,16.272,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,32.544,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,23.504,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,15.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,34.352,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,31.824,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,32.544,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
ERYTHROMYCIN OPHTH OINT UD,2500000578,CDM,250,RC,,,Outpatient,,,82.69,53.75,,82.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.84,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.54,72,,269.888,Percent of Total Billed Charges,72% of Total Billed Charges,62.02,75,,281.136,Percent of Total Billed charges,75% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,72,,269.888,Percent of Total Billed Charges,72% of Total Billed Charges,49.61,60,,224.912,Percent of Total Billed Charges,60% of Total Billed Charges,74.42,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,37.21,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,74.42,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.75,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,36.47,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,78.56,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,74.42,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,36.47,82.69,
NITROBID OINT 2PCT UD PKT,2500000579,CDM,250,RC,,,Outpatient,,,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,5.95,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,8.93,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,4.37,9.92,
PROPYLTHIOURACIL 50MG TAB,2500000580,CDM,250,RC,,,Outpatient,50,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
NEUTRA PHOSK PACKET,2500000581,CDM,250,RC,,,Outpatient,,,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,8.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,10.32,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,10.32,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,7.448,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,10.888,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,10.088,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,10.32,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
METHIMAZOLE 10MG TAB,2500000582,CDM,250,RC,,,Outpatient,10,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,5.872,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,6.12,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,5.872,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,4.896,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
HYDROCORTISONE 10MG TAB,2500000583,CDM,250,RC,,,Outpatient,10,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
CELLUVISC 1PCT 0.3ML OPHTH,2500000584,CDM,250,RC,,,Outpatient,0.3,ML,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,5.952,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,4.76,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
MISOPROSTOL 100MCG TAB,2500000585,CDM,250,RC,,,Outpatient,100,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
PAROXETINE 20MG TAB,2500000586,CDM,250,RC,,,Outpatient,20,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,103.192,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,82.552,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
BETADINE 10PCT SOLN,2500000587,CDM,250,RC,,,Outpatient,,,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,9.264,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
VERAPAMIL 120MG SA TAB,2500000588,CDM,250,RC,,,Outpatient,120,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,14.56,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
LEVOTHYROXINE 0.088MG TAB,2500000589,CDM,250,RC,,,Outpatient,0.088,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,8.6,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,6.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
DOXAZOSIN 2MG TAB,2500000590,CDM,250,RC,,,Outpatient,2,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
GLIPIZIDE 10MG TAB,2500000591,CDM,250,RC,,,Outpatient,10,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,38.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,35.56,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,37.048,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,35.56,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,29.632,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,46.048,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,23.024,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,46.048,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,33.256,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,22.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,48.6,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,45.024,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,46.048,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
TERCONAZOLE CRM 20GM,2500000592,CDM,250,RC,,,Outpatient,20,gm,181.91,118.24,,181.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,138.25,76,,16.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,130.98,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,136.43,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.98,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,109.15,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,163.72,90,,19.84,Percent of Total Billed Charges,90% of Total Billed Charges,81.86,45,,9.92,Percent of Total Billed Charges,45% of Total Billed Charges,163.72,90,,19.84,Percent of Total Billed Charges,90% of Total billed Charges,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.24,65,,14.328,Percent of total Billed Charges,65% of Total Billed Charges,80.22,44.1,,9.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,172.81,95,,20.944,Percent of Total Billed Charges,95% of Total Billed Charges,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.08,88,,19.4,Percent of Total Billed Charges,88% of Total Billed Charges,163.72,90,,19.84,Percent of Total Billed charges,90% of Total Billed Charges,80.22,181.91,
CEPASTAT LOZ,2500000593,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,41.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,49.216,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,24.608,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,49.216,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,35.544,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,24.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,51.952,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,48.128,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,49.216,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
HCTZ 25MG TAB,2500000594,CDM,250,RC,,,Outpatient,25,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,24.136,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,25.144,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,24.136,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,20.112,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
APAP/CAFF/BUTALB TAB,2500000595,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,44.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,118.12,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,123.04,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,118.12,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,98.432,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,52.392,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,26.2,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,52.392,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,37.84,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,25.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,55.304,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,51.232,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,52.392,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
LORATADINE 10MG TAB,2500000596,CDM,250,RC,,,Outpatient,10,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,36.384,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,29.104,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
NITROGLY 2.5MG CAP,2500000597,CDM,250,RC,,,Outpatient,2.5,GM,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,151.144,Percent of Total Billed Charges,72% of Total Billed Charges,22.33,75,,157.44,Percent of Total Billed charges,75% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,151.144,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,125.952,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
NICOTINE 21MG PATCH,2500000598,CDM,250,RC,,,Outpatient,21,GM,82.69,53.75,,82.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.84,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.54,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,62.02,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,49.61,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,74.42,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,37.21,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,74.42,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.75,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,36.47,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,78.56,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,74.42,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,36.47,82.69,
NICOTINE 7MG PATCH,2500000599,CDM,250,RC,,,Outpatient,7,GM,41.90,27.24,,41.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31.84,76,,284.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.17,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,31.43,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.17,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,25.14,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,37.71,90,,337.36,Percent of Total Billed Charges,90% of Total Billed Charges,18.86,45,,168.68,Percent of Total Billed Charges,45% of Total Billed Charges,37.71,90,,337.36,Percent of Total Billed Charges,90% of Total billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.24,65,,243.648,Percent of total Billed Charges,65% of Total Billed Charges,18.48,44.1,,165.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,39.81,95,,356.104,Percent of Total Billed Charges,95% of Total Billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.87,88,,329.864,Percent of Total Billed Charges,88% of Total Billed Charges,37.71,90,,337.36,Percent of Total Billed charges,90% of Total Billed Charges,18.48,41.9,
FLUOCINONIDE 0.05PCT CREAM,2500000600,CDM,250,RC,,,Outpatient,,,90.41,58.77,,90.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.71,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.1,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,67.81,75,,14.56,Percent of Total Billed charges,75% of Total Billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.1,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,54.25,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,81.37,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,40.68,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,81.37,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.77,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,39.87,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.89,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.56,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,81.37,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,39.87,90.41,
BACITRACIN OPHTH OINT 3.5G,2500000601,CDM,250,RC,,,Outpatient,,,114.66,74.53,,114.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.14,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.56,72,,16.512,Percent of Total Billed Charges,72% of Total Billed Charges,86,75,,17.2,Percent of Total Billed charges,75% of Total Billed Charges,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.56,72,,16.512,Percent of Total Billed Charges,72% of Total Billed Charges,68.8,60,,13.76,Percent of Total Billed Charges,60% of Total Billed Charges,103.19,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,51.6,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,103.19,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.53,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,50.57,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,108.93,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.9,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,103.19,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,50.57,114.66,
VIT A&D OINT 5GM,2500000602,CDM,250,RC,,,Outpatient,5,gm,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
PETROLATUM JELLY 30G,2500000603,CDM,250,RC,,,Outpatient,,,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,6.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,358.8,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,373.744,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,358.8,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,299,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,7.344,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,3.672,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,7.344,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,5.304,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,3.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,7.752,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,7.184,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,7.344,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
RANITIDINE SYRUP 10ML,2500000604,CDM,250,RC,,,Outpatient,10,ML,45.20,29.38,,45.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.35,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.54,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,33.9,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.54,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,27.12,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,40.68,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,20.34,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,40.68,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.38,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,19.93,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.94,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.78,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,40.68,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,19.93,45.2,
LIDO VISC .2PCT 20ML,2500000605,CDM,250,RC,,,Outpatient,20,ML,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,8.6,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,6.88,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
SALSALATE 500MG TAB,2500000606,CDM,250,RC,,,Outpatient,500,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
NEPHROCAPS,2500000607,CDM,250,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,104.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,17.864,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,123.832,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,61.92,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,123.832,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,89.432,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,60.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,130.712,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,121.08,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,123.832,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
RACEMICEPI 2.25% NEB,2500000608,CDM,250,RC,,,Outpatient,,,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
ASCORBIC ACID 500MG/5ML SYRUP,2500000609,CDM,250,RC,,,Outpatient,500,GM,14.33,9.31,,14.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.89,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.32,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,10.75,75,,13.232,Percent of Total Billed charges,75% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,8.6,60,,10.584,Percent of Total Billed Charges,60% of Total Billed Charges,12.9,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,12.9,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.31,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.61,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.61,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,12.9,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,6.32,14.33,
PRENATAL TAB,2500000610,CDM,250,RC,,,Outpatient,,,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,8.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,29.216,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,30.432,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,29.216,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,24.344,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,10.32,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,10.32,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,7.448,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,10.888,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,10.088,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,10.32,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
"ERGOCALCIFEROL 50,000 UNIT CAP",2500000611,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,14.56,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
HYOSCYAMINE 0.375MG TAB,2500000612,CDM,250,RC,,,Outpatient,0.375,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,37.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,42.336,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,33.872,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,44.456,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,22.224,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,44.456,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,32.104,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,21.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,46.92,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,43.464,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,44.456,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
CHLORHEXIDINE 15ML UD,2500000613,CDM,250,RC,,,Outpatient,15,ML,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,17.864,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
SOTALOL 80MG TAB,2500000614,CDM,250,RC,,,Outpatient,80,GM,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,5.95,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,8.93,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,4.37,9.92,
ISONIAZID 300MG TAB,2500000615,CDM,250,RC,,,Outpatient,300,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,25.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,30.168,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,15.088,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,30.168,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,21.792,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,14.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,31.848,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,29.496,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,30.168,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
BENZTROPINE 1MG TAB,2500000616,CDM,250,RC,,,Outpatient,1,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,124.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,174.64,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,181.912,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,174.64,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,145.528,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,147.648,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,73.824,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,147.648,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,106.64,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,72.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,155.856,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,144.368,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,147.648,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
ATENOLOL 25MG TAB,2500000617,CDM,250,RC,,,Outpatient,25,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,36.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,15.88,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,12.704,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,43.664,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,21.832,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,43.664,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,31.536,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,21.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,46.088,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,42.688,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,43.664,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
CALIUM ACETATE 667MG TAB,2500000618,CDM,250,RC,,,Outpatient,667,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,159.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,188.928,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,94.464,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,188.928,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,136.448,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,92.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,199.424,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,184.728,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,188.928,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
CHARCOAL/SORB 25GM/120ML,2500000619,CDM,250,RC,,,Outpatient,25,gm,63.95,41.57,,63.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,48.6,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.04,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,47.96,75,,9.264,Percent of Total Billed charges,75% of Total Billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.04,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,38.37,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,57.56,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,28.78,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,57.56,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.57,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,28.2,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,60.75,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.28,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,57.56,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,28.2,63.95,
HYDROCORTISONE 1% 30G,2500000620,CDM,250,RC,,,Outpatient,,,27.56,17.91,,27.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.95,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.84,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,20.67,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.84,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,24.8,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,12.4,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,24.8,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.91,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,12.15,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.18,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,24.8,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,12.15,27.56,
PHENERGAN 25MG SUP #4E,2500000621,CDM,250,RC,,,Outpatient,25,GM,68.36,44.43,,68.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.95,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49.22,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,51.27,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,41.02,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,61.52,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,30.76,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,61.52,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.43,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,30.15,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,64.94,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.16,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,61.52,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,30.15,68.36,
METOCLOPRAMIDE 10MG/10ML SOLN,2500000622,CDM,250,RC,,,Outpatient,10,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,17.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,187.336,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,195.144,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,187.336,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,156.112,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,20.64,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,10.32,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,20.64,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,14.912,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,10.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,21.792,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,20.184,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,20.64,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
LIDOCAINE 4# TOP SOLN,2500000623,CDM,250,RC,,,Outpatient,,,72.77,47.30,,72.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.31,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.39,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,54.58,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.39,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,65.49,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,32.75,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,65.49,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.3,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,32.09,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,69.13,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.04,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,65.49,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,32.09,72.77,
RAMIPRIL 2.5MG CAP,2500000624,CDM,250,RC,,,Outpatient,2.5,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,378.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,13.232,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,10.584,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,448.496,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,224.248,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,448.496,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,323.912,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,219.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,473.408,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,438.528,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,448.496,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
ACETAMINOPHEN 325MG SUPP,2500000625,CDM,250,RC,,,Outpatient,325,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,228.616,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,238.144,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,228.616,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,190.512,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
URSODIOL 300MG CAP,2500000626,CDM,250,RC,,,Outpatient,300,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,8.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,198.768,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,207.048,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,198.768,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,165.64,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,10.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,10.32,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,7.448,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,10.888,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,10.088,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,10.32,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
DURAGESIC 75MCG/HR PATCH,2500000627,CDM,250,RC,,,Outpatient,75,GM,468.56,304.56,,468.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,356.11,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,337.36,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,351.42,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.36,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,421.7,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,210.85,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,421.7,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.56,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,206.63,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,445.13,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.33,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,421.7,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,206.63,468.56,
BICITRA SOL 30ML,2500000628,CDM,250,RC,,,Outpatient,30,ML,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
LEVOTHROID 0.075MG TAB,2500000629,CDM,250,RC,,,Outpatient,0.075,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,33.08,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
BENADRYL 12.5MG/5ML SYRUP,2500000630,CDM,250,RC,,,Outpatient,12.5,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,13.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,24.136,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,25.144,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,24.136,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,20.112,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,15.88,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,7.936,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,15.88,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,11.464,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,16.76,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,15.52,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,15.88,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
PROCHLORPERAZINE 10MG/2ML,2500000631,CDM,250,RC,,,Outpatient,10,GM,10.20,6.63,,10.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.75,76,,30.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.34,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,7.65,75,,5.952,Percent of Total Billed charges,75% of Total Billed Charges,10.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.34,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,6.12,60,,4.76,Percent of Total Billed Charges,60% of Total Billed Charges,9.18,90,,36.52,Percent of Total Billed Charges,90% of Total Billed Charges,4.59,45,,18.256,Percent of Total Billed Charges,45% of Total Billed Charges,9.18,90,,36.52,Percent of Total Billed Charges,90% of Total billed Charges,10.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.63,65,,26.376,Percent of total Billed Charges,65% of Total Billed Charges,4.5,44.1,,17.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.69,95,,38.544,Percent of Total Billed Charges,95% of Total Billed Charges,10.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.98,88,,35.704,Percent of Total Billed Charges,88% of Total Billed Charges,9.18,90,,36.52,Percent of Total Billed charges,90% of Total Billed Charges,4.5,10.2,
KEFLEX HM 250MG 4S,2500000632,CDM,250,RC,,,Outpatient,250,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,328.312,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,341.992,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,328.312,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,273.592,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
PROZAC 10MG CAP,2500000633,CDM,250,RC,,,Outpatient,10,GM,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,42.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,72,,164.48,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,75,,171.328,Percent of Total Billed charges,75% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,72,,164.48,Percent of Total Billed Charges,72% of Total Billed Charges,5.95,60,,137.064,Percent of Total Billed Charges,60% of Total Billed Charges,8.93,90,,50.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,25.4,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,50.8,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,36.688,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,24.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,53.624,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,49.672,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,50.8,Percent of Total Billed charges,90% of Total Billed Charges,4.37,9.92,
LOMOTIL HM 4E,2500000634,CDM,250,RC,,,Outpatient,,,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
EMLA 5GM,2500000635,CDM,250,RC,,,Outpatient,5,gm,171.99,111.79,,171.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.71,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.83,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,128.99,75,,46.968,Percent of Total Billed charges,75% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.83,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,103.19,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,154.79,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,77.4,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,154.79,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.79,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,75.85,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.39,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.35,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,154.79,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,75.85,171.99,
DETROL 2MG TAB,2500000636,CDM,250,RC,,,Outpatient,2,GM,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,15.216,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,12.176,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
EVISTA 60MG TAB,2500000637,CDM,250,RC,,,Outpatient,60,GM,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,184.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,37.704,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,30.16,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,218.296,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,109.152,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,218.296,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,157.656,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,106.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,230.424,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,213.448,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,218.296,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
REMERON 15MG TAB,2500000638,CDM,250,RC,,,Outpatient,15,GM,14.33,9.31,,14.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.89,76,,16.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.32,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,10.75,75,,10.584,Percent of Total Billed charges,75% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,8.6,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,12.9,90,,19.048,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,9.528,Percent of Total Billed Charges,45% of Total Billed Charges,12.9,90,,19.048,Percent of Total Billed Charges,90% of Total billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.31,65,,13.76,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,9.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.61,95,,20.112,Percent of Total Billed Charges,95% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.61,88,,18.624,Percent of Total Billed Charges,88% of Total Billed Charges,12.9,90,,19.048,Percent of Total Billed charges,90% of Total Billed Charges,6.32,14.33,
ASACOL 400MG TAB,2500000639,CDM,250,RC,,,Outpatient,400,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
B.S.S. 30ML,2500000640,CDM,250,RC,,,Outpatient,30,ML,61.74,40.13,,61.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.92,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,44.45,72,,46.36,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,75,,48.288,Percent of Total Billed charges,75% of Total Billed Charges,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.45,72,,46.36,Percent of Total Billed Charges,72% of Total Billed Charges,37.04,60,,38.632,Percent of Total Billed Charges,60% of Total Billed Charges,55.57,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,27.78,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,55.57,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.13,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,27.23,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,58.65,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.33,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,55.57,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,27.23,61.74,
GLUROPHAGE 850MG TAB,2500000641,CDM,250,RC,,,Outpatient,850,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
HEMOCYTE PLUS TAB,2500000642,CDM,250,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,44.32,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,35.456,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
NICODERM 14MG PATCH,2500000643,CDM,250,RC,,,Outpatient,14,GM,41.90,27.24,,41.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31.84,76,,197.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.17,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,31.43,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.17,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,25.14,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,37.71,90,,234.176,Percent of Total Billed Charges,90% of Total Billed Charges,18.86,45,,117.088,Percent of Total Billed Charges,45% of Total Billed Charges,37.71,90,,234.176,Percent of Total Billed Charges,90% of Total billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.24,65,,169.128,Percent of total Billed Charges,65% of Total Billed Charges,18.48,44.1,,114.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,39.81,95,,247.184,Percent of Total Billed Charges,95% of Total Billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.87,88,,228.968,Percent of Total Billed Charges,88% of Total Billed Charges,37.71,90,,234.176,Percent of Total Billed charges,90% of Total Billed Charges,18.48,41.9,
NITRODUR 0.3MG PATCH,2500000644,CDM,250,RC,,,Outpatient,0.3,GM,205.07,133.30,,205.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,155.85,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,147.65,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,153.8,75,,44.984,Percent of Total Billed charges,75% of Total Billed Charges,205.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.65,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,123.04,60,,35.984,Percent of Total Billed Charges,60% of Total Billed Charges,184.56,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,92.28,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,184.56,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,205.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.3,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,90.44,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,194.82,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,205.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.46,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,184.56,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,90.44,205.07,
ZYPREXA 5MG TAB,2500000645,CDM,250,RC,,,Outpatient,5,GM,60.64,39.42,,60.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.09,76,,13.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.66,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,45.48,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,54.58,90,,15.88,Percent of Total Billed Charges,90% of Total Billed Charges,27.29,45,,7.936,Percent of Total Billed Charges,45% of Total Billed Charges,54.58,90,,15.88,Percent of Total Billed Charges,90% of Total billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.42,65,,11.464,Percent of total Billed Charges,65% of Total Billed Charges,26.74,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.61,95,,16.76,Percent of Total Billed Charges,95% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.36,88,,15.52,Percent of Total Billed Charges,88% of Total Billed Charges,54.58,90,,15.88,Percent of Total Billed charges,90% of Total Billed Charges,26.74,60.64,
AZOPT 1%0PHTH SOL,2500000646,CDM,250,RC,,,Outpatient,,,262.40,170.56,,262.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,199.42,76,,241.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,188.93,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,196.8,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,262.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.93,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,157.44,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,236.16,90,,285.768,Percent of Total Billed Charges,90% of Total Billed Charges,118.08,45,,142.888,Percent of Total Billed Charges,45% of Total Billed Charges,236.16,90,,285.768,Percent of Total Billed Charges,90% of Total billed Charges,262.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.56,65,,206.392,Percent of total Billed Charges,65% of Total Billed Charges,115.72,44.1,,140.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,249.28,95,,301.648,Percent of Total Billed Charges,95% of Total Billed Charges,262.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.91,88,,279.416,Percent of Total Billed Charges,88% of Total Billed Charges,236.16,90,,285.768,Percent of Total Billed charges,90% of Total Billed Charges,115.72,262.4,
CRIXIVAN 200MG CAP,2500000647,CDM,250,RC,,,Outpatient,200,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,209.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,248.456,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,124.232,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,248.456,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,179.44,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,121.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,262.264,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,242.936,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,248.456,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
HEMOCYTE 324MG TAB,2500000648,CDM,250,RC,,,Outpatient,324,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,15.88,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,12.704,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
SINGULAR 10MG TAB,2500000649,CDM,250,RC,,,Outpatient,10,GM,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,8.6,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,6.88,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
THERAGESIC CREME,2500000650,CDM,250,RC,,,Outpatient,,,28.67,18.64,,28.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21.79,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.64,72,,441.352,Percent of Total Billed Charges,72% of Total Billed Charges,21.5,75,,459.744,Percent of Total Billed charges,75% of Total Billed Charges,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.64,72,,441.352,Percent of Total Billed Charges,72% of Total Billed Charges,17.2,60,,367.792,Percent of Total Billed Charges,60% of Total Billed Charges,25.8,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,12.9,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,25.8,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.64,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,12.64,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,27.24,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.23,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,25.8,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,12.64,28.67,
VITAMIN E 1000 UNIT CAP,2500000651,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,25.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,408.968,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,426.008,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,408.968,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,340.808,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,30.168,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,15.088,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,30.168,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,21.792,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,14.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,31.848,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,29.496,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,30.168,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
COSPT OPHT SOL,2500000652,CDM,250,RC,,,Outpatient,,,622.91,404.89,,622.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,473.41,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,448.5,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,467.18,75,,10.584,Percent of Total Billed charges,75% of Total Billed Charges,622.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,448.5,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,373.75,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,560.62,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,280.31,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,560.62,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,622.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,622.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,622.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404.89,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,274.7,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,591.76,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,622.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,548.16,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,560.62,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,274.7,622.91,
VERSED 2MG/ML SYRUP 5ML,2500000653,CDM,250,RC,,,Outpatient,2,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,346.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,410.392,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,205.2,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,410.392,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,296.392,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,201.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,433.192,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,401.272,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,410.392,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
AVAPRO 150MG TAB,2500000654,CDM,250,RC,,,Outpatient,150,GM,14.33,9.31,,14.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.89,76,,173.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.32,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,10.75,75,,11.248,Percent of Total Billed charges,75% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,8.6,60,,8.992,Percent of Total Billed Charges,60% of Total Billed Charges,12.9,90,,205.6,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,102.8,Percent of Total Billed Charges,45% of Total Billed Charges,12.9,90,,205.6,Percent of Total Billed Charges,90% of Total billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.31,65,,148.488,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,100.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.61,95,,217.016,Percent of Total Billed Charges,95% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.61,88,,201.024,Percent of Total Billed Charges,88% of Total Billed Charges,12.9,90,,205.6,Percent of Total Billed charges,90% of Total Billed Charges,6.32,14.33,
VITAMIN B12 TAB 1000MCG,2500000655,CDM,250,RC,,,Outpatient,1000,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
EPIVIR 150MG TAB,2500000656,CDM,250,RC,,,Outpatient,150,GM,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,52.08,Percent of Total Billed Charges,72% of Total Billed Charges,22.33,75,,54.248,Percent of Total Billed charges,75% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,52.08,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,43.4,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
ERY TAB 500MG,2500000657,CDM,250,RC,,,Outpatient,500,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,15.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,18.256,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,9.128,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,18.256,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,13.184,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,8.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,19.272,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,17.856,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,18.256,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
FLOMAX 0.4MG CAP,2500000658,CDM,250,RC,,,Outpatient,0.4,GM,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,38.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.88,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,75,,16.536,Percent of Total Billed charges,75% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.88,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,60,,13.232,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,90,,45.248,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,22.624,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,45.248,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,32.68,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,22.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,47.76,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,44.24,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,45.248,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.05,
LAMISIL 250MG TAB,2500000659,CDM,250,RC,,,Outpatient,250,GM,50.72,32.97,,50.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38.55,76,,10.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36.52,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,38.04,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.52,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,30.43,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,45.65,90,,12.704,Percent of Total Billed Charges,90% of Total Billed Charges,22.82,45,,6.352,Percent of Total Billed Charges,45% of Total Billed Charges,45.65,90,,12.704,Percent of Total Billed Charges,90% of Total billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.97,65,,9.176,Percent of total Billed Charges,65% of Total Billed Charges,22.37,44.1,,6.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.18,95,,13.408,Percent of Total Billed Charges,95% of Total Billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.63,88,,12.416,Percent of Total Billed Charges,88% of Total Billed Charges,45.65,90,,12.704,Percent of Total Billed charges,90% of Total Billed Charges,22.37,50.72,
MYCOLOG OINT 15G,2500000660,CDM,250,RC,,,Outpatient,,,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,354.992,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,369.784,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,354.992,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,295.824,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
POLYTRIM OPHTH SOLN 10ML,2500000661,CDM,250,RC,,,Outpatient,10,ML,70.56,45.86,,70.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.63,76,,48.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.8,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.8,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,42.34,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,63.5,90,,57.944,Percent of Total Billed Charges,90% of Total Billed Charges,31.75,45,,28.976,Percent of Total Billed Charges,45% of Total Billed Charges,63.5,90,,57.944,Percent of Total Billed Charges,90% of Total billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.86,65,,41.848,Percent of total Billed Charges,65% of Total Billed Charges,31.12,44.1,,28.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.03,95,,61.168,Percent of Total Billed Charges,95% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.09,88,,56.656,Percent of Total Billed Charges,88% of Total Billed Charges,63.5,90,,57.944,Percent of Total Billed charges,90% of Total Billed Charges,31.12,70.56,
SEROQUEL 100MG TAB,2500000662,CDM,250,RC,,,Outpatient,100,GM,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,22.33,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
STRESS 600 TAB,2500000663,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,44.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,16.536,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,13.232,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,53.184,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,26.592,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,53.184,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,38.416,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,26.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,56.144,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,52.008,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,53.184,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
WELLBUTRIN SR 150MG,2500000664,CDM,250,RC,,,Outpatient,150,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,7.936,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,6.352,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
DIPROLENE .05 CREAM,2500000665,CDM,250,RC,,,Outpatient,,,303.19,197.07,,303.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,230.42,76,,45.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,218.3,72,,18.416,Percent of Total Billed Charges,72% of Total Billed Charges,227.39,75,,19.184,Percent of Total Billed charges,75% of Total Billed Charges,303.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.3,72,,18.416,Percent of Total Billed Charges,72% of Total Billed Charges,181.91,60,,15.344,Percent of Total Billed Charges,60% of Total Billed Charges,272.87,90,,53.976,Percent of Total Billed Charges,90% of Total Billed Charges,136.44,45,,26.992,Percent of Total Billed Charges,45% of Total Billed Charges,272.87,90,,53.976,Percent of Total Billed Charges,90% of Total billed Charges,303.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.07,65,,38.984,Percent of total Billed Charges,65% of Total Billed Charges,133.71,44.1,,26.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,288.03,95,,56.976,Percent of Total Billed Charges,95% of Total Billed Charges,303.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.81,88,,52.776,Percent of Total Billed Charges,88% of Total Billed Charges,272.87,90,,53.976,Percent of Total Billed charges,90% of Total Billed Charges,133.71,303.19,
LIPITOR 40MG TAB,2500000666,CDM,250,RC,,,Outpatient,40,GM,26.46,17.20,,26.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.11,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.05,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,75,,11.248,Percent of Total Billed charges,75% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.05,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,15.88,60,,8.992,Percent of Total Billed Charges,60% of Total Billed Charges,23.81,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,11.91,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,23.81,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,11.67,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.14,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.28,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,23.81,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,11.67,26.46,
SALIVA SUBSTITUTE,2500000667,CDM,250,RC,,,Outpatient,,,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
TOPAMAX 25MG TAB,2500000668,CDM,250,RC,,,Outpatient,25,GM,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,15.216,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,12.176,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
WELLBUTRIN SR 100MG,2500000669,CDM,250,RC,,,Outpatient,100,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,16.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,19.048,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,9.528,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,19.048,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,13.76,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,9.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,20.112,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,18.624,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,19.048,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
WELLBUTRIN 100MG TAB,2500000670,CDM,250,RC,,,Outpatient,100,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,8.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,10.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,10.32,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,7.448,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,10.888,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,10.088,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,10.32,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
BLEPHAMIDE .2 OPHT,2500000671,CDM,250,RC,,,Outpatient,,,325.24,211.41,,325.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,247.18,76,,465.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,234.17,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,243.93,75,,5.952,Percent of Total Billed charges,75% of Total Billed Charges,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.17,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,195.14,60,,4.76,Percent of Total Billed Charges,60% of Total Billed Charges,292.72,90,,551.696,Percent of Total Billed Charges,90% of Total Billed Charges,146.36,45,,275.848,Percent of Total Billed Charges,45% of Total Billed Charges,292.72,90,,551.696,Percent of Total Billed Charges,90% of Total billed Charges,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.41,65,,398.448,Percent of total Billed Charges,65% of Total Billed Charges,143.43,44.1,,270.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,308.98,95,,582.344,Percent of Total Billed Charges,95% of Total Billed Charges,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.21,88,,539.432,Percent of Total Billed Charges,88% of Total Billed Charges,292.72,90,,551.696,Percent of Total Billed charges,90% of Total Billed Charges,143.43,325.24,
DEMADEX 20MG TAB,2500000672,CDM,250,RC,,,Outpatient,20,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,431.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,511.208,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,255.6,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,511.208,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,369.208,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,250.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,539.608,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,499.848,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,511.208,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
EFFEXOR XR 37.5MG TA,2500000673,CDM,250,RC,,,Outpatient,37.5,GM,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,10.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.88,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.88,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,90,,12.704,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,6.352,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,12.704,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,9.176,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,6.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,13.408,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,12.416,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,12.704,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.05,
TOBRADEX OINT,2500000674,CDM,250,RC,,,Outpatient,,,396.90,257.99,,396.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,301.64,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,285.77,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,297.68,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,396.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.77,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,238.14,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,357.21,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,178.61,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,357.21,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,396.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.99,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,175.03,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,377.06,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,396.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.27,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,357.21,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,175.03,396.9,
METROGEL VAGINAL,2500000675,CDM,250,RC,,,Outpatient,,,345.08,224.30,,345.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,262.26,76,,11.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,248.46,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,258.81,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,345.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.46,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,207.05,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,310.57,90,,13.496,Percent of Total Billed Charges,90% of Total Billed Charges,155.29,45,,6.744,Percent of Total Billed Charges,45% of Total Billed Charges,310.57,90,,13.496,Percent of Total Billed Charges,90% of Total billed Charges,345.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.3,65,,9.744,Percent of total Billed Charges,65% of Total Billed Charges,152.18,44.1,,6.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,327.83,95,,14.24,Percent of Total Billed Charges,95% of Total Billed Charges,345.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.67,88,,13.192,Percent of Total Billed Charges,88% of Total Billed Charges,310.57,90,,13.496,Percent of Total Billed charges,90% of Total Billed Charges,152.18,345.08,
VICODIN TABS4(E),2500000676,CDM,250,RC,,,Outpatient,,,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
MIDODRINE 5MG TAB,2500000677,CDM,250,RC,,,Outpatient,5,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,54.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,65.096,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,32.544,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,65.096,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,47.016,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,31.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,68.712,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,63.648,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,65.096,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
TETRACAINE 0.5% SOLN,2500000678,CDM,250,RC,,,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
ACTOS 30MG TAB,2500000679,CDM,250,RC,,,Outpatient,30,GM,41.90,27.24,,41.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31.84,76,,16.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.17,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,31.43,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.17,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,25.14,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,37.71,90,,19.84,Percent of Total Billed Charges,90% of Total Billed Charges,18.86,45,,9.92,Percent of Total Billed Charges,45% of Total Billed Charges,37.71,90,,19.84,Percent of Total Billed Charges,90% of Total billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.24,65,,14.328,Percent of total Billed Charges,65% of Total Billed Charges,18.48,44.1,,9.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,39.81,95,,20.944,Percent of Total Billed Charges,95% of Total Billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.87,88,,19.4,Percent of Total Billed Charges,88% of Total Billed Charges,37.71,90,,19.84,Percent of Total Billed charges,90% of Total Billed Charges,18.48,41.9,
CELEXA 20MG TAB,2500000680,CDM,250,RC,,,Outpatient,20,GM,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,5.95,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,8.93,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,4.37,9.92,
PATANOL .1% OPHTH SOLN,2500000681,CDM,250,RC,,,Outpatient,,,569.99,370.49,,569.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,433.19,76,,374.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,410.39,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,427.49,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,569.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,410.39,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,341.99,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,512.99,90,,443.736,Percent of Total Billed Charges,90% of Total Billed Charges,256.5,45,,221.872,Percent of Total Billed Charges,45% of Total Billed Charges,512.99,90,,443.736,Percent of Total Billed Charges,90% of Total billed Charges,569.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.49,65,,320.48,Percent of total Billed Charges,65% of Total Billed Charges,251.37,44.1,,217.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,541.49,95,,468.392,Percent of Total Billed Charges,95% of Total Billed Charges,569.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.59,88,,433.872,Percent of Total Billed Charges,88% of Total Billed Charges,512.99,90,,443.736,Percent of Total Billed charges,90% of Total Billed Charges,251.37,569.99,
PSORCON .05 CREAM,2500000682,CDM,250,RC,,,Outpatient,,,285.55,185.61,,285.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,217.02,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,205.6,72,,271.8,Percent of Total Billed Charges,72% of Total Billed Charges,214.16,75,,283.12,Percent of Total Billed charges,75% of Total Billed Charges,285.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.6,72,,271.8,Percent of Total Billed Charges,72% of Total Billed Charges,171.33,60,,226.496,Percent of Total Billed Charges,60% of Total Billed Charges,257,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,128.5,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,257,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,285.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.61,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,125.93,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,271.27,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,285.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.28,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,257,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,125.93,285.55,
ATACAND 16MG TAB,2500000683,CDM,250,RC,,,Outpatient,16,GM,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
LEVAQUIN 250MG TAB,2500000684,CDM,250,RC,,,Outpatient,250,GM,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,16.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,461.04,Percent of Total Billed Charges,72% of Total Billed Charges,58.71,75,,480.256,Percent of Total Billed charges,75% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,461.04,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,384.2,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,19.84,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,9.92,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,19.84,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,14.328,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,9.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,20.944,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,19.4,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,19.84,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
TRIAMCINOLONE 0.025% CREAM,2500000685,CDM,250,RC,,,Outpatient,,,25.36,16.48,,25.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.27,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.26,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,19.02,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.26,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,15.22,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,22.82,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,11.41,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,22.82,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,65,,6.88,Percent of total Billed Charges,65% of Total Billed Charges,11.18,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.09,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,22.82,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,11.18,25.36,
ARAVA 10MG TAB,2500000686,CDM,250,RC,,,Outpatient,10,GM,62.84,40.85,,62.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.76,76,,19.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.24,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,47.13,75,,46.968,Percent of Total Billed charges,75% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.24,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,37.7,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,56.56,90,,23.016,Percent of Total Billed Charges,90% of Total Billed Charges,28.28,45,,11.512,Percent of Total Billed Charges,45% of Total Billed Charges,56.56,90,,23.016,Percent of Total Billed Charges,90% of Total billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.85,65,,16.624,Percent of total Billed Charges,65% of Total Billed Charges,27.71,44.1,,11.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.7,95,,24.296,Percent of Total Billed Charges,95% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.3,88,,22.504,Percent of Total Billed Charges,88% of Total Billed Charges,56.56,90,,23.016,Percent of Total Billed charges,90% of Total Billed Charges,27.71,62.84,
AGGRENOX 25/200 CAP,2500000687,CDM,250,RC,,,Outpatient,,,17.64,11.47,,17.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.41,76,,11.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.7,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,75,,5.952,Percent of Total Billed charges,75% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.7,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,10.58,60,,4.76,Percent of Total Billed Charges,60% of Total Billed Charges,15.88,90,,13.496,Percent of Total Billed Charges,90% of Total Billed Charges,7.94,45,,6.744,Percent of Total Billed Charges,45% of Total Billed Charges,15.88,90,,13.496,Percent of Total Billed Charges,90% of Total billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.47,65,,9.744,Percent of total Billed Charges,65% of Total Billed Charges,7.78,44.1,,6.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.76,95,,14.24,Percent of Total Billed Charges,95% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.52,88,,13.192,Percent of Total Billed Charges,88% of Total Billed Charges,15.88,90,,13.496,Percent of Total Billed charges,90% of Total Billed Charges,7.78,17.64,
ENSURE LIGHT SUPPL,2500000688,CDM,250,RC,,,Outpatient,,,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
CASODEX 50MG TAB,2500000689,CDM,250,RC,,,Outpatient,50,GM,80.48,52.31,,80.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,61.16,76,,15.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.95,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,60.36,75,,11.248,Percent of Total Billed charges,75% of Total Billed Charges,80.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.95,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,48.29,60,,8.992,Percent of Total Billed Charges,60% of Total Billed Charges,72.43,90,,18.256,Percent of Total Billed Charges,90% of Total Billed Charges,36.22,45,,9.128,Percent of Total Billed Charges,45% of Total Billed Charges,72.43,90,,18.256,Percent of Total Billed Charges,90% of Total billed Charges,80.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.31,65,,13.184,Percent of total Billed Charges,65% of Total Billed Charges,35.49,44.1,,8.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,76.46,95,,19.272,Percent of Total Billed Charges,95% of Total Billed Charges,80.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.82,88,,17.856,Percent of Total Billed Charges,88% of Total Billed Charges,72.43,90,,18.256,Percent of Total Billed charges,90% of Total Billed Charges,35.49,80.48,
PRINIVIL 2.5MG TAB,2500000690,CDM,250,RC,,,Outpatient,2.5,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,9.264,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
TRANS DERM SCOP 1.5MG PATCH,2500000691,CDM,250,RC,,,Outpatient,1.5,GM,73.87,48.02,,73.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.14,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.19,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,55.4,75,,14.56,Percent of Total Billed charges,75% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.19,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,44.32,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,66.48,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,33.24,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,66.48,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.02,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,32.58,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,70.18,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.01,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,66.48,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,32.58,73.87,
NIACIN 500MG TAB,2500000692,CDM,250,RC,,,Outpatient,500,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,46.992,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,48.952,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,46.992,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,39.16,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
POLYVIT W/IRON LIQ.,2500000693,CDM,250,RC,,,Outpatient,,,74.97,48.73,,74.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.98,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.98,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,56.23,75,,14.56,Percent of Total Billed charges,75% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.98,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,44.98,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,67.47,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,33.74,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,67.47,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.73,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,33.06,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,71.22,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.97,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,67.47,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,33.06,74.97,
ZOCOR 20MG TAB,2500000694,CDM,250,RC,,,Outpatient,20,GM,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
ZOCOR 40MG TAB,2500000695,CDM,250,RC,,,Outpatient,40,GM,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
MIRALAX 17GM POWDER,2500000696,CDM,250,RC,,,Outpatient,17,gm,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
LIPITOR 20MG TAB,2500000697,CDM,250,RC,,,Outpatient,20,GM,26.46,17.20,,26.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.11,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.05,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,75,,9.928,Percent of Total Billed charges,75% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.05,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,15.88,60,,7.936,Percent of Total Billed Charges,60% of Total Billed Charges,23.81,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,11.91,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,23.81,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,11.67,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.14,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.28,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,23.81,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,11.67,26.46,
REQUIP 0.5MG TAB,2500000698,CDM,250,RC,,,Outpatient,0.5,GM,14.33,9.31,,14.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.89,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.32,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,10.75,75,,24.472,Percent of Total Billed charges,75% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,8.6,60,,19.576,Percent of Total Billed Charges,60% of Total Billed Charges,12.9,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,12.9,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.31,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.61,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.61,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,12.9,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,6.32,14.33,
PULMICORT 0.25MG NEB,2500000699,CDM,250,RC,,,Outpatient,0.25,GM,766.24,498.06,,766.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,582.34,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,551.69,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,574.68,75,,9.928,Percent of Total Billed charges,75% of Total Billed Charges,766.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,551.69,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,459.74,60,,7.936,Percent of Total Billed Charges,60% of Total Billed Charges,689.62,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,344.81,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,689.62,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,766.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,766.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,766.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.06,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,337.91,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,727.93,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,766.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,674.29,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,689.62,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,337.91,766.24,
CIPRO HC OPHT SOLN,2500000700,CDM,250,RC,,,Outpatient,,,710.01,461.51,,710.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,539.61,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,511.21,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,532.51,75,,9.928,Percent of Total Billed charges,75% of Total Billed Charges,710.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511.21,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,426.01,60,,7.936,Percent of Total Billed Charges,60% of Total Billed Charges,639.01,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,319.5,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,639.01,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,710.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,710.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,710.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,461.51,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,313.11,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,674.51,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,710.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,624.81,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,639.01,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,313.11,710.01,
CIPROFLOXACIN 0.3 % OTRC SOLN,2500000701,CDM,250,RC,,,Outpatient,,,17.64,11.47,,17.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.41,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.7,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.7,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,10.58,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,15.88,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,7.94,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,15.88,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.47,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,7.78,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.76,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.52,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,15.88,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,7.78,17.64,
DILAUDID 2MG TAB,2500000702,CDM,250,RC,,,Outpatient,2,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,9.928,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,7.936,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
MICARDIS 40MG TAB,2500000703,CDM,250,RC,,,Outpatient,40,GM,18.74,12.18,,18.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.24,76,,286.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.49,72,,73.032,Percent of Total Billed Charges,72% of Total Billed Charges,14.06,75,,76.072,Percent of Total Billed charges,75% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.49,72,,73.032,Percent of Total Billed Charges,72% of Total Billed Charges,11.24,60,,60.856,Percent of Total Billed Charges,60% of Total Billed Charges,16.87,90,,339.744,Percent of Total Billed Charges,90% of Total Billed Charges,8.43,45,,169.872,Percent of Total Billed Charges,45% of Total Billed Charges,16.87,90,,339.744,Percent of Total Billed Charges,90% of Total billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.18,65,,245.376,Percent of total Billed Charges,65% of Total Billed Charges,8.26,44.1,,166.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.8,95,,358.624,Percent of Total Billed Charges,95% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,88,,332.2,Percent of Total Billed Charges,88% of Total Billed Charges,16.87,90,,339.744,Percent of Total Billed charges,90% of Total Billed Charges,8.26,18.74,
VOLTARENXR 100MG TAB,2500000704,CDM,250,RC,,,Outpatient,100,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
BLEPHLO OPHTH SOLN,2500000705,CDM,250,RC,,,Outpatient,,,90.41,58.77,,90.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.71,76,,486.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.1,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,67.81,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.1,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,54.25,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,81.37,90,,576.304,Percent of Total Billed Charges,90% of Total Billed Charges,40.68,45,,288.152,Percent of Total Billed Charges,45% of Total Billed Charges,81.37,90,,576.304,Percent of Total Billed Charges,90% of Total billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.77,65,,416.216,Percent of total Billed Charges,65% of Total Billed Charges,39.87,44.1,,282.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.89,95,,608.32,Percent of Total Billed Charges,95% of Total Billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.56,88,,563.496,Percent of Total Billed Charges,88% of Total Billed Charges,81.37,90,,576.304,Percent of Total Billed charges,90% of Total Billed Charges,39.87,90.41,
LOTENSIN 40MG TAB,2500000706,CDM,250,RC,,,Outpatient,40,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,37.704,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,30.16,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
ACTOS 15MG TAB,2500000707,CDM,250,RC,,,Outpatient,15,GM,27.56,17.91,,27.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.95,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.84,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,20.67,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.84,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,24.8,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,12.4,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,24.8,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.91,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,12.15,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.18,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,24.8,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,12.15,27.56,
ZOVIRAX 400MG TAB,2500000708,CDM,250,RC,,,Outpatient,400,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
DURAGESIC 100MCG PATCH,2500000709,CDM,250,RC,,,Outpatient,100,GM,616.30,400.60,,616.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,468.39,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,443.74,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,462.23,75,,17.864,Percent of Total Billed charges,75% of Total Billed Charges,616.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,443.74,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,369.78,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,554.67,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,277.34,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,554.67,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,616.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,616.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,616.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.6,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,271.79,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,585.49,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,616.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,542.34,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,554.67,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,271.79,616.3,
GLUCOTROL XL 2.5 TAB,2500000710,CDM,250,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,11.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,13.496,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,6.744,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,13.496,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,9.744,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,6.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,14.24,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,13.192,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,13.496,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
PRINIVIL 20MG TAB,2500000711,CDM,250,RC,,,Outpatient,20,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,12.568,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,10.056,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
PROTONIX 40MG TAB,2500000712,CDM,250,RC,,,Outpatient,40,GM,27.56,17.91,,27.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.95,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.84,72,,187.336,Percent of Total Billed Charges,72% of Total Billed Charges,20.67,75,,195.144,Percent of Total Billed charges,75% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.84,72,,187.336,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,60,,156.112,Percent of Total Billed Charges,60% of Total Billed Charges,24.8,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,12.4,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,24.8,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.91,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,12.15,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.18,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,24.8,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,12.15,27.56,
MOBIC 7.5MG TAB,2500000713,CDM,250,RC,,,Outpatient,7.5,GM,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,49.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,11.248,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,8.992,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,58.744,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,29.376,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,58.744,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,42.424,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,28.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,62.008,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,57.44,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,58.744,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
VALTREX 500MG TAB,2500000714,CDM,250,RC,,,Outpatient,500,GM,31.97,20.78,,31.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.3,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.02,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,23.98,75,,11.248,Percent of Total Billed charges,75% of Total Billed Charges,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.02,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,19.18,60,,8.992,Percent of Total Billed Charges,60% of Total Billed Charges,28.77,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,14.39,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,28.77,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.78,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,14.1,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.37,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.13,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,28.77,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,14.1,31.97,
ACTONEL 5MG TAB,2500000715,CDM,250,RC,,,Outpatient,5,GM,18.74,12.18,,18.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.24,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.49,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,14.06,75,,14.56,Percent of Total Billed charges,75% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.49,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,11.24,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,16.87,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,8.43,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,16.87,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.18,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,8.26,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.8,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,16.87,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,8.26,18.74,
MAVIK 2MG TAB,2500000716,CDM,250,RC,,,Outpatient,2,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,10.584,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
DETROL LA 4MG CAP,2500000717,CDM,250,RC,,,Outpatient,4,GM,25.36,16.48,,25.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.27,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.26,72,,30.48,Percent of Total Billed Charges,72% of Total Billed Charges,19.02,75,,31.752,Percent of Total Billed charges,75% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.26,72,,30.48,Percent of Total Billed Charges,72% of Total Billed Charges,15.22,60,,25.4,Percent of Total Billed Charges,60% of Total Billed Charges,22.82,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,11.41,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,22.82,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,11.18,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.09,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,22.82,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,11.18,25.36,
GLUCOPHAGE XR 500MG,2500000718,CDM,250,RC,,,Outpatient,500,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,15.216,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,12.176,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
MONOPRIL 20MG TAB,2500000719,CDM,250,RC,,,Outpatient,20,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,24.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,46.312,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,37.048,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,29.368,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,14.688,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,29.368,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,21.208,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,14.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,31,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,28.72,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,29.368,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
OXYCONTIN 20MG TAB,2500000720,CDM,250,RC,,,Outpatient,20,GM,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,24.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,75,,15.88,Percent of Total Billed charges,75% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,5.95,60,,12.704,Percent of Total Billed Charges,60% of Total Billed Charges,8.93,90,,29.368,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,14.688,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,29.368,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,21.208,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,14.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,31,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,28.72,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,29.368,Percent of Total Billed charges,90% of Total Billed Charges,4.37,9.92,
ESTRADIOL 1MG TAB,2500000721,CDM,250,RC,,,Outpatient,1,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,9.928,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,7.936,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
PLETAL 100MG TAB,2500000722,CDM,250,RC,,,Outpatient,100,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,19.848,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,15.88,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
ROXANOL 20MG ML LIQUID,2500000723,CDM,250,RC,,,Outpatient,20,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
OSCAL 500 TAB,2500000724,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
PEDI INFANT DECONG S,2500000725,CDM,250,RC,,,Outpatient,,,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,15.216,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,12.176,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
NAPROXEN 500MG TAB,2500000726,CDM,250,RC,,,Outpatient,500,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,77.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,9.928,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,7.936,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,91.288,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,45.648,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,91.288,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,65.928,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,44.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,96.36,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,89.264,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,91.288,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
ULTRACET 37.5/325 TAB,2500000727,CDM,250,RC,,,Outpatient,,,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,11.248,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,8.992,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
EXELON 1.5MG CAP,2500000728,CDM,250,RC,,,Outpatient,1.5,GM,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
TRICOR 54MG TAB,2500000729,CDM,250,RC,,,Outpatient,54,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,38.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,374.04,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,389.624,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,374.04,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,311.696,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,45.248,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,22.624,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,45.248,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,32.68,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,22.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,47.76,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,44.24,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,45.248,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
VIT D 400 UNIT CAP,2500000730,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,134.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,140.24,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,134.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,112.192,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
LUMIGAN OPHT SOLN,2500000731,CDM,250,RC,,,Outpatient,,,471.87,306.72,,471.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,358.62,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,339.75,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,353.9,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,471.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,339.75,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,283.12,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,424.68,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,212.34,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,424.68,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,471.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.72,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,208.09,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,448.28,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,471.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.25,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,424.68,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,208.09,471.87,
MORPHINE 15MG TAB,2500000732,CDM,250,RC,,,Outpatient,15,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,46.312,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,37.048,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
ALPHAGAN 0.15% OPHTH SOLN,2500000733,CDM,250,RC,,,Outpatient,,,800.42,520.27,,800.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608.32,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576.3,72,,32.392,Percent of Total Billed Charges,72% of Total Billed Charges,600.32,75,,33.736,Percent of Total Billed charges,75% of Total Billed Charges,800.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.3,72,,32.392,Percent of Total Billed Charges,72% of Total Billed Charges,480.25,60,,26.992,Percent of Total Billed Charges,60% of Total Billed Charges,720.38,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,360.19,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,720.38,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,800.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520.27,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,352.99,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,760.4,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,800.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704.37,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,720.38,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,352.99,800.42,
ALTACE 1.25MG CAP,2500000734,CDM,250,RC,,,Outpatient,1.25,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
FOSAMAX 70MG TAB,2500000735,CDM,250,RC,,,Outpatient,70,GM,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,197.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,58.71,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,234.176,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,117.088,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,234.176,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,169.128,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,114.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,247.184,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,228.968,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,234.176,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
STARLIX 120MG TAB,2500000736,CDM,250,RC,,,Outpatient,120,GM,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,11.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,5.95,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,8.93,90,,13.496,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,6.744,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,13.496,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,9.744,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,6.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,14.24,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,13.192,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,13.496,Percent of Total Billed charges,90% of Total Billed Charges,4.37,9.92,
DICLOXACILLIN 500MG TAB,2500000737,CDM,250,RC,,,Outpatient,500,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,11.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,85.096,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,88.648,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,85.096,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,70.912,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,13.496,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,6.744,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,13.496,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,9.744,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,6.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,14.24,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,13.192,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,13.496,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
MICARDIS 80MG TAB,2500000738,CDM,250,RC,,,Outpatient,80,GM,18.74,12.18,,18.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.24,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.49,72,,153.68,Percent of Total Billed Charges,72% of Total Billed Charges,14.06,75,,160.088,Percent of Total Billed charges,75% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.49,72,,153.68,Percent of Total Billed Charges,72% of Total Billed Charges,11.24,60,,128.072,Percent of Total Billed Charges,60% of Total Billed Charges,16.87,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,8.43,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,16.87,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.18,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,8.26,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.8,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,16.87,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,8.26,18.74,
RENAGEL 800MG TAB,2500000739,CDM,250,RC,,,Outpatient,800,GM,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,10.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,9.928,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,7.936,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,12.704,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,6.352,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,12.704,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,9.176,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,6.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,13.408,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,12.416,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,12.704,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
PREPERATION H OINT,2500000740,CDM,250,RC,,,Outpatient,,,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,32.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,219.088,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,228.216,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,219.088,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,182.576,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,38.104,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,19.048,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,38.104,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,27.52,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,18.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,40.216,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,37.256,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,38.104,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
NYSTATIN 10000 OINT,2500000741,CDM,250,RC,,,Outpatient,,,81.59,53.03,,81.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.01,76,,15.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,58.74,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,61.19,75,,9.928,Percent of Total Billed charges,75% of Total Billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.74,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,48.95,60,,7.936,Percent of Total Billed Charges,60% of Total Billed Charges,73.43,90,,18.256,Percent of Total Billed Charges,90% of Total Billed Charges,36.72,45,,9.128,Percent of Total Billed Charges,45% of Total Billed Charges,73.43,90,,18.256,Percent of Total Billed Charges,90% of Total billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.03,65,,13.184,Percent of total Billed Charges,65% of Total Billed Charges,35.98,44.1,,8.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,77.51,95,,19.272,Percent of Total Billed Charges,95% of Total Billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.8,88,,17.856,Percent of Total Billed Charges,88% of Total Billed Charges,73.43,90,,18.256,Percent of Total Billed charges,90% of Total Billed Charges,35.98,81.59,
SINGULAIR 5MG TAB,2500000742,CDM,250,RC,,,Outpatient,5,GM,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,46.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,55.568,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,27.784,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,55.568,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,40.136,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,27.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,58.656,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,54.336,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,55.568,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
UROCIT K TAB,2500000743,CDM,250,RC,,,Outpatient,,,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,16.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,19.048,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,9.528,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,19.048,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,13.76,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,9.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,20.112,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,18.624,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,19.048,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
FERROUS GLUCONATE 30,2500000744,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
LORTAB 10/650 TAB,2500000745,CDM,250,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,20.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,86.368,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,89.968,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,86.368,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,71.968,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,23.816,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,11.912,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,23.816,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,17.2,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,11.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,25.144,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,23.288,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,23.816,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
GALANTAMINE 8MG TAB,2500000746,CDM,250,RC,,,Outpatient,8,GM,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,99.696,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,103.856,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,99.696,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,83.08,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
XOPENEX 0.31MG NEB,2500000747,CDM,250,RC,J7614,HCPCS,Outpatient,0.31,GM,40.79,26.51,,40.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31,76,,48.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.18,350,,5.08,Fee Schedule,350% of BCBS fee schedule,5.18,350,,5.296,Fee Schedule,350% of BCBS fee schedule,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.18,350,,5.08,Fee Schedule,350% of BCBS PPO fee schedule,1.48,100,,4.232,Fee Schedule,100% of Blue ADV HMO fee schedule,36.71,90,,57.152,Percent of Total Billed Charges,90% of Total Billed Charges,18.36,45,,28.576,Percent of Total Billed Charges,45% of Total Billed Charges,36.71,90,,57.152,Percent of Total Billed Charges,90% of Total billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.51,65,,41.28,Percent of total Billed Charges,65% of Total Billed Charges,17.99,44.1,,28.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.75,95,,60.328,Percent of Total Billed Charges,95% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.9,88,,55.88,Percent of Total Billed Charges,88% of Total Billed Charges,36.71,90,,57.152,Percent of Total Billed charges,90% of Total Billed Charges,1.48,40.79,
XOPENEX 1.25MG NEB,2500000748,CDM,250,RC,,,Outpatient,1.25,GM,40.79,26.51,,40.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.37,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,30.59,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.37,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,24.47,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,36.71,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,18.36,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,36.71,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.51,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,17.99,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.75,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.9,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,36.71,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,17.99,40.79,
ACCUNEB 1.25MG/3ML NEB,2500000749,CDM,250,RC,J7614,HCPCS,Outpatient,1.25,GM,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,15.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.18,350,,8.256,Fee Schedule,350% of BCBS fee schedule,5.18,350,,8.6,Fee Schedule,350% of BCBS fee schedule,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.18,350,,8.256,Fee Schedule,350% of BCBS PPO fee schedule,1.48,100,,6.88,Fee Schedule,100% of Blue ADV HMO fee schedule,8.93,90,,18.256,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,9.128,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,18.256,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,13.184,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,8.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,19.272,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,17.856,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,18.256,Percent of Total Billed charges,90% of Total Billed Charges,1.48,9.92,
AUGMENTIN XR 1000 TAB,2500000750,CDM,250,RC,,,Outpatient,,,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,10.584,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
COMTAN 200MG TAB,2500000751,CDM,250,RC,,,Outpatient,200,GM,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,11.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,14.56,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,13.496,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,6.744,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,13.496,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,9.744,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,6.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,14.24,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,13.192,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,13.496,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
NORCO 10/325 TAB,2500000752,CDM,250,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
PAXIL CR 12.5MG TAB,2500000753,CDM,250,RC,,,Outpatient,12.5,GM,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,394.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,467.544,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,233.776,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,467.544,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,337.672,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,229.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,493.52,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,457.16,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,467.544,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
ACTONEL 35MG TAB,2500000754,CDM,250,RC,,,Outpatient,35,GM,126.79,82.41,,126.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,96.36,76,,142.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.29,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,95.09,75,,21.168,Percent of Total Billed charges,75% of Total Billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.29,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,76.07,60,,16.936,Percent of Total Billed Charges,60% of Total Billed Charges,114.11,90,,168.288,Percent of Total Billed Charges,90% of Total Billed Charges,57.06,45,,84.144,Percent of Total Billed Charges,45% of Total Billed Charges,114.11,90,,168.288,Percent of Total Billed Charges,90% of Total billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.41,65,,121.536,Percent of total Billed Charges,65% of Total Billed Charges,55.91,44.1,,82.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,120.45,95,,177.632,Percent of Total Billed Charges,95% of Total Billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.58,88,,164.544,Percent of Total Billed Charges,88% of Total Billed Charges,114.11,90,,168.288,Percent of Total Billed charges,90% of Total Billed Charges,55.91,126.79,
TEGRETOL XR 200MG TAB,2500000755,CDM,250,RC,,,Outpatient,200,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
ABILIFY 10MG TAB,2500000756,CDM,250,RC,,,Outpatient,10,GM,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,46.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,55.568,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,27.784,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,55.568,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,40.136,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,27.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,58.656,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,54.336,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,55.568,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
ARIMIDEX 1MG TAB,2500000757,CDM,250,RC,,,Outpatient,1,GM,62.84,40.85,,62.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.76,76,,34.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.24,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,47.13,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.24,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,37.7,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,56.56,90,,40.488,Percent of Total Billed Charges,90% of Total Billed Charges,28.28,45,,20.24,Percent of Total Billed Charges,45% of Total Billed Charges,56.56,90,,40.488,Percent of Total Billed Charges,90% of Total billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.85,65,,29.24,Percent of total Billed Charges,65% of Total Billed Charges,27.71,44.1,,19.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.7,95,,42.736,Percent of Total Billed Charges,95% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.3,88,,39.584,Percent of Total Billed Charges,88% of Total Billed Charges,56.56,90,,40.488,Percent of Total Billed charges,90% of Total Billed Charges,27.71,62.84,
FOLIC ACID 0.4MG TAB,2500000758,CDM,250,RC,,,Outpatient,0.4,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
HIPREX 1G TAB,2500000759,CDM,250,RC,,,Outpatient,,,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,43,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,34.4,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
RESTASIS 0.05% OPHTH SOLN,2500000760,CDM,250,RC,,,Outpatient,,,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,22.33,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
LEXAPRO 10MG TAB,2500000761,CDM,250,RC,,,Outpatient,10,GM,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,89.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,8.6,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,6.88,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,106.376,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,53.184,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,106.376,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,76.824,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,52.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,112.28,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,104.008,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,106.376,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
ZETIA 10MG TAB,2500000762,CDM,250,RC,,,Outpatient,10,GM,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,29.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,15.71,75,,9.264,Percent of Total Billed charges,75% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,34.928,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,17.464,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,34.928,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,25.224,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,17.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,36.864,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,34.152,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,34.928,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
OMNICEF 125/5ML ORAL SUSP,2500000763,CDM,250,RC,,,Outpatient,5,ML,325.24,211.41,,325.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,247.18,76,,162.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,234.17,72,,29.216,Percent of Total Billed Charges,72% of Total Billed Charges,243.93,75,,30.432,Percent of Total Billed charges,75% of Total Billed Charges,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.17,72,,29.216,Percent of Total Billed Charges,72% of Total Billed Charges,195.14,60,,24.344,Percent of Total Billed Charges,60% of Total Billed Charges,292.72,90,,192.104,Percent of Total Billed Charges,90% of Total Billed Charges,146.36,45,,96.048,Percent of Total Billed Charges,45% of Total Billed Charges,292.72,90,,192.104,Percent of Total Billed Charges,90% of Total billed Charges,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.41,65,,138.744,Percent of total Billed Charges,65% of Total Billed Charges,143.43,44.1,,94.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,308.98,95,,202.776,Percent of Total Billed Charges,95% of Total Billed Charges,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.21,88,,187.832,Percent of Total Billed Charges,88% of Total Billed Charges,292.72,90,,192.104,Percent of Total Billed charges,90% of Total Billed Charges,143.43,325.24,
NAMENDA 10MG TAB,2500000764,CDM,250,RC,,,Outpatient,10,GM,18.74,12.18,,18.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.24,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.49,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,14.06,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.49,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,11.24,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,16.87,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,8.43,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,16.87,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.18,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,8.26,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.8,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,16.87,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,8.26,18.74,
TRILEPTAL 300MG TAB,2500000765,CDM,250,RC,,,Outpatient,300,GM,18.74,12.18,,18.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.24,76,,231.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.49,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,14.06,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.49,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,11.24,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,16.87,90,,273.856,Percent of Total Billed Charges,90% of Total Billed Charges,8.43,45,,136.928,Percent of Total Billed Charges,45% of Total Billed Charges,16.87,90,,273.856,Percent of Total Billed Charges,90% of Total billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.18,65,,197.784,Percent of total Billed Charges,65% of Total Billed Charges,8.26,44.1,,134.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.8,95,,289.072,Percent of Total Billed Charges,95% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,88,,267.776,Percent of Total Billed Charges,88% of Total Billed Charges,16.87,90,,273.856,Percent of Total Billed charges,90% of Total Billed Charges,8.26,18.74,
FORADIL 12MCG CAP,2500000766,CDM,250,RC,,,Outpatient,12,GM,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,28.448,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,22.76,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
SEROQUEL 25MG TAB,2500000767,CDM,250,RC,,,Outpatient,25,GM,17.64,11.47,,17.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.41,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.7,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,75,,8.6,Percent of Total Billed charges,75% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.7,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,10.58,60,,6.88,Percent of Total Billed Charges,60% of Total Billed Charges,15.88,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,7.94,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,15.88,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.47,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,7.78,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.76,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.52,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,15.88,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,7.78,17.64,
SPIRIVA 18MCG CAP,2500000768,CDM,250,RC,,,Outpatient,18,GM,52.92,34.40,,52.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.22,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.1,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,39.69,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.1,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,31.75,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,47.63,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,23.81,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,47.63,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.4,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,23.34,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.27,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.57,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,47.63,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,23.34,52.92,
EFFEXOR XR 75MG CAP,2500000769,CDM,250,RC,,,Outpatient,75,GM,25.36,16.48,,25.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.27,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.26,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,19.02,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.26,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,15.22,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,22.82,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,11.41,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,22.82,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,11.18,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.09,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,22.82,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,11.18,25.36,
PLAN B 0.75MG TABS,2500000770,CDM,250,RC,,,Outpatient,0.75,GM,77.18,50.17,,77.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.66,76,,91.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.57,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,57.89,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.57,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,69.46,90,,107.96,Percent of Total Billed Charges,90% of Total Billed Charges,34.73,45,,53.976,Percent of Total Billed Charges,45% of Total Billed Charges,69.46,90,,107.96,Percent of Total Billed Charges,90% of Total billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.17,65,,77.968,Percent of total Billed Charges,65% of Total Billed Charges,34.04,44.1,,52.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.32,95,,113.952,Percent of Total Billed Charges,95% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.92,88,,105.56,Percent of Total Billed Charges,88% of Total Billed Charges,69.46,90,,107.96,Percent of Total Billed charges,90% of Total Billed Charges,34.04,77.18,
RISPERDALM 0.5MG TA,2500000771,CDM,250,RC,,,Outpatient,0.5,GM,26.46,17.20,,26.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.11,76,,105.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.05,72,,53.976,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,75,,56.224,Percent of Total Billed charges,75% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.05,72,,53.976,Percent of Total Billed Charges,72% of Total Billed Charges,15.88,60,,44.984,Percent of Total Billed Charges,60% of Total Billed Charges,23.81,90,,124.624,Percent of Total Billed Charges,90% of Total Billed Charges,11.91,45,,62.312,Percent of Total Billed Charges,45% of Total Billed Charges,23.81,90,,124.624,Percent of Total Billed Charges,90% of Total billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,65,,90.008,Percent of total Billed Charges,65% of Total Billed Charges,11.67,44.1,,61.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.14,95,,131.552,Percent of Total Billed Charges,95% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.28,88,,121.856,Percent of Total Billed Charges,88% of Total Billed Charges,23.81,90,,124.624,Percent of Total Billed charges,90% of Total Billed Charges,11.67,26.46,
TARKA 4240 TAB,2500000772,CDM,250,RC,,,Outpatient,,,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
WELLBUTRIN XL 150MG,2500000773,CDM,250,RC,,,Outpatient,150,GM,33.08,21.50,,33.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.14,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.82,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,24.81,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.82,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,29.77,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,14.89,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,29.77,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.5,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,14.59,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.43,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.11,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,29.77,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,14.59,33.08,
CONSTULOSE 10MG/15ML ORAL SUSP,2500000774,CDM,250,RC,,,Outpatient,10,GM,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,8.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,10.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,10.32,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,7.448,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,10.888,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,10.088,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,10.32,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
ALBUTEROL 2.5MG/0.5ML NEB,2500000775,CDM,250,RC,J7613,HCPCS,Outpatient,2.5,GM,79.38,51.60,,79.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60.33,76,,10.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.28,350,,5.712,Fee Schedule,350% of BCBS fee schedule,0.28,350,,5.952,Fee Schedule,350% of BCBS fee schedule,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.28,350,,5.712,Fee Schedule,350% of BCBS PPO fee schedule,0.08,100,,4.76,Fee Schedule,100% of Blue ADV HMO fee schedule,71.44,90,,12.704,Percent of Total Billed Charges,90% of Total Billed Charges,35.72,45,,6.352,Percent of Total Billed Charges,45% of Total Billed Charges,71.44,90,,12.704,Percent of Total Billed Charges,90% of Total billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,65,,9.176,Percent of total Billed Charges,65% of Total Billed Charges,35.01,44.1,,6.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,75.41,95,,13.408,Percent of Total Billed Charges,95% of Total Billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.85,88,,12.416,Percent of Total Billed Charges,88% of Total Billed Charges,71.44,90,,12.704,Percent of Total Billed charges,90% of Total Billed Charges,0.08,79.38,
PHENOBARB 20MG/5ML SOLN,2500000776,CDM,250,RC,,,Outpatient,20,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
TRICOR 145MG TAB,2500000777,CDM,250,RC,,,Outpatient,145,GM,25.36,16.48,,25.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.27,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.26,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,19.02,75,,220.944,Percent of Total Billed charges,75% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.26,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,15.22,60,,176.752,Percent of Total Billed Charges,60% of Total Billed Charges,22.82,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,11.41,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,22.82,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,11.18,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.09,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,22.82,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,11.18,25.36,
MEGACE 400MG/10ML SUSP,2500000778,CDM,250,RC,,,Outpatient,400,GM,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,358.8,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,373.744,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,358.8,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,299,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
AVODART 0.5MG CAP,2500000779,CDM,250,RC,,,Outpatient,0.5,GM,18.74,12.18,,18.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.24,76,,21.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.49,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,14.06,75,,8.6,Percent of Total Billed charges,75% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.49,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,11.24,60,,6.88,Percent of Total Billed Charges,60% of Total Billed Charges,16.87,90,,25.4,Percent of Total Billed Charges,90% of Total Billed Charges,8.43,45,,12.704,Percent of Total Billed Charges,45% of Total Billed Charges,16.87,90,,25.4,Percent of Total Billed Charges,90% of Total billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.18,65,,18.344,Percent of total Billed Charges,65% of Total Billed Charges,8.26,44.1,,12.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.8,95,,26.816,Percent of Total Billed Charges,95% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,88,,24.84,Percent of Total Billed Charges,88% of Total Billed Charges,16.87,90,,25.4,Percent of Total Billed charges,90% of Total Billed Charges,8.26,18.74,
CARAFATE 1GM/10ML SUSP,2500000780,CDM,250,RC,,,Outpatient,1,gm,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
CIPRODEX OPHTH SOLN,2500000781,CDM,250,RC,,,Outpatient,,,649.37,422.09,,649.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,493.52,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,467.55,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,487.03,75,,11.248,Percent of Total Billed charges,75% of Total Billed Charges,649.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,467.55,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,389.62,60,,8.992,Percent of Total Billed Charges,60% of Total Billed Charges,584.43,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,292.22,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,584.43,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,649.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.09,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,286.37,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,616.9,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,649.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,571.45,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,584.43,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,286.37,649.37,
AUGMENT 600MG/5ML ORAL SUSP,2500000782,CDM,250,RC,,,Outpatient,600,GM,233.73,151.92,,233.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,177.63,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,168.29,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,175.3,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.29,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,140.24,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,210.36,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,105.18,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,210.36,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.92,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,103.07,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,222.04,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.68,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,210.36,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,103.07,233.73,
ROBITUSSIN DM 5ML UD,2500000783,CDM,250,RC,,,Outpatient,5,ML,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,32.392,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,33.736,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,32.392,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,26.992,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
FEMARA 2.5MG TAB,2500000784,CDM,250,RC,,,Outpatient,2.5,GM,77.18,50.17,,77.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.66,76,,43.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.57,72,,16.512,Percent of Total Billed Charges,72% of Total Billed Charges,57.89,75,,17.2,Percent of Total Billed charges,75% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.57,72,,16.512,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,60,,13.76,Percent of Total Billed Charges,60% of Total Billed Charges,69.46,90,,51.592,Percent of Total Billed Charges,90% of Total Billed Charges,34.73,45,,25.8,Percent of Total Billed Charges,45% of Total Billed Charges,69.46,90,,51.592,Percent of Total Billed Charges,90% of Total billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.17,65,,37.264,Percent of total Billed Charges,65% of Total Billed Charges,34.04,44.1,,25.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.32,95,,54.464,Percent of Total Billed Charges,95% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.92,88,,50.448,Percent of Total Billed Charges,88% of Total Billed Charges,69.46,90,,51.592,Percent of Total Billed charges,90% of Total Billed Charges,34.04,77.18,
LIDODERM 5% PATCH,2500000785,CDM,250,RC,,,Outpatient,,,56.23,36.55,,56.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.73,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.49,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,42.17,75,,36.384,Percent of Total Billed charges,75% of Total Billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.49,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,33.74,60,,29.104,Percent of Total Billed Charges,60% of Total Billed Charges,50.61,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,25.3,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,50.61,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.55,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,24.8,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.42,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.48,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,50.61,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,24.8,56.23,
LANOXIN 0.05MG/ML SOLN,2500000786,CDM,250,RC,,,Outpatient,0.05,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,8.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,10.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,10.32,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,7.448,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,10.888,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,10.088,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,10.32,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
BENADRYL 25MG/10 ML UD ELIXIR,2500000787,CDM,250,RC,,,Outpatient,25,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,12.568,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,10.056,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
NYSTATIN 5ML ORAL SUSP,2500000788,CDM,250,RC,,,Outpatient,5,ML,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,30.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,8.6,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,6.88,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,36.52,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,18.256,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,36.52,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,26.376,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,17.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,38.544,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,35.704,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,36.52,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
ISOPTO HYOSCINE 0.25% SOLN,2500000789,CDM,250,RC,,,Outpatient,,,147.74,96.03,,147.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,112.28,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,106.37,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,110.81,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,147.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.37,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,88.64,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,132.97,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,66.48,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,132.97,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,147.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.03,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,65.15,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,140.35,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,147.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.01,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,132.97,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,65.15,147.74,
PULMICORT 0.5MG/2ML NEB,2500000790,CDM,250,RC,J7626,HCPCS,Outpatient,0.5,GM,48.51,31.53,,48.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.87,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.33,350,,43.816,Fee Schedule,350% of BCBS fee schedule,22.33,350,,45.64,Fee Schedule,350% of BCBS fee schedule,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.33,350,,43.816,Fee Schedule,350% of BCBS PPO fee schedule,6.38,100,,36.512,Fee Schedule,100% of Blue ADV HMO fee schedule,43.66,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,21.83,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,43.66,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.53,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,21.39,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.08,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.69,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,43.66,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,6.38,48.51,
ZIOX 405 OINTMENT,2500000791,CDM,250,RC,,,Outpatient,,,266.81,173.43,,266.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,202.78,76,,28.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,192.1,72,,73.032,Percent of Total Billed Charges,72% of Total Billed Charges,200.11,75,,76.072,Percent of Total Billed charges,75% of Total Billed Charges,266.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.1,72,,73.032,Percent of Total Billed Charges,72% of Total Billed Charges,160.09,60,,60.856,Percent of Total Billed Charges,60% of Total Billed Charges,240.13,90,,34.136,Percent of Total Billed Charges,90% of Total Billed Charges,120.06,45,,17.064,Percent of Total Billed Charges,45% of Total Billed Charges,240.13,90,,34.136,Percent of Total Billed Charges,90% of Total billed Charges,266.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.43,65,,24.656,Percent of total Billed Charges,65% of Total Billed Charges,117.66,44.1,,16.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,253.47,95,,36.032,Percent of Total Billed Charges,95% of Total Billed Charges,266.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.79,88,,33.376,Percent of Total Billed Charges,88% of Total Billed Charges,240.13,90,,34.136,Percent of Total Billed charges,90% of Total Billed Charges,117.66,266.81,
VAGISIL CREAM,2500000792,CDM,250,RC,,,Outpatient,,,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,8.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,27.12,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,21.696,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,10.32,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,10.32,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,7.448,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,10.888,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,10.088,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,10.32,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
OMNICEF 250/5 ORAL SUSP,2500000793,CDM,250,RC,,,Outpatient,,,380.36,247.23,,380.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,289.07,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,273.86,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,285.27,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,380.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.86,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,228.22,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,342.32,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,171.16,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,342.32,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,380.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.23,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,167.74,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,361.34,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,380.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.72,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,342.32,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,167.74,380.36,
LITTLE NOSES SALINE,2500000794,CDM,250,RC,,,Outpatient,,,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
COREG 25MG TAB,2500000795,CDM,250,RC,,,Outpatient,25,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
TYLENOL W/CODEINE TAB 4S,2500000796,CDM,250,RC,,,Outpatient,,,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,56.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,94.616,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,98.56,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,94.616,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,78.848,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,67.472,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,33.736,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,67.472,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,48.728,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,33.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,71.216,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,65.968,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,67.472,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
TYLENOL W/CODEINE TAB 4E,2500000797,CDM,250,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
VENTOLIN INHALER (E),2500000798,CDM,250,RC,,,Outpatient,,,149.94,97.46,,149.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,113.95,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,107.96,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,112.46,75,,12.568,Percent of Total Billed charges,75% of Total Billed Charges,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.96,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,89.96,60,,10.056,Percent of Total Billed Charges,60% of Total Billed Charges,134.95,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,67.47,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,134.95,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.46,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,66.12,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.44,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.95,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,134.95,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,66.12,149.94,
VENTOLIN INHALER (S),2500000799,CDM,250,RC,,,Outpatient,,,173.09,112.51,,173.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,131.55,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,124.62,72,,48.264,Percent of Total Billed Charges,72% of Total Billed Charges,129.82,75,,50.272,Percent of Total Billed charges,75% of Total Billed Charges,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.62,72,,48.264,Percent of Total Billed Charges,72% of Total Billed Charges,103.85,60,,40.216,Percent of Total Billed Charges,60% of Total Billed Charges,155.78,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,77.89,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,155.78,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.51,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,76.33,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,164.44,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.32,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,155.78,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,76.33,173.09,
AMOXIL 250MG CAP (E) 4,2500000800,CDM,250,RC,,,Outpatient,250,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,153.04,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,159.424,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,153.04,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,127.536,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
AMOXIL 250MG CAP (S) 4,2500000801,CDM,250,RC,,,Outpatient,250,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,114.304,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,119.072,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,114.304,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,95.256,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
AMOXIL 125MG/5ML SUS E 100ML,2500000802,CDM,250,RC,,,Outpatient,125,GM,14.33,9.31,,14.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.89,76,,223.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.32,72,,2897.688,Percent of Total Billed Charges,72% of Total Billed Charges,10.75,75,,3018.424,Percent of Total Billed charges,75% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,72,,2897.688,Percent of Total Billed Charges,72% of Total Billed Charges,8.6,60,,2414.744,Percent of Total Billed Charges,60% of Total Billed Charges,12.9,90,,265.136,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,132.568,Percent of Total Billed Charges,45% of Total Billed Charges,12.9,90,,265.136,Percent of Total Billed Charges,90% of Total billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.31,65,,191.488,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,129.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.61,95,,279.864,Percent of Total Billed Charges,95% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.61,88,,259.24,Percent of Total Billed Charges,88% of Total Billed Charges,12.9,90,,265.136,Percent of Total Billed charges,90% of Total Billed Charges,6.32,14.33,
AMOXIL 125MG/5ML SUS S 100ML,2500000803,CDM,250,RC,,,Outpatient,125,GM,17.64,11.47,,17.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.41,76,,378.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.7,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,75,,18.52,Percent of Total Billed charges,75% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.7,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,10.58,60,,14.816,Percent of Total Billed Charges,60% of Total Billed Charges,15.88,90,,448.496,Percent of Total Billed Charges,90% of Total Billed Charges,7.94,45,,224.248,Percent of Total Billed Charges,45% of Total Billed Charges,15.88,90,,448.496,Percent of Total Billed Charges,90% of Total billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.47,65,,323.912,Percent of total Billed Charges,65% of Total Billed Charges,7.78,44.1,,219.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.76,95,,473.408,Percent of Total Billed Charges,95% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.52,88,,438.528,Percent of Total Billed Charges,88% of Total Billed Charges,15.88,90,,448.496,Percent of Total Billed charges,90% of Total Billed Charges,7.78,17.64,
AMOXIL 250MG/5ML SUS E 100ML,2500000804,CDM,250,RC,,,Outpatient,250,GM,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,8.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,10.32,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,10.32,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,7.448,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,10.888,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,10.088,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,10.32,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
AMOXIL 250MG/5ML SUS S 100ML,2500000805,CDM,250,RC,,,Outpatient,250,GM,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,8.6,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,6.88,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
KEFLEX 250MG CAP (S),2500000806,CDM,250,RC,,,Outpatient,250,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,11.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,13.496,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,6.744,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,13.496,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,9.744,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,6.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,14.24,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,13.192,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,13.496,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
KEFLEX 125MG/5ML SUS,2500000807,CDM,250,RC,,,Outpatient,125,GM,35.28,22.93,,35.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.81,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.4,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.4,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,21.17,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,31.75,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,15.88,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,31.75,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.93,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,15.56,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.52,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.05,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,31.75,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,15.56,35.28,
VIBRAMYCIN 100MG TAB,2500000808,CDM,250,RC,,,Outpatient,100,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,34.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,24.768,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,25.8,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,24.768,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,20.64,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,40.488,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,20.24,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,40.488,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,29.24,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,19.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,42.736,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,39.584,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,40.488,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
BACTRIM DS TABS (E) 2,2500000809,CDM,250,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,17.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,26.464,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,21.168,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,20.64,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,10.32,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,20.64,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,14.912,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,10.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,21.792,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,20.184,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,20.64,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
BACTRIM DS TABS (S) 2,2500000810,CDM,250,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,36.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,43.664,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,21.832,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,43.664,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,31.536,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,21.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,46.088,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,42.688,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,43.664,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
MIRAPEX 1MG TAB,2500000811,CDM,250,RC,,,Outpatient,1,GM,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
KEFLEX 250/5 SUSP (E,2500000812,CDM,250,RC,,,Outpatient,,,71.66,46.58,,71.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.46,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.6,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,53.75,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,43,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,64.49,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,32.25,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,64.49,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.58,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,31.6,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.08,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,64.49,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,31.6,71.66,
TYLENOL W/CODN ELX(E 60ML,2500000813,CDM,250,RC,,,Outpatient,60,ML,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,8.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,10.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,10.32,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,7.448,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,10.888,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,10.088,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,10.32,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
TYLENOL W/CODN ELX(S 60ML,2500000814,CDM,250,RC,,,Outpatient,60,ML,14.33,9.31,,14.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.89,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.32,72,,455.96,Percent of Total Billed Charges,72% of Total Billed Charges,10.75,75,,474.96,Percent of Total Billed charges,75% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,72,,455.96,Percent of Total Billed Charges,72% of Total Billed Charges,8.6,60,,379.968,Percent of Total Billed Charges,60% of Total Billed Charges,12.9,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,12.9,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.31,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.61,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.61,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,12.9,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,6.32,14.33,
LYRICA 75MG TAB,2500000815,CDM,250,RC,,,Outpatient,75,GM,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,46.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,54.768,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,27.384,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,54.768,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,39.56,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,26.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,57.816,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,53.552,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,54.768,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
KEFLEX 250/5 (S),2500000816,CDM,250,RC,,,Outpatient,,,50.72,32.97,,50.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38.55,76,,77.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36.52,72,,567.088,Percent of Total Billed Charges,72% of Total Billed Charges,38.04,75,,590.72,Percent of Total Billed charges,75% of Total Billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.52,72,,567.088,Percent of Total Billed Charges,72% of Total Billed Charges,30.43,60,,472.576,Percent of Total Billed Charges,60% of Total Billed Charges,45.65,90,,91.288,Percent of Total Billed Charges,90% of Total Billed Charges,22.82,45,,45.648,Percent of Total Billed Charges,45% of Total Billed Charges,45.65,90,,91.288,Percent of Total Billed Charges,90% of Total billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.97,65,,65.928,Percent of total Billed Charges,65% of Total Billed Charges,22.37,44.1,,44.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.18,95,,96.36,Percent of Total Billed Charges,95% of Total Billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.63,88,,89.264,Percent of Total Billed Charges,88% of Total Billed Charges,45.65,90,,91.288,Percent of Total Billed charges,90% of Total Billed Charges,22.37,50.72,
MIRAPEX 0.25MG TAB,2500000817,CDM,250,RC,,,Outpatient,0.25,GM,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,27.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,782.368,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,814.968,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,782.368,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,651.976,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,32.544,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,16.272,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,32.544,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,23.504,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,15.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,34.352,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,31.824,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,32.544,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
PROTONIX 20MG TABLET,2500000822,CDM,250,RC,,,Outpatient,20,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
CELLCEPT 500MG TAB,2500000823,CDM,250,RC,,,Outpatient,500,GM,47.41,30.82,,47.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.03,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.14,72,,19.688,Percent of Total Billed Charges,72% of Total Billed Charges,35.56,75,,20.512,Percent of Total Billed charges,75% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.14,72,,19.688,Percent of Total Billed Charges,72% of Total Billed Charges,28.45,60,,16.408,Percent of Total Billed Charges,60% of Total Billed Charges,42.67,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,21.33,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,42.67,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.82,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,20.91,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.04,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.72,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,42.67,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,20.91,47.41,
BENICAR 20MG TAB,2500000824,CDM,250,RC,,,Outpatient,20,GM,14.33,9.31,,14.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.89,76,,50.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.32,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,10.75,75,,9.928,Percent of Total Billed charges,75% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,8.6,60,,7.936,Percent of Total Billed Charges,60% of Total Billed Charges,12.9,90,,60.328,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,30.168,Percent of Total Billed Charges,45% of Total Billed Charges,12.9,90,,60.328,Percent of Total Billed Charges,90% of Total billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.31,65,,43.568,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,29.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.61,95,,63.68,Percent of Total Billed Charges,95% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.61,88,,58.992,Percent of Total Billed Charges,88% of Total Billed Charges,12.9,90,,60.328,Percent of Total Billed charges,90% of Total Billed Charges,6.32,14.33,
OXCODONE 5MG IR CAP,2500000825,CDM,250,RC,,,Outpatient,5,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,161.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,19.848,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,15.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,191.304,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,95.656,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,191.304,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,138.168,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,93.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,201.936,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,187.056,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,191.304,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
THERAGESIC CREAM,2500000826,CDM,250,RC,,,Outpatient,,,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,120.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,9.264,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,142.888,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,71.44,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,142.888,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,103.192,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,70.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,150.824,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,139.712,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,142.888,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
NORCO 5MG/325MG TAB,2500000827,CDM,250,RC,,,Outpatient,5,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,3058.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,3622.112,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,1811.056,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,3622.112,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,2615.968,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,1774.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,3823.336,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,3541.616,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,3622.112,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
PROVIGIL 100MG TAB,2500000828,CDM,250,RC,,,Outpatient,100,GM,93.71,60.91,,93.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,71.22,76,,18.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,67.47,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,70.28,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,93.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.47,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,56.23,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,84.34,90,,22.224,Percent of Total Billed Charges,90% of Total Billed Charges,42.17,45,,11.112,Percent of Total Billed Charges,45% of Total Billed Charges,84.34,90,,22.224,Percent of Total Billed Charges,90% of Total billed Charges,93.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.91,65,,16.056,Percent of total Billed Charges,65% of Total Billed Charges,41.33,44.1,,10.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,89.02,95,,23.464,Percent of Total Billed Charges,95% of Total Billed Charges,93.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.46,88,,21.736,Percent of Total Billed Charges,88% of Total Billed Charges,84.34,90,,22.224,Percent of Total Billed charges,90% of Total Billed Charges,41.33,93.71,
CALCIUM GLUCONATE 50,2500000829,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,5.952,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,4.76,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
AMITIZA 24MCG CAP,2500000830,CDM,250,RC,,,Outpatient,24,GM,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,8.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,10.32,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,10.32,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,7.448,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,10.888,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,10.088,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,10.32,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
DEPAKOTE 125MG CAP,2500000831,CDM,250,RC,,,Outpatient,125,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
BYSTOLIC 5MG TAB,2500000832,CDM,250,RC,,,Outpatient,5,GM,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,72,,116.216,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,75,,121.056,Percent of Total Billed charges,75% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,72,,116.216,Percent of Total Billed Charges,72% of Total Billed Charges,5.95,60,,96.848,Percent of Total Billed Charges,60% of Total Billed Charges,8.93,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,4.37,9.92,
CLARITIN D12 TAB,2500000833,CDM,250,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,26.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,30.96,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,15.48,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,30.96,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,22.36,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,15.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,32.68,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,30.272,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,30.96,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
ALPHAGAN 0.1% 5ML OPHTH SOLN,2500000834,CDM,250,RC,,,Outpatient,5,ML,368.24,239.36,,368.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,279.86,76,,26.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,265.13,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,276.18,75,,18.52,Percent of Total Billed charges,75% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.13,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,220.94,60,,14.816,Percent of Total Billed Charges,60% of Total Billed Charges,331.42,90,,31.752,Percent of Total Billed Charges,90% of Total Billed Charges,165.71,45,,15.88,Percent of Total Billed Charges,45% of Total Billed Charges,331.42,90,,31.752,Percent of Total Billed Charges,90% of Total billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.36,65,,22.936,Percent of total Billed Charges,65% of Total Billed Charges,162.39,44.1,,15.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,349.83,95,,33.52,Percent of Total Billed Charges,95% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.05,88,,31.048,Percent of Total Billed Charges,88% of Total Billed Charges,331.42,90,,31.752,Percent of Total Billed charges,90% of Total Billed Charges,162.39,368.24,
NEVANAC OPHTH SOLN,2500000835,CDM,250,RC,,,Outpatient,,,622.91,404.89,,622.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,473.41,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,448.5,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,467.18,75,,16.536,Percent of Total Billed charges,75% of Total Billed Charges,622.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,448.5,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,373.75,60,,13.232,Percent of Total Billed Charges,60% of Total Billed Charges,560.62,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,280.31,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,560.62,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,622.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,622.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,622.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404.89,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,274.7,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,591.76,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,622.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,548.16,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,560.62,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,274.7,622.91,
BACTROBAN 2% OINT,2500000836,CDM,250,RC,,,Outpatient,,,14.33,9.31,,14.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.89,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.32,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,10.75,75,,11.248,Percent of Total Billed charges,75% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,8.6,60,,8.992,Percent of Total Billed Charges,60% of Total Billed Charges,12.9,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,12.9,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.31,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.61,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.61,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,12.9,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,6.32,14.33,
FIORINAL W/CODEINE TAB,2500000837,CDM,250,RC,,,Outpatient,,,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,37.472,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,39.032,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,37.472,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,31.224,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
PRADAXA 150MG CAP,2500000838,CDM,250,RC,,,Outpatient,150,GM,18.74,12.18,,18.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.24,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.49,72,,242.592,Percent of Total Billed Charges,72% of Total Billed Charges,14.06,75,,252.696,Percent of Total Billed charges,75% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.49,72,,242.592,Percent of Total Billed Charges,72% of Total Billed Charges,11.24,60,,202.16,Percent of Total Billed Charges,60% of Total Billed Charges,16.87,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,8.43,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,16.87,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.18,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,8.26,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.8,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,16.87,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,8.26,18.74,
ISOSORBIDE MONO 20MG TAB,2500000839,CDM,250,RC,,,Outpatient,20,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,481.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,332.76,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,346.624,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,332.76,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,277.304,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,569.952,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,284.976,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,569.952,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,411.632,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,279.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,601.616,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,557.288,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,569.952,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
EXELON PATCH 4.6MG/24HR PATCH,2500000840,CDM,250,RC,,,Outpatient,4.6,GM,56.23,36.55,,56.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.73,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.49,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,42.17,75,,23.152,Percent of Total Billed charges,75% of Total Billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.49,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,33.74,60,,18.52,Percent of Total Billed Charges,60% of Total Billed Charges,50.61,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,25.3,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,50.61,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.55,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,24.8,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.42,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.48,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,50.61,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,24.8,56.23,
CYMBALTA 30 MG CAP,2500000841,CDM,250,RC,,,Outpatient,30,GM,28.67,18.64,,28.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21.79,76,,598.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.64,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,21.5,75,,7.936,Percent of Total Billed charges,75% of Total Billed Charges,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.64,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,17.2,60,,6.352,Percent of Total Billed Charges,60% of Total Billed Charges,25.8,90,,708.864,Percent of Total Billed Charges,90% of Total Billed Charges,12.9,45,,354.432,Percent of Total Billed Charges,45% of Total Billed Charges,25.8,90,,708.864,Percent of Total Billed Charges,90% of Total billed Charges,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.64,65,,511.952,Percent of total Billed Charges,65% of Total Billed Charges,12.64,44.1,,347.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,27.24,95,,748.24,Percent of Total Billed Charges,95% of Total Billed Charges,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.23,88,,693.112,Percent of Total Billed Charges,88% of Total Billed Charges,25.8,90,,708.864,Percent of Total Billed charges,90% of Total Billed Charges,12.64,28.67,
NIX LICE TREATMENT 2,2500000842,CDM,250,RC,,,Outpatient,,,60.64,39.42,,60.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.09,76,,825.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.66,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,45.48,75,,3.904,Percent of Total Billed charges,75% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,60,,3.12,Percent of Total Billed Charges,60% of Total Billed Charges,54.58,90,,977.96,Percent of Total Billed Charges,90% of Total Billed Charges,27.29,45,,488.984,Percent of Total Billed Charges,45% of Total Billed Charges,54.58,90,,977.96,Percent of Total Billed Charges,90% of Total billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.42,65,,706.304,Percent of total Billed Charges,65% of Total Billed Charges,26.74,44.1,,479.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.61,95,,1032.296,Percent of Total Billed Charges,95% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.36,88,,956.232,Percent of Total Billed Charges,88% of Total Billed Charges,54.58,90,,977.96,Percent of Total Billed charges,90% of Total Billed Charges,26.74,60.64,
FIECAINIDE 100MG TAB,2500000843,CDM,250,RC,,,Outpatient,100,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,7.2,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
COREG CR 10MG TAB,2500000844,CDM,250,RC,,,Outpatient,10,GM,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,19.232,Percent of Total Billed Charges,72% of Total Billed Charges,15.71,75,,20.032,Percent of Total Billed charges,75% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,19.232,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,16.024,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
ALFUZOSIN 10MG ER TAB,2500000845,CDM,250,RC,,,Outpatient,10,GM,14.33,9.31,,14.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.89,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.32,72,,13.272,Percent of Total Billed Charges,72% of Total Billed Charges,10.75,75,,13.824,Percent of Total Billed charges,75% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,72,,13.272,Percent of Total Billed Charges,72% of Total Billed Charges,8.6,60,,11.056,Percent of Total Billed Charges,60% of Total Billed Charges,12.9,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,12.9,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.31,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.61,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.61,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,12.9,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,6.32,14.33,
VENTOLIN 90MCG INHALER,2500000846,CDM,250,RC,,,Outpatient,90,GM,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,7.344,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,7.648,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,7.344,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,6.12,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
KETOCANAZOLE 2% CR 15G,2500000847,CDM,250,RC,,,Outpatient,,,76.07,49.45,,76.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,57.81,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,54.77,72,,170.208,Percent of Total Billed Charges,72% of Total Billed Charges,57.05,75,,177.304,Percent of Total Billed charges,75% of Total Billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.77,72,,170.208,Percent of Total Billed Charges,72% of Total Billed Charges,45.64,60,,141.84,Percent of Total Billed Charges,60% of Total Billed Charges,68.46,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,34.23,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,68.46,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.45,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,33.55,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,72.27,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.94,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,68.46,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,33.55,76.07,
FLUOCINODINE 0.05% CR 60G,2500000848,CDM,250,RC,,,Outpatient,,,126.79,82.41,,126.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,96.36,76,,20.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.29,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,95.09,75,,3.904,Percent of Total Billed charges,75% of Total Billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.29,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,76.07,60,,3.12,Percent of Total Billed Charges,60% of Total Billed Charges,114.11,90,,24.608,Percent of Total Billed Charges,90% of Total Billed Charges,57.06,45,,12.304,Percent of Total Billed Charges,45% of Total Billed Charges,114.11,90,,24.608,Percent of Total Billed Charges,90% of Total billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.41,65,,17.776,Percent of total Billed Charges,65% of Total Billed Charges,55.91,44.1,,12.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,120.45,95,,25.976,Percent of Total Billed Charges,95% of Total Billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.58,88,,24.064,Percent of Total Billed Charges,88% of Total Billed Charges,114.11,90,,24.608,Percent of Total Billed charges,90% of Total Billed Charges,55.91,126.79,
ZITHROMAX 200MG/5ML SUSP UD,2500000849,CDM,250,RC,,,Outpatient,200,GM,45.20,29.38,,45.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.35,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.54,72,,47.664,Percent of Total Billed Charges,72% of Total Billed Charges,33.9,75,,49.648,Percent of Total Billed charges,75% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.54,72,,47.664,Percent of Total Billed Charges,72% of Total Billed Charges,27.12,60,,39.72,Percent of Total Billed Charges,60% of Total Billed Charges,40.68,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,20.34,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,40.68,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.38,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,19.93,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.94,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.78,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,40.68,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,19.93,45.2,
CITIRIZINE 5MG/5ML LIQ UD,2500000850,CDM,250,RC,,,Outpatient,5,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,20.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,15.112,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,15.744,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,15.112,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,12.592,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,23.816,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,11.912,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,23.816,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,17.2,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,11.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,25.144,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,23.288,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,23.816,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
LORATADINE 5 MG/5ML SYRUP UD,2500000851,CDM,250,RC,,,Outpatient,5,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,216.144,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,225.152,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,216.144,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,180.12,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
BISOPROLOL 5 MG CAP,2500000852,CDM,250,RC,,,Outpatient,5,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,12.24,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,12.752,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,12.24,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,10.2,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
ELLA 30MG TAB,2500000853,CDM,250,RC,,,Outpatient,30,GM,164.27,106.78,,164.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.85,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,118.27,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,123.2,75,,3.904,Percent of Total Billed charges,75% of Total Billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.27,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,98.56,60,,3.12,Percent of Total Billed Charges,60% of Total Billed Charges,147.84,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,73.92,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,147.84,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.78,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,72.44,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,156.06,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.56,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,147.84,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,72.44,164.27,
FLECAINIDE 50MG TAB,2500000854,CDM,250,RC,,,Outpatient,50,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,3.904,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,3.12,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
COREG CR 10 MG TAB,2500000855,CDM,250,RC,,,Outpatient,10,GM,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,15.71,75,,3.904,Percent of Total Billed charges,75% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,3.12,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
CARDEC DROPS 30 ML,2500000856,CDM,250,RC,,,Outpatient,30,ML,83.79,54.46,,83.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,63.68,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,60.33,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,62.84,75,,3.904,Percent of Total Billed charges,75% of Total Billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.33,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,50.27,60,,3.12,Percent of Total Billed Charges,60% of Total Billed Charges,75.41,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,37.71,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,75.41,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.46,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,36.95,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,79.6,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.74,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,75.41,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,36.95,83.79,
JTAN DPD DROPS 30 ML,2500000857,CDM,250,RC,,,Outpatient,30,ML,265.70,172.71,,265.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,201.93,76,,122.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,191.3,72,,69.984,Percent of Total Billed Charges,72% of Total Billed Charges,199.28,75,,72.904,Percent of Total Billed charges,75% of Total Billed Charges,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.3,72,,69.984,Percent of Total Billed Charges,72% of Total Billed Charges,159.42,60,,58.32,Percent of Total Billed Charges,60% of Total Billed Charges,239.13,90,,145.264,Percent of Total Billed Charges,90% of Total Billed Charges,119.57,45,,72.632,Percent of Total Billed Charges,45% of Total Billed Charges,239.13,90,,145.264,Percent of Total Billed Charges,90% of Total billed Charges,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.71,65,,104.912,Percent of total Billed Charges,65% of Total Billed Charges,117.17,44.1,,71.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,252.42,95,,153.336,Percent of Total Billed Charges,95% of Total Billed Charges,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.82,88,,142.04,Percent of Total Billed Charges,88% of Total Billed Charges,239.13,90,,145.264,Percent of Total Billed charges,90% of Total Billed Charges,117.17,265.7,
TOBRADEX OINT 3.5G,2500000858,CDM,250,RC,,,Outpatient,,,198.45,128.99,,198.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,150.82,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,142.88,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,148.84,75,,7.2,Percent of Total Billed charges,75% of Total Billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.88,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,119.07,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,178.61,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,89.3,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,178.61,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.99,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,87.52,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,188.53,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.64,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,178.61,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,87.52,198.45,
KEFLEX 250/5 SUSP 100ML (S),2500000859,CDM,250,RC,,,Outpatient,100,ML,5030.71,3269.96,,5030.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3823.34,76,,18.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3622.11,72,,177.84,Percent of Total Billed Charges,72% of Total Billed Charges,3773.03,75,,185.248,Percent of Total Billed charges,75% of Total Billed Charges,5030.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3622.11,72,,177.84,Percent of Total Billed Charges,72% of Total Billed Charges,3018.43,60,,148.2,Percent of Total Billed Charges,60% of Total Billed Charges,4527.64,90,,22.224,Percent of Total Billed Charges,90% of Total Billed Charges,2263.82,45,,11.112,Percent of Total Billed Charges,45% of Total Billed Charges,4527.64,90,,22.224,Percent of Total Billed Charges,90% of Total billed Charges,5030.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5030.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5030.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3269.96,65,,16.056,Percent of total Billed Charges,65% of Total Billed Charges,2218.54,44.1,,10.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,4779.17,95,,23.464,Percent of Total Billed Charges,95% of Total Billed Charges,5030.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4427.02,88,,21.736,Percent of Total Billed Charges,88% of Total Billed Charges,4527.64,90,,22.224,Percent of Total Billed charges,90% of Total Billed Charges,2218.54,5030.71,
KEFLEX 125/5 SUSP 100ML (S),2500000860,CDM,250,RC,,,Outpatient,100,ML,30.87,20.07,,30.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.46,76,,16.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.23,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,75,,3.904,Percent of Total Billed charges,75% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.23,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,18.52,60,,3.12,Percent of Total Billed Charges,60% of Total Billed Charges,27.78,90,,19.84,Percent of Total Billed Charges,90% of Total Billed Charges,13.89,45,,9.92,Percent of Total Billed Charges,45% of Total Billed Charges,27.78,90,,19.84,Percent of Total Billed Charges,90% of Total billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.07,65,,14.328,Percent of total Billed Charges,65% of Total Billed Charges,13.61,44.1,,9.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.33,95,,20.944,Percent of Total Billed Charges,95% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.17,88,,19.4,Percent of Total Billed Charges,88% of Total Billed Charges,27.78,90,,19.84,Percent of Total Billed charges,90% of Total Billed Charges,13.61,30.87,
ICHTHAMMOL 20% OINT 28 GM,2500000861,CDM,250,RC,,,Outpatient,28,gm,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,11.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,25.992,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,27.072,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,25.992,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,21.656,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,13.496,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,6.744,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,13.496,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,9.744,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,6.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,14.24,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,13.192,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,13.496,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
INPRATROPIUM NASAL SPRAY 15ML,2500000862,CDM,250,RC,,,Outpatient,15,ML,14.33,9.31,,14.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.89,76,,39.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.32,72,,6.336,Percent of Total Billed Charges,72% of Total Billed Charges,10.75,75,,6.6,Percent of Total Billed charges,75% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,72,,6.336,Percent of Total Billed Charges,72% of Total Billed Charges,8.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,12.9,90,,46.84,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,23.416,Percent of Total Billed Charges,45% of Total Billed Charges,12.9,90,,46.84,Percent of Total Billed Charges,90% of Total billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.31,65,,33.824,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,22.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.61,95,,49.44,Percent of Total Billed Charges,95% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.61,88,,45.792,Percent of Total Billed Charges,88% of Total Billed Charges,12.9,90,,46.84,Percent of Total Billed charges,90% of Total Billed Charges,6.32,14.33,
PERMETHRIN 5% CR 60G,2500000863,CDM,250,RC,,,Outpatient,,,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,256.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,179.424,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,186.904,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,179.424,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,149.52,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,303.232,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,151.616,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,303.232,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,219,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,148.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,320.08,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,296.496,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,303.232,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
LIDOCAINE 2% UROJECT 10 ML,2500000864,CDM,250,RC,,,Outpatient,10,ML,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,351.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,73.296,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,76.352,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,73.296,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,61.08,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,415.952,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,207.976,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,415.952,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,300.408,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,203.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,439.056,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,406.704,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,415.952,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
TAMIFLU 45 MG CAP,2500000865,CDM,250,RC,,,Outpatient,45,GM,43.00,27.95,,43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,32.68,76,,23.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.96,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,32.25,75,,3.904,Percent of Total Billed charges,75% of Total Billed Charges,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.96,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,25.8,60,,3.12,Percent of Total Billed Charges,60% of Total Billed Charges,38.7,90,,27.784,Percent of Total Billed Charges,90% of Total Billed Charges,19.35,45,,13.896,Percent of Total Billed Charges,45% of Total Billed Charges,38.7,90,,27.784,Percent of Total Billed Charges,90% of Total billed Charges,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.95,65,,20.064,Percent of total Billed Charges,65% of Total Billed Charges,18.96,44.1,,13.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,40.85,95,,29.328,Percent of Total Billed Charges,95% of Total Billed Charges,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.84,88,,27.168,Percent of Total Billed Charges,88% of Total Billed Charges,38.7,90,,27.784,Percent of Total Billed charges,90% of Total Billed Charges,18.96,43,
CRESTOR 40MG TAB,2500000866,CDM,250,RC,,,Outpatient,40,GM,44.10,28.67,,44.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33.52,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,31.75,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,75,,3.904,Percent of Total Billed charges,75% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.75,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,60,,3.12,Percent of Total Billed Charges,60% of Total Billed Charges,39.69,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,19.85,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,39.69,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,65,,6.88,Percent of total Billed Charges,65% of Total Billed Charges,19.45,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.9,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.81,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,39.69,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,19.45,44.1,
ONDANSTRON 1MG/ML LIQUID,2500000867,CDM,250,RC,,,Outpatient,1,GM,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,3.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,13.68,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,14.248,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,13.68,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,11.4,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,4.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,2.344,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,4.68,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,3.384,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,2.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,4.944,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,4.576,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,4.68,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
PYRAZINAMIDE 500MG TAB,2500000868,CDM,250,RC,,,Outpatient,500,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,5.76,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,6,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,5.76,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,6.24,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
DAPSONE 100MG TAB,2500000869,CDM,250,RC,,,Outpatient,100,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,20.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,3.904,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,3.12,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,24.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,12.024,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,24.04,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,17.36,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,11.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,25.376,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,23.504,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,24.04,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
AUGMENTIN 200MG/5ML UD,2500000870,CDM,250,RC,,,Outpatient,200,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,14.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,15.264,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,15.904,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,15.264,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,12.72,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,16.592,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,8.296,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,16.592,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,11.984,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,8.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,17.512,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,16.224,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,16.592,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
ADVAIR HFA 45/21 INHALER,2500000871,CDM,250,RC,,,Outpatient,,,791.60,514.54,,791.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,601.62,76,,7.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,569.95,72,,18.864,Percent of Total Billed Charges,72% of Total Billed Charges,593.7,75,,19.648,Percent of Total Billed charges,75% of Total Billed Charges,791.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569.95,72,,18.864,Percent of Total Billed Charges,72% of Total Billed Charges,474.96,60,,15.72,Percent of Total Billed Charges,60% of Total Billed Charges,712.44,90,,9.184,Percent of Total Billed Charges,90% of Total Billed Charges,356.22,45,,4.592,Percent of Total Billed Charges,45% of Total Billed Charges,712.44,90,,9.184,Percent of Total Billed Charges,90% of Total billed Charges,791.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,791.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,791.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,514.54,65,,6.632,Percent of total Billed Charges,65% of Total Billed Charges,349.1,44.1,,4.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,752.02,95,,9.688,Percent of Total Billed Charges,95% of Total Billed Charges,791.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,696.61,88,,8.976,Percent of Total Billed Charges,88% of Total Billed Charges,712.44,90,,9.184,Percent of Total Billed charges,90% of Total Billed Charges,349.1,791.6,
NORCO 7.5/325MG TAB,2500000872,CDM,250,RC,,,Outpatient,325,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,179.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,239.408,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,249.384,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,239.408,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,199.504,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,212.76,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,106.384,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,212.76,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,153.664,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,104.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,224.584,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,208.032,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,212.76,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
ADVAIR HFA 115/21 INHALER,2500000873,CDM,250,RC,,,Outpatient,,,984.53,639.94,,984.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,748.24,76,,3.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,708.86,72,,1211.024,Percent of Total Billed Charges,72% of Total Billed Charges,738.4,75,,1261.48,Percent of Total Billed charges,75% of Total Billed Charges,984.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,708.86,72,,1211.024,Percent of Total Billed Charges,72% of Total Billed Charges,590.72,60,,1009.184,Percent of Total Billed Charges,60% of Total Billed Charges,886.08,90,,4.68,Percent of Total Billed Charges,90% of Total Billed Charges,443.04,45,,2.344,Percent of Total Billed Charges,45% of Total Billed Charges,886.08,90,,4.68,Percent of Total Billed Charges,90% of Total billed Charges,984.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,984.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,984.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,639.94,65,,3.384,Percent of total Billed Charges,65% of Total Billed Charges,434.18,44.1,,2.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,935.3,95,,4.944,Percent of Total Billed Charges,95% of Total Billed Charges,984.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,866.39,88,,4.576,Percent of Total Billed Charges,88% of Total Billed Charges,886.08,90,,4.68,Percent of Total Billed charges,90% of Total Billed Charges,434.18,984.53,
ADVAIR HFA 230/21 INHALER,2500000874,CDM,250,RC,,,Outpatient,,,1358.28,882.88,,1358.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1032.29,76,,50.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,977.96,72,,688.384,Percent of Total Billed Charges,72% of Total Billed Charges,1018.71,75,,717.064,Percent of Total Billed charges,75% of Total Billed Charges,1358.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,977.96,72,,688.384,Percent of Total Billed Charges,72% of Total Billed Charges,814.97,60,,573.656,Percent of Total Billed Charges,60% of Total Billed Charges,1222.45,90,,59.584,Percent of Total Billed Charges,90% of Total Billed Charges,611.23,45,,29.792,Percent of Total Billed Charges,45% of Total Billed Charges,1222.45,90,,59.584,Percent of Total Billed Charges,90% of Total billed Charges,1358.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1358.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1358.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,882.88,65,,43.032,Percent of total Billed Charges,65% of Total Billed Charges,599,44.1,,29.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,1290.37,95,,62.888,Percent of Total Billed Charges,95% of Total Billed Charges,1358.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1195.29,88,,58.256,Percent of Total Billed Charges,88% of Total Billed Charges,1222.45,90,,59.584,Percent of Total Billed charges,90% of Total Billed Charges,599,1358.28,
DOCUSATE SODIUM LIQ 100MG/10ML,2500000875,CDM,250,RC,,,Outpatient,100,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,15.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,697.912,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,726.992,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,697.912,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,581.592,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,18.896,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,9.448,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,18.896,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,13.648,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,9.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,19.944,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,18.472,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,18.896,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
GLYCERIN SUPP ADULT,2500000876,CDM,250,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,228.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,128.28,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,133.624,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,128.28,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,106.904,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,270.184,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,135.088,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,270.184,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,195.128,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,132.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,285.192,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,264.176,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,270.184,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
FLORISTOR 250MG CAP,2500000877,CDM,250,RC,,,Outpatient,250,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,12.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,440.08,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,458.416,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,440.08,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,366.736,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,15.304,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,7.648,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,15.304,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,11.048,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,7.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,16.152,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,14.96,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,15.304,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
NAC 600 MG CAP,2500000878,CDM,250,RC,,,Outpatient,600,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,3.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,2964.368,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,3087.88,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,2964.368,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,2470.304,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,4.68,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,2.344,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,4.68,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,3.384,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,2.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,4.944,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,4.576,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,4.68,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
DOMEBORO PACKET,2500000879,CDM,250,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,3.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,644.568,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,671.424,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,644.568,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,537.136,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,4.68,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,2.344,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,4.68,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,3.384,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,2.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,4.944,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,4.576,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,4.68,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
GEODON 20MG CAPSULE,2500000880,CDM,250,RC,,,Outpatient,20,GM,34.18,22.22,,34.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.98,76,,3.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.61,72,,563.912,Percent of Total Billed Charges,72% of Total Billed Charges,25.64,75,,587.416,Percent of Total Billed charges,75% of Total Billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.61,72,,563.912,Percent of Total Billed Charges,72% of Total Billed Charges,20.51,60,,469.928,Percent of Total Billed Charges,60% of Total Billed Charges,30.76,90,,4.68,Percent of Total Billed Charges,90% of Total Billed Charges,15.38,45,,2.344,Percent of Total Billed Charges,45% of Total Billed Charges,30.76,90,,4.68,Percent of Total Billed Charges,90% of Total billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.22,65,,3.384,Percent of total Billed Charges,65% of Total Billed Charges,15.07,44.1,,2.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.47,95,,4.944,Percent of Total Billed Charges,95% of Total Billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.08,88,,4.576,Percent of Total Billed Charges,88% of Total Billed Charges,30.76,90,,4.68,Percent of Total Billed charges,90% of Total Billed Charges,15.07,34.18,
CEFDINIR 125MG/5 UD,2500000881,CDM,250,RC,,,Outpatient,125,GM,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,3.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,4.68,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,2.344,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,4.68,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,3.384,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,2.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,4.944,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,4.576,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,4.68,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
CEFDINIR 250MG/5 UD,2500000882,CDM,250,RC,,,Outpatient,250,GM,33.08,21.50,,33.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.14,76,,73.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.82,72,,398.168,Percent of Total Billed Charges,72% of Total Billed Charges,24.81,75,,414.76,Percent of Total Billed charges,75% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.82,72,,398.168,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,60,,331.808,Percent of Total Billed Charges,60% of Total Billed Charges,29.77,90,,87.48,Percent of Total Billed Charges,90% of Total Billed Charges,14.89,45,,43.744,Percent of Total Billed Charges,45% of Total Billed Charges,29.77,90,,87.48,Percent of Total Billed Charges,90% of Total billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.5,65,,63.184,Percent of total Billed Charges,65% of Total Billed Charges,14.59,44.1,,42.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.43,95,,92.344,Percent of Total Billed Charges,95% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.11,88,,85.536,Percent of Total Billed Charges,88% of Total Billed Charges,29.77,90,,87.48,Percent of Total Billed charges,90% of Total Billed Charges,14.59,33.08,
CEFPROZIL 250MG/5 UD,2500000883,CDM,250,RC,,,Outpatient,250,GM,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,269.888,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,281.136,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,269.888,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,224.912,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,6.24,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
CEPHALEXIN 125/5 UD,2500000884,CDM,250,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,187.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,539.784,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,562.28,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,539.784,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,449.824,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,222.304,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,111.152,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,222.304,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,160.552,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,108.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,234.648,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,217.36,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,222.304,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
CEPHALEXIN 250/5 UD,2500000885,CDM,250,RC,,,Outpatient,,,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,3.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,318.152,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,331.408,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,318.152,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,265.128,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,4.68,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,2.344,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,4.68,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,3.384,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,2.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,4.944,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,4.576,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,4.68,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
GABAPENTIN 600MG TAB,2500000886,CDM,250,RC,,,Outpatient,600,GM,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,27.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,72,,335.304,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,75,,349.272,Percent of Total Billed charges,75% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,72,,335.304,Percent of Total Billed Charges,72% of Total Billed Charges,5.95,60,,279.416,Percent of Total Billed Charges,60% of Total Billed Charges,8.93,90,,32.488,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,16.24,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,32.488,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,23.464,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,15.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,34.288,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,31.768,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,32.488,Percent of Total Billed charges,90% of Total Billed Charges,4.37,9.92,
METHAZOLAMIDE 25MG TAB,2500000887,CDM,250,RC,,,Outpatient,25,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,6.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,448.976,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,467.68,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,448.976,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,374.144,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,3.96,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,7.92,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,5.72,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,3.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,8.36,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,7.744,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,7.92,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
CALCIUM GLUCONATE 500MG TAB,2500000888,CDM,250,RC,,,Outpatient,500,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,189.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,365.784,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,381.024,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,365.784,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,304.816,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,224.28,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,112.144,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,224.28,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,161.984,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,109.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,236.744,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,219.296,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,224.28,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
NEXT CHOICE 1.5MG TAB,2500000889,CDM,250,RC,,,Outpatient,1.5,GM,201.76,131.14,,201.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,153.34,76,,77.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,145.27,72,,348,Percent of Total Billed Charges,72% of Total Billed Charges,151.32,75,,362.504,Percent of Total Billed charges,75% of Total Billed Charges,201.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.27,72,,348,Percent of Total Billed Charges,72% of Total Billed Charges,121.06,60,,290,Percent of Total Billed Charges,60% of Total Billed Charges,181.58,90,,91.624,Percent of Total Billed Charges,90% of Total Billed Charges,90.79,45,,45.808,Percent of Total Billed Charges,45% of Total Billed Charges,181.58,90,,91.624,Percent of Total Billed Charges,90% of Total billed Charges,201.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.14,65,,66.168,Percent of total Billed Charges,65% of Total Billed Charges,88.98,44.1,,44.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,191.67,95,,96.712,Percent of Total Billed Charges,95% of Total Billed Charges,201.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.55,88,,89.584,Percent of Total Billed Charges,88% of Total Billed Charges,181.58,90,,91.624,Percent of Total Billed charges,90% of Total Billed Charges,88.98,201.76,
BSS OPTH SOL 15ML,2500000890,CDM,250,RC,,,Outpatient,15,ML,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,3.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,238.144,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,248.064,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,238.144,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,198.448,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,4.68,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,2.344,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,4.68,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,3.384,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,2.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,4.944,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,4.576,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,4.68,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
EFFIENT 10 MG TAB,2500000891,CDM,250,RC,,,Outpatient,10,GM,30.87,20.07,,30.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.46,76,,3.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.23,72,,1809.224,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,75,,1884.616,Percent of Total Billed charges,75% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.23,72,,1809.224,Percent of Total Billed Charges,72% of Total Billed Charges,18.52,60,,1507.688,Percent of Total Billed Charges,60% of Total Billed Charges,27.78,90,,4.68,Percent of Total Billed Charges,90% of Total Billed Charges,13.89,45,,2.344,Percent of Total Billed Charges,45% of Total Billed Charges,27.78,90,,4.68,Percent of Total Billed Charges,90% of Total billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.07,65,,3.384,Percent of total Billed Charges,65% of Total Billed Charges,13.61,44.1,,2.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.33,95,,4.944,Percent of Total Billed Charges,95% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.17,88,,4.576,Percent of Total Billed Charges,88% of Total Billed Charges,27.78,90,,4.68,Percent of Total Billed charges,90% of Total Billed Charges,13.61,30.87,
DALIRESP 500MG TAB,2500000892,CDM,250,RC,,,Outpatient,500,GM,27.56,17.91,,27.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.95,76,,14.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.84,72,,737.28,Percent of Total Billed Charges,72% of Total Billed Charges,20.67,75,,768,Percent of Total Billed charges,75% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.84,72,,737.28,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,60,,614.4,Percent of Total Billed Charges,60% of Total Billed Charges,24.8,90,,17.104,Percent of Total Billed Charges,90% of Total Billed Charges,12.4,45,,8.552,Percent of Total Billed Charges,45% of Total Billed Charges,24.8,90,,17.104,Percent of Total Billed Charges,90% of Total billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.91,65,,12.352,Percent of total Billed Charges,65% of Total Billed Charges,12.15,44.1,,8.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.18,95,,18.048,Percent of Total Billed Charges,95% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,88,,16.72,Percent of Total Billed Charges,88% of Total Billed Charges,24.8,90,,17.104,Percent of Total Billed charges,90% of Total Billed Charges,12.15,27.56,
RANEXA 500MG TAB,2500000893,CDM,250,RC,,,Outpatient,500,GM,18.74,12.18,,18.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.24,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.49,72,,472.472,Percent of Total Billed Charges,72% of Total Billed Charges,14.06,75,,492.16,Percent of Total Billed charges,75% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.49,72,,472.472,Percent of Total Billed Charges,72% of Total Billed Charges,11.24,60,,393.728,Percent of Total Billed Charges,60% of Total Billed Charges,16.87,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,8.43,45,,3.6,Percent of Total Billed Charges,45% of Total Billed Charges,16.87,90,,7.2,Percent of Total Billed Charges,90% of Total billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.18,65,,5.2,Percent of total Billed Charges,65% of Total Billed Charges,8.26,44.1,,3.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.8,95,,7.6,Percent of Total Billed Charges,95% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,88,,7.04,Percent of Total Billed Charges,88% of Total Billed Charges,16.87,90,,7.2,Percent of Total Billed charges,90% of Total Billed Charges,8.26,18.74,
TAMIFLU 75MG CAP,2500000894,CDM,250,RC,,,Outpatient,75,GM,65.05,42.28,,65.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.44,76,,3.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.84,72,,530.928,Percent of Total Billed Charges,72% of Total Billed Charges,48.79,75,,553.048,Percent of Total Billed charges,75% of Total Billed Charges,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.84,72,,530.928,Percent of Total Billed Charges,72% of Total Billed Charges,39.03,60,,442.44,Percent of Total Billed Charges,60% of Total Billed Charges,58.55,90,,4.68,Percent of Total Billed Charges,90% of Total Billed Charges,29.27,45,,2.344,Percent of Total Billed Charges,45% of Total Billed Charges,58.55,90,,4.68,Percent of Total Billed Charges,90% of Total billed Charges,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.28,65,,3.384,Percent of total Billed Charges,65% of Total Billed Charges,28.69,44.1,,2.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,61.8,95,,4.944,Percent of Total Billed Charges,95% of Total Billed Charges,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.24,88,,4.576,Percent of Total Billed Charges,88% of Total Billed Charges,58.55,90,,4.68,Percent of Total Billed charges,90% of Total Billed Charges,28.69,65.05,
FLONASE INHALER,2500000895,CDM,250,RC,,,Outpatient,,,421.16,273.75,,421.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,320.08,76,,16.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,303.24,72,,259.2,Percent of Total Billed Charges,72% of Total Billed Charges,315.87,75,,270,Percent of Total Billed charges,75% of Total Billed Charges,421.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.24,72,,259.2,Percent of Total Billed Charges,72% of Total Billed Charges,252.7,60,,216,Percent of Total Billed Charges,60% of Total Billed Charges,379.04,90,,19.08,Percent of Total Billed Charges,90% of Total Billed Charges,189.52,45,,9.544,Percent of Total Billed Charges,45% of Total Billed Charges,379.04,90,,19.08,Percent of Total Billed Charges,90% of Total billed Charges,421.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,421.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,421.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.75,65,,13.784,Percent of total Billed Charges,65% of Total Billed Charges,185.73,44.1,,9.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,400.1,95,,20.144,Percent of Total Billed Charges,95% of Total Billed Charges,421.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.62,88,,18.656,Percent of Total Billed Charges,88% of Total Billed Charges,379.04,90,,19.08,Percent of Total Billed charges,90% of Total Billed Charges,185.73,421.16,
NASONEX NASAL INHALER,2500000896,CDM,250,RC,,,Outpatient,,,577.71,375.51,,577.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,439.06,76,,19.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.95,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,433.28,75,,21.832,Percent of Total Billed charges,75% of Total Billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.95,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,346.63,60,,17.464,Percent of Total Billed Charges,60% of Total Billed Charges,519.94,90,,23.584,Percent of Total Billed Charges,90% of Total Billed Charges,259.97,45,,11.792,Percent of Total Billed Charges,45% of Total Billed Charges,519.94,90,,23.584,Percent of Total Billed Charges,90% of Total billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.51,65,,17.032,Percent of total Billed Charges,65% of Total Billed Charges,254.77,44.1,,11.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,548.82,95,,24.888,Percent of Total Billed Charges,95% of Total Billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.38,88,,23.056,Percent of Total Billed Charges,88% of Total Billed Charges,519.94,90,,23.584,Percent of Total Billed charges,90% of Total Billed Charges,254.77,577.71,
RESTORIL 7.5MG CAP,2500000897,CDM,250,RC,,,Outpatient,7.5,GM,38.59,25.08,,38.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.33,76,,252.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.78,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,28.94,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.78,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,34.73,90,,299.264,Percent of Total Billed Charges,90% of Total Billed Charges,17.37,45,,149.632,Percent of Total Billed Charges,45% of Total Billed Charges,34.73,90,,299.264,Percent of Total Billed Charges,90% of Total billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.08,65,,216.136,Percent of total Billed Charges,65% of Total Billed Charges,17.02,44.1,,146.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.66,95,,315.888,Percent of Total Billed Charges,95% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.96,88,,292.608,Percent of Total Billed Charges,88% of Total Billed Charges,34.73,90,,299.264,Percent of Total Billed charges,90% of Total Billed Charges,17.02,38.59,
LORTAB 2.5/167/5ML SOLN UD,2500000899,CDM,250,RC,,,Outpatient,5,ML,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,726.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,860.48,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,430.24,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,860.48,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,621.456,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,421.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,908.28,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,841.36,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,860.48,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
DIMETAPP 118ML,2500000913,CDM,250,RC,,,Outpatient,118,ML,6.50,4.23,,6.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.94,76,,473.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.68,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,4.88,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.68,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,3.9,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,5.85,90,,561.216,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,280.608,Percent of Total Billed Charges,45% of Total Billed Charges,5.85,90,,561.216,Percent of Total Billed Charges,90% of Total billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,65,,405.328,Percent of total Billed Charges,65% of Total Billed Charges,2.87,44.1,,275,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.18,95,,592.4,Percent of Total Billed Charges,95% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,88,,548.744,Percent of Total Billed Charges,88% of Total Billed Charges,5.85,90,,561.216,Percent of Total Billed charges,90% of Total Billed Charges,2.87,6.5,
SODIUM BICARBONATE 4.2% (VIAL),2500000969,CDM,250,RC,,,Outpatient,,,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,29.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.64,72,,35.56,Percent of Total Billed Charges,72% of Total Billed Charges,9,75,,37.048,Percent of Total Billed charges,75% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.64,72,,35.56,Percent of Total Billed Charges,72% of Total Billed Charges,7.2,60,,29.632,Percent of Total Billed Charges,60% of Total Billed Charges,10.8,90,,34.928,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,17.464,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,34.928,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,25.224,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,17.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,36.864,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,34.152,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,34.928,Percent of Total Billed charges,90% of Total Billed Charges,5.29,12,
MONSEL'S 8ML,2500000970,CDM,250,RC,,,Outpatient,8,ML,33.39,21.70,,33.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.38,76,,19.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.04,72,,280.048,Percent of Total Billed Charges,72% of Total Billed Charges,25.04,75,,291.72,Percent of Total Billed charges,75% of Total Billed Charges,33.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.04,72,,280.048,Percent of Total Billed Charges,72% of Total Billed Charges,20.03,60,,233.376,Percent of Total Billed Charges,60% of Total Billed Charges,30.05,90,,23.016,Percent of Total Billed Charges,90% of Total Billed Charges,15.03,45,,11.512,Percent of Total Billed Charges,45% of Total Billed Charges,30.05,90,,23.016,Percent of Total Billed Charges,90% of Total billed Charges,33.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.7,65,,16.624,Percent of total Billed Charges,65% of Total Billed Charges,14.72,44.1,,11.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.72,95,,24.296,Percent of Total Billed Charges,95% of Total Billed Charges,33.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.38,88,,22.504,Percent of Total Billed Charges,88% of Total Billed Charges,30.05,90,,23.016,Percent of Total Billed charges,90% of Total Billed Charges,14.72,33.39,
ESOMEPRAZOLE 40MG,2500000971,CDM,250,RC,,,Outpatient,40,GM,23.04,14.98,,23.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.51,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.59,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,17.28,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,23.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.59,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,13.82,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,20.74,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,10.37,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,20.74,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,23.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.98,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,10.16,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.89,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,23.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.28,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,20.74,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,10.16,23.04,
COSOPT PF,2500000972,CDM,250,RC,,,Outpatient,,,12.75,8.29,,12.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.69,76,,36.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.18,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,9.56,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,12.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.18,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,7.65,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,11.48,90,,43.664,Percent of Total Billed Charges,90% of Total Billed Charges,5.74,45,,21.832,Percent of Total Billed Charges,45% of Total Billed Charges,11.48,90,,43.664,Percent of Total Billed Charges,90% of Total billed Charges,12.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.29,65,,31.536,Percent of total Billed Charges,65% of Total Billed Charges,5.62,44.1,,21.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.11,95,,46.088,Percent of Total Billed Charges,95% of Total Billed Charges,12.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.22,88,,42.688,Percent of Total Billed Charges,88% of Total Billed Charges,11.48,90,,43.664,Percent of Total Billed charges,90% of Total Billed Charges,5.62,12.75,
SPIRIVA 18MCG 5 CAPS,2500000973,CDM,250,RC,,,Outpatient,18,GM,295.50,192.08,,295.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,224.58,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,212.76,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,221.63,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,295.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.76,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,177.3,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,265.95,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,132.98,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,265.95,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,295.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.08,65,,6.88,Percent of total Billed Charges,65% of Total Billed Charges,130.32,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,280.73,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,295.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.04,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,265.95,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,130.32,295.5,
VITAMIN D 5000 UNITS CAP,2500000974,CDM,250,RC,,,Outpatient,,,6.50,4.23,,6.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.94,76,,20.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.68,72,,46.36,Percent of Total Billed Charges,72% of Total Billed Charges,4.88,75,,48.288,Percent of Total Billed charges,75% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.68,72,,46.36,Percent of Total Billed Charges,72% of Total Billed Charges,3.9,60,,38.632,Percent of Total Billed Charges,60% of Total Billed Charges,5.85,90,,24.608,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,12.304,Percent of Total Billed Charges,45% of Total Billed Charges,5.85,90,,24.608,Percent of Total Billed Charges,90% of Total billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,65,,17.776,Percent of total Billed Charges,65% of Total Billed Charges,2.87,44.1,,12.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.18,95,,25.976,Percent of Total Billed Charges,95% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,88,,24.064,Percent of Total Billed Charges,88% of Total Billed Charges,5.85,90,,24.608,Percent of Total Billed charges,90% of Total Billed Charges,2.87,6.5,
VANCOMYCIN 125MG TAB,2500000975,CDM,250,RC,,,Outpatient,125,GM,82.75,53.79,,82.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.89,76,,99.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.58,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,62.06,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,82.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.58,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,49.65,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,74.48,90,,118.272,Percent of Total Billed Charges,90% of Total Billed Charges,37.24,45,,59.136,Percent of Total Billed Charges,45% of Total Billed Charges,74.48,90,,118.272,Percent of Total Billed Charges,90% of Total billed Charges,82.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.79,65,,85.424,Percent of total Billed Charges,65% of Total Billed Charges,36.49,44.1,,57.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,78.61,95,,124.848,Percent of Total Billed Charges,95% of Total Billed Charges,82.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.82,88,,115.648,Percent of Total Billed Charges,88% of Total Billed Charges,74.48,90,,118.272,Percent of Total Billed charges,90% of Total Billed Charges,36.49,82.75,
VANCOMYCIN 50MG/ML ORAL,2500000976,CDM,250,RC,,,Outpatient,50,GM,26.24,17.06,,26.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.94,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.89,72,,31.112,Percent of Total Billed Charges,72% of Total Billed Charges,19.68,75,,32.416,Percent of Total Billed charges,75% of Total Billed Charges,26.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.89,72,,31.112,Percent of Total Billed Charges,72% of Total Billed Charges,15.74,60,,25.928,Percent of Total Billed Charges,60% of Total Billed Charges,23.62,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,11.81,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,23.62,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,26.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.06,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,11.57,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.93,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,26.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.09,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,23.62,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,11.57,26.24,
BRIDION 100MG/ML,2500000977,CDM,250,RC,,,Outpatient,100,GM,375.25,243.91,,375.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285.19,76,,16.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270.18,72,,71.76,Percent of Total Billed Charges,72% of Total Billed Charges,281.44,75,,74.752,Percent of Total Billed charges,75% of Total Billed Charges,375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.18,72,,71.76,Percent of Total Billed Charges,72% of Total Billed Charges,225.15,60,,59.8,Percent of Total Billed Charges,60% of Total Billed Charges,337.73,90,,19.048,Percent of Total Billed Charges,90% of Total Billed Charges,168.86,45,,9.528,Percent of Total Billed Charges,45% of Total Billed Charges,337.73,90,,19.048,Percent of Total Billed Charges,90% of Total billed Charges,375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.91,65,,13.76,Percent of total Billed Charges,65% of Total Billed Charges,165.49,44.1,,9.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.49,95,,20.112,Percent of Total Billed Charges,95% of Total Billed Charges,375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330.22,88,,18.624,Percent of Total Billed Charges,88% of Total Billed Charges,337.73,90,,19.048,Percent of Total Billed charges,90% of Total Billed Charges,165.49,375.25,
KEPPRA 500 MG 5ML,2500000978,CDM,250,RC,,,Outpatient,500,GM,21.25,13.81,,21.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.15,76,,144.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.3,72,,90.176,Percent of Total Billed Charges,72% of Total Billed Charges,15.94,75,,93.936,Percent of Total Billed charges,75% of Total Billed Charges,21.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.3,72,,90.176,Percent of Total Billed Charges,72% of Total Billed Charges,12.75,60,,75.152,Percent of Total Billed Charges,60% of Total Billed Charges,19.13,90,,171.464,Percent of Total Billed Charges,90% of Total Billed Charges,9.56,45,,85.728,Percent of Total Billed Charges,45% of Total Billed Charges,19.13,90,,171.464,Percent of Total Billed Charges,90% of Total billed Charges,21.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.81,65,,123.832,Percent of total Billed Charges,65% of Total Billed Charges,9.37,44.1,,84.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.19,95,,180.984,Percent of Total Billed Charges,95% of Total Billed Charges,21.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.7,88,,167.648,Percent of Total Billed Charges,88% of Total Billed Charges,19.13,90,,171.464,Percent of Total Billed charges,90% of Total Billed Charges,9.37,21.25,
BROMFED DM 5ML UD,2500000979,CDM,250,RC,,,Outpatient,5,ML,6.50,4.23,,6.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.94,76,,30.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.68,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,4.88,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.68,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,3.9,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,5.85,90,,35.72,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,17.856,Percent of Total Billed Charges,45% of Total Billed Charges,5.85,90,,35.72,Percent of Total Billed Charges,90% of Total billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,65,,25.8,Percent of total Billed Charges,65% of Total Billed Charges,2.87,44.1,,17.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.18,95,,37.704,Percent of Total Billed Charges,95% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,88,,34.928,Percent of Total Billed Charges,88% of Total Billed Charges,5.85,90,,35.72,Percent of Total Billed charges,90% of Total Billed Charges,2.87,6.5,
MEPERIDINE HLC 50MG,2500000980,CDM,250,RC,,,Outpatient,50,GM,6.50,4.23,,6.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.94,76,,29.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.68,72,,53.344,Percent of Total Billed Charges,72% of Total Billed Charges,4.88,75,,55.568,Percent of Total Billed charges,75% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.68,72,,53.344,Percent of Total Billed Charges,72% of Total Billed Charges,3.9,60,,44.456,Percent of Total Billed Charges,60% of Total Billed Charges,5.85,90,,34.928,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,17.464,Percent of Total Billed Charges,45% of Total Billed Charges,5.85,90,,34.928,Percent of Total Billed Charges,90% of Total billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,65,,25.224,Percent of total Billed Charges,65% of Total Billed Charges,2.87,44.1,,17.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.18,95,,36.864,Percent of Total Billed Charges,95% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,88,,34.152,Percent of Total Billed Charges,88% of Total Billed Charges,5.85,90,,34.928,Percent of Total Billed charges,90% of Total Billed Charges,2.87,6.5,
CLONAZEPAM ODT 0.5MG TAB,2500000981,CDM,250,RC,,,Outpatient,0.5,GM,6.50,4.23,,6.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.94,76,,15.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.68,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,4.88,75,,23.152,Percent of Total Billed charges,75% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.68,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,3.9,60,,18.52,Percent of Total Billed Charges,60% of Total Billed Charges,5.85,90,,18.256,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,9.128,Percent of Total Billed Charges,45% of Total Billed Charges,5.85,90,,18.256,Percent of Total Billed Charges,90% of Total billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,65,,13.184,Percent of total Billed Charges,65% of Total Billed Charges,2.87,44.1,,8.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.18,95,,19.272,Percent of Total Billed Charges,95% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,88,,17.856,Percent of Total Billed Charges,88% of Total Billed Charges,5.85,90,,18.256,Percent of Total Billed charges,90% of Total Billed Charges,2.87,6.5,
EZ PAQUE 176GM,2500000982,CDM,250,RC,,,Outpatient,176,gm,6.50,4.23,,6.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.94,76,,42.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.68,72,,43.816,Percent of Total Billed Charges,72% of Total Billed Charges,4.88,75,,45.64,Percent of Total Billed charges,75% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.68,72,,43.816,Percent of Total Billed Charges,72% of Total Billed Charges,3.9,60,,36.512,Percent of Total Billed Charges,60% of Total Billed Charges,5.85,90,,50.008,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,25.008,Percent of Total Billed Charges,45% of Total Billed Charges,5.85,90,,50.008,Percent of Total Billed Charges,90% of Total billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,65,,36.12,Percent of total Billed Charges,65% of Total Billed Charges,2.87,44.1,,24.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.18,95,,52.792,Percent of Total Billed Charges,95% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,88,,48.896,Percent of Total Billed Charges,88% of Total Billed Charges,5.85,90,,50.008,Percent of Total Billed charges,90% of Total Billed Charges,2.87,6.5,
TRANEXAMIC ACID 100MG/ML 10ML,2500000983,CDM,250,RC,,,Outpatient,100,GM,121.50,78.98,,121.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,92.34,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,87.48,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,91.13,75,,28.448,Percent of Total Billed charges,75% of Total Billed Charges,121.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.48,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,72.9,60,,22.76,Percent of Total Billed Charges,60% of Total Billed Charges,109.35,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,54.68,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,109.35,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,121.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.98,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,53.58,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,115.43,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,121.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.92,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,109.35,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,53.58,121.5,
DEXAMETHASONE 10MG/1CC INJ,2500000984,CDM,250,RC,,,Outpatient,10,GM,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,22.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.64,72,,38.104,Percent of Total Billed Charges,72% of Total Billed Charges,9,75,,39.688,Percent of Total Billed charges,75% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.64,72,,38.104,Percent of Total Billed Charges,72% of Total Billed Charges,7.2,60,,31.752,Percent of Total Billed Charges,60% of Total Billed Charges,10.8,90,,26.192,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,13.096,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,26.192,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,18.92,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,12.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,27.648,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,25.608,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,26.192,Percent of Total Billed charges,90% of Total Billed Charges,5.29,12,
SOTRADECOL 1% 20MG/2ML,2500000985,CDM,250,RC,,,Outpatient,20,GM,308.75,200.69,,308.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,234.65,76,,66.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,222.3,72,,358.8,Percent of Total Billed Charges,72% of Total Billed Charges,231.56,75,,373.744,Percent of Total Billed charges,75% of Total Billed Charges,308.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.3,72,,358.8,Percent of Total Billed Charges,72% of Total Billed Charges,185.25,60,,299,Percent of Total Billed Charges,60% of Total Billed Charges,277.88,90,,78.592,Percent of Total Billed Charges,90% of Total Billed Charges,138.94,45,,39.296,Percent of Total Billed Charges,45% of Total Billed Charges,277.88,90,,78.592,Percent of Total Billed Charges,90% of Total billed Charges,308.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.69,65,,56.76,Percent of total Billed Charges,65% of Total Billed Charges,136.16,44.1,,38.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,293.31,95,,82.952,Percent of Total Billed Charges,95% of Total Billed Charges,308.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.7,88,,76.84,Percent of Total Billed Charges,88% of Total Billed Charges,277.88,90,,78.592,Percent of Total Billed charges,90% of Total Billed Charges,136.16,308.75,
FLORASTORKIDS 250MG PWPK,2500000986,CDM,250,RC,,,Outpatient,250,GM,6.50,4.23,,6.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.94,76,,23.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.68,72,,28.576,Percent of Total Billed Charges,72% of Total Billed Charges,4.88,75,,29.768,Percent of Total Billed charges,75% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.68,72,,28.576,Percent of Total Billed Charges,72% of Total Billed Charges,3.9,60,,23.816,Percent of Total Billed Charges,60% of Total Billed Charges,5.85,90,,27.784,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,13.896,Percent of Total Billed Charges,45% of Total Billed Charges,5.85,90,,27.784,Percent of Total Billed Charges,90% of Total billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,65,,20.064,Percent of total Billed Charges,65% of Total Billed Charges,2.87,44.1,,13.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.18,95,,29.328,Percent of Total Billed Charges,95% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,88,,27.168,Percent of Total Billed Charges,88% of Total Billed Charges,5.85,90,,27.784,Percent of Total Billed charges,90% of Total Billed Charges,2.87,6.5,
LIDOCAINE 4% CREA,2500000987,CDM,250,RC,,,Outpatient,,,45.12,29.33,,45.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.29,76,,20.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.49,72,,33.656,Percent of Total Billed Charges,72% of Total Billed Charges,33.84,75,,35.056,Percent of Total Billed charges,75% of Total Billed Charges,45.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.49,72,,33.656,Percent of Total Billed Charges,72% of Total Billed Charges,27.07,60,,28.048,Percent of Total Billed Charges,60% of Total Billed Charges,40.61,90,,23.816,Percent of Total Billed Charges,90% of Total Billed Charges,20.3,45,,11.912,Percent of Total Billed Charges,45% of Total Billed Charges,40.61,90,,23.816,Percent of Total Billed Charges,90% of Total billed Charges,45.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.33,65,,17.2,Percent of total Billed Charges,65% of Total Billed Charges,19.9,44.1,,11.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.86,95,,25.144,Percent of Total Billed Charges,95% of Total Billed Charges,45.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.71,88,,23.288,Percent of Total Billed Charges,88% of Total Billed Charges,40.61,90,,23.816,Percent of Total Billed charges,90% of Total Billed Charges,19.9,45.12,
METRONIDAZOLE 20MG/ML,2500000988,CDM,250,RC,,,Outpatient,20,GM,11.00,7.15,,11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.36,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.92,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,8.25,75,,36.384,Percent of Total Billed charges,75% of Total Billed Charges,11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.92,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,6.6,60,,29.104,Percent of Total Billed Charges,60% of Total Billed Charges,9.9,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,9.9,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.15,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,4.85,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.45,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.68,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,9.9,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,4.85,11,
VANCOMYCIN 25MG/ML,2500000989,CDM,250,RC,,,Outpatient,25,GM,311.50,202.48,,311.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,236.74,76,,13.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,224.28,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,233.63,75,,29.104,Percent of Total Billed charges,75% of Total Billed Charges,311.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.28,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,186.9,60,,23.288,Percent of Total Billed Charges,60% of Total Billed Charges,280.35,90,,15.88,Percent of Total Billed Charges,90% of Total Billed Charges,140.18,45,,7.936,Percent of Total Billed Charges,45% of Total Billed Charges,280.35,90,,15.88,Percent of Total Billed Charges,90% of Total billed Charges,311.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,311.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,311.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.48,65,,11.464,Percent of total Billed Charges,65% of Total Billed Charges,137.37,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,295.93,95,,16.76,Percent of Total Billed Charges,95% of Total Billed Charges,311.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.12,88,,15.52,Percent of Total Billed Charges,88% of Total Billed Charges,280.35,90,,15.88,Percent of Total Billed charges,90% of Total Billed Charges,137.37,311.5,
LOTRISONE CR 45GM,2500000990,CDM,250,RC,,,Outpatient,45,gm,127.25,82.71,,127.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,96.71,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.62,72,,194.328,Percent of Total Billed Charges,72% of Total Billed Charges,95.44,75,,202.424,Percent of Total Billed charges,75% of Total Billed Charges,127.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.62,72,,194.328,Percent of Total Billed Charges,72% of Total Billed Charges,76.35,60,,161.936,Percent of Total Billed Charges,60% of Total Billed Charges,114.53,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,57.26,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,114.53,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,127.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.71,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,56.12,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,120.89,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,127.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.98,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,114.53,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,56.12,127.25,
MISOPROSTOL 200MCG TAB,2500000991,CDM,250,RC,,,Outpatient,200,GM,6.50,4.23,,6.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.94,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.68,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,4.88,75,,14.56,Percent of Total Billed charges,75% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.68,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,3.9,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,5.85,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,5.85,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,2.87,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.18,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,5.85,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,2.87,6.5,
ROBITUSSIN AC SYRUP 10ML UD,2500000992,CDM,250,RC,,,Outpatient,10,ML,6.50,4.23,,6.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.94,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.68,72,,129.552,Percent of Total Billed Charges,72% of Total Billed Charges,4.88,75,,134.944,Percent of Total Billed charges,75% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.68,72,,129.552,Percent of Total Billed Charges,72% of Total Billed Charges,3.9,60,,107.96,Percent of Total Billed Charges,60% of Total Billed Charges,5.85,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,5.85,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,2.87,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.18,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,5.85,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,2.87,6.5,
ELIQUIS 2.5MG TAB,2500000993,CDM,250,RC,,,Outpatient,2.5,GM,23.75,15.44,,23.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.05,76,,15.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.1,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,17.81,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,23.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.1,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,14.25,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,21.38,90,,18.256,Percent of Total Billed Charges,90% of Total Billed Charges,10.69,45,,9.128,Percent of Total Billed Charges,45% of Total Billed Charges,21.38,90,,18.256,Percent of Total Billed Charges,90% of Total billed Charges,23.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,65,,13.184,Percent of total Billed Charges,65% of Total Billed Charges,10.47,44.1,,8.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.56,95,,19.272,Percent of Total Billed Charges,95% of Total Billed Charges,23.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.9,88,,17.856,Percent of Total Billed Charges,88% of Total Billed Charges,21.38,90,,18.256,Percent of Total Billed charges,90% of Total Billed Charges,10.47,23.75,
LANOLIN CRM 7GM,2500000994,CDM,250,RC,,,Outpatient,7,gm,10.00,6.50,,10,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.6,76,,48.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.2,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,7.5,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.2,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,6,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,9,90,,57.152,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,45,,28.576,Percent of Total Billed Charges,45% of Total Billed Charges,9,90,,57.152,Percent of Total Billed Charges,90% of Total billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,65,,41.28,Percent of total Billed Charges,65% of Total Billed Charges,4.41,44.1,,28.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.5,95,,60.328,Percent of Total Billed Charges,95% of Total Billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.8,88,,55.88,Percent of Total Billed Charges,88% of Total Billed Charges,9,90,,57.152,Percent of Total Billed charges,90% of Total Billed Charges,4.41,10,
CAFFINE 200MG TAB,2500000995,CDM,250,RC,,,Outpatient,200,GM,6.50,4.23,,6.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.94,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.68,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,4.88,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.68,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,3.9,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,5.85,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,5.85,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,2.87,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.18,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,5.85,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,2.87,6.5,
ENTRESTO 24MG / 26MG TAB,2500000996,CDM,250,RC,,,Outpatient,24,GM,26.50,17.23,,26.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.14,76,,20.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.08,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,19.88,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,26.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.08,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,15.9,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,23.85,90,,23.816,Percent of Total Billed Charges,90% of Total Billed Charges,11.93,45,,11.912,Percent of Total Billed Charges,45% of Total Billed Charges,23.85,90,,23.816,Percent of Total Billed Charges,90% of Total billed Charges,26.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.23,65,,17.2,Percent of total Billed Charges,65% of Total Billed Charges,11.69,44.1,,11.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.18,95,,25.144,Percent of Total Billed Charges,95% of Total Billed Charges,26.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.32,88,,23.288,Percent of Total Billed Charges,88% of Total Billed Charges,23.85,90,,23.816,Percent of Total Billed charges,90% of Total Billed Charges,11.69,26.5,
MOUTH KOTE SPRAY 240ML,2500000997,CDM,250,RC,,,Outpatient,240,ML,32.75,21.29,,32.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.89,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.58,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,24.56,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,32.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.58,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,19.65,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,29.48,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,14.74,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,29.48,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,32.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.29,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,14.44,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.11,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,32.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.82,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,29.48,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,14.44,32.75,
TRYPAN BLUE 0.06% OP,2500000998,CDM,250,RC,,,Outpatient,,,415.64,270.17,,415.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,315.89,76,,138.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,299.26,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,311.73,75,,8.6,Percent of Total Billed charges,75% of Total Billed Charges,415.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,299.26,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,249.38,60,,6.88,Percent of Total Billed Charges,60% of Total Billed Charges,374.08,90,,164.32,Percent of Total Billed Charges,90% of Total Billed Charges,187.04,45,,82.16,Percent of Total Billed Charges,45% of Total Billed Charges,374.08,90,,164.32,Percent of Total Billed Charges,90% of Total billed Charges,415.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.17,65,,118.672,Percent of total Billed Charges,65% of Total Billed Charges,183.3,44.1,,80.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,394.86,95,,173.448,Percent of Total Billed Charges,95% of Total Billed Charges,415.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365.76,88,,160.664,Percent of Total Billed Charges,88% of Total Billed Charges,374.08,90,,164.32,Percent of Total Billed charges,90% of Total Billed Charges,183.3,415.64,
CYANIDE ANTIDOTE KIT,2500000999,CDM,250,RC,,,Outpatient,,,2102.47,1366.61,,2102.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1597.88,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1513.78,72,,38.736,Percent of Total Billed Charges,72% of Total Billed Charges,1576.85,75,,40.352,Percent of Total Billed charges,75% of Total Billed Charges,2102.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1513.78,72,,38.736,Percent of Total Billed Charges,72% of Total Billed Charges,1261.48,60,,32.28,Percent of Total Billed Charges,60% of Total Billed Charges,1892.22,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,946.11,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,1892.22,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,2102.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2102.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2102.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1366.61,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,927.19,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,1997.35,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,2102.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1850.17,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,1892.22,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,927.19,2102.47,
DIASTAT 5MG GEL,2500001000,CDM,250,RC,,,Outpatient,5,GM,1195.11,776.82,,1195.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,908.28,76,,37.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,860.48,72,,50.168,Percent of Total Billed Charges,72% of Total Billed Charges,896.33,75,,52.264,Percent of Total Billed charges,75% of Total Billed Charges,1195.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,860.48,72,,50.168,Percent of Total Billed Charges,72% of Total Billed Charges,717.07,60,,41.808,Percent of Total Billed Charges,60% of Total Billed Charges,1075.6,90,,44.456,Percent of Total Billed Charges,90% of Total Billed Charges,537.8,45,,22.224,Percent of Total Billed Charges,45% of Total Billed Charges,1075.6,90,,44.456,Percent of Total Billed Charges,90% of Total billed Charges,1195.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1195.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1195.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,776.82,65,,32.104,Percent of total Billed Charges,65% of Total Billed Charges,527.04,44.1,,21.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,1135.35,95,,46.92,Percent of Total Billed Charges,95% of Total Billed Charges,1195.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1051.7,88,,43.464,Percent of Total Billed Charges,88% of Total Billed Charges,1075.6,90,,44.456,Percent of Total Billed charges,90% of Total Billed Charges,527.04,1195.11,
FLOVENT 220MG INHALE,2500001001,CDM,250,RC,,,Outpatient,220,GM,1211.65,787.57,,1211.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,920.85,76,,295.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,872.39,72,,174,Percent of Total Billed Charges,72% of Total Billed Charges,908.74,75,,181.256,Percent of Total Billed charges,75% of Total Billed Charges,1211.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,872.39,72,,174,Percent of Total Billed Charges,72% of Total Billed Charges,726.99,60,,145,Percent of Total Billed Charges,60% of Total Billed Charges,1090.49,90,,350.064,Percent of Total Billed Charges,90% of Total Billed Charges,545.24,45,,175.032,Percent of Total Billed Charges,45% of Total Billed Charges,1090.49,90,,350.064,Percent of Total Billed Charges,90% of Total billed Charges,1211.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1211.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1211.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,787.57,65,,252.824,Percent of total Billed Charges,65% of Total Billed Charges,534.34,44.1,,171.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,1151.07,95,,369.512,Percent of Total Billed Charges,95% of Total Billed Charges,1211.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1066.25,88,,342.288,Percent of Total Billed Charges,88% of Total Billed Charges,1090.49,90,,350.064,Percent of Total Billed charges,90% of Total Billed Charges,534.34,1211.65,
PROSTIN VR PEDI,2500001002,CDM,250,RC,,,Outpatient,,,222.71,144.76,,222.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,169.26,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,160.35,72,,22.864,Percent of Total Billed Charges,72% of Total Billed Charges,167.03,75,,23.816,Percent of Total Billed charges,75% of Total Billed Charges,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.35,72,,22.864,Percent of Total Billed Charges,72% of Total Billed Charges,133.63,60,,19.048,Percent of Total Billed Charges,60% of Total Billed Charges,200.44,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,100.22,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,200.44,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.76,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,98.22,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,211.57,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.98,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,200.44,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,98.22,222.71,
LOVENOX 100MG INJ,2500001004,CDM,636,RC,J1650,HCPCS,Outpatient,100,GM,454.23,295.25,,454.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,345.21,76,,41.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.95,350,,189.88,Fee Schedule,350% of BCBS fee schedule,0.95,350,,197.792,Fee Schedule,350% of BCBS fee schedule,454.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.95,350,,189.88,Fee Schedule,350% of BCBS PPO fee schedule,0.27,100,,158.232,Fee Schedule,100% of Blue ADV HMO fee schedule,408.81,90,,49.216,Percent of Total Billed Charges,90% of Total Billed Charges,204.4,45,,24.608,Percent of Total Billed Charges,45% of Total Billed Charges,408.81,90,,49.216,Percent of Total Billed Charges,90% of Total billed Charges,454.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,454.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,454.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.25,65,,35.544,Percent of total Billed Charges,65% of Total Billed Charges,200.32,44.1,,24.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,431.52,95,,51.952,Percent of Total Billed Charges,95% of Total Billed Charges,454.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.72,88,,48.128,Percent of Total Billed Charges,88% of Total Billed Charges,408.81,90,,49.216,Percent of Total Billed charges,90% of Total Billed Charges,0.27,454.23,
ADVAIR DISKUS INHALE,2500001005,CDM,250,RC,,,Outpatient,,,764.03,496.62,,764.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,580.66,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,550.1,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,573.02,75,,46.968,Percent of Total Billed charges,75% of Total Billed Charges,764.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.1,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,458.42,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,687.63,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,343.81,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,687.63,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,764.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,764.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,764.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,496.62,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,336.94,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,725.83,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,764.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.35,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,687.63,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,336.94,764.03,
PROSTIN E2 SUPP,2500001006,CDM,250,RC,,,Outpatient,,,5146.47,3345.21,,5146.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3911.32,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3705.46,72,,158.76,Percent of Total Billed Charges,72% of Total Billed Charges,3859.85,75,,165.376,Percent of Total Billed charges,75% of Total Billed Charges,5146.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3705.46,72,,158.76,Percent of Total Billed Charges,72% of Total Billed Charges,3087.88,60,,132.304,Percent of Total Billed Charges,60% of Total Billed Charges,4631.82,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,2315.91,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,4631.82,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,5146.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5146.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5146.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3345.21,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,2269.59,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,4889.15,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,5146.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4528.89,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,4631.82,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,2269.59,5146.47,
ALBUMIN 25% 100ML/VI,2500001007,CDM,250,RC,,,Outpatient,100,ML,1119.04,727.38,,1119.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,850.47,76,,48.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,805.71,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,839.28,75,,11.248,Percent of Total Billed charges,75% of Total Billed Charges,1119.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,805.71,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,671.42,60,,8.992,Percent of Total Billed Charges,60% of Total Billed Charges,1007.14,90,,57.944,Percent of Total Billed Charges,90% of Total Billed Charges,503.57,45,,28.976,Percent of Total Billed Charges,45% of Total Billed Charges,1007.14,90,,57.944,Percent of Total Billed Charges,90% of Total billed Charges,1119.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1119.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1119.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,727.38,65,,41.848,Percent of total Billed Charges,65% of Total Billed Charges,493.5,44.1,,28.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1063.09,95,,61.168,Percent of Total Billed Charges,95% of Total Billed Charges,1119.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,984.76,88,,56.656,Percent of Total Billed Charges,88% of Total Billed Charges,1007.14,90,,57.944,Percent of Total Billed charges,90% of Total Billed Charges,493.5,1119.04,
CERVIDIL 10MG/SUPP,2500001008,CDM,250,RC,,,Outpatient,10,GM,979.02,636.36,,979.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,744.06,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,704.89,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,734.27,75,,12.568,Percent of Total Billed charges,75% of Total Billed Charges,979.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704.89,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,587.41,60,,10.056,Percent of Total Billed Charges,60% of Total Billed Charges,881.12,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,440.56,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,881.12,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,979.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,979.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,979.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,636.36,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,431.75,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,930.07,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,979.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,861.54,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,881.12,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,431.75,979.02,
MIACALCIN SPRAY,2500001009,CDM,250,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,32.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,11.248,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,8.992,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,38.896,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,19.448,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,38.896,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,28.088,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,19.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,41.056,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,38.032,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,38.896,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
VISCOAT,2500001010,CDM,250,RC,,,Outpatient,,,691.27,449.33,,691.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,525.37,76,,75.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,497.71,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,518.45,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,691.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497.71,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,414.76,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,622.14,90,,89.696,Percent of Total Billed Charges,90% of Total Billed Charges,311.07,45,,44.848,Percent of Total Billed Charges,45% of Total Billed Charges,622.14,90,,89.696,Percent of Total Billed Charges,90% of Total billed Charges,691.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,691.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,691.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,449.33,65,,64.784,Percent of total Billed Charges,65% of Total Billed Charges,304.85,44.1,,43.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,656.71,95,,94.68,Percent of Total Billed Charges,95% of Total Billed Charges,691.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,608.32,88,,87.704,Percent of Total Billed Charges,88% of Total Billed Charges,622.14,90,,89.696,Percent of Total Billed charges,90% of Total Billed Charges,304.85,691.27,
ADVAIR DISKUS 100/50,2500001011,CDM,250,RC,,,Outpatient,,,468.56,304.56,,468.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,356.11,76,,95.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,337.36,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,351.42,75,,43,Percent of Total Billed charges,75% of Total Billed Charges,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.36,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,60,,34.4,Percent of Total Billed Charges,60% of Total Billed Charges,421.7,90,,112.72,Percent of Total Billed Charges,90% of Total Billed Charges,210.85,45,,56.36,Percent of Total Billed Charges,45% of Total Billed Charges,421.7,90,,112.72,Percent of Total Billed Charges,90% of Total billed Charges,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.56,65,,81.408,Percent of total Billed Charges,65% of Total Billed Charges,206.63,44.1,,55.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,445.13,95,,118.984,Percent of Total Billed Charges,95% of Total Billed Charges,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.33,88,,110.216,Percent of Total Billed Charges,88% of Total Billed Charges,421.7,90,,112.72,Percent of Total Billed charges,90% of Total Billed Charges,206.63,468.56,
ADVAIR DISKUS 250/50,2500001012,CDM,250,RC,,,Outpatient,,,937.13,609.13,,937.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,712.22,76,,24.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,674.73,72,,24.768,Percent of Total Billed Charges,72% of Total Billed Charges,702.85,75,,25.8,Percent of Total Billed charges,75% of Total Billed Charges,937.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,674.73,72,,24.768,Percent of Total Billed Charges,72% of Total Billed Charges,562.28,60,,20.64,Percent of Total Billed Charges,60% of Total Billed Charges,843.42,90,,28.576,Percent of Total Billed Charges,90% of Total Billed Charges,421.71,45,,14.288,Percent of Total Billed Charges,45% of Total Billed Charges,843.42,90,,28.576,Percent of Total Billed Charges,90% of Total billed Charges,937.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,937.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,937.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,609.13,65,,20.64,Percent of total Billed Charges,65% of Total Billed Charges,413.27,44.1,,14,Percent of Total Billed Charges,44.1% of Total Billed Charges,890.27,95,,30.168,Percent of Total Billed Charges,95% of Total Billed Charges,937.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,824.67,88,,27.944,Percent of Total Billed Charges,88% of Total Billed Charges,843.42,90,,28.576,Percent of Total Billed charges,90% of Total Billed Charges,413.27,937.13,
NASACORT AQ SPRAY,2500001013,CDM,250,RC,,,Outpatient,,,552.35,359.03,,552.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,419.79,76,,116.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,397.69,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,414.26,75,,5.952,Percent of Total Billed charges,75% of Total Billed Charges,552.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.69,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,331.41,60,,4.76,Percent of Total Billed Charges,60% of Total Billed Charges,497.12,90,,138.128,Percent of Total Billed Charges,90% of Total Billed Charges,248.56,45,,69.064,Percent of Total Billed Charges,45% of Total Billed Charges,497.12,90,,138.128,Percent of Total Billed Charges,90% of Total billed Charges,552.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.03,65,,99.76,Percent of total Billed Charges,65% of Total Billed Charges,243.59,44.1,,67.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,524.73,95,,145.8,Percent of Total Billed Charges,95% of Total Billed Charges,552.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,486.07,88,,135.056,Percent of Total Billed Charges,88% of Total Billed Charges,497.12,90,,138.128,Percent of Total Billed charges,90% of Total Billed Charges,243.59,552.35,
FLOVENT 44MG INH,2500001014,CDM,250,RC,,,Outpatient,44,GM,582.12,378.38,,582.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,442.41,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,419.13,72,,142.88,Percent of Total Billed Charges,72% of Total Billed Charges,436.59,75,,148.84,Percent of Total Billed charges,75% of Total Billed Charges,582.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.13,72,,142.88,Percent of Total Billed Charges,72% of Total Billed Charges,349.27,60,,119.072,Percent of Total Billed Charges,60% of Total Billed Charges,523.91,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,261.95,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,523.91,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,582.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,582.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,582.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.38,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,256.71,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,553.01,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,582.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,512.27,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,523.91,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,256.71,582.12,
FLOVENT 110MCG INJ,2500001015,CDM,250,RC,,,Outpatient,110,GM,779.47,506.66,,779.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,592.4,76,,56.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,561.22,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,584.6,75,,21.832,Percent of Total Billed charges,75% of Total Billed Charges,779.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561.22,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,467.68,60,,17.464,Percent of Total Billed Charges,60% of Total Billed Charges,701.52,90,,66.68,Percent of Total Billed Charges,90% of Total Billed Charges,350.76,45,,33.336,Percent of Total Billed Charges,45% of Total Billed Charges,701.52,90,,66.68,Percent of Total Billed Charges,90% of Total billed Charges,779.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,779.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,779.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.66,65,,48.16,Percent of total Billed Charges,65% of Total Billed Charges,343.75,44.1,,32.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,740.5,95,,70.384,Percent of Total Billed Charges,95% of Total Billed Charges,779.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.93,88,,65.2,Percent of Total Billed Charges,88% of Total Billed Charges,701.52,90,,66.68,Percent of Total Billed charges,90% of Total Billed Charges,343.75,779.47,
HEMABATE 250MCG INJ,2500001016,CDM,250,RC,,,Outpatient,250,GM,635.04,412.78,,635.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,482.63,76,,23.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,457.23,72,,128.28,Percent of Total Billed Charges,72% of Total Billed Charges,476.28,75,,133.624,Percent of Total Billed charges,75% of Total Billed Charges,635.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,457.23,72,,128.28,Percent of Total Billed Charges,72% of Total Billed Charges,381.02,60,,106.904,Percent of Total Billed Charges,60% of Total Billed Charges,571.54,90,,27.784,Percent of Total Billed Charges,90% of Total Billed Charges,285.77,45,,13.896,Percent of Total Billed Charges,45% of Total Billed Charges,571.54,90,,27.784,Percent of Total Billed Charges,90% of Total billed Charges,635.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,635.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,635.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.78,65,,20.064,Percent of total Billed Charges,65% of Total Billed Charges,280.05,44.1,,13.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,603.29,95,,29.328,Percent of Total Billed Charges,95% of Total Billed Charges,635.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.84,88,,27.168,Percent of Total Billed Charges,88% of Total Billed Charges,571.54,90,,27.784,Percent of Total Billed charges,90% of Total Billed Charges,280.05,635.04,
SANDOSTATIN 0.05MCG,2500001017,CDM,250,RC,J2354,HCPCS,Outpatient,0.05,GM,51.82,33.68,,51.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,39.38,76,,46.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.09,350,,145.424,Fee Schedule,350% of BCBS fee schedule,1.09,350,,151.48,Fee Schedule,350% of BCBS fee schedule,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.09,350,,145.424,Fee Schedule,350% of BCBS PPO fee schedule,0.31,100,,121.184,Fee Schedule,100% of Blue ADV HMO fee schedule,46.64,90,,54.768,Percent of Total Billed Charges,90% of Total Billed Charges,23.32,45,,27.384,Percent of Total Billed Charges,45% of Total Billed Charges,46.64,90,,54.768,Percent of Total Billed Charges,90% of Total billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.68,65,,39.56,Percent of total Billed Charges,65% of Total Billed Charges,22.85,44.1,,26.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,49.23,95,,57.816,Percent of Total Billed Charges,95% of Total Billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.6,88,,53.552,Percent of Total Billed Charges,88% of Total Billed Charges,46.64,90,,54.768,Percent of Total Billed charges,90% of Total Billed Charges,0.31,51.82,
BREVIBLOC 250MG INJ,2500001018,CDM,250,RC,,,Outpatient,250,GM,604.17,392.71,,604.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,459.17,76,,28.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,435,72,,25.92,Percent of Total Billed Charges,72% of Total Billed Charges,453.13,75,,27,Percent of Total Billed charges,75% of Total Billed Charges,604.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435,72,,25.92,Percent of Total Billed Charges,72% of Total Billed Charges,362.5,60,,21.6,Percent of Total Billed Charges,60% of Total Billed Charges,543.75,90,,34.136,Percent of Total Billed Charges,90% of Total Billed Charges,271.88,45,,17.064,Percent of Total Billed Charges,45% of Total Billed Charges,543.75,90,,34.136,Percent of Total Billed Charges,90% of Total billed Charges,604.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,604.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,604.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.71,65,,24.656,Percent of total Billed Charges,65% of Total Billed Charges,266.44,44.1,,16.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,573.96,95,,36.032,Percent of Total Billed Charges,95% of Total Billed Charges,604.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531.67,88,,33.376,Percent of Total Billed Charges,88% of Total Billed Charges,543.75,90,,34.136,Percent of Total Billed charges,90% of Total Billed Charges,266.44,604.17,
VIGAMOX 0.5% OPHTH D,2500001019,CDM,250,RC,,,Outpatient,,,413.44,268.74,,413.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,314.21,76,,40.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297.68,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,310.08,75,,7.2,Percent of Total Billed charges,75% of Total Billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,248.06,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,372.1,90,,47.632,Percent of Total Billed Charges,90% of Total Billed Charges,186.05,45,,23.816,Percent of Total Billed Charges,45% of Total Billed Charges,372.1,90,,47.632,Percent of Total Billed Charges,90% of Total billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.74,65,,34.4,Percent of total Billed Charges,65% of Total Billed Charges,182.33,44.1,,23.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,392.77,95,,50.272,Percent of Total Billed Charges,95% of Total Billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.83,88,,46.568,Percent of Total Billed Charges,88% of Total Billed Charges,372.1,90,,47.632,Percent of Total Billed charges,90% of Total Billed Charges,182.33,413.44,
VAPRISOL DEX 5% 20MG,2500001020,CDM,250,RC,,,Outpatient,20,GM,3141.02,2041.66,,3141.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2387.18,76,,378.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2261.53,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,2355.77,75,,7.2,Percent of Total Billed charges,75% of Total Billed Charges,3141.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2261.53,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,1884.61,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,2826.92,90,,448.496,Percent of Total Billed Charges,90% of Total Billed Charges,1413.46,45,,224.248,Percent of Total Billed Charges,45% of Total Billed Charges,2826.92,90,,448.496,Percent of Total Billed Charges,90% of Total billed Charges,3141.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3141.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3141.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2041.66,65,,323.912,Percent of total Billed Charges,65% of Total Billed Charges,1385.19,44.1,,219.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,2983.97,95,,473.408,Percent of Total Billed Charges,95% of Total Billed Charges,3141.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2764.1,88,,438.528,Percent of Total Billed Charges,88% of Total Billed Charges,2826.92,90,,448.496,Percent of Total Billed charges,90% of Total Billed Charges,1385.19,3141.02,
CUROSURF 240MG/3ML V,2500001021,CDM,250,RC,,,Outpatient,240,GM,1280.00,832.00,,1280,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,972.8,76,,30.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,921.6,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,960,75,,21.832,Percent of Total Billed charges,75% of Total Billed Charges,1280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,921.6,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,768,60,,17.464,Percent of Total Billed Charges,60% of Total Billed Charges,1152,90,,35.72,Percent of Total Billed Charges,90% of Total Billed Charges,576,45,,17.856,Percent of Total Billed Charges,45% of Total Billed Charges,1152,90,,35.72,Percent of Total Billed Charges,90% of Total billed Charges,1280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,832,65,,25.8,Percent of total Billed Charges,65% of Total Billed Charges,564.48,44.1,,17.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,1216,95,,37.704,Percent of Total Billed Charges,95% of Total Billed Charges,1280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1126.4,88,,34.928,Percent of Total Billed Charges,88% of Total Billed Charges,1152,90,,35.72,Percent of Total Billed charges,90% of Total Billed Charges,564.48,1280,
BREVIBLOC 2500MG/250,2500001022,CDM,250,RC,,,Outpatient,2500,GM,820.26,533.17,,820.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,623.4,76,,35.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,590.59,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,615.2,75,,7.2,Percent of Total Billed charges,75% of Total Billed Charges,820.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,590.59,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,492.16,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,738.23,90,,42.072,Percent of Total Billed Charges,90% of Total Billed Charges,369.12,45,,21.032,Percent of Total Billed Charges,45% of Total Billed Charges,738.23,90,,42.072,Percent of Total Billed Charges,90% of Total billed Charges,820.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,820.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,820.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,533.17,65,,30.384,Percent of total Billed Charges,65% of Total Billed Charges,361.73,44.1,,20.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,779.25,95,,44.408,Percent of Total Billed Charges,95% of Total Billed Charges,820.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,721.83,88,,41.136,Percent of Total Billed Charges,88% of Total Billed Charges,738.23,90,,42.072,Percent of Total Billed charges,90% of Total Billed Charges,361.73,820.26,
ANGIOMAX 250MG INJ,2500001023,CDM,250,RC,J0583,HCPCS,Outpatient,250,GM,4073.74,2647.93,,4073.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3096.04,76,,36.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.08,350,,6.912,Fee Schedule,350% of BCBS fee schedule,5.08,350,,7.2,Fee Schedule,350% of BCBS fee schedule,4073.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.08,350,,6.912,Fee Schedule,350% of BCBS PPO fee schedule,1.45,100,,5.76,Fee Schedule,100% of Blue ADV HMO fee schedule,3666.37,90,,43.664,Percent of Total Billed Charges,90% of Total Billed Charges,1833.18,45,,21.832,Percent of Total Billed Charges,45% of Total Billed Charges,3666.37,90,,43.664,Percent of Total Billed Charges,90% of Total billed Charges,4073.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4073.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4073.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2647.93,65,,31.536,Percent of total Billed Charges,65% of Total Billed Charges,1796.52,44.1,,21.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,3870.05,95,,46.088,Percent of Total Billed Charges,95% of Total Billed Charges,4073.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3584.89,88,,42.688,Percent of Total Billed Charges,88% of Total Billed Charges,3666.37,90,,43.664,Percent of Total Billed charges,90% of Total Billed Charges,1.45,4073.74,
NITROLINGUAL SPRAY 12GM,2500001024,CDM,250,RC,,,Outpatient,12,gm,921.75,599.14,,921.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,700.53,76,,29.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,663.66,72,,12,Percent of Total Billed Charges,72% of Total Billed Charges,691.31,75,,12.496,Percent of Total Billed charges,75% of Total Billed Charges,921.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,663.66,72,,12,Percent of Total Billed Charges,72% of Total Billed Charges,553.05,60,,10,Percent of Total Billed Charges,60% of Total Billed Charges,829.58,90,,34.928,Percent of Total Billed Charges,90% of Total Billed Charges,414.79,45,,17.464,Percent of Total Billed Charges,45% of Total Billed Charges,829.58,90,,34.928,Percent of Total Billed Charges,90% of Total billed Charges,921.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,921.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,921.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,599.14,65,,25.224,Percent of total Billed Charges,65% of Total Billed Charges,406.49,44.1,,17.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,875.66,95,,36.864,Percent of Total Billed Charges,95% of Total Billed Charges,921.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,811.14,88,,34.152,Percent of Total Billed Charges,88% of Total Billed Charges,829.58,90,,34.928,Percent of Total Billed charges,90% of Total Billed Charges,406.49,921.75,
OFLOXACIN 0.3% 5ML OTIC,2500001025,CDM,250,RC,,,Outpatient,5,ML,450.00,292.50,,450,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,342,76,,205.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,324,72,,22.296,Percent of Total Billed Charges,72% of Total Billed Charges,337.5,75,,23.224,Percent of Total Billed charges,75% of Total Billed Charges,450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324,72,,22.296,Percent of Total Billed Charges,72% of Total Billed Charges,270,60,,18.584,Percent of Total Billed Charges,60% of Total Billed Charges,405,90,,242.904,Percent of Total Billed Charges,90% of Total Billed Charges,202.5,45,,121.456,Percent of Total Billed Charges,45% of Total Billed Charges,405,90,,242.904,Percent of Total Billed Charges,90% of Total billed Charges,450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.5,65,,175.432,Percent of total Billed Charges,65% of Total Billed Charges,198.45,44.1,,119.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,427.5,95,,256.4,Percent of Total Billed Charges,95% of Total Billed Charges,450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,88,,237.512,Percent of Total Billed Charges,88% of Total Billed Charges,405,90,,242.904,Percent of Total Billed charges,90% of Total Billed Charges,198.45,450,
STERILE H2O FOR INJ 1000ML,2500001026,CDM,250,RC,,,Outpatient,1000,ML,36.38,23.65,,36.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.65,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.19,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,27.29,75,,7.936,Percent of Total Billed charges,75% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.19,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,21.83,60,,6.352,Percent of Total Billed Charges,60% of Total Billed Charges,32.74,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,16.37,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,32.74,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.65,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,16.04,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.56,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.01,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,32.74,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,16.04,36.38,
STERIL H2O FOR INJ 10ML,2500001027,CDM,250,RC,,,Outpatient,10,ML,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,136.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,161.936,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,80.968,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,161.936,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,116.952,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,79.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,170.928,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,158.336,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,161.936,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
D10W 250 ML SOLN,2500001028,CDM,250,RC,,,Outpatient,250,ML,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
SOD CHLORIDE FOR INJ 10ML,2500001029,CDM,250,RC,,,Outpatient,10,ML,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,32.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,38.896,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,19.448,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,38.896,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,28.088,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,19.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,41.056,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,38.032,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,38.896,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
D10W 500ML/1000ML,2500001034,CDM,250,RC,,,Outpatient,500,ML,132.30,86.00,,132.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.55,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.26,72,,419.76,Percent of Total Billed Charges,72% of Total Billed Charges,99.23,75,,437.248,Percent of Total Billed charges,75% of Total Billed Charges,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.26,72,,419.76,Percent of Total Billed Charges,72% of Total Billed Charges,79.38,60,,349.8,Percent of Total Billed Charges,60% of Total Billed Charges,119.07,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,59.54,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,119.07,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,58.34,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.69,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.42,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,119.07,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,58.34,132.3,
D10W 1/4NS 250 ML SOLN,2500001035,CDM,250,RC,,,Outpatient,250,ML,38.59,25.08,,38.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.33,76,,8.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.78,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,28.94,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.78,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,34.73,90,,10.32,Percent of Total Billed Charges,90% of Total Billed Charges,17.37,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,34.73,90,,10.32,Percent of Total Billed Charges,90% of Total billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.08,65,,7.448,Percent of total Billed Charges,65% of Total Billed Charges,17.02,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.66,95,,10.888,Percent of Total Billed Charges,95% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.96,88,,10.088,Percent of Total Billed Charges,88% of Total Billed Charges,34.73,90,,10.32,Percent of Total Billed charges,90% of Total Billed Charges,17.02,38.59,
D10W 1/4NS 500 ML SOLN,2500001036,CDM,250,RC,,,Outpatient,500,ML,33.08,21.50,,33.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.14,76,,40.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.82,72,,192.416,Percent of Total Billed Charges,72% of Total Billed Charges,24.81,75,,200.44,Percent of Total Billed charges,75% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.82,72,,192.416,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,60,,160.352,Percent of Total Billed Charges,60% of Total Billed Charges,29.77,90,,48.424,Percent of Total Billed Charges,90% of Total Billed Charges,14.89,45,,24.208,Percent of Total Billed Charges,45% of Total Billed Charges,29.77,90,,48.424,Percent of Total Billed Charges,90% of Total billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.5,65,,34.968,Percent of total Billed Charges,65% of Total Billed Charges,14.59,44.1,,23.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.43,95,,51.112,Percent of Total Billed Charges,95% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.11,88,,47.344,Percent of Total Billed Charges,88% of Total Billed Charges,29.77,90,,48.424,Percent of Total Billed charges,90% of Total Billed Charges,14.59,33.08,
500CC D5 LR IV SOLN,2500001037,CDM,250,RC,,,Outpatient,,,61.74,40.13,,61.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.92,76,,52.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,44.45,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,75,,23.152,Percent of Total Billed charges,75% of Total Billed Charges,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.45,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,37.04,60,,18.52,Percent of Total Billed Charges,60% of Total Billed Charges,55.57,90,,62.712,Percent of Total Billed Charges,90% of Total Billed Charges,27.78,45,,31.36,Percent of Total Billed Charges,45% of Total Billed Charges,55.57,90,,62.712,Percent of Total Billed Charges,90% of Total billed Charges,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.13,65,,45.296,Percent of total Billed Charges,65% of Total Billed Charges,27.23,44.1,,30.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,58.65,95,,66.2,Percent of Total Billed Charges,95% of Total Billed Charges,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.33,88,,61.32,Percent of Total Billed Charges,88% of Total Billed Charges,55.57,90,,62.712,Percent of Total Billed charges,90% of Total Billed Charges,27.23,61.74,
1000CC D5 LR IV SOLN,2500001038,CDM,250,RC,,,Outpatient,,,56.23,36.55,,56.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.73,76,,183.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.49,72,,159.264,Percent of Total Billed Charges,72% of Total Billed Charges,42.17,75,,165.904,Percent of Total Billed charges,75% of Total Billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.49,72,,159.264,Percent of Total Billed Charges,72% of Total Billed Charges,33.74,60,,132.72,Percent of Total Billed Charges,60% of Total Billed Charges,50.61,90,,217.504,Percent of Total Billed Charges,90% of Total Billed Charges,25.3,45,,108.752,Percent of Total Billed Charges,45% of Total Billed Charges,50.61,90,,217.504,Percent of Total Billed Charges,90% of Total billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.55,65,,157.088,Percent of total Billed Charges,65% of Total Billed Charges,24.8,44.1,,106.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.42,95,,229.592,Percent of Total Billed Charges,95% of Total Billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.48,88,,212.672,Percent of Total Billed Charges,88% of Total Billed Charges,50.61,90,,217.504,Percent of Total Billed charges,90% of Total Billed Charges,24.8,56.23,
DEXTROSE 50% 500ML IV SOLN,2500001039,CDM,250,RC,,,Outpatient,500,ML,195.14,126.84,,195.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,148.31,76,,24.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,140.5,72,,205.12,Percent of Total Billed Charges,72% of Total Billed Charges,146.36,75,,213.664,Percent of Total Billed charges,75% of Total Billed Charges,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.5,72,,205.12,Percent of Total Billed Charges,72% of Total Billed Charges,117.08,60,,170.936,Percent of Total Billed Charges,60% of Total Billed Charges,175.63,90,,28.576,Percent of Total Billed Charges,90% of Total Billed Charges,87.81,45,,14.288,Percent of Total Billed Charges,45% of Total Billed Charges,175.63,90,,28.576,Percent of Total Billed Charges,90% of Total billed Charges,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.84,65,,20.64,Percent of total Billed Charges,65% of Total Billed Charges,86.06,44.1,,14,Percent of Total Billed Charges,44.1% of Total Billed Charges,185.38,95,,30.168,Percent of Total Billed Charges,95% of Total Billed Charges,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.72,88,,27.944,Percent of Total Billed Charges,88% of Total Billed Charges,175.63,90,,28.576,Percent of Total Billed charges,90% of Total Billed Charges,86.06,195.14,
3% SOD CHLORIDE 500ML SOLN,2500001040,CDM,250,RC,,,Outpatient,500,ML,49.61,32.25,,49.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,37.7,76,,517.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,35.72,72,,574.712,Percent of Total Billed Charges,72% of Total Billed Charges,37.21,75,,598.656,Percent of Total Billed charges,75% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.72,72,,574.712,Percent of Total Billed Charges,72% of Total Billed Charges,29.77,60,,478.928,Percent of Total Billed Charges,60% of Total Billed Charges,44.65,90,,612.816,Percent of Total Billed Charges,90% of Total Billed Charges,22.32,45,,306.408,Percent of Total Billed Charges,45% of Total Billed Charges,44.65,90,,612.816,Percent of Total Billed Charges,90% of Total billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.25,65,,442.584,Percent of total Billed Charges,65% of Total Billed Charges,21.88,44.1,,300.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,47.13,95,,646.856,Percent of Total Billed Charges,95% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,88,,599.192,Percent of Total Billed Charges,88% of Total Billed Charges,44.65,90,,612.816,Percent of Total Billed charges,90% of Total Billed Charges,21.88,49.61,
CARDIZEM 5MG/ML INJ,2500001041,CDM,250,RC,,,Outpatient,5,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,200.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,44.984,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,35.984,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,237.352,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,118.672,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,237.352,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,171.416,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,116.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,250.536,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,232.072,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,237.352,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
CARDIZEM 5MG/ML INJ,2500001042,CDM,250,RC,,,Outpatient,5,GM,26.46,17.20,,26.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.11,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.05,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,75,,10.584,Percent of Total Billed charges,75% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.05,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,15.88,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,23.81,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,11.91,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,23.81,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,11.67,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.14,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.28,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,23.81,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,11.67,26.46,
CLEOCIN 900MG INJ,2500001043,CDM,250,RC,,,Outpatient,900,GM,27.56,17.91,,27.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.95,76,,167.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.84,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,20.67,75,,7.936,Percent of Total Billed charges,75% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.84,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,60,,6.352,Percent of Total Billed Charges,60% of Total Billed Charges,24.8,90,,198.456,Percent of Total Billed Charges,90% of Total Billed Charges,12.4,45,,99.224,Percent of Total Billed Charges,45% of Total Billed Charges,24.8,90,,198.456,Percent of Total Billed Charges,90% of Total billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.91,65,,143.328,Percent of total Billed Charges,65% of Total Billed Charges,12.15,44.1,,97.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.18,95,,209.48,Percent of Total Billed Charges,95% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,88,,194.04,Percent of Total Billed Charges,88% of Total Billed Charges,24.8,90,,198.456,Percent of Total Billed charges,90% of Total Billed Charges,12.15,27.56,
LIDO W/EPI 1PCT 20ML INJ,2500001044,CDM,250,RC,,,Outpatient,20,ML,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,11.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,13.496,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,6.744,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,13.496,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,9.744,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,6.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,14.24,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,13.192,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,13.496,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
LABETALOL 100MG/20ML INJ,2500001045,CDM,250,RC,,,Outpatient,100,GM,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,72,,575.352,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,75,,599.32,Percent of Total Billed charges,75% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,72,,575.352,Percent of Total Billed Charges,72% of Total Billed Charges,5.95,60,,479.456,Percent of Total Billed Charges,60% of Total Billed Charges,8.93,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,4.37,9.92,
NEXTERONE 150 MG/100ML INJ,2500001046,CDM,250,RC,J0282,HCPCS,Outpatient,150,GM,179.71,116.81,,179.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,136.58,76,,11.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.7,350,,3.744,Fee Schedule,350% of BCBS fee schedule,0.7,350,,3.904,Fee Schedule,350% of BCBS fee schedule,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.7,350,,3.744,Fee Schedule,350% of BCBS PPO fee schedule,0.2,100,,3.12,Fee Schedule,100% of Blue ADV HMO fee schedule,161.74,90,,13.496,Percent of Total Billed Charges,90% of Total Billed Charges,80.87,45,,6.744,Percent of Total Billed Charges,45% of Total Billed Charges,161.74,90,,13.496,Percent of Total Billed Charges,90% of Total billed Charges,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.81,65,,9.744,Percent of total Billed Charges,65% of Total Billed Charges,79.25,44.1,,6.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,170.72,95,,14.24,Percent of Total Billed Charges,95% of Total Billed Charges,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.14,88,,13.192,Percent of Total Billed Charges,88% of Total Billed Charges,161.74,90,,13.496,Percent of Total Billed charges,90% of Total Billed Charges,0.2,179.71,
LIDO 2GM/500ML INJ,2500001047,CDM,250,RC,J2002,HCPCS,Outpatient,2,gm,126.79,82.41,,126.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,96.36,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.29,72,,19.688,Percent of Total Billed Charges,72% of Total Billed Charges,95.09,75,,20.512,Percent of Total Billed charges,75% of Total Billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.29,72,,19.688,Percent of Total Billed Charges,72% of Total Billed Charges,76.07,60,,16.408,Percent of Total Billed Charges,60% of Total Billed Charges,114.11,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,57.06,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,114.11,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.41,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,55.91,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,120.45,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.58,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,114.11,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,55.91,126.79,
LIDO 1PCT 20ML VL INJ,2500001048,CDM,250,RC,J2003,HCPCS,Outpatient,20,ML,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,43.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,84.456,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,87.976,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,84.456,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,70.384,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,51.592,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,25.8,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,51.592,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,37.264,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,25.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,54.464,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,50.448,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,51.592,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
LIDO WEPI 2PCT 10ML INJ,2500001049,CDM,250,RC,,,Outpatient,10,ML,44.10,28.67,,44.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33.52,76,,26.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,31.75,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,75,,14.56,Percent of Total Billed charges,75% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.75,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,39.69,90,,30.96,Percent of Total Billed Charges,90% of Total Billed Charges,19.85,45,,15.48,Percent of Total Billed Charges,45% of Total Billed Charges,39.69,90,,30.96,Percent of Total Billed Charges,90% of Total billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,65,,22.36,Percent of total Billed Charges,65% of Total Billed Charges,19.45,44.1,,15.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.9,95,,32.68,Percent of Total Billed Charges,95% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.81,88,,30.272,Percent of Total Billed Charges,88% of Total Billed Charges,39.69,90,,30.96,Percent of Total Billed charges,90% of Total Billed Charges,19.45,44.1,
LIDOCAINE HCL 2% 10ML INJ,2500001050,CDM,250,RC,J2003,HCPCS,Outpatient,10,ML,35.28,22.93,,35.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.81,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.4,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.4,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,21.17,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,31.75,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,15.88,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,31.75,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.93,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,15.56,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.52,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.05,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,31.75,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,15.56,35.28,
LIDOCAINE HCL 2% 20 ML INJ,2500001051,CDM,250,RC,J2002,HCPCS,Outpatient,20,ML,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,107.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,7.2,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,127.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,63.904,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,127.8,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,92.304,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,62.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,134.904,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,124.96,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,127.8,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
BUPIVACAINEMPF/EPIN INJ,2500001052,CDM,250,RC,,,Outpatient,,,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,150.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,178.6,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,89.304,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,178.6,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,128.992,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,87.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,188.528,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,174.632,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,178.6,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
BUPIVACAINEMPF/EPIN INJ,2500001053,CDM,250,RC,,,Outpatient,,,45.20,29.38,,45.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.35,76,,22.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.54,72,,92.08,Percent of Total Billed Charges,72% of Total Billed Charges,33.9,75,,95.92,Percent of Total Billed charges,75% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.54,72,,92.08,Percent of Total Billed Charges,72% of Total Billed Charges,27.12,60,,76.736,Percent of Total Billed Charges,60% of Total Billed Charges,40.68,90,,26.192,Percent of Total Billed Charges,90% of Total Billed Charges,20.34,45,,13.096,Percent of Total Billed Charges,45% of Total Billed Charges,40.68,90,,26.192,Percent of Total Billed Charges,90% of Total billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.38,65,,18.92,Percent of total Billed Charges,65% of Total Billed Charges,19.93,44.1,,12.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.94,95,,27.648,Percent of Total Billed Charges,95% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.78,88,,25.608,Percent of Total Billed Charges,88% of Total Billed Charges,40.68,90,,26.192,Percent of Total Billed charges,90% of Total Billed Charges,19.93,45.2,
D10W 500ML SOLN,2500001054,CDM,250,RC,,,Outpatient,500,ML,174.20,113.23,,174.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,132.39,76,,135.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,125.42,72,,257.192,Percent of Total Billed Charges,72% of Total Billed Charges,130.65,75,,267.904,Percent of Total Billed charges,75% of Total Billed Charges,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.42,72,,257.192,Percent of Total Billed Charges,72% of Total Billed Charges,104.52,60,,214.328,Percent of Total Billed Charges,60% of Total Billed Charges,156.78,90,,160.352,Percent of Total Billed Charges,90% of Total Billed Charges,78.39,45,,80.176,Percent of Total Billed Charges,45% of Total Billed Charges,156.78,90,,160.352,Percent of Total Billed Charges,90% of Total billed Charges,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.23,65,,115.808,Percent of total Billed Charges,65% of Total Billed Charges,76.82,44.1,,78.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,165.49,95,,169.256,Percent of Total Billed Charges,95% of Total Billed Charges,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.3,88,,156.784,Percent of Total Billed Charges,88% of Total Billed Charges,156.78,90,,160.352,Percent of Total Billed charges,90% of Total Billed Charges,76.82,174.2,
NITRO 25MG/250ML INJ,2500001055,CDM,250,RC,,,Outpatient,25,GM,89.30,58.05,,89.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.87,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.3,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,66.98,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.3,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,53.58,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,80.37,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,40.19,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,80.37,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.05,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,39.38,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,84.84,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.58,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,80.37,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,39.38,89.3,
TRACE MTE 5 10ML INJ,2500001056,CDM,250,RC,,,Outpatient,10,ML,25.36,16.48,,25.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.27,76,,80.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.26,72,,144.792,Percent of Total Billed Charges,72% of Total Billed Charges,19.02,75,,150.824,Percent of Total Billed charges,75% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.26,72,,144.792,Percent of Total Billed Charges,72% of Total Billed Charges,15.22,60,,120.656,Percent of Total Billed Charges,60% of Total Billed Charges,22.82,90,,95.256,Percent of Total Billed Charges,90% of Total Billed Charges,11.41,45,,47.632,Percent of Total Billed Charges,45% of Total Billed Charges,22.82,90,,95.256,Percent of Total Billed Charges,90% of Total billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,65,,68.8,Percent of total Billed Charges,65% of Total Billed Charges,11.18,44.1,,46.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.09,95,,100.552,Percent of Total Billed Charges,95% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,88,,93.136,Percent of Total Billed Charges,88% of Total Billed Charges,22.82,90,,95.256,Percent of Total Billed charges,90% of Total Billed Charges,11.18,25.36,
INDIGO CARMINE 5ML INJ,2500001057,CDM,250,RC,,,Outpatient,5,ML,40.79,26.51,,40.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31,76,,152.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.37,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,30.59,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.37,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,24.47,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,36.71,90,,180.984,Percent of Total Billed Charges,90% of Total Billed Charges,18.36,45,,90.496,Percent of Total Billed Charges,45% of Total Billed Charges,36.71,90,,180.984,Percent of Total Billed Charges,90% of Total billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.51,65,,130.712,Percent of total Billed Charges,65% of Total Billed Charges,17.99,44.1,,88.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.75,95,,191.04,Percent of Total Billed Charges,95% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.9,88,,176.968,Percent of Total Billed Charges,88% of Total Billed Charges,36.71,90,,180.984,Percent of Total Billed charges,90% of Total Billed Charges,17.99,40.79,
NACL 50MEQ/20ML INJ,2500001059,CDM,250,RC,,,Outpatient,20,ML,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,144.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,171.464,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,85.728,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,171.464,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,130.152,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,84.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,180.984,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,167.648,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,171.464,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
XYLOCAINE 1.5PCT 1ML INJ,2500001060,CDM,250,RC,,,Outpatient,1,ML,38.59,25.08,,38.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.33,76,,144.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.78,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,28.94,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.78,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,34.73,90,,171.464,Percent of Total Billed Charges,90% of Total Billed Charges,17.37,45,,85.728,Percent of Total Billed Charges,45% of Total Billed Charges,34.73,90,,171.464,Percent of Total Billed Charges,90% of Total billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.08,65,,130.152,Percent of total Billed Charges,65% of Total Billed Charges,17.02,44.1,,84.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.66,95,,180.984,Percent of Total Billed Charges,95% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.96,88,,167.648,Percent of Total Billed Charges,88% of Total Billed Charges,34.73,90,,171.464,Percent of Total Billed charges,90% of Total Billed Charges,17.02,38.59,
SENSORCAINE 0.5% 30ML,2500001061,CDM,250,RC,,,Outpatient,30,ML,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,27.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,150.504,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,156.776,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,150.504,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,125.416,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,16.2,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,32.4,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,23.4,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,15.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,34.2,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,31.68,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,32.4,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
LANTUS INSULIN 100ML INJ,2500001062,CDM,250,RC,,,Outpatient,100,ML,56.23,36.55,,56.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.73,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.49,72,,48.264,Percent of Total Billed Charges,72% of Total Billed Charges,42.17,75,,50.272,Percent of Total Billed charges,75% of Total Billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.49,72,,48.264,Percent of Total Billed Charges,72% of Total Billed Charges,33.74,60,,40.216,Percent of Total Billed Charges,60% of Total Billed Charges,50.61,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,25.3,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,50.61,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.55,65,,6.24,Percent of total Billed Charges,65% of Total Billed Charges,24.8,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.42,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.48,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,50.61,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,24.8,56.23,
THROMBINTOP .5000UNIT INJ,2500001063,CDM,250,RC,,,Outpatient,,,393.59,255.83,,393.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.13,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,283.38,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,295.19,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.38,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,236.15,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,354.23,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,177.12,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,354.23,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.83,65,,6.24,Percent of total Billed Charges,65% of Total Billed Charges,173.57,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,373.91,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.36,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,354.23,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,173.57,393.59,
XYLOCAINE 5% 35GM OINT,2500001064,CDM,250,RC,,,Outpatient,35,gm,292.16,189.90,,292.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,222.04,76,,22.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,210.36,72,,313.712,Percent of Total Billed Charges,72% of Total Billed Charges,219.12,75,,326.784,Percent of Total Billed charges,75% of Total Billed Charges,292.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.36,72,,313.712,Percent of Total Billed Charges,72% of Total Billed Charges,175.3,60,,261.424,Percent of Total Billed Charges,60% of Total Billed Charges,262.94,90,,26.192,Percent of Total Billed Charges,90% of Total Billed Charges,131.47,45,,13.096,Percent of Total Billed Charges,45% of Total Billed Charges,262.94,90,,26.192,Percent of Total Billed Charges,90% of Total billed Charges,292.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.9,65,,18.92,Percent of total Billed Charges,65% of Total Billed Charges,128.84,44.1,,12.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,277.55,95,,27.648,Percent of Total Billed Charges,95% of Total Billed Charges,292.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.1,88,,25.608,Percent of Total Billed Charges,88% of Total Billed Charges,262.94,90,,26.192,Percent of Total Billed charges,90% of Total Billed Charges,128.84,292.16,
AMICAR 250MG INJ,2500001065,CDM,250,RC,,,Outpatient,250,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,392.456,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,408.808,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,392.456,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,327.048,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,6.24,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
BACITRACN 50000U INJ,2500001066,CDM,250,RC,,,Outpatient,,,49.61,32.25,,49.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,37.7,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,35.72,72,,9.504,Percent of Total Billed Charges,72% of Total Billed Charges,37.21,75,,9.904,Percent of Total Billed charges,75% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.72,72,,9.504,Percent of Total Billed Charges,72% of Total Billed Charges,29.77,60,,7.92,Percent of Total Billed Charges,60% of Total Billed Charges,44.65,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,22.32,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,44.65,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.25,65,,6.24,Percent of total Billed Charges,65% of Total Billed Charges,21.88,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,47.13,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,44.65,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,21.88,49.61,
BREVIBLOC 10MG/ML INJ,2500001067,CDM,250,RC,,,Outpatient,10,GM,58.43,37.98,,58.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,44.41,76,,12.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.07,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,43.82,75,,3.904,Percent of Total Billed charges,75% of Total Billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.07,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,35.06,60,,3.12,Percent of Total Billed Charges,60% of Total Billed Charges,52.59,90,,15,Percent of Total Billed Charges,90% of Total Billed Charges,26.29,45,,7.496,Percent of Total Billed Charges,45% of Total Billed Charges,52.59,90,,15,Percent of Total Billed Charges,90% of Total billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.98,65,,10.832,Percent of total Billed Charges,65% of Total Billed Charges,25.77,44.1,,7.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,55.51,95,,15.832,Percent of Total Billed Charges,95% of Total Billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.42,88,,14.664,Percent of Total Billed Charges,88% of Total Billed Charges,52.59,90,,15,Percent of Total Billed charges,90% of Total Billed Charges,25.77,58.43,
CALCIUM CHL 10% INJ,2500001068,CDM,250,RC,,,Outpatient,,,46.31,30.10,,46.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.2,76,,23.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.34,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,34.73,75,,7.2,Percent of Total Billed charges,75% of Total Billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.34,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,27.79,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,41.68,90,,27.872,Percent of Total Billed Charges,90% of Total Billed Charges,20.84,45,,13.936,Percent of Total Billed Charges,45% of Total Billed Charges,41.68,90,,27.872,Percent of Total Billed Charges,90% of Total billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.1,65,,20.128,Percent of total Billed Charges,65% of Total Billed Charges,20.42,44.1,,13.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,43.99,95,,29.416,Percent of Total Billed Charges,95% of Total Billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.75,88,,27.248,Percent of Total Billed Charges,88% of Total Billed Charges,41.68,90,,27.872,Percent of Total Billed charges,90% of Total Billed Charges,20.42,46.31,
DEXTROSE 50% SYRINGE INJ,2500001069,CDM,250,RC,,,Outpatient,,,52.92,34.40,,52.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.22,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.1,72,,568.8,Percent of Total Billed Charges,72% of Total Billed Charges,39.69,75,,592.504,Percent of Total Billed charges,75% of Total Billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.1,72,,568.8,Percent of Total Billed Charges,72% of Total Billed Charges,31.75,60,,474,Percent of Total Billed Charges,60% of Total Billed Charges,47.63,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,23.81,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,47.63,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.4,65,,6.88,Percent of total Billed Charges,65% of Total Billed Charges,23.34,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.27,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.57,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,47.63,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,23.34,52.92,
DOPRAM 20MG/ML INJ,2500001070,CDM,250,RC,,,Outpatient,20,GM,302.09,196.36,,302.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,229.59,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,217.5,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,226.57,75,,44.984,Percent of Total Billed charges,75% of Total Billed Charges,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.5,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,181.25,60,,35.984,Percent of Total Billed Charges,60% of Total Billed Charges,271.88,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,135.94,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,271.88,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.36,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,133.22,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,286.99,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.84,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,271.88,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,133.22,302.09,
FLAGYL IV 500MG INJ,2500001071,CDM,250,RC,,,Outpatient,500,GM,175.30,113.95,,175.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,133.23,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,126.22,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,131.48,75,,10.584,Percent of Total Billed charges,75% of Total Billed Charges,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.22,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,105.18,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,157.77,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,78.89,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,157.77,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.95,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,77.31,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,166.54,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.26,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,157.77,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,77.31,175.3,
FOLVITE 5MG INJ 1ML INJ,2500001072,CDM,250,RC,,,Outpatient,1,GM,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,74.296,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,77.392,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,74.296,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,61.912,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
HESPAN INJ,2500001073,CDM,250,RC,,,Outpatient,,,293.27,190.63,,293.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,222.89,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,211.15,72,,74.296,Percent of Total Billed Charges,72% of Total Billed Charges,219.95,75,,77.392,Percent of Total Billed charges,75% of Total Billed Charges,293.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.15,72,,74.296,Percent of Total Billed Charges,72% of Total Billed Charges,175.96,60,,61.912,Percent of Total Billed Charges,60% of Total Billed Charges,263.94,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,131.97,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,263.94,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,293.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.63,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,129.33,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,278.61,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,293.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258.08,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,263.94,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,129.33,293.27,
ISOPTIN 5MG/2ML AMP INJ,2500001074,CDM,250,RC,,,Outpatient,5,GM,37.49,24.37,,37.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.49,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.99,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,28.12,75,,44.984,Percent of Total Billed charges,75% of Total Billed Charges,37.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.99,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,22.49,60,,35.984,Percent of Total Billed Charges,60% of Total Billed Charges,33.74,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,16.87,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,33.74,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,37.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.37,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,16.53,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.62,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,37.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.99,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,33.74,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,16.53,37.49,
IMITREX 6MG INJ,2500001075,CDM,250,RC,J3030,HCPCS,Outpatient,6,GM,280.04,182.03,,280.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,212.83,76,,494.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.67,350,,184.752,Fee Schedule,350% of BCBS fee schedule,84.67,350,,192.448,Fee Schedule,350% of BCBS fee schedule,280.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.67,350,,184.752,Fee Schedule,350% of BCBS PPO fee schedule,24.19,100,,153.96,Fee Schedule,100% of Blue ADV HMO fee schedule,252.04,90,,585.832,Percent of Total Billed Charges,90% of Total Billed Charges,126.02,45,,292.912,Percent of Total Billed Charges,45% of Total Billed Charges,252.04,90,,585.832,Percent of Total Billed Charges,90% of Total billed Charges,280.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182.03,65,,423.096,Percent of total Billed Charges,65% of Total Billed Charges,123.5,44.1,,287.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,266.04,95,,618.376,Percent of Total Billed Charges,95% of Total Billed Charges,280.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.44,88,,572.808,Percent of Total Billed Charges,88% of Total Billed Charges,252.04,90,,585.832,Percent of Total Billed charges,90% of Total Billed Charges,24.19,280.04,
ISUPREL 1CC INJ,2500001076,CDM,250,RC,,,Outpatient,,,48.51,31.53,,48.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.87,76,,309.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.93,72,,225.072,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,75,,234.448,Percent of Total Billed charges,75% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,72,,225.072,Percent of Total Billed Charges,72% of Total Billed Charges,29.11,60,,187.56,Percent of Total Billed Charges,60% of Total Billed Charges,43.66,90,,366.736,Percent of Total Billed Charges,90% of Total Billed Charges,21.83,45,,183.368,Percent of Total Billed Charges,45% of Total Billed Charges,43.66,90,,366.736,Percent of Total Billed Charges,90% of Total billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.53,65,,264.864,Percent of total Billed Charges,65% of Total Billed Charges,21.39,44.1,,179.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.08,95,,387.112,Percent of Total Billed Charges,95% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.69,88,,358.592,Percent of Total Billed Charges,88% of Total Billed Charges,43.66,90,,366.736,Percent of Total Billed charges,90% of Total Billed Charges,21.39,48.51,
MVI12 TWO 5ML INJ,2500001077,CDM,250,RC,,,Outpatient,5,ML,31.97,20.78,,31.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.3,76,,443.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.02,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,23.98,75,,9.272,Percent of Total Billed charges,75% of Total Billed Charges,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.02,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,19.18,60,,7.416,Percent of Total Billed Charges,60% of Total Billed Charges,28.77,90,,524.704,Percent of Total Billed Charges,90% of Total Billed Charges,14.39,45,,262.352,Percent of Total Billed Charges,45% of Total Billed Charges,28.77,90,,524.704,Percent of Total Billed Charges,90% of Total billed Charges,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.78,65,,378.952,Percent of total Billed Charges,65% of Total Billed Charges,14.1,44.1,,257.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.37,95,,553.848,Percent of Total Billed Charges,95% of Total Billed Charges,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.13,88,,513.04,Percent of Total Billed Charges,88% of Total Billed Charges,28.77,90,,524.704,Percent of Total Billed charges,90% of Total Billed Charges,14.1,31.97,
MARCAINE .25% / 30ML INJ,2500001078,CDM,250,RC,,,Outpatient,30,ML,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,670.32,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,698.248,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,670.32,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,558.6,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
MARCAIN .25% /  50 ML INJ,2500001079,CDM,250,RC,,,Outpatient,50,ML,60.64,39.42,,60.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.09,76,,203.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.66,72,,59.696,Percent of Total Billed Charges,72% of Total Billed Charges,45.48,75,,62.184,Percent of Total Billed charges,75% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,72,,59.696,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,60,,49.744,Percent of Total Billed Charges,60% of Total Billed Charges,54.58,90,,240.52,Percent of Total Billed Charges,90% of Total Billed Charges,27.29,45,,120.264,Percent of Total Billed Charges,45% of Total Billed Charges,54.58,90,,240.52,Percent of Total Billed Charges,90% of Total billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.42,65,,173.712,Percent of total Billed Charges,65% of Total Billed Charges,26.74,44.1,,117.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.61,95,,253.888,Percent of Total Billed Charges,95% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.36,88,,235.176,Percent of Total Billed Charges,88% of Total Billed Charges,54.58,90,,240.52,Percent of Total Billed charges,90% of Total Billed Charges,26.74,60.64,
MARCAINE 5% & EPI INJ,2500001080,CDM,250,RC,,,Outpatient,,,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,23.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,7.776,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,8.104,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,7.776,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,6.48,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,27.784,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,13.896,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,27.784,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,20.064,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,13.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,29.328,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,27.168,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,27.784,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
MARCAINE .75% PLAIN INJ,2500001081,CDM,250,RC,,,Outpatient,,,34.18,22.22,,34.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.98,76,,168.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.61,72,,19.696,Percent of Total Billed Charges,72% of Total Billed Charges,25.64,75,,20.52,Percent of Total Billed charges,75% of Total Billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.61,72,,19.696,Percent of Total Billed Charges,72% of Total Billed Charges,20.51,60,,16.416,Percent of Total Billed Charges,60% of Total Billed Charges,30.76,90,,199.08,Percent of Total Billed Charges,90% of Total Billed Charges,15.38,45,,99.544,Percent of Total Billed Charges,45% of Total Billed Charges,30.76,90,,199.08,Percent of Total Billed Charges,90% of Total billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.22,65,,143.784,Percent of total Billed Charges,65% of Total Billed Charges,15.07,44.1,,97.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.47,95,,210.144,Percent of Total Billed Charges,95% of Total Billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.08,88,,194.656,Percent of Total Billed Charges,88% of Total Billed Charges,30.76,90,,199.08,Percent of Total Billed charges,90% of Total Billed Charges,15.07,34.18,
ROMAZICON 1MG/10ML,2500001082,CDM,250,RC,,,Outpatient,1,GM,164.27,106.78,,164.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.85,76,,216.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,118.27,72,,486.296,Percent of Total Billed Charges,72% of Total Billed Charges,123.2,75,,506.56,Percent of Total Billed charges,75% of Total Billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.27,72,,486.296,Percent of Total Billed Charges,72% of Total Billed Charges,98.56,60,,405.248,Percent of Total Billed Charges,60% of Total Billed Charges,147.84,90,,256.4,Percent of Total Billed Charges,90% of Total Billed Charges,73.92,45,,128.2,Percent of Total Billed Charges,45% of Total Billed Charges,147.84,90,,256.4,Percent of Total Billed Charges,90% of Total billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.78,65,,185.176,Percent of total Billed Charges,65% of Total Billed Charges,72.44,44.1,,125.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,156.06,95,,270.64,Percent of Total Billed Charges,95% of Total Billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.56,88,,250.704,Percent of Total Billed Charges,88% of Total Billed Charges,147.84,90,,256.4,Percent of Total Billed charges,90% of Total Billed Charges,72.44,164.27,
NEOSYNEPHRINE 1% AMP,2500001083,CDM,250,RC,J2370,HCPCS,Outpatient,,,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,606.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.12,350,,3.744,Fee Schedule,350% of BCBS fee schedule,3.12,350,,3.904,Fee Schedule,350% of BCBS fee schedule,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.12,350,,3.744,Fee Schedule,350% of BCBS PPO fee schedule,0.89,100,,3.12,Fee Schedule,100% of Blue ADV HMO fee schedule,13.9,90,,718.384,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,359.192,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,718.384,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,518.832,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,352.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,758.296,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,702.424,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,718.384,Percent of Total Billed charges,90% of Total Billed Charges,0.89,15.44,
NEUT 5ML INJ,2500001084,CDM,250,RC,J3490,HCPCS,Outpatient,5,ML,26.46,17.20,,26.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.11,76,,45.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.05,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,75,,3.904,Percent of Total Billed charges,75% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.05,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,15.88,60,,3.12,Percent of Total Billed Charges,60% of Total Billed Charges,23.81,90,,53.976,Percent of Total Billed Charges,90% of Total Billed Charges,11.91,45,,26.992,Percent of Total Billed Charges,45% of Total Billed Charges,23.81,90,,53.976,Percent of Total Billed Charges,90% of Total billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,65,,38.984,Percent of total Billed Charges,65% of Total Billed Charges,11.67,44.1,,26.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.14,95,,56.976,Percent of Total Billed Charges,95% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.28,88,,52.776,Percent of Total Billed Charges,88% of Total Billed Charges,23.81,90,,53.976,Percent of Total Billed charges,90% of Total Billed Charges,11.67,26.46,
NIPRID 50MG 5CC VIAL INJ,2500001085,CDM,250,RC,,,Outpatient,50,GM,238.14,154.79,,238.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,180.99,76,,10.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,171.46,72,,1183.104,Percent of Total Billed Charges,72% of Total Billed Charges,178.61,75,,1232.4,Percent of Total Billed charges,75% of Total Billed Charges,238.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.46,72,,1183.104,Percent of Total Billed Charges,72% of Total Billed Charges,142.88,60,,985.92,Percent of Total Billed Charges,60% of Total Billed Charges,214.33,90,,12.704,Percent of Total Billed Charges,90% of Total Billed Charges,107.16,45,,6.352,Percent of Total Billed Charges,45% of Total Billed Charges,214.33,90,,12.704,Percent of Total Billed Charges,90% of Total billed Charges,238.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.79,65,,9.176,Percent of total Billed Charges,65% of Total Billed Charges,105.02,44.1,,6.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,226.23,95,,13.408,Percent of Total Billed Charges,95% of Total Billed Charges,238.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.56,88,,12.416,Percent of Total Billed Charges,88% of Total Billed Charges,214.33,90,,12.704,Percent of Total Billed charges,90% of Total Billed Charges,105.02,238.14,
NORCURON 10MG INJ,2500001086,CDM,250,RC,,,Outpatient,10,GM,49.61,32.25,,49.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,37.7,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,35.72,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,37.21,75,,3.904,Percent of Total Billed charges,75% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.72,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,29.77,60,,3.12,Percent of Total Billed Charges,60% of Total Billed Charges,44.65,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,22.32,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,44.65,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.25,65,,6.88,Percent of total Billed Charges,65% of Total Billed Charges,21.88,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,47.13,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,44.65,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,21.88,49.61,
PAVULON 10MG/5ML INJ,2500001087,CDM,250,RC,,,Outpatient,10,GM,48.51,31.53,,48.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.87,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.93,72,,385.784,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,75,,401.864,Percent of Total Billed charges,75% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,72,,385.784,Percent of Total Billed Charges,72% of Total Billed Charges,29.11,60,,321.488,Percent of Total Billed Charges,60% of Total Billed Charges,43.66,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,21.83,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,43.66,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.53,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,21.39,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.08,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.69,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,43.66,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,21.39,48.51,
PITRESSIN 20 UNITS INJ,2500001088,CDM,250,RC,,,Outpatient,,,25.36,16.48,,25.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.27,76,,607.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.26,72,,7.096,Percent of Total Billed Charges,72% of Total Billed Charges,19.02,75,,7.392,Percent of Total Billed charges,75% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.26,72,,7.096,Percent of Total Billed Charges,72% of Total Billed Charges,15.22,60,,5.912,Percent of Total Billed Charges,60% of Total Billed Charges,22.82,90,,719.184,Percent of Total Billed Charges,90% of Total Billed Charges,11.41,45,,359.592,Percent of Total Billed Charges,45% of Total Billed Charges,22.82,90,,719.184,Percent of Total Billed Charges,90% of Total billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,65,,519.416,Percent of total Billed Charges,65% of Total Billed Charges,11.18,44.1,,352.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.09,95,,759.144,Percent of Total Billed Charges,95% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,88,,703.208,Percent of Total Billed Charges,88% of Total Billed Charges,22.82,90,,719.184,Percent of Total Billed charges,90% of Total Billed Charges,11.18,25.36,
POLYMYXIN B 500000 INJ,2500001089,CDM,250,RC,,,Outpatient,,,69.46,45.15,,69.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.79,76,,97.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.01,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,52.1,75,,3.904,Percent of Total Billed charges,75% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.01,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,41.68,60,,3.12,Percent of Total Billed Charges,60% of Total Billed Charges,62.51,90,,115.096,Percent of Total Billed Charges,90% of Total Billed Charges,31.26,45,,57.552,Percent of Total Billed Charges,45% of Total Billed Charges,62.51,90,,115.096,Percent of Total Billed Charges,90% of Total billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.15,65,,83.128,Percent of total Billed Charges,65% of Total Billed Charges,30.63,44.1,,56.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.99,95,,121.496,Percent of Total Billed Charges,95% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,88,,112.544,Percent of Total Billed Charges,88% of Total Billed Charges,62.51,90,,115.096,Percent of Total Billed charges,90% of Total Billed Charges,30.63,69.46,
POTASSIUM ACETATE 40MEQ INJ,2500001090,CDM,250,RC,,,Outpatient,,,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,3.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,13.232,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,10.584,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,4.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,2.344,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,4.68,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,3.384,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,2.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,4.944,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,4.576,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,4.68,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
SOD BICARB SY 50CC INJ,2500001091,CDM,250,RC,,,Outpatient,,,36.38,23.65,,36.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.65,76,,20.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.19,72,,4750.216,Percent of Total Billed Charges,72% of Total Billed Charges,27.29,75,,4948.144,Percent of Total Billed charges,75% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.19,72,,4750.216,Percent of Total Billed Charges,72% of Total Billed Charges,21.83,60,,3958.512,Percent of Total Billed Charges,60% of Total Billed Charges,32.74,90,,24.608,Percent of Total Billed Charges,90% of Total Billed Charges,16.37,45,,12.304,Percent of Total Billed Charges,45% of Total Billed Charges,32.74,90,,24.608,Percent of Total Billed Charges,90% of Total billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.65,65,,17.776,Percent of total Billed Charges,65% of Total Billed Charges,16.04,44.1,,12.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.56,95,,25.976,Percent of Total Billed Charges,95% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.01,88,,24.064,Percent of Total Billed Charges,88% of Total Billed Charges,32.74,90,,24.608,Percent of Total Billed charges,90% of Total Billed Charges,16.04,36.38,
SYNTHROID INJ 200MCG,2500001092,CDM,250,RC,,,Outpatient,200,GM,109.15,70.95,,109.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.95,76,,89.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,78.59,72,,69.408,Percent of Total Billed Charges,72% of Total Billed Charges,81.86,75,,72.304,Percent of Total Billed charges,75% of Total Billed Charges,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.59,72,,69.408,Percent of Total Billed Charges,72% of Total Billed Charges,65.49,60,,57.84,Percent of Total Billed Charges,60% of Total Billed Charges,98.24,90,,105.576,Percent of Total Billed Charges,90% of Total Billed Charges,49.12,45,,52.784,Percent of Total Billed Charges,45% of Total Billed Charges,98.24,90,,105.576,Percent of Total Billed Charges,90% of Total billed Charges,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.95,65,,76.248,Percent of total Billed Charges,65% of Total Billed Charges,48.14,44.1,,51.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,103.69,95,,111.44,Percent of Total Billed Charges,95% of Total Billed Charges,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.05,88,,103.224,Percent of Total Billed Charges,88% of Total Billed Charges,98.24,90,,105.576,Percent of Total Billed charges,90% of Total Billed Charges,48.14,109.15,
LABETALOL INJ 5MG/ML INJ,2500001093,CDM,250,RC,,,Outpatient,5,GM,38.59,25.08,,38.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.33,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.78,72,,33.12,Percent of Total Billed Charges,72% of Total Billed Charges,28.94,75,,34.504,Percent of Total Billed charges,75% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.78,72,,33.12,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,60,,27.6,Percent of Total Billed Charges,60% of Total Billed Charges,34.73,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,17.37,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,34.73,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.08,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,17.02,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.66,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.96,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,34.73,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,17.02,38.59,
TRIDIL MAINT 50MG/10ML INJ,2500001094,CDM,250,RC,,,Outpatient,50,GM,33.08,21.50,,33.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.14,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.82,72,,115.648,Percent of Total Billed Charges,72% of Total Billed Charges,24.81,75,,120.472,Percent of Total Billed charges,75% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.82,72,,115.648,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,60,,96.376,Percent of Total Billed Charges,60% of Total Billed Charges,29.77,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,14.89,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,29.77,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.5,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,14.59,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.43,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.11,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,29.77,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,14.59,33.08,
XYLOCAINE 1% 30ML INJ,2500001095,CDM,250,RC,J2003,HCPCS,Outpatient,30,ML,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,13.264,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,13.816,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,13.264,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,11.056,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,6.24,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
XYLOCAINE 100MG/5CC INJ,2500001096,CDM,250,RC,J2003,HCPCS,Outpatient,100,GM,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.88,72,,114.136,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,75,,118.888,Percent of Total Billed charges,75% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.88,72,,114.136,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,60,,95.112,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.05,
XYLOCAINE 1% ADD CC INJ,2500001097,CDM,250,RC,J2003,HCPCS,Outpatient,,,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,97.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,9.36,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,9.752,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,9.36,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,7.8,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,115.096,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,57.552,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,115.096,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,83.128,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,56.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,121.496,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,112.544,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,115.096,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
KETAMINE 500MG/5ML INJ,2500001098,CDM,250,RC,,,Outpatient,500,GM,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,271.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,191.232,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,199.2,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,191.232,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,159.36,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,321.488,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,160.744,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,321.488,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,232.184,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,157.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,339.344,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,314.344,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,321.488,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
LOPRESSOR 5MG INJ,2500001099,CDM,250,RC,,,Outpatient,5,GM,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,9.36,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,9.752,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,9.36,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,7.8,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
ALFENTA 2ML INJ,2500001100,CDM,250,RC,,,Outpatient,2,ML,25.36,16.48,,25.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.27,76,,152.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.26,72,,4.768,Percent of Total Billed Charges,72% of Total Billed Charges,19.02,75,,4.968,Percent of Total Billed charges,75% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.26,72,,4.768,Percent of Total Billed Charges,72% of Total Billed Charges,15.22,60,,3.976,Percent of Total Billed Charges,60% of Total Billed Charges,22.82,90,,180.984,Percent of Total Billed Charges,90% of Total Billed Charges,11.41,45,,90.496,Percent of Total Billed Charges,45% of Total Billed Charges,22.82,90,,180.984,Percent of Total Billed Charges,90% of Total billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,65,,130.712,Percent of total Billed Charges,65% of Total Billed Charges,11.18,44.1,,88.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.09,95,,191.04,Percent of Total Billed Charges,95% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,88,,176.968,Percent of Total Billed Charges,88% of Total Billed Charges,22.82,90,,180.984,Percent of Total Billed charges,90% of Total Billed Charges,11.18,25.36,
BSS 30ML INJ,2500001101,CDM,250,RC,,,Outpatient,30,ML,79.38,51.60,,79.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60.33,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.15,72,,6.408,Percent of Total Billed Charges,72% of Total Billed Charges,59.54,75,,6.68,Percent of Total Billed charges,75% of Total Billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.15,72,,6.408,Percent of Total Billed Charges,72% of Total Billed Charges,47.63,60,,5.344,Percent of Total Billed Charges,60% of Total Billed Charges,71.44,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,35.72,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,71.44,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,35.01,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,75.41,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.85,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,71.44,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,35.01,79.38,
SODIUM CHLOR 9% 3ML INJ,2500001102,CDM,250,RC,,,Outpatient,3,ML,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,142.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,9,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,9.376,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,9,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,7.504,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,169.08,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,84.536,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,169.08,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,122.112,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,82.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,178.472,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,165.32,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,169.08,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
SOD BICARB 4.2% PEDI INJ,2500001103,CDM,250,RC,,,Outpatient,,,33.08,21.50,,33.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.14,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.82,72,,286.328,Percent of Total Billed Charges,72% of Total Billed Charges,24.81,75,,298.264,Percent of Total Billed charges,75% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.82,72,,286.328,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,60,,238.608,Percent of Total Billed Charges,60% of Total Billed Charges,29.77,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,14.89,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,29.77,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.5,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,14.59,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.43,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.11,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,29.77,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,14.59,33.08,
DEXTROSE 25% SYG10ML INJ,2500001104,CDM,250,RC,,,Outpatient,10,ML,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,7.432,Percent of Total Billed Charges,72% of Total Billed Charges,22.33,75,,7.744,Percent of Total Billed charges,75% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,7.432,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,6.192,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
ENLON INJ 10MG/ML INJ,2500001105,CDM,250,RC,,,Outpatient,10,GM,228.22,148.34,,228.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,173.45,76,,158.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,164.32,72,,457.952,Percent of Total Billed Charges,72% of Total Billed Charges,171.17,75,,477.032,Percent of Total Billed charges,75% of Total Billed Charges,228.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.32,72,,457.952,Percent of Total Billed Charges,72% of Total Billed Charges,136.93,60,,381.624,Percent of Total Billed Charges,60% of Total Billed Charges,205.4,90,,188.128,Percent of Total Billed Charges,90% of Total Billed Charges,102.7,45,,94.064,Percent of Total Billed Charges,45% of Total Billed Charges,205.4,90,,188.128,Percent of Total Billed Charges,90% of Total billed Charges,228.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.34,65,,135.872,Percent of total Billed Charges,65% of Total Billed Charges,100.65,44.1,,92.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,216.81,95,,198.584,Percent of Total Billed Charges,95% of Total Billed Charges,228.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.83,88,,183.952,Percent of Total Billed Charges,88% of Total Billed Charges,205.4,90,,188.128,Percent of Total Billed charges,90% of Total Billed Charges,100.65,228.22,
SODIUM ACETATE 40MEQ INJ,2500001106,CDM,250,RC,,,Outpatient,,,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,50.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,0.328,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,0.344,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,0.328,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,0.272,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,60.328,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,30.168,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,60.328,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,43.568,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,29.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,63.68,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,58.992,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,60.328,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
AMIDATE 2MG/M/INJ,2500001107,CDM,250,RC,,,Outpatient,2,GM,61.74,40.13,,61.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.92,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,44.45,72,,2689.496,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,75,,2801.56,Percent of Total Billed charges,75% of Total Billed Charges,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.45,72,,2689.496,Percent of Total Billed Charges,72% of Total Billed Charges,37.04,60,,2241.248,Percent of Total Billed Charges,60% of Total Billed Charges,55.57,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,27.78,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,55.57,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.13,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,27.23,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,58.65,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.33,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,55.57,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,27.23,61.74,
DANTRIUM 20MG INJ,2500001108,CDM,250,RC,,,Outpatient,20,GM,486.20,316.03,,486.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,369.51,76,,331.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,350.06,72,,18.36,Percent of Total Billed Charges,72% of Total Billed Charges,364.65,75,,19.12,Percent of Total Billed charges,75% of Total Billed Charges,486.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.06,72,,18.36,Percent of Total Billed Charges,72% of Total Billed Charges,291.72,60,,15.296,Percent of Total Billed Charges,60% of Total Billed Charges,437.58,90,,392.144,Percent of Total Billed Charges,90% of Total Billed Charges,218.79,45,,196.072,Percent of Total Billed Charges,45% of Total Billed Charges,437.58,90,,392.144,Percent of Total Billed Charges,90% of Total billed Charges,486.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,486.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,486.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.03,65,,283.216,Percent of total Billed Charges,65% of Total Billed Charges,214.41,44.1,,192.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,461.89,95,,413.928,Percent of Total Billed Charges,95% of Total Billed Charges,486.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.86,88,,383.424,Percent of Total Billed Charges,88% of Total Billed Charges,437.58,90,,392.144,Percent of Total Billed charges,90% of Total Billed Charges,214.41,486.2,
SODIUM PHOSPHATE 60MEQ INJ,2500001109,CDM,250,RC,,,Outpatient,,,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,414.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,12.192,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,12.704,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,12.192,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,10.16,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,490.576,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,245.288,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,490.576,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,354.304,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,240.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,517.824,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,479.672,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,490.576,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
NS 1000W/KCL 20MEQ SOLN,2500001110,CDM,250,RC,J3480,HCPCS,Outpatient,,,68.36,44.43,,68.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.95,76,,10.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.14,350,,624.008,Fee Schedule,350% of BCBS fee schedule,0.14,350,,650.008,Fee Schedule,350% of BCBS fee schedule,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.14,350,,624.008,Fee Schedule,350% of BCBS PPO fee schedule,0.04,100,,520.008,Fee Schedule,100% of Blue ADV HMO fee schedule,61.52,90,,11.88,Percent of Total Billed Charges,90% of Total Billed Charges,30.76,45,,5.944,Percent of Total Billed Charges,45% of Total Billed Charges,61.52,90,,11.88,Percent of Total Billed Charges,90% of Total billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.43,65,,8.584,Percent of total Billed Charges,65% of Total Billed Charges,30.15,44.1,,5.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,64.94,95,,12.544,Percent of Total Billed Charges,95% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.16,88,,11.616,Percent of Total Billed Charges,88% of Total Billed Charges,61.52,90,,11.88,Percent of Total Billed charges,90% of Total Billed Charges,0.04,68.36,
NS 1000W/KCL 40MEQ SOLN,2500001111,CDM,250,RC,J3480,HCPCS,Outpatient,,,68.36,44.43,,68.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.95,76,,3.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.14,350,,255.424,Fee Schedule,350% of BCBS fee schedule,0.14,350,,266.072,Fee Schedule,350% of BCBS fee schedule,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.14,350,,255.424,Fee Schedule,350% of BCBS PPO fee schedule,0.04,100,,212.856,Fee Schedule,100% of Blue ADV HMO fee schedule,61.52,90,,4.68,Percent of Total Billed Charges,90% of Total Billed Charges,30.76,45,,2.344,Percent of Total Billed Charges,45% of Total Billed Charges,61.52,90,,4.68,Percent of Total Billed Charges,90% of Total billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.43,65,,3.384,Percent of total Billed Charges,65% of Total Billed Charges,30.15,44.1,,2.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,64.94,95,,4.944,Percent of Total Billed Charges,95% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.16,88,,4.576,Percent of Total Billed Charges,88% of Total Billed Charges,61.52,90,,4.68,Percent of Total Billed charges,90% of Total Billed Charges,0.04,68.36,
CALCIUM GLUC 0.465MEQ/ML INJ,2500001112,CDM,250,RC,,,Outpatient,1,ML,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,144.112,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,150.12,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,144.112,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,120.096,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,6.24,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
POT PHOSPHATE 4.4M/ML INJ,2500001113,CDM,250,RC,,,Outpatient,1,ML,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,600.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,181.728,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,189.304,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,181.728,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,151.44,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,711,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,355.504,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,711,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,513.504,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,348.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,750.504,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,695.2,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,711,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
NIMBEX 2MG 1ML INJ,2500001114,CDM,250,RC,,,Outpatient,2,GM,80.48,52.31,,80.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,61.16,76,,45.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.95,72,,79.2,Percent of Total Billed Charges,72% of Total Billed Charges,60.36,75,,82.504,Percent of Total Billed charges,75% of Total Billed Charges,80.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.95,72,,79.2,Percent of Total Billed Charges,72% of Total Billed Charges,48.29,60,,66,Percent of Total Billed Charges,60% of Total Billed Charges,72.43,90,,53.976,Percent of Total Billed Charges,90% of Total Billed Charges,36.22,45,,26.992,Percent of Total Billed Charges,45% of Total Billed Charges,72.43,90,,53.976,Percent of Total Billed Charges,90% of Total billed Charges,80.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.31,65,,38.984,Percent of total Billed Charges,65% of Total Billed Charges,35.49,44.1,,26.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,76.46,95,,56.976,Percent of Total Billed Charges,95% of Total Billed Charges,80.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.82,88,,52.776,Percent of Total Billed Charges,88% of Total Billed Charges,72.43,90,,53.976,Percent of Total Billed charges,90% of Total Billed Charges,35.49,80.48,
BUPIVACAINE 0.75%/DEX INJ,2500001115,CDM,250,RC,,,Outpatient,,,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,10.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,14306.544,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,14902.648,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,14306.544,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,11922.12,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,12.704,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,6.352,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,12.704,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,9.176,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,6.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,13.408,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,12.416,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,12.704,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
TENORMIN 0.5MG/ML 10,2500001116,CDM,250,RC,,,Outpatient,0.5,GM,54.02,35.11,,54.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.06,76,,78.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.89,72,,283.352,Percent of Total Billed Charges,72% of Total Billed Charges,40.52,75,,295.16,Percent of Total Billed charges,75% of Total Billed Charges,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.89,72,,283.352,Percent of Total Billed Charges,72% of Total Billed Charges,32.41,60,,236.128,Percent of Total Billed Charges,60% of Total Billed Charges,48.62,90,,92.872,Percent of Total Billed Charges,90% of Total Billed Charges,24.31,45,,46.44,Percent of Total Billed Charges,45% of Total Billed Charges,48.62,90,,92.872,Percent of Total Billed Charges,90% of Total billed Charges,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.11,65,,67.072,Percent of total Billed Charges,65% of Total Billed Charges,23.82,44.1,,45.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,51.32,95,,98.032,Percent of Total Billed Charges,95% of Total Billed Charges,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.54,88,,90.808,Percent of Total Billed Charges,88% of Total Billed Charges,48.62,90,,92.872,Percent of Total Billed charges,90% of Total Billed Charges,23.82,54.02,
NEOSPORIN G.U. IRRIT INJ,2500001117,CDM,250,RC,,,Outpatient,,,124.58,80.98,,124.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,94.68,76,,78.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,89.7,72,,3715.456,Percent of Total Billed Charges,72% of Total Billed Charges,93.44,75,,3870.272,Percent of Total Billed charges,75% of Total Billed Charges,124.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.7,72,,3715.456,Percent of Total Billed Charges,72% of Total Billed Charges,74.75,60,,3096.216,Percent of Total Billed Charges,60% of Total Billed Charges,112.12,90,,92.872,Percent of Total Billed Charges,90% of Total Billed Charges,56.06,45,,46.44,Percent of Total Billed Charges,45% of Total Billed Charges,112.12,90,,92.872,Percent of Total Billed Charges,90% of Total billed Charges,124.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.98,65,,67.072,Percent of total Billed Charges,65% of Total Billed Charges,54.94,44.1,,45.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,118.35,95,,98.032,Percent of Total Billed Charges,95% of Total Billed Charges,124.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.63,88,,90.808,Percent of Total Billed Charges,88% of Total Billed Charges,112.12,90,,92.872,Percent of Total Billed charges,90% of Total Billed Charges,54.94,124.58,
INTRALIPIDS 20% 250ML INJ,2500001118,CDM,250,RC,,,Outpatient,250,ML,156.56,101.76,,156.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,118.99,76,,45.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,112.72,72,,748.44,Percent of Total Billed Charges,72% of Total Billed Charges,117.42,75,,779.632,Percent of Total Billed charges,75% of Total Billed Charges,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.72,72,,748.44,Percent of Total Billed Charges,72% of Total Billed Charges,93.94,60,,623.704,Percent of Total Billed Charges,60% of Total Billed Charges,140.9,90,,53.976,Percent of Total Billed Charges,90% of Total Billed Charges,70.45,45,,26.992,Percent of Total Billed Charges,45% of Total Billed Charges,140.9,90,,53.976,Percent of Total Billed Charges,90% of Total billed Charges,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.76,65,,38.984,Percent of total Billed Charges,65% of Total Billed Charges,69.04,44.1,,26.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,148.73,95,,56.976,Percent of Total Billed Charges,95% of Total Billed Charges,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.77,88,,52.776,Percent of Total Billed Charges,88% of Total Billed Charges,140.9,90,,53.976,Percent of Total Billed charges,90% of Total Billed Charges,69.04,156.56,
HEPARIN NS 2U/ML 500ML SOLN,2500001119,CDM,250,RC,J1644,HCPCS,Outpatient,500,ML,39.69,25.80,,39.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,30.16,76,,195.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.67,350,,45.416,Fee Schedule,350% of BCBS fee schedule,0.67,350,,47.312,Fee Schedule,350% of BCBS fee schedule,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.67,350,,45.416,Fee Schedule,350% of BCBS PPO fee schedule,0.19,100,,37.848,Fee Schedule,100% of Blue ADV HMO fee schedule,35.72,90,,230.944,Percent of Total Billed Charges,90% of Total Billed Charges,17.86,45,,115.472,Percent of Total Billed Charges,45% of Total Billed Charges,35.72,90,,230.944,Percent of Total Billed Charges,90% of Total billed Charges,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.8,65,,166.792,Percent of total Billed Charges,65% of Total Billed Charges,17.5,44.1,,113.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.71,95,,243.768,Percent of Total Billed Charges,95% of Total Billed Charges,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,88,,225.808,Percent of Total Billed Charges,88% of Total Billed Charges,35.72,90,,230.944,Percent of Total Billed charges,90% of Total Billed Charges,0.19,39.69,
PENICILLIN 3MMU/50ML INJ,2500001120,CDM,250,RC,J2540,HCPCS,Outpatient,50,ML,191.84,124.70,,191.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,145.8,76,,237.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.41,350,,192.848,Fee Schedule,350% of BCBS fee schedule,4.41,350,,200.88,Fee Schedule,350% of BCBS fee schedule,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,350,,192.848,Fee Schedule,350% of BCBS PPO fee schedule,1.26,100,,160.704,Fee Schedule,100% of Blue ADV HMO fee schedule,172.66,90,,281.344,Percent of Total Billed Charges,90% of Total Billed Charges,86.33,45,,140.672,Percent of Total Billed Charges,45% of Total Billed Charges,172.66,90,,281.344,Percent of Total Billed Charges,90% of Total billed Charges,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.7,65,,203.192,Percent of total Billed Charges,65% of Total Billed Charges,84.6,44.1,,137.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,182.25,95,,296.968,Percent of Total Billed Charges,95% of Total Billed Charges,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.82,88,,275.088,Percent of Total Billed Charges,88% of Total Billed Charges,172.66,90,,281.344,Percent of Total Billed charges,90% of Total Billed Charges,1.26,191.84,
NIMBEX 10MG/ML 20ML INJ,2500001121,CDM,250,RC,,,Outpatient,10,GM,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,9.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,257.128,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,267.84,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,257.128,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,214.272,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,11.128,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,11.128,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,11.744,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,10.88,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,11.128,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
CLEOCIN 900MG/50ML INJ,2500001122,CDM,250,RC,,,Outpatient,900,GM,92.61,60.20,,92.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,70.38,76,,7.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,66.68,72,,153.68,Percent of Total Billed Charges,72% of Total Billed Charges,69.46,75,,160.08,Percent of Total Billed charges,75% of Total Billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.68,72,,153.68,Percent of Total Billed Charges,72% of Total Billed Charges,55.57,60,,128.064,Percent of Total Billed Charges,60% of Total Billed Charges,83.35,90,,8.464,Percent of Total Billed Charges,90% of Total Billed Charges,41.67,45,,4.232,Percent of Total Billed Charges,45% of Total Billed Charges,83.35,90,,8.464,Percent of Total Billed Charges,90% of Total billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.2,65,,6.112,Percent of total Billed Charges,65% of Total Billed Charges,40.84,44.1,,4.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,87.98,95,,8.928,Percent of Total Billed Charges,95% of Total Billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.5,88,,8.272,Percent of Total Billed Charges,88% of Total Billed Charges,83.35,90,,8.464,Percent of Total Billed charges,90% of Total Billed Charges,40.84,92.61,
PEPCID 20MG/50ML PB INJ,2500001123,CDM,250,RC,J3490,HCPCS,Outpatient,20,GM,38.59,25.08,,38.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.33,76,,707.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.78,72,,186.176,Percent of Total Billed Charges,72% of Total Billed Charges,28.94,75,,193.936,Percent of Total Billed charges,75% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.78,72,,186.176,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,60,,155.144,Percent of Total Billed Charges,60% of Total Billed Charges,34.73,90,,837.904,Percent of Total Billed Charges,90% of Total Billed Charges,17.37,45,,418.952,Percent of Total Billed Charges,45% of Total Billed Charges,34.73,90,,837.904,Percent of Total Billed Charges,90% of Total billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.08,65,,605.152,Percent of total Billed Charges,65% of Total Billed Charges,17.02,44.1,,410.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.66,95,,884.448,Percent of Total Billed Charges,95% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.96,88,,819.28,Percent of Total Billed Charges,88% of Total Billed Charges,34.73,90,,837.904,Percent of Total Billed charges,90% of Total Billed Charges,17.02,38.59,
CLEOCIN 600MG/50ML INJ,2500001124,CDM,250,RC,,,Outpatient,600,GM,76.07,49.45,,76.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,57.81,76,,63.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,54.77,72,,21.816,Percent of Total Billed Charges,72% of Total Billed Charges,57.05,75,,22.72,Percent of Total Billed charges,75% of Total Billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.77,72,,21.816,Percent of Total Billed Charges,72% of Total Billed Charges,45.64,60,,18.176,Percent of Total Billed Charges,60% of Total Billed Charges,68.46,90,,74.624,Percent of Total Billed Charges,90% of Total Billed Charges,34.23,45,,37.312,Percent of Total Billed Charges,45% of Total Billed Charges,68.46,90,,74.624,Percent of Total Billed Charges,90% of Total billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.45,65,,53.896,Percent of total Billed Charges,65% of Total Billed Charges,33.55,44.1,,36.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,72.27,95,,78.768,Percent of Total Billed Charges,95% of Total Billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.94,88,,72.96,Percent of Total Billed Charges,88% of Total Billed Charges,68.46,90,,74.624,Percent of Total Billed charges,90% of Total Billed Charges,33.55,76.07,
CARDIZEM 100MG/10ML INJ,2500001125,CDM,250,RC,,,Outpatient,100,GM,47.41,30.82,,47.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.03,76,,8.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.14,72,,219.456,Percent of Total Billed Charges,72% of Total Billed Charges,35.56,75,,228.6,Percent of Total Billed charges,75% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.14,72,,219.456,Percent of Total Billed Charges,72% of Total Billed Charges,28.45,60,,182.88,Percent of Total Billed Charges,60% of Total Billed Charges,42.67,90,,9.72,Percent of Total Billed Charges,90% of Total Billed Charges,21.33,45,,4.864,Percent of Total Billed Charges,45% of Total Billed Charges,42.67,90,,9.72,Percent of Total Billed Charges,90% of Total billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.82,65,,7.024,Percent of total Billed Charges,65% of Total Billed Charges,20.91,44.1,,4.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.04,95,,10.264,Percent of Total Billed Charges,95% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.72,88,,9.504,Percent of Total Billed Charges,88% of Total Billed Charges,42.67,90,,9.72,Percent of Total Billed charges,90% of Total Billed Charges,20.91,47.41,
LR1000 W/OXYTOCIN 20 UNIT SOLN,2500001126,CDM,250,RC,,,Outpatient,,,66.15,43.00,,66.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,50.27,76,,20.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47.63,72,,56.192,Percent of Total Billed Charges,72% of Total Billed Charges,49.61,75,,58.528,Percent of Total Billed charges,75% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.63,72,,56.192,Percent of Total Billed Charges,72% of Total Billed Charges,39.69,60,,46.824,Percent of Total Billed Charges,60% of Total Billed Charges,59.54,90,,24.624,Percent of Total Billed Charges,90% of Total Billed Charges,29.77,45,,12.312,Percent of Total Billed Charges,45% of Total Billed Charges,59.54,90,,24.624,Percent of Total Billed Charges,90% of Total billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,65,,17.784,Percent of total Billed Charges,65% of Total Billed Charges,29.17,44.1,,12.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.84,95,,25.992,Percent of Total Billed Charges,95% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.21,88,,24.08,Percent of Total Billed Charges,88% of Total Billed Charges,59.54,90,,24.624,Percent of Total Billed charges,90% of Total Billed Charges,29.17,66.15,
RIFAMPIN 600MG VIAL INJ,2500001127,CDM,250,RC,,,Outpatient,600,GM,622.91,404.89,,622.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,473.41,76,,513.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,448.5,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,467.18,75,,7.2,Percent of Total Billed charges,75% of Total Billed Charges,622.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,448.5,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,373.75,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,560.62,90,,607.872,Percent of Total Billed Charges,90% of Total Billed Charges,280.31,45,,303.936,Percent of Total Billed Charges,45% of Total Billed Charges,560.62,90,,607.872,Percent of Total Billed Charges,90% of Total billed Charges,622.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,622.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,622.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404.89,65,,439.024,Percent of total Billed Charges,65% of Total Billed Charges,274.7,44.1,,297.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,591.76,95,,641.648,Percent of Total Billed Charges,95% of Total Billed Charges,622.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,548.16,88,,594.368,Percent of Total Billed Charges,88% of Total Billed Charges,560.62,90,,607.872,Percent of Total Billed charges,90% of Total Billed Charges,274.7,622.91,
CARDIZEM 125MG/25ML INJ,2500001128,CDM,250,RC,,,Outpatient,125,GM,49.61,32.25,,49.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,37.7,76,,3.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,35.72,72,,226.8,Percent of Total Billed Charges,72% of Total Billed Charges,37.21,75,,236.248,Percent of Total Billed charges,75% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.72,72,,226.8,Percent of Total Billed Charges,72% of Total Billed Charges,29.77,60,,189,Percent of Total Billed Charges,60% of Total Billed Charges,44.65,90,,4.68,Percent of Total Billed Charges,90% of Total Billed Charges,22.32,45,,2.344,Percent of Total Billed Charges,45% of Total Billed Charges,44.65,90,,4.68,Percent of Total Billed Charges,90% of Total billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.25,65,,3.384,Percent of total Billed Charges,65% of Total Billed Charges,21.88,44.1,,2.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,47.13,95,,4.944,Percent of Total Billed Charges,95% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,88,,4.576,Percent of Total Billed Charges,88% of Total Billed Charges,44.65,90,,4.68,Percent of Total Billed charges,90% of Total Billed Charges,21.88,49.61,
DEHYDRATED ALCOHOL INJ,2500001129,CDM,250,RC,,,Outpatient,,,58.43,37.98,,58.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,44.41,76,,3.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.07,72,,0.008,Percent of Total Billed Charges,72% of Total Billed Charges,43.82,75,,0.008,Percent of Total Billed charges,75% of Total Billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.07,72,,0.008,Percent of Total Billed Charges,72% of Total Billed Charges,35.06,60,,0.008,Percent of Total Billed Charges,60% of Total Billed Charges,52.59,90,,4.68,Percent of Total Billed Charges,90% of Total Billed Charges,26.29,45,,2.344,Percent of Total Billed Charges,45% of Total Billed Charges,52.59,90,,4.68,Percent of Total Billed Charges,90% of Total billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.98,65,,3.384,Percent of total Billed Charges,65% of Total Billed Charges,25.77,44.1,,2.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,55.51,95,,4.944,Percent of Total Billed Charges,95% of Total Billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.42,88,,4.576,Percent of Total Billed Charges,88% of Total Billed Charges,52.59,90,,4.68,Percent of Total Billed charges,90% of Total Billed Charges,25.77,58.43,
CLEOCIN 300MG/50ML INJ,2500001130,CDM,250,RC,,,Outpatient,300,GM,60.64,39.42,,60.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.09,76,,1248.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.66,72,,166.104,Percent of Total Billed Charges,72% of Total Billed Charges,45.48,75,,173.024,Percent of Total Billed charges,75% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,72,,166.104,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,60,,138.416,Percent of Total Billed Charges,60% of Total Billed Charges,54.58,90,,1478.88,Percent of Total Billed Charges,90% of Total Billed Charges,27.29,45,,739.44,Percent of Total Billed Charges,45% of Total Billed Charges,54.58,90,,1478.88,Percent of Total Billed Charges,90% of Total billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.42,65,,1068.08,Percent of total Billed Charges,65% of Total Billed Charges,26.74,44.1,,724.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.61,95,,1561.04,Percent of Total Billed Charges,95% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.36,88,,1446.016,Percent of Total Billed Charges,88% of Total Billed Charges,54.58,90,,1478.88,Percent of Total Billed charges,90% of Total Billed Charges,26.74,60.64,
SENSORCAINE0.05%W/EPI INJ,2500001131,CDM,250,RC,,,Outpatient,,,48.51,31.53,,48.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.87,76,,3.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.93,72,,170.64,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,75,,177.752,Percent of Total Billed charges,75% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,72,,170.64,Percent of Total Billed Charges,72% of Total Billed Charges,29.11,60,,142.2,Percent of Total Billed Charges,60% of Total Billed Charges,43.66,90,,4.68,Percent of Total Billed Charges,90% of Total Billed Charges,21.83,45,,2.344,Percent of Total Billed Charges,45% of Total Billed Charges,43.66,90,,4.68,Percent of Total Billed Charges,90% of Total billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.53,65,,3.384,Percent of total Billed Charges,65% of Total Billed Charges,21.39,44.1,,2.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.08,95,,4.944,Percent of Total Billed Charges,95% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.69,88,,4.576,Percent of Total Billed Charges,88% of Total Billed Charges,43.66,90,,4.68,Percent of Total Billed charges,90% of Total Billed Charges,21.39,48.51,
MANNITOL 500ML IV SOLN,2500001132,CDM,250,RC,,,Outpatient,500,ML,337.37,219.29,,337.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,256.4,76,,407.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,242.91,72,,9.88,Percent of Total Billed Charges,72% of Total Billed Charges,253.03,75,,10.288,Percent of Total Billed charges,75% of Total Billed Charges,337.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.91,72,,9.88,Percent of Total Billed Charges,72% of Total Billed Charges,202.42,60,,8.232,Percent of Total Billed Charges,60% of Total Billed Charges,303.63,90,,482.232,Percent of Total Billed Charges,90% of Total Billed Charges,151.82,45,,241.12,Percent of Total Billed Charges,45% of Total Billed Charges,303.63,90,,482.232,Percent of Total Billed Charges,90% of Total billed Charges,337.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.29,65,,348.28,Percent of total Billed Charges,65% of Total Billed Charges,148.78,44.1,,236.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,320.5,95,,509.024,Percent of Total Billed Charges,95% of Total Billed Charges,337.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.89,88,,471.52,Percent of Total Billed Charges,88% of Total Billed Charges,303.63,90,,482.232,Percent of Total Billed charges,90% of Total Billed Charges,148.78,337.37,
SENSORCAINE0.75%10ML INJ,2500001133,CDM,250,RC,,,Outpatient,10,ML,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,28.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,4.248,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,4.424,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,4.248,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,3.536,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,16.92,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,33.84,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,24.44,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,16.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,35.72,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,33.088,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,33.84,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
AA8.5/D10WELECTROLYT SOLN,2500001134,CDM,250,RC,,,Outpatient,,,224.91,146.19,,224.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,170.93,76,,7.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,161.94,72,,16.04,Percent of Total Billed Charges,72% of Total Billed Charges,168.68,75,,16.712,Percent of Total Billed charges,75% of Total Billed Charges,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.94,72,,16.04,Percent of Total Billed Charges,72% of Total Billed Charges,134.95,60,,13.368,Percent of Total Billed Charges,60% of Total Billed Charges,202.42,90,,8.872,Percent of Total Billed Charges,90% of Total Billed Charges,101.21,45,,4.432,Percent of Total Billed Charges,45% of Total Billed Charges,202.42,90,,8.872,Percent of Total Billed Charges,90% of Total billed Charges,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.19,65,,6.408,Percent of total Billed Charges,65% of Total Billed Charges,99.19,44.1,,4.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.66,95,,9.36,Percent of Total Billed Charges,95% of Total Billed Charges,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.92,88,,8.672,Percent of Total Billed Charges,88% of Total Billed Charges,202.42,90,,8.872,Percent of Total Billed charges,90% of Total Billed Charges,99.19,224.91,
POTASSIUM PHOSPHATES INJ,2500001135,CDM,250,RC,,,Outpatient,,,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,86.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,80.624,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,83.984,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,80.624,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,67.184,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,102.384,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,51.192,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,102.384,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,73.944,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,50.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,108.072,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,100.112,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,102.384,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
DIPRIVAN 1% 100ML INJ,2500001136,CDM,250,RC,J2704,HCPCS,Outpatient,100,ML,54.02,35.11,,54.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.06,76,,326.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.25,350,,0.008,Fee Schedule,350% of BCBS fee schedule,0.25,350,,0.008,Fee Schedule,350% of BCBS fee schedule,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.25,350,,0.008,Fee Schedule,350% of BCBS PPO fee schedule,0.07,100,,0.008,Fee Schedule,100% of Blue ADV HMO fee schedule,48.62,90,,386.216,Percent of Total Billed Charges,90% of Total Billed Charges,24.31,45,,193.104,Percent of Total Billed Charges,45% of Total Billed Charges,48.62,90,,386.216,Percent of Total Billed Charges,90% of Total billed Charges,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.11,65,,278.936,Percent of total Billed Charges,65% of Total Billed Charges,23.82,44.1,,189.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,51.32,95,,407.672,Percent of Total Billed Charges,95% of Total Billed Charges,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.54,88,,377.632,Percent of Total Billed Charges,88% of Total Billed Charges,48.62,90,,386.216,Percent of Total Billed charges,90% of Total Billed Charges,0.07,54.02,
ZIDOOVUDINE 50MG/5ML INJ,2500001137,CDM,250,RC,,,Outpatient,50,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,3.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,748.44,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,779.632,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,748.44,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,623.704,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,4.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,2.344,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,4.68,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,3.384,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,2.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,4.944,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,4.576,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,4.68,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
XYLOCAINE MPF 2% 2ML,2500001138,CDM,250,RC,,,Outpatient,2,ML,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,13.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,0.008,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,0.008,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,0.008,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,0.008,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,15.88,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,7.936,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,15.88,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,11.464,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,16.76,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,15.52,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,15.88,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
MIDAZOLAM 5MG/5ML INJ,2500001139,CDM,250,RC,J2250,HCPCS,Outpatient,5,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,5014.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.39,350,,245.232,Fee Schedule,350% of BCBS fee schedule,0.39,350,,255.448,Fee Schedule,350% of BCBS fee schedule,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.39,350,,245.232,Fee Schedule,350% of BCBS PPO fee schedule,0.11,100,,204.36,Fee Schedule,100% of Blue ADV HMO fee schedule,5.96,90,,5937.768,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,2968.888,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,5937.768,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,4288.392,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,2909.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,6267.648,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,5805.816,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,5937.768,Percent of Total Billed charges,90% of Total Billed Charges,0.11,6.62,
LIDOCAINE 2% WEPI INJ 20ML,2500001140,CDM,250,RC,,,Outpatient,20,ML,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,73.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,95.624,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,99.616,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,95.624,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,79.688,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,86.76,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,43.384,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,86.76,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,62.664,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,42.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,91.584,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,84.832,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,86.76,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
XYLOCAINE 2% 10 ML INJ,2500001141,CDM,250,RC,,,Outpatient,10,ML,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,34.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,146.888,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,153.016,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,146.888,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,122.408,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,41.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,20.704,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,41.4,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,29.904,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,20.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,43.704,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,40.48,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,41.4,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
ENION PLUS INJ,2500001142,CDM,250,RC,,,Outpatient,,,14.33,9.31,,14.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.89,76,,317.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.32,72,,1448.688,Percent of Total Billed Charges,72% of Total Billed Charges,10.75,75,,1509.048,Percent of Total Billed charges,75% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,72,,1448.688,Percent of Total Billed Charges,72% of Total Billed Charges,8.6,60,,1207.24,Percent of Total Billed Charges,60% of Total Billed Charges,12.9,90,,375.408,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,187.704,Percent of Total Billed Charges,45% of Total Billed Charges,12.9,90,,375.408,Percent of Total Billed Charges,90% of Total billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.31,65,,271.128,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,183.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.61,95,,396.264,Percent of Total Billed Charges,95% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.61,88,,367.064,Percent of Total Billed Charges,88% of Total Billed Charges,12.9,90,,375.408,Percent of Total Billed charges,90% of Total Billed Charges,6.32,14.33,
OFIRMEV 10MG/1ML INJ,2500001143,CDM,250,RC,,,Outpatient,10,GM,67.25,43.71,,67.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.11,76,,122.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,48.42,72,,18,Percent of Total Billed Charges,72% of Total Billed Charges,50.44,75,,18.752,Percent of Total Billed charges,75% of Total Billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.42,72,,18,Percent of Total Billed Charges,72% of Total Billed Charges,40.35,60,,15,Percent of Total Billed Charges,60% of Total Billed Charges,60.53,90,,144.56,Percent of Total Billed Charges,90% of Total Billed Charges,30.26,45,,72.28,Percent of Total Billed Charges,45% of Total Billed Charges,60.53,90,,144.56,Percent of Total Billed Charges,90% of Total billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.71,65,,104.408,Percent of total Billed Charges,65% of Total Billed Charges,29.66,44.1,,70.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,63.89,95,,152.592,Percent of Total Billed Charges,95% of Total Billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.18,88,,141.352,Percent of Total Billed Charges,88% of Total Billed Charges,60.53,90,,144.56,Percent of Total Billed charges,90% of Total Billed Charges,29.66,67.25,
METHOTREXATE 250MG 10ML INJ,2500001145,CDM,250,RC,,,Outpatient,250,GM,87.10,56.62,,87.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.2,76,,120.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.71,72,,67.536,Percent of Total Billed Charges,72% of Total Billed Charges,65.33,75,,70.352,Percent of Total Billed charges,75% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.71,72,,67.536,Percent of Total Billed Charges,72% of Total Billed Charges,52.26,60,,56.28,Percent of Total Billed Charges,60% of Total Billed Charges,78.39,90,,142.672,Percent of Total Billed Charges,90% of Total Billed Charges,39.2,45,,71.336,Percent of Total Billed Charges,45% of Total Billed Charges,78.39,90,,142.672,Percent of Total Billed Charges,90% of Total billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.62,65,,103.04,Percent of total Billed Charges,65% of Total Billed Charges,38.41,44.1,,69.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.75,95,,150.592,Percent of Total Billed Charges,95% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.65,88,,139.496,Percent of Total Billed Charges,88% of Total Billed Charges,78.39,90,,142.672,Percent of Total Billed charges,90% of Total Billed Charges,38.41,87.1,
LEVOTHYROXINE 100MCG INJ,2500001146,CDM,250,RC,,,Outpatient,100,GM,302.09,196.36,,302.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,229.59,76,,9.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,217.5,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,226.57,75,,3.904,Percent of Total Billed charges,75% of Total Billed Charges,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.5,72,,3.744,Percent of Total Billed Charges,72% of Total Billed Charges,181.25,60,,3.12,Percent of Total Billed Charges,60% of Total Billed Charges,271.88,90,,11.704,Percent of Total Billed Charges,90% of Total Billed Charges,135.94,45,,5.848,Percent of Total Billed Charges,45% of Total Billed Charges,271.88,90,,11.704,Percent of Total Billed Charges,90% of Total billed Charges,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.36,65,,8.448,Percent of total Billed Charges,65% of Total Billed Charges,133.22,44.1,,5.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,286.99,95,,12.352,Percent of Total Billed Charges,95% of Total Billed Charges,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.84,88,,11.44,Percent of Total Billed Charges,88% of Total Billed Charges,271.88,90,,11.704,Percent of Total Billed charges,90% of Total Billed Charges,133.22,302.09,
FLUMAXENIL 0.5MG/5ML INJ,2500001147,CDM,250,RC,,,Outpatient,0.5,GM,39.69,25.80,,39.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,30.16,76,,201.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.58,72,,262.944,Percent of Total Billed Charges,72% of Total Billed Charges,29.77,75,,273.904,Percent of Total Billed charges,75% of Total Billed Charges,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.58,72,,262.944,Percent of Total Billed Charges,72% of Total Billed Charges,23.81,60,,219.12,Percent of Total Billed Charges,60% of Total Billed Charges,35.72,90,,239.04,Percent of Total Billed Charges,90% of Total Billed Charges,17.86,45,,119.52,Percent of Total Billed Charges,45% of Total Billed Charges,35.72,90,,239.04,Percent of Total Billed Charges,90% of Total billed Charges,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.8,65,,172.64,Percent of total Billed Charges,65% of Total Billed Charges,17.5,44.1,,117.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.71,95,,252.32,Percent of Total Billed Charges,95% of Total Billed Charges,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,88,,233.728,Percent of Total Billed Charges,88% of Total Billed Charges,35.72,90,,239.04,Percent of Total Billed charges,90% of Total Billed Charges,17.5,39.69,
DUO VISC OPHTH INJ,2500001148,CDM,250,RC,,,Outpatient,,,851.13,553.23,,851.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,646.86,76,,9.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,612.81,72,,28.576,Percent of Total Billed Charges,72% of Total Billed Charges,638.35,75,,29.768,Percent of Total Billed charges,75% of Total Billed Charges,851.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.81,72,,28.576,Percent of Total Billed Charges,72% of Total Billed Charges,510.68,60,,23.816,Percent of Total Billed Charges,60% of Total Billed Charges,766.02,90,,11.704,Percent of Total Billed Charges,90% of Total Billed Charges,383.01,45,,5.848,Percent of Total Billed Charges,45% of Total Billed Charges,766.02,90,,11.704,Percent of Total Billed Charges,90% of Total billed Charges,851.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,851.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,851.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,553.23,65,,8.448,Percent of total Billed Charges,65% of Total Billed Charges,375.35,44.1,,5.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,808.57,95,,12.352,Percent of Total Billed Charges,95% of Total Billed Charges,851.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,748.99,88,,11.44,Percent of Total Billed Charges,88% of Total Billed Charges,766.02,90,,11.704,Percent of Total Billed charges,90% of Total Billed Charges,375.35,851.13,
HEPATITIS B VACCINE,2500001150,CDM,250,RC,,,Outpatient,,,329.65,214.27,,329.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,250.53,76,,6.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,237.35,72,,28.576,Percent of Total Billed Charges,72% of Total Billed Charges,247.24,75,,29.768,Percent of Total Billed charges,75% of Total Billed Charges,329.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.35,72,,28.576,Percent of Total Billed Charges,72% of Total Billed Charges,197.79,60,,23.816,Percent of Total Billed Charges,60% of Total Billed Charges,296.69,90,,8.016,Percent of Total Billed Charges,90% of Total Billed Charges,148.34,45,,4.008,Percent of Total Billed Charges,45% of Total Billed Charges,296.69,90,,8.016,Percent of Total Billed Charges,90% of Total billed Charges,329.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.27,65,,5.784,Percent of total Billed Charges,65% of Total Billed Charges,145.38,44.1,,3.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,313.17,95,,8.456,Percent of Total Billed Charges,95% of Total Billed Charges,329.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290.09,88,,7.832,Percent of Total Billed Charges,88% of Total Billed Charges,296.69,90,,8.016,Percent of Total Billed charges,90% of Total Billed Charges,145.38,329.65,
PENICILLIN G PROCAIN INJ,2500001151,CDM,250,RC,,,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,9.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,32.392,Percent of Total Billed Charges,72% of Total Billed Charges,58.71,75,,33.736,Percent of Total Billed charges,75% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,32.392,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,26.992,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,11.256,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,5.624,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,11.256,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,8.128,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,5.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,11.88,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,11,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,11.256,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
VITRASE 200 UNITS/ML,2500001152,CDM,250,RC,,,Outpatient,1,ML,275.63,179.16,,275.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209.48,76,,80.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198.45,72,,26.672,Percent of Total Billed Charges,72% of Total Billed Charges,206.72,75,,27.784,Percent of Total Billed charges,75% of Total Billed Charges,275.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.45,72,,26.672,Percent of Total Billed Charges,72% of Total Billed Charges,165.38,60,,22.232,Percent of Total Billed Charges,60% of Total Billed Charges,248.07,90,,95.368,Percent of Total Billed Charges,90% of Total Billed Charges,124.03,45,,47.68,Percent of Total Billed Charges,45% of Total Billed Charges,248.07,90,,95.368,Percent of Total Billed Charges,90% of Total billed Charges,275.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.16,65,,68.872,Percent of total Billed Charges,65% of Total Billed Charges,121.55,44.1,,46.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.85,95,,100.664,Percent of Total Billed Charges,95% of Total Billed Charges,275.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.55,88,,93.248,Percent of Total Billed Charges,88% of Total Billed Charges,248.07,90,,95.368,Percent of Total Billed charges,90% of Total Billed Charges,121.55,275.63,
EPHEDRINE SULF 50MG/ML INJ,2500001153,CDM,250,RC,,,Outpatient,50,GM,18.74,12.18,,18.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.24,76,,302.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.49,72,,29.216,Percent of Total Billed Charges,72% of Total Billed Charges,14.06,75,,30.432,Percent of Total Billed charges,75% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.49,72,,29.216,Percent of Total Billed Charges,72% of Total Billed Charges,11.24,60,,24.344,Percent of Total Billed Charges,60% of Total Billed Charges,16.87,90,,357.912,Percent of Total Billed Charges,90% of Total Billed Charges,8.43,45,,178.96,Percent of Total Billed Charges,45% of Total Billed Charges,16.87,90,,357.912,Percent of Total Billed Charges,90% of Total billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.18,65,,6.712,Percent of total Billed Charges,65% of Total Billed Charges,8.26,44.1,,175.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.8,95,,377.8,Percent of Total Billed Charges,95% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,88,,349.96,Percent of Total Billed Charges,88% of Total Billed Charges,16.87,90,,357.912,Percent of Total Billed charges,90% of Total Billed Charges,8.26,18.74,
LEVOPHED 4MG/4ML INJ,2500001154,CDM,250,RC,,,Outpatient,4,GM,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,7.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,15.71,75,,33.08,Percent of Total Billed charges,75% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,9.288,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,4.648,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,9.288,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,413.424,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,4.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,9.808,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,9.08,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,9.288,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
SUFENTA 50MCG/1ML INJ,2500001155,CDM,250,RC,,,Outpatient,50,GM,18.74,12.18,,18.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.24,76,,483.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.49,72,,160.664,Percent of Total Billed Charges,72% of Total Billed Charges,14.06,75,,167.36,Percent of Total Billed charges,75% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.49,72,,160.664,Percent of Total Billed Charges,72% of Total Billed Charges,11.24,60,,133.888,Percent of Total Billed Charges,60% of Total Billed Charges,16.87,90,,572.44,Percent of Total Billed Charges,90% of Total Billed Charges,8.43,45,,286.216,Percent of Total Billed Charges,45% of Total Billed Charges,16.87,90,,572.44,Percent of Total Billed Charges,90% of Total billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.18,65,,0.296,Percent of total Billed Charges,65% of Total Billed Charges,8.26,44.1,,280.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.8,95,,604.24,Percent of Total Billed Charges,95% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,88,,559.712,Percent of Total Billed Charges,88% of Total Billed Charges,16.87,90,,572.44,Percent of Total Billed charges,90% of Total Billed Charges,8.26,18.74,
THORAZINE 25MG/1ML INJ,2500001156,CDM,250,RC,,,Outpatient,25,GM,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,0.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,58.424,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,60.856,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,58.424,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,48.688,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,0.408,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,0.208,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,0.408,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,2428.024,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,0.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,0.432,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,0.4,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,0.408,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
ATRACURIUM 10ML INJ,2500001157,CDM,250,RC,,,Outpatient,10,ML,71.66,46.58,,71.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.46,76,,2838.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.6,72,,185.432,Percent of Total Billed Charges,72% of Total Billed Charges,53.75,75,,193.16,Percent of Total Billed charges,75% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,72,,185.432,Percent of Total Billed Charges,72% of Total Billed Charges,43,60,,154.528,Percent of Total Billed Charges,60% of Total Billed Charges,64.49,90,,3361.872,Percent of Total Billed Charges,90% of Total Billed Charges,32.25,45,,1680.936,Percent of Total Billed Charges,45% of Total Billed Charges,64.49,90,,3361.872,Percent of Total Billed Charges,90% of Total billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.58,65,,16.576,Percent of total Billed Charges,65% of Total Billed Charges,31.6,44.1,,1647.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.08,95,,3548.648,Percent of Total Billed Charges,95% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,88,,3287.168,Percent of Total Billed Charges,88% of Total Billed Charges,64.49,90,,3361.872,Percent of Total Billed charges,90% of Total Billed Charges,31.6,71.66,
DEPACON 100MG INJ,2500001158,CDM,250,RC,,,Outpatient,100,GM,43.00,27.95,,43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,32.68,76,,19.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.96,72,,39.376,Percent of Total Billed Charges,72% of Total Billed Charges,32.25,75,,41.016,Percent of Total Billed charges,75% of Total Billed Charges,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.96,72,,39.376,Percent of Total Billed Charges,72% of Total Billed Charges,25.8,60,,32.816,Percent of Total Billed Charges,60% of Total Billed Charges,38.7,90,,22.944,Percent of Total Billed Charges,90% of Total Billed Charges,19.35,45,,11.472,Percent of Total Billed Charges,45% of Total Billed Charges,38.7,90,,22.944,Percent of Total Billed Charges,90% of Total billed Charges,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.95,65,,194.48,Percent of total Billed Charges,65% of Total Billed Charges,18.96,44.1,,11.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,40.85,95,,24.224,Percent of Total Billed Charges,95% of Total Billed Charges,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.84,88,,22.44,Percent of Total Billed Charges,88% of Total Billed Charges,38.7,90,,22.944,Percent of Total Billed charges,90% of Total Billed Charges,18.96,43,
BUMEX 0.25MG/ML 10ML,2500001159,CDM,250,RC,,,Outpatient,0.25,GM,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,227.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,72,,39.376,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,75,,41.016,Percent of Total Billed charges,75% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,72,,39.376,Percent of Total Billed Charges,72% of Total Billed Charges,5.95,60,,32.816,Percent of Total Billed Charges,60% of Total Billed Charges,8.93,90,,269.28,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,134.64,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,269.28,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,11.008,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,131.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,284.24,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,263.296,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,269.28,Percent of Total Billed charges,90% of Total Billed Charges,4.37,9.92,
PROPOFOL 10MG/ML 50ML INJ,2500001160,CDM,250,RC,J2704,HCPCS,Outpatient,10,GM,177.50,115.38,,177.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,134.9,76,,12.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.25,350,,39.376,Fee Schedule,350% of BCBS fee schedule,0.25,350,,41.016,Fee Schedule,350% of BCBS fee schedule,177.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.25,350,,39.376,Fee Schedule,350% of BCBS PPO fee schedule,0.07,100,,32.816,Fee Schedule,100% of Blue ADV HMO fee schedule,159.75,90,,15.24,Percent of Total Billed Charges,90% of Total Billed Charges,79.88,45,,7.624,Percent of Total Billed Charges,45% of Total Billed Charges,159.75,90,,15.24,Percent of Total Billed Charges,90% of Total billed Charges,177.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.38,65,,7.632,Percent of total Billed Charges,65% of Total Billed Charges,78.28,44.1,,7.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,168.63,95,,16.088,Percent of Total Billed Charges,95% of Total Billed Charges,177.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.2,88,,14.904,Percent of Total Billed Charges,88% of Total Billed Charges,159.75,90,,15.24,Percent of Total Billed charges,90% of Total Billed Charges,0.07,177.5,
CLINIMIX E/D50 AA 8,2500001161,CDM,250,RC,,,Outpatient,,,248.06,161.24,,248.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,188.53,76,,8.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,178.6,72,,165.744,Percent of Total Billed Charges,72% of Total Billed Charges,186.05,75,,172.648,Percent of Total Billed charges,75% of Total Billed Charges,248.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.6,72,,165.744,Percent of Total Billed Charges,72% of Total Billed Charges,148.84,60,,138.12,Percent of Total Billed Charges,60% of Total Billed Charges,223.25,90,,10.568,Percent of Total Billed Charges,90% of Total Billed Charges,111.63,45,,5.288,Percent of Total Billed Charges,45% of Total Billed Charges,223.25,90,,10.568,Percent of Total Billed Charges,90% of Total billed Charges,248.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.24,65,,7.48,Percent of total Billed Charges,65% of Total Billed Charges,109.39,44.1,,5.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,235.66,95,,11.16,Percent of Total Billed Charges,95% of Total Billed Charges,248.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.29,88,,10.336,Percent of Total Billed Charges,88% of Total Billed Charges,223.25,90,,10.568,Percent of Total Billed charges,90% of Total Billed Charges,109.39,248.06,
HECTEROL 2MCG/ML 2ML,2500001162,CDM,250,RC,,,Outpatient,2,GM,36.38,23.65,,36.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.65,76,,8.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.19,72,,170.192,Percent of Total Billed Charges,72% of Total Billed Charges,27.29,75,,177.28,Percent of Total Billed charges,75% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.19,72,,170.192,Percent of Total Billed Charges,72% of Total Billed Charges,21.83,60,,141.824,Percent of Total Billed Charges,60% of Total Billed Charges,32.74,90,,10.352,Percent of Total Billed Charges,90% of Total Billed Charges,16.37,45,,5.176,Percent of Total Billed Charges,45% of Total Billed Charges,32.74,90,,10.352,Percent of Total Billed Charges,90% of Total billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.65,65,,563.344,Percent of total Billed Charges,65% of Total Billed Charges,16.04,44.1,,5.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.56,95,,10.928,Percent of Total Billed Charges,95% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.01,88,,10.12,Percent of Total Billed Charges,88% of Total Billed Charges,32.74,90,,10.352,Percent of Total Billed charges,90% of Total Billed Charges,16.04,36.38,
INTRALIPID 10% 500ML,2500001163,CDM,250,RC,,,Outpatient,500,ML,222.71,144.76,,222.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,169.26,76,,658.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,160.35,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,167.03,75,,43.664,Percent of Total Billed charges,75% of Total Billed Charges,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.35,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,133.63,60,,34.928,Percent of Total Billed Charges,60% of Total Billed Charges,200.44,90,,780.016,Percent of Total Billed Charges,90% of Total Billed Charges,100.22,45,,390.008,Percent of Total Billed Charges,45% of Total Billed Charges,200.44,90,,780.016,Percent of Total Billed Charges,90% of Total billed Charges,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.76,65,,230.592,Percent of total Billed Charges,65% of Total Billed Charges,98.22,44.1,,382.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,211.57,95,,823.344,Percent of Total Billed Charges,95% of Total Billed Charges,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.98,88,,762.68,Percent of Total Billed Charges,88% of Total Billed Charges,200.44,90,,780.016,Percent of Total Billed charges,90% of Total Billed Charges,98.22,222.71,
MORPHINE SULFATE 5MG,2500001164,CDM,250,RC,J2270,HCPCS,Outpatient,5,GM,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,269.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.25,350,,0.432,Fee Schedule,350% of BCBS fee schedule,0.25,350,,0.448,Fee Schedule,350% of BCBS fee schedule,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.25,350,,0.432,Fee Schedule,350% of BCBS PPO fee schedule,0.07,100,,0.36,Fee Schedule,100% of Blue ADV HMO fee schedule,26.79,90,,319.288,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,159.64,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,319.288,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,130.104,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,156.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,337.024,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,312.192,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,319.288,Percent of Total Billed charges,90% of Total Billed Charges,0.07,29.77,
ZOSYN 4.5 GRAM VIAL,2500001165,CDM,250,RC,J2543,HCPCS,Outpatient,,,132.30,86.00,,132.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.55,76,,152.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.96,350,,323.688,Fee Schedule,350% of BCBS fee schedule,8.96,350,,337.176,Fee Schedule,350% of BCBS fee schedule,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.96,350,,323.688,Fee Schedule,350% of BCBS PPO fee schedule,2.56,100,,269.744,Fee Schedule,100% of Blue ADV HMO fee schedule,119.07,90,,180.144,Percent of Total Billed Charges,90% of Total Billed Charges,59.54,45,,90.072,Percent of Total Billed Charges,45% of Total Billed Charges,119.07,90,,180.144,Percent of Total Billed Charges,90% of Total billed Charges,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,65,,164.064,Percent of total Billed Charges,65% of Total Billed Charges,58.34,44.1,,88.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.69,95,,190.152,Percent of Total Billed Charges,95% of Total Billed Charges,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.42,88,,176.144,Percent of Total Billed Charges,88% of Total Billed Charges,119.07,90,,180.144,Percent of Total Billed charges,90% of Total Billed Charges,2.56,132.3,
AMIODARONE 360MG/D5,2500001166,CDM,250,RC,J0282,HCPCS,Outpatient,360,GM,251.37,163.39,,251.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,191.04,76,,191.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.7,350,,242.496,Fee Schedule,350% of BCBS fee schedule,0.7,350,,252.6,Fee Schedule,350% of BCBS fee schedule,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.7,350,,242.496,Fee Schedule,350% of BCBS PPO fee schedule,0.2,100,,202.08,Fee Schedule,100% of Blue ADV HMO fee schedule,226.23,90,,227.16,Percent of Total Billed Charges,90% of Total Billed Charges,113.12,45,,113.584,Percent of Total Billed Charges,45% of Total Billed Charges,226.23,90,,227.16,Percent of Total Billed Charges,90% of Total billed Charges,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.39,65,,71.504,Percent of total Billed Charges,65% of Total Billed Charges,110.85,44.1,,111.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,238.8,95,,239.784,Percent of Total Billed Charges,95% of Total Billed Charges,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.21,88,,222.112,Percent of Total Billed Charges,88% of Total Billed Charges,226.23,90,,227.16,Percent of Total Billed charges,90% of Total Billed Charges,0.2,251.37,
RELISTOR 12MG/06 ML,2500001167,CDM,250,RC,,,Outpatient,12,GM,252.47,164.11,,252.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,191.88,76,,83.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,181.78,72,,76.608,Percent of Total Billed Charges,72% of Total Billed Charges,189.35,75,,79.8,Percent of Total Billed charges,75% of Total Billed Charges,252.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.78,72,,76.608,Percent of Total Billed Charges,72% of Total Billed Charges,151.48,60,,63.84,Percent of Total Billed Charges,60% of Total Billed Charges,227.22,90,,99,Percent of Total Billed Charges,90% of Total Billed Charges,113.61,45,,49.504,Percent of Total Billed Charges,45% of Total Billed Charges,227.22,90,,99,Percent of Total Billed Charges,90% of Total billed Charges,252.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.11,65,,12915.632,Percent of total Billed Charges,65% of Total Billed Charges,111.34,44.1,,48.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,239.85,95,,104.504,Percent of Total Billed Charges,95% of Total Billed Charges,252.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.17,88,,96.8,Percent of Total Billed Charges,88% of Total Billed Charges,227.22,90,,99,Percent of Total Billed charges,90% of Total Billed Charges,111.34,252.47,
TEFLARO 600MG INJ,2500001169,CDM,636,RC,J0712,HCPCS,Outpatient,600,GM,238.14,154.79,,4.93,125,,,Fee Schedule,125% of CMS OPPS Rate,180.99,76,,15101.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.38,350,,302.4,Fee Schedule,350% of BCBS fee schedule,9.38,350,,315,Fee Schedule,350% of BCBS fee schedule,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,9.38,350,,302.4,Fee Schedule,350% of BCBS PPO fee schedule,2.68,100,,252,Fee Schedule,100% of Blue ADV HMO fee schedule,214.33,90,,17883.184,Percent of Total Billed Charges,90% of Total Billed Charges,107.16,45,,8941.592,Percent of Total Billed Charges,45% of Total Billed Charges,214.33,90,,17883.184,Percent of Total Billed Charges,90% of Total billed Charges,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,162.69,65,,255.8,Percent of total Billed Charges,65% of Total Billed Charges,105.02,44.1,,8762.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,226.23,95,,18876.688,Percent of Total Billed Charges,95% of Total Billed Charges,2.96,75,,,Fee Schedule,75% of CMS OPPS Rate,209.56,88,,17485.776,Percent of Total Billed Charges,88% of Total Billed Charges,214.33,90,,17883.184,Percent of Total Billed charges,90% of Total Billed Charges,2.68,226.23,
TEFLARO 400 MG INJ,2500001170,CDM,636,RC,J0712,HCPCS,Outpatient,400,GM,238.14,154.79,,4.93,125,,,Fee Schedule,125% of CMS OPPS Rate,180.99,76,,299.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.38,350,,66.816,Fee Schedule,350% of BCBS fee schedule,9.38,350,,69.6,Fee Schedule,350% of BCBS fee schedule,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,9.38,350,,66.816,Fee Schedule,350% of BCBS PPO fee schedule,2.68,100,,55.68,Fee Schedule,100% of Blue ADV HMO fee schedule,214.33,90,,354.192,Percent of Total Billed Charges,90% of Total Billed Charges,107.16,45,,177.096,Percent of Total Billed Charges,45% of Total Billed Charges,214.33,90,,354.192,Percent of Total Billed Charges,90% of Total billed Charges,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,162.69,65,,3354.232,Percent of total Billed Charges,65% of Total Billed Charges,105.02,44.1,,173.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,226.23,95,,373.864,Percent of Total Billed Charges,95% of Total Billed Charges,2.96,75,,,Fee Schedule,75% of CMS OPPS Rate,209.56,88,,346.32,Percent of Total Billed Charges,88% of Total Billed Charges,214.33,90,,354.192,Percent of Total Billed charges,90% of Total Billed Charges,2.68,226.23,
DAKIN'S SOLUTION,2500001172,CDM,250,RC,,,Outpatient,,,45.00,29.25,,45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.2,76,,790.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.4,72,,198.144,Percent of Total Billed Charges,72% of Total Billed Charges,33.75,75,,206.4,Percent of Total Billed charges,75% of Total Billed Charges,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.4,72,,198.144,Percent of Total Billed Charges,72% of Total Billed Charges,27,60,,165.12,Percent of Total Billed Charges,60% of Total Billed Charges,40.5,90,,935.552,Percent of Total Billed Charges,90% of Total Billed Charges,20.25,45,,467.776,Percent of Total Billed Charges,45% of Total Billed Charges,40.5,90,,935.552,Percent of Total Billed Charges,90% of Total billed Charges,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.25,65,,41,Percent of total Billed Charges,65% of Total Billed Charges,19.85,44.1,,458.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.75,95,,987.528,Percent of Total Billed Charges,95% of Total Billed Charges,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.6,88,,914.76,Percent of Total Billed Charges,88% of Total Billed Charges,40.5,90,,935.552,Percent of Total Billed charges,90% of Total Billed Charges,19.85,45,
STERIL H2O FOR INJ 20ML,2500001173,CDM,250,RC,,,Outpatient,20,ML,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,47.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.64,72,,148.032,Percent of Total Billed Charges,72% of Total Billed Charges,9,75,,154.2,Percent of Total Billed charges,75% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.64,72,,148.032,Percent of Total Billed Charges,72% of Total Billed Charges,7.2,60,,123.36,Percent of Total Billed Charges,60% of Total Billed Charges,10.8,90,,56.776,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,28.384,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,56.776,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,174.096,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,27.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,59.928,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,55.512,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,56.776,Percent of Total Billed charges,90% of Total Billed Charges,5.29,12,
STERIL H20 FOR INJ 50ML,2500001174,CDM,250,RC,,,Outpatient,50,ML,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,203.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.64,72,,228.672,Percent of Total Billed Charges,72% of Total Billed Charges,9,75,,238.2,Percent of Total Billed charges,75% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.64,72,,228.672,Percent of Total Billed Charges,72% of Total Billed Charges,7.2,60,,190.56,Percent of Total Billed Charges,60% of Total Billed Charges,10.8,90,,241.056,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,120.528,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,241.056,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,232.128,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,118.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,254.448,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,235.696,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,241.056,Percent of Total Billed charges,90% of Total Billed Charges,5.29,12,
STERILE H2O  FOR INH 3000ML,2500001175,CDM,250,RC,,,Outpatient,3000,ML,36.38,23.65,,36.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.65,76,,271.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.19,72,,91.584,Percent of Total Billed Charges,72% of Total Billed Charges,27.29,75,,95.4,Percent of Total Billed charges,75% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.19,72,,91.584,Percent of Total Billed Charges,72% of Total Billed Charges,21.83,60,,76.32,Percent of Total Billed Charges,60% of Total Billed Charges,32.74,90,,321.408,Percent of Total Billed Charges,90% of Total Billed Charges,16.37,45,,160.704,Percent of Total Billed Charges,45% of Total Billed Charges,32.74,90,,321.408,Percent of Total Billed Charges,90% of Total billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.65,65,,138.736,Percent of total Billed Charges,65% of Total Billed Charges,16.04,44.1,,157.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.56,95,,339.264,Percent of Total Billed Charges,95% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.01,88,,314.264,Percent of Total Billed Charges,88% of Total Billed Charges,32.74,90,,321.408,Percent of Total Billed charges,90% of Total Billed Charges,16.04,36.38,
SOD CHLORIDE FOR INJ 20ML,2500001176,CDM,250,RC,,,Outpatient,20,ML,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,162.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.64,72,,65.088,Percent of Total Billed Charges,72% of Total Billed Charges,9,75,,67.8,Percent of Total Billed charges,75% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.64,72,,65.088,Percent of Total Billed Charges,72% of Total Billed Charges,7.2,60,,54.24,Percent of Total Billed Charges,60% of Total Billed Charges,10.8,90,,192.096,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,96.048,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,192.096,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,168.072,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,94.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,202.768,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,187.824,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,192.096,Percent of Total Billed charges,90% of Total Billed Charges,5.29,12,
SOD CHLORIDE FOR INJ 20ML,2500001177,CDM,250,RC,,,Outpatient,20,ML,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,196.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.64,72,,99.072,Percent of Total Billed Charges,72% of Total Billed Charges,9,75,,103.2,Percent of Total Billed charges,75% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.64,72,,99.072,Percent of Total Billed Charges,72% of Total Billed Charges,7.2,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,10.8,90,,232.72,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,116.36,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,232.72,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,19.696,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,114.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,245.648,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,227.544,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,232.72,Percent of Total Billed charges,90% of Total Billed Charges,5.29,12,
PT BACITRACIN + ZINC 1 OZ,2500001184,CDM,250,RC,,,Outpatient,,,20.83,13.54,,20.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.83,76,,23.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,15.62,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,20.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,12.5,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,18.75,90,,27.264,Percent of Total Billed Charges,90% of Total Billed Charges,9.37,45,,13.632,Percent of Total Billed Charges,45% of Total Billed Charges,18.75,90,,27.264,Percent of Total Billed Charges,90% of Total billed Charges,20.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.54,65,,198.12,Percent of total Billed Charges,65% of Total Billed Charges,9.19,44.1,,13.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.79,95,,28.784,Percent of Total Billed Charges,95% of Total Billed Charges,20.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.33,88,,26.664,Percent of Total Billed Charges,88% of Total Billed Charges,18.75,90,,27.264,Percent of Total Billed charges,90% of Total Billed Charges,9.19,20.83,
PT NEOSPORIN 0.5 OZ,2500001185,CDM,250,RC,,,Outpatient,,,38.71,25.16,,38.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.42,76,,231.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.87,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,29.03,75,,23.152,Percent of Total Billed charges,75% of Total Billed Charges,38.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.87,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,23.23,60,,18.52,Percent of Total Billed Charges,60% of Total Billed Charges,34.84,90,,274.32,Percent of Total Billed Charges,90% of Total Billed Charges,17.42,45,,137.16,Percent of Total Billed Charges,45% of Total Billed Charges,34.84,90,,274.32,Percent of Total Billed Charges,90% of Total billed Charges,38.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.16,65,,50.728,Percent of total Billed Charges,65% of Total Billed Charges,17.07,44.1,,134.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.77,95,,289.56,Percent of Total Billed Charges,95% of Total Billed Charges,38.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.06,88,,268.224,Percent of Total Billed Charges,88% of Total Billed Charges,34.84,90,,274.32,Percent of Total Billed charges,90% of Total Billed Charges,17.07,38.71,
AMICAR 500MG TAB,2500001186,CDM,250,RC,,,Outpatient,500,GM,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,59.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,148.6,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,154.792,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,148.6,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,123.832,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,70.24,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,35.12,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,70.24,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,153.4,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,34.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,74.136,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,68.672,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,70.24,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
PROVENTIL 4MG TAB,2500001187,CDM,250,RC,,,Outpatient,4,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,179.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,212.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,106.2,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,212.4,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,6.24,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,104.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,224.2,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,207.68,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,212.4,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
PROVENTIL REPETABS 4MG,2500001188,CDM,250,RC,,,Outpatient,4,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,44.352,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,46.2,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,44.352,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,36.96,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,204.752,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
PROVENTIL 2MG/5ML SYRUP,2500001189,CDM,250,RC,,,Outpatient,2,GM,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,239.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,254.008,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,264.592,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,254.008,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,211.672,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,283.504,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,141.752,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,283.504,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,0.008,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,138.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,299.248,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,277.2,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,283.504,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
ALBUTEROL 2MG TAB,2500001190,CDM,250,RC,,,Outpatient,2,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,0.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,52.704,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,54.904,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,52.704,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,43.92,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,4.432,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,0.008,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,6.408,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,4.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,0.008,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,0.008,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,0.008,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
ZOVIRAX 200MG/5ML SUSP,2500001191,CDM,250,RC,,,Outpatient,200,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,7.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,254.048,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,264.632,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,254.048,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,211.704,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,8.872,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,103.816,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,8.872,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,149.952,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,101.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,9.36,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,8.672,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,8.872,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
ZOVIRAX OINT 15GM,2500001192,CDM,250,RC,,,Outpatient,15,gm,813.65,528.87,,813.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,618.37,76,,175.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,585.83,72,,63.488,Percent of Total Billed Charges,72% of Total Billed Charges,610.24,75,,66.136,Percent of Total Billed charges,75% of Total Billed Charges,813.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,585.83,72,,63.488,Percent of Total Billed Charges,72% of Total Billed Charges,488.19,60,,52.904,Percent of Total Billed Charges,60% of Total Billed Charges,732.29,90,,207.624,Percent of Total Billed Charges,90% of Total Billed Charges,366.14,45,,106.648,Percent of Total Billed Charges,45% of Total Billed Charges,732.29,90,,207.624,Percent of Total Billed Charges,90% of Total billed Charges,813.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,813.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,813.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,528.87,65,,154.048,Percent of total Billed Charges,65% of Total Billed Charges,358.82,44.1,,104.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,772.97,95,,219.16,Percent of Total Billed Charges,95% of Total Billed Charges,813.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,716.01,88,,203.016,Percent of Total Billed Charges,88% of Total Billed Charges,732.29,90,,207.624,Percent of Total Billed charges,90% of Total Billed Charges,358.82,813.65,
ZOVIRAX 5% CREAM,2500001193,CDM,250,RC,,,Outpatient,,,509.36,331.08,,509.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,387.11,76,,180.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,366.74,72,,44.352,Percent of Total Billed Charges,72% of Total Billed Charges,382.02,75,,46.2,Percent of Total Billed charges,75% of Total Billed Charges,509.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.74,72,,44.352,Percent of Total Billed Charges,72% of Total Billed Charges,305.62,60,,36.96,Percent of Total Billed Charges,60% of Total Billed Charges,458.42,90,,213.304,Percent of Total Billed Charges,90% of Total Billed Charges,229.21,45,,6.176,Percent of Total Billed Charges,45% of Total Billed Charges,458.42,90,,213.304,Percent of Total Billed Charges,90% of Total billed Charges,509.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,509.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,509.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,331.08,65,,8.92,Percent of total Billed Charges,65% of Total Billed Charges,224.63,44.1,,6.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,483.89,95,,225.152,Percent of Total Billed Charges,95% of Total Billed Charges,509.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,448.24,88,,208.56,Percent of Total Billed Charges,88% of Total Billed Charges,458.42,90,,213.304,Percent of Total Billed charges,90% of Total Billed Charges,224.63,509.36,
IOPIDINE 0.5% OPHTH SOLN,2500001194,CDM,250,RC,,,Outpatient,,,728.75,473.69,,728.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,553.85,76,,10.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,524.7,72,,69.12,Percent of Total Billed Charges,72% of Total Billed Charges,546.56,75,,72,Percent of Total Billed charges,75% of Total Billed Charges,728.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,524.7,72,,69.12,Percent of Total Billed Charges,72% of Total Billed Charges,437.25,60,,57.6,Percent of Total Billed Charges,60% of Total Billed Charges,655.88,90,,12.352,Percent of Total Billed Charges,90% of Total Billed Charges,327.94,45,,5.8,Percent of Total Billed Charges,45% of Total Billed Charges,655.88,90,,12.352,Percent of Total Billed Charges,90% of Total billed Charges,728.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,728.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,728.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.69,65,,8.384,Percent of total Billed Charges,65% of Total Billed Charges,321.38,44.1,,5.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,692.31,95,,13.032,Percent of Total Billed Charges,95% of Total Billed Charges,728.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,641.3,88,,12.072,Percent of Total Billed Charges,88% of Total Billed Charges,655.88,90,,12.352,Percent of Total Billed charges,90% of Total Billed Charges,321.38,728.75,
BUMEX 1MG/4ML INJ,2500001195,CDM,250,RC,,,Outpatient,1,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,9.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,72,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,75,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,72,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,60,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,11.608,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,2.656,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,11.608,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,3.832,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,2.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,12.248,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,11.352,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,11.608,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
ACULAR 0.5% OPHTH SOLN,2500001196,CDM,250,RC,,,Outpatient,,,334.06,217.14,,334.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,253.89,76,,4.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,240.52,72,,69.12,Percent of Total Billed Charges,72% of Total Billed Charges,250.55,75,,72,Percent of Total Billed charges,75% of Total Billed Charges,334.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.52,72,,69.12,Percent of Total Billed Charges,72% of Total Billed Charges,200.44,60,,57.6,Percent of Total Billed Charges,60% of Total Billed Charges,300.65,90,,5.304,Percent of Total Billed Charges,90% of Total Billed Charges,150.33,45,,10.024,Percent of Total Billed Charges,45% of Total Billed Charges,300.65,90,,5.304,Percent of Total Billed Charges,90% of Total billed Charges,334.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.14,65,,14.48,Percent of total Billed Charges,65% of Total Billed Charges,147.32,44.1,,9.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,317.36,95,,5.6,Percent of Total Billed Charges,95% of Total Billed Charges,334.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.97,88,,5.192,Percent of Total Billed Charges,88% of Total Billed Charges,300.65,90,,5.304,Percent of Total Billed charges,90% of Total Billed Charges,147.32,334.06,
LASIX 10MG ORAL SOL,2500001197,CDM,250,RC,,,Outpatient,10,GM,38.59,25.08,,38.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.33,76,,16.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.78,72,,3089.472,Percent of Total Billed Charges,72% of Total Billed Charges,28.94,75,,3218.2,Percent of Total Billed charges,75% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.78,72,,3089.472,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,60,,2574.56,Percent of Total Billed Charges,60% of Total Billed Charges,34.73,90,,20.056,Percent of Total Billed Charges,90% of Total Billed Charges,17.37,45,,50.392,Percent of Total Billed Charges,45% of Total Billed Charges,34.73,90,,20.056,Percent of Total Billed Charges,90% of Total billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.08,65,,72.784,Percent of total Billed Charges,65% of Total Billed Charges,17.02,44.1,,49.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.66,95,,21.168,Percent of Total Billed Charges,95% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.96,88,,19.608,Percent of Total Billed Charges,88% of Total Billed Charges,34.73,90,,20.056,Percent of Total Billed charges,90% of Total Billed Charges,17.02,38.59,
GENTAMICIN 0.1% OINT,2500001198,CDM,250,RC,,,Outpatient,,,276.50,179.73,,276.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,210.14,76,,85.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,199.08,72,,28.8,Percent of Total Billed Charges,72% of Total Billed Charges,207.38,75,,30,Percent of Total Billed charges,75% of Total Billed Charges,276.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.08,72,,28.8,Percent of Total Billed Charges,72% of Total Billed Charges,165.9,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,248.85,90,,100.776,Percent of Total Billed Charges,90% of Total Billed Charges,124.43,45,,467.776,Percent of Total Billed Charges,45% of Total Billed Charges,248.85,90,,100.776,Percent of Total Billed Charges,90% of Total billed Charges,276.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.73,65,,0.008,Percent of total Billed Charges,65% of Total Billed Charges,121.94,44.1,,458.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,262.68,95,,106.376,Percent of Total Billed Charges,95% of Total Billed Charges,276.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.32,88,,98.536,Percent of Total Billed Charges,88% of Total Billed Charges,248.85,90,,100.776,Percent of Total Billed charges,90% of Total Billed Charges,121.94,276.5,
BETAXOLOL 0.25PCT OPHTH SUSP,2500001199,CDM,250,RC,,,Outpatient,,,356.11,231.47,,356.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,270.64,76,,0.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,256.4,72,,72.4,Percent of Total Billed Charges,72% of Total Billed Charges,267.08,75,,75.416,Percent of Total Billed charges,75% of Total Billed Charges,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.4,72,,72.4,Percent of Total Billed Charges,72% of Total Billed Charges,213.67,60,,60.328,Percent of Total Billed Charges,60% of Total Billed Charges,320.5,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,160.25,45,,153.272,Percent of Total Billed Charges,45% of Total Billed Charges,320.5,90,,0.008,Percent of Total Billed Charges,90% of Total billed Charges,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.47,65,,675.68,Percent of total Billed Charges,65% of Total Billed Charges,157.04,44.1,,150.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,338.3,95,,0.008,Percent of Total Billed Charges,95% of Total Billed Charges,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.38,88,,0.008,Percent of Total Billed Charges,88% of Total Billed Charges,320.5,90,,0.008,Percent of Total Billed charges,90% of Total Billed Charges,157.04,356.11,
DDAVP SPRAY,2500001200,CDM,250,RC,,,Outpatient,,,997.76,648.54,,997.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,758.3,76,,790.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,718.39,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,748.32,75,,60,Percent of Total Billed charges,75% of Total Billed Charges,997.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,718.39,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,598.66,60,,48,Percent of Total Billed Charges,60% of Total Billed Charges,897.98,90,,935.552,Percent of Total Billed Charges,90% of Total Billed Charges,448.99,45,,59.768,Percent of Total Billed Charges,45% of Total Billed Charges,897.98,90,,935.552,Percent of Total Billed Charges,90% of Total billed Charges,997.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,997.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,997.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,648.54,65,,0.008,Percent of total Billed Charges,65% of Total Billed Charges,440.01,44.1,,58.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,947.87,95,,987.528,Percent of Total Billed Charges,95% of Total Billed Charges,997.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.03,88,,914.76,Percent of Total Billed Charges,88% of Total Billed Charges,897.98,90,,935.552,Percent of Total Billed charges,90% of Total Billed Charges,440.01,997.76,
NEO/POLY(BACI OPHTH OINT 3.5G),2500001201,CDM,250,RC,,,Outpatient,,,74.97,48.73,,74.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.98,76,,0.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.98,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,56.23,75,,15.216,Percent of Total Billed charges,75% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.98,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,44.98,60,,12.176,Percent of Total Billed Charges,60% of Total Billed Charges,67.47,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,33.74,45,,11.744,Percent of Total Billed Charges,45% of Total Billed Charges,67.47,90,,0.008,Percent of Total Billed Charges,90% of Total billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.73,65,,221.392,Percent of total Billed Charges,65% of Total Billed Charges,33.06,44.1,,11.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,71.22,95,,0.008,Percent of Total Billed Charges,95% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.97,88,,0.008,Percent of Total Billed Charges,88% of Total Billed Charges,67.47,90,,0.008,Percent of Total Billed charges,90% of Total Billed Charges,33.06,74.97,
COMPAZINE 25MG SUPP,2500001202,CDM,250,RC,,,Outpatient,25,GM,17.64,11.47,,17.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.41,76,,258.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.7,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,75,,16.536,Percent of Total Billed charges,75% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.7,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,10.58,60,,13.232,Percent of Total Billed Charges,60% of Total Billed Charges,15.88,90,,306.544,Percent of Total Billed Charges,90% of Total Billed Charges,7.94,45,,91.808,Percent of Total Billed Charges,45% of Total Billed Charges,15.88,90,,306.544,Percent of Total Billed Charges,90% of Total billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.47,65,,86.328,Percent of total Billed Charges,65% of Total Billed Charges,7.78,44.1,,89.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.76,95,,323.568,Percent of Total Billed Charges,95% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.52,88,,299.728,Percent of Total Billed Charges,88% of Total Billed Charges,15.88,90,,306.544,Percent of Total Billed charges,90% of Total Billed Charges,7.78,17.64,
PHENERGAN 25MG TABS S 4,2500001203,CDM,250,RC,,,Outpatient,25,GM,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,100.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,133.36,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,138.92,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,133.36,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,111.136,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,119.536,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,905.432,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,119.536,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,16.96,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,887.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,126.176,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,116.88,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,119.536,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
PROMETHAZINE 6.25MG/5ML SYRUP,2500001204,CDM,250,RC,,,Outpatient,6.25,GM,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,19.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,538.512,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,560.952,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,538.512,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,448.76,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,183.616,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,10.8,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,23.488,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,132.608,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,10.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,24.792,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,22.968,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,23.488,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
MITOMYCIN 20MG INJ,2500001205,CDM,250,RC,,,Outpatient,20,GM,998.87,649.27,,998.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,759.14,76,,155.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,719.19,72,,127.64,Percent of Total Billed Charges,72% of Total Billed Charges,749.15,75,,132.96,Percent of Total Billed charges,75% of Total Billed Charges,998.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,719.19,72,,127.64,Percent of Total Billed Charges,72% of Total Billed Charges,599.32,60,,106.368,Percent of Total Billed Charges,60% of Total Billed Charges,898.98,90,,1810.856,Percent of Total Billed Charges,90% of Total Billed Charges,449.49,45,,11.248,Percent of Total Billed Charges,45% of Total Billed Charges,898.98,90,,183.616,Percent of Total Billed Charges,90% of Total billed Charges,998.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,998.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,998.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649.27,65,,1307.84,Percent of total Billed Charges,65% of Total Billed Charges,440.5,44.1,,11.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,948.93,95,,193.816,Percent of Total Billed Charges,95% of Total Billed Charges,998.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,879.01,88,,179.536,Percent of Total Billed Charges,88% of Total Billed Charges,898.98,90,,183.616,Percent of Total Billed charges,90% of Total Billed Charges,440.5,998.87,
RETROVIR 200MG/20 ML INJ,2500001206,CDM,250,RC,J3485,HCPCS,Outpatient,200,GM,159.86,103.91,,159.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,121.49,76,,1529.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.11,350,,54.424,Fee Schedule,350% of BCBS fee schedule,5.11,350,,56.688,Fee Schedule,350% of BCBS fee schedule,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.11,350,,54.424,Fee Schedule,350% of BCBS PPO fee schedule,1.46,100,,45.352,Fee Schedule,100% of Blue ADV HMO fee schedule,143.87,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,71.94,45,,7.432,Percent of Total Billed Charges,45% of Total Billed Charges,143.87,90,,1810.856,Percent of Total Billed Charges,90% of Total billed Charges,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.91,65,,15.6,Percent of total Billed Charges,65% of Total Billed Charges,70.5,44.1,,7.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,151.87,95,,1911.464,Percent of Total Billed Charges,95% of Total Billed Charges,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.68,88,,1770.616,Percent of Total Billed Charges,88% of Total Billed Charges,143.87,90,,1810.856,Percent of Total Billed charges,90% of Total Billed Charges,1.46,159.86,
CRESTOR 10MG TAB,2500001207,CDM,250,RC,,,Outpatient,10,GM,6.50,4.23,,6.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.94,76,,18.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.68,72,,80.72,Percent of Total Billed Charges,72% of Total Billed Charges,4.88,75,,84.088,Percent of Total Billed charges,75% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.68,72,,80.72,Percent of Total Billed Charges,72% of Total Billed Charges,3.9,60,,67.264,Percent of Total Billed Charges,60% of Total Billed Charges,5.85,90,,22.504,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,131.4,Percent of Total Billed Charges,45% of Total Billed Charges,5.85,90,,21.6,Percent of Total Billed Charges,90% of Total billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,65,,16.248,Percent of total Billed Charges,65% of Total Billed Charges,2.87,44.1,,128.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.18,95,,22.8,Percent of Total Billed Charges,95% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,88,,21.12,Percent of Total Billed Charges,88% of Total Billed Charges,5.85,90,,21.6,Percent of Total Billed charges,90% of Total Billed Charges,2.87,6.5,
PEN-VEE 250MG/5ML SUSP 100ML,2500001208,CDM,250,RC,,,Outpatient,250,GM,34.18,22.22,,34.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.98,76,,19,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.61,72,,54.424,Percent of Total Billed Charges,72% of Total Billed Charges,25.64,75,,56.688,Percent of Total Billed charges,75% of Total Billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.61,72,,54.424,Percent of Total Billed Charges,72% of Total Billed Charges,20.51,60,,45.352,Percent of Total Billed Charges,60% of Total Billed Charges,30.76,90,,14.872,Percent of Total Billed Charges,90% of Total Billed Charges,15.38,45,,16.2,Percent of Total Billed Charges,45% of Total Billed Charges,30.76,90,,22.504,Percent of Total Billed Charges,90% of Total billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.22,65,,10.736,Percent of total Billed Charges,65% of Total Billed Charges,15.07,44.1,,15.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.47,95,,23.752,Percent of Total Billed Charges,95% of Total Billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.08,88,,22,Percent of Total Billed Charges,88% of Total Billed Charges,30.76,90,,22.504,Percent of Total Billed charges,90% of Total Billed Charges,15.07,34.18,
NEOSPORIN OPHTH SOL S 10ML,2500001209,CDM,250,RC,,,Outpatient,10,ML,146.63,95.31,,146.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,111.44,76,,12.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,105.57,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,109.97,75,,21.832,Percent of Total Billed charges,75% of Total Billed Charges,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.57,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,87.98,60,,17.464,Percent of Total Billed Charges,60% of Total Billed Charges,131.97,90,,262.8,Percent of Total Billed Charges,90% of Total Billed Charges,65.98,45,,29.968,Percent of Total Billed Charges,45% of Total Billed Charges,131.97,90,,14.872,Percent of Total Billed Charges,90% of Total billed Charges,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.31,65,,189.8,Percent of total Billed Charges,65% of Total Billed Charges,64.66,44.1,,29.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,139.3,95,,15.696,Percent of Total Billed Charges,95% of Total Billed Charges,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.03,88,,14.536,Percent of Total Billed Charges,88% of Total Billed Charges,131.97,90,,14.872,Percent of Total Billed charges,90% of Total Billed Charges,64.66,146.63,
TETRACAINE 1% OPHTH,2500001210,CDM,250,RC,,,Outpatient,,,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,221.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,80.72,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,84.088,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,80.72,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,67.264,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,262.8,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,23.4,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,277.4,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,256.96,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,262.8,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
LIDO W/EPI 1PCT 20ML INJ,2500001211,CDM,250,RC,,,Outpatient,20,ML,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,27.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,2.848,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,2.968,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,2.848,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,2.368,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,59.944,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,27.448,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,32.4,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,43.288,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,26.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,34.2,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,31.68,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,32.4,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
LIDO 1% W/EPI 30ML INJ,2500001212,CDM,250,RC,,,Outpatient,30,ML,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,50.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.64,72,,518.192,Percent of Total Billed Charges,72% of Total Billed Charges,9,75,,539.784,Percent of Total Billed charges,75% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.64,72,,518.192,Percent of Total Billed Charges,72% of Total Billed Charges,7.2,60,,431.824,Percent of Total Billed Charges,60% of Total Billed Charges,10.8,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,6.84,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,59.944,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,6.88,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,6.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,63.272,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,58.608,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,59.944,Percent of Total Billed charges,90% of Total Billed Charges,5.29,12,
MAXZIDE 75/50 TAB,2500001213,CDM,250,RC,,,Outpatient,,,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,88.272,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,91.952,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,88.272,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,73.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,54.904,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,164.344,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,39.648,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,161.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
LEVSIN DROPS,2500001214,CDM,250,RC,,,Outpatient,,,159.86,103.91,,159.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,121.49,76,,46.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,115.1,72,,34.296,Percent of Total Billed Charges,72% of Total Billed Charges,119.9,75,,35.728,Percent of Total Billed charges,75% of Total Billed Charges,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.1,72,,34.296,Percent of Total Billed Charges,72% of Total Billed Charges,95.92,60,,28.576,Percent of Total Billed Charges,60% of Total Billed Charges,143.87,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,71.94,45,,15.032,Percent of Total Billed Charges,45% of Total Billed Charges,143.87,90,,54.904,Percent of Total Billed Charges,90% of Total billed Charges,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.91,65,,9.88,Percent of total Billed Charges,65% of Total Billed Charges,70.5,44.1,,14.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,151.87,95,,57.952,Percent of Total Billed Charges,95% of Total Billed Charges,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.68,88,,53.68,Percent of Total Billed Charges,88% of Total Billed Charges,143.87,90,,54.904,Percent of Total Billed charges,90% of Total Billed Charges,70.5,159.86,
ZYVOX 600MG TAB,2500001215,CDM,250,RC,,,Outpatient,600,GM,446.51,290.23,,446.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,339.35,76,,11.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,321.49,72,,1117.672,Percent of Total Billed Charges,72% of Total Billed Charges,334.88,75,,1164.24,Percent of Total Billed charges,75% of Total Billed Charges,446.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,321.49,72,,1117.672,Percent of Total Billed Charges,72% of Total Billed Charges,267.91,60,,931.392,Percent of Total Billed Charges,60% of Total Billed Charges,401.86,90,,328.68,Percent of Total Billed Charges,90% of Total Billed Charges,200.93,45,,13.504,Percent of Total Billed Charges,45% of Total Billed Charges,401.86,90,,13.68,Percent of Total Billed Charges,90% of Total billed Charges,446.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290.23,65,,237.384,Percent of total Billed Charges,65% of Total Billed Charges,196.91,44.1,,13.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,424.18,95,,14.44,Percent of Total Billed Charges,95% of Total Billed Charges,446.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.93,88,,13.376,Percent of Total Billed Charges,88% of Total Billed Charges,401.86,90,,13.68,Percent of Total Billed charges,90% of Total Billed Charges,196.91,446.51,
MAGNESIUM SULF 1GM/2ML INJ,2500001216,CDM,250,RC,,,Outpatient,1,gm,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,277.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,43.816,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,45.64,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,43.816,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,36.512,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,30.064,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,7.2,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,328.68,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,21.712,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,7.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,346.944,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,321.376,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,328.68,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
OCUFLOX 03% OPHTH SOLN,2500001217,CDM,250,RC,,,Outpatient,,,251.37,163.39,,251.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,191.04,76,,25.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,180.99,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,188.53,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.99,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,150.82,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,226.23,90,,27,Percent of Total Billed Charges,90% of Total Billed Charges,113.12,45,,164.344,Percent of Total Billed Charges,45% of Total Billed Charges,226.23,90,,30.064,Percent of Total Billed Charges,90% of Total billed Charges,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.39,65,,19.504,Percent of total Billed Charges,65% of Total Billed Charges,110.85,44.1,,161.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,238.8,95,,31.728,Percent of Total Billed Charges,95% of Total Billed Charges,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.21,88,,29.392,Percent of Total Billed Charges,88% of Total Billed Charges,226.23,90,,30.064,Percent of Total Billed charges,90% of Total Billed Charges,110.85,251.37,
TALWIN 50MG TAB,2500001218,CDM,250,RC,,,Outpatient,50,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,22.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,1074.488,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,1119.256,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,1074.488,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,895.408,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,42.208,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,27,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,10.4,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,41.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,28.504,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,26.4,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,27,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
PILOCAR 4% OPHTH SOLN,2500001219,CDM,250,RC,,,Outpatient,,,234.83,152.64,,234.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,178.47,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,169.08,72,,13.336,Percent of Total Billed Charges,72% of Total Billed Charges,176.12,75,,13.888,Percent of Total Billed charges,75% of Total Billed Charges,234.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.08,72,,13.336,Percent of Total Billed Charges,72% of Total Billed Charges,140.9,60,,11.112,Percent of Total Billed Charges,60% of Total Billed Charges,211.35,90,,328.68,Percent of Total Billed Charges,90% of Total Billed Charges,105.67,45,,2.344,Percent of Total Billed Charges,45% of Total Billed Charges,211.35,90,,14.4,Percent of Total Billed Charges,90% of Total billed Charges,234.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.64,65,,237.384,Percent of total Billed Charges,65% of Total Billed Charges,103.56,44.1,,2.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,223.09,95,,15.2,Percent of Total Billed Charges,95% of Total Billed Charges,234.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.65,88,,14.08,Percent of Total Billed Charges,88% of Total Billed Charges,211.35,90,,14.4,Percent of Total Billed charges,90% of Total Billed Charges,103.56,234.83,
COMPAZINE 10MG TAB,2500001220,CDM,250,RC,,,Outpatient,10,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,277.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,38.104,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,39.688,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,38.104,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,31.752,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,84.424,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,164.344,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,328.68,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,60.968,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,161.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,346.944,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,321.376,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,328.68,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
QUINIDINE 324MG TAB,2500001221,CDM,250,RC,,,Outpatient,324,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,71.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,30.48,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,31.752,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,30.48,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,25.4,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,4.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,13.504,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,84.424,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,3.384,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,13.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,89.112,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,82.544,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,84.424,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
NAROPIN 2MG/ML 200ML,2500001222,CDM,250,RC,,,Outpatient,2,GM,261.29,169.84,,261.29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,198.58,76,,3.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,188.13,72,,289.576,Percent of Total Billed Charges,72% of Total Billed Charges,195.97,75,,301.648,Percent of Total Billed charges,75% of Total Billed Charges,261.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.13,72,,289.576,Percent of Total Billed Charges,72% of Total Billed Charges,156.77,60,,241.312,Percent of Total Billed Charges,60% of Total Billed Charges,235.16,90,,328.68,Percent of Total Billed Charges,90% of Total Billed Charges,117.58,45,,7.2,Percent of Total Billed Charges,45% of Total Billed Charges,235.16,90,,4.68,Percent of Total Billed Charges,90% of Total billed Charges,261.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.84,65,,237.384,Percent of total Billed Charges,65% of Total Billed Charges,115.23,44.1,,7.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,248.23,95,,4.944,Percent of Total Billed Charges,95% of Total Billed Charges,261.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.94,88,,4.576,Percent of Total Billed Charges,88% of Total Billed Charges,235.16,90,,4.68,Percent of Total Billed charges,90% of Total Billed Charges,115.23,261.29,
MURO 128 2% OPHTH SOLN,2500001223,CDM,250,RC,,,Outpatient,,,83.79,54.46,,83.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,63.68,76,,277.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,60.33,72,,549.312,Percent of Total Billed Charges,72% of Total Billed Charges,62.84,75,,572.2,Percent of Total Billed charges,75% of Total Billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.33,72,,549.312,Percent of Total Billed Charges,72% of Total Billed Charges,50.27,60,,457.76,Percent of Total Billed Charges,60% of Total Billed Charges,75.41,90,,27,Percent of Total Billed Charges,90% of Total Billed Charges,37.71,45,,504.664,Percent of Total Billed Charges,45% of Total Billed Charges,75.41,90,,328.68,Percent of Total Billed Charges,90% of Total billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.46,65,,19.504,Percent of total Billed Charges,65% of Total Billed Charges,36.95,44.1,,494.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,79.6,95,,346.944,Percent of Total Billed Charges,95% of Total Billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.74,88,,321.376,Percent of Total Billed Charges,88% of Total Billed Charges,75.41,90,,328.68,Percent of Total Billed charges,90% of Total Billed Charges,36.95,83.79,
THEOPHYLL 100MG TAB,2500001224,CDM,250,RC,,,Outpatient,100,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,22.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,2507.136,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,2507.136,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,2507.136,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,2089.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,16.92,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,27,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,10.4,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,16.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,28.504,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,26.4,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,27,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
TIMOLOL 0.5PCT SOL-G OPHTH,2500001225,CDM,250,RC,,,Outpatient,,,544.64,354.02,,544.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,413.93,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,392.14,72,,2538.896,Percent of Total Billed Charges,72% of Total Billed Charges,408.48,75,,2538.896,Percent of Total Billed charges,75% of Total Billed Charges,544.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.14,72,,2538.896,Percent of Total Billed Charges,72% of Total Billed Charges,326.78,60,,2115.744,Percent of Total Billed Charges,60% of Total Billed Charges,490.18,90,,1009.336,Percent of Total Billed Charges,90% of Total Billed Charges,245.09,45,,21.032,Percent of Total Billed Charges,45% of Total Billed Charges,490.18,90,,14.4,Percent of Total Billed Charges,90% of Total billed Charges,544.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,544.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,544.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.02,65,,728.96,Percent of total Billed Charges,65% of Total Billed Charges,240.19,44.1,,20.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,517.41,95,,15.2,Percent of Total Billed Charges,95% of Total Billed Charges,544.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.28,88,,14.08,Percent of Total Billed Charges,88% of Total Billed Charges,490.18,90,,14.4,Percent of Total Billed charges,90% of Total Billed Charges,240.19,544.64,
VIROPTIC 1% OPHTH SOLN,2500001226,CDM,250,RC,,,Outpatient,,,681.35,442.88,,681.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,517.83,76,,852.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,490.57,72,,17475.032,Percent of Total Billed Charges,72% of Total Billed Charges,511.01,75,,17475.032,Percent of Total Billed charges,75% of Total Billed Charges,681.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.57,72,,17475.032,Percent of Total Billed Charges,72% of Total Billed Charges,408.81,60,,14562.528,Percent of Total Billed Charges,60% of Total Billed Charges,613.22,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,306.61,45,,16.672,Percent of Total Billed Charges,45% of Total Billed Charges,613.22,90,,1009.336,Percent of Total Billed Charges,90% of Total billed Charges,681.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,681.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,681.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,442.88,65,,24.44,Percent of total Billed Charges,65% of Total Billed Charges,300.48,44.1,,16.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,647.28,95,,1065.408,Percent of Total Billed Charges,95% of Total Billed Charges,681.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,599.59,88,,986.904,Percent of Total Billed Charges,88% of Total Billed Charges,613.22,90,,1009.336,Percent of Total Billed charges,90% of Total Billed Charges,300.48,681.35,
STROMECTOL 3MG,2500001227,CDM,250,RC,,,Outpatient,3,GM,16.50,10.73,,16.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.54,76,,28.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.88,72,,1524.728,Percent of Total Billed Charges,72% of Total Billed Charges,12.38,75,,1524.728,Percent of Total Billed charges,75% of Total Billed Charges,16.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.88,72,,1524.728,Percent of Total Billed Charges,72% of Total Billed Charges,9.9,60,,1270.608,Percent of Total Billed Charges,60% of Total Billed Charges,14.85,90,,42.072,Percent of Total Billed Charges,90% of Total Billed Charges,7.43,45,,20.24,Percent of Total Billed Charges,45% of Total Billed Charges,14.85,90,,33.84,Percent of Total Billed Charges,90% of Total billed Charges,16.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.73,65,,30.384,Percent of total Billed Charges,65% of Total Billed Charges,7.28,44.1,,19.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.68,95,,35.72,Percent of Total Billed Charges,95% of Total Billed Charges,16.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.52,88,,33.088,Percent of Total Billed Charges,88% of Total Billed Charges,14.85,90,,33.84,Percent of Total Billed charges,90% of Total Billed Charges,7.28,16.5,
SILDENAFIL 20MG TAB,2500001235,CDM,250,RC,,,Outpatient,20,GM,6.50,4.23,,6.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.94,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.68,72,,3804.528,Percent of Total Billed Charges,72% of Total Billed Charges,4.88,75,,3804.528,Percent of Total Billed charges,75% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.68,72,,3804.528,Percent of Total Billed Charges,72% of Total Billed Charges,3.9,60,,3170.44,Percent of Total Billed Charges,60% of Total Billed Charges,5.85,90,,36.52,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,6.744,Percent of Total Billed Charges,45% of Total Billed Charges,5.85,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,65,,26.944,Percent of total Billed Charges,65% of Total Billed Charges,2.87,44.1,,6.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.18,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,5.85,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,2.87,6.5,
BUPIVACAINE 0.5% 10ML,2500001236,CDM,250,RC,J0665,HCPCS,Outpatient,10,ML,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,31.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.64,72,,261.64,Percent of Total Billed Charges,72% of Total Billed Charges,9,75,,272.536,Percent of Total Billed charges,75% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.64,72,,261.64,Percent of Total Billed Charges,72% of Total Billed Charges,7.2,60,,218.032,Percent of Total Billed Charges,60% of Total Billed Charges,10.8,90,,40.488,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,37.312,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,32.68,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,39.384,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,36.48,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,37.312,Percent of Total Billed charges,90% of Total Billed Charges,5.29,12,
METHOTREXATE 125MG/5ML INJ,2500001237,CDM,250,RC,,,Outpatient,125,GM,987.50,641.88,,987.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,750.5,76,,38.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,711,72,,1338.032,Percent of Total Billed Charges,72% of Total Billed Charges,740.63,75,,1393.784,Percent of Total Billed charges,75% of Total Billed Charges,987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,711,72,,1338.032,Percent of Total Billed Charges,72% of Total Billed Charges,592.5,60,,1115.024,Percent of Total Billed Charges,60% of Total Billed Charges,888.75,90,,35.72,Percent of Total Billed Charges,90% of Total Billed Charges,444.38,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,888.75,90,,45.248,Percent of Total Billed Charges,90% of Total billed Charges,987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,641.88,65,,9.744,Percent of total Billed Charges,65% of Total Billed Charges,435.49,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,938.13,95,,47.76,Percent of Total Billed Charges,95% of Total Billed Charges,987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,869,88,,44.24,Percent of Total Billed Charges,88% of Total Billed Charges,888.75,90,,45.248,Percent of Total Billed charges,90% of Total Billed Charges,435.49,987.5,
NEO/POLY(BACI OPHTH OINT 3.5G),2500001239,CDM,250,RC,,,Outpatient,,,74.97,48.73,,74.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.98,76,,11.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.98,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,56.23,75,,114.44,Percent of Total Billed charges,75% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.98,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,44.98,60,,91.552,Percent of Total Billed Charges,60% of Total Billed Charges,67.47,90,,40.488,Percent of Total Billed Charges,90% of Total Billed Charges,33.74,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,67.47,90,,13.496,Percent of Total Billed Charges,90% of Total billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.73,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,33.06,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,71.22,95,,14.24,Percent of Total Billed Charges,95% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.97,88,,13.192,Percent of Total Billed Charges,88% of Total Billed Charges,67.47,90,,13.496,Percent of Total Billed charges,90% of Total Billed Charges,33.06,74.97,
COMPAZINE 25MG SUPP,2500001240,CDM,250,RC,,,Outpatient,25,GM,17.64,11.47,,17.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.41,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.7,72,,2.304,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,75,,2.4,Percent of Total Billed charges,75% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.7,72,,2.304,Percent of Total Billed Charges,72% of Total Billed Charges,10.58,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,15.88,90,,35.72,Percent of Total Billed Charges,90% of Total Billed Charges,7.94,45,,16.272,Percent of Total Billed Charges,45% of Total Billed Charges,15.88,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.47,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,7.78,44.1,,15.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.76,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.52,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,15.88,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,7.78,17.64,
METRONIDAZOLE VAGINAL GEL 0.75,2500001241,CDM,250,RC,,,Outpatient,,,128.99,83.84,,128.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.03,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,92.87,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,96.74,75,,43,Percent of Total Billed charges,75% of Total Billed Charges,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.87,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,77.39,60,,34.4,Percent of Total Billed Charges,60% of Total Billed Charges,116.09,90,,40.488,Percent of Total Billed Charges,90% of Total Billed Charges,58.05,45,,19.048,Percent of Total Billed Charges,45% of Total Billed Charges,116.09,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.84,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,56.88,44.1,,18.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,122.54,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.51,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,116.09,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,56.88,128.99,
METRONIDAZOLE VAGINAL GEL0.75%,2500001242,CDM,250,RC,,,Outpatient,,,128.99,83.84,,128.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.03,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,92.87,72,,52.08,Percent of Total Billed Charges,72% of Total Billed Charges,96.74,75,,54.248,Percent of Total Billed charges,75% of Total Billed Charges,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.87,72,,52.08,Percent of Total Billed Charges,72% of Total Billed Charges,77.39,60,,43.4,Percent of Total Billed Charges,60% of Total Billed Charges,116.09,90,,33.344,Percent of Total Billed Charges,90% of Total Billed Charges,58.05,45,,18.256,Percent of Total Billed Charges,45% of Total Billed Charges,116.09,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.84,65,,23.504,Percent of total Billed Charges,65% of Total Billed Charges,56.88,44.1,,17.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,122.54,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.51,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,116.09,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,56.88,128.99,
NEO/POLY(BACI OPHTH OINT 3.5G),2500001244,CDM,250,RC,,,Outpatient,,,74.97,48.73,,74.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.98,76,,32.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.98,72,,59.056,Percent of Total Billed Charges,72% of Total Billed Charges,56.23,75,,61.52,Percent of Total Billed charges,75% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.98,72,,59.056,Percent of Total Billed Charges,72% of Total Billed Charges,44.98,60,,49.216,Percent of Total Billed Charges,60% of Total Billed Charges,67.47,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,33.74,45,,17.856,Percent of Total Billed Charges,45% of Total Billed Charges,67.47,90,,38.104,Percent of Total Billed Charges,90% of Total billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.73,65,,26.376,Percent of total Billed Charges,65% of Total Billed Charges,33.06,44.1,,17.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,71.22,95,,40.216,Percent of Total Billed Charges,95% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.97,88,,37.256,Percent of Total Billed Charges,88% of Total Billed Charges,67.47,90,,38.104,Percent of Total Billed charges,90% of Total Billed Charges,33.06,74.97,
BSS PLUS IRRIGATION 500ML,2500001245,CDM,250,RC,,,Outpatient,500,ML,320.75,208.49,,320.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,243.77,76,,30.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,230.94,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,240.56,75,,44.32,Percent of Total Billed charges,75% of Total Billed Charges,320.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.94,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,192.45,60,,35.456,Percent of Total Billed Charges,60% of Total Billed Charges,288.68,90,,200.832,Percent of Total Billed Charges,90% of Total Billed Charges,144.34,45,,20.24,Percent of Total Billed Charges,45% of Total Billed Charges,288.68,90,,36.52,Percent of Total Billed Charges,90% of Total billed Charges,320.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.49,65,,29.24,Percent of total Billed Charges,65% of Total Billed Charges,141.45,44.1,,19.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,304.71,95,,38.544,Percent of Total Billed Charges,95% of Total Billed Charges,320.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.26,88,,35.704,Percent of Total Billed Charges,88% of Total Billed Charges,288.68,90,,36.52,Percent of Total Billed charges,90% of Total Billed Charges,141.45,320.75,
MOCHOLE-E KIT 1%,2500001248,CDM,250,RC,,,Outpatient,,,390.75,253.99,,390.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,296.97,76,,34.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,281.34,72,,54.424,Percent of Total Billed Charges,72% of Total Billed Charges,293.06,75,,56.688,Percent of Total Billed charges,75% of Total Billed Charges,390.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,281.34,72,,54.424,Percent of Total Billed Charges,72% of Total Billed Charges,234.45,60,,45.352,Percent of Total Billed Charges,60% of Total Billed Charges,351.68,90,,49.216,Percent of Total Billed Charges,90% of Total Billed Charges,175.84,45,,16.672,Percent of Total Billed Charges,45% of Total Billed Charges,351.68,90,,40.488,Percent of Total Billed Charges,90% of Total billed Charges,390.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,253.99,65,,25.8,Percent of total Billed Charges,65% of Total Billed Charges,172.32,44.1,,16.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,371.21,95,,42.736,Percent of Total Billed Charges,95% of Total Billed Charges,390.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.86,88,,39.584,Percent of Total Billed Charges,88% of Total Billed Charges,351.68,90,,40.488,Percent of Total Billed charges,90% of Total Billed Charges,172.32,390.75,
LITTLE REMEDIES 0.125% 15ML,2500001249,CDM,250,RC,,,Outpatient,15,ML,15.45,10.04,,15.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.74,76,,30.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,11.59,75,,91.288,Percent of Total Billed charges,75% of Total Billed Charges,15.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,9.27,60,,73.032,Percent of Total Billed Charges,60% of Total Billed Charges,13.91,90,,49.216,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,18.256,Percent of Total Billed Charges,45% of Total Billed Charges,13.91,90,,35.72,Percent of Total Billed Charges,90% of Total billed Charges,15.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,29.24,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,17.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.68,95,,37.704,Percent of Total Billed Charges,95% of Total Billed Charges,15.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.6,88,,34.928,Percent of Total Billed Charges,88% of Total Billed Charges,13.91,90,,35.72,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.45,
PREDNISONE 5MG/5ML SOLU,2500001250,CDM,250,RC,J7512,HCPCS,Outpatient,5,GM,11.75,7.64,,11.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.93,76,,34.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.04,350,,57.16,Fee Schedule,350% of BCBS fee schedule,0.04,350,,59.536,Fee Schedule,350% of BCBS fee schedule,11.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.04,350,,57.16,Fee Schedule,350% of BCBS PPO fee schedule,0.01,100,,47.632,Fee Schedule,100% of Blue ADV HMO fee schedule,10.58,90,,49.216,Percent of Total Billed Charges,90% of Total Billed Charges,5.29,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,10.58,90,,40.488,Percent of Total Billed Charges,90% of Total billed Charges,11.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.64,65,,24.08,Percent of total Billed Charges,65% of Total Billed Charges,5.18,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.16,95,,42.736,Percent of Total Billed Charges,95% of Total Billed Charges,11.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.34,88,,39.584,Percent of Total Billed Charges,88% of Total Billed Charges,10.58,90,,40.488,Percent of Total Billed charges,90% of Total Billed Charges,0.01,11.75,
MUPIROCIN 2% 30G,2500001251,CDM,250,RC,,,Outpatient,,,1163.75,756.44,,1163.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,884.45,76,,28.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,837.9,72,,83.824,Percent of Total Billed Charges,72% of Total Billed Charges,872.81,75,,87.32,Percent of Total Billed charges,75% of Total Billed Charges,1163.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,837.9,72,,83.824,Percent of Total Billed Charges,72% of Total Billed Charges,698.25,60,,69.856,Percent of Total Billed Charges,60% of Total Billed Charges,1047.38,90,,207.184,Percent of Total Billed Charges,90% of Total Billed Charges,523.69,45,,100.416,Percent of Total Billed Charges,45% of Total Billed Charges,1047.38,90,,33.344,Percent of Total Billed Charges,90% of Total billed Charges,1163.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1163.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1163.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.44,65,,26.376,Percent of total Billed Charges,65% of Total Billed Charges,513.21,44.1,,98.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,1105.56,95,,35.192,Percent of Total Billed Charges,95% of Total Billed Charges,1163.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1024.1,88,,32.6,Percent of Total Billed Charges,88% of Total Billed Charges,1047.38,90,,33.344,Percent of Total Billed charges,90% of Total Billed Charges,513.21,1163.75,
SOD THIOSULFATE 25% INJ,2500001258,CDM,250,RC,,,Outpatient,,,103.64,67.37,,103.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,78.77,76,,41.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,74.62,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,77.73,75,,16.536,Percent of Total Billed charges,75% of Total Billed Charges,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.62,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,62.18,60,,13.232,Percent of Total Billed Charges,60% of Total Billed Charges,93.28,90,,378,Percent of Total Billed Charges,90% of Total Billed Charges,46.64,45,,106.368,Percent of Total Billed Charges,45% of Total Billed Charges,93.28,90,,49.216,Percent of Total Billed Charges,90% of Total billed Charges,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.37,65,,35.544,Percent of total Billed Charges,65% of Total Billed Charges,45.71,44.1,,104.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,98.46,95,,51.952,Percent of Total Billed Charges,95% of Total Billed Charges,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.2,88,,48.128,Percent of Total Billed Charges,88% of Total Billed Charges,93.28,90,,49.216,Percent of Total Billed charges,90% of Total Billed Charges,45.71,103.64,
NEVIRAPINE 50MG/5ML SUSP,2500001259,CDM,250,RC,,,Outpatient,50,GM,13.50,8.78,,13.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.26,76,,41.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.72,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,10.13,75,,46.312,Percent of Total Billed charges,75% of Total Billed Charges,13.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.72,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,8.1,60,,37.048,Percent of Total Billed Charges,60% of Total Billed Charges,12.15,90,,83.52,Percent of Total Billed Charges,90% of Total Billed Charges,6.08,45,,26.2,Percent of Total Billed Charges,45% of Total Billed Charges,12.15,90,,49.216,Percent of Total Billed Charges,90% of Total billed Charges,13.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.78,65,,149.632,Percent of total Billed Charges,65% of Total Billed Charges,5.95,44.1,,25.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.83,95,,51.952,Percent of Total Billed Charges,95% of Total Billed Charges,13.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.88,88,,48.128,Percent of Total Billed Charges,88% of Total Billed Charges,12.15,90,,49.216,Percent of Total Billed charges,90% of Total Billed Charges,5.95,13.5,
LANOLIN CREAM 40GM,2500001260,CDM,250,RC,,,Outpatient,40,gm,34.20,22.23,,34.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.99,76,,174.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.62,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,25.65,75,,16.536,Percent of Total Billed charges,75% of Total Billed Charges,34.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.62,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,20.52,60,,13.232,Percent of Total Billed Charges,60% of Total Billed Charges,30.78,90,,55.44,Percent of Total Billed Charges,90% of Total Billed Charges,15.39,45,,0.272,Percent of Total Billed Charges,45% of Total Billed Charges,30.78,90,,207.184,Percent of Total Billed Charges,90% of Total billed Charges,34.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.23,65,,153.648,Percent of total Billed Charges,65% of Total Billed Charges,15.08,44.1,,0.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.49,95,,218.688,Percent of Total Billed Charges,95% of Total Billed Charges,34.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.1,88,,202.576,Percent of Total Billed Charges,88% of Total Billed Charges,30.78,90,,207.184,Percent of Total Billed charges,90% of Total Billed Charges,15.08,34.2,
ASCOR 250000 MG/50 ML INJ,2500001261,CDM,250,RC,,,Outpatient,250000,GM,844.27,548.78,,844.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,641.65,76,,179.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,607.87,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,633.2,75,,46.312,Percent of Total Billed charges,75% of Total Billed Charges,844.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.87,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,506.56,60,,37.048,Percent of Total Billed Charges,60% of Total Billed Charges,759.84,90,,247.68,Percent of Total Billed Charges,90% of Total Billed Charges,379.92,45,,202.304,Percent of Total Billed Charges,45% of Total Billed Charges,759.84,90,,212.736,Percent of Total Billed Charges,90% of Total billed Charges,844.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,844.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,844.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,548.78,65,,37.84,Percent of total Billed Charges,65% of Total Billed Charges,372.32,44.1,,198.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,802.06,95,,224.56,Percent of Total Billed Charges,95% of Total Billed Charges,844.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,742.96,88,,208.008,Percent of Total Billed Charges,88% of Total Billed Charges,759.84,90,,212.736,Percent of Total Billed charges,90% of Total Billed Charges,372.32,844.27,
MELATONIN 5MG TAB,2500001262,CDM,250,RC,,,Outpatient,5,GM,6.50,4.23,,6.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.94,76,,44.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.68,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,4.88,75,,46.968,Percent of Total Billed charges,75% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.68,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,3.9,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,5.85,90,,185.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,151.56,Percent of Total Billed Charges,45% of Total Billed Charges,5.85,90,,52.392,Percent of Total Billed Charges,90% of Total billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,65,,0.392,Percent of total Billed Charges,65% of Total Billed Charges,2.87,44.1,,148.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.18,95,,55.304,Percent of Total Billed Charges,95% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,88,,51.232,Percent of Total Billed Charges,88% of Total Billed Charges,5.85,90,,52.392,Percent of Total Billed charges,90% of Total Billed Charges,2.87,6.5,
MELATONIN 3MG TAB,2500001263,CDM,250,RC,,,Outpatient,3,GM,6.50,4.23,,6.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.94,76,,0.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.68,72,,48.896,Percent of Total Billed Charges,72% of Total Billed Charges,4.88,75,,50.936,Percent of Total Billed charges,75% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.68,72,,48.896,Percent of Total Billed Charges,72% of Total Billed Charges,3.9,60,,40.744,Percent of Total Billed Charges,60% of Total Billed Charges,5.85,90,,285.84,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,47.88,Percent of Total Billed Charges,45% of Total Billed Charges,5.85,90,,0.544,Percent of Total Billed Charges,90% of Total billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,65,,292.216,Percent of total Billed Charges,65% of Total Billed Charges,2.87,44.1,,46.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.18,95,,0.568,Percent of Total Billed Charges,95% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,88,,0.528,Percent of Total Billed Charges,88% of Total Billed Charges,5.85,90,,0.544,Percent of Total Billed charges,90% of Total Billed Charges,2.87,6.5,
REMDESIVIR 100MG INJ,2500001264,CDM,250,RC,,,Outpatient,100,GM,2054.00,1335.10,,2054,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1561.04,76,,341.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1478.88,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,1540.5,75,,46.312,Percent of Total Billed charges,75% of Total Billed Charges,2054,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1478.88,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,1232.4,60,,37.048,Percent of Total Billed Charges,60% of Total Billed Charges,1848.6,90,,114.48,Percent of Total Billed Charges,90% of Total Billed Charges,924.3,45,,189,Percent of Total Billed Charges,45% of Total Billed Charges,1848.6,90,,404.608,Percent of Total Billed Charges,90% of Total billed Charges,2054,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2054,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2054,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1335.1,65,,218.92,Percent of total Billed Charges,65% of Total Billed Charges,905.81,44.1,,185.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,1951.3,95,,427.088,Percent of Total Billed Charges,95% of Total Billed Charges,2054,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1807.52,88,,395.616,Percent of Total Billed Charges,88% of Total Billed Charges,1848.6,90,,404.608,Percent of Total Billed charges,90% of Total Billed Charges,905.81,2054,
STRESS WITH IRON TAB,2500001265,CDM,250,RC,,,Outpatient,,,6.50,4.23,,6.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.94,76,,255.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.68,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,4.88,75,,46.312,Percent of Total Billed charges,75% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.68,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,3.9,60,,37.048,Percent of Total Billed Charges,60% of Total Billed Charges,5.85,90,,81.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,41.76,Percent of Total Billed Charges,45% of Total Billed Charges,5.85,90,,303.12,Percent of Total Billed Charges,90% of Total billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,65,,69.16,Percent of total Billed Charges,65% of Total Billed Charges,2.87,44.1,,40.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.18,95,,319.96,Percent of Total Billed Charges,95% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,88,,296.384,Percent of Total Billed Charges,88% of Total Billed Charges,5.85,90,,303.12,Percent of Total Billed charges,90% of Total Billed Charges,2.87,6.5,
DIFICID 200MG TAB,2500001266,CDM,250,RC,,,Outpatient,200,GM,669.77,435.35,,669.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,509.03,76,,80.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,482.23,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,502.33,75,,46.968,Percent of Total Billed charges,75% of Total Billed Charges,669.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.23,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,401.86,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,602.79,90,,123.84,Percent of Total Billed Charges,90% of Total Billed Charges,301.4,45,,27.72,Percent of Total Billed Charges,45% of Total Billed Charges,602.79,90,,95.76,Percent of Total Billed Charges,90% of Total billed Charges,669.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,669.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,669.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.35,65,,273,Percent of total Billed Charges,65% of Total Billed Charges,295.37,44.1,,27.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,636.28,95,,101.08,Percent of Total Billed Charges,95% of Total Billed Charges,669.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,589.4,88,,93.632,Percent of Total Billed Charges,88% of Total Billed Charges,602.79,90,,95.76,Percent of Total Billed charges,90% of Total Billed Charges,295.37,669.77,
"HEPARIN/0.45% NS 25,000U/250ML",2500001267,CDM,250,RC,J1644,HCPCS,Outpatient,250,ML,47.00,30.55,,47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.72,76,,319.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.67,350,,88.904,Fee Schedule,350% of BCBS fee schedule,0.67,350,,92.608,Fee Schedule,350% of BCBS fee schedule,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.67,350,,88.904,Fee Schedule,350% of BCBS PPO fee schedule,0.19,100,,74.088,Fee Schedule,100% of Blue ADV HMO fee schedule,42.3,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,45,,123.84,Percent of Total Billed Charges,45% of Total Billed Charges,42.3,90,,378,Percent of Total Billed Charges,90% of Total billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.55,65,,60.32,Percent of total Billed Charges,65% of Total Billed Charges,20.73,44.1,,121.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.65,95,,399,Percent of Total Billed Charges,95% of Total Billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.36,88,,369.6,Percent of Total Billed Charges,88% of Total Billed Charges,42.3,90,,378,Percent of Total Billed charges,90% of Total Billed Charges,0.19,47,
ZENPEP 10000 UNITS CAP,2500001268,CDM,250,RC,,,Outpatient,,,12.32,8.01,,12.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.36,76,,70.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.87,72,,33.024,Percent of Total Billed Charges,72% of Total Billed Charges,9.24,75,,34.4,Percent of Total Billed charges,75% of Total Billed Charges,12.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.87,72,,33.024,Percent of Total Billed Charges,72% of Total Billed Charges,7.39,60,,27.52,Percent of Total Billed Charges,60% of Total Billed Charges,11.09,90,,27.784,Percent of Total Billed Charges,90% of Total Billed Charges,5.54,45,,92.52,Percent of Total Billed Charges,45% of Total Billed Charges,11.09,90,,83.52,Percent of Total Billed Charges,90% of Total billed Charges,12.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.01,65,,40.04,Percent of total Billed Charges,65% of Total Billed Charges,5.43,44.1,,90.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.7,95,,88.16,Percent of Total Billed Charges,95% of Total Billed Charges,12.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.84,88,,81.664,Percent of Total Billed Charges,88% of Total Billed Charges,11.09,90,,83.52,Percent of Total Billed charges,90% of Total Billed Charges,5.43,12.32,
FONDAPRINUX 2.5MG/0.5ML INJ,2500001269,CDM,250,RC,J1652,HCPCS,Outpatient,2.5,GM,142.20,92.43,,142.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,108.07,76,,46.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.25,350,,291.488,Fee Schedule,350% of BCBS fee schedule,7.25,350,,303.632,Fee Schedule,350% of BCBS fee schedule,142.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.25,350,,291.488,Fee Schedule,350% of BCBS PPO fee schedule,2.07,100,,242.904,Fee Schedule,100% of Blue ADV HMO fee schedule,127.98,90,,185.752,Percent of Total Billed Charges,90% of Total Billed Charges,63.99,45,,142.92,Percent of Total Billed Charges,45% of Total Billed Charges,127.98,90,,55.44,Percent of Total Billed Charges,90% of Total billed Charges,142.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.43,65,,178.88,Percent of total Billed Charges,65% of Total Billed Charges,62.71,44.1,,140.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,135.09,95,,58.52,Percent of Total Billed Charges,95% of Total Billed Charges,142.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.14,88,,54.208,Percent of Total Billed Charges,88% of Total Billed Charges,127.98,90,,55.44,Percent of Total Billed charges,90% of Total Billed Charges,2.07,142.2,
FONDAPRINUX 10MG/0.8MG INJ,2500001270,CDM,250,RC,J1652,HCPCS,Outpatient,10,GM,536.41,348.67,,536.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.67,76,,209.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.25,350,,257.192,Fee Schedule,350% of BCBS fee schedule,7.25,350,,267.904,Fee Schedule,350% of BCBS fee schedule,536.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.25,350,,257.192,Fee Schedule,350% of BCBS PPO fee schedule,2.07,100,,214.328,Fee Schedule,100% of Blue ADV HMO fee schedule,482.77,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,241.38,45,,57.24,Percent of Total Billed Charges,45% of Total Billed Charges,482.77,90,,247.68,Percent of Total Billed Charges,90% of Total billed Charges,536.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,536.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,536.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.67,65,,133.64,Percent of total Billed Charges,65% of Total Billed Charges,236.56,44.1,,56.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.59,95,,261.44,Percent of Total Billed Charges,95% of Total Billed Charges,536.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.04,88,,242.176,Percent of Total Billed Charges,88% of Total Billed Charges,482.77,90,,247.68,Percent of Total Billed charges,90% of Total Billed Charges,2.07,536.41,
HYDROCORTISONE 1% PACKETS,2500001271,CDM,250,RC,,,Outpatient,,,6.50,4.23,,6.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.94,76,,156.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.68,72,,39.376,Percent of Total Billed Charges,72% of Total Billed Charges,4.88,75,,41.016,Percent of Total Billed charges,75% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.68,72,,39.376,Percent of Total Billed Charges,72% of Total Billed Charges,3.9,60,,32.816,Percent of Total Billed Charges,60% of Total Billed Charges,5.85,90,,55.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,40.68,Percent of Total Billed Charges,45% of Total Billed Charges,5.85,90,,185.04,Percent of Total Billed Charges,90% of Total billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,65,,206.44,Percent of total Billed Charges,65% of Total Billed Charges,2.87,44.1,,39.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.18,95,,195.32,Percent of Total Billed Charges,95% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,88,,180.928,Percent of Total Billed Charges,88% of Total Billed Charges,5.85,90,,185.04,Percent of Total Billed charges,90% of Total Billed Charges,2.87,6.5,
Misoprostol  25 mcg,2500001276,CDM,250,RC,,,Outpatient,25,GM,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,104.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.88,72,,38.736,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,75,,40.352,Percent of Total Billed charges,75% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.88,72,,38.736,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,60,,32.28,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,90,,79.36,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,92.88,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,123.84,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,91.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,130.72,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,121.088,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,123.84,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.05,
Cyanokit 5gm,2500001277,CDM,250,RC,,,Outpatient,5,gm,8246.90,5360.49,,8246.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6267.64,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5937.77,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,6185.18,75,,46.968,Percent of Total Billed charges,75% of Total Billed Charges,8246.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5937.77,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,4948.14,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,7422.21,90,,55.44,Percent of Total Billed Charges,90% of Total Billed Charges,3711.11,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,7422.21,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,8246.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8246.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8246.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5360.49,65,,20.064,Percent of total Billed Charges,65% of Total Billed Charges,3636.88,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,7834.56,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,8246.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7257.27,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,7422.21,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,3636.88,8246.9,
Dermoplast First Aid Spray,2500001278,CDM,250,RC,,,Outpatient,,,120.50,78.33,,120.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,91.58,76,,23.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,86.76,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,90.38,75,,46.968,Percent of Total Billed charges,75% of Total Billed Charges,120.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.76,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,72.3,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,108.45,90,,86.4,Percent of Total Billed Charges,90% of Total Billed Charges,54.23,45,,27.72,Percent of Total Billed Charges,45% of Total Billed Charges,108.45,90,,27.784,Percent of Total Billed Charges,90% of Total billed Charges,120.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.33,65,,134.152,Percent of total Billed Charges,65% of Total Billed Charges,53.14,44.1,,27.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,114.48,95,,29.328,Percent of Total Billed Charges,95% of Total Billed Charges,120.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.04,88,,27.168,Percent of Total Billed Charges,88% of Total Billed Charges,108.45,90,,27.784,Percent of Total Billed charges,90% of Total Billed Charges,53.14,120.5,
Solarcaine Spray 127gm,2500001279,CDM,250,RC,,,Outpatient,127,gm,57.50,37.38,,57.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.7,76,,156.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.4,72,,102.24,Percent of Total Billed Charges,72% of Total Billed Charges,43.13,75,,106.504,Percent of Total Billed charges,75% of Total Billed Charges,57.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.4,72,,102.24,Percent of Total Billed Charges,72% of Total Billed Charges,34.5,60,,85.2,Percent of Total Billed Charges,60% of Total Billed Charges,51.75,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,25.88,45,,158.752,Percent of Total Billed Charges,45% of Total Billed Charges,51.75,90,,185.752,Percent of Total Billed Charges,90% of Total billed Charges,57.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.38,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,25.36,44.1,,155.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.63,95,,196.072,Percent of Total Billed Charges,95% of Total Billed Charges,57.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.6,88,,181.624,Percent of Total Billed Charges,88% of Total Billed Charges,51.75,90,,185.752,Percent of Total Billed charges,90% of Total Billed Charges,25.36,57.5,
Duraclon 1000mcg/10ml vial,2500001280,CDM,250,RC,J0735,HCPCS,Outpatient,1000,GM,521.40,338.91,,521.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,396.26,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,48.72,350,,45.088,Fee Schedule,350% of BCBS fee schedule,48.72,350,,46.968,Fee Schedule,350% of BCBS fee schedule,521.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.72,350,,45.088,Fee Schedule,350% of BCBS PPO fee schedule,13.92,100,,37.576,Fee Schedule,100% of Blue ADV HMO fee schedule,469.26,90,,86.4,Percent of Total Billed Charges,90% of Total Billed Charges,234.63,45,,32.944,Percent of Total Billed Charges,45% of Total Billed Charges,469.26,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,521.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,338.91,65,,40.04,Percent of total Billed Charges,65% of Total Billed Charges,229.94,44.1,,32.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,495.33,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,521.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,458.83,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,469.26,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,13.92,521.4,
Fosfomycin 3gm Powder,2500001282,CDM,250,RC,,,Outpatient,3,gm,200.78,130.51,,200.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152.59,76,,268.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144.56,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,150.59,75,,16.536,Percent of Total Billed charges,75% of Total Billed Charges,200.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.56,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,120.47,60,,13.232,Percent of Total Billed Charges,60% of Total Billed Charges,180.7,90,,36,Percent of Total Billed Charges,90% of Total Billed Charges,90.35,45,,39.68,Percent of Total Billed Charges,45% of Total Billed Charges,180.7,90,,317.504,Percent of Total Billed Charges,90% of Total billed Charges,200.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.51,65,,47.584,Percent of total Billed Charges,65% of Total Billed Charges,88.54,44.1,,38.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,190.74,95,,335.144,Percent of Total Billed Charges,95% of Total Billed Charges,200.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.69,88,,310.448,Percent of Total Billed Charges,88% of Total Billed Charges,180.7,90,,317.504,Percent of Total Billed charges,90% of Total Billed Charges,88.54,200.78,
Fluvoxamine 100mg tab,2500001284,CDM,250,RC,,,Outpatient,100,GM,23.03,14.97,,23.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.5,76,,268.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.58,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,17.27,75,,29.104,Percent of Total Billed charges,75% of Total Billed Charges,23.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.58,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,13.82,60,,23.288,Percent of Total Billed Charges,60% of Total Billed Charges,20.73,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,10.36,45,,43.2,Percent of Total Billed Charges,45% of Total Billed Charges,20.73,90,,317.56,Percent of Total Billed Charges,90% of Total billed Charges,23.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.97,65,,57.312,Percent of total Billed Charges,65% of Total Billed Charges,10.16,44.1,,42.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.88,95,,335.2,Percent of Total Billed Charges,95% of Total Billed Charges,23.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.27,88,,310.496,Percent of Total Billed Charges,88% of Total Billed Charges,20.73,90,,317.56,Percent of Total Billed charges,90% of Total Billed Charges,10.16,23.03,
Baricitinib 2mg tab,2500001285,CDM,250,RC,,,Outpatient,2,GM,198.15,128.80,,198.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,150.59,76,,67.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,142.67,72,,221.624,Percent of Total Billed Charges,72% of Total Billed Charges,148.61,75,,230.864,Percent of Total Billed charges,75% of Total Billed Charges,198.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.67,72,,221.624,Percent of Total Billed Charges,72% of Total Billed Charges,118.89,60,,184.688,Percent of Total Billed Charges,60% of Total Billed Charges,178.34,90,,28.048,Percent of Total Billed Charges,90% of Total Billed Charges,89.17,45,,45,Percent of Total Billed Charges,45% of Total Billed Charges,178.34,90,,79.36,Percent of Total Billed Charges,90% of Total billed Charges,198.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.8,65,,40.04,Percent of total Billed Charges,65% of Total Billed Charges,87.38,44.1,,44.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,188.24,95,,83.768,Percent of Total Billed Charges,95% of Total Billed Charges,198.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.37,88,,77.592,Percent of Total Billed Charges,88% of Total Billed Charges,178.34,90,,79.36,Percent of Total Billed charges,90% of Total Billed Charges,87.38,198.15,
Refresh Plus 0.5% 0.4ml Ophth,2500001286,CDM,250,RC,,,Outpatient,0.4,ML,16.25,10.56,,16.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.35,76,,46.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.7,72,,219.728,Percent of Total Billed Charges,72% of Total Billed Charges,12.19,75,,228.88,Percent of Total Billed charges,75% of Total Billed Charges,16.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.7,72,,219.728,Percent of Total Billed Charges,72% of Total Billed Charges,9.75,60,,183.104,Percent of Total Billed Charges,60% of Total Billed Charges,14.63,90,,18.256,Percent of Total Billed Charges,90% of Total Billed Charges,7.31,45,,43.2,Percent of Total Billed Charges,45% of Total Billed Charges,14.63,90,,55.44,Percent of Total Billed Charges,90% of Total billed Charges,16.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,65,,62.4,Percent of total Billed Charges,65% of Total Billed Charges,7.17,44.1,,42.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.44,95,,58.52,Percent of Total Billed Charges,95% of Total Billed Charges,16.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.3,88,,54.208,Percent of Total Billed Charges,88% of Total Billed Charges,14.63,90,,55.44,Percent of Total Billed charges,90% of Total Billed Charges,7.17,16.25,
Norepinephrine IN D5W 8mg/250m,2500001287,CDM,250,RC,,,Outpatient,8,GM,332.00,215.80,,332,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,252.32,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,239.04,72,,216.544,Percent of Total Billed Charges,72% of Total Billed Charges,249,75,,225.568,Percent of Total Billed charges,75% of Total Billed Charges,332,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.04,72,,216.544,Percent of Total Billed Charges,72% of Total Billed Charges,199.2,60,,180.456,Percent of Total Billed Charges,60% of Total Billed Charges,298.8,90,,84.048,Percent of Total Billed Charges,90% of Total Billed Charges,149.4,45,,1930.92,Percent of Total Billed Charges,45% of Total Billed Charges,298.8,90,,86.4,Percent of Total Billed Charges,90% of Total billed Charges,332,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.8,65,,65,Percent of total Billed Charges,65% of Total Billed Charges,146.41,44.1,,1892.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,315.4,95,,91.2,Percent of Total Billed Charges,95% of Total Billed Charges,332,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.16,88,,84.48,Percent of Total Billed Charges,88% of Total Billed Charges,298.8,90,,86.4,Percent of Total Billed charges,90% of Total Billed Charges,146.41,332,
SIMETH,2500001288,CDM,250,RC,,,Outpatient,,,16.25,10.56,,16.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.35,76,,76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.7,72,,243.224,Percent of Total Billed Charges,72% of Total Billed Charges,12.19,75,,253.36,Percent of Total Billed charges,75% of Total Billed Charges,16.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.7,72,,243.224,Percent of Total Billed Charges,72% of Total Billed Charges,9.75,60,,202.688,Percent of Total Billed Charges,60% of Total Billed Charges,14.63,90,,84.016,Percent of Total Billed Charges,90% of Total Billed Charges,7.31,45,,18,Percent of Total Billed Charges,45% of Total Billed Charges,14.63,90,,90,Percent of Total Billed Charges,90% of Total billed Charges,16.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,65,,62.4,Percent of total Billed Charges,65% of Total Billed Charges,7.17,44.1,,17.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.44,95,,95,Percent of Total Billed Charges,95% of Total Billed Charges,16.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.3,88,,88,Percent of Total Billed Charges,88% of Total Billed Charges,14.63,90,,90,Percent of Total Billed charges,90% of Total Billed Charges,7.17,16.25,
Albuterol/ipratropium 0.5mg/3m,2500001290,CDM,250,RC,,,Outpatient,0.5,GM,8.28,5.38,,8.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.29,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.96,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,6.21,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,8.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.96,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,7.45,90,,19.84,Percent of Total Billed Charges,90% of Total Billed Charges,3.73,45,,45.248,Percent of Total Billed Charges,45% of Total Billed Charges,7.45,90,,86.4,Percent of Total Billed Charges,90% of Total billed Charges,8.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.38,65,,2789.104,Percent of total Billed Charges,65% of Total Billed Charges,3.65,44.1,,44.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.87,95,,91.2,Percent of Total Billed Charges,95% of Total Billed Charges,8.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.29,88,,84.48,Percent of Total Billed Charges,88% of Total Billed Charges,7.45,90,,86.4,Percent of Total Billed charges,90% of Total Billed Charges,3.65,8.28,
Lidocaine 2% 11ml Jelly,2500001292,CDM,250,RC,,,Outpatient,11,ML,11.13,7.23,,11.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.46,76,,3261.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.01,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,8.35,75,,27.12,Percent of Total Billed charges,75% of Total Billed Charges,11.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.01,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,6.68,60,,21.696,Percent of Total Billed Charges,60% of Total Billed Charges,10.02,90,,166.704,Percent of Total Billed Charges,90% of Total Billed Charges,5.01,45,,36,Percent of Total Billed Charges,45% of Total Billed Charges,10.02,90,,3861.832,Percent of Total Billed Charges,90% of Total billed Charges,11.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.23,65,,26,Percent of total Billed Charges,65% of Total Billed Charges,4.91,44.1,,35.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.57,95,,4076.384,Percent of Total Billed Charges,95% of Total Billed Charges,11.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.79,88,,3776.016,Percent of Total Billed Charges,88% of Total Billed Charges,10.02,90,,3861.832,Percent of Total Billed charges,90% of Total Billed Charges,4.91,11.13,
Sutab 1.479-0.225-0.188gm Tab,2500001293,CDM,250,RC,,,Outpatient,0.188,gm,15.63,10.16,,15.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.88,76,,30.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.25,72,,29.848,Percent of Total Billed Charges,72% of Total Billed Charges,11.72,75,,31.096,Percent of Total Billed charges,75% of Total Billed Charges,15.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.25,72,,29.848,Percent of Total Billed Charges,72% of Total Billed Charges,9.38,60,,24.872,Percent of Total Billed Charges,60% of Total Billed Charges,14.07,90,,673.144,Percent of Total Billed Charges,90% of Total Billed Charges,7.03,45,,14.024,Percent of Total Billed Charges,45% of Total Billed Charges,14.07,90,,36,Percent of Total Billed Charges,90% of Total billed Charges,15.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.16,65,,65.36,Percent of total Billed Charges,65% of Total Billed Charges,6.89,44.1,,13.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.85,95,,38,Percent of Total Billed Charges,95% of Total Billed Charges,15.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.75,88,,35.2,Percent of Total Billed Charges,88% of Total Billed Charges,14.07,90,,36,Percent of Total Billed charges,90% of Total Billed Charges,6.89,15.63,
Aprepitant 40mg caps,2500001294,CDM,636,RC,J8501,HCPCS,Outpatient,40,GM,132.45,86.09,,132.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.66,76,,76.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.48,350,,23.496,Fee Schedule,350% of BCBS fee schedule,25.48,350,,24.472,Fee Schedule,350% of BCBS fee schedule,132.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.48,350,,23.496,Fee Schedule,350% of BCBS PPO fee schedule,7.28,100,,19.576,Fee Schedule,100% of Blue ADV HMO fee schedule,119.21,90,,159.552,Percent of Total Billed Charges,90% of Total Billed Charges,59.6,45,,9.128,Percent of Total Billed Charges,45% of Total Billed Charges,119.21,90,,90.496,Percent of Total Billed Charges,90% of Total billed Charges,132.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.09,65,,52,Percent of total Billed Charges,65% of Total Billed Charges,58.41,44.1,,8.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.83,95,,95.528,Percent of Total Billed Charges,95% of Total Billed Charges,132.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.56,88,,88.488,Percent of Total Billed Charges,88% of Total Billed Charges,119.21,90,,90.496,Percent of Total Billed charges,90% of Total Billed Charges,7.28,132.45,
Exparel 13.3mg/ml inj,2500001295,CDM,250,RC,J0666,HCPCS,Outpatient,13.3,GM,497.10,323.12,,1.82,125,,,Fee Schedule,125% of CMS OPPS Rate,377.8,76,,60.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.91,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,372.83,75,,17.864,Percent of Total Billed charges,75% of Total Billed Charges,1.45,100,,,Fee Schedule,100% of CMS OPPS Rate,357.91,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,298.26,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,447.39,90,,68.024,Percent of Total Billed Charges,90% of Total Billed Charges,223.7,45,,42.024,Percent of Total Billed Charges,45% of Total Billed Charges,447.39,90,,72,Percent of Total Billed Charges,90% of Total billed Charges,1.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2.72,200,,20.256,Fee Schedule,200% of CMS OPPS Rate,219.22,44.1,,41.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.25,95,,76,Percent of Total Billed Charges,95% of Total Billed Charges,1.08,75,,,Fee Schedule,75% of CMS OPPS Rate,437.45,88,,70.4,Percent of Total Billed Charges,88% of Total Billed Charges,447.39,90,,72,Percent of Total Billed charges,90% of Total Billed Charges,1.08,472.25,
Tikosyn (Dofetilide) Capsule,2500001299,CDM,250,RC,,,Outpatient,,,12.90,8.39,,12.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.8,76,,70.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.29,72,,11.472,Percent of Total Billed Charges,72% of Total Billed Charges,9.68,75,,11.944,Percent of Total Billed charges,75% of Total Billed Charges,12.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.29,72,,11.472,Percent of Total Billed Charges,72% of Total Billed Charges,7.74,60,,9.56,Percent of Total Billed Charges,60% of Total Billed Charges,11.61,90,,100.904,Percent of Total Billed Charges,90% of Total Billed Charges,5.81,45,,336.568,Percent of Total Billed Charges,45% of Total Billed Charges,11.61,90,,84.016,Percent of Total Billed Charges,90% of Total billed Charges,12.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.39,65,,120.392,Percent of total Billed Charges,65% of Total Billed Charges,5.69,44.1,,329.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.26,95,,88.688,Percent of Total Billed Charges,95% of Total Billed Charges,12.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.35,88,,82.152,Percent of Total Billed Charges,88% of Total Billed Charges,11.61,90,,84.016,Percent of Total Billed charges,90% of Total Billed Charges,5.69,12.9,
Jardiance 10mg tab,2500001300,CDM,250,RC,,,Outpatient,10,GM,795.05,516.78,,795.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,604.24,76,,16.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,572.44,72,,10.304,Percent of Total Billed Charges,72% of Total Billed Charges,596.29,75,,10.736,Percent of Total Billed charges,75% of Total Billed Charges,795.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,572.44,72,,10.304,Percent of Total Billed Charges,72% of Total Billed Charges,477.03,60,,8.584,Percent of Total Billed Charges,60% of Total Billed Charges,715.55,90,,3.56,Percent of Total Billed Charges,90% of Total Billed Charges,357.77,45,,79.776,Percent of Total Billed Charges,45% of Total Billed Charges,715.55,90,,19.84,Percent of Total Billed Charges,90% of Total billed Charges,795.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,795.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,795.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,516.78,65,,486.16,Percent of total Billed Charges,65% of Total Billed Charges,350.62,44.1,,78.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,755.3,95,,20.944,Percent of Total Billed Charges,95% of Total Billed Charges,795.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,699.64,88,,19.4,Percent of Total Billed Charges,88% of Total Billed Charges,715.55,90,,19.84,Percent of Total Billed charges,90% of Total Billed Charges,350.62,795.05,
Flavoxate  100mg tab,2500001301,CDM,250,RC,,,Outpatient,100,GM,0.57,0.37,,0.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.43,76,,140.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.41,72,,3.024,Percent of Total Billed Charges,72% of Total Billed Charges,0.43,75,,3.152,Percent of Total Billed charges,75% of Total Billed Charges,0.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.41,72,,3.024,Percent of Total Billed Charges,72% of Total Billed Charges,0.34,60,,2.52,Percent of Total Billed Charges,60% of Total Billed Charges,0.51,90,,647.744,Percent of Total Billed Charges,90% of Total Billed Charges,0.26,45,,34.016,Percent of Total Billed Charges,45% of Total Billed Charges,0.51,90,,166.704,Percent of Total Billed Charges,90% of Total billed Charges,0.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.37,65,,115.232,Percent of total Billed Charges,65% of Total Billed Charges,0.25,44.1,,33.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.54,95,,175.96,Percent of Total Billed Charges,95% of Total Billed Charges,0.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.5,88,,163,Percent of Total Billed Charges,88% of Total Billed Charges,0.51,90,,166.704,Percent of Total Billed charges,90% of Total Billed Charges,0.25,0.57,
Bludigo 40mg/5ml inj,2500001302,CDM,250,RC,,,Outpatient,40,GM,4669.27,3035.03,,4669.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3548.65,76,,568.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3361.87,72,,8.816,Percent of Total Billed Charges,72% of Total Billed Charges,3501.95,75,,9.184,Percent of Total Billed charges,75% of Total Billed Charges,4669.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3361.87,72,,8.816,Percent of Total Billed Charges,72% of Total Billed Charges,2801.56,60,,7.352,Percent of Total Billed Charges,60% of Total Billed Charges,4202.34,90,,110.344,Percent of Total Billed Charges,90% of Total Billed Charges,2101.17,45,,50.448,Percent of Total Billed Charges,45% of Total Billed Charges,4202.34,90,,673.144,Percent of Total Billed Charges,90% of Total billed Charges,4669.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4669.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4669.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3035.03,65,,49.128,Percent of total Billed Charges,65% of Total Billed Charges,2059.15,44.1,,49.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,4435.81,95,,710.536,Percent of Total Billed Charges,95% of Total Billed Charges,4669.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4108.96,88,,658.184,Percent of Total Billed Charges,88% of Total Billed Charges,4202.34,90,,673.144,Percent of Total Billed charges,90% of Total Billed Charges,2059.15,4669.27,
Emla 2.5% (30g) cream,2500001303,CDM,250,RC,,,Outpatient,,,31.87,20.72,,31.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.22,76,,134.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.95,72,,8.168,Percent of Total Billed Charges,72% of Total Billed Charges,23.9,75,,8.512,Percent of Total Billed charges,75% of Total Billed Charges,31.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.95,72,,8.168,Percent of Total Billed Charges,72% of Total Billed Charges,19.12,60,,6.808,Percent of Total Billed Charges,60% of Total Billed Charges,28.68,90,,42.872,Percent of Total Billed Charges,90% of Total Billed Charges,14.34,45,,34.016,Percent of Total Billed Charges,45% of Total Billed Charges,28.68,90,,159.552,Percent of Total Billed Charges,90% of Total billed Charges,31.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.72,65,,72.872,Percent of total Billed Charges,65% of Total Billed Charges,14.05,44.1,,33.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.28,95,,168.416,Percent of Total Billed Charges,95% of Total Billed Charges,31.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.05,88,,156.008,Percent of Total Billed Charges,88% of Total Billed Charges,28.68,90,,159.552,Percent of Total Billed charges,90% of Total Billed Charges,14.05,31.87,
Hylenex 150u/ml inj,2500001304,CDM,250,RC,J3473,HCPCS,Outpatient,1,ML,374.00,243.10,,374,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.24,76,,57.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.3,350,,17.224,Fee Schedule,350% of BCBS fee schedule,1.3,350,,17.944,Fee Schedule,350% of BCBS fee schedule,374,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,350,,17.224,Fee Schedule,350% of BCBS PPO fee schedule,0.37,100,,14.352,Fee Schedule,100% of Blue ADV HMO fee schedule,336.6,90,,1397.088,Percent of Total Billed Charges,90% of Total Billed Charges,168.3,45,,13.096,Percent of Total Billed Charges,45% of Total Billed Charges,336.6,90,,68.024,Percent of Total Billed Charges,90% of Total billed Charges,374,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.1,65,,49.128,Percent of total Billed Charges,65% of Total Billed Charges,164.93,44.1,,12.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,355.3,95,,71.808,Percent of Total Billed Charges,95% of Total Billed Charges,374,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.12,88,,66.512,Percent of Total Billed Charges,88% of Total Billed Charges,336.6,90,,68.024,Percent of Total Billed charges,90% of Total Billed Charges,0.37,374,
Epinephrine 1mg/ml amp INH,2500001305,CDM,250,RC,,,Outpatient,1,GM,21.17,13.76,,21.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.09,76,,85.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.24,72,,6.656,Percent of Total Billed Charges,72% of Total Billed Charges,15.88,75,,6.928,Percent of Total Billed charges,75% of Total Billed Charges,21.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.24,72,,6.656,Percent of Total Billed Charges,72% of Total Billed Charges,12.7,60,,5.544,Percent of Total Billed Charges,60% of Total Billed Charges,19.05,90,,54.768,Percent of Total Billed Charges,90% of Total Billed Charges,9.53,45,,50.448,Percent of Total Billed Charges,45% of Total Billed Charges,19.05,90,,100.904,Percent of Total Billed Charges,90% of Total billed Charges,21.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.76,65,,18.92,Percent of total Billed Charges,65% of Total Billed Charges,9.34,44.1,,49.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.11,95,,106.504,Percent of Total Billed Charges,95% of Total Billed Charges,21.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.63,88,,98.656,Percent of Total Billed Charges,88% of Total Billed Charges,19.05,90,,100.904,Percent of Total Billed charges,90% of Total Billed Charges,9.34,21.17,
Acetylcysteine 20% 2000mg/10ml,2500001306,CDM,250,RC,J7608,HCPCS,Outpatient,2000,GM,14.68,9.54,,14.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.16,76,,57.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.7,350,,22.64,Fee Schedule,350% of BCBS fee schedule,14.7,350,,23.584,Fee Schedule,350% of BCBS fee schedule,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.7,350,,22.64,Fee Schedule,350% of BCBS PPO fee schedule,4.2,100,,18.872,Fee Schedule,100% of Blue ADV HMO fee schedule,13.21,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,6.61,45,,1.776,Percent of Total Billed Charges,45% of Total Billed Charges,13.21,90,,68.024,Percent of Total Billed Charges,90% of Total billed Charges,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.54,65,,72.872,Percent of total Billed Charges,65% of Total Billed Charges,6.47,44.1,,1.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.95,95,,71.808,Percent of Total Billed Charges,95% of Total Billed Charges,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.92,88,,66.512,Percent of Total Billed Charges,88% of Total Billed Charges,13.21,90,,68.024,Percent of Total Billed charges,90% of Total Billed Charges,4.2,14.7,
Acetylcysteine 10% 1000mg/10ml,2500001307,CDM,250,RC,J7608,HCPCS,Outpatient,1000,GM,14.38,9.35,,14.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.93,76,,22.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.7,350,,7.912,Fee Schedule,350% of BCBS fee schedule,14.7,350,,8.248,Fee Schedule,350% of BCBS fee schedule,14.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.7,350,,7.912,Fee Schedule,350% of BCBS PPO fee schedule,4.2,100,,6.592,Fee Schedule,100% of Blue ADV HMO fee schedule,12.94,90,,1343.112,Percent of Total Billed Charges,90% of Total Billed Charges,6.47,45,,323.872,Percent of Total Billed Charges,45% of Total Billed Charges,12.94,90,,26.192,Percent of Total Billed Charges,90% of Total billed Charges,14.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.35,65,,2.568,Percent of total Billed Charges,65% of Total Billed Charges,6.34,44.1,,317.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.66,95,,27.648,Percent of Total Billed Charges,95% of Total Billed Charges,14.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.65,88,,25.608,Percent of Total Billed Charges,88% of Total Billed Charges,12.94,90,,26.192,Percent of Total Billed charges,90% of Total Billed Charges,4.2,14.7,
Empagliflozin 25mg Tab,2500001308,CDM,250,RC,,,Outpatient,25,GM,1083.35,704.18,,1083.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,823.35,76,,85.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,780.01,72,,2.088,Percent of Total Billed Charges,72% of Total Billed Charges,812.51,75,,2.176,Percent of Total Billed charges,75% of Total Billed Charges,1083.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.01,72,,2.088,Percent of Total Billed Charges,72% of Total Billed Charges,650.01,60,,1.736,Percent of Total Billed Charges,60% of Total Billed Charges,975.02,90,,16.672,Percent of Total Billed Charges,90% of Total Billed Charges,487.51,45,,55.168,Percent of Total Billed Charges,45% of Total Billed Charges,975.02,90,,100.904,Percent of Total Billed Charges,90% of Total billed Charges,1083.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1083.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1083.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704.18,65,,467.816,Percent of total Billed Charges,65% of Total Billed Charges,477.76,44.1,,54.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,1029.18,95,,106.504,Percent of Total Billed Charges,95% of Total Billed Charges,1083.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,953.35,88,,98.656,Percent of Total Billed Charges,88% of Total Billed Charges,975.02,90,,100.904,Percent of Total Billed charges,90% of Total Billed Charges,477.76,1083.35,
Phenol EZ Swab 89%,2500001309,CDM,250,RC,,,Outpatient,,,443.45,288.24,,443.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,337.02,76,,3,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,319.28,72,,1.832,Percent of Total Billed Charges,72% of Total Billed Charges,332.59,75,,1.912,Percent of Total Billed charges,75% of Total Billed Charges,443.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319.28,72,,1.832,Percent of Total Billed Charges,72% of Total Billed Charges,266.07,60,,1.528,Percent of Total Billed Charges,60% of Total Billed Charges,399.11,90,,47.632,Percent of Total Billed Charges,90% of Total Billed Charges,199.55,45,,21.432,Percent of Total Billed Charges,45% of Total Billed Charges,399.11,90,,3.56,Percent of Total Billed Charges,90% of Total billed Charges,443.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,443.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,443.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.24,65,,79.688,Percent of total Billed Charges,65% of Total Billed Charges,195.56,44.1,,21.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,421.28,95,,3.752,Percent of Total Billed Charges,95% of Total Billed Charges,443.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.24,88,,3.48,Percent of Total Billed Charges,88% of Total Billed Charges,399.11,90,,3.56,Percent of Total Billed charges,90% of Total Billed Charges,195.56,443.45,
Malarone 250mg/100mg Tab,2500001310,CDM,250,RC,,,Outpatient,250,GM,250.20,162.63,,250.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,190.15,76,,546.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,180.14,72,,1.832,Percent of Total Billed Charges,72% of Total Billed Charges,187.65,75,,1.912,Percent of Total Billed charges,75% of Total Billed Charges,250.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.14,72,,1.832,Percent of Total Billed Charges,72% of Total Billed Charges,150.12,60,,1.528,Percent of Total Billed Charges,60% of Total Billed Charges,225.18,90,,38.104,Percent of Total Billed Charges,90% of Total Billed Charges,112.59,45,,698.544,Percent of Total Billed Charges,45% of Total Billed Charges,225.18,90,,647.744,Percent of Total Billed Charges,90% of Total billed Charges,250.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.63,65,,30.96,Percent of total Billed Charges,65% of Total Billed Charges,110.34,44.1,,684.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,237.69,95,,683.728,Percent of Total Billed Charges,95% of Total Billed Charges,250.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.18,88,,633.344,Percent of Total Billed Charges,88% of Total Billed Charges,225.18,90,,647.744,Percent of Total Billed charges,90% of Total Billed Charges,110.34,250.2,
Coartem 20mg/120mg Tab,2500001311,CDM,250,RC,,,Outpatient,20,GM,315.50,205.08,,315.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,239.78,76,,93.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,227.16,72,,1.832,Percent of Total Billed Charges,72% of Total Billed Charges,236.63,75,,1.912,Percent of Total Billed charges,75% of Total Billed Charges,315.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.16,72,,1.832,Percent of Total Billed Charges,72% of Total Billed Charges,189.3,60,,1.528,Percent of Total Billed Charges,60% of Total Billed Charges,283.95,90,,361.976,Percent of Total Billed Charges,90% of Total Billed Charges,141.98,45,,27.384,Percent of Total Billed Charges,45% of Total Billed Charges,283.95,90,,110.344,Percent of Total Billed Charges,90% of Total billed Charges,315.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.08,65,,1009.008,Percent of total Billed Charges,65% of Total Billed Charges,139.14,44.1,,26.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,299.73,95,,116.472,Percent of Total Billed Charges,95% of Total Billed Charges,315.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.64,88,,107.888,Percent of Total Billed Charges,88% of Total Billed Charges,283.95,90,,110.344,Percent of Total Billed charges,90% of Total Billed Charges,139.14,315.5,
Amvisc Plus 0.8ml,2500001312,CDM,250,RC,,,Outpatient,0.8,ML,137.50,89.38,,137.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,104.5,76,,36.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,99,72,,8.12,Percent of Total Billed Charges,72% of Total Billed Charges,103.13,75,,8.464,Percent of Total Billed charges,75% of Total Billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,72,,8.12,Percent of Total Billed Charges,72% of Total Billed Charges,82.5,60,,6.768,Percent of Total Billed Charges,60% of Total Billed Charges,123.75,90,,686.632,Percent of Total Billed Charges,90% of Total Billed Charges,61.88,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,123.75,90,,42.872,Percent of Total Billed Charges,90% of Total billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.38,65,,39.56,Percent of total Billed Charges,65% of Total Billed Charges,60.64,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,130.63,95,,45.248,Percent of Total Billed Charges,95% of Total Billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121,88,,41.92,Percent of Total Billed Charges,88% of Total Billed Charges,123.75,90,,42.872,Percent of Total Billed charges,90% of Total Billed Charges,60.64,137.5,
Artesunate 110mg inj,2500001313,CDM,250,RC,J3490,HCPCS,Outpatient,110,GM,24837.75,16144.54,,24837.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18876.69,76,,1179.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17883.18,72,,17.856,Percent of Total Billed Charges,72% of Total Billed Charges,18628.31,75,,18.6,Percent of Total Billed charges,75% of Total Billed Charges,24837.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17883.18,72,,17.856,Percent of Total Billed Charges,72% of Total Billed Charges,14902.65,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,22353.98,90,,3133.92,Percent of Total Billed Charges,90% of Total Billed Charges,11176.99,45,,671.552,Percent of Total Billed Charges,45% of Total Billed Charges,22353.98,90,,1397.088,Percent of Total Billed Charges,90% of Total billed Charges,24837.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24837.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24837.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16144.54,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,10953.45,44.1,,658.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,23595.86,95,,1474.704,Percent of Total Billed Charges,95% of Total Billed Charges,24837.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21857.22,88,,1366.04,Percent of Total Billed Charges,88% of Total Billed Charges,22353.98,90,,1397.088,Percent of Total Billed charges,90% of Total Billed Charges,10953.45,24837.75,
Malarone 62.5MG/25MG Tab,2500001314,CDM,250,RC,,,Outpatient,62.5,GM,491.93,319.75,,491.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,373.87,76,,46.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,354.19,72,,17.856,Percent of Total Billed Charges,72% of Total Billed Charges,368.95,75,,18.6,Percent of Total Billed charges,75% of Total Billed Charges,491.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.19,72,,17.856,Percent of Total Billed Charges,72% of Total Billed Charges,295.16,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,442.74,90,,3173.616,Percent of Total Billed Charges,90% of Total Billed Charges,221.37,45,,8.336,Percent of Total Billed Charges,45% of Total Billed Charges,442.74,90,,54.768,Percent of Total Billed Charges,90% of Total billed Charges,491.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319.75,65,,970.024,Percent of total Billed Charges,65% of Total Billed Charges,216.94,44.1,,8.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,467.33,95,,57.816,Percent of Total Billed Charges,95% of Total Billed Charges,491.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,432.9,88,,53.552,Percent of Total Billed Charges,88% of Total Billed Charges,442.74,90,,54.768,Percent of Total Billed charges,90% of Total Billed Charges,216.94,491.93,
Arexvy 0.5ml,2500001315,CDM,250,RC,,,Outpatient,0.5,ML,6450.45,4192.79,,6450.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4902.34,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4644.32,72,,221.624,Percent of Total Billed Charges,72% of Total Billed Charges,4837.84,75,,230.864,Percent of Total Billed charges,75% of Total Billed Charges,6450.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4644.32,72,,221.624,Percent of Total Billed Charges,72% of Total Billed Charges,3870.27,60,,184.688,Percent of Total Billed Charges,60% of Total Billed Charges,5805.41,90,,21843.792,Percent of Total Billed Charges,90% of Total Billed Charges,2902.7,45,,23.816,Percent of Total Billed Charges,45% of Total Billed Charges,5805.41,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,6450.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6450.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6450.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4192.79,65,,12.04,Percent of total Billed Charges,65% of Total Billed Charges,2844.65,44.1,,23.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,6127.93,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,6450.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5676.4,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,5805.41,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,2844.65,6450.45,
Beyfortus 50mg/0.5ml inj,2500001316,CDM,250,RC,,,Outpatient,50,GM,1299.38,844.60,,1299.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,987.53,76,,1134.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,935.55,72,,11.52,Percent of Total Billed Charges,72% of Total Billed Charges,974.54,75,,12,Percent of Total Billed charges,75% of Total Billed Charges,1299.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,935.55,72,,11.52,Percent of Total Billed Charges,72% of Total Billed Charges,779.63,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,1169.44,90,,1905.912,Percent of Total Billed Charges,90% of Total Billed Charges,584.72,45,,19.048,Percent of Total Billed Charges,45% of Total Billed Charges,1169.44,90,,1343.112,Percent of Total Billed Charges,90% of Total billed Charges,1299.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1299.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1299.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,844.6,65,,34.4,Percent of total Billed Charges,65% of Total Billed Charges,573.03,44.1,,18.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,1234.41,95,,1417.728,Percent of Total Billed Charges,95% of Total Billed Charges,1299.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1143.45,88,,1313.264,Percent of Total Billed Charges,88% of Total Billed Charges,1169.44,90,,1343.112,Percent of Total Billed charges,90% of Total Billed Charges,573.03,1299.38,
Phenylephrine 10% (5ml),2500001318,CDM,250,RC,,,Outpatient,5,ML,78.85,51.25,,78.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.93,76,,14.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.77,72,,11.52,Percent of Total Billed Charges,72% of Total Billed Charges,59.14,75,,12,Percent of Total Billed charges,75% of Total Billed Charges,78.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.77,72,,11.52,Percent of Total Billed Charges,72% of Total Billed Charges,47.31,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,70.97,90,,2087.696,Percent of Total Billed Charges,90% of Total Billed Charges,35.48,45,,180.984,Percent of Total Billed Charges,45% of Total Billed Charges,70.97,90,,16.672,Percent of Total Billed Charges,90% of Total billed Charges,78.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.25,65,,27.52,Percent of total Billed Charges,65% of Total Billed Charges,34.77,44.1,,177.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.91,95,,17.592,Percent of Total Billed Charges,95% of Total Billed Charges,78.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.39,88,,16.296,Percent of Total Billed Charges,88% of Total Billed Charges,70.97,90,,16.672,Percent of Total Billed charges,90% of Total Billed Charges,34.77,78.85,
Vancomycin 750mg/150ml  premix,2500001319,CDM,250,RC,J3372,HCPCS,Outpatient,750,GM,334.80,217.62,,334.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,254.45,76,,40.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,241.06,72,,112.288,Percent of Total Billed Charges,72% of Total Billed Charges,251.1,75,,116.968,Percent of Total Billed charges,75% of Total Billed Charges,334.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.06,72,,112.288,Percent of Total Billed Charges,72% of Total Billed Charges,200.88,60,,93.568,Percent of Total Billed Charges,60% of Total Billed Charges,301.32,90,,93.672,Percent of Total Billed Charges,90% of Total Billed Charges,150.66,45,,343.32,Percent of Total Billed Charges,45% of Total Billed Charges,301.32,90,,47.632,Percent of Total Billed Charges,90% of Total billed Charges,334.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.62,65,,261.424,Percent of total Billed Charges,65% of Total Billed Charges,147.65,44.1,,336.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,318.06,95,,50.272,Percent of Total Billed Charges,95% of Total Billed Charges,334.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.62,88,,46.568,Percent of Total Billed Charges,88% of Total Billed Charges,301.32,90,,47.632,Percent of Total Billed charges,90% of Total Billed Charges,147.65,334.8,
Vancomycin 1gm/200ml premix,2500001320,CDM,250,RC,J3372,HCPCS,Outpatient,1,gm,446.40,290.16,,446.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,339.26,76,,32.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,321.41,72,,25.92,Percent of Total Billed Charges,72% of Total Billed Charges,334.8,75,,27,Percent of Total Billed charges,75% of Total Billed Charges,446.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,321.41,72,,25.92,Percent of Total Billed Charges,72% of Total Billed Charges,267.84,60,,21.6,Percent of Total Billed Charges,60% of Total Billed Charges,401.76,90,,535.024,Percent of Total Billed Charges,90% of Total Billed Charges,200.88,45,,1566.96,Percent of Total Billed Charges,45% of Total Billed Charges,401.76,90,,38.104,Percent of Total Billed Charges,90% of Total billed Charges,446.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290.16,65,,495.904,Percent of total Billed Charges,65% of Total Billed Charges,196.86,44.1,,1535.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,424.08,95,,40.216,Percent of Total Billed Charges,95% of Total Billed Charges,446.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.83,88,,37.256,Percent of Total Billed Charges,88% of Total Billed Charges,401.76,90,,38.104,Percent of Total Billed charges,90% of Total Billed Charges,196.86,446.4,
Vancomycin 1.25gm/250ml premix,2500001321,CDM,250,RC,J3372,HCPCS,Outpatient,1.25,gm,266.80,173.42,,266.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,202.77,76,,305.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,192.1,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,200.1,75,,15.88,Percent of Total Billed charges,75% of Total Billed Charges,266.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.1,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,160.08,60,,12.704,Percent of Total Billed Charges,60% of Total Billed Charges,240.12,90,,535.024,Percent of Total Billed Charges,90% of Total Billed Charges,120.06,45,,1586.808,Percent of Total Billed Charges,45% of Total Billed Charges,240.12,90,,361.976,Percent of Total Billed Charges,90% of Total billed Charges,266.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.42,65,,2263.392,Percent of total Billed Charges,65% of Total Billed Charges,117.66,44.1,,1555.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,253.46,95,,382.08,Percent of Total Billed Charges,95% of Total Billed Charges,266.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.78,88,,353.928,Percent of Total Billed Charges,88% of Total Billed Charges,240.12,90,,361.976,Percent of Total Billed charges,90% of Total Billed Charges,117.66,266.8,
Vancomycin 1.5gm/300ml  premix,2500001322,CDM,250,RC,J3372,HCPCS,Outpatient,1.5,gm,323.22,210.09,,323.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,245.65,76,,579.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,232.72,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,242.42,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,323.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.72,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,193.93,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,290.9,90,,4420.672,Percent of Total Billed Charges,90% of Total Billed Charges,145.45,45,,10921.896,Percent of Total Billed Charges,45% of Total Billed Charges,290.9,90,,686.632,Percent of Total Billed Charges,90% of Total billed Charges,323.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.09,65,,2292.056,Percent of total Billed Charges,65% of Total Billed Charges,142.54,44.1,,10703.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,307.06,95,,724.784,Percent of Total Billed Charges,95% of Total Billed Charges,323.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.43,88,,671.376,Percent of Total Billed Charges,88% of Total Billed Charges,290.9,90,,686.632,Percent of Total Billed charges,90% of Total Billed Charges,142.54,323.22,
Betadine 5% (30ml) ophth Soln,2500001323,CDM,250,RC,,,Outpatient,30,ML,37.87,24.62,,37.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.78,76,,2646.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.27,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,28.4,75,,13.232,Percent of Total Billed charges,75% of Total Billed Charges,37.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.27,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,22.72,60,,10.584,Percent of Total Billed Charges,60% of Total Billed Charges,34.08,90,,61.12,Percent of Total Billed Charges,90% of Total Billed Charges,17.04,45,,952.96,Percent of Total Billed Charges,45% of Total Billed Charges,34.08,90,,3133.92,Percent of Total Billed Charges,90% of Total billed Charges,37.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.62,65,,15776.072,Percent of total Billed Charges,65% of Total Billed Charges,16.7,44.1,,933.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.98,95,,3308.032,Percent of Total Billed Charges,95% of Total Billed Charges,37.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.33,88,,3064.28,Percent of Total Billed Charges,88% of Total Billed Charges,34.08,90,,3133.92,Percent of Total Billed charges,90% of Total Billed Charges,16.7,37.87,
Lortab 7.5-325mg/15ml oral sol,2500001324,CDM,250,RC,,,Outpatient,325,GM,381.00,247.65,,381,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,289.56,76,,2679.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,274.32,72,,80.016,Percent of Total Billed Charges,72% of Total Billed Charges,285.75,75,,83.352,Percent of Total Billed charges,75% of Total Billed Charges,381,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.32,72,,80.016,Percent of Total Billed Charges,72% of Total Billed Charges,228.6,60,,66.68,Percent of Total Billed Charges,60% of Total Billed Charges,342.9,90,,97.64,Percent of Total Billed Charges,90% of Total Billed Charges,171.45,45,,1043.848,Percent of Total Billed Charges,45% of Total Billed Charges,342.9,90,,3173.616,Percent of Total Billed Charges,90% of Total billed Charges,381,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.65,65,,1376.496,Percent of total Billed Charges,65% of Total Billed Charges,168.02,44.1,,1022.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,361.95,95,,3349.928,Percent of Total Billed Charges,95% of Total Billed Charges,381,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,335.28,88,,3103.088,Percent of Total Billed Charges,88% of Total Billed Charges,342.9,90,,3173.616,Percent of Total Billed charges,90% of Total Billed Charges,168.02,381,
Barium Sulfate 750mg,2500001325,CDM,250,RC,,,Outpatient,750,GM,97.55,63.41,,97.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,74.14,76,,18445.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,70.24,72,,76.208,Percent of Total Billed Charges,72% of Total Billed Charges,73.16,75,,79.384,Percent of Total Billed charges,75% of Total Billed Charges,97.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.24,72,,76.208,Percent of Total Billed Charges,72% of Total Billed Charges,58.53,60,,63.504,Percent of Total Billed Charges,60% of Total Billed Charges,87.8,90,,4755.656,Percent of Total Billed Charges,90% of Total Billed Charges,43.9,45,,46.84,Percent of Total Billed Charges,45% of Total Billed Charges,87.8,90,,21843.792,Percent of Total Billed Charges,90% of Total billed Charges,97.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.41,65,,1507.784,Percent of total Billed Charges,65% of Total Billed Charges,43.02,44.1,,45.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,92.67,95,,23057.336,Percent of Total Billed Charges,95% of Total Billed Charges,97.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.84,88,,21358.376,Percent of Total Billed Charges,88% of Total Billed Charges,87.8,90,,21843.792,Percent of Total Billed charges,90% of Total Billed Charges,43.02,97.55,
"Rhogam 1,500 unit inj. Syringe",2500001326,CDM,250,RC,J2788,HCPCS,Outpatient,,,295.00,191.75,,295,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,224.2,76,,1609.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.33,350,,9.528,Fee Schedule,350% of BCBS fee schedule,101.33,350,,9.928,Fee Schedule,350% of BCBS fee schedule,295,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.33,350,,9.528,Fee Schedule,350% of BCBS PPO fee schedule,28.95,100,,7.936,Fee Schedule,100% of Blue ADV HMO fee schedule,265.5,90,,327.048,Percent of Total Billed Charges,90% of Total Billed Charges,132.75,45,,267.512,Percent of Total Billed Charges,45% of Total Billed Charges,265.5,90,,1905.912,Percent of Total Billed Charges,90% of Total billed Charges,295,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.75,65,,67.656,Percent of total Billed Charges,65% of Total Billed Charges,130.1,44.1,,262.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,280.25,95,,2011.8,Percent of Total Billed Charges,95% of Total Billed Charges,295,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.6,88,,1863.56,Percent of Total Billed Charges,88% of Total Billed Charges,265.5,90,,1905.912,Percent of Total Billed charges,90% of Total Billed Charges,28.95,295,
PHENYLEPHRINE HCL INJECTION,2500001327,CDM,250,RC,J2371,HCPCS,Outpatient,,,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,1762.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.64,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,9,75,,29.104,Percent of Total Billed charges,75% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.64,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,7.2,60,,23.288,Percent of Total Billed Charges,60% of Total Billed Charges,10.8,90,,1672.536,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,267.512,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,2087.696,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,386.408,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,262.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,2203.68,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,2041.304,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,2087.696,Percent of Total Billed charges,90% of Total Billed Charges,5.29,12,
Vancomycin 2g/400ml premix bag,2500001328,CDM,250,RC,J3372,HCPCS,Outpatient,,,393.75,255.94,,393.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.25,76,,79.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,283.5,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,295.31,75,,49.616,Percent of Total Billed charges,75% of Total Billed Charges,393.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.5,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,236.25,60,,39.688,Percent of Total Billed Charges,60% of Total Billed Charges,354.38,90,,137.328,Percent of Total Billed Charges,90% of Total Billed Charges,177.19,45,,2210.336,Percent of Total Billed Charges,45% of Total Billed Charges,354.38,90,,93.672,Percent of Total Billed Charges,90% of Total billed Charges,393.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.94,65,,386.408,Percent of total Billed Charges,65% of Total Billed Charges,173.64,44.1,,2166.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.06,95,,98.88,Percent of Total Billed Charges,95% of Total Billed Charges,393.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.5,88,,91.592,Percent of Total Billed Charges,88% of Total Billed Charges,354.38,90,,93.672,Percent of Total Billed charges,90% of Total Billed Charges,173.64,393.75,
Beyfortus 100mg/1ml(State),2500001329,CDM,250,RC,,,Outpatient,,,0.01,0.01,,0.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.01,76,,451.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,72,,76.208,Percent of Total Billed Charges,72% of Total Billed Charges,0.01,75,,79.384,Percent of Total Billed charges,75% of Total Billed Charges,0.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.01,72,,76.208,Percent of Total Billed Charges,72% of Total Billed Charges,0.01,60,,63.504,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,535.024,Percent of Total Billed Charges,90% of Total billed Charges,0.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.01,65,,3192.704,Percent of total Billed Charges,65% of Total Billed Charges,,,,,Other,Not separately reimbursable,0.01,95,,564.752,Percent of Total Billed Charges,95% of Total Billed Charges,0.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.01,88,,523.136,Percent of Total Billed Charges,88% of Total Billed Charges,0.01,90,,535.024,Percent of Total Billed charges,90% of Total Billed Charges,0.01,0.01,
Amikacin 500MG/2ML inj,2500001330,CDM,250,RC,J0278,HCPCS,Outpatient,,,12.32,8.01,,12.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.36,76,,451.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.92,350,,38.104,Fee Schedule,350% of BCBS fee schedule,3.92,350,,39.688,Fee Schedule,350% of BCBS fee schedule,12.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.92,350,,38.104,Fee Schedule,350% of BCBS PPO fee schedule,1.12,100,,31.752,Fee Schedule,100% of Blue ADV HMO fee schedule,11.09,90,,51.592,Percent of Total Billed Charges,90% of Total Billed Charges,5.54,45,,48.816,Percent of Total Billed Charges,45% of Total Billed Charges,11.09,90,,535.024,Percent of Total Billed Charges,90% of Total billed Charges,12.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.01,65,,44.144,Percent of total Billed Charges,65% of Total Billed Charges,5.43,44.1,,47.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.7,95,,564.752,Percent of Total Billed Charges,95% of Total Billed Charges,12.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.84,88,,523.136,Percent of Total Billed Charges,88% of Total Billed Charges,11.09,90,,535.024,Percent of Total Billed charges,90% of Total Billed Charges,1.12,12.32,
Spikevax 50mcg/0.5ml syringe,2500001331,CDM,250,RC,,,Outpatient,,,288.37,187.44,,288.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,219.16,76,,3733.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,207.63,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,216.28,75,,23.152,Percent of Total Billed charges,75% of Total Billed Charges,288.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.63,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,173.02,60,,18.52,Percent of Total Billed Charges,60% of Total Billed Charges,259.53,90,,65.096,Percent of Total Billed Charges,90% of Total Billed Charges,129.77,45,,2377.832,Percent of Total Billed Charges,45% of Total Billed Charges,259.53,90,,4420.672,Percent of Total Billed Charges,90% of Total billed Charges,288.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.44,65,,70.52,Percent of total Billed Charges,65% of Total Billed Charges,127.17,44.1,,2330.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,273.95,95,,4666.264,Percent of Total Billed Charges,95% of Total Billed Charges,288.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,253.77,88,,4322.432,Percent of Total Billed Charges,88% of Total Billed Charges,259.53,90,,4420.672,Percent of Total Billed charges,90% of Total Billed Charges,127.17,288.37,
Comirnaty 30mcg/0.3ml syringe,2500001332,CDM,250,RC,,,Outpatient,,,296.25,192.56,,296.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,225.15,76,,51.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,213.3,72,,89.536,Percent of Total Billed Charges,72% of Total Billed Charges,222.19,75,,93.272,Percent of Total Billed charges,75% of Total Billed Charges,296.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.3,72,,89.536,Percent of Total Billed Charges,72% of Total Billed Charges,177.75,60,,74.616,Percent of Total Billed Charges,60% of Total Billed Charges,266.63,90,,62.712,Percent of Total Billed Charges,90% of Total Billed Charges,133.31,45,,163.52,Percent of Total Billed Charges,45% of Total Billed Charges,266.63,90,,61.12,Percent of Total Billed Charges,90% of Total billed Charges,296.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.56,65,,3434.64,Percent of total Billed Charges,65% of Total Billed Charges,130.65,44.1,,160.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,281.44,95,,64.52,Percent of Total Billed Charges,95% of Total Billed Charges,296.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.7,88,,59.76,Percent of Total Billed Charges,88% of Total Billed Charges,266.63,90,,61.12,Percent of Total Billed charges,90% of Total Billed Charges,130.65,296.25,
Brilinta 60mg Tab,2500001333,CDM,250,RC,,,Outpatient,,,17.15,11.15,,17.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.03,76,,82.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.35,72,,69.856,Percent of Total Billed Charges,72% of Total Billed Charges,12.86,75,,72.768,Percent of Total Billed charges,75% of Total Billed Charges,17.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.35,72,,69.856,Percent of Total Billed Charges,72% of Total Billed Charges,10.29,60,,58.216,Percent of Total Billed Charges,60% of Total Billed Charges,15.44,90,,73.824,Percent of Total Billed Charges,90% of Total Billed Charges,7.72,45,,836.272,Percent of Total Billed Charges,45% of Total Billed Charges,15.44,90,,97.64,Percent of Total Billed Charges,90% of Total billed Charges,17.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.15,65,,236.2,Percent of total Billed Charges,65% of Total Billed Charges,7.56,44.1,,819.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.29,95,,103.064,Percent of Total Billed Charges,95% of Total Billed Charges,17.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.09,88,,95.472,Percent of Total Billed Charges,88% of Total Billed Charges,15.44,90,,97.64,Percent of Total Billed charges,90% of Total Billed Charges,7.56,17.15,
Ferrlecit 62.5mg/5ml inj,2500001334,CDM,250,RC,J2916,HCPCS,Outpatient,,,16.12,10.48,,16.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.25,76,,4015.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.4,350,,31.112,Fee Schedule,350% of BCBS fee schedule,15.4,350,,32.416,Fee Schedule,350% of BCBS fee schedule,16.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.4,350,,31.112,Fee Schedule,350% of BCBS PPO fee schedule,4.4,100,,25.928,Fee Schedule,100% of Blue ADV HMO fee schedule,14.51,90,,53.184,Percent of Total Billed Charges,90% of Total Billed Charges,7.25,45,,68.664,Percent of Total Billed Charges,45% of Total Billed Charges,14.51,90,,4755.656,Percent of Total Billed Charges,90% of Total billed Charges,16.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.48,65,,1207.944,Percent of total Billed Charges,65% of Total Billed Charges,7.11,44.1,,67.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.31,95,,5019.864,Percent of Total Billed Charges,95% of Total Billed Charges,16.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.19,88,,4649.976,Percent of Total Billed Charges,88% of Total Billed Charges,14.51,90,,4755.656,Percent of Total Billed charges,90% of Total Billed Charges,4.4,16.12,
"Lido w/Epi2% 1/100,00 INJ 20ml",2500001335,CDM,250,RC,,,Outpatient,,,7.37,4.79,,7.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.6,76,,276.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.31,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,5.53,75,,53.584,Percent of Total Billed charges,75% of Total Billed Charges,7.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.31,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,4.42,60,,42.864,Percent of Total Billed Charges,60% of Total Billed Charges,6.63,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,3.32,45,,1.44,Percent of Total Billed Charges,45% of Total Billed Charges,6.63,90,,327.048,Percent of Total Billed Charges,90% of Total billed Charges,7.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.79,65,,99.176,Percent of total Billed Charges,65% of Total Billed Charges,3.25,44.1,,1.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,7,95,,345.216,Percent of Total Billed Charges,95% of Total Billed Charges,7.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.49,88,,319.776,Percent of Total Billed Charges,88% of Total Billed Charges,6.63,90,,327.048,Percent of Total Billed charges,90% of Total Billed Charges,3.25,7.37,
"LIDOCAINE 1%1:200,000 30ML INJ",2500001336,CDM,250,RC,,,Outpatient,,,27.85,18.10,,27.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21.17,76,,1412.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.05,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,20.89,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,27.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.05,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,16.71,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,25.07,90,,100.904,Percent of Total Billed Charges,90% of Total Billed Charges,12.53,45,,25.8,Percent of Total Billed Charges,45% of Total Billed Charges,25.07,90,,1672.536,Percent of Total Billed Charges,90% of Total billed Charges,27.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.1,65,,2.08,Percent of total Billed Charges,65% of Total Billed Charges,12.28,44.1,,25.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.46,95,,1765.456,Percent of Total Billed Charges,95% of Total Billed Charges,27.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.51,88,,1635.368,Percent of Total Billed Charges,88% of Total Billed Charges,25.07,90,,1672.536,Percent of Total Billed charges,90% of Total Billed Charges,12.28,27.85,
Vancomycin 250mg/5ml (150ml),2500001337,CDM,250,RC,,,Outpatient,,,139.97,90.98,,139.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.38,76,,115.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.78,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,104.98,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,139.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.78,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,83.98,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,125.97,90,,68.024,Percent of Total Billed Charges,90% of Total Billed Charges,62.99,45,,32.544,Percent of Total Billed Charges,45% of Total Billed Charges,125.97,90,,137.328,Percent of Total Billed Charges,90% of Total billed Charges,139.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.98,65,,37.264,Percent of total Billed Charges,65% of Total Billed Charges,61.73,44.1,,31.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,132.97,95,,144.952,Percent of Total Billed Charges,95% of Total Billed Charges,139.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.17,88,,134.272,Percent of Total Billed Charges,88% of Total Billed Charges,125.97,90,,137.328,Percent of Total Billed charges,90% of Total Billed Charges,61.73,139.97,
Beyfortus 50mg/0.5ml inj(State,2500001338,CDM,250,RC,,,Outpatient,,,0.01,0.01,,0.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.01,76,,2.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,0.01,75,,21.832,Percent of Total Billed charges,75% of Total Billed Charges,0.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.01,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,0.01,60,,17.464,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,90,,109.552,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,2.88,Percent of Total Billed Charges,90% of Total billed Charges,0.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.01,65,,47.016,Percent of total Billed Charges,65% of Total Billed Charges,,,,,Other,Not separately reimbursable,0.01,95,,3.04,Percent of Total Billed Charges,95% of Total Billed Charges,0.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.01,88,,2.816,Percent of Total Billed Charges,88% of Total Billed Charges,0.01,90,,2.88,Percent of Total Billed charges,90% of Total Billed Charges,0.01,0.01,
Beyfortus 100mg/ml inj,2500001339,CDM,250,RC,,,Outpatient,,,1299.38,844.60,,1299.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,987.53,76,,43.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,935.55,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,974.54,75,,14.56,Percent of Total Billed charges,75% of Total Billed Charges,1299.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,935.55,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,779.63,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,1169.44,90,,71.448,Percent of Total Billed Charges,90% of Total Billed Charges,584.72,45,,36.912,Percent of Total Billed Charges,45% of Total Billed Charges,1169.44,90,,51.592,Percent of Total Billed Charges,90% of Total billed Charges,1299.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1299.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1299.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,844.6,65,,45.296,Percent of total Billed Charges,65% of Total Billed Charges,573.03,44.1,,36.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,1234.41,95,,54.464,Percent of Total Billed Charges,95% of Total Billed Charges,1299.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1143.45,88,,50.448,Percent of Total Billed Charges,88% of Total Billed Charges,1169.44,90,,51.592,Percent of Total Billed charges,90% of Total Billed Charges,573.03,1299.38,
Krystexxa 8mg/ml inj,2500001340,CDM,250,RC,J2507,HCPCS,Outpatient,,,0.01,0.01,,0.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.01,76,,54.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.01,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,0.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.01,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,0.01,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,0.01,90,,104.784,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,100,,26.592,Fee Schedule,Pays based on 100% of TX Medicaid rate,0.01,90,,65.096,Percent of Total Billed Charges,90% of Total billed Charges,0.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.01,65,,53.312,Percent of total Billed Charges,65% of Total Billed Charges,0.01,100,,26.064,Fee Schedule,Pays based on 100% of TX Medicaid rate,0.01,95,,68.712,Percent of Total Billed Charges,95% of Total Billed Charges,0.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.01,88,,63.648,Percent of Total Billed Charges,88% of Total Billed Charges,0.01,90,,65.096,Percent of Total Billed charges,90% of Total Billed Charges,0.01,0.01,
Thrombin/Fibrinog/Apro/Cal 2ml,2500001341,CDM,250,RC,,,Outpatient,,,425.75,276.74,,425.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,323.57,76,,52.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,306.54,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,319.31,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,425.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.54,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,255.45,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,383.18,90,,52.392,Percent of Total Billed Charges,90% of Total Billed Charges,191.59,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,383.18,90,,62.712,Percent of Total Billed Charges,90% of Total billed Charges,425.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,425.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,425.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.74,65,,38.416,Percent of total Billed Charges,65% of Total Billed Charges,187.76,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,404.46,95,,66.2,Percent of Total Billed Charges,95% of Total Billed Charges,425.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.66,88,,61.32,Percent of Total Billed Charges,88% of Total Billed Charges,383.18,90,,62.712,Percent of Total Billed charges,90% of Total Billed Charges,187.76,425.75,
Varibar Thin Honey 250ml bttl,2500001342,CDM,250,RC,,,Outpatient,,,166.02,107.91,,166.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,126.18,76,,62.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,119.53,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,124.52,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,166.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.53,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,99.61,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,149.42,90,,27.784,Percent of Total Billed Charges,90% of Total Billed Charges,74.71,45,,50.448,Percent of Total Billed Charges,45% of Total Billed Charges,149.42,90,,73.824,Percent of Total Billed Charges,90% of Total billed Charges,166.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.91,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,73.21,44.1,,49.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,157.72,95,,77.92,Percent of Total Billed Charges,95% of Total Billed Charges,166.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.1,88,,72.184,Percent of Total Billed Charges,88% of Total Billed Charges,149.42,90,,73.824,Percent of Total Billed charges,90% of Total Billed Charges,73.21,166.02,
Heparin 300u/3ml Lck Flush Syr,2500001348,CDM,250,RC,J1642,HCPCS,Outpatient,,,32.62,21.20,,32.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.79,76,,60.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.07,350,,15.24,Fee Schedule,350% of BCBS fee schedule,0.07,350,,15.88,Fee Schedule,350% of BCBS fee schedule,32.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.07,350,,15.24,Fee Schedule,350% of BCBS PPO fee schedule,0.02,100,,12.704,Fee Schedule,100% of Blue ADV HMO fee schedule,,,,,Other,Not Separately Reimbursable,14.68,45,,13.896,Percent of Total Billed Charges,45% of Total Billed Charges,29.36,90,,71.448,Percent of Total Billed Charges,90% of Total billed Charges,32.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.2,65,,37.84,Percent of total Billed Charges,65% of Total Billed Charges,14.39,44.1,,13.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.99,95,,75.416,Percent of Total Billed Charges,95% of Total Billed Charges,32.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.71,88,,69.856,Percent of Total Billed Charges,88% of Total Billed Charges,29.36,90,,71.448,Percent of Total Billed charges,90% of Total Billed Charges,0.02,32.62,
Tranexamic Acd 1000mg/100ml IV,2500001349,CDM,250,RC,,,Outpatient,,,255.02,165.76,,255.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,193.82,76,,88.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,183.61,72,,31.112,Percent of Total Billed Charges,72% of Total Billed Charges,191.27,75,,32.416,Percent of Total Billed charges,75% of Total Billed Charges,255.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.61,72,,31.112,Percent of Total Billed Charges,72% of Total Billed Charges,153.01,60,,25.928,Percent of Total Billed Charges,60% of Total Billed Charges,229.52,90,,19.84,Percent of Total Billed Charges,90% of Total Billed Charges,114.76,45,,13.896,Percent of Total Billed Charges,45% of Total Billed Charges,229.52,90,,104.784,Percent of Total Billed Charges,90% of Total billed Charges,255.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.76,65,,20.064,Percent of total Billed Charges,65% of Total Billed Charges,112.46,44.1,,13.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,242.27,95,,110.6,Percent of Total Billed Charges,95% of Total Billed Charges,255.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.42,88,,102.456,Percent of Total Billed Charges,88% of Total Billed Charges,229.52,90,,104.784,Percent of Total Billed charges,90% of Total Billed Charges,112.46,255.02,
Indocyanine Green 25mg/vial,2500001350,CDM,250,RC,,,Outpatient,,,2515.08,1634.80,,2515.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1911.46,76,,44.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1810.86,72,,393.088,Percent of Total Billed Charges,72% of Total Billed Charges,1886.31,75,,409.472,Percent of Total Billed charges,75% of Total Billed Charges,2515.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1810.86,72,,393.088,Percent of Total Billed Charges,72% of Total Billed Charges,1509.05,60,,327.576,Percent of Total Billed Charges,60% of Total Billed Charges,2263.57,90,,55.568,Percent of Total Billed Charges,90% of Total Billed Charges,1131.79,45,,26.2,Percent of Total Billed Charges,45% of Total Billed Charges,2263.57,90,,52.392,Percent of Total Billed Charges,90% of Total billed Charges,2515.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2515.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2515.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1634.8,65,,20.064,Percent of total Billed Charges,65% of Total Billed Charges,1109.15,44.1,,25.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,2389.33,95,,55.304,Percent of Total Billed Charges,95% of Total Billed Charges,2515.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2213.27,88,,51.232,Percent of Total Billed Charges,88% of Total Billed Charges,2263.57,90,,52.392,Percent of Total Billed charges,90% of Total Billed Charges,1109.15,2515.08,
Omnipaque 350 (200ml),2500001351,CDM,250,RC,Q9967,HCPCS,Outpatient,,,30.00,19.50,,30,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.8,76,,23.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.37,350,,29.216,Fee Schedule,350% of BCBS fee schedule,1.37,350,,30.432,Fee Schedule,350% of BCBS fee schedule,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.37,350,,29.216,Fee Schedule,350% of BCBS PPO fee schedule,0.39,100,,24.344,Fee Schedule,100% of Blue ADV HMO fee schedule,27,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,45,,35.72,Percent of Total Billed Charges,45% of Total Billed Charges,27,90,,27.784,Percent of Total Billed Charges,90% of Total billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.5,65,,37.84,Percent of total Billed Charges,65% of Total Billed Charges,13.23,44.1,,35.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.5,95,,29.328,Percent of Total Billed Charges,95% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.4,88,,27.168,Percent of Total Billed Charges,88% of Total Billed Charges,27,90,,27.784,Percent of Total Billed charges,90% of Total Billed Charges,0.39,30,
Mupirocin 2% 1gm onit,2500001352,CDM,250,RC,,,Outpatient,,,31.25,20.31,,31.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.75,76,,23.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.5,72,,243.224,Percent of Total Billed Charges,72% of Total Billed Charges,23.44,75,,253.36,Percent of Total Billed charges,75% of Total Billed Charges,31.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.5,72,,243.224,Percent of Total Billed Charges,72% of Total Billed Charges,18.75,60,,202.688,Percent of Total Billed Charges,60% of Total Billed Charges,28.13,90,,61.12,Percent of Total Billed Charges,90% of Total Billed Charges,14.06,45,,13.896,Percent of Total Billed Charges,45% of Total Billed Charges,28.13,90,,27.784,Percent of Total Billed Charges,90% of Total billed Charges,31.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.31,65,,51.6,Percent of total Billed Charges,65% of Total Billed Charges,13.78,44.1,,13.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.69,95,,29.328,Percent of Total Billed Charges,95% of Total Billed Charges,31.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.5,88,,27.168,Percent of Total Billed Charges,88% of Total Billed Charges,28.13,90,,27.784,Percent of Total Billed charges,90% of Total Billed Charges,13.78,31.25,
E-Z Gas,2500001353,CDM,250,RC,,,Outpatient,,,20.65,13.42,,20.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.69,76,,44.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.87,72,,243.224,Percent of Total Billed Charges,72% of Total Billed Charges,15.49,75,,253.36,Percent of Total Billed charges,75% of Total Billed Charges,20.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.87,72,,243.224,Percent of Total Billed Charges,72% of Total Billed Charges,12.39,60,,202.688,Percent of Total Billed Charges,60% of Total Billed Charges,18.59,90,,55.568,Percent of Total Billed Charges,90% of Total Billed Charges,9.29,45,,9.92,Percent of Total Billed Charges,45% of Total Billed Charges,18.59,90,,52.392,Percent of Total Billed Charges,90% of Total billed Charges,20.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.42,65,,20.064,Percent of total Billed Charges,65% of Total Billed Charges,9.11,44.1,,9.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.62,95,,55.304,Percent of Total Billed Charges,95% of Total Billed Charges,20.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.17,88,,51.232,Percent of Total Billed Charges,88% of Total Billed Charges,18.59,90,,52.392,Percent of Total Billed charges,90% of Total Billed Charges,9.11,20.65,
PROHANCE 17ML,2550000001,CDM,255,RC,A9579,HCPCS,Outpatient,17,ML,365.00,237.25,,365,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,277.4,76,,23.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.74,350,,42.336,Fee Schedule,350% of BCBS fee schedule,7.74,350,,44.104,Fee Schedule,350% of BCBS fee schedule,365,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.74,350,,42.336,Fee Schedule,350% of BCBS PPO fee schedule,2.21,100,,35.28,Fee Schedule,100% of Blue ADV HMO fee schedule,328.5,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,164.25,45,,9.92,Percent of Total Billed Charges,45% of Total Billed Charges,328.5,90,,27.784,Percent of Total Billed Charges,90% of Total billed Charges,365,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.25,65,,40.136,Percent of total Billed Charges,65% of Total Billed Charges,160.97,44.1,,9.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,346.75,95,,29.328,Percent of Total Billed Charges,95% of Total Billed Charges,365,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,321.2,88,,27.168,Percent of Total Billed Charges,88% of Total Billed Charges,328.5,90,,27.784,Percent of Total Billed charges,90% of Total Billed Charges,2.21,365,
PROHANCE 10ML,2550000002,CDM,255,RC,A9579,HCPCS,Outpatient,10,ML,45.00,29.25,,45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.2,76,,16.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.74,350,,14.32,Fee Schedule,350% of BCBS fee schedule,7.74,350,,14.92,Fee Schedule,350% of BCBS fee schedule,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.74,350,,14.32,Fee Schedule,350% of BCBS PPO fee schedule,2.21,100,,11.936,Fee Schedule,100% of Blue ADV HMO fee schedule,40.5,90,,111.136,Percent of Total Billed Charges,90% of Total Billed Charges,20.25,45,,27.784,Percent of Total Billed Charges,45% of Total Billed Charges,40.5,90,,19.84,Percent of Total Billed Charges,90% of Total billed Charges,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.25,65,,14.328,Percent of total Billed Charges,65% of Total Billed Charges,19.85,44.1,,27.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.75,95,,20.944,Percent of Total Billed Charges,95% of Total Billed Charges,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.6,88,,19.4,Percent of Total Billed Charges,88% of Total Billed Charges,40.5,90,,19.84,Percent of Total Billed charges,90% of Total Billed Charges,2.21,45,
PROHANCE 20ML,2550000003,CDM,255,RC,A9579,HCPCS,Outpatient,20,ML,83.25,54.11,,83.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,63.27,76,,46.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.74,350,,4.84,Fee Schedule,350% of BCBS fee schedule,7.74,350,,5.04,Fee Schedule,350% of BCBS fee schedule,83.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.74,350,,4.84,Fee Schedule,350% of BCBS PPO fee schedule,2.21,100,,4.032,Fee Schedule,100% of Blue ADV HMO fee schedule,74.93,90,,41.28,Percent of Total Billed Charges,90% of Total Billed Charges,37.46,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,74.93,90,,55.568,Percent of Total Billed Charges,90% of Total billed Charges,83.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.11,65,,40.136,Percent of total Billed Charges,65% of Total Billed Charges,36.71,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,79.09,95,,58.656,Percent of Total Billed Charges,95% of Total Billed Charges,83.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.26,88,,54.336,Percent of Total Billed Charges,88% of Total Billed Charges,74.93,90,,55.568,Percent of Total Billed charges,90% of Total Billed Charges,2.21,83.25,
GADOLINIUM PER ML,2550000004,CDM,255,RC,A9579,HCPCS,Outpatient,1,ML,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,16.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.74,350,,0.336,Fee Schedule,350% of BCBS fee schedule,7.74,350,,0.352,Fee Schedule,350% of BCBS fee schedule,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.74,350,,0.336,Fee Schedule,350% of BCBS PPO fee schedule,2.21,100,,0.28,Fee Schedule,100% of Blue ADV HMO fee schedule,11.91,90,,364.36,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,30.56,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,19.84,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,29.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,20.944,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,19.4,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,19.84,Percent of Total Billed charges,90% of Total Billed Charges,2.21,13.23,
GASTROGRAFFIN 30ML,2550000005,CDM,255,RC,Q9963,HCPCS,Outpatient,30,ML,76.25,49.56,,76.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,57.95,76,,46.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.67,350,,0.32,Fee Schedule,350% of BCBS fee schedule,0.67,350,,0.328,Fee Schedule,350% of BCBS fee schedule,76.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.67,350,,0.32,Fee Schedule,350% of BCBS PPO fee schedule,0.19,100,,0.264,Fee Schedule,100% of Blue ADV HMO fee schedule,68.63,90,,321.488,Percent of Total Billed Charges,90% of Total Billed Charges,34.31,45,,27.784,Percent of Total Billed Charges,45% of Total Billed Charges,68.63,90,,55.568,Percent of Total Billed Charges,90% of Total billed Charges,76.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.56,65,,44.144,Percent of total Billed Charges,65% of Total Billed Charges,33.63,44.1,,27.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,72.44,95,,58.656,Percent of Total Billed Charges,95% of Total Billed Charges,76.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.1,88,,54.336,Percent of Total Billed Charges,88% of Total Billed Charges,68.63,90,,55.568,Percent of Total Billed charges,90% of Total Billed Charges,0.19,76.25,
GASTROGRAFFIN 120ML,2550000006,CDM,255,RC,Q9963,HCPCS,Outpatient,120,ML,19.00,12.35,,19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.44,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.67,350,,0.32,Fee Schedule,350% of BCBS fee schedule,0.67,350,,0.328,Fee Schedule,350% of BCBS fee schedule,19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.67,350,,0.32,Fee Schedule,350% of BCBS PPO fee schedule,0.19,100,,0.264,Fee Schedule,100% of Blue ADV HMO fee schedule,17.1,90,,49.216,Percent of Total Billed Charges,90% of Total Billed Charges,8.55,45,,27.784,Percent of Total Billed Charges,45% of Total Billed Charges,17.1,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.35,65,,40.136,Percent of total Billed Charges,65% of Total Billed Charges,8.38,44.1,,27.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.05,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.72,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,17.1,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,0.19,19,
ISOVUE 370 76% 150ML,2550000007,CDM,255,RC,Q9967,HCPCS,Outpatient,150,ML,456.50,296.73,,456.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,346.94,76,,51.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.37,350,,0.2,Fee Schedule,350% of BCBS fee schedule,1.37,350,,0.208,Fee Schedule,350% of BCBS fee schedule,456.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.37,350,,0.2,Fee Schedule,350% of BCBS PPO fee schedule,0.39,100,,0.168,Fee Schedule,100% of Blue ADV HMO fee schedule,410.85,90,,153.2,Percent of Total Billed Charges,90% of Total Billed Charges,205.43,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,410.85,90,,61.12,Percent of Total Billed Charges,90% of Total billed Charges,456.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.73,65,,40.136,Percent of total Billed Charges,65% of Total Billed Charges,201.32,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,433.68,95,,64.52,Percent of Total Billed Charges,95% of Total Billed Charges,456.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.72,88,,59.76,Percent of Total Billed Charges,88% of Total Billed Charges,410.85,90,,61.12,Percent of Total Billed charges,90% of Total Billed Charges,0.39,456.5,
ISOVUE 370 76% 100ML,2550000008,CDM,255,RC,Q9967,HCPCS,Outpatient,100,ML,41.75,27.14,,41.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31.73,76,,46.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.37,350,,0.808,Fee Schedule,350% of BCBS fee schedule,1.37,350,,0.84,Fee Schedule,350% of BCBS fee schedule,41.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.37,350,,0.808,Fee Schedule,350% of BCBS PPO fee schedule,0.39,100,,0.672,Fee Schedule,100% of Blue ADV HMO fee schedule,37.58,90,,48.424,Percent of Total Billed Charges,90% of Total Billed Charges,18.79,45,,55.568,Percent of Total Billed Charges,45% of Total Billed Charges,37.58,90,,55.568,Percent of Total Billed Charges,90% of Total billed Charges,41.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.14,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,18.41,44.1,,54.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,39.66,95,,58.656,Percent of Total Billed Charges,95% of Total Billed Charges,41.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.74,88,,54.336,Percent of Total Billed Charges,88% of Total Billed Charges,37.58,90,,55.568,Percent of Total Billed charges,90% of Total Billed Charges,0.39,41.75,
ISOVUE 300 61% 100ML,2550000009,CDM,255,RC,Q9967,HCPCS,Outpatient,100,ML,37.50,24.38,,37.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.5,76,,46.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.37,350,,0.72,Fee Schedule,350% of BCBS fee schedule,1.37,350,,0.752,Fee Schedule,350% of BCBS fee schedule,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.37,350,,0.72,Fee Schedule,350% of BCBS PPO fee schedule,0.39,100,,0.6,Fee Schedule,100% of Blue ADV HMO fee schedule,33.75,90,,172.256,Percent of Total Billed Charges,90% of Total Billed Charges,16.88,45,,20.64,Percent of Total Billed Charges,45% of Total Billed Charges,33.75,90,,55.568,Percent of Total Billed Charges,90% of Total billed Charges,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.38,65,,80.264,Percent of total Billed Charges,65% of Total Billed Charges,16.54,44.1,,20.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.63,95,,58.656,Percent of Total Billed Charges,95% of Total Billed Charges,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33,88,,54.336,Percent of Total Billed Charges,88% of Total Billed Charges,33.75,90,,55.568,Percent of Total Billed charges,90% of Total Billed Charges,0.39,37.5,
ISOVUE 300 61% 50ML,2550000010,CDM,255,RC,Q9967,HCPCS,Outpatient,50,ML,20.00,13.00,,20,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.2,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.37,350,,0.896,Fee Schedule,350% of BCBS fee schedule,1.37,350,,0.936,Fee Schedule,350% of BCBS fee schedule,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.37,350,,0.896,Fee Schedule,350% of BCBS PPO fee schedule,0.39,100,,0.752,Fee Schedule,100% of Blue ADV HMO fee schedule,18,90,,48.424,Percent of Total Billed Charges,90% of Total Billed Charges,9,45,,182.176,Percent of Total Billed Charges,45% of Total Billed Charges,18,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13,65,,29.808,Percent of total Billed Charges,65% of Total Billed Charges,8.82,44.1,,178.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,19,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.6,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,18,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,0.39,20,
ISOVUE 370 76% 125ML,2550000011,CDM,255,RC,Q9967,HCPCS,Outpatient,125,ML,456.50,296.73,,456.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,346.94,76,,93.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.37,350,,6.464,Fee Schedule,350% of BCBS fee schedule,1.37,350,,6.736,Fee Schedule,350% of BCBS fee schedule,456.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.37,350,,6.464,Fee Schedule,350% of BCBS PPO fee schedule,0.39,100,,5.384,Fee Schedule,100% of Blue ADV HMO fee schedule,410.85,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,205.43,45,,160.744,Percent of Total Billed Charges,45% of Total Billed Charges,410.85,90,,111.136,Percent of Total Billed Charges,90% of Total billed Charges,456.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.73,65,,263.144,Percent of total Billed Charges,65% of Total Billed Charges,201.32,44.1,,157.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,433.68,95,,117.304,Percent of Total Billed Charges,95% of Total Billed Charges,456.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.72,88,,108.664,Percent of Total Billed Charges,88% of Total Billed Charges,410.85,90,,111.136,Percent of Total Billed charges,90% of Total Billed Charges,0.39,456.5,
POLIBAR 1900ML,2550000012,CDM,255,RC,,,Outpatient,1900,ML,117.25,76.21,,117.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,89.11,76,,34.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.42,72,,1.04,Percent of Total Billed Charges,72% of Total Billed Charges,87.94,75,,1.088,Percent of Total Billed charges,75% of Total Billed Charges,117.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.42,72,,1.04,Percent of Total Billed Charges,72% of Total Billed Charges,70.35,60,,0.872,Percent of Total Billed Charges,60% of Total Billed Charges,105.53,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,52.76,45,,24.608,Percent of Total Billed Charges,45% of Total Billed Charges,105.53,90,,41.28,Percent of Total Billed Charges,90% of Total billed Charges,117.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.21,65,,232.184,Percent of total Billed Charges,65% of Total Billed Charges,51.71,44.1,,24.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,111.39,95,,43.568,Percent of Total Billed Charges,95% of Total Billed Charges,117.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.18,88,,40.36,Percent of Total Billed Charges,88% of Total Billed Charges,105.53,90,,41.28,Percent of Total Billed charges,90% of Total Billed Charges,51.71,117.25,
EZ PAQUE 96% 6.2OZ,2550000013,CDM,255,RC,,,Outpatient,,,6.50,4.23,,6.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.94,76,,307.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.68,72,,1.416,Percent of Total Billed Charges,72% of Total Billed Charges,4.88,75,,1.48,Percent of Total Billed charges,75% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.68,72,,1.416,Percent of Total Billed Charges,72% of Total Billed Charges,3.9,60,,1.184,Percent of Total Billed Charges,60% of Total Billed Charges,5.85,90,,127.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,76.6,Percent of Total Billed Charges,45% of Total Billed Charges,5.85,90,,364.36,Percent of Total Billed Charges,90% of Total billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,65,,35.544,Percent of total Billed Charges,65% of Total Billed Charges,2.87,44.1,,75.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.18,95,,384.6,Percent of Total Billed Charges,95% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,88,,356.256,Percent of Total Billed Charges,88% of Total Billed Charges,5.85,90,,364.36,Percent of Total Billed charges,90% of Total Billed Charges,2.87,6.5,
EPINEPHRINE KIT 1MG/10ML,2550000015,CDM,255,RC,,,Outpatient,1,GM,456.50,296.73,,456.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,346.94,76,,41.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,328.68,72,,2.664,Percent of Total Billed Charges,72% of Total Billed Charges,342.38,75,,2.776,Percent of Total Billed charges,75% of Total Billed Charges,456.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.68,72,,2.664,Percent of Total Billed Charges,72% of Total Billed Charges,273.9,60,,2.216,Percent of Total Billed Charges,60% of Total Billed Charges,410.85,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,205.43,45,,86.128,Percent of Total Billed Charges,45% of Total Billed Charges,410.85,90,,49.216,Percent of Total Billed Charges,90% of Total billed Charges,456.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.73,65,,34.968,Percent of total Billed Charges,65% of Total Billed Charges,201.32,44.1,,84.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,433.68,95,,51.952,Percent of Total Billed Charges,95% of Total Billed Charges,456.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.72,88,,48.128,Percent of Total Billed Charges,88% of Total Billed Charges,410.85,90,,49.216,Percent of Total Billed charges,90% of Total Billed Charges,201.32,456.5,
Omnipaque 300mg/ml 100ml,2550000020,CDM,254,RC,Q9967,HCPCS,Outpatient,300,GM,37.50,24.38,,37.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.5,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.37,350,,19.056,Fee Schedule,350% of BCBS fee schedule,1.37,350,,19.848,Fee Schedule,350% of BCBS fee schedule,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.37,350,,19.056,Fee Schedule,350% of BCBS PPO fee schedule,0.39,100,,15.88,Fee Schedule,100% of Blue ADV HMO fee schedule,33.75,90,,274.656,Percent of Total Billed Charges,90% of Total Billed Charges,16.88,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,33.75,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.38,65,,92.304,Percent of total Billed Charges,65% of Total Billed Charges,16.54,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.63,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,33.75,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,0.39,37.5,
Omnipaque 300mg/ml 50ml,2550000021,CDM,254,RC,Q9967,HCPCS,Outpatient,300,GM,20.00,13.00,,20,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.2,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.37,350,,18.336,Fee Schedule,350% of BCBS fee schedule,1.37,350,,19.104,Fee Schedule,350% of BCBS fee schedule,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.37,350,,18.336,Fee Schedule,350% of BCBS PPO fee schedule,0.39,100,,15.28,Fee Schedule,100% of Blue ADV HMO fee schedule,18,90,,270.688,Percent of Total Billed Charges,90% of Total Billed Charges,9,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,18,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,8.82,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,19,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.6,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,18,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,0.39,20,
Gadoxetate Disodium 181.43mg/m,2550000022,CDM,254,RC,A9581,HCPCS,Outpatient,,,1401.85,911.20,,1401.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1065.41,76,,107.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,54.32,350,,37.792,Fee Schedule,350% of BCBS fee schedule,54.32,350,,39.368,Fee Schedule,350% of BCBS fee schedule,1401.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.32,350,,37.792,Fee Schedule,350% of BCBS PPO fee schedule,15.52,100,,31.496,Fee Schedule,100% of Blue ADV HMO fee schedule,1261.67,90,,304.024,Percent of Total Billed Charges,90% of Total Billed Charges,630.83,45,,9.92,Percent of Total Billed Charges,45% of Total Billed Charges,1261.67,90,,127.8,Percent of Total Billed Charges,90% of Total billed Charges,1401.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1401.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1401.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,911.2,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,618.22,44.1,,9.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,1331.76,95,,134.904,Percent of Total Billed Charges,95% of Total Billed Charges,1401.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1233.63,88,,124.96,Percent of Total Billed Charges,88% of Total Billed Charges,1261.67,90,,127.8,Percent of Total Billed charges,90% of Total Billed Charges,15.52,1401.85,
SODIUM CHLORIDE 0.9% SOLUTION,2580000001,CDM,258,RC,J7030,HCPCS,Outpatient,,,47.00,30.55,,47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.72,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.86,350,,32.272,Fee Schedule,350% of BCBS fee schedule,57.86,350,,33.616,Fee Schedule,350% of BCBS fee schedule,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.86,350,,32.272,Fee Schedule,350% of BCBS PPO fee schedule,16.53,100,,26.896,Fee Schedule,100% of Blue ADV HMO fee schedule,42.3,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,45,,5.568,Percent of Total Billed Charges,45% of Total Billed Charges,42.3,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.55,65,,14.328,Percent of total Billed Charges,65% of Total Billed Charges,20.73,44.1,,5.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.65,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.36,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,42.3,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,16.53,57.86,
500CC NS IV SOLN,2580000002,CDM,258,RC,J7040,HCPCS,Outpatient,,,58.43,37.98,,58.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,44.41,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.95,350,,70.784,Fee Schedule,350% of BCBS fee schedule,28.95,350,,73.736,Fee Schedule,350% of BCBS fee schedule,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.95,350,,70.784,Fee Schedule,350% of BCBS PPO fee schedule,8.27,100,,58.984,Fee Schedule,100% of Blue ADV HMO fee schedule,52.59,90,,32.544,Percent of Total Billed Charges,90% of Total Billed Charges,26.29,45,,17.464,Percent of Total Billed Charges,45% of Total Billed Charges,52.59,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.98,65,,8.04,Percent of total Billed Charges,65% of Total Billed Charges,25.77,44.1,,17.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,55.51,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.42,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,52.59,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,8.27,58.43,
1000CC D5NS IV SOLN,2580000003,CDM,258,RC,J7042,HCPCS,Outpatient,,,46.31,30.10,,46.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.2,76,,16.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.6,350,,20.216,Fee Schedule,350% of BCBS fee schedule,5.6,350,,21.064,Fee Schedule,350% of BCBS fee schedule,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.6,350,,20.216,Fee Schedule,350% of BCBS PPO fee schedule,1.6,100,,16.848,Fee Schedule,100% of Blue ADV HMO fee schedule,41.68,90,,37.312,Percent of Total Billed Charges,90% of Total Billed Charges,20.84,45,,138.52,Percent of Total Billed Charges,45% of Total Billed Charges,41.68,90,,19.84,Percent of Total Billed Charges,90% of Total billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.1,65,,25.224,Percent of total Billed Charges,65% of Total Billed Charges,20.42,44.1,,135.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,43.99,95,,20.944,Percent of Total Billed Charges,95% of Total Billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.75,88,,19.4,Percent of Total Billed Charges,88% of Total Billed Charges,41.68,90,,19.84,Percent of Total Billed charges,90% of Total Billed Charges,1.6,46.31,
500CC D5NS IV SOLN,2580000004,CDM,258,RC,J7042,HCPCS,Outpatient,,,56.23,36.55,,56.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.73,76,,9.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.6,350,,27.848,Fee Schedule,350% of BCBS fee schedule,5.6,350,,29.008,Fee Schedule,350% of BCBS fee schedule,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.6,350,,27.848,Fee Schedule,350% of BCBS PPO fee schedule,1.6,100,,23.208,Fee Schedule,100% of Blue ADV HMO fee schedule,50.61,90,,29.368,Percent of Total Billed Charges,90% of Total Billed Charges,25.3,45,,137.328,Percent of Total Billed Charges,45% of Total Billed Charges,50.61,90,,11.128,Percent of Total Billed Charges,90% of Total billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.55,65,,200.08,Percent of total Billed Charges,65% of Total Billed Charges,24.8,44.1,,134.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.42,95,,11.752,Percent of Total Billed Charges,95% of Total Billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.48,88,,10.88,Percent of Total Billed Charges,88% of Total Billed Charges,50.61,90,,11.128,Percent of Total Billed charges,90% of Total Billed Charges,1.6,56.23,
D5NS W/KCL 40MG 1000ML,2580000005,CDM,258,RC,J7042,HCPCS,Outpatient,40,GM,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,29.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.6,350,,9.216,Fee Schedule,350% of BCBS fee schedule,5.6,350,,9.6,Fee Schedule,350% of BCBS fee schedule,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.6,350,,9.216,Fee Schedule,350% of BCBS PPO fee schedule,1.6,100,,7.68,Fee Schedule,100% of Blue ADV HMO fee schedule,19.85,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,135.344,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,34.928,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,198.368,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,132.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,36.864,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,34.152,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,34.928,Percent of Total Billed charges,90% of Total Billed Charges,1.6,22.05,
50ML NS MINIBAG PLUS,2580000006,CDM,258,RC,J7050,HCPCS,Outpatient,50,ML,67.25,43.71,,67.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.11,76,,233.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.46,350,,7.488,Fee Schedule,350% of BCBS fee schedule,14.46,350,,7.8,Fee Schedule,350% of BCBS fee schedule,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.46,350,,7.488,Fee Schedule,350% of BCBS PPO fee schedule,4.13,100,,6.24,Fee Schedule,100% of Blue ADV HMO fee schedule,,,,,Other,Not Separately Reimbursable,30.26,45,,152.016,Percent of Total Billed Charges,45% of Total Billed Charges,60.53,90,,277.032,Percent of Total Billed Charges,90% of Total billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.71,65,,195.496,Percent of total Billed Charges,65% of Total Billed Charges,29.66,44.1,,148.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,63.89,95,,292.424,Percent of Total Billed Charges,95% of Total Billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.18,88,,270.88,Percent of Total Billed Charges,88% of Total Billed Charges,60.53,90,,277.032,Percent of Total Billed charges,90% of Total Billed Charges,4.13,67.25,
NS 100 MINI BAG PLUS,2580000007,CDM,258,RC,J7050,HCPCS,Outpatient,,,67.25,43.71,,67.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.11,76,,231.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.46,350,,936,Fee Schedule,350% of BCBS fee schedule,14.46,350,,975,Fee Schedule,350% of BCBS fee schedule,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.46,350,,936,Fee Schedule,350% of BCBS PPO fee schedule,4.13,100,,780,Fee Schedule,100% of Blue ADV HMO fee schedule,,,,,Other,Not Separately Reimbursable,30.26,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,60.53,90,,274.656,Percent of Total Billed Charges,90% of Total billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.71,65,,219.576,Percent of total Billed Charges,65% of Total Billed Charges,29.66,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,63.89,95,,289.92,Percent of Total Billed Charges,95% of Total Billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.18,88,,268.552,Percent of Total Billed Charges,88% of Total Billed Charges,60.53,90,,274.656,Percent of Total Billed charges,90% of Total Billed Charges,4.13,67.25,
50CC NS IV SOLN,2580000008,CDM,258,RC,J7050,HCPCS,Outpatient,,,47.41,30.82,,47.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.03,76,,228.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.46,350,,142.56,Fee Schedule,350% of BCBS fee schedule,14.46,350,,148.504,Fee Schedule,350% of BCBS fee schedule,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.46,350,,142.56,Fee Schedule,350% of BCBS PPO fee schedule,4.13,100,,118.8,Fee Schedule,100% of Blue ADV HMO fee schedule,,,,,Other,Not Separately Reimbursable,21.33,45,,16.272,Percent of Total Billed Charges,45% of Total Billed Charges,42.67,90,,270.688,Percent of Total Billed Charges,90% of Total billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.82,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,20.91,44.1,,15.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.04,95,,285.72,Percent of Total Billed Charges,95% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.72,88,,264.672,Percent of Total Billed Charges,88% of Total Billed Charges,42.67,90,,270.688,Percent of Total Billed charges,90% of Total Billed Charges,4.13,47.41,
100CC NS IV SOLN,2580000009,CDM,258,RC,J7050,HCPCS,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,256.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.46,350,,216,Fee Schedule,350% of BCBS fee schedule,14.46,350,,225,Fee Schedule,350% of BCBS fee schedule,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.46,350,,216,Fee Schedule,350% of BCBS PPO fee schedule,4.13,100,,180,Fee Schedule,100% of Blue ADV HMO fee schedule,,,,,Other,Not Separately Reimbursable,35.23,45,,18.656,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,304.024,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,23.504,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,18.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,320.92,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,297.272,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,304.024,Percent of Total Billed charges,90% of Total Billed Charges,4.13,78.28,
250CC NS IV SOLN,2580000011,CDM,258,RC,J7050,HCPCS,Outpatient,,,51.82,33.68,,51.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,39.38,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.46,350,,0.112,Fee Schedule,350% of BCBS fee schedule,14.46,350,,0.112,Fee Schedule,350% of BCBS fee schedule,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.46,350,,0.112,Fee Schedule,350% of BCBS PPO fee schedule,4.13,100,,0.088,Fee Schedule,100% of Blue ADV HMO fee schedule,,,,,Other,Not Separately Reimbursable,23.32,45,,14.688,Percent of Total Billed Charges,45% of Total Billed Charges,46.64,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.68,65,,26.944,Percent of total Billed Charges,65% of Total Billed Charges,22.85,44.1,,14.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,49.23,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.6,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,46.64,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,4.13,51.82,
NS 25ML INJ SOLN,2580000012,CDM,258,RC,J7050,HCPCS,Outpatient,25,ML,62.84,40.85,,62.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.76,76,,27.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.46,350,,0.896,Fee Schedule,350% of BCBS fee schedule,14.46,350,,0.928,Fee Schedule,350% of BCBS fee schedule,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.46,350,,0.896,Fee Schedule,350% of BCBS PPO fee schedule,4.13,100,,0.744,Fee Schedule,100% of Blue ADV HMO fee schedule,,,,,Other,Not Separately Reimbursable,28.28,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,56.56,90,,32.544,Percent of Total Billed Charges,90% of Total billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.85,65,,21.208,Percent of total Billed Charges,65% of Total Billed Charges,27.71,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.7,95,,34.352,Percent of Total Billed Charges,95% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.3,88,,31.824,Percent of Total Billed Charges,88% of Total Billed Charges,56.56,90,,32.544,Percent of Total Billed charges,90% of Total Billed Charges,4.13,62.84,
NS 100ML ADDVANTAGE SOLN,2580000013,CDM,258,RC,J7050,HCPCS,Outpatient,100,ML,18.74,12.18,,18.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.24,76,,31.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.46,350,,0.944,Fee Schedule,350% of BCBS fee schedule,14.46,350,,0.984,Fee Schedule,350% of BCBS fee schedule,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.46,350,,0.944,Fee Schedule,350% of BCBS PPO fee schedule,4.13,100,,0.784,Fee Schedule,100% of Blue ADV HMO fee schedule,,,,,Other,Not Separately Reimbursable,8.43,45,,1.08,Percent of Total Billed Charges,45% of Total Billed Charges,16.87,90,,37.312,Percent of Total Billed Charges,90% of Total billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.18,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,8.26,44.1,,1.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.8,95,,39.384,Percent of Total Billed Charges,95% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,88,,36.48,Percent of Total Billed Charges,88% of Total Billed Charges,16.87,90,,37.312,Percent of Total Billed charges,90% of Total Billed Charges,4.13,18.74,
SODIUM BICARB 50MEQ INJ,2580000014,CDM,258,RC,J7050,HCPCS,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,24.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.46,350,,0.984,Fee Schedule,350% of BCBS fee schedule,14.46,350,,1.024,Fee Schedule,350% of BCBS fee schedule,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.46,350,,0.984,Fee Schedule,350% of BCBS PPO fee schedule,4.13,100,,0.824,Fee Schedule,100% of Blue ADV HMO fee schedule,,,,,Other,Not Separately Reimbursable,1.98,45,,1.448,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,29.368,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,1.56,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,1.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,31,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,28.72,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,29.368,Percent of Total Billed charges,90% of Total Billed Charges,1.94,14.46,
50CC D5W IV SOLN,2580000016,CDM,258,RC,J7060,HCPCS,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,1.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.41,350,,2.688,Fee Schedule,350% of BCBS fee schedule,25.41,350,,2.8,Fee Schedule,350% of BCBS fee schedule,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.41,350,,2.688,Fee Schedule,350% of BCBS PPO fee schedule,7.26,100,,2.24,Fee Schedule,100% of Blue ADV HMO fee schedule,49.62,90,,8.32,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,7.168,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,2.16,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,6.88,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,7.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,2.28,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,2.112,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,2.16,Percent of Total Billed charges,90% of Total Billed Charges,7.26,55.13,
100CC D5W IV SOLN,2580000017,CDM,258,RC,J7060,HCPCS,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,2.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.41,350,,3.336,Fee Schedule,350% of BCBS fee schedule,25.41,350,,3.472,Fee Schedule,350% of BCBS fee schedule,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.41,350,,3.336,Fee Schedule,350% of BCBS PPO fee schedule,7.26,100,,2.776,Fee Schedule,100% of Blue ADV HMO fee schedule,49.62,90,,28.304,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,6.44,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,2.904,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,10.352,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,6.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,3.064,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,2.84,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,2.904,Percent of Total Billed charges,90% of Total Billed Charges,7.26,55.13,
IV D5W 1000CC SOLN,2580000018,CDM,258,RC,J7060,HCPCS,Outpatient,,,45.20,29.38,,45.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.35,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.41,350,,7.368,Fee Schedule,350% of BCBS fee schedule,25.41,350,,7.672,Fee Schedule,350% of BCBS fee schedule,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.41,350,,7.368,Fee Schedule,350% of BCBS PPO fee schedule,7.26,100,,6.136,Fee Schedule,100% of Blue ADV HMO fee schedule,40.68,90,,9.896,Percent of Total Billed Charges,90% of Total Billed Charges,20.34,45,,1.888,Percent of Total Billed Charges,45% of Total Billed Charges,40.68,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.38,65,,9.304,Percent of total Billed Charges,65% of Total Billed Charges,19.93,44.1,,1.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.94,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.78,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,40.68,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,7.26,45.2,
500CC D5W IV SOLN,2580000019,CDM,258,RC,J7060,HCPCS,Outpatient,,,52.92,34.40,,52.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.22,76,,12.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.41,350,,14.8,Fee Schedule,350% of BCBS fee schedule,25.41,350,,15.424,Fee Schedule,350% of BCBS fee schedule,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.41,350,,14.8,Fee Schedule,350% of BCBS PPO fee schedule,7.26,100,,12.336,Fee Schedule,100% of Blue ADV HMO fee schedule,47.63,90,,2.608,Percent of Total Billed Charges,90% of Total Billed Charges,23.81,45,,5.512,Percent of Total Billed Charges,45% of Total Billed Charges,47.63,90,,14.336,Percent of Total Billed Charges,90% of Total billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.4,65,,2.728,Percent of total Billed Charges,65% of Total Billed Charges,23.34,44.1,,5.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.27,95,,15.128,Percent of Total Billed Charges,95% of Total Billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.57,88,,14.016,Percent of Total Billed Charges,88% of Total Billed Charges,47.63,90,,14.336,Percent of Total Billed charges,90% of Total Billed Charges,7.26,52.92,
500CC LR IV SOLN,2580000022,CDM,258,RC,J7120,HCPCS,Outpatient,,,50.72,32.97,,50.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38.55,76,,10.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.55,350,,7.488,Fee Schedule,350% of BCBS fee schedule,18.55,350,,7.8,Fee Schedule,350% of BCBS fee schedule,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.55,350,,7.488,Fee Schedule,350% of BCBS PPO fee schedule,5.3,100,,6.24,Fee Schedule,100% of Blue ADV HMO fee schedule,45.65,90,,2.288,Percent of Total Billed Charges,90% of Total Billed Charges,22.82,45,,5.104,Percent of Total Billed Charges,45% of Total Billed Charges,45.65,90,,12.88,Percent of Total Billed Charges,90% of Total billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.97,65,,7.96,Percent of total Billed Charges,65% of Total Billed Charges,22.37,44.1,,5,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.18,95,,13.6,Percent of Total Billed Charges,95% of Total Billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.63,88,,12.592,Percent of Total Billed Charges,88% of Total Billed Charges,45.65,90,,12.88,Percent of Total Billed charges,90% of Total Billed Charges,5.3,50.72,
1000CC LR RINGERS IV SOLN,2580000023,CDM,258,RC,J7120,HCPCS,Outpatient,,,56.23,36.55,,56.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.73,76,,3.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.55,350,,1.024,Fee Schedule,350% of BCBS fee schedule,18.55,350,,1.072,Fee Schedule,350% of BCBS fee schedule,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.55,350,,1.024,Fee Schedule,350% of BCBS PPO fee schedule,5.3,100,,0.856,Fee Schedule,100% of Blue ADV HMO fee schedule,50.61,90,,2.288,Percent of Total Billed Charges,90% of Total Billed Charges,25.3,45,,10.768,Percent of Total Billed Charges,45% of Total Billed Charges,50.61,90,,3.784,Percent of Total Billed Charges,90% of Total billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.55,65,,7.376,Percent of total Billed Charges,65% of Total Billed Charges,24.8,44.1,,10.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.42,95,,3.992,Percent of Total Billed Charges,95% of Total Billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.48,88,,3.696,Percent of Total Billed Charges,88% of Total Billed Charges,50.61,90,,3.784,Percent of Total Billed charges,90% of Total Billed Charges,5.3,56.23,
1000CC D5 1/2 NS IV SOLN,2580000024,CDM,258,RC,,,Outpatient,,,49.61,32.25,,49.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,37.7,76,,9.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,35.72,72,,1.024,Percent of Total Billed Charges,72% of Total Billed Charges,37.21,75,,1.072,Percent of Total Billed charges,75% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.72,72,,1.024,Percent of Total Billed Charges,72% of Total Billed Charges,29.77,60,,0.856,Percent of Total Billed Charges,60% of Total Billed Charges,44.65,90,,2.288,Percent of Total Billed Charges,90% of Total Billed Charges,22.32,45,,4.16,Percent of Total Billed Charges,45% of Total Billed Charges,44.65,90,,11.024,Percent of Total Billed Charges,90% of Total billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.25,65,,15.552,Percent of total Billed Charges,65% of Total Billed Charges,21.88,44.1,,4.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,47.13,95,,11.632,Percent of Total Billed Charges,95% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,88,,10.776,Percent of Total Billed Charges,88% of Total Billed Charges,44.65,90,,11.024,Percent of Total Billed charges,90% of Total Billed Charges,21.88,49.61,
D5 0.2% NS 500CC IV SOLN,2580000025,CDM,258,RC,,,Outpatient,,,56.23,36.55,,56.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.73,76,,8.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.49,72,,1.024,Percent of Total Billed Charges,72% of Total Billed Charges,42.17,75,,1.072,Percent of Total Billed charges,75% of Total Billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.49,72,,1.024,Percent of Total Billed Charges,72% of Total Billed Charges,33.74,60,,0.856,Percent of Total Billed Charges,60% of Total Billed Charges,50.61,90,,10.152,Percent of Total Billed Charges,90% of Total Billed Charges,25.3,45,,14.152,Percent of Total Billed Charges,45% of Total Billed Charges,50.61,90,,10.208,Percent of Total Billed Charges,90% of Total billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.55,65,,6.008,Percent of total Billed Charges,65% of Total Billed Charges,24.8,44.1,,13.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.42,95,,10.776,Percent of Total Billed Charges,95% of Total Billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.48,88,,9.984,Percent of Total Billed Charges,88% of Total Billed Charges,50.61,90,,10.208,Percent of Total Billed charges,90% of Total Billed Charges,24.8,56.23,
D5 0.2% NS 1000ML IV SOLN,2580000026,CDM,258,RC,,,Outpatient,1000,ML,49.61,32.25,,49.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,37.7,76,,18.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,35.72,72,,1.336,Percent of Total Billed Charges,72% of Total Billed Charges,37.21,75,,1.392,Percent of Total Billed charges,75% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.72,72,,1.336,Percent of Total Billed Charges,72% of Total Billed Charges,29.77,60,,1.112,Percent of Total Billed Charges,60% of Total Billed Charges,44.65,90,,22.32,Percent of Total Billed Charges,90% of Total Billed Charges,22.32,45,,4.944,Percent of Total Billed Charges,45% of Total Billed Charges,44.65,90,,21.528,Percent of Total Billed Charges,90% of Total billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.25,65,,20.44,Percent of total Billed Charges,65% of Total Billed Charges,21.88,44.1,,4.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,47.13,95,,22.728,Percent of Total Billed Charges,95% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,88,,21.048,Percent of Total Billed Charges,88% of Total Billed Charges,44.65,90,,21.528,Percent of Total Billed charges,90% of Total Billed Charges,21.88,49.61,
500CC D5W 1/2 NS IV SOLN,2580000027,CDM,258,RC,,,Outpatient,,,56.23,36.55,,56.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.73,76,,7.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.49,72,,1.336,Percent of Total Billed Charges,72% of Total Billed Charges,42.17,75,,1.392,Percent of Total Billed charges,75% of Total Billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.49,72,,1.336,Percent of Total Billed Charges,72% of Total Billed Charges,33.74,60,,1.112,Percent of Total Billed Charges,60% of Total Billed Charges,50.61,90,,22.32,Percent of Total Billed Charges,90% of Total Billed Charges,25.3,45,,1.304,Percent of Total Billed Charges,45% of Total Billed Charges,50.61,90,,8.32,Percent of Total Billed Charges,90% of Total billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.55,65,,7.144,Percent of total Billed Charges,65% of Total Billed Charges,24.8,44.1,,1.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.42,95,,8.776,Percent of Total Billed Charges,95% of Total Billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.48,88,,8.128,Percent of Total Billed Charges,88% of Total Billed Charges,50.61,90,,8.32,Percent of Total Billed charges,90% of Total Billed Charges,24.8,56.23,
1000CC 1/2 NS SOLN,2580000028,CDM,258,RC,,,Outpatient,,,46.31,30.10,,46.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.2,76,,23.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.34,72,,0.088,Percent of Total Billed Charges,72% of Total Billed Charges,34.73,75,,0.088,Percent of Total Billed charges,75% of Total Billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.34,72,,0.088,Percent of Total Billed Charges,72% of Total Billed Charges,27.79,60,,0.072,Percent of Total Billed Charges,60% of Total Billed Charges,41.68,90,,277.032,Percent of Total Billed Charges,90% of Total Billed Charges,20.84,45,,1.144,Percent of Total Billed Charges,45% of Total Billed Charges,41.68,90,,28.304,Percent of Total Billed Charges,90% of Total billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.1,65,,1.88,Percent of total Billed Charges,65% of Total Billed Charges,20.42,44.1,,1.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,43.99,95,,29.872,Percent of Total Billed Charges,95% of Total Billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.75,88,,27.672,Percent of Total Billed Charges,88% of Total Billed Charges,41.68,90,,28.304,Percent of Total Billed charges,90% of Total Billed Charges,20.42,46.31,
1000CC D10W IV SOLN,2580000029,CDM,258,RC,,,Outpatient,,,50.72,32.97,,50.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38.55,76,,8.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36.52,72,,0.472,Percent of Total Billed Charges,72% of Total Billed Charges,38.04,75,,0.496,Percent of Total Billed charges,75% of Total Billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.52,72,,0.472,Percent of Total Billed Charges,72% of Total Billed Charges,30.43,60,,0.392,Percent of Total Billed Charges,60% of Total Billed Charges,45.65,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,22.82,45,,1.144,Percent of Total Billed Charges,45% of Total Billed Charges,45.65,90,,9.896,Percent of Total Billed Charges,90% of Total billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.97,65,,1.656,Percent of total Billed Charges,65% of Total Billed Charges,22.37,44.1,,1.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.18,95,,10.44,Percent of Total Billed Charges,95% of Total Billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.63,88,,9.672,Percent of Total Billed Charges,88% of Total Billed Charges,45.65,90,,9.896,Percent of Total Billed charges,90% of Total Billed Charges,22.37,50.72,
500CC 1/2 NS IV SOLN,2580000030,CDM,258,RC,,,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,2.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,1.352,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,1.408,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,1.352,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,1.128,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,1.144,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,2.608,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,1.656,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,1.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,2.752,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,2.552,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,2.608,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
TRAVASOL DIOW/8.5% AA SOLN,2580000031,CDM,258,RC,,,Outpatient,,,278.93,181.30,,278.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,211.99,76,,1.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,200.83,72,,367.2,Percent of Total Billed Charges,72% of Total Billed Charges,209.2,75,,382.504,Percent of Total Billed charges,75% of Total Billed Charges,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.83,72,,367.2,Percent of Total Billed Charges,72% of Total Billed Charges,167.36,60,,306,Percent of Total Billed Charges,60% of Total Billed Charges,251.04,90,,140.36,Percent of Total Billed Charges,90% of Total Billed Charges,125.52,45,,5.08,Percent of Total Billed Charges,45% of Total Billed Charges,251.04,90,,2.288,Percent of Total Billed Charges,90% of Total billed Charges,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.3,65,,1.656,Percent of total Billed Charges,65% of Total Billed Charges,123.01,44.1,,4.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,264.98,95,,2.416,Percent of Total Billed Charges,95% of Total Billed Charges,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.46,88,,2.24,Percent of Total Billed Charges,88% of Total Billed Charges,251.04,90,,2.288,Percent of Total Billed charges,90% of Total Billed Charges,123.01,278.93,
PLASMALYTEA 1000CC SOLN,2580000032,CDM,258,RC,,,Outpatient,,,101.43,65.93,,101.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,77.09,76,,1.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,73.03,72,,356.4,Percent of Total Billed Charges,72% of Total Billed Charges,76.07,75,,371.248,Percent of Total Billed charges,75% of Total Billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.03,72,,356.4,Percent of Total Billed Charges,72% of Total Billed Charges,60.86,60,,297,Percent of Total Billed Charges,60% of Total Billed Charges,91.29,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,45.64,45,,11.16,Percent of Total Billed Charges,45% of Total Billed Charges,91.29,90,,2.288,Percent of Total Billed Charges,90% of Total billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.93,65,,7.336,Percent of total Billed Charges,65% of Total Billed Charges,44.73,44.1,,10.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,96.36,95,,2.416,Percent of Total Billed Charges,95% of Total Billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.26,88,,2.24,Percent of Total Billed Charges,88% of Total Billed Charges,91.29,90,,2.288,Percent of Total Billed charges,90% of Total Billed Charges,44.73,101.43,
TRAVASOL 8.5% 500CC SOLN,2580000033,CDM,258,RC,,,Outpatient,,,321.93,209.25,,321.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,244.67,76,,1.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,231.79,72,,68.4,Percent of Total Billed Charges,72% of Total Billed Charges,241.45,75,,71.248,Percent of Total Billed charges,75% of Total Billed Charges,321.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.79,72,,68.4,Percent of Total Billed Charges,72% of Total Billed Charges,193.16,60,,57,Percent of Total Billed Charges,60% of Total Billed Charges,289.74,90,,19.048,Percent of Total Billed Charges,90% of Total Billed Charges,144.87,45,,11.16,Percent of Total Billed Charges,45% of Total Billed Charges,289.74,90,,2.288,Percent of Total Billed Charges,90% of Total billed Charges,321.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,321.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,321.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.25,65,,16.12,Percent of total Billed Charges,65% of Total Billed Charges,141.97,44.1,,10.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,305.83,95,,2.416,Percent of Total Billed Charges,95% of Total Billed Charges,321.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.3,88,,2.24,Percent of Total Billed Charges,88% of Total Billed Charges,289.74,90,,2.288,Percent of Total Billed charges,90% of Total Billed Charges,141.97,321.93,
D5 .2NS W/20K 1000ML SOLN,2580000034,CDM,258,RC,,,Outpatient,1000,ML,68.36,44.43,,68.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.95,76,,8.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49.22,72,,17.08,Percent of Total Billed Charges,72% of Total Billed Charges,51.27,75,,17.792,Percent of Total Billed charges,75% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,72,,17.08,Percent of Total Billed Charges,72% of Total Billed Charges,41.02,60,,14.232,Percent of Total Billed Charges,60% of Total Billed Charges,61.52,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,30.76,45,,138.52,Percent of Total Billed Charges,45% of Total Billed Charges,61.52,90,,10.152,Percent of Total Billed Charges,90% of Total billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.43,65,,16.12,Percent of total Billed Charges,65% of Total Billed Charges,30.15,44.1,,135.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,64.94,95,,10.72,Percent of Total Billed Charges,95% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.16,88,,9.928,Percent of Total Billed Charges,88% of Total Billed Charges,61.52,90,,10.152,Percent of Total Billed charges,90% of Total Billed Charges,30.15,68.36,
D5 .45NS W/20K 1000M SOLN,2580000035,CDM,258,RC,,,Outpatient,,,68.36,44.43,,68.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.95,76,,18.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49.22,72,,23.552,Percent of Total Billed Charges,72% of Total Billed Charges,51.27,75,,24.536,Percent of Total Billed charges,75% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,72,,23.552,Percent of Total Billed Charges,72% of Total Billed Charges,41.02,60,,19.624,Percent of Total Billed Charges,60% of Total Billed Charges,61.52,90,,15.88,Percent of Total Billed Charges,90% of Total Billed Charges,30.76,45,,7.2,Percent of Total Billed Charges,45% of Total Billed Charges,61.52,90,,22.32,Percent of Total Billed Charges,90% of Total billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.43,65,,200.08,Percent of total Billed Charges,65% of Total Billed Charges,30.15,44.1,,7.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,64.94,95,,23.56,Percent of Total Billed Charges,95% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.16,88,,21.824,Percent of Total Billed Charges,88% of Total Billed Charges,61.52,90,,22.32,Percent of Total Billed charges,90% of Total Billed Charges,30.15,68.36,
D5 .45NS W/40K 1000M SOLN,2580000036,CDM,258,RC,,,Outpatient,,,68.36,44.43,,68.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.95,76,,18.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49.22,72,,132.696,Percent of Total Billed Charges,72% of Total Billed Charges,51.27,75,,138.232,Percent of Total Billed charges,75% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,72,,132.696,Percent of Total Billed Charges,72% of Total Billed Charges,41.02,60,,110.584,Percent of Total Billed Charges,60% of Total Billed Charges,61.52,90,,100.024,Percent of Total Billed Charges,90% of Total Billed Charges,30.76,45,,7.2,Percent of Total Billed Charges,45% of Total Billed Charges,61.52,90,,22.32,Percent of Total Billed Charges,90% of Total billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.43,65,,10.4,Percent of total Billed Charges,65% of Total Billed Charges,30.15,44.1,,7.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,64.94,95,,23.56,Percent of Total Billed Charges,95% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.16,88,,21.824,Percent of Total Billed Charges,88% of Total Billed Charges,61.52,90,,22.32,Percent of Total Billed charges,90% of Total Billed Charges,30.15,68.36,
TRAVASOL 8.5 W/D50 SOLN,2580000037,CDM,258,RC,,,Outpatient,,,287.75,187.04,,287.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,218.69,76,,233.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,207.18,72,,25.664,Percent of Total Billed Charges,72% of Total Billed Charges,215.81,75,,26.728,Percent of Total Billed charges,75% of Total Billed Charges,287.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.18,72,,25.664,Percent of Total Billed Charges,72% of Total Billed Charges,172.65,60,,21.384,Percent of Total Billed Charges,60% of Total Billed Charges,258.98,90,,95.256,Percent of Total Billed Charges,90% of Total Billed Charges,129.49,45,,70.176,Percent of Total Billed Charges,45% of Total Billed Charges,258.98,90,,277.032,Percent of Total Billed Charges,90% of Total billed Charges,287.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,287.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,287.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.04,65,,10.4,Percent of total Billed Charges,65% of Total Billed Charges,126.9,44.1,,68.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,273.36,95,,292.424,Percent of Total Billed Charges,95% of Total Billed Charges,287.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,253.22,88,,270.88,Percent of Total Billed Charges,88% of Total Billed Charges,258.98,90,,277.032,Percent of Total Billed charges,90% of Total Billed Charges,126.9,287.75,
TRAVASOL 8.5% W/ELEC SOLN,2580000038,CDM,258,RC,,,Outpatient,,,295.47,192.06,,295.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,224.56,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,212.74,72,,167.616,Percent of Total Billed Charges,72% of Total Billed Charges,221.6,75,,174.6,Percent of Total Billed charges,75% of Total Billed Charges,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.74,72,,167.616,Percent of Total Billed Charges,72% of Total Billed Charges,177.28,60,,139.68,Percent of Total Billed Charges,60% of Total Billed Charges,265.92,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,132.96,45,,16.2,Percent of Total Billed Charges,45% of Total Billed Charges,265.92,90,,14.4,Percent of Total Billed Charges,90% of Total billed Charges,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.06,65,,101.368,Percent of total Billed Charges,65% of Total Billed Charges,130.3,44.1,,15.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,280.7,95,,15.2,Percent of Total Billed Charges,95% of Total Billed Charges,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.01,88,,14.08,Percent of Total Billed Charges,88% of Total Billed Charges,265.92,90,,14.4,Percent of Total Billed charges,90% of Total Billed Charges,130.3,295.47,
1/2NS 1000ML W/KCI 20 MEQ SOLN,2580000039,CDM,258,RC,,,Outpatient,1000,ML,72.77,47.30,,72.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.31,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.39,72,,175.048,Percent of Total Billed Charges,72% of Total Billed Charges,54.58,75,,182.344,Percent of Total Billed charges,75% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.39,72,,175.048,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,60,,145.872,Percent of Total Billed Charges,60% of Total Billed Charges,65.49,90,,34.928,Percent of Total Billed Charges,90% of Total Billed Charges,32.75,45,,9.528,Percent of Total Billed Charges,45% of Total Billed Charges,65.49,90,,14.4,Percent of Total Billed Charges,90% of Total billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.3,65,,23.4,Percent of total Billed Charges,65% of Total Billed Charges,32.09,44.1,,9.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,69.13,95,,15.2,Percent of Total Billed Charges,95% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.04,88,,14.08,Percent of Total Billed Charges,88% of Total Billed Charges,65.49,90,,14.4,Percent of Total Billed charges,90% of Total Billed Charges,32.09,72.77,
0.9%Sodium Chloride 5ml flush,2580000040,CDM,258,RC,,,Outpatient,5,ML,0.75,0.49,,0.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.57,76,,118.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.54,72,,24.424,Percent of Total Billed Charges,72% of Total Billed Charges,0.56,75,,25.44,Percent of Total Billed charges,75% of Total Billed Charges,0.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.54,72,,24.424,Percent of Total Billed Charges,72% of Total Billed Charges,0.45,60,,20.352,Percent of Total Billed Charges,60% of Total Billed Charges,0.68,90,,59.536,Percent of Total Billed Charges,90% of Total Billed Charges,0.34,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,0.68,90,,140.36,Percent of Total Billed Charges,90% of Total billed Charges,0.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.49,65,,13.76,Percent of total Billed Charges,65% of Total Billed Charges,0.33,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.71,95,,148.152,Percent of Total Billed Charges,95% of Total Billed Charges,0.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.66,88,,137.24,Percent of Total Billed Charges,88% of Total Billed Charges,0.68,90,,140.36,Percent of Total Billed charges,90% of Total Billed Charges,0.33,0.75,
HEALO GV 14MG/ML,2590000001,CDM,259,RC,,,Outpatient,14,GM,561.96,365.27,,561.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,427.09,76,,27.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,404.61,72,,41.096,Percent of Total Billed Charges,72% of Total Billed Charges,421.47,75,,42.808,Percent of Total Billed charges,75% of Total Billed Charges,561.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404.61,72,,41.096,Percent of Total Billed Charges,72% of Total Billed Charges,337.18,60,,34.248,Percent of Total Billed Charges,60% of Total Billed Charges,505.76,90,,95.256,Percent of Total Billed Charges,90% of Total Billed Charges,252.88,45,,7.936,Percent of Total Billed Charges,45% of Total Billed Charges,505.76,90,,32.4,Percent of Total Billed Charges,90% of Total billed Charges,561.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365.27,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,247.82,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,533.86,95,,34.2,Percent of Total Billed Charges,95% of Total Billed Charges,561.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,494.52,88,,31.68,Percent of Total Billed Charges,88% of Total Billed Charges,505.76,90,,32.4,Percent of Total Billed charges,90% of Total Billed Charges,247.82,561.96,
INF HYDRAT INITIAL 31-60 MIN,2600000001,CDM,260,RC,,,Outpatient,,,421.00,273.65,,421,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,319.96,76,,16.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,303.12,72,,205.968,Percent of Total Billed Charges,72% of Total Billed Charges,315.75,75,,214.552,Percent of Total Billed charges,75% of Total Billed Charges,421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.12,72,,205.968,Percent of Total Billed Charges,72% of Total Billed Charges,252.6,60,,171.64,Percent of Total Billed Charges,60% of Total Billed Charges,378.9,90,,47.632,Percent of Total Billed Charges,90% of Total Billed Charges,189.45,45,,50.008,Percent of Total Billed Charges,45% of Total Billed Charges,378.9,90,,19.048,Percent of Total Billed Charges,90% of Total billed Charges,421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.65,65,,11.464,Percent of total Billed Charges,65% of Total Billed Charges,185.66,44.1,,49.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,399.95,95,,20.112,Percent of Total Billed Charges,95% of Total Billed Charges,421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.48,88,,18.624,Percent of Total Billed Charges,88% of Total Billed Charges,378.9,90,,19.048,Percent of Total Billed charges,90% of Total Billed Charges,185.66,421,
INF HYDR ADDL 60 MIN,2600000002,CDM,260,RC,,,Outpatient,,,133.00,86.45,,133,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,101.08,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.76,72,,205.968,Percent of Total Billed Charges,72% of Total Billed Charges,99.75,75,,214.552,Percent of Total Billed charges,75% of Total Billed Charges,133,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.76,72,,205.968,Percent of Total Billed Charges,72% of Total Billed Charges,79.8,60,,171.64,Percent of Total Billed Charges,60% of Total Billed Charges,119.7,90,,27.784,Percent of Total Billed Charges,90% of Total Billed Charges,59.85,45,,47.632,Percent of Total Billed Charges,45% of Total Billed Charges,119.7,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,133,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.45,65,,72.24,Percent of total Billed Charges,65% of Total Billed Charges,58.65,44.1,,46.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,126.35,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,133,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.04,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,119.7,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,58.65,133,
Inf Ther Initial up to 1Hr,2600000003,CDM,260,RC,,,Outpatient,,,525.00,341.25,,525,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,399,76,,13.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,378,72,,205.968,Percent of Total Billed Charges,72% of Total Billed Charges,393.75,75,,214.552,Percent of Total Billed charges,75% of Total Billed Charges,525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378,72,,205.968,Percent of Total Billed Charges,72% of Total Billed Charges,315,60,,171.64,Percent of Total Billed Charges,60% of Total Billed Charges,472.5,90,,111.928,Percent of Total Billed Charges,90% of Total Billed Charges,236.25,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,472.5,90,,15.88,Percent of Total Billed Charges,90% of Total billed Charges,525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.25,65,,68.8,Percent of total Billed Charges,65% of Total Billed Charges,231.53,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,498.75,95,,16.76,Percent of Total Billed Charges,95% of Total Billed Charges,525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462,88,,15.52,Percent of Total Billed Charges,88% of Total Billed Charges,472.5,90,,15.88,Percent of Total Billed charges,90% of Total Billed Charges,231.53,525,
INF THER ADDL 60 MIN,2600000004,CDM,260,RC,,,Outpatient,,,116.00,75.40,,116,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,88.16,76,,84.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,83.52,72,,205.968,Percent of Total Billed Charges,72% of Total Billed Charges,87,75,,214.552,Percent of Total Billed charges,75% of Total Billed Charges,116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.52,72,,205.968,Percent of Total Billed Charges,72% of Total Billed Charges,69.6,60,,171.64,Percent of Total Billed Charges,60% of Total Billed Charges,104.4,90,,87.32,Percent of Total Billed Charges,90% of Total Billed Charges,52.2,45,,17.464,Percent of Total Billed Charges,45% of Total Billed Charges,104.4,90,,100.024,Percent of Total Billed Charges,90% of Total billed Charges,116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.4,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,51.16,44.1,,17.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,110.2,95,,105.576,Percent of Total Billed Charges,95% of Total Billed Charges,116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.08,88,,97.8,Percent of Total Billed Charges,88% of Total Billed Charges,104.4,90,,100.024,Percent of Total Billed charges,90% of Total Billed Charges,51.16,116,
INF ADDTL SEQ 1690,2600000005,CDM,260,RC,,,Outpatient,,,77.00,50.05,,77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.52,76,,80.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.44,72,,467.704,Percent of Total Billed Charges,72% of Total Billed Charges,57.75,75,,487.192,Percent of Total Billed charges,75% of Total Billed Charges,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.44,72,,467.704,Percent of Total Billed Charges,72% of Total Billed Charges,46.2,60,,389.752,Percent of Total Billed Charges,60% of Total Billed Charges,69.3,90,,38.896,Percent of Total Billed Charges,90% of Total Billed Charges,34.65,45,,29.768,Percent of Total Billed Charges,45% of Total Billed Charges,69.3,90,,95.256,Percent of Total Billed Charges,90% of Total billed Charges,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.05,65,,25.224,Percent of total Billed Charges,65% of Total Billed Charges,33.96,44.1,,29.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.15,95,,100.552,Percent of Total Billed Charges,95% of Total Billed Charges,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.76,88,,93.136,Percent of Total Billed Charges,88% of Total Billed Charges,69.3,90,,95.256,Percent of Total Billed charges,90% of Total Billed Charges,33.96,77,
INF CONCURRENT,2600000006,CDM,260,RC,,,Outpatient,,,344.00,223.60,,344,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,261.44,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,247.68,72,,561.224,Percent of Total Billed Charges,72% of Total Billed Charges,258,75,,584.608,Percent of Total Billed charges,75% of Total Billed Charges,344,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.68,72,,561.224,Percent of Total Billed Charges,72% of Total Billed Charges,206.4,60,,467.688,Percent of Total Billed Charges,60% of Total Billed Charges,309.6,90,,64.296,Percent of Total Billed Charges,90% of Total Billed Charges,154.8,45,,47.632,Percent of Total Billed Charges,45% of Total Billed Charges,309.6,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,344,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,344,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,344,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,223.6,65,,43,Percent of total Billed Charges,65% of Total Billed Charges,151.7,44.1,,46.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,326.8,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,344,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.72,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,309.6,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,151.7,344,
INJ IM SQ AB,2600000007,CDM,260,RC,,,Outpatient,,,257.00,167.05,,257,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,195.32,76,,29.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,185.04,72,,13.592,Percent of Total Billed Charges,72% of Total Billed Charges,192.75,75,,14.16,Percent of Total Billed charges,75% of Total Billed Charges,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.04,72,,13.592,Percent of Total Billed Charges,72% of Total Billed Charges,154.2,60,,11.328,Percent of Total Billed Charges,60% of Total Billed Charges,231.3,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,115.65,45,,23.816,Percent of Total Billed Charges,45% of Total Billed Charges,231.3,90,,34.928,Percent of Total Billed Charges,90% of Total billed Charges,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.05,65,,68.8,Percent of total Billed Charges,65% of Total Billed Charges,113.34,44.1,,23.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,244.15,95,,36.864,Percent of Total Billed Charges,95% of Total Billed Charges,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.16,88,,34.152,Percent of Total Billed Charges,88% of Total Billed Charges,231.3,90,,34.928,Percent of Total Billed charges,90% of Total Billed Charges,113.34,257,
Ther/Proph/DX IV Push 1st,2600000008,CDM,260,RC,,,Outpatient,,,397.00,258.05,,397,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,301.72,76,,50.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,285.84,72,,2.072,Percent of Total Billed Charges,72% of Total Billed Charges,297.75,75,,2.16,Percent of Total Billed charges,75% of Total Billed Charges,397,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.84,72,,2.072,Percent of Total Billed Charges,72% of Total Billed Charges,238.2,60,,1.728,Percent of Total Billed Charges,60% of Total Billed Charges,357.3,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,178.65,45,,13.896,Percent of Total Billed Charges,45% of Total Billed Charges,357.3,90,,59.536,Percent of Total Billed Charges,90% of Total billed Charges,397,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258.05,65,,34.4,Percent of total Billed Charges,65% of Total Billed Charges,175.08,44.1,,13.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,377.15,95,,62.848,Percent of Total Billed Charges,95% of Total Billed Charges,397,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.36,88,,58.216,Percent of Total Billed Charges,88% of Total Billed Charges,357.3,90,,59.536,Percent of Total Billed charges,90% of Total Billed Charges,175.08,397,
IV PUSH ADDL SEQ NEW,2600000009,CDM,260,RC,,,Outpatient,,,159.00,103.35,,159,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.84,76,,80.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.48,72,,55.744,Percent of Total Billed Charges,72% of Total Billed Charges,119.25,75,,58.072,Percent of Total Billed charges,75% of Total Billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.48,72,,55.744,Percent of Total Billed Charges,72% of Total Billed Charges,95.4,60,,46.456,Percent of Total Billed Charges,60% of Total Billed Charges,143.1,90,,26.192,Percent of Total Billed Charges,90% of Total Billed Charges,71.55,45,,55.96,Percent of Total Billed Charges,45% of Total Billed Charges,143.1,90,,95.256,Percent of Total Billed Charges,90% of Total billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.35,65,,20.064,Percent of total Billed Charges,65% of Total Billed Charges,70.12,44.1,,54.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,151.05,95,,100.552,Percent of Total Billed Charges,95% of Total Billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.92,88,,93.136,Percent of Total Billed Charges,88% of Total Billed Charges,143.1,90,,95.256,Percent of Total Billed charges,90% of Total Billed Charges,70.12,159,
IV PUSH ADDL SEQ SAM,2600000010,CDM,260,RC,,,Outpatient,,,113.00,73.45,,113,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,85.88,76,,40.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,81.36,72,,55.744,Percent of Total Billed Charges,72% of Total Billed Charges,84.75,75,,58.072,Percent of Total Billed charges,75% of Total Billed Charges,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.36,72,,55.744,Percent of Total Billed Charges,72% of Total Billed Charges,67.8,60,,46.456,Percent of Total Billed Charges,60% of Total Billed Charges,101.7,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,50.85,45,,43.664,Percent of Total Billed Charges,45% of Total Billed Charges,101.7,90,,47.632,Percent of Total Billed Charges,90% of Total billed Charges,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.45,65,,80.832,Percent of total Billed Charges,65% of Total Billed Charges,49.83,44.1,,42.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,107.35,95,,50.272,Percent of Total Billed Charges,95% of Total Billed Charges,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.44,88,,46.568,Percent of Total Billed Charges,88% of Total Billed Charges,101.7,90,,47.632,Percent of Total Billed charges,90% of Total Billed Charges,49.83,113,
VISIPAQUE 320 200CC CONTRAST,2600000011,CDM,260,RC,,,Outpatient,,,172.00,111.80,,172,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.72,76,,23.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.84,72,,12.688,Percent of Total Billed Charges,72% of Total Billed Charges,129,75,,13.216,Percent of Total Billed charges,75% of Total Billed Charges,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.84,72,,12.688,Percent of Total Billed Charges,72% of Total Billed Charges,103.2,60,,10.576,Percent of Total Billed Charges,60% of Total Billed Charges,154.8,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,77.4,45,,19.448,Percent of Total Billed Charges,45% of Total Billed Charges,154.8,90,,27.784,Percent of Total Billed Charges,90% of Total billed Charges,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.8,65,,63.064,Percent of total Billed Charges,65% of Total Billed Charges,75.85,44.1,,19.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.4,95,,29.328,Percent of Total Billed Charges,95% of Total Billed Charges,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.36,88,,27.168,Percent of Total Billed Charges,88% of Total Billed Charges,154.8,90,,27.784,Percent of Total Billed charges,90% of Total Billed Charges,75.85,172,
LIDOCAINE 4% PF 5ML,2600000012,CDM,260,RC,,,Outpatient,,,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,94.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,2.416,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,2.52,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,2.416,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,2.016,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,32.152,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,111.928,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,28.088,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,31.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,118.144,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,109.44,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,111.928,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
NOVOLIN 70/30 INSULIN INJ,2600000013,CDM,260,RC,,,Outpatient,,,38.59,25.08,,38.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.33,76,,73.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.78,72,,6.04,Percent of Total Billed Charges,72% of Total Billed Charges,28.94,75,,6.288,Percent of Total Billed charges,75% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.78,72,,6.04,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,60,,5.032,Percent of Total Billed Charges,60% of Total Billed Charges,34.73,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,17.37,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,34.73,90,,87.32,Percent of Total Billed Charges,90% of Total billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.08,65,,46.44,Percent of total Billed Charges,65% of Total Billed Charges,17.02,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.66,95,,92.176,Percent of Total Billed Charges,95% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.96,88,,85.384,Percent of Total Billed Charges,88% of Total Billed Charges,34.73,90,,87.32,Percent of Total Billed charges,90% of Total Billed Charges,17.02,38.59,
IV THERAPY  MISC IN,2600000014,CDM,260,RC,,,Outpatient,,,257.99,167.69,,257.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,196.07,76,,32.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,185.75,72,,6.04,Percent of Total Billed Charges,72% of Total Billed Charges,193.49,75,,6.288,Percent of Total Billed charges,75% of Total Billed Charges,257.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.75,72,,6.04,Percent of Total Billed Charges,72% of Total Billed Charges,154.79,60,,5.032,Percent of Total Billed Charges,60% of Total Billed Charges,232.19,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,116.1,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,232.19,90,,38.896,Percent of Total Billed Charges,90% of Total billed Charges,257.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.69,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,113.77,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,245.09,95,,41.056,Percent of Total Billed Charges,95% of Total Billed Charges,257.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.03,88,,38.032,Percent of Total Billed Charges,88% of Total Billed Charges,232.19,90,,38.896,Percent of Total Billed charges,90% of Total Billed Charges,113.77,257.99,
THEOPHYLLINE 80MG/15ML ELIXIR,2600000015,CDM,260,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,54.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,6.04,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,6.288,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,6.04,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,5.032,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,26.192,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,13.096,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,64.296,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,12.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,67.872,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,62.864,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,64.296,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
IV THER INF DIFF/SEQ 16-90 MIN,2600000017,CDM,260,RC,,,Outpatient,,,77.00,50.05,,77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.52,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.44,72,,6.04,Percent of Total Billed Charges,72% of Total Billed Charges,57.75,75,,6.288,Percent of Total Billed charges,75% of Total Billed Charges,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.44,72,,6.04,Percent of Total Billed Charges,72% of Total Billed Charges,46.2,60,,5.032,Percent of Total Billed Charges,60% of Total Billed Charges,69.3,90,,32.544,Percent of Total Billed Charges,90% of Total Billed Charges,34.65,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,69.3,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.05,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,33.96,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.15,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.76,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,69.3,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,33.96,77,
INF HYDRAT INITIAL 31-90MIN,2600000018,CDM,260,RC,,,Outpatient,,,440.98,286.64,,440.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,335.14,76,,22.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,317.51,72,,6.04,Percent of Total Billed Charges,72% of Total Billed Charges,330.74,75,,6.288,Percent of Total Billed charges,75% of Total Billed Charges,440.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,317.51,72,,6.04,Percent of Total Billed Charges,72% of Total Billed Charges,264.59,60,,5.032,Percent of Total Billed Charges,60% of Total Billed Charges,396.88,90,,19.84,Percent of Total Billed Charges,90% of Total Billed Charges,198.44,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,396.88,90,,26.192,Percent of Total Billed Charges,90% of Total billed Charges,440.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.64,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,194.47,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,418.93,95,,27.648,Percent of Total Billed Charges,95% of Total Billed Charges,440.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,388.06,88,,25.608,Percent of Total Billed Charges,88% of Total Billed Charges,396.88,90,,26.192,Percent of Total Billed charges,90% of Total Billed Charges,194.47,440.98,
INF HYDRAT EA ADD 60MIN,2600000019,CDM,260,RC,,,Outpatient,,,91.50,59.48,,91.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,69.54,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.88,72,,6.04,Percent of Total Billed Charges,72% of Total Billed Charges,68.63,75,,6.288,Percent of Total Billed charges,75% of Total Billed Charges,91.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.88,72,,6.04,Percent of Total Billed Charges,72% of Total Billed Charges,54.9,60,,5.032,Percent of Total Billed Charges,60% of Total Billed Charges,82.35,90,,19.048,Percent of Total Billed Charges,90% of Total Billed Charges,41.18,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,82.35,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,91.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.48,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,40.35,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,86.93,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,91.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.52,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,82.35,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,40.35,91.5,
INF THERAPY INITL UP TO 60MIN,2600000020,CDM,260,RC,,,Outpatient,,,441.05,286.68,,441.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,335.2,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,317.56,72,,6.04,Percent of Total Billed Charges,72% of Total Billed Charges,330.79,75,,6.288,Percent of Total Billed charges,75% of Total Billed Charges,441.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,317.56,72,,6.04,Percent of Total Billed Charges,72% of Total Billed Charges,264.63,60,,5.032,Percent of Total Billed Charges,60% of Total Billed Charges,396.95,90,,38.896,Percent of Total Billed Charges,90% of Total Billed Charges,198.47,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,396.95,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,441.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,441.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,441.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.68,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,194.5,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,419,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,441.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,388.12,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,396.95,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,194.5,441.05,
INF THER ADDLT 60MIN,2600000021,CDM,260,RC,,,Outpatient,,,110.22,71.64,,110.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,83.77,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,79.36,72,,6.04,Percent of Total Billed Charges,72% of Total Billed Charges,82.67,75,,6.288,Percent of Total Billed charges,75% of Total Billed Charges,110.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.36,72,,6.04,Percent of Total Billed Charges,72% of Total Billed Charges,66.13,60,,5.032,Percent of Total Billed Charges,60% of Total Billed Charges,99.2,90,,491.368,Percent of Total Billed Charges,90% of Total Billed Charges,49.6,45,,13.096,Percent of Total Billed Charges,45% of Total Billed Charges,99.2,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,110.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.64,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,48.61,44.1,,12.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,104.71,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,110.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.99,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,99.2,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,48.61,110.22,
MED INF SEQUANTIAL,2600000022,CDM,260,RC,,,Outpatient,,,77.00,50.05,,77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.52,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.44,72,,6.04,Percent of Total Billed Charges,72% of Total Billed Charges,57.75,75,,6.288,Percent of Total Billed charges,75% of Total Billed Charges,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.44,72,,6.04,Percent of Total Billed Charges,72% of Total Billed Charges,46.2,60,,5.032,Percent of Total Billed Charges,60% of Total Billed Charges,69.3,90,,36.52,Percent of Total Billed Charges,90% of Total Billed Charges,34.65,45,,43.664,Percent of Total Billed Charges,45% of Total Billed Charges,69.3,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.05,65,,18.92,Percent of total Billed Charges,65% of Total Billed Charges,33.96,44.1,,42.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.15,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.76,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,69.3,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,33.96,77,
EZIO AD 10AD 15G INT  DL 25MM,2700000001,CDM,270,RC,,,Outpatient,,,120.00,78.00,,120,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,91.2,76,,16.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,86.4,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,90,75,,120,Percent of Total Billed charges,75% of Total Billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.4,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,72,60,,96,Percent of Total Billed Charges,60% of Total Billed Charges,108,90,,17.896,Percent of Total Billed Charges,90% of Total Billed Charges,54,45,,245.68,Percent of Total Billed Charges,45% of Total Billed Charges,108,90,,19.84,Percent of Total Billed Charges,90% of Total billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78,65,,28.088,Percent of total Billed Charges,65% of Total Billed Charges,52.92,44.1,,240.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,114,95,,20.944,Percent of Total Billed Charges,95% of Total Billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.6,88,,19.4,Percent of Total Billed Charges,88% of Total Billed Charges,108,90,,19.84,Percent of Total Billed charges,90% of Total Billed Charges,52.92,120,
EZIO AD 10AD 15G INTE OBE 45MM,2700000002,CDM,270,RC,,,Outpatient,,,125.00,81.25,,125,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95,76,,16.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90,72,,219.456,Percent of Total Billed Charges,72% of Total Billed Charges,93.75,75,,228.6,Percent of Total Billed charges,75% of Total Billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,72,,219.456,Percent of Total Billed Charges,72% of Total Billed Charges,75,60,,182.88,Percent of Total Billed Charges,60% of Total Billed Charges,112.5,90,,6.048,Percent of Total Billed Charges,90% of Total Billed Charges,56.25,45,,18.256,Percent of Total Billed Charges,45% of Total Billed Charges,112.5,90,,19.048,Percent of Total Billed Charges,90% of Total billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.25,65,,354.872,Percent of total Billed Charges,65% of Total Billed Charges,55.13,44.1,,17.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,118.75,95,,20.112,Percent of Total Billed Charges,95% of Total Billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110,88,,18.624,Percent of Total Billed Charges,88% of Total Billed Charges,112.5,90,,19.048,Percent of Total Billed charges,90% of Total Billed Charges,55.13,125,
EZIO AD 10PA 15G INTE NDL 15MM,2700000003,CDM,270,RC,,,Outpatient,,,120.00,78.00,,120,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,91.2,76,,32.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,86.4,72,,33.024,Percent of Total Billed Charges,72% of Total Billed Charges,90,75,,34.4,Percent of Total Billed charges,75% of Total Billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.4,72,,33.024,Percent of Total Billed Charges,72% of Total Billed Charges,72,60,,27.52,Percent of Total Billed Charges,60% of Total Billed Charges,108,90,,0.424,Percent of Total Billed Charges,90% of Total Billed Charges,54,45,,152.016,Percent of Total Billed Charges,45% of Total Billed Charges,108,90,,38.896,Percent of Total Billed Charges,90% of Total billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78,65,,26.376,Percent of total Billed Charges,65% of Total Billed Charges,52.92,44.1,,148.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,114,95,,41.056,Percent of Total Billed Charges,95% of Total Billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.6,88,,38.032,Percent of Total Billed Charges,88% of Total Billed Charges,108,90,,38.896,Percent of Total Billed charges,90% of Total Billed Charges,52.92,120,
hysteroscopy w endo ablation,2700000004,CDM,360,RC,,,Outpatient,,,5363.66,3486.38,,5363.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4076.38,76,,414.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3861.84,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,4022.75,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,5363.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3861.84,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,3218.2,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,4827.29,90,,0.4,Percent of Total Billed Charges,90% of Total Billed Charges,2413.65,45,,152.016,Percent of Total Billed Charges,45% of Total Billed Charges,4827.29,90,,491.368,Percent of Total Billed Charges,90% of Total billed Charges,5363.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5363.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5363.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3486.38,65,,219.576,Percent of total Billed Charges,65% of Total Billed Charges,2365.37,44.1,,148.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,5095.48,95,,518.664,Percent of Total Billed Charges,95% of Total Billed Charges,5363.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4720.02,88,,480.448,Percent of Total Billed Charges,88% of Total Billed Charges,4827.29,90,,491.368,Percent of Total Billed charges,90% of Total Billed Charges,2365.37,5363.66,
EVIDENCE COLLECTION,2700000005,CDM,272,RC,,,Outpatient,,,50.00,32.50,,50,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38,76,,30.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36,72,,92.72,Percent of Total Billed Charges,72% of Total Billed Charges,37.5,75,,96.584,Percent of Total Billed charges,75% of Total Billed Charges,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36,72,,92.72,Percent of Total Billed Charges,72% of Total Billed Charges,30,60,,77.264,Percent of Total Billed Charges,60% of Total Billed Charges,45,90,,0.4,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,45,,152.016,Percent of Total Billed Charges,45% of Total Billed Charges,45,90,,36.52,Percent of Total Billed Charges,90% of Total billed Charges,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.5,65,,219.576,Percent of total Billed Charges,65% of Total Billed Charges,22.05,44.1,,148.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,47.5,95,,38.544,Percent of Total Billed Charges,95% of Total Billed Charges,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44,88,,35.704,Percent of Total Billed Charges,88% of Total Billed Charges,45,90,,36.52,Percent of Total Billed charges,90% of Total Billed Charges,22.05,50,
EXCESS SUPPLIES AND MATERIALS,2700000006,CDM,270,RC,,,Outpatient,,,125.69,81.70,,125.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95.52,76,,256.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90.5,72,,90.176,Percent of Total Billed Charges,72% of Total Billed Charges,94.27,75,,93.936,Percent of Total Billed charges,75% of Total Billed Charges,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.5,72,,90.176,Percent of Total Billed Charges,72% of Total Billed Charges,75.41,60,,75.152,Percent of Total Billed Charges,60% of Total Billed Charges,113.12,90,,0.256,Percent of Total Billed Charges,90% of Total Billed Charges,56.56,45,,26.464,Percent of Total Billed Charges,45% of Total Billed Charges,113.12,90,,304.024,Percent of Total Billed Charges,90% of Total billed Charges,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.7,65,,219.576,Percent of total Billed Charges,65% of Total Billed Charges,55.43,44.1,,25.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,119.41,95,,320.92,Percent of Total Billed Charges,95% of Total Billed Charges,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.61,88,,297.272,Percent of Total Billed Charges,88% of Total Billed Charges,113.12,90,,304.024,Percent of Total Billed charges,90% of Total Billed Charges,55.43,125.69,
SANE SUPPLIES,2700000007,CDM,270,RC,,,Outpatient,,,100.00,65.00,,100,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,76,76,,256.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,72,72,,122.56,Percent of Total Billed Charges,72% of Total Billed Charges,75,75,,127.672,Percent of Total Billed charges,75% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72,72,,122.56,Percent of Total Billed Charges,72% of Total Billed Charges,60,60,,102.136,Percent of Total Billed Charges,60% of Total Billed Charges,90,90,,1.008,Percent of Total Billed Charges,90% of Total Billed Charges,45,45,,8.952,Percent of Total Billed Charges,45% of Total Billed Charges,90,90,,304.024,Percent of Total Billed Charges,90% of Total billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,65,,38.224,Percent of total Billed Charges,65% of Total Billed Charges,44.1,44.1,,8.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,95,95,,320.92,Percent of Total Billed Charges,95% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88,88,,297.272,Percent of Total Billed Charges,88% of Total Billed Charges,90,90,,304.024,Percent of Total Billed charges,90% of Total Billed Charges,44.1,100,
TRAY FOLEY 16FR SILI LATX FREE,2700000008,CDM,270,RC,A4338,HCPCS,Outpatient,,,38.96,25.32,,38.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.61,76,,256.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,48.3,350,,92.72,Fee Schedule,350% of BCBS fee schedule,48.3,350,,96.584,Fee Schedule,350% of BCBS fee schedule,38.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.3,350,,92.72,Fee Schedule,350% of BCBS PPO fee schedule,13.8,100,,77.264,Fee Schedule,100% of Blue ADV HMO fee schedule,35.06,90,,0.904,Percent of Total Billed Charges,90% of Total Billed Charges,17.53,45,,3.024,Percent of Total Billed Charges,45% of Total Billed Charges,35.06,90,,304.024,Percent of Total Billed Charges,90% of Total billed Charges,38.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.32,65,,12.928,Percent of total Billed Charges,65% of Total Billed Charges,17.18,44.1,,2.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.01,95,,320.92,Percent of Total Billed Charges,95% of Total Billed Charges,38.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.28,88,,297.272,Percent of Total Billed Charges,88% of Total Billed Charges,35.06,90,,304.024,Percent of Total Billed charges,90% of Total Billed Charges,13.8,48.3,
STERI STRIP 1/2 X 4,2700000009,CDM,270,RC,A4649,HCPCS,Outpatient,,,25.36,16.48,,25.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.27,76,,44.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.26,72,,92.72,Percent of Total Billed Charges,72% of Total Billed Charges,19.02,75,,96.584,Percent of Total Billed charges,75% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.26,72,,92.72,Percent of Total Billed Charges,72% of Total Billed Charges,15.22,60,,77.264,Percent of Total Billed Charges,60% of Total Billed Charges,22.82,90,,1.12,Percent of Total Billed Charges,90% of Total Billed Charges,11.41,45,,0.216,Percent of Total Billed Charges,45% of Total Billed Charges,22.82,90,,52.92,Percent of Total Billed Charges,90% of Total billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,65,,4.368,Percent of total Billed Charges,65% of Total Billed Charges,11.18,44.1,,0.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.09,95,,55.864,Percent of Total Billed Charges,95% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,88,,51.744,Percent of Total Billed Charges,88% of Total Billed Charges,22.82,90,,52.92,Percent of Total Billed charges,90% of Total Billed Charges,11.18,25.36,
TRACH UNCUF SZ 7,2700000010,CDM,270,RC,A7520,HCPCS,Outpatient,,,116.73,75.87,,116.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,88.71,76,,15.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,187.04,350,,90.176,Fee Schedule,350% of BCBS fee schedule,187.04,350,,93.936,Fee Schedule,350% of BCBS fee schedule,116.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.04,350,,90.176,Fee Schedule,350% of BCBS PPO fee schedule,53.44,100,,75.152,Fee Schedule,100% of Blue ADV HMO fee schedule,105.06,90,,8.08,Percent of Total Billed Charges,90% of Total Billed Charges,52.53,45,,0.2,Percent of Total Billed Charges,45% of Total Billed Charges,105.06,90,,17.896,Percent of Total Billed Charges,90% of Total billed Charges,116.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.87,65,,0.304,Percent of total Billed Charges,65% of Total Billed Charges,51.48,44.1,,0.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,110.89,95,,18.896,Percent of Total Billed Charges,95% of Total Billed Charges,116.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.72,88,,17.504,Percent of Total Billed Charges,88% of Total Billed Charges,105.06,90,,17.896,Percent of Total Billed charges,90% of Total Billed Charges,51.48,187.04,
TRACH UNCUF SZ 6,2700000011,CDM,270,RC,A7520,HCPCS,Outpatient,,,116.69,75.85,,116.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,88.68,76,,5.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,187.04,350,,94.616,Fee Schedule,350% of BCBS fee schedule,187.04,350,,98.56,Fee Schedule,350% of BCBS fee schedule,116.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.04,350,,94.616,Fee Schedule,350% of BCBS PPO fee schedule,53.44,100,,78.848,Fee Schedule,100% of Blue ADV HMO fee schedule,105.02,90,,1.304,Percent of Total Billed Charges,90% of Total Billed Charges,52.51,45,,0.2,Percent of Total Billed Charges,45% of Total Billed Charges,105.02,90,,6.048,Percent of Total Billed Charges,90% of Total billed Charges,116.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.85,65,,0.288,Percent of total Billed Charges,65% of Total Billed Charges,51.46,44.1,,0.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,110.86,95,,6.384,Percent of Total Billed Charges,95% of Total Billed Charges,116.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.69,88,,5.912,Percent of Total Billed Charges,88% of Total Billed Charges,105.02,90,,6.048,Percent of Total Billed charges,90% of Total Billed Charges,51.46,187.04,
TUBE LEVINE 18FR VEN,2700000012,CDM,272,RC,B4082,HCPCS,Outpatient,,,27.56,17.91,,16.33,125,,,Fee Schedule,125% of CMS OPPS Rate,20.95,76,,0.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.84,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,20.67,75,,13.232,Percent of Total Billed charges,75% of Total Billed Charges,13.06,100,,,Fee Schedule,100% of CMS OPPS Rate,19.84,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,60,,10.584,Percent of Total Billed Charges,60% of Total Billed Charges,24.8,90,,1.768,Percent of Total Billed Charges,90% of Total Billed Charges,12.4,45,,0.128,Percent of Total Billed Charges,45% of Total Billed Charges,24.8,90,,0.424,Percent of Total Billed Charges,90% of Total billed Charges,13.06,100,,,Fee Schedule,100% of CMS OPPS Rate,13.06,100,,,Fee Schedule,100% of CMS OPPS Rate,13.06,100,,,Fee Schedule,100% of CMS OPPS Rate,26.12,200,,0.288,Fee Schedule,200% of CMS OPPS Rate,12.15,44.1,,0.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.18,95,,0.448,Percent of Total Billed Charges,95% of Total Billed Charges,9.8,75,,,Fee Schedule,75% of CMS OPPS Rate,24.25,88,,0.416,Percent of Total Billed Charges,88% of Total Billed Charges,24.8,90,,0.424,Percent of Total Billed charges,90% of Total Billed Charges,9.8,26.18,
HOSPICE HOME CARE,2700000013,CDM,651,RC,Q5001,HCPCS,Outpatient,,,231.53,150.49,,231.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,175.96,76,,0.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,166.7,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,173.65,75,,16.536,Percent of Total Billed charges,75% of Total Billed Charges,231.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.7,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,138.92,60,,13.232,Percent of Total Billed Charges,60% of Total Billed Charges,208.38,90,,5.384,Percent of Total Billed Charges,90% of Total Billed Charges,104.19,45,,0.504,Percent of Total Billed Charges,45% of Total Billed Charges,208.38,90,,0.4,Percent of Total Billed Charges,90% of Total billed Charges,231.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.49,65,,0.184,Percent of total Billed Charges,65% of Total Billed Charges,102.1,44.1,,0.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,219.95,95,,0.416,Percent of Total Billed Charges,95% of Total Billed Charges,231.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.75,88,,0.384,Percent of Total Billed Charges,88% of Total Billed Charges,208.38,90,,0.4,Percent of Total Billed charges,90% of Total Billed Charges,102.1,231.53,
GENERAL IP CARE,2700000014,CDM,655,RC,Q5005,HCPCS,Outpatient,,,934.92,607.70,,934.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,710.54,76,,0.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,673.14,72,,39.376,Percent of Total Billed Charges,72% of Total Billed Charges,701.19,75,,41.016,Percent of Total Billed charges,75% of Total Billed Charges,934.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,673.14,72,,39.376,Percent of Total Billed Charges,72% of Total Billed Charges,560.95,60,,32.816,Percent of Total Billed Charges,60% of Total Billed Charges,841.43,90,,3.328,Percent of Total Billed Charges,90% of Total Billed Charges,420.71,45,,0.448,Percent of Total Billed Charges,45% of Total Billed Charges,841.43,90,,0.4,Percent of Total Billed Charges,90% of Total billed Charges,934.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,934.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,934.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.7,65,,0.728,Percent of total Billed Charges,65% of Total Billed Charges,412.3,44.1,,0.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,888.17,95,,0.416,Percent of Total Billed Charges,95% of Total Billed Charges,934.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,822.73,88,,0.384,Percent of Total Billed Charges,88% of Total Billed Charges,841.43,90,,0.4,Percent of Total Billed charges,90% of Total Billed Charges,412.3,934.92,
IP RESPITE CARE,2700000015,CDM,655,RC,Q5005,HCPCS,Outpatient,,,221.60,144.04,,221.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,168.42,76,,0.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,159.55,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,166.2,75,,24.472,Percent of Total Billed charges,75% of Total Billed Charges,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.55,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,132.96,60,,19.576,Percent of Total Billed Charges,60% of Total Billed Charges,199.44,90,,1.296,Percent of Total Billed Charges,90% of Total Billed Charges,99.72,45,,0.56,Percent of Total Billed Charges,45% of Total Billed Charges,199.44,90,,0.256,Percent of Total Billed Charges,90% of Total billed Charges,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.04,65,,0.648,Percent of total Billed Charges,65% of Total Billed Charges,97.73,44.1,,0.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,210.52,95,,0.264,Percent of Total Billed Charges,95% of Total Billed Charges,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.01,88,,0.248,Percent of Total Billed Charges,88% of Total Billed Charges,199.44,90,,0.256,Percent of Total Billed charges,90% of Total Billed Charges,97.73,221.6,
PEDS VENAFLOW ELITE CALF,2700000016,CDM,270,RC,,,Outpatient,,,94.48,61.41,,94.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,71.8,76,,0.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,68.03,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,70.86,75,,24.472,Percent of Total Billed charges,75% of Total Billed Charges,94.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.03,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,56.69,60,,19.576,Percent of Total Billed Charges,60% of Total Billed Charges,85.03,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,42.52,45,,4.04,Percent of Total Billed Charges,45% of Total Billed Charges,85.03,90,,1.008,Percent of Total Billed Charges,90% of Total billed Charges,94.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.41,65,,0.808,Percent of total Billed Charges,65% of Total Billed Charges,41.67,44.1,,3.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,89.76,95,,1.064,Percent of Total Billed Charges,95% of Total Billed Charges,94.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.14,88,,0.984,Percent of Total Billed Charges,88% of Total Billed Charges,85.03,90,,1.008,Percent of Total Billed charges,90% of Total Billed Charges,41.67,94.48,
PEDS DRESNG AQUACEL SURG 3.5X6,2700000017,CDM,270,RC,,,Outpatient,,,140.14,91.09,,140.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.51,76,,0.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.9,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,105.11,75,,24.472,Percent of Total Billed charges,75% of Total Billed Charges,140.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.9,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,84.08,60,,19.576,Percent of Total Billed Charges,60% of Total Billed Charges,126.13,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,63.06,45,,0.648,Percent of Total Billed Charges,45% of Total Billed Charges,126.13,90,,0.904,Percent of Total Billed Charges,90% of Total billed Charges,140.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.09,65,,5.832,Percent of total Billed Charges,65% of Total Billed Charges,61.8,44.1,,0.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,133.13,95,,0.952,Percent of Total Billed Charges,95% of Total Billed Charges,140.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.32,88,,0.88,Percent of Total Billed Charges,88% of Total Billed Charges,126.13,90,,0.904,Percent of Total Billed charges,90% of Total Billed Charges,61.8,140.14,
VENAFLOW ELITE CALF,2700000018,CDM,270,RC,,,Outpatient,,,94.48,61.41,,94.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,71.8,76,,0.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,68.03,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,70.86,75,,16.536,Percent of Total Billed charges,75% of Total Billed Charges,94.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.03,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,56.69,60,,13.232,Percent of Total Billed Charges,60% of Total Billed Charges,85.03,90,,4.248,Percent of Total Billed Charges,90% of Total Billed Charges,42.52,45,,0.888,Percent of Total Billed Charges,45% of Total Billed Charges,85.03,90,,1.12,Percent of Total Billed Charges,90% of Total billed Charges,94.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.41,65,,0.944,Percent of total Billed Charges,65% of Total Billed Charges,41.67,44.1,,0.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,89.76,95,,1.184,Percent of Total Billed Charges,95% of Total Billed Charges,94.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.14,88,,1.096,Percent of Total Billed Charges,88% of Total Billed Charges,85.03,90,,1.12,Percent of Total Billed charges,90% of Total Billed Charges,41.67,94.48,
TRANSFER GAIT BELT,2700000019,CDM,270,RC,,,Outpatient,,,36.38,23.65,,36.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.65,76,,6.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.19,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,27.29,75,,21.832,Percent of Total Billed charges,75% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.19,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,21.83,60,,17.464,Percent of Total Billed Charges,60% of Total Billed Charges,32.74,90,,23.816,Percent of Total Billed Charges,90% of Total Billed Charges,16.37,45,,2.696,Percent of Total Billed Charges,45% of Total Billed Charges,32.74,90,,8.08,Percent of Total Billed Charges,90% of Total billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.65,65,,1.28,Percent of total Billed Charges,65% of Total Billed Charges,16.04,44.1,,2.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.56,95,,8.528,Percent of Total Billed Charges,95% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.01,88,,7.896,Percent of Total Billed Charges,88% of Total Billed Charges,32.74,90,,8.08,Percent of Total Billed charges,90% of Total Billed Charges,16.04,36.38,
DRESNG AQUACEL SURG 3.5 X 6,2700000020,CDM,270,RC,,,Outpatient,,,140.14,91.09,,140.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.51,76,,1.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.9,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,105.11,75,,19.848,Percent of Total Billed charges,75% of Total Billed Charges,140.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.9,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,84.08,60,,15.88,Percent of Total Billed Charges,60% of Total Billed Charges,126.13,90,,22.928,Percent of Total Billed Charges,90% of Total Billed Charges,63.06,45,,1.664,Percent of Total Billed Charges,45% of Total Billed Charges,126.13,90,,1.304,Percent of Total Billed Charges,90% of Total billed Charges,140.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.09,65,,3.888,Percent of total Billed Charges,65% of Total Billed Charges,61.8,44.1,,1.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,133.13,95,,1.376,Percent of Total Billed Charges,95% of Total Billed Charges,140.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.32,88,,1.272,Percent of Total Billed Charges,88% of Total Billed Charges,126.13,90,,1.304,Percent of Total Billed charges,90% of Total Billed Charges,61.8,140.14,
VALVE LOPEZ,2700000021,CDM,270,RC,,,Outpatient,,,4.94,3.21,,4.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.75,76,,1.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.56,72,,29.848,Percent of Total Billed Charges,72% of Total Billed Charges,3.71,75,,31.096,Percent of Total Billed charges,75% of Total Billed Charges,4.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.56,72,,29.848,Percent of Total Billed Charges,72% of Total Billed Charges,2.96,60,,24.872,Percent of Total Billed Charges,60% of Total Billed Charges,4.45,90,,47.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.22,45,,0.648,Percent of Total Billed Charges,45% of Total Billed Charges,4.45,90,,1.768,Percent of Total Billed Charges,90% of Total billed Charges,4.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.21,65,,2.4,Percent of total Billed Charges,65% of Total Billed Charges,2.18,44.1,,0.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.69,95,,1.872,Percent of Total Billed Charges,95% of Total Billed Charges,4.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.35,88,,1.728,Percent of Total Billed Charges,88% of Total Billed Charges,4.45,90,,1.768,Percent of Total Billed charges,90% of Total Billed Charges,2.18,4.94,
CONTINUOUS HOME CARE,2700000022,CDM,270,RC,,,Outpatient,,,899.64,584.77,,899.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,683.73,76,,4.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,647.74,72,,97.8,Percent of Total Billed Charges,72% of Total Billed Charges,674.73,75,,101.872,Percent of Total Billed charges,75% of Total Billed Charges,899.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,647.74,72,,97.8,Percent of Total Billed Charges,72% of Total Billed Charges,539.78,60,,81.496,Percent of Total Billed Charges,60% of Total Billed Charges,809.68,90,,40.344,Percent of Total Billed Charges,90% of Total Billed Charges,404.84,45,,1.44,Percent of Total Billed Charges,45% of Total Billed Charges,809.68,90,,5.384,Percent of Total Billed Charges,90% of Total billed Charges,899.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,899.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,899.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,584.77,65,,0.936,Percent of total Billed Charges,65% of Total Billed Charges,396.74,44.1,,1.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,854.66,95,,5.688,Percent of Total Billed Charges,95% of Total Billed Charges,899.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,791.68,88,,5.264,Percent of Total Billed Charges,88% of Total Billed Charges,809.68,90,,5.384,Percent of Total Billed charges,90% of Total Billed Charges,396.74,899.64,
BIOMET GUIDEPIN,2700000023,CDM,270,RC,,,Outpatient,,,153.25,99.61,,153.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,116.47,76,,2.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,110.34,72,,97.8,Percent of Total Billed Charges,72% of Total Billed Charges,114.94,75,,101.872,Percent of Total Billed charges,75% of Total Billed Charges,153.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.34,72,,97.8,Percent of Total Billed Charges,72% of Total Billed Charges,91.95,60,,81.496,Percent of Total Billed Charges,60% of Total Billed Charges,137.93,90,,88.48,Percent of Total Billed Charges,90% of Total Billed Charges,68.96,45,,5.4,Percent of Total Billed Charges,45% of Total Billed Charges,137.93,90,,3.328,Percent of Total Billed Charges,90% of Total billed Charges,153.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.61,65,,2.08,Percent of total Billed Charges,65% of Total Billed Charges,67.58,44.1,,5.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,145.59,95,,3.512,Percent of Total Billed Charges,95% of Total Billed Charges,153.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.86,88,,3.256,Percent of Total Billed Charges,88% of Total Billed Charges,137.93,90,,3.328,Percent of Total Billed charges,90% of Total Billed Charges,67.58,153.25,
RETRO NEEDLE,2700000024,CDM,270,RC,,,Outpatient,,,59.54,38.70,,59.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.25,76,,1.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.87,72,,45.72,Percent of Total Billed Charges,72% of Total Billed Charges,44.66,75,,47.632,Percent of Total Billed charges,75% of Total Billed Charges,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.87,72,,45.72,Percent of Total Billed Charges,72% of Total Billed Charges,35.72,60,,38.104,Percent of Total Billed Charges,60% of Total Billed Charges,53.59,90,,25.272,Percent of Total Billed Charges,90% of Total Billed Charges,26.79,45,,2.128,Percent of Total Billed Charges,45% of Total Billed Charges,53.59,90,,1.296,Percent of Total Billed Charges,90% of Total billed Charges,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.7,65,,7.8,Percent of total Billed Charges,65% of Total Billed Charges,26.26,44.1,,2.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,56.56,95,,1.368,Percent of Total Billed Charges,95% of Total Billed Charges,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.4,88,,1.264,Percent of Total Billed Charges,88% of Total Billed Charges,53.59,90,,1.296,Percent of Total Billed charges,90% of Total Billed Charges,26.26,59.54,
LAP CHOLE KIT,2700000025,CDM,270,RC,,,Outpatient,,,1940.40,1261.26,,1940.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1474.7,76,,2.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1397.09,72,,98.432,Percent of Total Billed Charges,72% of Total Billed Charges,1455.3,75,,102.536,Percent of Total Billed charges,75% of Total Billed Charges,1940.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1397.09,72,,98.432,Percent of Total Billed Charges,72% of Total Billed Charges,1164.24,60,,82.024,Percent of Total Billed Charges,60% of Total Billed Charges,1746.36,90,,34.816,Percent of Total Billed Charges,90% of Total Billed Charges,873.18,45,,11.912,Percent of Total Billed Charges,45% of Total Billed Charges,1746.36,90,,2.88,Percent of Total Billed Charges,90% of Total billed Charges,1940.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1940.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1940.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1261.26,65,,3.072,Percent of total Billed Charges,65% of Total Billed Charges,855.72,44.1,,11.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,1843.38,95,,3.04,Percent of Total Billed Charges,95% of Total Billed Charges,1940.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1707.55,88,,2.816,Percent of Total Billed Charges,88% of Total Billed Charges,1746.36,90,,2.88,Percent of Total Billed charges,90% of Total Billed Charges,855.72,1940.4,
GERTIE MARX SP NDL 24GX3.5,2700000026,CDM,270,RC,,,Outpatient,,,76.07,49.45,,76.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,57.81,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,54.77,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,57.05,75,,43,Percent of Total Billed charges,75% of Total Billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.77,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,45.64,60,,34.4,Percent of Total Billed Charges,60% of Total Billed Charges,68.46,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,34.23,45,,11.464,Percent of Total Billed Charges,45% of Total Billed Charges,68.46,90,,10.8,Percent of Total Billed Charges,90% of Total billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.45,65,,17.2,Percent of total Billed Charges,65% of Total Billed Charges,33.55,44.1,,11.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,72.27,95,,11.4,Percent of Total Billed Charges,95% of Total Billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.94,88,,10.56,Percent of Total Billed Charges,88% of Total Billed Charges,68.46,90,,10.8,Percent of Total Billed charges,90% of Total Billed Charges,33.55,76.07,
PROCEDURE PK ARTHROS,2700000027,CDM,270,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,3.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,117.752,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,23.616,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,4.248,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,16.56,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,23.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,4.488,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,4.152,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,4.248,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
APPLIED MEDICAL STEN,2700000028,CDM,270,RC,,,Outpatient,,,1865.43,1212.53,,1865.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1417.73,76,,20.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1343.11,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,1399.07,75,,9.928,Percent of Total Billed charges,75% of Total Billed Charges,1865.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1343.11,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,1119.26,60,,7.936,Percent of Total Billed Charges,60% of Total Billed Charges,1678.89,90,,1170,Percent of Total Billed Charges,90% of Total Billed Charges,839.44,45,,20.168,Percent of Total Billed Charges,45% of Total Billed Charges,1678.89,90,,23.816,Percent of Total Billed Charges,90% of Total billed Charges,1865.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1865.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1865.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1212.53,65,,34.12,Percent of total Billed Charges,65% of Total Billed Charges,822.65,44.1,,19.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,1772.16,95,,25.144,Percent of Total Billed Charges,95% of Total Billed Charges,1865.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1641.58,88,,23.288,Percent of Total Billed Charges,88% of Total Billed Charges,1678.89,90,,23.816,Percent of Total Billed charges,90% of Total Billed Charges,822.65,1865.43,
DEPUY PREP KIT W/ RE,2700000029,CDM,270,RC,,,Outpatient,,,23.15,15.05,,23.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.59,76,,19.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.67,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,17.36,75,,12.568,Percent of Total Billed charges,75% of Total Billed Charges,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.67,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,13.89,60,,10.056,Percent of Total Billed Charges,60% of Total Billed Charges,20.84,90,,178.2,Percent of Total Billed Charges,90% of Total Billed Charges,10.42,45,,44.24,Percent of Total Billed Charges,45% of Total Billed Charges,20.84,90,,22.928,Percent of Total Billed Charges,90% of Total billed Charges,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.05,65,,29.136,Percent of total Billed Charges,65% of Total Billed Charges,10.21,44.1,,43.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.99,95,,24.2,Percent of Total Billed Charges,95% of Total Billed Charges,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.37,88,,22.416,Percent of Total Billed Charges,88% of Total Billed Charges,20.84,90,,22.928,Percent of Total Billed charges,90% of Total Billed Charges,10.21,23.15,
WYTEX CAST 6,2700000030,CDM,270,RC,,,Outpatient,,,66.15,43.00,,66.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,50.27,76,,39.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47.63,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,49.61,75,,16.536,Percent of Total Billed charges,75% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.63,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,39.69,60,,13.232,Percent of Total Billed Charges,60% of Total Billed Charges,59.54,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,29.77,45,,12.64,Percent of Total Billed Charges,45% of Total Billed Charges,59.54,90,,47.24,Percent of Total Billed Charges,90% of Total billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,65,,63.904,Percent of total Billed Charges,65% of Total Billed Charges,29.17,44.1,,12.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.84,95,,49.864,Percent of Total Billed Charges,95% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.21,88,,46.192,Percent of Total Billed Charges,88% of Total Billed Charges,59.54,90,,47.24,Percent of Total Billed charges,90% of Total Billed Charges,29.17,66.15,
STRYKER JUMBO PATRIO,2700000031,CDM,270,RC,,,Outpatient,,,52.92,34.40,,52.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.22,76,,34.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.1,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,39.69,75,,14.56,Percent of Total Billed charges,75% of Total Billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.1,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,31.75,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,47.63,90,,0.136,Percent of Total Billed Charges,90% of Total Billed Charges,23.81,45,,17.408,Percent of Total Billed Charges,45% of Total Billed Charges,47.63,90,,40.344,Percent of Total Billed Charges,90% of Total billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.4,65,,18.256,Percent of total Billed Charges,65% of Total Billed Charges,23.34,44.1,,17.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.27,95,,42.584,Percent of Total Billed Charges,95% of Total Billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.57,88,,39.448,Percent of Total Billed Charges,88% of Total Billed Charges,47.63,90,,40.344,Percent of Total Billed charges,90% of Total Billed Charges,23.34,52.92,
Z23591224 LOCKING,2700000032,CDM,270,RC,,,Outpatient,,,502.74,326.78,,502.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,382.08,76,,74.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,361.97,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,377.06,75,,21.832,Percent of Total Billed charges,75% of Total Billed Charges,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.97,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,301.64,60,,17.464,Percent of Total Billed Charges,60% of Total Billed Charges,452.47,90,,1.12,Percent of Total Billed Charges,90% of Total Billed Charges,226.23,45,,5.76,Percent of Total Billed Charges,45% of Total Billed Charges,452.47,90,,88.48,Percent of Total Billed Charges,90% of Total billed Charges,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.78,65,,25.144,Percent of total Billed Charges,65% of Total Billed Charges,221.71,44.1,,5.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,477.6,95,,93.4,Percent of Total Billed Charges,95% of Total Billed Charges,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,442.41,88,,86.512,Percent of Total Billed Charges,88% of Total Billed Charges,452.47,90,,88.48,Percent of Total Billed charges,90% of Total Billed Charges,221.71,502.74,
Z11474041 4.0 CANN,2700000033,CDM,270,RC,,,Outpatient,,,953.66,619.88,,953.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,724.78,76,,21.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,686.64,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,715.25,75,,28.448,Percent of Total Billed charges,75% of Total Billed Charges,953.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,686.64,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,572.2,60,,22.76,Percent of Total Billed Charges,60% of Total Billed Charges,858.29,90,,1.184,Percent of Total Billed Charges,90% of Total Billed Charges,429.15,45,,4.68,Percent of Total Billed Charges,45% of Total Billed Charges,858.29,90,,25.272,Percent of Total Billed Charges,90% of Total billed Charges,953.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,953.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,953.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,619.88,65,,8.32,Percent of total Billed Charges,65% of Total Billed Charges,420.56,44.1,,4.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,905.98,95,,26.68,Percent of Total Billed Charges,95% of Total Billed Charges,953.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,839.22,88,,24.712,Percent of Total Billed Charges,88% of Total Billed Charges,858.29,90,,25.272,Percent of Total Billed charges,90% of Total Billed Charges,420.56,953.66,
Z225718012 ITST 12,2700000034,CDM,278,RC,,,Outpatient,,,4352.67,2829.24,,4352.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3308.03,76,,29.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3133.92,72,,77.48,Percent of Total Billed Charges,72% of Total Billed Charges,3133.92,72,,80.704,Percent of Total Billed charges,72% of Total Billed Charges,4352.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3133.92,72,,77.48,Percent of Total Billed Charges,72% of Total Billed Charges,2611.6,60,,64.568,Percent of Total Billed Charges,60% of Total Billed Charges,3917.4,90,,1.232,Percent of Total Billed Charges,90% of Total Billed Charges,1958.7,45,,585,Percent of Total Billed Charges,45% of Total Billed Charges,3917.4,90,,34.816,Percent of Total Billed Charges,90% of Total billed Charges,4352.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4352.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4352.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2829.24,65,,6.76,Percent of total Billed Charges,65% of Total Billed Charges,1919.53,44.1,,573.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,4135.04,95,,36.744,Percent of Total Billed Charges,95% of Total Billed Charges,4352.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3830.35,88,,34.04,Percent of Total Billed Charges,88% of Total Billed Charges,3917.4,90,,34.816,Percent of Total Billed charges,90% of Total Billed Charges,1919.53,4352.67,
Z225330011 TIBIAL,2700000035,CDM,278,RC,,,Outpatient,,,4407.80,2865.07,,4407.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3349.93,76,,9.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3173.62,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,3173.62,72,,6.616,Percent of Total Billed charges,72% of Total Billed Charges,4407.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3173.62,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,2644.68,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,3967.02,90,,0.64,Percent of Total Billed Charges,90% of Total Billed Charges,1983.51,45,,89.104,Percent of Total Billed Charges,45% of Total Billed Charges,3967.02,90,,11.52,Percent of Total Billed Charges,90% of Total billed Charges,4407.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4407.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4407.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2865.07,65,,845,Percent of total Billed Charges,65% of Total Billed Charges,1943.84,44.1,,87.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,4187.41,95,,12.16,Percent of Total Billed Charges,95% of Total Billed Charges,4407.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3878.86,88,,11.264,Percent of Total Billed Charges,88% of Total Billed Charges,3967.02,90,,11.52,Percent of Total Billed charges,90% of Total Billed Charges,1943.84,4407.8,
Z78711361 FEMREVCA,2700000036,CDM,278,RC,,,Outpatient,,,30338.60,19720.09,,30338.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23057.34,76,,7.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21843.79,72,,88.904,Percent of Total Billed Charges,72% of Total Billed Charges,21843.79,72,,92.608,Percent of Total Billed charges,72% of Total Billed Charges,30338.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21843.79,72,,88.904,Percent of Total Billed Charges,72% of Total Billed Charges,18203.16,60,,74.088,Percent of Total Billed Charges,60% of Total Billed Charges,27304.74,90,,3.36,Percent of Total Billed Charges,90% of Total Billed Charges,13652.37,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,27304.74,90,,9.36,Percent of Total Billed Charges,90% of Total billed Charges,30338.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30338.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30338.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19720.09,65,,128.704,Percent of total Billed Charges,65% of Total Billed Charges,13379.32,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,28821.67,95,,9.88,Percent of Total Billed Charges,95% of Total Billed Charges,30338.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26697.97,88,,9.152,Percent of Total Billed Charges,88% of Total Billed Charges,27304.74,90,,9.36,Percent of Total Billed charges,90% of Total Billed Charges,13379.32,30338.6,
Z78710110 BUILDUP,2700000037,CDM,278,RC,,,Outpatient,,,2647.10,1720.62,,2647.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2011.8,76,,988,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1905.91,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,1905.91,72,,36.384,Percent of Total Billed charges,72% of Total Billed Charges,2647.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1905.91,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,1588.26,60,,29.104,Percent of Total Billed Charges,60% of Total Billed Charges,2382.39,90,,4.168,Percent of Total Billed Charges,90% of Total Billed Charges,1191.2,45,,0.072,Percent of Total Billed Charges,45% of Total Billed Charges,2382.39,90,,1170,Percent of Total Billed Charges,90% of Total billed Charges,2647.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2647.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2647.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1720.62,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1167.37,44.1,,0.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,2514.75,95,,1235,Percent of Total Billed Charges,95% of Total Billed Charges,2647.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2329.45,88,,1144,Percent of Total Billed Charges,88% of Total Billed Charges,2382.39,90,,1170,Percent of Total Billed charges,90% of Total Billed Charges,1167.37,2647.1,
Z781846 FEMORAL HEA,2700000038,CDM,278,RC,,,Outpatient,,,2899.58,1884.73,,2899.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2203.68,76,,150.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2087.7,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,2087.7,72,,1.984,Percent of Total Billed charges,72% of Total Billed Charges,2899.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2087.7,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,1739.75,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,2609.62,90,,9.208,Percent of Total Billed Charges,90% of Total Billed Charges,1304.81,45,,0.56,Percent of Total Billed Charges,45% of Total Billed Charges,2609.62,90,,178.2,Percent of Total Billed Charges,90% of Total billed Charges,2899.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2899.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2899.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1884.73,65,,0.096,Percent of total Billed Charges,65% of Total Billed Charges,1278.71,44.1,,0.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,2754.6,95,,188.104,Percent of Total Billed Charges,95% of Total Billed Charges,2899.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2551.63,88,,174.24,Percent of Total Billed Charges,88% of Total Billed Charges,2609.62,90,,178.2,Percent of Total Billed charges,90% of Total Billed Charges,1278.71,2899.58,
Z490004051 WASHER,2700000039,CDM,270,RC,,,Outpatient,,,130.10,84.57,,130.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.88,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,93.67,72,,83.824,Percent of Total Billed Charges,72% of Total Billed Charges,97.58,75,,87.32,Percent of Total Billed charges,75% of Total Billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.67,72,,83.824,Percent of Total Billed Charges,72% of Total Billed Charges,78.06,60,,69.856,Percent of Total Billed Charges,60% of Total Billed Charges,117.09,90,,18.504,Percent of Total Billed Charges,90% of Total Billed Charges,58.55,45,,0.592,Percent of Total Billed Charges,45% of Total Billed Charges,117.09,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.57,65,,0.808,Percent of total Billed Charges,65% of Total Billed Charges,57.37,44.1,,0.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,123.6,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.49,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,117.09,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,57.37,130.1,
Z22534055 5.5 CORT,2700000040,CDM,270,RC,,,Outpatient,,,743.09,483.01,,743.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,564.75,76,,0.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,535.02,72,,2.104,Percent of Total Billed Charges,72% of Total Billed Charges,557.32,75,,2.192,Percent of Total Billed charges,75% of Total Billed Charges,743.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.02,72,,2.104,Percent of Total Billed Charges,72% of Total Billed Charges,445.85,60,,1.752,Percent of Total Billed Charges,60% of Total Billed Charges,668.78,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,334.39,45,,0.616,Percent of Total Billed Charges,45% of Total Billed Charges,668.78,90,,0.136,Percent of Total Billed Charges,90% of Total billed Charges,743.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,743.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,743.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,483.01,65,,0.856,Percent of total Billed Charges,65% of Total Billed Charges,327.7,44.1,,0.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,705.94,95,,0.144,Percent of Total Billed Charges,95% of Total Billed Charges,743.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,653.92,88,,0.136,Percent of Total Billed Charges,88% of Total Billed Charges,668.78,90,,0.136,Percent of Total Billed charges,90% of Total Billed Charges,327.7,743.09,
Z22537555 5.5 CORT,2700000041,CDM,270,RC,,,Outpatient,,,743.09,483.01,,743.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,564.75,76,,0.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,535.02,72,,85.728,Percent of Total Billed Charges,72% of Total Billed Charges,557.32,75,,89.304,Percent of Total Billed charges,75% of Total Billed Charges,743.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.02,72,,85.728,Percent of Total Billed Charges,72% of Total Billed Charges,445.85,60,,71.44,Percent of Total Billed Charges,60% of Total Billed Charges,668.78,90,,1.28,Percent of Total Billed Charges,90% of Total Billed Charges,334.39,45,,0.32,Percent of Total Billed Charges,45% of Total Billed Charges,668.78,90,,1.12,Percent of Total Billed Charges,90% of Total billed Charges,743.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,743.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,743.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,483.01,65,,0.888,Percent of total Billed Charges,65% of Total Billed Charges,327.7,44.1,,0.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,705.94,95,,1.176,Percent of Total Billed Charges,95% of Total Billed Charges,743.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,653.92,88,,1.088,Percent of Total Billed Charges,88% of Total Billed Charges,668.78,90,,1.12,Percent of Total Billed charges,90% of Total Billed Charges,327.7,743.09,
Z22401216 RETROFEN,2700000042,CDM,278,RC,,,Outpatient,,,6139.82,3990.88,,6139.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4666.26,76,,1,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4420.67,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,4420.67,72,,1.328,Percent of Total Billed charges,72% of Total Billed Charges,6139.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4420.67,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,3683.89,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,5525.84,90,,1.28,Percent of Total Billed Charges,90% of Total Billed Charges,2762.92,45,,1.68,Percent of Total Billed Charges,45% of Total Billed Charges,5525.84,90,,1.184,Percent of Total Billed Charges,90% of Total billed Charges,6139.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6139.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6139.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3990.88,65,,0.464,Percent of total Billed Charges,65% of Total Billed Charges,2707.66,44.1,,1.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,5832.83,95,,1.248,Percent of Total Billed Charges,95% of Total Billed Charges,6139.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5403.04,88,,1.152,Percent of Total Billed Charges,88% of Total Billed Charges,5525.84,90,,1.184,Percent of Total Billed charges,90% of Total Billed Charges,2707.66,6139.82,
Z114794GUIDE PIN 1,2700000043,CDM,270,RC,,,Outpatient,,,84.89,55.18,,84.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,64.52,76,,1.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.12,72,,40.008,Percent of Total Billed Charges,72% of Total Billed Charges,63.67,75,,41.68,Percent of Total Billed charges,75% of Total Billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,72,,40.008,Percent of Total Billed Charges,72% of Total Billed Charges,50.93,60,,33.344,Percent of Total Billed Charges,60% of Total Billed Charges,76.4,90,,1.28,Percent of Total Billed Charges,90% of Total Billed Charges,38.2,45,,2.088,Percent of Total Billed Charges,45% of Total Billed Charges,76.4,90,,1.232,Percent of Total Billed Charges,90% of Total billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.18,65,,2.432,Percent of total Billed Charges,65% of Total Billed Charges,37.44,44.1,,2.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,80.65,95,,1.296,Percent of Total Billed Charges,95% of Total Billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.7,88,,1.2,Percent of Total Billed Charges,88% of Total Billed Charges,76.4,90,,1.232,Percent of Total Billed charges,90% of Total Billed Charges,37.44,84.89,
Z48352401 5.5 CORT,2700000044,CDM,270,RC,,,Outpatient,,,135.61,88.15,,135.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,103.06,76,,0.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,97.64,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,101.71,75,,15.216,Percent of Total Billed charges,75% of Total Billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.64,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,81.37,60,,12.176,Percent of Total Billed Charges,60% of Total Billed Charges,122.05,90,,1.672,Percent of Total Billed Charges,90% of Total Billed Charges,61.02,45,,4.608,Percent of Total Billed Charges,45% of Total Billed Charges,122.05,90,,0.64,Percent of Total Billed Charges,90% of Total billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.15,65,,3.008,Percent of total Billed Charges,65% of Total Billed Charges,59.8,44.1,,4.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,128.83,95,,0.68,Percent of Total Billed Charges,95% of Total Billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.34,88,,0.624,Percent of Total Billed Charges,88% of Total Billed Charges,122.05,90,,0.64,Percent of Total Billed charges,90% of Total Billed Charges,59.8,135.61,
Z225419509 HUMNAI,2700000045,CDM,278,RC,,,Outpatient,,,6605.08,4293.30,,6605.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5019.86,76,,2.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4755.66,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,4755.66,72,,19.848,Percent of Total Billed charges,72% of Total Billed Charges,6605.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4755.66,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,3963.05,60,,15.88,Percent of Total Billed Charges,60% of Total Billed Charges,5944.57,90,,1.672,Percent of Total Billed Charges,90% of Total Billed Charges,2972.29,45,,9.256,Percent of Total Billed Charges,45% of Total Billed Charges,5944.57,90,,3.36,Percent of Total Billed Charges,90% of Total billed Charges,6605.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6605.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6605.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4293.3,65,,6.648,Percent of total Billed Charges,65% of Total Billed Charges,2912.84,44.1,,9.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,6274.83,95,,3.552,Percent of Total Billed Charges,95% of Total Billed Charges,6605.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5812.47,88,,3.288,Percent of Total Billed Charges,88% of Total Billed Charges,5944.57,90,,3.36,Percent of Total Billed charges,90% of Total Billed Charges,2912.84,6605.08,
Z23592235 LOCKING,2700000046,CDM,270,RC,,,Outpatient,,,454.23,295.25,,454.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,345.21,76,,3.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,327.05,72,,177.176,Percent of Total Billed Charges,72% of Total Billed Charges,340.67,75,,184.56,Percent of Total Billed charges,75% of Total Billed Charges,454.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.05,72,,177.176,Percent of Total Billed Charges,72% of Total Billed Charges,272.54,60,,147.648,Percent of Total Billed Charges,60% of Total Billed Charges,408.81,90,,0.112,Percent of Total Billed Charges,90% of Total Billed Charges,204.4,45,,4.68,Percent of Total Billed Charges,45% of Total Billed Charges,408.81,90,,4.168,Percent of Total Billed Charges,90% of Total billed Charges,454.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,454.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,454.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.25,65,,13.368,Percent of total Billed Charges,65% of Total Billed Charges,200.32,44.1,,4.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,431.52,95,,4.4,Percent of Total Billed Charges,95% of Total Billed Charges,454.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.72,88,,4.08,Percent of Total Billed Charges,88% of Total Billed Charges,408.81,90,,4.168,Percent of Total Billed charges,90% of Total Billed Charges,200.32,454.23,
ORTHOSORB PIN,2700000047,CDM,270,RC,,,Outpatient,,,2322.97,1509.93,,2322.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1765.46,76,,7.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1672.54,72,,45.72,Percent of Total Billed Charges,72% of Total Billed Charges,1742.23,75,,47.632,Percent of Total Billed charges,75% of Total Billed Charges,2322.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1672.54,72,,45.72,Percent of Total Billed Charges,72% of Total Billed Charges,1393.78,60,,38.104,Percent of Total Billed Charges,60% of Total Billed Charges,2090.67,90,,0.592,Percent of Total Billed Charges,90% of Total Billed Charges,1045.34,45,,0.64,Percent of Total Billed Charges,45% of Total Billed Charges,2090.67,90,,9.208,Percent of Total Billed Charges,90% of Total billed Charges,2322.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.93,65,,6.76,Percent of total Billed Charges,65% of Total Billed Charges,1024.43,44.1,,0.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,2206.82,95,,9.72,Percent of Total Billed Charges,95% of Total Billed Charges,2322.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2044.21,88,,9.008,Percent of Total Billed Charges,88% of Total Billed Charges,2090.67,90,,9.208,Percent of Total Billed charges,90% of Total Billed Charges,1024.43,2322.97,
Z23484835 3.5 CORT,2700000048,CDM,270,RC,,,Outpatient,,,190.73,123.97,,190.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.95,76,,15.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,137.33,72,,45.72,Percent of Total Billed Charges,72% of Total Billed Charges,143.05,75,,47.632,Percent of Total Billed charges,75% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.33,72,,45.72,Percent of Total Billed Charges,72% of Total Billed Charges,114.44,60,,38.104,Percent of Total Billed Charges,60% of Total Billed Charges,171.66,90,,1.696,Percent of Total Billed Charges,90% of Total Billed Charges,85.83,45,,0.64,Percent of Total Billed Charges,45% of Total Billed Charges,171.66,90,,18.504,Percent of Total Billed Charges,90% of Total billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.97,65,,0.928,Percent of total Billed Charges,65% of Total Billed Charges,84.11,44.1,,0.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,181.19,95,,19.536,Percent of Total Billed Charges,95% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.84,88,,18.096,Percent of Total Billed Charges,88% of Total Billed Charges,171.66,90,,18.504,Percent of Total Billed charges,90% of Total Billed Charges,84.11,190.73,
EXTENSION SET 3 PORT MANIFOLD,2700000049,CDM,270,RC,,,Outpatient,,,4.00,2.60,,4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.04,76,,7.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.88,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,3,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.88,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,2.4,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.6,90,,459,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,45,,0.64,Percent of Total Billed Charges,45% of Total Billed Charges,3.6,90,,9.36,Percent of Total Billed Charges,90% of Total billed Charges,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.6,65,,0.928,Percent of total Billed Charges,65% of Total Billed Charges,1.76,44.1,,0.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.8,95,,9.88,Percent of Total Billed Charges,95% of Total Billed Charges,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.52,88,,9.152,Percent of Total Billed Charges,88% of Total Billed Charges,3.6,90,,9.36,Percent of Total Billed charges,90% of Total Billed Charges,1.76,4,
500CC NS FOR IRRIG SOLN,2700000051,CDM,270,RC,,,Outpatient,,,71.66,46.58,,71.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.46,76,,1.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.6,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,53.75,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,43,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,64.49,90,,445.504,Percent of Total Billed Charges,90% of Total Billed Charges,32.25,45,,0.832,Percent of Total Billed Charges,45% of Total Billed Charges,64.49,90,,1.28,Percent of Total Billed Charges,90% of Total billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.58,65,,0.928,Percent of total Billed Charges,65% of Total Billed Charges,31.6,44.1,,0.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.08,95,,1.352,Percent of Total Billed Charges,95% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,88,,1.256,Percent of Total Billed Charges,88% of Total Billed Charges,64.49,90,,1.28,Percent of Total Billed charges,90% of Total Billed Charges,31.6,71.66,
1500CC N/S FOR IRRIG SOLN,2700000052,CDM,270,RC,,,Outpatient,,,90.41,58.77,,90.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.71,76,,1.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.1,72,,45.72,Percent of Total Billed Charges,72% of Total Billed Charges,67.81,75,,47.632,Percent of Total Billed charges,75% of Total Billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.1,72,,45.72,Percent of Total Billed Charges,72% of Total Billed Charges,54.25,60,,38.104,Percent of Total Billed Charges,60% of Total Billed Charges,81.37,90,,85.504,Percent of Total Billed Charges,90% of Total Billed Charges,40.68,45,,0.832,Percent of Total Billed Charges,45% of Total Billed Charges,81.37,90,,1.28,Percent of Total Billed Charges,90% of Total billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.77,65,,1.208,Percent of total Billed Charges,65% of Total Billed Charges,39.87,44.1,,0.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.89,95,,1.352,Percent of Total Billed Charges,95% of Total Billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.56,88,,1.256,Percent of Total Billed Charges,88% of Total Billed Charges,81.37,90,,1.28,Percent of Total Billed charges,90% of Total Billed Charges,39.87,90.41,
3000CC H2O FOR IRRIG SOLN,2700000053,CDM,270,RC,,,Outpatient,,,87.10,56.62,,87.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.2,76,,1.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.71,72,,30.48,Percent of Total Billed Charges,72% of Total Billed Charges,65.33,75,,31.752,Percent of Total Billed charges,75% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.71,72,,30.48,Percent of Total Billed Charges,72% of Total Billed Charges,52.26,60,,25.4,Percent of Total Billed Charges,60% of Total Billed Charges,78.39,90,,21.352,Percent of Total Billed Charges,90% of Total Billed Charges,39.2,45,,0.056,Percent of Total Billed Charges,45% of Total Billed Charges,78.39,90,,1.28,Percent of Total Billed Charges,90% of Total billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.62,65,,1.208,Percent of total Billed Charges,65% of Total Billed Charges,38.41,44.1,,0.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.75,95,,1.352,Percent of Total Billed Charges,95% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.65,88,,1.256,Percent of Total Billed Charges,88% of Total Billed Charges,78.39,90,,1.28,Percent of Total Billed charges,90% of Total Billed Charges,38.41,87.1,
3000CC NS FOR IRRIG SOLN,2700000054,CDM,270,RC,,,Outpatient,,,102.53,66.64,,102.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,77.92,76,,1.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,73.82,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,76.9,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.82,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,61.52,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,92.28,90,,29.44,Percent of Total Billed Charges,90% of Total Billed Charges,46.14,45,,0.296,Percent of Total Billed Charges,45% of Total Billed Charges,92.28,90,,1.672,Percent of Total Billed Charges,90% of Total billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.64,65,,0.08,Percent of total Billed Charges,65% of Total Billed Charges,45.22,44.1,,0.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,97.4,95,,1.76,Percent of Total Billed Charges,95% of Total Billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.23,88,,1.632,Percent of Total Billed Charges,88% of Total Billed Charges,92.28,90,,1.672,Percent of Total Billed charges,90% of Total Billed Charges,45.22,102.53,
CURASOL GEL WOUND,2700000055,CDM,270,RC,,,Outpatient,,,73.87,48.02,,73.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.14,76,,1.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.19,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,55.4,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.19,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,44.32,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,66.48,90,,165.872,Percent of Total Billed Charges,90% of Total Billed Charges,33.24,45,,0.848,Percent of Total Billed Charges,45% of Total Billed Charges,66.48,90,,1.672,Percent of Total Billed Charges,90% of Total billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.02,65,,0.424,Percent of total Billed Charges,65% of Total Billed Charges,32.58,44.1,,0.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,70.18,95,,1.76,Percent of Total Billed Charges,95% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.01,88,,1.632,Percent of Total Billed Charges,88% of Total Billed Charges,66.48,90,,1.672,Percent of Total Billed charges,90% of Total Billed Charges,32.58,73.87,
NOVOSOURCE RENAL NUT,2700000056,CDM,270,RC,,,Outpatient,,,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,0.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,14.248,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,14.84,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,14.248,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,11.872,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,32.08,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,229.504,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,0.112,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,1.224,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,224.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,0.112,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,0.104,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,0.112,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
DRESNG AQUACEL SURG 3.5 X 6,2700000058,CDM,270,RC,,,Outpatient,,,140.14,91.09,,140.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.51,76,,1.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.9,72,,24.136,Percent of Total Billed Charges,72% of Total Billed Charges,105.11,75,,25.144,Percent of Total Billed charges,75% of Total Billed Charges,140.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.9,72,,24.136,Percent of Total Billed Charges,72% of Total Billed Charges,84.08,60,,20.112,Percent of Total Billed Charges,60% of Total Billed Charges,126.13,90,,218.808,Percent of Total Billed Charges,90% of Total Billed Charges,63.06,45,,42.752,Percent of Total Billed Charges,45% of Total Billed Charges,126.13,90,,1.696,Percent of Total Billed Charges,90% of Total billed Charges,140.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.09,65,,321.752,Percent of total Billed Charges,65% of Total Billed Charges,61.8,44.1,,41.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,133.13,95,,1.784,Percent of Total Billed Charges,95% of Total Billed Charges,140.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.32,88,,1.656,Percent of Total Billed Charges,88% of Total Billed Charges,126.13,90,,1.696,Percent of Total Billed charges,90% of Total Billed Charges,61.8,140.14,
VENAFLOW ELITE CALF,2700000059,CDM,270,RC,,,Outpatient,,,94.48,61.41,,94.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,71.8,76,,387.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,68.03,72,,118.12,Percent of Total Billed Charges,72% of Total Billed Charges,70.86,75,,123.04,Percent of Total Billed charges,75% of Total Billed Charges,94.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.03,72,,118.12,Percent of Total Billed Charges,72% of Total Billed Charges,56.69,60,,98.432,Percent of Total Billed Charges,60% of Total Billed Charges,85.03,90,,30.528,Percent of Total Billed Charges,90% of Total Billed Charges,42.52,45,,10.672,Percent of Total Billed Charges,45% of Total Billed Charges,85.03,90,,459,Percent of Total Billed Charges,90% of Total billed Charges,94.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.41,65,,61.752,Percent of total Billed Charges,65% of Total Billed Charges,41.67,44.1,,10.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,89.76,95,,484.504,Percent of Total Billed Charges,95% of Total Billed Charges,94.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.14,88,,448.8,Percent of Total Billed Charges,88% of Total Billed Charges,85.03,90,,459,Percent of Total Billed charges,90% of Total Billed Charges,41.67,94.48,
ALL PURPOSE TRAY,2700000060,CDM,270,RC,,,Outpatient,,,152.15,98.90,,152.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,115.63,76,,376.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,109.55,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,114.11,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.55,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,91.29,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,136.94,90,,51.376,Percent of Total Billed Charges,90% of Total Billed Charges,68.47,45,,14.72,Percent of Total Billed Charges,45% of Total Billed Charges,136.94,90,,445.504,Percent of Total Billed Charges,90% of Total billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.9,65,,15.416,Percent of total Billed Charges,65% of Total Billed Charges,67.1,44.1,,14.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,144.54,95,,470.248,Percent of Total Billed Charges,95% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.89,88,,435.6,Percent of Total Billed Charges,88% of Total Billed Charges,136.94,90,,445.504,Percent of Total Billed charges,90% of Total Billed Charges,67.1,152.15,
TED HOSE KNEE SM/REG,2700000061,CDM,270,RC,,,Outpatient,,,99.23,64.50,,99.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.41,76,,72.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71.45,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,74.42,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.45,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,59.54,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,89.31,90,,257.456,Percent of Total Billed Charges,90% of Total Billed Charges,44.65,45,,82.936,Percent of Total Billed Charges,45% of Total Billed Charges,89.31,90,,85.504,Percent of Total Billed Charges,90% of Total billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.5,65,,21.264,Percent of total Billed Charges,65% of Total Billed Charges,43.76,44.1,,81.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,94.27,95,,90.248,Percent of Total Billed Charges,95% of Total Billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.32,88,,83.6,Percent of Total Billed Charges,88% of Total Billed Charges,89.31,90,,85.504,Percent of Total Billed charges,90% of Total Billed Charges,43.76,99.23,
SCROTAL SUP SUSP XLG,2700000062,CDM,270,RC,,,Outpatient,,,145.53,94.59,,145.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.6,76,,18.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,104.78,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,109.15,75,,8.6,Percent of Total Billed charges,75% of Total Billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.78,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,87.32,60,,6.88,Percent of Total Billed Charges,60% of Total Billed Charges,130.98,90,,257.456,Percent of Total Billed Charges,90% of Total Billed Charges,65.49,45,,16.04,Percent of Total Billed Charges,45% of Total Billed Charges,130.98,90,,21.352,Percent of Total Billed Charges,90% of Total billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.59,65,,119.8,Percent of total Billed Charges,65% of Total Billed Charges,64.18,44.1,,15.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,138.25,95,,22.536,Percent of Total Billed Charges,95% of Total Billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.07,88,,20.872,Percent of Total Billed Charges,88% of Total Billed Charges,130.98,90,,21.352,Percent of Total Billed charges,90% of Total Billed Charges,64.18,145.53,
TED HOSE KNEE SM/LG,2700000063,CDM,270,RC,,,Outpatient,,,72.77,47.30,,72.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.31,76,,24.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.39,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,54.58,75,,42.336,Percent of Total Billed charges,75% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.39,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,60,,33.872,Percent of Total Billed Charges,60% of Total Billed Charges,65.49,90,,257.456,Percent of Total Billed Charges,90% of Total Billed Charges,32.75,45,,104.76,Percent of Total Billed Charges,45% of Total Billed Charges,65.49,90,,29.44,Percent of Total Billed Charges,90% of Total billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.3,65,,23.168,Percent of total Billed Charges,65% of Total Billed Charges,32.09,44.1,,102.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,69.13,95,,31.08,Percent of Total Billed Charges,95% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.04,88,,28.784,Percent of Total Billed Charges,88% of Total Billed Charges,65.49,90,,29.44,Percent of Total Billed charges,90% of Total Billed Charges,32.09,72.77,
TED HOSE KNEE MD/SM,2700000064,CDM,270,RC,,,Outpatient,,,38.59,25.08,,38.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.33,76,,140.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.78,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,28.94,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.78,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,34.73,90,,257.456,Percent of Total Billed Charges,90% of Total Billed Charges,17.37,45,,109.408,Percent of Total Billed Charges,45% of Total Billed Charges,34.73,90,,165.872,Percent of Total Billed Charges,90% of Total billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.08,65,,151.32,Percent of total Billed Charges,65% of Total Billed Charges,17.02,44.1,,107.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.66,95,,175.088,Percent of Total Billed Charges,95% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.96,88,,162.184,Percent of Total Billed Charges,88% of Total Billed Charges,34.73,90,,165.872,Percent of Total Billed charges,90% of Total Billed Charges,17.02,38.59,
TED HOSE KNEE MD/RG,2700000065,CDM,270,RC,,,Outpatient,,,38.59,25.08,,38.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.33,76,,27.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.78,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,28.94,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.78,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,34.73,90,,584.624,Percent of Total Billed Charges,90% of Total Billed Charges,17.37,45,,15.264,Percent of Total Billed Charges,45% of Total Billed Charges,34.73,90,,32.08,Percent of Total Billed Charges,90% of Total billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.08,65,,158.032,Percent of total Billed Charges,65% of Total Billed Charges,17.02,44.1,,14.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.66,95,,33.856,Percent of Total Billed Charges,95% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.96,88,,31.36,Percent of Total Billed Charges,88% of Total Billed Charges,34.73,90,,32.08,Percent of Total Billed charges,90% of Total Billed Charges,17.02,38.59,
TED HOSE KNEE MD/LNG,2700000066,CDM,270,RC,,,Outpatient,,,72.77,47.30,,72.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.31,76,,176.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.39,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,54.58,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.39,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,65.49,90,,701.536,Percent of Total Billed Charges,90% of Total Billed Charges,32.75,45,,25.688,Percent of Total Billed Charges,45% of Total Billed Charges,65.49,90,,209.52,Percent of Total Billed Charges,90% of Total billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.3,65,,22.048,Percent of total Billed Charges,65% of Total Billed Charges,32.09,44.1,,25.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,69.13,95,,221.16,Percent of Total Billed Charges,95% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.04,88,,204.864,Percent of Total Billed Charges,88% of Total Billed Charges,65.49,90,,209.52,Percent of Total Billed charges,90% of Total Billed Charges,32.09,72.77,
TED HOSE KNEE LG/SHT,2700000067,CDM,270,RC,,,Outpatient,,,99.23,64.50,,99.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.41,76,,184.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71.45,72,,24.768,Percent of Total Billed Charges,72% of Total Billed Charges,74.42,75,,25.8,Percent of Total Billed charges,75% of Total Billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.45,72,,24.768,Percent of Total Billed Charges,72% of Total Billed Charges,59.54,60,,20.64,Percent of Total Billed Charges,60% of Total Billed Charges,89.31,90,,16.992,Percent of Total Billed Charges,90% of Total Billed Charges,44.65,45,,128.728,Percent of Total Billed Charges,45% of Total Billed Charges,89.31,90,,218.808,Percent of Total Billed Charges,90% of Total billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.5,65,,37.104,Percent of total Billed Charges,65% of Total Billed Charges,43.76,44.1,,126.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,94.27,95,,230.968,Percent of Total Billed Charges,95% of Total Billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.32,88,,213.944,Percent of Total Billed Charges,88% of Total Billed Charges,89.31,90,,218.808,Percent of Total Billed charges,90% of Total Billed Charges,43.76,99.23,
TED HOSE KNEE LG/REG,2700000068,CDM,270,RC,,,Outpatient,,,38.59,25.08,,38.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.33,76,,25.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.78,72,,28.576,Percent of Total Billed Charges,72% of Total Billed Charges,28.94,75,,29.768,Percent of Total Billed charges,75% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.78,72,,28.576,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,60,,23.816,Percent of Total Billed Charges,60% of Total Billed Charges,34.73,90,,2.592,Percent of Total Billed Charges,90% of Total Billed Charges,17.37,45,,128.728,Percent of Total Billed Charges,45% of Total Billed Charges,34.73,90,,30.528,Percent of Total Billed Charges,90% of Total billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.08,65,,185.944,Percent of total Billed Charges,65% of Total Billed Charges,17.02,44.1,,126.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.66,95,,32.224,Percent of Total Billed Charges,95% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.96,88,,29.848,Percent of Total Billed Charges,88% of Total Billed Charges,34.73,90,,30.528,Percent of Total Billed charges,90% of Total Billed Charges,17.02,38.59,
TUBE LEVINE 14FR VEN,2700000069,CDM,270,RC,,,Outpatient,,,27.56,17.91,,27.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.95,76,,43.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.84,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,20.67,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.84,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,24.8,90,,69.68,Percent of Total Billed Charges,90% of Total Billed Charges,12.4,45,,128.728,Percent of Total Billed Charges,45% of Total Billed Charges,24.8,90,,51.376,Percent of Total Billed Charges,90% of Total billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.91,65,,185.944,Percent of total Billed Charges,65% of Total Billed Charges,12.15,44.1,,126.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.18,95,,54.224,Percent of Total Billed Charges,95% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,88,,50.232,Percent of Total Billed Charges,88% of Total Billed Charges,24.8,90,,51.376,Percent of Total Billed charges,90% of Total Billed Charges,12.15,27.56,
TED HOSE THIGH SM/ST,2700000070,CDM,270,RC,,,Outpatient,,,77.18,50.17,,77.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.66,76,,217.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.57,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,57.89,75,,7.936,Percent of Total Billed charges,75% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.57,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,60,,6.352,Percent of Total Billed Charges,60% of Total Billed Charges,69.46,90,,69.68,Percent of Total Billed Charges,90% of Total Billed Charges,34.73,45,,128.728,Percent of Total Billed Charges,45% of Total Billed Charges,69.46,90,,257.456,Percent of Total Billed Charges,90% of Total billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.17,65,,185.944,Percent of total Billed Charges,65% of Total Billed Charges,34.04,44.1,,126.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.32,95,,271.76,Percent of Total Billed Charges,95% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.92,88,,251.736,Percent of Total Billed Charges,88% of Total Billed Charges,69.46,90,,257.456,Percent of Total Billed charges,90% of Total Billed Charges,34.04,77.18,
TUBE LEVINE 16FR VEN,2700000071,CDM,270,RC,,,Outpatient,,,27.56,17.91,,27.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.95,76,,217.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.84,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,20.67,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.84,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,24.8,90,,15.864,Percent of Total Billed Charges,90% of Total Billed Charges,12.4,45,,292.312,Percent of Total Billed Charges,45% of Total Billed Charges,24.8,90,,257.456,Percent of Total Billed Charges,90% of Total billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.91,65,,185.944,Percent of total Billed Charges,65% of Total Billed Charges,12.15,44.1,,286.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.18,95,,271.76,Percent of Total Billed Charges,95% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,88,,251.736,Percent of Total Billed Charges,88% of Total Billed Charges,24.8,90,,257.456,Percent of Total Billed charges,90% of Total Billed Charges,12.15,27.56,
TED HOSE THIGH SM/RG,2700000072,CDM,270,RC,,,Outpatient,,,77.18,50.17,,77.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.66,76,,217.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.57,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,57.89,75,,13.232,Percent of Total Billed charges,75% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.57,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,60,,10.584,Percent of Total Billed Charges,60% of Total Billed Charges,69.46,90,,3.024,Percent of Total Billed Charges,90% of Total Billed Charges,34.73,45,,350.768,Percent of Total Billed Charges,45% of Total Billed Charges,69.46,90,,257.456,Percent of Total Billed Charges,90% of Total billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.17,65,,422.232,Percent of total Billed Charges,65% of Total Billed Charges,34.04,44.1,,343.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.32,95,,271.76,Percent of Total Billed Charges,95% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.92,88,,251.736,Percent of Total Billed Charges,88% of Total Billed Charges,69.46,90,,257.456,Percent of Total Billed charges,90% of Total Billed Charges,34.04,77.18,
TED HOSE THIGH MD/SM,2700000073,CDM,270,RC,,,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,217.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,58.71,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,7.544,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,8.496,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,257.456,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,506.664,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,8.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,271.76,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,251.736,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,257.456,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
TED HOSE THIGH MD/RG,2700000074,CDM,270,RC,,,Outpatient,,,84.89,55.18,,84.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,64.52,76,,493.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.12,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,63.67,75,,23.152,Percent of Total Billed charges,75% of Total Billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,50.93,60,,18.52,Percent of Total Billed Charges,60% of Total Billed Charges,76.4,90,,7.544,Percent of Total Billed Charges,90% of Total Billed Charges,38.2,45,,1.296,Percent of Total Billed Charges,45% of Total Billed Charges,76.4,90,,584.624,Percent of Total Billed Charges,90% of Total billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.18,65,,12.272,Percent of total Billed Charges,65% of Total Billed Charges,37.44,44.1,,1.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,80.65,95,,617.104,Percent of Total Billed Charges,95% of Total Billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.7,88,,571.632,Percent of Total Billed Charges,88% of Total Billed Charges,76.4,90,,584.624,Percent of Total Billed charges,90% of Total Billed Charges,37.44,84.89,
TED HOSE THIGH XL,2700000075,CDM,270,RC,,,Outpatient,,,77.18,50.17,,77.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.66,76,,592.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.57,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,57.89,75,,23.152,Percent of Total Billed charges,75% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.57,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,60,,18.52,Percent of Total Billed Charges,60% of Total Billed Charges,69.46,90,,7.544,Percent of Total Billed Charges,90% of Total Billed Charges,34.73,45,,34.84,Percent of Total Billed Charges,45% of Total Billed Charges,69.46,90,,701.536,Percent of Total Billed Charges,90% of Total billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.17,65,,1.872,Percent of total Billed Charges,65% of Total Billed Charges,34.04,44.1,,34.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.32,95,,740.504,Percent of Total Billed Charges,95% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.92,88,,685.944,Percent of Total Billed Charges,88% of Total Billed Charges,69.46,90,,701.536,Percent of Total Billed charges,90% of Total Billed Charges,34.04,77.18,
TED HOSE THIGH MD/LG,2700000076,CDM,270,RC,,,Outpatient,,,77.18,50.17,,77.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.66,76,,14.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.57,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,57.89,75,,43,Percent of Total Billed charges,75% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.57,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,60,,34.4,Percent of Total Billed Charges,60% of Total Billed Charges,69.46,90,,7.544,Percent of Total Billed Charges,90% of Total Billed Charges,34.73,45,,34.84,Percent of Total Billed Charges,45% of Total Billed Charges,69.46,90,,16.992,Percent of Total Billed Charges,90% of Total billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.17,65,,50.328,Percent of total Billed Charges,65% of Total Billed Charges,34.04,44.1,,34.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.32,95,,17.936,Percent of Total Billed Charges,95% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.92,88,,16.616,Percent of Total Billed Charges,88% of Total Billed Charges,69.46,90,,16.992,Percent of Total Billed charges,90% of Total Billed Charges,34.04,77.18,
TED HOSE THIGH LG/LG,2700000077,CDM,270,RC,,,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,2.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,58.71,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,7.544,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,7.928,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,2.592,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,50.328,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,2.736,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,2.536,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,2.592,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
TED HOSE THIGH LG/LN,2700000078,CDM,270,RC,,,Outpatient,,,154.35,100.33,,154.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,117.31,76,,58.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.13,72,,39.376,Percent of Total Billed Charges,72% of Total Billed Charges,115.76,75,,41.016,Percent of Total Billed charges,75% of Total Billed Charges,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.13,72,,39.376,Percent of Total Billed Charges,72% of Total Billed Charges,92.61,60,,32.816,Percent of Total Billed Charges,60% of Total Billed Charges,138.92,90,,7.544,Percent of Total Billed Charges,90% of Total Billed Charges,69.46,45,,1.512,Percent of Total Billed Charges,45% of Total Billed Charges,138.92,90,,69.68,Percent of Total Billed Charges,90% of Total billed Charges,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.33,65,,11.456,Percent of total Billed Charges,65% of Total Billed Charges,68.07,44.1,,1.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,146.63,95,,73.552,Percent of Total Billed Charges,95% of Total Billed Charges,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.83,88,,68.136,Percent of Total Billed Charges,88% of Total Billed Charges,138.92,90,,69.68,Percent of Total Billed charges,90% of Total Billed Charges,68.07,154.35,
STAPLE EXTRACTOR,2700000079,CDM,270,RC,,,Outpatient,,,57.33,37.26,,57.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.57,76,,58.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.28,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,43,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.28,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,34.4,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,51.6,90,,7.544,Percent of Total Billed Charges,90% of Total Billed Charges,25.8,45,,3.776,Percent of Total Billed Charges,45% of Total Billed Charges,51.6,90,,69.68,Percent of Total Billed Charges,90% of Total billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.26,65,,2.184,Percent of total Billed Charges,65% of Total Billed Charges,25.28,44.1,,3.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.46,95,,73.552,Percent of Total Billed Charges,95% of Total Billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.45,88,,68.136,Percent of Total Billed Charges,88% of Total Billed Charges,51.6,90,,69.68,Percent of Total Billed charges,90% of Total Billed Charges,25.28,57.33,
HIP ABDUCT PILLOW MD,2700000080,CDM,270,RC,,,Outpatient,,,506.05,328.93,,506.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,384.6,76,,13.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,364.36,72,,39.376,Percent of Total Billed Charges,72% of Total Billed Charges,379.54,75,,41.016,Percent of Total Billed charges,75% of Total Billed Charges,506.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.36,72,,39.376,Percent of Total Billed Charges,72% of Total Billed Charges,303.63,60,,32.816,Percent of Total Billed Charges,60% of Total Billed Charges,455.45,90,,7.544,Percent of Total Billed Charges,90% of Total Billed Charges,227.72,45,,3.776,Percent of Total Billed Charges,45% of Total Billed Charges,455.45,90,,15.864,Percent of Total Billed Charges,90% of Total billed Charges,506.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.93,65,,5.448,Percent of total Billed Charges,65% of Total Billed Charges,223.17,44.1,,3.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,480.75,95,,16.744,Percent of Total Billed Charges,95% of Total Billed Charges,506.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,445.32,88,,15.512,Percent of Total Billed Charges,88% of Total Billed Charges,455.45,90,,15.864,Percent of Total Billed charges,90% of Total Billed Charges,223.17,506.05,
HIP ABDUCT PILLOW SM,2700000081,CDM,270,RC,,,Outpatient,,,446.51,290.23,,446.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,339.35,76,,2.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,321.49,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,334.88,75,,15.88,Percent of Total Billed charges,75% of Total Billed Charges,446.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,321.49,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,267.91,60,,12.704,Percent of Total Billed Charges,60% of Total Billed Charges,401.86,90,,7.544,Percent of Total Billed Charges,90% of Total Billed Charges,200.93,45,,3.776,Percent of Total Billed Charges,45% of Total Billed Charges,401.86,90,,3.024,Percent of Total Billed Charges,90% of Total billed Charges,446.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290.23,65,,5.448,Percent of total Billed Charges,65% of Total Billed Charges,196.91,44.1,,3.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,424.18,95,,3.192,Percent of Total Billed Charges,95% of Total Billed Charges,446.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.93,88,,2.96,Percent of Total Billed Charges,88% of Total Billed Charges,401.86,90,,3.024,Percent of Total Billed charges,90% of Total Billed Charges,196.91,446.51,
SUSPENSORY W/O STRAP XLG,2700000082,CDM,270,RC,,,Outpatient,,,68.36,44.43,,68.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.95,76,,6.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49.22,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,51.27,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,41.02,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,61.52,90,,7.544,Percent of Total Billed Charges,90% of Total Billed Charges,30.76,45,,3.776,Percent of Total Billed Charges,45% of Total Billed Charges,61.52,90,,7.544,Percent of Total Billed Charges,90% of Total billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.43,65,,5.448,Percent of total Billed Charges,65% of Total Billed Charges,30.15,44.1,,3.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,64.94,95,,7.968,Percent of Total Billed Charges,95% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.16,88,,7.376,Percent of Total Billed Charges,88% of Total Billed Charges,61.52,90,,7.544,Percent of Total Billed charges,90% of Total Billed Charges,30.15,68.36,
CLZV SPLNT PAD CHILD,2700000083,CDM,270,RC,,,Outpatient,,,212.78,138.31,,212.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.71,76,,6.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153.2,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,159.59,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.2,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,127.67,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,191.5,90,,53.32,Percent of Total Billed Charges,90% of Total Billed Charges,95.75,45,,3.776,Percent of Total Billed Charges,45% of Total Billed Charges,191.5,90,,7.544,Percent of Total Billed Charges,90% of Total billed Charges,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.31,65,,5.448,Percent of total Billed Charges,65% of Total Billed Charges,93.84,44.1,,3.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,202.14,95,,7.968,Percent of Total Billed Charges,95% of Total Billed Charges,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.25,88,,7.376,Percent of Total Billed Charges,88% of Total Billed Charges,191.5,90,,7.544,Percent of Total Billed charges,90% of Total Billed Charges,93.84,212.78,
COLLES SPLNT CHILD/R,2700000084,CDM,270,RC,,,Outpatient,,,67.25,43.71,,67.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.11,76,,6.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,48.42,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,50.44,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.42,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,40.35,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,60.53,90,,57.296,Percent of Total Billed Charges,90% of Total Billed Charges,30.26,45,,3.776,Percent of Total Billed Charges,45% of Total Billed Charges,60.53,90,,7.544,Percent of Total Billed Charges,90% of Total billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.71,65,,5.448,Percent of total Billed Charges,65% of Total Billed Charges,29.66,44.1,,3.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,63.89,95,,7.968,Percent of Total Billed Charges,95% of Total Billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.18,88,,7.376,Percent of Total Billed Charges,88% of Total Billed Charges,60.53,90,,7.544,Percent of Total Billed charges,90% of Total Billed Charges,29.66,67.25,
COLLES SPLNT SM L,2700000085,CDM,270,RC,,,Outpatient,,,239.24,155.51,,239.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,181.82,76,,6.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,172.25,72,,19.688,Percent of Total Billed Charges,72% of Total Billed Charges,179.43,75,,20.512,Percent of Total Billed charges,75% of Total Billed Charges,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.25,72,,19.688,Percent of Total Billed Charges,72% of Total Billed Charges,143.54,60,,16.408,Percent of Total Billed Charges,60% of Total Billed Charges,215.32,90,,23.976,Percent of Total Billed Charges,90% of Total Billed Charges,107.66,45,,3.776,Percent of Total Billed Charges,45% of Total Billed Charges,215.32,90,,7.544,Percent of Total Billed Charges,90% of Total billed Charges,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.51,65,,5.448,Percent of total Billed Charges,65% of Total Billed Charges,105.5,44.1,,3.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,227.28,95,,7.968,Percent of Total Billed Charges,95% of Total Billed Charges,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.53,88,,7.376,Percent of Total Billed Charges,88% of Total Billed Charges,215.32,90,,7.544,Percent of Total Billed charges,90% of Total Billed Charges,105.5,239.24,
COLLES SPLNT SM R,2700000086,CDM,270,RC,,,Outpatient,,,67.25,43.71,,67.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.11,76,,6.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,48.42,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,50.44,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.42,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,40.35,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,60.53,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,30.26,45,,3.776,Percent of Total Billed Charges,45% of Total Billed Charges,60.53,90,,7.544,Percent of Total Billed Charges,90% of Total billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.71,65,,5.448,Percent of total Billed Charges,65% of Total Billed Charges,29.66,44.1,,3.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,63.89,95,,7.968,Percent of Total Billed Charges,95% of Total Billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.18,88,,7.376,Percent of Total Billed Charges,88% of Total Billed Charges,60.53,90,,7.544,Percent of Total Billed charges,90% of Total Billed Charges,29.66,67.25,
COLLES SPLNT MD L,2700000087,CDM,270,RC,,,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,6.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,54.616,Percent of Total Billed Charges,72% of Total Billed Charges,58.71,75,,56.896,Percent of Total Billed charges,75% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,54.616,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,45.512,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,68.272,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,3.776,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,7.544,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,5.448,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,3.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,7.968,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,7.376,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,7.544,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
COLLES SPLNT MD R,2700000088,CDM,270,RC,,,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,6.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,58.71,75,,17.864,Percent of Total Billed charges,75% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,144,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,3.776,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,7.544,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,5.448,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,3.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,7.968,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,7.376,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,7.544,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
COLLES SPLNT LG L,2700000089,CDM,270,RC,,,Outpatient,,,177.50,115.38,,177.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,134.9,76,,6.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,127.8,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,133.13,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,177.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.8,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,106.5,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,159.75,90,,274.32,Percent of Total Billed Charges,90% of Total Billed Charges,79.88,45,,26.656,Percent of Total Billed Charges,45% of Total Billed Charges,159.75,90,,7.544,Percent of Total Billed Charges,90% of Total billed Charges,177.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.38,65,,5.448,Percent of total Billed Charges,65% of Total Billed Charges,78.28,44.1,,26.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,168.63,95,,7.968,Percent of Total Billed Charges,95% of Total Billed Charges,177.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.2,88,,7.376,Percent of Total Billed Charges,88% of Total Billed Charges,159.75,90,,7.544,Percent of Total Billed charges,90% of Total Billed Charges,78.28,177.5,
COLLES SPLNT LG R,2700000090,CDM,270,RC,,,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,6.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,58.71,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,41.28,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,28.648,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,7.544,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,38.504,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,28.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,7.968,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,7.376,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,7.544,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
FEEDING TUBE 5FR,2700000091,CDM,270,RC,,,Outpatient,,,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,6.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,17.864,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,11.992,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,7.544,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,41.384,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,11.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,7.968,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,7.376,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,7.544,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
TUBE LEVINE 12FR VEN,2700000092,CDM,270,RC,,,Outpatient,,,27.56,17.91,,27.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.95,76,,45.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.84,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,20.67,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.84,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,24.8,90,,115.896,Percent of Total Billed Charges,90% of Total Billed Charges,12.4,45,,10.44,Percent of Total Billed Charges,45% of Total Billed Charges,24.8,90,,53.32,Percent of Total Billed Charges,90% of Total billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.91,65,,17.32,Percent of total Billed Charges,65% of Total Billed Charges,12.15,44.1,,10.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.18,95,,56.28,Percent of Total Billed Charges,95% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,88,,52.128,Percent of Total Billed Charges,88% of Total Billed Charges,24.8,90,,53.32,Percent of Total Billed charges,90% of Total Billed Charges,12.15,27.56,
ABD SUPP UNIVERSAL,2700000093,CDM,270,RC,,,Outpatient,,,15.46,10.05,,15.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.75,76,,48.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.13,72,,63.504,Percent of Total Billed Charges,72% of Total Billed Charges,11.6,75,,66.152,Percent of Total Billed charges,75% of Total Billed Charges,15.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.13,72,,63.504,Percent of Total Billed Charges,72% of Total Billed Charges,9.28,60,,52.92,Percent of Total Billed Charges,60% of Total Billed Charges,13.91,90,,112.72,Percent of Total Billed Charges,90% of Total Billed Charges,6.96,45,,34.136,Percent of Total Billed Charges,45% of Total Billed Charges,13.91,90,,57.296,Percent of Total Billed Charges,90% of Total billed Charges,15.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.05,65,,15.08,Percent of total Billed Charges,65% of Total Billed Charges,6.82,44.1,,33.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.69,95,,60.48,Percent of Total Billed Charges,95% of Total Billed Charges,15.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.6,88,,56.024,Percent of Total Billed Charges,88% of Total Billed Charges,13.91,90,,57.296,Percent of Total Billed charges,90% of Total Billed Charges,6.82,15.46,
AQUACEL 3.5X14,2700000094,CDM,270,RC,,,Outpatient,,,48.51,31.53,,48.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.87,76,,20.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.93,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,29.11,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,43.66,90,,153.2,Percent of Total Billed Charges,90% of Total Billed Charges,21.83,45,,72,Percent of Total Billed Charges,45% of Total Billed Charges,43.66,90,,23.976,Percent of Total Billed Charges,90% of Total billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.53,65,,49.304,Percent of total Billed Charges,65% of Total Billed Charges,21.39,44.1,,70.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.08,95,,25.312,Percent of Total Billed Charges,95% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.69,88,,23.44,Percent of Total Billed Charges,88% of Total Billed Charges,43.66,90,,23.976,Percent of Total Billed charges,90% of Total Billed Charges,21.39,48.51,
BAIR PAW FLEX STD KT,2700000095,CDM,270,RC,,,Outpatient,,,384.77,250.10,,384.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,292.43,76,,17.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,277.03,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,288.58,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,384.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.03,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,230.86,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,346.29,90,,115.896,Percent of Total Billed Charges,90% of Total Billed Charges,173.15,45,,137.16,Percent of Total Billed Charges,45% of Total Billed Charges,346.29,90,,20.88,Percent of Total Billed Charges,90% of Total billed Charges,384.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.1,65,,104,Percent of total Billed Charges,65% of Total Billed Charges,169.68,44.1,,134.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,365.53,95,,22.04,Percent of Total Billed Charges,95% of Total Billed Charges,384.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,338.6,88,,20.416,Percent of Total Billed Charges,88% of Total Billed Charges,346.29,90,,20.88,Percent of Total Billed charges,90% of Total Billed Charges,169.68,384.77,
BAIR PAW GOWN ADULT,2700000096,CDM,270,RC,,,Outpatient,,,381.47,247.96,,381.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,289.92,76,,57.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,274.66,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,286.1,75,,5.952,Percent of Total Billed charges,75% of Total Billed Charges,381.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.66,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,228.88,60,,4.76,Percent of Total Billed Charges,60% of Total Billed Charges,343.32,90,,115.896,Percent of Total Billed Charges,90% of Total Billed Charges,171.66,45,,20.64,Percent of Total Billed Charges,45% of Total Billed Charges,343.32,90,,68.272,Percent of Total Billed Charges,90% of Total billed Charges,381.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.96,65,,198.12,Percent of total Billed Charges,65% of Total Billed Charges,168.23,44.1,,20.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,362.4,95,,72.064,Percent of Total Billed Charges,95% of Total Billed Charges,381.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,335.69,88,,66.752,Percent of Total Billed Charges,88% of Total Billed Charges,343.32,90,,68.272,Percent of Total Billed charges,90% of Total Billed Charges,168.23,381.47,
BAIR PAWS PEDIATRIC,2700000097,CDM,270,RC,,,Outpatient,,,375.95,244.37,,375.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285.72,76,,121.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270.68,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,281.96,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,375.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.68,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,225.57,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,338.36,90,,112.72,Percent of Total Billed Charges,90% of Total Billed Charges,169.18,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,338.36,90,,144,Percent of Total Billed Charges,90% of Total billed Charges,375.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.37,65,,29.808,Percent of total Billed Charges,65% of Total Billed Charges,165.79,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,357.15,95,,152,Percent of Total Billed Charges,95% of Total Billed Charges,375.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330.84,88,,140.8,Percent of Total Billed Charges,88% of Total Billed Charges,338.36,90,,144,Percent of Total Billed charges,90% of Total Billed Charges,165.79,375.95,
SHOULDER IMMOBILIZER,2700000098,CDM,270,RC,,,Outpatient,,,422.26,274.47,,422.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,320.92,76,,231.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,304.03,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,316.7,75,,21.168,Percent of Total Billed charges,75% of Total Billed Charges,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.03,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,253.36,60,,16.936,Percent of Total Billed Charges,60% of Total Billed Charges,380.03,90,,118.272,Percent of Total Billed Charges,90% of Total Billed Charges,190.02,45,,57.952,Percent of Total Billed Charges,45% of Total Billed Charges,380.03,90,,274.32,Percent of Total Billed Charges,90% of Total billed Charges,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.47,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,186.22,44.1,,56.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,401.15,95,,289.56,Percent of Total Billed Charges,95% of Total Billed Charges,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.59,88,,268.224,Percent of Total Billed Charges,88% of Total Billed Charges,380.03,90,,274.32,Percent of Total Billed charges,90% of Total Billed Charges,186.22,422.26,
OSMOLITE 8OZ,2700000099,CDM,270,RC,,,Outpatient,,,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,34.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,84.456,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,87.976,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,84.456,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,70.384,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,15.88,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,56.36,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,41.28,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,83.704,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,55.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,43.568,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,40.36,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,41.28,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
SUSPENSORY W/O STRAP SM,2700000100,CDM,270,RC,,,Outpatient,,,45.20,29.38,,45.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.35,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.54,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,33.9,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.54,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,27.12,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,40.68,90,,19.84,Percent of Total Billed Charges,90% of Total Billed Charges,20.34,45,,76.6,Percent of Total Billed Charges,45% of Total Billed Charges,40.68,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.38,65,,81.408,Percent of total Billed Charges,65% of Total Billed Charges,19.93,44.1,,75.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.94,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.78,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,40.68,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,19.93,45.2,
BAIR HUGGER BLKTS FULL,2700000101,CDM,270,RC,,,Outpatient,,,51.82,33.68,,51.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,39.38,76,,97.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,37.31,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,38.87,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.31,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,31.09,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,46.64,90,,49.216,Percent of Total Billed Charges,90% of Total Billed Charges,23.32,45,,57.952,Percent of Total Billed Charges,45% of Total Billed Charges,46.64,90,,115.896,Percent of Total Billed Charges,90% of Total billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.68,65,,110.648,Percent of total Billed Charges,65% of Total Billed Charges,22.85,44.1,,56.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,49.23,95,,122.336,Percent of Total Billed Charges,95% of Total Billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.6,88,,113.32,Percent of Total Billed Charges,88% of Total Billed Charges,46.64,90,,115.896,Percent of Total Billed charges,90% of Total Billed Charges,22.85,51.82,
SIGMOIDISCOPE DISP,2700000102,CDM,270,RC,,,Outpatient,,,40.79,26.51,,40.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31,76,,95.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.37,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,30.59,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.37,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,24.47,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,36.71,90,,29.368,Percent of Total Billed Charges,90% of Total Billed Charges,18.36,45,,57.952,Percent of Total Billed Charges,45% of Total Billed Charges,36.71,90,,112.72,Percent of Total Billed Charges,90% of Total billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.51,65,,83.704,Percent of total Billed Charges,65% of Total Billed Charges,17.99,44.1,,56.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.75,95,,118.984,Percent of Total Billed Charges,95% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.9,88,,110.216,Percent of Total Billed Charges,88% of Total Billed Charges,36.71,90,,112.72,Percent of Total Billed charges,90% of Total Billed Charges,17.99,40.79,
GAUZE SPONG 4X4 NON ST,2700000103,CDM,270,RC,,,Outpatient,,,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,129.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,22.33,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,29.368,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,56.36,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,153.2,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,83.704,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,55.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,161.712,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,149.8,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,153.2,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
TOOTHETTE,2700000104,CDM,270,RC,,,Outpatient,,,3.00,1.95,,3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.28,76,,97.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.16,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,2.25,75,,15.216,Percent of Total Billed charges,75% of Total Billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.16,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,1.8,60,,12.176,Percent of Total Billed Charges,60% of Total Billed Charges,2.7,90,,29.368,Percent of Total Billed Charges,90% of Total Billed Charges,1.35,45,,59.136,Percent of Total Billed Charges,45% of Total Billed Charges,2.7,90,,115.896,Percent of Total Billed Charges,90% of Total billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.95,65,,81.408,Percent of total Billed Charges,65% of Total Billed Charges,1.32,44.1,,57.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.85,95,,122.336,Percent of Total Billed Charges,95% of Total Billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.64,88,,113.32,Percent of Total Billed Charges,88% of Total Billed Charges,2.7,90,,115.896,Percent of Total Billed charges,90% of Total Billed Charges,1.32,3,
BAND ELAS 4,2700000105,CDM,270,RC,,,Outpatient,,,4.03,2.62,,4.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.06,76,,97.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.9,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,3.02,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,4.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.9,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,2.42,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,3.63,90,,19.84,Percent of Total Billed Charges,90% of Total Billed Charges,1.81,45,,7.936,Percent of Total Billed Charges,45% of Total Billed Charges,3.63,90,,115.896,Percent of Total Billed Charges,90% of Total billed Charges,4.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.62,65,,85.424,Percent of total Billed Charges,65% of Total Billed Charges,1.78,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.83,95,,122.336,Percent of Total Billed Charges,95% of Total Billed Charges,4.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.55,88,,113.32,Percent of Total Billed Charges,88% of Total Billed Charges,3.63,90,,115.896,Percent of Total Billed charges,90% of Total Billed Charges,1.78,4.03,
SUPP SCROT SM,2700000106,CDM,270,RC,,,Outpatient,,,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,95.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,12.568,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,10.056,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,26.192,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,9.92,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,112.72,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,11.464,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,9.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,118.984,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,110.216,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,112.72,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
STKNG ANTIEMKN XLREG,2700000107,CDM,270,RC,,,Outpatient,,,19.91,12.94,,19.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.13,76,,99.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.34,72,,108.592,Percent of Total Billed Charges,72% of Total Billed Charges,14.93,75,,113.12,Percent of Total Billed charges,75% of Total Billed Charges,19.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.34,72,,108.592,Percent of Total Billed Charges,72% of Total Billed Charges,11.95,60,,90.496,Percent of Total Billed Charges,60% of Total Billed Charges,17.92,90,,23.816,Percent of Total Billed Charges,90% of Total Billed Charges,8.96,45,,24.608,Percent of Total Billed Charges,45% of Total Billed Charges,17.92,90,,118.272,Percent of Total Billed Charges,90% of Total billed Charges,19.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.94,65,,14.328,Percent of total Billed Charges,65% of Total Billed Charges,8.78,44.1,,24.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.91,95,,124.848,Percent of Total Billed Charges,95% of Total Billed Charges,19.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.52,88,,115.648,Percent of Total Billed Charges,88% of Total Billed Charges,17.92,90,,118.272,Percent of Total Billed charges,90% of Total Billed Charges,8.78,19.91,
TED KNEE XL,2700000108,CDM,270,RC,,,Outpatient,,,17.89,11.63,,17.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.6,76,,13.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.88,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,13.42,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,17.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.88,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,10.73,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,16.1,90,,37.312,Percent of Total Billed Charges,90% of Total Billed Charges,8.05,45,,14.688,Percent of Total Billed Charges,45% of Total Billed Charges,16.1,90,,15.88,Percent of Total Billed Charges,90% of Total billed Charges,17.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.63,65,,35.544,Percent of total Billed Charges,65% of Total Billed Charges,7.89,44.1,,14.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,17,95,,16.76,Percent of Total Billed Charges,95% of Total Billed Charges,17.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.74,88,,15.52,Percent of Total Billed Charges,88% of Total Billed Charges,16.1,90,,15.88,Percent of Total Billed charges,90% of Total Billed Charges,7.89,17.89,
FETAL MONITOR BELT,2700000109,CDM,270,RC,,,Outpatient,,,5.25,3.41,,5.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.99,76,,16.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.78,72,,15.368,Percent of Total Billed Charges,72% of Total Billed Charges,3.94,75,,16.008,Percent of Total Billed charges,75% of Total Billed Charges,5.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.78,72,,15.368,Percent of Total Billed Charges,72% of Total Billed Charges,3.15,60,,12.808,Percent of Total Billed Charges,60% of Total Billed Charges,4.73,90,,122.248,Percent of Total Billed Charges,90% of Total Billed Charges,2.36,45,,14.688,Percent of Total Billed Charges,45% of Total Billed Charges,4.73,90,,19.84,Percent of Total Billed Charges,90% of Total billed Charges,5.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.41,65,,21.208,Percent of total Billed Charges,65% of Total Billed Charges,2.32,44.1,,14.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.99,95,,20.944,Percent of Total Billed Charges,95% of Total Billed Charges,5.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.62,88,,19.4,Percent of Total Billed Charges,88% of Total Billed Charges,4.73,90,,19.84,Percent of Total Billed charges,90% of Total Billed Charges,2.32,5.25,
C COLLAR STIFF NECK ADULT,2700000110,CDM,270,RC,,,Outpatient,,,15.31,9.95,,15.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.64,76,,41.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.02,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,11.48,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,15.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.02,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,9.19,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,13.78,90,,122.248,Percent of Total Billed Charges,90% of Total Billed Charges,6.89,45,,14.688,Percent of Total Billed Charges,45% of Total Billed Charges,13.78,90,,49.216,Percent of Total Billed Charges,90% of Total billed Charges,15.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.95,65,,21.208,Percent of total Billed Charges,65% of Total Billed Charges,6.75,44.1,,14.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.54,95,,51.952,Percent of Total Billed Charges,95% of Total Billed Charges,15.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.47,88,,48.128,Percent of Total Billed Charges,88% of Total Billed Charges,13.78,90,,49.216,Percent of Total Billed charges,90% of Total Billed Charges,6.75,15.31,
C COLLAR STIFF NECK PEDI,2700000111,CDM,270,RC,,,Outpatient,,,14.18,9.22,,14.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.78,76,,24.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.21,72,,11.488,Percent of Total Billed Charges,72% of Total Billed Charges,10.64,75,,11.968,Percent of Total Billed charges,75% of Total Billed Charges,14.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.21,72,,11.488,Percent of Total Billed Charges,72% of Total Billed Charges,8.51,60,,9.576,Percent of Total Billed Charges,60% of Total Billed Charges,12.76,90,,57.152,Percent of Total Billed Charges,90% of Total Billed Charges,6.38,45,,9.92,Percent of Total Billed Charges,45% of Total Billed Charges,12.76,90,,29.368,Percent of Total Billed Charges,90% of Total billed Charges,14.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.22,65,,21.208,Percent of total Billed Charges,65% of Total Billed Charges,6.25,44.1,,9.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.47,95,,31,Percent of Total Billed Charges,95% of Total Billed Charges,14.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.48,88,,28.72,Percent of Total Billed Charges,88% of Total Billed Charges,12.76,90,,29.368,Percent of Total Billed charges,90% of Total Billed Charges,6.25,14.18,
FIBERGLASS TAPE 5 X 4,2700000112,CDM,270,RC,,,Outpatient,,,29.90,19.44,,29.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.72,76,,24.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.53,72,,12.096,Percent of Total Billed Charges,72% of Total Billed Charges,22.43,75,,12.6,Percent of Total Billed charges,75% of Total Billed Charges,29.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.53,72,,12.096,Percent of Total Billed Charges,72% of Total Billed Charges,17.94,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,26.91,90,,123.04,Percent of Total Billed Charges,90% of Total Billed Charges,13.46,45,,13.096,Percent of Total Billed Charges,45% of Total Billed Charges,26.91,90,,29.368,Percent of Total Billed Charges,90% of Total billed Charges,29.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.44,65,,14.328,Percent of total Billed Charges,65% of Total Billed Charges,13.19,44.1,,12.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.41,95,,31,Percent of Total Billed Charges,95% of Total Billed Charges,29.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.31,88,,28.72,Percent of Total Billed Charges,88% of Total Billed Charges,26.91,90,,29.368,Percent of Total Billed charges,90% of Total Billed Charges,13.19,29.9,
HOT PACK,2700000113,CDM,270,RC,,,Outpatient,,,11.55,7.51,,11.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.78,76,,24.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.32,72,,22.984,Percent of Total Billed Charges,72% of Total Billed Charges,8.66,75,,23.944,Percent of Total Billed charges,75% of Total Billed Charges,11.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.32,72,,22.984,Percent of Total Billed Charges,72% of Total Billed Charges,6.93,60,,19.152,Percent of Total Billed Charges,60% of Total Billed Charges,10.4,90,,51.592,Percent of Total Billed Charges,90% of Total Billed Charges,5.2,45,,11.912,Percent of Total Billed Charges,45% of Total Billed Charges,10.4,90,,29.368,Percent of Total Billed Charges,90% of Total billed Charges,11.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.51,65,,18.92,Percent of total Billed Charges,65% of Total Billed Charges,5.09,44.1,,11.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.97,95,,31,Percent of Total Billed Charges,95% of Total Billed Charges,11.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.16,88,,28.72,Percent of Total Billed Charges,88% of Total Billed Charges,10.4,90,,29.368,Percent of Total Billed charges,90% of Total Billed Charges,5.09,11.55,
HOLDER LIMB QUILT QK REL,2700000114,CDM,270,RC,,,Outpatient,,,39.31,25.55,,39.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.88,76,,16.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.3,72,,22.984,Percent of Total Billed Charges,72% of Total Billed Charges,29.48,75,,23.944,Percent of Total Billed charges,75% of Total Billed Charges,39.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.3,72,,22.984,Percent of Total Billed Charges,72% of Total Billed Charges,23.59,60,,19.152,Percent of Total Billed Charges,60% of Total Billed Charges,35.38,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,17.69,45,,18.656,Percent of Total Billed Charges,45% of Total Billed Charges,35.38,90,,19.84,Percent of Total Billed Charges,90% of Total billed Charges,39.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.55,65,,17.2,Percent of total Billed Charges,65% of Total Billed Charges,17.34,44.1,,18.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.34,95,,20.944,Percent of Total Billed Charges,95% of Total Billed Charges,39.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.59,88,,19.4,Percent of Total Billed Charges,88% of Total Billed Charges,35.38,90,,19.84,Percent of Total Billed charges,90% of Total Billed Charges,17.34,39.31,
VIVONEX RTF,2700000116,CDM,270,RC,,,Outpatient,,,13.74,8.93,,13.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.44,76,,22.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.89,72,,112.4,Percent of Total Billed Charges,72% of Total Billed Charges,10.31,75,,117.088,Percent of Total Billed charges,75% of Total Billed Charges,13.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.89,72,,112.4,Percent of Total Billed Charges,72% of Total Billed Charges,8.24,60,,93.664,Percent of Total Billed Charges,60% of Total Billed Charges,12.37,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,6.18,45,,61.128,Percent of Total Billed Charges,45% of Total Billed Charges,12.37,90,,26.192,Percent of Total Billed Charges,90% of Total billed Charges,13.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.93,65,,26.944,Percent of total Billed Charges,65% of Total Billed Charges,6.06,44.1,,59.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.05,95,,27.648,Percent of Total Billed Charges,95% of Total Billed Charges,13.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.09,88,,25.608,Percent of Total Billed Charges,88% of Total Billed Charges,12.37,90,,26.192,Percent of Total Billed charges,90% of Total Billed Charges,6.06,13.74,
PULMOCARE,2700000117,CDM,270,RC,,,Outpatient,,,3.62,2.35,,3.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.75,76,,20.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.61,72,,73.032,Percent of Total Billed Charges,72% of Total Billed Charges,2.72,75,,76.072,Percent of Total Billed charges,75% of Total Billed Charges,3.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.61,72,,73.032,Percent of Total Billed Charges,72% of Total Billed Charges,2.17,60,,60.856,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,1.63,45,,61.128,Percent of Total Billed Charges,45% of Total Billed Charges,3.26,90,,23.816,Percent of Total Billed Charges,90% of Total billed Charges,3.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.35,65,,88.288,Percent of total Billed Charges,65% of Total Billed Charges,1.6,44.1,,59.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.44,95,,25.144,Percent of Total Billed Charges,95% of Total Billed Charges,3.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.19,88,,23.288,Percent of Total Billed Charges,88% of Total Billed Charges,3.26,90,,23.816,Percent of Total Billed charges,90% of Total Billed Charges,1.6,3.62,
ENSURE STRWBRY,2700000118,CDM,270,RC,,,Outpatient,,,3.18,2.07,,3.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.42,76,,31.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.29,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,2.39,75,,9.928,Percent of Total Billed charges,75% of Total Billed Charges,3.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.29,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,1.91,60,,7.936,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,90,,19.84,Percent of Total Billed Charges,90% of Total Billed Charges,1.43,45,,28.576,Percent of Total Billed Charges,45% of Total Billed Charges,2.86,90,,37.312,Percent of Total Billed Charges,90% of Total billed Charges,3.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.07,65,,88.288,Percent of total Billed Charges,65% of Total Billed Charges,1.4,44.1,,28.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.02,95,,39.384,Percent of Total Billed Charges,95% of Total Billed Charges,3.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.8,88,,36.48,Percent of Total Billed Charges,88% of Total Billed Charges,2.86,90,,37.312,Percent of Total Billed charges,90% of Total Billed Charges,1.4,3.18,
ENSURE VANIL 8OZ,2700000119,CDM,270,RC,,,Outpatient,,,3.18,2.07,,3.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.42,76,,103.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.29,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,2.39,75,,14.56,Percent of Total Billed charges,75% of Total Billed Charges,3.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.29,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,1.91,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,1.43,45,,61.52,Percent of Total Billed Charges,45% of Total Billed Charges,2.86,90,,122.248,Percent of Total Billed Charges,90% of Total billed Charges,3.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.07,65,,41.28,Percent of total Billed Charges,65% of Total Billed Charges,1.4,44.1,,60.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.02,95,,129.04,Percent of Total Billed Charges,95% of Total Billed Charges,3.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.8,88,,119.536,Percent of Total Billed Charges,88% of Total Billed Charges,2.86,90,,122.248,Percent of Total Billed charges,90% of Total Billed Charges,1.4,3.18,
ENSURE CHOC 8 OZ,2700000120,CDM,270,RC,,,Outpatient,,,3.18,2.07,,3.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.42,76,,103.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.29,72,,32.392,Percent of Total Billed Charges,72% of Total Billed Charges,2.39,75,,33.736,Percent of Total Billed charges,75% of Total Billed Charges,3.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.29,72,,32.392,Percent of Total Billed Charges,72% of Total Billed Charges,1.91,60,,26.992,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,90,,26.192,Percent of Total Billed Charges,90% of Total Billed Charges,1.43,45,,25.8,Percent of Total Billed Charges,45% of Total Billed Charges,2.86,90,,122.248,Percent of Total Billed Charges,90% of Total billed Charges,3.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.07,65,,88.864,Percent of total Billed Charges,65% of Total Billed Charges,1.4,44.1,,25.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.02,95,,129.04,Percent of Total Billed Charges,95% of Total Billed Charges,3.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.8,88,,119.536,Percent of Total Billed Charges,88% of Total Billed Charges,2.86,90,,122.248,Percent of Total Billed charges,90% of Total Billed Charges,1.4,3.18,
PILL SPL ITTER,2700000121,CDM,270,RC,,,Outpatient,,,14.10,9.17,,14.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.72,76,,48.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.15,72,,95.256,Percent of Total Billed Charges,72% of Total Billed Charges,10.58,75,,99.232,Percent of Total Billed charges,75% of Total Billed Charges,14.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.15,72,,95.256,Percent of Total Billed Charges,72% of Total Billed Charges,8.46,60,,79.384,Percent of Total Billed Charges,60% of Total Billed Charges,12.69,90,,34.136,Percent of Total Billed Charges,90% of Total Billed Charges,6.35,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,12.69,90,,57.152,Percent of Total Billed Charges,90% of Total billed Charges,14.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.17,65,,37.264,Percent of total Billed Charges,65% of Total Billed Charges,6.22,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.4,95,,60.328,Percent of Total Billed Charges,95% of Total Billed Charges,14.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.41,88,,55.88,Percent of Total Billed Charges,88% of Total Billed Charges,12.69,90,,57.152,Percent of Total Billed charges,90% of Total Billed Charges,6.22,14.1,
GVL 1 STAT COBALT RANGER,2700000122,CDM,270,RC,,,Outpatient,,,31.00,20.15,,31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.56,76,,103.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.32,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,23.25,75,,11.248,Percent of Total Billed charges,75% of Total Billed Charges,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,18.6,60,,8.992,Percent of Total Billed Charges,60% of Total Billed Charges,27.9,90,,96.848,Percent of Total Billed Charges,90% of Total Billed Charges,13.95,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,27.9,90,,123.04,Percent of Total Billed Charges,90% of Total billed Charges,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.15,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,13.67,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.45,95,,129.88,Percent of Total Billed Charges,95% of Total Billed Charges,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.28,88,,120.304,Percent of Total Billed Charges,88% of Total Billed Charges,27.9,90,,123.04,Percent of Total Billed charges,90% of Total Billed Charges,13.67,31,
GVL 0 STAT COBALT RANGER,2700000123,CDM,270,RC,,,Outpatient,,,31.00,20.15,,31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.56,76,,43.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.32,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,23.25,75,,9.928,Percent of Total Billed charges,75% of Total Billed Charges,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,18.6,60,,7.936,Percent of Total Billed Charges,60% of Total Billed Charges,27.9,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,13.95,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,27.9,90,,51.592,Percent of Total Billed Charges,90% of Total billed Charges,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.15,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,13.67,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.45,95,,54.464,Percent of Total Billed Charges,95% of Total Billed Charges,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.28,88,,50.448,Percent of Total Billed Charges,88% of Total Billed Charges,27.9,90,,51.592,Percent of Total Billed charges,90% of Total Billed Charges,13.67,31,
BAIR PAW FLEX STD KIT,2700000124,CDM,270,RC,,,Outpatient,,,384.77,250.10,,384.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,292.43,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,277.03,72,,29.848,Percent of Total Billed Charges,72% of Total Billed Charges,288.58,75,,31.096,Percent of Total Billed charges,75% of Total Billed Charges,384.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.03,72,,29.848,Percent of Total Billed Charges,72% of Total Billed Charges,230.86,60,,24.872,Percent of Total Billed Charges,60% of Total Billed Charges,346.29,90,,111.136,Percent of Total Billed Charges,90% of Total Billed Charges,173.15,45,,9.92,Percent of Total Billed Charges,45% of Total Billed Charges,346.29,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,384.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.1,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,169.68,44.1,,9.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,365.53,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,384.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,338.6,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,346.29,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,169.68,384.77,
URINARY LEGBAG MEDUIM #1703230,2700000125,CDM,270,RC,,,Outpatient,,,20.00,13.00,,20,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.2,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.4,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,15,75,,16.536,Percent of Total Billed charges,75% of Total Billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.4,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,12,60,,13.232,Percent of Total Billed Charges,60% of Total Billed Charges,18,90,,43.664,Percent of Total Billed Charges,90% of Total Billed Charges,9,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,18,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13,65,,14.328,Percent of total Billed Charges,65% of Total Billed Charges,8.82,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,19,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.6,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,18,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,8.82,20,
URINARY LEGBAG LARGE #1703297,2700000126,CDM,270,RC,,,Outpatient,,,20.00,13.00,,20,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.2,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.4,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,15,75,,7.936,Percent of Total Billed charges,75% of Total Billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.4,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,12,60,,6.352,Percent of Total Billed Charges,60% of Total Billed Charges,18,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,9,45,,13.096,Percent of Total Billed Charges,45% of Total Billed Charges,18,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,8.82,44.1,,12.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,19,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.6,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,18,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,8.82,20,
LHC KIT (MANIFOLD) #727666,2700000127,CDM,270,RC,,,Outpatient,,,194.94,126.71,,194.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,148.15,76,,16.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,140.36,72,,213.376,Percent of Total Billed Charges,72% of Total Billed Charges,146.21,75,,222.264,Percent of Total Billed charges,75% of Total Billed Charges,194.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.36,72,,213.376,Percent of Total Billed Charges,72% of Total Billed Charges,116.96,60,,177.808,Percent of Total Billed Charges,60% of Total Billed Charges,175.45,90,,104.784,Percent of Total Billed Charges,90% of Total Billed Charges,87.72,45,,17.064,Percent of Total Billed Charges,45% of Total Billed Charges,175.45,90,,19.84,Percent of Total Billed Charges,90% of Total billed Charges,194.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.71,65,,18.92,Percent of total Billed Charges,65% of Total Billed Charges,85.97,44.1,,16.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,185.19,95,,20.944,Percent of Total Billed Charges,95% of Total Billed Charges,194.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.55,88,,19.4,Percent of Total Billed Charges,88% of Total Billed Charges,175.45,90,,19.84,Percent of Total Billed charges,90% of Total Billed Charges,85.97,194.94,
TOOTHETTE ORAL ANTISEPTIC,2700000128,CDM,270,RC,,,Outpatient,,,45.00,29.25,,45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.2,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.4,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,33.75,75,,73.432,Percent of Total Billed charges,75% of Total Billed Charges,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.4,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,27,60,,58.744,Percent of Total Billed Charges,60% of Total Billed Charges,40.5,90,,2.632,Percent of Total Billed Charges,90% of Total Billed Charges,20.25,45,,48.424,Percent of Total Billed Charges,45% of Total Billed Charges,40.5,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.25,65,,24.656,Percent of total Billed Charges,65% of Total Billed Charges,19.85,44.1,,47.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.75,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.6,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,40.5,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,19.85,45,
OXYGEN PER HOUR CHG,2700000129,CDM,270,RC,,,Outpatient,,,26.46,17.20,,26.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.11,76,,22.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.05,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.05,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,15.88,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,23.81,90,,107.168,Percent of Total Billed Charges,90% of Total Billed Charges,11.91,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,23.81,90,,26.192,Percent of Total Billed Charges,90% of Total billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,65,,69.944,Percent of total Billed Charges,65% of Total Billed Charges,11.67,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.14,95,,27.648,Percent of Total Billed Charges,95% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.28,88,,25.608,Percent of Total Billed Charges,88% of Total Billed Charges,23.81,90,,26.192,Percent of Total Billed charges,90% of Total Billed Charges,11.67,26.46,
ARTERIAL BLD GAS KIT,2700000130,CDM,270,RC,,,Outpatient,,,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,28.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,66.048,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,68.8,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,66.048,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,55.04,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,55.568,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,34.136,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,54.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,36.032,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,33.376,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,34.136,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
AERO HT,2700000131,CDM,270,RC,,,Outpatient,,,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,81.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.88,72,,35.56,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,75,,37.048,Percent of Total Billed charges,75% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.88,72,,35.56,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,60,,29.632,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,90,,50.008,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,21.832,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,96.848,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,80.264,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,21.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,102.224,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,94.696,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,96.848,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.05,
AMBU BAG W/MASK,2700000132,CDM,270,RC,,,Outpatient,,,138.92,90.30,,138.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,105.58,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.02,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,104.19,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.02,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,83.35,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,125.03,90,,18.256,Percent of Total Billed Charges,90% of Total Billed Charges,62.51,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,125.03,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.3,65,,31.536,Percent of total Billed Charges,65% of Total Billed Charges,61.26,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,131.97,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.25,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,125.03,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,61.26,138.92,
ISOLATION KIT,2700000133,CDM,270,RC,,,Outpatient,,,132.30,86.00,,132.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.55,76,,93.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.26,72,,13.336,Percent of Total Billed Charges,72% of Total Billed Charges,99.23,75,,13.888,Percent of Total Billed charges,75% of Total Billed Charges,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.26,72,,13.336,Percent of Total Billed Charges,72% of Total Billed Charges,79.38,60,,11.112,Percent of Total Billed Charges,60% of Total Billed Charges,119.07,90,,23.816,Percent of Total Billed Charges,90% of Total Billed Charges,59.54,45,,52.392,Percent of Total Billed Charges,45% of Total Billed Charges,119.07,90,,111.136,Percent of Total Billed Charges,90% of Total billed Charges,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,58.34,44.1,,51.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.69,95,,117.304,Percent of Total Billed Charges,95% of Total Billed Charges,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.42,88,,108.664,Percent of Total Billed Charges,88% of Total Billed Charges,119.07,90,,111.136,Percent of Total Billed charges,90% of Total Billed Charges,58.34,132.3,
HEAT MOISTURE EXCHAN,2700000134,CDM,270,RC,,,Outpatient,,,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,36.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,9.928,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,7.936,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,221.472,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,1.312,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,43.664,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,75.672,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,1.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,46.088,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,42.688,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,43.664,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
VENTILATOR CIRCUIT,2700000135,CDM,270,RC,,,Outpatient,,,48.51,31.53,,48.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.87,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.93,72,,14.512,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,75,,15.12,Percent of Total Billed charges,75% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,72,,14.512,Percent of Total Billed Charges,72% of Total Billed Charges,29.11,60,,12.096,Percent of Total Billed Charges,60% of Total Billed Charges,43.66,90,,57.152,Percent of Total Billed Charges,90% of Total Billed Charges,21.83,45,,53.584,Percent of Total Billed Charges,45% of Total Billed Charges,43.66,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.53,65,,1.896,Percent of total Billed Charges,65% of Total Billed Charges,21.39,44.1,,52.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.08,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.69,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,43.66,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,21.39,48.51,
INCENTIVE SPIROMETER,2700000136,CDM,270,RC,,,Outpatient,,,82.69,53.75,,82.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.84,76,,88.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.54,72,,10.368,Percent of Total Billed Charges,72% of Total Billed Charges,62.02,75,,10.8,Percent of Total Billed charges,75% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,72,,10.368,Percent of Total Billed Charges,72% of Total Billed Charges,49.61,60,,8.64,Percent of Total Billed Charges,60% of Total Billed Charges,74.42,90,,57.152,Percent of Total Billed Charges,90% of Total Billed Charges,37.21,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,74.42,90,,104.784,Percent of Total Billed Charges,90% of Total billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.75,65,,77.4,Percent of total Billed Charges,65% of Total Billed Charges,36.47,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,78.56,95,,110.6,Percent of Total Billed Charges,95% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,88,,102.456,Percent of Total Billed Charges,88% of Total Billed Charges,74.42,90,,104.784,Percent of Total Billed charges,90% of Total Billed Charges,36.47,82.69,
PEAK FLOWMETER,2700000137,CDM,270,RC,,,Outpatient,,,132.30,86.00,,132.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.55,76,,2.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.26,72,,2.072,Percent of Total Billed Charges,72% of Total Billed Charges,99.23,75,,2.16,Percent of Total Billed charges,75% of Total Billed Charges,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.26,72,,2.072,Percent of Total Billed Charges,72% of Total Billed Charges,79.38,60,,1.728,Percent of Total Billed Charges,60% of Total Billed Charges,119.07,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,59.54,45,,25.008,Percent of Total Billed Charges,45% of Total Billed Charges,119.07,90,,2.632,Percent of Total Billed Charges,90% of Total billed Charges,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,58.34,44.1,,24.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.69,95,,2.776,Percent of Total Billed Charges,95% of Total Billed Charges,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.42,88,,2.568,Percent of Total Billed Charges,88% of Total Billed Charges,119.07,90,,2.632,Percent of Total Billed charges,90% of Total Billed Charges,58.34,132.3,
MDI SPACER,2700000138,CDM,270,RC,,,Outpatient,,,66.15,43.00,,66.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,50.27,76,,90.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47.63,72,,2.208,Percent of Total Billed Charges,72% of Total Billed Charges,49.61,75,,2.304,Percent of Total Billed charges,75% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.63,72,,2.208,Percent of Total Billed Charges,72% of Total Billed Charges,39.69,60,,1.84,Percent of Total Billed Charges,60% of Total Billed Charges,59.54,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,29.77,45,,9.128,Percent of Total Billed Charges,45% of Total Billed Charges,59.54,90,,107.168,Percent of Total Billed Charges,90% of Total billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,65,,36.12,Percent of total Billed Charges,65% of Total Billed Charges,29.17,44.1,,8.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.84,95,,113.12,Percent of Total Billed Charges,95% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.21,88,,104.784,Percent of Total Billed Charges,88% of Total Billed Charges,59.54,90,,107.168,Percent of Total Billed charges,90% of Total Billed Charges,29.17,66.15,
ADULT HUMIDIFIER CHA,2700000139,CDM,270,RC,,,Outpatient,,,38.59,25.08,,38.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.33,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.78,72,,13.824,Percent of Total Billed Charges,72% of Total Billed Charges,28.94,75,,14.4,Percent of Total Billed charges,75% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.78,72,,13.824,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,34.73,90,,57.152,Percent of Total Billed Charges,90% of Total Billed Charges,17.37,45,,11.912,Percent of Total Billed Charges,45% of Total Billed Charges,34.73,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.08,65,,13.184,Percent of total Billed Charges,65% of Total Billed Charges,17.02,44.1,,11.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.66,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.96,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,34.73,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,17.02,38.59,
QUBE TENT,2700000140,CDM,270,RC,,,Outpatient,,,155.45,101.04,,155.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,118.14,76,,42.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.92,72,,2.04,Percent of Total Billed Charges,72% of Total Billed Charges,116.59,75,,2.128,Percent of Total Billed charges,75% of Total Billed Charges,155.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.92,72,,2.04,Percent of Total Billed Charges,72% of Total Billed Charges,93.27,60,,1.696,Percent of Total Billed Charges,60% of Total Billed Charges,139.91,90,,38.104,Percent of Total Billed Charges,90% of Total Billed Charges,69.95,45,,110.736,Percent of Total Billed Charges,45% of Total Billed Charges,139.91,90,,50.008,Percent of Total Billed Charges,90% of Total billed Charges,155.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.04,65,,17.2,Percent of total Billed Charges,65% of Total Billed Charges,68.55,44.1,,108.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,147.68,95,,52.792,Percent of Total Billed Charges,95% of Total Billed Charges,155.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.8,88,,48.896,Percent of Total Billed Charges,88% of Total Billed Charges,139.91,90,,50.008,Percent of Total Billed charges,90% of Total Billed Charges,68.55,155.45,
HEART NEBULIZER,2700000141,CDM,270,RC,,,Outpatient,,,121.28,78.83,,121.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,92.17,76,,15.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,87.32,72,,2,Percent of Total Billed Charges,72% of Total Billed Charges,90.96,75,,2.08,Percent of Total Billed charges,75% of Total Billed Charges,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.32,72,,2,Percent of Total Billed Charges,72% of Total Billed Charges,72.77,60,,1.664,Percent of Total Billed Charges,60% of Total Billed Charges,109.15,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,54.58,45,,28.576,Percent of Total Billed Charges,45% of Total Billed Charges,109.15,90,,18.256,Percent of Total Billed Charges,90% of Total billed Charges,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.83,65,,159.952,Percent of total Billed Charges,65% of Total Billed Charges,53.48,44.1,,28.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,115.22,95,,19.272,Percent of Total Billed Charges,95% of Total Billed Charges,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.73,88,,17.856,Percent of Total Billed Charges,88% of Total Billed Charges,109.15,90,,18.256,Percent of Total Billed charges,90% of Total Billed Charges,53.48,121.28,
DEEP VALVE PEEPVIV,2700000142,CDM,270,RC,,,Outpatient,,,54.02,35.11,,54.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.06,76,,20.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.89,72,,1.936,Percent of Total Billed Charges,72% of Total Billed Charges,40.52,75,,2.016,Percent of Total Billed charges,75% of Total Billed Charges,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.89,72,,1.936,Percent of Total Billed Charges,72% of Total Billed Charges,32.41,60,,1.616,Percent of Total Billed Charges,60% of Total Billed Charges,48.62,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,24.31,45,,28.576,Percent of Total Billed Charges,45% of Total Billed Charges,48.62,90,,23.816,Percent of Total Billed Charges,90% of Total billed Charges,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.11,65,,41.28,Percent of total Billed Charges,65% of Total Billed Charges,23.82,44.1,,28.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,51.32,95,,25.144,Percent of Total Billed Charges,95% of Total Billed Charges,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.54,88,,23.288,Percent of Total Billed Charges,88% of Total Billed Charges,48.62,90,,23.816,Percent of Total Billed charges,90% of Total Billed Charges,23.82,54.02,
EZ FLOW NEB,2700000143,CDM,270,RC,,,Outpatient,,,89.30,58.05,,89.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.87,76,,187.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.3,72,,1.944,Percent of Total Billed Charges,72% of Total Billed Charges,66.98,75,,2.032,Percent of Total Billed charges,75% of Total Billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.3,72,,1.944,Percent of Total Billed Charges,72% of Total Billed Charges,53.58,60,,1.624,Percent of Total Billed Charges,60% of Total Billed Charges,80.37,90,,17.808,Percent of Total Billed Charges,90% of Total Billed Charges,40.19,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,80.37,90,,221.472,Percent of Total Billed Charges,90% of Total billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.05,65,,41.28,Percent of total Billed Charges,65% of Total Billed Charges,39.38,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,84.84,95,,233.776,Percent of Total Billed Charges,95% of Total Billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.58,88,,216.552,Percent of Total Billed Charges,88% of Total Billed Charges,80.37,90,,221.472,Percent of Total Billed charges,90% of Total Billed Charges,39.38,89.3,
THERABAND,2700000144,CDM,270,RC,,,Outpatient,,,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,48.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,10.456,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,10.888,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,10.456,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,8.712,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,57.152,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,60.328,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,55.88,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,57.152,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
TELFA 2X2,2700000145,CDM,270,RC,,,Outpatient,,,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,48.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,14,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,14.584,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,14,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,11.664,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,30.168,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,28.576,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,57.152,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,28.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,60.328,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,55.88,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,57.152,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
THERAPUTTY,2700000146,CDM,270,RC,,,Outpatient,,,36.38,23.65,,36.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.65,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.19,72,,11.92,Percent of Total Billed Charges,72% of Total Billed Charges,27.29,75,,12.416,Percent of Total Billed charges,75% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.19,72,,11.92,Percent of Total Billed Charges,72% of Total Billed Charges,21.83,60,,9.928,Percent of Total Billed Charges,60% of Total Billed Charges,32.74,90,,147.648,Percent of Total Billed Charges,90% of Total Billed Charges,16.37,45,,19.048,Percent of Total Billed Charges,45% of Total Billed Charges,32.74,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.65,65,,41.28,Percent of total Billed Charges,65% of Total Billed Charges,16.04,44.1,,18.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.56,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.01,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,32.74,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,16.04,36.38,
PT STERIL KITS,2700000147,CDM,270,RC,,,Outpatient,,,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,9.68,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,10.08,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,9.68,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,8.064,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,27.52,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
COBAN 2,2700000148,CDM,270,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,48.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,9.216,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,9.6,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,9.216,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,57.152,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,60.328,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,55.88,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,57.152,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
CHLORAZENE 50 GM,2700000149,CDM,270,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,32.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,7.376,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,7.68,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,7.376,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,6.144,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,10.32,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,8.904,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,38.104,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,8.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,40.216,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,37.256,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,38.104,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
COFLEX NL,2700000150,CDM,270,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,8.296,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,8.64,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,8.296,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,6.912,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,50.8,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,12.856,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
COBAN 4,2700000151,CDM,270,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,17.096,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,17.808,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,17.096,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,14.248,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,15.088,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,14.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
TRANSFER BELT,2700000152,CDM,270,RC,,,Outpatient,,,36.38,23.65,,36.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.65,76,,15.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.19,72,,10.08,Percent of Total Billed Charges,72% of Total Billed Charges,27.29,75,,10.504,Percent of Total Billed charges,75% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.19,72,,10.08,Percent of Total Billed Charges,72% of Total Billed Charges,21.83,60,,8.4,Percent of Total Billed Charges,60% of Total Billed Charges,32.74,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,16.37,45,,73.824,Percent of Total Billed Charges,45% of Total Billed Charges,32.74,90,,17.808,Percent of Total Billed Charges,90% of Total billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.65,65,,21.792,Percent of total Billed Charges,65% of Total Billed Charges,16.04,44.1,,72.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.56,95,,18.792,Percent of Total Billed Charges,95% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.01,88,,17.408,Percent of Total Billed Charges,88% of Total Billed Charges,32.74,90,,17.808,Percent of Total Billed charges,90% of Total Billed Charges,16.04,36.38,
TOTAL HIP KIT,2700000153,CDM,270,RC,,,Outpatient,,,121.28,78.83,,121.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,92.17,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,87.32,72,,7.256,Percent of Total Billed Charges,72% of Total Billed Charges,90.96,75,,7.56,Percent of Total Billed charges,75% of Total Billed Charges,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.32,72,,7.256,Percent of Total Billed Charges,72% of Total Billed Charges,72.77,60,,6.048,Percent of Total Billed Charges,60% of Total Billed Charges,109.15,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,54.58,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,109.15,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.83,65,,106.64,Percent of total Billed Charges,65% of Total Billed Charges,53.48,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,115.22,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.73,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,109.15,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,53.48,121.28,
DIABETES INSOLE,2700000154,CDM,270,RC,,,Outpatient,,,45.20,29.38,,45.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.35,76,,25.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.54,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,33.9,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.54,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,27.12,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,40.68,90,,30.96,Percent of Total Billed Charges,90% of Total Billed Charges,20.34,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,40.68,90,,30.168,Percent of Total Billed Charges,90% of Total billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.38,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,19.93,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.94,95,,31.848,Percent of Total Billed Charges,95% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.78,88,,29.496,Percent of Total Billed Charges,88% of Total Billed Charges,40.68,90,,30.168,Percent of Total Billed charges,90% of Total Billed Charges,19.93,45.2,
THERABAND,2700000155,CDM,270,RC,,,Outpatient,,,27.56,17.91,,27.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.95,76,,124.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.84,72,,29.664,Percent of Total Billed Charges,72% of Total Billed Charges,20.67,75,,30.904,Percent of Total Billed charges,75% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.84,72,,29.664,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,60,,24.72,Percent of Total Billed Charges,60% of Total Billed Charges,24.8,90,,35.72,Percent of Total Billed Charges,90% of Total Billed Charges,12.4,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,24.8,90,,147.648,Percent of Total Billed Charges,90% of Total billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.91,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,12.15,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.18,95,,155.856,Percent of Total Billed Charges,95% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,88,,144.368,Percent of Total Billed Charges,88% of Total Billed Charges,24.8,90,,147.648,Percent of Total Billed charges,90% of Total Billed Charges,12.15,27.56,
THERAPUTTY,2700000156,CDM,270,RC,,,Outpatient,,,26.46,17.20,,26.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.11,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.05,72,,4.608,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,75,,4.8,Percent of Total Billed charges,75% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.05,72,,4.608,Percent of Total Billed Charges,72% of Total Billed Charges,15.88,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,23.81,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,11.91,45,,25.4,Percent of Total Billed Charges,45% of Total Billed Charges,23.81,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,65,,7.448,Percent of total Billed Charges,65% of Total Billed Charges,11.67,44.1,,24.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.14,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.28,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,23.81,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,11.67,26.46,
ELECTRODES,2700000157,CDM,270,RC,,,Outpatient,,,54.02,35.11,,54.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.06,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.89,72,,5.184,Percent of Total Billed Charges,72% of Total Billed Charges,40.52,75,,5.4,Percent of Total Billed charges,75% of Total Billed Charges,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.89,72,,5.184,Percent of Total Billed Charges,72% of Total Billed Charges,32.41,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,48.62,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,24.31,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,48.62,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.11,65,,36.688,Percent of total Billed Charges,65% of Total Billed Charges,23.82,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,51.32,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.54,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,48.62,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,23.82,54.02,
SANE SUPPLIES,2700000158,CDM,270,RC,,,Outpatient,,,682.45,443.59,,682.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,518.66,76,,8.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,491.36,72,,5.296,Percent of Total Billed Charges,72% of Total Billed Charges,511.84,75,,5.52,Percent of Total Billed charges,75% of Total Billed Charges,682.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.36,72,,5.296,Percent of Total Billed Charges,72% of Total Billed Charges,409.47,60,,4.416,Percent of Total Billed Charges,60% of Total Billed Charges,614.21,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,307.1,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,614.21,90,,10.32,Percent of Total Billed Charges,90% of Total billed Charges,682.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,682.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,682.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,443.59,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,300.96,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,648.33,95,,10.888,Percent of Total Billed Charges,95% of Total Billed Charges,682.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,600.56,88,,10.088,Percent of Total Billed Charges,88% of Total Billed Charges,614.21,90,,10.32,Percent of Total Billed charges,90% of Total Billed Charges,300.96,682.45,
DRUG FACILITATED SA,2700000159,CDM,270,RC,,,Outpatient,,,50.72,32.97,,50.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38.55,76,,42.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36.52,72,,35.336,Percent of Total Billed Charges,72% of Total Billed Charges,38.04,75,,36.808,Percent of Total Billed charges,75% of Total Billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.52,72,,35.336,Percent of Total Billed Charges,72% of Total Billed Charges,30.43,60,,29.448,Percent of Total Billed Charges,60% of Total Billed Charges,45.65,90,,15.88,Percent of Total Billed Charges,90% of Total Billed Charges,22.82,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,45.65,90,,50.8,Percent of Total Billed Charges,90% of Total billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.97,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,22.37,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.18,95,,53.624,Percent of Total Billed Charges,95% of Total Billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.63,88,,49.672,Percent of Total Billed Charges,88% of Total Billed Charges,45.65,90,,50.8,Percent of Total Billed charges,90% of Total Billed Charges,22.37,50.72,
SHOULDER IMMOB MED,2700000161,CDM,270,RC,,,Outpatient,,,422.26,274.47,,422.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,320.92,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,304.03,72,,1.968,Percent of Total Billed Charges,72% of Total Billed Charges,316.7,75,,2.056,Percent of Total Billed charges,75% of Total Billed Charges,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.03,72,,1.968,Percent of Total Billed Charges,72% of Total Billed Charges,253.36,60,,1.64,Percent of Total Billed Charges,60% of Total Billed Charges,380.03,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,190.02,45,,15.48,Percent of Total Billed Charges,45% of Total Billed Charges,380.03,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.47,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,186.22,44.1,,15.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,401.15,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.59,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,380.03,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,186.22,422.26,
SHOULDER IMMOB LG,2700000162,CDM,270,RC,,,Outpatient,,,422.26,274.47,,422.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,320.92,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,304.03,72,,3.92,Percent of Total Billed Charges,72% of Total Billed Charges,316.7,75,,4.08,Percent of Total Billed charges,75% of Total Billed Charges,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.03,72,,3.92,Percent of Total Billed Charges,72% of Total Billed Charges,253.36,60,,3.264,Percent of Total Billed Charges,60% of Total Billed Charges,380.03,90,,27.784,Percent of Total Billed Charges,90% of Total Billed Charges,190.02,45,,17.856,Percent of Total Billed Charges,45% of Total Billed Charges,380.03,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.47,65,,22.36,Percent of total Billed Charges,65% of Total Billed Charges,186.22,44.1,,17.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,401.15,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.59,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,380.03,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,186.22,422.26,
SHOULDER IMMOB XL,2700000163,CDM,270,RC,,,Outpatient,,,422.26,274.47,,422.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,320.92,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,304.03,72,,3.344,Percent of Total Billed Charges,72% of Total Billed Charges,316.7,75,,3.48,Percent of Total Billed charges,75% of Total Billed Charges,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.03,72,,3.344,Percent of Total Billed Charges,72% of Total Billed Charges,253.36,60,,2.784,Percent of Total Billed Charges,60% of Total Billed Charges,380.03,90,,27.784,Percent of Total Billed Charges,90% of Total Billed Charges,190.02,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,380.03,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.47,65,,25.8,Percent of total Billed Charges,65% of Total Billed Charges,186.22,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,401.15,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.59,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,380.03,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,186.22,422.26,
TED HOSE KNEE XL / REG,2700000164,CDM,270,RC,,,Outpatient,,,73.50,47.78,,73.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.86,76,,26.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.92,72,,45.792,Percent of Total Billed Charges,72% of Total Billed Charges,55.13,75,,47.704,Percent of Total Billed charges,75% of Total Billed Charges,73.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,72,,45.792,Percent of Total Billed Charges,72% of Total Billed Charges,44.1,60,,38.16,Percent of Total Billed Charges,60% of Total Billed Charges,66.15,90,,51.592,Percent of Total Billed Charges,90% of Total Billed Charges,33.08,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,66.15,90,,30.96,Percent of Total Billed Charges,90% of Total billed Charges,73.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.78,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,32.41,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,69.83,95,,32.68,Percent of Total Billed Charges,95% of Total Billed Charges,73.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.68,88,,30.272,Percent of Total Billed Charges,88% of Total Billed Charges,66.15,90,,30.96,Percent of Total Billed charges,90% of Total Billed Charges,32.41,73.5,
PASTE OSTOMY,2700000165,CDM,270,RC,,,Outpatient,,,24.86,16.16,,24.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.89,76,,30.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.9,72,,5.92,Percent of Total Billed Charges,72% of Total Billed Charges,18.65,75,,6.168,Percent of Total Billed charges,75% of Total Billed Charges,24.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.9,72,,5.92,Percent of Total Billed Charges,72% of Total Billed Charges,14.92,60,,4.936,Percent of Total Billed Charges,60% of Total Billed Charges,22.37,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,11.19,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,22.37,90,,35.72,Percent of Total Billed Charges,90% of Total billed Charges,24.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.16,65,,6.88,Percent of total Billed Charges,65% of Total Billed Charges,10.96,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.62,95,,37.704,Percent of Total Billed Charges,95% of Total Billed Charges,24.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.88,88,,34.928,Percent of Total Billed Charges,88% of Total Billed Charges,22.37,90,,35.72,Percent of Total Billed charges,90% of Total Billed Charges,10.96,24.86,
HOT PACK,2700000166,CDM,270,RC,,,Outpatient,,,8.40,5.46,,8.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.38,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.05,72,,15.848,Percent of Total Billed Charges,72% of Total Billed Charges,6.3,75,,16.512,Percent of Total Billed charges,75% of Total Billed Charges,8.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.05,72,,15.848,Percent of Total Billed Charges,72% of Total Billed Charges,5.04,60,,13.208,Percent of Total Billed Charges,60% of Total Billed Charges,7.56,90,,49.216,Percent of Total Billed Charges,90% of Total Billed Charges,3.78,45,,7.936,Percent of Total Billed Charges,45% of Total Billed Charges,7.56,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,8.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.46,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,3.7,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.98,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,8.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.39,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,7.56,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,3.7,8.4,
GUEDEL AIRWAY 10,2700000168,CDM,271,RC,,,Outpatient,,,0.59,0.38,,0.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.45,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.42,72,,29.232,Percent of Total Billed Charges,72% of Total Billed Charges,0.44,75,,30.448,Percent of Total Billed charges,75% of Total Billed Charges,0.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.42,72,,29.232,Percent of Total Billed Charges,72% of Total Billed Charges,0.35,60,,24.36,Percent of Total Billed Charges,60% of Total Billed Charges,0.53,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,0.27,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,0.53,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,0.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.38,65,,11.464,Percent of total Billed Charges,65% of Total Billed Charges,0.26,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.56,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,0.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.52,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,0.53,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,0.26,0.59,
GUEDEL AIRWAY 8,2700000169,CDM,271,RC,,,Outpatient,,,0.55,0.36,,0.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.42,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.4,72,,4.72,Percent of Total Billed Charges,72% of Total Billed Charges,0.41,75,,4.92,Percent of Total Billed charges,75% of Total Billed Charges,0.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.4,72,,4.72,Percent of Total Billed Charges,72% of Total Billed Charges,0.33,60,,3.936,Percent of Total Billed Charges,60% of Total Billed Charges,0.5,90,,49.216,Percent of Total Billed Charges,90% of Total Billed Charges,0.25,45,,13.896,Percent of Total Billed Charges,45% of Total Billed Charges,0.5,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,0.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.36,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,0.24,44.1,,13.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.52,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,0.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.48,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,0.5,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,0.24,0.55,
GUEDEL AIRWAY 7,2700000170,CDM,271,RC,,,Outpatient,,,0.55,0.36,,0.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.42,76,,13.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.4,72,,10.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.41,75,,10.504,Percent of Total Billed charges,75% of Total Billed Charges,0.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.4,72,,10.08,Percent of Total Billed Charges,72% of Total Billed Charges,0.33,60,,8.4,Percent of Total Billed Charges,60% of Total Billed Charges,0.5,90,,19.048,Percent of Total Billed Charges,90% of Total Billed Charges,0.25,45,,13.896,Percent of Total Billed Charges,45% of Total Billed Charges,0.5,90,,15.88,Percent of Total Billed Charges,90% of Total billed Charges,0.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.36,65,,20.064,Percent of total Billed Charges,65% of Total Billed Charges,0.24,44.1,,13.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.52,95,,16.76,Percent of Total Billed Charges,95% of Total Billed Charges,0.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.48,88,,15.52,Percent of Total Billed Charges,88% of Total Billed Charges,0.5,90,,15.88,Percent of Total Billed charges,90% of Total Billed Charges,0.24,0.55,
GUEDEL AIRWAY 6,2700000171,CDM,271,RC,,,Outpatient,,,0.35,0.23,,0.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.27,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.25,72,,2.936,Percent of Total Billed Charges,72% of Total Billed Charges,0.26,75,,3.064,Percent of Total Billed charges,75% of Total Billed Charges,0.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.25,72,,2.936,Percent of Total Billed Charges,72% of Total Billed Charges,0.21,60,,2.448,Percent of Total Billed Charges,60% of Total Billed Charges,0.32,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,0.16,45,,25.8,Percent of Total Billed Charges,45% of Total Billed Charges,0.32,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,0.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.23,65,,20.064,Percent of total Billed Charges,65% of Total Billed Charges,0.15,44.1,,25.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.33,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,0.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.31,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,0.32,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,0.15,0.35,
GUEDEL AIRWAY 9,2700000172,CDM,271,RC,,,Outpatient,,,1.40,0.91,,1.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.06,76,,23.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.01,72,,5.36,Percent of Total Billed Charges,72% of Total Billed Charges,1.05,75,,5.584,Percent of Total Billed charges,75% of Total Billed Charges,1.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.01,72,,5.36,Percent of Total Billed Charges,72% of Total Billed Charges,0.84,60,,4.464,Percent of Total Billed Charges,60% of Total Billed Charges,1.26,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.63,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,1.26,90,,27.784,Percent of Total Billed Charges,90% of Total billed Charges,1.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.91,65,,37.264,Percent of total Billed Charges,65% of Total Billed Charges,0.62,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.33,95,,29.328,Percent of Total Billed Charges,95% of Total Billed Charges,1.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.23,88,,27.168,Percent of Total Billed Charges,88% of Total Billed Charges,1.26,90,,27.784,Percent of Total Billed charges,90% of Total Billed Charges,0.62,1.4,
STRAIGHT UNCUFF 4.5,2700000173,CDM,272,RC,,,Outpatient,,,1.25,0.81,,1.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.95,76,,23.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.9,72,,6.68,Percent of Total Billed Charges,72% of Total Billed Charges,0.94,75,,6.96,Percent of Total Billed charges,75% of Total Billed Charges,1.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.9,72,,6.68,Percent of Total Billed Charges,72% of Total Billed Charges,0.75,60,,5.568,Percent of Total Billed Charges,60% of Total Billed Charges,1.13,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.56,45,,24.608,Percent of Total Billed Charges,45% of Total Billed Charges,1.13,90,,27.784,Percent of Total Billed Charges,90% of Total billed Charges,1.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.81,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,0.55,44.1,,24.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.19,95,,29.328,Percent of Total Billed Charges,95% of Total Billed Charges,1.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,88,,27.168,Percent of Total Billed Charges,88% of Total Billed Charges,1.13,90,,27.784,Percent of Total Billed charges,90% of Total Billed Charges,0.55,1.25,
STRAIGHT UNCUFF 4.0,2700000174,CDM,272,RC,,,Outpatient,,,1.56,1.01,,1.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.19,76,,43.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.12,72,,9.768,Percent of Total Billed Charges,72% of Total Billed Charges,1.17,75,,10.176,Percent of Total Billed charges,75% of Total Billed Charges,1.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.12,72,,9.768,Percent of Total Billed Charges,72% of Total Billed Charges,0.94,60,,8.144,Percent of Total Billed Charges,60% of Total Billed Charges,1.4,90,,24.608,Percent of Total Billed Charges,90% of Total Billed Charges,0.7,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,1.4,90,,51.592,Percent of Total Billed Charges,90% of Total billed Charges,1.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.01,65,,35.544,Percent of total Billed Charges,65% of Total Billed Charges,0.69,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.48,95,,54.464,Percent of Total Billed Charges,95% of Total Billed Charges,1.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.37,88,,50.448,Percent of Total Billed Charges,88% of Total Billed Charges,1.4,90,,51.592,Percent of Total Billed charges,90% of Total Billed Charges,0.69,1.56,
MARATHON SKIN PROTECTANT,2700000175,CDM,270,RC,,,Outpatient,,,11.22,7.29,,11.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.53,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.08,72,,133.376,Percent of Total Billed Charges,72% of Total Billed Charges,8.42,75,,138.936,Percent of Total Billed charges,75% of Total Billed Charges,11.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.08,72,,133.376,Percent of Total Billed Charges,72% of Total Billed Charges,6.73,60,,111.152,Percent of Total Billed Charges,60% of Total Billed Charges,10.1,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,5.05,45,,24.608,Percent of Total Billed Charges,45% of Total Billed Charges,10.1,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,11.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.29,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,4.95,44.1,,24.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.66,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,11.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.87,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,10.1,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,4.95,11.22,
CHLORAPREP 3ML,2700000176,CDM,270,RC,,,Outpatient,,,1.81,1.18,,1.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.38,76,,41.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.3,72,,6.752,Percent of Total Billed Charges,72% of Total Billed Charges,1.36,75,,7.032,Percent of Total Billed charges,75% of Total Billed Charges,1.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,72,,6.752,Percent of Total Billed Charges,72% of Total Billed Charges,1.09,60,,5.624,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,90,,68.272,Percent of Total Billed Charges,90% of Total Billed Charges,0.81,45,,9.528,Percent of Total Billed Charges,45% of Total Billed Charges,1.63,90,,49.216,Percent of Total Billed Charges,90% of Total billed Charges,1.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.18,65,,35.544,Percent of total Billed Charges,65% of Total Billed Charges,0.8,44.1,,9.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.72,95,,51.952,Percent of Total Billed Charges,95% of Total Billed Charges,1.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,88,,48.128,Percent of Total Billed Charges,88% of Total Billed Charges,1.63,90,,49.216,Percent of Total Billed charges,90% of Total Billed Charges,0.8,1.81,
micro clave connector,2700000177,CDM,270,RC,,,Outpatient,,,2.46,1.60,,2.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.87,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.77,72,,7.952,Percent of Total Billed Charges,72% of Total Billed Charges,1.85,75,,8.28,Percent of Total Billed charges,75% of Total Billed Charges,2.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.77,72,,7.952,Percent of Total Billed Charges,72% of Total Billed Charges,1.48,60,,6.624,Percent of Total Billed Charges,60% of Total Billed Charges,2.21,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,1.11,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,2.21,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,2.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.6,65,,13.76,Percent of total Billed Charges,65% of Total Billed Charges,1.08,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.34,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,2.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.16,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,2.21,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,1.08,2.46,
STATLOCK,2700000178,CDM,270,RC,,,Outpatient,,,7.48,4.86,,7.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.68,76,,41.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.39,72,,6.096,Percent of Total Billed Charges,72% of Total Billed Charges,5.61,75,,6.352,Percent of Total Billed charges,75% of Total Billed Charges,7.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.39,72,,6.096,Percent of Total Billed Charges,72% of Total Billed Charges,4.49,60,,5.08,Percent of Total Billed Charges,60% of Total Billed Charges,6.73,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,3.37,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,6.73,90,,49.216,Percent of Total Billed Charges,90% of Total billed Charges,7.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.86,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,3.3,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.11,95,,51.952,Percent of Total Billed Charges,95% of Total Billed Charges,7.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.58,88,,48.128,Percent of Total Billed Charges,88% of Total Billed Charges,6.73,90,,49.216,Percent of Total Billed charges,90% of Total Billed Charges,3.3,7.48,
MASTISOL LIQ ADHESIVE,2700000179,CDM,270,RC,,,Outpatient,,,4.62,3.00,,4.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.51,76,,16.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.33,72,,11.52,Percent of Total Billed Charges,72% of Total Billed Charges,3.47,75,,12,Percent of Total Billed charges,75% of Total Billed Charges,4.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.33,72,,11.52,Percent of Total Billed Charges,72% of Total Billed Charges,2.77,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.16,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,2.08,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,4.16,90,,19.048,Percent of Total Billed Charges,90% of Total billed Charges,4.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,2.04,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.39,95,,20.112,Percent of Total Billed Charges,95% of Total Billed Charges,4.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.07,88,,18.624,Percent of Total Billed Charges,88% of Total Billed Charges,4.16,90,,19.048,Percent of Total Billed charges,90% of Total Billed Charges,2.04,4.62,
IV START KIT,2700000180,CDM,270,RC,,,Outpatient,,,1.80,1.17,,1.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.37,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.3,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,1.35,75,,13.232,Percent of Total Billed charges,75% of Total Billed Charges,1.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,1.08,60,,10.584,Percent of Total Billed Charges,60% of Total Billed Charges,1.62,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,0.81,45,,12.304,Percent of Total Billed Charges,45% of Total Billed Charges,1.62,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,1.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.17,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,0.79,44.1,,12.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.71,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,1.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.58,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,1.62,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,0.79,1.8,
BLACK SPINAL NEEDLE 22G X7,2700000182,CDM,270,RC,,,Outpatient,,,4.00,2.60,,4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.04,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.88,72,,41.44,Percent of Total Billed Charges,72% of Total Billed Charges,3,75,,43.168,Percent of Total Billed charges,75% of Total Billed Charges,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.88,72,,41.44,Percent of Total Billed Charges,72% of Total Billed Charges,2.4,60,,34.528,Percent of Total Billed Charges,60% of Total Billed Charges,3.6,90,,79.384,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,45,,34.136,Percent of Total Billed Charges,45% of Total Billed Charges,3.6,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.6,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,1.76,44.1,,33.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.8,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.52,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,3.6,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,1.76,4,
ALCON 1.2 SIDEPORT KNIFE,2700000183,CDM,270,RC,,,Outpatient,,,15.00,9.75,,15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.4,76,,20.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.8,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,11.25,75,,21.832,Percent of Total Billed charges,75% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.8,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,9,60,,17.464,Percent of Total Billed Charges,60% of Total Billed Charges,13.5,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,6.75,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,13.5,90,,24.608,Percent of Total Billed Charges,90% of Total billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.75,65,,49.304,Percent of total Billed Charges,65% of Total Billed Charges,6.62,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.25,95,,25.976,Percent of Total Billed Charges,95% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.2,88,,24.064,Percent of Total Billed Charges,88% of Total Billed Charges,13.5,90,,24.608,Percent of Total Billed charges,90% of Total Billed Charges,6.62,15,
NASAL RAE TUBE UNCUFF 4.5,2700000184,CDM,270,RC,,,Outpatient,,,5.90,3.84,,5.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.48,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.25,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,4.43,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,5.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.25,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,3.54,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,5.31,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,2.66,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,5.31,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,5.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.84,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,2.6,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.61,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,5.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.19,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,5.31,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,2.6,5.9,
HIBICLENZ 4OZ,2700000185,CDM,270,RC,,,Outpatient,,,33.08,21.50,,33.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.14,76,,57.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.82,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,24.81,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.82,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,29.77,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,14.89,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,29.77,90,,68.272,Percent of Total Billed Charges,90% of Total billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.5,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,14.59,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.43,95,,72.064,Percent of Total Billed Charges,95% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.11,88,,66.752,Percent of Total Billed Charges,88% of Total Billed Charges,29.77,90,,68.272,Percent of Total Billed charges,90% of Total Billed Charges,14.59,33.08,
PT THERAHONEY 0.5 OZ,2700000187,CDM,270,RC,,,Outpatient,,,31.84,20.70,,31.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.2,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.92,72,,73.032,Percent of Total Billed Charges,72% of Total Billed Charges,23.88,75,,76.072,Percent of Total Billed charges,75% of Total Billed Charges,31.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.92,72,,73.032,Percent of Total Billed Charges,72% of Total Billed Charges,19.1,60,,60.856,Percent of Total Billed Charges,60% of Total Billed Charges,28.66,90,,25.4,Percent of Total Billed Charges,90% of Total Billed Charges,14.33,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,28.66,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,31.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.7,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,14.04,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.25,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,31.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.02,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,28.66,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,14.04,31.84,
PT THERAHONEY 1.5 OZ,2700000188,CDM,270,RC,,,Outpatient,,,65.61,42.65,,65.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.86,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47.24,72,,69.856,Percent of Total Billed Charges,72% of Total Billed Charges,49.21,75,,72.768,Percent of Total Billed charges,75% of Total Billed Charges,65.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.24,72,,69.856,Percent of Total Billed Charges,72% of Total Billed Charges,39.37,60,,58.216,Percent of Total Billed Charges,60% of Total Billed Charges,59.05,90,,105.576,Percent of Total Billed Charges,90% of Total Billed Charges,29.52,45,,39.688,Percent of Total Billed Charges,45% of Total Billed Charges,59.05,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,65.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.65,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,28.93,44.1,,38.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.33,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,65.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.74,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,59.05,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,28.93,65.61,
PT PURACOL AG 2X2,2700000189,CDM,270,RC,,,Outpatient,,,56.03,36.42,,56.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.58,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.34,72,,73.032,Percent of Total Billed Charges,72% of Total Billed Charges,42.02,75,,76.072,Percent of Total Billed charges,75% of Total Billed Charges,56.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.34,72,,73.032,Percent of Total Billed Charges,72% of Total Billed Charges,33.62,60,,60.856,Percent of Total Billed Charges,60% of Total Billed Charges,50.43,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,25.21,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,50.43,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,56.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.42,65,,57.328,Percent of total Billed Charges,65% of Total Billed Charges,24.71,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.23,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,56.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.31,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,50.43,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,24.71,56.03,
PT PURACOL AG 4X4,2700000190,CDM,270,RC,,,Outpatient,,,122.89,79.88,,122.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.4,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.48,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,92.17,75,,5.952,Percent of Total Billed charges,75% of Total Billed Charges,122.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.48,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,73.73,60,,4.76,Percent of Total Billed Charges,60% of Total Billed Charges,110.6,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,55.3,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,110.6,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,122.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.88,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,54.19,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.75,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,122.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.14,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,110.6,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,54.19,122.89,
PT OPTICELL AB 2X2,2700000191,CDM,270,RC,,,Outpatient,,,35.10,22.82,,35.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.68,76,,67.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.27,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,26.33,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,35.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.27,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,21.06,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,31.59,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,15.8,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,31.59,90,,79.384,Percent of Total Billed Charges,90% of Total billed Charges,35.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.82,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,15.48,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.35,95,,83.792,Percent of Total Billed Charges,95% of Total Billed Charges,35.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.89,88,,77.616,Percent of Total Billed Charges,88% of Total Billed Charges,31.59,90,,79.384,Percent of Total Billed charges,90% of Total Billed Charges,15.48,35.1,
PT OPTICELL AG 4X5,2700000192,CDM,270,RC,,,Outpatient,,,48.35,31.43,,48.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.75,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.81,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,36.26,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,48.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.81,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,29.01,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,43.52,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,21.76,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,43.52,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,48.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.43,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,21.32,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.93,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,48.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.55,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,43.52,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,21.32,48.35,
BAIR PAWS ADULT GOWN,2700000194,CDM,270,RC,,,Outpatient,,,16.00,10.40,,16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.16,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.52,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,12,75,,43,Percent of Total Billed charges,75% of Total Billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.52,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,9.6,60,,34.4,Percent of Total Billed Charges,60% of Total Billed Charges,14.4,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,45,,52.784,Percent of Total Billed Charges,45% of Total Billed Charges,14.4,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,65,,18.344,Percent of total Billed Charges,65% of Total Billed Charges,7.06,44.1,,51.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.2,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.08,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,14.4,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,7.06,16,
BAIR PAWS PEDI GOWN,2700000195,CDM,270,RC,,,Outpatient,,,13.00,8.45,,13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.88,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.36,72,,6.288,Percent of Total Billed Charges,72% of Total Billed Charges,9.75,75,,6.552,Percent of Total Billed charges,75% of Total Billed Charges,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.36,72,,6.288,Percent of Total Billed Charges,72% of Total Billed Charges,7.8,60,,5.24,Percent of Total Billed Charges,60% of Total Billed Charges,11.7,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,5.85,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,11.7,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.45,65,,76.248,Percent of total Billed Charges,65% of Total Billed Charges,5.73,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.35,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.44,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,11.7,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,5.73,13,
ARCH SARS COV 21lgG 100T US,2700000196,CDM,270,RC,,,Outpatient,,,1625.00,1056.25,,1625,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1235,76,,21.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1170,72,,11.712,Percent of Total Billed Charges,72% of Total Billed Charges,1218.75,75,,12.208,Percent of Total Billed charges,75% of Total Billed Charges,1625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170,72,,11.712,Percent of Total Billed Charges,72% of Total Billed Charges,975,60,,9.76,Percent of Total Billed Charges,60% of Total Billed Charges,1462.5,90,,135.744,Percent of Total Billed Charges,90% of Total Billed Charges,731.25,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,1462.5,90,,25.4,Percent of Total Billed Charges,90% of Total billed Charges,1625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1056.25,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,716.63,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,1543.75,95,,26.816,Percent of Total Billed Charges,95% of Total Billed Charges,1625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1430,88,,24.84,Percent of Total Billed Charges,88% of Total Billed Charges,1462.5,90,,25.4,Percent of Total Billed charges,90% of Total Billed Charges,716.63,1625,
ARCH SARS COV 2 lgG CAL US,2700000197,CDM,270,RC,,,Outpatient,,,247.50,160.88,,247.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,188.1,76,,89.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,178.2,72,,11.712,Percent of Total Billed Charges,72% of Total Billed Charges,185.63,75,,12.208,Percent of Total Billed charges,75% of Total Billed Charges,247.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.2,72,,11.712,Percent of Total Billed Charges,72% of Total Billed Charges,148.5,60,,9.76,Percent of Total Billed Charges,60% of Total Billed Charges,222.75,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,111.38,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,222.75,90,,105.576,Percent of Total Billed Charges,90% of Total billed Charges,247.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.88,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,109.15,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,235.13,95,,111.44,Percent of Total Billed Charges,95% of Total Billed Charges,247.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.8,88,,103.224,Percent of Total Billed Charges,88% of Total Billed Charges,222.75,90,,105.576,Percent of Total Billed charges,90% of Total Billed Charges,109.15,247.5,
ARCH SARS COV 2 LgG CTRL US,2700000198,CDM,270,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,11.712,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,12.208,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,11.712,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,9.76,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,19.208,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
RESP MULTI ADAPTER 15MM X 22MM,2700000199,CDM,270,RC,,,Outpatient,,,0.19,0.12,,0.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.14,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.14,72,,5.992,Percent of Total Billed Charges,72% of Total Billed Charges,0.14,75,,6.24,Percent of Total Billed charges,75% of Total Billed Charges,0.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.14,72,,5.992,Percent of Total Billed Charges,72% of Total Billed Charges,0.11,60,,4.992,Percent of Total Billed Charges,60% of Total Billed Charges,0.17,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.09,45,,9.128,Percent of Total Billed Charges,45% of Total Billed Charges,0.17,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,0.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.12,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,0.08,44.1,,8.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.18,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,0.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.17,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,0.17,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,0.08,0.19,
PRE-INFLATED ANES MASK SZ 5,2700000200,CDM,270,RC,,,Outpatient,,,1.55,1.01,,1.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.18,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.12,72,,5.992,Percent of Total Billed Charges,72% of Total Billed Charges,1.16,75,,6.24,Percent of Total Billed charges,75% of Total Billed Charges,1.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.12,72,,5.992,Percent of Total Billed Charges,72% of Total Billed Charges,0.93,60,,4.992,Percent of Total Billed Charges,60% of Total Billed Charges,1.4,90,,14.368,Percent of Total Billed Charges,90% of Total Billed Charges,0.7,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,1.4,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,1.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.01,65,,13.184,Percent of total Billed Charges,65% of Total Billed Charges,0.68,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.47,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,1.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.36,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,1.4,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,0.68,1.55,
PRE-INFLATED ANEST MASK SZ 6,2700000201,CDM,270,RC,,,Outpatient,,,1.64,1.07,,1.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.25,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.18,72,,29.664,Percent of Total Billed Charges,72% of Total Billed Charges,1.23,75,,30.904,Percent of Total Billed charges,75% of Total Billed Charges,1.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.18,72,,29.664,Percent of Total Billed Charges,72% of Total Billed Charges,0.98,60,,24.72,Percent of Total Billed Charges,60% of Total Billed Charges,1.48,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,0.74,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,1.48,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,1.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.07,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,0.72,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.56,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,1.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,1.48,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,0.72,1.64,
PRE-INFLATED ANEST MASK SZ 4,2700000202,CDM,270,RC,,,Outpatient,,,1.71,1.11,,1.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.3,76,,15.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.23,72,,29.232,Percent of Total Billed Charges,72% of Total Billed Charges,1.28,75,,30.448,Percent of Total Billed charges,75% of Total Billed Charges,1.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.23,72,,29.232,Percent of Total Billed Charges,72% of Total Billed Charges,1.03,60,,24.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.54,90,,28.728,Percent of Total Billed Charges,90% of Total Billed Charges,0.77,45,,67.872,Percent of Total Billed Charges,45% of Total Billed Charges,1.54,90,,18.256,Percent of Total Billed Charges,90% of Total billed Charges,1.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.11,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,0.75,44.1,,66.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.62,95,,19.272,Percent of Total Billed Charges,95% of Total Billed Charges,1.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.5,88,,17.856,Percent of Total Billed Charges,88% of Total Billed Charges,1.54,90,,18.256,Percent of Total Billed charges,90% of Total Billed Charges,0.75,1.71,
READY BABY WIPES,2700000203,CDM,270,RC,,,Outpatient,,,0.89,0.58,,0.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.68,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.64,72,,4.784,Percent of Total Billed Charges,72% of Total Billed Charges,0.67,75,,4.984,Percent of Total Billed charges,75% of Total Billed Charges,0.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.64,72,,4.784,Percent of Total Billed Charges,72% of Total Billed Charges,0.53,60,,3.984,Percent of Total Billed Charges,60% of Total Billed Charges,0.8,90,,28.728,Percent of Total Billed Charges,90% of Total Billed Charges,0.4,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,0.8,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,0.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.58,65,,98.032,Percent of total Billed Charges,65% of Total Billed Charges,0.39,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.85,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,0.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.78,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,0.8,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,0.39,0.89,
LARYNGOSCOPE BLADE MILLER SZ2,2700000204,CDM,270,RC,,,Outpatient,,,4.67,3.04,,4.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.55,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.36,72,,6.048,Percent of Total Billed Charges,72% of Total Billed Charges,3.5,75,,6.304,Percent of Total Billed charges,75% of Total Billed Charges,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.36,72,,6.048,Percent of Total Billed Charges,72% of Total Billed Charges,2.8,60,,5.04,Percent of Total Billed Charges,60% of Total Billed Charges,4.2,90,,140.504,Percent of Total Billed Charges,90% of Total Billed Charges,2.1,45,,9.608,Percent of Total Billed Charges,45% of Total Billed Charges,4.2,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.04,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,2.06,44.1,,9.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.44,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.11,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,4.2,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,2.06,4.67,
LARYNGOSCOPE BLADE DISP MACSZ3,2700000205,CDM,270,RC,,,Outpatient,,,5.79,3.76,,5.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.4,76,,114.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.17,72,,5.936,Percent of Total Billed Charges,72% of Total Billed Charges,4.34,75,,6.184,Percent of Total Billed charges,75% of Total Billed Charges,5.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.17,72,,5.936,Percent of Total Billed Charges,72% of Total Billed Charges,3.47,60,,4.944,Percent of Total Billed Charges,60% of Total Billed Charges,5.21,90,,91.288,Percent of Total Billed Charges,90% of Total Billed Charges,2.61,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,5.21,90,,135.744,Percent of Total Billed Charges,90% of Total billed Charges,5.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.76,65,,13.872,Percent of total Billed Charges,65% of Total Billed Charges,2.55,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.5,95,,143.28,Percent of Total Billed Charges,95% of Total Billed Charges,5.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.1,88,,132.728,Percent of Total Billed Charges,88% of Total Billed Charges,5.21,90,,135.744,Percent of Total Billed charges,90% of Total Billed Charges,2.55,5.79,
LARYNGOSCOPE BLD PHLLPS#2,2700000206,CDM,270,RC,,,Outpatient,,,12.79,8.31,,12.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.72,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.21,72,,5.992,Percent of Total Billed Charges,72% of Total Billed Charges,9.59,75,,6.24,Percent of Total Billed charges,75% of Total Billed Charges,12.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.21,72,,5.992,Percent of Total Billed Charges,72% of Total Billed Charges,7.67,60,,4.992,Percent of Total Billed Charges,60% of Total Billed Charges,11.51,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,5.76,45,,7.184,Percent of Total Billed Charges,45% of Total Billed Charges,11.51,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,12.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.31,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,5.64,44.1,,7.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.15,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,12.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.26,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,11.51,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,5.64,12.79,
SINGLE PATIENT EAR SENSOR,2700000207,CDM,270,RC,,,Outpatient,,,25.70,16.71,,25.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.53,76,,16.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.5,72,,5.992,Percent of Total Billed Charges,72% of Total Billed Charges,19.28,75,,6.24,Percent of Total Billed charges,75% of Total Billed Charges,25.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.5,72,,5.992,Percent of Total Billed Charges,72% of Total Billed Charges,15.42,60,,4.992,Percent of Total Billed Charges,60% of Total Billed Charges,23.13,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,11.57,45,,7.56,Percent of Total Billed Charges,45% of Total Billed Charges,23.13,90,,19.208,Percent of Total Billed Charges,90% of Total billed Charges,25.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.71,65,,10.376,Percent of total Billed Charges,65% of Total Billed Charges,11.33,44.1,,7.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.42,95,,20.28,Percent of Total Billed Charges,95% of Total Billed Charges,25.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.62,88,,18.784,Percent of Total Billed Charges,88% of Total Billed Charges,23.13,90,,19.208,Percent of Total Billed charges,90% of Total Billed Charges,11.33,25.7,
BAIR PAUS PEDI GOWN,2700000208,CDM,270,RC,,,Outpatient,,,13.00,8.45,,13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.88,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.36,72,,9.216,Percent of Total Billed Charges,72% of Total Billed Charges,9.75,75,,9.6,Percent of Total Billed charges,75% of Total Billed Charges,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.36,72,,9.216,Percent of Total Billed Charges,72% of Total Billed Charges,7.8,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,11.7,90,,40.488,Percent of Total Billed Charges,90% of Total Billed Charges,5.85,45,,14.368,Percent of Total Billed Charges,45% of Total Billed Charges,11.7,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.45,65,,10.92,Percent of total Billed Charges,65% of Total Billed Charges,5.73,44.1,,14.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.35,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.44,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,11.7,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,5.73,13,
Ensure Enlive Strawberry 8oz,2700000209,CDM,270,RC,,,Outpatient,,,1.78,1.16,,1.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.35,76,,12.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.28,72,,4.84,Percent of Total Billed Charges,72% of Total Billed Charges,1.34,75,,5.04,Percent of Total Billed charges,75% of Total Billed Charges,1.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.28,72,,4.84,Percent of Total Billed Charges,72% of Total Billed Charges,1.07,60,,4.032,Percent of Total Billed Charges,60% of Total Billed Charges,1.6,90,,119.072,Percent of Total Billed Charges,90% of Total Billed Charges,0.8,45,,14.368,Percent of Total Billed Charges,45% of Total Billed Charges,1.6,90,,14.368,Percent of Total Billed Charges,90% of Total billed Charges,1.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.16,65,,20.752,Percent of total Billed Charges,65% of Total Billed Charges,0.78,44.1,,14.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.69,95,,15.16,Percent of Total Billed Charges,95% of Total Billed Charges,1.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.57,88,,14.048,Percent of Total Billed Charges,88% of Total Billed Charges,1.6,90,,14.368,Percent of Total Billed charges,90% of Total Billed Charges,0.78,1.78,
Ensure Enlive Chocolate 8oz,2700000210,CDM,270,RC,,,Outpatient,,,1.78,1.16,,1.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.35,76,,12.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.28,72,,69.52,Percent of Total Billed Charges,72% of Total Billed Charges,1.34,75,,72.416,Percent of Total Billed charges,75% of Total Billed Charges,1.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.28,72,,69.52,Percent of Total Billed Charges,72% of Total Billed Charges,1.07,60,,57.928,Percent of Total Billed Charges,60% of Total Billed Charges,1.6,90,,13.496,Percent of Total Billed Charges,90% of Total Billed Charges,0.8,45,,70.248,Percent of Total Billed Charges,45% of Total Billed Charges,1.6,90,,15.12,Percent of Total Billed Charges,90% of Total billed Charges,1.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.16,65,,20.752,Percent of total Billed Charges,65% of Total Billed Charges,0.78,44.1,,68.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.69,95,,15.96,Percent of Total Billed Charges,95% of Total Billed Charges,1.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.57,88,,14.784,Percent of Total Billed Charges,88% of Total Billed Charges,1.6,90,,15.12,Percent of Total Billed charges,90% of Total Billed Charges,0.78,1.78,
Ensure Enlive Vanilla 8oz,2700000211,CDM,270,RC,,,Outpatient,,,1.78,1.16,,1.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.35,76,,24.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.28,72,,1.944,Percent of Total Billed Charges,72% of Total Billed Charges,1.34,75,,2.032,Percent of Total Billed charges,75% of Total Billed Charges,1.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.28,72,,1.944,Percent of Total Billed Charges,72% of Total Billed Charges,1.07,60,,1.624,Percent of Total Billed Charges,60% of Total Billed Charges,1.6,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,0.8,45,,45.648,Percent of Total Billed Charges,45% of Total Billed Charges,1.6,90,,28.728,Percent of Total Billed Charges,90% of Total billed Charges,1.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.16,65,,101.472,Percent of total Billed Charges,65% of Total Billed Charges,0.78,44.1,,44.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.69,95,,30.328,Percent of Total Billed Charges,95% of Total Billed Charges,1.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.57,88,,28.088,Percent of Total Billed Charges,88% of Total Billed Charges,1.6,90,,28.728,Percent of Total Billed charges,90% of Total Billed Charges,0.78,1.78,
TEXAS EXT CONDOM CATH SM,2700000212,CDM,270,RC,,,Outpatient,,,2.32,1.51,,2.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.76,76,,24.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.67,72,,15.12,Percent of Total Billed Charges,72% of Total Billed Charges,1.74,75,,15.752,Percent of Total Billed charges,75% of Total Billed Charges,2.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.67,72,,15.12,Percent of Total Billed Charges,72% of Total Billed Charges,1.39,60,,12.6,Percent of Total Billed Charges,60% of Total Billed Charges,2.09,90,,37.312,Percent of Total Billed Charges,90% of Total Billed Charges,1.04,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,2.09,90,,28.728,Percent of Total Billed Charges,90% of Total billed Charges,2.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.51,65,,65.928,Percent of total Billed Charges,65% of Total Billed Charges,1.02,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.2,95,,30.328,Percent of Total Billed Charges,95% of Total Billed Charges,2.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.04,88,,28.088,Percent of Total Billed Charges,88% of Total Billed Charges,2.09,90,,28.728,Percent of Total Billed charges,90% of Total Billed Charges,1.02,2.32,
TEXAS EXT CONDOM CATH LG,2700000213,CDM,270,RC,,,Outpatient,,,2.32,1.51,,2.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.76,76,,118.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.67,72,,19.352,Percent of Total Billed Charges,72% of Total Billed Charges,1.74,75,,20.16,Percent of Total Billed charges,75% of Total Billed Charges,2.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.67,72,,19.352,Percent of Total Billed Charges,72% of Total Billed Charges,1.39,60,,16.128,Percent of Total Billed Charges,60% of Total Billed Charges,2.09,90,,19.84,Percent of Total Billed Charges,90% of Total Billed Charges,1.04,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,2.09,90,,140.504,Percent of Total Billed Charges,90% of Total billed Charges,2.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.51,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,1.02,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.2,95,,148.304,Percent of Total Billed Charges,95% of Total Billed Charges,2.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.04,88,,137.376,Percent of Total Billed Charges,88% of Total Billed Charges,2.09,90,,140.504,Percent of Total Billed charges,90% of Total Billed Charges,1.02,2.32,
Ensure Vanilla 8oz Bottle,2700000214,CDM,270,RC,,,Outpatient,,,0.15,0.10,,0.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.11,76,,77.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.11,72,,21.168,Percent of Total Billed Charges,72% of Total Billed Charges,0.11,75,,22.048,Percent of Total Billed charges,75% of Total Billed Charges,0.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.11,72,,21.168,Percent of Total Billed Charges,72% of Total Billed Charges,0.09,60,,17.64,Percent of Total Billed Charges,60% of Total Billed Charges,0.14,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,0.07,45,,20.24,Percent of Total Billed Charges,45% of Total Billed Charges,0.14,90,,91.288,Percent of Total Billed Charges,90% of Total billed Charges,0.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.1,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,0.07,44.1,,19.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.14,95,,96.36,Percent of Total Billed Charges,95% of Total Billed Charges,0.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.13,88,,89.264,Percent of Total Billed Charges,88% of Total Billed Charges,0.14,90,,91.288,Percent of Total Billed charges,90% of Total Billed Charges,0.07,0.15,
BVI WECK-CEL EYE SPEARS,2700000215,CDM,270,RC,,,Outpatient,,,0.82,0.53,,0.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.62,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.59,72,,1.128,Percent of Total Billed Charges,72% of Total Billed Charges,0.62,75,,1.176,Percent of Total Billed charges,75% of Total Billed Charges,0.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.59,72,,1.128,Percent of Total Billed Charges,72% of Total Billed Charges,0.49,60,,0.944,Percent of Total Billed Charges,60% of Total Billed Charges,0.74,90,,266.72,Percent of Total Billed Charges,90% of Total Billed Charges,0.37,45,,59.536,Percent of Total Billed Charges,45% of Total Billed Charges,0.74,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,0.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.53,65,,29.24,Percent of total Billed Charges,65% of Total Billed Charges,0.36,44.1,,58.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.78,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,0.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,0.74,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,0.36,0.82,
BVI EYE SHIELD,2700000216,CDM,270,RC,,,Outpatient,,,2.35,1.53,,2.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.79,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.69,72,,1.984,Percent of Total Billed Charges,72% of Total Billed Charges,1.76,75,,2.072,Percent of Total Billed charges,75% of Total Billed Charges,2.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.69,72,,1.984,Percent of Total Billed Charges,72% of Total Billed Charges,1.41,60,,1.656,Percent of Total Billed Charges,60% of Total Billed Charges,2.12,90,,88.112,Percent of Total Billed Charges,90% of Total Billed Charges,1.06,45,,6.744,Percent of Total Billed Charges,45% of Total Billed Charges,2.12,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,2.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.53,65,,86,Percent of total Billed Charges,65% of Total Billed Charges,1.04,44.1,,6.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.23,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,2.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.07,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,2.12,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,1.04,2.35,
G31917 MULTI-BAND LIGATOR,2700000217,CDM,270,RC,,,Outpatient,,,637.50,414.38,,637.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,484.5,76,,34.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,459,72,,1.224,Percent of Total Billed Charges,72% of Total Billed Charges,478.13,75,,1.28,Percent of Total Billed charges,75% of Total Billed Charges,637.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,459,72,,1.224,Percent of Total Billed Charges,72% of Total Billed Charges,382.5,60,,1.024,Percent of Total Billed Charges,60% of Total Billed Charges,573.75,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,286.88,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,573.75,90,,40.488,Percent of Total Billed Charges,90% of Total billed Charges,637.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,637.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,637.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.38,65,,9.744,Percent of total Billed Charges,65% of Total Billed Charges,281.14,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,605.63,95,,42.736,Percent of Total Billed Charges,95% of Total Billed Charges,637.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,88,,39.584,Percent of Total Billed Charges,88% of Total Billed Charges,573.75,90,,40.488,Percent of Total Billed charges,90% of Total Billed Charges,281.14,637.5,
EZDILATE BALLOON DIL 16-17-18,2700000218,CDM,270,RC,,,Outpatient,,,618.75,402.19,,618.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,470.25,76,,100.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,445.5,72,,1.488,Percent of Total Billed Charges,72% of Total Billed Charges,464.06,75,,1.552,Percent of Total Billed charges,75% of Total Billed Charges,618.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,445.5,72,,1.488,Percent of Total Billed Charges,72% of Total Billed Charges,371.25,60,,1.24,Percent of Total Billed Charges,60% of Total Billed Charges,556.88,90,,82.552,Percent of Total Billed Charges,90% of Total Billed Charges,278.44,45,,18.656,Percent of Total Billed Charges,45% of Total Billed Charges,556.88,90,,119.072,Percent of Total Billed Charges,90% of Total billed Charges,618.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,402.19,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,272.87,44.1,,18.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,587.81,95,,125.688,Percent of Total Billed Charges,95% of Total Billed Charges,618.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,544.5,88,,116.424,Percent of Total Billed Charges,88% of Total Billed Charges,556.88,90,,119.072,Percent of Total Billed charges,90% of Total Billed Charges,272.87,618.75,
G57797 RETRIEVAL NET,2700000219,CDM,270,RC,,,Outpatient,,,118.75,77.19,,118.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,90.25,76,,11.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,85.5,72,,1.144,Percent of Total Billed Charges,72% of Total Billed Charges,89.06,75,,1.192,Percent of Total Billed charges,75% of Total Billed Charges,118.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.5,72,,1.144,Percent of Total Billed Charges,72% of Total Billed Charges,71.25,60,,0.952,Percent of Total Billed Charges,60% of Total Billed Charges,106.88,90,,44.456,Percent of Total Billed Charges,90% of Total Billed Charges,53.44,45,,9.92,Percent of Total Billed Charges,45% of Total Billed Charges,106.88,90,,13.496,Percent of Total Billed Charges,90% of Total billed Charges,118.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.19,65,,26.944,Percent of total Billed Charges,65% of Total Billed Charges,52.37,44.1,,9.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,112.81,95,,14.24,Percent of Total Billed Charges,95% of Total Billed Charges,118.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.5,88,,13.192,Percent of Total Billed Charges,88% of Total Billed Charges,106.88,90,,13.496,Percent of Total Billed charges,90% of Total Billed Charges,52.37,118.75,
CAPNOLINE SMRT CO2 SAMPL LN O2,2700000220,CDM,270,RC,,,Outpatient,,,29.65,19.27,,29.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.53,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.35,72,,8.216,Percent of Total Billed Charges,72% of Total Billed Charges,22.24,75,,8.56,Percent of Total Billed charges,75% of Total Billed Charges,29.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,72,,8.216,Percent of Total Billed Charges,72% of Total Billed Charges,17.79,60,,6.848,Percent of Total Billed Charges,60% of Total Billed Charges,26.69,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,13.34,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,26.69,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,29.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.27,65,,14.328,Percent of total Billed Charges,65% of Total Billed Charges,13.08,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.17,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,29.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.09,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,26.69,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,13.08,29.65,
CAPNLINE SMRT CO2 SMPL LN PEDI,2700000221,CDM,270,RC,,,Outpatient,,,40.89,26.58,,40.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31.08,76,,31.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.44,72,,1.656,Percent of Total Billed Charges,72% of Total Billed Charges,30.67,75,,1.728,Percent of Total Billed charges,75% of Total Billed Charges,40.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.44,72,,1.656,Percent of Total Billed Charges,72% of Total Billed Charges,24.53,60,,1.384,Percent of Total Billed Charges,60% of Total Billed Charges,36.8,90,,16.672,Percent of Total Billed Charges,90% of Total Billed Charges,18.4,45,,133.36,Percent of Total Billed Charges,45% of Total Billed Charges,36.8,90,,37.312,Percent of Total Billed Charges,90% of Total billed Charges,40.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.58,65,,6.88,Percent of total Billed Charges,65% of Total Billed Charges,18.03,44.1,,130.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.85,95,,39.384,Percent of Total Billed Charges,95% of Total Billed Charges,40.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.98,88,,36.48,Percent of Total Billed Charges,88% of Total Billed Charges,36.8,90,,37.312,Percent of Total Billed charges,90% of Total Billed Charges,18.03,40.89,
SERTERA 14GA SPRNG CORE DEVICE,2700000222,CDM,270,RC,,,Outpatient,,,230.38,149.75,,230.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,175.09,76,,16.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,165.87,72,,1.96,Percent of Total Billed Charges,72% of Total Billed Charges,172.79,75,,2.04,Percent of Total Billed charges,75% of Total Billed Charges,230.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.87,72,,1.96,Percent of Total Billed Charges,72% of Total Billed Charges,138.23,60,,1.632,Percent of Total Billed Charges,60% of Total Billed Charges,207.34,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,103.67,45,,44.056,Percent of Total Billed Charges,45% of Total Billed Charges,207.34,90,,19.84,Percent of Total Billed Charges,90% of Total billed Charges,230.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.75,65,,192.632,Percent of total Billed Charges,65% of Total Billed Charges,101.6,44.1,,43.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,218.86,95,,20.944,Percent of Total Billed Charges,95% of Total Billed Charges,230.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.73,88,,19.4,Percent of Total Billed Charges,88% of Total Billed Charges,207.34,90,,19.84,Percent of Total Billed charges,90% of Total Billed Charges,101.6,230.38,
SERTERA 14GA INTRODUCER,2700000223,CDM,270,RC,,,Outpatient,,,44.55,28.96,,44.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33.86,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.08,72,,0.4,Percent of Total Billed Charges,72% of Total Billed Charges,33.41,75,,0.424,Percent of Total Billed charges,75% of Total Billed Charges,44.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.08,72,,0.4,Percent of Total Billed Charges,72% of Total Billed Charges,26.73,60,,0.336,Percent of Total Billed Charges,60% of Total Billed Charges,40.1,90,,18.144,Percent of Total Billed Charges,90% of Total Billed Charges,20.05,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,40.1,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,44.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.96,65,,63.64,Percent of total Billed Charges,65% of Total Billed Charges,19.65,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.32,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,44.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.2,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,40.1,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,19.65,44.55,
TUMARK VISION 10CM,2700000224,CDM,270,RC,,,Outpatient,,,291.00,189.15,,291,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,221.16,76,,225.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,209.52,72,,0.528,Percent of Total Billed Charges,72% of Total Billed Charges,218.25,75,,0.552,Percent of Total Billed charges,75% of Total Billed Charges,291,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.52,72,,0.528,Percent of Total Billed Charges,72% of Total Billed Charges,174.6,60,,0.44,Percent of Total Billed Charges,60% of Total Billed Charges,261.9,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,130.95,45,,41.28,Percent of Total Billed Charges,45% of Total Billed Charges,261.9,90,,266.72,Percent of Total Billed Charges,90% of Total billed Charges,291,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.15,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,128.33,44.1,,40.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,276.45,95,,281.536,Percent of Total Billed Charges,95% of Total Billed Charges,291,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.08,88,,260.792,Percent of Total Billed Charges,88% of Total Billed Charges,261.9,90,,266.72,Percent of Total Billed charges,90% of Total Billed Charges,128.33,291,
GASLESS TIP APPLICATOR MIS 40C,2700000225,CDM,270,RC,,,Outpatient,,,303.90,197.54,,303.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,230.96,76,,74.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,218.81,72,,2.208,Percent of Total Billed Charges,72% of Total Billed Charges,227.93,75,,2.304,Percent of Total Billed charges,75% of Total Billed Charges,303.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.81,72,,2.208,Percent of Total Billed Charges,72% of Total Billed Charges,182.34,60,,1.84,Percent of Total Billed Charges,60% of Total Billed Charges,273.51,90,,2.592,Percent of Total Billed Charges,90% of Total Billed Charges,136.76,45,,22.224,Percent of Total Billed Charges,45% of Total Billed Charges,273.51,90,,88.112,Percent of Total Billed Charges,90% of Total billed Charges,303.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.54,65,,59.624,Percent of total Billed Charges,65% of Total Billed Charges,134.02,44.1,,21.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,288.71,95,,93.008,Percent of Total Billed Charges,95% of Total Billed Charges,303.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.43,88,,86.152,Percent of Total Billed Charges,88% of Total Billed Charges,273.51,90,,88.112,Percent of Total Billed charges,90% of Total Billed Charges,134.02,303.9,
ADULT/PEDI INTUB CO2 FILTER LN,2700000226,CDM,270,RC,,,Outpatient,,,42.40,27.56,,42.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,32.22,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.53,72,,2.44,Percent of Total Billed Charges,72% of Total Billed Charges,31.8,75,,2.536,Percent of Total Billed charges,75% of Total Billed Charges,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.53,72,,2.44,Percent of Total Billed Charges,72% of Total Billed Charges,25.44,60,,2.032,Percent of Total Billed Charges,60% of Total Billed Charges,38.16,90,,2.768,Percent of Total Billed Charges,90% of Total Billed Charges,19.08,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,38.16,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,65,,32.104,Percent of total Billed Charges,65% of Total Billed Charges,18.7,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,40.28,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.31,88,,0.776,Percent of Total Billed Charges,88% of Total Billed Charges,38.16,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,18.7,42.4,
"EZ10G ENDOLOOP PDS II, 0, 18",2700000227,CDM,270,RC,,,Outpatient,,,71.35,46.38,,71.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.23,76,,69.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.37,72,,3.752,Percent of Total Billed Charges,72% of Total Billed Charges,53.51,75,,3.912,Percent of Total Billed charges,75% of Total Billed Charges,71.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.37,72,,3.752,Percent of Total Billed Charges,72% of Total Billed Charges,42.81,60,,3.128,Percent of Total Billed Charges,60% of Total Billed Charges,64.22,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,32.11,45,,8.336,Percent of Total Billed Charges,45% of Total Billed Charges,64.22,90,,82.552,Percent of Total Billed Charges,90% of Total billed Charges,71.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.38,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,31.47,44.1,,8.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.78,95,,87.144,Percent of Total Billed Charges,95% of Total Billed Charges,71.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.79,88,,80.72,Percent of Total Billed Charges,88% of Total Billed Charges,64.22,90,,82.552,Percent of Total Billed charges,90% of Total Billed Charges,31.47,71.35,
GST45T BLACK RELOAD,2700000228,CDM,270,RC,,,Outpatient,,,357.58,232.43,,357.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,271.76,76,,37.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,257.46,72,,2.256,Percent of Total Billed Charges,72% of Total Billed Charges,268.19,75,,2.344,Percent of Total Billed charges,75% of Total Billed Charges,357.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.46,72,,2.256,Percent of Total Billed Charges,72% of Total Billed Charges,214.55,60,,1.88,Percent of Total Billed Charges,60% of Total Billed Charges,321.82,90,,2.552,Percent of Total Billed Charges,90% of Total Billed Charges,160.91,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,321.82,90,,44.456,Percent of Total Billed Charges,90% of Total billed Charges,357.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.43,65,,12.04,Percent of total Billed Charges,65% of Total Billed Charges,157.69,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,339.7,95,,46.92,Percent of Total Billed Charges,95% of Total Billed Charges,357.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.67,88,,43.464,Percent of Total Billed Charges,88% of Total Billed Charges,321.82,90,,44.456,Percent of Total Billed charges,90% of Total Billed Charges,157.69,357.58,
GST45G GREEN RELOAD,2700000229,CDM,270,RC,,,Outpatient,,,357.58,232.43,,357.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,271.76,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,257.46,72,,1.72,Percent of Total Billed Charges,72% of Total Billed Charges,268.19,75,,1.792,Percent of Total Billed charges,75% of Total Billed Charges,357.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.46,72,,1.72,Percent of Total Billed Charges,72% of Total Billed Charges,214.55,60,,1.432,Percent of Total Billed Charges,60% of Total Billed Charges,321.82,90,,2.496,Percent of Total Billed Charges,90% of Total Billed Charges,160.91,45,,9.072,Percent of Total Billed Charges,45% of Total Billed Charges,321.82,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,357.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.43,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,157.69,44.1,,8.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,339.7,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,357.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.67,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,321.82,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,157.69,357.58,
GST45D GOLD RELOAD,2700000230,CDM,270,RC,,,Outpatient,,,357.58,232.43,,357.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,271.76,76,,14.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,257.46,72,,0.856,Percent of Total Billed Charges,72% of Total Billed Charges,268.19,75,,0.896,Percent of Total Billed charges,75% of Total Billed Charges,357.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.46,72,,0.856,Percent of Total Billed Charges,72% of Total Billed Charges,214.55,60,,0.712,Percent of Total Billed Charges,60% of Total Billed Charges,321.82,90,,2.416,Percent of Total Billed Charges,90% of Total Billed Charges,160.91,45,,6.48,Percent of Total Billed Charges,45% of Total Billed Charges,321.82,90,,16.672,Percent of Total Billed Charges,90% of Total billed Charges,357.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.43,65,,13.104,Percent of total Billed Charges,65% of Total Billed Charges,157.69,44.1,,6.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,339.7,95,,17.592,Percent of Total Billed Charges,95% of Total Billed Charges,357.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.67,88,,16.296,Percent of Total Billed Charges,88% of Total Billed Charges,321.82,90,,16.672,Percent of Total Billed charges,90% of Total Billed Charges,157.69,357.58,
GST45B BLUE RELOAD,2700000231,CDM,270,RC,,,Outpatient,,,357.58,232.43,,357.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,271.76,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,257.46,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,268.19,75,,1.2,Percent of Total Billed charges,75% of Total Billed Charges,357.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.46,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,214.55,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,321.82,90,,2.432,Percent of Total Billed Charges,90% of Total Billed Charges,160.91,45,,1.296,Percent of Total Billed Charges,45% of Total Billed Charges,321.82,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,357.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.43,65,,9.36,Percent of total Billed Charges,65% of Total Billed Charges,157.69,44.1,,1.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,339.7,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,357.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.67,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,321.82,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,157.69,357.58,
ECH45S ECHELON 45 STAPLER,2700000232,CDM,270,RC,,,Outpatient,,,811.98,527.79,,811.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,617.1,76,,15.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,584.63,72,,7.144,Percent of Total Billed Charges,72% of Total Billed Charges,608.99,75,,7.44,Percent of Total Billed charges,75% of Total Billed Charges,811.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,584.63,72,,7.144,Percent of Total Billed Charges,72% of Total Billed Charges,487.19,60,,5.952,Percent of Total Billed Charges,60% of Total Billed Charges,730.78,90,,13.072,Percent of Total Billed Charges,90% of Total Billed Charges,365.39,45,,1.384,Percent of Total Billed Charges,45% of Total Billed Charges,730.78,90,,18.144,Percent of Total Billed Charges,90% of Total billed Charges,811.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,811.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,811.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,527.79,65,,1.872,Percent of total Billed Charges,65% of Total Billed Charges,358.08,44.1,,1.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,771.38,95,,19.152,Percent of Total Billed Charges,95% of Total Billed Charges,811.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,714.54,88,,17.744,Percent of Total Billed Charges,88% of Total Billed Charges,730.78,90,,18.144,Percent of Total Billed charges,90% of Total Billed Charges,358.08,811.98,
ECH60S ECHELON 60 STAPLER,2700000233,CDM,270,RC,,,Outpatient,,,974.35,633.33,,974.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,740.51,76,,10.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,701.53,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,730.76,75,,1.2,Percent of Total Billed charges,75% of Total Billed Charges,974.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,701.53,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,584.61,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,876.92,90,,17.496,Percent of Total Billed Charges,90% of Total Billed Charges,438.46,45,,8.64,Percent of Total Billed Charges,45% of Total Billed Charges,876.92,90,,12.96,Percent of Total Billed Charges,90% of Total billed Charges,974.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,974.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,974.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,633.33,65,,2,Percent of total Billed Charges,65% of Total Billed Charges,429.69,44.1,,8.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,925.63,95,,13.68,Percent of Total Billed Charges,95% of Total Billed Charges,974.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,857.43,88,,12.672,Percent of Total Billed Charges,88% of Total Billed Charges,876.92,90,,12.96,Percent of Total Billed charges,90% of Total Billed Charges,429.69,974.35,
PTFE COATED CAUTERY ELECTRODES,2700000234,CDM,270,RC,,,Outpatient,,,23.60,15.34,,23.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.94,76,,2.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.99,72,,1.72,Percent of Total Billed Charges,72% of Total Billed Charges,17.7,75,,1.792,Percent of Total Billed charges,75% of Total Billed Charges,23.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.99,72,,1.72,Percent of Total Billed Charges,72% of Total Billed Charges,14.16,60,,1.432,Percent of Total Billed Charges,60% of Total Billed Charges,21.24,90,,14.896,Percent of Total Billed Charges,90% of Total Billed Charges,10.62,45,,1.272,Percent of Total Billed Charges,45% of Total Billed Charges,21.24,90,,2.592,Percent of Total Billed Charges,90% of Total billed Charges,23.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.34,65,,12.48,Percent of total Billed Charges,65% of Total Billed Charges,10.41,44.1,,1.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.42,95,,2.736,Percent of Total Billed Charges,95% of Total Billed Charges,23.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.77,88,,2.536,Percent of Total Billed Charges,88% of Total Billed Charges,21.24,90,,2.592,Percent of Total Billed charges,90% of Total Billed Charges,10.41,23.6,
SUT 424H 0 PERMA HAND BLK CT-1,2700000235,CDM,270,RC,,,Outpatient,,,3.60,2.34,,3.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.74,76,,2.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.59,72,,17.28,Percent of Total Billed Charges,72% of Total Billed Charges,2.7,75,,18,Percent of Total Billed charges,75% of Total Billed Charges,3.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.59,72,,17.28,Percent of Total Billed Charges,72% of Total Billed Charges,2.16,60,,14.4,Percent of Total Billed Charges,60% of Total Billed Charges,3.24,90,,12.096,Percent of Total Billed Charges,90% of Total Billed Charges,1.62,45,,1.248,Percent of Total Billed Charges,45% of Total Billed Charges,3.24,90,,2.768,Percent of Total Billed Charges,90% of Total billed Charges,3.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.34,65,,1.84,Percent of total Billed Charges,65% of Total Billed Charges,1.59,44.1,,1.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.42,95,,2.92,Percent of Total Billed Charges,95% of Total Billed Charges,3.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.17,88,,2.704,Percent of Total Billed Charges,88% of Total Billed Charges,3.24,90,,2.768,Percent of Total Billed charges,90% of Total Billed Charges,1.59,3.6,
VLOCN2145 NON-ABSRBLE GS-22 9,2700000236,CDM,270,RC,,,Outpatient,,,96.78,62.91,,96.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.55,76,,14.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.68,72,,6.744,Percent of Total Billed Charges,72% of Total Billed Charges,72.59,75,,7.024,Percent of Total Billed charges,75% of Total Billed Charges,96.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.68,72,,6.744,Percent of Total Billed Charges,72% of Total Billed Charges,58.07,60,,5.624,Percent of Total Billed Charges,60% of Total Billed Charges,87.1,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,43.55,45,,1.208,Percent of Total Billed Charges,45% of Total Billed Charges,87.1,90,,17.28,Percent of Total Billed Charges,90% of Total billed Charges,96.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.91,65,,1.808,Percent of total Billed Charges,65% of Total Billed Charges,42.68,44.1,,1.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.94,95,,18.24,Percent of Total Billed Charges,95% of Total Billed Charges,96.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.17,88,,16.896,Percent of Total Billed Charges,88% of Total Billed Charges,87.1,90,,17.28,Percent of Total Billed charges,90% of Total Billed Charges,42.68,96.78,
"VLOCN2105 NON-ABSRBLE GS-22 6""",2700000237,CDM,270,RC,,,Outpatient,,,96.78,62.91,,96.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.55,76,,2.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.68,72,,10.232,Percent of Total Billed Charges,72% of Total Billed Charges,72.59,75,,10.656,Percent of Total Billed charges,75% of Total Billed Charges,96.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.68,72,,10.232,Percent of Total Billed Charges,72% of Total Billed Charges,58.07,60,,8.528,Percent of Total Billed Charges,60% of Total Billed Charges,87.1,90,,9.216,Percent of Total Billed Charges,90% of Total Billed Charges,43.55,45,,1.216,Percent of Total Billed Charges,45% of Total Billed Charges,87.1,90,,2.552,Percent of Total Billed Charges,90% of Total billed Charges,96.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.91,65,,1.744,Percent of total Billed Charges,65% of Total Billed Charges,42.68,44.1,,1.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.94,95,,2.688,Percent of Total Billed Charges,95% of Total Billed Charges,96.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.17,88,,2.496,Percent of Total Billed Charges,88% of Total Billed Charges,87.1,90,,2.552,Percent of Total Billed charges,90% of Total Billed Charges,42.68,96.78,
JP DRAIN ROUND 19FR,2700000238,CDM,270,RC,,,Outpatient,,,22.03,14.32,,22.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.74,76,,2.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.86,72,,20.16,Percent of Total Billed Charges,72% of Total Billed Charges,16.52,75,,21,Percent of Total Billed charges,75% of Total Billed Charges,22.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.86,72,,20.16,Percent of Total Billed Charges,72% of Total Billed Charges,13.22,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,19.83,90,,10.368,Percent of Total Billed Charges,90% of Total Billed Charges,9.91,45,,6.536,Percent of Total Billed Charges,45% of Total Billed Charges,19.83,90,,2.496,Percent of Total Billed Charges,90% of Total billed Charges,22.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.32,65,,1.76,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,6.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.93,95,,2.64,Percent of Total Billed Charges,95% of Total Billed Charges,22.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.39,88,,2.44,Percent of Total Billed Charges,88% of Total Billed Charges,19.83,90,,2.496,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.03,
BIOGEL PI IND SIZE 7 GLOVE,2700000239,CDM,270,RC,,,Outpatient,,,4.20,2.73,,4.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.19,76,,2.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.02,72,,17.28,Percent of Total Billed Charges,72% of Total Billed Charges,3.15,75,,18,Percent of Total Billed charges,75% of Total Billed Charges,4.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.02,72,,17.28,Percent of Total Billed Charges,72% of Total Billed Charges,2.52,60,,14.4,Percent of Total Billed Charges,60% of Total Billed Charges,3.78,90,,21.368,Percent of Total Billed Charges,90% of Total Billed Charges,1.89,45,,8.752,Percent of Total Billed Charges,45% of Total Billed Charges,3.78,90,,2.416,Percent of Total Billed Charges,90% of Total billed Charges,4.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.73,65,,9.44,Percent of total Billed Charges,65% of Total Billed Charges,1.85,44.1,,8.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.99,95,,2.552,Percent of Total Billed Charges,95% of Total Billed Charges,4.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.7,88,,2.368,Percent of Total Billed Charges,88% of Total Billed Charges,3.78,90,,2.416,Percent of Total Billed charges,90% of Total Billed Charges,1.85,4.2,
TED HOSE THIGH HI XL REG,2700000240,CDM,270,RC,,,Outpatient,,,10.48,6.81,,10.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.96,76,,2.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.55,72,,3.36,Percent of Total Billed Charges,72% of Total Billed Charges,7.86,75,,3.496,Percent of Total Billed charges,75% of Total Billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.55,72,,3.36,Percent of Total Billed Charges,72% of Total Billed Charges,6.29,60,,2.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.43,90,,12.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.72,45,,7.448,Percent of Total Billed Charges,45% of Total Billed Charges,9.43,90,,2.432,Percent of Total Billed Charges,90% of Total billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.81,65,,12.64,Percent of total Billed Charges,65% of Total Billed Charges,4.62,44.1,,7.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.96,95,,2.568,Percent of Total Billed Charges,95% of Total Billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.22,88,,2.376,Percent of Total Billed Charges,88% of Total Billed Charges,9.43,90,,2.432,Percent of Total Billed charges,90% of Total Billed Charges,4.62,10.48,
TED HOSE THIGH HI XL SHORT,2700000241,CDM,270,RC,,,Outpatient,,,10.48,6.81,,10.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.96,76,,11.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.55,72,,0.344,Percent of Total Billed Charges,72% of Total Billed Charges,7.86,75,,0.36,Percent of Total Billed charges,75% of Total Billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.55,72,,0.344,Percent of Total Billed Charges,72% of Total Billed Charges,6.29,60,,0.288,Percent of Total Billed Charges,60% of Total Billed Charges,9.43,90,,9.072,Percent of Total Billed Charges,90% of Total Billed Charges,4.72,45,,6.048,Percent of Total Billed Charges,45% of Total Billed Charges,9.43,90,,13.072,Percent of Total Billed Charges,90% of Total billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.81,65,,10.76,Percent of total Billed Charges,65% of Total Billed Charges,4.62,44.1,,5.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.96,95,,13.792,Percent of Total Billed Charges,95% of Total Billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.22,88,,12.776,Percent of Total Billed Charges,88% of Total Billed Charges,9.43,90,,13.072,Percent of Total Billed charges,90% of Total Billed Charges,4.62,10.48,
TED HOSE THIGH HI LRG LONG,2700000242,CDM,270,RC,,,Outpatient,,,10.48,6.81,,10.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.96,76,,14.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.55,72,,2.808,Percent of Total Billed Charges,72% of Total Billed Charges,7.86,75,,2.928,Percent of Total Billed charges,75% of Total Billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.55,72,,2.808,Percent of Total Billed Charges,72% of Total Billed Charges,6.29,60,,2.344,Percent of Total Billed Charges,60% of Total Billed Charges,9.43,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,4.72,45,,5.76,Percent of Total Billed Charges,45% of Total Billed Charges,9.43,90,,17.496,Percent of Total Billed Charges,90% of Total billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.81,65,,8.736,Percent of total Billed Charges,65% of Total Billed Charges,4.62,44.1,,5.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.96,95,,18.472,Percent of Total Billed Charges,95% of Total Billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.22,88,,17.104,Percent of Total Billed Charges,88% of Total Billed Charges,9.43,90,,17.496,Percent of Total Billed charges,90% of Total Billed Charges,4.62,10.48,
TED HOSE THIGH HI LRG REG,2700000243,CDM,270,RC,,,Outpatient,,,10.48,6.81,,10.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.96,76,,12.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.55,72,,21.656,Percent of Total Billed Charges,72% of Total Billed Charges,7.86,75,,22.56,Percent of Total Billed charges,75% of Total Billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.55,72,,21.656,Percent of Total Billed Charges,72% of Total Billed Charges,6.29,60,,18.048,Percent of Total Billed Charges,60% of Total Billed Charges,9.43,90,,37.08,Percent of Total Billed Charges,90% of Total Billed Charges,4.72,45,,4.608,Percent of Total Billed Charges,45% of Total Billed Charges,9.43,90,,14.896,Percent of Total Billed Charges,90% of Total billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.81,65,,8.32,Percent of total Billed Charges,65% of Total Billed Charges,4.62,44.1,,4.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.96,95,,15.728,Percent of Total Billed Charges,95% of Total Billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.22,88,,14.568,Percent of Total Billed Charges,88% of Total Billed Charges,9.43,90,,14.896,Percent of Total Billed charges,90% of Total Billed Charges,4.62,10.48,
TED HOSE THIGH HI LRG SHORT,2700000244,CDM,270,RC,,,Outpatient,,,10.48,6.81,,10.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.96,76,,10.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.55,72,,15.136,Percent of Total Billed Charges,72% of Total Billed Charges,7.86,75,,15.768,Percent of Total Billed charges,75% of Total Billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.55,72,,15.136,Percent of Total Billed Charges,72% of Total Billed Charges,6.29,60,,12.616,Percent of Total Billed Charges,60% of Total Billed Charges,9.43,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.72,45,,5.184,Percent of Total Billed Charges,45% of Total Billed Charges,9.43,90,,12.096,Percent of Total Billed Charges,90% of Total billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.81,65,,6.656,Percent of total Billed Charges,65% of Total Billed Charges,4.62,44.1,,5.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.96,95,,12.768,Percent of Total Billed Charges,95% of Total Billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.22,88,,11.824,Percent of Total Billed Charges,88% of Total Billed Charges,9.43,90,,12.096,Percent of Total Billed charges,90% of Total Billed Charges,4.62,10.48,
TED HOSE THIGH HI MED LONG,2700000245,CDM,270,RC,,,Outpatient,,,10.48,6.81,,10.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.96,76,,9.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.55,72,,12.344,Percent of Total Billed Charges,72% of Total Billed Charges,7.86,75,,12.856,Percent of Total Billed charges,75% of Total Billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.55,72,,12.344,Percent of Total Billed Charges,72% of Total Billed Charges,6.29,60,,10.288,Percent of Total Billed Charges,60% of Total Billed Charges,9.43,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,4.72,45,,10.688,Percent of Total Billed Charges,45% of Total Billed Charges,9.43,90,,11.52,Percent of Total Billed Charges,90% of Total billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.81,65,,7.488,Percent of total Billed Charges,65% of Total Billed Charges,4.62,44.1,,10.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.96,95,,12.16,Percent of Total Billed Charges,95% of Total Billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.22,88,,11.264,Percent of Total Billed Charges,88% of Total Billed Charges,9.43,90,,11.52,Percent of Total Billed charges,90% of Total Billed Charges,4.62,10.48,
TED HOSE THIGH HI MED REG,2700000246,CDM,270,RC,,,Outpatient,,,10.48,6.81,,10.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.96,76,,7.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.55,72,,0.624,Percent of Total Billed Charges,72% of Total Billed Charges,7.86,75,,0.648,Percent of Total Billed charges,75% of Total Billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.55,72,,0.624,Percent of Total Billed Charges,72% of Total Billed Charges,6.29,60,,0.52,Percent of Total Billed Charges,60% of Total Billed Charges,9.43,90,,6.624,Percent of Total Billed Charges,90% of Total Billed Charges,4.72,45,,6.304,Percent of Total Billed Charges,45% of Total Billed Charges,9.43,90,,9.216,Percent of Total Billed Charges,90% of Total billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.81,65,,15.432,Percent of total Billed Charges,65% of Total Billed Charges,4.62,44.1,,6.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.96,95,,9.728,Percent of Total Billed Charges,95% of Total Billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.22,88,,9.008,Percent of Total Billed Charges,88% of Total Billed Charges,9.43,90,,9.216,Percent of Total Billed charges,90% of Total Billed Charges,4.62,10.48,
TED HOSE THIGH HI MED SHORT,2700000247,CDM,270,RC,,,Outpatient,,,10.48,6.81,,10.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.96,76,,8.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.55,72,,15.312,Percent of Total Billed Charges,72% of Total Billed Charges,7.86,75,,15.952,Percent of Total Billed charges,75% of Total Billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.55,72,,15.312,Percent of Total Billed Charges,72% of Total Billed Charges,6.29,60,,12.76,Percent of Total Billed Charges,60% of Total Billed Charges,9.43,90,,44.176,Percent of Total Billed Charges,90% of Total Billed Charges,4.72,45,,4.536,Percent of Total Billed Charges,45% of Total Billed Charges,9.43,90,,10.368,Percent of Total Billed Charges,90% of Total billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.81,65,,9.104,Percent of total Billed Charges,65% of Total Billed Charges,4.62,44.1,,4.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.96,95,,10.944,Percent of Total Billed Charges,95% of Total Billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.22,88,,10.136,Percent of Total Billed Charges,88% of Total Billed Charges,9.43,90,,10.368,Percent of Total Billed charges,90% of Total Billed Charges,4.62,10.48,
TED HOSE THIGH HI SMALL LNG,2700000248,CDM,270,RC,,,Outpatient,,,10.48,6.81,,10.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.96,76,,18.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.55,72,,352.512,Percent of Total Billed Charges,72% of Total Billed Charges,7.86,75,,367.2,Percent of Total Billed charges,75% of Total Billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.55,72,,352.512,Percent of Total Billed Charges,72% of Total Billed Charges,6.29,60,,293.76,Percent of Total Billed Charges,60% of Total Billed Charges,9.43,90,,2.464,Percent of Total Billed Charges,90% of Total Billed Charges,4.72,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,9.43,90,,21.368,Percent of Total Billed Charges,90% of Total billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.81,65,,6.552,Percent of total Billed Charges,65% of Total Billed Charges,4.62,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.96,95,,22.56,Percent of Total Billed Charges,95% of Total Billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.22,88,,20.896,Percent of Total Billed Charges,88% of Total Billed Charges,9.43,90,,21.368,Percent of Total Billed charges,90% of Total Billed Charges,4.62,10.48,
TED HOSE THIGH HI SM SHORT,2700000249,CDM,270,RC,,,Outpatient,,,10.48,6.81,,10.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.96,76,,10.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.55,72,,33.784,Percent of Total Billed Charges,72% of Total Billed Charges,7.86,75,,35.192,Percent of Total Billed charges,75% of Total Billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.55,72,,33.784,Percent of Total Billed Charges,72% of Total Billed Charges,6.29,60,,28.152,Percent of Total Billed Charges,60% of Total Billed Charges,9.43,90,,4.896,Percent of Total Billed Charges,90% of Total Billed Charges,4.72,45,,18.544,Percent of Total Billed Charges,45% of Total Billed Charges,9.43,90,,12.6,Percent of Total Billed Charges,90% of Total billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.81,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,4.62,44.1,,18.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.96,95,,13.304,Percent of Total Billed Charges,95% of Total Billed Charges,10.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.22,88,,12.32,Percent of Total Billed Charges,88% of Total Billed Charges,9.43,90,,12.6,Percent of Total Billed charges,90% of Total Billed Charges,4.62,10.48,
"ZIMMER DISP CUFF 34""",2700000250,CDM,270,RC,,,Outpatient,,,74.05,48.13,,74.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.28,76,,7.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.32,72,,32.328,Percent of Total Billed Charges,72% of Total Billed Charges,55.54,75,,33.68,Percent of Total Billed charges,75% of Total Billed Charges,74.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.32,72,,32.328,Percent of Total Billed Charges,72% of Total Billed Charges,44.43,60,,26.944,Percent of Total Billed Charges,60% of Total Billed Charges,66.65,90,,4.176,Percent of Total Billed Charges,90% of Total Billed Charges,33.32,45,,2.88,Percent of Total Billed Charges,45% of Total Billed Charges,66.65,90,,9.072,Percent of Total Billed Charges,90% of Total billed Charges,74.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.13,65,,26.784,Percent of total Billed Charges,65% of Total Billed Charges,32.66,44.1,,2.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,70.35,95,,9.576,Percent of Total Billed Charges,95% of Total Billed Charges,74.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.16,88,,8.872,Percent of Total Billed Charges,88% of Total Billed Charges,66.65,90,,9.072,Percent of Total Billed charges,90% of Total Billed Charges,32.66,74.05,
"ZIMMER DISP CUFF 42""",2700000251,CDM,270,RC,,,Outpatient,,,79.58,51.73,,79.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60.48,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.3,72,,38.408,Percent of Total Billed Charges,72% of Total Billed Charges,59.69,75,,40.008,Percent of Total Billed charges,75% of Total Billed Charges,79.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.3,72,,38.408,Percent of Total Billed Charges,72% of Total Billed Charges,47.75,60,,32.008,Percent of Total Billed Charges,60% of Total Billed Charges,71.62,90,,57.24,Percent of Total Billed Charges,90% of Total Billed Charges,35.81,45,,3.24,Percent of Total Billed Charges,45% of Total Billed Charges,71.62,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,79.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.73,65,,4.16,Percent of total Billed Charges,65% of Total Billed Charges,35.09,44.1,,3.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,75.6,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,79.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.03,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,71.62,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,35.09,79.58,
ARTHROSCOPIC LEG HOLDER,2700000252,CDM,270,RC,,,Outpatient,,,33.30,21.65,,33.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.31,76,,31.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.98,72,,44.8,Percent of Total Billed Charges,72% of Total Billed Charges,24.98,75,,46.672,Percent of Total Billed charges,75% of Total Billed Charges,33.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.98,72,,44.8,Percent of Total Billed Charges,72% of Total Billed Charges,19.98,60,,37.336,Percent of Total Billed Charges,60% of Total Billed Charges,29.97,90,,7.4,Percent of Total Billed Charges,90% of Total Billed Charges,14.99,45,,3.312,Percent of Total Billed Charges,45% of Total Billed Charges,29.97,90,,37.08,Percent of Total Billed Charges,90% of Total billed Charges,33.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.65,65,,4.68,Percent of total Billed Charges,65% of Total Billed Charges,14.69,44.1,,3.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.64,95,,39.144,Percent of Total Billed Charges,95% of Total Billed Charges,33.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.3,88,,36.256,Percent of Total Billed Charges,88% of Total Billed Charges,29.97,90,,37.08,Percent of Total Billed charges,90% of Total Billed Charges,14.69,33.3,
ARTX GWRE  TRCR 045 LSRLN,2710000001,CDM,271,RC,,,Outpatient,,,29.00,18.85,,29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.04,76,,5.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.88,72,,18.712,Percent of Total Billed Charges,72% of Total Billed Charges,21.75,75,,19.488,Percent of Total Billed charges,75% of Total Billed Charges,29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.88,72,,18.712,Percent of Total Billed Charges,72% of Total Billed Charges,17.4,60,,15.592,Percent of Total Billed Charges,60% of Total Billed Charges,26.1,90,,36.544,Percent of Total Billed Charges,90% of Total Billed Charges,13.05,45,,1.232,Percent of Total Billed Charges,45% of Total Billed Charges,26.1,90,,6.48,Percent of Total Billed Charges,90% of Total billed Charges,29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.85,65,,31.904,Percent of total Billed Charges,65% of Total Billed Charges,12.79,44.1,,1.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,27.55,95,,6.84,Percent of Total Billed Charges,95% of Total Billed Charges,29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.52,88,,6.336,Percent of Total Billed Charges,88% of Total Billed Charges,26.1,90,,6.48,Percent of Total Billed charges,90% of Total Billed Charges,12.79,29,
ARM SLING LG,2710000002,CDM,271,RC,A4565,HCPCS,Outpatient,,,94.82,61.63,,94.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.06,76,,5.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.31,350,,23.904,Fee Schedule,350% of BCBS fee schedule,30.31,350,,24.904,Fee Schedule,350% of BCBS fee schedule,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.31,350,,23.904,Fee Schedule,350% of BCBS PPO fee schedule,8.66,100,,19.92,Fee Schedule,100% of Blue ADV HMO fee schedule,85.34,90,,5.904,Percent of Total Billed Charges,90% of Total Billed Charges,42.67,45,,2.448,Percent of Total Billed Charges,45% of Total Billed Charges,85.34,90,,6.624,Percent of Total Billed Charges,90% of Total billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.63,65,,1.776,Percent of total Billed Charges,65% of Total Billed Charges,41.82,44.1,,2.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,90.08,95,,6.992,Percent of Total Billed Charges,95% of Total Billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.44,88,,6.48,Percent of Total Billed Charges,88% of Total Billed Charges,85.34,90,,6.624,Percent of Total Billed charges,90% of Total Billed Charges,8.66,94.82,
RELOAD CR40G CONTOUR GREEN,2710000004,CDM,271,RC,,,Outpatient,,,200.00,130.00,,200,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152,76,,37.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144,72,,26.464,Percent of Total Billed Charges,72% of Total Billed Charges,150,75,,27.568,Percent of Total Billed charges,75% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144,72,,26.464,Percent of Total Billed Charges,72% of Total Billed Charges,120,60,,22.056,Percent of Total Billed Charges,60% of Total Billed Charges,180,90,,12.6,Percent of Total Billed Charges,90% of Total Billed Charges,90,45,,2.088,Percent of Total Billed Charges,45% of Total Billed Charges,180,90,,44.176,Percent of Total Billed Charges,90% of Total billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130,65,,3.536,Percent of total Billed Charges,65% of Total Billed Charges,88.2,44.1,,2.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,190,95,,46.624,Percent of Total Billed Charges,95% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,88,,43.192,Percent of Total Billed Charges,88% of Total Billed Charges,180,90,,44.176,Percent of Total Billed charges,90% of Total Billed Charges,88.2,200,
CONTOUR CUTTER STAPLER CS40B,2710000005,CDM,271,RC,,,Outpatient,,,381.00,247.65,,381,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,289.56,76,,2.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,274.32,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,285.75,75,,9,Percent of Total Billed charges,75% of Total Billed Charges,381,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.32,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,228.6,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,342.9,90,,3.672,Percent of Total Billed Charges,90% of Total Billed Charges,171.45,45,,28.624,Percent of Total Billed Charges,45% of Total Billed Charges,342.9,90,,2.464,Percent of Total Billed Charges,90% of Total billed Charges,381,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.65,65,,3.016,Percent of total Billed Charges,65% of Total Billed Charges,168.02,44.1,,28.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,361.95,95,,2.6,Percent of Total Billed Charges,95% of Total Billed Charges,381,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,335.28,88,,2.408,Percent of Total Billed Charges,88% of Total Billed Charges,342.9,90,,2.464,Percent of Total Billed charges,90% of Total Billed Charges,168.02,381,
URINE MTR OUTPUT DSP,2710000006,CDM,271,RC,,,Outpatient,,,57.33,37.26,,57.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.57,76,,4.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.28,72,,17.28,Percent of Total Billed Charges,72% of Total Billed Charges,43,75,,18,Percent of Total Billed charges,75% of Total Billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.28,72,,17.28,Percent of Total Billed Charges,72% of Total Billed Charges,34.4,60,,14.4,Percent of Total Billed Charges,60% of Total Billed Charges,51.6,90,,6.696,Percent of Total Billed Charges,90% of Total Billed Charges,25.8,45,,3.704,Percent of Total Billed Charges,45% of Total Billed Charges,51.6,90,,4.896,Percent of Total Billed Charges,90% of Total billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.26,65,,41.344,Percent of total Billed Charges,65% of Total Billed Charges,25.28,44.1,,3.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.46,95,,5.168,Percent of Total Billed Charges,95% of Total Billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.45,88,,4.784,Percent of Total Billed Charges,88% of Total Billed Charges,51.6,90,,4.896,Percent of Total Billed charges,90% of Total Billed Charges,25.28,57.33,
POUCH DRAIN OST 21/4,2710000007,CDM,271,RC,,,Outpatient,,,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,3.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,12.96,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,13.504,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,12.96,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,10.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,8.352,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,9.904,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,4.176,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,5.344,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,9.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,4.408,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,4.08,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,4.176,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
SHOE POST OP WM LG,2710000008,CDM,271,RC,,,Outpatient,,,160.97,104.63,,160.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,122.34,76,,48.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,115.9,72,,31.68,Percent of Total Billed Charges,72% of Total Billed Charges,120.73,75,,33,Percent of Total Billed charges,75% of Total Billed Charges,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.9,72,,31.68,Percent of Total Billed Charges,72% of Total Billed Charges,96.58,60,,26.4,Percent of Total Billed Charges,60% of Total Billed Charges,144.87,90,,12.208,Percent of Total Billed Charges,90% of Total Billed Charges,72.44,45,,18.272,Percent of Total Billed Charges,45% of Total Billed Charges,144.87,90,,57.24,Percent of Total Billed Charges,90% of Total billed Charges,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.63,65,,14.312,Percent of total Billed Charges,65% of Total Billed Charges,70.99,44.1,,17.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,152.92,95,,60.424,Percent of Total Billed Charges,95% of Total Billed Charges,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.65,88,,55.968,Percent of Total Billed Charges,88% of Total Billed Charges,144.87,90,,57.24,Percent of Total Billed charges,90% of Total Billed Charges,70.99,160.97,
SHOE POST OP WM MED,2710000009,CDM,271,RC,,,Outpatient,,,156.56,101.76,,156.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,118.99,76,,6.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,112.72,72,,360,Percent of Total Billed Charges,72% of Total Billed Charges,117.42,75,,375,Percent of Total Billed charges,75% of Total Billed Charges,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.72,72,,360,Percent of Total Billed Charges,72% of Total Billed Charges,93.94,60,,300,Percent of Total Billed Charges,60% of Total Billed Charges,140.9,90,,166.72,Percent of Total Billed Charges,90% of Total Billed Charges,70.45,45,,2.952,Percent of Total Billed Charges,45% of Total Billed Charges,140.9,90,,7.4,Percent of Total Billed Charges,90% of Total billed Charges,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.76,65,,26.392,Percent of total Billed Charges,65% of Total Billed Charges,69.04,44.1,,2.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,148.73,95,,7.816,Percent of Total Billed Charges,95% of Total Billed Charges,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.77,88,,7.24,Percent of Total Billed Charges,88% of Total Billed Charges,140.9,90,,7.4,Percent of Total Billed charges,90% of Total Billed Charges,69.04,156.56,
SHOE POST OP WM SM,2710000010,CDM,271,RC,,,Outpatient,,,212.78,138.31,,212.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.71,76,,16.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153.2,72,,151.2,Percent of Total Billed Charges,72% of Total Billed Charges,159.59,75,,157.504,Percent of Total Billed charges,75% of Total Billed Charges,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.2,72,,151.2,Percent of Total Billed Charges,72% of Total Billed Charges,127.67,60,,126,Percent of Total Billed Charges,60% of Total Billed Charges,191.5,90,,8.44,Percent of Total Billed Charges,90% of Total Billed Charges,95.75,45,,6.304,Percent of Total Billed Charges,45% of Total Billed Charges,191.5,90,,19.816,Percent of Total Billed Charges,90% of Total billed Charges,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.31,65,,4.264,Percent of total Billed Charges,65% of Total Billed Charges,93.84,44.1,,6.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,202.14,95,,20.912,Percent of Total Billed Charges,95% of Total Billed Charges,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.25,88,,19.376,Percent of Total Billed Charges,88% of Total Billed Charges,191.5,90,,19.816,Percent of Total Billed charges,90% of Total Billed Charges,93.84,212.78,
SHOE POST OP MEN LG,2710000011,CDM,271,RC,,,Outpatient,,,160.97,104.63,,160.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,122.34,76,,30.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,115.9,72,,3.36,Percent of Total Billed Charges,72% of Total Billed Charges,120.73,75,,3.496,Percent of Total Billed charges,75% of Total Billed Charges,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.9,72,,3.36,Percent of Total Billed Charges,72% of Total Billed Charges,96.58,60,,2.8,Percent of Total Billed Charges,60% of Total Billed Charges,144.87,90,,9.936,Percent of Total Billed Charges,90% of Total Billed Charges,72.44,45,,1.84,Percent of Total Billed Charges,45% of Total Billed Charges,144.87,90,,36.544,Percent of Total Billed Charges,90% of Total billed Charges,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.63,65,,9.104,Percent of total Billed Charges,65% of Total Billed Charges,70.99,44.1,,1.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,152.92,95,,38.568,Percent of Total Billed Charges,95% of Total Billed Charges,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.65,88,,35.728,Percent of Total Billed Charges,88% of Total Billed Charges,144.87,90,,36.544,Percent of Total Billed charges,90% of Total Billed Charges,70.99,160.97,
SHOE POST OP MEN MED,2710000012,CDM,271,RC,,,Outpatient,,,160.97,104.63,,160.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,122.34,76,,4.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,115.9,72,,83.52,Percent of Total Billed Charges,72% of Total Billed Charges,120.73,75,,87,Percent of Total Billed charges,75% of Total Billed Charges,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.9,72,,83.52,Percent of Total Billed Charges,72% of Total Billed Charges,96.58,60,,69.6,Percent of Total Billed Charges,60% of Total Billed Charges,144.87,90,,7.616,Percent of Total Billed Charges,90% of Total Billed Charges,72.44,45,,3.352,Percent of Total Billed Charges,45% of Total Billed Charges,144.87,90,,5.904,Percent of Total Billed Charges,90% of Total billed Charges,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.63,65,,2.656,Percent of total Billed Charges,65% of Total Billed Charges,70.99,44.1,,3.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,152.92,95,,6.232,Percent of Total Billed Charges,95% of Total Billed Charges,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.65,88,,5.776,Percent of Total Billed Charges,88% of Total Billed Charges,144.87,90,,5.904,Percent of Total Billed charges,90% of Total Billed Charges,70.99,160.97,
SHOE POST OP MEN SM,2710000013,CDM,271,RC,,,Outpatient,,,156.56,101.76,,156.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,118.99,76,,10.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,112.72,72,,3.08,Percent of Total Billed Charges,72% of Total Billed Charges,117.42,75,,3.208,Percent of Total Billed charges,75% of Total Billed Charges,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.72,72,,3.08,Percent of Total Billed Charges,72% of Total Billed Charges,93.94,60,,2.568,Percent of Total Billed Charges,60% of Total Billed Charges,140.9,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,70.45,45,,4.176,Percent of Total Billed Charges,45% of Total Billed Charges,140.9,90,,12.6,Percent of Total Billed Charges,90% of Total billed Charges,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.76,65,,4.84,Percent of total Billed Charges,65% of Total Billed Charges,69.04,44.1,,4.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,148.73,95,,13.304,Percent of Total Billed Charges,95% of Total Billed Charges,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.77,88,,12.32,Percent of Total Billed Charges,88% of Total Billed Charges,140.9,90,,12.6,Percent of Total Billed charges,90% of Total Billed Charges,69.04,156.56,
LARGE CAST SHOE,2710000014,CDM,271,RC,,,Outpatient,,,164.27,106.78,,164.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.85,76,,3.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,118.27,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,123.2,75,,36,Percent of Total Billed charges,75% of Total Billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.27,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,98.56,60,,28.8,Percent of Total Billed Charges,60% of Total Billed Charges,147.84,90,,15.88,Percent of Total Billed Charges,90% of Total Billed Charges,73.92,45,,6.104,Percent of Total Billed Charges,45% of Total Billed Charges,147.84,90,,3.672,Percent of Total Billed Charges,90% of Total billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.78,65,,6.032,Percent of total Billed Charges,65% of Total Billed Charges,72.44,44.1,,5.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,156.06,95,,3.88,Percent of Total Billed Charges,95% of Total Billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.56,88,,3.592,Percent of Total Billed Charges,88% of Total Billed Charges,147.84,90,,3.672,Percent of Total Billed charges,90% of Total Billed Charges,72.44,164.27,
POUCH DRAIN/OST,2710000015,CDM,271,RC,,,Outpatient,,,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,5.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.88,72,,1.208,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,75,,1.264,Percent of Total Billed charges,75% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.88,72,,1.208,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,60,,1.008,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,83.36,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,6.696,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,8.816,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,81.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,7.072,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,6.544,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,6.696,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.05,
POUCH STOMA/DRN 1 1/,2710000016,CDM,271,RC,,,Outpatient,,,27.56,17.91,,27.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.95,76,,7.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.84,72,,9.936,Percent of Total Billed Charges,72% of Total Billed Charges,20.67,75,,10.352,Percent of Total Billed charges,75% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.84,72,,9.936,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,60,,8.28,Percent of Total Billed Charges,60% of Total Billed Charges,24.8,90,,51.8,Percent of Total Billed Charges,90% of Total Billed Charges,12.4,45,,4.216,Percent of Total Billed Charges,45% of Total Billed Charges,24.8,90,,8.352,Percent of Total Billed Charges,90% of Total billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.91,65,,120.408,Percent of total Billed Charges,65% of Total Billed Charges,12.15,44.1,,4.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.18,95,,8.816,Percent of Total Billed Charges,95% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,88,,8.168,Percent of Total Billed Charges,88% of Total Billed Charges,24.8,90,,8.352,Percent of Total Billed charges,90% of Total Billed Charges,12.15,27.56,
POUCH DRAIN/OST 2,2710000017,CDM,271,RC,,,Outpatient,,,68.36,44.43,,68.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.95,76,,10.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49.22,72,,518.4,Percent of Total Billed Charges,72% of Total Billed Charges,51.27,75,,540,Percent of Total Billed charges,75% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,72,,518.4,Percent of Total Billed Charges,72% of Total Billed Charges,41.02,60,,432,Percent of Total Billed Charges,60% of Total Billed Charges,61.52,90,,26.192,Percent of Total Billed Charges,90% of Total Billed Charges,30.76,45,,4.968,Percent of Total Billed Charges,45% of Total Billed Charges,61.52,90,,12.208,Percent of Total Billed Charges,90% of Total billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.43,65,,6.096,Percent of total Billed Charges,65% of Total Billed Charges,30.15,44.1,,4.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,64.94,95,,12.888,Percent of Total Billed Charges,95% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.16,88,,11.936,Percent of Total Billed Charges,88% of Total Billed Charges,61.52,90,,12.208,Percent of Total Billed charges,90% of Total Billed Charges,30.15,68.36,
ARM SLING MD,2710000018,CDM,271,RC,,,Outpatient,,,40.79,26.51,,40.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31,76,,140.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.37,72,,8.24,Percent of Total Billed Charges,72% of Total Billed Charges,30.59,75,,8.584,Percent of Total Billed charges,75% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.37,72,,8.24,Percent of Total Billed Charges,72% of Total Billed Charges,24.47,60,,6.864,Percent of Total Billed Charges,60% of Total Billed Charges,36.71,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,18.36,45,,3.808,Percent of Total Billed Charges,45% of Total Billed Charges,36.71,90,,166.72,Percent of Total Billed Charges,90% of Total billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.51,65,,7.176,Percent of total Billed Charges,65% of Total Billed Charges,17.99,44.1,,3.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.75,95,,175.984,Percent of Total Billed Charges,95% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.9,88,,163.016,Percent of Total Billed Charges,88% of Total Billed Charges,36.71,90,,166.72,Percent of Total Billed charges,90% of Total Billed Charges,17.99,40.79,
ARM SLING SM,2710000019,CDM,271,RC,,,Outpatient,,,40.79,26.51,,40.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31,76,,7.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.37,72,,2.984,Percent of Total Billed Charges,72% of Total Billed Charges,30.59,75,,3.112,Percent of Total Billed charges,75% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.37,72,,2.984,Percent of Total Billed Charges,72% of Total Billed Charges,24.47,60,,2.488,Percent of Total Billed Charges,60% of Total Billed Charges,36.71,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,18.36,45,,7.2,Percent of Total Billed Charges,45% of Total Billed Charges,36.71,90,,8.44,Percent of Total Billed Charges,90% of Total billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.51,65,,5.504,Percent of total Billed Charges,65% of Total Billed Charges,17.99,44.1,,7.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.75,95,,8.904,Percent of Total Billed Charges,95% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.9,88,,8.248,Percent of Total Billed Charges,88% of Total Billed Charges,36.71,90,,8.44,Percent of Total Billed charges,90% of Total Billed Charges,17.99,40.79,
ARM SLING XLG,2710000020,CDM,271,RC,,,Outpatient,,,40.79,26.51,,40.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31,76,,8.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.37,72,,28.744,Percent of Total Billed Charges,72% of Total Billed Charges,30.59,75,,29.944,Percent of Total Billed charges,75% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.37,72,,28.744,Percent of Total Billed Charges,72% of Total Billed Charges,24.47,60,,23.952,Percent of Total Billed Charges,60% of Total Billed Charges,36.71,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,18.36,45,,7.936,Percent of Total Billed Charges,45% of Total Billed Charges,36.71,90,,9.936,Percent of Total Billed Charges,90% of Total billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.51,65,,10.4,Percent of total Billed Charges,65% of Total Billed Charges,17.99,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.75,95,,10.488,Percent of Total Billed Charges,95% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.9,88,,9.712,Percent of Total Billed Charges,88% of Total Billed Charges,36.71,90,,9.936,Percent of Total Billed charges,90% of Total Billed Charges,17.99,40.79,
BARRIER SKW/FL 4,2710000021,CDM,271,RC,,,Outpatient,,,27.56,17.91,,27.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.95,76,,6.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.84,72,,27.968,Percent of Total Billed Charges,72% of Total Billed Charges,20.67,75,,29.128,Percent of Total Billed charges,75% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.84,72,,27.968,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,60,,23.304,Percent of Total Billed Charges,60% of Total Billed Charges,24.8,90,,91.288,Percent of Total Billed Charges,90% of Total Billed Charges,12.4,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,24.8,90,,7.616,Percent of Total Billed Charges,90% of Total billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.91,65,,11.464,Percent of total Billed Charges,65% of Total Billed Charges,12.15,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.18,95,,8.04,Percent of Total Billed Charges,95% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,88,,7.448,Percent of Total Billed Charges,88% of Total Billed Charges,24.8,90,,7.616,Percent of Total Billed charges,90% of Total Billed Charges,12.15,27.56,
BARRIER SKW/FL 13/4,2710000022,CDM,271,RC,,,Outpatient,,,36.38,23.65,,36.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.65,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.19,72,,27.504,Percent of Total Billed Charges,72% of Total Billed Charges,27.29,75,,28.648,Percent of Total Billed charges,75% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.19,72,,27.504,Percent of Total Billed Charges,72% of Total Billed Charges,21.83,60,,22.92,Percent of Total Billed Charges,60% of Total Billed Charges,32.74,90,,87.32,Percent of Total Billed Charges,90% of Total Billed Charges,16.37,45,,25.896,Percent of Total Billed Charges,45% of Total Billed Charges,32.74,90,,14.4,Percent of Total Billed Charges,90% of Total billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.65,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,16.04,44.1,,25.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.56,95,,15.2,Percent of Total Billed Charges,95% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.01,88,,14.08,Percent of Total Billed Charges,88% of Total Billed Charges,32.74,90,,14.4,Percent of Total Billed charges,90% of Total Billed Charges,16.04,36.38,
BARRIER SKW/FL 2 3/4,2710000023,CDM,271,RC,,,Outpatient,,,33.08,21.50,,33.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.14,76,,13.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.82,72,,28.384,Percent of Total Billed Charges,72% of Total Billed Charges,24.81,75,,29.568,Percent of Total Billed charges,75% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.82,72,,28.384,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,60,,23.656,Percent of Total Billed Charges,60% of Total Billed Charges,29.77,90,,91.288,Percent of Total Billed Charges,90% of Total Billed Charges,14.89,45,,13.096,Percent of Total Billed Charges,45% of Total Billed Charges,29.77,90,,15.88,Percent of Total Billed Charges,90% of Total billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.5,65,,37.408,Percent of total Billed Charges,65% of Total Billed Charges,14.59,44.1,,12.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.43,95,,16.76,Percent of Total Billed Charges,95% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.11,88,,15.52,Percent of Total Billed Charges,88% of Total Billed Charges,29.77,90,,15.88,Percent of Total Billed charges,90% of Total Billed Charges,14.59,33.08,
POUCH DRAIN/OST 1.5,2710000024,CDM,271,RC,,,Outpatient,,,51.82,33.68,,51.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,39.38,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,37.31,72,,29.664,Percent of Total Billed Charges,72% of Total Billed Charges,38.87,75,,30.904,Percent of Total Billed charges,75% of Total Billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.31,72,,29.664,Percent of Total Billed Charges,72% of Total Billed Charges,31.09,60,,24.72,Percent of Total Billed Charges,60% of Total Billed Charges,46.64,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,23.32,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,46.64,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.68,65,,18.92,Percent of total Billed Charges,65% of Total Billed Charges,22.85,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,49.23,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.6,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,46.64,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,22.85,51.82,
METACARPEL ADULT LFT,2710000025,CDM,271,RC,,,Outpatient,,,169.79,110.36,,169.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.04,76,,43.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,122.25,72,,27.76,Percent of Total Billed Charges,72% of Total Billed Charges,127.34,75,,28.92,Percent of Total Billed charges,75% of Total Billed Charges,169.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.25,72,,27.76,Percent of Total Billed Charges,72% of Total Billed Charges,101.87,60,,23.136,Percent of Total Billed Charges,60% of Total Billed Charges,152.81,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,76.41,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,152.81,90,,51.8,Percent of Total Billed Charges,90% of Total billed Charges,169.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.36,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,74.88,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,161.3,95,,54.672,Percent of Total Billed Charges,95% of Total Billed Charges,169.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.42,88,,50.648,Percent of Total Billed Charges,88% of Total Billed Charges,152.81,90,,51.8,Percent of Total Billed charges,90% of Total Billed Charges,74.88,169.79,
METACRPL SPLNT ADL R,2710000026,CDM,271,RC,,,Outpatient,,,169.79,110.36,,169.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.04,76,,22.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,122.25,72,,28.912,Percent of Total Billed Charges,72% of Total Billed Charges,127.34,75,,30.12,Percent of Total Billed charges,75% of Total Billed Charges,169.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.25,72,,28.912,Percent of Total Billed Charges,72% of Total Billed Charges,101.87,60,,24.096,Percent of Total Billed Charges,60% of Total Billed Charges,152.81,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,76.41,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,152.81,90,,26.192,Percent of Total Billed Charges,90% of Total billed Charges,169.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.36,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,74.88,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,161.3,95,,27.648,Percent of Total Billed Charges,95% of Total Billed Charges,169.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.42,88,,25.608,Percent of Total Billed Charges,88% of Total Billed Charges,152.81,90,,26.192,Percent of Total Billed charges,90% of Total Billed Charges,74.88,169.79,
METACRPL SPLNT YTH R,2710000027,CDM,271,RC,,,Outpatient,,,79.38,51.60,,79.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60.33,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.15,72,,27.696,Percent of Total Billed Charges,72% of Total Billed Charges,59.54,75,,28.848,Percent of Total Billed charges,75% of Total Billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.15,72,,27.696,Percent of Total Billed Charges,72% of Total Billed Charges,47.63,60,,23.08,Percent of Total Billed Charges,60% of Total Billed Charges,71.44,90,,29.368,Percent of Total Billed Charges,90% of Total Billed Charges,35.72,45,,45.648,Percent of Total Billed Charges,45% of Total Billed Charges,71.44,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,35.01,44.1,,44.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,75.41,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.85,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,71.44,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,35.01,79.38,
HYPERINFLATION PEDI,2710000028,CDM,271,RC,,,Outpatient,,,170.89,111.08,,170.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.88,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.04,72,,401.76,Percent of Total Billed Charges,72% of Total Billed Charges,128.17,75,,418.504,Percent of Total Billed charges,75% of Total Billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.04,72,,401.76,Percent of Total Billed Charges,72% of Total Billed Charges,102.53,60,,334.8,Percent of Total Billed Charges,60% of Total Billed Charges,153.8,90,,51.592,Percent of Total Billed Charges,90% of Total Billed Charges,76.9,45,,43.664,Percent of Total Billed Charges,45% of Total Billed Charges,153.8,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.08,65,,65.928,Percent of total Billed Charges,65% of Total Billed Charges,75.36,44.1,,42.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,162.35,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.38,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,153.8,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,75.36,170.89,
SCROTAL SUP SUSP MD,2710000030,CDM,271,RC,,,Outpatient,,,71.66,46.58,,71.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.46,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.6,72,,607.68,Percent of Total Billed Charges,72% of Total Billed Charges,53.75,75,,633,Percent of Total Billed charges,75% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,72,,607.68,Percent of Total Billed Charges,72% of Total Billed Charges,43,60,,506.4,Percent of Total Billed Charges,60% of Total Billed Charges,64.49,90,,7.864,Percent of Total Billed Charges,90% of Total Billed Charges,32.25,45,,45.648,Percent of Total Billed Charges,45% of Total Billed Charges,64.49,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.58,65,,63.064,Percent of total Billed Charges,65% of Total Billed Charges,31.6,44.1,,44.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.08,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,64.49,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,31.6,71.66,
SCROTAL SUP SUSP LG,2710000031,CDM,271,RC,,,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,77.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,15.4,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,16.04,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,15.4,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,12.832,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,14.648,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,91.288,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,65.928,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,96.36,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,89.264,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,91.288,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
FEEDING TUBE 8FR 42',2710000032,CDM,271,RC,,,Outpatient,,,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,73.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,1.04,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,1.08,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,1.04,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,0.864,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,14.648,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,87.32,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,92.176,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,85.384,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,87.32,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
OSTOMY CLAMP,2710000033,CDM,271,RC,,,Outpatient,,,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,77.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,3.032,Percent of Total Billed Charges,72% of Total Billed Charges,15.71,75,,3.16,Percent of Total Billed charges,75% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,3.032,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,2.528,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,14.648,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,91.288,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,96.36,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,89.264,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,91.288,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
POUCH DRAIN OSTOMY,2710000034,CDM,271,RC,,,Outpatient,,,27.56,17.91,,27.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.95,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.84,72,,2.304,Percent of Total Billed Charges,72% of Total Billed Charges,20.67,75,,2.4,Percent of Total Billed charges,75% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.84,72,,2.304,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,24.8,90,,7.488,Percent of Total Billed Charges,90% of Total Billed Charges,12.4,45,,14.688,Percent of Total Billed Charges,45% of Total Billed Charges,24.8,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.91,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,12.15,44.1,,14.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.18,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,24.8,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,12.15,27.56,
POUCH DRAIN OSTOMY 4,2710000035,CDM,271,RC,,,Outpatient,,,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,47.512,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,49.488,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,47.512,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,39.592,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,7.488,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,25.8,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,21.208,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,25.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
BARRIER SKW/FL 2/14,2710000036,CDM,271,RC,,,Outpatient,,,36.38,23.65,,36.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.65,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.19,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,27.29,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.19,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,21.83,60,,3.184,Percent of Total Billed Charges,60% of Total Billed Charges,32.74,90,,37.08,Percent of Total Billed Charges,90% of Total Billed Charges,16.37,45,,3.928,Percent of Total Billed Charges,45% of Total Billed Charges,32.74,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.65,65,,37.264,Percent of total Billed Charges,65% of Total Billed Charges,16.04,44.1,,3.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.56,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.01,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,32.74,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,16.04,36.38,
BARRIER SKW/FL 11/2,2710000037,CDM,271,RC,,,Outpatient,,,47.41,30.82,,47.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.03,76,,24.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.14,72,,2.64,Percent of Total Billed Charges,72% of Total Billed Charges,35.56,75,,2.752,Percent of Total Billed charges,75% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.14,72,,2.64,Percent of Total Billed Charges,72% of Total Billed Charges,28.45,60,,2.2,Percent of Total Billed Charges,60% of Total Billed Charges,42.67,90,,36.544,Percent of Total Billed Charges,90% of Total Billed Charges,21.33,45,,7.32,Percent of Total Billed Charges,45% of Total Billed Charges,42.67,90,,29.368,Percent of Total Billed Charges,90% of Total billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.82,65,,5.68,Percent of total Billed Charges,65% of Total Billed Charges,20.91,44.1,,7.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.04,95,,31,Percent of Total Billed Charges,95% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.72,88,,28.72,Percent of Total Billed Charges,88% of Total Billed Charges,42.67,90,,29.368,Percent of Total Billed charges,90% of Total Billed Charges,20.91,47.41,
TRACTION BOOTS SUPP,2710000038,CDM,271,RC,,,Outpatient,,,134.51,87.43,,134.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,102.23,76,,43.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,96.85,72,,2.968,Percent of Total Billed Charges,72% of Total Billed Charges,100.88,75,,3.088,Percent of Total Billed charges,75% of Total Billed Charges,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.85,72,,2.968,Percent of Total Billed Charges,72% of Total Billed Charges,80.71,60,,2.472,Percent of Total Billed Charges,60% of Total Billed Charges,121.06,90,,5.976,Percent of Total Billed Charges,90% of Total Billed Charges,60.53,45,,7.32,Percent of Total Billed Charges,45% of Total Billed Charges,121.06,90,,51.592,Percent of Total Billed Charges,90% of Total billed Charges,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.43,65,,10.576,Percent of total Billed Charges,65% of Total Billed Charges,59.32,44.1,,7.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,127.78,95,,54.464,Percent of Total Billed Charges,95% of Total Billed Charges,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.37,88,,50.448,Percent of Total Billed Charges,88% of Total Billed Charges,121.06,90,,51.592,Percent of Total Billed charges,90% of Total Billed Charges,59.32,134.51,
IV START KIT,2710000039,CDM,271,RC,,,Outpatient,,,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,6.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,0.432,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,0.448,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,0.432,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,0.36,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,7.56,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,7.32,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,7.864,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,10.576,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,7.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,8.296,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,7.688,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,7.864,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
OB PACK,2710000040,CDM,271,RC,,,Outpatient,,,154.35,100.33,,154.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,117.31,76,,12.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.13,72,,213.984,Percent of Total Billed Charges,72% of Total Billed Charges,115.76,75,,222.904,Percent of Total Billed charges,75% of Total Billed Charges,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.13,72,,213.984,Percent of Total Billed Charges,72% of Total Billed Charges,92.61,60,,178.32,Percent of Total Billed Charges,60% of Total Billed Charges,138.92,90,,7.416,Percent of Total Billed Charges,90% of Total Billed Charges,69.46,45,,3.744,Percent of Total Billed Charges,45% of Total Billed Charges,138.92,90,,14.648,Percent of Total Billed Charges,90% of Total billed Charges,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.33,65,,10.576,Percent of total Billed Charges,65% of Total Billed Charges,68.07,44.1,,3.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,146.63,95,,15.456,Percent of Total Billed Charges,95% of Total Billed Charges,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.83,88,,14.32,Percent of Total Billed Charges,88% of Total Billed Charges,138.92,90,,14.648,Percent of Total Billed charges,90% of Total Billed Charges,68.07,154.35,
STOCKINETT IMPRV MD,2710000041,CDM,271,RC,,,Outpatient,,,60.64,39.42,,60.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.09,76,,12.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.66,72,,8.264,Percent of Total Billed Charges,72% of Total Billed Charges,45.48,75,,8.608,Percent of Total Billed charges,75% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,72,,8.264,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,60,,6.888,Percent of Total Billed Charges,60% of Total Billed Charges,54.58,90,,7.488,Percent of Total Billed Charges,90% of Total Billed Charges,27.29,45,,3.744,Percent of Total Billed Charges,45% of Total Billed Charges,54.58,90,,14.648,Percent of Total Billed Charges,90% of Total billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.42,65,,5.408,Percent of total Billed Charges,65% of Total Billed Charges,26.74,44.1,,3.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.61,95,,15.456,Percent of Total Billed Charges,95% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.36,88,,14.32,Percent of Total Billed Charges,88% of Total Billed Charges,54.58,90,,14.648,Percent of Total Billed charges,90% of Total Billed Charges,26.74,60.64,
INSYTEN AUTOGRD YEL,2710000042,CDM,271,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,12.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,2427.84,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,2529,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,2427.84,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,2023.2,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,7.488,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,18.544,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,14.648,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,5.408,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,18.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,15.456,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,14.32,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,14.648,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
STOCKINETT IMPRV XL,2710000043,CDM,271,RC,,,Outpatient,,,145.53,94.59,,145.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.6,76,,6.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,104.78,72,,2753.28,Percent of Total Billed Charges,72% of Total Billed Charges,109.15,75,,2868,Percent of Total Billed charges,75% of Total Billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.78,72,,2753.28,Percent of Total Billed Charges,72% of Total Billed Charges,87.32,60,,2294.4,Percent of Total Billed Charges,60% of Total Billed Charges,130.98,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,65.49,45,,18.272,Percent of Total Billed Charges,45% of Total Billed Charges,130.98,90,,7.488,Percent of Total Billed Charges,90% of Total billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.59,65,,26.784,Percent of total Billed Charges,65% of Total Billed Charges,64.18,44.1,,17.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,138.25,95,,7.904,Percent of Total Billed Charges,95% of Total Billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.07,88,,7.32,Percent of Total Billed Charges,88% of Total Billed Charges,130.98,90,,7.488,Percent of Total Billed charges,90% of Total Billed Charges,64.18,145.53,
SMALL COLD PACKS,2710000044,CDM,271,RC,,,Outpatient,,,3.65,2.37,,3.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.77,76,,6.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.63,72,,3078.72,Percent of Total Billed Charges,72% of Total Billed Charges,2.74,75,,3207,Percent of Total Billed charges,75% of Total Billed Charges,3.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.63,72,,3078.72,Percent of Total Billed Charges,72% of Total Billed Charges,2.19,60,,2565.6,Percent of Total Billed Charges,60% of Total Billed Charges,3.29,90,,6.048,Percent of Total Billed Charges,90% of Total Billed Charges,1.64,45,,2.992,Percent of Total Billed Charges,45% of Total Billed Charges,3.29,90,,7.488,Percent of Total Billed Charges,90% of Total billed Charges,3.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.37,65,,26.392,Percent of total Billed Charges,65% of Total Billed Charges,1.61,44.1,,2.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.47,95,,7.904,Percent of Total Billed Charges,95% of Total Billed Charges,3.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.21,88,,7.32,Percent of Total Billed Charges,88% of Total Billed Charges,3.29,90,,7.488,Percent of Total Billed charges,90% of Total Billed Charges,1.61,3.65,
ZOLL STAT PADZ,2710000045,CDM,271,RC,,,Outpatient,,,148.84,96.75,,148.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,113.12,76,,31.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,107.16,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,111.63,75,,36,Percent of Total Billed charges,75% of Total Billed Charges,148.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.16,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,89.3,60,,28.8,Percent of Total Billed Charges,60% of Total Billed Charges,133.96,90,,86.896,Percent of Total Billed Charges,90% of Total Billed Charges,66.98,45,,3.784,Percent of Total Billed Charges,45% of Total Billed Charges,133.96,90,,37.08,Percent of Total Billed Charges,90% of Total billed Charges,148.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.75,65,,4.32,Percent of total Billed Charges,65% of Total Billed Charges,65.64,44.1,,3.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,141.4,95,,39.144,Percent of Total Billed Charges,95% of Total Billed Charges,148.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.98,88,,36.256,Percent of Total Billed Charges,88% of Total Billed Charges,133.96,90,,37.08,Percent of Total Billed charges,90% of Total Billed Charges,65.64,148.84,
INSYTE AUTOGRD YEL 2,2710000046,CDM,271,RC,,,Outpatient,,,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,30.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,136.624,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,142.32,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,136.624,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,113.856,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,2.432,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,3.712,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,36.544,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,5.464,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,3.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,38.568,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,35.728,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,36.544,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
AMBU BAG W/MASK ADLU,2710000047,CDM,271,RC,,,Outpatient,,,69.46,45.15,,69.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.79,76,,5.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.01,72,,57.944,Percent of Total Billed Charges,72% of Total Billed Charges,52.1,75,,60.36,Percent of Total Billed charges,75% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.01,72,,57.944,Percent of Total Billed Charges,72% of Total Billed Charges,41.68,60,,48.288,Percent of Total Billed Charges,60% of Total Billed Charges,62.51,90,,18.904,Percent of Total Billed Charges,90% of Total Billed Charges,31.26,45,,3.744,Percent of Total Billed Charges,45% of Total Billed Charges,62.51,90,,5.976,Percent of Total Billed Charges,90% of Total billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.15,65,,5.36,Percent of total Billed Charges,65% of Total Billed Charges,30.63,44.1,,3.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.99,95,,6.312,Percent of Total Billed Charges,95% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,88,,5.84,Percent of Total Billed Charges,88% of Total Billed Charges,62.51,90,,5.976,Percent of Total Billed charges,90% of Total Billed Charges,30.63,69.46,
INFANT SZ 2 MASK,2710000048,CDM,271,RC,,,Outpatient,,,25.36,16.48,,25.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.27,76,,6.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.26,72,,51.304,Percent of Total Billed Charges,72% of Total Billed Charges,19.02,75,,53.44,Percent of Total Billed charges,75% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.26,72,,51.304,Percent of Total Billed Charges,72% of Total Billed Charges,15.22,60,,42.752,Percent of Total Billed Charges,60% of Total Billed Charges,22.82,90,,24.192,Percent of Total Billed Charges,90% of Total Billed Charges,11.41,45,,3.744,Percent of Total Billed Charges,45% of Total Billed Charges,22.82,90,,7.56,Percent of Total Billed Charges,90% of Total billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,65,,5.408,Percent of total Billed Charges,65% of Total Billed Charges,11.18,44.1,,3.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.09,95,,7.984,Percent of Total Billed Charges,95% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,88,,7.392,Percent of Total Billed Charges,88% of Total Billed Charges,22.82,90,,7.56,Percent of Total Billed charges,90% of Total Billed Charges,11.18,25.36,
INSTANT COLD PACK LA,2710000049,CDM,271,RC,,,Outpatient,,,33.08,21.50,,33.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.14,76,,6.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.82,72,,257.76,Percent of Total Billed Charges,72% of Total Billed Charges,24.81,75,,268.504,Percent of Total Billed charges,75% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.82,72,,257.76,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,60,,214.8,Percent of Total Billed Charges,60% of Total Billed Charges,29.77,90,,26.464,Percent of Total Billed Charges,90% of Total Billed Charges,14.89,45,,5.76,Percent of Total Billed Charges,45% of Total Billed Charges,29.77,90,,7.416,Percent of Total Billed Charges,90% of Total billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.5,65,,5.408,Percent of total Billed Charges,65% of Total Billed Charges,14.59,44.1,,5.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.43,95,,7.832,Percent of Total Billed Charges,95% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.11,88,,7.248,Percent of Total Billed Charges,88% of Total Billed Charges,29.77,90,,7.416,Percent of Total Billed charges,90% of Total Billed Charges,14.59,33.08,
PEDIDRY BOOTS SZ LG,2710000050,CDM,271,RC,,,Outpatient,,,307.60,199.94,,307.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,233.78,76,,6.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,221.47,72,,118.08,Percent of Total Billed Charges,72% of Total Billed Charges,230.7,75,,123,Percent of Total Billed charges,75% of Total Billed Charges,307.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.47,72,,118.08,Percent of Total Billed Charges,72% of Total Billed Charges,184.56,60,,98.4,Percent of Total Billed Charges,60% of Total Billed Charges,276.84,90,,1.408,Percent of Total Billed Charges,90% of Total Billed Charges,138.42,45,,3.024,Percent of Total Billed Charges,45% of Total Billed Charges,276.84,90,,7.488,Percent of Total Billed Charges,90% of Total billed Charges,307.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.94,65,,8.32,Percent of total Billed Charges,65% of Total Billed Charges,135.65,44.1,,2.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,292.22,95,,7.904,Percent of Total Billed Charges,95% of Total Billed Charges,307.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.69,88,,7.32,Percent of Total Billed Charges,88% of Total Billed Charges,276.84,90,,7.488,Percent of Total Billed charges,90% of Total Billed Charges,135.65,307.6,
MEDIUM CRUTCHES 5'2,2710000051,CDM,271,RC,,,Outpatient,,,79.38,51.60,,79.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60.33,76,,6.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.15,72,,20.16,Percent of Total Billed Charges,72% of Total Billed Charges,59.54,75,,21,Percent of Total Billed charges,75% of Total Billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.15,72,,20.16,Percent of Total Billed Charges,72% of Total Billed Charges,47.63,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,71.44,90,,2.488,Percent of Total Billed Charges,90% of Total Billed Charges,35.72,45,,43.448,Percent of Total Billed Charges,45% of Total Billed Charges,71.44,90,,7.488,Percent of Total Billed Charges,90% of Total billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,65,,4.368,Percent of total Billed Charges,65% of Total Billed Charges,35.01,44.1,,42.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,75.41,95,,7.904,Percent of Total Billed Charges,95% of Total Billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.85,88,,7.32,Percent of Total Billed Charges,88% of Total Billed Charges,71.44,90,,7.488,Percent of Total Billed charges,90% of Total Billed Charges,35.01,79.38,
ADULT CRUTCHES 5'10,2710000052,CDM,271,RC,,,Outpatient,,,79.38,51.60,,79.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60.33,76,,9.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.15,72,,20.16,Percent of Total Billed Charges,72% of Total Billed Charges,59.54,75,,21,Percent of Total Billed charges,75% of Total Billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.15,72,,20.16,Percent of Total Billed Charges,72% of Total Billed Charges,47.63,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,71.44,90,,1.536,Percent of Total Billed Charges,90% of Total Billed Charges,35.72,45,,1.216,Percent of Total Billed Charges,45% of Total Billed Charges,71.44,90,,11.52,Percent of Total Billed Charges,90% of Total billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,65,,62.76,Percent of total Billed Charges,65% of Total Billed Charges,35.01,44.1,,1.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,75.41,95,,12.16,Percent of Total Billed Charges,95% of Total Billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.85,88,,11.264,Percent of Total Billed Charges,88% of Total Billed Charges,71.44,90,,11.52,Percent of Total Billed charges,90% of Total Billed Charges,35.01,79.38,
DELEE SCT CATH 8FR W,2710000053,CDM,271,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,5.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,248.4,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,258.752,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,248.4,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,207,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,1.856,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,9.448,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,6.048,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,1.76,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,9.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,6.384,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,5.912,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,6.048,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
XEROFORM DRESSING 5,2710000054,CDM,271,RC,,,Outpatient,,,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,73.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,291.296,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,303.432,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,291.296,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,242.744,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,1.432,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,12.096,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,86.896,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,13.648,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,11.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,91.728,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,84.968,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,86.896,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
SMALL CRUTCHES 4'7T,2710000055,CDM,271,RC,,,Outpatient,,,79.38,51.60,,79.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60.33,76,,2.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.15,72,,99.536,Percent of Total Billed Charges,72% of Total Billed Charges,59.54,75,,103.68,Percent of Total Billed charges,75% of Total Billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.15,72,,99.536,Percent of Total Billed Charges,72% of Total Billed Charges,47.63,60,,82.944,Percent of Total Billed Charges,60% of Total Billed Charges,71.44,90,,10.264,Percent of Total Billed Charges,90% of Total Billed Charges,35.72,45,,13.232,Percent of Total Billed Charges,45% of Total Billed Charges,71.44,90,,2.432,Percent of Total Billed Charges,90% of Total billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,65,,17.472,Percent of total Billed Charges,65% of Total Billed Charges,35.01,44.1,,12.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,75.41,95,,2.568,Percent of Total Billed Charges,95% of Total Billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.85,88,,2.376,Percent of Total Billed Charges,88% of Total Billed Charges,71.44,90,,2.432,Percent of Total Billed charges,90% of Total Billed Charges,35.01,79.38,
KIT CATH & GLOVE 14F,2710000056,CDM,271,RC,,,Outpatient,,,52.92,34.40,,52.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.22,76,,15.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.1,72,,64.176,Percent of Total Billed Charges,72% of Total Billed Charges,39.69,75,,66.856,Percent of Total Billed charges,75% of Total Billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.1,72,,64.176,Percent of Total Billed Charges,72% of Total Billed Charges,31.75,60,,53.48,Percent of Total Billed Charges,60% of Total Billed Charges,47.63,90,,2.072,Percent of Total Billed Charges,90% of Total Billed Charges,23.81,45,,0.704,Percent of Total Billed Charges,45% of Total Billed Charges,47.63,90,,18.904,Percent of Total Billed Charges,90% of Total billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.4,65,,19.112,Percent of total Billed Charges,65% of Total Billed Charges,23.34,44.1,,0.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.27,95,,19.952,Percent of Total Billed Charges,95% of Total Billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.57,88,,18.48,Percent of Total Billed Charges,88% of Total Billed Charges,47.63,90,,18.904,Percent of Total Billed charges,90% of Total Billed Charges,23.34,52.92,
BARD PISTON IRRIGATI,2710000057,CDM,271,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,20.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,412.128,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,429.304,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,412.128,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,343.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,2.448,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.24,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,24.192,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,1.016,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,25.536,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,23.656,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,24.192,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
ELASTIC 4 WRAP,2710000058,CDM,271,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,22.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,222.712,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,231.992,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,222.712,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,185.592,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,0.504,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,0.768,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,26.464,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,1.792,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,0.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,27.928,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,25.872,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,26.464,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
REMEDY SKIN REPAIR C,2710000059,CDM,271,RC,,,Outpatient,,,24.73,16.07,,24.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.79,76,,1.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.81,72,,222.712,Percent of Total Billed Charges,72% of Total Billed Charges,18.55,75,,231.992,Percent of Total Billed charges,75% of Total Billed Charges,24.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.81,72,,222.712,Percent of Total Billed Charges,72% of Total Billed Charges,14.84,60,,185.592,Percent of Total Billed Charges,60% of Total Billed Charges,22.26,90,,0.664,Percent of Total Billed Charges,90% of Total Billed Charges,11.13,45,,0.928,Percent of Total Billed Charges,45% of Total Billed Charges,22.26,90,,1.408,Percent of Total Billed Charges,90% of Total billed Charges,24.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.07,65,,1.104,Percent of total Billed Charges,65% of Total Billed Charges,10.91,44.1,,0.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.49,95,,1.488,Percent of Total Billed Charges,95% of Total Billed Charges,24.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.76,88,,1.376,Percent of Total Billed Charges,88% of Total Billed Charges,22.26,90,,1.408,Percent of Total Billed charges,90% of Total Billed Charges,10.91,24.73,
INSYTE AUTOGUARD 14G,2710000060,CDM,271,RC,,,Outpatient,,,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,2.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,222.712,Percent of Total Billed Charges,72% of Total Billed Charges,15.71,75,,231.992,Percent of Total Billed charges,75% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,222.712,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,185.592,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,2.768,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,0.72,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,2.488,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,1.344,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,0.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,2.624,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,2.432,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,2.488,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
TUBE LUKEN 8CC,2710000061,CDM,271,RC,,,Outpatient,,,41.90,27.24,,41.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31.84,76,,1.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.17,72,,222.712,Percent of Total Billed Charges,72% of Total Billed Charges,31.43,75,,231.992,Percent of Total Billed charges,75% of Total Billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.17,72,,222.712,Percent of Total Billed Charges,72% of Total Billed Charges,25.14,60,,185.592,Percent of Total Billed Charges,60% of Total Billed Charges,37.71,90,,3.048,Percent of Total Billed Charges,90% of Total Billed Charges,18.86,45,,5.136,Percent of Total Billed Charges,45% of Total Billed Charges,37.71,90,,1.536,Percent of Total Billed Charges,90% of Total billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.24,65,,1.032,Percent of total Billed Charges,65% of Total Billed Charges,18.48,44.1,,5.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,39.81,95,,1.616,Percent of Total Billed Charges,95% of Total Billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.87,88,,1.496,Percent of Total Billed Charges,88% of Total Billed Charges,37.71,90,,1.536,Percent of Total Billed charges,90% of Total Billed Charges,18.48,41.9,
OXYG MASK 3 INONE 7,2710000062,CDM,271,RC,,,Outpatient,,,205.07,133.30,,205.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,155.85,76,,1.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,147.65,72,,222.712,Percent of Total Billed Charges,72% of Total Billed Charges,153.8,75,,231.992,Percent of Total Billed charges,75% of Total Billed Charges,205.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.65,72,,222.712,Percent of Total Billed Charges,72% of Total Billed Charges,123.04,60,,185.592,Percent of Total Billed Charges,60% of Total Billed Charges,184.56,90,,4.696,Percent of Total Billed Charges,90% of Total Billed Charges,92.28,45,,1.04,Percent of Total Billed Charges,45% of Total Billed Charges,184.56,90,,1.856,Percent of Total Billed Charges,90% of Total billed Charges,205.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.3,65,,7.416,Percent of total Billed Charges,65% of Total Billed Charges,90.44,44.1,,1.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,194.82,95,,1.96,Percent of Total Billed Charges,95% of Total Billed Charges,205.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.46,88,,1.816,Percent of Total Billed Charges,88% of Total Billed Charges,184.56,90,,1.856,Percent of Total Billed charges,90% of Total Billed Charges,90.44,205.07,
ELASTIC 3 WRAP,2710000063,CDM,271,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,1.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,291.312,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,303.448,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,291.312,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,242.76,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,2.816,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,1.224,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,1.432,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,1.496,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,1.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,1.512,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,1.4,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,1.432,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
XEROFORM GUAZE 2X2,2710000064,CDM,271,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,8.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,50.4,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,52.504,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,50.4,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,42,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,2.144,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.256,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,10.264,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,1.768,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,10.84,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,10.04,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,10.264,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
SUCTION CATH 14FR GF,2710000065,CDM,271,RC,,,Outpatient,,,14.33,9.31,,14.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.89,76,,1.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.32,72,,18.72,Percent of Total Billed Charges,72% of Total Billed Charges,10.75,75,,19.504,Percent of Total Billed charges,75% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,72,,18.72,Percent of Total Billed Charges,72% of Total Billed Charges,8.6,60,,15.6,Percent of Total Billed Charges,60% of Total Billed Charges,12.9,90,,1.072,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,0.328,Percent of Total Billed Charges,45% of Total Billed Charges,12.9,90,,2.072,Percent of Total Billed Charges,90% of Total billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.31,65,,0.368,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,0.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.61,95,,2.192,Percent of Total Billed Charges,95% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.61,88,,2.024,Percent of Total Billed Charges,88% of Total Billed Charges,12.9,90,,2.072,Percent of Total Billed charges,90% of Total Billed Charges,6.32,14.33,
FOLEY CATH 24FR 30CC,2710000066,CDM,271,RC,,,Outpatient,,,70.56,45.86,,70.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.63,76,,2.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.8,72,,18.72,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,75,,19.504,Percent of Total Billed charges,75% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.8,72,,18.72,Percent of Total Billed Charges,72% of Total Billed Charges,42.34,60,,15.6,Percent of Total Billed Charges,60% of Total Billed Charges,63.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,31.75,45,,1.384,Percent of Total Billed Charges,45% of Total Billed Charges,63.5,90,,2.448,Percent of Total Billed Charges,90% of Total billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.86,65,,0.48,Percent of total Billed Charges,65% of Total Billed Charges,31.12,44.1,,1.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.03,95,,2.584,Percent of Total Billed Charges,95% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.09,88,,2.392,Percent of Total Billed Charges,88% of Total Billed Charges,63.5,90,,2.448,Percent of Total Billed charges,90% of Total Billed Charges,31.12,70.56,
SUCTION CATH 10FR GF,2710000067,CDM,271,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,0.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,18.72,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,19.504,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,18.72,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,15.6,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,8.928,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,1.52,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,0.504,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,2,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,1.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,0.536,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,0.496,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,0.504,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
NEONATAL MASK SZ 1,2710000068,CDM,271,RC,,,Outpatient,,,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,0.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,18,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,18.752,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,18,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,15,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,2.344,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,0.664,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,2.2,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,2.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,0.696,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,0.648,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,0.664,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
EZ ENEMA BUCKET,2710000069,CDM,271,RC,,,Outpatient,,,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,2.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,18,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,18.752,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,18,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,15,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,2.144,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,1.408,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,2.768,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,3.392,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,1.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,2.92,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,2.704,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,2.768,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
TUBE LUKEN 20CC,2710000070,CDM,271,RC,,,Outpatient,,,43.00,27.95,,43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,32.68,76,,2.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.96,72,,18,Percent of Total Billed Charges,72% of Total Billed Charges,32.25,75,,18.752,Percent of Total Billed charges,75% of Total Billed Charges,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.96,72,,18,Percent of Total Billed Charges,72% of Total Billed Charges,25.8,60,,15,Percent of Total Billed Charges,60% of Total Billed Charges,38.7,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,19.35,45,,1.072,Percent of Total Billed Charges,45% of Total Billed Charges,38.7,90,,3.048,Percent of Total Billed Charges,90% of Total billed Charges,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.95,65,,2.032,Percent of total Billed Charges,65% of Total Billed Charges,18.96,44.1,,1.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,40.85,95,,3.216,Percent of Total Billed Charges,95% of Total Billed Charges,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.84,88,,2.976,Percent of Total Billed Charges,88% of Total Billed Charges,38.7,90,,3.048,Percent of Total Billed charges,90% of Total Billed Charges,18.96,43,
SCOTCHCAST PLUS TAPE,2710000071,CDM,271,RC,,,Outpatient,,,49.61,32.25,,49.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,37.7,76,,3.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,35.72,72,,14.152,Percent of Total Billed Charges,72% of Total Billed Charges,37.21,75,,14.744,Percent of Total Billed charges,75% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.72,72,,14.152,Percent of Total Billed Charges,72% of Total Billed Charges,29.77,60,,11.792,Percent of Total Billed Charges,60% of Total Billed Charges,44.65,90,,8.432,Percent of Total Billed Charges,90% of Total Billed Charges,22.32,45,,0.536,Percent of Total Billed Charges,45% of Total Billed Charges,44.65,90,,4.696,Percent of Total Billed Charges,90% of Total billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.25,65,,1.552,Percent of total Billed Charges,65% of Total Billed Charges,21.88,44.1,,0.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,47.13,95,,4.952,Percent of Total Billed Charges,95% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,88,,4.592,Percent of Total Billed Charges,88% of Total Billed Charges,44.65,90,,4.696,Percent of Total Billed charges,90% of Total Billed Charges,21.88,49.61,
SUCTION CATH 18FR GF,2710000072,CDM,271,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,2.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,28.352,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,29.536,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,28.352,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,23.624,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,12.784,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,0.72,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,2.816,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,0.776,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,0.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,2.968,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,2.752,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,2.816,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
FLEETS ADULT ENEMA,2710000073,CDM,271,RC,,,Outpatient,,,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,1.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,75.544,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,78.688,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,75.544,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,62.952,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,4.464,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,2.144,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,1.04,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,4.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,2.264,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,2.096,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,2.144,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
ARM BOARD DISP 9,2710000074,CDM,271,RC,,,Outpatient,,,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,0.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,16.816,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,17.52,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,16.816,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,14.016,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,0.72,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,1.072,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,6.448,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,0.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,1.136,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,1.048,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,1.072,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
RECTAL TUBE 30FR,2710000075,CDM,271,RC,,,Outpatient,,,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,1.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.88,72,,28.8,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,75,,30,Percent of Total Billed charges,75% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.88,72,,28.8,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,90,,4.2,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,1.072,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,1.44,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,1.04,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,1.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,1.52,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,1.408,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,1.44,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.05,
ELASTIC 2 WRAP,2710000077,CDM,271,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,7.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,20.88,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,21.752,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,20.88,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,17.4,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,0.432,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,10.8,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,8.928,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,1.552,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,10.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,9.424,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,8.728,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,8.928,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
CAST SHOE SMALL,2710000078,CDM,271,RC,,,Outpatient,,,38.59,25.08,,38.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.33,76,,1.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.78,72,,79.352,Percent of Total Billed Charges,72% of Total Billed Charges,28.94,75,,82.664,Percent of Total Billed charges,75% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.78,72,,79.352,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,60,,66.128,Percent of Total Billed Charges,60% of Total Billed Charges,34.73,90,,3.512,Percent of Total Billed Charges,90% of Total Billed Charges,17.37,45,,4.216,Percent of Total Billed Charges,45% of Total Billed Charges,34.73,90,,1.44,Percent of Total Billed Charges,90% of Total billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.08,65,,15.6,Percent of total Billed Charges,65% of Total Billed Charges,17.02,44.1,,4.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.66,95,,1.52,Percent of Total Billed Charges,95% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.96,88,,1.408,Percent of Total Billed Charges,88% of Total Billed Charges,34.73,90,,1.44,Percent of Total Billed charges,90% of Total Billed Charges,17.02,38.59,
CAST SHOE MEDIUM,2710000079,CDM,271,RC,,,Outpatient,,,38.59,25.08,,38.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.33,76,,1.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.78,72,,18.824,Percent of Total Billed Charges,72% of Total Billed Charges,28.94,75,,19.608,Percent of Total Billed charges,75% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.78,72,,18.824,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,60,,15.688,Percent of Total Billed Charges,60% of Total Billed Charges,34.73,90,,27.072,Percent of Total Billed Charges,90% of Total Billed Charges,17.37,45,,6.392,Percent of Total Billed Charges,45% of Total Billed Charges,34.73,90,,2.144,Percent of Total Billed Charges,90% of Total billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.08,65,,6.088,Percent of total Billed Charges,65% of Total Billed Charges,17.02,44.1,,6.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.66,95,,2.264,Percent of Total Billed Charges,95% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.96,88,,2.096,Percent of Total Billed Charges,88% of Total Billed Charges,34.73,90,,2.144,Percent of Total Billed charges,90% of Total Billed Charges,17.02,38.59,
FOLEY CATH 22FR 5CC,2710000080,CDM,271,RC,,,Outpatient,,,71.66,46.58,,71.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.46,76,,18.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.6,72,,9.36,Percent of Total Billed Charges,72% of Total Billed Charges,53.75,75,,9.752,Percent of Total Billed charges,75% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,72,,9.36,Percent of Total Billed Charges,72% of Total Billed Charges,43,60,,7.8,Percent of Total Billed Charges,60% of Total Billed Charges,64.49,90,,18.92,Percent of Total Billed Charges,90% of Total Billed Charges,32.25,45,,12.6,Percent of Total Billed Charges,45% of Total Billed Charges,64.49,90,,21.6,Percent of Total Billed Charges,90% of Total billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.58,65,,9.232,Percent of total Billed Charges,65% of Total Billed Charges,31.6,44.1,,12.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.08,95,,22.8,Percent of Total Billed Charges,95% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,88,,21.12,Percent of Total Billed Charges,88% of Total Billed Charges,64.49,90,,21.6,Percent of Total Billed charges,90% of Total Billed Charges,31.6,71.66,
CAST PADDING SPEC 6,2710000081,CDM,271,RC,,,Outpatient,,,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,7.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,12.488,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,13.008,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,12.488,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,10.408,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,15.432,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,10.8,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,8.432,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,18.2,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,10.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,8.896,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,8.24,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,8.432,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
FOLEY CATH 26FR 30CC,2710000082,CDM,271,RC,,,Outpatient,,,68.36,44.43,,68.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.95,76,,10.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49.22,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,51.27,75,,36,Percent of Total Billed charges,75% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,41.02,60,,28.8,Percent of Total Billed Charges,60% of Total Billed Charges,61.52,90,,0.776,Percent of Total Billed Charges,90% of Total Billed Charges,30.76,45,,2.096,Percent of Total Billed Charges,45% of Total Billed Charges,61.52,90,,12.784,Percent of Total Billed Charges,90% of Total billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.43,65,,15.6,Percent of total Billed Charges,65% of Total Billed Charges,30.15,44.1,,2.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,64.94,95,,13.496,Percent of Total Billed Charges,95% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.16,88,,12.504,Percent of Total Billed Charges,88% of Total Billed Charges,61.52,90,,12.784,Percent of Total Billed charges,90% of Total Billed Charges,30.15,68.36,
ELASTOPLAST 2 BANDA,2710000083,CDM,271,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,4.896,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,5.104,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,4.896,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,4.08,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,19.136,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,0.216,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,25.2,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,3.032,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,0.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,26.6,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,24.64,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,25.2,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
DISPOSABLE LARGE OXY,2710000085,CDM,271,RC,,,Outpatient,,,68.36,44.43,,68.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.95,76,,18.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49.22,72,,5.456,Percent of Total Billed Charges,72% of Total Billed Charges,51.27,75,,5.68,Percent of Total Billed charges,75% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,72,,5.456,Percent of Total Billed Charges,72% of Total Billed Charges,41.02,60,,4.544,Percent of Total Billed Charges,60% of Total Billed Charges,61.52,90,,440.64,Percent of Total Billed Charges,90% of Total Billed Charges,30.76,45,,1.76,Percent of Total Billed Charges,45% of Total Billed Charges,61.52,90,,21.6,Percent of Total Billed Charges,90% of Total billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.43,65,,0.312,Percent of total Billed Charges,65% of Total Billed Charges,30.15,44.1,,1.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,64.94,95,,22.8,Percent of Total Billed Charges,95% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.16,88,,21.12,Percent of Total Billed Charges,88% of Total Billed Charges,61.52,90,,21.6,Percent of Total Billed charges,90% of Total Billed Charges,30.15,68.36,
VENA FLOW DISP CALF,2710000086,CDM,271,RC,,,Outpatient,,,26.46,17.20,,26.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.11,76,,3.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.05,72,,2.024,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,75,,2.112,Percent of Total Billed charges,75% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.05,72,,2.024,Percent of Total Billed Charges,72% of Total Billed Charges,15.88,60,,1.688,Percent of Total Billed Charges,60% of Total Billed Charges,23.81,90,,42.232,Percent of Total Billed Charges,90% of Total Billed Charges,11.91,45,,13.536,Percent of Total Billed Charges,45% of Total Billed Charges,23.81,90,,4.2,Percent of Total Billed Charges,90% of Total billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,65,,2.536,Percent of total Billed Charges,65% of Total Billed Charges,11.67,44.1,,13.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.14,95,,4.432,Percent of Total Billed Charges,95% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.28,88,,4.104,Percent of Total Billed Charges,88% of Total Billed Charges,23.81,90,,4.2,Percent of Total Billed charges,90% of Total Billed Charges,11.67,26.46,
SUCTION CATH 16FR GF,2710000087,CDM,271,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,0.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,2.024,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,2.112,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,2.024,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,1.688,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,40.416,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,9.464,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,0.432,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,19.552,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,9.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,0.456,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,0.424,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,0.432,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
VASELINE GAUZE 1X8,2710000088,CDM,271,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,2.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,2.16,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,2.248,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,2.16,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,1.8,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,48.008,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,7.712,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,3.512,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,13.664,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,7.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,3.712,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,3.432,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,3.512,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
KLING 6,2710000089,CDM,271,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,22.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,2.52,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,2.624,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,2.52,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,2.096,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,56,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.392,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,27.072,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,11.144,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,28.576,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,26.472,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,27.072,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
RECTAL TUBE 24FR,2710000090,CDM,271,RC,,,Outpatient,,,34.18,22.22,,34.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.98,76,,15.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.61,72,,3.976,Percent of Total Billed Charges,72% of Total Billed Charges,25.64,75,,4.144,Percent of Total Billed charges,75% of Total Billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.61,72,,3.976,Percent of Total Billed Charges,72% of Total Billed Charges,20.51,60,,3.312,Percent of Total Billed Charges,60% of Total Billed Charges,30.76,90,,67.488,Percent of Total Billed Charges,90% of Total Billed Charges,15.38,45,,9.568,Percent of Total Billed Charges,45% of Total Billed Charges,30.76,90,,18.92,Percent of Total Billed Charges,90% of Total billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.22,65,,0.56,Percent of total Billed Charges,65% of Total Billed Charges,15.07,44.1,,9.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.47,95,,19.976,Percent of Total Billed Charges,95% of Total Billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.08,88,,18.504,Percent of Total Billed Charges,88% of Total Billed Charges,30.76,90,,18.92,Percent of Total Billed charges,90% of Total Billed Charges,15.07,34.18,
CAST PADDING SPEC 2,2710000091,CDM,271,RC,,,Outpatient,,,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,13.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,95.224,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,99.192,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,95.224,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,79.352,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,23.384,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,220.32,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,15.432,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,13.824,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,215.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,16.288,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,15.088,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,15.432,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
PLASTER BANDAGE 3,2710000093,CDM,271,RC,,,Outpatient,,,94.82,61.63,,94.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.06,76,,16.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,68.27,72,,22.272,Percent of Total Billed Charges,72% of Total Billed Charges,71.12,75,,23.2,Percent of Total Billed charges,75% of Total Billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.27,72,,22.272,Percent of Total Billed Charges,72% of Total Billed Charges,56.89,60,,18.56,Percent of Total Billed Charges,60% of Total Billed Charges,85.34,90,,33.088,Percent of Total Billed Charges,90% of Total Billed Charges,42.67,45,,20.208,Percent of Total Billed Charges,45% of Total Billed Charges,85.34,90,,19.136,Percent of Total Billed Charges,90% of Total billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.63,65,,30.496,Percent of total Billed Charges,65% of Total Billed Charges,41.82,44.1,,19.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,90.08,95,,20.2,Percent of Total Billed Charges,95% of Total Billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.44,88,,18.712,Percent of Total Billed Charges,88% of Total Billed Charges,85.34,90,,19.136,Percent of Total Billed charges,90% of Total Billed Charges,41.82,94.82,
RECTAL TUBE 26FR,2710000094,CDM,271,RC,,,Outpatient,,,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,372.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,302.4,Percent of Total Billed Charges,72% of Total Billed Charges,22.33,75,,315,Percent of Total Billed charges,75% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,302.4,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,252,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,24.008,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,440.64,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,29.184,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,23.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,465.12,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,430.848,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,440.64,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
SUCTION CATH 12FR GF,2710000095,CDM,271,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,35.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,30.712,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,31.992,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,30.712,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,25.592,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,28,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,42.232,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,34.672,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,27.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,44.576,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,41.288,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,42.232,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
VASELINE GAUZE 3X18,2710000096,CDM,271,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,34.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,31.68,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,33,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,31.68,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,26.4,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,16.2,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,33.744,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,40.416,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,40.448,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,33.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,42.656,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,39.512,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,40.416,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
TRACHEOSTOMY TUBE 7.,2710000097,CDM,271,RC,,,Outpatient,,,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,40.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,2.016,Percent of Total Billed Charges,72% of Total Billed Charges,22.33,75,,2.104,Percent of Total Billed charges,75% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,2.016,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,1.68,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,39.6,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,11.696,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,48.008,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,48.736,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,11.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,50.68,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,46.944,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,48.008,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
CATH PLUG/DRAIN TUBE,2710000098,CDM,271,RC,,,Outpatient,,,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,47.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,83.504,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,86.984,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,83.504,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,69.584,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,450,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,14.944,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,56,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,16.888,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,14.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,59.112,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,54.76,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,56,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
CBI BURN PACK,2710000099,CDM,271,RC,,,Outpatient,,,110.25,71.66,,110.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,83.79,76,,56.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,79.38,72,,37.8,Percent of Total Billed Charges,72% of Total Billed Charges,82.69,75,,39.376,Percent of Total Billed charges,75% of Total Billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,72,,37.8,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,60,,31.496,Percent of Total Billed Charges,60% of Total Billed Charges,99.23,90,,189,Percent of Total Billed Charges,90% of Total Billed Charges,49.61,45,,16.544,Percent of Total Billed Charges,45% of Total Billed Charges,99.23,90,,67.488,Percent of Total Billed Charges,90% of Total billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,65,,21.584,Percent of total Billed Charges,65% of Total Billed Charges,48.62,44.1,,16.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,104.74,95,,71.232,Percent of Total Billed Charges,95% of Total Billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,88,,65.984,Percent of Total Billed Charges,88% of Total Billed Charges,99.23,90,,67.488,Percent of Total Billed charges,90% of Total Billed Charges,48.62,110.25,
CAST PADDING SPEC 3,2710000100,CDM,271,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,19.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,51.12,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,53.248,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,51.12,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,42.6,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,4.2,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,5.4,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,23.384,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,23.896,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,5.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,24.688,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,22.864,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,23.384,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
CORD CLAMP STERILE,2710000101,CDM,271,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,25.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,2.352,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,2.448,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,2.352,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,1.96,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,104.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,10.8,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,29.88,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,7.8,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,10.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,31.544,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,29.216,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,29.88,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
SEPTISOL,2710000102,CDM,271,RC,,,Outpatient,,,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,27.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,72,,197.28,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,75,,205.504,Percent of Total Billed charges,75% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,72,,197.28,Percent of Total Billed Charges,72% of Total Billed Charges,5.95,60,,164.4,Percent of Total Billed Charges,60% of Total Billed Charges,8.93,90,,3.856,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,8.104,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,33.088,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,15.6,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,7.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,34.92,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,32.352,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,33.088,Percent of Total Billed charges,90% of Total Billed Charges,4.37,9.92,
VASELINE GAUZE 3X9,2710000103,CDM,271,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,12.856,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,13.392,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,12.856,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,10.712,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,43.2,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,19.8,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,10.8,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,11.704,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,19.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,11.4,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,10.56,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,10.8,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
FOLEY CATHETER 14FR,2710000104,CDM,271,RC,,,Outpatient,,,35.28,22.93,,35.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.81,76,,18.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.4,72,,12.856,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,75,,13.392,Percent of Total Billed charges,75% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.4,72,,12.856,Percent of Total Billed Charges,72% of Total Billed Charges,21.17,60,,10.712,Percent of Total Billed Charges,60% of Total Billed Charges,31.75,90,,1.512,Percent of Total Billed Charges,90% of Total Billed Charges,15.88,45,,225,Percent of Total Billed Charges,45% of Total Billed Charges,31.75,90,,21.6,Percent of Total Billed Charges,90% of Total billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.93,65,,28.6,Percent of total Billed Charges,65% of Total Billed Charges,15.56,44.1,,220.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.52,95,,22.8,Percent of Total Billed Charges,95% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.05,88,,21.12,Percent of Total Billed Charges,88% of Total Billed Charges,31.75,90,,21.6,Percent of Total Billed charges,90% of Total Billed Charges,15.56,35.28,
RECTAL TUBE 28FR,2710000105,CDM,271,RC,,,Outpatient,,,146.63,95.31,,146.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,111.44,76,,13.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,105.57,72,,13.304,Percent of Total Billed Charges,72% of Total Billed Charges,109.97,75,,13.864,Percent of Total Billed charges,75% of Total Billed Charges,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.57,72,,13.304,Percent of Total Billed Charges,72% of Total Billed Charges,87.98,60,,11.088,Percent of Total Billed Charges,60% of Total Billed Charges,131.97,90,,12.424,Percent of Total Billed Charges,90% of Total Billed Charges,65.98,45,,94.504,Percent of Total Billed Charges,45% of Total Billed Charges,131.97,90,,16.2,Percent of Total Billed Charges,90% of Total billed Charges,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.31,65,,325,Percent of total Billed Charges,65% of Total Billed Charges,64.66,44.1,,92.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,139.3,95,,17.104,Percent of Total Billed Charges,95% of Total Billed Charges,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.03,88,,15.84,Percent of Total Billed Charges,88% of Total Billed Charges,131.97,90,,16.2,Percent of Total Billed charges,90% of Total Billed Charges,64.66,146.63,
TRACHEA TUBE 5.0,2710000106,CDM,271,RC,,,Outpatient,,,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,33.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,13.304,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,13.864,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,13.304,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,11.088,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,648,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,2.096,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,39.6,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,136.504,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,2.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,41.8,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,38.72,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,39.6,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
TRACHEA TUBE 5.5,2710000107,CDM,271,RC,,,Outpatient,,,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,380,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,13.304,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,13.864,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,13.304,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,11.088,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,10.296,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,52.2,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,450,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,3.032,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,51.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,475,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,440,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,450,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
FOLEY CATH 24FR 5CC,2710000108,CDM,271,RC,,,Outpatient,,,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,159.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,13.304,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,13.864,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,13.304,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,11.088,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,3.728,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,1.928,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,189,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,75.4,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,1.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,199.504,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,184.8,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,189,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
KIT CATH & GLOVE 8FR,2710000109,CDM,271,RC,,,Outpatient,,,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,3.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,13.304,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,13.864,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,13.304,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,11.088,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,35.928,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,21.6,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,4.2,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,2.784,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,21.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,4.432,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,4.104,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,4.2,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
CERVICAL COLLAR XLA,2710000110,CDM,271,RC,,,Outpatient,,,25.36,16.48,,25.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.27,76,,88.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.26,72,,13.304,Percent of Total Billed Charges,72% of Total Billed Charges,19.02,75,,13.864,Percent of Total Billed charges,75% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.26,72,,13.304,Percent of Total Billed Charges,72% of Total Billed Charges,15.22,60,,11.088,Percent of Total Billed Charges,60% of Total Billed Charges,22.82,90,,34.96,Percent of Total Billed Charges,90% of Total Billed Charges,11.41,45,,0.76,Percent of Total Billed Charges,45% of Total Billed Charges,22.82,90,,104.4,Percent of Total Billed Charges,90% of Total billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,65,,31.2,Percent of total Billed Charges,65% of Total Billed Charges,11.18,44.1,,0.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.09,95,,110.2,Percent of Total Billed Charges,95% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,88,,102.08,Percent of Total Billed Charges,88% of Total Billed Charges,22.82,90,,104.4,Percent of Total Billed charges,90% of Total Billed Charges,11.18,25.36,
HIP ABDUCTION PILLOW,2710000111,CDM,271,RC,,,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,3.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,13.304,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,13.864,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,13.304,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,11.088,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,34.384,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,6.208,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,3.856,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,1.096,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,6.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,4.064,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,3.768,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,3.856,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
COLLES SPLINT SMALL,2710000112,CDM,271,RC,,,Outpatient,,,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,36.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,13.304,Percent of Total Billed Charges,72% of Total Billed Charges,15.71,75,,13.864,Percent of Total Billed charges,75% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,13.304,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,11.088,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,35.48,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,324,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,43.2,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,8.968,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,317.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,45.6,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,42.24,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,43.2,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
FIBERGLASS TAPE 2X4 DELTA LITE,2710000113,CDM,271,RC,,,Outpatient,,,188.53,122.54,,188.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,143.28,76,,1.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,135.74,72,,2.336,Percent of Total Billed Charges,72% of Total Billed Charges,141.4,75,,2.432,Percent of Total Billed charges,75% of Total Billed Charges,188.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.74,72,,2.336,Percent of Total Billed Charges,72% of Total Billed Charges,113.12,60,,1.944,Percent of Total Billed Charges,60% of Total Billed Charges,169.68,90,,37.08,Percent of Total Billed Charges,90% of Total Billed Charges,84.84,45,,5.152,Percent of Total Billed Charges,45% of Total Billed Charges,169.68,90,,1.512,Percent of Total Billed Charges,90% of Total billed Charges,188.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.54,65,,468,Percent of total Billed Charges,65% of Total Billed Charges,83.14,44.1,,5.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,179.1,95,,1.6,Percent of Total Billed Charges,95% of Total Billed Charges,188.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.91,88,,1.48,Percent of Total Billed Charges,88% of Total Billed Charges,169.68,90,,1.512,Percent of Total Billed charges,90% of Total Billed Charges,83.14,188.53,
ADULT AEROSOL MASK,2710000114,CDM,271,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,10.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,7.312,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,7.624,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,7.312,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,6.096,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,34.704,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,1.864,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,12.424,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,7.44,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,1.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,13.112,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,12.144,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,12.424,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
1000ML FEED FLUSH PUMP SET LF,2710000115,CDM,271,RC,,,Outpatient,,,26.68,17.34,,26.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.28,76,,547.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.21,72,,251.04,Percent of Total Billed Charges,72% of Total Billed Charges,20.01,75,,261.496,Percent of Total Billed charges,75% of Total Billed Charges,26.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.21,72,,251.04,Percent of Total Billed Charges,72% of Total Billed Charges,16.01,60,,209.2,Percent of Total Billed Charges,60% of Total Billed Charges,24.01,90,,36.144,Percent of Total Billed Charges,90% of Total Billed Charges,12.01,45,,17.968,Percent of Total Billed Charges,45% of Total Billed Charges,24.01,90,,648,Percent of Total Billed Charges,90% of Total billed Charges,26.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.34,65,,2.696,Percent of total Billed Charges,65% of Total Billed Charges,11.77,44.1,,17.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.35,95,,684,Percent of Total Billed Charges,95% of Total Billed Charges,26.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.48,88,,633.6,Percent of Total Billed Charges,88% of Total Billed Charges,24.01,90,,648,Percent of Total Billed charges,90% of Total Billed Charges,11.77,26.68,
760ML PREFILLED NEBUL LF 10/CS,2710000116,CDM,271,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,8.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,183.744,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,191.4,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,183.744,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,153.12,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,34.616,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,17.48,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,10.296,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,25.952,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,17.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,10.872,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,10.064,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,10.296,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
CUFF BP DISP INFANT,2710000117,CDM,271,RC,,,Outpatient,,,19.95,12.97,,19.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.16,76,,3.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.36,72,,2.504,Percent of Total Billed Charges,72% of Total Billed Charges,14.96,75,,2.608,Percent of Total Billed charges,75% of Total Billed Charges,19.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.36,72,,2.504,Percent of Total Billed Charges,72% of Total Billed Charges,11.97,60,,2.088,Percent of Total Billed Charges,60% of Total Billed Charges,17.96,90,,502.2,Percent of Total Billed Charges,90% of Total Billed Charges,8.98,45,,17.192,Percent of Total Billed Charges,45% of Total Billed Charges,17.96,90,,3.728,Percent of Total Billed Charges,90% of Total billed Charges,19.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.97,65,,25.248,Percent of total Billed Charges,65% of Total Billed Charges,8.8,44.1,,16.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.95,95,,3.936,Percent of Total Billed Charges,95% of Total Billed Charges,19.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.56,88,,3.648,Percent of Total Billed Charges,88% of Total Billed Charges,17.96,90,,3.728,Percent of Total Billed charges,90% of Total Billed Charges,8.8,19.95,
CUFF BP DISP ADLT SM,2710000118,CDM,271,RC,,,Outpatient,,,21.00,13.65,,21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.96,76,,30.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.12,72,,3.328,Percent of Total Billed Charges,72% of Total Billed Charges,15.75,75,,3.472,Percent of Total Billed charges,75% of Total Billed Charges,21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.12,72,,3.328,Percent of Total Billed Charges,72% of Total Billed Charges,12.6,60,,2.776,Percent of Total Billed Charges,60% of Total Billed Charges,18.9,90,,759.6,Percent of Total Billed Charges,90% of Total Billed Charges,9.45,45,,17.744,Percent of Total Billed Charges,45% of Total Billed Charges,18.9,90,,35.928,Percent of Total Billed Charges,90% of Total billed Charges,21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.65,65,,24.832,Percent of total Billed Charges,65% of Total Billed Charges,9.26,44.1,,17.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.95,95,,37.928,Percent of Total Billed Charges,95% of Total Billed Charges,21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.48,88,,35.128,Percent of Total Billed Charges,88% of Total Billed Charges,18.9,90,,35.928,Percent of Total Billed charges,90% of Total Billed Charges,9.26,21,
CUFF BP DISP ADLT LG,2710000119,CDM,271,RC,,,Outpatient,,,39.90,25.94,,39.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,30.32,76,,29.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.73,72,,6.104,Percent of Total Billed Charges,72% of Total Billed Charges,29.93,75,,6.36,Percent of Total Billed charges,75% of Total Billed Charges,39.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.73,72,,6.104,Percent of Total Billed Charges,72% of Total Billed Charges,23.94,60,,5.088,Percent of Total Billed Charges,60% of Total Billed Charges,35.91,90,,19.248,Percent of Total Billed Charges,90% of Total Billed Charges,17.96,45,,18.544,Percent of Total Billed Charges,45% of Total Billed Charges,35.91,90,,34.96,Percent of Total Billed Charges,90% of Total billed Charges,39.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.94,65,,25.624,Percent of total Billed Charges,65% of Total Billed Charges,17.6,44.1,,18.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.91,95,,36.896,Percent of Total Billed Charges,95% of Total Billed Charges,39.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.11,88,,34.176,Percent of Total Billed Charges,88% of Total Billed Charges,35.91,90,,34.96,Percent of Total Billed charges,90% of Total Billed Charges,17.6,39.9,
CUFF BP DISP THIGH,2710000120,CDM,271,RC,,,Outpatient,,,39.90,25.94,,39.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,30.32,76,,29.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.73,72,,6.104,Percent of Total Billed Charges,72% of Total Billed Charges,29.93,75,,6.36,Percent of Total Billed charges,75% of Total Billed Charges,39.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.73,72,,6.104,Percent of Total Billed Charges,72% of Total Billed Charges,23.94,60,,5.088,Percent of Total Billed Charges,60% of Total Billed Charges,35.91,90,,1.296,Percent of Total Billed Charges,90% of Total Billed Charges,17.96,45,,17.352,Percent of Total Billed Charges,45% of Total Billed Charges,35.91,90,,34.384,Percent of Total Billed Charges,90% of Total billed Charges,39.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.94,65,,26.784,Percent of total Billed Charges,65% of Total Billed Charges,17.6,44.1,,17.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.91,95,,36.288,Percent of Total Billed Charges,95% of Total Billed Charges,39.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.11,88,,33.616,Percent of Total Billed Charges,88% of Total Billed Charges,35.91,90,,34.384,Percent of Total Billed charges,90% of Total Billed Charges,17.6,39.9,
UMBILICAL CATH. TRAYS  5-CS,2710000121,CDM,271,RC,,,Outpatient,,,195.14,126.84,,195.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,148.31,76,,29.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,140.5,72,,6.104,Percent of Total Billed Charges,72% of Total Billed Charges,146.36,75,,6.36,Percent of Total Billed charges,75% of Total Billed Charges,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.5,72,,6.104,Percent of Total Billed Charges,72% of Total Billed Charges,117.08,60,,5.088,Percent of Total Billed Charges,60% of Total Billed Charges,175.63,90,,3.784,Percent of Total Billed Charges,90% of Total Billed Charges,87.81,45,,18.072,Percent of Total Billed Charges,45% of Total Billed Charges,175.63,90,,35.48,Percent of Total Billed Charges,90% of Total billed Charges,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.84,65,,25.064,Percent of total Billed Charges,65% of Total Billed Charges,86.06,44.1,,17.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,185.38,95,,37.456,Percent of Total Billed Charges,95% of Total Billed Charges,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.72,88,,34.696,Percent of Total Billed Charges,88% of Total Billed Charges,175.63,90,,35.48,Percent of Total Billed charges,90% of Total Billed Charges,86.06,195.14,
SPLINT PLASTER 4,2710000123,CDM,271,RC,,,Outpatient,,,126.79,82.41,,126.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,96.36,76,,29.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.29,72,,6.104,Percent of Total Billed Charges,72% of Total Billed Charges,95.09,75,,6.36,Percent of Total Billed charges,75% of Total Billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.29,72,,6.104,Percent of Total Billed Charges,72% of Total Billed Charges,76.07,60,,5.088,Percent of Total Billed Charges,60% of Total Billed Charges,114.11,90,,59.384,Percent of Total Billed Charges,90% of Total Billed Charges,57.06,45,,251.104,Percent of Total Billed Charges,45% of Total Billed Charges,114.11,90,,34.704,Percent of Total Billed Charges,90% of Total billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.41,65,,25,Percent of total Billed Charges,65% of Total Billed Charges,55.91,44.1,,246.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,120.45,95,,36.632,Percent of Total Billed Charges,95% of Total Billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.58,88,,33.936,Percent of Total Billed Charges,88% of Total Billed Charges,114.11,90,,34.704,Percent of Total Billed charges,90% of Total Billed Charges,55.91,126.79,
SPLINT PLASTER 5,2710000124,CDM,271,RC,,,Outpatient,,,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,30.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,6.104,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,6.36,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,6.104,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,5.088,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,4.776,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,379.8,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,36.144,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,362.704,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,372.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,38.152,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,35.344,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,36.144,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
SPLINT PLASTER 4X15,2710000125,CDM,271,RC,,,Outpatient,,,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,29.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,72,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,75,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,72,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,60,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,3.296,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,9.624,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,34.616,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,548.6,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,9.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,36.544,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,33.848,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,34.616,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
SPLINTING 3,2710000126,CDM,271,RC,,,Outpatient,,,56.23,36.55,,56.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.73,76,,424.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.49,72,,46.296,Percent of Total Billed Charges,72% of Total Billed Charges,42.17,75,,48.232,Percent of Total Billed charges,75% of Total Billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.49,72,,46.296,Percent of Total Billed Charges,72% of Total Billed Charges,33.74,60,,38.584,Percent of Total Billed Charges,60% of Total Billed Charges,50.61,90,,3.712,Percent of Total Billed Charges,90% of Total Billed Charges,25.3,45,,0.648,Percent of Total Billed Charges,45% of Total Billed Charges,50.61,90,,502.2,Percent of Total Billed Charges,90% of Total billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.55,65,,13.896,Percent of total Billed Charges,65% of Total Billed Charges,24.8,44.1,,0.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.42,95,,530.104,Percent of Total Billed Charges,95% of Total Billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.48,88,,491.04,Percent of Total Billed Charges,88% of Total Billed Charges,50.61,90,,502.2,Percent of Total Billed charges,90% of Total Billed Charges,24.8,56.23,
SPLINTING LAYER 4,2710000127,CDM,271,RC,,,Outpatient,,,165.38,107.50,,165.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,125.69,76,,641.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,119.07,72,,21.272,Percent of Total Billed Charges,72% of Total Billed Charges,124.04,75,,22.16,Percent of Total Billed charges,75% of Total Billed Charges,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.07,72,,21.272,Percent of Total Billed Charges,72% of Total Billed Charges,99.23,60,,17.728,Percent of Total Billed Charges,60% of Total Billed Charges,148.84,90,,0.544,Percent of Total Billed Charges,90% of Total Billed Charges,74.42,45,,1.896,Percent of Total Billed Charges,45% of Total Billed Charges,148.84,90,,759.6,Percent of Total Billed Charges,90% of Total billed Charges,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,65,,0.936,Percent of total Billed Charges,65% of Total Billed Charges,72.93,44.1,,1.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,157.11,95,,801.8,Percent of Total Billed Charges,95% of Total Billed Charges,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,88,,742.72,Percent of Total Billed Charges,88% of Total Billed Charges,148.84,90,,759.6,Percent of Total Billed charges,90% of Total Billed Charges,72.93,165.38,
SEXUAL ASSAULT COLLECT KIT,2710000128,CDM,271,RC,,,Outpatient,,,18.74,12.18,,18.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.24,76,,16.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.49,72,,15.336,Percent of Total Billed Charges,72% of Total Billed Charges,14.06,75,,15.976,Percent of Total Billed charges,75% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.49,72,,15.336,Percent of Total Billed Charges,72% of Total Billed Charges,11.24,60,,12.784,Percent of Total Billed Charges,60% of Total Billed Charges,16.87,90,,267.48,Percent of Total Billed Charges,90% of Total Billed Charges,8.43,45,,1.44,Percent of Total Billed Charges,45% of Total Billed Charges,16.87,90,,19.248,Percent of Total Billed Charges,90% of Total billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.18,65,,2.736,Percent of total Billed Charges,65% of Total Billed Charges,8.26,44.1,,1.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.8,95,,20.312,Percent of Total Billed Charges,95% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,88,,18.816,Percent of Total Billed Charges,88% of Total Billed Charges,16.87,90,,19.248,Percent of Total Billed charges,90% of Total Billed Charges,8.26,18.74,
SUCTION CATH 6FR KIT,2710000129,CDM,271,RC,,,Outpatient,,,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,1.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,5.952,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,6.2,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,5.952,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,4.96,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,10.336,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,29.696,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,1.296,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,2.08,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,29.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,1.368,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,1.264,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,1.296,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
CLOSED TRAE SUCTION 14 FR,2710000130,CDM,271,RC,,,Outpatient,,,51.82,33.68,,51.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,39.38,76,,3.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,37.31,72,,10.36,Percent of Total Billed Charges,72% of Total Billed Charges,38.87,75,,10.792,Percent of Total Billed charges,75% of Total Billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.31,72,,10.36,Percent of Total Billed Charges,72% of Total Billed Charges,31.09,60,,8.632,Percent of Total Billed Charges,60% of Total Billed Charges,46.64,90,,3034.8,Percent of Total Billed Charges,90% of Total Billed Charges,23.32,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,46.64,90,,3.784,Percent of Total Billed Charges,90% of Total billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.68,65,,42.888,Percent of total Billed Charges,65% of Total Billed Charges,22.85,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,49.23,95,,4,Percent of Total Billed Charges,95% of Total Billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.6,88,,3.704,Percent of Total Billed Charges,88% of Total Billed Charges,46.64,90,,3.784,Percent of Total Billed charges,90% of Total Billed Charges,22.85,51.82,
APPLICATOR 6 STERILE LF,2710000131,CDM,271,RC,,,Outpatient,,,27.56,17.91,,27.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.95,76,,2.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.84,72,,19.696,Percent of Total Billed Charges,72% of Total Billed Charges,20.67,75,,20.52,Percent of Total Billed charges,75% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.84,72,,19.696,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,60,,16.416,Percent of Total Billed Charges,60% of Total Billed Charges,24.8,90,,3441.6,Percent of Total Billed Charges,90% of Total Billed Charges,12.4,45,,1.648,Percent of Total Billed Charges,45% of Total Billed Charges,24.8,90,,2.88,Percent of Total Billed Charges,90% of Total billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.91,65,,3.448,Percent of total Billed Charges,65% of Total Billed Charges,12.15,44.1,,1.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.18,95,,3.04,Percent of Total Billed Charges,95% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,88,,2.816,Percent of Total Billed Charges,88% of Total Billed Charges,24.8,90,,2.88,Percent of Total Billed charges,90% of Total Billed Charges,12.15,27.56,
TUBE GAUZE 5/8,2710000132,CDM,271,RC,,,Outpatient,,,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,50.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,1.92,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,2,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,1.92,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,1.6,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,3848.4,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,1.856,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,59.384,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,2.384,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,1.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,62.688,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,58.064,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,59.384,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
NEBULIZER W/ADAPTER (50/CS),2710000133,CDM,271,RC,,,Outpatient,,,370.44,240.79,,370.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,281.53,76,,4.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,266.72,72,,2.272,Percent of Total Billed Charges,72% of Total Billed Charges,277.83,75,,2.368,Percent of Total Billed charges,75% of Total Billed Charges,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.72,72,,2.272,Percent of Total Billed Charges,72% of Total Billed Charges,222.26,60,,1.896,Percent of Total Billed Charges,60% of Total Billed Charges,333.4,90,,43.2,Percent of Total Billed Charges,90% of Total Billed Charges,166.7,45,,0.272,Percent of Total Billed Charges,45% of Total Billed Charges,333.4,90,,4.776,Percent of Total Billed Charges,90% of Total billed Charges,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.79,65,,2.68,Percent of total Billed Charges,65% of Total Billed Charges,163.36,44.1,,0.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,351.92,95,,5.04,Percent of Total Billed Charges,95% of Total Billed Charges,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.99,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,333.4,90,,4.776,Percent of Total Billed charges,90% of Total Billed Charges,163.36,370.44,
HUMIDIFIERS 340ML PREFILLED,2710000134,CDM,271,RC,,,Outpatient,,,122.38,79.55,,122.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.01,76,,2.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.11,72,,10.384,Percent of Total Billed Charges,72% of Total Billed Charges,91.79,75,,10.816,Percent of Total Billed charges,75% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.11,72,,10.384,Percent of Total Billed Charges,72% of Total Billed Charges,73.43,60,,8.656,Percent of Total Billed Charges,60% of Total Billed Charges,110.14,90,,170.784,Percent of Total Billed Charges,90% of Total Billed Charges,55.07,45,,133.744,Percent of Total Billed Charges,45% of Total Billed Charges,110.14,90,,3.296,Percent of Total Billed Charges,90% of Total billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.55,65,,0.392,Percent of total Billed Charges,65% of Total Billed Charges,53.97,44.1,,131.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.26,95,,3.48,Percent of Total Billed Charges,95% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.69,88,,3.224,Percent of Total Billed Charges,88% of Total Billed Charges,110.14,90,,3.296,Percent of Total Billed charges,90% of Total Billed Charges,53.97,122.38,
FACE TENT,2710000135,CDM,271,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,3.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,2.768,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,2.88,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,2.768,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,2.304,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,72.432,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,5.168,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,3.712,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,193.184,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,5.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,3.912,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,3.624,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,3.712,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
AMBU BAG PEDIATRIC W/MASK,2710000136,CDM,271,RC,,,Outpatient,,,114.66,74.53,,114.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.14,76,,0.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.56,72,,5.872,Percent of Total Billed Charges,72% of Total Billed Charges,86,75,,6.12,Percent of Total Billed charges,75% of Total Billed Charges,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.56,72,,5.872,Percent of Total Billed Charges,72% of Total Billed Charges,68.8,60,,4.896,Percent of Total Billed Charges,60% of Total Billed Charges,103.19,90,,64.128,Percent of Total Billed Charges,90% of Total Billed Charges,51.6,45,,1517.4,Percent of Total Billed Charges,45% of Total Billed Charges,103.19,90,,0.544,Percent of Total Billed Charges,90% of Total billed Charges,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.53,65,,7.464,Percent of total Billed Charges,65% of Total Billed Charges,50.57,44.1,,1487.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,108.93,95,,0.568,Percent of Total Billed Charges,95% of Total Billed Charges,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.9,88,,0.528,Percent of Total Billed Charges,88% of Total Billed Charges,103.19,90,,0.544,Percent of Total Billed charges,90% of Total Billed Charges,50.57,114.66,
AMBU BAG NEO-NAT W/MASK,2710000137,CDM,271,RC,,,Outpatient,,,61.74,40.13,,61.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.92,76,,225.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,44.45,72,,8.408,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,75,,8.76,Percent of Total Billed charges,75% of Total Billed Charges,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.45,72,,8.408,Percent of Total Billed Charges,72% of Total Billed Charges,37.04,60,,7.008,Percent of Total Billed Charges,60% of Total Billed Charges,55.57,90,,322.2,Percent of Total Billed Charges,90% of Total Billed Charges,27.78,45,,1720.8,Percent of Total Billed Charges,45% of Total Billed Charges,55.57,90,,267.48,Percent of Total Billed Charges,90% of Total billed Charges,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.13,65,,2191.8,Percent of total Billed Charges,65% of Total Billed Charges,27.23,44.1,,1686.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,58.65,95,,282.344,Percent of Total Billed Charges,95% of Total Billed Charges,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.33,88,,261.536,Percent of Total Billed Charges,88% of Total Billed Charges,55.57,90,,267.48,Percent of Total Billed charges,90% of Total Billed Charges,27.23,61.74,
ABG KITS LF,2710000138,CDM,271,RC,,,Outpatient,,,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,8.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,4.696,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,4.888,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,4.696,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,3.912,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,147.6,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,1924.2,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,10.336,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,2485.6,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,1885.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,10.904,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,10.104,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,10.336,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
VOLDYNE INCENTIVE SPIROMETER,2710000139,CDM,271,RC,,,Outpatient,,,23.15,15.05,,23.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.59,76,,2562.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.67,72,,0.576,Percent of Total Billed Charges,72% of Total Billed Charges,17.36,75,,0.6,Percent of Total Billed charges,75% of Total Billed Charges,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.67,72,,0.576,Percent of Total Billed Charges,72% of Total Billed Charges,13.89,60,,0.48,Percent of Total Billed Charges,60% of Total Billed Charges,20.84,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,10.42,45,,21.6,Percent of Total Billed Charges,45% of Total Billed Charges,20.84,90,,3034.8,Percent of Total Billed Charges,90% of Total billed Charges,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.05,65,,2779.4,Percent of total Billed Charges,65% of Total Billed Charges,10.21,44.1,,21.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.99,95,,3203.4,Percent of Total Billed Charges,95% of Total Billed Charges,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.37,88,,2967.36,Percent of Total Billed Charges,88% of Total Billed Charges,20.84,90,,3034.8,Percent of Total Billed charges,90% of Total Billed Charges,10.21,23.15,
ALUMINUM FINGER SPLINT SET LF,2710000140,CDM,271,RC,,,Outpatient,,,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,2906.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,56.272,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,58.624,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,56.272,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,46.896,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,85.392,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,3441.6,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,31.2,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,83.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,3632.8,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,3365.12,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,3441.6,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
CUFF BP DISP ADLT LG LONG,2710000141,CDM,271,RC,,,Outpatient,,,25.20,16.38,,25.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.15,76,,3249.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.14,72,,56.272,Percent of Total Billed Charges,72% of Total Billed Charges,18.9,75,,58.624,Percent of Total Billed charges,75% of Total Billed Charges,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.14,72,,56.272,Percent of Total Billed Charges,72% of Total Billed Charges,15.12,60,,46.896,Percent of Total Billed Charges,60% of Total Billed Charges,22.68,90,,310.504,Percent of Total Billed Charges,90% of Total Billed Charges,11.34,45,,36.216,Percent of Total Billed Charges,45% of Total Billed Charges,22.68,90,,3848.4,Percent of Total Billed Charges,90% of Total billed Charges,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.38,65,,123.344,Percent of total Billed Charges,65% of Total Billed Charges,11.11,44.1,,35.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.94,95,,4062.2,Percent of Total Billed Charges,95% of Total Billed Charges,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.18,88,,3762.88,Percent of Total Billed Charges,88% of Total Billed Charges,22.68,90,,3848.4,Percent of Total Billed charges,90% of Total Billed Charges,11.11,25.2,
STOCK ANTIEMB,2710000142,CDM,271,RC,,,Outpatient,,,18.00,11.70,,18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.68,76,,36.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.96,72,,98.432,Percent of Total Billed Charges,72% of Total Billed Charges,13.5,75,,102.536,Percent of Total Billed charges,75% of Total Billed Charges,18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.96,72,,98.432,Percent of Total Billed Charges,72% of Total Billed Charges,10.8,60,,82.024,Percent of Total Billed Charges,60% of Total Billed Charges,16.2,90,,364.12,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,45,,32.064,Percent of Total Billed Charges,45% of Total Billed Charges,16.2,90,,43.2,Percent of Total Billed Charges,90% of Total billed Charges,18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.7,65,,52.312,Percent of total Billed Charges,65% of Total Billed Charges,7.94,44.1,,31.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.1,95,,45.6,Percent of Total Billed Charges,95% of Total Billed Charges,18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.84,88,,42.24,Percent of Total Billed Charges,88% of Total Billed Charges,16.2,90,,43.2,Percent of Total Billed charges,90% of Total Billed Charges,7.94,18,
GLUCERNA 1.5,2710000143,CDM,271,RC,,,Outpatient,,,3.60,2.34,,3.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.74,76,,144.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.59,72,,29.128,Percent of Total Billed Charges,72% of Total Billed Charges,2.7,75,,30.344,Percent of Total Billed charges,75% of Total Billed Charges,3.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.59,72,,29.128,Percent of Total Billed Charges,72% of Total Billed Charges,2.16,60,,24.272,Percent of Total Billed Charges,60% of Total Billed Charges,3.24,90,,124.416,Percent of Total Billed Charges,90% of Total Billed Charges,1.62,45,,161.104,Percent of Total Billed Charges,45% of Total Billed Charges,3.24,90,,170.784,Percent of Total Billed Charges,90% of Total billed Charges,3.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.34,65,,46.32,Percent of total Billed Charges,65% of Total Billed Charges,1.59,44.1,,157.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.42,95,,180.272,Percent of Total Billed Charges,95% of Total Billed Charges,3.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.17,88,,166.992,Percent of Total Billed Charges,88% of Total Billed Charges,3.24,90,,170.784,Percent of Total Billed charges,90% of Total Billed Charges,1.59,3.6,
PREP BETADINE,2710000144,CDM,271,RC,,,Outpatient,,,3.84,2.50,,3.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.92,76,,61.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.76,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,2.88,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,3.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.76,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,2.3,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,3.46,90,,80.224,Percent of Total Billed Charges,90% of Total Billed Charges,1.73,45,,73.8,Percent of Total Billed Charges,45% of Total Billed Charges,3.46,90,,72.432,Percent of Total Billed Charges,90% of Total billed Charges,3.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.5,65,,232.704,Percent of total Billed Charges,65% of Total Billed Charges,1.69,44.1,,72.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.65,95,,76.456,Percent of Total Billed Charges,95% of Total Billed Charges,3.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.38,88,,70.824,Percent of Total Billed Charges,88% of Total Billed Charges,3.46,90,,72.432,Percent of Total Billed charges,90% of Total Billed Charges,1.69,3.84,
SET MICROBORE ETMICROBEORE,2710000145,CDM,271,RC,,,Outpatient,,,24.00,15.60,,24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.24,76,,54.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.28,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,18,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.28,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,14.4,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,21.6,90,,515.16,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,45,,12.6,Percent of Total Billed Charges,45% of Total Billed Charges,21.6,90,,64.128,Percent of Total Billed Charges,90% of Total billed Charges,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.6,65,,106.6,Percent of total Billed Charges,65% of Total Billed Charges,10.58,44.1,,12.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.8,95,,67.696,Percent of Total Billed Charges,95% of Total Billed Charges,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.12,88,,62.704,Percent of Total Billed Charges,88% of Total Billed Charges,21.6,90,,64.128,Percent of Total Billed charges,90% of Total Billed Charges,10.58,24,
JEVITY 1.5,2710000146,CDM,271,RC,,,Outpatient,,,3.54,2.30,,3.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.69,76,,272.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.55,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,2.66,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,3.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.55,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,2.12,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,3.19,90,,278.392,Percent of Total Billed Charges,90% of Total Billed Charges,1.59,45,,12.6,Percent of Total Billed Charges,45% of Total Billed Charges,3.19,90,,322.2,Percent of Total Billed Charges,90% of Total billed Charges,3.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.3,65,,18.2,Percent of total Billed Charges,65% of Total Billed Charges,1.56,44.1,,12.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.36,95,,340.104,Percent of Total Billed Charges,95% of Total Billed Charges,3.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.12,88,,315.04,Percent of Total Billed Charges,88% of Total Billed Charges,3.19,90,,322.2,Percent of Total Billed charges,90% of Total Billed Charges,1.56,3.54,
VELCR 4 BANDAGE,2710000147,CDM,271,RC,,,Outpatient,,,3.47,2.26,,3.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.64,76,,124.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.5,72,,98.432,Percent of Total Billed Charges,72% of Total Billed Charges,2.6,75,,102.536,Percent of Total Billed charges,75% of Total Billed Charges,3.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.5,72,,98.432,Percent of Total Billed Charges,72% of Total Billed Charges,2.08,60,,82.024,Percent of Total Billed Charges,60% of Total Billed Charges,3.12,90,,278.392,Percent of Total Billed Charges,90% of Total Billed Charges,1.56,45,,155.248,Percent of Total Billed Charges,45% of Total Billed Charges,3.12,90,,147.6,Percent of Total Billed Charges,90% of Total billed Charges,3.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.26,65,,18.2,Percent of total Billed Charges,65% of Total Billed Charges,1.53,44.1,,152.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.3,95,,155.8,Percent of Total Billed Charges,95% of Total Billed Charges,3.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.05,88,,144.32,Percent of Total Billed Charges,88% of Total Billed Charges,3.12,90,,147.6,Percent of Total Billed charges,90% of Total Billed Charges,1.53,3.47,
VELCR 3 BANDAGE,2710000148,CDM,271,RC,,,Outpatient,,,3.36,2.18,,3.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.55,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.42,72,,73.016,Percent of Total Billed Charges,72% of Total Billed Charges,2.52,75,,76.064,Percent of Total Billed charges,75% of Total Billed Charges,3.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.42,72,,73.016,Percent of Total Billed Charges,72% of Total Billed Charges,2.02,60,,60.848,Percent of Total Billed Charges,60% of Total Billed Charges,3.02,90,,278.392,Percent of Total Billed Charges,90% of Total Billed Charges,1.51,45,,182.056,Percent of Total Billed Charges,45% of Total Billed Charges,3.02,90,,25.2,Percent of Total Billed Charges,90% of Total billed Charges,3.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.18,65,,224.248,Percent of total Billed Charges,65% of Total Billed Charges,1.48,44.1,,178.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.19,95,,26.6,Percent of Total Billed Charges,95% of Total Billed Charges,3.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.96,88,,24.64,Percent of Total Billed Charges,88% of Total Billed Charges,3.02,90,,25.2,Percent of Total Billed charges,90% of Total Billed Charges,1.48,3.36,
VELCR 2 BANDAGE,2710000149,CDM,271,RC,,,Outpatient,,,3.38,2.20,,3.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.57,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.43,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,2.54,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,3.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.43,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,2.03,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,3.04,90,,278.392,Percent of Total Billed Charges,90% of Total Billed Charges,1.52,45,,62.208,Percent of Total Billed Charges,45% of Total Billed Charges,3.04,90,,25.2,Percent of Total Billed Charges,90% of Total billed Charges,3.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.2,65,,262.976,Percent of total Billed Charges,65% of Total Billed Charges,1.49,44.1,,60.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.21,95,,26.6,Percent of Total Billed Charges,95% of Total Billed Charges,3.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.97,88,,24.64,Percent of Total Billed Charges,88% of Total Billed Charges,3.04,90,,25.2,Percent of Total Billed charges,90% of Total Billed Charges,1.49,3.38,
STETH DISP,2710000150,CDM,271,RC,,,Outpatient,,,18.15,11.80,,18.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.79,76,,262.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.07,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,13.61,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,18.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.07,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,10.89,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,16.34,90,,278.392,Percent of Total Billed Charges,90% of Total Billed Charges,8.17,45,,40.112,Percent of Total Billed Charges,45% of Total Billed Charges,16.34,90,,310.504,Percent of Total Billed Charges,90% of Total billed Charges,18.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.8,65,,89.856,Percent of total Billed Charges,65% of Total Billed Charges,8,44.1,,39.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.24,95,,327.752,Percent of Total Billed Charges,95% of Total Billed Charges,18.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.97,88,,303.6,Percent of Total Billed Charges,88% of Total Billed Charges,16.34,90,,310.504,Percent of Total Billed charges,90% of Total Billed Charges,8,18.15,
NG SECURE DEVICE,2710000151,CDM,271,RC,,,Outpatient,,,24.30,15.80,,24.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.47,76,,307.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.5,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,18.23,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,24.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.5,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,14.58,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,21.87,90,,364.144,Percent of Total Billed Charges,90% of Total Billed Charges,10.94,45,,257.584,Percent of Total Billed Charges,45% of Total Billed Charges,21.87,90,,364.12,Percent of Total Billed Charges,90% of Total billed Charges,24.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.8,65,,57.936,Percent of total Billed Charges,65% of Total Billed Charges,10.72,44.1,,252.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.09,95,,384.344,Percent of Total Billed Charges,95% of Total Billed Charges,24.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.38,88,,356.024,Percent of Total Billed Charges,88% of Total Billed Charges,21.87,90,,364.12,Percent of Total Billed charges,90% of Total Billed Charges,10.72,24.3,
NASOPH 28FR,2710000152,CDM,271,RC,,,Outpatient,,,20.69,13.45,,20.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.72,76,,105.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.9,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,15.52,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,20.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.9,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,18.62,90,,63,Percent of Total Billed Charges,90% of Total Billed Charges,9.31,45,,139.192,Percent of Total Billed Charges,45% of Total Billed Charges,18.62,90,,124.416,Percent of Total Billed Charges,90% of Total billed Charges,20.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.45,65,,372.064,Percent of total Billed Charges,65% of Total Billed Charges,9.12,44.1,,136.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.66,95,,131.328,Percent of Total Billed Charges,95% of Total Billed Charges,20.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.21,88,,121.648,Percent of Total Billed Charges,88% of Total Billed Charges,18.62,90,,124.416,Percent of Total Billed charges,90% of Total Billed Charges,9.12,20.69,
SYR PUMP TBNG MCRBRE PRSS DISC,2710000153,CDM,271,RC,,,Outpatient,,,16.80,10.92,,16.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.77,76,,67.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.1,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,12.6,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,16.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.1,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,10.08,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,15.12,90,,23.4,Percent of Total Billed Charges,90% of Total Billed Charges,7.56,45,,139.192,Percent of Total Billed Charges,45% of Total Billed Charges,15.12,90,,80.224,Percent of Total Billed Charges,90% of Total billed Charges,16.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.92,65,,201.056,Percent of total Billed Charges,65% of Total Billed Charges,7.41,44.1,,136.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.96,95,,84.68,Percent of Total Billed Charges,95% of Total Billed Charges,16.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.78,88,,78.44,Percent of Total Billed Charges,88% of Total Billed Charges,15.12,90,,80.224,Percent of Total Billed charges,90% of Total Billed Charges,7.41,16.8,
SPO2 SENSOR ADULT DISP.,2710000154,CDM,271,RC,,,Outpatient,,,16.00,10.40,,16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.16,76,,435.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.52,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,12,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.52,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,9.6,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,14.4,90,,23.4,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,45,,139.192,Percent of Total Billed Charges,45% of Total Billed Charges,14.4,90,,515.16,Percent of Total Billed Charges,90% of Total billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,65,,201.056,Percent of total Billed Charges,65% of Total Billed Charges,7.06,44.1,,136.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.2,95,,543.784,Percent of Total Billed Charges,95% of Total Billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.08,88,,503.712,Percent of Total Billed Charges,88% of Total Billed Charges,14.4,90,,515.16,Percent of Total Billed charges,90% of Total Billed Charges,7.06,16,
SPO2 INF,2710000155,CDM,271,RC,,,Outpatient,,,12.80,8.32,,12.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.73,76,,235.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.22,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,9.6,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,12.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.22,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,7.68,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,11.52,90,,23.4,Percent of Total Billed Charges,90% of Total Billed Charges,5.76,45,,139.192,Percent of Total Billed Charges,45% of Total Billed Charges,11.52,90,,278.392,Percent of Total Billed Charges,90% of Total billed Charges,12.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.32,65,,201.056,Percent of total Billed Charges,65% of Total Billed Charges,5.64,44.1,,136.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.16,95,,293.856,Percent of Total Billed Charges,95% of Total Billed Charges,12.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.26,88,,272.2,Percent of Total Billed Charges,88% of Total Billed Charges,11.52,90,,278.392,Percent of Total Billed charges,90% of Total Billed Charges,5.64,12.8,
AMNIHOOK,2710000156,CDM,271,RC,,,Outpatient,,,14.40,9.36,,14.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.94,76,,235.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.37,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,10.8,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,14.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.37,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,8.64,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,12.96,90,,22.504,Percent of Total Billed Charges,90% of Total Billed Charges,6.48,45,,139.192,Percent of Total Billed Charges,45% of Total Billed Charges,12.96,90,,278.392,Percent of Total Billed Charges,90% of Total billed Charges,14.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.36,65,,201.056,Percent of total Billed Charges,65% of Total Billed Charges,6.35,44.1,,136.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.68,95,,293.856,Percent of Total Billed Charges,95% of Total Billed Charges,14.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.67,88,,272.2,Percent of Total Billed Charges,88% of Total Billed Charges,12.96,90,,278.392,Percent of Total Billed charges,90% of Total Billed Charges,6.35,14.4,
BELT GAIT,2710000157,CDM,271,RC,,,Outpatient,,,29.68,19.29,,29.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.56,76,,235.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.37,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,22.26,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,29.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.37,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,17.81,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,26.71,90,,22.504,Percent of Total Billed Charges,90% of Total Billed Charges,13.36,45,,182.072,Percent of Total Billed Charges,45% of Total Billed Charges,26.71,90,,278.392,Percent of Total Billed Charges,90% of Total billed Charges,29.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.29,65,,201.056,Percent of total Billed Charges,65% of Total Billed Charges,13.09,44.1,,178.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.2,95,,293.856,Percent of Total Billed Charges,95% of Total Billed Charges,29.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.12,88,,272.2,Percent of Total Billed Charges,88% of Total Billed Charges,26.71,90,,278.392,Percent of Total Billed charges,90% of Total Billed Charges,13.09,29.68,
NASOPH 32 FR,2710000158,CDM,271,RC,,,Outpatient,,,17.50,11.38,,17.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.3,76,,235.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.6,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,13.13,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.6,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,10.5,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,15.75,90,,22.504,Percent of Total Billed Charges,90% of Total Billed Charges,7.88,45,,31.504,Percent of Total Billed Charges,45% of Total Billed Charges,15.75,90,,278.392,Percent of Total Billed Charges,90% of Total billed Charges,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.38,65,,262.992,Percent of total Billed Charges,65% of Total Billed Charges,7.72,44.1,,30.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.63,95,,293.856,Percent of Total Billed Charges,95% of Total Billed Charges,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.4,88,,272.2,Percent of Total Billed Charges,88% of Total Billed Charges,15.75,90,,278.392,Percent of Total Billed charges,90% of Total Billed Charges,7.72,17.5,
SCRTL SUP SM,2710000159,CDM,271,RC,,,Outpatient,,,12.60,8.19,,12.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.58,76,,235.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.07,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,9.45,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,12.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.07,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,7.56,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,11.34,90,,17.688,Percent of Total Billed Charges,90% of Total Billed Charges,5.67,45,,11.704,Percent of Total Billed Charges,45% of Total Billed Charges,11.34,90,,278.392,Percent of Total Billed Charges,90% of Total billed Charges,12.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.19,65,,45.504,Percent of total Billed Charges,65% of Total Billed Charges,5.56,44.1,,11.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.97,95,,293.856,Percent of Total Billed Charges,95% of Total Billed Charges,12.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.09,88,,272.2,Percent of Total Billed Charges,88% of Total Billed Charges,11.34,90,,278.392,Percent of Total Billed charges,90% of Total Billed Charges,5.56,12.6,
BRIEF LG,2710000160,CDM,271,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,307.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,35.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,11.704,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,364.144,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,16.904,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,11.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,384.368,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,356.048,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,364.144,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
SPO2 NEO/ADLT,2710000161,CDM,271,RC,,,Outpatient,,,51.50,33.48,,51.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,39.14,76,,53.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,37.08,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,38.63,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.08,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,30.9,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,46.35,90,,94.432,Percent of Total Billed Charges,90% of Total Billed Charges,23.18,45,,11.704,Percent of Total Billed Charges,45% of Total Billed Charges,46.35,90,,63,Percent of Total Billed Charges,90% of Total billed Charges,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.48,65,,16.904,Percent of total Billed Charges,65% of Total Billed Charges,22.71,44.1,,11.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.93,95,,66.504,Percent of Total Billed Charges,95% of Total Billed Charges,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.32,88,,61.6,Percent of Total Billed Charges,88% of Total Billed Charges,46.35,90,,63,Percent of Total Billed charges,90% of Total Billed Charges,22.71,51.5,
BAG URINE INF,2710000162,CDM,271,RC,,,Outpatient,,,8.00,5.20,,8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.08,76,,19.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.76,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,6,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.76,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,4.8,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.2,90,,21.024,Percent of Total Billed Charges,90% of Total Billed Charges,3.6,45,,11.248,Percent of Total Billed Charges,45% of Total Billed Charges,7.2,90,,23.4,Percent of Total Billed Charges,90% of Total billed Charges,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.2,65,,16.904,Percent of total Billed Charges,65% of Total Billed Charges,3.53,44.1,,11.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.6,95,,24.704,Percent of Total Billed Charges,95% of Total Billed Charges,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.04,88,,22.88,Percent of Total Billed Charges,88% of Total Billed Charges,7.2,90,,23.4,Percent of Total Billed charges,90% of Total Billed Charges,3.53,8,
CIRC BELT,2710000163,CDM,271,RC,,,Outpatient,,,9.00,5.85,,9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.84,76,,19.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.48,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,6.75,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.48,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,5.4,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,8.1,90,,36,Percent of Total Billed Charges,90% of Total Billed Charges,4.05,45,,11.248,Percent of Total Billed Charges,45% of Total Billed Charges,8.1,90,,23.4,Percent of Total Billed Charges,90% of Total billed Charges,9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.85,65,,16.248,Percent of total Billed Charges,65% of Total Billed Charges,3.97,44.1,,11.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.55,95,,24.704,Percent of Total Billed Charges,95% of Total Billed Charges,9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.92,88,,22.88,Percent of Total Billed Charges,88% of Total Billed Charges,8.1,90,,23.4,Percent of Total Billed charges,90% of Total Billed Charges,3.97,9,
SET SECOND 35,2710000164,CDM,271,RC,,,Outpatient,,,9.20,5.98,,9.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.99,76,,19.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.62,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,6.9,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,9.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,5.52,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,8.28,90,,26.104,Percent of Total Billed Charges,90% of Total Billed Charges,4.14,45,,11.248,Percent of Total Billed Charges,45% of Total Billed Charges,8.28,90,,23.4,Percent of Total Billed Charges,90% of Total billed Charges,9.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.98,65,,16.248,Percent of total Billed Charges,65% of Total Billed Charges,4.06,44.1,,11.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.74,95,,24.704,Percent of Total Billed Charges,95% of Total Billed Charges,9.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.1,88,,22.88,Percent of Total Billed Charges,88% of Total Billed Charges,8.28,90,,23.4,Percent of Total Billed charges,90% of Total Billed Charges,4.06,9.2,
PASTE PREM,2710000165,CDM,271,RC,,,Outpatient,,,61.35,39.88,,61.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.63,76,,19,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,44.17,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,46.01,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,61.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.17,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,36.81,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,55.22,90,,99.192,Percent of Total Billed Charges,90% of Total Billed Charges,27.61,45,,8.848,Percent of Total Billed Charges,45% of Total Billed Charges,55.22,90,,22.504,Percent of Total Billed Charges,90% of Total billed Charges,61.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.88,65,,16.248,Percent of total Billed Charges,65% of Total Billed Charges,27.06,44.1,,8.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,58.28,95,,23.752,Percent of Total Billed Charges,95% of Total Billed Charges,61.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.99,88,,22,Percent of Total Billed Charges,88% of Total Billed Charges,55.22,90,,22.504,Percent of Total Billed charges,90% of Total Billed Charges,27.06,61.35,
BTTL PERINEAL,2710000166,CDM,271,RC,,,Outpatient,,,3.42,2.22,,3.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.6,76,,19,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.46,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,2.57,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,3.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.46,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,2.05,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,3.08,90,,23.528,Percent of Total Billed Charges,90% of Total Billed Charges,1.54,45,,17.72,Percent of Total Billed Charges,45% of Total Billed Charges,3.08,90,,22.504,Percent of Total Billed Charges,90% of Total billed Charges,3.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.22,65,,12.776,Percent of total Billed Charges,65% of Total Billed Charges,1.51,44.1,,17.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.25,95,,23.752,Percent of Total Billed Charges,95% of Total Billed Charges,3.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.01,88,,22,Percent of Total Billed Charges,88% of Total Billed Charges,3.08,90,,22.504,Percent of Total Billed charges,90% of Total Billed Charges,1.51,3.42,
PAD OB,2710000167,CDM,271,RC,,,Outpatient,,,6.80,4.42,,6.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.17,76,,19,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.9,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,5.1,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,6.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.9,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,4.08,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,6.12,90,,11.704,Percent of Total Billed Charges,90% of Total Billed Charges,3.06,45,,47.216,Percent of Total Billed Charges,45% of Total Billed Charges,6.12,90,,22.504,Percent of Total Billed Charges,90% of Total billed Charges,6.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.42,65,,25.592,Percent of total Billed Charges,65% of Total Billed Charges,3,44.1,,46.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.46,95,,23.752,Percent of Total Billed Charges,95% of Total Billed Charges,6.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.98,88,,22,Percent of Total Billed Charges,88% of Total Billed Charges,6.12,90,,22.504,Percent of Total Billed charges,90% of Total Billed Charges,3,6.8,
BRIEF XL OB,2710000168,CDM,271,RC,,,Outpatient,,,5.80,3.77,,5.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.41,76,,14.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.18,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,4.35,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,5.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.18,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,3.48,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,5.22,90,,15.608,Percent of Total Billed Charges,90% of Total Billed Charges,2.61,45,,10.512,Percent of Total Billed Charges,45% of Total Billed Charges,5.22,90,,17.688,Percent of Total Billed Charges,90% of Total billed Charges,5.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.77,65,,68.2,Percent of total Billed Charges,65% of Total Billed Charges,2.56,44.1,,10.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.51,95,,18.672,Percent of Total Billed Charges,95% of Total Billed Charges,5.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.1,88,,17.296,Percent of Total Billed Charges,88% of Total Billed Charges,5.22,90,,17.688,Percent of Total Billed charges,90% of Total Billed Charges,2.56,5.8,
KIT BABY LF,2710000169,CDM,271,RC,,,Outpatient,,,79.50,51.68,,79.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60.42,76,,29.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.24,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,59.63,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,79.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.24,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,47.7,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,71.55,90,,43.2,Percent of Total Billed Charges,90% of Total Billed Charges,35.78,45,,18,Percent of Total Billed Charges,45% of Total Billed Charges,71.55,90,,35.44,Percent of Total Billed Charges,90% of Total billed Charges,79.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.68,65,,15.184,Percent of total Billed Charges,65% of Total Billed Charges,35.06,44.1,,17.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,75.53,95,,37.408,Percent of Total Billed Charges,95% of Total Billed Charges,79.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.96,88,,34.648,Percent of Total Billed Charges,88% of Total Billed Charges,71.55,90,,35.44,Percent of Total Billed charges,90% of Total Billed Charges,35.06,79.5,
FETAL MONITOR BELT,2710000170,CDM,271,RC,,,Outpatient,,,10.28,6.68,,10.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.81,76,,79.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.4,72,,171.464,Percent of Total Billed Charges,72% of Total Billed Charges,7.71,75,,171.464,Percent of Total Billed charges,75% of Total Billed Charges,10.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.4,72,,171.464,Percent of Total Billed Charges,72% of Total Billed Charges,6.17,60,,142.888,Percent of Total Billed Charges,60% of Total Billed Charges,9.25,90,,6.12,Percent of Total Billed Charges,90% of Total Billed Charges,4.63,45,,13.048,Percent of Total Billed Charges,45% of Total Billed Charges,9.25,90,,94.432,Percent of Total Billed Charges,90% of Total billed Charges,10.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.68,65,,26,Percent of total Billed Charges,65% of Total Billed Charges,4.53,44.1,,12.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.77,95,,99.672,Percent of Total Billed Charges,95% of Total Billed Charges,10.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.05,88,,92.328,Percent of Total Billed Charges,88% of Total Billed Charges,9.25,90,,94.432,Percent of Total Billed charges,90% of Total Billed Charges,4.53,10.28,
HEELBO,2710000171,CDM,271,RC,,,Outpatient,,,27.52,17.89,,27.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.92,76,,17.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.81,72,,171.464,Percent of Total Billed Charges,72% of Total Billed Charges,20.64,75,,171.464,Percent of Total Billed charges,75% of Total Billed Charges,27.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.81,72,,171.464,Percent of Total Billed Charges,72% of Total Billed Charges,16.51,60,,142.888,Percent of Total Billed Charges,60% of Total Billed Charges,24.77,90,,6.816,Percent of Total Billed Charges,90% of Total Billed Charges,12.38,45,,49.6,Percent of Total Billed Charges,45% of Total Billed Charges,24.77,90,,21.024,Percent of Total Billed Charges,90% of Total billed Charges,27.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.89,65,,18.848,Percent of total Billed Charges,65% of Total Billed Charges,12.14,44.1,,48.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.14,95,,22.192,Percent of Total Billed Charges,95% of Total Billed Charges,27.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.22,88,,20.56,Percent of Total Billed Charges,88% of Total Billed Charges,24.77,90,,21.024,Percent of Total Billed charges,90% of Total Billed Charges,12.14,27.52,
SENSOR SPO2 INF,2710000172,CDM,271,RC,,,Outpatient,,,50.75,32.99,,50.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38.57,76,,30.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36.54,72,,171.464,Percent of Total Billed Charges,72% of Total Billed Charges,38.06,75,,171.464,Percent of Total Billed charges,75% of Total Billed Charges,50.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.54,72,,171.464,Percent of Total Billed Charges,72% of Total Billed Charges,30.45,60,,142.888,Percent of Total Billed Charges,60% of Total Billed Charges,45.68,90,,2.536,Percent of Total Billed Charges,90% of Total Billed Charges,22.84,45,,11.768,Percent of Total Billed Charges,45% of Total Billed Charges,45.68,90,,36,Percent of Total Billed Charges,90% of Total billed Charges,50.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.99,65,,71.64,Percent of total Billed Charges,65% of Total Billed Charges,22.38,44.1,,11.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.21,95,,38,Percent of Total Billed Charges,95% of Total Billed Charges,50.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.66,88,,35.2,Percent of Total Billed Charges,88% of Total Billed Charges,45.68,90,,36,Percent of Total Billed charges,90% of Total Billed Charges,22.38,50.75,
CATH TEXAS MALE,2710000173,CDM,271,RC,,,Outpatient,,,8.20,5.33,,8.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.23,76,,22.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.9,72,,171.464,Percent of Total Billed Charges,72% of Total Billed Charges,6.15,75,,171.464,Percent of Total Billed charges,75% of Total Billed Charges,8.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.9,72,,171.464,Percent of Total Billed Charges,72% of Total Billed Charges,4.92,60,,142.888,Percent of Total Billed Charges,60% of Total Billed Charges,7.38,90,,2.536,Percent of Total Billed Charges,90% of Total Billed Charges,3.69,45,,5.848,Percent of Total Billed Charges,45% of Total Billed Charges,7.38,90,,26.104,Percent of Total Billed Charges,90% of Total billed Charges,8.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.33,65,,16.992,Percent of total Billed Charges,65% of Total Billed Charges,3.62,44.1,,5.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.79,95,,27.552,Percent of Total Billed Charges,95% of Total Billed Charges,8.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.22,88,,25.52,Percent of Total Billed Charges,88% of Total Billed Charges,7.38,90,,26.104,Percent of Total Billed charges,90% of Total Billed Charges,3.62,8.2,
COBAN 4,2710000174,CDM,271,RC,,,Outpatient,,,17.50,11.38,,17.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.3,76,,83.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.6,72,,171.464,Percent of Total Billed Charges,72% of Total Billed Charges,13.13,75,,171.464,Percent of Total Billed charges,75% of Total Billed Charges,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.6,72,,171.464,Percent of Total Billed Charges,72% of Total Billed Charges,10.5,60,,142.888,Percent of Total Billed Charges,60% of Total Billed Charges,15.75,90,,2.704,Percent of Total Billed Charges,90% of Total Billed Charges,7.88,45,,7.808,Percent of Total Billed Charges,45% of Total Billed Charges,15.75,90,,99.192,Percent of Total Billed Charges,90% of Total billed Charges,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.38,65,,8.448,Percent of total Billed Charges,65% of Total Billed Charges,7.72,44.1,,7.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.63,95,,104.704,Percent of Total Billed Charges,95% of Total Billed Charges,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.4,88,,96.992,Percent of Total Billed Charges,88% of Total Billed Charges,15.75,90,,99.192,Percent of Total Billed charges,90% of Total Billed Charges,7.72,17.5,
COBAN 1,2710000175,CDM,271,RC,,,Outpatient,,,5.10,3.32,,5.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.88,76,,19.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.67,72,,171.464,Percent of Total Billed Charges,72% of Total Billed Charges,3.83,75,,171.464,Percent of Total Billed charges,75% of Total Billed Charges,5.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.67,72,,171.464,Percent of Total Billed Charges,72% of Total Billed Charges,3.06,60,,142.888,Percent of Total Billed Charges,60% of Total Billed Charges,4.59,90,,3.144,Percent of Total Billed Charges,90% of Total Billed Charges,2.3,45,,21.6,Percent of Total Billed Charges,45% of Total Billed Charges,4.59,90,,23.528,Percent of Total Billed Charges,90% of Total billed Charges,5.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.32,65,,11.272,Percent of total Billed Charges,65% of Total Billed Charges,2.25,44.1,,21.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.85,95,,24.84,Percent of Total Billed Charges,95% of Total Billed Charges,5.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.49,88,,23.008,Percent of Total Billed Charges,88% of Total Billed Charges,4.59,90,,23.528,Percent of Total Billed charges,90% of Total Billed Charges,2.25,5.1,
COBAN 2,2710000176,CDM,271,RC,,,Outpatient,,,9.30,6.05,,9.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.07,76,,9.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.7,72,,1889.28,Percent of Total Billed Charges,72% of Total Billed Charges,6.98,75,,1968,Percent of Total Billed charges,75% of Total Billed Charges,9.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.7,72,,1889.28,Percent of Total Billed Charges,72% of Total Billed Charges,5.58,60,,1574.4,Percent of Total Billed Charges,60% of Total Billed Charges,8.37,90,,4.968,Percent of Total Billed Charges,90% of Total Billed Charges,4.19,45,,3.064,Percent of Total Billed Charges,45% of Total Billed Charges,8.37,90,,11.704,Percent of Total Billed Charges,90% of Total billed Charges,9.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.05,65,,31.2,Percent of total Billed Charges,65% of Total Billed Charges,4.1,44.1,,3,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.84,95,,12.352,Percent of Total Billed Charges,95% of Total Billed Charges,9.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.18,88,,11.44,Percent of Total Billed Charges,88% of Total Billed Charges,8.37,90,,11.704,Percent of Total Billed charges,90% of Total Billed Charges,4.1,9.3,
COBAN 3,2710000177,CDM,271,RC,,,Outpatient,,,11.60,7.54,,11.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.82,76,,13.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.35,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,8.7,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,11.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.35,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,6.96,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,10.44,90,,119.032,Percent of Total Billed Charges,90% of Total Billed Charges,5.22,45,,3.408,Percent of Total Billed Charges,45% of Total Billed Charges,10.44,90,,15.608,Percent of Total Billed Charges,90% of Total billed Charges,11.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.54,65,,4.424,Percent of total Billed Charges,65% of Total Billed Charges,5.12,44.1,,3.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.02,95,,16.48,Percent of Total Billed Charges,95% of Total Billed Charges,11.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.21,88,,15.264,Percent of Total Billed Charges,88% of Total Billed Charges,10.44,90,,15.608,Percent of Total Billed charges,90% of Total Billed Charges,5.12,11.6,
COBAN 6,2710000178,CDM,271,RC,,,Outpatient,,,16.96,11.02,,16.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.89,76,,36.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.21,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,12.72,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,16.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.21,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,10.18,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,15.26,90,,36,Percent of Total Billed Charges,90% of Total Billed Charges,7.63,45,,1.264,Percent of Total Billed Charges,45% of Total Billed Charges,15.26,90,,43.2,Percent of Total Billed Charges,90% of Total billed Charges,16.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.02,65,,4.928,Percent of total Billed Charges,65% of Total Billed Charges,7.48,44.1,,1.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.11,95,,45.6,Percent of Total Billed Charges,95% of Total Billed Charges,16.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.92,88,,42.24,Percent of Total Billed Charges,88% of Total Billed Charges,15.26,90,,43.2,Percent of Total Billed charges,90% of Total Billed Charges,7.48,16.96,
CENT LN 3 LUMEN 7FR 20CM,2710000179,CDM,271,RC,,,Outpatient,,,231.56,150.51,,231.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,175.99,76,,5.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,166.72,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,173.67,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,231.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.72,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,138.94,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,208.4,90,,27.84,Percent of Total Billed Charges,90% of Total Billed Charges,104.2,45,,1.264,Percent of Total Billed Charges,45% of Total Billed Charges,208.4,90,,6.12,Percent of Total Billed Charges,90% of Total billed Charges,231.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.51,65,,1.832,Percent of total Billed Charges,65% of Total Billed Charges,102.12,44.1,,1.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,219.98,95,,6.464,Percent of Total Billed Charges,95% of Total Billed Charges,231.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.77,88,,5.984,Percent of Total Billed Charges,88% of Total Billed Charges,208.4,90,,6.12,Percent of Total Billed charges,90% of Total Billed Charges,102.12,231.56,
BOTTLE DR. BROWN'S,2710000180,CDM,271,RC,,,Outpatient,,,11.72,7.62,,11.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.91,76,,5.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.44,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,8.79,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,11.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.44,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,7.03,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,10.55,90,,378,Percent of Total Billed Charges,90% of Total Billed Charges,5.27,45,,1.352,Percent of Total Billed Charges,45% of Total Billed Charges,10.55,90,,6.816,Percent of Total Billed Charges,90% of Total billed Charges,11.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.62,65,,1.832,Percent of total Billed Charges,65% of Total Billed Charges,5.17,44.1,,1.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.13,95,,7.2,Percent of Total Billed Charges,95% of Total Billed Charges,11.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.31,88,,6.664,Percent of Total Billed Charges,88% of Total Billed Charges,10.55,90,,6.816,Percent of Total Billed charges,90% of Total Billed Charges,5.17,11.72,
CUP SIPPY,2710000181,CDM,271,RC,,,Outpatient,,,13.80,8.97,,13.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.49,76,,2.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.94,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,10.35,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,13.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.94,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,8.28,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,12.42,90,,38.392,Percent of Total Billed Charges,90% of Total Billed Charges,6.21,45,,1.576,Percent of Total Billed Charges,45% of Total Billed Charges,12.42,90,,2.536,Percent of Total Billed Charges,90% of Total billed Charges,13.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.97,65,,1.952,Percent of total Billed Charges,65% of Total Billed Charges,6.09,44.1,,1.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.11,95,,2.672,Percent of Total Billed Charges,95% of Total Billed Charges,13.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.14,88,,2.48,Percent of Total Billed Charges,88% of Total Billed Charges,12.42,90,,2.536,Percent of Total Billed charges,90% of Total Billed Charges,6.09,13.8,
BOX LUNCH,2710000182,CDM,271,RC,,,Outpatient,,,10.58,6.88,,10.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.04,76,,2.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.62,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,10.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.62,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,6.35,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,9.52,90,,39.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.76,45,,2.488,Percent of Total Billed Charges,45% of Total Billed Charges,9.52,90,,2.536,Percent of Total Billed Charges,90% of Total billed Charges,10.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.88,65,,2.272,Percent of total Billed Charges,65% of Total Billed Charges,4.67,44.1,,2.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.05,95,,2.672,Percent of Total Billed Charges,95% of Total Billed Charges,10.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.31,88,,2.48,Percent of Total Billed Charges,88% of Total Billed Charges,9.52,90,,2.536,Percent of Total Billed charges,90% of Total Billed Charges,4.67,10.58,
"COBAN 4"" BRIGHTS 18RLLS/CS",2710000183,CDM,271,RC,,,Outpatient,,,20.00,13.00,,20,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.2,76,,2.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.4,72,,2062.08,Percent of Total Billed Charges,72% of Total Billed Charges,15,75,,2148,Percent of Total Billed charges,75% of Total Billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.4,72,,2062.08,Percent of Total Billed Charges,72% of Total Billed Charges,12,60,,1718.4,Percent of Total Billed Charges,60% of Total Billed Charges,18,90,,2.52,Percent of Total Billed Charges,90% of Total Billed Charges,9,45,,59.512,Percent of Total Billed Charges,45% of Total Billed Charges,18,90,,2.704,Percent of Total Billed Charges,90% of Total billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13,65,,3.592,Percent of total Billed Charges,65% of Total Billed Charges,8.82,44.1,,58.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,19,95,,2.848,Percent of Total Billed Charges,95% of Total Billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.6,88,,2.64,Percent of Total Billed Charges,88% of Total Billed Charges,18,90,,2.704,Percent of Total Billed charges,90% of Total Billed Charges,8.82,20,
HEATED O2/P/HR,2710000184,CDM,271,RC,,,Outpatient,,,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,2.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.88,72,,1282.144,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,75,,1335.568,Percent of Total Billed charges,75% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.88,72,,1282.144,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,60,,1068.456,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,90,,104.376,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,18,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,3.144,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,85.968,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,17.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,3.32,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,3.08,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,3.144,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.05,
ENDOTRACHEAL TUBE TA,2710000185,CDM,271,RC,,,Outpatient,,,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,4.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,87.696,Percent of Total Billed Charges,72% of Total Billed Charges,15.71,75,,91.352,Percent of Total Billed charges,75% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,87.696,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,73.08,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,47.248,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,13.92,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,4.968,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,26,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,13.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,5.248,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,4.856,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,4.968,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
ANCHOR FAST GUARD,2710000186,CDM,271,RC,,,Outpatient,,,71.94,46.76,,71.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.67,76,,100.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.8,72,,94.616,Percent of Total Billed Charges,72% of Total Billed Charges,53.96,75,,98.56,Percent of Total Billed charges,75% of Total Billed Charges,71.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.8,72,,94.616,Percent of Total Billed Charges,72% of Total Billed Charges,43.16,60,,78.848,Percent of Total Billed Charges,60% of Total Billed Charges,64.75,90,,63.904,Percent of Total Billed Charges,90% of Total Billed Charges,32.37,45,,189,Percent of Total Billed Charges,45% of Total Billed Charges,64.75,90,,119.032,Percent of Total Billed Charges,90% of Total billed Charges,71.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.76,65,,20.112,Percent of total Billed Charges,65% of Total Billed Charges,31.73,44.1,,185.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.34,95,,125.64,Percent of Total Billed Charges,95% of Total Billed Charges,71.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.31,88,,116.384,Percent of Total Billed Charges,88% of Total Billed Charges,64.75,90,,119.032,Percent of Total Billed charges,90% of Total Billed Charges,31.73,71.94,
ELECTRODES,2710000187,CDM,271,RC,,,Outpatient,,,36.38,23.65,,36.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.65,76,,30.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.19,72,,38.736,Percent of Total Billed Charges,72% of Total Billed Charges,27.29,75,,40.352,Percent of Total Billed charges,75% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.19,72,,38.736,Percent of Total Billed Charges,72% of Total Billed Charges,21.83,60,,32.28,Percent of Total Billed Charges,60% of Total Billed Charges,32.74,90,,2.936,Percent of Total Billed Charges,90% of Total Billed Charges,16.37,45,,19.192,Percent of Total Billed Charges,45% of Total Billed Charges,32.74,90,,36,Percent of Total Billed Charges,90% of Total billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.65,65,,273,Percent of total Billed Charges,65% of Total Billed Charges,16.04,44.1,,18.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.56,95,,38,Percent of Total Billed Charges,95% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.01,88,,35.2,Percent of Total Billed Charges,88% of Total Billed Charges,32.74,90,,36,Percent of Total Billed charges,90% of Total Billed Charges,16.04,36.38,
FOLEY CATH 24FR 30CC,2710000188,CDM,271,RC,,,Outpatient,,,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,23.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,38.736,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,40.352,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,38.736,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,32.28,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,246.6,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,19.8,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,27.84,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,27.728,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,19.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,29.392,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,27.224,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,27.84,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
FOLEY CATH 26FR 30CC,2710000189,CDM,271,RC,,,Outpatient,,,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,319.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,103.192,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,82.552,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,16.072,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,1.264,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,378,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,28.6,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,1.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,399,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,369.6,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,378,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
COUDE CATH 18FR 30CC,2710000190,CDM,271,RC,,,Outpatient,,,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,32.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,101.944,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,106.192,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,101.944,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,84.952,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,16.072,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,52.192,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,38.392,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,1.824,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,51.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,40.52,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,37.536,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,38.392,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
CHEST TUBE TROCAR 24,2710000191,CDM,271,RC,,,Outpatient,,,126.79,82.41,,126.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,96.36,76,,33.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.29,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,95.09,75,,46.968,Percent of Total Billed charges,75% of Total Billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.29,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,76.07,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,114.11,90,,16.632,Percent of Total Billed Charges,90% of Total Billed Charges,57.06,45,,23.624,Percent of Total Billed Charges,45% of Total Billed Charges,114.11,90,,39.6,Percent of Total Billed Charges,90% of Total billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.41,65,,75.384,Percent of total Billed Charges,65% of Total Billed Charges,55.91,44.1,,23.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,120.45,95,,41.8,Percent of Total Billed Charges,95% of Total Billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.58,88,,38.72,Percent of Total Billed Charges,88% of Total Billed Charges,114.11,90,,39.6,Percent of Total Billed charges,90% of Total Billed Charges,55.91,126.79,
CHEST TUBE TROCAR 28,2710000192,CDM,271,RC,,,Outpatient,,,121.28,78.83,,121.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,92.17,76,,2.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,87.32,72,,175.392,Percent of Total Billed Charges,72% of Total Billed Charges,90.96,75,,182.704,Percent of Total Billed charges,75% of Total Billed Charges,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.32,72,,175.392,Percent of Total Billed Charges,72% of Total Billed Charges,72.77,60,,146.16,Percent of Total Billed Charges,60% of Total Billed Charges,109.15,90,,16.632,Percent of Total Billed Charges,90% of Total Billed Charges,54.58,45,,31.952,Percent of Total Billed Charges,45% of Total Billed Charges,109.15,90,,2.52,Percent of Total Billed Charges,90% of Total billed Charges,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.83,65,,34.12,Percent of total Billed Charges,65% of Total Billed Charges,53.48,44.1,,31.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,115.22,95,,2.664,Percent of Total Billed Charges,95% of Total Billed Charges,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.73,88,,2.464,Percent of Total Billed Charges,88% of Total Billed Charges,109.15,90,,2.52,Percent of Total Billed charges,90% of Total Billed Charges,53.48,121.28,
CHEST TUBE TROCAR 32,2710000193,CDM,271,RC,,,Outpatient,,,126.79,82.41,,126.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,96.36,76,,88.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.29,72,,112.896,Percent of Total Billed Charges,72% of Total Billed Charges,95.09,75,,117.6,Percent of Total Billed charges,75% of Total Billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.29,72,,112.896,Percent of Total Billed Charges,72% of Total Billed Charges,76.07,60,,94.08,Percent of Total Billed Charges,60% of Total Billed Charges,114.11,90,,16.632,Percent of Total Billed Charges,90% of Total Billed Charges,57.06,45,,1.472,Percent of Total Billed Charges,45% of Total Billed Charges,114.11,90,,104.376,Percent of Total Billed Charges,90% of Total billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.41,65,,46.152,Percent of total Billed Charges,65% of Total Billed Charges,55.91,44.1,,1.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,120.45,95,,110.176,Percent of Total Billed Charges,95% of Total Billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.58,88,,102.056,Percent of Total Billed Charges,88% of Total Billed Charges,114.11,90,,104.376,Percent of Total Billed charges,90% of Total Billed Charges,55.91,126.79,
CHEST TUBE 36FR,2710000194,CDM,271,RC,,,Outpatient,,,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,39.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,72,,175.392,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,75,,182.704,Percent of Total Billed charges,75% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,72,,175.392,Percent of Total Billed Charges,72% of Total Billed Charges,5.95,60,,146.16,Percent of Total Billed Charges,60% of Total Billed Charges,8.93,90,,16.632,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,123.304,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,47.248,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,2.12,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,120.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,49.872,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,46.2,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,47.248,Percent of Total Billed charges,90% of Total Billed Charges,4.37,9.92,
CHEST TUBE 40FR,2710000195,CDM,271,RC,,,Outpatient,,,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,53.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,112.896,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,117.6,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,112.896,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,94.08,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,16.632,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,8.032,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,63.904,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,178.104,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,7.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,67.448,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,62.48,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,63.904,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
TRACHEA TUBE 9.0,2710000196,CDM,271,RC,,,Outpatient,,,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,2.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,34.2,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,27.36,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,16.632,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,8.032,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,2.936,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,11.608,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,7.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,3.104,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,2.872,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,2.936,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
WOUND DRAIN COLLECT,2710000197,CDM,271,RC,,,Outpatient,,,40.79,26.51,,40.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31,76,,208.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.37,72,,126.856,Percent of Total Billed Charges,72% of Total Billed Charges,30.59,75,,132.144,Percent of Total Billed charges,75% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.37,72,,126.856,Percent of Total Billed Charges,72% of Total Billed Charges,24.47,60,,105.712,Percent of Total Billed Charges,60% of Total Billed Charges,36.71,90,,16.632,Percent of Total Billed Charges,90% of Total Billed Charges,18.36,45,,8.32,Percent of Total Billed Charges,45% of Total Billed Charges,36.71,90,,246.6,Percent of Total Billed Charges,90% of Total billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.51,65,,11.608,Percent of total Billed Charges,65% of Total Billed Charges,17.99,44.1,,8.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.75,95,,260.304,Percent of Total Billed Charges,95% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.9,88,,241.12,Percent of Total Billed Charges,88% of Total Billed Charges,36.71,90,,246.6,Percent of Total Billed charges,90% of Total Billed Charges,17.99,40.79,
BAIR HUGGER BLANKET,2710000198,CDM,271,RC,,,Outpatient,,,71.66,46.58,,71.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.46,76,,13.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.6,72,,126.856,Percent of Total Billed Charges,72% of Total Billed Charges,53.75,75,,132.144,Percent of Total Billed charges,75% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,72,,126.856,Percent of Total Billed Charges,72% of Total Billed Charges,43,60,,105.712,Percent of Total Billed Charges,60% of Total Billed Charges,64.49,90,,16.632,Percent of Total Billed Charges,90% of Total Billed Charges,32.25,45,,8.32,Percent of Total Billed Charges,45% of Total Billed Charges,64.49,90,,16.072,Percent of Total Billed Charges,90% of Total billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.58,65,,12.016,Percent of total Billed Charges,65% of Total Billed Charges,31.6,44.1,,8.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.08,95,,16.96,Percent of Total Billed Charges,95% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,88,,15.712,Percent of Total Billed Charges,88% of Total Billed Charges,64.49,90,,16.072,Percent of Total Billed charges,90% of Total Billed Charges,31.6,71.66,
SUCTION CANNISTER 1500 ML,2710000199,CDM,271,RC,,,Outpatient,,,10.92,7.10,,10.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.3,76,,13.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.86,72,,126.856,Percent of Total Billed Charges,72% of Total Billed Charges,8.19,75,,132.144,Percent of Total Billed charges,75% of Total Billed Charges,10.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.86,72,,126.856,Percent of Total Billed Charges,72% of Total Billed Charges,6.55,60,,105.712,Percent of Total Billed Charges,60% of Total Billed Charges,9.83,90,,2.92,Percent of Total Billed Charges,90% of Total Billed Charges,4.91,45,,8.32,Percent of Total Billed Charges,45% of Total Billed Charges,9.83,90,,16.072,Percent of Total Billed Charges,90% of Total billed Charges,10.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.1,65,,12.016,Percent of total Billed Charges,65% of Total Billed Charges,4.82,44.1,,8.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.37,95,,16.96,Percent of Total Billed Charges,95% of Total Billed Charges,10.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.61,88,,15.712,Percent of Total Billed Charges,88% of Total Billed Charges,9.83,90,,16.072,Percent of Total Billed charges,90% of Total Billed Charges,4.82,10.92,
TRACH CANNULA SZ 6 DISP,2710000200,CDM,271,RC,,,Outpatient,,,20.34,13.22,,20.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.46,76,,14.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.64,72,,126.856,Percent of Total Billed Charges,72% of Total Billed Charges,15.26,75,,132.144,Percent of Total Billed charges,75% of Total Billed Charges,20.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.64,72,,126.856,Percent of Total Billed Charges,72% of Total Billed Charges,12.2,60,,105.712,Percent of Total Billed Charges,60% of Total Billed Charges,18.31,90,,9.144,Percent of Total Billed Charges,90% of Total Billed Charges,9.15,45,,8.32,Percent of Total Billed Charges,45% of Total Billed Charges,18.31,90,,16.632,Percent of Total Billed Charges,90% of Total billed Charges,20.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.22,65,,12.016,Percent of total Billed Charges,65% of Total Billed Charges,8.97,44.1,,8.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.32,95,,17.56,Percent of Total Billed Charges,95% of Total Billed Charges,20.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.9,88,,16.264,Percent of Total Billed Charges,88% of Total Billed Charges,18.31,90,,16.632,Percent of Total Billed charges,90% of Total Billed Charges,8.97,20.34,
TRACH CANNULA SZ 7 DISP,2710000201,CDM,271,RC,,,Outpatient,,,20.34,13.22,,20.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.46,76,,14.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.64,72,,160.664,Percent of Total Billed Charges,72% of Total Billed Charges,15.26,75,,167.36,Percent of Total Billed charges,75% of Total Billed Charges,20.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.64,72,,160.664,Percent of Total Billed Charges,72% of Total Billed Charges,12.2,60,,133.888,Percent of Total Billed Charges,60% of Total Billed Charges,18.31,90,,313.8,Percent of Total Billed Charges,90% of Total Billed Charges,9.15,45,,8.32,Percent of Total Billed Charges,45% of Total Billed Charges,18.31,90,,16.632,Percent of Total Billed Charges,90% of Total billed Charges,20.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.22,65,,12.016,Percent of total Billed Charges,65% of Total Billed Charges,8.97,44.1,,8.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.32,95,,17.56,Percent of Total Billed Charges,95% of Total Billed Charges,20.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.9,88,,16.264,Percent of Total Billed Charges,88% of Total Billed Charges,18.31,90,,16.632,Percent of Total Billed charges,90% of Total Billed Charges,8.97,20.34,
TRACH CANNULA SZ 8 DISP,2710000202,CDM,271,RC,,,Outpatient,,,20.34,13.22,,20.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.46,76,,14.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.64,72,,160.664,Percent of Total Billed Charges,72% of Total Billed Charges,15.26,75,,167.36,Percent of Total Billed charges,75% of Total Billed Charges,20.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.64,72,,160.664,Percent of Total Billed Charges,72% of Total Billed Charges,12.2,60,,133.888,Percent of Total Billed Charges,60% of Total Billed Charges,18.31,90,,229.68,Percent of Total Billed Charges,90% of Total Billed Charges,9.15,45,,8.32,Percent of Total Billed Charges,45% of Total Billed Charges,18.31,90,,16.632,Percent of Total Billed Charges,90% of Total billed Charges,20.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.22,65,,12.016,Percent of total Billed Charges,65% of Total Billed Charges,8.97,44.1,,8.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.32,95,,17.56,Percent of Total Billed Charges,95% of Total Billed Charges,20.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.9,88,,16.264,Percent of Total Billed Charges,88% of Total Billed Charges,18.31,90,,16.632,Percent of Total Billed charges,90% of Total Billed Charges,8.97,20.34,
TUBE FEED 10 FR,2710000203,CDM,271,RC,,,Outpatient,,,10.40,6.76,,10.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.9,76,,14.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.49,72,,160.664,Percent of Total Billed Charges,72% of Total Billed Charges,7.8,75,,167.36,Percent of Total Billed charges,75% of Total Billed Charges,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.49,72,,160.664,Percent of Total Billed Charges,72% of Total Billed Charges,6.24,60,,133.888,Percent of Total Billed Charges,60% of Total Billed Charges,9.36,90,,3.136,Percent of Total Billed Charges,90% of Total Billed Charges,4.68,45,,8.32,Percent of Total Billed Charges,45% of Total Billed Charges,9.36,90,,16.632,Percent of Total Billed Charges,90% of Total billed Charges,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.76,65,,12.016,Percent of total Billed Charges,65% of Total Billed Charges,4.59,44.1,,8.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.88,95,,17.56,Percent of Total Billed Charges,95% of Total Billed Charges,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.15,88,,16.264,Percent of Total Billed Charges,88% of Total Billed Charges,9.36,90,,16.632,Percent of Total Billed charges,90% of Total Billed Charges,4.59,10.4,
TUBE FEED PED 6.5 FR,2710000204,CDM,271,RC,,,Outpatient,,,10.40,6.76,,10.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.9,76,,14.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.49,72,,160.664,Percent of Total Billed Charges,72% of Total Billed Charges,7.8,75,,167.36,Percent of Total Billed charges,75% of Total Billed Charges,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.49,72,,160.664,Percent of Total Billed Charges,72% of Total Billed Charges,6.24,60,,133.888,Percent of Total Billed Charges,60% of Total Billed Charges,9.36,90,,4.16,Percent of Total Billed Charges,90% of Total Billed Charges,4.68,45,,8.32,Percent of Total Billed Charges,45% of Total Billed Charges,9.36,90,,16.632,Percent of Total Billed Charges,90% of Total billed Charges,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.76,65,,12.016,Percent of total Billed Charges,65% of Total Billed Charges,4.59,44.1,,8.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.88,95,,17.56,Percent of Total Billed Charges,95% of Total Billed Charges,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.15,88,,16.264,Percent of Total Billed Charges,88% of Total Billed Charges,9.36,90,,16.632,Percent of Total Billed charges,90% of Total Billed Charges,4.59,10.4,
SENSOR SPO2 NEO/ADLT,2710000205,CDM,271,RC,,,Outpatient,,,51.50,33.48,,51.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,39.14,76,,14.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,37.08,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,38.63,75,,21.168,Percent of Total Billed charges,75% of Total Billed Charges,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.08,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,30.9,60,,16.936,Percent of Total Billed Charges,60% of Total Billed Charges,46.35,90,,7.632,Percent of Total Billed Charges,90% of Total Billed Charges,23.18,45,,1.456,Percent of Total Billed Charges,45% of Total Billed Charges,46.35,90,,16.632,Percent of Total Billed Charges,90% of Total billed Charges,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.48,65,,12.016,Percent of total Billed Charges,65% of Total Billed Charges,22.71,44.1,,1.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.93,95,,17.56,Percent of Total Billed Charges,95% of Total Billed Charges,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.32,88,,16.264,Percent of Total Billed Charges,88% of Total Billed Charges,46.35,90,,16.632,Percent of Total Billed charges,90% of Total Billed Charges,22.71,51.5,
SENSOR SPO2 INFANT DISP,2710000206,CDM,271,RC,,,Outpatient,,,50.75,32.99,,50.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38.57,76,,14.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36.54,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,38.06,75,,21.168,Percent of Total Billed charges,75% of Total Billed Charges,50.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.54,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,30.45,60,,16.936,Percent of Total Billed Charges,60% of Total Billed Charges,45.68,90,,7.632,Percent of Total Billed Charges,90% of Total Billed Charges,22.84,45,,4.576,Percent of Total Billed Charges,45% of Total Billed Charges,45.68,90,,16.632,Percent of Total Billed Charges,90% of Total billed Charges,50.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.99,65,,2.104,Percent of total Billed Charges,65% of Total Billed Charges,22.38,44.1,,4.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.21,95,,17.56,Percent of Total Billed Charges,95% of Total Billed Charges,50.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.66,88,,16.264,Percent of Total Billed Charges,88% of Total Billed Charges,45.68,90,,16.632,Percent of Total Billed charges,90% of Total Billed Charges,22.38,50.75,
SYR FEEDPED 35ML,2710000207,CDM,271,RC,,,Outpatient,,,8.30,5.40,,8.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.31,76,,14.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.98,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,6.23,75,,21.168,Percent of Total Billed charges,75% of Total Billed Charges,8.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.98,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,4.98,60,,16.936,Percent of Total Billed Charges,60% of Total Billed Charges,7.47,90,,7.632,Percent of Total Billed Charges,90% of Total Billed Charges,3.74,45,,156.896,Percent of Total Billed Charges,45% of Total Billed Charges,7.47,90,,16.632,Percent of Total Billed Charges,90% of Total billed Charges,8.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.4,65,,6.608,Percent of total Billed Charges,65% of Total Billed Charges,3.66,44.1,,153.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.89,95,,17.56,Percent of Total Billed Charges,95% of Total Billed Charges,8.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.3,88,,16.264,Percent of Total Billed Charges,88% of Total Billed Charges,7.47,90,,16.632,Percent of Total Billed charges,90% of Total Billed Charges,3.66,8.3,
TRAY TRACH INSEERT DISP,2710000208,CDM,271,RC,,,Outpatient,,,10.50,6.83,,10.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.98,76,,2.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.56,72,,381.656,Percent of Total Billed Charges,72% of Total Billed Charges,7.88,75,,397.56,Percent of Total Billed charges,75% of Total Billed Charges,10.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.56,72,,381.656,Percent of Total Billed Charges,72% of Total Billed Charges,6.3,60,,318.048,Percent of Total Billed Charges,60% of Total Billed Charges,9.45,90,,7.632,Percent of Total Billed Charges,90% of Total Billed Charges,4.73,45,,114.84,Percent of Total Billed Charges,45% of Total Billed Charges,9.45,90,,2.92,Percent of Total Billed Charges,90% of Total billed Charges,10.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.83,65,,226.632,Percent of total Billed Charges,65% of Total Billed Charges,4.63,44.1,,112.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.98,95,,3.08,Percent of Total Billed Charges,95% of Total Billed Charges,10.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.24,88,,2.848,Percent of Total Billed Charges,88% of Total Billed Charges,9.45,90,,2.92,Percent of Total Billed charges,90% of Total Billed Charges,4.63,10.5,
TUBE FEED PED EXT 35,2710000209,CDM,271,RC,,,Outpatient,,,10.30,6.70,,10.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.83,76,,7.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.42,72,,115.584,Percent of Total Billed Charges,72% of Total Billed Charges,7.73,75,,120.4,Percent of Total Billed charges,75% of Total Billed Charges,10.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.42,72,,115.584,Percent of Total Billed Charges,72% of Total Billed Charges,6.18,60,,96.32,Percent of Total Billed Charges,60% of Total Billed Charges,9.27,90,,7.632,Percent of Total Billed Charges,90% of Total Billed Charges,4.64,45,,1.568,Percent of Total Billed Charges,45% of Total Billed Charges,9.27,90,,9.144,Percent of Total Billed Charges,90% of Total billed Charges,10.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.7,65,,165.88,Percent of total Billed Charges,65% of Total Billed Charges,4.54,44.1,,1.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.79,95,,9.656,Percent of Total Billed Charges,95% of Total Billed Charges,10.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.06,88,,8.944,Percent of Total Billed Charges,88% of Total Billed Charges,9.27,90,,9.144,Percent of Total Billed charges,90% of Total Billed Charges,4.54,10.3,
TUBE FEED PED EXT 60,2710000210,CDM,271,RC,,,Outpatient,,,10.40,6.76,,10.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.9,76,,264.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.49,72,,115.584,Percent of Total Billed Charges,72% of Total Billed Charges,7.8,75,,120.4,Percent of Total Billed charges,75% of Total Billed Charges,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.49,72,,115.584,Percent of Total Billed Charges,72% of Total Billed Charges,6.24,60,,96.32,Percent of Total Billed Charges,60% of Total Billed Charges,9.36,90,,7.632,Percent of Total Billed Charges,90% of Total Billed Charges,4.68,45,,2.08,Percent of Total Billed Charges,45% of Total Billed Charges,9.36,90,,313.8,Percent of Total Billed Charges,90% of Total billed Charges,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.76,65,,2.264,Percent of total Billed Charges,65% of Total Billed Charges,4.59,44.1,,2.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.88,95,,331.232,Percent of Total Billed Charges,95% of Total Billed Charges,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.15,88,,306.824,Percent of Total Billed Charges,88% of Total Billed Charges,9.36,90,,313.8,Percent of Total Billed charges,90% of Total Billed Charges,4.59,10.4,
SYR FEED PED 60ML,2710000211,CDM,271,RC,,,Outpatient,,,10.40,6.76,,10.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.9,76,,193.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.49,72,,172.8,Percent of Total Billed Charges,72% of Total Billed Charges,7.8,75,,180,Percent of Total Billed charges,75% of Total Billed Charges,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.49,72,,172.8,Percent of Total Billed Charges,72% of Total Billed Charges,6.24,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,9.36,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,4.68,45,,3.816,Percent of Total Billed Charges,45% of Total Billed Charges,9.36,90,,229.68,Percent of Total Billed Charges,90% of Total billed Charges,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.76,65,,3.008,Percent of total Billed Charges,65% of Total Billed Charges,4.59,44.1,,3.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.88,95,,242.44,Percent of Total Billed Charges,95% of Total Billed Charges,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.15,88,,224.576,Percent of Total Billed Charges,88% of Total Billed Charges,9.36,90,,229.68,Percent of Total Billed charges,90% of Total Billed Charges,4.59,10.4,
SENSOR SPO2 ADLT DISP,2710000212,CDM,271,RC,,,Outpatient,,,16.00,10.40,,16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.16,76,,2.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.52,72,,152.408,Percent of Total Billed Charges,72% of Total Billed Charges,12,75,,158.76,Percent of Total Billed charges,75% of Total Billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.52,72,,152.408,Percent of Total Billed Charges,72% of Total Billed Charges,9.6,60,,127.008,Percent of Total Billed Charges,60% of Total Billed Charges,14.4,90,,57.872,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,45,,3.816,Percent of Total Billed Charges,45% of Total Billed Charges,14.4,90,,3.136,Percent of Total Billed Charges,90% of Total billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,65,,5.512,Percent of total Billed Charges,65% of Total Billed Charges,7.06,44.1,,3.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.2,95,,3.304,Percent of Total Billed Charges,95% of Total Billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.08,88,,3.064,Percent of Total Billed Charges,88% of Total Billed Charges,14.4,90,,3.136,Percent of Total Billed charges,90% of Total Billed Charges,7.06,16,
GOWN SURG XXL,2710000213,CDM,272,RC,,,Outpatient,,,8.40,5.46,,8.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.38,76,,3.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.05,72,,107.96,Percent of Total Billed Charges,72% of Total Billed Charges,6.3,75,,112.456,Percent of Total Billed charges,75% of Total Billed Charges,8.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.05,72,,107.96,Percent of Total Billed Charges,72% of Total Billed Charges,5.04,60,,89.968,Percent of Total Billed Charges,60% of Total Billed Charges,7.56,90,,26.592,Percent of Total Billed Charges,90% of Total Billed Charges,3.78,45,,3.816,Percent of Total Billed Charges,45% of Total Billed Charges,7.56,90,,4.16,Percent of Total Billed Charges,90% of Total billed Charges,8.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.46,65,,5.512,Percent of total Billed Charges,65% of Total Billed Charges,3.7,44.1,,3.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.98,95,,4.392,Percent of Total Billed Charges,95% of Total Billed Charges,8.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.39,88,,4.072,Percent of Total Billed Charges,88% of Total Billed Charges,7.56,90,,4.16,Percent of Total Billed charges,90% of Total Billed Charges,3.7,8.4,
TRAY CHEST TUBE INSERT,2710000214,CDM,271,RC,,,Outpatient,,,120.69,78.45,,120.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,91.72,76,,6.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,86.9,72,,16.704,Percent of Total Billed Charges,72% of Total Billed Charges,90.52,75,,17.4,Percent of Total Billed charges,75% of Total Billed Charges,120.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.9,72,,16.704,Percent of Total Billed Charges,72% of Total Billed Charges,72.41,60,,13.92,Percent of Total Billed Charges,60% of Total Billed Charges,108.62,90,,19.176,Percent of Total Billed Charges,90% of Total Billed Charges,54.31,45,,3.816,Percent of Total Billed Charges,45% of Total Billed Charges,108.62,90,,7.632,Percent of Total Billed Charges,90% of Total billed Charges,120.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.45,65,,5.512,Percent of total Billed Charges,65% of Total Billed Charges,53.22,44.1,,3.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,114.66,95,,8.056,Percent of Total Billed Charges,95% of Total Billed Charges,120.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.21,88,,7.464,Percent of Total Billed Charges,88% of Total Billed Charges,108.62,90,,7.632,Percent of Total Billed charges,90% of Total Billed Charges,53.22,120.69,
JEVITY 1.0,2710000215,CDM,271,RC,,,Outpatient,,,3.38,2.20,,3.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.57,76,,6.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.43,72,,65.664,Percent of Total Billed Charges,72% of Total Billed Charges,2.54,75,,68.4,Percent of Total Billed charges,75% of Total Billed Charges,3.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.43,72,,65.664,Percent of Total Billed Charges,72% of Total Billed Charges,2.03,60,,54.72,Percent of Total Billed Charges,60% of Total Billed Charges,3.04,90,,7.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.52,45,,3.816,Percent of Total Billed Charges,45% of Total Billed Charges,3.04,90,,7.632,Percent of Total Billed Charges,90% of Total billed Charges,3.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.2,65,,5.512,Percent of total Billed Charges,65% of Total Billed Charges,1.49,44.1,,3.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.21,95,,8.056,Percent of Total Billed Charges,95% of Total Billed Charges,3.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.97,88,,7.464,Percent of Total Billed Charges,88% of Total Billed Charges,3.04,90,,7.632,Percent of Total Billed charges,90% of Total Billed Charges,1.49,3.38,
"CUFF,BP,DISP,1TB,ADL",2710000216,CDM,271,RC,,,Outpatient,,,26.25,17.06,,26.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.95,76,,6.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.9,72,,22.464,Percent of Total Billed Charges,72% of Total Billed Charges,19.69,75,,23.4,Percent of Total Billed charges,75% of Total Billed Charges,26.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.9,72,,22.464,Percent of Total Billed Charges,72% of Total Billed Charges,15.75,60,,18.72,Percent of Total Billed Charges,60% of Total Billed Charges,23.63,90,,12.944,Percent of Total Billed Charges,90% of Total Billed Charges,11.81,45,,3.816,Percent of Total Billed Charges,45% of Total Billed Charges,23.63,90,,7.632,Percent of Total Billed Charges,90% of Total billed Charges,26.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.06,65,,5.512,Percent of total Billed Charges,65% of Total Billed Charges,11.58,44.1,,3.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.94,95,,8.056,Percent of Total Billed Charges,95% of Total Billed Charges,26.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.1,88,,7.464,Percent of Total Billed Charges,88% of Total Billed Charges,23.63,90,,7.632,Percent of Total Billed charges,90% of Total Billed Charges,11.58,26.25,
"CUFF,BP,DISP,1TUBE,C",2710000217,CDM,271,RC,,,Outpatient,,,33.60,21.84,,33.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.54,76,,6.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.19,72,,180.352,Percent of Total Billed Charges,72% of Total Billed Charges,25.2,75,,187.864,Percent of Total Billed charges,75% of Total Billed Charges,33.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.19,72,,180.352,Percent of Total Billed Charges,72% of Total Billed Charges,20.16,60,,150.296,Percent of Total Billed Charges,60% of Total Billed Charges,30.24,90,,24.624,Percent of Total Billed Charges,90% of Total Billed Charges,15.12,45,,45,Percent of Total Billed Charges,45% of Total Billed Charges,30.24,90,,7.632,Percent of Total Billed Charges,90% of Total billed Charges,33.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.84,65,,5.512,Percent of total Billed Charges,65% of Total Billed Charges,14.82,44.1,,44.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.92,95,,8.056,Percent of Total Billed Charges,95% of Total Billed Charges,33.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.57,88,,7.464,Percent of Total Billed Charges,88% of Total Billed Charges,30.24,90,,7.632,Percent of Total Billed charges,90% of Total Billed Charges,14.82,33.6,
"CUFF,BP,DISP,1TUBE",2710000218,CDM,271,RC,,,Outpatient,,,36.75,23.89,,36.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.93,76,,6.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.46,72,,180.352,Percent of Total Billed Charges,72% of Total Billed Charges,27.56,75,,187.864,Percent of Total Billed charges,75% of Total Billed Charges,36.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,72,,180.352,Percent of Total Billed Charges,72% of Total Billed Charges,22.05,60,,150.296,Percent of Total Billed Charges,60% of Total Billed Charges,33.08,90,,2.4,Percent of Total Billed Charges,90% of Total Billed Charges,16.54,45,,28.936,Percent of Total Billed Charges,45% of Total Billed Charges,33.08,90,,7.632,Percent of Total Billed Charges,90% of Total billed Charges,36.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.89,65,,65,Percent of total Billed Charges,65% of Total Billed Charges,16.21,44.1,,28.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.91,95,,8.056,Percent of Total Billed Charges,95% of Total Billed Charges,36.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.34,88,,7.464,Percent of Total Billed Charges,88% of Total Billed Charges,33.08,90,,7.632,Percent of Total Billed charges,90% of Total Billed Charges,16.21,36.75,
BREATHING BAG 1L LATEX FREE,2710000219,CDM,271,RC,,,Outpatient,,,1.96,1.27,,1.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.49,76,,6.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.41,72,,26.496,Percent of Total Billed Charges,72% of Total Billed Charges,1.47,75,,27.6,Percent of Total Billed charges,75% of Total Billed Charges,1.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.41,72,,26.496,Percent of Total Billed Charges,72% of Total Billed Charges,1.18,60,,22.08,Percent of Total Billed Charges,60% of Total Billed Charges,1.76,90,,2.848,Percent of Total Billed Charges,90% of Total Billed Charges,0.88,45,,13.296,Percent of Total Billed Charges,45% of Total Billed Charges,1.76,90,,7.632,Percent of Total Billed Charges,90% of Total billed Charges,1.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.27,65,,41.8,Percent of total Billed Charges,65% of Total Billed Charges,0.86,44.1,,13.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.86,95,,8.056,Percent of Total Billed Charges,95% of Total Billed Charges,1.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.72,88,,7.464,Percent of Total Billed Charges,88% of Total Billed Charges,1.76,90,,7.632,Percent of Total Billed charges,90% of Total Billed Charges,0.86,1.96,
BREATHING BAG 2L LATEX FREE,2710000220,CDM,271,RC,,,Outpatient,,,3.45,2.24,,3.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.62,76,,76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.48,72,,36.832,Percent of Total Billed Charges,72% of Total Billed Charges,2.59,75,,38.368,Percent of Total Billed charges,75% of Total Billed Charges,3.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.48,72,,36.832,Percent of Total Billed Charges,72% of Total Billed Charges,2.07,60,,30.696,Percent of Total Billed Charges,60% of Total Billed Charges,3.11,90,,12.984,Percent of Total Billed Charges,90% of Total Billed Charges,1.55,45,,9.584,Percent of Total Billed Charges,45% of Total Billed Charges,3.11,90,,90,Percent of Total Billed Charges,90% of Total billed Charges,3.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.24,65,,19.2,Percent of total Billed Charges,65% of Total Billed Charges,1.52,44.1,,9.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.28,95,,95,Percent of Total Billed Charges,95% of Total Billed Charges,3.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.04,88,,88,Percent of Total Billed Charges,88% of Total Billed Charges,3.11,90,,90,Percent of Total Billed charges,90% of Total Billed Charges,1.52,3.45,
IV CATH 22G X 1 JELCO,2710000221,CDM,271,RC,,,Outpatient,,,2.13,1.38,,2.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.62,76,,48.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.53,72,,36.832,Percent of Total Billed Charges,72% of Total Billed Charges,1.6,75,,38.368,Percent of Total Billed charges,75% of Total Billed Charges,2.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.53,72,,36.832,Percent of Total Billed Charges,72% of Total Billed Charges,1.28,60,,30.696,Percent of Total Billed Charges,60% of Total Billed Charges,1.92,90,,3.456,Percent of Total Billed Charges,90% of Total Billed Charges,0.96,45,,3.72,Percent of Total Billed Charges,45% of Total Billed Charges,1.92,90,,57.872,Percent of Total Billed Charges,90% of Total billed Charges,2.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.38,65,,13.848,Percent of total Billed Charges,65% of Total Billed Charges,0.94,44.1,,3.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.02,95,,61.088,Percent of Total Billed Charges,95% of Total Billed Charges,2.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.87,88,,56.584,Percent of Total Billed Charges,88% of Total Billed Charges,1.92,90,,57.872,Percent of Total Billed charges,90% of Total Billed Charges,0.94,2.13,
IV CATH 20G X1 3/4 JELCO,2710000222,CDM,271,RC,,,Outpatient,,,2.58,1.68,,2.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.96,76,,22.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.86,72,,45.792,Percent of Total Billed Charges,72% of Total Billed Charges,1.94,75,,47.704,Percent of Total Billed charges,75% of Total Billed Charges,2.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.86,72,,45.792,Percent of Total Billed Charges,72% of Total Billed Charges,1.55,60,,38.16,Percent of Total Billed Charges,60% of Total Billed Charges,2.32,90,,7.344,Percent of Total Billed Charges,90% of Total Billed Charges,1.16,45,,6.472,Percent of Total Billed Charges,45% of Total Billed Charges,2.32,90,,26.592,Percent of Total Billed Charges,90% of Total billed Charges,2.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.68,65,,5.368,Percent of total Billed Charges,65% of Total Billed Charges,1.14,44.1,,6.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.45,95,,28.064,Percent of Total Billed Charges,95% of Total Billed Charges,2.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.27,88,,26,Percent of Total Billed Charges,88% of Total Billed Charges,2.32,90,,26.592,Percent of Total Billed charges,90% of Total Billed Charges,1.14,2.58,
IV CATH 16G X 1 1/4 CATHLON,2710000223,CDM,271,RC,,,Outpatient,,,1.99,1.29,,1.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.51,76,,16.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.43,72,,1455.152,Percent of Total Billed Charges,72% of Total Billed Charges,1.49,75,,1515.784,Percent of Total Billed charges,75% of Total Billed Charges,1.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.43,72,,1455.152,Percent of Total Billed Charges,72% of Total Billed Charges,1.19,60,,1212.624,Percent of Total Billed Charges,60% of Total Billed Charges,1.79,90,,10.512,Percent of Total Billed Charges,90% of Total Billed Charges,0.9,45,,12.312,Percent of Total Billed Charges,45% of Total Billed Charges,1.79,90,,19.176,Percent of Total Billed Charges,90% of Total billed Charges,1.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.29,65,,9.352,Percent of total Billed Charges,65% of Total Billed Charges,0.88,44.1,,12.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.89,95,,20.24,Percent of Total Billed Charges,95% of Total Billed Charges,1.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.75,88,,18.744,Percent of Total Billed Charges,88% of Total Billed Charges,1.79,90,,19.176,Percent of Total Billed charges,90% of Total Billed Charges,0.88,1.99,
ADULT BREATHING CIRCUITS,2710000224,CDM,271,RC,,,Outpatient,,,14.26,9.27,,14.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.84,76,,6.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.27,72,,690.08,Percent of Total Billed Charges,72% of Total Billed Charges,10.7,75,,718.832,Percent of Total Billed charges,75% of Total Billed Charges,14.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.27,72,,690.08,Percent of Total Billed Charges,72% of Total Billed Charges,8.56,60,,575.064,Percent of Total Billed Charges,60% of Total Billed Charges,12.83,90,,5.872,Percent of Total Billed Charges,90% of Total Billed Charges,6.42,45,,1.2,Percent of Total Billed Charges,45% of Total Billed Charges,12.83,90,,7.44,Percent of Total Billed Charges,90% of Total billed Charges,14.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.27,65,,17.784,Percent of total Billed Charges,65% of Total Billed Charges,6.29,44.1,,1.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.55,95,,7.848,Percent of Total Billed Charges,95% of Total Billed Charges,14.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.55,88,,7.272,Percent of Total Billed Charges,88% of Total Billed Charges,12.83,90,,7.44,Percent of Total Billed charges,90% of Total Billed Charges,6.29,14.26,
IV CATH 18G X 1 1/4 CATHLON,2710000225,CDM,271,RC,,,Outpatient,,,2.88,1.87,,2.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.19,76,,10.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.07,72,,244.944,Percent of Total Billed Charges,72% of Total Billed Charges,2.16,75,,255.152,Percent of Total Billed charges,75% of Total Billed Charges,2.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.07,72,,244.944,Percent of Total Billed Charges,72% of Total Billed Charges,1.73,60,,204.12,Percent of Total Billed Charges,60% of Total Billed Charges,2.59,90,,0.72,Percent of Total Billed Charges,90% of Total Billed Charges,1.3,45,,1.424,Percent of Total Billed Charges,45% of Total Billed Charges,2.59,90,,12.944,Percent of Total Billed Charges,90% of Total billed Charges,2.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.87,65,,1.728,Percent of total Billed Charges,65% of Total Billed Charges,1.27,44.1,,1.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.74,95,,13.664,Percent of Total Billed Charges,95% of Total Billed Charges,2.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.53,88,,12.656,Percent of Total Billed Charges,88% of Total Billed Charges,2.59,90,,12.944,Percent of Total Billed charges,90% of Total Billed Charges,1.27,2.88,
NASAL CANNULA SALTER STYLE,2710000226,CDM,271,RC,,,Outpatient,,,3.40,2.21,,3.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.58,76,,20.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.45,72,,153.216,Percent of Total Billed Charges,72% of Total Billed Charges,2.55,75,,159.6,Percent of Total Billed charges,75% of Total Billed Charges,3.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.45,72,,153.216,Percent of Total Billed Charges,72% of Total Billed Charges,2.04,60,,127.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,90,,70.344,Percent of Total Billed Charges,90% of Total Billed Charges,1.53,45,,6.488,Percent of Total Billed Charges,45% of Total Billed Charges,3.06,90,,24.624,Percent of Total Billed Charges,90% of Total billed Charges,3.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,65,,2.056,Percent of total Billed Charges,65% of Total Billed Charges,1.5,44.1,,6.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.23,95,,25.992,Percent of Total Billed Charges,95% of Total Billed Charges,3.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.99,88,,24.08,Percent of Total Billed Charges,88% of Total Billed Charges,3.06,90,,24.624,Percent of Total Billed charges,90% of Total Billed Charges,1.5,3.4,
"ARM BOARD DISP 9""",2710000227,CDM,271,RC,,,Outpatient,,,0.70,0.46,,0.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.53,76,,2.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.5,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,0.53,75,,27.12,Percent of Total Billed charges,75% of Total Billed Charges,0.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.5,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,0.42,60,,21.696,Percent of Total Billed Charges,60% of Total Billed Charges,0.63,90,,70.344,Percent of Total Billed Charges,90% of Total Billed Charges,0.32,45,,1.728,Percent of Total Billed Charges,45% of Total Billed Charges,0.63,90,,2.4,Percent of Total Billed Charges,90% of Total billed Charges,0.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.46,65,,9.376,Percent of total Billed Charges,65% of Total Billed Charges,0.31,44.1,,1.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.67,95,,2.528,Percent of Total Billed Charges,95% of Total Billed Charges,0.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.62,88,,2.344,Percent of Total Billed Charges,88% of Total Billed Charges,0.63,90,,2.4,Percent of Total Billed charges,90% of Total Billed Charges,0.31,0.7,
"ARM BOARD DISP 17.5""",2710000228,CDM,271,RC,,,Outpatient,,,0.92,0.60,,0.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.7,76,,2.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.66,72,,174,Percent of Total Billed Charges,72% of Total Billed Charges,0.69,75,,181.256,Percent of Total Billed charges,75% of Total Billed Charges,0.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.66,72,,174,Percent of Total Billed Charges,72% of Total Billed Charges,0.55,60,,145,Percent of Total Billed Charges,60% of Total Billed Charges,0.83,90,,123.04,Percent of Total Billed Charges,90% of Total Billed Charges,0.41,45,,3.672,Percent of Total Billed Charges,45% of Total Billed Charges,0.83,90,,2.848,Percent of Total Billed Charges,90% of Total billed Charges,0.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.6,65,,2.496,Percent of total Billed Charges,65% of Total Billed Charges,0.41,44.1,,3.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.87,95,,3,Percent of Total Billed Charges,95% of Total Billed Charges,0.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.81,88,,2.784,Percent of Total Billed Charges,88% of Total Billed Charges,0.83,90,,2.848,Percent of Total Billed charges,90% of Total Billed Charges,0.41,0.92,
CUFF BP DISP ADLT REG,2710000229,CDM,271,RC,,,Outpatient,,,3.84,2.50,,3.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.92,76,,10.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.76,72,,151.488,Percent of Total Billed Charges,72% of Total Billed Charges,2.88,75,,157.8,Percent of Total Billed charges,75% of Total Billed Charges,3.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.76,72,,151.488,Percent of Total Billed Charges,72% of Total Billed Charges,2.3,60,,126.24,Percent of Total Billed Charges,60% of Total Billed Charges,3.46,90,,36.408,Percent of Total Billed Charges,90% of Total Billed Charges,1.73,45,,5.256,Percent of Total Billed Charges,45% of Total Billed Charges,3.46,90,,12.984,Percent of Total Billed Charges,90% of Total billed Charges,3.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.5,65,,5.304,Percent of total Billed Charges,65% of Total Billed Charges,1.69,44.1,,5.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.65,95,,13.704,Percent of Total Billed Charges,95% of Total Billed Charges,3.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.38,88,,12.696,Percent of Total Billed Charges,88% of Total Billed Charges,3.46,90,,12.984,Percent of Total Billed charges,90% of Total Billed Charges,1.69,3.84,
CUFF BP DISP ADLT REG LONG,2710000230,CDM,271,RC,,,Outpatient,,,4.23,2.75,,4.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.21,76,,2.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.05,72,,952.56,Percent of Total Billed Charges,72% of Total Billed Charges,3.17,75,,992.248,Percent of Total Billed charges,75% of Total Billed Charges,4.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.05,72,,952.56,Percent of Total Billed Charges,72% of Total Billed Charges,2.54,60,,793.8,Percent of Total Billed Charges,60% of Total Billed Charges,3.81,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,1.9,45,,2.936,Percent of Total Billed Charges,45% of Total Billed Charges,3.81,90,,3.456,Percent of Total Billed Charges,90% of Total billed Charges,4.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.75,65,,7.592,Percent of total Billed Charges,65% of Total Billed Charges,1.87,44.1,,2.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.02,95,,3.648,Percent of Total Billed Charges,95% of Total Billed Charges,4.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.72,88,,3.376,Percent of Total Billed Charges,88% of Total Billed Charges,3.81,90,,3.456,Percent of Total Billed charges,90% of Total Billed Charges,1.87,4.23,
CUFF BP DISP ADLT LRG LONG,2710000231,CDM,271,RC,,,Outpatient,,,6.52,4.24,,6.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.96,76,,6.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.69,72,,990.664,Percent of Total Billed Charges,72% of Total Billed Charges,4.89,75,,1031.944,Percent of Total Billed charges,75% of Total Billed Charges,6.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.69,72,,990.664,Percent of Total Billed Charges,72% of Total Billed Charges,3.91,60,,825.552,Percent of Total Billed Charges,60% of Total Billed Charges,5.87,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,0.36,Percent of Total Billed Charges,45% of Total Billed Charges,5.87,90,,7.344,Percent of Total Billed Charges,90% of Total billed Charges,6.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.24,65,,4.24,Percent of total Billed Charges,65% of Total Billed Charges,2.88,44.1,,0.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.19,95,,7.752,Percent of Total Billed Charges,95% of Total Billed Charges,6.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.74,88,,7.184,Percent of Total Billed Charges,88% of Total Billed Charges,5.87,90,,7.344,Percent of Total Billed charges,90% of Total Billed Charges,2.88,6.52,
CUFF BP DISP ADLT SM,2710000232,CDM,271,RC,,,Outpatient,,,3.91,2.54,,3.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.97,76,,8.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.82,72,,40.896,Percent of Total Billed Charges,72% of Total Billed Charges,2.93,75,,42.6,Percent of Total Billed charges,75% of Total Billed Charges,3.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.82,72,,40.896,Percent of Total Billed Charges,72% of Total Billed Charges,2.35,60,,34.08,Percent of Total Billed Charges,60% of Total Billed Charges,3.52,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,1.76,45,,35.176,Percent of Total Billed Charges,45% of Total Billed Charges,3.52,90,,10.512,Percent of Total Billed Charges,90% of Total billed Charges,3.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.54,65,,0.52,Percent of total Billed Charges,65% of Total Billed Charges,1.72,44.1,,34.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.71,95,,11.096,Percent of Total Billed Charges,95% of Total Billed Charges,3.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.44,88,,10.28,Percent of Total Billed Charges,88% of Total Billed Charges,3.52,90,,10.512,Percent of Total Billed charges,90% of Total Billed Charges,1.72,3.91,
SKIN TEMP PROBE DISPOSABLE,2710000233,CDM,271,RC,,,Outpatient,,,2.98,1.94,,2.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.26,76,,4.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.15,72,,204.944,Percent of Total Billed Charges,72% of Total Billed Charges,2.24,75,,213.488,Percent of Total Billed charges,75% of Total Billed Charges,2.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,72,,204.944,Percent of Total Billed Charges,72% of Total Billed Charges,1.79,60,,170.792,Percent of Total Billed Charges,60% of Total Billed Charges,2.68,90,,123.04,Percent of Total Billed Charges,90% of Total Billed Charges,1.34,45,,35.176,Percent of Total Billed Charges,45% of Total Billed Charges,2.68,90,,5.872,Percent of Total Billed Charges,90% of Total billed Charges,2.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,65,,50.808,Percent of total Billed Charges,65% of Total Billed Charges,1.31,44.1,,34.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.83,95,,6.192,Percent of Total Billed Charges,95% of Total Billed Charges,2.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.62,88,,5.736,Percent of Total Billed Charges,88% of Total Billed Charges,2.68,90,,5.872,Percent of Total Billed charges,90% of Total Billed Charges,1.31,2.98,
CHILD SMALL MASK SZ 3,2710000234,CDM,271,RC,,,Outpatient,,,1.49,0.97,,1.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.13,76,,0.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.07,72,,133.376,Percent of Total Billed Charges,72% of Total Billed Charges,1.12,75,,138.936,Percent of Total Billed charges,75% of Total Billed Charges,1.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.07,72,,133.376,Percent of Total Billed Charges,72% of Total Billed Charges,0.89,60,,111.152,Percent of Total Billed Charges,60% of Total Billed Charges,1.34,90,,91.272,Percent of Total Billed Charges,90% of Total Billed Charges,0.67,45,,61.52,Percent of Total Billed Charges,45% of Total Billed Charges,1.34,90,,0.72,Percent of Total Billed Charges,90% of Total billed Charges,1.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,65,,50.808,Percent of total Billed Charges,65% of Total Billed Charges,0.66,44.1,,60.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.42,95,,0.76,Percent of Total Billed Charges,95% of Total Billed Charges,1.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.31,88,,0.704,Percent of Total Billed Charges,88% of Total Billed Charges,1.34,90,,0.72,Percent of Total Billed charges,90% of Total Billed Charges,0.66,1.49,
CHILD SMALL MASK SZ 3,2710000235,CDM,271,RC,,,Outpatient,,,2.00,1.30,,2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.52,76,,59.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.44,72,,160.992,Percent of Total Billed Charges,72% of Total Billed Charges,1.5,75,,160.992,Percent of Total Billed charges,75% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,72,,160.992,Percent of Total Billed Charges,72% of Total Billed Charges,1.2,60,,134.16,Percent of Total Billed Charges,60% of Total Billed Charges,1.8,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,0.9,45,,18.208,Percent of Total Billed Charges,45% of Total Billed Charges,1.8,90,,70.344,Percent of Total Billed Charges,90% of Total billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,65,,88.864,Percent of total Billed Charges,65% of Total Billed Charges,0.88,44.1,,17.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.9,95,,74.256,Percent of Total Billed Charges,95% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.76,88,,68.784,Percent of Total Billed Charges,88% of Total Billed Charges,1.8,90,,70.344,Percent of Total Billed charges,90% of Total Billed Charges,0.88,2,
3-WAY LARGE BORE STOPCOCK,2710000236,CDM,271,RC,,,Outpatient,,,12.40,8.06,,12.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.42,76,,59.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.93,72,,255.92,Percent of Total Billed Charges,72% of Total Billed Charges,9.3,75,,266.584,Percent of Total Billed charges,75% of Total Billed Charges,12.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.93,72,,255.92,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,60,,213.272,Percent of Total Billed Charges,60% of Total Billed Charges,11.16,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,5.58,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,11.16,90,,70.344,Percent of Total Billed Charges,90% of Total billed Charges,12.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.06,65,,26.296,Percent of total Billed Charges,65% of Total Billed Charges,5.47,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.78,95,,74.256,Percent of Total Billed Charges,95% of Total Billed Charges,12.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.91,88,,68.784,Percent of Total Billed Charges,88% of Total Billed Charges,11.16,90,,70.344,Percent of Total Billed charges,90% of Total Billed Charges,5.47,12.4,
CHILD SMALL MASK SZ3,2710000237,CDM,271,RC,,,Outpatient,,,2.00,1.30,,2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.52,76,,103.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.44,72,,11.016,Percent of Total Billed Charges,72% of Total Billed Charges,1.5,75,,11.472,Percent of Total Billed charges,75% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,72,,11.016,Percent of Total Billed Charges,72% of Total Billed Charges,1.2,60,,9.176,Percent of Total Billed Charges,60% of Total Billed Charges,1.8,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,0.9,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,1.8,90,,123.04,Percent of Total Billed Charges,90% of Total billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,0.88,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.9,95,,129.88,Percent of Total Billed Charges,95% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.76,88,,120.304,Percent of Total Billed Charges,88% of Total Billed Charges,1.8,90,,123.04,Percent of Total Billed charges,90% of Total Billed Charges,0.88,2,
SKIN TEMP PROBE DISPOSABLE,2710000238,CDM,271,RC,,,Outpatient,,,2.98,1.94,,2.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.26,76,,30.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.15,72,,141.12,Percent of Total Billed Charges,72% of Total Billed Charges,2.24,75,,147,Percent of Total Billed charges,75% of Total Billed Charges,2.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,72,,141.12,Percent of Total Billed Charges,72% of Total Billed Charges,1.79,60,,117.6,Percent of Total Billed Charges,60% of Total Billed Charges,2.68,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,1.34,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,2.68,90,,36.408,Percent of Total Billed Charges,90% of Total billed Charges,2.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,1.31,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.83,95,,38.432,Percent of Total Billed Charges,95% of Total Billed Charges,2.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.62,88,,35.6,Percent of Total Billed Charges,88% of Total Billed Charges,2.68,90,,36.408,Percent of Total Billed charges,90% of Total Billed Charges,1.31,2.98,
PRIMARY W/O FILTER TUBING,2710000239,CDM,271,RC,,,Outpatient,,,30.00,19.50,,30,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.8,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.6,72,,133.376,Percent of Total Billed Charges,72% of Total Billed Charges,22.5,75,,138.936,Percent of Total Billed charges,75% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.6,72,,133.376,Percent of Total Billed Charges,72% of Total Billed Charges,18,60,,111.152,Percent of Total Billed Charges,60% of Total Billed Charges,27,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,45,,61.52,Percent of Total Billed Charges,45% of Total Billed Charges,27,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.5,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,13.23,44.1,,60.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.5,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.4,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,27,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,13.23,30,
PAIN EASE SPRAY 1.0OZ,2710000240,CDM,271,RC,,,Outpatient,,,11.71,7.61,,11.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.9,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.43,72,,160.992,Percent of Total Billed Charges,72% of Total Billed Charges,8.78,75,,167.704,Percent of Total Billed charges,75% of Total Billed Charges,11.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.43,72,,160.992,Percent of Total Billed Charges,72% of Total Billed Charges,7.03,60,,134.16,Percent of Total Billed Charges,60% of Total Billed Charges,10.54,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,5.27,45,,45.64,Percent of Total Billed Charges,45% of Total Billed Charges,10.54,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,11.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.61,65,,88.864,Percent of total Billed Charges,65% of Total Billed Charges,5.16,44.1,,44.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.12,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,11.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.3,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,10.54,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,5.16,11.71,
ADULT VITAL ELECTRODES,2710000241,CDM,271,RC,,,Outpatient,,,17.76,11.54,,17.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.5,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.79,72,,107.656,Percent of Total Billed Charges,72% of Total Billed Charges,13.32,75,,112.144,Percent of Total Billed charges,75% of Total Billed Charges,17.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.79,72,,107.656,Percent of Total Billed Charges,72% of Total Billed Charges,10.66,60,,89.712,Percent of Total Billed Charges,60% of Total Billed Charges,15.98,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,15.98,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,17.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.54,65,,65.92,Percent of total Billed Charges,65% of Total Billed Charges,7.83,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.87,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,17.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.63,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,15.98,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,7.83,17.76,
Cannula Adult Oral/Nasal CO2,2710000242,CDM,271,RC,,,Outpatient,,,35.00,22.75,,35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.6,76,,103.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.2,72,,107.656,Percent of Total Billed Charges,72% of Total Billed Charges,26.25,75,,112.144,Percent of Total Billed charges,75% of Total Billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.2,72,,107.656,Percent of Total Billed Charges,72% of Total Billed Charges,21,60,,89.712,Percent of Total Billed Charges,60% of Total Billed Charges,31.5,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,15.75,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,31.5,90,,123.04,Percent of Total Billed Charges,90% of Total billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.75,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,15.44,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.25,95,,129.88,Percent of Total Billed Charges,95% of Total Billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.8,88,,120.304,Percent of Total Billed Charges,88% of Total Billed Charges,31.5,90,,123.04,Percent of Total Billed charges,90% of Total Billed Charges,15.44,35,
Sterile RF Headcover (6177),2710000243,CDM,271,RC,,,Outpatient,,,30.00,19.50,,30,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.8,76,,77.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.6,72,,204.488,Percent of Total Billed Charges,72% of Total Billed Charges,22.5,75,,213.008,Percent of Total Billed charges,75% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.6,72,,204.488,Percent of Total Billed Charges,72% of Total Billed Charges,18,60,,170.408,Percent of Total Billed Charges,60% of Total Billed Charges,27,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,27,90,,91.272,Percent of Total Billed Charges,90% of Total billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.5,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,13.23,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.5,95,,96.344,Percent of Total Billed Charges,95% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.4,88,,89.248,Percent of Total Billed Charges,88% of Total Billed Charges,27,90,,91.272,Percent of Total Billed charges,90% of Total Billed Charges,13.23,30,
TED Hose Knee SM/Long,2710000244,CDM,271,RC,,,Outpatient,,,5.83,3.79,,5.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.43,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.2,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,4.37,75,,918,Percent of Total Billed charges,75% of Total Billed Charges,5.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.2,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,3.5,60,,734.4,Percent of Total Billed Charges,60% of Total Billed Charges,5.25,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.62,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,5.25,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,5.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.79,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,2.57,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.54,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,5.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.13,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,5.25,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,2.57,5.83,
Incont Breifs-Med LF,2710000245,CDM,271,RC,,,Outpatient,,,0.60,0.39,,0.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.46,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.43,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,0.45,75,,918,Percent of Total Billed charges,75% of Total Billed Charges,0.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.43,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,0.36,60,,734.4,Percent of Total Billed Charges,60% of Total Billed Charges,0.54,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,0.27,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,0.54,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,0.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.39,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,0.26,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.57,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,0.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.53,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,0.54,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,0.26,0.6,
TED Hose Knee Sm/Reg,2710000246,CDM,271,RC,,,Outpatient,,,4.88,3.17,,4.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.71,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.51,72,,204.488,Percent of Total Billed Charges,72% of Total Billed Charges,3.66,75,,213.008,Percent of Total Billed charges,75% of Total Billed Charges,4.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.51,72,,204.488,Percent of Total Billed Charges,72% of Total Billed Charges,2.93,60,,170.408,Percent of Total Billed Charges,60% of Total Billed Charges,4.39,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.2,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,4.39,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,4.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.17,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,2.15,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.64,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,4.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.29,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,4.39,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,2.15,4.88,
Rad Rest,2710000247,CDM,271,RC,,,Outpatient,,,37.60,24.44,,37.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.58,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.07,72,,255.92,Percent of Total Billed Charges,72% of Total Billed Charges,28.2,75,,266.584,Percent of Total Billed charges,75% of Total Billed Charges,37.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.07,72,,255.92,Percent of Total Billed Charges,72% of Total Billed Charges,22.56,60,,213.272,Percent of Total Billed Charges,60% of Total Billed Charges,33.84,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,16.92,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,33.84,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,37.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.44,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,16.58,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.72,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,37.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.09,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,33.84,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,16.58,37.6,
Adult Circuits Medline,2710000248,CDM,271,RC,,,Outpatient,,,26.28,17.08,,26.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.97,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.92,72,,53.088,Percent of Total Billed Charges,72% of Total Billed Charges,19.71,75,,55.296,Percent of Total Billed charges,75% of Total Billed Charges,26.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.92,72,,53.088,Percent of Total Billed Charges,72% of Total Billed Charges,15.77,60,,44.24,Percent of Total Billed Charges,60% of Total Billed Charges,23.65,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,11.83,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,23.65,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,26.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.08,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,11.59,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.97,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,26.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.13,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,23.65,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,11.59,26.28,
Particulate Filter,2710000249,CDM,271,RC,,,Outpatient,,,21.43,13.93,,21.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.29,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.43,72,,53.088,Percent of Total Billed Charges,72% of Total Billed Charges,16.07,75,,55.296,Percent of Total Billed charges,75% of Total Billed Charges,21.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.43,72,,53.088,Percent of Total Billed Charges,72% of Total Billed Charges,12.86,60,,44.24,Percent of Total Billed Charges,60% of Total Billed Charges,19.29,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,9.64,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,19.29,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,21.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.93,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,9.45,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.36,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,21.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.86,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,19.29,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,9.45,21.43,
Air Inlet Foam Filter,2710000250,CDM,271,RC,,,Outpatient,,,1.08,0.70,,1.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.82,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.78,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,0.81,75,,36,Percent of Total Billed charges,75% of Total Billed Charges,1.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.78,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,0.65,60,,28.8,Percent of Total Billed Charges,60% of Total Billed Charges,0.97,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,0.49,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,0.97,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,1.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.7,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,0.48,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.03,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,1.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.95,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,0.97,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,0.48,1.08,
"Circuit,Disp, 22mm, Non heated",2710000251,CDM,271,RC,,,Outpatient,,,26.58,17.28,,26.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.2,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.14,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,19.94,75,,54,Percent of Total Billed charges,75% of Total Billed Charges,26.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.14,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,15.95,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,23.92,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,11.96,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,23.92,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,26.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.28,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,11.72,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.25,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,26.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.39,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,23.92,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,11.72,26.58,
Sam Junct Tourniquet,2710000252,CDM,271,RC,,,Outpatient,,,612.00,397.80,,612,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.12,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.64,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,459,75,,54,Percent of Total Billed charges,75% of Total Billed Charges,612,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.64,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,367.2,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,550.8,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,275.4,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,550.8,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,612,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.8,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,269.89,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.4,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,612,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.56,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,550.8,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,269.89,612,
Sam Chest Seals,2710000253,CDM,271,RC,,,Outpatient,,,58.65,38.12,,58.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,44.57,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.23,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,43.99,75,,54,Percent of Total Billed charges,75% of Total Billed Charges,58.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.23,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,35.19,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,52.79,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,26.39,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,52.79,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,58.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.12,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,25.86,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,55.72,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,58.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.61,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,52.79,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,25.86,58.65,
Chitosam 100,2710000254,CDM,271,RC,,,Outpatient,,,56.13,36.48,,56.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.66,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.41,72,,661.712,Percent of Total Billed Charges,72% of Total Billed Charges,42.1,75,,689.288,Percent of Total Billed charges,75% of Total Billed Charges,56.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.41,72,,661.712,Percent of Total Billed Charges,72% of Total Billed Charges,33.68,60,,551.432,Percent of Total Billed Charges,60% of Total Billed Charges,50.52,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,25.26,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,50.52,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,56.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.48,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,24.75,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.32,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,56.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.39,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,50.52,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,24.75,56.13,
Hyperthermia Blanket,2710000255,CDM,271,RC,,,Outpatient,,,66.68,43.34,,66.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,50.68,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,48.01,72,,83.824,Percent of Total Billed Charges,72% of Total Billed Charges,50.01,75,,87.32,Percent of Total Billed charges,75% of Total Billed Charges,66.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.01,72,,83.824,Percent of Total Billed Charges,72% of Total Billed Charges,40.01,60,,69.856,Percent of Total Billed Charges,60% of Total Billed Charges,60.01,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,30.01,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,60.01,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,66.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.34,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,29.41,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,63.35,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,66.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.68,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,60.01,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,29.41,66.68,
Getinge Ocean Drain 2050,2710000256,CDM,271,RC,,,Outpatient,,,77.78,50.56,,77.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.11,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56,72,,8.456,Percent of Total Billed Charges,72% of Total Billed Charges,58.34,75,,8.808,Percent of Total Billed charges,75% of Total Billed Charges,77.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56,72,,8.456,Percent of Total Billed Charges,72% of Total Billed Charges,46.67,60,,7.048,Percent of Total Billed Charges,60% of Total Billed Charges,70,90,,214.328,Percent of Total Billed Charges,90% of Total Billed Charges,35,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,70,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,77.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.56,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,34.3,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.89,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,77.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.45,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,70,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,34.3,77.78,
Getinge Oasis Drain Pedi 3612,2710000257,CDM,271,RC,,,Outpatient,,,93.73,60.92,,93.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,71.23,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,67.49,72,,33.656,Percent of Total Billed Charges,72% of Total Billed Charges,70.3,75,,35.056,Percent of Total Billed charges,75% of Total Billed Charges,93.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.49,72,,33.656,Percent of Total Billed Charges,72% of Total Billed Charges,56.24,60,,28.048,Percent of Total Billed Charges,60% of Total Billed Charges,84.36,90,,214.328,Percent of Total Billed Charges,90% of Total Billed Charges,42.18,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,84.36,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,93.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.92,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,41.33,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,89.04,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,93.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.48,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,84.36,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,41.33,93.73,
Microemboli Blood Filter,2710000258,CDM,271,RC,,,Outpatient,,,32.48,21.11,,32.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.68,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.39,72,,106.688,Percent of Total Billed Charges,72% of Total Billed Charges,24.36,75,,111.136,Percent of Total Billed charges,75% of Total Billed Charges,32.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.39,72,,106.688,Percent of Total Billed Charges,72% of Total Billed Charges,19.49,60,,88.904,Percent of Total Billed Charges,60% of Total Billed Charges,29.23,90,,214.328,Percent of Total Billed Charges,90% of Total Billed Charges,14.62,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,29.23,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,32.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.11,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,14.32,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.86,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,32.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.58,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,29.23,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,14.32,32.48,
"Med Crutche 5""2"" to 5'10""(sub)",2710000259,CDM,271,RC,,,Outpatient,,,41.50,26.98,,41.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31.54,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.88,72,,77.752,Percent of Total Billed Charges,72% of Total Billed Charges,31.13,75,,80.992,Percent of Total Billed charges,75% of Total Billed Charges,41.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.88,72,,77.752,Percent of Total Billed Charges,72% of Total Billed Charges,24.9,60,,64.792,Percent of Total Billed Charges,60% of Total Billed Charges,37.35,90,,214.328,Percent of Total Billed Charges,90% of Total Billed Charges,18.68,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,37.35,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,41.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.98,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,18.3,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,39.43,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,41.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.52,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,37.35,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,18.3,41.5,
Anasept Antisept Skin Gel 3oz,2710000260,CDM,271,RC,,,Outpatient,,,45.95,29.87,,45.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.92,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.08,72,,456.592,Percent of Total Billed Charges,72% of Total Billed Charges,34.46,75,,475.624,Percent of Total Billed charges,75% of Total Billed Charges,45.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,72,,456.592,Percent of Total Billed Charges,72% of Total Billed Charges,27.57,60,,380.496,Percent of Total Billed Charges,60% of Total Billed Charges,41.36,90,,214.328,Percent of Total Billed Charges,90% of Total Billed Charges,20.68,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,41.36,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,45.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.87,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,20.26,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,43.65,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,45.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.44,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,41.36,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,20.26,45.95,
Dial-A-Flows Set,2710000261,CDM,271,RC,,,Outpatient,,,15.00,9.75,,15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.4,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.8,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,11.25,75,,36,Percent of Total Billed charges,75% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.8,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,9,60,,28.8,Percent of Total Billed Charges,60% of Total Billed Charges,13.5,90,,214.328,Percent of Total Billed Charges,90% of Total Billed Charges,6.75,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,13.5,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.75,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,6.62,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.25,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.2,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,13.5,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,6.62,15,
Hip Arthroscopy & FX Body Strp,2710000262,CDM,271,RC,,,Outpatient,,,30.00,19.50,,30,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.8,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.6,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,22.5,75,,28.448,Percent of Total Billed charges,75% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.6,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,18,60,,22.76,Percent of Total Billed Charges,60% of Total Billed Charges,27,90,,2361.6,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,45,,107.168,Percent of Total Billed Charges,45% of Total Billed Charges,27,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.5,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,13.23,44.1,,105.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.5,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.4,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,27,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,13.23,30,
"Armboard pad, large",2710000263,CDM,271,RC,,,Outpatient,,,22.50,14.63,,22.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.1,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.2,72,,141.12,Percent of Total Billed Charges,72% of Total Billed Charges,16.88,75,,141.12,Percent of Total Billed charges,75% of Total Billed Charges,22.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.2,72,,141.12,Percent of Total Billed Charges,72% of Total Billed Charges,13.5,60,,117.6,Percent of Total Billed Charges,60% of Total Billed Charges,20.25,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,10.13,45,,107.168,Percent of Total Billed Charges,45% of Total Billed Charges,20.25,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,22.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.63,65,,154.792,Percent of total Billed Charges,65% of Total Billed Charges,9.92,44.1,,105.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.38,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,22.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.8,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,20.25,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,9.92,22.5,
Boot Cradle Liner OSI Table,2710000264,CDM,271,RC,,,Outpatient,,,55.00,35.75,,55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.8,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.6,72,,62.72,Percent of Total Billed Charges,72% of Total Billed Charges,41.25,75,,65.336,Percent of Total Billed charges,75% of Total Billed Charges,55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.6,72,,62.72,Percent of Total Billed Charges,72% of Total Billed Charges,33,60,,52.264,Percent of Total Billed Charges,60% of Total Billed Charges,49.5,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,24.75,45,,107.168,Percent of Total Billed Charges,45% of Total Billed Charges,49.5,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.75,65,,154.792,Percent of total Billed Charges,65% of Total Billed Charges,24.26,44.1,,105.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.25,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.4,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,49.5,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,24.26,55,
Peg Board Kit,2710000265,CDM,271,RC,,,Outpatient,,,625.00,406.25,,625,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475,76,,180.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450,72,,1277.488,Percent of Total Billed Charges,72% of Total Billed Charges,468.75,75,,1330.72,Percent of Total Billed charges,75% of Total Billed Charges,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450,72,,1277.488,Percent of Total Billed Charges,72% of Total Billed Charges,375,60,,1064.576,Percent of Total Billed Charges,60% of Total Billed Charges,562.5,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,281.25,45,,107.168,Percent of Total Billed Charges,45% of Total Billed Charges,562.5,90,,214.328,Percent of Total Billed Charges,90% of Total billed Charges,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.25,65,,154.792,Percent of total Billed Charges,65% of Total Billed Charges,275.63,44.1,,105.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.75,95,,226.24,Percent of Total Billed Charges,95% of Total Billed Charges,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550,88,,209.568,Percent of Total Billed Charges,88% of Total Billed Charges,562.5,90,,214.328,Percent of Total Billed charges,90% of Total Billed Charges,275.63,625,
Pink Pad Kit XL,2710000266,CDM,271,RC,,,Outpatient,,,262.50,170.63,,262.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,199.5,76,,180.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,189,72,,3450.24,Percent of Total Billed Charges,72% of Total Billed Charges,196.88,75,,3450.24,Percent of Total Billed charges,75% of Total Billed Charges,262.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189,72,,3450.24,Percent of Total Billed Charges,72% of Total Billed Charges,157.5,60,,2875.2,Percent of Total Billed Charges,60% of Total Billed Charges,236.25,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,118.13,45,,107.168,Percent of Total Billed Charges,45% of Total Billed Charges,236.25,90,,214.328,Percent of Total Billed Charges,90% of Total billed Charges,262.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.63,65,,154.792,Percent of total Billed Charges,65% of Total Billed Charges,115.76,44.1,,105.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,249.38,95,,226.24,Percent of Total Billed Charges,95% of Total Billed Charges,262.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231,88,,209.568,Percent of Total Billed Charges,88% of Total Billed Charges,236.25,90,,214.328,Percent of Total Billed charges,90% of Total Billed Charges,115.76,262.5,
Duoderm Extra Thin 6 x 6,2710000267,CDM,271,RC,,,Outpatient,,,5.83,3.79,,5.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.43,76,,180.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.2,72,,3450.24,Percent of Total Billed Charges,72% of Total Billed Charges,4.37,75,,3450.24,Percent of Total Billed charges,75% of Total Billed Charges,5.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.2,72,,3450.24,Percent of Total Billed Charges,72% of Total Billed Charges,3.5,60,,2875.2,Percent of Total Billed Charges,60% of Total Billed Charges,5.25,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.62,45,,107.168,Percent of Total Billed Charges,45% of Total Billed Charges,5.25,90,,214.328,Percent of Total Billed Charges,90% of Total billed Charges,5.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.79,65,,154.792,Percent of total Billed Charges,65% of Total Billed Charges,2.57,44.1,,105.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.54,95,,226.24,Percent of Total Billed Charges,95% of Total Billed Charges,5.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.13,88,,209.568,Percent of Total Billed Charges,88% of Total Billed Charges,5.25,90,,214.328,Percent of Total Billed charges,90% of Total Billed Charges,2.57,5.83,
Metacarpel Splint STH Left,2710000268,CDM,271,RC,,,Outpatient,,,145.00,94.25,,145,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.2,76,,180.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,104.4,72,,3450.24,Percent of Total Billed Charges,72% of Total Billed Charges,108.75,75,,3450.24,Percent of Total Billed charges,75% of Total Billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.4,72,,3450.24,Percent of Total Billed Charges,72% of Total Billed Charges,87,60,,2875.2,Percent of Total Billed Charges,60% of Total Billed Charges,130.5,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,65.25,45,,1180.8,Percent of Total Billed Charges,45% of Total Billed Charges,130.5,90,,214.328,Percent of Total Billed Charges,90% of Total billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.25,65,,154.792,Percent of total Billed Charges,65% of Total Billed Charges,63.95,44.1,,1157.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,137.75,95,,226.24,Percent of Total Billed Charges,95% of Total Billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.6,88,,209.568,Percent of Total Billed Charges,88% of Total Billed Charges,130.5,90,,214.328,Percent of Total Billed charges,90% of Total Billed Charges,63.95,145,
Small Adult Mask (Sub),2710000269,CDM,271,RC,,,Outpatient,,,5.35,3.48,,5.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.07,76,,180.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.85,72,,3450.24,Percent of Total Billed Charges,72% of Total Billed Charges,4.01,75,,3450.24,Percent of Total Billed charges,75% of Total Billed Charges,5.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.85,72,,3450.24,Percent of Total Billed Charges,72% of Total Billed Charges,3.21,60,,2875.2,Percent of Total Billed Charges,60% of Total Billed Charges,4.82,90,,2577.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.41,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,4.82,90,,214.328,Percent of Total Billed Charges,90% of Total billed Charges,5.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.48,65,,1705.6,Percent of total Billed Charges,65% of Total Billed Charges,2.36,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.08,95,,226.24,Percent of Total Billed Charges,95% of Total Billed Charges,5.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.71,88,,209.568,Percent of Total Billed Charges,88% of Total Billed Charges,4.82,90,,214.328,Percent of Total Billed charges,90% of Total Billed Charges,2.36,5.35,
Endocuff Vision MD Blue 11.0,2710000270,CDM,271,RC,,,Outpatient,,,60.00,39.00,,60,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.6,76,,180.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.2,72,,3450.24,Percent of Total Billed Charges,72% of Total Billed Charges,45,75,,3450.24,Percent of Total Billed charges,75% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.2,72,,3450.24,Percent of Total Billed Charges,72% of Total Billed Charges,36,60,,2875.2,Percent of Total Billed Charges,60% of Total Billed Charges,54,90,,1602.688,Percent of Total Billed Charges,90% of Total Billed Charges,27,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,54,90,,214.328,Percent of Total Billed Charges,90% of Total billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,26.46,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,57,95,,226.24,Percent of Total Billed Charges,95% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.8,88,,209.568,Percent of Total Billed Charges,88% of Total Billed Charges,54,90,,214.328,Percent of Total Billed charges,90% of Total Billed Charges,26.46,60,
Inkless Footprinter,2710000271,CDM,271,RC,,,Outpatient,,,2.10,1.37,,2.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.6,76,,1994.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.51,72,,476.28,Percent of Total Billed Charges,72% of Total Billed Charges,1.58,75,,476.28,Percent of Total Billed charges,75% of Total Billed Charges,2.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.51,72,,476.28,Percent of Total Billed Charges,72% of Total Billed Charges,1.26,60,,396.904,Percent of Total Billed Charges,60% of Total Billed Charges,1.89,90,,109.624,Percent of Total Billed Charges,90% of Total Billed Charges,0.95,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,1.89,90,,2361.6,Percent of Total Billed Charges,90% of Total billed Charges,2.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.37,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,0.93,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,2,95,,2492.8,Percent of Total Billed Charges,95% of Total Billed Charges,2.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.85,88,,2309.12,Percent of Total Billed Charges,88% of Total Billed Charges,1.89,90,,2361.6,Percent of Total Billed charges,90% of Total Billed Charges,0.93,2.1,
Nasal Rae Cuffed 4.5,2710000272,CDM,271,RC,,,Outpatient,,,17.25,11.21,,17.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.11,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.42,72,,476.28,Percent of Total Billed Charges,72% of Total Billed Charges,12.94,75,,476.28,Percent of Total Billed charges,75% of Total Billed Charges,17.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.42,72,,476.28,Percent of Total Billed Charges,72% of Total Billed Charges,10.35,60,,396.904,Percent of Total Billed Charges,60% of Total Billed Charges,15.53,90,,118.272,Percent of Total Billed Charges,90% of Total Billed Charges,7.76,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,15.53,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,17.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.21,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,7.61,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.39,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,17.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.18,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,15.53,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,7.61,17.25,
PENUMBRA CANISTER-INDIGO SYSTM,2710000273,CDM,271,RC,,,Outpatient,,,900.00,585.00,,900,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,684,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,648,72,,313.92,Percent of Total Billed Charges,72% of Total Billed Charges,675,75,,327,Percent of Total Billed charges,75% of Total Billed Charges,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,648,72,,313.92,Percent of Total Billed Charges,72% of Total Billed Charges,540,60,,261.6,Percent of Total Billed Charges,60% of Total Billed Charges,810,90,,48.424,Percent of Total Billed Charges,90% of Total Billed Charges,405,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,810,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,585,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,396.9,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,855,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,792,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,810,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,396.9,900,
Cuff Pressure Connecting tube,2710000274,CDM,271,RC,,,Outpatient,,,14.30,9.30,,14.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.87,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.3,72,,119.752,Percent of Total Billed Charges,72% of Total Billed Charges,10.73,75,,124.744,Percent of Total Billed charges,75% of Total Billed Charges,14.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.3,72,,119.752,Percent of Total Billed Charges,72% of Total Billed Charges,8.58,60,,99.792,Percent of Total Billed Charges,60% of Total Billed Charges,12.87,90,,48.424,Percent of Total Billed Charges,90% of Total Billed Charges,6.44,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,12.87,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,14.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.3,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,6.31,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.59,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,14.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.58,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,12.87,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,6.31,14.3,
SUCTION CANISTER 1500ML(SUB,2710000275,CDM,271,RC,,,Outpatient,,,5.18,3.37,,5.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.94,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.73,72,,119.752,Percent of Total Billed Charges,72% of Total Billed Charges,3.89,75,,124.744,Percent of Total Billed charges,75% of Total Billed Charges,5.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.73,72,,119.752,Percent of Total Billed Charges,72% of Total Billed Charges,3.11,60,,99.792,Percent of Total Billed Charges,60% of Total Billed Charges,4.66,90,,123.832,Percent of Total Billed Charges,90% of Total Billed Charges,2.33,45,,1288.8,Percent of Total Billed Charges,45% of Total Billed Charges,4.66,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,5.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.37,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,2.28,44.1,,1263.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.92,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,5.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.56,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,4.66,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,2.28,5.18,
Wrst Frm Splt w/Abd thmb Lg LT,2710000276,CDM,271,RC,,,Outpatient,,,49.90,32.44,,49.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,37.92,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,35.93,72,,164.656,Percent of Total Billed Charges,72% of Total Billed Charges,37.43,75,,171.52,Percent of Total Billed charges,75% of Total Billed Charges,49.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.93,72,,164.656,Percent of Total Billed Charges,72% of Total Billed Charges,29.94,60,,137.216,Percent of Total Billed Charges,60% of Total Billed Charges,44.91,90,,127.432,Percent of Total Billed Charges,90% of Total Billed Charges,22.46,45,,801.344,Percent of Total Billed Charges,45% of Total Billed Charges,44.91,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,49.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.44,65,,1861.6,Percent of total Billed Charges,65% of Total Billed Charges,22.01,44.1,,785.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,47.41,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,49.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.91,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,44.91,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,22.01,49.9,
Wrst Frm Splt w/Abd Md LT,2710000277,CDM,271,RC,,,Outpatient,,,48.55,31.56,,48.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.9,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.96,72,,74.848,Percent of Total Billed Charges,72% of Total Billed Charges,36.41,75,,77.968,Percent of Total Billed charges,75% of Total Billed Charges,48.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.96,72,,74.848,Percent of Total Billed Charges,72% of Total Billed Charges,29.13,60,,62.368,Percent of Total Billed Charges,60% of Total Billed Charges,43.7,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,21.85,45,,54.808,Percent of Total Billed Charges,45% of Total Billed Charges,43.7,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,48.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.56,65,,1157.496,Percent of total Billed Charges,65% of Total Billed Charges,21.41,44.1,,53.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.12,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,48.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.72,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,43.7,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,21.41,48.55,
Wrst Frm Splt s/Abd Thmb Sm LT,2710000278,CDM,271,RC,,,Outpatient,,,47.75,31.04,,47.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.29,76,,2176.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.38,72,,74.848,Percent of Total Billed Charges,72% of Total Billed Charges,35.81,75,,77.968,Percent of Total Billed charges,75% of Total Billed Charges,47.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.38,72,,74.848,Percent of Total Billed Charges,72% of Total Billed Charges,28.65,60,,62.368,Percent of Total Billed Charges,60% of Total Billed Charges,42.98,90,,219.24,Percent of Total Billed Charges,90% of Total Billed Charges,21.49,45,,59.136,Percent of Total Billed Charges,45% of Total Billed Charges,42.98,90,,2577.6,Percent of Total Billed Charges,90% of Total billed Charges,47.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.04,65,,79.168,Percent of total Billed Charges,65% of Total Billed Charges,21.06,44.1,,57.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.36,95,,2720.8,Percent of Total Billed Charges,95% of Total Billed Charges,47.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.02,88,,2520.32,Percent of Total Billed Charges,88% of Total Billed Charges,42.98,90,,2577.6,Percent of Total Billed charges,90% of Total Billed Charges,21.06,47.75,
Wrst Frm Splt w/Abd XS LT,2710000279,CDM,271,RC,,,Outpatient,,,49.28,32.03,,49.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,37.45,76,,1353.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,35.48,72,,42.944,Percent of Total Billed Charges,72% of Total Billed Charges,36.96,75,,44.728,Percent of Total Billed charges,75% of Total Billed Charges,49.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.48,72,,42.944,Percent of Total Billed Charges,72% of Total Billed Charges,29.57,60,,35.784,Percent of Total Billed Charges,60% of Total Billed Charges,44.35,90,,141.12,Percent of Total Billed Charges,90% of Total Billed Charges,22.18,45,,24.208,Percent of Total Billed Charges,45% of Total Billed Charges,44.35,90,,1602.688,Percent of Total Billed Charges,90% of Total billed Charges,49.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.03,65,,85.424,Percent of total Billed Charges,65% of Total Billed Charges,21.73,44.1,,23.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.82,95,,1691.72,Percent of Total Billed Charges,95% of Total Billed Charges,49.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.37,88,,1567.072,Percent of Total Billed Charges,88% of Total Billed Charges,44.35,90,,1602.688,Percent of Total Billed charges,90% of Total Billed Charges,21.73,49.28,
Wrst Frm Splt w/Abd Thmb Lg Rt,2710000280,CDM,271,RC,,,Outpatient,,,51.50,33.48,,51.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,39.14,76,,92.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,37.08,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,38.63,75,,480,Percent of Total Billed charges,75% of Total Billed Charges,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.08,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,30.9,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,46.35,90,,219.24,Percent of Total Billed Charges,90% of Total Billed Charges,23.18,45,,24.208,Percent of Total Billed Charges,45% of Total Billed Charges,46.35,90,,109.624,Percent of Total Billed Charges,90% of Total billed Charges,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.48,65,,34.968,Percent of total Billed Charges,65% of Total Billed Charges,22.71,44.1,,23.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.93,95,,115.712,Percent of Total Billed Charges,95% of Total Billed Charges,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.32,88,,107.184,Percent of Total Billed Charges,88% of Total Billed Charges,46.35,90,,109.624,Percent of Total Billed charges,90% of Total Billed Charges,22.71,51.5,
Wrst Frm Splt w/abd thmb S RT,2710000281,CDM,271,RC,,,Outpatient,,,48.20,31.33,,48.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.63,76,,99.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.7,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,36.15,75,,480,Percent of Total Billed charges,75% of Total Billed Charges,48.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.7,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,28.92,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,43.38,90,,141.12,Percent of Total Billed Charges,90% of Total Billed Charges,21.69,45,,61.92,Percent of Total Billed Charges,45% of Total Billed Charges,43.38,90,,118.272,Percent of Total Billed Charges,90% of Total billed Charges,48.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.33,65,,34.968,Percent of total Billed Charges,65% of Total Billed Charges,21.26,44.1,,60.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.79,95,,124.848,Percent of Total Billed Charges,95% of Total Billed Charges,48.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.42,88,,115.648,Percent of Total Billed Charges,88% of Total Billed Charges,43.38,90,,118.272,Percent of Total Billed charges,90% of Total Billed Charges,21.26,48.2,
Wrst Frm Splt w/Abd thmb XS Rt,2710000282,CDM,271,RC,,,Outpatient,,,50.20,32.63,,50.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38.15,76,,40.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36.14,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,37.65,75,,480,Percent of Total Billed charges,75% of Total Billed Charges,50.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.14,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,30.12,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,45.18,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,22.59,45,,63.72,Percent of Total Billed Charges,45% of Total Billed Charges,45.18,90,,48.424,Percent of Total Billed Charges,90% of Total billed Charges,50.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.63,65,,89.432,Percent of total Billed Charges,65% of Total Billed Charges,22.14,44.1,,62.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,47.69,95,,51.112,Percent of Total Billed Charges,95% of Total Billed Charges,50.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.18,88,,47.344,Percent of Total Billed Charges,88% of Total Billed Charges,45.18,90,,48.424,Percent of Total Billed charges,90% of Total Billed Charges,22.14,50.2,
Wrst Frm Splt W/abd Thmb Md RT,2710000283,CDM,271,RC,,,Outpatient,,,48.08,31.25,,48.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.54,76,,40.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.62,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,36.06,75,,480,Percent of Total Billed charges,75% of Total Billed Charges,48.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.62,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,28.85,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,43.27,90,,22.32,Percent of Total Billed Charges,90% of Total Billed Charges,21.64,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,43.27,90,,48.424,Percent of Total Billed Charges,90% of Total billed Charges,48.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.25,65,,92.032,Percent of total Billed Charges,65% of Total Billed Charges,21.2,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.68,95,,51.112,Percent of Total Billed Charges,95% of Total Billed Charges,48.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.31,88,,47.344,Percent of Total Billed Charges,88% of Total Billed Charges,43.27,90,,48.424,Percent of Total Billed charges,90% of Total Billed Charges,21.2,48.08,
ARTHREX DRILL 4MM CANN,2710000284,CDM,271,RC,,,Outpatient,,,697.50,453.38,,697.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,530.1,76,,104.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,502.2,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,523.13,75,,480,Percent of Total Billed charges,75% of Total Billed Charges,697.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.2,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,418.5,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,627.75,90,,158.576,Percent of Total Billed Charges,90% of Total Billed Charges,313.88,45,,109.624,Percent of Total Billed Charges,45% of Total Billed Charges,627.75,90,,123.832,Percent of Total Billed Charges,90% of Total billed Charges,697.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,697.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,697.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.38,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,307.6,44.1,,107.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,662.63,95,,130.712,Percent of Total Billed Charges,95% of Total Billed Charges,697.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,613.8,88,,121.08,Percent of Total Billed Charges,88% of Total Billed Charges,627.75,90,,123.832,Percent of Total Billed charges,90% of Total Billed Charges,307.6,697.5,
ARTHREX TENODESIS GRFT SZNG KT,2710000285,CDM,271,RC,,,Outpatient,,,1055.00,685.75,,1055,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,801.8,76,,107.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,759.6,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,791.25,75,,480,Percent of Total Billed charges,75% of Total Billed Charges,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759.6,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,633,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,949.5,90,,158.576,Percent of Total Billed Charges,90% of Total Billed Charges,474.75,45,,70.56,Percent of Total Billed Charges,45% of Total Billed Charges,949.5,90,,127.432,Percent of Total Billed Charges,90% of Total billed Charges,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.75,65,,158.344,Percent of total Billed Charges,65% of Total Billed Charges,465.26,44.1,,69.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,1002.25,95,,134.512,Percent of Total Billed Charges,95% of Total Billed Charges,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,928.4,88,,124.6,Percent of Total Billed Charges,88% of Total Billed Charges,949.5,90,,127.432,Percent of Total Billed charges,90% of Total Billed Charges,465.26,1055,
COUNCILL TIP CATH 20/5/2(SUB),2710000286,CDM,271,RC,,,Outpatient,,,26.73,17.37,,26.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.31,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.25,72,,180.352,Percent of Total Billed Charges,72% of Total Billed Charges,20.05,75,,187.864,Percent of Total Billed charges,75% of Total Billed Charges,26.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.25,72,,180.352,Percent of Total Billed Charges,72% of Total Billed Charges,16.04,60,,150.296,Percent of Total Billed Charges,60% of Total Billed Charges,24.06,90,,158.576,Percent of Total Billed Charges,90% of Total Billed Charges,12.03,45,,109.624,Percent of Total Billed Charges,45% of Total Billed Charges,24.06,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,26.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.37,65,,101.92,Percent of total Billed Charges,65% of Total Billed Charges,11.79,44.1,,107.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.39,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,26.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.52,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,24.06,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,11.79,26.73,
CAVILON NO-STING BARRIER 1ML,2710000287,CDM,271,RC,,,Outpatient,,,1.80,1.17,,1.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.37,76,,185.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.3,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,1.35,75,,84,Percent of Total Billed charges,75% of Total Billed Charges,1.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,1.08,60,,67.2,Percent of Total Billed Charges,60% of Total Billed Charges,1.62,90,,158.576,Percent of Total Billed Charges,90% of Total Billed Charges,0.81,45,,70.56,Percent of Total Billed Charges,45% of Total Billed Charges,1.62,90,,219.24,Percent of Total Billed Charges,90% of Total billed Charges,1.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.17,65,,158.344,Percent of total Billed Charges,65% of Total Billed Charges,0.79,44.1,,69.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.71,95,,231.424,Percent of Total Billed Charges,95% of Total Billed Charges,1.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.58,88,,214.368,Percent of Total Billed Charges,88% of Total Billed Charges,1.62,90,,219.24,Percent of Total Billed charges,90% of Total Billed Charges,0.79,1.8,
CAVILON NO-STING BARRIER 3ML,2710000288,CDM,271,RC,,,Outpatient,,,5.26,3.42,,5.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4,76,,119.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.79,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,3.95,75,,84,Percent of Total Billed charges,75% of Total Billed Charges,5.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.79,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,3.16,60,,67.2,Percent of Total Billed Charges,60% of Total Billed Charges,4.73,90,,200.832,Percent of Total Billed Charges,90% of Total Billed Charges,2.37,45,,20.52,Percent of Total Billed Charges,45% of Total Billed Charges,4.73,90,,141.12,Percent of Total Billed Charges,90% of Total billed Charges,5.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.42,65,,101.92,Percent of total Billed Charges,65% of Total Billed Charges,2.32,44.1,,20.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,5,95,,148.96,Percent of Total Billed Charges,95% of Total Billed Charges,5.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.63,88,,137.984,Percent of Total Billed Charges,88% of Total Billed Charges,4.73,90,,141.12,Percent of Total Billed charges,90% of Total Billed Charges,2.32,5.26,
DEFEE CATH 10FR (SUB),2710000289,CDM,271,RC,,,Outpatient,,,4.00,2.60,,4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.04,76,,185.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.88,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,3,75,,84,Percent of Total Billed charges,75% of Total Billed Charges,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.88,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,2.4,60,,67.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.6,90,,200.832,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,45,,11.16,Percent of Total Billed Charges,45% of Total Billed Charges,3.6,90,,219.24,Percent of Total Billed Charges,90% of Total billed Charges,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.6,65,,29.64,Percent of total Billed Charges,65% of Total Billed Charges,1.76,44.1,,10.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.8,95,,231.424,Percent of Total Billed Charges,95% of Total Billed Charges,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.52,88,,214.368,Percent of Total Billed Charges,88% of Total Billed Charges,3.6,90,,219.24,Percent of Total Billed charges,90% of Total Billed Charges,1.76,4,
TALKTOOLS SENSI OCEAN,2710000290,CDM,271,RC,,,Outpatient,,,82.48,53.61,,82.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.68,76,,119.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.39,72,,69.352,Percent of Total Billed Charges,72% of Total Billed Charges,61.86,75,,72.24,Percent of Total Billed charges,75% of Total Billed Charges,82.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.39,72,,69.352,Percent of Total Billed Charges,72% of Total Billed Charges,49.49,60,,57.792,Percent of Total Billed Charges,60% of Total Billed Charges,74.23,90,,200.832,Percent of Total Billed Charges,90% of Total Billed Charges,37.12,45,,79.288,Percent of Total Billed Charges,45% of Total Billed Charges,74.23,90,,141.12,Percent of Total Billed Charges,90% of Total billed Charges,82.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.61,65,,16.12,Percent of total Billed Charges,65% of Total Billed Charges,36.37,44.1,,77.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,78.36,95,,148.96,Percent of Total Billed Charges,95% of Total Billed Charges,82.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.58,88,,137.984,Percent of Total Billed Charges,88% of Total Billed Charges,74.23,90,,141.12,Percent of Total Billed charges,90% of Total Billed Charges,36.37,82.48,
Tissue Trap Specimen Sock,2710000291,CDM,271,RC,,,Outpatient,,,6.63,4.31,,6.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.04,76,,34.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,86.448,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,90.048,Percent of Total Billed charges,75% of Total Billed Charges,6.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,86.448,Percent of Total Billed Charges,72% of Total Billed Charges,3.98,60,,72.04,Percent of Total Billed Charges,60% of Total Billed Charges,5.97,90,,200.832,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,79.288,Percent of Total Billed Charges,45% of Total Billed Charges,5.97,90,,41.04,Percent of Total Billed Charges,90% of Total billed Charges,6.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.31,65,,114.528,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,77.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.3,95,,43.32,Percent of Total Billed Charges,95% of Total Billed Charges,6.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,40.128,Percent of Total Billed Charges,88% of Total Billed Charges,5.97,90,,41.04,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.63,
Breathing bag 2L,2710000292,CDM,271,RC,,,Outpatient,,,4.58,2.98,,4.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.48,76,,18.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.3,72,,74.368,Percent of Total Billed Charges,72% of Total Billed Charges,3.44,75,,77.464,Percent of Total Billed charges,75% of Total Billed Charges,4.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.3,72,,74.368,Percent of Total Billed Charges,72% of Total Billed Charges,2.75,60,,61.976,Percent of Total Billed Charges,60% of Total Billed Charges,4.12,90,,25.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.06,45,,79.288,Percent of Total Billed Charges,45% of Total Billed Charges,4.12,90,,22.32,Percent of Total Billed Charges,90% of Total billed Charges,4.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.98,65,,114.528,Percent of total Billed Charges,65% of Total Billed Charges,2.02,44.1,,77.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.35,95,,23.56,Percent of Total Billed Charges,95% of Total Billed Charges,4.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.03,88,,21.824,Percent of Total Billed Charges,88% of Total Billed Charges,4.12,90,,22.32,Percent of Total Billed charges,90% of Total Billed Charges,2.02,4.58,
DELEE CATH 10FR(EA),2710000293,CDM,271,RC,,,Outpatient,,,5.15,3.35,,5.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.91,76,,133.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.71,72,,99.976,Percent of Total Billed Charges,72% of Total Billed Charges,3.86,75,,104.144,Percent of Total Billed charges,75% of Total Billed Charges,5.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.71,72,,99.976,Percent of Total Billed Charges,72% of Total Billed Charges,3.09,60,,83.312,Percent of Total Billed Charges,60% of Total Billed Charges,4.64,90,,25.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.32,45,,79.288,Percent of Total Billed Charges,45% of Total Billed Charges,4.64,90,,158.576,Percent of Total Billed Charges,90% of Total billed Charges,5.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.35,65,,114.528,Percent of total Billed Charges,65% of Total Billed Charges,2.27,44.1,,77.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.89,95,,167.384,Percent of Total Billed Charges,95% of Total Billed Charges,5.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.53,88,,155.048,Percent of Total Billed Charges,88% of Total Billed Charges,4.64,90,,158.576,Percent of Total Billed charges,90% of Total Billed Charges,2.27,5.15,
Suction Connecting Tubing 3/16,2710000294,CDM,271,RC,,,Outpatient,,,0.75,0.49,,0.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.57,76,,133.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.54,72,,338.472,Percent of Total Billed Charges,72% of Total Billed Charges,0.56,75,,352.576,Percent of Total Billed charges,75% of Total Billed Charges,0.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.54,72,,338.472,Percent of Total Billed Charges,72% of Total Billed Charges,0.45,60,,282.064,Percent of Total Billed Charges,60% of Total Billed Charges,0.68,90,,25.4,Percent of Total Billed Charges,90% of Total Billed Charges,0.34,45,,100.416,Percent of Total Billed Charges,45% of Total Billed Charges,0.68,90,,158.576,Percent of Total Billed Charges,90% of Total billed Charges,0.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.49,65,,114.528,Percent of total Billed Charges,65% of Total Billed Charges,0.33,44.1,,98.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.71,95,,167.384,Percent of Total Billed Charges,95% of Total Billed Charges,0.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.66,88,,155.048,Percent of Total Billed Charges,88% of Total Billed Charges,0.68,90,,158.576,Percent of Total Billed charges,90% of Total Billed Charges,0.33,0.75,
RAPIDLOC MALLABLE GRFT RETRCTR,2710000295,CDM,271,RC,,,Outpatient,,,371.50,241.48,,371.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,282.34,76,,133.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,267.48,72,,144.576,Percent of Total Billed Charges,72% of Total Billed Charges,278.63,75,,150.6,Percent of Total Billed charges,75% of Total Billed Charges,371.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.48,72,,144.576,Percent of Total Billed Charges,72% of Total Billed Charges,222.9,60,,120.48,Percent of Total Billed Charges,60% of Total Billed Charges,334.35,90,,477.072,Percent of Total Billed Charges,90% of Total Billed Charges,167.18,45,,100.416,Percent of Total Billed Charges,45% of Total Billed Charges,334.35,90,,158.576,Percent of Total Billed Charges,90% of Total billed Charges,371.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.48,65,,145.04,Percent of total Billed Charges,65% of Total Billed Charges,163.83,44.1,,98.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,352.93,95,,167.384,Percent of Total Billed Charges,95% of Total Billed Charges,371.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.92,88,,155.048,Percent of Total Billed Charges,88% of Total Billed Charges,334.35,90,,158.576,Percent of Total Billed charges,90% of Total Billed Charges,163.83,371.5,
GENERAL TEMP PROBE M1024231V,2710000296,CDM,271,RC,,,Outpatient,,,14.35,9.33,,14.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.91,76,,133.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.33,72,,8.352,Percent of Total Billed Charges,72% of Total Billed Charges,10.76,75,,8.704,Percent of Total Billed charges,75% of Total Billed Charges,14.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.33,72,,8.352,Percent of Total Billed Charges,72% of Total Billed Charges,8.61,60,,6.96,Percent of Total Billed Charges,60% of Total Billed Charges,12.92,90,,144.472,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,45,,100.416,Percent of Total Billed Charges,45% of Total Billed Charges,12.92,90,,158.576,Percent of Total Billed Charges,90% of Total billed Charges,14.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.33,65,,145.04,Percent of total Billed Charges,65% of Total Billed Charges,6.33,44.1,,98.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.63,95,,167.384,Percent of Total Billed Charges,95% of Total Billed Charges,14.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.63,88,,155.048,Percent of Total Billed Charges,88% of Total Billed Charges,12.92,90,,158.576,Percent of Total Billed charges,90% of Total Billed Charges,6.33,14.35,
LEVEEN COACCES SYSTM 3.0/15/15,2710000297,CDM,271,RC,C1889,HCPCS,Outpatient,,,4215.00,2739.75,,4215,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3203.4,76,,169.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3034.8,72,,27.264,Percent of Total Billed Charges,72% of Total Billed Charges,3161.25,75,,28.4,Percent of Total Billed charges,75% of Total Billed Charges,4215,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3034.8,72,,27.264,Percent of Total Billed Charges,72% of Total Billed Charges,2529,60,,22.72,Percent of Total Billed Charges,60% of Total Billed Charges,3793.5,90,,144.472,Percent of Total Billed Charges,90% of Total Billed Charges,1896.75,45,,100.416,Percent of Total Billed Charges,45% of Total Billed Charges,3793.5,90,,200.832,Percent of Total Billed Charges,90% of Total billed Charges,4215,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4215,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4215,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2739.75,65,,145.04,Percent of total Billed Charges,65% of Total Billed Charges,1858.82,44.1,,98.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,4004.25,95,,211.984,Percent of Total Billed Charges,95% of Total Billed Charges,4215,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3709.2,88,,196.368,Percent of Total Billed Charges,88% of Total Billed Charges,3793.5,90,,200.832,Percent of Total Billed charges,90% of Total Billed Charges,1858.82,4215,
LEVEEN COACCES SYSTM 3.5/15/15,2710000298,CDM,271,RC,C1889,HCPCS,Outpatient,,,4780.00,3107.00,,4780,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3632.8,76,,169.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3441.6,72,,27.264,Percent of Total Billed Charges,72% of Total Billed Charges,3585,75,,28.4,Percent of Total Billed charges,75% of Total Billed Charges,4780,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3441.6,72,,27.264,Percent of Total Billed Charges,72% of Total Billed Charges,2868,60,,22.72,Percent of Total Billed Charges,60% of Total Billed Charges,4302,90,,216,Percent of Total Billed Charges,90% of Total Billed Charges,2151,45,,12.704,Percent of Total Billed Charges,45% of Total Billed Charges,4302,90,,200.832,Percent of Total Billed Charges,90% of Total billed Charges,4780,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4780,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4780,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3107,65,,145.04,Percent of total Billed Charges,65% of Total Billed Charges,2107.98,44.1,,12.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,4541,95,,211.984,Percent of Total Billed Charges,95% of Total Billed Charges,4780,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4206.4,88,,196.368,Percent of Total Billed Charges,88% of Total Billed Charges,4302,90,,200.832,Percent of Total Billed charges,90% of Total Billed Charges,2107.98,4780,
LEVEEN COACCES SYSTM 4.0/15/15,2710000299,CDM,271,RC,C1889,HCPCS,Outpatient,,,5345.00,3474.25,,5345,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4062.2,76,,169.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3848.4,72,,570.496,Percent of Total Billed Charges,72% of Total Billed Charges,4008.75,75,,594.272,Percent of Total Billed charges,75% of Total Billed Charges,5345,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3848.4,72,,570.496,Percent of Total Billed Charges,72% of Total Billed Charges,3207,60,,475.416,Percent of Total Billed Charges,60% of Total Billed Charges,4810.5,90,,190.512,Percent of Total Billed Charges,90% of Total Billed Charges,2405.25,45,,12.704,Percent of Total Billed Charges,45% of Total Billed Charges,4810.5,90,,200.832,Percent of Total Billed Charges,90% of Total billed Charges,5345,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5345,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5345,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3474.25,65,,18.344,Percent of total Billed Charges,65% of Total Billed Charges,2357.15,44.1,,12.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,5077.75,95,,211.984,Percent of Total Billed Charges,95% of Total Billed Charges,5345,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4703.6,88,,196.368,Percent of Total Billed Charges,88% of Total Billed Charges,4810.5,90,,200.832,Percent of Total Billed charges,90% of Total Billed Charges,2357.15,5345,
ROYAL FLUSH PIG 5F 90CM,2710000300,CDM,271,RC,C1887,HCPCS,Outpatient,,,60.00,39.00,,60,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.6,76,,169.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.2,72,,570.496,Percent of Total Billed Charges,72% of Total Billed Charges,45,75,,594.272,Percent of Total Billed charges,75% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.2,72,,570.496,Percent of Total Billed Charges,72% of Total Billed Charges,36,60,,475.416,Percent of Total Billed Charges,60% of Total Billed Charges,54,90,,134.952,Percent of Total Billed Charges,90% of Total Billed Charges,27,45,,12.704,Percent of Total Billed Charges,45% of Total Billed Charges,54,90,,200.832,Percent of Total Billed Charges,90% of Total billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39,65,,18.344,Percent of total Billed Charges,65% of Total Billed Charges,26.46,44.1,,12.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,57,95,,211.984,Percent of Total Billed Charges,95% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.8,88,,196.368,Percent of Total Billed Charges,88% of Total Billed Charges,54,90,,200.832,Percent of Total Billed charges,90% of Total Billed Charges,26.46,60,
OB Pack (Sub),2710000301,CDM,271,RC,,,Outpatient,,,237.20,154.18,,237.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,180.27,76,,21.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,170.78,72,,309.896,Percent of Total Billed Charges,72% of Total Billed Charges,177.9,75,,322.816,Percent of Total Billed charges,75% of Total Billed Charges,237.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.78,72,,309.896,Percent of Total Billed Charges,72% of Total Billed Charges,142.32,60,,258.248,Percent of Total Billed Charges,60% of Total Billed Charges,213.48,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,106.74,45,,238.536,Percent of Total Billed Charges,45% of Total Billed Charges,213.48,90,,25.4,Percent of Total Billed Charges,90% of Total billed Charges,237.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.18,65,,18.344,Percent of total Billed Charges,65% of Total Billed Charges,104.61,44.1,,233.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,225.34,95,,26.816,Percent of Total Billed Charges,95% of Total Billed Charges,237.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.74,88,,24.84,Percent of Total Billed Charges,88% of Total Billed Charges,213.48,90,,25.4,Percent of Total Billed charges,90% of Total Billed Charges,104.61,237.2,
Polypropelene Suture,2710000302,CDM,271,RC,,,Outpatient,,,100.60,65.39,,100.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,76.46,76,,21.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,72.43,72,,361.976,Percent of Total Billed Charges,72% of Total Billed Charges,75.45,75,,377.056,Percent of Total Billed charges,75% of Total Billed Charges,100.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.43,72,,361.976,Percent of Total Billed Charges,72% of Total Billed Charges,60.36,60,,301.648,Percent of Total Billed Charges,60% of Total Billed Charges,90.54,90,,82.08,Percent of Total Billed Charges,90% of Total Billed Charges,45.27,45,,72.24,Percent of Total Billed Charges,45% of Total Billed Charges,90.54,90,,25.4,Percent of Total Billed Charges,90% of Total billed Charges,100.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.39,65,,344.552,Percent of total Billed Charges,65% of Total Billed Charges,44.36,44.1,,70.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,95.57,95,,26.816,Percent of Total Billed Charges,95% of Total Billed Charges,100.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.53,88,,24.84,Percent of Total Billed Charges,88% of Total Billed Charges,90.54,90,,25.4,Percent of Total Billed charges,90% of Total Billed Charges,44.36,100.6,
NOVII PATCH,2710000303,CDM,271,RC,,,Outpatient,,,89.07,57.90,,89.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.69,76,,21.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.13,72,,79.376,Percent of Total Billed Charges,72% of Total Billed Charges,66.8,75,,82.688,Percent of Total Billed charges,75% of Total Billed Charges,89.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.13,72,,79.376,Percent of Total Billed Charges,72% of Total Billed Charges,53.44,60,,66.152,Percent of Total Billed Charges,60% of Total Billed Charges,80.16,90,,28.08,Percent of Total Billed Charges,90% of Total Billed Charges,40.08,45,,72.24,Percent of Total Billed Charges,45% of Total Billed Charges,80.16,90,,25.4,Percent of Total Billed Charges,90% of Total billed Charges,89.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.9,65,,104.344,Percent of total Billed Charges,65% of Total Billed Charges,39.28,44.1,,70.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,84.62,95,,26.816,Percent of Total Billed Charges,95% of Total Billed Charges,89.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.38,88,,24.84,Percent of Total Billed Charges,88% of Total Billed Charges,80.16,90,,25.4,Percent of Total Billed charges,90% of Total Billed Charges,39.28,89.07,
AGBA PI MIDLINE 2L 5.5F X 15CM,2710000304,CDM,271,RC,C1751,HCPCS,Outpatient,,,447.50,290.88,,447.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,340.1,76,,402.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,322.2,72,,79.376,Percent of Total Billed Charges,72% of Total Billed Charges,335.63,75,,82.688,Percent of Total Billed charges,75% of Total Billed Charges,447.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,322.2,72,,79.376,Percent of Total Billed Charges,72% of Total Billed Charges,268.5,60,,66.152,Percent of Total Billed Charges,60% of Total Billed Charges,402.75,90,,225.44,Percent of Total Billed Charges,90% of Total Billed Charges,201.38,45,,108,Percent of Total Billed Charges,45% of Total Billed Charges,402.75,90,,477.072,Percent of Total Billed Charges,90% of Total billed Charges,447.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,447.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,447.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290.88,65,,104.344,Percent of total Billed Charges,65% of Total Billed Charges,197.35,44.1,,105.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,425.13,95,,503.576,Percent of Total Billed Charges,95% of Total Billed Charges,447.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.8,88,,466.472,Percent of Total Billed Charges,88% of Total Billed Charges,402.75,90,,477.072,Percent of Total Billed charges,90% of Total Billed Charges,197.35,447.5,
EXT DWELL CATH KIT 20G X 6CM,2710000305,CDM,271,RC,,,Outpatient,,,205.00,133.25,,205,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,155.8,76,,122,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,147.6,72,,99.696,Percent of Total Billed Charges,72% of Total Billed Charges,153.75,75,,103.856,Percent of Total Billed charges,75% of Total Billed Charges,205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.6,72,,99.696,Percent of Total Billed Charges,72% of Total Billed Charges,123,60,,83.08,Percent of Total Billed Charges,60% of Total Billed Charges,184.5,90,,225.44,Percent of Total Billed Charges,90% of Total Billed Charges,92.25,45,,95.256,Percent of Total Billed Charges,45% of Total Billed Charges,184.5,90,,144.472,Percent of Total Billed Charges,90% of Total billed Charges,205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.25,65,,156,Percent of total Billed Charges,65% of Total Billed Charges,90.41,44.1,,93.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,194.75,95,,152.504,Percent of Total Billed Charges,95% of Total Billed Charges,205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.4,88,,141.264,Percent of Total Billed Charges,88% of Total Billed Charges,184.5,90,,144.472,Percent of Total Billed charges,90% of Total Billed Charges,90.41,205,
GLIDE THRU SHEATH 4F X 7CM,2710000306,CDM,270,RC,C1892,HCPCS,Outpatient,,,35.00,22.75,,35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.6,76,,122,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.2,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,26.25,75,,26.464,Percent of Total Billed charges,75% of Total Billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.2,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,21,60,,21.168,Percent of Total Billed Charges,60% of Total Billed Charges,31.5,90,,33.12,Percent of Total Billed Charges,90% of Total Billed Charges,15.75,45,,67.472,Percent of Total Billed Charges,45% of Total Billed Charges,31.5,90,,144.472,Percent of Total Billed Charges,90% of Total billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.75,65,,137.592,Percent of total Billed Charges,65% of Total Billed Charges,15.44,44.1,,66.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.25,95,,152.504,Percent of Total Billed Charges,95% of Total Billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.8,88,,141.264,Percent of Total Billed Charges,88% of Total Billed Charges,31.5,90,,144.472,Percent of Total Billed charges,90% of Total Billed Charges,15.44,35,
GLIDE THRU SHEATH 5F X 7CM,2710000307,CDM,270,RC,C1892,HCPCS,Outpatient,,,35.00,22.75,,35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.6,76,,182.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.2,72,,20.736,Percent of Total Billed Charges,72% of Total Billed Charges,26.25,75,,21.6,Percent of Total Billed charges,75% of Total Billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.2,72,,20.736,Percent of Total Billed Charges,72% of Total Billed Charges,21,60,,17.28,Percent of Total Billed Charges,60% of Total Billed Charges,31.5,90,,46.048,Percent of Total Billed Charges,90% of Total Billed Charges,15.75,45,,10.44,Percent of Total Billed Charges,45% of Total Billed Charges,31.5,90,,216,Percent of Total Billed Charges,90% of Total billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.75,65,,97.464,Percent of total Billed Charges,65% of Total Billed Charges,15.44,44.1,,10.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.25,95,,228,Percent of Total Billed Charges,95% of Total Billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.8,88,,211.2,Percent of Total Billed Charges,88% of Total Billed Charges,31.5,90,,216,Percent of Total Billed charges,90% of Total Billed Charges,15.44,35,
Guardus Overtube/ESO,2710000308,CDM,271,RC,,,Outpatient,,,431.25,280.31,,431.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,327.75,76,,160.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,310.5,72,,249.408,Percent of Total Billed Charges,72% of Total Billed Charges,323.44,75,,249.408,Percent of Total Billed charges,75% of Total Billed Charges,431.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,310.5,72,,249.408,Percent of Total Billed Charges,72% of Total Billed Charges,258.75,60,,207.84,Percent of Total Billed Charges,60% of Total Billed Charges,388.13,90,,46.048,Percent of Total Billed Charges,90% of Total Billed Charges,194.06,45,,41.04,Percent of Total Billed Charges,45% of Total Billed Charges,388.13,90,,190.512,Percent of Total Billed Charges,90% of Total billed Charges,431.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,431.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,431.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280.31,65,,15.08,Percent of total Billed Charges,65% of Total Billed Charges,190.18,44.1,,40.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,409.69,95,,201.096,Percent of Total Billed Charges,95% of Total Billed Charges,431.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.5,88,,186.28,Percent of Total Billed Charges,88% of Total Billed Charges,388.13,90,,190.512,Percent of Total Billed charges,90% of Total Billed Charges,190.18,431.25,
Guardus Overtube/Gastric,2710000309,CDM,271,RC,,,Outpatient,,,505.72,328.72,,505.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,384.35,76,,113.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,364.12,72,,249.408,Percent of Total Billed Charges,72% of Total Billed Charges,379.29,75,,249.408,Percent of Total Billed charges,75% of Total Billed Charges,505.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.12,72,,249.408,Percent of Total Billed Charges,72% of Total Billed Charges,303.43,60,,207.84,Percent of Total Billed Charges,60% of Total Billed Charges,455.15,90,,57.24,Percent of Total Billed Charges,90% of Total Billed Charges,227.57,45,,14.04,Percent of Total Billed Charges,45% of Total Billed Charges,455.15,90,,134.952,Percent of Total Billed Charges,90% of Total billed Charges,505.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,505.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,505.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.72,65,,59.28,Percent of total Billed Charges,65% of Total Billed Charges,223.02,44.1,,13.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,480.43,95,,142.448,Percent of Total Billed Charges,95% of Total Billed Charges,505.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,445.03,88,,131.952,Percent of Total Billed Charges,88% of Total Billed Charges,455.15,90,,134.952,Percent of Total Billed charges,90% of Total Billed Charges,223.02,505.72,
Advincula Delineator 3.5,2710000310,CDM,271,RC,,,Outpatient,,,172.80,112.32,,172.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,131.33,76,,17.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,124.42,72,,10.944,Percent of Total Billed Charges,72% of Total Billed Charges,129.6,75,,11.4,Percent of Total Billed charges,75% of Total Billed Charges,172.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.42,72,,10.944,Percent of Total Billed Charges,72% of Total Billed Charges,103.68,60,,9.12,Percent of Total Billed Charges,60% of Total Billed Charges,155.52,90,,1818.936,Percent of Total Billed Charges,90% of Total Billed Charges,77.76,45,,112.72,Percent of Total Billed Charges,45% of Total Billed Charges,155.52,90,,20.88,Percent of Total Billed Charges,90% of Total billed Charges,172.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.32,65,,20.28,Percent of total Billed Charges,65% of Total Billed Charges,76.2,44.1,,110.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,164.16,95,,22.04,Percent of Total Billed Charges,95% of Total Billed Charges,172.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.06,88,,20.416,Percent of Total Billed Charges,88% of Total Billed Charges,155.52,90,,20.88,Percent of Total Billed charges,90% of Total Billed Charges,76.2,172.8,
"EZ Clean 13 1/2"" Ball lap Elec",2710000311,CDM,271,RC,,,Outpatient,,,111.42,72.42,,111.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,84.68,76,,69.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,80.22,72,,595.584,Percent of Total Billed Charges,72% of Total Billed Charges,83.57,75,,620.4,Percent of Total Billed charges,75% of Total Billed Charges,111.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.22,72,,595.584,Percent of Total Billed Charges,72% of Total Billed Charges,66.85,60,,496.32,Percent of Total Billed Charges,60% of Total Billed Charges,100.28,90,,862.6,Percent of Total Billed Charges,90% of Total Billed Charges,50.14,45,,112.72,Percent of Total Billed Charges,45% of Total Billed Charges,100.28,90,,82.08,Percent of Total Billed Charges,90% of Total billed Charges,111.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.42,65,,162.816,Percent of total Billed Charges,65% of Total Billed Charges,49.14,44.1,,110.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,105.85,95,,86.64,Percent of Total Billed Charges,95% of Total Billed Charges,111.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.05,88,,80.256,Percent of Total Billed Charges,88% of Total Billed Charges,100.28,90,,82.08,Percent of Total Billed charges,90% of Total Billed Charges,49.14,111.42,
Echelon Flex NP 60 Stapler,2710000312,CDM,271,RC,,,Outpatient,,,715.50,465.08,,715.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,543.78,76,,23.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,515.16,72,,24.936,Percent of Total Billed Charges,72% of Total Billed Charges,536.63,75,,25.976,Percent of Total Billed charges,75% of Total Billed Charges,715.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,515.16,72,,24.936,Percent of Total Billed Charges,72% of Total Billed Charges,429.3,60,,20.776,Percent of Total Billed Charges,60% of Total Billed Charges,643.95,90,,306.184,Percent of Total Billed Charges,90% of Total Billed Charges,321.98,45,,16.56,Percent of Total Billed Charges,45% of Total Billed Charges,643.95,90,,28.08,Percent of Total Billed Charges,90% of Total billed Charges,715.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,715.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,715.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.08,65,,162.816,Percent of total Billed Charges,65% of Total Billed Charges,315.54,44.1,,16.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,679.73,95,,29.64,Percent of Total Billed Charges,95% of Total Billed Charges,715.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,629.64,88,,27.456,Percent of Total Billed Charges,88% of Total Billed Charges,643.95,90,,28.08,Percent of Total Billed charges,90% of Total Billed Charges,315.54,715.5,
Reload ECR 60M Gray,2710000313,CDM,271,RC,,,Outpatient,,,386.65,251.32,,386.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,293.85,76,,190.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,278.39,72,,4.144,Percent of Total Billed Charges,72% of Total Billed Charges,289.99,75,,4.32,Percent of Total Billed charges,75% of Total Billed Charges,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.39,72,,4.144,Percent of Total Billed Charges,72% of Total Billed Charges,231.99,60,,3.456,Percent of Total Billed Charges,60% of Total Billed Charges,347.99,90,,191.52,Percent of Total Billed Charges,90% of Total Billed Charges,173.99,45,,23.024,Percent of Total Billed Charges,45% of Total Billed Charges,347.99,90,,225.44,Percent of Total Billed Charges,90% of Total billed Charges,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.32,65,,23.92,Percent of total Billed Charges,65% of Total Billed Charges,170.51,44.1,,22.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,367.32,95,,237.96,Percent of Total Billed Charges,95% of Total Billed Charges,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.25,88,,220.432,Percent of Total Billed Charges,88% of Total Billed Charges,347.99,90,,225.44,Percent of Total Billed charges,90% of Total Billed Charges,170.51,386.65,
reload GST 60W White,2710000314,CDM,271,RC,,,Outpatient,,,386.65,251.32,,386.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,293.85,76,,190.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,278.39,72,,9.216,Percent of Total Billed Charges,72% of Total Billed Charges,289.99,75,,9.6,Percent of Total Billed charges,75% of Total Billed Charges,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.39,72,,9.216,Percent of Total Billed Charges,72% of Total Billed Charges,231.99,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,347.99,90,,32.544,Percent of Total Billed Charges,90% of Total Billed Charges,173.99,45,,23.024,Percent of Total Billed Charges,45% of Total Billed Charges,347.99,90,,225.44,Percent of Total Billed Charges,90% of Total billed Charges,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.32,65,,33.256,Percent of total Billed Charges,65% of Total Billed Charges,170.51,44.1,,22.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,367.32,95,,237.96,Percent of Total Billed Charges,95% of Total Billed Charges,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.25,88,,220.432,Percent of Total Billed Charges,88% of Total Billed Charges,347.99,90,,225.44,Percent of Total Billed charges,90% of Total Billed Charges,170.51,386.65,
Reload GST 60B Blue,2710000315,CDM,271,RC,,,Outpatient,,,386.65,251.32,,386.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,293.85,76,,27.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,278.39,72,,181.992,Percent of Total Billed Charges,72% of Total Billed Charges,289.99,75,,181.992,Percent of Total Billed charges,75% of Total Billed Charges,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.39,72,,181.992,Percent of Total Billed Charges,72% of Total Billed Charges,231.99,60,,151.664,Percent of Total Billed Charges,60% of Total Billed Charges,347.99,90,,217.504,Percent of Total Billed Charges,90% of Total Billed Charges,173.99,45,,28.624,Percent of Total Billed Charges,45% of Total Billed Charges,347.99,90,,33.12,Percent of Total Billed Charges,90% of Total billed Charges,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.32,65,,33.256,Percent of total Billed Charges,65% of Total Billed Charges,170.51,44.1,,28.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,367.32,95,,34.96,Percent of Total Billed Charges,95% of Total Billed Charges,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.25,88,,32.384,Percent of Total Billed Charges,88% of Total Billed Charges,347.99,90,,33.12,Percent of Total Billed charges,90% of Total Billed Charges,170.51,386.65,
Reload GST 60D Gold,2710000316,CDM,271,RC,,,Outpatient,,,386.65,251.32,,386.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,293.85,76,,38.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,278.39,72,,30.848,Percent of Total Billed Charges,72% of Total Billed Charges,289.99,75,,32.128,Percent of Total Billed charges,75% of Total Billed Charges,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.39,72,,30.848,Percent of Total Billed Charges,72% of Total Billed Charges,231.99,60,,25.704,Percent of Total Billed Charges,60% of Total Billed Charges,347.99,90,,189.36,Percent of Total Billed Charges,90% of Total Billed Charges,173.99,45,,909.472,Percent of Total Billed Charges,45% of Total Billed Charges,347.99,90,,46.048,Percent of Total Billed Charges,90% of Total billed Charges,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.32,65,,41.344,Percent of total Billed Charges,65% of Total Billed Charges,170.51,44.1,,891.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,367.32,95,,48.6,Percent of Total Billed Charges,95% of Total Billed Charges,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.25,88,,45.024,Percent of Total Billed Charges,88% of Total Billed Charges,347.99,90,,46.048,Percent of Total Billed charges,90% of Total Billed Charges,170.51,386.65,
Reload GST 60G Green,2710000317,CDM,271,RC,,,Outpatient,,,386.65,251.32,,386.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,293.85,76,,38.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,278.39,72,,30.848,Percent of Total Billed Charges,72% of Total Billed Charges,289.99,75,,32.128,Percent of Total Billed charges,75% of Total Billed Charges,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.39,72,,30.848,Percent of Total Billed Charges,72% of Total Billed Charges,231.99,60,,25.704,Percent of Total Billed Charges,60% of Total Billed Charges,347.99,90,,1190.704,Percent of Total Billed Charges,90% of Total Billed Charges,173.99,45,,431.296,Percent of Total Billed Charges,45% of Total Billed Charges,347.99,90,,46.048,Percent of Total Billed Charges,90% of Total billed Charges,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.32,65,,1313.68,Percent of total Billed Charges,65% of Total Billed Charges,170.51,44.1,,422.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,367.32,95,,48.6,Percent of Total Billed Charges,95% of Total Billed Charges,386.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.25,88,,45.024,Percent of Total Billed Charges,88% of Total Billed Charges,347.99,90,,46.048,Percent of Total Billed charges,90% of Total Billed Charges,170.51,386.65,
EZ Balloon Dilator 13.5-14.5,2710000318,CDM,271,RC,,,Outpatient,,,505.75,328.74,,505.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,384.37,76,,48.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,364.14,72,,145.152,Percent of Total Billed Charges,72% of Total Billed Charges,379.31,75,,151.2,Percent of Total Billed charges,75% of Total Billed Charges,505.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.14,72,,145.152,Percent of Total Billed Charges,72% of Total Billed Charges,303.45,60,,120.96,Percent of Total Billed Charges,60% of Total Billed Charges,455.18,90,,1238.328,Percent of Total Billed Charges,90% of Total Billed Charges,227.59,45,,153.088,Percent of Total Billed Charges,45% of Total Billed Charges,455.18,90,,57.24,Percent of Total Billed Charges,90% of Total billed Charges,505.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,505.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,505.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.74,65,,622.984,Percent of total Billed Charges,65% of Total Billed Charges,223.04,44.1,,150.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,480.46,95,,60.424,Percent of Total Billed Charges,95% of Total Billed Charges,505.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,445.06,88,,55.968,Percent of Total Billed Charges,88% of Total Billed Charges,455.18,90,,57.24,Percent of Total Billed charges,90% of Total Billed Charges,223.04,505.75,
Inflation Device for EBD,2710000319,CDM,271,RC,,,Outpatient,,,87.50,56.88,,87.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.5,76,,1535.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63,72,,145.152,Percent of Total Billed Charges,72% of Total Billed Charges,65.63,75,,151.2,Percent of Total Billed charges,75% of Total Billed Charges,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63,72,,145.152,Percent of Total Billed Charges,72% of Total Billed Charges,52.5,60,,120.96,Percent of Total Billed Charges,60% of Total Billed Charges,78.75,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,39.38,45,,95.76,Percent of Total Billed Charges,45% of Total Billed Charges,78.75,90,,1818.936,Percent of Total Billed Charges,90% of Total billed Charges,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.88,65,,221.128,Percent of total Billed Charges,65% of Total Billed Charges,38.59,44.1,,93.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.13,95,,1919.992,Percent of Total Billed Charges,95% of Total Billed Charges,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77,88,,1778.512,Percent of Total Billed Charges,88% of Total Billed Charges,78.75,90,,1818.936,Percent of Total Billed charges,90% of Total Billed Charges,38.59,87.5,
"Zimmer Disp Cuff 18""",2710000320,CDM,271,RC,,,Outpatient,,,32.50,21.13,,32.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.7,76,,728.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.4,72,,144.792,Percent of Total Billed Charges,72% of Total Billed Charges,24.38,75,,150.824,Percent of Total Billed charges,75% of Total Billed Charges,32.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.4,72,,144.792,Percent of Total Billed Charges,72% of Total Billed Charges,19.5,60,,120.656,Percent of Total Billed Charges,60% of Total Billed Charges,29.25,90,,256.184,Percent of Total Billed Charges,90% of Total Billed Charges,14.63,45,,16.272,Percent of Total Billed Charges,45% of Total Billed Charges,29.25,90,,862.6,Percent of Total Billed Charges,90% of Total billed Charges,32.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.13,65,,138.32,Percent of total Billed Charges,65% of Total Billed Charges,14.33,44.1,,15.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.88,95,,910.52,Percent of Total Billed Charges,95% of Total Billed Charges,32.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.6,88,,843.424,Percent of Total Billed Charges,88% of Total Billed Charges,29.25,90,,862.6,Percent of Total Billed charges,90% of Total Billed Charges,14.33,32.5,
"Zimmer Disp Cuff 24""",2710000321,CDM,271,RC,,,Outpatient,,,32.50,21.13,,32.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.7,76,,258.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.4,72,,323.032,Percent of Total Billed Charges,72% of Total Billed Charges,24.38,75,,336.496,Percent of Total Billed charges,75% of Total Billed Charges,32.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.4,72,,323.032,Percent of Total Billed Charges,72% of Total Billed Charges,19.5,60,,269.192,Percent of Total Billed Charges,60% of Total Billed Charges,29.25,90,,55.504,Percent of Total Billed Charges,90% of Total Billed Charges,14.63,45,,108.752,Percent of Total Billed Charges,45% of Total Billed Charges,29.25,90,,306.184,Percent of Total Billed Charges,90% of Total billed Charges,32.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.13,65,,23.504,Percent of total Billed Charges,65% of Total Billed Charges,14.33,44.1,,106.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.88,95,,323.192,Percent of Total Billed Charges,95% of Total Billed Charges,32.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.6,88,,299.376,Percent of Total Billed Charges,88% of Total Billed Charges,29.25,90,,306.184,Percent of Total Billed charges,90% of Total Billed Charges,14.33,32.5,
"Zimmer Disp Cuff 30""",2710000322,CDM,271,RC,,,Outpatient,,,32.50,21.13,,32.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.7,76,,161.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.4,72,,323.032,Percent of Total Billed Charges,72% of Total Billed Charges,24.38,75,,336.496,Percent of Total Billed charges,75% of Total Billed Charges,32.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.4,72,,323.032,Percent of Total Billed Charges,72% of Total Billed Charges,19.5,60,,269.192,Percent of Total Billed Charges,60% of Total Billed Charges,29.25,90,,166.72,Percent of Total Billed Charges,90% of Total Billed Charges,14.63,45,,94.68,Percent of Total Billed Charges,45% of Total Billed Charges,29.25,90,,191.52,Percent of Total Billed Charges,90% of Total billed Charges,32.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.13,65,,157.088,Percent of total Billed Charges,65% of Total Billed Charges,14.33,44.1,,92.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.88,95,,202.16,Percent of Total Billed Charges,95% of Total Billed Charges,32.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.6,88,,187.264,Percent of Total Billed Charges,88% of Total Billed Charges,29.25,90,,191.52,Percent of Total Billed charges,90% of Total Billed Charges,14.33,32.5,
"Zimmer DPDB Disp Cuff 12""",2710000323,CDM,271,RC,,,Outpatient,,,31.25,20.31,,31.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.75,76,,27.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.5,72,,387.216,Percent of Total Billed Charges,72% of Total Billed Charges,23.44,75,,403.352,Percent of Total Billed charges,75% of Total Billed Charges,31.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.5,72,,387.216,Percent of Total Billed Charges,72% of Total Billed Charges,18.75,60,,322.68,Percent of Total Billed Charges,60% of Total Billed Charges,28.13,90,,201.24,Percent of Total Billed Charges,90% of Total Billed Charges,14.06,45,,595.352,Percent of Total Billed Charges,45% of Total Billed Charges,28.13,90,,32.544,Percent of Total Billed Charges,90% of Total billed Charges,31.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.31,65,,136.76,Percent of total Billed Charges,65% of Total Billed Charges,13.78,44.1,,583.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.69,95,,34.352,Percent of Total Billed Charges,95% of Total Billed Charges,31.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.5,88,,31.824,Percent of Total Billed Charges,88% of Total Billed Charges,28.13,90,,32.544,Percent of Total Billed charges,90% of Total Billed Charges,13.78,31.25,
"Zimmer DPDB Disp Cuff 18""",2710000324,CDM,271,RC,,,Outpatient,,,31.25,20.31,,31.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.75,76,,183.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.5,72,,387.216,Percent of Total Billed Charges,72% of Total Billed Charges,23.44,75,,403.352,Percent of Total Billed charges,75% of Total Billed Charges,31.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.5,72,,387.216,Percent of Total Billed Charges,72% of Total Billed Charges,18.75,60,,322.68,Percent of Total Billed Charges,60% of Total Billed Charges,28.13,90,,319.904,Percent of Total Billed Charges,90% of Total Billed Charges,14.06,45,,619.168,Percent of Total Billed Charges,45% of Total Billed Charges,28.13,90,,217.504,Percent of Total Billed Charges,90% of Total billed Charges,31.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.31,65,,859.952,Percent of total Billed Charges,65% of Total Billed Charges,13.78,44.1,,606.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.69,95,,229.592,Percent of Total Billed Charges,95% of Total Billed Charges,31.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.5,88,,212.672,Percent of Total Billed Charges,88% of Total Billed Charges,28.13,90,,217.504,Percent of Total Billed charges,90% of Total Billed Charges,13.78,31.25,
"Zimmer DPDB Disp Cuff 24""",2710000325,CDM,271,RC,,,Outpatient,,,31.25,20.31,,31.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.75,76,,159.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.5,72,,339,Percent of Total Billed Charges,72% of Total Billed Charges,23.44,75,,353.128,Percent of Total Billed charges,75% of Total Billed Charges,31.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.5,72,,339,Percent of Total Billed Charges,72% of Total Billed Charges,18.75,60,,282.496,Percent of Total Billed Charges,60% of Total Billed Charges,28.13,90,,13.768,Percent of Total Billed Charges,90% of Total Billed Charges,14.06,45,,25.56,Percent of Total Billed Charges,45% of Total Billed Charges,28.13,90,,189.36,Percent of Total Billed Charges,90% of Total billed Charges,31.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.31,65,,894.352,Percent of total Billed Charges,65% of Total Billed Charges,13.78,44.1,,25.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.69,95,,199.88,Percent of Total Billed Charges,95% of Total Billed Charges,31.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.5,88,,185.152,Percent of Total Billed Charges,88% of Total Billed Charges,28.13,90,,189.36,Percent of Total Billed charges,90% of Total Billed Charges,13.78,31.25,
IP Drain Round 10FR,2710000326,CDM,271,RC,,,Outpatient,,,24.57,15.97,,24.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.67,76,,1005.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.69,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,18.43,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,24.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.69,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,14.74,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,22.11,90,,176.4,Percent of Total Billed Charges,90% of Total Billed Charges,11.06,45,,128.088,Percent of Total Billed Charges,45% of Total Billed Charges,22.11,90,,1190.704,Percent of Total Billed Charges,90% of Total billed Charges,24.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.97,65,,36.92,Percent of total Billed Charges,65% of Total Billed Charges,10.84,44.1,,125.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.34,95,,1256.848,Percent of Total Billed Charges,95% of Total Billed Charges,24.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.62,88,,1164.24,Percent of Total Billed Charges,88% of Total Billed Charges,22.11,90,,1190.704,Percent of Total Billed charges,90% of Total Billed Charges,10.84,24.57,
Olymp Snare Mstr Hot/Cold 15MM,2710000327,CDM,271,RC,,,Outpatient,,,49.22,31.99,,49.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,37.41,76,,1045.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,35.44,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,36.92,75,,394.8,Percent of Total Billed charges,75% of Total Billed Charges,49.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.44,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,29.53,60,,315.84,Percent of Total Billed Charges,60% of Total Billed Charges,44.3,90,,166.72,Percent of Total Billed Charges,90% of Total Billed Charges,22.15,45,,27.752,Percent of Total Billed Charges,45% of Total Billed Charges,44.3,90,,1238.328,Percent of Total Billed Charges,90% of Total billed Charges,49.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.99,65,,185.024,Percent of total Billed Charges,65% of Total Billed Charges,21.71,44.1,,27.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.76,95,,1307.128,Percent of Total Billed Charges,95% of Total Billed Charges,49.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.31,88,,1210.808,Percent of Total Billed Charges,88% of Total Billed Charges,44.3,90,,1238.328,Percent of Total Billed charges,90% of Total Billed Charges,21.71,49.22,
J-Vac Reservoir 150ml (2161),2710000328,CDM,271,RC,,,Outpatient,,,131.15,85.25,,131.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,99.67,76,,43.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,94.43,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,98.36,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,131.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.43,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,78.69,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,118.04,90,,201.24,Percent of Total Billed Charges,90% of Total Billed Charges,59.02,45,,83.36,Percent of Total Billed Charges,45% of Total Billed Charges,118.04,90,,51.12,Percent of Total Billed Charges,90% of Total billed Charges,131.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.25,65,,40.088,Percent of total Billed Charges,65% of Total Billed Charges,57.84,44.1,,81.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,124.59,95,,53.96,Percent of Total Billed Charges,95% of Total Billed Charges,131.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.41,88,,49.984,Percent of Total Billed Charges,88% of Total Billed Charges,118.04,90,,51.12,Percent of Total Billed charges,90% of Total Billed Charges,57.84,131.15,
Berkley Collctn tubing (SUB),2710000329,CDM,271,RC,,,Outpatient,,,29.20,18.98,,29.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.19,76,,216.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.02,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,21.9,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,29.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.02,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,17.52,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,26.28,90,,134.568,Percent of Total Billed Charges,90% of Total Billed Charges,13.14,45,,100.624,Percent of Total Billed Charges,45% of Total Billed Charges,26.28,90,,256.184,Percent of Total Billed Charges,90% of Total billed Charges,29.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.98,65,,120.408,Percent of total Billed Charges,65% of Total Billed Charges,12.88,44.1,,98.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,27.74,95,,270.416,Percent of Total Billed Charges,95% of Total Billed Charges,29.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.7,88,,250.488,Percent of Total Billed Charges,88% of Total Billed Charges,26.28,90,,256.184,Percent of Total Billed charges,90% of Total Billed Charges,12.88,29.2,
Arm Protectors for Pink Pad Kt,2710000330,CDM,271,RC,,,Outpatient,,,50.00,32.50,,50,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38,76,,46.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,37.5,75,,394.8,Percent of Total Billed charges,75% of Total Billed Charges,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,30,60,,315.84,Percent of Total Billed Charges,60% of Total Billed Charges,45,90,,134.568,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,45,,159.952,Percent of Total Billed Charges,45% of Total Billed Charges,45,90,,55.504,Percent of Total Billed Charges,90% of Total billed Charges,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.5,65,,145.344,Percent of total Billed Charges,65% of Total Billed Charges,22.05,44.1,,156.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,47.5,95,,58.592,Percent of Total Billed Charges,95% of Total Billed Charges,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44,88,,54.272,Percent of Total Billed Charges,88% of Total Billed Charges,45,90,,55.504,Percent of Total Billed charges,90% of Total Billed Charges,22.05,50,
APM C0Q19 8x100 ZTHR,2710000331,CDM,271,RC,,,Outpatient,,,36.25,23.56,,36.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.55,76,,140.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.1,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,27.19,75,,394.8,Percent of Total Billed charges,75% of Total Billed Charges,36.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.1,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,21.75,60,,315.84,Percent of Total Billed Charges,60% of Total Billed Charges,32.63,90,,255.608,Percent of Total Billed Charges,90% of Total Billed Charges,16.31,45,,6.88,Percent of Total Billed Charges,45% of Total Billed Charges,32.63,90,,166.72,Percent of Total Billed Charges,90% of Total billed Charges,36.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.56,65,,231.04,Percent of total Billed Charges,65% of Total Billed Charges,15.99,44.1,,6.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.44,95,,175.984,Percent of Total Billed Charges,95% of Total Billed Charges,36.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.9,88,,163.016,Percent of Total Billed Charges,88% of Total Billed Charges,32.63,90,,166.72,Percent of Total Billed charges,90% of Total Billed Charges,15.99,36.25,
Microline Atrau Grasper,2710000332,CDM,271,RC,,,Outpatient,,,137.77,89.55,,137.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,104.71,76,,169.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,99.19,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,103.33,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,137.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.19,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,82.66,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,123.99,90,,1101.6,Percent of Total Billed Charges,90% of Total Billed Charges,62,45,,88.2,Percent of Total Billed Charges,45% of Total Billed Charges,123.99,90,,201.24,Percent of Total Billed Charges,90% of Total billed Charges,137.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.55,65,,9.944,Percent of total Billed Charges,65% of Total Billed Charges,60.76,44.1,,86.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,130.88,95,,212.424,Percent of Total Billed Charges,95% of Total Billed Charges,137.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.24,88,,196.768,Percent of Total Billed Charges,88% of Total Billed Charges,123.99,90,,201.24,Percent of Total Billed charges,90% of Total Billed Charges,60.76,137.77,
"VLOC 90 Size 0.9"" VLOCM2146",2710000333,CDM,271,RC,,,Outpatient,,,32.68,21.24,,32.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.84,76,,270.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.53,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,24.51,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,32.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.53,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,19.61,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,29.41,90,,1101.6,Percent of Total Billed Charges,90% of Total Billed Charges,14.71,45,,83.36,Percent of Total Billed Charges,45% of Total Billed Charges,29.41,90,,319.904,Percent of Total Billed Charges,90% of Total billed Charges,32.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.24,65,,127.4,Percent of total Billed Charges,65% of Total Billed Charges,14.41,44.1,,81.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.05,95,,337.672,Percent of Total Billed Charges,95% of Total Billed Charges,32.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.76,88,,312.792,Percent of Total Billed Charges,88% of Total Billed Charges,29.41,90,,319.904,Percent of Total Billed charges,90% of Total Billed Charges,14.41,32.68,
Guidelines CT Grid Local Ndl,2710000334,CDM,271,RC,,,Outpatient,,,16.25,10.56,,16.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.35,76,,11.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.7,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,12.19,75,,394.8,Percent of Total Billed charges,75% of Total Billed Charges,16.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.7,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,9.75,60,,315.84,Percent of Total Billed Charges,60% of Total Billed Charges,14.63,90,,255.608,Percent of Total Billed Charges,90% of Total Billed Charges,7.31,45,,100.624,Percent of Total Billed Charges,45% of Total Billed Charges,14.63,90,,13.768,Percent of Total Billed Charges,90% of Total billed Charges,16.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,65,,120.408,Percent of total Billed Charges,65% of Total Billed Charges,7.17,44.1,,98.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.44,95,,14.528,Percent of Total Billed Charges,95% of Total Billed Charges,16.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.3,88,,13.464,Percent of Total Billed Charges,88% of Total Billed Charges,14.63,90,,13.768,Percent of Total Billed charges,90% of Total Billed Charges,7.17,16.25,
"Guidelines 7"" x 7.5 Grid",2710000335,CDM,271,RC,,,Outpatient,,,21.68,14.09,,21.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.48,76,,148.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.61,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,16.26,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,21.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.61,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,13.01,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,19.51,90,,319.904,Percent of Total Billed Charges,90% of Total Billed Charges,9.76,45,,67.288,Percent of Total Billed Charges,45% of Total Billed Charges,19.51,90,,176.4,Percent of Total Billed Charges,90% of Total billed Charges,21.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.09,65,,145.344,Percent of total Billed Charges,65% of Total Billed Charges,9.56,44.1,,65.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.6,95,,186.2,Percent of Total Billed Charges,95% of Total Billed Charges,21.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.08,88,,172.48,Percent of Total Billed Charges,88% of Total Billed Charges,19.51,90,,176.4,Percent of Total Billed charges,90% of Total Billed Charges,9.56,21.68,
Beckman EZ Spoon Reg Green,2710000336,CDM,271,RC,,,Outpatient,,,60.00,39.00,,60,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.6,76,,140.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.2,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,45,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.2,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,36,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,54,90,,66.352,Percent of Total Billed Charges,90% of Total Billed Charges,27,45,,67.288,Percent of Total Billed Charges,45% of Total Billed Charges,54,90,,166.72,Percent of Total Billed Charges,90% of Total billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39,65,,97.192,Percent of total Billed Charges,65% of Total Billed Charges,26.46,44.1,,65.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,57,95,,175.984,Percent of Total Billed Charges,95% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.8,88,,163.016,Percent of Total Billed Charges,88% of Total Billed Charges,54,90,,166.72,Percent of Total Billed charges,90% of Total Billed Charges,26.46,60,
Maroon Spoon Small,2710000337,CDM,271,RC,,,Outpatient,,,8.50,5.53,,8.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.46,76,,169.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.12,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,6.38,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,8.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.12,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,5.1,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,7.65,90,,66.352,Percent of Total Billed Charges,90% of Total Billed Charges,3.83,45,,127.8,Percent of Total Billed Charges,45% of Total Billed Charges,7.65,90,,201.24,Percent of Total Billed Charges,90% of Total billed Charges,8.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.53,65,,97.192,Percent of total Billed Charges,65% of Total Billed Charges,3.75,44.1,,125.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.08,95,,212.424,Percent of Total Billed Charges,95% of Total Billed Charges,8.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.48,88,,196.768,Percent of Total Billed Charges,88% of Total Billed Charges,7.65,90,,201.24,Percent of Total Billed charges,90% of Total Billed Charges,3.75,8.5,
Maroon Spoon Large,2710000338,CDM,271,RC,,,Outpatient,,,9.47,6.16,,9.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.2,76,,113.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.82,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,7.1,75,,394.8,Percent of Total Billed charges,75% of Total Billed Charges,9.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.82,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,5.68,60,,315.84,Percent of Total Billed Charges,60% of Total Billed Charges,8.52,90,,43.2,Percent of Total Billed Charges,90% of Total Billed Charges,4.26,45,,550.8,Percent of Total Billed Charges,45% of Total Billed Charges,8.52,90,,134.568,Percent of Total Billed Charges,90% of Total billed Charges,9.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.16,65,,184.608,Percent of total Billed Charges,65% of Total Billed Charges,4.18,44.1,,539.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,9,95,,142.048,Percent of Total Billed Charges,95% of Total Billed Charges,9.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.33,88,,131.576,Percent of Total Billed Charges,88% of Total Billed Charges,8.52,90,,134.568,Percent of Total Billed charges,90% of Total Billed Charges,4.18,9.47,
BP CUFF - INFANT,2710000339,CDM,271,RC,,,Outpatient,,,3.52,2.29,,3.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.68,76,,113.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.53,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,2.64,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,3.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.53,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,2.11,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,3.17,90,,64.8,Percent of Total Billed Charges,90% of Total Billed Charges,1.58,45,,550.8,Percent of Total Billed Charges,45% of Total Billed Charges,3.17,90,,134.568,Percent of Total Billed Charges,90% of Total billed Charges,3.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.29,65,,795.6,Percent of total Billed Charges,65% of Total Billed Charges,1.55,44.1,,539.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.34,95,,142.048,Percent of Total Billed Charges,95% of Total Billed Charges,3.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.1,88,,131.576,Percent of Total Billed Charges,88% of Total Billed Charges,3.17,90,,134.568,Percent of Total Billed charges,90% of Total Billed Charges,1.55,3.52,
BP CUFF - CHILD,2710000340,CDM,271,RC,,,Outpatient,,,3.52,2.29,,3.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.68,76,,215.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.53,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,2.64,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,3.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.53,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,2.11,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,3.17,90,,64.8,Percent of Total Billed Charges,90% of Total Billed Charges,1.58,45,,127.8,Percent of Total Billed Charges,45% of Total Billed Charges,3.17,90,,255.608,Percent of Total Billed Charges,90% of Total billed Charges,3.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.29,65,,795.6,Percent of total Billed Charges,65% of Total Billed Charges,1.55,44.1,,125.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.34,95,,269.808,Percent of Total Billed Charges,95% of Total Billed Charges,3.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.1,88,,249.928,Percent of Total Billed Charges,88% of Total Billed Charges,3.17,90,,255.608,Percent of Total Billed charges,90% of Total Billed Charges,1.55,3.52,
BP CUFF - REG ADULT LONG,2710000341,CDM,271,RC,,,Outpatient,,,3.75,2.44,,3.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.85,76,,930.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.7,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,2.81,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,3.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.7,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,2.25,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,3.38,90,,64.8,Percent of Total Billed Charges,90% of Total Billed Charges,1.69,45,,159.952,Percent of Total Billed Charges,45% of Total Billed Charges,3.38,90,,1101.6,Percent of Total Billed Charges,90% of Total billed Charges,3.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.44,65,,184.608,Percent of total Billed Charges,65% of Total Billed Charges,1.65,44.1,,156.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.56,95,,1162.8,Percent of Total Billed Charges,95% of Total Billed Charges,3.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.3,88,,1077.12,Percent of Total Billed Charges,88% of Total Billed Charges,3.38,90,,1101.6,Percent of Total Billed charges,90% of Total Billed Charges,1.65,3.75,
BP CUFF - LARGE ADULT,2710000342,CDM,271,RC,,,Outpatient,,,4.37,2.84,,4.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.32,76,,930.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.15,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,3.28,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,4.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.15,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,2.62,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,3.93,90,,827.144,Percent of Total Billed Charges,90% of Total Billed Charges,1.97,45,,33.176,Percent of Total Billed Charges,45% of Total Billed Charges,3.93,90,,1101.6,Percent of Total Billed Charges,90% of Total billed Charges,4.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.84,65,,231.04,Percent of total Billed Charges,65% of Total Billed Charges,1.93,44.1,,32.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.15,95,,1162.8,Percent of Total Billed Charges,95% of Total Billed Charges,4.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.85,88,,1077.12,Percent of Total Billed Charges,88% of Total Billed Charges,3.93,90,,1101.6,Percent of Total Billed charges,90% of Total Billed Charges,1.93,4.37,
BP CUFF - THIGH,2710000343,CDM,271,RC,,,Outpatient,,,6.90,4.49,,6.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.24,76,,215.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.97,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,5.18,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,6.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.97,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,4.14,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,6.21,90,,104.784,Percent of Total Billed Charges,90% of Total Billed Charges,3.11,45,,33.176,Percent of Total Billed Charges,45% of Total Billed Charges,6.21,90,,255.608,Percent of Total Billed Charges,90% of Total billed Charges,6.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.49,65,,47.92,Percent of total Billed Charges,65% of Total Billed Charges,3.04,44.1,,32.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.56,95,,269.808,Percent of Total Billed Charges,95% of Total Billed Charges,6.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.07,88,,249.928,Percent of Total Billed Charges,88% of Total Billed Charges,6.21,90,,255.608,Percent of Total Billed charges,90% of Total Billed Charges,3.04,6.9,
BL5115-4 CATRCT CASSTTE/TUBING,2710000344,CDM,271,RC,,,Outpatient,,,165.32,107.46,,165.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,125.64,76,,270.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,119.03,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,123.99,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,165.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.03,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,99.19,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,148.79,90,,10.568,Percent of Total Billed Charges,90% of Total Billed Charges,74.39,45,,21.6,Percent of Total Billed Charges,45% of Total Billed Charges,148.79,90,,319.904,Percent of Total Billed Charges,90% of Total billed Charges,165.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.46,65,,47.92,Percent of total Billed Charges,65% of Total Billed Charges,72.91,44.1,,21.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,157.05,95,,337.672,Percent of Total Billed Charges,95% of Total Billed Charges,165.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.48,88,,312.792,Percent of Total Billed Charges,88% of Total Billed Charges,148.79,90,,319.904,Percent of Total Billed charges,90% of Total Billed Charges,72.91,165.32,
BL3420S PHACO TIP/NEEDLE,2710000345,CDM,271,RC,,,Outpatient,,,50.00,32.50,,50,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38,76,,56.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,37.5,75,,394.8,Percent of Total Billed charges,75% of Total Billed Charges,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,30,60,,315.84,Percent of Total Billed Charges,60% of Total Billed Charges,45,90,,42.072,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,45,90,,66.352,Percent of Total Billed Charges,90% of Total billed Charges,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.5,65,,31.2,Percent of total Billed Charges,65% of Total Billed Charges,22.05,44.1,,31.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,47.5,95,,70.04,Percent of Total Billed Charges,95% of Total Billed Charges,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44,88,,64.88,Percent of Total Billed Charges,88% of Total Billed Charges,45,90,,66.352,Percent of Total Billed charges,90% of Total Billed Charges,22.05,50,
BL3124S YELLOW SLEEVES MICS,2710000346,CDM,271,RC,,,Outpatient,,,38.67,25.14,,38.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.39,76,,56.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.84,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,29,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,38.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.84,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,23.2,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,34.8,90,,133.36,Percent of Total Billed Charges,90% of Total Billed Charges,17.4,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,34.8,90,,66.352,Percent of Total Billed Charges,90% of Total billed Charges,38.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.14,65,,46.8,Percent of total Billed Charges,65% of Total Billed Charges,17.05,44.1,,31.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.74,95,,70.04,Percent of Total Billed Charges,95% of Total Billed Charges,38.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.03,88,,64.88,Percent of Total Billed Charges,88% of Total Billed Charges,34.8,90,,66.352,Percent of Total Billed charges,90% of Total Billed Charges,17.05,38.67,
BL5625S 25G ANT VIT CUTTR,2710000347,CDM,271,RC,,,Outpatient,,,525.00,341.25,,525,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,399,76,,36.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,378,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,393.75,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,315,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,472.5,90,,97.184,Percent of Total Billed Charges,90% of Total Billed Charges,236.25,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,472.5,90,,43.2,Percent of Total Billed Charges,90% of Total billed Charges,525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.25,65,,46.8,Percent of total Billed Charges,65% of Total Billed Charges,231.53,44.1,,31.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,498.75,95,,45.6,Percent of Total Billed Charges,95% of Total Billed Charges,525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462,88,,42.24,Percent of Total Billed Charges,88% of Total Billed Charges,472.5,90,,43.2,Percent of Total Billed charges,90% of Total Billed Charges,231.53,525,
BL3190 VIT CUTTR ADAPTER KIT,2710000348,CDM,271,RC,,,Outpatient,,,53.32,34.66,,53.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.52,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.39,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,39.99,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,53.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.39,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,31.99,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,47.99,90,,570.744,Percent of Total Billed Charges,90% of Total Billed Charges,23.99,45,,413.568,Percent of Total Billed Charges,45% of Total Billed Charges,47.99,90,,64.8,Percent of Total Billed Charges,90% of Total billed Charges,53.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.66,65,,46.8,Percent of total Billed Charges,65% of Total Billed Charges,23.51,44.1,,405.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.65,95,,68.4,Percent of Total Billed Charges,95% of Total Billed Charges,53.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.92,88,,63.36,Percent of Total Billed Charges,88% of Total Billed Charges,47.99,90,,64.8,Percent of Total Billed charges,90% of Total Billed Charges,23.51,53.32,
85913S CURVED DISP I/A,2710000349,CDM,271,RC,,,Outpatient,,,55.00,35.75,,55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.8,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.6,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,41.25,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.6,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,33,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,49.5,90,,43.2,Percent of Total Billed Charges,90% of Total Billed Charges,24.75,45,,52.392,Percent of Total Billed Charges,45% of Total Billed Charges,49.5,90,,64.8,Percent of Total Billed Charges,90% of Total billed Charges,55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.75,65,,597.384,Percent of total Billed Charges,65% of Total Billed Charges,24.26,44.1,,51.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.25,95,,68.4,Percent of Total Billed Charges,95% of Total Billed Charges,55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.4,88,,63.36,Percent of Total Billed Charges,88% of Total Billed Charges,49.5,90,,64.8,Percent of Total Billed charges,90% of Total Billed Charges,24.26,55,
BP Cuff Small Adult,2710000350,CDM,271,RC,,,Outpatient,,,3.50,2.28,,3.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.66,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.52,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,2.63,75,,394.8,Percent of Total Billed charges,75% of Total Billed Charges,3.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.52,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,2.1,60,,315.84,Percent of Total Billed Charges,60% of Total Billed Charges,3.15,90,,34.136,Percent of Total Billed Charges,90% of Total Billed Charges,1.58,45,,5.288,Percent of Total Billed Charges,45% of Total Billed Charges,3.15,90,,64.8,Percent of Total Billed Charges,90% of Total billed Charges,3.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.28,65,,75.672,Percent of total Billed Charges,65% of Total Billed Charges,1.54,44.1,,5.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.33,95,,68.4,Percent of Total Billed Charges,95% of Total Billed Charges,3.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.08,88,,63.36,Percent of Total Billed Charges,88% of Total Billed Charges,3.15,90,,64.8,Percent of Total Billed charges,90% of Total Billed Charges,1.54,3.5,
Walker Short Leg Non-Skid LG,2710000351,CDM,271,RC,,,Outpatient,,,144.97,94.23,,144.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.18,76,,698.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,104.38,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,108.73,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,144.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.38,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,86.98,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,130.47,90,,176.4,Percent of Total Billed Charges,90% of Total Billed Charges,65.24,45,,21.032,Percent of Total Billed Charges,45% of Total Billed Charges,130.47,90,,827.144,Percent of Total Billed Charges,90% of Total billed Charges,144.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.23,65,,7.632,Percent of total Billed Charges,65% of Total Billed Charges,63.93,44.1,,20.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,137.72,95,,873.096,Percent of Total Billed Charges,95% of Total Billed Charges,144.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.57,88,,808.76,Percent of Total Billed Charges,88% of Total Billed Charges,130.47,90,,827.144,Percent of Total Billed charges,90% of Total Billed Charges,63.93,144.97,
Walker Short Leg Non-Skid Med,2710000352,CDM,271,RC,,,Outpatient,,,65.62,42.65,,65.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.87,76,,88.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47.25,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,49.22,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,65.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.25,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,39.37,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,59.06,90,,78.4,Percent of Total Billed Charges,90% of Total Billed Charges,29.53,45,,66.68,Percent of Total Billed Charges,45% of Total Billed Charges,59.06,90,,104.784,Percent of Total Billed Charges,90% of Total billed Charges,65.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.65,65,,30.384,Percent of total Billed Charges,65% of Total Billed Charges,28.94,44.1,,65.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.34,95,,110.6,Percent of Total Billed Charges,95% of Total Billed Charges,65.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.75,88,,102.456,Percent of Total Billed Charges,88% of Total Billed Charges,59.06,90,,104.784,Percent of Total Billed charges,90% of Total Billed Charges,28.94,65.62,
Walker Short Leg Non-Skid SM,2710000353,CDM,271,RC,,,Outpatient,,,88.75,57.69,,88.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.45,76,,8.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.9,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,66.56,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,88.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.9,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,53.25,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,79.88,90,,1596.856,Percent of Total Billed Charges,90% of Total Billed Charges,39.94,45,,48.592,Percent of Total Billed Charges,45% of Total Billed Charges,79.88,90,,10.568,Percent of Total Billed Charges,90% of Total billed Charges,88.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.69,65,,96.312,Percent of total Billed Charges,65% of Total Billed Charges,39.14,44.1,,47.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,84.31,95,,11.16,Percent of Total Billed Charges,95% of Total Billed Charges,88.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.1,88,,10.336,Percent of Total Billed Charges,88% of Total Billed Charges,79.88,90,,10.568,Percent of Total Billed charges,90% of Total Billed Charges,39.14,88.75,
"IV Autoguard 18G x 1.88""",2710000354,CDM,271,RC,,,Outpatient,,,4.08,2.65,,4.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.1,76,,35.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.94,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,3.06,75,,394.8,Percent of Total Billed charges,75% of Total Billed Charges,4.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.94,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,2.45,60,,315.84,Percent of Total Billed Charges,60% of Total Billed Charges,3.67,90,,4312.8,Percent of Total Billed Charges,90% of Total Billed Charges,1.84,45,,285.376,Percent of Total Billed Charges,45% of Total Billed Charges,3.67,90,,42.072,Percent of Total Billed Charges,90% of Total billed Charges,4.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.65,65,,70.192,Percent of total Billed Charges,65% of Total Billed Charges,1.8,44.1,,279.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.88,95,,44.408,Percent of Total Billed Charges,95% of Total Billed Charges,4.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.59,88,,41.136,Percent of Total Billed Charges,88% of Total Billed Charges,3.67,90,,42.072,Percent of Total Billed charges,90% of Total Billed Charges,1.8,4.08,
MIDLINE ARROW 4F X 20CM,2710000355,CDM,271,RC,C1751,HCPCS,Outpatient,,,342.50,222.63,,342.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,260.3,76,,112.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,246.6,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,256.88,75,,394.8,Percent of Total Billed charges,75% of Total Billed Charges,342.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.6,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,205.5,60,,315.84,Percent of Total Billed Charges,60% of Total Billed Charges,308.25,90,,4312.8,Percent of Total Billed Charges,90% of Total Billed Charges,154.13,45,,21.6,Percent of Total Billed Charges,45% of Total Billed Charges,308.25,90,,133.36,Percent of Total Billed Charges,90% of Total billed Charges,342.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.63,65,,412.208,Percent of total Billed Charges,65% of Total Billed Charges,151.04,44.1,,21.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,325.38,95,,140.768,Percent of Total Billed Charges,95% of Total Billed Charges,342.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.4,88,,130.392,Percent of Total Billed Charges,88% of Total Billed Charges,308.25,90,,133.36,Percent of Total Billed charges,90% of Total Billed Charges,151.04,342.5,
OVAL-8 SPLINT SZ 2,2710000356,CDM,271,RC,,,Outpatient,,,22.32,14.51,,22.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.96,76,,82.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.07,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,16.74,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,22.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.07,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,13.39,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,20.09,90,,4312.8,Percent of Total Billed Charges,90% of Total Billed Charges,10.04,45,,17.064,Percent of Total Billed Charges,45% of Total Billed Charges,20.09,90,,97.184,Percent of Total Billed Charges,90% of Total billed Charges,22.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.51,65,,31.2,Percent of total Billed Charges,65% of Total Billed Charges,9.84,44.1,,16.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.2,95,,102.584,Percent of Total Billed Charges,95% of Total Billed Charges,22.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.64,88,,95.024,Percent of Total Billed Charges,88% of Total Billed Charges,20.09,90,,97.184,Percent of Total Billed charges,90% of Total Billed Charges,9.84,22.32,
OVAL-8 SPLINT 5 PK SZ 3,2710000357,CDM,271,RC,,,Outpatient,,,22.32,14.51,,22.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.96,76,,481.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.07,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,16.74,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,22.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.07,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,13.39,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,20.09,90,,4312.8,Percent of Total Billed Charges,90% of Total Billed Charges,10.04,45,,88.2,Percent of Total Billed Charges,45% of Total Billed Charges,20.09,90,,570.744,Percent of Total Billed Charges,90% of Total billed Charges,22.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.51,65,,24.656,Percent of total Billed Charges,65% of Total Billed Charges,9.84,44.1,,86.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.2,95,,602.456,Percent of Total Billed Charges,95% of Total Billed Charges,22.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.64,88,,558.064,Percent of Total Billed Charges,88% of Total Billed Charges,20.09,90,,570.744,Percent of Total Billed charges,90% of Total Billed Charges,9.84,22.32,
OVAL-8 SPLINT 5 PK SZ 4,2710000358,CDM,271,RC,,,Outpatient,,,23.10,15.02,,23.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.56,76,,36.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,17.33,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,13.86,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,20.79,90,,4312.8,Percent of Total Billed Charges,90% of Total Billed Charges,10.4,45,,39.2,Percent of Total Billed Charges,45% of Total Billed Charges,20.79,90,,43.2,Percent of Total Billed Charges,90% of Total billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.02,65,,127.4,Percent of total Billed Charges,65% of Total Billed Charges,10.19,44.1,,38.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.95,95,,45.6,Percent of Total Billed Charges,95% of Total Billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.33,88,,42.24,Percent of Total Billed Charges,88% of Total Billed Charges,20.79,90,,43.2,Percent of Total Billed charges,90% of Total Billed Charges,10.19,23.1,
OVAL-8 SPLINT 5 PK SZ 5,2710000359,CDM,271,RC,,,Outpatient,,,23.10,15.02,,23.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.56,76,,28.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.63,72,,1052.896,Percent of Total Billed Charges,72% of Total Billed Charges,17.33,75,,1096.768,Percent of Total Billed charges,75% of Total Billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.63,72,,1052.896,Percent of Total Billed Charges,72% of Total Billed Charges,13.86,60,,877.416,Percent of Total Billed Charges,60% of Total Billed Charges,20.79,90,,595.352,Percent of Total Billed Charges,90% of Total Billed Charges,10.4,45,,798.432,Percent of Total Billed Charges,45% of Total Billed Charges,20.79,90,,34.136,Percent of Total Billed Charges,90% of Total billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.02,65,,56.624,Percent of total Billed Charges,65% of Total Billed Charges,10.19,44.1,,782.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.95,95,,36.032,Percent of Total Billed Charges,95% of Total Billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.33,88,,33.376,Percent of Total Billed Charges,88% of Total Billed Charges,20.79,90,,34.136,Percent of Total Billed charges,90% of Total Billed Charges,10.19,23.1,
OVAL-8 SPLINT 5 PK SZ 6,2710000360,CDM,271,RC,,,Outpatient,,,23.10,15.02,,23.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.56,76,,148.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,17.33,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,13.86,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,20.79,90,,595.352,Percent of Total Billed Charges,90% of Total Billed Charges,10.4,45,,2156.4,Percent of Total Billed Charges,45% of Total Billed Charges,20.79,90,,176.4,Percent of Total Billed Charges,90% of Total billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.02,65,,1153.288,Percent of total Billed Charges,65% of Total Billed Charges,10.19,44.1,,2113.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.95,95,,186.2,Percent of Total Billed Charges,95% of Total Billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.33,88,,172.48,Percent of Total Billed Charges,88% of Total Billed Charges,20.79,90,,176.4,Percent of Total Billed charges,90% of Total Billed Charges,10.19,23.1,
OVAL-8 SPLINT 5 PK SZ 7,2710000361,CDM,271,RC,,,Outpatient,,,23.10,15.02,,23.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.56,76,,66.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,17.33,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,13.86,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,20.79,90,,392.4,Percent of Total Billed Charges,90% of Total Billed Charges,10.4,45,,2156.4,Percent of Total Billed Charges,45% of Total Billed Charges,20.79,90,,78.4,Percent of Total Billed Charges,90% of Total billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.02,65,,3114.8,Percent of total Billed Charges,65% of Total Billed Charges,10.19,44.1,,2113.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.95,95,,82.76,Percent of Total Billed Charges,95% of Total Billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.33,88,,76.656,Percent of Total Billed Charges,88% of Total Billed Charges,20.79,90,,78.4,Percent of Total Billed charges,90% of Total Billed Charges,10.19,23.1,
OVAL-8 SPLINT 5 PK SZ 8,2710000362,CDM,271,RC,,,Outpatient,,,23.10,15.02,,23.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.56,76,,1348.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,17.33,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,13.86,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,20.79,90,,149.688,Percent of Total Billed Charges,90% of Total Billed Charges,10.4,45,,2156.4,Percent of Total Billed Charges,45% of Total Billed Charges,20.79,90,,1596.856,Percent of Total Billed Charges,90% of Total billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.02,65,,3114.8,Percent of total Billed Charges,65% of Total Billed Charges,10.19,44.1,,2113.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.95,95,,1685.576,Percent of Total Billed Charges,95% of Total Billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.33,88,,1561.376,Percent of Total Billed Charges,88% of Total Billed Charges,20.79,90,,1596.856,Percent of Total Billed charges,90% of Total Billed Charges,10.19,23.1,
OVAL-8 SPLINT 5 PK SZ 9,2710000363,CDM,271,RC,,,Outpatient,,,23.10,15.02,,23.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.56,76,,3641.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,17.33,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,13.86,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,20.79,90,,149.688,Percent of Total Billed Charges,90% of Total Billed Charges,10.4,45,,2156.4,Percent of Total Billed Charges,45% of Total Billed Charges,20.79,90,,4312.8,Percent of Total Billed Charges,90% of Total billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.02,65,,3114.8,Percent of total Billed Charges,65% of Total Billed Charges,10.19,44.1,,2113.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.95,95,,4552.4,Percent of Total Billed Charges,95% of Total Billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.33,88,,4216.96,Percent of Total Billed Charges,88% of Total Billed Charges,20.79,90,,4312.8,Percent of Total Billed charges,90% of Total Billed Charges,10.19,23.1,
OVAL 8 SINGLE RING SIZE 10,2710000364,CDM,271,RC,,,Outpatient,,,23.10,15.02,,23.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.56,76,,3641.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,17.33,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,13.86,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,20.79,90,,205.816,Percent of Total Billed Charges,90% of Total Billed Charges,10.4,45,,2156.4,Percent of Total Billed Charges,45% of Total Billed Charges,20.79,90,,4312.8,Percent of Total Billed Charges,90% of Total billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.02,65,,3114.8,Percent of total Billed Charges,65% of Total Billed Charges,10.19,44.1,,2113.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.95,95,,4552.4,Percent of Total Billed Charges,95% of Total Billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.33,88,,4216.96,Percent of Total Billed Charges,88% of Total Billed Charges,20.79,90,,4312.8,Percent of Total Billed charges,90% of Total Billed Charges,10.19,23.1,
OVAL 8 SINGLE RING SIZE 11,2710000365,CDM,271,RC,,,Outpatient,,,23.10,15.02,,23.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.56,76,,3641.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,17.33,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,13.86,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,20.79,90,,93.56,Percent of Total Billed Charges,90% of Total Billed Charges,10.4,45,,297.68,Percent of Total Billed Charges,45% of Total Billed Charges,20.79,90,,4312.8,Percent of Total Billed Charges,90% of Total billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.02,65,,3114.8,Percent of total Billed Charges,65% of Total Billed Charges,10.19,44.1,,291.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.95,95,,4552.4,Percent of Total Billed Charges,95% of Total Billed Charges,23.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.33,88,,4216.96,Percent of Total Billed Charges,88% of Total Billed Charges,20.79,90,,4312.8,Percent of Total Billed charges,90% of Total Billed Charges,10.19,23.1,
BVI BEAVER MINI-BLADE,2710000366,CDM,271,RC,,,Outpatient,,,4.05,2.63,,4.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.08,76,,3641.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.92,72,,1052.896,Percent of Total Billed Charges,72% of Total Billed Charges,3.04,75,,1096.768,Percent of Total Billed charges,75% of Total Billed Charges,4.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.92,72,,1052.896,Percent of Total Billed Charges,72% of Total Billed Charges,2.43,60,,877.416,Percent of Total Billed Charges,60% of Total Billed Charges,3.65,90,,93.56,Percent of Total Billed Charges,90% of Total Billed Charges,1.82,45,,297.68,Percent of Total Billed Charges,45% of Total Billed Charges,3.65,90,,4312.8,Percent of Total Billed Charges,90% of Total billed Charges,4.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.63,65,,429.976,Percent of total Billed Charges,65% of Total Billed Charges,1.79,44.1,,291.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.85,95,,4552.4,Percent of Total Billed Charges,95% of Total Billed Charges,4.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.56,88,,4216.96,Percent of Total Billed Charges,88% of Total Billed Charges,3.65,90,,4312.8,Percent of Total Billed charges,90% of Total Billed Charges,1.79,4.05,
ESOPHAGEAL/RECTAL TEMP PROBE,2710000367,CDM,271,RC,,,Outpatient,,,12.70,8.26,,12.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.65,76,,3641.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.14,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,9.53,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,12.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.14,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,7.62,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,11.43,90,,53.68,Percent of Total Billed Charges,90% of Total Billed Charges,5.72,45,,196.2,Percent of Total Billed Charges,45% of Total Billed Charges,11.43,90,,4312.8,Percent of Total Billed Charges,90% of Total billed Charges,12.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.26,65,,429.976,Percent of total Billed Charges,65% of Total Billed Charges,5.6,44.1,,192.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.07,95,,4552.4,Percent of Total Billed Charges,95% of Total Billed Charges,12.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.18,88,,4216.96,Percent of Total Billed Charges,88% of Total Billed Charges,11.43,90,,4312.8,Percent of Total Billed charges,90% of Total Billed Charges,5.6,12.7,
HVT 2.0 AEROSOL DPC HIGH FLOW,2710000368,CDM,271,RC,,,Outpatient,,,435.83,283.29,,435.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,331.23,76,,502.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,313.8,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,326.87,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,435.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.8,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,261.5,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,392.25,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,196.12,45,,74.848,Percent of Total Billed Charges,45% of Total Billed Charges,392.25,90,,595.352,Percent of Total Billed Charges,90% of Total billed Charges,435.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.29,65,,283.4,Percent of total Billed Charges,65% of Total Billed Charges,192.2,44.1,,73.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,414.04,95,,628.432,Percent of Total Billed Charges,95% of Total Billed Charges,435.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,383.53,88,,582.12,Percent of Total Billed Charges,88% of Total Billed Charges,392.25,90,,595.352,Percent of Total Billed charges,90% of Total Billed Charges,192.2,435.83,
ADULT/PEDI DISPOSABLE PATIENT,2710000369,CDM,271,RC,,,Outpatient,,,319.00,207.35,,319,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,242.44,76,,502.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,229.68,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,239.25,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,319,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.68,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,191.4,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,287.1,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,143.55,45,,74.848,Percent of Total Billed Charges,45% of Total Billed Charges,287.1,90,,595.352,Percent of Total Billed Charges,90% of Total billed Charges,319,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.35,65,,108.112,Percent of total Billed Charges,65% of Total Billed Charges,140.68,44.1,,73.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,303.05,95,,628.432,Percent of Total Billed Charges,95% of Total Billed Charges,319,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280.72,88,,582.12,Percent of Total Billed Charges,88% of Total Billed Charges,287.1,90,,595.352,Percent of Total Billed charges,90% of Total Billed Charges,140.68,319,
NEWBORN RESTRAINTS,2710000370,CDM,271,RC,,,Outpatient,,,4.35,2.83,,4.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.31,76,,331.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.13,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,3.26,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,4.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.13,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,2.61,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,3.92,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,1.96,45,,102.912,Percent of Total Billed Charges,45% of Total Billed Charges,3.92,90,,392.4,Percent of Total Billed Charges,90% of Total billed Charges,4.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.83,65,,108.112,Percent of total Billed Charges,65% of Total Billed Charges,1.92,44.1,,100.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.13,95,,414.2,Percent of Total Billed Charges,95% of Total Billed Charges,4.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.83,88,,383.68,Percent of Total Billed Charges,88% of Total Billed Charges,3.92,90,,392.4,Percent of Total Billed charges,90% of Total Billed Charges,1.92,4.35,
Temper Foam Blocks,2710000371,CDM,271,RC,,,Outpatient,,,5.78,3.76,,5.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.39,76,,126.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.16,72,,1052.896,Percent of Total Billed Charges,72% of Total Billed Charges,4.34,75,,1096.768,Percent of Total Billed charges,75% of Total Billed Charges,5.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.16,72,,1052.896,Percent of Total Billed Charges,72% of Total Billed Charges,3.47,60,,877.416,Percent of Total Billed Charges,60% of Total Billed Charges,5.2,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,2.6,45,,46.776,Percent of Total Billed Charges,45% of Total Billed Charges,5.2,90,,149.688,Percent of Total Billed Charges,90% of Total billed Charges,5.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.76,65,,148.648,Percent of total Billed Charges,65% of Total Billed Charges,2.55,44.1,,45.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.49,95,,158.008,Percent of Total Billed Charges,95% of Total Billed Charges,5.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.09,88,,146.36,Percent of Total Billed Charges,88% of Total Billed Charges,5.2,90,,149.688,Percent of Total Billed charges,90% of Total Billed Charges,2.55,5.78,
"Compression Glove, Left, Small",2710000372,CDM,271,RC,,,Outpatient,,,10.60,6.89,,10.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.06,76,,126.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,7.95,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,6.36,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,9.54,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,4.77,45,,46.776,Percent of Total Billed Charges,45% of Total Billed Charges,9.54,90,,149.688,Percent of Total Billed Charges,90% of Total billed Charges,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.89,65,,67.568,Percent of total Billed Charges,65% of Total Billed Charges,4.67,44.1,,45.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.07,95,,158.008,Percent of Total Billed Charges,95% of Total Billed Charges,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.33,88,,146.36,Percent of Total Billed Charges,88% of Total Billed Charges,9.54,90,,149.688,Percent of Total Billed charges,90% of Total Billed Charges,4.67,10.6,
"Compression Glove, Left, Mediu",2710000373,CDM,271,RC,,,Outpatient,,,10.60,6.89,,10.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.06,76,,173.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,7.95,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,6.36,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,9.54,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,4.77,45,,26.84,Percent of Total Billed Charges,45% of Total Billed Charges,9.54,90,,205.816,Percent of Total Billed Charges,90% of Total billed Charges,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.89,65,,67.568,Percent of total Billed Charges,65% of Total Billed Charges,4.67,44.1,,26.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.07,95,,217.256,Percent of Total Billed Charges,95% of Total Billed Charges,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.33,88,,201.248,Percent of Total Billed Charges,88% of Total Billed Charges,9.54,90,,205.816,Percent of Total Billed charges,90% of Total Billed Charges,4.67,10.6,
"Compression Glove, Left, Large",2710000374,CDM,271,RC,,,Outpatient,,,10.60,6.89,,10.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.06,76,,79,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,7.95,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,6.36,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,9.54,90,,225.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.77,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,9.54,90,,93.56,Percent of Total Billed Charges,90% of Total billed Charges,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.89,65,,38.768,Percent of total Billed Charges,65% of Total Billed Charges,4.67,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.07,95,,98.752,Percent of Total Billed Charges,95% of Total Billed Charges,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.33,88,,91.48,Percent of Total Billed Charges,88% of Total Billed Charges,9.54,90,,93.56,Percent of Total Billed charges,90% of Total Billed Charges,4.67,10.6,
"Compression Glove, Right, Smal",2710000375,CDM,271,RC,,,Outpatient,,,10.60,6.89,,10.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.06,76,,79,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,7.95,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,6.36,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,9.54,90,,100.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.77,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,9.54,90,,93.56,Percent of Total Billed Charges,90% of Total billed Charges,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.89,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,4.67,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.07,95,,98.752,Percent of Total Billed Charges,95% of Total Billed Charges,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.33,88,,91.48,Percent of Total Billed Charges,88% of Total Billed Charges,9.54,90,,93.56,Percent of Total Billed charges,90% of Total Billed Charges,4.67,10.6,
"Compression Glove, Right, Medi",2710000376,CDM,271,RC,,,Outpatient,,,10.60,6.89,,10.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.06,76,,45.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,7.95,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,6.36,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,9.54,90,,100.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.77,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,9.54,90,,53.68,Percent of Total Billed Charges,90% of Total billed Charges,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.89,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,4.67,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.07,95,,56.656,Percent of Total Billed Charges,95% of Total Billed Charges,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.33,88,,52.48,Percent of Total Billed Charges,88% of Total Billed Charges,9.54,90,,53.68,Percent of Total Billed charges,90% of Total Billed Charges,4.67,10.6,
"Compression Glove, Right, Larg",2710000377,CDM,271,RC,,,Outpatient,,,10.60,6.89,,10.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.06,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,7.95,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,6.36,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,9.54,90,,100.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.77,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,9.54,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.89,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,4.67,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.07,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,10.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.33,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,9.54,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,4.67,10.6,
APPLICATOR ULTRA MIST,2710000378,CDM,271,RC,,,Outpatient,,,125.00,81.25,,125,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,93.75,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,75,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,112.5,90,,86.688,Percent of Total Billed Charges,90% of Total Billed Charges,56.25,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,112.5,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.25,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,55.13,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,118.75,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,112.5,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,55.13,125,
IODOSORB GEL 40 GR,2710000379,CDM,271,RC,,,Outpatient,,,80.38,52.25,,80.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,61.09,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.87,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,60.29,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,80.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.87,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,48.23,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,72.34,90,,108.056,Percent of Total Billed Charges,90% of Total Billed Charges,36.17,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,72.34,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,80.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.25,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,35.45,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,76.36,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,80.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.73,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,72.34,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,35.45,80.38,
IODOSORB GEL 10 GR,2710000380,CDM,271,RC,,,Outpatient,,,36.93,24.00,,36.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.07,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.59,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,27.7,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,36.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.59,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,22.16,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,33.24,90,,92.96,Percent of Total Billed Charges,90% of Total Billed Charges,16.62,45,,112.72,Percent of Total Billed Charges,45% of Total Billed Charges,33.24,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,36.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,16.29,44.1,,110.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.08,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,36.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.5,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,33.24,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,16.29,36.93,
ENDOFORM ANTIMICROB DERMAL 2X2,2710000381,CDM,271,RC,,,Outpatient,,,26.63,17.31,,26.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.24,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.17,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,19.97,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,26.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.17,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,15.98,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,23.97,90,,124.968,Percent of Total Billed Charges,90% of Total Billed Charges,11.98,45,,50.4,Percent of Total Billed Charges,45% of Total Billed Charges,23.97,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,26.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.31,65,,162.816,Percent of total Billed Charges,65% of Total Billed Charges,11.74,44.1,,49.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.3,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,26.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.43,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,23.97,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,11.74,26.63,
HYDROFERA BLU 9MM TUN CLS FOAM,2710000382,CDM,271,RC,,,Outpatient,,,10.33,6.71,,10.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.85,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.44,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,7.75,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,10.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.44,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,6.2,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,9.3,90,,423.096,Percent of Total Billed Charges,90% of Total Billed Charges,4.65,45,,50.4,Percent of Total Billed Charges,45% of Total Billed Charges,9.3,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,10.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.71,65,,72.8,Percent of total Billed Charges,65% of Total Billed Charges,4.56,44.1,,49.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.81,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,10.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.09,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,9.3,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,4.56,10.33,
HYDROFERA BLUE CLSC FOAM 4X4,2710000383,CDM,271,RC,,,Outpatient,,,17.98,11.69,,17.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.66,76,,190.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.95,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,13.49,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,17.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.95,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,10.79,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,16.18,90,,180.72,Percent of Total Billed Charges,90% of Total Billed Charges,8.09,45,,50.4,Percent of Total Billed Charges,45% of Total Billed Charges,16.18,90,,225.44,Percent of Total Billed Charges,90% of Total billed Charges,17.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.69,65,,72.8,Percent of total Billed Charges,65% of Total Billed Charges,7.93,44.1,,49.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.08,95,,237.96,Percent of Total Billed Charges,95% of Total Billed Charges,17.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.82,88,,220.432,Percent of Total Billed Charges,88% of Total Billed Charges,16.18,90,,225.44,Percent of Total Billed charges,90% of Total Billed Charges,7.93,17.98,
HYDROFERA BLUE CLSC FOAM 6X6,2710000384,CDM,271,RC,,,Outpatient,,,34.20,22.23,,34.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.99,76,,85.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.62,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,25.65,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,34.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.62,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,20.52,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,30.78,90,,55.504,Percent of Total Billed Charges,90% of Total Billed Charges,15.39,45,,43.344,Percent of Total Billed Charges,45% of Total Billed Charges,30.78,90,,100.8,Percent of Total Billed Charges,90% of Total billed Charges,34.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.23,65,,72.8,Percent of total Billed Charges,65% of Total Billed Charges,15.08,44.1,,42.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.49,95,,106.4,Percent of Total Billed Charges,95% of Total Billed Charges,34.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.1,88,,98.56,Percent of Total Billed Charges,88% of Total Billed Charges,30.78,90,,100.8,Percent of Total Billed charges,90% of Total Billed Charges,15.08,34.2,
A & D OINTMENT 4OZ TUBE,2710000385,CDM,271,RC,,,Outpatient,,,3.33,2.16,,3.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.53,76,,85.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.4,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,2.5,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,3.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.4,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,2,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,3,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.5,45,,54.032,Percent of Total Billed Charges,45% of Total Billed Charges,3,90,,100.8,Percent of Total Billed Charges,90% of Total billed Charges,3.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.16,65,,62.608,Percent of total Billed Charges,65% of Total Billed Charges,1.47,44.1,,52.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.16,95,,106.4,Percent of Total Billed Charges,95% of Total Billed Charges,3.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.93,88,,98.56,Percent of Total Billed Charges,88% of Total Billed Charges,3,90,,100.8,Percent of Total Billed charges,90% of Total Billed Charges,1.47,3.33,
"COBAN BLUE 4""X5YD",2710000386,CDM,271,RC,,,Outpatient,,,3.95,2.57,,3.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3,76,,85.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.84,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,2.96,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,3.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.84,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,2.37,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,3.56,90,,34.08,Percent of Total Billed Charges,90% of Total Billed Charges,1.78,45,,46.48,Percent of Total Billed Charges,45% of Total Billed Charges,3.56,90,,100.8,Percent of Total Billed Charges,90% of Total billed Charges,3.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.57,65,,78.04,Percent of total Billed Charges,65% of Total Billed Charges,1.74,44.1,,45.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.75,95,,106.4,Percent of Total Billed Charges,95% of Total Billed Charges,3.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.48,88,,98.56,Percent of Total Billed Charges,88% of Total Billed Charges,3.56,90,,100.8,Percent of Total Billed charges,90% of Total Billed Charges,1.74,3.95,
TRANS Q FLEX ELECTRODES,2710000387,CDM,271,RC,,,Outpatient,,,18.03,11.72,,18.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.7,76,,73.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.98,72,,214.328,Percent of Total Billed Charges,72% of Total Billed Charges,13.52,75,,214.328,Percent of Total Billed charges,75% of Total Billed Charges,18.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.98,72,,214.328,Percent of Total Billed Charges,72% of Total Billed Charges,10.82,60,,178.608,Percent of Total Billed Charges,60% of Total Billed Charges,16.23,90,,34.08,Percent of Total Billed Charges,90% of Total Billed Charges,8.11,45,,62.488,Percent of Total Billed Charges,45% of Total Billed Charges,16.23,90,,86.688,Percent of Total Billed Charges,90% of Total billed Charges,18.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.72,65,,67.136,Percent of total Billed Charges,65% of Total Billed Charges,7.95,44.1,,61.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.13,95,,91.504,Percent of Total Billed Charges,95% of Total Billed Charges,18.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.87,88,,84.76,Percent of Total Billed Charges,88% of Total Billed Charges,16.23,90,,86.688,Percent of Total Billed charges,90% of Total Billed Charges,7.95,18.03,
ADAPTIC TOUCH 3X4.25 DRSSNG,2710000388,CDM,271,RC,,,Outpatient,,,4.80,3.12,,4.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.65,76,,91.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.46,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,3.6,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,4.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.46,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,2.88,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,4.32,90,,713.128,Percent of Total Billed Charges,90% of Total Billed Charges,2.16,45,,211.544,Percent of Total Billed Charges,45% of Total Billed Charges,4.32,90,,108.056,Percent of Total Billed Charges,90% of Total billed Charges,4.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.12,65,,90.256,Percent of total Billed Charges,65% of Total Billed Charges,2.12,44.1,,207.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.56,95,,114.064,Percent of Total Billed Charges,95% of Total Billed Charges,4.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.22,88,,105.656,Percent of Total Billed Charges,88% of Total Billed Charges,4.32,90,,108.056,Percent of Total Billed charges,90% of Total Billed Charges,2.12,4.8,
HYDROFERA 2X2 CLASSIC,2710000389,CDM,271,RC,,,Outpatient,,,10.20,6.63,,10.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.75,76,,78.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.34,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,7.65,75,,54,Percent of Total Billed charges,75% of Total Billed Charges,10.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.34,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,6.12,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,9.18,90,,713.128,Percent of Total Billed Charges,90% of Total Billed Charges,4.59,45,,90.36,Percent of Total Billed Charges,45% of Total Billed Charges,9.18,90,,92.96,Percent of Total Billed Charges,90% of Total billed Charges,10.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.63,65,,305.568,Percent of total Billed Charges,65% of Total Billed Charges,4.5,44.1,,88.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.69,95,,98.12,Percent of Total Billed Charges,95% of Total Billed Charges,10.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.98,88,,90.896,Percent of Total Billed Charges,88% of Total Billed Charges,9.18,90,,92.96,Percent of Total Billed charges,90% of Total Billed Charges,4.5,10.2,
OPTIFORM 7X7,2710000390,CDM,271,RC,,,Outpatient,,,14.60,9.49,,14.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.1,76,,105.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.51,72,,1158.312,Percent of Total Billed Charges,72% of Total Billed Charges,10.95,75,,1158.312,Percent of Total Billed charges,75% of Total Billed Charges,14.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.51,72,,1158.312,Percent of Total Billed Charges,72% of Total Billed Charges,8.76,60,,965.264,Percent of Total Billed Charges,60% of Total Billed Charges,13.14,90,,387.376,Percent of Total Billed Charges,90% of Total Billed Charges,6.57,45,,27.752,Percent of Total Billed Charges,45% of Total Billed Charges,13.14,90,,124.968,Percent of Total Billed Charges,90% of Total billed Charges,14.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.49,65,,130.52,Percent of total Billed Charges,65% of Total Billed Charges,6.44,44.1,,27.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.87,95,,131.912,Percent of Total Billed Charges,95% of Total Billed Charges,14.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.85,88,,122.192,Percent of Total Billed Charges,88% of Total Billed Charges,13.14,90,,124.968,Percent of Total Billed charges,90% of Total Billed Charges,6.44,14.6,
ANTIFUNGAL MOISTURE CREAM BAZA,2710000391,CDM,271,RC,,,Outpatient,,,8.15,5.30,,8.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.19,76,,357.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.87,72,,1158.312,Percent of Total Billed Charges,72% of Total Billed Charges,6.11,75,,1158.312,Percent of Total Billed charges,75% of Total Billed Charges,8.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.87,72,,1158.312,Percent of Total Billed Charges,72% of Total Billed Charges,4.89,60,,965.264,Percent of Total Billed Charges,60% of Total Billed Charges,7.34,90,,452.472,Percent of Total Billed Charges,90% of Total Billed Charges,3.67,45,,5.224,Percent of Total Billed Charges,45% of Total Billed Charges,7.34,90,,423.096,Percent of Total Billed Charges,90% of Total billed Charges,8.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.3,65,,40.088,Percent of total Billed Charges,65% of Total Billed Charges,3.59,44.1,,5.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.74,95,,446.6,Percent of Total Billed Charges,95% of Total Billed Charges,8.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,88,,413.688,Percent of Total Billed Charges,88% of Total Billed Charges,7.34,90,,423.096,Percent of Total Billed charges,90% of Total Billed Charges,3.59,8.15,
10 MLE ROTATNG LUER LCKFEM,2720000001,CDM,272,RC,,,Outpatient,,,1.00,0.65,,1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.76,76,,152.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.72,72,,1231.976,Percent of Total Billed Charges,72% of Total Billed Charges,0.75,75,,1231.976,Percent of Total Billed charges,75% of Total Billed Charges,1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,72,,1231.976,Percent of Total Billed Charges,72% of Total Billed Charges,0.6,60,,1026.648,Percent of Total Billed Charges,60% of Total Billed Charges,0.9,90,,99.224,Percent of Total Billed Charges,90% of Total Billed Charges,0.45,45,,17.04,Percent of Total Billed Charges,45% of Total Billed Charges,0.9,90,,180.72,Percent of Total Billed Charges,90% of Total billed Charges,1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.65,65,,7.544,Percent of total Billed Charges,65% of Total Billed Charges,0.44,44.1,,16.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.95,95,,190.76,Percent of Total Billed Charges,95% of Total Billed Charges,1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.88,88,,176.704,Percent of Total Billed Charges,88% of Total Billed Charges,0.9,90,,180.72,Percent of Total Billed charges,90% of Total Billed Charges,0.44,1,
1000ML DRN BTLE W/O DRAIN LINE,2720000002,CDM,272,RC,,,Outpatient,,,97.70,63.51,,97.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,74.25,76,,46.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,70.34,72,,1231.976,Percent of Total Billed Charges,72% of Total Billed Charges,73.28,75,,1231.976,Percent of Total Billed charges,75% of Total Billed Charges,97.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.34,72,,1231.976,Percent of Total Billed Charges,72% of Total Billed Charges,58.62,60,,1026.648,Percent of Total Billed Charges,60% of Total Billed Charges,87.93,90,,99.224,Percent of Total Billed Charges,90% of Total Billed Charges,43.97,45,,17.04,Percent of Total Billed Charges,45% of Total Billed Charges,87.93,90,,55.504,Percent of Total Billed Charges,90% of Total billed Charges,97.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.51,65,,24.608,Percent of total Billed Charges,65% of Total Billed Charges,43.09,44.1,,16.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,92.82,95,,58.592,Percent of Total Billed Charges,95% of Total Billed Charges,97.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.98,88,,54.272,Percent of Total Billed Charges,88% of Total Billed Charges,87.93,90,,55.504,Percent of Total Billed charges,90% of Total Billed Charges,43.09,97.7,
1000ML DRN BTLE W/O LINE,2720000003,CDM,272,RC,,,Outpatient,,,97.70,63.51,,97.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,74.25,76,,8.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,70.34,72,,130.864,Percent of Total Billed Charges,72% of Total Billed Charges,73.28,75,,130.864,Percent of Total Billed charges,75% of Total Billed Charges,97.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.34,72,,130.864,Percent of Total Billed Charges,72% of Total Billed Charges,58.62,60,,109.056,Percent of Total Billed Charges,60% of Total Billed Charges,87.93,90,,124.624,Percent of Total Billed Charges,90% of Total Billed Charges,43.97,45,,356.56,Percent of Total Billed Charges,45% of Total Billed Charges,87.93,90,,10.44,Percent of Total Billed Charges,90% of Total billed Charges,97.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.51,65,,24.608,Percent of total Billed Charges,65% of Total Billed Charges,43.09,44.1,,349.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,92.82,95,,11.024,Percent of Total Billed Charges,95% of Total Billed Charges,97.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.98,88,,10.208,Percent of Total Billed Charges,88% of Total Billed Charges,87.93,90,,10.44,Percent of Total Billed charges,90% of Total Billed Charges,43.09,97.7,
4F 65CM STRAIGHT GLIDE CATH,2720000004,CDM,272,RC,C1887,HCPCS,Outpatient,,,170.89,111.08,,170.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.88,76,,28.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.04,72,,27.344,Percent of Total Billed Charges,72% of Total Billed Charges,128.17,75,,28.48,Percent of Total Billed charges,75% of Total Billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.04,72,,27.344,Percent of Total Billed Charges,72% of Total Billed Charges,102.53,60,,22.784,Percent of Total Billed Charges,60% of Total Billed Charges,153.8,90,,31.752,Percent of Total Billed Charges,90% of Total Billed Charges,76.9,45,,356.56,Percent of Total Billed Charges,45% of Total Billed Charges,153.8,90,,34.08,Percent of Total Billed Charges,90% of Total billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.08,65,,515.032,Percent of total Billed Charges,65% of Total Billed Charges,75.36,44.1,,349.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,162.35,95,,35.968,Percent of Total Billed Charges,95% of Total Billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.38,88,,33.32,Percent of Total Billed Charges,88% of Total Billed Charges,153.8,90,,34.08,Percent of Total Billed charges,90% of Total Billed Charges,75.36,170.89,
5F 100CM FL6 IMPUL DIAG CATH,2720000005,CDM,272,RC,C1887,HCPCS,Outpatient,,,50.57,32.87,,50.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38.43,76,,28.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36.41,72,,163.2,Percent of Total Billed Charges,72% of Total Billed Charges,37.93,75,,170.008,Percent of Total Billed charges,75% of Total Billed Charges,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.41,72,,163.2,Percent of Total Billed Charges,72% of Total Billed Charges,30.34,60,,136,Percent of Total Billed Charges,60% of Total Billed Charges,45.51,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,22.76,45,,193.688,Percent of Total Billed Charges,45% of Total Billed Charges,45.51,90,,34.08,Percent of Total Billed Charges,90% of Total billed Charges,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.87,65,,515.032,Percent of total Billed Charges,65% of Total Billed Charges,22.3,44.1,,189.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.04,95,,35.968,Percent of Total Billed Charges,95% of Total Billed Charges,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.5,88,,33.32,Percent of Total Billed Charges,88% of Total Billed Charges,45.51,90,,34.08,Percent of Total Billed charges,90% of Total Billed Charges,22.3,50.57,
5F 4X120X135 EVRC 014 PTA BALL,2720000006,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,602.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,323.872,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,337.368,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,323.872,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,269.896,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,311.76,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,226.232,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,713.128,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,279.768,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,221.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,752.744,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,697.28,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,713.128,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5F 4X200X135 EVRC 014 PTA BALL,2720000007,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,602.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,323.872,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,337.368,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,323.872,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,269.896,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,311.76,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,49.608,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,713.128,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,326.784,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,48.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,752.744,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,697.28,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,713.128,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5F 4X20X135 EVRC  014 PTA BALL,2720000008,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,327.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,103.68,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,103.68,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,103.68,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,86.4,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,49.608,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,387.376,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,71.664,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,48.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,408.896,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,378.768,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,387.376,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5F 65CM ANGLE TAPER GLDE CATH,2720000009,CDM,272,RC,C1887,HCPCS,Outpatient,,,170.89,111.08,,170.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.88,76,,382.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.04,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,128.17,75,,150,Percent of Total Billed charges,75% of Total Billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.04,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,102.53,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,153.8,90,,744.48,Percent of Total Billed Charges,90% of Total Billed Charges,76.9,45,,62.312,Percent of Total Billed Charges,45% of Total Billed Charges,153.8,90,,452.472,Percent of Total Billed Charges,90% of Total billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.08,65,,71.664,Percent of total Billed Charges,65% of Total Billed Charges,75.36,44.1,,61.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,162.35,95,,477.608,Percent of Total Billed Charges,95% of Total Billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.38,88,,442.416,Percent of Total Billed Charges,88% of Total Billed Charges,153.8,90,,452.472,Percent of Total Billed charges,90% of Total Billed Charges,75.36,170.89,
5F STIFFEN VS 7CM MP NDLE KIT,2720000010,CDM,272,RC,C1894,HCPCS,Outpatient,,,126.77,82.40,,126.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,96.35,76,,83.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.27,72,,981.136,Percent of Total Billed Charges,72% of Total Billed Charges,95.08,75,,1022.016,Percent of Total Billed charges,75% of Total Billed Charges,126.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.27,72,,981.136,Percent of Total Billed Charges,72% of Total Billed Charges,76.06,60,,817.616,Percent of Total Billed Charges,60% of Total Billed Charges,114.09,90,,31.168,Percent of Total Billed Charges,90% of Total Billed Charges,57.05,45,,15.88,Percent of Total Billed Charges,45% of Total Billed Charges,114.09,90,,99.224,Percent of Total Billed Charges,90% of Total billed Charges,126.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.4,65,,90.008,Percent of total Billed Charges,65% of Total Billed Charges,55.91,44.1,,15.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,120.43,95,,104.736,Percent of Total Billed Charges,95% of Total Billed Charges,126.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.56,88,,97.016,Percent of Total Billed Charges,88% of Total Billed Charges,114.09,90,,99.224,Percent of Total Billed charges,90% of Total Billed Charges,55.91,126.77,
5FR 4X20X80 EVRC 014 OTWPTA BA,2720000011,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,83.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,160.128,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,166.8,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,160.128,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,133.44,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,5.184,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,12.96,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,99.224,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,22.936,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,12.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,104.736,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,97.016,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,99.224,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5FR 4X40X135 EVRC 014 OTWPTA B,2720000012,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,105.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,144,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,155.88,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,124.624,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,18.72,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,152.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,131.552,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,121.856,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,124.624,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5FR 4X40X80 EVRC 014 OTWPTA BA,2720000013,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,26.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,88.904,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,92.608,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,88.904,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,74.088,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,227.488,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,155.88,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,31.752,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,225.16,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,152.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,33.52,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,31.048,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,31.752,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5FR 4X60X135 EVRC 014 OTWPTA B,2720000014,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,21.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,88.904,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,92.608,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,88.904,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,74.088,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,38.56,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,6.84,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,25.92,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,225.16,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,6.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,27.36,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,25.344,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,25.92,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5FR 4X80X135 EVRC 014 OTWPTA B,2720000015,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,263.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,109.224,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,113.776,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,109.224,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,91.024,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,38.56,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,372.24,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,311.76,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,9.88,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,364.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,329.08,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,304.832,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,311.76,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5FR 5X20X135 EVRC 014 OTWPTA B,2720000016,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,263.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,191.784,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,199.776,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,191.784,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,159.824,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,181.44,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,15.584,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,311.76,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,537.68,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,15.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,329.08,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,304.832,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,311.76,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5FR 5X20X80 EVRC 014 OTWPTA BA,2720000017,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,11.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,173.952,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,181.2,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,173.952,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,144.96,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,181.44,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,2.592,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,13.68,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,22.512,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,2.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,14.44,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,13.376,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,13.68,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5FR 5X40X135 EVRC O14 OTWPTA B,2720000018,CDM,272,RC,C1724,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,628.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,84.672,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,88.2,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,84.672,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,70.56,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,180.984,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,5.76,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,744.48,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,3.744,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,5.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,785.84,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,727.936,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,744.48,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5FR 5X40X80 EVRC 014 OTWPTA BA,2720000019,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,26.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,437.76,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,456,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,437.76,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,364.8,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,403.792,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,113.744,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,31.168,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,8.32,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,111.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,32.904,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,30.48,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,31.168,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5FR 5X60X135 EVRC 014 OTWPTA B,2720000020,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,4.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,221.184,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,230.4,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,221.184,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,184.32,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,403.792,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,19.28,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,5.184,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,164.296,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,18.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,5.472,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,5.072,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,5.184,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5FR 5X80X135 EVRC 014 OTWPTA B,2720000021,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,9.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,91.008,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,94.8,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,91.008,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,75.84,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,484.024,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,19.28,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,11.52,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,27.848,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,18.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,12.16,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,11.264,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,11.52,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5FR 6X20X135 EVRC OTW PTA BAL,2720000022,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,192.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,100.8,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,105,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,100.8,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,84,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,484.024,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,90.72,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,227.488,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,27.848,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,88.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,240.128,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,222.432,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,227.488,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5FR 6X20X80 EVRC 014 OTWPTA BA,2720000023,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,32.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,424.512,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,442.2,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,424.512,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,353.76,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,423.752,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,90.72,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,38.56,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,131.04,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,88.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,40.696,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,37.696,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,38.56,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5FR 6X40X135 EVRC 014 OTWPTA B,2720000024,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,32.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,100.8,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,105,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,100.8,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,84,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,90.496,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,38.56,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,131.04,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,88.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,40.696,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,37.696,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,38.56,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5FR 6X40X80 EVRC 014 OTWPTA BA,2720000025,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,153.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,229.248,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,238.8,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,229.248,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,191.04,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,473.76,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,201.896,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,181.44,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,130.712,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,197.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,191.52,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,177.408,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,181.44,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5FR 6X60X135 EVRC 014 OTWPTA B,2720000026,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,153.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,100.8,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,105,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,100.8,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,84,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,201.896,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,181.44,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,291.624,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,197.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,191.52,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,177.408,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,181.44,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5FR 6X80X135 EVRC 014 OTWPTA B,2720000027,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,152.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,105.408,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,109.8,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,105.408,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,87.84,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,242.008,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,180.984,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,291.624,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,237.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,191.04,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,176.968,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,180.984,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5FR 6X80X80 EVRC 014 OTWPTA BA,2720000028,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,340.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,1.328,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,1.384,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,1.328,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,1.104,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,473.76,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,242.008,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,403.792,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,349.568,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,237.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,426.224,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,394.816,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,403.792,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5FR 7X20X135 EVRC 014 OTWPTA B,2720000029,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,340.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,189.248,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,197.128,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,189.248,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,157.704,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,473.76,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,211.872,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,403.792,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,349.568,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,207.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,426.224,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,394.816,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,403.792,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5FR 7X20X80 EVRC 014 OTWPTA BA,2720000030,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,408.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,41.912,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,34.928,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,484.024,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,306.04,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,510.912,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,473.264,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,484.024,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5FR 7X40X80 EVRC 014 OTWPTA BA,2720000031,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,408.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,41.912,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,34.928,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,236.88,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,484.024,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,232.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,510.912,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,473.264,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,484.024,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
5FX100X20 CRAG MCNAM INFU CATH,2720000032,CDM,278,RC,C1751,HCPCS,Outpatient,,,297.68,193.49,,297.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,226.24,76,,357.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,214.33,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,214.33,72,,41.912,Percent of Total Billed charges,72% of Total Billed Charges,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.33,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,178.61,60,,34.928,Percent of Total Billed Charges,60% of Total Billed Charges,267.91,90,,473.76,Percent of Total Billed Charges,90% of Total Billed Charges,133.96,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,267.91,90,,423.752,Percent of Total Billed Charges,90% of Total billed Charges,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.49,65,,342.16,Percent of total Billed Charges,65% of Total Billed Charges,131.28,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,282.8,95,,447.288,Percent of Total Billed Charges,95% of Total Billed Charges,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.96,88,,414.336,Percent of Total Billed Charges,88% of Total Billed Charges,267.91,90,,423.752,Percent of Total Billed charges,90% of Total Billed Charges,131.28,297.68,
5FX100X30 CRAG MCNAM INFU CATH,2720000033,CDM,278,RC,C1751,HCPCS,Outpatient,,,297.68,193.49,,297.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,226.24,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,214.33,72,,173.952,Percent of Total Billed Charges,72% of Total Billed Charges,214.33,72,,181.2,Percent of Total Billed charges,72% of Total Billed Charges,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.33,72,,173.952,Percent of Total Billed Charges,72% of Total Billed Charges,178.61,60,,144.96,Percent of Total Billed Charges,60% of Total Billed Charges,267.91,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,133.96,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,267.91,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.49,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,131.28,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,282.8,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.96,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,267.91,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,131.28,297.68,
5FX100X40 CRAG MCNAM INFU CATH,2720000034,CDM,278,RC,C1751,HCPCS,Outpatient,,,297.68,193.49,,297.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,226.24,76,,400.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,214.33,72,,173.952,Percent of Total Billed Charges,72% of Total Billed Charges,214.33,72,,181.2,Percent of Total Billed charges,72% of Total Billed Charges,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.33,72,,173.952,Percent of Total Billed Charges,72% of Total Billed Charges,178.61,60,,144.96,Percent of Total Billed Charges,60% of Total Billed Charges,267.91,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,133.96,45,,236.88,Percent of Total Billed Charges,45% of Total Billed Charges,267.91,90,,473.76,Percent of Total Billed Charges,90% of Total billed Charges,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.49,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,131.28,44.1,,232.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,282.8,95,,500.08,Percent of Total Billed Charges,95% of Total Billed Charges,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.96,88,,463.232,Percent of Total Billed Charges,88% of Total Billed Charges,267.91,90,,473.76,Percent of Total Billed charges,90% of Total Billed Charges,131.28,297.68,
5FX100X50 CRAG MCNAM INFU CATH,2720000035,CDM,278,RC,C1751,HCPCS,Outpatient,,,297.68,193.49,,297.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,226.24,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,214.33,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,214.33,72,,13.232,Percent of Total Billed charges,72% of Total Billed Charges,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.33,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,178.61,60,,10.584,Percent of Total Billed Charges,60% of Total Billed Charges,267.91,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,133.96,45,,236.88,Percent of Total Billed Charges,45% of Total Billed Charges,267.91,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.49,65,,342.16,Percent of total Billed Charges,65% of Total Billed Charges,131.28,44.1,,232.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,282.8,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.96,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,267.91,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,131.28,297.68,
5FX135X50 CRAG MCNAM INFU CATH,2720000036,CDM,278,RC,C1751,HCPCS,Outpatient,,,297.68,193.49,,297.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,226.24,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,214.33,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,214.33,72,,13.232,Percent of Total Billed charges,72% of Total Billed Charges,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.33,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,178.61,60,,10.584,Percent of Total Billed Charges,60% of Total Billed Charges,267.91,90,,473.76,Percent of Total Billed Charges,90% of Total Billed Charges,133.96,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,267.91,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.49,65,,342.16,Percent of total Billed Charges,65% of Total Billed Charges,131.28,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,282.8,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.96,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,267.91,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,131.28,297.68,
5FX65X20 CRAG MCNAM INFU CATH,2720000037,CDM,278,RC,C1751,HCPCS,Outpatient,,,297.68,193.49,,297.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,226.24,76,,400.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,214.33,72,,94.08,Percent of Total Billed Charges,72% of Total Billed Charges,214.33,72,,98.008,Percent of Total Billed charges,72% of Total Billed Charges,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.33,72,,94.08,Percent of Total Billed Charges,72% of Total Billed Charges,178.61,60,,78.4,Percent of Total Billed Charges,60% of Total Billed Charges,267.91,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,133.96,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,267.91,90,,473.76,Percent of Total Billed Charges,90% of Total billed Charges,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.49,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,131.28,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,282.8,95,,500.08,Percent of Total Billed Charges,95% of Total Billed Charges,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.96,88,,463.232,Percent of Total Billed Charges,88% of Total Billed Charges,267.91,90,,473.76,Percent of Total Billed charges,90% of Total Billed Charges,131.28,297.68,
6F 6X80X130 IP AD PTA BALO CTH,2720000038,CDM,272,RC,C2623,HCPCS,Outpatient,,,3280.00,2132.00,,3280,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2492.8,76,,400.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2361.6,72,,105.84,Percent of Total Billed Charges,72% of Total Billed Charges,2460,75,,110.248,Percent of Total Billed charges,75% of Total Billed Charges,3280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2361.6,72,,105.84,Percent of Total Billed Charges,72% of Total Billed Charges,1968,60,,88.2,Percent of Total Billed Charges,60% of Total Billed Charges,2952,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,1476,45,,236.88,Percent of Total Billed Charges,45% of Total Billed Charges,2952,90,,473.76,Percent of Total Billed Charges,90% of Total billed Charges,3280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2132,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,1446.48,44.1,,232.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,3116,95,,500.08,Percent of Total Billed Charges,95% of Total Billed Charges,3280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2886.4,88,,463.232,Percent of Total Billed Charges,88% of Total Billed Charges,2952,90,,473.76,Percent of Total Billed charges,90% of Total Billed Charges,1446.48,3280,
6FR 8X20X80 EVRC 014 OTWPTA BA,2720000039,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,100.032,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,104.2,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,100.032,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,83.36,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,342.16,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
6FR 8X40X135 EVRC 014 OTWPTA B,2720000040,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,105.84,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,110.248,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,105.84,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,88.2,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
6FR 8X40X80 EVRC 014 OTWPTA BA,2720000041,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,400.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,100.032,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,104.2,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,100.032,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,83.36,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,473.76,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,500.08,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,463.232,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,473.76,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
6FR 8X60X80 EVRC 014 OTWPTA BA,2720000042,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,94.08,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,98.008,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,94.08,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,78.4,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,236.88,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,232.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
6FR 9X40X80 EVRC 014 OTWPTA BA,2720000043,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,108.152,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,112.656,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,108.152,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,90.128,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,473.76,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,342.16,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
7FR 12X40X80 EVRC 014 OTW PTA,2720000044,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,54,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
ADMIRAL 6F 5X150X130 BALLOON,2720000045,CDM,272,RC,C2623,HCPCS,Outpatient,,,3580.00,2327.00,,3580,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2720.8,76,,400.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2577.6,72,,32.4,Percent of Total Billed Charges,72% of Total Billed Charges,2685,75,,33.752,Percent of Total Billed charges,75% of Total Billed Charges,3580,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2577.6,72,,32.4,Percent of Total Billed Charges,72% of Total Billed Charges,2148,60,,27,Percent of Total Billed Charges,60% of Total Billed Charges,3222,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,1611,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,3222,90,,473.76,Percent of Total Billed Charges,90% of Total billed Charges,3580,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3580,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3580,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2327,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,1578.78,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,3401,95,,500.08,Percent of Total Billed Charges,95% of Total Billed Charges,3580,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3150.4,88,,463.232,Percent of Total Billed Charges,88% of Total Billed Charges,3222,90,,473.76,Percent of Total Billed charges,90% of Total Billed Charges,1578.78,3580,
ADVANT GLIDEWRE 25X0.035X260CM,2720000046,CDM,272,RC,C1769,HCPCS,Outpatient,,,2225.95,1446.87,,2225.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1691.72,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1602.68,72,,129.552,Percent of Total Billed Charges,72% of Total Billed Charges,1669.46,75,,134.944,Percent of Total Billed charges,75% of Total Billed Charges,2225.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1602.68,72,,129.552,Percent of Total Billed Charges,72% of Total Billed Charges,1335.57,60,,107.96,Percent of Total Billed Charges,60% of Total Billed Charges,2003.36,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,1001.68,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,2003.36,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,2225.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1446.87,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,981.64,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,2114.65,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,2225.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1958.84,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,2003.36,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,981.64,2225.95,
FLUIDSMART INFLOW TUBING SET,2720000047,CDM,272,RC,,,Outpatient,,,152.25,98.96,,152.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,115.71,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,109.62,72,,789.12,Percent of Total Billed Charges,72% of Total Billed Charges,114.19,75,,822,Percent of Total Billed charges,75% of Total Billed Charges,152.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.62,72,,789.12,Percent of Total Billed Charges,72% of Total Billed Charges,91.35,60,,657.6,Percent of Total Billed Charges,60% of Total Billed Charges,137.03,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,68.51,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,137.03,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,152.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.96,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,67.14,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,144.64,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,152.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.98,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,137.03,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,67.14,152.25,
AMPLATZ 0.035 X 180CM WIRE,2720000048,CDM,272,RC,C1769,HCPCS,Outpatient,,,164.27,106.78,,164.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.85,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,118.27,72,,1163.52,Percent of Total Billed Charges,72% of Total Billed Charges,123.2,75,,1212,Percent of Total Billed charges,75% of Total Billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.27,72,,1163.52,Percent of Total Billed Charges,72% of Total Billed Charges,98.56,60,,969.6,Percent of Total Billed Charges,60% of Total Billed Charges,147.84,90,,473.76,Percent of Total Billed Charges,90% of Total Billed Charges,73.92,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,147.84,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.78,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,72.44,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,156.06,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.56,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,147.84,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,72.44,164.27,
AMPLATZ ES 0.035 X 180 CK WRE,2720000049,CDM,272,RC,C1769,HCPCS,Outpatient,,,67.25,43.71,,67.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.11,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,48.42,72,,31.368,Percent of Total Billed Charges,72% of Total Billed Charges,50.44,75,,32.68,Percent of Total Billed charges,75% of Total Billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.42,72,,31.368,Percent of Total Billed Charges,72% of Total Billed Charges,40.35,60,,26.144,Percent of Total Billed Charges,60% of Total Billed Charges,60.53,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,30.26,45,,236.88,Percent of Total Billed Charges,45% of Total Billed Charges,60.53,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.71,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,29.66,44.1,,232.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,63.89,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.18,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,60.53,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,29.66,67.25,
AMPLATZ ES 0.035 X 260 CK WRE,2720000050,CDM,272,RC,C1769,HCPCS,Outpatient,,,67.25,43.71,,67.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.11,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,48.42,72,,74.304,Percent of Total Billed Charges,72% of Total Billed Charges,50.44,75,,74.304,Percent of Total Billed charges,75% of Total Billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.42,72,,74.304,Percent of Total Billed Charges,72% of Total Billed Charges,40.35,60,,61.92,Percent of Total Billed Charges,60% of Total Billed Charges,60.53,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,30.26,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,60.53,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.71,65,,342.16,Percent of total Billed Charges,65% of Total Billed Charges,29.66,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,63.89,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.18,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,60.53,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,29.66,67.25,
AMPLATZ STRGT 0.035X260CM WRE,2720000051,CDM,272,RC,C1769,HCPCS,Outpatient,,,171.99,111.79,,171.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.71,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.83,72,,74.304,Percent of Total Billed Charges,72% of Total Billed Charges,128.99,75,,77.4,Percent of Total Billed charges,75% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.83,72,,74.304,Percent of Total Billed Charges,72% of Total Billed Charges,103.19,60,,61.92,Percent of Total Billed Charges,60% of Total Billed Charges,154.79,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,77.4,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,154.79,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.79,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,75.85,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.39,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.35,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,154.79,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,75.85,171.99,
AMPLATZ ULT STIFF 0.035X145CM,2720000052,CDM,272,RC,C1769,HCPCS,Outpatient,,,176.99,115.04,,176.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,134.51,76,,400.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,127.43,72,,5071.432,Percent of Total Billed Charges,72% of Total Billed Charges,132.74,75,,5071.432,Percent of Total Billed charges,75% of Total Billed Charges,176.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.43,72,,5071.432,Percent of Total Billed Charges,72% of Total Billed Charges,106.19,60,,4226.192,Percent of Total Billed Charges,60% of Total Billed Charges,159.29,90,,473.76,Percent of Total Billed Charges,90% of Total Billed Charges,79.65,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,159.29,90,,473.76,Percent of Total Billed Charges,90% of Total billed Charges,176.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.04,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,78.05,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,168.14,95,,500.08,Percent of Total Billed Charges,95% of Total Billed Charges,176.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.75,88,,463.232,Percent of Total Billed Charges,88% of Total Billed Charges,159.29,90,,473.76,Percent of Total Billed charges,90% of Total Billed Charges,78.05,176.99,
ANGIO GDEWRE 0.035X260CM 3MMJ,2720000053,CDM,272,RC,C1769,HCPCS,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,1516.472,Percent of Total Billed Charges,72% of Total Billed Charges,58.71,75,,1579.664,Percent of Total Billed charges,75% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,1516.472,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,1263.728,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,473.76,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
ANSEL 0 5F 90CM CATH [018/035],2720000054,CDM,272,RC,C1887,HCPCS,Outpatient,,,304.50,197.93,,304.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,231.42,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,219.24,72,,34938.632,Percent of Total Billed Charges,72% of Total Billed Charges,228.38,75,,36394.408,Percent of Total Billed charges,75% of Total Billed Charges,304.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.24,72,,34938.632,Percent of Total Billed Charges,72% of Total Billed Charges,182.7,60,,29115.528,Percent of Total Billed Charges,60% of Total Billed Charges,274.05,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,137.03,45,,236.88,Percent of Total Billed Charges,45% of Total Billed Charges,274.05,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,304.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.93,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,134.28,44.1,,232.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,289.28,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,304.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.96,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,274.05,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,134.28,304.5,
ANSEL 0 7F 45CM CATH (018/038),2720000055,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.00,127.40,,196,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,148.96,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.12,72,,44.32,Percent of Total Billed Charges,72% of Total Billed Charges,147,75,,46.168,Percent of Total Billed charges,75% of Total Billed Charges,196,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,72,,44.32,Percent of Total Billed Charges,72% of Total Billed Charges,117.6,60,,36.936,Percent of Total Billed Charges,60% of Total Billed Charges,176.4,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,88.2,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,176.4,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,196,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.4,65,,342.16,Percent of total Billed Charges,65% of Total Billed Charges,86.44,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.2,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,196,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.48,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,176.4,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,86.44,196,
ANSEL 1 5F 90CM CATH [018/038],2720000056,CDM,272,RC,C1887,HCPCS,Outpatient,,,304.50,197.93,,304.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,231.42,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,219.24,72,,203.848,Percent of Total Billed Charges,72% of Total Billed Charges,228.38,75,,212.344,Percent of Total Billed charges,75% of Total Billed Charges,304.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.24,72,,203.848,Percent of Total Billed Charges,72% of Total Billed Charges,182.7,60,,169.872,Percent of Total Billed Charges,60% of Total Billed Charges,274.05,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,137.03,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,274.05,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,304.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.93,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,134.28,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,289.28,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,304.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.96,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,274.05,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,134.28,304.5,
ANSEL 1 7F 45CM CATH (018/038),2720000057,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.00,127.40,,196,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,148.96,76,,400.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.12,72,,203.848,Percent of Total Billed Charges,72% of Total Billed Charges,147,75,,212.344,Percent of Total Billed charges,75% of Total Billed Charges,196,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,72,,203.848,Percent of Total Billed Charges,72% of Total Billed Charges,117.6,60,,169.872,Percent of Total Billed Charges,60% of Total Billed Charges,176.4,90,,1316.128,Percent of Total Billed Charges,90% of Total Billed Charges,88.2,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,176.4,90,,473.76,Percent of Total Billed Charges,90% of Total billed Charges,196,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.4,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,86.44,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.2,95,,500.08,Percent of Total Billed Charges,95% of Total Billed Charges,196,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.48,88,,463.232,Percent of Total Billed Charges,88% of Total Billed Charges,176.4,90,,473.76,Percent of Total Billed charges,90% of Total Billed Charges,86.44,196,
APM ALEXIS XSML SHRT RETRACTOR,2720000058,CDM,272,RC,,,Outpatient,,,57.00,37.05,,57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.32,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.04,72,,211.464,Percent of Total Billed Charges,72% of Total Billed Charges,42.75,75,,220.28,Percent of Total Billed charges,75% of Total Billed Charges,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.04,72,,211.464,Percent of Total Billed Charges,72% of Total Billed Charges,34.2,60,,176.224,Percent of Total Billed Charges,60% of Total Billed Charges,51.3,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,25.65,45,,236.88,Percent of Total Billed Charges,45% of Total Billed Charges,51.3,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.05,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,25.14,44.1,,232.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.15,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.16,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,51.3,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,25.14,57,
AQUACEL SURGICAL DRESS 3.5X6,2720000059,CDM,272,RC,A6196,HCPCS,Outpatient,,,31.00,20.15,,31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.56,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.98,350,,1071.944,Fee Schedule,350% of BCBS fee schedule,28.98,350,,1116.616,Fee Schedule,350% of BCBS fee schedule,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.98,350,,1071.944,Fee Schedule,350% of BCBS PPO fee schedule,8.28,100,,893.288,Fee Schedule,100% of Blue ADV HMO fee schedule,27.9,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,13.95,45,,236.88,Percent of Total Billed Charges,45% of Total Billed Charges,27.9,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.15,65,,342.16,Percent of total Billed Charges,65% of Total Billed Charges,13.67,44.1,,232.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.45,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.28,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,27.9,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,8.28,31,
AQUATRACK 0.035X260 REG GLDEWR,2720000060,CDM,272,RC,C1887,HCPCS,Outpatient,,,220.24,143.16,,220.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,167.38,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,158.57,72,,18.416,Percent of Total Billed Charges,72% of Total Billed Charges,165.18,75,,19.184,Percent of Total Billed charges,75% of Total Billed Charges,220.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.57,72,,18.416,Percent of Total Billed Charges,72% of Total Billed Charges,132.14,60,,15.344,Percent of Total Billed Charges,60% of Total Billed Charges,198.22,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,99.11,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,198.22,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,220.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.16,65,,342.16,Percent of total Billed Charges,65% of Total Billed Charges,97.13,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,209.23,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,220.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.81,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,198.22,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,97.13,220.24,
AQUATRCK 0.035X180 REG GLDEWRE,2720000061,CDM,272,RC,C1769,HCPCS,Outpatient,,,220.24,143.16,,220.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,167.38,76,,400.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,158.57,72,,2587.152,Percent of Total Billed Charges,72% of Total Billed Charges,165.18,75,,2694.952,Percent of Total Billed charges,75% of Total Billed Charges,220.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.57,72,,2587.152,Percent of Total Billed Charges,72% of Total Billed Charges,132.14,60,,2155.96,Percent of Total Billed Charges,60% of Total Billed Charges,198.22,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,99.11,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,198.22,90,,473.76,Percent of Total Billed Charges,90% of Total billed Charges,220.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.16,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,97.13,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,209.23,95,,500.08,Percent of Total Billed Charges,95% of Total Billed Charges,220.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.81,88,,463.232,Percent of Total Billed Charges,88% of Total Billed Charges,198.22,90,,473.76,Percent of Total Billed charges,90% of Total Billed Charges,97.13,220.24,
AQUATRCK 0.035X180 STF GLDEWRE,2720000062,CDM,272,RC,C1769,HCPCS,Outpatient,,,220.24,143.16,,220.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,167.38,76,,400.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,158.57,72,,4261.12,Percent of Total Billed Charges,72% of Total Billed Charges,165.18,75,,4438.672,Percent of Total Billed charges,75% of Total Billed Charges,220.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.57,72,,4261.12,Percent of Total Billed Charges,72% of Total Billed Charges,132.14,60,,3550.936,Percent of Total Billed Charges,60% of Total Billed Charges,198.22,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,99.11,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,198.22,90,,473.76,Percent of Total Billed Charges,90% of Total billed Charges,220.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.16,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,97.13,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,209.23,95,,500.08,Percent of Total Billed Charges,95% of Total Billed Charges,220.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.81,88,,463.232,Percent of Total Billed Charges,88% of Total Billed Charges,198.22,90,,473.76,Percent of Total Billed charges,90% of Total Billed Charges,97.13,220.24,
AQUATRK 0.035X260 STIF GLDEWRE,2720000063,CDM,272,RC,C1769,HCPCS,Outpatient,,,220.24,143.16,,220.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,167.38,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,158.57,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,165.18,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,220.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.57,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,132.14,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,198.22,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,99.11,45,,658.064,Percent of Total Billed Charges,45% of Total Billed Charges,198.22,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,220.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.16,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,97.13,44.1,,644.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,209.23,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,220.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.81,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,198.22,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,97.13,220.24,
ARTHRO SPART ANCHOR 5.5 NDLES,2720000064,CDM,272,RC,,,Outpatient,,,278.93,181.30,,278.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,211.99,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,200.83,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,209.2,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.83,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,167.36,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,251.04,90,,1316.128,Percent of Total Billed Charges,90% of Total Billed Charges,125.52,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,251.04,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.3,65,,950.536,Percent of total Billed Charges,65% of Total Billed Charges,123.01,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,264.98,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.46,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,251.04,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,123.01,278.93,
ARTHRO SPART ANCHOR 5.5MM,2720000065,CDM,272,RC,,,Outpatient,,,278.93,181.30,,278.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,211.99,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,200.83,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,209.2,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.83,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,167.36,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,251.04,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,125.52,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,251.04,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.3,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,123.01,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,264.98,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.46,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,251.04,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,123.01,278.93,
ARTHRO SPART ANCHOR 6.5/NDLES,2720000066,CDM,272,RC,,,Outpatient,,,278.93,181.30,,278.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,211.99,76,,1111.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,200.83,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,209.2,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.83,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,167.36,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,251.04,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,125.52,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,251.04,90,,1316.128,Percent of Total Billed Charges,90% of Total billed Charges,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.3,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,123.01,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,264.98,95,,1389.24,Percent of Total Billed Charges,95% of Total Billed Charges,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.46,88,,1286.88,Percent of Total Billed Charges,88% of Total Billed Charges,251.04,90,,1316.128,Percent of Total Billed charges,90% of Total Billed Charges,123.01,278.93,
ARTHRO SPART ANCHOR 6.5MM,2720000067,CDM,272,RC,,,Outpatient,,,278.93,181.30,,278.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,211.99,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,200.83,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,209.2,75,,394.8,Percent of Total Billed charges,75% of Total Billed Charges,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.83,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,167.36,60,,315.84,Percent of Total Billed Charges,60% of Total Billed Charges,251.04,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,125.52,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,251.04,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.3,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,123.01,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,264.98,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.46,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,251.04,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,123.01,278.93,
ARTHRO SPD SITCH WRE SUT/WHITE,2720000068,CDM,272,RC,,,Outpatient,,,35.28,22.93,,35.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.81,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.4,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.4,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,21.17,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,31.75,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,15.88,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,31.75,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.93,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,15.56,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.52,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.05,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,31.75,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,15.56,35.28,
ARTHRO SPD STCH WRE SUT BLK CO,2720000069,CDM,272,RC,,,Outpatient,,,35.28,22.93,,35.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.81,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.4,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.4,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,21.17,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,31.75,90,,1316.128,Percent of Total Billed Charges,90% of Total Billed Charges,15.88,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,31.75,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.93,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,15.56,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.52,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.05,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,31.75,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,15.56,35.28,
ARTHRO SPD STCH WRE SUT COBR,2720000070,CDM,272,RC,,,Outpatient,,,35.28,22.93,,35.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.81,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.4,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.4,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,21.17,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,31.75,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,15.88,45,,658.064,Percent of Total Billed Charges,45% of Total Billed Charges,31.75,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.93,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,15.56,44.1,,644.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.52,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.05,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,31.75,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,15.56,35.28,
ARTHROCARE 2.3 SHRT BEVEL WAND,2720000071,CDM,272,RC,A4649,HCPCS,Outpatient,,,662.60,430.69,,662.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,503.58,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,477.07,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,496.95,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,662.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,477.07,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,397.56,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,596.34,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,298.17,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,596.34,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,662.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,662.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,662.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.69,65,,950.536,Percent of total Billed Charges,65% of Total Billed Charges,292.21,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,629.47,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,662.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.09,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,596.34,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,292.21,662.6,
ARTHROCARE 8175 SUTURE CARTR,2720000072,CDM,272,RC,A4649,HCPCS,Outpatient,,,200.66,130.43,,200.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152.5,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144.48,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,150.5,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.48,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,120.4,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,180.59,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,90.3,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,180.59,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.43,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,88.49,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,190.63,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.58,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,180.59,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,88.49,200.66,
ARTHROCARE 8176 SUTURE CARTR,2720000073,CDM,272,RC,A4649,HCPCS,Outpatient,,,200.66,130.43,,200.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152.5,76,,1111.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144.48,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,150.5,75,,394.8,Percent of Total Billed charges,75% of Total Billed Charges,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.48,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,120.4,60,,315.84,Percent of Total Billed Charges,60% of Total Billed Charges,180.59,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,90.3,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,180.59,90,,1316.128,Percent of Total Billed Charges,90% of Total billed Charges,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.43,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,88.49,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,190.63,95,,1389.24,Percent of Total Billed Charges,95% of Total Billed Charges,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.58,88,,1286.88,Percent of Total Billed Charges,88% of Total Billed Charges,180.59,90,,1316.128,Percent of Total Billed charges,90% of Total Billed Charges,88.49,200.66,
ARTHROCARE COBLATR EVAC 70XTRA,2720000074,CDM,272,RC,,,Outpatient,,,300.00,195.00,,300,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,228,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,216,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,225,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,180,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,270,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,135,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,270,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,132.3,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,285,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,270,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,132.3,300,
ARTHROCARE FIRSTPASS NDLE/SUT,2720000075,CDM,272,RC,A4649,HCPCS,Outpatient,,,264.60,171.99,,264.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,201.1,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,190.51,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,198.45,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,264.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.51,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,158.76,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,238.14,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,119.07,45,,658.064,Percent of Total Billed Charges,45% of Total Billed Charges,238.14,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,264.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,116.69,44.1,,644.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,251.37,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,264.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.85,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,238.14,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,116.69,264.6,
ARTHROCARE SMRT STICH CONECTOR,2720000076,CDM,272,RC,A4649,HCPCS,Outpatient,,,187.43,121.83,,187.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,142.45,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,134.95,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,140.57,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.95,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,112.46,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,168.69,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,84.34,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,168.69,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.83,65,,950.536,Percent of total Billed Charges,65% of Total Billed Charges,82.66,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,178.06,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.94,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,168.69,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,82.66,187.43,
"ARTHRX GDEWRE 0.86MM/LSR,LN,SS",2720000077,CDM,272,RC,,,Outpatient,,,29.00,18.85,,29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.04,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.88,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,21.75,75,,394.8,Percent of Total Billed charges,75% of Total Billed Charges,29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.88,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,17.4,60,,315.84,Percent of Total Billed Charges,60% of Total Billed Charges,26.1,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,13.05,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,26.1,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.85,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,12.79,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,27.55,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.52,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,26.1,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,12.79,29,
ARTHRX PROSTOP PLUS GDWRE .054,2720000078,CDM,272,RC,,,Outpatient,,,114.00,74.10,,114,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,86.64,76,,1111.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.08,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,85.5,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,114,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.08,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,68.4,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,102.6,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,51.3,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,102.6,90,,1316.128,Percent of Total Billed Charges,90% of Total billed Charges,114,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.1,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,50.27,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,108.3,95,,1389.24,Percent of Total Billed Charges,95% of Total Billed Charges,114,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.32,88,,1286.88,Percent of Total Billed Charges,88% of Total Billed Charges,102.6,90,,1316.128,Percent of Total Billed charges,90% of Total Billed Charges,50.27,114,
ARTHX GDEWRE TROCAR TIP 1.35MM,2720000079,CDM,272,RC,,,Outpatient,,,39.00,25.35,,39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.64,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.08,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,29.25,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.08,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,23.4,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,35.1,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,17.55,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,35.1,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.35,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,17.2,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.05,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.32,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,35.1,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,17.2,39,
ASAHI BRO 4.5 0.014 X 180CM WR,2720000080,CDM,272,RC,C1769,HCPCS,Outpatient,,,313.11,203.52,,313.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.96,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225.44,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,234.83,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.44,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,187.87,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,281.8,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,140.9,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,281.8,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.52,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,138.08,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,297.45,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.54,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,281.8,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,138.08,313.11,
ASAHI PROWATER 0.014X180CM WRE,2720000081,CDM,272,RC,C1769,HCPCS,Outpatient,,,313.11,203.52,,313.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.96,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225.44,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,234.83,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.44,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,187.87,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,281.8,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,140.9,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,281.8,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.52,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,138.08,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,297.45,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.54,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,281.8,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,138.08,313.11,
BARD OPEN CDE TIP CATH 24/3/30,2720000082,CDM,272,RC,,,Outpatient,,,46.00,29.90,,46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.96,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.12,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,34.5,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.12,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,27.6,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,41.4,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,20.7,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,41.4,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.9,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,20.29,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,43.7,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.48,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,41.4,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,20.29,46,
BENTSON 0.035 X 180CM GUIDEWRE,2720000083,CDM,272,RC,C1769,HCPCS,Outpatient,,,63.95,41.57,,63.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,48.6,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.04,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,47.96,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.04,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,38.37,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,57.56,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,28.78,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,57.56,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.57,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,28.2,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,60.75,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.28,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,57.56,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,28.2,63.95,
BENTSON 0.035 X 260CM GUIDEWRE,2720000084,CDM,272,RC,C1769,HCPCS,Outpatient,,,63.95,41.57,,63.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,48.6,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.04,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,47.96,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.04,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,38.37,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,57.56,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,28.78,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,57.56,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.57,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,28.2,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,60.75,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.28,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,57.56,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,28.2,63.95,
BERKLEY LARGE COLLECTION SYS,2720000085,CDM,272,RC,,,Outpatient,,,79.50,51.68,,79.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60.42,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.24,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,59.63,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,79.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.24,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,47.7,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,71.55,90,,267.912,Percent of Total Billed Charges,90% of Total Billed Charges,35.78,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,71.55,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,79.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.68,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,35.06,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,75.53,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,79.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.96,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,71.55,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,35.06,79.5,
BIOMET 432170 FEM KNEE MLD 70M,2720000086,CDM,272,RC,,,Outpatient,,,2526.30,1642.10,,2526.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1919.99,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1818.94,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,1894.73,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,2526.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.94,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,1515.78,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,2273.67,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,1136.84,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,2273.67,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,2526.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2526.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2526.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1642.1,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,1114.1,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,2399.99,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,2526.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2223.14,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,2273.67,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,1114.1,2526.3,
BIOMET 433175 TIB KNEE MLD 75M,2720000087,CDM,272,RC,,,Outpatient,,,1198.05,778.73,,1198.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,910.52,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,862.6,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,898.54,75,,394.8,Percent of Total Billed charges,75% of Total Billed Charges,1198.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,862.6,72,,379.008,Percent of Total Billed Charges,72% of Total Billed Charges,718.83,60,,315.84,Percent of Total Billed Charges,60% of Total Billed Charges,1078.25,90,,64.8,Percent of Total Billed Charges,90% of Total Billed Charges,539.12,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,1078.25,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,1198.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1198.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1198.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,778.73,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,528.34,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,1138.15,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,1198.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1054.28,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,1078.25,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,528.34,1198.05,
BMW ELIT STRAIGHT 0.014 X 190,2720000088,CDM,272,RC,C1769,HCPCS,Outpatient,,,425.25,276.41,,425.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,323.19,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,306.18,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,318.94,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,425.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.18,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,255.15,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,382.73,90,,1447.888,Percent of Total Billed Charges,90% of Total Billed Charges,191.36,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,382.73,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,425.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,425.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,425.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.41,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,187.54,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,403.99,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,425.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.22,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,382.73,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,187.54,425.25,
BMW ELITE .014X190 JTIP GDEWRE,2720000089,CDM,272,RC,C1769,HCPCS,Outpatient,,,266.00,172.90,,266,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,202.16,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,191.52,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,199.5,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,266,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.52,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,159.6,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,239.4,90,,1447.888,Percent of Total Billed Charges,90% of Total Billed Charges,119.7,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,239.4,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,266,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.9,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,117.31,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,252.7,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,266,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.08,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,239.4,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,117.31,266,
BS .038 STRAIGHT TIP AMPL WIRE,2720000090,CDM,272,RC,C1726,HCPCS,Outpatient,,,45.20,29.38,,45.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.35,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.54,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,33.9,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.54,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,27.12,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,40.68,90,,1539.976,Percent of Total Billed Charges,90% of Total Billed Charges,20.34,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,40.68,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.38,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,19.93,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.94,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.78,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,40.68,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,19.93,45.2,
BS 4CM  12FR UROMAX BAL KIT,2720000091,CDM,272,RC,C1726,HCPCS,Outpatient,,,302.09,196.36,,302.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,229.59,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,217.5,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,226.57,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.5,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,181.25,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,271.88,90,,1539.976,Percent of Total Billed Charges,90% of Total Billed Charges,135.94,45,,133.96,Percent of Total Billed Charges,45% of Total Billed Charges,271.88,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.36,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,133.22,44.1,,131.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,286.99,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.84,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,271.88,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,133.22,302.09,
BS ESCAPE 1.9X120 NITINOL BASK,2720000092,CDM,272,RC,C1726,HCPCS,Outpatient,,,263.00,170.95,,263,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,199.88,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,189.36,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,197.25,75,,480,Percent of Total Billed charges,75% of Total Billed Charges,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.36,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,157.8,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,236.7,90,,163.584,Percent of Total Billed Charges,90% of Total Billed Charges,118.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,236.7,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.95,65,,193.496,Percent of total Billed Charges,65% of Total Billed Charges,115.98,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,249.85,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.44,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,236.7,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,115.98,263,
CANTATA 2.5150CM MICRO CATH,2720000093,CDM,272,RC,C1887,HCPCS,Outpatient,,,1653.75,1074.94,,1653.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1256.85,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1190.7,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,1240.31,75,,480,Percent of Total Billed charges,75% of Total Billed Charges,1653.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1190.7,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,992.25,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,1488.38,90,,34.176,Percent of Total Billed Charges,90% of Total Billed Charges,744.19,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,1488.38,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,1653.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1653.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1653.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1074.94,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,729.3,44.1,,31.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,1571.06,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,1653.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1455.3,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,1488.38,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,729.3,1653.75,
CANTATA 2.8150CM MICRO CATH,2720000094,CDM,272,RC,C1887,HCPCS,Outpatient,,,1719.90,1117.94,,1719.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1307.12,76,,226.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1238.33,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,1289.93,75,,480,Percent of Total Billed charges,75% of Total Billed Charges,1719.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1238.33,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,1031.94,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,1547.91,90,,204.008,Percent of Total Billed Charges,90% of Total Billed Charges,773.96,45,,723.944,Percent of Total Billed Charges,45% of Total Billed Charges,1547.91,90,,267.912,Percent of Total Billed Charges,90% of Total billed Charges,1719.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1719.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1719.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1117.94,65,,46.8,Percent of total Billed Charges,65% of Total Billed Charges,758.48,44.1,,709.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,1633.91,95,,282.8,Percent of Total Billed Charges,95% of Total Billed Charges,1719.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1513.51,88,,261.96,Percent of Total Billed Charges,88% of Total Billed Charges,1547.91,90,,267.912,Percent of Total Billed charges,90% of Total Billed Charges,758.48,1719.9,
CAREY ALZAT CNS 24FJ 16F CATH,2720000095,CDM,272,RC,C1729,HCPCS,Outpatient,,,71.00,46.15,,71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.96,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.12,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,53.25,75,,480,Percent of Total Billed charges,75% of Total Billed Charges,71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.12,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,42.6,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,63.9,90,,404.84,Percent of Total Billed Charges,90% of Total Billed Charges,31.95,45,,723.944,Percent of Total Billed Charges,45% of Total Billed Charges,63.9,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.15,65,,1045.696,Percent of total Billed Charges,65% of Total Billed Charges,31.31,44.1,,709.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.45,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.48,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,63.9,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,31.31,71,
CAREYALZATECOONS 24FJ 16F ST,2720000096,CDM,272,RC,,,Outpatient,,,355.81,231.28,,355.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,270.42,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,256.18,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,266.86,75,,480,Percent of Total Billed charges,75% of Total Billed Charges,355.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.18,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,213.49,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,320.23,90,,404.84,Percent of Total Billed Charges,90% of Total Billed Charges,160.11,45,,769.984,Percent of Total Billed Charges,45% of Total Billed Charges,320.23,90,,64.8,Percent of Total Billed Charges,90% of Total billed Charges,355.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.28,65,,1045.696,Percent of total Billed Charges,65% of Total Billed Charges,156.91,44.1,,754.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,338.02,95,,68.4,Percent of Total Billed Charges,95% of Total Billed Charges,355.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.11,88,,63.36,Percent of Total Billed Charges,88% of Total Billed Charges,320.23,90,,64.8,Percent of Total Billed charges,90% of Total Billed Charges,156.91,355.81,
CATH FOLY 16F 30CC 3 WY3101110,2720000097,CDM,272,RC,A4346,HCPCS,Outpatient,,,77.09,50.11,,77.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.59,76,,1222.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.56,350,,460.8,Fee Schedule,350% of BCBS fee schedule,65.56,350,,480,Fee Schedule,350% of BCBS fee schedule,77.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.56,350,,460.8,Fee Schedule,350% of BCBS PPO fee schedule,18.73,100,,384,Fee Schedule,100% of Blue ADV HMO fee schedule,69.38,90,,129.6,Percent of Total Billed Charges,90% of Total Billed Charges,34.69,45,,769.984,Percent of Total Billed Charges,45% of Total Billed Charges,69.38,90,,1447.888,Percent of Total Billed Charges,90% of Total billed Charges,77.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.11,65,,1112.2,Percent of total Billed Charges,65% of Total Billed Charges,34,44.1,,754.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.24,95,,1528.328,Percent of Total Billed Charges,95% of Total Billed Charges,77.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.84,88,,1415.712,Percent of Total Billed Charges,88% of Total Billed Charges,69.38,90,,1447.888,Percent of Total Billed charges,90% of Total Billed Charges,18.73,77.09,
CE LNE ST 3 LUMEN 7FX20CM 2714,2720000098,CDM,272,RC,C1751,HCPCS,Outpatient,,,231.56,150.51,,231.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,175.99,76,,1222.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,166.72,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,173.67,75,,480,Percent of Total Billed charges,75% of Total Billed Charges,231.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.72,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,138.94,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,208.4,90,,180,Percent of Total Billed Charges,90% of Total Billed Charges,104.2,45,,81.792,Percent of Total Billed Charges,45% of Total Billed Charges,208.4,90,,1447.888,Percent of Total Billed Charges,90% of Total billed Charges,231.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.51,65,,1112.2,Percent of total Billed Charges,65% of Total Billed Charges,102.12,44.1,,80.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,219.98,95,,1528.328,Percent of Total Billed Charges,95% of Total Billed Charges,231.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.77,88,,1415.712,Percent of Total Billed Charges,88% of Total Billed Charges,208.4,90,,1447.888,Percent of Total Billed charges,90% of Total Billed Charges,102.12,231.56,
CE LNE ST 4 LUMEN 8FX16CM 1359,2720000099,CDM,278,RC,C1751,HCPCS,Outpatient,,,279.50,181.68,,279.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,212.42,76,,1300.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,201.24,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,201.24,72,,480,Percent of Total Billed charges,72% of Total Billed Charges,279.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.24,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,167.7,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,251.55,90,,1226.416,Percent of Total Billed Charges,90% of Total Billed Charges,125.78,45,,17.088,Percent of Total Billed Charges,45% of Total Billed Charges,251.55,90,,1539.976,Percent of Total Billed Charges,90% of Total billed Charges,279.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.68,65,,118.144,Percent of total Billed Charges,65% of Total Billed Charges,123.26,44.1,,16.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,265.53,95,,1625.528,Percent of Total Billed Charges,95% of Total Billed Charges,279.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.96,88,,1505.752,Percent of Total Billed Charges,88% of Total Billed Charges,251.55,90,,1539.976,Percent of Total Billed charges,90% of Total Billed Charges,123.26,279.5,
CE LNE ST 4 LUMEN 8FX20CM 1144,2720000100,CDM,272,RC,C1751,HCPCS,Outpatient,,,444.31,288.80,,444.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,337.68,76,,1300.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,319.9,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,333.23,75,,480,Percent of Total Billed charges,75% of Total Billed Charges,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319.9,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,266.59,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,399.88,90,,200.16,Percent of Total Billed Charges,90% of Total Billed Charges,199.94,45,,102,Percent of Total Billed Charges,45% of Total Billed Charges,399.88,90,,1539.976,Percent of Total Billed Charges,90% of Total billed Charges,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.8,65,,24.688,Percent of total Billed Charges,65% of Total Billed Charges,195.94,44.1,,99.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,422.09,95,,1625.528,Percent of Total Billed Charges,95% of Total Billed Charges,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.99,88,,1505.752,Percent of Total Billed Charges,88% of Total Billed Charges,399.88,90,,1539.976,Percent of Total Billed charges,90% of Total Billed Charges,195.94,444.31,
CENT VEN DRSING CHNGE 2603777,2720000101,CDM,272,RC,,,Outpatient,,,19.12,12.43,,19.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.53,76,,138.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.77,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,14.34,75,,480,Percent of Total Billed charges,75% of Total Billed Charges,19.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.77,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,11.47,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,17.21,90,,180,Percent of Total Billed Charges,90% of Total Billed Charges,8.6,45,,202.424,Percent of Total Billed Charges,45% of Total Billed Charges,17.21,90,,163.584,Percent of Total Billed Charges,90% of Total billed Charges,19.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.43,65,,147.336,Percent of total Billed Charges,65% of Total Billed Charges,8.43,44.1,,198.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.16,95,,172.672,Percent of Total Billed Charges,95% of Total Billed Charges,19.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.83,88,,159.952,Percent of Total Billed Charges,88% of Total Billed Charges,17.21,90,,163.584,Percent of Total Billed charges,90% of Total Billed Charges,8.43,19.12,
CENTLINE SET 3 LUMEN 7FX16CM,2720000102,CDM,272,RC,C1751,HCPCS,Outpatient,,,245.00,159.25,,245,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,186.2,76,,28.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,176.4,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,183.75,75,,480,Percent of Total Billed charges,75% of Total Billed Charges,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.4,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,147,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,220.5,90,,111.136,Percent of Total Billed Charges,90% of Total Billed Charges,110.25,45,,202.424,Percent of Total Billed Charges,45% of Total Billed Charges,220.5,90,,34.176,Percent of Total Billed Charges,90% of Total billed Charges,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.25,65,,292.384,Percent of total Billed Charges,65% of Total Billed Charges,108.05,44.1,,198.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,232.75,95,,36.08,Percent of Total Billed Charges,95% of Total Billed Charges,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.6,88,,33.416,Percent of Total Billed Charges,88% of Total Billed Charges,220.5,90,,34.176,Percent of Total Billed charges,90% of Total Billed Charges,108.05,245,
CENTLINE SET 3 LUMEN 7FX20CM,2720000103,CDM,272,RC,C1751,HCPCS,Outpatient,,,231.56,150.51,,231.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,175.99,76,,172.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,166.72,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,173.67,75,,480,Percent of Total Billed charges,75% of Total Billed Charges,231.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.72,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,138.94,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,208.4,90,,111.136,Percent of Total Billed Charges,90% of Total Billed Charges,104.2,45,,64.8,Percent of Total Billed Charges,45% of Total Billed Charges,208.4,90,,204.008,Percent of Total Billed Charges,90% of Total billed Charges,231.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.51,65,,292.384,Percent of total Billed Charges,65% of Total Billed Charges,102.12,44.1,,63.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,219.98,95,,215.336,Percent of Total Billed Charges,95% of Total Billed Charges,231.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.77,88,,199.472,Percent of Total Billed Charges,88% of Total Billed Charges,208.4,90,,204.008,Percent of Total Billed charges,90% of Total Billed Charges,102.12,231.56,
CENTLINE SET 4 LUMEN 8FX16CM,2720000104,CDM,272,RC,C1751,HCPCS,Outpatient,,,279.50,181.68,,279.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,212.42,76,,341.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,201.24,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,209.63,75,,480,Percent of Total Billed charges,75% of Total Billed Charges,279.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.24,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,167.7,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,251.55,90,,136.536,Percent of Total Billed Charges,90% of Total Billed Charges,125.78,45,,90,Percent of Total Billed Charges,45% of Total Billed Charges,251.55,90,,404.84,Percent of Total Billed Charges,90% of Total billed Charges,279.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.68,65,,93.6,Percent of total Billed Charges,65% of Total Billed Charges,123.26,44.1,,88.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,265.53,95,,427.336,Percent of Total Billed Charges,95% of Total Billed Charges,279.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.96,88,,395.848,Percent of Total Billed Charges,88% of Total Billed Charges,251.55,90,,404.84,Percent of Total Billed charges,90% of Total Billed Charges,123.26,279.5,
CHIBA 4/6 20/15 NV INTROD ST,2720000105,CDM,272,RC,,,Outpatient,,,186.90,121.49,,186.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,142.04,76,,341.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,134.57,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,140.18,75,,480,Percent of Total Billed charges,75% of Total Billed Charges,186.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.57,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,112.14,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,168.21,90,,239.728,Percent of Total Billed Charges,90% of Total Billed Charges,84.11,45,,613.208,Percent of Total Billed Charges,45% of Total Billed Charges,168.21,90,,404.84,Percent of Total Billed Charges,90% of Total billed Charges,186.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.49,65,,130,Percent of total Billed Charges,65% of Total Billed Charges,82.42,44.1,,600.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,177.56,95,,427.336,Percent of Total Billed Charges,95% of Total Billed Charges,186.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.47,88,,395.848,Percent of Total Billed Charges,88% of Total Billed Charges,168.21,90,,404.84,Percent of Total Billed charges,90% of Total Billed Charges,82.42,186.9,
CHIBA 4/6 21/15 NV INTROD ST,2720000106,CDM,272,RC,,,Outpatient,,,186.90,121.49,,186.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,142.04,76,,109.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,134.57,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,140.18,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,186.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.57,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,112.14,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,168.21,90,,217.44,Percent of Total Billed Charges,90% of Total Billed Charges,84.11,45,,100.08,Percent of Total Billed Charges,45% of Total Billed Charges,168.21,90,,129.6,Percent of Total Billed Charges,90% of Total billed Charges,186.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.49,65,,885.744,Percent of total Billed Charges,65% of Total Billed Charges,82.42,44.1,,98.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,177.56,95,,136.8,Percent of Total Billed Charges,95% of Total Billed Charges,186.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.47,88,,126.72,Percent of Total Billed Charges,88% of Total Billed Charges,168.21,90,,129.6,Percent of Total Billed charges,90% of Total Billed Charges,82.42,186.9,
CHO PT ES STRAIGHT 182CMX .014,2720000107,CDM,272,RC,C1769,HCPCS,Outpatient,,,355.01,230.76,,355.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,269.81,76,,152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,255.61,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,266.26,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,355.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.61,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,213.01,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,319.51,90,,105.84,Percent of Total Billed Charges,90% of Total Billed Charges,159.75,45,,90,Percent of Total Billed Charges,45% of Total Billed Charges,319.51,90,,180,Percent of Total Billed Charges,90% of Total billed Charges,355.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.76,65,,144.56,Percent of total Billed Charges,65% of Total Billed Charges,156.56,44.1,,88.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,337.26,95,,190,Percent of Total Billed Charges,95% of Total Billed Charges,355.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.41,88,,176,Percent of Total Billed Charges,88% of Total Billed Charges,319.51,90,,180,Percent of Total Billed charges,90% of Total Billed Charges,156.56,355.01,
CHOCO 5F 2.5X120 O14 OTW BAL,2720000108,CDM,272,RC,C1725,HCPCS,Outpatient,,,1530.00,994.50,,1530,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1162.8,76,,1035.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1101.6,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,1147.5,75,,216,Percent of Total Billed charges,75% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1101.6,72,,207.36,Percent of Total Billed Charges,72% of Total Billed Charges,918,60,,172.8,Percent of Total Billed Charges,60% of Total Billed Charges,1377,90,,547.2,Percent of Total Billed Charges,90% of Total Billed Charges,688.5,45,,55.568,Percent of Total Billed Charges,45% of Total Billed Charges,1377,90,,1226.416,Percent of Total Billed Charges,90% of Total billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.5,65,,130,Percent of total Billed Charges,65% of Total Billed Charges,674.73,44.1,,54.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,1453.5,95,,1294.552,Percent of Total Billed Charges,95% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1346.4,88,,1199.168,Percent of Total Billed Charges,88% of Total Billed Charges,1377,90,,1226.416,Percent of Total Billed charges,90% of Total Billed Charges,674.73,1530,
CHOCO 5F 3X40 014 OTW PTA BAL,2720000109,CDM,272,RC,C1725,HCPCS,Outpatient,,,1530.00,994.50,,1530,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1162.8,76,,169.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1101.6,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,1147.5,75,,918,Percent of Total Billed charges,75% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1101.6,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,918,60,,734.4,Percent of Total Billed Charges,60% of Total Billed Charges,1377,90,,276.48,Percent of Total Billed Charges,90% of Total Billed Charges,688.5,45,,55.568,Percent of Total Billed Charges,45% of Total Billed Charges,1377,90,,200.16,Percent of Total Billed Charges,90% of Total billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.5,65,,80.264,Percent of total Billed Charges,65% of Total Billed Charges,674.73,44.1,,54.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,1453.5,95,,211.28,Percent of Total Billed Charges,95% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1346.4,88,,195.712,Percent of Total Billed Charges,88% of Total Billed Charges,1377,90,,200.16,Percent of Total Billed charges,90% of Total Billed Charges,674.73,1530,
CHOICE PT ES JTIP 0.014X182CM,2720000110,CDM,272,RC,C1769,HCPCS,Outpatient,,,355.01,230.76,,355.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,269.81,76,,152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,255.61,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,266.26,75,,918,Percent of Total Billed charges,75% of Total Billed Charges,355.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.61,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,213.01,60,,734.4,Percent of Total Billed Charges,60% of Total Billed Charges,319.51,90,,113.76,Percent of Total Billed Charges,90% of Total Billed Charges,159.75,45,,68.264,Percent of Total Billed Charges,45% of Total Billed Charges,319.51,90,,180,Percent of Total Billed Charges,90% of Total billed Charges,355.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.76,65,,80.264,Percent of total Billed Charges,65% of Total Billed Charges,156.56,44.1,,66.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,337.26,95,,190,Percent of Total Billed Charges,95% of Total Billed Charges,355.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.41,88,,176,Percent of Total Billed Charges,88% of Total Billed Charges,319.51,90,,180,Percent of Total Billed charges,90% of Total Billed Charges,156.56,355.01,
CNT LN 4 LUM 8FX20CM 1144 CATH,2720000111,CDM,272,RC,C1751,HCPCS,Outpatient,,,444.31,288.80,,444.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,337.68,76,,93.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,319.9,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,333.23,75,,918,Percent of Total Billed charges,75% of Total Billed Charges,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319.9,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,266.59,60,,734.4,Percent of Total Billed Charges,60% of Total Billed Charges,399.88,90,,126,Percent of Total Billed Charges,90% of Total Billed Charges,199.94,45,,119.864,Percent of Total Billed Charges,45% of Total Billed Charges,399.88,90,,111.136,Percent of Total Billed Charges,90% of Total billed Charges,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.8,65,,98.608,Percent of total Billed Charges,65% of Total Billed Charges,195.94,44.1,,117.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,422.09,95,,117.304,Percent of Total Billed Charges,95% of Total Billed Charges,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.99,88,,108.664,Percent of Total Billed Charges,88% of Total Billed Charges,399.88,90,,111.136,Percent of Total Billed charges,90% of Total Billed Charges,195.94,444.31,
CO AX 15G X 11.8CM NDLE (1077),2720000112,CDM,272,RC,,,Outpatient,,,92.16,59.90,,92.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,70.04,76,,93.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,66.36,72,,463.584,Percent of Total Billed Charges,72% of Total Billed Charges,69.12,75,,482.896,Percent of Total Billed charges,75% of Total Billed Charges,92.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.36,72,,463.584,Percent of Total Billed Charges,72% of Total Billed Charges,55.3,60,,386.32,Percent of Total Billed Charges,60% of Total Billed Charges,82.94,90,,530.64,Percent of Total Billed Charges,90% of Total Billed Charges,41.47,45,,108.72,Percent of Total Billed Charges,45% of Total Billed Charges,82.94,90,,111.136,Percent of Total Billed Charges,90% of Total billed Charges,92.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.9,65,,173.136,Percent of total Billed Charges,65% of Total Billed Charges,40.64,44.1,,106.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,87.55,95,,117.304,Percent of Total Billed Charges,95% of Total Billed Charges,92.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.1,88,,108.664,Percent of Total Billed Charges,88% of Total Billed Charges,82.94,90,,111.136,Percent of Total Billed charges,90% of Total Billed Charges,40.64,92.16,
CO AX 15G X 6.8CM NDLE (1076),2720000113,CDM,272,RC,,,Outpatient,,,92.16,59.90,,92.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,70.04,76,,115.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,66.36,72,,568.36,Percent of Total Billed Charges,72% of Total Billed Charges,69.12,75,,592.048,Percent of Total Billed charges,75% of Total Billed Charges,92.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.36,72,,568.36,Percent of Total Billed Charges,72% of Total Billed Charges,55.3,60,,473.632,Percent of Total Billed Charges,60% of Total Billed Charges,82.94,90,,126,Percent of Total Billed Charges,90% of Total Billed Charges,41.47,45,,52.92,Percent of Total Billed Charges,45% of Total Billed Charges,82.94,90,,136.536,Percent of Total Billed Charges,90% of Total billed Charges,92.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.9,65,,157.04,Percent of total Billed Charges,65% of Total Billed Charges,40.64,44.1,,51.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,87.55,95,,144.12,Percent of Total Billed Charges,95% of Total Billed Charges,92.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.1,88,,133.496,Percent of Total Billed Charges,88% of Total Billed Charges,82.94,90,,136.536,Percent of Total Billed charges,90% of Total Billed Charges,40.64,92.16,
CO AX 17G X 16.8CM NDLE (1143),2720000114,CDM,272,RC,,,Outpatient,,,60.00,39.00,,60,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.6,76,,202.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.2,72,,360.704,Percent of Total Billed Charges,72% of Total Billed Charges,45,75,,375.736,Percent of Total Billed charges,75% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.2,72,,360.704,Percent of Total Billed Charges,72% of Total Billed Charges,36,60,,300.584,Percent of Total Billed Charges,60% of Total Billed Charges,54,90,,286.56,Percent of Total Billed Charges,90% of Total Billed Charges,27,45,,273.6,Percent of Total Billed Charges,45% of Total Billed Charges,54,90,,239.728,Percent of Total Billed Charges,90% of Total billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39,65,,76.44,Percent of total Billed Charges,65% of Total Billed Charges,26.46,44.1,,268.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,57,95,,253.048,Percent of Total Billed Charges,95% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.8,88,,234.4,Percent of Total Billed Charges,88% of Total Billed Charges,54,90,,239.728,Percent of Total Billed charges,90% of Total Billed Charges,26.46,60,
CONMD VCRE UTER MANIPU XL 40MM,2720000115,CDM,272,RC,,,Outpatient,,,90.00,58.50,,90,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.4,76,,183.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.8,72,,37.472,Percent of Total Billed Charges,72% of Total Billed Charges,67.5,75,,39.032,Percent of Total Billed charges,75% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.8,72,,37.472,Percent of Total Billed Charges,72% of Total Billed Charges,54,60,,31.224,Percent of Total Billed Charges,60% of Total Billed Charges,81,90,,126,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,45,,138.24,Percent of Total Billed Charges,45% of Total Billed Charges,81,90,,217.44,Percent of Total Billed Charges,90% of Total billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.5,65,,395.2,Percent of total Billed Charges,65% of Total Billed Charges,39.69,44.1,,135.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.5,95,,229.52,Percent of Total Billed Charges,95% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,88,,212.608,Percent of Total Billed Charges,88% of Total Billed Charges,81,90,,217.44,Percent of Total Billed charges,90% of Total Billed Charges,39.69,90,
CONMED VCARE MANIPULTR LG 37MM,2720000116,CDM,272,RC,,,Outpatient,,,90.00,58.50,,90,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.4,76,,89.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.8,72,,95.256,Percent of Total Billed Charges,72% of Total Billed Charges,67.5,75,,99.232,Percent of Total Billed charges,75% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.8,72,,95.256,Percent of Total Billed Charges,72% of Total Billed Charges,54,60,,79.384,Percent of Total Billed Charges,60% of Total Billed Charges,81,90,,131.76,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,45,,56.88,Percent of Total Billed Charges,45% of Total Billed Charges,81,90,,105.84,Percent of Total Billed Charges,90% of Total billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.5,65,,199.68,Percent of total Billed Charges,65% of Total Billed Charges,39.69,44.1,,55.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.5,95,,111.72,Percent of Total Billed Charges,95% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,88,,103.488,Percent of Total Billed Charges,88% of Total Billed Charges,81,90,,105.84,Percent of Total Billed charges,90% of Total Billed Charges,39.69,90,
CONMED VCARE MANIPULTR MD 34MM,2720000117,CDM,272,RC,,,Outpatient,,,90.00,58.50,,90,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.4,76,,462.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.8,72,,164.48,Percent of Total Billed Charges,72% of Total Billed Charges,67.5,75,,171.328,Percent of Total Billed charges,75% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.8,72,,164.48,Percent of Total Billed Charges,72% of Total Billed Charges,54,60,,137.064,Percent of Total Billed Charges,60% of Total Billed Charges,81,90,,1.656,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,45,,63,Percent of Total Billed Charges,45% of Total Billed Charges,81,90,,547.2,Percent of Total Billed Charges,90% of Total billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.5,65,,82.16,Percent of total Billed Charges,65% of Total Billed Charges,39.69,44.1,,61.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.5,95,,577.6,Percent of Total Billed Charges,95% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,88,,535.04,Percent of Total Billed Charges,88% of Total Billed Charges,81,90,,547.2,Percent of Total Billed charges,90% of Total Billed Charges,39.69,90,
CONTRALATERAL F 5F 65CM CATH,2720000118,CDM,272,RC,C1887,HCPCS,Outpatient,,,1148.81,746.73,,1148.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,873.1,76,,233.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,827.14,72,,63.504,Percent of Total Billed Charges,72% of Total Billed Charges,861.61,75,,66.152,Percent of Total Billed charges,75% of Total Billed Charges,1148.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,827.14,72,,63.504,Percent of Total Billed Charges,72% of Total Billed Charges,689.29,60,,52.92,Percent of Total Billed Charges,60% of Total Billed Charges,1033.93,90,,236.56,Percent of Total Billed Charges,90% of Total Billed Charges,516.96,45,,265.32,Percent of Total Billed Charges,45% of Total Billed Charges,1033.93,90,,276.48,Percent of Total Billed Charges,90% of Total billed Charges,1148.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1148.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1148.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,746.73,65,,91,Percent of total Billed Charges,65% of Total Billed Charges,506.63,44.1,,260.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,1091.37,95,,291.84,Percent of Total Billed Charges,95% of Total Billed Charges,1148.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1010.95,88,,270.336,Percent of Total Billed Charges,88% of Total Billed Charges,1033.93,90,,276.48,Percent of Total Billed charges,90% of Total Billed Charges,506.63,1148.81,
COOK 5F MICROPUNCT STIFFENDED,2720000119,CDM,272,RC,C1894,HCPCS,Outpatient,,,145.53,94.59,,145.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.6,76,,96.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,104.78,72,,818.568,Percent of Total Billed Charges,72% of Total Billed Charges,109.15,75,,852.672,Percent of Total Billed charges,75% of Total Billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.78,72,,818.568,Percent of Total Billed Charges,72% of Total Billed Charges,87.32,60,,682.136,Percent of Total Billed Charges,60% of Total Billed Charges,130.98,90,,52.392,Percent of Total Billed Charges,90% of Total Billed Charges,65.49,45,,63,Percent of Total Billed Charges,45% of Total Billed Charges,130.98,90,,113.76,Percent of Total Billed Charges,90% of Total billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.59,65,,383.24,Percent of total Billed Charges,65% of Total Billed Charges,64.18,44.1,,61.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,138.25,95,,120.08,Percent of Total Billed Charges,95% of Total Billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.07,88,,111.232,Percent of Total Billed Charges,88% of Total Billed Charges,130.98,90,,113.76,Percent of Total Billed charges,90% of Total Billed Charges,64.18,145.53,
COOK BP 18G X 7CM ACCESS NDLE,2720000120,CDM,272,RC,,,Outpatient,,,14.68,9.54,,14.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.16,76,,106.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.57,72,,104.36,Percent of Total Billed Charges,72% of Total Billed Charges,11.01,75,,108.712,Percent of Total Billed charges,75% of Total Billed Charges,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.57,72,,104.36,Percent of Total Billed Charges,72% of Total Billed Charges,8.81,60,,86.968,Percent of Total Billed Charges,60% of Total Billed Charges,13.21,90,,52.392,Percent of Total Billed Charges,90% of Total Billed Charges,6.61,45,,143.28,Percent of Total Billed Charges,45% of Total Billed Charges,13.21,90,,126,Percent of Total Billed Charges,90% of Total billed Charges,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.54,65,,91,Percent of total Billed Charges,65% of Total Billed Charges,6.47,44.1,,140.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.95,95,,133,Percent of Total Billed Charges,95% of Total Billed Charges,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.92,88,,123.2,Percent of Total Billed Charges,88% of Total Billed Charges,13.21,90,,126,Percent of Total Billed charges,90% of Total Billed Charges,6.47,14.68,
COOK DUAL LUMEN URET CATH 5/10,2720000121,CDM,272,RC,C1758,HCPCS,Outpatient,,,58.43,37.98,,58.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,44.41,76,,448.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.07,72,,181.992,Percent of Total Billed Charges,72% of Total Billed Charges,43.82,75,,189.576,Percent of Total Billed charges,75% of Total Billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.07,72,,181.992,Percent of Total Billed Charges,72% of Total Billed Charges,35.06,60,,151.664,Percent of Total Billed Charges,60% of Total Billed Charges,52.59,90,,52.392,Percent of Total Billed Charges,90% of Total Billed Charges,26.29,45,,63,Percent of Total Billed Charges,45% of Total Billed Charges,52.59,90,,530.64,Percent of Total Billed Charges,90% of Total billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.98,65,,206.96,Percent of total Billed Charges,65% of Total Billed Charges,25.77,44.1,,61.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,55.51,95,,560.12,Percent of Total Billed Charges,95% of Total Billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.42,88,,518.848,Percent of Total Billed Charges,88% of Total Billed Charges,52.59,90,,530.64,Percent of Total Billed charges,90% of Total Billed Charges,25.77,58.43,
COOK URETEROSCOPY BALLOON CATH,2720000122,CDM,272,RC,C1758,HCPCS,Outpatient,,,185.22,120.39,,185.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,140.77,76,,106.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,133.36,72,,304.816,Percent of Total Billed Charges,72% of Total Billed Charges,138.92,75,,317.52,Percent of Total Billed charges,75% of Total Billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.36,72,,304.816,Percent of Total Billed Charges,72% of Total Billed Charges,111.13,60,,254.016,Percent of Total Billed Charges,60% of Total Billed Charges,166.7,90,,217.44,Percent of Total Billed Charges,90% of Total Billed Charges,83.35,45,,65.88,Percent of Total Billed Charges,45% of Total Billed Charges,166.7,90,,126,Percent of Total Billed Charges,90% of Total billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.39,65,,91,Percent of total Billed Charges,65% of Total Billed Charges,81.68,44.1,,64.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,175.96,95,,133,Percent of Total Billed Charges,95% of Total Billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.99,88,,123.2,Percent of Total Billed Charges,88% of Total Billed Charges,166.7,90,,126,Percent of Total Billed charges,90% of Total Billed Charges,81.68,185.22,
COPE SUT ANCHOR ST 17/12//2 CK,2720000123,CDM,272,RC,,,Outpatient,,,134.98,87.74,,134.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,102.58,76,,241.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,97.19,72,,241.488,Percent of Total Billed Charges,72% of Total Billed Charges,101.24,75,,251.552,Percent of Total Billed charges,75% of Total Billed Charges,134.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.19,72,,241.488,Percent of Total Billed Charges,72% of Total Billed Charges,80.99,60,,201.24,Percent of Total Billed Charges,60% of Total Billed Charges,121.48,90,,217.44,Percent of Total Billed Charges,90% of Total Billed Charges,60.74,45,,0.832,Percent of Total Billed Charges,45% of Total Billed Charges,121.48,90,,286.56,Percent of Total Billed Charges,90% of Total billed Charges,134.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.74,65,,95.16,Percent of total Billed Charges,65% of Total Billed Charges,59.53,44.1,,0.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,128.23,95,,302.48,Percent of Total Billed Charges,95% of Total Billed Charges,134.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.78,88,,280.192,Percent of Total Billed Charges,88% of Total Billed Charges,121.48,90,,286.56,Percent of Total Billed charges,90% of Total Billed Charges,59.53,134.98,
CORDIS 4F CORO MULT STRT PIG,2720000124,CDM,272,RC,C1887,HCPCS,Outpatient,,,792.70,515.26,,792.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,602.45,76,,106.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,570.74,72,,108.152,Percent of Total Billed Charges,72% of Total Billed Charges,594.53,75,,112.656,Percent of Total Billed charges,75% of Total Billed Charges,792.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,570.74,72,,108.152,Percent of Total Billed Charges,72% of Total Billed Charges,475.62,60,,90.128,Percent of Total Billed Charges,60% of Total Billed Charges,713.43,90,,15.88,Percent of Total Billed Charges,90% of Total Billed Charges,356.72,45,,118.28,Percent of Total Billed Charges,45% of Total Billed Charges,713.43,90,,126,Percent of Total Billed Charges,90% of Total billed Charges,792.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,792.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,792.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,515.26,65,,1.2,Percent of total Billed Charges,65% of Total Billed Charges,349.58,44.1,,115.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,753.07,95,,133,Percent of Total Billed Charges,95% of Total Billed Charges,792.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,697.58,88,,123.2,Percent of Total Billed Charges,88% of Total Billed Charges,713.43,90,,126,Percent of Total Billed charges,90% of Total Billed Charges,349.58,792.7,
CORDIS 4F PIGTAIL 145* CATH,2720000125,CDM,272,RC,C1887,HCPCS,Outpatient,,,60.00,39.00,,60,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.6,76,,111.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.2,72,,160.128,Percent of Total Billed Charges,72% of Total Billed Charges,45,75,,166.8,Percent of Total Billed charges,75% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.2,72,,160.128,Percent of Total Billed Charges,72% of Total Billed Charges,36,60,,133.44,Percent of Total Billed Charges,60% of Total Billed Charges,54,90,,15.88,Percent of Total Billed Charges,90% of Total Billed Charges,27,45,,26.2,Percent of Total Billed Charges,45% of Total Billed Charges,54,90,,131.76,Percent of Total Billed Charges,90% of Total billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39,65,,170.848,Percent of total Billed Charges,65% of Total Billed Charges,26.46,44.1,,25.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,57,95,,139.08,Percent of Total Billed Charges,95% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.8,88,,128.832,Percent of Total Billed Charges,88% of Total Billed Charges,54,90,,131.76,Percent of Total Billed charges,90% of Total Billed Charges,26.46,60,
CORDIS 4F PIGTAIL STRGHT CATH,2720000126,CDM,272,RC,C1887,HCPCS,Outpatient,,,47.41,30.82,,47.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.03,76,,1.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.14,72,,323.872,Percent of Total Billed Charges,72% of Total Billed Charges,35.56,75,,337.368,Percent of Total Billed charges,75% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.14,72,,323.872,Percent of Total Billed Charges,72% of Total Billed Charges,28.45,60,,269.896,Percent of Total Billed Charges,60% of Total Billed Charges,42.67,90,,117.608,Percent of Total Billed Charges,90% of Total Billed Charges,21.33,45,,26.2,Percent of Total Billed Charges,45% of Total Billed Charges,42.67,90,,1.656,Percent of Total Billed Charges,90% of Total billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.82,65,,37.84,Percent of total Billed Charges,65% of Total Billed Charges,20.91,44.1,,25.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.04,95,,1.752,Percent of Total Billed Charges,95% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.72,88,,1.616,Percent of Total Billed Charges,88% of Total Billed Charges,42.67,90,,1.656,Percent of Total Billed charges,90% of Total Billed Charges,20.91,47.41,
CT ILN ST 3 LUMEN 7FX16CM 1358,2720000127,CDM,278,RC,C1751,HCPCS,Outpatient,,,245.00,159.25,,245,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,186.2,76,,199.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,176.4,72,,610.848,Percent of Total Billed Charges,72% of Total Billed Charges,176.4,72,,610.848,Percent of Total Billed charges,72% of Total Billed Charges,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.4,72,,610.848,Percent of Total Billed Charges,72% of Total Billed Charges,147,60,,509.04,Percent of Total Billed Charges,60% of Total Billed Charges,220.5,90,,132.304,Percent of Total Billed Charges,90% of Total Billed Charges,110.25,45,,26.2,Percent of Total Billed Charges,45% of Total Billed Charges,220.5,90,,236.56,Percent of Total Billed Charges,90% of Total billed Charges,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.25,65,,37.84,Percent of total Billed Charges,65% of Total Billed Charges,108.05,44.1,,25.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,232.75,95,,249.696,Percent of Total Billed Charges,95% of Total Billed Charges,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.6,88,,231.296,Percent of Total Billed Charges,88% of Total Billed Charges,220.5,90,,236.56,Percent of Total Billed charges,90% of Total Billed Charges,108.05,245,
CTL LNE SET 2 LUM 4FX3CM 2714,2720000128,CDM,272,RC,C1751,HCPCS,Outpatient,,,108.89,70.78,,108.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.76,76,,44.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,78.4,72,,486.624,Percent of Total Billed Charges,72% of Total Billed Charges,81.67,75,,486.624,Percent of Total Billed charges,75% of Total Billed Charges,108.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.4,72,,486.624,Percent of Total Billed Charges,72% of Total Billed Charges,65.33,60,,405.52,Percent of Total Billed Charges,60% of Total Billed Charges,98,90,,125.04,Percent of Total Billed Charges,90% of Total Billed Charges,49,45,,108.72,Percent of Total Billed Charges,45% of Total Billed Charges,98,90,,52.392,Percent of Total Billed Charges,90% of Total billed Charges,108.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.78,65,,37.84,Percent of total Billed Charges,65% of Total Billed Charges,48.02,44.1,,106.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,103.45,95,,55.304,Percent of Total Billed Charges,95% of Total Billed Charges,108.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.82,88,,51.232,Percent of Total Billed Charges,88% of Total Billed Charges,98,90,,52.392,Percent of Total Billed charges,90% of Total Billed Charges,48.02,108.89,
CTRIX NOVOS PLS MENSCAL RPR SY,2720000129,CDM,272,RC,,,Outpatient,,,2217.86,1441.61,,2217.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1685.57,76,,44.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1596.86,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,1663.4,75,,144,Percent of Total Billed charges,75% of Total Billed Charges,2217.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1596.86,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,1330.72,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,1996.07,90,,132.304,Percent of Total Billed Charges,90% of Total Billed Charges,998.04,45,,108.72,Percent of Total Billed Charges,45% of Total Billed Charges,1996.07,90,,52.392,Percent of Total Billed Charges,90% of Total billed Charges,2217.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2217.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2217.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1441.61,65,,157.04,Percent of total Billed Charges,65% of Total Billed Charges,978.08,44.1,,106.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,2106.97,95,,55.304,Percent of Total Billed Charges,95% of Total Billed Charges,2217.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1951.72,88,,51.232,Percent of Total Billed Charges,88% of Total Billed Charges,1996.07,90,,52.392,Percent of Total Billed charges,90% of Total Billed Charges,978.08,2217.86,
EKOS 6F 0.035 12CMX106CM CATH,2720000130,CDM,278,RC,C1887,HCPCS,Outpatient,,,5990.00,3893.50,,5990,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4552.4,76,,44.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4312.8,72,,610.848,Percent of Total Billed Charges,72% of Total Billed Charges,4312.8,72,,636.304,Percent of Total Billed charges,72% of Total Billed Charges,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4312.8,72,,610.848,Percent of Total Billed Charges,72% of Total Billed Charges,3594,60,,509.04,Percent of Total Billed Charges,60% of Total Billed Charges,5391,90,,125.04,Percent of Total Billed Charges,90% of Total Billed Charges,2695.5,45,,7.936,Percent of Total Billed Charges,45% of Total Billed Charges,5391,90,,52.392,Percent of Total Billed Charges,90% of Total billed Charges,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3893.5,65,,157.04,Percent of total Billed Charges,65% of Total Billed Charges,2641.59,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,5690.5,95,,55.304,Percent of Total Billed Charges,95% of Total Billed Charges,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5271.2,88,,51.232,Percent of Total Billed Charges,88% of Total Billed Charges,5391,90,,52.392,Percent of Total Billed charges,90% of Total Billed Charges,2641.59,5990,
EKOS 6F 0.035 18CMX106CM CATH,2720000131,CDM,278,RC,C1887,HCPCS,Outpatient,,,5990.00,3893.50,,5990,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4552.4,76,,183.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4312.8,72,,62.72,Percent of Total Billed Charges,72% of Total Billed Charges,4312.8,72,,65.336,Percent of Total Billed charges,72% of Total Billed Charges,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4312.8,72,,62.72,Percent of Total Billed Charges,72% of Total Billed Charges,3594,60,,52.264,Percent of Total Billed Charges,60% of Total Billed Charges,5391,90,,117.608,Percent of Total Billed Charges,90% of Total Billed Charges,2695.5,45,,7.936,Percent of Total Billed Charges,45% of Total Billed Charges,5391,90,,217.44,Percent of Total Billed Charges,90% of Total billed Charges,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3893.5,65,,11.464,Percent of total Billed Charges,65% of Total Billed Charges,2641.59,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,5690.5,95,,229.52,Percent of Total Billed Charges,95% of Total Billed Charges,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5271.2,88,,212.608,Percent of Total Billed Charges,88% of Total Billed Charges,5391,90,,217.44,Percent of Total Billed charges,90% of Total Billed Charges,2641.59,5990,
EKOS 6F 0.035 30CMX106CM CATH,2720000132,CDM,278,RC,C1887,HCPCS,Outpatient,,,5990.00,3893.50,,5990,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4552.4,76,,183.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4312.8,72,,486.624,Percent of Total Billed Charges,72% of Total Billed Charges,4312.8,72,,506.896,Percent of Total Billed charges,72% of Total Billed Charges,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4312.8,72,,486.624,Percent of Total Billed Charges,72% of Total Billed Charges,3594,60,,405.52,Percent of Total Billed Charges,60% of Total Billed Charges,5391,90,,135.184,Percent of Total Billed Charges,90% of Total Billed Charges,2695.5,45,,58.8,Percent of Total Billed Charges,45% of Total Billed Charges,5391,90,,217.44,Percent of Total Billed Charges,90% of Total billed Charges,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3893.5,65,,11.464,Percent of total Billed Charges,65% of Total Billed Charges,2641.59,44.1,,57.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,5690.5,95,,229.52,Percent of Total Billed Charges,95% of Total Billed Charges,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5271.2,88,,212.608,Percent of Total Billed Charges,88% of Total Billed Charges,5391,90,,217.44,Percent of Total Billed charges,90% of Total Billed Charges,2641.59,5990,
EKOS 6F 0.035 50CMX106CM CATH,2720000133,CDM,278,RC,C1887,HCPCS,Outpatient,,,5990.00,3893.50,,5990,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4552.4,76,,13.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4312.8,72,,255.92,Percent of Total Billed Charges,72% of Total Billed Charges,4312.8,72,,266.584,Percent of Total Billed charges,72% of Total Billed Charges,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4312.8,72,,255.92,Percent of Total Billed Charges,72% of Total Billed Charges,3594,60,,213.272,Percent of Total Billed Charges,60% of Total Billed Charges,5391,90,,64.8,Percent of Total Billed Charges,90% of Total Billed Charges,2695.5,45,,66.152,Percent of Total Billed Charges,45% of Total Billed Charges,5391,90,,15.88,Percent of Total Billed Charges,90% of Total billed Charges,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3893.5,65,,84.936,Percent of total Billed Charges,65% of Total Billed Charges,2641.59,44.1,,64.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,5690.5,95,,16.76,Percent of Total Billed Charges,95% of Total Billed Charges,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5271.2,88,,15.52,Percent of Total Billed Charges,88% of Total Billed Charges,5391,90,,15.88,Percent of Total Billed charges,90% of Total Billed Charges,2641.59,5990,
EKOS 6F O.035 40CMX106CM CATH,2720000134,CDM,278,RC,C1887,HCPCS,Outpatient,,,5990.00,3893.50,,5990,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4552.4,76,,13.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4312.8,72,,159.4,Percent of Total Billed Charges,72% of Total Billed Charges,4312.8,72,,166.04,Percent of Total Billed charges,72% of Total Billed Charges,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4312.8,72,,159.4,Percent of Total Billed Charges,72% of Total Billed Charges,3594,60,,132.832,Percent of Total Billed Charges,60% of Total Billed Charges,5391,90,,40.504,Percent of Total Billed Charges,90% of Total Billed Charges,2695.5,45,,62.52,Percent of Total Billed Charges,45% of Total Billed Charges,5391,90,,15.88,Percent of Total Billed Charges,90% of Total billed Charges,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3893.5,65,,95.552,Percent of total Billed Charges,65% of Total Billed Charges,2641.59,44.1,,61.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,5690.5,95,,16.76,Percent of Total Billed Charges,95% of Total Billed Charges,5990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5271.2,88,,15.52,Percent of Total Billed Charges,88% of Total Billed Charges,5391,90,,15.88,Percent of Total Billed charges,90% of Total Billed Charges,2641.59,5990,
EMBOSP MICROS 300500 SYR 20ML,2720000135,CDM,278,RC,C1889,HCPCS,Outpatient,,,826.88,537.47,,826.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,628.43,76,,99.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,595.35,72,,92.08,Percent of Total Billed Charges,72% of Total Billed Charges,595.35,72,,95.92,Percent of Total Billed charges,72% of Total Billed Charges,826.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,595.35,72,,92.08,Percent of Total Billed Charges,72% of Total Billed Charges,496.13,60,,76.736,Percent of Total Billed Charges,60% of Total Billed Charges,744.19,90,,161.936,Percent of Total Billed Charges,90% of Total Billed Charges,372.1,45,,66.152,Percent of Total Billed Charges,45% of Total Billed Charges,744.19,90,,117.608,Percent of Total Billed Charges,90% of Total billed Charges,826.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537.47,65,,90.312,Percent of total Billed Charges,65% of Total Billed Charges,364.65,44.1,,64.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,785.54,95,,124.136,Percent of Total Billed Charges,95% of Total Billed Charges,826.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,727.65,88,,114.992,Percent of Total Billed Charges,88% of Total Billed Charges,744.19,90,,117.608,Percent of Total Billed charges,90% of Total Billed Charges,364.65,826.88,
EMBOSP MICROS 500700 SYR 20ML,2720000136,CDM,278,RC,C1889,HCPCS,Outpatient,,,826.88,537.47,,826.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,628.43,76,,111.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,595.35,72,,59.696,Percent of Total Billed Charges,72% of Total Billed Charges,595.35,72,,62.184,Percent of Total Billed charges,72% of Total Billed Charges,826.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,595.35,72,,59.696,Percent of Total Billed Charges,72% of Total Billed Charges,496.13,60,,49.744,Percent of Total Billed Charges,60% of Total Billed Charges,744.19,90,,986.4,Percent of Total Billed Charges,90% of Total Billed Charges,372.1,45,,62.52,Percent of Total Billed Charges,45% of Total Billed Charges,744.19,90,,132.304,Percent of Total Billed Charges,90% of Total billed Charges,826.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537.47,65,,95.552,Percent of total Billed Charges,65% of Total Billed Charges,364.65,44.1,,61.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,785.54,95,,139.648,Percent of Total Billed Charges,95% of Total Billed Charges,826.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,727.65,88,,129.36,Percent of Total Billed Charges,88% of Total Billed Charges,744.19,90,,132.304,Percent of Total Billed charges,90% of Total Billed Charges,364.65,826.88,
ENSEAL  X1 CVD JAW TIS SEALER,2720000137,CDM,272,RC,,,Outpatient,,,545.00,354.25,,545,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.2,76,,105.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,392.4,72,,59.696,Percent of Total Billed Charges,72% of Total Billed Charges,408.75,75,,62.184,Percent of Total Billed charges,75% of Total Billed Charges,545,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.4,72,,59.696,Percent of Total Billed Charges,72% of Total Billed Charges,327,60,,49.744,Percent of Total Billed Charges,60% of Total Billed Charges,490.5,90,,1454.4,Percent of Total Billed Charges,90% of Total Billed Charges,245.25,45,,58.8,Percent of Total Billed Charges,45% of Total Billed Charges,490.5,90,,125.04,Percent of Total Billed Charges,90% of Total billed Charges,545,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,545,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,545,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.25,65,,90.312,Percent of total Billed Charges,65% of Total Billed Charges,240.35,44.1,,57.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,517.75,95,,131.992,Percent of Total Billed Charges,95% of Total Billed Charges,545,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.6,88,,122.264,Percent of Total Billed Charges,88% of Total Billed Charges,490.5,90,,125.04,Percent of Total Billed charges,90% of Total Billed Charges,240.35,545,
ENTUIT IP GASTROSTOMY SET MED,2720000138,CDM,272,RC,,,Outpatient,,,207.90,135.14,,207.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,158,76,,111.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,149.69,72,,22.864,Percent of Total Billed Charges,72% of Total Billed Charges,155.93,75,,23.816,Percent of Total Billed charges,75% of Total Billed Charges,207.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.69,72,,22.864,Percent of Total Billed Charges,72% of Total Billed Charges,124.74,60,,19.048,Percent of Total Billed Charges,60% of Total Billed Charges,187.11,90,,39.208,Percent of Total Billed Charges,90% of Total Billed Charges,93.56,45,,67.592,Percent of Total Billed Charges,45% of Total Billed Charges,187.11,90,,132.304,Percent of Total Billed Charges,90% of Total billed Charges,207.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.14,65,,84.936,Percent of total Billed Charges,65% of Total Billed Charges,91.68,44.1,,66.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,197.51,95,,139.648,Percent of Total Billed Charges,95% of Total Billed Charges,207.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182.95,88,,129.36,Percent of Total Billed Charges,88% of Total Billed Charges,187.11,90,,132.304,Percent of Total Billed charges,90% of Total Billed Charges,91.68,207.9,
ENTUIT IP GASTROSTOMY ST SM,2720000139,CDM,272,RC,,,Outpatient,,,207.90,135.14,,207.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,158,76,,105.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,149.69,72,,22.864,Percent of Total Billed Charges,72% of Total Billed Charges,155.93,75,,23.816,Percent of Total Billed charges,75% of Total Billed Charges,207.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.69,72,,22.864,Percent of Total Billed Charges,72% of Total Billed Charges,124.74,60,,19.048,Percent of Total Billed Charges,60% of Total Billed Charges,187.11,90,,92.88,Percent of Total Billed Charges,90% of Total Billed Charges,93.56,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,187.11,90,,125.04,Percent of Total Billed Charges,90% of Total billed Charges,207.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.14,65,,97.632,Percent of total Billed Charges,65% of Total Billed Charges,91.68,44.1,,31.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,197.51,95,,131.992,Percent of Total Billed Charges,95% of Total Billed Charges,207.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182.95,88,,122.264,Percent of Total Billed Charges,88% of Total Billed Charges,187.11,90,,125.04,Percent of Total Billed charges,90% of Total Billed Charges,91.68,207.9,
ENTUIT SECURE GI SUT ANCHOR ST,2720000140,CDM,272,RC,,,Outpatient,,,285.86,185.81,,285.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,217.25,76,,99.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,205.82,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,214.4,75,,10.584,Percent of Total Billed charges,75% of Total Billed Charges,285.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.82,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,171.52,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,257.27,90,,92.88,Percent of Total Billed Charges,90% of Total Billed Charges,128.64,45,,20.248,Percent of Total Billed Charges,45% of Total Billed Charges,257.27,90,,117.608,Percent of Total Billed Charges,90% of Total billed Charges,285.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.81,65,,46.8,Percent of total Billed Charges,65% of Total Billed Charges,126.06,44.1,,19.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,271.57,95,,124.136,Percent of Total Billed Charges,95% of Total Billed Charges,285.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.56,88,,114.992,Percent of Total Billed Charges,88% of Total Billed Charges,257.27,90,,117.608,Percent of Total Billed charges,90% of Total Billed Charges,126.06,285.86,
ENTUIT THRI 14F BR GT FDING TU,2720000141,CDM,272,RC,,,Outpatient,,,129.94,84.46,,129.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.75,76,,114.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,93.56,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,97.46,75,,10.584,Percent of Total Billed charges,75% of Total Billed Charges,129.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.56,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,77.96,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,116.95,90,,6339.288,Percent of Total Billed Charges,90% of Total Billed Charges,58.47,45,,80.968,Percent of Total Billed Charges,45% of Total Billed Charges,116.95,90,,135.184,Percent of Total Billed Charges,90% of Total billed Charges,129.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.46,65,,29.248,Percent of total Billed Charges,65% of Total Billed Charges,57.3,44.1,,79.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,123.44,95,,142.696,Percent of Total Billed Charges,95% of Total Billed Charges,129.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.35,88,,132.184,Percent of Total Billed Charges,88% of Total Billed Charges,116.95,90,,135.184,Percent of Total Billed charges,90% of Total Billed Charges,57.3,129.94,
ENTUIT THRI 18F BR GT FDING TU,2720000142,CDM,272,RC,,,Outpatient,,,129.94,84.46,,129.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.75,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,93.56,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,97.46,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,129.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.56,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,77.96,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,116.95,90,,1895.592,Percent of Total Billed Charges,90% of Total Billed Charges,58.47,45,,493.2,Percent of Total Billed Charges,45% of Total Billed Charges,116.95,90,,64.8,Percent of Total Billed Charges,90% of Total billed Charges,129.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.46,65,,116.952,Percent of total Billed Charges,65% of Total Billed Charges,57.3,44.1,,483.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,123.44,95,,68.4,Percent of Total Billed Charges,95% of Total Billed Charges,129.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.35,88,,63.36,Percent of Total Billed Charges,88% of Total Billed Charges,116.95,90,,64.8,Percent of Total Billed charges,90% of Total Billed Charges,57.3,129.94,
EPIDUR ANES TRY PERIFX FX CNT,2720000143,CDM,272,RC,,,Outpatient,,,74.55,48.46,,74.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.66,76,,34.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.68,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,55.91,75,,12.568,Percent of Total Billed charges,75% of Total Billed Charges,74.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.68,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,44.73,60,,10.056,Percent of Total Billed Charges,60% of Total Billed Charges,67.1,90,,43673.296,Percent of Total Billed Charges,90% of Total Billed Charges,33.55,45,,727.2,Percent of Total Billed Charges,45% of Total Billed Charges,67.1,90,,40.504,Percent of Total Billed Charges,90% of Total billed Charges,74.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.46,65,,712.4,Percent of total Billed Charges,65% of Total Billed Charges,32.88,44.1,,712.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,70.82,95,,42.752,Percent of Total Billed Charges,95% of Total Billed Charges,74.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.6,88,,39.6,Percent of Total Billed Charges,88% of Total Billed Charges,67.1,90,,40.504,Percent of Total Billed charges,90% of Total Billed Charges,32.88,74.55,
EUPHORA NC 2 .25 X 12 RX BAL,2720000144,CDM,272,RC,C1725,HCPCS,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,136.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,42.336,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,33.872,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,55.408,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,19.608,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,161.936,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,1050.4,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,19.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,170.928,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,158.336,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,161.936,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
EUPHORA NC 2 .25 X 15 RX BAL,2720000145,CDM,272,RC,C1725,HCPCS,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,832.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,14.56,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,70.648,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,46.44,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,986.4,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,28.32,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,45.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,1041.2,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,964.48,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,986.4,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
EUPHORA NC 2.75 X 12 RX BAL,2720000146,CDM,272,RC,C1725,HCPCS,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,1228.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,63.504,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,66.152,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,63.504,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,52.92,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,7.576,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,46.44,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,1454.4,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,67.08,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,45.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,1535.2,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,1422.08,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,1454.4,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
EUPHORA NC 2.75 X 15 RX BAL,2720000147,CDM,272,RC,C1725,HCPCS,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,33.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,147.328,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,153.472,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,147.328,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,122.776,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,21.024,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,3169.648,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,39.208,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,67.08,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,3106.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,41.392,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,38.336,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,39.208,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
EUPHORA NC 3.25 X 12 RX BAL,2720000148,CDM,272,RC,C1725,HCPCS,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,78.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,63.504,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,66.152,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,63.504,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,52.92,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,947.8,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,92.88,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,4578.376,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,928.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,98.04,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,90.816,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,92.88,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
EUPHORA NC 3.25 X 15 RX BAL,2720000149,CDM,272,RC,C1725,HCPCS,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,78.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,113.672,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,118.408,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,113.672,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,94.728,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,17.392,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,21836.648,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,92.88,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,1369.04,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,21399.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,98.04,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,90.816,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,92.88,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
EXTRA SUPPORT F 0.014X190 WRE,2720000150,CDM,272,RC,C1769,HCPCS,Outpatient,,,313.11,203.52,,313.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.96,76,,5353.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225.44,72,,65.72,Percent of Total Billed Charges,72% of Total Billed Charges,234.83,75,,68.464,Percent of Total Billed charges,75% of Total Billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.44,72,,65.72,Percent of Total Billed Charges,72% of Total Billed Charges,187.87,60,,54.768,Percent of Total Billed Charges,60% of Total Billed Charges,281.8,90,,17.392,Percent of Total Billed Charges,90% of Total Billed Charges,140.9,45,,27.704,Percent of Total Billed Charges,45% of Total Billed Charges,281.8,90,,6339.288,Percent of Total Billed Charges,90% of Total billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.52,65,,31541.824,Percent of total Billed Charges,65% of Total Billed Charges,138.08,44.1,,27.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,297.45,95,,6691.472,Percent of Total Billed Charges,95% of Total Billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.54,88,,6198.416,Percent of Total Billed Charges,88% of Total Billed Charges,281.8,90,,6339.288,Percent of Total Billed charges,90% of Total Billed Charges,138.08,313.11,
F CORE BX 16G X 15CM NDLE 1079,2720000151,CDM,272,RC,,,Outpatient,,,140.00,91.00,,140,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.4,76,,1600.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.8,72,,65.72,Percent of Total Billed Charges,72% of Total Billed Charges,105,75,,68.464,Percent of Total Billed charges,75% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.8,72,,65.72,Percent of Total Billed Charges,72% of Total Billed Charges,84,60,,54.768,Percent of Total Billed Charges,60% of Total Billed Charges,126,90,,26.992,Percent of Total Billed Charges,90% of Total Billed Charges,63,45,,35.32,Percent of Total Billed Charges,45% of Total Billed Charges,126,90,,1895.592,Percent of Total Billed Charges,90% of Total billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91,65,,40.016,Percent of total Billed Charges,65% of Total Billed Charges,61.74,44.1,,34.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,133,95,,2000.904,Percent of Total Billed Charges,95% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.2,88,,1853.472,Percent of Total Billed Charges,88% of Total Billed Charges,126,90,,1895.592,Percent of Total Billed charges,90% of Total Billed Charges,61.74,140,
F CORE BX 16G X10CM NDLE 1078,2720000152,CDM,272,RC,,,Outpatient,,,140.00,91.00,,140,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.4,76,,36879.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.8,72,,34.112,Percent of Total Billed Charges,72% of Total Billed Charges,105,75,,35.536,Percent of Total Billed charges,75% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.8,72,,34.112,Percent of Total Billed Charges,72% of Total Billed Charges,84,60,,28.424,Percent of Total Billed Charges,60% of Total Billed Charges,126,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,63,45,,3.784,Percent of Total Billed Charges,45% of Total Billed Charges,126,90,,43673.296,Percent of Total Billed Charges,90% of Total billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91,65,,51.024,Percent of total Billed Charges,65% of Total Billed Charges,61.74,44.1,,3.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,133,95,,46099.584,Percent of Total Billed Charges,95% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.2,88,,42702.776,Percent of Total Billed Charges,88% of Total Billed Charges,126,90,,43673.296,Percent of Total Billed charges,90% of Total Billed Charges,61.74,140,
F CORE BX 18G X 20CM NDLE 1142,2720000153,CDM,272,RC,,,Outpatient,,,140.00,91.00,,140,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.4,76,,46.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.8,72,,10.584,Percent of Total Billed Charges,72% of Total Billed Charges,105,75,,11.032,Percent of Total Billed charges,75% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.8,72,,10.584,Percent of Total Billed Charges,72% of Total Billed Charges,84,60,,8.824,Percent of Total Billed Charges,60% of Total Billed Charges,126,90,,254.808,Percent of Total Billed Charges,90% of Total Billed Charges,63,45,,10.512,Percent of Total Billed Charges,45% of Total Billed Charges,126,90,,55.408,Percent of Total Billed Charges,90% of Total billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91,65,,5.472,Percent of total Billed Charges,65% of Total Billed Charges,61.74,44.1,,10.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,133,95,,58.48,Percent of Total Billed Charges,95% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.2,88,,54.176,Percent of Total Billed Charges,88% of Total Billed Charges,126,90,,55.408,Percent of Total Billed charges,90% of Total Billed Charges,61.74,140,
FLEX SHETH 5FX11CM W/O WR GUDE,2720000154,CDM,272,RC,C1894,HCPCS,Outpatient,,,120.40,78.26,,120.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,91.5,76,,59.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,86.69,72,,10.584,Percent of Total Billed Charges,72% of Total Billed Charges,90.3,75,,11.032,Percent of Total Billed charges,75% of Total Billed Charges,120.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.69,72,,10.584,Percent of Total Billed Charges,72% of Total Billed Charges,72.24,60,,8.824,Percent of Total Billed Charges,60% of Total Billed Charges,108.36,90,,254.808,Percent of Total Billed Charges,90% of Total Billed Charges,54.18,45,,2.88,Percent of Total Billed Charges,45% of Total Billed Charges,108.36,90,,70.648,Percent of Total Billed Charges,90% of Total billed Charges,120.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.26,65,,15.184,Percent of total Billed Charges,65% of Total Billed Charges,53.1,44.1,,2.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,114.38,95,,74.568,Percent of Total Billed Charges,95% of Total Billed Charges,120.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.95,88,,69.08,Percent of Total Billed Charges,88% of Total Billed Charges,108.36,90,,70.648,Percent of Total Billed charges,90% of Total Billed Charges,53.1,120.4,
FLEX SHETH 5FX24CM W/O WR GUDE,2720000155,CDM,272,RC,C1766,HCPCS,Outpatient,,,150.08,97.55,,150.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114.06,76,,6.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.06,72,,73.152,Percent of Total Billed Charges,72% of Total Billed Charges,112.56,75,,76.2,Percent of Total Billed charges,75% of Total Billed Charges,150.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.06,72,,73.152,Percent of Total Billed Charges,72% of Total Billed Charges,90.05,60,,60.96,Percent of Total Billed Charges,60% of Total Billed Charges,135.07,90,,264.336,Percent of Total Billed Charges,90% of Total Billed Charges,67.54,45,,8.696,Percent of Total Billed Charges,45% of Total Billed Charges,135.07,90,,7.576,Percent of Total Billed Charges,90% of Total billed Charges,150.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.55,65,,4.16,Percent of total Billed Charges,65% of Total Billed Charges,66.19,44.1,,8.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.58,95,,7.992,Percent of Total Billed Charges,95% of Total Billed Charges,150.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.07,88,,7.408,Percent of Total Billed Charges,88% of Total Billed Charges,135.07,90,,7.576,Percent of Total Billed charges,90% of Total Billed Charges,66.19,150.08,
FLEX SHETH 6FX11CM W/O WR GUDE,2720000156,CDM,272,RC,C1894,HCPCS,Outpatient,,,129.11,83.92,,129.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.12,76,,17.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,92.96,72,,73.152,Percent of Total Billed Charges,72% of Total Billed Charges,96.83,75,,76.2,Percent of Total Billed charges,75% of Total Billed Charges,129.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.96,72,,73.152,Percent of Total Billed Charges,72% of Total Billed Charges,77.47,60,,60.96,Percent of Total Billed Charges,60% of Total Billed Charges,116.2,90,,1339.936,Percent of Total Billed Charges,90% of Total Billed Charges,58.1,45,,8.696,Percent of Total Billed Charges,45% of Total Billed Charges,116.2,90,,21.024,Percent of Total Billed Charges,90% of Total billed Charges,129.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.92,65,,12.56,Percent of total Billed Charges,65% of Total Billed Charges,56.94,44.1,,8.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,122.65,95,,22.192,Percent of Total Billed Charges,95% of Total Billed Charges,129.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.62,88,,20.56,Percent of Total Billed Charges,88% of Total Billed Charges,116.2,90,,21.024,Percent of Total Billed charges,90% of Total Billed Charges,56.94,129.11,
FLEX SHETH 6FX24CM W/O WR GUDE,2720000157,CDM,272,RC,C1766,HCPCS,Outpatient,,,173.57,112.82,,173.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,131.91,76,,4.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,124.97,72,,137.8,Percent of Total Billed Charges,72% of Total Billed Charges,130.18,75,,143.544,Percent of Total Billed charges,75% of Total Billed Charges,173.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.97,72,,137.8,Percent of Total Billed Charges,72% of Total Billed Charges,104.14,60,,114.832,Percent of Total Billed Charges,60% of Total Billed Charges,156.21,90,,23.016,Percent of Total Billed Charges,90% of Total Billed Charges,78.11,45,,13.496,Percent of Total Billed Charges,45% of Total Billed Charges,156.21,90,,5.76,Percent of Total Billed Charges,90% of Total billed Charges,173.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.82,65,,12.56,Percent of total Billed Charges,65% of Total Billed Charges,76.54,44.1,,13.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,164.89,95,,6.08,Percent of Total Billed Charges,95% of Total Billed Charges,173.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.74,88,,5.632,Percent of Total Billed Charges,88% of Total Billed Charges,156.21,90,,5.76,Percent of Total Billed charges,90% of Total Billed Charges,76.54,173.57,
FLOW DIRECTED 5.3F BAL CATH,2720000158,CDM,272,RC,C2628,HCPCS,Outpatient,,,587.63,381.96,,587.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,446.6,76,,14.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,423.09,72,,52.08,Percent of Total Billed Charges,72% of Total Billed Charges,440.72,75,,54.248,Percent of Total Billed charges,75% of Total Billed Charges,587.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,423.09,72,,52.08,Percent of Total Billed Charges,72% of Total Billed Charges,352.58,60,,43.4,Percent of Total Billed Charges,60% of Total Billed Charges,528.87,90,,2.216,Percent of Total Billed Charges,90% of Total Billed Charges,264.43,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,528.87,90,,17.392,Percent of Total Billed Charges,90% of Total billed Charges,587.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,587.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,587.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.96,65,,19.496,Percent of total Billed Charges,65% of Total Billed Charges,259.14,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,558.25,95,,18.36,Percent of Total Billed Charges,95% of Total Billed Charges,587.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,517.11,88,,17.008,Percent of Total Billed Charges,88% of Total Billed Charges,528.87,90,,17.392,Percent of Total Billed charges,90% of Total Billed Charges,259.14,587.63,
FOGARTY 5.5F 40CM CAT CLOT MAN,2720000159,CDM,272,RC,C1887,HCPCS,Outpatient,,,251.00,163.15,,251,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,190.76,76,,14.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,180.72,72,,117.48,Percent of Total Billed Charges,72% of Total Billed Charges,188.25,75,,122.376,Percent of Total Billed charges,75% of Total Billed Charges,251,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.72,72,,117.48,Percent of Total Billed Charges,72% of Total Billed Charges,150.6,60,,97.904,Percent of Total Billed Charges,60% of Total Billed Charges,225.9,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,112.95,45,,127.408,Percent of Total Billed Charges,45% of Total Billed Charges,225.9,90,,17.392,Percent of Total Billed Charges,90% of Total billed Charges,251,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.15,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,110.69,44.1,,124.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,238.45,95,,18.36,Percent of Total Billed Charges,95% of Total Billed Charges,251,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.88,88,,17.008,Percent of Total Billed Charges,88% of Total Billed Charges,225.9,90,,17.392,Percent of Total Billed charges,90% of Total Billed Charges,110.69,251,
FOLEY CATH 16F 3WY 30CC SILIC,2720000160,CDM,272,RC,A4346,HCPCS,Outpatient,,,77.09,50.11,,77.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.59,76,,22.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.56,350,,40.008,Fee Schedule,350% of BCBS fee schedule,65.56,350,,41.68,Fee Schedule,350% of BCBS fee schedule,77.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.56,350,,40.008,Fee Schedule,350% of BCBS PPO fee schedule,18.73,100,,33.344,Fee Schedule,100% of Blue ADV HMO fee schedule,69.38,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,34.69,45,,127.408,Percent of Total Billed Charges,45% of Total Billed Charges,69.38,90,,26.992,Percent of Total Billed Charges,90% of Total billed Charges,77.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.11,65,,184.032,Percent of total Billed Charges,65% of Total Billed Charges,34,44.1,,124.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.24,95,,28.496,Percent of Total Billed Charges,95% of Total Billed Charges,77.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.84,88,,26.392,Percent of Total Billed Charges,88% of Total Billed Charges,69.38,90,,26.992,Percent of Total Billed charges,90% of Total Billed Charges,18.73,77.09,
FOLEY CATH SECURE DEV #1703339,2720000161,CDM,272,RC,,,Outpatient,,,14.50,9.43,,14.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.02,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.44,72,,292.752,Percent of Total Billed Charges,72% of Total Billed Charges,10.88,75,,304.952,Percent of Total Billed charges,75% of Total Billed Charges,14.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.44,72,,292.752,Percent of Total Billed Charges,72% of Total Billed Charges,8.7,60,,243.96,Percent of Total Billed Charges,60% of Total Billed Charges,13.05,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,6.53,45,,132.168,Percent of Total Billed Charges,45% of Total Billed Charges,13.05,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,14.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.43,65,,184.032,Percent of total Billed Charges,65% of Total Billed Charges,6.39,44.1,,129.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.78,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,14.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.76,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,13.05,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,6.39,14.5,
FOLEY CATH TRY 16F (260000278),2720000162,CDM,272,RC,,,Outpatient,,,47.33,30.76,,47.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.97,76,,215.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.08,72,,62.24,Percent of Total Billed Charges,72% of Total Billed Charges,35.5,75,,64.832,Percent of Total Billed charges,75% of Total Billed Charges,47.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.08,72,,62.24,Percent of Total Billed Charges,72% of Total Billed Charges,28.4,60,,51.864,Percent of Total Billed Charges,60% of Total Billed Charges,42.6,90,,84.048,Percent of Total Billed Charges,90% of Total Billed Charges,21.3,45,,669.968,Percent of Total Billed Charges,45% of Total Billed Charges,42.6,90,,254.808,Percent of Total Billed Charges,90% of Total billed Charges,47.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.76,65,,190.904,Percent of total Billed Charges,65% of Total Billed Charges,20.87,44.1,,656.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.96,95,,268.968,Percent of Total Billed Charges,95% of Total Billed Charges,47.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.65,88,,249.144,Percent of Total Billed Charges,88% of Total Billed Charges,42.6,90,,254.808,Percent of Total Billed charges,90% of Total Billed Charges,20.87,47.33,
FOLEY CATH TRY 18F (260000260),2720000163,CDM,272,RC,,,Outpatient,,,47.33,30.76,,47.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.97,76,,215.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.08,72,,73.664,Percent of Total Billed Charges,72% of Total Billed Charges,35.5,75,,76.736,Percent of Total Billed charges,75% of Total Billed Charges,47.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.08,72,,73.664,Percent of Total Billed Charges,72% of Total Billed Charges,28.4,60,,61.384,Percent of Total Billed Charges,60% of Total Billed Charges,42.6,90,,90.488,Percent of Total Billed Charges,90% of Total Billed Charges,21.3,45,,11.512,Percent of Total Billed Charges,45% of Total Billed Charges,42.6,90,,254.808,Percent of Total Billed Charges,90% of Total billed Charges,47.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.76,65,,967.728,Percent of total Billed Charges,65% of Total Billed Charges,20.87,44.1,,11.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.96,95,,268.968,Percent of Total Billed Charges,95% of Total Billed Charges,47.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.65,88,,249.144,Percent of Total Billed Charges,88% of Total Billed Charges,42.6,90,,254.808,Percent of Total Billed charges,90% of Total Billed Charges,20.87,47.33,
GELBEAD 300500 EMBOSPH (3801),2720000164,CDM,272,RC,,,Outpatient,,,990.45,643.79,,990.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,752.74,76,,223.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,713.12,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,742.84,75,,9.928,Percent of Total Billed charges,75% of Total Billed Charges,990.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,713.12,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,594.27,60,,7.936,Percent of Total Billed Charges,60% of Total Billed Charges,891.41,90,,95.096,Percent of Total Billed Charges,90% of Total Billed Charges,445.7,45,,1.112,Percent of Total Billed Charges,45% of Total Billed Charges,891.41,90,,264.336,Percent of Total Billed Charges,90% of Total billed Charges,990.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,990.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,990.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,643.79,65,,16.624,Percent of total Billed Charges,65% of Total Billed Charges,436.79,44.1,,1.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,940.93,95,,279.016,Percent of Total Billed Charges,95% of Total Billed Charges,990.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,871.6,88,,258.456,Percent of Total Billed Charges,88% of Total Billed Charges,891.41,90,,264.336,Percent of Total Billed charges,90% of Total Billed Charges,436.79,990.45,
GELBEAD 500700 EMBOSH (3802),2720000165,CDM,272,RC,,,Outpatient,,,990.45,643.79,,990.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,752.74,76,,1131.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,713.12,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,742.84,75,,10.584,Percent of Total Billed charges,75% of Total Billed Charges,990.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,713.12,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,594.27,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,891.41,90,,95.128,Percent of Total Billed Charges,90% of Total Billed Charges,445.7,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,891.41,90,,1339.936,Percent of Total Billed Charges,90% of Total billed Charges,990.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,990.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,990.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,643.79,65,,1.6,Percent of total Billed Charges,65% of Total Billed Charges,436.79,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,940.93,95,,1414.376,Percent of Total Billed Charges,95% of Total Billed Charges,990.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,871.6,88,,1310.16,Percent of Total Billed Charges,88% of Total Billed Charges,891.41,90,,1339.936,Percent of Total Billed charges,90% of Total Billed Charges,436.79,990.45,
GLDEWRE STD ANG 0.035 X 180CM,2720000166,CDM,272,RC,C1769,HCPCS,Outpatient,,,538.02,349.71,,538.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,408.9,76,,19.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,387.37,72,,43.816,Percent of Total Billed Charges,72% of Total Billed Charges,403.52,75,,45.64,Percent of Total Billed charges,75% of Total Billed Charges,538.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,387.37,72,,43.816,Percent of Total Billed Charges,72% of Total Billed Charges,322.81,60,,36.512,Percent of Total Billed Charges,60% of Total Billed Charges,484.22,90,,84.016,Percent of Total Billed Charges,90% of Total Billed Charges,242.11,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,484.22,90,,23.016,Percent of Total Billed Charges,90% of Total billed Charges,538.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.71,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,237.27,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,511.12,95,,24.296,Percent of Total Billed Charges,95% of Total Billed Charges,538.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.46,88,,22.504,Percent of Total Billed Charges,88% of Total Billed Charges,484.22,90,,23.016,Percent of Total Billed charges,90% of Total Billed Charges,237.27,538.02,
GLIDEWRE STIF ANG 0.035X180CM,2720000167,CDM,272,RC,C1769,HCPCS,Outpatient,,,628.43,408.48,,628.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,477.61,76,,1.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,452.47,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,471.32,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,628.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,452.47,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,377.06,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,565.59,90,,3233.944,Percent of Total Billed Charges,90% of Total Billed Charges,282.79,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,565.59,90,,2.216,Percent of Total Billed Charges,90% of Total billed Charges,628.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,628.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,628.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,408.48,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,277.14,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,597.01,95,,2.344,Percent of Total Billed Charges,95% of Total Billed Charges,628.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,553.02,88,,2.168,Percent of Total Billed Charges,88% of Total Billed Charges,565.59,90,,2.216,Percent of Total Billed charges,90% of Total Billed Charges,277.14,628.43,
GOLDENBERG COIL 11GX4 NDL,2720000168,CDM,272,RC,,,Outpatient,,,137.81,89.58,,137.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,104.74,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,99.22,72,,77.48,Percent of Total Billed Charges,72% of Total Billed Charges,103.36,75,,80.704,Percent of Total Billed charges,75% of Total Billed Charges,137.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.22,72,,77.48,Percent of Total Billed Charges,72% of Total Billed Charges,82.69,60,,64.568,Percent of Total Billed Charges,60% of Total Billed Charges,124.03,90,,5326.4,Percent of Total Billed Charges,90% of Total Billed Charges,62.01,45,,42.024,Percent of Total Billed Charges,45% of Total Billed Charges,124.03,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,137.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.58,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,60.77,44.1,,41.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,130.92,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,137.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.27,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,124.03,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,60.77,137.81,
GOLDENBERG COIL 11GX6 NDL,2720000169,CDM,272,RC,,,Outpatient,,,137.81,89.58,,137.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,104.74,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,99.22,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,103.36,75,,53.584,Percent of Total Billed charges,75% of Total Billed Charges,137.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.22,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,82.69,60,,42.864,Percent of Total Billed Charges,60% of Total Billed Charges,124.03,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,62.01,45,,45.248,Percent of Total Billed Charges,45% of Total Billed Charges,124.03,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,137.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.58,65,,60.696,Percent of total Billed Charges,65% of Total Billed Charges,60.77,44.1,,44.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,130.92,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,137.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.27,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,124.03,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,60.77,137.81,
HISTOACRY TOPICAL SKIN ADH,2720000170,CDM,272,RC,,,Outpatient,,,173.09,112.51,,173.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,131.55,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,124.62,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,129.82,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.62,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,103.85,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,155.78,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,77.89,45,,47.552,Percent of Total Billed Charges,45% of Total Billed Charges,155.78,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.51,65,,65.352,Percent of total Billed Charges,65% of Total Billed Charges,76.33,44.1,,46.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,164.44,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.32,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,155.78,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,76.33,173.09,
IMPULSE 5F PIGTAIL 145 CATH,2720000171,CDM,272,RC,C1887,HCPCS,Outpatient,,,44.10,28.67,,44.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33.52,76,,70.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,31.75,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.75,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,39.69,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,19.85,45,,47.56,Percent of Total Billed Charges,45% of Total Billed Charges,39.69,90,,84.048,Percent of Total Billed Charges,90% of Total billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,65,,68.68,Percent of total Billed Charges,65% of Total Billed Charges,19.45,44.1,,46.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.9,95,,88.712,Percent of Total Billed Charges,95% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.81,88,,82.176,Percent of Total Billed Charges,88% of Total Billed Charges,39.69,90,,84.048,Percent of Total Billed charges,90% of Total Billed Charges,19.45,44.1,
INSRB SUBCUTICULAR SKN STAPLER,2720000172,CDM,272,RC,,,Outpatient,,,36.00,23.40,,36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.36,76,,76.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.92,72,,245.128,Percent of Total Billed Charges,72% of Total Billed Charges,27,75,,255.344,Percent of Total Billed charges,75% of Total Billed Charges,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.92,72,,245.128,Percent of Total Billed Charges,72% of Total Billed Charges,21.6,60,,204.272,Percent of Total Billed Charges,60% of Total Billed Charges,32.4,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,45,,42.008,Percent of Total Billed Charges,45% of Total Billed Charges,32.4,90,,90.488,Percent of Total Billed Charges,90% of Total billed Charges,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.4,65,,68.704,Percent of total Billed Charges,65% of Total Billed Charges,15.88,44.1,,41.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.2,95,,95.52,Percent of Total Billed Charges,95% of Total Billed Charges,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.68,88,,88.48,Percent of Total Billed Charges,88% of Total Billed Charges,32.4,90,,90.488,Percent of Total Billed charges,90% of Total Billed Charges,15.88,36,
JEJUNAL FEED TUB 22F (020022),2720000173,CDM,278,RC,,,Outpatient,,,433.00,281.45,,433,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,329.08,76,,80.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,311.76,72,,248.304,Percent of Total Billed Charges,72% of Total Billed Charges,311.76,72,,258.648,Percent of Total Billed charges,72% of Total Billed Charges,433,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,311.76,72,,248.304,Percent of Total Billed Charges,72% of Total Billed Charges,259.8,60,,206.92,Percent of Total Billed Charges,60% of Total Billed Charges,389.7,90,,473.76,Percent of Total Billed Charges,90% of Total Billed Charges,194.85,45,,1616.976,Percent of Total Billed Charges,45% of Total Billed Charges,389.7,90,,95.096,Percent of Total Billed Charges,90% of Total billed Charges,433,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,433,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,433,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,281.45,65,,60.68,Percent of total Billed Charges,65% of Total Billed Charges,190.95,44.1,,1584.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,411.35,95,,100.384,Percent of Total Billed Charges,95% of Total Billed Charges,433,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.04,88,,92.984,Percent of Total Billed Charges,88% of Total Billed Charges,389.7,90,,95.096,Percent of Total Billed charges,90% of Total Billed Charges,190.95,433,
JEJUNAL FEED TUB 24F (020024),2720000174,CDM,278,RC,,,Outpatient,,,433.00,281.45,,433,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,329.08,76,,80.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,311.76,72,,280.048,Percent of Total Billed Charges,72% of Total Billed Charges,311.76,72,,291.72,Percent of Total Billed charges,72% of Total Billed Charges,433,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,311.76,72,,280.048,Percent of Total Billed Charges,72% of Total Billed Charges,259.8,60,,233.376,Percent of Total Billed Charges,60% of Total Billed Charges,389.7,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,194.85,45,,2663.2,Percent of Total Billed Charges,45% of Total Billed Charges,389.7,90,,95.128,Percent of Total Billed Charges,90% of Total billed Charges,433,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,433,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,433,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,281.45,65,,2335.624,Percent of total Billed Charges,65% of Total Billed Charges,190.95,44.1,,2609.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,411.35,95,,100.408,Percent of Total Billed Charges,95% of Total Billed Charges,433,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.04,88,,93.016,Percent of Total Billed Charges,88% of Total Billed Charges,389.7,90,,95.128,Percent of Total Billed charges,90% of Total Billed Charges,190.95,433,
LAP SMOKE FILTRATION TUBING ST,2720000175,CDM,272,RC,,,Outpatient,,,19.00,12.35,,19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.44,76,,70.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.68,72,,71.128,Percent of Total Billed Charges,72% of Total Billed Charges,14.25,75,,74.088,Percent of Total Billed charges,75% of Total Billed Charges,19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.68,72,,71.128,Percent of Total Billed Charges,72% of Total Billed Charges,11.4,60,,59.272,Percent of Total Billed Charges,60% of Total Billed Charges,17.1,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,8.55,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,17.1,90,,84.016,Percent of Total Billed Charges,90% of Total billed Charges,19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.35,65,,3846.848,Percent of total Billed Charges,65% of Total Billed Charges,8.38,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.05,95,,88.688,Percent of Total Billed Charges,95% of Total Billed Charges,19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.72,88,,82.152,Percent of Total Billed Charges,88% of Total Billed Charges,17.1,90,,84.016,Percent of Total Billed charges,90% of Total Billed Charges,8.38,19,
LIVER BX ST 7F  18G 60CM 20MM,2720000176,CDM,272,RC,,,Outpatient,,,1034.00,672.10,,1034,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,785.84,76,,2730.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,744.48,72,,258.464,Percent of Total Billed Charges,72% of Total Billed Charges,775.5,75,,269.232,Percent of Total Billed charges,75% of Total Billed Charges,1034,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,744.48,72,,258.464,Percent of Total Billed Charges,72% of Total Billed Charges,620.4,60,,215.384,Percent of Total Billed Charges,60% of Total Billed Charges,930.6,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,465.3,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,930.6,90,,3233.944,Percent of Total Billed Charges,90% of Total billed Charges,1034,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1034,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1034,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.1,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,455.99,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,982.3,95,,3413.608,Percent of Total Billed Charges,95% of Total Billed Charges,1034,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,909.92,88,,3162.08,Percent of Total Billed Charges,88% of Total Billed Charges,930.6,90,,3233.944,Percent of Total Billed charges,90% of Total Billed Charges,455.99,1034,
MIC 3PRT GASTRO FT  28F 010028,2720000177,CDM,272,RC,,,Outpatient,,,43.29,28.14,,43.29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,32.9,76,,4497.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,31.17,72,,114.944,Percent of Total Billed Charges,72% of Total Billed Charges,32.47,75,,119.728,Percent of Total Billed charges,75% of Total Billed Charges,43.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.17,72,,114.944,Percent of Total Billed Charges,72% of Total Billed Charges,25.97,60,,95.784,Percent of Total Billed Charges,60% of Total Billed Charges,38.96,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,19.48,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,38.96,90,,5326.4,Percent of Total Billed Charges,90% of Total billed Charges,43.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.14,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,19.09,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.13,95,,5622.312,Percent of Total Billed Charges,95% of Total Billed Charges,43.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.1,88,,5208.04,Percent of Total Billed Charges,88% of Total Billed Charges,38.96,90,,5326.4,Percent of Total Billed charges,90% of Total Billed Charges,19.09,43.29,
MICRO NDLE 21G X 7 CM (G02304),2720000178,CDM,272,RC,,,Outpatient,,,7.20,4.68,,7.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.47,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.18,72,,180.352,Percent of Total Billed Charges,72% of Total Billed Charges,5.4,75,,187.864,Percent of Total Billed charges,75% of Total Billed Charges,7.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.18,72,,180.352,Percent of Total Billed Charges,72% of Total Billed Charges,4.32,60,,150.296,Percent of Total Billed Charges,60% of Total Billed Charges,6.48,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,3.24,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,6.48,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,7.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.68,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,3.18,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.84,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,7.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.34,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,6.48,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,3.18,7.2,
MICRO NDLE ET 21G X7 CM G08387,2720000179,CDM,272,RC,,,Outpatient,,,16.00,10.40,,16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.16,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.52,72,,180.352,Percent of Total Billed Charges,72% of Total Billed Charges,12,75,,187.864,Percent of Total Billed charges,75% of Total Billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.52,72,,180.352,Percent of Total Billed Charges,72% of Total Billed Charges,9.6,60,,150.296,Percent of Total Billed Charges,60% of Total Billed Charges,14.4,90,,473.76,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,45,,236.88,Percent of Total Billed Charges,45% of Total Billed Charges,14.4,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,7.06,44.1,,232.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.2,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.08,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,14.4,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,7.06,16,
MP DRAINAGE CATH 12F X 15CM ST,2720000180,CDM,278,RC,C1729,HCPCS,Outpatient,,,315.96,205.37,,315.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,240.13,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,227.49,72,,180.352,Percent of Total Billed Charges,72% of Total Billed Charges,227.49,72,,187.864,Percent of Total Billed charges,72% of Total Billed Charges,315.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.49,72,,180.352,Percent of Total Billed Charges,72% of Total Billed Charges,189.58,60,,150.296,Percent of Total Billed Charges,60% of Total Billed Charges,284.36,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,142.18,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,284.36,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,315.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.37,65,,342.16,Percent of total Billed Charges,65% of Total Billed Charges,139.34,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,300.16,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,315.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.04,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,284.36,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,139.34,315.96,
MPN .018 X 40CM ANGLED TIP WRE,2720000181,CDM,272,RC,C1769,HCPCS,Outpatient,,,53.55,34.81,,53.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.7,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.56,72,,793.8,Percent of Total Billed Charges,72% of Total Billed Charges,40.16,75,,826.88,Percent of Total Billed charges,75% of Total Billed Charges,53.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.56,72,,793.8,Percent of Total Billed Charges,72% of Total Billed Charges,32.13,60,,661.504,Percent of Total Billed Charges,60% of Total Billed Charges,48.2,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,24.1,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,48.2,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,53.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.81,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,23.62,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.87,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,53.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.12,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,48.2,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,23.62,53.55,
MPN .018 X 40CM STRGHT TIP WRE,2720000182,CDM,272,RC,C1769,HCPCS,Outpatient,,,53.55,34.81,,53.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.7,76,,400.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.56,72,,793.8,Percent of Total Billed Charges,72% of Total Billed Charges,40.16,75,,826.88,Percent of Total Billed charges,75% of Total Billed Charges,53.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.56,72,,793.8,Percent of Total Billed Charges,72% of Total Billed Charges,32.13,60,,661.504,Percent of Total Billed Charges,60% of Total Billed Charges,48.2,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,24.1,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,48.2,90,,473.76,Percent of Total Billed Charges,90% of Total billed Charges,53.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.81,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,23.62,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.87,95,,500.08,Percent of Total Billed Charges,95% of Total Billed Charges,53.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.12,88,,463.232,Percent of Total Billed Charges,88% of Total Billed Charges,48.2,90,,473.76,Percent of Total Billed charges,90% of Total Billed Charges,23.62,53.55,
MS 5F 130CM (20CM) INFUS CATH,2720000183,CDM,272,RC,C1751,HCPCS,Outpatient,,,252.00,163.80,,252,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,191.52,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,181.44,72,,196.864,Percent of Total Billed Charges,72% of Total Billed Charges,189,75,,205.072,Percent of Total Billed charges,75% of Total Billed Charges,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.44,72,,196.864,Percent of Total Billed Charges,72% of Total Billed Charges,151.2,60,,164.056,Percent of Total Billed Charges,60% of Total Billed Charges,226.8,90,,473.76,Percent of Total Billed Charges,90% of Total Billed Charges,113.4,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,226.8,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.8,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,111.13,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,239.4,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.76,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,226.8,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,111.13,252,
MS 5F 65CM 15CM INFUS CATH CK,2720000184,CDM,272,RC,C1751,HCPCS,Outpatient,,,252.00,163.80,,252,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,191.52,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,181.44,72,,101.944,Percent of Total Billed Charges,72% of Total Billed Charges,189,75,,106.192,Percent of Total Billed charges,75% of Total Billed Charges,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.44,72,,101.944,Percent of Total Billed Charges,72% of Total Billed Charges,151.2,60,,84.952,Percent of Total Billed Charges,60% of Total Billed Charges,226.8,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,113.4,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,226.8,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.8,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,111.13,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,239.4,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.76,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,226.8,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,111.13,252,
MST PACK/CHANG IOL CUTTING KIT,2720000185,CDM,272,RC,,,Outpatient,,,251.37,163.39,,251.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,191.04,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,180.99,72,,38.736,Percent of Total Billed Charges,72% of Total Billed Charges,188.53,75,,40.352,Percent of Total Billed charges,75% of Total Billed Charges,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.99,72,,38.736,Percent of Total Billed Charges,72% of Total Billed Charges,150.82,60,,32.28,Percent of Total Billed Charges,60% of Total Billed Charges,226.23,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,113.12,45,,236.88,Percent of Total Billed Charges,45% of Total Billed Charges,226.23,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.39,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,110.85,44.1,,232.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,238.8,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.21,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,226.23,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,110.85,251.37,
MULTI PURP 10.2F DRAINAGE ST,2720000186,CDM,272,RC,,,Outpatient,,,560.82,364.53,,560.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,426.22,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,403.79,72,,395.632,Percent of Total Billed Charges,72% of Total Billed Charges,420.62,75,,412.12,Percent of Total Billed charges,75% of Total Billed Charges,560.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,403.79,72,,395.632,Percent of Total Billed Charges,72% of Total Billed Charges,336.49,60,,329.696,Percent of Total Billed Charges,60% of Total Billed Charges,504.74,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,252.37,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,504.74,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,560.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,560.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,560.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.53,65,,342.16,Percent of total Billed Charges,65% of Total Billed Charges,247.32,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,532.78,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,560.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.52,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,504.74,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,247.32,560.82,
MULTI PURP 10.2F DRAINAGE ST,2720000187,CDM,272,RC,,,Outpatient,,,560.82,364.53,,560.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,426.22,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,403.79,72,,458.504,Percent of Total Billed Charges,72% of Total Billed Charges,420.62,75,,477.608,Percent of Total Billed charges,75% of Total Billed Charges,560.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,403.79,72,,458.504,Percent of Total Billed Charges,72% of Total Billed Charges,336.49,60,,382.088,Percent of Total Billed Charges,60% of Total Billed Charges,504.74,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,252.37,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,504.74,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,560.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,560.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,560.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.53,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,247.32,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,532.78,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,560.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.52,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,504.74,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,247.32,560.82,
MULTI PURP 8.5 FR DRAINAGE ST,2720000188,CDM,272,RC,,,Outpatient,,,672.25,436.96,,672.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,510.91,76,,400.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,484.02,72,,4731.048,Percent of Total Billed Charges,72% of Total Billed Charges,504.19,75,,4928.176,Percent of Total Billed charges,75% of Total Billed Charges,672.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484.02,72,,4731.048,Percent of Total Billed Charges,72% of Total Billed Charges,403.35,60,,3942.544,Percent of Total Billed Charges,60% of Total Billed Charges,605.03,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,302.51,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,605.03,90,,473.76,Percent of Total Billed Charges,90% of Total billed Charges,672.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,436.96,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,296.46,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,638.64,95,,500.08,Percent of Total Billed Charges,95% of Total Billed Charges,672.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,591.58,88,,463.232,Percent of Total Billed Charges,88% of Total Billed Charges,605.03,90,,473.76,Percent of Total Billed charges,90% of Total Billed Charges,296.46,672.25,
MULTI PURP 8.5F DRAINAGE ST,2720000189,CDM,272,RC,,,Outpatient,,,672.25,436.96,,672.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,510.91,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,484.02,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,504.19,75,,26.464,Percent of Total Billed charges,75% of Total Billed Charges,672.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484.02,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,403.35,60,,21.168,Percent of Total Billed Charges,60% of Total Billed Charges,605.03,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,302.51,45,,236.88,Percent of Total Billed Charges,45% of Total Billed Charges,605.03,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,672.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,436.96,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,296.46,44.1,,232.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,638.64,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,672.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,591.58,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,605.03,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,296.46,672.25,
MULTIPURP DRNGE CATH 14FX25CM,2720000190,CDM,272,RC,C1729,HCPCS,Outpatient,,,588.54,382.55,,588.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,447.29,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,423.75,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,441.41,75,,26.464,Percent of Total Billed charges,75% of Total Billed Charges,588.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,423.75,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,353.12,60,,21.168,Percent of Total Billed Charges,60% of Total Billed Charges,529.69,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,264.84,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,529.69,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,588.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,588.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,588.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.55,65,,342.16,Percent of total Billed Charges,65% of Total Billed Charges,259.55,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,559.11,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,588.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,517.92,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,529.69,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,259.55,588.54,
NC ELITE 4F 2X120X150 0.14 OTW,2720000191,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELITE 4F 2X210X150 0.14 OTW,2720000192,CDM,272,RC,C1725,HCPCS,Outpatient,,,658.00,427.70,,658,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,500.08,76,,400.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,473.76,72,,71.128,Percent of Total Billed Charges,72% of Total Billed Charges,493.5,75,,74.088,Percent of Total Billed charges,75% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.76,72,,71.128,Percent of Total Billed Charges,72% of Total Billed Charges,394.8,60,,59.272,Percent of Total Billed Charges,60% of Total Billed Charges,592.2,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,296.1,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,592.2,90,,473.76,Percent of Total Billed Charges,90% of Total billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.7,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,290.18,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,625.1,95,,500.08,Percent of Total Billed Charges,95% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.04,88,,463.232,Percent of Total Billed Charges,88% of Total Billed Charges,592.2,90,,473.76,Percent of Total Billed charges,90% of Total Billed Charges,290.18,658,
NC ELITE 4F 2X40X150 0.14 OTW,2720000193,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,473.76,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELITE 4F 3X120X150 0.14 OTW,2720000194,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,71.128,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,74.088,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,71.128,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,59.272,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELITE 4F 3X150X150 0.14 OTW,2720000195,CDM,272,RC,C1725,HCPCS,Outpatient,,,658.00,427.70,,658,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,500.08,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,473.76,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,493.5,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.76,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,394.8,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,592.2,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,296.1,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,592.2,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.7,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,290.18,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,625.1,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.04,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,592.2,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,290.18,658,
NC ELITE 4F 3X210X150 0.14 OTW,2720000196,CDM,272,RC,C1725,HCPCS,Outpatient,,,658.00,427.70,,658,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,500.08,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,473.76,72,,39.376,Percent of Total Billed Charges,72% of Total Billed Charges,493.5,75,,41.016,Percent of Total Billed charges,75% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.76,72,,39.376,Percent of Total Billed Charges,72% of Total Billed Charges,394.8,60,,32.816,Percent of Total Billed Charges,60% of Total Billed Charges,592.2,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,296.1,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,592.2,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.7,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,290.18,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,625.1,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.04,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,592.2,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,290.18,658,
NC ELITE 4F 3X40X150 0.14 OTW,2720000197,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELITE 4F 3X80X150 0.14 OTW,2720000198,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELITE 4F 4X150X150 0.14 OTW,2720000199,CDM,272,RC,C1725,HCPCS,Outpatient,,,658.00,427.70,,658,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,500.08,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,473.76,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,493.5,75,,73.432,Percent of Total Billed charges,75% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.76,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,394.8,60,,58.744,Percent of Total Billed Charges,60% of Total Billed Charges,592.2,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,296.1,45,,236.88,Percent of Total Billed Charges,45% of Total Billed Charges,592.2,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.7,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,290.18,44.1,,232.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,625.1,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.04,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,592.2,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,290.18,658,
NC ELITE 4F 4X80X150 0.14 OTW,2720000200,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,26.464,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,21.168,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,342.16,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELITE 5F 5X100X150 0.14 OTW,2720000201,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELITE 5F 5X120X150 0.14 OTW,2720000202,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,400.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,83.192,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,86.656,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,83.192,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,69.328,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,473.76,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,500.08,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,463.232,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,473.76,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELITE 5F 5X150X150 0.14 OTW,2720000203,CDM,272,RC,C1725,HCPCS,Outpatient,,,658.00,427.70,,658,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,500.08,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,473.76,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,493.5,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.76,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,394.8,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,592.2,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,296.1,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,592.2,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.7,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,290.18,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,625.1,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.04,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,592.2,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,290.18,658,
NC ELITE 5F 5X20X150 0.14 OTW,2720000204,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELITE 5F 5X40X150 0.14 OTW,2720000205,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELITE 5F 5X60X150 0.14 OTW,2720000206,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELITE 5F 5X80X150 0.14 OTW,2720000207,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,83.192,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,86.656,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,83.192,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,69.328,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELITE 5F 6X100X150 0.14 OTW,2720000208,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELITE 5F 6X120X150 0.14 OTW,2720000209,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,13.232,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,10.584,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELITE 5F 6X150X150 0.14 OTW,2720000210,CDM,272,RC,C1725,HCPCS,Outpatient,,,658.00,427.70,,658,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,500.08,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,473.76,72,,167.016,Percent of Total Billed Charges,72% of Total Billed Charges,493.5,75,,173.976,Percent of Total Billed charges,75% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.76,72,,167.016,Percent of Total Billed Charges,72% of Total Billed Charges,394.8,60,,139.184,Percent of Total Billed Charges,60% of Total Billed Charges,592.2,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,296.1,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,592.2,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.7,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,290.18,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,625.1,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.04,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,592.2,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,290.18,658,
NC ELITE 5F 6X20X150 0.14 OTW,2720000211,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,72.4,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,75.416,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,72.4,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,60.328,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELITE 5F 6X40X150 0.14 OTW,2720000212,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,40.008,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,41.68,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,40.008,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,33.344,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELITE 5F 6X60X150 0.14 OTW,2720000213,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELITE 5F 6X80X150 0.14 OTW,2720000214,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELITE 6F 6X200X150 0.14 OTW,2720000215,CDM,272,RC,C1725,HCPCS,Outpatient,,,658.00,427.70,,658,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,500.08,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,473.76,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,493.5,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.76,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,394.8,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,592.2,90,,1101.6,Percent of Total Billed Charges,90% of Total Billed Charges,296.1,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,592.2,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.7,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,290.18,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,625.1,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.04,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,592.2,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,290.18,658,
NC ELTE 4F 1.5X20X150 0.14 OTW,2720000216,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,24.472,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,19.576,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,1101.6,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELTE 4F 1.5X40X150 0.14 OTW,2720000217,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,24.472,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,19.576,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,1101.6,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELTE 4F 2.5X120X150 0.14OTW,2720000218,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,24.472,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,19.576,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,579.48,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELTE 4F 2.5X150X150 0.14OTW,2720000219,CDM,272,RC,C1725,HCPCS,Outpatient,,,658.00,427.70,,658,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,500.08,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,473.76,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,493.5,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.76,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,394.8,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,592.2,90,,710.456,Percent of Total Billed Charges,90% of Total Billed Charges,296.1,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,592.2,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.7,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,290.18,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,625.1,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.04,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,592.2,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,290.18,658,
NC ELTE 4F 2.5X210X150 0.14OTW,2720000220,CDM,272,RC,C1725,HCPCS,Outpatient,,,658.00,427.70,,658,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,500.08,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,473.76,72,,174,Percent of Total Billed Charges,72% of Total Billed Charges,493.5,75,,181.256,Percent of Total Billed charges,75% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.76,72,,174,Percent of Total Billed Charges,72% of Total Billed Charges,394.8,60,,145,Percent of Total Billed Charges,60% of Total Billed Charges,592.2,90,,450.88,Percent of Total Billed Charges,90% of Total Billed Charges,296.1,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,592.2,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.7,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,290.18,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,625.1,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.04,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,592.2,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,290.18,658,
NC ELTE 4F 2.5X40X150 0.14 OTW,2720000221,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,83.192,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,86.656,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,83.192,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,69.328,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,46.84,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,550.8,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,539.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELTE 4F 3.5X40X150 0.14 OTW,2720000222,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,46.968,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,119.072,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,550.8,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,795.6,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,539.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC QUANTUM 12X3.5 BALLOON CATH,2720000223,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,78.744,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,82.024,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,78.744,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,65.624,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,205.6,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,550.8,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,795.6,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,539.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 2 X 8 BALLOON CATH,2720000224,CDM,272,RC,C1725,HCPCS,Outpatient,,,1827.95,1188.17,,1827.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1389.24,76,,930.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1316.12,72,,74.936,Percent of Total Billed Charges,72% of Total Billed Charges,1370.96,75,,78.064,Percent of Total Billed charges,75% of Total Billed Charges,1827.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1316.12,72,,74.936,Percent of Total Billed Charges,72% of Total Billed Charges,1096.77,60,,62.448,Percent of Total Billed Charges,60% of Total Billed Charges,1645.16,90,,79.384,Percent of Total Billed Charges,90% of Total Billed Charges,822.58,45,,289.736,Percent of Total Billed Charges,45% of Total Billed Charges,1645.16,90,,1101.6,Percent of Total Billed Charges,90% of Total billed Charges,1827.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1827.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1827.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1188.17,65,,795.6,Percent of total Billed Charges,65% of Total Billed Charges,806.13,44.1,,283.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,1736.55,95,,1162.8,Percent of Total Billed Charges,95% of Total Billed Charges,1827.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.6,88,,1077.12,Percent of Total Billed Charges,88% of Total Billed Charges,1645.16,90,,1101.6,Percent of Total Billed charges,90% of Total Billed Charges,806.13,1827.95,
NC QUANTUM 2.25 X 12 BAL CATH,2720000225,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,930.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,1023.208,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,355.224,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,1101.6,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,418.512,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,348.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,1162.8,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,1077.12,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,1101.6,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 2.25 X 15 BAL CATH,2720000226,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,930.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,130.448,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,225.44,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,1101.6,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,513.104,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,220.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,1162.8,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,1077.12,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,1101.6,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 2.25 X 8 BAL CATH,2720000227,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,489.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,74.936,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,78.064,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,74.936,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,62.448,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,227.488,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,23.416,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,579.48,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,325.632,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,22.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,611.672,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,566.6,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,579.48,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 2.5X15 BALLOON CATH,2720000228,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,599.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,381.024,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,59.536,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,710.456,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,33.824,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,58.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,749.92,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,694.664,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,710.456,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 2.5X20 BALLOON CATH,2720000229,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,380.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,301.864,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,102.8,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,450.88,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,86,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,100.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,475.928,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,440.856,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,450.88,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 2.5X8 BALLOON CATH,2720000230,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,39.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,135.184,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,39.688,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,46.84,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,148.488,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,38.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,49.44,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,45.792,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,46.84,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 2.75X15 BAL CATH,2720000231,CDM,272,RC,C1725,HCPCS,Outpatient,,,1827.95,1188.17,,1827.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1389.24,76,,100.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1316.12,72,,361.336,Percent of Total Billed Charges,72% of Total Billed Charges,1370.96,75,,376.392,Percent of Total Billed charges,75% of Total Billed Charges,1827.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1316.12,72,,361.336,Percent of Total Billed Charges,72% of Total Billed Charges,1096.77,60,,301.112,Percent of Total Billed Charges,60% of Total Billed Charges,1645.16,90,,200.16,Percent of Total Billed Charges,90% of Total Billed Charges,822.58,45,,511.6,Percent of Total Billed Charges,45% of Total Billed Charges,1645.16,90,,119.072,Percent of Total Billed Charges,90% of Total billed Charges,1827.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1827.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1827.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1188.17,65,,57.328,Percent of total Billed Charges,65% of Total Billed Charges,806.13,44.1,,501.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,1736.55,95,,125.688,Percent of Total Billed Charges,95% of Total Billed Charges,1827.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.6,88,,116.424,Percent of Total Billed Charges,88% of Total Billed Charges,1645.16,90,,119.072,Percent of Total Billed charges,90% of Total Billed Charges,806.13,1827.95,
NC QUANTUM 2X12 BALLOON CATH,2720000232,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,173.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,361.336,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,376.392,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,361.336,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,301.112,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,404.84,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,65.224,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,205.6,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,738.984,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,63.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,217.016,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,201.024,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,205.6,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 3.5X15 BALLOON CATH,2720000233,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,67.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,361.336,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,376.392,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,361.336,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,301.112,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,763.56,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,113.744,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,79.384,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,94.216,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,111.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,83.792,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,77.616,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,79.384,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 3.5X20 BALLOON CATH,2720000234,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,864.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,361.336,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,376.392,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,361.336,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,301.112,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,608.28,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,190.512,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,1023.208,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,164.296,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,186.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,1080.048,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,1000.472,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,1023.208,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 3X12 BALLOON CATH,2720000235,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,110.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,480.72,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,500.752,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,480.72,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,400.6,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,180,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,150.928,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,130.448,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,275.184,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,147.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,137.696,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,127.552,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,130.448,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 3X15 BALLOON CATH,2720000236,CDM,272,RC,C1725,HCPCS,Outpatient,,,1827.95,1188.17,,1827.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1389.24,76,,192.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1316.12,72,,480.72,Percent of Total Billed Charges,72% of Total Billed Charges,1370.96,75,,500.752,Percent of Total Billed charges,75% of Total Billed Charges,1827.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1316.12,72,,480.72,Percent of Total Billed Charges,72% of Total Billed Charges,1096.77,60,,400.6,Percent of Total Billed Charges,60% of Total Billed Charges,1645.16,90,,763.56,Percent of Total Billed Charges,90% of Total Billed Charges,822.58,45,,67.592,Percent of Total Billed Charges,45% of Total Billed Charges,1645.16,90,,227.488,Percent of Total Billed Charges,90% of Total billed Charges,1827.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1827.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1827.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1188.17,65,,218.008,Percent of total Billed Charges,65% of Total Billed Charges,806.13,44.1,,66.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,1736.55,95,,240.128,Percent of Total Billed Charges,95% of Total Billed Charges,1827.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.6,88,,222.432,Percent of Total Billed Charges,88% of Total Billed Charges,1645.16,90,,227.488,Percent of Total Billed charges,90% of Total Billed Charges,806.13,1827.95,
NC QUANTUM 3X20 BALLOON CATH,2720000237,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,321.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,480.72,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,500.752,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,480.72,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,400.6,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,78.4,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,100.08,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,381.024,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,97.632,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,98.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,402.192,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,372.56,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,381.024,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 4.5X12 BALLOON CATH,2720000238,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,254.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,480.72,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,500.752,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,480.72,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,400.6,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,608.28,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,202.424,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,301.864,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,144.56,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,198.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,318.632,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,295.152,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,301.864,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 4X12 BALLOON CATH,2720000239,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,114.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,389.92,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,406.168,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,389.92,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,324.928,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,319.904,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,381.784,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,135.184,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,292.384,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,374.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,142.696,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,132.184,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,135.184,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 4X15 BALLOON CATH,2720000240,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,169.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,389.92,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,406.168,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,389.92,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,324.928,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,199.248,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,304.136,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,200.16,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,551.464,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,298.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,211.28,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,195.712,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,200.16,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 4X20 BALLOON CATH,2720000241,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,341.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,389.92,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,406.168,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,389.92,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,324.928,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,115.096,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,90,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,404.84,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,439.312,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,88.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,427.336,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,395.848,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,404.84,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 4X8 BALLOON CATH,2720000242,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,644.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,389.92,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,406.168,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,389.92,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,324.928,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,74.624,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,381.784,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,763.56,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,130,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,374.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,805.984,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,746.592,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,763.56,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 5X12 BALLOON CATH,2720000243,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,513.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,707.44,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,736.912,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,707.44,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,589.528,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,74.624,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,39.2,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,608.28,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,551.464,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,38.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,642.072,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,594.76,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,608.28,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 5X15 BALLOON CATH,2720000244,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,222.904,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,232.192,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,222.904,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,185.752,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,28.576,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,304.136,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,180,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,56.624,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,298.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,190,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,176,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,180,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 8 X 3 BALLOON CATH,2720000245,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,644.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,262.912,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,273.864,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,262.912,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,219.088,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,28.576,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,159.952,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,763.56,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,439.312,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,156.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,805.984,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,746.592,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,763.56,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 8 X 3.5 BAL CATH,2720000246,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,66.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,201.304,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,209.696,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,201.304,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,167.752,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,12.704,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,99.624,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,78.4,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,231.04,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,97.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,82.76,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,76.656,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,78.4,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 8X2.75 BALLOON CATH,2720000247,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,513.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,149.232,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,155.456,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,149.232,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,124.36,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,12.704,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,57.552,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,608.28,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,143.896,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,56.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,642.072,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,594.76,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,608.28,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 8X4.5 BALLOON CATH,2720000248,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,270.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,733.472,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,764.032,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,733.472,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,611.224,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,37.312,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,319.904,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,83.128,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,36.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,337.672,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,312.792,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,319.904,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM 8X5 BALLOON CATH,2720000249,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,168.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,117.752,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,37.312,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,199.248,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,53.896,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,36.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,210.312,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,194.816,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,199.248,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM AMR 2.25 X 20 BAL,2720000250,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,97.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,33.08,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,50.8,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,14.288,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,115.096,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,53.896,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,14,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,121.496,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,112.544,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,115.096,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUATUM 4.5X15 BALLOON CATH,2720000251,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,63.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,43,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,34.4,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,14.288,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,74.624,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,20.64,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,14,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,78.768,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,72.96,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,74.624,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NSTER EMBOIL/COIL 181410 .018,2720000252,CDM,278,RC,C1889,HCPCS,Outpatient,,,372.10,241.87,,372.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,282.8,76,,63.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,267.91,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,267.91,72,,42.336,Percent of Total Billed charges,72% of Total Billed Charges,372.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.91,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,223.26,60,,33.872,Percent of Total Billed Charges,60% of Total Billed Charges,334.89,90,,79.384,Percent of Total Billed Charges,90% of Total Billed Charges,167.45,45,,6.352,Percent of Total Billed Charges,45% of Total Billed Charges,334.89,90,,74.624,Percent of Total Billed Charges,90% of Total billed Charges,372.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,372.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,372.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.87,65,,20.64,Percent of total Billed Charges,65% of Total Billed Charges,164.1,44.1,,6.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,353.5,95,,78.768,Percent of Total Billed Charges,95% of Total Billed Charges,372.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.45,88,,72.96,Percent of Total Billed Charges,88% of Total Billed Charges,334.89,90,,74.624,Percent of Total Billed charges,90% of Total Billed Charges,164.1,372.1,
WA22702S Plasmaloop 24 FR Med,2720000253,CDM,272,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,24.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,42.336,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,33.872,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,184.16,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,6.352,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,28.576,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,9.176,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,6.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,30.168,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,27.944,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,28.576,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
ONMED VCARE UTERMANIPU SM 32MM,2720000254,CDM,272,RC,,,Outpatient,,,90.00,58.50,,90,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.4,76,,24.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.8,72,,175.272,Percent of Total Billed Charges,72% of Total Billed Charges,67.5,75,,182.576,Percent of Total Billed charges,75% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.8,72,,175.272,Percent of Total Billed Charges,72% of Total Billed Charges,54,60,,146.056,Percent of Total Billed Charges,60% of Total Billed Charges,81,90,,79.384,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,81,90,,28.576,Percent of Total Billed Charges,90% of Total billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.5,65,,9.176,Percent of total Billed Charges,65% of Total Billed Charges,39.69,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.5,95,,30.168,Percent of Total Billed Charges,95% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,88,,27.944,Percent of Total Billed Charges,88% of Total Billed Charges,81,90,,28.576,Percent of Total Billed charges,90% of Total Billed Charges,39.69,90,
PALINDRO PREC HSI 19CMX36 SPRT,2720000255,CDM,278,RC,C1750,HCPCS,Outpatient,,,2010.96,1307.12,,2010.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1528.33,76,,10.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1447.89,72,,175.272,Percent of Total Billed Charges,72% of Total Billed Charges,1447.89,72,,182.576,Percent of Total Billed charges,72% of Total Billed Charges,2010.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1447.89,72,,175.272,Percent of Total Billed Charges,72% of Total Billed Charges,1206.58,60,,146.056,Percent of Total Billed Charges,60% of Total Billed Charges,1809.86,90,,142.096,Percent of Total Billed Charges,90% of Total Billed Charges,904.93,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,1809.86,90,,12.704,Percent of Total Billed Charges,90% of Total billed Charges,2010.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2010.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2010.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1307.12,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,886.83,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1910.41,95,,13.408,Percent of Total Billed Charges,95% of Total Billed Charges,2010.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1769.64,88,,12.416,Percent of Total Billed Charges,88% of Total Billed Charges,1809.86,90,,12.704,Percent of Total Billed charges,90% of Total Billed Charges,886.83,2010.96,
PALINDRO PREC HSI 23CMX40 SPRT,2720000256,CDM,278,RC,C1750,HCPCS,Outpatient,,,2010.96,1307.12,,2010.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1528.33,76,,10.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1447.89,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,1447.89,72,,43,Percent of Total Billed charges,72% of Total Billed Charges,2010.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1447.89,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,1206.58,60,,34.4,Percent of Total Billed Charges,60% of Total Billed Charges,1809.86,90,,82.152,Percent of Total Billed Charges,90% of Total Billed Charges,904.93,45,,25.4,Percent of Total Billed Charges,45% of Total Billed Charges,1809.86,90,,12.704,Percent of Total Billed Charges,90% of Total billed Charges,2010.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2010.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2010.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1307.12,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,886.83,44.1,,24.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,1910.41,95,,13.408,Percent of Total Billed Charges,95% of Total Billed Charges,2010.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1769.64,88,,12.416,Percent of Total Billed Charges,88% of Total Billed Charges,1809.86,90,,12.704,Percent of Total Billed charges,90% of Total Billed Charges,886.83,2010.96,
PALINDROME PREC HSI 19CM X 36,2720000257,CDM,278,RC,C1750,HCPCS,Outpatient,,,2138.85,1390.25,,2138.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1625.53,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1539.97,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,1539.97,72,,42.336,Percent of Total Billed charges,72% of Total Billed Charges,2138.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1539.97,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,1283.31,60,,33.872,Percent of Total Billed Charges,60% of Total Billed Charges,1924.97,90,,82.152,Percent of Total Billed Charges,90% of Total Billed Charges,962.48,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,1924.97,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,2138.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2138.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2138.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1390.25,65,,36.688,Percent of total Billed Charges,65% of Total Billed Charges,943.23,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,2031.91,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,2138.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1882.19,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,1924.97,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,943.23,2138.85,
PALINDROME PREC HSI 23CM X 40,2720000258,CDM,278,RC,C1750,HCPCS,Outpatient,,,2138.85,1390.25,,2138.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1625.53,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1539.97,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,1539.97,72,,42.336,Percent of Total Billed charges,72% of Total Billed Charges,2138.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1539.97,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,1283.31,60,,33.872,Percent of Total Billed Charges,60% of Total Billed Charges,1924.97,90,,42.64,Percent of Total Billed Charges,90% of Total Billed Charges,962.48,45,,39.688,Percent of Total Billed Charges,45% of Total Billed Charges,1924.97,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,2138.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2138.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2138.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1390.25,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,943.23,44.1,,38.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,2031.91,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,2138.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1882.19,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,1924.97,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,943.23,2138.85,
PEG 20 BRTTRI REP GT TBE 1687,2720000259,CDM,278,RC,,,Outpatient,,,227.20,147.68,,227.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,172.67,76,,42.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,163.58,72,,98.432,Percent of Total Billed Charges,72% of Total Billed Charges,163.58,72,,102.536,Percent of Total Billed charges,72% of Total Billed Charges,227.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.58,72,,98.432,Percent of Total Billed Charges,72% of Total Billed Charges,136.32,60,,82.024,Percent of Total Billed Charges,60% of Total Billed Charges,204.48,90,,13.232,Percent of Total Billed Charges,90% of Total Billed Charges,102.24,45,,92.08,Percent of Total Billed Charges,45% of Total Billed Charges,204.48,90,,50.8,Percent of Total Billed Charges,90% of Total billed Charges,227.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.68,65,,57.328,Percent of total Billed Charges,65% of Total Billed Charges,100.2,44.1,,90.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,215.84,95,,53.624,Percent of Total Billed Charges,95% of Total Billed Charges,227.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.94,88,,49.672,Percent of Total Billed Charges,88% of Total Billed Charges,204.48,90,,50.8,Percent of Total Billed charges,90% of Total Billed Charges,100.2,227.2,
PICC &CVC DRESNG CHNGE (10130),2720000260,CDM,272,RC,,,Outpatient,,,47.47,30.86,,47.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.08,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.18,72,,98.432,Percent of Total Billed Charges,72% of Total Billed Charges,35.6,75,,102.536,Percent of Total Billed charges,75% of Total Billed Charges,47.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,72,,98.432,Percent of Total Billed Charges,72% of Total Billed Charges,28.48,60,,82.024,Percent of Total Billed Charges,60% of Total Billed Charges,42.72,90,,13.232,Percent of Total Billed Charges,90% of Total Billed Charges,21.36,45,,39.688,Percent of Total Billed Charges,45% of Total Billed Charges,42.72,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,47.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.86,65,,133.008,Percent of total Billed Charges,65% of Total Billed Charges,20.93,44.1,,38.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.1,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,47.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.77,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,42.72,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,20.93,47.47,
PNEUMOTHORAX KIT  MULTIPURPOSE,2720000261,CDM,272,RC,,,Outpatient,,,283.34,184.17,,283.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,215.34,76,,67.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,204,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,212.51,75,,91.288,Percent of Total Billed charges,75% of Total Billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,170,60,,73.032,Percent of Total Billed Charges,60% of Total Billed Charges,255.01,90,,91.44,Percent of Total Billed Charges,90% of Total Billed Charges,127.5,45,,71.048,Percent of Total Billed Charges,45% of Total Billed Charges,255.01,90,,79.384,Percent of Total Billed Charges,90% of Total billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.17,65,,57.328,Percent of total Billed Charges,65% of Total Billed Charges,124.95,44.1,,69.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,269.17,95,,83.792,Percent of Total Billed Charges,95% of Total Billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.34,88,,77.616,Percent of Total Billed Charges,88% of Total Billed Charges,255.01,90,,79.384,Percent of Total Billed charges,90% of Total Billed Charges,124.95,283.34,
POWERLINE 5F DUAL MICROINTROD,2720000262,CDM,272,RC,C1751,HCPCS,Outpatient,,,562.28,365.48,,562.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,427.33,76,,155.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,404.84,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,421.71,75,,91.288,Percent of Total Billed charges,75% of Total Billed Charges,562.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404.84,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,337.37,60,,73.032,Percent of Total Billed Charges,60% of Total Billed Charges,506.05,90,,91.44,Percent of Total Billed Charges,90% of Total Billed Charges,253.03,45,,41.08,Percent of Total Billed Charges,45% of Total Billed Charges,506.05,90,,184.16,Percent of Total Billed Charges,90% of Total billed Charges,562.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365.48,65,,102.624,Percent of total Billed Charges,65% of Total Billed Charges,247.97,44.1,,40.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,534.17,95,,194.392,Percent of Total Billed Charges,95% of Total Billed Charges,562.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,494.81,88,,180.072,Percent of Total Billed Charges,88% of Total Billed Charges,506.05,90,,184.16,Percent of Total Billed charges,90% of Total Billed Charges,247.97,562.28,
POWERLINE 6F DUAL MICROINTROD,2720000263,CDM,272,RC,C1751,HCPCS,Outpatient,,,562.28,365.48,,562.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,427.33,76,,67.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,404.84,72,,18.088,Percent of Total Billed Charges,72% of Total Billed Charges,421.71,75,,18.84,Percent of Total Billed charges,75% of Total Billed Charges,562.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404.84,72,,18.088,Percent of Total Billed Charges,72% of Total Billed Charges,337.37,60,,15.072,Percent of Total Billed Charges,60% of Total Billed Charges,506.05,90,,172.256,Percent of Total Billed Charges,90% of Total Billed Charges,253.03,45,,41.08,Percent of Total Billed Charges,45% of Total Billed Charges,506.05,90,,79.384,Percent of Total Billed Charges,90% of Total billed Charges,562.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365.48,65,,59.336,Percent of total Billed Charges,65% of Total Billed Charges,247.97,44.1,,40.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,534.17,95,,83.792,Percent of Total Billed Charges,95% of Total Billed Charges,562.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,494.81,88,,77.616,Percent of Total Billed Charges,88% of Total Billed Charges,506.05,90,,79.384,Percent of Total Billed charges,90% of Total Billed Charges,247.97,562.28,
POWERWAND ED SNG 3FX6CM 92019,2720000264,CDM,278,RC,C1751,HCPCS,Outpatient,,,180.00,117.00,,180,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,136.8,76,,119.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,129.6,72,,18.088,Percent of Total Billed Charges,72% of Total Billed Charges,129.6,72,,18.84,Percent of Total Billed charges,72% of Total Billed Charges,180,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.6,72,,18.088,Percent of Total Billed Charges,72% of Total Billed Charges,108,60,,15.072,Percent of Total Billed Charges,60% of Total Billed Charges,162,90,,65.096,Percent of Total Billed Charges,90% of Total Billed Charges,81,45,,21.32,Percent of Total Billed Charges,45% of Total Billed Charges,162,90,,142.096,Percent of Total Billed Charges,90% of Total billed Charges,180,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117,65,,59.336,Percent of total Billed Charges,65% of Total Billed Charges,79.38,44.1,,20.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,171,95,,149.984,Percent of Total Billed Charges,95% of Total Billed Charges,180,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.4,88,,138.936,Percent of Total Billed Charges,88% of Total Billed Charges,162,90,,142.096,Percent of Total Billed charges,90% of Total Billed Charges,79.38,180,
POWERWAND XL KIT 4FX8CM 94104,2720000265,CDM,272,RC,C1751,HCPCS,Outpatient,,,250.00,162.50,,250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,190,76,,69.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,180,72,,60.424,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,75,,62.944,Percent of Total Billed charges,75% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180,72,,60.424,Percent of Total Billed Charges,72% of Total Billed Charges,150,60,,50.352,Percent of Total Billed Charges,60% of Total Billed Charges,225,90,,146.848,Percent of Total Billed Charges,90% of Total Billed Charges,112.5,45,,6.616,Percent of Total Billed Charges,45% of Total Billed Charges,225,90,,82.152,Percent of Total Billed Charges,90% of Total billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.5,65,,30.792,Percent of total Billed Charges,65% of Total Billed Charges,110.25,44.1,,6.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,237.5,95,,86.72,Percent of Total Billed Charges,95% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220,88,,80.328,Percent of Total Billed Charges,88% of Total Billed Charges,225,90,,82.152,Percent of Total Billed charges,90% of Total Billed Charges,110.25,250,
PROGREAT 2.8 FX130CM CATH,2720000266,CDM,272,RC,C1887,HCPCS,Outpatient,,,1703.36,1107.18,,1703.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1294.55,76,,69.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1226.42,72,,60.424,Percent of Total Billed Charges,72% of Total Billed Charges,1277.52,75,,62.944,Percent of Total Billed charges,75% of Total Billed Charges,1703.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1226.42,72,,60.424,Percent of Total Billed Charges,72% of Total Billed Charges,1022.02,60,,50.352,Percent of Total Billed Charges,60% of Total Billed Charges,1533.02,90,,50.008,Percent of Total Billed Charges,90% of Total Billed Charges,766.51,45,,6.616,Percent of Total Billed Charges,45% of Total Billed Charges,1533.02,90,,82.152,Percent of Total Billed Charges,90% of Total billed Charges,1703.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1703.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1703.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1107.18,65,,9.56,Percent of total Billed Charges,65% of Total Billed Charges,751.18,44.1,,6.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,1618.19,95,,86.72,Percent of Total Billed Charges,95% of Total Billed Charges,1703.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1498.96,88,,80.328,Percent of Total Billed Charges,88% of Total Billed Charges,1533.02,90,,82.152,Percent of Total Billed charges,90% of Total Billed Charges,751.18,1703.36,
PWERHND XL SING 4F X 8CM 94102,2720000267,CDM,272,RC,C1751,HCPCS,Outpatient,,,278.00,180.70,,278,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,211.28,76,,36.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,200.16,72,,60.424,Percent of Total Billed Charges,72% of Total Billed Charges,208.5,75,,62.944,Percent of Total Billed charges,75% of Total Billed Charges,278,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.16,72,,60.424,Percent of Total Billed Charges,72% of Total Billed Charges,166.8,60,,50.352,Percent of Total Billed Charges,60% of Total Billed Charges,250.2,90,,365.944,Percent of Total Billed Charges,90% of Total Billed Charges,125.1,45,,45.72,Percent of Total Billed Charges,45% of Total Billed Charges,250.2,90,,42.64,Percent of Total Billed Charges,90% of Total billed Charges,278,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.7,65,,9.56,Percent of total Billed Charges,65% of Total Billed Charges,122.6,44.1,,44.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,264.1,95,,45.008,Percent of Total Billed Charges,95% of Total Billed Charges,278,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.64,88,,41.688,Percent of Total Billed Charges,88% of Total Billed Charges,250.2,90,,42.64,Percent of Total Billed charges,90% of Total Billed Charges,122.6,278,
PWRHAND XL KIT 5F X 10CM 94115,2720000268,CDM,278,RC,C1751,HCPCS,Outpatient,,,250.00,162.50,,250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,190,76,,11.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,180,72,,60.424,Percent of Total Billed Charges,72% of Total Billed Charges,180,72,,62.944,Percent of Total Billed charges,72% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180,72,,60.424,Percent of Total Billed Charges,72% of Total Billed Charges,150,60,,50.352,Percent of Total Billed Charges,60% of Total Billed Charges,225,90,,77.8,Percent of Total Billed Charges,90% of Total Billed Charges,112.5,45,,45.72,Percent of Total Billed Charges,45% of Total Billed Charges,225,90,,13.232,Percent of Total Billed Charges,90% of Total billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.5,65,,66.04,Percent of total Billed Charges,65% of Total Billed Charges,110.25,44.1,,44.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,237.5,95,,13.968,Percent of Total Billed Charges,95% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220,88,,12.936,Percent of Total Billed Charges,88% of Total Billed Charges,225,90,,13.232,Percent of Total Billed charges,90% of Total Billed Charges,110.25,250,
RDRUN STAND 0.035X180CM ANGLE,2720000269,CDM,272,RC,C1769,HCPCS,Outpatient,,,154.35,100.33,,154.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,117.31,76,,11.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.13,72,,812.448,Percent of Total Billed Charges,72% of Total Billed Charges,115.76,75,,846.304,Percent of Total Billed charges,75% of Total Billed Charges,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.13,72,,812.448,Percent of Total Billed Charges,72% of Total Billed Charges,92.61,60,,677.04,Percent of Total Billed Charges,60% of Total Billed Charges,138.92,90,,92.08,Percent of Total Billed Charges,90% of Total Billed Charges,69.46,45,,86.128,Percent of Total Billed Charges,45% of Total Billed Charges,138.92,90,,13.232,Percent of Total Billed Charges,90% of Total billed Charges,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.33,65,,66.04,Percent of total Billed Charges,65% of Total Billed Charges,68.07,44.1,,84.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,146.63,95,,13.968,Percent of Total Billed Charges,95% of Total Billed Charges,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.83,88,,12.936,Percent of Total Billed Charges,88% of Total Billed Charges,138.92,90,,13.232,Percent of Total Billed charges,90% of Total Billed Charges,68.07,154.35,
RDRUN STAND 0.035X260CM ANGLE,2720000270,CDM,272,RC,C1769,HCPCS,Outpatient,,,154.35,100.33,,154.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,117.31,76,,77.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.13,72,,173.952,Percent of Total Billed Charges,72% of Total Billed Charges,115.76,75,,181.2,Percent of Total Billed charges,75% of Total Billed Charges,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.13,72,,173.952,Percent of Total Billed Charges,72% of Total Billed Charges,92.61,60,,144.96,Percent of Total Billed Charges,60% of Total Billed Charges,138.92,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,69.46,45,,32.544,Percent of Total Billed Charges,45% of Total Billed Charges,138.92,90,,91.44,Percent of Total Billed Charges,90% of Total billed Charges,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.33,65,,124.408,Percent of total Billed Charges,65% of Total Billed Charges,68.07,44.1,,31.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,146.63,95,,96.52,Percent of Total Billed Charges,95% of Total Billed Charges,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.83,88,,89.408,Percent of Total Billed Charges,88% of Total Billed Charges,138.92,90,,91.44,Percent of Total Billed charges,90% of Total Billed Charges,68.07,154.35,
RDRUN STIF 0.035X180CM ANG UNI,2720000271,CDM,272,RC,C1769,HCPCS,Outpatient,,,189.63,123.26,,189.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.12,76,,77.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,136.53,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,142.22,75,,57.6,Percent of Total Billed charges,75% of Total Billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.53,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,113.78,60,,46.08,Percent of Total Billed Charges,60% of Total Billed Charges,170.67,90,,12.704,Percent of Total Billed Charges,90% of Total Billed Charges,85.33,45,,73.424,Percent of Total Billed Charges,45% of Total Billed Charges,170.67,90,,91.44,Percent of Total Billed Charges,90% of Total billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.26,65,,47.016,Percent of total Billed Charges,65% of Total Billed Charges,83.63,44.1,,71.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,180.15,95,,96.52,Percent of Total Billed Charges,95% of Total Billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.87,88,,89.408,Percent of Total Billed Charges,88% of Total Billed Charges,170.67,90,,91.44,Percent of Total Billed charges,90% of Total Billed Charges,83.63,189.63,
RUBIC.035 X 90 CM CROSING CATH,2720000272,CDM,272,RC,C1887,HCPCS,Outpatient,,,332.96,216.42,,332.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,253.05,76,,145.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,239.73,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,249.72,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.73,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,199.78,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,299.66,90,,54.768,Percent of Total Billed Charges,90% of Total Billed Charges,149.83,45,,25.008,Percent of Total Billed Charges,45% of Total Billed Charges,299.66,90,,172.256,Percent of Total Billed Charges,90% of Total billed Charges,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.42,65,,106.056,Percent of total Billed Charges,65% of Total Billed Charges,146.84,44.1,,24.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,316.31,95,,181.824,Percent of Total Billed Charges,95% of Total Billed Charges,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293,88,,168.424,Percent of Total Billed Charges,88% of Total Billed Charges,299.66,90,,172.256,Percent of Total Billed charges,90% of Total Billed Charges,146.84,332.96,
RUBICON 018X135CM SUPPORT CAT,2720000273,CDM,272,RC,C1887,HCPCS,Outpatient,,,302.00,196.30,,302,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,229.52,76,,54.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,217.44,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,226.5,75,,57.6,Percent of Total Billed charges,75% of Total Billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.44,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,181.2,60,,46.08,Percent of Total Billed Charges,60% of Total Billed Charges,271.8,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,135.9,45,,182.968,Percent of Total Billed Charges,45% of Total Billed Charges,271.8,90,,65.096,Percent of Total Billed Charges,90% of Total billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.3,65,,36.12,Percent of total Billed Charges,65% of Total Billed Charges,133.18,44.1,,179.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,286.9,95,,68.712,Percent of Total Billed Charges,95% of Total Billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.76,88,,63.648,Percent of Total Billed Charges,88% of Total Billed Charges,271.8,90,,65.096,Percent of Total Billed charges,90% of Total Billed Charges,133.18,302,
RUNWAY 6F MP1 SH GUIDE CATH,2720000274,CDM,272,RC,C1887,HCPCS,Outpatient,,,147.00,95.55,,147,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,111.72,76,,124.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,105.84,72,,127.008,Percent of Total Billed Charges,72% of Total Billed Charges,110.25,75,,132.304,Percent of Total Billed charges,75% of Total Billed Charges,147,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.84,72,,127.008,Percent of Total Billed Charges,72% of Total Billed Charges,88.2,60,,105.84,Percent of Total Billed Charges,60% of Total Billed Charges,132.3,90,,96.848,Percent of Total Billed Charges,90% of Total Billed Charges,66.15,45,,38.896,Percent of Total Billed Charges,45% of Total Billed Charges,132.3,90,,146.848,Percent of Total Billed Charges,90% of Total billed Charges,147,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.55,65,,264.288,Percent of total Billed Charges,65% of Total Billed Charges,64.83,44.1,,38.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,139.65,95,,155.008,Percent of Total Billed Charges,95% of Total Billed Charges,147,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.36,88,,143.584,Percent of Total Billed Charges,88% of Total Billed Charges,132.3,90,,146.848,Percent of Total Billed charges,90% of Total Billed Charges,64.83,147,
STKR 3.0MM ASNIS MICRO SCW 16/,2720000275,CDM,272,RC,,,Outpatient,,,760.00,494.00,,760,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,577.6,76,,42.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,547.2,72,,362.608,Percent of Total Billed Charges,72% of Total Billed Charges,570,75,,377.72,Percent of Total Billed charges,75% of Total Billed Charges,760,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.2,72,,362.608,Percent of Total Billed Charges,72% of Total Billed Charges,456,60,,302.176,Percent of Total Billed Charges,60% of Total Billed Charges,684,90,,64.296,Percent of Total Billed Charges,90% of Total Billed Charges,342,45,,46.04,Percent of Total Billed Charges,45% of Total Billed Charges,684,90,,50.008,Percent of Total Billed Charges,90% of Total billed Charges,760,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,760,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,760,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,494,65,,56.184,Percent of total Billed Charges,65% of Total Billed Charges,335.16,44.1,,45.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,722,95,,52.792,Percent of Total Billed Charges,95% of Total Billed Charges,760,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,668.8,88,,48.896,Percent of Total Billed Charges,88% of Total Billed Charges,684,90,,50.008,Percent of Total Billed charges,90% of Total Billed Charges,335.16,760,
STRKER CAN 2.7MM TW DRIL W/AO,2720000276,CDM,272,RC,,,Outpatient,,,384.00,249.60,,384,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,291.84,76,,309.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,276.48,72,,19.688,Percent of Total Billed Charges,72% of Total Billed Charges,288,75,,20.512,Percent of Total Billed charges,75% of Total Billed Charges,384,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.48,72,,19.688,Percent of Total Billed Charges,72% of Total Billed Charges,230.4,60,,16.408,Percent of Total Billed Charges,60% of Total Billed Charges,345.6,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,172.8,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,345.6,90,,365.944,Percent of Total Billed Charges,90% of Total billed Charges,384,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.6,65,,66.504,Percent of total Billed Charges,65% of Total Billed Charges,169.34,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,364.8,95,,386.272,Percent of Total Billed Charges,95% of Total Billed Charges,384,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.92,88,,357.808,Percent of Total Billed Charges,88% of Total Billed Charges,345.6,90,,365.944,Percent of Total Billed charges,90% of Total Billed Charges,169.34,384,
STRKER DRIL BIT 03.6MMX122MM,2720000277,CDM,272,RC,,,Outpatient,,,158.00,102.70,,158,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.08,76,,65.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,113.76,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,118.5,75,,44.984,Percent of Total Billed charges,75% of Total Billed Charges,158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.76,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,94.8,60,,35.984,Percent of Total Billed Charges,60% of Total Billed Charges,142.2,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,71.1,45,,6.352,Percent of Total Billed Charges,45% of Total Billed Charges,142.2,90,,77.8,Percent of Total Billed Charges,90% of Total billed Charges,158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.7,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,69.68,44.1,,6.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,150.1,95,,82.12,Percent of Total Billed Charges,95% of Total Billed Charges,158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.04,88,,76.064,Percent of Total Billed Charges,88% of Total Billed Charges,142.2,90,,77.8,Percent of Total Billed charges,90% of Total Billed Charges,69.68,158,
STRKR DRIL 2.6MMX122MM WL70MM,2720000278,CDM,272,RC,,,Outpatient,,,175.00,113.75,,175,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,133,76,,77.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,126,72,,63.504,Percent of Total Billed Charges,72% of Total Billed Charges,131.25,75,,66.152,Percent of Total Billed charges,75% of Total Billed Charges,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126,72,,63.504,Percent of Total Billed Charges,72% of Total Billed Charges,105,60,,52.92,Percent of Total Billed Charges,60% of Total Billed Charges,157.5,90,,306.408,Percent of Total Billed Charges,90% of Total Billed Charges,78.75,45,,27.384,Percent of Total Billed Charges,45% of Total Billed Charges,157.5,90,,92.08,Percent of Total Billed Charges,90% of Total billed Charges,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.75,65,,9.176,Percent of total Billed Charges,65% of Total Billed Charges,77.18,44.1,,26.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,166.25,95,,97.2,Percent of Total Billed Charges,95% of Total Billed Charges,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154,88,,90.032,Percent of Total Billed Charges,88% of Total Billed Charges,157.5,90,,92.08,Percent of Total Billed charges,90% of Total Billed Charges,77.18,175,
STRYKER 3.0MM ST PCKD INSTR KT,2720000279,CDM,272,RC,,,Outpatient,,,737.00,479.05,,737,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.12,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,530.64,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,552.75,75,,14.56,Percent of Total Billed charges,75% of Total Billed Charges,737,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.64,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,442.2,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,663.3,90,,310.376,Percent of Total Billed Charges,90% of Total Billed Charges,331.65,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,663.3,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,737,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.05,65,,39.56,Percent of total Billed Charges,65% of Total Billed Charges,325.02,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.15,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,737,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,648.56,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,663.3,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,325.02,737,
STRYKER CNTERSINK SCW 2.7/3.5,2720000280,CDM,272,RC,,,Outpatient,,,175.00,113.75,,175,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,133,76,,10.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,126,72,,63.504,Percent of Total Billed Charges,72% of Total Billed Charges,131.25,75,,66.152,Percent of Total Billed charges,75% of Total Billed Charges,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126,72,,63.504,Percent of Total Billed Charges,72% of Total Billed Charges,105,60,,52.92,Percent of Total Billed Charges,60% of Total Billed Charges,157.5,90,,350.064,Percent of Total Billed Charges,90% of Total Billed Charges,78.75,45,,48.424,Percent of Total Billed Charges,45% of Total Billed Charges,157.5,90,,12.704,Percent of Total Billed Charges,90% of Total billed Charges,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.75,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,77.18,44.1,,47.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,166.25,95,,13.408,Percent of Total Billed Charges,95% of Total Billed Charges,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154,88,,12.416,Percent of Total Billed Charges,88% of Total Billed Charges,157.5,90,,12.704,Percent of Total Billed charges,90% of Total Billed Charges,77.18,175,
STRYKR CAN 4.0MM TWST DRL W/A0,2720000281,CDM,272,RC,,,Outpatient,,,398.00,258.70,,398,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,302.48,76,,46.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,286.56,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,298.5,75,,21.168,Percent of Total Billed charges,75% of Total Billed Charges,398,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.56,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,238.8,60,,16.936,Percent of Total Billed Charges,60% of Total Billed Charges,358.2,90,,88.904,Percent of Total Billed Charges,90% of Total Billed Charges,179.1,45,,32.152,Percent of Total Billed Charges,45% of Total Billed Charges,358.2,90,,54.768,Percent of Total Billed Charges,90% of Total billed Charges,398,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258.7,65,,69.944,Percent of total Billed Charges,65% of Total Billed Charges,175.52,44.1,,31.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,378.1,95,,57.816,Percent of Total Billed Charges,95% of Total Billed Charges,398,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.24,88,,53.552,Percent of Total Billed Charges,88% of Total Billed Charges,358.2,90,,54.768,Percent of Total Billed charges,90% of Total Billed Charges,175.52,398,
STRYKR CNTRSNK FR SCWS 2.7/3.5,2720000282,CDM,272,RC,,,Outpatient,,,175.00,113.75,,175,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,133,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,126,72,,2299.48,Percent of Total Billed Charges,72% of Total Billed Charges,131.25,75,,2395.288,Percent of Total Billed charges,75% of Total Billed Charges,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126,72,,2299.48,Percent of Total Billed Charges,72% of Total Billed Charges,105,60,,1916.232,Percent of Total Billed Charges,60% of Total Billed Charges,157.5,90,,323.08,Percent of Total Billed Charges,90% of Total Billed Charges,78.75,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,157.5,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.75,65,,46.44,Percent of total Billed Charges,65% of Total Billed Charges,77.18,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,166.25,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,157.5,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,77.18,175,
STRYKR UNTH GDWRE 01.4MMX150MM,2720000283,CDM,272,RC,,,Outpatient,,,183.00,118.95,,183,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,139.08,76,,81.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,131.76,72,,73.552,Percent of Total Billed Charges,72% of Total Billed Charges,137.25,75,,76.624,Percent of Total Billed charges,75% of Total Billed Charges,183,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.76,72,,73.552,Percent of Total Billed Charges,72% of Total Billed Charges,109.8,60,,61.296,Percent of Total Billed Charges,60% of Total Billed Charges,164.7,90,,143.68,Percent of Total Billed Charges,90% of Total Billed Charges,82.35,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,164.7,90,,96.848,Percent of Total Billed Charges,90% of Total billed Charges,183,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.95,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,80.7,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,173.85,95,,102.224,Percent of Total Billed Charges,95% of Total Billed Charges,183,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.04,88,,94.696,Percent of Total Billed Charges,88% of Total Billed Charges,164.7,90,,96.848,Percent of Total Billed charges,90% of Total Billed Charges,80.7,183,
SUT PROL 20 CT1BL MONO 8423H,2720000284,CDM,272,RC,,,Outpatient,,,2.30,1.50,,2.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.75,76,,54.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.66,72,,73.552,Percent of Total Billed Charges,72% of Total Billed Charges,1.73,75,,76.624,Percent of Total Billed charges,75% of Total Billed Charges,2.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.66,72,,73.552,Percent of Total Billed Charges,72% of Total Billed Charges,1.38,60,,61.296,Percent of Total Billed Charges,60% of Total Billed Charges,2.07,90,,225.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.04,45,,153.208,Percent of Total Billed Charges,45% of Total Billed Charges,2.07,90,,64.296,Percent of Total Billed Charges,90% of Total billed Charges,2.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.5,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,1.01,44.1,,150.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.19,95,,67.872,Percent of Total Billed Charges,95% of Total Billed Charges,2.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.02,88,,62.864,Percent of Total Billed Charges,88% of Total Billed Charges,2.07,90,,64.296,Percent of Total Billed charges,90% of Total Billed Charges,1.01,2.3,
SWANGANZ THERMODILUTION 7FCATH,2720000285,CDM,272,RC,C1751,HCPCS,Outpatient,,,328.55,213.56,,328.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,249.7,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,236.56,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,246.41,75,,36,Percent of Total Billed charges,75% of Total Billed Charges,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.56,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,197.13,60,,28.8,Percent of Total Billed Charges,60% of Total Billed Charges,295.7,90,,225.44,Percent of Total Billed Charges,90% of Total Billed Charges,147.85,45,,155.192,Percent of Total Billed Charges,45% of Total Billed Charges,295.7,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.56,65,,221.296,Percent of total Billed Charges,65% of Total Billed Charges,144.89,44.1,,152.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,312.12,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.12,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,295.7,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,144.89,328.55,
TORNADO EMBOL COIL .01810/4MM,2720000286,CDM,278,RC,C1889,HCPCS,Outpatient,,,72.77,47.30,,72.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.31,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.39,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,52.39,72,,36,Percent of Total Billed charges,72% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.39,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,60,,28.8,Percent of Total Billed Charges,60% of Total Billed Charges,65.49,90,,225.44,Percent of Total Billed Charges,90% of Total Billed Charges,32.75,45,,175.032,Percent of Total Billed Charges,45% of Total Billed Charges,65.49,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.3,65,,224.16,Percent of total Billed Charges,65% of Total Billed Charges,32.09,44.1,,171.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,69.13,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.04,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,65.49,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,32.09,72.77,
TORNADO EMBOL COIL .0185/2MM,2720000287,CDM,278,RC,C1889,HCPCS,Outpatient,,,72.77,47.30,,72.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.31,76,,258.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.39,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,52.39,72,,36,Percent of Total Billed charges,72% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.39,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,60,,28.8,Percent of Total Billed Charges,60% of Total Billed Charges,65.49,90,,992.256,Percent of Total Billed Charges,90% of Total Billed Charges,32.75,45,,44.456,Percent of Total Billed Charges,45% of Total Billed Charges,65.49,90,,306.408,Percent of Total Billed Charges,90% of Total billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.3,65,,252.824,Percent of total Billed Charges,65% of Total Billed Charges,32.09,44.1,,43.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,69.13,95,,323.432,Percent of Total Billed Charges,95% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.04,88,,299.6,Percent of Total Billed Charges,88% of Total Billed Charges,65.49,90,,306.408,Percent of Total Billed charges,90% of Total Billed Charges,32.09,72.77,
TORNADO EMBOL COIL .0188/4MM,2720000288,CDM,278,RC,C1889,HCPCS,Outpatient,,,72.77,47.30,,72.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.31,76,,262.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.39,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,52.39,72,,36,Percent of Total Billed charges,72% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.39,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,60,,28.8,Percent of Total Billed Charges,60% of Total Billed Charges,65.49,90,,992.256,Percent of Total Billed Charges,90% of Total Billed Charges,32.75,45,,161.536,Percent of Total Billed Charges,45% of Total Billed Charges,65.49,90,,310.376,Percent of Total Billed Charges,90% of Total billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.3,65,,64.208,Percent of total Billed Charges,65% of Total Billed Charges,32.09,44.1,,158.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,69.13,95,,327.624,Percent of Total Billed Charges,95% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.04,88,,303.48,Percent of Total Billed Charges,88% of Total Billed Charges,65.49,90,,310.376,Percent of Total Billed charges,90% of Total Billed Charges,32.09,72.77,
TRAILBLAZER 4F 0.014X150X0.020,2720000289,CDM,272,RC,C1887,HCPCS,Outpatient,,,302.00,196.30,,302,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,229.52,76,,295.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,217.44,72,,371.496,Percent of Total Billed Charges,72% of Total Billed Charges,226.5,75,,386.976,Percent of Total Billed charges,75% of Total Billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.44,72,,371.496,Percent of Total Billed Charges,72% of Total Billed Charges,181.2,60,,309.584,Percent of Total Billed Charges,60% of Total Billed Charges,271.8,90,,246.08,Percent of Total Billed Charges,90% of Total Billed Charges,135.9,45,,71.84,Percent of Total Billed Charges,45% of Total Billed Charges,271.8,90,,350.064,Percent of Total Billed Charges,90% of Total billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.3,65,,233.336,Percent of total Billed Charges,65% of Total Billed Charges,133.18,44.1,,70.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,286.9,95,,369.512,Percent of Total Billed Charges,95% of Total Billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.76,88,,342.288,Percent of Total Billed Charges,88% of Total Billed Charges,271.8,90,,350.064,Percent of Total Billed charges,90% of Total Billed Charges,133.18,302,
TRAILBLAZER 5F 0.018X150X0.023,2720000290,CDM,272,RC,C1887,HCPCS,Outpatient,,,302.00,196.30,,302,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,229.52,76,,75.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,217.44,72,,73.016,Percent of Total Billed Charges,72% of Total Billed Charges,226.5,75,,76.064,Percent of Total Billed charges,75% of Total Billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.44,72,,73.016,Percent of Total Billed Charges,72% of Total Billed Charges,181.2,60,,60.848,Percent of Total Billed Charges,60% of Total Billed Charges,271.8,90,,127.432,Percent of Total Billed Charges,90% of Total Billed Charges,135.9,45,,112.72,Percent of Total Billed Charges,45% of Total Billed Charges,271.8,90,,88.904,Percent of Total Billed Charges,90% of Total billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.3,65,,103.768,Percent of total Billed Charges,65% of Total Billed Charges,133.18,44.1,,110.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,286.9,95,,93.848,Percent of Total Billed Charges,95% of Total Billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.76,88,,86.928,Percent of Total Billed Charges,88% of Total Billed Charges,271.8,90,,88.904,Percent of Total Billed charges,90% of Total Billed Charges,133.18,302,
TRAY LUMB PUNCT ADULT 22GX3.5,2720000291,CDM,272,RC,,,Outpatient,,,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,272.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.88,72,,1889.28,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,75,,1968,Percent of Total Billed charges,75% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.88,72,,1889.28,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,60,,1574.4,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,90,,48.424,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,112.72,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,323.08,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,162.816,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,110.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,341.024,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,315.896,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,323.08,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.05,
TRAY LUMBR PUNCT ADULT 22GX3.5,2720000292,CDM,272,RC,,,Outpatient,,,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,121.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.88,72,,227.984,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,75,,227.984,Percent of Total Billed charges,75% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.88,72,,227.984,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,60,,189.984,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,90,,494.536,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,112.72,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,143.68,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,162.816,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,110.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,151.656,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,140.48,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,143.68,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.05,
TRY CNT VN 2 L 4FR PEDI GDEWRE,2720000293,CDM,272,RC,C1769,HCPCS,Outpatient,,,163.34,106.17,,163.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.14,76,,190.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,117.6,72,,138.44,Percent of Total Billed Charges,72% of Total Billed Charges,122.51,75,,144.208,Percent of Total Billed charges,75% of Total Billed Charges,163.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.6,72,,138.44,Percent of Total Billed Charges,72% of Total Billed Charges,98,60,,115.368,Percent of Total Billed Charges,60% of Total Billed Charges,147.01,90,,573.128,Percent of Total Billed Charges,90% of Total Billed Charges,73.5,45,,496.128,Percent of Total Billed Charges,45% of Total Billed Charges,147.01,90,,225.44,Percent of Total Billed Charges,90% of Total billed Charges,163.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.17,65,,162.816,Percent of total Billed Charges,65% of Total Billed Charges,72.03,44.1,,486.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,155.17,95,,237.96,Percent of Total Billed Charges,95% of Total Billed Charges,163.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.74,88,,220.432,Percent of Total Billed Charges,88% of Total Billed Charges,147.01,90,,225.44,Percent of Total Billed charges,90% of Total Billed Charges,72.03,163.34,
TRY CNTR VEIN 3L 7FR 16CM  INT,2720000294,CDM,272,RC,C1894,HCPCS,Outpatient,,,183.75,119.44,,183.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,139.65,76,,190.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,132.3,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,137.81,75,,9.264,Percent of Total Billed charges,75% of Total Billed Charges,183.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.3,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,110.25,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,165.38,90,,5913.816,Percent of Total Billed Charges,90% of Total Billed Charges,82.69,45,,496.128,Percent of Total Billed Charges,45% of Total Billed Charges,165.38,90,,225.44,Percent of Total Billed Charges,90% of Total billed Charges,183.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.44,65,,716.624,Percent of total Billed Charges,65% of Total Billed Charges,81.03,44.1,,486.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,174.56,95,,237.96,Percent of Total Billed Charges,95% of Total Billed Charges,183.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.7,88,,220.432,Percent of Total Billed Charges,88% of Total Billed Charges,165.38,90,,225.44,Percent of Total Billed charges,90% of Total Billed Charges,81.03,183.75,
TRY CNTR VEIN 3L 7FR 20CM CATH,2720000295,CDM,272,RC,C1751,HCPCS,Outpatient,,,173.67,112.89,,173.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,131.99,76,,190.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,125.04,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,130.25,75,,9.264,Percent of Total Billed charges,75% of Total Billed Charges,173.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.04,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,104.2,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,156.3,90,,31.752,Percent of Total Billed Charges,90% of Total Billed Charges,78.15,45,,123.04,Percent of Total Billed Charges,45% of Total Billed Charges,156.3,90,,225.44,Percent of Total Billed Charges,90% of Total billed Charges,173.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.89,65,,716.624,Percent of total Billed Charges,65% of Total Billed Charges,76.59,44.1,,120.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,164.99,95,,237.96,Percent of Total Billed Charges,95% of Total Billed Charges,173.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.83,88,,220.432,Percent of Total Billed Charges,88% of Total Billed Charges,156.3,90,,225.44,Percent of Total Billed charges,90% of Total Billed Charges,76.59,173.67,
TRY CNTR VN 3L 7FR 16CM GDEWRE,2720000296,CDM,272,RC,C1751,HCPCS,Outpatient,,,183.75,119.44,,183.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,139.65,76,,837.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,132.3,72,,227.984,Percent of Total Billed Charges,72% of Total Billed Charges,137.81,75,,237.48,Percent of Total Billed charges,75% of Total Billed Charges,183.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.3,72,,227.984,Percent of Total Billed Charges,72% of Total Billed Charges,110.25,60,,189.984,Percent of Total Billed Charges,60% of Total Billed Charges,165.38,90,,31.752,Percent of Total Billed Charges,90% of Total Billed Charges,82.69,45,,63.72,Percent of Total Billed Charges,45% of Total Billed Charges,165.38,90,,992.256,Percent of Total Billed Charges,90% of Total billed Charges,183.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.44,65,,177.728,Percent of total Billed Charges,65% of Total Billed Charges,81.03,44.1,,62.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,174.56,95,,1047.376,Percent of Total Billed Charges,95% of Total Billed Charges,183.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.7,88,,970.2,Percent of Total Billed Charges,88% of Total Billed Charges,165.38,90,,992.256,Percent of Total Billed charges,90% of Total Billed Charges,81.03,183.75,
TRY CNTR VN 3L 7FR 20CM GDEWRE,2720000297,CDM,272,RC,C1769,HCPCS,Outpatient,,,173.67,112.89,,173.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,131.99,76,,837.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,125.04,72,,549.312,Percent of Total Billed Charges,72% of Total Billed Charges,130.25,75,,572.2,Percent of Total Billed charges,75% of Total Billed Charges,173.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.04,72,,549.312,Percent of Total Billed Charges,72% of Total Billed Charges,104.2,60,,457.76,Percent of Total Billed Charges,60% of Total Billed Charges,156.3,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,78.15,45,,24.208,Percent of Total Billed Charges,45% of Total Billed Charges,156.3,90,,992.256,Percent of Total Billed Charges,90% of Total billed Charges,173.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.89,65,,92.032,Percent of total Billed Charges,65% of Total Billed Charges,76.59,44.1,,23.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,164.99,95,,1047.376,Percent of Total Billed Charges,95% of Total Billed Charges,173.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.83,88,,970.2,Percent of Total Billed Charges,88% of Total Billed Charges,156.3,90,,992.256,Percent of Total Billed charges,90% of Total Billed Charges,76.59,173.67,
TRY CNTRL VEIN 2 L 4FR PED CAT,2720000298,CDM,272,RC,C1751,HCPCS,Outpatient,,,163.34,106.17,,163.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.14,76,,207.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,117.6,72,,142.88,Percent of Total Billed Charges,72% of Total Billed Charges,122.51,75,,148.84,Percent of Total Billed charges,75% of Total Billed Charges,163.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.6,72,,142.88,Percent of Total Billed Charges,72% of Total Billed Charges,98,60,,119.072,Percent of Total Billed Charges,60% of Total Billed Charges,147.01,90,,88.904,Percent of Total Billed Charges,90% of Total Billed Charges,73.5,45,,247.272,Percent of Total Billed Charges,45% of Total Billed Charges,147.01,90,,246.08,Percent of Total Billed Charges,90% of Total billed Charges,163.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.17,65,,34.968,Percent of total Billed Charges,65% of Total Billed Charges,72.03,44.1,,242.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,155.17,95,,259.752,Percent of Total Billed Charges,95% of Total Billed Charges,163.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.74,88,,240.616,Percent of Total Billed Charges,88% of Total Billed Charges,147.01,90,,246.08,Percent of Total Billed charges,90% of Total Billed Charges,72.03,163.34,
TRY CTRL VN CTR VN 4L16CM  INT,2720000299,CDM,272,RC,C1894,HCPCS,Outpatient,,,187.76,122.04,,187.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,142.7,76,,107.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,135.19,72,,62.24,Percent of Total Billed Charges,72% of Total Billed Charges,140.82,75,,64.832,Percent of Total Billed charges,75% of Total Billed Charges,187.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.19,72,,62.24,Percent of Total Billed Charges,72% of Total Billed Charges,112.66,60,,51.864,Percent of Total Billed Charges,60% of Total Billed Charges,168.98,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,84.49,45,,286.56,Percent of Total Billed Charges,45% of Total Billed Charges,168.98,90,,127.432,Percent of Total Billed Charges,90% of Total billed Charges,187.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.04,65,,357.168,Percent of total Billed Charges,65% of Total Billed Charges,82.8,44.1,,280.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,178.37,95,,134.512,Percent of Total Billed Charges,95% of Total Billed Charges,187.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.23,88,,124.6,Percent of Total Billed Charges,88% of Total Billed Charges,168.98,90,,127.432,Percent of Total Billed charges,90% of Total Billed Charges,82.8,187.76,
TTFCOR MVB CRE 035X145X1.5,2720000300,CDM,272,RC,C1769,HCPCS,Outpatient,,,90.00,58.50,,90,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.4,76,,40.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.8,72,,833.808,Percent of Total Billed Charges,72% of Total Billed Charges,67.5,75,,868.552,Percent of Total Billed charges,75% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.8,72,,833.808,Percent of Total Billed Charges,72% of Total Billed Charges,54,60,,694.84,Percent of Total Billed Charges,60% of Total Billed Charges,81,90,,88.904,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,45,,2956.904,Percent of Total Billed Charges,45% of Total Billed Charges,81,90,,48.424,Percent of Total Billed Charges,90% of Total billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.5,65,,413.928,Percent of total Billed Charges,65% of Total Billed Charges,39.69,44.1,,2897.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.5,95,,51.112,Percent of Total Billed Charges,95% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,88,,47.344,Percent of Total Billed Charges,88% of Total Billed Charges,81,90,,48.424,Percent of Total Billed charges,90% of Total Billed Charges,39.69,90,
TURP TUBING YTYPE IRRIG SET,2720000301,CDM,272,RC,,,Outpatient,,,56.25,36.56,,56.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.75,76,,417.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.5,72,,1044.288,Percent of Total Billed Charges,72% of Total Billed Charges,42.19,75,,1087.8,Percent of Total Billed charges,75% of Total Billed Charges,56.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.5,72,,1044.288,Percent of Total Billed Charges,72% of Total Billed Charges,33.75,60,,870.24,Percent of Total Billed Charges,60% of Total Billed Charges,50.63,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,25.31,45,,15.88,Percent of Total Billed Charges,45% of Total Billed Charges,50.63,90,,494.536,Percent of Total Billed Charges,90% of Total billed Charges,56.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.56,65,,4271.088,Percent of total Billed Charges,65% of Total Billed Charges,24.81,44.1,,15.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.44,95,,522.016,Percent of Total Billed Charges,95% of Total Billed Charges,56.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.5,88,,483.552,Percent of Total Billed Charges,88% of Total Billed Charges,50.63,90,,494.536,Percent of Total Billed charges,90% of Total Billed Charges,24.81,56.25,
V18 CONTROL WRE 0.014X300X8CM,2720000302,CDM,272,RC,C1769,HCPCS,Outpatient,,,224.91,146.19,,224.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,170.93,76,,483.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,161.94,72,,105.416,Percent of Total Billed Charges,72% of Total Billed Charges,168.68,75,,109.816,Percent of Total Billed charges,75% of Total Billed Charges,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.94,72,,105.416,Percent of Total Billed Charges,72% of Total Billed Charges,134.95,60,,87.848,Percent of Total Billed Charges,60% of Total Billed Charges,202.42,90,,49.216,Percent of Total Billed Charges,90% of Total Billed Charges,101.21,45,,15.88,Percent of Total Billed Charges,45% of Total Billed Charges,202.42,90,,573.128,Percent of Total Billed Charges,90% of Total billed Charges,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.19,65,,22.936,Percent of total Billed Charges,65% of Total Billed Charges,99.19,44.1,,15.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.66,95,,604.968,Percent of Total Billed Charges,95% of Total Billed Charges,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.92,88,,560.392,Percent of Total Billed Charges,88% of Total Billed Charges,202.42,90,,573.128,Percent of Total Billed charges,90% of Total Billed Charges,99.19,224.91,
VERRATA PLS P  10185P/10300P,2720000303,CDM,272,RC,C1769,HCPCS,Outpatient,,,1370.00,890.50,,1370,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1041.2,76,,4993.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,986.4,72,,106.688,Percent of Total Billed Charges,72% of Total Billed Charges,1027.5,75,,111.136,Percent of Total Billed charges,75% of Total Billed Charges,1370,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,986.4,72,,106.688,Percent of Total Billed Charges,72% of Total Billed Charges,822,60,,88.904,Percent of Total Billed Charges,60% of Total Billed Charges,1233,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,616.5,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,1233,90,,5913.816,Percent of Total Billed Charges,90% of Total billed Charges,1370,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1370,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1370,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,890.5,65,,22.936,Percent of total Billed Charges,65% of Total Billed Charges,604.17,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,1301.5,95,,6242.36,Percent of Total Billed Charges,95% of Total Billed Charges,1370,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1205.6,88,,5782.392,Percent of Total Billed Charges,88% of Total Billed Charges,1233,90,,5913.816,Percent of Total Billed charges,90% of Total Billed Charges,604.17,1370,
VISION PV 0.035 IVUS CAT 88901,2720000304,CDM,272,RC,C1753,HCPCS,Outpatient,,,2020.00,1313.00,,2020,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1535.2,76,,26.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1454.4,72,,123.2,Percent of Total Billed Charges,72% of Total Billed Charges,1515,75,,128.336,Percent of Total Billed charges,75% of Total Billed Charges,2020,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1454.4,72,,123.2,Percent of Total Billed Charges,72% of Total Billed Charges,1212,60,,102.664,Percent of Total Billed Charges,60% of Total Billed Charges,1818,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,909,45,,44.456,Percent of Total Billed Charges,45% of Total Billed Charges,1818,90,,31.752,Percent of Total Billed Charges,90% of Total billed Charges,2020,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2020,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2020,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1313,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,890.82,44.1,,43.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,1919,95,,33.52,Percent of Total Billed Charges,95% of Total Billed Charges,2020,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.6,88,,31.048,Percent of Total Billed Charges,88% of Total Billed Charges,1818,90,,31.752,Percent of Total Billed charges,90% of Total Billed Charges,890.82,2020,
VYNIL CONN TUBE 30CM (7271403),2720000305,CDM,272,RC,,,Outpatient,,,54.46,35.40,,54.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.39,76,,26.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.21,72,,97.8,Percent of Total Billed Charges,72% of Total Billed Charges,40.85,75,,101.872,Percent of Total Billed charges,75% of Total Billed Charges,54.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.21,72,,97.8,Percent of Total Billed Charges,72% of Total Billed Charges,32.68,60,,81.496,Percent of Total Billed Charges,60% of Total Billed Charges,49.01,90,,88.112,Percent of Total Billed Charges,90% of Total Billed Charges,24.51,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,49.01,90,,31.752,Percent of Total Billed Charges,90% of Total billed Charges,54.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.4,65,,64.208,Percent of total Billed Charges,65% of Total Billed Charges,24.02,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,51.74,95,,33.52,Percent of Total Billed Charges,95% of Total Billed Charges,54.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.92,88,,31.048,Percent of Total Billed Charges,88% of Total Billed Charges,49.01,90,,31.752,Percent of Total Billed charges,90% of Total Billed Charges,24.02,54.46,
Z249004443 CALIB/4.3 DRIL LG,2720000306,CDM,278,RC,C1713,HCPCS,Outpatient,,,129.00,83.85,,129,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.04,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,92.88,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,92.88,72,,103.192,Percent of Total Billed charges,72% of Total Billed Charges,129,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.88,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,77.4,60,,82.552,Percent of Total Billed Charges,60% of Total Billed Charges,116.1,90,,31.752,Percent of Total Billed Charges,90% of Total Billed Charges,58.05,45,,44.456,Percent of Total Billed Charges,45% of Total Billed Charges,116.1,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,129,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.85,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,56.89,44.1,,43.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,122.55,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,129,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.52,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,116.1,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,56.89,129,
Z249004443 CALIB/4.3 DRIL LG,2720000307,CDM,272,RC,,,Outpatient,,,129.00,83.85,,129,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.04,76,,75.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,92.88,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,96.75,75,,94.6,Percent of Total Billed charges,75% of Total Billed Charges,129,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.88,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,77.4,60,,75.68,Percent of Total Billed Charges,60% of Total Billed Charges,116.1,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,58.05,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,116.1,90,,88.904,Percent of Total Billed Charges,90% of Total billed Charges,129,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.85,65,,64.208,Percent of total Billed Charges,65% of Total Billed Charges,56.89,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,122.55,95,,93.848,Percent of Total Billed Charges,95% of Total Billed Charges,129,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.52,88,,86.928,Percent of Total Billed Charges,88% of Total Billed Charges,116.1,90,,88.904,Percent of Total Billed charges,90% of Total Billed Charges,56.89,129,
ZIMMER SUBCHONDROPLASTY KNE KT,2720000308,CDM,278,RC,,,Outpatient,,,8804.57,5722.97,,8804.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6691.47,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6339.29,72,,29.216,Percent of Total Billed Charges,72% of Total Billed Charges,6339.29,72,,30.432,Percent of Total Billed charges,72% of Total Billed Charges,8804.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6339.29,72,,29.216,Percent of Total Billed Charges,72% of Total Billed Charges,5282.74,60,,24.344,Percent of Total Billed Charges,60% of Total Billed Charges,7924.11,90,,103.992,Percent of Total Billed Charges,90% of Total Billed Charges,3962.06,45,,24.608,Percent of Total Billed Charges,45% of Total Billed Charges,7924.11,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,8804.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8804.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8804.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5722.97,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,3882.82,44.1,,24.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,8364.34,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,8804.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7748.02,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,7924.11,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,3882.82,8804.57,
INSERT 1 ELECTRODE PM-DEFIB,2720000309,CDM,360,RC,,,Outpatient,,,2632.77,1711.30,,2632.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2000.91,76,,75.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1895.59,72,,48.896,Percent of Total Billed Charges,72% of Total Billed Charges,1974.58,75,,50.936,Percent of Total Billed charges,75% of Total Billed Charges,2632.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1895.59,72,,48.896,Percent of Total Billed Charges,72% of Total Billed Charges,1579.66,60,,40.744,Percent of Total Billed Charges,60% of Total Billed Charges,2369.49,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,1184.75,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,2369.49,90,,88.904,Percent of Total Billed Charges,90% of Total billed Charges,2632.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2632.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2632.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1711.3,65,,35.544,Percent of total Billed Charges,65% of Total Billed Charges,1161.05,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,2501.13,95,,93.848,Percent of Total Billed Charges,95% of Total Billed Charges,2632.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2316.84,88,,86.928,Percent of Total Billed Charges,88% of Total Billed Charges,2369.49,90,,88.904,Percent of Total Billed charges,90% of Total Billed Charges,1161.05,2632.77,
DEFRIB PACEMAKR DUAL,2720000310,CDM,360,RC,,,Outpatient,,,60657.35,39427.28,,60657.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46099.59,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43673.29,72,,19.688,Percent of Total Billed Charges,72% of Total Billed Charges,45493.01,75,,20.512,Percent of Total Billed charges,75% of Total Billed Charges,60657.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43673.29,72,,19.688,Percent of Total Billed Charges,72% of Total Billed Charges,36394.41,60,,16.408,Percent of Total Billed Charges,60% of Total Billed Charges,54591.62,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,27295.81,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,54591.62,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,60657.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60657.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60657.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39427.28,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,26749.89,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,57624.48,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,60657.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53378.47,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,54591.62,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,26749.89,60657.35,
COMBINED SPINAL EPIDURAL SET,2720000311,CDM,272,RC,A4215,HCPCS,Outpatient,,,76.95,50.02,,76.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.48,76,,41.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.4,72,,180.984,Percent of Total Billed Charges,72% of Total Billed Charges,57.71,75,,188.528,Percent of Total Billed charges,75% of Total Billed Charges,76.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.4,72,,180.984,Percent of Total Billed Charges,72% of Total Billed Charges,46.17,60,,150.824,Percent of Total Billed Charges,60% of Total Billed Charges,69.26,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,34.63,45,,44.056,Percent of Total Billed Charges,45% of Total Billed Charges,69.26,90,,49.216,Percent of Total Billed Charges,90% of Total billed Charges,76.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.02,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,33.93,44.1,,43.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.1,95,,51.952,Percent of Total Billed Charges,95% of Total Billed Charges,76.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.72,88,,48.128,Percent of Total Billed Charges,88% of Total Billed Charges,69.26,90,,49.216,Percent of Total Billed charges,90% of Total Billed Charges,33.93,76.95,
CATH TRAY FOLEY 16FR,2720000312,CDM,272,RC,A4314,HCPCS,Outpatient,,,98.12,63.78,,98.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,74.57,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,99.61,350,,13.976,Fee Schedule,350% of BCBS fee schedule,99.61,350,,14.56,Fee Schedule,350% of BCBS fee schedule,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.61,350,,13.976,Fee Schedule,350% of BCBS PPO fee schedule,28.46,100,,11.648,Fee Schedule,100% of Blue ADV HMO fee schedule,88.31,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,44.15,45,,15.88,Percent of Total Billed Charges,45% of Total Billed Charges,88.31,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.78,65,,63.64,Percent of total Billed Charges,65% of Total Billed Charges,43.27,44.1,,15.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,93.21,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.35,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,88.31,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,28.46,99.61,
TRAY FOLEY 18FR SILI LF,2720000313,CDM,272,RC,A4315,HCPCS,Outpatient,,,10.52,6.84,,10.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.26,350,,12.704,Fee Schedule,350% of BCBS fee schedule,101.26,350,,13.232,Fee Schedule,350% of BCBS fee schedule,10.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.26,350,,12.704,Fee Schedule,350% of BCBS PPO fee schedule,28.93,100,,10.584,Fee Schedule,100% of Blue ADV HMO fee schedule,9.47,90,,103.992,Percent of Total Billed Charges,90% of Total Billed Charges,4.73,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,9.47,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,10.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.84,65,,22.936,Percent of total Billed Charges,65% of Total Billed Charges,4.64,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.99,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,10.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.26,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,9.47,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,4.64,101.26,
CATH FOL 06FRX3CC PED,2720000314,CDM,272,RC,A4338,HCPCS,Outpatient,,,29.20,18.98,,29.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.19,76,,74.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,48.3,350,,74.936,Fee Schedule,350% of BCBS fee schedule,48.3,350,,78.064,Fee Schedule,350% of BCBS fee schedule,29.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.3,350,,74.936,Fee Schedule,350% of BCBS PPO fee schedule,13.8,100,,62.448,Fee Schedule,100% of Blue ADV HMO fee schedule,26.28,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,13.14,45,,51.992,Percent of Total Billed Charges,45% of Total Billed Charges,26.28,90,,88.112,Percent of Total Billed Charges,90% of Total billed Charges,29.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.98,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,12.88,44.1,,50.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,27.74,95,,93.008,Percent of Total Billed Charges,95% of Total Billed Charges,29.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.7,88,,86.152,Percent of Total Billed Charges,88% of Total Billed Charges,26.28,90,,88.112,Percent of Total Billed charges,90% of Total Billed Charges,12.88,48.3,
SILICONE FOLEY CATH 10FR 3CC,2720000315,CDM,272,RC,A4344,HCPCS,Outpatient,,,8.00,5.20,,8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.08,76,,26.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.62,350,,793.8,Fee Schedule,350% of BCBS fee schedule,53.62,350,,826.88,Fee Schedule,350% of BCBS fee schedule,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.62,350,,793.8,Fee Schedule,350% of BCBS PPO fee schedule,15.32,100,,661.504,Fee Schedule,100% of Blue ADV HMO fee schedule,7.2,90,,15.88,Percent of Total Billed Charges,90% of Total Billed Charges,3.6,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,7.2,90,,31.752,Percent of Total Billed Charges,90% of Total billed Charges,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.2,65,,75.104,Percent of total Billed Charges,65% of Total Billed Charges,3.53,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.6,95,,33.52,Percent of Total Billed Charges,95% of Total Billed Charges,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.04,88,,31.048,Percent of Total Billed Charges,88% of Total Billed Charges,7.2,90,,31.752,Percent of Total Billed charges,90% of Total Billed Charges,3.53,53.62,
CATHETER FOLEY 14FR 5CC LF SIL,2720000316,CDM,272,RC,A4344,HCPCS,Outpatient,,,24.16,15.70,,24.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.36,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.62,350,,115.584,Fee Schedule,350% of BCBS fee schedule,53.62,350,,120.4,Fee Schedule,350% of BCBS fee schedule,24.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.62,350,,115.584,Fee Schedule,350% of BCBS PPO fee schedule,15.32,100,,96.32,Fee Schedule,100% of Blue ADV HMO fee schedule,21.74,90,,208.768,Percent of Total Billed Charges,90% of Total Billed Charges,10.87,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,21.74,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,24.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.7,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,10.65,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.95,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,24.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.26,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,21.74,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,10.65,53.62,
CATHETER FOLEY 18FR SILICONE,2720000317,CDM,272,RC,A4344,HCPCS,Outpatient,,,24.16,15.70,,24.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.36,76,,87.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.62,350,,15.24,Fee Schedule,350% of BCBS fee schedule,53.62,350,,15.88,Fee Schedule,350% of BCBS fee schedule,24.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.62,350,,15.24,Fee Schedule,350% of BCBS PPO fee schedule,15.32,100,,12.704,Fee Schedule,100% of Blue ADV HMO fee schedule,21.74,90,,90.496,Percent of Total Billed Charges,90% of Total Billed Charges,10.87,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,21.74,90,,103.992,Percent of Total Billed Charges,90% of Total billed Charges,24.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.7,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,10.65,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.95,95,,109.768,Percent of Total Billed Charges,95% of Total Billed Charges,24.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.26,88,,101.68,Percent of Total Billed Charges,88% of Total Billed Charges,21.74,90,,103.992,Percent of Total Billed charges,90% of Total Billed Charges,10.65,53.62,
TRAY CATH URETHRAL,2720000318,CDM,272,RC,A4353,HCPCS,Outpatient,,,37.49,24.37,,37.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.49,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.55,350,,90.816,Fee Schedule,350% of BCBS fee schedule,27.55,350,,94.6,Fee Schedule,350% of BCBS fee schedule,37.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.55,350,,90.816,Fee Schedule,350% of BCBS PPO fee schedule,7.87,100,,75.68,Fee Schedule,100% of Blue ADV HMO fee schedule,33.74,90,,50.008,Percent of Total Billed Charges,90% of Total Billed Charges,16.87,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,33.74,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,37.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.37,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,16.53,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.62,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,37.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.99,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,33.74,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,7.87,37.49,
KIT CATHETER FEMALE,2720000319,CDM,272,RC,A4353,HCPCS,Outpatient,,,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.55,350,,106.688,Fee Schedule,350% of BCBS fee schedule,27.55,350,,111.136,Fee Schedule,350% of BCBS fee schedule,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.55,350,,106.688,Fee Schedule,350% of BCBS PPO fee schedule,7.87,100,,88.904,Fee Schedule,100% of Blue ADV HMO fee schedule,17.87,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,51.992,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,50.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,7.87,27.55,
AMBIENT SUPER TURBO VAC 90,2720000320,CDM,272,RC,A4649,HCPCS,Outpatient,,,353.90,230.04,,353.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,268.96,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,254.81,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,265.43,75,,94.6,Percent of Total Billed charges,75% of Total Billed Charges,353.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,254.81,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,212.34,60,,75.68,Percent of Total Billed Charges,60% of Total Billed Charges,318.51,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,159.26,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,318.51,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,353.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.04,65,,75.104,Percent of total Billed Charges,65% of Total Billed Charges,156.07,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,336.21,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,353.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,311.43,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,318.51,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,156.07,353.9,
AMBIENT SUPER MULTI VAC 50,2720000321,CDM,272,RC,A4649,HCPCS,Outpatient,,,353.90,230.04,,353.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,268.96,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,254.81,72,,419.128,Percent of Total Billed Charges,72% of Total Billed Charges,265.43,75,,436.592,Percent of Total Billed charges,75% of Total Billed Charges,353.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,254.81,72,,419.128,Percent of Total Billed Charges,72% of Total Billed Charges,212.34,60,,349.272,Percent of Total Billed Charges,60% of Total Billed Charges,318.51,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,159.26,45,,7.936,Percent of Total Billed Charges,45% of Total Billed Charges,318.51,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,353.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.04,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,156.07,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,336.21,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,353.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,311.43,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,318.51,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,156.07,353.9,
ARTHROCARE OM8177 CART,2720000322,CDM,272,RC,A4649,HCPCS,Outpatient,,,367.13,238.63,,367.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,279.02,76,,87.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,264.33,72,,56.52,Percent of Total Billed Charges,72% of Total Billed Charges,275.35,75,,58.872,Percent of Total Billed charges,75% of Total Billed Charges,367.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.33,72,,56.52,Percent of Total Billed Charges,72% of Total Billed Charges,220.28,60,,47.096,Percent of Total Billed Charges,60% of Total Billed Charges,330.42,90,,29.368,Percent of Total Billed Charges,90% of Total Billed Charges,165.21,45,,104.384,Percent of Total Billed Charges,45% of Total Billed Charges,330.42,90,,103.992,Percent of Total Billed Charges,90% of Total billed Charges,367.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,367.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,367.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.63,65,,11.464,Percent of total Billed Charges,65% of Total Billed Charges,161.9,44.1,,102.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,348.77,95,,109.768,Percent of Total Billed Charges,95% of Total Billed Charges,367.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.07,88,,101.68,Percent of Total Billed Charges,88% of Total Billed Charges,330.42,90,,103.992,Percent of Total Billed charges,90% of Total Billed Charges,161.9,367.13,
ARTHROCARE 6.5 SCREW,2720000323,CDM,272,RC,A4649,HCPCS,Outpatient,,,1861.02,1209.66,,1861.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1414.38,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1339.93,72,,85.728,Percent of Total Billed Charges,72% of Total Billed Charges,1395.77,75,,89.304,Percent of Total Billed charges,75% of Total Billed Charges,1861.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1339.93,72,,85.728,Percent of Total Billed Charges,72% of Total Billed Charges,1116.61,60,,71.44,Percent of Total Billed Charges,60% of Total Billed Charges,1674.92,90,,29.368,Percent of Total Billed Charges,90% of Total Billed Charges,837.46,45,,45.248,Percent of Total Billed Charges,45% of Total Billed Charges,1674.92,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,1861.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1861.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1861.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1209.66,65,,150.776,Percent of total Billed Charges,65% of Total Billed Charges,820.71,44.1,,44.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,1767.97,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,1861.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1637.7,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,1674.92,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,820.71,1861.02,
LIQUID SKIN,2720000324,CDM,272,RC,A6250,HCPCS,Outpatient,,,31.97,20.78,,31.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.3,76,,13.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.02,72,,69.856,Percent of Total Billed Charges,72% of Total Billed Charges,23.98,75,,72.768,Percent of Total Billed charges,75% of Total Billed Charges,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.02,72,,69.856,Percent of Total Billed Charges,72% of Total Billed Charges,19.18,60,,58.216,Percent of Total Billed Charges,60% of Total Billed Charges,28.77,90,,29.368,Percent of Total Billed Charges,90% of Total Billed Charges,14.39,45,,25.008,Percent of Total Billed Charges,45% of Total Billed Charges,28.77,90,,15.88,Percent of Total Billed Charges,90% of Total billed Charges,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.78,65,,65.36,Percent of total Billed Charges,65% of Total Billed Charges,14.1,44.1,,24.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.37,95,,16.76,Percent of Total Billed Charges,95% of Total Billed Charges,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.13,88,,15.52,Percent of Total Billed Charges,88% of Total Billed Charges,28.77,90,,15.88,Percent of Total Billed charges,90% of Total Billed Charges,14.1,31.97,
ABD PAD,2720000325,CDM,272,RC,A6253,HCPCS,Outpatient,,,3.08,2.00,,3.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.34,76,,176.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.96,350,,80.648,Fee Schedule,350% of BCBS fee schedule,24.96,350,,84.016,Fee Schedule,350% of BCBS fee schedule,3.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.96,350,,80.648,Fee Schedule,350% of BCBS PPO fee schedule,7.13,100,,67.208,Fee Schedule,100% of Blue ADV HMO fee schedule,2.77,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,1.39,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,2.77,90,,208.768,Percent of Total Billed Charges,90% of Total billed Charges,3.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,65,,36.12,Percent of total Billed Charges,65% of Total Billed Charges,1.36,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.93,95,,220.368,Percent of Total Billed Charges,95% of Total Billed Charges,3.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.71,88,,204.128,Percent of Total Billed Charges,88% of Total Billed Charges,2.77,90,,208.768,Percent of Total Billed charges,90% of Total Billed Charges,1.36,24.96,
KLING 2,2720000326,CDM,272,RC,A6446,HCPCS,Outpatient,,,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,76.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.58,350,,212.736,Fee Schedule,350% of BCBS fee schedule,1.58,350,,221.608,Fee Schedule,350% of BCBS fee schedule,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.58,350,,212.736,Fee Schedule,350% of BCBS PPO fee schedule,0.45,100,,177.28,Fee Schedule,100% of Blue ADV HMO fee schedule,9.93,90,,217.504,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,90.496,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,95.528,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,88.488,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,90.496,Percent of Total Billed charges,90% of Total Billed Charges,0.45,11.03,
KLING 3,2720000327,CDM,272,RC,A6446,HCPCS,Outpatient,,,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,42.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.58,350,,113.04,Fee Schedule,350% of BCBS fee schedule,1.58,350,,117.752,Fee Schedule,350% of BCBS fee schedule,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.58,350,,113.04,Fee Schedule,350% of BCBS PPO fee schedule,0.45,100,,94.2,Fee Schedule,100% of Blue ADV HMO fee schedule,13.9,90,,103.992,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,50.008,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,52.792,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,48.896,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,50.008,Percent of Total Billed charges,90% of Total Billed Charges,0.45,15.44,
ELASTIC 6 WRAP,2720000328,CDM,272,RC,A6448,HCPCS,Outpatient,,,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.55,350,,92.08,Fee Schedule,350% of BCBS fee schedule,4.55,350,,95.92,Fee Schedule,350% of BCBS fee schedule,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.55,350,,92.08,Fee Schedule,350% of BCBS PPO fee schedule,1.3,100,,76.736,Fee Schedule,100% of Blue ADV HMO fee schedule,13.9,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,14.688,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,14.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,1.3,15.44,
TRACH UNCUFF SZ8,2720000329,CDM,272,RC,A7520,HCPCS,Outpatient,,,116.73,75.87,,116.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,88.71,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,187.04,350,,33.656,Fee Schedule,350% of BCBS fee schedule,187.04,350,,35.056,Fee Schedule,350% of BCBS fee schedule,116.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.04,350,,33.656,Fee Schedule,350% of BCBS PPO fee schedule,53.44,100,,28.048,Fee Schedule,100% of Blue ADV HMO fee schedule,105.06,90,,98.432,Percent of Total Billed Charges,90% of Total Billed Charges,52.53,45,,14.688,Percent of Total Billed Charges,45% of Total Billed Charges,105.06,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,116.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.87,65,,21.208,Percent of total Billed Charges,65% of Total Billed Charges,51.48,44.1,,14.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,110.89,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,116.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.72,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,105.06,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,51.48,187.04,
TRACH UNCUF SZ 9,2720000330,CDM,272,RC,A7520,HCPCS,Outpatient,,,125.68,81.69,,125.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95.52,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,187.04,350,,79.376,Fee Schedule,350% of BCBS fee schedule,187.04,350,,82.688,Fee Schedule,350% of BCBS fee schedule,125.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.04,350,,79.376,Fee Schedule,350% of BCBS PPO fee schedule,53.44,100,,66.152,Fee Schedule,100% of Blue ADV HMO fee schedule,113.11,90,,93.672,Percent of Total Billed Charges,90% of Total Billed Charges,56.56,45,,14.688,Percent of Total Billed Charges,45% of Total Billed Charges,113.11,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,125.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.69,65,,21.208,Percent of total Billed Charges,65% of Total Billed Charges,55.42,44.1,,14.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,119.4,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,125.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.6,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,113.11,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,53.44,187.04,
TRACH CUFF SZ 9,2720000331,CDM,272,RC,A7521,HCPCS,Outpatient,,,132.08,85.85,,132.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.38,76,,24.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,185.29,350,,103.512,Fee Schedule,350% of BCBS fee schedule,185.29,350,,107.824,Fee Schedule,350% of BCBS fee schedule,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.29,350,,103.512,Fee Schedule,350% of BCBS PPO fee schedule,52.94,100,,86.264,Fee Schedule,100% of Blue ADV HMO fee schedule,118.87,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,59.44,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,118.87,90,,29.368,Percent of Total Billed Charges,90% of Total billed Charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.85,65,,21.208,Percent of total Billed Charges,65% of Total Billed Charges,58.25,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.48,95,,31,Percent of Total Billed Charges,95% of Total Billed Charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.23,88,,28.72,Percent of Total Billed Charges,88% of Total Billed Charges,118.87,90,,29.368,Percent of Total Billed charges,90% of Total Billed Charges,52.94,185.29,
TRACH CUFF SZ 8,2720000332,CDM,272,RC,A7521,HCPCS,Outpatient,,,132.12,85.88,,132.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.41,76,,24.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,185.29,350,,22.224,Fee Schedule,350% of BCBS fee schedule,185.29,350,,23.152,Fee Schedule,350% of BCBS fee schedule,132.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.29,350,,22.224,Fee Schedule,350% of BCBS PPO fee schedule,52.94,100,,18.52,Fee Schedule,100% of Blue ADV HMO fee schedule,118.91,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,59.45,45,,108.752,Percent of Total Billed Charges,45% of Total Billed Charges,118.91,90,,29.368,Percent of Total Billed Charges,90% of Total billed Charges,132.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.88,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,58.26,44.1,,106.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.51,95,,31,Percent of Total Billed Charges,95% of Total Billed Charges,132.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.27,88,,28.72,Percent of Total Billed Charges,88% of Total Billed Charges,118.91,90,,29.368,Percent of Total Billed charges,90% of Total Billed Charges,52.94,185.29,
TRACH CUF SZ 6,2720000333,CDM,272,RC,A7521,HCPCS,Outpatient,,,116.69,75.85,,116.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,88.68,76,,24.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,185.29,350,,485.168,Fee Schedule,350% of BCBS fee schedule,185.29,350,,505.384,Fee Schedule,350% of BCBS fee schedule,116.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.29,350,,485.168,Fee Schedule,350% of BCBS PPO fee schedule,52.94,100,,404.312,Fee Schedule,100% of Blue ADV HMO fee schedule,105.02,90,,93.672,Percent of Total Billed Charges,90% of Total Billed Charges,52.51,45,,51.992,Percent of Total Billed Charges,45% of Total Billed Charges,105.02,90,,29.368,Percent of Total Billed Charges,90% of Total billed Charges,116.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.85,65,,157.088,Percent of total Billed Charges,65% of Total Billed Charges,51.46,44.1,,50.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,110.86,95,,31,Percent of Total Billed Charges,95% of Total Billed Charges,116.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.69,88,,28.72,Percent of Total Billed Charges,88% of Total Billed Charges,105.02,90,,29.368,Percent of Total Billed charges,90% of Total Billed Charges,51.46,185.29,
TRUEPATH CTO DEVICE,2720000334,CDM,272,RC,C1714,HCPCS,Outpatient,,,4491.59,2919.53,,4491.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3413.61,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3233.94,72,,80.016,Percent of Total Billed Charges,72% of Total Billed Charges,3368.69,75,,83.352,Percent of Total Billed charges,75% of Total Billed Charges,4491.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3233.94,72,,80.016,Percent of Total Billed Charges,72% of Total Billed Charges,2694.95,60,,66.68,Percent of Total Billed Charges,60% of Total Billed Charges,4042.43,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,2021.22,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,4042.43,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,4491.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4491.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4491.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2919.53,65,,75.104,Percent of total Billed Charges,65% of Total Billed Charges,1980.79,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,4267.01,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,4491.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3952.6,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,4042.43,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,1980.79,4491.59,
HAWKONE 6F SM 0.014 CATHETER,2720000335,CDM,272,RC,C1714,HCPCS,Outpatient,,,7397.78,4808.56,,7397.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5622.31,76,,183.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5326.4,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,5548.34,75,,42.336,Percent of Total Billed charges,75% of Total Billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5326.4,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,4438.67,60,,33.872,Percent of Total Billed Charges,60% of Total Billed Charges,6658,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,3329,45,,49.216,Percent of Total Billed Charges,45% of Total Billed Charges,6658,90,,217.504,Percent of Total Billed Charges,90% of Total billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4808.56,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,3262.42,44.1,,48.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,7027.89,95,,229.592,Percent of Total Billed Charges,95% of Total Billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6510.05,88,,212.672,Percent of Total Billed Charges,88% of Total Billed Charges,6658,90,,217.504,Percent of Total Billed charges,90% of Total Billed Charges,3262.42,7397.78,
NC QUANTUM AMR 2 X 15 BALLOON,2720000336,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,87.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,127.64,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,132.96,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,127.64,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,106.368,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,46.84,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,103.992,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,71.088,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,45.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,109.768,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,101.68,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,103.992,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM AMR 2 X 20 BALLOON,2720000337,CDM,272,RC,C1725,HCPCS,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,214.648,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,223.592,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,214.648,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,178.872,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,451.672,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,67.656,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
5FR7X40X135EVRCRS014OTW PTA BL,2720000338,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,83.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,110.496,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,115.104,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,110.496,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,92.08,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,451.672,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,98.432,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,103.896,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,96.24,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,98.432,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
6FR 10X40X80 014 OTW PTA BAL,2720000339,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,79.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,85.096,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,88.648,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,85.096,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,70.912,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,451.672,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,46.84,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,93.672,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,45.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,98.88,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,91.592,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,93.672,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
RAPIDCX 4F 4X150X170 RX 0.14,2720000340,CDM,272,RC,C1725,HCPCS,Outpatient,,,658.00,427.70,,658,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,500.08,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,473.76,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,493.5,75,,12.568,Percent of Total Billed charges,75% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.76,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,394.8,60,,10.056,Percent of Total Billed Charges,60% of Total Billed Charges,592.2,90,,451.672,Percent of Total Billed Charges,90% of Total Billed Charges,296.1,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,592.2,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.7,65,,67.656,Percent of total Billed Charges,65% of Total Billed Charges,290.18,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,625.1,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.04,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,592.2,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,290.18,658,
RAPIDCX 4F 2.5X120X170 RX 0.14,2720000341,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,74.936,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,78.064,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,74.936,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,62.448,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,600.904,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
RAPIDCX 4F 3X80X170 RX 0.14,2720000342,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,79.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,262.272,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,273.2,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,262.272,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,218.56,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,600.904,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,93.672,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,98.88,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,91.592,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,93.672,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
RAPIDCX 4F 2X120X170 RX 0.14,2720000343,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,189.88,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,197.792,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,189.88,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,158.232,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,600.904,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,225.832,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,221.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
RAPIDCX 4F 2.5X100X170 RX 0.14,2720000344,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,600.904,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,225.832,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,326.208,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,221.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
RAPIDCX 4F 2X100X170 RX 0.14,2720000345,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,65.408,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,68.136,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,65.408,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,54.512,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,487.4,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,225.832,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,326.208,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,221.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
RAPIDCX 4F 2X150X170 RX 0.14,2720000346,CDM,272,RC,C1725,HCPCS,Outpatient,,,658.00,427.70,,658,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,500.08,76,,381.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,473.76,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,493.5,75,,29.104,Percent of Total Billed charges,75% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.76,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,394.8,60,,23.288,Percent of Total Billed Charges,60% of Total Billed Charges,592.2,90,,487.4,Percent of Total Billed Charges,90% of Total Billed Charges,296.1,45,,225.832,Percent of Total Billed Charges,45% of Total Billed Charges,592.2,90,,451.672,Percent of Total Billed Charges,90% of Total billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.7,65,,326.208,Percent of total Billed Charges,65% of Total Billed Charges,290.18,44.1,,221.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,625.1,95,,476.76,Percent of Total Billed Charges,95% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.04,88,,441.632,Percent of Total Billed Charges,88% of Total Billed Charges,592.2,90,,451.672,Percent of Total Billed charges,90% of Total Billed Charges,290.18,658,
RAPIDCX 4F 3X120X170 RX 0.14,2720000347,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,381.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,74.296,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,77.392,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,74.296,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,61.912,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,487.4,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,300.456,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,451.672,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,326.208,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,294.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,476.76,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,441.632,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,451.672,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
RAPIDCX 4F 2.5X60X170 RX 0.14,2720000348,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,381.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,60.328,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,62.848,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,60.328,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,50.272,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,487.4,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,300.456,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,451.672,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,433.984,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,294.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,476.76,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,441.632,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,451.672,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
RAPIDCX 4F 4X120X170 RX 0.14,2720000349,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,381.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,97.16,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,101.208,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,97.16,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,80.968,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,884.296,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,300.456,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,451.672,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,433.984,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,294.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,476.76,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,441.632,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,451.672,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
RAPIDCX 4F 3X150X170 RX 0.14,2720000350,CDM,272,RC,C1725,HCPCS,Outpatient,,,658.00,427.70,,658,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,500.08,76,,507.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,473.76,72,,252.112,Percent of Total Billed Charges,72% of Total Billed Charges,493.5,75,,262.616,Percent of Total Billed charges,75% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.76,72,,252.112,Percent of Total Billed Charges,72% of Total Billed Charges,394.8,60,,210.088,Percent of Total Billed Charges,60% of Total Billed Charges,592.2,90,,278.624,Percent of Total Billed Charges,90% of Total Billed Charges,296.1,45,,300.456,Percent of Total Billed Charges,45% of Total Billed Charges,592.2,90,,600.904,Percent of Total Billed Charges,90% of Total billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.7,65,,433.984,Percent of total Billed Charges,65% of Total Billed Charges,290.18,44.1,,294.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,625.1,95,,634.288,Percent of Total Billed Charges,95% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.04,88,,587.552,Percent of Total Billed Charges,88% of Total Billed Charges,592.2,90,,600.904,Percent of Total Billed charges,90% of Total Billed Charges,290.18,658,
RAPIDCX 4F 4X40X170 RX 0.14,2720000351,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,507.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,65.408,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,68.136,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,65.408,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,54.512,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,328.64,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,243.696,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,600.904,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,433.984,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,238.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,634.288,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,587.552,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,600.904,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
RAPIDCX 4F 2X80X170 RX 0.14,2720000352,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,507.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,49.616,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,39.688,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,251.632,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,243.696,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,600.904,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,352.008,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,238.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,634.288,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,587.552,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,600.904,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
RAPIDCX 4F 3X20X170 RX 0.14,2720000353,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,507.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,100.976,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,105.184,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,100.976,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,84.144,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,186.544,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,243.696,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,600.904,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,352.008,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,238.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,634.288,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,587.552,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,600.904,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
RAPIDCX 4F 3X40X170 RX 0.14,2720000354,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,411.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,869.184,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,905.4,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,869.184,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,724.32,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,916.84,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,243.696,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,487.4,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,352.008,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,238.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,514.472,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,476.568,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,487.4,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
RAPIDCX 4F 2X20X170 RX 0.14,2720000355,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,411.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,107.96,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,112.456,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,107.96,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,89.968,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,442.152,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,487.4,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,352.008,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,433.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,514.472,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,476.568,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,487.4,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
RAPIDCX 4F 2X60X170 RX 0.14,2720000356,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,411.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,257.832,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,268.576,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,257.832,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,214.856,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,139.312,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,487.4,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,638.656,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,136.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,514.472,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,476.568,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,487.4,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
RAPIDCX 4F 3X100X170 RX 0.14,2720000357,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,411.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,251.472,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,261.952,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,251.472,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,209.56,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,51.592,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,164.32,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,487.4,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,201.232,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,161.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,514.472,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,476.568,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,487.4,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
RAPIDCX 4F 4X80X170 RX 0.14,2720000358,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,746.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,546.768,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,569.552,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,546.768,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,455.64,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,50.8,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,125.816,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,884.296,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,237.352,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,123.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,933.424,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,864.648,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,884.296,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
RAPIDCX 4F 2.5X80X170 RX 0.14,2720000359,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,235.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,93.984,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,97.904,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,93.984,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,78.32,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,50.8,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,93.272,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,278.624,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,181.736,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,91.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,294.104,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,272.432,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,278.624,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
RAPIDCX 4F 2.5X150X170 RX 0.14,2720000360,CDM,272,RC,C1725,HCPCS,Outpatient,,,658.00,427.70,,658,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,500.08,76,,277.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,473.76,72,,88.272,Percent of Total Billed Charges,72% of Total Billed Charges,493.5,75,,91.952,Percent of Total Billed charges,75% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.76,72,,88.272,Percent of Total Billed Charges,72% of Total Billed Charges,394.8,60,,73.56,Percent of Total Billed Charges,60% of Total Billed Charges,592.2,90,,219.088,Percent of Total Billed Charges,90% of Total Billed Charges,296.1,45,,458.424,Percent of Total Billed Charges,45% of Total Billed Charges,592.2,90,,328.64,Percent of Total Billed Charges,90% of Total billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.7,65,,134.728,Percent of total Billed Charges,65% of Total Billed Charges,290.18,44.1,,449.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,625.1,95,,346.896,Percent of Total Billed Charges,95% of Total Billed Charges,658,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.04,88,,321.336,Percent of Total Billed Charges,88% of Total Billed Charges,592.2,90,,328.64,Percent of Total Billed charges,90% of Total Billed Charges,290.18,658,
RAPIDCX 4F 2.5X20X170 RX 0.14,2720000361,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,212.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,62.872,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,65.488,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,62.872,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,52.392,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,219.088,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,251.632,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,662.16,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,265.616,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,246.04,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,251.632,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
RAPIDCX 4F 2.5X40X170 RX 0.14,2720000362,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,157.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,128.28,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,133.624,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,128.28,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,106.904,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,51.592,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,186.544,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,196.912,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,182.4,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,186.544,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
RAPIDCX 4F 2X40X170 RX 0.14,2720000363,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,774.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,46.312,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,37.048,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,50.8,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,25.8,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,916.84,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,25.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,967.776,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,896.464,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,916.84,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
RAPIDCX 4F 3X60X170 RX 0.14,2720000364,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,83.824,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,87.32,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,83.824,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,69.856,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,50.8,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,25.4,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,37.264,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,24.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
EUPHORA NC 3 X 12 RX BALLOON,2720000365,CDM,272,RC,C1725,HCPCS,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,94.6,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,75.68,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,123.04,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,25.4,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,36.688,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,24.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
EUPHORA NC 2.5 X 12 RX BALLOON,2720000366,CDM,272,RC,C1725,HCPCS,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,43.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,93.984,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,97.904,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,93.984,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,78.32,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,123.04,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,109.544,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,51.592,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,36.688,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,107.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,54.464,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,50.448,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,51.592,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
EUPHORA NC 3.5 X 15 RX BALLOON,2720000367,CDM,272,RC,C1725,HCPCS,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,42.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,144.152,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,150.16,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,144.152,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,120.128,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,109.552,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,109.544,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,50.8,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,158.232,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,107.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,53.624,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,49.672,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,50.8,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
EUPHORA NC 2.5 X 15 RX BALLOON,2720000368,CDM,272,RC,C1725,HCPCS,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,42.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,120.024,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,125.024,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,120.024,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,100.016,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,109.552,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,25.8,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,50.8,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,158.232,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,25.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,53.624,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,49.672,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,50.8,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
EUPHORA NC 4.5 X 15 RX BALLOON,2720000369,CDM,272,RC,C1725,HCPCS,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,185.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,112.4,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,117.088,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,112.4,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,93.664,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,22.608,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,25.4,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,219.088,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,37.264,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,24.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,231.264,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,214.224,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,219.088,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
EUPHORA NC 2 X 12 RX BALLOON,2720000370,CDM,272,RC,C1725,HCPCS,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,185.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,48.896,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,50.936,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,48.896,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,40.744,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,22.608,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,25.4,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,219.088,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,36.688,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,24.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,231.264,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,214.224,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,219.088,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
EUPHORA NC 5 X 12 RX BALLOON,2720000371,CDM,272,RC,C1725,HCPCS,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,43.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,35.56,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,37.048,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,35.56,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,29.632,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,75.528,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,61.52,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,51.592,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,36.688,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,60.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,54.464,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,50.448,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,51.592,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
EUPHORA NC 5 X 15 RX BALLOON,2720000372,CDM,272,RC,C1725,HCPCS,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,42.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,53.344,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,55.568,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,53.344,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,44.456,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,75.528,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,61.52,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,50.8,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,88.864,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,60.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,53.624,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,49.672,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,50.8,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
EUPHORA NC 4 X 15 RX BALLOON,2720000373,CDM,272,RC,C1725,HCPCS,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,42.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,127.64,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,132.96,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,127.64,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,106.368,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,75.528,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,54.776,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,50.8,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,88.864,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,53.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,53.624,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,49.672,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,50.8,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
EUPHORA NC 2 X 15 RX BALLOON,2720000374,CDM,272,RC,C1725,HCPCS,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,103.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,1224.36,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,1275.376,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,1224.36,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,1020.296,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,75.528,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,54.776,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,123.04,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,79.12,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,53.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,129.88,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,120.304,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,123.04,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
EUPHORA NC 3 X 15 RX BALLOON,2720000375,CDM,272,RC,C1725,HCPCS,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,103.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,1015.56,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,11.304,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,123.04,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,79.12,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,11.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,129.88,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,120.304,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,123.04,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
EUPHORA NC 4 X 12 RX BALLOON,2720000376,CDM,272,RC,C1725,HCPCS,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,92.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,38.104,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,39.688,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,38.104,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,31.752,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,217.44,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,11.304,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,109.552,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,16.328,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,11.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,115.632,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,107.112,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,109.552,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
EUPHORA NC 4.5 X 12 RX BALLOON,2720000377,CDM,272,RC,C1725,HCPCS,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,92.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,94.6,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,75.68,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,69.12,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,37.768,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,109.552,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,16.328,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,37.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,115.632,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,107.112,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,109.552,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
EUPHORA NC 3.5 X 12 RX BALLOON,2720000378,CDM,272,RC,C1725,HCPCS,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,19.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,239.408,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,249.384,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,239.408,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,199.504,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,37.768,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,22.608,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,54.552,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,37.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,23.864,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,22.104,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,22.608,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
EVERCR 5F 3X100X135 035 OTW,2720000379,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,19.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,49.616,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,39.688,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,69.12,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,37.768,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,22.608,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,54.552,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,37.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,23.864,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,22.104,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,22.608,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
EVERCR 5F 3X80X135 035 OTW,2720000380,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,63.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,49.616,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,39.688,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,158.76,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,37.768,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,75.528,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,54.552,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,37.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,79.728,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,73.848,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,75.528,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
EVERCR 5F 3X40X135 035 OTW,2720000381,CDM,272,RC,C1725,HCPCS,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,63.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,62.872,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,65.488,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,62.872,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,52.392,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,453.264,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,507.784,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,75.528,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,54.552,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,497.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,79.728,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,73.848,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,75.528,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
CHOCO 5F 3X120 O14 OTW BALLOON,2720000382,CDM,272,RC,C1725,HCPCS,Outpatient,,,1530.00,994.50,,1530,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1162.8,76,,63.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1101.6,72,,110.496,Percent of Total Billed Charges,72% of Total Billed Charges,1147.5,75,,115.104,Percent of Total Billed charges,75% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1101.6,72,,110.496,Percent of Total Billed Charges,72% of Total Billed Charges,918,60,,92.08,Percent of Total Billed Charges,60% of Total Billed Charges,1377,90,,24.608,Percent of Total Billed Charges,90% of Total Billed Charges,688.5,45,,108.72,Percent of Total Billed Charges,45% of Total Billed Charges,1377,90,,75.528,Percent of Total Billed Charges,90% of Total billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.5,65,,733.464,Percent of total Billed Charges,65% of Total Billed Charges,674.73,44.1,,106.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,1453.5,95,,79.728,Percent of Total Billed Charges,95% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1346.4,88,,73.848,Percent of Total Billed Charges,88% of Total Billed Charges,1377,90,,75.528,Percent of Total Billed charges,90% of Total Billed Charges,674.73,1530,
CHOCO 5F 4X40 O14 OTW BALLOON,2720000383,CDM,272,RC,C1725,HCPCS,Outpatient,,,1530.00,994.50,,1530,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1162.8,76,,63.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1101.6,72,,152.408,Percent of Total Billed Charges,72% of Total Billed Charges,1147.5,75,,158.76,Percent of Total Billed charges,75% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1101.6,72,,152.408,Percent of Total Billed Charges,72% of Total Billed Charges,918,60,,127.008,Percent of Total Billed Charges,60% of Total Billed Charges,1377,90,,53.976,Percent of Total Billed Charges,90% of Total Billed Charges,688.5,45,,34.56,Percent of Total Billed Charges,45% of Total Billed Charges,1377,90,,75.528,Percent of Total Billed Charges,90% of Total billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.5,65,,157.04,Percent of total Billed Charges,65% of Total Billed Charges,674.73,44.1,,33.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,1453.5,95,,79.728,Percent of Total Billed Charges,95% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1346.4,88,,73.848,Percent of Total Billed Charges,88% of Total Billed Charges,1377,90,,75.528,Percent of Total Billed charges,90% of Total Billed Charges,674.73,1530,
CHOCO 5F 4X120 014 OTW BALL,2720000384,CDM,272,RC,C1725,HCPCS,Outpatient,,,1530.00,994.50,,1530,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1162.8,76,,857.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1101.6,72,,121.296,Percent of Total Billed Charges,72% of Total Billed Charges,1147.5,75,,126.352,Percent of Total Billed charges,75% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1101.6,72,,121.296,Percent of Total Billed Charges,72% of Total Billed Charges,918,60,,101.08,Percent of Total Billed Charges,60% of Total Billed Charges,1377,90,,79.384,Percent of Total Billed Charges,90% of Total Billed Charges,688.5,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,1377,90,,1015.56,Percent of Total Billed Charges,90% of Total billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.5,65,,49.92,Percent of total Billed Charges,65% of Total Billed Charges,674.73,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,1453.5,95,,1071.984,Percent of Total Billed Charges,95% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1346.4,88,,992.992,Percent of Total Billed Charges,88% of Total Billed Charges,1377,90,,1015.56,Percent of Total Billed charges,90% of Total Billed Charges,674.73,1530,
URO MAX BALLOON CATH,2720000385,CDM,272,RC,C1726,HCPCS,Outpatient,,,804.83,523.14,,804.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,611.67,76,,183.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,579.48,72,,95.896,Percent of Total Billed Charges,72% of Total Billed Charges,603.62,75,,99.888,Percent of Total Billed charges,75% of Total Billed Charges,804.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.48,72,,95.896,Percent of Total Billed Charges,72% of Total Billed Charges,482.9,60,,79.912,Percent of Total Billed Charges,60% of Total Billed Charges,724.35,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,362.17,45,,34.56,Percent of Total Billed Charges,45% of Total Billed Charges,724.35,90,,217.44,Percent of Total Billed Charges,90% of Total billed Charges,804.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,804.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,804.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,523.14,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,354.93,44.1,,33.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,764.59,95,,229.52,Percent of Total Billed Charges,95% of Total Billed Charges,804.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,708.25,88,,212.608,Percent of Total Billed Charges,88% of Total Billed Charges,724.35,90,,217.44,Percent of Total Billed charges,90% of Total Billed Charges,354.93,804.83,
UROMAX BALLON KIT 12,2720000386,CDM,272,RC,C1726,HCPCS,Outpatient,,,986.74,641.38,,986.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,749.92,76,,58.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,710.45,72,,125.744,Percent of Total Billed Charges,72% of Total Billed Charges,740.06,75,,130.984,Percent of Total Billed charges,75% of Total Billed Charges,986.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,710.45,72,,125.744,Percent of Total Billed Charges,72% of Total Billed Charges,592.04,60,,104.784,Percent of Total Billed Charges,60% of Total Billed Charges,888.07,90,,79.384,Percent of Total Billed Charges,90% of Total Billed Charges,444.03,45,,79.384,Percent of Total Billed Charges,45% of Total Billed Charges,888.07,90,,69.12,Percent of Total Billed Charges,90% of Total billed Charges,986.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,986.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,986.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,641.38,65,,49.92,Percent of total Billed Charges,65% of Total Billed Charges,435.15,44.1,,77.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,937.4,95,,72.96,Percent of Total Billed Charges,95% of Total Billed Charges,986.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,868.33,88,,67.584,Percent of Total Billed Charges,88% of Total Billed Charges,888.07,90,,69.12,Percent of Total Billed charges,90% of Total Billed Charges,435.15,986.74,
BS FLEXIVA 200 TRAC TIP,2720000387,CDM,272,RC,C1726,HCPCS,Outpatient,,,626.22,407.04,,626.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.93,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.88,72,,485.168,Percent of Total Billed Charges,72% of Total Billed Charges,469.67,75,,505.384,Percent of Total Billed charges,75% of Total Billed Charges,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.88,72,,485.168,Percent of Total Billed Charges,72% of Total Billed Charges,375.73,60,,404.312,Percent of Total Billed Charges,60% of Total Billed Charges,563.6,90,,25.4,Percent of Total Billed Charges,90% of Total Billed Charges,281.8,45,,226.632,Percent of Total Billed Charges,45% of Total Billed Charges,563.6,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.04,65,,114.664,Percent of total Billed Charges,65% of Total Billed Charges,276.16,44.1,,222.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,594.91,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,551.07,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,563.6,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,276.16,626.22,
BS .038 STRAIGHT TIP ZIPWIRE,2720000388,CDM,272,RC,C1726,HCPCS,Outpatient,,,65.05,42.28,,65.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.44,76,,58.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.84,72,,161.936,Percent of Total Billed Charges,72% of Total Billed Charges,48.79,75,,168.688,Percent of Total Billed charges,75% of Total Billed Charges,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.84,72,,161.936,Percent of Total Billed Charges,72% of Total Billed Charges,39.03,60,,134.944,Percent of Total Billed Charges,60% of Total Billed Charges,58.55,90,,2874.352,Percent of Total Billed Charges,90% of Total Billed Charges,29.27,45,,12.304,Percent of Total Billed Charges,45% of Total Billed Charges,58.55,90,,69.12,Percent of Total Billed Charges,90% of Total billed Charges,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.28,65,,327.352,Percent of total Billed Charges,65% of Total Billed Charges,28.69,44.1,,12.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,61.8,95,,72.96,Percent of Total Billed Charges,95% of Total Billed Charges,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.24,88,,67.584,Percent of Total Billed Charges,88% of Total Billed Charges,58.55,90,,69.12,Percent of Total Billed charges,90% of Total Billed Charges,28.69,65.05,
TWO-WING MALECOT  12FR,2720000389,CDM,272,RC,C1729,HCPCS,Outpatient,,,165.38,107.50,,165.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,125.69,76,,134.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,119.07,72,,207.024,Percent of Total Billed Charges,72% of Total Billed Charges,124.04,75,,215.656,Percent of Total Billed charges,75% of Total Billed Charges,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.07,72,,207.024,Percent of Total Billed Charges,72% of Total Billed Charges,99.23,60,,172.52,Percent of Total Billed Charges,60% of Total Billed Charges,148.84,90,,91.944,Percent of Total Billed Charges,90% of Total Billed Charges,74.42,45,,26.992,Percent of Total Billed Charges,45% of Total Billed Charges,148.84,90,,158.76,Percent of Total Billed Charges,90% of Total billed Charges,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,65,,17.776,Percent of total Billed Charges,65% of Total Billed Charges,72.93,44.1,,26.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,157.11,95,,167.584,Percent of Total Billed Charges,95% of Total Billed Charges,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,88,,155.232,Percent of Total Billed Charges,88% of Total Billed Charges,148.84,90,,158.76,Percent of Total Billed charges,90% of Total Billed Charges,72.93,165.38,
BARD POWER TRIALYSIS,2720000390,CDM,272,RC,C1729,HCPCS,Outpatient,,,285.55,185.61,,285.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,217.02,76,,382.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,205.6,72,,110.496,Percent of Total Billed Charges,72% of Total Billed Charges,214.16,75,,115.104,Percent of Total Billed charges,75% of Total Billed Charges,285.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.6,72,,110.496,Percent of Total Billed Charges,72% of Total Billed Charges,171.33,60,,92.08,Percent of Total Billed Charges,60% of Total Billed Charges,257,90,,91.944,Percent of Total Billed Charges,90% of Total Billed Charges,128.5,45,,39.688,Percent of Total Billed Charges,45% of Total Billed Charges,257,90,,453.264,Percent of Total Billed Charges,90% of Total billed Charges,285.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.61,65,,38.984,Percent of total Billed Charges,65% of Total Billed Charges,125.93,44.1,,38.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,271.27,95,,478.44,Percent of Total Billed Charges,95% of Total Billed Charges,285.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.28,88,,443.192,Percent of Total Billed Charges,88% of Total Billed Charges,257,90,,453.264,Percent of Total Billed charges,90% of Total Billed Charges,125.93,285.55,
BARD NIAGRA SLIM CAT,2720000391,CDM,272,RC,C1729,HCPCS,Outpatient,,,110.25,71.66,,110.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,83.79,76,,20.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,79.38,72,,370.864,Percent of Total Billed Charges,72% of Total Billed Charges,82.69,75,,386.32,Percent of Total Billed charges,75% of Total Billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,72,,370.864,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,60,,309.056,Percent of Total Billed Charges,60% of Total Billed Charges,99.23,90,,43.2,Percent of Total Billed Charges,90% of Total Billed Charges,49.61,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,99.23,90,,24.608,Percent of Total Billed Charges,90% of Total billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,65,,57.328,Percent of total Billed Charges,65% of Total Billed Charges,48.62,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,104.74,95,,25.976,Percent of Total Billed Charges,95% of Total Billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,88,,24.064,Percent of Total Billed Charges,88% of Total Billed Charges,99.23,90,,24.608,Percent of Total Billed charges,90% of Total Billed Charges,48.62,110.25,
EXPORT 6F ASPIRATION CATHETER,2720000392,CDM,272,RC,C1729,HCPCS,Outpatient,,,1421.12,923.73,,1421.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1080.05,76,,45.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1023.21,72,,118.12,Percent of Total Billed Charges,72% of Total Billed Charges,1065.84,75,,123.04,Percent of Total Billed charges,75% of Total Billed Charges,1421.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1023.21,72,,118.12,Percent of Total Billed Charges,72% of Total Billed Charges,852.67,60,,98.432,Percent of Total Billed Charges,60% of Total Billed Charges,1279.01,90,,43.2,Percent of Total Billed Charges,90% of Total Billed Charges,639.5,45,,39.688,Percent of Total Billed Charges,45% of Total Billed Charges,1279.01,90,,53.976,Percent of Total Billed Charges,90% of Total billed Charges,1421.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1421.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1421.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.73,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,626.71,44.1,,38.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,1350.06,95,,56.976,Percent of Total Billed Charges,95% of Total Billed Charges,1421.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1250.59,88,,52.776,Percent of Total Billed Charges,88% of Total Billed Charges,1279.01,90,,53.976,Percent of Total Billed charges,90% of Total Billed Charges,626.71,1421.12,
HEIMLICK VALVE,2720000393,CDM,272,RC,C1729,HCPCS,Outpatient,,,181.18,117.77,,181.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,137.7,76,,67.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,130.45,72,,376.576,Percent of Total Billed Charges,72% of Total Billed Charges,135.89,75,,392.272,Percent of Total Billed charges,75% of Total Billed Charges,181.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.45,72,,376.576,Percent of Total Billed Charges,72% of Total Billed Charges,108.71,60,,313.816,Percent of Total Billed Charges,60% of Total Billed Charges,163.06,90,,43.2,Percent of Total Billed Charges,90% of Total Billed Charges,81.53,45,,12.704,Percent of Total Billed Charges,45% of Total Billed Charges,163.06,90,,79.384,Percent of Total Billed Charges,90% of Total billed Charges,181.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.77,65,,57.328,Percent of total Billed Charges,65% of Total Billed Charges,79.9,44.1,,12.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,172.12,95,,83.792,Percent of Total Billed Charges,95% of Total Billed Charges,181.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.44,88,,77.616,Percent of Total Billed Charges,88% of Total Billed Charges,163.06,90,,79.384,Percent of Total Billed charges,90% of Total Billed Charges,79.9,181.18,
MP DRAINAGE CATH 12FX15CM,2720000394,CDM,272,RC,C1729,HCPCS,Outpatient,,,315.96,205.37,,315.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,240.13,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,227.49,72,,104.784,Percent of Total Billed Charges,72% of Total Billed Charges,236.97,75,,109.144,Percent of Total Billed charges,75% of Total Billed Charges,315.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.49,72,,104.784,Percent of Total Billed Charges,72% of Total Billed Charges,189.58,60,,87.32,Percent of Total Billed Charges,60% of Total Billed Charges,284.36,90,,43.2,Percent of Total Billed Charges,90% of Total Billed Charges,142.18,45,,1437.176,Percent of Total Billed Charges,45% of Total Billed Charges,284.36,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,315.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.37,65,,18.344,Percent of total Billed Charges,65% of Total Billed Charges,139.34,44.1,,1408.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,300.16,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,315.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.04,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,284.36,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,139.34,315.96,
PERMA CATH,2720000395,CDM,272,RC,C1751,HCPCS,Outpatient,,,529.20,343.98,,529.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,402.19,76,,67.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,381.02,72,,72.4,Percent of Total Billed Charges,72% of Total Billed Charges,396.9,75,,75.416,Percent of Total Billed charges,75% of Total Billed Charges,529.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.02,72,,72.4,Percent of Total Billed Charges,72% of Total Billed Charges,317.52,60,,60.328,Percent of Total Billed Charges,60% of Total Billed Charges,476.28,90,,464.368,Percent of Total Billed Charges,90% of Total Billed Charges,238.14,45,,45.976,Percent of Total Billed Charges,45% of Total Billed Charges,476.28,90,,79.384,Percent of Total Billed Charges,90% of Total billed Charges,529.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.98,65,,2075.92,Percent of total Billed Charges,65% of Total Billed Charges,233.38,44.1,,45.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,502.74,95,,83.792,Percent of Total Billed Charges,95% of Total Billed Charges,529.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.7,88,,77.616,Percent of Total Billed Charges,88% of Total Billed Charges,476.28,90,,79.384,Percent of Total Billed charges,90% of Total Billed Charges,233.38,529.2,
TRAY CNTRL VEIN 4L 8.5 FR 16CM,2720000396,CDM,272,RC,C1751,HCPCS,Outpatient,,,419.25,272.51,,419.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,318.63,76,,21.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,301.86,72,,255.92,Percent of Total Billed Charges,72% of Total Billed Charges,314.44,75,,266.584,Percent of Total Billed charges,75% of Total Billed Charges,419.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.86,72,,255.92,Percent of Total Billed Charges,72% of Total Billed Charges,251.55,60,,213.272,Percent of Total Billed Charges,60% of Total Billed Charges,377.33,90,,91.272,Percent of Total Billed Charges,90% of Total Billed Charges,188.66,45,,45.976,Percent of Total Billed Charges,45% of Total Billed Charges,377.33,90,,25.4,Percent of Total Billed Charges,90% of Total billed Charges,419.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.51,65,,66.408,Percent of total Billed Charges,65% of Total Billed Charges,184.89,44.1,,45.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,398.29,95,,26.816,Percent of Total Billed Charges,95% of Total Billed Charges,419.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.94,88,,24.84,Percent of Total Billed Charges,88% of Total Billed Charges,377.33,90,,25.4,Percent of Total Billed charges,90% of Total Billed Charges,184.89,419.25,
TRY CTRL VEIN CTR VEIN 4L 16CM,2720000397,CDM,272,RC,C1751,HCPCS,Outpatient,,,187.76,122.04,,187.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,142.7,76,,2427.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,135.19,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,140.82,75,,95.256,Percent of Total Billed charges,75% of Total Billed Charges,187.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.19,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,112.66,60,,76.208,Percent of Total Billed Charges,60% of Total Billed Charges,168.98,90,,2361.6,Percent of Total Billed Charges,90% of Total Billed Charges,84.49,45,,21.6,Percent of Total Billed Charges,45% of Total Billed Charges,168.98,90,,2874.352,Percent of Total Billed Charges,90% of Total billed Charges,187.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.04,65,,66.408,Percent of total Billed Charges,65% of Total Billed Charges,82.8,44.1,,21.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,178.37,95,,3034.032,Percent of Total Billed Charges,95% of Total Billed Charges,187.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.23,88,,2810.472,Percent of Total Billed Charges,88% of Total Billed Charges,168.98,90,,2874.352,Percent of Total Billed charges,90% of Total Billed Charges,82.8,187.76,
POWER WAND 4FR SNGL,2720000398,CDM,272,RC,C1751,HCPCS,Outpatient,,,278.00,180.70,,278,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,211.28,76,,77.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,200.16,72,,321.968,Percent of Total Billed Charges,72% of Total Billed Charges,208.5,75,,335.384,Percent of Total Billed charges,75% of Total Billed Charges,278,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.16,72,,321.968,Percent of Total Billed Charges,72% of Total Billed Charges,166.8,60,,268.304,Percent of Total Billed Charges,60% of Total Billed Charges,250.2,90,,284.976,Percent of Total Billed Charges,90% of Total Billed Charges,125.1,45,,21.6,Percent of Total Billed Charges,45% of Total Billed Charges,250.2,90,,91.944,Percent of Total Billed Charges,90% of Total billed Charges,278,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.7,65,,31.2,Percent of total Billed Charges,65% of Total Billed Charges,122.6,44.1,,21.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,264.1,95,,97.056,Percent of Total Billed Charges,95% of Total Billed Charges,278,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.64,88,,89.904,Percent of Total Billed Charges,88% of Total Billed Charges,250.2,90,,91.944,Percent of Total Billed charges,90% of Total Billed Charges,122.6,278,
POWERLINE 6F DUAL INTERMEDIATE,2720000399,CDM,272,RC,C1751,HCPCS,Outpatient,,,562.28,365.48,,562.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,427.33,76,,77.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,404.84,72,,437.544,Percent of Total Billed Charges,72% of Total Billed Charges,421.71,75,,455.776,Percent of Total Billed charges,75% of Total Billed Charges,562.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404.84,72,,437.544,Percent of Total Billed Charges,72% of Total Billed Charges,337.37,60,,364.616,Percent of Total Billed Charges,60% of Total Billed Charges,506.05,90,,173.056,Percent of Total Billed Charges,90% of Total Billed Charges,253.03,45,,21.6,Percent of Total Billed Charges,45% of Total Billed Charges,506.05,90,,91.944,Percent of Total Billed Charges,90% of Total billed Charges,562.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365.48,65,,31.2,Percent of total Billed Charges,65% of Total Billed Charges,247.97,44.1,,21.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,534.17,95,,97.056,Percent of Total Billed Charges,95% of Total Billed Charges,562.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,494.81,88,,89.904,Percent of Total Billed Charges,88% of Total Billed Charges,506.05,90,,91.944,Percent of Total Billed charges,90% of Total Billed Charges,247.97,562.28,
CATHETER PICC 4FR SINGLE LUMEN,2720000400,CDM,278,RC,C1751,HCPCS,Outpatient,,,1060.50,689.33,,1060.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,805.98,76,,36.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,763.56,72,,102.88,Percent of Total Billed Charges,72% of Total Billed Charges,763.56,72,,107.168,Percent of Total Billed charges,72% of Total Billed Charges,1060.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,763.56,72,,102.88,Percent of Total Billed Charges,72% of Total Billed Charges,636.3,60,,85.736,Percent of Total Billed Charges,60% of Total Billed Charges,954.45,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,477.23,45,,21.6,Percent of Total Billed Charges,45% of Total Billed Charges,954.45,90,,43.2,Percent of Total Billed Charges,90% of Total billed Charges,1060.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1060.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1060.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,689.33,65,,31.2,Percent of total Billed Charges,65% of Total Billed Charges,467.68,44.1,,21.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,1007.48,95,,45.6,Percent of Total Billed Charges,95% of Total Billed Charges,1060.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,933.24,88,,42.24,Percent of Total Billed Charges,88% of Total Billed Charges,954.45,90,,43.2,Percent of Total Billed charges,90% of Total Billed Charges,467.68,1060.5,
POWERPICC 5F TRIPPLE LUMEN,2720000401,CDM,278,RC,C1751,HCPCS,Outpatient,,,844.83,549.14,,844.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,642.07,76,,36.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,608.28,72,,403.888,Percent of Total Billed Charges,72% of Total Billed Charges,608.28,72,,420.712,Percent of Total Billed charges,72% of Total Billed Charges,844.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,608.28,72,,403.888,Percent of Total Billed Charges,72% of Total Billed Charges,506.9,60,,336.568,Percent of Total Billed Charges,60% of Total Billed Charges,760.35,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,380.17,45,,232.184,Percent of Total Billed Charges,45% of Total Billed Charges,760.35,90,,43.2,Percent of Total Billed Charges,90% of Total billed Charges,844.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,844.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,844.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.14,65,,31.2,Percent of total Billed Charges,65% of Total Billed Charges,372.57,44.1,,227.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,802.59,95,,45.6,Percent of Total Billed Charges,95% of Total Billed Charges,844.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,743.45,88,,42.24,Percent of Total Billed Charges,88% of Total Billed Charges,760.35,90,,43.2,Percent of Total Billed charges,90% of Total Billed Charges,372.57,844.83,
POWERWAND KIT 4F X 8CM (72391),2720000402,CDM,278,RC,C1751,HCPCS,Outpatient,,,250.00,162.50,,250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,190,76,,36.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,180,72,,120.024,Percent of Total Billed Charges,72% of Total Billed Charges,180,72,,125.024,Percent of Total Billed charges,72% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180,72,,120.024,Percent of Total Billed Charges,72% of Total Billed Charges,150,60,,100.016,Percent of Total Billed Charges,60% of Total Billed Charges,225,90,,284.976,Percent of Total Billed Charges,90% of Total Billed Charges,112.5,45,,45.64,Percent of Total Billed Charges,45% of Total Billed Charges,225,90,,43.2,Percent of Total Billed Charges,90% of Total billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.5,65,,335.376,Percent of total Billed Charges,65% of Total Billed Charges,110.25,44.1,,44.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,237.5,95,,45.6,Percent of Total Billed Charges,95% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220,88,,42.24,Percent of Total Billed Charges,88% of Total Billed Charges,225,90,,43.2,Percent of Total Billed charges,90% of Total Billed Charges,110.25,250,
PICC 4FR SINGLE LUMEN,2720000403,CDM,272,RC,C1751,HCPCS,Outpatient,,,1060.50,689.33,,1060.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,805.98,76,,36.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,763.56,72,,985.584,Percent of Total Billed Charges,72% of Total Billed Charges,795.38,75,,1026.648,Percent of Total Billed charges,75% of Total Billed Charges,1060.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,763.56,72,,985.584,Percent of Total Billed Charges,72% of Total Billed Charges,636.3,60,,821.32,Percent of Total Billed Charges,60% of Total Billed Charges,954.45,90,,686.632,Percent of Total Billed Charges,90% of Total Billed Charges,477.23,45,,1180.8,Percent of Total Billed Charges,45% of Total Billed Charges,954.45,90,,43.2,Percent of Total Billed Charges,90% of Total billed Charges,1060.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1060.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1060.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,689.33,65,,65.92,Percent of total Billed Charges,65% of Total Billed Charges,467.68,44.1,,1157.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,1007.48,95,,45.6,Percent of Total Billed Charges,95% of Total Billed Charges,1060.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,933.24,88,,42.24,Percent of Total Billed Charges,88% of Total Billed Charges,954.45,90,,43.2,Percent of Total Billed charges,90% of Total Billed Charges,467.68,1060.5,
CENTRALLINE SET 2 LUMEN4FX3CM,2720000404,CDM,272,RC,C1751,HCPCS,Outpatient,,,108.89,70.78,,108.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.76,76,,392.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,78.4,72,,437.544,Percent of Total Billed Charges,72% of Total Billed Charges,81.67,75,,455.776,Percent of Total Billed charges,75% of Total Billed Charges,108.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.4,72,,437.544,Percent of Total Billed Charges,72% of Total Billed Charges,65.33,60,,364.616,Percent of Total Billed Charges,60% of Total Billed Charges,98,90,,178.6,Percent of Total Billed Charges,90% of Total Billed Charges,49,45,,142.488,Percent of Total Billed Charges,45% of Total Billed Charges,98,90,,464.368,Percent of Total Billed Charges,90% of Total billed Charges,108.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.78,65,,1705.6,Percent of total Billed Charges,65% of Total Billed Charges,48.02,44.1,,139.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,103.45,95,,490.168,Percent of Total Billed Charges,95% of Total Billed Charges,108.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.82,88,,454.048,Percent of Total Billed Charges,88% of Total Billed Charges,98,90,,464.368,Percent of Total Billed charges,90% of Total Billed Charges,48.02,108.89,
POWERPICC 5F TRIPLE LUMEN,2720000405,CDM,272,RC,C1751,HCPCS,Outpatient,,,844.83,549.14,,844.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,642.07,76,,77.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,608.28,72,,271.8,Percent of Total Billed Charges,72% of Total Billed Charges,633.62,75,,283.12,Percent of Total Billed charges,75% of Total Billed Charges,844.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,608.28,72,,271.8,Percent of Total Billed Charges,72% of Total Billed Charges,506.9,60,,226.496,Percent of Total Billed Charges,60% of Total Billed Charges,760.35,90,,77.8,Percent of Total Billed Charges,90% of Total Billed Charges,380.17,45,,86.528,Percent of Total Billed Charges,45% of Total Billed Charges,760.35,90,,91.272,Percent of Total Billed Charges,90% of Total billed Charges,844.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,844.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,844.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.14,65,,205.816,Percent of total Billed Charges,65% of Total Billed Charges,372.57,44.1,,84.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,802.59,95,,96.344,Percent of Total Billed Charges,95% of Total Billed Charges,844.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,743.45,88,,89.248,Percent of Total Billed Charges,88% of Total Billed Charges,760.35,90,,91.272,Percent of Total Billed charges,90% of Total Billed Charges,372.57,844.83,
CENTRALLINE 4 LUMEN 8FX20CM,2720000406,CDM,272,RC,C1751,HCPCS,Outpatient,,,444.31,288.80,,444.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,337.68,76,,1994.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,319.9,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,333.23,75,,44.32,Percent of Total Billed charges,75% of Total Billed Charges,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319.9,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,266.59,60,,35.456,Percent of Total Billed Charges,60% of Total Billed Charges,399.88,90,,1042.256,Percent of Total Billed Charges,90% of Total Billed Charges,199.94,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,399.88,90,,2361.6,Percent of Total Billed Charges,90% of Total billed Charges,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.8,65,,124.984,Percent of total Billed Charges,65% of Total Billed Charges,195.94,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,422.09,95,,2492.8,Percent of Total Billed Charges,95% of Total Billed Charges,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.99,88,,2309.12,Percent of Total Billed Charges,88% of Total Billed Charges,399.88,90,,2361.6,Percent of Total Billed charges,90% of Total Billed Charges,195.94,444.31,
FOGARTY ART EMBOL CA,2720000408,CDM,272,RC,C1757,HCPCS,Outpatient,,,276.73,179.87,,276.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,210.31,76,,240.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,199.25,72,,107.96,Percent of Total Billed Charges,72% of Total Billed Charges,207.55,75,,112.456,Percent of Total Billed charges,75% of Total Billed Charges,276.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.25,72,,107.96,Percent of Total Billed Charges,72% of Total Billed Charges,166.04,60,,89.968,Percent of Total Billed Charges,60% of Total Billed Charges,249.06,90,,1305.36,Percent of Total Billed Charges,90% of Total Billed Charges,124.53,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,249.06,90,,284.976,Percent of Total Billed Charges,90% of Total billed Charges,276.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.87,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,122.04,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,262.89,95,,300.808,Percent of Total Billed Charges,95% of Total Billed Charges,276.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.52,88,,278.64,Percent of Total Billed Charges,88% of Total Billed Charges,249.06,90,,284.976,Percent of Total Billed charges,90% of Total Billed Charges,122.04,276.73,
FOGARTY 2FR EMB CATH,2720000409,CDM,272,RC,C1757,HCPCS,Outpatient,,,159.86,103.91,,159.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,121.49,76,,146.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,115.1,72,,374.04,Percent of Total Billed Charges,72% of Total Billed Charges,119.9,75,,389.624,Percent of Total Billed charges,75% of Total Billed Charges,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.1,72,,374.04,Percent of Total Billed Charges,72% of Total Billed Charges,95.92,60,,311.696,Percent of Total Billed Charges,60% of Total Billed Charges,143.87,90,,131.776,Percent of Total Billed Charges,90% of Total Billed Charges,71.94,45,,142.488,Percent of Total Billed Charges,45% of Total Billed Charges,143.87,90,,173.056,Percent of Total Billed Charges,90% of Total billed Charges,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.91,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,70.5,44.1,,139.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,151.87,95,,182.664,Percent of Total Billed Charges,95% of Total Billed Charges,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.68,88,,169.208,Percent of Total Billed Charges,88% of Total Billed Charges,143.87,90,,173.056,Percent of Total Billed charges,90% of Total Billed Charges,70.5,159.86,
FOGARTY 3FR EMB CATH,2720000410,CDM,272,RC,C1757,HCPCS,Outpatient,,,103.64,67.37,,103.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,78.77,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,74.62,72,,114.304,Percent of Total Billed Charges,72% of Total Billed Charges,77.73,75,,119.072,Percent of Total Billed charges,75% of Total Billed Charges,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.62,72,,114.304,Percent of Total Billed Charges,72% of Total Billed Charges,62.18,60,,95.256,Percent of Total Billed Charges,60% of Total Billed Charges,93.28,90,,133.36,Percent of Total Billed Charges,90% of Total Billed Charges,46.64,45,,343.32,Percent of Total Billed Charges,45% of Total Billed Charges,93.28,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.37,65,,205.816,Percent of total Billed Charges,65% of Total Billed Charges,45.71,44.1,,336.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,98.46,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.2,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,93.28,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,45.71,103.64,
FOGARTY 4FR EMB CATH,2720000411,CDM,272,RC,C1757,HCPCS,Outpatient,,,103.64,67.37,,103.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,78.77,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,74.62,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,77.73,75,,220.944,Percent of Total Billed charges,75% of Total Billed Charges,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.62,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,62.18,60,,176.752,Percent of Total Billed Charges,60% of Total Billed Charges,93.28,90,,154,Percent of Total Billed Charges,90% of Total Billed Charges,46.64,45,,89.304,Percent of Total Billed Charges,45% of Total Billed Charges,93.28,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.37,65,,495.904,Percent of total Billed Charges,65% of Total Billed Charges,45.71,44.1,,87.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,98.46,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.2,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,93.28,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,45.71,103.64,
BARD COUNCIL TIP CATH 18,2720000412,CDM,272,RC,C1758,HCPCS,Outpatient,,,39.69,25.80,,39.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,30.16,76,,240.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.58,72,,295.928,Percent of Total Billed Charges,72% of Total Billed Charges,29.77,75,,308.264,Percent of Total Billed charges,75% of Total Billed Charges,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.58,72,,295.928,Percent of Total Billed Charges,72% of Total Billed Charges,23.81,60,,246.608,Percent of Total Billed Charges,60% of Total Billed Charges,35.72,90,,122.248,Percent of Total Billed Charges,90% of Total Billed Charges,17.86,45,,38.896,Percent of Total Billed Charges,45% of Total Billed Charges,35.72,90,,284.976,Percent of Total Billed Charges,90% of Total billed Charges,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.8,65,,128.992,Percent of total Billed Charges,65% of Total Billed Charges,17.5,44.1,,38.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.71,95,,300.808,Percent of Total Billed Charges,95% of Total Billed Charges,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,88,,278.64,Percent of Total Billed Charges,88% of Total Billed Charges,35.72,90,,284.976,Percent of Total Billed charges,90% of Total Billed Charges,17.5,39.69,
BARD COUNCIL TIP CATH 20,2720000413,CDM,272,RC,C1758,HCPCS,Outpatient,,,39.69,25.80,,39.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,30.16,76,,579.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.58,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,29.77,75,,129.656,Percent of Total Billed charges,75% of Total Billed Charges,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.58,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,23.81,60,,103.72,Percent of Total Billed Charges,60% of Total Billed Charges,35.72,90,,123.832,Percent of Total Billed Charges,90% of Total Billed Charges,17.86,45,,521.128,Percent of Total Billed Charges,45% of Total Billed Charges,35.72,90,,686.632,Percent of Total Billed Charges,90% of Total billed Charges,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.8,65,,56.184,Percent of total Billed Charges,65% of Total Billed Charges,17.5,44.1,,510.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.71,95,,724.784,Percent of Total Billed Charges,95% of Total Billed Charges,39.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,88,,671.376,Percent of Total Billed Charges,88% of Total Billed Charges,35.72,90,,686.632,Percent of Total Billed charges,90% of Total Billed Charges,17.5,39.69,
COOK WHISTLE TIP RIGHT CATH,2720000414,CDM,272,RC,C1758,HCPCS,Outpatient,,,17.64,11.47,,17.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.41,76,,150.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.7,72,,304.184,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,75,,316.864,Percent of Total Billed charges,75% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.7,72,,304.184,Percent of Total Billed Charges,72% of Total Billed Charges,10.58,60,,253.488,Percent of Total Billed Charges,60% of Total Billed Charges,15.88,90,,113.512,Percent of Total Billed Charges,90% of Total Billed Charges,7.94,45,,652.68,Percent of Total Billed Charges,45% of Total Billed Charges,15.88,90,,178.6,Percent of Total Billed Charges,90% of Total billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.47,65,,752.744,Percent of total Billed Charges,65% of Total Billed Charges,7.78,44.1,,639.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.76,95,,188.528,Percent of Total Billed Charges,95% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.52,88,,174.632,Percent of Total Billed Charges,88% of Total Billed Charges,15.88,90,,178.6,Percent of Total Billed charges,90% of Total Billed Charges,7.78,17.64,
COOK WHISTLE TIP LEFT CATH,2720000415,CDM,272,RC,C1758,HCPCS,Outpatient,,,17.64,11.47,,17.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.41,76,,65.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.7,72,,178.448,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,75,,185.88,Percent of Total Billed charges,75% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.7,72,,178.448,Percent of Total Billed Charges,72% of Total Billed Charges,10.58,60,,148.704,Percent of Total Billed Charges,60% of Total Billed Charges,15.88,90,,36.52,Percent of Total Billed Charges,90% of Total Billed Charges,7.94,45,,65.888,Percent of Total Billed Charges,45% of Total Billed Charges,15.88,90,,77.8,Percent of Total Billed Charges,90% of Total billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.47,65,,942.76,Percent of total Billed Charges,65% of Total Billed Charges,7.78,44.1,,64.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.76,95,,82.12,Percent of Total Billed Charges,95% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.52,88,,76.064,Percent of Total Billed Charges,88% of Total Billed Charges,15.88,90,,77.8,Percent of Total Billed charges,90% of Total Billed Charges,7.78,17.64,
COOK OPEN END CATH 6 X 70,2720000416,CDM,272,RC,C1758,HCPCS,Outpatient,,,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,880.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,114.304,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,119.072,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,114.304,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,95.256,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,61.12,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,66.68,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,1042.256,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,95.168,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,65.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,1100.16,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,1019.096,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,1042.256,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
COOK OPEN END CATH 5 X 70,2720000417,CDM,272,RC,C1758,HCPCS,Outpatient,,,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,1102.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,115.584,Percent of Total Billed Charges,72% of Total Billed Charges,15.71,75,,120.4,Percent of Total Billed charges,75% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,115.584,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,96.32,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,24.608,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,77,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,1305.36,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,96.312,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,75.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,1377.88,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,1276.352,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,1305.36,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
COOK DUAL LUMEN URETHERAL CATH,2720000418,CDM,272,RC,C1758,HCPCS,Outpatient,,,70.56,45.86,,70.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.63,76,,111.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.8,72,,107.32,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,75,,111.792,Percent of Total Billed charges,75% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.8,72,,107.32,Percent of Total Billed Charges,72% of Total Billed Charges,42.34,60,,89.432,Percent of Total Billed Charges,60% of Total Billed Charges,63.5,90,,226.232,Percent of Total Billed Charges,90% of Total Billed Charges,31.75,45,,61.128,Percent of Total Billed Charges,45% of Total Billed Charges,63.5,90,,131.776,Percent of Total Billed Charges,90% of Total billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.86,65,,111.224,Percent of total Billed Charges,65% of Total Billed Charges,31.12,44.1,,59.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.03,95,,139.096,Percent of Total Billed Charges,95% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.09,88,,128.848,Percent of Total Billed Charges,88% of Total Billed Charges,63.5,90,,131.776,Percent of Total Billed charges,90% of Total Billed Charges,31.12,70.56,
6FR SHEATH BOSTN SCI,2720000419,CDM,272,RC,C1766,HCPCS,Outpatient,,,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,112.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,295.928,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,308.264,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,295.928,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,246.608,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,61.92,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,133.36,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,88.288,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,60.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,140.768,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,130.392,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,133.36,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
5FR SHEATH BOSTN SCI,2720000420,CDM,272,RC,C1766,HCPCS,Outpatient,,,110.25,71.66,,110.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,83.79,76,,130.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,79.38,72,,11.912,Percent of Total Billed Charges,72% of Total Billed Charges,82.69,75,,12.408,Percent of Total Billed charges,75% of Total Billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,72,,11.912,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,60,,9.928,Percent of Total Billed Charges,60% of Total Billed Charges,99.23,90,,15.88,Percent of Total Billed Charges,90% of Total Billed Charges,49.61,45,,56.76,Percent of Total Billed Charges,45% of Total Billed Charges,99.23,90,,154,Percent of Total Billed Charges,90% of Total billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,65,,89.432,Percent of total Billed Charges,65% of Total Billed Charges,48.62,44.1,,55.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,104.74,95,,162.56,Percent of Total Billed Charges,95% of Total Billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,88,,150.576,Percent of Total Billed Charges,88% of Total Billed Charges,99.23,90,,154,Percent of Total Billed charges,90% of Total Billed Charges,48.62,110.25,
7FR RENAL SHEATH BS,2720000421,CDM,272,RC,C1766,HCPCS,Outpatient,,,255.78,166.26,,255.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,194.39,76,,103.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,184.16,72,,196.224,Percent of Total Billed Charges,72% of Total Billed Charges,191.84,75,,204.4,Percent of Total Billed charges,75% of Total Billed Charges,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.16,72,,196.224,Percent of Total Billed Charges,72% of Total Billed Charges,153.47,60,,163.52,Percent of Total Billed Charges,60% of Total Billed Charges,230.2,90,,93.672,Percent of Total Billed Charges,90% of Total Billed Charges,115.1,45,,18.256,Percent of Total Billed Charges,45% of Total Billed Charges,230.2,90,,122.248,Percent of Total Billed Charges,90% of Total billed Charges,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.26,65,,81.984,Percent of total Billed Charges,65% of Total Billed Charges,112.8,44.1,,17.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,242.99,95,,129.04,Percent of Total Billed Charges,95% of Total Billed Charges,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.09,88,,119.536,Percent of Total Billed Charges,88% of Total Billed Charges,230.2,90,,122.248,Percent of Total Billed charges,90% of Total Billed Charges,112.8,255.78,
7FR BS SHEATH 16034,2720000422,CDM,272,RC,C1766,HCPCS,Outpatient,,,110.25,71.66,,110.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,83.79,76,,104.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,79.38,72,,178.448,Percent of Total Billed Charges,72% of Total Billed Charges,82.69,75,,185.88,Percent of Total Billed charges,75% of Total Billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,72,,178.448,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,60,,148.704,Percent of Total Billed Charges,60% of Total Billed Charges,99.23,90,,992.256,Percent of Total Billed Charges,90% of Total Billed Charges,49.61,45,,30.56,Percent of Total Billed Charges,45% of Total Billed Charges,99.23,90,,123.832,Percent of Total Billed Charges,90% of Total billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,65,,26.376,Percent of total Billed Charges,65% of Total Billed Charges,48.62,44.1,,29.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,104.74,95,,130.712,Percent of Total Billed Charges,95% of Total Billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,88,,121.08,Percent of Total Billed Charges,88% of Total Billed Charges,99.23,90,,123.832,Percent of Total Billed charges,90% of Total Billed Charges,48.62,110.25,
5F GLIDESHEATH NK,2720000423,CDM,272,RC,C1894,HCPCS,Outpatient,,,197.35,128.28,,197.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.99,76,,95.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,142.09,72,,106.688,Percent of Total Billed Charges,72% of Total Billed Charges,148.01,75,,111.136,Percent of Total Billed charges,75% of Total Billed Charges,197.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.09,72,,106.688,Percent of Total Billed Charges,72% of Total Billed Charges,118.41,60,,88.904,Percent of Total Billed Charges,60% of Total Billed Charges,177.62,90,,144.472,Percent of Total Billed Charges,90% of Total Billed Charges,88.81,45,,12.304,Percent of Total Billed Charges,45% of Total Billed Charges,177.62,90,,113.512,Percent of Total Billed Charges,90% of Total billed Charges,197.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.28,65,,44.144,Percent of total Billed Charges,65% of Total Billed Charges,87.03,44.1,,12.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,187.48,95,,119.824,Percent of Total Billed Charges,95% of Total Billed Charges,197.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.67,88,,110.992,Percent of Total Billed Charges,88% of Total Billed Charges,177.62,90,,113.512,Percent of Total Billed charges,90% of Total Billed Charges,87.03,197.35,
PINNACLE R/0 5F 10CM SHEATH,2720000424,CDM,272,RC,C1894,HCPCS,Outpatient,,,114.10,74.17,,114.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,86.72,76,,30.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.15,72,,108.592,Percent of Total Billed Charges,72% of Total Billed Charges,85.58,75,,113.12,Percent of Total Billed charges,75% of Total Billed Charges,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.15,72,,108.592,Percent of Total Billed Charges,72% of Total Billed Charges,68.46,60,,90.496,Percent of Total Billed Charges,60% of Total Billed Charges,102.69,90,,19.048,Percent of Total Billed Charges,90% of Total Billed Charges,51.35,45,,113.112,Percent of Total Billed Charges,45% of Total Billed Charges,102.69,90,,36.52,Percent of Total Billed Charges,90% of Total billed Charges,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.17,65,,17.776,Percent of total Billed Charges,65% of Total Billed Charges,50.32,44.1,,110.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,108.4,95,,38.544,Percent of Total Billed Charges,95% of Total Billed Charges,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.41,88,,35.704,Percent of Total Billed Charges,88% of Total Billed Charges,102.69,90,,36.52,Percent of Total Billed charges,90% of Total Billed Charges,50.32,114.1,
PINNACLE R/O 7F 25CM SHEATH,2720000425,CDM,272,RC,C1894,HCPCS,Outpatient,,,114.10,74.17,,114.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,86.72,76,,51.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.15,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,85.58,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.15,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,68.46,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,102.69,90,,113.512,Percent of Total Billed Charges,90% of Total Billed Charges,51.35,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,102.69,90,,61.12,Percent of Total Billed Charges,90% of Total billed Charges,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.17,65,,163.392,Percent of total Billed Charges,65% of Total Billed Charges,50.32,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,108.4,95,,64.52,Percent of Total Billed Charges,95% of Total Billed Charges,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.41,88,,59.76,Percent of Total Billed Charges,88% of Total Billed Charges,102.69,90,,61.12,Percent of Total Billed charges,90% of Total Billed Charges,50.32,114.1,
5F 25CM R/O SUPER SHEATH,2720000426,CDM,272,RC,C1894,HCPCS,Outpatient,,,59.22,38.49,,59.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.01,76,,20.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.64,72,,120.024,Percent of Total Billed Charges,72% of Total Billed Charges,44.42,75,,125.024,Percent of Total Billed charges,75% of Total Billed Charges,59.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.64,72,,120.024,Percent of Total Billed Charges,72% of Total Billed Charges,35.53,60,,100.016,Percent of Total Billed Charges,60% of Total Billed Charges,53.3,90,,133.36,Percent of Total Billed Charges,90% of Total Billed Charges,26.65,45,,7.936,Percent of Total Billed Charges,45% of Total Billed Charges,53.3,90,,24.608,Percent of Total Billed Charges,90% of Total billed Charges,59.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.49,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,26.12,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,56.26,95,,25.976,Percent of Total Billed Charges,95% of Total Billed Charges,59.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.11,88,,24.064,Percent of Total Billed Charges,88% of Total Billed Charges,53.3,90,,24.608,Percent of Total Billed charges,90% of Total Billed Charges,26.12,59.22,
AVANTI 6F 11CM SHEATH,2720000427,CDM,272,RC,C1766,HCPCS,Outpatient,,,18.38,11.95,,18.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.97,76,,191.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.23,72,,58.424,Percent of Total Billed Charges,72% of Total Billed Charges,13.79,75,,60.856,Percent of Total Billed charges,75% of Total Billed Charges,18.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,72,,58.424,Percent of Total Billed Charges,72% of Total Billed Charges,11.03,60,,48.688,Percent of Total Billed Charges,60% of Total Billed Charges,16.54,90,,113.512,Percent of Total Billed Charges,90% of Total Billed Charges,8.27,45,,46.84,Percent of Total Billed Charges,45% of Total Billed Charges,16.54,90,,226.232,Percent of Total Billed Charges,90% of Total billed Charges,18.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.95,65,,11.464,Percent of total Billed Charges,65% of Total Billed Charges,8.11,44.1,,45.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.46,95,,238.8,Percent of Total Billed Charges,95% of Total Billed Charges,18.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.17,88,,221.2,Percent of Total Billed Charges,88% of Total Billed Charges,16.54,90,,226.232,Percent of Total Billed charges,90% of Total Billed Charges,8.11,18.38,
AVANTI 5F 11CM SHEATH,2720000428,CDM,272,RC,C1766,HCPCS,Outpatient,,,18.38,11.95,,18.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.97,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.23,72,,24.768,Percent of Total Billed Charges,72% of Total Billed Charges,13.79,75,,25.8,Percent of Total Billed charges,75% of Total Billed Charges,18.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,72,,24.768,Percent of Total Billed Charges,72% of Total Billed Charges,11.03,60,,20.64,Percent of Total Billed Charges,60% of Total Billed Charges,16.54,90,,523.912,Percent of Total Billed Charges,90% of Total Billed Charges,8.27,45,,496.128,Percent of Total Billed Charges,45% of Total Billed Charges,16.54,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,18.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.95,65,,67.656,Percent of total Billed Charges,65% of Total Billed Charges,8.11,44.1,,486.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.46,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,18.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.17,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,16.54,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,8.11,18.38,
PEEL AWAY SHEATH 24F X 13CM,2720000429,CDM,272,RC,C1892,HCPCS,Outpatient,,,127.00,82.55,,127,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,96.52,76,,13.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.44,72,,548.672,Percent of Total Billed Charges,72% of Total Billed Charges,95.25,75,,571.536,Percent of Total Billed charges,75% of Total Billed Charges,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.44,72,,548.672,Percent of Total Billed Charges,72% of Total Billed Charges,76.2,60,,457.232,Percent of Total Billed Charges,60% of Total Billed Charges,114.3,90,,70.648,Percent of Total Billed Charges,90% of Total Billed Charges,57.15,45,,72.24,Percent of Total Billed Charges,45% of Total Billed Charges,114.3,90,,15.88,Percent of Total Billed Charges,90% of Total billed Charges,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.55,65,,716.624,Percent of total Billed Charges,65% of Total Billed Charges,56.01,44.1,,70.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,120.65,95,,16.76,Percent of Total Billed Charges,95% of Total Billed Charges,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.76,88,,15.52,Percent of Total Billed Charges,88% of Total Billed Charges,114.3,90,,15.88,Percent of Total Billed charges,90% of Total Billed Charges,56.01,127,
PEEL AWAY SHEATH 26F X 13CM,2720000430,CDM,272,RC,C1892,HCPCS,Outpatient,,,127.00,82.55,,127,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,96.52,76,,79.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.44,72,,32.392,Percent of Total Billed Charges,72% of Total Billed Charges,95.25,75,,33.736,Percent of Total Billed charges,75% of Total Billed Charges,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.44,72,,32.392,Percent of Total Billed Charges,72% of Total Billed Charges,76.2,60,,26.992,Percent of Total Billed Charges,60% of Total Billed Charges,114.3,90,,107.168,Percent of Total Billed Charges,90% of Total Billed Charges,57.15,45,,9.528,Percent of Total Billed Charges,45% of Total Billed Charges,114.3,90,,93.672,Percent of Total Billed Charges,90% of Total billed Charges,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.55,65,,104.344,Percent of total Billed Charges,65% of Total Billed Charges,56.01,44.1,,9.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,120.65,95,,98.88,Percent of Total Billed Charges,95% of Total Billed Charges,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.76,88,,91.592,Percent of Total Billed Charges,88% of Total Billed Charges,114.3,90,,93.672,Percent of Total Billed charges,90% of Total Billed Charges,56.01,127,
GUIDE WIRE,2720000431,CDM,272,RC,C1769,HCPCS,Outpatient,,,239.24,155.51,,239.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,181.82,76,,837.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,172.25,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,179.43,75,,43,Percent of Total Billed charges,75% of Total Billed Charges,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.25,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,143.54,60,,34.4,Percent of Total Billed Charges,60% of Total Billed Charges,215.32,90,,87.32,Percent of Total Billed Charges,90% of Total Billed Charges,107.66,45,,56.76,Percent of Total Billed Charges,45% of Total Billed Charges,215.32,90,,992.256,Percent of Total Billed Charges,90% of Total billed Charges,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.51,65,,13.76,Percent of total Billed Charges,65% of Total Billed Charges,105.5,44.1,,55.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,227.28,95,,1047.376,Percent of Total Billed Charges,95% of Total Billed Charges,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.53,88,,970.2,Percent of Total Billed Charges,88% of Total Billed Charges,215.32,90,,992.256,Percent of Total Billed charges,90% of Total Billed Charges,105.5,239.24,
PTFE 35 GUIDEWIRE,2720000432,CDM,272,RC,C1769,HCPCS,Outpatient,,,90.41,58.77,,90.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.71,76,,122,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.1,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,67.81,75,,49.616,Percent of Total Billed charges,75% of Total Billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.1,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,54.25,60,,39.688,Percent of Total Billed Charges,60% of Total Billed Charges,81.37,90,,100.816,Percent of Total Billed Charges,90% of Total Billed Charges,40.68,45,,66.68,Percent of Total Billed Charges,45% of Total Billed Charges,81.37,90,,144.472,Percent of Total Billed Charges,90% of Total billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.77,65,,81.984,Percent of total Billed Charges,65% of Total Billed Charges,39.87,44.1,,65.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.89,95,,152.504,Percent of Total Billed Charges,95% of Total Billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.56,88,,141.264,Percent of Total Billed Charges,88% of Total Billed Charges,81.37,90,,144.472,Percent of Total Billed charges,90% of Total Billed Charges,39.87,90.41,
GLIDE WIRE,2720000433,CDM,272,RC,C1769,HCPCS,Outpatient,,,203.96,132.57,,203.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,155.01,76,,16.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,146.85,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,152.97,75,,36.384,Percent of Total Billed charges,75% of Total Billed Charges,203.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.85,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,122.38,60,,29.104,Percent of Total Billed Charges,60% of Total Billed Charges,183.56,90,,265.928,Percent of Total Billed Charges,90% of Total Billed Charges,91.78,45,,56.76,Percent of Total Billed Charges,45% of Total Billed Charges,183.56,90,,19.048,Percent of Total Billed Charges,90% of Total billed Charges,203.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.57,65,,96.312,Percent of total Billed Charges,65% of Total Billed Charges,89.95,44.1,,55.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,193.76,95,,20.112,Percent of Total Billed Charges,95% of Total Billed Charges,203.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.48,88,,18.624,Percent of Total Billed Charges,88% of Total Billed Charges,183.56,90,,19.048,Percent of Total Billed charges,90% of Total Billed Charges,89.95,203.96,
NITRO1/GUIDEWIRE,2720000434,CDM,272,RC,C1769,HCPCS,Outpatient,,,69.46,45.15,,69.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.79,76,,95.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.01,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,52.1,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.01,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,41.68,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,62.51,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,31.26,45,,261.952,Percent of Total Billed Charges,45% of Total Billed Charges,62.51,90,,113.512,Percent of Total Billed Charges,90% of Total billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.15,65,,81.984,Percent of total Billed Charges,65% of Total Billed Charges,30.63,44.1,,256.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.99,95,,119.824,Percent of Total Billed Charges,95% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,88,,110.992,Percent of Total Billed Charges,88% of Total Billed Charges,62.51,90,,113.512,Percent of Total Billed charges,90% of Total Billed Charges,30.63,69.46,
GLIDEWIRE .025,2720000435,CDM,272,RC,C1769,HCPCS,Outpatient,,,508.25,330.36,,508.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,386.27,76,,112.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,365.94,72,,224.808,Percent of Total Billed Charges,72% of Total Billed Charges,381.19,75,,234.176,Percent of Total Billed charges,75% of Total Billed Charges,508.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365.94,72,,224.808,Percent of Total Billed Charges,72% of Total Billed Charges,304.95,60,,187.336,Percent of Total Billed Charges,60% of Total Billed Charges,457.43,90,,115.096,Percent of Total Billed Charges,90% of Total Billed Charges,228.71,45,,35.32,Percent of Total Billed Charges,45% of Total Billed Charges,457.43,90,,133.36,Percent of Total Billed Charges,90% of Total billed Charges,508.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330.36,65,,378.376,Percent of total Billed Charges,65% of Total Billed Charges,224.14,44.1,,34.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,482.84,95,,140.768,Percent of Total Billed Charges,95% of Total Billed Charges,508.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,447.26,88,,130.392,Percent of Total Billed Charges,88% of Total Billed Charges,457.43,90,,133.36,Percent of Total Billed charges,90% of Total Billed Charges,224.14,508.25,
SYN 2.8 GUIDE WIRE,2720000436,CDM,272,RC,C1769,HCPCS,Outpatient,,,108.05,70.23,,108.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.12,76,,95.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.8,72,,40.008,Percent of Total Billed Charges,72% of Total Billed Charges,81.04,75,,41.68,Percent of Total Billed charges,75% of Total Billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.8,72,,40.008,Percent of Total Billed Charges,72% of Total Billed Charges,64.83,60,,33.344,Percent of Total Billed Charges,60% of Total Billed Charges,97.25,90,,42.072,Percent of Total Billed Charges,90% of Total Billed Charges,48.62,45,,53.584,Percent of Total Billed Charges,45% of Total Billed Charges,97.25,90,,113.512,Percent of Total Billed Charges,90% of Total billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.23,65,,51.024,Percent of total Billed Charges,65% of Total Billed Charges,47.65,44.1,,52.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.65,95,,119.824,Percent of Total Billed Charges,95% of Total Billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.08,88,,110.992,Percent of Total Billed Charges,88% of Total Billed Charges,97.25,90,,113.512,Percent of Total Billed charges,90% of Total Billed Charges,47.65,108.05,
SYNT 3.2 GUIDEWIRE,2720000437,CDM,272,RC,C1769,HCPCS,Outpatient,,,127.89,83.13,,127.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,97.2,76,,442.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,92.08,72,,155.584,Percent of Total Billed Charges,72% of Total Billed Charges,95.92,75,,162.064,Percent of Total Billed charges,75% of Total Billed Charges,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.08,72,,155.584,Percent of Total Billed Charges,72% of Total Billed Charges,76.73,60,,129.656,Percent of Total Billed Charges,60% of Total Billed Charges,115.1,90,,99.224,Percent of Total Billed Charges,90% of Total Billed Charges,57.55,45,,43.664,Percent of Total Billed Charges,45% of Total Billed Charges,115.1,90,,523.912,Percent of Total Billed Charges,90% of Total billed Charges,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.13,65,,77.4,Percent of total Billed Charges,65% of Total Billed Charges,56.4,44.1,,42.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,121.5,95,,553.016,Percent of Total Billed Charges,95% of Total Billed Charges,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.54,88,,512.264,Percent of Total Billed Charges,88% of Total Billed Charges,115.1,90,,523.912,Percent of Total Billed charges,90% of Total Billed Charges,56.4,127.89,
3MM J WIRE 145CM BOS,2720000438,CDM,272,RC,C1769,HCPCS,Outpatient,,,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,59.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,277.512,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,289.072,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,277.512,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,231.256,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,129.392,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,50.408,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,70.648,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,63.064,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,49.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,74.568,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,69.08,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,70.648,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
CORE WIRES 3MM J 175,2720000439,CDM,272,RC,C1769,HCPCS,Outpatient,,,17.64,11.47,,17.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.41,76,,90.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.7,72,,60.328,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,75,,62.848,Percent of Total Billed charges,75% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.7,72,,60.328,Percent of Total Billed Charges,72% of Total Billed Charges,10.58,60,,50.272,Percent of Total Billed Charges,60% of Total Billed Charges,15.88,90,,27.784,Percent of Total Billed Charges,90% of Total Billed Charges,7.94,45,,132.96,Percent of Total Billed Charges,45% of Total Billed Charges,15.88,90,,107.168,Percent of Total Billed Charges,90% of Total billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.47,65,,72.808,Percent of total Billed Charges,65% of Total Billed Charges,7.78,44.1,,130.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.76,95,,113.12,Percent of Total Billed Charges,95% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.52,88,,104.784,Percent of Total Billed Charges,88% of Total Billed Charges,15.88,90,,107.168,Percent of Total Billed charges,90% of Total Billed Charges,7.78,17.64,
ANGIO GUIDEWIRE 0.025 X 145CM,2720000440,CDM,272,RC,C1769,HCPCS,Outpatient,,,76.07,49.45,,76.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,57.81,76,,73.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,54.77,72,,100.336,Percent of Total Billed Charges,72% of Total Billed Charges,57.05,75,,104.52,Percent of Total Billed charges,75% of Total Billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.77,72,,100.336,Percent of Total Billed Charges,72% of Total Billed Charges,45.64,60,,83.616,Percent of Total Billed Charges,60% of Total Billed Charges,68.46,90,,606.464,Percent of Total Billed Charges,90% of Total Billed Charges,34.23,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,68.46,90,,87.32,Percent of Total Billed Charges,90% of Total billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.45,65,,192.056,Percent of total Billed Charges,65% of Total Billed Charges,33.55,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,72.27,95,,92.176,Percent of Total Billed Charges,95% of Total Billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.94,88,,85.384,Percent of Total Billed Charges,88% of Total Billed Charges,68.46,90,,87.32,Percent of Total Billed charges,90% of Total Billed Charges,33.55,76.07,
STRAIGHT STIF 180CM,2720000441,CDM,272,RC,C1769,HCPCS,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,85.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,213.376,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,222.264,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,213.376,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,177.808,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,100.024,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,57.552,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,100.816,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,56.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,106.416,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,98.576,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,100.816,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
ANGLD NONSTIF 260CM,2720000442,CDM,272,RC,C1769,HCPCS,Outpatient,,,134.51,87.43,,134.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,102.23,76,,224.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,96.85,72,,114.304,Percent of Total Billed Charges,72% of Total Billed Charges,100.88,75,,119.072,Percent of Total Billed charges,75% of Total Billed Charges,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.85,72,,114.304,Percent of Total Billed Charges,72% of Total Billed Charges,80.71,60,,95.256,Percent of Total Billed Charges,60% of Total Billed Charges,121.06,90,,50.8,Percent of Total Billed Charges,90% of Total Billed Charges,60.53,45,,21.032,Percent of Total Billed Charges,45% of Total Billed Charges,121.06,90,,265.928,Percent of Total Billed Charges,90% of Total billed Charges,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.43,65,,83.128,Percent of total Billed Charges,65% of Total Billed Charges,59.32,44.1,,20.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,127.78,95,,280.696,Percent of Total Billed Charges,95% of Total Billed Charges,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.37,88,,260.016,Percent of Total Billed Charges,88% of Total Billed Charges,121.06,90,,265.928,Percent of Total Billed charges,90% of Total Billed Charges,59.32,134.51,
STD 150CM ANGLED 46,2720000443,CDM,272,RC,C1769,HCPCS,Outpatient,,,89.30,58.05,,89.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.87,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.3,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,66.98,75,,21.832,Percent of Total Billed charges,75% of Total Billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.3,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,53.58,60,,17.464,Percent of Total Billed Charges,60% of Total Billed Charges,80.37,90,,159.552,Percent of Total Billed Charges,90% of Total Billed Charges,40.19,45,,49.608,Percent of Total Billed Charges,45% of Total Billed Charges,80.37,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.05,65,,30.384,Percent of total Billed Charges,65% of Total Billed Charges,39.38,44.1,,48.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,84.84,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.58,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,80.37,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,39.38,89.3,
TEGT ANGLD CATH #HNB,2720000444,CDM,272,RC,C1769,HCPCS,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,97.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,104.144,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,108.488,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,104.144,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,86.792,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,268.312,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,64.696,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,115.096,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,71.664,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,63.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,121.496,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,112.544,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,115.096,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
ANGLD STIF 180CM SHF,2720000445,CDM,272,RC,C1769,HCPCS,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,35.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,118.752,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,123.704,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,118.752,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,98.96,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,138.128,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,13.896,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,42.072,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,93.448,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,13.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,44.408,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,41.136,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,42.072,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
CHOICE PT 0.018 X 300CM JTIP,2720000446,CDM,272,RC,C1769,HCPCS,Outpatient,,,425.57,276.62,,425.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,323.43,76,,83.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,306.41,72,,176.544,Percent of Total Billed Charges,72% of Total Billed Charges,319.18,75,,183.904,Percent of Total Billed charges,75% of Total Billed Charges,425.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.41,72,,176.544,Percent of Total Billed Charges,72% of Total Billed Charges,255.34,60,,147.12,Percent of Total Billed Charges,60% of Total Billed Charges,383.01,90,,106.376,Percent of Total Billed Charges,90% of Total Billed Charges,191.51,45,,303.232,Percent of Total Billed Charges,45% of Total Billed Charges,383.01,90,,99.224,Percent of Total Billed Charges,90% of Total billed Charges,425.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,425.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,425.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.62,65,,20.064,Percent of total Billed Charges,65% of Total Billed Charges,187.68,44.1,,297.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,404.29,95,,104.736,Percent of Total Billed Charges,95% of Total Billed Charges,425.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.5,88,,97.016,Percent of Total Billed Charges,88% of Total Billed Charges,383.01,90,,99.224,Percent of Total Billed charges,90% of Total Billed Charges,187.68,425.57,
WHOLLEY WIRE 0.035 X 145CM,2720000447,CDM,272,RC,C1769,HCPCS,Outpatient,,,431.08,280.20,,431.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,327.62,76,,109.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,310.38,72,,179.088,Percent of Total Billed Charges,72% of Total Billed Charges,323.31,75,,186.544,Percent of Total Billed charges,75% of Total Billed Charges,431.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,310.38,72,,179.088,Percent of Total Billed Charges,72% of Total Billed Charges,258.65,60,,149.24,Percent of Total Billed Charges,60% of Total Billed Charges,387.97,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,193.99,45,,50.008,Percent of Total Billed Charges,45% of Total Billed Charges,387.97,90,,129.392,Percent of Total Billed Charges,90% of Total billed Charges,431.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,431.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,431.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280.2,65,,438,Percent of total Billed Charges,65% of Total Billed Charges,190.11,44.1,,49.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,409.53,95,,136.576,Percent of Total Billed Charges,95% of Total Billed Charges,431.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.35,88,,126.512,Percent of Total Billed Charges,88% of Total Billed Charges,387.97,90,,129.392,Percent of Total Billed charges,90% of Total Billed Charges,190.11,431.08,
WHOLLEY WIRE 0.035 X 175CM,2720000448,CDM,272,RC,C1769,HCPCS,Outpatient,,,486.20,316.03,,486.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,369.51,76,,23.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,350.06,72,,262.912,Percent of Total Billed Charges,72% of Total Billed Charges,364.65,75,,273.864,Percent of Total Billed charges,75% of Total Billed Charges,486.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.06,72,,262.912,Percent of Total Billed Charges,72% of Total Billed Charges,291.72,60,,219.088,Percent of Total Billed Charges,60% of Total Billed Charges,437.58,90,,93.672,Percent of Total Billed Charges,90% of Total Billed Charges,218.79,45,,25.4,Percent of Total Billed Charges,45% of Total Billed Charges,437.58,90,,27.784,Percent of Total Billed Charges,90% of Total billed Charges,486.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,486.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,486.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.03,65,,72.24,Percent of total Billed Charges,65% of Total Billed Charges,214.41,44.1,,24.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,461.89,95,,29.328,Percent of Total Billed Charges,95% of Total Billed Charges,486.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.86,88,,27.168,Percent of Total Billed Charges,88% of Total Billed Charges,437.58,90,,27.784,Percent of Total Billed charges,90% of Total Billed Charges,214.41,486.2,
BENTSON GUIDEWIRES #,2720000449,CDM,272,RC,C1769,HCPCS,Outpatient,,,123.48,80.26,,123.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.84,76,,512.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.91,72,,599.48,Percent of Total Billed Charges,72% of Total Billed Charges,92.61,75,,624.456,Percent of Total Billed charges,75% of Total Billed Charges,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.91,72,,599.48,Percent of Total Billed Charges,72% of Total Billed Charges,74.09,60,,499.568,Percent of Total Billed Charges,60% of Total Billed Charges,111.13,90,,327.84,Percent of Total Billed Charges,90% of Total Billed Charges,55.57,45,,79.776,Percent of Total Billed Charges,45% of Total Billed Charges,111.13,90,,606.464,Percent of Total Billed Charges,90% of Total billed Charges,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.26,65,,36.688,Percent of total Billed Charges,65% of Total Billed Charges,54.45,44.1,,78.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,117.31,95,,640.152,Percent of Total Billed Charges,95% of Total Billed Charges,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.66,88,,592.984,Percent of Total Billed Charges,88% of Total Billed Charges,111.13,90,,606.464,Percent of Total Billed charges,90% of Total Billed Charges,54.45,123.48,
V14 CONTROL WIRE 0.014X300CM,2720000450,CDM,272,RC,C1769,HCPCS,Outpatient,,,448.72,291.67,,448.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,341.03,76,,84.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,323.08,72,,296.568,Percent of Total Billed Charges,72% of Total Billed Charges,336.54,75,,308.92,Percent of Total Billed charges,75% of Total Billed Charges,448.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.08,72,,296.568,Percent of Total Billed Charges,72% of Total Billed Charges,269.23,60,,247.136,Percent of Total Billed Charges,60% of Total Billed Charges,403.85,90,,237.352,Percent of Total Billed Charges,90% of Total Billed Charges,201.92,45,,134.152,Percent of Total Billed Charges,45% of Total Billed Charges,403.85,90,,100.024,Percent of Total Billed Charges,90% of Total billed Charges,448.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,448.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,448.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291.67,65,,115.232,Percent of total Billed Charges,65% of Total Billed Charges,197.89,44.1,,131.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,426.28,95,,105.576,Percent of Total Billed Charges,95% of Total Billed Charges,448.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.87,88,,97.8,Percent of Total Billed Charges,88% of Total Billed Charges,403.85,90,,100.024,Percent of Total Billed charges,90% of Total Billed Charges,197.89,448.72,
GLIDEWIRE ANGLED 0.035 X 260CM,2720000451,CDM,272,RC,C1769,HCPCS,Outpatient,,,199.55,129.71,,199.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,151.66,76,,42.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,143.68,72,,30.48,Percent of Total Billed Charges,72% of Total Billed Charges,149.66,75,,31.752,Percent of Total Billed charges,75% of Total Billed Charges,199.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.68,72,,30.48,Percent of Total Billed Charges,72% of Total Billed Charges,119.73,60,,25.4,Percent of Total Billed Charges,60% of Total Billed Charges,179.6,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,89.8,45,,69.064,Percent of Total Billed Charges,45% of Total Billed Charges,179.6,90,,50.8,Percent of Total Billed Charges,90% of Total billed Charges,199.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.71,65,,193.776,Percent of total Billed Charges,65% of Total Billed Charges,88,44.1,,67.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,189.57,95,,53.624,Percent of Total Billed Charges,95% of Total Billed Charges,199.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.6,88,,49.672,Percent of Total Billed Charges,88% of Total Billed Charges,179.6,90,,50.8,Percent of Total Billed charges,90% of Total Billed Charges,88,199.55,
BMW 0.014X300 WIRE,2720000452,CDM,272,RC,C1769,HCPCS,Outpatient,,,313.11,203.52,,313.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.96,76,,134.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225.44,72,,119.384,Percent of Total Billed Charges,72% of Total Billed Charges,234.83,75,,124.36,Percent of Total Billed charges,75% of Total Billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.44,72,,119.384,Percent of Total Billed Charges,72% of Total Billed Charges,187.87,60,,99.488,Percent of Total Billed Charges,60% of Total Billed Charges,281.8,90,,81.76,Percent of Total Billed Charges,90% of Total Billed Charges,140.9,45,,53.184,Percent of Total Billed Charges,45% of Total Billed Charges,281.8,90,,159.552,Percent of Total Billed Charges,90% of Total billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.52,65,,99.76,Percent of total Billed Charges,65% of Total Billed Charges,138.08,44.1,,52.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,297.45,95,,168.416,Percent of Total Billed Charges,95% of Total Billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.54,88,,156.008,Percent of Total Billed Charges,88% of Total Billed Charges,281.8,90,,159.552,Percent of Total Billed charges,90% of Total Billed Charges,138.08,313.11,
WHISPER MS 0.014X190,2720000453,CDM,272,RC,C1769,HCPCS,Outpatient,,,313.11,203.52,,313.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.96,76,,226.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225.44,72,,158.76,Percent of Total Billed Charges,72% of Total Billed Charges,234.83,75,,165.376,Percent of Total Billed charges,75% of Total Billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.44,72,,158.76,Percent of Total Billed Charges,72% of Total Billed Charges,187.87,60,,132.304,Percent of Total Billed Charges,60% of Total Billed Charges,281.8,90,,34.928,Percent of Total Billed Charges,90% of Total Billed Charges,140.9,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,281.8,90,,268.312,Percent of Total Billed Charges,90% of Total billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.52,65,,76.824,Percent of total Billed Charges,65% of Total Billed Charges,138.08,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,297.45,95,,283.216,Percent of Total Billed Charges,95% of Total Billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.54,88,,262.344,Percent of Total Billed Charges,88% of Total Billed Charges,281.8,90,,268.312,Percent of Total Billed charges,90% of Total Billed Charges,138.08,313.11,
BMW 0.014X190 WIRE,2720000454,CDM,272,RC,C1769,HCPCS,Outpatient,,,313.11,203.52,,313.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.96,76,,116.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225.44,72,,120.664,Percent of Total Billed Charges,72% of Total Billed Charges,234.83,75,,125.688,Percent of Total Billed charges,75% of Total Billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.44,72,,120.664,Percent of Total Billed Charges,72% of Total Billed Charges,187.87,60,,100.552,Percent of Total Billed Charges,60% of Total Billed Charges,281.8,90,,92.872,Percent of Total Billed Charges,90% of Total Billed Charges,140.9,45,,46.84,Percent of Total Billed Charges,45% of Total Billed Charges,281.8,90,,138.128,Percent of Total Billed Charges,90% of Total billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.52,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,138.08,44.1,,45.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,297.45,95,,145.8,Percent of Total Billed Charges,95% of Total Billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.54,88,,135.056,Percent of Total Billed Charges,88% of Total Billed Charges,281.8,90,,138.128,Percent of Total Billed charges,90% of Total Billed Charges,138.08,313.11,
AERIS 175CM PRESSURE WIRE,2720000455,CDM,272,RC,C1769,HCPCS,Outpatient,,,1378.13,895.78,,1378.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1047.38,76,,89.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,992.25,72,,62.872,Percent of Total Billed Charges,72% of Total Billed Charges,1033.6,75,,65.488,Percent of Total Billed charges,75% of Total Billed Charges,1378.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,992.25,72,,62.872,Percent of Total Billed Charges,72% of Total Billed Charges,826.88,60,,52.392,Percent of Total Billed Charges,60% of Total Billed Charges,1240.32,90,,75.416,Percent of Total Billed Charges,90% of Total Billed Charges,620.16,45,,163.92,Percent of Total Billed Charges,45% of Total Billed Charges,1240.32,90,,106.376,Percent of Total Billed Charges,90% of Total billed Charges,1378.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1378.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1378.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,895.78,65,,67.656,Percent of total Billed Charges,65% of Total Billed Charges,607.76,44.1,,160.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,1309.22,95,,112.28,Percent of Total Billed Charges,95% of Total Billed Charges,1378.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1212.75,88,,104.008,Percent of Total Billed Charges,88% of Total Billed Charges,1240.32,90,,106.376,Percent of Total Billed charges,90% of Total Billed Charges,607.76,1378.13,
AERIS 300CM PRESSURE WIRE,2720000456,CDM,272,RC,C1769,HCPCS,Outpatient,,,1378.13,895.78,,1378.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1047.38,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,992.25,72,,28.576,Percent of Total Billed Charges,72% of Total Billed Charges,1033.6,75,,29.768,Percent of Total Billed charges,75% of Total Billed Charges,1378.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,992.25,72,,28.576,Percent of Total Billed Charges,72% of Total Billed Charges,826.88,60,,23.816,Percent of Total Billed Charges,60% of Total Billed Charges,1240.32,90,,121.448,Percent of Total Billed Charges,90% of Total Billed Charges,620.16,45,,118.672,Percent of Total Billed Charges,45% of Total Billed Charges,1240.32,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,1378.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1378.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1378.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,895.78,65,,236.768,Percent of total Billed Charges,65% of Total Billed Charges,607.76,44.1,,116.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,1309.22,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,1378.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1212.75,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,1240.32,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,607.76,1378.13,
PT 2 STRAIGHT 0.014X185,2720000457,CDM,272,RC,C1769,HCPCS,Outpatient,,,341.78,222.16,,341.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,259.75,76,,79.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,246.08,72,,401.976,Percent of Total Billed Charges,72% of Total Billed Charges,256.34,75,,418.728,Percent of Total Billed charges,75% of Total Billed Charges,341.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.08,72,,401.976,Percent of Total Billed Charges,72% of Total Billed Charges,205.07,60,,334.984,Percent of Total Billed Charges,60% of Total Billed Charges,307.6,90,,315.136,Percent of Total Billed Charges,90% of Total Billed Charges,153.8,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,307.6,90,,93.672,Percent of Total Billed Charges,90% of Total billed Charges,341.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.16,65,,171.416,Percent of total Billed Charges,65% of Total Billed Charges,150.72,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,324.69,95,,98.88,Percent of Total Billed Charges,95% of Total Billed Charges,341.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.77,88,,91.592,Percent of Total Billed Charges,88% of Total Billed Charges,307.6,90,,93.672,Percent of Total Billed charges,90% of Total Billed Charges,150.72,341.78,
AMPLATZ ULTRA STIF,2720000458,CDM,272,RC,C1769,HCPCS,Outpatient,,,176.99,115.04,,176.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,134.51,76,,276.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,127.43,72,,357.528,Percent of Total Billed Charges,72% of Total Billed Charges,132.74,75,,372.424,Percent of Total Billed charges,75% of Total Billed Charges,176.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.43,72,,357.528,Percent of Total Billed Charges,72% of Total Billed Charges,106.19,60,,297.944,Percent of Total Billed Charges,60% of Total Billed Charges,159.29,90,,81.76,Percent of Total Billed Charges,90% of Total Billed Charges,79.65,45,,40.88,Percent of Total Billed Charges,45% of Total Billed Charges,159.29,90,,327.84,Percent of Total Billed Charges,90% of Total billed Charges,176.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.04,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,78.05,44.1,,40.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,168.14,95,,346.048,Percent of Total Billed Charges,95% of Total Billed Charges,176.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.75,88,,320.552,Percent of Total Billed Charges,88% of Total Billed Charges,159.29,90,,327.84,Percent of Total Billed charges,90% of Total Billed Charges,78.05,176.99,
AMPLATZ .035X260,2720000459,CDM,272,RC,C1769,HCPCS,Outpatient,,,67.25,43.71,,67.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.11,76,,200.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,48.42,72,,120.024,Percent of Total Billed Charges,72% of Total Billed Charges,50.44,75,,125.024,Percent of Total Billed charges,75% of Total Billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.42,72,,120.024,Percent of Total Billed Charges,72% of Total Billed Charges,40.35,60,,100.016,Percent of Total Billed Charges,60% of Total Billed Charges,60.53,90,,59.536,Percent of Total Billed Charges,90% of Total Billed Charges,30.26,45,,17.464,Percent of Total Billed Charges,45% of Total Billed Charges,60.53,90,,237.352,Percent of Total Billed Charges,90% of Total billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.71,65,,59.048,Percent of total Billed Charges,65% of Total Billed Charges,29.66,44.1,,17.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,63.89,95,,250.536,Percent of Total Billed Charges,95% of Total Billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.18,88,,232.072,Percent of Total Billed Charges,88% of Total Billed Charges,60.53,90,,237.352,Percent of Total Billed charges,90% of Total Billed Charges,29.66,67.25,
ZERO TIP BASKET 2.4X,2720000460,CDM,272,RC,C1773,HCPCS,Outpatient,,,686.86,446.46,,686.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,522.01,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,494.54,72,,468.664,Percent of Total Billed Charges,72% of Total Billed Charges,515.15,75,,488.192,Percent of Total Billed charges,75% of Total Billed Charges,686.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,494.54,72,,468.664,Percent of Total Billed Charges,72% of Total Billed Charges,412.12,60,,390.552,Percent of Total Billed Charges,60% of Total Billed Charges,618.17,90,,126.216,Percent of Total Billed Charges,90% of Total Billed Charges,309.09,45,,46.44,Percent of Total Billed Charges,45% of Total Billed Charges,618.17,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,686.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,686.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,686.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.46,65,,25.224,Percent of total Billed Charges,65% of Total Billed Charges,302.91,44.1,,45.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,652.52,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,686.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,604.44,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,618.17,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,302.91,686.86,
STONE RETREIVAL COIL,2720000461,CDM,272,RC,C1773,HCPCS,Outpatient,,,796.01,517.41,,796.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,604.97,76,,69.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,573.13,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,597.01,75,,37.704,Percent of Total Billed charges,75% of Total Billed Charges,796.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,573.13,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,477.61,60,,30.16,Percent of Total Billed Charges,60% of Total Billed Charges,716.41,90,,1086.48,Percent of Total Billed Charges,90% of Total Billed Charges,358.2,45,,37.704,Percent of Total Billed Charges,45% of Total Billed Charges,716.41,90,,81.76,Percent of Total Billed Charges,90% of Total billed Charges,796.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,517.41,65,,67.072,Percent of total Billed Charges,65% of Total Billed Charges,351.04,44.1,,36.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,756.21,95,,86.304,Percent of Total Billed Charges,95% of Total Billed Charges,796.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,700.49,88,,79.944,Percent of Total Billed Charges,88% of Total Billed Charges,716.41,90,,81.76,Percent of Total Billed charges,90% of Total Billed Charges,351.04,796.01,
SPIDERFX EPD,2720000462,CDM,272,RC,C1884,HCPCS,Outpatient,,,8213.63,5338.86,,8213.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6242.36,76,,29.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5913.81,72,,262.912,Percent of Total Billed Charges,72% of Total Billed Charges,6160.22,75,,273.864,Percent of Total Billed charges,75% of Total Billed Charges,8213.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5913.81,72,,262.912,Percent of Total Billed Charges,72% of Total Billed Charges,4928.18,60,,219.088,Percent of Total Billed Charges,60% of Total Billed Charges,7392.27,90,,134.952,Percent of Total Billed Charges,90% of Total Billed Charges,3696.13,45,,60.728,Percent of Total Billed Charges,45% of Total Billed Charges,7392.27,90,,34.928,Percent of Total Billed Charges,90% of Total billed Charges,8213.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8213.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8213.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5338.86,65,,54.464,Percent of total Billed Charges,65% of Total Billed Charges,3622.21,44.1,,59.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,7802.95,95,,36.864,Percent of Total Billed Charges,95% of Total Billed Charges,8213.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7227.99,88,,34.152,Percent of Total Billed Charges,88% of Total Billed Charges,7392.27,90,,34.928,Percent of Total Billed charges,90% of Total Billed Charges,3622.21,8213.63,
CAS1 5F 100CM CATHETER,2720000463,CDM,272,RC,C1887,HCPCS,Outpatient,,,44.10,28.67,,44.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33.52,76,,78.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,31.75,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,75,,29.104,Percent of Total Billed charges,75% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.75,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,60,,23.288,Percent of Total Billed Charges,60% of Total Billed Charges,39.69,90,,322.288,Percent of Total Billed Charges,90% of Total Billed Charges,19.85,45,,157.568,Percent of Total Billed Charges,45% of Total Billed Charges,39.69,90,,92.872,Percent of Total Billed Charges,90% of Total billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,65,,87.712,Percent of total Billed Charges,65% of Total Billed Charges,19.45,44.1,,154.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.9,95,,98.032,Percent of Total Billed Charges,95% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.81,88,,90.808,Percent of Total Billed Charges,88% of Total Billed Charges,39.69,90,,92.872,Percent of Total Billed charges,90% of Total Billed Charges,19.45,44.1,
CAS2 5F 100CM CATHETER,2720000464,CDM,272,RC,C1887,HCPCS,Outpatient,,,44.10,28.67,,44.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33.52,76,,63.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,31.75,72,,37.472,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,75,,39.032,Percent of Total Billed charges,75% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.75,72,,37.472,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,60,,31.224,Percent of Total Billed Charges,60% of Total Billed Charges,39.69,90,,314.344,Percent of Total Billed Charges,90% of Total Billed Charges,19.85,45,,40.88,Percent of Total Billed Charges,45% of Total Billed Charges,39.69,90,,75.416,Percent of Total Billed Charges,90% of Total billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,65,,227.6,Percent of total Billed Charges,65% of Total Billed Charges,19.45,44.1,,40.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.9,95,,79.6,Percent of Total Billed Charges,95% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.81,88,,73.736,Percent of Total Billed Charges,88% of Total Billed Charges,39.69,90,,75.416,Percent of Total Billed charges,90% of Total Billed Charges,19.45,44.1,
IMPULSE 5F FR4 CATHETER,2720000465,CDM,272,RC,C1887,HCPCS,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,102.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,24.136,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,25.144,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,24.136,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,20.112,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,683.464,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,29.768,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,121.448,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,59.048,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,29.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,128.2,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,118.752,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,121.448,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
IMPULSE 5F AL1 CATHETER,2720000466,CDM,272,RC,C1887,HCPCS,Outpatient,,,123.48,80.26,,123.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.84,76,,266.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.91,72,,5529.928,Percent of Total Billed Charges,72% of Total Billed Charges,92.61,75,,5760.344,Percent of Total Billed charges,75% of Total Billed Charges,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.91,72,,5529.928,Percent of Total Billed Charges,72% of Total Billed Charges,74.09,60,,4608.272,Percent of Total Billed Charges,60% of Total Billed Charges,111.13,90,,117.48,Percent of Total Billed Charges,90% of Total Billed Charges,55.57,45,,63.112,Percent of Total Billed Charges,45% of Total Billed Charges,111.13,90,,315.136,Percent of Total Billed Charges,90% of Total billed Charges,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.26,65,,43,Percent of total Billed Charges,65% of Total Billed Charges,54.45,44.1,,61.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,117.31,95,,332.648,Percent of Total Billed Charges,95% of Total Billed Charges,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.66,88,,308.136,Percent of Total Billed Charges,88% of Total Billed Charges,111.13,90,,315.136,Percent of Total Billed charges,90% of Total Billed Charges,54.45,123.48,
IMPULSE 5F AL2 CATHETER,2720000467,CDM,272,RC,C1887,HCPCS,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,69.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,156.224,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,162.736,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,156.224,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,130.184,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,110.344,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,543.24,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,81.76,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,91.16,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,532.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,86.304,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,79.944,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,81.76,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
IMPULSE 5F AR1 CATHETER,2720000468,CDM,272,RC,C1887,HCPCS,Outpatient,,,123.48,80.26,,123.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.84,76,,50.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.91,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,92.61,75,,43.664,Percent of Total Billed charges,75% of Total Billed Charges,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.91,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,74.09,60,,34.928,Percent of Total Billed Charges,60% of Total Billed Charges,111.13,90,,78.592,Percent of Total Billed Charges,90% of Total Billed Charges,55.57,45,,67.472,Percent of Total Billed Charges,45% of Total Billed Charges,111.13,90,,59.536,Percent of Total Billed Charges,90% of Total billed Charges,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.26,65,,784.68,Percent of total Billed Charges,65% of Total Billed Charges,54.45,44.1,,66.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,117.31,95,,62.848,Percent of Total Billed Charges,95% of Total Billed Charges,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.66,88,,58.216,Percent of Total Billed Charges,88% of Total Billed Charges,111.13,90,,59.536,Percent of Total Billed charges,90% of Total Billed Charges,54.45,123.48,
IMPULSE 5F AR2 CATHETER,2720000469,CDM,272,RC,C1887,HCPCS,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,106.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,372.768,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,388.304,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,372.768,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,310.64,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,160.352,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,161.144,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,126.216,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,97.464,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,157.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,133.232,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,123.408,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,126.216,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
IMPULSE 5F FL3.5 CATHETER,2720000470,CDM,272,RC,C1887,HCPCS,Outpatient,,,68.36,44.43,,68.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.95,76,,917.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49.22,72,,113.672,Percent of Total Billed Charges,72% of Total Billed Charges,51.27,75,,118.408,Percent of Total Billed charges,75% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,72,,113.672,Percent of Total Billed Charges,72% of Total Billed Charges,41.02,60,,94.728,Percent of Total Billed Charges,60% of Total Billed Charges,61.52,90,,55.568,Percent of Total Billed Charges,90% of Total Billed Charges,30.76,45,,157.176,Percent of Total Billed Charges,45% of Total Billed Charges,61.52,90,,1086.48,Percent of Total Billed Charges,90% of Total billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.43,65,,232.76,Percent of total Billed Charges,65% of Total Billed Charges,30.15,44.1,,154.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,64.94,95,,1146.84,Percent of Total Billed Charges,95% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.16,88,,1062.336,Percent of Total Billed Charges,88% of Total Billed Charges,61.52,90,,1086.48,Percent of Total Billed charges,90% of Total Billed Charges,30.15,68.36,
IMPULSE 5F FL4 CATHETER,2720000471,CDM,272,RC,C1887,HCPCS,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,113.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,430.56,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,448.504,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,430.56,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,358.8,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,104.784,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,341.728,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,134.952,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,227.024,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,334.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,142.448,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,131.952,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,134.952,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
IMPULSE 5F FL4.5 CATHETER,2720000472,CDM,272,RC,C1887,HCPCS,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,272.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,129.656,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,103.72,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,113.512,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,58.744,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,322.288,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,493.608,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,57.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,340.192,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,315.128,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,322.288,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
IMPULSE 5F FR-3.5 CATHETER,2720000473,CDM,272,RC,,,Outpatient,,,122.38,79.55,,122.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.01,76,,265.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.11,72,,226.704,Percent of Total Billed Charges,72% of Total Billed Charges,91.79,75,,236.152,Percent of Total Billed charges,75% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.11,72,,226.704,Percent of Total Billed Charges,72% of Total Billed Charges,73.43,60,,188.92,Percent of Total Billed Charges,60% of Total Billed Charges,110.14,90,,117.48,Percent of Total Billed Charges,90% of Total Billed Charges,55.07,45,,55.168,Percent of Total Billed Charges,45% of Total Billed Charges,110.14,90,,314.344,Percent of Total Billed Charges,90% of Total billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.55,65,,84.848,Percent of total Billed Charges,65% of Total Billed Charges,53.97,44.1,,54.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.26,95,,331.808,Percent of Total Billed Charges,95% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.69,88,,307.36,Percent of Total Billed Charges,88% of Total Billed Charges,110.14,90,,314.344,Percent of Total Billed charges,90% of Total Billed Charges,53.97,122.38,
DIAG CATH 100CM FR4F,2720000474,CDM,272,RC,C1887,HCPCS,Outpatient,,,44.10,28.67,,44.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33.52,76,,577.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,31.75,72,,69.216,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,75,,72.104,Percent of Total Billed charges,75% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.75,72,,69.216,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,60,,57.68,Percent of Total Billed Charges,60% of Total Billed Charges,39.69,90,,180.192,Percent of Total Billed Charges,90% of Total Billed Charges,19.85,45,,39.296,Percent of Total Billed Charges,45% of Total Billed Charges,39.69,90,,683.464,Percent of Total Billed Charges,90% of Total billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,65,,79.688,Percent of total Billed Charges,65% of Total Billed Charges,19.45,44.1,,38.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.9,95,,721.432,Percent of Total Billed Charges,95% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.81,88,,668.272,Percent of Total Billed Charges,88% of Total Billed Charges,39.69,90,,683.464,Percent of Total Billed charges,90% of Total Billed Charges,19.45,44.1,
IMPULSE 5F FR5 CATHETER,2720000475,CDM,272,RC,C1887,HCPCS,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,99.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,461.04,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,480.256,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,461.04,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,384.2,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,150.024,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,80.176,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,117.48,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,56.76,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,78.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,124.008,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,114.872,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,117.48,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
IMPULSE 5F IMT CATHETER,2720000476,CDM,272,RC,C1887,HCPCS,Outpatient,,,144.43,93.88,,144.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,109.77,76,,93.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,103.99,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,108.32,75,,29.104,Percent of Total Billed charges,75% of Total Billed Charges,144.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.99,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,86.66,60,,23.288,Percent of Total Billed Charges,60% of Total Billed Charges,129.99,90,,140.504,Percent of Total Billed Charges,90% of Total Billed Charges,64.99,45,,27.784,Percent of Total Billed Charges,45% of Total Billed Charges,129.99,90,,110.344,Percent of Total Billed Charges,90% of Total billed Charges,144.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.88,65,,115.808,Percent of total Billed Charges,65% of Total Billed Charges,63.69,44.1,,27.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,137.21,95,,116.472,Percent of Total Billed Charges,95% of Total Billed Charges,144.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.1,88,,107.888,Percent of Total Billed Charges,88% of Total Billed Charges,129.99,90,,110.344,Percent of Total Billed charges,90% of Total Billed Charges,63.69,144.43,
IMPULSE 5F LCB CATHETER,2720000477,CDM,272,RC,C1887,HCPCS,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,66.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,30.48,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,31.752,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,30.48,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,25.4,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,61.12,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,52.392,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,78.592,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,40.136,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,51.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,82.952,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,76.84,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,78.592,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
IMPULSE 5F RCB CATHETER,2720000478,CDM,272,RC,C1887,HCPCS,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,135.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,29.848,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,31.096,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,29.848,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,24.872,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,44.456,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,56.76,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,160.352,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,75.672,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,55.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,169.256,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,156.784,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,160.352,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
IMPULSE 5F MPA1 CATHETER,2720000479,CDM,272,RC,C1887,HCPCS,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,46.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,33.08,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,66.68,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,58.744,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,55.568,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,81.984,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,57.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,58.656,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,54.336,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,55.568,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
IMPULSE 5F MPA2 CATHETER,2720000480,CDM,272,RC,C1887,HCPCS,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,88.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,621.8,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,647.704,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,621.8,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,518.168,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,159.552,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,90.096,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,104.784,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,84.848,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,88.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,110.6,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,102.456,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,104.784,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
SON1 5F CATHETER,2720000481,CDM,272,RC,C1887,HCPCS,Outpatient,,,144.43,93.88,,144.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,109.77,76,,95.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,103.99,72,,406.424,Percent of Total Billed Charges,72% of Total Billed Charges,108.32,75,,423.36,Percent of Total Billed charges,75% of Total Billed Charges,144.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.99,72,,406.424,Percent of Total Billed Charges,72% of Total Billed Charges,86.66,60,,338.688,Percent of Total Billed Charges,60% of Total Billed Charges,129.99,90,,1530.448,Percent of Total Billed Charges,90% of Total Billed Charges,64.99,45,,75.016,Percent of Total Billed Charges,45% of Total Billed Charges,129.99,90,,113.512,Percent of Total Billed Charges,90% of Total billed Charges,144.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.88,65,,130.144,Percent of total Billed Charges,65% of Total Billed Charges,63.69,44.1,,73.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,137.21,95,,119.824,Percent of Total Billed Charges,95% of Total Billed Charges,144.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.1,88,,110.992,Percent of Total Billed Charges,88% of Total Billed Charges,129.99,90,,113.512,Percent of Total Billed charges,90% of Total Billed Charges,63.69,144.43,
IMPULSE 5F PIGTAIL CATHETER,2720000482,CDM,272,RC,C1887,HCPCS,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,99.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,616.624,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,642.32,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,616.624,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,513.856,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,70.248,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,117.48,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,108.352,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,68.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,124.008,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,114.872,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,117.48,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
DIAG CATH MDL D5F MU,2720000483,CDM,272,RC,C1887,HCPCS,Outpatient,,,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,152.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.88,72,,282.592,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,75,,294.368,Percent of Total Billed charges,75% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.88,72,,282.592,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,60,,235.496,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,90,,47.632,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,30.56,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,180.192,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,101.472,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,29.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,190.208,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,176.192,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,180.192,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.05,
IMPULSE 5F MULTIPACK CATHETERS,2720000484,CDM,272,RC,C1887,HCPCS,Outpatient,,,289.96,188.47,,289.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,220.37,76,,126.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,208.77,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,217.47,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.77,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,173.98,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,260.96,90,,113.512,Percent of Total Billed Charges,90% of Total Billed Charges,130.48,45,,22.224,Percent of Total Billed Charges,45% of Total Billed Charges,260.96,90,,150.024,Percent of Total Billed Charges,90% of Total billed Charges,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.47,65,,44.144,Percent of total Billed Charges,65% of Total Billed Charges,127.87,44.1,,21.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,275.46,95,,158.36,Percent of Total Billed Charges,95% of Total Billed Charges,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.16,88,,146.696,Percent of Total Billed Charges,88% of Total Billed Charges,260.96,90,,150.024,Percent of Total Billed charges,90% of Total Billed Charges,127.87,289.96,
CORDIS 4F JL3.5 CATHETER,2720000485,CDM,272,RC,C1887,HCPCS,Outpatient,,,125.69,81.70,,125.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95.52,76,,118.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90.5,72,,96.528,Percent of Total Billed Charges,72% of Total Billed Charges,94.27,75,,100.552,Percent of Total Billed charges,75% of Total Billed Charges,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.5,72,,96.528,Percent of Total Billed Charges,72% of Total Billed Charges,75.41,60,,80.44,Percent of Total Billed Charges,60% of Total Billed Charges,113.12,90,,299.264,Percent of Total Billed Charges,90% of Total Billed Charges,56.56,45,,33.336,Percent of Total Billed Charges,45% of Total Billed Charges,113.12,90,,140.504,Percent of Total Billed Charges,90% of Total billed Charges,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.7,65,,32.104,Percent of total Billed Charges,65% of Total Billed Charges,55.43,44.1,,32.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,119.41,95,,148.304,Percent of Total Billed Charges,95% of Total Billed Charges,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.61,88,,137.376,Percent of Total Billed Charges,88% of Total Billed Charges,113.12,90,,140.504,Percent of Total Billed charges,90% of Total Billed Charges,55.43,125.69,
CORDIS 4F JL4 CATHETER,2720000486,CDM,272,RC,C1887,HCPCS,Outpatient,,,69.46,45.15,,69.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.79,76,,51.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.01,72,,259.728,Percent of Total Billed Charges,72% of Total Billed Charges,52.1,75,,270.552,Percent of Total Billed charges,75% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.01,72,,259.728,Percent of Total Billed Charges,72% of Total Billed Charges,41.68,60,,216.44,Percent of Total Billed Charges,60% of Total Billed Charges,62.51,90,,59.536,Percent of Total Billed Charges,90% of Total Billed Charges,31.26,45,,79.776,Percent of Total Billed Charges,45% of Total Billed Charges,62.51,90,,61.12,Percent of Total Billed Charges,90% of Total billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.15,65,,48.16,Percent of total Billed Charges,65% of Total Billed Charges,30.63,44.1,,78.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.99,95,,64.52,Percent of Total Billed Charges,95% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,88,,59.76,Percent of Total Billed Charges,88% of Total Billed Charges,62.51,90,,61.12,Percent of Total Billed charges,90% of Total Billed Charges,30.63,69.46,
CORDIS 4F JL5 CATHETER,2720000487,CDM,272,RC,C1887,HCPCS,Outpatient,,,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,37.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,259.728,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,270.552,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,259.728,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,216.44,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,59.536,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,765.224,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,44.456,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,115.232,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,749.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,46.92,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,43.464,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,44.456,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
CORDIS 4F JR4 CATHETER,2720000488,CDM,272,RC,C1887,HCPCS,Outpatient,,,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,56.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,977.96,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,1018.712,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,977.96,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,814.968,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,78.592,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,66.68,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,1105.32,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,70.384,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,65.2,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,66.68,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
DAV 4F 0.035 100CM CATHETER,2720000489,CDM,272,RC,C1887,HCPCS,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,134.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,374.04,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,389.624,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,374.04,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,311.696,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,138.128,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,23.816,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,159.552,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,23.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,168.416,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,156.008,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,159.552,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
DAV 5F 0.035 100CM CATHETER,2720000490,CDM,272,RC,C1887,HCPCS,Outpatient,,,40.79,26.51,,40.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31,76,,1292.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.37,72,,231.152,Percent of Total Billed Charges,72% of Total Billed Charges,30.59,75,,240.784,Percent of Total Billed charges,75% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.37,72,,231.152,Percent of Total Billed Charges,72% of Total Billed Charges,24.47,60,,192.632,Percent of Total Billed Charges,60% of Total Billed Charges,36.71,90,,190.512,Percent of Total Billed Charges,90% of Total Billed Charges,18.36,45,,56.76,Percent of Total Billed Charges,45% of Total Billed Charges,36.71,90,,1530.448,Percent of Total Billed Charges,90% of Total billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.51,65,,34.4,Percent of total Billed Charges,65% of Total Billed Charges,17.99,44.1,,55.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.75,95,,1615.472,Percent of Total Billed Charges,95% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.9,88,,1496.44,Percent of Total Billed Charges,88% of Total Billed Charges,36.71,90,,1530.448,Percent of Total Billed charges,90% of Total Billed Charges,17.99,40.79,
SIM1 4F 0.035 100CM CATHETER,2720000491,CDM,272,RC,C1887,HCPCS,Outpatient,,,40.79,26.51,,40.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.37,72,,229.888,Percent of Total Billed Charges,72% of Total Billed Charges,30.59,75,,239.464,Percent of Total Billed charges,75% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.37,72,,229.888,Percent of Total Billed Charges,72% of Total Billed Charges,24.47,60,,191.576,Percent of Total Billed Charges,60% of Total Billed Charges,36.71,90,,151.616,Percent of Total Billed Charges,90% of Total Billed Charges,18.36,45,,149.632,Percent of Total Billed Charges,45% of Total Billed Charges,36.71,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.51,65,,81.984,Percent of total Billed Charges,65% of Total Billed Charges,17.99,44.1,,146.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.75,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.9,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,36.71,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,17.99,40.79,
SIM1 CEREB CATH #HNB,2720000492,CDM,272,RC,C1887,HCPCS,Outpatient,,,40.79,26.51,,40.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31,76,,40.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.37,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,30.59,75,,114.44,Percent of Total Billed charges,75% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.37,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,24.47,60,,91.552,Percent of Total Billed Charges,60% of Total Billed Charges,36.71,90,,119.864,Percent of Total Billed Charges,90% of Total Billed Charges,18.36,45,,29.768,Percent of Total Billed Charges,45% of Total Billed Charges,36.71,90,,47.632,Percent of Total Billed Charges,90% of Total billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.51,65,,216.136,Percent of total Billed Charges,65% of Total Billed Charges,17.99,44.1,,29.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.75,95,,50.272,Percent of Total Billed Charges,95% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.9,88,,46.568,Percent of Total Billed Charges,88% of Total Billed Charges,36.71,90,,47.632,Percent of Total Billed charges,90% of Total Billed Charges,17.99,40.79,
SIM2 4F 0.035 100CM CATHETER,2720000493,CDM,272,RC,C1887,HCPCS,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,95.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,123.832,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,128.992,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,123.832,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,103.192,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,157.176,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,29.768,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,113.512,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,43,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,29.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,119.824,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,110.992,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,113.512,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
SIM2 CEREB CHAT HNBR,2720000494,CDM,272,RC,C1887,HCPCS,Outpatient,,,302.09,196.36,,302.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,229.59,76,,252.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,217.5,72,,231.152,Percent of Total Billed Charges,72% of Total Billed Charges,226.57,75,,240.784,Percent of Total Billed charges,75% of Total Billed Charges,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.5,72,,231.152,Percent of Total Billed Charges,72% of Total Billed Charges,181.25,60,,192.632,Percent of Total Billed Charges,60% of Total Billed Charges,271.88,90,,606.464,Percent of Total Billed Charges,90% of Total Billed Charges,135.94,45,,39.296,Percent of Total Billed Charges,45% of Total Billed Charges,271.88,90,,299.264,Percent of Total Billed Charges,90% of Total billed Charges,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.36,65,,43,Percent of total Billed Charges,65% of Total Billed Charges,133.22,44.1,,38.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,286.99,95,,315.888,Percent of Total Billed Charges,95% of Total Billed Charges,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.84,88,,292.608,Percent of Total Billed Charges,88% of Total Billed Charges,271.88,90,,299.264,Percent of Total Billed charges,90% of Total Billed Charges,133.22,302.09,
BERN SELECTIVE 4F CATHETER,2720000495,CDM,272,RC,C1887,HCPCS,Outpatient,,,144.43,93.88,,144.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,109.77,76,,50.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,103.99,72,,107.96,Percent of Total Billed Charges,72% of Total Billed Charges,108.32,75,,112.456,Percent of Total Billed charges,75% of Total Billed Charges,144.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.99,72,,107.96,Percent of Total Billed Charges,72% of Total Billed Charges,86.66,60,,89.968,Percent of Total Billed Charges,60% of Total Billed Charges,129.99,90,,202.424,Percent of Total Billed Charges,90% of Total Billed Charges,64.99,45,,69.064,Percent of Total Billed Charges,45% of Total Billed Charges,129.99,90,,59.536,Percent of Total Billed Charges,90% of Total billed Charges,144.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.88,65,,56.76,Percent of total Billed Charges,65% of Total Billed Charges,63.69,44.1,,67.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,137.21,95,,62.848,Percent of Total Billed Charges,95% of Total Billed Charges,144.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.1,88,,58.216,Percent of Total Billed Charges,88% of Total Billed Charges,129.99,90,,59.536,Percent of Total Billed charges,90% of Total Billed Charges,63.69,144.43,
C2 SELECTIVE 4F CATHETER,2720000496,CDM,272,RC,C1887,HCPCS,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,50.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,226.704,Percent of Total Billed Charges,72% of Total Billed Charges,58.71,75,,236.152,Percent of Total Billed charges,75% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,226.704,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,188.92,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,258.784,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,95.256,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,59.536,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,99.76,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,93.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,62.848,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,58.216,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,59.536,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
H1H SELECTIVE 4F CATHETER,2720000497,CDM,272,RC,C1887,HCPCS,Outpatient,,,136.71,88.86,,136.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,103.9,76,,66.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,98.43,72,,240.68,Percent of Total Billed Charges,72% of Total Billed Charges,102.53,75,,250.712,Percent of Total Billed charges,75% of Total Billed Charges,136.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.43,72,,240.68,Percent of Total Billed Charges,72% of Total Billed Charges,82.03,60,,200.568,Percent of Total Billed Charges,60% of Total Billed Charges,123.04,90,,138.128,Percent of Total Billed Charges,90% of Total Billed Charges,61.52,45,,75.808,Percent of Total Billed Charges,45% of Total Billed Charges,123.04,90,,78.592,Percent of Total Billed Charges,90% of Total billed Charges,136.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.86,65,,137.592,Percent of total Billed Charges,65% of Total Billed Charges,60.29,44.1,,74.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,129.87,95,,82.952,Percent of Total Billed Charges,95% of Total Billed Charges,136.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.3,88,,76.84,Percent of Total Billed Charges,88% of Total Billed Charges,123.04,90,,78.592,Percent of Total Billed charges,90% of Total Billed Charges,60.29,136.71,
CORDIS 4FR AR MOD CATHETER,2720000498,CDM,272,RC,C1887,HCPCS,Outpatient,,,130.10,84.57,,130.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.88,76,,116.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,93.67,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,97.58,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.67,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,78.06,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,117.09,90,,463.576,Percent of Total Billed Charges,90% of Total Billed Charges,58.55,45,,59.936,Percent of Total Billed Charges,45% of Total Billed Charges,117.09,90,,138.128,Percent of Total Billed Charges,90% of Total billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.57,65,,109.504,Percent of total Billed Charges,65% of Total Billed Charges,57.37,44.1,,58.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,123.6,95,,145.8,Percent of Total Billed Charges,95% of Total Billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.49,88,,135.056,Percent of Total Billed Charges,88% of Total Billed Charges,117.09,90,,138.128,Percent of Total Billed charges,90% of Total Billed Charges,57.37,130.1,
CORDIS 4FR 3DRC CATHETER,2720000499,CDM,272,RC,C1887,HCPCS,Outpatient,,,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,160.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,277.512,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,289.072,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,277.512,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,231.256,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,147.648,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,78.592,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,190.512,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,86.568,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,77.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,201.096,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,186.28,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,190.512,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
CORDIS 4FR RCB CATHETER,2720000500,CDM,272,RC,C1887,HCPCS,Outpatient,,,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,128.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,95.256,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,76.208,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,470.72,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,303.232,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,151.616,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,113.52,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,297.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,160.04,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,148.248,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,151.616,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
CORDIS 4FR LCB CATHETER,2720000501,CDM,272,RC,C1887,HCPCS,Outpatient,,,130.10,84.57,,130.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.88,76,,101.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,93.67,72,,81.92,Percent of Total Billed Charges,72% of Total Billed Charges,97.58,75,,85.336,Percent of Total Billed charges,75% of Total Billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.67,72,,81.92,Percent of Total Billed Charges,72% of Total Billed Charges,78.06,60,,68.264,Percent of Total Billed Charges,60% of Total Billed Charges,117.09,90,,130.976,Percent of Total Billed Charges,90% of Total Billed Charges,58.55,45,,101.208,Percent of Total Billed Charges,45% of Total Billed Charges,117.09,90,,119.864,Percent of Total Billed Charges,90% of Total billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.57,65,,438,Percent of total Billed Charges,65% of Total Billed Charges,57.37,44.1,,99.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,123.6,95,,126.528,Percent of Total Billed Charges,95% of Total Billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.49,88,,117.2,Percent of Total Billed Charges,88% of Total Billed Charges,117.09,90,,119.864,Percent of Total Billed charges,90% of Total Billed Charges,57.37,130.1,
CORDIS 4FR IM CATHETER,2720000502,CDM,272,RC,C1887,HCPCS,Outpatient,,,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,132.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,325.776,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,339.352,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,325.776,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,271.48,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,90.496,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,129.392,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,157.176,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,146.192,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,126.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,165.912,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,153.68,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,157.176,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
CORDIS 4F AL1 CATHETER,2720000503,CDM,272,RC,C1887,HCPCS,Outpatient,,,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,512.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,9.928,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,7.936,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,319.904,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,69.064,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,606.464,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,186.896,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,67.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,640.152,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,592.984,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,606.464,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
CORDIS 4F MPA2 125 CATHETER,2720000504,CDM,272,RC,C1887,HCPCS,Outpatient,,,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,170.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,116.848,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,121.72,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,116.848,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,97.376,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,114.304,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,231.792,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,202.424,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,99.76,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,227.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,213.664,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,197.92,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,202.424,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
GLIDECATH STR 5FR 100CM,2720000505,CDM,272,RC,C1887,HCPCS,Outpatient,,,627.32,407.76,,627.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,476.76,76,,218.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,451.67,72,,95.256,Percent of Total Billed Charges,72% of Total Billed Charges,470.49,75,,99.232,Percent of Total Billed charges,75% of Total Billed Charges,627.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,451.67,72,,95.256,Percent of Total Billed Charges,72% of Total Billed Charges,376.39,60,,79.384,Percent of Total Billed Charges,60% of Total Billed Charges,564.59,90,,402.456,Percent of Total Billed Charges,90% of Total Billed Charges,282.29,45,,73.824,Percent of Total Billed Charges,45% of Total Billed Charges,564.59,90,,258.784,Percent of Total Billed Charges,90% of Total billed Charges,627.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,627.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,627.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.76,65,,334.808,Percent of total Billed Charges,65% of Total Billed Charges,276.65,44.1,,72.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,595.95,95,,273.16,Percent of Total Billed Charges,95% of Total Billed Charges,627.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.04,88,,253.032,Percent of Total Billed Charges,88% of Total Billed Charges,564.59,90,,258.784,Percent of Total Billed charges,90% of Total Billed Charges,276.65,627.32,
GLIDECATH ANG 5FR 100CM,2720000506,CDM,272,RC,C1887,HCPCS,Outpatient,,,627.32,407.76,,627.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,476.76,76,,116.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,451.67,72,,421.032,Percent of Total Billed Charges,72% of Total Billed Charges,470.49,75,,438.576,Percent of Total Billed charges,75% of Total Billed Charges,627.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,451.67,72,,421.032,Percent of Total Billed Charges,72% of Total Billed Charges,376.39,60,,350.864,Percent of Total Billed Charges,60% of Total Billed Charges,564.59,90,,546.928,Percent of Total Billed Charges,90% of Total Billed Charges,282.29,45,,235.36,Percent of Total Billed Charges,45% of Total Billed Charges,564.59,90,,138.128,Percent of Total Billed Charges,90% of Total billed Charges,627.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,627.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,627.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.76,65,,106.64,Percent of total Billed Charges,65% of Total Billed Charges,276.65,44.1,,230.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,595.95,95,,145.8,Percent of Total Billed Charges,95% of Total Billed Charges,627.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.04,88,,135.056,Percent of Total Billed Charges,88% of Total Billed Charges,564.59,90,,138.128,Percent of Total Billed charges,90% of Total Billed Charges,276.65,627.32,
GLIDEDCATH STR 4FR 100CM,2720000507,CDM,272,RC,C1887,HCPCS,Outpatient,,,627.32,407.76,,627.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,476.76,76,,391.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,451.67,72,,586.776,Percent of Total Billed Charges,72% of Total Billed Charges,470.49,75,,611.224,Percent of Total Billed charges,75% of Total Billed Charges,627.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,451.67,72,,586.776,Percent of Total Billed Charges,72% of Total Billed Charges,376.39,60,,488.984,Percent of Total Billed Charges,60% of Total Billed Charges,564.59,90,,128.6,Percent of Total Billed Charges,90% of Total Billed Charges,282.29,45,,65.488,Percent of Total Billed Charges,45% of Total Billed Charges,564.59,90,,463.576,Percent of Total Billed Charges,90% of Total billed Charges,627.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,627.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,627.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.76,65,,339.968,Percent of total Billed Charges,65% of Total Billed Charges,276.65,44.1,,64.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,595.95,95,,489.336,Percent of Total Billed Charges,95% of Total Billed Charges,627.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.04,88,,453.28,Percent of Total Billed Charges,88% of Total Billed Charges,564.59,90,,463.576,Percent of Total Billed charges,90% of Total Billed Charges,276.65,627.32,
GLIDECATH ANG 4FR 100CM,2720000508,CDM,272,RC,C1887,HCPCS,Outpatient,,,627.32,407.76,,627.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,476.76,76,,124.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,451.67,72,,156.224,Percent of Total Billed Charges,72% of Total Billed Charges,470.49,75,,162.736,Percent of Total Billed charges,75% of Total Billed Charges,627.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,451.67,72,,156.224,Percent of Total Billed Charges,72% of Total Billed Charges,376.39,60,,130.184,Percent of Total Billed Charges,60% of Total Billed Charges,564.59,90,,504.856,Percent of Total Billed Charges,90% of Total Billed Charges,282.29,45,,45.248,Percent of Total Billed Charges,45% of Total Billed Charges,564.59,90,,147.648,Percent of Total Billed Charges,90% of Total billed Charges,627.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,627.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,627.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.76,65,,94.592,Percent of total Billed Charges,65% of Total Billed Charges,276.65,44.1,,44.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,595.95,95,,155.856,Percent of Total Billed Charges,95% of Total Billed Charges,627.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.04,88,,144.368,Percent of Total Billed Charges,88% of Total Billed Charges,564.59,90,,147.648,Percent of Total Billed charges,90% of Total Billed Charges,276.65,627.32,
ANSEL 0 5F 55CM CATHETER,2720000509,CDM,272,RC,C1887,HCPCS,Outpatient,,,834.59,542.48,,834.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,634.29,76,,397.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,600.9,72,,120.024,Percent of Total Billed Charges,72% of Total Billed Charges,625.94,75,,125.024,Percent of Total Billed charges,75% of Total Billed Charges,834.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,600.9,72,,120.024,Percent of Total Billed Charges,72% of Total Billed Charges,500.75,60,,100.016,Percent of Total Billed Charges,60% of Total Billed Charges,751.13,90,,150.024,Percent of Total Billed Charges,90% of Total Billed Charges,375.57,45,,159.952,Percent of Total Billed Charges,45% of Total Billed Charges,751.13,90,,470.72,Percent of Total Billed Charges,90% of Total billed Charges,834.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,834.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,834.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,542.48,65,,65.36,Percent of total Billed Charges,65% of Total Billed Charges,368.05,44.1,,156.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,792.86,95,,496.872,Percent of Total Billed Charges,95% of Total Billed Charges,834.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,734.44,88,,460.264,Percent of Total Billed Charges,88% of Total Billed Charges,751.13,90,,470.72,Percent of Total Billed charges,90% of Total Billed Charges,368.05,834.59,
ANSEL 1 5F 55CM CATHETER,2720000510,CDM,272,RC,C1887,HCPCS,Outpatient,,,834.59,542.48,,834.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,634.29,76,,110.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,600.9,72,,100.336,Percent of Total Billed Charges,72% of Total Billed Charges,625.94,75,,104.52,Percent of Total Billed charges,75% of Total Billed Charges,834.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,600.9,72,,100.336,Percent of Total Billed Charges,72% of Total Billed Charges,500.75,60,,83.616,Percent of Total Billed Charges,60% of Total Billed Charges,751.13,90,,1231.976,Percent of Total Billed Charges,90% of Total Billed Charges,375.57,45,,57.152,Percent of Total Billed Charges,45% of Total Billed Charges,751.13,90,,130.976,Percent of Total Billed Charges,90% of Total billed Charges,834.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,834.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,834.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,542.48,65,,231.04,Percent of total Billed Charges,65% of Total Billed Charges,368.05,44.1,,56.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,792.86,95,,138.248,Percent of Total Billed Charges,95% of Total Billed Charges,834.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,734.44,88,,128.064,Percent of Total Billed Charges,88% of Total Billed Charges,751.13,90,,130.976,Percent of Total Billed charges,90% of Total Billed Charges,368.05,834.59,
ANSEL 1 6F 55CM CATHETER,2720000511,CDM,272,RC,C1887,HCPCS,Outpatient,,,834.59,542.48,,834.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,634.29,76,,76.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,600.9,72,,45.72,Percent of Total Billed Charges,72% of Total Billed Charges,625.94,75,,47.632,Percent of Total Billed charges,75% of Total Billed Charges,834.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,600.9,72,,45.72,Percent of Total Billed Charges,72% of Total Billed Charges,500.75,60,,38.104,Percent of Total Billed Charges,60% of Total Billed Charges,751.13,90,,546.928,Percent of Total Billed Charges,90% of Total Billed Charges,375.57,45,,201.232,Percent of Total Billed Charges,45% of Total Billed Charges,751.13,90,,90.496,Percent of Total Billed Charges,90% of Total billed Charges,834.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,834.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,834.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,542.48,65,,82.552,Percent of total Billed Charges,65% of Total Billed Charges,368.05,44.1,,197.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,792.86,95,,95.528,Percent of Total Billed Charges,95% of Total Billed Charges,834.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,734.44,88,,88.488,Percent of Total Billed Charges,88% of Total Billed Charges,751.13,90,,90.496,Percent of Total Billed charges,90% of Total Billed Charges,368.05,834.59,
ANSEL 1 6F 55CM CATHETER,2720000512,CDM,272,RC,C1887,HCPCS,Outpatient,,,834.59,542.48,,834.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,634.29,76,,270.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,600.9,72,,30.48,Percent of Total Billed Charges,72% of Total Billed Charges,625.94,75,,31.752,Percent of Total Billed charges,75% of Total Billed Charges,834.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,600.9,72,,30.48,Percent of Total Billed Charges,72% of Total Billed Charges,500.75,60,,25.4,Percent of Total Billed Charges,60% of Total Billed Charges,751.13,90,,339.744,Percent of Total Billed Charges,90% of Total Billed Charges,375.57,45,,273.464,Percent of Total Billed Charges,45% of Total Billed Charges,751.13,90,,319.904,Percent of Total Billed Charges,90% of Total billed Charges,834.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,834.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,834.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,542.48,65,,290.664,Percent of total Billed Charges,65% of Total Billed Charges,368.05,44.1,,267.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,792.86,95,,337.672,Percent of Total Billed Charges,95% of Total Billed Charges,834.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,734.44,88,,312.792,Percent of Total Billed Charges,88% of Total Billed Charges,751.13,90,,319.904,Percent of Total Billed charges,90% of Total Billed Charges,368.05,834.59,
ANSEL 0 5F 45CM CATHETER,2720000513,CDM,272,RC,C1887,HCPCS,Outpatient,,,676.94,440.01,,676.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,514.47,76,,96.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,487.4,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,507.71,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,676.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487.4,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,406.16,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,609.25,90,,53.184,Percent of Total Billed Charges,90% of Total Billed Charges,304.62,45,,64.296,Percent of Total Billed Charges,45% of Total Billed Charges,609.25,90,,114.304,Percent of Total Billed Charges,90% of Total billed Charges,676.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,676.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,676.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.01,65,,395,Percent of total Billed Charges,65% of Total Billed Charges,298.53,44.1,,63.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,643.09,95,,120.656,Percent of Total Billed Charges,95% of Total Billed Charges,676.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,595.71,88,,111.768,Percent of Total Billed Charges,88% of Total Billed Charges,609.25,90,,114.304,Percent of Total Billed charges,90% of Total Billed Charges,298.53,676.94,
ANSEL 1 5F 45CM CATHETER,2720000514,CDM,272,RC,C1887,HCPCS,Outpatient,,,676.94,440.01,,676.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,514.47,76,,339.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,487.4,72,,29.216,Percent of Total Billed Charges,72% of Total Billed Charges,507.71,75,,30.432,Percent of Total Billed charges,75% of Total Billed Charges,676.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487.4,72,,29.216,Percent of Total Billed Charges,72% of Total Billed Charges,406.16,60,,24.344,Percent of Total Billed Charges,60% of Total Billed Charges,609.25,90,,134.952,Percent of Total Billed Charges,90% of Total Billed Charges,304.62,45,,252.432,Percent of Total Billed Charges,45% of Total Billed Charges,609.25,90,,402.456,Percent of Total Billed Charges,90% of Total billed Charges,676.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,676.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,676.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.01,65,,92.88,Percent of total Billed Charges,65% of Total Billed Charges,298.53,44.1,,247.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,643.09,95,,424.816,Percent of Total Billed Charges,95% of Total Billed Charges,676.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,595.71,88,,393.512,Percent of Total Billed Charges,88% of Total Billed Charges,609.25,90,,402.456,Percent of Total Billed charges,90% of Total Billed Charges,298.53,676.94,
ANSEL 0 6F 45CM CATHETER,2720000515,CDM,272,RC,C1887,HCPCS,Outpatient,,,676.94,440.01,,676.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,514.47,76,,461.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,487.4,72,,920.168,Percent of Total Billed Charges,72% of Total Billed Charges,507.71,75,,958.512,Percent of Total Billed charges,75% of Total Billed Charges,676.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487.4,72,,920.168,Percent of Total Billed Charges,72% of Total Billed Charges,406.16,60,,766.808,Percent of Total Billed Charges,60% of Total Billed Charges,609.25,90,,467.544,Percent of Total Billed Charges,90% of Total Billed Charges,304.62,45,,75.016,Percent of Total Billed Charges,45% of Total Billed Charges,609.25,90,,546.928,Percent of Total Billed Charges,90% of Total billed Charges,676.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,676.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,676.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.01,65,,364.616,Percent of total Billed Charges,65% of Total Billed Charges,298.53,44.1,,73.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,643.09,95,,577.312,Percent of Total Billed Charges,95% of Total Billed Charges,676.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,595.71,88,,534.776,Percent of Total Billed Charges,88% of Total Billed Charges,609.25,90,,546.928,Percent of Total Billed charges,90% of Total Billed Charges,298.53,676.94,
ANSEL 1 6F 45CM,2720000516,CDM,272,RC,C1887,HCPCS,Outpatient,,,676.94,440.01,,676.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,514.47,76,,108.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,487.4,72,,542.96,Percent of Total Billed Charges,72% of Total Billed Charges,507.71,75,,565.584,Percent of Total Billed charges,75% of Total Billed Charges,676.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487.4,72,,542.96,Percent of Total Billed Charges,72% of Total Billed Charges,406.16,60,,452.464,Percent of Total Billed Charges,60% of Total Billed Charges,609.25,90,,142.888,Percent of Total Billed Charges,90% of Total Billed Charges,304.62,45,,615.992,Percent of Total Billed Charges,45% of Total Billed Charges,609.25,90,,128.6,Percent of Total Billed Charges,90% of Total billed Charges,676.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,676.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,676.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.01,65,,108.352,Percent of total Billed Charges,65% of Total Billed Charges,298.53,44.1,,603.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,643.09,95,,135.744,Percent of Total Billed Charges,95% of Total Billed Charges,676.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,595.71,88,,125.744,Percent of Total Billed Charges,88% of Total Billed Charges,609.25,90,,128.6,Percent of Total Billed charges,90% of Total Billed Charges,298.53,676.94,
ANSEL 1 6F 90CM,2720000517,CDM,272,RC,C1887,HCPCS,Outpatient,,,1228.19,798.32,,1228.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,933.42,76,,426.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,884.3,72,,244.488,Percent of Total Billed Charges,72% of Total Billed Charges,921.14,75,,254.68,Percent of Total Billed charges,75% of Total Billed Charges,1228.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,884.3,72,,244.488,Percent of Total Billed Charges,72% of Total Billed Charges,736.91,60,,203.744,Percent of Total Billed Charges,60% of Total Billed Charges,1105.37,90,,265.136,Percent of Total Billed Charges,90% of Total Billed Charges,552.69,45,,273.464,Percent of Total Billed Charges,45% of Total Billed Charges,1105.37,90,,504.856,Percent of Total Billed Charges,90% of Total billed Charges,1228.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1228.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1228.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,798.32,65,,889.76,Percent of total Billed Charges,65% of Total Billed Charges,541.63,44.1,,267.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,1166.78,95,,532.904,Percent of Total Billed Charges,95% of Total Billed Charges,1228.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1080.81,88,,493.64,Percent of Total Billed Charges,88% of Total Billed Charges,1105.37,90,,504.856,Percent of Total Billed charges,90% of Total Billed Charges,541.63,1228.19,
QUICK CROSS 018X150,2720000518,CDM,272,RC,C1887,HCPCS,Outpatient,,,386.98,251.54,,386.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,294.1,76,,126.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,278.63,72,,208.296,Percent of Total Billed Charges,72% of Total Billed Charges,290.24,75,,216.976,Percent of Total Billed charges,75% of Total Billed Charges,386.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.63,72,,208.296,Percent of Total Billed Charges,72% of Total Billed Charges,232.19,60,,173.576,Percent of Total Billed Charges,60% of Total Billed Charges,348.28,90,,369.912,Percent of Total Billed Charges,90% of Total Billed Charges,174.14,45,,169.872,Percent of Total Billed Charges,45% of Total Billed Charges,348.28,90,,150.024,Percent of Total Billed Charges,90% of Total billed Charges,386.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.54,65,,395,Percent of total Billed Charges,65% of Total Billed Charges,170.66,44.1,,166.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,367.63,95,,158.36,Percent of Total Billed Charges,95% of Total Billed Charges,386.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.54,88,,146.696,Percent of Total Billed Charges,88% of Total Billed Charges,348.28,90,,150.024,Percent of Total Billed charges,90% of Total Billed Charges,170.66,386.98,
QUICK CROSS SELECT 0.018 X 150,2720000519,CDM,272,RC,C1887,HCPCS,Outpatient,,,456.44,296.69,,456.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,346.89,76,,1040.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,328.64,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,342.33,75,,114.44,Percent of Total Billed charges,75% of Total Billed Charges,456.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.64,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,273.86,60,,91.552,Percent of Total Billed Charges,60% of Total Billed Charges,410.8,90,,155.584,Percent of Total Billed Charges,90% of Total Billed Charges,205.4,45,,26.592,Percent of Total Billed Charges,45% of Total Billed Charges,410.8,90,,1231.976,Percent of Total Billed Charges,90% of Total billed Charges,456.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.69,65,,245.376,Percent of total Billed Charges,65% of Total Billed Charges,201.29,44.1,,26.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,433.62,95,,1300.424,Percent of Total Billed Charges,95% of Total Billed Charges,456.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.67,88,,1204.6,Percent of Total Billed Charges,88% of Total Billed Charges,410.8,90,,1231.976,Percent of Total Billed charges,90% of Total Billed Charges,201.29,456.44,
TRAIL BLAZER 5F 035 X 150,2720000520,CDM,272,RC,C1887,HCPCS,Outpatient,,,349.49,227.17,,349.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,265.61,76,,461.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,251.63,72,,99.696,Percent of Total Billed Charges,72% of Total Billed Charges,262.12,75,,103.856,Percent of Total Billed charges,75% of Total Billed Charges,349.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.63,72,,99.696,Percent of Total Billed Charges,72% of Total Billed Charges,209.69,60,,83.08,Percent of Total Billed Charges,60% of Total Billed Charges,314.54,90,,380.232,Percent of Total Billed Charges,90% of Total Billed Charges,157.27,45,,67.472,Percent of Total Billed Charges,45% of Total Billed Charges,314.54,90,,546.928,Percent of Total Billed Charges,90% of Total billed Charges,349.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.17,65,,38.416,Percent of total Billed Charges,65% of Total Billed Charges,154.13,44.1,,66.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,332.02,95,,577.312,Percent of Total Billed Charges,95% of Total Billed Charges,349.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.55,88,,534.776,Percent of Total Billed Charges,88% of Total Billed Charges,314.54,90,,546.928,Percent of Total Billed charges,90% of Total Billed Charges,154.13,349.49,
90CM MP DESTINATION,2720000521,CDM,272,RC,C1887,HCPCS,Outpatient,,,259.09,168.41,,259.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,196.91,76,,286.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,186.54,72,,68.584,Percent of Total Billed Charges,72% of Total Billed Charges,194.32,75,,71.44,Percent of Total Billed charges,75% of Total Billed Charges,259.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.54,72,,68.584,Percent of Total Billed Charges,72% of Total Billed Charges,155.45,60,,57.152,Percent of Total Billed Charges,60% of Total Billed Charges,233.18,90,,223.056,Percent of Total Billed Charges,90% of Total Billed Charges,116.59,45,,233.776,Percent of Total Billed Charges,45% of Total Billed Charges,233.18,90,,339.744,Percent of Total Billed Charges,90% of Total billed Charges,259.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.41,65,,97.464,Percent of total Billed Charges,65% of Total Billed Charges,114.26,44.1,,229.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,246.14,95,,358.624,Percent of Total Billed Charges,95% of Total Billed Charges,259.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228,88,,332.2,Percent of Total Billed Charges,88% of Total Billed Charges,233.18,90,,339.744,Percent of Total Billed charges,90% of Total Billed Charges,114.26,259.09,
EXPORT AP 6FR CATHETER,2720000522,CDM,272,RC,C1887,HCPCS,Outpatient,,,1273.39,827.70,,1273.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,967.78,76,,44.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,916.84,72,,139.072,Percent of Total Billed Charges,72% of Total Billed Charges,955.04,75,,144.872,Percent of Total Billed charges,75% of Total Billed Charges,1273.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.84,72,,139.072,Percent of Total Billed Charges,72% of Total Billed Charges,764.03,60,,115.896,Percent of Total Billed Charges,60% of Total Billed Charges,1146.05,90,,142.888,Percent of Total Billed Charges,90% of Total Billed Charges,573.03,45,,71.44,Percent of Total Billed Charges,45% of Total Billed Charges,1146.05,90,,53.184,Percent of Total Billed Charges,90% of Total billed Charges,1273.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1273.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1273.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,827.7,65,,337.672,Percent of total Billed Charges,65% of Total Billed Charges,561.56,44.1,,70.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,1209.72,95,,56.144,Percent of Total Billed Charges,95% of Total Billed Charges,1273.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1120.58,88,,52.008,Percent of Total Billed Charges,88% of Total Billed Charges,1146.05,90,,53.184,Percent of Total Billed charges,90% of Total Billed Charges,561.56,1273.39,
RUNWAY GUIDE 6FR FL6 CATHETER,2720000523,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,113.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,44.32,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,35.456,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,144.472,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,132.568,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,134.952,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,103.192,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,129.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,142.448,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,131.952,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,134.952,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
6F FL4 IMPULSE DIAG CATH,2720000524,CDM,272,RC,C1887,HCPCS,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,394.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,15.88,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,12.704,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,134.152,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,184.96,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,467.544,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,191.488,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,181.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,493.52,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,457.16,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,467.544,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
VCF 5F 65CM FLUSH CATHETER,2720000525,CDM,272,RC,C1887,HCPCS,Outpatient,,,71.66,46.58,,71.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.46,76,,120.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.6,72,,253.384,Percent of Total Billed Charges,72% of Total Billed Charges,53.75,75,,263.944,Percent of Total Billed charges,75% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,72,,253.384,Percent of Total Billed Charges,72% of Total Billed Charges,43,60,,211.152,Percent of Total Billed Charges,60% of Total Billed Charges,64.49,90,,369.912,Percent of Total Billed Charges,90% of Total Billed Charges,32.25,45,,77.792,Percent of Total Billed Charges,45% of Total Billed Charges,64.49,90,,142.888,Percent of Total Billed Charges,90% of Total billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.58,65,,267.16,Percent of total Billed Charges,65% of Total Billed Charges,31.6,44.1,,76.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.08,95,,150.824,Percent of Total Billed Charges,95% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,88,,139.712,Percent of Total Billed Charges,88% of Total Billed Charges,64.49,90,,142.888,Percent of Total Billed charges,90% of Total Billed Charges,31.6,71.66,
SIM 1 5F 100CM CATHETER,2720000526,CDM,272,RC,C1887,HCPCS,Outpatient,,,70.56,45.86,,70.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.63,76,,223.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.8,72,,57.16,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,75,,59.536,Percent of Total Billed charges,75% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.8,72,,57.16,Percent of Total Billed Charges,72% of Total Billed Charges,42.34,60,,47.632,Percent of Total Billed Charges,60% of Total Billed Charges,63.5,90,,14.888,Percent of Total Billed Charges,90% of Total Billed Charges,31.75,45,,190.12,Percent of Total Billed Charges,45% of Total Billed Charges,63.5,90,,265.136,Percent of Total Billed Charges,90% of Total billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.86,65,,112.368,Percent of total Billed Charges,65% of Total Billed Charges,31.12,44.1,,186.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.03,95,,279.864,Percent of Total Billed Charges,95% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.09,88,,259.24,Percent of Total Billed Charges,88% of Total Billed Charges,63.5,90,,265.136,Percent of Total Billed charges,90% of Total Billed Charges,31.12,70.56,
MIK 5F 80CM CATHETER,2720000527,CDM,272,RC,C1887,HCPCS,Outpatient,,,70.56,45.86,,70.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.63,76,,312.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.8,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,75,,21.168,Percent of Total Billed charges,75% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.8,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,42.34,60,,16.936,Percent of Total Billed Charges,60% of Total Billed Charges,63.5,90,,245.28,Percent of Total Billed Charges,90% of Total Billed Charges,31.75,45,,111.528,Percent of Total Billed Charges,45% of Total Billed Charges,63.5,90,,369.912,Percent of Total Billed Charges,90% of Total billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.86,65,,274.616,Percent of total Billed Charges,65% of Total Billed Charges,31.12,44.1,,109.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.03,95,,390.464,Percent of Total Billed Charges,95% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.09,88,,361.696,Percent of Total Billed Charges,88% of Total Billed Charges,63.5,90,,369.912,Percent of Total Billed charges,90% of Total Billed Charges,31.12,70.56,
ANSEL 1 10F  45CM CATHETER,2720000528,CDM,272,RC,C1887,HCPCS,Outpatient,,,304.29,197.79,,304.29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,231.26,76,,131.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,219.09,72,,18.416,Percent of Total Billed Charges,72% of Total Billed Charges,228.22,75,,19.184,Percent of Total Billed charges,75% of Total Billed Charges,304.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.09,72,,18.416,Percent of Total Billed Charges,72% of Total Billed Charges,182.57,60,,15.344,Percent of Total Billed Charges,60% of Total Billed Charges,273.86,90,,223.056,Percent of Total Billed Charges,90% of Total Billed Charges,136.93,45,,71.44,Percent of Total Billed Charges,45% of Total Billed Charges,273.86,90,,155.584,Percent of Total Billed Charges,90% of Total billed Charges,304.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.79,65,,161.096,Percent of total Billed Charges,65% of Total Billed Charges,134.19,44.1,,70.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,289.08,95,,164.232,Percent of Total Billed Charges,95% of Total Billed Charges,304.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.78,88,,152.128,Percent of Total Billed Charges,88% of Total Billed Charges,273.86,90,,155.584,Percent of Total Billed charges,90% of Total Billed Charges,134.19,304.29,
ANSEL 1  9F  45CM CATHETER,2720000529,CDM,272,RC,C1887,HCPCS,Outpatient,,,304.29,197.79,,304.29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,231.26,76,,321.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,219.09,72,,99.696,Percent of Total Billed Charges,72% of Total Billed Charges,228.22,75,,103.856,Percent of Total Billed charges,75% of Total Billed Charges,304.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.09,72,,99.696,Percent of Total Billed Charges,72% of Total Billed Charges,182.57,60,,83.08,Percent of Total Billed Charges,60% of Total Billed Charges,273.86,90,,133.36,Percent of Total Billed Charges,90% of Total Billed Charges,136.93,45,,72.24,Percent of Total Billed Charges,45% of Total Billed Charges,273.86,90,,380.232,Percent of Total Billed Charges,90% of Total billed Charges,304.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.79,65,,103.192,Percent of total Billed Charges,65% of Total Billed Charges,134.19,44.1,,70.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,289.08,95,,401.36,Percent of Total Billed Charges,95% of Total Billed Charges,304.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.78,88,,371.784,Percent of Total Billed Charges,88% of Total Billed Charges,273.86,90,,380.232,Percent of Total Billed charges,90% of Total Billed Charges,134.19,304.29,
APC 7F PULMONARY CATHETER,2720000530,CDM,272,RC,C1887,HCPCS,Outpatient,,,71.66,46.58,,71.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.46,76,,188.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.6,72,,101.608,Percent of Total Billed Charges,72% of Total Billed Charges,53.75,75,,105.84,Percent of Total Billed charges,75% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,72,,101.608,Percent of Total Billed Charges,72% of Total Billed Charges,43,60,,84.672,Percent of Total Billed Charges,60% of Total Billed Charges,64.49,90,,135.744,Percent of Total Billed Charges,90% of Total Billed Charges,32.25,45,,67.072,Percent of Total Billed Charges,45% of Total Billed Charges,64.49,90,,223.056,Percent of Total Billed Charges,90% of Total billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.58,65,,104.344,Percent of total Billed Charges,65% of Total Billed Charges,31.6,44.1,,65.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.08,95,,235.448,Percent of Total Billed Charges,95% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,88,,218.096,Percent of Total Billed Charges,88% of Total Billed Charges,64.49,90,,223.056,Percent of Total Billed charges,90% of Total Billed Charges,31.6,71.66,
C2 5FR 65CM CATHETER,2720000531,CDM,272,RC,C1887,HCPCS,Outpatient,,,70.56,45.86,,70.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.63,76,,120.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.8,72,,75.568,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,75,,78.72,Percent of Total Billed charges,75% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.8,72,,75.568,Percent of Total Billed Charges,72% of Total Billed Charges,42.34,60,,62.976,Percent of Total Billed Charges,60% of Total Billed Charges,63.5,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,31.75,45,,184.96,Percent of Total Billed Charges,45% of Total Billed Charges,63.5,90,,142.888,Percent of Total Billed Charges,90% of Total billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.86,65,,96.888,Percent of total Billed Charges,65% of Total Billed Charges,31.12,44.1,,181.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.03,95,,150.824,Percent of Total Billed Charges,95% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.09,88,,139.712,Percent of Total Billed Charges,88% of Total Billed Charges,63.5,90,,142.888,Percent of Total Billed charges,90% of Total Billed Charges,31.12,70.56,
C2 5FR 100CM CATHETER,2720000532,CDM,272,RC,C1887,HCPCS,Outpatient,,,70.56,45.86,,70.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.63,76,,122,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.8,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.8,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,42.34,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,63.5,90,,150.024,Percent of Total Billed Charges,90% of Total Billed Charges,31.75,45,,7.448,Percent of Total Billed Charges,45% of Total Billed Charges,63.5,90,,144.472,Percent of Total Billed Charges,90% of Total billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.86,65,,267.16,Percent of total Billed Charges,65% of Total Billed Charges,31.12,44.1,,7.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.03,95,,152.504,Percent of Total Billed Charges,95% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.09,88,,141.264,Percent of Total Billed Charges,88% of Total Billed Charges,63.5,90,,144.472,Percent of Total Billed charges,90% of Total Billed Charges,31.12,70.56,
GLIDECATH ANG 4F 65CM,2720000533,CDM,272,RC,C1887,HCPCS,Outpatient,,,170.89,111.08,,170.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.88,76,,113.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.04,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,128.17,75,,13.232,Percent of Total Billed charges,75% of Total Billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.04,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,102.53,60,,10.584,Percent of Total Billed Charges,60% of Total Billed Charges,153.8,90,,73.032,Percent of Total Billed Charges,90% of Total Billed Charges,76.9,45,,122.64,Percent of Total Billed Charges,45% of Total Billed Charges,153.8,90,,134.152,Percent of Total Billed Charges,90% of Total billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.08,65,,10.752,Percent of total Billed Charges,65% of Total Billed Charges,75.36,44.1,,120.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,162.35,95,,141.6,Percent of Total Billed Charges,95% of Total Billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.38,88,,131.168,Percent of Total Billed Charges,88% of Total Billed Charges,153.8,90,,134.152,Percent of Total Billed charges,90% of Total Billed Charges,75.36,170.89,
GLIDECATH STR 5F 65CM,2720000534,CDM,272,RC,C1887,HCPCS,Outpatient,,,170.89,111.08,,170.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.88,76,,312.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.04,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,128.17,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.04,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,102.53,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,153.8,90,,30.96,Percent of Total Billed Charges,90% of Total Billed Charges,76.9,45,,111.528,Percent of Total Billed Charges,45% of Total Billed Charges,153.8,90,,369.912,Percent of Total Billed Charges,90% of Total billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.08,65,,177.152,Percent of total Billed Charges,65% of Total Billed Charges,75.36,44.1,,109.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,162.35,95,,390.464,Percent of Total Billed Charges,95% of Total Billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.38,88,,361.696,Percent of Total Billed Charges,88% of Total Billed Charges,153.8,90,,369.912,Percent of Total Billed charges,90% of Total Billed Charges,75.36,170.89,
ANSEL 0 12F 45CM CATHETER,2720000535,CDM,272,RC,C1887,HCPCS,Outpatient,,,152.15,98.90,,152.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,115.63,76,,12.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,109.55,72,,35.56,Percent of Total Billed Charges,72% of Total Billed Charges,114.11,75,,37.048,Percent of Total Billed charges,75% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.55,72,,35.56,Percent of Total Billed Charges,72% of Total Billed Charges,91.29,60,,29.632,Percent of Total Billed Charges,60% of Total Billed Charges,136.94,90,,685.84,Percent of Total Billed Charges,90% of Total Billed Charges,68.47,45,,66.68,Percent of Total Billed Charges,45% of Total Billed Charges,136.94,90,,14.888,Percent of Total Billed Charges,90% of Total billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.9,65,,161.096,Percent of total Billed Charges,65% of Total Billed Charges,67.1,44.1,,65.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,144.54,95,,15.72,Percent of Total Billed Charges,95% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.89,88,,14.56,Percent of Total Billed Charges,88% of Total Billed Charges,136.94,90,,14.888,Percent of Total Billed charges,90% of Total Billed Charges,67.1,152.15,
ANSEL 1 12F 45CM CATHETER,2720000536,CDM,272,RC,C1887,HCPCS,Outpatient,,,152.15,98.90,,152.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,115.63,76,,207.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,109.55,72,,125.104,Percent of Total Billed Charges,72% of Total Billed Charges,114.11,75,,130.312,Percent of Total Billed charges,75% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.55,72,,125.104,Percent of Total Billed Charges,72% of Total Billed Charges,91.29,60,,104.248,Percent of Total Billed Charges,60% of Total Billed Charges,136.94,90,,40.488,Percent of Total Billed Charges,90% of Total Billed Charges,68.47,45,,67.872,Percent of Total Billed Charges,45% of Total Billed Charges,136.94,90,,245.28,Percent of Total Billed Charges,90% of Total billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.9,65,,96.312,Percent of total Billed Charges,65% of Total Billed Charges,67.1,44.1,,66.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,144.54,95,,258.912,Percent of Total Billed Charges,95% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.89,88,,239.832,Percent of Total Billed Charges,88% of Total Billed Charges,136.94,90,,245.28,Percent of Total Billed charges,90% of Total Billed Charges,67.1,152.15,
UNIVERSAL 5F 65CM CATHETER,2720000537,CDM,272,RC,C1887,HCPCS,Outpatient,,,31.40,20.41,,31.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.86,76,,188.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.61,72,,58.424,Percent of Total Billed Charges,72% of Total Billed Charges,23.55,75,,60.856,Percent of Total Billed charges,75% of Total Billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.61,72,,58.424,Percent of Total Billed Charges,72% of Total Billed Charges,18.84,60,,48.688,Percent of Total Billed Charges,60% of Total Billed Charges,28.26,90,,51.592,Percent of Total Billed Charges,90% of Total Billed Charges,14.13,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,28.26,90,,223.056,Percent of Total Billed Charges,90% of Total billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.41,65,,98.032,Percent of total Billed Charges,65% of Total Billed Charges,13.85,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.83,95,,235.448,Percent of Total Billed Charges,95% of Total Billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.63,88,,218.096,Percent of Total Billed Charges,88% of Total Billed Charges,28.26,90,,223.056,Percent of Total Billed charges,90% of Total Billed Charges,13.85,31.4,
TEMPO SIM 2 5F CATHETER,2720000538,CDM,272,RC,C1887,HCPCS,Outpatient,,,31.40,20.41,,31.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.86,76,,112.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.61,72,,52.712,Percent of Total Billed Charges,72% of Total Billed Charges,23.55,75,,54.904,Percent of Total Billed charges,75% of Total Billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.61,72,,52.712,Percent of Total Billed Charges,72% of Total Billed Charges,18.84,60,,43.928,Percent of Total Billed Charges,60% of Total Billed Charges,28.26,90,,59.536,Percent of Total Billed Charges,90% of Total Billed Charges,14.13,45,,75.016,Percent of Total Billed Charges,45% of Total Billed Charges,28.26,90,,133.36,Percent of Total Billed Charges,90% of Total billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.41,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,13.85,44.1,,73.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.83,95,,140.768,Percent of Total Billed Charges,95% of Total Billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.63,88,,130.392,Percent of Total Billed Charges,88% of Total Billed Charges,28.26,90,,133.36,Percent of Total Billed charges,90% of Total Billed Charges,13.85,31.4,
TEMPO AQUA SIM 1 4 4F CATHETER,2720000539,CDM,272,RC,C1887,HCPCS,Outpatient,,,104.90,68.19,,104.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.72,76,,114.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75.53,72,,107.96,Percent of Total Billed Charges,72% of Total Billed Charges,78.68,75,,112.456,Percent of Total Billed charges,75% of Total Billed Charges,104.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.53,72,,107.96,Percent of Total Billed Charges,72% of Total Billed Charges,62.94,60,,89.968,Percent of Total Billed Charges,60% of Total Billed Charges,94.41,90,,43.664,Percent of Total Billed Charges,90% of Total Billed Charges,47.21,45,,36.512,Percent of Total Billed Charges,45% of Total Billed Charges,94.41,90,,135.744,Percent of Total Billed Charges,90% of Total billed Charges,104.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.19,65,,108.352,Percent of total Billed Charges,65% of Total Billed Charges,46.26,44.1,,35.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,99.66,95,,143.28,Percent of Total Billed Charges,95% of Total Billed Charges,104.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.31,88,,132.728,Percent of Total Billed Charges,88% of Total Billed Charges,94.41,90,,135.744,Percent of Total Billed charges,90% of Total Billed Charges,46.26,104.9,
TEMPO AQUA SIM 1 5F CATHETER,2720000540,CDM,272,RC,C1887,HCPCS,Outpatient,,,104.90,68.19,,104.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.72,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75.53,72,,57.792,Percent of Total Billed Charges,72% of Total Billed Charges,78.68,75,,60.2,Percent of Total Billed charges,75% of Total Billed Charges,104.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.53,72,,57.792,Percent of Total Billed Charges,72% of Total Billed Charges,62.94,60,,48.16,Percent of Total Billed Charges,60% of Total Billed Charges,94.41,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,47.21,45,,15.48,Percent of Total Billed Charges,45% of Total Billed Charges,94.41,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,104.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.19,65,,52.744,Percent of total Billed Charges,65% of Total Billed Charges,46.26,44.1,,15.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,99.66,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,104.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.31,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,94.41,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,46.26,104.9,
TEMPO AQUA SIM 2 4F CATHETER,2720000541,CDM,272,RC,C1887,HCPCS,Outpatient,,,104.90,68.19,,104.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.72,76,,126.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75.53,72,,180.984,Percent of Total Billed Charges,72% of Total Billed Charges,78.68,75,,188.528,Percent of Total Billed charges,75% of Total Billed Charges,104.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.53,72,,180.984,Percent of Total Billed Charges,72% of Total Billed Charges,62.94,60,,150.824,Percent of Total Billed Charges,60% of Total Billed Charges,94.41,90,,281.008,Percent of Total Billed Charges,90% of Total Billed Charges,47.21,45,,342.92,Percent of Total Billed Charges,45% of Total Billed Charges,94.41,90,,150.024,Percent of Total Billed Charges,90% of Total billed Charges,104.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.19,65,,22.36,Percent of total Billed Charges,65% of Total Billed Charges,46.26,44.1,,336.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,99.66,95,,158.36,Percent of Total Billed Charges,95% of Total Billed Charges,104.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.31,88,,146.696,Percent of Total Billed Charges,88% of Total Billed Charges,94.41,90,,150.024,Percent of Total Billed charges,90% of Total Billed Charges,46.26,104.9,
TEMPO AQUA SIM 2 5F CATHETER,2720000542,CDM,272,RC,C1887,HCPCS,Outpatient,,,104.90,68.19,,104.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.72,76,,61.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75.53,72,,402.616,Percent of Total Billed Charges,72% of Total Billed Charges,78.68,75,,419.392,Percent of Total Billed charges,75% of Total Billed Charges,104.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.53,72,,402.616,Percent of Total Billed Charges,72% of Total Billed Charges,62.94,60,,335.512,Percent of Total Billed Charges,60% of Total Billed Charges,94.41,90,,50.008,Percent of Total Billed Charges,90% of Total Billed Charges,47.21,45,,20.24,Percent of Total Billed Charges,45% of Total Billed Charges,94.41,90,,73.032,Percent of Total Billed Charges,90% of Total billed Charges,104.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.19,65,,495.328,Percent of total Billed Charges,65% of Total Billed Charges,46.26,44.1,,19.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,99.66,95,,77.088,Percent of Total Billed Charges,95% of Total Billed Charges,104.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.31,88,,71.408,Percent of Total Billed Charges,88% of Total Billed Charges,94.41,90,,73.032,Percent of Total Billed charges,90% of Total Billed Charges,46.26,104.9,
PROGREAT 2.4F X 150CM,2720000543,CDM,272,RC,C1887,HCPCS,Outpatient,,,1410.50,916.83,,1410.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1071.98,76,,26.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1015.56,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,1057.88,75,,15.216,Percent of Total Billed charges,75% of Total Billed Charges,1410.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1015.56,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,846.3,60,,12.176,Percent of Total Billed Charges,60% of Total Billed Charges,1269.45,90,,194.48,Percent of Total Billed Charges,90% of Total Billed Charges,634.73,45,,25.8,Percent of Total Billed Charges,45% of Total Billed Charges,1269.45,90,,30.96,Percent of Total Billed Charges,90% of Total billed Charges,1410.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1410.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1410.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.83,65,,29.24,Percent of total Billed Charges,65% of Total Billed Charges,622.03,44.1,,25.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,1339.98,95,,32.68,Percent of Total Billed Charges,95% of Total Billed Charges,1410.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1241.24,88,,30.272,Percent of Total Billed Charges,88% of Total Billed Charges,1269.45,90,,30.96,Percent of Total Billed charges,90% of Total Billed Charges,622.03,1410.5,
RUBICON 018 X 90CM SUPPORT CAT,2720000544,CDM,272,RC,C1887,HCPCS,Outpatient,,,302.00,196.30,,302,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,229.52,76,,579.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,217.44,72,,1536.8,Percent of Total Billed Charges,72% of Total Billed Charges,226.5,75,,1600.832,Percent of Total Billed charges,75% of Total Billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.44,72,,1536.8,Percent of Total Billed Charges,72% of Total Billed Charges,181.2,60,,1280.664,Percent of Total Billed Charges,60% of Total Billed Charges,271.8,90,,346.888,Percent of Total Billed Charges,90% of Total Billed Charges,135.9,45,,29.768,Percent of Total Billed Charges,45% of Total Billed Charges,271.8,90,,685.84,Percent of Total Billed Charges,90% of Total billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.3,65,,37.264,Percent of total Billed Charges,65% of Total Billed Charges,133.18,44.1,,29.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,286.9,95,,723.944,Percent of Total Billed Charges,95% of Total Billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.76,88,,670.6,Percent of Total Billed Charges,88% of Total Billed Charges,271.8,90,,685.84,Percent of Total Billed charges,90% of Total Billed Charges,133.18,302,
CORDIS 4F JL4.5 CATHETER,2720000545,CDM,272,RC,C1887,HCPCS,Outpatient,,,96.00,62.40,,96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.96,76,,34.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.12,72,,1265.632,Percent of Total Billed Charges,72% of Total Billed Charges,72,75,,1318.368,Percent of Total Billed charges,75% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.12,72,,1265.632,Percent of Total Billed Charges,72% of Total Billed Charges,57.6,60,,1054.696,Percent of Total Billed Charges,60% of Total Billed Charges,86.4,90,,75.416,Percent of Total Billed Charges,90% of Total Billed Charges,43.2,45,,21.832,Percent of Total Billed Charges,45% of Total Billed Charges,86.4,90,,40.488,Percent of Total Billed Charges,90% of Total billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.4,65,,43,Percent of total Billed Charges,65% of Total Billed Charges,42.34,44.1,,21.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.2,95,,42.736,Percent of Total Billed Charges,95% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.48,88,,39.584,Percent of Total Billed Charges,88% of Total Billed Charges,86.4,90,,40.488,Percent of Total Billed charges,90% of Total Billed Charges,42.34,96,
CORDIS 4F JR5 CATHETER,2720000546,CDM,272,RC,C1887,HCPCS,Outpatient,,,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,43.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,413.416,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,430.64,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,413.416,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,344.512,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,125.424,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,51.592,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,31.536,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,54.464,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,50.448,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,51.592,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
CORDIS 4F JR3.5 CATHETER,2720000547,CDM,272,RC,C1887,HCPCS,Outpatient,,,96.00,62.40,,96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.96,76,,50.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.12,72,,413.416,Percent of Total Billed Charges,72% of Total Billed Charges,72,75,,430.64,Percent of Total Billed charges,75% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.12,72,,413.416,Percent of Total Billed Charges,72% of Total Billed Charges,57.6,60,,344.512,Percent of Total Billed Charges,60% of Total Billed Charges,86.4,90,,266.72,Percent of Total Billed Charges,90% of Total Billed Charges,43.2,45,,140.504,Percent of Total Billed Charges,45% of Total Billed Charges,86.4,90,,59.536,Percent of Total Billed Charges,90% of Total billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.4,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,42.34,44.1,,137.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.2,95,,62.848,Percent of Total Billed Charges,95% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.48,88,,58.216,Percent of Total Billed Charges,88% of Total Billed Charges,86.4,90,,59.536,Percent of Total Billed charges,90% of Total Billed Charges,42.34,96,
INTRODUCER KIT,2720000548,CDM,272,RC,C1892,HCPCS,Outpatient,,,220.50,143.33,,220.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,167.58,76,,36.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,158.76,72,,147.328,Percent of Total Billed Charges,72% of Total Billed Charges,165.38,75,,153.472,Percent of Total Billed charges,75% of Total Billed Charges,220.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,72,,147.328,Percent of Total Billed Charges,72% of Total Billed Charges,132.3,60,,122.776,Percent of Total Billed Charges,60% of Total Billed Charges,198.45,90,,142.888,Percent of Total Billed Charges,90% of Total Billed Charges,99.23,45,,25.008,Percent of Total Billed Charges,45% of Total Billed Charges,198.45,90,,43.664,Percent of Total Billed Charges,90% of Total billed Charges,220.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.33,65,,202.952,Percent of total Billed Charges,65% of Total Billed Charges,97.24,44.1,,24.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,209.48,95,,46.088,Percent of Total Billed Charges,95% of Total Billed Charges,220.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.04,88,,42.688,Percent of Total Billed Charges,88% of Total Billed Charges,198.45,90,,43.664,Percent of Total Billed charges,90% of Total Billed Charges,97.24,220.5,
FORTE PLUS SHEATH,2720000549,CDM,272,RC,C1894,HCPCS,Outpatient,,,629.53,409.19,,629.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,478.44,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,453.26,72,,2972.624,Percent of Total Billed Charges,72% of Total Billed Charges,472.15,75,,3096.48,Percent of Total Billed charges,75% of Total Billed Charges,629.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.26,72,,2972.624,Percent of Total Billed Charges,72% of Total Billed Charges,377.72,60,,2477.184,Percent of Total Billed Charges,60% of Total Billed Charges,566.58,90,,26.192,Percent of Total Billed Charges,90% of Total Billed Charges,283.29,45,,97.24,Percent of Total Billed Charges,45% of Total Billed Charges,566.58,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,629.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,629.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,629.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.19,65,,36.12,Percent of total Billed Charges,65% of Total Billed Charges,277.62,44.1,,95.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,598.05,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,629.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,553.99,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,566.58,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,277.62,629.53,
SHEATH 4FR 10CM SUPP,2720000550,CDM,272,RC,C1894,HCPCS,Outpatient,,,34.18,22.22,,34.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.98,76,,237.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.61,72,,548.672,Percent of Total Billed Charges,72% of Total Billed Charges,25.64,75,,571.536,Percent of Total Billed charges,75% of Total Billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.61,72,,548.672,Percent of Total Billed Charges,72% of Total Billed Charges,20.51,60,,457.232,Percent of Total Billed Charges,60% of Total Billed Charges,30.76,90,,130.184,Percent of Total Billed Charges,90% of Total Billed Charges,15.38,45,,173.448,Percent of Total Billed Charges,45% of Total Billed Charges,30.76,90,,281.008,Percent of Total Billed Charges,90% of Total billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.22,65,,140.456,Percent of total Billed Charges,65% of Total Billed Charges,15.07,44.1,,169.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.47,95,,296.624,Percent of Total Billed Charges,95% of Total Billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.08,88,,274.768,Percent of Total Billed Charges,88% of Total Billed Charges,30.76,90,,281.008,Percent of Total Billed charges,90% of Total Billed Charges,15.07,34.18,
SHEATH 5FR 10CM SUPP,2720000551,CDM,272,RC,C1894,HCPCS,Outpatient,,,74.97,48.73,,74.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.98,76,,42.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.98,72,,54.616,Percent of Total Billed Charges,72% of Total Billed Charges,56.23,75,,56.896,Percent of Total Billed charges,75% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.98,72,,54.616,Percent of Total Billed Charges,72% of Total Billed Charges,44.98,60,,45.512,Percent of Total Billed Charges,60% of Total Billed Charges,67.47,90,,148.44,Percent of Total Billed Charges,90% of Total Billed Charges,33.74,45,,37.704,Percent of Total Billed Charges,45% of Total Billed Charges,67.47,90,,50.008,Percent of Total Billed Charges,90% of Total billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.73,65,,250.528,Percent of total Billed Charges,65% of Total Billed Charges,33.06,44.1,,36.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,71.22,95,,52.792,Percent of Total Billed Charges,95% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.97,88,,48.896,Percent of Total Billed Charges,88% of Total Billed Charges,67.47,90,,50.008,Percent of Total Billed charges,90% of Total Billed Charges,33.06,74.97,
SHEATH 6FX10CM .038,2720000552,CDM,272,RC,C1894,HCPCS,Outpatient,,,110.25,71.66,,110.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,83.79,76,,164.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,79.38,72,,45.72,Percent of Total Billed Charges,72% of Total Billed Charges,82.69,75,,47.632,Percent of Total Billed charges,75% of Total Billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,72,,45.72,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,60,,38.104,Percent of Total Billed Charges,60% of Total Billed Charges,99.23,90,,220.68,Percent of Total Billed Charges,90% of Total Billed Charges,49.61,45,,62.712,Percent of Total Billed Charges,45% of Total Billed Charges,99.23,90,,194.48,Percent of Total Billed Charges,90% of Total billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,65,,54.464,Percent of total Billed Charges,65% of Total Billed Charges,48.62,44.1,,61.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,104.74,95,,205.28,Percent of Total Billed Charges,95% of Total Billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,88,,190.16,Percent of Total Billed Charges,88% of Total Billed Charges,99.23,90,,194.48,Percent of Total Billed charges,90% of Total Billed Charges,48.62,110.25,
SHEATH 5FX10CM .038,2720000553,CDM,272,RC,C1894,HCPCS,Outpatient,,,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,292.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,51.6,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,41.28,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,223.856,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,133.36,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,346.888,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,90.584,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,130.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,366.16,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,339.184,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,346.888,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
SHEATH 4FR 10CM SUP,2720000554,CDM,272,RC,C1894,HCPCS,Outpatient,,,110.25,71.66,,110.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,83.79,76,,63.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,79.38,72,,54.616,Percent of Total Billed Charges,72% of Total Billed Charges,82.69,75,,56.896,Percent of Total Billed charges,75% of Total Billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,72,,54.616,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,60,,45.512,Percent of Total Billed Charges,60% of Total Billed Charges,99.23,90,,328.64,Percent of Total Billed Charges,90% of Total Billed Charges,49.61,45,,71.44,Percent of Total Billed Charges,45% of Total Billed Charges,99.23,90,,75.416,Percent of Total Billed Charges,90% of Total billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,65,,192.632,Percent of total Billed Charges,65% of Total Billed Charges,48.62,44.1,,70.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,104.74,95,,79.6,Percent of Total Billed Charges,95% of Total Billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,88,,73.736,Percent of Total Billed Charges,88% of Total Billed Charges,99.23,90,,75.416,Percent of Total Billed charges,90% of Total Billed Charges,48.62,110.25,
SHEATH 5FR NOWIRE 10,2720000555,CDM,272,RC,C1894,HCPCS,Outpatient,,,35.28,22.93,,35.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.81,76,,105.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.4,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,75,,15.88,Percent of Total Billed charges,75% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.4,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,21.17,60,,12.704,Percent of Total Billed Charges,60% of Total Billed Charges,31.75,90,,749.344,Percent of Total Billed Charges,90% of Total Billed Charges,15.88,45,,13.096,Percent of Total Billed Charges,45% of Total Billed Charges,31.75,90,,125.424,Percent of Total Billed Charges,90% of Total billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.93,65,,103.192,Percent of total Billed Charges,65% of Total Billed Charges,15.56,44.1,,12.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.52,95,,132.392,Percent of Total Billed Charges,95% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.05,88,,122.64,Percent of Total Billed Charges,88% of Total Billed Charges,31.75,90,,125.424,Percent of Total Billed charges,90% of Total Billed Charges,15.56,35.28,
4F COOK MP SOFT,2720000556,CDM,272,RC,C1894,HCPCS,Outpatient,,,3992.15,2594.90,,3992.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3034.03,76,,225.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2874.35,72,,93.984,Percent of Total Billed Charges,72% of Total Billed Charges,2994.11,75,,97.904,Percent of Total Billed charges,75% of Total Billed Charges,3992.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2874.35,72,,93.984,Percent of Total Billed Charges,72% of Total Billed Charges,2395.29,60,,78.32,Percent of Total Billed Charges,60% of Total Billed Charges,3592.94,90,,370.704,Percent of Total Billed Charges,90% of Total Billed Charges,1796.47,45,,65.088,Percent of Total Billed Charges,45% of Total Billed Charges,3592.94,90,,266.72,Percent of Total Billed Charges,90% of Total billed Charges,3992.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3992.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3992.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2594.9,65,,18.92,Percent of total Billed Charges,65% of Total Billed Charges,1760.54,44.1,,63.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,3792.54,95,,281.536,Percent of Total Billed Charges,95% of Total Billed Charges,3992.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3513.09,88,,260.792,Percent of Total Billed Charges,88% of Total Billed Charges,3592.94,90,,266.72,Percent of Total Billed charges,90% of Total Billed Charges,1760.54,3992.15,
PEEL AWAY INTRO 20F 13CM,2720000557,CDM,272,RC,C1892,HCPCS,Outpatient,,,127.70,83.01,,127.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,97.05,76,,120.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.94,72,,98.432,Percent of Total Billed Charges,72% of Total Billed Charges,95.78,75,,102.536,Percent of Total Billed charges,75% of Total Billed Charges,127.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.94,72,,98.432,Percent of Total Billed Charges,72% of Total Billed Charges,76.62,60,,82.024,Percent of Total Billed Charges,60% of Total Billed Charges,114.93,90,,38.104,Percent of Total Billed Charges,90% of Total Billed Charges,57.47,45,,74.224,Percent of Total Billed Charges,45% of Total Billed Charges,114.93,90,,142.888,Percent of Total Billed Charges,90% of Total billed Charges,127.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.01,65,,94.024,Percent of total Billed Charges,65% of Total Billed Charges,56.32,44.1,,72.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,121.32,95,,150.824,Percent of Total Billed Charges,95% of Total Billed Charges,127.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.38,88,,139.712,Percent of Total Billed Charges,88% of Total Billed Charges,114.93,90,,142.888,Percent of Total Billed charges,90% of Total Billed Charges,56.32,127.7,
PEEL AWAY INTRO 22F 13CM,2720000558,CDM,272,RC,C1892,HCPCS,Outpatient,,,127.70,83.01,,127.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,97.05,76,,22.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.94,72,,50.168,Percent of Total Billed Charges,72% of Total Billed Charges,95.78,75,,52.264,Percent of Total Billed charges,75% of Total Billed Charges,127.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.94,72,,50.168,Percent of Total Billed Charges,72% of Total Billed Charges,76.62,60,,41.808,Percent of Total Billed Charges,60% of Total Billed Charges,114.93,90,,149.232,Percent of Total Billed Charges,90% of Total Billed Charges,57.47,45,,110.344,Percent of Total Billed Charges,45% of Total Billed Charges,114.93,90,,26.192,Percent of Total Billed Charges,90% of Total billed Charges,127.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.01,65,,107.208,Percent of total Billed Charges,65% of Total Billed Charges,56.32,44.1,,108.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,121.32,95,,27.648,Percent of Total Billed Charges,95% of Total Billed Charges,127.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.38,88,,25.608,Percent of Total Billed Charges,88% of Total Billed Charges,114.93,90,,26.192,Percent of Total Billed charges,90% of Total Billed Charges,56.32,127.7,
PEEL AWAY INTRO 14F X 15CM,2720000559,CDM,272,RC,C1894,HCPCS,Outpatient,,,60.00,39.00,,60,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.6,76,,109.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.2,72,,50.168,Percent of Total Billed Charges,72% of Total Billed Charges,45,75,,52.264,Percent of Total Billed charges,75% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.2,72,,50.168,Percent of Total Billed Charges,72% of Total Billed Charges,36,60,,41.808,Percent of Total Billed Charges,60% of Total Billed Charges,54,90,,198.456,Percent of Total Billed Charges,90% of Total Billed Charges,27,45,,111.928,Percent of Total Billed Charges,45% of Total Billed Charges,54,90,,130.184,Percent of Total Billed Charges,90% of Total billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39,65,,159.384,Percent of total Billed Charges,65% of Total Billed Charges,26.46,44.1,,109.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,57,95,,137.416,Percent of Total Billed Charges,95% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.8,88,,127.288,Percent of Total Billed Charges,88% of Total Billed Charges,54,90,,130.184,Percent of Total Billed charges,90% of Total Billed Charges,26.46,60,
PEEL AWAY INTRO 18F X 15CM,2720000560,CDM,272,RC,C1894,HCPCS,Outpatient,,,60.00,39.00,,60,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.6,76,,125.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.2,72,,90.176,Percent of Total Billed Charges,72% of Total Billed Charges,45,75,,93.936,Percent of Total Billed charges,75% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.2,72,,90.176,Percent of Total Billed Charges,72% of Total Billed Charges,36,60,,75.152,Percent of Total Billed Charges,60% of Total Billed Charges,54,90,,150.824,Percent of Total Billed Charges,90% of Total Billed Charges,27,45,,164.32,Percent of Total Billed Charges,45% of Total Billed Charges,54,90,,148.44,Percent of Total Billed Charges,90% of Total billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39,65,,161.672,Percent of total Billed Charges,65% of Total Billed Charges,26.46,44.1,,161.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,57,95,,156.688,Percent of Total Billed Charges,95% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.8,88,,145.144,Percent of Total Billed Charges,88% of Total Billed Charges,54,90,,148.44,Percent of Total Billed charges,90% of Total Billed Charges,26.46,60,
PEEL AWAY INTRO 12F X 15CM,2720000561,CDM,272,RC,C1894,HCPCS,Outpatient,,,60.00,39.00,,60,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.6,76,,186.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.2,72,,106.688,Percent of Total Billed Charges,72% of Total Billed Charges,45,75,,111.136,Percent of Total Billed charges,75% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.2,72,,106.688,Percent of Total Billed Charges,72% of Total Billed Charges,36,60,,88.904,Percent of Total Billed Charges,60% of Total Billed Charges,54,90,,78.592,Percent of Total Billed Charges,90% of Total Billed Charges,27,45,,374.672,Percent of Total Billed Charges,45% of Total Billed Charges,54,90,,220.68,Percent of Total Billed Charges,90% of Total billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39,65,,237.352,Percent of total Billed Charges,65% of Total Billed Charges,26.46,44.1,,367.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,57,95,,232.944,Percent of Total Billed Charges,95% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.8,88,,215.776,Percent of Total Billed Charges,88% of Total Billed Charges,54,90,,220.68,Percent of Total Billed charges,90% of Total Billed Charges,26.46,60,
PEEL AWAY INTRO 16F X 15CM,2720000562,CDM,272,RC,C1894,HCPCS,Outpatient,,,60.00,39.00,,60,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.6,76,,189.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.2,72,,106.688,Percent of Total Billed Charges,72% of Total Billed Charges,45,75,,111.136,Percent of Total Billed charges,75% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.2,72,,106.688,Percent of Total Billed Charges,72% of Total Billed Charges,36,60,,88.904,Percent of Total Billed Charges,60% of Total Billed Charges,54,90,,35.72,Percent of Total Billed Charges,90% of Total Billed Charges,27,45,,185.352,Percent of Total Billed Charges,45% of Total Billed Charges,54,90,,223.856,Percent of Total Billed Charges,90% of Total billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39,65,,541.192,Percent of total Billed Charges,65% of Total Billed Charges,26.46,44.1,,181.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,57,95,,236.288,Percent of Total Billed Charges,95% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.8,88,,218.88,Percent of Total Billed Charges,88% of Total Billed Charges,54,90,,223.856,Percent of Total Billed charges,90% of Total Billed Charges,26.46,60,
5F COOK MP STIFF,2720000563,CDM,272,RC,C1894,HCPCS,Outpatient,,,644.96,419.22,,644.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,490.17,76,,277.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,464.37,72,,50.168,Percent of Total Billed Charges,72% of Total Billed Charges,483.72,75,,52.264,Percent of Total Billed charges,75% of Total Billed Charges,644.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,464.37,72,,50.168,Percent of Total Billed Charges,72% of Total Billed Charges,386.98,60,,41.808,Percent of Total Billed Charges,60% of Total Billed Charges,580.46,90,,502.472,Percent of Total Billed Charges,90% of Total Billed Charges,290.23,45,,19.048,Percent of Total Billed Charges,45% of Total Billed Charges,580.46,90,,328.64,Percent of Total Billed Charges,90% of Total billed Charges,644.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,644.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,644.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.22,65,,267.736,Percent of total Billed Charges,65% of Total Billed Charges,284.43,44.1,,18.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,612.71,95,,346.896,Percent of Total Billed Charges,95% of Total Billed Charges,644.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,567.56,88,,321.336,Percent of Total Billed Charges,88% of Total Billed Charges,580.46,90,,328.64,Percent of Total Billed charges,90% of Total Billed Charges,284.43,644.96,
4F STIFEN 7CM MP NEEDLE KIT,2720000564,CDM,272,RC,C1894,HCPCS,Outpatient,,,126.77,82.40,,126.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,96.35,76,,632.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.27,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,95.08,75,,19.848,Percent of Total Billed charges,75% of Total Billed Charges,126.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.27,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,76.06,60,,15.88,Percent of Total Billed Charges,60% of Total Billed Charges,114.09,90,,446.912,Percent of Total Billed Charges,90% of Total Billed Charges,57.05,45,,74.616,Percent of Total Billed Charges,45% of Total Billed Charges,114.09,90,,749.344,Percent of Total Billed Charges,90% of Total billed Charges,126.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.4,65,,27.52,Percent of total Billed Charges,65% of Total Billed Charges,55.91,44.1,,73.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,120.43,95,,790.976,Percent of Total Billed Charges,95% of Total Billed Charges,126.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.56,88,,732.696,Percent of Total Billed Charges,88% of Total Billed Charges,114.09,90,,749.344,Percent of Total Billed charges,90% of Total Billed Charges,55.91,126.77,
ADMIRAL 5F 4X60X130 035 OTW,2720000565,CDM,272,RC,C2623,HCPCS,Outpatient,,,3280.00,2132.00,,3280,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2492.8,76,,313.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2361.6,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,2460,75,,19.848,Percent of Total Billed charges,75% of Total Billed Charges,3280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2361.6,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,1968,60,,15.88,Percent of Total Billed Charges,60% of Total Billed Charges,2952,90,,150.024,Percent of Total Billed Charges,90% of Total Billed Charges,1476,45,,99.224,Percent of Total Billed Charges,45% of Total Billed Charges,2952,90,,370.704,Percent of Total Billed Charges,90% of Total billed Charges,3280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2132,65,,107.784,Percent of total Billed Charges,65% of Total Billed Charges,1446.48,44.1,,97.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,3116,95,,391.304,Percent of Total Billed Charges,95% of Total Billed Charges,3280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2886.4,88,,362.472,Percent of Total Billed Charges,88% of Total Billed Charges,2952,90,,370.704,Percent of Total Billed charges,90% of Total Billed Charges,1446.48,3280,
QUILL YA-2024Q MONO.SZ2 SUTURE,2720000566,CDM,278,RC,C2626,HCPCS,Outpatient,,,395.80,257.27,,395.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,300.81,76,,32.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.98,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,284.98,72,,15.88,Percent of Total Billed charges,72% of Total Billed Charges,395.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.98,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,237.48,60,,12.704,Percent of Total Billed Charges,60% of Total Billed Charges,356.22,90,,585.832,Percent of Total Billed Charges,90% of Total Billed Charges,178.11,45,,75.416,Percent of Total Billed Charges,45% of Total Billed Charges,356.22,90,,38.104,Percent of Total Billed Charges,90% of Total billed Charges,395.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,395.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,395.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.27,65,,143.328,Percent of total Billed Charges,65% of Total Billed Charges,174.55,44.1,,73.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,376.01,95,,40.216,Percent of Total Billed Charges,95% of Total Billed Charges,395.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.3,88,,37.256,Percent of Total Billed Charges,88% of Total Billed Charges,356.22,90,,38.104,Percent of Total Billed charges,90% of Total Billed Charges,174.55,395.8,
SUPRA PUBIC FOLEY,2720000567,CDM,272,RC,C2627,HCPCS,Outpatient,,,240.35,156.23,,240.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,182.67,76,,126.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,173.05,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,180.26,75,,15.88,Percent of Total Billed charges,75% of Total Billed Charges,240.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.05,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,144.21,60,,12.704,Percent of Total Billed Charges,60% of Total Billed Charges,216.32,90,,45.248,Percent of Total Billed Charges,90% of Total Billed Charges,108.16,45,,39.296,Percent of Total Billed Charges,45% of Total Billed Charges,216.32,90,,149.232,Percent of Total Billed Charges,90% of Total billed Charges,240.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.23,65,,108.928,Percent of total Billed Charges,65% of Total Billed Charges,105.99,44.1,,38.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,228.33,95,,157.528,Percent of Total Billed Charges,95% of Total Billed Charges,240.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.51,88,,145.92,Percent of Total Billed Charges,88% of Total Billed Charges,216.32,90,,149.232,Percent of Total Billed charges,90% of Total Billed Charges,105.99,240.35,
PEDS ADAPTIC 3X8,2720000568,CDM,272,RC,,,Outpatient,,,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,167.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,62.872,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,65.488,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,62.872,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,52.392,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,328.64,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,17.856,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,198.456,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,56.76,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,17.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,209.48,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,194.04,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,198.456,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
ADAPTIC 3X8,2720000569,CDM,272,RC,,,Outpatient,,,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,127.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,46.312,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,37.048,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,34.928,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,251.24,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,150.824,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,25.8,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,246.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,159.208,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,147.472,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,150.824,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
CUSTOM CATARACT PCK,2720000570,CDM,272,RC,,,Outpatient,,,395.80,257.27,,395.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,300.81,76,,66.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.98,72,,57.792,Percent of Total Billed Charges,72% of Total Billed Charges,296.85,75,,60.2,Percent of Total Billed charges,75% of Total Billed Charges,395.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.98,72,,57.792,Percent of Total Billed Charges,72% of Total Billed Charges,237.48,60,,48.16,Percent of Total Billed Charges,60% of Total Billed Charges,356.22,90,,46.84,Percent of Total Billed Charges,90% of Total Billed Charges,178.11,45,,223.456,Percent of Total Billed Charges,45% of Total Billed Charges,356.22,90,,78.592,Percent of Total Billed Charges,90% of Total billed Charges,395.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,395.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,395.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.27,65,,362.896,Percent of total Billed Charges,65% of Total Billed Charges,174.55,44.1,,218.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,376.01,95,,82.952,Percent of Total Billed Charges,95% of Total Billed Charges,395.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.3,88,,76.84,Percent of Total Billed Charges,88% of Total Billed Charges,356.22,90,,78.592,Percent of Total Billed charges,90% of Total Billed Charges,174.55,395.8,
HARMONIC WAVE,2720000571,CDM,272,RC,,,Outpatient,,,953.66,619.88,,953.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,724.78,76,,30.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,686.64,72,,65.408,Percent of Total Billed Charges,72% of Total Billed Charges,715.25,75,,68.136,Percent of Total Billed charges,75% of Total Billed Charges,953.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,686.64,72,,65.408,Percent of Total Billed Charges,72% of Total Billed Charges,572.2,60,,54.512,Percent of Total Billed Charges,60% of Total Billed Charges,858.29,90,,30.168,Percent of Total Billed Charges,90% of Total Billed Charges,429.15,45,,75.016,Percent of Total Billed Charges,45% of Total Billed Charges,858.29,90,,35.72,Percent of Total Billed Charges,90% of Total billed Charges,953.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,953.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,953.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,619.88,65,,322.768,Percent of total Billed Charges,65% of Total Billed Charges,420.56,44.1,,73.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,905.98,95,,37.704,Percent of Total Billed Charges,95% of Total Billed Charges,953.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,839.22,88,,34.928,Percent of Total Billed Charges,88% of Total Billed Charges,858.29,90,,35.72,Percent of Total Billed charges,90% of Total Billed Charges,420.56,953.66,
ANASTOCLIP REMOVER,2720000572,CDM,272,RC,,,Outpatient,,,248.06,161.24,,248.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,188.53,76,,424.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,178.6,72,,34.296,Percent of Total Billed Charges,72% of Total Billed Charges,186.05,75,,35.728,Percent of Total Billed charges,75% of Total Billed Charges,248.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.6,72,,34.296,Percent of Total Billed Charges,72% of Total Billed Charges,148.84,60,,28.576,Percent of Total Billed Charges,60% of Total Billed Charges,223.25,90,,6912.408,Percent of Total Billed Charges,90% of Total Billed Charges,111.63,45,,292.912,Percent of Total Billed Charges,45% of Total Billed Charges,223.25,90,,502.472,Percent of Total Billed Charges,90% of Total billed Charges,248.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.24,65,,108.352,Percent of total Billed Charges,65% of Total Billed Charges,109.39,44.1,,287.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,235.66,95,,530.392,Percent of Total Billed Charges,95% of Total Billed Charges,248.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.29,88,,491.304,Percent of Total Billed Charges,88% of Total Billed Charges,223.25,90,,502.472,Percent of Total Billed charges,90% of Total Billed Charges,109.39,248.06,
PEG TUBE KIT,2720000573,CDM,272,RC,,,Outpatient,,,108.05,70.23,,108.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.12,76,,377.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.8,72,,281.328,Percent of Total Billed Charges,72% of Total Billed Charges,81.04,75,,293.048,Percent of Total Billed charges,75% of Total Billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.8,72,,281.328,Percent of Total Billed Charges,72% of Total Billed Charges,64.83,60,,234.44,Percent of Total Billed Charges,60% of Total Billed Charges,97.25,90,,195.28,Percent of Total Billed Charges,90% of Total Billed Charges,48.62,45,,22.624,Percent of Total Billed Charges,45% of Total Billed Charges,97.25,90,,446.912,Percent of Total Billed Charges,90% of Total billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.23,65,,423.096,Percent of total Billed Charges,65% of Total Billed Charges,47.65,44.1,,22.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.65,95,,471.736,Percent of Total Billed Charges,95% of Total Billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.08,88,,436.976,Percent of Total Billed Charges,88% of Total Billed Charges,97.25,90,,446.912,Percent of Total Billed charges,90% of Total Billed Charges,47.65,108.05,
ECHELON45 STAPLER,2720000574,CDM,272,RC,,,Outpatient,,,1447.58,940.93,,1447.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1100.16,76,,126.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1042.26,72,,262.272,Percent of Total Billed Charges,72% of Total Billed Charges,1085.69,75,,273.2,Percent of Total Billed charges,75% of Total Billed Charges,1447.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1042.26,72,,262.272,Percent of Total Billed Charges,72% of Total Billed Charges,868.55,60,,218.56,Percent of Total Billed Charges,60% of Total Billed Charges,1302.82,90,,52.392,Percent of Total Billed Charges,90% of Total Billed Charges,651.41,45,,164.32,Percent of Total Billed Charges,45% of Total Billed Charges,1302.82,90,,150.024,Percent of Total Billed Charges,90% of Total billed Charges,1447.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1447.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1447.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,940.93,65,,32.68,Percent of total Billed Charges,65% of Total Billed Charges,638.38,44.1,,161.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,1375.2,95,,158.36,Percent of Total Billed Charges,95% of Total Billed Charges,1447.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1273.87,88,,146.696,Percent of Total Billed Charges,88% of Total Billed Charges,1302.82,90,,150.024,Percent of Total Billed charges,90% of Total Billed Charges,638.38,1447.58,
RELOAD GST45W ECHELON STAPLER,2720000575,CDM,272,RC,,,Outpatient,,,1813.00,1178.45,,1813,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1377.88,76,,494.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1305.36,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,1359.75,75,,10.584,Percent of Total Billed charges,75% of Total Billed Charges,1813,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1305.36,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,1087.8,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,1631.7,90,,465.96,Percent of Total Billed Charges,90% of Total Billed Charges,815.85,45,,17.464,Percent of Total Billed Charges,45% of Total Billed Charges,1631.7,90,,585.832,Percent of Total Billed Charges,90% of Total billed Charges,1813,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1813,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1813,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.45,65,,237.352,Percent of total Billed Charges,65% of Total Billed Charges,799.53,44.1,,17.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,1722.35,95,,618.376,Percent of Total Billed Charges,95% of Total Billed Charges,1813,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1595.44,88,,572.808,Percent of Total Billed Charges,88% of Total Billed Charges,1631.7,90,,585.832,Percent of Total Billed charges,90% of Total Billed Charges,799.53,1813,
BARDEX 22 TIP,2720000576,CDM,272,RC,,,Outpatient,,,183.02,118.96,,183.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,139.1,76,,38.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,131.77,72,,106.688,Percent of Total Billed Charges,72% of Total Billed Charges,137.27,75,,111.136,Percent of Total Billed charges,75% of Total Billed Charges,183.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.77,72,,106.688,Percent of Total Billed Charges,72% of Total Billed Charges,109.81,60,,88.904,Percent of Total Billed Charges,60% of Total Billed Charges,164.72,90,,142.096,Percent of Total Billed Charges,90% of Total Billed Charges,82.36,45,,23.416,Percent of Total Billed Charges,45% of Total Billed Charges,164.72,90,,45.248,Percent of Total Billed Charges,90% of Total billed Charges,183.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.96,65,,25.224,Percent of total Billed Charges,65% of Total Billed Charges,80.71,44.1,,22.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,173.87,95,,47.76,Percent of Total Billed Charges,95% of Total Billed Charges,183.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.06,88,,44.24,Percent of Total Billed Charges,88% of Total Billed Charges,164.72,90,,45.248,Percent of Total Billed charges,90% of Total Billed Charges,80.71,183.02,
BARDEX 24 TIP,2720000577,CDM,272,RC,,,Outpatient,,,185.22,120.39,,185.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,140.77,76,,277.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,133.36,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,138.92,75,,51.6,Percent of Total Billed charges,75% of Total Billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.36,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,111.13,60,,41.28,Percent of Total Billed Charges,60% of Total Billed Charges,166.7,90,,538.2,Percent of Total Billed Charges,90% of Total Billed Charges,83.35,45,,15.088,Percent of Total Billed Charges,45% of Total Billed Charges,166.7,90,,328.64,Percent of Total Billed Charges,90% of Total billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.39,65,,33.824,Percent of total Billed Charges,65% of Total Billed Charges,81.68,44.1,,14.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,175.96,95,,346.896,Percent of Total Billed Charges,95% of Total Billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.99,88,,321.336,Percent of Total Billed Charges,88% of Total Billed Charges,166.7,90,,328.64,Percent of Total Billed charges,90% of Total Billed Charges,81.68,185.22,
SURGICAL RETRACTOR,2720000578,CDM,272,RC,,,Outpatient,,,213.89,139.03,,213.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,162.56,76,,29.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,154,72,,60.328,Percent of Total Billed Charges,72% of Total Billed Charges,160.42,75,,62.848,Percent of Total Billed charges,75% of Total Billed Charges,213.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154,72,,60.328,Percent of Total Billed Charges,72% of Total Billed Charges,128.33,60,,50.272,Percent of Total Billed Charges,60% of Total Billed Charges,192.5,90,,155.584,Percent of Total Billed Charges,90% of Total Billed Charges,96.25,45,,3456.208,Percent of Total Billed Charges,45% of Total Billed Charges,192.5,90,,34.928,Percent of Total Billed Charges,90% of Total billed Charges,213.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.03,65,,21.792,Percent of total Billed Charges,65% of Total Billed Charges,94.33,44.1,,3387.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,203.2,95,,36.864,Percent of Total Billed Charges,95% of Total Billed Charges,213.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.22,88,,34.152,Percent of Total Billed Charges,88% of Total Billed Charges,192.5,90,,34.928,Percent of Total Billed charges,90% of Total Billed Charges,94.33,213.89,
SURGICAL STAYS,2720000579,CDM,272,RC,,,Outpatient,,,169.79,110.36,,169.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.04,76,,39.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,122.25,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,127.34,75,,9.264,Percent of Total Billed charges,75% of Total Billed Charges,169.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.25,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,101.87,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,152.81,90,,283.384,Percent of Total Billed Charges,90% of Total Billed Charges,76.41,45,,97.64,Percent of Total Billed Charges,45% of Total Billed Charges,152.81,90,,46.84,Percent of Total Billed Charges,90% of Total billed Charges,169.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.36,65,,4992.296,Percent of total Billed Charges,65% of Total Billed Charges,74.88,44.1,,95.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,161.3,95,,49.44,Percent of Total Billed Charges,95% of Total Billed Charges,169.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.42,88,,45.792,Percent of Total Billed Charges,88% of Total Billed Charges,152.81,90,,46.84,Percent of Total Billed charges,90% of Total Billed Charges,74.88,169.79,
MINI FLARED,2720000580,CDM,272,RC,,,Outpatient,,,171.99,111.79,,171.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.71,76,,25.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.83,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,128.99,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.83,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,103.19,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,154.79,90,,86.52,Percent of Total Billed Charges,90% of Total Billed Charges,77.4,45,,26.2,Percent of Total Billed Charges,45% of Total Billed Charges,154.79,90,,30.168,Percent of Total Billed Charges,90% of Total billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.79,65,,141.032,Percent of total Billed Charges,65% of Total Billed Charges,75.85,44.1,,25.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.39,95,,31.848,Percent of Total Billed Charges,95% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.35,88,,29.496,Percent of Total Billed Charges,88% of Total Billed Charges,154.79,90,,30.168,Percent of Total Billed charges,90% of Total Billed Charges,75.85,171.99,
OLYM SCLEROTH NEEDLE,2720000581,CDM,272,RC,,,Outpatient,,,157.66,102.48,,157.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,119.82,76,,5837.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,113.52,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,118.25,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.52,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,94.6,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,141.89,90,,576.304,Percent of Total Billed Charges,90% of Total Billed Charges,70.95,45,,232.984,Percent of Total Billed Charges,45% of Total Billed Charges,141.89,90,,6912.408,Percent of Total Billed Charges,90% of Total billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.48,65,,37.84,Percent of total Billed Charges,65% of Total Billed Charges,69.53,44.1,,228.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,149.78,95,,7296.432,Percent of Total Billed Charges,95% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.74,88,,6758.8,Percent of Total Billed Charges,88% of Total Billed Charges,141.89,90,,6912.408,Percent of Total Billed charges,90% of Total Billed Charges,69.53,157.66,
TURBO SONIC 1.1 SUP,2720000582,CDM,272,RC,,,Outpatient,,,50.72,32.97,,50.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38.55,76,,164.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36.52,72,,132.088,Percent of Total Billed Charges,72% of Total Billed Charges,38.04,75,,137.592,Percent of Total Billed charges,75% of Total Billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.52,72,,132.088,Percent of Total Billed Charges,72% of Total Billed Charges,30.43,60,,110.072,Percent of Total Billed Charges,60% of Total Billed Charges,45.65,90,,34.928,Percent of Total Billed Charges,90% of Total Billed Charges,22.82,45,,71.048,Percent of Total Billed Charges,45% of Total Billed Charges,45.65,90,,195.28,Percent of Total Billed Charges,90% of Total billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.97,65,,336.528,Percent of total Billed Charges,65% of Total Billed Charges,22.37,44.1,,69.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.18,95,,206.128,Percent of Total Billed Charges,95% of Total Billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.63,88,,190.936,Percent of Total Billed Charges,88% of Total Billed Charges,45.65,90,,195.28,Percent of Total Billed charges,90% of Total Billed Charges,22.37,50.72,
CLEAR CUT KNIFE SUP,2720000583,CDM,272,RC,,,Outpatient,,,84.89,55.18,,84.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,64.52,76,,44.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.12,72,,116.216,Percent of Total Billed Charges,72% of Total Billed Charges,63.67,75,,121.056,Percent of Total Billed charges,75% of Total Billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,72,,116.216,Percent of Total Billed Charges,72% of Total Billed Charges,50.93,60,,96.848,Percent of Total Billed Charges,60% of Total Billed Charges,76.4,90,,38.104,Percent of Total Billed Charges,90% of Total Billed Charges,38.2,45,,269.104,Percent of Total Billed Charges,45% of Total Billed Charges,76.4,90,,52.392,Percent of Total Billed Charges,90% of Total billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.18,65,,102.624,Percent of total Billed Charges,65% of Total Billed Charges,37.44,44.1,,263.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,80.65,95,,55.304,Percent of Total Billed Charges,95% of Total Billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.7,88,,51.232,Percent of Total Billed Charges,88% of Total Billed Charges,76.4,90,,52.392,Percent of Total Billed charges,90% of Total Billed Charges,37.44,84.89,
ROUND BURR SUP,2720000584,CDM,272,RC,,,Outpatient,,,34.18,22.22,,34.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.98,76,,393.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.61,72,,317.52,Percent of Total Billed Charges,72% of Total Billed Charges,25.64,75,,330.752,Percent of Total Billed charges,75% of Total Billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.61,72,,317.52,Percent of Total Billed Charges,72% of Total Billed Charges,20.51,60,,264.6,Percent of Total Billed Charges,60% of Total Billed Charges,30.76,90,,37.312,Percent of Total Billed Charges,90% of Total Billed Charges,15.38,45,,77.792,Percent of Total Billed Charges,45% of Total Billed Charges,30.76,90,,465.96,Percent of Total Billed Charges,90% of Total billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.22,65,,388.704,Percent of total Billed Charges,65% of Total Billed Charges,15.07,44.1,,76.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.47,95,,491.848,Percent of Total Billed Charges,95% of Total Billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.08,88,,455.608,Percent of Total Billed Charges,88% of Total Billed Charges,30.76,90,,465.96,Percent of Total Billed charges,90% of Total Billed Charges,15.07,34.18,
TISSEAL FROZEN 2ML,2720000585,CDM,272,RC,,,Outpatient,,,314.21,204.24,,314.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,238.8,76,,119.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,226.23,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,235.66,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.23,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,188.53,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,282.79,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,141.39,45,,141.696,Percent of Total Billed Charges,45% of Total Billed Charges,282.79,90,,142.096,Percent of Total Billed Charges,90% of Total billed Charges,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.24,65,,112.368,Percent of total Billed Charges,65% of Total Billed Charges,138.57,44.1,,138.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,298.5,95,,149.984,Percent of Total Billed Charges,95% of Total Billed Charges,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.5,88,,138.936,Percent of Total Billed Charges,88% of Total Billed Charges,282.79,90,,142.096,Percent of Total Billed charges,90% of Total Billed Charges,138.57,314.21,
TOOMEY SYRINGE,2720000586,CDM,272,RC,,,Outpatient,,,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,454.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,777.248,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,43.264,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,538.2,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,204.664,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,42.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,568.104,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,526.24,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,538.2,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
BAG-A-FLOW,2720000587,CDM,272,RC,,,Outpatient,,,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,131.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.88,72,,39.376,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,75,,41.016,Percent of Total Billed charges,75% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.88,72,,39.376,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,60,,32.816,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,90,,508.032,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,288.152,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,155.584,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,62.488,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,282.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,164.232,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,152.128,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,155.584,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.05,
OMNICUP,2720000588,CDM,272,RC,,,Outpatient,,,130.10,84.57,,130.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.88,76,,239.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,93.67,72,,94.616,Percent of Total Billed Charges,72% of Total Billed Charges,97.58,75,,98.56,Percent of Total Billed charges,75% of Total Billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.67,72,,94.616,Percent of Total Billed Charges,72% of Total Billed Charges,78.06,60,,78.848,Percent of Total Billed Charges,60% of Total Billed Charges,117.09,90,,770.784,Percent of Total Billed Charges,90% of Total Billed Charges,58.55,45,,17.464,Percent of Total Billed Charges,45% of Total Billed Charges,117.09,90,,283.384,Percent of Total Billed Charges,90% of Total billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.57,65,,416.216,Percent of total Billed Charges,65% of Total Billed Charges,57.37,44.1,,17.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,123.6,95,,299.128,Percent of Total Billed Charges,95% of Total Billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.49,88,,277.088,Percent of Total Billed Charges,88% of Total Billed Charges,117.09,90,,283.384,Percent of Total Billed charges,90% of Total Billed Charges,57.37,130.1,
VERSAJET,2720000589,CDM,272,RC,,,Outpatient,,,1378.13,895.78,,1378.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1047.38,76,,73.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,992.25,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,1033.6,75,,24.472,Percent of Total Billed charges,75% of Total Billed Charges,1378.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,992.25,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,826.88,60,,19.576,Percent of Total Billed Charges,60% of Total Billed Charges,1240.32,90,,353.24,Percent of Total Billed Charges,90% of Total Billed Charges,620.16,45,,19.048,Percent of Total Billed Charges,45% of Total Billed Charges,1240.32,90,,86.52,Percent of Total Billed Charges,90% of Total billed Charges,1378.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1378.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1378.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,895.78,65,,25.224,Percent of total Billed Charges,65% of Total Billed Charges,607.76,44.1,,18.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,1309.22,95,,91.328,Percent of Total Billed Charges,95% of Total Billed Charges,1378.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1212.75,88,,84.6,Percent of Total Billed Charges,88% of Total Billed Charges,1240.32,90,,86.52,Percent of Total Billed charges,90% of Total Billed Charges,607.76,1378.13,
BROWN DERMATONE BLAD,2720000590,CDM,272,RC,,,Outpatient,,,200.66,130.43,,200.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152.5,76,,486.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144.48,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,150.5,75,,13.232,Percent of Total Billed charges,75% of Total Billed Charges,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.48,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,120.4,60,,10.584,Percent of Total Billed Charges,60% of Total Billed Charges,180.59,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,90.3,45,,18.656,Percent of Total Billed Charges,45% of Total Billed Charges,180.59,90,,576.304,Percent of Total Billed Charges,90% of Total billed Charges,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.43,65,,27.52,Percent of total Billed Charges,65% of Total Billed Charges,88.49,44.1,,18.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,190.63,95,,608.32,Percent of Total Billed Charges,95% of Total Billed Charges,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.58,88,,563.496,Percent of Total Billed Charges,88% of Total Billed Charges,180.59,90,,576.304,Percent of Total Billed charges,90% of Total Billed Charges,88.49,200.66,
COBAN 2,2720000591,CDM,272,RC,,,Outpatient,,,26.46,17.20,,26.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.11,76,,29.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.05,72,,34.296,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,75,,35.728,Percent of Total Billed charges,75% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.05,72,,34.296,Percent of Total Billed Charges,72% of Total Billed Charges,15.88,60,,28.576,Percent of Total Billed Charges,60% of Total Billed Charges,23.81,90,,120.656,Percent of Total Billed Charges,90% of Total Billed Charges,11.91,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,23.81,90,,34.928,Percent of Total Billed Charges,90% of Total billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,65,,26.944,Percent of total Billed Charges,65% of Total Billed Charges,11.67,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.14,95,,36.864,Percent of Total Billed Charges,95% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.28,88,,34.152,Percent of Total Billed Charges,88% of Total Billed Charges,23.81,90,,34.928,Percent of Total Billed charges,90% of Total Billed Charges,11.67,26.46,
CAROTID ART SHUNT,2720000592,CDM,272,RC,,,Outpatient,,,157.66,102.48,,157.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,119.82,76,,32.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,113.52,72,,58.424,Percent of Total Billed Charges,72% of Total Billed Charges,118.25,75,,60.856,Percent of Total Billed charges,75% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.52,72,,58.424,Percent of Total Billed Charges,72% of Total Billed Charges,94.6,60,,48.688,Percent of Total Billed Charges,60% of Total Billed Charges,141.89,90,,324.664,Percent of Total Billed Charges,90% of Total Billed Charges,70.95,45,,388.624,Percent of Total Billed Charges,45% of Total Billed Charges,141.89,90,,38.104,Percent of Total Billed Charges,90% of Total billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.48,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,69.53,44.1,,380.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,149.78,95,,40.216,Percent of Total Billed Charges,95% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.74,88,,37.256,Percent of Total Billed Charges,88% of Total Billed Charges,141.89,90,,38.104,Percent of Total Billed charges,90% of Total Billed Charges,69.53,157.66,
TAUT CHOLANGRIOGRAM CATH,2720000593,CDM,272,RC,,,Outpatient,,,185.22,120.39,,185.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,140.77,76,,31.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,133.36,72,,58.424,Percent of Total Billed Charges,72% of Total Billed Charges,138.92,75,,60.856,Percent of Total Billed charges,75% of Total Billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.36,72,,58.424,Percent of Total Billed Charges,72% of Total Billed Charges,111.13,60,,48.688,Percent of Total Billed Charges,60% of Total Billed Charges,166.7,90,,324.664,Percent of Total Billed Charges,90% of Total Billed Charges,83.35,45,,254.016,Percent of Total Billed Charges,45% of Total Billed Charges,166.7,90,,37.312,Percent of Total Billed Charges,90% of Total billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.39,65,,561.344,Percent of total Billed Charges,65% of Total Billed Charges,81.68,44.1,,248.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,175.96,95,,39.384,Percent of Total Billed Charges,95% of Total Billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.99,88,,36.48,Percent of Total Billed Charges,88% of Total Billed Charges,166.7,90,,37.312,Percent of Total Billed charges,90% of Total Billed Charges,81.68,185.22,
DPYMITEK EXPRESS NE,2720000594,CDM,272,RC,,,Outpatient,,,157.66,102.48,,157.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,119.82,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,113.52,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,118.25,75,,17.864,Percent of Total Billed charges,75% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.52,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,94.6,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,141.89,90,,1222.456,Percent of Total Billed Charges,90% of Total Billed Charges,70.95,45,,385.392,Percent of Total Billed Charges,45% of Total Billed Charges,141.89,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.48,65,,366.912,Percent of total Billed Charges,65% of Total Billed Charges,69.53,44.1,,377.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,149.78,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.74,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,141.89,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,69.53,157.66,
ESCAPE 390200,2720000595,CDM,272,RC,,,Outpatient,,,727.65,472.97,,727.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,553.01,76,,656.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,523.91,72,,495.968,Percent of Total Billed Charges,72% of Total Billed Charges,545.74,75,,516.632,Percent of Total Billed charges,75% of Total Billed Charges,727.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,523.91,72,,495.968,Percent of Total Billed Charges,72% of Total Billed Charges,436.59,60,,413.304,Percent of Total Billed Charges,60% of Total Billed Charges,654.89,90,,467.544,Percent of Total Billed Charges,90% of Total Billed Charges,327.44,45,,176.616,Percent of Total Billed Charges,45% of Total Billed Charges,654.89,90,,777.248,Percent of Total Billed Charges,90% of Total billed Charges,727.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,727.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,727.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.97,65,,556.672,Percent of total Billed Charges,65% of Total Billed Charges,320.89,44.1,,173.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,691.27,95,,820.424,Percent of Total Billed Charges,95% of Total Billed Charges,727.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,640.33,88,,759.976,Percent of Total Billed Charges,88% of Total Billed Charges,654.89,90,,777.248,Percent of Total Billed charges,90% of Total Billed Charges,320.89,727.65,
EYE SHIELD,2720000596,CDM,272,RC,,,Outpatient,,,98.12,63.78,,98.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,74.57,76,,429.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,70.65,72,,2085.472,Percent of Total Billed Charges,72% of Total Billed Charges,73.59,75,,2172.368,Percent of Total Billed charges,75% of Total Billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.65,72,,2085.472,Percent of Total Billed Charges,72% of Total Billed Charges,58.87,60,,1737.896,Percent of Total Billed Charges,60% of Total Billed Charges,88.31,90,,288.944,Percent of Total Billed Charges,90% of Total Billed Charges,44.15,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,88.31,90,,508.032,Percent of Total Billed Charges,90% of Total billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.78,65,,255.12,Percent of total Billed Charges,65% of Total Billed Charges,43.27,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,93.21,95,,536.256,Percent of Total Billed Charges,95% of Total Billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.35,88,,496.744,Percent of Total Billed Charges,88% of Total Billed Charges,88.31,90,,508.032,Percent of Total Billed charges,90% of Total Billed Charges,43.27,98.12,
DERMACARRIER 3 TO 1,2720000597,CDM,272,RC,,,Outpatient,,,148.84,96.75,,148.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,113.12,76,,650.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,107.16,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,111.63,75,,36.384,Percent of Total Billed charges,75% of Total Billed Charges,148.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.16,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,89.3,60,,29.104,Percent of Total Billed Charges,60% of Total Billed Charges,133.96,90,,287.36,Percent of Total Billed Charges,90% of Total Billed Charges,66.98,45,,60.328,Percent of Total Billed Charges,45% of Total Billed Charges,133.96,90,,770.784,Percent of Total Billed Charges,90% of Total billed Charges,148.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.75,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,65.64,44.1,,59.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,141.4,95,,813.6,Percent of Total Billed Charges,95% of Total Billed Charges,148.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.98,88,,753.656,Percent of Total Billed Charges,88% of Total Billed Charges,133.96,90,,770.784,Percent of Total Billed charges,90% of Total Billed Charges,65.64,148.84,
ESMARK 6,2720000598,CDM,272,RC,,,Outpatient,,,121.28,78.83,,121.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,92.17,76,,298.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,87.32,72,,1604.744,Percent of Total Billed Charges,72% of Total Billed Charges,90.96,75,,1671.616,Percent of Total Billed charges,75% of Total Billed Charges,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.32,72,,1604.744,Percent of Total Billed Charges,72% of Total Billed Charges,72.77,60,,1337.288,Percent of Total Billed Charges,60% of Total Billed Charges,109.15,90,,137.328,Percent of Total Billed Charges,90% of Total Billed Charges,54.58,45,,162.328,Percent of Total Billed Charges,45% of Total Billed Charges,109.15,90,,353.24,Percent of Total Billed Charges,90% of Total billed Charges,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.83,65,,87.144,Percent of total Billed Charges,65% of Total Billed Charges,53.48,44.1,,159.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,115.22,95,,372.864,Percent of Total Billed Charges,95% of Total Billed Charges,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.73,88,,345.392,Percent of Total Billed Charges,88% of Total Billed Charges,109.15,90,,353.24,Percent of Total Billed charges,90% of Total Billed Charges,53.48,121.28,
CHROMIC 5-0 792G SUTURE,2720000599,CDM,272,RC,,,Outpatient,,,140.02,91.01,,140.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.42,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.81,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,105.02,75,,44.984,Percent of Total Billed charges,75% of Total Billed Charges,140.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.81,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,84.01,60,,35.984,Percent of Total Billed Charges,60% of Total Billed Charges,126.02,90,,154.792,Percent of Total Billed Charges,90% of Total Billed Charges,63.01,45,,162.328,Percent of Total Billed Charges,45% of Total Billed Charges,126.02,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,140.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.01,65,,234.48,Percent of total Billed Charges,65% of Total Billed Charges,61.75,44.1,,159.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,133.02,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,140.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.22,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,126.02,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,61.75,140.02,
PHILLIPS FOLLOWER 10FR,2720000600,CDM,272,RC,,,Outpatient,,,369.34,240.07,,369.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,280.7,76,,101.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,265.92,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,277.01,75,,44.984,Percent of Total Billed charges,75% of Total Billed Charges,369.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.92,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,221.6,60,,35.984,Percent of Total Billed Charges,60% of Total Billed Charges,332.41,90,,288.944,Percent of Total Billed Charges,90% of Total Billed Charges,166.2,45,,611.224,Percent of Total Billed Charges,45% of Total Billed Charges,332.41,90,,120.656,Percent of Total Billed Charges,90% of Total billed Charges,369.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.07,65,,234.48,Percent of total Billed Charges,65% of Total Billed Charges,162.88,44.1,,599,Percent of Total Billed Charges,44.1% of Total Billed Charges,350.87,95,,127.36,Percent of Total Billed Charges,95% of Total Billed Charges,369.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.02,88,,117.976,Percent of Total Billed Charges,88% of Total Billed Charges,332.41,90,,120.656,Percent of Total Billed charges,90% of Total Billed Charges,162.88,369.34,
FOGARTY BILIARY CATH,2720000601,CDM,272,RC,,,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,274.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,49.616,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,39.688,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,134.952,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,233.776,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,324.664,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,882.88,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,229.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,342.696,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,317.448,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,324.664,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
GIGLI SAW,2720000602,CDM,272,RC,,,Outpatient,,,159.86,103.91,,159.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,121.49,76,,274.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,115.1,72,,55.408,Percent of Total Billed Charges,72% of Total Billed Charges,119.9,75,,57.72,Percent of Total Billed charges,75% of Total Billed Charges,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.1,72,,55.408,Percent of Total Billed Charges,72% of Total Billed Charges,95.92,60,,46.176,Percent of Total Billed Charges,60% of Total Billed Charges,143.87,90,,283.384,Percent of Total Billed Charges,90% of Total Billed Charges,71.94,45,,144.472,Percent of Total Billed Charges,45% of Total Billed Charges,143.87,90,,324.664,Percent of Total Billed Charges,90% of Total billed Charges,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.91,65,,337.672,Percent of total Billed Charges,65% of Total Billed Charges,70.5,44.1,,141.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,151.87,95,,342.696,Percent of Total Billed Charges,95% of Total Billed Charges,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.68,88,,317.448,Percent of Total Billed Charges,88% of Total Billed Charges,143.87,90,,324.664,Percent of Total Billed charges,90% of Total Billed Charges,70.5,159.86,
BLADE SURG C/ST 010,2720000603,CDM,272,RC,,,Outpatient,,,58.43,37.98,,58.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,44.41,76,,1032.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.07,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,43.82,75,,12.568,Percent of Total Billed charges,75% of Total Billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.07,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,35.06,60,,10.056,Percent of Total Billed Charges,60% of Total Billed Charges,52.59,90,,300.856,Percent of Total Billed Charges,90% of Total Billed Charges,26.29,45,,143.68,Percent of Total Billed Charges,45% of Total Billed Charges,52.59,90,,1222.456,Percent of Total Billed Charges,90% of Total billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.98,65,,208.68,Percent of total Billed Charges,65% of Total Billed Charges,25.77,44.1,,140.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,55.51,95,,1290.368,Percent of Total Billed Charges,95% of Total Billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.42,88,,1195.288,Percent of Total Billed Charges,88% of Total Billed Charges,52.59,90,,1222.456,Percent of Total Billed charges,90% of Total Billed Charges,25.77,58.43,
GEL FOAM 50,2720000604,CDM,272,RC,,,Outpatient,,,137.81,89.58,,137.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,104.74,76,,394.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,99.22,72,,764.208,Percent of Total Billed Charges,72% of Total Billed Charges,103.36,75,,796.048,Percent of Total Billed charges,75% of Total Billed Charges,137.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.22,72,,764.208,Percent of Total Billed Charges,72% of Total Billed Charges,82.69,60,,636.84,Percent of Total Billed Charges,60% of Total Billed Charges,124.03,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,62.01,45,,68.664,Percent of Total Billed Charges,45% of Total Billed Charges,124.03,90,,467.544,Percent of Total Billed Charges,90% of Total billed Charges,137.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.58,65,,207.536,Percent of total Billed Charges,65% of Total Billed Charges,60.77,44.1,,67.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,130.92,95,,493.52,Percent of Total Billed Charges,95% of Total Billed Charges,137.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.27,88,,457.16,Percent of Total Billed Charges,88% of Total Billed Charges,124.03,90,,467.544,Percent of Total Billed charges,90% of Total Billed Charges,60.77,137.81,
HEMOVAC LG,2720000605,CDM,272,RC,,,Outpatient,,,179.71,116.81,,179.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,136.58,76,,244,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,129.39,72,,698.544,Percent of Total Billed Charges,72% of Total Billed Charges,134.78,75,,727.648,Percent of Total Billed charges,75% of Total Billed Charges,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.39,72,,698.544,Percent of Total Billed Charges,72% of Total Billed Charges,107.83,60,,582.12,Percent of Total Billed Charges,60% of Total Billed Charges,161.74,90,,346.888,Percent of Total Billed Charges,90% of Total Billed Charges,80.87,45,,77.4,Percent of Total Billed Charges,45% of Total Billed Charges,161.74,90,,288.944,Percent of Total Billed Charges,90% of Total billed Charges,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.81,65,,99.176,Percent of total Billed Charges,65% of Total Billed Charges,79.25,44.1,,75.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,170.72,95,,304.992,Percent of Total Billed Charges,95% of Total Billed Charges,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.14,88,,282.52,Percent of Total Billed Charges,88% of Total Billed Charges,161.74,90,,288.944,Percent of Total Billed charges,90% of Total Billed Charges,79.25,179.71,
PROCEDURE PACK BASIC,2720000606,CDM,272,RC,,,Outpatient,,,38.59,25.08,,38.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.33,76,,242.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.78,72,,270.528,Percent of Total Billed Charges,72% of Total Billed Charges,28.94,75,,281.8,Percent of Total Billed charges,75% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.78,72,,270.528,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,60,,225.44,Percent of Total Billed Charges,60% of Total Billed Charges,34.73,90,,114.304,Percent of Total Billed Charges,90% of Total Billed Charges,17.37,45,,144.472,Percent of Total Billed Charges,45% of Total Billed Charges,34.73,90,,287.36,Percent of Total Billed Charges,90% of Total billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.08,65,,111.792,Percent of total Billed Charges,65% of Total Billed Charges,17.02,44.1,,141.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.66,95,,303.32,Percent of Total Billed Charges,95% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.96,88,,280.976,Percent of Total Billed Charges,88% of Total Billed Charges,34.73,90,,287.36,Percent of Total Billed charges,90% of Total Billed Charges,17.02,38.59,
LDS STAPLES POWERED,2720000607,CDM,272,RC,,,Outpatient,,,842.31,547.50,,842.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,640.16,76,,115.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,606.46,72,,158.12,Percent of Total Billed Charges,72% of Total Billed Charges,631.73,75,,164.712,Percent of Total Billed charges,75% of Total Billed Charges,842.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,606.46,72,,158.12,Percent of Total Billed Charges,72% of Total Billed Charges,505.39,60,,131.768,Percent of Total Billed Charges,60% of Total Billed Charges,758.08,90,,102.4,Percent of Total Billed Charges,90% of Total Billed Charges,379.04,45,,67.472,Percent of Total Billed Charges,45% of Total Billed Charges,758.08,90,,137.328,Percent of Total Billed Charges,90% of Total billed Charges,842.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,842.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,842.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.5,65,,208.68,Percent of total Billed Charges,65% of Total Billed Charges,371.46,44.1,,66.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,800.19,95,,144.952,Percent of Total Billed Charges,95% of Total Billed Charges,842.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,741.23,88,,134.272,Percent of Total Billed Charges,88% of Total Billed Charges,758.08,90,,137.328,Percent of Total Billed charges,90% of Total Billed Charges,371.46,842.31,
LEEP RADIUS ELECTRODE 1X1,2720000608,CDM,272,RC,,,Outpatient,,,138.92,90.30,,138.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,105.58,76,,130.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.02,72,,158.12,Percent of Total Billed Charges,72% of Total Billed Charges,104.19,75,,164.712,Percent of Total Billed charges,75% of Total Billed Charges,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.02,72,,158.12,Percent of Total Billed Charges,72% of Total Billed Charges,83.35,60,,131.768,Percent of Total Billed Charges,60% of Total Billed Charges,125.03,90,,407.216,Percent of Total Billed Charges,90% of Total Billed Charges,62.51,45,,141.696,Percent of Total Billed Charges,45% of Total Billed Charges,125.03,90,,154.792,Percent of Total Billed Charges,90% of Total billed Charges,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.3,65,,97.464,Percent of total Billed Charges,65% of Total Billed Charges,61.26,44.1,,138.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,131.97,95,,163.392,Percent of Total Billed Charges,95% of Total Billed Charges,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.25,88,,151.352,Percent of Total Billed Charges,88% of Total Billed Charges,125.03,90,,154.792,Percent of Total Billed charges,90% of Total Billed Charges,61.26,138.92,
POTTS COURNAND,2720000609,CDM,272,RC,,,Outpatient,,,70.56,45.86,,70.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.63,76,,244,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.8,72,,306.728,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,75,,319.504,Percent of Total Billed charges,75% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.8,72,,306.728,Percent of Total Billed Charges,72% of Total Billed Charges,42.34,60,,255.608,Percent of Total Billed Charges,60% of Total Billed Charges,63.5,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,31.75,45,,150.424,Percent of Total Billed Charges,45% of Total Billed Charges,63.5,90,,288.944,Percent of Total Billed Charges,90% of Total billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.86,65,,204.664,Percent of total Billed Charges,65% of Total Billed Charges,31.12,44.1,,147.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.03,95,,304.992,Percent of Total Billed Charges,95% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.09,88,,282.52,Percent of Total Billed Charges,88% of Total Billed Charges,63.5,90,,288.944,Percent of Total Billed charges,90% of Total Billed Charges,31.12,70.56,
SIMPULSE IRRIGATION,2720000610,CDM,272,RC,,,Outpatient,,,221.60,144.04,,221.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,168.42,76,,113.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,159.55,72,,57.16,Percent of Total Billed Charges,72% of Total Billed Charges,166.2,75,,59.536,Percent of Total Billed charges,75% of Total Billed Charges,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.55,72,,57.16,Percent of Total Billed Charges,72% of Total Billed Charges,132.96,60,,47.632,Percent of Total Billed Charges,60% of Total Billed Charges,199.44,90,,146.056,Percent of Total Billed Charges,90% of Total Billed Charges,99.72,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,199.44,90,,134.952,Percent of Total Billed Charges,90% of Total billed Charges,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.04,65,,217.28,Percent of total Billed Charges,65% of Total Billed Charges,97.73,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,210.52,95,,142.448,Percent of Total Billed Charges,95% of Total Billed Charges,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.01,88,,131.952,Percent of Total Billed Charges,88% of Total Billed Charges,199.44,90,,134.952,Percent of Total Billed charges,90% of Total Billed Charges,97.73,221.6,
SURGICEL 4X8,2720000611,CDM,272,RC,,,Outpatient,,,372.65,242.22,,372.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,283.21,76,,239.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,268.31,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,279.49,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,372.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.31,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,223.59,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,335.39,90,,119.072,Percent of Total Billed Charges,90% of Total Billed Charges,167.69,45,,173.448,Percent of Total Billed Charges,45% of Total Billed Charges,335.39,90,,283.384,Percent of Total Billed Charges,90% of Total billed Charges,372.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,372.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,372.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.22,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,164.34,44.1,,169.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,354.02,95,,299.128,Percent of Total Billed Charges,95% of Total Billed Charges,372.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.93,88,,277.088,Percent of Total Billed Charges,88% of Total Billed Charges,335.39,90,,283.384,Percent of Total Billed charges,90% of Total Billed Charges,164.34,372.65,
SURGICEL 2X3,2720000612,CDM,272,RC,,,Outpatient,,,191.84,124.70,,191.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,145.8,76,,254.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,138.12,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,143.88,75,,24.472,Percent of Total Billed charges,75% of Total Billed Charges,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.12,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,115.1,60,,19.576,Percent of Total Billed Charges,60% of Total Billed Charges,172.66,90,,526.288,Percent of Total Billed Charges,90% of Total Billed Charges,86.33,45,,57.152,Percent of Total Billed Charges,45% of Total Billed Charges,172.66,90,,300.856,Percent of Total Billed Charges,90% of Total billed Charges,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.7,65,,250.528,Percent of total Billed Charges,65% of Total Billed Charges,84.6,44.1,,56.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,182.25,95,,317.568,Percent of Total Billed Charges,95% of Total Billed Charges,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.82,88,,294.168,Percent of Total Billed Charges,88% of Total Billed Charges,172.66,90,,300.856,Percent of Total Billed charges,90% of Total Billed Charges,84.6,191.84,
INSUFFLATOR TUBING,2720000613,CDM,272,RC,,,Outpatient,,,147.74,96.03,,147.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,112.28,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,106.37,72,,803.328,Percent of Total Billed Charges,72% of Total Billed Charges,110.81,75,,836.8,Percent of Total Billed charges,75% of Total Billed Charges,147.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.37,72,,803.328,Percent of Total Billed Charges,72% of Total Billed Charges,88.64,60,,669.44,Percent of Total Billed Charges,60% of Total Billed Charges,132.97,90,,733.472,Percent of Total Billed Charges,90% of Total Billed Charges,66.48,45,,51.2,Percent of Total Billed Charges,45% of Total Billed Charges,132.97,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,147.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.03,65,,82.552,Percent of total Billed Charges,65% of Total Billed Charges,65.15,44.1,,50.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,140.35,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,147.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.01,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,132.97,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,65.15,147.74,
VESSEL LOOPS,2720000614,CDM,272,RC,,,Outpatient,,,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,292.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,15.71,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,195.28,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,203.608,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,346.888,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,73.952,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,199.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,366.16,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,339.184,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,346.888,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
VISCERA RETAINER,2720000615,CDM,272,RC,,,Outpatient,,,130.10,84.57,,130.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.88,76,,96.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,93.67,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,97.58,75,,10.16,Percent of Total Billed charges,75% of Total Billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.67,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,78.06,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,117.09,90,,150.024,Percent of Total Billed Charges,90% of Total Billed Charges,58.55,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,117.09,90,,114.304,Percent of Total Billed Charges,90% of Total billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.57,65,,294.104,Percent of total Billed Charges,65% of Total Billed Charges,57.37,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,123.6,95,,120.656,Percent of Total Billed Charges,95% of Total Billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.49,88,,111.768,Percent of Total Billed Charges,88% of Total Billed Charges,117.09,90,,114.304,Percent of Total Billed charges,90% of Total Billed Charges,57.37,130.1,
BONE CEMENT,2720000616,CDM,272,RC,,,Outpatient,,,455.33,295.96,,455.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,346.05,76,,86.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,327.84,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,341.5,75,,17.864,Percent of Total Billed charges,75% of Total Billed Charges,455.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.84,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,273.2,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,409.8,90,,125.424,Percent of Total Billed Charges,90% of Total Billed Charges,204.9,45,,73.032,Percent of Total Billed Charges,45% of Total Billed Charges,409.8,90,,102.4,Percent of Total Billed Charges,90% of Total billed Charges,455.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,455.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,455.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.96,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,200.8,44.1,,71.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,432.56,95,,108.088,Percent of Total Billed Charges,95% of Total Billed Charges,455.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.69,88,,100.12,Percent of Total Billed Charges,88% of Total Billed Charges,409.8,90,,102.4,Percent of Total Billed charges,90% of Total Billed Charges,200.8,455.33,
PURSTRING 65,2720000617,CDM,272,RC,,,Outpatient,,,329.65,214.27,,329.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,250.53,76,,343.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,237.35,72,,19.96,Percent of Total Billed Charges,72% of Total Billed Charges,247.24,75,,20.792,Percent of Total Billed charges,75% of Total Billed Charges,329.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.35,72,,19.96,Percent of Total Billed Charges,72% of Total Billed Charges,197.79,60,,16.632,Percent of Total Billed Charges,60% of Total Billed Charges,296.69,90,,57.152,Percent of Total Billed Charges,90% of Total Billed Charges,148.34,45,,59.536,Percent of Total Billed Charges,45% of Total Billed Charges,296.69,90,,407.216,Percent of Total Billed Charges,90% of Total billed Charges,329.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.27,65,,105.488,Percent of total Billed Charges,65% of Total Billed Charges,145.38,44.1,,58.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,313.17,95,,429.84,Percent of Total Billed Charges,95% of Total Billed Charges,329.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290.09,88,,398.168,Percent of Total Billed Charges,88% of Total Billed Charges,296.69,90,,407.216,Percent of Total Billed charges,90% of Total Billed Charges,145.38,329.65,
BONE WAX,2720000618,CDM,272,RC,,,Outpatient,,,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,19.96,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,20.792,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,19.96,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,16.632,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,38.104,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,263.144,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,86,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,257.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
TRU CUT BX NEEDLE,2720000619,CDM,272,RC,,,Outpatient,,,113.56,73.81,,113.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,86.31,76,,123.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,81.76,72,,36.288,Percent of Total Billed Charges,72% of Total Billed Charges,85.17,75,,37.8,Percent of Total Billed charges,75% of Total Billed Charges,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.76,72,,36.288,Percent of Total Billed Charges,72% of Total Billed Charges,68.14,60,,30.24,Percent of Total Billed Charges,60% of Total Billed Charges,102.2,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,51.1,45,,366.736,Percent of Total Billed Charges,45% of Total Billed Charges,102.2,90,,146.056,Percent of Total Billed Charges,90% of Total billed Charges,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.81,65,,380.096,Percent of total Billed Charges,65% of Total Billed Charges,50.08,44.1,,359.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,107.88,95,,154.176,Percent of Total Billed Charges,95% of Total Billed Charges,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.93,88,,142.816,Percent of Total Billed Charges,88% of Total Billed Charges,102.2,90,,146.056,Percent of Total Billed charges,90% of Total Billed Charges,50.08,113.56,
JURGAN PIN BALLS .045,2720000621,CDM,272,RC,,,Outpatient,,,48.51,31.53,,48.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.87,76,,100.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.93,72,,1062.632,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,75,,1106.912,Percent of Total Billed charges,75% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,72,,1062.632,Percent of Total Billed Charges,72% of Total Billed Charges,29.11,60,,885.528,Percent of Total Billed Charges,60% of Total Billed Charges,43.66,90,,36.52,Percent of Total Billed Charges,90% of Total Billed Charges,21.83,45,,97.64,Percent of Total Billed Charges,45% of Total Billed Charges,43.66,90,,119.072,Percent of Total Billed Charges,90% of Total billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.53,65,,529.728,Percent of total Billed Charges,65% of Total Billed Charges,21.39,44.1,,95.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.08,95,,125.688,Percent of Total Billed Charges,95% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.69,88,,116.424,Percent of Total Billed Charges,88% of Total Billed Charges,43.66,90,,119.072,Percent of Total Billed charges,90% of Total Billed Charges,21.39,48.51,
RAPID INFUSION CATH,2720000622,CDM,272,RC,,,Outpatient,,,128.99,83.84,,128.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.03,76,,444.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,92.87,72,,1062.632,Percent of Total Billed Charges,72% of Total Billed Charges,96.74,75,,1106.912,Percent of Total Billed charges,75% of Total Billed Charges,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.87,72,,1062.632,Percent of Total Billed Charges,72% of Total Billed Charges,77.39,60,,885.528,Percent of Total Billed Charges,60% of Total Billed Charges,116.09,90,,1150.216,Percent of Total Billed Charges,90% of Total Billed Charges,58.05,45,,75.016,Percent of Total Billed Charges,45% of Total Billed Charges,116.09,90,,526.288,Percent of Total Billed Charges,90% of Total billed Charges,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.84,65,,141.032,Percent of total Billed Charges,65% of Total Billed Charges,56.88,44.1,,73.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,122.54,95,,555.528,Percent of Total Billed Charges,95% of Total Billed Charges,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.51,88,,514.592,Percent of Total Billed Charges,88% of Total Billed Charges,116.09,90,,526.288,Percent of Total Billed charges,90% of Total Billed Charges,56.88,128.99,
ENTROPY SENSOR,2720000623,CDM,272,RC,,,Outpatient,,,104.74,68.08,,104.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.6,76,,619.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75.41,72,,1062.632,Percent of Total Billed Charges,72% of Total Billed Charges,78.56,75,,1106.912,Percent of Total Billed charges,75% of Total Billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.41,72,,1062.632,Percent of Total Billed Charges,72% of Total Billed Charges,62.84,60,,885.528,Percent of Total Billed Charges,60% of Total Billed Charges,94.27,90,,678.704,Percent of Total Billed Charges,90% of Total Billed Charges,47.13,45,,62.712,Percent of Total Billed Charges,45% of Total Billed Charges,94.27,90,,733.472,Percent of Total Billed Charges,90% of Total billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.08,65,,108.352,Percent of total Billed Charges,65% of Total Billed Charges,46.19,44.1,,61.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,99.5,95,,774.216,Percent of Total Billed Charges,95% of Total Billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.17,88,,717.168,Percent of Total Billed Charges,88% of Total Billed Charges,94.27,90,,733.472,Percent of Total Billed charges,90% of Total Billed Charges,46.19,104.74,
BIG SUCKER,2720000624,CDM,272,RC,,,Outpatient,,,168.68,109.64,,168.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,128.2,76,,164.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,121.45,72,,1062.632,Percent of Total Billed Charges,72% of Total Billed Charges,126.51,75,,1106.912,Percent of Total Billed charges,75% of Total Billed Charges,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.45,72,,1062.632,Percent of Total Billed Charges,72% of Total Billed Charges,101.21,60,,885.528,Percent of Total Billed Charges,60% of Total Billed Charges,151.81,90,,305.608,Percent of Total Billed Charges,90% of Total Billed Charges,75.91,45,,28.576,Percent of Total Billed Charges,45% of Total Billed Charges,151.81,90,,195.28,Percent of Total Billed Charges,90% of Total billed Charges,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.64,65,,90.584,Percent of total Billed Charges,65% of Total Billed Charges,74.39,44.1,,28.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,160.25,95,,206.128,Percent of Total Billed Charges,95% of Total Billed Charges,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.44,88,,190.936,Percent of Total Billed Charges,88% of Total Billed Charges,151.81,90,,195.28,Percent of Total Billed charges,90% of Total Billed Charges,74.39,168.68,
PROC PACK CSECTION,2720000625,CDM,272,RC,,,Outpatient,,,437.69,284.50,,437.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,332.64,76,,126.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,315.14,72,,14.512,Percent of Total Billed Charges,72% of Total Billed Charges,328.27,75,,15.12,Percent of Total Billed charges,75% of Total Billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.14,72,,14.512,Percent of Total Billed Charges,72% of Total Billed Charges,262.61,60,,12.096,Percent of Total Billed Charges,60% of Total Billed Charges,393.92,90,,260.368,Percent of Total Billed Charges,90% of Total Billed Charges,196.96,45,,19.048,Percent of Total Billed Charges,45% of Total Billed Charges,393.92,90,,150.024,Percent of Total Billed Charges,90% of Total billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.5,65,,41.28,Percent of total Billed Charges,65% of Total Billed Charges,193.02,44.1,,18.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,415.81,95,,158.36,Percent of Total Billed Charges,95% of Total Billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.17,88,,146.696,Percent of Total Billed Charges,88% of Total Billed Charges,393.92,90,,150.024,Percent of Total Billed charges,90% of Total Billed Charges,193.02,437.69,
VEIN STRIPPER,2720000626,CDM,272,RC,,,Outpatient,,,113.56,73.81,,113.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,86.31,76,,105.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,81.76,72,,18.144,Percent of Total Billed Charges,72% of Total Billed Charges,85.17,75,,18.904,Percent of Total Billed charges,75% of Total Billed Charges,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.76,72,,18.144,Percent of Total Billed Charges,72% of Total Billed Charges,68.14,60,,15.12,Percent of Total Billed Charges,60% of Total Billed Charges,102.2,90,,137.328,Percent of Total Billed Charges,90% of Total Billed Charges,51.1,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,102.2,90,,125.424,Percent of Total Billed Charges,90% of Total billed Charges,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.81,65,,27.52,Percent of total Billed Charges,65% of Total Billed Charges,50.08,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,107.88,95,,132.392,Percent of Total Billed Charges,95% of Total Billed Charges,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.93,88,,122.64,Percent of Total Billed Charges,88% of Total Billed Charges,102.2,90,,125.424,Percent of Total Billed charges,90% of Total Billed Charges,50.08,113.56,
ALCON CRESCENT KNIFE,2720000627,CDM,272,RC,,,Outpatient,,,82.69,53.75,,82.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.84,76,,48.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.54,72,,90.72,Percent of Total Billed Charges,72% of Total Billed Charges,62.02,75,,94.504,Percent of Total Billed charges,75% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,72,,90.72,Percent of Total Billed Charges,72% of Total Billed Charges,49.61,60,,75.6,Percent of Total Billed Charges,60% of Total Billed Charges,74.42,90,,124.624,Percent of Total Billed Charges,90% of Total Billed Charges,37.21,45,,18.256,Percent of Total Billed Charges,45% of Total Billed Charges,74.42,90,,57.152,Percent of Total Billed Charges,90% of Total billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.75,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,36.47,44.1,,17.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,78.56,95,,60.328,Percent of Total Billed Charges,95% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,88,,55.88,Percent of Total Billed Charges,88% of Total Billed Charges,74.42,90,,57.152,Percent of Total Billed charges,90% of Total Billed Charges,36.47,82.69,
ENDO CLOSE,2720000628,CDM,272,RC,,,Outpatient,,,175.30,113.95,,175.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,133.23,76,,32.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,126.22,72,,1084.408,Percent of Total Billed Charges,72% of Total Billed Charges,131.48,75,,1129.592,Percent of Total Billed charges,75% of Total Billed Charges,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.22,72,,1084.408,Percent of Total Billed Charges,72% of Total Billed Charges,105.18,60,,903.672,Percent of Total Billed Charges,60% of Total Billed Charges,157.77,90,,85.728,Percent of Total Billed Charges,90% of Total Billed Charges,78.89,45,,575.104,Percent of Total Billed Charges,45% of Total Billed Charges,157.77,90,,38.104,Percent of Total Billed Charges,90% of Total billed Charges,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.95,65,,26.376,Percent of total Billed Charges,65% of Total Billed Charges,77.31,44.1,,563.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,166.54,95,,40.216,Percent of Total Billed Charges,95% of Total Billed Charges,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.26,88,,37.256,Percent of Total Billed Charges,88% of Total Billed Charges,157.77,90,,38.104,Percent of Total Billed charges,90% of Total Billed Charges,77.31,175.3,
FALLOPE RING KIT,2720000629,CDM,272,RC,,,Outpatient,,,1509.00,980.85,,1509,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1146.84,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1086.48,72,,107.048,Percent of Total Billed Charges,72% of Total Billed Charges,1131.75,75,,111.512,Percent of Total Billed charges,75% of Total Billed Charges,1509,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1086.48,72,,107.048,Percent of Total Billed Charges,72% of Total Billed Charges,905.4,60,,89.208,Percent of Total Billed Charges,60% of Total Billed Charges,1358.1,90,,173.848,Percent of Total Billed Charges,90% of Total Billed Charges,679.05,45,,339.352,Percent of Total Billed Charges,45% of Total Billed Charges,1358.1,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,1509,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,980.85,65,,830.712,Percent of total Billed Charges,65% of Total Billed Charges,665.47,44.1,,332.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,1433.55,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,1509,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1327.92,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,1358.1,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,665.47,1509,
ALCON IRIS RETRACTOR,2720000630,CDM,272,RC,,,Outpatient,,,187.43,121.83,,187.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,142.45,76,,30.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,134.95,72,,451.784,Percent of Total Billed Charges,72% of Total Billed Charges,140.57,75,,470.608,Percent of Total Billed charges,75% of Total Billed Charges,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.95,72,,451.784,Percent of Total Billed Charges,72% of Total Billed Charges,112.46,60,,376.488,Percent of Total Billed Charges,60% of Total Billed Charges,168.69,90,,53.184,Percent of Total Billed Charges,90% of Total Billed Charges,84.34,45,,152.808,Percent of Total Billed Charges,45% of Total Billed Charges,168.69,90,,36.52,Percent of Total Billed Charges,90% of Total billed Charges,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.83,65,,490.176,Percent of total Billed Charges,65% of Total Billed Charges,82.66,44.1,,149.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,178.06,95,,38.544,Percent of Total Billed Charges,95% of Total Billed Charges,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.94,88,,35.704,Percent of Total Billed Charges,88% of Total Billed Charges,168.69,90,,36.52,Percent of Total Billed charges,90% of Total Billed Charges,82.66,187.43,
HYDRO SURG IRR TUBIN,2720000631,CDM,272,RC,,,Outpatient,,,447.62,290.95,,447.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,340.19,76,,971.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,322.29,72,,997.92,Percent of Total Billed Charges,72% of Total Billed Charges,335.72,75,,1039.504,Percent of Total Billed charges,75% of Total Billed Charges,447.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,322.29,72,,997.92,Percent of Total Billed Charges,72% of Total Billed Charges,268.57,60,,831.6,Percent of Total Billed Charges,60% of Total Billed Charges,402.86,90,,19.048,Percent of Total Billed Charges,90% of Total Billed Charges,201.43,45,,130.184,Percent of Total Billed Charges,45% of Total Billed Charges,402.86,90,,1150.216,Percent of Total Billed Charges,90% of Total billed Charges,447.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,447.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,447.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290.95,65,,220.72,Percent of total Billed Charges,65% of Total Billed Charges,197.4,44.1,,127.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,425.24,95,,1214.112,Percent of Total Billed Charges,95% of Total Billed Charges,447.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.91,88,,1124.656,Percent of Total Billed Charges,88% of Total Billed Charges,402.86,90,,1150.216,Percent of Total Billed charges,90% of Total Billed Charges,197.4,447.62,
HARMONIC SCLPL DISS,2720000632,CDM,272,RC,,,Outpatient,,,436.59,283.78,,436.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,331.81,76,,573.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,314.34,72,,451.784,Percent of Total Billed Charges,72% of Total Billed Charges,327.44,75,,470.608,Percent of Total Billed charges,75% of Total Billed Charges,436.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.34,72,,451.784,Percent of Total Billed Charges,72% of Total Billed Charges,261.95,60,,376.488,Percent of Total Billed Charges,60% of Total Billed Charges,392.93,90,,316.728,Percent of Total Billed Charges,90% of Total Billed Charges,196.47,45,,68.664,Percent of Total Billed Charges,45% of Total Billed Charges,392.93,90,,678.704,Percent of Total Billed Charges,90% of Total billed Charges,436.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,436.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,436.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.78,65,,188.04,Percent of total Billed Charges,65% of Total Billed Charges,192.54,44.1,,67.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,414.76,95,,716.408,Percent of Total Billed Charges,95% of Total Billed Charges,436.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.2,88,,663.616,Percent of Total Billed Charges,88% of Total Billed Charges,392.93,90,,678.704,Percent of Total Billed charges,90% of Total Billed Charges,192.54,436.59,
HARMONC SCALPL CURVD,2720000634,CDM,272,RC,,,Outpatient,,,949.25,617.01,,949.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,721.43,76,,258.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,683.46,72,,451.784,Percent of Total Billed Charges,72% of Total Billed Charges,711.94,75,,470.608,Percent of Total Billed charges,75% of Total Billed Charges,949.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,683.46,72,,451.784,Percent of Total Billed Charges,72% of Total Billed Charges,569.55,60,,376.488,Percent of Total Billed Charges,60% of Total Billed Charges,854.33,90,,71.448,Percent of Total Billed Charges,90% of Total Billed Charges,427.16,45,,62.312,Percent of Total Billed Charges,45% of Total Billed Charges,854.33,90,,305.608,Percent of Total Billed Charges,90% of Total billed Charges,949.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,949.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,949.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,617.01,65,,99.176,Percent of total Billed Charges,65% of Total Billed Charges,418.62,44.1,,61.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,901.79,95,,322.592,Percent of Total Billed Charges,95% of Total Billed Charges,949.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,835.34,88,,298.816,Percent of Total Billed Charges,88% of Total Billed Charges,854.33,90,,305.608,Percent of Total Billed charges,90% of Total Billed Charges,418.62,949.25,
STRYKER BARREL 5.5,2720000635,CDM,272,RC,,,Outpatient,,,163.17,106.06,,163.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.01,76,,219.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,117.48,72,,352.512,Percent of Total Billed Charges,72% of Total Billed Charges,122.38,75,,367.2,Percent of Total Billed charges,75% of Total Billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.48,72,,352.512,Percent of Total Billed Charges,72% of Total Billed Charges,97.9,60,,293.76,Percent of Total Billed Charges,60% of Total Billed Charges,146.85,90,,25.4,Percent of Total Billed Charges,90% of Total Billed Charges,73.43,45,,42.864,Percent of Total Billed Charges,45% of Total Billed Charges,146.85,90,,260.368,Percent of Total Billed Charges,90% of Total billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.06,65,,90.008,Percent of total Billed Charges,65% of Total Billed Charges,71.96,44.1,,42.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,155.01,95,,274.832,Percent of Total Billed Charges,95% of Total Billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.59,88,,254.584,Percent of Total Billed Charges,88% of Total Billed Charges,146.85,90,,260.368,Percent of Total Billed charges,90% of Total Billed Charges,71.96,163.17,
STRYKER EGG B4RR BLI,2720000636,CDM,272,RC,,,Outpatient,,,153.25,99.61,,153.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,116.47,76,,115.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,110.34,72,,101.376,Percent of Total Billed Charges,72% of Total Billed Charges,114.94,75,,105.6,Percent of Total Billed charges,75% of Total Billed Charges,153.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.34,72,,101.376,Percent of Total Billed Charges,72% of Total Billed Charges,91.95,60,,84.48,Percent of Total Billed Charges,60% of Total Billed Charges,137.93,90,,23.016,Percent of Total Billed Charges,90% of Total Billed Charges,68.96,45,,86.92,Percent of Total Billed Charges,45% of Total Billed Charges,137.93,90,,137.328,Percent of Total Billed Charges,90% of Total billed Charges,153.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.61,65,,61.92,Percent of total Billed Charges,65% of Total Billed Charges,67.58,44.1,,85.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,145.59,95,,144.952,Percent of Total Billed Charges,95% of Total Billed Charges,153.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.86,88,,134.272,Percent of Total Billed Charges,88% of Total Billed Charges,137.93,90,,137.328,Percent of Total Billed charges,90% of Total Billed Charges,67.58,153.25,
TURBO SONICS KIT,2720000637,CDM,272,RC,,,Outpatient,,,109.15,70.95,,109.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.95,76,,105.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,78.59,72,,221.76,Percent of Total Billed Charges,72% of Total Billed Charges,81.86,75,,231,Percent of Total Billed charges,75% of Total Billed Charges,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.59,72,,221.76,Percent of Total Billed Charges,72% of Total Billed Charges,65.49,60,,184.8,Percent of Total Billed Charges,60% of Total Billed Charges,98.24,90,,124.624,Percent of Total Billed Charges,90% of Total Billed Charges,49.12,45,,26.592,Percent of Total Billed Charges,45% of Total Billed Charges,98.24,90,,124.624,Percent of Total Billed Charges,90% of Total billed Charges,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.95,65,,125.552,Percent of total Billed Charges,65% of Total Billed Charges,48.14,44.1,,26.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,103.69,95,,131.552,Percent of Total Billed Charges,95% of Total Billed Charges,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.05,88,,121.856,Percent of Total Billed Charges,88% of Total Billed Charges,98.24,90,,124.624,Percent of Total Billed charges,90% of Total Billed Charges,48.14,109.15,
TURBO SONICS FLARED,2720000638,CDM,272,RC,,,Outpatient,,,222.71,144.76,,222.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,169.26,76,,72.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,160.35,72,,118.08,Percent of Total Billed Charges,72% of Total Billed Charges,167.03,75,,123,Percent of Total Billed charges,75% of Total Billed Charges,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.35,72,,118.08,Percent of Total Billed Charges,72% of Total Billed Charges,133.63,60,,98.4,Percent of Total Billed Charges,60% of Total Billed Charges,200.44,90,,127.008,Percent of Total Billed Charges,90% of Total Billed Charges,100.22,45,,9.528,Percent of Total Billed Charges,45% of Total Billed Charges,200.44,90,,85.728,Percent of Total Billed Charges,90% of Total billed Charges,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.76,65,,38.416,Percent of total Billed Charges,65% of Total Billed Charges,98.22,44.1,,9.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,211.57,95,,90.496,Percent of Total Billed Charges,95% of Total Billed Charges,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.98,88,,83.824,Percent of Total Billed Charges,88% of Total Billed Charges,200.44,90,,85.728,Percent of Total Billed charges,90% of Total Billed Charges,98.22,222.71,
UNFOLDER,2720000639,CDM,272,RC,,,Outpatient,,,77.18,50.17,,77.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.66,76,,146.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.57,72,,89.28,Percent of Total Billed Charges,72% of Total Billed Charges,57.89,75,,93,Percent of Total Billed charges,75% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.57,72,,89.28,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,60,,74.4,Percent of Total Billed Charges,60% of Total Billed Charges,69.46,90,,94.464,Percent of Total Billed Charges,90% of Total Billed Charges,34.73,45,,158.368,Percent of Total Billed Charges,45% of Total Billed Charges,69.46,90,,173.848,Percent of Total Billed Charges,90% of Total billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.17,65,,13.76,Percent of total Billed Charges,65% of Total Billed Charges,34.04,44.1,,155.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.32,95,,183.504,Percent of Total Billed Charges,95% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.92,88,,169.984,Percent of Total Billed Charges,88% of Total Billed Charges,69.46,90,,173.848,Percent of Total Billed charges,90% of Total Billed Charges,34.04,77.18,
STRKR ANGLED AGG PLU,2720000640,CDM,272,RC,,,Outpatient,,,145.53,94.59,,145.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.6,76,,44.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,104.78,72,,195.264,Percent of Total Billed Charges,72% of Total Billed Charges,109.15,75,,203.4,Percent of Total Billed charges,75% of Total Billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.78,72,,195.264,Percent of Total Billed Charges,72% of Total Billed Charges,87.32,60,,162.72,Percent of Total Billed Charges,60% of Total Billed Charges,130.98,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,65.49,45,,35.72,Percent of Total Billed Charges,45% of Total Billed Charges,130.98,90,,53.184,Percent of Total Billed Charges,90% of Total billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.59,65,,228.752,Percent of total Billed Charges,65% of Total Billed Charges,64.18,44.1,,35.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,138.25,95,,56.144,Percent of Total Billed Charges,95% of Total Billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.07,88,,52.008,Percent of Total Billed Charges,88% of Total Billed Charges,130.98,90,,53.184,Percent of Total Billed charges,90% of Total Billed Charges,64.18,145.53,
STRYKER RESECTOR 5.O,2720000641,CDM,272,RC,,,Outpatient,,,157.66,102.48,,157.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,119.82,76,,16.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,113.52,72,,13.248,Percent of Total Billed Charges,72% of Total Billed Charges,118.25,75,,13.8,Percent of Total Billed charges,75% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.52,72,,13.248,Percent of Total Billed Charges,72% of Total Billed Charges,94.6,60,,11.04,Percent of Total Billed Charges,60% of Total Billed Charges,141.89,90,,15.88,Percent of Total Billed Charges,90% of Total Billed Charges,70.95,45,,12.704,Percent of Total Billed Charges,45% of Total Billed Charges,141.89,90,,19.048,Percent of Total Billed Charges,90% of Total billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.48,65,,51.6,Percent of total Billed Charges,65% of Total Billed Charges,69.53,44.1,,12.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,149.78,95,,20.112,Percent of Total Billed Charges,95% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.74,88,,18.624,Percent of Total Billed Charges,88% of Total Billed Charges,141.89,90,,19.048,Percent of Total Billed charges,90% of Total Billed Charges,69.53,157.66,
STRYKER BARREL BURR,2720000642,CDM,272,RC,,,Outpatient,,,163.17,106.06,,163.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.01,76,,267.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,117.48,72,,35.136,Percent of Total Billed Charges,72% of Total Billed Charges,122.38,75,,36.6,Percent of Total Billed charges,75% of Total Billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.48,72,,35.136,Percent of Total Billed Charges,72% of Total Billed Charges,97.9,60,,29.28,Percent of Total Billed Charges,60% of Total Billed Charges,146.85,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,73.43,45,,11.512,Percent of Total Billed Charges,45% of Total Billed Charges,146.85,90,,316.728,Percent of Total Billed Charges,90% of Total billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.06,65,,18.344,Percent of total Billed Charges,65% of Total Billed Charges,71.96,44.1,,11.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,155.01,95,,334.328,Percent of Total Billed Charges,95% of Total Billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.59,88,,309.688,Percent of Total Billed Charges,88% of Total Billed Charges,146.85,90,,316.728,Percent of Total Billed charges,90% of Total Billed Charges,71.96,163.17,
STORZ ENODMAT HYSH T,2720000643,CDM,272,RC,,,Outpatient,,,250.27,162.68,,250.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,190.21,76,,60.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,180.19,72,,89.28,Percent of Total Billed Charges,72% of Total Billed Charges,187.7,75,,93,Percent of Total Billed charges,75% of Total Billed Charges,250.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.19,72,,89.28,Percent of Total Billed Charges,72% of Total Billed Charges,150.16,60,,74.4,Percent of Total Billed Charges,60% of Total Billed Charges,225.24,90,,44.456,Percent of Total Billed Charges,90% of Total Billed Charges,112.62,45,,62.312,Percent of Total Billed Charges,45% of Total Billed Charges,225.24,90,,71.448,Percent of Total Billed Charges,90% of Total billed Charges,250.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.68,65,,16.624,Percent of total Billed Charges,65% of Total Billed Charges,110.37,44.1,,61.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,237.76,95,,75.416,Percent of Total Billed Charges,95% of Total Billed Charges,250.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.24,88,,69.856,Percent of Total Billed Charges,88% of Total Billed Charges,225.24,90,,71.448,Percent of Total Billed charges,90% of Total Billed Charges,110.37,250.27,
GORTEX SUTURES,2720000644,CDM,272,RC,,,Outpatient,,,208.37,135.44,,208.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,158.36,76,,21.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.03,72,,116.352,Percent of Total Billed Charges,72% of Total Billed Charges,156.28,75,,121.2,Percent of Total Billed charges,75% of Total Billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.03,72,,116.352,Percent of Total Billed Charges,72% of Total Billed Charges,125.02,60,,96.96,Percent of Total Billed Charges,60% of Total Billed Charges,187.53,90,,156.376,Percent of Total Billed Charges,90% of Total Billed Charges,93.77,45,,63.504,Percent of Total Billed Charges,45% of Total Billed Charges,187.53,90,,25.4,Percent of Total Billed Charges,90% of Total billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.44,65,,90.008,Percent of total Billed Charges,65% of Total Billed Charges,91.89,44.1,,62.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,197.95,95,,26.816,Percent of Total Billed Charges,95% of Total Billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.37,88,,24.84,Percent of Total Billed Charges,88% of Total Billed Charges,187.53,90,,25.4,Percent of Total Billed charges,90% of Total Billed Charges,91.89,208.37,
PROCEDURE PACK HIP,2720000645,CDM,272,RC,,,Outpatient,,,195.14,126.84,,195.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,148.31,76,,19.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,140.5,72,,31.68,Percent of Total Billed Charges,72% of Total Billed Charges,146.36,75,,33,Percent of Total Billed charges,75% of Total Billed Charges,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.5,72,,31.68,Percent of Total Billed Charges,72% of Total Billed Charges,117.08,60,,26.4,Percent of Total Billed Charges,60% of Total Billed Charges,175.63,90,,73.032,Percent of Total Billed Charges,90% of Total Billed Charges,87.81,45,,47.232,Percent of Total Billed Charges,45% of Total Billed Charges,175.63,90,,23.016,Percent of Total Billed Charges,90% of Total billed Charges,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.84,65,,91.728,Percent of total Billed Charges,65% of Total Billed Charges,86.06,44.1,,46.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,185.38,95,,24.296,Percent of Total Billed Charges,95% of Total Billed Charges,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.72,88,,22.504,Percent of Total Billed Charges,88% of Total Billed Charges,175.63,90,,23.016,Percent of Total Billed charges,90% of Total Billed Charges,86.06,195.14,
PROC PACK EENT,2720000646,CDM,272,RC,,,Outpatient,,,84.89,55.18,,84.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,64.52,76,,105.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.12,72,,15.92,Percent of Total Billed Charges,72% of Total Billed Charges,63.67,75,,16.584,Percent of Total Billed charges,75% of Total Billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,72,,15.92,Percent of Total Billed Charges,72% of Total Billed Charges,50.93,60,,13.264,Percent of Total Billed Charges,60% of Total Billed Charges,76.4,90,,65.888,Percent of Total Billed Charges,90% of Total Billed Charges,38.2,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,76.4,90,,124.624,Percent of Total Billed Charges,90% of Total billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.18,65,,68.224,Percent of total Billed Charges,65% of Total Billed Charges,37.44,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,80.65,95,,131.552,Percent of Total Billed Charges,95% of Total Billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.7,88,,121.856,Percent of Total Billed Charges,88% of Total Billed Charges,76.4,90,,124.624,Percent of Total Billed charges,90% of Total Billed Charges,37.44,84.89,
PROC PACK LAPAROTOMY,2720000647,CDM,272,RC,,,Outpatient,,,61.74,40.13,,61.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.92,76,,107.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,44.45,72,,222.912,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,75,,232.2,Percent of Total Billed charges,75% of Total Billed Charges,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.45,72,,222.912,Percent of Total Billed Charges,72% of Total Billed Charges,37.04,60,,185.76,Percent of Total Billed Charges,60% of Total Billed Charges,55.57,90,,134.952,Percent of Total Billed Charges,90% of Total Billed Charges,27.78,45,,7.936,Percent of Total Billed Charges,45% of Total Billed Charges,55.57,90,,127.008,Percent of Total Billed Charges,90% of Total billed Charges,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.13,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,27.23,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,58.65,95,,134.064,Percent of Total Billed Charges,95% of Total Billed Charges,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.33,88,,124.184,Percent of Total Billed Charges,88% of Total Billed Charges,55.57,90,,127.008,Percent of Total Billed charges,90% of Total Billed Charges,27.23,61.74,
PROC PACKEXTREMITY,2720000648,CDM,272,RC,,,Outpatient,,,92.61,60.20,,92.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,70.38,76,,79.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,66.68,72,,122.112,Percent of Total Billed Charges,72% of Total Billed Charges,69.46,75,,127.2,Percent of Total Billed charges,75% of Total Billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.68,72,,122.112,Percent of Total Billed Charges,72% of Total Billed Charges,55.57,60,,101.76,Percent of Total Billed Charges,60% of Total Billed Charges,83.35,90,,72.24,Percent of Total Billed Charges,90% of Total Billed Charges,41.67,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,83.35,90,,94.464,Percent of Total Billed Charges,90% of Total billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.2,65,,11.464,Percent of total Billed Charges,65% of Total Billed Charges,40.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,87.98,95,,99.712,Percent of Total Billed Charges,95% of Total Billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.5,88,,92.368,Percent of Total Billed Charges,88% of Total Billed Charges,83.35,90,,94.464,Percent of Total Billed charges,90% of Total Billed Charges,40.84,92.61,
HEMOVAC MEDIUM,2720000649,CDM,272,RC,,,Outpatient,,,221.60,144.04,,221.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,168.42,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,159.55,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,166.2,75,,3,Percent of Total Billed charges,75% of Total Billed Charges,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.55,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,132.96,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,199.44,90,,226.232,Percent of Total Billed Charges,90% of Total Billed Charges,99.72,45,,22.224,Percent of Total Billed Charges,45% of Total Billed Charges,199.44,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.04,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,97.73,44.1,,21.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,210.52,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.01,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,199.44,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,97.73,221.6,
NERVE BLOCKS,2720000650,CDM,272,RC,,,Outpatient,,,2125.62,1381.65,,2125.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1615.47,76,,13.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1530.45,72,,2.304,Percent of Total Billed Charges,72% of Total Billed Charges,1594.22,75,,2.4,Percent of Total Billed charges,75% of Total Billed Charges,2125.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530.45,72,,2.304,Percent of Total Billed Charges,72% of Total Billed Charges,1275.37,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,1913.06,90,,503.272,Percent of Total Billed Charges,90% of Total Billed Charges,956.53,45,,78.192,Percent of Total Billed Charges,45% of Total Billed Charges,1913.06,90,,15.88,Percent of Total Billed Charges,90% of Total billed Charges,2125.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2125.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2125.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1381.65,65,,32.104,Percent of total Billed Charges,65% of Total Billed Charges,937.4,44.1,,76.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,2019.34,95,,16.76,Percent of Total Billed Charges,95% of Total Billed Charges,2125.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1870.55,88,,15.52,Percent of Total Billed Charges,88% of Total Billed Charges,1913.06,90,,15.88,Percent of Total Billed charges,90% of Total Billed Charges,937.4,2125.62,
DISP TOURNIQUET CUF,2720000651,CDM,272,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,31.104,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,32.4,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,31.104,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,25.92,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,18.256,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,36.512,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,112.936,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,35.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
URO DRAINAGE BAG SYS,2720000652,CDM,272,RC,,,Outpatient,,,66.15,43.00,,66.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,50.27,76,,37.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47.63,72,,339.264,Percent of Total Billed Charges,72% of Total Billed Charges,49.61,75,,353.4,Percent of Total Billed charges,75% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.63,72,,339.264,Percent of Total Billed Charges,72% of Total Billed Charges,39.69,60,,282.72,Percent of Total Billed Charges,60% of Total Billed Charges,59.54,90,,1921,Percent of Total Billed Charges,90% of Total Billed Charges,29.77,45,,32.944,Percent of Total Billed Charges,45% of Total Billed Charges,59.54,90,,44.456,Percent of Total Billed Charges,90% of Total billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,65,,52.744,Percent of total Billed Charges,65% of Total Billed Charges,29.17,44.1,,32.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.84,95,,46.92,Percent of Total Billed Charges,95% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.21,88,,43.464,Percent of Total Billed Charges,88% of Total Billed Charges,59.54,90,,44.456,Percent of Total Billed charges,90% of Total Billed Charges,29.17,66.15,
NERVE STIMULATORS DI,2720000653,CDM,272,RC,,,Outpatient,,,157.66,102.48,,157.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,119.82,76,,132.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,113.52,72,,38.016,Percent of Total Billed Charges,72% of Total Billed Charges,118.25,75,,39.6,Percent of Total Billed charges,75% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.52,72,,38.016,Percent of Total Billed Charges,72% of Total Billed Charges,94.6,60,,31.68,Percent of Total Billed Charges,60% of Total Billed Charges,141.89,90,,1582.04,Percent of Total Billed Charges,90% of Total Billed Charges,70.95,45,,67.472,Percent of Total Billed Charges,45% of Total Billed Charges,141.89,90,,156.376,Percent of Total Billed Charges,90% of Total billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.48,65,,47.584,Percent of total Billed Charges,65% of Total Billed Charges,69.53,44.1,,66.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,149.78,95,,165.064,Percent of Total Billed Charges,95% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.74,88,,152.904,Percent of Total Billed Charges,88% of Total Billed Charges,141.89,90,,156.376,Percent of Total Billed charges,90% of Total Billed Charges,69.53,157.66,
IRRIGATING CYCTITOME,2720000654,CDM,272,RC,,,Outpatient,,,415.64,270.17,,415.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,315.89,76,,61.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,299.26,72,,2.304,Percent of Total Billed Charges,72% of Total Billed Charges,311.73,75,,2.4,Percent of Total Billed charges,75% of Total Billed Charges,415.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,299.26,72,,2.304,Percent of Total Billed Charges,72% of Total Billed Charges,249.38,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,374.08,90,,516.768,Percent of Total Billed Charges,90% of Total Billed Charges,187.04,45,,36.12,Percent of Total Billed Charges,45% of Total Billed Charges,374.08,90,,73.032,Percent of Total Billed Charges,90% of Total billed Charges,415.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.17,65,,97.464,Percent of total Billed Charges,65% of Total Billed Charges,183.3,44.1,,35.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,394.86,95,,77.088,Percent of Total Billed Charges,95% of Total Billed Charges,415.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365.76,88,,71.408,Percent of Total Billed Charges,88% of Total Billed Charges,374.08,90,,73.032,Percent of Total Billed charges,90% of Total Billed Charges,183.3,415.64,
ESU HANTROL CANTERY,2720000655,CDM,272,RC,,,Outpatient,,,82.69,53.75,,82.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.84,76,,55.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.54,72,,13.248,Percent of Total Billed Charges,72% of Total Billed Charges,62.02,75,,13.8,Percent of Total Billed charges,75% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,72,,13.248,Percent of Total Billed Charges,72% of Total Billed Charges,49.61,60,,11.04,Percent of Total Billed Charges,60% of Total Billed Charges,74.42,90,,516.768,Percent of Total Billed Charges,90% of Total Billed Charges,37.21,45,,113.112,Percent of Total Billed Charges,45% of Total Billed Charges,74.42,90,,65.888,Percent of Total Billed Charges,90% of Total billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.75,65,,52.168,Percent of total Billed Charges,65% of Total Billed Charges,36.47,44.1,,110.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,78.56,95,,69.544,Percent of Total Billed Charges,95% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,88,,64.424,Percent of Total Billed Charges,88% of Total Billed Charges,74.42,90,,65.888,Percent of Total Billed charges,90% of Total Billed Charges,36.47,82.69,
SILK 3-0 C0135,2720000656,CDM,272,RC,,,Outpatient,,,82.69,53.75,,82.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.84,76,,113.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.54,72,,20.736,Percent of Total Billed Charges,72% of Total Billed Charges,62.02,75,,21.6,Percent of Total Billed charges,75% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,72,,20.736,Percent of Total Billed Charges,72% of Total Billed Charges,49.61,60,,17.28,Percent of Total Billed Charges,60% of Total Billed Charges,74.42,90,,184.16,Percent of Total Billed Charges,90% of Total Billed Charges,37.21,45,,251.64,Percent of Total Billed Charges,45% of Total Billed Charges,74.42,90,,134.952,Percent of Total Billed Charges,90% of Total billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.75,65,,163.392,Percent of total Billed Charges,65% of Total Billed Charges,36.47,44.1,,246.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,78.56,95,,142.448,Percent of Total Billed Charges,95% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,88,,131.952,Percent of Total Billed Charges,88% of Total Billed Charges,74.42,90,,134.952,Percent of Total Billed charges,90% of Total Billed Charges,36.47,82.69,
PROLENE 1 8425H,2720000657,CDM,272,RC,,,Outpatient,,,109.15,70.95,,109.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.95,76,,61,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,78.59,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,81.86,75,,3,Percent of Total Billed charges,75% of Total Billed Charges,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.59,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,65.49,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,98.24,90,,3715.776,Percent of Total Billed Charges,90% of Total Billed Charges,49.12,45,,9.128,Percent of Total Billed Charges,45% of Total Billed Charges,98.24,90,,72.24,Percent of Total Billed Charges,90% of Total billed Charges,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.95,65,,363.472,Percent of total Billed Charges,65% of Total Billed Charges,48.14,44.1,,8.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,103.69,95,,76.248,Percent of Total Billed Charges,95% of Total Billed Charges,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.05,88,,70.632,Percent of Total Billed Charges,88% of Total Billed Charges,98.24,90,,72.24,Percent of Total Billed charges,90% of Total Billed Charges,48.14,109.15,
ETHILON 6-0 1856G,2720000658,CDM,272,RC,,,Outpatient,,,191.84,124.70,,191.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,145.8,76,,191.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,138.12,72,,6.336,Percent of Total Billed Charges,72% of Total Billed Charges,143.88,75,,6.6,Percent of Total Billed charges,75% of Total Billed Charges,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.12,72,,6.336,Percent of Total Billed Charges,72% of Total Billed Charges,115.1,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,172.66,90,,685.84,Percent of Total Billed Charges,90% of Total Billed Charges,86.33,45,,960.496,Percent of Total Billed Charges,45% of Total Billed Charges,172.66,90,,226.232,Percent of Total Billed Charges,90% of Total billed Charges,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.7,65,,13.184,Percent of total Billed Charges,65% of Total Billed Charges,84.6,44.1,,941.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,182.25,95,,238.8,Percent of Total Billed Charges,95% of Total Billed Charges,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.82,88,,221.2,Percent of Total Billed Charges,88% of Total Billed Charges,172.66,90,,226.232,Percent of Total Billed charges,90% of Total Billed Charges,84.6,191.84,
LINVATEC MENISCTHOM,2720000659,CDM,272,RC,,,Outpatient,,,264.60,171.99,,264.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,201.1,76,,424.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,190.51,72,,112.896,Percent of Total Billed Charges,72% of Total Billed Charges,198.45,75,,117.6,Percent of Total Billed charges,75% of Total Billed Charges,264.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.51,72,,112.896,Percent of Total Billed Charges,72% of Total Billed Charges,158.76,60,,94.08,Percent of Total Billed Charges,60% of Total Billed Charges,238.14,90,,68.272,Percent of Total Billed Charges,90% of Total Billed Charges,119.07,45,,791.024,Percent of Total Billed Charges,45% of Total Billed Charges,238.14,90,,503.272,Percent of Total Billed Charges,90% of Total billed Charges,264.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,65,,1387.384,Percent of total Billed Charges,65% of Total Billed Charges,116.69,44.1,,775.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,251.37,95,,531.232,Percent of Total Billed Charges,95% of Total Billed Charges,264.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.85,88,,492.088,Percent of Total Billed Charges,88% of Total Billed Charges,238.14,90,,503.272,Percent of Total Billed charges,90% of Total Billed Charges,116.69,264.6,
STRYKER PUMP SET/KNE,2720000660,CDM,272,RC,,,Outpatient,,,210.58,136.88,,210.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,160.04,76,,15.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,151.62,72,,89.856,Percent of Total Billed Charges,72% of Total Billed Charges,157.94,75,,93.6,Percent of Total Billed charges,75% of Total Billed Charges,210.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.62,72,,89.856,Percent of Total Billed Charges,72% of Total Billed Charges,126.35,60,,74.88,Percent of Total Billed Charges,60% of Total Billed Charges,189.52,90,,57.152,Percent of Total Billed Charges,90% of Total Billed Charges,94.76,45,,258.384,Percent of Total Billed Charges,45% of Total Billed Charges,189.52,90,,18.256,Percent of Total Billed Charges,90% of Total billed Charges,210.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.88,65,,1142.584,Percent of total Billed Charges,65% of Total Billed Charges,92.87,44.1,,253.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,200.05,95,,19.272,Percent of Total Billed Charges,95% of Total Billed Charges,210.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.31,88,,17.856,Percent of Total Billed Charges,88% of Total Billed Charges,189.52,90,,18.256,Percent of Total Billed charges,90% of Total Billed Charges,92.87,210.58,
STRYKER GRAVITY TUBI,2720000661,CDM,272,RC,,,Outpatient,,,166.48,108.21,,166.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,126.52,76,,1622.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,119.87,72,,20.736,Percent of Total Billed Charges,72% of Total Billed Charges,124.86,75,,21.6,Percent of Total Billed charges,75% of Total Billed Charges,166.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.87,72,,20.736,Percent of Total Billed Charges,72% of Total Billed Charges,99.89,60,,17.28,Percent of Total Billed Charges,60% of Total Billed Charges,149.83,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,74.92,45,,258.384,Percent of Total Billed Charges,45% of Total Billed Charges,149.83,90,,1921,Percent of Total Billed Charges,90% of Total billed Charges,166.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.21,65,,373.216,Percent of total Billed Charges,65% of Total Billed Charges,73.42,44.1,,253.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,158.16,95,,2027.72,Percent of Total Billed Charges,95% of Total Billed Charges,166.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.5,88,,1878.304,Percent of Total Billed Charges,88% of Total Billed Charges,149.83,90,,1921,Percent of Total Billed charges,90% of Total Billed Charges,73.42,166.48,
HEWSTON SUTURE,2720000662,CDM,272,RC,,,Outpatient,,,218.30,141.90,,218.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,165.91,76,,1335.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,157.18,72,,13.248,Percent of Total Billed Charges,72% of Total Billed Charges,163.73,75,,13.8,Percent of Total Billed charges,75% of Total Billed Charges,218.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.18,72,,13.248,Percent of Total Billed Charges,72% of Total Billed Charges,130.98,60,,11.04,Percent of Total Billed Charges,60% of Total Billed Charges,196.47,90,,68.272,Percent of Total Billed Charges,90% of Total Billed Charges,98.24,45,,92.08,Percent of Total Billed Charges,45% of Total Billed Charges,196.47,90,,1582.04,Percent of Total Billed Charges,90% of Total billed Charges,218.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.9,65,,373.216,Percent of total Billed Charges,65% of Total Billed Charges,96.27,44.1,,90.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,207.39,95,,1669.936,Percent of Total Billed Charges,95% of Total Billed Charges,218.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.1,88,,1546.888,Percent of Total Billed Charges,88% of Total Billed Charges,196.47,90,,1582.04,Percent of Total Billed charges,90% of Total Billed Charges,96.27,218.3,
HARM SCALP/COAG SHEA,2720000663,CDM,272,RC,,,Outpatient,,,842.31,547.50,,842.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,640.16,76,,436.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,606.46,72,,37.44,Percent of Total Billed Charges,72% of Total Billed Charges,631.73,75,,39,Percent of Total Billed charges,75% of Total Billed Charges,842.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,606.46,72,,37.44,Percent of Total Billed Charges,72% of Total Billed Charges,505.39,60,,31.2,Percent of Total Billed Charges,60% of Total Billed Charges,758.08,90,,19.048,Percent of Total Billed Charges,90% of Total Billed Charges,379.04,45,,1857.888,Percent of Total Billed Charges,45% of Total Billed Charges,758.08,90,,516.768,Percent of Total Billed Charges,90% of Total billed Charges,842.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,842.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,842.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.5,65,,133.008,Percent of total Billed Charges,65% of Total Billed Charges,371.46,44.1,,1820.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,800.19,95,,545.472,Percent of Total Billed Charges,95% of Total Billed Charges,842.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,741.23,88,,505.28,Percent of Total Billed Charges,88% of Total Billed Charges,758.08,90,,516.768,Percent of Total Billed charges,90% of Total Billed Charges,371.46,842.31,
PROX LINEAR TLC55,2720000664,CDM,272,RC,,,Outpatient,,,281.14,182.74,,281.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,213.67,76,,436.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,202.42,72,,32.256,Percent of Total Billed Charges,72% of Total Billed Charges,210.86,75,,33.6,Percent of Total Billed charges,75% of Total Billed Charges,281.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.42,72,,32.256,Percent of Total Billed Charges,72% of Total Billed Charges,168.68,60,,26.88,Percent of Total Billed Charges,60% of Total Billed Charges,253.03,90,,117.48,Percent of Total Billed Charges,90% of Total Billed Charges,126.51,45,,342.92,Percent of Total Billed Charges,45% of Total Billed Charges,253.03,90,,516.768,Percent of Total Billed Charges,90% of Total billed Charges,281.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,281.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,281.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182.74,65,,2683.616,Percent of total Billed Charges,65% of Total Billed Charges,123.98,44.1,,336.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,267.08,95,,545.472,Percent of Total Billed Charges,95% of Total Billed Charges,281.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.4,88,,505.28,Percent of Total Billed Charges,88% of Total Billed Charges,253.03,90,,516.768,Percent of Total Billed charges,90% of Total Billed Charges,123.98,281.14,
PROX CUTTER TCR55 RI,2720000665,CDM,272,RC,,,Outpatient,,,359.42,233.62,,359.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.16,76,,155.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,258.78,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,269.57,75,,1.2,Percent of Total Billed charges,75% of Total Billed Charges,359.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258.78,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,215.65,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,323.48,90,,123.04,Percent of Total Billed Charges,90% of Total Billed Charges,161.74,45,,34.136,Percent of Total Billed Charges,45% of Total Billed Charges,323.48,90,,184.16,Percent of Total Billed Charges,90% of Total billed Charges,359.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.62,65,,495.328,Percent of total Billed Charges,65% of Total Billed Charges,158.5,44.1,,33.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,341.45,95,,194.392,Percent of Total Billed Charges,95% of Total Billed Charges,359.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.29,88,,180.072,Percent of Total Billed Charges,88% of Total Billed Charges,323.48,90,,184.16,Percent of Total Billed charges,90% of Total Billed Charges,158.5,359.42,
PROX CUTR VAS TUR55,2720000666,CDM,272,RC,,,Outpatient,,,191.84,124.70,,191.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,145.8,76,,3137.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,138.12,72,,1.728,Percent of Total Billed Charges,72% of Total Billed Charges,143.88,75,,1.8,Percent of Total Billed charges,75% of Total Billed Charges,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.12,72,,1.728,Percent of Total Billed Charges,72% of Total Billed Charges,115.1,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,172.66,90,,62.712,Percent of Total Billed Charges,90% of Total Billed Charges,86.33,45,,28.576,Percent of Total Billed Charges,45% of Total Billed Charges,172.66,90,,3715.776,Percent of Total Billed Charges,90% of Total billed Charges,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.7,65,,49.304,Percent of total Billed Charges,65% of Total Billed Charges,84.6,44.1,,28.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,182.25,95,,3922.208,Percent of Total Billed Charges,95% of Total Billed Charges,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.82,88,,3633.2,Percent of Total Billed Charges,88% of Total Billed Charges,172.66,90,,3715.776,Percent of Total Billed charges,90% of Total Billed Charges,84.6,191.84,
PROX RIO STAPLER TX3,2720000667,CDM,272,RC,,,Outpatient,,,643.86,418.51,,643.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,489.33,76,,579.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,463.58,72,,27.072,Percent of Total Billed Charges,72% of Total Billed Charges,482.9,75,,28.2,Percent of Total Billed charges,75% of Total Billed Charges,643.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,463.58,72,,27.072,Percent of Total Billed Charges,72% of Total Billed Charges,386.32,60,,22.56,Percent of Total Billed Charges,60% of Total Billed Charges,579.47,90,,62.712,Percent of Total Billed Charges,90% of Total Billed Charges,289.74,45,,30.96,Percent of Total Billed Charges,45% of Total Billed Charges,579.47,90,,685.84,Percent of Total Billed Charges,90% of Total billed Charges,643.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,643.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,643.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,418.51,65,,41.28,Percent of total Billed Charges,65% of Total Billed Charges,283.94,44.1,,30.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,611.67,95,,723.944,Percent of Total Billed Charges,95% of Total Billed Charges,643.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.6,88,,670.6,Percent of Total Billed Charges,88% of Total Billed Charges,579.47,90,,685.84,Percent of Total Billed charges,90% of Total Billed Charges,283.94,643.86,
PROX RIO STAPLER XR3,2720000668,CDM,272,RC,,,Outpatient,,,205.07,133.30,,205.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,155.85,76,,57.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,147.65,72,,7.488,Percent of Total Billed Charges,72% of Total Billed Charges,153.8,75,,7.8,Percent of Total Billed charges,75% of Total Billed Charges,205.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.65,72,,7.488,Percent of Total Billed Charges,72% of Total Billed Charges,123.04,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,184.56,90,,112.72,Percent of Total Billed Charges,90% of Total Billed Charges,92.28,45,,34.136,Percent of Total Billed Charges,45% of Total Billed Charges,184.56,90,,68.272,Percent of Total Billed Charges,90% of Total billed Charges,205.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.3,65,,44.72,Percent of total Billed Charges,65% of Total Billed Charges,90.44,44.1,,33.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,194.82,95,,72.064,Percent of Total Billed Charges,95% of Total Billed Charges,205.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.46,88,,66.752,Percent of Total Billed Charges,88% of Total Billed Charges,184.56,90,,68.272,Percent of Total Billed charges,90% of Total Billed Charges,90.44,205.07,
PROX RIO STAPLER TX6,2720000669,CDM,272,RC,,,Outpatient,,,653.78,424.96,,653.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,496.87,76,,48.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,470.72,72,,10.368,Percent of Total Billed Charges,72% of Total Billed Charges,490.34,75,,10.8,Percent of Total Billed charges,75% of Total Billed Charges,653.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,470.72,72,,10.368,Percent of Total Billed Charges,72% of Total Billed Charges,392.27,60,,8.64,Percent of Total Billed Charges,60% of Total Billed Charges,588.4,90,,133.36,Percent of Total Billed Charges,90% of Total Billed Charges,294.2,45,,9.528,Percent of Total Billed Charges,45% of Total Billed Charges,588.4,90,,57.152,Percent of Total Billed Charges,90% of Total billed Charges,653.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,653.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,653.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.96,65,,49.304,Percent of total Billed Charges,65% of Total Billed Charges,288.32,44.1,,9.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,621.09,95,,60.328,Percent of Total Billed Charges,95% of Total Billed Charges,653.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.33,88,,55.88,Percent of Total Billed Charges,88% of Total Billed Charges,588.4,90,,57.152,Percent of Total Billed charges,90% of Total Billed Charges,288.32,653.78,
ENDOLOOPSURGI TIE,2720000670,CDM,272,RC,,,Outpatient,,,181.91,118.24,,181.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,138.25,76,,52.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,130.98,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,136.43,75,,1.2,Percent of Total Billed charges,75% of Total Billed Charges,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.98,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,109.15,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,163.72,90,,133.36,Percent of Total Billed Charges,90% of Total Billed Charges,81.86,45,,58.744,Percent of Total Billed Charges,45% of Total Billed Charges,163.72,90,,61.92,Percent of Total Billed Charges,90% of Total billed Charges,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.24,65,,13.76,Percent of total Billed Charges,65% of Total Billed Charges,80.22,44.1,,57.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,172.81,95,,65.36,Percent of Total Billed Charges,95% of Total Billed Charges,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.08,88,,60.544,Percent of Total Billed Charges,88% of Total Billed Charges,163.72,90,,61.92,Percent of Total Billed charges,90% of Total Billed Charges,80.22,181.91,
PROX SKIN STAPLER PR,2720000671,CDM,272,RC,,,Outpatient,,,125.69,81.70,,125.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95.52,76,,57.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90.5,72,,23.04,Percent of Total Billed Charges,72% of Total Billed Charges,94.27,75,,24,Percent of Total Billed charges,75% of Total Billed Charges,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.5,72,,23.04,Percent of Total Billed Charges,72% of Total Billed Charges,75.41,60,,19.2,Percent of Total Billed Charges,60% of Total Billed Charges,113.12,90,,62.712,Percent of Total Billed Charges,90% of Total Billed Charges,56.56,45,,61.52,Percent of Total Billed Charges,45% of Total Billed Charges,113.12,90,,68.272,Percent of Total Billed Charges,90% of Total billed Charges,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.7,65,,84.848,Percent of total Billed Charges,65% of Total Billed Charges,55.43,44.1,,60.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,119.41,95,,72.064,Percent of Total Billed Charges,95% of Total Billed Charges,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.61,88,,66.752,Percent of Total Billed Charges,88% of Total Billed Charges,113.12,90,,68.272,Percent of Total Billed charges,90% of Total Billed Charges,55.43,125.69,
ENDOPATH CURVED DISS,2720000672,CDM,272,RC,,,Outpatient,,,444.31,288.80,,444.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,337.68,76,,16.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,319.9,72,,235.584,Percent of Total Billed Charges,72% of Total Billed Charges,333.23,75,,245.4,Percent of Total Billed charges,75% of Total Billed Charges,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319.9,72,,235.584,Percent of Total Billed Charges,72% of Total Billed Charges,266.59,60,,196.32,Percent of Total Billed Charges,60% of Total Billed Charges,399.88,90,,23.816,Percent of Total Billed Charges,90% of Total Billed Charges,199.94,45,,31.36,Percent of Total Billed Charges,45% of Total Billed Charges,399.88,90,,19.048,Percent of Total Billed Charges,90% of Total billed Charges,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.8,65,,88.864,Percent of total Billed Charges,65% of Total Billed Charges,195.94,44.1,,30.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,422.09,95,,20.112,Percent of Total Billed Charges,95% of Total Billed Charges,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.99,88,,18.624,Percent of Total Billed Charges,88% of Total Billed Charges,399.88,90,,19.048,Percent of Total Billed charges,90% of Total Billed Charges,195.94,444.31,
ENDOPATH CURVED SCIS,2720000673,CDM,272,RC,,,Outpatient,,,158.76,103.19,,158.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.66,76,,99.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.31,72,,89.856,Percent of Total Billed Charges,72% of Total Billed Charges,119.07,75,,93.6,Percent of Total Billed charges,75% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.31,72,,89.856,Percent of Total Billed Charges,72% of Total Billed Charges,95.26,60,,74.88,Percent of Total Billed Charges,60% of Total Billed Charges,142.88,90,,23.816,Percent of Total Billed Charges,90% of Total Billed Charges,71.44,45,,31.36,Percent of Total Billed Charges,45% of Total Billed Charges,142.88,90,,117.48,Percent of Total Billed Charges,90% of Total billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.19,65,,45.296,Percent of total Billed Charges,65% of Total Billed Charges,70.01,44.1,,30.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,150.82,95,,124.008,Percent of Total Billed Charges,95% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.71,88,,114.872,Percent of Total Billed Charges,88% of Total Billed Charges,142.88,90,,117.48,Percent of Total Billed charges,90% of Total Billed Charges,70.01,158.76,
PROX ART STAPLER AX5,2720000674,CDM,272,RC,,,Outpatient,,,558.97,363.33,,558.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,424.82,76,,103.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,402.46,72,,16.704,Percent of Total Billed Charges,72% of Total Billed Charges,419.23,75,,17.4,Percent of Total Billed charges,75% of Total Billed Charges,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,402.46,72,,16.704,Percent of Total Billed Charges,72% of Total Billed Charges,335.38,60,,13.92,Percent of Total Billed Charges,60% of Total Billed Charges,503.07,90,,19.048,Percent of Total Billed Charges,90% of Total Billed Charges,251.54,45,,56.36,Percent of Total Billed Charges,45% of Total Billed Charges,503.07,90,,123.04,Percent of Total Billed Charges,90% of Total billed Charges,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.33,65,,45.296,Percent of total Billed Charges,65% of Total Billed Charges,246.51,44.1,,55.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,531.02,95,,129.88,Percent of Total Billed Charges,95% of Total Billed Charges,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.89,88,,120.304,Percent of Total Billed Charges,88% of Total Billed Charges,503.07,90,,123.04,Percent of Total Billed charges,90% of Total Billed Charges,246.51,558.97,
29 CVD INTRALUMIN STAPLER,2720000675,CDM,272,RC,,,Outpatient,,,759.62,493.75,,759.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,577.31,76,,52.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,546.93,72,,17.28,Percent of Total Billed Charges,72% of Total Billed Charges,569.72,75,,18,Percent of Total Billed charges,75% of Total Billed Charges,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.93,72,,17.28,Percent of Total Billed Charges,72% of Total Billed Charges,455.77,60,,14.4,Percent of Total Billed Charges,60% of Total Billed Charges,683.66,90,,19.048,Percent of Total Billed Charges,90% of Total Billed Charges,341.83,45,,66.68,Percent of Total Billed Charges,45% of Total Billed Charges,683.66,90,,62.712,Percent of Total Billed Charges,90% of Total billed Charges,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.75,65,,81.408,Percent of total Billed Charges,65% of Total Billed Charges,334.99,44.1,,65.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,721.64,95,,66.2,Percent of Total Billed Charges,95% of Total Billed Charges,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,668.47,88,,61.32,Percent of Total Billed Charges,88% of Total Billed Charges,683.66,90,,62.712,Percent of Total Billed charges,90% of Total Billed Charges,334.99,759.62,
RELOAD XR60B,2720000676,CDM,272,RC,,,Outpatient,,,178.61,116.10,,178.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,135.74,76,,52.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,128.6,72,,6.336,Percent of Total Billed Charges,72% of Total Billed Charges,133.96,75,,6.6,Percent of Total Billed charges,75% of Total Billed Charges,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.6,72,,6.336,Percent of Total Billed Charges,72% of Total Billed Charges,107.17,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,160.75,90,,78.592,Percent of Total Billed Charges,90% of Total Billed Charges,80.37,45,,66.68,Percent of Total Billed Charges,45% of Total Billed Charges,160.75,90,,62.712,Percent of Total Billed Charges,90% of Total billed Charges,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.1,65,,96.312,Percent of total Billed Charges,65% of Total Billed Charges,78.77,44.1,,65.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,169.68,95,,66.2,Percent of Total Billed Charges,95% of Total Billed Charges,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.18,88,,61.32,Percent of Total Billed Charges,88% of Total Billed Charges,160.75,90,,62.712,Percent of Total Billed charges,90% of Total Billed Charges,78.77,178.61,
PROX RIO STAPLER TLH,2720000677,CDM,272,RC,,,Outpatient,,,701.19,455.77,,701.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,532.9,76,,95.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,504.86,72,,1.32,Percent of Total Billed Charges,72% of Total Billed Charges,525.89,75,,1.376,Percent of Total Billed charges,75% of Total Billed Charges,701.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,504.86,72,,1.32,Percent of Total Billed Charges,72% of Total Billed Charges,420.71,60,,1.096,Percent of Total Billed Charges,60% of Total Billed Charges,631.07,90,,55.568,Percent of Total Billed Charges,90% of Total Billed Charges,315.54,45,,31.36,Percent of Total Billed Charges,45% of Total Billed Charges,631.07,90,,112.72,Percent of Total Billed Charges,90% of Total billed Charges,701.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,701.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,701.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,455.77,65,,96.312,Percent of total Billed Charges,65% of Total Billed Charges,309.22,44.1,,30.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,666.13,95,,118.984,Percent of Total Billed Charges,95% of Total Billed Charges,701.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,617.05,88,,110.216,Percent of Total Billed Charges,88% of Total Billed Charges,631.07,90,,112.72,Percent of Total Billed charges,90% of Total Billed Charges,309.22,701.19,
PROX STAPLER RIO TRH,2720000678,CDM,272,RC,,,Outpatient,,,208.37,135.44,,208.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,158.36,76,,112.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.03,72,,41.472,Percent of Total Billed Charges,72% of Total Billed Charges,156.28,75,,43.2,Percent of Total Billed charges,75% of Total Billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.03,72,,41.472,Percent of Total Billed Charges,72% of Total Billed Charges,125.02,60,,34.56,Percent of Total Billed Charges,60% of Total Billed Charges,187.53,90,,72.24,Percent of Total Billed Charges,90% of Total Billed Charges,93.77,45,,11.912,Percent of Total Billed Charges,45% of Total Billed Charges,187.53,90,,133.36,Percent of Total Billed Charges,90% of Total billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.44,65,,45.296,Percent of total Billed Charges,65% of Total Billed Charges,91.89,44.1,,11.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,197.95,95,,140.768,Percent of Total Billed Charges,95% of Total Billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.37,88,,130.392,Percent of Total Billed Charges,88% of Total Billed Charges,187.53,90,,133.36,Percent of Total Billed charges,90% of Total Billed Charges,91.89,208.37,
ETS FLEX 45 VASCULAR,2720000679,CDM,272,RC,,,Outpatient,,,1711.08,1112.20,,1711.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1300.42,76,,112.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1231.98,72,,77.76,Percent of Total Billed Charges,72% of Total Billed Charges,1283.31,75,,81,Percent of Total Billed charges,75% of Total Billed Charges,1711.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1231.98,72,,77.76,Percent of Total Billed Charges,72% of Total Billed Charges,1026.65,60,,64.8,Percent of Total Billed Charges,60% of Total Billed Charges,1539.97,90,,81.76,Percent of Total Billed Charges,90% of Total Billed Charges,769.99,45,,11.912,Percent of Total Billed Charges,45% of Total Billed Charges,1539.97,90,,133.36,Percent of Total Billed Charges,90% of Total billed Charges,1711.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1711.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1711.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1112.2,65,,17.2,Percent of total Billed Charges,65% of Total Billed Charges,754.59,44.1,,11.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,1625.53,95,,140.768,Percent of Total Billed Charges,95% of Total Billed Charges,1711.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1505.75,88,,130.392,Percent of Total Billed Charges,88% of Total Billed Charges,1539.97,90,,133.36,Percent of Total Billed charges,90% of Total Billed Charges,754.59,1711.08,
PROX CUD STAPLR CDH,2720000680,CDM,272,RC,,,Outpatient,,,759.62,493.75,,759.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,577.31,76,,52.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,546.93,72,,0.984,Percent of Total Billed Charges,72% of Total Billed Charges,569.72,75,,1.024,Percent of Total Billed charges,75% of Total Billed Charges,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.93,72,,0.984,Percent of Total Billed Charges,72% of Total Billed Charges,455.77,60,,0.824,Percent of Total Billed Charges,60% of Total Billed Charges,683.66,90,,42.872,Percent of Total Billed Charges,90% of Total Billed Charges,341.83,45,,9.528,Percent of Total Billed Charges,45% of Total Billed Charges,683.66,90,,62.712,Percent of Total Billed Charges,90% of Total billed Charges,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.75,65,,17.2,Percent of total Billed Charges,65% of Total Billed Charges,334.99,44.1,,9.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,721.64,95,,66.2,Percent of Total Billed Charges,95% of Total Billed Charges,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,668.47,88,,61.32,Percent of Total Billed Charges,88% of Total Billed Charges,683.66,90,,62.712,Percent of Total Billed charges,90% of Total Billed Charges,334.99,759.62,
SCW 45 OPEN CUTTER,2720000681,CDM,272,RC,,,Outpatient,,,471.87,306.72,,471.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,358.62,76,,20.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,339.75,72,,172.8,Percent of Total Billed Charges,72% of Total Billed Charges,353.9,75,,180,Percent of Total Billed charges,75% of Total Billed Charges,471.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,339.75,72,,172.8,Percent of Total Billed Charges,72% of Total Billed Charges,283.12,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,424.68,90,,351.656,Percent of Total Billed Charges,90% of Total Billed Charges,212.34,45,,9.528,Percent of Total Billed Charges,45% of Total Billed Charges,424.68,90,,23.816,Percent of Total Billed Charges,90% of Total billed Charges,471.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.72,65,,13.76,Percent of total Billed Charges,65% of Total Billed Charges,208.09,44.1,,9.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,448.28,95,,25.144,Percent of Total Billed Charges,95% of Total Billed Charges,471.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.25,88,,23.288,Percent of Total Billed Charges,88% of Total Billed Charges,424.68,90,,23.816,Percent of Total Billed charges,90% of Total Billed Charges,208.09,471.87,
REDUCER CAP ONE SEAL,2720000682,CDM,272,RC,,,Outpatient,,,73.87,48.02,,73.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.14,76,,20.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.19,72,,54.144,Percent of Total Billed Charges,72% of Total Billed Charges,55.4,75,,56.4,Percent of Total Billed charges,75% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.19,72,,54.144,Percent of Total Billed Charges,72% of Total Billed Charges,44.32,60,,45.12,Percent of Total Billed Charges,60% of Total Billed Charges,66.48,90,,327.84,Percent of Total Billed Charges,90% of Total Billed Charges,33.24,45,,39.296,Percent of Total Billed Charges,45% of Total Billed Charges,66.48,90,,23.816,Percent of Total Billed Charges,90% of Total billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.02,65,,13.76,Percent of total Billed Charges,65% of Total Billed Charges,32.58,44.1,,38.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,70.18,95,,25.144,Percent of Total Billed Charges,95% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.01,88,,23.288,Percent of Total Billed Charges,88% of Total Billed Charges,66.48,90,,23.816,Percent of Total Billed charges,90% of Total Billed Charges,32.58,73.87,
PNEUMONEEDLE 120,2720000683,CDM,272,RC,,,Outpatient,,,187.43,121.83,,187.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,142.45,76,,16.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,134.95,72,,172.8,Percent of Total Billed Charges,72% of Total Billed Charges,140.57,75,,180,Percent of Total Billed charges,75% of Total Billed Charges,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.95,72,,172.8,Percent of Total Billed Charges,72% of Total Billed Charges,112.46,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,168.69,90,,12.704,Percent of Total Billed Charges,90% of Total Billed Charges,84.34,45,,27.784,Percent of Total Billed Charges,45% of Total Billed Charges,168.69,90,,19.048,Percent of Total Billed Charges,90% of Total billed Charges,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.83,65,,56.76,Percent of total Billed Charges,65% of Total Billed Charges,82.66,44.1,,27.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,178.06,95,,20.112,Percent of Total Billed Charges,95% of Total Billed Charges,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.94,88,,18.624,Percent of Total Billed Charges,88% of Total Billed Charges,168.69,90,,19.048,Percent of Total Billed charges,90% of Total Billed Charges,82.66,187.43,
LIGACLIP ERCA LG,2720000684,CDM,272,RC,,,Outpatient,,,649.37,422.09,,649.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,493.52,76,,16.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,467.55,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,487.03,75,,3,Percent of Total Billed charges,75% of Total Billed Charges,649.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,467.55,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,389.62,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,584.43,90,,133.36,Percent of Total Billed Charges,90% of Total Billed Charges,292.22,45,,36.12,Percent of Total Billed Charges,45% of Total Billed Charges,584.43,90,,19.048,Percent of Total Billed Charges,90% of Total billed Charges,649.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.09,65,,40.136,Percent of total Billed Charges,65% of Total Billed Charges,286.37,44.1,,35.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,616.9,95,,20.112,Percent of Total Billed Charges,95% of Total Billed Charges,649.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,571.45,88,,18.624,Percent of Total Billed Charges,88% of Total Billed Charges,584.43,90,,19.048,Percent of Total Billed charges,90% of Total Billed Charges,286.37,649.37,
ENDO BLUNT TIP 5MM D,2720000685,CDM,272,RC,,,Outpatient,,,198.45,128.99,,198.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,150.82,76,,66.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,142.88,72,,2.304,Percent of Total Billed Charges,72% of Total Billed Charges,148.84,75,,2.4,Percent of Total Billed charges,75% of Total Billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.88,72,,2.304,Percent of Total Billed Charges,72% of Total Billed Charges,119.07,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,178.61,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,89.3,45,,40.88,Percent of Total Billed Charges,45% of Total Billed Charges,178.61,90,,78.592,Percent of Total Billed Charges,90% of Total billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.99,65,,52.168,Percent of total Billed Charges,65% of Total Billed Charges,87.52,44.1,,40.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,188.53,95,,82.952,Percent of Total Billed Charges,95% of Total Billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.64,88,,76.84,Percent of Total Billed Charges,88% of Total Billed Charges,178.61,90,,78.592,Percent of Total Billed charges,90% of Total Billed Charges,87.52,198.45,
PROX R101 STAPLER TX,2720000686,CDM,272,RC,,,Outpatient,,,368.24,239.36,,368.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,279.86,76,,46.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,265.13,72,,104.256,Percent of Total Billed Charges,72% of Total Billed Charges,276.18,75,,108.6,Percent of Total Billed charges,75% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.13,72,,104.256,Percent of Total Billed Charges,72% of Total Billed Charges,220.94,60,,86.88,Percent of Total Billed Charges,60% of Total Billed Charges,331.42,90,,75.416,Percent of Total Billed Charges,90% of Total Billed Charges,165.71,45,,21.432,Percent of Total Billed Charges,45% of Total Billed Charges,331.42,90,,55.568,Percent of Total Billed Charges,90% of Total billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.36,65,,59.048,Percent of total Billed Charges,65% of Total Billed Charges,162.39,44.1,,21.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,349.83,95,,58.656,Percent of Total Billed Charges,95% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.05,88,,54.336,Percent of Total Billed Charges,88% of Total Billed Charges,331.42,90,,55.568,Percent of Total Billed charges,90% of Total Billed Charges,162.39,368.24,
ENDO BABCOCK 5MM,2720000687,CDM,272,RC,,,Outpatient,,,513.77,333.95,,513.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,390.47,76,,61,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,369.91,72,,69.12,Percent of Total Billed Charges,72% of Total Billed Charges,385.33,75,,72,Percent of Total Billed charges,75% of Total Billed Charges,513.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.91,72,,69.12,Percent of Total Billed Charges,72% of Total Billed Charges,308.26,60,,57.6,Percent of Total Billed Charges,60% of Total Billed Charges,462.39,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,231.2,45,,175.824,Percent of Total Billed Charges,45% of Total Billed Charges,462.39,90,,72.24,Percent of Total Billed Charges,90% of Total billed Charges,513.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.95,65,,30.96,Percent of total Billed Charges,65% of Total Billed Charges,226.57,44.1,,172.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,488.08,95,,76.248,Percent of Total Billed Charges,95% of Total Billed Charges,513.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,452.12,88,,70.632,Percent of Total Billed Charges,88% of Total Billed Charges,462.39,90,,72.24,Percent of Total Billed charges,90% of Total Billed Charges,226.57,513.77,
PROX R101 STAPLER XR,2720000688,CDM,272,RC,,,Outpatient,,,216.09,140.46,,216.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,164.23,76,,69.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,155.58,72,,104.256,Percent of Total Billed Charges,72% of Total Billed Charges,162.07,75,,108.6,Percent of Total Billed charges,75% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.58,72,,104.256,Percent of Total Billed Charges,72% of Total Billed Charges,129.65,60,,86.88,Percent of Total Billed Charges,60% of Total Billed Charges,194.48,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,97.24,45,,163.92,Percent of Total Billed Charges,45% of Total Billed Charges,194.48,90,,81.76,Percent of Total Billed Charges,90% of Total billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.46,65,,253.976,Percent of total Billed Charges,65% of Total Billed Charges,95.3,44.1,,160.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,205.29,95,,86.304,Percent of Total Billed Charges,95% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.16,88,,79.944,Percent of Total Billed Charges,88% of Total Billed Charges,194.48,90,,81.76,Percent of Total Billed charges,90% of Total Billed Charges,95.3,216.09,
TROCAR BLUNT TIP 10/,2720000690,CDM,272,RC,,,Outpatient,,,528.10,343.27,,528.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,401.36,76,,36.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,380.23,72,,4.032,Percent of Total Billed Charges,72% of Total Billed Charges,396.08,75,,4.2,Percent of Total Billed charges,75% of Total Billed Charges,528.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.23,72,,4.032,Percent of Total Billed Charges,72% of Total Billed Charges,316.86,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,475.29,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,237.65,45,,6.352,Percent of Total Billed Charges,45% of Total Billed Charges,475.29,90,,42.872,Percent of Total Billed Charges,90% of Total billed Charges,528.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,528.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,528.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.27,65,,236.768,Percent of total Billed Charges,65% of Total Billed Charges,232.89,44.1,,6.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,501.7,95,,45.248,Percent of Total Billed Charges,95% of Total Billed Charges,528.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,464.73,88,,41.92,Percent of Total Billed Charges,88% of Total Billed Charges,475.29,90,,42.872,Percent of Total Billed charges,90% of Total Billed Charges,232.89,528.1,
TROCAR DILATN TIP 5M,2720000691,CDM,272,RC,,,Outpatient,,,309.80,201.37,,309.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,235.45,76,,296.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,223.06,72,,99.072,Percent of Total Billed Charges,72% of Total Billed Charges,232.35,75,,103.2,Percent of Total Billed charges,75% of Total Billed Charges,309.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,223.06,72,,99.072,Percent of Total Billed Charges,72% of Total Billed Charges,185.88,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,278.82,90,,165.112,Percent of Total Billed Charges,90% of Total Billed Charges,139.41,45,,66.68,Percent of Total Billed Charges,45% of Total Billed Charges,278.82,90,,351.656,Percent of Total Billed Charges,90% of Total billed Charges,309.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.37,65,,9.176,Percent of total Billed Charges,65% of Total Billed Charges,136.62,44.1,,65.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,294.31,95,,371.192,Percent of Total Billed Charges,95% of Total Billed Charges,309.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.62,88,,343.84,Percent of Total Billed Charges,88% of Total Billed Charges,278.82,90,,351.656,Percent of Total Billed charges,90% of Total Billed Charges,136.62,309.8,
TROCAR DILATN TIP 10,2720000692,CDM,272,RC,,,Outpatient,,,198.45,128.99,,198.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,150.82,76,,276.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,142.88,72,,136.512,Percent of Total Billed Charges,72% of Total Billed Charges,148.84,75,,142.2,Percent of Total Billed charges,75% of Total Billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.88,72,,136.512,Percent of Total Billed Charges,72% of Total Billed Charges,119.07,60,,113.76,Percent of Total Billed Charges,60% of Total Billed Charges,178.61,90,,145.264,Percent of Total Billed Charges,90% of Total Billed Charges,89.3,45,,30.96,Percent of Total Billed Charges,45% of Total Billed Charges,178.61,90,,327.84,Percent of Total Billed Charges,90% of Total billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.99,65,,96.312,Percent of total Billed Charges,65% of Total Billed Charges,87.52,44.1,,30.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,188.53,95,,346.048,Percent of Total Billed Charges,95% of Total Billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.64,88,,320.552,Percent of Total Billed Charges,88% of Total Billed Charges,178.61,90,,327.84,Percent of Total Billed charges,90% of Total Billed Charges,87.52,198.45,
TROCR DI TIP 10/12MM,2720000693,CDM,272,RC,,,Outpatient,,,200.66,130.43,,200.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152.5,76,,10.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144.48,72,,1.024,Percent of Total Billed Charges,72% of Total Billed Charges,150.5,75,,1.072,Percent of Total Billed charges,75% of Total Billed Charges,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.48,72,,1.024,Percent of Total Billed Charges,72% of Total Billed Charges,120.4,60,,0.856,Percent of Total Billed Charges,60% of Total Billed Charges,180.59,90,,396.904,Percent of Total Billed Charges,90% of Total Billed Charges,90.3,45,,37.704,Percent of Total Billed Charges,45% of Total Billed Charges,180.59,90,,12.704,Percent of Total Billed Charges,90% of Total billed Charges,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.43,65,,44.72,Percent of total Billed Charges,65% of Total Billed Charges,88.49,44.1,,36.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,190.63,95,,13.408,Percent of Total Billed Charges,95% of Total Billed Charges,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.58,88,,12.416,Percent of Total Billed Charges,88% of Total Billed Charges,180.59,90,,12.704,Percent of Total Billed charges,90% of Total Billed Charges,88.49,200.66,
LIGA CLIP 20 MOM,2720000694,CDM,272,RC,,,Outpatient,,,186.32,121.11,,186.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,141.6,76,,112.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,134.15,72,,0.896,Percent of Total Billed Charges,72% of Total Billed Charges,139.74,75,,0.936,Percent of Total Billed charges,75% of Total Billed Charges,186.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.15,72,,0.896,Percent of Total Billed Charges,72% of Total Billed Charges,111.79,60,,0.752,Percent of Total Billed Charges,60% of Total Billed Charges,167.69,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,83.84,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,167.69,90,,133.36,Percent of Total Billed Charges,90% of Total billed Charges,186.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.11,65,,54.464,Percent of total Billed Charges,65% of Total Billed Charges,82.17,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,177,95,,140.768,Percent of Total Billed Charges,95% of Total Billed Charges,186.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.96,88,,130.392,Percent of Total Billed Charges,88% of Total Billed Charges,167.69,90,,133.36,Percent of Total Billed charges,90% of Total Billed Charges,82.17,186.32,
ENDO CATCH GOLD 10MM,2720000695,CDM,272,RC,,,Outpatient,,,513.77,333.95,,513.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,390.47,76,,52.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,369.91,72,,1.04,Percent of Total Billed Charges,72% of Total Billed Charges,385.33,75,,1.08,Percent of Total Billed charges,75% of Total Billed Charges,513.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.91,72,,1.04,Percent of Total Billed Charges,72% of Total Billed Charges,308.26,60,,0.864,Percent of Total Billed Charges,60% of Total Billed Charges,462.39,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,231.2,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,462.39,90,,61.92,Percent of Total Billed Charges,90% of Total billed Charges,513.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.95,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,226.57,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,488.08,95,,65.36,Percent of Total Billed Charges,95% of Total Billed Charges,513.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,452.12,88,,60.544,Percent of Total Billed Charges,88% of Total Billed Charges,462.39,90,,61.92,Percent of Total Billed charges,90% of Total Billed Charges,226.57,513.77,
DERMABOND,2720000696,CDM,272,RC,,,Outpatient,,,20.68,13.44,,20.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.72,76,,63.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.89,72,,40.896,Percent of Total Billed Charges,72% of Total Billed Charges,15.51,75,,42.6,Percent of Total Billed charges,75% of Total Billed Charges,20.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.89,72,,40.896,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,60,,34.08,Percent of Total Billed Charges,60% of Total Billed Charges,18.61,90,,49.216,Percent of Total Billed Charges,90% of Total Billed Charges,9.31,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,18.61,90,,75.416,Percent of Total Billed Charges,90% of Total billed Charges,20.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.44,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,9.12,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.65,95,,79.6,Percent of Total Billed Charges,95% of Total Billed Charges,20.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.2,88,,73.736,Percent of Total Billed Charges,88% of Total Billed Charges,18.61,90,,75.416,Percent of Total Billed charges,90% of Total Billed Charges,9.12,20.68,
STORZ ELECT CUTTING,2720000697,CDM,272,RC,,,Outpatient,,,340.67,221.44,,340.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,258.91,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,245.28,72,,14.4,Percent of Total Billed Charges,72% of Total Billed Charges,255.5,75,,15,Percent of Total Billed charges,75% of Total Billed Charges,340.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.28,72,,14.4,Percent of Total Billed Charges,72% of Total Billed Charges,204.4,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,306.6,90,,118.272,Percent of Total Billed Charges,90% of Total Billed Charges,153.3,45,,82.552,Percent of Total Billed Charges,45% of Total Billed Charges,306.6,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,340.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.44,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,150.24,44.1,,80.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,323.64,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,340.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,299.79,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,306.6,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,150.24,340.67,
STORZ ELEC COAG,2720000698,CDM,272,RC,,,Outpatient,,,309.80,201.37,,309.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,235.45,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,223.06,72,,20.736,Percent of Total Billed Charges,72% of Total Billed Charges,232.35,75,,21.6,Percent of Total Billed charges,75% of Total Billed Charges,309.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,223.06,72,,20.736,Percent of Total Billed Charges,72% of Total Billed Charges,185.88,60,,17.28,Percent of Total Billed Charges,60% of Total Billed Charges,278.82,90,,29.368,Percent of Total Billed Charges,90% of Total Billed Charges,139.41,45,,72.632,Percent of Total Billed Charges,45% of Total Billed Charges,278.82,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,309.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.37,65,,119.248,Percent of total Billed Charges,65% of Total Billed Charges,136.62,44.1,,71.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,294.31,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,309.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.62,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,278.82,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,136.62,309.8,
EASY CORE BX,2720000699,CDM,272,RC,,,Outpatient,,,185.22,120.39,,185.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,140.77,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,133.36,72,,85.824,Percent of Total Billed Charges,72% of Total Billed Charges,138.92,75,,89.4,Percent of Total Billed charges,75% of Total Billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.36,72,,85.824,Percent of Total Billed Charges,72% of Total Billed Charges,111.13,60,,71.52,Percent of Total Billed Charges,60% of Total Billed Charges,166.7,90,,15.88,Percent of Total Billed Charges,90% of Total Billed Charges,83.35,45,,198.448,Percent of Total Billed Charges,45% of Total Billed Charges,166.7,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.39,65,,104.912,Percent of total Billed Charges,65% of Total Billed Charges,81.68,44.1,,194.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,175.96,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.99,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,166.7,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,81.68,185.22,
SENSOR DUAL FLX GUID,2720000700,CDM,272,RC,,,Outpatient,,,188.53,122.54,,188.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,143.28,76,,139.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,135.74,72,,115.776,Percent of Total Billed Charges,72% of Total Billed Charges,141.4,75,,120.6,Percent of Total Billed charges,75% of Total Billed Charges,188.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.74,72,,115.776,Percent of Total Billed Charges,72% of Total Billed Charges,113.12,60,,96.48,Percent of Total Billed Charges,60% of Total Billed Charges,169.68,90,,42.872,Percent of Total Billed Charges,90% of Total Billed Charges,84.84,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,169.68,90,,165.112,Percent of Total Billed Charges,90% of Total billed Charges,188.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.54,65,,286.648,Percent of total Billed Charges,65% of Total Billed Charges,83.14,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,179.1,95,,174.28,Percent of Total Billed Charges,95% of Total Billed Charges,188.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.91,88,,161.44,Percent of Total Billed Charges,88% of Total Billed Charges,169.68,90,,165.112,Percent of Total Billed charges,90% of Total Billed Charges,83.14,188.53,
GEMINI HEL BASKET 2X,2720000701,CDM,272,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,122.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,16.704,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,17.4,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,16.704,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,13.92,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,73.032,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,145.264,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,153.336,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,142.04,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,145.264,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
OPEN ENDEO URETERAL,2720000702,CDM,272,RC,,,Outpatient,,,208.37,135.44,,208.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,158.36,76,,335.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.03,72,,115.776,Percent of Total Billed Charges,72% of Total Billed Charges,156.28,75,,120.6,Percent of Total Billed charges,75% of Total Billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.03,72,,115.776,Percent of Total Billed Charges,72% of Total Billed Charges,125.02,60,,96.48,Percent of Total Billed Charges,60% of Total Billed Charges,187.53,90,,73.032,Percent of Total Billed Charges,90% of Total Billed Charges,93.77,45,,24.608,Percent of Total Billed Charges,45% of Total Billed Charges,187.53,90,,396.904,Percent of Total Billed Charges,90% of Total billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.44,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,91.89,44.1,,24.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,197.95,95,,418.952,Percent of Total Billed Charges,95% of Total Billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.37,88,,388.08,Percent of Total Billed Charges,88% of Total Billed Charges,187.53,90,,396.904,Percent of Total Billed charges,90% of Total Billed Charges,91.89,208.37,
8/10 DILATOR SHEATH,2720000703,CDM,272,RC,,,Outpatient,,,101.43,65.93,,101.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,77.09,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,73.03,72,,0.856,Percent of Total Billed Charges,72% of Total Billed Charges,76.07,75,,0.896,Percent of Total Billed charges,75% of Total Billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.03,72,,0.856,Percent of Total Billed Charges,72% of Total Billed Charges,60.86,60,,0.712,Percent of Total Billed Charges,60% of Total Billed Charges,91.29,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,45.64,45,,59.136,Percent of Total Billed Charges,45% of Total Billed Charges,91.29,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.93,65,,35.544,Percent of total Billed Charges,65% of Total Billed Charges,44.73,44.1,,57.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,96.36,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.26,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,91.29,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,44.73,101.43,
UROVAC BLADDER EVACU,2720000704,CDM,272,RC,,,Outpatient,,,43.00,27.95,,43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,32.68,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.96,72,,0.528,Percent of Total Billed Charges,72% of Total Billed Charges,32.25,75,,0.544,Percent of Total Billed charges,75% of Total Billed Charges,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.96,72,,0.528,Percent of Total Billed Charges,72% of Total Billed Charges,25.8,60,,0.44,Percent of Total Billed Charges,60% of Total Billed Charges,38.7,90,,619.96,Percent of Total Billed Charges,90% of Total Billed Charges,19.35,45,,14.688,Percent of Total Billed Charges,45% of Total Billed Charges,38.7,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.95,65,,85.424,Percent of total Billed Charges,65% of Total Billed Charges,18.96,44.1,,14.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,40.85,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.84,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,38.7,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,18.96,43,
PIRANHA 3FR BIOPSY F,2720000705,CDM,272,RC,,,Outpatient,,,952.56,619.16,,952.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,723.95,76,,41.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,685.84,72,,84.096,Percent of Total Billed Charges,72% of Total Billed Charges,714.42,75,,87.6,Percent of Total Billed charges,75% of Total Billed Charges,952.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.84,72,,84.096,Percent of Total Billed Charges,72% of Total Billed Charges,571.54,60,,70.08,Percent of Total Billed Charges,60% of Total Billed Charges,857.3,90,,2606.84,Percent of Total Billed Charges,90% of Total Billed Charges,428.65,45,,7.936,Percent of Total Billed Charges,45% of Total Billed Charges,857.3,90,,49.216,Percent of Total Billed Charges,90% of Total billed Charges,952.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,952.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,952.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,619.16,65,,21.208,Percent of total Billed Charges,65% of Total Billed Charges,420.08,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,904.93,95,,51.952,Percent of Total Billed Charges,95% of Total Billed Charges,952.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,838.25,88,,48.128,Percent of Total Billed Charges,88% of Total Billed Charges,857.3,90,,49.216,Percent of Total Billed charges,90% of Total Billed Charges,420.08,952.56,
SEDTRACE,2720000706,CDM,272,RC,,,Outpatient,,,56.23,36.55,,56.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.73,76,,99.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.49,72,,58.752,Percent of Total Billed Charges,72% of Total Billed Charges,42.17,75,,61.2,Percent of Total Billed charges,75% of Total Billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.49,72,,58.752,Percent of Total Billed Charges,72% of Total Billed Charges,33.74,60,,48.96,Percent of Total Billed Charges,60% of Total Billed Charges,50.61,90,,43.664,Percent of Total Billed Charges,90% of Total Billed Charges,25.3,45,,21.432,Percent of Total Billed Charges,45% of Total Billed Charges,50.61,90,,118.272,Percent of Total Billed Charges,90% of Total billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.55,65,,11.464,Percent of total Billed Charges,65% of Total Billed Charges,24.8,44.1,,21.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.42,95,,124.848,Percent of Total Billed Charges,95% of Total Billed Charges,56.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.48,88,,115.648,Percent of Total Billed Charges,88% of Total Billed Charges,50.61,90,,118.272,Percent of Total Billed charges,90% of Total Billed Charges,24.8,56.23,
CYSTO PACK,2720000707,CDM,272,RC,,,Outpatient,,,71.66,46.58,,71.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.46,76,,24.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.6,72,,58.752,Percent of Total Billed Charges,72% of Total Billed Charges,53.75,75,,61.2,Percent of Total Billed charges,75% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,72,,58.752,Percent of Total Billed Charges,72% of Total Billed Charges,43,60,,48.96,Percent of Total Billed Charges,60% of Total Billed Charges,64.49,90,,2005.936,Percent of Total Billed Charges,90% of Total Billed Charges,32.25,45,,36.512,Percent of Total Billed Charges,45% of Total Billed Charges,64.49,90,,29.368,Percent of Total Billed Charges,90% of Total billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.58,65,,30.96,Percent of total Billed Charges,65% of Total Billed Charges,31.6,44.1,,35.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.08,95,,31,Percent of Total Billed Charges,95% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,88,,28.72,Percent of Total Billed Charges,88% of Total Billed Charges,64.49,90,,29.368,Percent of Total Billed charges,90% of Total Billed Charges,31.6,71.66,
PROC PACK LAPAROSCOP,2720000708,CDM,272,RC,,,Outpatient,,,82.69,53.75,,82.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.84,76,,13.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.54,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,62.02,75,,51.6,Percent of Total Billed charges,75% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,49.61,60,,41.28,Percent of Total Billed Charges,60% of Total Billed Charges,74.42,90,,53.976,Percent of Total Billed Charges,90% of Total Billed Charges,37.21,45,,36.512,Percent of Total Billed Charges,45% of Total Billed Charges,74.42,90,,15.88,Percent of Total Billed Charges,90% of Total billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.75,65,,52.744,Percent of total Billed Charges,65% of Total Billed Charges,36.47,44.1,,35.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,78.56,95,,16.76,Percent of Total Billed Charges,95% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,88,,15.52,Percent of Total Billed Charges,88% of Total Billed Charges,74.42,90,,15.88,Percent of Total Billed charges,90% of Total Billed Charges,36.47,82.69,
PROC PACK LITHOTOMY,2720000709,CDM,272,RC,,,Outpatient,,,60.64,39.42,,60.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.09,76,,36.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.66,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,45.48,75,,51.6,Percent of Total Billed charges,75% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,60,,41.28,Percent of Total Billed Charges,60% of Total Billed Charges,54.58,90,,53.976,Percent of Total Billed Charges,90% of Total Billed Charges,27.29,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,54.58,90,,42.872,Percent of Total Billed Charges,90% of Total billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.42,65,,52.744,Percent of total Billed Charges,65% of Total Billed Charges,26.74,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.61,95,,45.248,Percent of Total Billed Charges,95% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.36,88,,41.92,Percent of Total Billed Charges,88% of Total Billed Charges,54.58,90,,42.872,Percent of Total Billed charges,90% of Total Billed Charges,26.74,60.64,
UMBILICAL TAPE,2720000710,CDM,272,RC,,,Outpatient,,,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,61.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,33.656,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,35.056,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,33.656,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,28.048,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,59.536,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,309.976,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,73.032,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,303.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,77.088,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,71.408,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,73.032,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
BARD URO TRAY,2720000711,CDM,272,RC,,,Outpatient,,,390.29,253.69,,390.29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,296.62,76,,61.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,281.01,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,292.72,75,,46.968,Percent of Total Billed charges,75% of Total Billed Charges,390.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,281.01,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,234.17,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,351.26,90,,69.264,Percent of Total Billed Charges,90% of Total Billed Charges,175.63,45,,1303.416,Percent of Total Billed Charges,45% of Total Billed Charges,351.26,90,,73.032,Percent of Total Billed Charges,90% of Total billed Charges,390.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,253.69,65,,447.744,Percent of total Billed Charges,65% of Total Billed Charges,172.12,44.1,,1277.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,370.78,95,,77.088,Percent of Total Billed Charges,95% of Total Billed Charges,390.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.46,88,,71.408,Percent of Total Billed Charges,88% of Total Billed Charges,351.26,90,,73.032,Percent of Total Billed charges,90% of Total Billed Charges,172.12,390.29,
SPIRAL FILIFORM TIP 3FR,2720000712,CDM,272,RC,,,Outpatient,,,69.46,45.15,,69.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.79,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.01,72,,58.424,Percent of Total Billed Charges,72% of Total Billed Charges,52.1,75,,60.856,Percent of Total Billed charges,75% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.01,72,,58.424,Percent of Total Billed Charges,72% of Total Billed Charges,41.68,60,,48.688,Percent of Total Billed Charges,60% of Total Billed Charges,62.51,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,31.26,45,,21.832,Percent of Total Billed Charges,45% of Total Billed Charges,62.51,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.15,65,,1882.72,Percent of total Billed Charges,65% of Total Billed Charges,30.63,44.1,,21.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.99,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,62.51,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,30.63,69.46,
STORZ COLD KNIFE,2720000713,CDM,272,RC,,,Outpatient,,,270.11,175.57,,270.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,205.28,76,,523.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,194.48,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,202.58,75,,9.264,Percent of Total Billed charges,75% of Total Billed Charges,270.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.48,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,162.07,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,243.1,90,,955.264,Percent of Total Billed Charges,90% of Total Billed Charges,121.55,45,,1002.968,Percent of Total Billed Charges,45% of Total Billed Charges,243.1,90,,619.96,Percent of Total Billed Charges,90% of Total billed Charges,270.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.57,65,,31.536,Percent of total Billed Charges,65% of Total Billed Charges,119.12,44.1,,982.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,256.6,95,,654.4,Percent of Total Billed Charges,95% of Total Billed Charges,270.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.7,88,,606.176,Percent of Total Billed Charges,88% of Total Billed Charges,243.1,90,,619.96,Percent of Total Billed charges,90% of Total Billed Charges,119.12,270.11,
STORZ HOOK COLD KNIF,2720000714,CDM,272,RC,,,Outpatient,,,481.79,313.16,,481.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,366.16,76,,2201.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,346.89,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,361.34,75,,33.08,Percent of Total Billed charges,75% of Total Billed Charges,481.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.89,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,289.07,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,433.61,90,,873.184,Percent of Total Billed Charges,90% of Total Billed Charges,216.81,45,,26.992,Percent of Total Billed Charges,45% of Total Billed Charges,433.61,90,,2606.84,Percent of Total Billed Charges,90% of Total billed Charges,481.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,481.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,481.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.16,65,,1448.728,Percent of total Billed Charges,65% of Total Billed Charges,212.47,44.1,,26.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,457.7,95,,2751.664,Percent of Total Billed Charges,95% of Total Billed Charges,481.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,423.98,88,,2548.912,Percent of Total Billed Charges,88% of Total Billed Charges,433.61,90,,2606.84,Percent of Total Billed charges,90% of Total Billed Charges,212.47,481.79,
SHORTCUT KNIFE,2720000715,CDM,272,RC,,,Outpatient,,,104.74,68.08,,104.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.6,76,,36.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75.41,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,78.56,75,,33.08,Percent of Total Billed charges,75% of Total Billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.41,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,62.84,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,94.27,90,,338.16,Percent of Total Billed Charges,90% of Total Billed Charges,47.13,45,,26.992,Percent of Total Billed Charges,45% of Total Billed Charges,94.27,90,,43.664,Percent of Total Billed Charges,90% of Total billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.08,65,,38.984,Percent of total Billed Charges,65% of Total Billed Charges,46.19,44.1,,26.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,99.5,95,,46.088,Percent of Total Billed Charges,95% of Total Billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.17,88,,42.688,Percent of Total Billed Charges,88% of Total Billed Charges,94.27,90,,43.664,Percent of Total Billed charges,90% of Total Billed Charges,46.19,104.74,
CEMENT MIX BOWL,2720000716,CDM,272,RC,,,Outpatient,,,174.20,113.23,,174.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,132.39,76,,1693.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,125.42,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,130.65,75,,33.08,Percent of Total Billed charges,75% of Total Billed Charges,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.42,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,104.52,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,156.78,90,,197.656,Percent of Total Billed Charges,90% of Total Billed Charges,78.39,45,,29.768,Percent of Total Billed Charges,45% of Total Billed Charges,156.78,90,,2005.936,Percent of Total Billed Charges,90% of Total billed Charges,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.23,65,,38.984,Percent of total Billed Charges,65% of Total Billed Charges,76.82,44.1,,29.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,165.49,95,,2117.376,Percent of Total Billed Charges,95% of Total Billed Charges,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.3,88,,1961.36,Percent of Total Billed Charges,88% of Total Billed Charges,156.78,90,,2005.936,Percent of Total Billed charges,90% of Total Billed Charges,76.82,174.2,
MICRO SAGITTAL SAW BLD 9.5,2720000717,CDM,272,RC,,,Outpatient,,,370.44,240.79,,370.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,281.53,76,,45.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,266.72,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,277.83,75,,9.264,Percent of Total Billed charges,75% of Total Billed Charges,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.72,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,222.26,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,333.4,90,,197.656,Percent of Total Billed Charges,90% of Total Billed Charges,166.7,45,,34.632,Percent of Total Billed Charges,45% of Total Billed Charges,333.4,90,,53.976,Percent of Total Billed Charges,90% of Total billed Charges,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.79,65,,43,Percent of total Billed Charges,65% of Total Billed Charges,163.36,44.1,,33.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,351.92,95,,56.976,Percent of Total Billed Charges,95% of Total Billed Charges,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.99,88,,52.776,Percent of Total Billed Charges,88% of Total Billed Charges,333.4,90,,53.976,Percent of Total Billed charges,90% of Total Billed Charges,163.36,370.44,
MINI-DRIVER SAGITTAL SAW BLADE,2720000718,CDM,272,RC,,,Outpatient,,,198.45,128.99,,198.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,150.82,76,,45.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,142.88,72,,136.536,Percent of Total Billed Charges,72% of Total Billed Charges,148.84,75,,142.224,Percent of Total Billed charges,75% of Total Billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.88,72,,136.536,Percent of Total Billed Charges,72% of Total Billed Charges,119.07,60,,113.776,Percent of Total Billed Charges,60% of Total Billed Charges,178.61,90,,383.408,Percent of Total Billed Charges,90% of Total Billed Charges,89.3,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,178.61,90,,53.976,Percent of Total Billed Charges,90% of Total billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.99,65,,50.024,Percent of total Billed Charges,65% of Total Billed Charges,87.52,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,188.53,95,,56.976,Percent of Total Billed Charges,95% of Total Billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.64,88,,52.776,Percent of Total Billed Charges,88% of Total Billed Charges,178.61,90,,53.976,Percent of Total Billed charges,90% of Total Billed Charges,87.52,198.45,
VACURETTE CU 8MM,2720000719,CDM,272,RC,,,Outpatient,,,36.38,23.65,,36.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.65,76,,50.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.19,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,27.29,75,,5.952,Percent of Total Billed charges,75% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.19,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,21.83,60,,4.76,Percent of Total Billed Charges,60% of Total Billed Charges,32.74,90,,71.448,Percent of Total Billed Charges,90% of Total Billed Charges,16.37,45,,477.632,Percent of Total Billed Charges,45% of Total Billed Charges,32.74,90,,59.536,Percent of Total Billed Charges,90% of Total billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.65,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,16.04,44.1,,468.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.56,95,,62.848,Percent of Total Billed Charges,95% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.01,88,,58.216,Percent of Total Billed Charges,88% of Total Billed Charges,32.74,90,,59.536,Percent of Total Billed charges,90% of Total Billed Charges,16.04,36.38,
5MM TROCAR STAB SLEE,2720000720,CDM,272,RC,,,Outpatient,,,180.81,117.53,,180.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,137.42,76,,58.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,130.18,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,135.61,75,,5.952,Percent of Total Billed charges,75% of Total Billed Charges,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.18,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,108.49,60,,4.76,Percent of Total Billed Charges,60% of Total Billed Charges,162.73,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,81.36,45,,436.592,Percent of Total Billed Charges,45% of Total Billed Charges,162.73,90,,69.264,Percent of Total Billed Charges,90% of Total billed Charges,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.53,65,,689.912,Percent of total Billed Charges,65% of Total Billed Charges,79.74,44.1,,427.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,171.77,95,,73.112,Percent of Total Billed Charges,95% of Total Billed Charges,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.11,88,,67.728,Percent of Total Billed Charges,88% of Total Billed Charges,162.73,90,,69.264,Percent of Total Billed charges,90% of Total Billed Charges,79.74,180.81,
10/11 TROCAR STAB SL,2720000721,CDM,272,RC,,,Outpatient,,,206.17,134.01,,206.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,156.69,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,148.44,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,154.63,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,206.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.44,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,123.7,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,185.55,90,,29.368,Percent of Total Billed Charges,90% of Total Billed Charges,92.78,45,,169.08,Percent of Total Billed Charges,45% of Total Billed Charges,185.55,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,206.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.01,65,,630.632,Percent of total Billed Charges,65% of Total Billed Charges,90.92,44.1,,165.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,195.86,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,206.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.43,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,185.55,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,90.92,206.17,
LIGACLIP ALL PORT,2720000722,CDM,272,RC,,,Outpatient,,,306.50,199.23,,306.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,232.94,76,,806.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,220.68,72,,97.16,Percent of Total Billed Charges,72% of Total Billed Charges,229.88,75,,101.208,Percent of Total Billed charges,75% of Total Billed Charges,306.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.68,72,,97.16,Percent of Total Billed Charges,72% of Total Billed Charges,183.9,60,,80.968,Percent of Total Billed Charges,60% of Total Billed Charges,275.85,90,,1004.152,Percent of Total Billed Charges,90% of Total Billed Charges,137.93,45,,98.824,Percent of Total Billed Charges,45% of Total Billed Charges,275.85,90,,955.264,Percent of Total Billed Charges,90% of Total billed Charges,306.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.23,65,,244.232,Percent of total Billed Charges,65% of Total Billed Charges,135.17,44.1,,96.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,291.18,95,,1008.328,Percent of Total Billed Charges,95% of Total Billed Charges,306.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.72,88,,934.032,Percent of Total Billed Charges,88% of Total Billed Charges,275.85,90,,955.264,Percent of Total Billed charges,90% of Total Billed Charges,135.17,306.5,
RELOAD TRT55,2720000723,CDM,272,RC,,,Outpatient,,,310.91,202.09,,310.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,236.29,76,,737.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,223.86,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,233.18,75,,12.568,Percent of Total Billed charges,75% of Total Billed Charges,310.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,223.86,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,186.55,60,,10.056,Percent of Total Billed Charges,60% of Total Billed Charges,279.82,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,139.91,45,,98.824,Percent of Total Billed Charges,45% of Total Billed Charges,279.82,90,,873.184,Percent of Total Billed Charges,90% of Total billed Charges,310.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,310.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,310.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.09,65,,142.752,Percent of total Billed Charges,65% of Total Billed Charges,137.11,44.1,,96.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,295.36,95,,921.688,Percent of Total Billed Charges,95% of Total Billed Charges,310.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.6,88,,853.776,Percent of Total Billed Charges,88% of Total Billed Charges,279.82,90,,873.184,Percent of Total Billed charges,90% of Total Billed Charges,137.11,310.91,
PROX RLD LINER CUTR,2720000724,CDM,272,RC,,,Outpatient,,,456.44,296.69,,456.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,346.89,76,,285.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,328.64,72,,56.52,Percent of Total Billed Charges,72% of Total Billed Charges,342.33,75,,58.872,Percent of Total Billed charges,75% of Total Billed Charges,456.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.64,72,,56.52,Percent of Total Billed Charges,72% of Total Billed Charges,273.86,60,,47.096,Percent of Total Billed Charges,60% of Total Billed Charges,410.8,90,,12.704,Percent of Total Billed Charges,90% of Total Billed Charges,205.4,45,,191.704,Percent of Total Billed Charges,45% of Total Billed Charges,410.8,90,,338.16,Percent of Total Billed Charges,90% of Total billed Charges,456.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.69,65,,142.752,Percent of total Billed Charges,65% of Total Billed Charges,201.29,44.1,,187.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,433.62,95,,356.952,Percent of Total Billed Charges,95% of Total Billed Charges,456.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.67,88,,330.648,Percent of Total Billed Charges,88% of Total Billed Charges,410.8,90,,338.16,Percent of Total Billed charges,90% of Total Billed Charges,201.29,456.44,
PROXIMATE HCS PPHO3,2720000725,CDM,272,RC,,,Outpatient,,,1040.76,676.49,,1040.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,790.98,76,,166.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,749.35,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,780.57,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,1040.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,749.35,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,624.46,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,936.68,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,468.34,45,,35.72,Percent of Total Billed Charges,45% of Total Billed Charges,936.68,90,,197.656,Percent of Total Billed Charges,90% of Total billed Charges,1040.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1040.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1040.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,676.49,65,,276.904,Percent of total Billed Charges,65% of Total Billed Charges,458.98,44.1,,35.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,988.72,95,,208.632,Percent of Total Billed Charges,95% of Total Billed Charges,1040.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,915.87,88,,193.264,Percent of Total Billed Charges,88% of Total Billed Charges,936.68,90,,197.656,Percent of Total Billed charges,90% of Total Billed Charges,458.98,1040.76,
VULCOM SAPHYRE,2720000726,CDM,272,RC,,,Outpatient,,,514.87,334.67,,514.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,391.3,76,,166.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,370.71,72,,63.504,Percent of Total Billed Charges,72% of Total Billed Charges,386.15,75,,66.152,Percent of Total Billed charges,75% of Total Billed Charges,514.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.71,72,,63.504,Percent of Total Billed Charges,72% of Total Billed Charges,308.92,60,,52.92,Percent of Total Billed Charges,60% of Total Billed Charges,463.38,90,,24.952,Percent of Total Billed Charges,90% of Total Billed Charges,231.69,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,463.38,90,,197.656,Percent of Total Billed Charges,90% of Total billed Charges,514.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,514.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,514.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.67,65,,51.6,Percent of total Billed Charges,65% of Total Billed Charges,227.06,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,489.13,95,,208.632,Percent of Total Billed Charges,95% of Total Billed Charges,514.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.09,88,,193.264,Percent of Total Billed Charges,88% of Total Billed Charges,463.38,90,,197.656,Percent of Total Billed charges,90% of Total Billed Charges,227.06,514.87,
STRYKER BURR W RIBS,2720000727,CDM,272,RC,,,Outpatient,,,52.92,34.40,,52.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.22,76,,323.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.1,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,39.69,75,,42.336,Percent of Total Billed charges,75% of Total Billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.1,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,31.75,60,,33.872,Percent of Total Billed Charges,60% of Total Billed Charges,47.63,90,,24.952,Percent of Total Billed Charges,90% of Total Billed Charges,23.81,45,,14.688,Percent of Total Billed Charges,45% of Total Billed Charges,47.63,90,,383.408,Percent of Total Billed Charges,90% of Total billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.4,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,23.34,44.1,,14.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.27,95,,404.704,Percent of Total Billed Charges,95% of Total Billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.57,88,,374.888,Percent of Total Billed Charges,88% of Total Billed Charges,47.63,90,,383.408,Percent of Total Billed charges,90% of Total Billed Charges,23.34,52.92,
STRYKER AGGRESS IVE,2720000728,CDM,272,RC,,,Outpatient,,,207.27,134.73,,207.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,157.53,76,,60.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,149.23,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,155.45,75,,42.336,Percent of Total Billed charges,75% of Total Billed Charges,207.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.23,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,124.36,60,,33.872,Percent of Total Billed Charges,60% of Total Billed Charges,186.54,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,93.27,45,,502.08,Percent of Total Billed Charges,45% of Total Billed Charges,186.54,90,,71.448,Percent of Total Billed Charges,90% of Total billed Charges,207.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.73,65,,21.208,Percent of total Billed Charges,65% of Total Billed Charges,91.41,44.1,,492.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,196.91,95,,75.416,Percent of Total Billed Charges,95% of Total Billed Charges,207.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182.4,88,,69.856,Percent of Total Billed Charges,88% of Total Billed Charges,186.54,90,,71.448,Percent of Total Billed charges,90% of Total Billed Charges,91.41,207.27,
COOK 12/14X35 ACCESS SHTH,2720000729,CDM,272,RC,,,Outpatient,,,275.63,179.16,,275.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209.48,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198.45,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,206.72,75,,42.336,Percent of Total Billed charges,75% of Total Billed Charges,275.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.45,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,165.38,60,,33.872,Percent of Total Billed Charges,60% of Total Billed Charges,248.07,90,,1328.296,Percent of Total Billed Charges,90% of Total Billed Charges,124.03,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,248.07,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,275.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.16,65,,725.224,Percent of total Billed Charges,65% of Total Billed Charges,121.55,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.85,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,275.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.55,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,248.07,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,121.55,275.63,
COAXIAL DILATION SHE,2720000730,CDM,272,RC,,,Outpatient,,,209.48,136.16,,209.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,159.2,76,,24.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.83,72,,142.248,Percent of Total Billed Charges,72% of Total Billed Charges,157.11,75,,148.176,Percent of Total Billed charges,75% of Total Billed Charges,209.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.83,72,,142.248,Percent of Total Billed Charges,72% of Total Billed Charges,125.69,60,,118.544,Percent of Total Billed Charges,60% of Total Billed Charges,188.53,90,,1328.296,Percent of Total Billed Charges,90% of Total Billed Charges,94.27,45,,6.352,Percent of Total Billed Charges,45% of Total Billed Charges,188.53,90,,29.368,Percent of Total Billed Charges,90% of Total billed Charges,209.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.16,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,92.38,44.1,,6.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,199.01,95,,31,Percent of Total Billed Charges,95% of Total Billed Charges,209.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.34,88,,28.72,Percent of Total Billed Charges,88% of Total Billed Charges,188.53,90,,29.368,Percent of Total Billed charges,90% of Total Billed Charges,92.38,209.48,
LEEP TUBING,2720000731,CDM,272,RC,,,Outpatient,,,109.15,70.95,,109.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.95,76,,847.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,78.59,72,,31.112,Percent of Total Billed Charges,72% of Total Billed Charges,81.86,75,,32.416,Percent of Total Billed charges,75% of Total Billed Charges,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.59,72,,31.112,Percent of Total Billed Charges,72% of Total Billed Charges,65.49,60,,25.928,Percent of Total Billed Charges,60% of Total Billed Charges,98.24,90,,1328.296,Percent of Total Billed Charges,90% of Total Billed Charges,49.12,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,98.24,90,,1004.152,Percent of Total Billed Charges,90% of Total billed Charges,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.95,65,,9.176,Percent of total Billed Charges,65% of Total Billed Charges,48.14,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,103.69,95,,1059.944,Percent of Total Billed Charges,95% of Total Billed Charges,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.05,88,,981.84,Percent of Total Billed Charges,88% of Total Billed Charges,98.24,90,,1004.152,Percent of Total Billed charges,90% of Total Billed Charges,48.14,109.15,
BERKLEY DISP TOPS,2720000732,CDM,272,RC,,,Outpatient,,,49.61,32.25,,49.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,37.7,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,35.72,72,,48.264,Percent of Total Billed Charges,72% of Total Billed Charges,37.21,75,,50.272,Percent of Total Billed charges,75% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.72,72,,48.264,Percent of Total Billed Charges,72% of Total Billed Charges,29.77,60,,40.216,Percent of Total Billed Charges,60% of Total Billed Charges,44.65,90,,1328.296,Percent of Total Billed Charges,90% of Total Billed Charges,22.32,45,,12.472,Percent of Total Billed Charges,45% of Total Billed Charges,44.65,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.25,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,21.88,44.1,,12.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,47.13,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,44.65,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,21.88,49.61,
ENDORETRACT II,2720000733,CDM,272,RC,,,Outpatient,,,697.88,453.62,,697.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,530.39,76,,10.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,502.47,72,,48.264,Percent of Total Billed Charges,72% of Total Billed Charges,523.41,75,,50.272,Percent of Total Billed charges,75% of Total Billed Charges,697.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.47,72,,48.264,Percent of Total Billed Charges,72% of Total Billed Charges,418.73,60,,40.216,Percent of Total Billed Charges,60% of Total Billed Charges,628.09,90,,18.144,Percent of Total Billed Charges,90% of Total Billed Charges,314.05,45,,12.472,Percent of Total Billed Charges,45% of Total Billed Charges,628.09,90,,12.704,Percent of Total Billed Charges,90% of Total billed Charges,697.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,697.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,697.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.62,65,,18.016,Percent of total Billed Charges,65% of Total Billed Charges,307.77,44.1,,12.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,662.99,95,,13.408,Percent of Total Billed Charges,95% of Total Billed Charges,697.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,614.13,88,,12.416,Percent of Total Billed Charges,88% of Total Billed Charges,628.09,90,,12.704,Percent of Total Billed charges,90% of Total Billed Charges,307.77,697.88,
ENDO UNIVERSAL 65,2720000734,CDM,272,RC,,,Outpatient,,,620.71,403.46,,620.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,471.74,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,446.91,72,,65.408,Percent of Total Billed Charges,72% of Total Billed Charges,465.53,75,,68.136,Percent of Total Billed charges,75% of Total Billed Charges,620.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.91,72,,65.408,Percent of Total Billed Charges,72% of Total Billed Charges,372.43,60,,54.512,Percent of Total Billed Charges,60% of Total Billed Charges,558.64,90,,22.68,Percent of Total Billed Charges,90% of Total Billed Charges,279.32,45,,22.68,Percent of Total Billed Charges,45% of Total Billed Charges,558.64,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,620.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,620.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,620.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,403.46,65,,18.016,Percent of total Billed Charges,65% of Total Billed Charges,273.73,44.1,,22.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,589.67,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,620.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.22,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,558.64,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,273.73,620.71,
MULTIFIRE ENDO HERNI,2720000735,CDM,272,RC,,,Outpatient,,,208.37,135.44,,208.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,158.36,76,,21.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.03,72,,48.264,Percent of Total Billed Charges,72% of Total Billed Charges,156.28,75,,50.272,Percent of Total Billed charges,75% of Total Billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.03,72,,48.264,Percent of Total Billed Charges,72% of Total Billed Charges,125.02,60,,40.216,Percent of Total Billed Charges,60% of Total Billed Charges,187.53,90,,113.4,Percent of Total Billed Charges,90% of Total Billed Charges,93.77,45,,664.144,Percent of Total Billed Charges,45% of Total Billed Charges,187.53,90,,24.952,Percent of Total Billed Charges,90% of Total billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.44,65,,32.76,Percent of total Billed Charges,65% of Total Billed Charges,91.89,44.1,,650.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,197.95,95,,26.336,Percent of Total Billed Charges,95% of Total Billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.37,88,,24.392,Percent of Total Billed Charges,88% of Total Billed Charges,187.53,90,,24.952,Percent of Total Billed charges,90% of Total Billed Charges,91.89,208.37,
RELOAD TR45W 2.5,2720000736,CDM,272,RC,,,Outpatient,,,813.65,528.87,,813.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,618.37,76,,21.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,585.83,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,610.24,75,,21.168,Percent of Total Billed charges,75% of Total Billed Charges,813.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,585.83,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,488.19,60,,16.936,Percent of Total Billed Charges,60% of Total Billed Charges,732.29,90,,1355.512,Percent of Total Billed Charges,90% of Total Billed Charges,366.14,45,,664.144,Percent of Total Billed Charges,45% of Total Billed Charges,732.29,90,,24.952,Percent of Total Billed Charges,90% of Total billed Charges,813.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,813.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,813.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,528.87,65,,959.32,Percent of total Billed Charges,65% of Total Billed Charges,358.82,44.1,,650.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,772.97,95,,26.336,Percent of Total Billed Charges,95% of Total Billed Charges,813.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,716.01,88,,24.392,Percent of Total Billed Charges,88% of Total Billed Charges,732.29,90,,24.952,Percent of Total Billed charges,90% of Total Billed Charges,358.82,813.65,
1 COATED BLADE,2720000737,CDM,272,RC,,,Outpatient,,,62.84,40.85,,62.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.76,76,,38.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.24,72,,48.264,Percent of Total Billed Charges,72% of Total Billed Charges,47.13,75,,50.272,Percent of Total Billed charges,75% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.24,72,,48.264,Percent of Total Billed Charges,72% of Total Billed Charges,37.7,60,,40.216,Percent of Total Billed Charges,60% of Total Billed Charges,56.56,90,,133.816,Percent of Total Billed Charges,90% of Total Billed Charges,28.28,45,,664.144,Percent of Total Billed Charges,45% of Total Billed Charges,56.56,90,,45.36,Percent of Total Billed Charges,90% of Total billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.85,65,,959.32,Percent of total Billed Charges,65% of Total Billed Charges,27.71,44.1,,650.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.7,95,,47.88,Percent of Total Billed Charges,95% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.3,88,,44.352,Percent of Total Billed Charges,88% of Total Billed Charges,56.56,90,,45.36,Percent of Total Billed charges,90% of Total Billed Charges,27.71,62.84,
VITRECTOR II VITREOU,2720000738,CDM,272,RC,,,Outpatient,,,456.44,296.69,,456.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,346.89,76,,1121.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,328.64,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,342.33,75,,13.232,Percent of Total Billed charges,75% of Total Billed Charges,456.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.64,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,273.86,60,,10.584,Percent of Total Billed Charges,60% of Total Billed Charges,410.8,90,,564.736,Percent of Total Billed Charges,90% of Total Billed Charges,205.4,45,,664.144,Percent of Total Billed Charges,45% of Total Billed Charges,410.8,90,,1328.296,Percent of Total Billed Charges,90% of Total billed Charges,456.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.69,65,,959.32,Percent of total Billed Charges,65% of Total Billed Charges,201.29,44.1,,650.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,433.62,95,,1402.088,Percent of Total Billed Charges,95% of Total Billed Charges,456.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.67,88,,1298.776,Percent of Total Billed Charges,88% of Total Billed Charges,410.8,90,,1328.296,Percent of Total Billed charges,90% of Total Billed Charges,201.29,456.44,
SHARPOINT 60 PILOT T,2720000739,CDM,272,RC,,,Outpatient,,,48.51,31.53,,48.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.87,76,,1121.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.93,72,,86.368,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,75,,89.968,Percent of Total Billed charges,75% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,72,,86.368,Percent of Total Billed Charges,72% of Total Billed Charges,29.11,60,,71.968,Percent of Total Billed Charges,60% of Total Billed Charges,43.66,90,,1247.4,Percent of Total Billed Charges,90% of Total Billed Charges,21.83,45,,9.072,Percent of Total Billed Charges,45% of Total Billed Charges,43.66,90,,1328.296,Percent of Total Billed Charges,90% of Total billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.53,65,,959.32,Percent of total Billed Charges,65% of Total Billed Charges,21.39,44.1,,8.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.08,95,,1402.088,Percent of Total Billed Charges,95% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.69,88,,1298.776,Percent of Total Billed Charges,88% of Total Billed Charges,43.66,90,,1328.296,Percent of Total Billed charges,90% of Total Billed Charges,21.39,48.51,
WETFIELD HEMOSTATIC,2720000740,CDM,272,RC,,,Outpatient,,,65.05,42.28,,65.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.44,76,,1121.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.84,72,,100.976,Percent of Total Billed Charges,72% of Total Billed Charges,48.79,75,,105.184,Percent of Total Billed charges,75% of Total Billed Charges,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.84,72,,100.976,Percent of Total Billed Charges,72% of Total Billed Charges,39.03,60,,84.144,Percent of Total Billed Charges,60% of Total Billed Charges,58.55,90,,564.736,Percent of Total Billed Charges,90% of Total Billed Charges,29.27,45,,11.344,Percent of Total Billed Charges,45% of Total Billed Charges,58.55,90,,1328.296,Percent of Total Billed Charges,90% of Total billed Charges,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.28,65,,13.104,Percent of total Billed Charges,65% of Total Billed Charges,28.69,44.1,,11.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,61.8,95,,1402.088,Percent of Total Billed Charges,95% of Total Billed Charges,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.24,88,,1298.776,Percent of Total Billed Charges,88% of Total Billed Charges,58.55,90,,1328.296,Percent of Total Billed charges,90% of Total Billed Charges,28.69,65.05,
WETFIELD CABLE METRO,2720000741,CDM,272,RC,,,Outpatient,,,41.90,27.24,,41.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31.84,76,,1121.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.17,72,,154.32,Percent of Total Billed Charges,72% of Total Billed Charges,31.43,75,,160.744,Percent of Total Billed charges,75% of Total Billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.17,72,,154.32,Percent of Total Billed Charges,72% of Total Billed Charges,25.14,60,,128.6,Percent of Total Billed Charges,60% of Total Billed Charges,37.71,90,,564.736,Percent of Total Billed Charges,90% of Total Billed Charges,18.86,45,,56.704,Percent of Total Billed Charges,45% of Total Billed Charges,37.71,90,,1328.296,Percent of Total Billed Charges,90% of Total billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.24,65,,16.384,Percent of total Billed Charges,65% of Total Billed Charges,18.48,44.1,,55.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,39.81,95,,1402.088,Percent of Total Billed Charges,95% of Total Billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.87,88,,1298.776,Percent of Total Billed Charges,88% of Total Billed Charges,37.71,90,,1328.296,Percent of Total Billed charges,90% of Total Billed Charges,18.48,41.9,
ESSURE KIT,2720000742,CDM,272,RC,,,Outpatient,,,9600.57,6240.37,,9600.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7296.43,76,,15.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6912.41,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,7200.43,75,,9.264,Percent of Total Billed charges,75% of Total Billed Charges,9600.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6912.41,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,5760.34,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,8640.51,90,,440.64,Percent of Total Billed Charges,90% of Total Billed Charges,4320.26,45,,677.752,Percent of Total Billed Charges,45% of Total Billed Charges,8640.51,90,,18.144,Percent of Total Billed Charges,90% of Total billed Charges,9600.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9600.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9600.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6240.37,65,,81.904,Percent of total Billed Charges,65% of Total Billed Charges,4233.85,44.1,,664.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,9120.54,95,,19.152,Percent of Total Billed Charges,95% of Total Billed Charges,9600.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8448.5,88,,17.744,Percent of Total Billed Charges,88% of Total Billed Charges,8640.51,90,,18.144,Percent of Total Billed charges,90% of Total Billed Charges,4233.85,9600.57,
ABSORB O MAT,2720000743,CDM,272,RC,,,Outpatient,,,271.22,176.29,,271.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,206.13,76,,19.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,195.28,72,,56.52,Percent of Total Billed Charges,72% of Total Billed Charges,203.42,75,,58.872,Percent of Total Billed charges,75% of Total Billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.28,72,,56.52,Percent of Total Billed Charges,72% of Total Billed Charges,162.73,60,,47.096,Percent of Total Billed Charges,60% of Total Billed Charges,244.1,90,,126.72,Percent of Total Billed Charges,90% of Total Billed Charges,122.05,45,,66.904,Percent of Total Billed Charges,45% of Total Billed Charges,244.1,90,,22.68,Percent of Total Billed Charges,90% of Total billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.29,65,,978.976,Percent of total Billed Charges,65% of Total Billed Charges,119.61,44.1,,65.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,257.66,95,,23.944,Percent of Total Billed Charges,95% of Total Billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.67,88,,22.176,Percent of Total Billed Charges,88% of Total Billed Charges,244.1,90,,22.68,Percent of Total Billed charges,90% of Total Billed Charges,119.61,271.22,
RAY PAQUE SAFETY TOW,2720000744,CDM,272,RC,,,Outpatient,,,72.77,47.30,,72.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.31,76,,95.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.39,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,54.58,75,,69.456,Percent of Total Billed charges,75% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.39,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,60,,55.568,Percent of Total Billed Charges,60% of Total Billed Charges,65.49,90,,277.2,Percent of Total Billed Charges,90% of Total Billed Charges,32.75,45,,282.368,Percent of Total Billed Charges,45% of Total Billed Charges,65.49,90,,113.4,Percent of Total Billed Charges,90% of Total billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.3,65,,96.64,Percent of total Billed Charges,65% of Total Billed Charges,32.09,44.1,,276.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,69.13,95,,119.704,Percent of Total Billed Charges,95% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.04,88,,110.88,Percent of Total Billed Charges,88% of Total Billed Charges,65.49,90,,113.4,Percent of Total Billed charges,90% of Total Billed Charges,32.09,72.77,
ON QPAIN PUMP,2720000746,CDM,272,RC,,,Outpatient,,,647.17,420.66,,647.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,491.85,76,,1144.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,465.96,72,,63.504,Percent of Total Billed Charges,72% of Total Billed Charges,485.38,75,,66.152,Percent of Total Billed charges,75% of Total Billed Charges,647.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.96,72,,63.504,Percent of Total Billed Charges,72% of Total Billed Charges,388.3,60,,52.92,Percent of Total Billed Charges,60% of Total Billed Charges,582.45,90,,147.6,Percent of Total Billed Charges,90% of Total Billed Charges,291.23,45,,623.704,Percent of Total Billed Charges,45% of Total Billed Charges,582.45,90,,1355.512,Percent of Total Billed Charges,90% of Total billed Charges,647.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,647.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,647.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,420.66,65,,407.864,Percent of total Billed Charges,65% of Total Billed Charges,285.4,44.1,,611.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,614.81,95,,1430.816,Percent of Total Billed Charges,95% of Total Billed Charges,647.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569.51,88,,1325.384,Percent of Total Billed Charges,88% of Total Billed Charges,582.45,90,,1355.512,Percent of Total Billed charges,90% of Total Billed Charges,285.4,647.17,
ON Q PAIN PUMP,2720000747,CDM,272,RC,,,Outpatient,,,197.35,128.28,,197.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.99,76,,113,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,142.09,72,,46.992,Percent of Total Billed Charges,72% of Total Billed Charges,148.01,75,,48.952,Percent of Total Billed charges,75% of Total Billed Charges,197.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.09,72,,46.992,Percent of Total Billed Charges,72% of Total Billed Charges,118.41,60,,39.16,Percent of Total Billed Charges,60% of Total Billed Charges,177.62,90,,111.6,Percent of Total Billed Charges,90% of Total Billed Charges,88.81,45,,282.368,Percent of Total Billed Charges,45% of Total Billed Charges,177.62,90,,133.816,Percent of Total Billed Charges,90% of Total billed Charges,197.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.28,65,,900.904,Percent of total Billed Charges,65% of Total Billed Charges,87.03,44.1,,276.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,187.48,95,,141.248,Percent of Total Billed Charges,95% of Total Billed Charges,197.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.67,88,,130.84,Percent of Total Billed Charges,88% of Total Billed Charges,177.62,90,,133.816,Percent of Total Billed charges,90% of Total Billed Charges,87.03,197.35,
DPY PREP KIT,2720000748,CDM,272,RC,,,Outpatient,,,747.50,485.88,,747.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,568.1,76,,476.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,538.2,72,,69.216,Percent of Total Billed Charges,72% of Total Billed Charges,560.63,75,,72.104,Percent of Total Billed charges,75% of Total Billed Charges,747.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.2,72,,69.216,Percent of Total Billed Charges,72% of Total Billed Charges,448.5,60,,57.68,Percent of Total Billed Charges,60% of Total Billed Charges,672.75,90,,244.08,Percent of Total Billed Charges,90% of Total Billed Charges,336.38,45,,282.368,Percent of Total Billed Charges,45% of Total Billed Charges,672.75,90,,564.736,Percent of Total Billed Charges,90% of Total billed Charges,747.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,747.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,747.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.88,65,,407.864,Percent of total Billed Charges,65% of Total Billed Charges,329.65,44.1,,276.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,710.13,95,,596.104,Percent of Total Billed Charges,95% of Total Billed Charges,747.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,657.8,88,,552.184,Percent of Total Billed Charges,88% of Total Billed Charges,672.75,90,,564.736,Percent of Total Billed charges,90% of Total Billed Charges,329.65,747.5,
TROCAR DILAT TIP 10,2720000749,CDM,272,RC,,,Outpatient,,,216.09,140.46,,216.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,164.23,76,,1053.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,155.58,72,,62.872,Percent of Total Billed Charges,72% of Total Billed Charges,162.07,75,,65.488,Percent of Total Billed charges,75% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.58,72,,62.872,Percent of Total Billed Charges,72% of Total Billed Charges,129.65,60,,52.392,Percent of Total Billed Charges,60% of Total Billed Charges,194.48,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,97.24,45,,220.32,Percent of Total Billed Charges,45% of Total Billed Charges,194.48,90,,1247.4,Percent of Total Billed Charges,90% of Total billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.46,65,,407.864,Percent of total Billed Charges,65% of Total Billed Charges,95.3,44.1,,215.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,205.29,95,,1316.704,Percent of Total Billed Charges,95% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.16,88,,1219.68,Percent of Total Billed Charges,88% of Total Billed Charges,194.48,90,,1247.4,Percent of Total Billed charges,90% of Total Billed Charges,95.3,216.09,
STABIL EYES TENSION,2720000750,CDM,272,RC,,,Outpatient,,,393.59,255.83,,393.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.13,76,,476.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,283.38,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,295.19,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.38,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,236.15,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,354.23,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,177.12,45,,63.36,Percent of Total Billed Charges,45% of Total Billed Charges,354.23,90,,564.736,Percent of Total Billed Charges,90% of Total billed Charges,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.83,65,,318.24,Percent of total Billed Charges,65% of Total Billed Charges,173.57,44.1,,62.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,373.91,95,,596.104,Percent of Total Billed Charges,95% of Total Billed Charges,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.36,88,,552.184,Percent of Total Billed Charges,88% of Total Billed Charges,354.23,90,,564.736,Percent of Total Billed charges,90% of Total Billed Charges,173.57,393.59,
HOTLINE FLUID WARMING SET,2720000751,CDM,272,RC,,,Outpatient,,,120.17,78.11,,120.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,91.33,76,,476.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,86.52,72,,76.208,Percent of Total Billed Charges,72% of Total Billed Charges,90.13,75,,79.384,Percent of Total Billed charges,75% of Total Billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.52,72,,76.208,Percent of Total Billed Charges,72% of Total Billed Charges,72.1,60,,63.504,Percent of Total Billed Charges,60% of Total Billed Charges,108.15,90,,111.6,Percent of Total Billed Charges,90% of Total Billed Charges,54.08,45,,138.6,Percent of Total Billed Charges,45% of Total Billed Charges,108.15,90,,564.736,Percent of Total Billed Charges,90% of Total billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.11,65,,91.52,Percent of total Billed Charges,65% of Total Billed Charges,52.99,44.1,,135.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,114.16,95,,596.104,Percent of Total Billed Charges,95% of Total Billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.75,88,,552.184,Percent of Total Billed Charges,88% of Total Billed Charges,108.15,90,,564.736,Percent of Total Billed charges,90% of Total Billed Charges,52.99,120.17,
TISSUE LINK BIPOLAR,2720000752,CDM,272,RC,,,Outpatient,,,800.42,520.27,,800.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608.32,76,,372.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576.3,72,,274.336,Percent of Total Billed Charges,72% of Total Billed Charges,600.32,75,,285.768,Percent of Total Billed charges,75% of Total Billed Charges,800.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.3,72,,274.336,Percent of Total Billed Charges,72% of Total Billed Charges,480.25,60,,228.616,Percent of Total Billed Charges,60% of Total Billed Charges,720.38,90,,145.44,Percent of Total Billed Charges,90% of Total Billed Charges,360.19,45,,73.8,Percent of Total Billed Charges,45% of Total Billed Charges,720.38,90,,440.64,Percent of Total Billed Charges,90% of Total billed Charges,800.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520.27,65,,200.2,Percent of total Billed Charges,65% of Total Billed Charges,352.99,44.1,,72.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,760.4,95,,465.12,Percent of Total Billed Charges,95% of Total Billed Charges,800.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704.37,88,,430.848,Percent of Total Billed Charges,88% of Total Billed Charges,720.38,90,,440.64,Percent of Total Billed charges,90% of Total Billed Charges,352.99,800.42,
OPTI GARD EYE ADULT,2720000753,CDM,272,RC,,,Outpatient,,,48.51,31.53,,48.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.87,76,,107.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.93,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,29.11,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,43.66,90,,39.6,Percent of Total Billed Charges,90% of Total Billed Charges,21.83,45,,55.8,Percent of Total Billed Charges,45% of Total Billed Charges,43.66,90,,126.72,Percent of Total Billed Charges,90% of Total billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.53,65,,106.6,Percent of total Billed Charges,65% of Total Billed Charges,21.39,44.1,,54.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.08,95,,133.76,Percent of Total Billed Charges,95% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.69,88,,123.904,Percent of Total Billed Charges,88% of Total Billed Charges,43.66,90,,126.72,Percent of Total Billed charges,90% of Total Billed Charges,21.39,48.51,
OPTI GARD EYE CHILD,2720000754,CDM,272,RC,,,Outpatient,,,52.92,34.40,,52.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.22,76,,234.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.1,72,,57.792,Percent of Total Billed Charges,72% of Total Billed Charges,39.69,75,,60.2,Percent of Total Billed charges,75% of Total Billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.1,72,,57.792,Percent of Total Billed Charges,72% of Total Billed Charges,31.75,60,,48.16,Percent of Total Billed Charges,60% of Total Billed Charges,47.63,90,,19.904,Percent of Total Billed Charges,90% of Total Billed Charges,23.81,45,,122.04,Percent of Total Billed Charges,45% of Total Billed Charges,47.63,90,,277.2,Percent of Total Billed Charges,90% of Total billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.4,65,,80.6,Percent of total Billed Charges,65% of Total Billed Charges,23.34,44.1,,119.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.27,95,,292.6,Percent of Total Billed Charges,95% of Total Billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.57,88,,271.04,Percent of Total Billed Charges,88% of Total Billed Charges,47.63,90,,277.2,Percent of Total Billed charges,90% of Total Billed Charges,23.34,52.92,
UTERINE MANIPULATOR,2720000755,CDM,272,RC,,,Outpatient,,,51.82,33.68,,51.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,39.38,76,,124.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,37.31,72,,2.224,Percent of Total Billed Charges,72% of Total Billed Charges,38.87,75,,2.32,Percent of Total Billed charges,75% of Total Billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.31,72,,2.224,Percent of Total Billed Charges,72% of Total Billed Charges,31.09,60,,1.856,Percent of Total Billed Charges,60% of Total Billed Charges,46.64,90,,278.64,Percent of Total Billed Charges,90% of Total Billed Charges,23.32,45,,8.28,Percent of Total Billed Charges,45% of Total Billed Charges,46.64,90,,147.6,Percent of Total Billed Charges,90% of Total billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.68,65,,176.28,Percent of total Billed Charges,65% of Total Billed Charges,22.85,44.1,,8.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,49.23,95,,155.8,Percent of Total Billed Charges,95% of Total Billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.6,88,,144.32,Percent of Total Billed Charges,88% of Total Billed Charges,46.64,90,,147.6,Percent of Total Billed charges,90% of Total Billed Charges,22.85,51.82,
CENTER DRAIN BAG 400,2720000756,CDM,272,RC,,,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,94.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,7.256,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,7.56,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,7.256,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,6.048,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,152.64,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,21.96,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,111.6,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,11.96,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,21.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,117.8,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,109.12,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,111.6,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
DRILL BITS,2720000757,CDM,272,RC,,,Outpatient,,,1079.51,701.68,,1079.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,820.43,76,,206.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,777.25,72,,4.4,Percent of Total Billed Charges,72% of Total Billed Charges,809.63,75,,4.584,Percent of Total Billed charges,75% of Total Billed Charges,1079.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,777.25,72,,4.4,Percent of Total Billed Charges,72% of Total Billed Charges,647.71,60,,3.664,Percent of Total Billed Charges,60% of Total Billed Charges,971.56,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,485.78,45,,55.8,Percent of Total Billed Charges,45% of Total Billed Charges,971.56,90,,244.08,Percent of Total Billed Charges,90% of Total billed Charges,1079.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1079.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1079.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,701.68,65,,31.72,Percent of total Billed Charges,65% of Total Billed Charges,476.06,44.1,,54.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,1025.53,95,,257.64,Percent of Total Billed Charges,95% of Total Billed Charges,1079.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,949.97,88,,238.656,Percent of Total Billed Charges,88% of Total Billed Charges,971.56,90,,244.08,Percent of Total Billed charges,90% of Total Billed Charges,476.06,1079.51,
SAGITAL SAW BLADE,2720000758,CDM,272,RC,,,Outpatient,,,705.60,458.64,,705.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,536.26,76,,13.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,508.03,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,529.2,75,,29.104,Percent of Total Billed charges,75% of Total Billed Charges,705.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.03,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,423.36,60,,23.288,Percent of Total Billed Charges,60% of Total Billed Charges,635.04,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,317.52,45,,72.72,Percent of Total Billed Charges,45% of Total Billed Charges,635.04,90,,16.56,Percent of Total Billed Charges,90% of Total billed Charges,705.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,705.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,705.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,458.64,65,,80.6,Percent of total Billed Charges,65% of Total Billed Charges,311.17,44.1,,71.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,670.32,95,,17.48,Percent of Total Billed Charges,95% of Total Billed Charges,705.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,620.93,88,,16.192,Percent of Total Billed Charges,88% of Total Billed Charges,635.04,90,,16.56,Percent of Total Billed charges,90% of Total Billed Charges,311.17,705.6,
RECIPROCATING SAW BL,2720000759,CDM,272,RC,,,Outpatient,,,1070.53,695.84,,1070.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,813.6,76,,37.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,770.78,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,802.9,75,,29.104,Percent of Total Billed charges,75% of Total Billed Charges,1070.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770.78,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,642.32,60,,23.288,Percent of Total Billed Charges,60% of Total Billed Charges,963.48,90,,38.88,Percent of Total Billed Charges,90% of Total Billed Charges,481.74,45,,19.8,Percent of Total Billed Charges,45% of Total Billed Charges,963.48,90,,43.92,Percent of Total Billed Charges,90% of Total billed Charges,1070.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1070.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1070.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.84,65,,105.04,Percent of total Billed Charges,65% of Total Billed Charges,472.1,44.1,,19.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,1017,95,,46.36,Percent of Total Billed Charges,95% of Total Billed Charges,1070.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,942.07,88,,42.944,Percent of Total Billed Charges,88% of Total Billed Charges,963.48,90,,43.92,Percent of Total Billed charges,90% of Total Billed Charges,472.1,1070.53,
BIOACCESS DRILL,2720000760,CDM,272,RC,,,Outpatient,,,490.61,318.90,,490.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.86,76,,94.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,353.24,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,367.96,75,,29.104,Percent of Total Billed charges,75% of Total Billed Charges,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.24,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,294.37,60,,23.288,Percent of Total Billed Charges,60% of Total Billed Charges,441.55,90,,424.08,Percent of Total Billed Charges,90% of Total Billed Charges,220.77,45,,9.952,Percent of Total Billed Charges,45% of Total Billed Charges,441.55,90,,111.6,Percent of Total Billed Charges,90% of Total billed Charges,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.9,65,,28.6,Percent of total Billed Charges,65% of Total Billed Charges,216.36,44.1,,9.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,466.08,95,,117.8,Percent of Total Billed Charges,95% of Total Billed Charges,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,431.74,88,,109.12,Percent of Total Billed Charges,88% of Total Billed Charges,441.55,90,,111.6,Percent of Total Billed charges,90% of Total Billed Charges,216.36,490.61,
BIOACESS WIRE COLLEC,2720000761,CDM,272,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,122.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,5.952,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,4.76,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,47.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,139.32,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,145.44,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,14.376,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,136.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,153.52,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,142.208,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,145.44,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
SMITH&NEPHEW KNOT PU,2720000762,CDM,272,RC,,,Outpatient,,,167.58,108.93,,167.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,127.36,76,,33.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,120.66,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,125.69,75,,43.664,Percent of Total Billed charges,75% of Total Billed Charges,167.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.66,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,100.55,60,,34.928,Percent of Total Billed Charges,60% of Total Billed Charges,150.82,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,75.41,45,,76.32,Percent of Total Billed Charges,45% of Total Billed Charges,150.82,90,,39.6,Percent of Total Billed Charges,90% of Total billed Charges,167.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.93,65,,201.24,Percent of total Billed Charges,65% of Total Billed Charges,73.9,44.1,,74.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,159.2,95,,41.8,Percent of Total Billed Charges,95% of Total Billed Charges,167.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.47,88,,38.72,Percent of Total Billed Charges,88% of Total Billed Charges,150.82,90,,39.6,Percent of Total Billed charges,90% of Total Billed Charges,73.9,167.58,
SMITH&NEPHEW CURVED,2720000763,CDM,272,RC,,,Outpatient,,,450.92,293.10,,450.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,342.7,76,,16.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,324.66,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,338.19,75,,9.928,Percent of Total Billed charges,75% of Total Billed Charges,450.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.66,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,270.55,60,,7.936,Percent of Total Billed Charges,60% of Total Billed Charges,405.83,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,202.91,45,,1.8,Percent of Total Billed Charges,45% of Total Billed Charges,405.83,90,,19.904,Percent of Total Billed Charges,90% of Total billed Charges,450.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.1,65,,110.24,Percent of total Billed Charges,65% of Total Billed Charges,198.86,44.1,,1.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,428.37,95,,21.008,Percent of Total Billed Charges,95% of Total Billed Charges,450.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.81,88,,19.456,Percent of Total Billed Charges,88% of Total Billed Charges,405.83,90,,19.904,Percent of Total Billed charges,90% of Total Billed Charges,198.86,450.92,
SMITH&NEPHEW STRAIGH,2720000764,CDM,272,RC,,,Outpatient,,,450.92,293.10,,450.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,342.7,76,,235.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,324.66,72,,92.08,Percent of Total Billed Charges,72% of Total Billed Charges,338.19,75,,95.92,Percent of Total Billed charges,75% of Total Billed Charges,450.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.66,72,,92.08,Percent of Total Billed Charges,72% of Total Billed Charges,270.55,60,,76.736,Percent of Total Billed Charges,60% of Total Billed Charges,405.83,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,202.91,45,,1.44,Percent of Total Billed Charges,45% of Total Billed Charges,405.83,90,,278.64,Percent of Total Billed Charges,90% of Total billed Charges,450.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.1,65,,2.6,Percent of total Billed Charges,65% of Total Billed Charges,198.86,44.1,,1.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,428.37,95,,294.12,Percent of Total Billed Charges,95% of Total Billed Charges,450.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.81,88,,272.448,Percent of Total Billed Charges,88% of Total Billed Charges,405.83,90,,278.64,Percent of Total Billed charges,90% of Total Billed Charges,198.86,450.92,
ENDOBUTTON 20MM,2720000765,CDM,272,RC,,,Outpatient,,,1697.85,1103.60,,1697.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1290.37,76,,128.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1222.45,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,1273.39,75,,28.448,Percent of Total Billed charges,75% of Total Billed Charges,1697.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1222.45,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,1018.71,60,,22.76,Percent of Total Billed Charges,60% of Total Billed Charges,1528.07,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,764.03,45,,19.44,Percent of Total Billed Charges,45% of Total Billed Charges,1528.07,90,,152.64,Percent of Total Billed Charges,90% of Total billed Charges,1697.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1697.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1697.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1103.6,65,,2.08,Percent of total Billed Charges,65% of Total Billed Charges,748.75,44.1,,19.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1612.96,95,,161.12,Percent of Total Billed Charges,95% of Total Billed Charges,1697.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1494.11,88,,149.248,Percent of Total Billed Charges,88% of Total Billed Charges,1528.07,90,,152.64,Percent of Total Billed charges,90% of Total Billed Charges,748.75,1697.85,
DYONICS 4.5 INCISOR,2720000766,CDM,272,RC,,,Outpatient,,,649.37,422.09,,649.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,493.52,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,467.55,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,487.03,75,,51.6,Percent of Total Billed charges,75% of Total Billed Charges,649.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,467.55,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,389.62,60,,41.28,Percent of Total Billed Charges,60% of Total Billed Charges,584.43,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,292.22,45,,212.04,Percent of Total Billed Charges,45% of Total Billed Charges,584.43,90,,3.6,Percent of Total Billed Charges,90% of Total billed Charges,649.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.09,65,,28.08,Percent of total Billed Charges,65% of Total Billed Charges,286.37,44.1,,207.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,616.9,95,,3.8,Percent of Total Billed Charges,95% of Total Billed Charges,649.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,571.45,88,,3.52,Percent of Total Billed Charges,88% of Total Billed Charges,584.43,90,,3.6,Percent of Total Billed charges,90% of Total Billed Charges,286.37,649.37,
DYONICS 3.5 FULL RAD,2720000767,CDM,272,RC,,,Outpatient,,,401.31,260.85,,401.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,305,76,,2.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,288.94,72,,74.296,Percent of Total Billed Charges,72% of Total Billed Charges,300.98,75,,77.392,Percent of Total Billed charges,75% of Total Billed Charges,401.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.94,72,,74.296,Percent of Total Billed Charges,72% of Total Billed Charges,240.79,60,,61.912,Percent of Total Billed Charges,60% of Total Billed Charges,361.18,90,,141.12,Percent of Total Billed Charges,90% of Total Billed Charges,180.59,45,,23.76,Percent of Total Billed Charges,45% of Total Billed Charges,361.18,90,,2.88,Percent of Total Billed Charges,90% of Total billed Charges,401.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.85,65,,306.28,Percent of total Billed Charges,65% of Total Billed Charges,176.98,44.1,,23.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,381.24,95,,3.04,Percent of Total Billed Charges,95% of Total Billed Charges,401.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.15,88,,2.816,Percent of Total Billed Charges,88% of Total Billed Charges,361.18,90,,2.88,Percent of Total Billed charges,90% of Total Billed Charges,176.98,401.31,
DYONICS 4.5 CU FULL,2720000768,CDM,272,RC,,,Outpatient,,,399.11,259.42,,399.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,303.32,76,,32.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,287.36,72,,56.52,Percent of Total Billed Charges,72% of Total Billed Charges,299.33,75,,58.872,Percent of Total Billed charges,75% of Total Billed Charges,399.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,287.36,72,,56.52,Percent of Total Billed Charges,72% of Total Billed Charges,239.47,60,,47.096,Percent of Total Billed Charges,60% of Total Billed Charges,359.2,90,,112.32,Percent of Total Billed Charges,90% of Total Billed Charges,179.6,45,,1.44,Percent of Total Billed Charges,45% of Total Billed Charges,359.2,90,,38.88,Percent of Total Billed Charges,90% of Total billed Charges,399.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.42,65,,34.32,Percent of total Billed Charges,65% of Total Billed Charges,176.01,44.1,,1.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,379.15,95,,41.04,Percent of Total Billed Charges,95% of Total Billed Charges,399.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,351.22,88,,38.016,Percent of Total Billed Charges,88% of Total Billed Charges,359.2,90,,38.88,Percent of Total Billed charges,90% of Total Billed Charges,176.01,399.11,
DYONICS 4.5 TURBOWHI,2720000769,CDM,272,RC,,,Outpatient,,,190.73,123.97,,190.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.95,76,,358.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,137.33,72,,33.024,Percent of Total Billed Charges,72% of Total Billed Charges,143.05,75,,34.4,Percent of Total Billed charges,75% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.33,72,,33.024,Percent of Total Billed Charges,72% of Total Billed Charges,114.44,60,,27.52,Percent of Total Billed Charges,60% of Total Billed Charges,171.66,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,85.83,45,,8.28,Percent of Total Billed Charges,45% of Total Billed Charges,171.66,90,,424.08,Percent of Total Billed Charges,90% of Total billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.97,65,,2.08,Percent of total Billed Charges,65% of Total Billed Charges,84.11,44.1,,8.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,181.19,95,,447.64,Percent of Total Billed Charges,95% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.84,88,,414.656,Percent of Total Billed Charges,88% of Total Billed Charges,171.66,90,,424.08,Percent of Total Billed charges,90% of Total Billed Charges,84.11,190.73,
DYONICS 5.5 INCISOR,2720000770,CDM,272,RC,,,Outpatient,,,214.99,139.74,,214.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,163.39,76,,40.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,154.79,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,161.24,75,,51.6,Percent of Total Billed charges,75% of Total Billed Charges,214.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.79,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,128.99,60,,41.28,Percent of Total Billed Charges,60% of Total Billed Charges,193.49,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,96.75,45,,12.96,Percent of Total Billed Charges,45% of Total Billed Charges,193.49,90,,47.52,Percent of Total Billed Charges,90% of Total billed Charges,214.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.74,65,,11.96,Percent of total Billed Charges,65% of Total Billed Charges,94.81,44.1,,12.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,204.24,95,,50.16,Percent of Total Billed Charges,95% of Total Billed Charges,214.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.19,88,,46.464,Percent of Total Billed Charges,88% of Total Billed Charges,193.49,90,,47.52,Percent of Total Billed charges,90% of Total Billed Charges,94.81,214.99,
DYONICS 4.O ACROMIOB,2720000771,CDM,272,RC,,,Outpatient,,,401.31,260.85,,401.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,305,76,,2.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,288.94,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,300.98,75,,43.664,Percent of Total Billed charges,75% of Total Billed Charges,401.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.94,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,240.79,60,,34.928,Percent of Total Billed Charges,60% of Total Billed Charges,361.18,90,,46.8,Percent of Total Billed Charges,90% of Total Billed Charges,180.59,45,,1.8,Percent of Total Billed Charges,45% of Total Billed Charges,361.18,90,,2.88,Percent of Total Billed Charges,90% of Total billed Charges,401.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.85,65,,18.72,Percent of total Billed Charges,65% of Total Billed Charges,176.98,44.1,,1.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,381.24,95,,3.04,Percent of Total Billed Charges,95% of Total Billed Charges,401.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.15,88,,2.816,Percent of Total Billed Charges,88% of Total Billed Charges,361.18,90,,2.88,Percent of Total Billed charges,90% of Total Billed Charges,176.98,401.31,
DYONICS 4.0 ACROMION,2720000772,CDM,272,RC,,,Outpatient,,,187.43,121.83,,187.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,142.45,76,,13.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,134.95,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,140.57,75,,42.336,Percent of Total Billed charges,75% of Total Billed Charges,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.95,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,112.46,60,,33.872,Percent of Total Billed Charges,60% of Total Billed Charges,168.69,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,84.34,45,,3.96,Percent of Total Billed Charges,45% of Total Billed Charges,168.69,90,,16.56,Percent of Total Billed Charges,90% of Total billed Charges,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.83,65,,2.6,Percent of total Billed Charges,65% of Total Billed Charges,82.66,44.1,,3.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,178.06,95,,17.48,Percent of Total Billed Charges,95% of Total Billed Charges,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.94,88,,16.192,Percent of Total Billed Charges,88% of Total Billed Charges,168.69,90,,16.56,Percent of Total Billed charges,90% of Total Billed Charges,82.66,187.43,
5.0 CANN DRILL,2720000773,CDM,272,RC,,,Outpatient,,,393.59,255.83,,393.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.13,76,,21.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,283.38,72,,94.616,Percent of Total Billed Charges,72% of Total Billed Charges,295.19,75,,98.56,Percent of Total Billed charges,75% of Total Billed Charges,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.38,72,,94.616,Percent of Total Billed Charges,72% of Total Billed Charges,236.15,60,,78.848,Percent of Total Billed Charges,60% of Total Billed Charges,354.23,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,177.12,45,,70.56,Percent of Total Billed Charges,45% of Total Billed Charges,354.23,90,,25.92,Percent of Total Billed Charges,90% of Total billed Charges,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.83,65,,5.72,Percent of total Billed Charges,65% of Total Billed Charges,173.57,44.1,,69.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,373.91,95,,27.36,Percent of Total Billed Charges,95% of Total Billed Charges,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.36,88,,25.344,Percent of Total Billed Charges,88% of Total Billed Charges,354.23,90,,25.92,Percent of Total Billed charges,90% of Total Billed Charges,173.57,393.59,
4.5/5.0 EASY OUT,2720000780,CDM,272,RC,,,Outpatient,,,417.85,271.60,,417.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,317.57,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,300.85,72,,98.432,Percent of Total Billed Charges,72% of Total Billed Charges,313.39,75,,102.536,Percent of Total Billed charges,75% of Total Billed Charges,417.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.85,72,,98.432,Percent of Total Billed Charges,72% of Total Billed Charges,250.71,60,,82.024,Percent of Total Billed Charges,60% of Total Billed Charges,376.07,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,188.03,45,,56.16,Percent of Total Billed Charges,45% of Total Billed Charges,376.07,90,,3.6,Percent of Total Billed Charges,90% of Total billed Charges,417.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.6,65,,101.92,Percent of total Billed Charges,65% of Total Billed Charges,184.27,44.1,,55.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,396.96,95,,3.8,Percent of Total Billed Charges,95% of Total Billed Charges,417.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,367.71,88,,3.52,Percent of Total Billed Charges,88% of Total Billed Charges,376.07,90,,3.6,Percent of Total Billed charges,90% of Total Billed Charges,184.27,417.85,
3.8 CANN DRILL BIT,2720000781,CDM,272,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,6.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,24.472,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,19.576,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,12.96,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,7.92,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,81.12,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,12.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,8.36,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,7.744,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,7.92,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
4.5 CANN DRILL BIT,2720000782,CDM,272,RC,,,Outpatient,,,481.79,313.16,,481.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,366.16,76,,119.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,346.89,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,361.34,75,,29.104,Percent of Total Billed charges,75% of Total Billed Charges,481.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.89,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,289.07,60,,23.288,Percent of Total Billed Charges,60% of Total Billed Charges,433.61,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,216.81,45,,8.28,Percent of Total Billed Charges,45% of Total Billed Charges,433.61,90,,141.12,Percent of Total Billed Charges,90% of Total billed Charges,481.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,481.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,481.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.16,65,,18.72,Percent of total Billed Charges,65% of Total Billed Charges,212.47,44.1,,8.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,457.7,95,,148.96,Percent of Total Billed Charges,95% of Total Billed Charges,481.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,423.98,88,,137.984,Percent of Total Billed Charges,88% of Total Billed Charges,433.61,90,,141.12,Percent of Total Billed charges,90% of Total Billed Charges,212.47,481.79,
2.0X9 GUIDE PIN,2720000783,CDM,272,RC,,,Outpatient,,,158.76,103.19,,158.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.66,76,,94.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.31,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,119.07,75,,19.848,Percent of Total Billed charges,75% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.31,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,95.26,60,,15.88,Percent of Total Billed Charges,60% of Total Billed Charges,142.88,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,71.44,45,,23.4,Percent of Total Billed Charges,45% of Total Billed Charges,142.88,90,,112.32,Percent of Total Billed Charges,90% of Total billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.19,65,,11.96,Percent of total Billed Charges,65% of Total Billed Charges,70.01,44.1,,22.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,150.82,95,,118.56,Percent of Total Billed Charges,95% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.71,88,,109.824,Percent of Total Billed Charges,88% of Total Billed Charges,142.88,90,,112.32,Percent of Total Billed charges,90% of Total Billed Charges,70.01,158.76,
TRACH TUBE 7.0-10.0,2720000784,CDM,272,RC,,,Outpatient,,,142.22,92.44,,142.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,108.09,76,,21.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,102.4,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,106.67,75,,24.472,Percent of Total Billed charges,75% of Total Billed Charges,142.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.4,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,85.33,60,,19.576,Percent of Total Billed Charges,60% of Total Billed Charges,128,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,64,45,,20.16,Percent of Total Billed Charges,45% of Total Billed Charges,128,90,,25.92,Percent of Total Billed Charges,90% of Total billed Charges,142.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.44,65,,33.8,Percent of total Billed Charges,65% of Total Billed Charges,62.72,44.1,,19.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,135.11,95,,27.36,Percent of Total Billed Charges,95% of Total Billed Charges,142.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.15,88,,25.344,Percent of Total Billed Charges,88% of Total Billed Charges,128,90,,25.92,Percent of Total Billed charges,90% of Total Billed Charges,62.72,142.22,
TWINFIX SUTURE ANCHO,2720000785,CDM,272,RC,,,Outpatient,,,565.58,367.63,,565.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,429.84,76,,13.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,407.22,72,,36.832,Percent of Total Billed Charges,72% of Total Billed Charges,424.19,75,,38.368,Percent of Total Billed charges,75% of Total Billed Charges,565.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.22,72,,36.832,Percent of Total Billed Charges,72% of Total Billed Charges,339.35,60,,30.696,Percent of Total Billed Charges,60% of Total Billed Charges,509.02,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,254.51,45,,0.72,Percent of Total Billed Charges,45% of Total Billed Charges,509.02,90,,16.56,Percent of Total Billed Charges,90% of Total billed Charges,565.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,565.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,565.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,367.63,65,,29.12,Percent of total Billed Charges,65% of Total Billed Charges,249.42,44.1,,0.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,537.3,95,,17.48,Percent of Total Billed Charges,95% of Total Billed Charges,565.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497.71,88,,16.192,Percent of Total Billed Charges,88% of Total Billed Charges,509.02,90,,16.56,Percent of Total Billed charges,90% of Total Billed Charges,249.42,565.58,
COFLEX 2,2720000786,CDM,272,RC,,,Outpatient,,,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,39.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,36.832,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,38.368,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,36.832,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,30.696,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,294.48,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,1.08,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,46.8,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,1.04,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,1.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,49.4,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,45.76,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,46.8,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
BONANND,2720000787,CDM,272,RC,,,Outpatient,,,202.86,131.86,,202.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,154.17,76,,34.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,146.06,72,,100.976,Percent of Total Billed Charges,72% of Total Billed Charges,152.15,75,,105.184,Percent of Total Billed charges,75% of Total Billed Charges,202.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.06,72,,100.976,Percent of Total Billed Charges,72% of Total Billed Charges,121.72,60,,84.144,Percent of Total Billed Charges,60% of Total Billed Charges,182.57,90,,112.32,Percent of Total Billed Charges,90% of Total Billed Charges,91.29,45,,16.92,Percent of Total Billed Charges,45% of Total Billed Charges,182.57,90,,40.32,Percent of Total Billed Charges,90% of Total billed Charges,202.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.86,65,,1.56,Percent of total Billed Charges,65% of Total Billed Charges,89.46,44.1,,16.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,192.72,95,,42.56,Percent of Total Billed Charges,95% of Total Billed Charges,202.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.52,88,,39.424,Percent of Total Billed Charges,88% of Total Billed Charges,182.57,90,,40.32,Percent of Total Billed charges,90% of Total Billed Charges,89.46,202.86,
HUMI,2720000788,CDM,272,RC,,,Outpatient,,,165.38,107.50,,165.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,125.69,76,,1.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,119.07,72,,97.16,Percent of Total Billed Charges,72% of Total Billed Charges,124.04,75,,101.208,Percent of Total Billed charges,75% of Total Billed Charges,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.07,72,,97.16,Percent of Total Billed Charges,72% of Total Billed Charges,99.23,60,,80.968,Percent of Total Billed Charges,60% of Total Billed Charges,148.84,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,74.42,45,,4.68,Percent of Total Billed Charges,45% of Total Billed Charges,148.84,90,,1.44,Percent of Total Billed Charges,90% of Total billed Charges,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,65,,24.44,Percent of total Billed Charges,65% of Total Billed Charges,72.93,44.1,,4.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,157.11,95,,1.52,Percent of Total Billed Charges,95% of Total Billed Charges,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,88,,1.408,Percent of Total Billed Charges,88% of Total Billed Charges,148.84,90,,1.44,Percent of Total Billed charges,90% of Total Billed Charges,72.93,165.38,
VULCAN SCULPTOR S 60,2720000790,CDM,272,RC,,,Outpatient,,,730.96,475.12,,730.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,555.53,76,,1.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,526.29,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,548.22,75,,13.232,Percent of Total Billed charges,75% of Total Billed Charges,730.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,526.29,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,438.58,60,,10.584,Percent of Total Billed Charges,60% of Total Billed Charges,657.86,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,328.93,45,,6.48,Percent of Total Billed Charges,45% of Total Billed Charges,657.86,90,,2.16,Percent of Total Billed Charges,90% of Total billed Charges,730.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,730.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,730.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475.12,65,,6.76,Percent of total Billed Charges,65% of Total Billed Charges,322.35,44.1,,6.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,694.41,95,,2.28,Percent of Total Billed Charges,95% of Total Billed Charges,730.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,643.24,88,,2.112,Percent of Total Billed Charges,88% of Total Billed Charges,657.86,90,,2.16,Percent of Total Billed charges,90% of Total Billed Charges,322.35,730.96,
VULCAN LIGAMENT CHIS,2720000791,CDM,272,RC,,,Outpatient,,,1018.71,662.16,,1018.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,774.22,76,,28.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,733.47,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,764.03,75,,13.232,Percent of Total Billed charges,75% of Total Billed Charges,1018.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,733.47,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,611.23,60,,10.584,Percent of Total Billed Charges,60% of Total Billed Charges,916.84,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,458.42,45,,0.72,Percent of Total Billed Charges,45% of Total Billed Charges,916.84,90,,33.84,Percent of Total Billed Charges,90% of Total billed Charges,1018.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1018.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1018.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,662.16,65,,9.36,Percent of total Billed Charges,65% of Total Billed Charges,449.25,44.1,,0.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,967.77,95,,35.72,Percent of Total Billed Charges,95% of Total Billed Charges,1018.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,896.46,88,,33.088,Percent of Total Billed Charges,88% of Total Billed Charges,916.84,90,,33.84,Percent of Total Billed charges,90% of Total Billed Charges,449.25,1018.71,
VULCAN SCULPTOR S 90,2720000792,CDM,272,RC,,,Outpatient,,,271.22,176.29,,271.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,206.13,76,,7.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,195.28,72,,56.52,Percent of Total Billed Charges,72% of Total Billed Charges,203.42,75,,58.872,Percent of Total Billed charges,75% of Total Billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.28,72,,56.52,Percent of Total Billed Charges,72% of Total Billed Charges,162.73,60,,47.096,Percent of Total Billed Charges,60% of Total Billed Charges,244.1,90,,1.648,Percent of Total Billed Charges,90% of Total Billed Charges,122.05,45,,14.4,Percent of Total Billed Charges,45% of Total Billed Charges,244.1,90,,9.36,Percent of Total Billed Charges,90% of Total billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.29,65,,1.04,Percent of total Billed Charges,65% of Total Billed Charges,119.61,44.1,,14.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,257.66,95,,9.88,Percent of Total Billed Charges,95% of Total Billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.67,88,,9.152,Percent of Total Billed Charges,88% of Total Billed Charges,244.1,90,,9.36,Percent of Total Billed charges,90% of Total Billed Charges,119.61,271.22,
TRT55 RELOAD 55MM,2720000793,CDM,272,RC,,,Outpatient,,,208.37,135.44,,208.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,158.36,76,,10.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.03,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,156.28,75,,13.232,Percent of Total Billed charges,75% of Total Billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.03,72,,12.704,Percent of Total Billed Charges,72% of Total Billed Charges,125.02,60,,10.584,Percent of Total Billed Charges,60% of Total Billed Charges,187.53,90,,51.84,Percent of Total Billed Charges,90% of Total Billed Charges,93.77,45,,147.24,Percent of Total Billed Charges,45% of Total Billed Charges,187.53,90,,12.96,Percent of Total Billed Charges,90% of Total billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.44,65,,20.8,Percent of total Billed Charges,65% of Total Billed Charges,91.89,44.1,,144.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,197.95,95,,13.68,Percent of Total Billed Charges,95% of Total Billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.37,88,,12.672,Percent of Total Billed Charges,88% of Total Billed Charges,187.53,90,,12.96,Percent of Total Billed charges,90% of Total Billed Charges,91.89,208.37,
XR30B RELOAD 30MM,2720000794,CDM,272,RC,,,Outpatient,,,174.20,113.23,,174.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,132.39,76,,1.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,125.42,72,,97.16,Percent of Total Billed Charges,72% of Total Billed Charges,130.65,75,,101.208,Percent of Total Billed charges,75% of Total Billed Charges,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.42,72,,97.16,Percent of Total Billed Charges,72% of Total Billed Charges,104.52,60,,80.968,Percent of Total Billed Charges,60% of Total Billed Charges,156.78,90,,97.2,Percent of Total Billed Charges,90% of Total Billed Charges,78.39,45,,56.16,Percent of Total Billed Charges,45% of Total Billed Charges,156.78,90,,1.44,Percent of Total Billed Charges,90% of Total billed Charges,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.23,65,,212.68,Percent of total Billed Charges,65% of Total Billed Charges,76.82,44.1,,55.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,165.49,95,,1.52,Percent of Total Billed Charges,95% of Total Billed Charges,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.3,88,,1.408,Percent of Total Billed Charges,88% of Total Billed Charges,156.78,90,,1.44,Percent of Total Billed charges,90% of Total Billed Charges,76.82,174.2,
FEMORAL CANAL TIP,2720000795,CDM,272,RC,,,Outpatient,,,79.38,51.60,,79.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60.33,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.15,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,59.54,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.15,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,47.63,60,,1.584,Percent of Total Billed Charges,60% of Total Billed Charges,71.44,90,,1.232,Percent of Total Billed Charges,90% of Total Billed Charges,35.72,45,,10.44,Percent of Total Billed Charges,45% of Total Billed Charges,71.44,90,,28.8,Percent of Total Billed Charges,90% of Total billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,65,,81.12,Percent of total Billed Charges,65% of Total Billed Charges,35.01,44.1,,10.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,75.41,95,,30.4,Percent of Total Billed Charges,95% of Total Billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.85,88,,28.16,Percent of Total Billed Charges,88% of Total Billed Charges,71.44,90,,28.8,Percent of Total Billed charges,90% of Total Billed Charges,35.01,79.38,
STRYKER DRI-LOK CANN 6.5X75,2720000796,CDM,272,RC,,,Outpatient,,,52.92,34.40,,52.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.22,76,,248.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.1,72,,33.024,Percent of Total Billed Charges,72% of Total Billed Charges,39.69,75,,34.4,Percent of Total Billed charges,75% of Total Billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.1,72,,33.024,Percent of Total Billed Charges,72% of Total Billed Charges,31.75,60,,27.52,Percent of Total Billed Charges,60% of Total Billed Charges,47.63,90,,216,Percent of Total Billed Charges,90% of Total Billed Charges,23.81,45,,10.8,Percent of Total Billed Charges,45% of Total Billed Charges,47.63,90,,294.48,Percent of Total Billed Charges,90% of Total billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.4,65,,15.08,Percent of total Billed Charges,65% of Total Billed Charges,23.34,44.1,,10.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.27,95,,310.84,Percent of Total Billed Charges,95% of Total Billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.57,88,,287.936,Percent of Total Billed Charges,88% of Total Billed Charges,47.63,90,,294.48,Percent of Total Billed charges,90% of Total Billed Charges,23.34,52.92,
MENISECTOMY ELECTROD,2720000797,CDM,272,RC,,,Outpatient,,,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,94.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,19.848,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,15.88,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,67.68,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,3.96,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,112.32,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,15.6,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,3.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,118.56,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,109.824,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,112.32,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
GODDIE T EAR TUBES,2720000798,CDM,272,RC,,,Outpatient,,,50.72,32.97,,50.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38.55,76,,17.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36.52,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,38.04,75,,21.168,Percent of Total Billed charges,75% of Total Billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.52,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,30.43,60,,16.936,Percent of Total Billed Charges,60% of Total Billed Charges,45.65,90,,216,Percent of Total Billed Charges,90% of Total Billed Charges,22.82,45,,0.824,Percent of Total Billed Charges,45% of Total Billed Charges,45.65,90,,20.88,Percent of Total Billed Charges,90% of Total billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.97,65,,5.72,Percent of total Billed Charges,65% of Total Billed Charges,22.37,44.1,,0.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.18,95,,22.04,Percent of Total Billed Charges,95% of Total Billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.63,88,,20.416,Percent of Total Billed Charges,88% of Total Billed Charges,45.65,90,,20.88,Percent of Total Billed charges,90% of Total Billed Charges,22.37,50.72,
LAP HARMONIC SCALPER,2720000799,CDM,272,RC,,,Outpatient,,,1597.52,1038.39,,1597.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1214.12,76,,18.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1150.21,72,,180.984,Percent of Total Billed Charges,72% of Total Billed Charges,1198.14,75,,188.528,Percent of Total Billed charges,75% of Total Billed Charges,1597.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1150.21,72,,180.984,Percent of Total Billed Charges,72% of Total Billed Charges,958.51,60,,150.824,Percent of Total Billed Charges,60% of Total Billed Charges,1437.77,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,718.88,45,,25.92,Percent of Total Billed Charges,45% of Total Billed Charges,1437.77,90,,21.6,Percent of Total Billed Charges,90% of Total billed Charges,1597.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1597.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1597.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1038.39,65,,1.192,Percent of total Billed Charges,65% of Total Billed Charges,704.51,44.1,,25.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,1517.64,95,,22.8,Percent of Total Billed Charges,95% of Total Billed Charges,1597.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1405.82,88,,21.12,Percent of Total Billed Charges,88% of Total Billed Charges,1437.77,90,,21.6,Percent of Total Billed charges,90% of Total Billed Charges,704.51,1597.52,
PFC SIGMA SAW BLADE,2720000800,CDM,272,RC,,,Outpatient,,,942.64,612.72,,942.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,716.41,76,,6.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,678.7,72,,88.904,Percent of Total Billed Charges,72% of Total Billed Charges,706.98,75,,92.608,Percent of Total Billed charges,75% of Total Billed Charges,942.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678.7,72,,88.904,Percent of Total Billed Charges,72% of Total Billed Charges,565.58,60,,74.088,Percent of Total Billed Charges,60% of Total Billed Charges,848.38,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,424.19,45,,48.6,Percent of Total Billed Charges,45% of Total Billed Charges,848.38,90,,7.92,Percent of Total Billed Charges,90% of Total billed Charges,942.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,942.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,942.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.72,65,,37.44,Percent of total Billed Charges,65% of Total Billed Charges,415.7,44.1,,47.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,895.51,95,,8.36,Percent of Total Billed Charges,95% of Total Billed Charges,942.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,829.52,88,,7.744,Percent of Total Billed Charges,88% of Total Billed Charges,848.38,90,,7.92,Percent of Total Billed charges,90% of Total Billed Charges,415.7,942.64,
BIOACCESS AO/SYNTHES,2720000801,CDM,272,RC,,,Outpatient,,,424.46,275.90,,424.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,322.59,76,,1.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,305.61,72,,98.432,Percent of Total Billed Charges,72% of Total Billed Charges,318.35,75,,102.536,Percent of Total Billed charges,75% of Total Billed Charges,424.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305.61,72,,98.432,Percent of Total Billed Charges,72% of Total Billed Charges,254.68,60,,82.024,Percent of Total Billed Charges,60% of Total Billed Charges,382.01,90,,130.32,Percent of Total Billed Charges,90% of Total Billed Charges,191.01,45,,0.616,Percent of Total Billed Charges,45% of Total Billed Charges,382.01,90,,1.648,Percent of Total Billed Charges,90% of Total billed Charges,424.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.9,65,,70.2,Percent of total Billed Charges,65% of Total Billed Charges,187.19,44.1,,0.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,403.24,95,,1.744,Percent of Total Billed Charges,95% of Total Billed Charges,424.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.52,88,,1.616,Percent of Total Billed Charges,88% of Total Billed Charges,382.01,90,,1.648,Percent of Total Billed charges,90% of Total Billed Charges,187.19,424.46,
STORZ DISP COLD KNIF,2720000802,CDM,272,RC,,,Outpatient,,,361.62,235.05,,361.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,274.83,76,,43.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,260.37,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,271.22,75,,21.168,Percent of Total Billed charges,75% of Total Billed Charges,361.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.37,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,216.97,60,,16.936,Percent of Total Billed Charges,60% of Total Billed Charges,325.46,90,,86.4,Percent of Total Billed Charges,90% of Total Billed Charges,162.73,45,,108,Percent of Total Billed Charges,45% of Total Billed Charges,325.46,90,,51.84,Percent of Total Billed Charges,90% of Total billed Charges,361.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.05,65,,0.888,Percent of total Billed Charges,65% of Total Billed Charges,159.47,44.1,,105.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,343.54,95,,54.72,Percent of Total Billed Charges,95% of Total Billed Charges,361.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.23,88,,50.688,Percent of Total Billed Charges,88% of Total Billed Charges,325.46,90,,51.84,Percent of Total Billed charges,90% of Total Billed Charges,159.47,361.62,
ROLLERBALL ELECTRODE,2720000803,CDM,272,RC,,,Outpatient,,,190.73,123.97,,190.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.95,76,,82.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,137.33,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,143.05,75,,19.848,Percent of Total Billed charges,75% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.33,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,114.44,60,,15.88,Percent of Total Billed Charges,60% of Total Billed Charges,171.66,90,,130.32,Percent of Total Billed Charges,90% of Total Billed Charges,85.83,45,,33.84,Percent of Total Billed Charges,45% of Total Billed Charges,171.66,90,,97.2,Percent of Total Billed Charges,90% of Total billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.97,65,,156,Percent of total Billed Charges,65% of Total Billed Charges,84.11,44.1,,33.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,181.19,95,,102.6,Percent of Total Billed Charges,95% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.84,88,,95.04,Percent of Total Billed Charges,88% of Total Billed Charges,171.66,90,,97.2,Percent of Total Billed charges,90% of Total Billed Charges,84.11,190.73,
IMP DISPOSABLE PAD,2720000804,CDM,272,RC,,,Outpatient,,,173.09,112.51,,173.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,131.55,76,,1.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,124.62,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,129.82,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.62,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,103.85,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,155.78,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,77.89,45,,108,Percent of Total Billed Charges,45% of Total Billed Charges,155.78,90,,1.232,Percent of Total Billed Charges,90% of Total billed Charges,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.51,65,,48.88,Percent of total Billed Charges,65% of Total Billed Charges,76.33,44.1,,105.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,164.44,95,,1.296,Percent of Total Billed Charges,95% of Total Billed Charges,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.32,88,,1.2,Percent of Total Billed Charges,88% of Total Billed Charges,155.78,90,,1.232,Percent of Total Billed charges,90% of Total Billed Charges,76.33,173.09,
DISP CUFF DUAL BLADD,2720000805,CDM,272,RC,,,Outpatient,,,119.07,77.40,,119.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,90.49,76,,182.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,85.73,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,89.3,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.73,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,71.44,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,107.16,90,,123.84,Percent of Total Billed Charges,90% of Total Billed Charges,53.58,45,,1.8,Percent of Total Billed Charges,45% of Total Billed Charges,107.16,90,,216,Percent of Total Billed Charges,90% of Total billed Charges,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,65,,156,Percent of total Billed Charges,65% of Total Billed Charges,52.51,44.1,,1.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,113.12,95,,228,Percent of Total Billed Charges,95% of Total Billed Charges,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.78,88,,211.2,Percent of Total Billed Charges,88% of Total Billed Charges,107.16,90,,216,Percent of Total Billed charges,90% of Total Billed Charges,52.51,119.07,
ASPIRATION INJ NEEDL,2720000806,CDM,272,RC,,,Outpatient,,,241.45,156.94,,241.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,183.5,76,,57.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,173.84,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,181.09,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,241.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.84,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,144.87,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,217.31,90,,170.64,Percent of Total Billed Charges,90% of Total Billed Charges,108.65,45,,1.44,Percent of Total Billed Charges,45% of Total Billed Charges,217.31,90,,67.68,Percent of Total Billed Charges,90% of Total billed Charges,241.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.94,65,,2.6,Percent of total Billed Charges,65% of Total Billed Charges,106.48,44.1,,1.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,229.38,95,,71.44,Percent of Total Billed Charges,95% of Total Billed Charges,241.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.48,88,,66.176,Percent of Total Billed Charges,88% of Total Billed Charges,217.31,90,,67.68,Percent of Total Billed charges,90% of Total Billed Charges,106.48,241.45,
FOLEY CATH TRAY LATE,2720000807,CDM,272,RC,,,Outpatient,,,73.87,48.02,,73.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.14,76,,182.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.19,72,,6.368,Percent of Total Billed Charges,72% of Total Billed Charges,55.4,75,,6.632,Percent of Total Billed charges,75% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.19,72,,6.368,Percent of Total Billed Charges,72% of Total Billed Charges,44.32,60,,5.304,Percent of Total Billed Charges,60% of Total Billed Charges,66.48,90,,1.28,Percent of Total Billed Charges,90% of Total Billed Charges,33.24,45,,65.16,Percent of Total Billed Charges,45% of Total Billed Charges,66.48,90,,216,Percent of Total Billed Charges,90% of Total billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.02,65,,2.08,Percent of total Billed Charges,65% of Total Billed Charges,32.58,44.1,,63.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,70.18,95,,228,Percent of Total Billed Charges,95% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.01,88,,211.2,Percent of Total Billed Charges,88% of Total Billed Charges,66.48,90,,216,Percent of Total Billed charges,90% of Total Billed Charges,32.58,73.87,
URETHRAL CATH TRAY,2720000808,CDM,272,RC,,,Outpatient,,,26.46,17.20,,26.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.11,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.05,72,,6.368,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,75,,6.632,Percent of Total Billed charges,75% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.05,72,,6.368,Percent of Total Billed Charges,72% of Total Billed Charges,15.88,60,,5.304,Percent of Total Billed Charges,60% of Total Billed Charges,23.81,90,,1.12,Percent of Total Billed Charges,90% of Total Billed Charges,11.91,45,,43.2,Percent of Total Billed Charges,45% of Total Billed Charges,23.81,90,,3.6,Percent of Total Billed Charges,90% of Total billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,65,,94.12,Percent of total Billed Charges,65% of Total Billed Charges,11.67,44.1,,42.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.14,95,,3.8,Percent of Total Billed Charges,95% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.28,88,,3.52,Percent of Total Billed Charges,88% of Total Billed Charges,23.81,90,,3.6,Percent of Total Billed charges,90% of Total Billed Charges,11.67,26.46,
CLOUD 9,2720000809,CDM,272,RC,,,Outpatient,,,439.90,285.94,,439.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,334.32,76,,2.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,316.73,72,,14.616,Percent of Total Billed Charges,72% of Total Billed Charges,329.93,75,,15.224,Percent of Total Billed charges,75% of Total Billed Charges,439.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.73,72,,14.616,Percent of Total Billed Charges,72% of Total Billed Charges,263.94,60,,12.176,Percent of Total Billed Charges,60% of Total Billed Charges,395.91,90,,1.296,Percent of Total Billed Charges,90% of Total Billed Charges,197.96,45,,65.16,Percent of Total Billed Charges,45% of Total Billed Charges,395.91,90,,2.88,Percent of Total Billed Charges,90% of Total billed Charges,439.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,439.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,439.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.94,65,,62.4,Percent of total Billed Charges,65% of Total Billed Charges,194,44.1,,63.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,417.91,95,,3.04,Percent of Total Billed Charges,95% of Total Billed Charges,439.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,387.11,88,,2.816,Percent of Total Billed Charges,88% of Total Billed Charges,395.91,90,,2.88,Percent of Total Billed charges,90% of Total Billed Charges,194,439.9,
BALLARD FLEX TUBE,2720000810,CDM,272,RC,,,Outpatient,,,99.23,64.50,,99.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.41,76,,110.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71.45,72,,14.616,Percent of Total Billed Charges,72% of Total Billed Charges,74.42,75,,15.224,Percent of Total Billed charges,75% of Total Billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.45,72,,14.616,Percent of Total Billed Charges,72% of Total Billed Charges,59.54,60,,12.176,Percent of Total Billed Charges,60% of Total Billed Charges,89.31,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,44.65,45,,2.52,Percent of Total Billed Charges,45% of Total Billed Charges,89.31,90,,130.32,Percent of Total Billed Charges,90% of Total billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.5,65,,94.12,Percent of total Billed Charges,65% of Total Billed Charges,43.76,44.1,,2.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,94.27,95,,137.56,Percent of Total Billed Charges,95% of Total Billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.32,88,,127.424,Percent of Total Billed Charges,88% of Total Billed Charges,89.31,90,,130.32,Percent of Total Billed charges,90% of Total Billed Charges,43.76,99.23,
ENDOTUBE UNCUFF 2.5,2720000811,CDM,272,RC,,,Outpatient,,,35.28,22.93,,35.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.81,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.4,72,,14.616,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,75,,15.224,Percent of Total Billed charges,75% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.4,72,,14.616,Percent of Total Billed Charges,72% of Total Billed Charges,21.17,60,,12.176,Percent of Total Billed Charges,60% of Total Billed Charges,31.75,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,15.88,45,,61.92,Percent of Total Billed Charges,45% of Total Billed Charges,31.75,90,,86.4,Percent of Total Billed Charges,90% of Total billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.93,65,,3.64,Percent of total Billed Charges,65% of Total Billed Charges,15.56,44.1,,60.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.52,95,,91.2,Percent of Total Billed Charges,95% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.05,88,,84.48,Percent of Total Billed Charges,88% of Total Billed Charges,31.75,90,,86.4,Percent of Total Billed charges,90% of Total Billed Charges,15.56,35.28,
IV CATH 16X1 1/4,2720000812,CDM,272,RC,,,Outpatient,,,31.97,20.78,,31.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.3,76,,110.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.02,72,,81.696,Percent of Total Billed Charges,72% of Total Billed Charges,23.98,75,,85.096,Percent of Total Billed charges,75% of Total Billed Charges,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.02,72,,81.696,Percent of Total Billed Charges,72% of Total Billed Charges,19.18,60,,68.08,Percent of Total Billed Charges,60% of Total Billed Charges,28.77,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,14.39,45,,85.32,Percent of Total Billed Charges,45% of Total Billed Charges,28.77,90,,130.32,Percent of Total Billed Charges,90% of Total billed Charges,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.78,65,,89.44,Percent of total Billed Charges,65% of Total Billed Charges,14.1,44.1,,83.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.37,95,,137.56,Percent of Total Billed Charges,95% of Total Billed Charges,31.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.13,88,,127.424,Percent of Total Billed Charges,88% of Total Billed Charges,28.77,90,,130.32,Percent of Total Billed charges,90% of Total Billed Charges,14.1,31.97,
DIC 6.0 TRACH TUBE,2720000813,CDM,272,RC,,,Outpatient,,,173.09,112.51,,173.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,131.55,76,,4.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,124.62,72,,89.392,Percent of Total Billed Charges,72% of Total Billed Charges,129.82,75,,93.112,Percent of Total Billed charges,75% of Total Billed Charges,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.62,72,,89.392,Percent of Total Billed Charges,72% of Total Billed Charges,103.85,60,,74.488,Percent of Total Billed Charges,60% of Total Billed Charges,155.78,90,,107.28,Percent of Total Billed Charges,90% of Total Billed Charges,77.89,45,,0.64,Percent of Total Billed Charges,45% of Total Billed Charges,155.78,90,,5.04,Percent of Total Billed Charges,90% of Total billed Charges,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.51,65,,123.24,Percent of total Billed Charges,65% of Total Billed Charges,76.33,44.1,,0.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,164.44,95,,5.32,Percent of Total Billed Charges,95% of Total Billed Charges,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.32,88,,4.928,Percent of Total Billed Charges,88% of Total Billed Charges,155.78,90,,5.04,Percent of Total Billed charges,90% of Total Billed Charges,76.33,173.09,
PEDI 2.5 TRACH TUBE,2720000814,CDM,272,RC,,,Outpatient,,,176.40,114.66,,176.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,134.06,76,,104.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,127.01,72,,9.448,Percent of Total Billed Charges,72% of Total Billed Charges,132.3,75,,9.84,Percent of Total Billed charges,75% of Total Billed Charges,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.01,72,,9.448,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,60,,7.872,Percent of Total Billed Charges,60% of Total Billed Charges,158.76,90,,144.72,Percent of Total Billed Charges,90% of Total Billed Charges,79.38,45,,0.56,Percent of Total Billed Charges,45% of Total Billed Charges,158.76,90,,123.84,Percent of Total Billed Charges,90% of Total billed Charges,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.66,65,,0.928,Percent of total Billed Charges,65% of Total Billed Charges,77.79,44.1,,0.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,167.58,95,,130.72,Percent of Total Billed Charges,95% of Total Billed Charges,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.23,88,,121.088,Percent of Total Billed Charges,88% of Total Billed Charges,158.76,90,,123.84,Percent of Total Billed charges,90% of Total Billed Charges,77.79,176.4,
TUBING SET HAMON END,2720000815,CDM,272,RC,,,Outpatient,,,131.20,85.28,,131.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,99.71,76,,144.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,94.46,72,,8.88,Percent of Total Billed Charges,72% of Total Billed Charges,98.4,75,,9.248,Percent of Total Billed charges,75% of Total Billed Charges,131.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.46,72,,8.88,Percent of Total Billed Charges,72% of Total Billed Charges,78.72,60,,7.4,Percent of Total Billed Charges,60% of Total Billed Charges,118.08,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,59.04,45,,0.648,Percent of Total Billed Charges,45% of Total Billed Charges,118.08,90,,170.64,Percent of Total Billed Charges,90% of Total billed Charges,131.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.28,65,,0.808,Percent of total Billed Charges,65% of Total Billed Charges,57.86,44.1,,0.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,124.64,95,,180.12,Percent of Total Billed Charges,95% of Total Billed Charges,131.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.46,88,,166.848,Percent of Total Billed Charges,88% of Total Billed Charges,118.08,90,,170.64,Percent of Total Billed charges,90% of Total Billed Charges,57.86,131.2,
PRECUT TANDEM TUBES,2720000816,CDM,272,RC,,,Outpatient,,,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,1.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,9.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,10.032,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,9.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,8.024,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,144.72,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,25.56,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,1.28,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,0.936,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,25.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,1.352,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,1.256,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,1.28,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
DISP CLIPPER BLADES,2720000817,CDM,272,RC,,,Outpatient,,,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,0.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.88,72,,80.488,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,75,,83.84,Percent of Total Billed charges,75% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.88,72,,80.488,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,60,,67.072,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,90,,1.072,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,9,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,1.12,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,36.92,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,8.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,1.184,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,1.096,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,1.12,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.05,
3FR METAL CYT BUSH,2720000818,CDM,272,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,80.488,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,83.84,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,80.488,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,67.072,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,0.656,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,12.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1.296,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,13,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,12.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1.368,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1.264,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1.296,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
KNIFE 11 CUTTING INS,2720000819,CDM,272,RC,,,Outpatient,,,61.74,40.13,,61.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.92,76,,43.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,44.45,72,,6.808,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,75,,7.096,Percent of Total Billed charges,75% of Total Billed Charges,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.45,72,,6.808,Percent of Total Billed Charges,72% of Total Billed Charges,37.04,60,,5.672,Percent of Total Billed Charges,60% of Total Billed Charges,55.57,90,,105.12,Percent of Total Billed Charges,90% of Total Billed Charges,27.78,45,,53.64,Percent of Total Billed Charges,45% of Total Billed Charges,55.57,90,,51.12,Percent of Total Billed Charges,90% of Total billed Charges,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.13,65,,18.72,Percent of total Billed Charges,65% of Total Billed Charges,27.23,44.1,,52.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,58.65,95,,53.96,Percent of Total Billed Charges,95% of Total Billed Charges,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.33,88,,49.984,Percent of Total Billed Charges,88% of Total Billed Charges,55.57,90,,51.12,Percent of Total Billed charges,90% of Total Billed Charges,27.23,61.74,
SINGLE USE GRSP FCPS,2720000820,CDM,272,RC,,,Outpatient,,,217.19,141.17,,217.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,165.06,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,156.38,72,,8.576,Percent of Total Billed Charges,72% of Total Billed Charges,162.89,75,,8.936,Percent of Total Billed charges,75% of Total Billed Charges,217.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.38,72,,8.576,Percent of Total Billed Charges,72% of Total Billed Charges,130.31,60,,7.144,Percent of Total Billed Charges,60% of Total Billed Charges,195.47,90,,73.44,Percent of Total Billed Charges,90% of Total Billed Charges,97.74,45,,72.36,Percent of Total Billed Charges,45% of Total Billed Charges,195.47,90,,18,Percent of Total Billed Charges,90% of Total billed Charges,217.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.17,65,,77.48,Percent of total Billed Charges,65% of Total Billed Charges,95.78,44.1,,70.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,206.33,95,,19,Percent of Total Billed Charges,95% of Total Billed Charges,217.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.13,88,,17.6,Percent of Total Billed Charges,88% of Total Billed Charges,195.47,90,,18,Percent of Total Billed charges,90% of Total Billed Charges,95.78,217.19,
4.5 TURBOWHISK BLADE,2720000821,CDM,272,RC,,,Outpatient,,,101.43,65.93,,101.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,77.09,76,,21.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,73.03,72,,0.968,Percent of Total Billed Charges,72% of Total Billed Charges,76.07,75,,1.008,Percent of Total Billed charges,75% of Total Billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.03,72,,0.968,Percent of Total Billed Charges,72% of Total Billed Charges,60.86,60,,0.808,Percent of Total Billed Charges,60% of Total Billed Charges,91.29,90,,73.44,Percent of Total Billed Charges,90% of Total Billed Charges,45.64,45,,10.44,Percent of Total Billed Charges,45% of Total Billed Charges,91.29,90,,25.92,Percent of Total Billed Charges,90% of Total billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.93,65,,104.52,Percent of total Billed Charges,65% of Total Billed Charges,44.73,44.1,,10.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,96.36,95,,27.36,Percent of Total Billed Charges,95% of Total Billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.26,88,,25.344,Percent of Total Billed Charges,88% of Total Billed Charges,91.29,90,,25.92,Percent of Total Billed charges,90% of Total Billed Charges,44.73,101.43,
RADIUS ELITE BLADE,2720000822,CDM,272,RC,,,Outpatient,,,91.51,59.48,,91.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,69.55,76,,90.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.89,72,,68.424,Percent of Total Billed Charges,72% of Total Billed Charges,68.63,75,,71.272,Percent of Total Billed charges,75% of Total Billed Charges,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.89,72,,68.424,Percent of Total Billed Charges,72% of Total Billed Charges,54.91,60,,57.016,Percent of Total Billed Charges,60% of Total Billed Charges,82.36,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,41.18,45,,72.36,Percent of Total Billed Charges,45% of Total Billed Charges,82.36,90,,107.28,Percent of Total Billed Charges,90% of Total billed Charges,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.48,65,,15.08,Percent of total Billed Charges,65% of Total Billed Charges,40.36,44.1,,70.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,86.93,95,,113.24,Percent of Total Billed Charges,95% of Total Billed Charges,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.53,88,,104.896,Percent of Total Billed Charges,88% of Total Billed Charges,82.36,90,,107.28,Percent of Total Billed charges,90% of Total Billed Charges,40.36,91.51,
ACROMIOBLASTER,2720000823,CDM,272,RC,,,Outpatient,,,187.43,121.83,,187.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,142.45,76,,122.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,134.95,72,,89.392,Percent of Total Billed Charges,72% of Total Billed Charges,140.57,75,,93.112,Percent of Total Billed charges,75% of Total Billed Charges,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.95,72,,89.392,Percent of Total Billed Charges,72% of Total Billed Charges,112.46,60,,74.488,Percent of Total Billed Charges,60% of Total Billed Charges,168.69,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,84.34,45,,0.536,Percent of Total Billed Charges,45% of Total Billed Charges,168.69,90,,144.72,Percent of Total Billed Charges,90% of Total billed Charges,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.83,65,,104.52,Percent of total Billed Charges,65% of Total Billed Charges,82.66,44.1,,0.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,178.06,95,,152.76,Percent of Total Billed Charges,95% of Total Billed Charges,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.94,88,,141.504,Percent of Total Billed Charges,88% of Total Billed Charges,168.69,90,,144.72,Percent of Total Billed charges,90% of Total Billed Charges,82.66,187.43,
DPY DRILL BIT 2.8,2720000824,CDM,272,RC,,,Outpatient,,,100.33,65.21,,100.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,76.25,76,,17.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,72.24,72,,108.96,Percent of Total Billed Charges,72% of Total Billed Charges,75.25,75,,113.504,Percent of Total Billed charges,75% of Total Billed Charges,100.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.24,72,,108.96,Percent of Total Billed Charges,72% of Total Billed Charges,60.2,60,,90.8,Percent of Total Billed Charges,60% of Total Billed Charges,90.3,90,,42.072,Percent of Total Billed Charges,90% of Total Billed Charges,45.15,45,,0.328,Percent of Total Billed Charges,45% of Total Billed Charges,90.3,90,,20.88,Percent of Total Billed Charges,90% of Total billed Charges,100.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.21,65,,0.776,Percent of total Billed Charges,65% of Total Billed Charges,44.25,44.1,,0.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,95.31,95,,22.04,Percent of Total Billed Charges,95% of Total Billed Charges,100.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.29,88,,20.416,Percent of Total Billed Charges,88% of Total Billed Charges,90.3,90,,20.88,Percent of Total Billed charges,90% of Total Billed Charges,44.25,100.33,
SRN DRILL SLEEVE 11M,2720000825,CDM,272,RC,,,Outpatient,,,314.21,204.24,,314.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,238.8,76,,122.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,226.23,72,,72.584,Percent of Total Billed Charges,72% of Total Billed Charges,235.66,75,,75.616,Percent of Total Billed charges,75% of Total Billed Charges,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.23,72,,72.584,Percent of Total Billed Charges,72% of Total Billed Charges,188.53,60,,60.488,Percent of Total Billed Charges,60% of Total Billed Charges,282.79,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,141.39,45,,52.56,Percent of Total Billed Charges,45% of Total Billed Charges,282.79,90,,144.72,Percent of Total Billed Charges,90% of Total billed Charges,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.24,65,,0.472,Percent of total Billed Charges,65% of Total Billed Charges,138.57,44.1,,51.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,298.5,95,,152.76,Percent of Total Billed Charges,95% of Total Billed Charges,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.5,88,,141.504,Percent of Total Billed Charges,88% of Total Billed Charges,282.79,90,,144.72,Percent of Total Billed charges,90% of Total Billed Charges,138.57,314.21,
SRN BGS PLUG 11MM,2720000826,CDM,272,RC,,,Outpatient,,,698.99,454.34,,698.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,531.23,76,,0.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,503.27,72,,72.584,Percent of Total Billed Charges,72% of Total Billed Charges,524.24,75,,75.616,Percent of Total Billed charges,75% of Total Billed Charges,698.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,503.27,72,,72.584,Percent of Total Billed Charges,72% of Total Billed Charges,419.39,60,,60.488,Percent of Total Billed Charges,60% of Total Billed Charges,629.09,90,,73.032,Percent of Total Billed Charges,90% of Total Billed Charges,314.55,45,,36.72,Percent of Total Billed Charges,45% of Total Billed Charges,629.09,90,,1.072,Percent of Total Billed Charges,90% of Total billed Charges,698.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,698.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,698.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,454.34,65,,75.92,Percent of total Billed Charges,65% of Total Billed Charges,308.25,44.1,,35.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,664.04,95,,1.136,Percent of Total Billed Charges,95% of Total Billed Charges,698.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,615.11,88,,1.048,Percent of Total Billed Charges,88% of Total Billed Charges,629.09,90,,1.072,Percent of Total Billed charges,90% of Total Billed Charges,308.25,698.99,
LEEP ELECT PAD,2720000827,CDM,272,RC,,,Outpatient,,,25.36,16.48,,25.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.27,76,,0.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.26,72,,72.584,Percent of Total Billed Charges,72% of Total Billed Charges,19.02,75,,75.616,Percent of Total Billed charges,75% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.26,72,,72.584,Percent of Total Billed Charges,72% of Total Billed Charges,15.22,60,,60.488,Percent of Total Billed Charges,60% of Total Billed Charges,22.82,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,11.41,45,,36.72,Percent of Total Billed Charges,45% of Total Billed Charges,22.82,90,,0.656,Percent of Total Billed Charges,90% of Total billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,65,,53.04,Percent of total Billed Charges,65% of Total Billed Charges,11.18,44.1,,35.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.09,95,,0.688,Percent of Total Billed Charges,95% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,88,,0.64,Percent of Total Billed Charges,88% of Total Billed Charges,22.82,90,,0.656,Percent of Total Billed charges,90% of Total Billed Charges,11.18,25.36,
PERM CATH DEVICE,2720000828,CDM,272,RC,,,Outpatient,,,2668.05,1734.23,,2668.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2027.72,76,,88.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1921,72,,77.128,Percent of Total Billed Charges,72% of Total Billed Charges,2001.04,75,,80.344,Percent of Total Billed charges,75% of Total Billed Charges,2668.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1921,72,,77.128,Percent of Total Billed Charges,72% of Total Billed Charges,1600.83,60,,64.272,Percent of Total Billed Charges,60% of Total Billed Charges,2401.25,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,1200.62,45,,30.96,Percent of Total Billed Charges,45% of Total Billed Charges,2401.25,90,,105.12,Percent of Total Billed Charges,90% of Total billed Charges,2668.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2668.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2668.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1734.23,65,,53.04,Percent of total Billed Charges,65% of Total Billed Charges,1176.61,44.1,,30.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,2534.65,95,,110.96,Percent of Total Billed Charges,95% of Total Billed Charges,2668.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2347.88,88,,102.784,Percent of Total Billed Charges,88% of Total Billed Charges,2401.25,90,,105.12,Percent of Total Billed charges,90% of Total Billed Charges,1176.61,2668.05,
DPY LIFE NG,2720000829,CDM,272,RC,,,Outpatient,,,2197.28,1428.23,,2197.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1669.93,76,,62.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1582.04,72,,77.128,Percent of Total Billed Charges,72% of Total Billed Charges,1647.96,75,,80.344,Percent of Total Billed charges,75% of Total Billed Charges,2197.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1582.04,72,,77.128,Percent of Total Billed Charges,72% of Total Billed Charges,1318.37,60,,64.272,Percent of Total Billed Charges,60% of Total Billed Charges,1977.55,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,988.78,45,,30.96,Percent of Total Billed Charges,45% of Total Billed Charges,1977.55,90,,73.44,Percent of Total Billed Charges,90% of Total billed Charges,2197.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2197.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2197.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1428.23,65,,44.72,Percent of total Billed Charges,65% of Total Billed Charges,969,44.1,,30.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,2087.42,95,,77.52,Percent of Total Billed Charges,95% of Total Billed Charges,2197.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1933.61,88,,71.808,Percent of Total Billed Charges,88% of Total Billed Charges,1977.55,90,,73.44,Percent of Total Billed charges,90% of Total Billed Charges,969,2197.28,
SYNT 11.0 HELICAL BL,2720000830,CDM,272,RC,,,Outpatient,,,717.73,466.52,,717.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,545.47,76,,62.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,516.77,72,,77.128,Percent of Total Billed Charges,72% of Total Billed Charges,538.3,75,,80.344,Percent of Total Billed charges,75% of Total Billed Charges,717.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,516.77,72,,77.128,Percent of Total Billed Charges,72% of Total Billed Charges,430.64,60,,64.272,Percent of Total Billed Charges,60% of Total Billed Charges,645.96,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,322.98,45,,21.032,Percent of Total Billed Charges,45% of Total Billed Charges,645.96,90,,73.44,Percent of Total Billed Charges,90% of Total billed Charges,717.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,717.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,717.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,466.52,65,,44.72,Percent of total Billed Charges,65% of Total Billed Charges,316.52,44.1,,20.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,681.84,95,,77.52,Percent of Total Billed Charges,95% of Total Billed Charges,717.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,631.6,88,,71.808,Percent of Total Billed Charges,88% of Total Billed Charges,645.96,90,,73.44,Percent of Total Billed charges,90% of Total Billed Charges,316.52,717.73,
SYN II HELICAL BLADE,2720000831,CDM,272,RC,,,Outpatient,,,717.73,466.52,,717.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,545.47,76,,52.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,516.77,72,,282.928,Percent of Total Billed Charges,72% of Total Billed Charges,538.3,75,,294.712,Percent of Total Billed charges,75% of Total Billed Charges,717.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,516.77,72,,282.928,Percent of Total Billed Charges,72% of Total Billed Charges,430.64,60,,235.768,Percent of Total Billed Charges,60% of Total Billed Charges,645.96,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,322.98,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,645.96,90,,61.92,Percent of Total Billed Charges,90% of Total billed Charges,717.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,717.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,717.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,466.52,65,,30.384,Percent of total Billed Charges,65% of Total Billed Charges,316.52,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,681.84,95,,65.36,Percent of Total Billed Charges,95% of Total Billed Charges,717.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,631.6,88,,60.544,Percent of Total Billed Charges,88% of Total Billed Charges,645.96,90,,61.92,Percent of Total Billed charges,90% of Total Billed Charges,316.52,717.73,
SYN FLUTED DRILL BIT,2720000832,CDM,272,RC,,,Outpatient,,,255.78,166.26,,255.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,194.39,76,,52.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,184.16,72,,324.416,Percent of Total Billed Charges,72% of Total Billed Charges,191.84,75,,337.936,Percent of Total Billed charges,75% of Total Billed Charges,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.16,72,,324.416,Percent of Total Billed Charges,72% of Total Billed Charges,153.47,60,,270.344,Percent of Total Billed Charges,60% of Total Billed Charges,230.2,90,,170.672,Percent of Total Billed Charges,90% of Total Billed Charges,115.1,45,,36.512,Percent of Total Billed Charges,45% of Total Billed Charges,230.2,90,,61.92,Percent of Total Billed Charges,90% of Total billed Charges,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.26,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,112.8,44.1,,35.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,242.99,95,,65.36,Percent of Total Billed Charges,95% of Total Billed Charges,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.09,88,,60.544,Percent of Total Billed Charges,88% of Total Billed Charges,230.2,90,,61.92,Percent of Total Billed charges,90% of Total Billed Charges,112.8,255.78,
HOLAP FIBERS,2720000833,CDM,272,RC,,,Outpatient,,,5160.80,3354.52,,5160.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3922.21,76,,35.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3715.78,72,,35.712,Percent of Total Billed Charges,72% of Total Billed Charges,3870.6,75,,37.2,Percent of Total Billed charges,75% of Total Billed Charges,5160.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3715.78,72,,35.712,Percent of Total Billed Charges,72% of Total Billed Charges,3096.48,60,,29.76,Percent of Total Billed Charges,60% of Total Billed Charges,4644.72,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,2322.36,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,4644.72,90,,42.072,Percent of Total Billed Charges,90% of Total billed Charges,5160.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5160.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5160.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3354.52,65,,52.744,Percent of total Billed Charges,65% of Total Billed Charges,2275.91,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,4902.76,95,,44.408,Percent of Total Billed Charges,95% of Total Billed Charges,5160.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4541.5,88,,41.136,Percent of Total Billed Charges,88% of Total Billed Charges,4644.72,90,,42.072,Percent of Total Billed charges,90% of Total Billed Charges,2275.91,5160.8,
OATS KIT,2720000834,CDM,272,RC,,,Outpatient,,,952.56,619.16,,952.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,723.95,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,685.84,72,,8.592,Percent of Total Billed Charges,72% of Total Billed Charges,714.42,75,,8.944,Percent of Total Billed charges,75% of Total Billed Charges,952.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.84,72,,8.592,Percent of Total Billed Charges,72% of Total Billed Charges,571.54,60,,7.16,Percent of Total Billed Charges,60% of Total Billed Charges,857.3,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,428.65,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,857.3,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,952.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,952.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,952.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,619.16,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,420.08,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,904.93,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,952.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,838.25,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,857.3,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,420.08,952.56,
SCD FOOT,2720000835,CDM,272,RC,,,Outpatient,,,94.82,61.63,,94.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.06,76,,61.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,68.27,72,,18.624,Percent of Total Billed Charges,72% of Total Billed Charges,71.12,75,,19.408,Percent of Total Billed charges,75% of Total Billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.27,72,,18.624,Percent of Total Billed Charges,72% of Total Billed Charges,56.89,60,,15.52,Percent of Total Billed Charges,60% of Total Billed Charges,85.34,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,42.67,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,85.34,90,,73.032,Percent of Total Billed Charges,90% of Total billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.63,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,41.82,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,90.08,95,,77.088,Percent of Total Billed Charges,95% of Total Billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.44,88,,71.408,Percent of Total Billed Charges,88% of Total Billed Charges,85.34,90,,73.032,Percent of Total Billed charges,90% of Total Billed Charges,41.82,94.82,
SCD CALF,2720000836,CDM,272,RC,,,Outpatient,,,79.38,51.60,,79.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60.33,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.15,72,,5.144,Percent of Total Billed Charges,72% of Total Billed Charges,59.54,75,,5.36,Percent of Total Billed charges,75% of Total Billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.15,72,,5.144,Percent of Total Billed Charges,72% of Total Billed Charges,47.63,60,,4.288,Percent of Total Billed Charges,60% of Total Billed Charges,71.44,90,,121.448,Percent of Total Billed Charges,90% of Total Billed Charges,35.72,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,71.44,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,35.01,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,75.41,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.85,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,71.44,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,35.01,79.38,
SCD THIGH,2720000837,CDM,272,RC,,,Outpatient,,,86.00,55.90,,86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,65.36,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.92,72,,4.784,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,75,,4.984,Percent of Total Billed charges,75% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.92,72,,4.784,Percent of Total Billed Charges,72% of Total Billed Charges,51.6,60,,3.984,Percent of Total Billed Charges,60% of Total Billed Charges,77.4,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,38.7,45,,0.432,Percent of Total Billed Charges,45% of Total Billed Charges,77.4,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.9,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,37.93,44.1,,0.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,81.7,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.68,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,77.4,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,37.93,86,
SCD THIGH XL,2720000838,CDM,272,RC,,,Outpatient,,,94.82,61.63,,94.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.06,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,68.27,72,,8.528,Percent of Total Billed Charges,72% of Total Billed Charges,71.12,75,,8.888,Percent of Total Billed charges,75% of Total Billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.27,72,,8.528,Percent of Total Billed Charges,72% of Total Billed Charges,56.89,60,,7.112,Percent of Total Billed Charges,60% of Total Billed Charges,85.34,90,,70.648,Percent of Total Billed Charges,90% of Total Billed Charges,42.67,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,85.34,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.63,65,,0.624,Percent of total Billed Charges,65% of Total Billed Charges,41.82,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,90.08,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.44,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,85.34,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,41.82,94.82,
DURAPREP 6ML KIT,2720000839,CDM,272,RC,,,Outpatient,,,26.46,17.20,,26.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.11,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.05,72,,2.128,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,75,,2.224,Percent of Total Billed charges,75% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.05,72,,2.128,Percent of Total Billed Charges,72% of Total Billed Charges,15.88,60,,1.776,Percent of Total Billed Charges,60% of Total Billed Charges,23.81,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,11.91,45,,85.336,Percent of Total Billed Charges,45% of Total Billed Charges,23.81,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,11.67,44.1,,83.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.14,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.28,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,23.81,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,11.67,26.46,
OPEN COUDE TIP CATH,2720000840,CDM,272,RC,,,Outpatient,,,163.17,106.06,,163.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.01,76,,0.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,117.48,72,,3.992,Percent of Total Billed Charges,72% of Total Billed Charges,122.38,75,,4.16,Percent of Total Billed charges,75% of Total Billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.48,72,,3.992,Percent of Total Billed Charges,72% of Total Billed Charges,97.9,60,,3.328,Percent of Total Billed Charges,60% of Total Billed Charges,146.85,90,,79.384,Percent of Total Billed Charges,90% of Total Billed Charges,73.43,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,146.85,90,,0.864,Percent of Total Billed Charges,90% of Total billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.06,65,,123.264,Percent of total Billed Charges,65% of Total Billed Charges,71.96,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,155.01,95,,0.912,Percent of Total Billed Charges,95% of Total Billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.59,88,,0.848,Percent of Total Billed Charges,88% of Total Billed Charges,146.85,90,,0.864,Percent of Total Billed charges,90% of Total Billed Charges,71.96,163.17,
FLOSEAL ENDOSCOPIC A,2720000841,CDM,272,RC,,,Outpatient,,,170.89,111.08,,170.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.88,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.04,72,,8.016,Percent of Total Billed Charges,72% of Total Billed Charges,128.17,75,,8.352,Percent of Total Billed charges,75% of Total Billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.04,72,,8.016,Percent of Total Billed Charges,72% of Total Billed Charges,102.53,60,,6.68,Percent of Total Billed Charges,60% of Total Billed Charges,153.8,90,,50.8,Percent of Total Billed Charges,90% of Total Billed Charges,76.9,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,153.8,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.08,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,75.36,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,162.35,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.38,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,153.8,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,75.36,170.89,
APM COR47 12X100GEL,2720000842,CDM,272,RC,,,Outpatient,,,87.10,56.62,,87.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.2,76,,144.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.71,72,,22.064,Percent of Total Billed Charges,72% of Total Billed Charges,65.33,75,,22.984,Percent of Total Billed charges,75% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.71,72,,22.064,Percent of Total Billed Charges,72% of Total Billed Charges,52.26,60,,18.384,Percent of Total Billed Charges,60% of Total Billed Charges,78.39,90,,50.8,Percent of Total Billed Charges,90% of Total Billed Charges,39.2,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,78.39,90,,170.672,Percent of Total Billed Charges,90% of Total billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.62,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,38.41,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.75,95,,180.152,Percent of Total Billed Charges,95% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.65,88,,166.88,Percent of Total Billed Charges,88% of Total Billed Charges,78.39,90,,170.672,Percent of Total Billed charges,90% of Total Billed Charges,38.41,87.1,
APM COR50 12X30 GEL,2720000843,CDM,272,RC,,,Outpatient,,,87.10,56.62,,87.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.2,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.71,72,,2.384,Percent of Total Billed Charges,72% of Total Billed Charges,65.33,75,,2.488,Percent of Total Billed charges,75% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.71,72,,2.384,Percent of Total Billed Charges,72% of Total Billed Charges,52.26,60,,1.984,Percent of Total Billed Charges,60% of Total Billed Charges,78.39,90,,50.8,Percent of Total Billed Charges,90% of Total Billed Charges,39.2,45,,60.728,Percent of Total Billed Charges,45% of Total Billed Charges,78.39,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.62,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,38.41,44.1,,59.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.75,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.65,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,78.39,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,38.41,87.1,
APM CTB03 5X100 SHLD,2720000844,CDM,272,RC,,,Outpatient,,,156.56,101.76,,156.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,118.99,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,112.72,72,,2.032,Percent of Total Billed Charges,72% of Total Billed Charges,117.42,75,,2.12,Percent of Total Billed charges,75% of Total Billed Charges,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.72,72,,2.032,Percent of Total Billed Charges,72% of Total Billed Charges,93.94,60,,1.696,Percent of Total Billed Charges,60% of Total Billed Charges,140.9,90,,177.808,Percent of Total Billed Charges,90% of Total Billed Charges,70.45,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,140.9,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.76,65,,87.712,Percent of total Billed Charges,65% of Total Billed Charges,69.04,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,148.73,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.77,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,140.9,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,69.04,156.56,
APM COR63 11X100 SHL,2720000845,CDM,272,RC,,,Outpatient,,,185.22,120.39,,185.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,140.77,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,133.36,72,,4.84,Percent of Total Billed Charges,72% of Total Billed Charges,138.92,75,,5.04,Percent of Total Billed charges,75% of Total Billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.36,72,,4.84,Percent of Total Billed Charges,72% of Total Billed Charges,111.13,60,,4.032,Percent of Total Billed Charges,60% of Total Billed Charges,166.7,90,,38.896,Percent of Total Billed Charges,90% of Total Billed Charges,83.35,45,,35.32,Percent of Total Billed Charges,45% of Total Billed Charges,166.7,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.39,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,81.68,44.1,,34.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,175.96,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.99,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,166.7,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,81.68,185.22,
APM COR67 12X100 SHL,2720000846,CDM,272,RC,,,Outpatient,,,185.22,120.39,,185.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,140.77,76,,102.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,133.36,72,,2.192,Percent of Total Billed Charges,72% of Total Billed Charges,138.92,75,,2.28,Percent of Total Billed charges,75% of Total Billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.36,72,,2.192,Percent of Total Billed Charges,72% of Total Billed Charges,111.13,60,,1.824,Percent of Total Billed Charges,60% of Total Billed Charges,166.7,90,,60.328,Percent of Total Billed Charges,90% of Total Billed Charges,83.35,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,166.7,90,,121.448,Percent of Total Billed Charges,90% of Total billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.39,65,,51.024,Percent of total Billed Charges,65% of Total Billed Charges,81.68,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,175.96,95,,128.2,Percent of Total Billed Charges,95% of Total Billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.99,88,,118.752,Percent of Total Billed Charges,88% of Total Billed Charges,166.7,90,,121.448,Percent of Total Billed charges,90% of Total Billed Charges,81.68,185.22,
APM CT 502 5X100 Z T,2720000847,CDM,272,RC,,,Outpatient,,,87.10,56.62,,87.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.2,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.71,72,,5.992,Percent of Total Billed Charges,72% of Total Billed Charges,65.33,75,,6.24,Percent of Total Billed charges,75% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.71,72,,5.992,Percent of Total Billed Charges,72% of Total Billed Charges,52.26,60,,4.992,Percent of Total Billed Charges,60% of Total Billed Charges,78.39,90,,60.328,Percent of Total Billed Charges,90% of Total Billed Charges,39.2,45,,39.688,Percent of Total Billed Charges,45% of Total Billed Charges,78.39,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.62,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,38.41,44.1,,38.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.75,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.65,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,78.39,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,38.41,87.1,
APM COR71 11X100 TH/,2720000848,CDM,272,RC,,,Outpatient,,,33.08,21.50,,33.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.14,76,,59.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.82,72,,9.56,Percent of Total Billed Charges,72% of Total Billed Charges,24.81,75,,9.96,Percent of Total Billed charges,75% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.82,72,,9.56,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,60,,7.968,Percent of Total Billed Charges,60% of Total Billed Charges,29.77,90,,81.76,Percent of Total Billed Charges,90% of Total Billed Charges,14.89,45,,25.4,Percent of Total Billed Charges,45% of Total Billed Charges,29.77,90,,70.648,Percent of Total Billed Charges,90% of Total billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.5,65,,57.328,Percent of total Billed Charges,65% of Total Billed Charges,14.59,44.1,,24.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.43,95,,74.568,Percent of Total Billed Charges,95% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.11,88,,69.08,Percent of Total Billed Charges,88% of Total Billed Charges,29.77,90,,70.648,Percent of Total Billed charges,90% of Total Billed Charges,14.59,33.08,
APM COR73 12X100 THD,2720000849,CDM,272,RC,,,Outpatient,,,33.08,21.50,,33.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.14,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.82,72,,135.784,Percent of Total Billed Charges,72% of Total Billed Charges,24.81,75,,141.448,Percent of Total Billed charges,75% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.82,72,,135.784,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,60,,113.152,Percent of Total Billed Charges,60% of Total Billed Charges,29.77,90,,60.328,Percent of Total Billed Charges,90% of Total Billed Charges,14.89,45,,25.4,Percent of Total Billed Charges,45% of Total Billed Charges,29.77,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.5,65,,36.688,Percent of total Billed Charges,65% of Total Billed Charges,14.59,44.1,,24.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.43,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.11,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,29.77,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,14.59,33.08,
APM C2201 120 INSUFF,2720000850,CDM,272,RC,,,Outpatient,,,26.46,17.20,,26.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.11,76,,67.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.05,72,,7.68,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,75,,8.008,Percent of Total Billed charges,75% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.05,72,,7.68,Percent of Total Billed Charges,72% of Total Billed Charges,15.88,60,,6.4,Percent of Total Billed Charges,60% of Total Billed Charges,23.81,90,,25.4,Percent of Total Billed Charges,90% of Total Billed Charges,11.91,45,,25.4,Percent of Total Billed Charges,45% of Total Billed Charges,23.81,90,,79.384,Percent of Total Billed Charges,90% of Total billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,65,,36.688,Percent of total Billed Charges,65% of Total Billed Charges,11.67,44.1,,24.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.14,95,,83.792,Percent of Total Billed Charges,95% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.28,88,,77.616,Percent of Total Billed Charges,88% of Total Billed Charges,23.81,90,,79.384,Percent of Total Billed charges,90% of Total Billed Charges,11.67,26.46,
APM C2202 150 INSUFF,2720000851,CDM,272,RC,,,Outpatient,,,26.46,17.20,,26.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.11,76,,42.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.05,72,,5.816,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,75,,6.064,Percent of Total Billed charges,75% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.05,72,,5.816,Percent of Total Billed Charges,72% of Total Billed Charges,15.88,60,,4.848,Percent of Total Billed Charges,60% of Total Billed Charges,23.81,90,,60.328,Percent of Total Billed Charges,90% of Total Billed Charges,11.91,45,,88.904,Percent of Total Billed Charges,45% of Total Billed Charges,23.81,90,,50.8,Percent of Total Billed Charges,90% of Total billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,65,,36.688,Percent of total Billed Charges,65% of Total Billed Charges,11.67,44.1,,87.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.14,95,,53.624,Percent of Total Billed Charges,95% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.28,88,,49.672,Percent of Total Billed Charges,88% of Total Billed Charges,23.81,90,,50.8,Percent of Total Billed charges,90% of Total Billed Charges,11.67,26.46,
APM CD001 10MM RETRI,2720000852,CDM,272,RC,,,Outpatient,,,109.15,70.95,,109.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.95,76,,42.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,78.59,72,,8.072,Percent of Total Billed Charges,72% of Total Billed Charges,81.86,75,,8.416,Percent of Total Billed charges,75% of Total Billed Charges,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.59,72,,8.072,Percent of Total Billed Charges,72% of Total Billed Charges,65.49,60,,6.728,Percent of Total Billed Charges,60% of Total Billed Charges,98.24,90,,15.88,Percent of Total Billed Charges,90% of Total Billed Charges,49.12,45,,19.448,Percent of Total Billed Charges,45% of Total Billed Charges,98.24,90,,50.8,Percent of Total Billed Charges,90% of Total billed Charges,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.95,65,,128.416,Percent of total Billed Charges,65% of Total Billed Charges,48.14,44.1,,19.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,103.69,95,,53.624,Percent of Total Billed Charges,95% of Total Billed Charges,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.05,88,,49.672,Percent of Total Billed Charges,88% of Total Billed Charges,98.24,90,,50.8,Percent of Total Billed charges,90% of Total Billed Charges,48.14,109.15,
APM CB030 DD LAP SCI,2720000853,CDM,272,RC,,,Outpatient,,,77.18,50.17,,77.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.66,76,,42.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.57,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,57.89,75,,8.608,Percent of Total Billed charges,75% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.57,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,60,,6.88,Percent of Total Billed Charges,60% of Total Billed Charges,69.46,90,,107.96,Percent of Total Billed Charges,90% of Total Billed Charges,34.73,45,,30.168,Percent of Total Billed Charges,45% of Total Billed Charges,69.46,90,,50.8,Percent of Total Billed Charges,90% of Total billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.17,65,,28.088,Percent of total Billed Charges,65% of Total Billed Charges,34.04,44.1,,29.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.32,95,,53.624,Percent of Total Billed Charges,95% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.92,88,,49.672,Percent of Total Billed Charges,88% of Total Billed Charges,69.46,90,,50.8,Percent of Total Billed charges,90% of Total Billed Charges,34.04,77.18,
APM C4130 DD GRASPER,2720000854,CDM,272,RC,,,Outpatient,,,100.33,65.21,,100.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,76.25,76,,150.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,72.24,72,,8.648,Percent of Total Billed Charges,72% of Total Billed Charges,75.25,75,,9.016,Percent of Total Billed charges,75% of Total Billed Charges,100.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.24,72,,8.648,Percent of Total Billed Charges,72% of Total Billed Charges,60.2,60,,7.208,Percent of Total Billed Charges,60% of Total Billed Charges,90.3,90,,126.216,Percent of Total Billed Charges,90% of Total Billed Charges,45.15,45,,30.168,Percent of Total Billed Charges,45% of Total Billed Charges,90.3,90,,177.808,Percent of Total Billed Charges,90% of Total billed Charges,100.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.21,65,,43.568,Percent of total Billed Charges,65% of Total Billed Charges,44.25,44.1,,29.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,95.31,95,,187.688,Percent of Total Billed Charges,95% of Total Billed Charges,100.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.29,88,,173.856,Percent of Total Billed Charges,88% of Total Billed Charges,90.3,90,,177.808,Percent of Total Billed charges,90% of Total Billed Charges,44.25,100.33,
APM C0Q53 5X150 SHLD,2720000855,CDM,272,RC,,,Outpatient,,,113.56,73.81,,113.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,86.31,76,,32.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,81.76,72,,12.072,Percent of Total Billed Charges,72% of Total Billed Charges,85.17,75,,12.576,Percent of Total Billed charges,75% of Total Billed Charges,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.76,72,,12.072,Percent of Total Billed Charges,72% of Total Billed Charges,68.14,60,,10.064,Percent of Total Billed Charges,60% of Total Billed Charges,102.2,90,,192.896,Percent of Total Billed Charges,90% of Total Billed Charges,51.1,45,,40.88,Percent of Total Billed Charges,45% of Total Billed Charges,102.2,90,,38.896,Percent of Total Billed Charges,90% of Total billed Charges,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.81,65,,43.568,Percent of total Billed Charges,65% of Total Billed Charges,50.08,44.1,,40.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,107.88,95,,41.056,Percent of Total Billed Charges,95% of Total Billed Charges,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.93,88,,38.032,Percent of Total Billed Charges,88% of Total Billed Charges,102.2,90,,38.896,Percent of Total Billed charges,90% of Total Billed Charges,50.08,113.56,
APM COR69 12X150 SHL,2720000856,CDM,272,RC,,,Outpatient,,,59.54,38.70,,59.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.25,76,,50.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.87,72,,5.008,Percent of Total Billed Charges,72% of Total Billed Charges,44.66,75,,5.224,Percent of Total Billed charges,75% of Total Billed Charges,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.87,72,,5.008,Percent of Total Billed Charges,72% of Total Billed Charges,35.72,60,,4.176,Percent of Total Billed Charges,60% of Total Billed Charges,53.59,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,26.79,45,,30.168,Percent of Total Billed Charges,45% of Total Billed Charges,53.59,90,,60.328,Percent of Total Billed Charges,90% of Total billed Charges,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.7,65,,59.048,Percent of total Billed Charges,65% of Total Billed Charges,26.26,44.1,,29.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,56.56,95,,63.68,Percent of Total Billed Charges,95% of Total Billed Charges,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.4,88,,58.992,Percent of Total Billed Charges,88% of Total Billed Charges,53.59,90,,60.328,Percent of Total Billed charges,90% of Total Billed Charges,26.26,59.54,
FLOSEAL 10ML,2720000857,CDM,272,RC,,,Outpatient,,,488.41,317.47,,488.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,371.19,76,,50.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,351.66,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,366.31,75,,225,Percent of Total Billed charges,75% of Total Billed Charges,488.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,351.66,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,293.05,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,439.57,90,,70.648,Percent of Total Billed Charges,90% of Total Billed Charges,219.78,45,,12.704,Percent of Total Billed Charges,45% of Total Billed Charges,439.57,90,,60.328,Percent of Total Billed Charges,90% of Total billed Charges,488.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,317.47,65,,43.568,Percent of total Billed Charges,65% of Total Billed Charges,215.39,44.1,,12.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,463.99,95,,63.68,Percent of Total Billed Charges,95% of Total Billed Charges,488.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,429.8,88,,58.992,Percent of Total Billed Charges,88% of Total Billed Charges,439.57,90,,60.328,Percent of Total Billed charges,90% of Total Billed Charges,215.39,488.41,
FLOSEAL 5ML,2720000858,CDM,272,RC,,,Outpatient,,,455.33,295.96,,455.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,346.05,76,,69.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,327.84,72,,16.848,Percent of Total Billed Charges,72% of Total Billed Charges,341.5,75,,17.552,Percent of Total Billed charges,75% of Total Billed Charges,455.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.84,72,,16.848,Percent of Total Billed Charges,72% of Total Billed Charges,273.2,60,,14.04,Percent of Total Billed Charges,60% of Total Billed Charges,409.8,90,,83.344,Percent of Total Billed Charges,90% of Total Billed Charges,204.9,45,,30.168,Percent of Total Billed Charges,45% of Total Billed Charges,409.8,90,,81.76,Percent of Total Billed Charges,90% of Total billed Charges,455.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,455.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,455.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.96,65,,18.344,Percent of total Billed Charges,65% of Total Billed Charges,200.8,44.1,,29.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,432.56,95,,86.304,Percent of Total Billed Charges,95% of Total Billed Charges,455.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.69,88,,79.944,Percent of Total Billed Charges,88% of Total Billed Charges,409.8,90,,81.76,Percent of Total Billed charges,90% of Total Billed Charges,200.8,455.33,
ULTRASOUND COVER STE,2720000859,CDM,272,RC,,,Outpatient,,,17.64,11.47,,17.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.41,76,,50.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.7,72,,17.992,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,75,,18.736,Percent of Total Billed charges,75% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.7,72,,17.992,Percent of Total Billed Charges,72% of Total Billed Charges,10.58,60,,14.992,Percent of Total Billed Charges,60% of Total Billed Charges,15.88,90,,79.384,Percent of Total Billed Charges,90% of Total Billed Charges,7.94,45,,7.936,Percent of Total Billed Charges,45% of Total Billed Charges,15.88,90,,60.328,Percent of Total Billed Charges,90% of Total billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.47,65,,43.568,Percent of total Billed Charges,65% of Total Billed Charges,7.78,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.76,95,,63.68,Percent of Total Billed Charges,95% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.52,88,,58.992,Percent of Total Billed Charges,88% of Total Billed Charges,15.88,90,,60.328,Percent of Total Billed charges,90% of Total Billed Charges,7.78,17.64,
APM CF173 12X100 OPT,2720000860,CDM,272,RC,,,Outpatient,,,185.22,120.39,,185.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,140.77,76,,21.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,133.36,72,,9.504,Percent of Total Billed Charges,72% of Total Billed Charges,138.92,75,,9.904,Percent of Total Billed charges,75% of Total Billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.36,72,,9.504,Percent of Total Billed Charges,72% of Total Billed Charges,111.13,60,,7.92,Percent of Total Billed Charges,60% of Total Billed Charges,166.7,90,,58.744,Percent of Total Billed Charges,90% of Total Billed Charges,83.35,45,,53.976,Percent of Total Billed Charges,45% of Total Billed Charges,166.7,90,,25.4,Percent of Total Billed Charges,90% of Total billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.39,65,,11.464,Percent of total Billed Charges,65% of Total Billed Charges,81.68,44.1,,52.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,175.96,95,,26.816,Percent of Total Billed Charges,95% of Total Billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.99,88,,24.84,Percent of Total Billed Charges,88% of Total Billed Charges,166.7,90,,25.4,Percent of Total Billed charges,90% of Total Billed Charges,81.68,185.22,
APM C0707 STAB CONE,2720000861,CDM,272,RC,,,Outpatient,,,86.00,55.90,,86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,65.36,76,,50.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.92,72,,12.104,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,75,,12.608,Percent of Total Billed charges,75% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.92,72,,12.104,Percent of Total Billed Charges,72% of Total Billed Charges,51.6,60,,10.088,Percent of Total Billed Charges,60% of Total Billed Charges,77.4,90,,86.52,Percent of Total Billed Charges,90% of Total Billed Charges,38.7,45,,63.112,Percent of Total Billed Charges,45% of Total Billed Charges,77.4,90,,60.328,Percent of Total Billed Charges,90% of Total billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.9,65,,77.968,Percent of total Billed Charges,65% of Total Billed Charges,37.93,44.1,,61.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,81.7,95,,63.68,Percent of Total Billed Charges,95% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.68,88,,58.992,Percent of Total Billed Charges,88% of Total Billed Charges,77.4,90,,60.328,Percent of Total Billed charges,90% of Total Billed Charges,37.93,86,
APM DISP ALEXIS RETR,2720000862,CDM,272,RC,,,Outpatient,,,104.74,68.08,,104.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.6,76,,13.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75.41,72,,8.616,Percent of Total Billed Charges,72% of Total Billed Charges,78.56,75,,8.976,Percent of Total Billed charges,75% of Total Billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.41,72,,8.616,Percent of Total Billed Charges,72% of Total Billed Charges,62.84,60,,7.184,Percent of Total Billed Charges,60% of Total Billed Charges,94.27,90,,78.592,Percent of Total Billed Charges,90% of Total Billed Charges,47.13,45,,96.448,Percent of Total Billed Charges,45% of Total Billed Charges,94.27,90,,15.88,Percent of Total Billed Charges,90% of Total billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.08,65,,91.16,Percent of total Billed Charges,65% of Total Billed Charges,46.19,44.1,,94.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,99.5,95,,16.76,Percent of Total Billed Charges,95% of Total Billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.17,88,,15.52,Percent of Total Billed Charges,88% of Total Billed Charges,94.27,90,,15.88,Percent of Total Billed charges,90% of Total Billed Charges,46.19,104.74,
ALARIS SMARTSITE BUR,2720000863,CDM,272,RC,,,Outpatient,,,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,91.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,22.76,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,23.712,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,22.76,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,18.968,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,107.96,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,139.312,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,113.952,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,105.56,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,107.96,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
ALARIS SMARTSITE GRA,2720000864,CDM,272,RC,,,Outpatient,,,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,106.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,145.152,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,151.2,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,145.152,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,120.96,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,95.256,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,35.32,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,126.216,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,34.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,133.232,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,123.408,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,126.216,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
ALARIS 60 DROP GRAVI,2720000865,CDM,272,RC,,,Outpatient,,,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,162.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,7.144,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,7.44,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,7.144,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,5.952,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,342.92,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,41.672,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,192.896,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,51.024,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,40.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,203.608,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,188.608,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,192.896,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
ALEXIS RETRACTOR CS,2720000866,CDM,272,RC,,,Outpatient,,,229.32,149.06,,229.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,174.28,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,165.11,72,,76.08,Percent of Total Billed Charges,72% of Total Billed Charges,171.99,75,,79.248,Percent of Total Billed charges,75% of Total Billed Charges,229.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.11,72,,76.08,Percent of Total Billed Charges,72% of Total Billed Charges,137.59,60,,63.4,Percent of Total Billed Charges,60% of Total Billed Charges,206.39,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,103.19,45,,39.688,Percent of Total Billed Charges,45% of Total Billed Charges,206.39,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,229.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.06,65,,60.192,Percent of total Billed Charges,65% of Total Billed Charges,101.13,44.1,,38.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,217.85,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,229.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.8,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,206.39,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,101.13,229.32,
ENDOSCOPIC 5MM CLIP,2720000867,CDM,272,RC,,,Outpatient,,,201.76,131.14,,201.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,153.34,76,,59.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,145.27,72,,19.112,Percent of Total Billed Charges,72% of Total Billed Charges,151.32,75,,19.912,Percent of Total Billed charges,75% of Total Billed Charges,201.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.27,72,,19.112,Percent of Total Billed Charges,72% of Total Billed Charges,121.06,60,,15.928,Percent of Total Billed Charges,60% of Total Billed Charges,181.58,90,,72.24,Percent of Total Billed Charges,90% of Total Billed Charges,90.79,45,,29.376,Percent of Total Billed Charges,45% of Total Billed Charges,181.58,90,,70.648,Percent of Total Billed Charges,90% of Total billed Charges,201.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.14,65,,57.328,Percent of total Billed Charges,65% of Total Billed Charges,88.98,44.1,,28.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,191.67,95,,74.568,Percent of Total Billed Charges,95% of Total Billed Charges,201.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.55,88,,69.08,Percent of Total Billed Charges,88% of Total Billed Charges,181.58,90,,70.648,Percent of Total Billed charges,90% of Total Billed Charges,88.98,201.76,
ENSEAL LAPAROSCOPIC,2720000868,CDM,272,RC,,,Outpatient,,,551.25,358.31,,551.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,418.95,76,,70.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,396.9,72,,13.64,Percent of Total Billed Charges,72% of Total Billed Charges,413.44,75,,14.208,Percent of Total Billed charges,75% of Total Billed Charges,551.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.9,72,,13.64,Percent of Total Billed Charges,72% of Total Billed Charges,330.75,60,,11.368,Percent of Total Billed Charges,60% of Total Billed Charges,496.13,90,,2.776,Percent of Total Billed Charges,90% of Total Billed Charges,248.06,45,,43.264,Percent of Total Billed Charges,45% of Total Billed Charges,496.13,90,,83.344,Percent of Total Billed Charges,90% of Total billed Charges,551.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,551.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,551.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.31,65,,42.424,Percent of total Billed Charges,65% of Total Billed Charges,243.1,44.1,,42.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,523.69,95,,87.976,Percent of Total Billed Charges,95% of Total Billed Charges,551.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.1,88,,81.496,Percent of Total Billed Charges,88% of Total Billed Charges,496.13,90,,83.344,Percent of Total Billed charges,90% of Total Billed Charges,243.1,551.25,
MAGMA PORT TUBE 20,2720000869,CDM,272,RC,,,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,67.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,1.744,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,1.816,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,1.744,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,1.456,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,9.072,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,39.296,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,79.384,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,62.488,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,38.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,83.792,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,77.616,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,79.384,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
MAGMA PORT TUBE 22,2720000870,CDM,272,RC,,,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,49.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,9.448,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,9.84,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,9.448,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,7.872,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,5.504,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,58.744,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,56.76,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,62.008,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,57.44,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,58.744,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
LIGACLIP MCA MC520,2720000871,CDM,272,RC,,,Outpatient,,,68.36,44.43,,68.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.95,76,,73.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49.22,72,,3.856,Percent of Total Billed Charges,72% of Total Billed Charges,51.27,75,,4.024,Percent of Total Billed charges,75% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,72,,3.856,Percent of Total Billed Charges,72% of Total Billed Charges,41.02,60,,3.216,Percent of Total Billed Charges,60% of Total Billed Charges,61.52,90,,34.928,Percent of Total Billed Charges,90% of Total Billed Charges,30.76,45,,47.632,Percent of Total Billed Charges,45% of Total Billed Charges,61.52,90,,86.52,Percent of Total Billed Charges,90% of Total billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.43,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,30.15,44.1,,46.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,64.94,95,,91.328,Percent of Total Billed Charges,95% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.16,88,,84.6,Percent of Total Billed Charges,88% of Total Billed Charges,61.52,90,,86.52,Percent of Total Billed charges,90% of Total Billed Charges,30.15,68.36,
LIGACLIP MCA MSM20,2720000872,CDM,272,RC,,,Outpatient,,,164.27,106.78,,164.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.85,76,,66.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,118.27,72,,18.112,Percent of Total Billed Charges,72% of Total Billed Charges,123.2,75,,18.864,Percent of Total Billed charges,75% of Total Billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.27,72,,18.112,Percent of Total Billed Charges,72% of Total Billed Charges,98.56,60,,15.088,Percent of Total Billed Charges,60% of Total Billed Charges,147.84,90,,34.928,Percent of Total Billed Charges,90% of Total Billed Charges,73.92,45,,171.464,Percent of Total Billed Charges,45% of Total Billed Charges,147.84,90,,78.592,Percent of Total Billed Charges,90% of Total billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.78,65,,68.8,Percent of total Billed Charges,65% of Total Billed Charges,72.44,44.1,,168.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,156.06,95,,82.952,Percent of Total Billed Charges,95% of Total Billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.56,88,,76.84,Percent of Total Billed Charges,88% of Total Billed Charges,147.84,90,,78.592,Percent of Total Billed charges,90% of Total Billed Charges,72.44,164.27,
VESSEL LOOP WHITE,2720000873,CDM,272,RC,,,Outpatient,,,40.79,26.51,,40.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.37,72,,5.992,Percent of Total Billed Charges,72% of Total Billed Charges,30.59,75,,6.24,Percent of Total Billed charges,75% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.37,72,,5.992,Percent of Total Billed Charges,72% of Total Billed Charges,24.47,60,,4.992,Percent of Total Billed Charges,60% of Total Billed Charges,36.71,90,,34.928,Percent of Total Billed Charges,90% of Total Billed Charges,18.36,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,36.71,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.51,65,,247.664,Percent of total Billed Charges,65% of Total Billed Charges,17.99,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.75,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.9,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,36.71,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,17.99,40.79,
SUTURE BOOT YELLOW,2720000874,CDM,272,RC,,,Outpatient,,,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,80.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.88,72,,5.92,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,75,,6.168,Percent of Total Billed charges,75% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.88,72,,5.92,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,60,,4.936,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,36.12,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,95.256,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,35.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,100.552,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,93.136,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,95.256,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.05,
BLADE SUPER 15,2720000875,CDM,272,RC,,,Outpatient,,,59.54,38.70,,59.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.25,76,,289.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.87,72,,1.808,Percent of Total Billed Charges,72% of Total Billed Charges,44.66,75,,1.888,Percent of Total Billed charges,75% of Total Billed Charges,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.87,72,,1.808,Percent of Total Billed Charges,72% of Total Billed Charges,35.72,60,,1.504,Percent of Total Billed Charges,60% of Total Billed Charges,53.59,90,,52.392,Percent of Total Billed Charges,90% of Total Billed Charges,26.79,45,,1.392,Percent of Total Billed Charges,45% of Total Billed Charges,53.59,90,,342.92,Percent of Total Billed Charges,90% of Total billed Charges,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.7,65,,52.168,Percent of total Billed Charges,65% of Total Billed Charges,26.26,44.1,,1.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,56.56,95,,361.976,Percent of Total Billed Charges,95% of Total Billed Charges,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.4,88,,335.304,Percent of Total Billed Charges,88% of Total Billed Charges,53.59,90,,342.92,Percent of Total Billed charges,90% of Total Billed Charges,26.26,59.54,
V71 8MHZ PROBE TIP 2,2720000876,CDM,272,RC,,,Outpatient,,,101.43,65.93,,101.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,77.09,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,73.03,72,,67.216,Percent of Total Billed Charges,72% of Total Billed Charges,76.07,75,,70.016,Percent of Total Billed charges,75% of Total Billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.03,72,,67.216,Percent of Total Billed Charges,72% of Total Billed Charges,60.86,60,,56.008,Percent of Total Billed Charges,60% of Total Billed Charges,91.29,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,45.64,45,,4.536,Percent of Total Billed Charges,45% of Total Billed Charges,91.29,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.93,65,,2.008,Percent of total Billed Charges,65% of Total Billed Charges,44.73,44.1,,4.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,96.36,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.26,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,91.29,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,44.73,101.43,
V71 8MHZ PROBE TIP 3,2720000877,CDM,272,RC,,,Outpatient,,,101.43,65.93,,101.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,77.09,76,,61,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,73.03,72,,11.056,Percent of Total Billed Charges,72% of Total Billed Charges,76.07,75,,11.52,Percent of Total Billed charges,75% of Total Billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.03,72,,11.056,Percent of Total Billed Charges,72% of Total Billed Charges,60.86,60,,9.216,Percent of Total Billed Charges,60% of Total Billed Charges,91.29,90,,115.096,Percent of Total Billed Charges,90% of Total Billed Charges,45.64,45,,2.752,Percent of Total Billed Charges,45% of Total Billed Charges,91.29,90,,72.24,Percent of Total Billed Charges,90% of Total billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.93,65,,6.552,Percent of total Billed Charges,65% of Total Billed Charges,44.73,44.1,,2.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,96.36,95,,76.248,Percent of Total Billed Charges,95% of Total Billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.26,88,,70.632,Percent of Total Billed Charges,88% of Total Billed Charges,91.29,90,,72.24,Percent of Total Billed charges,90% of Total Billed Charges,44.73,101.43,
LINVATEC OVAL BUR,2720000878,CDM,272,RC,,,Outpatient,,,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,2.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,10.312,Percent of Total Billed Charges,72% of Total Billed Charges,22.33,75,,10.744,Percent of Total Billed charges,75% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,10.312,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,8.592,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,34.136,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,17.464,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,2.776,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,3.976,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,17.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,2.936,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,2.72,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,2.776,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
ENDOBUTTON BTB 20MM,2720000879,CDM,272,RC,,,Outpatient,,,861.05,559.68,,861.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,654.4,76,,7.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,619.96,72,,14.928,Percent of Total Billed Charges,72% of Total Billed Charges,645.79,75,,15.552,Percent of Total Billed charges,75% of Total Billed Charges,861.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,619.96,72,,14.928,Percent of Total Billed Charges,72% of Total Billed Charges,516.63,60,,12.44,Percent of Total Billed Charges,60% of Total Billed Charges,774.95,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,387.47,45,,17.464,Percent of Total Billed Charges,45% of Total Billed Charges,774.95,90,,9.072,Percent of Total Billed Charges,90% of Total billed Charges,861.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,861.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,861.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.68,65,,25.224,Percent of total Billed Charges,65% of Total Billed Charges,379.72,44.1,,17.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,818,95,,9.576,Percent of Total Billed Charges,95% of Total Billed Charges,861.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,757.72,88,,8.872,Percent of Total Billed Charges,88% of Total Billed Charges,774.95,90,,9.072,Percent of Total Billed charges,90% of Total Billed Charges,379.72,861.05,
ARTHROCARE KIT FIRST PASS,2720000880,CDM,272,RC,,,Outpatient,,,3620.61,2353.40,,3620.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2751.66,76,,4.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2606.84,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,2715.46,75,,150,Percent of Total Billed charges,75% of Total Billed Charges,3620.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2606.84,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,2172.37,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,3258.55,90,,92.872,Percent of Total Billed Charges,90% of Total Billed Charges,1629.27,45,,17.464,Percent of Total Billed Charges,45% of Total Billed Charges,3258.55,90,,5.504,Percent of Total Billed Charges,90% of Total billed Charges,3620.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3620.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3620.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2353.4,65,,25.224,Percent of total Billed Charges,65% of Total Billed Charges,1596.69,44.1,,17.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,3439.58,95,,5.808,Percent of Total Billed Charges,95% of Total Billed Charges,3620.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3186.14,88,,5.376,Percent of Total Billed Charges,88% of Total Billed Charges,3258.55,90,,5.504,Percent of Total Billed charges,90% of Total Billed Charges,1596.69,3620.61,
ARTHROCARE SPEEDSTITCH NEEDLE,2720000881,CDM,272,RC,,,Outpatient,,,60.64,39.42,,60.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.09,76,,29.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.66,72,,7.272,Percent of Total Billed Charges,72% of Total Billed Charges,45.48,75,,7.576,Percent of Total Billed charges,75% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,72,,7.272,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,60,,6.056,Percent of Total Billed Charges,60% of Total Billed Charges,54.58,90,,70.648,Percent of Total Billed Charges,90% of Total Billed Charges,27.29,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,54.58,90,,34.928,Percent of Total Billed Charges,90% of Total billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.42,65,,25.224,Percent of total Billed Charges,65% of Total Billed Charges,26.74,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.61,95,,36.864,Percent of Total Billed Charges,95% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.36,88,,34.152,Percent of Total Billed Charges,88% of Total Billed Charges,54.58,90,,34.928,Percent of Total Billed charges,90% of Total Billed Charges,26.74,60.64,
BIOMET WRISTFIX KIT,2720000882,CDM,272,RC,,,Outpatient,,,2786.02,1810.91,,2786.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2117.38,76,,29.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2005.93,72,,14.424,Percent of Total Billed Charges,72% of Total Billed Charges,2089.52,75,,15.024,Percent of Total Billed charges,75% of Total Billed Charges,2786.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2005.93,72,,14.424,Percent of Total Billed Charges,72% of Total Billed Charges,1671.61,60,,12.016,Percent of Total Billed Charges,60% of Total Billed Charges,2507.42,90,,41.28,Percent of Total Billed Charges,90% of Total Billed Charges,1253.71,45,,26.2,Percent of Total Billed Charges,45% of Total Billed Charges,2507.42,90,,34.928,Percent of Total Billed Charges,90% of Total billed Charges,2786.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2786.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2786.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1810.91,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,1228.63,44.1,,25.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,2646.72,95,,36.864,Percent of Total Billed Charges,95% of Total Billed Charges,2786.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2451.7,88,,34.152,Percent of Total Billed Charges,88% of Total Billed Charges,2507.42,90,,34.928,Percent of Total Billed charges,90% of Total Billed Charges,1228.63,2786.02,
BS GLIDEWIRE ENDO ANGLED TIP,2720000883,CDM,272,RC,,,Outpatient,,,74.97,48.73,,74.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.98,76,,29.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.98,72,,10.552,Percent of Total Billed Charges,72% of Total Billed Charges,56.23,75,,10.992,Percent of Total Billed charges,75% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.98,72,,10.552,Percent of Total Billed Charges,72% of Total Billed Charges,44.98,60,,8.792,Percent of Total Billed Charges,60% of Total Billed Charges,67.47,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,33.74,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,67.47,90,,34.928,Percent of Total Billed Charges,90% of Total billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.73,65,,37.84,Percent of total Billed Charges,65% of Total Billed Charges,33.06,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,71.22,95,,36.864,Percent of Total Billed Charges,95% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.97,88,,34.152,Percent of Total Billed Charges,88% of Total Billed Charges,67.47,90,,34.928,Percent of Total Billed charges,90% of Total Billed Charges,33.06,74.97,
BS GLIDEWIRE ENDO STRAIGHT TIP,2720000884,CDM,272,RC,,,Outpatient,,,74.97,48.73,,74.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.98,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.98,72,,12.168,Percent of Total Billed Charges,72% of Total Billed Charges,56.23,75,,12.672,Percent of Total Billed charges,75% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.98,72,,12.168,Percent of Total Billed Charges,72% of Total Billed Charges,44.98,60,,10.136,Percent of Total Billed Charges,60% of Total Billed Charges,67.47,90,,52.392,Percent of Total Billed Charges,90% of Total Billed Charges,33.74,45,,57.552,Percent of Total Billed Charges,45% of Total Billed Charges,67.47,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.73,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,33.06,44.1,,56.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,71.22,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.97,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,67.47,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,33.06,74.97,
BS SINGLE ACTION PUMP SYSTEM,2720000885,CDM,272,RC,,,Outpatient,,,82.69,53.75,,82.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.84,76,,44.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.54,72,,9.56,Percent of Total Billed Charges,72% of Total Billed Charges,62.02,75,,9.96,Percent of Total Billed charges,75% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,72,,9.56,Percent of Total Billed Charges,72% of Total Billed Charges,49.61,60,,7.968,Percent of Total Billed Charges,60% of Total Billed Charges,74.42,90,,50.8,Percent of Total Billed Charges,90% of Total Billed Charges,37.21,45,,17.064,Percent of Total Billed Charges,45% of Total Billed Charges,74.42,90,,52.392,Percent of Total Billed Charges,90% of Total billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.75,65,,83.128,Percent of total Billed Charges,65% of Total Billed Charges,36.47,44.1,,16.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,78.56,95,,55.304,Percent of Total Billed Charges,95% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,88,,51.232,Percent of Total Billed Charges,88% of Total Billed Charges,74.42,90,,52.392,Percent of Total Billed charges,90% of Total Billed Charges,36.47,82.69,
PATHFINDER PLUS BULB IRRIGATOR,2720000886,CDM,272,RC,,,Outpatient,,,96.20,62.53,,96.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.11,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.26,72,,6.624,Percent of Total Billed Charges,72% of Total Billed Charges,72.15,75,,6.904,Percent of Total Billed charges,75% of Total Billed Charges,96.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.26,72,,6.624,Percent of Total Billed Charges,72% of Total Billed Charges,57.72,60,,5.52,Percent of Total Billed Charges,60% of Total Billed Charges,86.58,90,,118.272,Percent of Total Billed Charges,90% of Total Billed Charges,43.29,45,,30.96,Percent of Total Billed Charges,45% of Total Billed Charges,86.58,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,96.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.53,65,,24.656,Percent of total Billed Charges,65% of Total Billed Charges,42.42,44.1,,30.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.39,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,96.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.66,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,86.58,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,42.42,96.2,
COOK FLO ADAPTER,2720000887,CDM,272,RC,,,Outpatient,,,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,97.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,7.952,Percent of Total Billed Charges,72% of Total Billed Charges,15.71,75,,8.28,Percent of Total Billed charges,75% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,7.952,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,6.624,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,123.04,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,46.44,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,115.096,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,44.72,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,45.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,121.496,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,112.544,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,115.096,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
WA22760S Olympus HF Elect BTN,2720000888,CDM,272,RC,,,Outpatient,,,1326.75,862.39,,1326.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1008.33,76,,28.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,955.26,72,,9.616,Percent of Total Billed Charges,72% of Total Billed Charges,995.06,75,,10.024,Percent of Total Billed charges,75% of Total Billed Charges,1326.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,955.26,72,,9.616,Percent of Total Billed Charges,72% of Total Billed Charges,796.05,60,,8.016,Percent of Total Billed Charges,60% of Total Billed Charges,1194.08,90,,29.368,Percent of Total Billed Charges,90% of Total Billed Charges,597.04,45,,35.32,Percent of Total Billed Charges,45% of Total Billed Charges,1194.08,90,,34.136,Percent of Total Billed Charges,90% of Total billed Charges,1326.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1326.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1326.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,862.39,65,,67.072,Percent of total Billed Charges,65% of Total Billed Charges,585.1,44.1,,34.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,1260.41,95,,36.032,Percent of Total Billed Charges,95% of Total Billed Charges,1326.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1167.54,88,,33.376,Percent of Total Billed Charges,88% of Total Billed Charges,1194.08,90,,34.136,Percent of Total Billed charges,90% of Total Billed Charges,585.1,1326.75,
CETERIX SUTURE PASSER,2720000889,CDM,272,RC,,,Outpatient,,,1212.75,788.29,,1212.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,921.69,76,,52.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,873.18,72,,9.616,Percent of Total Billed Charges,72% of Total Billed Charges,909.56,75,,10.024,Percent of Total Billed charges,75% of Total Billed Charges,1212.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,873.18,72,,9.616,Percent of Total Billed Charges,72% of Total Billed Charges,727.65,60,,8.016,Percent of Total Billed Charges,60% of Total Billed Charges,1091.48,90,,34.928,Percent of Total Billed Charges,90% of Total Billed Charges,545.74,45,,20.64,Percent of Total Billed Charges,45% of Total Billed Charges,1091.48,90,,61.92,Percent of Total Billed Charges,90% of Total billed Charges,1212.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1212.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1212.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,788.29,65,,51.024,Percent of total Billed Charges,65% of Total Billed Charges,534.82,44.1,,20.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,1152.11,95,,65.36,Percent of Total Billed Charges,95% of Total Billed Charges,1212.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1067.22,88,,60.544,Percent of Total Billed Charges,88% of Total Billed Charges,1091.48,90,,61.92,Percent of Total Billed charges,90% of Total Billed Charges,534.82,1212.75,
CETERIX KNOT PUSHER,2720000890,CDM,272,RC,,,Outpatient,,,469.67,305.29,,469.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,356.95,76,,78.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,338.16,72,,9.616,Percent of Total Billed Charges,72% of Total Billed Charges,352.25,75,,10.024,Percent of Total Billed charges,75% of Total Billed Charges,469.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,338.16,72,,9.616,Percent of Total Billed Charges,72% of Total Billed Charges,281.8,60,,8.016,Percent of Total Billed Charges,60% of Total Billed Charges,422.7,90,,23.816,Percent of Total Billed Charges,90% of Total Billed Charges,211.35,45,,30.96,Percent of Total Billed Charges,45% of Total Billed Charges,422.7,90,,92.872,Percent of Total Billed Charges,90% of Total billed Charges,469.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,469.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,469.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305.29,65,,29.808,Percent of total Billed Charges,65% of Total Billed Charges,207.12,44.1,,30.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,446.19,95,,98.032,Percent of Total Billed Charges,95% of Total Billed Charges,469.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.31,88,,90.808,Percent of Total Billed Charges,88% of Total Billed Charges,422.7,90,,92.872,Percent of Total Billed charges,90% of Total Billed Charges,207.12,469.67,
CETERIX 2.0 SUTURE,2720000891,CDM,272,RC,,,Outpatient,,,274.52,178.44,,274.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,208.64,76,,59.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,197.65,72,,76.328,Percent of Total Billed Charges,72% of Total Billed Charges,205.89,75,,79.512,Percent of Total Billed charges,75% of Total Billed Charges,274.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.65,72,,76.328,Percent of Total Billed Charges,72% of Total Billed Charges,164.71,60,,63.608,Percent of Total Billed Charges,60% of Total Billed Charges,247.07,90,,29.368,Percent of Total Billed Charges,90% of Total Billed Charges,123.53,45,,26.2,Percent of Total Billed Charges,45% of Total Billed Charges,247.07,90,,70.648,Percent of Total Billed Charges,90% of Total billed Charges,274.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.44,65,,44.72,Percent of total Billed Charges,65% of Total Billed Charges,121.06,44.1,,25.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,260.79,95,,74.568,Percent of Total Billed Charges,95% of Total Billed Charges,274.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.58,88,,69.08,Percent of Total Billed Charges,88% of Total Billed Charges,247.07,90,,70.648,Percent of Total Billed charges,90% of Total Billed Charges,121.06,274.52,
CETERIX O SUTURE,2720000892,CDM,272,RC,,,Outpatient,,,274.52,178.44,,274.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,208.64,76,,34.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,197.65,72,,76.328,Percent of Total Billed Charges,72% of Total Billed Charges,205.89,75,,79.512,Percent of Total Billed charges,75% of Total Billed Charges,274.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.65,72,,76.328,Percent of Total Billed Charges,72% of Total Billed Charges,164.71,60,,63.608,Percent of Total Billed Charges,60% of Total Billed Charges,247.07,90,,46.048,Percent of Total Billed Charges,90% of Total Billed Charges,123.53,45,,25.4,Percent of Total Billed Charges,45% of Total Billed Charges,247.07,90,,41.28,Percent of Total Billed Charges,90% of Total billed Charges,274.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.44,65,,37.84,Percent of total Billed Charges,65% of Total Billed Charges,121.06,44.1,,24.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,260.79,95,,43.568,Percent of Total Billed Charges,95% of Total Billed Charges,274.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.58,88,,40.36,Percent of Total Billed Charges,88% of Total Billed Charges,247.07,90,,41.28,Percent of Total Billed charges,90% of Total Billed Charges,121.06,274.52,
METRONIC TEST PACK,2720000893,CDM,272,RC,,,Outpatient,,,532.51,346.13,,532.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,404.71,76,,52.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,383.41,72,,76.328,Percent of Total Billed Charges,72% of Total Billed Charges,399.38,75,,79.512,Percent of Total Billed charges,75% of Total Billed Charges,532.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,383.41,72,,76.328,Percent of Total Billed Charges,72% of Total Billed Charges,319.51,60,,63.608,Percent of Total Billed Charges,60% of Total Billed Charges,479.26,90,,46.048,Percent of Total Billed Charges,90% of Total Billed Charges,239.63,45,,59.136,Percent of Total Billed Charges,45% of Total Billed Charges,479.26,90,,61.92,Percent of Total Billed Charges,90% of Total billed Charges,532.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,532.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,532.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.13,65,,36.688,Percent of total Billed Charges,65% of Total Billed Charges,234.84,44.1,,57.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,505.88,95,,65.36,Percent of Total Billed Charges,95% of Total Billed Charges,532.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,468.61,88,,60.544,Percent of Total Billed Charges,88% of Total Billed Charges,479.26,90,,61.92,Percent of Total Billed charges,90% of Total Billed Charges,234.84,532.51,
RESURE SEALANT,2720000894,CDM,272,RC,,,Outpatient,,,99.23,64.50,,99.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.41,76,,44.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71.45,72,,76.328,Percent of Total Billed Charges,72% of Total Billed Charges,74.42,75,,79.512,Percent of Total Billed charges,75% of Total Billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.45,72,,76.328,Percent of Total Billed Charges,72% of Total Billed Charges,59.54,60,,63.608,Percent of Total Billed Charges,60% of Total Billed Charges,89.31,90,,126.216,Percent of Total Billed Charges,90% of Total Billed Charges,44.65,45,,61.52,Percent of Total Billed Charges,45% of Total Billed Charges,89.31,90,,52.392,Percent of Total Billed Charges,90% of Total billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.5,65,,85.424,Percent of total Billed Charges,65% of Total Billed Charges,43.76,44.1,,60.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,94.27,95,,55.304,Percent of Total Billed Charges,95% of Total Billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.32,88,,51.232,Percent of Total Billed Charges,88% of Total Billed Charges,89.31,90,,52.392,Percent of Total Billed charges,90% of Total Billed Charges,43.76,99.23,
MANI OPTHAMIC KNIFE,2720000895,CDM,272,RC,,,Outpatient,,,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,42.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,120,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,96,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,121.448,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,14.688,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,50.8,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,88.864,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,14.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,53.624,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,49.672,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,50.8,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
BL I&A CAPSULE GUARD,2720000896,CDM,272,RC,,,Outpatient,,,40.79,26.51,,40.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31,76,,99.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.37,72,,69.216,Percent of Total Billed Charges,72% of Total Billed Charges,30.59,75,,72.104,Percent of Total Billed charges,75% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.37,72,,69.216,Percent of Total Billed Charges,72% of Total Billed Charges,24.47,60,,57.68,Percent of Total Billed Charges,60% of Total Billed Charges,36.71,90,,15.88,Percent of Total Billed Charges,90% of Total Billed Charges,18.36,45,,17.464,Percent of Total Billed Charges,45% of Total Billed Charges,36.71,90,,118.272,Percent of Total Billed Charges,90% of Total billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.51,65,,21.208,Percent of total Billed Charges,65% of Total Billed Charges,17.99,44.1,,17.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.75,95,,124.848,Percent of Total Billed Charges,95% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.9,88,,115.648,Percent of Total Billed Charges,88% of Total Billed Charges,36.71,90,,118.272,Percent of Total Billed charges,90% of Total Billed Charges,17.99,40.79,
EXPEEDA FIBER,2720000897,CDM,272,RC,,,Outpatient,,,1394.66,906.53,,1394.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1059.94,76,,103.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1004.16,72,,52.08,Percent of Total Billed Charges,72% of Total Billed Charges,1046,75,,54.248,Percent of Total Billed charges,75% of Total Billed Charges,1394.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1004.16,72,,52.08,Percent of Total Billed Charges,72% of Total Billed Charges,836.8,60,,43.4,Percent of Total Billed Charges,60% of Total Billed Charges,1255.19,90,,15.88,Percent of Total Billed Charges,90% of Total Billed Charges,627.6,45,,11.912,Percent of Total Billed Charges,45% of Total Billed Charges,1255.19,90,,123.04,Percent of Total Billed Charges,90% of Total billed Charges,1394.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1394.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1394.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,906.53,65,,25.224,Percent of total Billed Charges,65% of Total Billed Charges,615.05,44.1,,11.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,1324.93,95,,129.88,Percent of Total Billed Charges,95% of Total Billed Charges,1394.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1227.3,88,,120.304,Percent of Total Billed Charges,88% of Total Billed Charges,1255.19,90,,123.04,Percent of Total Billed charges,90% of Total Billed Charges,615.05,1394.66,
MST ALLEGRO I / A TIP,2720000898,CDM,272,RC,,,Outpatient,,,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,24.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,309.896,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,322.816,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,309.896,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,258.248,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,70.648,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,14.688,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,29.368,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,17.2,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,14.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,31,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,28.72,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,29.368,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
MST A1 RED SILICONE SLEEVE,2720000899,CDM,278,RC,,,Outpatient,,,17.64,11.47,,17.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.41,76,,29.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.7,72,,37.328,Percent of Total Billed Charges,72% of Total Billed Charges,12.7,72,,38.888,Percent of Total Billed charges,72% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.7,72,,37.328,Percent of Total Billed Charges,72% of Total Billed Charges,10.58,60,,31.112,Percent of Total Billed Charges,60% of Total Billed Charges,15.88,90,,15.88,Percent of Total Billed Charges,90% of Total Billed Charges,7.94,45,,23.024,Percent of Total Billed Charges,45% of Total Billed Charges,15.88,90,,34.928,Percent of Total Billed Charges,90% of Total billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.47,65,,21.208,Percent of total Billed Charges,65% of Total Billed Charges,7.78,44.1,,22.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.76,95,,36.864,Percent of Total Billed Charges,95% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.52,88,,34.152,Percent of Total Billed Charges,88% of Total Billed Charges,15.88,90,,34.928,Percent of Total Billed charges,90% of Total Billed Charges,7.78,17.64,
COOK BENTSON WIRE GUIDE,2720000900,CDM,272,RC,,,Outpatient,,,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,20.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,67.216,Percent of Total Billed Charges,72% of Total Billed Charges,22.33,75,,70.016,Percent of Total Billed charges,75% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,67.216,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,56.008,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,121.448,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,23.024,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,23.816,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,33.256,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,22.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,25.144,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,23.288,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,23.816,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
CLEAR-TRAC CANNULA 8.5 X 72,2720000901,CDM,272,RC,,,Outpatient,,,34.65,22.52,,34.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.33,76,,24.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.95,72,,24.28,Percent of Total Billed Charges,72% of Total Billed Charges,25.99,75,,25.288,Percent of Total Billed charges,75% of Total Billed Charges,34.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.95,72,,24.28,Percent of Total Billed Charges,72% of Total Billed Charges,20.79,60,,20.232,Percent of Total Billed Charges,60% of Total Billed Charges,31.19,90,,2.376,Percent of Total Billed Charges,90% of Total Billed Charges,15.59,45,,63.112,Percent of Total Billed Charges,45% of Total Billed Charges,31.19,90,,29.368,Percent of Total Billed Charges,90% of Total billed Charges,34.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.52,65,,33.256,Percent of total Billed Charges,65% of Total Billed Charges,15.28,44.1,,61.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.92,95,,31,Percent of Total Billed Charges,95% of Total Billed Charges,34.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.49,88,,28.72,Percent of Total Billed Charges,88% of Total Billed Charges,31.19,90,,29.368,Percent of Total Billed charges,90% of Total Billed Charges,15.28,34.65,
CLEAR-TRAC CANNULA 8 X 72,2720000902,CDM,272,RC,,,Outpatient,,,34.65,22.52,,34.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.33,76,,38.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.95,72,,13.248,Percent of Total Billed Charges,72% of Total Billed Charges,25.99,75,,13.8,Percent of Total Billed charges,75% of Total Billed Charges,34.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.95,72,,13.248,Percent of Total Billed Charges,72% of Total Billed Charges,20.79,60,,11.04,Percent of Total Billed Charges,60% of Total Billed Charges,31.19,90,,41.28,Percent of Total Billed Charges,90% of Total Billed Charges,15.59,45,,60.728,Percent of Total Billed Charges,45% of Total Billed Charges,31.19,90,,46.048,Percent of Total Billed Charges,90% of Total billed Charges,34.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.52,65,,91.16,Percent of total Billed Charges,65% of Total Billed Charges,15.28,44.1,,59.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.92,95,,48.6,Percent of Total Billed Charges,95% of Total Billed Charges,34.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.49,88,,45.024,Percent of Total Billed Charges,88% of Total Billed Charges,31.19,90,,46.048,Percent of Total Billed charges,90% of Total Billed Charges,15.28,34.65,
TAPERED AWL 3.8,2720000903,CDM,272,RC,,,Outpatient,,,63.00,40.95,,63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.88,76,,38.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.36,72,,13.248,Percent of Total Billed Charges,72% of Total Billed Charges,47.25,75,,13.8,Percent of Total Billed charges,75% of Total Billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.36,72,,13.248,Percent of Total Billed Charges,72% of Total Billed Charges,37.8,60,,11.04,Percent of Total Billed Charges,60% of Total Billed Charges,56.7,90,,23.816,Percent of Total Billed Charges,90% of Total Billed Charges,28.35,45,,7.936,Percent of Total Billed Charges,45% of Total Billed Charges,56.7,90,,46.048,Percent of Total Billed Charges,90% of Total billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.95,65,,87.712,Percent of total Billed Charges,65% of Total Billed Charges,27.78,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.85,95,,48.6,Percent of Total Billed Charges,95% of Total Billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.44,88,,45.024,Percent of Total Billed Charges,88% of Total Billed Charges,56.7,90,,46.048,Percent of Total Billed charges,90% of Total Billed Charges,27.78,63,
HEALCOIL DILATOR 4.75,2720000904,CDM,272,RC,,,Outpatient,,,1844.85,1199.15,,1844.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1402.09,76,,106.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1328.29,72,,21.888,Percent of Total Billed Charges,72% of Total Billed Charges,1383.64,75,,22.8,Percent of Total Billed charges,75% of Total Billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1328.29,72,,21.888,Percent of Total Billed Charges,72% of Total Billed Charges,1106.91,60,,18.24,Percent of Total Billed Charges,60% of Total Billed Charges,1660.37,90,,25.4,Percent of Total Billed Charges,90% of Total Billed Charges,830.18,45,,7.936,Percent of Total Billed Charges,45% of Total Billed Charges,1660.37,90,,126.216,Percent of Total Billed Charges,90% of Total billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1199.15,65,,11.464,Percent of total Billed Charges,65% of Total Billed Charges,813.58,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,1752.61,95,,133.232,Percent of Total Billed Charges,95% of Total Billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1623.47,88,,123.408,Percent of Total Billed Charges,88% of Total Billed Charges,1660.37,90,,126.216,Percent of Total Billed charges,90% of Total Billed Charges,813.58,1844.85,
S&N HEALCOIL PK WITH TAPE 5.5,2720000905,CDM,272,RC,,,Outpatient,,,1844.85,1199.15,,1844.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1402.09,76,,102.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1328.29,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,1383.64,75,,36,Percent of Total Billed charges,75% of Total Billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1328.29,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,1106.91,60,,28.8,Percent of Total Billed Charges,60% of Total Billed Charges,1660.37,90,,226.232,Percent of Total Billed Charges,90% of Total Billed Charges,830.18,45,,35.32,Percent of Total Billed Charges,45% of Total Billed Charges,1660.37,90,,121.448,Percent of Total Billed Charges,90% of Total billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1199.15,65,,11.464,Percent of total Billed Charges,65% of Total Billed Charges,813.58,44.1,,34.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,1752.61,95,,128.2,Percent of Total Billed Charges,95% of Total Billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1623.47,88,,118.752,Percent of Total Billed Charges,88% of Total Billed Charges,1660.37,90,,121.448,Percent of Total Billed charges,90% of Total Billed Charges,813.58,1844.85,
S&N MULTIFIX 5.5 PEEK,2720000906,CDM,272,RC,,,Outpatient,,,1844.85,1199.15,,1844.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1402.09,76,,13.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1328.29,72,,5.184,Percent of Total Billed Charges,72% of Total Billed Charges,1383.64,75,,5.4,Percent of Total Billed charges,75% of Total Billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1328.29,72,,5.184,Percent of Total Billed Charges,72% of Total Billed Charges,1106.91,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1660.37,90,,111.136,Percent of Total Billed Charges,90% of Total Billed Charges,830.18,45,,7.936,Percent of Total Billed Charges,45% of Total Billed Charges,1660.37,90,,15.88,Percent of Total Billed Charges,90% of Total billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1199.15,65,,51.024,Percent of total Billed Charges,65% of Total Billed Charges,813.58,44.1,,7.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,1752.61,95,,16.76,Percent of Total Billed Charges,95% of Total Billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1623.47,88,,15.52,Percent of Total Billed Charges,88% of Total Billed Charges,1660.37,90,,15.88,Percent of Total Billed charges,90% of Total Billed Charges,813.58,1844.85,
S&N MULTIFIX 6.5 PEEK,2720000907,CDM,272,RC,,,Outpatient,,,1844.85,1199.15,,1844.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1402.09,76,,13.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1328.29,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,1383.64,75,,1.2,Percent of Total Billed charges,75% of Total Billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1328.29,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,1106.91,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,1660.37,90,,123.04,Percent of Total Billed Charges,90% of Total Billed Charges,830.18,45,,60.728,Percent of Total Billed Charges,45% of Total Billed Charges,1660.37,90,,15.88,Percent of Total Billed Charges,90% of Total billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1199.15,65,,11.464,Percent of total Billed Charges,65% of Total Billed Charges,813.58,44.1,,59.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,1752.61,95,,16.76,Percent of Total Billed Charges,95% of Total Billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1623.47,88,,15.52,Percent of Total Billed Charges,88% of Total Billed Charges,1660.37,90,,15.88,Percent of Total Billed charges,90% of Total Billed Charges,813.58,1844.85,
ACUMED WS 1505 ST K WIER,2720000908,CDM,272,RC,,,Outpatient,,,25.20,16.38,,25.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.15,76,,59.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.14,72,,35.136,Percent of Total Billed Charges,72% of Total Billed Charges,18.9,75,,36.6,Percent of Total Billed charges,75% of Total Billed Charges,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.14,72,,35.136,Percent of Total Billed Charges,72% of Total Billed Charges,15.12,60,,29.28,Percent of Total Billed Charges,60% of Total Billed Charges,22.68,90,,25.4,Percent of Total Billed Charges,90% of Total Billed Charges,11.34,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,22.68,90,,70.648,Percent of Total Billed Charges,90% of Total billed Charges,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.38,65,,87.712,Percent of total Billed Charges,65% of Total Billed Charges,11.11,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.94,95,,74.568,Percent of Total Billed Charges,95% of Total Billed Charges,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.18,88,,69.08,Percent of Total Billed Charges,88% of Total Billed Charges,22.68,90,,70.648,Percent of Total Billed charges,90% of Total Billed Charges,11.11,25.2,
SMITH NEPHEW DISP FACE MASK,2720000909,CDM,272,RC,,,Outpatient,,,31.50,20.48,,31.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.94,76,,13.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.68,72,,35.136,Percent of Total Billed Charges,72% of Total Billed Charges,23.63,75,,36.6,Percent of Total Billed charges,75% of Total Billed Charges,31.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.68,72,,35.136,Percent of Total Billed Charges,72% of Total Billed Charges,18.9,60,,29.28,Percent of Total Billed Charges,60% of Total Billed Charges,28.35,90,,23.816,Percent of Total Billed Charges,90% of Total Billed Charges,14.18,45,,20.64,Percent of Total Billed Charges,45% of Total Billed Charges,28.35,90,,15.88,Percent of Total Billed Charges,90% of Total billed Charges,31.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.48,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,13.89,44.1,,20.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.93,95,,16.76,Percent of Total Billed Charges,95% of Total Billed Charges,31.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.72,88,,15.52,Percent of Total Billed Charges,88% of Total Billed Charges,28.35,90,,15.88,Percent of Total Billed charges,90% of Total Billed Charges,13.89,31.5,
SMITH NEPHEW ULTRA TAPE,2720000910,CDM,272,RC,,,Outpatient,,,157.50,102.38,,157.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,119.7,76,,102.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,113.4,72,,30.528,Percent of Total Billed Charges,72% of Total Billed Charges,118.13,75,,31.8,Percent of Total Billed charges,75% of Total Billed Charges,157.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.4,72,,30.528,Percent of Total Billed Charges,72% of Total Billed Charges,94.5,60,,25.44,Percent of Total Billed Charges,60% of Total Billed Charges,141.75,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,70.88,45,,11.912,Percent of Total Billed Charges,45% of Total Billed Charges,141.75,90,,121.448,Percent of Total Billed Charges,90% of Total billed Charges,157.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.38,65,,29.808,Percent of total Billed Charges,65% of Total Billed Charges,69.46,44.1,,11.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,149.63,95,,128.2,Percent of Total Billed Charges,95% of Total Billed Charges,157.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.6,88,,118.752,Percent of Total Billed Charges,88% of Total Billed Charges,141.75,90,,121.448,Percent of Total Billed charges,90% of Total Billed Charges,69.46,157.5,
CETERIX CARTRIDGE IMPLANT,2720000911,CDM,272,RC,,,Outpatient,,,1882.65,1223.72,,1882.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1430.81,76,,2.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1355.51,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,1411.99,75,,1.2,Percent of Total Billed charges,75% of Total Billed Charges,1882.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1355.51,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,1129.59,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,1694.39,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,847.19,45,,12.704,Percent of Total Billed Charges,45% of Total Billed Charges,1694.39,90,,2.376,Percent of Total Billed Charges,90% of Total billed Charges,1882.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1882.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1882.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1223.72,65,,17.2,Percent of total Billed Charges,65% of Total Billed Charges,830.25,44.1,,12.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,1788.52,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,1882.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1656.73,88,,2.32,Percent of Total Billed Charges,88% of Total Billed Charges,1694.39,90,,2.376,Percent of Total Billed charges,90% of Total Billed Charges,830.25,1882.65,
BIOMET IRRIGATION TUBING,2720000912,CDM,272,RC,,,Outpatient,,,185.85,120.80,,185.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,141.25,76,,34.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,133.81,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,139.39,75,,1.2,Percent of Total Billed charges,75% of Total Billed Charges,185.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.81,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,111.51,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,167.27,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,83.63,45,,113.112,Percent of Total Billed Charges,45% of Total Billed Charges,167.27,90,,41.28,Percent of Total Billed Charges,90% of Total billed Charges,185.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.8,65,,18.344,Percent of total Billed Charges,65% of Total Billed Charges,81.96,44.1,,110.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,176.56,95,,43.568,Percent of Total Billed Charges,95% of Total Billed Charges,185.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.55,88,,40.36,Percent of Total Billed Charges,88% of Total Billed Charges,167.27,90,,41.28,Percent of Total Billed charges,90% of Total Billed Charges,81.96,185.85,
BIOMET 423883 6.5 OSTEOTOME,2720000913,CDM,272,RC,,,Outpatient,,,784.35,509.83,,784.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,596.11,76,,20.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,564.73,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,588.26,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,784.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,564.73,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,470.61,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,705.92,90,,7.96,Percent of Total Billed Charges,90% of Total Billed Charges,352.96,45,,55.568,Percent of Total Billed Charges,45% of Total Billed Charges,705.92,90,,23.816,Percent of Total Billed Charges,90% of Total billed Charges,784.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,784.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,784.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,509.83,65,,163.392,Percent of total Billed Charges,65% of Total Billed Charges,345.9,44.1,,54.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,745.13,95,,25.144,Percent of Total Billed Charges,95% of Total Billed Charges,784.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,690.23,88,,23.288,Percent of Total Billed Charges,88% of Total Billed Charges,705.92,90,,23.816,Percent of Total Billed charges,90% of Total Billed Charges,345.9,784.35,
BIOMET ULTRADRIVE KIT,2720000914,CDM,272,RC,,,Outpatient,,,1732.50,1126.13,,1732.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1316.7,76,,21.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1247.4,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,1299.38,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,1732.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1247.4,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,1039.5,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,1559.25,90,,7.96,Percent of Total Billed Charges,90% of Total Billed Charges,779.63,45,,61.52,Percent of Total Billed Charges,45% of Total Billed Charges,1559.25,90,,25.4,Percent of Total Billed Charges,90% of Total billed Charges,1732.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1732.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1732.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1126.13,65,,80.264,Percent of total Billed Charges,65% of Total Billed Charges,764.03,44.1,,60.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,1645.88,95,,26.816,Percent of Total Billed Charges,95% of Total Billed Charges,1732.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1524.6,88,,24.84,Percent of Total Billed Charges,88% of Total Billed Charges,1559.25,90,,25.4,Percent of Total Billed charges,90% of Total Billed Charges,764.03,1732.5,
EXTENDER ULTRA DRIVE 60MM BMET,2720000915,CDM,272,RC,,,Outpatient,,,784.35,509.83,,784.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,596.11,76,,191.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,564.73,72,,255.92,Percent of Total Billed Charges,72% of Total Billed Charges,588.26,75,,266.584,Percent of Total Billed charges,75% of Total Billed Charges,784.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,564.73,72,,255.92,Percent of Total Billed Charges,72% of Total Billed Charges,470.61,60,,213.272,Percent of Total Billed Charges,60% of Total Billed Charges,705.92,90,,18.264,Percent of Total Billed Charges,90% of Total Billed Charges,352.96,45,,12.704,Percent of Total Billed Charges,45% of Total Billed Charges,705.92,90,,226.232,Percent of Total Billed Charges,90% of Total billed Charges,784.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,784.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,784.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,509.83,65,,88.864,Percent of total Billed Charges,65% of Total Billed Charges,345.9,44.1,,12.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,745.13,95,,238.8,Percent of Total Billed Charges,95% of Total Billed Charges,784.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,690.23,88,,221.2,Percent of Total Billed Charges,88% of Total Billed Charges,705.92,90,,226.232,Percent of Total Billed charges,90% of Total Billed Charges,345.9,784.35,
GOUGE ULTRA DRIVE 8MM BMET,2720000916,CDM,272,RC,,,Outpatient,,,784.35,509.83,,784.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,596.11,76,,93.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,564.73,72,,140.984,Percent of Total Billed Charges,72% of Total Billed Charges,588.26,75,,146.856,Percent of Total Billed charges,75% of Total Billed Charges,784.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,564.73,72,,140.984,Percent of Total Billed Charges,72% of Total Billed Charges,470.61,60,,117.488,Percent of Total Billed Charges,60% of Total Billed Charges,705.92,90,,18.264,Percent of Total Billed Charges,90% of Total Billed Charges,352.96,45,,11.912,Percent of Total Billed Charges,45% of Total Billed Charges,705.92,90,,111.136,Percent of Total Billed Charges,90% of Total billed Charges,784.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,784.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,784.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,509.83,65,,18.344,Percent of total Billed Charges,65% of Total Billed Charges,345.9,44.1,,11.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,745.13,95,,117.304,Percent of Total Billed Charges,95% of Total Billed Charges,784.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,690.23,88,,108.664,Percent of Total Billed Charges,88% of Total Billed Charges,705.92,90,,111.136,Percent of Total Billed charges,90% of Total Billed Charges,345.9,784.35,
PCE45A POWERED LINEAR STAPLER,2720000917,CDM,272,RC,,,Outpatient,,,612.00,397.80,,612,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.12,76,,103.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.64,72,,177.176,Percent of Total Billed Charges,72% of Total Billed Charges,459,75,,184.56,Percent of Total Billed charges,75% of Total Billed Charges,612,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.64,72,,177.176,Percent of Total Billed Charges,72% of Total Billed Charges,367.2,60,,147.648,Percent of Total Billed Charges,60% of Total Billed Charges,550.8,90,,18.264,Percent of Total Billed Charges,90% of Total Billed Charges,275.4,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,550.8,90,,123.04,Percent of Total Billed Charges,90% of Total billed Charges,612,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.8,65,,17.2,Percent of total Billed Charges,65% of Total Billed Charges,269.89,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.4,95,,129.88,Percent of Total Billed Charges,95% of Total Billed Charges,612,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.56,88,,120.304,Percent of Total Billed Charges,88% of Total Billed Charges,550.8,90,,123.04,Percent of Total Billed charges,90% of Total Billed Charges,269.89,612,
Z24803641 4.0 CANN SCW 36MM,2720000918,CDM,272,RC,,,Outpatient,,,176.00,114.40,,176,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,133.76,76,,21.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,126.72,72,,106.688,Percent of Total Billed Charges,72% of Total Billed Charges,132,75,,111.136,Percent of Total Billed charges,75% of Total Billed Charges,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.72,72,,106.688,Percent of Total Billed Charges,72% of Total Billed Charges,105.6,60,,88.904,Percent of Total Billed Charges,60% of Total Billed Charges,158.4,90,,102.12,Percent of Total Billed Charges,90% of Total Billed Charges,79.2,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,158.4,90,,25.4,Percent of Total Billed Charges,90% of Total billed Charges,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.4,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,77.62,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,167.2,95,,26.816,Percent of Total Billed Charges,95% of Total Billed Charges,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.88,88,,24.84,Percent of Total Billed Charges,88% of Total Billed Charges,158.4,90,,25.4,Percent of Total Billed charges,90% of Total Billed Charges,77.62,176,
Z480718025 FLUTED DRILL BIT,2720000919,CDM,272,RC,,,Outpatient,,,385.00,250.25,,385,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,292.6,76,,20.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,277.2,72,,40.008,Percent of Total Billed Charges,72% of Total Billed Charges,288.75,75,,41.68,Percent of Total Billed charges,75% of Total Billed Charges,385,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.2,72,,40.008,Percent of Total Billed Charges,72% of Total Billed Charges,231,60,,33.344,Percent of Total Billed Charges,60% of Total Billed Charges,346.5,90,,111.736,Percent of Total Billed Charges,90% of Total Billed Charges,173.25,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,346.5,90,,23.816,Percent of Total Billed Charges,90% of Total billed Charges,385,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.25,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,169.79,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,365.75,95,,25.144,Percent of Total Billed Charges,95% of Total Billed Charges,385,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,338.8,88,,23.288,Percent of Total Billed Charges,88% of Total Billed Charges,346.5,90,,23.816,Percent of Total Billed charges,90% of Total Billed Charges,169.79,385,
Z236017127 DRILL BIT,2720000920,CDM,272,RC,,,Outpatient,,,205.00,133.25,,205,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,155.8,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,147.6,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,153.75,75,,21.168,Percent of Total Billed charges,75% of Total Billed Charges,205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.6,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,123,60,,16.936,Percent of Total Billed Charges,60% of Total Billed Charges,184.5,90,,11.808,Percent of Total Billed Charges,90% of Total Billed Charges,92.25,45,,3.976,Percent of Total Billed Charges,45% of Total Billed Charges,184.5,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.25,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,90.41,44.1,,3.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,194.75,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.4,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,184.5,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,90.41,205,
Z236020527 DRILL BIT,2720000921,CDM,272,RC,,,Outpatient,,,155.00,100.75,,155,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,117.8,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.6,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,116.25,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.6,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,93,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,139.5,90,,11.096,Percent of Total Billed Charges,90% of Total Billed Charges,69.75,45,,3.976,Percent of Total Billed Charges,45% of Total Billed Charges,139.5,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.75,65,,5.744,Percent of total Billed Charges,65% of Total Billed Charges,68.36,44.1,,3.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,147.25,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.4,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,139.5,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,68.36,155,
ACUMED HT 0915 1.5 HEX DRIVER,2720000922,CDM,272,RC,,,Outpatient,,,339.00,220.35,,339,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,257.64,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,244.08,72,,108.592,Percent of Total Billed Charges,72% of Total Billed Charges,254.25,75,,113.12,Percent of Total Billed charges,75% of Total Billed Charges,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.08,72,,108.592,Percent of Total Billed Charges,72% of Total Billed Charges,203.4,60,,90.496,Percent of Total Billed Charges,60% of Total Billed Charges,305.1,90,,12.04,Percent of Total Billed Charges,90% of Total Billed Charges,152.55,45,,9.136,Percent of Total Billed Charges,45% of Total Billed Charges,305.1,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.35,65,,5.744,Percent of total Billed Charges,65% of Total Billed Charges,149.5,44.1,,8.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,322.05,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.32,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,305.1,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,149.5,339,
JACKSON PRATT 100CC RESERVOIR,2720000923,CDM,272,RC,,,Outpatient,,,23.00,14.95,,23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.48,76,,6.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.56,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,17.25,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.56,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,13.8,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,20.7,90,,100.608,Percent of Total Billed Charges,90% of Total Billed Charges,10.35,45,,9.136,Percent of Total Billed Charges,45% of Total Billed Charges,20.7,90,,7.96,Percent of Total Billed Charges,90% of Total billed Charges,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.95,65,,13.192,Percent of total Billed Charges,65% of Total Billed Charges,10.14,44.1,,8.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.85,95,,8.4,Percent of Total Billed Charges,95% of Total Billed Charges,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.24,88,,7.776,Percent of Total Billed Charges,88% of Total Billed Charges,20.7,90,,7.96,Percent of Total Billed charges,90% of Total Billed Charges,10.14,23,
JACKSON PRATT ROUND DRAIN 19FR,2720000924,CDM,272,RC,,,Outpatient,,,61.00,39.65,,61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.36,76,,6.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.92,72,,19.352,Percent of Total Billed Charges,72% of Total Billed Charges,45.75,75,,20.16,Percent of Total Billed charges,75% of Total Billed Charges,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.92,72,,19.352,Percent of Total Billed Charges,72% of Total Billed Charges,36.6,60,,16.128,Percent of Total Billed Charges,60% of Total Billed Charges,54.9,90,,100.608,Percent of Total Billed Charges,90% of Total Billed Charges,27.45,45,,9.136,Percent of Total Billed Charges,45% of Total Billed Charges,54.9,90,,7.96,Percent of Total Billed Charges,90% of Total billed Charges,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.65,65,,13.192,Percent of total Billed Charges,65% of Total Billed Charges,26.9,44.1,,8.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.95,95,,8.4,Percent of Total Billed Charges,95% of Total Billed Charges,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.68,88,,7.776,Percent of Total Billed Charges,88% of Total Billed Charges,54.9,90,,7.96,Percent of Total Billed charges,90% of Total Billed Charges,26.9,61,
CAR THOM CLOSE SYSTEM,2720000925,CDM,272,RC,,,Outpatient,,,155.00,100.75,,155,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,117.8,76,,15.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.6,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,116.25,75,,91.288,Percent of Total Billed charges,75% of Total Billed Charges,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.6,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,93,60,,73.032,Percent of Total Billed Charges,60% of Total Billed Charges,139.5,90,,8.512,Percent of Total Billed Charges,90% of Total Billed Charges,69.75,45,,51.056,Percent of Total Billed Charges,45% of Total Billed Charges,139.5,90,,18.264,Percent of Total Billed Charges,90% of Total billed Charges,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.75,65,,13.192,Percent of total Billed Charges,65% of Total Billed Charges,68.36,44.1,,50.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,147.25,95,,19.28,Percent of Total Billed Charges,95% of Total Billed Charges,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.4,88,,17.864,Percent of Total Billed Charges,88% of Total Billed Charges,139.5,90,,18.264,Percent of Total Billed charges,90% of Total Billed Charges,68.36,155,
CAR THOM CLOSE SYS XL,2720000926,CDM,272,RC,,,Outpatient,,,202.00,131.30,,202,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,153.52,76,,15.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,145.44,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,151.5,75,,14.56,Percent of Total Billed charges,75% of Total Billed Charges,202,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.44,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,121.2,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,181.8,90,,10.72,Percent of Total Billed Charges,90% of Total Billed Charges,90.9,45,,55.872,Percent of Total Billed Charges,45% of Total Billed Charges,181.8,90,,18.264,Percent of Total Billed Charges,90% of Total billed Charges,202,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.3,65,,73.752,Percent of total Billed Charges,65% of Total Billed Charges,89.08,44.1,,54.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,191.9,95,,19.28,Percent of Total Billed Charges,95% of Total Billed Charges,202,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.76,88,,17.864,Percent of Total Billed Charges,88% of Total Billed Charges,181.8,90,,18.264,Percent of Total Billed charges,90% of Total Billed Charges,89.08,202,
CLARIFY VIS SYSTEM(DHELP),2720000927,CDM,272,RC,,,Outpatient,,,55.00,35.75,,55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.8,76,,15.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.6,72,,45.72,Percent of Total Billed Charges,72% of Total Billed Charges,41.25,75,,47.632,Percent of Total Billed charges,75% of Total Billed Charges,55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.6,72,,45.72,Percent of Total Billed Charges,72% of Total Billed Charges,33,60,,38.104,Percent of Total Billed Charges,60% of Total Billed Charges,49.5,90,,1.208,Percent of Total Billed Charges,90% of Total Billed Charges,24.75,45,,5.904,Percent of Total Billed Charges,45% of Total Billed Charges,49.5,90,,18.264,Percent of Total Billed Charges,90% of Total billed Charges,55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.75,65,,80.696,Percent of total Billed Charges,65% of Total Billed Charges,24.26,44.1,,5.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.25,95,,19.28,Percent of Total Billed Charges,95% of Total Billed Charges,55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.4,88,,17.864,Percent of Total Billed Charges,88% of Total Billed Charges,49.5,90,,18.264,Percent of Total Billed charges,90% of Total Billed Charges,24.26,55,
CONMED L HOOK ELECTRODE,2720000928,CDM,272,RC,,,Outpatient,,,27.64,17.97,,27.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21.01,76,,86.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.9,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,20.73,75,,49.616,Percent of Total Billed charges,75% of Total Billed Charges,27.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.9,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,16.58,60,,39.688,Percent of Total Billed Charges,60% of Total Billed Charges,24.88,90,,85.528,Percent of Total Billed Charges,90% of Total Billed Charges,12.44,45,,5.544,Percent of Total Billed Charges,45% of Total Billed Charges,24.88,90,,102.12,Percent of Total Billed Charges,90% of Total billed Charges,27.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.97,65,,8.528,Percent of total Billed Charges,65% of Total Billed Charges,12.19,44.1,,5.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.26,95,,107.792,Percent of Total Billed Charges,95% of Total Billed Charges,27.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.32,88,,99.848,Percent of Total Billed Charges,88% of Total Billed Charges,24.88,90,,102.12,Percent of Total Billed charges,90% of Total Billed Charges,12.19,27.64,
CONTOUR CUTTER STAPLER CS40G,2720000929,CDM,272,RC,,,Outpatient,,,387.00,251.55,,387,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,294.12,76,,94.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,278.64,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,290.25,75,,28.448,Percent of Total Billed charges,75% of Total Billed Charges,387,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.64,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,232.2,60,,22.76,Percent of Total Billed Charges,60% of Total Billed Charges,348.3,90,,111.736,Percent of Total Billed Charges,90% of Total Billed Charges,174.15,45,,6.016,Percent of Total Billed Charges,45% of Total Billed Charges,348.3,90,,111.736,Percent of Total Billed Charges,90% of Total billed Charges,387,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,387,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,387,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.55,65,,8.016,Percent of total Billed Charges,65% of Total Billed Charges,170.67,44.1,,5.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,367.65,95,,117.944,Percent of Total Billed Charges,95% of Total Billed Charges,387,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.56,88,,109.256,Percent of Total Billed Charges,88% of Total Billed Charges,348.3,90,,111.736,Percent of Total Billed charges,90% of Total Billed Charges,170.67,387,
RELOAD CR40B CONTOUR BLUE,2720000930,CDM,272,RC,,,Outpatient,,,212.00,137.80,,212,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.12,76,,9.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,152.64,72,,66.048,Percent of Total Billed Charges,72% of Total Billed Charges,159,75,,68.8,Percent of Total Billed charges,75% of Total Billed Charges,212,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.64,72,,66.048,Percent of Total Billed Charges,72% of Total Billed Charges,127.2,60,,55.04,Percent of Total Billed Charges,60% of Total Billed Charges,190.8,90,,136.2,Percent of Total Billed Charges,90% of Total Billed Charges,95.4,45,,50.304,Percent of Total Billed Charges,45% of Total Billed Charges,190.8,90,,11.808,Percent of Total Billed Charges,90% of Total billed Charges,212,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.8,65,,8.696,Percent of total Billed Charges,65% of Total Billed Charges,93.49,44.1,,49.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,201.4,95,,12.464,Percent of Total Billed Charges,95% of Total Billed Charges,212,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.56,88,,11.544,Percent of Total Billed Charges,88% of Total Billed Charges,190.8,90,,11.808,Percent of Total Billed charges,90% of Total Billed Charges,93.49,212,
CONMED DISP CABLE,2720000931,CDM,272,RC,,,Outpatient,,,5.00,3.25,,5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.8,76,,9.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.6,72,,159.4,Percent of Total Billed Charges,72% of Total Billed Charges,3.75,75,,166.04,Percent of Total Billed charges,75% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.6,72,,159.4,Percent of Total Billed Charges,72% of Total Billed Charges,3,60,,132.832,Percent of Total Billed Charges,60% of Total Billed Charges,4.5,90,,90.736,Percent of Total Billed Charges,90% of Total Billed Charges,2.25,45,,50.304,Percent of Total Billed Charges,45% of Total Billed Charges,4.5,90,,11.096,Percent of Total Billed Charges,90% of Total billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.25,65,,72.656,Percent of total Billed Charges,65% of Total Billed Charges,2.21,44.1,,49.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.75,95,,11.712,Percent of Total Billed Charges,95% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.4,88,,10.848,Percent of Total Billed Charges,88% of Total Billed Charges,4.5,90,,11.096,Percent of Total Billed charges,90% of Total Billed Charges,2.21,5,
CHLORAPREP ORANGE 10.5 ML,2720000932,CDM,272,RC,,,Outpatient,,,4.00,2.60,,4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.04,76,,10.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.88,72,,313.072,Percent of Total Billed Charges,72% of Total Billed Charges,3,75,,326.12,Percent of Total Billed charges,75% of Total Billed Charges,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.88,72,,313.072,Percent of Total Billed Charges,72% of Total Billed Charges,2.4,60,,260.896,Percent of Total Billed Charges,60% of Total Billed Charges,3.6,90,,90.736,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,45,,4.256,Percent of Total Billed Charges,45% of Total Billed Charges,3.6,90,,12.04,Percent of Total Billed Charges,90% of Total billed Charges,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.6,65,,72.656,Percent of total Billed Charges,65% of Total Billed Charges,1.76,44.1,,4.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.8,95,,12.704,Percent of Total Billed Charges,95% of Total Billed Charges,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.52,88,,11.768,Percent of Total Billed Charges,88% of Total Billed Charges,3.6,90,,12.04,Percent of Total Billed charges,90% of Total Billed Charges,1.76,4,
TRAXI EXTENDER,2720000933,CDM,272,RC,,,Outpatient,,,54.00,35.10,,54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.04,76,,84.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.88,72,,435.64,Percent of Total Billed Charges,72% of Total Billed Charges,40.5,75,,453.792,Percent of Total Billed charges,75% of Total Billed Charges,54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.88,72,,435.64,Percent of Total Billed Charges,72% of Total Billed Charges,32.4,60,,363.032,Percent of Total Billed Charges,60% of Total Billed Charges,48.6,90,,90.736,Percent of Total Billed Charges,90% of Total Billed Charges,24.3,45,,5.36,Percent of Total Billed Charges,45% of Total Billed Charges,48.6,90,,100.608,Percent of Total Billed Charges,90% of Total billed Charges,54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.1,65,,6.144,Percent of total Billed Charges,65% of Total Billed Charges,23.81,44.1,,5.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,51.3,95,,106.192,Percent of Total Billed Charges,95% of Total Billed Charges,54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.52,88,,98.368,Percent of Total Billed Charges,88% of Total Billed Charges,48.6,90,,100.608,Percent of Total Billed charges,90% of Total Billed Charges,23.81,54,
HARMONIC 1000 SHEARS 36CM,2720000934,CDM,272,RC,,,Outpatient,,,589.00,382.85,,589,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,447.64,76,,84.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,424.08,72,,556.296,Percent of Total Billed Charges,72% of Total Billed Charges,441.75,75,,579.472,Percent of Total Billed charges,75% of Total Billed Charges,589,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.08,72,,556.296,Percent of Total Billed Charges,72% of Total Billed Charges,353.4,60,,463.576,Percent of Total Billed Charges,60% of Total Billed Charges,530.1,90,,96.408,Percent of Total Billed Charges,90% of Total Billed Charges,265.05,45,,0.608,Percent of Total Billed Charges,45% of Total Billed Charges,530.1,90,,100.608,Percent of Total Billed Charges,90% of Total billed Charges,589,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,589,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,589,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.85,65,,7.744,Percent of total Billed Charges,65% of Total Billed Charges,259.75,44.1,,0.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,559.55,95,,106.192,Percent of Total Billed Charges,95% of Total Billed Charges,589,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,518.32,88,,98.368,Percent of Total Billed Charges,88% of Total Billed Charges,530.1,90,,100.608,Percent of Total Billed charges,90% of Total Billed Charges,259.75,589,
TRAXI RETRACT,2720000935,CDM,272,RC,,,Outpatient,,,66.00,42.90,,66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,50.16,76,,7.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47.52,72,,8766.096,Percent of Total Billed Charges,72% of Total Billed Charges,49.5,75,,9131.344,Percent of Total Billed charges,75% of Total Billed Charges,66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.52,72,,8766.096,Percent of Total Billed Charges,72% of Total Billed Charges,39.6,60,,7305.08,Percent of Total Billed Charges,60% of Total Billed Charges,59.4,90,,96.408,Percent of Total Billed Charges,90% of Total Billed Charges,29.7,45,,42.768,Percent of Total Billed Charges,45% of Total Billed Charges,59.4,90,,8.512,Percent of Total Billed Charges,90% of Total billed Charges,66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.9,65,,0.872,Percent of total Billed Charges,65% of Total Billed Charges,29.11,44.1,,41.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.7,95,,8.984,Percent of Total Billed Charges,95% of Total Billed Charges,66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.08,88,,8.32,Percent of Total Billed Charges,88% of Total Billed Charges,59.4,90,,8.512,Percent of Total Billed charges,90% of Total Billed Charges,29.11,66,
ACCUSOUND UTERINE SOUND,2720000936,CDM,272,RC,,,Outpatient,,,4.00,2.60,,4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.04,76,,9.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.88,72,,5900.792,Percent of Total Billed Charges,72% of Total Billed Charges,3,75,,6146.656,Percent of Total Billed charges,75% of Total Billed Charges,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.88,72,,5900.792,Percent of Total Billed Charges,72% of Total Billed Charges,2.4,60,,4917.328,Percent of Total Billed Charges,60% of Total Billed Charges,3.6,90,,96.408,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,45,,55.872,Percent of Total Billed Charges,45% of Total Billed Charges,3.6,90,,10.72,Percent of Total Billed Charges,90% of Total billed Charges,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.6,65,,61.768,Percent of total Billed Charges,65% of Total Billed Charges,1.76,44.1,,54.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.8,95,,11.32,Percent of Total Billed Charges,95% of Total Billed Charges,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.52,88,,10.48,Percent of Total Billed Charges,88% of Total Billed Charges,3.6,90,,10.72,Percent of Total Billed charges,90% of Total Billed Charges,1.76,4,
APM CTF01 5X150ZTHR,2720000937,CDM,272,RC,,,Outpatient,,,23.00,14.95,,23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.48,76,,1.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.56,72,,8891.192,Percent of Total Billed Charges,72% of Total Billed Charges,17.25,75,,9261.664,Percent of Total Billed charges,75% of Total Billed Charges,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.56,72,,8891.192,Percent of Total Billed Charges,72% of Total Billed Charges,13.8,60,,7409.328,Percent of Total Billed Charges,60% of Total Billed Charges,20.7,90,,353.656,Percent of Total Billed Charges,90% of Total Billed Charges,10.35,45,,68.104,Percent of Total Billed Charges,45% of Total Billed Charges,20.7,90,,1.208,Percent of Total Billed Charges,90% of Total billed Charges,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.95,65,,80.696,Percent of total Billed Charges,65% of Total Billed Charges,10.14,44.1,,66.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.85,95,,1.28,Percent of Total Billed Charges,95% of Total Billed Charges,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.24,88,,1.184,Percent of Total Billed Charges,88% of Total Billed Charges,20.7,90,,1.208,Percent of Total Billed charges,90% of Total Billed Charges,10.14,23,
APM CTF71 12X150 ZTHR,2720000938,CDM,272,RC,,,Outpatient,,,36.00,23.40,,36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.36,76,,72.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.92,72,,2750.36,Percent of Total Billed Charges,72% of Total Billed Charges,27,75,,2864.96,Percent of Total Billed charges,75% of Total Billed Charges,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.92,72,,2750.36,Percent of Total Billed Charges,72% of Total Billed Charges,21.6,60,,2291.968,Percent of Total Billed Charges,60% of Total Billed Charges,32.4,90,,405.52,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,45,,45.368,Percent of Total Billed Charges,45% of Total Billed Charges,32.4,90,,85.528,Percent of Total Billed Charges,90% of Total billed Charges,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.4,65,,98.368,Percent of total Billed Charges,65% of Total Billed Charges,15.88,44.1,,44.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.2,95,,90.28,Percent of Total Billed Charges,95% of Total Billed Charges,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.68,88,,83.632,Percent of Total Billed Charges,88% of Total Billed Charges,32.4,90,,85.528,Percent of Total Billed charges,90% of Total Billed Charges,15.88,36,
PDS 0 LOOP Z990G SUTURE,2720000939,CDM,272,RC,,,Outpatient,,,5.00,3.25,,5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.8,76,,94.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.6,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,3.75,75,,10.584,Percent of Total Billed charges,75% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.6,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,3,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,4.5,90,,44.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.25,45,,45.368,Percent of Total Billed Charges,45% of Total Billed Charges,4.5,90,,111.736,Percent of Total Billed Charges,90% of Total billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.25,65,,65.528,Percent of total Billed Charges,65% of Total Billed Charges,2.21,44.1,,44.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.75,95,,117.944,Percent of Total Billed Charges,95% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.4,88,,109.256,Percent of Total Billed Charges,88% of Total Billed Charges,4.5,90,,111.736,Percent of Total Billed charges,90% of Total Billed Charges,2.21,5,
VICRYL 30 CR J838D SUTURE,2720000940,CDM,272,RC,,,Outpatient,,,11.00,7.15,,11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.36,76,,115.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.92,72,,48.896,Percent of Total Billed Charges,72% of Total Billed Charges,8.25,75,,50.936,Percent of Total Billed charges,75% of Total Billed Charges,11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.92,72,,48.896,Percent of Total Billed Charges,72% of Total Billed Charges,6.6,60,,40.744,Percent of Total Billed Charges,60% of Total Billed Charges,9.9,90,,10.736,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,45,,45.368,Percent of Total Billed Charges,45% of Total Billed Charges,9.9,90,,136.2,Percent of Total Billed Charges,90% of Total billed Charges,11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.15,65,,65.528,Percent of total Billed Charges,65% of Total Billed Charges,4.85,44.1,,44.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.45,95,,143.768,Percent of Total Billed Charges,95% of Total Billed Charges,11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.68,88,,133.176,Percent of Total Billed Charges,88% of Total Billed Charges,9.9,90,,136.2,Percent of Total Billed charges,90% of Total Billed Charges,4.85,11,
SURGIWAND SUCTION IRRIGATOR,2720000941,CDM,272,RC,,,Outpatient,,,196.00,127.40,,196,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,148.96,76,,76.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.12,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,147,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,196,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,117.6,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,176.4,90,,23.288,Percent of Total Billed Charges,90% of Total Billed Charges,88.2,45,,48.208,Percent of Total Billed Charges,45% of Total Billed Charges,176.4,90,,90.736,Percent of Total Billed Charges,90% of Total billed Charges,196,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.4,65,,65.528,Percent of total Billed Charges,65% of Total Billed Charges,86.44,44.1,,47.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.2,95,,95.776,Percent of Total Billed Charges,95% of Total Billed Charges,196,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.48,88,,88.72,Percent of Total Billed Charges,88% of Total Billed Charges,176.4,90,,90.736,Percent of Total Billed charges,90% of Total Billed Charges,86.44,196,
PEEL APARTINTRODUCER 8FR,2720000942,CDM,272,RC,,,Outpatient,,,156.00,101.40,,156,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,118.56,76,,76.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,112.32,72,,128.28,Percent of Total Billed Charges,72% of Total Billed Charges,117,75,,133.624,Percent of Total Billed charges,75% of Total Billed Charges,156,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.32,72,,128.28,Percent of Total Billed Charges,72% of Total Billed Charges,93.6,60,,106.904,Percent of Total Billed Charges,60% of Total Billed Charges,140.4,90,,6.432,Percent of Total Billed Charges,90% of Total Billed Charges,70.2,45,,48.208,Percent of Total Billed Charges,45% of Total Billed Charges,140.4,90,,90.736,Percent of Total Billed Charges,90% of Total billed Charges,156,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.4,65,,69.632,Percent of total Billed Charges,65% of Total Billed Charges,68.8,44.1,,47.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,148.2,95,,95.776,Percent of Total Billed Charges,95% of Total Billed Charges,156,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.28,88,,88.72,Percent of Total Billed Charges,88% of Total Billed Charges,140.4,90,,90.736,Percent of Total Billed charges,90% of Total Billed Charges,68.8,156,
APM COR83 12X60 ZTHR,2720000943,CDM,272,RC,,,Outpatient,,,36.00,23.40,,36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.36,76,,76.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.92,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,27,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.92,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,21.6,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,32.4,90,,5.976,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,45,,48.208,Percent of Total Billed Charges,45% of Total Billed Charges,32.4,90,,90.736,Percent of Total Billed Charges,90% of Total billed Charges,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.4,65,,69.632,Percent of total Billed Charges,65% of Total Billed Charges,15.88,44.1,,47.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.2,95,,95.776,Percent of Total Billed Charges,95% of Total Billed Charges,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.68,88,,88.72,Percent of Total Billed Charges,88% of Total Billed Charges,32.4,90,,90.736,Percent of Total Billed charges,90% of Total Billed Charges,15.88,36,
APM CTR05 5X55 ZTHR,2720000944,CDM,272,RC,,,Outpatient,,,23.00,14.95,,23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.48,76,,81.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.56,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,17.25,75,,8.6,Percent of Total Billed charges,75% of Total Billed Charges,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.56,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,13.8,60,,6.88,Percent of Total Billed Charges,60% of Total Billed Charges,20.7,90,,10.664,Percent of Total Billed Charges,90% of Total Billed Charges,10.35,45,,176.832,Percent of Total Billed Charges,45% of Total Billed Charges,20.7,90,,96.408,Percent of Total Billed Charges,90% of Total billed Charges,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.95,65,,69.632,Percent of total Billed Charges,65% of Total Billed Charges,10.14,44.1,,173.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.85,95,,101.768,Percent of Total Billed Charges,95% of Total Billed Charges,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.24,88,,94.264,Percent of Total Billed Charges,88% of Total Billed Charges,20.7,90,,96.408,Percent of Total Billed charges,90% of Total Billed Charges,10.14,23,
CORE SUCTION IRRIGATOR,2720000945,CDM,272,RC,,,Outpatient,,,65.00,42.25,,65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.4,76,,81.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.8,72,,129.552,Percent of Total Billed Charges,72% of Total Billed Charges,48.75,75,,134.944,Percent of Total Billed charges,75% of Total Billed Charges,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.8,72,,129.552,Percent of Total Billed Charges,72% of Total Billed Charges,39,60,,107.96,Percent of Total Billed Charges,60% of Total Billed Charges,58.5,90,,2.664,Percent of Total Billed Charges,90% of Total Billed Charges,29.25,45,,202.76,Percent of Total Billed Charges,45% of Total Billed Charges,58.5,90,,96.408,Percent of Total Billed Charges,90% of Total billed Charges,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.25,65,,255.416,Percent of total Billed Charges,65% of Total Billed Charges,28.67,44.1,,198.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,61.75,95,,101.768,Percent of Total Billed Charges,95% of Total Billed Charges,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.2,88,,94.264,Percent of Total Billed Charges,88% of Total Billed Charges,58.5,90,,96.408,Percent of Total Billed charges,90% of Total Billed Charges,28.67,65,
ULTRAPROBE II NEEDLE GUIDE,2720000946,CDM,272,RC,,,Outpatient,,,56.00,36.40,,56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.56,76,,81.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.32,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,42,75,,27.12,Percent of Total Billed charges,75% of Total Billed Charges,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.32,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,33.6,60,,21.696,Percent of Total Billed Charges,60% of Total Billed Charges,50.4,90,,4.992,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,45,,22.32,Percent of Total Billed Charges,45% of Total Billed Charges,50.4,90,,96.408,Percent of Total Billed Charges,90% of Total billed Charges,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.4,65,,292.872,Percent of total Billed Charges,65% of Total Billed Charges,24.7,44.1,,21.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.2,95,,101.768,Percent of Total Billed Charges,95% of Total Billed Charges,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.28,88,,94.264,Percent of Total Billed Charges,88% of Total Billed Charges,50.4,90,,96.408,Percent of Total Billed charges,90% of Total Billed Charges,24.7,56,
PUNCH BIOPSY 4MM DISPOSABLE,2720000947,CDM,272,RC,,,Outpatient,,,2.00,1.30,,2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.52,76,,298.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.44,72,,177.808,Percent of Total Billed Charges,72% of Total Billed Charges,1.5,75,,185.224,Percent of Total Billed charges,75% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,72,,177.808,Percent of Total Billed Charges,72% of Total Billed Charges,1.2,60,,148.176,Percent of Total Billed Charges,60% of Total Billed Charges,1.8,90,,10.024,Percent of Total Billed Charges,90% of Total Billed Charges,0.9,45,,5.368,Percent of Total Billed Charges,45% of Total Billed Charges,1.8,90,,353.656,Percent of Total Billed Charges,90% of Total billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,65,,32.24,Percent of total Billed Charges,65% of Total Billed Charges,0.88,44.1,,5.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.9,95,,373.304,Percent of Total Billed Charges,95% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.76,88,,345.8,Percent of Total Billed Charges,88% of Total Billed Charges,1.8,90,,353.656,Percent of Total Billed charges,90% of Total Billed Charges,0.88,2,
PUNCH BIOPSY 6MM DISPOSABLE,2720000948,CDM,272,RC,,,Outpatient,,,3.00,1.95,,3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.28,76,,342.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.16,72,,480.088,Percent of Total Billed Charges,72% of Total Billed Charges,2.25,75,,500.096,Percent of Total Billed charges,75% of Total Billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.16,72,,480.088,Percent of Total Billed Charges,72% of Total Billed Charges,1.8,60,,400.072,Percent of Total Billed Charges,60% of Total Billed Charges,2.7,90,,27.576,Percent of Total Billed Charges,90% of Total Billed Charges,1.35,45,,11.64,Percent of Total Billed Charges,45% of Total Billed Charges,2.7,90,,405.52,Percent of Total Billed Charges,90% of Total billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.95,65,,7.752,Percent of total Billed Charges,65% of Total Billed Charges,1.32,44.1,,11.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.85,95,,428.048,Percent of Total Billed Charges,95% of Total Billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.64,88,,396.504,Percent of Total Billed Charges,88% of Total Billed Charges,2.7,90,,405.52,Percent of Total Billed charges,90% of Total Billed Charges,1.32,3,
FULL CORE BX 16G X 10CM,2720000949,CDM,272,RC,,,Outpatient,,,47.00,30.55,,47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.72,76,,37.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.84,72,,395,Percent of Total Billed Charges,72% of Total Billed Charges,35.25,75,,411.456,Percent of Total Billed charges,75% of Total Billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.84,72,,395,Percent of Total Billed Charges,72% of Total Billed Charges,28.2,60,,329.168,Percent of Total Billed Charges,60% of Total Billed Charges,42.3,90,,2.984,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,45,,3.216,Percent of Total Billed Charges,45% of Total Billed Charges,42.3,90,,44.64,Percent of Total Billed Charges,90% of Total billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.55,65,,16.816,Percent of total Billed Charges,65% of Total Billed Charges,20.73,44.1,,3.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.65,95,,47.12,Percent of Total Billed Charges,95% of Total Billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.36,88,,43.648,Percent of Total Billed Charges,88% of Total Billed Charges,42.3,90,,44.64,Percent of Total Billed charges,90% of Total Billed Charges,20.73,47,
CO AXIAL INTRO NEEDLE,2720000950,CDM,272,RC,,,Outpatient,,,13.00,8.45,,13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.88,76,,9.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.36,72,,480.088,Percent of Total Billed Charges,72% of Total Billed Charges,9.75,75,,500.096,Percent of Total Billed charges,75% of Total Billed Charges,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.36,72,,480.088,Percent of Total Billed Charges,72% of Total Billed Charges,7.8,60,,400.072,Percent of Total Billed Charges,60% of Total Billed Charges,11.7,90,,2.544,Percent of Total Billed Charges,90% of Total Billed Charges,5.85,45,,2.992,Percent of Total Billed Charges,45% of Total Billed Charges,11.7,90,,10.736,Percent of Total Billed Charges,90% of Total billed Charges,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.45,65,,4.64,Percent of total Billed Charges,65% of Total Billed Charges,5.73,44.1,,2.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.35,95,,11.328,Percent of Total Billed Charges,95% of Total Billed Charges,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.44,88,,10.496,Percent of Total Billed Charges,88% of Total Billed Charges,11.7,90,,10.736,Percent of Total Billed charges,90% of Total Billed Charges,5.73,13,
K WIRE .062,2720000951,CDM,272,RC,,,Outpatient,,,18.00,11.70,,18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.68,76,,19.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.96,72,,395,Percent of Total Billed Charges,72% of Total Billed Charges,13.5,75,,411.456,Percent of Total Billed charges,75% of Total Billed Charges,18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.96,72,,395,Percent of Total Billed Charges,72% of Total Billed Charges,10.8,60,,329.168,Percent of Total Billed Charges,60% of Total Billed Charges,16.2,90,,6.048,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,45,,5.328,Percent of Total Billed Charges,45% of Total Billed Charges,16.2,90,,23.288,Percent of Total Billed Charges,90% of Total billed Charges,18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.7,65,,4.32,Percent of total Billed Charges,65% of Total Billed Charges,7.94,44.1,,5.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.1,95,,24.576,Percent of Total Billed Charges,95% of Total Billed Charges,18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.84,88,,22.768,Percent of Total Billed Charges,88% of Total Billed Charges,16.2,90,,23.288,Percent of Total Billed charges,90% of Total Billed Charges,7.94,18,
NUROLON O 5424H SUTURE,2720000952,CDM,272,RC,,,Outpatient,,,2.00,1.30,,2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.52,76,,5.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.44,72,,10.48,Percent of Total Billed Charges,72% of Total Billed Charges,1.5,75,,10.912,Percent of Total Billed charges,75% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,72,,10.48,Percent of Total Billed Charges,72% of Total Billed Charges,1.2,60,,8.728,Percent of Total Billed Charges,60% of Total Billed Charges,1.8,90,,2.736,Percent of Total Billed Charges,90% of Total Billed Charges,0.9,45,,1.336,Percent of Total Billed Charges,45% of Total Billed Charges,1.8,90,,6.432,Percent of Total Billed Charges,90% of Total billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,65,,7.704,Percent of total Billed Charges,65% of Total Billed Charges,0.88,44.1,,1.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.9,95,,6.784,Percent of Total Billed Charges,95% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.76,88,,6.288,Percent of Total Billed Charges,88% of Total Billed Charges,1.8,90,,6.432,Percent of Total Billed charges,90% of Total Billed Charges,0.88,2,
BEACH CHAIR SHOULDER PACK,2720000953,CDM,272,RC,,,Outpatient,,,40.00,26.00,,40,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,30.4,76,,5.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.8,72,,148.6,Percent of Total Billed Charges,72% of Total Billed Charges,30,75,,148.6,Percent of Total Billed charges,75% of Total Billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.8,72,,148.6,Percent of Total Billed Charges,72% of Total Billed Charges,24,60,,123.832,Percent of Total Billed Charges,60% of Total Billed Charges,36,90,,7.488,Percent of Total Billed Charges,90% of Total Billed Charges,18,45,,2.496,Percent of Total Billed Charges,45% of Total Billed Charges,36,90,,5.976,Percent of Total Billed Charges,90% of Total billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26,65,,1.928,Percent of total Billed Charges,65% of Total Billed Charges,17.64,44.1,,2.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,38,95,,6.312,Percent of Total Billed Charges,95% of Total Billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.2,88,,5.84,Percent of Total Billed Charges,88% of Total Billed Charges,36,90,,5.976,Percent of Total Billed charges,90% of Total Billed Charges,17.64,40,
ACUMED 1.5MM DRIVER BIT,2720000954,CDM,272,RC,,,Outpatient,,,409.00,265.85,,409,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,310.84,76,,9.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,294.48,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,306.75,75,,87.64,Percent of Total Billed charges,75% of Total Billed Charges,409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.48,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,245.4,60,,73.032,Percent of Total Billed Charges,60% of Total Billed Charges,368.1,90,,11.952,Percent of Total Billed Charges,90% of Total Billed Charges,184.05,45,,5.008,Percent of Total Billed Charges,45% of Total Billed Charges,368.1,90,,10.664,Percent of Total Billed Charges,90% of Total billed Charges,409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.85,65,,3.6,Percent of total Billed Charges,65% of Total Billed Charges,180.37,44.1,,4.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,388.55,95,,11.256,Percent of Total Billed Charges,95% of Total Billed Charges,409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.92,88,,10.424,Percent of Total Billed Charges,88% of Total Billed Charges,368.1,90,,10.664,Percent of Total Billed charges,90% of Total Billed Charges,180.37,409,
ACUMED 3.5MM DRILL BIT,2720000955,CDM,272,RC,,,Outpatient,,,156.00,101.40,,156,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,118.56,76,,2.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,112.32,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,117,75,,87.64,Percent of Total Billed charges,75% of Total Billed Charges,156,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.32,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,93.6,60,,73.032,Percent of Total Billed Charges,60% of Total Billed Charges,140.4,90,,169.736,Percent of Total Billed Charges,90% of Total Billed Charges,70.2,45,,13.792,Percent of Total Billed Charges,45% of Total Billed Charges,140.4,90,,2.664,Percent of Total Billed Charges,90% of Total billed Charges,156,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.4,65,,7.24,Percent of total Billed Charges,65% of Total Billed Charges,68.8,44.1,,13.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,148.2,95,,2.816,Percent of Total Billed Charges,95% of Total Billed Charges,156,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.28,88,,2.608,Percent of Total Billed Charges,88% of Total Billed Charges,140.4,90,,2.664,Percent of Total Billed charges,90% of Total Billed Charges,68.8,156,
DISP INJECTOR COLONOSCOPE,2720000956,CDM,272,RC,,,Outpatient,,,29.00,18.85,,29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.04,76,,4.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.88,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,21.75,75,,91.288,Percent of Total Billed charges,75% of Total Billed Charges,29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.88,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,17.4,60,,73.032,Percent of Total Billed Charges,60% of Total Billed Charges,26.1,90,,9.608,Percent of Total Billed Charges,90% of Total Billed Charges,13.05,45,,1.488,Percent of Total Billed Charges,45% of Total Billed Charges,26.1,90,,4.992,Percent of Total Billed Charges,90% of Total billed Charges,29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.85,65,,19.92,Percent of total Billed Charges,65% of Total Billed Charges,12.79,44.1,,1.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,27.55,95,,5.264,Percent of Total Billed Charges,95% of Total Billed Charges,29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.52,88,,4.88,Percent of Total Billed Charges,88% of Total Billed Charges,26.1,90,,4.992,Percent of Total Billed charges,90% of Total Billed Charges,12.79,29,
DISP INJECTOR GASTROSCOPIE,2720000957,CDM,272,RC,,,Outpatient,,,30.00,19.50,,30,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.8,76,,8.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.6,72,,163.2,Percent of Total Billed Charges,72% of Total Billed Charges,22.5,75,,170.008,Percent of Total Billed charges,75% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.6,72,,163.2,Percent of Total Billed Charges,72% of Total Billed Charges,18,60,,136,Percent of Total Billed Charges,60% of Total Billed Charges,27,90,,7.272,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,45,,1.272,Percent of Total Billed Charges,45% of Total Billed Charges,27,90,,10.024,Percent of Total Billed Charges,90% of Total billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.5,65,,2.152,Percent of total Billed Charges,65% of Total Billed Charges,13.23,44.1,,1.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.5,95,,10.576,Percent of Total Billed Charges,95% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.4,88,,9.8,Percent of Total Billed Charges,88% of Total Billed Charges,27,90,,10.024,Percent of Total Billed charges,90% of Total Billed Charges,13.23,30,
DISP COLONOSCOPE SNARE,2720000958,CDM,272,RC,,,Outpatient,,,11.00,7.15,,11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.36,76,,23.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.92,72,,163.2,Percent of Total Billed Charges,72% of Total Billed Charges,8.25,75,,170.008,Percent of Total Billed charges,75% of Total Billed Charges,11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.92,72,,163.2,Percent of Total Billed Charges,72% of Total Billed Charges,6.6,60,,136,Percent of Total Billed Charges,60% of Total Billed Charges,9.9,90,,10.096,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,45,,3.024,Percent of Total Billed Charges,45% of Total Billed Charges,9.9,90,,27.576,Percent of Total Billed Charges,90% of Total billed Charges,11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.15,65,,1.832,Percent of total Billed Charges,65% of Total Billed Charges,4.85,44.1,,2.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.45,95,,29.112,Percent of Total Billed Charges,95% of Total Billed Charges,11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.68,88,,26.96,Percent of Total Billed Charges,88% of Total Billed Charges,9.9,90,,27.576,Percent of Total Billed charges,90% of Total Billed Charges,4.85,11,
SIGMOID SUCTION TUBING,2720000959,CDM,272,RC,,,Outpatient,,,2.29,1.49,,2.29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.74,76,,2.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.65,72,,302.28,Percent of Total Billed Charges,72% of Total Billed Charges,1.72,75,,302.28,Percent of Total Billed charges,75% of Total Billed Charges,2.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.65,72,,302.28,Percent of Total Billed Charges,72% of Total Billed Charges,1.37,60,,251.896,Percent of Total Billed Charges,60% of Total Billed Charges,2.06,90,,10.328,Percent of Total Billed Charges,90% of Total Billed Charges,1.03,45,,1.368,Percent of Total Billed Charges,45% of Total Billed Charges,2.06,90,,2.984,Percent of Total Billed Charges,90% of Total billed Charges,2.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.49,65,,4.368,Percent of total Billed Charges,65% of Total Billed Charges,1.01,44.1,,1.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.18,95,,3.144,Percent of Total Billed Charges,95% of Total Billed Charges,2.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.02,88,,2.912,Percent of Total Billed Charges,88% of Total Billed Charges,2.06,90,,2.984,Percent of Total Billed charges,90% of Total Billed Charges,1.01,2.29,
OLYMPUS QUICKCLIP 2L,2720000960,CDM,272,RC,,,Outpatient,,,72.00,46.80,,72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.72,76,,2.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.84,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,54,75,,9.928,Percent of Total Billed charges,75% of Total Billed Charges,72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.84,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,43.2,60,,7.936,Percent of Total Billed Charges,60% of Total Billed Charges,64.8,90,,10.816,Percent of Total Billed Charges,90% of Total Billed Charges,32.4,45,,3.744,Percent of Total Billed Charges,45% of Total Billed Charges,64.8,90,,2.544,Percent of Total Billed Charges,90% of Total billed Charges,72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.8,65,,1.976,Percent of total Billed Charges,65% of Total Billed Charges,31.75,44.1,,3.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.4,95,,2.68,Percent of Total Billed Charges,95% of Total Billed Charges,72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.36,88,,2.488,Percent of Total Billed Charges,88% of Total Billed Charges,64.8,90,,2.544,Percent of Total Billed charges,90% of Total Billed Charges,31.75,72,
INFINITI ANTERIOR VITRECTOMY,2720000961,CDM,272,RC,,,Outpatient,,,135.00,87.75,,135,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,102.6,76,,5.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,97.2,72,,279.416,Percent of Total Billed Charges,72% of Total Billed Charges,101.25,75,,279.416,Percent of Total Billed charges,75% of Total Billed Charges,135,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.2,72,,279.416,Percent of Total Billed Charges,72% of Total Billed Charges,81,60,,232.848,Percent of Total Billed Charges,60% of Total Billed Charges,121.5,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,60.75,45,,5.976,Percent of Total Billed Charges,45% of Total Billed Charges,121.5,90,,6.048,Percent of Total Billed Charges,90% of Total billed Charges,135,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.75,65,,5.408,Percent of total Billed Charges,65% of Total Billed Charges,59.54,44.1,,5.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,128.25,95,,6.384,Percent of Total Billed Charges,95% of Total Billed Charges,135,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.8,88,,5.912,Percent of Total Billed Charges,88% of Total Billed Charges,121.5,90,,6.048,Percent of Total Billed charges,90% of Total Billed Charges,59.54,135,
VM KEITH NEEDLE 2 1/2,2720000962,CDM,272,RC,,,Outpatient,,,1.71,1.11,,1.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.3,76,,2.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.23,72,,279.416,Percent of Total Billed Charges,72% of Total Billed Charges,1.28,75,,279.416,Percent of Total Billed charges,75% of Total Billed Charges,1.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.23,72,,279.416,Percent of Total Billed Charges,72% of Total Billed Charges,1.03,60,,232.848,Percent of Total Billed Charges,60% of Total Billed Charges,1.54,90,,6.264,Percent of Total Billed Charges,90% of Total Billed Charges,0.77,45,,84.864,Percent of Total Billed Charges,45% of Total Billed Charges,1.54,90,,2.736,Percent of Total Billed Charges,90% of Total billed Charges,1.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.11,65,,8.632,Percent of total Billed Charges,65% of Total Billed Charges,0.75,44.1,,83.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.62,95,,2.888,Percent of Total Billed Charges,95% of Total Billed Charges,1.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.5,88,,2.672,Percent of Total Billed Charges,88% of Total Billed Charges,1.54,90,,2.736,Percent of Total Billed charges,90% of Total Billed Charges,0.75,1.71,
ARTHROCARE TURBINATOR,2720000963,CDM,272,RC,,,Outpatient,,,300.00,195.00,,300,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,228,76,,6.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,216,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,225,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,180,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,270,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,135,45,,4.8,Percent of Total Billed Charges,45% of Total Billed Charges,270,90,,7.488,Percent of Total Billed Charges,90% of Total billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195,65,,122.584,Percent of total Billed Charges,65% of Total Billed Charges,132.3,44.1,,4.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,285,95,,7.904,Percent of Total Billed Charges,95% of Total Billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264,88,,7.32,Percent of Total Billed Charges,88% of Total Billed Charges,270,90,,7.488,Percent of Total Billed charges,90% of Total Billed Charges,132.3,300,
SINU FOAM DRESSING,2720000964,CDM,272,RC,,,Outpatient,,,94.00,61.10,,94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,71.44,76,,10.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,67.68,72,,32.056,Percent of Total Billed Charges,72% of Total Billed Charges,70.5,75,,33.392,Percent of Total Billed charges,75% of Total Billed Charges,94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.68,72,,32.056,Percent of Total Billed Charges,72% of Total Billed Charges,56.4,60,,26.712,Percent of Total Billed Charges,60% of Total Billed Charges,84.6,90,,21.064,Percent of Total Billed Charges,90% of Total Billed Charges,42.3,45,,3.64,Percent of Total Billed Charges,45% of Total Billed Charges,84.6,90,,11.952,Percent of Total Billed Charges,90% of Total billed Charges,94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.1,65,,6.936,Percent of total Billed Charges,65% of Total Billed Charges,41.45,44.1,,3.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,89.3,95,,12.616,Percent of Total Billed Charges,95% of Total Billed Charges,94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.72,88,,11.688,Percent of Total Billed Charges,88% of Total Billed Charges,84.6,90,,11.952,Percent of Total Billed charges,90% of Total Billed Charges,41.45,94,
ARTHROCARE REFLEX ULTA PTR,2720000965,CDM,272,RC,,,Outpatient,,,300.00,195.00,,300,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,228,76,,143.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,216,72,,30.848,Percent of Total Billed Charges,72% of Total Billed Charges,225,75,,32.128,Percent of Total Billed charges,75% of Total Billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216,72,,30.848,Percent of Total Billed Charges,72% of Total Billed Charges,180,60,,25.704,Percent of Total Billed Charges,60% of Total Billed Charges,270,90,,22.488,Percent of Total Billed Charges,90% of Total Billed Charges,135,45,,5.048,Percent of Total Billed Charges,45% of Total Billed Charges,270,90,,169.736,Percent of Total Billed Charges,90% of Total billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195,65,,5.256,Percent of total Billed Charges,65% of Total Billed Charges,132.3,44.1,,4.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,285,95,,179.16,Percent of Total Billed Charges,95% of Total Billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264,88,,165.96,Percent of Total Billed Charges,88% of Total Billed Charges,270,90,,169.736,Percent of Total Billed charges,90% of Total Billed Charges,132.3,300,
PROLENE 30 8687H PS2,2720000966,CDM,272,RC,,,Outpatient,,,5.00,3.25,,5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.8,76,,8.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.6,72,,85.36,Percent of Total Billed Charges,72% of Total Billed Charges,3.75,75,,88.912,Percent of Total Billed charges,75% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.6,72,,85.36,Percent of Total Billed Charges,72% of Total Billed Charges,3,60,,71.128,Percent of Total Billed Charges,60% of Total Billed Charges,4.5,90,,11.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.25,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,4.5,90,,9.608,Percent of Total Billed Charges,90% of Total billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.25,65,,7.288,Percent of total Billed Charges,65% of Total Billed Charges,2.21,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.75,95,,10.136,Percent of Total Billed Charges,95% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.4,88,,9.392,Percent of Total Billed Charges,88% of Total Billed Charges,4.5,90,,9.608,Percent of Total Billed charges,90% of Total Billed Charges,2.21,5,
VICRYL 30 J427H PS2,2720000967,CDM,272,RC,,,Outpatient,,,4.00,2.60,,4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.04,76,,6.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.88,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,3,75,,46.312,Percent of Total Billed charges,75% of Total Billed Charges,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.88,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,2.4,60,,37.048,Percent of Total Billed Charges,60% of Total Billed Charges,3.6,90,,15.128,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,45,,5.408,Percent of Total Billed Charges,45% of Total Billed Charges,3.6,90,,7.272,Percent of Total Billed Charges,90% of Total billed Charges,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.6,65,,7.456,Percent of total Billed Charges,65% of Total Billed Charges,1.76,44.1,,5.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.8,95,,7.68,Percent of Total Billed Charges,95% of Total Billed Charges,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.52,88,,7.112,Percent of Total Billed Charges,88% of Total Billed Charges,3.6,90,,7.272,Percent of Total Billed charges,90% of Total Billed Charges,1.76,4,
STRYKER 2.6 DRILL BIT 135MM,2720000968,CDM,272,RC,,,Outpatient,,,181.00,117.65,,181,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,137.56,76,,8.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,130.32,72,,3.704,Percent of Total Billed Charges,72% of Total Billed Charges,135.75,75,,3.856,Percent of Total Billed charges,75% of Total Billed Charges,181,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.32,72,,3.704,Percent of Total Billed Charges,72% of Total Billed Charges,108.6,60,,3.088,Percent of Total Billed Charges,60% of Total Billed Charges,162.9,90,,10.768,Percent of Total Billed Charges,90% of Total Billed Charges,81.45,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,162.9,90,,10.096,Percent of Total Billed Charges,90% of Total billed Charges,181,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.65,65,,7.808,Percent of total Billed Charges,65% of Total Billed Charges,79.82,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,171.95,95,,10.656,Percent of Total Billed Charges,95% of Total Billed Charges,181,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.28,88,,9.872,Percent of Total Billed Charges,88% of Total Billed Charges,162.9,90,,10.096,Percent of Total Billed charges,90% of Total Billed Charges,79.82,181,
STRYKER 2MM KWIRE,2720000969,CDM,272,RC,,,Outpatient,,,120.00,78.00,,120,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,91.2,76,,8.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,86.4,72,,76.208,Percent of Total Billed Charges,72% of Total Billed Charges,90,75,,79.384,Percent of Total Billed charges,75% of Total Billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.4,72,,76.208,Percent of Total Billed Charges,72% of Total Billed Charges,72,60,,63.504,Percent of Total Billed Charges,60% of Total Billed Charges,108,90,,28.456,Percent of Total Billed Charges,90% of Total Billed Charges,54,45,,3.136,Percent of Total Billed Charges,45% of Total Billed Charges,108,90,,10.328,Percent of Total Billed Charges,90% of Total billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,52.92,44.1,,3.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,114,95,,10.896,Percent of Total Billed Charges,95% of Total Billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.6,88,,10.096,Percent of Total Billed Charges,88% of Total Billed Charges,108,90,,10.328,Percent of Total Billed charges,90% of Total Billed Charges,52.92,120,
STRYKER 3.5 OVERDRILL 122MM,2720000970,CDM,272,RC,,,Outpatient,,,181.00,117.65,,181,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,137.56,76,,9.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,130.32,72,,16.168,Percent of Total Billed Charges,72% of Total Billed Charges,135.75,75,,16.84,Percent of Total Billed charges,75% of Total Billed Charges,181,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.32,72,,16.168,Percent of Total Billed Charges,72% of Total Billed Charges,108.6,60,,13.472,Percent of Total Billed Charges,60% of Total Billed Charges,162.9,90,,181.44,Percent of Total Billed Charges,90% of Total Billed Charges,81.45,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,162.9,90,,10.816,Percent of Total Billed Charges,90% of Total billed Charges,181,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.65,65,,4.528,Percent of total Billed Charges,65% of Total Billed Charges,79.82,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,171.95,95,,11.416,Percent of Total Billed Charges,95% of Total Billed Charges,181,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.28,88,,10.576,Percent of Total Billed Charges,88% of Total Billed Charges,162.9,90,,10.816,Percent of Total Billed charges,90% of Total Billed Charges,79.82,181,
PROLENE 30 8687H PS2,2720000971,CDM,272,RC,,,Outpatient,,,7.00,4.55,,7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.32,76,,12.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.04,72,,84.064,Percent of Total Billed Charges,72% of Total Billed Charges,5.25,75,,87.568,Percent of Total Billed charges,75% of Total Billed Charges,7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.04,72,,84.064,Percent of Total Billed Charges,72% of Total Billed Charges,4.2,60,,70.056,Percent of Total Billed Charges,60% of Total Billed Charges,6.3,90,,8.928,Percent of Total Billed Charges,90% of Total Billed Charges,3.15,45,,10.528,Percent of Total Billed Charges,45% of Total Billed Charges,6.3,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.55,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,3.09,44.1,,10.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.65,95,,15.928,Percent of Total Billed Charges,95% of Total Billed Charges,7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.16,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,6.3,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,3.09,7,
STRYKER ANCHORAGE FIX PIN,2720000972,CDM,272,RC,,,Outpatient,,,172.00,111.80,,172,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.72,76,,5.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.84,72,,6.528,Percent of Total Billed Charges,72% of Total Billed Charges,129,75,,6.808,Percent of Total Billed charges,75% of Total Billed Charges,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.84,72,,6.528,Percent of Total Billed Charges,72% of Total Billed Charges,103.2,60,,5.44,Percent of Total Billed Charges,60% of Total Billed Charges,154.8,90,,95.096,Percent of Total Billed Charges,90% of Total Billed Charges,77.4,45,,11.24,Percent of Total Billed Charges,45% of Total Billed Charges,154.8,90,,6.264,Percent of Total Billed Charges,90% of Total billed Charges,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.8,65,,15.208,Percent of total Billed Charges,65% of Total Billed Charges,75.85,44.1,,11.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.4,95,,6.616,Percent of Total Billed Charges,95% of Total Billed Charges,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.36,88,,6.128,Percent of Total Billed Charges,88% of Total Billed Charges,154.8,90,,6.264,Percent of Total Billed charges,90% of Total Billed Charges,75.85,172,
ACUMED 800627 2.3 DRILL BIT,2720000973,CDM,272,RC,,,Outpatient,,,237.00,154.05,,237,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,180.12,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,170.64,72,,6.528,Percent of Total Billed Charges,72% of Total Billed Charges,177.75,75,,6.808,Percent of Total Billed charges,75% of Total Billed Charges,237,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.64,72,,6.528,Percent of Total Billed Charges,72% of Total Billed Charges,142.2,60,,5.44,Percent of Total Billed Charges,60% of Total Billed Charges,213.3,90,,23.888,Percent of Total Billed Charges,90% of Total Billed Charges,106.65,45,,5.944,Percent of Total Billed Charges,45% of Total Billed Charges,213.3,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,237,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.05,65,,16.24,Percent of total Billed Charges,65% of Total Billed Charges,104.52,44.1,,5.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,225.15,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,237,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.56,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,213.3,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,104.52,237,
VICRYL 1 J281H CT,2720000974,CDM,272,RC,,,Outpatient,,,1.78,1.16,,1.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.35,76,,17.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.28,72,,8.456,Percent of Total Billed Charges,72% of Total Billed Charges,1.34,75,,8.808,Percent of Total Billed charges,75% of Total Billed Charges,1.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.28,72,,8.456,Percent of Total Billed Charges,72% of Total Billed Charges,1.07,60,,7.048,Percent of Total Billed Charges,60% of Total Billed Charges,1.6,90,,17.048,Percent of Total Billed Charges,90% of Total Billed Charges,0.8,45,,7.56,Percent of Total Billed Charges,45% of Total Billed Charges,1.6,90,,21.064,Percent of Total Billed Charges,90% of Total billed Charges,1.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.16,65,,8.584,Percent of total Billed Charges,65% of Total Billed Charges,0.78,44.1,,7.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.69,95,,22.232,Percent of Total Billed Charges,95% of Total Billed Charges,1.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.57,88,,20.592,Percent of Total Billed Charges,88% of Total Billed Charges,1.6,90,,21.064,Percent of Total Billed charges,90% of Total Billed Charges,0.78,1.78,
VICRYL 30 J258H CT1,2720000975,CDM,272,RC,,,Outpatient,,,1.56,1.01,,1.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.19,76,,18.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.12,72,,5.032,Percent of Total Billed Charges,72% of Total Billed Charges,1.17,75,,5.24,Percent of Total Billed charges,75% of Total Billed Charges,1.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.12,72,,5.032,Percent of Total Billed Charges,72% of Total Billed Charges,0.94,60,,4.192,Percent of Total Billed Charges,60% of Total Billed Charges,1.4,90,,2.184,Percent of Total Billed Charges,90% of Total Billed Charges,0.7,45,,5.384,Percent of Total Billed Charges,45% of Total Billed Charges,1.4,90,,22.488,Percent of Total Billed Charges,90% of Total billed Charges,1.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.01,65,,10.928,Percent of total Billed Charges,65% of Total Billed Charges,0.69,44.1,,5.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.48,95,,23.736,Percent of Total Billed Charges,95% of Total Billed Charges,1.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.37,88,,21.984,Percent of Total Billed Charges,88% of Total Billed Charges,1.4,90,,22.488,Percent of Total Billed charges,90% of Total Billed Charges,0.69,1.56,
VICRYL1 J359H CT 36,2720000976,CDM,272,RC,,,Outpatient,,,1.80,1.17,,1.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.37,76,,10.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.3,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,1.35,75,,17.144,Percent of Total Billed charges,75% of Total Billed Charges,1.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,1.08,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,1.62,90,,11.808,Percent of Total Billed Charges,90% of Total Billed Charges,0.81,45,,14.224,Percent of Total Billed Charges,45% of Total Billed Charges,1.62,90,,11.88,Percent of Total Billed Charges,90% of Total billed Charges,1.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.17,65,,7.776,Percent of total Billed Charges,65% of Total Billed Charges,0.79,44.1,,13.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.71,95,,12.544,Percent of Total Billed Charges,95% of Total Billed Charges,1.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.58,88,,11.616,Percent of Total Billed Charges,88% of Total Billed Charges,1.62,90,,11.88,Percent of Total Billed charges,90% of Total Billed Charges,0.79,1.8,
Z48066011 1.1 QC DRILL BIT,2720000977,CDM,272,RC,,,Outpatient,,,71.00,46.15,,71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.96,76,,12.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.12,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,53.25,75,,17.144,Percent of Total Billed charges,75% of Total Billed Charges,71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.12,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,42.6,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,63.9,90,,4.824,Percent of Total Billed Charges,90% of Total Billed Charges,31.95,45,,90.72,Percent of Total Billed Charges,45% of Total Billed Charges,63.9,90,,15.128,Percent of Total Billed Charges,90% of Total billed Charges,71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.15,65,,20.552,Percent of total Billed Charges,65% of Total Billed Charges,31.31,44.1,,88.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.45,95,,15.968,Percent of Total Billed Charges,95% of Total Billed Charges,71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.48,88,,14.792,Percent of Total Billed Charges,88% of Total Billed Charges,63.9,90,,15.128,Percent of Total Billed charges,90% of Total Billed Charges,31.31,71,
ALCON PARTS KIT 2.2MM,2720000978,CDM,272,RC,,,Outpatient,,,25.00,16.25,,25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19,76,,9.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,18.75,75,,17.144,Percent of Total Billed charges,75% of Total Billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,15,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,22.5,90,,22.64,Percent of Total Billed Charges,90% of Total Billed Charges,11.25,45,,4.464,Percent of Total Billed Charges,45% of Total Billed Charges,22.5,90,,10.768,Percent of Total Billed Charges,90% of Total billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.25,65,,131.04,Percent of total Billed Charges,65% of Total Billed Charges,11.03,44.1,,4.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.75,95,,11.368,Percent of Total Billed Charges,95% of Total Billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22,88,,10.528,Percent of Total Billed Charges,88% of Total Billed Charges,22.5,90,,10.768,Percent of Total Billed charges,90% of Total Billed Charges,11.03,25,
APM C0R85 12X100MM BLT TIP SYS,2720000979,CDM,272,RC,,,Outpatient,,,36.00,23.40,,36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.36,76,,24.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.92,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,27,75,,17.144,Percent of Total Billed charges,75% of Total Billed Charges,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.92,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,21.6,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,32.4,90,,7.488,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,45,,47.552,Percent of Total Billed Charges,45% of Total Billed Charges,32.4,90,,28.456,Percent of Total Billed Charges,90% of Total billed Charges,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.4,65,,6.448,Percent of total Billed Charges,65% of Total Billed Charges,15.88,44.1,,46.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.2,95,,30.032,Percent of Total Billed Charges,95% of Total Billed Charges,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.68,88,,27.824,Percent of Total Billed Charges,88% of Total Billed Charges,32.4,90,,28.456,Percent of Total Billed charges,90% of Total Billed Charges,15.88,36,
MALYUGIN RING 6.25,2720000980,CDM,272,RC,,,Outpatient,,,149.00,96.85,,149,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,113.24,76,,153.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,107.28,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,111.75,75,,17.144,Percent of Total Billed charges,75% of Total Billed Charges,149,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.28,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,89.4,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,134.1,90,,7.4,Percent of Total Billed Charges,90% of Total Billed Charges,67.05,45,,11.944,Percent of Total Billed Charges,45% of Total Billed Charges,134.1,90,,181.44,Percent of Total Billed Charges,90% of Total billed Charges,149,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.85,65,,68.68,Percent of total Billed Charges,65% of Total Billed Charges,65.71,44.1,,11.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,141.55,95,,191.52,Percent of Total Billed Charges,95% of Total Billed Charges,149,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.12,88,,177.408,Percent of Total Billed Charges,88% of Total Billed Charges,134.1,90,,181.44,Percent of Total Billed charges,90% of Total Billed Charges,65.71,149,
"ARTHREX DRILL BIT, CANN 1.7MM",2720000981,CDM,272,RC,,,Outpatient,,,201.00,130.65,,201,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152.76,76,,7.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144.72,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,150.75,75,,17.144,Percent of Total Billed charges,75% of Total Billed Charges,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.72,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,120.6,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,180.9,90,,2.264,Percent of Total Billed Charges,90% of Total Billed Charges,90.45,45,,8.528,Percent of Total Billed Charges,45% of Total Billed Charges,180.9,90,,8.928,Percent of Total Billed Charges,90% of Total billed Charges,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.65,65,,17.256,Percent of total Billed Charges,65% of Total Billed Charges,88.64,44.1,,8.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,190.95,95,,9.424,Percent of Total Billed Charges,95% of Total Billed Charges,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.88,88,,8.728,Percent of Total Billed Charges,88% of Total Billed Charges,180.9,90,,8.928,Percent of Total Billed charges,90% of Total Billed Charges,88.64,201,
ARTHREX .062 GDWIRE TRCR TIP,2720000982,CDM,272,RC,,,Outpatient,,,29.00,18.85,,29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.04,76,,80.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.88,72,,4.144,Percent of Total Billed Charges,72% of Total Billed Charges,21.75,75,,4.312,Percent of Total Billed charges,75% of Total Billed Charges,29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.88,72,,4.144,Percent of Total Billed Charges,72% of Total Billed Charges,17.4,60,,3.448,Percent of Total Billed Charges,60% of Total Billed Charges,26.1,90,,84.016,Percent of Total Billed Charges,90% of Total Billed Charges,13.05,45,,1.088,Percent of Total Billed Charges,45% of Total Billed Charges,26.1,90,,95.096,Percent of Total Billed Charges,90% of Total billed Charges,29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.85,65,,12.312,Percent of total Billed Charges,65% of Total Billed Charges,12.79,44.1,,1.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,27.55,95,,100.384,Percent of Total Billed Charges,95% of Total Billed Charges,29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.52,88,,92.984,Percent of Total Billed Charges,88% of Total Billed Charges,26.1,90,,95.096,Percent of Total Billed charges,90% of Total Billed Charges,12.79,29,
ARTHREX COUNTERSINK 3.0MM CANN,2720000983,CDM,272,RC,,,Outpatient,,,201.00,130.65,,201,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152.76,76,,20.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144.72,72,,1.304,Percent of Total Billed Charges,72% of Total Billed Charges,150.75,75,,1.36,Percent of Total Billed charges,75% of Total Billed Charges,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.72,72,,1.304,Percent of Total Billed Charges,72% of Total Billed Charges,120.6,60,,1.088,Percent of Total Billed Charges,60% of Total Billed Charges,180.9,90,,13.824,Percent of Total Billed Charges,90% of Total Billed Charges,90.45,45,,5.904,Percent of Total Billed Charges,45% of Total Billed Charges,180.9,90,,23.888,Percent of Total Billed Charges,90% of Total billed Charges,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.65,65,,1.576,Percent of total Billed Charges,65% of Total Billed Charges,88.64,44.1,,5.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,190.95,95,,25.216,Percent of Total Billed Charges,95% of Total Billed Charges,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.88,88,,23.36,Percent of Total Billed Charges,88% of Total Billed Charges,180.9,90,,23.888,Percent of Total Billed charges,90% of Total Billed Charges,88.64,201,
BLADE SUR C/ST 015C,2720000984,CDM,272,RC,,,Outpatient,,,1.49,0.97,,1.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.13,76,,14.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.07,72,,1.344,Percent of Total Billed Charges,72% of Total Billed Charges,1.12,75,,1.4,Percent of Total Billed charges,75% of Total Billed Charges,1.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.07,72,,1.344,Percent of Total Billed Charges,72% of Total Billed Charges,0.89,60,,1.12,Percent of Total Billed Charges,60% of Total Billed Charges,1.34,90,,12.888,Percent of Total Billed Charges,90% of Total Billed Charges,0.67,45,,2.416,Percent of Total Billed Charges,45% of Total Billed Charges,1.34,90,,17.048,Percent of Total Billed Charges,90% of Total billed Charges,1.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,65,,8.528,Percent of total Billed Charges,65% of Total Billed Charges,0.66,44.1,,2.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.42,95,,18,Percent of Total Billed Charges,95% of Total Billed Charges,1.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.31,88,,16.672,Percent of Total Billed Charges,88% of Total Billed Charges,1.34,90,,17.048,Percent of Total Billed charges,90% of Total Billed Charges,0.66,1.49,
SUCTION TUBING 12 LF,2720000985,CDM,272,RC,,,Outpatient,,,0.91,0.59,,0.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.69,76,,1.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.66,72,,8.464,Percent of Total Billed Charges,72% of Total Billed Charges,0.68,75,,8.824,Percent of Total Billed charges,75% of Total Billed Charges,0.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.66,72,,8.464,Percent of Total Billed Charges,72% of Total Billed Charges,0.55,60,,7.056,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,90,,18.664,Percent of Total Billed Charges,90% of Total Billed Charges,0.41,45,,11.32,Percent of Total Billed Charges,45% of Total Billed Charges,0.82,90,,2.184,Percent of Total Billed Charges,90% of Total billed Charges,0.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.59,65,,3.488,Percent of total Billed Charges,65% of Total Billed Charges,0.4,44.1,,11.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.86,95,,2.304,Percent of Total Billed Charges,95% of Total Billed Charges,0.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.8,88,,2.136,Percent of Total Billed Charges,88% of Total Billed Charges,0.82,90,,2.184,Percent of Total Billed charges,90% of Total Billed Charges,0.4,0.91,
ARTHREX BBTAK THREADED,2720000986,CDM,272,RC,,,Outpatient,,,146.00,94.90,,146,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.96,76,,9.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,105.12,72,,5191,Percent of Total Billed Charges,72% of Total Billed Charges,109.5,75,,5407.288,Percent of Total Billed charges,75% of Total Billed Charges,146,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.12,72,,5191,Percent of Total Billed Charges,72% of Total Billed Charges,87.6,60,,4325.832,Percent of Total Billed Charges,60% of Total Billed Charges,131.4,90,,180,Percent of Total Billed Charges,90% of Total Billed Charges,65.7,45,,3.744,Percent of Total Billed Charges,45% of Total Billed Charges,131.4,90,,11.808,Percent of Total Billed Charges,90% of Total billed Charges,146,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.9,65,,16.352,Percent of total Billed Charges,65% of Total Billed Charges,64.39,44.1,,3.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,138.7,95,,12.464,Percent of Total Billed Charges,95% of Total Billed Charges,146,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.48,88,,11.544,Percent of Total Billed Charges,88% of Total Billed Charges,131.4,90,,11.808,Percent of Total Billed charges,90% of Total Billed Charges,64.39,146,
ARTHREX TENDON SHUTTLE SM,2720000987,CDM,272,RC,,,Outpatient,,,102.00,66.30,,102,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,77.52,76,,4.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,73.44,72,,425.536,Percent of Total Billed Charges,72% of Total Billed Charges,76.5,75,,425.536,Percent of Total Billed charges,75% of Total Billed Charges,102,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.44,72,,425.536,Percent of Total Billed Charges,72% of Total Billed Charges,61.2,60,,354.616,Percent of Total Billed Charges,60% of Total Billed Charges,91.8,90,,9.088,Percent of Total Billed Charges,90% of Total Billed Charges,45.9,45,,3.704,Percent of Total Billed Charges,45% of Total Billed Charges,91.8,90,,4.824,Percent of Total Billed Charges,90% of Total billed Charges,102,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.3,65,,5.408,Percent of total Billed Charges,65% of Total Billed Charges,44.98,44.1,,3.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,96.9,95,,5.096,Percent of Total Billed Charges,95% of Total Billed Charges,102,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.76,88,,4.72,Percent of Total Billed Charges,88% of Total Billed Charges,91.8,90,,4.824,Percent of Total Billed charges,90% of Total Billed Charges,44.98,102,
ARTHREX 2.5MM DRILL BIT CALIB,2720000988,CDM,272,RC,,,Outpatient,,,102.00,66.30,,102,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,77.52,76,,19.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,73.44,72,,500.84,Percent of Total Billed Charges,72% of Total Billed Charges,76.5,75,,500.84,Percent of Total Billed charges,75% of Total Billed Charges,102,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.44,72,,500.84,Percent of Total Billed Charges,72% of Total Billed Charges,61.2,60,,417.368,Percent of Total Billed Charges,60% of Total Billed Charges,91.8,90,,18.032,Percent of Total Billed Charges,90% of Total Billed Charges,45.9,45,,1.128,Percent of Total Billed Charges,45% of Total Billed Charges,91.8,90,,22.64,Percent of Total Billed Charges,90% of Total billed Charges,102,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.3,65,,5.344,Percent of total Billed Charges,65% of Total Billed Charges,44.98,44.1,,1.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,96.9,95,,23.896,Percent of Total Billed Charges,95% of Total Billed Charges,102,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.76,88,,22.136,Percent of Total Billed Charges,88% of Total Billed Charges,91.8,90,,22.64,Percent of Total Billed charges,90% of Total Billed Charges,44.98,102,
ARTHREX FIBERTAPE,2720000989,CDM,272,RC,,,Outpatient,,,86.00,55.90,,86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,65.36,76,,6.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.92,72,,500.84,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,75,,500.84,Percent of Total Billed charges,75% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.92,72,,500.84,Percent of Total Billed Charges,72% of Total Billed Charges,51.6,60,,417.368,Percent of Total Billed Charges,60% of Total Billed Charges,77.4,90,,13.192,Percent of Total Billed Charges,90% of Total Billed Charges,38.7,45,,42.008,Percent of Total Billed Charges,45% of Total Billed Charges,77.4,90,,7.488,Percent of Total Billed Charges,90% of Total billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.9,65,,1.632,Percent of total Billed Charges,65% of Total Billed Charges,37.93,44.1,,41.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,81.7,95,,7.904,Percent of Total Billed Charges,95% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.68,88,,7.32,Percent of Total Billed Charges,88% of Total Billed Charges,77.4,90,,7.488,Percent of Total Billed charges,90% of Total Billed Charges,37.93,86,
ARTHREX FIBERLOOP #2 BLUE,2720000990,CDM,272,RC,,,Outpatient,,,86.00,55.90,,86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,65.36,76,,6.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.92,72,,277.936,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,75,,277.936,Percent of Total Billed charges,75% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.92,72,,277.936,Percent of Total Billed Charges,72% of Total Billed Charges,51.6,60,,231.616,Percent of Total Billed Charges,60% of Total Billed Charges,77.4,90,,15.208,Percent of Total Billed Charges,90% of Total Billed Charges,38.7,45,,6.912,Percent of Total Billed Charges,45% of Total Billed Charges,77.4,90,,7.4,Percent of Total Billed Charges,90% of Total billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.9,65,,60.68,Percent of total Billed Charges,65% of Total Billed Charges,37.93,44.1,,6.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,81.7,95,,7.816,Percent of Total Billed Charges,95% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.68,88,,7.24,Percent of Total Billed Charges,88% of Total Billed Charges,77.4,90,,7.4,Percent of Total Billed charges,90% of Total Billed Charges,37.93,86,
STERILE WATER FOR IR 500ML,2720000991,CDM,272,RC,,,Outpatient,,,58.43,37.98,,58.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,44.41,76,,1.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.07,72,,277.936,Percent of Total Billed Charges,72% of Total Billed Charges,43.82,75,,277.936,Percent of Total Billed charges,75% of Total Billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.07,72,,277.936,Percent of Total Billed Charges,72% of Total Billed Charges,35.06,60,,231.616,Percent of Total Billed Charges,60% of Total Billed Charges,52.59,90,,11.952,Percent of Total Billed Charges,90% of Total Billed Charges,26.29,45,,6.448,Percent of Total Billed Charges,45% of Total Billed Charges,52.59,90,,2.264,Percent of Total Billed Charges,90% of Total billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.98,65,,9.984,Percent of total Billed Charges,65% of Total Billed Charges,25.77,44.1,,6.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,55.51,95,,2.384,Percent of Total Billed Charges,95% of Total Billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.42,88,,2.208,Percent of Total Billed Charges,88% of Total Billed Charges,52.59,90,,2.264,Percent of Total Billed charges,90% of Total Billed Charges,25.77,58.43,
STERILE WATER FOR IR 1500ML,2720000992,CDM,272,RC,,,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,70.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,70.76,Percent of Total Billed Charges,72% of Total Billed Charges,58.71,75,,73.712,Percent of Total Billed charges,75% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,70.76,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,58.968,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,8.28,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,9.328,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,84.016,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,9.312,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,9.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,88.688,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,82.152,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,84.016,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
SORBITOL IRR SOLN 3000ML,2720000993,CDM,272,RC,,,Outpatient,,,101.43,65.93,,101.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,77.09,76,,11.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,73.03,72,,70.76,Percent of Total Billed Charges,72% of Total Billed Charges,76.07,75,,73.712,Percent of Total Billed charges,75% of Total Billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.03,72,,70.76,Percent of Total Billed Charges,72% of Total Billed Charges,60.86,60,,58.968,Percent of Total Billed Charges,60% of Total Billed Charges,91.29,90,,9.936,Percent of Total Billed Charges,90% of Total Billed Charges,45.64,45,,90,Percent of Total Billed Charges,45% of Total Billed Charges,91.29,90,,13.824,Percent of Total Billed Charges,90% of Total billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.93,65,,13.48,Percent of total Billed Charges,65% of Total Billed Charges,44.73,44.1,,88.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,96.36,95,,14.592,Percent of Total Billed Charges,95% of Total Billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.26,88,,13.52,Percent of Total Billed Charges,88% of Total Billed Charges,91.29,90,,13.824,Percent of Total Billed charges,90% of Total Billed Charges,44.73,101.43,
IODOFORM NUGUAZE 1/4 INCH,2720000994,CDM,272,RC,,,Outpatient,,,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,10.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,70.76,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,73.712,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,70.76,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,58.968,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,12.024,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,4.544,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,12.888,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,130,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,4.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,13.608,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,12.6,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,12.888,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
IODOFORM NUGUAZE 1/2 INCH,2720000995,CDM,272,RC,,,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,15.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,70.76,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,73.712,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,70.76,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,58.968,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,12.024,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,9.016,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,18.664,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,6.56,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,8.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,19.696,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,18.248,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,18.664,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
IODOFORM NUGUAZE 1 INCH,2720000996,CDM,272,RC,,,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,70.76,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,73.712,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,70.76,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,58.968,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,12.024,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,6.592,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,180,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,13.024,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,6.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,190,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,176,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,180,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
IODO NUGAUZE 1IN,2720000997,CDM,272,RC,,,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,7.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,214.904,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,214.904,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,214.904,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,179.088,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,95.416,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,7.6,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,9.088,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,9.528,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,7.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,9.592,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,8.888,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,9.088,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
HEPARIN FLUSH KIT INJ,2720000999,CDM,272,RC,J1642,HCPCS,Outpatient,,,1.20,0.78,,1.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.91,76,,11.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.07,350,,186.08,Fee Schedule,350% of BCBS fee schedule,0.07,350,,186.08,Fee Schedule,350% of BCBS fee schedule,1.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.07,350,,186.08,Fee Schedule,350% of BCBS PPO fee schedule,0.02,100,,155.064,Fee Schedule,100% of Blue ADV HMO fee schedule,,,,,Other,Not Separately Reimbursable,0.54,45,,4.144,Percent of Total Billed Charges,45% of Total Billed Charges,1.08,90,,13.192,Percent of Total Billed Charges,90% of Total billed Charges,1.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.78,65,,8.632,Percent of total Billed Charges,65% of Total Billed Charges,0.53,44.1,,4.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.14,95,,13.92,Percent of Total Billed Charges,95% of Total Billed Charges,1.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.06,88,,12.896,Percent of Total Billed Charges,88% of Total Billed Charges,1.08,90,,13.192,Percent of Total Billed charges,90% of Total Billed Charges,0.02,1.2,
ADAPTIC 3X8,2720001000,CDM,272,RC,,,Outpatient,,,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,12.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,38.592,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,40.2,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,38.592,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,95.416,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,4.968,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,15.208,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,5.984,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,4.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,16.048,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,14.872,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,15.208,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
RADIAL ARTERY CTH ST,2720001001,CDM,272,RC,,,Outpatient,,,237.04,154.08,,237.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,180.15,76,,10.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,170.67,72,,155.52,Percent of Total Billed Charges,72% of Total Billed Charges,177.78,75,,162,Percent of Total Billed charges,75% of Total Billed Charges,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.67,72,,155.52,Percent of Total Billed Charges,72% of Total Billed Charges,142.22,60,,129.6,Percent of Total Billed Charges,60% of Total Billed Charges,213.34,90,,144,Percent of Total Billed Charges,90% of Total Billed Charges,106.67,45,,6.016,Percent of Total Billed Charges,45% of Total Billed Charges,213.34,90,,11.952,Percent of Total Billed Charges,90% of Total billed Charges,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.08,65,,7.176,Percent of total Billed Charges,65% of Total Billed Charges,104.53,44.1,,5.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,225.19,95,,12.616,Percent of Total Billed Charges,95% of Total Billed Charges,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.6,88,,11.688,Percent of Total Billed Charges,88% of Total Billed Charges,213.34,90,,11.952,Percent of Total Billed charges,90% of Total Billed Charges,104.53,237.04,
ALL PURP CATH 12FR,2720001002,CDM,272,RC,,,Outpatient,,,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,6.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,72,,50.112,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,75,,52.2,Percent of Total Billed charges,75% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,72,,50.112,Percent of Total Billed Charges,72% of Total Billed Charges,5.95,60,,41.76,Percent of Total Billed Charges,60% of Total Billed Charges,8.93,90,,86.52,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,6.016,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,8.28,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,8.688,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,5.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,8.744,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,8.096,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,8.28,Percent of Total Billed charges,90% of Total Billed Charges,4.37,9.92,
ALL PURP CATH 14FR,2720001003,CDM,272,RC,,,Outpatient,,,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,8.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,72,,49.976,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,75,,52.056,Percent of Total Billed charges,75% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,72,,49.976,Percent of Total Billed Charges,72% of Total Billed Charges,5.95,60,,41.648,Percent of Total Billed Charges,60% of Total Billed Charges,8.93,90,,65.096,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,6.016,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,9.936,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,8.688,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,5.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,10.488,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,9.712,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,9.936,Percent of Total Billed charges,90% of Total Billed Charges,4.37,9.92,
ALL PURP CATH 16FR,2720001004,CDM,272,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,10.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,180.832,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,180.832,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,180.832,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,150.696,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,387.376,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,47.704,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,12.024,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,8.688,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,46.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,12.696,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,11.76,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,12.024,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
PLEUR EVAC DISP,2720001005,CDM,272,RC,,,Outpatient,,,168.68,109.64,,168.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,128.2,76,,10.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,121.45,72,,77.776,Percent of Total Billed Charges,72% of Total Billed Charges,126.51,75,,81.016,Percent of Total Billed charges,75% of Total Billed Charges,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.45,72,,77.776,Percent of Total Billed Charges,72% of Total Billed Charges,101.21,60,,64.816,Percent of Total Billed Charges,60% of Total Billed Charges,151.81,90,,46.664,Percent of Total Billed Charges,90% of Total Billed Charges,75.91,45,,47.704,Percent of Total Billed Charges,45% of Total Billed Charges,151.81,90,,12.024,Percent of Total Billed Charges,90% of Total billed Charges,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.64,65,,68.912,Percent of total Billed Charges,65% of Total Billed Charges,74.39,44.1,,46.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,160.25,95,,12.696,Percent of Total Billed Charges,95% of Total Billed Charges,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.44,88,,11.76,Percent of Total Billed Charges,88% of Total Billed Charges,151.81,90,,12.024,Percent of Total Billed charges,90% of Total Billed Charges,74.39,168.68,
ALL PURP CATH 18FR,2720001006,CDM,272,RC,,,Outpatient,,,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,10.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,48.28,Percent of Total Billed Charges,72% of Total Billed Charges,15.71,75,,50.296,Percent of Total Billed charges,75% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,48.28,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,40.232,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,84.016,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,47.704,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,12.024,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,68.912,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,46.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,12.696,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,11.76,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,12.024,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
CATH TRAY 18RD,2720001007,CDM,272,RC,,,Outpatient,,,98.12,63.78,,98.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,74.57,76,,80.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,70.65,72,,9.064,Percent of Total Billed Charges,72% of Total Billed Charges,73.59,75,,9.44,Percent of Total Billed charges,75% of Total Billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.65,72,,9.064,Percent of Total Billed Charges,72% of Total Billed Charges,58.87,60,,7.552,Percent of Total Billed Charges,60% of Total Billed Charges,88.31,90,,30.352,Percent of Total Billed Charges,90% of Total Billed Charges,44.15,45,,47.704,Percent of Total Billed Charges,45% of Total Billed Charges,88.31,90,,95.416,Percent of Total Billed Charges,90% of Total billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.78,65,,68.912,Percent of total Billed Charges,65% of Total Billed Charges,43.27,44.1,,46.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,93.21,95,,100.712,Percent of Total Billed Charges,95% of Total Billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.35,88,,93.296,Percent of Total Billed Charges,88% of Total Billed Charges,88.31,90,,95.416,Percent of Total Billed charges,90% of Total Billed Charges,43.27,98.12,
INVASIV MONITOR KIT,2720001008,CDM,272,RC,,,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,80.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,19.4,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,20.208,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,19.4,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,16.168,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,72,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,95.416,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,68.912,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,70.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,100.712,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,93.296,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,95.416,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
FOLEY CATH 10F 3CC,2720001009,CDM,272,RC,,,Outpatient,,,110.25,71.66,,110.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,83.79,76,,80.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,79.38,72,,76.672,Percent of Total Billed Charges,72% of Total Billed Charges,82.69,75,,79.864,Percent of Total Billed charges,75% of Total Billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,72,,76.672,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,60,,63.896,Percent of Total Billed Charges,60% of Total Billed Charges,99.23,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,49.61,45,,43.264,Percent of Total Billed Charges,45% of Total Billed Charges,99.23,90,,95.416,Percent of Total Billed Charges,90% of Total billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,65,,104,Percent of total Billed Charges,65% of Total Billed Charges,48.62,44.1,,42.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,104.74,95,,100.712,Percent of Total Billed Charges,95% of Total Billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,88,,93.296,Percent of Total Billed Charges,88% of Total Billed Charges,99.23,90,,95.416,Percent of Total Billed charges,90% of Total Billed Charges,48.62,110.25,
FOLEY CATH 12F 5CC,2720001010,CDM,272,RC,,,Outpatient,,,70.56,45.86,,70.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.63,76,,80.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.8,72,,19.576,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,75,,20.392,Percent of Total Billed charges,75% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.8,72,,19.576,Percent of Total Billed Charges,72% of Total Billed Charges,42.34,60,,16.312,Percent of Total Billed Charges,60% of Total Billed Charges,63.5,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,31.75,45,,32.544,Percent of Total Billed Charges,45% of Total Billed Charges,63.5,90,,95.416,Percent of Total Billed Charges,90% of Total billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.86,65,,62.488,Percent of total Billed Charges,65% of Total Billed Charges,31.12,44.1,,31.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.03,95,,100.712,Percent of Total Billed Charges,95% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.09,88,,93.296,Percent of Total Billed Charges,88% of Total Billed Charges,63.5,90,,95.416,Percent of Total Billed charges,90% of Total Billed Charges,31.12,70.56,
FOLEY CATH 16F 5CC 2,2720001011,CDM,272,RC,,,Outpatient,,,70.56,45.86,,70.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.63,76,,121.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.8,72,,13.824,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,75,,14.4,Percent of Total Billed charges,75% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.8,72,,13.824,Percent of Total Billed Charges,72% of Total Billed Charges,42.34,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,63.5,90,,43.2,Percent of Total Billed Charges,90% of Total Billed Charges,31.75,45,,193.688,Percent of Total Billed Charges,45% of Total Billed Charges,63.5,90,,144,Percent of Total Billed Charges,90% of Total billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.86,65,,47.016,Percent of total Billed Charges,65% of Total Billed Charges,31.12,44.1,,189.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.03,95,,152,Percent of Total Billed Charges,95% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.09,88,,140.8,Percent of Total Billed Charges,88% of Total Billed Charges,63.5,90,,144,Percent of Total Billed charges,90% of Total Billed Charges,31.12,70.56,
FOLEY CATH 18F 5CC 2,2720001012,CDM,272,RC,,,Outpatient,,,70.56,45.86,,70.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.63,76,,73.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.8,72,,13.824,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,75,,14.4,Percent of Total Billed charges,75% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.8,72,,13.824,Percent of Total Billed Charges,72% of Total Billed Charges,42.34,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,63.5,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,31.75,45,,23.328,Percent of Total Billed Charges,45% of Total Billed Charges,63.5,90,,86.52,Percent of Total Billed Charges,90% of Total billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.86,65,,279.768,Percent of total Billed Charges,65% of Total Billed Charges,31.12,44.1,,22.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.03,95,,91.328,Percent of Total Billed Charges,95% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.09,88,,84.6,Percent of Total Billed Charges,88% of Total Billed Charges,63.5,90,,86.52,Percent of Total Billed charges,90% of Total Billed Charges,31.12,70.56,
THERAPEUTIC LENS,2720001013,CDM,272,RC,,,Outpatient,,,246.96,160.52,,246.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,187.69,76,,54.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,177.81,72,,13.824,Percent of Total Billed Charges,72% of Total Billed Charges,185.22,75,,14.4,Percent of Total Billed charges,75% of Total Billed Charges,246.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.81,72,,13.824,Percent of Total Billed Charges,72% of Total Billed Charges,148.18,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,222.26,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,111.13,45,,42.008,Percent of Total Billed Charges,45% of Total Billed Charges,222.26,90,,65.096,Percent of Total Billed Charges,90% of Total billed Charges,246.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.52,65,,33.704,Percent of total Billed Charges,65% of Total Billed Charges,108.91,44.1,,41.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,234.61,95,,68.712,Percent of Total Billed Charges,95% of Total Billed Charges,246.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.32,88,,63.648,Percent of Total Billed Charges,88% of Total Billed Charges,222.26,90,,65.096,Percent of Total Billed charges,90% of Total Billed Charges,108.91,246.96,
ST ANTI REFLUX VALVE,2720001014,CDM,272,RC,,,Outpatient,,,54.02,35.11,,54.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.06,76,,327.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.89,72,,22.12,Percent of Total Billed Charges,72% of Total Billed Charges,40.52,75,,23.04,Percent of Total Billed charges,75% of Total Billed Charges,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.89,72,,22.12,Percent of Total Billed Charges,72% of Total Billed Charges,32.41,60,,18.432,Percent of Total Billed Charges,60% of Total Billed Charges,48.62,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,24.31,45,,15.176,Percent of Total Billed Charges,45% of Total Billed Charges,48.62,90,,387.376,Percent of Total Billed Charges,90% of Total billed Charges,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.11,65,,60.68,Percent of total Billed Charges,65% of Total Billed Charges,23.82,44.1,,14.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,51.32,95,,408.896,Percent of Total Billed Charges,95% of Total Billed Charges,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.54,88,,378.768,Percent of Total Billed Charges,88% of Total Billed Charges,48.62,90,,387.376,Percent of Total Billed charges,90% of Total Billed Charges,23.82,54.02,
FOLEY CATH 16F 30CC,2720001015,CDM,272,RC,,,Outpatient,,,83.79,54.46,,83.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,63.68,76,,39.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,60.33,72,,17.376,Percent of Total Billed Charges,72% of Total Billed Charges,62.84,75,,18.096,Percent of Total Billed charges,75% of Total Billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.33,72,,17.376,Percent of Total Billed Charges,72% of Total Billed Charges,50.27,60,,14.48,Percent of Total Billed Charges,60% of Total Billed Charges,75.41,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,37.71,45,,8.28,Percent of Total Billed Charges,45% of Total Billed Charges,75.41,90,,46.664,Percent of Total Billed Charges,90% of Total billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.46,65,,21.92,Percent of total Billed Charges,65% of Total Billed Charges,36.95,44.1,,8.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,79.6,95,,49.256,Percent of Total Billed Charges,95% of Total Billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.74,88,,45.624,Percent of Total Billed Charges,88% of Total Billed Charges,75.41,90,,46.664,Percent of Total Billed charges,90% of Total Billed Charges,36.95,83.79,
FOLEY CATH 18F 30CC,2720001016,CDM,272,RC,,,Outpatient,,,83.79,54.46,,83.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,63.68,76,,70.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,60.33,72,,50.352,Percent of Total Billed Charges,72% of Total Billed Charges,62.84,75,,52.456,Percent of Total Billed charges,75% of Total Billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.33,72,,50.352,Percent of Total Billed Charges,72% of Total Billed Charges,50.27,60,,41.96,Percent of Total Billed Charges,60% of Total Billed Charges,75.41,90,,38.16,Percent of Total Billed Charges,90% of Total Billed Charges,37.71,45,,8.28,Percent of Total Billed Charges,45% of Total Billed Charges,75.41,90,,84.016,Percent of Total Billed Charges,90% of Total billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.46,65,,11.96,Percent of total Billed Charges,65% of Total Billed Charges,36.95,44.1,,8.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,79.6,95,,88.688,Percent of Total Billed Charges,95% of Total Billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.74,88,,82.152,Percent of Total Billed Charges,88% of Total Billed Charges,75.41,90,,84.016,Percent of Total Billed charges,90% of Total Billed Charges,36.95,83.79,
FOLEY CATH 20F 30CC,2720001017,CDM,272,RC,,,Outpatient,,,113.56,73.81,,113.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,86.31,76,,25.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,81.76,72,,34.776,Percent of Total Billed Charges,72% of Total Billed Charges,85.17,75,,36.224,Percent of Total Billed charges,75% of Total Billed Charges,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.76,72,,34.776,Percent of Total Billed Charges,72% of Total Billed Charges,68.14,60,,28.976,Percent of Total Billed Charges,60% of Total Billed Charges,102.2,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,51.1,45,,13.68,Percent of Total Billed Charges,45% of Total Billed Charges,102.2,90,,30.352,Percent of Total Billed Charges,90% of Total billed Charges,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.81,65,,11.96,Percent of total Billed Charges,65% of Total Billed Charges,50.08,44.1,,13.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,107.88,95,,32.032,Percent of Total Billed Charges,95% of Total Billed Charges,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.93,88,,29.672,Percent of Total Billed Charges,88% of Total Billed Charges,102.2,90,,30.352,Percent of Total Billed charges,90% of Total Billed Charges,50.08,113.56,
FOLEY CATH 22F 30CC,2720001018,CDM,272,RC,,,Outpatient,,,83.79,54.46,,83.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,63.68,76,,13.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,60.33,72,,20.736,Percent of Total Billed Charges,72% of Total Billed Charges,62.84,75,,21.6,Percent of Total Billed charges,75% of Total Billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.33,72,,20.736,Percent of Total Billed Charges,72% of Total Billed Charges,50.27,60,,17.28,Percent of Total Billed Charges,60% of Total Billed Charges,75.41,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,37.71,45,,21.6,Percent of Total Billed Charges,45% of Total Billed Charges,75.41,90,,16.56,Percent of Total Billed Charges,90% of Total billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.46,65,,19.76,Percent of total Billed Charges,65% of Total Billed Charges,36.95,44.1,,21.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,79.6,95,,17.48,Percent of Total Billed Charges,95% of Total Billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.74,88,,16.192,Percent of Total Billed Charges,88% of Total Billed Charges,75.41,90,,16.56,Percent of Total Billed charges,90% of Total Billed Charges,36.95,83.79,
TRACHEA TBE 3.0 MRPH,2720001019,CDM,272,RC,,,Outpatient,,,35.28,22.93,,35.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.81,76,,13.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.4,72,,48.648,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,75,,50.68,Percent of Total Billed charges,75% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.4,72,,48.648,Percent of Total Billed Charges,72% of Total Billed Charges,21.17,60,,40.544,Percent of Total Billed Charges,60% of Total Billed Charges,31.75,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,15.88,45,,3.24,Percent of Total Billed Charges,45% of Total Billed Charges,31.75,90,,16.56,Percent of Total Billed Charges,90% of Total billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.93,65,,31.2,Percent of total Billed Charges,65% of Total Billed Charges,15.56,44.1,,3.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.52,95,,17.48,Percent of Total Billed Charges,95% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.05,88,,16.192,Percent of Total Billed Charges,88% of Total Billed Charges,31.75,90,,16.56,Percent of Total Billed charges,90% of Total Billed Charges,15.56,35.28,
FOLEY CATH 28F 30CC,2720001020,CDM,272,RC,,,Outpatient,,,83.79,54.46,,83.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,63.68,76,,23.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,60.33,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,62.84,75,,53.584,Percent of Total Billed charges,75% of Total Billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.33,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,50.27,60,,42.872,Percent of Total Billed Charges,60% of Total Billed Charges,75.41,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,37.71,45,,0.72,Percent of Total Billed Charges,45% of Total Billed Charges,75.41,90,,27.36,Percent of Total Billed Charges,90% of Total billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.46,65,,4.68,Percent of total Billed Charges,65% of Total Billed Charges,36.95,44.1,,0.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,79.6,95,,28.88,Percent of Total Billed Charges,95% of Total Billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.74,88,,26.752,Percent of Total Billed Charges,88% of Total Billed Charges,75.41,90,,27.36,Percent of Total Billed charges,90% of Total Billed Charges,36.95,83.79,
TRACHEA TBE 6.0 MRPH,2720001021,CDM,272,RC,,,Outpatient,,,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,36.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.88,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,75,,53.584,Percent of Total Billed charges,75% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.88,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,60,,42.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,90,,319.904,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,21.96,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,43.2,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,1.04,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,21.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,45.6,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,42.24,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,43.2,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.05,
TRACHEA TBE 6.5 MRPH,2720001022,CDM,272,RC,,,Outpatient,,,149.94,97.46,,149.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,113.95,76,,5.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,107.96,72,,1728,Percent of Total Billed Charges,72% of Total Billed Charges,112.46,75,,1800,Percent of Total Billed charges,75% of Total Billed Charges,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.96,72,,1728,Percent of Total Billed Charges,72% of Total Billed Charges,89.96,60,,1440,Percent of Total Billed Charges,60% of Total Billed Charges,134.95,90,,176.224,Percent of Total Billed Charges,90% of Total Billed Charges,67.47,45,,21.96,Percent of Total Billed Charges,45% of Total Billed Charges,134.95,90,,6.48,Percent of Total Billed Charges,90% of Total billed Charges,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.46,65,,31.72,Percent of total Billed Charges,65% of Total Billed Charges,66.12,44.1,,21.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.44,95,,6.84,Percent of Total Billed Charges,95% of Total Billed Charges,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.95,88,,6.336,Percent of Total Billed Charges,88% of Total Billed Charges,134.95,90,,6.48,Percent of Total Billed charges,90% of Total Billed Charges,66.12,149.94,
FOLEY CATH 20F 30CC,2720001023,CDM,272,RC,,,Outpatient,,,175.30,113.95,,175.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,133.23,76,,1.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,126.22,72,,85.248,Percent of Total Billed Charges,72% of Total Billed Charges,131.48,75,,88.8,Percent of Total Billed charges,75% of Total Billed Charges,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.22,72,,85.248,Percent of Total Billed Charges,72% of Total Billed Charges,105.18,60,,71.04,Percent of Total Billed Charges,60% of Total Billed Charges,157.77,90,,221.472,Percent of Total Billed Charges,90% of Total Billed Charges,78.89,45,,19.08,Percent of Total Billed Charges,45% of Total Billed Charges,157.77,90,,1.44,Percent of Total Billed Charges,90% of Total billed Charges,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.95,65,,31.72,Percent of total Billed Charges,65% of Total Billed Charges,77.31,44.1,,18.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,166.54,95,,1.52,Percent of Total Billed Charges,95% of Total Billed Charges,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.26,88,,1.408,Percent of Total Billed Charges,88% of Total Billed Charges,157.77,90,,1.44,Percent of Total Billed charges,90% of Total Billed Charges,77.31,175.3,
NEEDLE SPINAL 22X3.5,2720001024,CDM,272,RC,,,Outpatient,,,267.91,174.14,,267.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,203.61,76,,37.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,192.9,72,,20.736,Percent of Total Billed Charges,72% of Total Billed Charges,200.93,75,,21.6,Percent of Total Billed charges,75% of Total Billed Charges,267.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.9,72,,20.736,Percent of Total Billed Charges,72% of Total Billed Charges,160.75,60,,17.28,Percent of Total Billed Charges,60% of Total Billed Charges,241.12,90,,133.36,Percent of Total Billed Charges,90% of Total Billed Charges,120.56,45,,0.72,Percent of Total Billed Charges,45% of Total Billed Charges,241.12,90,,43.92,Percent of Total Billed Charges,90% of Total billed Charges,267.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.14,65,,27.56,Percent of total Billed Charges,65% of Total Billed Charges,118.15,44.1,,0.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,254.51,95,,46.36,Percent of Total Billed Charges,95% of Total Billed Charges,267.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.76,88,,42.944,Percent of Total Billed Charges,88% of Total Billed Charges,241.12,90,,43.92,Percent of Total Billed charges,90% of Total Billed Charges,118.15,267.91,
PAD 3X4,2720001025,CDM,272,RC,,,Outpatient,,,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,37.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,48.96,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,51,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,48.96,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,40.8,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,50.008,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,0.72,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,43.92,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,1.04,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,0.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,46.36,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,42.944,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,43.92,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
14FR BLADDER CARE TR,2720001026,CDM,272,RC,,,Outpatient,,,98.12,63.78,,98.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,74.57,76,,32.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,70.65,72,,9.216,Percent of Total Billed Charges,72% of Total Billed Charges,73.59,75,,9.6,Percent of Total Billed charges,75% of Total Billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.65,72,,9.216,Percent of Total Billed Charges,72% of Total Billed Charges,58.87,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,88.31,90,,25.4,Percent of Total Billed Charges,90% of Total Billed Charges,44.15,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,88.31,90,,38.16,Percent of Total Billed Charges,90% of Total billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.78,65,,1.04,Percent of total Billed Charges,65% of Total Billed Charges,43.27,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,93.21,95,,40.28,Percent of Total Billed Charges,95% of Total Billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.35,88,,37.312,Percent of Total Billed Charges,88% of Total Billed Charges,88.31,90,,38.16,Percent of Total Billed charges,90% of Total Billed Charges,43.27,98.12,
FOLEY CATH 16F 5CC 3,2720001027,CDM,272,RC,,,Outpatient,,,115.76,75.24,,115.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.98,76,,1.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,83.35,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,86.82,75,,90,Percent of Total Billed charges,75% of Total Billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.35,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,69.46,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,104.18,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,52.09,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,104.18,90,,1.44,Percent of Total Billed Charges,90% of Total billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.24,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,51.05,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,109.97,95,,1.52,Percent of Total Billed Charges,95% of Total Billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.87,88,,1.408,Percent of Total Billed Charges,88% of Total Billed Charges,104.18,90,,1.44,Percent of Total Billed charges,90% of Total Billed Charges,51.05,115.76,
FOLEY CTH 18F 5CC 3,2720001028,CDM,272,RC,,,Outpatient,,,110.25,71.66,,110.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,83.79,76,,1.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,79.38,72,,37.44,Percent of Total Billed Charges,72% of Total Billed Charges,82.69,75,,39,Percent of Total Billed charges,75% of Total Billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,72,,37.44,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,60,,31.2,Percent of Total Billed Charges,60% of Total Billed Charges,99.23,90,,135.744,Percent of Total Billed Charges,90% of Total Billed Charges,49.61,45,,159.952,Percent of Total Billed Charges,45% of Total Billed Charges,99.23,90,,1.44,Percent of Total Billed Charges,90% of Total billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,48.62,44.1,,156.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,104.74,95,,1.52,Percent of Total Billed Charges,95% of Total Billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,88,,1.408,Percent of Total Billed Charges,88% of Total Billed Charges,99.23,90,,1.44,Percent of Total Billed charges,90% of Total Billed Charges,48.62,110.25,
FOLEY CTH 20F 5CC 3,2720001029,CDM,272,RC,,,Outpatient,,,81.59,53.03,,81.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.01,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,58.74,72,,22.072,Percent of Total Billed Charges,72% of Total Billed Charges,61.19,75,,22.992,Percent of Total Billed charges,75% of Total Billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.74,72,,22.072,Percent of Total Billed Charges,72% of Total Billed Charges,48.95,60,,18.392,Percent of Total Billed Charges,60% of Total Billed Charges,73.43,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,36.72,45,,88.112,Percent of Total Billed Charges,45% of Total Billed Charges,73.43,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.03,65,,231.04,Percent of total Billed Charges,65% of Total Billed Charges,35.98,44.1,,86.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,77.51,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.8,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,73.43,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,35.98,81.59,
ARROW TWIN CATH,2720001030,CDM,272,RC,,,Outpatient,,,120.17,78.11,,120.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,91.33,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,86.52,72,,22.072,Percent of Total Billed Charges,72% of Total Billed Charges,90.13,75,,22.992,Percent of Total Billed charges,75% of Total Billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.52,72,,22.072,Percent of Total Billed Charges,72% of Total Billed Charges,72.1,60,,18.392,Percent of Total Billed Charges,60% of Total Billed Charges,108.15,90,,24.192,Percent of Total Billed Charges,90% of Total Billed Charges,54.08,45,,110.736,Percent of Total Billed Charges,45% of Total Billed Charges,108.15,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.11,65,,127.272,Percent of total Billed Charges,65% of Total Billed Charges,52.99,44.1,,108.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,114.16,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.75,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,108.15,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,52.99,120.17,
CATH FLY 26F 5CC 3WY,2720001031,CDM,272,RC,,,Outpatient,,,109.15,70.95,,109.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.95,76,,270.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,78.59,72,,56.8,Percent of Total Billed Charges,72% of Total Billed Charges,81.86,75,,59.168,Percent of Total Billed charges,75% of Total Billed Charges,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.59,72,,56.8,Percent of Total Billed Charges,72% of Total Billed Charges,65.49,60,,47.336,Percent of Total Billed Charges,60% of Total Billed Charges,98.24,90,,109.552,Percent of Total Billed Charges,90% of Total Billed Charges,49.12,45,,66.68,Percent of Total Billed Charges,45% of Total Billed Charges,98.24,90,,319.904,Percent of Total Billed Charges,90% of Total billed Charges,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.95,65,,159.952,Percent of total Billed Charges,65% of Total Billed Charges,48.14,44.1,,65.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,103.69,95,,337.672,Percent of Total Billed Charges,95% of Total Billed Charges,109.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.05,88,,312.792,Percent of Total Billed Charges,88% of Total Billed Charges,98.24,90,,319.904,Percent of Total Billed charges,90% of Total Billed Charges,48.14,109.15,
KERLIX ROLL N/S,2720001032,CDM,272,RC,,,Outpatient,,,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,148.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,32.512,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,33.872,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,32.512,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,27.096,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,25.008,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,176.224,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,96.312,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,24.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,186.016,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,172.312,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,176.224,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
CHEST TUBE TROCAR 20,2720001033,CDM,272,RC,,,Outpatient,,,132.30,86.00,,132.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.55,76,,187.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.26,72,,132.976,Percent of Total Billed Charges,72% of Total Billed Charges,99.23,75,,138.52,Percent of Total Billed charges,75% of Total Billed Charges,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.26,72,,132.976,Percent of Total Billed Charges,72% of Total Billed Charges,79.38,60,,110.816,Percent of Total Billed Charges,60% of Total Billed Charges,119.07,90,,57.152,Percent of Total Billed Charges,90% of Total Billed Charges,59.54,45,,12.704,Percent of Total Billed Charges,45% of Total Billed Charges,119.07,90,,221.472,Percent of Total Billed Charges,90% of Total billed Charges,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,65,,36.12,Percent of total Billed Charges,65% of Total Billed Charges,58.34,44.1,,12.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.69,95,,233.776,Percent of Total Billed Charges,95% of Total Billed Charges,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.42,88,,216.552,Percent of Total Billed Charges,88% of Total Billed Charges,119.07,90,,221.472,Percent of Total Billed charges,90% of Total Billed Charges,58.34,132.3,
SUBCLVN CTH DBL LUMN,2720001034,CDM,272,RC,,,Outpatient,,,476.28,309.58,,476.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,361.97,76,,112.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,342.92,72,,132.976,Percent of Total Billed Charges,72% of Total Billed Charges,357.21,75,,138.52,Percent of Total Billed charges,75% of Total Billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.92,72,,132.976,Percent of Total Billed Charges,72% of Total Billed Charges,285.77,60,,110.816,Percent of Total Billed Charges,60% of Total Billed Charges,428.65,90,,59.536,Percent of Total Billed Charges,90% of Total Billed Charges,214.33,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,428.65,90,,133.36,Percent of Total Billed Charges,90% of Total billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.58,65,,18.344,Percent of total Billed Charges,65% of Total Billed Charges,210.04,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,452.47,95,,140.768,Percent of Total Billed Charges,95% of Total Billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.13,88,,130.392,Percent of Total Billed Charges,88% of Total Billed Charges,428.65,90,,133.36,Percent of Total Billed charges,90% of Total Billed Charges,210.04,476.28,
FEEDING TUBE 8FR 15',2720001035,CDM,272,RC,,,Outpatient,,,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,42.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,132.976,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,138.52,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,132.976,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,110.816,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,34.136,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,67.872,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,50.008,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,66.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,52.792,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,48.896,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,50.008,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
DRN W/NRT VL 5912,2720001036,CDM,272,RC,,,Outpatient,,,100.33,65.21,,100.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,76.25,76,,21.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,72.24,72,,132.976,Percent of Total Billed Charges,72% of Total Billed Charges,75.25,75,,138.52,Percent of Total Billed charges,75% of Total Billed Charges,100.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.24,72,,132.976,Percent of Total Billed Charges,72% of Total Billed Charges,60.2,60,,110.816,Percent of Total Billed Charges,60% of Total Billed Charges,90.3,90,,82.552,Percent of Total Billed Charges,90% of Total Billed Charges,45.15,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,90.3,90,,25.4,Percent of Total Billed Charges,90% of Total billed Charges,100.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.21,65,,98.032,Percent of total Billed Charges,65% of Total Billed Charges,44.25,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,95.31,95,,26.816,Percent of Total Billed Charges,95% of Total Billed Charges,100.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.29,88,,24.84,Percent of Total Billed Charges,88% of Total Billed Charges,90.3,90,,25.4,Percent of Total Billed charges,90% of Total Billed Charges,44.25,100.33,
DRESS TEGA 4X4.75,2720001037,CDM,272,RC,,,Outpatient,,,3.86,2.51,,3.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.93,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.78,72,,188.696,Percent of Total Billed Charges,72% of Total Billed Charges,2.9,75,,196.56,Percent of Total Billed charges,75% of Total Billed Charges,3.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.78,72,,188.696,Percent of Total Billed Charges,72% of Total Billed Charges,2.32,60,,157.248,Percent of Total Billed Charges,60% of Total Billed Charges,3.47,90,,199.248,Percent of Total Billed Charges,90% of Total Billed Charges,1.74,45,,12.096,Percent of Total Billed Charges,45% of Total Billed Charges,3.47,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,3.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.51,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,1.7,44.1,,11.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.67,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,3.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.4,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,3.47,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,1.7,3.86,
DRESS TEGA 6X8,2720001038,CDM,272,RC,,,Outpatient,,,12.60,8.19,,12.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.58,76,,114.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.07,72,,197.12,Percent of Total Billed Charges,72% of Total Billed Charges,9.45,75,,205.336,Percent of Total Billed charges,75% of Total Billed Charges,12.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.07,72,,197.12,Percent of Total Billed Charges,72% of Total Billed Charges,7.56,60,,164.264,Percent of Total Billed Charges,60% of Total Billed Charges,11.34,90,,391.344,Percent of Total Billed Charges,90% of Total Billed Charges,5.67,45,,54.776,Percent of Total Billed Charges,45% of Total Billed Charges,11.34,90,,135.744,Percent of Total Billed Charges,90% of Total billed Charges,12.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.19,65,,17.472,Percent of total Billed Charges,65% of Total Billed Charges,5.56,44.1,,53.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.97,95,,143.28,Percent of Total Billed Charges,95% of Total Billed Charges,12.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.09,88,,132.728,Percent of Total Billed Charges,88% of Total Billed Charges,11.34,90,,135.744,Percent of Total Billed charges,90% of Total Billed Charges,5.56,12.6,
DRESS TEGA 8X12,2720001039,CDM,272,RC,,,Outpatient,,,7.64,4.97,,7.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.81,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.5,72,,198.936,Percent of Total Billed Charges,72% of Total Billed Charges,5.73,75,,207.224,Percent of Total Billed charges,75% of Total Billed Charges,7.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.5,72,,198.936,Percent of Total Billed Charges,72% of Total Billed Charges,4.58,60,,165.776,Percent of Total Billed Charges,60% of Total Billed Charges,6.88,90,,544.552,Percent of Total Billed Charges,90% of Total Billed Charges,3.44,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,6.88,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,7.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.97,65,,79.12,Percent of total Billed Charges,65% of Total Billed Charges,3.37,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.26,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,7.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.72,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,6.88,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,3.37,7.64,
PENROSE DRAIN 1/4',2720001040,CDM,272,RC,,,Outpatient,,,48.51,31.53,,48.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.87,76,,20.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.93,72,,132.976,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,75,,138.52,Percent of Total Billed charges,75% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,72,,132.976,Percent of Total Billed Charges,72% of Total Billed Charges,29.11,60,,110.816,Percent of Total Billed Charges,60% of Total Billed Charges,43.66,90,,695.368,Percent of Total Billed Charges,90% of Total Billed Charges,21.83,45,,28.576,Percent of Total Billed Charges,45% of Total Billed Charges,43.66,90,,24.192,Percent of Total Billed Charges,90% of Total billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.53,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,21.39,44.1,,28.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.08,95,,25.536,Percent of Total Billed Charges,95% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.69,88,,23.656,Percent of Total Billed Charges,88% of Total Billed Charges,43.66,90,,24.192,Percent of Total Billed charges,90% of Total Billed Charges,21.39,48.51,
PENROSE DRAIN,2720001041,CDM,272,RC,,,Outpatient,,,48.51,31.53,,48.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.87,76,,92.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.93,72,,132.976,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,75,,138.52,Percent of Total Billed charges,75% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,72,,132.976,Percent of Total Billed Charges,72% of Total Billed Charges,29.11,60,,110.816,Percent of Total Billed Charges,60% of Total Billed Charges,43.66,90,,10957.616,Percent of Total Billed Charges,90% of Total Billed Charges,21.83,45,,29.768,Percent of Total Billed Charges,45% of Total Billed Charges,43.66,90,,109.552,Percent of Total Billed Charges,90% of Total billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.53,65,,41.28,Percent of total Billed Charges,65% of Total Billed Charges,21.39,44.1,,29.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.08,95,,115.632,Percent of Total Billed Charges,95% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.69,88,,107.112,Percent of Total Billed Charges,88% of Total Billed Charges,43.66,90,,109.552,Percent of Total Billed charges,90% of Total Billed Charges,21.39,48.51,
PENROSE DRAIN 1',2720001043,CDM,272,RC,,,Outpatient,,,48.51,31.53,,48.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.87,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.93,72,,47.048,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,75,,49.008,Percent of Total Billed charges,75% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,72,,47.048,Percent of Total Billed Charges,72% of Total Billed Charges,29.11,60,,39.208,Percent of Total Billed Charges,60% of Total Billed Charges,43.66,90,,7375.992,Percent of Total Billed Charges,90% of Total Billed Charges,21.83,45,,17.064,Percent of Total Billed Charges,45% of Total Billed Charges,43.66,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.53,65,,43,Percent of total Billed Charges,65% of Total Billed Charges,21.39,44.1,,16.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.08,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.69,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,43.66,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,21.39,48.51,
TRAY SUTURE REMOVAL,2720001045,CDM,272,RC,,,Outpatient,,,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,48.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,72,,30.152,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,75,,31.408,Percent of Total Billed charges,75% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,72,,30.152,Percent of Total Billed Charges,72% of Total Billed Charges,5.95,60,,25.128,Percent of Total Billed Charges,60% of Total Billed Charges,8.93,90,,11113.992,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,41.28,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,57.152,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,24.656,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,40.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,60.328,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,55.88,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,57.152,Percent of Total Billed charges,90% of Total Billed Charges,4.37,9.92,
TRAY LMB/PNCT INFNT,2720001046,CDM,272,RC,,,Outpatient,,,72.77,47.30,,72.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.31,76,,50.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.39,72,,21.776,Percent of Total Billed Charges,72% of Total Billed Charges,54.58,75,,22.68,Percent of Total Billed charges,75% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.39,72,,21.776,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,60,,18.144,Percent of Total Billed Charges,60% of Total Billed Charges,65.49,90,,3437.952,Percent of Total Billed Charges,90% of Total Billed Charges,32.75,45,,99.624,Percent of Total Billed Charges,45% of Total Billed Charges,65.49,90,,59.536,Percent of Total Billed Charges,90% of Total billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.3,65,,59.624,Percent of total Billed Charges,65% of Total Billed Charges,32.09,44.1,,97.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,69.13,95,,62.848,Percent of Total Billed Charges,95% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.04,88,,58.216,Percent of Total Billed Charges,88% of Total Billed Charges,65.49,90,,59.536,Percent of Total Billed charges,90% of Total Billed Charges,32.09,72.77,
GAUZE SPONGE STERILE,2720001047,CDM,272,RC,,,Outpatient,,,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,28.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,72.576,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,75.6,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,72.576,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,60.48,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,12.704,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,195.672,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,34.136,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,143.896,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,191.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,36.032,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,33.376,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,34.136,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
TRAY LMB/PNCT ADLT,2720001048,CDM,272,RC,,,Outpatient,,,159.86,103.91,,159.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,121.49,76,,69.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,115.1,72,,21.776,Percent of Total Billed Charges,72% of Total Billed Charges,119.9,75,,22.68,Percent of Total Billed charges,75% of Total Billed Charges,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.1,72,,21.776,Percent of Total Billed Charges,72% of Total Billed Charges,95.92,60,,18.144,Percent of Total Billed Charges,60% of Total Billed Charges,143.87,90,,61.12,Percent of Total Billed Charges,90% of Total Billed Charges,71.94,45,,272.272,Percent of Total Billed Charges,45% of Total Billed Charges,143.87,90,,82.552,Percent of Total Billed Charges,90% of Total billed Charges,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.91,65,,282.632,Percent of total Billed Charges,65% of Total Billed Charges,70.5,44.1,,266.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,151.87,95,,87.144,Percent of Total Billed Charges,95% of Total Billed Charges,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.68,88,,80.72,Percent of Total Billed Charges,88% of Total Billed Charges,143.87,90,,82.552,Percent of Total Billed charges,90% of Total Billed Charges,70.5,159.86,
TRACH CLEAN TRAY W/G,2720001049,CDM,272,RC,,,Outpatient,,,47.41,30.82,,47.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.03,76,,168.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.14,72,,72.576,Percent of Total Billed Charges,72% of Total Billed Charges,35.56,75,,75.6,Percent of Total Billed charges,75% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.14,72,,72.576,Percent of Total Billed Charges,72% of Total Billed Charges,28.45,60,,60.48,Percent of Total Billed Charges,60% of Total Billed Charges,42.67,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,21.33,45,,347.688,Percent of Total Billed Charges,45% of Total Billed Charges,42.67,90,,199.248,Percent of Total Billed Charges,90% of Total billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.82,65,,393.288,Percent of total Billed Charges,65% of Total Billed Charges,20.91,44.1,,340.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.04,95,,210.312,Percent of Total Billed Charges,95% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.72,88,,194.816,Percent of Total Billed Charges,88% of Total Billed Charges,42.67,90,,199.248,Percent of Total Billed charges,90% of Total Billed Charges,20.91,47.41,
COUDE CATH 12 FR 5CC,2720001050,CDM,272,RC,,,Outpatient,,,86.00,55.90,,86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,65.36,76,,330.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.92,72,,21.776,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,75,,22.68,Percent of Total Billed charges,75% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.92,72,,21.776,Percent of Total Billed Charges,72% of Total Billed Charges,51.6,60,,18.144,Percent of Total Billed Charges,60% of Total Billed Charges,77.4,90,,160.352,Percent of Total Billed Charges,90% of Total Billed Charges,38.7,45,,5478.808,Percent of Total Billed Charges,45% of Total Billed Charges,77.4,90,,391.344,Percent of Total Billed Charges,90% of Total billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.9,65,,502.208,Percent of total Billed Charges,65% of Total Billed Charges,37.93,44.1,,5369.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,81.7,95,,413.08,Percent of Total Billed Charges,95% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.68,88,,382.648,Percent of Total Billed Charges,88% of Total Billed Charges,77.4,90,,391.344,Percent of Total Billed charges,90% of Total Billed Charges,37.93,86,
COUDE CATH 14FR 5CC,2720001051,CDM,272,RC,,,Outpatient,,,128.99,83.84,,128.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.03,76,,459.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,92.87,72,,72.576,Percent of Total Billed Charges,72% of Total Billed Charges,96.74,75,,75.6,Percent of Total Billed charges,75% of Total Billed Charges,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.87,72,,72.576,Percent of Total Billed Charges,72% of Total Billed Charges,77.39,60,,60.48,Percent of Total Billed Charges,60% of Total Billed Charges,116.09,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,58.05,45,,3687.992,Percent of Total Billed Charges,45% of Total Billed Charges,116.09,90,,544.552,Percent of Total Billed Charges,90% of Total billed Charges,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.84,65,,7913.832,Percent of total Billed Charges,65% of Total Billed Charges,56.88,44.1,,3614.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,122.54,95,,574.8,Percent of Total Billed Charges,95% of Total Billed Charges,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.51,88,,532.448,Percent of Total Billed Charges,88% of Total Billed Charges,116.09,90,,544.552,Percent of Total Billed charges,90% of Total Billed Charges,56.88,128.99,
FOLEY CATH 14F 5CC,2720001052,CDM,272,RC,,,Outpatient,,,98.12,63.78,,98.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,74.57,76,,587.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,70.65,72,,119.752,Percent of Total Billed Charges,72% of Total Billed Charges,73.59,75,,124.744,Percent of Total Billed charges,75% of Total Billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.65,72,,119.752,Percent of Total Billed Charges,72% of Total Billed Charges,58.87,60,,99.792,Percent of Total Billed Charges,60% of Total Billed Charges,88.31,90,,10.32,Percent of Total Billed Charges,90% of Total Billed Charges,44.15,45,,5557,Percent of Total Billed Charges,45% of Total Billed Charges,88.31,90,,695.368,Percent of Total Billed Charges,90% of Total billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.78,65,,5327.104,Percent of total Billed Charges,65% of Total Billed Charges,43.27,44.1,,5445.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,93.21,95,,734,Percent of Total Billed Charges,95% of Total Billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.35,88,,679.92,Percent of Total Billed Charges,88% of Total Billed Charges,88.31,90,,695.368,Percent of Total Billed charges,90% of Total Billed Charges,43.27,98.12,
DISP SKIN STAPLES,2720001053,CDM,272,RC,,,Outpatient,,,57.33,37.26,,57.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.57,76,,9253.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.28,72,,198.936,Percent of Total Billed Charges,72% of Total Billed Charges,43,75,,207.224,Percent of Total Billed charges,75% of Total Billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.28,72,,198.936,Percent of Total Billed Charges,72% of Total Billed Charges,34.4,60,,165.776,Percent of Total Billed Charges,60% of Total Billed Charges,51.6,90,,161.936,Percent of Total Billed Charges,90% of Total Billed Charges,25.8,45,,1718.976,Percent of Total Billed Charges,45% of Total Billed Charges,51.6,90,,10957.616,Percent of Total Billed Charges,90% of Total billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.26,65,,8026.776,Percent of total Billed Charges,65% of Total Billed Charges,25.28,44.1,,1684.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.46,95,,11566.368,Percent of Total Billed Charges,95% of Total Billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.45,88,,10714.112,Percent of Total Billed Charges,88% of Total Billed Charges,51.6,90,,10957.616,Percent of Total Billed charges,90% of Total Billed Charges,25.28,57.33,
COUDE CTH 2W 5CC 18F,2720001054,CDM,272,RC,,,Outpatient,,,86.00,55.90,,86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,65.36,76,,6228.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.92,72,,198.936,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,75,,207.224,Percent of Total Billed charges,75% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.92,72,,198.936,Percent of Total Billed Charges,72% of Total Billed Charges,51.6,60,,165.776,Percent of Total Billed Charges,60% of Total Billed Charges,77.4,90,,32.544,Percent of Total Billed Charges,90% of Total Billed Charges,38.7,45,,6.352,Percent of Total Billed Charges,45% of Total Billed Charges,77.4,90,,7375.992,Percent of Total Billed Charges,90% of Total billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.9,65,,2482.96,Percent of total Billed Charges,65% of Total Billed Charges,37.93,44.1,,6.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,81.7,95,,7785.768,Percent of Total Billed Charges,95% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.68,88,,7212.08,Percent of Total Billed Charges,88% of Total Billed Charges,77.4,90,,7375.992,Percent of Total Billed charges,90% of Total Billed Charges,37.93,86,
COUDE CTH 2W 5CC 16F,2720001055,CDM,272,RC,,,Outpatient,,,72.77,47.30,,72.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.31,76,,9385.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.39,72,,104.928,Percent of Total Billed Charges,72% of Total Billed Charges,54.58,75,,109.296,Percent of Total Billed charges,75% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.39,72,,104.928,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,60,,87.44,Percent of Total Billed Charges,60% of Total Billed Charges,65.49,90,,222.264,Percent of Total Billed Charges,90% of Total Billed Charges,32.75,45,,30.56,Percent of Total Billed Charges,45% of Total Billed Charges,65.49,90,,11113.992,Percent of Total Billed Charges,90% of Total billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.3,65,,9.176,Percent of total Billed Charges,65% of Total Billed Charges,32.09,44.1,,29.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,69.13,95,,11731.44,Percent of Total Billed Charges,95% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.04,88,,10867.016,Percent of Total Billed Charges,88% of Total Billed Charges,65.49,90,,11113.992,Percent of Total Billed charges,90% of Total Billed Charges,32.09,72.77,
FOLEY CATH 22F 5CC 2,2720001056,CDM,272,RC,,,Outpatient,,,70.56,45.86,,70.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.63,76,,2903.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.8,72,,95.752,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,75,,99.736,Percent of Total Billed charges,75% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.8,72,,95.752,Percent of Total Billed Charges,72% of Total Billed Charges,42.34,60,,79.792,Percent of Total Billed Charges,60% of Total Billed Charges,63.5,90,,600.112,Percent of Total Billed Charges,90% of Total Billed Charges,31.75,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,63.5,90,,3437.952,Percent of Total Billed Charges,90% of Total billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.86,65,,44.144,Percent of total Billed Charges,65% of Total Billed Charges,31.12,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.03,95,,3628.944,Percent of Total Billed Charges,95% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.09,88,,3361.552,Percent of Total Billed Charges,88% of Total Billed Charges,63.5,90,,3437.952,Percent of Total Billed charges,90% of Total Billed Charges,31.12,70.56,
WOUND DRAIN COLLCT,2720001057,CDM,272,RC,,,Outpatient,,,164.27,106.78,,164.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.85,76,,10.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,118.27,72,,88.288,Percent of Total Billed Charges,72% of Total Billed Charges,123.2,75,,91.968,Percent of Total Billed charges,75% of Total Billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.27,72,,88.288,Percent of Total Billed Charges,72% of Total Billed Charges,98.56,60,,73.576,Percent of Total Billed Charges,60% of Total Billed Charges,147.84,90,,493.744,Percent of Total Billed Charges,90% of Total Billed Charges,73.92,45,,80.176,Percent of Total Billed Charges,45% of Total Billed Charges,147.84,90,,12.704,Percent of Total Billed Charges,90% of Total billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.78,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,72.44,44.1,,78.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,156.06,95,,13.408,Percent of Total Billed Charges,95% of Total Billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.56,88,,12.416,Percent of Total Billed Charges,88% of Total Billed Charges,147.84,90,,12.704,Percent of Total Billed charges,90% of Total Billed Charges,72.44,164.27,
TRACHEA TBE 8.0 MCGL,2720001058,CDM,272,RC,,,Outpatient,,,170.89,111.08,,170.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.88,76,,51.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.04,72,,197.12,Percent of Total Billed Charges,72% of Total Billed Charges,128.17,75,,205.336,Percent of Total Billed charges,75% of Total Billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.04,72,,197.12,Percent of Total Billed Charges,72% of Total Billed Charges,102.53,60,,164.264,Percent of Total Billed Charges,60% of Total Billed Charges,153.8,90,,600.112,Percent of Total Billed Charges,90% of Total Billed Charges,76.9,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,153.8,90,,61.12,Percent of Total Billed Charges,90% of Total billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.08,65,,115.808,Percent of total Billed Charges,65% of Total Billed Charges,75.36,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,162.35,95,,64.52,Percent of Total Billed Charges,95% of Total Billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.38,88,,59.76,Percent of Total Billed Charges,88% of Total Billed Charges,153.8,90,,61.12,Percent of Total Billed charges,90% of Total Billed Charges,75.36,170.89,
TRACHEA TBE 2.5 MRPH,2720001059,CDM,272,RC,,,Outpatient,,,40.79,26.51,,40.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.37,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,30.59,75,,17.864,Percent of Total Billed charges,75% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.37,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,24.47,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,36.71,90,,493.744,Percent of Total Billed Charges,90% of Total Billed Charges,18.36,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,36.71,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.51,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,17.99,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.75,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.9,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,36.71,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,17.99,40.79,
CENTRAL VENOUS DRESS,2720001060,CDM,272,RC,,,Outpatient,,,48.51,31.53,,48.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.87,76,,135.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.93,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,75,,91.288,Percent of Total Billed charges,75% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,29.11,60,,73.032,Percent of Total Billed Charges,60% of Total Billed Charges,43.66,90,,13.096,Percent of Total Billed Charges,90% of Total Billed Charges,21.83,45,,80.968,Percent of Total Billed Charges,45% of Total Billed Charges,43.66,90,,160.352,Percent of Total Billed Charges,90% of Total billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.53,65,,7.448,Percent of total Billed Charges,65% of Total Billed Charges,21.39,44.1,,79.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.08,95,,169.256,Percent of Total Billed Charges,95% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.69,88,,156.784,Percent of Total Billed Charges,88% of Total Billed Charges,43.66,90,,160.352,Percent of Total Billed charges,90% of Total Billed Charges,21.39,48.51,
TRACHEA TUBE 2.0 MM,2720001061,CDM,272,RC,,,Outpatient,,,33.08,21.50,,33.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.14,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.82,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,24.81,75,,17.864,Percent of Total Billed charges,75% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.82,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,29.77,90,,185.752,Percent of Total Billed Charges,90% of Total Billed Charges,14.89,45,,16.272,Percent of Total Billed Charges,45% of Total Billed Charges,29.77,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.5,65,,116.952,Percent of total Billed Charges,65% of Total Billed Charges,14.59,44.1,,15.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.43,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.11,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,29.77,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,14.59,33.08,
TRACHEA TBE 3.5 MRPH,2720001062,CDM,272,RC,,,Outpatient,,,40.79,26.51,,40.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31,76,,8.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.37,72,,11.52,Percent of Total Billed Charges,72% of Total Billed Charges,30.59,75,,12,Percent of Total Billed charges,75% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.37,72,,11.52,Percent of Total Billed Charges,72% of Total Billed Charges,24.47,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,36.71,90,,109.552,Percent of Total Billed Charges,90% of Total Billed Charges,18.36,45,,111.136,Percent of Total Billed Charges,45% of Total Billed Charges,36.71,90,,10.32,Percent of Total Billed Charges,90% of Total billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.51,65,,23.504,Percent of total Billed Charges,65% of Total Billed Charges,17.99,44.1,,108.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.75,95,,10.888,Percent of Total Billed Charges,95% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.9,88,,10.088,Percent of Total Billed Charges,88% of Total Billed Charges,36.71,90,,10.32,Percent of Total Billed charges,90% of Total Billed Charges,17.99,40.79,
TRACHEA TBE 4.0 MRPH,2720001063,CDM,272,RC,,,Outpatient,,,63.95,41.57,,63.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,48.6,76,,136.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.04,72,,32.056,Percent of Total Billed Charges,72% of Total Billed Charges,47.96,75,,33.392,Percent of Total Billed charges,75% of Total Billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.04,72,,32.056,Percent of Total Billed Charges,72% of Total Billed Charges,38.37,60,,26.712,Percent of Total Billed Charges,60% of Total Billed Charges,57.56,90,,109.552,Percent of Total Billed Charges,90% of Total Billed Charges,28.78,45,,300.056,Percent of Total Billed Charges,45% of Total Billed Charges,57.56,90,,161.936,Percent of Total Billed Charges,90% of Total billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.57,65,,160.528,Percent of total Billed Charges,65% of Total Billed Charges,28.2,44.1,,294.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,60.75,95,,170.928,Percent of Total Billed Charges,95% of Total Billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.28,88,,158.336,Percent of Total Billed Charges,88% of Total Billed Charges,57.56,90,,161.936,Percent of Total Billed charges,90% of Total Billed Charges,28.2,63.95,
TRACHEA TBE 4.5 MRPH,2720001064,CDM,272,RC,,,Outpatient,,,63.95,41.57,,63.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,48.6,76,,27.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.04,72,,49.976,Percent of Total Billed Charges,72% of Total Billed Charges,47.96,75,,52.056,Percent of Total Billed charges,75% of Total Billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.04,72,,49.976,Percent of Total Billed Charges,72% of Total Billed Charges,38.37,60,,41.648,Percent of Total Billed Charges,60% of Total Billed Charges,57.56,90,,109.552,Percent of Total Billed Charges,90% of Total Billed Charges,28.78,45,,246.872,Percent of Total Billed Charges,45% of Total Billed Charges,57.56,90,,32.544,Percent of Total Billed Charges,90% of Total billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.57,65,,433.416,Percent of total Billed Charges,65% of Total Billed Charges,28.2,44.1,,241.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,60.75,95,,34.352,Percent of Total Billed Charges,95% of Total Billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.28,88,,31.824,Percent of Total Billed Charges,88% of Total Billed Charges,57.56,90,,32.544,Percent of Total Billed charges,90% of Total Billed Charges,28.2,63.95,
FOLEY CATH 16F 30CC,2720001065,CDM,272,RC,,,Outpatient,,,175.30,113.95,,175.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,133.23,76,,187.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,126.22,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,131.48,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.22,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,105.18,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,157.77,90,,204.008,Percent of Total Billed Charges,90% of Total Billed Charges,78.89,45,,300.056,Percent of Total Billed Charges,45% of Total Billed Charges,157.77,90,,222.264,Percent of Total Billed Charges,90% of Total billed Charges,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.95,65,,356.592,Percent of total Billed Charges,65% of Total Billed Charges,77.31,44.1,,294.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,166.54,95,,234.616,Percent of Total Billed Charges,95% of Total Billed Charges,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.26,88,,217.328,Percent of Total Billed Charges,88% of Total Billed Charges,157.77,90,,222.264,Percent of Total Billed charges,90% of Total Billed Charges,77.31,175.3,
TRACHEA TBE 7.0 MRPH,2720001066,CDM,272,RC,,,Outpatient,,,168.68,109.64,,168.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,128.2,76,,506.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,121.45,72,,11.52,Percent of Total Billed Charges,72% of Total Billed Charges,126.51,75,,12,Percent of Total Billed charges,75% of Total Billed Charges,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.45,72,,11.52,Percent of Total Billed Charges,72% of Total Billed Charges,101.21,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,151.81,90,,204.008,Percent of Total Billed Charges,90% of Total Billed Charges,75.91,45,,246.872,Percent of Total Billed Charges,45% of Total Billed Charges,151.81,90,,600.112,Percent of Total Billed Charges,90% of Total billed Charges,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.64,65,,433.416,Percent of total Billed Charges,65% of Total Billed Charges,74.39,44.1,,241.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,160.25,95,,633.456,Percent of Total Billed Charges,95% of Total Billed Charges,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.44,88,,586.776,Percent of Total Billed Charges,88% of Total Billed Charges,151.81,90,,600.112,Percent of Total Billed charges,90% of Total Billed Charges,74.39,168.68,
TRACHEA TBE 7.5 MRPH,2720001067,CDM,272,RC,,,Outpatient,,,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,416.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.88,72,,8.456,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,75,,8.808,Percent of Total Billed charges,75% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.88,72,,8.456,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,60,,7.048,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,90,,377.848,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,6.552,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,493.744,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,356.592,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,6.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,521.176,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,482.776,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,493.744,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.05,
TRACHEA TBE 8.0 MRPH,2720001068,CDM,272,RC,,,Outpatient,,,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,506.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.88,72,,5.032,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,75,,5.24,Percent of Total Billed charges,75% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.88,72,,5.032,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,60,,4.192,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,92.88,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,600.112,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,9.456,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,91.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,633.456,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,586.776,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,600.112,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.05,
FOLEY CATH 22F 30CC,2720001069,CDM,272,RC,,,Outpatient,,,98.12,63.78,,98.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,74.57,76,,416.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,70.65,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,73.59,75,,91.288,Percent of Total Billed charges,75% of Total Billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.65,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,58.87,60,,73.032,Percent of Total Billed Charges,60% of Total Billed Charges,88.31,90,,349.272,Percent of Total Billed Charges,90% of Total Billed Charges,44.15,45,,54.776,Percent of Total Billed Charges,45% of Total Billed Charges,88.31,90,,493.744,Percent of Total Billed Charges,90% of Total billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.78,65,,134.152,Percent of total Billed Charges,65% of Total Billed Charges,43.27,44.1,,53.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,93.21,95,,521.176,Percent of Total Billed Charges,95% of Total Billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.35,88,,482.776,Percent of Total Billed Charges,88% of Total Billed Charges,88.31,90,,493.744,Percent of Total Billed charges,90% of Total Billed Charges,43.27,98.12,
TRACHEA TBE 8.5 MRPH,2720001070,CDM,272,RC,,,Outpatient,,,22.05,14.33,,22.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.76,76,,11.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.88,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,75,,9.928,Percent of Total Billed charges,75% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.88,72,,9.528,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,60,,7.936,Percent of Total Billed Charges,60% of Total Billed Charges,19.85,90,,349.272,Percent of Total Billed Charges,90% of Total Billed Charges,9.92,45,,54.776,Percent of Total Billed Charges,45% of Total Billed Charges,19.85,90,,13.096,Percent of Total Billed Charges,90% of Total billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,65,,79.12,Percent of total Billed Charges,65% of Total Billed Charges,9.72,44.1,,53.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.95,95,,13.824,Percent of Total Billed Charges,95% of Total Billed Charges,22.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.4,88,,12.808,Percent of Total Billed Charges,88% of Total Billed Charges,19.85,90,,13.096,Percent of Total Billed charges,90% of Total Billed Charges,9.72,22.05,
ER LACERATION TRAY,2720001071,CDM,272,RC,,,Outpatient,,,168.68,109.64,,168.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,128.2,76,,156.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,121.45,72,,163.2,Percent of Total Billed Charges,72% of Total Billed Charges,126.51,75,,170.008,Percent of Total Billed charges,75% of Total Billed Charges,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.45,72,,163.2,Percent of Total Billed Charges,72% of Total Billed Charges,101.21,60,,136,Percent of Total Billed Charges,60% of Total Billed Charges,151.81,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,75.91,45,,54.776,Percent of Total Billed Charges,45% of Total Billed Charges,151.81,90,,185.752,Percent of Total Billed Charges,90% of Total billed Charges,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.64,65,,79.12,Percent of total Billed Charges,65% of Total Billed Charges,74.39,44.1,,53.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,160.25,95,,196.072,Percent of Total Billed Charges,95% of Total Billed Charges,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.44,88,,181.624,Percent of Total Billed Charges,88% of Total Billed Charges,151.81,90,,185.752,Percent of Total Billed charges,90% of Total Billed Charges,74.39,168.68,
DRESS TEGA 2 3/8 X 2.75,2720001072,CDM,272,RC,,,Outpatient,,,3.30,2.15,,3.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.51,76,,92.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,6.528,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,6.808,Percent of Total Billed charges,75% of Total Billed Charges,3.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,6.528,Percent of Total Billed Charges,72% of Total Billed Charges,1.98,60,,5.44,Percent of Total Billed Charges,60% of Total Billed Charges,2.97,90,,40.072,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,102,Percent of Total Billed Charges,45% of Total Billed Charges,2.97,90,,109.552,Percent of Total Billed Charges,90% of Total billed Charges,3.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,79.12,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,99.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,115.632,Percent of Total Billed Charges,95% of Total Billed Charges,3.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.9,88,,107.112,Percent of Total Billed Charges,88% of Total Billed Charges,2.97,90,,109.552,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.3,
FOLEY CATH 8F 3CC,2720001073,CDM,272,RC,,,Outpatient,,,57.33,37.26,,57.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.57,76,,92.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.28,72,,6.528,Percent of Total Billed Charges,72% of Total Billed Charges,43,75,,6.808,Percent of Total Billed charges,75% of Total Billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.28,72,,6.528,Percent of Total Billed Charges,72% of Total Billed Charges,34.4,60,,5.44,Percent of Total Billed Charges,60% of Total Billed Charges,51.6,90,,38.56,Percent of Total Billed Charges,90% of Total Billed Charges,25.8,45,,102,Percent of Total Billed Charges,45% of Total Billed Charges,51.6,90,,109.552,Percent of Total Billed Charges,90% of Total billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.26,65,,147.336,Percent of total Billed Charges,65% of Total Billed Charges,25.28,44.1,,99.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.46,95,,115.632,Percent of Total Billed Charges,95% of Total Billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.45,88,,107.112,Percent of Total Billed Charges,88% of Total Billed Charges,51.6,90,,109.552,Percent of Total Billed charges,90% of Total Billed Charges,25.28,57.33,
FOLEY CATH 20F 5CC 2,2720001074,CDM,272,RC,,,Outpatient,,,33.08,21.50,,33.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.14,76,,92.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.82,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,24.81,75,,17.864,Percent of Total Billed charges,75% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.82,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,29.77,90,,106.696,Percent of Total Billed Charges,90% of Total Billed Charges,14.89,45,,188.928,Percent of Total Billed Charges,45% of Total Billed Charges,29.77,90,,109.552,Percent of Total Billed Charges,90% of Total billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.5,65,,147.336,Percent of total Billed Charges,65% of Total Billed Charges,14.59,44.1,,185.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.43,95,,115.632,Percent of Total Billed Charges,95% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.11,88,,107.112,Percent of Total Billed Charges,88% of Total Billed Charges,29.77,90,,109.552,Percent of Total Billed charges,90% of Total Billed Charges,14.59,33.08,
ELSTPLST ADH BNDG 3,2720001075,CDM,272,RC,,,Outpatient,,,35.28,22.93,,35.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.81,76,,172.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.4,72,,425.536,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,75,,443.272,Percent of Total Billed charges,75% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.4,72,,425.536,Percent of Total Billed Charges,72% of Total Billed Charges,21.17,60,,354.616,Percent of Total Billed Charges,60% of Total Billed Charges,31.75,90,,55.568,Percent of Total Billed Charges,90% of Total Billed Charges,15.88,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,31.75,90,,204.008,Percent of Total Billed Charges,90% of Total billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.93,65,,272.888,Percent of total Billed Charges,65% of Total Billed Charges,15.56,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.52,95,,215.336,Percent of Total Billed Charges,95% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.05,88,,199.472,Percent of Total Billed Charges,88% of Total Billed Charges,31.75,90,,204.008,Percent of Total Billed charges,90% of Total Billed Charges,15.56,35.28,
TRAY CIRCUMSICION,2720001076,CDM,272,RC,,,Outpatient,,,314.21,204.24,,314.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,238.8,76,,172.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,226.23,72,,1.304,Percent of Total Billed Charges,72% of Total Billed Charges,235.66,75,,1.36,Percent of Total Billed charges,75% of Total Billed Charges,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.23,72,,1.304,Percent of Total Billed Charges,72% of Total Billed Charges,188.53,60,,1.088,Percent of Total Billed Charges,60% of Total Billed Charges,282.79,90,,4.632,Percent of Total Billed Charges,90% of Total Billed Charges,141.39,45,,174.64,Percent of Total Billed Charges,45% of Total Billed Charges,282.79,90,,204.008,Percent of Total Billed Charges,90% of Total billed Charges,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.24,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,138.57,44.1,,171.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,298.5,95,,215.336,Percent of Total Billed Charges,95% of Total Billed Charges,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.5,88,,199.472,Percent of Total Billed Charges,88% of Total Billed Charges,282.79,90,,204.008,Percent of Total Billed charges,90% of Total Billed Charges,138.57,314.21,
BIOPSY NEEDLE 14GX1,2720001077,CDM,272,RC,,,Outpatient,,,154.35,100.33,,154.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,117.31,76,,319.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.13,72,,8.456,Percent of Total Billed Charges,72% of Total Billed Charges,115.76,75,,8.808,Percent of Total Billed charges,75% of Total Billed Charges,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.13,72,,8.456,Percent of Total Billed Charges,72% of Total Billed Charges,92.61,60,,7.048,Percent of Total Billed Charges,60% of Total Billed Charges,138.92,90,,95.256,Percent of Total Billed Charges,90% of Total Billed Charges,69.46,45,,174.64,Percent of Total Billed Charges,45% of Total Billed Charges,138.92,90,,377.848,Percent of Total Billed Charges,90% of Total billed Charges,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.33,65,,252.256,Percent of total Billed Charges,65% of Total Billed Charges,68.07,44.1,,171.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,146.63,95,,398.84,Percent of Total Billed Charges,95% of Total Billed Charges,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.83,88,,369.456,Percent of Total Billed Charges,88% of Total Billed Charges,138.92,90,,377.848,Percent of Total Billed charges,90% of Total Billed Charges,68.07,154.35,
TRACHEA TBE 7.0 MCGL,2720001078,CDM,272,RC,,,Outpatient,,,170.89,111.08,,170.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.88,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.04,72,,50.112,Percent of Total Billed Charges,72% of Total Billed Charges,128.17,75,,52.2,Percent of Total Billed charges,75% of Total Billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.04,72,,50.112,Percent of Total Billed Charges,72% of Total Billed Charges,102.53,60,,41.76,Percent of Total Billed Charges,60% of Total Billed Charges,153.8,90,,20.208,Percent of Total Billed Charges,90% of Total Billed Charges,76.9,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,153.8,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.08,65,,252.256,Percent of total Billed Charges,65% of Total Billed Charges,75.36,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,162.35,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,170.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.38,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,153.8,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,75.36,170.89,
NEEDLE SPINAL 22GX1.,2720001079,CDM,272,RC,,,Outpatient,,,35.28,22.93,,35.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.81,76,,294.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.4,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.4,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,21.17,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,31.75,90,,105.088,Percent of Total Billed Charges,90% of Total Billed Charges,15.88,45,,20.032,Percent of Total Billed Charges,45% of Total Billed Charges,31.75,90,,349.272,Percent of Total Billed Charges,90% of Total billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.93,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,15.56,44.1,,19.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.52,95,,368.68,Percent of Total Billed Charges,95% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.05,88,,341.512,Percent of Total Billed Charges,88% of Total Billed Charges,31.75,90,,349.272,Percent of Total Billed charges,90% of Total Billed Charges,15.56,35.28,
NEEDLE SPINAL 20X3 1,2720001080,CDM,272,RC,,,Outpatient,,,33.08,21.50,,33.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.14,76,,294.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.82,72,,45.72,Percent of Total Billed Charges,72% of Total Billed Charges,24.81,75,,47.632,Percent of Total Billed charges,75% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.82,72,,45.72,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,60,,38.104,Percent of Total Billed Charges,60% of Total Billed Charges,29.77,90,,8.168,Percent of Total Billed Charges,90% of Total Billed Charges,14.89,45,,19.28,Percent of Total Billed Charges,45% of Total Billed Charges,29.77,90,,349.272,Percent of Total Billed Charges,90% of Total billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.5,65,,28.936,Percent of total Billed Charges,65% of Total Billed Charges,14.59,44.1,,18.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.43,95,,368.68,Percent of Total Billed Charges,95% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.11,88,,341.512,Percent of Total Billed Charges,88% of Total Billed Charges,29.77,90,,349.272,Percent of Total Billed charges,90% of Total Billed Charges,14.59,33.08,
IV BD NEXIVA 18X1.25,2720001081,CDM,272,RC,,,Outpatient,,,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,20.736,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,21.6,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,20.736,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,17.28,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,8.168,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,53.352,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,27.848,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,52.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
IV BD NEXIVA 20X1,2720001082,CDM,272,RC,,,Outpatient,,,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,33.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,1.344,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,1.4,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,1.344,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,1.12,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,10.568,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,27.784,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,40.072,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,77.056,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,27.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,42.296,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,39.176,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,40.072,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
IV BD NEXIVA 20X1.25,2720001083,CDM,272,RC,,,Outpatient,,,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,32.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,1079.568,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,1124.552,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,1079.568,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,899.64,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,6.288,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,2.312,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,38.56,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,40.136,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,2.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,40.696,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,37.696,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,38.56,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
TRAY FOLEY SIL 16FR,2720001084,CDM,272,RC,,,Outpatient,,,11.05,7.18,,11.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.4,76,,90.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.96,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,8.29,75,,17.864,Percent of Total Billed charges,75% of Total Billed Charges,11.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.96,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,6.63,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,9.95,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,4.97,45,,47.632,Percent of Total Billed Charges,45% of Total Billed Charges,9.95,90,,106.696,Percent of Total Billed Charges,90% of Total billed Charges,11.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.18,65,,3.344,Percent of total Billed Charges,65% of Total Billed Charges,4.87,44.1,,46.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.5,95,,112.624,Percent of Total Billed Charges,95% of Total Billed Charges,11.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.72,88,,104.328,Percent of Total Billed Charges,88% of Total Billed Charges,9.95,90,,106.696,Percent of Total Billed charges,90% of Total Billed Charges,4.87,11.05,
TRAY FOLEY SIL 18FR,2720001085,CDM,272,RC,,,Outpatient,,,11.05,7.18,,11.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.4,76,,46.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.96,72,,85.248,Percent of Total Billed Charges,72% of Total Billed Charges,8.29,75,,88.8,Percent of Total Billed charges,75% of Total Billed Charges,11.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.96,72,,85.248,Percent of Total Billed Charges,72% of Total Billed Charges,6.63,60,,71.04,Percent of Total Billed Charges,60% of Total Billed Charges,9.95,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,4.97,45,,10.104,Percent of Total Billed Charges,45% of Total Billed Charges,9.95,90,,55.568,Percent of Total Billed Charges,90% of Total billed Charges,11.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.18,65,,68.8,Percent of total Billed Charges,65% of Total Billed Charges,4.87,44.1,,9.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.5,95,,58.656,Percent of Total Billed Charges,95% of Total Billed Charges,11.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.72,88,,54.336,Percent of Total Billed Charges,88% of Total Billed Charges,9.95,90,,55.568,Percent of Total Billed charges,90% of Total Billed Charges,4.87,11.05,
CATH FOLEY SIL 14FR,2720001086,CDM,272,RC,,,Outpatient,,,25.37,16.49,,25.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.28,76,,3.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.27,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,19.03,75,,17.864,Percent of Total Billed charges,75% of Total Billed Charges,25.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.27,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,15.22,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,22.83,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,11.42,45,,52.544,Percent of Total Billed Charges,45% of Total Billed Charges,22.83,90,,4.632,Percent of Total Billed Charges,90% of Total billed Charges,25.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,65,,14.6,Percent of total Billed Charges,65% of Total Billed Charges,11.19,44.1,,51.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.1,95,,4.888,Percent of Total Billed Charges,95% of Total Billed Charges,25.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.33,88,,4.528,Percent of Total Billed Charges,88% of Total Billed Charges,22.83,90,,4.632,Percent of Total Billed charges,90% of Total Billed Charges,11.19,25.37,
CATH FOLEY SIL 16FR,2720001087,CDM,272,RC,,,Outpatient,,,25.37,16.49,,25.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.28,76,,80.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.27,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,19.03,75,,17.864,Percent of Total Billed charges,75% of Total Billed Charges,25.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.27,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,15.22,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,22.83,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,11.42,45,,4.08,Percent of Total Billed Charges,45% of Total Billed Charges,22.83,90,,95.256,Percent of Total Billed Charges,90% of Total billed Charges,25.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,65,,75.896,Percent of total Billed Charges,65% of Total Billed Charges,11.19,44.1,,4,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.1,95,,100.552,Percent of Total Billed Charges,95% of Total Billed Charges,25.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.33,88,,93.136,Percent of Total Billed Charges,88% of Total Billed Charges,22.83,90,,95.256,Percent of Total Billed charges,90% of Total Billed Charges,11.19,25.37,
CATH FOLEY SIL 18FR,2720001088,CDM,272,RC,,,Outpatient,,,25.37,16.49,,25.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.28,76,,17.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.27,72,,11.016,Percent of Total Billed Charges,72% of Total Billed Charges,19.03,75,,11.472,Percent of Total Billed charges,75% of Total Billed Charges,25.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.27,72,,11.016,Percent of Total Billed Charges,72% of Total Billed Charges,15.22,60,,9.176,Percent of Total Billed Charges,60% of Total Billed Charges,22.83,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,11.42,45,,4.08,Percent of Total Billed Charges,45% of Total Billed Charges,22.83,90,,20.208,Percent of Total Billed Charges,90% of Total billed Charges,25.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,65,,5.896,Percent of total Billed Charges,65% of Total Billed Charges,11.19,44.1,,4,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.1,95,,21.336,Percent of Total Billed Charges,95% of Total Billed Charges,25.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.33,88,,19.76,Percent of Total Billed Charges,88% of Total Billed Charges,22.83,90,,20.208,Percent of Total Billed charges,90% of Total Billed Charges,11.19,25.37,
TUBE TRACH UNCUFF 8.0,2720001089,CDM,272,RC,,,Outpatient,,,141.83,92.19,,141.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.79,76,,88.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,102.12,72,,27.344,Percent of Total Billed Charges,72% of Total Billed Charges,106.37,75,,28.48,Percent of Total Billed charges,75% of Total Billed Charges,141.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.12,72,,27.344,Percent of Total Billed Charges,72% of Total Billed Charges,85.1,60,,22.784,Percent of Total Billed Charges,60% of Total Billed Charges,127.65,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,63.82,45,,5.288,Percent of Total Billed Charges,45% of Total Billed Charges,127.65,90,,105.088,Percent of Total Billed Charges,90% of Total billed Charges,141.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.19,65,,5.896,Percent of total Billed Charges,65% of Total Billed Charges,62.55,44.1,,5.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.74,95,,110.92,Percent of Total Billed Charges,95% of Total Billed Charges,141.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.81,88,,102.752,Percent of Total Billed Charges,88% of Total Billed Charges,127.65,90,,105.088,Percent of Total Billed charges,90% of Total Billed Charges,62.55,141.83,
TUBE TRACH CUFF 9.0,2720001090,CDM,272,RC,,,Outpatient,,,155.19,100.87,,155.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,117.94,76,,6.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.74,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,116.39,75,,27.12,Percent of Total Billed charges,75% of Total Billed Charges,155.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.74,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,93.11,60,,21.696,Percent of Total Billed Charges,60% of Total Billed Charges,139.67,90,,5.176,Percent of Total Billed Charges,90% of Total Billed Charges,69.84,45,,3.144,Percent of Total Billed Charges,45% of Total Billed Charges,139.67,90,,8.168,Percent of Total Billed Charges,90% of Total billed Charges,155.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.87,65,,7.632,Percent of total Billed Charges,65% of Total Billed Charges,68.44,44.1,,3.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,147.43,95,,8.616,Percent of Total Billed Charges,95% of Total Billed Charges,155.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.57,88,,7.984,Percent of Total Billed Charges,88% of Total Billed Charges,139.67,90,,8.168,Percent of Total Billed charges,90% of Total Billed Charges,68.44,155.19,
PATCH BIO 1.9 X 1.5,2720001091,CDM,272,RC,,,Outpatient,,,16.40,10.66,,16.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.46,76,,6.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.81,72,,118.544,Percent of Total Billed Charges,72% of Total Billed Charges,12.3,75,,123.48,Percent of Total Billed charges,75% of Total Billed Charges,16.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.81,72,,118.544,Percent of Total Billed Charges,72% of Total Billed Charges,9.84,60,,98.784,Percent of Total Billed Charges,60% of Total Billed Charges,14.76,90,,1.632,Percent of Total Billed Charges,90% of Total Billed Charges,7.38,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,14.76,90,,8.168,Percent of Total Billed Charges,90% of Total billed Charges,16.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.66,65,,4.536,Percent of total Billed Charges,65% of Total Billed Charges,7.23,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.58,95,,8.616,Percent of Total Billed Charges,95% of Total Billed Charges,16.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.43,88,,7.984,Percent of Total Billed Charges,88% of Total Billed Charges,14.76,90,,8.168,Percent of Total Billed charges,90% of Total Billed Charges,7.23,16.4,
PATCH BIO 2.5 X 4.0,2720001092,CDM,272,RC,,,Outpatient,,,15.41,10.02,,15.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.71,76,,8.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.1,72,,66.264,Percent of Total Billed Charges,72% of Total Billed Charges,11.56,75,,69.024,Percent of Total Billed charges,75% of Total Billed Charges,15.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.1,72,,66.264,Percent of Total Billed Charges,72% of Total Billed Charges,9.25,60,,55.216,Percent of Total Billed Charges,60% of Total Billed Charges,13.87,90,,1.68,Percent of Total Billed Charges,90% of Total Billed Charges,6.93,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,13.87,90,,10.568,Percent of Total Billed Charges,90% of Total billed Charges,15.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.02,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,6.8,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.64,95,,11.16,Percent of Total Billed Charges,95% of Total Billed Charges,15.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.56,88,,10.336,Percent of Total Billed Charges,88% of Total Billed Charges,13.87,90,,10.568,Percent of Total Billed charges,90% of Total Billed Charges,6.8,15.41,
PATCH BIO 2.5 X 7,2720001093,CDM,272,RC,,,Outpatient,,,16.72,10.87,,16.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.71,76,,5.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.04,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,12.54,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,16.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.04,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,10.03,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,15.05,90,,10.584,Percent of Total Billed Charges,90% of Total Billed Charges,7.52,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,15.05,90,,6.288,Percent of Total Billed Charges,90% of Total billed Charges,16.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.87,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,7.37,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.88,95,,6.632,Percent of Total Billed Charges,95% of Total Billed Charges,16.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.71,88,,6.144,Percent of Total Billed Charges,88% of Total Billed Charges,15.05,90,,6.288,Percent of Total Billed charges,90% of Total Billed Charges,7.37,16.72,
TUBE TRACH CUFF 6.0,2720001094,CDM,272,RC,,,Outpatient,,,139.73,90.82,,139.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.19,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.61,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,104.8,75,,23.152,Percent of Total Billed charges,75% of Total Billed Charges,139.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.61,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,83.84,60,,18.52,Percent of Total Billed Charges,60% of Total Billed Charges,125.76,90,,6488.752,Percent of Total Billed Charges,90% of Total Billed Charges,62.88,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,125.76,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,139.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.82,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,61.62,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,132.74,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,139.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.96,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,125.76,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,61.62,139.73,
TUBE TRACH CUFF 8.0,2720001095,CDM,272,RC,,,Outpatient,,,139.73,90.82,,139.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.19,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.61,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,104.8,75,,43.664,Percent of Total Billed charges,75% of Total Billed Charges,139.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.61,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,83.84,60,,34.928,Percent of Total Billed Charges,60% of Total Billed Charges,125.76,90,,531.92,Percent of Total Billed Charges,90% of Total Billed Charges,62.88,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,125.76,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,139.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.82,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,61.62,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,132.74,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,139.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.96,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,125.76,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,61.62,139.73,
TUBING BLOOD WARM,2720001096,CDM,272,RC,,,Outpatient,,,11.82,7.68,,11.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.98,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.51,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,8.87,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,11.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.51,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,7.09,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,10.64,90,,626.048,Percent of Total Billed Charges,90% of Total Billed Charges,5.32,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,10.64,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,11.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.68,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,5.21,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.23,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,11.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,10.64,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,5.21,11.82,
TRAY DRSNG PICC,2720001097,CDM,272,RC,,,Outpatient,,,14.89,9.68,,14.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.32,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.72,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,11.17,75,,23.152,Percent of Total Billed charges,75% of Total Billed Charges,14.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.72,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,8.93,60,,18.52,Percent of Total Billed Charges,60% of Total Billed Charges,13.4,90,,626.048,Percent of Total Billed Charges,90% of Total Billed Charges,6.7,45,,2.592,Percent of Total Billed Charges,45% of Total Billed Charges,13.4,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,14.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.68,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,6.57,44.1,,2.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.15,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,14.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.1,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,13.4,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,6.57,14.89,
UBAG PEDI,2720001098,CDM,272,RC,,,Outpatient,,,1.68,1.09,,1.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.28,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.21,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,1.26,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,1.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.21,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,1.01,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,1.51,90,,347.424,Percent of Total Billed Charges,90% of Total Billed Charges,0.76,45,,0.816,Percent of Total Billed Charges,45% of Total Billed Charges,1.51,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,1.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.09,65,,3.736,Percent of total Billed Charges,65% of Total Billed Charges,0.74,44.1,,0.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.6,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,1.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.48,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,1.51,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,0.74,1.68,
TRAY THORACENTESIS,2720001099,CDM,272,RC,,,Outpatient,,,118.79,77.21,,118.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,90.28,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,85.53,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,89.09,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,118.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.53,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,71.27,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,106.91,90,,347.424,Percent of Total Billed Charges,90% of Total Billed Charges,53.46,45,,0.84,Percent of Total Billed Charges,45% of Total Billed Charges,106.91,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,118.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.21,65,,1.184,Percent of total Billed Charges,65% of Total Billed Charges,52.39,44.1,,0.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,112.85,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,118.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.54,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,106.91,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,52.39,118.79,
TUBE TRACH CUFF 7.0,2720001100,CDM,272,RC,,,Outpatient,,,155.19,100.87,,155.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,117.94,76,,4.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.74,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,116.39,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,155.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.74,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,93.11,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,139.67,90,,88.456,Percent of Total Billed Charges,90% of Total Billed Charges,69.84,45,,5.296,Percent of Total Billed Charges,45% of Total Billed Charges,139.67,90,,5.176,Percent of Total Billed Charges,90% of Total billed Charges,155.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.87,65,,1.208,Percent of total Billed Charges,65% of Total Billed Charges,68.44,44.1,,5.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,147.43,95,,5.464,Percent of Total Billed Charges,95% of Total Billed Charges,155.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.57,88,,5.064,Percent of Total Billed Charges,88% of Total Billed Charges,139.67,90,,5.176,Percent of Total Billed charges,90% of Total Billed Charges,68.44,155.19,
TUBE TRACH CUFF 6.0,2720001101,CDM,272,RC,,,Outpatient,,,189.17,122.96,,189.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,143.77,76,,1.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,136.2,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,141.88,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,189.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.2,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,113.5,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,170.25,90,,88.456,Percent of Total Billed Charges,90% of Total Billed Charges,85.13,45,,3244.376,Percent of Total Billed Charges,45% of Total Billed Charges,170.25,90,,1.632,Percent of Total Billed Charges,90% of Total billed Charges,189.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.96,65,,7.648,Percent of total Billed Charges,65% of Total Billed Charges,83.42,44.1,,3179.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,179.71,95,,1.728,Percent of Total Billed Charges,95% of Total Billed Charges,189.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.47,88,,1.6,Percent of Total Billed Charges,88% of Total Billed Charges,170.25,90,,1.632,Percent of Total Billed charges,90% of Total Billed Charges,83.42,189.17,
TRACH UNCUFF FENESTRATED 6.0,2720001102,CDM,272,RC,,,Outpatient,,,126.02,81.91,,126.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95.78,76,,1.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90.73,72,,45.72,Percent of Total Billed Charges,72% of Total Billed Charges,94.52,75,,47.632,Percent of Total Billed charges,75% of Total Billed Charges,126.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.73,72,,45.72,Percent of Total Billed Charges,72% of Total Billed Charges,75.61,60,,38.104,Percent of Total Billed Charges,60% of Total Billed Charges,113.42,90,,88.456,Percent of Total Billed Charges,90% of Total Billed Charges,56.71,45,,265.96,Percent of Total Billed Charges,45% of Total Billed Charges,113.42,90,,1.68,Percent of Total Billed Charges,90% of Total billed Charges,126.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.91,65,,4686.32,Percent of total Billed Charges,65% of Total Billed Charges,55.57,44.1,,260.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,119.72,95,,1.768,Percent of Total Billed Charges,95% of Total Billed Charges,126.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.9,88,,1.64,Percent of Total Billed Charges,88% of Total Billed Charges,113.42,90,,1.68,Percent of Total Billed charges,90% of Total Billed Charges,55.57,126.02,
TRACH UNCUFF FENESTRATED 7.0,2720001103,CDM,272,RC,,,Outpatient,,,126.02,81.91,,126.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95.78,76,,8.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90.73,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,94.52,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,126.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.73,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,75.61,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,113.42,90,,88.456,Percent of Total Billed Charges,90% of Total Billed Charges,56.71,45,,313.024,Percent of Total Billed Charges,45% of Total Billed Charges,113.42,90,,10.584,Percent of Total Billed Charges,90% of Total billed Charges,126.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.91,65,,384.168,Percent of total Billed Charges,65% of Total Billed Charges,55.57,44.1,,306.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,119.72,95,,11.176,Percent of Total Billed Charges,95% of Total Billed Charges,126.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.9,88,,10.352,Percent of Total Billed Charges,88% of Total Billed Charges,113.42,90,,10.584,Percent of Total Billed charges,90% of Total Billed Charges,55.57,126.02,
TRACH UNCUFF FENESTRATED 8.0,2720001104,CDM,272,RC,,,Outpatient,,,126.02,81.91,,126.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95.78,76,,5479.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90.73,72,,72.4,Percent of Total Billed Charges,72% of Total Billed Charges,94.52,75,,75.416,Percent of Total Billed charges,75% of Total Billed Charges,126.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.73,72,,72.4,Percent of Total Billed Charges,72% of Total Billed Charges,75.61,60,,60.328,Percent of Total Billed Charges,60% of Total Billed Charges,113.42,90,,88.456,Percent of Total Billed Charges,90% of Total Billed Charges,56.71,45,,313.024,Percent of Total Billed Charges,45% of Total Billed Charges,113.42,90,,6488.752,Percent of Total Billed Charges,90% of Total billed Charges,126.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.91,65,,452.144,Percent of total Billed Charges,65% of Total Billed Charges,55.57,44.1,,306.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,119.72,95,,6849.232,Percent of Total Billed Charges,95% of Total Billed Charges,126.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.9,88,,6344.552,Percent of Total Billed Charges,88% of Total Billed Charges,113.42,90,,6488.752,Percent of Total Billed charges,90% of Total Billed Charges,55.57,126.02,
TRACH CUFFED FENESTRATED 6.0,2720001105,CDM,272,RC,,,Outpatient,,,133.90,87.04,,133.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,101.76,76,,449.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,96.41,72,,19.688,Percent of Total Billed Charges,72% of Total Billed Charges,100.43,75,,20.512,Percent of Total Billed charges,75% of Total Billed Charges,133.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.41,72,,19.688,Percent of Total Billed Charges,72% of Total Billed Charges,80.34,60,,16.408,Percent of Total Billed Charges,60% of Total Billed Charges,120.51,90,,268.632,Percent of Total Billed Charges,90% of Total Billed Charges,60.26,45,,173.712,Percent of Total Billed Charges,45% of Total Billed Charges,120.51,90,,531.92,Percent of Total Billed Charges,90% of Total billed Charges,133.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.04,65,,452.144,Percent of total Billed Charges,65% of Total Billed Charges,59.05,44.1,,170.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,127.21,95,,561.472,Percent of Total Billed Charges,95% of Total Billed Charges,133.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.83,88,,520.104,Percent of Total Billed Charges,88% of Total Billed Charges,120.51,90,,531.92,Percent of Total Billed charges,90% of Total Billed Charges,59.05,133.9,
TRACH CUFFED FENESTRATED 7.0,2720001106,CDM,272,RC,,,Outpatient,,,133.90,87.04,,133.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,101.76,76,,528.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,96.41,72,,33.024,Percent of Total Billed Charges,72% of Total Billed Charges,100.43,75,,34.4,Percent of Total Billed charges,75% of Total Billed Charges,133.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.41,72,,33.024,Percent of Total Billed Charges,72% of Total Billed Charges,80.34,60,,27.52,Percent of Total Billed Charges,60% of Total Billed Charges,120.51,90,,232.6,Percent of Total Billed Charges,90% of Total Billed Charges,60.26,45,,173.712,Percent of Total Billed Charges,45% of Total Billed Charges,120.51,90,,626.048,Percent of Total Billed Charges,90% of Total billed Charges,133.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.04,65,,250.912,Percent of total Billed Charges,65% of Total Billed Charges,59.05,44.1,,170.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,127.21,95,,660.824,Percent of Total Billed Charges,95% of Total Billed Charges,133.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.83,88,,612.136,Percent of Total Billed Charges,88% of Total Billed Charges,120.51,90,,626.048,Percent of Total Billed charges,90% of Total Billed Charges,59.05,133.9,
TRACH CUFFED FENESTRATED 8.0,2720001107,CDM,272,RC,,,Outpatient,,,133.90,87.04,,133.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,101.76,76,,528.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,96.41,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,100.43,75,,49.616,Percent of Total Billed charges,75% of Total Billed Charges,133.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.41,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,80.34,60,,39.688,Percent of Total Billed Charges,60% of Total Billed Charges,120.51,90,,232.6,Percent of Total Billed Charges,90% of Total Billed Charges,60.26,45,,44.224,Percent of Total Billed Charges,45% of Total Billed Charges,120.51,90,,626.048,Percent of Total Billed Charges,90% of Total billed Charges,133.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.04,65,,250.912,Percent of total Billed Charges,65% of Total Billed Charges,59.05,44.1,,43.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,127.21,95,,660.824,Percent of Total Billed Charges,95% of Total Billed Charges,133.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.83,88,,612.136,Percent of Total Billed Charges,88% of Total Billed Charges,120.51,90,,626.048,Percent of Total Billed charges,90% of Total Billed Charges,59.05,133.9,
CATHETER PICC 5FR DUAL LUMEN,2720001108,CDM,272,RC,,,Outpatient,,,491.19,319.27,,491.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,373.3,76,,293.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,353.66,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,368.39,75,,15.88,Percent of Total Billed charges,75% of Total Billed Charges,491.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.66,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,294.71,60,,12.704,Percent of Total Billed Charges,60% of Total Billed Charges,442.07,90,,48.24,Percent of Total Billed Charges,90% of Total Billed Charges,221.04,45,,44.224,Percent of Total Billed Charges,45% of Total Billed Charges,442.07,90,,347.424,Percent of Total Billed Charges,90% of Total billed Charges,491.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319.27,65,,63.88,Percent of total Billed Charges,65% of Total Billed Charges,216.61,44.1,,43.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,466.63,95,,366.72,Percent of Total Billed Charges,95% of Total Billed Charges,491.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,432.25,88,,339.704,Percent of Total Billed Charges,88% of Total Billed Charges,442.07,90,,347.424,Percent of Total Billed charges,90% of Total Billed Charges,216.61,491.19,
CATHETER PICC 5FR TRIPLE LUMEN,2720001109,CDM,272,RC,,,Outpatient,,,563.22,366.09,,563.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,428.05,76,,293.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,405.52,72,,71.128,Percent of Total Billed Charges,72% of Total Billed Charges,422.42,75,,74.088,Percent of Total Billed charges,75% of Total Billed Charges,563.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.52,72,,71.128,Percent of Total Billed Charges,72% of Total Billed Charges,337.93,60,,59.272,Percent of Total Billed Charges,60% of Total Billed Charges,506.9,90,,194.4,Percent of Total Billed Charges,90% of Total Billed Charges,253.45,45,,44.224,Percent of Total Billed Charges,45% of Total Billed Charges,506.9,90,,347.424,Percent of Total Billed Charges,90% of Total billed Charges,563.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.09,65,,63.88,Percent of total Billed Charges,65% of Total Billed Charges,248.38,44.1,,43.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,535.06,95,,366.72,Percent of Total Billed Charges,95% of Total Billed Charges,563.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495.63,88,,339.704,Percent of Total Billed Charges,88% of Total Billed Charges,506.9,90,,347.424,Percent of Total Billed charges,90% of Total Billed Charges,248.38,563.22,
TUBE FEED DUAL 8FR,2720001110,CDM,272,RC,,,Outpatient,,,62.00,40.30,,62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.12,76,,74.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,44.64,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,46.5,75,,21.832,Percent of Total Billed charges,75% of Total Billed Charges,62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.64,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,37.2,60,,17.464,Percent of Total Billed Charges,60% of Total Billed Charges,55.8,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,27.9,45,,44.224,Percent of Total Billed Charges,45% of Total Billed Charges,55.8,90,,88.456,Percent of Total Billed Charges,90% of Total billed Charges,62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.3,65,,63.88,Percent of total Billed Charges,65% of Total Billed Charges,27.34,44.1,,43.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,58.9,95,,93.368,Percent of Total Billed Charges,95% of Total Billed Charges,62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.56,88,,86.488,Percent of Total Billed Charges,88% of Total Billed Charges,55.8,90,,88.456,Percent of Total Billed charges,90% of Total Billed Charges,27.34,62,
TRAY PICC FRSNG CHNG,2720001111,CDM,272,RC,,,Outpatient,,,14.91,9.69,,14.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.33,76,,74.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.74,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,11.18,75,,27.12,Percent of Total Billed charges,75% of Total Billed Charges,14.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.74,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,8.95,60,,21.696,Percent of Total Billed Charges,60% of Total Billed Charges,13.42,90,,62.464,Percent of Total Billed Charges,90% of Total Billed Charges,6.71,45,,44.224,Percent of Total Billed Charges,45% of Total Billed Charges,13.42,90,,88.456,Percent of Total Billed Charges,90% of Total billed Charges,14.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.69,65,,63.88,Percent of total Billed Charges,65% of Total Billed Charges,6.58,44.1,,43.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.16,95,,93.368,Percent of Total Billed Charges,95% of Total Billed Charges,14.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.12,88,,86.488,Percent of Total Billed Charges,88% of Total Billed Charges,13.42,90,,88.456,Percent of Total Billed charges,90% of Total Billed Charges,6.58,14.91,
PRIMARY IV TUBING,2720001112,CDM,272,RC,,,Outpatient,,,32.34,21.02,,32.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.58,76,,74.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.28,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,24.26,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,32.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.28,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,19.4,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,29.11,90,,226.048,Percent of Total Billed Charges,90% of Total Billed Charges,14.55,45,,134.32,Percent of Total Billed Charges,45% of Total Billed Charges,29.11,90,,88.456,Percent of Total Billed Charges,90% of Total billed Charges,32.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.02,65,,63.88,Percent of total Billed Charges,65% of Total Billed Charges,14.26,44.1,,131.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.72,95,,93.368,Percent of Total Billed Charges,95% of Total Billed Charges,32.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.46,88,,86.488,Percent of Total Billed Charges,88% of Total Billed Charges,29.11,90,,88.456,Percent of Total Billed charges,90% of Total Billed Charges,14.26,32.34,
URINE COLLECTION COMPLETE,2720001113,CDM,272,RC,,,Outpatient,,,8.93,5.80,,8.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.79,76,,74.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.43,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,6.7,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,8.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.43,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,5.36,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,8.04,90,,97.224,Percent of Total Billed Charges,90% of Total Billed Charges,4.02,45,,116.296,Percent of Total Billed Charges,45% of Total Billed Charges,8.04,90,,88.456,Percent of Total Billed Charges,90% of Total billed Charges,8.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.8,65,,194.016,Percent of total Billed Charges,65% of Total Billed Charges,3.94,44.1,,113.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.48,95,,93.368,Percent of Total Billed Charges,95% of Total Billed Charges,8.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.86,88,,86.488,Percent of Total Billed Charges,88% of Total Billed Charges,8.04,90,,88.456,Percent of Total Billed charges,90% of Total Billed Charges,3.94,8.93,
STOPCOCK 3 WAY,2720001114,CDM,272,RC,,,Outpatient,,,8.30,5.40,,8.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.31,76,,74.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.98,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,6.23,75,,1.328,Percent of Total Billed charges,75% of Total Billed Charges,8.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.98,72,,1.272,Percent of Total Billed Charges,72% of Total Billed Charges,4.98,60,,1.064,Percent of Total Billed Charges,60% of Total Billed Charges,7.47,90,,60.352,Percent of Total Billed Charges,90% of Total Billed Charges,3.74,45,,116.296,Percent of Total Billed Charges,45% of Total Billed Charges,7.47,90,,88.456,Percent of Total Billed Charges,90% of Total billed Charges,8.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.4,65,,167.984,Percent of total Billed Charges,65% of Total Billed Charges,3.66,44.1,,113.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.89,95,,93.368,Percent of Total Billed Charges,95% of Total Billed Charges,8.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.3,88,,86.488,Percent of Total Billed Charges,88% of Total Billed Charges,7.47,90,,88.456,Percent of Total Billed charges,90% of Total Billed Charges,3.66,8.3,
AMNIHOOK,2720001115,CDM,272,RC,,,Outpatient,,,14.81,9.63,,14.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.26,76,,226.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.66,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,11.11,75,,12.568,Percent of Total Billed charges,75% of Total Billed Charges,14.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.66,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,8.89,60,,10.056,Percent of Total Billed Charges,60% of Total Billed Charges,13.33,90,,11.328,Percent of Total Billed Charges,90% of Total Billed Charges,6.66,45,,24.12,Percent of Total Billed Charges,45% of Total Billed Charges,13.33,90,,268.632,Percent of Total Billed Charges,90% of Total billed Charges,14.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.63,65,,167.984,Percent of total Billed Charges,65% of Total Billed Charges,6.53,44.1,,23.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.07,95,,283.56,Percent of Total Billed Charges,95% of Total Billed Charges,14.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.03,88,,262.664,Percent of Total Billed Charges,88% of Total Billed Charges,13.33,90,,268.632,Percent of Total Billed charges,90% of Total Billed Charges,6.53,14.81,
SPECI PAN,2720001116,CDM,272,RC,,,Outpatient,,,3.70,2.41,,3.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.81,76,,196.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.66,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,2.78,75,,21.832,Percent of Total Billed charges,75% of Total Billed Charges,3.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.66,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,2.22,60,,17.464,Percent of Total Billed Charges,60% of Total Billed Charges,3.33,90,,24.248,Percent of Total Billed Charges,90% of Total Billed Charges,1.67,45,,97.2,Percent of Total Billed Charges,45% of Total Billed Charges,3.33,90,,232.6,Percent of Total Billed Charges,90% of Total billed Charges,3.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.41,65,,34.84,Percent of total Billed Charges,65% of Total Billed Charges,1.63,44.1,,95.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.52,95,,245.52,Percent of Total Billed Charges,95% of Total Billed Charges,3.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.26,88,,227.424,Percent of Total Billed Charges,88% of Total Billed Charges,3.33,90,,232.6,Percent of Total Billed charges,90% of Total Billed Charges,1.63,3.7,
SECONDARY TUBING,2720001117,CDM,272,RC,,,Outpatient,,,6.93,4.50,,6.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.27,76,,196.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.99,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,5.2,75,,27.12,Percent of Total Billed charges,75% of Total Billed Charges,6.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.99,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,4.16,60,,21.696,Percent of Total Billed Charges,60% of Total Billed Charges,6.24,90,,95.84,Percent of Total Billed Charges,90% of Total Billed Charges,3.12,45,,31.32,Percent of Total Billed Charges,45% of Total Billed Charges,6.24,90,,232.6,Percent of Total Billed Charges,90% of Total billed Charges,6.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.5,65,,140.4,Percent of total Billed Charges,65% of Total Billed Charges,3.06,44.1,,30.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.58,95,,245.52,Percent of Total Billed Charges,95% of Total Billed Charges,6.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.1,88,,227.424,Percent of Total Billed Charges,88% of Total Billed Charges,6.24,90,,232.6,Percent of Total Billed charges,90% of Total Billed Charges,3.06,6.93,
HUBER NEEDLE,2720001118,CDM,272,RC,,,Outpatient,,,13.92,9.05,,13.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.58,76,,40.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.02,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,10.44,75,,10.584,Percent of Total Billed charges,75% of Total Billed Charges,13.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.02,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,8.35,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,12.53,90,,24.464,Percent of Total Billed Charges,90% of Total Billed Charges,6.26,45,,31.232,Percent of Total Billed Charges,45% of Total Billed Charges,12.53,90,,48.24,Percent of Total Billed Charges,90% of Total billed Charges,13.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.05,65,,45.24,Percent of total Billed Charges,65% of Total Billed Charges,6.14,44.1,,30.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.22,95,,50.92,Percent of Total Billed Charges,95% of Total Billed Charges,13.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.25,88,,47.168,Percent of Total Billed Charges,88% of Total Billed Charges,12.53,90,,48.24,Percent of Total Billed charges,90% of Total Billed Charges,6.14,13.92,
PRIMARY TUBING W/FILTER,2720001119,CDM,272,RC,,,Outpatient,,,38.30,24.90,,38.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.11,76,,164.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.58,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,28.73,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,38.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.58,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,22.98,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,34.47,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,17.24,45,,113.024,Percent of Total Billed Charges,45% of Total Billed Charges,34.47,90,,194.4,Percent of Total Billed Charges,90% of Total billed Charges,38.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.9,65,,45.112,Percent of total Billed Charges,65% of Total Billed Charges,16.89,44.1,,110.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.39,95,,205.2,Percent of Total Billed Charges,95% of Total Billed Charges,38.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.7,88,,190.08,Percent of Total Billed Charges,88% of Total Billed Charges,34.47,90,,194.4,Percent of Total Billed charges,90% of Total Billed Charges,16.89,38.3,
KERLIX STERILE,2720001120,CDM,272,RC,,,Outpatient,,,4.14,2.69,,4.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.15,76,,52.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.98,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,3.11,75,,14.56,Percent of Total Billed charges,75% of Total Billed Charges,4.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.98,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,3.73,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,1.86,45,,48.608,Percent of Total Billed Charges,45% of Total Billed Charges,3.73,90,,62.64,Percent of Total Billed Charges,90% of Total billed Charges,4.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.69,65,,163.256,Percent of total Billed Charges,65% of Total Billed Charges,1.83,44.1,,47.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.93,95,,66.12,Percent of Total Billed Charges,95% of Total Billed Charges,4.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.64,88,,61.248,Percent of Total Billed Charges,88% of Total Billed Charges,3.73,90,,62.64,Percent of Total Billed charges,90% of Total Billed Charges,1.83,4.14,
SPECIMEN CUP,2720001121,CDM,272,RC,,,Outpatient,,,3.53,2.29,,3.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.68,76,,52.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.54,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,75,,15.88,Percent of Total Billed charges,75% of Total Billed Charges,3.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.54,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,2.12,60,,12.704,Percent of Total Billed Charges,60% of Total Billed Charges,3.18,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,1.59,45,,30.176,Percent of Total Billed Charges,45% of Total Billed Charges,3.18,90,,62.464,Percent of Total Billed Charges,90% of Total billed Charges,3.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.29,65,,70.216,Percent of total Billed Charges,65% of Total Billed Charges,1.56,44.1,,29.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.35,95,,65.936,Percent of Total Billed Charges,95% of Total Billed Charges,3.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.11,88,,61.08,Percent of Total Billed Charges,88% of Total Billed Charges,3.18,90,,62.464,Percent of Total Billed charges,90% of Total Billed Charges,1.56,3.53,
URINE CBAG PEDI,2720001122,CDM,272,RC,,,Outpatient,,,8.40,5.46,,8.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.38,76,,190.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.05,72,,16.512,Percent of Total Billed Charges,72% of Total Billed Charges,6.3,75,,17.2,Percent of Total Billed charges,75% of Total Billed Charges,8.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.05,72,,16.512,Percent of Total Billed Charges,72% of Total Billed Charges,5.04,60,,13.76,Percent of Total Billed Charges,60% of Total Billed Charges,7.56,90,,27.648,Percent of Total Billed Charges,90% of Total Billed Charges,3.78,45,,5.664,Percent of Total Billed Charges,45% of Total Billed Charges,7.56,90,,226.048,Percent of Total Billed Charges,90% of Total billed Charges,8.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.46,65,,43.584,Percent of total Billed Charges,65% of Total Billed Charges,3.7,44.1,,5.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.98,95,,238.6,Percent of Total Billed Charges,95% of Total Billed Charges,8.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.39,88,,221.024,Percent of Total Billed Charges,88% of Total Billed Charges,7.56,90,,226.048,Percent of Total Billed charges,90% of Total Billed Charges,3.7,8.4,
YANKAUER SUCTION,2720001123,CDM,272,RC,,,Outpatient,,,3.80,2.47,,3.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.89,76,,82.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.74,72,,23.424,Percent of Total Billed Charges,72% of Total Billed Charges,2.85,75,,24.4,Percent of Total Billed charges,75% of Total Billed Charges,3.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.74,72,,23.424,Percent of Total Billed Charges,72% of Total Billed Charges,2.28,60,,19.52,Percent of Total Billed Charges,60% of Total Billed Charges,3.42,90,,21.712,Percent of Total Billed Charges,90% of Total Billed Charges,1.71,45,,12.128,Percent of Total Billed Charges,45% of Total Billed Charges,3.42,90,,97.224,Percent of Total Billed Charges,90% of Total billed Charges,3.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.47,65,,8.176,Percent of total Billed Charges,65% of Total Billed Charges,1.68,44.1,,11.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.61,95,,102.624,Percent of Total Billed Charges,95% of Total Billed Charges,3.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.34,88,,95.064,Percent of Total Billed Charges,88% of Total Billed Charges,3.42,90,,97.224,Percent of Total Billed charges,90% of Total Billed Charges,1.68,3.8,
TUBE FEED PED 5FR,2720001124,CDM,272,RC,,,Outpatient,,,10.40,6.76,,10.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.9,76,,50.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.49,72,,60.456,Percent of Total Billed Charges,72% of Total Billed Charges,7.8,75,,62.976,Percent of Total Billed charges,75% of Total Billed Charges,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.49,72,,60.456,Percent of Total Billed Charges,72% of Total Billed Charges,6.24,60,,50.384,Percent of Total Billed Charges,60% of Total Billed Charges,9.36,90,,62.944,Percent of Total Billed Charges,90% of Total Billed Charges,4.68,45,,47.92,Percent of Total Billed Charges,45% of Total Billed Charges,9.36,90,,60.352,Percent of Total Billed Charges,90% of Total billed Charges,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.76,65,,17.512,Percent of total Billed Charges,65% of Total Billed Charges,4.59,44.1,,46.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.88,95,,63.704,Percent of Total Billed Charges,95% of Total Billed Charges,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.15,88,,59.008,Percent of Total Billed Charges,88% of Total Billed Charges,9.36,90,,60.352,Percent of Total Billed charges,90% of Total Billed Charges,4.59,10.4,
BRACHIAL DRAPE STER,2720001125,CDM,272,RC,,,Outpatient,,,16.60,10.79,,16.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.62,76,,9.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.95,72,,32.16,Percent of Total Billed Charges,72% of Total Billed Charges,12.45,75,,33.504,Percent of Total Billed charges,75% of Total Billed Charges,16.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.95,72,,32.16,Percent of Total Billed Charges,72% of Total Billed Charges,9.96,60,,26.8,Percent of Total Billed Charges,60% of Total Billed Charges,14.94,90,,43.464,Percent of Total Billed Charges,90% of Total Billed Charges,7.47,45,,12.232,Percent of Total Billed Charges,45% of Total Billed Charges,14.94,90,,11.328,Percent of Total Billed Charges,90% of Total billed Charges,16.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.79,65,,69.216,Percent of total Billed Charges,65% of Total Billed Charges,7.32,44.1,,11.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.77,95,,11.952,Percent of Total Billed Charges,95% of Total Billed Charges,16.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.61,88,,11.072,Percent of Total Billed Charges,88% of Total Billed Charges,14.94,90,,11.328,Percent of Total Billed charges,90% of Total Billed Charges,7.32,16.6,
CNTL LINE SET 4 LUM 8.5FR 20CM,2720001126,CDM,272,RC,,,Outpatient,,,235.74,153.23,,235.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,179.16,76,,20.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,169.73,72,,34.784,Percent of Total Billed Charges,72% of Total Billed Charges,176.81,75,,36.232,Percent of Total Billed charges,75% of Total Billed Charges,235.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.73,72,,34.784,Percent of Total Billed Charges,72% of Total Billed Charges,141.44,60,,28.984,Percent of Total Billed Charges,60% of Total Billed Charges,212.17,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,106.08,45,,8.64,Percent of Total Billed Charges,45% of Total Billed Charges,212.17,90,,24.248,Percent of Total Billed Charges,90% of Total billed Charges,235.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.23,65,,17.672,Percent of total Billed Charges,65% of Total Billed Charges,103.96,44.1,,8.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,223.95,95,,25.6,Percent of Total Billed Charges,95% of Total Billed Charges,235.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.45,88,,23.712,Percent of Total Billed Charges,88% of Total Billed Charges,212.17,90,,24.248,Percent of Total Billed charges,90% of Total Billed Charges,103.96,235.74,
TRAY PICC DRSS CHANGE STATLOCK,2720001127,CDM,272,RC,,,Outpatient,,,13.34,8.67,,13.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.14,76,,80.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.6,72,,35.088,Percent of Total Billed Charges,72% of Total Billed Charges,10.01,75,,36.544,Percent of Total Billed charges,75% of Total Billed Charges,13.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.6,72,,35.088,Percent of Total Billed Charges,72% of Total Billed Charges,8,60,,29.24,Percent of Total Billed Charges,60% of Total Billed Charges,12.01,90,,60.808,Percent of Total Billed Charges,90% of Total Billed Charges,6,45,,8.64,Percent of Total Billed Charges,45% of Total Billed Charges,12.01,90,,95.84,Percent of Total Billed Charges,90% of Total billed Charges,13.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.67,65,,12.48,Percent of total Billed Charges,65% of Total Billed Charges,5.88,44.1,,8.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.67,95,,101.16,Percent of Total Billed Charges,95% of Total Billed Charges,13.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.74,88,,93.712,Percent of Total Billed Charges,88% of Total Billed Charges,12.01,90,,95.84,Percent of Total Billed charges,90% of Total Billed Charges,5.88,13.34,
CONNECTOR NEUT PRESS CLEAR,2720001128,CDM,272,RC,,,Outpatient,,,10.10,6.57,,10.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.68,76,,20.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.27,72,,13.408,Percent of Total Billed Charges,72% of Total Billed Charges,7.58,75,,13.968,Percent of Total Billed charges,75% of Total Billed Charges,10.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.27,72,,13.408,Percent of Total Billed Charges,72% of Total Billed Charges,6.06,60,,11.176,Percent of Total Billed Charges,60% of Total Billed Charges,9.09,90,,64.304,Percent of Total Billed Charges,90% of Total Billed Charges,4.55,45,,8.64,Percent of Total Billed Charges,45% of Total Billed Charges,9.09,90,,24.464,Percent of Total Billed Charges,90% of Total billed Charges,10.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.57,65,,12.48,Percent of total Billed Charges,65% of Total Billed Charges,4.45,44.1,,8.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.6,95,,25.824,Percent of Total Billed Charges,95% of Total Billed Charges,10.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.89,88,,23.92,Percent of Total Billed Charges,88% of Total Billed Charges,9.09,90,,24.464,Percent of Total Billed charges,90% of Total Billed Charges,4.45,10.1,
DRSSNG BIOPAT 1.9CM .75 1.5MM,2720001129,CDM,272,RC,,,Outpatient,,,14.02,9.11,,14.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.66,76,,14.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.09,72,,20.08,Percent of Total Billed Charges,72% of Total Billed Charges,10.52,75,,20.92,Percent of Total Billed charges,75% of Total Billed Charges,14.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.09,72,,20.08,Percent of Total Billed Charges,72% of Total Billed Charges,8.41,60,,16.736,Percent of Total Billed Charges,60% of Total Billed Charges,12.62,90,,64.304,Percent of Total Billed Charges,90% of Total Billed Charges,6.31,45,,13.824,Percent of Total Billed Charges,45% of Total Billed Charges,12.62,90,,17.28,Percent of Total Billed Charges,90% of Total billed Charges,14.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.11,65,,12.48,Percent of total Billed Charges,65% of Total Billed Charges,6.18,44.1,,13.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.32,95,,18.24,Percent of Total Billed Charges,95% of Total Billed Charges,14.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.34,88,,16.896,Percent of Total Billed Charges,88% of Total Billed Charges,12.62,90,,17.28,Percent of Total Billed charges,90% of Total Billed Charges,6.18,14.02,
BIOPATCH .75 X1.5CM,2720001130,CDM,272,RC,,,Outpatient,,,14.34,9.32,,14.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.9,76,,14.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.32,72,,20.688,Percent of Total Billed Charges,72% of Total Billed Charges,10.76,75,,21.544,Percent of Total Billed charges,75% of Total Billed Charges,14.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,72,,20.688,Percent of Total Billed Charges,72% of Total Billed Charges,8.6,60,,17.24,Percent of Total Billed Charges,60% of Total Billed Charges,12.91,90,,2160,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,10.856,Percent of Total Billed Charges,45% of Total Billed Charges,12.91,90,,17.28,Percent of Total Billed Charges,90% of Total billed Charges,14.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.32,65,,19.968,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,10.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.62,95,,18.24,Percent of Total Billed Charges,95% of Total Billed Charges,14.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.62,88,,16.896,Percent of Total Billed Charges,88% of Total Billed Charges,12.91,90,,17.28,Percent of Total Billed charges,90% of Total Billed Charges,6.32,14.34,
BIOPATCH 2.5CM 4.0MM,2720001131,CDM,272,RC,,,Outpatient,,,15.02,9.76,,15.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.42,76,,14.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.81,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,11.27,75,,43.664,Percent of Total Billed charges,75% of Total Billed Charges,15.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.81,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,9.01,60,,34.928,Percent of Total Billed Charges,60% of Total Billed Charges,13.52,90,,106.56,Percent of Total Billed Charges,90% of Total Billed Charges,6.76,45,,31.472,Percent of Total Billed Charges,45% of Total Billed Charges,13.52,90,,17.28,Percent of Total Billed Charges,90% of Total billed Charges,15.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.76,65,,15.68,Percent of total Billed Charges,65% of Total Billed Charges,6.62,44.1,,30.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.27,95,,18.24,Percent of Total Billed Charges,95% of Total Billed Charges,15.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.22,88,,16.896,Percent of Total Billed Charges,88% of Total Billed Charges,13.52,90,,17.28,Percent of Total Billed charges,90% of Total Billed Charges,6.62,15.02,
SYRNG TUBING,2720001132,CDM,272,RC,,,Outpatient,,,20.96,13.62,,20.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.93,76,,23.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.09,72,,2.208,Percent of Total Billed Charges,72% of Total Billed Charges,15.72,75,,2.304,Percent of Total Billed charges,75% of Total Billed Charges,20.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.09,72,,2.208,Percent of Total Billed Charges,72% of Total Billed Charges,12.58,60,,1.84,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,21.736,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,27.648,Percent of Total Billed Charges,90% of Total billed Charges,20.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,45.456,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,21.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.91,95,,29.184,Percent of Total Billed Charges,95% of Total Billed Charges,20.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,27.032,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,27.648,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.96,
URINE KIT COMPLETE,2720001133,CDM,272,RC,,,Outpatient,,,8.70,5.66,,8.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.61,76,,18.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.26,72,,2.184,Percent of Total Billed Charges,72% of Total Billed Charges,6.53,75,,2.272,Percent of Total Billed charges,75% of Total Billed Charges,8.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.26,72,,2.184,Percent of Total Billed Charges,72% of Total Billed Charges,5.22,60,,1.816,Percent of Total Billed Charges,60% of Total Billed Charges,7.83,90,,61.2,Percent of Total Billed Charges,90% of Total Billed Charges,3.92,45,,12.96,Percent of Total Billed Charges,45% of Total Billed Charges,7.83,90,,21.712,Percent of Total Billed Charges,90% of Total billed Charges,8.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.66,65,,31.392,Percent of total Billed Charges,65% of Total Billed Charges,3.84,44.1,,12.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.27,95,,22.92,Percent of Total Billed Charges,95% of Total Billed Charges,8.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.66,88,,21.232,Percent of Total Billed Charges,88% of Total Billed Charges,7.83,90,,21.712,Percent of Total Billed charges,90% of Total Billed Charges,3.84,8.7,
POWER WAND 3FX6CM,2720001134,CDM,272,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,53.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,1.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,2.04,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,1.96,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,1.632,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,30.408,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,62.944,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,18.72,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,29.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,66.44,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,61.544,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,62.944,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
STABL Z PAD,2720001135,CDM,272,RC,,,Outpatient,,,29.25,19.01,,29.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.23,76,,36.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.06,72,,16.688,Percent of Total Billed Charges,72% of Total Billed Charges,21.94,75,,17.384,Percent of Total Billed charges,75% of Total Billed Charges,29.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.06,72,,16.688,Percent of Total Billed Charges,72% of Total Billed Charges,17.55,60,,13.904,Percent of Total Billed Charges,60% of Total Billed Charges,26.33,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,13.16,45,,32.152,Percent of Total Billed Charges,45% of Total Billed Charges,26.33,90,,43.464,Percent of Total Billed Charges,90% of Total billed Charges,29.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.01,65,,43.92,Percent of total Billed Charges,65% of Total Billed Charges,12.9,44.1,,31.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,27.79,95,,45.88,Percent of Total Billed Charges,95% of Total Billed Charges,29.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.74,88,,42.504,Percent of Total Billed Charges,88% of Total Billed Charges,26.33,90,,43.464,Percent of Total Billed charges,90% of Total Billed Charges,12.9,29.25,
EXUDERM 4X3.6,2720001136,CDM,272,RC,,,Outpatient,,,31.23,20.30,,31.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.73,76,,21.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.49,72,,21.2,Percent of Total Billed Charges,72% of Total Billed Charges,23.42,75,,22.08,Percent of Total Billed charges,75% of Total Billed Charges,31.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.49,72,,21.2,Percent of Total Billed Charges,72% of Total Billed Charges,18.74,60,,17.664,Percent of Total Billed Charges,60% of Total Billed Charges,28.11,90,,46.8,Percent of Total Billed Charges,90% of Total Billed Charges,14.05,45,,32.152,Percent of Total Billed Charges,45% of Total Billed Charges,28.11,90,,25.92,Percent of Total Billed Charges,90% of Total billed Charges,31.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.3,65,,46.44,Percent of total Billed Charges,65% of Total Billed Charges,13.77,44.1,,31.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.67,95,,27.36,Percent of Total Billed Charges,95% of Total Billed Charges,31.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.48,88,,25.344,Percent of Total Billed Charges,88% of Total Billed Charges,28.11,90,,25.92,Percent of Total Billed charges,90% of Total Billed Charges,13.77,31.23,
EXUDERM 4X4,2720001137,CDM,272,RC,,,Outpatient,,,16.50,10.73,,16.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.54,76,,51.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.88,72,,57.16,Percent of Total Billed Charges,72% of Total Billed Charges,12.38,75,,59.536,Percent of Total Billed charges,75% of Total Billed Charges,16.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.88,72,,57.16,Percent of Total Billed Charges,72% of Total Billed Charges,9.9,60,,47.632,Percent of Total Billed Charges,60% of Total Billed Charges,14.85,90,,27.592,Percent of Total Billed Charges,90% of Total Billed Charges,7.43,45,,1080,Percent of Total Billed Charges,45% of Total Billed Charges,14.85,90,,60.808,Percent of Total Billed Charges,90% of Total billed Charges,16.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.73,65,,46.44,Percent of total Billed Charges,65% of Total Billed Charges,7.28,44.1,,1058.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.68,95,,64.192,Percent of Total Billed Charges,95% of Total Billed Charges,16.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.52,88,,59.456,Percent of Total Billed Charges,88% of Total Billed Charges,14.85,90,,60.808,Percent of Total Billed charges,90% of Total Billed Charges,7.28,16.5,
EXUDERM 2X2,2720001138,CDM,272,RC,,,Outpatient,,,21.01,13.66,,21.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.97,76,,54.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.13,72,,14.4,Percent of Total Billed Charges,72% of Total Billed Charges,15.76,75,,15,Percent of Total Billed charges,75% of Total Billed Charges,21.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.13,72,,14.4,Percent of Total Billed Charges,72% of Total Billed Charges,12.61,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,18.91,90,,27.592,Percent of Total Billed Charges,90% of Total Billed Charges,9.45,45,,53.28,Percent of Total Billed Charges,45% of Total Billed Charges,18.91,90,,64.304,Percent of Total Billed Charges,90% of Total billed Charges,21.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.66,65,,1560,Percent of total Billed Charges,65% of Total Billed Charges,9.27,44.1,,52.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.96,95,,67.872,Percent of Total Billed Charges,95% of Total Billed Charges,21.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.49,88,,62.872,Percent of Total Billed Charges,88% of Total Billed Charges,18.91,90,,64.304,Percent of Total Billed charges,90% of Total Billed Charges,9.27,21.01,
EXUDERM SAC 6X6.5,2720001139,CDM,272,RC,,,Outpatient,,,14.96,9.72,,14.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.37,76,,54.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.77,72,,28.224,Percent of Total Billed Charges,72% of Total Billed Charges,11.22,75,,29.4,Percent of Total Billed charges,75% of Total Billed Charges,14.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.77,72,,28.224,Percent of Total Billed Charges,72% of Total Billed Charges,8.98,60,,23.52,Percent of Total Billed Charges,60% of Total Billed Charges,13.46,90,,71,Percent of Total Billed Charges,90% of Total Billed Charges,6.73,45,,12.96,Percent of Total Billed Charges,45% of Total Billed Charges,13.46,90,,64.304,Percent of Total Billed Charges,90% of Total billed Charges,14.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.72,65,,76.96,Percent of total Billed Charges,65% of Total Billed Charges,6.6,44.1,,12.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.21,95,,67.872,Percent of Total Billed Charges,95% of Total Billed Charges,14.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.16,88,,62.872,Percent of Total Billed Charges,88% of Total Billed Charges,13.46,90,,64.304,Percent of Total Billed charges,90% of Total Billed Charges,6.6,14.96,
LOPEZ VALVE,2720001140,CDM,272,RC,,,Outpatient,,,39.52,25.69,,39.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,30.04,76,,1824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.45,72,,9.792,Percent of Total Billed Charges,72% of Total Billed Charges,29.64,75,,10.2,Percent of Total Billed charges,75% of Total Billed Charges,39.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.45,72,,9.792,Percent of Total Billed Charges,72% of Total Billed Charges,23.71,60,,8.16,Percent of Total Billed Charges,60% of Total Billed Charges,35.57,90,,40.648,Percent of Total Billed Charges,90% of Total Billed Charges,17.78,45,,30.6,Percent of Total Billed Charges,45% of Total Billed Charges,35.57,90,,2160,Percent of Total Billed Charges,90% of Total billed Charges,39.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.69,65,,18.72,Percent of total Billed Charges,65% of Total Billed Charges,17.43,44.1,,29.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.54,95,,2280,Percent of Total Billed Charges,95% of Total Billed Charges,39.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.78,88,,2112,Percent of Total Billed Charges,88% of Total Billed Charges,35.57,90,,2160,Percent of Total Billed charges,90% of Total Billed Charges,17.43,39.52,
POWER WAND POWER WAND 5FX10CM,2720001141,CDM,272,RC,,,Outpatient,,,252.00,163.80,,252,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,191.52,76,,89.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,181.44,72,,60.96,Percent of Total Billed Charges,72% of Total Billed Charges,189,75,,63.504,Percent of Total Billed charges,75% of Total Billed Charges,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.44,72,,60.96,Percent of Total Billed Charges,72% of Total Billed Charges,151.2,60,,50.8,Percent of Total Billed Charges,60% of Total Billed Charges,226.8,90,,166.216,Percent of Total Billed Charges,90% of Total Billed Charges,113.4,45,,5.76,Percent of Total Billed Charges,45% of Total Billed Charges,226.8,90,,106.56,Percent of Total Billed Charges,90% of Total billed Charges,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.8,65,,44.2,Percent of total Billed Charges,65% of Total Billed Charges,111.13,44.1,,5.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,239.4,95,,112.48,Percent of Total Billed Charges,95% of Total Billed Charges,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.76,88,,104.192,Percent of Total Billed Charges,88% of Total Billed Charges,226.8,90,,106.56,Percent of Total Billed charges,90% of Total Billed Charges,111.13,252,
3 WAY STOPCOCK,2720001142,CDM,272,RC,,,Outpatient,,,12.40,8.06,,12.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.42,76,,21.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.93,72,,60.96,Percent of Total Billed Charges,72% of Total Billed Charges,9.3,75,,63.504,Percent of Total Billed charges,75% of Total Billed Charges,12.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.93,72,,60.96,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,60,,50.8,Percent of Total Billed Charges,60% of Total Billed Charges,11.16,90,,166.216,Percent of Total Billed Charges,90% of Total Billed Charges,5.58,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,11.16,90,,25.92,Percent of Total Billed Charges,90% of Total billed Charges,12.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.06,65,,8.32,Percent of total Billed Charges,65% of Total Billed Charges,5.47,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.78,95,,27.36,Percent of Total Billed Charges,95% of Total Billed Charges,12.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.91,88,,25.344,Percent of Total Billed Charges,88% of Total Billed Charges,11.16,90,,25.92,Percent of Total Billed charges,90% of Total Billed Charges,5.47,12.4,
TRACH CUFF SZ7,2720001143,CDM,272,RC,,,Outpatient,,,132.08,85.85,,132.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.38,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.1,72,,296.752,Percent of Total Billed Charges,72% of Total Billed Charges,99.06,75,,309.12,Percent of Total Billed charges,75% of Total Billed Charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.1,72,,296.752,Percent of Total Billed Charges,72% of Total Billed Charges,79.25,60,,247.296,Percent of Total Billed Charges,60% of Total Billed Charges,118.87,90,,166.216,Percent of Total Billed Charges,90% of Total Billed Charges,59.44,45,,23.4,Percent of Total Billed Charges,45% of Total Billed Charges,118.87,90,,61.2,Percent of Total Billed Charges,90% of Total billed Charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.85,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,58.25,44.1,,22.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.48,95,,64.6,Percent of Total Billed Charges,95% of Total Billed Charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.23,88,,59.84,Percent of Total Billed Charges,88% of Total Billed Charges,118.87,90,,61.2,Percent of Total Billed charges,90% of Total Billed Charges,58.25,132.08,
PCA TUBE,2720001144,CDM,272,RC,,,Outpatient,,,33.18,21.57,,33.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.22,76,,9.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.89,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,24.89,75,,44.32,Percent of Total Billed charges,75% of Total Billed Charges,33.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.89,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,19.91,60,,35.456,Percent of Total Billed Charges,60% of Total Billed Charges,29.86,90,,166.216,Percent of Total Billed Charges,90% of Total Billed Charges,14.93,45,,13.792,Percent of Total Billed Charges,45% of Total Billed Charges,29.86,90,,11.52,Percent of Total Billed Charges,90% of Total billed Charges,33.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.57,65,,33.8,Percent of total Billed Charges,65% of Total Billed Charges,14.63,44.1,,13.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.52,95,,12.16,Percent of Total Billed Charges,95% of Total Billed Charges,33.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.2,88,,11.264,Percent of Total Billed Charges,88% of Total Billed Charges,29.86,90,,11.52,Percent of Total Billed charges,90% of Total Billed Charges,14.63,33.18,
PRESS T CONNECT,2720001145,CDM,272,RC,,,Outpatient,,,23.68,15.39,,23.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.05,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,17.76,75,,23.152,Percent of Total Billed charges,75% of Total Billed Charges,23.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.05,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,14.21,60,,18.52,Percent of Total Billed Charges,60% of Total Billed Charges,21.31,90,,235.872,Percent of Total Billed Charges,90% of Total Billed Charges,10.66,45,,13.792,Percent of Total Billed Charges,45% of Total Billed Charges,21.31,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,23.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.39,65,,19.928,Percent of total Billed Charges,65% of Total Billed Charges,10.44,44.1,,13.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.5,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,23.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.84,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,21.31,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,10.44,23.68,
GAUZE TOPPER,2720001146,CDM,272,RC,,,Outpatient,,,3.03,1.97,,3.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.3,76,,39.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.18,72,,167.016,Percent of Total Billed Charges,72% of Total Billed Charges,2.27,75,,173.976,Percent of Total Billed charges,75% of Total Billed Charges,3.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.18,72,,167.016,Percent of Total Billed Charges,72% of Total Billed Charges,1.82,60,,139.184,Percent of Total Billed Charges,60% of Total Billed Charges,2.73,90,,246.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.36,45,,35.496,Percent of Total Billed Charges,45% of Total Billed Charges,2.73,90,,46.8,Percent of Total Billed Charges,90% of Total billed Charges,3.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.97,65,,19.928,Percent of total Billed Charges,65% of Total Billed Charges,1.34,44.1,,34.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.88,95,,49.4,Percent of Total Billed Charges,95% of Total Billed Charges,3.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.67,88,,45.76,Percent of Total Billed Charges,88% of Total Billed Charges,2.73,90,,46.8,Percent of Total Billed charges,90% of Total Billed Charges,1.34,3.03,
IV CATH 16GA 1.7,2720001147,CDM,272,RC,,,Outpatient,,,16.40,10.66,,16.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.46,76,,23.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.81,72,,239.408,Percent of Total Billed Charges,72% of Total Billed Charges,12.3,75,,249.384,Percent of Total Billed charges,75% of Total Billed Charges,16.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.81,72,,239.408,Percent of Total Billed Charges,72% of Total Billed Charges,9.84,60,,199.504,Percent of Total Billed Charges,60% of Total Billed Charges,14.76,90,,248.664,Percent of Total Billed Charges,90% of Total Billed Charges,7.38,45,,20.32,Percent of Total Billed Charges,45% of Total Billed Charges,14.76,90,,27.592,Percent of Total Billed Charges,90% of Total billed Charges,16.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.66,65,,51.28,Percent of total Billed Charges,65% of Total Billed Charges,7.23,44.1,,19.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.58,95,,29.12,Percent of Total Billed Charges,95% of Total Billed Charges,16.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.43,88,,26.976,Percent of Total Billed Charges,88% of Total Billed Charges,14.76,90,,27.592,Percent of Total Billed charges,90% of Total Billed Charges,7.23,16.4,
SET EXT W/LL,2720001148,CDM,272,RC,,,Outpatient,,,6.70,4.36,,6.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.09,76,,23.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.82,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,5.03,75,,44.984,Percent of Total Billed charges,75% of Total Billed Charges,6.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.82,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,4.02,60,,35.984,Percent of Total Billed Charges,60% of Total Billed Charges,6.03,90,,166.216,Percent of Total Billed Charges,90% of Total Billed Charges,3.02,45,,83.112,Percent of Total Billed Charges,45% of Total Billed Charges,6.03,90,,27.592,Percent of Total Billed Charges,90% of Total billed Charges,6.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.36,65,,29.352,Percent of total Billed Charges,65% of Total Billed Charges,2.95,44.1,,81.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.37,95,,29.12,Percent of Total Billed Charges,95% of Total Billed Charges,6.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.9,88,,26.976,Percent of Total Billed Charges,88% of Total Billed Charges,6.03,90,,27.592,Percent of Total Billed charges,90% of Total Billed Charges,2.95,6.7,
TUBE BLD SET,2720001149,CDM,272,RC,,,Outpatient,,,31.44,20.44,,31.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.89,76,,59.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.64,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,23.58,75,,5.952,Percent of Total Billed charges,75% of Total Billed Charges,31.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.64,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,18.86,60,,4.76,Percent of Total Billed Charges,60% of Total Billed Charges,28.3,90,,166.216,Percent of Total Billed Charges,90% of Total Billed Charges,14.15,45,,83.112,Percent of Total Billed Charges,45% of Total Billed Charges,28.3,90,,71,Percent of Total Billed Charges,90% of Total billed Charges,31.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.44,65,,120.048,Percent of total Billed Charges,65% of Total Billed Charges,13.87,44.1,,81.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.87,95,,74.944,Percent of Total Billed Charges,95% of Total Billed Charges,31.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.67,88,,69.424,Percent of Total Billed Charges,88% of Total Billed Charges,28.3,90,,71,Percent of Total Billed charges,90% of Total Billed Charges,13.87,31.44,
TUBE FEED 5FR,2720001150,CDM,272,RC,,,Outpatient,,,10.40,6.76,,10.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.9,76,,34.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.49,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,7.8,75,,5.952,Percent of Total Billed charges,75% of Total Billed Charges,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.49,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,6.24,60,,4.76,Percent of Total Billed Charges,60% of Total Billed Charges,9.36,90,,58.808,Percent of Total Billed Charges,90% of Total Billed Charges,4.68,45,,83.112,Percent of Total Billed Charges,45% of Total Billed Charges,9.36,90,,40.648,Percent of Total Billed Charges,90% of Total billed Charges,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.76,65,,120.048,Percent of total Billed Charges,65% of Total Billed Charges,4.59,44.1,,81.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.88,95,,42.904,Percent of Total Billed Charges,95% of Total Billed Charges,10.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.15,88,,39.744,Percent of Total Billed Charges,88% of Total Billed Charges,9.36,90,,40.648,Percent of Total Billed charges,90% of Total Billed Charges,4.59,10.4,
BURETTE SMART SITE,2720001151,CDM,272,RC,,,Outpatient,,,10.28,6.68,,10.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.81,76,,140.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.4,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,7.71,75,,5.952,Percent of Total Billed charges,75% of Total Billed Charges,10.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.4,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,6.17,60,,4.76,Percent of Total Billed Charges,60% of Total Billed Charges,9.25,90,,37.696,Percent of Total Billed Charges,90% of Total Billed Charges,4.63,45,,83.112,Percent of Total Billed Charges,45% of Total Billed Charges,9.25,90,,166.216,Percent of Total Billed Charges,90% of Total billed Charges,10.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.68,65,,120.048,Percent of total Billed Charges,65% of Total Billed Charges,4.53,44.1,,81.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.77,95,,175.456,Percent of Total Billed Charges,95% of Total Billed Charges,10.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.05,88,,162.528,Percent of Total Billed Charges,88% of Total Billed Charges,9.25,90,,166.216,Percent of Total Billed charges,90% of Total Billed Charges,4.53,10.28,
SMART TIP CAN,2720001152,CDM,272,RC,,,Outpatient,,,3.14,2.04,,3.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.39,76,,140.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.26,72,,60.96,Percent of Total Billed Charges,72% of Total Billed Charges,2.36,75,,63.504,Percent of Total Billed charges,75% of Total Billed Charges,3.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.26,72,,60.96,Percent of Total Billed Charges,72% of Total Billed Charges,1.88,60,,50.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.83,90,,27.216,Percent of Total Billed Charges,90% of Total Billed Charges,1.41,45,,117.936,Percent of Total Billed Charges,45% of Total Billed Charges,2.83,90,,166.216,Percent of Total Billed Charges,90% of Total billed Charges,3.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.04,65,,120.048,Percent of total Billed Charges,65% of Total Billed Charges,1.38,44.1,,115.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.98,95,,175.456,Percent of Total Billed Charges,95% of Total Billed Charges,3.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.76,88,,162.528,Percent of Total Billed Charges,88% of Total Billed Charges,2.83,90,,166.216,Percent of Total Billed charges,90% of Total Billed Charges,1.38,3.14,
TRACH UNCUF,2720001153,CDM,272,RC,,,Outpatient,,,116.69,75.85,,116.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,88.68,76,,140.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.02,72,,52.08,Percent of Total Billed Charges,72% of Total Billed Charges,87.52,75,,54.248,Percent of Total Billed charges,75% of Total Billed Charges,116.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.02,72,,52.08,Percent of Total Billed Charges,72% of Total Billed Charges,70.01,60,,43.4,Percent of Total Billed Charges,60% of Total Billed Charges,105.02,90,,90.72,Percent of Total Billed Charges,90% of Total Billed Charges,52.51,45,,123.2,Percent of Total Billed Charges,45% of Total Billed Charges,105.02,90,,166.216,Percent of Total Billed Charges,90% of Total billed Charges,116.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.85,65,,170.352,Percent of total Billed Charges,65% of Total Billed Charges,51.46,44.1,,120.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,110.86,95,,175.456,Percent of Total Billed Charges,95% of Total Billed Charges,116.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.69,88,,162.528,Percent of Total Billed Charges,88% of Total Billed Charges,105.02,90,,166.216,Percent of Total Billed charges,90% of Total Billed Charges,51.46,116.69,
TRAY VAG IRR,2720001154,CDM,272,RC,,,Outpatient,,,19.20,12.48,,19.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.59,76,,140.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.82,72,,11.344,Percent of Total Billed Charges,72% of Total Billed Charges,14.4,75,,11.824,Percent of Total Billed charges,75% of Total Billed Charges,19.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.82,72,,11.344,Percent of Total Billed Charges,72% of Total Billed Charges,11.52,60,,9.456,Percent of Total Billed Charges,60% of Total Billed Charges,17.28,90,,27.216,Percent of Total Billed Charges,90% of Total Billed Charges,8.64,45,,124.336,Percent of Total Billed Charges,45% of Total Billed Charges,17.28,90,,166.216,Percent of Total Billed Charges,90% of Total billed Charges,19.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.48,65,,177.952,Percent of total Billed Charges,65% of Total Billed Charges,8.47,44.1,,121.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.24,95,,175.456,Percent of Total Billed Charges,95% of Total Billed Charges,19.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.9,88,,162.528,Percent of Total Billed Charges,88% of Total Billed Charges,17.28,90,,166.216,Percent of Total Billed charges,90% of Total Billed Charges,8.47,19.2,
PRSS RATED EXT SET,2720001155,CDM,272,RC,,,Outpatient,,,17.90,11.64,,17.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.6,76,,199.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.89,72,,67.32,Percent of Total Billed Charges,72% of Total Billed Charges,13.43,75,,70.12,Percent of Total Billed charges,75% of Total Billed Charges,17.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.89,72,,67.32,Percent of Total Billed Charges,72% of Total Billed Charges,10.74,60,,56.096,Percent of Total Billed Charges,60% of Total Billed Charges,16.11,90,,90.72,Percent of Total Billed Charges,90% of Total Billed Charges,8.06,45,,83.112,Percent of Total Billed Charges,45% of Total Billed Charges,16.11,90,,235.872,Percent of Total Billed Charges,90% of Total billed Charges,17.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,65,,179.592,Percent of total Billed Charges,65% of Total Billed Charges,7.89,44.1,,81.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.01,95,,248.976,Percent of Total Billed Charges,95% of Total Billed Charges,17.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.75,88,,230.632,Percent of Total Billed Charges,88% of Total Billed Charges,16.11,90,,235.872,Percent of Total Billed charges,90% of Total Billed Charges,7.89,17.9,
CATH PED 5FR SOFT,2720001156,CDM,272,RC,,,Outpatient,,,25.92,16.85,,25.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.7,76,,208.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.66,72,,102.88,Percent of Total Billed Charges,72% of Total Billed Charges,19.44,75,,107.168,Percent of Total Billed charges,75% of Total Billed Charges,25.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.66,72,,102.88,Percent of Total Billed Charges,72% of Total Billed Charges,15.55,60,,85.736,Percent of Total Billed Charges,60% of Total Billed Charges,23.33,90,,27.216,Percent of Total Billed Charges,90% of Total Billed Charges,11.66,45,,83.112,Percent of Total Billed Charges,45% of Total Billed Charges,23.33,90,,246.4,Percent of Total Billed Charges,90% of Total billed Charges,25.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.85,65,,120.048,Percent of total Billed Charges,65% of Total Billed Charges,11.43,44.1,,81.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.62,95,,260.088,Percent of Total Billed Charges,95% of Total Billed Charges,25.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.81,88,,240.92,Percent of Total Billed Charges,88% of Total Billed Charges,23.33,90,,246.4,Percent of Total Billed charges,90% of Total Billed Charges,11.43,25.92,
POWER WAND 4FR,2720001157,CDM,272,RC,,,Outpatient,,,250.00,162.50,,250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,190,76,,209.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,180,72,,162.568,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,75,,169.344,Percent of Total Billed charges,75% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180,72,,162.568,Percent of Total Billed Charges,72% of Total Billed Charges,150,60,,135.472,Percent of Total Billed Charges,60% of Total Billed Charges,225,90,,90.72,Percent of Total Billed Charges,90% of Total Billed Charges,112.5,45,,29.408,Percent of Total Billed Charges,45% of Total Billed Charges,225,90,,248.664,Percent of Total Billed Charges,90% of Total billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.5,65,,120.048,Percent of total Billed Charges,65% of Total Billed Charges,110.25,44.1,,28.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,237.5,95,,262.48,Percent of Total Billed Charges,95% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220,88,,243.144,Percent of Total Billed Charges,88% of Total Billed Charges,225,90,,248.664,Percent of Total Billed charges,90% of Total Billed Charges,110.25,250,
WIPE FOLEY CARE,2720001158,CDM,272,RC,,,Outpatient,,,12.62,8.20,,12.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.59,76,,140.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.09,72,,46.08,Percent of Total Billed Charges,72% of Total Billed Charges,9.47,75,,48,Percent of Total Billed charges,75% of Total Billed Charges,12.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.09,72,,46.08,Percent of Total Billed Charges,72% of Total Billed Charges,7.57,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,11.36,90,,149.688,Percent of Total Billed Charges,90% of Total Billed Charges,5.68,45,,18.848,Percent of Total Billed Charges,45% of Total Billed Charges,11.36,90,,166.216,Percent of Total Billed Charges,90% of Total billed Charges,12.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.2,65,,42.472,Percent of total Billed Charges,65% of Total Billed Charges,5.57,44.1,,18.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.99,95,,175.456,Percent of Total Billed Charges,95% of Total Billed Charges,12.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.11,88,,162.528,Percent of Total Billed Charges,88% of Total Billed Charges,11.36,90,,166.216,Percent of Total Billed charges,90% of Total Billed Charges,5.57,12.62,
MEPIEX 3X3,2720001159,CDM,272,RC,,,Outpatient,,,25.04,16.28,,25.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.03,76,,140.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.03,72,,316.8,Percent of Total Billed Charges,72% of Total Billed Charges,18.78,75,,330,Percent of Total Billed charges,75% of Total Billed Charges,25.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.03,72,,316.8,Percent of Total Billed Charges,72% of Total Billed Charges,15.02,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,22.54,90,,248.664,Percent of Total Billed Charges,90% of Total Billed Charges,11.27,45,,13.608,Percent of Total Billed Charges,45% of Total Billed Charges,22.54,90,,166.216,Percent of Total Billed Charges,90% of Total billed Charges,25.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.28,65,,27.224,Percent of total Billed Charges,65% of Total Billed Charges,11.04,44.1,,13.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.79,95,,175.456,Percent of Total Billed Charges,95% of Total Billed Charges,25.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.04,88,,162.528,Percent of Total Billed Charges,88% of Total Billed Charges,22.54,90,,166.216,Percent of Total Billed charges,90% of Total Billed Charges,11.04,25.04,
MEPILEX 7.2X7.2,2720001160,CDM,272,RC,,,Outpatient,,,18.32,11.91,,18.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.92,76,,49.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.19,72,,65.088,Percent of Total Billed Charges,72% of Total Billed Charges,13.74,75,,67.8,Percent of Total Billed charges,75% of Total Billed Charges,18.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.19,72,,65.088,Percent of Total Billed Charges,72% of Total Billed Charges,10.99,60,,54.24,Percent of Total Billed Charges,60% of Total Billed Charges,16.49,90,,248.664,Percent of Total Billed Charges,90% of Total Billed Charges,8.24,45,,45.36,Percent of Total Billed Charges,45% of Total Billed Charges,16.49,90,,58.808,Percent of Total Billed Charges,90% of Total billed Charges,18.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,65,,19.656,Percent of total Billed Charges,65% of Total Billed Charges,8.08,44.1,,44.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.4,95,,62.08,Percent of Total Billed Charges,95% of Total Billed Charges,18.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.12,88,,57.504,Percent of Total Billed Charges,88% of Total Billed Charges,16.49,90,,58.808,Percent of Total Billed charges,90% of Total Billed Charges,8.08,18.32,
MEPILEX 1.6X2,2720001161,CDM,272,RC,,,Outpatient,,,21.12,13.73,,21.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.05,76,,31.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.21,72,,65.088,Percent of Total Billed Charges,72% of Total Billed Charges,15.84,75,,67.8,Percent of Total Billed charges,75% of Total Billed Charges,21.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.21,72,,65.088,Percent of Total Billed Charges,72% of Total Billed Charges,12.67,60,,54.24,Percent of Total Billed Charges,60% of Total Billed Charges,19.01,90,,131.152,Percent of Total Billed Charges,90% of Total Billed Charges,9.5,45,,13.608,Percent of Total Billed Charges,45% of Total Billed Charges,19.01,90,,37.696,Percent of Total Billed Charges,90% of Total billed Charges,21.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.73,65,,65.52,Percent of total Billed Charges,65% of Total Billed Charges,9.31,44.1,,13.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.06,95,,39.784,Percent of Total Billed Charges,95% of Total Billed Charges,21.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.59,88,,36.856,Percent of Total Billed Charges,88% of Total Billed Charges,19.01,90,,37.696,Percent of Total Billed charges,90% of Total Billed Charges,9.31,21.12,
BRACH DRAPE,2720001162,CDM,272,RC,,,Outpatient,,,16.60,10.79,,16.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.62,76,,22.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.95,72,,14.4,Percent of Total Billed Charges,72% of Total Billed Charges,12.45,75,,15,Percent of Total Billed charges,75% of Total Billed Charges,16.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.95,72,,14.4,Percent of Total Billed Charges,72% of Total Billed Charges,9.96,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,14.94,90,,119.688,Percent of Total Billed Charges,90% of Total Billed Charges,7.47,45,,45.36,Percent of Total Billed Charges,45% of Total Billed Charges,14.94,90,,27.216,Percent of Total Billed Charges,90% of Total billed Charges,16.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.79,65,,19.656,Percent of total Billed Charges,65% of Total Billed Charges,7.32,44.1,,44.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.77,95,,28.728,Percent of Total Billed Charges,95% of Total Billed Charges,16.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.61,88,,26.608,Percent of Total Billed Charges,88% of Total Billed Charges,14.94,90,,27.216,Percent of Total Billed charges,90% of Total Billed Charges,7.32,16.6,
UBAG STERILE 200ML,2720001163,CDM,272,RC,,,Outpatient,,,11.50,7.48,,11.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.74,76,,76.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.28,72,,65.088,Percent of Total Billed Charges,72% of Total Billed Charges,8.63,75,,67.8,Percent of Total Billed charges,75% of Total Billed Charges,11.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.28,72,,65.088,Percent of Total Billed Charges,72% of Total Billed Charges,6.9,60,,54.24,Percent of Total Billed Charges,60% of Total Billed Charges,10.35,90,,110.36,Percent of Total Billed Charges,90% of Total Billed Charges,5.18,45,,13.608,Percent of Total Billed Charges,45% of Total Billed Charges,10.35,90,,90.72,Percent of Total Billed Charges,90% of Total billed Charges,11.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.48,65,,65.52,Percent of total Billed Charges,65% of Total Billed Charges,5.07,44.1,,13.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.93,95,,95.76,Percent of Total Billed Charges,95% of Total Billed Charges,11.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.12,88,,88.704,Percent of Total Billed Charges,88% of Total Billed Charges,10.35,90,,90.72,Percent of Total Billed charges,90% of Total Billed Charges,5.07,11.5,
PED URINE COLL,2720001164,CDM,272,RC,,,Outpatient,,,13.80,8.97,,13.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.49,76,,22.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.94,72,,14.4,Percent of Total Billed Charges,72% of Total Billed Charges,10.35,75,,15,Percent of Total Billed charges,75% of Total Billed Charges,13.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.94,72,,14.4,Percent of Total Billed Charges,72% of Total Billed Charges,8.28,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,12.42,90,,246.4,Percent of Total Billed Charges,90% of Total Billed Charges,6.21,45,,45.36,Percent of Total Billed Charges,45% of Total Billed Charges,12.42,90,,27.216,Percent of Total Billed Charges,90% of Total billed Charges,13.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.97,65,,19.656,Percent of total Billed Charges,65% of Total Billed Charges,6.09,44.1,,44.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.11,95,,28.728,Percent of Total Billed Charges,95% of Total Billed Charges,13.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.14,88,,26.608,Percent of Total Billed Charges,88% of Total Billed Charges,12.42,90,,27.216,Percent of Total Billed charges,90% of Total Billed Charges,6.09,13.8,
TUBE REPLOGLE8,2720001165,CDM,272,RC,,,Outpatient,,,16.70,10.86,,16.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.69,76,,76.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.02,72,,14.4,Percent of Total Billed Charges,72% of Total Billed Charges,12.53,75,,15,Percent of Total Billed charges,75% of Total Billed Charges,16.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.02,72,,14.4,Percent of Total Billed Charges,72% of Total Billed Charges,10.02,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,15.03,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,7.52,45,,74.848,Percent of Total Billed Charges,45% of Total Billed Charges,15.03,90,,90.72,Percent of Total Billed Charges,90% of Total billed Charges,16.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.86,65,,65.52,Percent of total Billed Charges,65% of Total Billed Charges,7.36,44.1,,73.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.87,95,,95.76,Percent of Total Billed Charges,95% of Total Billed Charges,16.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.7,88,,88.704,Percent of Total Billed Charges,88% of Total Billed Charges,15.03,90,,90.72,Percent of Total Billed charges,90% of Total Billed Charges,7.36,16.7,
TUBE REPLOGLE 6,2720001166,CDM,272,RC,,,Outpatient,,,16.70,10.86,,16.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.69,76,,22.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.02,72,,221.76,Percent of Total Billed Charges,72% of Total Billed Charges,12.53,75,,231,Percent of Total Billed charges,75% of Total Billed Charges,16.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.02,72,,221.76,Percent of Total Billed Charges,72% of Total Billed Charges,10.02,60,,184.8,Percent of Total Billed Charges,60% of Total Billed Charges,15.03,90,,109.552,Percent of Total Billed Charges,90% of Total Billed Charges,7.52,45,,124.336,Percent of Total Billed Charges,45% of Total Billed Charges,15.03,90,,27.216,Percent of Total Billed Charges,90% of Total billed Charges,16.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.86,65,,108.112,Percent of total Billed Charges,65% of Total Billed Charges,7.36,44.1,,121.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.87,95,,28.728,Percent of Total Billed Charges,95% of Total Billed Charges,16.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.7,88,,26.608,Percent of Total Billed Charges,88% of Total Billed Charges,15.03,90,,27.216,Percent of Total Billed charges,90% of Total Billed Charges,7.36,16.7,
TUBE REPLOGLE 10FR,2720001167,CDM,272,RC,,,Outpatient,,,16.70,10.86,,16.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.69,76,,76.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.02,72,,221.76,Percent of Total Billed Charges,72% of Total Billed Charges,12.53,75,,231,Percent of Total Billed charges,75% of Total Billed Charges,16.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.02,72,,221.76,Percent of Total Billed Charges,72% of Total Billed Charges,10.02,60,,184.8,Percent of Total Billed Charges,60% of Total Billed Charges,15.03,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,7.52,45,,124.336,Percent of Total Billed Charges,45% of Total Billed Charges,15.03,90,,90.72,Percent of Total Billed Charges,90% of Total billed Charges,16.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.86,65,,179.592,Percent of total Billed Charges,65% of Total Billed Charges,7.36,44.1,,121.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.87,95,,95.76,Percent of Total Billed Charges,95% of Total Billed Charges,16.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.7,88,,88.704,Percent of Total Billed Charges,88% of Total Billed Charges,15.03,90,,90.72,Percent of Total Billed charges,90% of Total Billed Charges,7.36,16.7,
URINE COLL PED 5.0,2720001168,CDM,272,RC,,,Outpatient,,,132.52,86.14,,132.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.72,76,,126.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.41,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,99.39,75,,54,Percent of Total Billed charges,75% of Total Billed Charges,132.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.41,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,79.51,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,119.27,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,59.63,45,,65.576,Percent of Total Billed Charges,45% of Total Billed Charges,119.27,90,,149.688,Percent of Total Billed Charges,90% of Total billed Charges,132.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.14,65,,179.592,Percent of total Billed Charges,65% of Total Billed Charges,58.44,44.1,,64.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.89,95,,158.008,Percent of Total Billed Charges,95% of Total Billed Charges,132.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.62,88,,146.36,Percent of Total Billed Charges,88% of Total Billed Charges,119.27,90,,149.688,Percent of Total Billed charges,90% of Total Billed Charges,58.44,132.52,
URINE COLL PED 6.5,2720001169,CDM,272,RC,,,Outpatient,,,132.52,86.14,,132.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.72,76,,209.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.41,72,,46.08,Percent of Total Billed Charges,72% of Total Billed Charges,99.39,75,,48,Percent of Total Billed charges,75% of Total Billed Charges,132.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.41,72,,46.08,Percent of Total Billed Charges,72% of Total Billed Charges,79.51,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,119.27,90,,40.072,Percent of Total Billed Charges,90% of Total Billed Charges,59.63,45,,59.84,Percent of Total Billed Charges,45% of Total Billed Charges,119.27,90,,248.664,Percent of Total Billed Charges,90% of Total billed Charges,132.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.14,65,,94.72,Percent of total Billed Charges,65% of Total Billed Charges,58.44,44.1,,58.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.89,95,,262.48,Percent of Total Billed Charges,95% of Total Billed Charges,132.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.62,88,,243.144,Percent of Total Billed Charges,88% of Total Billed Charges,119.27,90,,248.664,Percent of Total Billed charges,90% of Total Billed Charges,58.44,132.52,
URINE COLL PED 8.0,2720001170,CDM,272,RC,,,Outpatient,,,132.52,86.14,,132.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.72,76,,209.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.41,72,,21.888,Percent of Total Billed Charges,72% of Total Billed Charges,99.39,75,,22.8,Percent of Total Billed charges,75% of Total Billed Charges,132.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.41,72,,21.888,Percent of Total Billed Charges,72% of Total Billed Charges,79.51,60,,18.24,Percent of Total Billed Charges,60% of Total Billed Charges,119.27,90,,62.464,Percent of Total Billed Charges,90% of Total Billed Charges,59.63,45,,55.184,Percent of Total Billed Charges,45% of Total Billed Charges,119.27,90,,248.664,Percent of Total Billed Charges,90% of Total billed Charges,132.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.14,65,,86.44,Percent of total Billed Charges,65% of Total Billed Charges,58.44,44.1,,54.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.89,95,,262.48,Percent of Total Billed Charges,95% of Total Billed Charges,132.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.62,88,,243.144,Percent of Total Billed Charges,88% of Total Billed Charges,119.27,90,,248.664,Percent of Total Billed charges,90% of Total Billed Charges,58.44,132.52,
URINE COLL PED 3.5,2720001171,CDM,272,RC,,,Outpatient,,,132.52,86.14,,132.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.72,76,,110.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.41,72,,43.2,Percent of Total Billed Charges,72% of Total Billed Charges,99.39,75,,45,Percent of Total Billed charges,75% of Total Billed Charges,132.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.41,72,,43.2,Percent of Total Billed Charges,72% of Total Billed Charges,79.51,60,,36,Percent of Total Billed Charges,60% of Total Billed Charges,119.27,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,59.63,45,,123.2,Percent of Total Billed Charges,45% of Total Billed Charges,119.27,90,,131.152,Percent of Total Billed Charges,90% of Total billed Charges,132.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.14,65,,79.704,Percent of total Billed Charges,65% of Total Billed Charges,58.44,44.1,,120.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.89,95,,138.44,Percent of Total Billed Charges,95% of Total Billed Charges,132.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.62,88,,128.24,Percent of Total Billed Charges,88% of Total Billed Charges,119.27,90,,131.152,Percent of Total Billed charges,90% of Total Billed Charges,58.44,132.52,
FECAL MGNT,2720001172,CDM,272,RC,,,Outpatient,,,200.00,130.00,,200,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152,76,,101.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,150,75,,3,Percent of Total Billed charges,75% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,120,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,180,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,90,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,180,90,,119.688,Percent of Total Billed Charges,90% of Total billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130,65,,177.952,Percent of total Billed Charges,65% of Total Billed Charges,88.2,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,190,95,,126.336,Percent of Total Billed Charges,95% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,88,,117.024,Percent of Total Billed Charges,88% of Total Billed Charges,180,90,,119.688,Percent of Total Billed charges,90% of Total Billed Charges,88.2,200,
Glidescope Spectrm Lopro S1,2720001173,CDM,272,RC,,,Outpatient,,,120.17,78.11,,120.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,91.33,76,,93.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,86.52,72,,7.488,Percent of Total Billed Charges,72% of Total Billed Charges,90.13,75,,7.8,Percent of Total Billed charges,75% of Total Billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.52,72,,7.488,Percent of Total Billed Charges,72% of Total Billed Charges,72.1,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,108.15,90,,10.568,Percent of Total Billed Charges,90% of Total Billed Charges,54.08,45,,54.776,Percent of Total Billed Charges,45% of Total Billed Charges,108.15,90,,110.36,Percent of Total Billed Charges,90% of Total billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.11,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,52.99,44.1,,53.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,114.16,95,,116.496,Percent of Total Billed Charges,95% of Total Billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.75,88,,107.912,Percent of Total Billed Charges,88% of Total Billed Charges,108.15,90,,110.36,Percent of Total Billed charges,90% of Total Billed Charges,52.99,120.17,
Glidescope Spectrm Lopro S4,2720001174,CDM,272,RC,,,Outpatient,,,90.41,58.77,,90.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.71,76,,208.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.1,72,,1278.144,Percent of Total Billed Charges,72% of Total Billed Charges,67.81,75,,1331.4,Percent of Total Billed charges,75% of Total Billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.1,72,,1278.144,Percent of Total Billed Charges,72% of Total Billed Charges,54.25,60,,1065.12,Percent of Total Billed Charges,60% of Total Billed Charges,81.37,90,,6.288,Percent of Total Billed Charges,90% of Total Billed Charges,40.68,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,81.37,90,,246.4,Percent of Total Billed Charges,90% of Total billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.77,65,,79.12,Percent of total Billed Charges,65% of Total Billed Charges,39.87,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.89,95,,260.088,Percent of Total Billed Charges,95% of Total Billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.56,88,,240.92,Percent of Total Billed Charges,88% of Total Billed Charges,81.37,90,,246.4,Percent of Total Billed charges,90% of Total Billed Charges,39.87,90.41,
ON Q C BLOC CONTINUO,2720001175,CDM,272,RC,,,Outpatient,,,538.02,349.71,,538.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,408.9,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,387.37,72,,109.44,Percent of Total Billed Charges,72% of Total Billed Charges,403.52,75,,114,Percent of Total Billed charges,75% of Total Billed Charges,538.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,387.37,72,,109.44,Percent of Total Billed Charges,72% of Total Billed Charges,322.81,60,,91.2,Percent of Total Billed Charges,60% of Total Billed Charges,484.22,90,,109.552,Percent of Total Billed Charges,90% of Total Billed Charges,242.11,45,,7.2,Percent of Total Billed Charges,45% of Total Billed Charges,484.22,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,538.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.71,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,237.27,44.1,,7.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,511.12,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,538.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.46,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,484.22,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,237.27,538.02,
TUOHY NEEDLE 17G X 3.5 PERIFIX,2720001176,CDM,272,RC,,,Outpatient,,,64.81,42.13,,64.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.26,76,,92.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.66,72,,73.152,Percent of Total Billed Charges,72% of Total Billed Charges,48.61,75,,76.2,Percent of Total Billed charges,75% of Total Billed Charges,64.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.66,72,,73.152,Percent of Total Billed Charges,72% of Total Billed Charges,38.89,60,,60.96,Percent of Total Billed Charges,60% of Total Billed Charges,58.33,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,29.16,45,,20.032,Percent of Total Billed Charges,45% of Total Billed Charges,58.33,90,,109.552,Percent of Total Billed Charges,90% of Total billed Charges,64.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.13,65,,10.4,Percent of total Billed Charges,65% of Total Billed Charges,28.58,44.1,,19.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,61.57,95,,115.632,Percent of Total Billed Charges,95% of Total Billed Charges,64.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.03,88,,107.112,Percent of Total Billed Charges,88% of Total Billed Charges,58.33,90,,109.552,Percent of Total Billed charges,90% of Total Billed Charges,28.58,64.81,
EPIDURAL ANESTHESIA TRAY,2720001177,CDM,272,RC,,,Outpatient,,,116.69,75.85,,116.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,88.68,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.02,72,,1.04,Percent of Total Billed Charges,72% of Total Billed Charges,87.52,75,,1.08,Percent of Total Billed charges,75% of Total Billed Charges,116.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.02,72,,1.04,Percent of Total Billed Charges,72% of Total Billed Charges,70.01,60,,0.864,Percent of Total Billed Charges,60% of Total Billed Charges,105.02,90,,204.008,Percent of Total Billed Charges,90% of Total Billed Charges,52.51,45,,31.232,Percent of Total Billed Charges,45% of Total Billed Charges,105.02,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,116.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.85,65,,28.936,Percent of total Billed Charges,65% of Total Billed Charges,51.46,44.1,,30.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,110.86,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,116.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.69,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,105.02,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,51.46,116.69,
SYRINGE EPIDURAL 5ML GLASS,2720001178,CDM,272,RC,,,Outpatient,,,42.15,27.40,,42.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,32.03,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.35,72,,17.28,Percent of Total Billed Charges,72% of Total Billed Charges,31.61,75,,18,Percent of Total Billed charges,75% of Total Billed Charges,42.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.35,72,,17.28,Percent of Total Billed Charges,72% of Total Billed Charges,25.29,60,,14.4,Percent of Total Billed Charges,60% of Total Billed Charges,37.94,90,,8.168,Percent of Total Billed Charges,90% of Total Billed Charges,18.97,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,37.94,90,,14.4,Percent of Total Billed Charges,90% of Total billed Charges,42.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.4,65,,45.112,Percent of total Billed Charges,65% of Total Billed Charges,18.59,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,40.04,95,,15.2,Percent of Total Billed Charges,95% of Total Billed Charges,42.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.09,88,,14.08,Percent of Total Billed Charges,88% of Total Billed Charges,37.94,90,,14.4,Percent of Total Billed charges,90% of Total Billed Charges,18.59,42.15,
APM CTF03 5X100 Z THREAD,2720001180,CDM,272,RC,,,Outpatient,,,23.00,14.95,,23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.48,76,,33.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.56,72,,5.184,Percent of Total Billed Charges,72% of Total Billed Charges,17.25,75,,5.4,Percent of Total Billed charges,75% of Total Billed Charges,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.56,72,,5.184,Percent of Total Billed Charges,72% of Total Billed Charges,13.8,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,20.7,90,,8.168,Percent of Total Billed Charges,90% of Total Billed Charges,10.35,45,,7.2,Percent of Total Billed Charges,45% of Total Billed Charges,20.7,90,,40.072,Percent of Total Billed Charges,90% of Total billed Charges,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.95,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,10.14,44.1,,7.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.85,95,,42.296,Percent of Total Billed Charges,95% of Total Billed Charges,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.24,88,,39.176,Percent of Total Billed Charges,88% of Total Billed Charges,20.7,90,,40.072,Percent of Total Billed charges,90% of Total Billed Charges,10.14,23,
APM CTF03 5X100 Z THREAD,2720001184,CDM,272,RC,,,Outpatient,,,23.00,14.95,,23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.48,76,,52.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.56,72,,18.432,Percent of Total Billed Charges,72% of Total Billed Charges,17.25,75,,19.2,Percent of Total Billed charges,75% of Total Billed Charges,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.56,72,,18.432,Percent of Total Billed Charges,72% of Total Billed Charges,13.8,60,,15.36,Percent of Total Billed Charges,60% of Total Billed Charges,20.7,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,10.35,45,,5.288,Percent of Total Billed Charges,45% of Total Billed Charges,20.7,90,,62.464,Percent of Total Billed Charges,90% of Total billed Charges,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.95,65,,10.4,Percent of total Billed Charges,65% of Total Billed Charges,10.14,44.1,,5.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.85,95,,65.936,Percent of Total Billed Charges,95% of Total Billed Charges,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.24,88,,61.08,Percent of Total Billed Charges,88% of Total Billed Charges,20.7,90,,62.464,Percent of Total Billed charges,90% of Total Billed Charges,10.14,23,
ENDOSCOPIC TATTOOING DYE,2720001185,CDM,272,RC,,,Outpatient,,,38.00,24.70,,38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.88,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.36,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,28.5,75,,1.2,Percent of Total Billed charges,75% of Total Billed Charges,38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.36,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,22.8,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,34.2,90,,531.92,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,45,,3.144,Percent of Total Billed Charges,45% of Total Billed Charges,34.2,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.7,65,,7.632,Percent of total Billed Charges,65% of Total Billed Charges,16.76,44.1,,3.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.1,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.44,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,34.2,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,16.76,38,
SCISSORS INSERT CVDMETZ  36CM,2720001186,CDM,272,RC,,,Outpatient,,,60.00,39.00,,60,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.6,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.2,72,,2.176,Percent of Total Billed Charges,72% of Total Billed Charges,45,75,,2.272,Percent of Total Billed charges,75% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.2,72,,2.176,Percent of Total Billed Charges,72% of Total Billed Charges,36,60,,1.816,Percent of Total Billed Charges,60% of Total Billed Charges,54,90,,1.632,Percent of Total Billed Charges,90% of Total Billed Charges,27,45,,54.776,Percent of Total Billed Charges,45% of Total Billed Charges,54,90,,14.4,Percent of Total Billed Charges,90% of Total billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39,65,,4.536,Percent of total Billed Charges,65% of Total Billed Charges,26.46,44.1,,53.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,57,95,,15.2,Percent of Total Billed Charges,95% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.8,88,,14.08,Percent of Total Billed Charges,88% of Total Billed Charges,54,90,,14.4,Percent of Total Billed charges,90% of Total Billed Charges,26.46,60,
HI-FLOW CANISTER KIT 3000CC,2720001187,CDM,272,RC,,,Outpatient,,,9.00,5.85,,9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.84,76,,8.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.48,72,,2.176,Percent of Total Billed Charges,72% of Total Billed Charges,6.75,75,,2.272,Percent of Total Billed charges,75% of Total Billed Charges,9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.48,72,,2.176,Percent of Total Billed Charges,72% of Total Billed Charges,5.4,60,,1.816,Percent of Total Billed Charges,60% of Total Billed Charges,8.1,90,,10.568,Percent of Total Billed Charges,90% of Total Billed Charges,4.05,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,8.1,90,,10.568,Percent of Total Billed Charges,90% of Total billed Charges,9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.85,65,,79.12,Percent of total Billed Charges,65% of Total Billed Charges,3.97,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.55,95,,11.16,Percent of Total Billed Charges,95% of Total Billed Charges,9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.92,88,,10.336,Percent of Total Billed Charges,88% of Total Billed Charges,8.1,90,,10.568,Percent of Total Billed charges,90% of Total Billed Charges,3.97,9,
SUCTION CANNISTER 3000,2720001188,CDM,272,RC,,,Outpatient,,,2.00,1.30,,2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.52,76,,5.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.44,72,,5.256,Percent of Total Billed Charges,72% of Total Billed Charges,1.5,75,,5.48,Percent of Total Billed charges,75% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,72,,5.256,Percent of Total Billed Charges,72% of Total Billed Charges,1.2,60,,4.384,Percent of Total Billed Charges,60% of Total Billed Charges,1.8,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,0.9,45,,102,Percent of Total Billed Charges,45% of Total Billed Charges,1.8,90,,6.288,Percent of Total Billed Charges,90% of Total billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,0.88,44.1,,99.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.9,95,,6.632,Percent of Total Billed Charges,95% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.76,88,,6.144,Percent of Total Billed Charges,88% of Total Billed Charges,1.8,90,,6.288,Percent of Total Billed charges,90% of Total Billed Charges,0.88,2,
GLIDESCOPE SPECTRUM LO PROS2,2720001189,CDM,272,RC,,,Outpatient,,,61.00,39.65,,61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.36,76,,92.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.92,72,,1,Percent of Total Billed Charges,72% of Total Billed Charges,45.75,75,,1.04,Percent of Total Billed charges,75% of Total Billed Charges,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.92,72,,1,Percent of Total Billed Charges,72% of Total Billed Charges,36.6,60,,0.832,Percent of Total Billed Charges,60% of Total Billed Charges,54.9,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,27.45,45,,4.08,Percent of Total Billed Charges,45% of Total Billed Charges,54.9,90,,109.552,Percent of Total Billed Charges,90% of Total billed Charges,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.65,65,,147.336,Percent of total Billed Charges,65% of Total Billed Charges,26.9,44.1,,4,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.95,95,,115.632,Percent of Total Billed Charges,95% of Total Billed Charges,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.68,88,,107.112,Percent of Total Billed Charges,88% of Total Billed Charges,54.9,90,,109.552,Percent of Total Billed charges,90% of Total Billed Charges,26.9,61,
GLIDESCOPE SPECTRUM LO PROSL,2720001190,CDM,272,RC,,,Outpatient,,,61.00,39.65,,61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.36,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.92,72,,6.184,Percent of Total Billed Charges,72% of Total Billed Charges,45.75,75,,6.44,Percent of Total Billed charges,75% of Total Billed Charges,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.92,72,,6.184,Percent of Total Billed Charges,72% of Total Billed Charges,36.6,60,,5.152,Percent of Total Billed Charges,60% of Total Billed Charges,54.9,90,,57.152,Percent of Total Billed Charges,90% of Total Billed Charges,27.45,45,,4.08,Percent of Total Billed Charges,45% of Total Billed Charges,54.9,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.65,65,,5.896,Percent of total Billed Charges,65% of Total Billed Charges,26.9,44.1,,4,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.95,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.68,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,54.9,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,26.9,61,
GLIDESCPE SPECTRUM LO PRO S3`,2720001191,CDM,272,RC,,,Outpatient,,,53.00,34.45,,53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.28,76,,172.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.16,72,,7.144,Percent of Total Billed Charges,72% of Total Billed Charges,39.75,75,,7.44,Percent of Total Billed charges,75% of Total Billed Charges,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.16,72,,7.144,Percent of Total Billed Charges,72% of Total Billed Charges,31.8,60,,5.952,Percent of Total Billed Charges,60% of Total Billed Charges,47.7,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,23.85,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,47.7,90,,204.008,Percent of Total Billed Charges,90% of Total billed Charges,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.45,65,,5.896,Percent of total Billed Charges,65% of Total Billed Charges,23.37,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.35,95,,215.336,Percent of Total Billed Charges,95% of Total Billed Charges,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.64,88,,199.472,Percent of Total Billed Charges,88% of Total Billed Charges,47.7,90,,204.008,Percent of Total Billed charges,90% of Total Billed Charges,23.37,53,
HILO 3.5 TRACHEL TUBE MURPH,2720001192,CDM,272,RC,,,Outpatient,,,2.00,1.30,,2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.52,76,,6.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.44,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,1.5,75,,3,Percent of Total Billed charges,75% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,1.2,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.8,90,,1.68,Percent of Total Billed Charges,90% of Total Billed Charges,0.9,45,,265.96,Percent of Total Billed Charges,45% of Total Billed Charges,1.8,90,,8.168,Percent of Total Billed Charges,90% of Total billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,0.88,44.1,,260.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.9,95,,8.616,Percent of Total Billed Charges,95% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.76,88,,7.984,Percent of Total Billed Charges,88% of Total Billed Charges,1.8,90,,8.168,Percent of Total Billed charges,90% of Total Billed Charges,0.88,2,
HILO 4.0 TRACHEAL TUBE MURPH,2720001193,CDM,272,RC,,,Outpatient,,,2.00,1.30,,2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.52,76,,6.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.44,72,,1.928,Percent of Total Billed Charges,72% of Total Billed Charges,1.5,75,,2.008,Percent of Total Billed charges,75% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,72,,1.928,Percent of Total Billed Charges,72% of Total Billed Charges,1.2,60,,1.608,Percent of Total Billed Charges,60% of Total Billed Charges,1.8,90,,1349.464,Percent of Total Billed Charges,90% of Total Billed Charges,0.9,45,,0.816,Percent of Total Billed Charges,45% of Total Billed Charges,1.8,90,,8.168,Percent of Total Billed Charges,90% of Total billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,65,,384.168,Percent of total Billed Charges,65% of Total Billed Charges,0.88,44.1,,0.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.9,95,,8.616,Percent of Total Billed Charges,95% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.76,88,,7.984,Percent of Total Billed Charges,88% of Total Billed Charges,1.8,90,,8.168,Percent of Total Billed charges,90% of Total Billed Charges,0.88,2,
SALINE LINE W/DRIP 7,2720001194,CDM,272,RC,,,Outpatient,,,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,5.256,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,5.48,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,5.256,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,4.384,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,5.288,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,1.184,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,5.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
CONTRST LNE W/VENTD,2720001195,CDM,272,RC,,,Outpatient,,,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,449.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,3.456,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,3.6,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,3.456,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,106.56,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,31.32,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,531.92,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,7.632,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,30.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,561.472,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,520.104,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,531.92,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
CONTRST INJ HIPRES 3,2720001196,CDM,272,RC,,,Outpatient,,,444.31,288.80,,444.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,337.68,76,,1.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,319.9,72,,3.24,Percent of Total Billed Charges,72% of Total Billed Charges,333.23,75,,3.376,Percent of Total Billed charges,75% of Total Billed Charges,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319.9,72,,3.24,Percent of Total Billed Charges,72% of Total Billed Charges,266.59,60,,2.704,Percent of Total Billed Charges,60% of Total Billed Charges,399.88,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,199.94,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,399.88,90,,1.632,Percent of Total Billed Charges,90% of Total billed Charges,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.8,65,,45.24,Percent of total Billed Charges,65% of Total Billed Charges,195.94,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,422.09,95,,1.728,Percent of Total Billed Charges,95% of Total Billed Charges,444.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.99,88,,1.6,Percent of Total Billed Charges,88% of Total Billed Charges,399.88,90,,1.632,Percent of Total Billed charges,90% of Total Billed Charges,195.94,444.31,
TEMPORARY PACING CAT,2720001197,CDM,272,RC,,,Outpatient,,,244.76,159.09,,244.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,186.02,76,,8.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,176.23,72,,3.304,Percent of Total Billed Charges,72% of Total Billed Charges,183.57,75,,3.44,Percent of Total Billed charges,75% of Total Billed Charges,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.23,72,,3.304,Percent of Total Billed Charges,72% of Total Billed Charges,146.86,60,,2.752,Percent of Total Billed Charges,60% of Total Billed Charges,220.28,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,110.14,45,,28.576,Percent of Total Billed Charges,45% of Total Billed Charges,220.28,90,,10.568,Percent of Total Billed Charges,90% of Total billed Charges,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.09,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,107.94,44.1,,28.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,232.52,95,,11.16,Percent of Total Billed Charges,95% of Total Billed Charges,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.39,88,,10.336,Percent of Total Billed Charges,88% of Total Billed Charges,220.28,90,,10.568,Percent of Total Billed charges,90% of Total Billed Charges,107.94,244.76,
CATH LAB PK SUP,2720001198,CDM,272,RC,,,Outpatient,,,307.60,199.94,,307.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,233.78,76,,52.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,221.47,72,,5.256,Percent of Total Billed Charges,72% of Total Billed Charges,230.7,75,,5.48,Percent of Total Billed charges,75% of Total Billed Charges,307.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.47,72,,5.256,Percent of Total Billed Charges,72% of Total Billed Charges,184.56,60,,4.384,Percent of Total Billed Charges,60% of Total Billed Charges,276.84,90,,13.768,Percent of Total Billed Charges,90% of Total Billed Charges,138.42,45,,12.96,Percent of Total Billed Charges,45% of Total Billed Charges,276.84,90,,62.64,Percent of Total Billed Charges,90% of Total billed Charges,307.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.94,65,,41.28,Percent of total Billed Charges,65% of Total Billed Charges,135.65,44.1,,12.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,292.22,95,,66.12,Percent of Total Billed Charges,95% of Total Billed Charges,307.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.69,88,,61.248,Percent of Total Billed Charges,88% of Total Billed Charges,276.84,90,,62.64,Percent of Total Billed charges,90% of Total Billed Charges,135.65,307.6,
PACEMAKER PK SUP,2720001199,CDM,272,RC,,,Outpatient,,,185.22,120.39,,185.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,140.77,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,133.36,72,,1.848,Percent of Total Billed Charges,72% of Total Billed Charges,138.92,75,,1.928,Percent of Total Billed charges,75% of Total Billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.36,72,,1.848,Percent of Total Billed Charges,72% of Total Billed Charges,111.13,60,,1.544,Percent of Total Billed Charges,60% of Total Billed Charges,166.7,90,,34.176,Percent of Total Billed Charges,90% of Total Billed Charges,83.35,45,,0.84,Percent of Total Billed Charges,45% of Total Billed Charges,166.7,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.39,65,,18.72,Percent of total Billed Charges,65% of Total Billed Charges,81.68,44.1,,0.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,175.96,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.99,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,166.7,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,81.68,185.22,
DERMABOND 0.7ML,2720001200,CDM,272,RC,,,Outpatient,,,69.46,45.15,,69.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.79,76,,48.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.01,72,,9.608,Percent of Total Billed Charges,72% of Total Billed Charges,52.1,75,,10.008,Percent of Total Billed charges,75% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.01,72,,9.608,Percent of Total Billed Charges,72% of Total Billed Charges,41.68,60,,8.008,Percent of Total Billed Charges,60% of Total Billed Charges,62.51,90,,32.544,Percent of Total Billed Charges,90% of Total Billed Charges,31.26,45,,674.728,Percent of Total Billed Charges,45% of Total Billed Charges,62.51,90,,57.152,Percent of Total Billed Charges,90% of Total billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.15,65,,1.208,Percent of total Billed Charges,65% of Total Billed Charges,30.63,44.1,,661.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.99,95,,60.328,Percent of Total Billed Charges,95% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,88,,55.88,Percent of Total Billed Charges,88% of Total Billed Charges,62.51,90,,57.152,Percent of Total Billed charges,90% of Total Billed Charges,30.63,69.46,
SUTURE SLK BLK BR 2,2720001201,CDM,272,RC,,,Outpatient,,,35.28,22.93,,35.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.81,76,,21.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.4,72,,5.424,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,75,,5.648,Percent of Total Billed charges,75% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.4,72,,5.424,Percent of Total Billed Charges,72% of Total Billed Charges,21.17,60,,4.52,Percent of Total Billed Charges,60% of Total Billed Charges,31.75,90,,148.176,Percent of Total Billed Charges,90% of Total Billed Charges,15.88,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,31.75,90,,25.92,Percent of Total Billed Charges,90% of Total billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.93,65,,974.608,Percent of total Billed Charges,65% of Total Billed Charges,15.56,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.52,95,,27.36,Percent of Total Billed Charges,95% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.05,88,,25.344,Percent of Total Billed Charges,88% of Total Billed Charges,31.75,90,,25.92,Percent of Total Billed charges,90% of Total Billed Charges,15.56,35.28,
30 VICRYL J416OH SU,2720001202,CDM,272,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,1.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,0.208,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,0.216,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,0.208,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,0.176,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,82.832,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,53.28,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,1.68,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,52.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,1.768,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,1.64,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,1.68,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
ZOLL PRO PADZ SUP,2720001203,CDM,271,RC,,,Outpatient,,,188.53,122.54,,188.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,143.28,76,,1139.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,135.74,72,,7.632,Percent of Total Billed Charges,72% of Total Billed Charges,141.4,75,,7.952,Percent of Total Billed charges,75% of Total Billed Charges,188.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.74,72,,7.632,Percent of Total Billed Charges,72% of Total Billed Charges,113.12,60,,6.36,Percent of Total Billed Charges,60% of Total Billed Charges,169.68,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,84.84,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,169.68,90,,1349.464,Percent of Total Billed Charges,90% of Total billed Charges,188.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.54,65,,76.96,Percent of total Billed Charges,65% of Total Billed Charges,83.14,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,179.1,95,,1424.432,Percent of Total Billed Charges,95% of Total Billed Charges,188.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.91,88,,1319.472,Percent of Total Billed Charges,88% of Total Billed Charges,169.68,90,,1349.464,Percent of Total Billed charges,90% of Total Billed Charges,83.14,188.53,
TRANSLU ELECTRODS PK,2720001204,CDM,272,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,7.16,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,7.456,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,7.16,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,5.968,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,27.784,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
COOK PERCUT ENTRY ND,2720001205,CDM,272,RC,,,Outpatient,,,33.60,21.84,,33.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.54,76,,89.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.19,72,,37.112,Percent of Total Billed Charges,72% of Total Billed Charges,25.2,75,,38.656,Percent of Total Billed charges,75% of Total Billed Charges,33.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.19,72,,37.112,Percent of Total Billed Charges,72% of Total Billed Charges,20.16,60,,30.928,Percent of Total Billed Charges,60% of Total Billed Charges,30.24,90,,52.392,Percent of Total Billed Charges,90% of Total Billed Charges,15.12,45,,6.88,Percent of Total Billed Charges,45% of Total Billed Charges,30.24,90,,106.56,Percent of Total Billed Charges,90% of Total billed Charges,33.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.84,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,14.82,44.1,,6.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.92,95,,112.48,Percent of Total Billed Charges,95% of Total Billed Charges,33.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.57,88,,104.192,Percent of Total Billed Charges,88% of Total Billed Charges,30.24,90,,106.56,Percent of Total Billed charges,90% of Total Billed Charges,14.82,33.6,
FEMOSTOP PLUS SUP,2720001206,CDM,272,RC,,,Outpatient,,,152.15,98.90,,152.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,115.63,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,109.55,72,,7.16,Percent of Total Billed Charges,72% of Total Billed Charges,114.11,75,,7.456,Percent of Total Billed charges,75% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.55,72,,7.16,Percent of Total Billed Charges,72% of Total Billed Charges,91.29,60,,5.968,Percent of Total Billed Charges,60% of Total Billed Charges,136.94,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,68.47,45,,17.088,Percent of Total Billed Charges,45% of Total Billed Charges,136.94,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.9,65,,9.944,Percent of total Billed Charges,65% of Total Billed Charges,67.1,44.1,,16.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,144.54,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.89,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,136.94,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,67.1,152.15,
BOVIE ESU CAUTERY TI,2720001207,CDM,272,RC,,,Outpatient,,,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,7.16,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,7.456,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,7.16,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,5.968,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,27.784,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,16.272,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,24.688,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,15.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
BOVIE ESU GRNDN PAD,2720001208,CDM,272,RC,,,Outpatient,,,79.38,51.60,,79.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60.33,76,,11.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.15,72,,0.608,Percent of Total Billed Charges,72% of Total Billed Charges,59.54,75,,0.64,Percent of Total Billed charges,75% of Total Billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.15,72,,0.608,Percent of Total Billed Charges,72% of Total Billed Charges,47.63,60,,0.512,Percent of Total Billed Charges,60% of Total Billed Charges,71.44,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,35.72,45,,74.088,Percent of Total Billed Charges,45% of Total Billed Charges,71.44,90,,13.768,Percent of Total Billed Charges,90% of Total billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,65,,23.504,Percent of total Billed Charges,65% of Total Billed Charges,35.01,44.1,,72.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,75.41,95,,14.528,Percent of Total Billed Charges,95% of Total Billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.85,88,,13.464,Percent of Total Billed Charges,88% of Total Billed Charges,71.44,90,,13.768,Percent of Total Billed charges,90% of Total Billed Charges,35.01,79.38,
BOVIE ESU HANTROL CA,2720001209,CDM,272,RC,,,Outpatient,,,82.69,53.75,,82.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.84,76,,28.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.54,72,,7.16,Percent of Total Billed Charges,72% of Total Billed Charges,62.02,75,,7.456,Percent of Total Billed charges,75% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,72,,7.16,Percent of Total Billed Charges,72% of Total Billed Charges,49.61,60,,5.968,Percent of Total Billed Charges,60% of Total Billed Charges,74.42,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,37.21,45,,41.416,Percent of Total Billed Charges,45% of Total Billed Charges,74.42,90,,34.176,Percent of Total Billed Charges,90% of Total billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.75,65,,107.016,Percent of total Billed Charges,65% of Total Billed Charges,36.47,44.1,,40.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,78.56,95,,36.08,Percent of Total Billed Charges,95% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,88,,33.416,Percent of Total Billed Charges,88% of Total Billed Charges,74.42,90,,34.176,Percent of Total Billed charges,90% of Total Billed Charges,36.47,82.69,
RAYTEC #10 4X4 SUPP,2720001210,CDM,272,RC,,,Outpatient,,,47.41,30.82,,47.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.03,76,,27.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.14,72,,5.44,Percent of Total Billed Charges,72% of Total Billed Charges,35.56,75,,5.664,Percent of Total Billed charges,75% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.14,72,,5.44,Percent of Total Billed Charges,72% of Total Billed Charges,28.45,60,,4.528,Percent of Total Billed Charges,60% of Total Billed Charges,42.67,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,21.33,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,42.67,90,,32.544,Percent of Total Billed Charges,90% of Total billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.82,65,,59.824,Percent of total Billed Charges,65% of Total Billed Charges,20.91,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.04,95,,34.352,Percent of Total Billed Charges,95% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.72,88,,31.824,Percent of Total Billed Charges,88% of Total Billed Charges,42.67,90,,32.544,Percent of Total Billed charges,90% of Total Billed Charges,20.91,47.41,
SURGICAL SCALPEL BLA,2720001211,CDM,272,RC,,,Outpatient,,,114.66,74.53,,114.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.14,76,,125.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.56,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,86,75,,1.2,Percent of Total Billed charges,75% of Total Billed Charges,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.56,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,68.8,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,103.19,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,51.6,45,,13.896,Percent of Total Billed Charges,45% of Total Billed Charges,103.19,90,,148.176,Percent of Total Billed Charges,90% of Total billed Charges,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.53,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,50.57,44.1,,13.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,108.93,95,,156.408,Percent of Total Billed Charges,95% of Total Billed Charges,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.9,88,,144.88,Percent of Total Billed Charges,88% of Total Billed Charges,103.19,90,,148.176,Percent of Total Billed charges,90% of Total Billed Charges,50.57,114.66,
PERICARDIO TRAY #PC1,2720001212,CDM,272,RC,,,Outpatient,,,276.73,179.87,,276.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,210.31,76,,69.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,199.25,72,,3.424,Percent of Total Billed Charges,72% of Total Billed Charges,207.55,75,,3.568,Percent of Total Billed charges,75% of Total Billed Charges,276.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.25,72,,3.424,Percent of Total Billed Charges,72% of Total Billed Charges,166.04,60,,2.856,Percent of Total Billed Charges,60% of Total Billed Charges,249.06,90,,57.152,Percent of Total Billed Charges,90% of Total Billed Charges,124.53,45,,26.2,Percent of Total Billed Charges,45% of Total Billed Charges,249.06,90,,82.832,Percent of Total Billed Charges,90% of Total billed Charges,276.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.87,65,,20.064,Percent of total Billed Charges,65% of Total Billed Charges,122.04,44.1,,25.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,262.89,95,,87.432,Percent of Total Billed Charges,95% of Total Billed Charges,276.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.52,88,,80.992,Percent of Total Billed Charges,88% of Total Billed Charges,249.06,90,,82.832,Percent of Total Billed charges,90% of Total Billed Charges,122.04,276.73,
KYPHON MIXER A07A,2720001213,CDM,272,RC,,,Outpatient,,,543.53,353.29,,543.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,413.08,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,391.34,72,,10.808,Percent of Total Billed Charges,72% of Total Billed Charges,407.65,75,,11.264,Percent of Total Billed charges,75% of Total Billed Charges,543.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,391.34,72,,10.808,Percent of Total Billed Charges,72% of Total Billed Charges,326.12,60,,9.008,Percent of Total Billed Charges,60% of Total Billed Charges,489.18,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,244.59,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,489.18,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,543.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,543.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,543.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.29,65,,37.84,Percent of total Billed Charges,65% of Total Billed Charges,239.7,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,516.35,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,543.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,478.31,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,489.18,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,239.7,543.53,
KYPHX HVR BONE CEME,2720001214,CDM,272,RC,,,Outpatient,,,756.32,491.61,,756.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,574.8,76,,23.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,544.55,72,,2.304,Percent of Total Billed Charges,72% of Total Billed Charges,567.24,75,,2.4,Percent of Total Billed charges,75% of Total Billed Charges,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,544.55,72,,2.304,Percent of Total Billed Charges,72% of Total Billed Charges,453.79,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,680.69,90,,90.496,Percent of Total Billed Charges,90% of Total Billed Charges,340.34,45,,13.896,Percent of Total Billed Charges,45% of Total Billed Charges,680.69,90,,27.784,Percent of Total Billed Charges,90% of Total billed Charges,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.61,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,333.54,44.1,,13.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,718.5,95,,29.328,Percent of Total Billed Charges,95% of Total Billed Charges,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,665.56,88,,27.168,Percent of Total Billed Charges,88% of Total Billed Charges,680.69,90,,27.784,Percent of Total Billed charges,90% of Total Billed Charges,333.54,756.32,
BONE CEMENT&KYPHON M,2720001215,CDM,272,RC,,,Outpatient,,,965.79,627.76,,965.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,734,76,,44.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,695.37,72,,100.224,Percent of Total Billed Charges,72% of Total Billed Charges,724.34,75,,104.4,Percent of Total Billed charges,75% of Total Billed Charges,965.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.37,72,,100.224,Percent of Total Billed Charges,72% of Total Billed Charges,579.47,60,,83.52,Percent of Total Billed Charges,60% of Total Billed Charges,869.21,90,,24.608,Percent of Total Billed Charges,90% of Total Billed Charges,434.61,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,869.21,90,,52.392,Percent of Total Billed Charges,90% of Total billed Charges,965.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,965.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,965.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,627.76,65,,20.064,Percent of total Billed Charges,65% of Total Billed Charges,425.91,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,917.5,95,,55.304,Percent of Total Billed Charges,95% of Total Billed Charges,965.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,849.9,88,,51.232,Percent of Total Billed Charges,88% of Total Billed Charges,869.21,90,,52.392,Percent of Total Billed charges,90% of Total Billed Charges,425.91,965.79,
KPT 2003 TRAY XPANDE,2720001216,CDM,272,RC,,,Outpatient,,,15218.91,9892.29,,15218.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11566.37,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10957.62,72,,10.648,Percent of Total Billed Charges,72% of Total Billed Charges,11414.18,75,,11.088,Percent of Total Billed charges,75% of Total Billed Charges,15218.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10957.62,72,,10.648,Percent of Total Billed Charges,72% of Total Billed Charges,9131.35,60,,8.872,Percent of Total Billed Charges,60% of Total Billed Charges,13697.02,90,,41.28,Percent of Total Billed Charges,90% of Total Billed Charges,6848.51,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,13697.02,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,15218.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15218.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15218.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9892.29,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,6711.54,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,14457.96,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,15218.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13392.64,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,13697.02,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,6711.54,15218.91,
KPT 2004 TRAY XPANDE,2720001217,CDM,272,RC,,,Outpatient,,,10244.43,6658.88,,10244.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7785.77,76,,23.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7375.99,72,,100.976,Percent of Total Billed Charges,72% of Total Billed Charges,7683.32,75,,105.184,Percent of Total Billed charges,75% of Total Billed Charges,10244.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7375.99,72,,100.976,Percent of Total Billed Charges,72% of Total Billed Charges,6146.66,60,,84.144,Percent of Total Billed Charges,60% of Total Billed Charges,9219.99,90,,59.536,Percent of Total Billed Charges,90% of Total Billed Charges,4609.99,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,9219.99,90,,27.784,Percent of Total Billed Charges,90% of Total billed Charges,10244.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10244.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10244.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6658.88,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,4517.79,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,9732.21,95,,29.328,Percent of Total Billed Charges,95% of Total Billed Charges,10244.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9015.1,88,,27.168,Percent of Total Billed Charges,88% of Total Billed Charges,9219.99,90,,27.784,Percent of Total Billed charges,90% of Total Billed Charges,4517.79,10244.43,
KPT 2005 TRAY EXPAND,2720001218,CDM,272,RC,,,Outpatient,,,15436.10,10033.47,,15436.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11731.44,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11113.99,72,,11.072,Percent of Total Billed Charges,72% of Total Billed Charges,11577.08,75,,11.536,Percent of Total Billed charges,75% of Total Billed Charges,15436.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11113.99,72,,11.072,Percent of Total Billed Charges,72% of Total Billed Charges,9261.66,60,,9.224,Percent of Total Billed Charges,60% of Total Billed Charges,13892.49,90,,19.048,Percent of Total Billed Charges,90% of Total Billed Charges,6946.25,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,13892.49,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,15436.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15436.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15436.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10033.47,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,6807.32,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,14664.3,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,15436.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13583.77,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,13892.49,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,6807.32,15436.1,
KYPHX EXPRESS INFLT,2720001219,CDM,272,RC,,,Outpatient,,,4774.93,3103.70,,4774.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3628.95,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3437.95,72,,11.76,Percent of Total Billed Charges,72% of Total Billed Charges,3581.2,75,,12.256,Percent of Total Billed charges,75% of Total Billed Charges,4774.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3437.95,72,,11.76,Percent of Total Billed Charges,72% of Total Billed Charges,2864.96,60,,9.8,Percent of Total Billed Charges,60% of Total Billed Charges,4297.44,90,,88.904,Percent of Total Billed Charges,90% of Total Billed Charges,2148.72,45,,28.576,Percent of Total Billed Charges,45% of Total Billed Charges,4297.44,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,4774.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4774.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4774.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3103.7,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,2105.74,44.1,,28.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,4536.18,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,4774.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4201.94,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,4297.44,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,2105.74,4774.93,
22X5 BLK SPINAL NEED,2720001220,CDM,272,RC,,,Outpatient,,,17.64,11.47,,17.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.41,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.7,72,,13.824,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,75,,14.4,Percent of Total Billed charges,75% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.7,72,,13.824,Percent of Total Billed Charges,72% of Total Billed Charges,10.58,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,15.88,90,,26.192,Percent of Total Billed Charges,90% of Total Billed Charges,7.94,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,15.88,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.47,65,,41.28,Percent of total Billed Charges,65% of Total Billed Charges,7.78,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.76,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.52,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,15.88,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,7.78,17.64,
SINGLE SHOT EPIDURAL,2720001221,CDM,272,RC,,,Outpatient,,,84.89,55.18,,84.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,64.52,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.12,72,,1.728,Percent of Total Billed Charges,72% of Total Billed Charges,63.67,75,,1.8,Percent of Total Billed charges,75% of Total Billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,72,,1.728,Percent of Total Billed Charges,72% of Total Billed Charges,50.93,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,76.4,90,,32.544,Percent of Total Billed Charges,90% of Total Billed Charges,38.2,45,,45.248,Percent of Total Billed Charges,45% of Total Billed Charges,76.4,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.18,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,37.44,44.1,,44.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,80.65,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.7,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,76.4,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,37.44,84.89,
17GX3.5 TOUHY NEEDLE,2720001222,CDM,272,RC,,,Outpatient,,,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,48.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,4.608,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,4.8,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,4.608,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,12.304,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,57.152,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,65.36,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,12.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,60.328,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,55.88,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,57.152,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
ENCORE INFLA DEV 15,2720001223,CDM,272,RC,,,Outpatient,,,222.71,144.76,,222.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,169.26,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,160.35,72,,10.368,Percent of Total Billed Charges,72% of Total Billed Charges,167.03,75,,10.8,Percent of Total Billed charges,75% of Total Billed Charges,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.35,72,,10.368,Percent of Total Billed Charges,72% of Total Billed Charges,133.63,60,,8.64,Percent of Total Billed Charges,60% of Total Billed Charges,200.44,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,100.22,45,,20.64,Percent of Total Billed Charges,45% of Total Billed Charges,200.44,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.76,65,,17.776,Percent of total Billed Charges,65% of Total Billed Charges,98.22,44.1,,20.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,211.57,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.98,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,200.44,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,98.22,222.71,
PDS II SUTURE Z824G,2720001224,CDM,272,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,76.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,17.856,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,18.6,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,17.856,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,1.592,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,29.768,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,90.496,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,29.808,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,29.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,95.528,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,88.488,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,90.496,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
DISP BLADE CLIPPERS,2720001225,CDM,272,RC,,,Outpatient,,,14.33,9.31,,14.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.89,76,,20.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.32,72,,1.728,Percent of Total Billed Charges,72% of Total Billed Charges,10.75,75,,1.8,Percent of Total Billed charges,75% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,72,,1.728,Percent of Total Billed Charges,72% of Total Billed Charges,8.6,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,12.9,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,9.528,Percent of Total Billed Charges,45% of Total Billed Charges,12.9,90,,24.608,Percent of Total Billed Charges,90% of Total billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.31,65,,43,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,9.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.61,95,,25.976,Percent of Total Billed Charges,95% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.61,88,,24.064,Percent of Total Billed Charges,88% of Total Billed Charges,12.9,90,,24.608,Percent of Total Billed charges,90% of Total Billed Charges,6.32,14.33,
CUSTOM CATH PK DYNJ2,2720001226,CDM,272,RC,,,Outpatient,,,224.91,146.19,,224.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,170.93,76,,34.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,161.94,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,168.68,75,,9,Percent of Total Billed charges,75% of Total Billed Charges,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.94,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,134.95,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,202.42,90,,26.192,Percent of Total Billed Charges,90% of Total Billed Charges,101.21,45,,44.456,Percent of Total Billed Charges,45% of Total Billed Charges,202.42,90,,41.28,Percent of Total Billed Charges,90% of Total billed Charges,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.19,65,,13.76,Percent of total Billed Charges,65% of Total Billed Charges,99.19,44.1,,43.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.66,95,,43.568,Percent of Total Billed Charges,95% of Total Billed Charges,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.92,88,,40.36,Percent of Total Billed Charges,88% of Total Billed Charges,202.42,90,,41.28,Percent of Total Billed charges,90% of Total Billed Charges,99.19,224.91,
SUTURE 4-0 PROLENE #,2720001227,CDM,272,RC,,,Outpatient,,,45.20,29.38,,45.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.35,76,,50.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.54,72,,20.16,Percent of Total Billed Charges,72% of Total Billed Charges,33.9,75,,21,Percent of Total Billed charges,75% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.54,72,,20.16,Percent of Total Billed Charges,72% of Total Billed Charges,27.12,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,40.68,90,,32.544,Percent of Total Billed Charges,90% of Total Billed Charges,20.34,45,,13.096,Percent of Total Billed Charges,45% of Total Billed Charges,40.68,90,,59.536,Percent of Total Billed Charges,90% of Total billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.38,65,,64.208,Percent of total Billed Charges,65% of Total Billed Charges,19.93,44.1,,12.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.94,95,,62.848,Percent of Total Billed Charges,95% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.78,88,,58.216,Percent of Total Billed Charges,88% of Total Billed Charges,40.68,90,,59.536,Percent of Total Billed charges,90% of Total Billed Charges,19.93,45.2,
TEMP PACINGCATHW/BAL,2720001228,CDM,272,RC,C1751,HCPCS,Outpatient,,,308.70,200.66,,308.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,234.61,76,,16.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,222.26,72,,5.76,Percent of Total Billed Charges,72% of Total Billed Charges,231.53,75,,6,Percent of Total Billed charges,75% of Total Billed Charges,308.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.26,72,,5.76,Percent of Total Billed Charges,72% of Total Billed Charges,185.22,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,277.83,90,,12.704,Percent of Total Billed Charges,90% of Total Billed Charges,138.92,45,,16.272,Percent of Total Billed Charges,45% of Total Billed Charges,277.83,90,,19.048,Percent of Total Billed Charges,90% of Total billed Charges,308.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.66,65,,18.92,Percent of total Billed Charges,65% of Total Billed Charges,136.14,44.1,,15.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,293.27,95,,20.112,Percent of Total Billed Charges,95% of Total Billed Charges,308.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.66,88,,18.624,Percent of Total Billed Charges,88% of Total Billed Charges,277.83,90,,19.048,Percent of Total Billed charges,90% of Total Billed Charges,136.14,308.7,
2.0 VICRYL J602 SUTU,2720001229,CDM,272,RC,,,Outpatient,,,833.49,541.77,,833.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,633.45,76,,75.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,600.11,72,,13.824,Percent of Total Billed Charges,72% of Total Billed Charges,625.12,75,,14.4,Percent of Total Billed charges,75% of Total Billed Charges,833.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,600.11,72,,13.824,Percent of Total Billed Charges,72% of Total Billed Charges,500.09,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,750.14,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,375.07,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,750.14,90,,88.904,Percent of Total Billed Charges,90% of Total billed Charges,833.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,833.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,833.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,541.77,65,,23.504,Percent of total Billed Charges,65% of Total Billed Charges,367.57,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,791.82,95,,93.848,Percent of Total Billed Charges,95% of Total Billed Charges,833.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,733.47,88,,86.928,Percent of Total Billed Charges,88% of Total Billed Charges,750.14,90,,88.904,Percent of Total Billed charges,90% of Total Billed Charges,367.57,833.49,
4.0 VICRYL J415 SUTU,2720001230,CDM,272,RC,,,Outpatient,,,685.76,445.74,,685.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,521.18,76,,22.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,493.75,72,,7.488,Percent of Total Billed Charges,72% of Total Billed Charges,514.32,75,,7.8,Percent of Total Billed charges,75% of Total Billed Charges,685.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.75,72,,7.488,Percent of Total Billed Charges,72% of Total Billed Charges,411.46,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,617.18,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,308.59,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,617.18,90,,26.192,Percent of Total Billed Charges,90% of Total billed Charges,685.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,445.74,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,302.42,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,651.47,95,,27.648,Percent of Total Billed Charges,95% of Total Billed Charges,685.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,603.47,88,,25.608,Percent of Total Billed Charges,88% of Total Billed Charges,617.18,90,,26.192,Percent of Total Billed charges,90% of Total Billed Charges,302.42,685.76,
30 VICRYL PS1 J936,2720001231,CDM,272,RC,,,Outpatient,,,833.49,541.77,,833.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,633.45,76,,27.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,600.11,72,,5.76,Percent of Total Billed Charges,72% of Total Billed Charges,625.12,75,,6,Percent of Total Billed charges,75% of Total Billed Charges,833.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,600.11,72,,5.76,Percent of Total Billed Charges,72% of Total Billed Charges,500.09,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,750.14,90,,19.048,Percent of Total Billed Charges,90% of Total Billed Charges,375.07,45,,0.792,Percent of Total Billed Charges,45% of Total Billed Charges,750.14,90,,32.544,Percent of Total Billed Charges,90% of Total billed Charges,833.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,833.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,833.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,541.77,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,367.57,44.1,,0.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,791.82,95,,34.352,Percent of Total Billed Charges,95% of Total Billed Charges,833.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,733.47,88,,31.824,Percent of Total Billed Charges,88% of Total Billed Charges,750.14,90,,32.544,Percent of Total Billed charges,90% of Total Billed Charges,367.57,833.49,
40 VICRYL PS1 J935,2720001232,CDM,272,RC,,,Outpatient,,,685.76,445.74,,685.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,521.18,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,493.75,72,,73.728,Percent of Total Billed Charges,72% of Total Billed Charges,514.32,75,,73.728,Percent of Total Billed charges,75% of Total Billed Charges,685.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.75,72,,73.728,Percent of Total Billed Charges,72% of Total Billed Charges,411.46,60,,61.44,Percent of Total Billed Charges,60% of Total Billed Charges,617.18,90,,20.64,Percent of Total Billed Charges,90% of Total Billed Charges,308.59,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,617.18,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,685.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,445.74,65,,1.152,Percent of total Billed Charges,65% of Total Billed Charges,302.42,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,651.47,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,685.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,603.47,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,617.18,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,302.42,685.76,
NEEDLE GUIDE KIT  21G,2720001233,CDM,272,RC,,,Outpatient,,,18.19,11.82,,18.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.82,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.1,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,13.64,75,,7.2,Percent of Total Billed charges,75% of Total Billed Charges,18.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.1,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,10.91,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,16.37,90,,29.272,Percent of Total Billed Charges,90% of Total Billed Charges,8.19,45,,13.096,Percent of Total Billed Charges,45% of Total Billed Charges,16.37,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,18.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.82,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,8.02,44.1,,12.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.28,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,18.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.01,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,16.37,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,8.02,18.19,
POWER PICC 5 FR DUAL LUMEN KIT,2720001234,CDM,278,RC,,,Outpatient,,,257.99,167.69,,257.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,196.07,76,,1.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,185.75,72,,36.288,Percent of Total Billed Charges,72% of Total Billed Charges,185.75,72,,37.8,Percent of Total Billed charges,72% of Total Billed Charges,257.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.75,72,,36.288,Percent of Total Billed Charges,72% of Total Billed Charges,154.79,60,,30.24,Percent of Total Billed Charges,60% of Total Billed Charges,232.19,90,,75.568,Percent of Total Billed Charges,90% of Total Billed Charges,116.1,45,,16.272,Percent of Total Billed Charges,45% of Total Billed Charges,232.19,90,,1.592,Percent of Total Billed Charges,90% of Total billed Charges,257.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.69,65,,18.92,Percent of total Billed Charges,65% of Total Billed Charges,113.77,44.1,,15.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,245.09,95,,1.68,Percent of Total Billed Charges,95% of Total Billed Charges,257.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.03,88,,1.552,Percent of Total Billed Charges,88% of Total Billed Charges,232.19,90,,1.592,Percent of Total Billed charges,90% of Total Billed Charges,113.77,257.99,
COOK 6FR 15CM DILATOR,2720001235,CDM,278,RC,C1889,HCPCS,Outpatient,,,152.15,98.90,,152.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,115.63,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,109.55,72,,1.36,Percent of Total Billed Charges,72% of Total Billed Charges,109.55,72,,1.416,Percent of Total Billed charges,72% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.55,72,,1.36,Percent of Total Billed Charges,72% of Total Billed Charges,91.29,60,,1.136,Percent of Total Billed Charges,60% of Total Billed Charges,136.94,90,,40.208,Percent of Total Billed Charges,90% of Total Billed Charges,68.47,45,,6.352,Percent of Total Billed Charges,45% of Total Billed Charges,136.94,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.9,65,,23.504,Percent of total Billed Charges,65% of Total Billed Charges,67.1,44.1,,6.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,144.54,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.89,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,136.94,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,67.1,152.15,
COOK 8FR 15CM DILATOR,2720001236,CDM,278,RC,C1889,HCPCS,Outpatient,,,152.15,98.90,,152.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,115.63,76,,22.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,109.55,72,,36.288,Percent of Total Billed Charges,72% of Total Billed Charges,109.55,72,,37.8,Percent of Total Billed charges,72% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.55,72,,36.288,Percent of Total Billed Charges,72% of Total Billed Charges,91.29,60,,30.24,Percent of Total Billed Charges,60% of Total Billed Charges,136.94,90,,43.48,Percent of Total Billed Charges,90% of Total Billed Charges,68.47,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,136.94,90,,26.192,Percent of Total Billed Charges,90% of Total billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.9,65,,9.176,Percent of total Billed Charges,65% of Total Billed Charges,67.1,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,144.54,95,,27.648,Percent of Total Billed Charges,95% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.89,88,,25.608,Percent of Total Billed Charges,88% of Total Billed Charges,136.94,90,,26.192,Percent of Total Billed charges,90% of Total Billed Charges,67.1,152.15,
COOK 10FR 15CM DILATOR,2720001237,CDM,272,RC,,,Outpatient,,,152.15,98.90,,152.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,115.63,76,,27.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,109.55,72,,29.376,Percent of Total Billed Charges,72% of Total Billed Charges,114.11,75,,30.6,Percent of Total Billed charges,75% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.55,72,,29.376,Percent of Total Billed Charges,72% of Total Billed Charges,91.29,60,,24.48,Percent of Total Billed Charges,60% of Total Billed Charges,136.94,90,,43.856,Percent of Total Billed Charges,90% of Total Billed Charges,68.47,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,136.94,90,,32.544,Percent of Total Billed Charges,90% of Total billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.9,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,67.1,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,144.54,95,,34.352,Percent of Total Billed Charges,95% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.89,88,,31.824,Percent of Total Billed Charges,88% of Total Billed Charges,136.94,90,,32.544,Percent of Total Billed charges,90% of Total Billed Charges,67.1,152.15,
PNEUMOTHORAX KIT STRAIGHT,2720001238,CDM,272,RC,,,Outpatient,,,283.34,184.17,,283.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,215.34,76,,10.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,204,72,,0.576,Percent of Total Billed Charges,72% of Total Billed Charges,212.51,75,,0.6,Percent of Total Billed charges,75% of Total Billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204,72,,0.576,Percent of Total Billed Charges,72% of Total Billed Charges,170,60,,0.48,Percent of Total Billed Charges,60% of Total Billed Charges,255.01,90,,16.76,Percent of Total Billed Charges,90% of Total Billed Charges,127.5,45,,9.528,Percent of Total Billed Charges,45% of Total Billed Charges,255.01,90,,12.704,Percent of Total Billed Charges,90% of Total billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.17,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,124.95,44.1,,9.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,269.17,95,,13.408,Percent of Total Billed Charges,95% of Total Billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.34,88,,12.416,Percent of Total Billed Charges,88% of Total Billed Charges,255.01,90,,12.704,Percent of Total Billed charges,90% of Total Billed Charges,124.95,283.34,
PNEUMOTHORAX KIT PIGTAIL,2720001239,CDM,272,RC,,,Outpatient,,,283.34,184.17,,283.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,215.34,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,204,72,,19.584,Percent of Total Billed Charges,72% of Total Billed Charges,212.51,75,,20.4,Percent of Total Billed charges,75% of Total Billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204,72,,19.584,Percent of Total Billed Charges,72% of Total Billed Charges,170,60,,16.32,Percent of Total Billed Charges,60% of Total Billed Charges,255.01,90,,25.096,Percent of Total Billed Charges,90% of Total Billed Charges,127.5,45,,10.32,Percent of Total Billed Charges,45% of Total Billed Charges,255.01,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.17,65,,13.76,Percent of total Billed Charges,65% of Total Billed Charges,124.95,44.1,,10.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,269.17,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.34,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,255.01,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,124.95,283.34,
D STAT FLOWABLE HEMOSTAT,2720001240,CDM,278,RC,,,Outpatient,,,524.79,341.11,,524.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,398.84,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,377.85,72,,28.224,Percent of Total Billed Charges,72% of Total Billed Charges,377.85,72,,29.4,Percent of Total Billed charges,72% of Total Billed Charges,524.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.85,72,,28.224,Percent of Total Billed Charges,72% of Total Billed Charges,314.87,60,,23.52,Percent of Total Billed Charges,60% of Total Billed Charges,472.31,90,,25.856,Percent of Total Billed Charges,90% of Total Billed Charges,236.16,45,,14.64,Percent of Total Billed Charges,45% of Total Billed Charges,472.31,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,524.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,524.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,524.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.11,65,,14.912,Percent of total Billed Charges,65% of Total Billed Charges,231.43,44.1,,14.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,498.55,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,524.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,461.82,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,472.31,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,231.43,524.79,
COOK 4CM X 21G NEEDLE,2720001241,CDM,272,RC,,,Outpatient,,,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,16.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,1.728,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,1.8,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,1.728,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,52.392,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,37.784,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,19.048,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,21.144,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,37.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,20.112,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,18.624,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,19.048,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
PVA EMBOLIZATION PARTICLES 500,2720001242,CDM,278,RC,C1889,HCPCS,Outpatient,,,485.10,315.32,,485.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,368.68,76,,17.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,349.27,72,,2.376,Percent of Total Billed Charges,72% of Total Billed Charges,349.27,72,,2.48,Percent of Total Billed charges,72% of Total Billed Charges,485.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.27,72,,2.376,Percent of Total Billed Charges,72% of Total Billed Charges,291.06,60,,1.984,Percent of Total Billed Charges,60% of Total Billed Charges,436.59,90,,2.768,Percent of Total Billed Charges,90% of Total Billed Charges,218.3,45,,20.104,Percent of Total Billed Charges,45% of Total Billed Charges,436.59,90,,20.64,Percent of Total Billed Charges,90% of Total billed Charges,485.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.32,65,,54.576,Percent of total Billed Charges,65% of Total Billed Charges,213.93,44.1,,19.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,460.85,95,,21.792,Percent of Total Billed Charges,95% of Total Billed Charges,485.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.89,88,,20.184,Percent of Total Billed Charges,88% of Total Billed Charges,436.59,90,,20.64,Percent of Total Billed charges,90% of Total Billed Charges,213.93,485.1,
PVA EMBOLIZATION PARTICLES 300,2720001243,CDM,278,RC,C1889,HCPCS,Outpatient,,,485.10,315.32,,485.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,368.68,76,,24.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,349.27,72,,5.76,Percent of Total Billed Charges,72% of Total Billed Charges,349.27,72,,6,Percent of Total Billed charges,72% of Total Billed Charges,485.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.27,72,,5.76,Percent of Total Billed Charges,72% of Total Billed Charges,291.06,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,436.59,90,,2.728,Percent of Total Billed Charges,90% of Total Billed Charges,218.3,45,,21.744,Percent of Total Billed Charges,45% of Total Billed Charges,436.59,90,,29.272,Percent of Total Billed Charges,90% of Total billed Charges,485.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.32,65,,29.04,Percent of total Billed Charges,65% of Total Billed Charges,213.93,44.1,,21.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,460.85,95,,30.904,Percent of Total Billed Charges,95% of Total Billed Charges,485.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.89,88,,28.624,Percent of Total Billed Charges,88% of Total Billed Charges,436.59,90,,29.272,Percent of Total Billed charges,90% of Total Billed Charges,213.93,485.1,
MICRONEEDLE 21G X 9CM,2720001244,CDM,272,RC,,,Outpatient,,,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,63.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,18.432,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,19.2,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,18.432,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,15.36,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,2.448,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,21.928,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,75.568,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,31.4,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,21.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,79.768,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,73.888,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,75.568,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
ULTRA PRO II NEEDLE GUIDE,2720001245,CDM,272,RC,,,Outpatient,,,55.65,36.17,,55.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.29,76,,33.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.07,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,41.74,75,,9,Percent of Total Billed charges,75% of Total Billed Charges,55.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.07,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,33.39,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,50.09,90,,20.856,Percent of Total Billed Charges,90% of Total Billed Charges,25.04,45,,8.384,Percent of Total Billed Charges,45% of Total Billed Charges,50.09,90,,40.208,Percent of Total Billed Charges,90% of Total billed Charges,55.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.17,65,,31.672,Percent of total Billed Charges,65% of Total Billed Charges,24.54,44.1,,8.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.87,95,,42.44,Percent of Total Billed Charges,95% of Total Billed Charges,55.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.97,88,,39.312,Percent of Total Billed Charges,88% of Total Billed Charges,50.09,90,,40.208,Percent of Total Billed charges,90% of Total Billed Charges,24.54,55.65,
AMPLATZ ES .035 X 80CM WIRE,2720001246,CDM,272,RC,C1769,HCPCS,Outpatient,,,53.55,34.81,,53.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.7,76,,36.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.56,72,,42.624,Percent of Total Billed Charges,72% of Total Billed Charges,40.16,75,,44.4,Percent of Total Billed charges,75% of Total Billed Charges,53.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.56,72,,42.624,Percent of Total Billed Charges,72% of Total Billed Charges,32.13,60,,35.52,Percent of Total Billed Charges,60% of Total Billed Charges,48.2,90,,26.496,Percent of Total Billed Charges,90% of Total Billed Charges,24.1,45,,12.552,Percent of Total Billed Charges,45% of Total Billed Charges,48.2,90,,43.48,Percent of Total Billed Charges,90% of Total billed Charges,53.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.81,65,,12.104,Percent of total Billed Charges,65% of Total Billed Charges,23.62,44.1,,12.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.87,95,,45.896,Percent of Total Billed Charges,95% of Total Billed Charges,53.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.12,88,,42.512,Percent of Total Billed Charges,88% of Total Billed Charges,48.2,90,,43.48,Percent of Total Billed charges,90% of Total Billed Charges,23.62,53.55,
VASCU TAPE (30CM) G&T,2720001247,CDM,272,RC,,,Outpatient,,,148.19,96.32,,148.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,112.62,76,,37.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,106.7,72,,42.624,Percent of Total Billed Charges,72% of Total Billed Charges,111.14,75,,44.4,Percent of Total Billed charges,75% of Total Billed Charges,148.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.7,72,,42.624,Percent of Total Billed Charges,72% of Total Billed Charges,88.91,60,,35.52,Percent of Total Billed Charges,60% of Total Billed Charges,133.37,90,,71.448,Percent of Total Billed Charges,90% of Total Billed Charges,66.69,45,,12.928,Percent of Total Billed Charges,45% of Total Billed Charges,133.37,90,,43.856,Percent of Total Billed Charges,90% of Total billed Charges,148.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.32,65,,18.128,Percent of total Billed Charges,65% of Total Billed Charges,65.35,44.1,,12.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,140.78,95,,46.288,Percent of Total Billed Charges,95% of Total Billed Charges,148.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.41,88,,42.88,Percent of Total Billed Charges,88% of Total Billed Charges,133.37,90,,43.856,Percent of Total Billed charges,90% of Total Billed Charges,65.35,148.19,
#2 BIDIRECTIONAL TORQUE WRENCH,2720001248,CDM,272,RC,,,Outpatient,,,77.18,50.17,,77.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.66,76,,14.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.57,72,,1278.144,Percent of Total Billed Charges,72% of Total Billed Charges,57.89,75,,1331.4,Percent of Total Billed charges,75% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.57,72,,1278.144,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,60,,1065.12,Percent of Total Billed Charges,60% of Total Billed Charges,69.46,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,34.73,45,,26.2,Percent of Total Billed Charges,45% of Total Billed Charges,69.46,90,,16.76,Percent of Total Billed Charges,90% of Total billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.17,65,,18.672,Percent of total Billed Charges,65% of Total Billed Charges,34.04,44.1,,25.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.32,95,,17.696,Percent of Total Billed Charges,95% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.92,88,,16.392,Percent of Total Billed Charges,88% of Total Billed Charges,69.46,90,,16.76,Percent of Total Billed charges,90% of Total Billed Charges,34.04,77.18,
VICRYL 30 SUTURE J 416 H,2720001249,CDM,272,RC,,,Outpatient,,,6.43,4.18,,6.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.89,76,,21.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.63,72,,54.144,Percent of Total Billed Charges,72% of Total Billed Charges,4.82,75,,56.4,Percent of Total Billed charges,75% of Total Billed Charges,6.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.63,72,,54.144,Percent of Total Billed Charges,72% of Total Billed Charges,3.86,60,,45.12,Percent of Total Billed Charges,60% of Total Billed Charges,5.79,90,,35.28,Percent of Total Billed Charges,90% of Total Billed Charges,2.89,45,,1.384,Percent of Total Billed Charges,45% of Total Billed Charges,5.79,90,,25.096,Percent of Total Billed Charges,90% of Total billed Charges,6.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.18,65,,37.84,Percent of total Billed Charges,65% of Total Billed Charges,2.84,44.1,,1.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.11,95,,26.496,Percent of Total Billed Charges,95% of Total Billed Charges,6.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.66,88,,24.544,Percent of Total Billed Charges,88% of Total Billed Charges,5.79,90,,25.096,Percent of Total Billed charges,90% of Total Billed Charges,2.84,6.43,
D STAT DRY PATCH,2720001250,CDM,272,RC,,,Outpatient,,,132.30,86.00,,132.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.55,76,,21.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.26,72,,64.512,Percent of Total Billed Charges,72% of Total Billed Charges,99.23,75,,67.2,Percent of Total Billed charges,75% of Total Billed Charges,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.26,72,,64.512,Percent of Total Billed Charges,72% of Total Billed Charges,79.38,60,,53.76,Percent of Total Billed Charges,60% of Total Billed Charges,119.07,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,59.54,45,,1.368,Percent of Total Billed Charges,45% of Total Billed Charges,119.07,90,,25.856,Percent of Total Billed Charges,90% of Total billed Charges,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,65,,2,Percent of total Billed Charges,65% of Total Billed Charges,58.34,44.1,,1.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.69,95,,27.288,Percent of Total Billed Charges,95% of Total Billed Charges,132.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.42,88,,25.28,Percent of Total Billed Charges,88% of Total Billed Charges,119.07,90,,25.856,Percent of Total Billed charges,90% of Total Billed Charges,58.34,132.3,
TERUM TORQUE DEVICE,2720001251,CDM,272,RC,,,Outpatient,,,28.07,18.25,,28.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21.33,76,,44.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.21,72,,91.584,Percent of Total Billed Charges,72% of Total Billed Charges,21.05,75,,95.4,Percent of Total Billed charges,75% of Total Billed Charges,28.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.21,72,,91.584,Percent of Total Billed Charges,72% of Total Billed Charges,16.84,60,,76.32,Percent of Total Billed Charges,60% of Total Billed Charges,25.26,90,,76.208,Percent of Total Billed Charges,90% of Total Billed Charges,12.63,45,,1.224,Percent of Total Billed Charges,45% of Total Billed Charges,25.26,90,,52.392,Percent of Total Billed Charges,90% of Total billed Charges,28.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.25,65,,1.968,Percent of total Billed Charges,65% of Total Billed Charges,12.38,44.1,,1.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.67,95,,55.304,Percent of Total Billed Charges,95% of Total Billed Charges,28.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.7,88,,51.232,Percent of Total Billed Charges,88% of Total Billed Charges,25.26,90,,52.392,Percent of Total Billed charges,90% of Total Billed Charges,12.38,28.07,
ZOLL PP RADIOLUSCENT,2720001252,CDM,271,RC,,,Outpatient,,,145.95,94.87,,145.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.92,76,,2.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,105.08,72,,76.032,Percent of Total Billed Charges,72% of Total Billed Charges,109.46,75,,79.2,Percent of Total Billed charges,75% of Total Billed Charges,145.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.08,72,,76.032,Percent of Total Billed Charges,72% of Total Billed Charges,87.57,60,,63.36,Percent of Total Billed Charges,60% of Total Billed Charges,131.36,90,,76.208,Percent of Total Billed Charges,90% of Total Billed Charges,65.68,45,,10.432,Percent of Total Billed Charges,45% of Total Billed Charges,131.36,90,,2.768,Percent of Total Billed Charges,90% of Total billed Charges,145.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.87,65,,1.768,Percent of total Billed Charges,65% of Total Billed Charges,64.36,44.1,,10.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,138.65,95,,2.92,Percent of Total Billed Charges,95% of Total Billed Charges,145.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.44,88,,2.704,Percent of Total Billed Charges,88% of Total Billed Charges,131.36,90,,2.768,Percent of Total Billed charges,90% of Total Billed Charges,64.36,145.95,
COOK 20G X 4CM,2720001253,CDM,272,RC,,,Outpatient,,,11.34,7.37,,11.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.62,76,,2.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.16,72,,108.864,Percent of Total Billed Charges,72% of Total Billed Charges,8.51,75,,113.4,Percent of Total Billed charges,75% of Total Billed Charges,11.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.16,72,,108.864,Percent of Total Billed Charges,72% of Total Billed Charges,6.8,60,,90.72,Percent of Total Billed Charges,60% of Total Billed Charges,10.21,90,,370.944,Percent of Total Billed Charges,90% of Total Billed Charges,5.1,45,,13.248,Percent of Total Billed Charges,45% of Total Billed Charges,10.21,90,,2.728,Percent of Total Billed Charges,90% of Total billed Charges,11.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.37,65,,15.064,Percent of total Billed Charges,65% of Total Billed Charges,5,44.1,,12.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.77,95,,2.88,Percent of Total Billed Charges,95% of Total Billed Charges,11.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.98,88,,2.672,Percent of Total Billed Charges,88% of Total Billed Charges,10.21,90,,2.728,Percent of Total Billed charges,90% of Total Billed Charges,5,11.34,
COOK 18G X 5CM ACCESS NEEDLE,2720001254,CDM,272,RC,,,Outpatient,,,11.34,7.37,,11.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.62,76,,2.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.16,72,,8.064,Percent of Total Billed Charges,72% of Total Billed Charges,8.51,75,,8.4,Percent of Total Billed charges,75% of Total Billed Charges,11.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.16,72,,8.064,Percent of Total Billed Charges,72% of Total Billed Charges,6.8,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,10.21,90,,53.184,Percent of Total Billed Charges,90% of Total Billed Charges,5.1,45,,35.72,Percent of Total Billed Charges,45% of Total Billed Charges,10.21,90,,2.448,Percent of Total Billed Charges,90% of Total billed Charges,11.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.37,65,,19.136,Percent of total Billed Charges,65% of Total Billed Charges,5,44.1,,35.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.77,95,,2.584,Percent of Total Billed Charges,95% of Total Billed Charges,11.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.98,88,,2.392,Percent of Total Billed Charges,88% of Total Billed Charges,10.21,90,,2.448,Percent of Total Billed charges,90% of Total Billed Charges,5,11.34,
COOK 18G X 7CM ACCESS NEEDLE,2720001255,CDM,272,RC,,,Outpatient,,,14.68,9.54,,14.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.16,76,,17.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.57,72,,35.136,Percent of Total Billed Charges,72% of Total Billed Charges,11.01,75,,36.6,Percent of Total Billed charges,75% of Total Billed Charges,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.57,72,,35.136,Percent of Total Billed Charges,72% of Total Billed Charges,8.81,60,,29.28,Percent of Total Billed Charges,60% of Total Billed Charges,13.21,90,,27.784,Percent of Total Billed Charges,90% of Total Billed Charges,6.61,45,,9,Percent of Total Billed Charges,45% of Total Billed Charges,13.21,90,,20.856,Percent of Total Billed Charges,90% of Total billed Charges,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.54,65,,51.6,Percent of total Billed Charges,65% of Total Billed Charges,6.47,44.1,,8.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.95,95,,22.016,Percent of Total Billed Charges,95% of Total Billed Charges,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.92,88,,20.392,Percent of Total Billed Charges,88% of Total Billed Charges,13.21,90,,20.856,Percent of Total Billed charges,90% of Total Billed Charges,6.47,14.68,
SPINAL NEEDLE 22G X 7,2720001256,CDM,272,RC,,,Outpatient,,,8.73,5.67,,8.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.63,76,,22.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.29,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,6.55,75,,7.2,Percent of Total Billed charges,75% of Total Billed Charges,8.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.29,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,5.24,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,7.86,90,,208.768,Percent of Total Billed Charges,90% of Total Billed Charges,3.93,45,,17.64,Percent of Total Billed Charges,45% of Total Billed Charges,7.86,90,,26.496,Percent of Total Billed Charges,90% of Total billed Charges,8.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.67,65,,13,Percent of total Billed Charges,65% of Total Billed Charges,3.85,44.1,,17.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.29,95,,27.968,Percent of Total Billed Charges,95% of Total Billed Charges,8.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.68,88,,25.904,Percent of Total Billed Charges,88% of Total Billed Charges,7.86,90,,26.496,Percent of Total Billed charges,90% of Total Billed Charges,3.85,8.73,
COOK 12F 20CM DILATOR,2720001257,CDM,278,RC,C1889,HCPCS,Outpatient,,,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,60.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,129.024,Percent of Total Billed Charges,72% of Total Billed Charges,21.43,72,,134.4,Percent of Total Billed charges,72% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,129.024,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,107.52,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,299.264,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,6.12,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,71.448,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,25.48,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,6,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,75.416,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,69.856,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,71.448,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
COOK 14F 20CM DILATOR,2720001258,CDM,278,RC,C1889,HCPCS,Outpatient,,,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,17.28,Percent of Total Billed Charges,72% of Total Billed Charges,21.43,72,,18,Percent of Total Billed charges,72% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,17.28,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,14.4,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,53.976,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,38.104,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,18,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,8.84,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,37.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,19,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,17.6,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,18,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
COOK 16F 20CM DILATOR,2720001259,CDM,278,RC,C1889,HCPCS,Outpatient,,,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,29.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,17.856,Percent of Total Billed Charges,72% of Total Billed Charges,21.43,72,,18.6,Percent of Total Billed charges,72% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,17.856,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,38.104,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,35.28,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,55.04,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,37.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,37.24,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,34.496,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,35.28,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
COOK 20F 20CM DILATOR,2720001260,CDM,278,RC,C1889,HCPCS,Outpatient,,,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,10.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,18.432,Percent of Total Billed Charges,72% of Total Billed Charges,21.43,72,,19.2,Percent of Total Billed charges,72% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,18.432,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,15.36,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,185.472,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,12.24,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,55.04,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,181.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,12.92,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,11.968,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,12.24,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
COOK 22F 20CM DILATOR,2720001261,CDM,278,RC,C1889,HCPCS,Outpatient,,,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,64.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,35.136,Percent of Total Billed Charges,72% of Total Billed Charges,21.43,72,,36.6,Percent of Total Billed charges,72% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,35.136,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,29.28,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,26.592,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,76.208,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,267.904,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,26.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,80.44,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,74.512,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,76.208,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
COOK 24F 20CM DILATOR,2720001262,CDM,278,RC,C1889,HCPCS,Outpatient,,,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,64.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,35.136,Percent of Total Billed Charges,72% of Total Billed Charges,21.43,72,,36.6,Percent of Total Billed charges,72% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,35.136,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,29.28,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,76.208,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,13.896,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,76.208,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,38.416,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,13.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,80.44,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,74.512,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,76.208,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
MERIT DISPOSAL DEPOT,2720001263,CDM,272,RC,,,Outpatient,,,7.19,4.67,,7.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.46,76,,313.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.18,72,,11.52,Percent of Total Billed Charges,72% of Total Billed Charges,5.39,75,,12,Percent of Total Billed charges,75% of Total Billed Charges,7.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.18,72,,11.52,Percent of Total Billed Charges,72% of Total Billed Charges,4.31,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,6.47,90,,65.096,Percent of Total Billed Charges,90% of Total Billed Charges,3.24,45,,104.384,Percent of Total Billed Charges,45% of Total Billed Charges,6.47,90,,370.944,Percent of Total Billed Charges,90% of Total billed Charges,7.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.67,65,,20.064,Percent of total Billed Charges,65% of Total Billed Charges,3.17,44.1,,102.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.83,95,,391.552,Percent of Total Billed Charges,95% of Total Billed Charges,7.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.33,88,,362.704,Percent of Total Billed Charges,88% of Total Billed Charges,6.47,90,,370.944,Percent of Total Billed charges,90% of Total Billed Charges,3.17,7.19,
SPINAL NEEDLE 20G X 3.5IN,2720001264,CDM,272,RC,,,Outpatient,,,2.27,1.48,,2.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.73,76,,44.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.63,72,,28.8,Percent of Total Billed Charges,72% of Total Billed Charges,1.7,75,,30,Percent of Total Billed charges,75% of Total Billed Charges,2.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.63,72,,28.8,Percent of Total Billed Charges,72% of Total Billed Charges,1.36,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,90,,14.184,Percent of Total Billed Charges,90% of Total Billed Charges,1.02,45,,149.632,Percent of Total Billed Charges,45% of Total Billed Charges,2.04,90,,53.184,Percent of Total Billed Charges,90% of Total billed Charges,2.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.48,65,,150.776,Percent of total Billed Charges,65% of Total Billed Charges,1,44.1,,146.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.16,95,,56.144,Percent of Total Billed Charges,95% of Total Billed Charges,2.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,88,,52.008,Percent of Total Billed Charges,88% of Total Billed Charges,2.04,90,,53.184,Percent of Total Billed charges,90% of Total Billed Charges,1,2.27,
SPINAL NEEDLE 22G X 3.5IN,2720001265,CDM,272,RC,,,Outpatient,,,2.33,1.51,,2.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.77,76,,23.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.68,72,,73.152,Percent of Total Billed Charges,72% of Total Billed Charges,1.75,75,,76.2,Percent of Total Billed charges,75% of Total Billed Charges,2.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.68,72,,73.152,Percent of Total Billed Charges,72% of Total Billed Charges,1.4,60,,60.96,Percent of Total Billed Charges,60% of Total Billed Charges,2.1,90,,84.144,Percent of Total Billed Charges,90% of Total Billed Charges,1.05,45,,26.992,Percent of Total Billed Charges,45% of Total Billed Charges,2.1,90,,27.784,Percent of Total Billed Charges,90% of Total billed Charges,2.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.51,65,,216.136,Percent of total Billed Charges,65% of Total Billed Charges,1.03,44.1,,26.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.21,95,,29.328,Percent of Total Billed Charges,95% of Total Billed Charges,2.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.05,88,,27.168,Percent of Total Billed Charges,88% of Total Billed Charges,2.1,90,,27.784,Percent of Total Billed charges,90% of Total Billed Charges,1.03,2.33,
BIOPATCH 1 INCH DRESSING,2720001266,CDM,272,RC,,,Outpatient,,,14.70,9.56,,14.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.17,76,,176.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.58,72,,46.08,Percent of Total Billed Charges,72% of Total Billed Charges,11.03,75,,48,Percent of Total Billed charges,75% of Total Billed Charges,14.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.58,72,,46.08,Percent of Total Billed Charges,72% of Total Billed Charges,8.82,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,13.23,90,,128.6,Percent of Total Billed Charges,90% of Total Billed Charges,6.62,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,13.23,90,,208.768,Percent of Total Billed Charges,90% of Total billed Charges,14.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.56,65,,38.984,Percent of total Billed Charges,65% of Total Billed Charges,6.48,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.97,95,,220.368,Percent of Total Billed Charges,95% of Total Billed Charges,14.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.94,88,,204.128,Percent of Total Billed Charges,88% of Total Billed Charges,13.23,90,,208.768,Percent of Total Billed charges,90% of Total Billed Charges,6.48,14.7,
KYPHON KEX 152EB,2720001267,CDM,272,RC,,,Outpatient,,,9012.15,5857.90,,9012.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6849.23,76,,252.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6488.75,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,6759.11,75,,54,Percent of Total Billed charges,75% of Total Billed Charges,9012.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6488.75,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,5407.29,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,8110.94,90,,203.216,Percent of Total Billed Charges,90% of Total Billed Charges,4055.47,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,8110.94,90,,299.264,Percent of Total Billed Charges,90% of Total billed Charges,9012.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9012.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9012.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5857.9,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,3974.36,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,8561.54,95,,315.888,Percent of Total Billed Charges,95% of Total Billed Charges,9012.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7930.69,88,,292.608,Percent of Total Billed Charges,88% of Total Billed Charges,8110.94,90,,299.264,Percent of Total Billed charges,90% of Total Billed Charges,3974.36,9012.15,
URETHRAL DILATOR SET,2720001268,CDM,278,RC,C1889,HCPCS,Outpatient,,,738.78,480.21,,738.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,561.47,76,,45.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531.92,72,,21.888,Percent of Total Billed Charges,72% of Total Billed Charges,531.92,72,,22.8,Percent of Total Billed charges,72% of Total Billed Charges,738.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531.92,72,,21.888,Percent of Total Billed Charges,72% of Total Billed Charges,443.27,60,,18.24,Percent of Total Billed Charges,60% of Total Billed Charges,664.9,90,,57.6,Percent of Total Billed Charges,90% of Total Billed Charges,332.45,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,664.9,90,,53.976,Percent of Total Billed Charges,90% of Total billed Charges,738.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,738.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,738.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.21,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,325.8,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,701.84,95,,56.976,Percent of Total Billed Charges,95% of Total Billed Charges,738.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,650.13,88,,52.776,Percent of Total Billed Charges,88% of Total Billed Charges,664.9,90,,53.976,Percent of Total Billed charges,90% of Total Billed Charges,325.8,738.78,
NESTER EMBO COIL 14123.7,2720001269,CDM,278,RC,C1889,HCPCS,Outpatient,,,869.51,565.18,,869.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,660.83,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,626.05,72,,17.28,Percent of Total Billed Charges,72% of Total Billed Charges,626.05,72,,18,Percent of Total Billed charges,72% of Total Billed Charges,869.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,626.05,72,,17.28,Percent of Total Billed Charges,72% of Total Billed Charges,521.71,60,,14.4,Percent of Total Billed Charges,60% of Total Billed Charges,782.56,90,,396,Percent of Total Billed Charges,90% of Total Billed Charges,391.28,45,,38.104,Percent of Total Billed Charges,45% of Total Billed Charges,782.56,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,869.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,869.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,869.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,565.18,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,383.45,44.1,,37.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,826.03,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,869.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,765.17,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,782.56,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,383.45,869.51,
NESTER EMBO COIL 14143.2,2720001270,CDM,278,RC,C1889,HCPCS,Outpatient,,,869.51,565.18,,869.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,660.83,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,626.05,72,,13.248,Percent of Total Billed Charges,72% of Total Billed Charges,626.05,72,,13.8,Percent of Total Billed charges,72% of Total Billed Charges,869.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,626.05,72,,13.248,Percent of Total Billed Charges,72% of Total Billed Charges,521.71,60,,11.04,Percent of Total Billed Charges,60% of Total Billed Charges,782.56,90,,81.36,Percent of Total Billed Charges,90% of Total Billed Charges,391.28,45,,32.544,Percent of Total Billed Charges,45% of Total Billed Charges,782.56,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,869.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,869.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,869.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,565.18,65,,55.04,Percent of total Billed Charges,65% of Total Billed Charges,383.45,44.1,,31.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,826.03,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,869.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,765.17,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,782.56,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,383.45,869.51,
NESTER EMBO COIL 20183.5,2720001271,CDM,278,RC,C1889,HCPCS,Outpatient,,,482.53,313.64,,482.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,366.72,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,347.42,72,,65.088,Percent of Total Billed Charges,72% of Total Billed Charges,347.42,72,,67.8,Percent of Total Billed charges,72% of Total Billed Charges,482.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.42,72,,65.088,Percent of Total Billed Charges,72% of Total Billed Charges,289.52,60,,54.24,Percent of Total Billed Charges,60% of Total Billed Charges,434.28,90,,81.36,Percent of Total Billed Charges,90% of Total Billed Charges,217.14,45,,7.096,Percent of Total Billed Charges,45% of Total Billed Charges,434.28,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,482.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.64,65,,47.016,Percent of total Billed Charges,65% of Total Billed Charges,212.8,44.1,,6.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,458.4,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,482.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.63,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,434.28,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,212.8,482.53,
NESTER EMBO COIL 20203.2,2720001272,CDM,278,RC,C1889,HCPCS,Outpatient,,,482.53,313.64,,482.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,366.72,76,,64.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,347.42,72,,16.128,Percent of Total Billed Charges,72% of Total Billed Charges,347.42,72,,16.8,Percent of Total Billed charges,72% of Total Billed Charges,482.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.42,72,,16.128,Percent of Total Billed Charges,72% of Total Billed Charges,289.52,60,,13.44,Percent of Total Billed Charges,60% of Total Billed Charges,434.28,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,217.14,45,,42.072,Percent of Total Billed Charges,45% of Total Billed Charges,434.28,90,,76.208,Percent of Total Billed Charges,90% of Total billed Charges,482.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.64,65,,10.248,Percent of total Billed Charges,65% of Total Billed Charges,212.8,44.1,,41.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,458.4,95,,80.44,Percent of Total Billed Charges,95% of Total Billed Charges,482.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.63,88,,74.512,Percent of Total Billed Charges,88% of Total Billed Charges,434.28,90,,76.208,Percent of Total Billed charges,90% of Total Billed Charges,212.8,482.53,
HEMOSTAT BAND XXL 37CM (VS),2720001273,CDM,272,RC,,,Outpatient,,,122.85,79.85,,122.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.37,76,,54.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.45,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,92.14,75,,1.2,Percent of Total Billed charges,75% of Total Billed Charges,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.45,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,73.71,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,110.57,90,,81.36,Percent of Total Billed Charges,90% of Total Billed Charges,55.28,45,,64.296,Percent of Total Billed Charges,45% of Total Billed Charges,110.57,90,,65.096,Percent of Total Billed Charges,90% of Total billed Charges,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.85,65,,60.776,Percent of total Billed Charges,65% of Total Billed Charges,54.18,44.1,,63.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.71,95,,68.712,Percent of Total Billed Charges,95% of Total Billed Charges,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.11,88,,63.648,Percent of Total Billed Charges,88% of Total Billed Charges,110.57,90,,65.096,Percent of Total Billed charges,90% of Total Billed Charges,54.18,122.85,
HEMOSTAT BAND XL 29CM (VS),2720001274,CDM,272,RC,,,Outpatient,,,122.85,79.85,,122.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.37,76,,11.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.45,72,,30.528,Percent of Total Billed Charges,72% of Total Billed Charges,92.14,75,,31.8,Percent of Total Billed charges,75% of Total Billed Charges,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.45,72,,30.528,Percent of Total Billed Charges,72% of Total Billed Charges,73.71,60,,25.44,Percent of Total Billed Charges,60% of Total Billed Charges,110.57,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,55.28,45,,101.608,Percent of Total Billed Charges,45% of Total Billed Charges,110.57,90,,14.184,Percent of Total Billed Charges,90% of Total billed Charges,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.85,65,,92.88,Percent of total Billed Charges,65% of Total Billed Charges,54.18,44.1,,99.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.71,95,,14.976,Percent of Total Billed Charges,95% of Total Billed Charges,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.11,88,,13.872,Percent of Total Billed Charges,88% of Total Billed Charges,110.57,90,,14.184,Percent of Total Billed charges,90% of Total Billed Charges,54.18,122.85,
HEMOSTAT BAND LONG 27CM (VS),2720001275,CDM,272,RC,,,Outpatient,,,122.85,79.85,,122.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.37,76,,71.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.45,72,,222.336,Percent of Total Billed Charges,72% of Total Billed Charges,92.14,75,,231.6,Percent of Total Billed charges,75% of Total Billed Charges,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.45,72,,222.336,Percent of Total Billed Charges,72% of Total Billed Charges,73.71,60,,185.28,Percent of Total Billed Charges,60% of Total Billed Charges,110.57,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,55.28,45,,28.8,Percent of Total Billed Charges,45% of Total Billed Charges,110.57,90,,84.144,Percent of Total Billed Charges,90% of Total billed Charges,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.85,65,,146.768,Percent of total Billed Charges,65% of Total Billed Charges,54.18,44.1,,28.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.71,95,,88.824,Percent of Total Billed Charges,95% of Total Billed Charges,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.11,88,,82.28,Percent of Total Billed Charges,88% of Total Billed Charges,110.57,90,,84.144,Percent of Total Billed charges,90% of Total Billed Charges,54.18,122.85,
HEMOSTAT BAND REG 24CM (VS),2720001276,CDM,272,RC,,,Outpatient,,,122.85,79.85,,122.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.37,76,,108.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.45,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,92.14,75,,1.2,Percent of Total Billed charges,75% of Total Billed Charges,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.45,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,73.71,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,110.57,90,,277.2,Percent of Total Billed Charges,90% of Total Billed Charges,55.28,45,,198,Percent of Total Billed Charges,45% of Total Billed Charges,110.57,90,,128.6,Percent of Total Billed Charges,90% of Total billed Charges,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.85,65,,41.6,Percent of total Billed Charges,65% of Total Billed Charges,54.18,44.1,,194.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.71,95,,135.744,Percent of Total Billed Charges,95% of Total Billed Charges,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.11,88,,125.744,Percent of Total Billed Charges,88% of Total Billed Charges,110.57,90,,128.6,Percent of Total Billed charges,90% of Total Billed Charges,54.18,122.85,
HEMOSTAT BAND SHORT 21CM (VS),2720001277,CDM,272,RC,,,Outpatient,,,122.85,79.85,,122.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.37,76,,171.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.45,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,92.14,75,,3,Percent of Total Billed charges,75% of Total Billed Charges,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.45,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,73.71,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,110.57,90,,277.2,Percent of Total Billed Charges,90% of Total Billed Charges,55.28,45,,40.68,Percent of Total Billed Charges,45% of Total Billed Charges,110.57,90,,203.216,Percent of Total Billed Charges,90% of Total billed Charges,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.85,65,,286,Percent of total Billed Charges,65% of Total Billed Charges,54.18,44.1,,39.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.71,95,,214.504,Percent of Total Billed Charges,95% of Total Billed Charges,122.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.11,88,,198.696,Percent of Total Billed Charges,88% of Total Billed Charges,110.57,90,,203.216,Percent of Total Billed charges,90% of Total Billed Charges,54.18,122.85,
NESTER EMBO/COIL 1832 (.018),2720001278,CDM,278,RC,C1889,HCPCS,Outpatient,,,373.10,242.52,,373.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,283.56,76,,48.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,268.63,72,,311.616,Percent of Total Billed Charges,72% of Total Billed Charges,268.63,72,,324.6,Percent of Total Billed charges,72% of Total Billed Charges,373.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.63,72,,311.616,Percent of Total Billed Charges,72% of Total Billed Charges,223.86,60,,259.68,Percent of Total Billed Charges,60% of Total Billed Charges,335.79,90,,64.8,Percent of Total Billed Charges,90% of Total Billed Charges,167.9,45,,40.68,Percent of Total Billed Charges,45% of Total Billed Charges,335.79,90,,57.6,Percent of Total Billed Charges,90% of Total billed Charges,373.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.52,65,,58.76,Percent of total Billed Charges,65% of Total Billed Charges,164.54,44.1,,39.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,354.45,95,,60.8,Percent of Total Billed Charges,95% of Total Billed Charges,373.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.33,88,,56.32,Percent of Total Billed Charges,88% of Total Billed Charges,335.79,90,,57.6,Percent of Total Billed charges,90% of Total Billed Charges,164.54,373.1,
HILAL 180.50 (.018),2720001279,CDM,278,RC,C1889,HCPCS,Outpatient,,,323.05,209.98,,323.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,245.52,76,,334.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,232.6,72,,87.552,Percent of Total Billed Charges,72% of Total Billed Charges,232.6,72,,91.2,Percent of Total Billed charges,72% of Total Billed Charges,323.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.6,72,,87.552,Percent of Total Billed Charges,72% of Total Billed Charges,193.83,60,,72.96,Percent of Total Billed Charges,60% of Total Billed Charges,290.75,90,,57.6,Percent of Total Billed Charges,90% of Total Billed Charges,145.37,45,,9,Percent of Total Billed Charges,45% of Total Billed Charges,290.75,90,,396,Percent of Total Billed Charges,90% of Total billed Charges,323.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.98,65,,58.76,Percent of total Billed Charges,65% of Total Billed Charges,142.47,44.1,,8.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,306.9,95,,418,Percent of Total Billed Charges,95% of Total Billed Charges,323.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.28,88,,387.2,Percent of Total Billed Charges,88% of Total Billed Charges,290.75,90,,396,Percent of Total Billed charges,90% of Total Billed Charges,142.47,323.05,
HILAL 181.00 (.018),2720001280,CDM,278,RC,C1889,HCPCS,Outpatient,,,323.05,209.98,,323.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,245.52,76,,68.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,232.6,72,,4261.12,Percent of Total Billed Charges,72% of Total Billed Charges,232.6,72,,4438.672,Percent of Total Billed charges,72% of Total Billed Charges,323.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.6,72,,4261.12,Percent of Total Billed Charges,72% of Total Billed Charges,193.83,60,,3550.936,Percent of Total Billed Charges,60% of Total Billed Charges,290.75,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,145.37,45,,40.68,Percent of Total Billed Charges,45% of Total Billed Charges,290.75,90,,81.36,Percent of Total Billed Charges,90% of Total billed Charges,323.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.98,65,,13,Percent of total Billed Charges,65% of Total Billed Charges,142.47,44.1,,39.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,306.9,95,,85.88,Percent of Total Billed Charges,95% of Total Billed Charges,323.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.28,88,,79.552,Percent of Total Billed Charges,88% of Total Billed Charges,290.75,90,,81.36,Percent of Total Billed charges,90% of Total Billed Charges,142.47,323.05,
JACKSON PRATT,2720001281,CDM,272,RC,,,Outpatient,,,67.00,43.55,,67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,50.92,76,,68.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,48.24,72,,4261.12,Percent of Total Billed Charges,72% of Total Billed Charges,50.25,75,,4438.672,Percent of Total Billed charges,75% of Total Billed Charges,67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.24,72,,4261.12,Percent of Total Billed Charges,72% of Total Billed Charges,40.2,60,,3550.936,Percent of Total Billed Charges,60% of Total Billed Charges,60.3,90,,54,Percent of Total Billed Charges,90% of Total Billed Charges,30.15,45,,9,Percent of Total Billed Charges,45% of Total Billed Charges,60.3,90,,81.36,Percent of Total Billed Charges,90% of Total billed Charges,67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.55,65,,58.76,Percent of total Billed Charges,65% of Total Billed Charges,29.55,44.1,,8.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,63.65,95,,85.88,Percent of Total Billed Charges,95% of Total Billed Charges,67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.96,88,,79.552,Percent of Total Billed Charges,88% of Total Billed Charges,60.3,90,,81.36,Percent of Total Billed charges,90% of Total Billed Charges,29.55,67,
FEMOSTOP GOLD,2720001282,CDM,272,RC,,,Outpatient,,,270.00,175.50,,270,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,205.2,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,194.4,72,,4261.12,Percent of Total Billed Charges,72% of Total Billed Charges,202.5,75,,4438.672,Percent of Total Billed charges,75% of Total Billed Charges,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.4,72,,4261.12,Percent of Total Billed Charges,72% of Total Billed Charges,162,60,,3550.936,Percent of Total Billed Charges,60% of Total Billed Charges,243,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,121.5,45,,9,Percent of Total Billed Charges,45% of Total Billed Charges,243,90,,18,Percent of Total Billed Charges,90% of Total billed Charges,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.5,65,,13,Percent of total Billed Charges,65% of Total Billed Charges,119.07,44.1,,8.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,256.5,95,,19,Percent of Total Billed Charges,95% of Total Billed Charges,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.6,88,,17.6,Percent of Total Billed Charges,88% of Total Billed Charges,243,90,,18,Percent of Total Billed charges,90% of Total Billed Charges,119.07,270,
YUEH NEEDLE 5FX15CM,2720001283,CDM,272,RC,,,Outpatient,,,87.00,56.55,,87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.12,76,,68.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.64,72,,4261.12,Percent of Total Billed Charges,72% of Total Billed Charges,65.25,75,,4438.672,Percent of Total Billed charges,75% of Total Billed Charges,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.64,72,,4261.12,Percent of Total Billed Charges,72% of Total Billed Charges,52.2,60,,3550.936,Percent of Total Billed Charges,60% of Total Billed Charges,78.3,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,39.15,45,,138.6,Percent of Total Billed Charges,45% of Total Billed Charges,78.3,90,,81.36,Percent of Total Billed Charges,90% of Total billed Charges,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.55,65,,13,Percent of total Billed Charges,65% of Total Billed Charges,38.37,44.1,,135.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.65,95,,85.88,Percent of Total Billed Charges,95% of Total Billed Charges,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.56,88,,79.552,Percent of Total Billed Charges,88% of Total Billed Charges,78.3,90,,81.36,Percent of Total Billed charges,90% of Total Billed Charges,38.37,87,
YUEH (THORA) NEEDLE 5FX10CM,2720001284,CDM,272,RC,,,Outpatient,,,86.76,56.39,,86.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,65.94,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.47,72,,4261.12,Percent of Total Billed Charges,72% of Total Billed Charges,65.07,75,,4438.672,Percent of Total Billed charges,75% of Total Billed Charges,86.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.47,72,,4261.12,Percent of Total Billed Charges,72% of Total Billed Charges,52.06,60,,3550.936,Percent of Total Billed Charges,60% of Total Billed Charges,78.08,90,,1597.68,Percent of Total Billed Charges,90% of Total Billed Charges,39.04,45,,138.6,Percent of Total Billed Charges,45% of Total Billed Charges,78.08,90,,18,Percent of Total Billed Charges,90% of Total billed Charges,86.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.39,65,,200.2,Percent of total Billed Charges,65% of Total Billed Charges,38.26,44.1,,135.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.42,95,,19,Percent of Total Billed Charges,95% of Total Billed Charges,86.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.35,88,,17.6,Percent of Total Billed Charges,88% of Total Billed Charges,78.08,90,,18,Percent of Total Billed charges,90% of Total Billed Charges,38.26,86.76,
NESTER MICROCOIL 1833,2720001285,CDM,278,RC,C1889,HCPCS,Outpatient,,,313.95,204.07,,313.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,238.6,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,226.04,72,,4261.12,Percent of Total Billed Charges,72% of Total Billed Charges,226.04,72,,4438.672,Percent of Total Billed charges,72% of Total Billed Charges,313.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.04,72,,4261.12,Percent of Total Billed Charges,72% of Total Billed Charges,188.37,60,,3550.936,Percent of Total Billed Charges,60% of Total Billed Charges,282.56,90,,136.8,Percent of Total Billed Charges,90% of Total Billed Charges,141.28,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,282.56,90,,18,Percent of Total Billed Charges,90% of Total billed Charges,313.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.07,65,,200.2,Percent of total Billed Charges,65% of Total Billed Charges,138.45,44.1,,31.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,298.25,95,,19,Percent of Total Billed Charges,95% of Total Billed Charges,313.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.28,88,,17.6,Percent of Total Billed Charges,88% of Total Billed Charges,282.56,90,,18,Percent of Total Billed charges,90% of Total Billed Charges,138.45,313.95,
THORA/PARA: PARACENTESIS TRAY,2720001286,CDM,272,RC,,,Outpatient,,,135.03,87.77,,135.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,102.62,76,,234.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,97.22,72,,4261.12,Percent of Total Billed Charges,72% of Total Billed Charges,101.27,75,,4438.672,Percent of Total Billed charges,75% of Total Billed Charges,135.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.22,72,,4261.12,Percent of Total Billed Charges,72% of Total Billed Charges,81.02,60,,3550.936,Percent of Total Billed Charges,60% of Total Billed Charges,121.53,90,,91.44,Percent of Total Billed Charges,90% of Total Billed Charges,60.76,45,,28.8,Percent of Total Billed Charges,45% of Total Billed Charges,121.53,90,,277.2,Percent of Total Billed Charges,90% of Total billed Charges,135.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.77,65,,46.8,Percent of total Billed Charges,65% of Total Billed Charges,59.55,44.1,,28.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,128.28,95,,292.6,Percent of Total Billed Charges,95% of Total Billed Charges,135.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.83,88,,271.04,Percent of Total Billed Charges,88% of Total Billed Charges,121.53,90,,277.2,Percent of Total Billed charges,90% of Total Billed Charges,59.55,135.03,
CANISTER GUARDIAN LVC 12L,2720001287,CDM,272,RC,,,Outpatient,,,83.82,54.48,,83.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,63.7,76,,234.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,60.35,72,,4261.12,Percent of Total Billed Charges,72% of Total Billed Charges,62.87,75,,4438.672,Percent of Total Billed charges,75% of Total Billed Charges,83.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.35,72,,4261.12,Percent of Total Billed Charges,72% of Total Billed Charges,50.29,60,,3550.936,Percent of Total Billed Charges,60% of Total Billed Charges,75.44,90,,1.296,Percent of Total Billed Charges,90% of Total Billed Charges,37.72,45,,13.68,Percent of Total Billed Charges,45% of Total Billed Charges,75.44,90,,277.2,Percent of Total Billed Charges,90% of Total billed Charges,83.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.48,65,,41.6,Percent of total Billed Charges,65% of Total Billed Charges,36.96,44.1,,13.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,79.63,95,,292.6,Percent of Total Billed Charges,95% of Total Billed Charges,83.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.76,88,,271.04,Percent of Total Billed Charges,88% of Total Billed Charges,75.44,90,,277.2,Percent of Total Billed charges,90% of Total Billed Charges,36.96,83.82,
ETHILON 20 664H,2720001288,CDM,272,RC,,,Outpatient,,,15.73,10.22,,15.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.95,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.33,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,11.8,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,15.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.33,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,9.44,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,14.16,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,7.08,45,,27,Percent of Total Billed Charges,45% of Total Billed Charges,14.16,90,,64.8,Percent of Total Billed Charges,90% of Total billed Charges,15.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.22,65,,19.76,Percent of total Billed Charges,65% of Total Billed Charges,6.94,44.1,,26.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.94,95,,68.4,Percent of Total Billed Charges,95% of Total Billed Charges,15.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.84,88,,63.36,Percent of Total Billed Charges,88% of Total Billed Charges,14.16,90,,64.8,Percent of Total Billed charges,90% of Total Billed Charges,6.94,15.73,
TUBING PCA,2720001290,CDM,272,RC,,,Outpatient,,,33.68,21.89,,33.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.6,76,,48.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.25,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,25.26,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,33.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,20.21,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,30.31,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,15.16,45,,1.8,Percent of Total Billed Charges,45% of Total Billed Charges,30.31,90,,57.6,Percent of Total Billed Charges,90% of Total billed Charges,33.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.89,65,,39,Percent of total Billed Charges,65% of Total Billed Charges,14.85,44.1,,1.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,32,95,,60.8,Percent of Total Billed Charges,95% of Total Billed Charges,33.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.64,88,,56.32,Percent of Total Billed Charges,88% of Total Billed Charges,30.31,90,,57.6,Percent of Total Billed charges,90% of Total Billed Charges,14.85,33.68,
CHEST DRAIN PLEUR EVAC OASIS,2720001291,CDM,272,RC,,,Outpatient,,,133.11,86.52,,133.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,101.16,76,,23.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.84,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,99.83,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,133.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.84,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,79.87,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,119.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,59.9,45,,4.68,Percent of Total Billed Charges,45% of Total Billed Charges,119.8,90,,27.36,Percent of Total Billed Charges,90% of Total billed Charges,133.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.52,65,,2.6,Percent of total Billed Charges,65% of Total Billed Charges,58.7,44.1,,4.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,126.45,95,,28.88,Percent of Total Billed Charges,95% of Total Billed Charges,133.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.14,88,,26.752,Percent of Total Billed Charges,88% of Total Billed Charges,119.8,90,,27.36,Percent of Total Billed charges,90% of Total Billed Charges,58.7,133.11,
FOLEY CATH TRAY 14F (2600658),2720001292,CDM,272,RC,,,Outpatient,,,33.98,22.09,,33.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.82,76,,45.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.47,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,25.49,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,33.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.47,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,20.39,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,30.58,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,15.29,45,,798.84,Percent of Total Billed Charges,45% of Total Billed Charges,30.58,90,,54,Percent of Total Billed Charges,90% of Total billed Charges,33.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.09,65,,6.76,Percent of total Billed Charges,65% of Total Billed Charges,14.99,44.1,,782.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.28,95,,57,Percent of Total Billed Charges,95% of Total Billed Charges,33.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.9,88,,52.8,Percent of Total Billed Charges,88% of Total Billed Charges,30.58,90,,54,Percent of Total Billed charges,90% of Total Billed Charges,14.99,33.98,
FOLEY CATH 14F (#1196),2720001293,CDM,272,RC,,,Outpatient,,,24.00,15.60,,24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.24,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.28,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,18,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.28,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,14.4,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,21.6,90,,2.72,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,45,,68.4,Percent of Total Billed Charges,45% of Total Billed Charges,21.6,90,,3.6,Percent of Total Billed Charges,90% of Total billed Charges,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.6,65,,1153.88,Percent of total Billed Charges,65% of Total Billed Charges,10.58,44.1,,67.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.8,95,,3.8,Percent of Total Billed Charges,95% of Total Billed Charges,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.12,88,,3.52,Percent of Total Billed Charges,88% of Total Billed Charges,21.6,90,,3.6,Percent of Total Billed charges,90% of Total Billed Charges,10.58,24,
FOLEY CATH 16F (#1197),2720001294,CDM,272,RC,,,Outpatient,,,24.00,15.60,,24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.24,76,,7.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.28,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,18,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.28,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,14.4,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,21.6,90,,2.72,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,45,,45.72,Percent of Total Billed Charges,45% of Total Billed Charges,21.6,90,,9.36,Percent of Total Billed Charges,90% of Total billed Charges,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.6,65,,98.8,Percent of total Billed Charges,65% of Total Billed Charges,10.58,44.1,,44.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.8,95,,9.88,Percent of Total Billed Charges,95% of Total Billed Charges,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.12,88,,9.152,Percent of Total Billed Charges,88% of Total Billed Charges,21.6,90,,9.36,Percent of Total Billed charges,90% of Total Billed Charges,10.58,24,
FOLEY CATH 18F (#1198),2720001295,CDM,272,RC,,,Outpatient,,,24.00,15.60,,24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.24,76,,1349.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.28,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,18,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.28,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,14.4,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,21.6,90,,6.576,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,45,,0.648,Percent of Total Billed Charges,45% of Total Billed Charges,21.6,90,,1597.68,Percent of Total Billed Charges,90% of Total billed Charges,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.6,65,,66.04,Percent of total Billed Charges,65% of Total Billed Charges,10.58,44.1,,0.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.8,95,,1686.44,Percent of Total Billed Charges,95% of Total Billed Charges,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.12,88,,1562.176,Percent of Total Billed Charges,88% of Total Billed Charges,21.6,90,,1597.68,Percent of Total Billed charges,90% of Total Billed Charges,10.58,24,
FOLEY URINE BAG (#1703057),2720001296,CDM,272,RC,,,Outpatient,,,38.40,24.96,,38.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.18,76,,115.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.65,72,,104.784,Percent of Total Billed Charges,72% of Total Billed Charges,28.8,75,,109.144,Percent of Total Billed charges,75% of Total Billed Charges,38.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.65,72,,104.784,Percent of Total Billed Charges,72% of Total Billed Charges,23.04,60,,87.32,Percent of Total Billed Charges,60% of Total Billed Charges,34.56,90,,1.248,Percent of Total Billed Charges,90% of Total Billed Charges,17.28,45,,10.8,Percent of Total Billed Charges,45% of Total Billed Charges,34.56,90,,136.8,Percent of Total Billed Charges,90% of Total billed Charges,38.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.96,65,,0.936,Percent of total Billed Charges,65% of Total Billed Charges,16.93,44.1,,10.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.48,95,,144.4,Percent of Total Billed Charges,95% of Total Billed Charges,38.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.79,88,,133.76,Percent of Total Billed Charges,88% of Total Billed Charges,34.56,90,,136.8,Percent of Total Billed charges,90% of Total Billed Charges,16.93,38.4,
CYSTO TUBING,2720001297,CDM,272,RC,,,Outpatient,,,30.16,19.60,,30.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.92,76,,77.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.72,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,22.62,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,30.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.72,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,18.1,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,27.14,90,,7.728,Percent of Total Billed Charges,90% of Total Billed Charges,13.57,45,,3.24,Percent of Total Billed Charges,45% of Total Billed Charges,27.14,90,,91.44,Percent of Total Billed Charges,90% of Total billed Charges,30.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.6,65,,15.6,Percent of total Billed Charges,65% of Total Billed Charges,13.3,44.1,,3.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.65,95,,96.52,Percent of Total Billed Charges,95% of Total Billed Charges,30.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.54,88,,89.408,Percent of Total Billed Charges,88% of Total Billed Charges,27.14,90,,91.44,Percent of Total Billed charges,90% of Total Billed Charges,13.3,30.16,
16F 3WAY FOLEY CATH LATEX FREE,2720001298,CDM,272,RC,,,Outpatient,,,87.42,56.82,,87.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.44,76,,1.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.94,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,65.57,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,87.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.94,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,52.45,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,78.68,90,,8.928,Percent of Total Billed Charges,90% of Total Billed Charges,39.34,45,,11.52,Percent of Total Billed Charges,45% of Total Billed Charges,78.68,90,,1.296,Percent of Total Billed Charges,90% of Total billed Charges,87.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.82,65,,4.68,Percent of total Billed Charges,65% of Total Billed Charges,38.55,44.1,,11.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.05,95,,1.368,Percent of Total Billed Charges,95% of Total Billed Charges,87.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.93,88,,1.264,Percent of Total Billed Charges,88% of Total Billed Charges,78.68,90,,1.296,Percent of Total Billed charges,90% of Total Billed Charges,38.55,87.42,
16F 3WAY 5CC FOLEY CATH,2720001299,CDM,272,RC,,,Outpatient,,,60.37,39.24,,60.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.88,76,,18.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.47,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,45.28,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,60.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.47,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,36.22,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,54.33,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,27.17,45,,0.72,Percent of Total Billed Charges,45% of Total Billed Charges,54.33,90,,21.6,Percent of Total Billed Charges,90% of Total billed Charges,60.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.24,65,,16.64,Percent of total Billed Charges,65% of Total Billed Charges,26.62,44.1,,0.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.35,95,,22.8,Percent of Total Billed Charges,95% of Total Billed Charges,60.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.13,88,,21.12,Percent of Total Billed Charges,88% of Total Billed Charges,54.33,90,,21.6,Percent of Total Billed charges,90% of Total Billed Charges,26.62,60.37,
HUBER NEEDLE,2720001300,CDM,272,RC,,,Outpatient,,,36.00,23.40,,36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.36,76,,5.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.92,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,27,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.92,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,21.6,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,32.4,90,,2.416,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,45,,1.36,Percent of Total Billed Charges,45% of Total Billed Charges,32.4,90,,6.48,Percent of Total Billed Charges,90% of Total billed Charges,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.4,65,,1.04,Percent of total Billed Charges,65% of Total Billed Charges,15.88,44.1,,1.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.2,95,,6.84,Percent of Total Billed Charges,95% of Total Billed Charges,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.68,88,,6.336,Percent of Total Billed Charges,88% of Total Billed Charges,32.4,90,,6.48,Percent of Total Billed charges,90% of Total Billed Charges,15.88,36,
LOR SYRINGE 5ML GLASS,2720001301,CDM,272,RC,,,Outpatient,,,84.46,54.90,,84.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,64.19,76,,19.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,60.81,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,63.35,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,84.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.81,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,50.68,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,76.01,90,,6.576,Percent of Total Billed Charges,90% of Total Billed Charges,38.01,45,,1.36,Percent of Total Billed Charges,45% of Total Billed Charges,76.01,90,,23.04,Percent of Total Billed Charges,90% of Total billed Charges,84.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.9,65,,1.968,Percent of total Billed Charges,65% of Total Billed Charges,37.25,44.1,,1.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,80.24,95,,24.32,Percent of Total Billed Charges,95% of Total Billed Charges,84.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.32,88,,22.528,Percent of Total Billed Charges,88% of Total Billed Charges,76.01,90,,23.04,Percent of Total Billed charges,90% of Total Billed Charges,37.25,84.46,
DILATOR 10F X 20CM,2720001303,CDM,272,RC,,,Outpatient,,,89.31,58.05,,89.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.88,76,,1.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.3,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,66.98,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,89.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.3,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,53.59,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,80.38,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,40.19,45,,3.288,Percent of Total Billed Charges,45% of Total Billed Charges,80.38,90,,1.44,Percent of Total Billed Charges,90% of Total billed Charges,89.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.05,65,,1.968,Percent of total Billed Charges,65% of Total Billed Charges,39.39,44.1,,3.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,84.84,95,,1.52,Percent of Total Billed Charges,95% of Total Billed Charges,89.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.59,88,,1.408,Percent of Total Billed Charges,88% of Total Billed Charges,80.38,90,,1.44,Percent of Total Billed charges,90% of Total Billed Charges,39.39,89.31,
COOK DILATOR 10F X 20CM,2720001304,CDM,272,RC,,,Outpatient,,,89.31,58.05,,89.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.88,76,,2.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.3,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,66.98,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,89.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.3,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,53.59,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,80.38,90,,4.056,Percent of Total Billed Charges,90% of Total Billed Charges,40.19,45,,0.624,Percent of Total Billed Charges,45% of Total Billed Charges,80.38,90,,2.72,Percent of Total Billed Charges,90% of Total billed Charges,89.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.05,65,,4.744,Percent of total Billed Charges,65% of Total Billed Charges,39.39,44.1,,0.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,84.84,95,,2.872,Percent of Total Billed Charges,95% of Total Billed Charges,89.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.59,88,,2.664,Percent of Total Billed Charges,88% of Total Billed Charges,80.38,90,,2.72,Percent of Total Billed charges,90% of Total Billed Charges,39.39,89.31,
CATH PLEURX 7000B (2217),2720001305,CDM,272,RC,,,Outpatient,,,3000.00,1950.00,,3000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2280,76,,2.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2160,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,2250,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,3000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2160,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,1800,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,2700,90,,4.128,Percent of Total Billed Charges,90% of Total Billed Charges,1350,45,,3.864,Percent of Total Billed Charges,45% of Total Billed Charges,2700,90,,2.72,Percent of Total Billed Charges,90% of Total billed Charges,3000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1950,65,,0.896,Percent of total Billed Charges,65% of Total Billed Charges,1323,44.1,,3.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,2850,95,,2.872,Percent of Total Billed Charges,95% of Total Billed Charges,3000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2640,88,,2.664,Percent of Total Billed Charges,88% of Total Billed Charges,2700,90,,2.72,Percent of Total Billed charges,90% of Total Billed Charges,1323,3000,
PLEURX BOTTLE WITH CONNECTOR,2720001306,CDM,272,RC,,,Outpatient,,,148.00,96.20,,148,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,112.48,76,,5.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,106.56,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,111,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,148,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.56,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,88.8,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,133.2,90,,6.576,Percent of Total Billed Charges,90% of Total Billed Charges,66.6,45,,4.464,Percent of Total Billed Charges,45% of Total Billed Charges,133.2,90,,6.576,Percent of Total Billed Charges,90% of Total billed Charges,148,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.2,65,,5.576,Percent of total Billed Charges,65% of Total Billed Charges,65.27,44.1,,4.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,140.6,95,,6.936,Percent of Total Billed Charges,95% of Total Billed Charges,148,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.24,88,,6.424,Percent of Total Billed Charges,88% of Total Billed Charges,133.2,90,,6.576,Percent of Total Billed charges,90% of Total Billed Charges,65.27,148,
COAX INTRO NEEDLE 13G X 5.1CM,2720001307,CDM,272,RC,,,Outpatient,,,36.00,23.40,,36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.36,76,,1.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.92,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,27,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.92,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,21.6,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,32.4,90,,2.312,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,45,,1.8,Percent of Total Billed Charges,45% of Total Billed Charges,32.4,90,,1.248,Percent of Total Billed Charges,90% of Total billed Charges,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.4,65,,6.448,Percent of total Billed Charges,65% of Total Billed Charges,15.88,44.1,,1.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.2,95,,1.312,Percent of Total Billed Charges,95% of Total Billed Charges,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.68,88,,1.216,Percent of Total Billed Charges,88% of Total Billed Charges,32.4,90,,1.248,Percent of Total Billed charges,90% of Total Billed Charges,15.88,36,
TRU CORE II 14G X 10CM,2720001308,CDM,272,RC,,,Outpatient,,,85.00,55.25,,85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,64.6,76,,6.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.2,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,63.75,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.2,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,51,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,76.5,90,,12.008,Percent of Total Billed Charges,90% of Total Billed Charges,38.25,45,,1.208,Percent of Total Billed Charges,45% of Total Billed Charges,76.5,90,,7.728,Percent of Total Billed Charges,90% of Total billed Charges,85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.25,65,,2.6,Percent of total Billed Charges,65% of Total Billed Charges,37.49,44.1,,1.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,80.75,95,,8.152,Percent of Total Billed Charges,95% of Total Billed Charges,85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.8,88,,7.552,Percent of Total Billed Charges,88% of Total Billed Charges,76.5,90,,7.728,Percent of Total Billed charges,90% of Total Billed Charges,37.49,85,
SET EXT 6 INCH TUBING,2720001309,CDM,272,RC,,,Outpatient,,,16.00,10.40,,16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.16,76,,7.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.52,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,12,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.52,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,9.6,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,14.4,90,,6.776,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,45,,3.288,Percent of Total Billed Charges,45% of Total Billed Charges,14.4,90,,8.928,Percent of Total Billed Charges,90% of Total billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,65,,1.744,Percent of total Billed Charges,65% of Total Billed Charges,7.06,44.1,,3.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.2,95,,9.424,Percent of Total Billed Charges,95% of Total Billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.08,88,,8.728,Percent of Total Billed Charges,88% of Total Billed Charges,14.4,90,,8.928,Percent of Total Billed charges,90% of Total Billed Charges,7.06,16,
V MARK BBX MARKER 15G X 10.8CM,2720001310,CDM,272,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,112.5,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,0.256,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,2.16,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,3.6,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,4.744,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,2.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,3.8,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,3.52,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,3.6,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
YUEH NEEDLE 5F X 7CM (G09489),2720001311,CDM,272,RC,,,Outpatient,,,65.00,42.25,,65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.4,76,,2.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.8,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,48.75,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.8,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,39,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,58.5,90,,9.544,Percent of Total Billed Charges,90% of Total Billed Charges,29.25,45,,2.024,Percent of Total Billed Charges,45% of Total Billed Charges,58.5,90,,2.416,Percent of Total Billed Charges,90% of Total billed Charges,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.25,65,,3.12,Percent of total Billed Charges,65% of Total Billed Charges,28.67,44.1,,1.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,61.75,95,,2.544,Percent of Total Billed Charges,95% of Total Billed Charges,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.2,88,,2.36,Percent of Total Billed Charges,88% of Total Billed Charges,58.5,90,,2.416,Percent of Total Billed charges,90% of Total Billed Charges,28.67,65,
TUOHY NEEDLE 17G X 4.5 PERIFIX,2720001312,CDM,272,RC,,,Outpatient,,,38.32,24.91,,38.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.12,76,,5.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.59,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,28.74,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,38.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.59,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,22.99,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,34.49,90,,8.952,Percent of Total Billed Charges,90% of Total Billed Charges,17.24,45,,2.064,Percent of Total Billed Charges,45% of Total Billed Charges,34.49,90,,6.576,Percent of Total Billed Charges,90% of Total billed Charges,38.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.91,65,,2.928,Percent of total Billed Charges,65% of Total Billed Charges,16.9,44.1,,2.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.4,95,,6.936,Percent of Total Billed Charges,95% of Total Billed Charges,38.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.72,88,,6.424,Percent of Total Billed Charges,88% of Total Billed Charges,34.49,90,,6.576,Percent of Total Billed charges,90% of Total Billed Charges,16.9,38.32,
TUOHY NEEDLE 17G X 6 PERIFIX,2720001313,CDM,272,RC,,,Outpatient,,,38.32,24.91,,38.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.12,76,,3.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.59,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,28.74,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,38.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.59,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,22.99,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,34.49,90,,46.392,Percent of Total Billed Charges,90% of Total Billed Charges,17.24,45,,3.288,Percent of Total Billed Charges,45% of Total Billed Charges,34.49,90,,4.32,Percent of Total Billed Charges,90% of Total billed Charges,38.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.91,65,,2.976,Percent of total Billed Charges,65% of Total Billed Charges,16.9,44.1,,3.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.4,95,,4.56,Percent of Total Billed Charges,95% of Total Billed Charges,38.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.72,88,,4.224,Percent of Total Billed Charges,88% of Total Billed Charges,34.49,90,,4.32,Percent of Total Billed charges,90% of Total Billed Charges,16.9,38.32,
DILATOR 10F X 20CM (COOK),2720001314,CDM,272,RC,,,Outpatient,,,98.61,64.10,,98.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,74.94,76,,3.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,73.96,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,98.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,59.17,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,88.75,90,,8.952,Percent of Total Billed Charges,90% of Total Billed Charges,44.37,45,,1.152,Percent of Total Billed Charges,45% of Total Billed Charges,88.75,90,,4.056,Percent of Total Billed Charges,90% of Total billed Charges,98.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.1,65,,4.744,Percent of total Billed Charges,65% of Total Billed Charges,43.49,44.1,,1.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,93.68,95,,4.28,Percent of Total Billed Charges,95% of Total Billed Charges,98.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.78,88,,3.96,Percent of Total Billed Charges,88% of Total Billed Charges,88.75,90,,4.056,Percent of Total Billed charges,90% of Total Billed Charges,43.49,98.61,
BOVIE (CAUTERY) PEN TEMP 2200F,2720001315,CDM,272,RC,,,Outpatient,,,56.45,36.69,,56.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.9,76,,3.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.64,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,42.34,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,56.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.64,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,33.87,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,50.81,90,,8.952,Percent of Total Billed Charges,90% of Total Billed Charges,25.4,45,,6.008,Percent of Total Billed Charges,45% of Total Billed Charges,50.81,90,,4.128,Percent of Total Billed Charges,90% of Total billed Charges,56.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.69,65,,1.672,Percent of total Billed Charges,65% of Total Billed Charges,24.89,44.1,,5.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.63,95,,4.352,Percent of Total Billed Charges,95% of Total Billed Charges,56.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.68,88,,4.032,Percent of Total Billed Charges,88% of Total Billed Charges,50.81,90,,4.128,Percent of Total Billed charges,90% of Total Billed Charges,24.89,56.45,
DAWSON MUELLER 8FR / 15CM,2720001317,CDM,272,RC,,,Outpatient,,,230.86,150.06,,230.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,175.45,76,,5.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,166.22,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,173.15,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.22,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,138.52,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,207.77,90,,0.76,Percent of Total Billed Charges,90% of Total Billed Charges,103.89,45,,3.384,Percent of Total Billed Charges,45% of Total Billed Charges,207.77,90,,6.576,Percent of Total Billed Charges,90% of Total billed Charges,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.06,65,,8.672,Percent of total Billed Charges,65% of Total Billed Charges,101.81,44.1,,3.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,219.32,95,,6.936,Percent of Total Billed Charges,95% of Total Billed Charges,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.16,88,,6.424,Percent of Total Billed Charges,88% of Total Billed Charges,207.77,90,,6.576,Percent of Total Billed charges,90% of Total Billed Charges,101.81,230.86,
DAWSON MUELLER 10FR / 15 CM,2720001318,CDM,272,RC,,,Outpatient,,,230.86,150.06,,230.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,175.45,76,,1.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,166.22,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,173.15,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.22,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,138.52,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,207.77,90,,8.952,Percent of Total Billed Charges,90% of Total Billed Charges,103.89,45,,0.128,Percent of Total Billed Charges,45% of Total Billed Charges,207.77,90,,2.312,Percent of Total Billed Charges,90% of Total billed Charges,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.06,65,,4.896,Percent of total Billed Charges,65% of Total Billed Charges,101.81,44.1,,0.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,219.32,95,,2.44,Percent of Total Billed Charges,95% of Total Billed Charges,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.16,88,,2.256,Percent of Total Billed Charges,88% of Total Billed Charges,207.77,90,,2.312,Percent of Total Billed charges,90% of Total Billed Charges,101.81,230.86,
DAWSON MUELLER 8FR / 25 CM,2720001319,CDM,272,RC,,,Outpatient,,,230.86,150.06,,230.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,175.45,76,,10.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,166.22,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,173.15,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.22,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,138.52,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,207.77,90,,6.8,Percent of Total Billed Charges,90% of Total Billed Charges,103.89,45,,4.768,Percent of Total Billed Charges,45% of Total Billed Charges,207.77,90,,12.008,Percent of Total Billed Charges,90% of Total billed Charges,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.06,65,,0.184,Percent of total Billed Charges,65% of Total Billed Charges,101.81,44.1,,4.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,219.32,95,,12.68,Percent of Total Billed Charges,95% of Total Billed Charges,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.16,88,,11.744,Percent of Total Billed Charges,88% of Total Billed Charges,207.77,90,,12.008,Percent of Total Billed charges,90% of Total Billed Charges,101.81,230.86,
DAWSON MUELLER 10FR / 25 CM,2720001320,CDM,272,RC,,,Outpatient,,,230.86,150.06,,230.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,175.45,76,,5.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,166.22,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,173.15,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.22,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,138.52,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,207.77,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,103.89,45,,4.472,Percent of Total Billed Charges,45% of Total Billed Charges,207.77,90,,6.776,Percent of Total Billed Charges,90% of Total billed Charges,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.06,65,,6.888,Percent of total Billed Charges,65% of Total Billed Charges,101.81,44.1,,4.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,219.32,95,,7.152,Percent of Total Billed Charges,95% of Total Billed Charges,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.16,88,,6.624,Percent of Total Billed Charges,88% of Total Billed Charges,207.77,90,,6.776,Percent of Total Billed charges,90% of Total Billed Charges,101.81,230.86,
HICKMAN 6.5FR SINGLE,2720001321,CDM,272,RC,,,Outpatient,,,327.60,212.94,,327.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,248.98,76,,0.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,235.87,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,245.7,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,327.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.87,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,196.56,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,294.84,90,,4.288,Percent of Total Billed Charges,90% of Total Billed Charges,147.42,45,,23.192,Percent of Total Billed Charges,45% of Total Billed Charges,294.84,90,,0.256,Percent of Total Billed Charges,90% of Total billed Charges,327.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.94,65,,6.464,Percent of total Billed Charges,65% of Total Billed Charges,144.47,44.1,,22.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,311.22,95,,0.272,Percent of Total Billed Charges,95% of Total Billed Charges,327.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.29,88,,0.256,Percent of Total Billed Charges,88% of Total Billed Charges,294.84,90,,0.256,Percent of Total Billed charges,90% of Total Billed Charges,144.47,327.6,
PNEUMO MP KIT COOK,2720001322,CDM,272,RC,,,Outpatient,,,342.22,222.44,,342.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,260.09,76,,8.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,246.4,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,256.67,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,342.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.4,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,205.33,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,308,90,,13.512,Percent of Total Billed Charges,90% of Total Billed Charges,154,45,,4.472,Percent of Total Billed Charges,45% of Total Billed Charges,308,90,,9.544,Percent of Total Billed Charges,90% of Total billed Charges,342.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.44,65,,33.504,Percent of total Billed Charges,65% of Total Billed Charges,150.92,44.1,,4.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,325.11,95,,10.072,Percent of Total Billed Charges,95% of Total Billed Charges,342.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.15,88,,9.328,Percent of Total Billed Charges,88% of Total Billed Charges,308,90,,9.544,Percent of Total Billed charges,90% of Total Billed Charges,150.92,342.22,
M2 BONE BX SET,2720001323,CDM,272,RC,,,Outpatient,,,345.37,224.49,,345.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,262.48,76,,7.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,248.67,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,259.03,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,345.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.67,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,207.22,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,310.83,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,155.42,45,,4.472,Percent of Total Billed Charges,45% of Total Billed Charges,310.83,90,,8.952,Percent of Total Billed Charges,90% of Total billed Charges,345.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.49,65,,6.464,Percent of total Billed Charges,65% of Total Billed Charges,152.31,44.1,,4.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,328.1,95,,9.448,Percent of Total Billed Charges,95% of Total Billed Charges,345.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.93,88,,8.752,Percent of Total Billed Charges,88% of Total Billed Charges,310.83,90,,8.952,Percent of Total Billed charges,90% of Total Billed Charges,152.31,345.37,
DAWSON MUELLER 12FR / 25CM,2720001324,CDM,272,RC,,,Outpatient,,,230.86,150.06,,230.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,175.45,76,,39.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,166.22,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,173.15,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.22,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,138.52,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,207.77,90,,125.28,Percent of Total Billed Charges,90% of Total Billed Charges,103.89,45,,0.384,Percent of Total Billed Charges,45% of Total Billed Charges,207.77,90,,46.392,Percent of Total Billed Charges,90% of Total billed Charges,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.06,65,,6.464,Percent of total Billed Charges,65% of Total Billed Charges,101.81,44.1,,0.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,219.32,95,,48.968,Percent of Total Billed Charges,95% of Total Billed Charges,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.16,88,,45.36,Percent of Total Billed Charges,88% of Total Billed Charges,207.77,90,,46.392,Percent of Total Billed charges,90% of Total Billed Charges,101.81,230.86,
DAWSON MUELLER 14FR / 25CM,2720001325,CDM,272,RC,,,Outpatient,,,230.86,150.06,,230.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,175.45,76,,7.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,166.22,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,173.15,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.22,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,138.52,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,207.77,90,,13.304,Percent of Total Billed Charges,90% of Total Billed Charges,103.89,45,,4.472,Percent of Total Billed Charges,45% of Total Billed Charges,207.77,90,,8.952,Percent of Total Billed Charges,90% of Total billed Charges,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.06,65,,0.552,Percent of total Billed Charges,65% of Total Billed Charges,101.81,44.1,,4.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,219.32,95,,9.448,Percent of Total Billed Charges,95% of Total Billed Charges,230.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.16,88,,8.752,Percent of Total Billed Charges,88% of Total Billed Charges,207.77,90,,8.952,Percent of Total Billed charges,90% of Total Billed Charges,101.81,230.86,
BASIC BIOPSY TRAY,2720001326,CDM,272,RC,,,Outpatient,,,81.68,53.09,,81.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.08,76,,7.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,58.81,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,61.26,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,81.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.81,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,49.01,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,73.51,90,,126.216,Percent of Total Billed Charges,90% of Total Billed Charges,36.76,45,,3.4,Percent of Total Billed Charges,45% of Total Billed Charges,73.51,90,,8.952,Percent of Total Billed Charges,90% of Total billed Charges,81.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.09,65,,6.464,Percent of total Billed Charges,65% of Total Billed Charges,36.02,44.1,,3.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,77.6,95,,9.448,Percent of Total Billed Charges,95% of Total Billed Charges,81.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.88,88,,8.752,Percent of Total Billed Charges,88% of Total Billed Charges,73.51,90,,8.952,Percent of Total Billed charges,90% of Total Billed Charges,36.02,81.68,
LP TRAY W/ WHITACRE,2720001327,CDM,272,RC,,,Outpatient,,,52.35,34.03,,52.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,39.79,76,,0.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,37.69,72,,116.848,Percent of Total Billed Charges,72% of Total Billed Charges,39.26,75,,121.72,Percent of Total Billed charges,75% of Total Billed Charges,52.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.69,72,,116.848,Percent of Total Billed Charges,72% of Total Billed Charges,31.41,60,,97.376,Percent of Total Billed Charges,60% of Total Billed Charges,47.12,90,,13.84,Percent of Total Billed Charges,90% of Total Billed Charges,23.56,45,,0.72,Percent of Total Billed Charges,45% of Total Billed Charges,47.12,90,,0.76,Percent of Total Billed Charges,90% of Total billed Charges,52.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.03,65,,4.912,Percent of total Billed Charges,65% of Total Billed Charges,23.09,44.1,,0.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,49.73,95,,0.808,Percent of Total Billed Charges,95% of Total Billed Charges,52.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.07,88,,0.744,Percent of Total Billed Charges,88% of Total Billed Charges,47.12,90,,0.76,Percent of Total Billed charges,90% of Total Billed Charges,23.09,52.35,
CO AX INTRO 15GA / 6.8CM,2720001328,CDM,272,RC,,,Outpatient,,,37.80,24.57,,37.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.73,76,,7.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.22,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,28.35,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,37.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.22,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,22.68,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,34.02,90,,14.704,Percent of Total Billed Charges,90% of Total Billed Charges,17.01,45,,2.144,Percent of Total Billed Charges,45% of Total Billed Charges,34.02,90,,8.952,Percent of Total Billed Charges,90% of Total billed Charges,37.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.57,65,,1.04,Percent of total Billed Charges,65% of Total Billed Charges,16.67,44.1,,2.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.91,95,,9.448,Percent of Total Billed Charges,95% of Total Billed Charges,37.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.26,88,,8.752,Percent of Total Billed Charges,88% of Total Billed Charges,34.02,90,,8.952,Percent of Total Billed charges,90% of Total Billed Charges,16.67,37.8,
FC BX 16 GA / 10 CM,2720001329,CDM,272,RC,,,Outpatient,,,126.00,81.90,,126,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95.76,76,,5.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90.72,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,94.5,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,126,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.72,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,75.6,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,113.4,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,56.7,45,,6.76,Percent of Total Billed Charges,45% of Total Billed Charges,113.4,90,,6.8,Percent of Total Billed Charges,90% of Total billed Charges,126,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.9,65,,3.096,Percent of total Billed Charges,65% of Total Billed Charges,55.57,44.1,,6.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,119.7,95,,7.176,Percent of Total Billed Charges,95% of Total Billed Charges,126,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.88,88,,6.648,Percent of Total Billed Charges,88% of Total Billed Charges,113.4,90,,6.8,Percent of Total Billed charges,90% of Total Billed Charges,55.57,126,
CO AX INTRO 15 GA / 11.8CM,2720001330,CDM,272,RC,,,Outpatient,,,37.80,24.57,,37.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.73,76,,1.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.22,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,28.35,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,37.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.22,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,22.68,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,34.02,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,17.01,45,,1.44,Percent of Total Billed Charges,45% of Total Billed Charges,34.02,90,,1.44,Percent of Total Billed Charges,90% of Total billed Charges,37.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.57,65,,9.76,Percent of total Billed Charges,65% of Total Billed Charges,16.67,44.1,,1.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.91,95,,1.52,Percent of Total Billed Charges,95% of Total Billed Charges,37.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.26,88,,1.408,Percent of Total Billed Charges,88% of Total Billed Charges,34.02,90,,1.44,Percent of Total Billed charges,90% of Total Billed Charges,16.67,37.8,
FC BX 16 GA / 15 CM,2720001331,CDM,272,RC,,,Outpatient,,,126.00,81.90,,126,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95.76,76,,3.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90.72,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,94.5,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,126,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.72,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,75.6,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,113.4,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,56.7,45,,62.64,Percent of Total Billed Charges,45% of Total Billed Charges,113.4,90,,4.288,Percent of Total Billed Charges,90% of Total billed Charges,126,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.9,65,,2.08,Percent of total Billed Charges,65% of Total Billed Charges,55.57,44.1,,61.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,119.7,95,,4.52,Percent of Total Billed Charges,95% of Total Billed Charges,126,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.88,88,,4.192,Percent of Total Billed Charges,88% of Total Billed Charges,113.4,90,,4.288,Percent of Total Billed charges,90% of Total Billed Charges,55.57,126,
CO AX INTRO 17 GA / 16.9 CM,2720001332,CDM,272,RC,,,Outpatient,,,37.80,24.57,,37.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.73,76,,11.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.22,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,28.35,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,37.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.22,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,22.68,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,34.02,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,17.01,45,,6.656,Percent of Total Billed Charges,45% of Total Billed Charges,34.02,90,,13.512,Percent of Total Billed Charges,90% of Total billed Charges,37.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.57,65,,90.48,Percent of total Billed Charges,65% of Total Billed Charges,16.67,44.1,,6.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.91,95,,14.264,Percent of Total Billed Charges,95% of Total Billed Charges,37.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.26,88,,13.216,Percent of Total Billed Charges,88% of Total Billed Charges,34.02,90,,13.512,Percent of Total Billed charges,90% of Total Billed Charges,16.67,37.8,
FC BX 18 GA / 20 CM,2720001333,CDM,272,RC,,,Outpatient,,,126.00,81.90,,126,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95.76,76,,2.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90.72,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,94.5,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,126,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.72,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,75.6,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,113.4,90,,22.32,Percent of Total Billed Charges,90% of Total Billed Charges,56.7,45,,63.112,Percent of Total Billed Charges,45% of Total Billed Charges,113.4,90,,2.88,Percent of Total Billed Charges,90% of Total billed Charges,126,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.9,65,,9.608,Percent of total Billed Charges,65% of Total Billed Charges,55.57,44.1,,61.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,119.7,95,,3.04,Percent of Total Billed Charges,95% of Total Billed Charges,126,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.88,88,,2.816,Percent of Total Billed Charges,88% of Total Billed Charges,113.4,90,,2.88,Percent of Total Billed charges,90% of Total Billed Charges,55.57,126,
MP PIGTAIL 16FR / 25 CM,2720001334,CDM,272,RC,,,Outpatient,,,207.90,135.14,,207.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,158,76,,105.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,149.69,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,155.93,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,207.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.69,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,124.74,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,187.11,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,93.56,45,,6.92,Percent of Total Billed Charges,45% of Total Billed Charges,187.11,90,,125.28,Percent of Total Billed Charges,90% of Total billed Charges,207.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.14,65,,91.16,Percent of total Billed Charges,65% of Total Billed Charges,91.68,44.1,,6.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,197.51,95,,132.24,Percent of Total Billed Charges,95% of Total Billed Charges,207.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182.95,88,,122.496,Percent of Total Billed Charges,88% of Total Billed Charges,187.11,90,,125.28,Percent of Total Billed charges,90% of Total Billed Charges,91.68,207.9,
M2 BONE BX SET 14G / 10CM,2720001335,CDM,272,RC,,,Outpatient,,,345.37,224.49,,345.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,262.48,76,,11.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,248.67,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,259.03,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,345.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.67,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,207.22,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,310.83,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,155.42,45,,7.352,Percent of Total Billed Charges,45% of Total Billed Charges,310.83,90,,13.304,Percent of Total Billed Charges,90% of Total billed Charges,345.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.49,65,,9.992,Percent of total Billed Charges,65% of Total Billed Charges,152.31,44.1,,7.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,328.1,95,,14.048,Percent of Total Billed Charges,95% of Total Billed Charges,345.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.93,88,,13.008,Percent of Total Billed Charges,88% of Total Billed Charges,310.83,90,,13.304,Percent of Total Billed charges,90% of Total Billed Charges,152.31,345.37,
M2 BONE BX SET 14G / 15 CM,2720001336,CDM,272,RC,,,Outpatient,,,345.37,224.49,,345.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,262.48,76,,106.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,248.67,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,259.03,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,345.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.67,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,207.22,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,310.83,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,155.42,45,,8.64,Percent of Total Billed Charges,45% of Total Billed Charges,310.83,90,,126.216,Percent of Total Billed Charges,90% of Total billed Charges,345.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.49,65,,10.616,Percent of total Billed Charges,65% of Total Billed Charges,152.31,44.1,,8.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,328.1,95,,133.232,Percent of Total Billed Charges,95% of Total Billed Charges,345.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.93,88,,123.408,Percent of Total Billed Charges,88% of Total Billed Charges,310.83,90,,126.216,Percent of Total Billed charges,90% of Total Billed Charges,152.31,345.37,
GOLDENBERG 11G / 6 INCH,2720001337,CDM,272,RC,,,Outpatient,,,182.16,118.40,,182.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,138.44,76,,11.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,131.16,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,136.62,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,182.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.16,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,109.3,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,163.94,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,81.97,45,,1.08,Percent of Total Billed Charges,45% of Total Billed Charges,163.94,90,,13.84,Percent of Total Billed Charges,90% of Total billed Charges,182.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.4,65,,12.48,Percent of total Billed Charges,65% of Total Billed Charges,80.33,44.1,,1.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,173.05,95,,14.608,Percent of Total Billed Charges,95% of Total Billed Charges,182.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.3,88,,13.528,Percent of Total Billed Charges,88% of Total Billed Charges,163.94,90,,13.84,Percent of Total Billed charges,90% of Total Billed Charges,80.33,182.16,
IVR CUSTOM PACK,2720001338,CDM,272,RC,,,Outpatient,,,166.23,108.05,,166.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,126.33,76,,12.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,119.69,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,124.67,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,166.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.69,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,99.74,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,149.61,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,74.8,45,,2.88,Percent of Total Billed Charges,45% of Total Billed Charges,149.61,90,,14.704,Percent of Total Billed Charges,90% of Total billed Charges,166.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.05,65,,1.56,Percent of total Billed Charges,65% of Total Billed Charges,73.31,44.1,,2.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,157.92,95,,15.52,Percent of Total Billed Charges,95% of Total Billed Charges,166.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.28,88,,14.376,Percent of Total Billed Charges,88% of Total Billed Charges,149.61,90,,14.704,Percent of Total Billed charges,90% of Total Billed Charges,73.31,166.23,
JP BULB 100ML,2720001339,CDM,272,RC,,,Outpatient,,,153.28,99.63,,153.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,116.49,76,,14.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,110.36,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,114.96,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,153.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.36,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,91.97,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,137.95,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,68.98,45,,6.48,Percent of Total Billed Charges,45% of Total Billed Charges,137.95,90,,17.28,Percent of Total Billed Charges,90% of Total billed Charges,153.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.63,65,,4.16,Percent of total Billed Charges,65% of Total Billed Charges,67.6,44.1,,6.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,145.62,95,,18.24,Percent of Total Billed Charges,95% of Total Billed Charges,153.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.89,88,,16.896,Percent of Total Billed Charges,88% of Total Billed Charges,137.95,90,,17.28,Percent of Total Billed charges,90% of Total Billed Charges,67.6,153.28,
PNEUMO KIT STRAIGHT,2720001340,CDM,272,RC,,,Outpatient,,,342.22,222.44,,342.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,260.09,76,,1.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,246.4,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,256.67,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,342.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.4,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,205.33,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,308,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,154,45,,11.16,Percent of Total Billed Charges,45% of Total Billed Charges,308,90,,2.16,Percent of Total Billed Charges,90% of Total billed Charges,342.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.44,65,,9.36,Percent of total Billed Charges,65% of Total Billed Charges,150.92,44.1,,10.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,325.11,95,,2.28,Percent of Total Billed Charges,95% of Total Billed Charges,342.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.15,88,,2.112,Percent of Total Billed Charges,88% of Total Billed Charges,308,90,,2.16,Percent of Total Billed charges,90% of Total Billed Charges,150.92,342.22,
COOK 24F 20 CM DILATOR,2720001341,CDM,272,RC,,,Outpatient,,,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,4.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,22.33,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,92.16,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,1.08,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,5.76,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,16.12,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,1.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,6.08,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,5.632,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,5.76,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
COOK 6FR 15CM DILATOR,2720001342,CDM,272,RC,,,Outpatient,,,152.15,98.90,,152.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,115.63,76,,10.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,109.55,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,114.11,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.55,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,91.29,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,136.94,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,68.47,45,,5.4,Percent of Total Billed Charges,45% of Total Billed Charges,136.94,90,,12.96,Percent of Total Billed Charges,90% of Total billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.9,65,,1.56,Percent of total Billed Charges,65% of Total Billed Charges,67.1,44.1,,5.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,144.54,95,,13.68,Percent of Total Billed Charges,95% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.89,88,,12.672,Percent of Total Billed Charges,88% of Total Billed Charges,136.94,90,,12.96,Percent of Total Billed charges,90% of Total Billed Charges,67.1,152.15,
COOK 20F 20CM DILATOR,2720001343,CDM,272,RC,,,Outpatient,,,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,18.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,22.33,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,12.6,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,22.32,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,7.8,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,12.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,23.56,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,21.824,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,22.32,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
URINARY LEGBAG LARGE,2720001344,CDM,272,RC,,,Outpatient,,,20.00,13.00,,20,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.2,76,,1.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.4,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,15,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.4,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,12,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,18,90,,1.696,Percent of Total Billed Charges,90% of Total Billed Charges,9,45,,3.6,Percent of Total Billed Charges,45% of Total Billed Charges,18,90,,2.16,Percent of Total Billed Charges,90% of Total billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13,65,,18.2,Percent of total Billed Charges,65% of Total Billed Charges,8.82,44.1,,3.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,19,95,,2.28,Percent of Total Billed Charges,95% of Total Billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.6,88,,2.112,Percent of Total Billed Charges,88% of Total Billed Charges,18,90,,2.16,Percent of Total Billed charges,90% of Total Billed Charges,8.82,20,
ULTRA PRO II NEEDLE GUIDE,2720001345,CDM,272,RC,,,Outpatient,,,55.65,36.17,,55.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.29,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.07,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,41.74,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,55.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.07,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,33.39,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,50.09,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,25.04,45,,8.64,Percent of Total Billed Charges,45% of Total Billed Charges,50.09,90,,10.8,Percent of Total Billed Charges,90% of Total billed Charges,55.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.17,65,,5.2,Percent of total Billed Charges,65% of Total Billed Charges,24.54,44.1,,8.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.87,95,,11.4,Percent of Total Billed Charges,95% of Total Billed Charges,55.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.97,88,,10.56,Percent of Total Billed Charges,88% of Total Billed Charges,50.09,90,,10.8,Percent of Total Billed charges,90% of Total Billed Charges,24.54,55.65,
YUEH THORA NEEDLE 5FX10CM,2720001346,CDM,272,RC,,,Outpatient,,,86.76,56.39,,86.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,65.94,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.47,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,65.07,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,86.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.47,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,52.06,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,78.08,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,39.04,45,,4.68,Percent of Total Billed Charges,45% of Total Billed Charges,78.08,90,,25.2,Percent of Total Billed Charges,90% of Total billed Charges,86.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.39,65,,12.48,Percent of total Billed Charges,65% of Total Billed Charges,38.26,44.1,,4.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.42,95,,26.6,Percent of Total Billed Charges,95% of Total Billed Charges,86.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.35,88,,24.64,Percent of Total Billed Charges,88% of Total Billed Charges,78.08,90,,25.2,Percent of Total Billed charges,90% of Total Billed Charges,38.26,86.76,
MP NEEDLE 21GX7CM,2720001347,CDM,272,RC,,,Outpatient,,,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,0.72,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,3.6,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,7.2,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,6.76,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,3.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,7.6,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,7.04,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,7.2,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.72,
URINARY LEGBAG MEDIUM,2720001348,CDM,272,RC,,,Outpatient,,,20.00,13.00,,20,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.2,76,,14.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.4,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,15,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.4,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,12,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,18,90,,24.48,Percent of Total Billed Charges,90% of Total Billed Charges,9,45,,46.08,Percent of Total Billed Charges,45% of Total Billed Charges,18,90,,17.28,Percent of Total Billed Charges,90% of Total billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13,65,,5.2,Percent of total Billed Charges,65% of Total Billed Charges,8.82,44.1,,45.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,19,95,,18.24,Percent of Total Billed Charges,95% of Total Billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.6,88,,16.896,Percent of Total Billed Charges,88% of Total Billed Charges,18,90,,17.28,Percent of Total Billed charges,90% of Total Billed Charges,8.82,20,
COOK 18GX7CM ACCESS NEEDLE,2720001349,CDM,272,RC,,,Outpatient,,,14.68,9.54,,14.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.16,76,,7.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.57,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,11.01,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.57,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,8.81,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,13.21,90,,35.28,Percent of Total Billed Charges,90% of Total Billed Charges,6.61,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,13.21,90,,9.36,Percent of Total Billed Charges,90% of Total billed Charges,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.54,65,,66.56,Percent of total Billed Charges,65% of Total Billed Charges,6.47,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.95,95,,9.88,Percent of Total Billed Charges,95% of Total Billed Charges,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.92,88,,9.152,Percent of Total Billed Charges,88% of Total Billed Charges,13.21,90,,9.36,Percent of Total Billed charges,90% of Total Billed Charges,6.47,14.68,
SPINAL NEEDLE 22GX7,2720001350,CDM,272,RC,,,Outpatient,,,8.73,5.67,,8.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.63,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.29,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,6.55,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,8.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.29,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,5.24,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,7.86,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,3.93,45,,22.68,Percent of Total Billed Charges,45% of Total Billed Charges,7.86,90,,7.2,Percent of Total Billed Charges,90% of Total billed Charges,8.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.67,65,,6.24,Percent of total Billed Charges,65% of Total Billed Charges,3.85,44.1,,22.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.29,95,,7.6,Percent of Total Billed Charges,95% of Total Billed Charges,8.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.68,88,,7.04,Percent of Total Billed Charges,88% of Total Billed Charges,7.86,90,,7.2,Percent of Total Billed charges,90% of Total Billed Charges,3.85,8.73,
COOK 8FR 15CM DILATOR,2720001351,CDM,272,RC,,,Outpatient,,,152.15,98.90,,152.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,115.63,76,,77.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,109.55,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,114.11,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.55,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,91.29,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,136.94,90,,2.976,Percent of Total Billed Charges,90% of Total Billed Charges,68.47,45,,0.848,Percent of Total Billed Charges,45% of Total Billed Charges,136.94,90,,92.16,Percent of Total Billed Charges,90% of Total billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.9,65,,32.76,Percent of total Billed Charges,65% of Total Billed Charges,67.1,44.1,,0.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,144.54,95,,97.28,Percent of Total Billed Charges,95% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.89,88,,90.112,Percent of Total Billed Charges,88% of Total Billed Charges,136.94,90,,92.16,Percent of Total Billed charges,90% of Total Billed Charges,67.1,152.15,
COOK 4CMX21G NEEDLE,2720001352,CDM,272,RC,,,Outpatient,,,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.91,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.91,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,22.68,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,1.224,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,22.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.54,
PNEUMOTHORAX KIT PIGTAIL,2720001353,CDM,272,RC,,,Outpatient,,,283.34,184.17,,283.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,215.34,76,,38.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,204,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,212.51,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,170,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,255.01,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,127.5,45,,18.36,Percent of Total Billed Charges,45% of Total Billed Charges,255.01,90,,45.36,Percent of Total Billed Charges,90% of Total billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.17,65,,32.76,Percent of total Billed Charges,65% of Total Billed Charges,124.95,44.1,,17.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,269.17,95,,47.88,Percent of Total Billed Charges,95% of Total Billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.34,88,,44.352,Percent of Total Billed Charges,88% of Total Billed Charges,255.01,90,,45.36,Percent of Total Billed charges,90% of Total Billed Charges,124.95,283.34,
COOK 18G X 5CM ACCESS NEEDLE,2720001354,CDM,272,RC,,,Outpatient,,,11.34,7.37,,11.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.62,76,,1.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.16,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,8.51,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,11.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.16,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,6.8,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,10.21,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,5.1,45,,0.36,Percent of Total Billed Charges,45% of Total Billed Charges,10.21,90,,1.696,Percent of Total Billed Charges,90% of Total billed Charges,11.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.37,65,,26.52,Percent of total Billed Charges,65% of Total Billed Charges,5,44.1,,0.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.77,95,,1.792,Percent of Total Billed Charges,95% of Total Billed Charges,11.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.98,88,,1.664,Percent of Total Billed Charges,88% of Total Billed Charges,10.21,90,,1.696,Percent of Total Billed charges,90% of Total Billed Charges,5,11.34,
COOK 20GX4CM,2720001355,CDM,272,RC,,,Outpatient,,,11.34,7.37,,11.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.62,76,,38.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.16,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,8.51,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,11.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.16,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,6.8,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,10.21,90,,53.28,Percent of Total Billed Charges,90% of Total Billed Charges,5.1,45,,12.24,Percent of Total Billed Charges,45% of Total Billed Charges,10.21,90,,45.36,Percent of Total Billed Charges,90% of Total billed Charges,11.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.37,65,,0.52,Percent of total Billed Charges,65% of Total Billed Charges,5,44.1,,11.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.77,95,,47.88,Percent of Total Billed Charges,95% of Total Billed Charges,11.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.98,88,,44.352,Percent of Total Billed Charges,88% of Total Billed Charges,10.21,90,,45.36,Percent of Total Billed charges,90% of Total Billed Charges,5,11.34,
COOK 1F 20 CM DILATOR,2720001356,CDM,272,RC,,,Outpatient,,,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,31.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,22.33,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,53.28,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,17.64,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,36.72,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,17.68,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,17.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,38.76,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,35.904,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,36.72,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
URETHRAL DILATOR SET,2720001357,CDM,272,RC,,,Outpatient,,,738.78,480.21,,738.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,561.47,76,,0.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531.92,72,,1033.848,Percent of Total Billed Charges,72% of Total Billed Charges,554.09,75,,1076.92,Percent of Total Billed charges,75% of Total Billed Charges,738.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531.92,72,,1033.848,Percent of Total Billed Charges,72% of Total Billed Charges,443.27,60,,861.536,Percent of Total Billed Charges,60% of Total Billed Charges,664.9,90,,1597.68,Percent of Total Billed Charges,90% of Total Billed Charges,332.45,45,,1.08,Percent of Total Billed Charges,45% of Total Billed Charges,664.9,90,,0.72,Percent of Total Billed Charges,90% of Total billed Charges,738.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,738.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,738.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.21,65,,25.48,Percent of total Billed Charges,65% of Total Billed Charges,325.8,44.1,,1.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,701.84,95,,0.76,Percent of Total Billed Charges,95% of Total Billed Charges,738.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,650.13,88,,0.704,Percent of Total Billed Charges,88% of Total Billed Charges,664.9,90,,0.72,Percent of Total Billed charges,90% of Total Billed Charges,325.8,738.78,
SPINAL NEEDLE 20GX3.5 IN,2720001358,CDM,272,RC,,,Outpatient,,,2.27,1.48,,2.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.73,76,,20.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,1.7,75,,1090.816,Percent of Total Billed charges,75% of Total Billed Charges,2.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.63,72,,1047.176,Percent of Total Billed Charges,72% of Total Billed Charges,1.36,60,,872.648,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,90,,67.68,Percent of Total Billed Charges,90% of Total Billed Charges,1.02,45,,1.488,Percent of Total Billed Charges,45% of Total Billed Charges,2.04,90,,24.48,Percent of Total Billed Charges,90% of Total billed Charges,2.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.48,65,,1.56,Percent of total Billed Charges,65% of Total Billed Charges,1,44.1,,1.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.16,95,,25.84,Percent of Total Billed Charges,95% of Total Billed Charges,2.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,88,,23.936,Percent of Total Billed Charges,88% of Total Billed Charges,2.04,90,,24.48,Percent of Total Billed charges,90% of Total Billed Charges,1,2.27,
COOK BP 18GX7CM ACCESS NEEDLE,2720001359,CDM,272,RC,,,Outpatient,,,14.68,9.54,,14.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.16,76,,29.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.57,72,,1052.896,Percent of Total Billed Charges,72% of Total Billed Charges,11.01,75,,1096.768,Percent of Total Billed charges,75% of Total Billed Charges,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.57,72,,1052.896,Percent of Total Billed Charges,72% of Total Billed Charges,8.81,60,,877.416,Percent of Total Billed Charges,60% of Total Billed Charges,13.21,90,,80.64,Percent of Total Billed Charges,90% of Total Billed Charges,6.61,45,,3.6,Percent of Total Billed Charges,45% of Total Billed Charges,13.21,90,,35.28,Percent of Total Billed Charges,90% of Total billed Charges,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.54,65,,2.144,Percent of total Billed Charges,65% of Total Billed Charges,6.47,44.1,,3.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.95,95,,37.24,Percent of Total Billed Charges,95% of Total Billed Charges,14.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.92,88,,34.496,Percent of Total Billed Charges,88% of Total Billed Charges,13.21,90,,35.28,Percent of Total Billed charges,90% of Total Billed Charges,6.47,14.68,
YUEH 5FX15CM,2720001360,CDM,272,RC,,,Outpatient,,,87.00,56.55,,87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.12,76,,1.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.64,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,65.25,75,,1101.4,Percent of Total Billed charges,75% of Total Billed Charges,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.64,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,52.2,60,,881.12,Percent of Total Billed Charges,60% of Total Billed Charges,78.3,90,,114.48,Percent of Total Billed Charges,90% of Total Billed Charges,39.15,45,,11.52,Percent of Total Billed Charges,45% of Total Billed Charges,78.3,90,,2.16,Percent of Total Billed Charges,90% of Total billed Charges,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.55,65,,5.2,Percent of total Billed Charges,65% of Total Billed Charges,38.37,44.1,,11.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.65,95,,2.28,Percent of Total Billed Charges,95% of Total Billed Charges,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.56,88,,2.112,Percent of Total Billed Charges,88% of Total Billed Charges,78.3,90,,2.16,Percent of Total Billed charges,90% of Total Billed Charges,38.37,87,
MP NEEDLE 21GX9CM,2720001361,CDM,272,RC,,,Outpatient,,,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,2.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,1101.4,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,881.12,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,95.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,5.4,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,2.976,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,16.64,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,5.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,3.136,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,2.904,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,2.976,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
COOK 12F 20CM DILATOR,2720001362,CDM,272,RC,,,Outpatient,,,79.38,51.60,,79.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60.33,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.15,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,59.54,75,,1101.4,Percent of Total Billed charges,75% of Total Billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.15,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,47.63,60,,881.12,Percent of Total Billed Charges,60% of Total Billed Charges,71.44,90,,136.08,Percent of Total Billed Charges,90% of Total Billed Charges,35.72,45,,26.64,Percent of Total Billed Charges,45% of Total Billed Charges,71.44,90,,7.2,Percent of Total Billed Charges,90% of Total billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,65,,7.8,Percent of total Billed Charges,65% of Total Billed Charges,35.01,44.1,,26.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,75.41,95,,7.6,Percent of Total Billed Charges,95% of Total Billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.85,88,,7.04,Percent of Total Billed Charges,88% of Total Billed Charges,71.44,90,,7.2,Percent of Total Billed charges,90% of Total Billed Charges,35.01,79.38,
HUBER NEEDLE,2720001363,CDM,272,RC,,,Outpatient,,,36.00,23.40,,36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.36,76,,19.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.92,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,27,75,,1101.4,Percent of Total Billed charges,75% of Total Billed Charges,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.92,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,21.6,60,,881.12,Percent of Total Billed Charges,60% of Total Billed Charges,32.4,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,45,,26.64,Percent of Total Billed Charges,45% of Total Billed Charges,32.4,90,,23.04,Percent of Total Billed Charges,90% of Total billed Charges,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.4,65,,38.48,Percent of total Billed Charges,65% of Total Billed Charges,15.88,44.1,,26.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.2,95,,24.32,Percent of Total Billed Charges,95% of Total Billed Charges,36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.68,88,,22.528,Percent of Total Billed Charges,88% of Total Billed Charges,32.4,90,,23.04,Percent of Total Billed charges,90% of Total Billed Charges,15.88,36,
SPINAL NEEDLE,2720001364,CDM,272,RC,,,Outpatient,,,2.33,1.51,,2.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.77,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.68,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,1.75,75,,1101.4,Percent of Total Billed charges,75% of Total Billed Charges,2.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.68,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,1.4,60,,881.12,Percent of Total Billed Charges,60% of Total Billed Charges,2.1,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,1.05,45,,798.84,Percent of Total Billed Charges,45% of Total Billed Charges,2.1,90,,10.8,Percent of Total Billed Charges,90% of Total billed Charges,2.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.51,65,,38.48,Percent of total Billed Charges,65% of Total Billed Charges,1.03,44.1,,782.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.21,95,,11.4,Percent of Total Billed Charges,95% of Total Billed Charges,2.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.05,88,,10.56,Percent of Total Billed Charges,88% of Total Billed Charges,2.1,90,,10.8,Percent of Total Billed charges,90% of Total Billed Charges,1.03,2.33,
POWERPORT 8F CV PORT CATH,2720001365,CDM,272,RC,,,Outpatient,,,1874.25,1218.26,,1874.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1424.43,76,,44.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1349.46,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,1405.69,75,,1101.4,Percent of Total Billed charges,75% of Total Billed Charges,1874.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1349.46,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,1124.55,60,,881.12,Percent of Total Billed Charges,60% of Total Billed Charges,1686.83,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,843.41,45,,33.84,Percent of Total Billed Charges,45% of Total Billed Charges,1686.83,90,,53.28,Percent of Total Billed Charges,90% of Total billed Charges,1874.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1874.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1874.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1218.26,65,,1153.88,Percent of total Billed Charges,65% of Total Billed Charges,826.54,44.1,,33.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,1780.54,95,,56.24,Percent of Total Billed Charges,95% of Total Billed Charges,1874.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1649.34,88,,52.096,Percent of Total Billed Charges,88% of Total Billed Charges,1686.83,90,,53.28,Percent of Total Billed charges,90% of Total Billed Charges,826.54,1874.25,
COOK 22F 20CM DILATIO,2720001366,CDM,272,RC,,,Outpatient,,,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,44.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,22.33,75,,1101.4,Percent of Total Billed charges,75% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,881.12,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,161.28,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,40.32,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,53.28,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,48.88,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,39.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,56.24,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,52.096,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,53.28,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
PLEUX BOTTLE W CONNECTOR,2720001367,CDM,272,RC,,,Outpatient,,,148.00,96.20,,148,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,112.48,76,,1349.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,106.56,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,111,75,,1101.4,Percent of Total Billed charges,75% of Total Billed Charges,148,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.56,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,88.8,60,,881.12,Percent of Total Billed Charges,60% of Total Billed Charges,133.2,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,66.6,45,,57.24,Percent of Total Billed Charges,45% of Total Billed Charges,133.2,90,,1597.68,Percent of Total Billed Charges,90% of Total billed Charges,148,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.2,65,,58.24,Percent of total Billed Charges,65% of Total Billed Charges,65.27,44.1,,56.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,140.6,95,,1686.44,Percent of Total Billed Charges,95% of Total Billed Charges,148,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.24,88,,1562.176,Percent of Total Billed Charges,88% of Total Billed Charges,133.2,90,,1597.68,Percent of Total Billed charges,90% of Total Billed Charges,65.27,148,
COOK 16F 20CM DILATOR,2720001368,CDM,272,RC,,,Outpatient,,,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,57.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,1065.6,Percent of Total Billed Charges,72% of Total Billed Charges,22.33,75,,1110,Percent of Total Billed charges,75% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,1065.6,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,888,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,22.32,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,47.52,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,67.68,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,82.68,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,46.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,71.44,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,66.176,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,67.68,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
COOK 18F 20 CM DILATOR,2720001369,CDM,272,RC,,,Outpatient,,,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,68.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,1065.6,Percent of Total Billed Charges,72% of Total Billed Charges,22.33,75,,1110,Percent of Total Billed charges,75% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,1065.6,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,888,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,68.04,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,80.64,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,68.64,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,66.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,85.12,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,78.848,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,80.64,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
CENTRAL VENOUS DRESSING CHANGE,2720001370,CDM,272,RC,,,Outpatient,,,19.12,12.43,,19.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.53,76,,96.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.77,72,,1065.6,Percent of Total Billed Charges,72% of Total Billed Charges,14.34,75,,1110,Percent of Total Billed charges,75% of Total Billed Charges,19.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.77,72,,1065.6,Percent of Total Billed Charges,72% of Total Billed Charges,11.47,60,,888,Percent of Total Billed Charges,60% of Total Billed Charges,17.21,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,8.6,45,,5.04,Percent of Total Billed Charges,45% of Total Billed Charges,17.21,90,,114.48,Percent of Total Billed Charges,90% of Total billed Charges,19.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.43,65,,98.28,Percent of total Billed Charges,65% of Total Billed Charges,8.43,44.1,,4.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.16,95,,120.84,Percent of Total Billed Charges,95% of Total Billed Charges,19.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.83,88,,111.936,Percent of Total Billed Charges,88% of Total Billed Charges,17.21,90,,114.48,Percent of Total Billed charges,90% of Total Billed Charges,8.43,19.12,
PICC & CVC DRESSING CHANGE,2720001371,CDM,272,RC,,,Outpatient,,,47.47,30.86,,47.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.08,76,,80.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.18,72,,1065.6,Percent of Total Billed Charges,72% of Total Billed Charges,35.6,75,,1110,Percent of Total Billed charges,75% of Total Billed Charges,47.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,72,,1065.6,Percent of Total Billed Charges,72% of Total Billed Charges,28.48,60,,888,Percent of Total Billed Charges,60% of Total Billed Charges,42.72,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,21.36,45,,21.96,Percent of Total Billed Charges,45% of Total Billed Charges,42.72,90,,95.04,Percent of Total Billed Charges,90% of Total billed Charges,47.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.86,65,,7.28,Percent of total Billed Charges,65% of Total Billed Charges,20.93,44.1,,21.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.1,95,,100.32,Percent of Total Billed Charges,95% of Total Billed Charges,47.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.77,88,,92.928,Percent of Total Billed Charges,88% of Total Billed Charges,42.72,90,,95.04,Percent of Total Billed charges,90% of Total Billed Charges,20.93,47.47,
TRACH CARE WET PAK K,2720001372,CDM,272,RC,,,Outpatient,,,45.20,29.38,,45.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.35,76,,114.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.54,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,33.9,75,,1101.4,Percent of Total Billed charges,75% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.54,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,27.12,60,,881.12,Percent of Total Billed Charges,60% of Total Billed Charges,40.68,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,20.34,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,40.68,90,,136.08,Percent of Total Billed Charges,90% of Total billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.38,65,,31.72,Percent of total Billed Charges,65% of Total Billed Charges,19.93,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.94,95,,143.64,Percent of Total Billed Charges,95% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.78,88,,133.056,Percent of Total Billed Charges,88% of Total Billed Charges,40.68,90,,136.08,Percent of Total Billed charges,90% of Total Billed Charges,19.93,45.2,
FLOW SAFE II EZ,2720001373,CDM,272,RC,,,Outpatient,,,205.80,133.77,,205.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,156.41,76,,8.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,148.18,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,154.35,75,,1101.4,Percent of Total Billed charges,75% of Total Billed Charges,205.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.18,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,123.48,60,,881.12,Percent of Total Billed Charges,60% of Total Billed Charges,185.22,90,,36,Percent of Total Billed Charges,90% of Total Billed Charges,92.61,45,,80.64,Percent of Total Billed Charges,45% of Total Billed Charges,185.22,90,,10.08,Percent of Total Billed Charges,90% of Total billed Charges,205.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.77,65,,6.24,Percent of total Billed Charges,65% of Total Billed Charges,90.76,44.1,,79.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,195.51,95,,10.64,Percent of Total Billed Charges,95% of Total Billed Charges,205.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.1,88,,9.856,Percent of Total Billed Charges,88% of Total Billed Charges,185.22,90,,10.08,Percent of Total Billed charges,90% of Total Billed Charges,90.76,205.8,
CUFFILL ETT SYR,2720001374,CDM,272,RC,,,Outpatient,,,115.04,74.78,,115.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.43,76,,37.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.83,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,86.28,75,,1101.4,Percent of Total Billed charges,75% of Total Billed Charges,115.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.83,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,69.02,60,,881.12,Percent of Total Billed Charges,60% of Total Billed Charges,103.54,90,,91.44,Percent of Total Billed Charges,90% of Total Billed Charges,51.77,45,,10.8,Percent of Total Billed Charges,45% of Total Billed Charges,103.54,90,,43.92,Percent of Total Billed Charges,90% of Total billed Charges,115.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.78,65,,116.48,Percent of total Billed Charges,65% of Total Billed Charges,50.73,44.1,,10.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,109.29,95,,46.36,Percent of Total Billed Charges,95% of Total Billed Charges,115.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.24,88,,42.944,Percent of Total Billed Charges,88% of Total Billed Charges,103.54,90,,43.92,Percent of Total Billed charges,90% of Total Billed Charges,50.73,115.04,
STRATASORB 2X2,2720001375,CDM,272,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,1101.4,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,1057.344,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,881.12,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,57.6,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,11.16,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,15.6,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,10.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
FIBRACOL,2720001376,CDM,272,RC,,,Outpatient,,,38.59,25.08,,38.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.33,76,,136.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.78,72,,192.08,Percent of Total Billed Charges,72% of Total Billed Charges,28.94,75,,200.08,Percent of Total Billed charges,75% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.78,72,,192.08,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,60,,160.064,Percent of Total Billed Charges,60% of Total Billed Charges,34.73,90,,64.8,Percent of Total Billed Charges,90% of Total Billed Charges,17.37,45,,11.52,Percent of Total Billed Charges,45% of Total Billed Charges,34.73,90,,161.28,Percent of Total Billed Charges,90% of Total billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.08,65,,16.12,Percent of total Billed Charges,65% of Total Billed Charges,17.02,44.1,,11.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.66,95,,170.24,Percent of Total Billed Charges,95% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.96,88,,157.696,Percent of Total Billed Charges,88% of Total Billed Charges,34.73,90,,161.28,Percent of Total Billed charges,90% of Total Billed Charges,17.02,38.59,
FIBRACOL PUS 4X4,2720001377,CDM,272,RC,,,Outpatient,,,72.77,47.30,,72.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.31,76,,18.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.39,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,54.58,75,,9,Percent of Total Billed charges,75% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.39,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,65.49,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,32.75,45,,21.96,Percent of Total Billed Charges,45% of Total Billed Charges,65.49,90,,21.6,Percent of Total Billed Charges,90% of Total billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.3,65,,16.64,Percent of total Billed Charges,65% of Total Billed Charges,32.09,44.1,,21.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,69.13,95,,22.8,Percent of Total Billed Charges,95% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.04,88,,21.12,Percent of Total Billed Charges,88% of Total Billed Charges,65.49,90,,21.6,Percent of Total Billed charges,90% of Total Billed Charges,32.09,72.77,
ALGISITE M 3X4 1/2,2720001378,CDM,272,RC,,,Outpatient,,,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,18.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,11.216,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,11.68,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,11.216,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,9.344,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,21.96,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,22.32,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,31.72,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,21.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,23.56,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,21.824,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,22.32,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
ALGISITE M 4X4,2720001379,CDM,272,RC,,,Outpatient,,,38.59,25.08,,38.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.33,76,,19.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.78,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,28.94,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.78,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,34.73,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,17.37,45,,7.2,Percent of Total Billed Charges,45% of Total Billed Charges,34.73,90,,23.04,Percent of Total Billed Charges,90% of Total billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.08,65,,31.72,Percent of total Billed Charges,65% of Total Billed Charges,17.02,44.1,,7.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.66,95,,24.32,Percent of Total Billed Charges,95% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.96,88,,22.528,Percent of Total Billed Charges,88% of Total Billed Charges,34.73,90,,23.04,Percent of Total Billed charges,90% of Total Billed Charges,17.02,38.59,
ALGISITE M 2X2,2720001380,CDM,272,RC,,,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,37.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,213.12,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,222,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,213.12,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,177.6,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,81.36,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,18,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,43.92,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,10.4,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,17.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,46.36,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,42.944,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,43.92,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
ALLEVYA NON ADHES4X4,2720001381,CDM,272,RC,,,Outpatient,,,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,37.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,45.72,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,43.92,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,26,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,44.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,46.36,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,42.944,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,43.92,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
ALLEVYN NON ADHESIVE,2720001382,CDM,272,RC,,,Outpatient,,,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,327.6,Percent of Total Billed charges,75% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,314.496,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,262.08,Percent of Total Billed Charges,60% of Total Billed Charges,2.98,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,28.8,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,14.4,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,66.04,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,28.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,15.2,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,14.08,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,14.4,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.31,
SILVASORB 4X4,2720001383,CDM,272,RC,,,Outpatient,,,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,30.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,5.4,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,5.624,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,5.4,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,4.496,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,38.16,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,36,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,41.6,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,31.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,38,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,35.2,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,36,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
EXUDERM 6X6,2720001384,CDM,272,RC,,,Outpatient,,,79.38,51.60,,79.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60.33,76,,77.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.15,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,59.54,75,,1.2,Percent of Total Billed charges,75% of Total Billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.15,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,47.63,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,71.44,90,,277.92,Percent of Total Billed Charges,90% of Total Billed Charges,35.72,45,,13.68,Percent of Total Billed Charges,45% of Total Billed Charges,71.44,90,,91.44,Percent of Total Billed Charges,90% of Total billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,65,,46.8,Percent of total Billed Charges,65% of Total Billed Charges,35.01,44.1,,13.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,75.41,95,,96.52,Percent of Total Billed Charges,95% of Total Billed Charges,79.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.85,88,,89.408,Percent of Total Billed Charges,88% of Total Billed Charges,71.44,90,,91.44,Percent of Total Billed charges,90% of Total Billed Charges,35.01,79.38,
STRATASORB 4X4,2720001385,CDM,272,RC,,,Outpatient,,,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,48.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,1.728,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,1.8,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,1.728,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,10.8,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,57.6,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,19.76,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,10.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,60.8,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,56.32,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,57.6,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
EXUDERM SACRUM 4X3.6,2720001386,CDM,272,RC,,,Outpatient,,,125.69,81.70,,125.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95.52,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90.5,72,,1.728,Percent of Total Billed Charges,72% of Total Billed Charges,94.27,75,,1.8,Percent of Total Billed charges,75% of Total Billed Charges,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.5,72,,1.728,Percent of Total Billed Charges,72% of Total Billed Charges,75.41,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,113.12,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,56.56,45,,8.28,Percent of Total Billed Charges,45% of Total Billed Charges,113.12,90,,64.8,Percent of Total Billed Charges,90% of Total billed Charges,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.7,65,,15.6,Percent of total Billed Charges,65% of Total Billed Charges,55.43,44.1,,8.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,119.41,95,,68.4,Percent of Total Billed Charges,95% of Total Billed Charges,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.61,88,,63.36,Percent of Total Billed Charges,88% of Total Billed Charges,113.12,90,,64.8,Percent of Total Billed charges,90% of Total Billed Charges,55.43,125.69,
EXUDERM SATIN 2X2,2720001387,CDM,272,RC,,,Outpatient,,,34.18,22.22,,34.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.98,76,,23.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.61,72,,46.08,Percent of Total Billed Charges,72% of Total Billed Charges,25.64,75,,48,Percent of Total Billed charges,75% of Total Billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.61,72,,46.08,Percent of Total Billed Charges,72% of Total Billed Charges,20.51,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,30.76,90,,389.52,Percent of Total Billed Charges,90% of Total Billed Charges,15.38,45,,40.68,Percent of Total Billed Charges,45% of Total Billed Charges,30.76,90,,27.36,Percent of Total Billed Charges,90% of Total billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.22,65,,11.96,Percent of total Billed Charges,65% of Total Billed Charges,15.07,44.1,,39.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.47,95,,28.88,Percent of Total Billed Charges,95% of Total Billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.08,88,,26.752,Percent of Total Billed Charges,88% of Total Billed Charges,30.76,90,,27.36,Percent of Total Billed charges,90% of Total Billed Charges,15.07,34.18,
EXUDERM SATIN 4X4,2720001388,CDM,272,RC,,,Outpatient,,,57.33,37.26,,57.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.57,76,,18.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.28,72,,20.16,Percent of Total Billed Charges,72% of Total Billed Charges,43,75,,21,Percent of Total Billed charges,75% of Total Billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.28,72,,20.16,Percent of Total Billed Charges,72% of Total Billed Charges,34.4,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,51.6,90,,109.44,Percent of Total Billed Charges,90% of Total Billed Charges,25.8,45,,10.08,Percent of Total Billed Charges,45% of Total Billed Charges,51.6,90,,21.6,Percent of Total Billed Charges,90% of Total billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.26,65,,58.76,Percent of total Billed Charges,65% of Total Billed Charges,25.28,44.1,,9.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.46,95,,22.8,Percent of Total Billed Charges,95% of Total Billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.45,88,,21.12,Percent of Total Billed Charges,88% of Total Billed Charges,51.6,90,,21.6,Percent of Total Billed charges,90% of Total Billed Charges,25.28,57.33,
SILVASORB 4X4 SLEET,2720001389,CDM,272,RC,,,Outpatient,,,82.69,53.75,,82.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.84,76,,13.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.54,72,,14.976,Percent of Total Billed Charges,72% of Total Billed Charges,62.02,75,,15.6,Percent of Total Billed charges,75% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,72,,14.976,Percent of Total Billed Charges,72% of Total Billed Charges,49.61,60,,12.48,Percent of Total Billed Charges,60% of Total Billed Charges,74.42,90,,5326.4,Percent of Total Billed Charges,90% of Total Billed Charges,37.21,45,,0.72,Percent of Total Billed Charges,45% of Total Billed Charges,74.42,90,,16.56,Percent of Total Billed Charges,90% of Total billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.75,65,,14.56,Percent of total Billed Charges,65% of Total Billed Charges,36.47,44.1,,0.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,78.56,95,,17.48,Percent of Total Billed Charges,95% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,88,,16.192,Percent of Total Billed Charges,88% of Total Billed Charges,74.42,90,,16.56,Percent of Total Billed charges,90% of Total Billed Charges,36.47,82.69,
SILVASORB GEL,2720001390,CDM,272,RC,,,Outpatient,,,26.46,17.20,,26.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.11,76,,68.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.05,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,75,,918,Percent of Total Billed charges,75% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.05,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,15.88,60,,734.4,Percent of Total Billed Charges,60% of Total Billed Charges,23.81,90,,5326.4,Percent of Total Billed Charges,90% of Total Billed Charges,11.91,45,,19.08,Percent of Total Billed Charges,45% of Total Billed Charges,23.81,90,,81.36,Percent of Total Billed Charges,90% of Total billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,65,,1.04,Percent of total Billed Charges,65% of Total Billed Charges,11.67,44.1,,18.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.14,95,,85.88,Percent of Total Billed Charges,95% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.28,88,,79.552,Percent of Total Billed Charges,88% of Total Billed Charges,23.81,90,,81.36,Percent of Total Billed charges,90% of Total Billed Charges,11.67,26.46,
ARGLAES POWDER 10GM,2720001391,CDM,272,RC,,,Outpatient,,,123.48,80.26,,123.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.84,76,,17.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.91,72,,36.288,Percent of Total Billed Charges,72% of Total Billed Charges,92.61,75,,37.8,Percent of Total Billed charges,75% of Total Billed Charges,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.91,72,,36.288,Percent of Total Billed Charges,72% of Total Billed Charges,74.09,60,,30.24,Percent of Total Billed Charges,60% of Total Billed Charges,111.13,90,,5326.4,Percent of Total Billed Charges,90% of Total Billed Charges,55.57,45,,138.96,Percent of Total Billed Charges,45% of Total Billed Charges,111.13,90,,20.16,Percent of Total Billed Charges,90% of Total billed Charges,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.26,65,,27.56,Percent of total Billed Charges,65% of Total Billed Charges,54.45,44.1,,136.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,117.31,95,,21.28,Percent of Total Billed Charges,95% of Total Billed Charges,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.66,88,,19.712,Percent of Total Billed Charges,88% of Total Billed Charges,111.13,90,,20.16,Percent of Total Billed charges,90% of Total Billed Charges,54.45,123.48,
SKINTEGRITY 1 FL OZ,2720001392,CDM,272,RC,,,Outpatient,,,36.38,23.65,,36.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.65,76,,1.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.19,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,27.29,75,,918,Percent of Total Billed charges,75% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.19,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,21.83,60,,734.4,Percent of Total Billed Charges,60% of Total Billed Charges,32.74,90,,5326.4,Percent of Total Billed Charges,90% of Total Billed Charges,16.37,45,,0.72,Percent of Total Billed Charges,45% of Total Billed Charges,32.74,90,,1.44,Percent of Total Billed Charges,90% of Total billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.65,65,,200.72,Percent of total Billed Charges,65% of Total Billed Charges,16.04,44.1,,0.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.56,95,,1.52,Percent of Total Billed Charges,95% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.01,88,,1.408,Percent of Total Billed Charges,88% of Total Billed Charges,32.74,90,,1.44,Percent of Total Billed charges,90% of Total Billed Charges,16.04,36.38,
MEDFILL PARTICLES 10,2720001393,CDM,272,RC,,,Outpatient,,,45.20,29.38,,45.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.35,76,,32.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.54,72,,41.472,Percent of Total Billed Charges,72% of Total Billed Charges,33.9,75,,43.2,Percent of Total Billed charges,75% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.54,72,,41.472,Percent of Total Billed Charges,72% of Total Billed Charges,27.12,60,,34.56,Percent of Total Billed Charges,60% of Total Billed Charges,40.68,90,,5326.4,Percent of Total Billed Charges,90% of Total Billed Charges,20.34,45,,1.8,Percent of Total Billed Charges,45% of Total Billed Charges,40.68,90,,38.16,Percent of Total Billed Charges,90% of Total billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.38,65,,1.04,Percent of total Billed Charges,65% of Total Billed Charges,19.93,44.1,,1.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.94,95,,40.28,Percent of Total Billed Charges,95% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.78,88,,37.312,Percent of Total Billed Charges,88% of Total Billed Charges,40.68,90,,38.16,Percent of Total Billed charges,90% of Total Billed Charges,19.93,45.2,
SORBSON 4X8,2720001394,CDM,272,RC,,,Outpatient,,,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,234.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,48.648,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,50.68,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,48.648,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,40.544,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,5326.4,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,194.76,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,277.92,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,2.6,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,190.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,293.36,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,271.744,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,277.92,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
SORBSON 4X4,2720001395,CDM,272,RC,,,Outpatient,,,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,1.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,30.848,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,32.128,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,30.848,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,25.704,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,5326.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,54.72,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,1.44,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,281.32,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,53.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,1.52,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,1.408,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,1.44,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
CHLORAZENE 15 GM,2720001396,CDM,272,RC,,,Outpatient,,,2.21,1.44,,2.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.68,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.59,72,,77.776,Percent of Total Billed Charges,72% of Total Billed Charges,1.66,75,,81.016,Percent of Total Billed charges,75% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,72,,77.776,Percent of Total Billed Charges,72% of Total Billed Charges,1.33,60,,64.816,Percent of Total Billed Charges,60% of Total Billed Charges,1.99,90,,5326.4,Percent of Total Billed Charges,90% of Total Billed Charges,0.99,45,,2663.2,Percent of Total Billed Charges,45% of Total Billed Charges,1.99,90,,3.6,Percent of Total Billed Charges,90% of Total billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,65,,79.04,Percent of total Billed Charges,65% of Total Billed Charges,0.97,44.1,,2609.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.1,95,,3.8,Percent of Total Billed Charges,95% of Total Billed Charges,2.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.94,88,,3.52,Percent of Total Billed Charges,88% of Total Billed Charges,1.99,90,,3.6,Percent of Total Billed charges,90% of Total Billed Charges,0.97,2.21,
PROFORE,2720001397,CDM,272,RC,,,Outpatient,,,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,328.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,15.71,75,,53.584,Percent of Total Billed charges,75% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,42.872,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,2663.2,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,389.52,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,3846.848,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,2609.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,411.16,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,380.864,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,389.52,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
DUODERM 4x4 XTR THIN,2720001398,CDM,272,RC,,,Outpatient,,,36.38,23.65,,36.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.65,76,,92.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.19,72,,37.328,Percent of Total Billed Charges,72% of Total Billed Charges,27.29,75,,38.888,Percent of Total Billed charges,75% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.19,72,,37.328,Percent of Total Billed Charges,72% of Total Billed Charges,21.83,60,,31.112,Percent of Total Billed Charges,60% of Total Billed Charges,32.74,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,16.37,45,,2663.2,Percent of Total Billed Charges,45% of Total Billed Charges,32.74,90,,109.44,Percent of Total Billed Charges,90% of Total billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.65,65,,3846.848,Percent of total Billed Charges,65% of Total Billed Charges,16.04,44.1,,2609.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.56,95,,115.52,Percent of Total Billed Charges,95% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.01,88,,107.008,Percent of Total Billed Charges,88% of Total Billed Charges,32.74,90,,109.44,Percent of Total Billed charges,90% of Total Billed Charges,16.04,36.38,
MEDIFIL,2720001399,CDM,272,RC,,,Outpatient,,,45.20,29.38,,45.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.35,76,,4497.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.54,72,,129.552,Percent of Total Billed Charges,72% of Total Billed Charges,33.9,75,,134.944,Percent of Total Billed charges,75% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.54,72,,129.552,Percent of Total Billed Charges,72% of Total Billed Charges,27.12,60,,107.96,Percent of Total Billed Charges,60% of Total Billed Charges,40.68,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,20.34,45,,2663.2,Percent of Total Billed Charges,45% of Total Billed Charges,40.68,90,,5326.4,Percent of Total Billed Charges,90% of Total billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.38,65,,3846.848,Percent of total Billed Charges,65% of Total Billed Charges,19.93,44.1,,2609.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.94,95,,5622.312,Percent of Total Billed Charges,95% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.78,88,,5208.04,Percent of Total Billed Charges,88% of Total Billed Charges,40.68,90,,5326.4,Percent of Total Billed charges,90% of Total Billed Charges,19.93,45.2,
PRIMAPORE 4X8,2720001400,CDM,272,RC,,,Outpatient,,,17.64,11.47,,17.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.41,76,,4497.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.7,72,,316.8,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,75,,330,Percent of Total Billed charges,75% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.7,72,,316.8,Percent of Total Billed Charges,72% of Total Billed Charges,10.58,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,15.88,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,7.94,45,,2663.2,Percent of Total Billed Charges,45% of Total Billed Charges,15.88,90,,5326.4,Percent of Total Billed Charges,90% of Total billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.47,65,,3846.848,Percent of total Billed Charges,65% of Total Billed Charges,7.78,44.1,,2609.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.76,95,,5622.312,Percent of Total Billed Charges,95% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.52,88,,5208.04,Percent of Total Billed Charges,88% of Total Billed Charges,15.88,90,,5326.4,Percent of Total Billed charges,90% of Total Billed Charges,7.78,17.64,
ALLEVYN 6X6,2720001401,CDM,272,RC,,,Outpatient,,,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,4497.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,9.216,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,9.6,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,9.216,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,2663.2,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,5326.4,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,3846.848,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,2609.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,5622.312,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,5208.04,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,5326.4,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
OPTILOCK SM,2720001402,CDM,272,RC,,,Outpatient,,,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,4497.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,18.2,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,2663.2,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,5326.4,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,3846.848,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,2609.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,5622.312,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,5208.04,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,5326.4,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
OPTILOCK MED,2720001403,CDM,272,RC,,,Outpatient,,,26.46,17.20,,26.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.11,76,,4497.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.05,72,,3.4,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,75,,3.544,Percent of Total Billed charges,75% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.05,72,,3.4,Percent of Total Billed Charges,72% of Total Billed Charges,15.88,60,,2.832,Percent of Total Billed Charges,60% of Total Billed Charges,23.81,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,11.91,45,,2663.2,Percent of Total Billed Charges,45% of Total Billed Charges,23.81,90,,5326.4,Percent of Total Billed Charges,90% of Total billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,65,,3846.848,Percent of total Billed Charges,65% of Total Billed Charges,11.67,44.1,,2609.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.14,95,,5622.312,Percent of Total Billed Charges,95% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.28,88,,5208.04,Percent of Total Billed Charges,88% of Total Billed Charges,23.81,90,,5326.4,Percent of Total Billed charges,90% of Total Billed Charges,11.67,26.46,
OPTILOCK LG,2720001404,CDM,272,RC,,,Outpatient,,,28.67,18.64,,28.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21.79,76,,4497.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.64,72,,15.552,Percent of Total Billed Charges,72% of Total Billed Charges,21.5,75,,16.2,Percent of Total Billed charges,75% of Total Billed Charges,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.64,72,,15.552,Percent of Total Billed Charges,72% of Total Billed Charges,17.2,60,,12.96,Percent of Total Billed Charges,60% of Total Billed Charges,25.8,90,,130.976,Percent of Total Billed Charges,90% of Total Billed Charges,12.9,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,25.8,90,,5326.4,Percent of Total Billed Charges,90% of Total billed Charges,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.64,65,,3846.848,Percent of total Billed Charges,65% of Total Billed Charges,12.64,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,27.24,95,,5622.312,Percent of Total Billed Charges,95% of Total Billed Charges,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.23,88,,5208.04,Percent of Total Billed Charges,88% of Total Billed Charges,25.8,90,,5326.4,Percent of Total Billed charges,90% of Total Billed Charges,12.64,28.67,
AQUACEL AG ADVANTAGE 2X2,2720001405,CDM,272,RC,,,Outpatient,,,40.66,26.43,,40.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,30.9,76,,4497.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.28,72,,14.976,Percent of Total Billed Charges,72% of Total Billed Charges,30.5,75,,15.6,Percent of Total Billed charges,75% of Total Billed Charges,40.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.28,72,,14.976,Percent of Total Billed Charges,72% of Total Billed Charges,24.4,60,,12.48,Percent of Total Billed Charges,60% of Total Billed Charges,36.59,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,18.3,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,36.59,90,,5326.4,Percent of Total Billed Charges,90% of Total billed Charges,40.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.43,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,17.93,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.63,95,,5622.312,Percent of Total Billed Charges,95% of Total Billed Charges,40.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.78,88,,5208.04,Percent of Total Billed Charges,88% of Total Billed Charges,36.59,90,,5326.4,Percent of Total Billed charges,90% of Total Billed Charges,17.93,40.66,
AQUACEL AG ADVANTAGE 6X6,2720001406,CDM,272,RC,,,Outpatient,,,104.96,68.22,,104.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.77,76,,4497.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75.57,72,,12.672,Percent of Total Billed Charges,72% of Total Billed Charges,78.72,75,,13.2,Percent of Total Billed charges,75% of Total Billed Charges,104.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.57,72,,12.672,Percent of Total Billed Charges,72% of Total Billed Charges,62.98,60,,10.56,Percent of Total Billed Charges,60% of Total Billed Charges,94.46,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,47.23,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,94.46,90,,5326.4,Percent of Total Billed Charges,90% of Total billed Charges,104.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.22,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,46.29,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,99.71,95,,5622.312,Percent of Total Billed Charges,95% of Total Billed Charges,104.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.36,88,,5208.04,Percent of Total Billed Charges,88% of Total Billed Charges,94.46,90,,5326.4,Percent of Total Billed charges,90% of Total Billed Charges,46.29,104.96,
PT AQUACEL AG STRIP,2720001407,CDM,272,RC,,,Outpatient,,,55.84,36.30,,55.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.44,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.2,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,41.88,75,,1.2,Percent of Total Billed charges,75% of Total Billed Charges,55.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.2,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,33.5,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,50.26,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,25.13,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,50.26,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,55.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.3,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,24.63,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.05,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,55.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.14,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,50.26,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,24.63,55.84,
PT PRISMA,2720001408,CDM,272,RC,,,Outpatient,,,60.39,39.25,,60.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.9,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.48,72,,66.24,Percent of Total Billed Charges,72% of Total Billed Charges,45.29,75,,69,Percent of Total Billed charges,75% of Total Billed Charges,60.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.48,72,,66.24,Percent of Total Billed Charges,72% of Total Billed Charges,36.23,60,,55.2,Percent of Total Billed Charges,60% of Total Billed Charges,54.35,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,27.18,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,54.35,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,60.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.25,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,26.63,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.37,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,60.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.14,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,54.35,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,26.63,60.39,
PT SILVERCEL 4X4,2720001409,CDM,272,RC,,,Outpatient,,,60.91,39.59,,60.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.29,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.86,72,,66.24,Percent of Total Billed Charges,72% of Total Billed Charges,45.68,75,,69,Percent of Total Billed charges,75% of Total Billed Charges,60.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.86,72,,66.24,Percent of Total Billed Charges,72% of Total Billed Charges,36.55,60,,55.2,Percent of Total Billed Charges,60% of Total Billed Charges,54.82,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,27.41,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,54.82,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,60.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.59,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,26.86,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.86,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,60.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.6,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,54.82,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,26.86,60.91,
PT MEPILEX 2X2,2720001410,CDM,272,RC,,,Outpatient,,,23.28,15.13,,23.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.69,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.76,72,,66.24,Percent of Total Billed Charges,72% of Total Billed Charges,17.46,75,,69,Percent of Total Billed charges,75% of Total Billed Charges,23.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.76,72,,66.24,Percent of Total Billed Charges,72% of Total Billed Charges,13.97,60,,55.2,Percent of Total Billed Charges,60% of Total Billed Charges,20.95,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,10.48,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,20.95,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,23.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.13,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,10.27,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.12,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,23.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.49,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,20.95,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,10.27,23.28,
PT MEPILEX 3X3,2720001411,CDM,272,RC,,,Outpatient,,,34.86,22.66,,34.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.49,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.1,72,,1.928,Percent of Total Billed Charges,72% of Total Billed Charges,26.15,75,,2.008,Percent of Total Billed charges,75% of Total Billed Charges,34.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.1,72,,1.928,Percent of Total Billed Charges,72% of Total Billed Charges,20.92,60,,1.608,Percent of Total Billed Charges,60% of Total Billed Charges,31.37,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,15.69,45,,65.488,Percent of Total Billed Charges,45% of Total Billed Charges,31.37,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,34.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.66,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,15.37,44.1,,64.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.12,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,34.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.68,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,31.37,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,15.37,34.86,
PT MEPILEX 4X4,2720001412,CDM,272,RC,,,Outpatient,,,35.91,23.34,,35.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.29,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.86,72,,10.944,Percent of Total Billed Charges,72% of Total Billed Charges,26.93,75,,11.4,Percent of Total Billed charges,75% of Total Billed Charges,35.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.86,72,,10.944,Percent of Total Billed Charges,72% of Total Billed Charges,21.55,60,,9.12,Percent of Total Billed Charges,60% of Total Billed Charges,32.32,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,16.16,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,32.32,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,35.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.34,65,,94.592,Percent of total Billed Charges,65% of Total Billed Charges,15.84,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.11,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,35.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.6,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,32.32,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,15.84,35.91,
PT MEPILEX 7X7,2720001413,CDM,272,RC,,,Outpatient,,,72.77,47.30,,72.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.31,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.39,72,,5.256,Percent of Total Billed Charges,72% of Total Billed Charges,54.58,75,,5.48,Percent of Total Billed charges,75% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.39,72,,5.256,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,60,,4.384,Percent of Total Billed Charges,60% of Total Billed Charges,65.49,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,32.75,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,65.49,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.3,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,32.09,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,69.13,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.04,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,65.49,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,32.09,72.77,
PT KERLIX,2720001414,CDM,272,RC,,,Outpatient,,,3.84,2.50,,3.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.92,76,,110.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.76,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,2.88,75,,1.2,Percent of Total Billed charges,75% of Total Billed Charges,3.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.76,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,2.3,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,3.46,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,1.73,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,3.46,90,,130.976,Percent of Total Billed Charges,90% of Total billed Charges,3.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.5,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,1.69,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.65,95,,138.248,Percent of Total Billed Charges,95% of Total Billed Charges,3.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.38,88,,128.064,Percent of Total Billed Charges,88% of Total Billed Charges,3.46,90,,130.976,Percent of Total Billed charges,90% of Total Billed Charges,1.69,3.84,
PT GAUZE 4 X 4,2720001415,CDM,272,RC,,,Outpatient,,,3.79,2.46,,3.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.88,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.73,72,,4.608,Percent of Total Billed Charges,72% of Total Billed Charges,2.84,75,,4.8,Percent of Total Billed charges,75% of Total Billed Charges,3.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.73,72,,4.608,Percent of Total Billed Charges,72% of Total Billed Charges,2.27,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,3.41,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,1.71,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,3.41,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,3.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.46,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,1.67,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.6,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,3.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.34,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,3.41,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,1.67,3.79,
PT COMBINE  ABD,2720001416,CDM,272,RC,,,Outpatient,,,3.40,2.21,,3.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.58,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.45,72,,8.064,Percent of Total Billed Charges,72% of Total Billed Charges,2.55,75,,8.4,Percent of Total Billed charges,75% of Total Billed Charges,3.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.45,72,,8.064,Percent of Total Billed Charges,72% of Total Billed Charges,2.04,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,1.53,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,3.06,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,3.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,1.5,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.23,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,3.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.99,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,3.06,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,1.5,3.4,
PT CARRAKLENZ 6 OZ,2720001417,CDM,272,RC,,,Outpatient,,,28.97,18.83,,28.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.02,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.86,72,,47.232,Percent of Total Billed Charges,72% of Total Billed Charges,21.73,75,,49.2,Percent of Total Billed charges,75% of Total Billed Charges,28.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.86,72,,47.232,Percent of Total Billed Charges,72% of Total Billed Charges,17.38,60,,39.36,Percent of Total Billed Charges,60% of Total Billed Charges,26.07,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,13.04,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,26.07,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,28.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.83,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,12.78,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,27.52,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,28.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.49,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,26.07,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,12.78,28.97,
PT CARRAKLENZ 8 OZ,2720001418,CDM,272,RC,,,Outpatient,,,36.80,23.92,,36.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.97,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.5,72,,54.72,Percent of Total Billed Charges,72% of Total Billed Charges,27.6,75,,57,Percent of Total Billed charges,75% of Total Billed Charges,36.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.5,72,,54.72,Percent of Total Billed Charges,72% of Total Billed Charges,22.08,60,,45.6,Percent of Total Billed Charges,60% of Total Billed Charges,33.12,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,16.56,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,33.12,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,36.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.92,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,16.23,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.96,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,36.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.38,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,33.12,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,16.23,36.8,
DERMABOND/STAPLES,2720001419,CDM,272,RC,,,Outpatient,,,99.23,64.50,,99.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.41,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71.45,72,,633.6,Percent of Total Billed Charges,72% of Total Billed Charges,74.42,75,,660,Percent of Total Billed charges,75% of Total Billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.45,72,,633.6,Percent of Total Billed Charges,72% of Total Billed Charges,59.54,60,,528,Percent of Total Billed Charges,60% of Total Billed Charges,89.31,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,44.65,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,89.31,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.5,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,43.76,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,94.27,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.32,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,89.31,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,43.76,99.23,
PERIFIX FX CONT EPIDU ST/CATH,2720001420,CDM,272,RC,,,Outpatient,,,25.00,16.25,,25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,18.75,75,,1.2,Percent of Total Billed charges,75% of Total Billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,15,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,22.5,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,11.25,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,22.5,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.25,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,11.03,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.75,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,22.5,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,11.03,25,
POLYANIDE PERIFIX EPIDUR CATH,2720001421,CDM,272,RC,,,Outpatient,,,49.00,31.85,,49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,37.24,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,35.28,72,,4.432,Percent of Total Billed Charges,72% of Total Billed Charges,36.75,75,,4.624,Percent of Total Billed charges,75% of Total Billed Charges,49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,72,,4.432,Percent of Total Billed Charges,72% of Total Billed Charges,29.4,60,,3.696,Percent of Total Billed Charges,60% of Total Billed Charges,44.1,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,22.05,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,44.1,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.85,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,21.61,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.55,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.12,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,44.1,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,21.61,49,
FOLEY CATH 20F 5CC 2WY,2720001427,CDM,272,RC,,,Outpatient,,,17.00,11.05,,17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.92,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.24,72,,14.4,Percent of Total Billed Charges,72% of Total Billed Charges,12.75,75,,15,Percent of Total Billed charges,75% of Total Billed Charges,17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.24,72,,14.4,Percent of Total Billed Charges,72% of Total Billed Charges,10.2,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,15.3,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,7.65,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,15.3,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.05,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,7.5,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.15,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.96,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,15.3,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,7.5,17,
MEDTRONIC INTERSTIM 3576,2720001428,CDM,272,RC,,,Outpatient,,,105.84,68.80,,105.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,80.44,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,76.2,72,,14.4,Percent of Total Billed Charges,72% of Total Billed Charges,79.38,75,,15,Percent of Total Billed charges,75% of Total Billed Charges,105.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.2,72,,14.4,Percent of Total Billed Charges,72% of Total Billed Charges,63.5,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,95.26,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,47.63,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,95.26,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,105.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.8,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,46.68,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,100.55,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,105.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.14,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,95.26,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,46.68,105.84,
MEDTRONIC ANTENNA,2720001429,CDM,272,RC,,,Outpatient,,,105.84,68.80,,105.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,80.44,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,76.2,72,,14.4,Percent of Total Billed Charges,72% of Total Billed Charges,79.38,75,,15,Percent of Total Billed charges,75% of Total Billed Charges,105.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.2,72,,14.4,Percent of Total Billed Charges,72% of Total Billed Charges,63.5,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,95.26,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,47.63,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,95.26,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,105.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.8,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,46.68,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,100.55,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,105.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.14,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,95.26,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,46.68,105.84,
GUIDED BILIARY DILATOR SET,2720001430,CDM,272,RC,,,Outpatient,,,515.20,334.88,,515.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,391.55,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,370.94,72,,3.456,Percent of Total Billed Charges,72% of Total Billed Charges,386.4,75,,3.6,Percent of Total Billed charges,75% of Total Billed Charges,515.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.94,72,,3.456,Percent of Total Billed Charges,72% of Total Billed Charges,309.12,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,463.68,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,231.84,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,463.68,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,515.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,515.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,515.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.88,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,227.2,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,489.44,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,515.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.38,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,463.68,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,227.2,515.2,
CYSTO TUBING,2720001431,CDM,272,RC,,,Outpatient,,,73.87,48.02,,73.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.14,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.19,72,,3.456,Percent of Total Billed Charges,72% of Total Billed Charges,55.4,75,,3.6,Percent of Total Billed charges,75% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.19,72,,3.456,Percent of Total Billed Charges,72% of Total Billed Charges,44.32,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,66.48,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,33.24,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,66.48,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.02,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,32.58,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,70.18,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.01,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,66.48,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,32.58,73.87,
NEEDLE SPINAL 25G X3 1/2,2720001432,CDM,272,RC,,,Outpatient,,,38.59,25.08,,38.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.33,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.78,72,,3.456,Percent of Total Billed Charges,72% of Total Billed Charges,28.94,75,,3.6,Percent of Total Billed charges,75% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.78,72,,3.456,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,34.73,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,17.37,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,34.73,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.08,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,17.02,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.66,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.96,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,34.73,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,17.02,38.59,
DOUBLE VENOUS CATH TRAY,2720001433,CDM,272,RC,,,Outpatient,,,289.96,188.47,,289.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,220.37,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,208.77,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,217.47,75,,3,Percent of Total Billed charges,75% of Total Billed Charges,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.77,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,173.98,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,260.96,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,130.48,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,260.96,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.47,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,127.87,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,275.46,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.16,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,260.96,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,127.87,289.96,
BONE MARROW TRAY,2720001434,CDM,272,RC,,,Outpatient,,,415.64,270.17,,415.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,315.89,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,299.26,72,,106.56,Percent of Total Billed Charges,72% of Total Billed Charges,311.73,75,,111,Percent of Total Billed charges,75% of Total Billed Charges,415.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,299.26,72,,106.56,Percent of Total Billed Charges,72% of Total Billed Charges,249.38,60,,88.8,Percent of Total Billed Charges,60% of Total Billed Charges,374.08,90,,146.056,Percent of Total Billed Charges,90% of Total Billed Charges,187.04,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,374.08,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,415.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.17,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,183.3,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,394.86,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,415.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365.76,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,374.08,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,183.3,415.64,
CATH FOLEY 18FR 30CC 3WY,2720001435,CDM,272,RC,,,Outpatient,,,74.97,48.73,,74.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.98,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.98,72,,316.8,Percent of Total Billed Charges,72% of Total Billed Charges,56.23,75,,330,Percent of Total Billed charges,75% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.98,72,,316.8,Percent of Total Billed Charges,72% of Total Billed Charges,44.98,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,67.47,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,33.74,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,67.47,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.73,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,33.06,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,71.22,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.97,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,67.47,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,33.06,74.97,
CATH ALL PURPOSE 8 FR RED RUB,2720001436,CDM,272,RC,,,Outpatient,,,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,72,,134.784,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,75,,140.4,Percent of Total Billed charges,75% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,72,,134.784,Percent of Total Billed Charges,72% of Total Billed Charges,5.95,60,,112.32,Percent of Total Billed Charges,60% of Total Billed Charges,8.93,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,4.37,9.92,
CATH ALL PURPO 10 FR/RED RUB,2720001437,CDM,272,RC,,,Outpatient,,,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,72,,167.616,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,75,,174.6,Percent of Total Billed charges,75% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,72,,167.616,Percent of Total Billed Charges,72% of Total Billed Charges,5.95,60,,139.68,Percent of Total Billed Charges,60% of Total Billed Charges,8.93,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,4.37,9.92,
CATH ALL PURPO 20 FR RED RUBB,2720001438,CDM,272,RC,,,Outpatient,,,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,72,,475.2,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,75,,495,Percent of Total Billed charges,75% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,72,,475.2,Percent of Total Billed Charges,72% of Total Billed Charges,5.95,60,,396,Percent of Total Billed Charges,60% of Total Billed Charges,8.93,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,4.37,9.92,
UMBILICAL ART CATH 3.5FR 10/CS,2720001439,CDM,272,RC,,,Outpatient,,,105.84,68.80,,105.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,80.44,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,76.2,72,,100.224,Percent of Total Billed Charges,72% of Total Billed Charges,79.38,75,,104.4,Percent of Total Billed charges,75% of Total Billed Charges,105.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.2,72,,100.224,Percent of Total Billed Charges,72% of Total Billed Charges,63.5,60,,83.52,Percent of Total Billed Charges,60% of Total Billed Charges,95.26,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,47.63,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,95.26,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,105.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.8,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,46.68,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,100.55,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,105.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.14,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,95.26,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,46.68,105.84,
UMBILICAL ART CATH 5FR  10/CS,2720001440,CDM,272,RC,,,Outpatient,,,90.41,58.77,,90.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.71,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.1,72,,73.152,Percent of Total Billed Charges,72% of Total Billed Charges,67.81,75,,76.2,Percent of Total Billed charges,75% of Total Billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.1,72,,73.152,Percent of Total Billed Charges,72% of Total Billed Charges,54.25,60,,60.96,Percent of Total Billed Charges,60% of Total Billed Charges,81.37,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,40.68,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,81.37,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.77,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,39.87,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.89,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,90.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.56,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,81.37,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,39.87,90.41,
STERILE LABEL SW/MARKER,2720001441,CDM,272,RC,,,Outpatient,,,19.70,12.81,,19.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.97,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.18,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,14.78,75,,918,Percent of Total Billed charges,75% of Total Billed Charges,19.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.18,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,11.82,60,,734.4,Percent of Total Billed Charges,60% of Total Billed Charges,17.73,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,8.87,45,,73.032,Percent of Total Billed Charges,45% of Total Billed Charges,17.73,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,19.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.81,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,8.69,44.1,,71.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.72,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,19.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.34,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,17.73,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,8.69,19.7,
7FR REVERSE BERM ANGIO CATH,2720001442,CDM,272,RC,,,Outpatient,,,116.87,75.97,,116.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,88.82,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.15,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,87.65,75,,918,Percent of Total Billed charges,75% of Total Billed Charges,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.15,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,70.12,60,,734.4,Percent of Total Billed Charges,60% of Total Billed Charges,105.18,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,52.59,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,105.18,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.97,65,,105.488,Percent of total Billed Charges,65% of Total Billed Charges,51.54,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,111.03,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.85,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,105.18,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,51.54,116.87,
7FR T-TIP MONITORI SWAN-GANZ,2720001443,CDM,272,RC,,,Outpatient,,,178.61,116.10,,178.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,135.74,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,128.6,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,133.96,75,,918,Percent of Total Billed charges,75% of Total Billed Charges,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.6,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,107.17,60,,734.4,Percent of Total Billed Charges,60% of Total Billed Charges,160.75,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,80.37,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,160.75,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.1,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,78.77,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,169.68,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.18,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,160.75,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,78.77,178.61,
CHOICE PT ES J 182CM X .014 WI,2720001444,CDM,272,RC,,,Outpatient,,,282.24,183.46,,282.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,214.5,76,,123.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,203.21,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,211.68,75,,918,Percent of Total Billed charges,75% of Total Billed Charges,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.21,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,169.34,60,,734.4,Percent of Total Billed Charges,60% of Total Billed Charges,254.02,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,127.01,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,254.02,90,,146.056,Percent of Total Billed Charges,90% of Total billed Charges,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.46,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,124.47,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,268.13,95,,154.176,Percent of Total Billed Charges,95% of Total Billed Charges,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.37,88,,142.816,Percent of Total Billed Charges,88% of Total Billed Charges,254.02,90,,146.056,Percent of Total Billed charges,90% of Total Billed Charges,124.47,282.24,
CORDIS 4F PIG STRAIGHT CATHETE,2720001445,CDM,272,RC,,,Outpatient,,,80.00,52.00,,80,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60.8,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.6,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,60,75,,918,Percent of Total Billed charges,75% of Total Billed Charges,80,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.6,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,48,60,,734.4,Percent of Total Billed Charges,60% of Total Billed Charges,72,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,36,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,72,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,80,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,35.28,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,76,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,80,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.4,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,72,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,35.28,80,
GUINTHER TULIP VC FIL RET SET,2720001446,CDM,272,RC,C1773,HCPCS,Outpatient,,,550.00,357.50,,550,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,418,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,396,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,412.5,75,,918,Percent of Total Billed charges,75% of Total Billed Charges,550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,330,60,,734.4,Percent of Total Billed Charges,60% of Total Billed Charges,495,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,247.5,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,495,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.5,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,242.55,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,522.5,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,495,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,242.55,550,
C1 5F 100CM BT 0.035 CATHETER,2720001447,CDM,272,RC,C1887,HCPCS,Outpatient,,,113.00,73.45,,113,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,85.88,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,81.36,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,84.75,75,,918,Percent of Total Billed charges,75% of Total Billed Charges,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.36,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,67.8,60,,734.4,Percent of Total Billed Charges,60% of Total Billed Charges,101.7,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,50.85,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,101.7,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.45,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,49.83,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,107.35,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.44,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,101.7,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,49.83,113,
C1 5F 65CM BT 0.035 CATHETER,2720001448,CDM,272,RC,C1887,HCPCS,Outpatient,,,113.00,73.45,,113,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,85.88,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,81.36,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,84.75,75,,918,Percent of Total Billed charges,75% of Total Billed Charges,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.36,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,67.8,60,,734.4,Percent of Total Billed Charges,60% of Total Billed Charges,101.7,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,50.85,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,101.7,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.45,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,49.83,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,107.35,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.44,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,101.7,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,49.83,113,
IVBD NEXIVA 18G X 1.25 INCH,2720001449,CDM,272,RC,,,Outpatient,,,25.00,16.25,,25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18,72,,83.52,Percent of Total Billed Charges,72% of Total Billed Charges,18.75,75,,87,Percent of Total Billed charges,75% of Total Billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18,72,,83.52,Percent of Total Billed Charges,72% of Total Billed Charges,15,60,,69.6,Percent of Total Billed Charges,60% of Total Billed Charges,22.5,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,11.25,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,22.5,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.25,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,11.03,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.75,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,22.5,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,11.03,25,
SIMI 5F 65CM BT 0.035 CATHETER,2720001450,CDM,272,RC,C1887,HCPCS,Outpatient,,,113.00,73.45,,113,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,85.88,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,81.36,72,,29.952,Percent of Total Billed Charges,72% of Total Billed Charges,84.75,75,,31.2,Percent of Total Billed charges,75% of Total Billed Charges,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.36,72,,29.952,Percent of Total Billed Charges,72% of Total Billed Charges,67.8,60,,24.96,Percent of Total Billed Charges,60% of Total Billed Charges,101.7,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,50.85,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,101.7,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.45,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,49.83,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,107.35,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.44,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,101.7,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,49.83,113,
IVBD NEXIVA 22G X 1 INCH,2720001451,CDM,272,RC,,,Outpatient,,,25.00,16.25,,25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,18.75,75,,3.976,Percent of Total Billed charges,75% of Total Billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18,72,,3.816,Percent of Total Billed Charges,72% of Total Billed Charges,15,60,,3.176,Percent of Total Billed Charges,60% of Total Billed Charges,22.5,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,11.25,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,22.5,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.25,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,11.03,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.75,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,22.5,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,11.03,25,
IVBD NEXIVA 20G X 1 INCH,2720001452,CDM,272,RC,,,Outpatient,,,25.00,16.25,,25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,18.75,75,,3,Percent of Total Billed charges,75% of Total Billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,15,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,22.5,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,11.25,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,22.5,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.25,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,11.03,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.75,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,22.5,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,11.03,25,
HEMOLOCK MD/LG CLIP,2720001453,CDM,272,RC,,,Outpatient,,,385.00,250.25,,385,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,292.6,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,277.2,72,,34.272,Percent of Total Billed Charges,72% of Total Billed Charges,288.75,75,,35.704,Percent of Total Billed charges,75% of Total Billed Charges,385,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.2,72,,34.272,Percent of Total Billed Charges,72% of Total Billed Charges,231,60,,28.56,Percent of Total Billed Charges,60% of Total Billed Charges,346.5,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,173.25,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,346.5,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,385,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.25,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,169.79,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,365.75,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,385,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,338.8,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,346.5,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,169.79,385,
HEMOLOCK LG CLIP,2720001454,CDM,272,RC,,,Outpatient,,,385.00,250.25,,385,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,292.6,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,277.2,72,,3.88,Percent of Total Billed Charges,72% of Total Billed Charges,288.75,75,,4.048,Percent of Total Billed charges,75% of Total Billed Charges,385,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.2,72,,3.88,Percent of Total Billed Charges,72% of Total Billed Charges,231,60,,3.232,Percent of Total Billed Charges,60% of Total Billed Charges,346.5,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,173.25,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,346.5,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,385,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.25,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,169.79,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,365.75,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,385,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,338.8,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,346.5,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,169.79,385,
STYKER FLYTE TOGA 3XLG,2720001455,CDM,272,RC,,,Outpatient,,,90.00,58.50,,90,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.4,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.8,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,67.5,75,,7.2,Percent of Total Billed charges,75% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.8,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,54,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,81,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,81,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.5,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,39.69,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.5,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,81,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,39.69,90,
STYKER FLYTE TOGA X LARGE,2720001456,CDM,272,RC,,,Outpatient,,,80.00,52.00,,80,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60.8,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.6,72,,3.84,Percent of Total Billed Charges,72% of Total Billed Charges,60,75,,4,Percent of Total Billed charges,75% of Total Billed Charges,80,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.6,72,,3.84,Percent of Total Billed Charges,72% of Total Billed Charges,48,60,,3.2,Percent of Total Billed Charges,60% of Total Billed Charges,72,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,36,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,72,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,80,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,35.28,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,76,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,80,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.4,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,72,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,35.28,80,
WRAPON PAD XL,2720001457,CDM,272,RC,,,Outpatient,,,38.00,24.70,,38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.88,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.36,72,,1.872,Percent of Total Billed Charges,72% of Total Billed Charges,28.5,75,,1.952,Percent of Total Billed charges,75% of Total Billed Charges,38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.36,72,,1.872,Percent of Total Billed Charges,72% of Total Billed Charges,22.8,60,,1.56,Percent of Total Billed Charges,60% of Total Billed Charges,34.2,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,34.2,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.7,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,16.76,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.1,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.44,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,34.2,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,16.76,38,
BREG POLAR CARE CUBE,2720001458,CDM,272,RC,,,Outpatient,,,75.00,48.75,,75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,57,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,54,72,,2.536,Percent of Total Billed Charges,72% of Total Billed Charges,56.25,75,,2.64,Percent of Total Billed charges,75% of Total Billed Charges,75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54,72,,2.536,Percent of Total Billed Charges,72% of Total Billed Charges,45,60,,2.112,Percent of Total Billed Charges,60% of Total Billed Charges,67.5,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,33.75,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,67.5,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.75,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,33.08,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,71.25,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,67.5,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,33.08,75,
BIOSEAL SURGICAL BUTTONS,2720001459,CDM,272,RC,,,Outpatient,,,5.00,3.25,,5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.8,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.6,72,,2.664,Percent of Total Billed Charges,72% of Total Billed Charges,3.75,75,,2.776,Percent of Total Billed charges,75% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.6,72,,2.664,Percent of Total Billed Charges,72% of Total Billed Charges,3,60,,2.224,Percent of Total Billed Charges,60% of Total Billed Charges,4.5,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.25,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,4.5,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.25,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,2.21,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.75,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.4,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,4.5,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,2.21,5,
PULL OUT SUTURE SET,2720001460,CDM,272,RC,,,Outpatient,,,13.00,8.45,,13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.88,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.36,72,,4.976,Percent of Total Billed Charges,72% of Total Billed Charges,9.75,75,,5.184,Percent of Total Billed charges,75% of Total Billed Charges,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.36,72,,4.976,Percent of Total Billed Charges,72% of Total Billed Charges,7.8,60,,4.144,Percent of Total Billed Charges,60% of Total Billed Charges,11.7,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,5.85,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,11.7,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.45,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,5.73,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.35,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.44,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,11.7,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,5.73,13,
CETERIX NOVOTITCH PRO,2720001461,CDM,272,RC,,,Outpatient,,,2219.00,1442.35,,2219,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1686.44,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1597.68,72,,5.44,Percent of Total Billed Charges,72% of Total Billed Charges,1664.25,75,,5.672,Percent of Total Billed charges,75% of Total Billed Charges,2219,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1597.68,72,,5.44,Percent of Total Billed Charges,72% of Total Billed Charges,1331.4,60,,4.536,Percent of Total Billed Charges,60% of Total Billed Charges,1997.1,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,998.55,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,1997.1,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,2219,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2219,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2219,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1442.35,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,978.58,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,2108.05,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,2219,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1952.72,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,1997.1,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,978.58,2219,
ENT CEPS DISP,2720001462,CDM,272,RC,,,Outpatient,,,190.00,123.50,,190,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.4,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,136.8,72,,2.248,Percent of Total Billed Charges,72% of Total Billed Charges,142.5,75,,2.344,Percent of Total Billed charges,75% of Total Billed Charges,190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.8,72,,2.248,Percent of Total Billed Charges,72% of Total Billed Charges,114,60,,1.872,Percent of Total Billed Charges,60% of Total Billed Charges,171,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,85.5,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,171,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.5,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,83.79,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,180.5,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.2,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,171,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,83.79,190,
Z281001100 GDEWRE 3.0X100,2720001463,CDM,272,RC,,,Outpatient,,,127.00,82.55,,127,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,96.52,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.44,72,,1.728,Percent of Total Billed Charges,72% of Total Billed Charges,95.25,75,,1.8,Percent of Total Billed charges,75% of Total Billed Charges,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.44,72,,1.728,Percent of Total Billed Charges,72% of Total Billed Charges,76.2,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,114.3,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,57.15,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,114.3,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.55,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,56.01,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,120.65,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.76,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,114.3,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,56.01,127,
ARGYLE 30F NASOPHARYNGEAL,2720001464,CDM,272,RC,,,Outpatient,,,1.80,1.17,,1.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.37,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.3,72,,2.168,Percent of Total Billed Charges,72% of Total Billed Charges,1.35,75,,2.256,Percent of Total Billed charges,75% of Total Billed Charges,1.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,72,,2.168,Percent of Total Billed Charges,72% of Total Billed Charges,1.08,60,,1.808,Percent of Total Billed Charges,60% of Total Billed Charges,1.62,90,,1292.304,Percent of Total Billed Charges,90% of Total Billed Charges,0.81,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,1.62,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,1.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.17,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,0.79,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.71,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,1.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.58,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,1.62,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,0.79,1.8,
SLEEVE SCD VENAFLOW XL,2720001465,CDM,272,RC,,,Outpatient,,,30.00,19.50,,30,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.8,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.6,72,,22.456,Percent of Total Billed Charges,72% of Total Billed Charges,22.5,75,,23.392,Percent of Total Billed charges,75% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.6,72,,22.456,Percent of Total Billed Charges,72% of Total Billed Charges,18,60,,18.712,Percent of Total Billed Charges,60% of Total Billed Charges,27,90,,1308.976,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,27,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.5,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,13.23,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.5,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.4,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,27,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,13.23,30,
BILATERAL EXTREMITY DRAPE,2720001466,CDM,272,RC,,,Outpatient,,,9.00,5.85,,9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.84,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.48,72,,10.656,Percent of Total Billed Charges,72% of Total Billed Charges,6.75,75,,11.104,Percent of Total Billed charges,75% of Total Billed Charges,9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.48,72,,10.656,Percent of Total Billed Charges,72% of Total Billed Charges,5.4,60,,8.88,Percent of Total Billed Charges,60% of Total Billed Charges,8.1,90,,1316.128,Percent of Total Billed Charges,90% of Total Billed Charges,4.05,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,8.1,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.85,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,3.97,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.55,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.92,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,8.1,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,3.97,9,
ZOLL STAT PADZ ADULT,2720001468,CDM,272,RC,,,Outpatient,,,32.00,20.80,,32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.32,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.04,72,,20.728,Percent of Total Billed Charges,72% of Total Billed Charges,24,75,,21.592,Percent of Total Billed charges,75% of Total Billed Charges,32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.04,72,,20.728,Percent of Total Billed Charges,72% of Total Billed Charges,19.2,60,,17.272,Percent of Total Billed Charges,60% of Total Billed Charges,28.8,90,,1321.672,Percent of Total Billed Charges,90% of Total Billed Charges,14.4,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,28.8,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.8,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,14.11,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.4,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.16,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,28.8,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,14.11,32,
TUBING CONNECTING 5IN 1,2720001469,CDM,272,RC,,,Outpatient,,,2.00,1.30,,2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.52,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.44,72,,20.728,Percent of Total Billed Charges,72% of Total Billed Charges,1.5,75,,21.592,Percent of Total Billed charges,75% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,72,,20.728,Percent of Total Billed Charges,72% of Total Billed Charges,1.2,60,,17.272,Percent of Total Billed Charges,60% of Total Billed Charges,1.8,90,,1321.672,Percent of Total Billed Charges,90% of Total Billed Charges,0.9,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,1.8,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,0.88,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.9,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.76,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,1.8,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,0.88,2,
GLOVES STERILE SZ 7.5,2720001470,CDM,272,RC,,,Outpatient,,,3.78,2.46,,3.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.87,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.72,72,,20.728,Percent of Total Billed Charges,72% of Total Billed Charges,2.84,75,,21.592,Percent of Total Billed charges,75% of Total Billed Charges,3.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.72,72,,20.728,Percent of Total Billed Charges,72% of Total Billed Charges,2.27,60,,17.272,Percent of Total Billed Charges,60% of Total Billed Charges,3.4,90,,1321.672,Percent of Total Billed Charges,90% of Total Billed Charges,1.7,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,3.4,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,3.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.46,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,1.67,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.59,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,3.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.33,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,3.4,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,1.67,3.78,
"Glove,Sensicare SZ 6",2720001471,CDM,272,RC,,,Outpatient,,,3.78,2.46,,3.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.87,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.72,72,,20.728,Percent of Total Billed Charges,72% of Total Billed Charges,2.84,75,,21.592,Percent of Total Billed charges,75% of Total Billed Charges,3.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.72,72,,20.728,Percent of Total Billed Charges,72% of Total Billed Charges,2.27,60,,17.272,Percent of Total Billed Charges,60% of Total Billed Charges,3.4,90,,1321.672,Percent of Total Billed Charges,90% of Total Billed Charges,1.7,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,3.4,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,3.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.46,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,1.67,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.59,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,3.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.33,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,3.4,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,1.67,3.78,
NASAL RAE TUBE UNCUF 4.0,2720001472,CDM,272,RC,,,Outpatient,,,9.13,5.93,,9.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.94,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.57,72,,20.728,Percent of Total Billed Charges,72% of Total Billed Charges,6.85,75,,21.592,Percent of Total Billed charges,75% of Total Billed Charges,9.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.57,72,,20.728,Percent of Total Billed Charges,72% of Total Billed Charges,5.48,60,,17.272,Percent of Total Billed Charges,60% of Total Billed Charges,8.22,90,,1321.672,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,45,,646.152,Percent of Total Billed Charges,45% of Total Billed Charges,8.22,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,9.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.93,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,4.03,44.1,,633.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.67,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,9.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.03,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,8.22,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,4.03,9.13,
HI LO TRACHEAL TUBE 5.5,2720001473,CDM,272,RC,,,Outpatient,,,1.73,1.12,,1.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.31,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.25,72,,2.456,Percent of Total Billed Charges,72% of Total Billed Charges,1.3,75,,2.56,Percent of Total Billed charges,75% of Total Billed Charges,1.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.25,72,,2.456,Percent of Total Billed Charges,72% of Total Billed Charges,1.04,60,,2.048,Percent of Total Billed Charges,60% of Total Billed Charges,1.56,90,,1321.672,Percent of Total Billed Charges,90% of Total Billed Charges,0.78,45,,654.488,Percent of Total Billed Charges,45% of Total Billed Charges,1.56,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,1.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.12,65,,933.336,Percent of total Billed Charges,65% of Total Billed Charges,0.76,44.1,,641.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.64,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,1.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.52,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,1.56,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,0.76,1.73,
NASAL RAE TUBE 8.0,2720001474,CDM,272,RC,,,Outpatient,,,10.73,6.97,,10.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.15,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.73,72,,2.456,Percent of Total Billed Charges,72% of Total Billed Charges,8.05,75,,2.56,Percent of Total Billed charges,75% of Total Billed Charges,10.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.73,72,,2.456,Percent of Total Billed Charges,72% of Total Billed Charges,6.44,60,,2.048,Percent of Total Billed Charges,60% of Total Billed Charges,9.66,90,,1321.672,Percent of Total Billed Charges,90% of Total Billed Charges,4.83,45,,658.064,Percent of Total Billed Charges,45% of Total Billed Charges,9.66,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,10.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.97,65,,945.368,Percent of total Billed Charges,65% of Total Billed Charges,4.73,44.1,,644.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.19,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,10.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.44,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,9.66,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,4.73,10.73,
NASAL RAE TUBE CUFF 7.5,2720001475,CDM,272,RC,,,Outpatient,,,12.40,8.06,,12.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.42,76,,1091.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.93,72,,2.456,Percent of Total Billed Charges,72% of Total Billed Charges,9.3,75,,2.56,Percent of Total Billed charges,75% of Total Billed Charges,12.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.93,72,,2.456,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,60,,2.048,Percent of Total Billed Charges,60% of Total Billed Charges,11.16,90,,1321.672,Percent of Total Billed Charges,90% of Total Billed Charges,5.58,45,,660.84,Percent of Total Billed Charges,45% of Total Billed Charges,11.16,90,,1292.304,Percent of Total Billed Charges,90% of Total billed Charges,12.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.06,65,,950.536,Percent of total Billed Charges,65% of Total Billed Charges,5.47,44.1,,647.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.78,95,,1364.104,Percent of Total Billed Charges,95% of Total Billed Charges,12.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.91,88,,1263.592,Percent of Total Billed Charges,88% of Total Billed Charges,11.16,90,,1292.304,Percent of Total Billed charges,90% of Total Billed Charges,5.47,12.4,
NASAL RAE TUBE CUFF 6.5,2720001476,CDM,272,RC,,,Outpatient,,,5.00,3.25,,5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.8,76,,1105.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.6,72,,2.456,Percent of Total Billed Charges,72% of Total Billed Charges,3.75,75,,2.56,Percent of Total Billed charges,75% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.6,72,,2.456,Percent of Total Billed Charges,72% of Total Billed Charges,3,60,,2.048,Percent of Total Billed Charges,60% of Total Billed Charges,4.5,90,,1332,Percent of Total Billed Charges,90% of Total Billed Charges,2.25,45,,660.84,Percent of Total Billed Charges,45% of Total Billed Charges,4.5,90,,1308.976,Percent of Total Billed Charges,90% of Total billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.25,65,,954.544,Percent of total Billed Charges,65% of Total Billed Charges,2.21,44.1,,647.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.75,95,,1381.696,Percent of Total Billed Charges,95% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.4,88,,1279.888,Percent of Total Billed Charges,88% of Total Billed Charges,4.5,90,,1308.976,Percent of Total Billed charges,90% of Total Billed Charges,2.21,5,
ORAL RAE UNCUFF 5.0,2720001477,CDM,272,RC,,,Outpatient,,,3.35,2.18,,3.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.55,76,,1111.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.41,72,,2.456,Percent of Total Billed Charges,72% of Total Billed Charges,2.51,75,,2.56,Percent of Total Billed charges,75% of Total Billed Charges,3.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.41,72,,2.456,Percent of Total Billed Charges,72% of Total Billed Charges,2.01,60,,2.048,Percent of Total Billed Charges,60% of Total Billed Charges,3.02,90,,1332,Percent of Total Billed Charges,90% of Total Billed Charges,1.51,45,,660.84,Percent of Total Billed Charges,45% of Total Billed Charges,3.02,90,,1316.128,Percent of Total Billed Charges,90% of Total billed Charges,3.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.18,65,,954.544,Percent of total Billed Charges,65% of Total Billed Charges,1.48,44.1,,647.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.18,95,,1389.24,Percent of Total Billed Charges,95% of Total Billed Charges,3.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.95,88,,1286.88,Percent of Total Billed Charges,88% of Total Billed Charges,3.02,90,,1316.128,Percent of Total Billed charges,90% of Total Billed Charges,1.48,3.35,
NASAL RAE TUBE CUFFED 5.5,2720001478,CDM,272,RC,,,Outpatient,,,9.13,5.93,,9.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.94,76,,1116.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.57,72,,2.456,Percent of Total Billed Charges,72% of Total Billed Charges,6.85,75,,2.56,Percent of Total Billed charges,75% of Total Billed Charges,9.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.57,72,,2.456,Percent of Total Billed Charges,72% of Total Billed Charges,5.48,60,,2.048,Percent of Total Billed Charges,60% of Total Billed Charges,8.22,90,,1332,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,45,,660.84,Percent of Total Billed Charges,45% of Total Billed Charges,8.22,90,,1321.672,Percent of Total Billed Charges,90% of Total billed Charges,9.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.93,65,,954.544,Percent of total Billed Charges,65% of Total Billed Charges,4.03,44.1,,647.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.67,95,,1395.104,Percent of Total Billed Charges,95% of Total Billed Charges,9.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.03,88,,1292.304,Percent of Total Billed Charges,88% of Total Billed Charges,8.22,90,,1321.672,Percent of Total Billed charges,90% of Total Billed Charges,4.03,9.13,
ORAL RAE UNCUFF 6.5,2720001479,CDM,272,RC,,,Outpatient,,,6.00,3.90,,6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.56,76,,1116.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.32,72,,2.456,Percent of Total Billed Charges,72% of Total Billed Charges,4.5,75,,2.56,Percent of Total Billed charges,75% of Total Billed Charges,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.32,72,,2.456,Percent of Total Billed Charges,72% of Total Billed Charges,3.6,60,,2.048,Percent of Total Billed Charges,60% of Total Billed Charges,5.4,90,,1332,Percent of Total Billed Charges,90% of Total Billed Charges,2.7,45,,660.84,Percent of Total Billed Charges,45% of Total Billed Charges,5.4,90,,1321.672,Percent of Total Billed Charges,90% of Total billed Charges,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.9,65,,954.544,Percent of total Billed Charges,65% of Total Billed Charges,2.65,44.1,,647.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.7,95,,1395.104,Percent of Total Billed Charges,95% of Total Billed Charges,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.28,88,,1292.304,Percent of Total Billed Charges,88% of Total Billed Charges,5.4,90,,1321.672,Percent of Total Billed charges,90% of Total Billed Charges,2.65,6,
NASAL AIRWAY 26FR,2720001480,CDM,272,RC,,,Outpatient,,,5.63,3.66,,5.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.28,76,,1116.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.05,72,,2.376,Percent of Total Billed Charges,72% of Total Billed Charges,4.22,75,,2.48,Percent of Total Billed charges,75% of Total Billed Charges,5.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.05,72,,2.376,Percent of Total Billed Charges,72% of Total Billed Charges,3.38,60,,1.984,Percent of Total Billed Charges,60% of Total Billed Charges,5.07,90,,1321.672,Percent of Total Billed Charges,90% of Total Billed Charges,2.53,45,,660.84,Percent of Total Billed Charges,45% of Total Billed Charges,5.07,90,,1321.672,Percent of Total Billed Charges,90% of Total billed Charges,5.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.66,65,,954.544,Percent of total Billed Charges,65% of Total Billed Charges,2.48,44.1,,647.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.35,95,,1395.104,Percent of Total Billed Charges,95% of Total Billed Charges,5.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.95,88,,1292.304,Percent of Total Billed Charges,88% of Total Billed Charges,5.07,90,,1321.672,Percent of Total Billed charges,90% of Total Billed Charges,2.48,5.63,
NASAL RAE TUBE CUFF 7.0,2720001481,CDM,272,RC,,,Outpatient,,,5.73,3.72,,5.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.35,76,,1116.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.13,72,,1.784,Percent of Total Billed Charges,72% of Total Billed Charges,4.3,75,,1.864,Percent of Total Billed charges,75% of Total Billed Charges,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.13,72,,1.784,Percent of Total Billed Charges,72% of Total Billed Charges,3.44,60,,1.488,Percent of Total Billed Charges,60% of Total Billed Charges,5.16,90,,1321.672,Percent of Total Billed Charges,90% of Total Billed Charges,2.58,45,,660.84,Percent of Total Billed Charges,45% of Total Billed Charges,5.16,90,,1321.672,Percent of Total Billed Charges,90% of Total billed Charges,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.72,65,,954.544,Percent of total Billed Charges,65% of Total Billed Charges,2.53,44.1,,647.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.44,95,,1395.104,Percent of Total Billed Charges,95% of Total Billed Charges,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.04,88,,1292.304,Percent of Total Billed Charges,88% of Total Billed Charges,5.16,90,,1321.672,Percent of Total Billed charges,90% of Total Billed Charges,2.53,5.73,
NASAL RAE TUBE CUFFED 5.0,2720001482,CDM,272,RC,,,Outpatient,,,9.13,5.93,,9.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.94,76,,1116.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.57,72,,1.608,Percent of Total Billed Charges,72% of Total Billed Charges,6.85,75,,1.672,Percent of Total Billed charges,75% of Total Billed Charges,9.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.57,72,,1.608,Percent of Total Billed Charges,72% of Total Billed Charges,5.48,60,,1.336,Percent of Total Billed Charges,60% of Total Billed Charges,8.22,90,,1321.672,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,45,,660.84,Percent of Total Billed Charges,45% of Total Billed Charges,8.22,90,,1321.672,Percent of Total Billed Charges,90% of Total billed Charges,9.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.93,65,,954.544,Percent of total Billed Charges,65% of Total Billed Charges,4.03,44.1,,647.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.67,95,,1395.104,Percent of Total Billed Charges,95% of Total Billed Charges,9.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.03,88,,1292.304,Percent of Total Billed Charges,88% of Total Billed Charges,8.22,90,,1321.672,Percent of Total Billed charges,90% of Total Billed Charges,4.03,9.13,
ORAL RAE UNCUFF 5.5,2720001483,CDM,272,RC,,,Outpatient,,,3.21,2.09,,3.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.44,76,,1116.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.31,72,,2.688,Percent of Total Billed Charges,72% of Total Billed Charges,2.41,75,,2.8,Percent of Total Billed charges,75% of Total Billed Charges,3.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.31,72,,2.688,Percent of Total Billed Charges,72% of Total Billed Charges,1.93,60,,2.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.89,90,,1321.672,Percent of Total Billed Charges,90% of Total Billed Charges,1.44,45,,666,Percent of Total Billed Charges,45% of Total Billed Charges,2.89,90,,1321.672,Percent of Total Billed Charges,90% of Total billed Charges,3.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.09,65,,954.544,Percent of total Billed Charges,65% of Total Billed Charges,1.42,44.1,,652.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.05,95,,1395.104,Percent of Total Billed Charges,95% of Total Billed Charges,3.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.82,88,,1292.304,Percent of Total Billed Charges,88% of Total Billed Charges,2.89,90,,1321.672,Percent of Total Billed charges,90% of Total Billed Charges,1.42,3.21,
PICC & CVC DRSG TRY W STATLOCK,2720001484,CDM,272,RC,,,Outpatient,,,16.68,10.84,,16.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.68,76,,1116.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.01,72,,2.688,Percent of Total Billed Charges,72% of Total Billed Charges,12.51,75,,2.8,Percent of Total Billed charges,75% of Total Billed Charges,16.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.01,72,,2.688,Percent of Total Billed Charges,72% of Total Billed Charges,10.01,60,,2.24,Percent of Total Billed Charges,60% of Total Billed Charges,15.01,90,,240.096,Percent of Total Billed Charges,90% of Total Billed Charges,7.51,45,,666,Percent of Total Billed Charges,45% of Total Billed Charges,15.01,90,,1321.672,Percent of Total Billed Charges,90% of Total billed Charges,16.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.84,65,,962,Percent of total Billed Charges,65% of Total Billed Charges,7.36,44.1,,652.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.85,95,,1395.104,Percent of Total Billed Charges,95% of Total Billed Charges,16.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.68,88,,1292.304,Percent of Total Billed Charges,88% of Total Billed Charges,15.01,90,,1321.672,Percent of Total Billed charges,90% of Total Billed Charges,7.36,16.68,
PRIMARY IV TUBING,2720001486,CDM,272,RC,,,Outpatient,,,9.41,6.12,,9.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.15,76,,1116.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.78,72,,2.688,Percent of Total Billed Charges,72% of Total Billed Charges,7.06,75,,2.8,Percent of Total Billed charges,75% of Total Billed Charges,9.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.78,72,,2.688,Percent of Total Billed Charges,72% of Total Billed Charges,5.65,60,,2.24,Percent of Total Billed Charges,60% of Total Billed Charges,8.47,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.23,45,,666,Percent of Total Billed Charges,45% of Total Billed Charges,8.47,90,,1321.672,Percent of Total Billed Charges,90% of Total billed Charges,9.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.12,65,,962,Percent of total Billed Charges,65% of Total Billed Charges,4.15,44.1,,652.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.94,95,,1395.104,Percent of Total Billed Charges,95% of Total Billed Charges,9.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.28,88,,1292.304,Percent of Total Billed Charges,88% of Total Billed Charges,8.47,90,,1321.672,Percent of Total Billed charges,90% of Total Billed Charges,4.15,9.41,
TEGADERM 2 3/8 X 2.75,2720001487,CDM,272,RC,,,Outpatient,,,0.36,0.23,,0.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.27,76,,1124.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.26,72,,0.744,Percent of Total Billed Charges,72% of Total Billed Charges,0.27,75,,0.776,Percent of Total Billed charges,75% of Total Billed Charges,0.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.26,72,,0.744,Percent of Total Billed Charges,72% of Total Billed Charges,0.22,60,,0.616,Percent of Total Billed Charges,60% of Total Billed Charges,0.32,90,,14.016,Percent of Total Billed Charges,90% of Total Billed Charges,0.16,45,,666,Percent of Total Billed Charges,45% of Total Billed Charges,0.32,90,,1332,Percent of Total Billed Charges,90% of Total billed Charges,0.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.23,65,,962,Percent of total Billed Charges,65% of Total Billed Charges,0.16,44.1,,652.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.34,95,,1406,Percent of Total Billed Charges,95% of Total Billed Charges,0.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.32,88,,1302.4,Percent of Total Billed Charges,88% of Total Billed Charges,0.32,90,,1332,Percent of Total Billed charges,90% of Total Billed Charges,0.16,0.36,
"HUBER NEEDLE 20G X1""",2720001488,CDM,272,RC,,,Outpatient,,,13.25,8.61,,13.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.07,76,,1124.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.54,72,,1.816,Percent of Total Billed Charges,72% of Total Billed Charges,9.94,75,,1.888,Percent of Total Billed charges,75% of Total Billed Charges,13.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.54,72,,1.816,Percent of Total Billed Charges,72% of Total Billed Charges,7.95,60,,1.512,Percent of Total Billed Charges,60% of Total Billed Charges,11.93,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,5.96,45,,660.84,Percent of Total Billed Charges,45% of Total Billed Charges,11.93,90,,1332,Percent of Total Billed Charges,90% of Total billed Charges,13.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.61,65,,962,Percent of total Billed Charges,65% of Total Billed Charges,5.84,44.1,,647.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.59,95,,1406,Percent of Total Billed Charges,95% of Total Billed Charges,13.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.66,88,,1302.4,Percent of Total Billed Charges,88% of Total Billed Charges,11.93,90,,1332,Percent of Total Billed charges,90% of Total Billed Charges,5.84,13.25,
IV CATHETER 22X1,2720001489,CDM,272,RC,,,Outpatient,,,12.43,8.08,,12.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.45,76,,1124.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.95,72,,1.448,Percent of Total Billed Charges,72% of Total Billed Charges,9.32,75,,1.504,Percent of Total Billed charges,75% of Total Billed Charges,12.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.95,72,,1.448,Percent of Total Billed Charges,72% of Total Billed Charges,7.46,60,,1.208,Percent of Total Billed Charges,60% of Total Billed Charges,11.19,90,,266.4,Percent of Total Billed Charges,90% of Total Billed Charges,5.59,45,,660.84,Percent of Total Billed Charges,45% of Total Billed Charges,11.19,90,,1332,Percent of Total Billed Charges,90% of Total billed Charges,12.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.08,65,,954.544,Percent of total Billed Charges,65% of Total Billed Charges,5.48,44.1,,647.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.81,95,,1406,Percent of Total Billed Charges,95% of Total Billed Charges,12.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.94,88,,1302.4,Percent of Total Billed Charges,88% of Total Billed Charges,11.19,90,,1332,Percent of Total Billed charges,90% of Total Billed Charges,5.48,12.43,
BLOOD SET TUBING,2720001490,CDM,272,RC,,,Outpatient,,,64.43,41.88,,64.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,48.97,76,,1124.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.39,72,,0.872,Percent of Total Billed Charges,72% of Total Billed Charges,48.32,75,,0.912,Percent of Total Billed charges,75% of Total Billed Charges,64.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.39,72,,0.872,Percent of Total Billed Charges,72% of Total Billed Charges,38.66,60,,0.728,Percent of Total Billed Charges,60% of Total Billed Charges,57.99,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,28.99,45,,660.84,Percent of Total Billed Charges,45% of Total Billed Charges,57.99,90,,1332,Percent of Total Billed Charges,90% of Total billed Charges,64.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.88,65,,954.544,Percent of total Billed Charges,65% of Total Billed Charges,28.41,44.1,,647.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,61.21,95,,1406,Percent of Total Billed Charges,95% of Total Billed Charges,64.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.7,88,,1302.4,Percent of Total Billed Charges,88% of Total Billed Charges,57.99,90,,1332,Percent of Total Billed charges,90% of Total Billed Charges,28.41,64.43,
IV CATHETER 18X 1.25,2720001491,CDM,272,RC,,,Outpatient,,,12.43,8.08,,12.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.45,76,,1116.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.95,72,,1.328,Percent of Total Billed Charges,72% of Total Billed Charges,9.32,75,,1.384,Percent of Total Billed charges,75% of Total Billed Charges,12.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.95,72,,1.328,Percent of Total Billed Charges,72% of Total Billed Charges,7.46,60,,1.112,Percent of Total Billed Charges,60% of Total Billed Charges,11.19,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,5.59,45,,660.84,Percent of Total Billed Charges,45% of Total Billed Charges,11.19,90,,1321.672,Percent of Total Billed Charges,90% of Total billed Charges,12.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.08,65,,954.544,Percent of total Billed Charges,65% of Total Billed Charges,5.48,44.1,,647.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.81,95,,1395.104,Percent of Total Billed Charges,95% of Total Billed Charges,12.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.94,88,,1292.304,Percent of Total Billed Charges,88% of Total Billed Charges,11.19,90,,1321.672,Percent of Total Billed charges,90% of Total Billed Charges,5.48,12.43,
IV CATHETER 20X 1.25,2720001492,CDM,272,RC,,,Outpatient,,,12.43,8.08,,12.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.45,76,,1116.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.95,72,,1.488,Percent of Total Billed Charges,72% of Total Billed Charges,9.32,75,,1.552,Percent of Total Billed charges,75% of Total Billed Charges,12.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.95,72,,1.488,Percent of Total Billed Charges,72% of Total Billed Charges,7.46,60,,1.24,Percent of Total Billed Charges,60% of Total Billed Charges,11.19,90,,6.744,Percent of Total Billed Charges,90% of Total Billed Charges,5.59,45,,120.048,Percent of Total Billed Charges,45% of Total Billed Charges,11.19,90,,1321.672,Percent of Total Billed Charges,90% of Total billed Charges,12.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.08,65,,954.544,Percent of total Billed Charges,65% of Total Billed Charges,5.48,44.1,,117.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.81,95,,1395.104,Percent of Total Billed Charges,95% of Total Billed Charges,12.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.94,88,,1292.304,Percent of Total Billed Charges,88% of Total Billed Charges,11.19,90,,1321.672,Percent of Total Billed charges,90% of Total Billed Charges,5.48,12.43,
TEGADERM 4X 4.75,2720001493,CDM,272,RC,,,Outpatient,,,1.06,0.69,,1.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.81,76,,1116.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.76,72,,146.88,Percent of Total Billed Charges,72% of Total Billed Charges,0.8,75,,153,Percent of Total Billed charges,75% of Total Billed Charges,1.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.76,72,,146.88,Percent of Total Billed Charges,72% of Total Billed Charges,0.64,60,,122.4,Percent of Total Billed Charges,60% of Total Billed Charges,0.95,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.48,45,,5.4,Percent of Total Billed Charges,45% of Total Billed Charges,0.95,90,,1321.672,Percent of Total Billed Charges,90% of Total billed Charges,1.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.69,65,,173.408,Percent of total Billed Charges,65% of Total Billed Charges,0.47,44.1,,5.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.01,95,,1395.104,Percent of Total Billed Charges,95% of Total Billed Charges,1.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.93,88,,1292.304,Percent of Total Billed Charges,88% of Total Billed Charges,0.95,90,,1321.672,Percent of Total Billed charges,90% of Total Billed Charges,0.47,1.06,
IV CATHETER 20X1,2720001494,CDM,272,RC,,,Outpatient,,,12.43,8.08,,12.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.45,76,,1116.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.95,72,,2.456,Percent of Total Billed Charges,72% of Total Billed Charges,9.32,75,,2.56,Percent of Total Billed charges,75% of Total Billed Charges,12.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.95,72,,2.456,Percent of Total Billed Charges,72% of Total Billed Charges,7.46,60,,2.048,Percent of Total Billed Charges,60% of Total Billed Charges,11.19,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,5.59,45,,7.008,Percent of Total Billed Charges,45% of Total Billed Charges,11.19,90,,1321.672,Percent of Total Billed Charges,90% of Total billed Charges,12.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.08,65,,7.8,Percent of total Billed Charges,65% of Total Billed Charges,5.48,44.1,,6.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.81,95,,1395.104,Percent of Total Billed Charges,95% of Total Billed Charges,12.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.94,88,,1292.304,Percent of Total Billed Charges,88% of Total Billed Charges,11.19,90,,1321.672,Percent of Total Billed charges,90% of Total Billed Charges,5.48,12.43,
CYSTO TUBING SET IV,2720001495,CDM,272,RC,,,Outpatient,,,9.44,6.14,,9.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.17,76,,202.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.8,72,,2.096,Percent of Total Billed Charges,72% of Total Billed Charges,7.08,75,,2.184,Percent of Total Billed charges,75% of Total Billed Charges,9.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.8,72,,2.096,Percent of Total Billed Charges,72% of Total Billed Charges,5.66,60,,1.744,Percent of Total Billed Charges,60% of Total Billed Charges,8.5,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,4.25,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,8.5,90,,240.096,Percent of Total Billed Charges,90% of Total billed Charges,9.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.14,65,,10.128,Percent of total Billed Charges,65% of Total Billed Charges,4.16,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.97,95,,253.44,Percent of Total Billed Charges,95% of Total Billed Charges,9.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.31,88,,234.76,Percent of Total Billed Charges,88% of Total Billed Charges,8.5,90,,240.096,Percent of Total Billed charges,90% of Total Billed Charges,4.16,9.44,
MEDLINE SZ4 MASK CHD SM ADULT,2720001496,CDM,272,RC,,,Outpatient,,,2.00,1.30,,2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.52,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.44,72,,2.32,Percent of Total Billed Charges,72% of Total Billed Charges,1.5,75,,2.416,Percent of Total Billed charges,75% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,72,,2.32,Percent of Total Billed Charges,72% of Total Billed Charges,1.2,60,,1.936,Percent of Total Billed Charges,60% of Total Billed Charges,1.8,90,,57.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.9,45,,133.2,Percent of Total Billed Charges,45% of Total Billed Charges,1.8,90,,10.8,Percent of Total Billed Charges,90% of Total billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,0.88,44.1,,130.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.9,95,,11.4,Percent of Total Billed Charges,95% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.76,88,,10.56,Percent of Total Billed Charges,88% of Total Billed Charges,1.8,90,,10.8,Percent of Total Billed charges,90% of Total Billed Charges,0.88,2,
CENTRAL VENOUS DRESSING CHANGE,2720001497,CDM,272,RC,,,Outpatient,,,5.95,3.87,,5.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.52,76,,11.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.28,72,,2.232,Percent of Total Billed Charges,72% of Total Billed Charges,4.46,75,,2.32,Percent of Total Billed charges,75% of Total Billed Charges,5.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.28,72,,2.232,Percent of Total Billed Charges,72% of Total Billed Charges,3.57,60,,1.856,Percent of Total Billed Charges,60% of Total Billed Charges,5.36,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.68,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,5.36,90,,14.016,Percent of Total Billed Charges,90% of Total billed Charges,5.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.87,65,,192.4,Percent of total Billed Charges,65% of Total Billed Charges,2.62,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.65,95,,14.8,Percent of Total Billed Charges,95% of Total Billed Charges,5.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.24,88,,13.704,Percent of Total Billed Charges,88% of Total Billed Charges,5.36,90,,14.016,Percent of Total Billed charges,90% of Total Billed Charges,2.62,5.95,
BIOPATCH 1 INCH DRESSING,2720001498,CDM,272,RC,,,Outpatient,,,18.77,12.20,,18.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.27,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.51,72,,2.152,Percent of Total Billed Charges,72% of Total Billed Charges,14.08,75,,2.248,Percent of Total Billed charges,75% of Total Billed Charges,18.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.51,72,,2.152,Percent of Total Billed Charges,72% of Total Billed Charges,11.26,60,,1.792,Percent of Total Billed Charges,60% of Total Billed Charges,16.89,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,8.45,45,,196.56,Percent of Total Billed Charges,45% of Total Billed Charges,16.89,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,18.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.2,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,8.28,44.1,,192.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.83,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,18.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.52,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,16.89,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,8.28,18.77,
SILK 6-0 639G SUTURE,2720001500,CDM,272,RC,,,Outpatient,,,4.00,2.60,,4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.04,76,,224.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.88,72,,1.968,Percent of Total Billed Charges,72% of Total Billed Charges,3,75,,2.056,Percent of Total Billed charges,75% of Total Billed Charges,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.88,72,,1.968,Percent of Total Billed Charges,72% of Total Billed Charges,2.4,60,,1.64,Percent of Total Billed Charges,60% of Total Billed Charges,3.6,90,,1101.6,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,45,,3.376,Percent of Total Billed Charges,45% of Total Billed Charges,3.6,90,,266.4,Percent of Total Billed Charges,90% of Total billed Charges,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.6,65,,283.92,Percent of total Billed Charges,65% of Total Billed Charges,1.76,44.1,,3.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.8,95,,281.2,Percent of Total Billed Charges,95% of Total Billed Charges,4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.52,88,,260.48,Percent of Total Billed Charges,88% of Total Billed Charges,3.6,90,,266.4,Percent of Total Billed charges,90% of Total Billed Charges,1.76,4,
Z80922208 GDEWRE 2.2X711MMJ,2720001501,CDM,272,RC,,,Outpatient,,,174.00,113.10,,174,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,132.24,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,125.28,72,,1.984,Percent of Total Billed Charges,72% of Total Billed Charges,130.5,75,,2.072,Percent of Total Billed charges,75% of Total Billed Charges,174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.28,72,,1.984,Percent of Total Billed Charges,72% of Total Billed Charges,104.4,60,,1.656,Percent of Total Billed Charges,60% of Total Billed Charges,156.6,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,78.3,45,,0.72,Percent of Total Billed Charges,45% of Total Billed Charges,156.6,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.1,65,,4.872,Percent of total Billed Charges,65% of Total Billed Charges,76.73,44.1,,0.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,165.3,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.12,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,156.6,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,76.73,174,
CATH TRAY FOLEY 14FR,2720001502,CDM,272,RC,,,Outpatient,,,18.48,12.01,,18.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.04,76,,331.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.31,72,,2.008,Percent of Total Billed Charges,72% of Total Billed Charges,13.86,75,,2.096,Percent of Total Billed charges,75% of Total Billed Charges,18.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.31,72,,2.008,Percent of Total Billed Charges,72% of Total Billed Charges,11.09,60,,1.672,Percent of Total Billed Charges,60% of Total Billed Charges,16.63,90,,1101.6,Percent of Total Billed Charges,90% of Total Billed Charges,8.32,45,,1.08,Percent of Total Billed Charges,45% of Total Billed Charges,16.63,90,,393.12,Percent of Total Billed Charges,90% of Total billed Charges,18.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.01,65,,1.04,Percent of total Billed Charges,65% of Total Billed Charges,8.15,44.1,,1.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.56,95,,414.96,Percent of Total Billed Charges,95% of Total Billed Charges,18.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.26,88,,384.384,Percent of Total Billed Charges,88% of Total Billed Charges,16.63,90,,393.12,Percent of Total Billed charges,90% of Total Billed Charges,8.15,18.48,
CATH FOLEY 16FR 30CC 3 WY,2720001503,CDM,272,RC,,,Outpatient,,,175.30,113.95,,175.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,133.23,76,,5.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,126.22,72,,2.096,Percent of Total Billed Charges,72% of Total Billed Charges,131.48,75,,2.184,Percent of Total Billed charges,75% of Total Billed Charges,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.22,72,,2.096,Percent of Total Billed Charges,72% of Total Billed Charges,105.18,60,,1.744,Percent of Total Billed Charges,60% of Total Billed Charges,157.77,90,,51.84,Percent of Total Billed Charges,90% of Total Billed Charges,78.89,45,,1.08,Percent of Total Billed Charges,45% of Total Billed Charges,157.77,90,,6.744,Percent of Total Billed Charges,90% of Total billed Charges,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.95,65,,1.56,Percent of total Billed Charges,65% of Total Billed Charges,77.31,44.1,,1.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,166.54,95,,7.12,Percent of Total Billed Charges,95% of Total Billed Charges,175.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.26,88,,6.6,Percent of Total Billed Charges,88% of Total Billed Charges,157.77,90,,6.744,Percent of Total Billed charges,90% of Total Billed Charges,77.31,175.3,
CATH TRAY FOLEY 18FR,2720001504,CDM,272,RC,,,Outpatient,,,19.22,12.49,,19.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.61,76,,1.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.84,72,,2.72,Percent of Total Billed Charges,72% of Total Billed Charges,14.42,75,,2.832,Percent of Total Billed charges,75% of Total Billed Charges,19.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.84,72,,2.72,Percent of Total Billed Charges,72% of Total Billed Charges,11.53,60,,2.264,Percent of Total Billed Charges,60% of Total Billed Charges,17.3,90,,60.808,Percent of Total Billed Charges,90% of Total Billed Charges,8.65,45,,28.8,Percent of Total Billed Charges,45% of Total Billed Charges,17.3,90,,1.44,Percent of Total Billed Charges,90% of Total billed Charges,19.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.49,65,,1.56,Percent of total Billed Charges,65% of Total Billed Charges,8.48,44.1,,28.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.26,95,,1.52,Percent of Total Billed Charges,95% of Total Billed Charges,19.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.91,88,,1.408,Percent of Total Billed Charges,88% of Total Billed Charges,17.3,90,,1.44,Percent of Total Billed charges,90% of Total Billed Charges,8.48,19.22,
CATH TRAY FOLEY 16FR,2720001505,CDM,272,RC,,,Outpatient,,,20.42,13.27,,20.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.52,76,,1.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.7,72,,1.608,Percent of Total Billed Charges,72% of Total Billed Charges,15.32,75,,1.672,Percent of Total Billed charges,75% of Total Billed Charges,20.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.7,72,,1.608,Percent of Total Billed Charges,72% of Total Billed Charges,12.25,60,,1.336,Percent of Total Billed Charges,60% of Total Billed Charges,18.38,90,,38.56,Percent of Total Billed Charges,90% of Total Billed Charges,9.19,45,,12.6,Percent of Total Billed Charges,45% of Total Billed Charges,18.38,90,,2.16,Percent of Total Billed Charges,90% of Total billed Charges,20.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.27,65,,41.6,Percent of total Billed Charges,65% of Total Billed Charges,9.01,44.1,,12.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.4,95,,2.28,Percent of Total Billed Charges,95% of Total Billed Charges,20.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.97,88,,2.112,Percent of Total Billed Charges,88% of Total Billed Charges,18.38,90,,2.16,Percent of Total Billed charges,90% of Total Billed Charges,9.01,20.42,
MAXGAURD PR T-CONNECT,2720001506,CDM,272,RC,,,Outpatient,,,24.00,15.60,,24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.24,76,,1.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.28,72,,1.632,Percent of Total Billed Charges,72% of Total Billed Charges,18,75,,1.696,Percent of Total Billed charges,75% of Total Billed Charges,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.28,72,,1.632,Percent of Total Billed Charges,72% of Total Billed Charges,14.4,60,,1.36,Percent of Total Billed Charges,60% of Total Billed Charges,21.6,90,,97.224,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,45,,9.36,Percent of Total Billed Charges,45% of Total Billed Charges,21.6,90,,2.16,Percent of Total Billed Charges,90% of Total billed Charges,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.6,65,,18.2,Percent of total Billed Charges,65% of Total Billed Charges,10.58,44.1,,9.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.8,95,,2.28,Percent of Total Billed Charges,95% of Total Billed Charges,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.12,88,,2.112,Percent of Total Billed Charges,88% of Total Billed Charges,21.6,90,,2.16,Percent of Total Billed charges,90% of Total Billed Charges,10.58,24,
TEGADERM 2X2,2720001507,CDM,272,RC,,,Outpatient,,,3.00,1.95,,3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.28,76,,48.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.16,72,,1.656,Percent of Total Billed Charges,72% of Total Billed Charges,2.25,75,,1.72,Percent of Total Billed charges,75% of Total Billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.16,72,,1.656,Percent of Total Billed Charges,72% of Total Billed Charges,1.8,60,,1.376,Percent of Total Billed Charges,60% of Total Billed Charges,2.7,90,,64.304,Percent of Total Billed Charges,90% of Total Billed Charges,1.35,45,,550.8,Percent of Total Billed Charges,45% of Total Billed Charges,2.7,90,,57.6,Percent of Total Billed Charges,90% of Total billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.95,65,,13.52,Percent of total Billed Charges,65% of Total Billed Charges,1.32,44.1,,539.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.85,95,,60.8,Percent of Total Billed Charges,95% of Total Billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.64,88,,56.32,Percent of Total Billed Charges,88% of Total Billed Charges,2.7,90,,57.6,Percent of Total Billed charges,90% of Total Billed Charges,1.32,3,
IV START KIT LSL3381,2720001508,CDM,272,RC,,,Outpatient,,,8.00,5.20,,8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.08,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.76,72,,10.76,Percent of Total Billed Charges,72% of Total Billed Charges,6,75,,11.208,Percent of Total Billed charges,75% of Total Billed Charges,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.76,72,,10.76,Percent of Total Billed Charges,72% of Total Billed Charges,4.8,60,,8.968,Percent of Total Billed Charges,60% of Total Billed Charges,7.2,90,,46.664,Percent of Total Billed Charges,90% of Total Billed Charges,3.6,45,,22.68,Percent of Total Billed Charges,45% of Total Billed Charges,7.2,90,,25.2,Percent of Total Billed Charges,90% of Total billed Charges,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.2,65,,795.6,Percent of total Billed Charges,65% of Total Billed Charges,3.53,44.1,,22.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.6,95,,26.6,Percent of Total Billed Charges,95% of Total Billed Charges,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.04,88,,24.64,Percent of Total Billed Charges,88% of Total Billed Charges,7.2,90,,25.2,Percent of Total Billed charges,90% of Total Billed Charges,3.53,8,
TEGADERM 8X12,2720001509,CDM,272,RC,,,Outpatient,,,18.00,11.70,,18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.68,76,,15.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.96,72,,2.728,Percent of Total Billed Charges,72% of Total Billed Charges,13.5,75,,2.84,Percent of Total Billed charges,75% of Total Billed Charges,18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.96,72,,2.728,Percent of Total Billed Charges,72% of Total Billed Charges,10.8,60,,2.272,Percent of Total Billed Charges,60% of Total Billed Charges,16.2,90,,161.936,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,45,,550.8,Percent of Total Billed Charges,45% of Total Billed Charges,16.2,90,,18.72,Percent of Total Billed Charges,90% of Total billed Charges,18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.7,65,,32.76,Percent of total Billed Charges,65% of Total Billed Charges,7.94,44.1,,539.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.1,95,,19.76,Percent of Total Billed Charges,95% of Total Billed Charges,18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.84,88,,18.304,Percent of Total Billed Charges,88% of Total Billed Charges,16.2,90,,18.72,Percent of Total Billed charges,90% of Total Billed Charges,7.94,18,
SMARTSITE GRAVITY SET 100,2720001510,CDM,272,RC,,,Outpatient,,,31.00,20.15,,31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.56,76,,930.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.32,72,,2.728,Percent of Total Billed Charges,72% of Total Billed Charges,23.25,75,,2.84,Percent of Total Billed charges,75% of Total Billed Charges,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,72,,2.728,Percent of Total Billed Charges,72% of Total Billed Charges,18.6,60,,2.272,Percent of Total Billed Charges,60% of Total Billed Charges,27.9,90,,396,Percent of Total Billed Charges,90% of Total Billed Charges,13.95,45,,25.92,Percent of Total Billed Charges,45% of Total Billed Charges,27.9,90,,1101.6,Percent of Total Billed Charges,90% of Total billed Charges,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.15,65,,795.6,Percent of total Billed Charges,65% of Total Billed Charges,13.67,44.1,,25.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.45,95,,1162.8,Percent of Total Billed Charges,95% of Total Billed Charges,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.28,88,,1077.12,Percent of Total Billed Charges,88% of Total Billed Charges,27.9,90,,1101.6,Percent of Total Billed charges,90% of Total Billed Charges,13.67,31,
TEGADERM 4X4,2720001511,CDM,272,RC,,,Outpatient,,,3.00,1.95,,3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.28,76,,38.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.16,72,,1.408,Percent of Total Billed Charges,72% of Total Billed Charges,2.25,75,,1.464,Percent of Total Billed charges,75% of Total Billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.16,72,,1.408,Percent of Total Billed Charges,72% of Total Billed Charges,1.8,60,,1.168,Percent of Total Billed Charges,60% of Total Billed Charges,2.7,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,1.35,45,,30.408,Percent of Total Billed Charges,45% of Total Billed Charges,2.7,90,,45.36,Percent of Total Billed Charges,90% of Total billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.95,65,,37.44,Percent of total Billed Charges,65% of Total Billed Charges,1.32,44.1,,29.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.85,95,,47.88,Percent of Total Billed Charges,95% of Total Billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.64,88,,44.352,Percent of Total Billed Charges,88% of Total Billed Charges,2.7,90,,45.36,Percent of Total Billed charges,90% of Total Billed Charges,1.32,3,
CHLORAPREP 3ML,2720001512,CDM,272,RC,,,Outpatient,,,15.00,9.75,,15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.4,76,,930.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.8,72,,2.736,Percent of Total Billed Charges,72% of Total Billed Charges,11.25,75,,2.848,Percent of Total Billed charges,75% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.8,72,,2.736,Percent of Total Billed Charges,72% of Total Billed Charges,9,60,,2.28,Percent of Total Billed Charges,60% of Total Billed Charges,13.5,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,6.75,45,,19.28,Percent of Total Billed Charges,45% of Total Billed Charges,13.5,90,,1101.6,Percent of Total Billed Charges,90% of Total billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.75,65,,43.92,Percent of total Billed Charges,65% of Total Billed Charges,6.62,44.1,,18.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.25,95,,1162.8,Percent of Total Billed Charges,95% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.2,88,,1077.12,Percent of Total Billed Charges,88% of Total Billed Charges,13.5,90,,1101.6,Percent of Total Billed charges,90% of Total Billed Charges,6.62,15,
STATLOK IV START KIT IVK0100,2720001513,CDM,272,RC,,,Outpatient,,,35.00,22.75,,35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.6,76,,43.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.2,72,,5.952,Percent of Total Billed Charges,72% of Total Billed Charges,26.25,75,,6.208,Percent of Total Billed charges,75% of Total Billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.2,72,,5.952,Percent of Total Billed Charges,72% of Total Billed Charges,21,60,,4.96,Percent of Total Billed Charges,60% of Total Billed Charges,31.5,90,,4.248,Percent of Total Billed Charges,90% of Total Billed Charges,15.75,45,,48.608,Percent of Total Billed Charges,45% of Total Billed Charges,31.5,90,,51.84,Percent of Total Billed Charges,90% of Total billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.75,65,,27.848,Percent of total Billed Charges,65% of Total Billed Charges,15.44,44.1,,47.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.25,95,,54.72,Percent of Total Billed Charges,95% of Total Billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.8,88,,50.688,Percent of Total Billed Charges,88% of Total Billed Charges,31.5,90,,51.84,Percent of Total Billed charges,90% of Total Billed Charges,15.44,35,
MARATHON SKIN PROTECTANT,2720001514,CDM,272,RC,,,Outpatient,,,10.00,6.50,,10,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.6,76,,51.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.2,72,,5.952,Percent of Total Billed Charges,72% of Total Billed Charges,7.5,75,,6.208,Percent of Total Billed charges,75% of Total Billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.2,72,,5.952,Percent of Total Billed Charges,72% of Total Billed Charges,6,60,,4.96,Percent of Total Billed Charges,60% of Total Billed Charges,9,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,45,,32.152,Percent of Total Billed Charges,45% of Total Billed Charges,9,90,,60.808,Percent of Total Billed Charges,90% of Total billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,65,,70.216,Percent of total Billed Charges,65% of Total Billed Charges,4.41,44.1,,31.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.5,95,,64.192,Percent of Total Billed Charges,95% of Total Billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.8,88,,59.456,Percent of Total Billed Charges,88% of Total Billed Charges,9,90,,60.808,Percent of Total Billed charges,90% of Total Billed Charges,4.41,10,
STATLOK CATH STABILIZER,2720001515,CDM,272,RC,,,Outpatient,,,24.00,15.60,,24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.24,76,,32.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.28,72,,2.456,Percent of Total Billed Charges,72% of Total Billed Charges,18,75,,2.56,Percent of Total Billed charges,75% of Total Billed Charges,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.28,72,,2.456,Percent of Total Billed Charges,72% of Total Billed Charges,14.4,60,,2.048,Percent of Total Billed Charges,60% of Total Billed Charges,21.6,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,45,,23.328,Percent of Total Billed Charges,45% of Total Billed Charges,21.6,90,,38.56,Percent of Total Billed Charges,90% of Total billed Charges,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.6,65,,46.44,Percent of total Billed Charges,65% of Total Billed Charges,10.58,44.1,,22.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.8,95,,40.696,Percent of Total Billed Charges,95% of Total Billed Charges,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.12,88,,37.696,Percent of Total Billed Charges,88% of Total Billed Charges,21.6,90,,38.56,Percent of Total Billed charges,90% of Total Billed Charges,10.58,24,
TEGADERM 6X8,2720001516,CDM,272,RC,,,Outpatient,,,13.00,8.45,,13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.88,76,,82.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.36,72,,22.456,Percent of Total Billed Charges,72% of Total Billed Charges,9.75,75,,23.392,Percent of Total Billed charges,75% of Total Billed Charges,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.36,72,,22.456,Percent of Total Billed Charges,72% of Total Billed Charges,7.8,60,,18.712,Percent of Total Billed Charges,60% of Total Billed Charges,11.7,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,5.85,45,,80.968,Percent of Total Billed Charges,45% of Total Billed Charges,11.7,90,,97.224,Percent of Total Billed Charges,90% of Total billed Charges,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.45,65,,33.704,Percent of total Billed Charges,65% of Total Billed Charges,5.73,44.1,,79.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.35,95,,102.624,Percent of Total Billed Charges,95% of Total Billed Charges,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.44,88,,95.064,Percent of Total Billed Charges,88% of Total Billed Charges,11.7,90,,97.224,Percent of Total Billed charges,90% of Total Billed Charges,5.73,13,
MICRO CLAVE NUET CONNECTOR,2720001517,CDM,272,RC,,,Outpatient,,,10.00,6.50,,10,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.6,76,,54.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.2,72,,10.656,Percent of Total Billed Charges,72% of Total Billed Charges,7.5,75,,11.104,Percent of Total Billed charges,75% of Total Billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.2,72,,10.656,Percent of Total Billed Charges,72% of Total Billed Charges,6,60,,8.88,Percent of Total Billed Charges,60% of Total Billed Charges,9,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,45,,198,Percent of Total Billed Charges,45% of Total Billed Charges,9,90,,64.304,Percent of Total Billed Charges,90% of Total billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,65,,116.952,Percent of total Billed Charges,65% of Total Billed Charges,4.41,44.1,,194.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.5,95,,67.872,Percent of Total Billed Charges,95% of Total Billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.8,88,,62.872,Percent of Total Billed Charges,88% of Total Billed Charges,9,90,,64.304,Percent of Total Billed charges,90% of Total Billed Charges,4.41,10,
1 RING PUPIL EXPANDER,2720001518,CDM,278,RC,,,Outpatient,,,128.00,83.20,,128,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,97.28,76,,39.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,92.16,72,,20.728,Percent of Total Billed Charges,72% of Total Billed Charges,92.16,72,,21.592,Percent of Total Billed charges,72% of Total Billed Charges,128,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.16,72,,20.728,Percent of Total Billed Charges,72% of Total Billed Charges,76.8,60,,17.272,Percent of Total Billed Charges,60% of Total Billed Charges,115.2,90,,82.8,Percent of Total Billed Charges,90% of Total Billed Charges,57.6,45,,5.76,Percent of Total Billed Charges,45% of Total Billed Charges,115.2,90,,46.664,Percent of Total Billed Charges,90% of Total billed Charges,128,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.2,65,,286,Percent of total Billed Charges,65% of Total Billed Charges,56.45,44.1,,5.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,121.6,95,,49.256,Percent of Total Billed Charges,95% of Total Billed Charges,128,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.64,88,,45.624,Percent of Total Billed Charges,88% of Total Billed Charges,115.2,90,,46.664,Percent of Total Billed charges,90% of Total Billed Charges,56.45,128,
ALCON DISP POLYMER I/A TIP CVD,2720001519,CDM,272,RC,,,Outpatient,,,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,136.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.64,72,,2.688,Percent of Total Billed Charges,72% of Total Billed Charges,9,75,,2.8,Percent of Total Billed charges,75% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.64,72,,2.688,Percent of Total Billed Charges,72% of Total Billed Charges,7.2,60,,2.24,Percent of Total Billed Charges,60% of Total Billed Charges,10.8,90,,82.8,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,161.936,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,8.32,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,170.928,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,158.336,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,161.936,Percent of Total Billed charges,90% of Total Billed Charges,5.29,12,
SAFEHEATH 9FX13CM PLI KIT SS9,2720001521,CDM,272,RC,C1894,HCPCS,Outpatient,,,63.00,40.95,,63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.88,76,,334.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.36,72,,2.688,Percent of Total Billed Charges,72% of Total Billed Charges,47.25,75,,2.8,Percent of Total Billed charges,75% of Total Billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.36,72,,2.688,Percent of Total Billed Charges,72% of Total Billed Charges,37.8,60,,2.24,Percent of Total Billed Charges,60% of Total Billed Charges,56.7,90,,82.8,Percent of Total Billed Charges,90% of Total Billed Charges,28.35,45,,2.128,Percent of Total Billed Charges,45% of Total Billed Charges,56.7,90,,396,Percent of Total Billed Charges,90% of Total billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.95,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,27.78,44.1,,2.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.85,95,,418,Percent of Total Billed Charges,95% of Total Billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.44,88,,387.2,Percent of Total Billed Charges,88% of Total Billed Charges,56.7,90,,396,Percent of Total Billed charges,90% of Total Billed Charges,27.78,63,
INTUBATING STYLET 14FR,2720001522,CDM,272,RC,,,Outpatient,,,2.36,1.53,,2.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.79,76,,9.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.7,72,,2.688,Percent of Total Billed Charges,72% of Total Billed Charges,1.77,75,,2.8,Percent of Total Billed charges,75% of Total Billed Charges,2.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.7,72,,2.688,Percent of Total Billed Charges,72% of Total Billed Charges,1.42,60,,2.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.12,90,,2.416,Percent of Total Billed Charges,90% of Total Billed Charges,1.06,45,,9.72,Percent of Total Billed Charges,45% of Total Billed Charges,2.12,90,,11.52,Percent of Total Billed Charges,90% of Total billed Charges,2.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.53,65,,3.072,Percent of total Billed Charges,65% of Total Billed Charges,1.04,44.1,,9.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.24,95,,12.16,Percent of Total Billed Charges,95% of Total Billed Charges,2.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.08,88,,11.264,Percent of Total Billed Charges,88% of Total Billed Charges,2.12,90,,11.52,Percent of Total Billed charges,90% of Total Billed Charges,1.04,2.36,
SAFESHEATH 9FX13CM PLI KIT SS9,2720001523,CDM,272,RC,C1894,HCPCS,Outpatient,,,63.00,40.95,,63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.88,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.36,72,,5.952,Percent of Total Billed Charges,72% of Total Billed Charges,47.25,75,,6.208,Percent of Total Billed charges,75% of Total Billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.36,72,,5.952,Percent of Total Billed Charges,72% of Total Billed Charges,37.8,60,,4.96,Percent of Total Billed Charges,60% of Total Billed Charges,56.7,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,28.35,45,,9.36,Percent of Total Billed Charges,45% of Total Billed Charges,56.7,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.95,65,,14.04,Percent of total Billed Charges,65% of Total Billed Charges,27.78,44.1,,9.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.85,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.44,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,56.7,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,27.78,63,
BS SENSOR ANG TIP 0.035X150,2720001524,CDM,272,RC,,,Outpatient,,,51.00,33.15,,51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38.76,76,,3.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36.72,72,,267.84,Percent of Total Billed Charges,72% of Total Billed Charges,38.25,75,,279,Percent of Total Billed charges,75% of Total Billed Charges,51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.72,72,,267.84,Percent of Total Billed Charges,72% of Total Billed Charges,30.6,60,,223.2,Percent of Total Billed Charges,60% of Total Billed Charges,45.9,90,,6.576,Percent of Total Billed Charges,90% of Total Billed Charges,22.95,45,,7.92,Percent of Total Billed Charges,45% of Total Billed Charges,45.9,90,,4.248,Percent of Total Billed Charges,90% of Total billed Charges,51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.15,65,,13.52,Percent of total Billed Charges,65% of Total Billed Charges,22.49,44.1,,7.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.45,95,,4.488,Percent of Total Billed Charges,95% of Total Billed Charges,51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.88,88,,4.152,Percent of Total Billed Charges,88% of Total Billed Charges,45.9,90,,4.248,Percent of Total Billed charges,90% of Total Billed Charges,22.49,51,
CRYSTALINE II TEMP TREND,2720001525,CDM,272,RC,,,Outpatient,,,1.00,0.65,,1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.76,76,,16.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.72,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,0.75,75,,165,Percent of Total Billed charges,75% of Total Billed Charges,1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,0.6,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,0.9,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.45,45,,0.72,Percent of Total Billed Charges,45% of Total Billed Charges,0.9,90,,19.44,Percent of Total Billed Charges,90% of Total billed Charges,1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.65,65,,11.44,Percent of total Billed Charges,65% of Total Billed Charges,0.44,44.1,,0.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.95,95,,20.52,Percent of Total Billed Charges,95% of Total Billed Charges,1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.88,88,,19.008,Percent of Total Billed Charges,88% of Total Billed Charges,0.9,90,,19.44,Percent of Total Billed charges,90% of Total Billed Charges,0.44,1,
SPINAL EPIDURAL SET 25G X 7.5,2720001527,CDM,272,RC,,,Outpatient,,,34.00,22.10,,34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.84,76,,15.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.48,72,,165.592,Percent of Total Billed Charges,72% of Total Billed Charges,25.5,75,,172.496,Percent of Total Billed charges,75% of Total Billed Charges,34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.48,72,,165.592,Percent of Total Billed Charges,72% of Total Billed Charges,20.4,60,,137.992,Percent of Total Billed Charges,60% of Total Billed Charges,30.6,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,45,,41.4,Percent of Total Billed Charges,45% of Total Billed Charges,30.6,90,,18.72,Percent of Total Billed Charges,90% of Total billed Charges,34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.1,65,,1.04,Percent of total Billed Charges,65% of Total Billed Charges,14.99,44.1,,40.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.3,95,,19.76,Percent of Total Billed Charges,95% of Total Billed Charges,34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.92,88,,18.304,Percent of Total Billed Charges,88% of Total Billed Charges,30.6,90,,18.72,Percent of Total Billed charges,90% of Total Billed Charges,14.99,34,
CLEARIFY VISULAIZATION SYSTEM,2720001528,CDM,272,RC,,,Outpatient,,,49.00,31.85,,49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,37.24,76,,13.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,35.28,72,,16.744,Percent of Total Billed Charges,72% of Total Billed Charges,36.75,75,,17.44,Percent of Total Billed charges,75% of Total Billed Charges,49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,72,,16.744,Percent of Total Billed Charges,72% of Total Billed Charges,29.4,60,,13.952,Percent of Total Billed Charges,60% of Total Billed Charges,44.1,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,22.05,45,,41.4,Percent of Total Billed Charges,45% of Total Billed Charges,44.1,90,,15.84,Percent of Total Billed Charges,90% of Total billed Charges,49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.85,65,,59.8,Percent of total Billed Charges,65% of Total Billed Charges,21.61,44.1,,40.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.55,95,,16.72,Percent of Total Billed Charges,95% of Total Billed Charges,49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.12,88,,15.488,Percent of Total Billed Charges,88% of Total Billed Charges,44.1,90,,15.84,Percent of Total Billed charges,90% of Total Billed Charges,21.61,49,
"CO-FLEX NL 2"" STERILE",2720001529,CDM,272,RC,,,Outpatient,,,3.00,1.95,,3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.28,76,,1.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.16,72,,8.064,Percent of Total Billed Charges,72% of Total Billed Charges,2.25,75,,8.4,Percent of Total Billed charges,75% of Total Billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.16,72,,8.064,Percent of Total Billed Charges,72% of Total Billed Charges,1.8,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.7,90,,59.04,Percent of Total Billed Charges,90% of Total Billed Charges,1.35,45,,41.4,Percent of Total Billed Charges,45% of Total Billed Charges,2.7,90,,1.44,Percent of Total Billed Charges,90% of Total billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.95,65,,59.8,Percent of total Billed Charges,65% of Total Billed Charges,1.32,44.1,,40.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.85,95,,1.52,Percent of Total Billed Charges,95% of Total Billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.64,88,,1.408,Percent of Total Billed Charges,88% of Total Billed Charges,2.7,90,,1.44,Percent of Total Billed charges,90% of Total Billed Charges,1.32,3,
NASAL DRESSING,2720001530,CDM,272,RC,,,Outpatient,,,4.13,2.68,,4.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.14,76,,69.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.97,72,,240.48,Percent of Total Billed Charges,72% of Total Billed Charges,3.1,75,,250.504,Percent of Total Billed charges,75% of Total Billed Charges,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.97,72,,240.48,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,60,,200.4,Percent of Total Billed Charges,60% of Total Billed Charges,3.72,90,,68.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.86,45,,1.208,Percent of Total Billed Charges,45% of Total Billed Charges,3.72,90,,82.8,Percent of Total Billed Charges,90% of Total billed Charges,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.68,65,,59.8,Percent of total Billed Charges,65% of Total Billed Charges,1.82,44.1,,1.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.92,95,,87.4,Percent of Total Billed Charges,95% of Total Billed Charges,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.63,88,,80.96,Percent of Total Billed Charges,88% of Total Billed Charges,3.72,90,,82.8,Percent of Total Billed charges,90% of Total Billed Charges,1.82,4.13,
LUGOL'S,2720001531,CDM,272,RC,,,Outpatient,,,10.00,6.50,,10,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.6,76,,69.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.2,72,,430.56,Percent of Total Billed Charges,72% of Total Billed Charges,7.5,75,,448.504,Percent of Total Billed charges,75% of Total Billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.2,72,,430.56,Percent of Total Billed Charges,72% of Total Billed Charges,6,60,,358.8,Percent of Total Billed Charges,60% of Total Billed Charges,9,90,,792,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,45,,6.84,Percent of Total Billed Charges,45% of Total Billed Charges,9,90,,82.8,Percent of Total Billed Charges,90% of Total billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,65,,1.744,Percent of total Billed Charges,65% of Total Billed Charges,4.41,44.1,,6.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.5,95,,87.4,Percent of Total Billed Charges,95% of Total Billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.8,88,,80.96,Percent of Total Billed Charges,88% of Total Billed Charges,9,90,,82.8,Percent of Total Billed charges,90% of Total Billed Charges,4.41,10,
BANANA 3.0 DISP KNIFE,2720001532,CDM,272,RC,,,Outpatient,,,32.00,20.80,,32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.32,76,,69.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.04,72,,162.72,Percent of Total Billed Charges,72% of Total Billed Charges,24,75,,169.504,Percent of Total Billed charges,75% of Total Billed Charges,32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.04,72,,162.72,Percent of Total Billed Charges,72% of Total Billed Charges,19.2,60,,135.6,Percent of Total Billed Charges,60% of Total Billed Charges,28.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,14.4,45,,3.288,Percent of Total Billed Charges,45% of Total Billed Charges,28.8,90,,82.8,Percent of Total Billed Charges,90% of Total billed Charges,32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.8,65,,9.88,Percent of total Billed Charges,65% of Total Billed Charges,14.11,44.1,,3.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.4,95,,87.4,Percent of Total Billed Charges,95% of Total Billed Charges,32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.16,88,,80.96,Percent of Total Billed Charges,88% of Total Billed Charges,28.8,90,,82.8,Percent of Total Billed charges,90% of Total Billed Charges,14.11,32,
OLYMPUS CIRCON SEAL,2720001533,CDM,272,RC,,,Outpatient,,,15.00,9.75,,15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.4,76,,2.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.8,72,,162.72,Percent of Total Billed Charges,72% of Total Billed Charges,11.25,75,,169.504,Percent of Total Billed charges,75% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.8,72,,162.72,Percent of Total Billed Charges,72% of Total Billed Charges,9,60,,135.6,Percent of Total Billed Charges,60% of Total Billed Charges,13.5,90,,5.544,Percent of Total Billed Charges,90% of Total Billed Charges,6.75,45,,0.72,Percent of Total Billed Charges,45% of Total Billed Charges,13.5,90,,2.416,Percent of Total Billed Charges,90% of Total billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.75,65,,4.744,Percent of total Billed Charges,65% of Total Billed Charges,6.62,44.1,,0.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.25,95,,2.544,Percent of Total Billed Charges,95% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.2,88,,2.36,Percent of Total Billed Charges,88% of Total Billed Charges,13.5,90,,2.416,Percent of Total Billed charges,90% of Total Billed Charges,6.62,15,
A22201C Cutting Loop 24F Mono,2720001534,CDM,272,RC,,,Outpatient,,,74.00,48.10,,74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.24,76,,11.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.28,72,,162.72,Percent of Total Billed Charges,72% of Total Billed Charges,55.5,75,,169.504,Percent of Total Billed charges,75% of Total Billed Charges,74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.28,72,,162.72,Percent of Total Billed Charges,72% of Total Billed Charges,44.4,60,,135.6,Percent of Total Billed Charges,60% of Total Billed Charges,66.6,90,,9.296,Percent of Total Billed Charges,90% of Total Billed Charges,33.3,45,,2.88,Percent of Total Billed Charges,45% of Total Billed Charges,66.6,90,,13.68,Percent of Total Billed Charges,90% of Total billed Charges,74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.1,65,,1.04,Percent of total Billed Charges,65% of Total Billed Charges,32.63,44.1,,2.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,70.3,95,,14.44,Percent of Total Billed Charges,95% of Total Billed Charges,74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.12,88,,13.376,Percent of Total Billed Charges,88% of Total Billed Charges,66.6,90,,13.68,Percent of Total Billed charges,90% of Total Billed Charges,32.63,74,
A22253C NDL 90 Deg Elect Mono,2720001535,CDM,272,RC,,,Outpatient,,,74.00,48.10,,74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.24,76,,5.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.28,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,55.5,75,,225,Percent of Total Billed charges,75% of Total Billed Charges,74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.28,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,44.4,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,66.6,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,33.3,45,,5.04,Percent of Total Billed Charges,45% of Total Billed Charges,66.6,90,,6.576,Percent of Total Billed Charges,90% of Total billed Charges,74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.1,65,,4.16,Percent of total Billed Charges,65% of Total Billed Charges,32.63,44.1,,4.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,70.3,95,,6.936,Percent of Total Billed Charges,95% of Total Billed Charges,74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.12,88,,6.424,Percent of Total Billed Charges,88% of Total Billed Charges,66.6,90,,6.576,Percent of Total Billed charges,90% of Total Billed Charges,32.63,74,
CETERIX NOVOSTITCH PRO MENISCA,2720001536,CDM,272,RC,,,Outpatient,,,2219.00,1442.35,,2219,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1686.44,76,,1.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1597.68,72,,217.96,Percent of Total Billed Charges,72% of Total Billed Charges,1664.25,75,,227.04,Percent of Total Billed charges,75% of Total Billed Charges,2219,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1597.68,72,,217.96,Percent of Total Billed Charges,72% of Total Billed Charges,1331.4,60,,181.632,Percent of Total Billed Charges,60% of Total Billed Charges,1997.1,90,,325.44,Percent of Total Billed Charges,90% of Total Billed Charges,998.55,45,,29.52,Percent of Total Billed Charges,45% of Total Billed Charges,1997.1,90,,1.44,Percent of Total Billed Charges,90% of Total billed Charges,2219,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2219,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2219,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1442.35,65,,7.28,Percent of total Billed Charges,65% of Total Billed Charges,978.58,44.1,,28.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,2108.05,95,,1.52,Percent of Total Billed Charges,95% of Total Billed Charges,2219,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1952.72,88,,1.408,Percent of Total Billed Charges,88% of Total Billed Charges,1997.1,90,,1.44,Percent of Total Billed charges,90% of Total Billed Charges,978.58,2219,
SINU FOAM DRESSING,2720001537,CDM,272,RC,,,Outpatient,,,94.00,61.10,,94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,71.44,76,,4.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,67.68,72,,23.672,Percent of Total Billed Charges,72% of Total Billed Charges,70.5,75,,24.664,Percent of Total Billed charges,75% of Total Billed Charges,94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.68,72,,23.672,Percent of Total Billed Charges,72% of Total Billed Charges,56.4,60,,19.728,Percent of Total Billed Charges,60% of Total Billed Charges,84.6,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,42.3,45,,34.2,Percent of Total Billed Charges,45% of Total Billed Charges,84.6,90,,5.76,Percent of Total Billed Charges,90% of Total billed Charges,94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.1,65,,42.64,Percent of total Billed Charges,65% of Total Billed Charges,41.45,44.1,,33.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,89.3,95,,6.08,Percent of Total Billed Charges,95% of Total Billed Charges,94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.72,88,,5.632,Percent of Total Billed Charges,88% of Total Billed Charges,84.6,90,,5.76,Percent of Total Billed charges,90% of Total Billed Charges,41.45,94,
ARTHREX FIBERLINK BLUE,2720001538,CDM,272,RC,,,Outpatient,,,112.00,72.80,,112,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,85.12,76,,8.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,80.64,72,,2.448,Percent of Total Billed Charges,72% of Total Billed Charges,84,75,,2.552,Percent of Total Billed charges,75% of Total Billed Charges,112,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.64,72,,2.448,Percent of Total Billed Charges,72% of Total Billed Charges,67.2,60,,2.04,Percent of Total Billed Charges,60% of Total Billed Charges,100.8,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,50.4,45,,396,Percent of Total Billed Charges,45% of Total Billed Charges,100.8,90,,10.08,Percent of Total Billed Charges,90% of Total billed Charges,112,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.8,65,,49.4,Percent of total Billed Charges,65% of Total Billed Charges,49.39,44.1,,388.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,106.4,95,,10.64,Percent of Total Billed Charges,95% of Total Billed Charges,112,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.56,88,,9.856,Percent of Total Billed Charges,88% of Total Billed Charges,100.8,90,,10.08,Percent of Total Billed charges,90% of Total Billed Charges,49.39,112,
DOPPLER PROBE 8MHZ DISP,2720001539,CDM,272,RC,,,Outpatient,,,159.00,103.35,,159,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.84,76,,49.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.48,72,,2.352,Percent of Total Billed Charges,72% of Total Billed Charges,119.25,75,,2.448,Percent of Total Billed charges,75% of Total Billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.48,72,,2.352,Percent of Total Billed Charges,72% of Total Billed Charges,95.4,60,,1.96,Percent of Total Billed Charges,60% of Total Billed Charges,143.1,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,71.55,45,,0.72,Percent of Total Billed Charges,45% of Total Billed Charges,143.1,90,,59.04,Percent of Total Billed Charges,90% of Total billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.35,65,,572,Percent of total Billed Charges,65% of Total Billed Charges,70.12,44.1,,0.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,151.05,95,,62.32,Percent of Total Billed Charges,95% of Total Billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.92,88,,57.728,Percent of Total Billed Charges,88% of Total Billed Charges,143.1,90,,59.04,Percent of Total Billed charges,90% of Total Billed Charges,70.12,159,
BS 12/14 FRX46,2720001540,CDM,272,RC,,,Outpatient,,,132.00,85.80,,132,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.32,76,,57.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.04,72,,5.04,Percent of Total Billed Charges,72% of Total Billed Charges,99,75,,5.248,Percent of Total Billed charges,75% of Total Billed Charges,132,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.04,72,,5.04,Percent of Total Billed Charges,72% of Total Billed Charges,79.2,60,,4.2,Percent of Total Billed Charges,60% of Total Billed Charges,118.8,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,59.4,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,118.8,90,,68.4,Percent of Total Billed Charges,90% of Total billed Charges,132,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.8,65,,1.04,Percent of total Billed Charges,65% of Total Billed Charges,58.21,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.4,95,,72.2,Percent of Total Billed Charges,95% of Total Billed Charges,132,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.16,88,,66.88,Percent of Total Billed Charges,88% of Total Billed Charges,118.8,90,,68.4,Percent of Total Billed charges,90% of Total Billed Charges,58.21,132,
BS TALON 3-PRONG GRASPER,2720001541,CDM,272,RC,,,Outpatient,,,189.00,122.85,,189,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,143.64,76,,668.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,136.08,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,141.75,75,,3,Percent of Total Billed charges,75% of Total Billed Charges,189,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.08,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,113.4,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,170.1,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,85.05,45,,4.648,Percent of Total Billed Charges,45% of Total Billed Charges,170.1,90,,792,Percent of Total Billed Charges,90% of Total billed Charges,189,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.85,65,,4.008,Percent of total Billed Charges,65% of Total Billed Charges,83.35,44.1,,4.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,179.55,95,,836,Percent of Total Billed Charges,95% of Total Billed Charges,189,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.32,88,,774.4,Percent of Total Billed Charges,88% of Total Billed Charges,170.1,90,,792,Percent of Total Billed charges,90% of Total Billed Charges,83.35,189,
BS URETERAL STENT 4.8FR,2720001542,CDM,272,RC,,,Outpatient,,,14.00,9.10,,14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.64,76,,1.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.08,72,,3.704,Percent of Total Billed Charges,72% of Total Billed Charges,10.5,75,,3.856,Percent of Total Billed charges,75% of Total Billed Charges,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.08,72,,3.704,Percent of Total Billed Charges,72% of Total Billed Charges,8.4,60,,3.088,Percent of Total Billed Charges,60% of Total Billed Charges,12.6,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,45,,1.08,Percent of Total Billed Charges,45% of Total Billed Charges,12.6,90,,1.44,Percent of Total Billed Charges,90% of Total billed Charges,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.1,65,,6.712,Percent of total Billed Charges,65% of Total Billed Charges,6.17,44.1,,1.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.3,95,,1.52,Percent of Total Billed Charges,95% of Total Billed Charges,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.32,88,,1.408,Percent of Total Billed Charges,88% of Total Billed Charges,12.6,90,,1.44,Percent of Total Billed charges,90% of Total Billed Charges,6.17,14,
BS .038 ANGLED ZIPWIRE,2720001543,CDM,272,RC,,,Outpatient,,,61.00,39.65,,61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.36,76,,4.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.92,72,,1.64,Percent of Total Billed Charges,72% of Total Billed Charges,45.75,75,,1.712,Percent of Total Billed charges,75% of Total Billed Charges,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.92,72,,1.64,Percent of Total Billed Charges,72% of Total Billed Charges,36.6,60,,1.368,Percent of Total Billed Charges,60% of Total Billed Charges,54.9,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,27.45,45,,162.72,Percent of Total Billed Charges,45% of Total Billed Charges,54.9,90,,5.544,Percent of Total Billed Charges,90% of Total billed Charges,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.65,65,,1.56,Percent of total Billed Charges,65% of Total Billed Charges,26.9,44.1,,159.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.95,95,,5.856,Percent of Total Billed Charges,95% of Total Billed Charges,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.68,88,,5.424,Percent of Total Billed Charges,88% of Total Billed Charges,54.9,90,,5.544,Percent of Total Billed charges,90% of Total Billed Charges,26.9,61,
ALCON 0.3MM POLYMER I/A TIP,2720001544,CDM,272,RC,,,Outpatient,,,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,7.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.64,72,,15.84,Percent of Total Billed Charges,72% of Total Billed Charges,9,75,,16.504,Percent of Total Billed charges,75% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.64,72,,15.84,Percent of Total Billed Charges,72% of Total Billed Charges,7.2,60,,13.2,Percent of Total Billed Charges,60% of Total Billed Charges,10.8,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,6.48,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,9.296,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,235.04,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,6.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,9.808,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,9.088,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,9.296,Percent of Total Billed charges,90% of Total Billed Charges,5.29,12,
ARTHREX 2.0MM DRILL BIT CMP FT,2720001545,CDM,272,RC,,,Outpatient,,,224.00,145.60,,224,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,170.24,76,,1.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,161.28,72,,3.096,Percent of Total Billed Charges,72% of Total Billed Charges,168,75,,3.232,Percent of Total Billed charges,75% of Total Billed Charges,224,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.28,72,,3.096,Percent of Total Billed Charges,72% of Total Billed Charges,134.4,60,,2.584,Percent of Total Billed Charges,60% of Total Billed Charges,201.6,90,,133.2,Percent of Total Billed Charges,90% of Total Billed Charges,100.8,45,,9,Percent of Total Billed Charges,45% of Total Billed Charges,201.6,90,,2.16,Percent of Total Billed Charges,90% of Total billed Charges,224,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.6,65,,9.36,Percent of total Billed Charges,65% of Total Billed Charges,98.78,44.1,,8.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,212.8,95,,2.28,Percent of Total Billed Charges,95% of Total Billed Charges,224,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.12,88,,2.112,Percent of Total Billed Charges,88% of Total Billed Charges,201.6,90,,2.16,Percent of Total Billed charges,90% of Total Billed Charges,98.78,224,
ARTHREX 0.86 MM GDEWIRE TROCAR,2720001546,CDM,272,RC,,,Outpatient,,,30.00,19.50,,30,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.8,76,,274.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.6,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,22.5,75,,6.616,Percent of Total Billed charges,75% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.6,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,18,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,27,90,,396,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,45,,9,Percent of Total Billed Charges,45% of Total Billed Charges,27,90,,325.44,Percent of Total Billed Charges,90% of Total billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.5,65,,13,Percent of total Billed Charges,65% of Total Billed Charges,13.23,44.1,,8.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.5,95,,343.52,Percent of Total Billed Charges,95% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.4,88,,318.208,Percent of Total Billed Charges,88% of Total Billed Charges,27,90,,325.44,Percent of Total Billed charges,90% of Total Billed Charges,13.23,30,
ALCON 2.4 ANGLED KNIFE,2720001547,CDM,272,RC,,,Outpatient,,,31.00,20.15,,31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.56,76,,10.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.32,72,,6.528,Percent of Total Billed Charges,72% of Total Billed Charges,23.25,75,,6.8,Percent of Total Billed charges,75% of Total Billed Charges,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,72,,6.528,Percent of Total Billed Charges,72% of Total Billed Charges,18.6,60,,5.44,Percent of Total Billed Charges,60% of Total Billed Charges,27.9,90,,168.48,Percent of Total Billed Charges,90% of Total Billed Charges,13.95,45,,9,Percent of Total Billed Charges,45% of Total Billed Charges,27.9,90,,12.96,Percent of Total Billed Charges,90% of Total billed Charges,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.15,65,,13,Percent of total Billed Charges,65% of Total Billed Charges,13.67,44.1,,8.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.45,95,,13.68,Percent of Total Billed Charges,95% of Total Billed Charges,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.28,88,,12.672,Percent of Total Billed Charges,88% of Total Billed Charges,27.9,90,,12.96,Percent of Total Billed charges,90% of Total Billed Charges,13.67,31,
CLEARCUT 2.6 DUAL BEVEL,2720001548,CDM,272,RC,,,Outpatient,,,32.00,20.80,,32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.32,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.04,72,,1.984,Percent of Total Billed Charges,72% of Total Billed Charges,24,75,,2.072,Percent of Total Billed charges,75% of Total Billed Charges,32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.04,72,,1.984,Percent of Total Billed Charges,72% of Total Billed Charges,19.2,60,,1.656,Percent of Total Billed Charges,60% of Total Billed Charges,28.8,90,,209.52,Percent of Total Billed Charges,90% of Total Billed Charges,14.4,45,,2.16,Percent of Total Billed Charges,45% of Total Billed Charges,28.8,90,,18,Percent of Total Billed Charges,90% of Total billed Charges,32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.8,65,,13,Percent of total Billed Charges,65% of Total Billed Charges,14.11,44.1,,2.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.4,95,,19,Percent of Total Billed Charges,95% of Total Billed Charges,32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.16,88,,17.6,Percent of Total Billed Charges,88% of Total Billed Charges,28.8,90,,18,Percent of Total Billed charges,90% of Total Billed Charges,14.11,32,
ULTRASLING 3MDM,2720001549,CDM,272,RC,,,Outpatient,,,61.00,39.65,,61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.36,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.92,72,,19.8,Percent of Total Billed Charges,72% of Total Billed Charges,45.75,75,,20.632,Percent of Total Billed charges,75% of Total Billed Charges,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.92,72,,19.8,Percent of Total Billed Charges,72% of Total Billed Charges,36.6,60,,16.504,Percent of Total Billed Charges,60% of Total Billed Charges,54.9,90,,594,Percent of Total Billed Charges,90% of Total Billed Charges,27.45,45,,2.16,Percent of Total Billed Charges,45% of Total Billed Charges,54.9,90,,18,Percent of Total Billed Charges,90% of Total billed Charges,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.65,65,,3.12,Percent of total Billed Charges,65% of Total Billed Charges,26.9,44.1,,2.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.95,95,,19,Percent of Total Billed Charges,95% of Total Billed Charges,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.68,88,,17.6,Percent of Total Billed Charges,88% of Total Billed Charges,54.9,90,,18,Percent of Total Billed charges,90% of Total Billed Charges,26.9,61,
ULTRASLING 3LG,2720001550,CDM,272,RC,,,Outpatient,,,61.00,39.65,,61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.36,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.92,72,,45.36,Percent of Total Billed Charges,72% of Total Billed Charges,45.75,75,,47.248,Percent of Total Billed charges,75% of Total Billed Charges,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.92,72,,45.36,Percent of Total Billed Charges,72% of Total Billed Charges,36.6,60,,37.8,Percent of Total Billed Charges,60% of Total Billed Charges,54.9,90,,125.28,Percent of Total Billed Charges,90% of Total Billed Charges,27.45,45,,2.16,Percent of Total Billed Charges,45% of Total Billed Charges,54.9,90,,18,Percent of Total Billed Charges,90% of Total billed Charges,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.65,65,,3.12,Percent of total Billed Charges,65% of Total Billed Charges,26.9,44.1,,2.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.95,95,,19,Percent of Total Billed Charges,95% of Total Billed Charges,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.68,88,,17.6,Percent of Total Billed Charges,88% of Total Billed Charges,54.9,90,,18,Percent of Total Billed charges,90% of Total Billed Charges,26.9,61,
ASTRINGYN,2720001551,CDM,272,RC,,,Outpatient,,,20.00,13.00,,20,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.2,76,,3.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.4,72,,45.36,Percent of Total Billed Charges,72% of Total Billed Charges,15,75,,47.248,Percent of Total Billed charges,75% of Total Billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.4,72,,45.36,Percent of Total Billed Charges,72% of Total Billed Charges,12,60,,37.8,Percent of Total Billed Charges,60% of Total Billed Charges,18,90,,91.44,Percent of Total Billed Charges,90% of Total Billed Charges,9,45,,1.8,Percent of Total Billed Charges,45% of Total Billed Charges,18,90,,4.32,Percent of Total Billed Charges,90% of Total billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13,65,,3.12,Percent of total Billed Charges,65% of Total Billed Charges,8.82,44.1,,1.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,19,95,,4.56,Percent of Total Billed Charges,95% of Total Billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.6,88,,4.224,Percent of Total Billed Charges,88% of Total Billed Charges,18,90,,4.32,Percent of Total Billed charges,90% of Total Billed Charges,8.82,20,
POPE BEVELED GROMMET VENT,2720001552,CDM,272,RC,,,Outpatient,,,50.00,32.50,,50,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38,76,,3.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36,72,,22.856,Percent of Total Billed Charges,72% of Total Billed Charges,37.5,75,,23.808,Percent of Total Billed charges,75% of Total Billed Charges,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36,72,,22.856,Percent of Total Billed Charges,72% of Total Billed Charges,30,60,,19.048,Percent of Total Billed Charges,60% of Total Billed Charges,45,90,,1101.6,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,45,,66.6,Percent of Total Billed Charges,45% of Total Billed Charges,45,90,,4.32,Percent of Total Billed Charges,90% of Total billed Charges,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.5,65,,2.6,Percent of total Billed Charges,65% of Total Billed Charges,22.05,44.1,,65.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,47.5,95,,4.56,Percent of Total Billed Charges,95% of Total Billed Charges,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44,88,,4.224,Percent of Total Billed Charges,88% of Total Billed Charges,45,90,,4.32,Percent of Total Billed charges,90% of Total Billed Charges,22.05,50,
Z281001100 GDEWRE 3.0X100,2720001553,CDM,272,RC,,,Outpatient,,,127.00,82.55,,127,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,96.52,76,,3.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.44,72,,7.4,Percent of Total Billed Charges,72% of Total Billed Charges,95.25,75,,7.712,Percent of Total Billed charges,75% of Total Billed Charges,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.44,72,,7.4,Percent of Total Billed Charges,72% of Total Billed Charges,76.2,60,,6.168,Percent of Total Billed Charges,60% of Total Billed Charges,114.3,90,,1101.6,Percent of Total Billed Charges,90% of Total Billed Charges,57.15,45,,198,Percent of Total Billed Charges,45% of Total Billed Charges,114.3,90,,4.32,Percent of Total Billed Charges,90% of Total billed Charges,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.55,65,,96.2,Percent of total Billed Charges,65% of Total Billed Charges,56.01,44.1,,194.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,120.65,95,,4.56,Percent of Total Billed Charges,95% of Total Billed Charges,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.76,88,,4.224,Percent of Total Billed Charges,88% of Total Billed Charges,114.3,90,,4.32,Percent of Total Billed charges,90% of Total Billed Charges,56.01,127,
STYKER FLYTE TOGA X LARGE,2720001554,CDM,272,RC,,,Outpatient,,,80.00,52.00,,80,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60.8,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.6,72,,2.088,Percent of Total Billed Charges,72% of Total Billed Charges,60,75,,2.176,Percent of Total Billed charges,75% of Total Billed Charges,80,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.6,72,,2.088,Percent of Total Billed Charges,72% of Total Billed Charges,48,60,,1.744,Percent of Total Billed Charges,60% of Total Billed Charges,72,90,,1101.6,Percent of Total Billed Charges,90% of Total Billed Charges,36,45,,84.24,Percent of Total Billed Charges,45% of Total Billed Charges,72,90,,3.6,Percent of Total Billed Charges,90% of Total billed Charges,80,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52,65,,286,Percent of total Billed Charges,65% of Total Billed Charges,35.28,44.1,,82.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,76,95,,3.8,Percent of Total Billed Charges,95% of Total Billed Charges,80,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.4,88,,3.52,Percent of Total Billed Charges,88% of Total Billed Charges,72,90,,3.6,Percent of Total Billed charges,90% of Total Billed Charges,35.28,80,
STYKER FLYTE TOGA 3X LG,2720001555,CDM,272,RC,,,Outpatient,,,90.00,58.50,,90,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.4,76,,112.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.8,72,,3.936,Percent of Total Billed Charges,72% of Total Billed Charges,67.5,75,,4.096,Percent of Total Billed charges,75% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.8,72,,3.936,Percent of Total Billed Charges,72% of Total Billed Charges,54,60,,3.28,Percent of Total Billed Charges,60% of Total Billed Charges,81,90,,1101.6,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,45,,104.76,Percent of Total Billed Charges,45% of Total Billed Charges,81,90,,133.2,Percent of Total Billed Charges,90% of Total billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.5,65,,121.68,Percent of total Billed Charges,65% of Total Billed Charges,39.69,44.1,,102.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.5,95,,140.6,Percent of Total Billed Charges,95% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,88,,130.24,Percent of Total Billed Charges,88% of Total Billed Charges,81,90,,133.2,Percent of Total Billed charges,90% of Total Billed Charges,39.69,90,
WRAPON PAD XL,2720001556,CDM,272,RC,,,Outpatient,,,38.00,24.70,,38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.88,76,,334.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.36,72,,3.936,Percent of Total Billed Charges,72% of Total Billed Charges,28.5,75,,4.096,Percent of Total Billed charges,75% of Total Billed Charges,38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.36,72,,3.936,Percent of Total Billed Charges,72% of Total Billed Charges,22.8,60,,3.28,Percent of Total Billed Charges,60% of Total Billed Charges,34.2,90,,1101.6,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,45,,297,Percent of Total Billed Charges,45% of Total Billed Charges,34.2,90,,396,Percent of Total Billed Charges,90% of Total billed Charges,38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.7,65,,151.32,Percent of total Billed Charges,65% of Total Billed Charges,16.76,44.1,,291.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.1,95,,418,Percent of Total Billed Charges,95% of Total Billed Charges,38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.44,88,,387.2,Percent of Total Billed Charges,88% of Total Billed Charges,34.2,90,,396,Percent of Total Billed charges,90% of Total Billed Charges,16.76,38,
SLEEVE SCD VENAFLOW XL,2720001557,CDM,272,RC,,,Outpatient,,,30.00,19.50,,30,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.8,76,,142.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.6,72,,7.4,Percent of Total Billed Charges,72% of Total Billed Charges,22.5,75,,7.712,Percent of Total Billed charges,75% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.6,72,,7.4,Percent of Total Billed Charges,72% of Total Billed Charges,18,60,,6.168,Percent of Total Billed Charges,60% of Total Billed Charges,27,90,,1101.6,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,45,,62.64,Percent of Total Billed Charges,45% of Total Billed Charges,27,90,,168.48,Percent of Total Billed Charges,90% of Total billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.5,65,,429,Percent of total Billed Charges,65% of Total Billed Charges,13.23,44.1,,61.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.5,95,,177.84,Percent of Total Billed Charges,95% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.4,88,,164.736,Percent of Total Billed Charges,88% of Total Billed Charges,27,90,,168.48,Percent of Total Billed charges,90% of Total Billed Charges,13.23,30,
DISP SCOPE WARMER,2720001558,CDM,272,RC,,,Outpatient,,,23.00,14.95,,23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.48,76,,176.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.56,72,,3.936,Percent of Total Billed Charges,72% of Total Billed Charges,17.25,75,,4.096,Percent of Total Billed charges,75% of Total Billed Charges,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.56,72,,3.936,Percent of Total Billed Charges,72% of Total Billed Charges,13.8,60,,3.28,Percent of Total Billed Charges,60% of Total Billed Charges,20.7,90,,1101.6,Percent of Total Billed Charges,90% of Total Billed Charges,10.35,45,,45.72,Percent of Total Billed Charges,45% of Total Billed Charges,20.7,90,,209.52,Percent of Total Billed Charges,90% of Total billed Charges,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.95,65,,90.48,Percent of total Billed Charges,65% of Total Billed Charges,10.14,44.1,,44.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.85,95,,221.16,Percent of Total Billed Charges,95% of Total Billed Charges,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.24,88,,204.864,Percent of Total Billed Charges,88% of Total Billed Charges,20.7,90,,209.52,Percent of Total Billed charges,90% of Total Billed Charges,10.14,23,
ZIMMER CEMENT MIXER,2720001559,CDM,272,RC,,,Outpatient,,,113.00,73.45,,113,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,85.88,76,,501.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,81.36,72,,2.088,Percent of Total Billed Charges,72% of Total Billed Charges,84.75,75,,2.176,Percent of Total Billed charges,75% of Total Billed Charges,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.36,72,,2.088,Percent of Total Billed Charges,72% of Total Billed Charges,67.8,60,,1.744,Percent of Total Billed Charges,60% of Total Billed Charges,101.7,90,,1101.6,Percent of Total Billed Charges,90% of Total Billed Charges,50.85,45,,550.8,Percent of Total Billed Charges,45% of Total Billed Charges,101.7,90,,594,Percent of Total Billed Charges,90% of Total billed Charges,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.45,65,,66.04,Percent of total Billed Charges,65% of Total Billed Charges,49.83,44.1,,539.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,107.35,95,,627,Percent of Total Billed Charges,95% of Total Billed Charges,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.44,88,,580.8,Percent of Total Billed Charges,88% of Total Billed Charges,101.7,90,,594,Percent of Total Billed charges,90% of Total Billed Charges,49.83,113,
ROUND DIAMOND BUR MDM,2720001560,CDM,272,RC,,,Outpatient,,,28.00,18.20,,28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21.28,76,,105.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.16,72,,3.936,Percent of Total Billed Charges,72% of Total Billed Charges,21,75,,4.096,Percent of Total Billed charges,75% of Total Billed Charges,28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.16,72,,3.936,Percent of Total Billed Charges,72% of Total Billed Charges,16.8,60,,3.28,Percent of Total Billed Charges,60% of Total Billed Charges,25.2,90,,104.4,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,45,,550.8,Percent of Total Billed Charges,45% of Total Billed Charges,25.2,90,,125.28,Percent of Total Billed Charges,90% of Total billed Charges,28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.2,65,,795.6,Percent of total Billed Charges,65% of Total Billed Charges,12.35,44.1,,539.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.6,95,,132.24,Percent of Total Billed Charges,95% of Total Billed Charges,28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.64,88,,122.496,Percent of Total Billed Charges,88% of Total Billed Charges,25.2,90,,125.28,Percent of Total Billed charges,90% of Total Billed Charges,12.35,28,
WECK-CEL SURG SPEARS,2720001561,CDM,272,RC,,,Outpatient,,,2.00,1.30,,2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.52,76,,77.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.44,72,,2.088,Percent of Total Billed Charges,72% of Total Billed Charges,1.5,75,,2.176,Percent of Total Billed charges,75% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,72,,2.088,Percent of Total Billed Charges,72% of Total Billed Charges,1.2,60,,1.744,Percent of Total Billed Charges,60% of Total Billed Charges,1.8,90,,37.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.9,45,,550.8,Percent of Total Billed Charges,45% of Total Billed Charges,1.8,90,,91.44,Percent of Total Billed Charges,90% of Total billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,65,,795.6,Percent of total Billed Charges,65% of Total Billed Charges,0.88,44.1,,539.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.9,95,,96.52,Percent of Total Billed Charges,95% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.76,88,,89.408,Percent of Total Billed Charges,88% of Total Billed Charges,1.8,90,,91.44,Percent of Total Billed charges,90% of Total Billed Charges,0.88,2,
LEEP READY KIT,2720001562,CDM,272,RC,,,Outpatient,,,53.00,34.45,,53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.28,76,,930.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.16,72,,2.088,Percent of Total Billed Charges,72% of Total Billed Charges,39.75,75,,2.176,Percent of Total Billed charges,75% of Total Billed Charges,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.16,72,,2.088,Percent of Total Billed Charges,72% of Total Billed Charges,31.8,60,,1.744,Percent of Total Billed Charges,60% of Total Billed Charges,47.7,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,23.85,45,,550.8,Percent of Total Billed Charges,45% of Total Billed Charges,47.7,90,,1101.6,Percent of Total Billed Charges,90% of Total billed Charges,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.45,65,,795.6,Percent of total Billed Charges,65% of Total Billed Charges,23.37,44.1,,539.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.35,95,,1162.8,Percent of Total Billed Charges,95% of Total Billed Charges,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.64,88,,1077.12,Percent of Total Billed Charges,88% of Total Billed Charges,47.7,90,,1101.6,Percent of Total Billed charges,90% of Total Billed Charges,23.37,53,
FAST FIX STRAIGHT NEEDLE,2720001563,CDM,272,RC,,,Outpatient,,,386.00,250.90,,386,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,293.36,76,,930.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,277.92,72,,14.408,Percent of Total Billed Charges,72% of Total Billed Charges,289.5,75,,15.016,Percent of Total Billed charges,75% of Total Billed Charges,386,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.92,72,,14.408,Percent of Total Billed Charges,72% of Total Billed Charges,231.6,60,,12.008,Percent of Total Billed Charges,60% of Total Billed Charges,347.4,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,173.7,45,,550.8,Percent of Total Billed Charges,45% of Total Billed Charges,347.4,90,,1101.6,Percent of Total Billed Charges,90% of Total billed Charges,386,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.9,65,,795.6,Percent of total Billed Charges,65% of Total Billed Charges,170.23,44.1,,539.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,366.7,95,,1162.8,Percent of Total Billed Charges,95% of Total Billed Charges,386,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,339.68,88,,1077.12,Percent of Total Billed Charges,88% of Total Billed Charges,347.4,90,,1101.6,Percent of Total Billed charges,90% of Total Billed Charges,170.23,386,
STAINLESS STEEL 3-0 497G,2720001564,CDM,272,RC,,,Outpatient,,,2.00,1.30,,2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.52,76,,930.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.44,72,,13.68,Percent of Total Billed Charges,72% of Total Billed Charges,1.5,75,,14.248,Percent of Total Billed charges,75% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,72,,13.68,Percent of Total Billed Charges,72% of Total Billed Charges,1.2,60,,11.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.8,90,,42.84,Percent of Total Billed Charges,90% of Total Billed Charges,0.9,45,,550.8,Percent of Total Billed Charges,45% of Total Billed Charges,1.8,90,,1101.6,Percent of Total Billed Charges,90% of Total billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,65,,795.6,Percent of total Billed Charges,65% of Total Billed Charges,0.88,44.1,,539.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.9,95,,1162.8,Percent of Total Billed Charges,95% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.76,88,,1077.12,Percent of Total Billed Charges,88% of Total Billed Charges,1.8,90,,1101.6,Percent of Total Billed charges,90% of Total Billed Charges,0.88,2,
ALCON OPTHALMIC KNIFE 15DEG,2720001565,CDM,272,RC,,,Outpatient,,,5.00,3.25,,5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.8,76,,930.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.6,72,,13.248,Percent of Total Billed Charges,72% of Total Billed Charges,3.75,75,,13.8,Percent of Total Billed charges,75% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.6,72,,13.248,Percent of Total Billed Charges,72% of Total Billed Charges,3,60,,11.04,Percent of Total Billed Charges,60% of Total Billed Charges,4.5,90,,4.856,Percent of Total Billed Charges,90% of Total Billed Charges,2.25,45,,550.8,Percent of Total Billed Charges,45% of Total Billed Charges,4.5,90,,1101.6,Percent of Total Billed Charges,90% of Total billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.25,65,,795.6,Percent of total Billed Charges,65% of Total Billed Charges,2.21,44.1,,539.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.75,95,,1162.8,Percent of Total Billed Charges,95% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.4,88,,1077.12,Percent of Total Billed Charges,88% of Total Billed Charges,4.5,90,,1101.6,Percent of Total Billed charges,90% of Total Billed Charges,2.21,5,
SMITH&NEPHEW FAST FIX 360,2720001566,CDM,272,RC,,,Outpatient,,,541.00,351.65,,541,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,411.16,76,,930.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,389.52,72,,13.68,Percent of Total Billed Charges,72% of Total Billed Charges,405.75,75,,14.248,Percent of Total Billed charges,75% of Total Billed Charges,541,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,389.52,72,,13.68,Percent of Total Billed Charges,72% of Total Billed Charges,324.6,60,,11.4,Percent of Total Billed Charges,60% of Total Billed Charges,486.9,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,243.45,45,,550.8,Percent of Total Billed Charges,45% of Total Billed Charges,486.9,90,,1101.6,Percent of Total Billed Charges,90% of Total billed Charges,541,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,541,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,541,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,351.65,65,,795.6,Percent of total Billed Charges,65% of Total Billed Charges,238.58,44.1,,539.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,513.95,95,,1162.8,Percent of Total Billed Charges,95% of Total Billed Charges,541,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.08,88,,1077.12,Percent of Total Billed Charges,88% of Total Billed Charges,486.9,90,,1101.6,Percent of Total Billed charges,90% of Total Billed Charges,238.58,541,
SMITH&NEPHEW KNOT PUSHER,2720001567,CDM,272,RC,,,Outpatient,,,152.00,98.80,,152,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,115.52,76,,930.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,109.44,72,,140.4,Percent of Total Billed Charges,72% of Total Billed Charges,114,75,,140.4,Percent of Total Billed charges,75% of Total Billed Charges,152,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.44,72,,140.4,Percent of Total Billed Charges,72% of Total Billed Charges,91.2,60,,117,Percent of Total Billed Charges,60% of Total Billed Charges,136.8,90,,4.8,Percent of Total Billed Charges,90% of Total Billed Charges,68.4,45,,52.2,Percent of Total Billed Charges,45% of Total Billed Charges,136.8,90,,1101.6,Percent of Total Billed Charges,90% of Total billed Charges,152,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.8,65,,795.6,Percent of total Billed Charges,65% of Total Billed Charges,67.03,44.1,,51.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,144.4,95,,1162.8,Percent of Total Billed Charges,95% of Total Billed Charges,152,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.76,88,,1077.12,Percent of Total Billed Charges,88% of Total Billed Charges,136.8,90,,1101.6,Percent of Total Billed charges,90% of Total Billed Charges,67.03,152,
VIANCE STANDARD X 15,2720001568,CDM,272,RC,,,Outpatient,,,7397.78,4808.56,,7397.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5622.31,76,,930.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5326.4,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,5548.34,75,,12.568,Percent of Total Billed charges,75% of Total Billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5326.4,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,4438.67,60,,10.056,Percent of Total Billed Charges,60% of Total Billed Charges,6658,90,,2.344,Percent of Total Billed Charges,90% of Total Billed Charges,3329,45,,18.72,Percent of Total Billed Charges,45% of Total Billed Charges,6658,90,,1101.6,Percent of Total Billed Charges,90% of Total billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4808.56,65,,75.4,Percent of total Billed Charges,65% of Total Billed Charges,3262.42,44.1,,18.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,7027.89,95,,1162.8,Percent of Total Billed Charges,95% of Total Billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6510.05,88,,1077.12,Percent of Total Billed Charges,88% of Total Billed Charges,6658,90,,1101.6,Percent of Total Billed charges,90% of Total Billed Charges,3262.42,7397.78,
HAWKONE 6F MED 0.014 CATHETER,2720001569,CDM,272,RC,,,Outpatient,,,7397.78,4808.56,,7397.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5622.31,76,,930.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5326.4,72,,40.824,Percent of Total Billed Charges,72% of Total Billed Charges,5548.34,75,,42.528,Percent of Total Billed charges,75% of Total Billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5326.4,72,,40.824,Percent of Total Billed Charges,72% of Total Billed Charges,4438.67,60,,34.024,Percent of Total Billed Charges,60% of Total Billed Charges,6658,90,,3.168,Percent of Total Billed Charges,90% of Total Billed Charges,3329,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,6658,90,,1101.6,Percent of Total Billed Charges,90% of Total billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4808.56,65,,27.04,Percent of total Billed Charges,65% of Total Billed Charges,3262.42,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,7027.89,95,,1162.8,Percent of Total Billed Charges,95% of Total Billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6510.05,88,,1077.12,Percent of Total Billed Charges,88% of Total Billed Charges,6658,90,,1101.6,Percent of Total Billed charges,90% of Total Billed Charges,3262.42,7397.78,
SILVRHAWK SH DS DISTAL VES TIP,2720001570,CDM,272,RC,,,Outpatient,,,7397.78,4808.56,,7397.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5622.31,76,,88.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5326.4,72,,41.032,Percent of Total Billed Charges,72% of Total Billed Charges,5548.34,75,,42.736,Percent of Total Billed charges,75% of Total Billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5326.4,72,,41.032,Percent of Total Billed Charges,72% of Total Billed Charges,4438.67,60,,34.192,Percent of Total Billed Charges,60% of Total Billed Charges,6658,90,,3.336,Percent of Total Billed Charges,90% of Total Billed Charges,3329,45,,1.8,Percent of Total Billed Charges,45% of Total Billed Charges,6658,90,,104.4,Percent of Total Billed Charges,90% of Total billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4808.56,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,3262.42,44.1,,1.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,7027.89,95,,110.2,Percent of Total Billed Charges,95% of Total Billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6510.05,88,,102.08,Percent of Total Billed Charges,88% of Total Billed Charges,6658,90,,104.4,Percent of Total Billed charges,90% of Total Billed Charges,3262.42,7397.78,
TURBOHAWK SX-C EXT T,2720001571,CDM,272,RC,,,Outpatient,,,7397.78,4808.56,,7397.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5622.31,76,,31.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5326.4,72,,47.52,Percent of Total Billed Charges,72% of Total Billed Charges,5548.34,75,,49.504,Percent of Total Billed charges,75% of Total Billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5326.4,72,,47.52,Percent of Total Billed Charges,72% of Total Billed Charges,4438.67,60,,39.6,Percent of Total Billed Charges,60% of Total Billed Charges,6658,90,,6.224,Percent of Total Billed Charges,90% of Total Billed Charges,3329,45,,21.424,Percent of Total Billed Charges,45% of Total Billed Charges,6658,90,,37.44,Percent of Total Billed Charges,90% of Total billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4808.56,65,,2.6,Percent of total Billed Charges,65% of Total Billed Charges,3262.42,44.1,,20.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,7027.89,95,,39.52,Percent of Total Billed Charges,95% of Total Billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6510.05,88,,36.608,Percent of Total Billed Charges,88% of Total Billed Charges,6658,90,,37.44,Percent of Total Billed charges,90% of Total Billed Charges,3262.42,7397.78,
TURBOHAWK SS-C STAND,2720001572,CDM,272,RC,,,Outpatient,,,7397.78,4808.56,,7397.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5622.31,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5326.4,72,,47.52,Percent of Total Billed Charges,72% of Total Billed Charges,5548.34,75,,49.504,Percent of Total Billed charges,75% of Total Billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5326.4,72,,47.52,Percent of Total Billed Charges,72% of Total Billed Charges,4438.67,60,,39.6,Percent of Total Billed Charges,60% of Total Billed Charges,6658,90,,6.808,Percent of Total Billed Charges,90% of Total Billed Charges,3329,45,,2.424,Percent of Total Billed Charges,45% of Total Billed Charges,6658,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4808.56,65,,30.944,Percent of total Billed Charges,65% of Total Billed Charges,3262.42,44.1,,2.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,7027.89,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6510.05,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,6658,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,3262.42,7397.78,
VIANCE FLEXIBLE X 15,2720001573,CDM,272,RC,,,Outpatient,,,7397.78,4808.56,,7397.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5622.31,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5326.4,72,,32.512,Percent of Total Billed Charges,72% of Total Billed Charges,5548.34,75,,33.872,Percent of Total Billed charges,75% of Total Billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5326.4,72,,32.512,Percent of Total Billed Charges,72% of Total Billed Charges,4438.67,60,,27.096,Percent of Total Billed Charges,60% of Total Billed Charges,6658,90,,2.808,Percent of Total Billed Charges,90% of Total Billed Charges,3329,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,6658,90,,3.6,Percent of Total Billed Charges,90% of Total billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4808.56,65,,3.504,Percent of total Billed Charges,65% of Total Billed Charges,3262.42,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,7027.89,95,,3.8,Percent of Total Billed Charges,95% of Total Billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6510.05,88,,3.52,Percent of Total Billed Charges,88% of Total Billed Charges,6658,90,,3.6,Percent of Total Billed charges,90% of Total Billed Charges,3262.42,7397.78,
TURBOHAWK TH LS-M ENDO,2720001574,CDM,272,RC,,,Outpatient,,,7397.78,4808.56,,7397.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5622.31,76,,36.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5326.4,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,5548.34,75,,36,Percent of Total Billed charges,75% of Total Billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5326.4,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,4438.67,60,,28.8,Percent of Total Billed Charges,60% of Total Billed Charges,6658,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,3329,45,,2.4,Percent of Total Billed Charges,45% of Total Billed Charges,6658,90,,42.84,Percent of Total Billed Charges,90% of Total billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4808.56,65,,6.24,Percent of total Billed Charges,65% of Total Billed Charges,3262.42,44.1,,2.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,7027.89,95,,45.224,Percent of Total Billed Charges,95% of Total Billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6510.05,88,,41.888,Percent of Total Billed Charges,88% of Total Billed Charges,6658,90,,42.84,Percent of Total Billed charges,90% of Total Billed Charges,3262.42,7397.78,
TURBOHAWK TH LS-C SURG,2720001575,CDM,272,RC,,,Outpatient,,,7397.78,4808.56,,7397.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5622.31,76,,4.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5326.4,72,,79.92,Percent of Total Billed Charges,72% of Total Billed Charges,5548.34,75,,83.248,Percent of Total Billed charges,75% of Total Billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5326.4,72,,79.92,Percent of Total Billed Charges,72% of Total Billed Charges,4438.67,60,,66.6,Percent of Total Billed Charges,60% of Total Billed Charges,6658,90,,2.704,Percent of Total Billed Charges,90% of Total Billed Charges,3329,45,,1.168,Percent of Total Billed Charges,45% of Total Billed Charges,6658,90,,4.856,Percent of Total Billed Charges,90% of Total billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4808.56,65,,3.472,Percent of total Billed Charges,65% of Total Billed Charges,3262.42,44.1,,1.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,7027.89,95,,5.12,Percent of Total Billed Charges,95% of Total Billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6510.05,88,,4.744,Percent of Total Billed Charges,88% of Total Billed Charges,6658,90,,4.856,Percent of Total Billed charges,90% of Total Billed Charges,3262.42,7397.78,
RX TREK 2.5X15,2720001576,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,0.136,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,0.136,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,0.136,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,0.112,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,28.072,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,1.688,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 3.5X15MM,2720001577,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,4.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,1.144,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,1.192,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,1.144,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,0.952,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,13.32,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.664,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,4.8,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.288,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,5.072,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,4.696,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,4.8,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX MINI TREK 3X15,2720001578,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,1.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,0.752,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,0.784,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,0.752,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,0.624,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,25.912,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,3.112,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,2.344,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.408,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,3.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,2.472,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,2.288,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,2.344,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
NC QUANTUM AMR 3X15,2720001579,CDM,272,RC,,,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,2.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,3.616,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,3.768,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,3.616,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,3.016,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,25.912,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,3.4,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,3.168,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,4.496,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,3.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,3.344,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,3.096,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,3.168,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
RX TREK 2.5X20MM,2720001580,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,0.048,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,0.048,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,0.048,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,0.04,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,25.912,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.408,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,3.336,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,4.912,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.52,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,3.256,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,3.336,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 2.5X25MM,2720001581,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,5.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,1.2,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,1.152,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,25.912,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.08,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,6.224,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.032,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,6.568,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,6.08,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,6.224,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 3.5X20MM,2720001582,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,5.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,430.56,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,448.504,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,430.56,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,358.8,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,25.912,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.352,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,6.808,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,1.56,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,7.184,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,6.656,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,6.808,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
NC QUANTUM AMR 2.75X,2720001583,CDM,272,RC,,,Outpatient,,,181.91,118.24,,181.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,138.25,76,,2.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,130.98,72,,0.32,Percent of Total Billed Charges,72% of Total Billed Charges,136.43,75,,0.328,Percent of Total Billed charges,75% of Total Billed Charges,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.98,72,,0.32,Percent of Total Billed Charges,72% of Total Billed Charges,109.15,60,,0.264,Percent of Total Billed Charges,60% of Total Billed Charges,163.72,90,,3.072,Percent of Total Billed Charges,90% of Total Billed Charges,81.86,45,,14.04,Percent of Total Billed Charges,45% of Total Billed Charges,163.72,90,,2.808,Percent of Total Billed Charges,90% of Total billed Charges,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.24,65,,1.952,Percent of total Billed Charges,65% of Total Billed Charges,80.22,44.1,,13.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,172.81,95,,2.968,Percent of Total Billed Charges,95% of Total Billed Charges,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.08,88,,2.744,Percent of Total Billed Charges,88% of Total Billed Charges,163.72,90,,2.808,Percent of Total Billed charges,90% of Total Billed Charges,80.22,181.91,
RX MINI TREK 1.20X6,2720001584,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,1.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,5.04,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,5.248,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,5.04,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,4.2,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,6.664,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,2.16,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,20.272,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,6.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,2.28,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,2.112,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,2.16,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX MINI TREK 1.20X8,2720001585,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,16.92,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,17.632,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,16.92,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,14.104,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,12.96,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,2.704,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,9.624,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,12.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,2.856,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,2.648,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,2.704,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX MINI TREK 1.20X12,2720001586,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,23.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,194.4,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,202.504,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,194.4,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,162,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,12.96,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,28.072,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,18.712,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,12.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,29.632,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,27.448,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,28.072,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX MINI TREK 1.20X15,2720001587,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,11.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,60.48,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,63,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,60.48,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,50.4,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,12.96,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,13.32,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,18.712,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,12.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,14.064,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,13.024,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,13.32,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX MINI TREK 1.20X20,2720001588,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,21.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,15.584,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,16.232,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,15.584,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,12.984,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,12.96,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,25.912,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,18.712,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,12.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,27.352,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,25.336,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,25.912,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX MINI TREK 1.5X6,2720001589,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,21.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,6.536,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,6.808,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,6.536,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,5.448,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,12.96,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,25.912,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,18.712,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,12.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,27.352,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,25.336,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,25.912,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX MINI TREK 1.5X8,2720001590,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,21.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,6.816,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,7.096,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,6.816,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,5.68,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,2.976,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.536,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,25.912,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,18.712,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,27.352,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,25.336,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,25.912,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX MINI TREK 1.5X12,2720001591,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,21.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,3.4,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,3.544,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,3.4,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,2.832,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,2.232,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.536,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,25.912,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.224,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,27.352,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,25.336,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,25.912,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX MINI TREK 1.5X15,2720001592,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,21.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,4.032,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,4.2,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,4.032,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,2.008,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.536,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,25.912,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.224,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,27.352,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,25.336,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,25.912,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX MINI TREK 1.5X20,2720001593,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,2.048,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,2.128,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,2.048,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,1.704,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,3.36,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.536,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.224,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.248,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,3.008,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX MINI TREK 2X6,2720001594,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,84.24,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,87.752,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,84.24,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,70.2,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,3.36,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.536,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.224,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.248,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,3.008,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX MINI TREK 2X8,2720001595,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,3.456,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,3.6,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,3.456,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,3.36,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.536,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.224,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.248,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,3.008,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX MINI TREK 2X12,2720001596,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,2.696,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,2.808,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,2.696,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,2.248,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,0.928,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.536,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.224,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.248,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,3.008,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX MINI TREK 2X15,2720001597,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,2.496,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,2.6,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,2.496,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,2.08,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,2.272,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.488,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.224,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.248,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,3.008,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX MINI TREK 2X20,2720001598,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,4.08,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,4.248,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,4.08,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,3.4,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,1.808,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.12,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.144,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.248,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,3.008,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX MINI TREK 2X25,2720001599,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,14.904,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,15.528,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,14.904,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,12.424,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,1.096,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.008,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,1.616,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,0.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.248,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,3.008,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX MINI TREK 3X6,2720001600,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,4.104,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,4.28,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,4.104,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,3.424,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,1.664,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.68,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,2.976,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,1.448,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.136,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,2.904,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,2.976,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX MINI TREK 3X8,2720001601,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,1.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,4.104,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,4.28,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,4.104,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,3.424,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,1.864,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.68,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,2.232,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.432,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,2.36,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,2.184,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,2.232,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX MINI TREK 3X12,2720001602,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,1.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,4.104,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,4.28,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,4.104,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,3.424,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,183.6,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.68,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,2.008,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.432,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,2.12,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,1.968,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,2.008,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX MINI TREK 3X20,2720001603,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,4.104,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,4.28,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,4.104,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,3.424,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,3.064,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,0.464,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,3.36,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.432,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,0.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.552,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,3.288,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,3.36,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX MINI TREK 3X25,2720001604,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,205.344,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,213.904,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,205.344,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,171.12,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,2.624,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.136,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,3.36,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,0.672,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.552,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,3.288,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,3.36,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 3.25X6MM,2720001605,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,25.92,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,27,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,25.92,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,21.6,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,2.904,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,0.904,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,3.36,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,1.64,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,0.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.552,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,3.288,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,3.36,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 3.25X8MM,2720001606,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,0.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,25.92,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,27,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,25.92,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,21.6,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,2.784,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,0.544,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,0.928,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,1.304,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,0.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,0.984,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,0.912,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,0.928,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 3.25X12MM,2720001607,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,1.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,72,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,75,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,72,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,60,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,2.696,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,0.832,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,2.272,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,0.792,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,0.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,2.392,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,2.216,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,2.272,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 3.25X15MM,2720001608,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,1.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,72,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,75,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,72,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,60,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,2.464,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,0.936,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,1.808,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,1.2,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,0.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,1.904,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,1.768,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,1.808,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 3.25X25MM,2720001609,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,0.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,5.76,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,6,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,5.76,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,2.488,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,91.8,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,1.096,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,1.344,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,89.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,1.152,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,1.072,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,1.096,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 3.5X6MM,2720001610,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,1.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,5.96,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,6.208,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,5.96,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,4.968,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,2.512,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.536,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,1.664,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,132.6,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,1.752,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,1.624,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,1.664,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 3.5X8MM,2720001611,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,1.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,5.96,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,6.208,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,5.96,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,4.968,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,2.624,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.312,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,1.864,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.216,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,1.968,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,1.824,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,1.864,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 2.25X6MM,2720001612,CDM,272,RC,,,Outpatient,,,202.86,131.86,,202.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,154.17,76,,155.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,146.06,72,,210.24,Percent of Total Billed Charges,72% of Total Billed Charges,152.15,75,,219,Percent of Total Billed charges,75% of Total Billed Charges,202.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.06,72,,210.24,Percent of Total Billed Charges,72% of Total Billed Charges,121.72,60,,175.2,Percent of Total Billed Charges,60% of Total Billed Charges,182.57,90,,3.4,Percent of Total Billed Charges,90% of Total Billed Charges,91.29,45,,1.448,Percent of Total Billed Charges,45% of Total Billed Charges,182.57,90,,183.6,Percent of Total Billed Charges,90% of Total billed Charges,202.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.86,65,,1.896,Percent of total Billed Charges,65% of Total Billed Charges,89.46,44.1,,1.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,192.72,95,,193.8,Percent of Total Billed Charges,95% of Total Billed Charges,202.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.52,88,,179.52,Percent of Total Billed Charges,88% of Total Billed Charges,182.57,90,,183.6,Percent of Total Billed charges,90% of Total Billed Charges,89.46,202.86,
RX TREK 2.25X8MM,2720001613,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,28.8,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,30,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,28.8,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,2.008,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.392,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,3.064,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.096,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.24,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,3,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,3.064,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 2.25X12MM,2720001614,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,3.856,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,4.024,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,3.856,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,3.216,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,2.04,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.344,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,2.624,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.016,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,2.768,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,2.56,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,2.624,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 2.25X15MM,2720001615,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,6.528,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,6.8,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,6.528,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,5.44,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,2.064,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.232,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,2.904,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,1.944,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.064,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,2.84,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,2.904,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 2.25X20MM,2720001616,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,12.832,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,13.368,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,12.832,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,10.696,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,13.448,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.24,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,2.784,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,1.776,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,2.944,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,2.728,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,2.784,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 2.25X25MM,2720001617,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,6.728,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,7.008,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,6.728,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,5.608,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,3.408,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.256,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,2.696,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,1.792,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,2.84,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,2.632,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,2.696,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 2.5X6,2720001618,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,285.264,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,297.152,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,285.264,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,237.72,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,3.408,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.312,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,2.464,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,1.816,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,2.6,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,2.408,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,2.464,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 2.5X8,2720001619,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,193.536,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,201.6,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,193.536,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,161.28,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,1.76,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.696,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,2.488,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,1.896,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,2.624,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,2.432,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,2.488,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 2.5X12,2720001620,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,69.12,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,72,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,69.12,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,57.6,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,3.424,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.008,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,2.512,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.456,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,0.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,2.656,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,2.456,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,2.512,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 2.75X6MM,2720001621,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,44.96,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,46.832,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,44.96,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,37.464,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,7.448,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.016,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,2.624,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,1.448,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,2.768,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,2.56,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,2.624,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 2.75X8MM,2720001622,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,51.4,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,53.536,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,51.4,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,42.832,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,7.448,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.032,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,3.4,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,1.472,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.584,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,3.32,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,3.4,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 2.75X12MM,2720001623,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,1.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,44.96,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,46.832,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,44.96,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,37.464,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,6.728,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,2.008,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,1.496,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,6.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,2.12,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,1.968,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,2.008,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 2.75X15MM,2720001624,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,1.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,0.92,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,0.96,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,0.92,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,0.768,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,28.072,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.704,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,2.04,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,9.712,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,2.152,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,1.992,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,2.04,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 2.75X20MM,2720001625,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,1.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,53.912,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,56.16,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,53.912,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,44.928,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,13.32,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.704,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,2.064,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.456,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,2.184,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,2.024,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,2.064,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 2.75X25MM,2720001626,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,11.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,5.76,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,6,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,5.76,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,25.912,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,0.88,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,13.448,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.456,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,0.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,14.2,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,13.152,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,13.448,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 3.5X12MM,2720001627,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,5.576,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,5.808,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,5.576,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,4.648,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,3.36,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.712,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,3.408,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,1.272,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.592,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,3.328,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,3.408,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 3.5X25MM,2720001628,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,13.552,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,14.12,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,13.552,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,11.296,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,3.36,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,3.72,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,3.408,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.472,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,3.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.592,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,3.328,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,3.408,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 3.75X6MM,2720001629,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,1.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,7.648,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,7.968,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,7.648,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,6.376,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,3.36,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,3.72,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,1.76,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,5.376,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,3.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,1.856,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,1.72,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,1.76,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 3.75X8MM,2720001630,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,6.88,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,7.168,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,6.88,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,5.736,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,7.448,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.536,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,3.424,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,5.376,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.608,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,3.344,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,3.424,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 3.75X12MM,2720001631,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,6.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,2.376,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,2.48,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,2.376,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,1.984,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,334.8,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,14.04,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,7.448,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.224,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,13.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,7.856,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,7.28,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,7.448,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 3.75X15MM,2720001632,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,6.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,7.344,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,7.648,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,7.344,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,6.12,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,6.664,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,7.448,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,20.272,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,6.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,7.856,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,7.28,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,7.448,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 3.75X20MM,2720001633,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,4.6,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,4.792,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,4.6,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,3.832,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,206.992,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,12.96,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,9.624,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,12.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.248,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,3.008,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,3.072,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 3.75X25MM,2720001634,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,23.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,21.24,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,22.128,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,21.24,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,17.704,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,20.928,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.68,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,28.072,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,18.712,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,29.632,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,27.448,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,28.072,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 4X6MM,2720001635,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,11.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,50.4,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,52.504,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,50.4,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,42,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.68,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,13.32,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.432,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,14.064,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,13.024,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,13.32,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 4X8MM,2720001636,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,21.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,5.544,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,5.776,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,5.544,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,4.624,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,300.6,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1.68,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,25.912,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.432,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,27.352,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,25.336,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,25.912,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 4X12MM,2720001637,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,3.24,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,3.376,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,3.24,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,2.704,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,538.2,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,3.72,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,3.36,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2.432,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,3.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.552,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,3.288,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,3.36,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 4X15MM,2720001638,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,3.416,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,3.56,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,3.416,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,2.848,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,203.4,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,167.4,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,3.36,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,5.376,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,164.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.552,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,3.288,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,3.36,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 4X20MM,2720001639,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,2.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,8.92,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,9.288,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,8.92,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,7.432,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,203.4,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,3.36,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,241.8,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,3.552,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,3.288,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,3.36,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 4X25MM,2720001640,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,6.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,6.8,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,7.08,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,6.8,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,5.664,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,203.4,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,103.496,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,7.448,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,101.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,7.856,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,7.28,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,7.448,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX TREK 2.5X12,2720001641,CDM,272,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,282.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,6.8,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,7.08,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,6.8,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,5.664,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,10.464,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,334.8,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,149.496,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,10.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,353.4,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,327.36,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,334.8,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
F CUTTING BALLOON 3X,2720001642,CDM,272,RC,,,Outpatient,,,1794.87,1166.67,,1794.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1364.1,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1292.31,72,,7.664,Percent of Total Billed Charges,72% of Total Billed Charges,1346.15,75,,7.984,Percent of Total Billed charges,75% of Total Billed Charges,1794.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1292.31,72,,7.664,Percent of Total Billed Charges,72% of Total Billed Charges,1076.92,60,,6.384,Percent of Total Billed Charges,60% of Total Billed Charges,1615.38,90,,272.448,Percent of Total Billed Charges,90% of Total Billed Charges,807.69,45,,5.04,Percent of Total Billed Charges,45% of Total Billed Charges,1615.38,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,1794.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1794.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1794.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.67,65,,15.12,Percent of total Billed Charges,65% of Total Billed Charges,791.54,44.1,,4.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,1705.13,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,1794.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1579.49,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,1615.38,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,791.54,1794.87,
NC QUANTUM AMR 2.75X,2720001643,CDM,272,RC,,,Outpatient,,,1818.02,1181.71,,1818.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.7,76,,174.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.97,72,,6.8,Percent of Total Billed Charges,72% of Total Billed Charges,1363.52,75,,7.08,Percent of Total Billed charges,75% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.97,72,,6.8,Percent of Total Billed Charges,72% of Total Billed Charges,1090.81,60,,5.664,Percent of Total Billed Charges,60% of Total Billed Charges,1636.22,90,,29.592,Percent of Total Billed Charges,90% of Total Billed Charges,818.11,45,,150.304,Percent of Total Billed Charges,45% of Total Billed Charges,1636.22,90,,206.992,Percent of Total Billed Charges,90% of Total billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.71,65,,7.28,Percent of total Billed Charges,65% of Total Billed Charges,801.75,44.1,,147.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,1727.12,95,,218.496,Percent of Total Billed Charges,95% of Total Billed Charges,1818.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.86,88,,202.392,Percent of Total Billed Charges,88% of Total Billed Charges,1636.22,90,,206.992,Percent of Total Billed charges,90% of Total Billed Charges,801.75,1818.02,
NC QUANTUM AMR 2.5X1,2720001644,CDM,272,RC,,,Outpatient,,,1827.95,1188.17,,1827.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1389.24,76,,17.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1316.12,72,,8.512,Percent of Total Billed Charges,72% of Total Billed Charges,1370.96,75,,8.872,Percent of Total Billed charges,75% of Total Billed Charges,1827.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1316.12,72,,8.512,Percent of Total Billed Charges,72% of Total Billed Charges,1096.77,60,,7.096,Percent of Total Billed Charges,60% of Total Billed Charges,1645.16,90,,3.064,Percent of Total Billed Charges,90% of Total Billed Charges,822.58,45,,269.104,Percent of Total Billed Charges,45% of Total Billed Charges,1645.16,90,,20.928,Percent of Total Billed Charges,90% of Total billed Charges,1827.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1827.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1827.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1188.17,65,,217.104,Percent of total Billed Charges,65% of Total Billed Charges,806.13,44.1,,263.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,1736.55,95,,22.096,Percent of Total Billed Charges,95% of Total Billed Charges,1827.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.6,88,,20.464,Percent of Total Billed Charges,88% of Total Billed Charges,1645.16,90,,20.928,Percent of Total Billed charges,90% of Total Billed Charges,806.13,1827.95,
EMERGE MR 1.5 X 8 BALLOON,2720001645,CDM,272,RC,,,Outpatient,,,1835.66,1193.18,,1835.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1395.1,76,,8.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1321.68,72,,5.76,Percent of Total Billed Charges,72% of Total Billed Charges,1376.75,75,,6,Percent of Total Billed charges,75% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.68,72,,5.76,Percent of Total Billed Charges,72% of Total Billed Charges,1101.4,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,1652.09,90,,2.936,Percent of Total Billed Charges,90% of Total Billed Charges,826.05,45,,101.704,Percent of Total Billed Charges,45% of Total Billed Charges,1652.09,90,,10.08,Percent of Total Billed Charges,90% of Total billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1193.18,65,,388.704,Percent of total Billed Charges,65% of Total Billed Charges,809.53,44.1,,99.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,1743.88,95,,10.64,Percent of Total Billed Charges,95% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1615.38,88,,9.856,Percent of Total Billed Charges,88% of Total Billed Charges,1652.09,90,,10.08,Percent of Total Billed charges,90% of Total Billed Charges,809.53,1835.66,
EMERGE MR 1.5 X 12 BALLOON,2720001646,CDM,272,RC,,,Outpatient,,,1835.66,1193.18,,1835.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1395.1,76,,253.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1321.68,72,,2.56,Percent of Total Billed Charges,72% of Total Billed Charges,1376.75,75,,2.672,Percent of Total Billed charges,75% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.68,72,,2.56,Percent of Total Billed Charges,72% of Total Billed Charges,1101.4,60,,2.136,Percent of Total Billed Charges,60% of Total Billed Charges,1652.09,90,,6.304,Percent of Total Billed Charges,90% of Total Billed Charges,826.05,45,,101.704,Percent of Total Billed Charges,45% of Total Billed Charges,1652.09,90,,300.6,Percent of Total Billed Charges,90% of Total billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1193.18,65,,146.904,Percent of total Billed Charges,65% of Total Billed Charges,809.53,44.1,,99.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,1743.88,95,,317.304,Percent of Total Billed Charges,95% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1615.38,88,,293.92,Percent of Total Billed Charges,88% of Total Billed Charges,1652.09,90,,300.6,Percent of Total Billed charges,90% of Total Billed Charges,809.53,1835.66,
EMERGE MR 1.5 X 15 BALLOON,2720001647,CDM,272,RC,,,Outpatient,,,1835.66,1193.18,,1835.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1395.1,76,,454.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1321.68,72,,1.8,Percent of Total Billed Charges,72% of Total Billed Charges,1376.75,75,,1.88,Percent of Total Billed charges,75% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.68,72,,1.8,Percent of Total Billed Charges,72% of Total Billed Charges,1101.4,60,,1.504,Percent of Total Billed Charges,60% of Total Billed Charges,1652.09,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,826.05,45,,101.704,Percent of Total Billed Charges,45% of Total Billed Charges,1652.09,90,,538.2,Percent of Total Billed Charges,90% of Total billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1193.18,65,,146.904,Percent of total Billed Charges,65% of Total Billed Charges,809.53,44.1,,99.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,1743.88,95,,568.104,Percent of Total Billed Charges,95% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1615.38,88,,526.24,Percent of Total Billed Charges,88% of Total Billed Charges,1652.09,90,,538.2,Percent of Total Billed charges,90% of Total Billed Charges,809.53,1835.66,
EMERGE MR 1.5 X 20 BALLOON,2720001648,CDM,272,RC,,,Outpatient,,,1835.66,1193.18,,1835.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1395.1,76,,171.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1321.68,72,,138.288,Percent of Total Billed Charges,72% of Total Billed Charges,1376.75,75,,144.048,Percent of Total Billed charges,75% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.68,72,,138.288,Percent of Total Billed Charges,72% of Total Billed Charges,1101.4,60,,115.24,Percent of Total Billed Charges,60% of Total Billed Charges,1652.09,90,,4.632,Percent of Total Billed Charges,90% of Total Billed Charges,826.05,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,1652.09,90,,203.4,Percent of Total Billed Charges,90% of Total billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1193.18,65,,146.904,Percent of total Billed Charges,65% of Total Billed Charges,809.53,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,1743.88,95,,214.704,Percent of Total Billed Charges,95% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1615.38,88,,198.88,Percent of Total Billed Charges,88% of Total Billed Charges,1652.09,90,,203.4,Percent of Total Billed charges,90% of Total Billed Charges,809.53,1835.66,
EMERGE MR 2 X 8 BALLOON,2720001649,CDM,272,RC,,,Outpatient,,,1835.66,1193.18,,1835.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1395.1,76,,171.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1321.68,72,,21.168,Percent of Total Billed Charges,72% of Total Billed Charges,1376.75,75,,22.048,Percent of Total Billed charges,75% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.68,72,,21.168,Percent of Total Billed Charges,72% of Total Billed Charges,1101.4,60,,17.64,Percent of Total Billed Charges,60% of Total Billed Charges,1652.09,90,,2.056,Percent of Total Billed Charges,90% of Total Billed Charges,826.05,45,,136.224,Percent of Total Billed Charges,45% of Total Billed Charges,1652.09,90,,203.4,Percent of Total Billed Charges,90% of Total billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1193.18,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,809.53,44.1,,133.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,1743.88,95,,214.704,Percent of Total Billed Charges,95% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1615.38,88,,198.88,Percent of Total Billed Charges,88% of Total Billed Charges,1652.09,90,,203.4,Percent of Total Billed charges,90% of Total Billed Charges,809.53,1835.66,
EMERGE MR 2 X 12 BALLOON,2720001650,CDM,272,RC,,,Outpatient,,,1835.66,1193.18,,1835.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1395.1,76,,171.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1321.68,72,,30.672,Percent of Total Billed Charges,72% of Total Billed Charges,1376.75,75,,31.952,Percent of Total Billed charges,75% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.68,72,,30.672,Percent of Total Billed Charges,72% of Total Billed Charges,1101.4,60,,25.56,Percent of Total Billed Charges,60% of Total Billed Charges,1652.09,90,,19.8,Percent of Total Billed Charges,90% of Total Billed Charges,826.05,45,,14.8,Percent of Total Billed Charges,45% of Total Billed Charges,1652.09,90,,203.4,Percent of Total Billed Charges,90% of Total billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1193.18,65,,196.768,Percent of total Billed Charges,65% of Total Billed Charges,809.53,44.1,,14.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,1743.88,95,,214.704,Percent of Total Billed Charges,95% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1615.38,88,,198.88,Percent of Total Billed Charges,88% of Total Billed Charges,1652.09,90,,203.4,Percent of Total Billed charges,90% of Total Billed Charges,809.53,1835.66,
EMERGE MR 2 X 15 BALLOON,2720001651,CDM,272,RC,,,Outpatient,,,1835.66,1193.18,,1835.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1395.1,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1321.68,72,,8.832,Percent of Total Billed Charges,72% of Total Billed Charges,1376.75,75,,9.2,Percent of Total Billed charges,75% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.68,72,,8.832,Percent of Total Billed Charges,72% of Total Billed Charges,1101.4,60,,7.36,Percent of Total Billed Charges,60% of Total Billed Charges,1652.09,90,,3.872,Percent of Total Billed Charges,90% of Total Billed Charges,826.05,45,,1.528,Percent of Total Billed Charges,45% of Total Billed Charges,1652.09,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1193.18,65,,21.376,Percent of total Billed Charges,65% of Total Billed Charges,809.53,44.1,,1.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,1743.88,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1615.38,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,1652.09,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,809.53,1835.66,
EMERGE MR 2 X 20 BALLOON,2720001652,CDM,272,RC,,,Outpatient,,,1835.66,1193.18,,1835.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1395.1,76,,230.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1321.68,72,,9.032,Percent of Total Billed Charges,72% of Total Billed Charges,1376.75,75,,9.408,Percent of Total Billed charges,75% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.68,72,,9.032,Percent of Total Billed Charges,72% of Total Billed Charges,1101.4,60,,7.528,Percent of Total Billed Charges,60% of Total Billed Charges,1652.09,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,826.05,45,,1.472,Percent of Total Billed Charges,45% of Total Billed Charges,1652.09,90,,272.448,Percent of Total Billed Charges,90% of Total billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1193.18,65,,2.208,Percent of total Billed Charges,65% of Total Billed Charges,809.53,44.1,,1.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,1743.88,95,,287.584,Percent of Total Billed Charges,95% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1615.38,88,,266.392,Percent of Total Billed Charges,88% of Total Billed Charges,1652.09,90,,272.448,Percent of Total Billed charges,90% of Total Billed Charges,809.53,1835.66,
EMERGE MR 2.5X8 BALL,2720001653,CDM,272,RC,,,Outpatient,,,1850.00,1202.50,,1850,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1406,76,,24.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1332,72,,1.256,Percent of Total Billed Charges,72% of Total Billed Charges,1387.5,75,,1.312,Percent of Total Billed charges,75% of Total Billed Charges,1850,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1332,72,,1.256,Percent of Total Billed Charges,72% of Total Billed Charges,1110,60,,1.048,Percent of Total Billed Charges,60% of Total Billed Charges,1665,90,,8.16,Percent of Total Billed Charges,90% of Total Billed Charges,832.5,45,,3.152,Percent of Total Billed Charges,45% of Total Billed Charges,1665,90,,29.592,Percent of Total Billed Charges,90% of Total billed Charges,1850,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1850,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1850,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1202.5,65,,2.12,Percent of total Billed Charges,65% of Total Billed Charges,815.85,44.1,,3.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,1757.5,95,,31.24,Percent of Total Billed Charges,95% of Total Billed Charges,1850,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1628,88,,28.936,Percent of Total Billed Charges,88% of Total Billed Charges,1665,90,,29.592,Percent of Total Billed charges,90% of Total Billed Charges,815.85,1850,
EMERGE MR 2.5X12 BAL,2720001654,CDM,272,RC,,,Outpatient,,,1850.00,1202.50,,1850,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1406,76,,2.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1332,72,,130.68,Percent of Total Billed Charges,72% of Total Billed Charges,1387.5,75,,136.128,Percent of Total Billed charges,75% of Total Billed Charges,1850,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1332,72,,130.68,Percent of Total Billed Charges,72% of Total Billed Charges,1110,60,,108.904,Percent of Total Billed Charges,60% of Total Billed Charges,1665,90,,2.488,Percent of Total Billed Charges,90% of Total Billed Charges,832.5,45,,1.8,Percent of Total Billed Charges,45% of Total Billed Charges,1665,90,,3.064,Percent of Total Billed Charges,90% of Total billed Charges,1850,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1850,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1850,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1202.5,65,,4.552,Percent of total Billed Charges,65% of Total Billed Charges,815.85,44.1,,1.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,1757.5,95,,3.232,Percent of Total Billed Charges,95% of Total Billed Charges,1850,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1628,88,,2.992,Percent of Total Billed Charges,88% of Total Billed Charges,1665,90,,3.064,Percent of Total Billed charges,90% of Total Billed Charges,815.85,1850,
EMERGE MR 2.5X15 BAL,2720001655,CDM,272,RC,,,Outpatient,,,1850.00,1202.50,,1850,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1406,76,,2.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1332,72,,126.688,Percent of Total Billed Charges,72% of Total Billed Charges,1387.5,75,,131.968,Percent of Total Billed charges,75% of Total Billed Charges,1850,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1332,72,,126.688,Percent of Total Billed Charges,72% of Total Billed Charges,1110,60,,105.576,Percent of Total Billed Charges,60% of Total Billed Charges,1665,90,,24.752,Percent of Total Billed Charges,90% of Total Billed Charges,832.5,45,,2.312,Percent of Total Billed Charges,45% of Total Billed Charges,1665,90,,2.936,Percent of Total Billed Charges,90% of Total billed Charges,1850,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1850,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1850,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1202.5,65,,2.6,Percent of total Billed Charges,65% of Total Billed Charges,815.85,44.1,,2.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,1757.5,95,,3.104,Percent of Total Billed Charges,95% of Total Billed Charges,1850,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1628,88,,2.872,Percent of Total Billed Charges,88% of Total Billed Charges,1665,90,,2.936,Percent of Total Billed charges,90% of Total Billed Charges,815.85,1850,
EMERGE MR 2.5X20 BAL,2720001656,CDM,272,RC,,,Outpatient,,,1850.00,1202.50,,1850,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1406,76,,5.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1332,72,,122.512,Percent of Total Billed Charges,72% of Total Billed Charges,1387.5,75,,127.624,Percent of Total Billed charges,75% of Total Billed Charges,1850,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1332,72,,122.512,Percent of Total Billed Charges,72% of Total Billed Charges,1110,60,,102.096,Percent of Total Billed Charges,60% of Total Billed Charges,1665,90,,56.704,Percent of Total Billed Charges,90% of Total Billed Charges,832.5,45,,1.024,Percent of Total Billed Charges,45% of Total Billed Charges,1665,90,,6.304,Percent of Total Billed Charges,90% of Total billed Charges,1850,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1850,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1850,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1202.5,65,,3.344,Percent of total Billed Charges,65% of Total Billed Charges,815.85,44.1,,1.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,1757.5,95,,6.648,Percent of Total Billed Charges,95% of Total Billed Charges,1850,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1628,88,,6.16,Percent of Total Billed Charges,88% of Total Billed Charges,1665,90,,6.304,Percent of Total Billed charges,90% of Total Billed Charges,815.85,1850,
EMERGE MR 3X8 BALLOO,2720001657,CDM,272,RC,,,Outpatient,,,1835.66,1193.18,,1835.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1395.1,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1321.68,72,,84.96,Percent of Total Billed Charges,72% of Total Billed Charges,1376.75,75,,88.504,Percent of Total Billed charges,75% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.68,72,,84.96,Percent of Total Billed Charges,72% of Total Billed Charges,1101.4,60,,70.8,Percent of Total Billed Charges,60% of Total Billed Charges,1652.09,90,,56.704,Percent of Total Billed Charges,90% of Total Billed Charges,826.05,45,,9.904,Percent of Total Billed Charges,45% of Total Billed Charges,1652.09,90,,3.6,Percent of Total Billed Charges,90% of Total billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1193.18,65,,1.48,Percent of total Billed Charges,65% of Total Billed Charges,809.53,44.1,,9.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,1743.88,95,,3.8,Percent of Total Billed Charges,95% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1615.38,88,,3.52,Percent of Total Billed Charges,88% of Total Billed Charges,1652.09,90,,3.6,Percent of Total Billed charges,90% of Total Billed Charges,809.53,1835.66,
EMERGE MR 3X12 BALLO,2720001658,CDM,272,RC,,,Outpatient,,,1835.66,1193.18,,1835.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1395.1,76,,3.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1321.68,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,1376.75,75,,127.504,Percent of Total Billed charges,75% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.68,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,1101.4,60,,102,Percent of Total Billed Charges,60% of Total Billed Charges,1652.09,90,,28.568,Percent of Total Billed Charges,90% of Total Billed Charges,826.05,45,,1.936,Percent of Total Billed Charges,45% of Total Billed Charges,1652.09,90,,4.632,Percent of Total Billed Charges,90% of Total billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1193.18,65,,14.304,Percent of total Billed Charges,65% of Total Billed Charges,809.53,44.1,,1.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,1743.88,95,,4.888,Percent of Total Billed Charges,95% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1615.38,88,,4.528,Percent of Total Billed Charges,88% of Total Billed Charges,1652.09,90,,4.632,Percent of Total Billed charges,90% of Total Billed Charges,809.53,1835.66,
EMERGE MR 3X15 BALLO,2720001659,CDM,272,RC,,,Outpatient,,,1835.66,1193.18,,1835.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1395.1,76,,1.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1321.68,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,1376.75,75,,127.504,Percent of Total Billed charges,75% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.68,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,1101.4,60,,102,Percent of Total Billed Charges,60% of Total Billed Charges,1652.09,90,,9.256,Percent of Total Billed Charges,90% of Total Billed Charges,826.05,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,1652.09,90,,2.056,Percent of Total Billed Charges,90% of Total billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1193.18,65,,2.8,Percent of total Billed Charges,65% of Total Billed Charges,809.53,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,1743.88,95,,2.168,Percent of Total Billed Charges,95% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1615.38,88,,2.008,Percent of Total Billed Charges,88% of Total Billed Charges,1652.09,90,,2.056,Percent of Total Billed charges,90% of Total Billed Charges,809.53,1835.66,
EMERGE MR 3X20 BALLO,2720001660,CDM,272,RC,,,Outpatient,,,1835.66,1193.18,,1835.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1395.1,76,,16.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1321.68,72,,27.36,Percent of Total Billed Charges,72% of Total Billed Charges,1376.75,75,,28.504,Percent of Total Billed charges,75% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.68,72,,27.36,Percent of Total Billed Charges,72% of Total Billed Charges,1101.4,60,,22.8,Percent of Total Billed Charges,60% of Total Billed Charges,1652.09,90,,2.616,Percent of Total Billed Charges,90% of Total Billed Charges,826.05,45,,4.08,Percent of Total Billed Charges,45% of Total Billed Charges,1652.09,90,,19.8,Percent of Total Billed Charges,90% of Total billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1193.18,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,809.53,44.1,,4,Percent of Total Billed Charges,44.1% of Total Billed Charges,1743.88,95,,20.904,Percent of Total Billed Charges,95% of Total Billed Charges,1835.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1615.38,88,,19.36,Percent of Total Billed Charges,88% of Total Billed Charges,1652.09,90,,19.8,Percent of Total Billed charges,90% of Total Billed Charges,809.53,1835.66,
8.5FR (25CM) DAWSON CATH DRN,2720001661,CDM,272,RC,,,Outpatient,,,333.47,216.76,,333.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,253.44,76,,3.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,240.1,72,,230.4,Percent of Total Billed Charges,72% of Total Billed Charges,250.1,75,,240,Percent of Total Billed charges,75% of Total Billed Charges,333.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.1,72,,230.4,Percent of Total Billed Charges,72% of Total Billed Charges,200.08,60,,192,Percent of Total Billed Charges,60% of Total Billed Charges,300.12,90,,4.92,Percent of Total Billed Charges,90% of Total Billed Charges,150.06,45,,1.24,Percent of Total Billed Charges,45% of Total Billed Charges,300.12,90,,3.872,Percent of Total Billed Charges,90% of Total billed Charges,333.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.76,65,,5.888,Percent of total Billed Charges,65% of Total Billed Charges,147.06,44.1,,1.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,316.8,95,,4.088,Percent of Total Billed Charges,95% of Total Billed Charges,333.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.45,88,,3.784,Percent of Total Billed Charges,88% of Total Billed Charges,300.12,90,,3.872,Percent of Total Billed charges,90% of Total Billed Charges,147.06,333.47,
CHLORAPREP ORANGE 26ML,2720001662,CDM,272,RC,,,Outpatient,,,15.00,9.75,,15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.4,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.8,72,,17.28,Percent of Total Billed Charges,72% of Total Billed Charges,11.25,75,,18,Percent of Total Billed charges,75% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.8,72,,17.28,Percent of Total Billed Charges,72% of Total Billed Charges,9,60,,14.4,Percent of Total Billed Charges,60% of Total Billed Charges,13.5,90,,4.92,Percent of Total Billed Charges,90% of Total Billed Charges,6.75,45,,12.376,Percent of Total Billed Charges,45% of Total Billed Charges,13.5,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.75,65,,1.792,Percent of total Billed Charges,65% of Total Billed Charges,6.62,44.1,,12.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.25,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.2,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,13.5,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,6.62,15,
NASAL RAE TUBE CUFF 4.5,2720001663,CDM,272,RC,,,Outpatient,,,19.47,12.66,,19.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.8,76,,6.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.02,72,,17.28,Percent of Total Billed Charges,72% of Total Billed Charges,14.6,75,,18,Percent of Total Billed charges,75% of Total Billed Charges,19.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.02,72,,17.28,Percent of Total Billed Charges,72% of Total Billed Charges,11.68,60,,14.4,Percent of Total Billed Charges,60% of Total Billed Charges,17.52,90,,9.256,Percent of Total Billed Charges,90% of Total Billed Charges,8.76,45,,28.352,Percent of Total Billed Charges,45% of Total Billed Charges,17.52,90,,8.16,Percent of Total Billed Charges,90% of Total billed Charges,19.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.66,65,,17.88,Percent of total Billed Charges,65% of Total Billed Charges,8.59,44.1,,27.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.5,95,,8.608,Percent of Total Billed Charges,95% of Total Billed Charges,19.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.13,88,,7.976,Percent of Total Billed Charges,88% of Total Billed Charges,17.52,90,,8.16,Percent of Total Billed charges,90% of Total Billed Charges,8.59,19.47,
NC ELITE 4F 014 4X120X150,2720001664,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,2.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,112.248,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,116.928,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,112.248,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,93.544,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,4.92,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,28.352,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,2.488,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,40.952,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,27.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,2.624,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,2.432,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,2.488,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
TRAILBLAZER 4F 035X 135CM,2720001665,CDM,272,RC,C1887,HCPCS,Outpatient,,,370.00,240.50,,370,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,281.2,76,,20.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,266.4,72,,106.92,Percent of Total Billed Charges,72% of Total Billed Charges,277.5,75,,111.376,Percent of Total Billed charges,75% of Total Billed Charges,370,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.4,72,,106.92,Percent of Total Billed Charges,72% of Total Billed Charges,222,60,,89.104,Percent of Total Billed Charges,60% of Total Billed Charges,333,90,,2.616,Percent of Total Billed Charges,90% of Total Billed Charges,166.5,45,,14.288,Percent of Total Billed Charges,45% of Total Billed Charges,333,90,,24.752,Percent of Total Billed Charges,90% of Total billed Charges,370,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.5,65,,40.952,Percent of total Billed Charges,65% of Total Billed Charges,163.17,44.1,,14,Percent of Total Billed Charges,44.1% of Total Billed Charges,351.5,95,,26.128,Percent of Total Billed Charges,95% of Total Billed Charges,370,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.6,88,,24.2,Percent of Total Billed Charges,88% of Total Billed Charges,333,90,,24.752,Percent of Total Billed charges,90% of Total Billed Charges,163.17,370,
NC ELITE 4F 014 4X40X 150,2720001666,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,47.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,17.28,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,18,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,17.28,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,14.4,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,4.92,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,4.624,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,56.704,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,20.632,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,4.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,59.848,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,55.44,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,56.704,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
NC ELITE 4F 014 2X80X150,2720001667,CDM,272,RC,C1725,HCPCS,Outpatient,,,546.00,354.90,,546,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.96,76,,47.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.12,72,,10.272,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,75,,10.696,Percent of Total Billed charges,75% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.12,72,,10.272,Percent of Total Billed Charges,72% of Total Billed Charges,327.6,60,,8.56,Percent of Total Billed Charges,60% of Total Billed Charges,491.4,90,,2.616,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,45,,1.304,Percent of Total Billed Charges,45% of Total Billed Charges,491.4,90,,56.704,Percent of Total Billed Charges,90% of Total billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.9,65,,6.68,Percent of total Billed Charges,65% of Total Billed Charges,240.79,44.1,,1.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.7,95,,59.848,Percent of Total Billed Charges,95% of Total Billed Charges,546,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.48,88,,55.44,Percent of Total Billed Charges,88% of Total Billed Charges,491.4,90,,56.704,Percent of Total Billed charges,90% of Total Billed Charges,240.79,546,
TURP TUBING,2720001668,CDM,272,RC,,,Outpatient,,,9.37,6.09,,9.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.12,76,,24.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.75,72,,4.312,Percent of Total Billed Charges,72% of Total Billed Charges,7.03,75,,4.488,Percent of Total Billed charges,75% of Total Billed Charges,9.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.75,72,,4.312,Percent of Total Billed Charges,72% of Total Billed Charges,5.62,60,,3.592,Percent of Total Billed Charges,60% of Total Billed Charges,8.43,90,,2.616,Percent of Total Billed Charges,90% of Total Billed Charges,4.22,45,,2.456,Percent of Total Billed Charges,45% of Total Billed Charges,8.43,90,,28.568,Percent of Total Billed Charges,90% of Total billed Charges,9.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.09,65,,1.888,Percent of total Billed Charges,65% of Total Billed Charges,4.13,44.1,,2.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.9,95,,30.16,Percent of Total Billed Charges,95% of Total Billed Charges,9.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.25,88,,27.936,Percent of Total Billed Charges,88% of Total Billed Charges,8.43,90,,28.568,Percent of Total Billed charges,90% of Total Billed Charges,4.13,9.37,
AQUASONIC 100 STERILE GEL 272,2720001669,CDM,272,RC,,,Outpatient,,,2.00,1.30,,2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.52,76,,7.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.44,72,,302.4,Percent of Total Billed Charges,72% of Total Billed Charges,1.5,75,,315,Percent of Total Billed charges,75% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,72,,302.4,Percent of Total Billed Charges,72% of Total Billed Charges,1.2,60,,252,Percent of Total Billed Charges,60% of Total Billed Charges,1.8,90,,18.016,Percent of Total Billed Charges,90% of Total Billed Charges,0.9,45,,2.456,Percent of Total Billed Charges,45% of Total Billed Charges,1.8,90,,9.256,Percent of Total Billed Charges,90% of Total billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,65,,3.552,Percent of total Billed Charges,65% of Total Billed Charges,0.88,44.1,,2.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.9,95,,9.768,Percent of Total Billed Charges,95% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.76,88,,9.048,Percent of Total Billed Charges,88% of Total Billed Charges,1.8,90,,9.256,Percent of Total Billed charges,90% of Total Billed Charges,0.88,2,
MSI DISP ANT/CHAMBER 27GX4MM,2720001670,CDM,272,RC,,,Outpatient,,,3.00,1.95,,3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.28,76,,2.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.16,72,,773.992,Percent of Total Billed Charges,72% of Total Billed Charges,2.25,75,,806.24,Percent of Total Billed charges,75% of Total Billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.16,72,,773.992,Percent of Total Billed Charges,72% of Total Billed Charges,1.8,60,,644.992,Percent of Total Billed Charges,60% of Total Billed Charges,2.7,90,,17.104,Percent of Total Billed Charges,90% of Total Billed Charges,1.35,45,,4.624,Percent of Total Billed Charges,45% of Total Billed Charges,2.7,90,,2.616,Percent of Total Billed Charges,90% of Total billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.95,65,,3.552,Percent of total Billed Charges,65% of Total Billed Charges,1.32,44.1,,4.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.85,95,,2.76,Percent of Total Billed Charges,95% of Total Billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.64,88,,2.552,Percent of Total Billed Charges,88% of Total Billed Charges,2.7,90,,2.616,Percent of Total Billed charges,90% of Total Billed Charges,1.32,3,
MSI DISP ANT/CHAMBER 30GX4MM,2720001671,CDM,272,RC,,,Outpatient,,,3.00,1.95,,3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.28,76,,4.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.16,72,,773.992,Percent of Total Billed Charges,72% of Total Billed Charges,2.25,75,,806.24,Percent of Total Billed charges,75% of Total Billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.16,72,,773.992,Percent of Total Billed Charges,72% of Total Billed Charges,1.8,60,,644.992,Percent of Total Billed Charges,60% of Total Billed Charges,2.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,1.35,45,,2.456,Percent of Total Billed Charges,45% of Total Billed Charges,2.7,90,,4.92,Percent of Total Billed Charges,90% of Total billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.95,65,,6.68,Percent of total Billed Charges,65% of Total Billed Charges,1.32,44.1,,2.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.85,95,,5.192,Percent of Total Billed Charges,95% of Total Billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.64,88,,4.808,Percent of Total Billed Charges,88% of Total Billed Charges,2.7,90,,4.92,Percent of Total Billed charges,90% of Total Billed Charges,1.32,3,
CANISTER WND DRN INFOVAC 300 M,2720001672,CDM,272,RC,,,Outpatient,,,80.00,52.00,,80,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60.8,76,,4.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.6,72,,5.96,Percent of Total Billed Charges,72% of Total Billed Charges,60,75,,6.208,Percent of Total Billed charges,75% of Total Billed Charges,80,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.6,72,,5.96,Percent of Total Billed Charges,72% of Total Billed Charges,48,60,,4.968,Percent of Total Billed Charges,60% of Total Billed Charges,72,90,,17.104,Percent of Total Billed Charges,90% of Total Billed Charges,36,45,,1.304,Percent of Total Billed Charges,45% of Total Billed Charges,72,90,,4.92,Percent of Total Billed Charges,90% of Total billed Charges,80,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52,65,,3.552,Percent of total Billed Charges,65% of Total Billed Charges,35.28,44.1,,1.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,76,95,,5.192,Percent of Total Billed Charges,95% of Total Billed Charges,80,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.4,88,,4.808,Percent of Total Billed Charges,88% of Total Billed Charges,72,90,,4.92,Percent of Total Billed charges,90% of Total Billed Charges,35.28,80,
KIT DRSG 10X7.5CM GRANUFOAM SM,2720001673,CDM,272,RC,,,Outpatient,,,35.00,22.75,,35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.6,76,,7.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.2,72,,6.328,Percent of Total Billed Charges,72% of Total Billed Charges,26.25,75,,6.592,Percent of Total Billed charges,75% of Total Billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.2,72,,6.328,Percent of Total Billed Charges,72% of Total Billed Charges,21,60,,5.272,Percent of Total Billed Charges,60% of Total Billed Charges,31.5,90,,175.504,Percent of Total Billed Charges,90% of Total Billed Charges,15.75,45,,2.456,Percent of Total Billed Charges,45% of Total Billed Charges,31.5,90,,9.256,Percent of Total Billed Charges,90% of Total billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.75,65,,1.888,Percent of total Billed Charges,65% of Total Billed Charges,15.44,44.1,,2.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.25,95,,9.768,Percent of Total Billed Charges,95% of Total Billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.8,88,,9.048,Percent of Total Billed Charges,88% of Total Billed Charges,31.5,90,,9.256,Percent of Total Billed charges,90% of Total Billed Charges,15.44,35,
ROBOTICS DRAPE LAVH,2720001674,CDM,272,RC,,,Outpatient,,,26.00,16.90,,26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.76,76,,4.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.72,72,,11.2,Percent of Total Billed Charges,72% of Total Billed Charges,19.5,75,,11.672,Percent of Total Billed charges,75% of Total Billed Charges,26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.72,72,,11.2,Percent of Total Billed Charges,72% of Total Billed Charges,15.6,60,,9.336,Percent of Total Billed Charges,60% of Total Billed Charges,23.4,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,45,,1.304,Percent of Total Billed Charges,45% of Total Billed Charges,23.4,90,,4.92,Percent of Total Billed Charges,90% of Total billed Charges,26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.9,65,,3.552,Percent of total Billed Charges,65% of Total Billed Charges,11.47,44.1,,1.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.7,95,,5.192,Percent of Total Billed Charges,95% of Total Billed Charges,26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.88,88,,4.808,Percent of Total Billed Charges,88% of Total Billed Charges,23.4,90,,4.92,Percent of Total Billed charges,90% of Total Billed Charges,11.47,26,
CHOCO 5F 3X80X150 0.014 OTW,2720001675,CDM,272,RC,,,Outpatient,,,1530.00,994.50,,1530,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1162.8,76,,2.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1101.6,72,,21.904,Percent of Total Billed Charges,72% of Total Billed Charges,1147.5,75,,22.816,Percent of Total Billed charges,75% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1101.6,72,,21.904,Percent of Total Billed Charges,72% of Total Billed Charges,918,60,,18.256,Percent of Total Billed Charges,60% of Total Billed Charges,1377,90,,51.032,Percent of Total Billed Charges,90% of Total Billed Charges,688.5,45,,1.304,Percent of Total Billed Charges,45% of Total Billed Charges,1377,90,,2.616,Percent of Total Billed Charges,90% of Total billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.5,65,,1.888,Percent of total Billed Charges,65% of Total Billed Charges,674.73,44.1,,1.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,1453.5,95,,2.76,Percent of Total Billed Charges,95% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1346.4,88,,2.552,Percent of Total Billed Charges,88% of Total Billed Charges,1377,90,,2.616,Percent of Total Billed charges,90% of Total Billed Charges,674.73,1530,
SAFESHEATH 7F X 13CM PLI KIT S,2720001676,CDM,272,RC,,,Outpatient,,,63.00,40.95,,63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.88,76,,4.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.36,72,,1.96,Percent of Total Billed Charges,72% of Total Billed Charges,47.25,75,,2.04,Percent of Total Billed charges,75% of Total Billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.36,72,,1.96,Percent of Total Billed Charges,72% of Total Billed Charges,37.8,60,,1.632,Percent of Total Billed Charges,60% of Total Billed Charges,56.7,90,,51.288,Percent of Total Billed Charges,90% of Total Billed Charges,28.35,45,,9.008,Percent of Total Billed Charges,45% of Total Billed Charges,56.7,90,,4.92,Percent of Total Billed Charges,90% of Total billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.95,65,,1.888,Percent of total Billed Charges,65% of Total Billed Charges,27.78,44.1,,8.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.85,95,,5.192,Percent of Total Billed Charges,95% of Total Billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.44,88,,4.808,Percent of Total Billed Charges,88% of Total Billed Charges,56.7,90,,4.92,Percent of Total Billed charges,90% of Total Billed Charges,27.78,63,
CHOCO 5D 4X40X135 014 PTA OTW,2720001677,CDM,272,RC,,,Outpatient,,,1530.00,994.50,,1530,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1162.8,76,,2.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1101.6,72,,19.08,Percent of Total Billed Charges,72% of Total Billed Charges,1147.5,75,,19.88,Percent of Total Billed charges,75% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1101.6,72,,19.08,Percent of Total Billed Charges,72% of Total Billed Charges,918,60,,15.904,Percent of Total Billed Charges,60% of Total Billed Charges,1377,90,,59.4,Percent of Total Billed Charges,90% of Total Billed Charges,688.5,45,,8.552,Percent of Total Billed Charges,45% of Total Billed Charges,1377,90,,2.616,Percent of Total Billed Charges,90% of Total billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.5,65,,13.008,Percent of total Billed Charges,65% of Total Billed Charges,674.73,44.1,,8.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,1453.5,95,,2.76,Percent of Total Billed Charges,95% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1346.4,88,,2.552,Percent of Total Billed Charges,88% of Total Billed Charges,1377,90,,2.616,Percent of Total Billed charges,90% of Total Billed Charges,674.73,1530,
CABLE SURGICAL DISP SM 12FT 58,2720001678,CDM,272,RC,,,Outpatient,,,72.00,46.80,,72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.72,76,,2.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.84,72,,8.32,Percent of Total Billed Charges,72% of Total Billed Charges,54,75,,8.672,Percent of Total Billed charges,75% of Total Billed Charges,72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.84,72,,8.32,Percent of Total Billed Charges,72% of Total Billed Charges,43.2,60,,6.936,Percent of Total Billed Charges,60% of Total Billed Charges,64.8,90,,59.4,Percent of Total Billed Charges,90% of Total Billed Charges,32.4,45,,8.28,Percent of Total Billed Charges,45% of Total Billed Charges,64.8,90,,2.616,Percent of Total Billed Charges,90% of Total billed Charges,72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.8,65,,12.352,Percent of total Billed Charges,65% of Total Billed Charges,31.75,44.1,,8.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.4,95,,2.76,Percent of Total Billed Charges,95% of Total Billed Charges,72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.36,88,,2.552,Percent of Total Billed Charges,88% of Total Billed Charges,64.8,90,,2.616,Percent of Total Billed charges,90% of Total Billed Charges,31.75,72,
LOR SYRINGE 5ML GLASS,2720001679,CDM,272,RC,,,Outpatient,,,84.46,54.90,,84.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,64.19,76,,15.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,60.81,72,,8.32,Percent of Total Billed Charges,72% of Total Billed Charges,63.35,75,,8.672,Percent of Total Billed charges,75% of Total Billed Charges,84.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.81,72,,8.32,Percent of Total Billed Charges,72% of Total Billed Charges,50.68,60,,6.936,Percent of Total Billed Charges,60% of Total Billed Charges,76.01,90,,40.648,Percent of Total Billed Charges,90% of Total Billed Charges,38.01,45,,8.552,Percent of Total Billed Charges,45% of Total Billed Charges,76.01,90,,18.016,Percent of Total Billed Charges,90% of Total billed Charges,84.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.9,65,,11.96,Percent of total Billed Charges,65% of Total Billed Charges,37.25,44.1,,8.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,80.24,95,,19.016,Percent of Total Billed Charges,95% of Total Billed Charges,84.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.32,88,,17.616,Percent of Total Billed Charges,88% of Total Billed Charges,76.01,90,,18.016,Percent of Total Billed charges,90% of Total Billed Charges,37.25,84.46,
AMPLATEZ ES.035X80 CM WIRE,2720001680,CDM,272,RC,,,Outpatient,,,53.55,34.81,,53.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.7,76,,14.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.56,72,,0.776,Percent of Total Billed Charges,72% of Total Billed Charges,40.16,75,,0.808,Percent of Total Billed charges,75% of Total Billed Charges,53.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.56,72,,0.776,Percent of Total Billed Charges,72% of Total Billed Charges,32.13,60,,0.648,Percent of Total Billed Charges,60% of Total Billed Charges,48.2,90,,43.2,Percent of Total Billed Charges,90% of Total Billed Charges,24.1,45,,87.752,Percent of Total Billed Charges,45% of Total Billed Charges,48.2,90,,17.104,Percent of Total Billed Charges,90% of Total billed Charges,53.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.81,65,,12.352,Percent of total Billed Charges,65% of Total Billed Charges,23.62,44.1,,85.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.87,95,,18.048,Percent of Total Billed Charges,95% of Total Billed Charges,53.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.12,88,,16.72,Percent of Total Billed Charges,88% of Total Billed Charges,48.2,90,,17.104,Percent of Total Billed charges,90% of Total Billed Charges,23.62,53.55,
THORA/PARA TRAY,2720001681,CDM,272,RC,,,Outpatient,,,135.03,87.77,,135.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,102.62,76,,13.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,97.22,72,,3.128,Percent of Total Billed Charges,72% of Total Billed Charges,101.27,75,,3.256,Percent of Total Billed charges,75% of Total Billed Charges,135.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.22,72,,3.128,Percent of Total Billed Charges,72% of Total Billed Charges,81.02,60,,2.608,Percent of Total Billed Charges,60% of Total Billed Charges,121.53,90,,99.904,Percent of Total Billed Charges,90% of Total Billed Charges,60.76,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,121.53,90,,16.56,Percent of Total Billed Charges,90% of Total billed Charges,135.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.77,65,,126.752,Percent of total Billed Charges,65% of Total Billed Charges,59.55,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,128.28,95,,17.48,Percent of Total Billed Charges,95% of Total Billed Charges,135.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.83,88,,16.192,Percent of Total Billed Charges,88% of Total Billed Charges,121.53,90,,16.56,Percent of Total Billed charges,90% of Total Billed Charges,59.55,135.03,
DILATOR 10FX20CM,2720001682,CDM,272,RC,,,Outpatient,,,89.31,58.05,,89.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.88,76,,14.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.3,72,,0.256,Percent of Total Billed Charges,72% of Total Billed Charges,66.98,75,,0.272,Percent of Total Billed charges,75% of Total Billed Charges,89.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.3,72,,0.256,Percent of Total Billed Charges,72% of Total Billed Charges,53.59,60,,0.216,Percent of Total Billed Charges,60% of Total Billed Charges,80.38,90,,0.168,Percent of Total Billed Charges,90% of Total Billed Charges,40.19,45,,25.52,Percent of Total Billed Charges,45% of Total Billed Charges,80.38,90,,17.104,Percent of Total Billed Charges,90% of Total billed Charges,89.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.05,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,39.39,44.1,,25.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,84.84,95,,18.048,Percent of Total Billed Charges,95% of Total Billed Charges,89.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.59,88,,16.72,Percent of Total Billed Charges,88% of Total Billed Charges,80.38,90,,17.104,Percent of Total Billed charges,90% of Total Billed Charges,39.39,89.31,
TUOHY NEEDLE17G X 3.5 PERIFIX,2720001683,CDM,272,RC,,,Outpatient,,,64.81,42.13,,64.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.26,76,,148.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.66,72,,17.64,Percent of Total Billed Charges,72% of Total Billed Charges,48.61,75,,18.376,Percent of Total Billed charges,75% of Total Billed Charges,64.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.66,72,,17.64,Percent of Total Billed Charges,72% of Total Billed Charges,38.89,60,,14.704,Percent of Total Billed Charges,60% of Total Billed Charges,58.33,90,,1.424,Percent of Total Billed Charges,90% of Total Billed Charges,29.16,45,,25.64,Percent of Total Billed Charges,45% of Total Billed Charges,58.33,90,,175.504,Percent of Total Billed Charges,90% of Total billed Charges,64.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.13,65,,36.856,Percent of total Billed Charges,65% of Total Billed Charges,28.58,44.1,,25.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,61.57,95,,185.248,Percent of Total Billed Charges,95% of Total Billed Charges,64.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.03,88,,171.6,Percent of Total Billed Charges,88% of Total Billed Charges,58.33,90,,175.504,Percent of Total Billed charges,90% of Total Billed Charges,28.58,64.81,
CUSTOM CATH PK DYNJ2,2720001684,CDM,272,RC,,,Outpatient,,,224.91,146.19,,224.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,170.93,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,161.94,72,,16.776,Percent of Total Billed Charges,72% of Total Billed Charges,168.68,75,,17.48,Percent of Total Billed charges,75% of Total Billed Charges,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.94,72,,16.776,Percent of Total Billed Charges,72% of Total Billed Charges,134.95,60,,13.984,Percent of Total Billed Charges,60% of Total Billed Charges,202.42,90,,0.936,Percent of Total Billed Charges,90% of Total Billed Charges,101.21,45,,29.704,Percent of Total Billed Charges,45% of Total Billed Charges,202.42,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.19,65,,37.04,Percent of total Billed Charges,65% of Total Billed Charges,99.19,44.1,,29.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.66,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.92,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,202.42,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,99.19,224.91,
GUINTHER TULIP VC FIL RET SET,2720001685,CDM,272,RC,,,Outpatient,,,550.00,357.50,,550,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,418,76,,43.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,396,72,,97.92,Percent of Total Billed Charges,72% of Total Billed Charges,412.5,75,,102,Percent of Total Billed charges,75% of Total Billed Charges,550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,72,,97.92,Percent of Total Billed Charges,72% of Total Billed Charges,330,60,,81.6,Percent of Total Billed Charges,60% of Total Billed Charges,495,90,,4.52,Percent of Total Billed Charges,90% of Total Billed Charges,247.5,45,,29.704,Percent of Total Billed Charges,45% of Total Billed Charges,495,90,,51.032,Percent of Total Billed Charges,90% of Total billed Charges,550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.5,65,,42.904,Percent of total Billed Charges,65% of Total Billed Charges,242.55,44.1,,29.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,522.5,95,,53.872,Percent of Total Billed Charges,95% of Total Billed Charges,550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484,88,,49.896,Percent of Total Billed Charges,88% of Total Billed Charges,495,90,,51.032,Percent of Total Billed charges,90% of Total Billed Charges,242.55,550,
SWIVEL ADAPTER,2720001686,CDM,272,RC,,,Outpatient,,,16.00,10.40,,16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.16,76,,43.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.52,72,,29.304,Percent of Total Billed Charges,72% of Total Billed Charges,12,75,,30.528,Percent of Total Billed charges,75% of Total Billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.52,72,,29.304,Percent of Total Billed Charges,72% of Total Billed Charges,9.6,60,,24.424,Percent of Total Billed Charges,60% of Total Billed Charges,14.4,90,,0.056,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,45,,20.32,Percent of Total Billed Charges,45% of Total Billed Charges,14.4,90,,51.288,Percent of Total Billed Charges,90% of Total billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,65,,42.904,Percent of total Billed Charges,65% of Total Billed Charges,7.06,44.1,,19.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.2,95,,54.136,Percent of Total Billed Charges,95% of Total Billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.08,88,,50.144,Percent of Total Billed Charges,88% of Total Billed Charges,14.4,90,,51.288,Percent of Total Billed charges,90% of Total Billed Charges,7.06,16,
LMA 2 UNIQUE PLUS,2720001687,CDM,272,RC,,,Outpatient,,,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,50.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,4.28,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,4.456,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,4.28,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,3.568,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,21.6,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,59.4,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,29.352,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,21.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,62.704,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,58.08,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,59.4,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
NASAL RAE TUBE UNCUFF 5.5,2720001688,CDM,272,RC,,,Outpatient,,,5.90,3.84,,5.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.48,76,,50.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.25,72,,3.544,Percent of Total Billed Charges,72% of Total Billed Charges,4.43,75,,3.688,Percent of Total Billed charges,75% of Total Billed Charges,5.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.25,72,,3.544,Percent of Total Billed Charges,72% of Total Billed Charges,3.54,60,,2.952,Percent of Total Billed Charges,60% of Total Billed Charges,5.31,90,,538.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.66,45,,49.952,Percent of Total Billed Charges,45% of Total Billed Charges,5.31,90,,59.4,Percent of Total Billed Charges,90% of Total billed Charges,5.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.84,65,,31.2,Percent of total Billed Charges,65% of Total Billed Charges,2.6,44.1,,48.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.61,95,,62.704,Percent of Total Billed Charges,95% of Total Billed Charges,5.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.19,88,,58.08,Percent of Total Billed Charges,88% of Total Billed Charges,5.31,90,,59.4,Percent of Total Billed charges,90% of Total Billed Charges,2.6,5.9,
URETERAL CATH ADAPTER,2720001689,CDM,272,RC,,,Outpatient,,,27.00,17.55,,27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.52,76,,34.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.44,72,,1.96,Percent of Total Billed Charges,72% of Total Billed Charges,20.25,75,,2.04,Percent of Total Billed charges,75% of Total Billed Charges,27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.44,72,,1.96,Percent of Total Billed Charges,72% of Total Billed Charges,16.2,60,,1.632,Percent of Total Billed Charges,60% of Total Billed Charges,24.3,90,,0.4,Percent of Total Billed Charges,90% of Total Billed Charges,12.15,45,,0.08,Percent of Total Billed Charges,45% of Total Billed Charges,24.3,90,,40.648,Percent of Total Billed Charges,90% of Total billed Charges,27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.55,65,,72.152,Percent of total Billed Charges,65% of Total Billed Charges,11.91,44.1,,0.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.65,95,,42.904,Percent of Total Billed Charges,95% of Total Billed Charges,27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.76,88,,39.744,Percent of Total Billed Charges,88% of Total Billed Charges,24.3,90,,40.648,Percent of Total Billed charges,90% of Total Billed Charges,11.91,27,
ROBOTICS DRAPE LAVH,2720001690,CDM,272,RC,,,Outpatient,,,26.00,16.90,,26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.76,76,,36.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.72,72,,2.392,Percent of Total Billed Charges,72% of Total Billed Charges,19.5,75,,2.488,Percent of Total Billed charges,75% of Total Billed Charges,26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.72,72,,2.392,Percent of Total Billed Charges,72% of Total Billed Charges,15.6,60,,1.992,Percent of Total Billed Charges,60% of Total Billed Charges,23.4,90,,6.304,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,45,,0.712,Percent of Total Billed Charges,45% of Total Billed Charges,23.4,90,,43.2,Percent of Total Billed Charges,90% of Total billed Charges,26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.9,65,,0.12,Percent of total Billed Charges,65% of Total Billed Charges,11.47,44.1,,0.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.7,95,,45.6,Percent of Total Billed Charges,95% of Total Billed Charges,26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.88,88,,42.24,Percent of Total Billed Charges,88% of Total Billed Charges,23.4,90,,43.2,Percent of Total Billed charges,90% of Total Billed Charges,11.47,26,
BS GATEWAY Y ADAPTOR,2720001691,CDM,272,RC,,,Outpatient,,,22.00,14.30,,22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.72,76,,84.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.84,72,,3.416,Percent of Total Billed Charges,72% of Total Billed Charges,16.5,75,,3.56,Percent of Total Billed charges,75% of Total Billed Charges,22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.84,72,,3.416,Percent of Total Billed Charges,72% of Total Billed Charges,13.2,60,,2.848,Percent of Total Billed Charges,60% of Total Billed Charges,19.8,90,,21.152,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,45,,0.472,Percent of Total Billed Charges,45% of Total Billed Charges,19.8,90,,99.904,Percent of Total Billed Charges,90% of Total billed Charges,22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.3,65,,1.032,Percent of total Billed Charges,65% of Total Billed Charges,9.7,44.1,,0.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.9,95,,105.448,Percent of Total Billed Charges,95% of Total Billed Charges,22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.36,88,,97.68,Percent of Total Billed Charges,88% of Total Billed Charges,19.8,90,,99.904,Percent of Total Billed charges,90% of Total Billed Charges,9.7,22,
PEDIATRIC NON-REBREATHERS,2720001692,CDM,272,RC,,,Outpatient,,,2.00,1.30,,2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.52,76,,0.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.44,72,,3.304,Percent of Total Billed Charges,72% of Total Billed Charges,1.5,75,,3.44,Percent of Total Billed charges,75% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,72,,3.304,Percent of Total Billed Charges,72% of Total Billed Charges,1.2,60,,2.752,Percent of Total Billed Charges,60% of Total Billed Charges,1.8,90,,243,Percent of Total Billed Charges,90% of Total Billed Charges,0.9,45,,2.264,Percent of Total Billed Charges,45% of Total Billed Charges,1.8,90,,0.168,Percent of Total Billed Charges,90% of Total billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,65,,0.68,Percent of total Billed Charges,65% of Total Billed Charges,0.88,44.1,,2.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.9,95,,0.176,Percent of Total Billed Charges,95% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.76,88,,0.16,Percent of Total Billed Charges,88% of Total Billed Charges,1.8,90,,0.168,Percent of Total Billed charges,90% of Total Billed Charges,0.88,2,
BARD BUTTON 18FRX3.4 LENGTH,2720001693,CDM,272,RC,,,Outpatient,,,115.00,74.75,,115,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.4,76,,1.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.8,72,,3.312,Percent of Total Billed Charges,72% of Total Billed Charges,86.25,75,,3.448,Percent of Total Billed charges,75% of Total Billed Charges,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.8,72,,3.312,Percent of Total Billed Charges,72% of Total Billed Charges,69,60,,2.76,Percent of Total Billed Charges,60% of Total Billed Charges,103.5,90,,75.6,Percent of Total Billed Charges,90% of Total Billed Charges,51.75,45,,0.032,Percent of Total Billed Charges,45% of Total Billed Charges,103.5,90,,1.424,Percent of Total Billed Charges,90% of Total billed Charges,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.75,65,,3.264,Percent of total Billed Charges,65% of Total Billed Charges,50.72,44.1,,0.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,109.25,95,,1.504,Percent of Total Billed Charges,95% of Total Billed Charges,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.2,88,,1.392,Percent of Total Billed Charges,88% of Total Billed Charges,103.5,90,,1.424,Percent of Total Billed charges,90% of Total Billed Charges,50.72,115,
BARD BUTTON 18FRX2.4 LENGTH,2720001694,CDM,272,RC,,,Outpatient,,,115.00,74.75,,115,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.4,76,,0.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.8,72,,3.304,Percent of Total Billed Charges,72% of Total Billed Charges,86.25,75,,3.44,Percent of Total Billed charges,75% of Total Billed Charges,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.8,72,,3.304,Percent of Total Billed Charges,72% of Total Billed Charges,69,60,,2.752,Percent of Total Billed Charges,60% of Total Billed Charges,103.5,90,,19.48,Percent of Total Billed Charges,90% of Total Billed Charges,51.75,45,,0.72,Percent of Total Billed Charges,45% of Total Billed Charges,103.5,90,,0.936,Percent of Total Billed Charges,90% of Total billed Charges,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.75,65,,0.04,Percent of total Billed Charges,65% of Total Billed Charges,50.72,44.1,,0.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,109.25,95,,0.992,Percent of Total Billed Charges,95% of Total Billed Charges,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.2,88,,0.912,Percent of Total Billed Charges,88% of Total Billed Charges,103.5,90,,0.936,Percent of Total Billed charges,90% of Total Billed Charges,50.72,115,
BARD BUTTON 24FRX3.4 LENGTH,2720001696,CDM,272,RC,,,Outpatient,,,115.00,74.75,,115,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.4,76,,3.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.8,72,,3.24,Percent of Total Billed Charges,72% of Total Billed Charges,86.25,75,,3.376,Percent of Total Billed charges,75% of Total Billed Charges,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.8,72,,3.24,Percent of Total Billed Charges,72% of Total Billed Charges,69,60,,2.704,Percent of Total Billed Charges,60% of Total Billed Charges,103.5,90,,8.176,Percent of Total Billed Charges,90% of Total Billed Charges,51.75,45,,269.104,Percent of Total Billed Charges,45% of Total Billed Charges,103.5,90,,4.52,Percent of Total Billed Charges,90% of Total billed Charges,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.75,65,,1.04,Percent of total Billed Charges,65% of Total Billed Charges,50.72,44.1,,263.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,109.25,95,,4.776,Percent of Total Billed Charges,95% of Total Billed Charges,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.2,88,,4.424,Percent of Total Billed Charges,88% of Total Billed Charges,103.5,90,,4.52,Percent of Total Billed charges,90% of Total Billed Charges,50.72,115,
NASAL RAE TUBE/UNCUFF 6.0,2720001697,CDM,272,RC,,,Outpatient,,,3.35,2.18,,3.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.55,76,,0.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.41,72,,3.92,Percent of Total Billed Charges,72% of Total Billed Charges,2.51,75,,4.08,Percent of Total Billed charges,75% of Total Billed Charges,3.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.41,72,,3.92,Percent of Total Billed Charges,72% of Total Billed Charges,2.01,60,,3.264,Percent of Total Billed Charges,60% of Total Billed Charges,3.02,90,,8.52,Percent of Total Billed Charges,90% of Total Billed Charges,1.51,45,,0.2,Percent of Total Billed Charges,45% of Total Billed Charges,3.02,90,,0.056,Percent of Total Billed Charges,90% of Total billed Charges,3.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.18,65,,388.704,Percent of total Billed Charges,65% of Total Billed Charges,1.48,44.1,,0.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.18,95,,0.064,Percent of Total Billed Charges,95% of Total Billed Charges,3.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.95,88,,0.056,Percent of Total Billed Charges,88% of Total Billed Charges,3.02,90,,0.056,Percent of Total Billed charges,90% of Total Billed Charges,1.48,3.35,
BAIR LG PEDI UNDERBDY BLANKET,2720001700,CDM,272,RC,,,Outpatient,,,19.00,12.35,,19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.44,76,,1.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.68,72,,3.792,Percent of Total Billed Charges,72% of Total Billed Charges,14.25,75,,3.952,Percent of Total Billed charges,75% of Total Billed Charges,19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.68,72,,3.792,Percent of Total Billed Charges,72% of Total Billed Charges,11.4,60,,3.16,Percent of Total Billed Charges,60% of Total Billed Charges,17.1,90,,4.248,Percent of Total Billed Charges,90% of Total Billed Charges,8.55,45,,3.152,Percent of Total Billed Charges,45% of Total Billed Charges,17.1,90,,1.44,Percent of Total Billed Charges,90% of Total billed Charges,19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.35,65,,0.288,Percent of total Billed Charges,65% of Total Billed Charges,8.38,44.1,,3.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.05,95,,1.52,Percent of Total Billed Charges,95% of Total Billed Charges,19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.72,88,,1.408,Percent of Total Billed Charges,88% of Total Billed Charges,17.1,90,,1.44,Percent of Total Billed charges,90% of Total Billed Charges,8.38,19,
NASAL RAE TUBE CUFFED 4.0,2720001701,CDM,272,RC,,,Outpatient,,,9.13,5.93,,9.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.94,76,,454.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.57,72,,3.92,Percent of Total Billed Charges,72% of Total Billed Charges,6.85,75,,4.08,Percent of Total Billed charges,75% of Total Billed Charges,9.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.57,72,,3.92,Percent of Total Billed Charges,72% of Total Billed Charges,5.48,60,,3.264,Percent of Total Billed Charges,60% of Total Billed Charges,8.22,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,45,,10.576,Percent of Total Billed Charges,45% of Total Billed Charges,8.22,90,,538.2,Percent of Total Billed Charges,90% of Total billed Charges,9.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.93,65,,4.552,Percent of total Billed Charges,65% of Total Billed Charges,4.03,44.1,,10.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.67,95,,568.104,Percent of Total Billed Charges,95% of Total Billed Charges,9.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.03,88,,526.24,Percent of Total Billed Charges,88% of Total Billed Charges,8.22,90,,538.2,Percent of Total Billed charges,90% of Total Billed Charges,4.03,9.13,
VICRYL O J 270H SUTURE CT-2,2720001702,CDM,272,RC,,,Outpatient,,,2.00,1.30,,2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.52,76,,0.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.44,72,,3.488,Percent of Total Billed Charges,72% of Total Billed Charges,1.5,75,,3.632,Percent of Total Billed charges,75% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,72,,3.488,Percent of Total Billed Charges,72% of Total Billed Charges,1.2,60,,2.904,Percent of Total Billed Charges,60% of Total Billed Charges,1.8,90,,2.56,Percent of Total Billed Charges,90% of Total Billed Charges,0.9,45,,121.504,Percent of Total Billed Charges,45% of Total Billed Charges,1.8,90,,0.4,Percent of Total Billed Charges,90% of Total billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,65,,15.28,Percent of total Billed Charges,65% of Total Billed Charges,0.88,44.1,,119.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.9,95,,0.416,Percent of Total Billed Charges,95% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.76,88,,0.384,Percent of Total Billed Charges,88% of Total Billed Charges,1.8,90,,0.4,Percent of Total Billed charges,90% of Total Billed Charges,0.88,2,
BERKLEY COLLECTION SET TUBING,2720001703,CDM,272,RC,,,Outpatient,,,8.00,5.20,,8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.08,76,,5.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.76,72,,1.056,Percent of Total Billed Charges,72% of Total Billed Charges,6,75,,1.096,Percent of Total Billed charges,75% of Total Billed Charges,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.76,72,,1.056,Percent of Total Billed Charges,72% of Total Billed Charges,4.8,60,,0.88,Percent of Total Billed Charges,60% of Total Billed Charges,7.2,90,,105.304,Percent of Total Billed Charges,90% of Total Billed Charges,3.6,45,,37.8,Percent of Total Billed Charges,45% of Total Billed Charges,7.2,90,,6.304,Percent of Total Billed Charges,90% of Total billed Charges,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.2,65,,175.504,Percent of total Billed Charges,65% of Total Billed Charges,3.53,44.1,,37.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.6,95,,6.648,Percent of Total Billed Charges,95% of Total Billed Charges,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.04,88,,6.16,Percent of Total Billed Charges,88% of Total Billed Charges,7.2,90,,6.304,Percent of Total Billed charges,90% of Total Billed Charges,3.53,8,
BERKLEY COLLECTION BOTTLE,2720001704,CDM,272,RC,,,Outpatient,,,14.00,9.10,,14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.64,76,,17.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.08,72,,4.024,Percent of Total Billed Charges,72% of Total Billed Charges,10.5,75,,4.192,Percent of Total Billed charges,75% of Total Billed Charges,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.08,72,,4.024,Percent of Total Billed Charges,72% of Total Billed Charges,8.4,60,,3.352,Percent of Total Billed Charges,60% of Total Billed Charges,12.6,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,45,,9.736,Percent of Total Billed Charges,45% of Total Billed Charges,12.6,90,,21.152,Percent of Total Billed Charges,90% of Total billed Charges,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.1,65,,54.6,Percent of total Billed Charges,65% of Total Billed Charges,6.17,44.1,,9.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.3,95,,22.328,Percent of Total Billed Charges,95% of Total Billed Charges,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.32,88,,20.68,Percent of Total Billed Charges,88% of Total Billed Charges,12.6,90,,21.152,Percent of Total Billed charges,90% of Total Billed Charges,6.17,14,
ARTHREX 2.5 DB CALIB,2720001705,CDM,272,RC,,,Outpatient,,,82.00,53.30,,82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.32,76,,205.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.04,72,,1.92,Percent of Total Billed Charges,72% of Total Billed Charges,61.5,75,,2,Percent of Total Billed charges,75% of Total Billed Charges,82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.04,72,,1.92,Percent of Total Billed Charges,72% of Total Billed Charges,49.2,60,,1.6,Percent of Total Billed Charges,60% of Total Billed Charges,73.8,90,,3.368,Percent of Total Billed Charges,90% of Total Billed Charges,36.9,45,,4.088,Percent of Total Billed Charges,45% of Total Billed Charges,73.8,90,,243,Percent of Total Billed Charges,90% of Total billed Charges,82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.3,65,,14.064,Percent of total Billed Charges,65% of Total Billed Charges,36.16,44.1,,4.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,77.9,95,,256.504,Percent of Total Billed Charges,95% of Total Billed Charges,82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.16,88,,237.6,Percent of Total Billed Charges,88% of Total Billed Charges,73.8,90,,243,Percent of Total Billed charges,90% of Total Billed Charges,36.16,82,
ARTHREX 1.7MM DB,2720001706,CDM,272,RC,,,Outpatient,,,95.00,61.75,,95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.2,76,,63.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,68.4,72,,3.448,Percent of Total Billed Charges,72% of Total Billed Charges,71.25,75,,3.592,Percent of Total Billed charges,75% of Total Billed Charges,95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.4,72,,3.448,Percent of Total Billed Charges,72% of Total Billed Charges,57,60,,2.872,Percent of Total Billed Charges,60% of Total Billed Charges,85.5,90,,3.12,Percent of Total Billed Charges,90% of Total Billed Charges,42.75,45,,4.256,Percent of Total Billed Charges,45% of Total Billed Charges,85.5,90,,75.6,Percent of Total Billed Charges,90% of Total billed Charges,95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.75,65,,5.904,Percent of total Billed Charges,65% of Total Billed Charges,41.9,44.1,,4.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,90.25,95,,79.8,Percent of Total Billed Charges,95% of Total Billed Charges,95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.6,88,,73.92,Percent of Total Billed Charges,88% of Total Billed Charges,85.5,90,,75.6,Percent of Total Billed charges,90% of Total Billed Charges,41.9,95,
ARTHREX FIBLCK IMP SYS STR,2720001707,CDM,272,RC,,,Outpatient,,,1100.00,715.00,,1100,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,836,76,,16.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,792,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,825,75,,1.984,Percent of Total Billed charges,75% of Total Billed Charges,1100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,792,72,,1.904,Percent of Total Billed Charges,72% of Total Billed Charges,660,60,,1.584,Percent of Total Billed Charges,60% of Total Billed Charges,990,90,,5.096,Percent of Total Billed Charges,90% of Total Billed Charges,495,45,,2.128,Percent of Total Billed Charges,45% of Total Billed Charges,990,90,,19.48,Percent of Total Billed Charges,90% of Total billed Charges,1100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,715,65,,6.152,Percent of total Billed Charges,65% of Total Billed Charges,485.1,44.1,,2.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,1045,95,,20.56,Percent of Total Billed Charges,95% of Total Billed Charges,1100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,968,88,,19.04,Percent of Total Billed Charges,88% of Total Billed Charges,990,90,,19.48,Percent of Total Billed charges,90% of Total Billed Charges,485.1,1100,
EPILOR 7ML LOR EPI SYRINGE,2720001708,CDM,272,RC,,,Outpatient,,,2.00,1.30,,2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.52,76,,6.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.44,72,,3.616,Percent of Total Billed Charges,72% of Total Billed Charges,1.5,75,,3.768,Percent of Total Billed charges,75% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,72,,3.616,Percent of Total Billed Charges,72% of Total Billed Charges,1.2,60,,3.016,Percent of Total Billed Charges,60% of Total Billed Charges,1.8,90,,18.632,Percent of Total Billed Charges,90% of Total Billed Charges,0.9,45,,2.52,Percent of Total Billed Charges,45% of Total Billed Charges,1.8,90,,8.176,Percent of Total Billed Charges,90% of Total billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,65,,3.072,Percent of total Billed Charges,65% of Total Billed Charges,0.88,44.1,,2.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.9,95,,8.624,Percent of Total Billed Charges,95% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.76,88,,7.992,Percent of Total Billed Charges,88% of Total Billed Charges,1.8,90,,8.176,Percent of Total Billed charges,90% of Total Billed Charges,0.88,2,
GEL FREE US PROBE COVER 60CM,2720001709,CDM,272,RC,,,Outpatient,,,7.70,5.01,,7.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.85,76,,7.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.54,72,,2.792,Percent of Total Billed Charges,72% of Total Billed Charges,5.78,75,,2.912,Percent of Total Billed charges,75% of Total Billed Charges,7.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.54,72,,2.792,Percent of Total Billed Charges,72% of Total Billed Charges,4.62,60,,2.328,Percent of Total Billed Charges,60% of Total Billed Charges,6.93,90,,5.136,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,1.28,Percent of Total Billed Charges,45% of Total Billed Charges,6.93,90,,8.52,Percent of Total Billed Charges,90% of Total billed Charges,7.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.01,65,,3.64,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,1.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.32,95,,8.992,Percent of Total Billed Charges,95% of Total Billed Charges,7.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.78,88,,8.328,Percent of Total Billed Charges,88% of Total Billed Charges,6.93,90,,8.52,Percent of Total Billed charges,90% of Total Billed Charges,3.4,7.7,
GEL FREE US PROBE COVER 147cm,2720001710,CDM,272,RC,,,Outpatient,,,12.91,8.39,,12.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.81,76,,3.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.3,72,,3.312,Percent of Total Billed Charges,72% of Total Billed Charges,9.68,75,,3.448,Percent of Total Billed charges,75% of Total Billed Charges,12.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.3,72,,3.312,Percent of Total Billed Charges,72% of Total Billed Charges,7.75,60,,2.76,Percent of Total Billed Charges,60% of Total Billed Charges,11.62,90,,5.136,Percent of Total Billed Charges,90% of Total Billed Charges,5.81,45,,52.648,Percent of Total Billed Charges,45% of Total Billed Charges,11.62,90,,4.248,Percent of Total Billed Charges,90% of Total billed Charges,12.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.39,65,,1.848,Percent of total Billed Charges,65% of Total Billed Charges,5.69,44.1,,51.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.26,95,,4.488,Percent of Total Billed Charges,95% of Total Billed Charges,12.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.36,88,,4.152,Percent of Total Billed Charges,88% of Total Billed Charges,11.62,90,,4.248,Percent of Total Billed charges,90% of Total Billed Charges,5.69,12.91,
"GLOVE, SENSICARE SZ 5.5",2720001711,CDM,272,RC,,,Outpatient,,,3.00,1.95,,3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.28,76,,4.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.16,72,,3.92,Percent of Total Billed Charges,72% of Total Billed Charges,2.25,75,,4.08,Percent of Total Billed charges,75% of Total Billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.16,72,,3.92,Percent of Total Billed Charges,72% of Total Billed Charges,1.8,60,,3.264,Percent of Total Billed Charges,60% of Total Billed Charges,2.7,90,,5.136,Percent of Total Billed Charges,90% of Total Billed Charges,1.35,45,,2.16,Percent of Total Billed Charges,45% of Total Billed Charges,2.7,90,,5.04,Percent of Total Billed Charges,90% of Total billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.95,65,,76.048,Percent of total Billed Charges,65% of Total Billed Charges,1.32,44.1,,2.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.85,95,,5.32,Percent of Total Billed Charges,95% of Total Billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.64,88,,4.928,Percent of Total Billed Charges,88% of Total Billed Charges,2.7,90,,5.04,Percent of Total Billed charges,90% of Total Billed Charges,1.32,3,
ARTHREX DISP KT FOR SWVCK,2720001712,CDM,272,RC,,,Outpatient,,,452.00,293.80,,452,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,343.52,76,,2.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,325.44,72,,2.088,Percent of Total Billed Charges,72% of Total Billed Charges,339,75,,2.176,Percent of Total Billed charges,75% of Total Billed Charges,452,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.44,72,,2.088,Percent of Total Billed Charges,72% of Total Billed Charges,271.2,60,,1.744,Percent of Total Billed Charges,60% of Total Billed Charges,406.8,90,,5.136,Percent of Total Billed Charges,90% of Total Billed Charges,203.4,45,,1.688,Percent of Total Billed Charges,45% of Total Billed Charges,406.8,90,,2.56,Percent of Total Billed Charges,90% of Total billed Charges,452,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,452,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,452,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.8,65,,3.12,Percent of total Billed Charges,65% of Total Billed Charges,199.33,44.1,,1.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,429.4,95,,2.696,Percent of Total Billed Charges,95% of Total Billed Charges,452,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.76,88,,2.496,Percent of Total Billed Charges,88% of Total Billed Charges,406.8,90,,2.56,Percent of Total Billed charges,90% of Total Billed Charges,199.33,452,
ANGIO CATH 14GX5.25,2720001713,CDM,272,RC,,,Outpatient,,,18.00,11.70,,18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.68,76,,88.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.96,72,,1.776,Percent of Total Billed Charges,72% of Total Billed Charges,13.5,75,,1.848,Percent of Total Billed charges,75% of Total Billed Charges,18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.96,72,,1.776,Percent of Total Billed Charges,72% of Total Billed Charges,10.8,60,,1.48,Percent of Total Billed Charges,60% of Total Billed Charges,16.2,90,,256.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,45,,1.56,Percent of Total Billed Charges,45% of Total Billed Charges,16.2,90,,105.304,Percent of Total Billed Charges,90% of Total billed Charges,18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.7,65,,2.432,Percent of total Billed Charges,65% of Total Billed Charges,7.94,44.1,,1.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.1,95,,111.152,Percent of Total Billed Charges,95% of Total Billed Charges,18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.84,88,,102.96,Percent of Total Billed Charges,88% of Total Billed Charges,16.2,90,,105.304,Percent of Total Billed charges,90% of Total Billed Charges,7.94,18,
SIM1 5F 65CM BT 0.035 CATHETER,2720001714,CDM,272,RC,C1887,HCPCS,Outpatient,,,25.00,16.25,,25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19,76,,3.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18,72,,1.6,Percent of Total Billed Charges,72% of Total Billed Charges,18.75,75,,1.672,Percent of Total Billed charges,75% of Total Billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18,72,,1.6,Percent of Total Billed Charges,72% of Total Billed Charges,15,60,,1.336,Percent of Total Billed Charges,60% of Total Billed Charges,22.5,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,11.25,45,,2.552,Percent of Total Billed Charges,45% of Total Billed Charges,22.5,90,,4.32,Percent of Total Billed Charges,90% of Total billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.25,65,,2.248,Percent of total Billed Charges,65% of Total Billed Charges,11.03,44.1,,2.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.75,95,,4.56,Percent of Total Billed Charges,95% of Total Billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22,88,,4.224,Percent of Total Billed Charges,88% of Total Billed Charges,22.5,90,,4.32,Percent of Total Billed charges,90% of Total Billed Charges,11.03,25,
C1 5F 100CM BT 0.035 CATHETER,2720001715,CDM,272,RC,C1887,HCPCS,Outpatient,,,25.00,16.25,,25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19,76,,2.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18,72,,0.832,Percent of Total Billed Charges,72% of Total Billed Charges,18.75,75,,0.872,Percent of Total Billed charges,75% of Total Billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18,72,,0.832,Percent of Total Billed Charges,72% of Total Billed Charges,15,60,,0.696,Percent of Total Billed Charges,60% of Total Billed Charges,22.5,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,11.25,45,,9.32,Percent of Total Billed Charges,45% of Total Billed Charges,22.5,90,,3.368,Percent of Total Billed Charges,90% of Total billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.25,65,,3.68,Percent of total Billed Charges,65% of Total Billed Charges,11.03,44.1,,9.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.75,95,,3.56,Percent of Total Billed Charges,95% of Total Billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22,88,,3.296,Percent of Total Billed Charges,88% of Total Billed Charges,22.5,90,,3.368,Percent of Total Billed charges,90% of Total Billed Charges,11.03,25,
C1 5F 65CM BT 0.035 CATHETER,2720001716,CDM,272,RC,C1887,HCPCS,Outpatient,,,25.00,16.25,,25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19,76,,2.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18,72,,1.408,Percent of Total Billed Charges,72% of Total Billed Charges,18.75,75,,1.472,Percent of Total Billed charges,75% of Total Billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18,72,,1.408,Percent of Total Billed Charges,72% of Total Billed Charges,15,60,,1.176,Percent of Total Billed Charges,60% of Total Billed Charges,22.5,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,11.25,45,,2.568,Percent of Total Billed Charges,45% of Total Billed Charges,22.5,90,,3.12,Percent of Total Billed Charges,90% of Total billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.25,65,,13.456,Percent of total Billed Charges,65% of Total Billed Charges,11.03,44.1,,2.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.75,95,,3.288,Percent of Total Billed Charges,95% of Total Billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22,88,,3.048,Percent of Total Billed Charges,88% of Total Billed Charges,22.5,90,,3.12,Percent of Total Billed charges,90% of Total Billed Charges,11.03,25,
TOUHY NEEDLE 18GX3.5 PERIFIX,2720001717,CDM,272,RC,,,Outpatient,,,6.00,3.90,,6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.56,76,,4.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.32,72,,1.344,Percent of Total Billed Charges,72% of Total Billed Charges,4.5,75,,1.4,Percent of Total Billed charges,75% of Total Billed Charges,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.32,72,,1.344,Percent of Total Billed Charges,72% of Total Billed Charges,3.6,60,,1.12,Percent of Total Billed Charges,60% of Total Billed Charges,5.4,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,2.7,45,,2.568,Percent of Total Billed Charges,45% of Total Billed Charges,5.4,90,,5.096,Percent of Total Billed Charges,90% of Total billed Charges,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.9,65,,3.704,Percent of total Billed Charges,65% of Total Billed Charges,2.65,44.1,,2.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.7,95,,5.384,Percent of Total Billed Charges,95% of Total Billed Charges,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.28,88,,4.984,Percent of Total Billed Charges,88% of Total Billed Charges,5.4,90,,5.096,Percent of Total Billed charges,90% of Total Billed Charges,2.65,6,
TOUHY NEEDLE 20GX3.5 PERIFIX,2720001718,CDM,272,RC,,,Outpatient,,,6.00,3.90,,6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.56,76,,15.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.32,72,,9.696,Percent of Total Billed Charges,72% of Total Billed Charges,4.5,75,,10.096,Percent of Total Billed charges,75% of Total Billed Charges,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.32,72,,9.696,Percent of Total Billed Charges,72% of Total Billed Charges,3.6,60,,8.08,Percent of Total Billed Charges,60% of Total Billed Charges,5.4,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.7,45,,2.568,Percent of Total Billed Charges,45% of Total Billed Charges,5.4,90,,18.632,Percent of Total Billed Charges,90% of Total billed Charges,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.9,65,,3.704,Percent of total Billed Charges,65% of Total Billed Charges,2.65,44.1,,2.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.7,95,,19.672,Percent of Total Billed Charges,95% of Total Billed Charges,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.28,88,,18.216,Percent of Total Billed Charges,88% of Total Billed Charges,5.4,90,,18.632,Percent of Total Billed charges,90% of Total Billed Charges,2.65,6,
TOUHY NEEDLE 20GX4 PERIFIX,2720001719,CDM,272,RC,,,Outpatient,,,6.00,3.90,,6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.56,76,,4.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.32,72,,1.8,Percent of Total Billed Charges,72% of Total Billed Charges,4.5,75,,1.88,Percent of Total Billed charges,75% of Total Billed Charges,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.32,72,,1.8,Percent of Total Billed Charges,72% of Total Billed Charges,3.6,60,,1.504,Percent of Total Billed Charges,60% of Total Billed Charges,5.4,90,,7.456,Percent of Total Billed Charges,90% of Total Billed Charges,2.7,45,,2.568,Percent of Total Billed Charges,45% of Total Billed Charges,5.4,90,,5.136,Percent of Total Billed Charges,90% of Total billed Charges,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.9,65,,3.704,Percent of total Billed Charges,65% of Total Billed Charges,2.65,44.1,,2.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.7,95,,5.416,Percent of Total Billed Charges,95% of Total Billed Charges,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.28,88,,5.016,Percent of Total Billed Charges,88% of Total Billed Charges,5.4,90,,5.136,Percent of Total Billed charges,90% of Total Billed Charges,2.65,6,
TOUHY NEEDLE 18GX4 PERIFIX,2720001720,CDM,272,RC,,,Outpatient,,,5.00,3.25,,5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.8,76,,4.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.6,72,,2.008,Percent of Total Billed Charges,72% of Total Billed Charges,3.75,75,,2.088,Percent of Total Billed charges,75% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.6,72,,2.008,Percent of Total Billed Charges,72% of Total Billed Charges,3,60,,1.672,Percent of Total Billed Charges,60% of Total Billed Charges,4.5,90,,7.456,Percent of Total Billed Charges,90% of Total Billed Charges,2.25,45,,128.344,Percent of Total Billed Charges,45% of Total Billed Charges,4.5,90,,5.136,Percent of Total Billed Charges,90% of Total billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.25,65,,3.704,Percent of total Billed Charges,65% of Total Billed Charges,2.21,44.1,,125.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.75,95,,5.416,Percent of Total Billed Charges,95% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.4,88,,5.016,Percent of Total Billed Charges,88% of Total Billed Charges,4.5,90,,5.136,Percent of Total Billed charges,90% of Total Billed Charges,2.21,5,
TRAILBLAZER 4F 035 X 135CM,2720001721,CDM,272,RC,C1887,HCPCS,Outpatient,,,185.00,120.25,,185,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,140.6,76,,4.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,133.2,72,,1.8,Percent of Total Billed Charges,72% of Total Billed Charges,138.75,75,,1.88,Percent of Total Billed charges,75% of Total Billed Charges,185,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.2,72,,1.8,Percent of Total Billed Charges,72% of Total Billed Charges,111,60,,1.504,Percent of Total Billed Charges,60% of Total Billed Charges,166.5,90,,262.8,Percent of Total Billed Charges,90% of Total Billed Charges,83.25,45,,16.2,Percent of Total Billed Charges,45% of Total Billed Charges,166.5,90,,5.136,Percent of Total Billed Charges,90% of Total billed Charges,185,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.25,65,,185.384,Percent of total Billed Charges,65% of Total Billed Charges,81.59,44.1,,15.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,175.75,95,,5.416,Percent of Total Billed Charges,95% of Total Billed Charges,185,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.8,88,,5.016,Percent of Total Billed Charges,88% of Total Billed Charges,166.5,90,,5.136,Percent of Total Billed charges,90% of Total Billed Charges,81.59,185,
GUINTHER TULIP VC FIL RET SET,2720001722,CDM,272,RC,C1773,HCPCS,Outpatient,,,550.00,357.50,,550,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,418,76,,4.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,396,72,,2.048,Percent of Total Billed Charges,72% of Total Billed Charges,412.5,75,,2.128,Percent of Total Billed charges,75% of Total Billed Charges,550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,72,,2.048,Percent of Total Billed Charges,72% of Total Billed Charges,330,60,,1.704,Percent of Total Billed Charges,60% of Total Billed Charges,495,90,,36,Percent of Total Billed Charges,90% of Total Billed Charges,247.5,45,,16.2,Percent of Total Billed Charges,45% of Total Billed Charges,495,90,,5.136,Percent of Total Billed Charges,90% of Total billed Charges,550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.5,65,,23.4,Percent of total Billed Charges,65% of Total Billed Charges,242.55,44.1,,15.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,522.5,95,,5.416,Percent of Total Billed Charges,95% of Total Billed Charges,550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484,88,,5.016,Percent of Total Billed Charges,88% of Total Billed Charges,495,90,,5.136,Percent of Total Billed charges,90% of Total Billed Charges,242.55,550,
EVERCROSS 5F 035 4X100X135,2720001723,CDM,272,RC,C1725,HCPCS,Outpatient,,,234.00,152.10,,234,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,177.84,76,,216.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,168.48,72,,4.928,Percent of Total Billed Charges,72% of Total Billed Charges,175.5,75,,5.128,Percent of Total Billed charges,75% of Total Billed Charges,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.48,72,,4.928,Percent of Total Billed Charges,72% of Total Billed Charges,140.4,60,,4.104,Percent of Total Billed Charges,60% of Total Billed Charges,210.6,90,,4.824,Percent of Total Billed Charges,90% of Total Billed Charges,105.3,45,,45,Percent of Total Billed Charges,45% of Total Billed Charges,210.6,90,,256.68,Percent of Total Billed Charges,90% of Total billed Charges,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.1,65,,23.4,Percent of total Billed Charges,65% of Total Billed Charges,103.19,44.1,,44.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,222.3,95,,270.944,Percent of Total Billed Charges,95% of Total Billed Charges,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.92,88,,250.976,Percent of Total Billed Charges,88% of Total Billed Charges,210.6,90,,256.68,Percent of Total Billed charges,90% of Total Billed Charges,103.19,234,
BONEPLST SUPP MOLD TRAY,2720001724,CDM,272,RC,,,Outpatient,,,291.00,189.15,,291,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,221.16,76,,27.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,209.52,72,,1.888,Percent of Total Billed Charges,72% of Total Billed Charges,218.25,75,,1.968,Percent of Total Billed charges,75% of Total Billed Charges,291,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.52,72,,1.888,Percent of Total Billed Charges,72% of Total Billed Charges,174.6,60,,1.576,Percent of Total Billed Charges,60% of Total Billed Charges,261.9,90,,8.16,Percent of Total Billed Charges,90% of Total Billed Charges,130.95,45,,45,Percent of Total Billed Charges,45% of Total Billed Charges,261.9,90,,32.4,Percent of Total Billed Charges,90% of Total billed Charges,291,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.15,65,,65,Percent of total Billed Charges,65% of Total Billed Charges,128.33,44.1,,44.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,276.45,95,,34.2,Percent of Total Billed Charges,95% of Total Billed Charges,291,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.08,88,,31.68,Percent of Total Billed Charges,88% of Total Billed Charges,261.9,90,,32.4,Percent of Total Billed charges,90% of Total Billed Charges,128.33,291,
BACTISURE WOUND LVGE,2720001725,CDM,272,RC,,,Outpatient,,,825.00,536.25,,825,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,627,76,,27.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,594,72,,4.968,Percent of Total Billed Charges,72% of Total Billed Charges,618.75,75,,5.176,Percent of Total Billed charges,75% of Total Billed Charges,825,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,594,72,,4.968,Percent of Total Billed Charges,72% of Total Billed Charges,495,60,,4.144,Percent of Total Billed Charges,60% of Total Billed Charges,742.5,90,,16.04,Percent of Total Billed Charges,90% of Total Billed Charges,371.25,45,,3.6,Percent of Total Billed Charges,45% of Total Billed Charges,742.5,90,,32.4,Percent of Total Billed Charges,90% of Total billed Charges,825,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,825,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,825,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,536.25,65,,65,Percent of total Billed Charges,65% of Total Billed Charges,363.83,44.1,,3.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,783.75,95,,34.2,Percent of Total Billed Charges,95% of Total Billed Charges,825,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,726,88,,31.68,Percent of Total Billed Charges,88% of Total Billed Charges,742.5,90,,32.4,Percent of Total Billed charges,90% of Total Billed Charges,363.83,825,
Z8092-32-238 GDEWRE 3.2X38,2720001726,CDM,272,RC,,,Outpatient,,,174.00,113.10,,174,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,132.24,76,,76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,125.28,72,,2.504,Percent of Total Billed Charges,72% of Total Billed Charges,130.5,75,,2.608,Percent of Total Billed charges,75% of Total Billed Charges,174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.28,72,,2.504,Percent of Total Billed Charges,72% of Total Billed Charges,104.4,60,,2.088,Percent of Total Billed Charges,60% of Total Billed Charges,156.6,90,,8.408,Percent of Total Billed Charges,90% of Total Billed Charges,78.3,45,,3.728,Percent of Total Billed Charges,45% of Total Billed Charges,156.6,90,,90,Percent of Total Billed Charges,90% of Total billed Charges,174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.1,65,,5.2,Percent of total Billed Charges,65% of Total Billed Charges,76.73,44.1,,3.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,165.3,95,,95,Percent of Total Billed Charges,95% of Total Billed Charges,174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.12,88,,88,Percent of Total Billed Charges,88% of Total Billed Charges,156.6,90,,90,Percent of Total Billed charges,90% of Total Billed Charges,76.73,174,
Z2810-01-080 BN GDEWRE 3.0X80,2720001727,CDM,272,RC,,,Outpatient,,,127.00,82.55,,127,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,96.52,76,,76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.44,72,,33.008,Percent of Total Billed Charges,72% of Total Billed Charges,95.25,75,,34.384,Percent of Total Billed charges,75% of Total Billed Charges,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.44,72,,33.008,Percent of Total Billed Charges,72% of Total Billed Charges,76.2,60,,27.504,Percent of Total Billed Charges,60% of Total Billed Charges,114.3,90,,356.584,Percent of Total Billed Charges,90% of Total Billed Charges,57.15,45,,3.728,Percent of Total Billed Charges,45% of Total Billed Charges,114.3,90,,90,Percent of Total Billed Charges,90% of Total billed Charges,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.55,65,,5.384,Percent of total Billed Charges,65% of Total Billed Charges,56.01,44.1,,3.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,120.65,95,,95,Percent of Total Billed Charges,95% of Total Billed Charges,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.76,88,,88,Percent of Total Billed Charges,88% of Total Billed Charges,114.3,90,,90,Percent of Total Billed charges,90% of Total Billed Charges,56.01,127,
CHOCO 5F 4X80X135 0.014 OTW,2720001728,CDM,272,RC,C1725,HCPCS,Outpatient,,,1530.00,994.50,,1530,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1162.8,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1101.6,72,,6.816,Percent of Total Billed Charges,72% of Total Billed Charges,1147.5,75,,7.096,Percent of Total Billed charges,75% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1101.6,72,,6.816,Percent of Total Billed Charges,72% of Total Billed Charges,918,60,,5.68,Percent of Total Billed Charges,60% of Total Billed Charges,1377,90,,241.92,Percent of Total Billed Charges,90% of Total Billed Charges,688.5,45,,131.4,Percent of Total Billed Charges,45% of Total Billed Charges,1377,90,,7.2,Percent of Total Billed Charges,90% of Total billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.5,65,,5.384,Percent of total Billed Charges,65% of Total Billed Charges,674.73,44.1,,128.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,1453.5,95,,7.6,Percent of Total Billed Charges,95% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1346.4,88,,7.04,Percent of Total Billed Charges,88% of Total Billed Charges,1377,90,,7.2,Percent of Total Billed charges,90% of Total Billed Charges,674.73,1530,
CHOCO 5F 2.5X40X150 0.014 OTW,2720001729,CDM,272,RC,C1725,HCPCS,Outpatient,,,1530.00,994.50,,1530,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1162.8,76,,6.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1101.6,72,,2.792,Percent of Total Billed Charges,72% of Total Billed Charges,1147.5,75,,2.912,Percent of Total Billed charges,75% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1101.6,72,,2.792,Percent of Total Billed Charges,72% of Total Billed Charges,918,60,,2.328,Percent of Total Billed Charges,60% of Total Billed Charges,1377,90,,86.4,Percent of Total Billed Charges,90% of Total Billed Charges,688.5,45,,18,Percent of Total Billed Charges,45% of Total Billed Charges,1377,90,,7.456,Percent of Total Billed Charges,90% of Total billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.5,65,,189.8,Percent of total Billed Charges,65% of Total Billed Charges,674.73,44.1,,17.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,1453.5,95,,7.864,Percent of Total Billed Charges,95% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1346.4,88,,7.288,Percent of Total Billed Charges,88% of Total Billed Charges,1377,90,,7.456,Percent of Total Billed charges,90% of Total Billed Charges,674.73,1530,
CHOCO 5F 2.5X80X150 0.14 OTW,2720001730,CDM,272,RC,C1725,HCPCS,Outpatient,,,1530.00,994.50,,1530,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1162.8,76,,6.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1101.6,72,,13.152,Percent of Total Billed Charges,72% of Total Billed Charges,1147.5,75,,13.696,Percent of Total Billed charges,75% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1101.6,72,,13.152,Percent of Total Billed Charges,72% of Total Billed Charges,918,60,,10.96,Percent of Total Billed Charges,60% of Total Billed Charges,1377,90,,56.2,Percent of Total Billed Charges,90% of Total Billed Charges,688.5,45,,2.416,Percent of Total Billed Charges,45% of Total Billed Charges,1377,90,,7.456,Percent of Total Billed Charges,90% of Total billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.5,65,,26,Percent of total Billed Charges,65% of Total Billed Charges,674.73,44.1,,2.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,1453.5,95,,7.864,Percent of Total Billed Charges,95% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1346.4,88,,7.288,Percent of Total Billed Charges,88% of Total Billed Charges,1377,90,,7.456,Percent of Total Billed charges,90% of Total Billed Charges,674.73,1530,
CHOCO 5F 3X80X150 0.014 OTW,2720001731,CDM,272,RC,C1725,HCPCS,Outpatient,,,1530.00,994.50,,1530,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1162.8,76,,221.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1101.6,72,,2.416,Percent of Total Billed Charges,72% of Total Billed Charges,1147.5,75,,2.52,Percent of Total Billed charges,75% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1101.6,72,,2.416,Percent of Total Billed Charges,72% of Total Billed Charges,918,60,,2.016,Percent of Total Billed Charges,60% of Total Billed Charges,1377,90,,64.248,Percent of Total Billed Charges,90% of Total Billed Charges,688.5,45,,4.08,Percent of Total Billed Charges,45% of Total Billed Charges,1377,90,,262.8,Percent of Total Billed Charges,90% of Total billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.5,65,,3.488,Percent of total Billed Charges,65% of Total Billed Charges,674.73,44.1,,4,Percent of Total Billed Charges,44.1% of Total Billed Charges,1453.5,95,,277.4,Percent of Total Billed Charges,95% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1346.4,88,,256.96,Percent of Total Billed Charges,88% of Total Billed Charges,1377,90,,262.8,Percent of Total Billed charges,90% of Total Billed Charges,674.73,1530,
CHOCO 5F 4X40X135 014 PTA OTW,2720001732,CDM,272,RC,,,Outpatient,,,1530.00,994.50,,1530,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1162.8,76,,30.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1101.6,72,,1.872,Percent of Total Billed Charges,72% of Total Billed Charges,1147.5,75,,1.952,Percent of Total Billed charges,75% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1101.6,72,,1.872,Percent of Total Billed Charges,72% of Total Billed Charges,918,60,,1.56,Percent of Total Billed Charges,60% of Total Billed Charges,1377,90,,56.2,Percent of Total Billed Charges,90% of Total Billed Charges,688.5,45,,8.024,Percent of Total Billed Charges,45% of Total Billed Charges,1377,90,,36,Percent of Total Billed Charges,90% of Total billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.5,65,,5.888,Percent of total Billed Charges,65% of Total Billed Charges,674.73,44.1,,7.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,1453.5,95,,38,Percent of Total Billed Charges,95% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1346.4,88,,35.2,Percent of Total Billed Charges,88% of Total Billed Charges,1377,90,,36,Percent of Total Billed charges,90% of Total Billed Charges,674.73,1530,
CHOCO 5F 5X40X120 0.018 OTW,2720001733,CDM,272,RC,C1725,HCPCS,Outpatient,,,1530.00,994.50,,1530,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1162.8,76,,4.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1101.6,72,,2.584,Percent of Total Billed Charges,72% of Total Billed Charges,1147.5,75,,2.688,Percent of Total Billed charges,75% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1101.6,72,,2.584,Percent of Total Billed Charges,72% of Total Billed Charges,918,60,,2.152,Percent of Total Billed Charges,60% of Total Billed Charges,1377,90,,1.152,Percent of Total Billed Charges,90% of Total Billed Charges,688.5,45,,4.208,Percent of Total Billed Charges,45% of Total Billed Charges,1377,90,,4.824,Percent of Total Billed Charges,90% of Total billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.5,65,,11.584,Percent of total Billed Charges,65% of Total Billed Charges,674.73,44.1,,4.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,1453.5,95,,5.096,Percent of Total Billed Charges,95% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1346.4,88,,4.72,Percent of Total Billed Charges,88% of Total Billed Charges,1377,90,,4.824,Percent of Total Billed charges,90% of Total Billed Charges,674.73,1530,
CHOCO 5F 5X80X120 0.018 OTW,2720001734,CDM,272,RC,C1725,HCPCS,Outpatient,,,1530.00,994.50,,1530,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1162.8,76,,6.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1101.6,72,,1.872,Percent of Total Billed Charges,72% of Total Billed Charges,1147.5,75,,1.952,Percent of Total Billed charges,75% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1101.6,72,,1.872,Percent of Total Billed Charges,72% of Total Billed Charges,918,60,,1.56,Percent of Total Billed Charges,60% of Total Billed Charges,1377,90,,67.392,Percent of Total Billed Charges,90% of Total Billed Charges,688.5,45,,178.288,Percent of Total Billed Charges,45% of Total Billed Charges,1377,90,,8.16,Percent of Total Billed Charges,90% of Total billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.5,65,,6.072,Percent of total Billed Charges,65% of Total Billed Charges,674.73,44.1,,174.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,1453.5,95,,8.608,Percent of Total Billed Charges,95% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1346.4,88,,7.976,Percent of Total Billed Charges,88% of Total Billed Charges,1377,90,,8.16,Percent of Total Billed charges,90% of Total Billed Charges,674.73,1530,
CHOCO 5F 5X120X120 0.018 OTW,2720001735,CDM,272,RC,C1725,HCPCS,Outpatient,,,1530.00,994.50,,1530,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1162.8,76,,13.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1101.6,72,,5.072,Percent of Total Billed Charges,72% of Total Billed Charges,1147.5,75,,5.28,Percent of Total Billed charges,75% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1101.6,72,,5.072,Percent of Total Billed Charges,72% of Total Billed Charges,918,60,,4.224,Percent of Total Billed Charges,60% of Total Billed Charges,1377,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,688.5,45,,120.96,Percent of Total Billed Charges,45% of Total Billed Charges,1377,90,,16.04,Percent of Total Billed Charges,90% of Total billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.5,65,,257.528,Percent of total Billed Charges,65% of Total Billed Charges,674.73,44.1,,118.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,1453.5,95,,16.936,Percent of Total Billed Charges,95% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1346.4,88,,15.688,Percent of Total Billed Charges,88% of Total Billed Charges,1377,90,,16.04,Percent of Total Billed charges,90% of Total Billed Charges,674.73,1530,
TRAILBLAZER 5F 0.035 X 90,2720001736,CDM,272,RC,C1887,HCPCS,Outpatient,,,145.00,94.25,,145,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.2,76,,7.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,104.4,72,,3.2,Percent of Total Billed Charges,72% of Total Billed Charges,108.75,75,,3.328,Percent of Total Billed charges,75% of Total Billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.4,72,,3.2,Percent of Total Billed Charges,72% of Total Billed Charges,87,60,,2.664,Percent of Total Billed Charges,60% of Total Billed Charges,130.5,90,,6.968,Percent of Total Billed Charges,90% of Total Billed Charges,65.25,45,,43.2,Percent of Total Billed Charges,45% of Total Billed Charges,130.5,90,,8.408,Percent of Total Billed Charges,90% of Total billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.25,65,,174.72,Percent of total Billed Charges,65% of Total Billed Charges,63.95,44.1,,42.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,137.75,95,,8.88,Percent of Total Billed Charges,95% of Total Billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.6,88,,8.224,Percent of Total Billed Charges,88% of Total Billed Charges,130.5,90,,8.408,Percent of Total Billed charges,90% of Total Billed Charges,63.95,145,
OPTISEAL 7F 13CM GLBL INTRO,2720001737,CDM,272,RC,C1892,HCPCS,Outpatient,,,52.00,33.80,,52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,39.52,76,,301.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,37.44,72,,3.672,Percent of Total Billed Charges,72% of Total Billed Charges,39,75,,3.832,Percent of Total Billed charges,75% of Total Billed Charges,52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.44,72,,3.672,Percent of Total Billed Charges,72% of Total Billed Charges,31.2,60,,3.064,Percent of Total Billed Charges,60% of Total Billed Charges,46.8,90,,16.944,Percent of Total Billed Charges,90% of Total Billed Charges,23.4,45,,28.096,Percent of Total Billed Charges,45% of Total Billed Charges,46.8,90,,356.584,Percent of Total Billed Charges,90% of Total billed Charges,52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.8,65,,62.4,Percent of total Billed Charges,65% of Total Billed Charges,22.93,44.1,,27.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,49.4,95,,376.392,Percent of Total Billed Charges,95% of Total Billed Charges,52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.76,88,,348.656,Percent of Total Billed Charges,88% of Total Billed Charges,46.8,90,,356.584,Percent of Total Billed charges,90% of Total Billed Charges,22.93,52,
IV BD NEXIVA 22 X 1,2720001738,CDM,272,RC,,,Outpatient,,,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,204.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.77,72,,3.304,Percent of Total Billed Charges,72% of Total Billed Charges,4.97,75,,3.44,Percent of Total Billed charges,75% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.77,72,,3.304,Percent of Total Billed Charges,72% of Total Billed Charges,3.97,60,,2.752,Percent of Total Billed Charges,60% of Total Billed Charges,5.96,90,,9.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,32.12,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,241.92,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,40.584,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,31.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,255.36,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,236.544,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,241.92,Percent of Total Billed charges,90% of Total Billed Charges,2.92,6.62,
7.0 ORAL RAE CUFFED,2720001739,CDM,272,RC,,,Outpatient,,,5.00,3.25,,5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.8,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.6,72,,3.8,Percent of Total Billed Charges,72% of Total Billed Charges,3.75,75,,3.96,Percent of Total Billed charges,75% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.6,72,,3.8,Percent of Total Billed Charges,72% of Total Billed Charges,3,60,,3.168,Percent of Total Billed Charges,60% of Total Billed Charges,4.5,90,,8.608,Percent of Total Billed Charges,90% of Total Billed Charges,2.25,45,,28.096,Percent of Total Billed Charges,45% of Total Billed Charges,4.5,90,,86.4,Percent of Total Billed Charges,90% of Total billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.25,65,,46.4,Percent of total Billed Charges,65% of Total Billed Charges,2.21,44.1,,27.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.75,95,,91.2,Percent of Total Billed Charges,95% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.4,88,,84.48,Percent of Total Billed Charges,88% of Total Billed Charges,4.5,90,,86.4,Percent of Total Billed charges,90% of Total Billed Charges,2.21,5,
Z480611035 DB 3.5,2720001740,CDM,272,RC,,,Outpatient,,,59.50,38.68,,59.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.22,76,,47.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.84,72,,1.84,Percent of Total Billed Charges,72% of Total Billed Charges,44.63,75,,1.92,Percent of Total Billed charges,75% of Total Billed Charges,59.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.84,72,,1.84,Percent of Total Billed Charges,72% of Total Billed Charges,35.7,60,,1.536,Percent of Total Billed Charges,60% of Total Billed Charges,53.55,90,,2.976,Percent of Total Billed Charges,90% of Total Billed Charges,26.78,45,,0.576,Percent of Total Billed Charges,45% of Total Billed Charges,53.55,90,,56.2,Percent of Total Billed Charges,90% of Total billed Charges,59.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.68,65,,40.584,Percent of total Billed Charges,65% of Total Billed Charges,26.24,44.1,,0.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,56.53,95,,59.32,Percent of Total Billed Charges,95% of Total Billed Charges,59.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.36,88,,54.944,Percent of Total Billed Charges,88% of Total Billed Charges,53.55,90,,56.2,Percent of Total Billed charges,90% of Total Billed Charges,26.24,59.5,
MICKEY STOMA MEASURE DEVICE,2720001741,CDM,272,RC,,,Outpatient,,,6.74,4.38,,6.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.12,76,,54.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.85,72,,6.496,Percent of Total Billed Charges,72% of Total Billed Charges,5.06,75,,6.768,Percent of Total Billed charges,75% of Total Billed Charges,6.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,72,,6.496,Percent of Total Billed Charges,72% of Total Billed Charges,4.04,60,,5.416,Percent of Total Billed Charges,60% of Total Billed Charges,6.07,90,,9.184,Percent of Total Billed Charges,90% of Total Billed Charges,3.03,45,,33.696,Percent of Total Billed Charges,45% of Total Billed Charges,6.07,90,,64.248,Percent of Total Billed Charges,90% of Total billed Charges,6.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.38,65,,0.832,Percent of total Billed Charges,65% of Total Billed Charges,2.97,44.1,,33.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.4,95,,67.816,Percent of Total Billed Charges,95% of Total Billed Charges,6.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.93,88,,62.816,Percent of Total Billed Charges,88% of Total Billed Charges,6.07,90,,64.248,Percent of Total Billed charges,90% of Total Billed Charges,2.97,6.74,
ACCURO LOC NDLE GDE KT,2720001742,CDM,272,RC,,,Outpatient,,,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,47.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.64,72,,1.984,Percent of Total Billed Charges,72% of Total Billed Charges,9,75,,2.072,Percent of Total Billed charges,75% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.64,72,,1.984,Percent of Total Billed Charges,72% of Total Billed Charges,7.2,60,,1.656,Percent of Total Billed Charges,60% of Total Billed Charges,10.8,90,,5.744,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,3.6,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,56.2,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,48.672,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,3.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,59.32,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,54.944,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,56.2,Percent of Total Billed charges,90% of Total Billed Charges,5.29,12,
ACCURO LOC NDLE GDE,2720001743,CDM,272,RC,,,Outpatient,,,6.67,4.34,,6.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.07,76,,0.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.8,72,,2.16,Percent of Total Billed Charges,72% of Total Billed Charges,5,75,,2.248,Percent of Total Billed charges,75% of Total Billed Charges,6.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.8,72,,2.16,Percent of Total Billed Charges,72% of Total Billed Charges,4,60,,1.8,Percent of Total Billed Charges,60% of Total Billed Charges,6,90,,26.552,Percent of Total Billed Charges,90% of Total Billed Charges,3,45,,3.488,Percent of Total Billed Charges,45% of Total Billed Charges,6,90,,1.152,Percent of Total Billed Charges,90% of Total billed Charges,6.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.34,65,,5.2,Percent of total Billed Charges,65% of Total Billed Charges,2.94,44.1,,3.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.34,95,,1.216,Percent of Total Billed Charges,95% of Total Billed Charges,6.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.87,88,,1.128,Percent of Total Billed Charges,88% of Total Billed Charges,6,90,,1.152,Percent of Total Billed charges,90% of Total Billed Charges,2.94,6.67,
BLOOD TUBING PLUM 360,2720001744,CDM,272,RC,,,Outpatient,,,3.25,2.11,,3.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.47,76,,56.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.34,72,,14.256,Percent of Total Billed Charges,72% of Total Billed Charges,2.44,75,,14.848,Percent of Total Billed charges,75% of Total Billed Charges,3.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.34,72,,14.256,Percent of Total Billed Charges,72% of Total Billed Charges,1.95,60,,11.88,Percent of Total Billed Charges,60% of Total Billed Charges,2.93,90,,63,Percent of Total Billed Charges,90% of Total Billed Charges,1.46,45,,8.472,Percent of Total Billed Charges,45% of Total Billed Charges,2.93,90,,67.392,Percent of Total Billed Charges,90% of Total billed Charges,3.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.11,65,,5.032,Percent of total Billed Charges,65% of Total Billed Charges,1.43,44.1,,8.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.09,95,,71.136,Percent of Total Billed Charges,95% of Total Billed Charges,3.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.86,88,,65.896,Percent of Total Billed Charges,88% of Total Billed Charges,2.93,90,,67.392,Percent of Total Billed charges,90% of Total Billed Charges,1.43,3.25,
PRIMARY TUBING PLUM 360,2720001745,CDM,272,RC,,,Outpatient,,,4.40,2.86,,4.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.34,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.17,72,,15.352,Percent of Total Billed Charges,72% of Total Billed Charges,3.3,75,,15.992,Percent of Total Billed charges,75% of Total Billed Charges,4.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.17,72,,15.352,Percent of Total Billed Charges,72% of Total Billed Charges,2.64,60,,12.792,Percent of Total Billed Charges,60% of Total Billed Charges,3.96,90,,6.936,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,4.784,Percent of Total Billed Charges,45% of Total Billed Charges,3.96,90,,7.2,Percent of Total Billed Charges,90% of Total billed Charges,4.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.86,65,,12.232,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,4.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.18,95,,7.6,Percent of Total Billed Charges,95% of Total Billed Charges,4.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.87,88,,7.04,Percent of Total Billed Charges,88% of Total Billed Charges,3.96,90,,7.2,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.4,
HEMOSTAT DISPOSABLE CURVE,2720001746,CDM,272,RC,,,Outpatient,,,4.63,3.01,,4.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.52,76,,5.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.33,72,,8.984,Percent of Total Billed Charges,72% of Total Billed Charges,3.47,75,,9.36,Percent of Total Billed charges,75% of Total Billed Charges,4.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.33,72,,8.984,Percent of Total Billed Charges,72% of Total Billed Charges,2.78,60,,7.488,Percent of Total Billed Charges,60% of Total Billed Charges,4.17,90,,4.056,Percent of Total Billed Charges,90% of Total Billed Charges,2.08,45,,4.304,Percent of Total Billed Charges,45% of Total Billed Charges,4.17,90,,6.968,Percent of Total Billed Charges,90% of Total billed Charges,4.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.01,65,,6.904,Percent of total Billed Charges,65% of Total Billed Charges,2.04,44.1,,4.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.4,95,,7.36,Percent of Total Billed Charges,95% of Total Billed Charges,4.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.07,88,,6.816,Percent of Total Billed Charges,88% of Total Billed Charges,4.17,90,,6.968,Percent of Total Billed charges,90% of Total Billed Charges,2.04,4.63,
"DRAPE, CENTRAL LINE, STERILE",2720001747,CDM,272,RC,,,Outpatient,,,8.64,5.62,,8.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.57,76,,14.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.22,72,,2.296,Percent of Total Billed Charges,72% of Total Billed Charges,6.48,75,,2.392,Percent of Total Billed charges,75% of Total Billed Charges,8.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.22,72,,2.296,Percent of Total Billed Charges,72% of Total Billed Charges,5.18,60,,1.912,Percent of Total Billed Charges,60% of Total Billed Charges,7.78,90,,4.272,Percent of Total Billed Charges,90% of Total Billed Charges,3.89,45,,1.488,Percent of Total Billed Charges,45% of Total Billed Charges,7.78,90,,16.944,Percent of Total Billed Charges,90% of Total billed Charges,8.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.62,65,,6.216,Percent of total Billed Charges,65% of Total Billed Charges,3.81,44.1,,1.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.21,95,,17.88,Percent of Total Billed Charges,95% of Total Billed Charges,8.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.6,88,,16.568,Percent of Total Billed Charges,88% of Total Billed Charges,7.78,90,,16.944,Percent of Total Billed charges,90% of Total Billed Charges,3.81,8.64,
INTRODUCER/BOUGIE 15 FRX70CM,2720001748,CDM,272,RC,,,Outpatient,,,9.45,6.14,,9.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.18,76,,8.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.8,72,,1.8,Percent of Total Billed Charges,72% of Total Billed Charges,7.09,75,,1.88,Percent of Total Billed charges,75% of Total Billed Charges,9.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.8,72,,1.8,Percent of Total Billed Charges,72% of Total Billed Charges,5.67,60,,1.504,Percent of Total Billed Charges,60% of Total Billed Charges,8.51,90,,11.144,Percent of Total Billed Charges,90% of Total Billed Charges,4.25,45,,4.592,Percent of Total Billed Charges,45% of Total Billed Charges,8.51,90,,9.56,Percent of Total Billed Charges,90% of Total billed Charges,9.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.14,65,,2.144,Percent of total Billed Charges,65% of Total Billed Charges,4.17,44.1,,4.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.98,95,,10.096,Percent of Total Billed Charges,95% of Total Billed Charges,9.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.32,88,,9.352,Percent of Total Billed Charges,88% of Total Billed Charges,8.51,90,,9.56,Percent of Total Billed charges,90% of Total Billed Charges,4.17,9.45,
IV UNIVERSAL FREPP APP IVK0100,2720001749,CDM,272,RC,,,Outpatient,,,3.90,2.54,,3.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.96,76,,7.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.81,72,,2.848,Percent of Total Billed Charges,72% of Total Billed Charges,2.93,75,,2.968,Percent of Total Billed charges,75% of Total Billed Charges,3.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.81,72,,2.848,Percent of Total Billed Charges,72% of Total Billed Charges,2.34,60,,2.376,Percent of Total Billed Charges,60% of Total Billed Charges,3.51,90,,8.496,Percent of Total Billed Charges,90% of Total Billed Charges,1.76,45,,2.872,Percent of Total Billed Charges,45% of Total Billed Charges,3.51,90,,8.608,Percent of Total Billed Charges,90% of Total billed Charges,3.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.54,65,,6.632,Percent of total Billed Charges,65% of Total Billed Charges,1.72,44.1,,2.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.71,95,,9.08,Percent of Total Billed Charges,95% of Total Billed Charges,3.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.43,88,,8.416,Percent of Total Billed Charges,88% of Total Billed Charges,3.51,90,,8.608,Percent of Total Billed charges,90% of Total Billed Charges,1.72,3.9,
IV PREMIUM MACRO IV0569,2720001750,CDM,272,RC,,,Outpatient,,,3.00,1.95,,3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.28,76,,2.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.16,72,,3.016,Percent of Total Billed Charges,72% of Total Billed Charges,2.25,75,,3.136,Percent of Total Billed charges,75% of Total Billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.16,72,,3.016,Percent of Total Billed Charges,72% of Total Billed Charges,1.8,60,,2.512,Percent of Total Billed Charges,60% of Total Billed Charges,2.7,90,,8.496,Percent of Total Billed Charges,90% of Total Billed Charges,1.35,45,,13.28,Percent of Total Billed Charges,45% of Total Billed Charges,2.7,90,,2.976,Percent of Total Billed Charges,90% of Total billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.95,65,,4.152,Percent of total Billed Charges,65% of Total Billed Charges,1.32,44.1,,13.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.85,95,,3.136,Percent of Total Billed Charges,95% of Total Billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.64,88,,2.904,Percent of Total Billed Charges,88% of Total Billed Charges,2.7,90,,2.976,Percent of Total Billed charges,90% of Total Billed Charges,1.32,3,
CATH SAFETY 26G,2720001751,CDM,272,RC,,,Outpatient,,,3.76,2.44,,3.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.86,76,,7.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.71,72,,2.968,Percent of Total Billed Charges,72% of Total Billed Charges,2.82,75,,3.088,Percent of Total Billed charges,75% of Total Billed Charges,3.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.71,72,,2.968,Percent of Total Billed Charges,72% of Total Billed Charges,2.26,60,,2.472,Percent of Total Billed Charges,60% of Total Billed Charges,3.38,90,,9.576,Percent of Total Billed Charges,90% of Total Billed Charges,1.69,45,,31.504,Percent of Total Billed Charges,45% of Total Billed Charges,3.38,90,,9.184,Percent of Total Billed Charges,90% of Total billed Charges,3.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.44,65,,19.176,Percent of total Billed Charges,65% of Total Billed Charges,1.66,44.1,,30.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.57,95,,9.688,Percent of Total Billed Charges,95% of Total Billed Charges,3.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,88,,8.976,Percent of Total Billed Charges,88% of Total Billed Charges,3.38,90,,9.184,Percent of Total Billed charges,90% of Total Billed Charges,1.66,3.76,
SUTURE PROLENE 2-0 D9207,2720001752,CDM,272,RC,,,Outpatient,,,38.99,25.34,,38.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.63,76,,4.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.07,72,,2.64,Percent of Total Billed Charges,72% of Total Billed Charges,29.24,75,,2.752,Percent of Total Billed charges,75% of Total Billed Charges,38.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.07,72,,2.64,Percent of Total Billed Charges,72% of Total Billed Charges,23.39,60,,2.2,Percent of Total Billed Charges,60% of Total Billed Charges,35.09,90,,8.496,Percent of Total Billed Charges,90% of Total Billed Charges,17.55,45,,3.464,Percent of Total Billed Charges,45% of Total Billed Charges,35.09,90,,5.744,Percent of Total Billed Charges,90% of Total billed Charges,38.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.34,65,,45.504,Percent of total Billed Charges,65% of Total Billed Charges,17.19,44.1,,3.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.04,95,,6.064,Percent of Total Billed Charges,95% of Total Billed Charges,38.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.31,88,,5.616,Percent of Total Billed Charges,88% of Total Billed Charges,35.09,90,,5.744,Percent of Total Billed charges,90% of Total Billed Charges,17.19,38.99,
SUTURE PROLENE 3-0 EPR8632G,2720001753,CDM,272,RC,,,Outpatient,,,18.50,12.03,,18.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.06,76,,22.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.32,72,,2.104,Percent of Total Billed Charges,72% of Total Billed Charges,13.88,75,,2.192,Percent of Total Billed charges,75% of Total Billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.32,72,,2.104,Percent of Total Billed Charges,72% of Total Billed Charges,11.1,60,,1.752,Percent of Total Billed Charges,60% of Total Billed Charges,16.65,90,,10.64,Percent of Total Billed Charges,90% of Total Billed Charges,8.33,45,,2.024,Percent of Total Billed Charges,45% of Total Billed Charges,16.65,90,,26.552,Percent of Total Billed Charges,90% of Total billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.03,65,,5.008,Percent of total Billed Charges,65% of Total Billed Charges,8.16,44.1,,1.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.58,95,,28.032,Percent of Total Billed Charges,95% of Total Billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.28,88,,25.96,Percent of Total Billed Charges,88% of Total Billed Charges,16.65,90,,26.552,Percent of Total Billed charges,90% of Total Billed Charges,8.16,18.5,
LMA UNIQUE AIRWAY SZ1,2720001754,CDM,272,RC,,,Outpatient,,,35.99,23.39,,35.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.35,76,,53.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.91,72,,2.784,Percent of Total Billed Charges,72% of Total Billed Charges,26.99,75,,2.896,Percent of Total Billed charges,75% of Total Billed Charges,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.91,72,,2.784,Percent of Total Billed Charges,72% of Total Billed Charges,21.59,60,,2.32,Percent of Total Billed Charges,60% of Total Billed Charges,32.39,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,45,,2.136,Percent of Total Billed Charges,45% of Total Billed Charges,32.39,90,,63,Percent of Total Billed Charges,90% of Total billed Charges,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.39,65,,2.928,Percent of total Billed Charges,65% of Total Billed Charges,15.87,44.1,,2.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.19,95,,66.504,Percent of Total Billed Charges,95% of Total Billed Charges,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.67,88,,61.6,Percent of Total Billed Charges,88% of Total Billed Charges,32.39,90,,63,Percent of Total Billed charges,90% of Total Billed Charges,15.87,35.99,
LMA UNIQUE AIRWAY SZ2,2720001755,CDM,272,RC,,,Outpatient,,,35.99,23.39,,35.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.35,76,,5.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.91,72,,5.808,Percent of Total Billed Charges,72% of Total Billed Charges,26.99,75,,6.048,Percent of Total Billed charges,75% of Total Billed Charges,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.91,72,,5.808,Percent of Total Billed Charges,72% of Total Billed Charges,21.59,60,,4.84,Percent of Total Billed Charges,60% of Total Billed Charges,32.39,90,,3.208,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,45,,5.576,Percent of Total Billed Charges,45% of Total Billed Charges,32.39,90,,6.936,Percent of Total Billed Charges,90% of Total billed Charges,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.39,65,,3.08,Percent of total Billed Charges,65% of Total Billed Charges,15.87,44.1,,5.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.19,95,,7.32,Percent of Total Billed Charges,95% of Total Billed Charges,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.67,88,,6.776,Percent of Total Billed Charges,88% of Total Billed Charges,32.39,90,,6.936,Percent of Total Billed charges,90% of Total Billed Charges,15.87,35.99,
LMA UNIQUE AIRWAY SZ 2,2720001756,CDM,272,RC,,,Outpatient,,,35.99,23.39,,35.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.35,76,,3.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.91,72,,3.304,Percent of Total Billed Charges,72% of Total Billed Charges,26.99,75,,3.44,Percent of Total Billed charges,75% of Total Billed Charges,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.91,72,,3.304,Percent of Total Billed Charges,72% of Total Billed Charges,21.59,60,,2.752,Percent of Total Billed Charges,60% of Total Billed Charges,32.39,90,,2.256,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,45,,4.248,Percent of Total Billed Charges,45% of Total Billed Charges,32.39,90,,4.056,Percent of Total Billed Charges,90% of Total billed Charges,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.39,65,,8.048,Percent of total Billed Charges,65% of Total Billed Charges,15.87,44.1,,4.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.19,95,,4.28,Percent of Total Billed Charges,95% of Total Billed Charges,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.67,88,,3.96,Percent of Total Billed Charges,88% of Total Billed Charges,32.39,90,,4.056,Percent of Total Billed charges,90% of Total Billed Charges,15.87,35.99,
LMA UNIQUE AIRWAY SZ 2.5,2720001757,CDM,272,RC,,,Outpatient,,,35.99,23.39,,35.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.35,76,,3.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.91,72,,2.392,Percent of Total Billed Charges,72% of Total Billed Charges,26.99,75,,2.488,Percent of Total Billed charges,75% of Total Billed Charges,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.91,72,,2.392,Percent of Total Billed Charges,72% of Total Billed Charges,21.59,60,,1.992,Percent of Total Billed Charges,60% of Total Billed Charges,32.39,90,,172.856,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,45,,4.248,Percent of Total Billed Charges,45% of Total Billed Charges,32.39,90,,4.272,Percent of Total Billed Charges,90% of Total billed Charges,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.39,65,,6.136,Percent of total Billed Charges,65% of Total Billed Charges,15.87,44.1,,4.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.19,95,,4.504,Percent of Total Billed Charges,95% of Total Billed Charges,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.67,88,,4.176,Percent of Total Billed Charges,88% of Total Billed Charges,32.39,90,,4.272,Percent of Total Billed charges,90% of Total Billed Charges,15.87,35.99,
LMA UNIQUE AIRWAY SZ 3,2720001758,CDM,272,RC,,,Outpatient,,,35.99,23.39,,35.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.35,76,,9.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.91,72,,2.496,Percent of Total Billed Charges,72% of Total Billed Charges,26.99,75,,2.6,Percent of Total Billed charges,75% of Total Billed Charges,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.91,72,,2.496,Percent of Total Billed Charges,72% of Total Billed Charges,21.59,60,,2.08,Percent of Total Billed Charges,60% of Total Billed Charges,32.39,90,,26.464,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,45,,4.792,Percent of Total Billed Charges,45% of Total Billed Charges,32.39,90,,11.144,Percent of Total Billed Charges,90% of Total billed Charges,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.39,65,,6.136,Percent of total Billed Charges,65% of Total Billed Charges,15.87,44.1,,4.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.19,95,,11.768,Percent of Total Billed Charges,95% of Total Billed Charges,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.67,88,,10.896,Percent of Total Billed Charges,88% of Total Billed Charges,32.39,90,,11.144,Percent of Total Billed charges,90% of Total Billed Charges,15.87,35.99,
CATH THORACIC STRGH ARGYL 12FR,2720001759,CDM,272,RC,,,Outpatient,,,4.27,2.78,,4.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.25,76,,7.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.07,72,,26.928,Percent of Total Billed Charges,72% of Total Billed Charges,3.2,75,,28.048,Percent of Total Billed charges,75% of Total Billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.07,72,,26.928,Percent of Total Billed Charges,72% of Total Billed Charges,2.56,60,,22.44,Percent of Total Billed Charges,60% of Total Billed Charges,3.84,90,,38.344,Percent of Total Billed Charges,90% of Total Billed Charges,1.92,45,,4.248,Percent of Total Billed Charges,45% of Total Billed Charges,3.84,90,,8.496,Percent of Total Billed Charges,90% of Total billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.78,65,,6.92,Percent of total Billed Charges,65% of Total Billed Charges,1.88,44.1,,4.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.06,95,,8.968,Percent of Total Billed Charges,95% of Total Billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.76,88,,8.304,Percent of Total Billed Charges,88% of Total Billed Charges,3.84,90,,8.496,Percent of Total Billed charges,90% of Total Billed Charges,1.88,4.27,
CATH THORACIC STRGHT 16FR,2720001760,CDM,272,RC,,,Outpatient,,,4.27,2.78,,4.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.25,76,,7.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.07,72,,26.928,Percent of Total Billed Charges,72% of Total Billed Charges,3.2,75,,28.048,Percent of Total Billed charges,75% of Total Billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.07,72,,26.928,Percent of Total Billed Charges,72% of Total Billed Charges,2.56,60,,22.44,Percent of Total Billed Charges,60% of Total Billed Charges,3.84,90,,11.04,Percent of Total Billed Charges,90% of Total Billed Charges,1.92,45,,5.32,Percent of Total Billed Charges,45% of Total Billed Charges,3.84,90,,8.496,Percent of Total Billed Charges,90% of Total billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.78,65,,6.136,Percent of total Billed Charges,65% of Total Billed Charges,1.88,44.1,,5.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.06,95,,8.968,Percent of Total Billed Charges,95% of Total Billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.76,88,,8.304,Percent of Total Billed Charges,88% of Total Billed Charges,3.84,90,,8.496,Percent of Total Billed charges,90% of Total Billed Charges,1.88,4.27,
CATH THORACIC STRGH ARGYL 20FR,2720001761,CDM,272,RC,,,Outpatient,,,4.27,2.78,,4.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.25,76,,8.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.07,72,,26.928,Percent of Total Billed Charges,72% of Total Billed Charges,3.2,75,,28.048,Percent of Total Billed charges,75% of Total Billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.07,72,,26.928,Percent of Total Billed Charges,72% of Total Billed Charges,2.56,60,,22.44,Percent of Total Billed Charges,60% of Total Billed Charges,3.84,90,,11.288,Percent of Total Billed Charges,90% of Total Billed Charges,1.92,45,,3.6,Percent of Total Billed Charges,45% of Total Billed Charges,3.84,90,,9.576,Percent of Total Billed Charges,90% of Total billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.78,65,,7.688,Percent of total Billed Charges,65% of Total Billed Charges,1.88,44.1,,3.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.06,95,,10.112,Percent of Total Billed Charges,95% of Total Billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.76,88,,9.36,Percent of Total Billed Charges,88% of Total Billed Charges,3.84,90,,9.576,Percent of Total Billed charges,90% of Total Billed Charges,1.88,4.27,
CATH THORACIC STRGH ARGYL 24FR,2720001762,CDM,272,RC,,,Outpatient,,,4.27,2.78,,4.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.25,76,,7.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.07,72,,26.928,Percent of Total Billed Charges,72% of Total Billed Charges,3.2,75,,28.048,Percent of Total Billed charges,75% of Total Billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.07,72,,26.928,Percent of Total Billed Charges,72% of Total Billed Charges,2.56,60,,22.44,Percent of Total Billed Charges,60% of Total Billed Charges,3.84,90,,1.568,Percent of Total Billed Charges,90% of Total Billed Charges,1.92,45,,1.6,Percent of Total Billed Charges,45% of Total Billed Charges,3.84,90,,8.496,Percent of Total Billed Charges,90% of Total billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.78,65,,5.2,Percent of total Billed Charges,65% of Total Billed Charges,1.88,44.1,,1.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.06,95,,8.968,Percent of Total Billed Charges,95% of Total Billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.76,88,,8.304,Percent of Total Billed Charges,88% of Total Billed Charges,3.84,90,,8.496,Percent of Total Billed charges,90% of Total Billed Charges,1.88,4.27,
CATH THORACIC STRGH ARGYL 32FR,2720001763,CDM,272,RC,,,Outpatient,,,4.27,2.78,,4.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.25,76,,8.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.07,72,,26.928,Percent of Total Billed Charges,72% of Total Billed Charges,3.2,75,,28.048,Percent of Total Billed charges,75% of Total Billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.07,72,,26.928,Percent of Total Billed Charges,72% of Total Billed Charges,2.56,60,,22.44,Percent of Total Billed Charges,60% of Total Billed Charges,3.84,90,,163.352,Percent of Total Billed Charges,90% of Total Billed Charges,1.92,45,,1.128,Percent of Total Billed Charges,45% of Total Billed Charges,3.84,90,,10.64,Percent of Total Billed Charges,90% of Total billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.78,65,,2.312,Percent of total Billed Charges,65% of Total Billed Charges,1.88,44.1,,1.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.06,95,,11.232,Percent of Total Billed Charges,95% of Total Billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.76,88,,10.408,Percent of Total Billed Charges,88% of Total Billed Charges,3.84,90,,10.64,Percent of Total Billed charges,90% of Total Billed Charges,1.88,4.27,
CATH THORACIC STRGH ARGYL 32FR,2720001764,CDM,272,RC,,,Outpatient,,,4.27,2.78,,4.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.25,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.07,72,,26.928,Percent of Total Billed Charges,72% of Total Billed Charges,3.2,75,,28.048,Percent of Total Billed charges,75% of Total Billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.07,72,,26.928,Percent of Total Billed Charges,72% of Total Billed Charges,2.56,60,,22.44,Percent of Total Billed Charges,60% of Total Billed Charges,3.84,90,,158.368,Percent of Total Billed Charges,90% of Total Billed Charges,1.92,45,,86.432,Percent of Total Billed Charges,45% of Total Billed Charges,3.84,90,,7.2,Percent of Total Billed Charges,90% of Total billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.78,65,,1.624,Percent of total Billed Charges,65% of Total Billed Charges,1.88,44.1,,84.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.06,95,,7.6,Percent of Total Billed Charges,95% of Total Billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.76,88,,7.04,Percent of Total Billed Charges,88% of Total Billed Charges,3.84,90,,7.2,Percent of Total Billed charges,90% of Total Billed Charges,1.88,4.27,
CATH THORACIC STRGH ARGYL 36FR,2720001765,CDM,272,RC,,,Outpatient,,,4.27,2.78,,4.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.25,76,,2.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.07,72,,26.928,Percent of Total Billed Charges,72% of Total Billed Charges,3.2,75,,28.048,Percent of Total Billed charges,75% of Total Billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.07,72,,26.928,Percent of Total Billed Charges,72% of Total Billed Charges,2.56,60,,22.44,Percent of Total Billed Charges,60% of Total Billed Charges,3.84,90,,153.144,Percent of Total Billed Charges,90% of Total Billed Charges,1.92,45,,13.232,Percent of Total Billed Charges,45% of Total Billed Charges,3.84,90,,3.208,Percent of Total Billed Charges,90% of Total billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.78,65,,124.84,Percent of total Billed Charges,65% of Total Billed Charges,1.88,44.1,,12.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.06,95,,3.384,Percent of Total Billed Charges,95% of Total Billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.76,88,,3.136,Percent of Total Billed Charges,88% of Total Billed Charges,3.84,90,,3.208,Percent of Total Billed charges,90% of Total Billed Charges,1.88,4.27,
NG TUBE 10FR,2720001766,CDM,272,RC,,,Outpatient,,,4.13,2.68,,4.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.14,76,,1.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.97,72,,5.04,Percent of Total Billed Charges,72% of Total Billed Charges,3.1,75,,5.248,Percent of Total Billed charges,75% of Total Billed Charges,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.97,72,,5.04,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,60,,4.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.72,90,,106.2,Percent of Total Billed Charges,90% of Total Billed Charges,1.86,45,,19.168,Percent of Total Billed Charges,45% of Total Billed Charges,3.72,90,,2.256,Percent of Total Billed Charges,90% of Total billed Charges,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.68,65,,19.112,Percent of total Billed Charges,65% of Total Billed Charges,1.82,44.1,,18.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.92,95,,2.376,Percent of Total Billed Charges,95% of Total Billed Charges,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.63,88,,2.2,Percent of Total Billed Charges,88% of Total Billed Charges,3.72,90,,2.256,Percent of Total Billed charges,90% of Total Billed Charges,1.82,4.13,
NASOPHARYNEAL AIRWAY SIZE 28,2720001767,CDM,272,RC,,,Outpatient,,,3.10,2.02,,3.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.36,76,,145.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.23,72,,26.928,Percent of Total Billed Charges,72% of Total Billed Charges,2.33,75,,28.048,Percent of Total Billed charges,75% of Total Billed Charges,3.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.23,72,,26.928,Percent of Total Billed Charges,72% of Total Billed Charges,1.86,60,,22.44,Percent of Total Billed Charges,60% of Total Billed Charges,2.79,90,,153,Percent of Total Billed Charges,90% of Total Billed Charges,1.4,45,,5.52,Percent of Total Billed Charges,45% of Total Billed Charges,2.79,90,,172.856,Percent of Total Billed Charges,90% of Total billed Charges,3.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.02,65,,27.688,Percent of total Billed Charges,65% of Total Billed Charges,1.37,44.1,,5.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.95,95,,182.464,Percent of Total Billed Charges,95% of Total Billed Charges,3.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.73,88,,169.016,Percent of Total Billed Charges,88% of Total Billed Charges,2.79,90,,172.856,Percent of Total Billed charges,90% of Total Billed Charges,1.37,3.1,
NASOPHARYNGEAL AIRWAY SZ34,2720001768,CDM,272,RC,,,Outpatient,,,2.79,1.81,,2.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.12,76,,22.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.01,72,,14.36,Percent of Total Billed Charges,72% of Total Billed Charges,2.09,75,,14.96,Percent of Total Billed charges,75% of Total Billed Charges,2.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.01,72,,14.36,Percent of Total Billed Charges,72% of Total Billed Charges,1.67,60,,11.968,Percent of Total Billed Charges,60% of Total Billed Charges,2.51,90,,153,Percent of Total Billed Charges,90% of Total Billed Charges,1.26,45,,5.648,Percent of Total Billed Charges,45% of Total Billed Charges,2.51,90,,26.464,Percent of Total Billed Charges,90% of Total billed Charges,2.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.81,65,,7.968,Percent of total Billed Charges,65% of Total Billed Charges,1.23,44.1,,5.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.65,95,,27.928,Percent of Total Billed Charges,95% of Total Billed Charges,2.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.46,88,,25.872,Percent of Total Billed Charges,88% of Total Billed Charges,2.51,90,,26.464,Percent of Total Billed charges,90% of Total Billed Charges,1.23,2.79,
LARYNGOSCOPE BLADE MILLER SZ0,2720001769,CDM,272,RC,,,Outpatient,,,4.67,3.04,,4.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.55,76,,32.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.36,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,3.5,75,,9,Percent of Total Billed charges,75% of Total Billed Charges,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.36,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,2.8,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,4.2,90,,34.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.1,45,,0.784,Percent of Total Billed Charges,45% of Total Billed Charges,4.2,90,,38.344,Percent of Total Billed Charges,90% of Total billed Charges,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.04,65,,8.152,Percent of total Billed Charges,65% of Total Billed Charges,2.06,44.1,,0.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.44,95,,40.472,Percent of Total Billed Charges,95% of Total Billed Charges,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.11,88,,37.488,Percent of Total Billed Charges,88% of Total Billed Charges,4.2,90,,38.344,Percent of Total Billed charges,90% of Total Billed Charges,2.06,4.67,
LARYNGOSCOPE BLADE MILLER SZ1,2720001770,CDM,272,RC,,,Outpatient,,,4.67,3.04,,4.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.55,76,,9.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.36,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,3.5,75,,9,Percent of Total Billed charges,75% of Total Billed Charges,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.36,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,2.8,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,4.2,90,,288,Percent of Total Billed Charges,90% of Total Billed Charges,2.1,45,,81.68,Percent of Total Billed Charges,45% of Total Billed Charges,4.2,90,,11.04,Percent of Total Billed Charges,90% of Total billed Charges,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.04,65,,1.136,Percent of total Billed Charges,65% of Total Billed Charges,2.06,44.1,,80.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.44,95,,11.648,Percent of Total Billed Charges,95% of Total Billed Charges,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.11,88,,10.792,Percent of Total Billed Charges,88% of Total Billed Charges,4.2,90,,11.04,Percent of Total Billed charges,90% of Total Billed Charges,2.06,4.67,
LARYGNOSCOPE BLADE MILLER SZ4,2720001771,CDM,272,RC,,,Outpatient,,,4.67,3.04,,4.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.55,76,,9.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.36,72,,13.68,Percent of Total Billed Charges,72% of Total Billed Charges,3.5,75,,14.248,Percent of Total Billed charges,75% of Total Billed Charges,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.36,72,,13.68,Percent of Total Billed Charges,72% of Total Billed Charges,2.8,60,,11.4,Percent of Total Billed Charges,60% of Total Billed Charges,4.2,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.1,45,,79.184,Percent of Total Billed Charges,45% of Total Billed Charges,4.2,90,,11.288,Percent of Total Billed Charges,90% of Total billed Charges,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.04,65,,117.976,Percent of total Billed Charges,65% of Total Billed Charges,2.06,44.1,,77.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.44,95,,11.92,Percent of Total Billed Charges,95% of Total Billed Charges,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.11,88,,11.04,Percent of Total Billed Charges,88% of Total Billed Charges,4.2,90,,11.288,Percent of Total Billed charges,90% of Total Billed Charges,2.06,4.67,
SUTURE CTD VICRYL 5 0RB 1J303H,2720001772,CDM,272,RC,,,Outpatient,,,1.29,0.84,,1.29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.98,76,,1.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.93,72,,93.6,Percent of Total Billed Charges,72% of Total Billed Charges,0.97,75,,97.504,Percent of Total Billed charges,75% of Total Billed Charges,1.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.93,72,,93.6,Percent of Total Billed Charges,72% of Total Billed Charges,0.77,60,,78,Percent of Total Billed Charges,60% of Total Billed Charges,1.16,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.58,45,,76.576,Percent of Total Billed Charges,45% of Total Billed Charges,1.16,90,,1.568,Percent of Total Billed Charges,90% of Total billed Charges,1.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.84,65,,114.376,Percent of total Billed Charges,65% of Total Billed Charges,0.57,44.1,,75.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.23,95,,1.656,Percent of Total Billed Charges,95% of Total Billed Charges,1.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.14,88,,1.536,Percent of Total Billed Charges,88% of Total Billed Charges,1.16,90,,1.568,Percent of Total Billed charges,90% of Total Billed Charges,0.57,1.29,
SUT CTD VCRSL 5 0 UND BR J495G,2720001773,CDM,272,RC,,,Outpatient,,,3.15,2.05,,3.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.39,76,,137.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.27,72,,0.464,Percent of Total Billed Charges,72% of Total Billed Charges,2.36,75,,0.48,Percent of Total Billed charges,75% of Total Billed Charges,3.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.27,72,,0.464,Percent of Total Billed Charges,72% of Total Billed Charges,1.89,60,,0.384,Percent of Total Billed Charges,60% of Total Billed Charges,2.84,90,,140.312,Percent of Total Billed Charges,90% of Total Billed Charges,1.42,45,,53.104,Percent of Total Billed Charges,45% of Total Billed Charges,2.84,90,,163.352,Percent of Total Billed Charges,90% of Total billed Charges,3.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.05,65,,110.608,Percent of total Billed Charges,65% of Total Billed Charges,1.39,44.1,,52.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.99,95,,172.432,Percent of Total Billed Charges,95% of Total Billed Charges,3.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.77,88,,159.72,Percent of Total Billed Charges,88% of Total Billed Charges,2.84,90,,163.352,Percent of Total Billed charges,90% of Total Billed Charges,1.39,3.15,
SUT ETHLN 2 0 BLK MONO PS 593H,2720001774,CDM,272,RC,,,Outpatient,,,2.51,1.63,,2.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.91,76,,133.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.81,72,,0.52,Percent of Total Billed Charges,72% of Total Billed Charges,1.88,75,,0.544,Percent of Total Billed charges,75% of Total Billed Charges,2.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.81,72,,0.52,Percent of Total Billed Charges,72% of Total Billed Charges,1.51,60,,0.432,Percent of Total Billed Charges,60% of Total Billed Charges,2.26,90,,133.656,Percent of Total Billed Charges,90% of Total Billed Charges,1.13,45,,76.504,Percent of Total Billed Charges,45% of Total Billed Charges,2.26,90,,158.368,Percent of Total Billed Charges,90% of Total billed Charges,2.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.63,65,,76.704,Percent of total Billed Charges,65% of Total Billed Charges,1.11,44.1,,74.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.38,95,,167.16,Percent of Total Billed Charges,95% of Total Billed Charges,2.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,88,,154.848,Percent of Total Billed Charges,88% of Total Billed Charges,2.26,90,,158.368,Percent of Total Billed charges,90% of Total Billed Charges,1.11,2.51,
SUTURE PLN GT 5 0 P3 18 686G,2720001775,CDM,272,RC,,,Outpatient,,,1.52,0.99,,1.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.16,76,,129.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.09,72,,0.464,Percent of Total Billed Charges,72% of Total Billed Charges,1.14,75,,0.48,Percent of Total Billed charges,75% of Total Billed Charges,1.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.09,72,,0.464,Percent of Total Billed Charges,72% of Total Billed Charges,0.91,60,,0.384,Percent of Total Billed Charges,60% of Total Billed Charges,1.37,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.68,45,,76.504,Percent of Total Billed Charges,45% of Total Billed Charges,1.37,90,,153.144,Percent of Total Billed Charges,90% of Total billed Charges,1.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.99,65,,110.504,Percent of total Billed Charges,65% of Total Billed Charges,0.67,44.1,,74.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.44,95,,161.656,Percent of Total Billed Charges,95% of Total Billed Charges,1.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.34,88,,149.744,Percent of Total Billed Charges,88% of Total Billed Charges,1.37,90,,153.144,Percent of Total Billed charges,90% of Total Billed Charges,0.67,1.52,
SUTURE ETHI 5 0 BLK MONO 698H,2720001776,CDM,272,RC,,,Outpatient,,,2.31,1.50,,2.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.76,76,,89.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.66,72,,0.464,Percent of Total Billed Charges,72% of Total Billed Charges,1.73,75,,0.48,Percent of Total Billed charges,75% of Total Billed Charges,2.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.66,72,,0.464,Percent of Total Billed Charges,72% of Total Billed Charges,1.39,60,,0.384,Percent of Total Billed Charges,60% of Total Billed Charges,2.08,90,,12.84,Percent of Total Billed Charges,90% of Total Billed Charges,1.04,45,,17.104,Percent of Total Billed Charges,45% of Total Billed Charges,2.08,90,,106.2,Percent of Total Billed Charges,90% of Total billed Charges,2.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.5,65,,110.504,Percent of total Billed Charges,65% of Total Billed Charges,1.02,44.1,,16.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.19,95,,112.104,Percent of Total Billed Charges,95% of Total Billed Charges,2.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.03,88,,103.84,Percent of Total Billed Charges,88% of Total Billed Charges,2.08,90,,106.2,Percent of Total Billed charges,90% of Total Billed Charges,1.02,2.31,
SUT ETHLN 4.0 BLK MON 699H P3,2720001777,CDM,272,RC,,,Outpatient,,,2.59,1.68,,2.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.97,76,,129.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.86,72,,32.656,Percent of Total Billed Charges,72% of Total Billed Charges,1.94,75,,34.024,Percent of Total Billed charges,75% of Total Billed Charges,2.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.86,72,,32.656,Percent of Total Billed Charges,72% of Total Billed Charges,1.55,60,,27.216,Percent of Total Billed Charges,60% of Total Billed Charges,2.33,90,,5.384,Percent of Total Billed Charges,90% of Total Billed Charges,1.17,45,,144,Percent of Total Billed Charges,45% of Total Billed Charges,2.33,90,,153,Percent of Total Billed Charges,90% of Total billed Charges,2.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.68,65,,24.704,Percent of total Billed Charges,65% of Total Billed Charges,1.14,44.1,,141.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.46,95,,161.504,Percent of Total Billed Charges,95% of Total Billed Charges,2.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.28,88,,149.6,Percent of Total Billed Charges,88% of Total Billed Charges,2.33,90,,153,Percent of Total Billed charges,90% of Total Billed Charges,1.14,2.59,
MELKER4.0 CUFF CRICO CATH SET,2720001778,CDM,272,RC,,,Outpatient,,,255.00,165.75,,255,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,193.8,76,,129.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,183.6,72,,33.312,Percent of Total Billed Charges,72% of Total Billed Charges,191.25,75,,34.696,Percent of Total Billed charges,75% of Total Billed Charges,255,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.6,72,,33.312,Percent of Total Billed Charges,72% of Total Billed Charges,153,60,,27.76,Percent of Total Billed Charges,60% of Total Billed Charges,229.5,90,,378,Percent of Total Billed Charges,90% of Total Billed Charges,114.75,45,,10.8,Percent of Total Billed Charges,45% of Total Billed Charges,229.5,90,,153,Percent of Total Billed Charges,90% of Total billed Charges,255,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.75,65,,208,Percent of total Billed Charges,65% of Total Billed Charges,112.46,44.1,,10.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,242.25,95,,161.504,Percent of Total Billed Charges,95% of Total Billed Charges,255,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.4,88,,149.6,Percent of Total Billed Charges,88% of Total Billed Charges,229.5,90,,153,Percent of Total Billed charges,90% of Total Billed Charges,112.46,255,
SUTURE PROLENE 5 0PC 5 8630G,2720001779,CDM,272,RC,,,Outpatient,,,4.26,2.77,,4.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.24,76,,28.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.07,72,,33.312,Percent of Total Billed Charges,72% of Total Billed Charges,3.2,75,,34.696,Percent of Total Billed charges,75% of Total Billed Charges,4.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.07,72,,33.312,Percent of Total Billed Charges,72% of Total Billed Charges,2.56,60,,27.76,Percent of Total Billed Charges,60% of Total Billed Charges,3.83,90,,967.488,Percent of Total Billed Charges,90% of Total Billed Charges,1.92,45,,10.8,Percent of Total Billed Charges,45% of Total Billed Charges,3.83,90,,34.2,Percent of Total Billed Charges,90% of Total billed Charges,4.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.77,65,,15.6,Percent of total Billed Charges,65% of Total Billed Charges,1.88,44.1,,10.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.05,95,,36.104,Percent of Total Billed Charges,95% of Total Billed Charges,4.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.75,88,,33.44,Percent of Total Billed Charges,88% of Total Billed Charges,3.83,90,,34.2,Percent of Total Billed charges,90% of Total Billed Charges,1.88,4.26,
SUT PROL 3 0 PS 1 MONO 8663G,2720001780,CDM,272,RC,,,Outpatient,,,3.64,2.37,,3.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.77,76,,243.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.62,72,,32.656,Percent of Total Billed Charges,72% of Total Billed Charges,2.73,75,,34.024,Percent of Total Billed charges,75% of Total Billed Charges,3.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.62,72,,32.656,Percent of Total Billed Charges,72% of Total Billed Charges,2.18,60,,27.216,Percent of Total Billed Charges,60% of Total Billed Charges,3.28,90,,967.488,Percent of Total Billed Charges,90% of Total Billed Charges,1.64,45,,70.16,Percent of Total Billed Charges,45% of Total Billed Charges,3.28,90,,288,Percent of Total Billed Charges,90% of Total billed Charges,3.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.37,65,,15.6,Percent of total Billed Charges,65% of Total Billed Charges,1.61,44.1,,68.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.46,95,,304,Percent of Total Billed Charges,95% of Total Billed Charges,3.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.2,88,,281.6,Percent of Total Billed Charges,88% of Total Billed Charges,3.28,90,,288,Percent of Total Billed charges,90% of Total Billed Charges,1.61,3.64,
SUTRE PROL 6 0P 3 BL MONO8695G,2720001781,CDM,272,RC,,,Outpatient,,,4.03,2.62,,4.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.06,76,,18.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.9,72,,293.872,Percent of Total Billed Charges,72% of Total Billed Charges,3.02,75,,306.12,Percent of Total Billed charges,75% of Total Billed Charges,4.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.9,72,,293.872,Percent of Total Billed Charges,72% of Total Billed Charges,2.42,60,,244.896,Percent of Total Billed Charges,60% of Total Billed Charges,3.63,90,,7.456,Percent of Total Billed Charges,90% of Total Billed Charges,1.81,45,,66.824,Percent of Total Billed Charges,45% of Total Billed Charges,3.63,90,,21.6,Percent of Total Billed Charges,90% of Total billed Charges,4.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.62,65,,101.336,Percent of total Billed Charges,65% of Total Billed Charges,1.78,44.1,,65.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.83,95,,22.8,Percent of Total Billed Charges,95% of Total Billed Charges,4.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.55,88,,21.12,Percent of Total Billed Charges,88% of Total Billed Charges,3.63,90,,21.6,Percent of Total Billed charges,90% of Total Billed Charges,1.78,4.03,
SUTRE PROLENE 5 0 18 P 3 8698G,2720001782,CDM,272,RC,,,Outpatient,,,3.87,2.52,,3.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.94,76,,18.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.79,72,,9.12,Percent of Total Billed Charges,72% of Total Billed Charges,2.9,75,,9.496,Percent of Total Billed charges,75% of Total Billed Charges,3.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.79,72,,9.12,Percent of Total Billed Charges,72% of Total Billed Charges,2.32,60,,7.6,Percent of Total Billed Charges,60% of Total Billed Charges,3.48,90,,7.904,Percent of Total Billed Charges,90% of Total Billed Charges,1.74,45,,10.8,Percent of Total Billed Charges,45% of Total Billed Charges,3.48,90,,21.6,Percent of Total Billed Charges,90% of Total billed Charges,3.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.52,65,,96.528,Percent of total Billed Charges,65% of Total Billed Charges,1.71,44.1,,10.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.68,95,,22.8,Percent of Total Billed Charges,95% of Total Billed Charges,3.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.41,88,,21.12,Percent of Total Billed Charges,88% of Total Billed Charges,3.48,90,,21.6,Percent of Total Billed charges,90% of Total Billed Charges,1.71,3.87,
SUTRE PROLENE 4 0 18 P 3 8699G,2720001783,CDM,272,RC,,,Outpatient,,,3.74,2.43,,3.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.84,76,,118.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.69,72,,9.12,Percent of Total Billed Charges,72% of Total Billed Charges,2.81,75,,9.496,Percent of Total Billed charges,75% of Total Billed Charges,3.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.69,72,,9.12,Percent of Total Billed Charges,72% of Total Billed Charges,2.24,60,,7.6,Percent of Total Billed Charges,60% of Total Billed Charges,3.37,90,,14.008,Percent of Total Billed Charges,90% of Total Billed Charges,1.68,45,,6.416,Percent of Total Billed Charges,45% of Total Billed Charges,3.37,90,,140.312,Percent of Total Billed Charges,90% of Total billed Charges,3.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.43,65,,15.6,Percent of total Billed Charges,65% of Total Billed Charges,1.65,44.1,,6.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.55,95,,148.112,Percent of Total Billed Charges,95% of Total Billed Charges,3.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.29,88,,137.192,Percent of Total Billed Charges,88% of Total Billed Charges,3.37,90,,140.312,Percent of Total Billed charges,90% of Total Billed Charges,1.65,3.74,
SUTURE VICRYL 4-0 J823G,2720001784,CDM,272,RC,,,Outpatient,,,3.42,2.22,,3.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.6,76,,112.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.46,72,,9.12,Percent of Total Billed Charges,72% of Total Billed Charges,2.57,75,,9.496,Percent of Total Billed charges,75% of Total Billed Charges,3.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.46,72,,9.12,Percent of Total Billed Charges,72% of Total Billed Charges,2.05,60,,7.6,Percent of Total Billed Charges,60% of Total Billed Charges,3.08,90,,27.384,Percent of Total Billed Charges,90% of Total Billed Charges,1.54,45,,2.696,Percent of Total Billed Charges,45% of Total Billed Charges,3.08,90,,133.656,Percent of Total Billed Charges,90% of Total billed Charges,3.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.22,65,,9.272,Percent of total Billed Charges,65% of Total Billed Charges,1.51,44.1,,2.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.25,95,,141.08,Percent of Total Billed Charges,95% of Total Billed Charges,3.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.01,88,,130.68,Percent of Total Billed Charges,88% of Total Billed Charges,3.08,90,,133.656,Percent of Total Billed charges,90% of Total Billed Charges,1.51,3.42,
SUTURE VICRYL 5-0 J822G,2720001785,CDM,272,RC,,,Outpatient,,,3.45,2.24,,3.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.62,76,,18.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.48,72,,17.312,Percent of Total Billed Charges,72% of Total Billed Charges,2.59,75,,18.032,Percent of Total Billed charges,75% of Total Billed Charges,3.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.48,72,,17.312,Percent of Total Billed Charges,72% of Total Billed Charges,2.07,60,,14.424,Percent of Total Billed Charges,60% of Total Billed Charges,3.11,90,,2.448,Percent of Total Billed Charges,90% of Total Billed Charges,1.55,45,,189,Percent of Total Billed Charges,45% of Total Billed Charges,3.11,90,,21.6,Percent of Total Billed Charges,90% of Total billed Charges,3.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.24,65,,3.888,Percent of total Billed Charges,65% of Total Billed Charges,1.52,44.1,,185.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.28,95,,22.8,Percent of Total Billed Charges,95% of Total Billed Charges,3.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.04,88,,21.12,Percent of Total Billed Charges,88% of Total Billed Charges,3.11,90,,21.6,Percent of Total Billed charges,90% of Total Billed Charges,1.52,3.45,
SUTURE VCRYL 6-0 J843G,2720001786,CDM,272,RC,,,Outpatient,,,3.49,2.27,,3.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.65,76,,10.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.51,72,,17.616,Percent of Total Billed Charges,72% of Total Billed Charges,2.62,75,,18.352,Percent of Total Billed charges,75% of Total Billed Charges,3.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.51,72,,17.616,Percent of Total Billed Charges,72% of Total Billed Charges,2.09,60,,14.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.14,90,,23.856,Percent of Total Billed Charges,90% of Total Billed Charges,1.57,45,,483.744,Percent of Total Billed Charges,45% of Total Billed Charges,3.14,90,,12.84,Percent of Total Billed Charges,90% of Total billed Charges,3.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.27,65,,273,Percent of total Billed Charges,65% of Total Billed Charges,1.54,44.1,,474.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.32,95,,13.552,Percent of Total Billed Charges,95% of Total Billed Charges,3.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.07,88,,12.552,Percent of Total Billed Charges,88% of Total Billed Charges,3.14,90,,12.84,Percent of Total Billed charges,90% of Total Billed Charges,1.54,3.49,
SUTURE VICRYL RAPIDE VR845,2720001787,CDM,272,RC,,,Outpatient,,,3.64,2.37,,3.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.77,76,,4.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.62,72,,13.872,Percent of Total Billed Charges,72% of Total Billed Charges,2.73,75,,14.448,Percent of Total Billed charges,75% of Total Billed Charges,3.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.62,72,,13.872,Percent of Total Billed Charges,72% of Total Billed Charges,2.18,60,,11.56,Percent of Total Billed Charges,60% of Total Billed Charges,3.28,90,,10.408,Percent of Total Billed Charges,90% of Total Billed Charges,1.64,45,,483.744,Percent of Total Billed Charges,45% of Total Billed Charges,3.28,90,,5.384,Percent of Total Billed Charges,90% of Total billed Charges,3.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.37,65,,698.736,Percent of total Billed Charges,65% of Total Billed Charges,1.61,44.1,,474.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.46,95,,5.688,Percent of Total Billed Charges,95% of Total Billed Charges,3.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.2,88,,5.264,Percent of Total Billed Charges,88% of Total Billed Charges,3.28,90,,5.384,Percent of Total Billed charges,90% of Total Billed Charges,1.61,3.64,
SUTURE VICRYL RAPIDE VR844,2720001788,CDM,272,RC,,,Outpatient,,,4.72,3.07,,4.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.59,76,,319.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.4,72,,17.336,Percent of Total Billed Charges,72% of Total Billed Charges,3.54,75,,18.064,Percent of Total Billed charges,75% of Total Billed Charges,4.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.4,72,,17.336,Percent of Total Billed Charges,72% of Total Billed Charges,2.83,60,,14.448,Percent of Total Billed Charges,60% of Total Billed Charges,4.25,90,,10.408,Percent of Total Billed Charges,90% of Total Billed Charges,2.12,45,,3.728,Percent of Total Billed Charges,45% of Total Billed Charges,4.25,90,,378,Percent of Total Billed Charges,90% of Total billed Charges,4.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.07,65,,698.736,Percent of total Billed Charges,65% of Total Billed Charges,2.08,44.1,,3.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.48,95,,399,Percent of Total Billed Charges,95% of Total Billed Charges,4.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.15,88,,369.6,Percent of Total Billed Charges,88% of Total Billed Charges,4.25,90,,378,Percent of Total Billed charges,90% of Total Billed Charges,2.08,4.72,
SUTURE ETHILON BLK MONOFI 3 0,2720001789,CDM,272,RC,,,Outpatient,,,2.79,1.81,,2.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.12,76,,816.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.01,72,,7.968,Percent of Total Billed Charges,72% of Total Billed Charges,2.09,75,,8.296,Percent of Total Billed charges,75% of Total Billed Charges,2.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.01,72,,7.968,Percent of Total Billed Charges,72% of Total Billed Charges,1.67,60,,6.64,Percent of Total Billed Charges,60% of Total Billed Charges,2.51,90,,0.976,Percent of Total Billed Charges,90% of Total Billed Charges,1.26,45,,3.952,Percent of Total Billed Charges,45% of Total Billed Charges,2.51,90,,967.488,Percent of Total Billed Charges,90% of Total billed Charges,2.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.81,65,,5.384,Percent of total Billed Charges,65% of Total Billed Charges,1.23,44.1,,3.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.65,95,,1021.232,Percent of Total Billed Charges,95% of Total Billed Charges,2.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.46,88,,945.984,Percent of Total Billed Charges,88% of Total Billed Charges,2.51,90,,967.488,Percent of Total Billed charges,90% of Total Billed Charges,1.23,2.79,
SUTURE ETHILO BLK MONOFIL 5 0,2720001790,CDM,272,RC,,,Outpatient,,,2.83,1.84,,2.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.15,76,,816.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.04,72,,1.76,Percent of Total Billed Charges,72% of Total Billed Charges,2.12,75,,1.832,Percent of Total Billed charges,75% of Total Billed Charges,2.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.04,72,,1.76,Percent of Total Billed Charges,72% of Total Billed Charges,1.7,60,,1.464,Percent of Total Billed Charges,60% of Total Billed Charges,2.55,90,,3.912,Percent of Total Billed Charges,90% of Total Billed Charges,1.27,45,,7,Percent of Total Billed Charges,45% of Total Billed Charges,2.55,90,,967.488,Percent of Total Billed Charges,90% of Total billed Charges,2.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.84,65,,5.712,Percent of total Billed Charges,65% of Total Billed Charges,1.25,44.1,,6.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.69,95,,1021.232,Percent of Total Billed Charges,95% of Total Billed Charges,2.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.49,88,,945.984,Percent of Total Billed Charges,88% of Total Billed Charges,2.55,90,,967.488,Percent of Total Billed charges,90% of Total Billed Charges,1.25,2.83,
SUTURE ETHILON BLK MONO 6 0,2720001791,CDM,272,RC,,,Outpatient,,,2.87,1.87,,2.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.18,76,,6.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.07,72,,1.728,Percent of Total Billed Charges,72% of Total Billed Charges,2.15,75,,1.8,Percent of Total Billed charges,75% of Total Billed Charges,2.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.07,72,,1.728,Percent of Total Billed Charges,72% of Total Billed Charges,1.72,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,2.58,90,,0.328,Percent of Total Billed Charges,90% of Total Billed Charges,1.29,45,,13.688,Percent of Total Billed Charges,45% of Total Billed Charges,2.58,90,,7.456,Percent of Total Billed Charges,90% of Total billed Charges,2.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.87,65,,10.112,Percent of total Billed Charges,65% of Total Billed Charges,1.27,44.1,,13.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.73,95,,7.864,Percent of Total Billed Charges,95% of Total Billed Charges,2.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.53,88,,7.288,Percent of Total Billed Charges,88% of Total Billed Charges,2.58,90,,7.456,Percent of Total Billed charges,90% of Total Billed Charges,1.27,2.87,
SUTURE PROLENE 4 0 8613G,2720001792,CDM,272,RC,,,Outpatient,,,18.68,12.14,,18.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.2,76,,6.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.45,72,,6.016,Percent of Total Billed Charges,72% of Total Billed Charges,14.01,75,,6.272,Percent of Total Billed charges,75% of Total Billed Charges,18.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.45,72,,6.016,Percent of Total Billed Charges,72% of Total Billed Charges,11.21,60,,5.016,Percent of Total Billed Charges,60% of Total Billed Charges,16.81,90,,22.056,Percent of Total Billed Charges,90% of Total Billed Charges,8.41,45,,1.224,Percent of Total Billed Charges,45% of Total Billed Charges,16.81,90,,7.904,Percent of Total Billed Charges,90% of Total billed Charges,18.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.14,65,,19.776,Percent of total Billed Charges,65% of Total Billed Charges,8.24,44.1,,1.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.75,95,,8.344,Percent of Total Billed Charges,95% of Total Billed Charges,18.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.44,88,,7.728,Percent of Total Billed Charges,88% of Total Billed Charges,16.81,90,,7.904,Percent of Total Billed charges,90% of Total Billed Charges,8.24,18.68,
SUTURE CHROMIC 3 0 1638H,2720001793,CDM,272,RC,,,Outpatient,,,4.73,3.07,,4.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.59,76,,11.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.41,72,,11.136,Percent of Total Billed Charges,72% of Total Billed Charges,3.55,75,,11.6,Percent of Total Billed charges,75% of Total Billed Charges,4.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.41,72,,11.136,Percent of Total Billed Charges,72% of Total Billed Charges,2.84,60,,9.28,Percent of Total Billed Charges,60% of Total Billed Charges,4.26,90,,20.976,Percent of Total Billed Charges,90% of Total Billed Charges,2.13,45,,11.928,Percent of Total Billed Charges,45% of Total Billed Charges,4.26,90,,14.008,Percent of Total Billed Charges,90% of Total billed Charges,4.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.07,65,,1.768,Percent of total Billed Charges,65% of Total Billed Charges,2.09,44.1,,11.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.49,95,,14.784,Percent of Total Billed Charges,95% of Total Billed Charges,4.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.16,88,,13.696,Percent of Total Billed Charges,88% of Total Billed Charges,4.26,90,,14.008,Percent of Total Billed charges,90% of Total Billed Charges,2.09,4.73,
SUTURE CHROMIC GUT 4 0 1637G,2720001794,CDM,272,RC,,,Outpatient,,,4.73,3.07,,4.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.59,76,,23.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.41,72,,11.264,Percent of Total Billed Charges,72% of Total Billed Charges,3.55,75,,11.728,Percent of Total Billed charges,75% of Total Billed Charges,4.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.41,72,,11.264,Percent of Total Billed Charges,72% of Total Billed Charges,2.84,60,,9.384,Percent of Total Billed Charges,60% of Total Billed Charges,4.26,90,,122.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.13,45,,5.2,Percent of Total Billed Charges,45% of Total Billed Charges,4.26,90,,27.384,Percent of Total Billed Charges,90% of Total billed Charges,4.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.07,65,,17.224,Percent of total Billed Charges,65% of Total Billed Charges,2.09,44.1,,5.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.49,95,,28.904,Percent of Total Billed Charges,95% of Total Billed Charges,4.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.16,88,,26.776,Percent of Total Billed Charges,88% of Total Billed Charges,4.26,90,,27.384,Percent of Total Billed charges,90% of Total Billed Charges,2.09,4.73,
SUTURE CHROMIC GUT 5 0 634G,2720001795,CDM,272,RC,,,Outpatient,,,2.44,1.59,,2.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.85,76,,2.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.76,72,,3.128,Percent of Total Billed Charges,72% of Total Billed Charges,1.83,75,,3.256,Percent of Total Billed charges,75% of Total Billed Charges,2.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.76,72,,3.128,Percent of Total Billed Charges,72% of Total Billed Charges,1.46,60,,2.608,Percent of Total Billed Charges,60% of Total Billed Charges,2.2,90,,36.632,Percent of Total Billed Charges,90% of Total Billed Charges,1.1,45,,5.2,Percent of Total Billed Charges,45% of Total Billed Charges,2.2,90,,2.448,Percent of Total Billed Charges,90% of Total billed Charges,2.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,65,,7.512,Percent of total Billed Charges,65% of Total Billed Charges,1.08,44.1,,5.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.32,95,,2.584,Percent of Total Billed Charges,95% of Total Billed Charges,2.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,88,,2.392,Percent of Total Billed Charges,88% of Total Billed Charges,2.2,90,,2.448,Percent of Total Billed charges,90% of Total Billed Charges,1.08,2.44,
SUTURE CHROMIC GUT 6 0 1635G,2720001796,CDM,272,RC,,,Outpatient,,,4.75,3.09,,4.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.61,76,,20.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.42,72,,2.872,Percent of Total Billed Charges,72% of Total Billed Charges,3.56,75,,2.992,Percent of Total Billed charges,75% of Total Billed Charges,4.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.42,72,,2.872,Percent of Total Billed Charges,72% of Total Billed Charges,2.85,60,,2.392,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,90,,5.352,Percent of Total Billed Charges,90% of Total Billed Charges,2.14,45,,0.488,Percent of Total Billed Charges,45% of Total Billed Charges,4.28,90,,23.856,Percent of Total Billed Charges,90% of Total billed Charges,4.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.09,65,,7.512,Percent of total Billed Charges,65% of Total Billed Charges,2.09,44.1,,0.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.51,95,,25.176,Percent of Total Billed Charges,95% of Total Billed Charges,4.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.18,88,,23.32,Percent of Total Billed Charges,88% of Total Billed Charges,4.28,90,,23.856,Percent of Total Billed charges,90% of Total Billed Charges,2.09,4.75,
NCGRATG NAC BKADE SZ 1,2720001797,CDM,272,RC,,,Outpatient,,,10.34,6.72,,10.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.86,76,,8.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.44,72,,2.912,Percent of Total Billed Charges,72% of Total Billed Charges,7.76,75,,3.032,Percent of Total Billed charges,75% of Total Billed Charges,10.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.44,72,,2.912,Percent of Total Billed Charges,72% of Total Billed Charges,6.2,60,,2.424,Percent of Total Billed Charges,60% of Total Billed Charges,9.31,90,,4.432,Percent of Total Billed Charges,90% of Total Billed Charges,4.65,45,,1.952,Percent of Total Billed Charges,45% of Total Billed Charges,9.31,90,,10.408,Percent of Total Billed Charges,90% of Total billed Charges,10.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.72,65,,0.704,Percent of total Billed Charges,65% of Total Billed Charges,4.56,44.1,,1.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.82,95,,10.984,Percent of Total Billed Charges,95% of Total Billed Charges,10.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.1,88,,10.176,Percent of Total Billed Charges,88% of Total Billed Charges,9.31,90,,10.408,Percent of Total Billed charges,90% of Total Billed Charges,4.56,10.34,
MCGRATH MAC BLADE SZ 2,2720001798,CDM,272,RC,,,Outpatient,,,10.34,6.72,,10.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.86,76,,8.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.44,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,7.76,75,,3,Percent of Total Billed charges,75% of Total Billed Charges,10.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.44,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,6.2,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,9.31,90,,2.448,Percent of Total Billed Charges,90% of Total Billed Charges,4.65,45,,0.16,Percent of Total Billed Charges,45% of Total Billed Charges,9.31,90,,10.408,Percent of Total Billed Charges,90% of Total billed Charges,10.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.72,65,,2.824,Percent of total Billed Charges,65% of Total Billed Charges,4.56,44.1,,0.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.82,95,,10.984,Percent of Total Billed Charges,95% of Total Billed Charges,10.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.1,88,,10.176,Percent of Total Billed Charges,88% of Total Billed Charges,9.31,90,,10.408,Percent of Total Billed charges,90% of Total Billed Charges,4.56,10.34,
CATH THORACIC STRGH ARGYL 28FR,2720001799,CDM,272,RC,,,Outpatient,,,4.27,2.78,,4.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.25,76,,0.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.07,72,,6.152,Percent of Total Billed Charges,72% of Total Billed Charges,3.2,75,,6.408,Percent of Total Billed charges,75% of Total Billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.07,72,,6.152,Percent of Total Billed Charges,72% of Total Billed Charges,2.56,60,,5.128,Percent of Total Billed Charges,60% of Total Billed Charges,3.84,90,,2.992,Percent of Total Billed Charges,90% of Total Billed Charges,1.92,45,,11.024,Percent of Total Billed Charges,45% of Total Billed Charges,3.84,90,,0.976,Percent of Total Billed Charges,90% of Total billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.78,65,,0.232,Percent of total Billed Charges,65% of Total Billed Charges,1.88,44.1,,10.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.06,95,,1.024,Percent of Total Billed Charges,95% of Total Billed Charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.76,88,,0.952,Percent of Total Billed Charges,88% of Total Billed Charges,3.84,90,,0.976,Percent of Total Billed charges,90% of Total Billed Charges,1.88,4.27,
"Suture, Prolene 2-0 D9207",2720001800,CDM,272,RC,,,Outpatient,,,38.99,25.34,,38.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.63,76,,3.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.07,72,,14.328,Percent of Total Billed Charges,72% of Total Billed Charges,29.24,75,,14.928,Percent of Total Billed charges,75% of Total Billed Charges,38.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.07,72,,14.328,Percent of Total Billed Charges,72% of Total Billed Charges,23.39,60,,11.944,Percent of Total Billed Charges,60% of Total Billed Charges,35.09,90,,4.272,Percent of Total Billed Charges,90% of Total Billed Charges,17.55,45,,10.488,Percent of Total Billed Charges,45% of Total Billed Charges,35.09,90,,3.912,Percent of Total Billed Charges,90% of Total billed Charges,38.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.34,65,,15.928,Percent of total Billed Charges,65% of Total Billed Charges,17.19,44.1,,10.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.04,95,,4.128,Percent of Total Billed Charges,95% of Total Billed Charges,38.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.31,88,,3.824,Percent of Total Billed Charges,88% of Total Billed Charges,35.09,90,,3.912,Percent of Total Billed charges,90% of Total Billed Charges,17.19,38.99,
"Suture, Prolene 3-0 EPR8632G",2720001801,CDM,272,RC,,,Outpatient,,,18.50,12.03,,18.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.06,76,,0.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.32,72,,14.144,Percent of Total Billed Charges,72% of Total Billed Charges,13.88,75,,14.728,Percent of Total Billed charges,75% of Total Billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.32,72,,14.144,Percent of Total Billed Charges,72% of Total Billed Charges,11.1,60,,11.784,Percent of Total Billed Charges,60% of Total Billed Charges,16.65,90,,4.128,Percent of Total Billed Charges,90% of Total Billed Charges,8.33,45,,61.2,Percent of Total Billed Charges,45% of Total Billed Charges,16.65,90,,0.328,Percent of Total Billed Charges,90% of Total billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.03,65,,15.144,Percent of total Billed Charges,65% of Total Billed Charges,8.16,44.1,,59.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.58,95,,0.344,Percent of Total Billed Charges,95% of Total Billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.28,88,,0.32,Percent of Total Billed Charges,88% of Total Billed Charges,16.65,90,,0.328,Percent of Total Billed charges,90% of Total Billed Charges,8.16,18.5,
LMA UNIQUE AIRWAY SZ 1.5,2720001802,CDM,272,RC,,,Outpatient,,,35.99,23.39,,35.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.35,76,,18.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.91,72,,30.256,Percent of Total Billed Charges,72% of Total Billed Charges,26.99,75,,31.52,Percent of Total Billed charges,75% of Total Billed Charges,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.91,72,,30.256,Percent of Total Billed Charges,72% of Total Billed Charges,21.59,60,,25.216,Percent of Total Billed Charges,60% of Total Billed Charges,32.39,90,,4.144,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,45,,18.32,Percent of Total Billed Charges,45% of Total Billed Charges,32.39,90,,22.056,Percent of Total Billed Charges,90% of Total billed Charges,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.39,65,,88.4,Percent of total Billed Charges,65% of Total Billed Charges,15.87,44.1,,17.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.19,95,,23.28,Percent of Total Billed Charges,95% of Total Billed Charges,35.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.67,88,,21.56,Percent of Total Billed Charges,88% of Total Billed Charges,32.39,90,,22.056,Percent of Total Billed charges,90% of Total Billed Charges,15.87,35.99,
LARYNGOSCOPE BLD DISP MAC SZ2,2720001803,CDM,272,RC,,,Outpatient,,,4.67,3.04,,4.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.55,76,,17.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.36,72,,14.184,Percent of Total Billed Charges,72% of Total Billed Charges,3.5,75,,14.776,Percent of Total Billed charges,75% of Total Billed Charges,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.36,72,,14.184,Percent of Total Billed Charges,72% of Total Billed Charges,2.8,60,,11.824,Percent of Total Billed Charges,60% of Total Billed Charges,4.2,90,,4.128,Percent of Total Billed Charges,90% of Total Billed Charges,2.1,45,,2.672,Percent of Total Billed Charges,45% of Total Billed Charges,4.2,90,,20.976,Percent of Total Billed Charges,90% of Total billed Charges,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.04,65,,26.456,Percent of total Billed Charges,65% of Total Billed Charges,2.06,44.1,,2.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.44,95,,22.136,Percent of Total Billed Charges,95% of Total Billed Charges,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.11,88,,20.504,Percent of Total Billed Charges,88% of Total Billed Charges,4.2,90,,20.976,Percent of Total Billed charges,90% of Total Billed Charges,2.06,4.67,
LARYNGOSCOPE BLADE MILLER SZ3,2720001804,CDM,272,RC,,,Outpatient,,,4.67,3.04,,4.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.55,76,,103.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.36,72,,4.12,Percent of Total Billed Charges,72% of Total Billed Charges,3.5,75,,4.288,Percent of Total Billed charges,75% of Total Billed Charges,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.36,72,,4.12,Percent of Total Billed Charges,72% of Total Billed Charges,2.8,60,,3.432,Percent of Total Billed Charges,60% of Total Billed Charges,4.2,90,,4.056,Percent of Total Billed Charges,90% of Total Billed Charges,2.1,45,,2.216,Percent of Total Billed Charges,45% of Total Billed Charges,4.2,90,,122.4,Percent of Total Billed Charges,90% of Total billed Charges,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.04,65,,3.864,Percent of total Billed Charges,65% of Total Billed Charges,2.06,44.1,,2.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.44,95,,129.2,Percent of Total Billed Charges,95% of Total Billed Charges,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.11,88,,119.68,Percent of Total Billed Charges,88% of Total Billed Charges,4.2,90,,122.4,Percent of Total Billed charges,90% of Total Billed Charges,2.06,4.67,
LARYGNOSCOPE BLADE MILLER SZ4,2720001805,CDM,272,RC,,,Outpatient,,,4.67,3.04,,4.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.55,76,,30.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.36,72,,13.672,Percent of Total Billed Charges,72% of Total Billed Charges,3.5,75,,14.24,Percent of Total Billed charges,75% of Total Billed Charges,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.36,72,,13.672,Percent of Total Billed Charges,72% of Total Billed Charges,2.8,60,,11.392,Percent of Total Billed Charges,60% of Total Billed Charges,4.2,90,,4.896,Percent of Total Billed Charges,90% of Total Billed Charges,2.1,45,,1.224,Percent of Total Billed Charges,45% of Total Billed Charges,4.2,90,,36.632,Percent of Total Billed Charges,90% of Total billed Charges,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.04,65,,3.2,Percent of total Billed Charges,65% of Total Billed Charges,2.06,44.1,,1.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.44,95,,38.672,Percent of Total Billed Charges,95% of Total Billed Charges,4.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.11,88,,35.816,Percent of Total Billed Charges,88% of Total Billed Charges,4.2,90,,36.632,Percent of Total Billed charges,90% of Total Billed Charges,2.06,4.67,
MCGRATH MAC BLADE SZ 1,2720001806,CDM,272,RC,,,Outpatient,,,10.34,6.72,,10.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.86,76,,4.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.44,72,,16.304,Percent of Total Billed Charges,72% of Total Billed Charges,7.76,75,,16.984,Percent of Total Billed charges,75% of Total Billed Charges,10.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.44,72,,16.304,Percent of Total Billed Charges,72% of Total Billed Charges,6.2,60,,13.584,Percent of Total Billed Charges,60% of Total Billed Charges,9.31,90,,4.736,Percent of Total Billed Charges,90% of Total Billed Charges,4.65,45,,1.496,Percent of Total Billed Charges,45% of Total Billed Charges,9.31,90,,5.352,Percent of Total Billed Charges,90% of Total billed Charges,10.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.72,65,,1.768,Percent of total Billed Charges,65% of Total Billed Charges,4.56,44.1,,1.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.82,95,,5.648,Percent of Total Billed Charges,95% of Total Billed Charges,10.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.1,88,,5.232,Percent of Total Billed Charges,88% of Total Billed Charges,9.31,90,,5.352,Percent of Total Billed charges,90% of Total Billed Charges,4.56,10.34,
ARTHREX DX FBRTAK ANCHR,2720001807,CDM,272,RC,,,Outpatient,,,465.00,302.25,,465,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,353.4,76,,3.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,334.8,72,,21.4,Percent of Total Billed Charges,72% of Total Billed Charges,348.75,75,,22.288,Percent of Total Billed charges,75% of Total Billed Charges,465,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.8,72,,21.4,Percent of Total Billed Charges,72% of Total Billed Charges,279,60,,17.832,Percent of Total Billed Charges,60% of Total Billed Charges,418.5,90,,4.896,Percent of Total Billed Charges,90% of Total Billed Charges,209.25,45,,2.136,Percent of Total Billed Charges,45% of Total Billed Charges,418.5,90,,4.432,Percent of Total Billed Charges,90% of Total billed Charges,465,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.25,65,,2.16,Percent of total Billed Charges,65% of Total Billed Charges,205.07,44.1,,2.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,441.75,95,,4.672,Percent of Total Billed Charges,95% of Total Billed Charges,465,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.2,88,,4.328,Percent of Total Billed Charges,88% of Total Billed Charges,418.5,90,,4.432,Percent of Total Billed charges,90% of Total Billed Charges,205.07,465,
ARTHREX DISP KT FOR DX FBRTAK,2720001808,CDM,272,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,2.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,16.288,Percent of Total Billed Charges,72% of Total Billed Charges,206.25,75,,16.968,Percent of Total Billed charges,75% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,16.288,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,13.576,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,4.36,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,2.064,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,2.448,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,3.08,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,2.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,2.584,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,2.392,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,2.448,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
Surgical Powder,2720001809,CDM,272,RC,,,Outpatient,,,287.49,186.87,,287.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,218.49,76,,2.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,206.99,72,,16.072,Percent of Total Billed Charges,72% of Total Billed Charges,215.62,75,,16.744,Percent of Total Billed charges,75% of Total Billed Charges,287.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.99,72,,16.072,Percent of Total Billed Charges,72% of Total Billed Charges,172.49,60,,13.392,Percent of Total Billed Charges,60% of Total Billed Charges,258.74,90,,1.32,Percent of Total Billed Charges,90% of Total Billed Charges,129.37,45,,2.072,Percent of Total Billed Charges,45% of Total Billed Charges,258.74,90,,2.992,Percent of Total Billed Charges,90% of Total billed Charges,287.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,287.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,287.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.87,65,,2.976,Percent of total Billed Charges,65% of Total Billed Charges,126.78,44.1,,2.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,273.12,95,,3.152,Percent of Total Billed Charges,95% of Total Billed Charges,287.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.99,88,,2.92,Percent of Total Billed Charges,88% of Total Billed Charges,258.74,90,,2.992,Percent of Total Billed charges,90% of Total Billed Charges,126.78,287.49,
Surgical Endoscopic Appl,2720001810,CDM,272,RC,,,Outpatient,,,29.07,18.90,,29.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.09,76,,3.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.93,72,,7.232,Percent of Total Billed Charges,72% of Total Billed Charges,21.8,75,,7.528,Percent of Total Billed charges,75% of Total Billed Charges,29.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.93,72,,7.232,Percent of Total Billed Charges,72% of Total Billed Charges,17.44,60,,6.024,Percent of Total Billed Charges,60% of Total Billed Charges,26.16,90,,5.024,Percent of Total Billed Charges,90% of Total Billed Charges,13.08,45,,2.064,Percent of Total Billed Charges,45% of Total Billed Charges,26.16,90,,4.272,Percent of Total Billed Charges,90% of Total billed Charges,29.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.9,65,,2.992,Percent of total Billed Charges,65% of Total Billed Charges,12.82,44.1,,2.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,27.62,95,,4.504,Percent of Total Billed Charges,95% of Total Billed Charges,29.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.58,88,,4.176,Percent of Total Billed Charges,88% of Total Billed Charges,26.16,90,,4.272,Percent of Total Billed charges,90% of Total Billed Charges,12.82,29.07,
BLUE ABSORBENT MAT,2720001811,CDM,272,RC,,,Outpatient,,,14.00,9.10,,14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.64,76,,3.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.08,72,,16.488,Percent of Total Billed Charges,72% of Total Billed Charges,10.5,75,,17.176,Percent of Total Billed charges,75% of Total Billed Charges,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.08,72,,16.488,Percent of Total Billed Charges,72% of Total Billed Charges,8.4,60,,13.744,Percent of Total Billed Charges,60% of Total Billed Charges,12.6,90,,2.4,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,45,,2.024,Percent of Total Billed Charges,45% of Total Billed Charges,12.6,90,,4.128,Percent of Total Billed Charges,90% of Total billed Charges,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.1,65,,2.976,Percent of total Billed Charges,65% of Total Billed Charges,6.17,44.1,,1.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.3,95,,4.352,Percent of Total Billed Charges,95% of Total Billed Charges,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.32,88,,4.032,Percent of Total Billed Charges,88% of Total Billed Charges,12.6,90,,4.128,Percent of Total Billed charges,90% of Total Billed Charges,6.17,14,
Trailblazer ANG 4F 0.014x150,2720001812,CDM,272,RC,,,Outpatient,,,417.50,271.38,,417.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,317.3,76,,3.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,300.6,72,,283.816,Percent of Total Billed Charges,72% of Total Billed Charges,313.13,75,,295.64,Percent of Total Billed charges,75% of Total Billed Charges,417.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.6,72,,283.816,Percent of Total Billed Charges,72% of Total Billed Charges,250.5,60,,236.512,Percent of Total Billed Charges,60% of Total Billed Charges,375.75,90,,4.304,Percent of Total Billed Charges,90% of Total Billed Charges,187.88,45,,2.448,Percent of Total Billed Charges,45% of Total Billed Charges,375.75,90,,4.144,Percent of Total Billed Charges,90% of Total billed Charges,417.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.38,65,,2.928,Percent of total Billed Charges,65% of Total Billed Charges,184.12,44.1,,2.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,396.63,95,,4.368,Percent of Total Billed Charges,95% of Total Billed Charges,417.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,367.4,88,,4.048,Percent of Total Billed Charges,88% of Total Billed Charges,375.75,90,,4.144,Percent of Total Billed charges,90% of Total Billed Charges,184.12,417.5,
NC ELITE 5F 5X200X150 014 BLN,2720001813,CDM,272,RC,,,Outpatient,,,747.50,485.88,,747.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,568.1,76,,3.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,538.2,72,,47.736,Percent of Total Billed Charges,72% of Total Billed Charges,560.63,75,,49.728,Percent of Total Billed charges,75% of Total Billed Charges,747.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.2,72,,47.736,Percent of Total Billed Charges,72% of Total Billed Charges,448.5,60,,39.784,Percent of Total Billed Charges,60% of Total Billed Charges,672.75,90,,2.376,Percent of Total Billed Charges,90% of Total Billed Charges,336.38,45,,2.368,Percent of Total Billed Charges,45% of Total Billed Charges,672.75,90,,4.128,Percent of Total Billed Charges,90% of Total billed Charges,747.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,747.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,747.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.88,65,,3.536,Percent of total Billed Charges,65% of Total Billed Charges,329.65,44.1,,2.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,710.13,95,,4.352,Percent of Total Billed Charges,95% of Total Billed Charges,747.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,657.8,88,,4.032,Percent of Total Billed Charges,88% of Total Billed Charges,672.75,90,,4.128,Percent of Total Billed charges,90% of Total Billed Charges,329.65,747.5,
EVERCROSS 5F 6X40X135 BALN,2720001814,CDM,272,RC,,,Outpatient,,,282.50,183.63,,282.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,214.7,76,,3.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,203.4,72,,50.024,Percent of Total Billed Charges,72% of Total Billed Charges,211.88,75,,52.112,Percent of Total Billed charges,75% of Total Billed Charges,282.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.4,72,,50.024,Percent of Total Billed Charges,72% of Total Billed Charges,169.5,60,,41.688,Percent of Total Billed Charges,60% of Total Billed Charges,254.25,90,,4.52,Percent of Total Billed Charges,90% of Total Billed Charges,127.13,45,,2.448,Percent of Total Billed Charges,45% of Total Billed Charges,254.25,90,,4.056,Percent of Total Billed Charges,90% of Total billed Charges,282.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.63,65,,3.424,Percent of total Billed Charges,65% of Total Billed Charges,124.58,44.1,,2.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,268.38,95,,4.28,Percent of Total Billed Charges,95% of Total Billed Charges,282.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.6,88,,3.96,Percent of Total Billed Charges,88% of Total Billed Charges,254.25,90,,4.056,Percent of Total Billed charges,90% of Total Billed Charges,124.58,282.5,
EVERCROSS 5F 4X40X135 BALN,2720001815,CDM,272,RC,,,Outpatient,,,282.50,183.63,,282.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,214.7,76,,4.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,203.4,72,,57.168,Percent of Total Billed Charges,72% of Total Billed Charges,211.88,75,,59.552,Percent of Total Billed charges,75% of Total Billed Charges,282.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.4,72,,57.168,Percent of Total Billed Charges,72% of Total Billed Charges,169.5,60,,47.64,Percent of Total Billed Charges,60% of Total Billed Charges,254.25,90,,3.496,Percent of Total Billed Charges,90% of Total Billed Charges,127.13,45,,2.176,Percent of Total Billed Charges,45% of Total Billed Charges,254.25,90,,4.896,Percent of Total Billed Charges,90% of Total billed Charges,282.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.63,65,,3.536,Percent of total Billed Charges,65% of Total Billed Charges,124.58,44.1,,2.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,268.38,95,,5.168,Percent of Total Billed Charges,95% of Total Billed Charges,282.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.6,88,,4.784,Percent of Total Billed Charges,88% of Total Billed Charges,254.25,90,,4.896,Percent of Total Billed charges,90% of Total Billed Charges,124.58,282.5,
EVERCROSS 5F 5X40X135 BALN,2720001816,CDM,272,RC,,,Outpatient,,,282.50,183.63,,282.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,214.7,76,,4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,203.4,72,,96.264,Percent of Total Billed Charges,72% of Total Billed Charges,211.88,75,,100.28,Percent of Total Billed charges,75% of Total Billed Charges,282.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.4,72,,96.264,Percent of Total Billed Charges,72% of Total Billed Charges,169.5,60,,80.224,Percent of Total Billed Charges,60% of Total Billed Charges,254.25,90,,4.144,Percent of Total Billed Charges,90% of Total Billed Charges,127.13,45,,0.656,Percent of Total Billed Charges,45% of Total Billed Charges,254.25,90,,4.736,Percent of Total Billed Charges,90% of Total billed Charges,282.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.63,65,,3.144,Percent of total Billed Charges,65% of Total Billed Charges,124.58,44.1,,0.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,268.38,95,,5,Percent of Total Billed Charges,95% of Total Billed Charges,282.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.6,88,,4.632,Percent of Total Billed Charges,88% of Total Billed Charges,254.25,90,,4.736,Percent of Total Billed charges,90% of Total Billed Charges,124.58,282.5,
EVERCROSS 5F 4X200X135 BALN,2720001817,CDM,272,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,4.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,19.384,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,20.192,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,19.384,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,16.152,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,4.896,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,2.512,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,4.896,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,0.952,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,2.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,5.168,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,4.784,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,4.896,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
MICKEY 18F X 3CM BUTTON KIT,2720001818,CDM,272,RC,,,Outpatient,,,378.40,245.96,,378.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,287.58,76,,3.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,272.45,72,,19.384,Percent of Total Billed Charges,72% of Total Billed Charges,283.8,75,,20.192,Percent of Total Billed charges,75% of Total Billed Charges,378.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.45,72,,19.384,Percent of Total Billed Charges,72% of Total Billed Charges,227.04,60,,16.152,Percent of Total Billed Charges,60% of Total Billed Charges,340.56,90,,2.616,Percent of Total Billed Charges,90% of Total Billed Charges,170.28,45,,1.2,Percent of Total Billed Charges,45% of Total Billed Charges,340.56,90,,4.36,Percent of Total Billed Charges,90% of Total billed Charges,378.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.96,65,,3.632,Percent of total Billed Charges,65% of Total Billed Charges,166.87,44.1,,1.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,359.48,95,,4.6,Percent of Total Billed Charges,95% of Total Billed Charges,378.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.99,88,,4.256,Percent of Total Billed Charges,88% of Total Billed Charges,340.56,90,,4.36,Percent of Total Billed charges,90% of Total Billed Charges,166.87,378.4,
TEMP PACER CABLES (DISPOSABLE),2720001819,CDM,272,RC,,,Outpatient,,,41.10,26.72,,41.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31.24,76,,1.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.59,72,,7.536,Percent of Total Billed Charges,72% of Total Billed Charges,30.83,75,,7.848,Percent of Total Billed charges,75% of Total Billed Charges,41.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.59,72,,7.536,Percent of Total Billed Charges,72% of Total Billed Charges,24.66,60,,6.28,Percent of Total Billed Charges,60% of Total Billed Charges,36.99,90,,2.216,Percent of Total Billed Charges,90% of Total Billed Charges,18.5,45,,2.152,Percent of Total Billed Charges,45% of Total Billed Charges,36.99,90,,1.32,Percent of Total Billed Charges,90% of Total billed Charges,41.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.72,65,,1.728,Percent of total Billed Charges,65% of Total Billed Charges,18.13,44.1,,2.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,39.05,95,,1.392,Percent of Total Billed Charges,95% of Total Billed Charges,41.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.17,88,,1.288,Percent of Total Billed Charges,88% of Total Billed Charges,36.99,90,,1.32,Percent of Total Billed charges,90% of Total Billed Charges,18.13,41.1,
SAFETY SCLPEL 15 BLADE-STERILE,2720001820,CDM,272,RC,,,Outpatient,,,4.25,2.76,,4.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.23,76,,4.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.06,72,,5.088,Percent of Total Billed Charges,72% of Total Billed Charges,3.19,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,4.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.06,72,,5.088,Percent of Total Billed Charges,72% of Total Billed Charges,2.55,60,,4.24,Percent of Total Billed Charges,60% of Total Billed Charges,3.83,90,,2,Percent of Total Billed Charges,90% of Total Billed Charges,1.91,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,3.83,90,,5.024,Percent of Total Billed Charges,90% of Total billed Charges,4.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.76,65,,3.112,Percent of total Billed Charges,65% of Total Billed Charges,1.87,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.04,95,,5.304,Percent of Total Billed Charges,95% of Total Billed Charges,4.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.74,88,,4.912,Percent of Total Billed Charges,88% of Total Billed Charges,3.83,90,,5.024,Percent of Total Billed charges,90% of Total Billed Charges,1.87,4.25,
SAFETY SCLPEL 11 BLADE- STERIL,2720001821,CDM,272,RC,,,Outpatient,,,4.08,2.65,,4.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.1,76,,2.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.94,72,,5.296,Percent of Total Billed Charges,72% of Total Billed Charges,3.06,75,,5.52,Percent of Total Billed charges,75% of Total Billed Charges,4.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.94,72,,5.296,Percent of Total Billed Charges,72% of Total Billed Charges,2.45,60,,4.416,Percent of Total Billed Charges,60% of Total Billed Charges,3.67,90,,1.048,Percent of Total Billed Charges,90% of Total Billed Charges,1.84,45,,2.264,Percent of Total Billed Charges,45% of Total Billed Charges,3.67,90,,2.4,Percent of Total Billed Charges,90% of Total billed Charges,4.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.65,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,1.8,44.1,,2.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.88,95,,2.528,Percent of Total Billed Charges,95% of Total Billed Charges,4.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.59,88,,2.344,Percent of Total Billed Charges,88% of Total Billed Charges,3.67,90,,2.4,Percent of Total Billed charges,90% of Total Billed Charges,1.8,4.08,
BANDED BAG 36 X 36,2720001822,CDM,272,RC,,,Outpatient,,,8.75,5.69,,8.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.65,76,,3.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.3,72,,5.088,Percent of Total Billed Charges,72% of Total Billed Charges,6.56,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,8.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.3,72,,5.088,Percent of Total Billed Charges,72% of Total Billed Charges,5.25,60,,4.24,Percent of Total Billed Charges,60% of Total Billed Charges,7.88,90,,1.768,Percent of Total Billed Charges,90% of Total Billed Charges,3.94,45,,1.744,Percent of Total Billed Charges,45% of Total Billed Charges,7.88,90,,4.304,Percent of Total Billed Charges,90% of Total billed Charges,8.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.69,65,,3.264,Percent of total Billed Charges,65% of Total Billed Charges,3.86,44.1,,1.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.31,95,,4.544,Percent of Total Billed Charges,95% of Total Billed Charges,8.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.7,88,,4.208,Percent of Total Billed Charges,88% of Total Billed Charges,7.88,90,,4.304,Percent of Total Billed charges,90% of Total Billed Charges,3.86,8.75,
ECG ELECTRODES RADIOLUSCENT,2720001823,CDM,272,RC,,,Outpatient,,,5.00,3.25,,5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.8,76,,2.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.6,72,,5.088,Percent of Total Billed Charges,72% of Total Billed Charges,3.75,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.6,72,,5.088,Percent of Total Billed Charges,72% of Total Billed Charges,3,60,,4.24,Percent of Total Billed Charges,60% of Total Billed Charges,4.5,90,,1.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.25,45,,2.072,Percent of Total Billed Charges,45% of Total Billed Charges,4.5,90,,2.376,Percent of Total Billed Charges,90% of Total billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.25,65,,2.52,Percent of total Billed Charges,65% of Total Billed Charges,2.21,44.1,,2.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.75,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.4,88,,2.32,Percent of Total Billed Charges,88% of Total Billed Charges,4.5,90,,2.376,Percent of Total Billed charges,90% of Total Billed Charges,2.21,5,
Mesalt Imp Wnd Dsg 3/4 x 39,2720001826,CDM,272,RC,,,Outpatient,,,6.43,4.18,,6.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.89,76,,3.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.63,72,,245.776,Percent of Total Billed Charges,72% of Total Billed Charges,4.82,75,,256.024,Percent of Total Billed charges,75% of Total Billed Charges,6.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.63,72,,245.776,Percent of Total Billed Charges,72% of Total Billed Charges,3.86,60,,204.816,Percent of Total Billed Charges,60% of Total Billed Charges,5.79,90,,12.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.89,45,,2.448,Percent of Total Billed Charges,45% of Total Billed Charges,5.79,90,,4.52,Percent of Total Billed Charges,90% of Total billed Charges,6.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.18,65,,2.992,Percent of total Billed Charges,65% of Total Billed Charges,2.84,44.1,,2.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.11,95,,4.776,Percent of Total Billed Charges,95% of Total Billed Charges,6.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.66,88,,4.424,Percent of Total Billed Charges,88% of Total Billed Charges,5.79,90,,4.52,Percent of Total Billed charges,90% of Total Billed Charges,2.84,6.43,
MAXPLUS POS CLEAR CONNECTOR,2720001827,CDM,272,RC,,,Outpatient,,,2.85,1.85,,2.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.17,76,,2.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.05,72,,136.504,Percent of Total Billed Charges,72% of Total Billed Charges,2.14,75,,142.192,Percent of Total Billed charges,75% of Total Billed Charges,2.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.05,72,,136.504,Percent of Total Billed Charges,72% of Total Billed Charges,1.71,60,,113.752,Percent of Total Billed Charges,60% of Total Billed Charges,2.57,90,,2.256,Percent of Total Billed Charges,90% of Total Billed Charges,1.28,45,,1.304,Percent of Total Billed Charges,45% of Total Billed Charges,2.57,90,,3.496,Percent of Total Billed Charges,90% of Total billed Charges,2.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.85,65,,3.536,Percent of total Billed Charges,65% of Total Billed Charges,1.26,44.1,,1.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.71,95,,3.688,Percent of Total Billed Charges,95% of Total Billed Charges,2.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.51,88,,3.416,Percent of Total Billed Charges,88% of Total Billed Charges,2.57,90,,3.496,Percent of Total Billed charges,90% of Total Billed Charges,1.26,2.85,
CONTAMINATION SLEEVE,2720001828,CDM,272,RC,,,Outpatient,,,27.50,17.88,,27.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.9,76,,3.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.8,72,,152.512,Percent of Total Billed Charges,72% of Total Billed Charges,20.63,75,,158.872,Percent of Total Billed charges,75% of Total Billed Charges,27.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.8,72,,152.512,Percent of Total Billed Charges,72% of Total Billed Charges,16.5,60,,127.096,Percent of Total Billed Charges,60% of Total Billed Charges,24.75,90,,2.504,Percent of Total Billed Charges,90% of Total Billed Charges,12.38,45,,1.112,Percent of Total Billed Charges,45% of Total Billed Charges,24.75,90,,4.144,Percent of Total Billed Charges,90% of Total billed Charges,27.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.88,65,,1.888,Percent of total Billed Charges,65% of Total Billed Charges,12.13,44.1,,1.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.13,95,,4.368,Percent of Total Billed Charges,95% of Total Billed Charges,27.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.2,88,,4.048,Percent of Total Billed Charges,88% of Total Billed Charges,24.75,90,,4.144,Percent of Total Billed charges,90% of Total Billed Charges,12.13,27.5,
MARQUIS STOPCOCKS,2720001829,CDM,272,RC,,,Outpatient,,,5.38,3.50,,5.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.09,76,,4.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.87,72,,22.664,Percent of Total Billed Charges,72% of Total Billed Charges,4.04,75,,23.608,Percent of Total Billed charges,75% of Total Billed Charges,5.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.87,72,,22.664,Percent of Total Billed Charges,72% of Total Billed Charges,3.23,60,,18.888,Percent of Total Billed Charges,60% of Total Billed Charges,4.84,90,,2.256,Percent of Total Billed Charges,90% of Total Billed Charges,2.42,45,,1,Percent of Total Billed Charges,45% of Total Billed Charges,4.84,90,,4.896,Percent of Total Billed Charges,90% of Total billed Charges,5.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.5,65,,1.6,Percent of total Billed Charges,65% of Total Billed Charges,2.37,44.1,,0.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.11,95,,5.168,Percent of Total Billed Charges,95% of Total Billed Charges,5.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.73,88,,4.784,Percent of Total Billed Charges,88% of Total Billed Charges,4.84,90,,4.896,Percent of Total Billed charges,90% of Total Billed Charges,2.37,5.38,
Nasal Rae Cuffed Tube 3.0,2720001830,CDM,272,RC,,,Outpatient,,,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,2.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,22.664,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,75,,23.608,Percent of Total Billed charges,75% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,22.664,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,18.888,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,2.56,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,0.52,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,2.616,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,1.448,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,0.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,2.76,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,2.552,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,2.616,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
NG Tube 6FR Ventrol,2720001831,CDM,272,RC,,,Outpatient,,,11.33,7.36,,11.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.61,76,,1.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.16,72,,50.288,Percent of Total Billed Charges,72% of Total Billed Charges,8.5,75,,52.384,Percent of Total Billed charges,75% of Total Billed Charges,11.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.16,72,,50.288,Percent of Total Billed Charges,72% of Total Billed Charges,6.8,60,,41.904,Percent of Total Billed Charges,60% of Total Billed Charges,10.2,90,,6.16,Percent of Total Billed Charges,90% of Total Billed Charges,5.1,45,,0.88,Percent of Total Billed Charges,45% of Total Billed Charges,10.2,90,,2.216,Percent of Total Billed Charges,90% of Total billed Charges,11.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.36,65,,0.752,Percent of total Billed Charges,65% of Total Billed Charges,5,44.1,,0.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.76,95,,2.344,Percent of Total Billed Charges,95% of Total Billed Charges,11.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.97,88,,2.168,Percent of Total Billed Charges,88% of Total Billed Charges,10.2,90,,2.216,Percent of Total Billed charges,90% of Total Billed Charges,5,11.33,
Armboard Strap Disp,2720001832,CDM,272,RC,,,Outpatient,,,3.45,2.24,,3.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.62,76,,1.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.48,72,,54.176,Percent of Total Billed Charges,72% of Total Billed Charges,2.59,75,,56.432,Percent of Total Billed charges,75% of Total Billed Charges,3.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.48,72,,54.176,Percent of Total Billed Charges,72% of Total Billed Charges,2.07,60,,45.144,Percent of Total Billed Charges,60% of Total Billed Charges,3.11,90,,2.36,Percent of Total Billed Charges,90% of Total Billed Charges,1.55,45,,0.84,Percent of Total Billed Charges,45% of Total Billed Charges,3.11,90,,2,Percent of Total Billed Charges,90% of Total billed Charges,3.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.24,65,,1.272,Percent of total Billed Charges,65% of Total Billed Charges,1.52,44.1,,0.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.28,95,,2.112,Percent of Total Billed Charges,95% of Total Billed Charges,3.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.04,88,,1.96,Percent of Total Billed Charges,88% of Total Billed Charges,3.11,90,,2,Percent of Total Billed charges,90% of Total Billed Charges,1.52,3.45,
One Step Centesis Catheter,2720001833,CDM,272,RC,,,Outpatient,,,34.38,22.35,,34.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.13,76,,0.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.75,72,,56.032,Percent of Total Billed Charges,72% of Total Billed Charges,25.79,75,,58.368,Percent of Total Billed charges,75% of Total Billed Charges,34.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.75,72,,56.032,Percent of Total Billed Charges,72% of Total Billed Charges,20.63,60,,46.696,Percent of Total Billed Charges,60% of Total Billed Charges,30.94,90,,6.216,Percent of Total Billed Charges,90% of Total Billed Charges,15.47,45,,6.056,Percent of Total Billed Charges,45% of Total Billed Charges,30.94,90,,1.048,Percent of Total Billed Charges,90% of Total billed Charges,34.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.35,65,,1.208,Percent of total Billed Charges,65% of Total Billed Charges,15.16,44.1,,5.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.66,95,,1.104,Percent of Total Billed Charges,95% of Total Billed Charges,34.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.25,88,,1.024,Percent of Total Billed Charges,88% of Total Billed Charges,30.94,90,,1.048,Percent of Total Billed charges,90% of Total Billed Charges,15.16,34.38,
Temno 18Gx6CM Biopsy Device,2720001834,CDM,272,RC,,,Outpatient,,,78.75,51.19,,78.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.85,76,,1.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.7,72,,54.016,Percent of Total Billed Charges,72% of Total Billed Charges,59.06,75,,56.272,Percent of Total Billed charges,75% of Total Billed Charges,78.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.7,72,,54.016,Percent of Total Billed Charges,72% of Total Billed Charges,47.25,60,,45.016,Percent of Total Billed Charges,60% of Total Billed Charges,70.88,90,,3.136,Percent of Total Billed Charges,90% of Total Billed Charges,35.44,45,,1.128,Percent of Total Billed Charges,45% of Total Billed Charges,70.88,90,,1.768,Percent of Total Billed Charges,90% of Total billed Charges,78.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.19,65,,8.752,Percent of total Billed Charges,65% of Total Billed Charges,34.73,44.1,,1.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.81,95,,1.864,Percent of Total Billed Charges,95% of Total Billed Charges,78.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.3,88,,1.728,Percent of Total Billed Charges,88% of Total Billed Charges,70.88,90,,1.768,Percent of Total Billed charges,90% of Total Billed Charges,34.73,78.75,
Temno 18GX11CM Biopsy Device,2720001835,CDM,272,RC,,,Outpatient,,,78.75,51.19,,78.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.85,76,,1.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.7,72,,99.04,Percent of Total Billed Charges,72% of Total Billed Charges,59.06,75,,103.168,Percent of Total Billed charges,75% of Total Billed Charges,78.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.7,72,,99.04,Percent of Total Billed Charges,72% of Total Billed Charges,47.25,60,,82.536,Percent of Total Billed Charges,60% of Total Billed Charges,70.88,90,,41.256,Percent of Total Billed Charges,90% of Total Billed Charges,35.44,45,,1.256,Percent of Total Billed Charges,45% of Total Billed Charges,70.88,90,,1.68,Percent of Total Billed Charges,90% of Total billed Charges,78.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.19,65,,1.624,Percent of total Billed Charges,65% of Total Billed Charges,34.73,44.1,,1.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.81,95,,1.768,Percent of Total Billed Charges,95% of Total Billed Charges,78.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.3,88,,1.64,Percent of Total Billed Charges,88% of Total Billed Charges,70.88,90,,1.68,Percent of Total Billed charges,90% of Total Billed Charges,34.73,78.75,
Cath Foley 20/30/3 Coude Tip,2720001836,CDM,272,RC,,,Outpatient,,,39.68,25.79,,39.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,30.16,76,,10.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.57,72,,99.04,Percent of Total Billed Charges,72% of Total Billed Charges,29.76,75,,103.168,Percent of Total Billed charges,75% of Total Billed Charges,39.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.57,72,,99.04,Percent of Total Billed Charges,72% of Total Billed Charges,23.81,60,,82.536,Percent of Total Billed Charges,60% of Total Billed Charges,35.71,90,,8.52,Percent of Total Billed Charges,90% of Total Billed Charges,17.86,45,,1.128,Percent of Total Billed Charges,45% of Total Billed Charges,35.71,90,,12.12,Percent of Total Billed Charges,90% of Total billed Charges,39.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.79,65,,1.808,Percent of total Billed Charges,65% of Total Billed Charges,17.5,44.1,,1.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.7,95,,12.792,Percent of Total Billed Charges,95% of Total Billed Charges,39.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.92,88,,11.848,Percent of Total Billed Charges,88% of Total Billed Charges,35.71,90,,12.12,Percent of Total Billed charges,90% of Total Billed Charges,17.5,39.68,
Huber Needle 20Gx3/4,2720001837,CDM,272,RC,,,Outpatient,,,12.85,8.35,,12.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.77,76,,1.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.25,72,,96.592,Percent of Total Billed Charges,72% of Total Billed Charges,9.64,75,,100.624,Percent of Total Billed charges,75% of Total Billed Charges,12.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.25,72,,96.592,Percent of Total Billed Charges,72% of Total Billed Charges,7.71,60,,80.496,Percent of Total Billed Charges,60% of Total Billed Charges,11.57,90,,3.496,Percent of Total Billed Charges,90% of Total Billed Charges,5.78,45,,1.28,Percent of Total Billed Charges,45% of Total Billed Charges,11.57,90,,2.256,Percent of Total Billed Charges,90% of Total billed Charges,12.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.35,65,,1.624,Percent of total Billed Charges,65% of Total Billed Charges,5.67,44.1,,1.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.21,95,,2.376,Percent of Total Billed Charges,95% of Total Billed Charges,12.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.31,88,,2.2,Percent of Total Billed Charges,88% of Total Billed Charges,11.57,90,,2.256,Percent of Total Billed charges,90% of Total Billed Charges,5.67,12.85,
Biogel Gloves Size 7.5,2720001838,CDM,272,RC,,,Outpatient,,,3.63,2.36,,3.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.76,76,,2.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.61,72,,99.04,Percent of Total Billed Charges,72% of Total Billed Charges,2.72,75,,103.168,Percent of Total Billed charges,75% of Total Billed Charges,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.61,72,,99.04,Percent of Total Billed Charges,72% of Total Billed Charges,2.18,60,,82.536,Percent of Total Billed Charges,60% of Total Billed Charges,3.27,90,,16.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.63,45,,3.08,Percent of Total Billed Charges,45% of Total Billed Charges,3.27,90,,2.504,Percent of Total Billed Charges,90% of Total billed Charges,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.36,65,,1.848,Percent of total Billed Charges,65% of Total Billed Charges,1.6,44.1,,3.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.45,95,,2.648,Percent of Total Billed Charges,95% of Total Billed Charges,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.19,88,,2.448,Percent of Total Billed Charges,88% of Total Billed Charges,3.27,90,,2.504,Percent of Total Billed charges,90% of Total Billed Charges,1.6,3.63,
"Glove, Sensicare Sz 8",2720001839,CDM,272,RC,,,Outpatient,,,6.83,4.44,,6.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.19,76,,1.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.92,72,,99.04,Percent of Total Billed Charges,72% of Total Billed Charges,5.12,75,,103.168,Percent of Total Billed charges,75% of Total Billed Charges,6.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.92,72,,99.04,Percent of Total Billed Charges,72% of Total Billed Charges,4.1,60,,82.536,Percent of Total Billed Charges,60% of Total Billed Charges,6.15,90,,3.024,Percent of Total Billed Charges,90% of Total Billed Charges,3.07,45,,1.184,Percent of Total Billed Charges,45% of Total Billed Charges,6.15,90,,2.256,Percent of Total Billed Charges,90% of Total billed Charges,6.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.44,65,,4.448,Percent of total Billed Charges,65% of Total Billed Charges,3.01,44.1,,1.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.49,95,,2.376,Percent of Total Billed Charges,95% of Total Billed Charges,6.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.01,88,,2.2,Percent of Total Billed Charges,88% of Total Billed Charges,6.15,90,,2.256,Percent of Total Billed charges,90% of Total Billed Charges,3.01,6.83,
"Glove, Sensicare Sz 8.5",2720001840,CDM,272,RC,,,Outpatient,,,6.83,4.44,,6.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.19,76,,2.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.92,72,,99.04,Percent of Total Billed Charges,72% of Total Billed Charges,5.12,75,,103.168,Percent of Total Billed charges,75% of Total Billed Charges,6.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.92,72,,99.04,Percent of Total Billed Charges,72% of Total Billed Charges,4.1,60,,82.536,Percent of Total Billed Charges,60% of Total Billed Charges,6.15,90,,2.344,Percent of Total Billed Charges,90% of Total Billed Charges,3.07,45,,3.104,Percent of Total Billed Charges,45% of Total Billed Charges,6.15,90,,2.56,Percent of Total Billed Charges,90% of Total billed Charges,6.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.44,65,,1.704,Percent of total Billed Charges,65% of Total Billed Charges,3.01,44.1,,3.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.49,95,,2.696,Percent of Total Billed Charges,95% of Total Billed Charges,6.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.01,88,,2.496,Percent of Total Billed Charges,88% of Total Billed Charges,6.15,90,,2.56,Percent of Total Billed charges,90% of Total Billed Charges,3.01,6.83,
Huber Needle 20g x 1.5,2720001841,CDM,272,RC,,,Outpatient,,,12.85,8.35,,12.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.77,76,,5.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.25,72,,31.504,Percent of Total Billed Charges,72% of Total Billed Charges,9.64,75,,32.824,Percent of Total Billed charges,75% of Total Billed Charges,12.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.25,72,,31.504,Percent of Total Billed Charges,72% of Total Billed Charges,7.71,60,,26.256,Percent of Total Billed Charges,60% of Total Billed Charges,11.57,90,,3.224,Percent of Total Billed Charges,90% of Total Billed Charges,5.78,45,,1.568,Percent of Total Billed Charges,45% of Total Billed Charges,11.57,90,,6.16,Percent of Total Billed Charges,90% of Total billed Charges,12.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.35,65,,4.488,Percent of total Billed Charges,65% of Total Billed Charges,5.67,44.1,,1.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.21,95,,6.496,Percent of Total Billed Charges,95% of Total Billed Charges,12.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.31,88,,6.016,Percent of Total Billed Charges,88% of Total Billed Charges,11.57,90,,6.16,Percent of Total Billed charges,90% of Total Billed Charges,5.67,12.85,
"Glove, Sensicare Sz 6.5",2720001842,CDM,272,RC,,,Outpatient,,,6.83,4.44,,6.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.19,76,,1.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.92,72,,27.576,Percent of Total Billed Charges,72% of Total Billed Charges,5.12,75,,28.728,Percent of Total Billed charges,75% of Total Billed Charges,6.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.92,72,,27.576,Percent of Total Billed Charges,72% of Total Billed Charges,4.1,60,,22.984,Percent of Total Billed Charges,60% of Total Billed Charges,6.15,90,,2.344,Percent of Total Billed Charges,90% of Total Billed Charges,3.07,45,,20.632,Percent of Total Billed Charges,45% of Total Billed Charges,6.15,90,,2.36,Percent of Total Billed Charges,90% of Total billed Charges,6.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.44,65,,2.264,Percent of total Billed Charges,65% of Total Billed Charges,3.01,44.1,,20.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.49,95,,2.496,Percent of Total Billed Charges,95% of Total Billed Charges,6.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.01,88,,2.312,Percent of Total Billed Charges,88% of Total Billed Charges,6.15,90,,2.36,Percent of Total Billed charges,90% of Total Billed Charges,3.01,6.83,
Biogel Gloves Sz 8,2720001843,CDM,272,RC,,,Outpatient,,,3.63,2.36,,3.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.76,76,,5.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.61,72,,11.912,Percent of Total Billed Charges,72% of Total Billed Charges,2.72,75,,12.408,Percent of Total Billed charges,75% of Total Billed Charges,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.61,72,,11.912,Percent of Total Billed Charges,72% of Total Billed Charges,2.18,60,,9.928,Percent of Total Billed Charges,60% of Total Billed Charges,3.27,90,,6.336,Percent of Total Billed Charges,90% of Total Billed Charges,1.63,45,,4.256,Percent of Total Billed Charges,45% of Total Billed Charges,3.27,90,,6.216,Percent of Total Billed Charges,90% of Total billed Charges,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.36,65,,29.8,Percent of total Billed Charges,65% of Total Billed Charges,1.6,44.1,,4.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.45,95,,6.56,Percent of Total Billed Charges,95% of Total Billed Charges,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.19,88,,6.072,Percent of Total Billed Charges,88% of Total Billed Charges,3.27,90,,6.216,Percent of Total Billed charges,90% of Total Billed Charges,1.6,3.63,
"Glove, Sensicare Sz 7",2720001844,CDM,272,RC,,,Outpatient,,,6.83,4.44,,6.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.19,76,,2.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.92,72,,48.808,Percent of Total Billed Charges,72% of Total Billed Charges,5.12,75,,50.84,Percent of Total Billed charges,75% of Total Billed Charges,6.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.92,72,,48.808,Percent of Total Billed Charges,72% of Total Billed Charges,4.1,60,,40.672,Percent of Total Billed Charges,60% of Total Billed Charges,6.15,90,,4,Percent of Total Billed Charges,90% of Total Billed Charges,3.07,45,,1.744,Percent of Total Billed Charges,45% of Total Billed Charges,6.15,90,,3.136,Percent of Total Billed Charges,90% of Total billed Charges,6.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.44,65,,6.152,Percent of total Billed Charges,65% of Total Billed Charges,3.01,44.1,,1.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.49,95,,3.304,Percent of Total Billed Charges,95% of Total Billed Charges,6.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.01,88,,3.064,Percent of Total Billed Charges,88% of Total Billed Charges,6.15,90,,3.136,Percent of Total Billed charges,90% of Total Billed Charges,3.01,6.83,
Biogel Gloves Sz 7,2720001845,CDM,272,RC,,,Outpatient,,,3.63,2.36,,3.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.76,76,,34.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.61,72,,2.736,Percent of Total Billed Charges,72% of Total Billed Charges,2.72,75,,2.848,Percent of Total Billed charges,75% of Total Billed Charges,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.61,72,,2.736,Percent of Total Billed Charges,72% of Total Billed Charges,2.18,60,,2.28,Percent of Total Billed Charges,60% of Total Billed Charges,3.27,90,,4.592,Percent of Total Billed Charges,90% of Total Billed Charges,1.63,45,,8.216,Percent of Total Billed Charges,45% of Total Billed Charges,3.27,90,,41.256,Percent of Total Billed Charges,90% of Total billed Charges,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.36,65,,2.52,Percent of total Billed Charges,65% of Total Billed Charges,1.6,44.1,,8.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.45,95,,43.552,Percent of Total Billed Charges,95% of Total Billed Charges,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.19,88,,40.336,Percent of Total Billed Charges,88% of Total Billed Charges,3.27,90,,41.256,Percent of Total Billed charges,90% of Total Billed Charges,1.6,3.63,
Biogel Gloves Sz 6.5,2720001846,CDM,272,RC,,,Outpatient,,,3.63,2.36,,3.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.76,76,,7.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.61,72,,7.56,Percent of Total Billed Charges,72% of Total Billed Charges,2.72,75,,7.88,Percent of Total Billed charges,75% of Total Billed Charges,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.61,72,,7.56,Percent of Total Billed Charges,72% of Total Billed Charges,2.18,60,,6.304,Percent of Total Billed Charges,60% of Total Billed Charges,3.27,90,,4.128,Percent of Total Billed Charges,90% of Total Billed Charges,1.63,45,,1.512,Percent of Total Billed Charges,45% of Total Billed Charges,3.27,90,,8.52,Percent of Total Billed Charges,90% of Total billed Charges,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.36,65,,11.872,Percent of total Billed Charges,65% of Total Billed Charges,1.6,44.1,,1.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.45,95,,8.992,Percent of Total Billed Charges,95% of Total Billed Charges,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.19,88,,8.328,Percent of Total Billed Charges,88% of Total Billed Charges,3.27,90,,8.52,Percent of Total Billed charges,90% of Total Billed Charges,1.6,3.63,
value Pak Screeners,2720001847,CDM,272,RC,,,Outpatient,,,25.02,16.26,,25.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.02,76,,2.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.01,72,,55.44,Percent of Total Billed Charges,72% of Total Billed Charges,18.77,75,,57.752,Percent of Total Billed charges,75% of Total Billed Charges,25.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.01,72,,55.44,Percent of Total Billed Charges,72% of Total Billed Charges,15.01,60,,46.2,Percent of Total Billed Charges,60% of Total Billed Charges,22.52,90,,4.752,Percent of Total Billed Charges,90% of Total Billed Charges,11.26,45,,1.168,Percent of Total Billed Charges,45% of Total Billed Charges,22.52,90,,3.496,Percent of Total Billed Charges,90% of Total billed Charges,25.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.26,65,,2.184,Percent of total Billed Charges,65% of Total Billed Charges,11.03,44.1,,1.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.77,95,,3.688,Percent of Total Billed Charges,95% of Total Billed Charges,25.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.02,88,,3.416,Percent of Total Billed Charges,88% of Total Billed Charges,22.52,90,,3.496,Percent of Total Billed charges,90% of Total Billed Charges,11.03,25.02,
Statlock Stabilize Dev 14F-16F,2720001848,CDM,272,RC,,,Outpatient,,,23.75,15.44,,23.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.05,76,,13.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.1,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,17.81,75,,36,Percent of Total Billed charges,75% of Total Billed Charges,23.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.1,72,,34.56,Percent of Total Billed Charges,72% of Total Billed Charges,14.25,60,,28.8,Percent of Total Billed Charges,60% of Total Billed Charges,21.38,90,,2.304,Percent of Total Billed Charges,90% of Total Billed Charges,10.69,45,,1.616,Percent of Total Billed Charges,45% of Total Billed Charges,21.38,90,,16.44,Percent of Total Billed Charges,90% of Total billed Charges,23.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,65,,1.688,Percent of total Billed Charges,65% of Total Billed Charges,10.47,44.1,,1.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.56,95,,17.352,Percent of Total Billed Charges,95% of Total Billed Charges,23.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.9,88,,16.072,Percent of Total Billed Charges,88% of Total Billed Charges,21.38,90,,16.44,Percent of Total Billed charges,90% of Total Billed Charges,10.47,23.75,
Statlock Stabilize Dev 6F-8F,2720001849,CDM,272,RC,,,Outpatient,,,23.00,14.95,,23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.48,76,,2.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.56,72,,55.44,Percent of Total Billed Charges,72% of Total Billed Charges,17.25,75,,57.752,Percent of Total Billed charges,75% of Total Billed Charges,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.56,72,,55.44,Percent of Total Billed Charges,72% of Total Billed Charges,13.8,60,,46.2,Percent of Total Billed Charges,60% of Total Billed Charges,20.7,90,,8.12,Percent of Total Billed Charges,90% of Total Billed Charges,10.35,45,,1.168,Percent of Total Billed Charges,45% of Total Billed Charges,20.7,90,,3.024,Percent of Total Billed Charges,90% of Total billed Charges,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.95,65,,2.328,Percent of total Billed Charges,65% of Total Billed Charges,10.14,44.1,,1.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.85,95,,3.192,Percent of Total Billed Charges,95% of Total Billed Charges,23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.24,88,,2.96,Percent of Total Billed Charges,88% of Total Billed Charges,20.7,90,,3.024,Percent of Total Billed charges,90% of Total Billed Charges,10.14,23,
Statlock Stabilize Dev 10F-12F,2720001850,CDM,272,RC,,,Outpatient,,,23.75,15.44,,23.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.05,76,,1.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.1,72,,55.44,Percent of Total Billed Charges,72% of Total Billed Charges,17.81,75,,57.752,Percent of Total Billed charges,75% of Total Billed Charges,23.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.1,72,,55.44,Percent of Total Billed Charges,72% of Total Billed Charges,14.25,60,,46.2,Percent of Total Billed Charges,60% of Total Billed Charges,21.38,90,,2.488,Percent of Total Billed Charges,90% of Total Billed Charges,10.69,45,,3.168,Percent of Total Billed Charges,45% of Total Billed Charges,21.38,90,,2.344,Percent of Total Billed Charges,90% of Total billed Charges,23.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,65,,1.688,Percent of total Billed Charges,65% of Total Billed Charges,10.47,44.1,,3.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.56,95,,2.472,Percent of Total Billed Charges,95% of Total Billed Charges,23.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.9,88,,2.288,Percent of Total Billed Charges,88% of Total Billed Charges,21.38,90,,2.344,Percent of Total Billed charges,90% of Total Billed Charges,10.47,23.75,
Entuit IP Gastrostomy Set LG,2720001851,CDM,278,RC,,,Outpatient,,,243.75,158.44,,243.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,185.25,76,,2.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,175.5,72,,55.44,Percent of Total Billed Charges,72% of Total Billed Charges,175.5,72,,57.752,Percent of Total Billed charges,72% of Total Billed Charges,243.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.5,72,,55.44,Percent of Total Billed Charges,72% of Total Billed Charges,146.25,60,,46.2,Percent of Total Billed Charges,60% of Total Billed Charges,219.38,90,,2.704,Percent of Total Billed Charges,90% of Total Billed Charges,109.69,45,,2,Percent of Total Billed Charges,45% of Total Billed Charges,219.38,90,,3.224,Percent of Total Billed Charges,90% of Total billed Charges,243.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.44,65,,4.576,Percent of total Billed Charges,65% of Total Billed Charges,107.49,44.1,,1.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,231.56,95,,3.408,Percent of Total Billed Charges,95% of Total Billed Charges,243.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.5,88,,3.152,Percent of Total Billed Charges,88% of Total Billed Charges,219.38,90,,3.224,Percent of Total Billed charges,90% of Total Billed Charges,107.49,243.75,
Vinyl Connecting Tube 40CM,2720001852,CDM,272,RC,,,Outpatient,,,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,1.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,15.71,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,17.824,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,2.296,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,2.344,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,2.888,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,2.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,2.472,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,2.288,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,2.344,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
Hamilton C1 Expiratory Valve,2720001853,CDM,272,RC,,,Outpatient,,,70.88,46.07,,70.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.87,76,,5.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.03,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,53.16,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,70.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.03,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,42.53,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,63.79,90,,19.192,Percent of Total Billed Charges,90% of Total Billed Charges,31.9,45,,2.064,Percent of Total Billed Charges,45% of Total Billed Charges,63.79,90,,6.336,Percent of Total Billed Charges,90% of Total billed Charges,70.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.07,65,,3.32,Percent of total Billed Charges,65% of Total Billed Charges,31.26,44.1,,2.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.34,95,,6.688,Percent of Total Billed Charges,95% of Total Billed Charges,70.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.37,88,,6.192,Percent of Total Billed Charges,88% of Total Billed Charges,63.79,90,,6.336,Percent of Total Billed charges,90% of Total Billed Charges,31.26,70.88,
Hamilton C1 Breathing Circuit,2720001854,CDM,272,RC,,,Outpatient,,,71.23,46.30,,71.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.13,76,,3.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.29,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,53.42,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,71.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.29,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,42.74,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,64.11,90,,11.232,Percent of Total Billed Charges,90% of Total Billed Charges,32.05,45,,2.376,Percent of Total Billed Charges,45% of Total Billed Charges,64.11,90,,4,Percent of Total Billed Charges,90% of Total billed Charges,71.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.3,65,,2.976,Percent of total Billed Charges,65% of Total Billed Charges,31.41,44.1,,2.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.67,95,,4.216,Percent of Total Billed Charges,95% of Total Billed Charges,71.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.68,88,,3.904,Percent of Total Billed Charges,88% of Total Billed Charges,64.11,90,,4,Percent of Total Billed charges,90% of Total Billed Charges,31.41,71.23,
NITINL ANGL TIP 018X100CM WIRE,2720001855,CDM,272,RC,C1769,HCPCS,Outpatient,,,82.50,53.63,,82.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.7,76,,3.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.4,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,61.88,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,82.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.4,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,49.5,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,74.25,90,,2.864,Percent of Total Billed Charges,90% of Total Billed Charges,37.13,45,,1.152,Percent of Total Billed Charges,45% of Total Billed Charges,74.25,90,,4.592,Percent of Total Billed Charges,90% of Total billed Charges,82.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.63,65,,3.432,Percent of total Billed Charges,65% of Total Billed Charges,36.38,44.1,,1.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,78.38,95,,4.848,Percent of Total Billed Charges,95% of Total Billed Charges,82.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.6,88,,4.488,Percent of Total Billed Charges,88% of Total Billed Charges,74.25,90,,4.592,Percent of Total Billed charges,90% of Total Billed Charges,36.38,82.5,
NITINL ANGL TIP 018X125CM WIRE,2720001856,CDM,272,RC,C1769,HCPCS,Outpatient,,,82.50,53.63,,82.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.7,76,,3.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.4,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,61.88,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,82.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.4,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,49.5,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,74.25,90,,2.256,Percent of Total Billed Charges,90% of Total Billed Charges,37.13,45,,4.064,Percent of Total Billed Charges,45% of Total Billed Charges,74.25,90,,4.128,Percent of Total Billed Charges,90% of Total billed Charges,82.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.63,65,,1.664,Percent of total Billed Charges,65% of Total Billed Charges,36.38,44.1,,3.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,78.38,95,,4.352,Percent of Total Billed Charges,95% of Total Billed Charges,82.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.6,88,,4.032,Percent of Total Billed Charges,88% of Total Billed Charges,74.25,90,,4.128,Percent of Total Billed charges,90% of Total Billed Charges,36.38,82.5,
Pressure Infusor Bag 500ml,2720001857,CDM,272,RC,,,Outpatient,,,56.45,36.69,,56.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.9,76,,4.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.64,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,42.34,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,56.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.64,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,33.87,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,50.81,90,,3.568,Percent of Total Billed Charges,90% of Total Billed Charges,25.4,45,,1.24,Percent of Total Billed Charges,45% of Total Billed Charges,50.81,90,,4.752,Percent of Total Billed Charges,90% of Total billed Charges,56.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.69,65,,5.864,Percent of total Billed Charges,65% of Total Billed Charges,24.89,44.1,,1.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.63,95,,5.016,Percent of Total Billed Charges,95% of Total Billed Charges,56.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.68,88,,4.648,Percent of Total Billed Charges,88% of Total Billed Charges,50.81,90,,4.752,Percent of Total Billed charges,90% of Total Billed Charges,24.89,56.45,
Pressure Infusor bag 1000ml,2720001858,CDM,272,RC,,,Outpatient,,,60.00,39.00,,60,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.6,76,,1.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.2,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,45,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.2,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,36,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,54,90,,3.768,Percent of Total Billed Charges,90% of Total Billed Charges,27,45,,1.352,Percent of Total Billed Charges,45% of Total Billed Charges,54,90,,2.304,Percent of Total Billed Charges,90% of Total billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39,65,,1.792,Percent of total Billed Charges,65% of Total Billed Charges,26.46,44.1,,1.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,57,95,,2.432,Percent of Total Billed Charges,95% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.8,88,,2.256,Percent of Total Billed Charges,88% of Total Billed Charges,54,90,,2.304,Percent of Total Billed charges,90% of Total Billed Charges,26.46,60,
Pressur Infusor bag 3000ml,2720001859,CDM,272,RC,,,Outpatient,,,138.75,90.19,,138.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,105.45,76,,6.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,99.9,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,104.06,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,138.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.9,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,83.25,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,124.88,90,,3.712,Percent of Total Billed Charges,90% of Total Billed Charges,62.44,45,,8.912,Percent of Total Billed Charges,45% of Total Billed Charges,124.88,90,,8.12,Percent of Total Billed Charges,90% of Total billed Charges,138.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.19,65,,1.952,Percent of total Billed Charges,65% of Total Billed Charges,61.19,44.1,,8.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,131.81,95,,8.576,Percent of Total Billed Charges,95% of Total Billed Charges,138.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.1,88,,7.944,Percent of Total Billed Charges,88% of Total Billed Charges,124.88,90,,8.12,Percent of Total Billed charges,90% of Total Billed Charges,61.19,138.75,
Telfa 3x8 (Curad) LF,2720001860,CDM,272,RC,,,Outpatient,,,0.23,0.15,,0.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.17,76,,2.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.17,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,0.17,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,0.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.17,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,0.14,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,0.21,90,,3.296,Percent of Total Billed Charges,90% of Total Billed Charges,0.1,45,,9.592,Percent of Total Billed Charges,45% of Total Billed Charges,0.21,90,,2.488,Percent of Total Billed Charges,90% of Total billed Charges,0.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.15,65,,12.872,Percent of total Billed Charges,65% of Total Billed Charges,0.1,44.1,,9.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.22,95,,2.624,Percent of Total Billed Charges,95% of Total Billed Charges,0.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.2,88,,2.432,Percent of Total Billed Charges,88% of Total Billed Charges,0.21,90,,2.488,Percent of Total Billed charges,90% of Total Billed Charges,0.1,0.23,
Telfa 4x8,2720001861,CDM,272,RC,,,Outpatient,,,1.98,1.29,,1.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.5,76,,2.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.43,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,1.49,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,1.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.43,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,1.19,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,1.78,90,,2.632,Percent of Total Billed Charges,90% of Total Billed Charges,0.89,45,,5.616,Percent of Total Billed Charges,45% of Total Billed Charges,1.78,90,,2.704,Percent of Total Billed Charges,90% of Total billed Charges,1.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.29,65,,13.856,Percent of total Billed Charges,65% of Total Billed Charges,0.87,44.1,,5.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.88,95,,2.848,Percent of Total Billed Charges,95% of Total Billed Charges,1.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.74,88,,2.64,Percent of Total Billed Charges,88% of Total Billed Charges,1.78,90,,2.704,Percent of Total Billed charges,90% of Total Billed Charges,0.87,1.98,
Steri Strip 1/8 X 3,2720001862,CDM,272,RC,,,Outpatient,,,1.30,0.85,,1.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.99,76,,15.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.94,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,0.98,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,1.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.94,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,0.78,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,1.17,90,,3.48,Percent of Total Billed Charges,90% of Total Billed Charges,0.59,45,,1.432,Percent of Total Billed Charges,45% of Total Billed Charges,1.17,90,,17.824,Percent of Total Billed Charges,90% of Total billed Charges,1.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.85,65,,8.112,Percent of total Billed Charges,65% of Total Billed Charges,0.57,44.1,,1.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.24,95,,18.808,Percent of Total Billed Charges,95% of Total Billed Charges,1.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.14,88,,17.424,Percent of Total Billed Charges,88% of Total Billed Charges,1.17,90,,17.824,Percent of Total Billed charges,90% of Total Billed Charges,0.57,1.3,
Sut Ethln 2-0 BLK Mono PS 593H,2720001863,CDM,272,RC,,,Outpatient,,,6.28,4.08,,6.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.77,76,,16.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.52,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,4.71,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,6.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.52,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,3.77,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,5.65,90,,7.256,Percent of Total Billed Charges,90% of Total Billed Charges,2.83,45,,1.128,Percent of Total Billed Charges,45% of Total Billed Charges,5.65,90,,19.192,Percent of Total Billed Charges,90% of Total billed Charges,6.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.08,65,,2.072,Percent of total Billed Charges,65% of Total Billed Charges,2.77,44.1,,1.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.97,95,,20.256,Percent of Total Billed Charges,95% of Total Billed Charges,6.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.53,88,,18.76,Percent of Total Billed Charges,88% of Total Billed Charges,5.65,90,,19.192,Percent of Total Billed charges,90% of Total Billed Charges,2.77,6.28,
Telfa 2x3 (Curad),2720001864,CDM,272,RC,,,Outpatient,,,0.08,0.05,,0.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.06,76,,9.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.06,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,0.06,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,0.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.06,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,0.05,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,0.07,90,,4.128,Percent of Total Billed Charges,90% of Total Billed Charges,0.04,45,,1.784,Percent of Total Billed Charges,45% of Total Billed Charges,0.07,90,,11.232,Percent of Total Billed Charges,90% of Total billed Charges,0.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.05,65,,1.624,Percent of total Billed Charges,65% of Total Billed Charges,0.04,44.1,,1.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.08,95,,11.856,Percent of Total Billed Charges,95% of Total Billed Charges,0.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.07,88,,10.984,Percent of Total Billed Charges,88% of Total Billed Charges,0.07,90,,11.232,Percent of Total Billed charges,90% of Total Billed Charges,0.04,0.08,
Steri Strip 1/4 x 4,2720001865,CDM,272,RC,,,Outpatient,,,2.00,1.30,,2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.52,76,,2.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.44,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,1.5,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.44,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,1.2,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,1.8,90,,2.992,Percent of Total Billed Charges,90% of Total Billed Charges,0.9,45,,1.88,Percent of Total Billed Charges,45% of Total Billed Charges,1.8,90,,2.864,Percent of Total Billed Charges,90% of Total billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.3,65,,2.576,Percent of total Billed Charges,65% of Total Billed Charges,0.88,44.1,,1.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.9,95,,3.024,Percent of Total Billed Charges,95% of Total Billed Charges,2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.76,88,,2.8,Percent of Total Billed Charges,88% of Total Billed Charges,1.8,90,,2.864,Percent of Total Billed charges,90% of Total Billed Charges,0.88,2,
Nanocross E 4F 014 3.5x150x150,2720001866,CDM,272,RC,C1725,HCPCS,Outpatient,,,747.50,485.88,,747.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,568.1,76,,1.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,538.2,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,560.63,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,747.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.2,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,448.5,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,672.75,90,,3.12,Percent of Total Billed Charges,90% of Total Billed Charges,336.38,45,,1.856,Percent of Total Billed Charges,45% of Total Billed Charges,672.75,90,,2.256,Percent of Total Billed Charges,90% of Total billed Charges,747.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,747.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,747.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.88,65,,2.72,Percent of total Billed Charges,65% of Total Billed Charges,329.65,44.1,,1.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,710.13,95,,2.376,Percent of Total Billed Charges,95% of Total Billed Charges,747.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,657.8,88,,2.2,Percent of Total Billed Charges,88% of Total Billed Charges,672.75,90,,2.256,Percent of Total Billed charges,90% of Total Billed Charges,329.65,747.5,
Cleaner Caut Tip 2x2 Sterile,2720001867,CDM,272,RC,,,Outpatient,,,0.55,0.36,,0.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.42,76,,3.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.4,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,0.41,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,0.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.4,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,0.33,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,0.5,90,,33.664,Percent of Total Billed Charges,90% of Total Billed Charges,0.25,45,,1.648,Percent of Total Billed Charges,45% of Total Billed Charges,0.5,90,,3.568,Percent of Total Billed Charges,90% of Total billed Charges,0.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.36,65,,2.68,Percent of total Billed Charges,65% of Total Billed Charges,0.24,44.1,,1.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.52,95,,3.76,Percent of Total Billed Charges,95% of Total Billed Charges,0.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.48,88,,3.488,Percent of Total Billed Charges,88% of Total Billed Charges,0.5,90,,3.568,Percent of Total Billed charges,90% of Total Billed Charges,0.24,0.55,
10ml/cc Control Syringe,2720001868,CDM,272,RC,,,Outpatient,,,8.75,5.69,,8.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.65,76,,3.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.3,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,6.56,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,8.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.3,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,5.25,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,7.88,90,,33.664,Percent of Total Billed Charges,90% of Total Billed Charges,3.94,45,,1.312,Percent of Total Billed Charges,45% of Total Billed Charges,7.88,90,,3.768,Percent of Total Billed Charges,90% of Total billed Charges,8.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.69,65,,2.384,Percent of total Billed Charges,65% of Total Billed Charges,3.86,44.1,,1.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.31,95,,3.976,Percent of Total Billed Charges,95% of Total Billed Charges,8.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.7,88,,3.68,Percent of Total Billed Charges,88% of Total Billed Charges,7.88,90,,3.768,Percent of Total Billed charges,90% of Total Billed Charges,3.86,8.75,
Cordis MPA-2 4F (100CM) Cath,2720001869,CDM,272,RC,C1887,HCPCS,Outpatient,,,29.38,19.10,,29.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.33,76,,3.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.15,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,22.04,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,29.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.15,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,17.63,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,26.44,90,,33.664,Percent of Total Billed Charges,90% of Total Billed Charges,13.22,45,,1.736,Percent of Total Billed Charges,45% of Total Billed Charges,26.44,90,,3.712,Percent of Total Billed Charges,90% of Total billed Charges,29.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.1,65,,1.896,Percent of total Billed Charges,65% of Total Billed Charges,12.96,44.1,,1.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,27.91,95,,3.912,Percent of Total Billed Charges,95% of Total Billed Charges,29.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.85,88,,3.624,Percent of Total Billed Charges,88% of Total Billed Charges,26.44,90,,3.712,Percent of Total Billed charges,90% of Total Billed Charges,12.96,29.38,
Asahi Confian Pro 9 180cm Wire,2720001870,CDM,272,RC,C1769,HCPCS,Outpatient,,,337.50,219.38,,337.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,256.5,76,,2.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,243,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,253.13,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,337.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,202.5,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,303.75,90,,33.664,Percent of Total Billed Charges,90% of Total Billed Charges,151.88,45,,3.632,Percent of Total Billed Charges,45% of Total Billed Charges,303.75,90,,3.296,Percent of Total Billed Charges,90% of Total billed Charges,337.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.38,65,,2.512,Percent of total Billed Charges,65% of Total Billed Charges,148.84,44.1,,3.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,320.63,95,,3.48,Percent of Total Billed Charges,95% of Total Billed Charges,337.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,88,,3.224,Percent of Total Billed Charges,88% of Total Billed Charges,303.75,90,,3.296,Percent of Total Billed charges,90% of Total Billed Charges,148.84,337.5,
Runway Guide 6F FL3,2720001871,CDM,272,RC,C1887,HCPCS,Outpatient,,,105.00,68.25,,105,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.8,76,,2.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75.6,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,78.75,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.6,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,63,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,94.5,90,,33.664,Percent of Total Billed Charges,90% of Total Billed Charges,47.25,45,,2.064,Percent of Total Billed Charges,45% of Total Billed Charges,94.5,90,,2.632,Percent of Total Billed Charges,90% of Total billed Charges,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.25,65,,5.24,Percent of total Billed Charges,65% of Total Billed Charges,46.31,44.1,,2.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,99.75,95,,2.776,Percent of Total Billed Charges,95% of Total Billed Charges,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.4,88,,2.568,Percent of Total Billed Charges,88% of Total Billed Charges,94.5,90,,2.632,Percent of Total Billed charges,90% of Total Billed Charges,46.31,105,
500ML Pressure Infusion Bag,2720001872,CDM,272,RC,,,Outpatient,,,27.05,17.58,,27.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.56,76,,2.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.48,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,20.29,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,27.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.48,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,16.23,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,24.35,90,,33.664,Percent of Total Billed Charges,90% of Total Billed Charges,12.17,45,,1.496,Percent of Total Billed Charges,45% of Total Billed Charges,24.35,90,,3.48,Percent of Total Billed Charges,90% of Total billed Charges,27.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.58,65,,2.976,Percent of total Billed Charges,65% of Total Billed Charges,11.93,44.1,,1.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.7,95,,3.672,Percent of Total Billed Charges,95% of Total Billed Charges,27.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.8,88,,3.4,Percent of Total Billed Charges,88% of Total Billed Charges,24.35,90,,3.48,Percent of Total Billed charges,90% of Total Billed Charges,11.93,27.05,
"Suture CHR Gut 5-0 PS-3 18""",2720001873,CDM,272,RC,,,Outpatient,,,11.35,7.38,,11.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.63,76,,6.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.17,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,8.51,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,11.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.17,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,6.81,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,10.22,90,,33.664,Percent of Total Billed Charges,90% of Total Billed Charges,5.11,45,,1.56,Percent of Total Billed Charges,45% of Total Billed Charges,10.22,90,,7.256,Percent of Total Billed Charges,90% of Total billed Charges,11.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.38,65,,2.16,Percent of total Billed Charges,65% of Total Billed Charges,5.01,44.1,,1.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.78,95,,7.664,Percent of Total Billed Charges,95% of Total Billed Charges,11.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.99,88,,7.096,Percent of Total Billed Charges,88% of Total Billed Charges,10.22,90,,7.256,Percent of Total Billed charges,90% of Total Billed Charges,5.01,11.35,
"Suture CHR Gut 4-0 PS-2 18""",2720001874,CDM,272,RC,,,Outpatient,,,11.83,7.69,,11.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.99,76,,3.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.52,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,8.87,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,11.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.52,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,7.1,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,10.65,90,,6.304,Percent of Total Billed Charges,90% of Total Billed Charges,5.32,45,,16.832,Percent of Total Billed Charges,45% of Total Billed Charges,10.65,90,,4.128,Percent of Total Billed Charges,90% of Total billed Charges,11.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.69,65,,2.248,Percent of total Billed Charges,65% of Total Billed Charges,5.22,44.1,,16.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.24,95,,4.352,Percent of Total Billed Charges,95% of Total Billed Charges,11.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.41,88,,4.032,Percent of Total Billed Charges,88% of Total Billed Charges,10.65,90,,4.128,Percent of Total Billed charges,90% of Total Billed Charges,5.22,11.83,
"Sut pliab mono Blk 6-0 18""",2720001875,CDM,272,RC,,,Outpatient,,,5.90,3.84,,5.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.48,76,,2.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.25,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,4.43,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,5.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.25,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,3.54,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,5.31,90,,33.664,Percent of Total Billed Charges,90% of Total Billed Charges,2.66,45,,16.832,Percent of Total Billed Charges,45% of Total Billed Charges,5.31,90,,2.992,Percent of Total Billed Charges,90% of Total billed Charges,5.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.84,65,,24.312,Percent of total Billed Charges,65% of Total Billed Charges,2.6,44.1,,16.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.61,95,,3.152,Percent of Total Billed Charges,95% of Total Billed Charges,5.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.19,88,,2.92,Percent of Total Billed Charges,88% of Total Billed Charges,5.31,90,,2.992,Percent of Total Billed charges,90% of Total Billed Charges,2.6,5.9,
"Sut Ethln 4-0 18""",2720001876,CDM,272,RC,,,Outpatient,,,7.00,4.55,,7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.32,76,,2.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.04,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,5.25,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.04,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,4.2,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,6.3,90,,17.952,Percent of Total Billed Charges,90% of Total Billed Charges,3.15,45,,16.832,Percent of Total Billed Charges,45% of Total Billed Charges,6.3,90,,3.12,Percent of Total Billed Charges,90% of Total billed Charges,7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.55,65,,24.312,Percent of total Billed Charges,65% of Total Billed Charges,3.09,44.1,,16.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.65,95,,3.288,Percent of Total Billed Charges,95% of Total Billed Charges,7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.16,88,,3.048,Percent of Total Billed Charges,88% of Total Billed Charges,6.3,90,,3.12,Percent of Total Billed charges,90% of Total Billed Charges,3.09,7,
ORAL AIRWAY 50MM INFANT,2720001877,CDM,272,RC,,,Outpatient,,,3.55,2.31,,3.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.7,76,,28.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.56,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,2.66,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,3.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.56,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,2.13,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,3.2,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,1.6,45,,16.832,Percent of Total Billed Charges,45% of Total Billed Charges,3.2,90,,33.664,Percent of Total Billed Charges,90% of Total billed Charges,3.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.31,65,,24.312,Percent of total Billed Charges,65% of Total Billed Charges,1.57,44.1,,16.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.37,95,,35.528,Percent of Total Billed Charges,95% of Total Billed Charges,3.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.12,88,,32.912,Percent of Total Billed Charges,88% of Total Billed Charges,3.2,90,,33.664,Percent of Total Billed charges,90% of Total Billed Charges,1.57,3.55,
PAD DEFIB ZOLL ONE STEP PEDI,2720001878,CDM,272,RC,,,Outpatient,,,146.25,95.06,,146.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,111.15,76,,28.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,105.3,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,109.69,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,146.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.3,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,87.75,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,131.63,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,65.81,45,,16.832,Percent of Total Billed Charges,45% of Total Billed Charges,131.63,90,,33.664,Percent of Total Billed Charges,90% of Total billed Charges,146.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.06,65,,24.312,Percent of total Billed Charges,65% of Total Billed Charges,64.5,44.1,,16.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,138.94,95,,35.528,Percent of Total Billed Charges,95% of Total Billed Charges,146.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.7,88,,32.912,Percent of Total Billed Charges,88% of Total Billed Charges,131.63,90,,33.664,Percent of Total Billed charges,90% of Total Billed Charges,64.5,146.25,
SUT ETHLN MONO BLK 048 TP-1,2720001879,CDM,272,RC,,,Outpatient,,,6.00,3.90,,6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.56,76,,28.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.32,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,4.5,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.32,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,3.6,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,5.4,90,,17.104,Percent of Total Billed Charges,90% of Total Billed Charges,2.7,45,,16.832,Percent of Total Billed Charges,45% of Total Billed Charges,5.4,90,,33.664,Percent of Total Billed Charges,90% of Total billed Charges,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.9,65,,24.312,Percent of total Billed Charges,65% of Total Billed Charges,2.65,44.1,,16.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.7,95,,35.528,Percent of Total Billed Charges,95% of Total Billed Charges,6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.28,88,,32.912,Percent of Total Billed Charges,88% of Total Billed Charges,5.4,90,,33.664,Percent of Total Billed charges,90% of Total Billed Charges,2.65,6,
SUT PRLN MONO BLUE 0 30 CTX,2720001880,CDM,272,RC,,,Outpatient,,,4.68,3.04,,4.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.56,76,,28.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.37,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,3.51,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,4.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.37,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,2.81,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.21,90,,117,Percent of Total Billed Charges,90% of Total Billed Charges,2.11,45,,16.832,Percent of Total Billed Charges,45% of Total Billed Charges,4.21,90,,33.664,Percent of Total Billed Charges,90% of Total billed Charges,4.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.04,65,,24.312,Percent of total Billed Charges,65% of Total Billed Charges,2.06,44.1,,16.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.45,95,,35.528,Percent of Total Billed Charges,95% of Total Billed Charges,4.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.12,88,,32.912,Percent of Total Billed Charges,88% of Total Billed Charges,4.21,90,,33.664,Percent of Total Billed charges,90% of Total Billed Charges,2.06,4.68,
SUT 0 36 CTD VIC UND BR CT XB,2720001881,CDM,272,RC,,,Outpatient,,,4.33,2.81,,4.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.29,76,,28.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.12,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,3.25,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,4.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.12,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,2.6,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,3.9,90,,0.576,Percent of Total Billed Charges,90% of Total Billed Charges,1.95,45,,3.152,Percent of Total Billed Charges,45% of Total Billed Charges,3.9,90,,33.664,Percent of Total Billed Charges,90% of Total billed Charges,4.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.81,65,,24.312,Percent of total Billed Charges,65% of Total Billed Charges,1.91,44.1,,3.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.11,95,,35.528,Percent of Total Billed Charges,95% of Total Billed Charges,4.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.81,88,,32.912,Percent of Total Billed Charges,88% of Total Billed Charges,3.9,90,,33.664,Percent of Total Billed charges,90% of Total Billed Charges,1.91,4.33,
"SUT PLBLZD MON BLK 5/0 18"" PC1",2720001882,CDM,272,RC,,,Outpatient,,,7.08,4.60,,7.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.38,76,,28.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.1,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,5.31,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,7.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.1,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,4.25,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,6.37,90,,0.648,Percent of Total Billed Charges,90% of Total Billed Charges,3.19,45,,16.832,Percent of Total Billed Charges,45% of Total Billed Charges,6.37,90,,33.664,Percent of Total Billed Charges,90% of Total billed Charges,7.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.6,65,,4.552,Percent of total Billed Charges,65% of Total Billed Charges,3.12,44.1,,16.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.73,95,,35.528,Percent of Total Billed Charges,95% of Total Billed Charges,7.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.23,88,,32.912,Percent of Total Billed Charges,88% of Total Billed Charges,6.37,90,,33.664,Percent of Total Billed charges,90% of Total Billed Charges,3.12,7.08,
BLADE MAC SZ 3 MCGRATH,2720001883,CDM,272,RC,,,Outpatient,,,25.88,16.82,,25.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.67,76,,28.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.63,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,19.41,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,25.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.63,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,15.53,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,23.29,90,,0.576,Percent of Total Billed Charges,90% of Total Billed Charges,11.65,45,,8.976,Percent of Total Billed Charges,45% of Total Billed Charges,23.29,90,,33.664,Percent of Total Billed Charges,90% of Total billed Charges,25.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.82,65,,24.312,Percent of total Billed Charges,65% of Total Billed Charges,11.41,44.1,,8.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.59,95,,35.528,Percent of Total Billed Charges,95% of Total Billed Charges,25.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.77,88,,32.912,Percent of Total Billed Charges,88% of Total Billed Charges,23.29,90,,33.664,Percent of Total Billed charges,90% of Total Billed Charges,11.41,25.88,
UNCUFF ENDO TUBE W/STYL 2.5MM,2720001884,CDM,272,RC,,,Outpatient,,,7.13,4.63,,7.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.42,76,,5.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.13,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,5.35,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,7.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.13,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,4.28,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,6.42,90,,0.576,Percent of Total Billed Charges,90% of Total Billed Charges,3.21,45,,5.4,Percent of Total Billed Charges,45% of Total Billed Charges,6.42,90,,6.304,Percent of Total Billed Charges,90% of Total billed Charges,7.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.63,65,,12.96,Percent of total Billed Charges,65% of Total Billed Charges,3.14,44.1,,5.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.77,95,,6.648,Percent of Total Billed Charges,95% of Total Billed Charges,7.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.27,88,,6.16,Percent of Total Billed Charges,88% of Total Billed Charges,6.42,90,,6.304,Percent of Total Billed charges,90% of Total Billed Charges,3.14,7.13,
UNCUFF ENDO TUBE W/STYL 3MM,2720001885,CDM,272,RC,,,Outpatient,,,7.13,4.63,,7.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.42,76,,28.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.13,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,5.35,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,7.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.13,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,4.28,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,6.42,90,,40.824,Percent of Total Billed Charges,90% of Total Billed Charges,3.21,45,,5.4,Percent of Total Billed Charges,45% of Total Billed Charges,6.42,90,,33.664,Percent of Total Billed Charges,90% of Total billed Charges,7.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.63,65,,7.8,Percent of total Billed Charges,65% of Total Billed Charges,3.14,44.1,,5.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.77,95,,35.528,Percent of Total Billed Charges,95% of Total Billed Charges,7.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.27,88,,32.912,Percent of Total Billed Charges,88% of Total Billed Charges,6.42,90,,33.664,Percent of Total Billed charges,90% of Total Billed Charges,3.14,7.13,
UNCUFF ENDO TUBE W/STYL 3.5MM,2720001886,CDM,272,RC,,,Outpatient,,,7.13,4.63,,7.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.42,76,,15.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.13,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,5.35,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,7.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.13,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,4.28,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,6.42,90,,41.64,Percent of Total Billed Charges,90% of Total Billed Charges,3.21,45,,8.552,Percent of Total Billed Charges,45% of Total Billed Charges,6.42,90,,17.952,Percent of Total Billed Charges,90% of Total billed Charges,7.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.63,65,,7.8,Percent of total Billed Charges,65% of Total Billed Charges,3.14,44.1,,8.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.77,95,,18.944,Percent of Total Billed Charges,95% of Total Billed Charges,7.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.27,88,,17.552,Percent of Total Billed Charges,88% of Total Billed Charges,6.42,90,,17.952,Percent of Total Billed charges,90% of Total Billed Charges,3.14,7.13,
UNCUFF ENDO TUBE W/STYL,2720001887,CDM,272,RC,,,Outpatient,,,7.13,4.63,,7.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.42,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.13,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,5.35,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,7.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.13,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,4.28,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,6.42,90,,41.64,Percent of Total Billed Charges,90% of Total Billed Charges,3.21,45,,58.504,Percent of Total Billed Charges,45% of Total Billed Charges,6.42,90,,10.8,Percent of Total Billed Charges,90% of Total billed Charges,7.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.63,65,,12.352,Percent of total Billed Charges,65% of Total Billed Charges,3.14,44.1,,57.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.77,95,,11.4,Percent of Total Billed Charges,95% of Total Billed Charges,7.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.27,88,,10.56,Percent of Total Billed Charges,88% of Total Billed Charges,6.42,90,,10.8,Percent of Total Billed charges,90% of Total Billed Charges,3.14,7.13,
EZ-IO PD 15G INTRA NDL 15MM,2720001888,CDM,272,RC,,,Outpatient,,,356.50,231.73,,356.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,270.94,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,256.68,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,267.38,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,356.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.68,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,213.9,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,320.85,90,,40.824,Percent of Total Billed Charges,90% of Total Billed Charges,160.43,45,,0.288,Percent of Total Billed Charges,45% of Total Billed Charges,320.85,90,,10.8,Percent of Total Billed Charges,90% of Total billed Charges,356.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.73,65,,84.504,Percent of total Billed Charges,65% of Total Billed Charges,157.22,44.1,,0.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,338.68,95,,11.4,Percent of Total Billed Charges,95% of Total Billed Charges,356.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.72,88,,10.56,Percent of Total Billed Charges,88% of Total Billed Charges,320.85,90,,10.8,Percent of Total Billed charges,90% of Total Billed Charges,157.22,356.5,
EZ-STABILIZER,2720001889,CDM,272,RC,,,Outpatient,,,45.00,29.25,,45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.2,76,,14.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.4,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,33.75,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.4,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,27,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,40.5,90,,367.344,Percent of Total Billed Charges,90% of Total Billed Charges,20.25,45,,0.328,Percent of Total Billed Charges,45% of Total Billed Charges,40.5,90,,17.104,Percent of Total Billed Charges,90% of Total billed Charges,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.25,65,,0.416,Percent of total Billed Charges,65% of Total Billed Charges,19.85,44.1,,0.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.75,95,,18.048,Percent of Total Billed Charges,95% of Total Billed Charges,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.6,88,,16.72,Percent of Total Billed Charges,88% of Total Billed Charges,40.5,90,,17.104,Percent of Total Billed charges,90% of Total Billed Charges,19.85,45,
EZ-IO 15G INTA NDL OBES 45MM,2720001890,CDM,272,RC,,,Outpatient,,,45.00,29.25,,45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.2,76,,98.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.4,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,33.75,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.4,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,27,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,40.5,90,,11.4,Percent of Total Billed Charges,90% of Total Billed Charges,20.25,45,,0.288,Percent of Total Billed Charges,45% of Total Billed Charges,40.5,90,,117,Percent of Total Billed Charges,90% of Total billed Charges,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.25,65,,0.472,Percent of total Billed Charges,65% of Total Billed Charges,19.85,44.1,,0.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.75,95,,123.504,Percent of Total Billed Charges,95% of Total Billed Charges,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.6,88,,114.4,Percent of Total Billed Charges,88% of Total Billed Charges,40.5,90,,117,Percent of Total Billed charges,90% of Total Billed Charges,19.85,45,
G TUBE 16FR MAGNA PORT,2720001891,CDM,272,RC,,,Outpatient,,,125.00,81.25,,125,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95,76,,0.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,93.75,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,75,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,112.5,90,,11.4,Percent of Total Billed Charges,90% of Total Billed Charges,56.25,45,,0.288,Percent of Total Billed Charges,45% of Total Billed Charges,112.5,90,,0.576,Percent of Total Billed Charges,90% of Total billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.25,65,,0.416,Percent of total Billed Charges,65% of Total Billed Charges,55.13,44.1,,0.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,118.75,95,,0.608,Percent of Total Billed Charges,95% of Total Billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110,88,,0.56,Percent of Total Billed Charges,88% of Total Billed Charges,112.5,90,,0.576,Percent of Total Billed charges,90% of Total Billed Charges,55.13,125,
G TUBE 18FR MAGNA  PORT,2720001892,CDM,272,RC,,,Outpatient,,,125.00,81.25,,125,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95,76,,0.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,93.75,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,75,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,112.5,90,,11.4,Percent of Total Billed Charges,90% of Total Billed Charges,56.25,45,,20.416,Percent of Total Billed Charges,45% of Total Billed Charges,112.5,90,,0.648,Percent of Total Billed Charges,90% of Total billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.25,65,,0.416,Percent of total Billed Charges,65% of Total Billed Charges,55.13,44.1,,20,Percent of Total Billed Charges,44.1% of Total Billed Charges,118.75,95,,0.688,Percent of Total Billed Charges,95% of Total Billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110,88,,0.632,Percent of Total Billed Charges,88% of Total Billed Charges,112.5,90,,0.648,Percent of Total Billed charges,90% of Total Billed Charges,55.13,125,
4.5 ORAL RAE CUFFED,2720001893,CDM,272,RC,,,Outpatient,,,10.00,6.50,,10,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.6,76,,0.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.2,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,7.5,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.2,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,6,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,9,90,,21.64,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,45,,20.816,Percent of Total Billed Charges,45% of Total Billed Charges,9,90,,0.576,Percent of Total Billed Charges,90% of Total billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,65,,29.488,Percent of total Billed Charges,65% of Total Billed Charges,4.41,44.1,,20.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.5,95,,0.608,Percent of Total Billed Charges,95% of Total Billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.8,88,,0.56,Percent of Total Billed Charges,88% of Total Billed Charges,9,90,,0.576,Percent of Total Billed charges,90% of Total Billed Charges,4.41,10,
ENDO TUBE UNCUFFED 2.0 & STYLE,2720001894,CDM,272,RC,,,Outpatient,,,10.35,6.73,,10.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.87,76,,0.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.45,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,7.76,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,10.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.45,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,6.21,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,9.32,90,,22.016,Percent of Total Billed Charges,90% of Total Billed Charges,4.66,45,,20.816,Percent of Total Billed Charges,45% of Total Billed Charges,9.32,90,,0.576,Percent of Total Billed Charges,90% of Total billed Charges,10.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.73,65,,30.072,Percent of total Billed Charges,65% of Total Billed Charges,4.56,44.1,,20.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.83,95,,0.608,Percent of Total Billed Charges,95% of Total Billed Charges,10.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.11,88,,0.56,Percent of Total Billed Charges,88% of Total Billed Charges,9.32,90,,0.576,Percent of Total Billed charges,90% of Total Billed Charges,4.56,10.35,
ENDO TUBE UNCUFFED 2.5 & STYLE,2720001895,CDM,272,RC,,,Outpatient,,,10.35,6.73,,10.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.87,76,,34.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.45,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,7.76,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,10.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.45,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,6.21,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,9.32,90,,17.336,Percent of Total Billed Charges,90% of Total Billed Charges,4.66,45,,20.416,Percent of Total Billed Charges,45% of Total Billed Charges,9.32,90,,40.824,Percent of Total Billed Charges,90% of Total billed Charges,10.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.73,65,,30.072,Percent of total Billed Charges,65% of Total Billed Charges,4.56,44.1,,20,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.83,95,,43.096,Percent of Total Billed Charges,95% of Total Billed Charges,10.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.11,88,,39.92,Percent of Total Billed Charges,88% of Total Billed Charges,9.32,90,,40.824,Percent of Total Billed charges,90% of Total Billed Charges,4.56,10.35,
G TUBE 24FR MAGNA PORT,2720001897,CDM,272,RC,,,Outpatient,,,365.00,237.25,,365,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,277.4,76,,35.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,262.8,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,273.75,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,365,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.8,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,219,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,328.5,90,,21.672,Percent of Total Billed Charges,90% of Total Billed Charges,164.25,45,,183.672,Percent of Total Billed Charges,45% of Total Billed Charges,328.5,90,,41.64,Percent of Total Billed Charges,90% of Total billed Charges,365,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.25,65,,29.488,Percent of total Billed Charges,65% of Total Billed Charges,160.97,44.1,,180,Percent of Total Billed Charges,44.1% of Total Billed Charges,346.75,95,,43.952,Percent of Total Billed Charges,95% of Total Billed Charges,365,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,321.2,88,,40.712,Percent of Total Billed Charges,88% of Total Billed Charges,328.5,90,,41.64,Percent of Total Billed charges,90% of Total Billed Charges,160.97,365,
ARTERIAL LINE TRAY,2720001898,CDM,272,RC,,,Outpatient,,,50.00,32.50,,50,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38,76,,35.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,37.5,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,30,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,45,90,,9.96,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,45,,5.696,Percent of Total Billed Charges,45% of Total Billed Charges,45,90,,41.64,Percent of Total Billed Charges,90% of Total billed Charges,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.5,65,,265.304,Percent of total Billed Charges,65% of Total Billed Charges,22.05,44.1,,5.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,47.5,95,,43.952,Percent of Total Billed Charges,95% of Total Billed Charges,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44,88,,40.712,Percent of Total Billed Charges,88% of Total Billed Charges,45,90,,41.64,Percent of Total Billed charges,90% of Total Billed Charges,22.05,50,
NASAL RAE TUBE/UNCUFF 6.5,2720001899,CDM,272,RC,,,Outpatient,,,6.70,4.36,,6.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.09,76,,34.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.82,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,5.03,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,6.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.82,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,4.02,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,6.03,90,,2.2,Percent of Total Billed Charges,90% of Total Billed Charges,3.02,45,,5.696,Percent of Total Billed Charges,45% of Total Billed Charges,6.03,90,,40.824,Percent of Total Billed Charges,90% of Total billed Charges,6.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.36,65,,8.232,Percent of total Billed Charges,65% of Total Billed Charges,2.95,44.1,,5.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.37,95,,43.096,Percent of Total Billed Charges,95% of Total Billed Charges,6.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.9,88,,39.92,Percent of Total Billed Charges,88% of Total Billed Charges,6.03,90,,40.824,Percent of Total Billed charges,90% of Total Billed Charges,2.95,6.7,
"PLN GUT 4-0 P-3 18"" 1644G SUT",2720001900,CDM,272,RC,,,Outpatient,,,11.33,7.36,,11.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.61,76,,310.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.16,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,8.5,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,11.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.16,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,6.8,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,10.2,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,5.1,45,,5.696,Percent of Total Billed Charges,45% of Total Billed Charges,10.2,90,,367.344,Percent of Total Billed Charges,90% of Total billed Charges,11.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.36,65,,8.232,Percent of total Billed Charges,65% of Total Billed Charges,5,44.1,,5.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.76,95,,387.752,Percent of Total Billed Charges,95% of Total Billed Charges,11.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.97,88,,359.184,Percent of Total Billed Charges,88% of Total Billed Charges,10.2,90,,367.344,Percent of Total Billed charges,90% of Total Billed Charges,5,11.33,
SUTURE VICRYL 4-0 J773D,2720001901,CDM,272,RC,,,Outpatient,,,22.28,14.48,,22.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.93,76,,9.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.04,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,16.71,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.04,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,13.37,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,20.05,90,,7.528,Percent of Total Billed Charges,90% of Total Billed Charges,10.03,45,,10.816,Percent of Total Billed Charges,45% of Total Billed Charges,20.05,90,,11.4,Percent of Total Billed Charges,90% of Total billed Charges,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.48,65,,8.232,Percent of total Billed Charges,65% of Total Billed Charges,9.83,44.1,,10.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.17,95,,12.032,Percent of Total Billed Charges,95% of Total Billed Charges,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.61,88,,11.144,Percent of Total Billed Charges,88% of Total Billed Charges,20.05,90,,11.4,Percent of Total Billed charges,90% of Total Billed Charges,9.83,22.28,
LARYNGOSCOPE BLK. SZ MAC 1,2720001902,CDM,272,RC,,,Outpatient,,,11.68,7.59,,11.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.88,76,,9.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.41,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,8.76,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,11.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.41,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,7.01,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,10.51,90,,13.92,Percent of Total Billed Charges,90% of Total Billed Charges,5.26,45,,11.008,Percent of Total Billed Charges,45% of Total Billed Charges,10.51,90,,11.4,Percent of Total Billed Charges,90% of Total billed Charges,11.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.59,65,,15.624,Percent of total Billed Charges,65% of Total Billed Charges,5.15,44.1,,10.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.1,95,,12.032,Percent of Total Billed Charges,95% of Total Billed Charges,11.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.28,88,,11.144,Percent of Total Billed Charges,88% of Total Billed Charges,10.51,90,,11.4,Percent of Total Billed charges,90% of Total Billed Charges,5.15,11.68,
Z2252-70-55 RECON SCW 70MM,2720001903,CDM,272,RC,,,Outpatient,,,495.25,321.91,,495.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,376.39,76,,9.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,356.58,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,371.44,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,495.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.58,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,297.15,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,445.73,90,,14.08,Percent of Total Billed Charges,90% of Total Billed Charges,222.86,45,,8.672,Percent of Total Billed Charges,45% of Total Billed Charges,445.73,90,,11.4,Percent of Total Billed Charges,90% of Total billed Charges,495.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,321.91,65,,15.904,Percent of total Billed Charges,65% of Total Billed Charges,218.41,44.1,,8.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,470.49,95,,12.032,Percent of Total Billed Charges,95% of Total Billed Charges,495.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.82,88,,11.144,Percent of Total Billed Charges,88% of Total Billed Charges,445.73,90,,11.4,Percent of Total Billed charges,90% of Total Billed Charges,218.41,495.25,
Z2253-37-42 4.2 CORT SCW 37,2720001904,CDM,272,RC,,,Outpatient,,,336.00,218.40,,336,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,255.36,76,,18.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,241.92,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,252,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.92,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,201.6,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,302.4,90,,3.912,Percent of Total Billed Charges,90% of Total Billed Charges,151.2,45,,10.84,Percent of Total Billed Charges,45% of Total Billed Charges,302.4,90,,21.64,Percent of Total Billed Charges,90% of Total billed Charges,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.4,65,,12.52,Percent of total Billed Charges,65% of Total Billed Charges,148.18,44.1,,10.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,319.2,95,,22.84,Percent of Total Billed Charges,95% of Total Billed Charges,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.68,88,,21.152,Percent of Total Billed Charges,88% of Total Billed Charges,302.4,90,,21.64,Percent of Total Billed charges,90% of Total Billed Charges,148.18,336,
Z1312-27-220 2.7 NONLCK SCW 20,2720001905,CDM,272,RC,,,Outpatient,,,120.00,78.00,,120,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,91.2,76,,18.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,86.4,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,90,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.4,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,72,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,108,90,,3.584,Percent of Total Billed Charges,90% of Total Billed Charges,54,45,,4.976,Percent of Total Billed Charges,45% of Total Billed Charges,108,90,,22.016,Percent of Total Billed Charges,90% of Total billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78,65,,15.656,Percent of total Billed Charges,65% of Total Billed Charges,52.92,44.1,,4.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,114,95,,23.24,Percent of Total Billed Charges,95% of Total Billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.6,88,,21.528,Percent of Total Billed Charges,88% of Total Billed Charges,108,90,,22.016,Percent of Total Billed charges,90% of Total Billed Charges,52.92,120,
King Airway Size 3,2720001906,CDM,272,RC,,,Outpatient,,,78.05,50.73,,78.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.32,76,,14.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.2,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,58.54,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,78.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.2,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,46.83,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,70.25,90,,3.64,Percent of Total Billed Charges,90% of Total Billed Charges,35.12,45,,1.096,Percent of Total Billed Charges,45% of Total Billed Charges,70.25,90,,17.336,Percent of Total Billed Charges,90% of Total billed Charges,78.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.73,65,,7.192,Percent of total Billed Charges,65% of Total Billed Charges,34.42,44.1,,1.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.15,95,,18.304,Percent of Total Billed Charges,95% of Total Billed Charges,78.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.68,88,,16.952,Percent of Total Billed Charges,88% of Total Billed Charges,70.25,90,,17.336,Percent of Total Billed charges,90% of Total Billed Charges,34.42,78.05,
King Airway Size 4,2720001907,CDM,272,RC,,,Outpatient,,,89.23,58.00,,89.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.81,76,,18.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.25,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,66.92,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,89.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.25,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,53.54,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,80.31,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,40.15,45,,1.08,Percent of Total Billed Charges,45% of Total Billed Charges,80.31,90,,21.672,Percent of Total Billed Charges,90% of Total billed Charges,89.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58,65,,1.584,Percent of total Billed Charges,65% of Total Billed Charges,39.35,44.1,,1.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,84.77,95,,22.88,Percent of Total Billed Charges,95% of Total Billed Charges,89.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.52,88,,21.192,Percent of Total Billed Charges,88% of Total Billed Charges,80.31,90,,21.672,Percent of Total Billed charges,90% of Total Billed Charges,39.35,89.23,
King Airway Size 5,2720001908,CDM,272,RC,,,Outpatient,,,78.05,50.73,,78.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.32,76,,8.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.2,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,58.54,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,78.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.2,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,46.83,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,70.25,90,,7.688,Percent of Total Billed Charges,90% of Total Billed Charges,35.12,45,,3.76,Percent of Total Billed Charges,45% of Total Billed Charges,70.25,90,,9.96,Percent of Total Billed Charges,90% of Total billed Charges,78.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.73,65,,1.56,Percent of total Billed Charges,65% of Total Billed Charges,34.42,44.1,,3.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.15,95,,10.512,Percent of Total Billed Charges,95% of Total Billed Charges,78.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.68,88,,9.736,Percent of Total Billed Charges,88% of Total Billed Charges,70.25,90,,9.96,Percent of Total Billed charges,90% of Total Billed Charges,34.42,78.05,
Bacteria Filters,2720001909,CDM,272,RC,,,Outpatient,,,1.60,1.04,,1.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.22,76,,1.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.15,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,1.2,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,1.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.15,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,0.96,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,1.44,90,,17.912,Percent of Total Billed Charges,90% of Total Billed Charges,0.72,45,,6.96,Percent of Total Billed Charges,45% of Total Billed Charges,1.44,90,,2.2,Percent of Total Billed Charges,90% of Total billed Charges,1.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.04,65,,5.432,Percent of total Billed Charges,65% of Total Billed Charges,0.71,44.1,,6.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.52,95,,2.32,Percent of Total Billed Charges,95% of Total Billed Charges,1.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.41,88,,2.144,Percent of Total Billed Charges,88% of Total Billed Charges,1.44,90,,2.2,Percent of Total Billed charges,90% of Total Billed Charges,0.71,1.6,
Vaporclean MH Filter,2720001910,CDM,272,RC,,,Outpatient,,,93.60,60.84,,93.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,71.14,76,,1.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,67.39,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,70.2,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,93.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.39,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,56.16,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,84.24,90,,17.68,Percent of Total Billed Charges,90% of Total Billed Charges,42.12,45,,7.04,Percent of Total Billed Charges,45% of Total Billed Charges,84.24,90,,2.16,Percent of Total Billed Charges,90% of Total billed Charges,93.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.84,65,,10.048,Percent of total Billed Charges,65% of Total Billed Charges,41.28,44.1,,6.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,88.92,95,,2.28,Percent of Total Billed Charges,95% of Total Billed Charges,93.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.37,88,,2.112,Percent of Total Billed Charges,88% of Total Billed Charges,84.24,90,,2.16,Percent of Total Billed charges,90% of Total Billed Charges,41.28,93.6,
5.0 Oral Rae Cuffed,2720001911,CDM,272,RC,,,Outpatient,,,10.00,6.50,,10,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.6,76,,6.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.2,72,,252,Percent of Total Billed Charges,72% of Total Billed Charges,7.5,75,,262.504,Percent of Total Billed charges,75% of Total Billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.2,72,,252,Percent of Total Billed Charges,72% of Total Billed Charges,6,60,,210,Percent of Total Billed Charges,60% of Total Billed Charges,9,90,,37.824,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,45,,1.952,Percent of Total Billed Charges,45% of Total Billed Charges,9,90,,7.528,Percent of Total Billed Charges,90% of Total billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,65,,10.168,Percent of total Billed Charges,65% of Total Billed Charges,4.41,44.1,,1.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.5,95,,7.944,Percent of Total Billed Charges,95% of Total Billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.8,88,,7.36,Percent of Total Billed Charges,88% of Total Billed Charges,9,90,,7.528,Percent of Total Billed charges,90% of Total Billed Charges,4.41,10,
5.5 Oral Rae Cuffed,2720001912,CDM,272,RC,,,Outpatient,,,9.68,6.29,,9.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.36,76,,11.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.97,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,7.26,75,,150,Percent of Total Billed charges,75% of Total Billed Charges,9.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.97,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,5.81,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,8.71,90,,17.736,Percent of Total Billed Charges,90% of Total Billed Charges,4.36,45,,1.792,Percent of Total Billed Charges,45% of Total Billed Charges,8.71,90,,13.92,Percent of Total Billed Charges,90% of Total billed Charges,9.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.29,65,,2.824,Percent of total Billed Charges,65% of Total Billed Charges,4.27,44.1,,1.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.2,95,,14.688,Percent of Total Billed Charges,95% of Total Billed Charges,9.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.52,88,,13.608,Percent of Total Billed Charges,88% of Total Billed Charges,8.71,90,,13.92,Percent of Total Billed charges,90% of Total Billed Charges,4.27,9.68,
6.0 Oral Rae Cuffed,2720001913,CDM,272,RC,,,Outpatient,,,23.53,15.29,,23.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.88,76,,11.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.94,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,17.65,75,,150,Percent of Total Billed charges,75% of Total Billed Charges,23.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.94,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,14.12,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,21.18,90,,5.152,Percent of Total Billed Charges,90% of Total Billed Charges,10.59,45,,1.816,Percent of Total Billed Charges,45% of Total Billed Charges,21.18,90,,14.08,Percent of Total Billed Charges,90% of Total billed Charges,23.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.29,65,,2.592,Percent of total Billed Charges,65% of Total Billed Charges,10.38,44.1,,1.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.35,95,,14.856,Percent of Total Billed Charges,95% of Total Billed Charges,23.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.71,88,,13.76,Percent of Total Billed Charges,88% of Total Billed Charges,21.18,90,,14.08,Percent of Total Billed charges,90% of Total Billed Charges,10.38,23.53,
6.5 Oral Rae Cuffed,2720001914,CDM,272,RC,,,Outpatient,,,13.28,8.63,,13.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.09,76,,3.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.56,72,,1281.488,Percent of Total Billed Charges,72% of Total Billed Charges,9.96,75,,1334.88,Percent of Total Billed charges,75% of Total Billed Charges,13.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.56,72,,1281.488,Percent of Total Billed Charges,72% of Total Billed Charges,7.97,60,,1067.904,Percent of Total Billed Charges,60% of Total Billed Charges,11.95,90,,17.088,Percent of Total Billed Charges,90% of Total Billed Charges,5.98,45,,1.8,Percent of Total Billed Charges,45% of Total Billed Charges,11.95,90,,3.912,Percent of Total Billed Charges,90% of Total billed Charges,13.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.63,65,,2.624,Percent of total Billed Charges,65% of Total Billed Charges,5.86,44.1,,1.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.62,95,,4.128,Percent of Total Billed Charges,95% of Total Billed Charges,13.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.69,88,,3.824,Percent of Total Billed Charges,88% of Total Billed Charges,11.95,90,,3.912,Percent of Total Billed charges,90% of Total Billed Charges,5.86,13.28,
8.0 Oral Rae Cuffed,2720001915,CDM,272,RC,,,Outpatient,,,11.95,7.77,,11.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.08,76,,3.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.6,72,,10.08,Percent of Total Billed Charges,72% of Total Billed Charges,8.96,75,,10.504,Percent of Total Billed charges,75% of Total Billed Charges,11.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,72,,10.08,Percent of Total Billed Charges,72% of Total Billed Charges,7.17,60,,8.4,Percent of Total Billed Charges,60% of Total Billed Charges,10.76,90,,20.376,Percent of Total Billed Charges,90% of Total Billed Charges,5.38,45,,3.848,Percent of Total Billed Charges,45% of Total Billed Charges,10.76,90,,3.584,Percent of Total Billed Charges,90% of Total billed Charges,11.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.77,65,,2.6,Percent of total Billed Charges,65% of Total Billed Charges,5.27,44.1,,3.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.35,95,,3.784,Percent of Total Billed Charges,95% of Total Billed Charges,11.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.52,88,,3.504,Percent of Total Billed Charges,88% of Total Billed Charges,10.76,90,,3.584,Percent of Total Billed charges,90% of Total Billed Charges,5.27,11.95,
8.5 Oral Rae Cuffed,2720001916,CDM,272,RC,,,Outpatient,,,4.13,2.68,,4.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.14,76,,3.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.97,72,,15.84,Percent of Total Billed Charges,72% of Total Billed Charges,3.1,75,,16.504,Percent of Total Billed charges,75% of Total Billed Charges,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.97,72,,15.84,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,60,,13.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.72,90,,26.752,Percent of Total Billed Charges,90% of Total Billed Charges,1.86,45,,8.96,Percent of Total Billed Charges,45% of Total Billed Charges,3.72,90,,3.64,Percent of Total Billed Charges,90% of Total billed Charges,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.68,65,,5.552,Percent of total Billed Charges,65% of Total Billed Charges,1.82,44.1,,8.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.92,95,,3.84,Percent of Total Billed Charges,95% of Total Billed Charges,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.63,88,,3.552,Percent of Total Billed Charges,88% of Total Billed Charges,3.72,90,,3.64,Percent of Total Billed charges,90% of Total Billed Charges,1.82,4.13,
4.0 Oral Rae Cuffed,2720001917,CDM,272,RC,,,Outpatient,,,12.75,8.29,,12.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.69,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.18,72,,10.08,Percent of Total Billed Charges,72% of Total Billed Charges,9.56,75,,10.504,Percent of Total Billed charges,75% of Total Billed Charges,12.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.18,72,,10.08,Percent of Total Billed Charges,72% of Total Billed Charges,7.65,60,,8.4,Percent of Total Billed Charges,60% of Total Billed Charges,11.48,90,,20.36,Percent of Total Billed Charges,90% of Total Billed Charges,5.74,45,,8.84,Percent of Total Billed Charges,45% of Total Billed Charges,11.48,90,,3.6,Percent of Total Billed Charges,90% of Total billed Charges,12.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.29,65,,12.936,Percent of total Billed Charges,65% of Total Billed Charges,5.62,44.1,,8.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.11,95,,3.8,Percent of Total Billed Charges,95% of Total Billed Charges,12.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.22,88,,3.52,Percent of Total Billed Charges,88% of Total Billed Charges,11.48,90,,3.6,Percent of Total Billed charges,90% of Total Billed Charges,5.62,12.75,
4.0 Oral Rae Uncuffed,2720001918,CDM,272,RC,,,Outpatient,,,7.98,5.19,,7.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.06,76,,6.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.75,72,,153,Percent of Total Billed Charges,72% of Total Billed Charges,5.99,75,,159.376,Percent of Total Billed charges,75% of Total Billed Charges,7.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.75,72,,153,Percent of Total Billed Charges,72% of Total Billed Charges,4.79,60,,127.504,Percent of Total Billed Charges,60% of Total Billed Charges,7.18,90,,20.088,Percent of Total Billed Charges,90% of Total Billed Charges,3.59,45,,18.912,Percent of Total Billed Charges,45% of Total Billed Charges,7.18,90,,7.688,Percent of Total Billed Charges,90% of Total billed Charges,7.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.19,65,,12.768,Percent of total Billed Charges,65% of Total Billed Charges,3.52,44.1,,18.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.58,95,,8.12,Percent of Total Billed Charges,95% of Total Billed Charges,7.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.02,88,,7.52,Percent of Total Billed Charges,88% of Total Billed Charges,7.18,90,,7.688,Percent of Total Billed charges,90% of Total Billed Charges,3.52,7.98,
LMA Supreme  size 5,2720001919,CDM,272,RC,,,Outpatient,,,36.88,23.97,,36.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.03,76,,15.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.55,72,,153,Percent of Total Billed Charges,72% of Total Billed Charges,27.66,75,,159.376,Percent of Total Billed charges,75% of Total Billed Charges,36.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.55,72,,153,Percent of Total Billed Charges,72% of Total Billed Charges,22.13,60,,127.504,Percent of Total Billed Charges,60% of Total Billed Charges,33.19,90,,9.04,Percent of Total Billed Charges,90% of Total Billed Charges,16.6,45,,8.864,Percent of Total Billed Charges,45% of Total Billed Charges,33.19,90,,17.912,Percent of Total Billed Charges,90% of Total billed Charges,36.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.97,65,,27.312,Percent of total Billed Charges,65% of Total Billed Charges,16.26,44.1,,8.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.04,95,,18.912,Percent of Total Billed Charges,95% of Total Billed Charges,36.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.45,88,,17.512,Percent of Total Billed Charges,88% of Total Billed Charges,33.19,90,,17.912,Percent of Total Billed charges,90% of Total Billed Charges,16.26,36.88,
Glidescope Rigid Stylet,2720001920,CDM,271,RC,,,Outpatient,,,87.50,56.88,,87.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.5,76,,14.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63,72,,36.544,Percent of Total Billed Charges,72% of Total Billed Charges,65.63,75,,38.072,Percent of Total Billed charges,75% of Total Billed Charges,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63,72,,36.544,Percent of Total Billed Charges,72% of Total Billed Charges,52.5,60,,30.456,Percent of Total Billed Charges,60% of Total Billed Charges,78.75,90,,20.616,Percent of Total Billed Charges,90% of Total Billed Charges,39.38,45,,2.576,Percent of Total Billed Charges,45% of Total Billed Charges,78.75,90,,17.68,Percent of Total Billed Charges,90% of Total billed Charges,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.88,65,,12.808,Percent of total Billed Charges,65% of Total Billed Charges,38.59,44.1,,2.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.13,95,,18.656,Percent of Total Billed Charges,95% of Total Billed Charges,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77,88,,17.28,Percent of Total Billed Charges,88% of Total Billed Charges,78.75,90,,17.68,Percent of Total Billed charges,90% of Total Billed Charges,38.59,87.5,
Nasal Rae Uncuffed 5.0,2720001921,CDM,272,RC,,,Outpatient,,,9.63,6.26,,9.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.32,76,,31.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.93,72,,1.744,Percent of Total Billed Charges,72% of Total Billed Charges,7.22,75,,1.816,Percent of Total Billed charges,75% of Total Billed Charges,9.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.93,72,,1.744,Percent of Total Billed Charges,72% of Total Billed Charges,5.78,60,,1.456,Percent of Total Billed Charges,60% of Total Billed Charges,8.67,90,,354.768,Percent of Total Billed Charges,90% of Total Billed Charges,4.33,45,,8.544,Percent of Total Billed Charges,45% of Total Billed Charges,8.67,90,,37.824,Percent of Total Billed Charges,90% of Total billed Charges,9.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.26,65,,3.72,Percent of total Billed Charges,65% of Total Billed Charges,4.25,44.1,,8.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.15,95,,39.92,Percent of Total Billed Charges,95% of Total Billed Charges,9.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.47,88,,36.984,Percent of Total Billed Charges,88% of Total Billed Charges,8.67,90,,37.824,Percent of Total Billed charges,90% of Total Billed Charges,4.25,9.63,
IV Cath 24G x 3/4 (Jelco),2720001922,CDM,272,RC,,,Outpatient,,,5.63,3.66,,5.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.28,76,,14.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.05,72,,56.16,Percent of Total Billed Charges,72% of Total Billed Charges,4.22,75,,58.504,Percent of Total Billed charges,75% of Total Billed Charges,5.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.05,72,,56.16,Percent of Total Billed Charges,72% of Total Billed Charges,3.38,60,,46.8,Percent of Total Billed Charges,60% of Total Billed Charges,5.07,90,,59.672,Percent of Total Billed Charges,90% of Total Billed Charges,2.53,45,,10.192,Percent of Total Billed Charges,45% of Total Billed Charges,5.07,90,,17.736,Percent of Total Billed Charges,90% of Total billed Charges,5.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.66,65,,12.336,Percent of total Billed Charges,65% of Total Billed Charges,2.48,44.1,,9.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.35,95,,18.72,Percent of Total Billed Charges,95% of Total Billed Charges,5.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.95,88,,17.336,Percent of Total Billed Charges,88% of Total Billed Charges,5.07,90,,17.736,Percent of Total Billed charges,90% of Total Billed Charges,2.48,5.63,
Inspiratory Filter,2720001923,CDM,272,RC,,,Outpatient,,,5.93,3.85,,5.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.51,76,,4.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.27,72,,310.52,Percent of Total Billed Charges,72% of Total Billed Charges,4.45,75,,323.464,Percent of Total Billed charges,75% of Total Billed Charges,5.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.27,72,,310.52,Percent of Total Billed Charges,72% of Total Billed Charges,3.56,60,,258.768,Percent of Total Billed Charges,60% of Total Billed Charges,5.34,90,,62.536,Percent of Total Billed Charges,90% of Total Billed Charges,2.67,45,,13.376,Percent of Total Billed Charges,45% of Total Billed Charges,5.34,90,,5.152,Percent of Total Billed Charges,90% of Total billed Charges,5.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.85,65,,14.72,Percent of total Billed Charges,65% of Total Billed Charges,2.62,44.1,,13.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.63,95,,5.432,Percent of Total Billed Charges,95% of Total Billed Charges,5.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.22,88,,5.032,Percent of Total Billed Charges,88% of Total Billed Charges,5.34,90,,5.152,Percent of Total Billed charges,90% of Total Billed Charges,2.62,5.93,
Oral Rae 3.5 Uncuffed,2720001924,CDM,272,RC,,,Outpatient,,,15.48,10.06,,15.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.76,76,,14.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.15,72,,23.52,Percent of Total Billed Charges,72% of Total Billed Charges,11.61,75,,24.496,Percent of Total Billed charges,75% of Total Billed Charges,15.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.15,72,,23.52,Percent of Total Billed Charges,72% of Total Billed Charges,9.29,60,,19.6,Percent of Total Billed Charges,60% of Total Billed Charges,13.93,90,,71.464,Percent of Total Billed Charges,90% of Total Billed Charges,6.97,45,,10.184,Percent of Total Billed Charges,45% of Total Billed Charges,13.93,90,,17.088,Percent of Total Billed Charges,90% of Total billed Charges,15.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.06,65,,19.32,Percent of total Billed Charges,65% of Total Billed Charges,6.83,44.1,,9.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.71,95,,18.032,Percent of Total Billed Charges,95% of Total Billed Charges,15.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,88,,16.704,Percent of Total Billed Charges,88% of Total Billed Charges,13.93,90,,17.088,Percent of Total Billed charges,90% of Total Billed Charges,6.83,15.48,
Nasal Rae Tube/ Uncuff 4.5,2720001925,CDM,272,RC,,,Outpatient,,,11.80,7.67,,11.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.97,76,,17.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.5,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,8.85,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,11.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.5,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,7.08,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,10.62,90,,120.336,Percent of Total Billed Charges,90% of Total Billed Charges,5.31,45,,10.048,Percent of Total Billed Charges,45% of Total Billed Charges,10.62,90,,20.376,Percent of Total Billed Charges,90% of Total billed Charges,11.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.67,65,,14.704,Percent of total Billed Charges,65% of Total Billed Charges,5.2,44.1,,9.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.21,95,,21.512,Percent of Total Billed Charges,95% of Total Billed Charges,11.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.38,88,,19.92,Percent of Total Billed Charges,88% of Total Billed Charges,10.62,90,,20.376,Percent of Total Billed charges,90% of Total Billed Charges,5.2,11.8,
Nasal Rae Tube/ Uncuff 5.0,2720001926,CDM,272,RC,,,Outpatient,,,11.80,7.67,,11.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.97,76,,22.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.5,72,,50.4,Percent of Total Billed Charges,72% of Total Billed Charges,8.85,75,,52.504,Percent of Total Billed charges,75% of Total Billed Charges,11.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.5,72,,50.4,Percent of Total Billed Charges,72% of Total Billed Charges,7.08,60,,42,Percent of Total Billed Charges,60% of Total Billed Charges,10.62,90,,24.232,Percent of Total Billed Charges,90% of Total Billed Charges,5.31,45,,4.52,Percent of Total Billed Charges,45% of Total Billed Charges,10.62,90,,26.752,Percent of Total Billed Charges,90% of Total billed Charges,11.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.67,65,,14.512,Percent of total Billed Charges,65% of Total Billed Charges,5.2,44.1,,4.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.21,95,,28.232,Percent of Total Billed Charges,95% of Total Billed Charges,11.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.38,88,,26.152,Percent of Total Billed Charges,88% of Total Billed Charges,10.62,90,,26.752,Percent of Total Billed charges,90% of Total Billed Charges,5.2,11.8,
4.5 Oral Rae uncuffed,2720001927,CDM,272,RC,,,Outpatient,,,13.30,8.65,,13.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.11,76,,17.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.58,72,,28.8,Percent of Total Billed Charges,72% of Total Billed Charges,9.98,75,,30,Percent of Total Billed charges,75% of Total Billed Charges,13.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.58,72,,28.8,Percent of Total Billed Charges,72% of Total Billed Charges,7.98,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,11.97,90,,24.232,Percent of Total Billed Charges,90% of Total Billed Charges,5.99,45,,10.304,Percent of Total Billed Charges,45% of Total Billed Charges,11.97,90,,20.36,Percent of Total Billed Charges,90% of Total billed Charges,13.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.65,65,,6.528,Percent of total Billed Charges,65% of Total Billed Charges,5.87,44.1,,10.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.64,95,,21.496,Percent of Total Billed Charges,95% of Total Billed Charges,13.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.7,88,,19.912,Percent of Total Billed Charges,88% of Total Billed Charges,11.97,90,,20.36,Percent of Total Billed charges,90% of Total Billed Charges,5.87,13.3,
7.5 Oral Rae Uncuffed,2720001928,CDM,272,RC,,,Outpatient,,,11.80,7.67,,11.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.97,76,,16.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.5,72,,3.6,Percent of Total Billed Charges,72% of Total Billed Charges,8.85,75,,3.752,Percent of Total Billed charges,75% of Total Billed Charges,11.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.5,72,,3.6,Percent of Total Billed Charges,72% of Total Billed Charges,7.08,60,,3,Percent of Total Billed Charges,60% of Total Billed Charges,10.62,90,,9.416,Percent of Total Billed Charges,90% of Total Billed Charges,5.31,45,,177.384,Percent of Total Billed Charges,45% of Total Billed Charges,10.62,90,,20.088,Percent of Total Billed Charges,90% of Total billed Charges,11.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.67,65,,14.888,Percent of total Billed Charges,65% of Total Billed Charges,5.2,44.1,,173.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.21,95,,21.208,Percent of Total Billed Charges,95% of Total Billed Charges,11.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.38,88,,19.64,Percent of Total Billed Charges,88% of Total Billed Charges,10.62,90,,20.088,Percent of Total Billed charges,90% of Total Billed Charges,5.2,11.8,
6.0 Oral Rae Cuffed,2720001929,CDM,272,RC,,,Outpatient,,,14.78,9.61,,14.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.23,76,,7.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.64,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,11.09,75,,60,Percent of Total Billed charges,75% of Total Billed Charges,14.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.64,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,8.87,60,,48,Percent of Total Billed Charges,60% of Total Billed Charges,13.3,90,,6.36,Percent of Total Billed Charges,90% of Total Billed Charges,6.65,45,,29.84,Percent of Total Billed Charges,45% of Total Billed Charges,13.3,90,,9.04,Percent of Total Billed Charges,90% of Total billed Charges,14.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.61,65,,256.216,Percent of total Billed Charges,65% of Total Billed Charges,6.52,44.1,,29.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.04,95,,9.536,Percent of Total Billed Charges,95% of Total Billed Charges,14.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.01,88,,8.832,Percent of Total Billed Charges,88% of Total Billed Charges,13.3,90,,9.04,Percent of Total Billed charges,90% of Total Billed Charges,6.52,14.78,
Nasal Rae tube/ Cuff 6.0,2720001930,CDM,272,RC,,,Outpatient,,,10.00,6.50,,10,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.6,76,,17.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.2,72,,93.568,Percent of Total Billed Charges,72% of Total Billed Charges,7.5,75,,97.472,Percent of Total Billed charges,75% of Total Billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.2,72,,93.568,Percent of Total Billed Charges,72% of Total Billed Charges,6,60,,77.976,Percent of Total Billed Charges,60% of Total Billed Charges,9,90,,6.624,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,45,,31.264,Percent of Total Billed Charges,45% of Total Billed Charges,9,90,,20.616,Percent of Total Billed Charges,90% of Total billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,65,,43.096,Percent of total Billed Charges,65% of Total Billed Charges,4.41,44.1,,30.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.5,95,,21.76,Percent of Total Billed Charges,95% of Total Billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.8,88,,20.152,Percent of Total Billed Charges,88% of Total Billed Charges,9,90,,20.616,Percent of Total Billed charges,90% of Total Billed Charges,4.41,10,
Glove Sensicare PI Micro SZ7.5,2720001931,CDM,272,RC,,,Outpatient,,,4.45,2.89,,4.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.38,76,,299.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.2,72,,4752,Percent of Total Billed Charges,72% of Total Billed Charges,3.34,75,,4950,Percent of Total Billed charges,75% of Total Billed Charges,4.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.2,72,,4752,Percent of Total Billed Charges,72% of Total Billed Charges,2.67,60,,3960,Percent of Total Billed Charges,60% of Total Billed Charges,4.01,90,,6.36,Percent of Total Billed Charges,90% of Total Billed Charges,2,45,,35.728,Percent of Total Billed Charges,45% of Total Billed Charges,4.01,90,,354.768,Percent of Total Billed Charges,90% of Total billed Charges,4.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.89,65,,45.16,Percent of total Billed Charges,65% of Total Billed Charges,1.96,44.1,,35.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.23,95,,374.472,Percent of Total Billed Charges,95% of Total Billed Charges,4.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.92,88,,346.88,Percent of Total Billed Charges,88% of Total Billed Charges,4.01,90,,354.768,Percent of Total Billed charges,90% of Total Billed Charges,1.96,4.45,
Mouthpiece disp,2720001932,CDM,272,RC,,,Outpatient,,,3.13,2.03,,3.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.38,76,,50.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.25,72,,11.88,Percent of Total Billed Charges,72% of Total Billed Charges,2.35,75,,12.376,Percent of Total Billed charges,75% of Total Billed Charges,3.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.25,72,,11.88,Percent of Total Billed Charges,72% of Total Billed Charges,1.88,60,,9.904,Percent of Total Billed Charges,60% of Total Billed Charges,2.82,90,,6.36,Percent of Total Billed Charges,90% of Total Billed Charges,1.41,45,,60.168,Percent of Total Billed Charges,45% of Total Billed Charges,2.82,90,,59.672,Percent of Total Billed Charges,90% of Total billed Charges,3.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.03,65,,51.608,Percent of total Billed Charges,65% of Total Billed Charges,1.38,44.1,,58.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.97,95,,62.992,Percent of Total Billed Charges,95% of Total Billed Charges,3.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.75,88,,58.344,Percent of Total Billed Charges,88% of Total Billed Charges,2.82,90,,59.672,Percent of Total Billed charges,90% of Total Billed Charges,1.38,3.13,
Bard Button 24FR x 2.4 length,2720001933,CDM,272,RC,,,Outpatient,,,240.08,156.05,,240.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,182.46,76,,52.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,172.86,72,,2.376,Percent of Total Billed Charges,72% of Total Billed Charges,180.06,75,,2.48,Percent of Total Billed charges,75% of Total Billed Charges,240.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.86,72,,2.376,Percent of Total Billed Charges,72% of Total Billed Charges,144.05,60,,1.984,Percent of Total Billed Charges,60% of Total Billed Charges,216.07,90,,307.224,Percent of Total Billed Charges,90% of Total Billed Charges,108.04,45,,12.112,Percent of Total Billed Charges,45% of Total Billed Charges,216.07,90,,62.536,Percent of Total Billed Charges,90% of Total billed Charges,240.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.05,65,,86.904,Percent of total Billed Charges,65% of Total Billed Charges,105.88,44.1,,11.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,228.08,95,,66.008,Percent of Total Billed Charges,95% of Total Billed Charges,240.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.27,88,,61.144,Percent of Total Billed Charges,88% of Total Billed Charges,216.07,90,,62.536,Percent of Total Billed charges,90% of Total Billed Charges,105.88,240.08,
Jamshidi Bone Marrow Bx/Asp ND,2720001934,CDM,272,RC,,,Outpatient,,,36.75,23.89,,36.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.93,76,,60.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.46,72,,4.208,Percent of Total Billed Charges,72% of Total Billed Charges,27.56,75,,4.384,Percent of Total Billed charges,75% of Total Billed Charges,36.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,72,,4.208,Percent of Total Billed Charges,72% of Total Billed Charges,22.05,60,,3.504,Percent of Total Billed Charges,60% of Total Billed Charges,33.08,90,,170.624,Percent of Total Billed Charges,90% of Total Billed Charges,16.54,45,,12.112,Percent of Total Billed Charges,45% of Total Billed Charges,33.08,90,,71.464,Percent of Total Billed Charges,90% of Total billed Charges,36.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.89,65,,17.496,Percent of total Billed Charges,65% of Total Billed Charges,16.21,44.1,,11.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.91,95,,75.432,Percent of Total Billed Charges,95% of Total Billed Charges,36.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.34,88,,69.872,Percent of Total Billed Charges,88% of Total Billed Charges,33.08,90,,71.464,Percent of Total Billed charges,90% of Total Billed Charges,16.21,36.75,
Leep Pre-Filter Smoke Evac,2720001935,CDM,272,RC,,,Outpatient,,,53.25,34.61,,53.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.47,76,,101.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.34,72,,73.384,Percent of Total Billed Charges,72% of Total Billed Charges,39.94,75,,76.44,Percent of Total Billed charges,75% of Total Billed Charges,53.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.34,72,,73.384,Percent of Total Billed Charges,72% of Total Billed Charges,31.95,60,,61.152,Percent of Total Billed Charges,60% of Total Billed Charges,47.93,90,,190.64,Percent of Total Billed Charges,90% of Total Billed Charges,23.96,45,,4.712,Percent of Total Billed Charges,45% of Total Billed Charges,47.93,90,,120.336,Percent of Total Billed Charges,90% of Total billed Charges,53.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.61,65,,17.496,Percent of total Billed Charges,65% of Total Billed Charges,23.48,44.1,,4.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.59,95,,127.016,Percent of Total Billed Charges,95% of Total Billed Charges,53.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.86,88,,117.656,Percent of Total Billed Charges,88% of Total Billed Charges,47.93,90,,120.336,Percent of Total Billed charges,90% of Total Billed Charges,23.48,53.25,
Leep Reducer Cap,2720001936,CDM,272,RC,,,Outpatient,,,15.33,9.96,,15.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.65,76,,20.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.04,72,,54.72,Percent of Total Billed Charges,72% of Total Billed Charges,11.5,75,,57,Percent of Total Billed charges,75% of Total Billed Charges,15.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.04,72,,54.72,Percent of Total Billed Charges,72% of Total Billed Charges,9.2,60,,45.6,Percent of Total Billed Charges,60% of Total Billed Charges,13.8,90,,28.336,Percent of Total Billed Charges,90% of Total Billed Charges,6.9,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,13.8,90,,24.232,Percent of Total Billed Charges,90% of Total billed Charges,15.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.96,65,,6.8,Percent of total Billed Charges,65% of Total Billed Charges,6.76,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.56,95,,25.576,Percent of Total Billed Charges,95% of Total Billed Charges,15.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.49,88,,23.688,Percent of Total Billed Charges,88% of Total Billed Charges,13.8,90,,24.232,Percent of Total Billed charges,90% of Total Billed Charges,6.76,15.33,
"Cath Foley 20Fr, 10Ml 2WY SLCN",2720001937,CDM,272,RC,,,Outpatient,,,15.68,10.19,,15.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.92,76,,20.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.29,72,,5.184,Percent of Total Billed Charges,72% of Total Billed Charges,11.76,75,,5.4,Percent of Total Billed charges,75% of Total Billed Charges,15.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.29,72,,5.184,Percent of Total Billed Charges,72% of Total Billed Charges,9.41,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,14.11,90,,28.336,Percent of Total Billed Charges,90% of Total Billed Charges,7.06,45,,3.312,Percent of Total Billed Charges,45% of Total Billed Charges,14.11,90,,24.232,Percent of Total Billed Charges,90% of Total billed Charges,15.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.19,65,,4.592,Percent of total Billed Charges,65% of Total Billed Charges,6.91,44.1,,3.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.9,95,,25.576,Percent of Total Billed Charges,95% of Total Billed Charges,15.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.8,88,,23.688,Percent of Total Billed Charges,88% of Total Billed Charges,14.11,90,,24.232,Percent of Total Billed charges,90% of Total Billed Charges,6.91,15.68,
Biogel Ind Glove Sz 8 GRN,2720001938,CDM,272,RC,,,Outpatient,,,2.18,1.42,,2.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.66,76,,7.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.57,72,,2.16,Percent of Total Billed Charges,72% of Total Billed Charges,1.64,75,,2.248,Percent of Total Billed charges,75% of Total Billed Charges,2.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.57,72,,2.16,Percent of Total Billed Charges,72% of Total Billed Charges,1.31,60,,1.8,Percent of Total Billed Charges,60% of Total Billed Charges,1.96,90,,62.856,Percent of Total Billed Charges,90% of Total Billed Charges,0.98,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,1.96,90,,9.416,Percent of Total Billed Charges,90% of Total billed Charges,2.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.42,65,,4.784,Percent of total Billed Charges,65% of Total Billed Charges,0.96,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.07,95,,9.944,Percent of Total Billed Charges,95% of Total Billed Charges,2.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.92,88,,9.208,Percent of Total Billed Charges,88% of Total Billed Charges,1.96,90,,9.416,Percent of Total Billed charges,90% of Total Billed Charges,0.96,2.18,
Synthes Drill Bit 1.5,2720001939,CDM,272,RC,,,Outpatient,,,226.88,147.47,,226.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,172.43,76,,5.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,163.35,72,,10.512,Percent of Total Billed Charges,72% of Total Billed Charges,170.16,75,,10.952,Percent of Total Billed charges,75% of Total Billed Charges,226.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.35,72,,10.512,Percent of Total Billed Charges,72% of Total Billed Charges,136.13,60,,8.76,Percent of Total Billed Charges,60% of Total Billed Charges,204.19,90,,67.72,Percent of Total Billed Charges,90% of Total Billed Charges,102.1,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,204.19,90,,6.36,Percent of Total Billed Charges,90% of Total billed Charges,226.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.47,65,,4.592,Percent of total Billed Charges,65% of Total Billed Charges,100.05,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,215.54,95,,6.712,Percent of Total Billed Charges,95% of Total Billed Charges,226.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.65,88,,6.216,Percent of Total Billed Charges,88% of Total Billed Charges,204.19,90,,6.36,Percent of Total Billed charges,90% of Total Billed Charges,100.05,226.88,
Synthes Drill Bit 2.0,2720001940,CDM,272,RC,,,Outpatient,,,219.95,142.97,,219.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,167.16,76,,5.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,158.36,72,,108,Percent of Total Billed Charges,72% of Total Billed Charges,164.96,75,,112.504,Percent of Total Billed charges,75% of Total Billed Charges,219.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.36,72,,108,Percent of Total Billed Charges,72% of Total Billed Charges,131.97,60,,90,Percent of Total Billed Charges,60% of Total Billed Charges,197.96,90,,70.04,Percent of Total Billed Charges,90% of Total Billed Charges,98.98,45,,153.616,Percent of Total Billed Charges,45% of Total Billed Charges,197.96,90,,6.624,Percent of Total Billed Charges,90% of Total billed Charges,219.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.97,65,,4.592,Percent of total Billed Charges,65% of Total Billed Charges,97,44.1,,150.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,208.95,95,,6.992,Percent of Total Billed Charges,95% of Total Billed Charges,219.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.56,88,,6.48,Percent of Total Billed Charges,88% of Total Billed Charges,197.96,90,,6.624,Percent of Total Billed charges,90% of Total Billed Charges,97,219.95,
Synthes Drill Bit 1.0,2720001941,CDM,272,RC,,,Outpatient,,,212.70,138.26,,212.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.65,76,,5.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153.14,72,,10.624,Percent of Total Billed Charges,72% of Total Billed Charges,159.53,75,,11.072,Percent of Total Billed charges,75% of Total Billed Charges,212.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.14,72,,10.624,Percent of Total Billed Charges,72% of Total Billed Charges,127.62,60,,8.856,Percent of Total Billed Charges,60% of Total Billed Charges,191.43,90,,67.52,Percent of Total Billed Charges,90% of Total Billed Charges,95.72,45,,85.312,Percent of Total Billed Charges,45% of Total Billed Charges,191.43,90,,6.36,Percent of Total Billed Charges,90% of Total billed Charges,212.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.26,65,,221.888,Percent of total Billed Charges,65% of Total Billed Charges,93.8,44.1,,83.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,202.07,95,,6.712,Percent of Total Billed Charges,95% of Total Billed Charges,212.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.18,88,,6.216,Percent of Total Billed Charges,88% of Total Billed Charges,191.43,90,,6.36,Percent of Total Billed charges,90% of Total Billed Charges,93.8,212.7,
Synthes Drill Bit 1.3,2720001942,CDM,272,RC,,,Outpatient,,,147.50,95.88,,147.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,112.1,76,,5.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,106.2,72,,79.2,Percent of Total Billed Charges,72% of Total Billed Charges,110.63,75,,82.504,Percent of Total Billed charges,75% of Total Billed Charges,147.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.2,72,,79.2,Percent of Total Billed Charges,72% of Total Billed Charges,88.5,60,,66,Percent of Total Billed Charges,60% of Total Billed Charges,132.75,90,,123.808,Percent of Total Billed Charges,90% of Total Billed Charges,66.38,45,,95.32,Percent of Total Billed Charges,45% of Total Billed Charges,132.75,90,,6.36,Percent of Total Billed Charges,90% of Total billed Charges,147.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.88,65,,123.232,Percent of total Billed Charges,65% of Total Billed Charges,65.05,44.1,,93.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,140.13,95,,6.712,Percent of Total Billed Charges,95% of Total Billed Charges,147.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.8,88,,6.216,Percent of Total Billed Charges,88% of Total Billed Charges,132.75,90,,6.36,Percent of Total Billed charges,90% of Total Billed Charges,65.05,147.5,
Synthes Drill Bit 1.8,2720001943,CDM,272,RC,,,Outpatient,,,212.50,138.13,,212.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.5,76,,259.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,159.38,75,,120,Percent of Total Billed charges,75% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,127.5,60,,96,Percent of Total Billed Charges,60% of Total Billed Charges,191.25,90,,123.808,Percent of Total Billed Charges,90% of Total Billed Charges,95.63,45,,14.168,Percent of Total Billed Charges,45% of Total Billed Charges,191.25,90,,307.224,Percent of Total Billed Charges,90% of Total billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.13,65,,137.688,Percent of total Billed Charges,65% of Total Billed Charges,93.71,44.1,,13.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,201.88,95,,324.296,Percent of Total Billed Charges,95% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187,88,,300.4,Percent of Total Billed Charges,88% of Total Billed Charges,191.25,90,,307.224,Percent of Total Billed charges,90% of Total Billed Charges,93.71,212.5,
Synthes Drill Bit 2.4,2720001944,CDM,272,RC,,,Outpatient,,,212.50,138.13,,212.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.5,76,,144.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153,72,,279.288,Percent of Total Billed Charges,72% of Total Billed Charges,159.38,75,,290.928,Percent of Total Billed charges,75% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153,72,,279.288,Percent of Total Billed Charges,72% of Total Billed Charges,127.5,60,,232.744,Percent of Total Billed Charges,60% of Total Billed Charges,191.25,90,,120.744,Percent of Total Billed Charges,90% of Total Billed Charges,95.63,45,,14.168,Percent of Total Billed Charges,45% of Total Billed Charges,191.25,90,,170.624,Percent of Total Billed Charges,90% of Total billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.13,65,,20.464,Percent of total Billed Charges,65% of Total Billed Charges,93.71,44.1,,13.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,201.88,95,,180.104,Percent of Total Billed Charges,95% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187,88,,166.832,Percent of Total Billed Charges,88% of Total Billed Charges,191.25,90,,170.624,Percent of Total Billed charges,90% of Total Billed Charges,93.71,212.5,
Twist Drill Bit 0.38 x 5,2720001945,CDM,272,RC,,,Outpatient,,,47.50,30.88,,47.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.1,76,,160.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.2,72,,279.288,Percent of Total Billed Charges,72% of Total Billed Charges,35.63,75,,290.928,Percent of Total Billed charges,75% of Total Billed Charges,47.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.2,72,,279.288,Percent of Total Billed Charges,72% of Total Billed Charges,28.5,60,,232.744,Percent of Total Billed Charges,60% of Total Billed Charges,42.75,90,,123.808,Percent of Total Billed Charges,90% of Total Billed Charges,21.38,45,,31.432,Percent of Total Billed Charges,45% of Total Billed Charges,42.75,90,,190.64,Percent of Total Billed Charges,90% of Total billed Charges,47.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.88,65,,20.464,Percent of total Billed Charges,65% of Total Billed Charges,20.95,44.1,,30.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.13,95,,201.232,Percent of Total Billed Charges,95% of Total Billed Charges,47.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.8,88,,186.408,Percent of Total Billed Charges,88% of Total Billed Charges,42.75,90,,190.64,Percent of Total Billed charges,90% of Total Billed Charges,20.95,47.5,
Synthes 1.5 T-Plate 4 holes,2720001946,CDM,272,RC,,,Outpatient,,,400.00,260.00,,400,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,304,76,,23.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,288,72,,9.984,Percent of Total Billed Charges,72% of Total Billed Charges,300,75,,10.4,Percent of Total Billed charges,75% of Total Billed Charges,400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288,72,,9.984,Percent of Total Billed Charges,72% of Total Billed Charges,240,60,,8.32,Percent of Total Billed Charges,60% of Total Billed Charges,360,90,,123.808,Percent of Total Billed Charges,90% of Total Billed Charges,180,45,,33.856,Percent of Total Billed Charges,45% of Total Billed Charges,360,90,,28.336,Percent of Total Billed Charges,90% of Total billed Charges,400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260,65,,45.4,Percent of total Billed Charges,65% of Total Billed Charges,176.4,44.1,,33.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,380,95,,29.904,Percent of Total Billed Charges,95% of Total Billed Charges,400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352,88,,27.704,Percent of Total Billed Charges,88% of Total Billed Charges,360,90,,28.336,Percent of Total Billed charges,90% of Total Billed Charges,176.4,400,
Twist Drill Bit 1/16 x 5,2720001947,CDM,272,RC,,,Outpatient,,,30.00,19.50,,30,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.8,76,,23.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.6,72,,4,Percent of Total Billed Charges,72% of Total Billed Charges,22.5,75,,4.168,Percent of Total Billed charges,75% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.6,72,,4,Percent of Total Billed Charges,72% of Total Billed Charges,18,60,,3.336,Percent of Total Billed Charges,60% of Total Billed Charges,27,90,,123.808,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,45,,35.024,Percent of Total Billed Charges,45% of Total Billed Charges,27,90,,28.336,Percent of Total Billed Charges,90% of Total billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.5,65,,48.904,Percent of total Billed Charges,65% of Total Billed Charges,13.23,44.1,,34.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.5,95,,29.904,Percent of Total Billed Charges,95% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.4,88,,27.704,Percent of Total Billed Charges,88% of Total Billed Charges,27,90,,28.336,Percent of Total Billed charges,90% of Total Billed Charges,13.23,30,
Twist Drill Bit 5/64 x 5,2720001948,CDM,272,RC,,,Outpatient,,,30.00,19.50,,30,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.8,76,,53.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.6,72,,83.144,Percent of Total Billed Charges,72% of Total Billed Charges,22.5,75,,86.608,Percent of Total Billed charges,75% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.6,72,,83.144,Percent of Total Billed Charges,72% of Total Billed Charges,18,60,,69.288,Percent of Total Billed Charges,60% of Total Billed Charges,27,90,,39.384,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,45,,33.76,Percent of Total Billed Charges,45% of Total Billed Charges,27,90,,62.856,Percent of Total Billed Charges,90% of Total billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.5,65,,50.584,Percent of total Billed Charges,65% of Total Billed Charges,13.23,44.1,,33.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.5,95,,66.352,Percent of Total Billed Charges,95% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.4,88,,61.456,Percent of Total Billed Charges,88% of Total Billed Charges,27,90,,62.856,Percent of Total Billed charges,90% of Total Billed Charges,13.23,30,
Lapsac 5x8 Tissue Pouch,2720001949,CDM,272,RC,,,Outpatient,,,194.88,126.67,,194.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,148.11,76,,57.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,140.31,72,,83.144,Percent of Total Billed Charges,72% of Total Billed Charges,146.16,75,,86.608,Percent of Total Billed charges,75% of Total Billed Charges,194.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.31,72,,83.144,Percent of Total Billed Charges,72% of Total Billed Charges,116.93,60,,69.288,Percent of Total Billed Charges,60% of Total Billed Charges,175.39,90,,34.472,Percent of Total Billed Charges,90% of Total Billed Charges,87.7,45,,61.904,Percent of Total Billed Charges,45% of Total Billed Charges,175.39,90,,67.72,Percent of Total Billed Charges,90% of Total billed Charges,194.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.67,65,,48.768,Percent of total Billed Charges,65% of Total Billed Charges,85.94,44.1,,60.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,185.14,95,,71.48,Percent of Total Billed Charges,95% of Total Billed Charges,194.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.49,88,,66.208,Percent of Total Billed Charges,88% of Total Billed Charges,175.39,90,,67.72,Percent of Total Billed charges,90% of Total Billed Charges,85.94,194.88,
Lapsac 8x10 Tissue Pouch,2720001950,CDM,272,RC,,,Outpatient,,,185.63,120.66,,185.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,141.08,76,,59.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,133.65,72,,577.384,Percent of Total Billed Charges,72% of Total Billed Charges,139.22,75,,601.44,Percent of Total Billed charges,75% of Total Billed Charges,185.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.65,72,,577.384,Percent of Total Billed Charges,72% of Total Billed Charges,111.38,60,,481.152,Percent of Total Billed Charges,60% of Total Billed Charges,167.07,90,,14.888,Percent of Total Billed Charges,90% of Total Billed Charges,83.53,45,,61.904,Percent of Total Billed Charges,45% of Total Billed Charges,167.07,90,,70.04,Percent of Total Billed Charges,90% of Total billed Charges,185.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.66,65,,89.416,Percent of total Billed Charges,65% of Total Billed Charges,81.86,44.1,,60.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,176.35,95,,73.936,Percent of Total Billed Charges,95% of Total Billed Charges,185.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.35,88,,68.488,Percent of Total Billed Charges,88% of Total Billed Charges,167.07,90,,70.04,Percent of Total Billed charges,90% of Total Billed Charges,81.86,185.63,
Twist Drill Bit 3/32 x5,2720001951,CDM,272,RC,,,Outpatient,,,30.00,19.50,,30,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.8,76,,57.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.6,72,,960.208,Percent of Total Billed Charges,72% of Total Billed Charges,22.5,75,,1000.216,Percent of Total Billed charges,75% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.6,72,,960.208,Percent of Total Billed Charges,72% of Total Billed Charges,18,60,,800.176,Percent of Total Billed Charges,60% of Total Billed Charges,27,90,,61.008,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,45,,60.376,Percent of Total Billed Charges,45% of Total Billed Charges,27,90,,67.52,Percent of Total Billed Charges,90% of Total billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.5,65,,89.416,Percent of total Billed Charges,65% of Total Billed Charges,13.23,44.1,,59.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.5,95,,71.272,Percent of Total Billed Charges,95% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.4,88,,66.024,Percent of Total Billed Charges,88% of Total Billed Charges,27,90,,67.52,Percent of Total Billed charges,90% of Total Billed Charges,13.23,30,
Berkley Tissue Trap,2720001952,CDM,272,RC,,,Outpatient,,,17.83,11.59,,17.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.55,76,,104.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.84,72,,25.056,Percent of Total Billed Charges,72% of Total Billed Charges,13.37,75,,26.104,Percent of Total Billed charges,75% of Total Billed Charges,17.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.84,72,,25.056,Percent of Total Billed Charges,72% of Total Billed Charges,10.7,60,,20.88,Percent of Total Billed Charges,60% of Total Billed Charges,16.05,90,,3.424,Percent of Total Billed Charges,90% of Total Billed Charges,8.02,45,,61.904,Percent of Total Billed Charges,45% of Total Billed Charges,16.05,90,,123.808,Percent of Total Billed Charges,90% of Total billed Charges,17.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.59,65,,87.208,Percent of total Billed Charges,65% of Total Billed Charges,7.86,44.1,,60.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.94,95,,130.68,Percent of Total Billed Charges,95% of Total Billed Charges,17.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.69,88,,121.056,Percent of Total Billed Charges,88% of Total Billed Charges,16.05,90,,123.808,Percent of Total Billed charges,90% of Total Billed Charges,7.86,17.83,
Pedi Bovie Pad,2720001953,CDM,272,RC,,,Outpatient,,,7.48,4.86,,7.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.68,76,,104.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.39,72,,1340.928,Percent of Total Billed Charges,72% of Total Billed Charges,5.61,75,,1396.8,Percent of Total Billed charges,75% of Total Billed Charges,7.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.39,72,,1340.928,Percent of Total Billed Charges,72% of Total Billed Charges,4.49,60,,1117.44,Percent of Total Billed Charges,60% of Total Billed Charges,6.73,90,,9.456,Percent of Total Billed Charges,90% of Total Billed Charges,3.37,45,,61.904,Percent of Total Billed Charges,45% of Total Billed Charges,6.73,90,,123.808,Percent of Total Billed Charges,90% of Total billed Charges,7.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.86,65,,89.416,Percent of total Billed Charges,65% of Total Billed Charges,3.3,44.1,,60.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.11,95,,130.68,Percent of Total Billed Charges,95% of Total Billed Charges,7.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.58,88,,121.056,Percent of Total Billed Charges,88% of Total Billed Charges,6.73,90,,123.808,Percent of Total Billed charges,90% of Total Billed Charges,3.3,7.48,
Synthes 1.5 Condy. Plate Right,2720001954,CDM,272,RC,,,Outpatient,,,525.00,341.25,,525,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,399,76,,101.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,378,72,,1340.928,Percent of Total Billed Charges,72% of Total Billed Charges,393.75,75,,1396.8,Percent of Total Billed charges,75% of Total Billed Charges,525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378,72,,1340.928,Percent of Total Billed Charges,72% of Total Billed Charges,315,60,,1117.44,Percent of Total Billed Charges,60% of Total Billed Charges,472.5,90,,69.304,Percent of Total Billed Charges,90% of Total Billed Charges,236.25,45,,61.904,Percent of Total Billed Charges,45% of Total Billed Charges,472.5,90,,120.744,Percent of Total Billed Charges,90% of Total billed Charges,525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.25,65,,89.416,Percent of total Billed Charges,65% of Total Billed Charges,231.53,44.1,,60.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,498.75,95,,127.456,Percent of Total Billed Charges,95% of Total Billed Charges,525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462,88,,118.064,Percent of Total Billed Charges,88% of Total Billed Charges,472.5,90,,120.744,Percent of Total Billed charges,90% of Total Billed Charges,231.53,525,
Hemashield BIF.Graft 18x9x9,2720001955,CDM,272,RC,,,Outpatient,,,1343.73,873.42,,1343.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1021.23,76,,104.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,967.49,72,,4.208,Percent of Total Billed Charges,72% of Total Billed Charges,1007.8,75,,4.384,Percent of Total Billed charges,75% of Total Billed Charges,1343.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,967.49,72,,4.208,Percent of Total Billed Charges,72% of Total Billed Charges,806.24,60,,3.504,Percent of Total Billed Charges,60% of Total Billed Charges,1209.36,90,,43.2,Percent of Total Billed Charges,90% of Total Billed Charges,604.68,45,,19.696,Percent of Total Billed Charges,45% of Total Billed Charges,1209.36,90,,123.808,Percent of Total Billed Charges,90% of Total billed Charges,1343.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1343.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1343.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,873.42,65,,89.416,Percent of total Billed Charges,65% of Total Billed Charges,592.58,44.1,,19.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,1276.54,95,,130.68,Percent of Total Billed Charges,95% of Total Billed Charges,1343.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1182.48,88,,121.056,Percent of Total Billed Charges,88% of Total Billed Charges,1209.36,90,,123.808,Percent of Total Billed charges,90% of Total Billed Charges,592.58,1343.73,
Hemashield BIF.Graft 16x8x8,2720001956,CDM,272,RC,,,Outpatient,,,1343.73,873.42,,1343.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1021.23,76,,104.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,967.49,72,,4.824,Percent of Total Billed Charges,72% of Total Billed Charges,1007.8,75,,5.032,Percent of Total Billed charges,75% of Total Billed Charges,1343.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,967.49,72,,4.824,Percent of Total Billed Charges,72% of Total Billed Charges,806.24,60,,4.024,Percent of Total Billed Charges,60% of Total Billed Charges,1209.36,90,,69.304,Percent of Total Billed Charges,90% of Total Billed Charges,604.68,45,,17.24,Percent of Total Billed Charges,45% of Total Billed Charges,1209.36,90,,123.808,Percent of Total Billed Charges,90% of Total billed Charges,1343.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1343.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1343.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,873.42,65,,28.448,Percent of total Billed Charges,65% of Total Billed Charges,592.58,44.1,,16.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,1276.54,95,,130.68,Percent of Total Billed Charges,95% of Total Billed Charges,1343.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1182.48,88,,121.056,Percent of Total Billed Charges,88% of Total Billed Charges,1209.36,90,,123.808,Percent of Total Billed charges,90% of Total Billed Charges,592.58,1343.73,
Endo Tube Uncuffed 3.0 & Style,2720001957,CDM,272,RC,,,Outpatient,,,10.35,6.73,,10.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.87,76,,104.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.45,72,,42.048,Percent of Total Billed Charges,72% of Total Billed Charges,7.76,75,,43.8,Percent of Total Billed charges,75% of Total Billed Charges,10.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.45,72,,42.048,Percent of Total Billed Charges,72% of Total Billed Charges,6.21,60,,35.04,Percent of Total Billed Charges,60% of Total Billed Charges,9.32,90,,69.304,Percent of Total Billed Charges,90% of Total Billed Charges,4.66,45,,7.448,Percent of Total Billed Charges,45% of Total Billed Charges,9.32,90,,123.808,Percent of Total Billed Charges,90% of Total billed Charges,10.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.73,65,,24.896,Percent of total Billed Charges,65% of Total Billed Charges,4.56,44.1,,7.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.83,95,,130.68,Percent of Total Billed Charges,95% of Total Billed Charges,10.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.11,88,,121.056,Percent of Total Billed Charges,88% of Total Billed Charges,9.32,90,,123.808,Percent of Total Billed charges,90% of Total Billed Charges,4.56,10.35,
Endo Tube Uncuffed 3.5 & Style,2720001958,CDM,272,RC,,,Outpatient,,,10.98,7.14,,10.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.34,76,,33.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.91,72,,37.728,Percent of Total Billed Charges,72% of Total Billed Charges,8.24,75,,39.304,Percent of Total Billed charges,75% of Total Billed Charges,10.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.91,72,,37.728,Percent of Total Billed Charges,72% of Total Billed Charges,6.59,60,,31.44,Percent of Total Billed Charges,60% of Total Billed Charges,9.88,90,,69.304,Percent of Total Billed Charges,90% of Total Billed Charges,4.94,45,,30.504,Percent of Total Billed Charges,45% of Total Billed Charges,9.88,90,,39.384,Percent of Total Billed Charges,90% of Total billed Charges,10.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,65,,10.752,Percent of total Billed Charges,65% of Total Billed Charges,4.84,44.1,,29.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.43,95,,41.576,Percent of Total Billed Charges,95% of Total Billed Charges,10.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.66,88,,38.512,Percent of Total Billed Charges,88% of Total Billed Charges,9.88,90,,39.384,Percent of Total Billed charges,90% of Total Billed Charges,4.84,10.98,
"Canister complete Kit, Hologic",2720001959,CDM,272,RC,,,Outpatient,,,19.45,12.64,,19.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.78,76,,29.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14,72,,37.728,Percent of Total Billed Charges,72% of Total Billed Charges,14.59,75,,39.304,Percent of Total Billed charges,75% of Total Billed Charges,19.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14,72,,37.728,Percent of Total Billed Charges,72% of Total Billed Charges,11.67,60,,31.44,Percent of Total Billed Charges,60% of Total Billed Charges,17.51,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,8.75,45,,1.712,Percent of Total Billed Charges,45% of Total Billed Charges,17.51,90,,34.472,Percent of Total Billed Charges,90% of Total billed Charges,19.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.64,65,,44.056,Percent of total Billed Charges,65% of Total Billed Charges,8.58,44.1,,1.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.48,95,,36.392,Percent of Total Billed Charges,95% of Total Billed Charges,19.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.12,88,,33.704,Percent of Total Billed Charges,88% of Total Billed Charges,17.51,90,,34.472,Percent of Total Billed charges,90% of Total Billed Charges,8.58,19.45,
Endo Cavity Needle Guide Kit,2720001960,CDM,272,RC,,,Outpatient,,,38.03,24.72,,38.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.9,76,,12.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.38,72,,35.568,Percent of Total Billed Charges,72% of Total Billed Charges,28.52,75,,37.048,Percent of Total Billed charges,75% of Total Billed Charges,38.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.38,72,,35.568,Percent of Total Billed Charges,72% of Total Billed Charges,22.82,60,,29.64,Percent of Total Billed Charges,60% of Total Billed Charges,34.23,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,17.11,45,,4.728,Percent of Total Billed Charges,45% of Total Billed Charges,34.23,90,,14.888,Percent of Total Billed Charges,90% of Total billed Charges,38.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.72,65,,2.472,Percent of total Billed Charges,65% of Total Billed Charges,16.77,44.1,,4.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.13,95,,15.72,Percent of Total Billed Charges,95% of Total Billed Charges,38.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.47,88,,14.56,Percent of Total Billed Charges,88% of Total Billed Charges,34.23,90,,14.888,Percent of Total Billed charges,90% of Total Billed Charges,16.77,38.03,
Vicryl 2-0 J328H Suture,2720001961,CDM,272,RC,,,Outpatient,,,3.40,2.21,,3.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.58,76,,51.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.45,72,,35.568,Percent of Total Billed Charges,72% of Total Billed Charges,2.55,75,,37.048,Percent of Total Billed charges,75% of Total Billed Charges,3.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.45,72,,35.568,Percent of Total Billed Charges,72% of Total Billed Charges,2.04,60,,29.64,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,1.53,45,,34.648,Percent of Total Billed Charges,45% of Total Billed Charges,3.06,90,,61.008,Percent of Total Billed Charges,90% of Total billed Charges,3.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,65,,6.824,Percent of total Billed Charges,65% of Total Billed Charges,1.5,44.1,,33.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.23,95,,64.392,Percent of Total Billed Charges,95% of Total Billed Charges,3.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.99,88,,59.648,Percent of Total Billed Charges,88% of Total Billed Charges,3.06,90,,61.008,Percent of Total Billed charges,90% of Total Billed Charges,1.5,3.4,
GERTIE MARX SP NDL 24GX5.0,2720001962,CDM,272,RC,,,Outpatient,,,33.13,21.53,,33.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.18,76,,2.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.85,72,,35.568,Percent of Total Billed Charges,72% of Total Billed Charges,24.85,75,,37.048,Percent of Total Billed charges,75% of Total Billed Charges,33.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.85,72,,35.568,Percent of Total Billed Charges,72% of Total Billed Charges,19.88,60,,29.64,Percent of Total Billed Charges,60% of Total Billed Charges,29.82,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,14.91,45,,21.6,Percent of Total Billed Charges,45% of Total Billed Charges,29.82,90,,3.424,Percent of Total Billed Charges,90% of Total billed Charges,33.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.53,65,,50.048,Percent of total Billed Charges,65% of Total Billed Charges,14.61,44.1,,21.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.47,95,,3.608,Percent of Total Billed Charges,95% of Total Billed Charges,33.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.15,88,,3.344,Percent of Total Billed Charges,88% of Total Billed Charges,29.82,90,,3.424,Percent of Total Billed charges,90% of Total Billed Charges,14.61,33.13,
SUSPENSORY W/O STRAP MED,2720001963,CDM,272,RC,,,Outpatient,,,14.45,9.39,,14.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.98,76,,7.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.4,72,,37.728,Percent of Total Billed Charges,72% of Total Billed Charges,10.84,75,,39.304,Percent of Total Billed charges,75% of Total Billed Charges,14.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,72,,37.728,Percent of Total Billed Charges,72% of Total Billed Charges,8.67,60,,31.44,Percent of Total Billed Charges,60% of Total Billed Charges,13.01,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,6.5,45,,34.648,Percent of Total Billed Charges,45% of Total Billed Charges,13.01,90,,9.456,Percent of Total Billed Charges,90% of Total billed Charges,14.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.39,65,,31.2,Percent of total Billed Charges,65% of Total Billed Charges,6.37,44.1,,33.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.73,95,,9.976,Percent of Total Billed Charges,95% of Total Billed Charges,14.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.72,88,,9.24,Percent of Total Billed Charges,88% of Total Billed Charges,13.01,90,,9.456,Percent of Total Billed charges,90% of Total Billed Charges,6.37,14.45,
SUSPENSORY W/O STRAP LG,2720001964,CDM,272,RC,,,Outpatient,,,14.45,9.39,,14.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.98,76,,58.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.4,72,,35.568,Percent of Total Billed Charges,72% of Total Billed Charges,10.84,75,,37.048,Percent of Total Billed charges,75% of Total Billed Charges,14.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,72,,35.568,Percent of Total Billed Charges,72% of Total Billed Charges,8.67,60,,29.64,Percent of Total Billed Charges,60% of Total Billed Charges,13.01,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,6.5,45,,34.648,Percent of Total Billed Charges,45% of Total Billed Charges,13.01,90,,69.304,Percent of Total Billed Charges,90% of Total billed Charges,14.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.39,65,,50.048,Percent of total Billed Charges,65% of Total Billed Charges,6.37,44.1,,33.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.73,95,,73.152,Percent of Total Billed Charges,95% of Total Billed Charges,14.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.72,88,,67.76,Percent of Total Billed Charges,88% of Total Billed Charges,13.01,90,,69.304,Percent of Total Billed charges,90% of Total Billed Charges,6.37,14.45,
CAST PADDING SPEC 4X4,2720001965,CDM,272,RC,,,Outpatient,,,1.35,0.88,,1.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.03,76,,36.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.97,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1.01,75,,225,Percent of Total Billed charges,75% of Total Billed Charges,1.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,0.81,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,0.61,45,,34.648,Percent of Total Billed Charges,45% of Total Billed Charges,1.22,90,,43.2,Percent of Total Billed Charges,90% of Total billed Charges,1.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.88,65,,50.048,Percent of total Billed Charges,65% of Total Billed Charges,0.6,44.1,,33.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.28,95,,45.6,Percent of Total Billed Charges,95% of Total Billed Charges,1.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.19,88,,42.24,Percent of Total Billed Charges,88% of Total Billed Charges,1.22,90,,43.2,Percent of Total Billed charges,90% of Total Billed Charges,0.6,1.35,
FIBERGLASS TAPE 3X4 DELTA LITE,2720001966,CDM,272,RC,,,Outpatient,,,5.43,3.53,,5.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.13,76,,58.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.91,72,,8.944,Percent of Total Billed Charges,72% of Total Billed Charges,4.07,75,,9.32,Percent of Total Billed charges,75% of Total Billed Charges,5.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.91,72,,8.944,Percent of Total Billed Charges,72% of Total Billed Charges,3.26,60,,7.456,Percent of Total Billed Charges,60% of Total Billed Charges,4.89,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,2.44,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,4.89,90,,69.304,Percent of Total Billed Charges,90% of Total billed Charges,5.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.53,65,,50.048,Percent of total Billed Charges,65% of Total Billed Charges,2.39,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.16,95,,73.152,Percent of Total Billed Charges,95% of Total Billed Charges,5.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.78,88,,67.76,Percent of Total Billed Charges,88% of Total Billed Charges,4.89,90,,69.304,Percent of Total Billed charges,90% of Total Billed Charges,2.39,5.43,
KLING 4?,2720001967,CDM,272,RC,,,Outpatient,,,0.45,0.29,,0.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.34,76,,58.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.32,72,,10.976,Percent of Total Billed Charges,72% of Total Billed Charges,0.34,75,,11.432,Percent of Total Billed charges,75% of Total Billed Charges,0.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.32,72,,10.976,Percent of Total Billed Charges,72% of Total Billed Charges,0.27,60,,9.144,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,0.2,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,0.41,90,,69.304,Percent of Total Billed Charges,90% of Total billed Charges,0.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.29,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,0.2,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.43,95,,73.152,Percent of Total Billed Charges,95% of Total Billed Charges,0.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.4,88,,67.76,Percent of Total Billed Charges,88% of Total Billed Charges,0.41,90,,69.304,Percent of Total Billed charges,90% of Total Billed Charges,0.2,0.45,
TWO-WING MALECOT 16FR,2720001968,CDM,272,RC,,,Outpatient,,,30.63,19.91,,30.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.28,76,,58.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.05,72,,10.44,Percent of Total Billed Charges,72% of Total Billed Charges,22.97,75,,10.88,Percent of Total Billed charges,75% of Total Billed Charges,30.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.05,72,,10.44,Percent of Total Billed Charges,72% of Total Billed Charges,18.38,60,,8.704,Percent of Total Billed Charges,60% of Total Billed Charges,27.57,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,13.78,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,27.57,90,,69.304,Percent of Total Billed Charges,90% of Total billed Charges,30.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.91,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,13.51,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.1,95,,73.152,Percent of Total Billed Charges,95% of Total Billed Charges,30.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.95,88,,67.76,Percent of Total Billed Charges,88% of Total Billed Charges,27.57,90,,69.304,Percent of Total Billed charges,90% of Total Billed Charges,13.51,30.63,
TWO-WING MALECOT 20FR,2720001969,CDM,272,RC,,,Outpatient,,,29.13,18.93,,29.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.14,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.97,72,,6.392,Percent of Total Billed Charges,72% of Total Billed Charges,21.85,75,,6.664,Percent of Total Billed charges,75% of Total Billed Charges,29.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.97,72,,6.392,Percent of Total Billed Charges,72% of Total Billed Charges,17.48,60,,5.328,Percent of Total Billed Charges,60% of Total Billed Charges,26.22,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,13.11,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,26.22,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,29.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.93,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,12.85,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,27.67,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,29.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.63,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,26.22,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,12.85,29.13,
AEROSTAT CHOLANGIGRAPHY CATH,2720001970,CDM,272,RC,,,Outpatient,,,170.00,110.50,,170,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.2,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,122.4,72,,11.488,Percent of Total Billed Charges,72% of Total Billed Charges,127.5,75,,11.968,Percent of Total Billed charges,75% of Total Billed Charges,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.4,72,,11.488,Percent of Total Billed Charges,72% of Total Billed Charges,102,60,,9.576,Percent of Total Billed Charges,60% of Total Billed Charges,153,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,76.5,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,153,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.5,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,74.97,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,161.5,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.6,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,153,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,74.97,170,
DERMACARRIERS 1 ?-1,2720001971,CDM,272,RC,,,Outpatient,,,50.88,33.07,,50.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38.67,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36.63,72,,18.464,Percent of Total Billed Charges,72% of Total Billed Charges,38.16,75,,19.232,Percent of Total Billed charges,75% of Total Billed Charges,50.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.63,72,,18.464,Percent of Total Billed Charges,72% of Total Billed Charges,30.53,60,,15.384,Percent of Total Billed Charges,60% of Total Billed Charges,45.79,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,22.9,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,45.79,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,50.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.07,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,22.44,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.34,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,50.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.77,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,45.79,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,22.44,50.88,
ESMARK 4,2720001972,CDM,272,RC,,,Outpatient,,,7.43,4.83,,7.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.65,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.35,72,,21.816,Percent of Total Billed Charges,72% of Total Billed Charges,5.57,75,,22.728,Percent of Total Billed charges,75% of Total Billed Charges,7.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.35,72,,21.816,Percent of Total Billed Charges,72% of Total Billed Charges,4.46,60,,18.184,Percent of Total Billed Charges,60% of Total Billed Charges,6.69,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,3.34,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,6.69,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,7.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.83,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,3.28,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.06,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,7.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.54,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,6.69,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,3.28,7.43,
PLAIN 5-0 H820G SUTURE,2720001973,CDM,272,RC,,,Outpatient,,,6.15,4.00,,6.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.67,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.43,72,,7.56,Percent of Total Billed Charges,72% of Total Billed Charges,4.61,75,,7.88,Percent of Total Billed charges,75% of Total Billed Charges,6.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.43,72,,7.56,Percent of Total Billed Charges,72% of Total Billed Charges,3.69,60,,6.304,Percent of Total Billed Charges,60% of Total Billed Charges,5.54,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,2.77,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,5.54,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,6.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,2.71,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.84,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,6.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.41,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,5.54,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,2.71,6.15,
VICRYL 2-0 VCP259H SUTURE,2720001974,CDM,272,RC,,,Outpatient,,,3.40,2.21,,3.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.58,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.45,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,2.55,75,,59.4,Percent of Total Billed charges,75% of Total Billed Charges,3.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.45,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,2.04,60,,47.52,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,1.53,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,3.06,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,3.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.21,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,1.5,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.23,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,3.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.99,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,3.06,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,1.5,3.4,
VICRYL 0 VCP603H SUTURE,2720001975,CDM,272,RC,,,Outpatient,,,4.15,2.70,,4.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.15,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.99,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,3.11,75,,59.4,Percent of Total Billed charges,75% of Total Billed Charges,4.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.99,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,2.49,60,,47.52,Percent of Total Billed Charges,60% of Total Billed Charges,3.74,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,1.87,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,3.74,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,4.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.7,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,1.83,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.94,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,4.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.65,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,3.74,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,1.83,4.15,
CHROMIC 1 813H,2720001976,CDM,272,RC,,,Outpatient,,,5.93,3.85,,5.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.51,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.27,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,4.45,75,,127.504,Percent of Total Billed charges,75% of Total Billed Charges,5.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.27,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,3.56,60,,102,Percent of Total Billed Charges,60% of Total Billed Charges,5.34,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,2.67,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,5.34,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,5.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.85,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,2.62,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.63,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,5.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.22,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,5.34,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,2.62,5.93,
CHROMIC 0 812H SUTURE,2720001977,CDM,272,RC,,,Outpatient,,,5.73,3.72,,5.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.35,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.13,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,4.3,75,,127.504,Percent of Total Billed charges,75% of Total Billed Charges,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.13,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,3.44,60,,102,Percent of Total Billed Charges,60% of Total Billed Charges,5.16,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,2.58,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,5.16,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.72,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,2.53,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.44,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.04,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,5.16,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,2.53,5.73,
CHROMIC 0 884H,2720001978,CDM,272,RC,,,Outpatient,,,5.75,3.74,,5.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.37,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.14,72,,110.552,Percent of Total Billed Charges,72% of Total Billed Charges,4.31,75,,115.16,Percent of Total Billed charges,75% of Total Billed Charges,5.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.14,72,,110.552,Percent of Total Billed Charges,72% of Total Billed Charges,3.45,60,,92.128,Percent of Total Billed Charges,60% of Total Billed Charges,5.18,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,5.18,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,5.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.74,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,2.54,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.46,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,5.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.06,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,5.18,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,2.54,5.75,
CHROMIC 3-0 G122H SUTURE,2720001979,CDM,272,RC,,,Outpatient,,,5.73,3.72,,5.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.35,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.13,72,,60.48,Percent of Total Billed Charges,72% of Total Billed Charges,4.3,75,,63,Percent of Total Billed charges,75% of Total Billed Charges,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.13,72,,60.48,Percent of Total Billed Charges,72% of Total Billed Charges,3.44,60,,50.4,Percent of Total Billed Charges,60% of Total Billed Charges,5.16,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,2.58,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,5.16,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.72,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,2.53,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.44,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.04,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,5.16,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,2.53,5.73,
CHROMIC 2-0 G123H SUTURE,2720001980,CDM,272,RC,,,Outpatient,,,5.63,3.66,,5.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.28,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.05,72,,50.4,Percent of Total Billed Charges,72% of Total Billed Charges,4.22,75,,52.504,Percent of Total Billed charges,75% of Total Billed Charges,5.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.05,72,,50.4,Percent of Total Billed Charges,72% of Total Billed Charges,3.38,60,,42,Percent of Total Billed Charges,60% of Total Billed Charges,5.07,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,2.53,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,5.07,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,5.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.66,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,2.48,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.35,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,5.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.95,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,5.07,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,2.48,5.63,
CHROMIC 2-0 L113G,2720001981,CDM,272,RC,,,Outpatient,,,6.80,4.42,,6.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.17,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.9,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,5.1,75,,127.504,Percent of Total Billed charges,75% of Total Billed Charges,6.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.9,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,4.08,60,,102,Percent of Total Billed Charges,60% of Total Billed Charges,6.12,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,3.06,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,6.12,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,6.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.42,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,3,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.46,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,6.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.98,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,6.12,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,3,6.8,
CHROMIC 0 L114G,2720001982,CDM,272,RC,,,Outpatient,,,6.58,4.28,,6.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.74,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,4.94,75,,127.504,Percent of Total Billed charges,75% of Total Billed Charges,6.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.74,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,3.95,60,,102,Percent of Total Billed Charges,60% of Total Billed Charges,5.92,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.96,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,5.92,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,6.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.28,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,2.9,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.25,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,6.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.79,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,5.92,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,2.9,6.58,
CHROMIC 1 L115G,2720001983,CDM,272,RC,,,Outpatient,,,6.80,4.42,,6.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.17,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.9,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,5.1,75,,127.504,Percent of Total Billed charges,75% of Total Billed Charges,6.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.9,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,4.08,60,,102,Percent of Total Billed Charges,60% of Total Billed Charges,6.12,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,3.06,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,6.12,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,6.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.42,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,3,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.46,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,6.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.98,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,6.12,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,3,6.8,
CHROMIC 4-0 U203H,2720001984,CDM,272,RC,,,Outpatient,,,6.05,3.93,,6.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.6,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.36,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,4.54,75,,127.504,Percent of Total Billed charges,75% of Total Billed Charges,6.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.36,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,3.63,60,,102,Percent of Total Billed Charges,60% of Total Billed Charges,5.45,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.72,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,5.45,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,6.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.93,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,2.67,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,6.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.32,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,5.45,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,2.67,6.05,
ETHIBOND 0 X186H TIES,2720001985,CDM,272,RC,,,Outpatient,,,1.83,1.19,,1.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.39,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.32,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,1.37,75,,127.504,Percent of Total Billed charges,75% of Total Billed Charges,1.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.32,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,1.1,60,,102,Percent of Total Billed Charges,60% of Total Billed Charges,1.65,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,0.82,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,1.65,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,1.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.19,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,0.81,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.74,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,1.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.61,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,1.65,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,0.81,1.83,
ETHILON 3-0 1663H,2720001986,CDM,272,RC,,,Outpatient,,,6.98,4.54,,6.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.3,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.03,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,5.24,75,,1312.504,Percent of Total Billed charges,75% of Total Billed Charges,6.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.03,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,4.19,60,,1050,Percent of Total Billed Charges,60% of Total Billed Charges,6.28,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,3.14,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,6.28,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,6.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.54,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,3.08,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.63,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,6.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.14,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,6.28,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,3.08,6.98,
ETHILON 3-0 1671H,2720001987,CDM,272,RC,,,Outpatient,,,3.33,2.16,,3.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.53,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.4,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,2.5,75,,1312.504,Percent of Total Billed charges,75% of Total Billed Charges,3.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.4,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,2,60,,1050,Percent of Total Billed Charges,60% of Total Billed Charges,3,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.5,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,3,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,3.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.16,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,1.47,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.16,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,3.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.93,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,3,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,1.47,3.33,
ETHILON 2 490T,2720001988,CDM,272,RC,,,Outpatient,,,5.98,3.89,,5.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.54,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.31,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,4.49,75,,1312.504,Percent of Total Billed charges,75% of Total Billed Charges,5.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.31,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,3.59,60,,1050,Percent of Total Billed Charges,60% of Total Billed Charges,5.38,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.69,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,5.38,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,5.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.89,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,2.64,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.68,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,5.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.26,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,5.38,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,2.64,5.98,
ETHILON 3-0 627H,2720001989,CDM,272,RC,,,Outpatient,,,3.30,2.15,,3.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.51,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,75,,1312.504,Percent of Total Billed charges,75% of Total Billed Charges,3.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.38,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,1.98,60,,1050,Percent of Total Billed Charges,60% of Total Billed Charges,2.97,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,2.97,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,3.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,3.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.9,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,2.97,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.3,
ETHILON 5-0 1666H,2720001990,CDM,272,RC,,,Outpatient,,,6.28,4.08,,6.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.77,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.52,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,4.71,75,,1312.504,Percent of Total Billed charges,75% of Total Billed Charges,6.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.52,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,3.77,60,,1050,Percent of Total Billed Charges,60% of Total Billed Charges,5.65,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.83,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,5.65,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,6.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.08,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,2.77,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.97,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,6.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.53,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,5.65,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,2.77,6.28,
PDS 0 Z352H,2720001991,CDM,272,RC,,,Outpatient,,,4.85,3.15,,4.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.69,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.49,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,3.64,75,,1312.504,Percent of Total Billed charges,75% of Total Billed Charges,4.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.49,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,2.91,60,,1050,Percent of Total Billed Charges,60% of Total Billed Charges,4.37,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.18,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,4.37,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,4.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.15,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,2.14,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.61,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,4.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.27,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,4.37,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,2.14,4.85,
PLAIN 3-0 842H,2720001992,CDM,272,RC,,,Outpatient,,,5.75,3.74,,5.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.37,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.14,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,4.31,75,,1312.504,Percent of Total Billed charges,75% of Total Billed Charges,5.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.14,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,3.45,60,,1050,Percent of Total Billed Charges,60% of Total Billed Charges,5.18,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,5.18,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,5.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.74,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,2.54,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.46,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,5.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.06,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,5.18,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,2.54,5.75,
PLAIN 2-0 L103G TIES,2720001993,CDM,272,RC,,,Outpatient,,,6.80,4.42,,6.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.17,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.9,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,5.1,75,,1312.504,Percent of Total Billed charges,75% of Total Billed Charges,6.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.9,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,4.08,60,,1050,Percent of Total Billed Charges,60% of Total Billed Charges,6.12,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,3.06,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,6.12,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,6.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.42,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,3,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.46,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,6.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.98,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,6.12,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,3,6.8,
SILK 4-0 A183H TIES,2720001994,CDM,272,RC,,,Outpatient,,,3.63,2.36,,3.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.76,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.61,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,2.72,75,,1312.504,Percent of Total Billed charges,75% of Total Billed Charges,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.61,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,2.18,60,,1050,Percent of Total Billed Charges,60% of Total Billed Charges,3.27,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.63,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,3.27,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.36,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,1.6,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.45,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,3.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.19,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,3.27,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,1.6,3.63,
SILK 3-0 A184H TIES,2720001995,CDM,272,RC,,,Outpatient,,,3.08,2.00,,3.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.34,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.22,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,2.31,75,,1312.504,Percent of Total Billed charges,75% of Total Billed Charges,3.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.22,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,1.85,60,,1050,Percent of Total Billed Charges,60% of Total Billed Charges,2.77,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.39,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,2.77,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,3.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,1.36,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.93,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,3.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.71,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,2.77,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,1.36,3.08,
SILK 2-0 A185H TIES,2720001996,CDM,272,RC,,,Outpatient,,,2.78,1.81,,2.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.11,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,2.09,75,,1312.504,Percent of Total Billed charges,75% of Total Billed Charges,2.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,1.67,60,,1050,Percent of Total Billed Charges,60% of Total Billed Charges,2.5,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.25,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,2.5,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,2.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.81,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,1.23,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.64,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,2.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.45,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,2.5,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,1.23,2.78,
SILK 0 A186H TIES,2720001997,CDM,272,RC,,,Outpatient,,,1.45,0.94,,1.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.1,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.04,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,1.09,75,,1312.504,Percent of Total Billed charges,75% of Total Billed Charges,1.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.04,72,,1260,Percent of Total Billed Charges,72% of Total Billed Charges,0.87,60,,1050,Percent of Total Billed Charges,60% of Total Billed Charges,1.31,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,0.65,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,1.31,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,1.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.94,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,0.64,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.38,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,1.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.28,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,1.31,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,0.64,1.45,
SILK 1 A307H TIES,2720001998,CDM,272,RC,,,Outpatient,,,2.45,1.59,,2.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.86,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.76,72,,8.568,Percent of Total Billed Charges,72% of Total Billed Charges,1.84,75,,8.928,Percent of Total Billed charges,75% of Total Billed Charges,2.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.76,72,,8.568,Percent of Total Billed Charges,72% of Total Billed Charges,1.47,60,,7.144,Percent of Total Billed Charges,60% of Total Billed Charges,2.21,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.1,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,2.21,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,2.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.59,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,1.08,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.33,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,2.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.16,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,2.21,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,1.08,2.45,
SILK 3-0 K832H,2720001999,CDM,272,RC,,,Outpatient,,,2.33,1.51,,2.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.77,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.68,72,,986.4,Percent of Total Billed Charges,72% of Total Billed Charges,1.75,75,,1027.504,Percent of Total Billed charges,75% of Total Billed Charges,2.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.68,72,,986.4,Percent of Total Billed Charges,72% of Total Billed Charges,1.4,60,,822,Percent of Total Billed Charges,60% of Total Billed Charges,2.1,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.05,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,2.1,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,2.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.51,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,1.03,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.21,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,2.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.05,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,2.1,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,1.03,2.33,
VICRYL 2-0 J111T TIES,2720002000,CDM,272,RC,,,Outpatient,,,16.83,10.94,,16.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.79,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.12,72,,986.4,Percent of Total Billed Charges,72% of Total Billed Charges,12.62,75,,1027.504,Percent of Total Billed charges,75% of Total Billed Charges,16.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.12,72,,986.4,Percent of Total Billed Charges,72% of Total Billed Charges,10.1,60,,822,Percent of Total Billed Charges,60% of Total Billed Charges,15.15,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,7.57,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,15.15,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,16.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.94,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,7.42,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.99,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,16.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.81,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,15.15,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,7.42,16.83,
VICRYL 0 J260H,2720002001,CDM,272,RC,,,Outpatient,,,3.13,2.03,,3.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.38,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.25,72,,1080,Percent of Total Billed Charges,72% of Total Billed Charges,2.35,75,,1125,Percent of Total Billed charges,75% of Total Billed Charges,3.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.25,72,,1080,Percent of Total Billed Charges,72% of Total Billed Charges,1.88,60,,900,Percent of Total Billed Charges,60% of Total Billed Charges,2.82,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.41,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,2.82,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,3.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.03,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,1.38,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.97,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,3.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.75,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,2.82,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,1.38,3.13,
VICRYL 1 J268H,2720002002,CDM,272,RC,,,Outpatient,,,3.48,2.26,,3.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.64,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.51,72,,2.208,Percent of Total Billed Charges,72% of Total Billed Charges,2.61,75,,2.296,Percent of Total Billed charges,75% of Total Billed Charges,3.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.51,72,,2.208,Percent of Total Billed Charges,72% of Total Billed Charges,2.09,60,,1.84,Percent of Total Billed Charges,60% of Total Billed Charges,3.13,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.57,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,3.13,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,3.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.26,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,1.53,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.31,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,3.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.06,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,3.13,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,1.53,3.48,
VICRYL 2-0 J259H,2720002003,CDM,272,RC,,,Outpatient,,,3.13,2.03,,3.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.38,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.25,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.35,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,3.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.25,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,1.88,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,2.82,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.41,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,2.82,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,3.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.03,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,1.38,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.97,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,3.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.75,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,2.82,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,1.38,3.13,
VICRYL 3-0 J327H,2720002004,CDM,272,RC,,,Outpatient,,,3.55,2.31,,3.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.7,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.56,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.66,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,3.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.56,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.13,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,3.2,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.6,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,3.2,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,3.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.31,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,1.57,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.37,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,3.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.12,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,3.2,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,1.57,3.55,
VICRYL 4-0 J494H P-3,2720002005,CDM,272,RC,,,Outpatient,,,8.55,5.56,,8.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.5,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.16,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,6.41,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,8.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.16,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,5.13,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,7.7,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,3.85,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,7.7,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,8.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.56,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,3.77,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.12,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,8.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.52,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,7.7,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,3.77,8.55,
VICRYL 4-0 J304H,2720002006,CDM,272,RC,,,Outpatient,,,3.28,2.13,,3.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.49,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.36,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.46,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,3.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.36,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,1.97,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,2.95,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.48,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,2.95,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,3.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.13,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,1.45,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.12,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,3.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.89,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,2.95,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,1.45,3.28,
VICRYL 5-0 J493H,2720002007,CDM,272,RC,,,Outpatient,,,8.63,5.61,,8.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.56,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.21,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,6.47,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,8.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.21,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,5.18,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,7.77,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,3.88,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,7.77,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,8.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.61,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,3.81,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.2,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,8.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.59,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,7.77,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,3.81,8.63,
VICRYL 2-0 J602H,2720002008,CDM,272,RC,,,Outpatient,,,4.35,2.83,,4.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.31,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.13,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,3.26,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,4.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.13,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.61,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,3.92,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.96,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,3.92,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,4.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.83,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,1.92,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,4.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.83,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,3.92,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,1.92,4.35,
MERSILENE RS22 5MM TAPE,2720002009,CDM,272,RC,,,Outpatient,,,57.30,37.25,,57.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.55,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.26,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,42.98,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,57.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.26,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,34.38,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,51.57,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,25.79,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,51.57,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,57.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.25,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,25.27,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.44,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,57.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.42,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,51.57,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,25.27,57.3,
PLAIN 4-0 PS-2 18? 1627H,2720002010,CDM,272,RC,,,Outpatient,,,11.83,7.69,,11.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.99,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.52,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,8.87,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,11.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.52,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,7.1,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,10.65,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,5.32,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,10.65,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,11.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.69,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,5.22,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.24,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,11.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.41,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,10.65,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,5.22,11.83,
PDS 1 Z353H,2720002011,CDM,272,RC,,,Outpatient,,,4.85,3.15,,4.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.69,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.49,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,3.64,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,4.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.49,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.91,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,4.37,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.18,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,4.37,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,4.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.15,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,2.14,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.61,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,4.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.27,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,4.37,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,2.14,4.85,
VICRYL 0 JJ41G,2720002012,CDM,272,RC,,,Outpatient,,,22.83,14.84,,22.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.35,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.44,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,17.12,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,22.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.44,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,13.7,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,20.55,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,10.27,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,20.55,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,22.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.84,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,10.07,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.69,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,22.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.09,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,20.55,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,10.07,22.83,
VICRYL 3-0 J205G,2720002013,CDM,272,RC,,,Outpatient,,,4.20,2.73,,4.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.19,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.02,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,3.15,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,4.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.02,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.52,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,3.78,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.89,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,3.78,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,4.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.73,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,1.85,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.99,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,4.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.7,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,3.78,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,1.85,4.2,
VICRYL 2-0 J328H,2720002014,CDM,272,RC,,,Outpatient,,,3.25,2.11,,3.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.47,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.34,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.44,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,3.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.34,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,1.95,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,2.93,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.46,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,2.93,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,3.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.11,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,1.43,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.09,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,3.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.86,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,2.93,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,1.43,3.25,
VICRYL 3-0 J442H,2720002015,CDM,272,RC,,,Outpatient,,,4.48,2.91,,4.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.4,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.23,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,3.36,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,4.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.23,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.69,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,4.03,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.02,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,4.03,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,4.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,1.98,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.26,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,4.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.94,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,4.03,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,1.98,4.48,
VICRYL 1 J261H,2720002016,CDM,272,RC,,,Outpatient,,,3.25,2.11,,3.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.47,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.34,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.44,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,3.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.34,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,1.95,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,2.93,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.46,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,2.93,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,3.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.11,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,1.43,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.09,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,3.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.86,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,2.93,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,1.43,3.25,
PDS 1 Z880G,2720002017,CDM,272,RC,,,Outpatient,,,8.80,5.72,,8.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.69,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.34,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,6.6,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,8.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.34,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,5.28,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,7.92,90,,315,Percent of Total Billed Charges,90% of Total Billed Charges,3.96,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,7.92,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,8.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,3.88,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.36,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,8.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.74,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,7.92,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,3.88,8.8,
CHROMIC 2-0 811H,2720002018,CDM,272,RC,,,Outpatient,,,5.55,3.61,,5.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.22,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,4.16,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,5.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,3.33,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,5,90,,180,Percent of Total Billed Charges,90% of Total Billed Charges,2.5,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,5,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,5.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.61,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,2.45,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.27,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,5.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.88,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,5,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,2.45,5.55,
ETHILON 4-0 1667H PS-2,2720002019,CDM,272,RC,,,Outpatient,,,6.38,4.15,,6.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.85,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.59,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,4.79,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,6.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.59,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,3.83,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,5.74,90,,180,Percent of Total Billed Charges,90% of Total Billed Charges,2.87,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,5.74,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,6.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.15,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,2.81,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.06,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,6.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.61,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,5.74,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,2.81,6.38,
PLAIN 0 N864H,2720002020,CDM,272,RC,,,Outpatient,,,5.73,3.72,,5.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.35,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.13,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,4.3,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.13,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,3.44,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,5.16,90,,1601.856,Percent of Total Billed Charges,90% of Total Billed Charges,2.58,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,5.16,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.72,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,2.53,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.44,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.04,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,5.16,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,2.53,5.73,
PLAIN 3-0 L102G TIES,2720002021,CDM,272,RC,,,Outpatient,,,6.60,4.29,,6.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.02,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.75,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,4.95,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,6.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.75,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,3.96,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,5.94,90,,12.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.97,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,5.94,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,6.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.29,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,2.91,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.27,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,6.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.81,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,5.94,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,2.91,6.6,
ETHIBOND 1 X425H,2720002022,CDM,272,RC,,,Outpatient,,,3.20,2.08,,3.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.43,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.3,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.4,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,3.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.3,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,1.92,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,2.88,90,,19.8,Percent of Total Billed Charges,90% of Total Billed Charges,1.44,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,2.88,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,3.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.08,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,1.41,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.04,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,3.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.82,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,2.88,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,1.41,3.2,
PLAIN 3-0 1630H,2720002023,CDM,272,RC,,,Outpatient,,,11.28,7.33,,11.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.57,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.12,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,8.46,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,11.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.12,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,6.77,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,10.15,90,,12.6,Percent of Total Billed Charges,90% of Total Billed Charges,5.08,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,10.15,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,11.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.33,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,4.97,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.72,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,11.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.93,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,10.15,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,4.97,11.28,
VICRYL 1 J947H,2720002024,CDM,272,RC,,,Outpatient,,,3.45,2.24,,3.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.62,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.48,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.59,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,3.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.48,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.07,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,3.11,90,,191.256,Percent of Total Billed Charges,90% of Total Billed Charges,1.55,45,,157.504,Percent of Total Billed Charges,45% of Total Billed Charges,3.11,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,3.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.24,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,1.52,44.1,,154.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.28,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,3.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.04,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,3.11,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,1.52,3.45,
VICRYL 1 CTX VCP977H,2720002025,CDM,272,RC,,,Outpatient,,,3.75,2.44,,3.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.85,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.7,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.81,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,3.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.7,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.25,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,3.38,90,,191.256,Percent of Total Billed Charges,90% of Total Billed Charges,1.69,45,,90,Percent of Total Billed Charges,45% of Total Billed Charges,3.38,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,3.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.44,65,,227.504,Percent of total Billed Charges,65% of Total Billed Charges,1.65,44.1,,88.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.56,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,3.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.3,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,3.38,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,1.65,3.75,
TI-CRON 5 3128-79,2720002026,CDM,272,RC,,,Outpatient,,,24.75,16.09,,24.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.81,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.82,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,18.56,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,24.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.82,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,14.85,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,22.28,90,,45.688,Percent of Total Billed Charges,90% of Total Billed Charges,11.14,45,,90,Percent of Total Billed Charges,45% of Total Billed Charges,22.28,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,24.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.09,65,,130,Percent of total Billed Charges,65% of Total Billed Charges,10.91,44.1,,88.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.51,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,24.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.78,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,22.28,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,10.91,24.75,
TI-CRON 2-0 2914-51,2720002027,CDM,272,RC,,,Outpatient,,,26.65,17.32,,26.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.25,76,,266,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.19,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,19.99,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,26.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.19,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,15.99,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,23.99,90,,2.184,Percent of Total Billed Charges,90% of Total Billed Charges,11.99,45,,800.928,Percent of Total Billed Charges,45% of Total Billed Charges,23.99,90,,315,Percent of Total Billed Charges,90% of Total billed Charges,26.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.32,65,,130,Percent of total Billed Charges,65% of Total Billed Charges,11.75,44.1,,784.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.32,95,,332.504,Percent of Total Billed Charges,95% of Total Billed Charges,26.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.45,88,,308,Percent of Total Billed Charges,88% of Total Billed Charges,23.99,90,,315,Percent of Total Billed charges,90% of Total Billed Charges,11.75,26.65,
VICRYL 0 J912G TIES,2720002028,CDM,272,RC,,,Outpatient,,,15.60,10.14,,15.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.86,76,,152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.23,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,11.7,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,15.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.23,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,9.36,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,14.04,90,,70.2,Percent of Total Billed Charges,90% of Total Billed Charges,7.02,45,,6.304,Percent of Total Billed Charges,45% of Total Billed Charges,14.04,90,,180,Percent of Total Billed Charges,90% of Total billed Charges,15.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.14,65,,1156.896,Percent of total Billed Charges,65% of Total Billed Charges,6.88,44.1,,6.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.82,95,,190,Percent of Total Billed Charges,95% of Total Billed Charges,15.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.73,88,,176,Percent of Total Billed Charges,88% of Total Billed Charges,14.04,90,,180,Percent of Total Billed charges,90% of Total Billed Charges,6.88,15.6,
VICRYL 2 J618H TIES,2720002029,CDM,272,RC,,,Outpatient,,,3.98,2.59,,3.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.02,76,,152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.87,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.99,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,3.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.39,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,3.58,90,,388.152,Percent of Total Billed Charges,90% of Total Billed Charges,1.79,45,,9.904,Percent of Total Billed Charges,45% of Total Billed Charges,3.58,90,,180,Percent of Total Billed Charges,90% of Total billed Charges,3.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.59,65,,9.104,Percent of total Billed Charges,65% of Total Billed Charges,1.76,44.1,,9.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.78,95,,190,Percent of Total Billed Charges,95% of Total Billed Charges,3.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.5,88,,176,Percent of Total Billed Charges,88% of Total Billed Charges,3.58,90,,180,Percent of Total Billed charges,90% of Total Billed Charges,1.76,3.98,
VICRYL 2-0 J417H,2720002030,CDM,272,RC,,,Outpatient,,,3.13,2.03,,3.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.38,76,,1352.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.25,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.35,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,3.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.25,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,1.88,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,2.82,90,,29.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.41,45,,6.304,Percent of Total Billed Charges,45% of Total Billed Charges,2.82,90,,1601.856,Percent of Total Billed Charges,90% of Total billed Charges,3.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.03,65,,14.304,Percent of total Billed Charges,65% of Total Billed Charges,1.38,44.1,,6.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.97,95,,1690.848,Percent of Total Billed Charges,95% of Total Billed Charges,3.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.75,88,,1566.256,Percent of Total Billed Charges,88% of Total Billed Charges,2.82,90,,1601.856,Percent of Total Billed charges,90% of Total Billed Charges,1.38,3.13,
PDS 2-0 Z333H,2720002031,CDM,272,RC,,,Outpatient,,,4.95,3.22,,4.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.76,76,,10.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.56,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,3.71,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,4.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.56,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.97,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,4.46,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,2.23,45,,95.624,Percent of Total Billed Charges,45% of Total Billed Charges,4.46,90,,12.6,Percent of Total Billed Charges,90% of Total billed Charges,4.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.22,65,,9.104,Percent of total Billed Charges,65% of Total Billed Charges,2.18,44.1,,93.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.7,95,,13.304,Percent of Total Billed Charges,95% of Total Billed Charges,4.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.36,88,,12.32,Percent of Total Billed Charges,88% of Total Billed Charges,4.46,90,,12.6,Percent of Total Billed charges,90% of Total Billed Charges,2.18,4.95,
SILK 4-0 A303H,2720002032,CDM,272,RC,,,Outpatient,,,5.23,3.40,,5.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.97,76,,16.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.77,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,3.92,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,5.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.77,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,3.14,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,4.71,90,,63,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,45,,95.624,Percent of Total Billed Charges,45% of Total Billed Charges,4.71,90,,19.8,Percent of Total Billed Charges,90% of Total billed Charges,5.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.4,65,,138.128,Percent of total Billed Charges,65% of Total Billed Charges,2.31,44.1,,93.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.97,95,,20.904,Percent of Total Billed Charges,95% of Total Billed Charges,5.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.6,88,,19.36,Percent of Total Billed Charges,88% of Total Billed Charges,4.71,90,,19.8,Percent of Total Billed charges,90% of Total Billed Charges,2.31,5.23,
SILK 3-0 A304H,2720002033,CDM,272,RC,,,Outpatient,,,5.15,3.35,,5.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.91,76,,10.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.71,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,3.86,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,5.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.71,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,3.09,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,4.64,90,,36,Percent of Total Billed Charges,90% of Total Billed Charges,2.32,45,,22.84,Percent of Total Billed Charges,45% of Total Billed Charges,4.64,90,,12.6,Percent of Total Billed Charges,90% of Total billed Charges,5.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.35,65,,138.128,Percent of total Billed Charges,65% of Total Billed Charges,2.27,44.1,,22.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.89,95,,13.304,Percent of Total Billed Charges,95% of Total Billed Charges,5.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.53,88,,12.32,Percent of Total Billed Charges,88% of Total Billed Charges,4.64,90,,12.6,Percent of Total Billed charges,90% of Total Billed Charges,2.27,5.15,
SILK 2-0 A305H,2720002034,CDM,272,RC,,,Outpatient,,,4.58,2.98,,4.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.48,76,,161.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.3,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,3.44,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,4.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.3,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.75,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,4.12,90,,4.504,Percent of Total Billed Charges,90% of Total Billed Charges,2.06,45,,1.088,Percent of Total Billed Charges,45% of Total Billed Charges,4.12,90,,191.256,Percent of Total Billed Charges,90% of Total billed Charges,4.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.98,65,,32.992,Percent of total Billed Charges,65% of Total Billed Charges,2.02,44.1,,1.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.35,95,,201.88,Percent of Total Billed Charges,95% of Total Billed Charges,4.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.03,88,,187,Percent of Total Billed Charges,88% of Total Billed Charges,4.12,90,,191.256,Percent of Total Billed charges,90% of Total Billed Charges,2.02,4.58,
MONOCRYL 2-0 CT-1 Y339H,2720002035,CDM,272,RC,,,Outpatient,,,3.65,2.37,,3.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.77,76,,161.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.63,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.74,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,3.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.63,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.19,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,3.29,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,1.64,45,,35.104,Percent of Total Billed Charges,45% of Total Billed Charges,3.29,90,,191.256,Percent of Total Billed Charges,90% of Total billed Charges,3.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.37,65,,1.576,Percent of total Billed Charges,65% of Total Billed Charges,1.61,44.1,,34.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.47,95,,201.88,Percent of Total Billed Charges,95% of Total Billed Charges,3.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.21,88,,187,Percent of Total Billed Charges,88% of Total Billed Charges,3.29,90,,191.256,Percent of Total Billed charges,90% of Total Billed Charges,1.61,3.65,
MONOCRYL 1 CTX Y399H,2720002036,CDM,272,RC,,,Outpatient,,,4.83,3.14,,4.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.67,76,,38.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.48,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,3.62,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,4.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.48,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.9,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,4.35,90,,116.968,Percent of Total Billed Charges,90% of Total Billed Charges,2.17,45,,194.08,Percent of Total Billed Charges,45% of Total Billed Charges,4.35,90,,45.688,Percent of Total Billed Charges,90% of Total billed Charges,4.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.14,65,,50.704,Percent of total Billed Charges,65% of Total Billed Charges,2.13,44.1,,190.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.59,95,,48.224,Percent of Total Billed Charges,95% of Total Billed Charges,4.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.25,88,,44.672,Percent of Total Billed Charges,88% of Total Billed Charges,4.35,90,,45.688,Percent of Total Billed charges,90% of Total Billed Charges,2.13,4.83,
MONOCRYL 4-0 Y426H,2720002037,CDM,272,RC,,,Outpatient,,,10.08,6.55,,10.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.66,76,,1.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.26,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,7.56,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,10.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.26,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,6.05,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,9.07,90,,5940,Percent of Total Billed Charges,90% of Total Billed Charges,4.54,45,,14.696,Percent of Total Billed Charges,45% of Total Billed Charges,9.07,90,,2.184,Percent of Total Billed Charges,90% of Total billed Charges,10.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.55,65,,280.336,Percent of total Billed Charges,65% of Total Billed Charges,4.45,44.1,,14.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.58,95,,2.304,Percent of Total Billed Charges,95% of Total Billed Charges,10.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.87,88,,2.136,Percent of Total Billed Charges,88% of Total Billed Charges,9.07,90,,2.184,Percent of Total Billed charges,90% of Total Billed Charges,4.45,10.08,
MONOCRYL 3-0 Y523H,2720002038,CDM,272,RC,,,Outpatient,,,5.73,3.72,,5.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.35,76,,59.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.13,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,4.3,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.13,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,3.44,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,5.16,90,,14.856,Percent of Total Billed Charges,90% of Total Billed Charges,2.58,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,5.16,90,,70.2,Percent of Total Billed Charges,90% of Total billed Charges,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.72,65,,21.232,Percent of total Billed Charges,65% of Total Billed Charges,2.53,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.44,95,,74.104,Percent of Total Billed Charges,95% of Total Billed Charges,5.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.04,88,,68.64,Percent of Total Billed Charges,88% of Total Billed Charges,5.16,90,,70.2,Percent of Total Billed charges,90% of Total Billed Charges,2.53,5.73,
MONOCRYL 2-0 Y945H,2720002039,CDM,272,RC,,,Outpatient,,,4.15,2.70,,4.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.15,76,,327.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.99,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,3.11,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,4.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.99,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.49,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,3.74,90,,2.976,Percent of Total Billed Charges,90% of Total Billed Charges,1.87,45,,31.504,Percent of Total Billed Charges,45% of Total Billed Charges,3.74,90,,388.152,Percent of Total Billed Charges,90% of Total billed Charges,4.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.7,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,1.83,44.1,,30.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.94,95,,409.72,Percent of Total Billed Charges,95% of Total Billed Charges,4.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.65,88,,379.528,Percent of Total Billed Charges,88% of Total Billed Charges,3.74,90,,388.152,Percent of Total Billed charges,90% of Total Billed Charges,1.83,4.15,
MONOCRYL 1 Y947H,2720002040,CDM,272,RC,,,Outpatient,,,4.33,2.81,,4.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.29,76,,24.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.12,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,3.25,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,4.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.12,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,2.6,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,3.9,90,,5.256,Percent of Total Billed Charges,90% of Total Billed Charges,1.95,45,,18,Percent of Total Billed Charges,45% of Total Billed Charges,3.9,90,,29.4,Percent of Total Billed Charges,90% of Total billed Charges,4.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.81,65,,45.504,Percent of total Billed Charges,65% of Total Billed Charges,1.91,44.1,,17.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.11,95,,31.032,Percent of Total Billed Charges,95% of Total Billed Charges,4.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.81,88,,28.744,Percent of Total Billed Charges,88% of Total Billed Charges,3.9,90,,29.4,Percent of Total Billed charges,90% of Total Billed Charges,1.91,4.33,
PHILLIPS FOLLOWER 12FR,2720002041,CDM,272,RC,,,Outpatient,,,46.75,30.39,,46.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.53,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.66,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,35.06,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.66,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,28.05,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,42.08,90,,91.728,Percent of Total Billed Charges,90% of Total Billed Charges,21.04,45,,2.248,Percent of Total Billed Charges,45% of Total Billed Charges,42.08,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.39,65,,26,Percent of total Billed Charges,65% of Total Billed Charges,20.62,44.1,,2.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.41,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.14,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,42.08,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,20.62,46.75,
PHILLIPS FOLLOWER 14FR,2720002042,CDM,272,RC,,,Outpatient,,,46.75,30.39,,46.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.53,76,,53.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.66,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,35.06,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.66,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,28.05,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,42.08,90,,68.4,Percent of Total Billed Charges,90% of Total Billed Charges,21.04,45,,36,Percent of Total Billed Charges,45% of Total Billed Charges,42.08,90,,63,Percent of Total Billed Charges,90% of Total billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.39,65,,3.248,Percent of total Billed Charges,65% of Total Billed Charges,20.62,44.1,,35.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.41,95,,66.504,Percent of Total Billed Charges,95% of Total Billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.14,88,,61.6,Percent of Total Billed Charges,88% of Total Billed Charges,42.08,90,,63,Percent of Total Billed charges,90% of Total Billed Charges,20.62,46.75,
PHILLIPS FOLLOWER 16FR,2720002043,CDM,272,RC,,,Outpatient,,,46.75,30.39,,46.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.53,76,,30.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.66,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,35.06,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.66,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,28.05,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,42.08,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,21.04,45,,58.48,Percent of Total Billed Charges,45% of Total Billed Charges,42.08,90,,36,Percent of Total Billed Charges,90% of Total billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.39,65,,52,Percent of total Billed Charges,65% of Total Billed Charges,20.62,44.1,,57.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.41,95,,38,Percent of Total Billed Charges,95% of Total Billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.14,88,,35.2,Percent of Total Billed Charges,88% of Total Billed Charges,42.08,90,,36,Percent of Total Billed charges,90% of Total Billed Charges,20.62,46.75,
PHILLIPS FOLLOWER 18FR,2720002044,CDM,272,RC,,,Outpatient,,,46.75,30.39,,46.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.53,76,,3.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.66,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,35.06,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.66,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,28.05,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,42.08,90,,2.704,Percent of Total Billed Charges,90% of Total Billed Charges,21.04,45,,2970,Percent of Total Billed Charges,45% of Total Billed Charges,42.08,90,,4.504,Percent of Total Billed Charges,90% of Total billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.39,65,,84.472,Percent of total Billed Charges,65% of Total Billed Charges,20.62,44.1,,2910.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.41,95,,4.752,Percent of Total Billed Charges,95% of Total Billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.14,88,,4.4,Percent of Total Billed Charges,88% of Total Billed Charges,42.08,90,,4.504,Percent of Total Billed charges,90% of Total Billed Charges,20.62,46.75,
PHILLIPS FOLLOWER 20FR,2720002045,CDM,272,RC,,,Outpatient,,,46.75,30.39,,46.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.53,76,,60.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.66,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,35.06,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.66,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,28.05,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,42.08,90,,13.144,Percent of Total Billed Charges,90% of Total Billed Charges,21.04,45,,7.424,Percent of Total Billed Charges,45% of Total Billed Charges,42.08,90,,72,Percent of Total Billed Charges,90% of Total billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.39,65,,4290,Percent of total Billed Charges,65% of Total Billed Charges,20.62,44.1,,7.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.41,95,,76,Percent of Total Billed Charges,95% of Total Billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.14,88,,70.4,Percent of Total Billed Charges,88% of Total Billed Charges,42.08,90,,72,Percent of Total Billed charges,90% of Total Billed Charges,20.62,46.75,
PHILLIPS FOLLOWER 22FR,2720002046,CDM,272,RC,,,Outpatient,,,46.75,30.39,,46.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.53,76,,98.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.66,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,35.06,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.66,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,28.05,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,42.08,90,,135,Percent of Total Billed Charges,90% of Total Billed Charges,21.04,45,,1.488,Percent of Total Billed Charges,45% of Total Billed Charges,42.08,90,,116.968,Percent of Total Billed Charges,90% of Total billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.39,65,,10.728,Percent of total Billed Charges,65% of Total Billed Charges,20.62,44.1,,1.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.41,95,,123.464,Percent of Total Billed Charges,95% of Total Billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.14,88,,114.368,Percent of Total Billed Charges,88% of Total Billed Charges,42.08,90,,116.968,Percent of Total Billed charges,90% of Total Billed Charges,20.62,46.75,
PHILLIPS FOLLOWER 24FR,2720002047,CDM,272,RC,,,Outpatient,,,46.75,30.39,,46.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.53,76,,5016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.66,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,35.06,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.66,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,28.05,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,42.08,90,,13.288,Percent of Total Billed Charges,90% of Total Billed Charges,21.04,45,,2.632,Percent of Total Billed Charges,45% of Total Billed Charges,42.08,90,,5940,Percent of Total Billed Charges,90% of Total billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.39,65,,2.144,Percent of total Billed Charges,65% of Total Billed Charges,20.62,44.1,,2.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.41,95,,6270,Percent of Total Billed Charges,95% of Total Billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.14,88,,5808,Percent of Total Billed Charges,88% of Total Billed Charges,42.08,90,,5940,Percent of Total Billed charges,90% of Total Billed Charges,20.62,46.75,
PHILLIPS FOLLOWER 26FR,2720002048,CDM,272,RC,,,Outpatient,,,8.75,5.69,,8.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.65,76,,12.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.3,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,6.56,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,8.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.3,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,5.25,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,7.88,90,,99,Percent of Total Billed Charges,90% of Total Billed Charges,3.94,45,,45.864,Percent of Total Billed Charges,45% of Total Billed Charges,7.88,90,,14.856,Percent of Total Billed Charges,90% of Total billed Charges,8.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.69,65,,3.8,Percent of total Billed Charges,65% of Total Billed Charges,3.86,44.1,,44.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.31,95,,15.68,Percent of Total Billed Charges,95% of Total Billed Charges,8.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.7,88,,14.52,Percent of Total Billed Charges,88% of Total Billed Charges,7.88,90,,14.856,Percent of Total Billed charges,90% of Total Billed Charges,3.86,8.75,
PHILLIPS FOLLOWER 8FR,2720002049,CDM,272,RC,,,Outpatient,,,46.75,30.39,,46.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.53,76,,2.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.66,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,35.06,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.66,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,28.05,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,42.08,90,,144,Percent of Total Billed Charges,90% of Total Billed Charges,21.04,45,,34.2,Percent of Total Billed Charges,45% of Total Billed Charges,42.08,90,,2.976,Percent of Total Billed Charges,90% of Total billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.39,65,,66.248,Percent of total Billed Charges,65% of Total Billed Charges,20.62,44.1,,33.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.41,95,,3.136,Percent of Total Billed Charges,95% of Total Billed Charges,46.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.14,88,,2.904,Percent of Total Billed Charges,88% of Total Billed Charges,42.08,90,,2.976,Percent of Total Billed charges,90% of Total Billed Charges,20.62,46.75,
Swab Phenol Pedinol EZ,2720002050,CDM,272,RC,,,Outpatient,,,24.93,16.20,,24.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.95,76,,4.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.95,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,18.7,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,24.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.95,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,14.96,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,22.44,90,,349.112,Percent of Total Billed Charges,90% of Total Billed Charges,11.22,45,,3.24,Percent of Total Billed Charges,45% of Total Billed Charges,22.44,90,,5.256,Percent of Total Billed Charges,90% of Total billed Charges,24.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.2,65,,49.4,Percent of total Billed Charges,65% of Total Billed Charges,10.99,44.1,,3.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.68,95,,5.552,Percent of Total Billed Charges,95% of Total Billed Charges,24.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.94,88,,5.136,Percent of Total Billed Charges,88% of Total Billed Charges,22.44,90,,5.256,Percent of Total Billed charges,90% of Total Billed Charges,10.99,24.93,
FB-240U.A Disp Bx Fcps Oval,2720002051,CDM,272,RC,,,Outpatient,,,15.00,9.75,,15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.4,76,,77.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.8,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,11.25,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.8,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,9,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,13.5,90,,349.112,Percent of Total Billed Charges,90% of Total Billed Charges,6.75,45,,1.352,Percent of Total Billed Charges,45% of Total Billed Charges,13.5,90,,91.728,Percent of Total Billed Charges,90% of Total billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.75,65,,4.68,Percent of total Billed Charges,65% of Total Billed Charges,6.62,44.1,,1.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.25,95,,96.824,Percent of Total Billed Charges,95% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.2,88,,89.688,Percent of Total Billed Charges,88% of Total Billed Charges,13.5,90,,91.728,Percent of Total Billed charges,90% of Total Billed Charges,6.62,15,
Secureport IV Adhesive,2720002052,CDM,272,RC,,,Outpatient,,,15.00,9.75,,15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.4,76,,57.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.8,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,11.25,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.8,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,9,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,13.5,90,,12.48,Percent of Total Billed Charges,90% of Total Billed Charges,6.75,45,,6.568,Percent of Total Billed Charges,45% of Total Billed Charges,13.5,90,,68.4,Percent of Total Billed Charges,90% of Total billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.75,65,,1.952,Percent of total Billed Charges,65% of Total Billed Charges,6.62,44.1,,6.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.25,95,,72.2,Percent of Total Billed Charges,95% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.2,88,,66.88,Percent of Total Billed Charges,88% of Total Billed Charges,13.5,90,,68.4,Percent of Total Billed charges,90% of Total Billed Charges,6.62,15,
Surgiseal 0.05ml Adhesive,2720002053,CDM,272,RC,,,Outpatient,,,23.75,15.44,,23.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.05,76,,5.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.1,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,17.81,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,23.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.1,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,14.25,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,21.38,90,,5.008,Percent of Total Billed Charges,90% of Total Billed Charges,10.69,45,,67.504,Percent of Total Billed Charges,45% of Total Billed Charges,21.38,90,,6.48,Percent of Total Billed Charges,90% of Total billed Charges,23.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,65,,9.488,Percent of total Billed Charges,65% of Total Billed Charges,10.47,44.1,,66.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.56,95,,6.84,Percent of Total Billed Charges,95% of Total Billed Charges,23.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.9,88,,6.336,Percent of Total Billed Charges,88% of Total Billed Charges,21.38,90,,6.48,Percent of Total Billed charges,90% of Total Billed Charges,10.47,23.75,
Synthes Drill Bit 1.1,2720002054,CDM,272,RC,,,Outpatient,,,162.50,105.63,,162.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,123.5,76,,2.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,117,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,121.88,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,162.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,97.5,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,146.25,90,,103.936,Percent of Total Billed Charges,90% of Total Billed Charges,73.13,45,,6.64,Percent of Total Billed Charges,45% of Total Billed Charges,146.25,90,,2.704,Percent of Total Billed Charges,90% of Total billed Charges,162.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.63,65,,97.504,Percent of total Billed Charges,65% of Total Billed Charges,71.66,44.1,,6.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,154.38,95,,2.848,Percent of Total Billed Charges,95% of Total Billed Charges,162.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143,88,,2.64,Percent of Total Billed Charges,88% of Total Billed Charges,146.25,90,,2.704,Percent of Total Billed charges,90% of Total Billed Charges,71.66,162.5,
BLADE SURG C/ST 011,2720002055,CDM,272,RC,,,Outpatient,,,0.80,0.52,,0.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.61,76,,11.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.58,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,0.6,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,0.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.58,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,0.48,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.72,90,,103.936,Percent of Total Billed Charges,90% of Total Billed Charges,0.36,45,,49.504,Percent of Total Billed Charges,45% of Total Billed Charges,0.72,90,,13.144,Percent of Total Billed Charges,90% of Total billed Charges,0.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.52,65,,9.592,Percent of total Billed Charges,65% of Total Billed Charges,0.35,44.1,,48.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.76,95,,13.872,Percent of Total Billed Charges,95% of Total Billed Charges,0.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.7,88,,12.848,Percent of Total Billed Charges,88% of Total Billed Charges,0.72,90,,13.144,Percent of Total Billed charges,90% of Total Billed Charges,0.35,0.8,
BLADE SURG C/ST 012,2720002056,CDM,272,RC,,,Outpatient,,,0.90,0.59,,0.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.68,76,,114,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.65,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,0.68,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,0.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.65,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,0.54,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.81,90,,721.728,Percent of Total Billed Charges,90% of Total Billed Charges,0.41,45,,72,Percent of Total Billed Charges,45% of Total Billed Charges,0.81,90,,135,Percent of Total Billed Charges,90% of Total billed Charges,0.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.59,65,,71.504,Percent of total Billed Charges,65% of Total Billed Charges,0.4,44.1,,70.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.86,95,,142.504,Percent of Total Billed Charges,95% of Total Billed Charges,0.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,88,,132,Percent of Total Billed Charges,88% of Total Billed Charges,0.81,90,,135,Percent of Total Billed charges,90% of Total Billed Charges,0.4,0.9,
BLADE SURG C/ST 015,2720002057,CDM,272,RC,,,Outpatient,,,0.80,0.52,,0.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.61,76,,11.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.58,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,0.6,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,0.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.58,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,0.48,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,0.72,90,,1200.264,Percent of Total Billed Charges,90% of Total Billed Charges,0.36,45,,174.56,Percent of Total Billed Charges,45% of Total Billed Charges,0.72,90,,13.288,Percent of Total Billed Charges,90% of Total billed Charges,0.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.52,65,,104,Percent of total Billed Charges,65% of Total Billed Charges,0.35,44.1,,171.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.76,95,,14.024,Percent of Total Billed Charges,95% of Total Billed Charges,0.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.7,88,,12.992,Percent of Total Billed Charges,88% of Total Billed Charges,0.72,90,,13.288,Percent of Total Billed charges,90% of Total Billed Charges,0.35,0.8,
BLADE SURG C/ST 020,2720002058,CDM,272,RC,,,Outpatient,,,0.80,0.52,,0.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.61,76,,83.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.58,72,,5.528,Percent of Total Billed Charges,72% of Total Billed Charges,0.6,75,,5.76,Percent of Total Billed charges,75% of Total Billed Charges,0.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.58,72,,5.528,Percent of Total Billed Charges,72% of Total Billed Charges,0.48,60,,4.608,Percent of Total Billed Charges,60% of Total Billed Charges,0.72,90,,31.32,Percent of Total Billed Charges,90% of Total Billed Charges,0.36,45,,174.56,Percent of Total Billed Charges,45% of Total Billed Charges,0.72,90,,99,Percent of Total Billed Charges,90% of Total billed Charges,0.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.52,65,,252.136,Percent of total Billed Charges,65% of Total Billed Charges,0.35,44.1,,171.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.76,95,,104.504,Percent of Total Billed Charges,95% of Total Billed Charges,0.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.7,88,,96.8,Percent of Total Billed Charges,88% of Total Billed Charges,0.72,90,,99,Percent of Total Billed charges,90% of Total Billed Charges,0.35,0.8,
LEEP RADIUS ELECTRODE 2X.8,2720002059,CDM,272,RC,,,Outpatient,,,56.70,36.86,,56.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.09,76,,121.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.82,72,,2.336,Percent of Total Billed Charges,72% of Total Billed Charges,42.53,75,,2.432,Percent of Total Billed charges,75% of Total Billed Charges,56.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.82,72,,2.336,Percent of Total Billed Charges,72% of Total Billed Charges,34.02,60,,1.944,Percent of Total Billed Charges,60% of Total Billed Charges,51.03,90,,1676.16,Percent of Total Billed Charges,90% of Total Billed Charges,25.52,45,,6.24,Percent of Total Billed Charges,45% of Total Billed Charges,51.03,90,,144,Percent of Total Billed Charges,90% of Total billed Charges,56.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.86,65,,252.136,Percent of total Billed Charges,65% of Total Billed Charges,25,44.1,,6.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.87,95,,152,Percent of Total Billed Charges,95% of Total Billed Charges,56.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.9,88,,140.8,Percent of Total Billed Charges,88% of Total Billed Charges,51.03,90,,144,Percent of Total Billed charges,90% of Total Billed Charges,25,56.7,
LEEP RADIUS ELECTRODE 2X1,2720002060,CDM,272,RC,,,Outpatient,,,57.83,37.59,,57.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.95,76,,294.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.64,72,,1.296,Percent of Total Billed Charges,72% of Total Billed Charges,43.37,75,,1.352,Percent of Total Billed charges,75% of Total Billed Charges,57.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.64,72,,1.296,Percent of Total Billed Charges,72% of Total Billed Charges,34.7,60,,1.08,Percent of Total Billed Charges,60% of Total Billed Charges,52.05,90,,1676.16,Percent of Total Billed Charges,90% of Total Billed Charges,26.02,45,,2.504,Percent of Total Billed Charges,45% of Total Billed Charges,52.05,90,,349.112,Percent of Total Billed Charges,90% of Total billed Charges,57.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.59,65,,9.008,Percent of total Billed Charges,65% of Total Billed Charges,25.5,44.1,,2.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.94,95,,368.512,Percent of Total Billed Charges,95% of Total Billed Charges,57.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.89,88,,341.352,Percent of Total Billed Charges,88% of Total Billed Charges,52.05,90,,349.112,Percent of Total Billed charges,90% of Total Billed Charges,25.5,57.83,
LEEP BALL ELECTRODE,2720002061,CDM,272,RC,,,Outpatient,,,57.83,37.59,,57.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.95,76,,294.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.64,72,,10.08,Percent of Total Billed Charges,72% of Total Billed Charges,43.37,75,,10.504,Percent of Total Billed charges,75% of Total Billed Charges,57.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.64,72,,10.08,Percent of Total Billed Charges,72% of Total Billed Charges,34.7,60,,8.4,Percent of Total Billed Charges,60% of Total Billed Charges,52.05,90,,5.256,Percent of Total Billed Charges,90% of Total Billed Charges,26.02,45,,51.968,Percent of Total Billed Charges,45% of Total Billed Charges,52.05,90,,349.112,Percent of Total Billed Charges,90% of Total billed Charges,57.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.59,65,,3.616,Percent of total Billed Charges,65% of Total Billed Charges,25.5,44.1,,50.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.94,95,,368.512,Percent of Total Billed Charges,95% of Total Billed Charges,57.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.89,88,,341.352,Percent of Total Billed Charges,88% of Total Billed Charges,52.05,90,,349.112,Percent of Total Billed charges,90% of Total Billed Charges,25.5,57.83,
LEEP CONDYLOMA ELECTRODE,2720002062,CDM,272,RC,,,Outpatient,,,56.70,36.86,,56.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.09,76,,10.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.82,72,,576,Percent of Total Billed Charges,72% of Total Billed Charges,42.53,75,,600,Percent of Total Billed charges,75% of Total Billed Charges,56.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.82,72,,576,Percent of Total Billed Charges,72% of Total Billed Charges,34.02,60,,480,Percent of Total Billed Charges,60% of Total Billed Charges,51.03,90,,6.032,Percent of Total Billed Charges,90% of Total Billed Charges,25.52,45,,51.968,Percent of Total Billed Charges,45% of Total Billed Charges,51.03,90,,12.48,Percent of Total Billed Charges,90% of Total billed Charges,56.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.86,65,,75.064,Percent of total Billed Charges,65% of Total Billed Charges,25,44.1,,50.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.87,95,,13.168,Percent of Total Billed Charges,95% of Total Billed Charges,56.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.9,88,,12.2,Percent of Total Billed Charges,88% of Total Billed Charges,51.03,90,,12.48,Percent of Total Billed charges,90% of Total Billed Charges,25,56.7,
PURSTRING 45,2720002063,CDM,272,RC,,,Outpatient,,,510.20,331.63,,510.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,387.75,76,,4.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,367.34,72,,576,Percent of Total Billed Charges,72% of Total Billed Charges,382.65,75,,600,Percent of Total Billed charges,75% of Total Billed Charges,510.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,367.34,72,,576,Percent of Total Billed Charges,72% of Total Billed Charges,306.12,60,,480,Percent of Total Billed Charges,60% of Total Billed Charges,459.18,90,,52.56,Percent of Total Billed Charges,90% of Total Billed Charges,229.59,45,,360.864,Percent of Total Billed Charges,45% of Total Billed Charges,459.18,90,,5.008,Percent of Total Billed Charges,90% of Total billed Charges,510.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,510.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,510.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,331.63,65,,75.064,Percent of total Billed Charges,65% of Total Billed Charges,225,44.1,,353.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,484.69,95,,5.28,Percent of Total Billed Charges,95% of Total Billed Charges,510.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,448.98,88,,4.896,Percent of Total Billed Charges,88% of Total Billed Charges,459.18,90,,5.008,Percent of Total Billed charges,90% of Total Billed Charges,225,510.2,
JURGAN PIN BALLS 3/32,2720002064,CDM,272,RC,,,Outpatient,,,15.83,10.29,,15.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.03,76,,87.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.4,72,,8.568,Percent of Total Billed Charges,72% of Total Billed Charges,11.87,75,,8.928,Percent of Total Billed charges,75% of Total Billed Charges,15.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.4,72,,8.568,Percent of Total Billed Charges,72% of Total Billed Charges,9.5,60,,7.144,Percent of Total Billed Charges,60% of Total Billed Charges,14.25,90,,47.16,Percent of Total Billed Charges,90% of Total Billed Charges,7.12,45,,600.128,Percent of Total Billed Charges,45% of Total Billed Charges,14.25,90,,103.936,Percent of Total Billed Charges,90% of Total billed Charges,15.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.29,65,,521.248,Percent of total Billed Charges,65% of Total Billed Charges,6.98,44.1,,588.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.04,95,,109.704,Percent of Total Billed Charges,95% of Total Billed Charges,15.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.93,88,,101.624,Percent of Total Billed Charges,88% of Total Billed Charges,14.25,90,,103.936,Percent of Total Billed charges,90% of Total Billed Charges,6.98,15.83,
JURGAN PIN BALLS 5/64,2720002065,CDM,272,RC,,,Outpatient,,,15.83,10.29,,15.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.03,76,,87.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.4,72,,82.08,Percent of Total Billed Charges,72% of Total Billed Charges,11.87,75,,85.504,Percent of Total Billed charges,75% of Total Billed Charges,15.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.4,72,,82.08,Percent of Total Billed Charges,72% of Total Billed Charges,9.5,60,,68.4,Percent of Total Billed Charges,60% of Total Billed Charges,14.25,90,,47.16,Percent of Total Billed Charges,90% of Total Billed Charges,7.12,45,,15.664,Percent of Total Billed Charges,45% of Total Billed Charges,14.25,90,,103.936,Percent of Total Billed Charges,90% of Total billed Charges,15.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.29,65,,866.856,Percent of total Billed Charges,65% of Total Billed Charges,6.98,44.1,,15.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.04,95,,109.704,Percent of Total Billed Charges,95% of Total Billed Charges,15.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.93,88,,101.624,Percent of Total Billed Charges,88% of Total Billed Charges,14.25,90,,103.936,Percent of Total Billed charges,90% of Total Billed Charges,6.98,15.83,
JURGAN PIN BALLS .062,2720002066,CDM,272,RC,,,Outpatient,,,15.83,10.29,,15.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.03,76,,609.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.4,72,,844.376,Percent of Total Billed Charges,72% of Total Billed Charges,11.87,75,,879.56,Percent of Total Billed charges,75% of Total Billed Charges,15.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.4,72,,844.376,Percent of Total Billed Charges,72% of Total Billed Charges,9.5,60,,703.648,Percent of Total Billed Charges,60% of Total Billed Charges,14.25,90,,44.464,Percent of Total Billed Charges,90% of Total Billed Charges,7.12,45,,838.08,Percent of Total Billed Charges,45% of Total Billed Charges,14.25,90,,721.728,Percent of Total Billed Charges,90% of Total billed Charges,15.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.29,65,,22.624,Percent of total Billed Charges,65% of Total Billed Charges,6.98,44.1,,821.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.04,95,,761.824,Percent of Total Billed Charges,95% of Total Billed Charges,15.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.93,88,,705.688,Percent of Total Billed Charges,88% of Total Billed Charges,14.25,90,,721.728,Percent of Total Billed charges,90% of Total Billed Charges,6.98,15.83,
ETHIBOND 2 MX69G,2720002067,CDM,272,RC,,,Outpatient,,,30.05,19.53,,30.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.84,76,,1013.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.64,72,,733.48,Percent of Total Billed Charges,72% of Total Billed Charges,22.54,75,,764.04,Percent of Total Billed charges,75% of Total Billed Charges,30.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.64,72,,733.48,Percent of Total Billed Charges,72% of Total Billed Charges,18.03,60,,611.232,Percent of Total Billed Charges,60% of Total Billed Charges,27.05,90,,44.464,Percent of Total Billed Charges,90% of Total Billed Charges,13.52,45,,838.08,Percent of Total Billed Charges,45% of Total Billed Charges,27.05,90,,1200.264,Percent of Total Billed Charges,90% of Total billed Charges,30.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.53,65,,1210.56,Percent of total Billed Charges,65% of Total Billed Charges,13.25,44.1,,821.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.55,95,,1266.944,Percent of Total Billed Charges,95% of Total Billed Charges,30.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.44,88,,1173.592,Percent of Total Billed Charges,88% of Total Billed Charges,27.05,90,,1200.264,Percent of Total Billed charges,90% of Total Billed Charges,13.25,30.05,
ETHIBOND 4-0 MX551,2720002068,CDM,272,RC,,,Outpatient,,,30.58,19.88,,30.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.24,76,,26.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.02,72,,648,Percent of Total Billed Charges,72% of Total Billed Charges,22.94,75,,675,Percent of Total Billed charges,75% of Total Billed Charges,30.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.02,72,,648,Percent of Total Billed Charges,72% of Total Billed Charges,18.35,60,,540,Percent of Total Billed Charges,60% of Total Billed Charges,27.52,90,,44.464,Percent of Total Billed Charges,90% of Total Billed Charges,13.76,45,,2.632,Percent of Total Billed Charges,45% of Total Billed Charges,27.52,90,,31.32,Percent of Total Billed Charges,90% of Total billed Charges,30.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.88,65,,1210.56,Percent of total Billed Charges,65% of Total Billed Charges,13.49,44.1,,2.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.05,95,,33.064,Percent of Total Billed Charges,95% of Total Billed Charges,30.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.91,88,,30.624,Percent of Total Billed Charges,88% of Total Billed Charges,27.52,90,,31.32,Percent of Total Billed charges,90% of Total Billed Charges,13.49,30.58,
ETHIBOND 0 CX41D,2720002069,CDM,272,RC,,,Outpatient,,,24.08,15.65,,24.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.3,76,,1415.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.34,72,,648,Percent of Total Billed Charges,72% of Total Billed Charges,18.06,75,,675,Percent of Total Billed charges,75% of Total Billed Charges,24.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.34,72,,648,Percent of Total Billed Charges,72% of Total Billed Charges,14.45,60,,540,Percent of Total Billed Charges,60% of Total Billed Charges,21.67,90,,47.16,Percent of Total Billed Charges,90% of Total Billed Charges,10.84,45,,3.016,Percent of Total Billed Charges,45% of Total Billed Charges,21.67,90,,1676.16,Percent of Total Billed Charges,90% of Total billed Charges,24.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.65,65,,3.8,Percent of total Billed Charges,65% of Total Billed Charges,10.62,44.1,,2.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.88,95,,1769.28,Percent of Total Billed Charges,95% of Total Billed Charges,24.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.19,88,,1638.912,Percent of Total Billed Charges,88% of Total Billed Charges,21.67,90,,1676.16,Percent of Total Billed charges,90% of Total Billed Charges,10.62,24.08,
ETHIBOND 5 MB66G,2720002070,CDM,272,RC,,,Outpatient,,,30.10,19.57,,30.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.88,76,,1415.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.67,72,,12.976,Percent of Total Billed Charges,72% of Total Billed Charges,22.58,75,,13.52,Percent of Total Billed charges,75% of Total Billed Charges,30.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.67,72,,12.976,Percent of Total Billed Charges,72% of Total Billed Charges,18.06,60,,10.816,Percent of Total Billed Charges,60% of Total Billed Charges,27.09,90,,44.464,Percent of Total Billed Charges,90% of Total Billed Charges,13.55,45,,26.28,Percent of Total Billed Charges,45% of Total Billed Charges,27.09,90,,1676.16,Percent of Total Billed Charges,90% of Total billed Charges,30.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.57,65,,4.36,Percent of total Billed Charges,65% of Total Billed Charges,13.27,44.1,,25.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.6,95,,1769.28,Percent of Total Billed Charges,95% of Total Billed Charges,30.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.49,88,,1638.912,Percent of Total Billed Charges,88% of Total Billed Charges,27.09,90,,1676.16,Percent of Total Billed charges,90% of Total Billed Charges,13.27,30.1,
PROLENE 3-0 8976H,2720002071,CDM,272,RC,,,Outpatient,,,13.83,8.99,,13.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.51,76,,4.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.96,72,,22.456,Percent of Total Billed Charges,72% of Total Billed Charges,10.37,75,,23.392,Percent of Total Billed charges,75% of Total Billed Charges,13.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.96,72,,22.456,Percent of Total Billed Charges,72% of Total Billed Charges,8.3,60,,18.712,Percent of Total Billed Charges,60% of Total Billed Charges,12.45,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,6.22,45,,23.584,Percent of Total Billed Charges,45% of Total Billed Charges,12.45,90,,5.256,Percent of Total Billed Charges,90% of Total billed Charges,13.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.99,65,,37.96,Percent of total Billed Charges,65% of Total Billed Charges,6.1,44.1,,23.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.14,95,,5.552,Percent of Total Billed Charges,95% of Total Billed Charges,13.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.17,88,,5.136,Percent of Total Billed Charges,88% of Total Billed Charges,12.45,90,,5.256,Percent of Total Billed charges,90% of Total Billed Charges,6.1,13.83,
SILK 4-0 K871H,2720002072,CDM,272,RC,,,Outpatient,,,3.05,1.98,,3.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.32,76,,5.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.2,72,,5.76,Percent of Total Billed Charges,72% of Total Billed Charges,2.29,75,,6,Percent of Total Billed charges,75% of Total Billed Charges,3.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.2,72,,5.76,Percent of Total Billed Charges,72% of Total Billed Charges,1.83,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.75,90,,11.184,Percent of Total Billed Charges,90% of Total Billed Charges,1.37,45,,23.584,Percent of Total Billed Charges,45% of Total Billed Charges,2.75,90,,6.032,Percent of Total Billed Charges,90% of Total billed Charges,3.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.98,65,,34.064,Percent of total Billed Charges,65% of Total Billed Charges,1.35,44.1,,23.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.9,95,,6.368,Percent of Total Billed Charges,95% of Total Billed Charges,3.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.68,88,,5.896,Percent of Total Billed Charges,88% of Total Billed Charges,2.75,90,,6.032,Percent of Total Billed charges,90% of Total Billed Charges,1.35,3.05,
SILK 3-0 K872H,2720002073,CDM,272,RC,,,Outpatient,,,3.00,1.95,,3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.28,76,,44.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.16,72,,2.912,Percent of Total Billed Charges,72% of Total Billed Charges,2.25,75,,3.032,Percent of Total Billed charges,75% of Total Billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.16,72,,2.912,Percent of Total Billed Charges,72% of Total Billed Charges,1.8,60,,2.424,Percent of Total Billed Charges,60% of Total Billed Charges,2.7,90,,13.72,Percent of Total Billed Charges,90% of Total Billed Charges,1.35,45,,22.232,Percent of Total Billed Charges,45% of Total Billed Charges,2.7,90,,52.56,Percent of Total Billed Charges,90% of Total billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.95,65,,34.064,Percent of total Billed Charges,65% of Total Billed Charges,1.32,44.1,,21.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.85,95,,55.48,Percent of Total Billed Charges,95% of Total Billed Charges,3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.64,88,,51.392,Percent of Total Billed Charges,88% of Total Billed Charges,2.7,90,,52.56,Percent of Total Billed charges,90% of Total Billed Charges,1.32,3,
PROLENE 2-0 8523H,2720002074,CDM,272,RC,,,Outpatient,,,10.45,6.79,,10.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.94,76,,39.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.52,72,,2.792,Percent of Total Billed Charges,72% of Total Billed Charges,7.84,75,,2.912,Percent of Total Billed charges,75% of Total Billed Charges,10.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.52,72,,2.792,Percent of Total Billed Charges,72% of Total Billed Charges,6.27,60,,2.328,Percent of Total Billed Charges,60% of Total Billed Charges,9.41,90,,13.056,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,45,,22.232,Percent of Total Billed Charges,45% of Total Billed Charges,9.41,90,,47.16,Percent of Total Billed Charges,90% of Total billed Charges,10.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,65,,32.112,Percent of total Billed Charges,65% of Total Billed Charges,4.61,44.1,,21.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.93,95,,49.784,Percent of Total Billed Charges,95% of Total Billed Charges,10.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.2,88,,46.112,Percent of Total Billed Charges,88% of Total Billed Charges,9.41,90,,47.16,Percent of Total Billed charges,90% of Total Billed Charges,4.61,10.45,
PROLENE 6-0 8706H,2720002075,CDM,272,RC,,,Outpatient,,,19.33,12.56,,19.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.69,76,,39.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.92,72,,3.112,Percent of Total Billed Charges,72% of Total Billed Charges,14.5,75,,3.24,Percent of Total Billed charges,75% of Total Billed Charges,19.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.92,72,,3.112,Percent of Total Billed Charges,72% of Total Billed Charges,11.6,60,,2.592,Percent of Total Billed Charges,60% of Total Billed Charges,17.4,90,,7.992,Percent of Total Billed Charges,90% of Total Billed Charges,8.7,45,,22.232,Percent of Total Billed Charges,45% of Total Billed Charges,17.4,90,,47.16,Percent of Total Billed Charges,90% of Total billed Charges,19.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.56,65,,32.112,Percent of total Billed Charges,65% of Total Billed Charges,8.52,44.1,,21.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.36,95,,49.784,Percent of Total Billed Charges,95% of Total Billed Charges,19.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.01,88,,46.112,Percent of Total Billed Charges,88% of Total Billed Charges,17.4,90,,47.16,Percent of Total Billed charges,90% of Total Billed Charges,8.52,19.33,
PROLENE 5-0 8720H,2720002076,CDM,272,RC,,,Outpatient,,,19.55,12.71,,19.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.86,76,,37.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.08,72,,32.72,Percent of Total Billed Charges,72% of Total Billed Charges,14.66,75,,34.08,Percent of Total Billed charges,75% of Total Billed Charges,19.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.08,72,,32.72,Percent of Total Billed Charges,72% of Total Billed Charges,11.73,60,,27.264,Percent of Total Billed Charges,60% of Total Billed Charges,17.6,90,,14.368,Percent of Total Billed Charges,90% of Total Billed Charges,8.8,45,,23.584,Percent of Total Billed Charges,45% of Total Billed Charges,17.6,90,,44.464,Percent of Total Billed Charges,90% of Total billed Charges,19.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.71,65,,32.112,Percent of total Billed Charges,65% of Total Billed Charges,8.62,44.1,,23.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.57,95,,46.928,Percent of Total Billed Charges,95% of Total Billed Charges,19.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,88,,43.472,Percent of Total Billed Charges,88% of Total Billed Charges,17.6,90,,44.464,Percent of Total Billed charges,90% of Total Billed Charges,8.62,19.55,
PROLENE 2-0 8833H,2720002077,CDM,272,RC,,,Outpatient,,,5.43,3.53,,5.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.13,76,,37.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.91,72,,131.04,Percent of Total Billed Charges,72% of Total Billed Charges,4.07,75,,136.504,Percent of Total Billed charges,75% of Total Billed Charges,5.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.91,72,,131.04,Percent of Total Billed Charges,72% of Total Billed Charges,3.26,60,,109.2,Percent of Total Billed Charges,60% of Total Billed Charges,4.89,90,,23.08,Percent of Total Billed Charges,90% of Total Billed Charges,2.44,45,,22.232,Percent of Total Billed Charges,45% of Total Billed Charges,4.89,90,,44.464,Percent of Total Billed Charges,90% of Total billed Charges,5.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.53,65,,34.064,Percent of total Billed Charges,65% of Total Billed Charges,2.39,44.1,,21.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.16,95,,46.928,Percent of Total Billed Charges,95% of Total Billed Charges,5.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.78,88,,43.472,Percent of Total Billed Charges,88% of Total Billed Charges,4.89,90,,44.464,Percent of Total Billed charges,90% of Total Billed Charges,2.39,5.43,
PROLENE 0 8424H,2720002078,CDM,272,RC,,,Outpatient,,,4.98,3.24,,4.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.78,76,,37.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.59,72,,131.04,Percent of Total Billed Charges,72% of Total Billed Charges,3.74,75,,136.504,Percent of Total Billed charges,75% of Total Billed Charges,4.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.59,72,,131.04,Percent of Total Billed Charges,72% of Total Billed Charges,2.99,60,,109.2,Percent of Total Billed Charges,60% of Total Billed Charges,4.48,90,,27.272,Percent of Total Billed Charges,90% of Total Billed Charges,2.24,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,4.48,90,,44.464,Percent of Total Billed Charges,90% of Total billed Charges,4.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.24,65,,32.112,Percent of total Billed Charges,65% of Total Billed Charges,2.2,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.73,95,,46.928,Percent of Total Billed Charges,95% of Total Billed Charges,4.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.38,88,,43.472,Percent of Total Billed Charges,88% of Total Billed Charges,4.48,90,,44.464,Percent of Total Billed charges,90% of Total Billed Charges,2.2,4.98,
PROLENE 2-0 8423H,2720002079,CDM,272,RC,,,Outpatient,,,5.05,3.28,,5.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.84,76,,39.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.64,72,,4165.92,Percent of Total Billed Charges,72% of Total Billed Charges,3.79,75,,4339.504,Percent of Total Billed charges,75% of Total Billed Charges,5.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.64,72,,4165.92,Percent of Total Billed Charges,72% of Total Billed Charges,3.03,60,,3471.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.55,90,,9.456,Percent of Total Billed Charges,90% of Total Billed Charges,2.27,45,,5.592,Percent of Total Billed Charges,45% of Total Billed Charges,4.55,90,,47.16,Percent of Total Billed Charges,90% of Total billed Charges,5.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.28,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,2.23,44.1,,5.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.8,95,,49.784,Percent of Total Billed Charges,95% of Total Billed Charges,5.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.44,88,,46.112,Percent of Total Billed Charges,88% of Total Billed Charges,4.55,90,,47.16,Percent of Total Billed charges,90% of Total Billed Charges,2.23,5.05,
PROLENE 2-0 8411H,2720002080,CDM,272,RC,,,Outpatient,,,5.00,3.25,,5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.8,76,,37.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.6,72,,4165.92,Percent of Total Billed Charges,72% of Total Billed Charges,3.75,75,,4339.504,Percent of Total Billed charges,75% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.6,72,,4165.92,Percent of Total Billed Charges,72% of Total Billed Charges,3,60,,3471.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.5,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,2.25,45,,6.856,Percent of Total Billed Charges,45% of Total Billed Charges,4.5,90,,44.464,Percent of Total Billed Charges,90% of Total billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.25,65,,8.072,Percent of total Billed Charges,65% of Total Billed Charges,2.21,44.1,,6.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.75,95,,46.928,Percent of Total Billed Charges,95% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.4,88,,43.472,Percent of Total Billed Charges,88% of Total Billed Charges,4.5,90,,44.464,Percent of Total Billed charges,90% of Total Billed Charges,2.21,5,
PROLENE 5-0 8555H,2720002081,CDM,272,RC,,,Outpatient,,,10.68,6.94,,10.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.12,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.69,72,,4165.92,Percent of Total Billed Charges,72% of Total Billed Charges,8.01,75,,4339.504,Percent of Total Billed charges,75% of Total Billed Charges,10.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.69,72,,4165.92,Percent of Total Billed Charges,72% of Total Billed Charges,6.41,60,,3471.6,Percent of Total Billed Charges,60% of Total Billed Charges,9.61,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,4.81,45,,6.528,Percent of Total Billed Charges,45% of Total Billed Charges,9.61,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,10.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.94,65,,9.904,Percent of total Billed Charges,65% of Total Billed Charges,4.71,44.1,,6.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.15,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,10.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.4,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,9.61,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,4.71,10.68,
PROLENE 7-0 8701H,2720002082,CDM,272,RC,,,Outpatient,,,24.88,16.17,,24.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.91,76,,9.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.91,72,,4.024,Percent of Total Billed Charges,72% of Total Billed Charges,18.66,75,,4.192,Percent of Total Billed charges,75% of Total Billed Charges,24.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.91,72,,4.024,Percent of Total Billed Charges,72% of Total Billed Charges,14.93,60,,3.352,Percent of Total Billed Charges,60% of Total Billed Charges,22.39,90,,153,Percent of Total Billed Charges,90% of Total Billed Charges,11.2,45,,4,Percent of Total Billed Charges,45% of Total Billed Charges,22.39,90,,11.184,Percent of Total Billed Charges,90% of Total billed Charges,24.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.17,65,,9.424,Percent of total Billed Charges,65% of Total Billed Charges,10.97,44.1,,3.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.64,95,,11.8,Percent of Total Billed Charges,95% of Total Billed Charges,24.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.89,88,,10.936,Percent of Total Billed Charges,88% of Total Billed Charges,22.39,90,,11.184,Percent of Total Billed charges,90% of Total Billed Charges,10.97,24.88,
PROLENE 6-0 8709H,2720002083,CDM,272,RC,,,Outpatient,,,24.55,15.96,,24.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.66,76,,11.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.68,72,,2030.4,Percent of Total Billed Charges,72% of Total Billed Charges,18.41,75,,2115,Percent of Total Billed charges,75% of Total Billed Charges,24.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.68,72,,2030.4,Percent of Total Billed Charges,72% of Total Billed Charges,14.73,60,,1692,Percent of Total Billed Charges,60% of Total Billed Charges,22.1,90,,153,Percent of Total Billed Charges,90% of Total Billed Charges,11.05,45,,7.184,Percent of Total Billed Charges,45% of Total Billed Charges,22.1,90,,13.72,Percent of Total Billed Charges,90% of Total billed Charges,24.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.96,65,,5.776,Percent of total Billed Charges,65% of Total Billed Charges,10.83,44.1,,7.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.32,95,,14.48,Percent of Total Billed Charges,95% of Total Billed Charges,24.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.6,88,,13.408,Percent of Total Billed Charges,88% of Total Billed Charges,22.1,90,,13.72,Percent of Total Billed charges,90% of Total Billed Charges,10.83,24.55,
PROLENE 7-0 8735H,2720002084,CDM,272,RC,,,Outpatient,,,52.53,34.14,,52.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,39.92,76,,11.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,37.82,72,,2030.4,Percent of Total Billed Charges,72% of Total Billed Charges,39.4,75,,2115,Percent of Total Billed charges,75% of Total Billed Charges,52.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.82,72,,2030.4,Percent of Total Billed Charges,72% of Total Billed Charges,31.52,60,,1692,Percent of Total Billed Charges,60% of Total Billed Charges,47.28,90,,138.192,Percent of Total Billed Charges,90% of Total Billed Charges,23.64,45,,11.536,Percent of Total Billed Charges,45% of Total Billed Charges,47.28,90,,13.056,Percent of Total Billed Charges,90% of Total billed Charges,52.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.14,65,,10.376,Percent of total Billed Charges,65% of Total Billed Charges,23.17,44.1,,11.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,49.9,95,,13.776,Percent of Total Billed Charges,95% of Total Billed Charges,52.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.23,88,,12.76,Percent of Total Billed Charges,88% of Total Billed Charges,47.28,90,,13.056,Percent of Total Billed charges,90% of Total Billed Charges,23.17,52.53,
PROLENE 6-0 8806H,2720002085,CDM,272,RC,,,Outpatient,,,24.63,16.01,,24.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.72,76,,6.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.73,72,,2577.6,Percent of Total Billed Charges,72% of Total Billed Charges,18.47,75,,2685,Percent of Total Billed charges,75% of Total Billed Charges,24.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.73,72,,2577.6,Percent of Total Billed Charges,72% of Total Billed Charges,14.78,60,,2148,Percent of Total Billed Charges,60% of Total Billed Charges,22.17,90,,75.6,Percent of Total Billed Charges,90% of Total Billed Charges,11.08,45,,13.64,Percent of Total Billed Charges,45% of Total Billed Charges,22.17,90,,7.992,Percent of Total Billed Charges,90% of Total billed Charges,24.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.01,65,,16.664,Percent of total Billed Charges,65% of Total Billed Charges,10.86,44.1,,13.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.4,95,,8.44,Percent of Total Billed Charges,95% of Total Billed Charges,24.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.67,88,,7.816,Percent of Total Billed Charges,88% of Total Billed Charges,22.17,90,,7.992,Percent of Total Billed charges,90% of Total Billed Charges,10.86,24.63,
ETHILON 6-0 689G,2720002086,CDM,272,RC,,,Outpatient,,,7.15,4.65,,7.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.43,76,,12.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.15,72,,3232.8,Percent of Total Billed Charges,72% of Total Billed Charges,5.36,75,,3367.504,Percent of Total Billed charges,75% of Total Billed Charges,7.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.15,72,,3232.8,Percent of Total Billed Charges,72% of Total Billed Charges,4.29,60,,2694,Percent of Total Billed Charges,60% of Total Billed Charges,6.44,90,,63,Percent of Total Billed Charges,90% of Total Billed Charges,3.22,45,,4.728,Percent of Total Billed Charges,45% of Total Billed Charges,6.44,90,,14.368,Percent of Total Billed Charges,90% of Total billed Charges,7.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.65,65,,19.696,Percent of total Billed Charges,65% of Total Billed Charges,3.15,44.1,,4.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.79,95,,15.16,Percent of Total Billed Charges,95% of Total Billed Charges,7.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.29,88,,14.048,Percent of Total Billed Charges,88% of Total Billed Charges,6.44,90,,14.368,Percent of Total Billed charges,90% of Total Billed Charges,3.15,7.15,
ETHILON 10-0 7718G,2720002087,CDM,272,RC,,,Outpatient,,,23.73,15.42,,23.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.03,76,,19.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.09,72,,2030.4,Percent of Total Billed Charges,72% of Total Billed Charges,17.8,75,,2115,Percent of Total Billed charges,75% of Total Billed Charges,23.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.09,72,,2030.4,Percent of Total Billed Charges,72% of Total Billed Charges,14.24,60,,1692,Percent of Total Billed Charges,60% of Total Billed Charges,21.36,90,,153,Percent of Total Billed Charges,90% of Total Billed Charges,10.68,45,,35.64,Percent of Total Billed Charges,45% of Total Billed Charges,21.36,90,,23.08,Percent of Total Billed Charges,90% of Total billed Charges,23.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.42,65,,6.824,Percent of total Billed Charges,65% of Total Billed Charges,10.46,44.1,,34.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.54,95,,24.36,Percent of Total Billed Charges,95% of Total Billed Charges,23.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.88,88,,22.56,Percent of Total Billed Charges,88% of Total Billed Charges,21.36,90,,23.08,Percent of Total Billed charges,90% of Total Billed Charges,10.46,23.73,
ETHILON 10-0 7770G,2720002088,CDM,272,RC,,,Outpatient,,,28.30,18.40,,28.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21.51,76,,23.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.38,72,,2145.6,Percent of Total Billed Charges,72% of Total Billed Charges,21.23,75,,2235,Percent of Total Billed charges,75% of Total Billed Charges,28.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.38,72,,2145.6,Percent of Total Billed Charges,72% of Total Billed Charges,16.98,60,,1788,Percent of Total Billed Charges,60% of Total Billed Charges,25.47,90,,153,Percent of Total Billed Charges,90% of Total Billed Charges,12.74,45,,35.64,Percent of Total Billed Charges,45% of Total Billed Charges,25.47,90,,27.272,Percent of Total Billed Charges,90% of Total billed Charges,28.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.4,65,,51.48,Percent of total Billed Charges,65% of Total Billed Charges,12.48,44.1,,34.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.89,95,,28.792,Percent of Total Billed Charges,95% of Total Billed Charges,28.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.9,88,,26.664,Percent of Total Billed Charges,88% of Total Billed Charges,25.47,90,,27.272,Percent of Total Billed charges,90% of Total Billed Charges,12.48,28.3,
VICRYL 9-0 V402G,2720002089,CDM,272,RC,,,Outpatient,,,37.15,24.15,,37.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.23,76,,7.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.75,72,,2145.6,Percent of Total Billed Charges,72% of Total Billed Charges,27.86,75,,2235,Percent of Total Billed charges,75% of Total Billed Charges,37.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.75,72,,2145.6,Percent of Total Billed Charges,72% of Total Billed Charges,22.29,60,,1788,Percent of Total Billed Charges,60% of Total Billed Charges,33.44,90,,153,Percent of Total Billed Charges,90% of Total Billed Charges,16.72,45,,76.504,Percent of Total Billed Charges,45% of Total Billed Charges,33.44,90,,9.456,Percent of Total Billed Charges,90% of Total billed Charges,37.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.15,65,,51.48,Percent of total Billed Charges,65% of Total Billed Charges,16.38,44.1,,74.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.29,95,,9.976,Percent of Total Billed Charges,95% of Total Billed Charges,37.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.69,88,,9.24,Percent of Total Billed Charges,88% of Total Billed Charges,33.44,90,,9.456,Percent of Total Billed charges,90% of Total Billed Charges,16.38,37.15,
VICRYL 8-0 J548G,2720002090,CDM,272,RC,,,Outpatient,,,28.28,18.38,,28.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21.49,76,,60.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.36,72,,2145.6,Percent of Total Billed Charges,72% of Total Billed Charges,21.21,75,,2235,Percent of Total Billed charges,75% of Total Billed Charges,28.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.36,72,,2145.6,Percent of Total Billed Charges,72% of Total Billed Charges,16.97,60,,1788,Percent of Total Billed Charges,60% of Total Billed Charges,25.45,90,,153,Percent of Total Billed Charges,90% of Total Billed Charges,12.73,45,,76.504,Percent of Total Billed Charges,45% of Total Billed Charges,25.45,90,,71.28,Percent of Total Billed Charges,90% of Total billed Charges,28.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.38,65,,110.504,Percent of total Billed Charges,65% of Total Billed Charges,12.47,44.1,,74.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.87,95,,75.24,Percent of Total Billed Charges,95% of Total Billed Charges,28.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.89,88,,69.696,Percent of Total Billed Charges,88% of Total Billed Charges,25.45,90,,71.28,Percent of Total Billed charges,90% of Total Billed Charges,12.47,28.28,
VICRYL 6-0 J570G,2720002091,CDM,272,RC,,,Outpatient,,,27.90,18.14,,27.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21.2,76,,60.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.09,72,,2145.6,Percent of Total Billed Charges,72% of Total Billed Charges,20.93,75,,2235,Percent of Total Billed charges,75% of Total Billed Charges,27.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.09,72,,2145.6,Percent of Total Billed Charges,72% of Total Billed Charges,16.74,60,,1788,Percent of Total Billed Charges,60% of Total Billed Charges,25.11,90,,153,Percent of Total Billed Charges,90% of Total Billed Charges,12.56,45,,69.096,Percent of Total Billed Charges,45% of Total Billed Charges,25.11,90,,71.28,Percent of Total Billed Charges,90% of Total billed Charges,27.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.14,65,,110.504,Percent of total Billed Charges,65% of Total Billed Charges,12.3,44.1,,67.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.51,95,,75.24,Percent of Total Billed Charges,95% of Total Billed Charges,27.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.55,88,,69.696,Percent of Total Billed Charges,88% of Total Billed Charges,25.11,90,,71.28,Percent of Total Billed charges,90% of Total Billed Charges,12.3,27.9,
PLAIN 5-0 1915G,2720002092,CDM,272,RC,,,Outpatient,,,12.55,8.16,,12.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.54,76,,129.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.04,72,,2872.8,Percent of Total Billed Charges,72% of Total Billed Charges,9.41,75,,2992.504,Percent of Total Billed charges,75% of Total Billed Charges,12.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.04,72,,2872.8,Percent of Total Billed Charges,72% of Total Billed Charges,7.53,60,,2394,Percent of Total Billed Charges,60% of Total Billed Charges,11.3,90,,1575,Percent of Total Billed Charges,90% of Total Billed Charges,5.65,45,,37.8,Percent of Total Billed Charges,45% of Total Billed Charges,11.3,90,,153,Percent of Total Billed Charges,90% of Total billed Charges,12.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.16,65,,99.8,Percent of total Billed Charges,65% of Total Billed Charges,5.53,44.1,,37.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.92,95,,161.504,Percent of Total Billed Charges,95% of Total Billed Charges,12.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.04,88,,149.6,Percent of Total Billed Charges,88% of Total Billed Charges,11.3,90,,153,Percent of Total Billed charges,90% of Total Billed Charges,5.53,12.55,
ETHILON 10-0 9031G,2720002093,CDM,272,RC,,,Outpatient,,,28.63,18.61,,28.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21.76,76,,129.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.61,72,,2872.8,Percent of Total Billed Charges,72% of Total Billed Charges,21.47,75,,2992.504,Percent of Total Billed charges,75% of Total Billed Charges,28.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.61,72,,2872.8,Percent of Total Billed Charges,72% of Total Billed Charges,17.18,60,,2394,Percent of Total Billed Charges,60% of Total Billed Charges,25.77,90,,1575,Percent of Total Billed Charges,90% of Total Billed Charges,12.88,45,,31.504,Percent of Total Billed Charges,45% of Total Billed Charges,25.77,90,,153,Percent of Total Billed Charges,90% of Total billed Charges,28.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.61,65,,54.6,Percent of total Billed Charges,65% of Total Billed Charges,12.63,44.1,,30.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,27.2,95,,161.504,Percent of Total Billed Charges,95% of Total Billed Charges,28.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.19,88,,149.6,Percent of Total Billed Charges,88% of Total Billed Charges,25.77,90,,153,Percent of Total Billed charges,90% of Total Billed Charges,12.63,28.63,
33 CVD INTRALUMIN STAPLER,2720002094,CDM,272,RC,,,Outpatient,,,492.73,320.27,,492.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,374.47,76,,116.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,354.77,72,,34.848,Percent of Total Billed Charges,72% of Total Billed Charges,369.55,75,,36.304,Percent of Total Billed charges,75% of Total Billed Charges,492.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.77,72,,34.848,Percent of Total Billed Charges,72% of Total Billed Charges,295.64,60,,29.04,Percent of Total Billed Charges,60% of Total Billed Charges,443.46,90,,1575,Percent of Total Billed Charges,90% of Total Billed Charges,221.73,45,,76.504,Percent of Total Billed Charges,45% of Total Billed Charges,443.46,90,,138.192,Percent of Total Billed Charges,90% of Total billed Charges,492.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320.27,65,,45.504,Percent of total Billed Charges,65% of Total Billed Charges,217.29,44.1,,74.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,468.09,95,,145.864,Percent of Total Billed Charges,95% of Total Billed Charges,492.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,433.6,88,,135.12,Percent of Total Billed Charges,88% of Total Billed Charges,443.46,90,,138.192,Percent of Total Billed charges,90% of Total Billed Charges,217.29,492.73,
RELOAD XR30V,2720002095,CDM,272,RC,,,Outpatient,,,82.88,53.87,,82.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.99,76,,63.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.67,72,,612,Percent of Total Billed Charges,72% of Total Billed Charges,62.16,75,,637.504,Percent of Total Billed charges,75% of Total Billed Charges,82.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.67,72,,612,Percent of Total Billed Charges,72% of Total Billed Charges,49.73,60,,510,Percent of Total Billed Charges,60% of Total Billed Charges,74.59,90,,1575,Percent of Total Billed Charges,90% of Total Billed Charges,37.3,45,,76.504,Percent of Total Billed Charges,45% of Total Billed Charges,74.59,90,,75.6,Percent of Total Billed Charges,90% of Total billed Charges,82.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.87,65,,110.504,Percent of total Billed Charges,65% of Total Billed Charges,36.55,44.1,,74.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,78.74,95,,79.8,Percent of Total Billed Charges,95% of Total Billed Charges,82.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.93,88,,73.92,Percent of Total Billed Charges,88% of Total Billed Charges,74.59,90,,75.6,Percent of Total Billed charges,90% of Total Billed Charges,36.55,82.88,
RELOAD XR60G,2720002096,CDM,272,RC,,,Outpatient,,,86.85,56.45,,86.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.01,76,,53.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.53,72,,612,Percent of Total Billed Charges,72% of Total Billed Charges,65.14,75,,637.504,Percent of Total Billed charges,75% of Total Billed Charges,86.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.53,72,,612,Percent of Total Billed Charges,72% of Total Billed Charges,52.11,60,,510,Percent of Total Billed Charges,60% of Total Billed Charges,78.17,90,,1575,Percent of Total Billed Charges,90% of Total Billed Charges,39.08,45,,76.504,Percent of Total Billed Charges,45% of Total Billed Charges,78.17,90,,63,Percent of Total Billed Charges,90% of Total billed Charges,86.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.45,65,,110.504,Percent of total Billed Charges,65% of Total Billed Charges,38.3,44.1,,74.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.51,95,,66.504,Percent of Total Billed Charges,95% of Total Billed Charges,86.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.43,88,,61.6,Percent of Total Billed Charges,88% of Total Billed Charges,78.17,90,,63,Percent of Total Billed charges,90% of Total Billed Charges,38.3,86.85,
PNEUMONEEDLE 150,2720002097,CDM,272,RC,,,Outpatient,,,99.25,64.51,,99.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.43,76,,129.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71.46,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,74.44,75,,225,Percent of Total Billed charges,75% of Total Billed Charges,99.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.46,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,59.55,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,89.33,90,,1575,Percent of Total Billed Charges,90% of Total Billed Charges,44.66,45,,76.504,Percent of Total Billed Charges,45% of Total Billed Charges,89.33,90,,153,Percent of Total Billed Charges,90% of Total billed Charges,99.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.51,65,,110.504,Percent of total Billed Charges,65% of Total Billed Charges,43.77,44.1,,74.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,94.29,95,,161.504,Percent of Total Billed Charges,95% of Total Billed Charges,99.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.34,88,,149.6,Percent of Total Billed Charges,88% of Total Billed Charges,89.33,90,,153,Percent of Total Billed charges,90% of Total Billed Charges,43.77,99.25,
LIGACLIP ERCA M/L,2720002098,CDM,272,RC,,,Outpatient,,,167.13,108.63,,167.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,127.02,76,,129.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,120.33,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,125.35,75,,225,Percent of Total Billed charges,75% of Total Billed Charges,167.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.33,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,100.28,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,150.42,90,,1575,Percent of Total Billed Charges,90% of Total Billed Charges,75.21,45,,76.504,Percent of Total Billed Charges,45% of Total Billed Charges,150.42,90,,153,Percent of Total Billed Charges,90% of Total billed Charges,167.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.63,65,,110.504,Percent of total Billed Charges,65% of Total Billed Charges,73.7,44.1,,74.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,158.77,95,,161.504,Percent of Total Billed Charges,95% of Total Billed Charges,167.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.07,88,,149.6,Percent of Total Billed Charges,88% of Total Billed Charges,150.42,90,,153,Percent of Total Billed charges,90% of Total Billed Charges,73.7,167.13,
SPIRAL FILIFORM TIP 4FR,2720002099,CDM,272,RC,,,Outpatient,,,33.65,21.87,,33.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.57,76,,129.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.23,72,,1368,Percent of Total Billed Charges,72% of Total Billed Charges,25.24,75,,1425,Percent of Total Billed charges,75% of Total Billed Charges,33.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.23,72,,1368,Percent of Total Billed Charges,72% of Total Billed Charges,20.19,60,,1140,Percent of Total Billed Charges,60% of Total Billed Charges,30.29,90,,1575,Percent of Total Billed Charges,90% of Total Billed Charges,15.14,45,,787.504,Percent of Total Billed Charges,45% of Total Billed Charges,30.29,90,,153,Percent of Total Billed Charges,90% of Total billed Charges,33.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.87,65,,110.504,Percent of total Billed Charges,65% of Total Billed Charges,14.84,44.1,,771.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.97,95,,161.504,Percent of Total Billed Charges,95% of Total Billed Charges,33.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.61,88,,149.6,Percent of Total Billed Charges,88% of Total Billed Charges,30.29,90,,153,Percent of Total Billed charges,90% of Total Billed Charges,14.84,33.65,
SPIRAL FILIFORM TIP 5FR,2720002100,CDM,272,RC,,,Outpatient,,,33.65,21.87,,33.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.57,76,,129.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.23,72,,4888.8,Percent of Total Billed Charges,72% of Total Billed Charges,25.24,75,,5092.504,Percent of Total Billed charges,75% of Total Billed Charges,33.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.23,72,,4888.8,Percent of Total Billed Charges,72% of Total Billed Charges,20.19,60,,4074,Percent of Total Billed Charges,60% of Total Billed Charges,30.29,90,,1575,Percent of Total Billed Charges,90% of Total Billed Charges,15.14,45,,787.504,Percent of Total Billed Charges,45% of Total Billed Charges,30.29,90,,153,Percent of Total Billed Charges,90% of Total billed Charges,33.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.87,65,,1137.504,Percent of total Billed Charges,65% of Total Billed Charges,14.84,44.1,,771.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.97,95,,161.504,Percent of Total Billed Charges,95% of Total Billed Charges,33.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.61,88,,149.6,Percent of Total Billed Charges,88% of Total Billed Charges,30.29,90,,153,Percent of Total Billed charges,90% of Total Billed Charges,14.84,33.65,
MICRO SAGITTAL SAW BLD 4.5,2720002101,CDM,272,RC,,,Outpatient,,,13.08,8.50,,13.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.94,76,,129.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.42,72,,4888.8,Percent of Total Billed Charges,72% of Total Billed Charges,9.81,75,,5092.504,Percent of Total Billed charges,75% of Total Billed Charges,13.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.42,72,,4888.8,Percent of Total Billed Charges,72% of Total Billed Charges,7.85,60,,4074,Percent of Total Billed Charges,60% of Total Billed Charges,11.77,90,,1575,Percent of Total Billed Charges,90% of Total Billed Charges,5.89,45,,787.504,Percent of Total Billed Charges,45% of Total Billed Charges,11.77,90,,153,Percent of Total Billed Charges,90% of Total billed Charges,13.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.5,65,,1137.504,Percent of total Billed Charges,65% of Total Billed Charges,5.77,44.1,,771.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.43,95,,161.504,Percent of Total Billed Charges,95% of Total Billed Charges,13.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.51,88,,149.6,Percent of Total Billed Charges,88% of Total Billed Charges,11.77,90,,153,Percent of Total Billed charges,90% of Total Billed Charges,5.77,13.08,
VACURETTE CU 9MM,2720002102,CDM,272,RC,,,Outpatient,,,8.83,5.74,,8.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.71,76,,1330,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.36,72,,4888.8,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,5092.504,Percent of Total Billed charges,75% of Total Billed Charges,8.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.36,72,,4888.8,Percent of Total Billed Charges,72% of Total Billed Charges,5.3,60,,4074,Percent of Total Billed Charges,60% of Total Billed Charges,7.95,90,,1575,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,787.504,Percent of Total Billed Charges,45% of Total Billed Charges,7.95,90,,1575,Percent of Total Billed Charges,90% of Total billed Charges,8.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.74,65,,1137.504,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,771.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.39,95,,1662.504,Percent of Total Billed Charges,95% of Total Billed Charges,8.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.77,88,,1540,Percent of Total Billed Charges,88% of Total Billed Charges,7.95,90,,1575,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.83,
VACURETTE CU 12MM,2720002103,CDM,272,RC,,,Outpatient,,,9.20,5.98,,9.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.99,76,,1330,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.62,72,,4888.8,Percent of Total Billed Charges,72% of Total Billed Charges,6.9,75,,5092.504,Percent of Total Billed charges,75% of Total Billed Charges,9.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,72,,4888.8,Percent of Total Billed Charges,72% of Total Billed Charges,5.52,60,,4074,Percent of Total Billed Charges,60% of Total Billed Charges,8.28,90,,1575,Percent of Total Billed Charges,90% of Total Billed Charges,4.14,45,,787.504,Percent of Total Billed Charges,45% of Total Billed Charges,8.28,90,,1575,Percent of Total Billed Charges,90% of Total billed Charges,9.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.98,65,,1137.504,Percent of total Billed Charges,65% of Total Billed Charges,4.06,44.1,,771.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.74,95,,1662.504,Percent of Total Billed Charges,95% of Total Billed Charges,9.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.1,88,,1540,Percent of Total Billed Charges,88% of Total Billed Charges,8.28,90,,1575,Percent of Total Billed charges,90% of Total Billed Charges,4.06,9.2,
VACURETTE CU 7MM,2720002104,CDM,272,RC,,,Outpatient,,,8.83,5.74,,8.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.71,76,,1330,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.36,72,,4888.8,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,5092.504,Percent of Total Billed charges,75% of Total Billed Charges,8.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.36,72,,4888.8,Percent of Total Billed Charges,72% of Total Billed Charges,5.3,60,,4074,Percent of Total Billed Charges,60% of Total Billed Charges,7.95,90,,10.712,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,787.504,Percent of Total Billed Charges,45% of Total Billed Charges,7.95,90,,1575,Percent of Total Billed Charges,90% of Total billed Charges,8.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.74,65,,1137.504,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,771.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.39,95,,1662.504,Percent of Total Billed Charges,95% of Total Billed Charges,8.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.77,88,,1540,Percent of Total Billed Charges,88% of Total Billed Charges,7.95,90,,1575,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.83,
VACURETTE CU 10MM,2720002105,CDM,272,RC,,,Outpatient,,,8.83,5.74,,8.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.71,76,,1330,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.36,72,,3556.8,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,3705,Percent of Total Billed charges,75% of Total Billed Charges,8.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.36,72,,3556.8,Percent of Total Billed Charges,72% of Total Billed Charges,5.3,60,,2964,Percent of Total Billed Charges,60% of Total Billed Charges,7.95,90,,1233,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,787.504,Percent of Total Billed Charges,45% of Total Billed Charges,7.95,90,,1575,Percent of Total Billed Charges,90% of Total billed Charges,8.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.74,65,,1137.504,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,771.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.39,95,,1662.504,Percent of Total Billed Charges,95% of Total Billed Charges,8.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.77,88,,1540,Percent of Total Billed Charges,88% of Total Billed Charges,7.95,90,,1575,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.83,
COOK 12/14X28 ACCESS SHTH,2720002106,CDM,272,RC,,,Outpatient,,,426.70,277.36,,426.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,324.29,76,,1330,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,307.22,72,,4888.8,Percent of Total Billed Charges,72% of Total Billed Charges,320.03,75,,5092.504,Percent of Total Billed charges,75% of Total Billed Charges,426.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.22,72,,4888.8,Percent of Total Billed Charges,72% of Total Billed Charges,256.02,60,,4074,Percent of Total Billed Charges,60% of Total Billed Charges,384.03,90,,1233,Percent of Total Billed Charges,90% of Total Billed Charges,192.02,45,,787.504,Percent of Total Billed Charges,45% of Total Billed Charges,384.03,90,,1575,Percent of Total Billed Charges,90% of Total billed Charges,426.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.36,65,,1137.504,Percent of total Billed Charges,65% of Total Billed Charges,188.17,44.1,,771.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,405.37,95,,1662.504,Percent of Total Billed Charges,95% of Total Billed Charges,426.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.5,88,,1540,Percent of Total Billed Charges,88% of Total Billed Charges,384.03,90,,1575,Percent of Total Billed charges,90% of Total Billed Charges,188.17,426.7,
RELOAD 6R45B 3.5,2720002107,CDM,272,RC,,,Outpatient,,,236.98,154.04,,236.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,180.1,76,,1330,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,170.63,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,177.74,75,,126,Percent of Total Billed charges,75% of Total Billed Charges,236.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.63,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,142.19,60,,100.8,Percent of Total Billed Charges,60% of Total Billed Charges,213.28,90,,1350,Percent of Total Billed Charges,90% of Total Billed Charges,106.64,45,,787.504,Percent of Total Billed Charges,45% of Total Billed Charges,213.28,90,,1575,Percent of Total Billed Charges,90% of Total billed Charges,236.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.04,65,,1137.504,Percent of total Billed Charges,65% of Total Billed Charges,104.51,44.1,,771.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,225.13,95,,1662.504,Percent of Total Billed Charges,95% of Total Billed Charges,236.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.54,88,,1540,Percent of Total Billed Charges,88% of Total Billed Charges,213.28,90,,1575,Percent of Total Billed charges,90% of Total Billed Charges,104.51,236.98,
RELOAD TR45G 4.5,2720002108,CDM,272,RC,,,Outpatient,,,264.78,172.11,,264.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,201.23,76,,1330,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,190.64,72,,187.776,Percent of Total Billed Charges,72% of Total Billed Charges,198.59,75,,195.6,Percent of Total Billed charges,75% of Total Billed Charges,264.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.64,72,,187.776,Percent of Total Billed Charges,72% of Total Billed Charges,158.87,60,,156.48,Percent of Total Billed Charges,60% of Total Billed Charges,238.3,90,,2.76,Percent of Total Billed Charges,90% of Total Billed Charges,119.15,45,,787.504,Percent of Total Billed Charges,45% of Total Billed Charges,238.3,90,,1575,Percent of Total Billed Charges,90% of Total billed Charges,264.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.11,65,,1137.504,Percent of total Billed Charges,65% of Total Billed Charges,116.77,44.1,,771.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,251.54,95,,1662.504,Percent of Total Billed Charges,95% of Total Billed Charges,264.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.01,88,,1540,Percent of Total Billed Charges,88% of Total Billed Charges,238.3,90,,1575,Percent of Total Billed charges,90% of Total Billed Charges,116.77,264.78,
STRYKER DRI-LOK CANN 8.0X75,2720002109,CDM,272,RC,,,Outpatient,,,39.35,25.58,,39.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.91,76,,1330,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.33,72,,153,Percent of Total Billed Charges,72% of Total Billed Charges,29.51,75,,159.376,Percent of Total Billed charges,75% of Total Billed Charges,39.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.33,72,,153,Percent of Total Billed Charges,72% of Total Billed Charges,23.61,60,,127.504,Percent of Total Billed Charges,60% of Total Billed Charges,35.42,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,17.71,45,,787.504,Percent of Total Billed Charges,45% of Total Billed Charges,35.42,90,,1575,Percent of Total Billed Charges,90% of Total billed Charges,39.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.58,65,,1137.504,Percent of total Billed Charges,65% of Total Billed Charges,17.35,44.1,,771.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.38,95,,1662.504,Percent of Total Billed Charges,95% of Total Billed Charges,39.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.63,88,,1540,Percent of Total Billed Charges,88% of Total Billed Charges,35.42,90,,1575,Percent of Total Billed charges,90% of Total Billed Charges,17.35,39.35,
STRYKER DRI-LOK 6.5 NT,2720002110,CDM,272,RC,,,Outpatient,,,39.35,25.58,,39.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.91,76,,1330,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.33,72,,36.056,Percent of Total Billed Charges,72% of Total Billed Charges,29.51,75,,37.56,Percent of Total Billed charges,75% of Total Billed Charges,39.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.33,72,,36.056,Percent of Total Billed Charges,72% of Total Billed Charges,23.61,60,,30.048,Percent of Total Billed Charges,60% of Total Billed Charges,35.42,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,17.71,45,,787.504,Percent of Total Billed Charges,45% of Total Billed Charges,35.42,90,,1575,Percent of Total Billed Charges,90% of Total billed Charges,39.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.58,65,,1137.504,Percent of total Billed Charges,65% of Total Billed Charges,17.35,44.1,,771.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.38,95,,1662.504,Percent of Total Billed Charges,95% of Total Billed Charges,39.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.63,88,,1540,Percent of Total Billed Charges,88% of Total Billed Charges,35.42,90,,1575,Percent of Total Billed charges,90% of Total Billed Charges,17.35,39.35,
DIC 7.0 TRACH TUBE,2720002111,CDM,272,RC,,,Outpatient,,,87.30,56.75,,87.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.35,76,,1330,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.86,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,65.48,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,87.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.86,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,52.38,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,78.57,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,39.29,45,,5.36,Percent of Total Billed Charges,45% of Total Billed Charges,78.57,90,,1575,Percent of Total Billed Charges,90% of Total billed Charges,87.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.75,65,,1137.504,Percent of total Billed Charges,65% of Total Billed Charges,38.5,44.1,,5.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.94,95,,1662.504,Percent of Total Billed Charges,95% of Total Billed Charges,87.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.82,88,,1540,Percent of Total Billed Charges,88% of Total Billed Charges,78.57,90,,1575,Percent of Total Billed charges,90% of Total Billed Charges,38.5,87.3,
DIC 8.0 TRACH TUBE,2720002112,CDM,272,RC,,,Outpatient,,,94.05,61.13,,94.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,71.48,76,,1330,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,67.72,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,70.54,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,94.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.72,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,56.43,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,84.65,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,42.32,45,,616.504,Percent of Total Billed Charges,45% of Total Billed Charges,84.65,90,,1575,Percent of Total Billed Charges,90% of Total billed Charges,94.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.13,65,,7.736,Percent of total Billed Charges,65% of Total Billed Charges,41.48,44.1,,604.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,89.35,95,,1662.504,Percent of Total Billed Charges,95% of Total Billed Charges,94.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.76,88,,1540,Percent of Total Billed Charges,88% of Total Billed Charges,84.65,90,,1575,Percent of Total Billed charges,90% of Total Billed Charges,41.48,94.05,
DIC 9.0 TRACH TUBE,2720002113,CDM,272,RC,,,Outpatient,,,97.28,63.23,,97.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.93,76,,1330,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,70.04,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,72.96,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,97.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.04,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,58.37,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,87.55,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,43.78,45,,616.504,Percent of Total Billed Charges,45% of Total Billed Charges,87.55,90,,1575,Percent of Total Billed Charges,90% of Total billed Charges,97.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.23,65,,890.504,Percent of total Billed Charges,65% of Total Billed Charges,42.9,44.1,,604.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,92.42,95,,1662.504,Percent of Total Billed Charges,95% of Total Billed Charges,97.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.61,88,,1540,Percent of Total Billed Charges,88% of Total Billed Charges,87.55,90,,1575,Percent of Total Billed charges,90% of Total Billed Charges,42.9,97.28,
DIC 10.0 TRACH TUBE,2720002114,CDM,272,RC,,,Outpatient,,,93.78,60.96,,93.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,71.27,76,,9.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,67.52,72,,4.784,Percent of Total Billed Charges,72% of Total Billed Charges,70.34,75,,4.984,Percent of Total Billed charges,75% of Total Billed Charges,93.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.52,72,,4.784,Percent of Total Billed Charges,72% of Total Billed Charges,56.27,60,,3.984,Percent of Total Billed Charges,60% of Total Billed Charges,84.4,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,42.2,45,,675,Percent of Total Billed Charges,45% of Total Billed Charges,84.4,90,,10.712,Percent of Total Billed Charges,90% of Total billed Charges,93.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.96,65,,890.504,Percent of total Billed Charges,65% of Total Billed Charges,41.36,44.1,,661.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,89.09,95,,11.312,Percent of Total Billed Charges,95% of Total Billed Charges,93.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.53,88,,10.472,Percent of Total Billed Charges,88% of Total Billed Charges,84.4,90,,10.712,Percent of Total Billed charges,90% of Total Billed Charges,41.36,93.78,
PEDI 3.0 TRACH TUBE,2720002115,CDM,272,RC,,,Outpatient,,,171.95,111.77,,171.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.68,76,,1041.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.8,72,,153,Percent of Total Billed Charges,72% of Total Billed Charges,128.96,75,,159.376,Percent of Total Billed charges,75% of Total Billed Charges,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.8,72,,153,Percent of Total Billed Charges,72% of Total Billed Charges,103.17,60,,127.504,Percent of Total Billed Charges,60% of Total Billed Charges,154.76,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,77.38,45,,1.376,Percent of Total Billed Charges,45% of Total Billed Charges,154.76,90,,1233,Percent of Total Billed Charges,90% of Total billed Charges,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.77,65,,975,Percent of total Billed Charges,65% of Total Billed Charges,75.83,44.1,,1.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.35,95,,1301.504,Percent of Total Billed Charges,95% of Total Billed Charges,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.32,88,,1205.6,Percent of Total Billed Charges,88% of Total Billed Charges,154.76,90,,1233,Percent of Total Billed charges,90% of Total Billed Charges,75.83,171.95,
PEDI 3.5 TRACH TUBE,2720002116,CDM,272,RC,,,Outpatient,,,171.95,111.77,,171.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.68,76,,1041.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.8,72,,153,Percent of Total Billed Charges,72% of Total Billed Charges,128.96,75,,159.376,Percent of Total Billed charges,75% of Total Billed Charges,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.8,72,,153,Percent of Total Billed Charges,72% of Total Billed Charges,103.17,60,,127.504,Percent of Total Billed Charges,60% of Total Billed Charges,154.76,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,77.38,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,154.76,90,,1233,Percent of Total Billed Charges,90% of Total billed Charges,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.77,65,,1.992,Percent of total Billed Charges,65% of Total Billed Charges,75.83,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.35,95,,1301.504,Percent of Total Billed Charges,95% of Total Billed Charges,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.32,88,,1205.6,Percent of Total Billed Charges,88% of Total Billed Charges,154.76,90,,1233,Percent of Total Billed charges,90% of Total Billed Charges,75.83,171.95,
PEDI 4.0 TRACH TUBE,2720002117,CDM,272,RC,,,Outpatient,,,167.70,109.01,,167.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,127.45,76,,1140,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,120.74,72,,153,Percent of Total Billed Charges,72% of Total Billed Charges,125.78,75,,159.376,Percent of Total Billed charges,75% of Total Billed Charges,167.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.74,72,,153,Percent of Total Billed Charges,72% of Total Billed Charges,100.62,60,,127.504,Percent of Total Billed Charges,60% of Total Billed Charges,150.93,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,75.47,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,150.93,90,,1350,Percent of Total Billed Charges,90% of Total billed Charges,167.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.01,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,73.96,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,159.32,95,,1425,Percent of Total Billed Charges,95% of Total Billed Charges,167.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.58,88,,1320,Percent of Total Billed Charges,88% of Total Billed Charges,150.93,90,,1350,Percent of Total Billed charges,90% of Total Billed Charges,73.96,167.7,
PEDI 4.5 TRACH TUBE,2720002118,CDM,272,RC,,,Outpatient,,,171.95,111.77,,171.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.68,76,,2.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.8,72,,8.096,Percent of Total Billed Charges,72% of Total Billed Charges,128.96,75,,8.432,Percent of Total Billed charges,75% of Total Billed Charges,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.8,72,,8.096,Percent of Total Billed Charges,72% of Total Billed Charges,103.17,60,,6.744,Percent of Total Billed Charges,60% of Total Billed Charges,154.76,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,77.38,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,154.76,90,,2.76,Percent of Total Billed Charges,90% of Total billed Charges,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.77,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,75.83,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.35,95,,2.912,Percent of Total Billed Charges,95% of Total Billed Charges,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.32,88,,2.696,Percent of Total Billed Charges,88% of Total Billed Charges,154.76,90,,2.76,Percent of Total Billed charges,90% of Total Billed Charges,75.83,171.95,
PEDI 5.0 TRACH TUBE,2720002119,CDM,272,RC,,,Outpatient,,,171.95,111.77,,171.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.68,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.8,72,,83.144,Percent of Total Billed Charges,72% of Total Billed Charges,128.96,75,,86.608,Percent of Total Billed charges,75% of Total Billed Charges,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.8,72,,83.144,Percent of Total Billed Charges,72% of Total Billed Charges,103.17,60,,69.288,Percent of Total Billed Charges,60% of Total Billed Charges,154.76,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,77.38,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,154.76,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.77,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,75.83,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.35,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.32,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,154.76,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,75.83,171.95,
PEDI 5.5 TRACH TUBE,2720002120,CDM,272,RC,,,Outpatient,,,171.95,111.77,,171.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.68,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.8,72,,83.144,Percent of Total Billed Charges,72% of Total Billed Charges,128.96,75,,86.608,Percent of Total Billed charges,75% of Total Billed Charges,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.8,72,,83.144,Percent of Total Billed Charges,72% of Total Billed Charges,103.17,60,,69.288,Percent of Total Billed Charges,60% of Total Billed Charges,154.76,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,77.38,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,154.76,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.77,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,75.83,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.35,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,171.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.32,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,154.76,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,75.83,171.95,
Blue Waffle Boot Heel Protectr,2720002121,CDM,272,RC,,,Outpatient,,,54.70,35.56,,54.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.57,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.38,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,41.03,75,,126,Percent of Total Billed charges,75% of Total Billed Charges,54.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.38,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,32.82,60,,100.8,Percent of Total Billed Charges,60% of Total Billed Charges,49.23,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,24.62,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,49.23,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,54.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.56,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,24.12,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,51.97,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,54.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.14,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,49.23,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,24.12,54.7,
WECK HEMOCLIP 15LG,2720002122,CDM,272,RC,,,Outpatient,,,47.88,31.12,,47.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.39,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.47,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,35.91,75,,126,Percent of Total Billed charges,75% of Total Billed Charges,47.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.47,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,28.73,60,,100.8,Percent of Total Billed Charges,60% of Total Billed Charges,43.09,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,21.55,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,43.09,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,47.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.12,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,21.12,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.49,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,47.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.13,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,43.09,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,21.12,47.88,
Dobhoff Naso Feed TB STD 12F,2720002123,CDM,272,RC,,,Outpatient,,,20.68,13.44,,20.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.72,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.89,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,15.51,75,,126,Percent of Total Billed charges,75% of Total Billed Charges,20.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.89,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,60,,100.8,Percent of Total Billed Charges,60% of Total Billed Charges,18.61,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,9.31,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,18.61,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,20.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.44,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,9.12,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.65,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,20.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.2,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,18.61,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,9.12,20.68,
BS .038 STD ANG ZIPWIRE,2720002124,CDM,272,RC,,,Outpatient,,,84.73,55.07,,84.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,64.39,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.01,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,63.55,75,,126,Percent of Total Billed charges,75% of Total Billed Charges,84.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.01,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,50.84,60,,100.8,Percent of Total Billed Charges,60% of Total Billed Charges,76.26,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,38.13,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,76.26,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,84.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.07,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,37.37,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,80.49,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,84.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.56,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,76.26,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,37.37,84.73,
Speci-Cath Urine Collect Kits,2720002125,CDM,272,RC,,,Outpatient,,,4.75,3.09,,4.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.61,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.42,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,3.56,75,,126,Percent of Total Billed charges,75% of Total Billed Charges,4.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.42,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,2.85,60,,100.8,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,2.14,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,4.28,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,4.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.09,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,2.09,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.51,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,4.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.18,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,4.28,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,2.09,4.75,
Cystoscopy Surgical Pack I,2720002126,CDM,272,RC,,,Outpatient,,,13.13,8.53,,13.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.98,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.45,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,9.85,75,,126,Percent of Total Billed charges,75% of Total Billed Charges,13.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.45,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,7.88,60,,100.8,Percent of Total Billed Charges,60% of Total Billed Charges,11.82,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,5.91,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,11.82,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,13.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.53,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,5.79,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.47,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,13.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.55,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,11.82,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,5.79,13.13,
Tiger 5F Radial 4.5 100CM,2720002127,CDM,272,RC,C1887,HCPCS,Outpatient,,,96.25,62.56,,96.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.15,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.3,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,72.19,75,,126,Percent of Total Billed charges,75% of Total Billed Charges,96.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.3,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,57.75,60,,100.8,Percent of Total Billed Charges,60% of Total Billed Charges,86.63,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,43.31,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,86.63,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,96.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.56,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,42.45,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.44,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,96.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.7,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,86.63,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,42.45,96.25,
OPTITORQUE 5F ANG PIGTAIL 110C,2720002128,CDM,272,RC,C1887,HCPCS,Outpatient,,,60.00,39.00,,60,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.6,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.2,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,45,75,,126,Percent of Total Billed charges,75% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.2,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,36,60,,100.8,Percent of Total Billed Charges,60% of Total Billed Charges,54,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,27,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,54,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,26.46,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,57,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,60,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.8,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,54,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,26.46,60,
JACKY 5F RADIAL 3.5 100CM,2720002129,CDM,272,RC,C1887,HCPCS,Outpatient,,,96.25,62.56,,96.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.15,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.3,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,72.19,75,,126,Percent of Total Billed charges,75% of Total Billed Charges,96.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.3,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,57.75,60,,100.8,Percent of Total Billed Charges,60% of Total Billed Charges,86.63,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,43.31,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,86.63,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,96.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.56,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,42.45,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.44,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,96.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.7,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,86.63,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,42.45,96.25,
TIGER 5F RADIAL 4.5 110CM,2720002130,CDM,272,RC,C1887,HCPCS,Outpatient,,,96.25,62.56,,96.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.15,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.3,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,72.19,75,,126,Percent of Total Billed charges,75% of Total Billed Charges,96.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.3,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,57.75,60,,100.8,Percent of Total Billed Charges,60% of Total Billed Charges,86.63,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,43.31,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,86.63,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,96.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.56,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,42.45,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.44,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,96.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.7,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,86.63,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,42.45,96.25,
JACKY 5F RADIAL 3.5 110CM,2720002131,CDM,272,RC,C1887,HCPCS,Outpatient,,,96.25,62.56,,96.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.15,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.3,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,72.19,75,,126,Percent of Total Billed charges,75% of Total Billed Charges,96.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.3,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,57.75,60,,100.8,Percent of Total Billed Charges,60% of Total Billed Charges,86.63,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,43.31,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,86.63,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,96.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.56,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,42.45,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.44,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,96.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.7,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,86.63,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,42.45,96.25,
NC EUPHORA RX 3.75MM X 20MM,2720002132,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,6.728,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,7.008,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,6.728,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,5.608,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 3.75MM X 15MM,2720002133,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,3.216,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,3.352,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,3.216,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,2.68,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 3.75MM X 12MM,2720002134,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,10.152,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,10.576,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,10.152,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 3.5MM X 8MM,2720002135,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,11.592,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,12.08,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,11.592,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,9.664,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 3MM X 8MM,2720002136,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,6.48,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,6.752,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,6.48,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,5.4,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 2.75MM X 8MM,2720002137,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,6.48,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,6.752,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,6.48,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,5.4,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 2.5MM X 20MM,2720002138,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,73.44,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,76.504,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,73.44,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,61.2,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 2.5MM X 8MM,2720002139,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,72,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,75,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,72,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,60,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 2.25MM X 8MM,2720002140,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,81,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,84.376,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,81,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,67.504,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 2MM X 8MM,2720002141,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,10.744,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,11.192,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,10.744,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,8.952,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 2MM X 6MM,2720002142,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,10.224,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,10.648,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,10.224,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,8.52,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 2.75MM X 10MM,2720002143,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,2736,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,2850,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,2736,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,2280,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 2.5MM X 25MM,2720002144,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,9748.8,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,10155,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,9748.8,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,8124,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 2.5MM X 10MM,2720002145,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,2728.8,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,2842.504,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,2728.8,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,2274,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 2MM X 25MM,2720002146,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,8020.8,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,8355,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,8020.8,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,6684,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 2MM X 10MM,2720002147,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,2383.2,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,2482.504,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,2383.2,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,1986,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 1.5MM X 15MM,2720002148,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,1.816,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,1.888,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,1.816,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,1.512,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 2.25MM X 20MM,2720002149,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,172.8,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,180,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,172.8,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 2.25MM X 15MM,2720002150,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,172.8,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,180,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,172.8,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 2.25MM X 12MM,2720002151,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,172.8,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,180,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,172.8,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 2.25MM X 10MM,2720002152,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,172.8,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,180,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,172.8,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 1.5MM X 10MM,2720002153,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,172.8,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,180,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,172.8,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
TELESCOPE 6F CATHETER GUIDE,2720002154,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,172.8,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,180,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,172.8,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 7F IMA GUIDE,2720002155,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,360,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,375,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,360,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,300,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 7F EBU3.5 GUIDE,2720002156,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,36,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,37.504,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,36,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,30,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 7F JR4 GUIDE,2720002157,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,36,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,37.504,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,36,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,30,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 5F EBU3.75 100CM GUID,2720002158,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,36,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,37.504,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,36,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,30,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 5F EBU3.5 100CM GUIDE,2720002159,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,36,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,37.504,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,36,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,30,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 5F JR4 GUIDE,2720002160,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,3.344,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,3.48,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,3.344,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,2.784,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 5F JL3.5 GUIDE,2720002161,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,24.48,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,25.504,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,24.48,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,20.4,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 5F JL4 GUIDE,2720002162,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F RBU3.5 GUIDE,2720002163,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,84,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,67.2,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F 3DRC GUIDE,2720002164,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,35.96,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,37.456,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,35.96,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,29.968,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,6.912,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F MP1 GUIDE,2720002165,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,11.52,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,12,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,11.52,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,2.92,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F IMA GUIDE,2720002166,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,127.504,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,102,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,1.624,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F HOCKEY S ID GUIDE,2720002167,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,50.4,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,52.504,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,50.4,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,42,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,12.6,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F HOCKEY S 3 GUIDE,2720002168,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,370.08,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,385.504,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,370.08,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,308.4,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,720,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F HOCKEY S 2 GUIDE,2720002169,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,372.96,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,388.504,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,372.96,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,310.8,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,720,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F HOCKEY S 1 GUIDE,2720002170,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,59.4,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,47.52,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,10.712,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F LCB GUIDE,2720002171,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,59.4,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,47.52,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,102.6,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,3.456,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,3.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F JR5 GUIDE,2720002172,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,59.4,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,47.52,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,1055.472,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,1.456,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,4.992,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,1.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F JR4 W/SH GUIDE,2720002173,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,59.4,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,47.52,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,916.848,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,0.808,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,2.104,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,0.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F JR4 GUIDE,2720002174,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,5.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,57.6,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,46.08,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,810,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,6.304,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,6.912,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,1.168,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,6.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,7.296,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,6.76,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,6.912,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F JR3.5 W/SH GUIDE,2720002175,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,2.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,57.6,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,46.08,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,810,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,360,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,2.92,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,9.104,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,352.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,3.08,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,2.848,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,2.92,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F JR3.5 GUIDE,2720002176,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,1.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,57.6,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,46.08,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,16.224,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,360,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,1.624,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,520,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,352.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,1.712,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,1.584,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,1.624,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F JR3 GUIDE,2720002177,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,10.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,57.6,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,46.08,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,28.064,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,5.36,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,12.6,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,520,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,5.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,13.304,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,12.32,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,12.6,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F JL5 GUIDE,2720002178,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,57.6,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,46.08,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,51.304,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,720,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,7.736,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,50.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,760,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,704,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,720,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F JL4.5 GUIDE,2720002179,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,57.6,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,46.08,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,3.64,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,527.736,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,720,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,74.104,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,517.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,760,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,704,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,720,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F JL4 W/SH GUIDE,2720002180,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,9.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,57.6,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,46.08,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,3.496,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,458.424,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,10.712,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,762.28,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,449.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,11.312,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,10.472,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,10.712,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F JL4 GUIDE,2720002181,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,86.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,324,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,337.504,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,324,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,270,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,3.888,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,405,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,102.6,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,662.168,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,396.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,108.304,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,100.32,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,102.6,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F JL3.5 W/SH GUIDE,2720002182,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,891.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,166.752,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,173.704,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,166.752,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,138.96,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,40.896,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,405,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,1055.472,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,585,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,396.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,1114.104,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,1032.016,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,1055.472,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6 JL3.5 GUIDE,2720002183,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,774.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,39.784,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,41.44,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,39.784,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,33.152,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,163.8,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,8.112,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,916.848,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,585,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,7.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,967.784,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,896.472,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,916.848,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F JL3 GUIDE,2720002184,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,684,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,221.616,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,230.848,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,221.616,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,184.68,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,163.8,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,14.032,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,810,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,11.712,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,13.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,855,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,792,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,810,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F AR2 GUIDE,2720002185,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,684,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,58.664,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,61.112,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,58.664,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,48.888,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,5207.4,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,3.6,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,810,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,20.272,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,3.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,855,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,792,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,810,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F AR1 GUIDE,2720002186,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,13.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,1281.6,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,1068,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,5207.4,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,1.816,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,16.224,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,5.2,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,1.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,17.12,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,15.864,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,16.224,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F AL.75 GUIDE,2720002187,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,23.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,1425.6,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,1188,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,5207.4,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,1.744,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,28.064,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,2.624,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,1.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,29.624,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,27.44,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,28.064,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LANCHER 6F AL1 GUIDE,2720002188,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,1425.6,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,1188,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,5.024,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,1.944,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,7.2,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,2.52,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,1.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,7.6,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,7.04,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,7.2,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F EBU5.0 GUIDE,2720002189,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,3.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,1425.6,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,1188,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,2538,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,20.448,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,3.64,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,2.808,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,20.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,3.84,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,3.552,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,3.64,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
VICTORY WIRE .0.18X25GX300CM,2720002190,CDM,272,RC,C1769,HCPCS,Outpatient,,,437.50,284.38,,437.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,332.5,76,,2.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,315,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,328.13,75,,1425.6,Percent of Total Billed charges,75% of Total Billed Charges,437.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,262.5,60,,1188,Percent of Total Billed Charges,60% of Total Billed Charges,393.75,90,,2538,Percent of Total Billed Charges,90% of Total Billed Charges,196.88,45,,81.904,Percent of Total Billed Charges,45% of Total Billed Charges,393.75,90,,3.496,Percent of Total Billed Charges,90% of Total billed Charges,437.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.38,65,,29.536,Percent of total Billed Charges,65% of Total Billed Charges,192.94,44.1,,80.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,415.63,95,,3.688,Percent of Total Billed Charges,95% of Total Billed Charges,437.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385,88,,3.416,Percent of Total Billed Charges,88% of Total Billed Charges,393.75,90,,3.496,Percent of Total Billed charges,90% of Total Billed Charges,192.94,437.5,
RUNTHROUGH 0.014 X 3000CM WIRE,2720002191,CDM,272,RC,C1769,HCPCS,Outpatient,,,250.00,162.50,,250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,190,76,,3.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,180,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,75,,1857.6,Percent of Total Billed charges,75% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,150,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,225,90,,3222,Percent of Total Billed Charges,90% of Total Billed Charges,112.5,45,,81.904,Percent of Total Billed Charges,45% of Total Billed Charges,225,90,,3.888,Percent of Total Billed Charges,90% of Total billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.5,65,,118.304,Percent of total Billed Charges,65% of Total Billed Charges,110.25,44.1,,80.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,237.5,95,,4.104,Percent of Total Billed Charges,95% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220,88,,3.8,Percent of Total Billed Charges,88% of Total Billed Charges,225,90,,3.888,Percent of Total Billed charges,90% of Total Billed Charges,110.25,250,
RUNTHROUGH 0.014 X 180CM WIRE,2720002192,CDM,272,RC,C1769,HCPCS,Outpatient,,,250.00,162.50,,250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,190,76,,34.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,180,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,75,,1425.6,Percent of Total Billed charges,75% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,150,60,,1188,Percent of Total Billed Charges,60% of Total Billed Charges,225,90,,4041,Percent of Total Billed Charges,90% of Total Billed Charges,112.5,45,,2603.704,Percent of Total Billed Charges,45% of Total Billed Charges,225,90,,40.896,Percent of Total Billed Charges,90% of Total billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.5,65,,118.304,Percent of total Billed Charges,65% of Total Billed Charges,110.25,44.1,,2551.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,237.5,95,,43.168,Percent of Total Billed Charges,95% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220,88,,39.984,Percent of Total Billed Charges,88% of Total Billed Charges,225,90,,40.896,Percent of Total Billed charges,90% of Total Billed Charges,110.25,250,
Ligasure Retrctble L-Hook Lap,2720002193,CDM,272,RC,,,Outpatient,,,2224.80,1446.12,,2224.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1690.85,76,,138.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1601.86,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,1668.6,75,,1857.6,Percent of Total Billed charges,75% of Total Billed Charges,2224.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1601.86,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,1334.88,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,2002.32,90,,2538,Percent of Total Billed Charges,90% of Total Billed Charges,1001.16,45,,2603.704,Percent of Total Billed Charges,45% of Total Billed Charges,2002.32,90,,163.8,Percent of Total Billed Charges,90% of Total billed Charges,2224.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2224.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2224.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1446.12,65,,3760.904,Percent of total Billed Charges,65% of Total Billed Charges,981.14,44.1,,2551.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,2113.56,95,,172.904,Percent of Total Billed Charges,95% of Total Billed Charges,2224.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1957.82,88,,160.16,Percent of Total Billed Charges,88% of Total Billed Charges,2002.32,90,,163.8,Percent of Total Billed charges,90% of Total Billed Charges,981.14,2224.8,
Dxterity TRA 5F Ultr 3.5 100CM,2720002194,CDM,272,RC,C1887,HCPCS,Outpatient,,,17.50,11.38,,17.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.3,76,,138.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.6,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,13.13,75,,1425.6,Percent of Total Billed charges,75% of Total Billed Charges,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.6,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,10.5,60,,1188,Percent of Total Billed Charges,60% of Total Billed Charges,15.75,90,,2682,Percent of Total Billed Charges,90% of Total Billed Charges,7.88,45,,2603.704,Percent of Total Billed Charges,45% of Total Billed Charges,15.75,90,,163.8,Percent of Total Billed Charges,90% of Total billed Charges,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.38,65,,3760.904,Percent of total Billed Charges,65% of Total Billed Charges,7.72,44.1,,2551.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.63,95,,172.904,Percent of Total Billed Charges,95% of Total Billed Charges,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.4,88,,160.16,Percent of Total Billed Charges,88% of Total Billed Charges,15.75,90,,163.8,Percent of Total Billed charges,90% of Total Billed Charges,7.72,17.5,
Dxterity 5F Diag Catheter Pack,2720002195,CDM,272,RC,C1887,HCPCS,Outpatient,,,27.50,17.88,,27.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.9,76,,4397.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.8,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,20.63,75,,1857.6,Percent of Total Billed charges,75% of Total Billed Charges,27.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.8,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,16.5,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,24.75,90,,2682,Percent of Total Billed Charges,90% of Total Billed Charges,12.38,45,,2.512,Percent of Total Billed Charges,45% of Total Billed Charges,24.75,90,,5207.4,Percent of Total Billed Charges,90% of Total billed Charges,27.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.88,65,,3760.904,Percent of total Billed Charges,65% of Total Billed Charges,12.13,44.1,,2.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.13,95,,5496.704,Percent of Total Billed Charges,95% of Total Billed Charges,27.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.2,88,,5091.68,Percent of Total Billed Charges,88% of Total Billed Charges,24.75,90,,5207.4,Percent of Total Billed charges,90% of Total Billed Charges,12.13,27.5,
Dxerity TRA 5F Ultra 4 100CM,2720002196,CDM,272,RC,C1887,HCPCS,Outpatient,,,17.50,11.38,,17.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.3,76,,4397.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.6,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,13.13,75,,1425.6,Percent of Total Billed charges,75% of Total Billed Charges,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.6,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,10.5,60,,1188,Percent of Total Billed Charges,60% of Total Billed Charges,15.75,90,,2682,Percent of Total Billed Charges,90% of Total Billed Charges,7.88,45,,1269,Percent of Total Billed Charges,45% of Total Billed Charges,15.75,90,,5207.4,Percent of Total Billed Charges,90% of Total billed Charges,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.38,65,,3.632,Percent of total Billed Charges,65% of Total Billed Charges,7.72,44.1,,1243.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.63,95,,5496.704,Percent of Total Billed Charges,95% of Total Billed Charges,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.4,88,,5091.68,Percent of Total Billed Charges,88% of Total Billed Charges,15.75,90,,5207.4,Percent of Total Billed charges,90% of Total Billed Charges,7.72,17.5,
Slender 5F 10CM DW 60-1050 GS,2720002197,CDM,272,RC,C1894,HCPCS,Outpatient,,,265.63,172.66,,265.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,201.88,76,,4397.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,191.25,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,199.22,75,,1425.6,Percent of Total Billed charges,75% of Total Billed Charges,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.25,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,159.38,60,,1188,Percent of Total Billed Charges,60% of Total Billed Charges,239.07,90,,2682,Percent of Total Billed Charges,90% of Total Billed Charges,119.53,45,,1269,Percent of Total Billed Charges,45% of Total Billed Charges,239.07,90,,5207.4,Percent of Total Billed Charges,90% of Total billed Charges,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.66,65,,1833,Percent of total Billed Charges,65% of Total Billed Charges,117.14,44.1,,1243.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,252.35,95,,5496.704,Percent of Total Billed Charges,95% of Total Billed Charges,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.75,88,,5091.68,Percent of Total Billed Charges,88% of Total Billed Charges,239.07,90,,5207.4,Percent of Total Billed charges,90% of Total Billed Charges,117.14,265.63,
Slender 6F 10CM DW 60-1060 GS,2720002198,CDM,272,RC,C1894,HCPCS,Outpatient,,,265.63,172.66,,265.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,201.88,76,,4.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,191.25,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,199.22,75,,1857.6,Percent of Total Billed charges,75% of Total Billed Charges,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.25,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,159.38,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,239.07,90,,3591,Percent of Total Billed Charges,90% of Total Billed Charges,119.53,45,,1611,Percent of Total Billed Charges,45% of Total Billed Charges,239.07,90,,5.024,Percent of Total Billed Charges,90% of Total billed Charges,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.66,65,,1833,Percent of total Billed Charges,65% of Total Billed Charges,117.14,44.1,,1578.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,252.35,95,,5.304,Percent of Total Billed Charges,95% of Total Billed Charges,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.75,88,,4.912,Percent of Total Billed Charges,88% of Total Billed Charges,239.07,90,,5.024,Percent of Total Billed charges,90% of Total Billed Charges,117.14,265.63,
Erase BSI Dressing Trays,2720002199,CDM,272,RC,,,Outpatient,,,63.45,41.24,,63.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,48.22,76,,2143.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.68,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,47.59,75,,1857.6,Percent of Total Billed charges,75% of Total Billed Charges,63.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.68,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,38.07,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,57.11,90,,3591,Percent of Total Billed Charges,90% of Total Billed Charges,28.55,45,,2020.504,Percent of Total Billed Charges,45% of Total Billed Charges,57.11,90,,2538,Percent of Total Billed Charges,90% of Total billed Charges,63.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.24,65,,2327,Percent of total Billed Charges,65% of Total Billed Charges,27.98,44.1,,1980.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,60.28,95,,2679,Percent of Total Billed Charges,95% of Total Billed Charges,63.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.84,88,,2481.6,Percent of Total Billed Charges,88% of Total Billed Charges,57.11,90,,2538,Percent of Total Billed charges,90% of Total Billed Charges,27.98,63.45,
"Non-Rebreathers, Infant",2720002200,CDM,272,RC,,,Outpatient,,,3.03,1.97,,3.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.3,76,,2143.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.18,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.27,75,,1857.6,Percent of Total Billed charges,75% of Total Billed Charges,3.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.18,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,1.82,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,2.73,90,,43.56,Percent of Total Billed Charges,90% of Total Billed Charges,1.36,45,,1269,Percent of Total Billed Charges,45% of Total Billed Charges,2.73,90,,2538,Percent of Total Billed Charges,90% of Total billed Charges,3.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.97,65,,2918.504,Percent of total Billed Charges,65% of Total Billed Charges,1.34,44.1,,1243.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.88,95,,2679,Percent of Total Billed Charges,95% of Total Billed Charges,3.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.67,88,,2481.6,Percent of Total Billed Charges,88% of Total Billed Charges,2.73,90,,2538,Percent of Total Billed charges,90% of Total Billed Charges,1.34,3.03,
TR Band Large Length,2720002201,CDM,272,RC,,,Outpatient,,,97.50,63.38,,97.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,74.1,76,,2720.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,70.2,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,73.13,75,,1857.6,Percent of Total Billed charges,75% of Total Billed Charges,97.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.2,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,58.5,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,87.75,90,,765,Percent of Total Billed Charges,90% of Total Billed Charges,43.88,45,,1341,Percent of Total Billed Charges,45% of Total Billed Charges,87.75,90,,3222,Percent of Total Billed Charges,90% of Total billed Charges,97.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.38,65,,1833,Percent of total Billed Charges,65% of Total Billed Charges,43,44.1,,1314.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,92.63,95,,3401,Percent of Total Billed Charges,95% of Total Billed Charges,97.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.8,88,,3150.4,Percent of Total Billed Charges,88% of Total Billed Charges,87.75,90,,3222,Percent of Total Billed charges,90% of Total Billed Charges,43,97.5,
Advincula Delineator 3.0CM,2720002202,CDM,272,RC,,,Outpatient,,,539.10,350.42,,539.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,409.72,76,,3412.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,388.15,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,404.33,75,,1857.6,Percent of Total Billed charges,75% of Total Billed Charges,539.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,388.15,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,323.46,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,485.19,90,,765,Percent of Total Billed Charges,90% of Total Billed Charges,242.6,45,,1341,Percent of Total Billed Charges,45% of Total Billed Charges,485.19,90,,4041,Percent of Total Billed Charges,90% of Total billed Charges,539.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,539.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,539.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.42,65,,1937,Percent of total Billed Charges,65% of Total Billed Charges,237.74,44.1,,1314.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,512.15,95,,4265.504,Percent of Total Billed Charges,95% of Total Billed Charges,539.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.41,88,,3951.2,Percent of Total Billed Charges,88% of Total Billed Charges,485.19,90,,4041,Percent of Total Billed charges,90% of Total Billed Charges,237.74,539.1,
T PIECE RESUSCITATOR NEONATAL,2720002203,CDM,272,RC,,,Outpatient,,,40.83,26.54,,40.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31.03,76,,2143.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.4,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,30.62,75,,1857.6,Percent of Total Billed charges,75% of Total Billed Charges,40.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.4,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,24.5,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,36.75,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,18.37,45,,1341,Percent of Total Billed Charges,45% of Total Billed Charges,36.75,90,,2538,Percent of Total Billed Charges,90% of Total billed Charges,40.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.54,65,,1937,Percent of total Billed Charges,65% of Total Billed Charges,18.01,44.1,,1314.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.79,95,,2679,Percent of Total Billed Charges,95% of Total Billed Charges,40.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.93,88,,2481.6,Percent of Total Billed Charges,88% of Total Billed Charges,36.75,90,,2538,Percent of Total Billed charges,90% of Total Billed Charges,18.01,40.83,
SC EUPHORA RX 3MM X 25MM,2720002204,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,2264.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,1857.6,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,1341,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,2682,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,1937,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,1314.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,2831,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,2622.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,2682,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
Guidewire/copilot kit-Abbott,2720002205,CDM,272,RC,,,Outpatient,,,87.50,56.88,,87.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.5,76,,2264.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,65.63,75,,1857.6,Percent of Total Billed charges,75% of Total Billed Charges,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,52.5,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,78.75,90,,1710,Percent of Total Billed Charges,90% of Total Billed Charges,39.38,45,,1795.504,Percent of Total Billed Charges,45% of Total Billed Charges,78.75,90,,2682,Percent of Total Billed Charges,90% of Total billed Charges,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.88,65,,1937,Percent of total Billed Charges,65% of Total Billed Charges,38.59,44.1,,1759.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.13,95,,2831,Percent of Total Billed Charges,95% of Total Billed Charges,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77,88,,2622.4,Percent of Total Billed Charges,88% of Total Billed Charges,78.75,90,,2682,Percent of Total Billed charges,90% of Total Billed Charges,38.59,87.5,
Copilot (Bleed control valve),2720002206,CDM,272,RC,,,Outpatient,,,50.00,32.50,,50,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38,76,,2264.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,37.5,75,,1857.6,Percent of Total Billed charges,75% of Total Billed Charges,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,30,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,45,90,,6111,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,45,,1795.504,Percent of Total Billed Charges,45% of Total Billed Charges,45,90,,2682,Percent of Total Billed Charges,90% of Total billed Charges,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.5,65,,2593.504,Percent of total Billed Charges,65% of Total Billed Charges,22.05,44.1,,1759.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,47.5,95,,2831,Percent of Total Billed Charges,95% of Total Billed Charges,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44,88,,2622.4,Percent of Total Billed Charges,88% of Total Billed Charges,45,90,,2682,Percent of Total Billed charges,90% of Total Billed Charges,22.05,50,
Guidewire Introducer (Abbott),2720002207,CDM,272,RC,,,Outpatient,,,6.25,4.06,,6.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.75,76,,2264.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.5,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,4.69,75,,1857.6,Percent of Total Billed charges,75% of Total Billed Charges,6.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.5,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,3.75,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,5.63,90,,6111,Percent of Total Billed Charges,90% of Total Billed Charges,2.81,45,,21.784,Percent of Total Billed Charges,45% of Total Billed Charges,5.63,90,,2682,Percent of Total Billed Charges,90% of Total billed Charges,6.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.06,65,,2593.504,Percent of total Billed Charges,65% of Total Billed Charges,2.76,44.1,,21.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.94,95,,2831,Percent of Total Billed Charges,95% of Total Billed Charges,6.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.5,88,,2622.4,Percent of Total Billed Charges,88% of Total Billed Charges,5.63,90,,2682,Percent of Total Billed charges,90% of Total Billed Charges,2.76,6.25,
20/30 Priority Pack w/Copilot,2720002208,CDM,272,RC,,,Outpatient,,,100.00,65.00,,100,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,76,76,,3032.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,72,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,75,75,,1857.6,Percent of Total Billed charges,75% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,60,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,90,90,,6111,Percent of Total Billed Charges,90% of Total Billed Charges,45,45,,382.504,Percent of Total Billed Charges,45% of Total Billed Charges,90,90,,3591,Percent of Total Billed Charges,90% of Total billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,65,,31.464,Percent of total Billed Charges,65% of Total Billed Charges,44.1,44.1,,374.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,95,95,,3790.504,Percent of Total Billed Charges,95% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88,88,,3511.2,Percent of Total Billed Charges,88% of Total Billed Charges,90,90,,3591,Percent of Total Billed charges,90% of Total Billed Charges,44.1,100,
Flex Cysto Grasping Forceps,2720002209,CDM,272,RC,,,Outpatient,,,162.45,105.59,,162.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,123.46,76,,3032.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,116.96,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,121.84,75,,1281.6,Percent of Total Billed charges,75% of Total Billed Charges,162.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.96,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,97.47,60,,1068,Percent of Total Billed Charges,60% of Total Billed Charges,146.21,90,,6111,Percent of Total Billed Charges,90% of Total Billed Charges,73.1,45,,382.504,Percent of Total Billed Charges,45% of Total Billed Charges,146.21,90,,3591,Percent of Total Billed Charges,90% of Total billed Charges,162.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.59,65,,552.504,Percent of total Billed Charges,65% of Total Billed Charges,71.64,44.1,,374.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,154.33,95,,3790.504,Percent of Total Billed Charges,95% of Total Billed Charges,162.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.96,88,,3511.2,Percent of Total Billed Charges,88% of Total Billed Charges,146.21,90,,3591,Percent of Total Billed charges,90% of Total Billed Charges,71.64,162.45,
Provu Disp Hndpce & Grndg Pad,2720002210,CDM,272,RC,,,Outpatient,,,8250.00,5362.50,,8250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6270,76,,36.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5940,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,6187.5,75,,1281.6,Percent of Total Billed charges,75% of Total Billed Charges,8250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5940,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,4950,60,,1068,Percent of Total Billed Charges,60% of Total Billed Charges,7425,90,,6111,Percent of Total Billed Charges,90% of Total Billed Charges,3712.5,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,7425,90,,43.56,Percent of Total Billed Charges,90% of Total billed Charges,8250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5362.5,65,,552.504,Percent of total Billed Charges,65% of Total Billed Charges,3638.25,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,7837.5,95,,45.984,Percent of Total Billed Charges,95% of Total Billed Charges,8250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7260,88,,42.592,Percent of Total Billed Charges,88% of Total Billed Charges,7425,90,,43.56,Percent of Total Billed charges,90% of Total Billed Charges,3638.25,8250,
Myosure Single Use Seal Set,2720002211,CDM,272,RC,,,Outpatient,,,20.63,13.41,,20.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.68,76,,646,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.85,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,15.47,75,,1281.6,Percent of Total Billed charges,75% of Total Billed Charges,20.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.85,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,12.38,60,,1068,Percent of Total Billed Charges,60% of Total Billed Charges,18.57,90,,4446,Percent of Total Billed Charges,90% of Total Billed Charges,9.28,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,18.57,90,,765,Percent of Total Billed Charges,90% of Total billed Charges,20.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.41,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,9.1,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.6,95,,807.504,Percent of Total Billed Charges,95% of Total Billed Charges,20.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.15,88,,748,Percent of Total Billed Charges,88% of Total Billed Charges,18.57,90,,765,Percent of Total Billed charges,90% of Total Billed Charges,9.1,20.63,
Cath Foley 24FR 5CC 2WY,2720002212,CDM,272,RC,,,Outpatient,,,4.13,2.68,,4.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.14,76,,646,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.97,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,3.1,75,,1281.6,Percent of Total Billed charges,75% of Total Billed Charges,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.97,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.48,60,,1068,Percent of Total Billed Charges,60% of Total Billed Charges,3.72,90,,6111,Percent of Total Billed Charges,90% of Total Billed Charges,1.86,45,,855,Percent of Total Billed Charges,45% of Total Billed Charges,3.72,90,,765,Percent of Total Billed Charges,90% of Total billed Charges,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.68,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1.82,44.1,,837.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.92,95,,807.504,Percent of Total Billed Charges,95% of Total Billed Charges,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.63,88,,748,Percent of Total Billed Charges,88% of Total Billed Charges,3.72,90,,765,Percent of Total Billed charges,90% of Total Billed Charges,1.82,4.13,
Cath Foley 26FR 5CC 2WY,2720002213,CDM,272,RC,,,Outpatient,,,7.30,4.75,,7.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.55,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.26,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,5.48,75,,1281.6,Percent of Total Billed charges,75% of Total Billed Charges,7.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.26,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,4.38,60,,1068,Percent of Total Billed Charges,60% of Total Billed Charges,6.57,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,45,,3055.504,Percent of Total Billed Charges,45% of Total Billed Charges,6.57,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,7.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.75,65,,1235,Percent of total Billed Charges,65% of Total Billed Charges,3.22,44.1,,2994.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.94,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,7.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.42,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,6.57,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,3.22,7.3,
Glidescope Spectrm Lopro S2,2720002214,CDM,272,RC,,,Outpatient,,,127.40,82.81,,127.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,96.82,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.73,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,95.55,75,,1281.6,Percent of Total Billed charges,75% of Total Billed Charges,127.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,76.44,60,,1068,Percent of Total Billed Charges,60% of Total Billed Charges,114.66,90,,234.72,Percent of Total Billed Charges,90% of Total Billed Charges,57.33,45,,3055.504,Percent of Total Billed Charges,45% of Total Billed Charges,114.66,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,127.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.81,65,,4413.504,Percent of total Billed Charges,65% of Total Billed Charges,56.18,44.1,,2994.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,121.03,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,127.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.11,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,114.66,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,56.18,127.4,
Glidescope Spectrm Lopro S3,2720002215,CDM,272,RC,,,Outpatient,,,95.00,61.75,,95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.2,76,,1444,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,68.4,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,71.25,75,,1425.6,Percent of Total Billed charges,75% of Total Billed Charges,95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.4,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,57,60,,1188,Percent of Total Billed Charges,60% of Total Billed Charges,85.5,90,,191.256,Percent of Total Billed Charges,90% of Total Billed Charges,42.75,45,,3055.504,Percent of Total Billed Charges,45% of Total Billed Charges,85.5,90,,1710,Percent of Total Billed Charges,90% of Total billed Charges,95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.75,65,,4413.504,Percent of total Billed Charges,65% of Total Billed Charges,41.9,44.1,,2994.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,90.25,95,,1805,Percent of Total Billed Charges,95% of Total Billed Charges,95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.6,88,,1672,Percent of Total Billed Charges,88% of Total Billed Charges,85.5,90,,1710,Percent of Total Billed charges,90% of Total Billed Charges,41.9,95,
"Glove, Sensicare Sz 8.5",2720002216,CDM,272,RC,,,Outpatient,,,9.00,5.85,,9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.84,76,,5160.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.48,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,6.75,75,,1425.6,Percent of Total Billed charges,75% of Total Billed Charges,9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.48,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,5.4,60,,1188,Percent of Total Billed Charges,60% of Total Billed Charges,8.1,90,,45.072,Percent of Total Billed Charges,90% of Total Billed Charges,4.05,45,,3055.504,Percent of Total Billed Charges,45% of Total Billed Charges,8.1,90,,6111,Percent of Total Billed Charges,90% of Total billed Charges,9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.85,65,,4413.504,Percent of total Billed Charges,65% of Total Billed Charges,3.97,44.1,,2994.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.55,95,,6450.504,Percent of Total Billed Charges,95% of Total Billed Charges,9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.92,88,,5975.2,Percent of Total Billed Charges,88% of Total Billed Charges,8.1,90,,6111,Percent of Total Billed charges,90% of Total Billed Charges,3.97,9,
Hi-Lo 5.0 Trach Tube Murph,2720002217,CDM,272,RC,,,Outpatient,,,3.75,2.44,,3.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.85,76,,5160.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.7,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.81,75,,1857.6,Percent of Total Billed charges,75% of Total Billed Charges,3.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.7,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,2.25,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,3.38,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,1.69,45,,3055.504,Percent of Total Billed Charges,45% of Total Billed Charges,3.38,90,,6111,Percent of Total Billed Charges,90% of Total billed Charges,3.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.44,65,,4413.504,Percent of total Billed Charges,65% of Total Billed Charges,1.65,44.1,,2994.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.56,95,,6450.504,Percent of Total Billed Charges,95% of Total Billed Charges,3.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.3,88,,5975.2,Percent of Total Billed Charges,88% of Total Billed Charges,3.38,90,,6111,Percent of Total Billed charges,90% of Total Billed Charges,1.65,3.75,
Nasal Rae Cffd Tube 3.5,2720002218,CDM,272,RC,,,Outpatient,,,18.25,11.86,,18.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.87,76,,5160.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.14,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,13.69,75,,1857.6,Percent of Total Billed charges,75% of Total Billed Charges,18.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.14,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,10.95,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,16.43,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,8.21,45,,2223,Percent of Total Billed Charges,45% of Total Billed Charges,16.43,90,,6111,Percent of Total Billed Charges,90% of Total billed Charges,18.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.86,65,,4413.504,Percent of total Billed Charges,65% of Total Billed Charges,8.05,44.1,,2178.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.34,95,,6450.504,Percent of Total Billed Charges,95% of Total Billed Charges,18.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.06,88,,5975.2,Percent of Total Billed Charges,88% of Total Billed Charges,16.43,90,,6111,Percent of Total Billed charges,90% of Total Billed Charges,8.05,18.25,
"Product, bushing, GE, Eviva",2720002219,CDM,272,RC,,,Outpatient,,,187.50,121.88,,187.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,142.5,76,,5160.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,135,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,140.63,75,,1857.6,Percent of Total Billed charges,75% of Total Billed Charges,187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,112.5,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,84.38,45,,3055.504,Percent of Total Billed Charges,45% of Total Billed Charges,168.75,90,,6111,Percent of Total Billed Charges,90% of Total billed Charges,187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.88,65,,3211,Percent of total Billed Charges,65% of Total Billed Charges,82.69,44.1,,2994.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,178.13,95,,6450.504,Percent of Total Billed Charges,95% of Total Billed Charges,187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165,88,,5975.2,Percent of Total Billed Charges,88% of Total Billed Charges,168.75,90,,6111,Percent of Total Billed charges,90% of Total Billed Charges,82.69,187.5,
Needle guide 9GA Round Eviva,2720002220,CDM,272,RC,,,Outpatient,,,18.45,11.99,,18.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.02,76,,5160.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.28,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,13.84,75,,1857.6,Percent of Total Billed charges,75% of Total Billed Charges,18.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.28,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,11.07,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,16.61,90,,5.976,Percent of Total Billed Charges,90% of Total Billed Charges,8.3,45,,75.6,Percent of Total Billed Charges,45% of Total Billed Charges,16.61,90,,6111,Percent of Total Billed Charges,90% of Total billed Charges,18.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.99,65,,4413.504,Percent of total Billed Charges,65% of Total Billed Charges,8.14,44.1,,74.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.53,95,,6450.504,Percent of Total Billed Charges,95% of Total Billed Charges,18.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.24,88,,5975.2,Percent of Total Billed Charges,88% of Total Billed Charges,16.61,90,,6111,Percent of Total Billed charges,90% of Total Billed Charges,8.14,18.45,
Tumark Professional Q Eviva,2720002221,CDM,272,RC,,,Outpatient,,,137.50,89.38,,137.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,104.5,76,,3754.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,99,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,103.13,75,,1857.6,Percent of Total Billed charges,75% of Total Billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,82.5,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,123.75,90,,191.256,Percent of Total Billed Charges,90% of Total Billed Charges,61.88,45,,117.36,Percent of Total Billed Charges,45% of Total Billed Charges,123.75,90,,4446,Percent of Total Billed Charges,90% of Total billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.38,65,,109.2,Percent of total Billed Charges,65% of Total Billed Charges,60.64,44.1,,115.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,130.63,95,,4693,Percent of Total Billed Charges,95% of Total Billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121,88,,4347.2,Percent of Total Billed Charges,88% of Total Billed Charges,123.75,90,,4446,Percent of Total Billed charges,90% of Total Billed Charges,60.64,137.5,
Tumark vision for Eviva STD,2720002222,CDM,272,RC,,,Outpatient,,,200.00,130.00,,200,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152,76,,5160.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144,72,,2577.6,Percent of Total Billed Charges,72% of Total Billed Charges,150,75,,2577.6,Percent of Total Billed charges,75% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144,72,,2577.6,Percent of Total Billed Charges,72% of Total Billed Charges,120,60,,2148,Percent of Total Billed Charges,60% of Total Billed Charges,180,90,,191.256,Percent of Total Billed Charges,90% of Total Billed Charges,90,45,,95.624,Percent of Total Billed Charges,45% of Total Billed Charges,180,90,,6111,Percent of Total Billed Charges,90% of Total billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130,65,,169.52,Percent of total Billed Charges,65% of Total Billed Charges,88.2,44.1,,93.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,190,95,,6450.504,Percent of Total Billed Charges,95% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,88,,5975.2,Percent of Total Billed Charges,88% of Total Billed Charges,180,90,,6111,Percent of Total Billed charges,90% of Total Billed Charges,88.2,200,
Eviva 9GA 13CM 20MM,2720002223,CDM,272,RC,,,Outpatient,,,484.88,315.17,,484.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,368.51,76,,127.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,349.11,72,,2577.6,Percent of Total Billed Charges,72% of Total Billed Charges,363.66,75,,2577.6,Percent of Total Billed charges,75% of Total Billed Charges,484.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.11,72,,2577.6,Percent of Total Billed Charges,72% of Total Billed Charges,290.93,60,,2148,Percent of Total Billed Charges,60% of Total Billed Charges,436.39,90,,191.256,Percent of Total Billed Charges,90% of Total Billed Charges,218.2,45,,22.536,Percent of Total Billed Charges,45% of Total Billed Charges,436.39,90,,151.2,Percent of Total Billed Charges,90% of Total billed Charges,484.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.17,65,,138.128,Percent of total Billed Charges,65% of Total Billed Charges,213.83,44.1,,22.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,460.64,95,,159.6,Percent of Total Billed Charges,95% of Total Billed Charges,484.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.69,88,,147.84,Percent of Total Billed Charges,88% of Total Billed Charges,436.39,90,,151.2,Percent of Total Billed charges,90% of Total Billed Charges,213.83,484.88,
Eviva 9GA 13CM 12MM Trocar,2720002224,CDM,272,RC,,,Outpatient,,,484.88,315.17,,484.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,368.51,76,,198.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,349.11,72,,2577.6,Percent of Total Billed Charges,72% of Total Billed Charges,363.66,75,,2577.6,Percent of Total Billed charges,75% of Total Billed Charges,484.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.11,72,,2577.6,Percent of Total Billed Charges,72% of Total Billed Charges,290.93,60,,2148,Percent of Total Billed Charges,60% of Total Billed Charges,436.39,90,,10.12,Percent of Total Billed Charges,90% of Total Billed Charges,218.2,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,436.39,90,,234.72,Percent of Total Billed Charges,90% of Total billed Charges,484.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.17,65,,32.552,Percent of total Billed Charges,65% of Total Billed Charges,213.83,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,460.64,95,,247.76,Percent of Total Billed Charges,95% of Total Billed Charges,484.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.69,88,,229.504,Percent of Total Billed Charges,88% of Total Billed Charges,436.39,90,,234.72,Percent of Total Billed charges,90% of Total Billed Charges,213.83,484.88,
Hyperinflation Bag w Manometer,2720002225,CDM,272,RC,,,Outpatient,,,17.33,11.26,,17.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.17,76,,161.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.48,72,,2577.6,Percent of Total Billed Charges,72% of Total Billed Charges,13,75,,2577.6,Percent of Total Billed charges,75% of Total Billed Charges,17.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.48,72,,2577.6,Percent of Total Billed Charges,72% of Total Billed Charges,10.4,60,,2148,Percent of Total Billed Charges,60% of Total Billed Charges,15.6,90,,103.936,Percent of Total Billed Charges,90% of Total Billed Charges,7.8,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,15.6,90,,191.256,Percent of Total Billed Charges,90% of Total billed Charges,17.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.26,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,7.64,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.46,95,,201.88,Percent of Total Billed Charges,95% of Total Billed Charges,17.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.25,88,,187,Percent of Total Billed Charges,88% of Total Billed Charges,15.6,90,,191.256,Percent of Total Billed charges,90% of Total Billed Charges,7.64,17.33,
Rem Olivamine Calaz Skin Prot,2720002226,CDM,272,RC,,,Outpatient,,,6.95,4.52,,6.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.28,76,,38.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5,72,,2577.6,Percent of Total Billed Charges,72% of Total Billed Charges,5.21,75,,2577.6,Percent of Total Billed charges,75% of Total Billed Charges,6.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,72,,2577.6,Percent of Total Billed Charges,72% of Total Billed Charges,4.17,60,,2148,Percent of Total Billed Charges,60% of Total Billed Charges,6.26,90,,103.936,Percent of Total Billed Charges,90% of Total Billed Charges,3.13,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,6.26,90,,45.072,Percent of Total Billed Charges,90% of Total billed Charges,6.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.52,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,3.06,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.6,95,,47.576,Percent of Total Billed Charges,95% of Total Billed Charges,6.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.12,88,,44.072,Percent of Total Billed Charges,88% of Total Billed Charges,6.26,90,,45.072,Percent of Total Billed charges,90% of Total Billed Charges,3.06,6.95,
Microline Disp Cobra,2720002227,CDM,272,RC,,,Outpatient,,,144.35,93.83,,144.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,109.71,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,103.93,72,,2577.6,Percent of Total Billed Charges,72% of Total Billed Charges,108.26,75,,2577.6,Percent of Total Billed charges,75% of Total Billed Charges,144.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.93,72,,2577.6,Percent of Total Billed Charges,72% of Total Billed Charges,86.61,60,,2148,Percent of Total Billed Charges,60% of Total Billed Charges,129.92,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,64.96,45,,2.992,Percent of Total Billed Charges,45% of Total Billed Charges,129.92,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,144.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.83,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,63.66,44.1,,2.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,137.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,144.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.03,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,129.92,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,63.66,144.35,
Microline Disp Grabber,2720002228,CDM,272,RC,,,Outpatient,,,144.35,93.83,,144.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,109.71,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,103.93,72,,2577.6,Percent of Total Billed Charges,72% of Total Billed Charges,108.26,75,,2577.6,Percent of Total Billed charges,75% of Total Billed Charges,144.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.93,72,,2577.6,Percent of Total Billed Charges,72% of Total Billed Charges,86.61,60,,2148,Percent of Total Billed Charges,60% of Total Billed Charges,129.92,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,64.96,45,,95.624,Percent of Total Billed Charges,45% of Total Billed Charges,129.92,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,144.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.83,65,,4.32,Percent of total Billed Charges,65% of Total Billed Charges,63.66,44.1,,93.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,137.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,144.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.03,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,129.92,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,63.66,144.35,
Abstack15 5MM Lap Fixtn device,2720002229,CDM,272,RC,,,Outpatient,,,1002.40,651.56,,1002.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,761.82,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,721.73,72,,2577.6,Percent of Total Billed Charges,72% of Total Billed Charges,751.8,75,,2577.6,Percent of Total Billed charges,75% of Total Billed Charges,1002.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,721.73,72,,2577.6,Percent of Total Billed Charges,72% of Total Billed Charges,601.44,60,,2148,Percent of Total Billed Charges,60% of Total Billed Charges,902.16,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,451.08,45,,95.624,Percent of Total Billed Charges,45% of Total Billed Charges,902.16,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,1002.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1002.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1002.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,651.56,65,,138.128,Percent of total Billed Charges,65% of Total Billed Charges,442.06,44.1,,93.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,952.28,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,1002.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,882.11,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,902.16,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,442.06,1002.4,
Balloon Trocar W Dissctn Blln,2720002230,CDM,272,RC,,,Outpatient,,,1667.03,1083.57,,1667.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1266.94,76,,5.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1200.26,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,1250.27,75,,1485,Percent of Total Billed charges,75% of Total Billed Charges,1667.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1200.26,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,1000.22,60,,1188,Percent of Total Billed Charges,60% of Total Billed Charges,1500.33,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,750.16,45,,95.624,Percent of Total Billed Charges,45% of Total Billed Charges,1500.33,90,,5.976,Percent of Total Billed Charges,90% of Total billed Charges,1667.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1667.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1667.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1083.57,65,,138.128,Percent of total Billed Charges,65% of Total Billed Charges,735.16,44.1,,93.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1583.68,95,,6.312,Percent of Total Billed Charges,95% of Total Billed Charges,1667.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1466.99,88,,5.84,Percent of Total Billed Charges,88% of Total Billed Charges,1500.33,90,,5.976,Percent of Total Billed charges,90% of Total Billed Charges,735.16,1667.03,
Statlock IABP (each),2720002231,CDM,272,RC,,,Outpatient,,,43.50,28.28,,43.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33.06,76,,161.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,31.32,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,32.63,75,,1485,Percent of Total Billed charges,75% of Total Billed Charges,43.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.32,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,26.1,60,,1188,Percent of Total Billed Charges,60% of Total Billed Charges,39.15,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,19.58,45,,5.056,Percent of Total Billed Charges,45% of Total Billed Charges,39.15,90,,191.256,Percent of Total Billed Charges,90% of Total billed Charges,43.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.28,65,,138.128,Percent of total Billed Charges,65% of Total Billed Charges,19.18,44.1,,4.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.33,95,,201.88,Percent of Total Billed Charges,95% of Total Billed Charges,43.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.28,88,,187,Percent of Total Billed Charges,88% of Total Billed Charges,39.15,90,,191.256,Percent of Total Billed charges,90% of Total Billed Charges,19.18,43.5,
SEN PLUS 8F 50CC IABP,2720002232,CDM,272,RC,,,Outpatient,,,2328.00,1513.20,,2328,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1769.28,76,,161.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1676.16,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,1746,75,,1935,Percent of Total Billed charges,75% of Total Billed Charges,2328,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1676.16,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,1396.8,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,2095.2,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,1047.6,45,,51.968,Percent of Total Billed Charges,45% of Total Billed Charges,2095.2,90,,191.256,Percent of Total Billed Charges,90% of Total billed Charges,2328,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2328,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2328,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1513.2,65,,7.304,Percent of total Billed Charges,65% of Total Billed Charges,1026.65,44.1,,50.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,2211.6,95,,201.88,Percent of Total Billed Charges,95% of Total Billed Charges,2328,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2048.64,88,,187,Percent of Total Billed Charges,88% of Total Billed Charges,2095.2,90,,191.256,Percent of Total Billed charges,90% of Total Billed Charges,1026.65,2328,
SEN PLUS 7.5F 40CC FO 1ABP,2720002233,CDM,272,RC,,,Outpatient,,,2328.00,1513.20,,2328,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1769.28,76,,161.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1676.16,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,1746,75,,1935,Percent of Total Billed charges,75% of Total Billed Charges,2328,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1676.16,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,1396.8,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,2095.2,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,1047.6,45,,51.968,Percent of Total Billed Charges,45% of Total Billed Charges,2095.2,90,,191.256,Percent of Total Billed Charges,90% of Total billed Charges,2328,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2328,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2328,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1513.2,65,,75.064,Percent of total Billed Charges,65% of Total Billed Charges,1026.65,44.1,,50.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,2211.6,95,,201.88,Percent of Total Billed Charges,95% of Total Billed Charges,2328,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2048.64,88,,187,Percent of Total Billed Charges,88% of Total Billed Charges,2095.2,90,,191.256,Percent of Total Billed charges,90% of Total Billed Charges,1026.65,2328,
"10"" MALE ROTATE LUER LOCK-FM",2720002234,CDM,272,RC,,,Outpatient,,,7.30,4.75,,7.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.55,76,,8.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.26,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,5.48,75,,1935,Percent of Total Billed charges,75% of Total Billed Charges,7.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.26,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,4.38,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,6.57,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,45,,75.6,Percent of Total Billed Charges,45% of Total Billed Charges,6.57,90,,10.12,Percent of Total Billed Charges,90% of Total billed Charges,7.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.75,65,,75.064,Percent of total Billed Charges,65% of Total Billed Charges,3.22,44.1,,74.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.94,95,,10.68,Percent of Total Billed Charges,95% of Total Billed Charges,7.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.42,88,,9.888,Percent of Total Billed Charges,88% of Total Billed Charges,6.57,90,,10.12,Percent of Total Billed charges,90% of Total Billed Charges,3.22,7.3,
18G X 9CM W/BP NEEDLE,2720002235,CDM,272,RC,,,Outpatient,,,8.38,5.45,,8.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.37,76,,87.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.03,72,,993.6,Percent of Total Billed Charges,72% of Total Billed Charges,6.29,75,,1035,Percent of Total Billed charges,75% of Total Billed Charges,8.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.03,72,,993.6,Percent of Total Billed Charges,72% of Total Billed Charges,5.03,60,,828,Percent of Total Billed Charges,60% of Total Billed Charges,7.54,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,3.77,45,,75.6,Percent of Total Billed Charges,45% of Total Billed Charges,7.54,90,,103.936,Percent of Total Billed Charges,90% of Total billed Charges,8.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.45,65,,109.2,Percent of total Billed Charges,65% of Total Billed Charges,3.7,44.1,,74.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.96,95,,109.704,Percent of Total Billed Charges,95% of Total Billed Charges,8.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.37,88,,101.624,Percent of Total Billed Charges,88% of Total Billed Charges,7.54,90,,103.936,Percent of Total Billed charges,90% of Total Billed Charges,3.7,8.38,
PINNACLE R/O 4F 25CM SHEATH,2720002236,CDM,272,RC,C1894,HCPCS,Outpatient,,,73.00,47.45,,73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.48,76,,87.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.56,72,,993.6,Percent of Total Billed Charges,72% of Total Billed Charges,54.75,75,,1035,Percent of Total Billed charges,75% of Total Billed Charges,73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.56,72,,993.6,Percent of Total Billed Charges,72% of Total Billed Charges,43.8,60,,828,Percent of Total Billed Charges,60% of Total Billed Charges,65.7,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,32.85,45,,75.6,Percent of Total Billed Charges,45% of Total Billed Charges,65.7,90,,103.936,Percent of Total Billed Charges,90% of Total billed Charges,73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.45,65,,109.2,Percent of total Billed Charges,65% of Total Billed Charges,32.19,44.1,,74.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,69.35,95,,109.704,Percent of Total Billed Charges,95% of Total Billed Charges,73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.24,88,,101.624,Percent of Total Billed Charges,88% of Total Billed Charges,65.7,90,,103.936,Percent of Total Billed charges,90% of Total Billed Charges,32.19,73,
PINNACLE R/O 9F 10CM SHEATH,2720002237,CDM,272,RC,C1894,HCPCS,Outpatient,,,65.50,42.58,,65.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.78,76,,127.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47.16,72,,993.6,Percent of Total Billed Charges,72% of Total Billed Charges,49.13,75,,1035,Percent of Total Billed charges,75% of Total Billed Charges,65.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.16,72,,993.6,Percent of Total Billed Charges,72% of Total Billed Charges,39.3,60,,828,Percent of Total Billed Charges,60% of Total Billed Charges,58.95,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,29.48,45,,75.6,Percent of Total Billed Charges,45% of Total Billed Charges,58.95,90,,151.2,Percent of Total Billed Charges,90% of Total billed Charges,65.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.58,65,,109.2,Percent of total Billed Charges,65% of Total Billed Charges,28.89,44.1,,74.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.23,95,,159.6,Percent of Total Billed Charges,95% of Total Billed Charges,65.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.64,88,,147.84,Percent of Total Billed Charges,88% of Total Billed Charges,58.95,90,,151.2,Percent of Total Billed charges,90% of Total Billed Charges,28.89,65.5,
PINNACLE R/O 8F 10CM SHEATH,2720002238,CDM,272,RC,C1894,HCPCS,Outpatient,,,65.50,42.58,,65.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.78,76,,127.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47.16,72,,338.4,Percent of Total Billed Charges,72% of Total Billed Charges,49.13,75,,352.504,Percent of Total Billed charges,75% of Total Billed Charges,65.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.16,72,,338.4,Percent of Total Billed Charges,72% of Total Billed Charges,39.3,60,,282,Percent of Total Billed Charges,60% of Total Billed Charges,58.95,90,,8.408,Percent of Total Billed Charges,90% of Total Billed Charges,29.48,45,,75.6,Percent of Total Billed Charges,45% of Total Billed Charges,58.95,90,,151.2,Percent of Total Billed Charges,90% of Total billed Charges,65.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.58,65,,109.2,Percent of total Billed Charges,65% of Total Billed Charges,28.89,44.1,,74.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.23,95,,159.6,Percent of Total Billed Charges,95% of Total Billed Charges,65.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.64,88,,147.84,Percent of Total Billed Charges,88% of Total Billed Charges,58.95,90,,151.2,Percent of Total Billed charges,90% of Total Billed Charges,28.89,65.5,
PINNACLE R/O 7F 6CM SHEATH,2720002239,CDM,272,RC,C1894,HCPCS,Outpatient,,,61.75,40.14,,61.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.93,76,,127.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,44.46,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,75,,1281.6,Percent of Total Billed charges,75% of Total Billed Charges,61.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.46,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,37.05,60,,1068,Percent of Total Billed Charges,60% of Total Billed Charges,55.58,90,,4.016,Percent of Total Billed Charges,90% of Total Billed Charges,27.79,45,,75.6,Percent of Total Billed Charges,45% of Total Billed Charges,55.58,90,,151.2,Percent of Total Billed Charges,90% of Total billed Charges,61.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.14,65,,109.2,Percent of total Billed Charges,65% of Total Billed Charges,27.23,44.1,,74.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,58.66,95,,159.6,Percent of Total Billed Charges,95% of Total Billed Charges,61.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.34,88,,147.84,Percent of Total Billed Charges,88% of Total Billed Charges,55.58,90,,151.2,Percent of Total Billed charges,90% of Total Billed Charges,27.23,61.75,
PINNACLE R/O 6F 6CM SHEATH,2720002240,CDM,272,RC,C1894,HCPCS,Outpatient,,,61.75,40.14,,61.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.93,76,,127.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,44.46,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,75,,1281.6,Percent of Total Billed charges,75% of Total Billed Charges,61.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.46,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,37.05,60,,1068,Percent of Total Billed Charges,60% of Total Billed Charges,55.58,90,,12.696,Percent of Total Billed Charges,90% of Total Billed Charges,27.79,45,,75.6,Percent of Total Billed Charges,45% of Total Billed Charges,55.58,90,,151.2,Percent of Total Billed Charges,90% of Total billed Charges,61.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.14,65,,109.2,Percent of total Billed Charges,65% of Total Billed Charges,27.23,44.1,,74.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,58.66,95,,159.6,Percent of Total Billed Charges,95% of Total Billed Charges,61.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.34,88,,147.84,Percent of Total Billed Charges,88% of Total Billed Charges,55.58,90,,151.2,Percent of Total Billed charges,90% of Total Billed Charges,27.23,61.75,
PINNACLE R/O 5F 6CM SHEATH,2720002241,CDM,272,RC,C1894,HCPCS,Outpatient,,,61.75,40.14,,61.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.93,76,,127.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,44.46,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,75,,1281.6,Percent of Total Billed charges,75% of Total Billed Charges,61.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.46,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,37.05,60,,1068,Percent of Total Billed Charges,60% of Total Billed Charges,55.58,90,,14.496,Percent of Total Billed Charges,90% of Total Billed Charges,27.79,45,,75.6,Percent of Total Billed Charges,45% of Total Billed Charges,55.58,90,,151.2,Percent of Total Billed Charges,90% of Total billed Charges,61.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.14,65,,109.2,Percent of total Billed Charges,65% of Total Billed Charges,27.23,44.1,,74.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,58.66,95,,159.6,Percent of Total Billed Charges,95% of Total Billed Charges,61.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.34,88,,147.84,Percent of Total Billed Charges,88% of Total Billed Charges,55.58,90,,151.2,Percent of Total Billed charges,90% of Total Billed Charges,27.23,61.75,
PINNACLE R/O 4F 10CM SHEATH,2720002242,CDM,272,RC,C1894,HCPCS,Outpatient,,,65.50,42.58,,65.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.78,76,,127.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47.16,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,49.13,75,,1281.6,Percent of Total Billed charges,75% of Total Billed Charges,65.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.16,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,39.3,60,,1068,Percent of Total Billed Charges,60% of Total Billed Charges,58.95,90,,8.104,Percent of Total Billed Charges,90% of Total Billed Charges,29.48,45,,75.6,Percent of Total Billed Charges,45% of Total Billed Charges,58.95,90,,151.2,Percent of Total Billed Charges,90% of Total billed Charges,65.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.58,65,,109.2,Percent of total Billed Charges,65% of Total Billed Charges,28.89,44.1,,74.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.23,95,,159.6,Percent of Total Billed Charges,95% of Total Billed Charges,65.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.64,88,,147.84,Percent of Total Billed Charges,88% of Total Billed Charges,58.95,90,,151.2,Percent of Total Billed charges,90% of Total Billed Charges,28.89,65.5,
PINNACLE R/O 4F 6CM SHEATH,2720002243,CDM,272,RC,C1894,HCPCS,Outpatient,,,61.75,40.14,,61.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.93,76,,127.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,44.46,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,75,,1425.6,Percent of Total Billed charges,75% of Total Billed Charges,61.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.46,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,37.05,60,,1188,Percent of Total Billed Charges,60% of Total Billed Charges,55.58,90,,8.104,Percent of Total Billed Charges,90% of Total Billed Charges,27.79,45,,75.6,Percent of Total Billed Charges,45% of Total Billed Charges,55.58,90,,151.2,Percent of Total Billed Charges,90% of Total billed Charges,61.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.14,65,,109.2,Percent of total Billed Charges,65% of Total Billed Charges,27.23,44.1,,74.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,58.66,95,,159.6,Percent of Total Billed Charges,95% of Total Billed Charges,61.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.34,88,,147.84,Percent of Total Billed Charges,88% of Total Billed Charges,55.58,90,,151.2,Percent of Total Billed charges,90% of Total Billed Charges,27.23,61.75,
Arthrx prof Drill Micro FT,2720002244,CDM,272,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,127.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,1281.6,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,1068,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,91.8,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,75.6,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,151.2,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,109.2,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,74.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,159.6,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,147.84,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,151.2,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
Airlife Smooth Bore Circuit,2720002245,CDM,272,RC,,,Outpatient,,,15.53,10.09,,15.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.8,76,,127.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.18,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,11.65,75,,1425.6,Percent of Total Billed charges,75% of Total Billed Charges,15.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.18,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,9.32,60,,1188,Percent of Total Billed Charges,60% of Total Billed Charges,13.98,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,6.99,45,,4.208,Percent of Total Billed Charges,45% of Total Billed Charges,13.98,90,,151.2,Percent of Total Billed Charges,90% of Total billed Charges,15.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.09,65,,109.2,Percent of total Billed Charges,65% of Total Billed Charges,6.85,44.1,,4.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.75,95,,159.6,Percent of Total Billed Charges,95% of Total Billed Charges,15.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.67,88,,147.84,Percent of Total Billed Charges,88% of Total Billed Charges,13.98,90,,151.2,Percent of Total Billed charges,90% of Total Billed Charges,6.85,15.53,
Vashe Wound Cleanser,2720002246,CDM,272,RC,,,Outpatient,,,19.05,12.38,,19.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.48,76,,127.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.72,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,14.29,75,,1425.6,Percent of Total Billed charges,75% of Total Billed Charges,19.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.72,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,11.43,60,,1188,Percent of Total Billed Charges,60% of Total Billed Charges,17.15,90,,101.256,Percent of Total Billed Charges,90% of Total Billed Charges,8.57,45,,2.008,Percent of Total Billed Charges,45% of Total Billed Charges,17.15,90,,151.2,Percent of Total Billed Charges,90% of Total billed Charges,19.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.38,65,,6.072,Percent of total Billed Charges,65% of Total Billed Charges,8.4,44.1,,1.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.1,95,,159.6,Percent of Total Billed Charges,95% of Total Billed Charges,19.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.76,88,,147.84,Percent of Total Billed Charges,88% of Total Billed Charges,17.15,90,,151.2,Percent of Total Billed charges,90% of Total Billed Charges,8.4,19.05,
Drawtex Hydroconductive Dressn,2720002247,CDM,272,RC,,,Outpatient,,,18.13,11.78,,18.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.78,76,,127.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.05,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,13.6,75,,1281.6,Percent of Total Billed charges,75% of Total Billed Charges,18.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.05,72,,1281.6,Percent of Total Billed Charges,72% of Total Billed Charges,10.88,60,,1068,Percent of Total Billed Charges,60% of Total Billed Charges,16.32,90,,13.432,Percent of Total Billed Charges,90% of Total Billed Charges,8.16,45,,6.344,Percent of Total Billed Charges,45% of Total Billed Charges,16.32,90,,151.2,Percent of Total Billed Charges,90% of Total billed Charges,18.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.78,65,,2.904,Percent of total Billed Charges,65% of Total Billed Charges,8,44.1,,6.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.22,95,,159.6,Percent of Total Billed Charges,95% of Total Billed Charges,18.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.95,88,,147.84,Percent of Total Billed Charges,88% of Total Billed Charges,16.32,90,,151.2,Percent of Total Billed charges,90% of Total Billed Charges,8,18.13,
"UrgoTul Contact Layer 4""x 5""",2720002248,CDM,272,RC,,,Outpatient,,,11.10,7.22,,11.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.44,76,,7.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.99,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,8.33,75,,1425.6,Percent of Total Billed charges,75% of Total Billed Charges,11.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.99,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,6.66,60,,1188,Percent of Total Billed Charges,60% of Total Billed Charges,9.99,90,,12.784,Percent of Total Billed Charges,90% of Total Billed Charges,5,45,,7.248,Percent of Total Billed Charges,45% of Total Billed Charges,9.99,90,,8.408,Percent of Total Billed Charges,90% of Total billed Charges,11.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.22,65,,9.168,Percent of total Billed Charges,65% of Total Billed Charges,4.9,44.1,,7.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.55,95,,8.88,Percent of Total Billed Charges,95% of Total Billed Charges,11.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.77,88,,8.224,Percent of Total Billed Charges,88% of Total Billed Charges,9.99,90,,8.408,Percent of Total Billed charges,90% of Total Billed Charges,4.9,11.1,
"UrgoTul Ag contact layer 4""x5""",2720002249,CDM,272,RC,,,Outpatient,,,19.95,12.97,,19.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.16,76,,3.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.36,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,14.96,75,,1857.6,Percent of Total Billed charges,75% of Total Billed Charges,19.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.36,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,11.97,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,17.96,90,,3420,Percent of Total Billed Charges,90% of Total Billed Charges,8.98,45,,4.048,Percent of Total Billed Charges,45% of Total Billed Charges,17.96,90,,4.016,Percent of Total Billed Charges,90% of Total billed Charges,19.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.97,65,,10.464,Percent of total Billed Charges,65% of Total Billed Charges,8.8,44.1,,3.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.95,95,,4.24,Percent of Total Billed Charges,95% of Total Billed Charges,19.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.56,88,,3.928,Percent of Total Billed Charges,88% of Total Billed Charges,17.96,90,,4.016,Percent of Total Billed charges,90% of Total Billed Charges,8.8,19.95,
UrgoK2 Lite Dual Compr Sys Reg,2720002250,CDM,272,RC,,,Outpatient,,,32.05,20.83,,32.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.36,76,,10.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.08,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,24.04,75,,1485,Percent of Total Billed charges,75% of Total Billed Charges,32.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.08,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,19.23,60,,1188,Percent of Total Billed Charges,60% of Total Billed Charges,28.85,90,,12186,Percent of Total Billed Charges,90% of Total Billed Charges,14.42,45,,4.048,Percent of Total Billed Charges,45% of Total Billed Charges,28.85,90,,12.696,Percent of Total Billed Charges,90% of Total billed Charges,32.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.83,65,,5.848,Percent of total Billed Charges,65% of Total Billed Charges,14.13,44.1,,3.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.45,95,,13.4,Percent of Total Billed Charges,95% of Total Billed Charges,32.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.2,88,,12.408,Percent of Total Billed Charges,88% of Total Billed Charges,28.85,90,,12.696,Percent of Total Billed charges,90% of Total Billed Charges,14.13,32.05,
UrgoK2 Lite Dual Compr Sys Lg,2720002251,CDM,272,RC,,,Outpatient,,,37.88,24.62,,37.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.79,76,,12.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.27,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,28.41,75,,1485,Percent of Total Billed charges,75% of Total Billed Charges,37.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.27,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,22.73,60,,1188,Percent of Total Billed Charges,60% of Total Billed Charges,34.09,90,,3411,Percent of Total Billed Charges,90% of Total Billed Charges,17.05,45,,45.904,Percent of Total Billed Charges,45% of Total Billed Charges,34.09,90,,14.496,Percent of Total Billed Charges,90% of Total billed Charges,37.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.62,65,,5.848,Percent of total Billed Charges,65% of Total Billed Charges,16.71,44.1,,44.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.99,95,,15.296,Percent of Total Billed Charges,95% of Total Billed Charges,37.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.33,88,,14.168,Percent of Total Billed Charges,88% of Total Billed Charges,34.09,90,,14.496,Percent of Total Billed charges,90% of Total Billed Charges,16.71,37.88,
Guidewire Bowl (5000ml),2720002252,CDM,272,RC,,,Outpatient,,,13.13,8.53,,13.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.98,76,,6.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.45,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,9.85,75,,1485,Percent of Total Billed charges,75% of Total Billed Charges,13.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.45,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,7.88,60,,1188,Percent of Total Billed Charges,60% of Total Billed Charges,11.82,90,,10026,Percent of Total Billed Charges,90% of Total Billed Charges,5.91,45,,45,Percent of Total Billed Charges,45% of Total Billed Charges,11.82,90,,8.104,Percent of Total Billed Charges,90% of Total billed Charges,13.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.53,65,,66.304,Percent of total Billed Charges,65% of Total Billed Charges,5.79,44.1,,44.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.47,95,,8.552,Percent of Total Billed Charges,95% of Total Billed Charges,13.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.55,88,,7.92,Percent of Total Billed Charges,88% of Total Billed Charges,11.82,90,,8.104,Percent of Total Billed charges,90% of Total Billed Charges,5.79,13.13,
Glidesheath Kit 6F 10CM,2720002253,CDM,272,RC,C1894,HCPCS,Outpatient,,,99.00,64.35,,99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.24,76,,6.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71.28,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,74.25,75,,1485,Percent of Total Billed charges,75% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.28,72,,1425.6,Percent of Total Billed Charges,72% of Total Billed Charges,59.4,60,,1188,Percent of Total Billed Charges,60% of Total Billed Charges,89.1,90,,2979,Percent of Total Billed Charges,90% of Total Billed Charges,44.55,45,,50.624,Percent of Total Billed Charges,45% of Total Billed Charges,89.1,90,,8.104,Percent of Total Billed Charges,90% of Total billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.35,65,,65,Percent of total Billed Charges,65% of Total Billed Charges,43.66,44.1,,49.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,94.05,95,,8.552,Percent of Total Billed Charges,95% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.12,88,,7.92,Percent of Total Billed Charges,88% of Total Billed Charges,89.1,90,,8.104,Percent of Total Billed charges,90% of Total Billed Charges,43.66,99,
Glidesheath Kit 5F 10CM,2720002254,CDM,272,RC,C1894,HCPCS,Outpatient,,,99.00,64.35,,99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.24,76,,77.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71.28,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,74.25,75,,1935,Percent of Total Billed charges,75% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.28,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,59.4,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,89.1,90,,2.272,Percent of Total Billed Charges,90% of Total Billed Charges,44.55,45,,6.712,Percent of Total Billed Charges,45% of Total Billed Charges,89.1,90,,91.8,Percent of Total Billed Charges,90% of Total billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.35,65,,73.128,Percent of total Billed Charges,65% of Total Billed Charges,43.66,44.1,,6.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,94.05,95,,96.904,Percent of Total Billed Charges,95% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.12,88,,89.76,Percent of Total Billed Charges,88% of Total Billed Charges,89.1,90,,91.8,Percent of Total Billed charges,90% of Total Billed Charges,43.66,99,
Pilot  50 0.14 x 300cm S Wire,2720002255,CDM,272,RC,C1769,HCPCS,Outpatient,,,212.50,138.13,,212.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.5,76,,76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,159.38,75,,1935,Percent of Total Billed charges,75% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,127.5,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,191.25,90,,216,Percent of Total Billed Charges,90% of Total Billed Charges,95.63,45,,6.392,Percent of Total Billed Charges,45% of Total Billed Charges,191.25,90,,90,Percent of Total Billed Charges,90% of Total billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.13,65,,9.696,Percent of total Billed Charges,65% of Total Billed Charges,93.71,44.1,,6.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,201.88,95,,95,Percent of Total Billed Charges,95% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187,88,,88,Percent of Total Billed Charges,88% of Total Billed Charges,191.25,90,,90,Percent of Total Billed charges,90% of Total Billed Charges,93.71,212.5,
Pilot 50 0.014 x 190cm S Wire,2720002256,CDM,272,RC,C1769,HCPCS,Outpatient,,,212.50,138.13,,212.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.5,76,,85.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,159.38,75,,1935,Percent of Total Billed charges,75% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,127.5,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,191.25,90,,216,Percent of Total Billed Charges,90% of Total Billed Charges,95.63,45,,1710,Percent of Total Billed Charges,45% of Total Billed Charges,191.25,90,,101.256,Percent of Total Billed Charges,90% of Total billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.13,65,,9.232,Percent of total Billed Charges,65% of Total Billed Charges,93.71,44.1,,1675.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,201.88,95,,106.88,Percent of Total Billed Charges,95% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187,88,,99,Percent of Total Billed Charges,88% of Total Billed Charges,191.25,90,,101.256,Percent of Total Billed charges,90% of Total Billed Charges,93.71,212.5,
Choice P T ES 0.014x300 S Wire,2720002257,CDM,272,RC,C1769,HCPCS,Outpatient,,,191.93,124.75,,191.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,145.87,76,,11.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,138.19,72,,338.4,Percent of Total Billed Charges,72% of Total Billed Charges,143.95,75,,352.504,Percent of Total Billed charges,75% of Total Billed Charges,191.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.19,72,,338.4,Percent of Total Billed Charges,72% of Total Billed Charges,115.16,60,,282,Percent of Total Billed Charges,60% of Total Billed Charges,172.74,90,,216,Percent of Total Billed Charges,90% of Total Billed Charges,86.37,45,,6093,Percent of Total Billed Charges,45% of Total Billed Charges,172.74,90,,13.432,Percent of Total Billed Charges,90% of Total billed Charges,191.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.75,65,,2470,Percent of total Billed Charges,65% of Total Billed Charges,84.64,44.1,,5971.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,182.33,95,,14.176,Percent of Total Billed Charges,95% of Total Billed Charges,191.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.9,88,,13.128,Percent of Total Billed Charges,88% of Total Billed Charges,172.74,90,,13.432,Percent of Total Billed charges,90% of Total Billed Charges,84.64,191.93,
VIP TD Swan Ganz 5L 7.5F 110cm,2720002258,CDM,272,RC,C1751,HCPCS,Outpatient,,,105.00,68.25,,105,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.8,76,,10.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75.6,72,,72,Percent of Total Billed Charges,72% of Total Billed Charges,78.75,75,,75,Percent of Total Billed charges,75% of Total Billed Charges,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.6,72,,72,Percent of Total Billed Charges,72% of Total Billed Charges,63,60,,60,Percent of Total Billed Charges,60% of Total Billed Charges,94.5,90,,216,Percent of Total Billed Charges,90% of Total Billed Charges,47.25,45,,1705.504,Percent of Total Billed Charges,45% of Total Billed Charges,94.5,90,,12.784,Percent of Total Billed Charges,90% of Total billed Charges,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.25,65,,8801,Percent of total Billed Charges,65% of Total Billed Charges,46.31,44.1,,1671.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,99.75,95,,13.488,Percent of Total Billed Charges,95% of Total Billed Charges,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.4,88,,12.496,Percent of Total Billed Charges,88% of Total Billed Charges,94.5,90,,12.784,Percent of Total Billed charges,90% of Total Billed Charges,46.31,105,
Monitor Swan Ganz 2L 7F 110cm,2720002259,CDM,272,RC,C1751,HCPCS,Outpatient,,,87.50,56.88,,87.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.5,76,,2888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,65.63,75,,1857.6,Percent of Total Billed charges,75% of Total Billed Charges,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63,72,,1857.6,Percent of Total Billed Charges,72% of Total Billed Charges,52.5,60,,1548,Percent of Total Billed Charges,60% of Total Billed Charges,78.75,90,,216,Percent of Total Billed Charges,90% of Total Billed Charges,39.38,45,,5013,Percent of Total Billed Charges,45% of Total Billed Charges,78.75,90,,3420,Percent of Total Billed Charges,90% of Total billed Charges,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.88,65,,2463.504,Percent of total Billed Charges,65% of Total Billed Charges,38.59,44.1,,4912.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.13,95,,3610,Percent of Total Billed Charges,95% of Total Billed Charges,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77,88,,3344,Percent of Total Billed Charges,88% of Total Billed Charges,78.75,90,,3420,Percent of Total Billed charges,90% of Total Billed Charges,38.59,87.5,
Powerturn 0.014 x 190Cm S Wire,2720002260,CDM,272,RC,C1769,HCPCS,Outpatient,,,212.50,138.13,,212.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.5,76,,10290.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153,72,,34.344,Percent of Total Billed Charges,72% of Total Billed Charges,159.38,75,,35.776,Percent of Total Billed charges,75% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153,72,,34.344,Percent of Total Billed Charges,72% of Total Billed Charges,127.5,60,,28.616,Percent of Total Billed Charges,60% of Total Billed Charges,191.25,90,,216,Percent of Total Billed Charges,90% of Total Billed Charges,95.63,45,,1489.504,Percent of Total Billed Charges,45% of Total Billed Charges,191.25,90,,12186,Percent of Total Billed Charges,90% of Total billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.13,65,,7241,Percent of total Billed Charges,65% of Total Billed Charges,93.71,44.1,,1459.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,201.88,95,,12863,Percent of Total Billed Charges,95% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187,88,,11915.2,Percent of Total Billed Charges,88% of Total Billed Charges,191.25,90,,12186,Percent of Total Billed charges,90% of Total Billed Charges,93.71,212.5,
Versaturn 0.014 x 190Cm S Wire,2720002261,CDM,272,RC,C1769,HCPCS,Outpatient,,,212.50,138.13,,212.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.5,76,,2880.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153,72,,163.08,Percent of Total Billed Charges,72% of Total Billed Charges,159.38,75,,169.88,Percent of Total Billed charges,75% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153,72,,163.08,Percent of Total Billed Charges,72% of Total Billed Charges,127.5,60,,135.904,Percent of Total Billed Charges,60% of Total Billed Charges,191.25,90,,450,Percent of Total Billed Charges,90% of Total Billed Charges,95.63,45,,1.136,Percent of Total Billed Charges,45% of Total Billed Charges,191.25,90,,3411,Percent of Total Billed Charges,90% of Total billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.13,65,,2151.504,Percent of total Billed Charges,65% of Total Billed Charges,93.71,44.1,,1.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,201.88,95,,3600.504,Percent of Total Billed Charges,95% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187,88,,3335.2,Percent of Total Billed Charges,88% of Total Billed Charges,191.25,90,,3411,Percent of Total Billed charges,90% of Total Billed Charges,93.71,212.5,
BMW Univrsl 0.014x190Cm S Wire,2720002262,CDM,272,RC,C1769,HCPCS,Outpatient,,,212.50,138.13,,212.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.5,76,,8466.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153,72,,163.08,Percent of Total Billed Charges,72% of Total Billed Charges,159.38,75,,169.88,Percent of Total Billed charges,75% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153,72,,163.08,Percent of Total Billed Charges,72% of Total Billed Charges,127.5,60,,135.904,Percent of Total Billed Charges,60% of Total Billed Charges,191.25,90,,45,Percent of Total Billed Charges,90% of Total Billed Charges,95.63,45,,108,Percent of Total Billed Charges,45% of Total Billed Charges,191.25,90,,10026,Percent of Total Billed Charges,90% of Total billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.13,65,,1.64,Percent of total Billed Charges,65% of Total Billed Charges,93.71,44.1,,105.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,201.88,95,,10583,Percent of Total Billed Charges,95% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187,88,,9803.2,Percent of Total Billed Charges,88% of Total Billed Charges,191.25,90,,10026,Percent of Total Billed charges,90% of Total Billed Charges,93.71,212.5,
Turntrac F 0.014x190Cm J Wire,2720002263,CDM,272,RC,C1769,HCPCS,Outpatient,,,212.50,138.13,,212.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.5,76,,2515.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153,72,,163.08,Percent of Total Billed Charges,72% of Total Billed Charges,159.38,75,,169.88,Percent of Total Billed charges,75% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153,72,,163.08,Percent of Total Billed Charges,72% of Total Billed Charges,127.5,60,,135.904,Percent of Total Billed Charges,60% of Total Billed Charges,191.25,90,,45,Percent of Total Billed Charges,90% of Total Billed Charges,95.63,45,,108,Percent of Total Billed Charges,45% of Total Billed Charges,191.25,90,,2979,Percent of Total Billed Charges,90% of Total billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.13,65,,156,Percent of total Billed Charges,65% of Total Billed Charges,93.71,44.1,,105.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,201.88,95,,3144.504,Percent of Total Billed Charges,95% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187,88,,2912.8,Percent of Total Billed Charges,88% of Total Billed Charges,191.25,90,,2979,Percent of Total Billed charges,90% of Total Billed Charges,93.71,212.5,
Turntrac F 0.014x190Cm S Wire,2720002264,CDM,272,RC,C1769,HCPCS,Outpatient,,,212.50,138.13,,212.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.5,76,,1.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153,72,,163.08,Percent of Total Billed Charges,72% of Total Billed Charges,159.38,75,,169.88,Percent of Total Billed charges,75% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153,72,,163.08,Percent of Total Billed Charges,72% of Total Billed Charges,127.5,60,,135.904,Percent of Total Billed Charges,60% of Total Billed Charges,191.25,90,,45,Percent of Total Billed Charges,90% of Total Billed Charges,95.63,45,,108,Percent of Total Billed Charges,45% of Total Billed Charges,191.25,90,,2.272,Percent of Total Billed Charges,90% of Total billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.13,65,,156,Percent of total Billed Charges,65% of Total Billed Charges,93.71,44.1,,105.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,201.88,95,,2.392,Percent of Total Billed Charges,95% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187,88,,2.216,Percent of Total Billed Charges,88% of Total Billed Charges,191.25,90,,2.272,Percent of Total Billed charges,90% of Total Billed Charges,93.71,212.5,
Angiosculpt Rx 6F 3.5 x 15,2720002265,CDM,272,RC,C1725,HCPCS,Outpatient,,,2187.50,1421.88,,2187.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1662.5,76,,182.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1575,72,,48.96,Percent of Total Billed Charges,72% of Total Billed Charges,1640.63,75,,51,Percent of Total Billed charges,75% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1575,72,,48.96,Percent of Total Billed Charges,72% of Total Billed Charges,1312.5,60,,40.8,Percent of Total Billed Charges,60% of Total Billed Charges,1968.75,90,,45,Percent of Total Billed Charges,90% of Total Billed Charges,984.38,45,,108,Percent of Total Billed Charges,45% of Total Billed Charges,1968.75,90,,216,Percent of Total Billed Charges,90% of Total billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1421.88,65,,156,Percent of total Billed Charges,65% of Total Billed Charges,964.69,44.1,,105.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,2078.13,95,,228,Percent of Total Billed Charges,95% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1925,88,,211.2,Percent of Total Billed Charges,88% of Total Billed Charges,1968.75,90,,216,Percent of Total Billed charges,90% of Total Billed Charges,964.69,2187.5,
Angiosculpt Rx 6F 3.5 x 10,2720002266,CDM,272,RC,C1725,HCPCS,Outpatient,,,2187.50,1421.88,,2187.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1662.5,76,,182.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1575,72,,48.96,Percent of Total Billed Charges,72% of Total Billed Charges,1640.63,75,,51,Percent of Total Billed charges,75% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1575,72,,48.96,Percent of Total Billed Charges,72% of Total Billed Charges,1312.5,60,,40.8,Percent of Total Billed Charges,60% of Total Billed Charges,1968.75,90,,4.176,Percent of Total Billed Charges,90% of Total Billed Charges,984.38,45,,108,Percent of Total Billed Charges,45% of Total Billed Charges,1968.75,90,,216,Percent of Total Billed Charges,90% of Total billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1421.88,65,,156,Percent of total Billed Charges,65% of Total Billed Charges,964.69,44.1,,105.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,2078.13,95,,228,Percent of Total Billed Charges,95% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1925,88,,211.2,Percent of Total Billed Charges,88% of Total Billed Charges,1968.75,90,,216,Percent of Total Billed charges,90% of Total Billed Charges,964.69,2187.5,
Angiosculpt Rx 6F 3.5 x 6,2720002267,CDM,272,RC,C1725,HCPCS,Outpatient,,,2187.50,1421.88,,2187.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1662.5,76,,182.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1575,72,,6.76,Percent of Total Billed Charges,72% of Total Billed Charges,1640.63,75,,7.04,Percent of Total Billed charges,75% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1575,72,,6.76,Percent of Total Billed Charges,72% of Total Billed Charges,1312.5,60,,5.632,Percent of Total Billed Charges,60% of Total Billed Charges,1968.75,90,,30.6,Percent of Total Billed Charges,90% of Total Billed Charges,984.38,45,,108,Percent of Total Billed Charges,45% of Total Billed Charges,1968.75,90,,216,Percent of Total Billed Charges,90% of Total billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1421.88,65,,156,Percent of total Billed Charges,65% of Total Billed Charges,964.69,44.1,,105.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,2078.13,95,,228,Percent of Total Billed Charges,95% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1925,88,,211.2,Percent of Total Billed Charges,88% of Total Billed Charges,1968.75,90,,216,Percent of Total Billed charges,90% of Total Billed Charges,964.69,2187.5,
Angiosculpt Rx 6F 3 x 15,2720002268,CDM,272,RC,C1725,HCPCS,Outpatient,,,2187.50,1421.88,,2187.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1662.5,76,,182.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1575,72,,102.96,Percent of Total Billed Charges,72% of Total Billed Charges,1640.63,75,,107.248,Percent of Total Billed charges,75% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1575,72,,102.96,Percent of Total Billed Charges,72% of Total Billed Charges,1312.5,60,,85.8,Percent of Total Billed Charges,60% of Total Billed Charges,1968.75,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,984.38,45,,225,Percent of Total Billed Charges,45% of Total Billed Charges,1968.75,90,,216,Percent of Total Billed Charges,90% of Total billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1421.88,65,,156,Percent of total Billed Charges,65% of Total Billed Charges,964.69,44.1,,220.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,2078.13,95,,228,Percent of Total Billed Charges,95% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1925,88,,211.2,Percent of Total Billed Charges,88% of Total Billed Charges,1968.75,90,,216,Percent of Total Billed charges,90% of Total Billed Charges,964.69,2187.5,
Angiosculpt Rx 6F 3 x 10,2720002269,CDM,272,RC,C1725,HCPCS,Outpatient,,,2187.50,1421.88,,2187.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1662.5,76,,182.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1575,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,1640.63,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1575,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,1312.5,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,1968.75,90,,100.8,Percent of Total Billed Charges,90% of Total Billed Charges,984.38,45,,22.504,Percent of Total Billed Charges,45% of Total Billed Charges,1968.75,90,,216,Percent of Total Billed Charges,90% of Total billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1421.88,65,,325,Percent of total Billed Charges,65% of Total Billed Charges,964.69,44.1,,22.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,2078.13,95,,228,Percent of Total Billed Charges,95% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1925,88,,211.2,Percent of Total Billed Charges,88% of Total Billed Charges,1968.75,90,,216,Percent of Total Billed charges,90% of Total Billed Charges,964.69,2187.5,
Angiosculpt Rx 6F 3 x 6,2720002270,CDM,272,RC,C1725,HCPCS,Outpatient,,,2187.50,1421.88,,2187.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1662.5,76,,182.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1575,72,,360,Percent of Total Billed Charges,72% of Total Billed Charges,1640.63,75,,375,Percent of Total Billed charges,75% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1575,72,,360,Percent of Total Billed Charges,72% of Total Billed Charges,1312.5,60,,300,Percent of Total Billed Charges,60% of Total Billed Charges,1968.75,90,,44.952,Percent of Total Billed Charges,90% of Total Billed Charges,984.38,45,,22.504,Percent of Total Billed Charges,45% of Total Billed Charges,1968.75,90,,216,Percent of Total Billed Charges,90% of Total billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1421.88,65,,32.504,Percent of total Billed Charges,65% of Total Billed Charges,964.69,44.1,,22.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,2078.13,95,,228,Percent of Total Billed Charges,95% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1925,88,,211.2,Percent of Total Billed Charges,88% of Total Billed Charges,1968.75,90,,216,Percent of Total Billed charges,90% of Total Billed Charges,964.69,2187.5,
Angiosculpt Rx 6F 2.5 x 15,2720002271,CDM,272,RC,C1725,HCPCS,Outpatient,,,2187.50,1421.88,,2187.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1662.5,76,,380,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1575,72,,2008.8,Percent of Total Billed Charges,72% of Total Billed Charges,1640.63,75,,2092.504,Percent of Total Billed charges,75% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1575,72,,2008.8,Percent of Total Billed Charges,72% of Total Billed Charges,1312.5,60,,1674,Percent of Total Billed Charges,60% of Total Billed Charges,1968.75,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,984.38,45,,22.504,Percent of Total Billed Charges,45% of Total Billed Charges,1968.75,90,,450,Percent of Total Billed Charges,90% of Total billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1421.88,65,,32.504,Percent of total Billed Charges,65% of Total Billed Charges,964.69,44.1,,22.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,2078.13,95,,475,Percent of Total Billed Charges,95% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1925,88,,440,Percent of Total Billed Charges,88% of Total Billed Charges,1968.75,90,,450,Percent of Total Billed charges,90% of Total Billed Charges,964.69,2187.5,
Angiosculpt Rx 6F 2.5 x 10,2720002272,CDM,272,RC,C1725,HCPCS,Outpatient,,,2187.50,1421.88,,2187.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1662.5,76,,38,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1575,72,,22.656,Percent of Total Billed Charges,72% of Total Billed Charges,1640.63,75,,23.6,Percent of Total Billed charges,75% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1575,72,,22.656,Percent of Total Billed Charges,72% of Total Billed Charges,1312.5,60,,18.88,Percent of Total Billed Charges,60% of Total Billed Charges,1968.75,90,,153,Percent of Total Billed Charges,90% of Total Billed Charges,984.38,45,,22.504,Percent of Total Billed Charges,45% of Total Billed Charges,1968.75,90,,45,Percent of Total Billed Charges,90% of Total billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1421.88,65,,32.504,Percent of total Billed Charges,65% of Total Billed Charges,964.69,44.1,,22.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,2078.13,95,,47.504,Percent of Total Billed Charges,95% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1925,88,,44,Percent of Total Billed Charges,88% of Total Billed Charges,1968.75,90,,45,Percent of Total Billed charges,90% of Total Billed Charges,964.69,2187.5,
Angiosculpt Rx 6F 2.5 x 6,2720002273,CDM,272,RC,C1725,HCPCS,Outpatient,,,2187.50,1421.88,,2187.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1662.5,76,,38,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1575,72,,16.328,Percent of Total Billed Charges,72% of Total Billed Charges,1640.63,75,,17.008,Percent of Total Billed charges,75% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1575,72,,16.328,Percent of Total Billed Charges,72% of Total Billed Charges,1312.5,60,,13.608,Percent of Total Billed Charges,60% of Total Billed Charges,1968.75,90,,63,Percent of Total Billed Charges,90% of Total Billed Charges,984.38,45,,2.088,Percent of Total Billed Charges,45% of Total Billed Charges,1968.75,90,,45,Percent of Total Billed Charges,90% of Total billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1421.88,65,,32.504,Percent of total Billed Charges,65% of Total Billed Charges,964.69,44.1,,2.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,2078.13,95,,47.504,Percent of Total Billed Charges,95% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1925,88,,44,Percent of Total Billed Charges,88% of Total Billed Charges,1968.75,90,,45,Percent of Total Billed charges,90% of Total Billed Charges,964.69,2187.5,
Angiosculpt Rx 6F 2 x 15,2720002274,CDM,272,RC,C1725,HCPCS,Outpatient,,,2187.50,1421.88,,2187.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1662.5,76,,38,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1575,72,,35.456,Percent of Total Billed Charges,72% of Total Billed Charges,1640.63,75,,36.928,Percent of Total Billed charges,75% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1575,72,,35.456,Percent of Total Billed Charges,72% of Total Billed Charges,1312.5,60,,29.544,Percent of Total Billed Charges,60% of Total Billed Charges,1968.75,90,,462.6,Percent of Total Billed Charges,90% of Total Billed Charges,984.38,45,,15.304,Percent of Total Billed Charges,45% of Total Billed Charges,1968.75,90,,45,Percent of Total Billed Charges,90% of Total billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1421.88,65,,3.016,Percent of total Billed Charges,65% of Total Billed Charges,964.69,44.1,,14.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,2078.13,95,,47.504,Percent of Total Billed Charges,95% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1925,88,,44,Percent of Total Billed Charges,88% of Total Billed Charges,1968.75,90,,45,Percent of Total Billed charges,90% of Total Billed Charges,964.69,2187.5,
Angiosculpt Rx 6F 2 x 10,2720002275,CDM,272,RC,C1725,HCPCS,Outpatient,,,2187.50,1421.88,,2187.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1662.5,76,,38,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1575,72,,72,Percent of Total Billed Charges,72% of Total Billed Charges,1640.63,75,,75,Percent of Total Billed charges,75% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1575,72,,72,Percent of Total Billed Charges,72% of Total Billed Charges,1312.5,60,,60,Percent of Total Billed Charges,60% of Total Billed Charges,1968.75,90,,466.2,Percent of Total Billed Charges,90% of Total Billed Charges,984.38,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,1968.75,90,,45,Percent of Total Billed Charges,90% of Total billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1421.88,65,,22.104,Percent of total Billed Charges,65% of Total Billed Charges,964.69,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,2078.13,95,,47.504,Percent of Total Billed Charges,95% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1925,88,,44,Percent of Total Billed Charges,88% of Total Billed Charges,1968.75,90,,45,Percent of Total Billed charges,90% of Total Billed Charges,964.69,2187.5,
Angiosculpt Rx 6F 2 x 6,2720002276,CDM,272,RC,C1725,HCPCS,Outpatient,,,2187.50,1421.88,,2187.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1662.5,76,,3.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1575,72,,53.28,Percent of Total Billed Charges,72% of Total Billed Charges,1640.63,75,,55.504,Percent of Total Billed charges,75% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1575,72,,53.28,Percent of Total Billed Charges,72% of Total Billed Charges,1312.5,60,,44.4,Percent of Total Billed Charges,60% of Total Billed Charges,1968.75,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,984.38,45,,50.4,Percent of Total Billed Charges,45% of Total Billed Charges,1968.75,90,,4.176,Percent of Total Billed Charges,90% of Total billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1421.88,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,964.69,44.1,,49.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,2078.13,95,,4.408,Percent of Total Billed Charges,95% of Total Billed Charges,2187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1925,88,,4.08,Percent of Total Billed Charges,88% of Total Billed Charges,1968.75,90,,4.176,Percent of Total Billed charges,90% of Total Billed Charges,964.69,2187.5,
Angiowire Straight 0.035 150CM,2720002277,CDM,272,RC,C1769,HCPCS,Outpatient,,,14.88,9.67,,14.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.31,76,,25.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.71,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,11.16,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,14.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.71,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,8.93,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,13.39,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,6.7,45,,22.472,Percent of Total Billed Charges,45% of Total Billed Charges,13.39,90,,30.6,Percent of Total Billed Charges,90% of Total billed Charges,14.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.67,65,,72.8,Percent of total Billed Charges,65% of Total Billed Charges,6.56,44.1,,22.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.14,95,,32.304,Percent of Total Billed Charges,95% of Total Billed Charges,14.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.09,88,,29.92,Percent of Total Billed Charges,88% of Total Billed Charges,13.39,90,,30.6,Percent of Total Billed charges,90% of Total Billed Charges,6.56,14.88,
Omniwire IFR J-Tip 185Cm,2720002278,CDM,272,RC,C1769,HCPCS,Outpatient,,,1712.50,1113.13,,1712.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1301.5,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1233,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,1284.38,75,,64.504,Percent of Total Billed charges,75% of Total Billed Charges,1712.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1233,72,,61.92,Percent of Total Billed Charges,72% of Total Billed Charges,1027.5,60,,51.6,Percent of Total Billed Charges,60% of Total Billed Charges,1541.25,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,770.63,45,,7.2,Percent of Total Billed Charges,45% of Total Billed Charges,1541.25,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,1712.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1712.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1712.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1113.13,65,,32.464,Percent of total Billed Charges,65% of Total Billed Charges,755.21,44.1,,7.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,1626.88,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,1712.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1507,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,1541.25,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,755.21,1712.5,
Omniwire IFR S-Tip 185CM,2720002279,CDM,272,RC,C1769,HCPCS,Outpatient,,,1712.50,1113.13,,1712.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1301.5,76,,85.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1233,72,,84.96,Percent of Total Billed Charges,72% of Total Billed Charges,1284.38,75,,88.504,Percent of Total Billed charges,75% of Total Billed Charges,1712.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1233,72,,84.96,Percent of Total Billed Charges,72% of Total Billed Charges,1027.5,60,,70.8,Percent of Total Billed Charges,60% of Total Billed Charges,1541.25,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,770.63,45,,76.504,Percent of Total Billed Charges,45% of Total Billed Charges,1541.25,90,,100.8,Percent of Total Billed Charges,90% of Total billed Charges,1712.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1712.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1712.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1113.13,65,,10.4,Percent of total Billed Charges,65% of Total Billed Charges,755.21,44.1,,74.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,1626.88,95,,106.4,Percent of Total Billed Charges,95% of Total Billed Charges,1712.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1507,88,,98.56,Percent of Total Billed Charges,88% of Total Billed Charges,1541.25,90,,100.8,Percent of Total Billed charges,90% of Total Billed Charges,755.21,1712.5,
Eagle Eye PST  150CM,2720002280,CDM,272,RC,C1753,HCPCS,Outpatient,,,1875.00,1218.75,,1875,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1425,76,,37.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1350,72,,36,Percent of Total Billed Charges,72% of Total Billed Charges,1406.25,75,,37.504,Percent of Total Billed charges,75% of Total Billed Charges,1875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1350,72,,36,Percent of Total Billed Charges,72% of Total Billed Charges,1125,60,,30,Percent of Total Billed Charges,60% of Total Billed Charges,1687.5,90,,69.12,Percent of Total Billed Charges,90% of Total Billed Charges,843.75,45,,31.504,Percent of Total Billed Charges,45% of Total Billed Charges,1687.5,90,,44.952,Percent of Total Billed Charges,90% of Total billed Charges,1875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1218.75,65,,110.504,Percent of total Billed Charges,65% of Total Billed Charges,826.88,44.1,,30.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,1781.25,95,,47.448,Percent of Total Billed Charges,95% of Total Billed Charges,1875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1650,88,,43.952,Percent of Total Billed Charges,88% of Total Billed Charges,1687.5,90,,44.952,Percent of Total Billed charges,90% of Total Billed Charges,826.88,1875,
Secondary Tubing,2720002281,CDM,272,RC,C1753,HCPCS,Outpatient,,,3.83,2.49,,3.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.91,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.76,72,,36,Percent of Total Billed Charges,72% of Total Billed Charges,2.87,75,,37.504,Percent of Total Billed charges,75% of Total Billed Charges,3.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.76,72,,36,Percent of Total Billed Charges,72% of Total Billed Charges,2.3,60,,30,Percent of Total Billed Charges,60% of Total Billed Charges,3.45,90,,69.12,Percent of Total Billed Charges,90% of Total Billed Charges,1.72,45,,231.304,Percent of Total Billed Charges,45% of Total Billed Charges,3.45,90,,14.4,Percent of Total Billed Charges,90% of Total billed Charges,3.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.49,65,,45.504,Percent of total Billed Charges,65% of Total Billed Charges,1.69,44.1,,226.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.64,95,,15.2,Percent of Total Billed Charges,95% of Total Billed Charges,3.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.37,88,,14.08,Percent of Total Billed Charges,88% of Total Billed Charges,3.45,90,,14.4,Percent of Total Billed charges,90% of Total Billed Charges,1.69,3.83,
NC EUPHORA RX 5MM X 8MM,2720002282,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,129.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,36,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,37.504,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,36,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,30,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,69.12,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,233.104,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,153,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,334.104,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,228.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,161.504,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,149.6,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,153,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 4MM X 27MM,2720002283,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,53.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,36,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,37.504,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,36,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,30,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,69.12,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,35.64,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,63,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,336.704,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,34.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,66.504,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,61.6,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,63,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 4MM X 20MM,2720002284,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,390.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,36,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,37.504,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,36,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,30,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,69.12,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,35.64,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,462.6,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,51.48,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,34.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,488.304,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,452.32,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,462.6,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 4.5MM X 8MM,2720002285,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,393.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,79.2,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,82.504,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,79.2,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,66,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,69.12,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,35.64,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,466.2,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,51.48,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,34.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,492.104,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,455.84,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,466.2,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 4MM X 8MM,2720002286,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,60.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,79.2,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,82.504,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,79.2,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,66,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,69.12,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,35.64,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,71.28,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,51.48,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,34.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,75.24,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,69.696,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,71.28,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 3.75MM X 27MM,2720002287,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,60.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,49.248,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,51.304,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,49.248,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,41.04,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,405,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,34.56,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,71.28,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,51.48,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,33.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,75.24,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,69.696,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,71.28,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 3.5MM X 27MM,2720002288,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,60.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,49.248,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,51.304,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,49.248,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,41.04,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,208.44,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,34.56,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,71.28,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,49.92,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,33.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,75.24,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,69.696,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,71.28,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 3.5MM X 20MM,2720002289,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,60.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,266.4,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,277.504,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,266.4,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,222,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,49.728,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,34.56,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,71.28,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,49.92,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,33.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,75.24,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,69.696,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,71.28,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 3.25MM X 20MM,2720002290,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,58.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,360,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,375,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,360,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,300,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,277.024,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,34.56,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,69.12,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,49.92,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,33.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,72.96,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,67.584,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,69.12,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 3.25MM X 8MM,2720002291,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,58.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,360,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,375,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,360,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,300,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,73.336,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,34.56,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,69.12,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,49.92,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,33.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,72.96,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,67.584,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,69.12,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 3MM X 20MM,2720002292,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,58.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,143.152,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,149.12,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,143.152,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,119.296,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,1602,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,34.56,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,69.12,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,49.92,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,33.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,72.96,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,67.584,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,69.12,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 2.75MM X 20MM,2720002293,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,58.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,13.968,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,14.552,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,13.968,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,11.64,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,34.56,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,69.12,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,49.92,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,33.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,72.96,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,67.584,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,69.12,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 2.5MM X 27MM,2720002294,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,58.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,1.688,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,1.76,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,1.688,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,1.408,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,202.504,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,69.12,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,49.92,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,198.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,72.96,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,67.584,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,69.12,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 2.5MM X 6MM,2720002295,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,58.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,6.368,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,6.632,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,6.368,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,5.304,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,104.224,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,69.12,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,292.504,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,102.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,72.96,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,67.584,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,69.12,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 2.25MM X 20MM,2720002296,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,58.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,15.408,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,16.048,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,15.408,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,12.84,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,24.864,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,69.12,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,150.544,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,24.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,72.96,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,67.584,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,69.12,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 2.25MM X 6MM,2720002297,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,342,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,90.72,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,94.504,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,90.72,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,75.6,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,138.512,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,405,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,35.92,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,135.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,427.504,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,396,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,405,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 2MM X 20MM,2720002298,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,176.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,113.76,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,118.504,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,113.76,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,94.8,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,36.664,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,208.44,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,200.072,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,35.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,220.024,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,203.808,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,208.44,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
NC EUPHORA RX 3MM x 27MM,2720002299,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,41.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,342.36,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,356.632,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,342.36,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,285.304,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,801,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,49.728,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,52.96,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,784.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,52.496,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,48.624,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,49.728,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 4MM X 25MM,2720002300,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,233.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,27.704,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,28.864,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,27.704,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,23.088,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,891,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,277.024,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,1157,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,873.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,292.408,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,270.864,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,277.024,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 4MM X 6MM,2720002301,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,61.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,44.712,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,46.576,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,44.712,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,37.264,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,891,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,73.336,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,1287,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,873.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,77.408,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,71.704,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,73.336,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 3.5MM X 30MM,2720002302,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,1352.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,41.896,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,43.64,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,41.896,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,34.912,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,891,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,1602,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,1287,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,873.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,1691,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,1566.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,1602,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 3.5MM X 25MM,2720002303,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,1504.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,35.992,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,37.488,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,35.992,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,29.992,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,891,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,1287,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,873.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,1881,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,1742.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 3.5MM X 10MM,2720002304,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,1504.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,51.6,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,53.752,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,51.6,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,43,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,1287,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,1881,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,1742.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 3.5MM X 6MM,2720002305,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,1504.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,15.112,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,15.736,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,15.112,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,12.592,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,891,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,873.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,1881,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,1742.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 3MM X 30MM,2720002306,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,1504.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,15.112,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,15.736,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,15.112,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,12.592,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,1287,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,1881,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,1742.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 3MM X 25MM,2720002307,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,15.112,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,15.736,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,15.112,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,12.592,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,891,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,873.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 3MM X 10MM,2720002308,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,1504.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,20.824,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,21.688,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,20.824,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,17.352,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,1287,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,1881,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,1742.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 3MM X 6MM,2720002309,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,20.12,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,20.96,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,20.12,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,16.768,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,891,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,873.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 2.75MM X 20MM,2720002310,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,1504.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,9,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,9.376,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,9,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,7.504,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,891,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,1287,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,873.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,1881,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,1742.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 2.5MM X 30MM,2720002311,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,36.72,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,38.248,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,36.72,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,30.6,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,1287,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 2.5MM X 6MM,2720002312,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,1504.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,248.4,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,258.752,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,248.4,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,207,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,1881,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,1742.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 2MM X 30MM,2720002313,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,1504.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,89.424,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,93.152,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,89.424,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,74.52,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,1881,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,1742.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,1782,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 2.25MM X 25MM,2720002314,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,12.488,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,13.008,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,12.488,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,10.408,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 2.25MM X 6MM,2720002315,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,328.104,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,341.776,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,328.104,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,273.424,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,1602,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPHORA RX 2MM X 6MM,2720002316,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,328.104,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,341.776,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,328.104,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,273.424,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,1602,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPOHRA RX 1.5MM X 20MM,2720002317,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,176.976,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,184.352,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,176.976,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,147.48,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,1602,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
SC EUPOHRA RX 1.5MM X 6MM,2720002318,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,2527.2,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,2632.504,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,2527.2,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,2106,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,1602,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
LAUNCHER 7F AL.75 GUIDE,2720002319,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,2527.2,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,2632.504,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,2527.2,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,2106,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,1602,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 7F AL1.0 GUIDE,2720002320,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,104.648,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,109.008,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,104.648,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,87.208,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,1602,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 7F JR4 W/SH GUIDE,2720002321,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,39.544,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,41.192,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,39.544,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,32.952,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,1782,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 7F JL5.0 GUIDE,2720002322,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,12.096,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,12.6,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,12.096,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,1782,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,801,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,784.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 7F JL4.0 GUIDE,2720002323,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,64.512,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,67.2,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,64.512,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,53.76,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,801,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,1157,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,784.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 7F JL3.5 GUIDE,2720002324,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,6768,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,7050,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,6768,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,5640,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,801,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,1157,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,784.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F SCR4.0 GUIDE,2720002325,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,1352.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,6768,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,7050,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,6768,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,5640,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,801,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,1602,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,1157,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,784.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,1691,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,1566.4,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,1602,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F SCR3.5 GUIDE,2720002326,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,1352.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,6768,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,7050,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,6768,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,5640,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,801,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,1602,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,1157,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,784.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,1691,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,1566.4,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,1602,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F RCB GUIDE,2720002327,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,1352.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,6768,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,7050,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,6768,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,5640,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,801,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,1602,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,1157,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,784.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,1691,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,1566.4,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,1602,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F RBU 4.5 GUIDE,2720002328,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,1352.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,4968,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,5175,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,4968,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,4140,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,3222,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,891,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,1602,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,1157,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,873.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,1691,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,1566.4,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,1602,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F RBU 4.0 GUIDE,2720002329,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,1352.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,4968,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,5175,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,4968,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,4140,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,3222,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,891,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,1602,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,1287,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,873.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,1691,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,1566.4,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,1602,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F NOTO GUIDE,2720002330,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,1352.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,4968,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,5175,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,4968,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,4140,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,3222,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,1602,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,1287,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,1691,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,1566.4,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,1602,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F MP2 GUIDE,2720002331,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,1504.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,4968,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,5175,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,4968,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,4140,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,3222,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,1782,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,1881,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,1742.4,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,1782,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F MP1SH GUIDE,2720002332,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,1504.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,4968,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,5175,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,4968,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,4140,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,3222,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,1782,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,1881,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,1742.4,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,1782,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F JL 6.0 GUIDE,2720002333,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,4968,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,5175,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,4968,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,4140,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,3222,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F AL 3.0 GUIDE,2720002334,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,4968,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,5175,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,4968,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,4140,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,3222,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F AL 2.0 GUIDE,2720002335,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,4968,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,5175,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,4968,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,4140,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,3222,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,1611,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,1578.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
LAUNCHER 6F AL 1.5 GUIDE,2720002336,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,4968,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,5175,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,4968,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,4140,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,1782,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,1611,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,2327,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,1578.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
Mepilex Foam border 4x4,2720002337,CDM,272,RC,,,Outpatient,,,9.60,6.24,,9.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.3,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.91,72,,3960,Percent of Total Billed Charges,72% of Total Billed Charges,7.2,75,,4125,Percent of Total Billed charges,75% of Total Billed Charges,9.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.91,72,,3960,Percent of Total Billed Charges,72% of Total Billed Charges,5.76,60,,3300,Percent of Total Billed Charges,60% of Total Billed Charges,8.64,90,,1782,Percent of Total Billed Charges,90% of Total Billed Charges,4.32,45,,1611,Percent of Total Billed Charges,45% of Total Billed Charges,8.64,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,9.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.24,65,,2327,Percent of total Billed Charges,65% of Total Billed Charges,4.23,44.1,,1578.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.12,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,9.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.45,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,8.64,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,4.23,9.6,
"Cath, Intermittent  8FR x 10",2720002338,CDM,272,RC,,,Outpatient,,,4.05,2.63,,4.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.08,76,,2720.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.92,72,,3960,Percent of Total Billed Charges,72% of Total Billed Charges,3.04,75,,4125,Percent of Total Billed charges,75% of Total Billed Charges,4.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.92,72,,3960,Percent of Total Billed Charges,72% of Total Billed Charges,2.43,60,,3300,Percent of Total Billed Charges,60% of Total Billed Charges,3.65,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,1.82,45,,1611,Percent of Total Billed Charges,45% of Total Billed Charges,3.65,90,,3222,Percent of Total Billed Charges,90% of Total billed Charges,4.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.63,65,,2327,Percent of total Billed Charges,65% of Total Billed Charges,1.79,44.1,,1578.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.85,95,,3401,Percent of Total Billed Charges,95% of Total Billed Charges,4.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.56,88,,3150.4,Percent of Total Billed Charges,88% of Total Billed Charges,3.65,90,,3222,Percent of Total Billed charges,90% of Total Billed Charges,1.79,4.05,
"Cath, intermittent  6FR x 10",2720002339,CDM,272,RC,,,Outpatient,,,2.25,1.46,,2.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.71,76,,2720.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.62,72,,3960,Percent of Total Billed Charges,72% of Total Billed Charges,1.69,75,,4125,Percent of Total Billed charges,75% of Total Billed Charges,2.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.62,72,,3960,Percent of Total Billed Charges,72% of Total Billed Charges,1.35,60,,3300,Percent of Total Billed Charges,60% of Total Billed Charges,2.03,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,1.01,45,,1611,Percent of Total Billed Charges,45% of Total Billed Charges,2.03,90,,3222,Percent of Total Billed Charges,90% of Total billed Charges,2.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.46,65,,2327,Percent of total Billed Charges,65% of Total Billed Charges,0.99,44.1,,1578.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.14,95,,3401,Percent of Total Billed Charges,95% of Total Billed Charges,2.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.98,88,,3150.4,Percent of Total Billed Charges,88% of Total Billed Charges,2.03,90,,3222,Percent of Total Billed charges,90% of Total Billed Charges,0.99,2.25,
Impulse Catheter 5F IM Curve,2720002340,CDM,272,RC,C1887,HCPCS,Outpatient,,,17.50,11.38,,17.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.3,76,,2720.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.6,72,,3960,Percent of Total Billed Charges,72% of Total Billed Charges,13.13,75,,4125,Percent of Total Billed charges,75% of Total Billed Charges,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.6,72,,3960,Percent of Total Billed Charges,72% of Total Billed Charges,10.5,60,,3300,Percent of Total Billed Charges,60% of Total Billed Charges,15.75,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,7.88,45,,1611,Percent of Total Billed Charges,45% of Total Billed Charges,15.75,90,,3222,Percent of Total Billed Charges,90% of Total billed Charges,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.38,65,,2327,Percent of total Billed Charges,65% of Total Billed Charges,7.72,44.1,,1578.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.63,95,,3401,Percent of Total Billed Charges,95% of Total Billed Charges,17.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.4,88,,3150.4,Percent of Total Billed Charges,88% of Total Billed Charges,15.75,90,,3222,Percent of Total Billed charges,90% of Total Billed Charges,7.72,17.5,
Telemark MC 0.014 150CM,2720002341,CDM,272,RC,C1887,HCPCS,Outpatient,,,1000.00,650.00,,1000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,760,76,,2720.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,720,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,750,75,,9,Percent of Total Billed charges,75% of Total Billed Charges,1000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,720,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,600,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,900,90,,1242,Percent of Total Billed Charges,90% of Total Billed Charges,450,45,,1611,Percent of Total Billed Charges,45% of Total Billed Charges,900,90,,3222,Percent of Total Billed Charges,90% of Total billed Charges,1000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,650,65,,2327,Percent of total Billed Charges,65% of Total Billed Charges,441,44.1,,1578.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,950,95,,3401,Percent of Total Billed Charges,95% of Total Billed Charges,1000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,880,88,,3150.4,Percent of Total Billed Charges,88% of Total Billed Charges,900,90,,3222,Percent of Total Billed charges,90% of Total Billed Charges,441,1000,
Telemark MC 0.014 135CM,2720002342,CDM,272,RC,C1887,HCPCS,Outpatient,,,1000.00,650.00,,1000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,760,76,,2720.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,720,72,,1222.56,Percent of Total Billed Charges,72% of Total Billed Charges,750,75,,1273.504,Percent of Total Billed charges,75% of Total Billed Charges,1000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,720,72,,1222.56,Percent of Total Billed Charges,72% of Total Billed Charges,600,60,,1018.8,Percent of Total Billed Charges,60% of Total Billed Charges,900,90,,1242,Percent of Total Billed Charges,90% of Total Billed Charges,450,45,,1611,Percent of Total Billed Charges,45% of Total Billed Charges,900,90,,3222,Percent of Total Billed Charges,90% of Total billed Charges,1000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,650,65,,2327,Percent of total Billed Charges,65% of Total Billed Charges,441,44.1,,1578.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,950,95,,3401,Percent of Total Billed Charges,95% of Total Billed Charges,1000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,880,88,,3150.4,Percent of Total Billed Charges,88% of Total Billed Charges,900,90,,3222,Percent of Total Billed charges,90% of Total Billed Charges,441,1000,
Angiowire Straight 0.035 150CM,2720002343,CDM,272,RC,C1769,HCPCS,Outpatient,,,14.88,9.67,,14.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.31,76,,2720.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.71,72,,1.912,Percent of Total Billed Charges,72% of Total Billed Charges,11.16,75,,1.992,Percent of Total Billed charges,75% of Total Billed Charges,14.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.71,72,,1.912,Percent of Total Billed Charges,72% of Total Billed Charges,8.93,60,,1.592,Percent of Total Billed Charges,60% of Total Billed Charges,13.39,90,,1242,Percent of Total Billed Charges,90% of Total Billed Charges,6.7,45,,891,Percent of Total Billed Charges,45% of Total Billed Charges,13.39,90,,3222,Percent of Total Billed Charges,90% of Total billed Charges,14.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.67,65,,2327,Percent of total Billed Charges,65% of Total Billed Charges,6.56,44.1,,873.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.14,95,,3401,Percent of Total Billed Charges,95% of Total Billed Charges,14.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.09,88,,3150.4,Percent of Total Billed Charges,88% of Total Billed Charges,13.39,90,,3222,Percent of Total Billed charges,90% of Total Billed Charges,6.56,14.88,
NEFF 21GX15Cm Perc Access Set,2720002344,CDM,272,RC,,,Outpatient,,,142.50,92.63,,142.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,108.3,76,,2720.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,102.6,72,,820.8,Percent of Total Billed Charges,72% of Total Billed Charges,106.88,75,,855,Percent of Total Billed charges,75% of Total Billed Charges,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.6,72,,820.8,Percent of Total Billed Charges,72% of Total Billed Charges,85.5,60,,684,Percent of Total Billed Charges,60% of Total Billed Charges,128.25,90,,423,Percent of Total Billed Charges,90% of Total Billed Charges,64.13,45,,891,Percent of Total Billed Charges,45% of Total Billed Charges,128.25,90,,3222,Percent of Total Billed Charges,90% of Total billed Charges,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.63,65,,1287,Percent of total Billed Charges,65% of Total Billed Charges,62.84,44.1,,873.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,135.38,95,,3401,Percent of Total Billed Charges,95% of Total Billed Charges,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.4,88,,3150.4,Percent of Total Billed Charges,88% of Total Billed Charges,128.25,90,,3222,Percent of Total Billed charges,90% of Total Billed Charges,62.84,142.5,
EN Snare 2MM-4MM,2720002345,CDM,272,RC,C1773,HCPCS,Outpatient,,,1465.93,952.85,,1465.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1114.11,76,,2720.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1055.47,72,,820.8,Percent of Total Billed Charges,72% of Total Billed Charges,1099.45,75,,855,Percent of Total Billed charges,75% of Total Billed Charges,1465.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.47,72,,820.8,Percent of Total Billed Charges,72% of Total Billed Charges,879.56,60,,684,Percent of Total Billed Charges,60% of Total Billed Charges,1319.34,90,,1602,Percent of Total Billed Charges,90% of Total Billed Charges,659.67,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,1319.34,90,,3222,Percent of Total Billed Charges,90% of Total billed Charges,1465.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1465.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1465.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,952.85,65,,1287,Percent of total Billed Charges,65% of Total Billed Charges,646.48,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,1392.63,95,,3401,Percent of Total Billed Charges,95% of Total Billed Charges,1465.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1290.02,88,,3150.4,Percent of Total Billed Charges,88% of Total Billed Charges,1319.34,90,,3222,Percent of Total Billed charges,90% of Total Billed Charges,646.48,1465.93,
One Snare 2MM,2720002346,CDM,272,RC,C1773,HCPCS,Outpatient,,,1273.40,827.71,,1273.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,967.78,76,,1504.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,916.85,72,,820.8,Percent of Total Billed Charges,72% of Total Billed Charges,955.05,75,,855,Percent of Total Billed charges,75% of Total Billed Charges,1273.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.85,72,,820.8,Percent of Total Billed Charges,72% of Total Billed Charges,764.04,60,,684,Percent of Total Billed Charges,60% of Total Billed Charges,1146.06,90,,1602,Percent of Total Billed Charges,90% of Total Billed Charges,573.03,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,1146.06,90,,1782,Percent of Total Billed Charges,90% of Total billed Charges,1273.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1273.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1273.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,827.71,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,561.57,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,1209.73,95,,1881,Percent of Total Billed Charges,95% of Total Billed Charges,1273.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1120.59,88,,1742.4,Percent of Total Billed Charges,88% of Total Billed Charges,1146.06,90,,1782,Percent of Total Billed charges,90% of Total Billed Charges,561.57,1273.4,
Finecross Cath 0.014 x130CM,2720002347,CDM,272,RC,C1887,HCPCS,Outpatient,,,1125.00,731.25,,1125,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,855,76,,1504.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,810,72,,820.8,Percent of Total Billed Charges,72% of Total Billed Charges,843.75,75,,855,Percent of Total Billed charges,75% of Total Billed Charges,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,810,72,,820.8,Percent of Total Billed Charges,72% of Total Billed Charges,675,60,,684,Percent of Total Billed Charges,60% of Total Billed Charges,1012.5,90,,1602,Percent of Total Billed Charges,90% of Total Billed Charges,506.25,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,1012.5,90,,1782,Percent of Total Billed Charges,90% of Total billed Charges,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,731.25,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,496.13,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,1068.75,95,,1881,Percent of Total Billed Charges,95% of Total Billed Charges,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,990,88,,1742.4,Percent of Total Billed Charges,88% of Total Billed Charges,1012.5,90,,1782,Percent of Total Billed charges,90% of Total Billed Charges,496.13,1125,
Finecross  Cath 0.014 x 150CM,2720002348,CDM,272,RC,C1887,HCPCS,Outpatient,,,1125.00,731.25,,1125,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,855,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,810,72,,648,Percent of Total Billed Charges,72% of Total Billed Charges,843.75,75,,675,Percent of Total Billed charges,75% of Total Billed Charges,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,810,72,,648,Percent of Total Billed Charges,72% of Total Billed Charges,675,60,,540,Percent of Total Billed Charges,60% of Total Billed Charges,1012.5,90,,1602,Percent of Total Billed Charges,90% of Total Billed Charges,506.25,45,,621,Percent of Total Billed Charges,45% of Total Billed Charges,1012.5,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,731.25,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,496.13,44.1,,608.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,1068.75,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,990,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,1012.5,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,496.13,1125,
Blood/Urine Specimen Kit,2720002349,CDM,272,RC,,,Outpatient,,,22.53,14.64,,22.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.12,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.22,72,,648,Percent of Total Billed Charges,72% of Total Billed Charges,16.9,75,,675,Percent of Total Billed charges,75% of Total Billed Charges,22.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.22,72,,648,Percent of Total Billed Charges,72% of Total Billed Charges,13.52,60,,540,Percent of Total Billed Charges,60% of Total Billed Charges,20.28,90,,1782,Percent of Total Billed Charges,90% of Total Billed Charges,10.14,45,,621,Percent of Total Billed Charges,45% of Total Billed Charges,20.28,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,22.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.64,65,,897,Percent of total Billed Charges,65% of Total Billed Charges,9.94,44.1,,608.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.4,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,22.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.83,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,20.28,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,9.94,22.53,
"Arg Shp Tp Trocar Cath 10FR 9""",2720002350,CDM,272,RC,,,Outpatient,,,38.98,25.34,,38.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.62,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.07,72,,756,Percent of Total Billed Charges,72% of Total Billed Charges,29.24,75,,787.504,Percent of Total Billed charges,75% of Total Billed Charges,38.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.07,72,,756,Percent of Total Billed Charges,72% of Total Billed Charges,23.39,60,,630,Percent of Total Billed Charges,60% of Total Billed Charges,35.08,90,,1602,Percent of Total Billed Charges,90% of Total Billed Charges,17.54,45,,621,Percent of Total Billed Charges,45% of Total Billed Charges,35.08,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,38.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.34,65,,897,Percent of total Billed Charges,65% of Total Billed Charges,17.19,44.1,,608.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.03,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,38.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.3,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,35.08,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,17.19,38.98,
Hemo-Nate Blood Filters,2720002351,CDM,272,RC,,,Outpatient,,,10.00,6.50,,10,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.6,76,,1048.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.2,72,,756,Percent of Total Billed Charges,72% of Total Billed Charges,7.5,75,,787.504,Percent of Total Billed charges,75% of Total Billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.2,72,,756,Percent of Total Billed Charges,72% of Total Billed Charges,6,60,,630,Percent of Total Billed Charges,60% of Total Billed Charges,9,90,,1782,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,45,,211.504,Percent of Total Billed Charges,45% of Total Billed Charges,9,90,,1242,Percent of Total Billed Charges,90% of Total billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,65,,897,Percent of total Billed Charges,65% of Total Billed Charges,4.41,44.1,,207.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.5,95,,1311,Percent of Total Billed Charges,95% of Total Billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.8,88,,1214.4,Percent of Total Billed Charges,88% of Total Billed Charges,9,90,,1242,Percent of Total Billed charges,90% of Total Billed Charges,4.41,10,
Light Guard Microbore Ext Sets,2720002352,CDM,272,RC,,,Outpatient,,,5.05,3.28,,5.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.84,76,,1048.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.64,72,,576,Percent of Total Billed Charges,72% of Total Billed Charges,3.79,75,,600,Percent of Total Billed charges,75% of Total Billed Charges,5.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.64,72,,576,Percent of Total Billed Charges,72% of Total Billed Charges,3.03,60,,480,Percent of Total Billed Charges,60% of Total Billed Charges,4.55,90,,1782,Percent of Total Billed Charges,90% of Total Billed Charges,2.27,45,,801,Percent of Total Billed Charges,45% of Total Billed Charges,4.55,90,,1242,Percent of Total Billed Charges,90% of Total billed Charges,5.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.28,65,,305.504,Percent of total Billed Charges,65% of Total Billed Charges,2.23,44.1,,784.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.8,95,,1311,Percent of Total Billed Charges,95% of Total Billed Charges,5.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.44,88,,1214.4,Percent of Total Billed Charges,88% of Total Billed Charges,4.55,90,,1242,Percent of Total Billed charges,90% of Total Billed Charges,2.23,5.05,
Spike IV bg access ck VLC/Clav,2720002353,CDM,272,RC,,,Outpatient,,,4.85,3.15,,4.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.69,76,,1048.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.49,72,,576,Percent of Total Billed Charges,72% of Total Billed Charges,3.64,75,,600,Percent of Total Billed charges,75% of Total Billed Charges,4.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.49,72,,576,Percent of Total Billed Charges,72% of Total Billed Charges,2.91,60,,480,Percent of Total Billed Charges,60% of Total Billed Charges,4.37,90,,1602,Percent of Total Billed Charges,90% of Total Billed Charges,2.18,45,,801,Percent of Total Billed Charges,45% of Total Billed Charges,4.37,90,,1242,Percent of Total Billed Charges,90% of Total billed Charges,4.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.15,65,,1157,Percent of total Billed Charges,65% of Total Billed Charges,2.14,44.1,,784.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.61,95,,1311,Percent of Total Billed Charges,95% of Total Billed Charges,4.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.27,88,,1214.4,Percent of Total Billed Charges,88% of Total Billed Charges,4.37,90,,1242,Percent of Total Billed charges,90% of Total Billed Charges,2.14,4.85,
Medi Vac Canister/Accessories,2720002354,CDM,272,RC,,,Outpatient,,,5.40,3.51,,5.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.1,76,,357.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.89,72,,266.888,Percent of Total Billed Charges,72% of Total Billed Charges,4.05,75,,278.008,Percent of Total Billed charges,75% of Total Billed Charges,5.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.89,72,,266.888,Percent of Total Billed Charges,72% of Total Billed Charges,3.24,60,,222.408,Percent of Total Billed Charges,60% of Total Billed Charges,4.86,90,,1782,Percent of Total Billed Charges,90% of Total Billed Charges,2.43,45,,801,Percent of Total Billed Charges,45% of Total Billed Charges,4.86,90,,423,Percent of Total Billed Charges,90% of Total billed Charges,5.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.51,65,,1157,Percent of total Billed Charges,65% of Total Billed Charges,2.38,44.1,,784.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.13,95,,446.504,Percent of Total Billed Charges,95% of Total Billed Charges,5.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.75,88,,413.6,Percent of Total Billed Charges,88% of Total Billed Charges,4.86,90,,423,Percent of Total Billed charges,90% of Total Billed Charges,2.38,5.4,
Lactina double breast pump kit,2720002355,CDM,272,RC,,,Outpatient,,,56.80,36.92,,56.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.17,76,,1352.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.9,72,,106.56,Percent of Total Billed Charges,72% of Total Billed Charges,42.6,75,,111,Percent of Total Billed charges,75% of Total Billed Charges,56.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.9,72,,106.56,Percent of Total Billed Charges,72% of Total Billed Charges,34.08,60,,88.8,Percent of Total Billed Charges,60% of Total Billed Charges,51.12,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,25.56,45,,801,Percent of Total Billed Charges,45% of Total Billed Charges,51.12,90,,1602,Percent of Total Billed Charges,90% of Total billed Charges,56.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.92,65,,1157,Percent of total Billed Charges,65% of Total Billed Charges,25.05,44.1,,784.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.96,95,,1691,Percent of Total Billed Charges,95% of Total Billed Charges,56.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.98,88,,1566.4,Percent of Total Billed Charges,88% of Total Billed Charges,51.12,90,,1602,Percent of Total Billed charges,90% of Total Billed Charges,25.05,56.8,
PINNACLE DESTINATION 6F 1 45CM,2720002356,CDM,272,RC,C1887,HCPCS,Outpatient,,,227.50,147.88,,227.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,172.9,76,,1352.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,163.8,72,,63.056,Percent of Total Billed Charges,72% of Total Billed Charges,170.63,75,,65.68,Percent of Total Billed charges,75% of Total Billed Charges,227.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.8,72,,63.056,Percent of Total Billed Charges,72% of Total Billed Charges,136.5,60,,52.544,Percent of Total Billed Charges,60% of Total Billed Charges,204.75,90,,1782,Percent of Total Billed Charges,90% of Total Billed Charges,102.38,45,,891,Percent of Total Billed Charges,45% of Total Billed Charges,204.75,90,,1602,Percent of Total Billed Charges,90% of Total billed Charges,227.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.88,65,,1157,Percent of total Billed Charges,65% of Total Billed Charges,100.33,44.1,,873.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,216.13,95,,1691,Percent of Total Billed Charges,95% of Total Billed Charges,227.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.2,88,,1566.4,Percent of Total Billed Charges,88% of Total Billed Charges,204.75,90,,1602,Percent of Total Billed charges,90% of Total Billed Charges,100.33,227.5,
PINNACLE DESTINATION 6F 0 45CM,2720002357,CDM,272,RC,C1887,HCPCS,Outpatient,,,227.50,147.88,,227.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,172.9,76,,1352.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,163.8,72,,59.456,Percent of Total Billed Charges,72% of Total Billed Charges,170.63,75,,61.936,Percent of Total Billed charges,75% of Total Billed Charges,227.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.8,72,,59.456,Percent of Total Billed Charges,72% of Total Billed Charges,136.5,60,,49.544,Percent of Total Billed Charges,60% of Total Billed Charges,204.75,90,,1782,Percent of Total Billed Charges,90% of Total Billed Charges,102.38,45,,801,Percent of Total Billed Charges,45% of Total Billed Charges,204.75,90,,1602,Percent of Total Billed Charges,90% of Total billed Charges,227.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.88,65,,1287,Percent of total Billed Charges,65% of Total Billed Charges,100.33,44.1,,784.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,216.13,95,,1691,Percent of Total Billed Charges,95% of Total Billed Charges,227.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.2,88,,1566.4,Percent of Total Billed Charges,88% of Total Billed Charges,204.75,90,,1602,Percent of Total Billed charges,90% of Total Billed Charges,100.33,227.5,
EKOS 6F (30CM) 135CM CATHETER,2720002358,CDM,272,RC,C1887,HCPCS,Outpatient,,,7232.50,4701.13,,7232.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5496.7,76,,1352.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5207.4,72,,3.368,Percent of Total Billed Charges,72% of Total Billed Charges,5424.38,75,,3.512,Percent of Total Billed charges,75% of Total Billed Charges,7232.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5207.4,72,,3.368,Percent of Total Billed Charges,72% of Total Billed Charges,4339.5,60,,2.808,Percent of Total Billed Charges,60% of Total Billed Charges,6509.25,90,,1782,Percent of Total Billed Charges,90% of Total Billed Charges,3254.63,45,,891,Percent of Total Billed Charges,45% of Total Billed Charges,6509.25,90,,1602,Percent of Total Billed Charges,90% of Total billed Charges,7232.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7232.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7232.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4701.13,65,,1157,Percent of total Billed Charges,65% of Total Billed Charges,3189.53,44.1,,873.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,6870.88,95,,1691,Percent of Total Billed Charges,95% of Total Billed Charges,7232.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6364.6,88,,1566.4,Percent of Total Billed Charges,88% of Total Billed Charges,6509.25,90,,1602,Percent of Total Billed charges,90% of Total Billed Charges,3189.53,7232.5,
EKOS 6F (40CM) 135CM CATHETER,2720002359,CDM,272,RC,C1887,HCPCS,Outpatient,,,7232.50,4701.13,,7232.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5496.7,76,,1504.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5207.4,72,,33.648,Percent of Total Billed Charges,72% of Total Billed Charges,5424.38,75,,35.056,Percent of Total Billed charges,75% of Total Billed Charges,7232.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5207.4,72,,33.648,Percent of Total Billed Charges,72% of Total Billed Charges,4339.5,60,,28.04,Percent of Total Billed Charges,60% of Total Billed Charges,6509.25,90,,1782,Percent of Total Billed Charges,90% of Total Billed Charges,3254.63,45,,891,Percent of Total Billed Charges,45% of Total Billed Charges,6509.25,90,,1782,Percent of Total Billed Charges,90% of Total billed Charges,7232.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7232.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7232.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4701.13,65,,1287,Percent of total Billed Charges,65% of Total Billed Charges,3189.53,44.1,,873.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,6870.88,95,,1881,Percent of Total Billed Charges,95% of Total Billed Charges,7232.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6364.6,88,,1742.4,Percent of Total Billed Charges,88% of Total Billed Charges,6509.25,90,,1782,Percent of Total Billed charges,90% of Total Billed Charges,3189.53,7232.5,
EKOS 6F (50CM) 135CM CATHETER,2720002360,CDM,272,RC,C1887,HCPCS,Outpatient,,,7232.50,4701.13,,7232.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5496.7,76,,1352.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5207.4,72,,120.384,Percent of Total Billed Charges,72% of Total Billed Charges,5424.38,75,,125.4,Percent of Total Billed charges,75% of Total Billed Charges,7232.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5207.4,72,,120.384,Percent of Total Billed Charges,72% of Total Billed Charges,4339.5,60,,100.32,Percent of Total Billed Charges,60% of Total Billed Charges,6509.25,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,3254.63,45,,801,Percent of Total Billed Charges,45% of Total Billed Charges,6509.25,90,,1602,Percent of Total Billed Charges,90% of Total billed Charges,7232.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7232.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7232.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4701.13,65,,1287,Percent of total Billed Charges,65% of Total Billed Charges,3189.53,44.1,,784.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,6870.88,95,,1691,Percent of Total Billed Charges,95% of Total Billed Charges,7232.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6364.6,88,,1566.4,Percent of Total Billed Charges,88% of Total Billed Charges,6509.25,90,,1602,Percent of Total Billed charges,90% of Total Billed Charges,3189.53,7232.5,
Gown 2728 Surg Imp SLV XL LF,2720002361,CDM,272,RC,,,Outpatient,,,6.98,4.54,,6.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.3,76,,1504.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.03,72,,89.28,Percent of Total Billed Charges,72% of Total Billed Charges,5.24,75,,93,Percent of Total Billed charges,75% of Total Billed Charges,6.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.03,72,,89.28,Percent of Total Billed Charges,72% of Total Billed Charges,4.19,60,,74.4,Percent of Total Billed Charges,60% of Total Billed Charges,6.28,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,3.14,45,,891,Percent of Total Billed Charges,45% of Total Billed Charges,6.28,90,,1782,Percent of Total Billed Charges,90% of Total billed Charges,6.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.54,65,,1157,Percent of total Billed Charges,65% of Total Billed Charges,3.08,44.1,,873.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.63,95,,1881,Percent of Total Billed Charges,95% of Total Billed Charges,6.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.14,88,,1742.4,Percent of Total Billed Charges,88% of Total Billed Charges,6.28,90,,1782,Percent of Total Billed charges,90% of Total Billed Charges,3.08,6.98,
ADMIRAL 6F 6MM X 40MM X 130CM,2720002362,CDM,272,RC,C2623,HCPCS,Outpatient,,,3525.00,2291.25,,3525,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2679,76,,1504.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2538,72,,208.256,Percent of Total Billed Charges,72% of Total Billed Charges,2643.75,75,,216.928,Percent of Total Billed charges,75% of Total Billed Charges,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2538,72,,208.256,Percent of Total Billed Charges,72% of Total Billed Charges,2115,60,,173.544,Percent of Total Billed Charges,60% of Total Billed Charges,3172.5,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,1586.25,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,3172.5,90,,1782,Percent of Total Billed Charges,90% of Total billed Charges,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2291.25,65,,1287,Percent of total Billed Charges,65% of Total Billed Charges,1554.53,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,3348.75,95,,1881,Percent of Total Billed Charges,95% of Total Billed Charges,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3102,88,,1742.4,Percent of Total Billed Charges,88% of Total Billed Charges,3172.5,90,,1782,Percent of Total Billed charges,90% of Total Billed Charges,1554.53,3525,
ADMIRAL 7F 6MM X 120MM X 130CM,2720002363,CDM,272,RC,C2623,HCPCS,Outpatient,,,3525.00,2291.25,,3525,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2679,76,,1352.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2538,72,,154.856,Percent of Total Billed Charges,72% of Total Billed Charges,2643.75,75,,161.312,Percent of Total Billed charges,75% of Total Billed Charges,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2538,72,,154.856,Percent of Total Billed Charges,72% of Total Billed Charges,2115,60,,129.048,Percent of Total Billed Charges,60% of Total Billed Charges,3172.5,90,,423,Percent of Total Billed Charges,90% of Total Billed Charges,1586.25,45,,891,Percent of Total Billed Charges,45% of Total Billed Charges,3172.5,90,,1602,Percent of Total Billed Charges,90% of Total billed Charges,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2291.25,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,1554.53,44.1,,873.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,3348.75,95,,1691,Percent of Total Billed Charges,95% of Total Billed Charges,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3102,88,,1566.4,Percent of Total Billed Charges,88% of Total Billed Charges,3172.5,90,,1602,Percent of Total Billed charges,90% of Total Billed Charges,1554.53,3525,
ADMIRAL 6F 6MM X 150MM X 150CM,2720002364,CDM,272,RC,C2623,HCPCS,Outpatient,,,4475.00,2908.75,,4475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3401,76,,1504.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3222,72,,43.96,Percent of Total Billed Charges,72% of Total Billed Charges,3356.25,75,,45.792,Percent of Total Billed charges,75% of Total Billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3222,72,,43.96,Percent of Total Billed Charges,72% of Total Billed Charges,2685,60,,36.632,Percent of Total Billed Charges,60% of Total Billed Charges,4027.5,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,2013.75,45,,891,Percent of Total Billed Charges,45% of Total Billed Charges,4027.5,90,,1782,Percent of Total Billed Charges,90% of Total billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2908.75,65,,1287,Percent of total Billed Charges,65% of Total Billed Charges,1973.48,44.1,,873.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,4251.25,95,,1881,Percent of Total Billed Charges,95% of Total Billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3938,88,,1742.4,Percent of Total Billed Charges,88% of Total Billed Charges,4027.5,90,,1782,Percent of Total Billed charges,90% of Total Billed Charges,1973.48,4475,
ADMIRAL 6F 6MM X 200MM X 130CM,2720002365,CDM,272,RC,C2623,HCPCS,Outpatient,,,5612.50,3648.13,,5612.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4265.5,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4041,72,,43.96,Percent of Total Billed Charges,72% of Total Billed Charges,4209.38,75,,45.792,Percent of Total Billed charges,75% of Total Billed Charges,5612.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4041,72,,43.96,Percent of Total Billed Charges,72% of Total Billed Charges,3367.5,60,,36.632,Percent of Total Billed Charges,60% of Total Billed Charges,5051.25,90,,2322,Percent of Total Billed Charges,90% of Total Billed Charges,2525.63,45,,891,Percent of Total Billed Charges,45% of Total Billed Charges,5051.25,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,5612.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5612.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5612.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3648.13,65,,1287,Percent of total Billed Charges,65% of Total Billed Charges,2475.11,44.1,,873.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,5331.88,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,5612.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4939,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,5051.25,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,2475.11,5612.5,
ADMIRAL 7F 7MM X 60MM X 130CM,2720002366,CDM,272,RC,C2623,HCPCS,Outpatient,,,3525.00,2291.25,,3525,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2679,76,,1504.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2538,72,,175.912,Percent of Total Billed Charges,72% of Total Billed Charges,2643.75,75,,183.24,Percent of Total Billed charges,75% of Total Billed Charges,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2538,72,,175.912,Percent of Total Billed Charges,72% of Total Billed Charges,2115,60,,146.592,Percent of Total Billed Charges,60% of Total Billed Charges,3172.5,90,,42.928,Percent of Total Billed Charges,90% of Total Billed Charges,1586.25,45,,891,Percent of Total Billed Charges,45% of Total Billed Charges,3172.5,90,,1782,Percent of Total Billed Charges,90% of Total billed Charges,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2291.25,65,,1287,Percent of total Billed Charges,65% of Total Billed Charges,1554.53,44.1,,873.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,3348.75,95,,1881,Percent of Total Billed Charges,95% of Total Billed Charges,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3102,88,,1742.4,Percent of Total Billed Charges,88% of Total Billed Charges,3172.5,90,,1782,Percent of Total Billed charges,90% of Total Billed Charges,1554.53,3525,
INPACT AV 6F 6MM X 40MM X 80CM,2720002367,CDM,272,RC,C2623,HCPCS,Outpatient,,,3725.00,2421.25,,3725,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2831,76,,1504.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2682,72,,19.44,Percent of Total Billed Charges,72% of Total Billed Charges,2793.75,75,,20.248,Percent of Total Billed charges,75% of Total Billed Charges,3725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2682,72,,19.44,Percent of Total Billed Charges,72% of Total Billed Charges,2235,60,,16.2,Percent of Total Billed Charges,60% of Total Billed Charges,3352.5,90,,203.856,Percent of Total Billed Charges,90% of Total Billed Charges,1676.25,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,3352.5,90,,1782,Percent of Total Billed Charges,90% of Total billed Charges,3725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2421.25,65,,1287,Percent of total Billed Charges,65% of Total Billed Charges,1642.73,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,3538.75,95,,1881,Percent of Total Billed Charges,95% of Total Billed Charges,3725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3278,88,,1742.4,Percent of Total Billed Charges,88% of Total Billed Charges,3352.5,90,,1782,Percent of Total Billed charges,90% of Total Billed Charges,1642.73,3725,
INPACT AV 6F 6MM X 60MM X 80CM,2720002368,CDM,272,RC,C2623,HCPCS,Outpatient,,,3725.00,2421.25,,3725,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2831,76,,1504.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2682,72,,19.44,Percent of Total Billed Charges,72% of Total Billed Charges,2793.75,75,,20.248,Percent of Total Billed charges,75% of Total Billed Charges,3725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2682,72,,19.44,Percent of Total Billed Charges,72% of Total Billed Charges,2235,60,,16.2,Percent of Total Billed Charges,60% of Total Billed Charges,3352.5,90,,203.856,Percent of Total Billed Charges,90% of Total Billed Charges,1676.25,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,3352.5,90,,1782,Percent of Total Billed Charges,90% of Total billed Charges,3725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2421.25,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,1642.73,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,3538.75,95,,1881,Percent of Total Billed Charges,95% of Total Billed Charges,3725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3278,88,,1742.4,Percent of Total Billed Charges,88% of Total Billed Charges,3352.5,90,,1782,Percent of Total Billed charges,90% of Total Billed Charges,1642.73,3725,
INPACT AV 7F 7MM X 40MM X 80CM,2720002369,CDM,272,RC,C2623,HCPCS,Outpatient,,,3725.00,2421.25,,3725,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2831,76,,1504.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2682,72,,19.44,Percent of Total Billed Charges,72% of Total Billed Charges,2793.75,75,,20.248,Percent of Total Billed charges,75% of Total Billed Charges,3725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2682,72,,19.44,Percent of Total Billed Charges,72% of Total Billed Charges,2235,60,,16.2,Percent of Total Billed Charges,60% of Total Billed Charges,3352.5,90,,203.856,Percent of Total Billed Charges,90% of Total Billed Charges,1676.25,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,3352.5,90,,1782,Percent of Total Billed Charges,90% of Total billed Charges,3725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2421.25,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,1642.73,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,3538.75,95,,1881,Percent of Total Billed Charges,95% of Total Billed Charges,3725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3278,88,,1742.4,Percent of Total Billed Charges,88% of Total Billed Charges,3352.5,90,,1782,Percent of Total Billed charges,90% of Total Billed Charges,1642.73,3725,
INPACT AV 7F 7MM X 60MM X 80CM,2720002370,CDM,272,RC,C2623,HCPCS,Outpatient,,,3725.00,2421.25,,3725,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2831,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2682,72,,19.44,Percent of Total Billed Charges,72% of Total Billed Charges,2793.75,75,,20.248,Percent of Total Billed charges,75% of Total Billed Charges,3725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2682,72,,19.44,Percent of Total Billed Charges,72% of Total Billed Charges,2235,60,,16.2,Percent of Total Billed Charges,60% of Total Billed Charges,3352.5,90,,203.856,Percent of Total Billed Charges,90% of Total Billed Charges,1676.25,45,,211.504,Percent of Total Billed Charges,45% of Total Billed Charges,3352.5,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,3725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2421.25,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,1642.73,44.1,,207.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,3538.75,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,3725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3278,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,3352.5,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,1642.73,3725,
INPACT AV 7F 8MM X 40MM X 80CM,2720002371,CDM,272,RC,C2623,HCPCS,Outpatient,,,4987.50,3241.88,,4987.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3790.5,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3591,72,,19.44,Percent of Total Billed Charges,72% of Total Billed Charges,3740.63,75,,20.248,Percent of Total Billed charges,75% of Total Billed Charges,4987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3591,72,,19.44,Percent of Total Billed Charges,72% of Total Billed Charges,2992.5,60,,16.2,Percent of Total Billed Charges,60% of Total Billed Charges,4488.75,90,,61.2,Percent of Total Billed Charges,90% of Total Billed Charges,2244.38,45,,45,Percent of Total Billed Charges,45% of Total Billed Charges,4488.75,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,4987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3241.88,65,,305.504,Percent of total Billed Charges,65% of Total Billed Charges,2199.49,44.1,,44.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,4738.13,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,4987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4389,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,4488.75,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,2199.49,4987.5,
INPACT AV 7F 8MM X 60MM X 80CM,2720002372,CDM,272,RC,C2623,HCPCS,Outpatient,,,4987.50,3241.88,,4987.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3790.5,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3591,72,,370.44,Percent of Total Billed Charges,72% of Total Billed Charges,3740.63,75,,385.872,Percent of Total Billed charges,75% of Total Billed Charges,4987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3591,72,,370.44,Percent of Total Billed Charges,72% of Total Billed Charges,2992.5,60,,308.696,Percent of Total Billed Charges,60% of Total Billed Charges,4488.75,90,,61.2,Percent of Total Billed Charges,90% of Total Billed Charges,2244.38,45,,1161,Percent of Total Billed Charges,45% of Total Billed Charges,4488.75,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,4987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3241.88,65,,65,Percent of total Billed Charges,65% of Total Billed Charges,2199.49,44.1,,1137.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,4738.13,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,4987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4389,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,4488.75,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,2199.49,4987.5,
Contra2 5F 65CM 0.035 Cath,2720002373,CDM,272,RC,C1887,HCPCS,Outpatient,,,60.50,39.33,,60.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.98,76,,357.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.56,72,,370.44,Percent of Total Billed Charges,72% of Total Billed Charges,45.38,75,,385.872,Percent of Total Billed charges,75% of Total Billed Charges,60.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.56,72,,370.44,Percent of Total Billed Charges,72% of Total Billed Charges,36.3,60,,308.696,Percent of Total Billed Charges,60% of Total Billed Charges,54.45,90,,8.448,Percent of Total Billed Charges,90% of Total Billed Charges,27.23,45,,21.464,Percent of Total Billed Charges,45% of Total Billed Charges,54.45,90,,423,Percent of Total Billed Charges,90% of Total billed Charges,60.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.33,65,,1677,Percent of total Billed Charges,65% of Total Billed Charges,26.68,44.1,,21.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.48,95,,446.504,Percent of Total Billed Charges,95% of Total Billed Charges,60.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.24,88,,413.6,Percent of Total Billed Charges,88% of Total Billed Charges,54.45,90,,423,Percent of Total Billed charges,90% of Total Billed Charges,26.68,60.5,
Teleport 2.1F x 135CM,2720002374,CDM,272,RC,C1887,HCPCS,Outpatient,,,1062.50,690.63,,1062.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,807.5,76,,76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,765,72,,4.16,Percent of Total Billed Charges,72% of Total Billed Charges,796.88,75,,4.336,Percent of Total Billed charges,75% of Total Billed Charges,1062.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,765,72,,4.16,Percent of Total Billed Charges,72% of Total Billed Charges,637.5,60,,3.464,Percent of Total Billed Charges,60% of Total Billed Charges,956.25,90,,128.704,Percent of Total Billed Charges,90% of Total Billed Charges,478.13,45,,101.928,Percent of Total Billed Charges,45% of Total Billed Charges,956.25,90,,90,Percent of Total Billed Charges,90% of Total billed Charges,1062.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1062.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1062.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,690.63,65,,31,Percent of total Billed Charges,65% of Total Billed Charges,468.56,44.1,,99.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,1009.38,95,,95,Percent of Total Billed Charges,95% of Total Billed Charges,1062.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,935,88,,88,Percent of Total Billed Charges,88% of Total Billed Charges,956.25,90,,90,Percent of Total Billed charges,90% of Total Billed Charges,468.56,1062.5,
Teleport 2.1F x 150CM,2720002375,CDM,272,RC,C1887,HCPCS,Outpatient,,,1062.50,690.63,,1062.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,807.5,76,,1960.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,765,72,,257.04,Percent of Total Billed Charges,72% of Total Billed Charges,796.88,75,,267.752,Percent of Total Billed charges,75% of Total Billed Charges,1062.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,765,72,,257.04,Percent of Total Billed Charges,72% of Total Billed Charges,637.5,60,,214.2,Percent of Total Billed Charges,60% of Total Billed Charges,956.25,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,478.13,45,,101.928,Percent of Total Billed Charges,45% of Total Billed Charges,956.25,90,,2322,Percent of Total Billed Charges,90% of Total billed Charges,1062.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1062.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1062.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,690.63,65,,147.224,Percent of total Billed Charges,65% of Total Billed Charges,468.56,44.1,,99.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,1009.38,95,,2451,Percent of Total Billed Charges,95% of Total Billed Charges,1062.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,935,88,,2270.4,Percent of Total Billed Charges,88% of Total Billed Charges,956.25,90,,2322,Percent of Total Billed charges,90% of Total Billed Charges,468.56,1062.5,
VIPER FT WIRE 0.014 X 335CM,2720002376,CDM,272,RC,C1769,HCPCS,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,36.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,122.208,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,127.304,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,122.208,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,101.84,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,450,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,101.928,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,42.928,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,147.224,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,99.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,45.312,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,41.976,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,42.928,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
VIPER FT WIRE 0.018 X 335CM,2720002377,CDM,272,RC,C1769,HCPCS,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,172.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,122.208,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,127.304,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,122.208,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,101.84,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,2511,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,101.928,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,203.856,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,147.224,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,99.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,215.176,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,199.32,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,203.856,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
WIRION EPD (FILTERWIRE),2720002378,CDM,272,RC,C1884,HCPCS,Outpatient,,,2375.00,1543.75,,2375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1805,76,,172.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1710,72,,3.112,Percent of Total Billed Charges,72% of Total Billed Charges,1781.25,75,,3.24,Percent of Total Billed charges,75% of Total Billed Charges,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1710,72,,3.112,Percent of Total Billed Charges,72% of Total Billed Charges,1425,60,,2.592,Percent of Total Billed Charges,60% of Total Billed Charges,2137.5,90,,28.32,Percent of Total Billed Charges,90% of Total Billed Charges,1068.75,45,,30.6,Percent of Total Billed Charges,45% of Total Billed Charges,2137.5,90,,203.856,Percent of Total Billed Charges,90% of Total billed Charges,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1543.75,65,,147.224,Percent of total Billed Charges,65% of Total Billed Charges,1047.38,44.1,,29.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,2256.25,95,,215.176,Percent of Total Billed Charges,95% of Total Billed Charges,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2090,88,,199.32,Percent of Total Billed Charges,88% of Total Billed Charges,2137.5,90,,203.856,Percent of Total Billed charges,90% of Total Billed Charges,1047.38,2375,
DIAMONDBACK PSC 1.25MM 145CM,2720002379,CDM,272,RC,C1724,HCPCS,Outpatient,,,8487.50,5516.88,,8487.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6450.5,76,,172.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6111,72,,157.88,Percent of Total Billed Charges,72% of Total Billed Charges,6365.63,75,,164.464,Percent of Total Billed charges,75% of Total Billed Charges,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6111,72,,157.88,Percent of Total Billed Charges,72% of Total Billed Charges,5092.5,60,,131.568,Percent of Total Billed Charges,60% of Total Billed Charges,7638.75,90,,20.416,Percent of Total Billed Charges,90% of Total Billed Charges,3819.38,45,,30.6,Percent of Total Billed Charges,45% of Total Billed Charges,7638.75,90,,203.856,Percent of Total Billed Charges,90% of Total billed Charges,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5516.88,65,,44.2,Percent of total Billed Charges,65% of Total Billed Charges,3742.99,44.1,,29.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,8063.13,95,,215.176,Percent of Total Billed Charges,95% of Total Billed Charges,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7469,88,,199.32,Percent of Total Billed Charges,88% of Total Billed Charges,7638.75,90,,203.856,Percent of Total Billed charges,90% of Total Billed Charges,3742.99,8487.5,
DIAMONDBACK PCC 1.5MM 145CM,2720002380,CDM,272,RC,C1724,HCPCS,Outpatient,,,8487.50,5516.88,,8487.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6450.5,76,,172.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6111,72,,295.2,Percent of Total Billed Charges,72% of Total Billed Charges,6365.63,75,,307.504,Percent of Total Billed charges,75% of Total Billed Charges,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6111,72,,295.2,Percent of Total Billed Charges,72% of Total Billed Charges,5092.5,60,,246,Percent of Total Billed Charges,60% of Total Billed Charges,7638.75,90,,44.32,Percent of Total Billed Charges,90% of Total Billed Charges,3819.38,45,,4.224,Percent of Total Billed Charges,45% of Total Billed Charges,7638.75,90,,203.856,Percent of Total Billed Charges,90% of Total billed Charges,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5516.88,65,,44.2,Percent of total Billed Charges,65% of Total Billed Charges,3742.99,44.1,,4.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,8063.13,95,,215.176,Percent of Total Billed Charges,95% of Total Billed Charges,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7469,88,,199.32,Percent of Total Billed Charges,88% of Total Billed Charges,7638.75,90,,203.856,Percent of Total Billed charges,90% of Total Billed Charges,3742.99,8487.5,
DIAMONDBACK PCC 2MM 145CM,2720002381,CDM,272,RC,C1724,HCPCS,Outpatient,,,8487.50,5516.88,,8487.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6450.5,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6111,72,,12.672,Percent of Total Billed Charges,72% of Total Billed Charges,6365.63,75,,13.2,Percent of Total Billed charges,75% of Total Billed Charges,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6111,72,,12.672,Percent of Total Billed Charges,72% of Total Billed Charges,5092.5,60,,10.56,Percent of Total Billed Charges,60% of Total Billed Charges,7638.75,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,3819.38,45,,64.352,Percent of Total Billed Charges,45% of Total Billed Charges,7638.75,90,,61.2,Percent of Total Billed Charges,90% of Total billed Charges,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5516.88,65,,6.096,Percent of total Billed Charges,65% of Total Billed Charges,3742.99,44.1,,63.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,8063.13,95,,64.6,Percent of Total Billed Charges,95% of Total Billed Charges,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7469,88,,59.84,Percent of Total Billed Charges,88% of Total Billed Charges,7638.75,90,,61.2,Percent of Total Billed charges,90% of Total Billed Charges,3742.99,8487.5,
DIAMONDBACK PSC 2MM 145CM,2720002382,CDM,272,RC,C1724,HCPCS,Outpatient,,,8487.50,5516.88,,8487.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6450.5,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6111,72,,79.2,Percent of Total Billed Charges,72% of Total Billed Charges,6365.63,75,,82.504,Percent of Total Billed charges,75% of Total Billed Charges,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6111,72,,79.2,Percent of Total Billed Charges,72% of Total Billed Charges,5092.5,60,,66,Percent of Total Billed Charges,60% of Total Billed Charges,7638.75,90,,66.6,Percent of Total Billed Charges,90% of Total Billed Charges,3819.38,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,7638.75,90,,61.2,Percent of Total Billed Charges,90% of Total billed Charges,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5516.88,65,,92.952,Percent of total Billed Charges,65% of Total Billed Charges,3742.99,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,8063.13,95,,64.6,Percent of Total Billed Charges,95% of Total Billed Charges,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7469,88,,59.84,Percent of Total Billed Charges,88% of Total Billed Charges,7638.75,90,,61.2,Percent of Total Billed charges,90% of Total Billed Charges,3742.99,8487.5,
DIAMONDBACK PMC 1.25MM 145CM,2720002383,CDM,272,RC,C1724,HCPCS,Outpatient,,,8487.50,5516.88,,8487.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6450.5,76,,7.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6111,72,,83.52,Percent of Total Billed Charges,72% of Total Billed Charges,6365.63,75,,87,Percent of Total Billed charges,75% of Total Billed Charges,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6111,72,,83.52,Percent of Total Billed Charges,72% of Total Billed Charges,5092.5,60,,69.6,Percent of Total Billed Charges,60% of Total Billed Charges,7638.75,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,3819.38,45,,225,Percent of Total Billed Charges,45% of Total Billed Charges,7638.75,90,,8.448,Percent of Total Billed Charges,90% of Total billed Charges,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5516.88,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,3742.99,44.1,,220.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,8063.13,95,,8.912,Percent of Total Billed Charges,95% of Total Billed Charges,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7469,88,,8.256,Percent of Total Billed Charges,88% of Total Billed Charges,7638.75,90,,8.448,Percent of Total Billed charges,90% of Total Billed Charges,3742.99,8487.5,
Admiral 5F 4MM x 250MM X 130CM,2720002384,CDM,272,RC,C2623,HCPCS,Outpatient,,,6175.00,4013.75,,6175,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4693,76,,108.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4446,72,,79.2,Percent of Total Billed Charges,72% of Total Billed Charges,4631.25,75,,82.504,Percent of Total Billed charges,75% of Total Billed Charges,6175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4446,72,,79.2,Percent of Total Billed Charges,72% of Total Billed Charges,3705,60,,66,Percent of Total Billed Charges,60% of Total Billed Charges,5557.5,90,,77.4,Percent of Total Billed Charges,90% of Total Billed Charges,2778.75,45,,1255.504,Percent of Total Billed Charges,45% of Total Billed Charges,5557.5,90,,128.704,Percent of Total Billed Charges,90% of Total billed Charges,6175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4013.75,65,,325,Percent of total Billed Charges,65% of Total Billed Charges,2723.18,44.1,,1230.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,5866.25,95,,135.848,Percent of Total Billed Charges,95% of Total Billed Charges,6175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5434,88,,125.84,Percent of Total Billed Charges,88% of Total Billed Charges,5557.5,90,,128.704,Percent of Total Billed charges,90% of Total Billed Charges,2723.18,6175,
Diamondback PSC 1.5MM 145CM,2720002385,CDM,272,RC,C1724,HCPCS,Outpatient,,,8487.50,5516.88,,8487.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6450.5,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6111,72,,83.52,Percent of Total Billed Charges,72% of Total Billed Charges,6365.63,75,,87,Percent of Total Billed charges,75% of Total Billed Charges,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6111,72,,83.52,Percent of Total Billed Charges,72% of Total Billed Charges,5092.5,60,,69.6,Percent of Total Billed Charges,60% of Total Billed Charges,7638.75,90,,106.2,Percent of Total Billed Charges,90% of Total Billed Charges,3819.38,45,,14.16,Percent of Total Billed Charges,45% of Total Billed Charges,7638.75,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5516.88,65,,1813.504,Percent of total Billed Charges,65% of Total Billed Charges,3742.99,44.1,,13.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,8063.13,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,8487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7469,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,7638.75,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,3742.99,8487.5,
Viperslide 100ml Bag,2720002386,CDM,272,RC,,,Outpatient,,,210.00,136.50,,210,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,159.6,76,,380,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,151.2,72,,79.2,Percent of Total Billed Charges,72% of Total Billed Charges,157.5,75,,82.504,Percent of Total Billed charges,75% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.2,72,,79.2,Percent of Total Billed Charges,72% of Total Billed Charges,126,60,,66,Percent of Total Billed Charges,60% of Total Billed Charges,189,90,,45,Percent of Total Billed Charges,90% of Total Billed Charges,94.5,45,,10.208,Percent of Total Billed Charges,45% of Total Billed Charges,189,90,,450,Percent of Total Billed Charges,90% of Total billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.5,65,,20.448,Percent of total Billed Charges,65% of Total Billed Charges,92.61,44.1,,10,Percent of Total Billed Charges,44.1% of Total Billed Charges,199.5,95,,475,Percent of Total Billed Charges,95% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.8,88,,440,Percent of Total Billed Charges,88% of Total Billed Charges,189,90,,450,Percent of Total Billed charges,90% of Total Billed Charges,92.61,210,
Trailblazer 4F 0.014 x 135CM,2720002387,CDM,272,RC,C1887,HCPCS,Outpatient,,,326.00,211.90,,326,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,247.76,76,,2120.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,234.72,72,,83.52,Percent of Total Billed Charges,72% of Total Billed Charges,244.5,75,,87,Percent of Total Billed charges,75% of Total Billed Charges,326,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.72,72,,83.52,Percent of Total Billed Charges,72% of Total Billed Charges,195.6,60,,69.6,Percent of Total Billed Charges,60% of Total Billed Charges,293.4,90,,45,Percent of Total Billed Charges,90% of Total Billed Charges,146.7,45,,22.16,Percent of Total Billed Charges,45% of Total Billed Charges,293.4,90,,2511,Percent of Total Billed Charges,90% of Total billed Charges,326,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.9,65,,14.744,Percent of total Billed Charges,65% of Total Billed Charges,143.77,44.1,,21.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,309.7,95,,2650.504,Percent of Total Billed Charges,95% of Total Billed Charges,326,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.88,88,,2455.2,Percent of Total Billed Charges,88% of Total Billed Charges,293.4,90,,2511,Percent of Total Billed charges,90% of Total Billed Charges,143.77,326,
Slender 7F 10CM DW 60-1070 GS,2720002388,CDM,272,RC,C1894,HCPCS,Outpatient,,,265.63,172.66,,265.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,201.88,76,,23.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,191.25,72,,79.2,Percent of Total Billed Charges,72% of Total Billed Charges,199.22,75,,82.504,Percent of Total Billed charges,75% of Total Billed Charges,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.25,72,,79.2,Percent of Total Billed Charges,72% of Total Billed Charges,159.38,60,,66,Percent of Total Billed Charges,60% of Total Billed Charges,239.07,90,,45,Percent of Total Billed Charges,90% of Total Billed Charges,119.53,45,,45,Percent of Total Billed Charges,45% of Total Billed Charges,239.07,90,,28.32,Percent of Total Billed Charges,90% of Total billed Charges,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.66,65,,32.008,Percent of total Billed Charges,65% of Total Billed Charges,117.14,44.1,,44.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,252.35,95,,29.888,Percent of Total Billed Charges,95% of Total Billed Charges,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.75,88,,27.688,Percent of Total Billed Charges,88% of Total Billed Charges,239.07,90,,28.32,Percent of Total Billed charges,90% of Total Billed Charges,117.14,265.63,
Kit Needle guide 21G 96 PR CVR,2720002389,CDM,272,RC,,,Outpatient,,,62.60,40.69,,62.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.58,76,,17.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.07,72,,83.52,Percent of Total Billed Charges,72% of Total Billed Charges,46.95,75,,87,Percent of Total Billed charges,75% of Total Billed Charges,62.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.07,72,,83.52,Percent of Total Billed Charges,72% of Total Billed Charges,37.56,60,,69.6,Percent of Total Billed Charges,60% of Total Billed Charges,56.34,90,,45,Percent of Total Billed Charges,90% of Total Billed Charges,28.17,45,,33.304,Percent of Total Billed Charges,45% of Total Billed Charges,56.34,90,,20.416,Percent of Total Billed Charges,90% of Total billed Charges,62.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.69,65,,65,Percent of total Billed Charges,65% of Total Billed Charges,27.61,44.1,,32.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.47,95,,21.544,Percent of Total Billed Charges,95% of Total Billed Charges,62.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.09,88,,19.96,Percent of Total Billed Charges,88% of Total Billed Charges,56.34,90,,20.416,Percent of Total Billed charges,90% of Total Billed Charges,27.61,62.6,
Launcher 7F EBU 3.0 Guide,2720002390,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,37.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,79.2,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,82.504,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,79.2,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,66,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,45,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,44.32,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,48.104,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,46.776,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,43.328,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,44.32,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
Launcher 7F EBU 3.0 SH Guide,2720002391,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,83.52,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,87,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,83.52,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,69.6,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,99,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,38.704,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,90,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,37.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,95,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,88,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,90,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
Launcher 7F EBU 3.5 90CM Guide,2720002392,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,56.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,89.968,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,93.72,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,89.968,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,74.976,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,99,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,53.104,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,66.6,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,55.904,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,52.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,70.304,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,65.12,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,66.6,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
"Urinary Drain Bags, sterile",2720002393,CDM,272,RC,,,Outpatient,,,8.30,5.40,,8.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.31,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.98,72,,114.52,Percent of Total Billed Charges,72% of Total Billed Charges,6.23,75,,119.296,Percent of Total Billed charges,75% of Total Billed Charges,8.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.98,72,,114.52,Percent of Total Billed Charges,72% of Total Billed Charges,4.98,60,,95.432,Percent of Total Billed Charges,60% of Total Billed Charges,7.47,90,,61.56,Percent of Total Billed Charges,90% of Total Billed Charges,3.74,45,,22.504,Percent of Total Billed Charges,45% of Total Billed Charges,7.47,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,8.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.4,65,,76.704,Percent of total Billed Charges,65% of Total Billed Charges,3.66,44.1,,22.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.89,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,8.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.3,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,7.47,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,3.66,8.3,
SLENDER 5F NI KIT 10CM 50-1050,2720002394,CDM,272,RC,C1894,HCPCS,Outpatient,,,265.63,172.66,,265.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,201.88,76,,65.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,191.25,72,,396,Percent of Total Billed Charges,72% of Total Billed Charges,199.22,75,,412.504,Percent of Total Billed charges,75% of Total Billed Charges,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.25,72,,396,Percent of Total Billed Charges,72% of Total Billed Charges,159.38,60,,330,Percent of Total Billed Charges,60% of Total Billed Charges,239.07,90,,61.56,Percent of Total Billed Charges,90% of Total Billed Charges,119.53,45,,22.504,Percent of Total Billed Charges,45% of Total Billed Charges,239.07,90,,77.4,Percent of Total Billed Charges,90% of Total billed Charges,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.66,65,,32.504,Percent of total Billed Charges,65% of Total Billed Charges,117.14,44.1,,22.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,252.35,95,,81.704,Percent of Total Billed Charges,95% of Total Billed Charges,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.75,88,,75.68,Percent of Total Billed Charges,88% of Total Billed Charges,239.07,90,,77.4,Percent of Total Billed charges,90% of Total Billed Charges,117.14,265.63,
SLENDER 6F NI KIT 10CM 50-1060,2720002395,CDM,272,RC,C1894,HCPCS,Outpatient,,,265.63,172.66,,265.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,201.88,76,,89.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,191.25,72,,341.28,Percent of Total Billed Charges,72% of Total Billed Charges,199.22,75,,355.504,Percent of Total Billed charges,75% of Total Billed Charges,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.25,72,,341.28,Percent of Total Billed Charges,72% of Total Billed Charges,159.38,60,,284.4,Percent of Total Billed Charges,60% of Total Billed Charges,239.07,90,,333,Percent of Total Billed Charges,90% of Total Billed Charges,119.53,45,,22.504,Percent of Total Billed Charges,45% of Total Billed Charges,239.07,90,,106.2,Percent of Total Billed Charges,90% of Total billed Charges,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.66,65,,32.504,Percent of total Billed Charges,65% of Total Billed Charges,117.14,44.1,,22.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,252.35,95,,112.104,Percent of Total Billed Charges,95% of Total Billed Charges,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.75,88,,103.84,Percent of Total Billed Charges,88% of Total Billed Charges,239.07,90,,106.2,Percent of Total Billed charges,90% of Total Billed Charges,117.14,265.63,
SLENDER 7F NI KIT 10CM 50-1070,2720002396,CDM,272,RC,C1894,HCPCS,Outpatient,,,265.63,172.66,,265.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,201.88,76,,38,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,191.25,72,,48.52,Percent of Total Billed Charges,72% of Total Billed Charges,199.22,75,,50.536,Percent of Total Billed charges,75% of Total Billed Charges,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.25,72,,48.52,Percent of Total Billed Charges,72% of Total Billed Charges,159.38,60,,40.432,Percent of Total Billed Charges,60% of Total Billed Charges,239.07,90,,450,Percent of Total Billed Charges,90% of Total Billed Charges,119.53,45,,22.504,Percent of Total Billed Charges,45% of Total Billed Charges,239.07,90,,45,Percent of Total Billed Charges,90% of Total billed Charges,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.66,65,,32.504,Percent of total Billed Charges,65% of Total Billed Charges,117.14,44.1,,22.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,252.35,95,,47.504,Percent of Total Billed Charges,95% of Total Billed Charges,265.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.75,88,,44,Percent of Total Billed Charges,88% of Total Billed Charges,239.07,90,,45,Percent of Total Billed charges,90% of Total Billed Charges,117.14,265.63,
Disposable Tips (Bilichek),2720002397,CDM,272,RC,,,Outpatient,,,14.05,9.13,,14.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.68,76,,38,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.12,72,,46.256,Percent of Total Billed Charges,72% of Total Billed Charges,10.54,75,,48.184,Percent of Total Billed charges,75% of Total Billed Charges,14.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.12,72,,46.256,Percent of Total Billed Charges,72% of Total Billed Charges,8.43,60,,38.544,Percent of Total Billed Charges,60% of Total Billed Charges,12.65,90,,450,Percent of Total Billed Charges,90% of Total Billed Charges,6.32,45,,22.504,Percent of Total Billed Charges,45% of Total Billed Charges,12.65,90,,45,Percent of Total Billed Charges,90% of Total billed Charges,14.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.13,65,,32.504,Percent of total Billed Charges,65% of Total Billed Charges,6.2,44.1,,22.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.35,95,,47.504,Percent of Total Billed Charges,95% of Total Billed Charges,14.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.36,88,,44,Percent of Total Billed Charges,88% of Total Billed Charges,12.65,90,,45,Percent of Total Billed charges,90% of Total Billed Charges,6.2,14.05,
Microline Disp Cobra,2720002398,CDM,272,RC,,,Outpatient,,,144.35,93.83,,144.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,109.71,76,,38,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,103.93,72,,2347.2,Percent of Total Billed Charges,72% of Total Billed Charges,108.26,75,,2445,Percent of Total Billed charges,75% of Total Billed Charges,144.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.93,72,,2347.2,Percent of Total Billed Charges,72% of Total Billed Charges,86.61,60,,1956,Percent of Total Billed Charges,60% of Total Billed Charges,129.92,90,,178.944,Percent of Total Billed Charges,90% of Total Billed Charges,64.96,45,,49.504,Percent of Total Billed Charges,45% of Total Billed Charges,129.92,90,,45,Percent of Total Billed Charges,90% of Total billed Charges,144.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.83,65,,32.504,Percent of total Billed Charges,65% of Total Billed Charges,63.66,44.1,,48.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,137.13,95,,47.504,Percent of Total Billed Charges,95% of Total Billed Charges,144.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.03,88,,44,Percent of Total Billed Charges,88% of Total Billed Charges,129.92,90,,45,Percent of Total Billed charges,90% of Total Billed Charges,63.66,144.35,
Microline Disp Grabber,2720002399,CDM,272,RC,,,Outpatient,,,144.35,93.83,,144.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,109.71,76,,38,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,103.93,72,,2347.2,Percent of Total Billed Charges,72% of Total Billed Charges,108.26,75,,2445,Percent of Total Billed charges,75% of Total Billed Charges,144.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.93,72,,2347.2,Percent of Total Billed Charges,72% of Total Billed Charges,86.61,60,,1956,Percent of Total Billed Charges,60% of Total Billed Charges,129.92,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,64.96,45,,49.504,Percent of Total Billed Charges,45% of Total Billed Charges,129.92,90,,45,Percent of Total Billed Charges,90% of Total billed Charges,144.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.83,65,,71.504,Percent of total Billed Charges,65% of Total Billed Charges,63.66,44.1,,48.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,137.13,95,,47.504,Percent of Total Billed Charges,95% of Total Billed Charges,144.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.03,88,,44,Percent of Total Billed Charges,88% of Total Billed Charges,129.92,90,,45,Percent of Total Billed charges,90% of Total Billed Charges,63.66,144.35,
HEARTRAIL IKARI LEFT 5F IL3.5,2720002400,CDM,272,RC,C1887,HCPCS,Outpatient,,,210.00,136.50,,210,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,159.6,76,,38,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,151.2,72,,46.152,Percent of Total Billed Charges,72% of Total Billed Charges,157.5,75,,48.072,Percent of Total Billed charges,75% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.2,72,,46.152,Percent of Total Billed Charges,72% of Total Billed Charges,126,60,,38.456,Percent of Total Billed Charges,60% of Total Billed Charges,189,90,,2.112,Percent of Total Billed Charges,90% of Total Billed Charges,94.5,45,,30.784,Percent of Total Billed Charges,45% of Total Billed Charges,189,90,,45,Percent of Total Billed Charges,90% of Total billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.5,65,,71.504,Percent of total Billed Charges,65% of Total Billed Charges,92.61,44.1,,30.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,199.5,95,,47.504,Percent of Total Billed Charges,95% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.8,88,,44,Percent of Total Billed Charges,88% of Total Billed Charges,189,90,,45,Percent of Total Billed charges,90% of Total Billed Charges,92.61,210,
HEARTRAIL IKARI LEFT 5F IL4.0,2720002401,CDM,272,RC,C1887,HCPCS,Outpatient,,,210.00,136.50,,210,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,159.6,76,,83.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,151.2,72,,74.52,Percent of Total Billed Charges,72% of Total Billed Charges,157.5,75,,77.624,Percent of Total Billed charges,75% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.2,72,,74.52,Percent of Total Billed Charges,72% of Total Billed Charges,126,60,,62.096,Percent of Total Billed Charges,60% of Total Billed Charges,189,90,,7.96,Percent of Total Billed Charges,90% of Total Billed Charges,94.5,45,,30.784,Percent of Total Billed Charges,45% of Total Billed Charges,189,90,,99,Percent of Total Billed Charges,90% of Total billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.5,65,,44.464,Percent of total Billed Charges,65% of Total Billed Charges,92.61,44.1,,30.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,199.5,95,,104.504,Percent of Total Billed Charges,95% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.8,88,,96.8,Percent of Total Billed Charges,88% of Total Billed Charges,189,90,,99,Percent of Total Billed charges,90% of Total Billed Charges,92.61,210,
HEARTRAIL IKARI RIGHT 5F IR1.0,2720002402,CDM,272,RC,C1887,HCPCS,Outpatient,,,210.00,136.50,,210,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,159.6,76,,83.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,151.2,72,,270.976,Percent of Total Billed Charges,72% of Total Billed Charges,157.5,75,,282.272,Percent of Total Billed charges,75% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.2,72,,270.976,Percent of Total Billed Charges,72% of Total Billed Charges,126,60,,225.816,Percent of Total Billed Charges,60% of Total Billed Charges,189,90,,19.264,Percent of Total Billed Charges,90% of Total Billed Charges,94.5,45,,166.504,Percent of Total Billed Charges,45% of Total Billed Charges,189,90,,99,Percent of Total Billed Charges,90% of Total billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.5,65,,44.464,Percent of total Billed Charges,65% of Total Billed Charges,92.61,44.1,,163.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,199.5,95,,104.504,Percent of Total Billed Charges,95% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.8,88,,96.8,Percent of Total Billed Charges,88% of Total Billed Charges,189,90,,99,Percent of Total Billed charges,90% of Total Billed Charges,92.61,210,
HEARTRAIL IKARI RIGHT 5F IR1.5,2720002403,CDM,272,RC,C1887,HCPCS,Outpatient,,,210.00,136.50,,210,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,159.6,76,,51.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,151.2,72,,766.08,Percent of Total Billed Charges,72% of Total Billed Charges,157.5,75,,798,Percent of Total Billed charges,75% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.2,72,,766.08,Percent of Total Billed Charges,72% of Total Billed Charges,126,60,,638.4,Percent of Total Billed Charges,60% of Total Billed Charges,189,90,,113.4,Percent of Total Billed Charges,90% of Total Billed Charges,94.5,45,,225,Percent of Total Billed Charges,45% of Total Billed Charges,189,90,,61.56,Percent of Total Billed Charges,90% of Total billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.5,65,,240.504,Percent of total Billed Charges,65% of Total Billed Charges,92.61,44.1,,220.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,199.5,95,,64.984,Percent of Total Billed Charges,95% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.8,88,,60.192,Percent of Total Billed Charges,88% of Total Billed Charges,189,90,,61.56,Percent of Total Billed charges,90% of Total Billed Charges,92.61,210,
HEARTRAIL TIG MOD 5F 4.0,2720002404,CDM,272,RC,C1887,HCPCS,Outpatient,,,210.00,136.50,,210,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,159.6,76,,51.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,151.2,72,,88.096,Percent of Total Billed Charges,72% of Total Billed Charges,157.5,75,,91.768,Percent of Total Billed charges,75% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.2,72,,88.096,Percent of Total Billed Charges,72% of Total Billed Charges,126,60,,73.416,Percent of Total Billed Charges,60% of Total Billed Charges,189,90,,142.2,Percent of Total Billed Charges,90% of Total Billed Charges,94.5,45,,225,Percent of Total Billed Charges,45% of Total Billed Charges,189,90,,61.56,Percent of Total Billed Charges,90% of Total billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.5,65,,325,Percent of total Billed Charges,65% of Total Billed Charges,92.61,44.1,,220.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,199.5,95,,64.984,Percent of Total Billed Charges,95% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.8,88,,60.192,Percent of Total Billed Charges,88% of Total Billed Charges,189,90,,61.56,Percent of Total Billed charges,90% of Total Billed Charges,92.61,210,
HEARTRAIL IKARI LEFT 6F IL3.5,2720002405,CDM,272,RC,C1887,HCPCS,Outpatient,,,210.00,136.50,,210,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,159.6,76,,281.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,151.2,72,,1080,Percent of Total Billed Charges,72% of Total Billed Charges,157.5,75,,1125,Percent of Total Billed charges,75% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.2,72,,1080,Percent of Total Billed Charges,72% of Total Billed Charges,126,60,,900,Percent of Total Billed Charges,60% of Total Billed Charges,189,90,,427.952,Percent of Total Billed Charges,90% of Total Billed Charges,94.5,45,,89.472,Percent of Total Billed Charges,45% of Total Billed Charges,189,90,,333,Percent of Total Billed Charges,90% of Total billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.5,65,,325,Percent of total Billed Charges,65% of Total Billed Charges,92.61,44.1,,87.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,199.5,95,,351.504,Percent of Total Billed Charges,95% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.8,88,,325.6,Percent of Total Billed Charges,88% of Total Billed Charges,189,90,,333,Percent of Total Billed charges,90% of Total Billed Charges,92.61,210,
HEARTRAIL IKARI LEFT 6F IL3.75,2720002406,CDM,272,RC,C1887,HCPCS,Outpatient,,,210.00,136.50,,210,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,159.6,76,,380,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,151.2,72,,1604.344,Percent of Total Billed Charges,72% of Total Billed Charges,157.5,75,,1671.192,Percent of Total Billed charges,75% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.2,72,,1604.344,Percent of Total Billed Charges,72% of Total Billed Charges,126,60,,1336.952,Percent of Total Billed Charges,60% of Total Billed Charges,189,90,,34.632,Percent of Total Billed Charges,90% of Total Billed Charges,94.5,45,,8.728,Percent of Total Billed Charges,45% of Total Billed Charges,189,90,,450,Percent of Total Billed Charges,90% of Total billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.5,65,,129.232,Percent of total Billed Charges,65% of Total Billed Charges,92.61,44.1,,8.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,199.5,95,,475,Percent of Total Billed Charges,95% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.8,88,,440,Percent of Total Billed Charges,88% of Total Billed Charges,189,90,,450,Percent of Total Billed charges,90% of Total Billed Charges,92.61,210,
HEARTRAIL IKARI LEFT 6F IL4.0,2720002407,CDM,272,RC,C1887,HCPCS,Outpatient,,,210.00,136.50,,210,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,159.6,76,,380,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,151.2,72,,1230.408,Percent of Total Billed Charges,72% of Total Billed Charges,157.5,75,,1281.672,Percent of Total Billed charges,75% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.2,72,,1230.408,Percent of Total Billed Charges,72% of Total Billed Charges,126,60,,1025.336,Percent of Total Billed Charges,60% of Total Billed Charges,189,90,,55.896,Percent of Total Billed Charges,90% of Total Billed Charges,94.5,45,,1.056,Percent of Total Billed Charges,45% of Total Billed Charges,189,90,,450,Percent of Total Billed Charges,90% of Total billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.5,65,,12.608,Percent of total Billed Charges,65% of Total Billed Charges,92.61,44.1,,1.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,199.5,95,,475,Percent of Total Billed Charges,95% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.8,88,,440,Percent of Total Billed Charges,88% of Total Billed Charges,189,90,,450,Percent of Total Billed charges,90% of Total Billed Charges,92.61,210,
HEARTRAIL IKARI LEFT 6F IL4.5,2720002408,CDM,272,RC,C1887,HCPCS,Outpatient,,,210.00,136.50,,210,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,159.6,76,,151.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,151.2,72,,756,Percent of Total Billed Charges,72% of Total Billed Charges,157.5,75,,787.504,Percent of Total Billed charges,75% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.2,72,,756,Percent of Total Billed Charges,72% of Total Billed Charges,126,60,,630,Percent of Total Billed Charges,60% of Total Billed Charges,189,90,,52.368,Percent of Total Billed Charges,90% of Total Billed Charges,94.5,45,,3.976,Percent of Total Billed Charges,45% of Total Billed Charges,189,90,,178.944,Percent of Total Billed Charges,90% of Total billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.5,65,,1.52,Percent of total Billed Charges,65% of Total Billed Charges,92.61,44.1,,3.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,199.5,95,,188.88,Percent of Total Billed Charges,95% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.8,88,,174.968,Percent of Total Billed Charges,88% of Total Billed Charges,189,90,,178.944,Percent of Total Billed charges,90% of Total Billed Charges,92.61,210,
HEARTRAIL IKARI RIGHT 6F IR1.0,2720002409,CDM,272,RC,C1887,HCPCS,Outpatient,,,210.00,136.50,,210,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,159.6,76,,14.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,151.2,72,,10.656,Percent of Total Billed Charges,72% of Total Billed Charges,157.5,75,,11.104,Percent of Total Billed charges,75% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.2,72,,10.656,Percent of Total Billed Charges,72% of Total Billed Charges,126,60,,8.88,Percent of Total Billed Charges,60% of Total Billed Charges,189,90,,44.984,Percent of Total Billed Charges,90% of Total Billed Charges,94.5,45,,9.632,Percent of Total Billed Charges,45% of Total Billed Charges,189,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.5,65,,5.744,Percent of total Billed Charges,65% of Total Billed Charges,92.61,44.1,,9.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,199.5,95,,18.432,Percent of Total Billed Charges,95% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.8,88,,17.072,Percent of Total Billed Charges,88% of Total Billed Charges,189,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,92.61,210,
HEARTRAIL IKARI RIGHT 6F IR2.0,2720002410,CDM,272,RC,C1887,HCPCS,Outpatient,,,210.00,136.50,,210,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,159.6,76,,1.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,151.2,72,,23.04,Percent of Total Billed Charges,72% of Total Billed Charges,157.5,75,,24,Percent of Total Billed charges,75% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.2,72,,23.04,Percent of Total Billed Charges,72% of Total Billed Charges,126,60,,19.2,Percent of Total Billed Charges,60% of Total Billed Charges,189,90,,64.496,Percent of Total Billed Charges,90% of Total Billed Charges,94.5,45,,56.704,Percent of Total Billed Charges,45% of Total Billed Charges,189,90,,2.112,Percent of Total Billed Charges,90% of Total billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.5,65,,13.912,Percent of total Billed Charges,65% of Total Billed Charges,92.61,44.1,,55.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,199.5,95,,2.224,Percent of Total Billed Charges,95% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.8,88,,2.064,Percent of Total Billed Charges,88% of Total Billed Charges,189,90,,2.112,Percent of Total Billed charges,90% of Total Billed Charges,92.61,210,
LARYNGOSCOPE BLD DISP MAC SZ,2720002411,CDM,272,RC,,,Outpatient,,,11.68,7.59,,11.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.88,76,,6.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.41,72,,10.656,Percent of Total Billed Charges,72% of Total Billed Charges,8.76,75,,11.104,Percent of Total Billed charges,75% of Total Billed Charges,11.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.41,72,,10.656,Percent of Total Billed Charges,72% of Total Billed Charges,7.01,60,,8.88,Percent of Total Billed Charges,60% of Total Billed Charges,10.51,90,,18.888,Percent of Total Billed Charges,90% of Total Billed Charges,5.26,45,,71.104,Percent of Total Billed Charges,45% of Total Billed Charges,10.51,90,,7.96,Percent of Total Billed Charges,90% of Total billed Charges,11.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.59,65,,81.904,Percent of total Billed Charges,65% of Total Billed Charges,5.15,44.1,,69.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.1,95,,8.4,Percent of Total Billed Charges,95% of Total Billed Charges,11.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.28,88,,7.776,Percent of Total Billed Charges,88% of Total Billed Charges,10.51,90,,7.96,Percent of Total Billed charges,90% of Total Billed Charges,5.15,11.68,
"Catheter, IV Supercath sfty 14",2720002412,CDM,272,RC,,,Outpatient,,,5.58,3.63,,5.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.24,76,,16.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.02,72,,23.04,Percent of Total Billed Charges,72% of Total Billed Charges,4.19,75,,24,Percent of Total Billed charges,75% of Total Billed Charges,5.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.02,72,,23.04,Percent of Total Billed Charges,72% of Total Billed Charges,3.35,60,,19.2,Percent of Total Billed Charges,60% of Total Billed Charges,5.02,90,,18.888,Percent of Total Billed Charges,90% of Total Billed Charges,2.51,45,,213.976,Percent of Total Billed Charges,45% of Total Billed Charges,5.02,90,,19.264,Percent of Total Billed Charges,90% of Total billed Charges,5.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.63,65,,102.704,Percent of total Billed Charges,65% of Total Billed Charges,2.46,44.1,,209.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.3,95,,20.328,Percent of Total Billed Charges,95% of Total Billed Charges,5.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.91,88,,18.832,Percent of Total Billed Charges,88% of Total Billed Charges,5.02,90,,19.264,Percent of Total Billed charges,90% of Total Billed Charges,2.46,5.58,
STAYFIX SMALL 5F-14F (680ME),2720002413,CDM,272,RC,,,Outpatient,,,17.63,11.46,,17.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.4,76,,95.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.69,72,,10.656,Percent of Total Billed Charges,72% of Total Billed Charges,13.22,75,,11.104,Percent of Total Billed charges,75% of Total Billed Charges,17.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.69,72,,10.656,Percent of Total Billed Charges,72% of Total Billed Charges,10.58,60,,8.88,Percent of Total Billed Charges,60% of Total Billed Charges,15.87,90,,18.888,Percent of Total Billed Charges,90% of Total Billed Charges,7.93,45,,17.32,Percent of Total Billed Charges,45% of Total Billed Charges,15.87,90,,113.4,Percent of Total Billed Charges,90% of Total billed Charges,17.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.46,65,,309.08,Percent of total Billed Charges,65% of Total Billed Charges,7.77,44.1,,16.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.75,95,,119.704,Percent of Total Billed Charges,95% of Total Billed Charges,17.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.51,88,,110.88,Percent of Total Billed Charges,88% of Total Billed Charges,15.87,90,,113.4,Percent of Total Billed charges,90% of Total Billed Charges,7.77,17.63,
STAYFIX LARGE 12F-22F (685ME),2720002414,CDM,272,RC,,,Outpatient,,,20.13,13.08,,20.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.3,76,,120.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.49,72,,23.04,Percent of Total Billed Charges,72% of Total Billed Charges,15.1,75,,24,Percent of Total Billed charges,75% of Total Billed Charges,20.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.49,72,,23.04,Percent of Total Billed Charges,72% of Total Billed Charges,12.08,60,,19.2,Percent of Total Billed Charges,60% of Total Billed Charges,18.12,90,,26.032,Percent of Total Billed Charges,90% of Total Billed Charges,9.06,45,,27.944,Percent of Total Billed Charges,45% of Total Billed Charges,18.12,90,,142.2,Percent of Total Billed Charges,90% of Total billed Charges,20.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.08,65,,25.016,Percent of total Billed Charges,65% of Total Billed Charges,8.88,44.1,,27.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.12,95,,150.104,Percent of Total Billed Charges,95% of Total Billed Charges,20.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.71,88,,139.04,Percent of Total Billed Charges,88% of Total Billed Charges,18.12,90,,142.2,Percent of Total Billed charges,90% of Total Billed Charges,8.88,20.13,
Vacurette CU 14MM,2720002415,CDM,272,RC,,,Outpatient,,,11.25,7.31,,11.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.55,76,,361.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.1,72,,10.656,Percent of Total Billed Charges,72% of Total Billed Charges,8.44,75,,11.104,Percent of Total Billed charges,75% of Total Billed Charges,11.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.1,72,,10.656,Percent of Total Billed Charges,72% of Total Billed Charges,6.75,60,,8.88,Percent of Total Billed Charges,60% of Total Billed Charges,10.13,90,,25.152,Percent of Total Billed Charges,90% of Total Billed Charges,5.06,45,,26.184,Percent of Total Billed Charges,45% of Total Billed Charges,10.13,90,,427.952,Percent of Total Billed Charges,90% of Total billed Charges,11.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.31,65,,40.368,Percent of total Billed Charges,65% of Total Billed Charges,4.96,44.1,,25.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.69,95,,451.728,Percent of Total Billed Charges,95% of Total Billed Charges,11.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.9,88,,418.44,Percent of Total Billed Charges,88% of Total Billed Charges,10.13,90,,427.952,Percent of Total Billed charges,90% of Total Billed Charges,4.96,11.25,
Vacurette CU 16MM,2720002416,CDM,272,RC,,,Outpatient,,,11.25,7.31,,11.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.55,76,,29.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.1,72,,23.04,Percent of Total Billed Charges,72% of Total Billed Charges,8.44,75,,24,Percent of Total Billed charges,75% of Total Billed Charges,11.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.1,72,,23.04,Percent of Total Billed Charges,72% of Total Billed Charges,6.75,60,,19.2,Percent of Total Billed Charges,60% of Total Billed Charges,10.13,90,,11.256,Percent of Total Billed Charges,90% of Total Billed Charges,5.06,45,,22.496,Percent of Total Billed Charges,45% of Total Billed Charges,10.13,90,,34.632,Percent of Total Billed Charges,90% of Total billed Charges,11.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.31,65,,37.816,Percent of total Billed Charges,65% of Total Billed Charges,4.96,44.1,,22.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.69,95,,36.56,Percent of Total Billed Charges,95% of Total Billed Charges,11.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.9,88,,33.864,Percent of Total Billed Charges,88% of Total Billed Charges,10.13,90,,34.632,Percent of Total Billed charges,90% of Total Billed Charges,4.96,11.25,
Microline Atrau mod Raptor,2720002417,CDM,272,RC,,,Outpatient,,,127.50,82.88,,127.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,96.9,76,,47.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.8,72,,10.656,Percent of Total Billed Charges,72% of Total Billed Charges,95.63,75,,11.104,Percent of Total Billed charges,75% of Total Billed Charges,127.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.8,72,,10.656,Percent of Total Billed Charges,72% of Total Billed Charges,76.5,60,,8.88,Percent of Total Billed Charges,60% of Total Billed Charges,114.75,90,,45.904,Percent of Total Billed Charges,90% of Total Billed Charges,57.38,45,,32.248,Percent of Total Billed Charges,45% of Total Billed Charges,114.75,90,,55.896,Percent of Total Billed Charges,90% of Total billed Charges,127.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.88,65,,32.488,Percent of total Billed Charges,65% of Total Billed Charges,56.23,44.1,,31.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,121.13,95,,59,Percent of Total Billed Charges,95% of Total Billed Charges,127.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.2,88,,54.648,Percent of Total Billed Charges,88% of Total Billed Charges,114.75,90,,55.896,Percent of Total Billed charges,90% of Total Billed Charges,56.23,127.5,
Microline Hook Scissor,2720002418,CDM,272,RC,,,Outpatient,,,125.00,81.25,,125,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95,76,,44.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90,72,,23.04,Percent of Total Billed Charges,72% of Total Billed Charges,93.75,75,,24,Percent of Total Billed charges,75% of Total Billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,72,,23.04,Percent of Total Billed Charges,72% of Total Billed Charges,75,60,,19.2,Percent of Total Billed Charges,60% of Total Billed Charges,112.5,90,,310.504,Percent of Total Billed Charges,90% of Total Billed Charges,56.25,45,,9.44,Percent of Total Billed Charges,45% of Total Billed Charges,112.5,90,,52.368,Percent of Total Billed Charges,90% of Total billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.25,65,,46.584,Percent of total Billed Charges,65% of Total Billed Charges,55.13,44.1,,9.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,118.75,95,,55.272,Percent of Total Billed Charges,95% of Total Billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110,88,,51.2,Percent of Total Billed Charges,88% of Total Billed Charges,112.5,90,,52.368,Percent of Total Billed charges,90% of Total Billed Charges,55.13,125,
Gastrostomy Tube 16F (entuit),2720002419,CDM,272,RC,,,Outpatient,,,140.63,91.41,,140.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.88,76,,37.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.25,72,,10.656,Percent of Total Billed Charges,72% of Total Billed Charges,105.47,75,,11.104,Percent of Total Billed charges,75% of Total Billed Charges,140.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.25,72,,10.656,Percent of Total Billed Charges,72% of Total Billed Charges,84.38,60,,8.88,Percent of Total Billed Charges,60% of Total Billed Charges,126.57,90,,111.784,Percent of Total Billed Charges,90% of Total Billed Charges,63.28,45,,9.44,Percent of Total Billed Charges,45% of Total Billed Charges,126.57,90,,44.984,Percent of Total Billed Charges,90% of Total billed Charges,140.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.41,65,,13.64,Percent of total Billed Charges,65% of Total Billed Charges,62.02,44.1,,9.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,133.6,95,,47.488,Percent of Total Billed Charges,95% of Total Billed Charges,140.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.75,88,,43.984,Percent of Total Billed Charges,88% of Total Billed Charges,126.57,90,,44.984,Percent of Total Billed charges,90% of Total Billed Charges,62.02,140.63,
LMA #3 (Sub),2720002420,CDM,272,RC,,,Outpatient,,,18.65,12.12,,18.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.17,76,,54.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.43,72,,10.656,Percent of Total Billed Charges,72% of Total Billed Charges,13.99,75,,11.104,Percent of Total Billed charges,75% of Total Billed Charges,18.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.43,72,,10.656,Percent of Total Billed Charges,72% of Total Billed Charges,11.19,60,,8.88,Percent of Total Billed Charges,60% of Total Billed Charges,16.79,90,,15.608,Percent of Total Billed Charges,90% of Total Billed Charges,8.39,45,,9.44,Percent of Total Billed Charges,45% of Total Billed Charges,16.79,90,,64.496,Percent of Total Billed Charges,90% of Total billed Charges,18.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.12,65,,13.64,Percent of total Billed Charges,65% of Total Billed Charges,8.22,44.1,,9.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.72,95,,68.08,Percent of Total Billed Charges,95% of Total Billed Charges,18.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.41,88,,63.064,Percent of Total Billed Charges,88% of Total Billed Charges,16.79,90,,64.496,Percent of Total Billed charges,90% of Total Billed Charges,8.22,18.65,
Nasal Rae Tube Cuff 4.0 (Sub),2720002421,CDM,272,RC,,,Outpatient,,,17.75,11.54,,17.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.49,76,,15.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.78,72,,23.04,Percent of Total Billed Charges,72% of Total Billed Charges,13.31,75,,24,Percent of Total Billed charges,75% of Total Billed Charges,17.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.78,72,,23.04,Percent of Total Billed Charges,72% of Total Billed Charges,10.65,60,,19.2,Percent of Total Billed Charges,60% of Total Billed Charges,15.98,90,,410.136,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,45,,13.016,Percent of Total Billed Charges,45% of Total Billed Charges,15.98,90,,18.888,Percent of Total Billed Charges,90% of Total billed Charges,17.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.54,65,,13.64,Percent of total Billed Charges,65% of Total Billed Charges,7.83,44.1,,12.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.86,95,,19.936,Percent of Total Billed Charges,95% of Total Billed Charges,17.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.62,88,,18.464,Percent of Total Billed Charges,88% of Total Billed Charges,15.98,90,,18.888,Percent of Total Billed charges,90% of Total Billed Charges,7.83,17.75,
CAT RX KIT INDIGO 140CM,2720002422,CDM,272,RC,C1887,HCPCS,Outpatient,,,4750.00,3087.50,,4750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3610,76,,15.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3420,72,,10.656,Percent of Total Billed Charges,72% of Total Billed Charges,3562.5,75,,11.104,Percent of Total Billed charges,75% of Total Billed Charges,4750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3420,72,,10.656,Percent of Total Billed Charges,72% of Total Billed Charges,2850,60,,8.88,Percent of Total Billed Charges,60% of Total Billed Charges,4275,90,,410.136,Percent of Total Billed Charges,90% of Total Billed Charges,2137.5,45,,12.576,Percent of Total Billed Charges,45% of Total Billed Charges,4275,90,,18.888,Percent of Total Billed Charges,90% of Total billed Charges,4750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3087.5,65,,18.8,Percent of total Billed Charges,65% of Total Billed Charges,2094.75,44.1,,12.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,4512.5,95,,19.936,Percent of Total Billed Charges,95% of Total Billed Charges,4750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4180,88,,18.464,Percent of Total Billed Charges,88% of Total Billed Charges,4275,90,,18.888,Percent of Total Billed charges,90% of Total Billed Charges,2094.75,4750,
CAT LGHT XTORQ INDIGO 12 100CM,2720002423,CDM,272,RC,C1887,HCPCS,Outpatient,,,16925.00,11001.25,,16925,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12863,76,,15.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12186,72,,2030.4,Percent of Total Billed Charges,72% of Total Billed Charges,12693.75,75,,2115,Percent of Total Billed charges,75% of Total Billed Charges,16925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12186,72,,2030.4,Percent of Total Billed Charges,72% of Total Billed Charges,10155,60,,1692,Percent of Total Billed Charges,60% of Total Billed Charges,15232.5,90,,221.224,Percent of Total Billed Charges,90% of Total Billed Charges,7616.25,45,,5.624,Percent of Total Billed Charges,45% of Total Billed Charges,15232.5,90,,18.888,Percent of Total Billed Charges,90% of Total billed Charges,16925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11001.25,65,,18.16,Percent of total Billed Charges,65% of Total Billed Charges,7463.93,44.1,,5.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,16078.75,95,,19.936,Percent of Total Billed Charges,95% of Total Billed Charges,16925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14894,88,,18.464,Percent of Total Billed Charges,88% of Total Billed Charges,15232.5,90,,18.888,Percent of Total Billed charges,90% of Total Billed Charges,7463.93,16925,
SEPARATOR 12,2720002424,CDM,272,RC,C1757,HCPCS,Outpatient,,,4737.50,3079.38,,4737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3600.5,76,,21.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3411,72,,58.472,Percent of Total Billed Charges,72% of Total Billed Charges,3553.13,75,,60.912,Percent of Total Billed charges,75% of Total Billed Charges,4737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3411,72,,58.472,Percent of Total Billed Charges,72% of Total Billed Charges,2842.5,60,,48.728,Percent of Total Billed Charges,60% of Total Billed Charges,4263.75,90,,3159,Percent of Total Billed Charges,90% of Total Billed Charges,2131.88,45,,22.952,Percent of Total Billed Charges,45% of Total Billed Charges,4263.75,90,,26.032,Percent of Total Billed Charges,90% of Total billed Charges,4737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3079.38,65,,8.128,Percent of total Billed Charges,65% of Total Billed Charges,2089.24,44.1,,22.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,4500.63,95,,27.472,Percent of Total Billed Charges,95% of Total Billed Charges,4737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4169,88,,25.448,Percent of Total Billed Charges,88% of Total Billed Charges,4263.75,90,,26.032,Percent of Total Billed charges,90% of Total Billed Charges,2089.24,4737.5,
CAT LIGHT XTORQ INDIGO 7 130CM,2720002425,CDM,272,RC,C1887,HCPCS,Outpatient,,,13925.00,9051.25,,13925,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10583,76,,21.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10026,72,,9.936,Percent of Total Billed Charges,72% of Total Billed Charges,10443.75,75,,10.352,Percent of Total Billed charges,75% of Total Billed Charges,13925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10026,72,,9.936,Percent of Total Billed Charges,72% of Total Billed Charges,8355,60,,8.28,Percent of Total Billed Charges,60% of Total Billed Charges,12532.5,90,,3159,Percent of Total Billed Charges,90% of Total Billed Charges,6266.25,45,,155.248,Percent of Total Billed Charges,45% of Total Billed Charges,12532.5,90,,25.152,Percent of Total Billed Charges,90% of Total billed Charges,13925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9051.25,65,,33.152,Percent of total Billed Charges,65% of Total Billed Charges,6140.93,44.1,,152.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,13228.75,95,,26.544,Percent of Total Billed Charges,95% of Total Billed Charges,13925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12254,88,,24.592,Percent of Total Billed Charges,88% of Total Billed Charges,12532.5,90,,25.152,Percent of Total Billed charges,90% of Total Billed Charges,6140.93,13925,
SEPARATOR 7,2720002426,CDM,272,RC,C1757,HCPCS,Outpatient,,,4137.50,2689.38,,4137.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3144.5,76,,9.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2979,72,,9,Percent of Total Billed Charges,72% of Total Billed Charges,3103.13,75,,9.376,Percent of Total Billed charges,75% of Total Billed Charges,4137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2979,72,,9,Percent of Total Billed Charges,72% of Total Billed Charges,2482.5,60,,7.496,Percent of Total Billed Charges,60% of Total Billed Charges,3723.75,90,,130.808,Percent of Total Billed Charges,90% of Total Billed Charges,1861.88,45,,55.888,Percent of Total Billed Charges,45% of Total Billed Charges,3723.75,90,,11.256,Percent of Total Billed Charges,90% of Total billed Charges,4137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2689.38,65,,224.248,Percent of total Billed Charges,65% of Total Billed Charges,1824.64,44.1,,54.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3930.63,95,,11.88,Percent of Total Billed Charges,95% of Total Billed Charges,4137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3641,88,,11,Percent of Total Billed Charges,88% of Total Billed Charges,3723.75,90,,11.256,Percent of Total Billed charges,90% of Total Billed Charges,1824.64,4137.5,
DELEE CATH 8FR (SUB),2720002427,CDM,272,RC,,,Outpatient,,,3.15,2.05,,3.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.39,76,,38.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.27,72,,9,Percent of Total Billed Charges,72% of Total Billed Charges,2.36,75,,9.376,Percent of Total Billed charges,75% of Total Billed Charges,3.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.27,72,,9,Percent of Total Billed Charges,72% of Total Billed Charges,1.89,60,,7.496,Percent of Total Billed Charges,60% of Total Billed Charges,2.84,90,,49.432,Percent of Total Billed Charges,90% of Total Billed Charges,1.42,45,,7.808,Percent of Total Billed Charges,45% of Total Billed Charges,2.84,90,,45.904,Percent of Total Billed Charges,90% of Total billed Charges,3.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.05,65,,80.728,Percent of total Billed Charges,65% of Total Billed Charges,1.39,44.1,,7.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.99,95,,48.448,Percent of Total Billed Charges,95% of Total Billed Charges,3.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.77,88,,44.88,Percent of Total Billed Charges,88% of Total Billed Charges,2.84,90,,45.904,Percent of Total Billed charges,90% of Total Billed Charges,1.39,3.15,
MONGO S WIRE 0.014 X 190CM,2720002428,CDM,272,RC,C1769,HCPCS,Outpatient,,,300.00,195.00,,300,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,228,76,,262.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,216,72,,9,Percent of Total Billed Charges,72% of Total Billed Charges,225,75,,9.376,Percent of Total Billed charges,75% of Total Billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216,72,,9,Percent of Total Billed Charges,72% of Total Billed Charges,180,60,,7.496,Percent of Total Billed Charges,60% of Total Billed Charges,270,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,135,45,,205.064,Percent of Total Billed Charges,45% of Total Billed Charges,270,90,,310.504,Percent of Total Billed Charges,90% of Total billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195,65,,11.272,Percent of total Billed Charges,65% of Total Billed Charges,132.3,44.1,,200.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,285,95,,327.752,Percent of Total Billed Charges,95% of Total Billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264,88,,303.6,Percent of Total Billed Charges,88% of Total Billed Charges,270,90,,310.504,Percent of Total Billed charges,90% of Total Billed Charges,132.3,300,
MONGO S WIRE 0.014 X 300CM,2720002429,CDM,272,RC,C1769,HCPCS,Outpatient,,,300.00,195.00,,300,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,228,76,,94.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,216,72,,9.512,Percent of Total Billed Charges,72% of Total Billed Charges,225,75,,9.912,Percent of Total Billed charges,75% of Total Billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216,72,,9.512,Percent of Total Billed Charges,72% of Total Billed Charges,180,60,,7.928,Percent of Total Billed Charges,60% of Total Billed Charges,270,90,,80.64,Percent of Total Billed Charges,90% of Total Billed Charges,135,45,,205.064,Percent of Total Billed Charges,45% of Total Billed Charges,270,90,,111.784,Percent of Total Billed Charges,90% of Total billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195,65,,296.208,Percent of total Billed Charges,65% of Total Billed Charges,132.3,44.1,,200.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,285,95,,117.992,Percent of Total Billed Charges,95% of Total Billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264,88,,109.296,Percent of Total Billed Charges,88% of Total Billed Charges,270,90,,111.784,Percent of Total Billed charges,90% of Total Billed Charges,132.3,300,
MINAMO WIRE S 0.014 X 190CM,2720002430,CDM,272,RC,C1769,HCPCS,Outpatient,,,300.00,195.00,,300,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,228,76,,13.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,216,72,,8.064,Percent of Total Billed Charges,72% of Total Billed Charges,225,75,,8.4,Percent of Total Billed charges,75% of Total Billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216,72,,8.064,Percent of Total Billed Charges,72% of Total Billed Charges,180,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,270,90,,8460,Percent of Total Billed Charges,90% of Total Billed Charges,135,45,,110.608,Percent of Total Billed Charges,45% of Total Billed Charges,270,90,,15.608,Percent of Total Billed Charges,90% of Total billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195,65,,296.208,Percent of total Billed Charges,65% of Total Billed Charges,132.3,44.1,,108.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,285,95,,16.48,Percent of Total Billed Charges,95% of Total Billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264,88,,15.264,Percent of Total Billed Charges,88% of Total Billed Charges,270,90,,15.608,Percent of Total Billed charges,90% of Total Billed Charges,132.3,300,
MINAMO WIRE S 0.014 X 300CM,2720002431,CDM,272,RC,C1769,HCPCS,Outpatient,,,300.00,195.00,,300,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,228,76,,346.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,216,72,,24.192,Percent of Total Billed Charges,72% of Total Billed Charges,225,75,,25.2,Percent of Total Billed charges,75% of Total Billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216,72,,24.192,Percent of Total Billed Charges,72% of Total Billed Charges,180,60,,20.16,Percent of Total Billed Charges,60% of Total Billed Charges,270,90,,8460,Percent of Total Billed Charges,90% of Total Billed Charges,135,45,,1579.504,Percent of Total Billed Charges,45% of Total Billed Charges,270,90,,410.136,Percent of Total Billed Charges,90% of Total billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195,65,,159.768,Percent of total Billed Charges,65% of Total Billed Charges,132.3,44.1,,1547.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,285,95,,432.92,Percent of Total Billed Charges,95% of Total Billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264,88,,401.016,Percent of Total Billed Charges,88% of Total Billed Charges,270,90,,410.136,Percent of Total Billed charges,90% of Total Billed Charges,132.3,300,
FIELDER XTA S 0.014 X 190CM,2720002432,CDM,272,RC,C1769,HCPCS,Outpatient,,,300.00,195.00,,300,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,228,76,,346.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,216,72,,46.152,Percent of Total Billed Charges,72% of Total Billed Charges,225,75,,48.072,Percent of Total Billed charges,75% of Total Billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216,72,,46.152,Percent of Total Billed Charges,72% of Total Billed Charges,180,60,,38.456,Percent of Total Billed Charges,60% of Total Billed Charges,270,90,,8460,Percent of Total Billed Charges,90% of Total Billed Charges,135,45,,1579.504,Percent of Total Billed Charges,45% of Total Billed Charges,270,90,,410.136,Percent of Total Billed Charges,90% of Total billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195,65,,2281.504,Percent of total Billed Charges,65% of Total Billed Charges,132.3,44.1,,1547.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,285,95,,432.92,Percent of Total Billed Charges,95% of Total Billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264,88,,401.016,Percent of Total Billed Charges,88% of Total Billed Charges,270,90,,410.136,Percent of Total Billed charges,90% of Total Billed Charges,132.3,300,
FIELDER XTA S 0.014 X 300CM,2720002433,CDM,272,RC,C1769,HCPCS,Outpatient,,,300.00,195.00,,300,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,228,76,,186.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,216,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,225,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,180,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,270,90,,8460,Percent of Total Billed Charges,90% of Total Billed Charges,135,45,,65.408,Percent of Total Billed Charges,45% of Total Billed Charges,270,90,,221.224,Percent of Total Billed Charges,90% of Total billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195,65,,2281.504,Percent of total Billed Charges,65% of Total Billed Charges,132.3,44.1,,64.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,285,95,,233.512,Percent of Total Billed Charges,95% of Total Billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264,88,,216.304,Percent of Total Billed Charges,88% of Total Billed Charges,270,90,,221.224,Percent of Total Billed charges,90% of Total Billed Charges,132.3,300,
EMBOSPHERE 700-900 20ML SYRNGE,2720002434,CDM,272,RC,C1889,HCPCS,Outpatient,,,625.00,406.25,,625,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475,76,,2667.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450,72,,398.16,Percent of Total Billed Charges,72% of Total Billed Charges,468.75,75,,414.752,Percent of Total Billed charges,75% of Total Billed Charges,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450,72,,398.16,Percent of Total Billed Charges,72% of Total Billed Charges,375,60,,331.8,Percent of Total Billed Charges,60% of Total Billed Charges,562.5,90,,6210,Percent of Total Billed Charges,90% of Total Billed Charges,281.25,45,,24.712,Percent of Total Billed Charges,45% of Total Billed Charges,562.5,90,,3159,Percent of Total Billed Charges,90% of Total billed Charges,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.25,65,,94.472,Percent of total Billed Charges,65% of Total Billed Charges,275.63,44.1,,24.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.75,95,,3334.504,Percent of Total Billed Charges,95% of Total Billed Charges,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550,88,,3088.8,Percent of Total Billed Charges,88% of Total Billed Charges,562.5,90,,3159,Percent of Total Billed charges,90% of Total Billed Charges,275.63,625,
VS 5F 0.038 80CM,2720002435,CDM,272,RC,C1887,HCPCS,Outpatient,,,62.50,40.63,,62.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.5,76,,2667.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45,72,,285.768,Percent of Total Billed Charges,72% of Total Billed Charges,46.88,75,,297.672,Percent of Total Billed charges,75% of Total Billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45,72,,285.768,Percent of Total Billed Charges,72% of Total Billed Charges,37.5,60,,238.136,Percent of Total Billed Charges,60% of Total Billed Charges,56.25,90,,6210,Percent of Total Billed Charges,90% of Total Billed Charges,28.13,45,,7.56,Percent of Total Billed Charges,45% of Total Billed Charges,56.25,90,,3159,Percent of Total Billed Charges,90% of Total billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.63,65,,35.696,Percent of total Billed Charges,65% of Total Billed Charges,27.56,44.1,,7.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.38,95,,3334.504,Percent of Total Billed Charges,95% of Total Billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55,88,,3088.8,Percent of Total Billed Charges,88% of Total Billed Charges,56.25,90,,3159,Percent of Total Billed charges,90% of Total Billed Charges,27.56,62.5,
VS1 5F 0.038 80CM,2720002436,CDM,272,RC,C1887,HCPCS,Outpatient,,,62.50,40.63,,62.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.5,76,,110.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45,72,,60.608,Percent of Total Billed Charges,72% of Total Billed Charges,46.88,75,,63.136,Percent of Total Billed charges,75% of Total Billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45,72,,60.608,Percent of Total Billed Charges,72% of Total Billed Charges,37.5,60,,50.504,Percent of Total Billed Charges,60% of Total Billed Charges,56.25,90,,6210,Percent of Total Billed Charges,90% of Total Billed Charges,28.13,45,,40.32,Percent of Total Billed Charges,45% of Total Billed Charges,56.25,90,,130.808,Percent of Total Billed Charges,90% of Total billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.63,65,,10.92,Percent of total Billed Charges,65% of Total Billed Charges,27.56,44.1,,39.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.38,95,,138.08,Percent of Total Billed Charges,95% of Total Billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55,88,,127.904,Percent of Total Billed Charges,88% of Total Billed Charges,56.25,90,,130.808,Percent of Total Billed charges,90% of Total Billed Charges,27.56,62.5,
JB1 5F 0.035 100CM,2720002437,CDM,272,RC,C1887,HCPCS,Outpatient,,,62.50,40.63,,62.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.5,76,,41.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45,72,,118.728,Percent of Total Billed Charges,72% of Total Billed Charges,46.88,75,,123.672,Percent of Total Billed charges,75% of Total Billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45,72,,118.728,Percent of Total Billed Charges,72% of Total Billed Charges,37.5,60,,98.936,Percent of Total Billed Charges,60% of Total Billed Charges,56.25,90,,6210,Percent of Total Billed Charges,90% of Total Billed Charges,28.13,45,,4230,Percent of Total Billed Charges,45% of Total Billed Charges,56.25,90,,49.432,Percent of Total Billed Charges,90% of Total billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.63,65,,58.24,Percent of total Billed Charges,65% of Total Billed Charges,27.56,44.1,,4145.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.38,95,,52.176,Percent of Total Billed Charges,95% of Total Billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55,88,,48.328,Percent of Total Billed Charges,88% of Total Billed Charges,56.25,90,,49.432,Percent of Total Billed charges,90% of Total Billed Charges,27.56,62.5,
VERT 5F 0.038 100CM,2720002438,CDM,272,RC,C1887,HCPCS,Outpatient,,,62.50,40.63,,62.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.5,76,,12.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45,72,,118.728,Percent of Total Billed Charges,72% of Total Billed Charges,46.88,75,,123.672,Percent of Total Billed charges,75% of Total Billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45,72,,118.728,Percent of Total Billed Charges,72% of Total Billed Charges,37.5,60,,98.936,Percent of Total Billed Charges,60% of Total Billed Charges,56.25,90,,6210,Percent of Total Billed Charges,90% of Total Billed Charges,28.13,45,,4230,Percent of Total Billed Charges,45% of Total Billed Charges,56.25,90,,15.12,Percent of Total Billed Charges,90% of Total billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.63,65,,6110,Percent of total Billed Charges,65% of Total Billed Charges,27.56,44.1,,4145.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.38,95,,15.96,Percent of Total Billed Charges,95% of Total Billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55,88,,14.784,Percent of Total Billed Charges,88% of Total Billed Charges,56.25,90,,15.12,Percent of Total Billed charges,90% of Total Billed Charges,27.56,62.5,
30'' MALE ROTATE LUER LOCK-FM,2720002439,CDM,272,RC,,,Outpatient,,,5.80,3.77,,5.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.41,76,,68.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.18,72,,138.048,Percent of Total Billed Charges,72% of Total Billed Charges,4.35,75,,143.8,Percent of Total Billed charges,75% of Total Billed Charges,5.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.18,72,,138.048,Percent of Total Billed Charges,72% of Total Billed Charges,3.48,60,,115.04,Percent of Total Billed Charges,60% of Total Billed Charges,5.22,90,,6210,Percent of Total Billed Charges,90% of Total Billed Charges,2.61,45,,4230,Percent of Total Billed Charges,45% of Total Billed Charges,5.22,90,,80.64,Percent of Total Billed Charges,90% of Total billed Charges,5.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.77,65,,6110,Percent of total Billed Charges,65% of Total Billed Charges,2.56,44.1,,4145.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.51,95,,85.12,Percent of Total Billed Charges,95% of Total Billed Charges,5.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.1,88,,78.848,Percent of Total Billed Charges,88% of Total Billed Charges,5.22,90,,80.64,Percent of Total Billed charges,90% of Total Billed Charges,2.56,5.8,
PHD (MERIT) ANGIOPLASTY PACK,2720002440,CDM,272,RC,,,Outpatient,,,42.50,27.63,,42.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,32.3,76,,7144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.6,72,,4.232,Percent of Total Billed Charges,72% of Total Billed Charges,31.88,75,,4.408,Percent of Total Billed charges,75% of Total Billed Charges,42.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.6,72,,4.232,Percent of Total Billed Charges,72% of Total Billed Charges,25.5,60,,3.528,Percent of Total Billed Charges,60% of Total Billed Charges,38.25,90,,6210,Percent of Total Billed Charges,90% of Total Billed Charges,19.13,45,,4230,Percent of Total Billed Charges,45% of Total Billed Charges,38.25,90,,8460,Percent of Total Billed Charges,90% of Total billed Charges,42.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.63,65,,6110,Percent of total Billed Charges,65% of Total Billed Charges,18.74,44.1,,4145.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,40.38,95,,8930,Percent of Total Billed Charges,95% of Total Billed Charges,42.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.4,88,,8272,Percent of Total Billed Charges,88% of Total Billed Charges,38.25,90,,8460,Percent of Total Billed charges,90% of Total Billed Charges,18.74,42.5,
SC SPRINTER OTW 1.5MM X 15MM,2720002441,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,7144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,4.376,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,4.56,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,4.376,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,3.648,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,6210,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,3105,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,8460,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,6110,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,3042.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,8930,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,8272,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,8460,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
BioPence Ultra w Coxial 16x10,2720002442,CDM,272,RC,,,Outpatient,,,140.00,91.00,,140,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.4,76,,7144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.8,72,,67.896,Percent of Total Billed Charges,72% of Total Billed Charges,105,75,,70.72,Percent of Total Billed charges,75% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.8,72,,67.896,Percent of Total Billed Charges,72% of Total Billed Charges,84,60,,56.576,Percent of Total Billed Charges,60% of Total Billed Charges,126,90,,6210,Percent of Total Billed Charges,90% of Total Billed Charges,63,45,,3105,Percent of Total Billed Charges,45% of Total Billed Charges,126,90,,8460,Percent of Total Billed Charges,90% of Total billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91,65,,4485,Percent of total Billed Charges,65% of Total Billed Charges,61.74,44.1,,3042.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,133,95,,8930,Percent of Total Billed Charges,95% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.2,88,,8272,Percent of Total Billed Charges,88% of Total Billed Charges,126,90,,8460,Percent of Total Billed charges,90% of Total Billed Charges,61.74,140,
Z2246-023 GUIDE PIN 3.2X304.8,2720002443,CDM,272,RC,,,Outpatient,,,62.43,40.58,,62.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.45,76,,7144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,44.95,72,,67.896,Percent of Total Billed Charges,72% of Total Billed Charges,46.82,75,,70.72,Percent of Total Billed charges,75% of Total Billed Charges,62.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.95,72,,67.896,Percent of Total Billed Charges,72% of Total Billed Charges,37.46,60,,56.576,Percent of Total Billed Charges,60% of Total Billed Charges,56.19,90,,4950,Percent of Total Billed Charges,90% of Total Billed Charges,28.09,45,,3105,Percent of Total Billed Charges,45% of Total Billed Charges,56.19,90,,8460,Percent of Total Billed Charges,90% of Total billed Charges,62.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.58,65,,4485,Percent of total Billed Charges,65% of Total Billed Charges,27.53,44.1,,3042.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.31,95,,8930,Percent of Total Billed Charges,95% of Total Billed Charges,62.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.94,88,,8272,Percent of Total Billed Charges,88% of Total Billed Charges,56.19,90,,8460,Percent of Total Billed charges,90% of Total Billed Charges,27.53,62.43,
BASIX INFLATION DEV KIT/MERIT,2720002444,CDM,272,RC,,,Outpatient,,,20.00,13.00,,20,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.2,76,,5244,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.4,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,15,75,,5.952,Percent of Total Billed charges,75% of Total Billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.4,72,,5.712,Percent of Total Billed Charges,72% of Total Billed Charges,12,60,,4.76,Percent of Total Billed Charges,60% of Total Billed Charges,18,90,,4950,Percent of Total Billed Charges,90% of Total Billed Charges,9,45,,3105,Percent of Total Billed Charges,45% of Total Billed Charges,18,90,,6210,Percent of Total Billed Charges,90% of Total billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13,65,,4485,Percent of total Billed Charges,65% of Total Billed Charges,8.82,44.1,,3042.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,19,95,,6555,Percent of Total Billed Charges,95% of Total Billed Charges,20,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.6,88,,6072,Percent of Total Billed Charges,88% of Total Billed Charges,18,90,,6210,Percent of Total Billed charges,90% of Total Billed Charges,8.82,20,
WHISPER XS 0.014 X 190CM WIRE,2720002445,CDM,272,RC,C1769,HCPCS,Outpatient,,,212.50,138.13,,212.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.5,76,,5244,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153,72,,2.632,Percent of Total Billed Charges,72% of Total Billed Charges,159.38,75,,2.744,Percent of Total Billed charges,75% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153,72,,2.632,Percent of Total Billed Charges,72% of Total Billed Charges,127.5,60,,2.192,Percent of Total Billed Charges,60% of Total Billed Charges,191.25,90,,4950,Percent of Total Billed Charges,90% of Total Billed Charges,95.63,45,,3105,Percent of Total Billed Charges,45% of Total Billed Charges,191.25,90,,6210,Percent of Total Billed Charges,90% of Total billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.13,65,,4485,Percent of total Billed Charges,65% of Total Billed Charges,93.71,44.1,,3042.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,201.88,95,,6555,Percent of Total Billed Charges,95% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187,88,,6072,Percent of Total Billed Charges,88% of Total Billed Charges,191.25,90,,6210,Percent of Total Billed charges,90% of Total Billed Charges,93.71,212.5,
MONITOR SWAN GANZ DL 5F 110CM,2720002446,CDM,272,RC,C1751,HCPCS,Outpatient,,,87.50,56.88,,87.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.5,76,,5244,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63,72,,2.448,Percent of Total Billed Charges,72% of Total Billed Charges,65.63,75,,2.552,Percent of Total Billed charges,75% of Total Billed Charges,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63,72,,2.448,Percent of Total Billed Charges,72% of Total Billed Charges,52.5,60,,2.04,Percent of Total Billed Charges,60% of Total Billed Charges,78.75,90,,4950,Percent of Total Billed Charges,90% of Total Billed Charges,39.38,45,,3105,Percent of Total Billed Charges,45% of Total Billed Charges,78.75,90,,6210,Percent of Total Billed Charges,90% of Total billed Charges,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.88,65,,4485,Percent of total Billed Charges,65% of Total Billed Charges,38.59,44.1,,3042.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.13,95,,6555,Percent of Total Billed Charges,95% of Total Billed Charges,87.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77,88,,6072,Percent of Total Billed Charges,88% of Total Billed Charges,78.75,90,,6210,Percent of Total Billed charges,90% of Total Billed Charges,38.59,87.5,
GLIDEWIRE ADVNTAGE 0.014X300CM,2720002447,CDM,272,RC,C1769,HCPCS,Outpatient,,,642.50,417.63,,642.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,488.3,76,,5244,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,462.6,72,,2.576,Percent of Total Billed Charges,72% of Total Billed Charges,481.88,75,,2.68,Percent of Total Billed charges,75% of Total Billed Charges,642.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.6,72,,2.576,Percent of Total Billed Charges,72% of Total Billed Charges,385.5,60,,2.144,Percent of Total Billed Charges,60% of Total Billed Charges,578.25,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,289.13,45,,3105,Percent of Total Billed Charges,45% of Total Billed Charges,578.25,90,,6210,Percent of Total Billed Charges,90% of Total billed Charges,642.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,642.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,642.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.63,65,,4485,Percent of total Billed Charges,65% of Total Billed Charges,283.34,44.1,,3042.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,610.38,95,,6555,Percent of Total Billed Charges,95% of Total Billed Charges,642.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,565.4,88,,6072,Percent of Total Billed Charges,88% of Total Billed Charges,578.25,90,,6210,Percent of Total Billed charges,90% of Total Billed Charges,283.34,642.5,
GLIDEWIRE ADVNTAGE 0.018X300CM,2720002448,CDM,272,RC,C1769,HCPCS,Outpatient,,,647.50,420.88,,647.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,492.1,76,,5244,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,466.2,72,,2.592,Percent of Total Billed Charges,72% of Total Billed Charges,485.63,75,,2.704,Percent of Total Billed charges,75% of Total Billed Charges,647.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,466.2,72,,2.592,Percent of Total Billed Charges,72% of Total Billed Charges,388.5,60,,2.16,Percent of Total Billed Charges,60% of Total Billed Charges,582.75,90,,1528.2,Percent of Total Billed Charges,90% of Total Billed Charges,291.38,45,,3105,Percent of Total Billed Charges,45% of Total Billed Charges,582.75,90,,6210,Percent of Total Billed Charges,90% of Total billed Charges,647.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,647.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,647.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,420.88,65,,4485,Percent of total Billed Charges,65% of Total Billed Charges,285.55,44.1,,3042.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,615.13,95,,6555,Percent of Total Billed Charges,95% of Total Billed Charges,647.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569.8,88,,6072,Percent of Total Billed Charges,88% of Total Billed Charges,582.75,90,,6210,Percent of Total Billed charges,90% of Total Billed Charges,285.55,647.5,
PINNACLE 10F 10CM PERI-SHEATH,2720002449,CDM,272,RC,C1894,HCPCS,Outpatient,,,99.00,64.35,,99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.24,76,,5244,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71.28,72,,2.624,Percent of Total Billed Charges,72% of Total Billed Charges,74.25,75,,2.728,Percent of Total Billed charges,75% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.28,72,,2.624,Percent of Total Billed Charges,72% of Total Billed Charges,59.4,60,,2.184,Percent of Total Billed Charges,60% of Total Billed Charges,89.1,90,,2.392,Percent of Total Billed Charges,90% of Total Billed Charges,44.55,45,,3105,Percent of Total Billed Charges,45% of Total Billed Charges,89.1,90,,6210,Percent of Total Billed Charges,90% of Total billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.35,65,,4485,Percent of total Billed Charges,65% of Total Billed Charges,43.66,44.1,,3042.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,94.05,95,,6555,Percent of Total Billed Charges,95% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.12,88,,6072,Percent of Total Billed Charges,88% of Total Billed Charges,89.1,90,,6210,Percent of Total Billed charges,90% of Total Billed Charges,43.66,99,
PINNACLE 11F 10CM PERI-SHEATH,2720002450,CDM,272,RC,C1894,HCPCS,Outpatient,,,99.00,64.35,,99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.24,76,,5244,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71.28,72,,71.28,Percent of Total Billed Charges,72% of Total Billed Charges,74.25,75,,74.248,Percent of Total Billed charges,75% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.28,72,,71.28,Percent of Total Billed Charges,72% of Total Billed Charges,59.4,60,,59.4,Percent of Total Billed Charges,60% of Total Billed Charges,89.1,90,,1026,Percent of Total Billed Charges,90% of Total Billed Charges,44.55,45,,2475,Percent of Total Billed Charges,45% of Total Billed Charges,89.1,90,,6210,Percent of Total Billed Charges,90% of Total billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.35,65,,4485,Percent of total Billed Charges,65% of Total Billed Charges,43.66,44.1,,2425.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,94.05,95,,6555,Percent of Total Billed Charges,95% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.12,88,,6072,Percent of Total Billed Charges,88% of Total Billed Charges,89.1,90,,6210,Percent of Total Billed charges,90% of Total Billed Charges,43.66,99,
PINNACLE 10F 25CM PERI-SHEATH,2720002451,CDM,272,RC,C1894,HCPCS,Outpatient,,,99.00,64.35,,99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.24,76,,5244,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71.28,72,,432,Percent of Total Billed Charges,72% of Total Billed Charges,74.25,75,,450,Percent of Total Billed charges,75% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.28,72,,432,Percent of Total Billed Charges,72% of Total Billed Charges,59.4,60,,360,Percent of Total Billed Charges,60% of Total Billed Charges,89.1,90,,1026,Percent of Total Billed Charges,90% of Total Billed Charges,44.55,45,,2475,Percent of Total Billed Charges,45% of Total Billed Charges,89.1,90,,6210,Percent of Total Billed Charges,90% of Total billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.35,65,,3575,Percent of total Billed Charges,65% of Total Billed Charges,43.66,44.1,,2425.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,94.05,95,,6555,Percent of Total Billed Charges,95% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.12,88,,6072,Percent of Total Billed Charges,88% of Total Billed Charges,89.1,90,,6210,Percent of Total Billed charges,90% of Total Billed Charges,43.66,99,
PINNACLE 11F 25CM PERI-SHEATH,2720002452,CDM,272,RC,C1894,HCPCS,Outpatient,,,99.00,64.35,,99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.24,76,,5244,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71.28,72,,432,Percent of Total Billed Charges,72% of Total Billed Charges,74.25,75,,450,Percent of Total Billed charges,75% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.28,72,,432,Percent of Total Billed Charges,72% of Total Billed Charges,59.4,60,,360,Percent of Total Billed Charges,60% of Total Billed Charges,89.1,90,,1026,Percent of Total Billed Charges,90% of Total Billed Charges,44.55,45,,2475,Percent of Total Billed Charges,45% of Total Billed Charges,89.1,90,,6210,Percent of Total Billed Charges,90% of Total billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.35,65,,3575,Percent of total Billed Charges,65% of Total Billed Charges,43.66,44.1,,2425.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,94.05,95,,6555,Percent of Total Billed Charges,95% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.12,88,,6072,Percent of Total Billed Charges,88% of Total Billed Charges,89.1,90,,6210,Percent of Total Billed charges,90% of Total Billed Charges,43.66,99,
TIG 6F RADIAL 4.5 100CM,2720002453,CDM,272,RC,C1887,HCPCS,Outpatient,,,96.00,62.40,,96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.96,76,,4180,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.12,72,,432,Percent of Total Billed Charges,72% of Total Billed Charges,72,75,,450,Percent of Total Billed charges,75% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.12,72,,432,Percent of Total Billed Charges,72% of Total Billed Charges,57.6,60,,360,Percent of Total Billed Charges,60% of Total Billed Charges,86.4,90,,1026,Percent of Total Billed Charges,90% of Total Billed Charges,43.2,45,,2475,Percent of Total Billed Charges,45% of Total Billed Charges,86.4,90,,4950,Percent of Total Billed Charges,90% of Total billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.4,65,,3575,Percent of total Billed Charges,65% of Total Billed Charges,42.34,44.1,,2425.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.2,95,,5225,Percent of Total Billed Charges,95% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.48,88,,4840,Percent of Total Billed Charges,88% of Total Billed Charges,86.4,90,,4950,Percent of Total Billed charges,90% of Total Billed Charges,42.34,96,
TIG 6F RADIAL 4.0 110CM,2720002454,CDM,272,RC,C1887,HCPCS,Outpatient,,,96.00,62.40,,96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.96,76,,4180,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.12,72,,4.64,Percent of Total Billed Charges,72% of Total Billed Charges,72,75,,4.832,Percent of Total Billed charges,75% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.12,72,,4.64,Percent of Total Billed Charges,72% of Total Billed Charges,57.6,60,,3.864,Percent of Total Billed Charges,60% of Total Billed Charges,86.4,90,,810,Percent of Total Billed Charges,90% of Total Billed Charges,43.2,45,,5.4,Percent of Total Billed Charges,45% of Total Billed Charges,86.4,90,,4950,Percent of Total Billed Charges,90% of Total billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.4,65,,3575,Percent of total Billed Charges,65% of Total Billed Charges,42.34,44.1,,5.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.2,95,,5225,Percent of Total Billed Charges,95% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.48,88,,4840,Percent of Total Billed Charges,88% of Total Billed Charges,86.4,90,,4950,Percent of Total Billed charges,90% of Total Billed Charges,42.34,96,
TIG 6F RADIAL 4.5 110CM,2720002455,CDM,272,RC,C1887,HCPCS,Outpatient,,,96.00,62.40,,96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.96,76,,4180,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.12,72,,3.24,Percent of Total Billed Charges,72% of Total Billed Charges,72,75,,3.376,Percent of Total Billed charges,75% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.12,72,,3.24,Percent of Total Billed Charges,72% of Total Billed Charges,57.6,60,,2.696,Percent of Total Billed Charges,60% of Total Billed Charges,86.4,90,,810,Percent of Total Billed Charges,90% of Total Billed Charges,43.2,45,,764.104,Percent of Total Billed Charges,45% of Total Billed Charges,86.4,90,,4950,Percent of Total Billed Charges,90% of Total billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.4,65,,7.8,Percent of total Billed Charges,65% of Total Billed Charges,42.34,44.1,,748.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.2,95,,5225,Percent of Total Billed Charges,95% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.48,88,,4840,Percent of Total Billed Charges,88% of Total Billed Charges,86.4,90,,4950,Percent of Total Billed charges,90% of Total Billed Charges,42.34,96,
JACKY 6F 3.5 RADIAL 100CM,2720002456,CDM,272,RC,C1887,HCPCS,Outpatient,,,96.00,62.40,,96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.96,76,,4180,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.12,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,72,75,,126,Percent of Total Billed charges,75% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.12,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,57.6,60,,100.8,Percent of Total Billed Charges,60% of Total Billed Charges,86.4,90,,945,Percent of Total Billed Charges,90% of Total Billed Charges,43.2,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,86.4,90,,4950,Percent of Total Billed Charges,90% of Total billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.4,65,,1103.704,Percent of total Billed Charges,65% of Total Billed Charges,42.34,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.2,95,,5225,Percent of Total Billed Charges,95% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.48,88,,4840,Percent of Total Billed Charges,88% of Total Billed Charges,86.4,90,,4950,Percent of Total Billed charges,90% of Total Billed Charges,42.34,96,
JACKY SARAH 6F 4 RADIAL 100CM,2720002457,CDM,272,RC,C1887,HCPCS,Outpatient,,,96.00,62.40,,96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.96,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.12,72,,37.584,Percent of Total Billed Charges,72% of Total Billed Charges,72,75,,39.152,Percent of Total Billed charges,75% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.12,72,,37.584,Percent of Total Billed Charges,72% of Total Billed Charges,57.6,60,,31.32,Percent of Total Billed Charges,60% of Total Billed Charges,86.4,90,,945,Percent of Total Billed Charges,90% of Total Billed Charges,43.2,45,,513,Percent of Total Billed Charges,45% of Total Billed Charges,86.4,90,,10.8,Percent of Total Billed Charges,90% of Total billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.4,65,,1.728,Percent of total Billed Charges,65% of Total Billed Charges,42.34,44.1,,502.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.2,95,,11.4,Percent of Total Billed Charges,95% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.48,88,,10.56,Percent of Total Billed Charges,88% of Total Billed Charges,86.4,90,,10.8,Percent of Total Billed charges,90% of Total Billed Charges,42.34,96,
JACKY 6F 3.5 RADIAL 110CM,2720002458,CDM,272,RC,C1887,HCPCS,Outpatient,,,96.00,62.40,,96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.96,76,,1290.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.12,72,,78.48,Percent of Total Billed Charges,72% of Total Billed Charges,72,75,,81.752,Percent of Total Billed charges,75% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.12,72,,78.48,Percent of Total Billed Charges,72% of Total Billed Charges,57.6,60,,65.4,Percent of Total Billed Charges,60% of Total Billed Charges,86.4,90,,720,Percent of Total Billed Charges,90% of Total Billed Charges,43.2,45,,513,Percent of Total Billed Charges,45% of Total Billed Charges,86.4,90,,1528.2,Percent of Total Billed Charges,90% of Total billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.4,65,,741,Percent of total Billed Charges,65% of Total Billed Charges,42.34,44.1,,502.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.2,95,,1613.104,Percent of Total Billed Charges,95% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.48,88,,1494.24,Percent of Total Billed Charges,88% of Total Billed Charges,86.4,90,,1528.2,Percent of Total Billed charges,90% of Total Billed Charges,42.34,96,
JACKY SARAH 6F 4 RADIAL 110CM,2720002459,CDM,272,RC,C1887,HCPCS,Outpatient,,,96.00,62.40,,96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.96,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.12,72,,5.744,Percent of Total Billed Charges,72% of Total Billed Charges,72,75,,5.984,Percent of Total Billed charges,75% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.12,72,,5.744,Percent of Total Billed Charges,72% of Total Billed Charges,57.6,60,,4.784,Percent of Total Billed Charges,60% of Total Billed Charges,86.4,90,,720,Percent of Total Billed Charges,90% of Total Billed Charges,43.2,45,,513,Percent of Total Billed Charges,45% of Total Billed Charges,86.4,90,,2.392,Percent of Total Billed Charges,90% of Total billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.4,65,,741,Percent of total Billed Charges,65% of Total Billed Charges,42.34,44.1,,502.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.2,95,,2.52,Percent of Total Billed Charges,95% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.48,88,,2.336,Percent of Total Billed Charges,88% of Total Billed Charges,86.4,90,,2.392,Percent of Total Billed charges,90% of Total Billed Charges,42.34,96,
PERCLOSE PROGLIDE SUTURE DVICE,2720002460,CDM,272,RC,C1760,HCPCS,Outpatient,,,562.50,365.63,,562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,427.5,76,,866.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,405,72,,18.144,Percent of Total Billed Charges,72% of Total Billed Charges,421.88,75,,18.904,Percent of Total Billed charges,75% of Total Billed Charges,562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405,72,,18.144,Percent of Total Billed Charges,72% of Total Billed Charges,337.5,60,,15.12,Percent of Total Billed Charges,60% of Total Billed Charges,506.25,90,,333.616,Percent of Total Billed Charges,90% of Total Billed Charges,253.13,45,,513,Percent of Total Billed Charges,45% of Total Billed Charges,506.25,90,,1026,Percent of Total Billed Charges,90% of Total billed Charges,562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365.63,65,,741,Percent of total Billed Charges,65% of Total Billed Charges,248.06,44.1,,502.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,534.38,95,,1083,Percent of Total Billed Charges,95% of Total Billed Charges,562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495,88,,1003.2,Percent of Total Billed Charges,88% of Total Billed Charges,506.25,90,,1026,Percent of Total Billed charges,90% of Total Billed Charges,248.06,562.5,
Ultra ClipII Breast Tiss Mrkr,2720002461,CDM,272,RC,,,Outpatient,,,289.50,188.18,,289.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,220.02,76,,866.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,208.44,72,,18.144,Percent of Total Billed Charges,72% of Total Billed Charges,217.13,75,,18.904,Percent of Total Billed charges,75% of Total Billed Charges,289.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.44,72,,18.144,Percent of Total Billed Charges,72% of Total Billed Charges,173.7,60,,15.12,Percent of Total Billed Charges,60% of Total Billed Charges,260.55,90,,133.2,Percent of Total Billed Charges,90% of Total Billed Charges,130.28,45,,405,Percent of Total Billed Charges,45% of Total Billed Charges,260.55,90,,1026,Percent of Total Billed Charges,90% of Total billed Charges,289.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.18,65,,741,Percent of total Billed Charges,65% of Total Billed Charges,127.67,44.1,,396.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,275.03,95,,1083,Percent of Total Billed Charges,95% of Total Billed Charges,289.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,254.76,88,,1003.2,Percent of Total Billed Charges,88% of Total Billed Charges,260.55,90,,1026,Percent of Total Billed charges,90% of Total Billed Charges,127.67,289.5,
Sngle J-Type Bn Marrow Bx Ndle,2720002462,CDM,272,RC,,,Outpatient,,,69.07,44.90,,69.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.49,76,,866.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49.73,72,,184.32,Percent of Total Billed Charges,72% of Total Billed Charges,51.8,75,,192,Percent of Total Billed charges,75% of Total Billed Charges,69.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.73,72,,184.32,Percent of Total Billed Charges,72% of Total Billed Charges,41.44,60,,153.6,Percent of Total Billed Charges,60% of Total Billed Charges,62.16,90,,78.816,Percent of Total Billed Charges,90% of Total Billed Charges,31.08,45,,405,Percent of Total Billed Charges,45% of Total Billed Charges,62.16,90,,1026,Percent of Total Billed Charges,90% of Total billed Charges,69.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.9,65,,585,Percent of total Billed Charges,65% of Total Billed Charges,30.46,44.1,,396.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.62,95,,1083,Percent of Total Billed Charges,95% of Total Billed Charges,69.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.78,88,,1003.2,Percent of Total Billed Charges,88% of Total Billed Charges,62.16,90,,1026,Percent of Total Billed charges,90% of Total Billed Charges,30.46,69.07,
FLUIDSMART INFLOW TUB SET(Sub),2720002463,CDM,272,RC,,,Outpatient,,,384.75,250.09,,384.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,292.41,76,,866.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,277.02,72,,335.992,Percent of Total Billed Charges,72% of Total Billed Charges,288.56,75,,349.992,Percent of Total Billed charges,75% of Total Billed Charges,384.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.02,72,,335.992,Percent of Total Billed Charges,72% of Total Billed Charges,230.85,60,,279.992,Percent of Total Billed Charges,60% of Total Billed Charges,346.28,90,,74.32,Percent of Total Billed Charges,90% of Total Billed Charges,173.14,45,,472.504,Percent of Total Billed Charges,45% of Total Billed Charges,346.28,90,,1026,Percent of Total Billed Charges,90% of Total billed Charges,384.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.09,65,,585,Percent of total Billed Charges,65% of Total Billed Charges,169.67,44.1,,463.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,365.51,95,,1083,Percent of Total Billed Charges,95% of Total Billed Charges,384.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,338.58,88,,1003.2,Percent of Total Billed Charges,88% of Total Billed Charges,346.28,90,,1026,Percent of Total Billed charges,90% of Total Billed Charges,169.67,384.75,
IVR Pack,2720002464,CDM,272,RC,,,Outpatient,,,101.85,66.20,,101.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,77.41,76,,684,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,73.33,72,,991.68,Percent of Total Billed Charges,72% of Total Billed Charges,76.39,75,,1033,Percent of Total Billed charges,75% of Total Billed Charges,101.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.33,72,,991.68,Percent of Total Billed Charges,72% of Total Billed Charges,61.11,60,,826.4,Percent of Total Billed Charges,60% of Total Billed Charges,91.67,90,,4.216,Percent of Total Billed Charges,90% of Total Billed Charges,45.83,45,,472.504,Percent of Total Billed Charges,45% of Total Billed Charges,91.67,90,,810,Percent of Total Billed Charges,90% of Total billed Charges,101.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.2,65,,682.504,Percent of total Billed Charges,65% of Total Billed Charges,44.92,44.1,,463.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,96.76,95,,855,Percent of Total Billed Charges,95% of Total Billed Charges,101.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.63,88,,792,Percent of Total Billed Charges,88% of Total Billed Charges,91.67,90,,810,Percent of Total Billed charges,90% of Total Billed Charges,44.92,101.85,
RUBY COMPLEX STND 3MM X 5CM,2720002465,CDM,278,RC,C1889,HCPCS,Outpatient,,,2225.00,1446.25,,2225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1691,76,,684,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1602,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,1602,72,,9,Percent of Total Billed charges,72% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1602,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,1335,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,2002.5,90,,42.064,Percent of Total Billed Charges,90% of Total Billed Charges,1001.25,45,,360,Percent of Total Billed Charges,45% of Total Billed Charges,2002.5,90,,810,Percent of Total Billed Charges,90% of Total billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1446.25,65,,682.504,Percent of total Billed Charges,65% of Total Billed Charges,981.23,44.1,,352.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,2113.75,95,,855,Percent of Total Billed Charges,95% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1958,88,,792,Percent of Total Billed Charges,88% of Total Billed Charges,2002.5,90,,810,Percent of Total Billed charges,90% of Total Billed Charges,981.23,2225,
RUBY COMPLEX STND 3MM X 12CM,2720002466,CDM,278,RC,C1889,HCPCS,Outpatient,,,2475.00,1608.75,,2475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1881,76,,798,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1782,72,,72,Percent of Total Billed Charges,72% of Total Billed Charges,1782,72,,75,Percent of Total Billed charges,72% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782,72,,72,Percent of Total Billed Charges,72% of Total Billed Charges,1485,60,,60,Percent of Total Billed Charges,60% of Total Billed Charges,2227.5,90,,150.48,Percent of Total Billed Charges,90% of Total Billed Charges,1113.75,45,,360,Percent of Total Billed Charges,45% of Total Billed Charges,2227.5,90,,945,Percent of Total Billed Charges,90% of Total billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.75,65,,520,Percent of total Billed Charges,65% of Total Billed Charges,1091.48,44.1,,352.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,2351.25,95,,997.504,Percent of Total Billed Charges,95% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178,88,,924,Percent of Total Billed Charges,88% of Total Billed Charges,2227.5,90,,945,Percent of Total Billed charges,90% of Total Billed Charges,1091.48,2475,
RUBY COMPLEX STND 3MM X 20CM,2720002467,CDM,278,RC,C1889,HCPCS,Outpatient,,,2475.00,1608.75,,2475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1881,76,,798,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1782,72,,16.528,Percent of Total Billed Charges,72% of Total Billed Charges,1782,72,,17.224,Percent of Total Billed charges,72% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782,72,,16.528,Percent of Total Billed Charges,72% of Total Billed Charges,1485,60,,13.776,Percent of Total Billed Charges,60% of Total Billed Charges,2227.5,90,,111.6,Percent of Total Billed Charges,90% of Total Billed Charges,1113.75,45,,166.808,Percent of Total Billed Charges,45% of Total Billed Charges,2227.5,90,,945,Percent of Total Billed Charges,90% of Total billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.75,65,,520,Percent of total Billed Charges,65% of Total Billed Charges,1091.48,44.1,,163.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,2351.25,95,,997.504,Percent of Total Billed Charges,95% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178,88,,924,Percent of Total Billed Charges,88% of Total Billed Charges,2227.5,90,,945,Percent of Total Billed charges,90% of Total Billed Charges,1091.48,2475,
RUBY COMPLEX STND 4MM X 10CM,2720002468,CDM,278,RC,C1889,HCPCS,Outpatient,,,2475.00,1608.75,,2475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1881,76,,608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1782,72,,720.36,Percent of Total Billed Charges,72% of Total Billed Charges,1782,72,,750.376,Percent of Total Billed charges,72% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782,72,,720.36,Percent of Total Billed Charges,72% of Total Billed Charges,1485,60,,600.296,Percent of Total Billed Charges,60% of Total Billed Charges,2227.5,90,,260.32,Percent of Total Billed Charges,90% of Total Billed Charges,1113.75,45,,66.6,Percent of Total Billed Charges,45% of Total Billed Charges,2227.5,90,,720,Percent of Total Billed Charges,90% of Total billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.75,65,,240.944,Percent of total Billed Charges,65% of Total Billed Charges,1091.48,44.1,,65.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,2351.25,95,,760,Percent of Total Billed Charges,95% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178,88,,704,Percent of Total Billed Charges,88% of Total Billed Charges,2227.5,90,,720,Percent of Total Billed charges,90% of Total Billed Charges,1091.48,2475,
RUBY COMPLEX STND 4MM X 20CM,2720002469,CDM,278,RC,C1889,HCPCS,Outpatient,,,2475.00,1608.75,,2475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1881,76,,608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1782,72,,714.224,Percent of Total Billed Charges,72% of Total Billed Charges,1782,72,,743.984,Percent of Total Billed charges,72% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782,72,,714.224,Percent of Total Billed Charges,72% of Total Billed Charges,1485,60,,595.184,Percent of Total Billed Charges,60% of Total Billed Charges,2227.5,90,,193.576,Percent of Total Billed Charges,90% of Total Billed Charges,1113.75,45,,39.408,Percent of Total Billed Charges,45% of Total Billed Charges,2227.5,90,,720,Percent of Total Billed Charges,90% of Total billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.75,65,,96.2,Percent of total Billed Charges,65% of Total Billed Charges,1091.48,44.1,,38.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,2351.25,95,,760,Percent of Total Billed Charges,95% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178,88,,704,Percent of Total Billed Charges,88% of Total Billed Charges,2227.5,90,,720,Percent of Total Billed charges,90% of Total Billed Charges,1091.48,2475,
RUBY COMPLEX STND 4MM X 35CM,2720002470,CDM,278,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,281.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,6.032,Percent of Total Billed Charges,72% of Total Billed Charges,2322,72,,6.28,Percent of Total Billed charges,72% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,6.032,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,5.024,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,54.952,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,37.16,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,333.616,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,56.928,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,36.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,352.144,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,326.2,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,333.616,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
RUBY COMPLEX STND 5MM X 12CM,2720002471,CDM,278,RC,C1889,HCPCS,Outpatient,,,2475.00,1608.75,,2475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1881,76,,112.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1782,72,,4.392,Percent of Total Billed Charges,72% of Total Billed Charges,1782,72,,4.576,Percent of Total Billed charges,72% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782,72,,4.392,Percent of Total Billed Charges,72% of Total Billed Charges,1485,60,,3.656,Percent of Total Billed Charges,60% of Total Billed Charges,2227.5,90,,54.952,Percent of Total Billed Charges,90% of Total Billed Charges,1113.75,45,,2.104,Percent of Total Billed Charges,45% of Total Billed Charges,2227.5,90,,133.2,Percent of Total Billed Charges,90% of Total billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.75,65,,53.672,Percent of total Billed Charges,65% of Total Billed Charges,1091.48,44.1,,2.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,2351.25,95,,140.6,Percent of Total Billed Charges,95% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178,88,,130.24,Percent of Total Billed Charges,88% of Total Billed Charges,2227.5,90,,133.2,Percent of Total Billed charges,90% of Total Billed Charges,1091.48,2475,
RUBY COMPLEX STND 5MM X 30CM,2720002472,CDM,278,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,66.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,2322,72,,5.296,Percent of Total Billed charges,72% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,219.888,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,21.032,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,78.816,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,3.04,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,20.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,83.2,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,77.064,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,78.816,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
RUBY COMPLEX STND 6MM X 20CM,2720002473,CDM,278,RC,C1889,HCPCS,Outpatient,,,2475.00,1608.75,,2475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1881,76,,62.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1782,72,,756,Percent of Total Billed Charges,72% of Total Billed Charges,1782,72,,787.504,Percent of Total Billed charges,72% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782,72,,756,Percent of Total Billed Charges,72% of Total Billed Charges,1485,60,,630,Percent of Total Billed Charges,60% of Total Billed Charges,2227.5,90,,24.304,Percent of Total Billed Charges,90% of Total Billed Charges,1113.75,45,,75.24,Percent of Total Billed Charges,45% of Total Billed Charges,2227.5,90,,74.32,Percent of Total Billed Charges,90% of Total billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.75,65,,30.376,Percent of total Billed Charges,65% of Total Billed Charges,1091.48,44.1,,73.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,2351.25,95,,78.448,Percent of Total Billed Charges,95% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178,88,,72.664,Percent of Total Billed Charges,88% of Total Billed Charges,2227.5,90,,74.32,Percent of Total Billed charges,90% of Total Billed Charges,1091.48,2475,
RUBY COMPLEX STND 6MM X 30CM,2720002474,CDM,278,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,3.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,37.44,Percent of Total Billed Charges,72% of Total Billed Charges,2322,72,,39,Percent of Total Billed charges,72% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,37.44,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,31.2,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,24.304,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,55.8,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,4.216,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,108.68,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,54.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,4.448,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,4.12,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,4.216,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
RUBY COMPLEX STND 7MM X 25CM,2720002475,CDM,278,RC,C1889,HCPCS,Outpatient,,,2475.00,1608.75,,2475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1881,76,,35.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1782,72,,37.44,Percent of Total Billed Charges,72% of Total Billed Charges,1782,72,,39,Percent of Total Billed charges,72% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782,72,,37.44,Percent of Total Billed Charges,72% of Total Billed Charges,1485,60,,31.2,Percent of Total Billed Charges,60% of Total Billed Charges,2227.5,90,,24.304,Percent of Total Billed Charges,90% of Total Billed Charges,1113.75,45,,130.16,Percent of Total Billed Charges,45% of Total Billed Charges,2227.5,90,,42.064,Percent of Total Billed Charges,90% of Total billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.75,65,,80.6,Percent of total Billed Charges,65% of Total Billed Charges,1091.48,44.1,,127.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,2351.25,95,,44.4,Percent of Total Billed Charges,95% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178,88,,41.128,Percent of Total Billed Charges,88% of Total Billed Charges,2227.5,90,,42.064,Percent of Total Billed charges,90% of Total Billed Charges,1091.48,2475,
RUBY COMPLEX STND 8MM X 25CM,2720002476,CDM,278,RC,C1889,HCPCS,Outpatient,,,2475.00,1608.75,,2475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1881,76,,127.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1782,72,,37.44,Percent of Total Billed Charges,72% of Total Billed Charges,1782,72,,39,Percent of Total Billed charges,72% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782,72,,37.44,Percent of Total Billed Charges,72% of Total Billed Charges,1485,60,,31.2,Percent of Total Billed Charges,60% of Total Billed Charges,2227.5,90,,24.304,Percent of Total Billed Charges,90% of Total Billed Charges,1113.75,45,,96.784,Percent of Total Billed Charges,45% of Total Billed Charges,2227.5,90,,150.48,Percent of Total Billed Charges,90% of Total billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.75,65,,188.008,Percent of total Billed Charges,65% of Total Billed Charges,1091.48,44.1,,94.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,2351.25,95,,158.84,Percent of Total Billed Charges,95% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178,88,,147.136,Percent of Total Billed Charges,88% of Total Billed Charges,2227.5,90,,150.48,Percent of Total Billed charges,90% of Total Billed Charges,1091.48,2475,
RUBY COMPLEX STND 8MM X 40CM,2720002477,CDM,278,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,94.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,37.44,Percent of Total Billed Charges,72% of Total Billed Charges,2322,72,,39,Percent of Total Billed charges,72% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,37.44,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,31.2,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,24.304,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,27.472,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,111.6,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,139.8,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,26.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,117.8,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,109.12,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,111.6,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
RUBY COMPLEX STND 10MM X 35CM,2720002478,CDM,278,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,219.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,22.32,Percent of Total Billed Charges,72% of Total Billed Charges,2322,72,,23.248,Percent of Total Billed charges,72% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,22.32,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,18.6,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,463.048,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,27.472,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,260.32,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,39.688,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,26.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,274.776,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,254.528,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,260.32,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
RUBY COMPLEX STND 12MM X 60CM,2720002479,CDM,278,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,163.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,21.816,Percent of Total Billed Charges,72% of Total Billed Charges,2322,72,,22.72,Percent of Total Billed charges,72% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,21.816,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,18.176,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,463.048,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,109.944,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,193.576,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,39.688,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,107.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,204.328,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,189.272,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,193.576,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
RUBY COMPLEX STND 16MM X 60CM,2720002480,CDM,278,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,46.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,2322,72,,54,Percent of Total Billed charges,72% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,5.2,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,12.152,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,54.952,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,158.808,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,11.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,58,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,53.728,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,54.952,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
RUBY COMPLEX STND 18MM X 60CM,2720002481,CDM,278,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,46.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,55.8,Percent of Total Billed Charges,72% of Total Billed Charges,2322,72,,58.12,Percent of Total Billed charges,72% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,55.8,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,46.496,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,321.304,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,12.152,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,54.952,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,17.552,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,11.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,58,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,53.728,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,54.952,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
RUBY COMPLEX STND 20MM X 60CM,2720002482,CDM,278,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,185.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,2322,72,,54,Percent of Total Billed charges,72% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,152.76,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,12.152,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,219.888,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,17.552,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,11.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,232.104,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,215,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,219.888,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
RUBY COMPLEX STND 24MM X 60CM,2720002483,CDM,278,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,20.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,55.8,Percent of Total Billed Charges,72% of Total Billed Charges,2322,72,,58.12,Percent of Total Billed charges,72% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,55.8,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,46.496,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,152.76,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,12.152,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,24.304,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,17.552,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,11.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,25.648,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,23.76,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,24.304,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
RUBY COMPLEX STND 28MM X 60CM,2720002484,CDM,278,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,20.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,2322,72,,54,Percent of Total Billed charges,72% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,3.888,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,12.152,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,24.304,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,17.552,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,11.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,25.648,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,23.76,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,24.304,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
RUBY COMPLEX STND 32MM X 60CM,2720002485,CDM,278,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,20.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,55.8,Percent of Total Billed Charges,72% of Total Billed Charges,2322,72,,58.12,Percent of Total Billed charges,72% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,55.8,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,46.496,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,197.352,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,231.52,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,24.304,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,17.552,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,226.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,25.648,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,23.76,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,24.304,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
RUBY COMPLEX STND 36MM X 60CM,2720002486,CDM,278,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,20.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,2322,72,,54,Percent of Total Billed charges,72% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,369,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,231.52,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,24.304,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,334.424,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,226.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,25.648,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,23.76,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,24.304,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
RUBY COMPLEX STND 40MM X 60CM,2720002487,CDM,278,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,20.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,55.8,Percent of Total Billed Charges,72% of Total Billed Charges,2322,72,,58.12,Percent of Total Billed charges,72% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,55.8,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,46.496,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,2.6,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,24.304,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,334.424,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,2.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,25.648,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,23.76,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,24.304,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
RUBY COMPLEX SOFT 2MM X 1CM,2720002488,CDM,278,RC,C1889,HCPCS,Outpatient,,,2225.00,1446.25,,2225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1691,76,,391.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1602,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,1602,72,,54,Percent of Total Billed charges,72% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1602,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,1335,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,2002.5,90,,99,Percent of Total Billed Charges,90% of Total Billed Charges,1001.25,45,,160.648,Percent of Total Billed Charges,45% of Total Billed Charges,2002.5,90,,463.048,Percent of Total Billed Charges,90% of Total billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1446.25,65,,3.752,Percent of total Billed Charges,65% of Total Billed Charges,981.23,44.1,,157.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,2113.75,95,,488.768,Percent of Total Billed Charges,95% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1958,88,,452.76,Percent of Total Billed Charges,88% of Total Billed Charges,2002.5,90,,463.048,Percent of Total Billed charges,90% of Total Billed Charges,981.23,2225,
RUBY COMPLEX SOFT 2MM X 2CM,2720002489,CDM,278,RC,C1889,HCPCS,Outpatient,,,2225.00,1446.25,,2225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1691,76,,391.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1602,72,,55.8,Percent of Total Billed Charges,72% of Total Billed Charges,1602,72,,58.12,Percent of Total Billed charges,72% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1602,72,,55.8,Percent of Total Billed Charges,72% of Total Billed Charges,1335,60,,46.496,Percent of Total Billed Charges,60% of Total Billed Charges,2002.5,90,,104.4,Percent of Total Billed Charges,90% of Total Billed Charges,1001.25,45,,76.384,Percent of Total Billed Charges,45% of Total Billed Charges,2002.5,90,,463.048,Percent of Total Billed Charges,90% of Total billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1446.25,65,,232.048,Percent of total Billed Charges,65% of Total Billed Charges,981.23,44.1,,74.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,2113.75,95,,488.768,Percent of Total Billed Charges,95% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1958,88,,452.76,Percent of Total Billed Charges,88% of Total Billed Charges,2002.5,90,,463.048,Percent of Total Billed charges,90% of Total Billed Charges,981.23,2225,
RUBY COMPLEX SOFT 2MM X 4CM,2720002490,CDM,278,RC,C1889,HCPCS,Outpatient,,,2225.00,1446.25,,2225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1691,76,,4.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1602,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,1602,72,,54,Percent of Total Billed charges,72% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1602,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,1335,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,2002.5,90,,99,Percent of Total Billed Charges,90% of Total Billed Charges,1001.25,45,,76.384,Percent of Total Billed Charges,45% of Total Billed Charges,2002.5,90,,5.2,Percent of Total Billed Charges,90% of Total billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1446.25,65,,110.328,Percent of total Billed Charges,65% of Total Billed Charges,981.23,44.1,,74.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,2113.75,95,,5.488,Percent of Total Billed Charges,95% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1958,88,,5.08,Percent of Total Billed Charges,88% of Total Billed Charges,2002.5,90,,5.2,Percent of Total Billed charges,90% of Total Billed Charges,981.23,2225,
RUBY COMPLEX SOFT 3MM X 5CM,2720002491,CDM,278,RC,C1889,HCPCS,Outpatient,,,2225.00,1446.25,,2225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1691,76,,271.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1602,72,,55.8,Percent of Total Billed Charges,72% of Total Billed Charges,1602,72,,58.12,Percent of Total Billed charges,72% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1602,72,,55.8,Percent of Total Billed Charges,72% of Total Billed Charges,1335,60,,46.496,Percent of Total Billed Charges,60% of Total Billed Charges,2002.5,90,,104.4,Percent of Total Billed Charges,90% of Total Billed Charges,1001.25,45,,1.944,Percent of Total Billed Charges,45% of Total Billed Charges,2002.5,90,,321.304,Percent of Total Billed Charges,90% of Total billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1446.25,65,,110.328,Percent of total Billed Charges,65% of Total Billed Charges,981.23,44.1,,1.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,2113.75,95,,339.152,Percent of Total Billed Charges,95% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1958,88,,314.16,Percent of Total Billed Charges,88% of Total Billed Charges,2002.5,90,,321.304,Percent of Total Billed charges,90% of Total Billed Charges,981.23,2225,
RUBY COMPLEX SOFT 3MM X 15CM,2720002492,CDM,278,RC,C1889,HCPCS,Outpatient,,,2225.00,1446.25,,2225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1691,76,,129,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1602,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,1602,72,,54,Percent of Total Billed charges,72% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1602,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,1335,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,2002.5,90,,99,Percent of Total Billed Charges,90% of Total Billed Charges,1001.25,45,,98.68,Percent of Total Billed Charges,45% of Total Billed Charges,2002.5,90,,152.76,Percent of Total Billed Charges,90% of Total billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1446.25,65,,2.808,Percent of total Billed Charges,65% of Total Billed Charges,981.23,44.1,,96.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,2113.75,95,,161.248,Percent of Total Billed Charges,95% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1958,88,,149.368,Percent of Total Billed Charges,88% of Total Billed Charges,2002.5,90,,152.76,Percent of Total Billed charges,90% of Total Billed Charges,981.23,2225,
RUBY COMPLEX SOFT 4MM X 6CM,2720002493,CDM,278,RC,C1889,HCPCS,Outpatient,,,2225.00,1446.25,,2225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1691,76,,129,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1602,72,,55.8,Percent of Total Billed Charges,72% of Total Billed Charges,1602,72,,58.12,Percent of Total Billed charges,72% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1602,72,,55.8,Percent of Total Billed Charges,72% of Total Billed Charges,1335,60,,46.496,Percent of Total Billed Charges,60% of Total Billed Charges,2002.5,90,,104.4,Percent of Total Billed Charges,90% of Total Billed Charges,1001.25,45,,184.504,Percent of Total Billed Charges,45% of Total Billed Charges,2002.5,90,,152.76,Percent of Total Billed Charges,90% of Total billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1446.25,65,,142.536,Percent of total Billed Charges,65% of Total Billed Charges,981.23,44.1,,180.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,2113.75,95,,161.248,Percent of Total Billed Charges,95% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1958,88,,149.368,Percent of Total Billed Charges,88% of Total Billed Charges,2002.5,90,,152.76,Percent of Total Billed charges,90% of Total Billed Charges,981.23,2225,
RUBY COMPLEX SOFT 4MM X 15CM,2720002494,CDM,278,RC,C1889,HCPCS,Outpatient,,,2475.00,1608.75,,2475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1881,76,,3.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1782,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,1782,72,,54,Percent of Total Billed charges,72% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,1485,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,2227.5,90,,99,Percent of Total Billed Charges,90% of Total Billed Charges,1113.75,45,,7.92,Percent of Total Billed Charges,45% of Total Billed Charges,2227.5,90,,3.888,Percent of Total Billed Charges,90% of Total billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.75,65,,266.504,Percent of total Billed Charges,65% of Total Billed Charges,1091.48,44.1,,7.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,2351.25,95,,4.104,Percent of Total Billed Charges,95% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178,88,,3.8,Percent of Total Billed Charges,88% of Total Billed Charges,2227.5,90,,3.888,Percent of Total Billed charges,90% of Total Billed Charges,1091.48,2475,
RUBY COMPLEX SOFT 6MM X 20CM,2720002495,CDM,278,RC,C1889,HCPCS,Outpatient,,,2475.00,1608.75,,2475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1881,76,,166.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1782,72,,55.8,Percent of Total Billed Charges,72% of Total Billed Charges,1782,72,,58.12,Percent of Total Billed charges,72% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782,72,,55.8,Percent of Total Billed Charges,72% of Total Billed Charges,1485,60,,46.496,Percent of Total Billed Charges,60% of Total Billed Charges,2227.5,90,,104.4,Percent of Total Billed Charges,90% of Total Billed Charges,1113.75,45,,49.504,Percent of Total Billed Charges,45% of Total Billed Charges,2227.5,90,,197.352,Percent of Total Billed Charges,90% of Total billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.75,65,,11.44,Percent of total Billed Charges,65% of Total Billed Charges,1091.48,44.1,,48.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,2351.25,95,,208.32,Percent of Total Billed Charges,95% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178,88,,192.968,Percent of Total Billed Charges,88% of Total Billed Charges,2227.5,90,,197.352,Percent of Total Billed charges,90% of Total Billed Charges,1091.48,2475,
RUBY COMPLEX SOFT 6MM X 30CM,2720002496,CDM,278,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,311.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,20.344,Percent of Total Billed Charges,72% of Total Billed Charges,2322,72,,21.192,Percent of Total Billed charges,72% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,20.344,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,16.952,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,99,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,52.2,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,369,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,71.504,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,51.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,389.504,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,360.8,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,369,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
RUBY COMPLEX SOFT 8MM X 35CM,2720002497,CDM,278,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,13.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,188.208,Percent of Total Billed Charges,72% of Total Billed Charges,2322,72,,196.048,Percent of Total Billed charges,72% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,188.208,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,156.84,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,104.4,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,49.504,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,15.84,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,75.4,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,48.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,16.72,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,15.488,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,15.84,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
RUBY COMPLEX SOFT 8MM X 60CM,2720002498,CDM,278,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,83.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,506.304,Percent of Total Billed Charges,72% of Total Billed Charges,2322,72,,527.4,Percent of Total Billed charges,72% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,506.304,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,421.92,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,112.464,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,52.2,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,99,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,71.504,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,51.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,104.504,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,96.8,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,99,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
RUBY COMPLEX SOFT 16MM X 50CM,2720002499,CDM,278,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,88.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,360,Percent of Total Billed Charges,72% of Total Billed Charges,2322,72,,375,Percent of Total Billed charges,72% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,360,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,300,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,143.152,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,49.504,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,104.4,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,75.4,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,48.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,110.2,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,102.08,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,104.4,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
RUBY COMPLEX SOFT 20MM X 60CM,2720002500,CDM,278,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,83.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,360,Percent of Total Billed Charges,72% of Total Billed Charges,2322,72,,375,Percent of Total Billed charges,72% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,360,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,300,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,495,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,52.2,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,99,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,71.504,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,51.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,104.504,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,96.8,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,99,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
POD 3,2720002501,CDM,278,RC,C1889,HCPCS,Outpatient,,,4475.00,2908.75,,4475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3401,76,,88.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3222,72,,1080,Percent of Total Billed Charges,72% of Total Billed Charges,3222,72,,1125,Percent of Total Billed charges,72% of Total Billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3222,72,,1080,Percent of Total Billed Charges,72% of Total Billed Charges,2685,60,,900,Percent of Total Billed Charges,60% of Total Billed Charges,4027.5,90,,426.6,Percent of Total Billed Charges,90% of Total Billed Charges,2013.75,45,,49.504,Percent of Total Billed Charges,45% of Total Billed Charges,4027.5,90,,104.4,Percent of Total Billed Charges,90% of Total billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2908.75,65,,75.4,Percent of total Billed Charges,65% of Total Billed Charges,1973.48,44.1,,48.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,4251.25,95,,110.2,Percent of Total Billed Charges,95% of Total Billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3938,88,,102.08,Percent of Total Billed Charges,88% of Total Billed Charges,4027.5,90,,104.4,Percent of Total Billed charges,90% of Total Billed Charges,1973.48,4475,
POD 4,2720002502,CDM,278,RC,C1889,HCPCS,Outpatient,,,4475.00,2908.75,,4475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3401,76,,83.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3222,72,,617.328,Percent of Total Billed Charges,72% of Total Billed Charges,3222,72,,643.048,Percent of Total Billed charges,72% of Total Billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3222,72,,617.328,Percent of Total Billed Charges,72% of Total Billed Charges,2685,60,,514.44,Percent of Total Billed Charges,60% of Total Billed Charges,4027.5,90,,60.648,Percent of Total Billed Charges,90% of Total Billed Charges,2013.75,45,,52.2,Percent of Total Billed Charges,45% of Total Billed Charges,4027.5,90,,99,Percent of Total Billed Charges,90% of Total billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2908.75,65,,71.504,Percent of total Billed Charges,65% of Total Billed Charges,1973.48,44.1,,51.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,4251.25,95,,104.504,Percent of Total Billed Charges,95% of Total Billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3938,88,,96.8,Percent of Total Billed Charges,88% of Total Billed Charges,4027.5,90,,99,Percent of Total Billed charges,90% of Total Billed Charges,1973.48,4475,
POD 5,2720002503,CDM,278,RC,C1889,HCPCS,Outpatient,,,4475.00,2908.75,,4475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3401,76,,88.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3222,72,,98.104,Percent of Total Billed Charges,72% of Total Billed Charges,3222,72,,102.192,Percent of Total Billed charges,72% of Total Billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3222,72,,98.104,Percent of Total Billed Charges,72% of Total Billed Charges,2685,60,,81.752,Percent of Total Billed Charges,60% of Total Billed Charges,4027.5,90,,57.816,Percent of Total Billed Charges,90% of Total Billed Charges,2013.75,45,,49.504,Percent of Total Billed Charges,45% of Total Billed Charges,4027.5,90,,104.4,Percent of Total Billed Charges,90% of Total billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2908.75,65,,75.4,Percent of total Billed Charges,65% of Total Billed Charges,1973.48,44.1,,48.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,4251.25,95,,110.2,Percent of Total Billed Charges,95% of Total Billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3938,88,,102.08,Percent of Total Billed Charges,88% of Total Billed Charges,4027.5,90,,104.4,Percent of Total Billed charges,90% of Total Billed Charges,1973.48,4475,
POD 6,2720002504,CDM,278,RC,C1889,HCPCS,Outpatient,,,4475.00,2908.75,,4475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3401,76,,83.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3222,72,,18.704,Percent of Total Billed Charges,72% of Total Billed Charges,3222,72,,19.48,Percent of Total Billed charges,72% of Total Billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3222,72,,18.704,Percent of Total Billed Charges,72% of Total Billed Charges,2685,60,,15.584,Percent of Total Billed Charges,60% of Total Billed Charges,4027.5,90,,2934,Percent of Total Billed Charges,90% of Total Billed Charges,2013.75,45,,52.2,Percent of Total Billed Charges,45% of Total Billed Charges,4027.5,90,,99,Percent of Total Billed Charges,90% of Total billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2908.75,65,,71.504,Percent of total Billed Charges,65% of Total Billed Charges,1973.48,44.1,,51.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,4251.25,95,,104.504,Percent of Total Billed Charges,95% of Total Billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3938,88,,96.8,Percent of Total Billed Charges,88% of Total Billed Charges,4027.5,90,,99,Percent of Total Billed charges,90% of Total Billed Charges,1973.48,4475,
POD 8,2720002505,CDM,278,RC,C1889,HCPCS,Outpatient,,,4475.00,2908.75,,4475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3401,76,,88.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3222,72,,18.704,Percent of Total Billed Charges,72% of Total Billed Charges,3222,72,,19.48,Percent of Total Billed charges,72% of Total Billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3222,72,,18.704,Percent of Total Billed Charges,72% of Total Billed Charges,2685,60,,15.584,Percent of Total Billed Charges,60% of Total Billed Charges,4027.5,90,,2934,Percent of Total Billed Charges,90% of Total Billed Charges,2013.75,45,,56.232,Percent of Total Billed Charges,45% of Total Billed Charges,4027.5,90,,104.4,Percent of Total Billed Charges,90% of Total billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2908.75,65,,75.4,Percent of total Billed Charges,65% of Total Billed Charges,1973.48,44.1,,55.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,4251.25,95,,110.2,Percent of Total Billed Charges,95% of Total Billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3938,88,,102.08,Percent of Total Billed Charges,88% of Total Billed Charges,4027.5,90,,104.4,Percent of Total Billed charges,90% of Total Billed Charges,1973.48,4475,
POD 10,2720002506,CDM,278,RC,C1889,HCPCS,Outpatient,,,4475.00,2908.75,,4475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3401,76,,83.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3222,72,,2347.2,Percent of Total Billed Charges,72% of Total Billed Charges,3222,72,,2445,Percent of Total Billed charges,72% of Total Billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3222,72,,2347.2,Percent of Total Billed Charges,72% of Total Billed Charges,2685,60,,1956,Percent of Total Billed Charges,60% of Total Billed Charges,4027.5,90,,57.688,Percent of Total Billed Charges,90% of Total Billed Charges,2013.75,45,,71.576,Percent of Total Billed Charges,45% of Total Billed Charges,4027.5,90,,99,Percent of Total Billed Charges,90% of Total billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2908.75,65,,81.224,Percent of total Billed Charges,65% of Total Billed Charges,1973.48,44.1,,70.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,4251.25,95,,104.504,Percent of Total Billed Charges,95% of Total Billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3938,88,,96.8,Percent of Total Billed Charges,88% of Total Billed Charges,4027.5,90,,99,Percent of Total Billed charges,90% of Total Billed Charges,1973.48,4475,
POD 12,2720002507,CDM,278,RC,C1889,HCPCS,Outpatient,,,4475.00,2908.75,,4475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3401,76,,88.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3222,72,,2347.2,Percent of Total Billed Charges,72% of Total Billed Charges,3222,72,,2445,Percent of Total Billed charges,72% of Total Billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3222,72,,2347.2,Percent of Total Billed Charges,72% of Total Billed Charges,2685,60,,1956,Percent of Total Billed Charges,60% of Total Billed Charges,4027.5,90,,93.144,Percent of Total Billed Charges,90% of Total Billed Charges,2013.75,45,,247.504,Percent of Total Billed Charges,45% of Total Billed Charges,4027.5,90,,104.4,Percent of Total Billed Charges,90% of Total billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2908.75,65,,103.384,Percent of total Billed Charges,65% of Total Billed Charges,1973.48,44.1,,242.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,4251.25,95,,110.2,Percent of Total Billed Charges,95% of Total Billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3938,88,,102.08,Percent of Total Billed Charges,88% of Total Billed Charges,4027.5,90,,104.4,Percent of Total Billed charges,90% of Total Billed Charges,1973.48,4475,
POD 14,2720002508,CDM,278,RC,C1889,HCPCS,Outpatient,,,4475.00,2908.75,,4475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3401,76,,94.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3222,72,,2347.2,Percent of Total Billed Charges,72% of Total Billed Charges,3222,72,,2445,Percent of Total Billed charges,72% of Total Billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3222,72,,2347.2,Percent of Total Billed Charges,72% of Total Billed Charges,2685,60,,1956,Percent of Total Billed Charges,60% of Total Billed Charges,4027.5,90,,338.728,Percent of Total Billed Charges,90% of Total Billed Charges,2013.75,45,,213.304,Percent of Total Billed Charges,45% of Total Billed Charges,4027.5,90,,112.464,Percent of Total Billed Charges,90% of Total billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2908.75,65,,357.504,Percent of total Billed Charges,65% of Total Billed Charges,1973.48,44.1,,209.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,4251.25,95,,118.712,Percent of Total Billed Charges,95% of Total Billed Charges,4475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3938,88,,109.968,Percent of Total Billed Charges,88% of Total Billed Charges,4027.5,90,,112.464,Percent of Total Billed charges,90% of Total Billed Charges,1973.48,4475,
POD PACKING COIL J-SOFT 5CM,2720002509,CDM,272,RC,C1889,HCPCS,Outpatient,,,2475.00,1608.75,,2475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1881,76,,120.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1782,72,,2.896,Percent of Total Billed Charges,72% of Total Billed Charges,1856.25,75,,3.016,Percent of Total Billed charges,75% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782,72,,2.896,Percent of Total Billed Charges,72% of Total Billed Charges,1485,60,,2.416,Percent of Total Billed Charges,60% of Total Billed Charges,2227.5,90,,957.6,Percent of Total Billed Charges,90% of Total Billed Charges,1113.75,45,,30.32,Percent of Total Billed Charges,45% of Total Billed Charges,2227.5,90,,143.152,Percent of Total Billed Charges,90% of Total billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.75,65,,308.104,Percent of total Billed Charges,65% of Total Billed Charges,1091.48,44.1,,29.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,2351.25,95,,151.104,Percent of Total Billed Charges,95% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178,88,,139.968,Percent of Total Billed Charges,88% of Total Billed Charges,2227.5,90,,143.152,Percent of Total Billed charges,90% of Total Billed Charges,1091.48,2475,
POD PACKING COIL J-SOFT 15CM,2720002510,CDM,272,RC,C1889,HCPCS,Outpatient,,,2475.00,1608.75,,2475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1881,76,,418,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1782,72,,7.344,Percent of Total Billed Charges,72% of Total Billed Charges,1856.25,75,,7.648,Percent of Total Billed charges,75% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782,72,,7.344,Percent of Total Billed Charges,72% of Total Billed Charges,1485,60,,6.12,Percent of Total Billed Charges,60% of Total Billed Charges,2227.5,90,,110.128,Percent of Total Billed Charges,90% of Total Billed Charges,1113.75,45,,28.912,Percent of Total Billed Charges,45% of Total Billed Charges,2227.5,90,,495,Percent of Total Billed Charges,90% of Total billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.75,65,,43.8,Percent of total Billed Charges,65% of Total Billed Charges,1091.48,44.1,,28.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,2351.25,95,,522.504,Percent of Total Billed Charges,95% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178,88,,484,Percent of Total Billed Charges,88% of Total Billed Charges,2227.5,90,,495,Percent of Total Billed charges,90% of Total Billed Charges,1091.48,2475,
POD PACKING COIL J-SOFT 30CM,2720002511,CDM,272,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,360.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,18.144,Percent of Total Billed Charges,72% of Total Billed Charges,2418.75,75,,18.904,Percent of Total Billed charges,75% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,18.144,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,15.12,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,1350,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,1467,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,426.6,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,41.76,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,1437.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,450.304,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,417.12,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,426.6,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
POD PACKING COIL J-SOFT 45CM,2720002512,CDM,272,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,51.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,18.424,Percent of Total Billed Charges,72% of Total Billed Charges,2418.75,75,,19.192,Percent of Total Billed charges,75% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,18.424,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,15.352,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,2005.432,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,1467,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,60.648,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,2119,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,1437.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,64.016,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,59.296,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,60.648,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
POD PACKING COIL J-SOFT 60CM,2720002513,CDM,272,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,48.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,2418.75,75,,3,Percent of Total Billed charges,75% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,2.88,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,1538.008,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,28.84,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,57.816,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,2119,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,28.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,61.032,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,56.528,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,57.816,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
LANTERN MICRO CATHETER 135-ST,2720002514,CDM,272,RC,C1887,HCPCS,Outpatient,,,1725.00,1121.25,,1725,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1311,76,,2477.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1242,72,,2.84,Percent of Total Billed Charges,72% of Total Billed Charges,1293.75,75,,2.96,Percent of Total Billed charges,75% of Total Billed Charges,1725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1242,72,,2.84,Percent of Total Billed Charges,72% of Total Billed Charges,1035,60,,2.368,Percent of Total Billed Charges,60% of Total Billed Charges,1552.5,90,,945,Percent of Total Billed Charges,90% of Total Billed Charges,776.25,45,,46.576,Percent of Total Billed Charges,45% of Total Billed Charges,1552.5,90,,2934,Percent of Total Billed Charges,90% of Total billed Charges,1725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1121.25,65,,41.664,Percent of total Billed Charges,65% of Total Billed Charges,760.73,44.1,,45.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,1638.75,95,,3097,Percent of Total Billed Charges,95% of Total Billed Charges,1725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1518,88,,2868.8,Percent of Total Billed Charges,88% of Total Billed Charges,1552.5,90,,2934,Percent of Total Billed charges,90% of Total Billed Charges,760.73,1725,
LANTERN MICRO CATHETER 135-45,2720002515,CDM,272,RC,C1887,HCPCS,Outpatient,,,1725.00,1121.25,,1725,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1311,76,,2477.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1242,72,,7.48,Percent of Total Billed Charges,72% of Total Billed Charges,1293.75,75,,7.792,Percent of Total Billed charges,75% of Total Billed Charges,1725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1242,72,,7.48,Percent of Total Billed Charges,72% of Total Billed Charges,1035,60,,6.232,Percent of Total Billed Charges,60% of Total Billed Charges,1552.5,90,,13.32,Percent of Total Billed Charges,90% of Total Billed Charges,776.25,45,,169.36,Percent of Total Billed Charges,45% of Total Billed Charges,1552.5,90,,2934,Percent of Total Billed Charges,90% of Total billed Charges,1725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1121.25,65,,67.272,Percent of total Billed Charges,65% of Total Billed Charges,760.73,44.1,,165.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,1638.75,95,,3097,Percent of Total Billed Charges,95% of Total Billed Charges,1725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1518,88,,2868.8,Percent of Total Billed Charges,88% of Total Billed Charges,1552.5,90,,2934,Percent of Total Billed charges,90% of Total Billed Charges,760.73,1725,
LANTERN MICRO CATHETER 150-ST,2720002516,CDM,272,RC,C1887,HCPCS,Outpatient,,,1725.00,1121.25,,1725,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1311,76,,48.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1242,72,,7.344,Percent of Total Billed Charges,72% of Total Billed Charges,1293.75,75,,7.648,Percent of Total Billed charges,75% of Total Billed Charges,1725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1242,72,,7.344,Percent of Total Billed Charges,72% of Total Billed Charges,1035,60,,6.12,Percent of Total Billed Charges,60% of Total Billed Charges,1552.5,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,776.25,45,,478.8,Percent of Total Billed Charges,45% of Total Billed Charges,1552.5,90,,57.688,Percent of Total Billed Charges,90% of Total billed Charges,1725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1121.25,65,,244.632,Percent of total Billed Charges,65% of Total Billed Charges,760.73,44.1,,469.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,1638.75,95,,60.888,Percent of Total Billed Charges,95% of Total Billed Charges,1725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1518,88,,56.408,Percent of Total Billed Charges,88% of Total Billed Charges,1552.5,90,,57.688,Percent of Total Billed charges,90% of Total Billed Charges,760.73,1725,
COIL DETACHMENT HANDLE,2720002517,CDM,272,RC,C1889,HCPCS,Outpatient,,,587.50,381.88,,587.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,446.5,76,,78.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,423,72,,4.608,Percent of Total Billed Charges,72% of Total Billed Charges,440.63,75,,4.8,Percent of Total Billed charges,75% of Total Billed Charges,587.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,423,72,,4.608,Percent of Total Billed Charges,72% of Total Billed Charges,352.5,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,528.75,90,,13.32,Percent of Total Billed Charges,90% of Total Billed Charges,264.38,45,,55.064,Percent of Total Billed Charges,45% of Total Billed Charges,528.75,90,,93.144,Percent of Total Billed Charges,90% of Total billed Charges,587.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,587.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,587.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.88,65,,691.6,Percent of total Billed Charges,65% of Total Billed Charges,259.09,44.1,,53.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,558.13,95,,98.32,Percent of Total Billed Charges,95% of Total Billed Charges,587.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,517,88,,91.08,Percent of Total Billed Charges,88% of Total Billed Charges,528.75,90,,93.144,Percent of Total Billed charges,90% of Total Billed Charges,259.09,587.5,
RUBY COIL LP 1MM X 2CM,2720002518,CDM,278,RC,C1889,HCPCS,Outpatient,,,2225.00,1446.25,,2225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1691,76,,286.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1602,72,,7.632,Percent of Total Billed Charges,72% of Total Billed Charges,1602,72,,7.952,Percent of Total Billed charges,72% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1602,72,,7.632,Percent of Total Billed Charges,72% of Total Billed Charges,1335,60,,6.36,Percent of Total Billed Charges,60% of Total Billed Charges,2002.5,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,1001.25,45,,675,Percent of Total Billed Charges,45% of Total Billed Charges,2002.5,90,,338.728,Percent of Total Billed Charges,90% of Total billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1446.25,65,,79.536,Percent of total Billed Charges,65% of Total Billed Charges,981.23,44.1,,661.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,2113.75,95,,357.544,Percent of Total Billed Charges,95% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1958,88,,331.2,Percent of Total Billed Charges,88% of Total Billed Charges,2002.5,90,,338.728,Percent of Total Billed charges,90% of Total Billed Charges,981.23,2225,
RUBY COIL LP 1MM X 5CM,2720002519,CDM,278,RC,C1889,HCPCS,Outpatient,,,2225.00,1446.25,,2225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1691,76,,808.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1602,72,,12.24,Percent of Total Billed Charges,72% of Total Billed Charges,1602,72,,12.752,Percent of Total Billed charges,72% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1602,72,,12.24,Percent of Total Billed Charges,72% of Total Billed Charges,1335,60,,10.2,Percent of Total Billed Charges,60% of Total Billed Charges,2002.5,90,,13.32,Percent of Total Billed Charges,90% of Total Billed Charges,1001.25,45,,1002.712,Percent of Total Billed Charges,45% of Total Billed Charges,2002.5,90,,957.6,Percent of Total Billed Charges,90% of Total billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1446.25,65,,975,Percent of total Billed Charges,65% of Total Billed Charges,981.23,44.1,,982.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,2113.75,95,,1010.8,Percent of Total Billed Charges,95% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1958,88,,936.32,Percent of Total Billed Charges,88% of Total Billed Charges,2002.5,90,,957.6,Percent of Total Billed charges,90% of Total Billed Charges,981.23,2225,
RUBY COIL LP 2MM X 2CM,2720002520,CDM,278,RC,C1889,HCPCS,Outpatient,,,2225.00,1446.25,,2225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1691,76,,92.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1602,72,,14.688,Percent of Total Billed Charges,72% of Total Billed Charges,1602,72,,15.304,Percent of Total Billed charges,72% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1602,72,,14.688,Percent of Total Billed Charges,72% of Total Billed Charges,1335,60,,12.24,Percent of Total Billed Charges,60% of Total Billed Charges,2002.5,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,1001.25,45,,769,Percent of Total Billed Charges,45% of Total Billed Charges,2002.5,90,,110.128,Percent of Total Billed Charges,90% of Total billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1446.25,65,,1448.368,Percent of total Billed Charges,65% of Total Billed Charges,981.23,44.1,,753.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,2113.75,95,,116.24,Percent of Total Billed Charges,95% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1958,88,,107.68,Percent of Total Billed Charges,88% of Total Billed Charges,2002.5,90,,110.128,Percent of Total Billed charges,90% of Total Billed Charges,981.23,2225,
RUBY COIL LP 2MM X 4CM,2720002521,CDM,278,RC,C1889,HCPCS,Outpatient,,,2225.00,1446.25,,2225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1691,76,,1140,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1602,72,,16.56,Percent of Total Billed Charges,72% of Total Billed Charges,1602,72,,17.248,Percent of Total Billed charges,72% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1602,72,,16.56,Percent of Total Billed Charges,72% of Total Billed Charges,1335,60,,13.8,Percent of Total Billed Charges,60% of Total Billed Charges,2002.5,90,,13.32,Percent of Total Billed Charges,90% of Total Billed Charges,1001.25,45,,472.504,Percent of Total Billed Charges,45% of Total Billed Charges,2002.5,90,,1350,Percent of Total Billed Charges,90% of Total billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1446.25,65,,1110.784,Percent of total Billed Charges,65% of Total Billed Charges,981.23,44.1,,463.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,2113.75,95,,1425,Percent of Total Billed Charges,95% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1958,88,,1320,Percent of Total Billed Charges,88% of Total Billed Charges,2002.5,90,,1350,Percent of Total Billed charges,90% of Total Billed Charges,981.23,2225,
RUBY COIL LP 2MM X 10CM,2720002522,CDM,278,RC,C1889,HCPCS,Outpatient,,,2475.00,1608.75,,2475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1881,76,,1693.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1782,72,,20.16,Percent of Total Billed Charges,72% of Total Billed Charges,1782,72,,21,Percent of Total Billed charges,72% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782,72,,20.16,Percent of Total Billed Charges,72% of Total Billed Charges,1485,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,2227.5,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,1113.75,45,,6.664,Percent of Total Billed Charges,45% of Total Billed Charges,2227.5,90,,2005.432,Percent of Total Billed Charges,90% of Total billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.75,65,,682.504,Percent of total Billed Charges,65% of Total Billed Charges,1091.48,44.1,,6.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,2351.25,95,,2116.84,Percent of Total Billed Charges,95% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178,88,,1960.864,Percent of Total Billed Charges,88% of Total Billed Charges,2227.5,90,,2005.432,Percent of Total Billed charges,90% of Total Billed Charges,1091.48,2475,
RUBY COIL LP 3MM X 4CM,2720002523,CDM,278,RC,C1889,HCPCS,Outpatient,,,2225.00,1446.25,,2225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1691,76,,1298.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1602,72,,25.168,Percent of Total Billed Charges,72% of Total Billed Charges,1602,72,,26.224,Percent of Total Billed charges,72% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1602,72,,25.168,Percent of Total Billed Charges,72% of Total Billed Charges,1335,60,,20.976,Percent of Total Billed Charges,60% of Total Billed Charges,2002.5,90,,13.32,Percent of Total Billed Charges,90% of Total Billed Charges,1001.25,45,,14.4,Percent of Total Billed Charges,45% of Total Billed Charges,2002.5,90,,1538.008,Percent of Total Billed Charges,90% of Total billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1446.25,65,,9.624,Percent of total Billed Charges,65% of Total Billed Charges,981.23,44.1,,14.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,2113.75,95,,1623.448,Percent of Total Billed Charges,95% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1958,88,,1503.832,Percent of Total Billed Charges,88% of Total Billed Charges,2002.5,90,,1538.008,Percent of Total Billed charges,90% of Total Billed Charges,981.23,2225,
RUBY COIL LP 3MM X 10CM,2720002524,CDM,278,RC,C1889,HCPCS,Outpatient,,,2475.00,1608.75,,2475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1881,76,,798,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1782,72,,22.264,Percent of Total Billed Charges,72% of Total Billed Charges,1782,72,,23.192,Percent of Total Billed charges,72% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782,72,,22.264,Percent of Total Billed Charges,72% of Total Billed Charges,1485,60,,18.552,Percent of Total Billed Charges,60% of Total Billed Charges,2227.5,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,1113.75,45,,6.664,Percent of Total Billed Charges,45% of Total Billed Charges,2227.5,90,,945,Percent of Total Billed Charges,90% of Total billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.75,65,,20.8,Percent of total Billed Charges,65% of Total Billed Charges,1091.48,44.1,,6.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,2351.25,95,,997.504,Percent of Total Billed Charges,95% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178,88,,924,Percent of Total Billed Charges,88% of Total Billed Charges,2227.5,90,,945,Percent of Total Billed charges,90% of Total Billed Charges,1091.48,2475,
RUBY COIL LP 3MM X 15CM,2720002525,CDM,278,RC,C1889,HCPCS,Outpatient,,,2475.00,1608.75,,2475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1881,76,,11.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1782,72,,4.264,Percent of Total Billed Charges,72% of Total Billed Charges,1782,72,,4.44,Percent of Total Billed charges,72% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782,72,,4.264,Percent of Total Billed Charges,72% of Total Billed Charges,1485,60,,3.552,Percent of Total Billed Charges,60% of Total Billed Charges,2227.5,90,,13.32,Percent of Total Billed Charges,90% of Total Billed Charges,1113.75,45,,14.4,Percent of Total Billed Charges,45% of Total Billed Charges,2227.5,90,,13.32,Percent of Total Billed Charges,90% of Total billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.75,65,,9.624,Percent of total Billed Charges,65% of Total Billed Charges,1091.48,44.1,,14.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,2351.25,95,,14.064,Percent of Total Billed Charges,95% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178,88,,13.024,Percent of Total Billed Charges,88% of Total Billed Charges,2227.5,90,,13.32,Percent of Total Billed charges,90% of Total Billed Charges,1091.48,2475,
RUBY COIL LP 4MM X 6CM,2720002526,CDM,278,RC,C1889,HCPCS,Outpatient,,,2225.00,1446.25,,2225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1691,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1602,72,,0.608,Percent of Total Billed Charges,72% of Total Billed Charges,1602,72,,0.632,Percent of Total Billed charges,72% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1602,72,,0.608,Percent of Total Billed Charges,72% of Total Billed Charges,1335,60,,0.504,Percent of Total Billed Charges,60% of Total Billed Charges,2002.5,90,,13.32,Percent of Total Billed Charges,90% of Total Billed Charges,1001.25,45,,6.664,Percent of Total Billed Charges,45% of Total Billed Charges,2002.5,90,,28.8,Percent of Total Billed Charges,90% of Total billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1446.25,65,,20.8,Percent of total Billed Charges,65% of Total Billed Charges,981.23,44.1,,6.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,2113.75,95,,30.4,Percent of Total Billed Charges,95% of Total Billed Charges,2225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1958,88,,28.16,Percent of Total Billed Charges,88% of Total Billed Charges,2002.5,90,,28.8,Percent of Total Billed charges,90% of Total Billed Charges,981.23,2225,
RUBY COIL LP 4MM X 15CM,2720002527,CDM,278,RC,C1889,HCPCS,Outpatient,,,2475.00,1608.75,,2475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1881,76,,11.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1782,72,,0.608,Percent of Total Billed Charges,72% of Total Billed Charges,1782,72,,0.632,Percent of Total Billed charges,72% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782,72,,0.608,Percent of Total Billed Charges,72% of Total Billed Charges,1485,60,,0.504,Percent of Total Billed Charges,60% of Total Billed Charges,2227.5,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,1113.75,45,,14.4,Percent of Total Billed Charges,45% of Total Billed Charges,2227.5,90,,13.32,Percent of Total Billed Charges,90% of Total billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.75,65,,9.624,Percent of total Billed Charges,65% of Total Billed Charges,1091.48,44.1,,14.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,2351.25,95,,14.064,Percent of Total Billed Charges,95% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178,88,,13.024,Percent of Total Billed Charges,88% of Total Billed Charges,2227.5,90,,13.32,Percent of Total Billed charges,90% of Total Billed Charges,1091.48,2475,
RUBY COIL LP 4MM X 30CM,2720002528,CDM,278,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,0.488,Percent of Total Billed Charges,72% of Total Billed Charges,2322,72,,0.512,Percent of Total Billed charges,72% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,0.488,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,0.408,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,13.32,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,6.664,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,28.8,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,20.8,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,6.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,30.4,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,28.16,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,28.8,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
PACKING COIL LP 3CM,2720002529,CDM,272,RC,C1889,HCPCS,Outpatient,,,2475.00,1608.75,,2475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1881,76,,11.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1782,72,,11.488,Percent of Total Billed Charges,72% of Total Billed Charges,1856.25,75,,11.968,Percent of Total Billed charges,75% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782,72,,11.488,Percent of Total Billed Charges,72% of Total Billed Charges,1485,60,,9.576,Percent of Total Billed Charges,60% of Total Billed Charges,2227.5,90,,2538,Percent of Total Billed Charges,90% of Total Billed Charges,1113.75,45,,14.4,Percent of Total Billed Charges,45% of Total Billed Charges,2227.5,90,,13.32,Percent of Total Billed Charges,90% of Total billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.75,65,,9.624,Percent of total Billed Charges,65% of Total Billed Charges,1091.48,44.1,,14.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,2351.25,95,,14.064,Percent of Total Billed Charges,95% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178,88,,13.024,Percent of Total Billed Charges,88% of Total Billed Charges,2227.5,90,,13.32,Percent of Total Billed charges,90% of Total Billed Charges,1091.48,2475,
PACKING COIL LP 6CM,2720002530,CDM,272,RC,C1889,HCPCS,Outpatient,,,2475.00,1608.75,,2475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1881,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1782,72,,19.584,Percent of Total Billed Charges,72% of Total Billed Charges,1856.25,75,,20.4,Percent of Total Billed charges,75% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782,72,,19.584,Percent of Total Billed Charges,72% of Total Billed Charges,1485,60,,16.32,Percent of Total Billed Charges,60% of Total Billed Charges,2227.5,90,,73.096,Percent of Total Billed Charges,90% of Total Billed Charges,1113.75,45,,6.664,Percent of Total Billed Charges,45% of Total Billed Charges,2227.5,90,,28.8,Percent of Total Billed Charges,90% of Total billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.75,65,,20.8,Percent of total Billed Charges,65% of Total Billed Charges,1091.48,44.1,,6.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,2351.25,95,,30.4,Percent of Total Billed Charges,95% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178,88,,28.16,Percent of Total Billed Charges,88% of Total Billed Charges,2227.5,90,,28.8,Percent of Total Billed charges,90% of Total Billed Charges,1091.48,2475,
PACKING COIL LP 10CM,2720002531,CDM,272,RC,C1889,HCPCS,Outpatient,,,2475.00,1608.75,,2475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1881,76,,11.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1782,72,,285.12,Percent of Total Billed Charges,72% of Total Billed Charges,1856.25,75,,297,Percent of Total Billed charges,75% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782,72,,285.12,Percent of Total Billed Charges,72% of Total Billed Charges,1485,60,,237.6,Percent of Total Billed Charges,60% of Total Billed Charges,2227.5,90,,12.424,Percent of Total Billed Charges,90% of Total Billed Charges,1113.75,45,,14.4,Percent of Total Billed Charges,45% of Total Billed Charges,2227.5,90,,13.32,Percent of Total Billed Charges,90% of Total billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.75,65,,9.624,Percent of total Billed Charges,65% of Total Billed Charges,1091.48,44.1,,14.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,2351.25,95,,14.064,Percent of Total Billed Charges,95% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178,88,,13.024,Percent of Total Billed Charges,88% of Total Billed Charges,2227.5,90,,13.32,Percent of Total Billed charges,90% of Total Billed Charges,1091.48,2475,
PACKING COIL LP 15CM,2720002532,CDM,272,RC,C1889,HCPCS,Outpatient,,,2475.00,1608.75,,2475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1881,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1782,72,,1016.928,Percent of Total Billed Charges,72% of Total Billed Charges,1856.25,75,,1059.304,Percent of Total Billed charges,75% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782,72,,1016.928,Percent of Total Billed Charges,72% of Total Billed Charges,1485,60,,847.44,Percent of Total Billed Charges,60% of Total Billed Charges,2227.5,90,,11.248,Percent of Total Billed Charges,90% of Total Billed Charges,1113.75,45,,6.664,Percent of Total Billed Charges,45% of Total Billed Charges,2227.5,90,,28.8,Percent of Total Billed Charges,90% of Total billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.75,65,,20.8,Percent of total Billed Charges,65% of Total Billed Charges,1091.48,44.1,,6.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,2351.25,95,,30.4,Percent of Total Billed Charges,95% of Total Billed Charges,2475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178,88,,28.16,Percent of Total Billed Charges,88% of Total Billed Charges,2227.5,90,,28.8,Percent of Total Billed charges,90% of Total Billed Charges,1091.48,2475,
PACKING COIL LP 30CM,2720002533,CDM,272,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,11.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,273.6,Percent of Total Billed Charges,72% of Total Billed Charges,2418.75,75,,285,Percent of Total Billed charges,75% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,273.6,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,228,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,11.248,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,6.664,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,13.32,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,9.624,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,6.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,14.064,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,13.024,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,13.32,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
PACKING COIL LP 45CM,2720002534,CDM,272,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,437.76,Percent of Total Billed Charges,72% of Total Billed Charges,2418.75,75,,456,Percent of Total Billed charges,75% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,437.76,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,364.8,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,11.248,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,14.4,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,28.8,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,9.624,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,14.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,30.4,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,28.16,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,28.8,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
PACKING COIL LP 60CM,2720002535,CDM,272,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,11.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,304.384,Percent of Total Billed Charges,72% of Total Billed Charges,2418.75,75,,317.072,Percent of Total Billed charges,75% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,304.384,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,253.656,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,11.896,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,6.664,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,13.32,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,20.8,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,6.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,14.064,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,13.024,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,13.32,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
LP DETACHMENT HANDLE,2720002536,CDM,272,RC,,,Outpatient,,,587.50,381.88,,587.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,446.5,76,,11.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,423,72,,39.024,Percent of Total Billed Charges,72% of Total Billed Charges,440.63,75,,40.648,Percent of Total Billed charges,75% of Total Billed Charges,587.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,423,72,,39.024,Percent of Total Billed Charges,72% of Total Billed Charges,352.5,60,,32.52,Percent of Total Billed Charges,60% of Total Billed Charges,528.75,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,264.38,45,,1269,Percent of Total Billed Charges,45% of Total Billed Charges,528.75,90,,13.32,Percent of Total Billed Charges,90% of Total billed Charges,587.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,587.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,587.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.88,65,,9.624,Percent of total Billed Charges,65% of Total Billed Charges,259.09,44.1,,1243.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,558.13,95,,14.064,Percent of Total Billed Charges,95% of Total Billed Charges,587.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,517,88,,13.024,Percent of Total Billed Charges,88% of Total Billed Charges,528.75,90,,13.32,Percent of Total Billed charges,90% of Total Billed Charges,259.09,587.5,
LAPIPLASTY SAW BLADE 40X11,2720002537,CDM,272,RC,,,Outpatient,,,125.00,81.25,,125,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90,72,,49.96,Percent of Total Billed Charges,72% of Total Billed Charges,93.75,75,,52.04,Percent of Total Billed charges,75% of Total Billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,72,,49.96,Percent of Total Billed Charges,72% of Total Billed Charges,75,60,,41.632,Percent of Total Billed Charges,60% of Total Billed Charges,112.5,90,,30.24,Percent of Total Billed Charges,90% of Total Billed Charges,56.25,45,,36.544,Percent of Total Billed Charges,45% of Total Billed Charges,112.5,90,,28.8,Percent of Total Billed Charges,90% of Total billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.25,65,,1833,Percent of total Billed Charges,65% of Total Billed Charges,55.13,44.1,,35.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,118.75,95,,30.4,Percent of Total Billed Charges,95% of Total Billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110,88,,28.16,Percent of Total Billed Charges,88% of Total Billed Charges,112.5,90,,28.8,Percent of Total Billed charges,90% of Total Billed Charges,55.13,125,
RUBY COMPLEX STND 14MM X 60CM,2720002538,CDM,278,RC,C1889,HCPCS,Outpatient,,,3225.00,2096.25,,3225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451,76,,11.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322,72,,4.376,Percent of Total Billed Charges,72% of Total Billed Charges,2322,72,,4.56,Percent of Total Billed charges,72% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322,72,,4.376,Percent of Total Billed Charges,72% of Total Billed Charges,1935,60,,3.648,Percent of Total Billed Charges,60% of Total Billed Charges,2902.5,90,,57.688,Percent of Total Billed Charges,90% of Total Billed Charges,1451.25,45,,6.208,Percent of Total Billed Charges,45% of Total Billed Charges,2902.5,90,,13.32,Percent of Total Billed Charges,90% of Total billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.25,65,,52.792,Percent of total Billed Charges,65% of Total Billed Charges,1422.23,44.1,,6.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.75,95,,14.064,Percent of Total Billed Charges,95% of Total Billed Charges,3225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838,88,,13.024,Percent of Total Billed Charges,88% of Total Billed Charges,2902.5,90,,13.32,Percent of Total Billed charges,90% of Total Billed Charges,1422.23,3225,
PERIFIX FX CONT EPI TRAY(SUB),2720002539,CDM,272,RC,,,Outpatient,,,59.62,38.75,,59.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.31,76,,2143.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.93,72,,446.4,Percent of Total Billed Charges,72% of Total Billed Charges,44.72,75,,465,Percent of Total Billed charges,75% of Total Billed Charges,59.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.93,72,,446.4,Percent of Total Billed Charges,72% of Total Billed Charges,35.77,60,,372,Percent of Total Billed Charges,60% of Total Billed Charges,53.66,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,26.83,45,,5.624,Percent of Total Billed Charges,45% of Total Billed Charges,53.66,90,,2538,Percent of Total Billed Charges,90% of Total billed Charges,59.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.75,65,,8.968,Percent of total Billed Charges,65% of Total Billed Charges,26.29,44.1,,5.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,56.64,95,,2679,Percent of Total Billed Charges,95% of Total Billed Charges,59.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.47,88,,2481.6,Percent of Total Billed Charges,88% of Total Billed Charges,53.66,90,,2538,Percent of Total Billed charges,90% of Total Billed Charges,26.29,59.62,
Neutral Humeral Fract Ortho SM,2720002540,CDM,272,RC,,,Outpatient,,,283.13,184.03,,283.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,215.18,76,,61.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,203.85,72,,453.6,Percent of Total Billed Charges,72% of Total Billed Charges,212.35,75,,472.504,Percent of Total Billed charges,75% of Total Billed Charges,283.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.85,72,,453.6,Percent of Total Billed Charges,72% of Total Billed Charges,169.88,60,,378,Percent of Total Billed Charges,60% of Total Billed Charges,254.82,90,,497.704,Percent of Total Billed Charges,90% of Total Billed Charges,127.41,45,,5.624,Percent of Total Billed Charges,45% of Total Billed Charges,254.82,90,,73.096,Percent of Total Billed Charges,90% of Total billed Charges,283.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.03,65,,8.12,Percent of total Billed Charges,65% of Total Billed Charges,124.86,44.1,,5.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,268.97,95,,77.152,Percent of Total Billed Charges,95% of Total Billed Charges,283.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.15,88,,71.472,Percent of Total Billed Charges,88% of Total Billed Charges,254.82,90,,73.096,Percent of Total Billed charges,90% of Total Billed Charges,124.86,283.13,
Neutral Humeral Fract Orth Med,2720002541,CDM,272,RC,,,Outpatient,,,283.13,184.03,,283.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,215.18,76,,10.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,203.85,72,,19.832,Percent of Total Billed Charges,72% of Total Billed Charges,212.35,75,,20.656,Percent of Total Billed charges,75% of Total Billed Charges,283.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.85,72,,19.832,Percent of Total Billed Charges,72% of Total Billed Charges,169.88,60,,16.528,Percent of Total Billed Charges,60% of Total Billed Charges,254.82,90,,357.208,Percent of Total Billed Charges,90% of Total Billed Charges,127.41,45,,5.624,Percent of Total Billed Charges,45% of Total Billed Charges,254.82,90,,12.424,Percent of Total Billed Charges,90% of Total billed Charges,283.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.03,65,,8.12,Percent of total Billed Charges,65% of Total Billed Charges,124.86,44.1,,5.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,268.97,95,,13.112,Percent of Total Billed Charges,95% of Total Billed Charges,283.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.15,88,,12.144,Percent of Total Billed Charges,88% of Total Billed Charges,254.82,90,,12.424,Percent of Total Billed charges,90% of Total Billed Charges,124.86,283.13,
Neutral Humeral Fract Orth Lg,2720002542,CDM,272,RC,,,Outpatient,,,283.13,184.03,,283.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,215.18,76,,9.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,203.85,72,,15.952,Percent of Total Billed Charges,72% of Total Billed Charges,212.35,75,,16.624,Percent of Total Billed charges,75% of Total Billed Charges,283.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.85,72,,15.952,Percent of Total Billed Charges,72% of Total Billed Charges,169.88,60,,13.296,Percent of Total Billed Charges,60% of Total Billed Charges,254.82,90,,75.76,Percent of Total Billed Charges,90% of Total Billed Charges,127.41,45,,5.944,Percent of Total Billed Charges,45% of Total Billed Charges,254.82,90,,11.248,Percent of Total Billed Charges,90% of Total billed Charges,283.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.03,65,,8.12,Percent of total Billed Charges,65% of Total Billed Charges,124.86,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,268.97,95,,11.872,Percent of Total Billed Charges,95% of Total Billed Charges,283.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.15,88,,11,Percent of Total Billed Charges,88% of Total Billed Charges,254.82,90,,11.248,Percent of Total Billed charges,90% of Total Billed Charges,124.86,283.13,
Neutral Humeral Fract Orth XLG,2720002543,CDM,272,RC,,,Outpatient,,,283.13,184.03,,283.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,215.18,76,,9.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,203.85,72,,647.8,Percent of Total Billed Charges,72% of Total Billed Charges,212.35,75,,674.792,Percent of Total Billed charges,75% of Total Billed Charges,283.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.85,72,,647.8,Percent of Total Billed Charges,72% of Total Billed Charges,169.88,60,,539.832,Percent of Total Billed Charges,60% of Total Billed Charges,254.82,90,,148.408,Percent of Total Billed Charges,90% of Total Billed Charges,127.41,45,,5.04,Percent of Total Billed Charges,45% of Total Billed Charges,254.82,90,,11.248,Percent of Total Billed Charges,90% of Total billed Charges,283.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.03,65,,8.592,Percent of total Billed Charges,65% of Total Billed Charges,124.86,44.1,,4.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,268.97,95,,11.872,Percent of Total Billed Charges,95% of Total Billed Charges,283.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.15,88,,11,Percent of Total Billed Charges,88% of Total Billed Charges,254.82,90,,11.248,Percent of Total Billed charges,90% of Total Billed Charges,124.86,283.13,
Radpad Femoral Shield,2720002544,CDM,272,RC,,,Outpatient,,,85.00,55.25,,85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,64.6,76,,9.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.2,72,,304.384,Percent of Total Billed Charges,72% of Total Billed Charges,63.75,75,,317.072,Percent of Total Billed charges,75% of Total Billed Charges,85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.2,72,,304.384,Percent of Total Billed Charges,72% of Total Billed Charges,51,60,,253.656,Percent of Total Billed Charges,60% of Total Billed Charges,76.5,90,,148.408,Percent of Total Billed Charges,90% of Total Billed Charges,38.25,45,,15.12,Percent of Total Billed Charges,45% of Total Billed Charges,76.5,90,,11.248,Percent of Total Billed Charges,90% of Total billed Charges,85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.25,65,,7.28,Percent of total Billed Charges,65% of Total Billed Charges,37.49,44.1,,14.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,80.75,95,,11.872,Percent of Total Billed Charges,95% of Total Billed Charges,85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.8,88,,11,Percent of Total Billed Charges,88% of Total Billed Charges,76.5,90,,11.248,Percent of Total Billed charges,90% of Total Billed Charges,37.49,85,
Radpad Multipurpose Shield,2720002545,CDM,272,RC,,,Outpatient,,,85.00,55.25,,85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,64.6,76,,10.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.2,72,,163.904,Percent of Total Billed Charges,72% of Total Billed Charges,63.75,75,,170.728,Percent of Total Billed charges,75% of Total Billed Charges,85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.2,72,,163.904,Percent of Total Billed Charges,72% of Total Billed Charges,51,60,,136.584,Percent of Total Billed Charges,60% of Total Billed Charges,76.5,90,,172.56,Percent of Total Billed Charges,90% of Total Billed Charges,38.25,45,,28.84,Percent of Total Billed Charges,45% of Total Billed Charges,76.5,90,,11.896,Percent of Total Billed Charges,90% of Total billed Charges,85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.25,65,,21.84,Percent of total Billed Charges,65% of Total Billed Charges,37.49,44.1,,28.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,80.75,95,,12.552,Percent of Total Billed Charges,95% of Total Billed Charges,85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.8,88,,11.632,Percent of Total Billed Charges,88% of Total Billed Charges,76.5,90,,11.896,Percent of Total Billed charges,90% of Total Billed Charges,37.49,85,
Nexiva Clsd IV Cath Syst Dual,2720002546,CDM,272,RC,,,Outpatient,,,11.73,7.62,,11.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.91,76,,8.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.45,72,,2347.2,Percent of Total Billed Charges,72% of Total Billed Charges,8.8,75,,2445,Percent of Total Billed charges,75% of Total Billed Charges,11.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.45,72,,2347.2,Percent of Total Billed Charges,72% of Total Billed Charges,7.04,60,,1956,Percent of Total Billed Charges,60% of Total Billed Charges,10.56,90,,5.296,Percent of Total Billed Charges,90% of Total Billed Charges,5.28,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,10.56,90,,10.08,Percent of Total Billed Charges,90% of Total billed Charges,11.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.62,65,,41.664,Percent of total Billed Charges,65% of Total Billed Charges,5.17,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.14,95,,10.64,Percent of Total Billed Charges,95% of Total Billed Charges,11.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,88,,9.856,Percent of Total Billed Charges,88% of Total Billed Charges,10.56,90,,10.08,Percent of Total Billed charges,90% of Total Billed Charges,5.17,11.73,
Arthrex BB-TAK NONTHD,2720002547,CDM,272,RC,,,Outpatient,,,178.75,116.19,,178.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,135.85,76,,25.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,128.7,72,,2347.2,Percent of Total Billed Charges,72% of Total Billed Charges,134.06,75,,2445,Percent of Total Billed charges,75% of Total Billed Charges,178.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.7,72,,2347.2,Percent of Total Billed Charges,72% of Total Billed Charges,107.25,60,,1956,Percent of Total Billed Charges,60% of Total Billed Charges,160.88,90,,5.472,Percent of Total Billed Charges,90% of Total Billed Charges,80.44,45,,248.848,Percent of Total Billed Charges,45% of Total Billed Charges,160.88,90,,30.24,Percent of Total Billed Charges,90% of Total billed Charges,178.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.19,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,78.83,44.1,,243.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,169.81,95,,31.92,Percent of Total Billed Charges,95% of Total Billed Charges,178.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.3,88,,29.568,Percent of Total Billed Charges,88% of Total Billed Charges,160.88,90,,30.24,Percent of Total Billed charges,90% of Total Billed Charges,78.83,178.75,
LAUNCHER 6F IMA 90CM GUIDE,2720002548,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,48.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,201.672,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,210.08,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,201.672,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,168.064,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,84.864,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,178.6,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,57.688,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,359.448,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,175.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,60.888,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,56.408,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,57.688,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
Distal Ext Instruments,2720002549,CDM,272,RC,,,Outpatient,,,625.00,406.25,,625,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450,72,,60.384,Percent of Total Billed Charges,72% of Total Billed Charges,468.75,75,,62.896,Percent of Total Billed charges,75% of Total Billed Charges,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450,72,,60.384,Percent of Total Billed Charges,72% of Total Billed Charges,375,60,,50.32,Percent of Total Billed Charges,60% of Total Billed Charges,562.5,90,,84.864,Percent of Total Billed Charges,90% of Total Billed Charges,281.25,45,,37.88,Percent of Total Billed Charges,45% of Total Billed Charges,562.5,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.25,65,,257.984,Percent of total Billed Charges,65% of Total Billed Charges,275.63,44.1,,37.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.75,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,562.5,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,275.63,625,
Jada System  2.0,2720002550,CDM,272,RC,,,Outpatient,,,3487.50,2266.88,,3487.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2650.5,76,,420.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2511,72,,199,Percent of Total Billed Charges,72% of Total Billed Charges,2615.63,75,,207.288,Percent of Total Billed charges,75% of Total Billed Charges,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2511,72,,199,Percent of Total Billed Charges,72% of Total Billed Charges,2092.5,60,,165.832,Percent of Total Billed Charges,60% of Total Billed Charges,3138.75,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,1569.38,45,,74.2,Percent of Total Billed Charges,45% of Total Billed Charges,3138.75,90,,497.704,Percent of Total Billed Charges,90% of Total billed Charges,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2266.88,65,,54.712,Percent of total Billed Charges,65% of Total Billed Charges,1537.99,44.1,,72.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,3313.13,95,,525.352,Percent of Total Billed Charges,95% of Total Billed Charges,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3069,88,,486.64,Percent of Total Billed Charges,88% of Total Billed Charges,3138.75,90,,497.704,Percent of Total Billed charges,90% of Total Billed Charges,1537.99,3487.5,
Disp Expiratory Valve,2720002551,CDM,272,RC,,,Outpatient,,,39.33,25.56,,39.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.89,76,,301.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.32,72,,60.384,Percent of Total Billed Charges,72% of Total Billed Charges,29.5,75,,62.896,Percent of Total Billed charges,75% of Total Billed Charges,39.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.32,72,,60.384,Percent of Total Billed Charges,72% of Total Billed Charges,23.6,60,,50.32,Percent of Total Billed Charges,60% of Total Billed Charges,35.4,90,,3.288,Percent of Total Billed Charges,90% of Total Billed Charges,17.7,45,,74.2,Percent of Total Billed Charges,45% of Total Billed Charges,35.4,90,,357.208,Percent of Total Billed Charges,90% of Total billed Charges,39.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.56,65,,107.184,Percent of total Billed Charges,65% of Total Billed Charges,17.34,44.1,,72.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.36,95,,377.048,Percent of Total Billed Charges,95% of Total Billed Charges,39.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.61,88,,349.272,Percent of Total Billed Charges,88% of Total Billed Charges,35.4,90,,357.208,Percent of Total Billed charges,90% of Total Billed Charges,17.34,39.33,
Disp Adult CO2 Cuvette,2720002552,CDM,272,RC,,,Outpatient,,,28.35,18.43,,28.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21.55,76,,63.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.41,72,,48.376,Percent of Total Billed Charges,72% of Total Billed Charges,21.26,75,,50.392,Percent of Total Billed charges,75% of Total Billed Charges,28.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.41,72,,48.376,Percent of Total Billed Charges,72% of Total Billed Charges,17.01,60,,40.312,Percent of Total Billed Charges,60% of Total Billed Charges,25.52,90,,3.064,Percent of Total Billed Charges,90% of Total Billed Charges,12.76,45,,86.28,Percent of Total Billed Charges,45% of Total Billed Charges,25.52,90,,75.76,Percent of Total Billed Charges,90% of Total billed Charges,28.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.43,65,,107.184,Percent of total Billed Charges,65% of Total Billed Charges,12.5,44.1,,84.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.93,95,,79.968,Percent of Total Billed Charges,95% of Total Billed Charges,28.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.95,88,,74.072,Percent of Total Billed Charges,88% of Total Billed Charges,25.52,90,,75.76,Percent of Total Billed charges,90% of Total Billed Charges,12.5,28.35,
Infinity ID Flow Sensor,2720002553,CDM,272,RC,,,Outpatient,,,61.55,40.01,,61.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.78,76,,125.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,44.32,72,,158.504,Percent of Total Billed Charges,72% of Total Billed Charges,46.16,75,,165.112,Percent of Total Billed charges,75% of Total Billed Charges,61.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.32,72,,158.504,Percent of Total Billed Charges,72% of Total Billed Charges,36.93,60,,132.088,Percent of Total Billed Charges,60% of Total Billed Charges,55.4,90,,3.216,Percent of Total Billed Charges,90% of Total Billed Charges,27.7,45,,2.648,Percent of Total Billed Charges,45% of Total Billed Charges,55.4,90,,148.408,Percent of Total Billed Charges,90% of Total billed Charges,61.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.01,65,,124.632,Percent of total Billed Charges,65% of Total Billed Charges,27.14,44.1,,2.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,58.47,95,,156.648,Percent of Total Billed Charges,95% of Total Billed Charges,61.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.16,88,,145.112,Percent of Total Billed Charges,88% of Total Billed Charges,55.4,90,,148.408,Percent of Total Billed charges,90% of Total Billed Charges,27.14,61.55,
6F SAFESHEATH II W/SIDEPORT,2720002554,CDM,272,RC,C1892,HCPCS,Outpatient,,,125.00,81.25,,125,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95,76,,125.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90,72,,5.584,Percent of Total Billed Charges,72% of Total Billed Charges,93.75,75,,5.824,Percent of Total Billed charges,75% of Total Billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,72,,5.584,Percent of Total Billed Charges,72% of Total Billed Charges,75,60,,4.656,Percent of Total Billed Charges,60% of Total Billed Charges,112.5,90,,3.24,Percent of Total Billed Charges,90% of Total Billed Charges,56.25,45,,2.736,Percent of Total Billed Charges,45% of Total Billed Charges,112.5,90,,148.408,Percent of Total Billed Charges,90% of Total billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.25,65,,3.824,Percent of total Billed Charges,65% of Total Billed Charges,55.13,44.1,,2.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,118.75,95,,156.648,Percent of Total Billed Charges,95% of Total Billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110,88,,145.112,Percent of Total Billed Charges,88% of Total Billed Charges,112.5,90,,148.408,Percent of Total Billed charges,90% of Total Billed Charges,55.13,125,
Arthrx 0.86 GWIRE TROCR THD,2720002555,CDM,272,RC,,,Outpatient,,,92.50,60.13,,92.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,70.3,76,,145.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,66.6,72,,9.176,Percent of Total Billed Charges,72% of Total Billed Charges,69.38,75,,9.56,Percent of Total Billed charges,75% of Total Billed Charges,92.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.6,72,,9.176,Percent of Total Billed Charges,72% of Total Billed Charges,55.5,60,,7.648,Percent of Total Billed Charges,60% of Total Billed Charges,83.25,90,,3.28,Percent of Total Billed Charges,90% of Total Billed Charges,41.63,45,,42.432,Percent of Total Billed Charges,45% of Total Billed Charges,83.25,90,,172.56,Percent of Total Billed Charges,90% of Total billed Charges,92.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.13,65,,3.952,Percent of total Billed Charges,65% of Total Billed Charges,40.79,44.1,,41.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,87.88,95,,182.152,Percent of Total Billed Charges,95% of Total Billed Charges,92.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.4,88,,168.728,Percent of Total Billed Charges,88% of Total Billed Charges,83.25,90,,172.56,Percent of Total Billed charges,90% of Total Billed Charges,40.79,92.5,
RUNWAY GUIDE 6F VL3,2720002556,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,4.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,4.12,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,4.288,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,4.12,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,3.432,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,89.104,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,42.432,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,5.296,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,61.296,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,41.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,5.584,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,5.176,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,5.296,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
RUNWAY GUIDE 6F VL3.5,2720002557,CDM,272,RC,C1887,HCPCS,Outpatient,,,107.50,69.88,,107.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.7,76,,4.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.4,72,,273.168,Percent of Total Billed Charges,72% of Total Billed Charges,80.63,75,,284.552,Percent of Total Billed charges,75% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,72,,273.168,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,60,,227.64,Percent of Total Billed Charges,60% of Total Billed Charges,96.75,90,,540,Percent of Total Billed Charges,90% of Total Billed Charges,48.38,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,96.75,90,,5.472,Percent of Total Billed Charges,90% of Total billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.88,65,,61.296,Percent of total Billed Charges,65% of Total Billed Charges,47.41,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.13,95,,5.776,Percent of Total Billed Charges,95% of Total Billed Charges,107.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.6,88,,5.352,Percent of Total Billed Charges,88% of Total Billed Charges,96.75,90,,5.472,Percent of Total Billed charges,90% of Total Billed Charges,47.41,107.5,
VSI 4F MICRO-INTRO KIT 9200V,2720002558,CDM,272,RC,C1894,HCPCS,Outpatient,,,147.50,95.88,,147.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,112.1,76,,71.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,106.2,72,,70.24,Percent of Total Billed Charges,72% of Total Billed Charges,110.63,75,,73.168,Percent of Total Billed charges,75% of Total Billed Charges,147.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.2,72,,70.24,Percent of Total Billed Charges,72% of Total Billed Charges,88.5,60,,58.536,Percent of Total Billed Charges,60% of Total Billed Charges,132.75,90,,540,Percent of Total Billed Charges,90% of Total Billed Charges,66.38,45,,1.648,Percent of Total Billed Charges,45% of Total Billed Charges,132.75,90,,84.864,Percent of Total Billed Charges,90% of Total billed Charges,147.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.88,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,65.05,44.1,,1.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,140.13,95,,89.584,Percent of Total Billed Charges,95% of Total Billed Charges,147.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.8,88,,82.984,Percent of Total Billed Charges,88% of Total Billed Charges,132.75,90,,84.864,Percent of Total Billed charges,90% of Total Billed Charges,65.05,147.5,
VASC BAND HEMOSTAT SHORT,2720002559,CDM,272,RC,,,Outpatient,,,62.50,40.63,,62.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.5,76,,71.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45,72,,366.824,Percent of Total Billed Charges,72% of Total Billed Charges,46.88,75,,382.112,Percent of Total Billed charges,75% of Total Billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45,72,,366.824,Percent of Total Billed Charges,72% of Total Billed Charges,37.5,60,,305.688,Percent of Total Billed Charges,60% of Total Billed Charges,56.25,90,,540,Percent of Total Billed Charges,90% of Total Billed Charges,28.13,45,,1.528,Percent of Total Billed Charges,45% of Total Billed Charges,56.25,90,,84.864,Percent of Total Billed Charges,90% of Total billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.63,65,,2.376,Percent of total Billed Charges,65% of Total Billed Charges,27.56,44.1,,1.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.38,95,,89.584,Percent of Total Billed Charges,95% of Total Billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55,88,,82.984,Percent of Total Billed Charges,88% of Total Billed Charges,56.25,90,,84.864,Percent of Total Billed charges,90% of Total Billed Charges,27.56,62.5,
VASC BAND HEMOSTAT REG,2720002560,CDM,272,RC,,,Outpatient,,,62.50,40.63,,62.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.5,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45,72,,310.64,Percent of Total Billed Charges,72% of Total Billed Charges,46.88,75,,323.584,Percent of Total Billed charges,75% of Total Billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45,72,,310.64,Percent of Total Billed Charges,72% of Total Billed Charges,37.5,60,,258.864,Percent of Total Billed Charges,60% of Total Billed Charges,56.25,90,,5.8,Percent of Total Billed Charges,90% of Total Billed Charges,28.13,45,,1.608,Percent of Total Billed Charges,45% of Total Billed Charges,56.25,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.63,65,,2.208,Percent of total Billed Charges,65% of Total Billed Charges,27.56,44.1,,1.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.38,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,56.25,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,27.56,62.5,
VASC BAND HEMOSTAT LONG,2720002561,CDM,272,RC,,,Outpatient,,,62.50,40.63,,62.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.5,76,,2.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45,72,,157.648,Percent of Total Billed Charges,72% of Total Billed Charges,46.88,75,,164.224,Percent of Total Billed charges,75% of Total Billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45,72,,157.648,Percent of Total Billed Charges,72% of Total Billed Charges,37.5,60,,131.376,Percent of Total Billed Charges,60% of Total Billed Charges,56.25,90,,4.048,Percent of Total Billed Charges,90% of Total Billed Charges,28.13,45,,1.624,Percent of Total Billed Charges,45% of Total Billed Charges,56.25,90,,3.288,Percent of Total Billed Charges,90% of Total billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.63,65,,2.328,Percent of total Billed Charges,65% of Total Billed Charges,27.56,44.1,,1.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.38,95,,3.472,Percent of Total Billed Charges,95% of Total Billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55,88,,3.216,Percent of Total Billed Charges,88% of Total Billed Charges,56.25,90,,3.288,Percent of Total Billed charges,90% of Total Billed Charges,27.56,62.5,
VASC BAND HEMOSTAT X LONG,2720002562,CDM,272,RC,,,Outpatient,,,62.50,40.63,,62.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.5,76,,2.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45,72,,92.104,Percent of Total Billed Charges,72% of Total Billed Charges,46.88,75,,95.944,Percent of Total Billed charges,75% of Total Billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45,72,,92.104,Percent of Total Billed Charges,72% of Total Billed Charges,37.5,60,,76.752,Percent of Total Billed Charges,60% of Total Billed Charges,56.25,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,28.13,45,,1.64,Percent of Total Billed Charges,45% of Total Billed Charges,56.25,90,,3.064,Percent of Total Billed Charges,90% of Total billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.63,65,,2.344,Percent of total Billed Charges,65% of Total Billed Charges,27.56,44.1,,1.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.38,95,,3.232,Percent of Total Billed Charges,95% of Total Billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55,88,,2.992,Percent of Total Billed Charges,88% of Total Billed Charges,56.25,90,,3.064,Percent of Total Billed charges,90% of Total Billed Charges,27.56,62.5,
VASC BAND HEMOSTAT XX LONG,2720002563,CDM,272,RC,,,Outpatient,,,62.50,40.63,,62.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.5,76,,2.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45,72,,157.648,Percent of Total Billed Charges,72% of Total Billed Charges,46.88,75,,164.224,Percent of Total Billed charges,75% of Total Billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45,72,,157.648,Percent of Total Billed Charges,72% of Total Billed Charges,37.5,60,,131.376,Percent of Total Billed Charges,60% of Total Billed Charges,56.25,90,,46.984,Percent of Total Billed Charges,90% of Total Billed Charges,28.13,45,,44.552,Percent of Total Billed Charges,45% of Total Billed Charges,56.25,90,,3.216,Percent of Total Billed Charges,90% of Total billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.63,65,,2.368,Percent of total Billed Charges,65% of Total Billed Charges,27.56,44.1,,43.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.38,95,,3.4,Percent of Total Billed Charges,95% of Total Billed Charges,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55,88,,3.144,Percent of Total Billed Charges,88% of Total Billed Charges,56.25,90,,3.216,Percent of Total Billed charges,90% of Total Billed Charges,27.56,62.5,
PEDAL ACCESS SET 4F,2720002564,CDM,272,RC,C1894,HCPCS,Outpatient,,,137.50,89.38,,137.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,104.5,76,,2.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,99,72,,95.216,Percent of Total Billed Charges,72% of Total Billed Charges,103.13,75,,99.184,Percent of Total Billed charges,75% of Total Billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,72,,95.216,Percent of Total Billed Charges,72% of Total Billed Charges,82.5,60,,79.344,Percent of Total Billed Charges,60% of Total Billed Charges,123.75,90,,98.104,Percent of Total Billed Charges,90% of Total Billed Charges,61.88,45,,270,Percent of Total Billed Charges,45% of Total Billed Charges,123.75,90,,3.24,Percent of Total Billed Charges,90% of Total billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.38,65,,64.352,Percent of total Billed Charges,65% of Total Billed Charges,60.64,44.1,,264.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,130.63,95,,3.424,Percent of Total Billed Charges,95% of Total Billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121,88,,3.168,Percent of Total Billed Charges,88% of Total Billed Charges,123.75,90,,3.24,Percent of Total Billed charges,90% of Total Billed Charges,60.64,137.5,
PEDAL ACCESS SET 5F,2720002565,CDM,272,RC,C1894,HCPCS,Outpatient,,,137.50,89.38,,137.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,104.5,76,,2.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,99,72,,62.44,Percent of Total Billed Charges,72% of Total Billed Charges,103.13,75,,65.04,Percent of Total Billed charges,75% of Total Billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,72,,62.44,Percent of Total Billed Charges,72% of Total Billed Charges,82.5,60,,52.032,Percent of Total Billed Charges,60% of Total Billed Charges,123.75,90,,7.176,Percent of Total Billed Charges,90% of Total Billed Charges,61.88,45,,270,Percent of Total Billed Charges,45% of Total Billed Charges,123.75,90,,3.28,Percent of Total Billed Charges,90% of Total billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.38,65,,390,Percent of total Billed Charges,65% of Total Billed Charges,60.64,44.1,,264.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,130.63,95,,3.456,Percent of Total Billed Charges,95% of Total Billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121,88,,3.2,Percent of Total Billed Charges,88% of Total Billed Charges,123.75,90,,3.28,Percent of Total Billed charges,90% of Total Billed Charges,60.64,137.5,
GAURDIAN II INTRO TORQUE,2720002566,CDM,272,RC,,,Outpatient,,,85.50,55.58,,85.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,64.98,76,,75.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.56,72,,226.336,Percent of Total Billed Charges,72% of Total Billed Charges,64.13,75,,235.768,Percent of Total Billed charges,75% of Total Billed Charges,85.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.56,72,,226.336,Percent of Total Billed Charges,72% of Total Billed Charges,51.3,60,,188.616,Percent of Total Billed Charges,60% of Total Billed Charges,76.95,90,,22.68,Percent of Total Billed Charges,90% of Total Billed Charges,38.48,45,,270,Percent of Total Billed Charges,45% of Total Billed Charges,76.95,90,,89.104,Percent of Total Billed Charges,90% of Total billed Charges,85.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.58,65,,390,Percent of total Billed Charges,65% of Total Billed Charges,37.71,44.1,,264.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,81.23,95,,94.048,Percent of Total Billed Charges,95% of Total Billed Charges,85.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.24,88,,87.12,Percent of Total Billed Charges,88% of Total Billed Charges,76.95,90,,89.104,Percent of Total Billed charges,90% of Total Billed Charges,37.71,85.5,
GAURDIAN II NC INTRO TORQUE,2720002567,CDM,272,RC,,,Outpatient,,,85.50,55.58,,85.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,64.98,76,,456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.56,72,,157.648,Percent of Total Billed Charges,72% of Total Billed Charges,64.13,75,,164.224,Percent of Total Billed charges,75% of Total Billed Charges,85.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.56,72,,157.648,Percent of Total Billed Charges,72% of Total Billed Charges,51.3,60,,131.376,Percent of Total Billed Charges,60% of Total Billed Charges,76.95,90,,22.68,Percent of Total Billed Charges,90% of Total Billed Charges,38.48,45,,2.896,Percent of Total Billed Charges,45% of Total Billed Charges,76.95,90,,540,Percent of Total Billed Charges,90% of Total billed Charges,85.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.58,65,,390,Percent of total Billed Charges,65% of Total Billed Charges,37.71,44.1,,2.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,81.23,95,,570,Percent of Total Billed Charges,95% of Total Billed Charges,85.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.24,88,,528,Percent of Total Billed Charges,88% of Total Billed Charges,76.95,90,,540,Percent of Total Billed charges,90% of Total Billed Charges,37.71,85.5,
Berman Std Cath (BOFA) 5F 80cm,2720002568,CDM,272,RC,C1887,HCPCS,Outpatient,,,462.50,300.63,,462.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,351.5,76,,456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,333,72,,103.016,Percent of Total Billed Charges,72% of Total Billed Charges,346.88,75,,107.312,Percent of Total Billed charges,75% of Total Billed Charges,462.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333,72,,103.016,Percent of Total Billed Charges,72% of Total Billed Charges,277.5,60,,85.848,Percent of Total Billed Charges,60% of Total Billed Charges,416.25,90,,230.4,Percent of Total Billed Charges,90% of Total Billed Charges,208.13,45,,2.024,Percent of Total Billed Charges,45% of Total Billed Charges,416.25,90,,540,Percent of Total Billed Charges,90% of Total billed Charges,462.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.63,65,,4.184,Percent of total Billed Charges,65% of Total Billed Charges,203.96,44.1,,1.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,439.38,95,,570,Percent of Total Billed Charges,95% of Total Billed Charges,462.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407,88,,528,Percent of Total Billed Charges,88% of Total Billed Charges,416.25,90,,540,Percent of Total Billed charges,90% of Total Billed Charges,203.96,462.5,
BERMAN REVERSE CATH 5F 80CM,2720002569,CDM,272,RC,C1887,HCPCS,Outpatient,,,625.00,406.25,,625,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475,76,,456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,468.75,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,375,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,562.5,90,,419.992,Percent of Total Billed Charges,90% of Total Billed Charges,281.25,45,,75.6,Percent of Total Billed Charges,45% of Total Billed Charges,562.5,90,,540,Percent of Total Billed Charges,90% of Total billed Charges,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.25,65,,2.92,Percent of total Billed Charges,65% of Total Billed Charges,275.63,44.1,,74.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.75,95,,570,Percent of Total Billed Charges,95% of Total Billed Charges,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550,88,,528,Percent of Total Billed Charges,88% of Total Billed Charges,562.5,90,,540,Percent of Total Billed charges,90% of Total Billed Charges,275.63,625,
BERMAN REVERSE CATH 7F 110CM,2720002570,CDM,272,RC,C1887,HCPCS,Outpatient,,,625.00,406.25,,625,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475,76,,4.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,468.75,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,375,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,562.5,90,,1239.6,Percent of Total Billed Charges,90% of Total Billed Charges,281.25,45,,23.488,Percent of Total Billed Charges,45% of Total Billed Charges,562.5,90,,5.8,Percent of Total Billed Charges,90% of Total billed Charges,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.25,65,,109.2,Percent of total Billed Charges,65% of Total Billed Charges,275.63,44.1,,23.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.75,95,,6.12,Percent of Total Billed Charges,95% of Total Billed Charges,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550,88,,5.664,Percent of Total Billed Charges,88% of Total Billed Charges,562.5,90,,5.8,Percent of Total Billed charges,90% of Total Billed Charges,275.63,625,
Stapler Skin 35CT Wide NS,2720002571,CDM,272,RC,,,Outpatient,,,248.53,161.54,,248.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,188.88,76,,3.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,178.94,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,186.4,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,248.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.94,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,149.12,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,223.68,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,111.84,45,,49.048,Percent of Total Billed Charges,45% of Total Billed Charges,223.68,90,,4.048,Percent of Total Billed Charges,90% of Total billed Charges,248.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.54,65,,33.928,Percent of total Billed Charges,65% of Total Billed Charges,109.6,44.1,,48.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,236.1,95,,4.272,Percent of Total Billed Charges,95% of Total Billed Charges,248.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.71,88,,3.96,Percent of Total Billed Charges,88% of Total Billed Charges,223.68,90,,4.048,Percent of Total Billed charges,90% of Total Billed Charges,109.6,248.53,
LMA#2.5 w/Silicone Cuff,2720002572,CDM,272,RC,,,Outpatient,,,24.25,15.76,,24.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.43,76,,127.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.46,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,18.19,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,24.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.46,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,14.55,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,10.91,45,,3.592,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,151.2,Percent of Total Billed Charges,90% of Total billed Charges,24.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.76,65,,70.848,Percent of total Billed Charges,65% of Total Billed Charges,10.69,44.1,,3.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.04,95,,159.6,Percent of Total Billed Charges,95% of Total Billed Charges,24.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.34,88,,147.84,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,151.2,Percent of Total Billed charges,90% of Total Billed Charges,10.69,24.25,
Hyfrecator Electrolase Stl tip,2720002573,CDM,272,RC,,,Outpatient,,,2.93,1.90,,2.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.23,76,,39.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.11,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,2.2,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,2.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.11,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,1.76,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,2.64,90,,20.664,Percent of Total Billed Charges,90% of Total Billed Charges,1.32,45,,11.344,Percent of Total Billed Charges,45% of Total Billed Charges,2.64,90,,46.984,Percent of Total Billed Charges,90% of Total billed Charges,2.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.9,65,,5.184,Percent of total Billed Charges,65% of Total Billed Charges,1.29,44.1,,11.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.78,95,,49.592,Percent of Total Billed Charges,95% of Total Billed Charges,2.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.58,88,,45.936,Percent of Total Billed Charges,88% of Total Billed Charges,2.64,90,,46.984,Percent of Total Billed charges,90% of Total Billed Charges,1.29,2.93,
HI-FLOW CANISTER KIT 3000(SUB),2720002574,CDM,272,RC,,,Outpatient,,,11.05,7.18,,11.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.4,76,,82.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.96,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,8.29,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,11.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.96,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,6.63,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,9.95,90,,900.448,Percent of Total Billed Charges,90% of Total Billed Charges,4.97,45,,11.344,Percent of Total Billed Charges,45% of Total Billed Charges,9.95,90,,98.104,Percent of Total Billed Charges,90% of Total billed Charges,11.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.18,65,,16.384,Percent of total Billed Charges,65% of Total Billed Charges,4.87,44.1,,11.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.5,95,,103.552,Percent of Total Billed Charges,95% of Total Billed Charges,11.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.72,88,,95.92,Percent of Total Billed Charges,88% of Total Billed Charges,9.95,90,,98.104,Percent of Total Billed charges,90% of Total Billed Charges,4.87,11.05,
SKIN STAPLER 35W(SUB),2720002575,CDM,272,RC,,,Outpatient,,,26.75,17.39,,26.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.33,76,,6.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.26,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,20.06,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,26.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.26,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,16.05,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,24.08,90,,892.776,Percent of Total Billed Charges,90% of Total Billed Charges,12.04,45,,115.2,Percent of Total Billed Charges,45% of Total Billed Charges,24.08,90,,7.176,Percent of Total Billed Charges,90% of Total billed Charges,26.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.39,65,,16.384,Percent of total Billed Charges,65% of Total Billed Charges,11.8,44.1,,112.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.41,95,,7.576,Percent of Total Billed Charges,95% of Total Billed Charges,26.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.54,88,,7.016,Percent of Total Billed Charges,88% of Total Billed Charges,24.08,90,,7.176,Percent of Total Billed charges,90% of Total Billed Charges,11.8,26.75,
ARTHREX HOHMANN RETRCTR 8X16CM,2720002576,CDM,272,RC,,,Outpatient,,,157.50,102.38,,157.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,119.7,76,,19.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,113.4,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,118.13,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,157.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.4,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,94.5,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,141.75,90,,7.536,Percent of Total Billed Charges,90% of Total Billed Charges,70.88,45,,209.992,Percent of Total Billed Charges,45% of Total Billed Charges,141.75,90,,22.68,Percent of Total Billed Charges,90% of Total billed Charges,157.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.38,65,,166.4,Percent of total Billed Charges,65% of Total Billed Charges,69.46,44.1,,205.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,149.63,95,,23.944,Percent of Total Billed Charges,95% of Total Billed Charges,157.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.6,88,,22.176,Percent of Total Billed Charges,88% of Total Billed Charges,141.75,90,,22.68,Percent of Total Billed charges,90% of Total Billed Charges,69.46,157.5,
ARTHREX DRILL BIT 3.5MM,2720002577,CDM,272,RC,,,Outpatient,,,197.50,128.38,,197.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,150.1,76,,19.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,142.2,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,148.13,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,197.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.2,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,118.5,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,177.75,90,,5.488,Percent of Total Billed Charges,90% of Total Billed Charges,88.88,45,,619.8,Percent of Total Billed Charges,45% of Total Billed Charges,177.75,90,,22.68,Percent of Total Billed Charges,90% of Total billed Charges,197.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.38,65,,303.328,Percent of total Billed Charges,65% of Total Billed Charges,87.1,44.1,,607.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,187.63,95,,23.944,Percent of Total Billed Charges,95% of Total Billed Charges,197.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.8,88,,22.176,Percent of Total Billed Charges,88% of Total Billed Charges,177.75,90,,22.68,Percent of Total Billed charges,90% of Total Billed Charges,87.1,197.5,
Advicula Delineator,2720002578,CDM,272,RC,,,Outpatient,,,594.38,386.35,,594.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,451.73,76,,194.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,427.95,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,445.79,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,594.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.95,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,356.63,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,534.94,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,267.47,45,,5.4,Percent of Total Billed Charges,45% of Total Billed Charges,534.94,90,,230.4,Percent of Total Billed Charges,90% of Total billed Charges,594.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,594.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,594.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.35,65,,895.272,Percent of total Billed Charges,65% of Total Billed Charges,262.12,44.1,,5.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,564.66,95,,243.2,Percent of Total Billed Charges,95% of Total Billed Charges,594.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,523.05,88,,225.28,Percent of Total Billed Charges,88% of Total Billed Charges,534.94,90,,230.4,Percent of Total Billed charges,90% of Total Billed Charges,262.12,594.38,
OB PACK (Sub),2720002579,CDM,272,RC,,,Outpatient,,,48.10,31.27,,48.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.56,76,,354.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.63,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,36.08,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,48.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.63,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,28.86,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,43.29,90,,945,Percent of Total Billed Charges,90% of Total Billed Charges,21.65,45,,45,Percent of Total Billed Charges,45% of Total Billed Charges,43.29,90,,419.992,Percent of Total Billed Charges,90% of Total billed Charges,48.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.27,65,,7.8,Percent of total Billed Charges,65% of Total Billed Charges,21.21,44.1,,44.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.7,95,,443.32,Percent of Total Billed Charges,95% of Total Billed Charges,48.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.33,88,,410.656,Percent of Total Billed Charges,88% of Total Billed Charges,43.29,90,,419.992,Percent of Total Billed charges,90% of Total Billed Charges,21.21,48.1,
Coude Foley Cath 14FR 10ml 2wy,2720002580,CDM,272,RC,,,Outpatient,,,77.63,50.46,,77.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59,76,,1046.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.89,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,58.22,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,77.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.89,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,46.58,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,69.87,90,,46.8,Percent of Total Billed Charges,90% of Total Billed Charges,34.93,45,,10.336,Percent of Total Billed Charges,45% of Total Billed Charges,69.87,90,,1239.6,Percent of Total Billed Charges,90% of Total billed Charges,77.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.46,65,,65,Percent of total Billed Charges,65% of Total Billed Charges,34.23,44.1,,10.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.75,95,,1308.472,Percent of Total Billed Charges,95% of Total Billed Charges,77.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.31,88,,1212.056,Percent of Total Billed Charges,88% of Total Billed Charges,69.87,90,,1239.6,Percent of Total Billed charges,90% of Total Billed Charges,34.23,77.63,
Coude Foley Cath 16FR 10ml2way,2720002581,CDM,272,RC,,,Outpatient,,,72.73,47.27,,72.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.27,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.37,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,54.55,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,72.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.37,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,43.64,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,65.46,90,,46.8,Percent of Total Billed Charges,90% of Total Billed Charges,32.73,45,,450.224,Percent of Total Billed Charges,45% of Total Billed Charges,65.46,90,,10.8,Percent of Total Billed Charges,90% of Total billed Charges,72.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.27,65,,14.928,Percent of total Billed Charges,65% of Total Billed Charges,32.07,44.1,,441.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,69.09,95,,11.4,Percent of Total Billed Charges,95% of Total Billed Charges,72.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64,88,,10.56,Percent of Total Billed Charges,88% of Total Billed Charges,65.46,90,,10.8,Percent of Total Billed charges,90% of Total Billed Charges,32.07,72.73,
Coude Foley Cath 18FR 10ml 2wy,2720002582,CDM,272,RC,,,Outpatient,,,62.48,40.61,,62.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.48,76,,76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,44.99,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,46.86,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,62.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.99,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,37.49,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,56.23,90,,46.8,Percent of Total Billed Charges,90% of Total Billed Charges,28.12,45,,446.392,Percent of Total Billed Charges,45% of Total Billed Charges,56.23,90,,90,Percent of Total Billed Charges,90% of Total billed Charges,62.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.61,65,,650.32,Percent of total Billed Charges,65% of Total Billed Charges,27.55,44.1,,437.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.36,95,,95,Percent of Total Billed Charges,95% of Total Billed Charges,62.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.98,88,,88,Percent of Total Billed Charges,88% of Total Billed Charges,56.23,90,,90,Percent of Total Billed charges,90% of Total Billed Charges,27.55,62.48,
Coude Foley Cath 20FR 10ml 2wy,2720002583,CDM,272,RC,,,Outpatient,,,89.58,58.23,,89.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.08,76,,17.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.5,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,67.19,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,89.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.5,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,53.75,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,80.62,90,,46.8,Percent of Total Billed Charges,90% of Total Billed Charges,40.31,45,,3.768,Percent of Total Billed Charges,45% of Total Billed Charges,80.62,90,,20.664,Percent of Total Billed Charges,90% of Total billed Charges,89.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.23,65,,644.784,Percent of total Billed Charges,65% of Total Billed Charges,39.5,44.1,,3.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.1,95,,21.816,Percent of Total Billed Charges,95% of Total Billed Charges,89.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.83,88,,20.208,Percent of Total Billed Charges,88% of Total Billed Charges,80.62,90,,20.664,Percent of Total Billed charges,90% of Total Billed Charges,39.5,89.58,
Council Tip Cath 16FR 5ML 2way,2720002584,CDM,272,RC,,,Outpatient,,,26.23,17.05,,26.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.93,76,,760.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.89,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,19.67,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,26.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.89,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,15.74,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,23.61,90,,27.904,Percent of Total Billed Charges,90% of Total Billed Charges,11.8,45,,2.744,Percent of Total Billed Charges,45% of Total Billed Charges,23.61,90,,900.448,Percent of Total Billed Charges,90% of Total billed Charges,26.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.05,65,,5.448,Percent of total Billed Charges,65% of Total Billed Charges,11.57,44.1,,2.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.92,95,,950.472,Percent of Total Billed Charges,95% of Total Billed Charges,26.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.08,88,,880.44,Percent of Total Billed Charges,88% of Total Billed Charges,23.61,90,,900.448,Percent of Total Billed charges,90% of Total Billed Charges,11.57,26.23,
Council Tip Cath 18FR 5ML 2way,2720002585,CDM,272,RC,,,Outpatient,,,26.23,17.05,,26.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.93,76,,753.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.89,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,19.67,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,26.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.89,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,15.74,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,23.61,90,,27.264,Percent of Total Billed Charges,90% of Total Billed Charges,11.8,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,23.61,90,,892.776,Percent of Total Billed Charges,90% of Total billed Charges,26.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.05,65,,3.96,Percent of total Billed Charges,65% of Total Billed Charges,11.57,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.92,95,,942.376,Percent of Total Billed Charges,95% of Total Billed Charges,26.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.08,88,,872.936,Percent of Total Billed Charges,88% of Total Billed Charges,23.61,90,,892.776,Percent of Total Billed charges,90% of Total Billed Charges,11.57,26.23,
Council Tip Cath 20FR 5ML 2way,2720002586,CDM,272,RC,,,Outpatient,,,26.23,17.05,,26.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.93,76,,6.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.89,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,19.67,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,26.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.89,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,15.74,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,23.61,90,,64.8,Percent of Total Billed Charges,90% of Total Billed Charges,11.8,45,,472.504,Percent of Total Billed Charges,45% of Total Billed Charges,23.61,90,,7.536,Percent of Total Billed Charges,90% of Total billed Charges,26.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.05,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,11.57,44.1,,463.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.92,95,,7.96,Percent of Total Billed Charges,95% of Total Billed Charges,26.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.08,88,,7.368,Percent of Total Billed Charges,88% of Total Billed Charges,23.61,90,,7.536,Percent of Total Billed charges,90% of Total Billed Charges,11.57,26.23,
BLADE MAC SZ 4 MCGRATH,2720002587,CDM,272,RC,,,Outpatient,,,36.15,23.50,,36.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.47,76,,4.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.03,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,27.11,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,36.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.03,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,21.69,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,32.54,90,,69.744,Percent of Total Billed Charges,90% of Total Billed Charges,16.27,45,,23.4,Percent of Total Billed Charges,45% of Total Billed Charges,32.54,90,,5.488,Percent of Total Billed Charges,90% of Total billed Charges,36.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.5,65,,682.504,Percent of total Billed Charges,65% of Total Billed Charges,15.94,44.1,,22.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.34,95,,5.792,Percent of Total Billed Charges,95% of Total Billed Charges,36.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.81,88,,5.368,Percent of Total Billed Charges,88% of Total Billed Charges,32.54,90,,5.488,Percent of Total Billed charges,90% of Total Billed Charges,15.94,36.15,
LMA#3 Unique Plus Pack,2720002588,CDM,272,RC,,,Outpatient,,,34.93,22.70,,34.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.55,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.15,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,26.2,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,34.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.15,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,20.96,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,31.44,90,,64.8,Percent of Total Billed Charges,90% of Total Billed Charges,15.72,45,,23.4,Percent of Total Billed Charges,45% of Total Billed Charges,31.44,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,34.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.7,65,,33.8,Percent of total Billed Charges,65% of Total Billed Charges,15.4,44.1,,22.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.18,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,34.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.74,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,31.44,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,15.4,34.93,
Syringe Epidural 5Ml Glass-Sub,2720002589,CDM,272,RC,,,Outpatient,,,15.63,10.16,,15.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.88,76,,798,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.25,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,11.72,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,15.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.25,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,9.38,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,14.07,90,,69.744,Percent of Total Billed Charges,90% of Total Billed Charges,7.03,45,,23.4,Percent of Total Billed Charges,45% of Total Billed Charges,14.07,90,,945,Percent of Total Billed Charges,90% of Total billed Charges,15.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.16,65,,33.8,Percent of total Billed Charges,65% of Total Billed Charges,6.89,44.1,,22.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.85,95,,997.504,Percent of Total Billed Charges,95% of Total Billed Charges,15.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.75,88,,924,Percent of Total Billed Charges,88% of Total Billed Charges,14.07,90,,945,Percent of Total Billed charges,90% of Total Billed Charges,6.89,15.63,
Sammons Preston Hip Kit I & II,2720002590,CDM,272,RC,,,Outpatient,,,63.75,41.44,,63.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,48.45,76,,39.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.9,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,47.81,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,63.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.9,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,38.25,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,57.38,90,,64.8,Percent of Total Billed Charges,90% of Total Billed Charges,28.69,45,,23.4,Percent of Total Billed Charges,45% of Total Billed Charges,57.38,90,,46.8,Percent of Total Billed Charges,90% of Total billed Charges,63.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.44,65,,33.8,Percent of total Billed Charges,65% of Total Billed Charges,28.11,44.1,,22.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,60.56,95,,49.4,Percent of Total Billed Charges,95% of Total Billed Charges,63.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.1,88,,45.76,Percent of Total Billed Charges,88% of Total Billed Charges,57.38,90,,46.8,Percent of Total Billed charges,90% of Total Billed Charges,28.11,63.75,
POWERWAND XL QUICK KIT 4FR 10C,2720002591,CDM,272,RC,,,Outpatient,,,431.25,280.31,,431.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,327.75,76,,39.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,310.5,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,323.44,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,431.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,310.5,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,258.75,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,388.13,90,,69.744,Percent of Total Billed Charges,90% of Total Billed Charges,194.06,45,,13.952,Percent of Total Billed Charges,45% of Total Billed Charges,388.13,90,,46.8,Percent of Total Billed Charges,90% of Total billed Charges,431.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,431.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,431.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280.31,65,,33.8,Percent of total Billed Charges,65% of Total Billed Charges,190.18,44.1,,13.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,409.69,95,,49.4,Percent of Total Billed Charges,95% of Total Billed Charges,431.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.5,88,,45.76,Percent of Total Billed Charges,88% of Total Billed Charges,388.13,90,,46.8,Percent of Total Billed charges,90% of Total Billed Charges,190.18,431.25,
POWERWAND XL SINGLE STERILE 3F,2720002592,CDM,272,RC,,,Outpatient,,,155.25,100.91,,155.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,117.99,76,,39.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.78,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,116.44,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,155.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.78,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,93.15,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,139.73,90,,64.8,Percent of Total Billed Charges,90% of Total Billed Charges,69.86,45,,13.632,Percent of Total Billed Charges,45% of Total Billed Charges,139.73,90,,46.8,Percent of Total Billed Charges,90% of Total billed Charges,155.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.91,65,,20.152,Percent of total Billed Charges,65% of Total Billed Charges,68.47,44.1,,13.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,147.49,95,,49.4,Percent of Total Billed Charges,95% of Total Billed Charges,155.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.62,88,,45.76,Percent of Total Billed Charges,88% of Total Billed Charges,139.73,90,,46.8,Percent of Total Billed charges,90% of Total Billed Charges,68.47,155.25,
CATH COUDE 20FR 5CC 2WY,2720002593,CDM,272,RC,,,Outpatient,,,21.68,14.09,,21.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.48,76,,39.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.61,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,16.26,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,21.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.61,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,13.01,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,19.51,90,,69.744,Percent of Total Billed Charges,90% of Total Billed Charges,9.76,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,19.51,90,,46.8,Percent of Total Billed Charges,90% of Total billed Charges,21.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.09,65,,19.696,Percent of total Billed Charges,65% of Total Billed Charges,9.56,44.1,,31.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.6,95,,49.4,Percent of Total Billed Charges,95% of Total Billed Charges,21.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.08,88,,45.76,Percent of Total Billed Charges,88% of Total Billed Charges,19.51,90,,46.8,Percent of Total Billed charges,90% of Total Billed Charges,9.56,21.68,
BERENSTEIN OCCL BLN 6F X 80CM,2720002594,CDM,272,RC,C2628,HCPCS,Outpatient,,,569.63,370.26,,569.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.92,76,,23.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,410.13,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,427.22,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,569.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,410.13,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,341.78,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,512.67,90,,64.8,Percent of Total Billed Charges,90% of Total Billed Charges,256.33,45,,34.872,Percent of Total Billed Charges,45% of Total Billed Charges,512.67,90,,27.904,Percent of Total Billed Charges,90% of Total billed Charges,569.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.26,65,,46.8,Percent of total Billed Charges,65% of Total Billed Charges,251.21,44.1,,34.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,541.15,95,,29.448,Percent of Total Billed Charges,95% of Total Billed Charges,569.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.27,88,,27.28,Percent of Total Billed Charges,88% of Total Billed Charges,512.67,90,,27.904,Percent of Total Billed charges,90% of Total Billed Charges,251.21,569.63,
STANDARD OCCL BLN 7F X 100CM,2720002595,CDM,272,RC,C2628,HCPCS,Outpatient,,,569.63,370.26,,569.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.92,76,,23.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,410.13,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,427.22,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,569.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,410.13,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,341.78,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,512.67,90,,69.744,Percent of Total Billed Charges,90% of Total Billed Charges,256.33,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,512.67,90,,27.264,Percent of Total Billed Charges,90% of Total billed Charges,569.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.26,65,,50.376,Percent of total Billed Charges,65% of Total Billed Charges,251.21,44.1,,31.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,541.15,95,,28.784,Percent of Total Billed Charges,95% of Total Billed Charges,569.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.27,88,,26.664,Percent of Total Billed Charges,88% of Total Billed Charges,512.67,90,,27.264,Percent of Total Billed charges,90% of Total Billed Charges,251.21,569.63,
POWERWAND XL KIT 4F X 10CM,2720002596,CDM,272,RC,C1751,HCPCS,Outpatient,,,307.25,199.71,,307.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,233.51,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,221.22,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,230.44,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,307.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.22,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,184.35,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,276.53,90,,64.8,Percent of Total Billed Charges,90% of Total Billed Charges,138.26,45,,34.872,Percent of Total Billed Charges,45% of Total Billed Charges,276.53,90,,64.8,Percent of Total Billed Charges,90% of Total billed Charges,307.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.71,65,,46.8,Percent of total Billed Charges,65% of Total Billed Charges,135.5,44.1,,34.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,291.89,95,,68.4,Percent of Total Billed Charges,95% of Total Billed Charges,307.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.38,88,,63.36,Percent of Total Billed Charges,88% of Total Billed Charges,276.53,90,,64.8,Percent of Total Billed charges,90% of Total Billed Charges,135.5,307.25,
OUTBACK ELITE 120CM RE-ENTRY,2720002597,CDM,272,RC,C1725,HCPCS,Outpatient,,,4387.50,2851.88,,4387.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3334.5,76,,58.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3159,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,3290.63,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,4387.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3159,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,2632.5,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,3948.75,90,,69.744,Percent of Total Billed Charges,90% of Total Billed Charges,1974.38,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,3948.75,90,,69.744,Percent of Total Billed Charges,90% of Total billed Charges,4387.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4387.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4387.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2851.88,65,,50.376,Percent of total Billed Charges,65% of Total Billed Charges,1934.89,44.1,,31.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,4168.13,95,,73.624,Percent of Total Billed Charges,95% of Total Billed Charges,4387.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3861,88,,68.2,Percent of Total Billed Charges,88% of Total Billed Charges,3948.75,90,,69.744,Percent of Total Billed charges,90% of Total Billed Charges,1934.89,4387.5,
OUTBACK ELITE 80CM RE-ENTRY,2720002598,CDM,272,RC,C1725,HCPCS,Outpatient,,,4387.50,2851.88,,4387.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3334.5,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3159,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,3290.63,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,4387.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3159,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,2632.5,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,3948.75,90,,64.8,Percent of Total Billed Charges,90% of Total Billed Charges,1974.38,45,,34.872,Percent of Total Billed Charges,45% of Total Billed Charges,3948.75,90,,64.8,Percent of Total Billed Charges,90% of Total billed Charges,4387.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4387.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4387.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2851.88,65,,46.8,Percent of total Billed Charges,65% of Total Billed Charges,1934.89,44.1,,34.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,4168.13,95,,68.4,Percent of Total Billed Charges,95% of Total Billed Charges,4387.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3861,88,,63.36,Percent of Total Billed Charges,88% of Total Billed Charges,3948.75,90,,64.8,Percent of Total Billed charges,90% of Total Billed Charges,1934.89,4387.5,
Mother and Baby kit,2720002599,CDM,272,RC,,,Outpatient,,,181.68,118.09,,181.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,138.08,76,,58.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,130.81,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,136.26,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,181.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.81,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,109.01,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,163.51,90,,69.744,Percent of Total Billed Charges,90% of Total Billed Charges,81.76,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,163.51,90,,69.744,Percent of Total Billed Charges,90% of Total billed Charges,181.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.09,65,,50.376,Percent of total Billed Charges,65% of Total Billed Charges,80.12,44.1,,31.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,172.6,95,,73.624,Percent of Total Billed Charges,95% of Total Billed Charges,181.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.88,88,,68.2,Percent of Total Billed Charges,88% of Total Billed Charges,163.51,90,,69.744,Percent of Total Billed charges,90% of Total Billed Charges,80.12,181.68,
Post-Partum Kit,2720002600,CDM,272,RC,,,Outpatient,,,68.65,44.62,,68.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.17,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49.43,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,51.49,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,68.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.43,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,41.19,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,61.79,90,,64.8,Percent of Total Billed Charges,90% of Total Billed Charges,30.89,45,,34.872,Percent of Total Billed Charges,45% of Total Billed Charges,61.79,90,,64.8,Percent of Total Billed Charges,90% of Total billed Charges,68.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.62,65,,46.8,Percent of total Billed Charges,65% of Total Billed Charges,30.27,44.1,,34.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.22,95,,68.4,Percent of Total Billed Charges,95% of Total Billed Charges,68.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.41,88,,63.36,Percent of Total Billed Charges,88% of Total Billed Charges,61.79,90,,64.8,Percent of Total Billed charges,90% of Total Billed Charges,30.27,68.65,
Procedural Oxygen mask,2720002601,CDM,272,RC,,,Outpatient,,,21.00,13.65,,21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.96,76,,58.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.12,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,15.75,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.12,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,12.6,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,18.9,90,,69.744,Percent of Total Billed Charges,90% of Total Billed Charges,9.45,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,18.9,90,,69.744,Percent of Total Billed Charges,90% of Total billed Charges,21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.65,65,,50.376,Percent of total Billed Charges,65% of Total Billed Charges,9.26,44.1,,31.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.95,95,,73.624,Percent of Total Billed Charges,95% of Total Billed Charges,21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.48,88,,68.2,Percent of Total Billed Charges,88% of Total Billed Charges,18.9,90,,69.744,Percent of Total Billed charges,90% of Total Billed Charges,9.26,21,
GlideWire Ang 1.5 .035 x 260cm,2720002602,CDM,272,RC,C1769,HCPCS,Outpatient,,,112.00,72.80,,112,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,85.12,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,80.64,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,84,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,112,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.64,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,67.2,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,100.8,90,,25.432,Percent of Total Billed Charges,90% of Total Billed Charges,50.4,45,,34.872,Percent of Total Billed Charges,45% of Total Billed Charges,100.8,90,,64.8,Percent of Total Billed Charges,90% of Total billed Charges,112,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.8,65,,46.8,Percent of total Billed Charges,65% of Total Billed Charges,49.39,44.1,,34.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,106.4,95,,68.4,Percent of Total Billed Charges,95% of Total Billed Charges,112,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.56,88,,63.36,Percent of Total Billed Charges,88% of Total Billed Charges,100.8,90,,64.8,Percent of Total Billed charges,90% of Total Billed Charges,49.39,112,
IVL C2 2.5 X 12MM,2720002603,CDM,272,RC,C1761,HCPCS,Outpatient,,,11750.00,7637.50,,11750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8930,76,,58.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8460,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,8812.5,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8460,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,7050,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,10575,90,,235.264,Percent of Total Billed Charges,90% of Total Billed Charges,5287.5,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,10575,90,,69.744,Percent of Total Billed Charges,90% of Total billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7637.5,65,,50.376,Percent of total Billed Charges,65% of Total Billed Charges,5181.75,44.1,,31.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,11162.5,95,,73.624,Percent of Total Billed Charges,95% of Total Billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10340,88,,68.2,Percent of Total Billed Charges,88% of Total Billed Charges,10575,90,,69.744,Percent of Total Billed charges,90% of Total Billed Charges,5181.75,11750,
IVL C2 3 X 12MM,2720002604,CDM,272,RC,C1761,HCPCS,Outpatient,,,11750.00,7637.50,,11750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8930,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8460,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,8812.5,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8460,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,7050,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,10575,90,,632.88,Percent of Total Billed Charges,90% of Total Billed Charges,5287.5,45,,34.872,Percent of Total Billed Charges,45% of Total Billed Charges,10575,90,,64.8,Percent of Total Billed Charges,90% of Total billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7637.5,65,,46.8,Percent of total Billed Charges,65% of Total Billed Charges,5181.75,44.1,,34.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,11162.5,95,,68.4,Percent of Total Billed Charges,95% of Total Billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10340,88,,63.36,Percent of Total Billed Charges,88% of Total Billed Charges,10575,90,,64.8,Percent of Total Billed charges,90% of Total Billed Charges,5181.75,11750,
IVL C2 3.5 X 12MM,2720002605,CDM,272,RC,C1761,HCPCS,Outpatient,,,11750.00,7637.50,,11750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8930,76,,58.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8460,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,8812.5,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8460,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,7050,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,10575,90,,450,Percent of Total Billed Charges,90% of Total Billed Charges,5287.5,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,10575,90,,69.744,Percent of Total Billed Charges,90% of Total billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7637.5,65,,50.376,Percent of total Billed Charges,65% of Total Billed Charges,5181.75,44.1,,31.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,11162.5,95,,73.624,Percent of Total Billed Charges,95% of Total Billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10340,88,,68.2,Percent of Total Billed Charges,88% of Total Billed Charges,10575,90,,69.744,Percent of Total Billed charges,90% of Total Billed Charges,5181.75,11750,
IVL C2 4 X 12MM,2720002606,CDM,272,RC,C1761,HCPCS,Outpatient,,,11750.00,7637.50,,11750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8930,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8460,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,8812.5,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8460,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,7050,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,10575,90,,450,Percent of Total Billed Charges,90% of Total Billed Charges,5287.5,45,,34.872,Percent of Total Billed Charges,45% of Total Billed Charges,10575,90,,64.8,Percent of Total Billed Charges,90% of Total billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7637.5,65,,46.8,Percent of total Billed Charges,65% of Total Billed Charges,5181.75,44.1,,34.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,11162.5,95,,68.4,Percent of Total Billed Charges,95% of Total Billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10340,88,,63.36,Percent of Total Billed Charges,88% of Total Billed Charges,10575,90,,64.8,Percent of Total Billed charges,90% of Total Billed Charges,5181.75,11750,
IVL M5+ 3.5 X 60MM,2720002607,CDM,272,RC,C1725,HCPCS,Outpatient,,,8625.00,5606.25,,8625,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6555,76,,58.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6210,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,6468.75,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6210,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,5175,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,7762.5,90,,1350,Percent of Total Billed Charges,90% of Total Billed Charges,3881.25,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,7762.5,90,,69.744,Percent of Total Billed Charges,90% of Total billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5606.25,65,,50.376,Percent of total Billed Charges,65% of Total Billed Charges,3803.63,44.1,,31.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,8193.75,95,,73.624,Percent of Total Billed Charges,95% of Total Billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7590,88,,68.2,Percent of Total Billed Charges,88% of Total Billed Charges,7762.5,90,,69.744,Percent of Total Billed charges,90% of Total Billed Charges,3803.63,8625,
IVL M5+ 4 X 60MM,2720002608,CDM,272,RC,C1725,HCPCS,Outpatient,,,8625.00,5606.25,,8625,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6555,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6210,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,6468.75,75,,13.16,Percent of Total Billed charges,75% of Total Billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6210,72,,12.632,Percent of Total Billed Charges,72% of Total Billed Charges,5175,60,,10.528,Percent of Total Billed Charges,60% of Total Billed Charges,7762.5,90,,771.664,Percent of Total Billed Charges,90% of Total Billed Charges,3881.25,45,,34.872,Percent of Total Billed Charges,45% of Total Billed Charges,7762.5,90,,64.8,Percent of Total Billed Charges,90% of Total billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5606.25,65,,46.8,Percent of total Billed Charges,65% of Total Billed Charges,3803.63,44.1,,34.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,8193.75,95,,68.4,Percent of Total Billed Charges,95% of Total Billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7590,88,,63.36,Percent of Total Billed Charges,88% of Total Billed Charges,7762.5,90,,64.8,Percent of Total Billed charges,90% of Total Billed Charges,3803.63,8625,
IVL M5+ 4.5 X 60MM,2720002609,CDM,272,RC,C1725,HCPCS,Outpatient,,,8625.00,5606.25,,8625,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6555,76,,58.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6210,72,,21.6,Percent of Total Billed Charges,72% of Total Billed Charges,6468.75,75,,22.504,Percent of Total Billed charges,75% of Total Billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6210,72,,21.6,Percent of Total Billed Charges,72% of Total Billed Charges,5175,60,,18,Percent of Total Billed Charges,60% of Total Billed Charges,7762.5,90,,122.632,Percent of Total Billed Charges,90% of Total Billed Charges,3881.25,45,,12.712,Percent of Total Billed Charges,45% of Total Billed Charges,7762.5,90,,69.744,Percent of Total Billed Charges,90% of Total billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5606.25,65,,50.376,Percent of total Billed Charges,65% of Total Billed Charges,3803.63,44.1,,12.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,8193.75,95,,73.624,Percent of Total Billed Charges,95% of Total Billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7590,88,,68.2,Percent of Total Billed Charges,88% of Total Billed Charges,7762.5,90,,69.744,Percent of Total Billed charges,90% of Total Billed Charges,3803.63,8625,
IVL M5+ 5 X 60MM,2720002610,CDM,272,RC,C1725,HCPCS,Outpatient,,,8625.00,5606.25,,8625,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6555,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6210,72,,21.6,Percent of Total Billed Charges,72% of Total Billed Charges,6468.75,75,,22.504,Percent of Total Billed charges,75% of Total Billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6210,72,,21.6,Percent of Total Billed Charges,72% of Total Billed Charges,5175,60,,18,Percent of Total Billed Charges,60% of Total Billed Charges,7762.5,90,,23.376,Percent of Total Billed Charges,90% of Total Billed Charges,3881.25,45,,117.632,Percent of Total Billed Charges,45% of Total Billed Charges,7762.5,90,,64.8,Percent of Total Billed Charges,90% of Total billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5606.25,65,,18.368,Percent of total Billed Charges,65% of Total Billed Charges,3803.63,44.1,,115.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,8193.75,95,,68.4,Percent of Total Billed Charges,95% of Total Billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7590,88,,63.36,Percent of Total Billed Charges,88% of Total Billed Charges,7762.5,90,,64.8,Percent of Total Billed charges,90% of Total Billed Charges,3803.63,8625,
IVL M5+ 5.5 X 60MM,2720002611,CDM,272,RC,C1725,HCPCS,Outpatient,,,8625.00,5606.25,,8625,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6555,76,,58.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6210,72,,21.6,Percent of Total Billed Charges,72% of Total Billed Charges,6468.75,75,,22.504,Percent of Total Billed charges,75% of Total Billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6210,72,,21.6,Percent of Total Billed Charges,72% of Total Billed Charges,5175,60,,18,Percent of Total Billed Charges,60% of Total Billed Charges,7762.5,90,,23.376,Percent of Total Billed Charges,90% of Total Billed Charges,3881.25,45,,316.44,Percent of Total Billed Charges,45% of Total Billed Charges,7762.5,90,,69.744,Percent of Total Billed Charges,90% of Total billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5606.25,65,,169.912,Percent of total Billed Charges,65% of Total Billed Charges,3803.63,44.1,,310.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,8193.75,95,,73.624,Percent of Total Billed Charges,95% of Total Billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7590,88,,68.2,Percent of Total Billed Charges,88% of Total Billed Charges,7762.5,90,,69.744,Percent of Total Billed charges,90% of Total Billed Charges,3803.63,8625,
IVL M5+ 6 X 60MM,2720002612,CDM,272,RC,C1725,HCPCS,Outpatient,,,8625.00,5606.25,,8625,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6555,76,,21.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6210,72,,21.6,Percent of Total Billed Charges,72% of Total Billed Charges,6468.75,75,,22.504,Percent of Total Billed charges,75% of Total Billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6210,72,,21.6,Percent of Total Billed Charges,72% of Total Billed Charges,5175,60,,18,Percent of Total Billed Charges,60% of Total Billed Charges,7762.5,90,,2934,Percent of Total Billed Charges,90% of Total Billed Charges,3881.25,45,,225,Percent of Total Billed Charges,45% of Total Billed Charges,7762.5,90,,25.432,Percent of Total Billed Charges,90% of Total billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5606.25,65,,457.08,Percent of total Billed Charges,65% of Total Billed Charges,3803.63,44.1,,220.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,8193.75,95,,26.84,Percent of Total Billed Charges,95% of Total Billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7590,88,,24.864,Percent of Total Billed Charges,88% of Total Billed Charges,7762.5,90,,25.432,Percent of Total Billed charges,90% of Total Billed Charges,3803.63,8625,
IVL M5+ 6.5 X 60MM,2720002613,CDM,272,RC,C1725,HCPCS,Outpatient,,,8625.00,5606.25,,8625,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6555,76,,198.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6210,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,6468.75,75,,126,Percent of Total Billed charges,75% of Total Billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6210,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,5175,60,,100.8,Percent of Total Billed Charges,60% of Total Billed Charges,7762.5,90,,2934,Percent of Total Billed Charges,90% of Total Billed Charges,3881.25,45,,225,Percent of Total Billed Charges,45% of Total Billed Charges,7762.5,90,,235.264,Percent of Total Billed Charges,90% of Total billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5606.25,65,,325,Percent of total Billed Charges,65% of Total Billed Charges,3803.63,44.1,,220.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,8193.75,95,,248.328,Percent of Total Billed Charges,95% of Total Billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7590,88,,230.032,Percent of Total Billed Charges,88% of Total Billed Charges,7762.5,90,,235.264,Percent of Total Billed charges,90% of Total Billed Charges,3803.63,8625,
IVL M5+ 7 X 60MM,2720002614,CDM,272,RC,C1725,HCPCS,Outpatient,,,8625.00,5606.25,,8625,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6555,76,,534.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6210,72,,49.816,Percent of Total Billed Charges,72% of Total Billed Charges,6468.75,75,,51.888,Percent of Total Billed charges,75% of Total Billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6210,72,,49.816,Percent of Total Billed Charges,72% of Total Billed Charges,5175,60,,41.512,Percent of Total Billed Charges,60% of Total Billed Charges,7762.5,90,,2934,Percent of Total Billed Charges,90% of Total Billed Charges,3881.25,45,,675,Percent of Total Billed Charges,45% of Total Billed Charges,7762.5,90,,632.88,Percent of Total Billed Charges,90% of Total billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5606.25,65,,325,Percent of total Billed Charges,65% of Total Billed Charges,3803.63,44.1,,661.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,8193.75,95,,668.04,Percent of Total Billed Charges,95% of Total Billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7590,88,,618.816,Percent of Total Billed Charges,88% of Total Billed Charges,7762.5,90,,632.88,Percent of Total Billed charges,90% of Total Billed Charges,3803.63,8625,
IVL M5+ 8 X 60MM,2720002615,CDM,272,RC,C1725,HCPCS,Outpatient,,,8625.00,5606.25,,8625,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6555,76,,380,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6210,72,,6768,Percent of Total Billed Charges,72% of Total Billed Charges,6468.75,75,,7050,Percent of Total Billed charges,75% of Total Billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6210,72,,6768,Percent of Total Billed Charges,72% of Total Billed Charges,5175,60,,5640,Percent of Total Billed Charges,60% of Total Billed Charges,7762.5,90,,3.624,Percent of Total Billed Charges,90% of Total Billed Charges,3881.25,45,,385.832,Percent of Total Billed Charges,45% of Total Billed Charges,7762.5,90,,450,Percent of Total Billed Charges,90% of Total billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5606.25,65,,975,Percent of total Billed Charges,65% of Total Billed Charges,3803.63,44.1,,378.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,8193.75,95,,475,Percent of Total Billed Charges,95% of Total Billed Charges,8625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7590,88,,440,Percent of Total Billed Charges,88% of Total Billed Charges,7762.5,90,,450,Percent of Total Billed charges,90% of Total Billed Charges,3803.63,8625,
IVL S4 KIT 2.5 X 40MM,2720002616,CDM,272,RC,C1725,HCPCS,Outpatient,,,6875.00,4468.75,,6875,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5225,76,,380,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4950,72,,6768,Percent of Total Billed Charges,72% of Total Billed Charges,5156.25,75,,7050,Percent of Total Billed charges,75% of Total Billed Charges,6875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4950,72,,6768,Percent of Total Billed Charges,72% of Total Billed Charges,4125,60,,5640,Percent of Total Billed Charges,60% of Total Billed Charges,6187.5,90,,9.184,Percent of Total Billed Charges,90% of Total Billed Charges,3093.75,45,,61.312,Percent of Total Billed Charges,45% of Total Billed Charges,6187.5,90,,450,Percent of Total Billed Charges,90% of Total billed Charges,6875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4468.75,65,,557.312,Percent of total Billed Charges,65% of Total Billed Charges,3031.88,44.1,,60.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,6531.25,95,,475,Percent of Total Billed Charges,95% of Total Billed Charges,6875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6050,88,,440,Percent of Total Billed Charges,88% of Total Billed Charges,6187.5,90,,450,Percent of Total Billed charges,90% of Total Billed Charges,3031.88,6875,
IVL S4 KIT 3 X 40MM,2720002617,CDM,272,RC,C1725,HCPCS,Outpatient,,,6875.00,4468.75,,6875,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5225,76,,1140,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4950,72,,6768,Percent of Total Billed Charges,72% of Total Billed Charges,5156.25,75,,7050,Percent of Total Billed charges,75% of Total Billed Charges,6875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4950,72,,6768,Percent of Total Billed Charges,72% of Total Billed Charges,4125,60,,5640,Percent of Total Billed Charges,60% of Total Billed Charges,6187.5,90,,22.68,Percent of Total Billed Charges,90% of Total Billed Charges,3093.75,45,,11.688,Percent of Total Billed Charges,45% of Total Billed Charges,6187.5,90,,1350,Percent of Total Billed Charges,90% of Total billed Charges,6875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4468.75,65,,88.568,Percent of total Billed Charges,65% of Total Billed Charges,3031.88,44.1,,11.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,6531.25,95,,1425,Percent of Total Billed Charges,95% of Total Billed Charges,6875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6050,88,,1320,Percent of Total Billed Charges,88% of Total Billed Charges,6187.5,90,,1350,Percent of Total Billed charges,90% of Total Billed Charges,3031.88,6875,
IVL S4 KIT 3.5 X 40MM,2720002618,CDM,272,RC,C1725,HCPCS,Outpatient,,,6875.00,4468.75,,6875,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5225,76,,651.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4950,72,,6768,Percent of Total Billed Charges,72% of Total Billed Charges,5156.25,75,,7050,Percent of Total Billed charges,75% of Total Billed Charges,6875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4950,72,,6768,Percent of Total Billed Charges,72% of Total Billed Charges,4125,60,,5640,Percent of Total Billed Charges,60% of Total Billed Charges,6187.5,90,,23.024,Percent of Total Billed Charges,90% of Total Billed Charges,3093.75,45,,11.688,Percent of Total Billed Charges,45% of Total Billed Charges,6187.5,90,,771.664,Percent of Total Billed Charges,90% of Total billed Charges,6875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4468.75,65,,16.888,Percent of total Billed Charges,65% of Total Billed Charges,3031.88,44.1,,11.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,6531.25,95,,814.528,Percent of Total Billed Charges,95% of Total Billed Charges,6875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6050,88,,754.512,Percent of Total Billed Charges,88% of Total Billed Charges,6187.5,90,,771.664,Percent of Total Billed charges,90% of Total Billed Charges,3031.88,6875,
IVL S4 KIT 4 X 40MM,2720002619,CDM,272,RC,C1725,HCPCS,Outpatient,,,6875.00,4468.75,,6875,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5225,76,,103.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4950,72,,6768,Percent of Total Billed Charges,72% of Total Billed Charges,5156.25,75,,7050,Percent of Total Billed charges,75% of Total Billed Charges,6875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4950,72,,6768,Percent of Total Billed Charges,72% of Total Billed Charges,4125,60,,5640,Percent of Total Billed Charges,60% of Total Billed Charges,6187.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,3093.75,45,,1467,Percent of Total Billed Charges,45% of Total Billed Charges,6187.5,90,,122.632,Percent of Total Billed Charges,90% of Total billed Charges,6875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4468.75,65,,16.888,Percent of total Billed Charges,65% of Total Billed Charges,3031.88,44.1,,1437.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,6531.25,95,,129.44,Percent of Total Billed Charges,95% of Total Billed Charges,6875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6050,88,,119.904,Percent of Total Billed Charges,88% of Total Billed Charges,6187.5,90,,122.632,Percent of Total Billed charges,90% of Total Billed Charges,3031.88,6875,
IVL SHOCKWAVE CABLE SLEEVE,2720002620,CDM,272,RC,,,Outpatient,,,15.00,9.75,,15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.4,76,,19.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.8,72,,6768,Percent of Total Billed Charges,72% of Total Billed Charges,11.25,75,,7050,Percent of Total Billed charges,75% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.8,72,,6768,Percent of Total Billed Charges,72% of Total Billed Charges,9,60,,5640,Percent of Total Billed Charges,60% of Total Billed Charges,13.5,90,,3.552,Percent of Total Billed Charges,90% of Total Billed Charges,6.75,45,,1467,Percent of Total Billed Charges,45% of Total Billed Charges,13.5,90,,23.376,Percent of Total Billed Charges,90% of Total billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.75,65,,2119,Percent of total Billed Charges,65% of Total Billed Charges,6.62,44.1,,1437.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.25,95,,24.68,Percent of Total Billed Charges,95% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.2,88,,22.856,Percent of Total Billed Charges,88% of Total Billed Charges,13.5,90,,23.376,Percent of Total Billed charges,90% of Total Billed Charges,6.62,15,
REDIGUARD IABP 8F 40CC,2720002621,CDM,272,RC,,,Outpatient,,,2122.50,1379.63,,2122.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1613.1,76,,19.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1528.2,72,,234.144,Percent of Total Billed Charges,72% of Total Billed Charges,1591.88,75,,243.904,Percent of Total Billed charges,75% of Total Billed Charges,2122.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.2,72,,234.144,Percent of Total Billed Charges,72% of Total Billed Charges,1273.5,60,,195.12,Percent of Total Billed Charges,60% of Total Billed Charges,1910.25,90,,9.344,Percent of Total Billed Charges,90% of Total Billed Charges,955.13,45,,1467,Percent of Total Billed Charges,45% of Total Billed Charges,1910.25,90,,23.376,Percent of Total Billed Charges,90% of Total billed Charges,2122.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2122.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2122.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1379.63,65,,2119,Percent of total Billed Charges,65% of Total Billed Charges,936.02,44.1,,1437.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,2016.38,95,,24.68,Percent of Total Billed Charges,95% of Total Billed Charges,2122.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1867.8,88,,22.856,Percent of Total Billed Charges,88% of Total Billed Charges,1910.25,90,,23.376,Percent of Total Billed charges,90% of Total Billed Charges,936.02,2122.5,
Cath Urethral Tray 15FR(sub),2720002622,CDM,272,RC,,,Outpatient,,,3.32,2.16,,3.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,2477.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.39,72,,19.08,Percent of Total Billed Charges,72% of Total Billed Charges,2.49,75,,19.88,Percent of Total Billed charges,75% of Total Billed Charges,3.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.39,72,,19.08,Percent of Total Billed Charges,72% of Total Billed Charges,1.99,60,,15.904,Percent of Total Billed Charges,60% of Total Billed Charges,2.99,90,,9.184,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,1.808,Percent of Total Billed Charges,45% of Total Billed Charges,2.99,90,,2934,Percent of Total Billed Charges,90% of Total billed Charges,3.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.16,65,,2119,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,1.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.15,95,,3097,Percent of Total Billed Charges,95% of Total Billed Charges,3.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.92,88,,2868.8,Percent of Total Billed Charges,88% of Total Billed Charges,2.99,90,,2934,Percent of Total Billed charges,90% of Total Billed Charges,1.46,3.32,
SUPERCROSS 0.014 45 130CM,2720002623,CDM,272,RC,C1887,HCPCS,Outpatient,,,1425.00,926.25,,1425,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1083,76,,2477.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1026,72,,133.92,Percent of Total Billed Charges,72% of Total Billed Charges,1068.75,75,,139.504,Percent of Total Billed charges,75% of Total Billed Charges,1425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1026,72,,133.92,Percent of Total Billed Charges,72% of Total Billed Charges,855,60,,111.6,Percent of Total Billed Charges,60% of Total Billed Charges,1282.5,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,641.25,45,,4.592,Percent of Total Billed Charges,45% of Total Billed Charges,1282.5,90,,2934,Percent of Total Billed Charges,90% of Total billed Charges,1425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,926.25,65,,2.616,Percent of total Billed Charges,65% of Total Billed Charges,628.43,44.1,,4.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,1353.75,95,,3097,Percent of Total Billed Charges,95% of Total Billed Charges,1425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1254,88,,2868.8,Percent of Total Billed Charges,88% of Total Billed Charges,1282.5,90,,2934,Percent of Total Billed charges,90% of Total Billed Charges,628.43,1425,
SUPERCROSS 0.014 45 150CM,2720002624,CDM,272,RC,C1887,HCPCS,Outpatient,,,1425.00,926.25,,1425,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1083,76,,2477.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1026,72,,7.488,Percent of Total Billed Charges,72% of Total Billed Charges,1068.75,75,,7.8,Percent of Total Billed charges,75% of Total Billed Charges,1425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1026,72,,7.488,Percent of Total Billed Charges,72% of Total Billed Charges,855,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,1282.5,90,,9.544,Percent of Total Billed Charges,90% of Total Billed Charges,641.25,45,,11.344,Percent of Total Billed Charges,45% of Total Billed Charges,1282.5,90,,2934,Percent of Total Billed Charges,90% of Total billed Charges,1425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,926.25,65,,6.632,Percent of total Billed Charges,65% of Total Billed Charges,628.43,44.1,,11.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,1353.75,95,,3097,Percent of Total Billed Charges,95% of Total Billed Charges,1425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1254,88,,2868.8,Percent of Total Billed Charges,88% of Total Billed Charges,1282.5,90,,2934,Percent of Total Billed charges,90% of Total Billed Charges,628.43,1425,
SUPERCROSS 0.014 90 130CM,2720002625,CDM,272,RC,C1887,HCPCS,Outpatient,,,1425.00,926.25,,1425,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1083,76,,3.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1026,72,,1029.6,Percent of Total Billed Charges,72% of Total Billed Charges,1068.75,75,,1072.504,Percent of Total Billed charges,75% of Total Billed Charges,1425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1026,72,,1029.6,Percent of Total Billed Charges,72% of Total Billed Charges,855,60,,858,Percent of Total Billed Charges,60% of Total Billed Charges,1282.5,90,,15.304,Percent of Total Billed Charges,90% of Total Billed Charges,641.25,45,,11.512,Percent of Total Billed Charges,45% of Total Billed Charges,1282.5,90,,3.624,Percent of Total Billed Charges,90% of Total billed Charges,1425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,926.25,65,,16.384,Percent of total Billed Charges,65% of Total Billed Charges,628.43,44.1,,11.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,1353.75,95,,3.824,Percent of Total Billed Charges,95% of Total Billed Charges,1425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1254,88,,3.544,Percent of Total Billed Charges,88% of Total Billed Charges,1282.5,90,,3.624,Percent of Total Billed charges,90% of Total Billed Charges,628.43,1425,
SUPERCROSS 0.014 90 150CM,2720002626,CDM,272,RC,C1887,HCPCS,Outpatient,,,1425.00,926.25,,1425,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1083,76,,7.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1026,72,,936,Percent of Total Billed Charges,72% of Total Billed Charges,1068.75,75,,975,Percent of Total Billed charges,75% of Total Billed Charges,1425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1026,72,,936,Percent of Total Billed Charges,72% of Total Billed Charges,855,60,,780,Percent of Total Billed Charges,60% of Total Billed Charges,1282.5,90,,18.36,Percent of Total Billed Charges,90% of Total Billed Charges,641.25,45,,1.8,Percent of Total Billed Charges,45% of Total Billed Charges,1282.5,90,,9.184,Percent of Total Billed Charges,90% of Total billed Charges,1425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,926.25,65,,16.632,Percent of total Billed Charges,65% of Total Billed Charges,628.43,44.1,,1.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,1353.75,95,,9.688,Percent of Total Billed Charges,95% of Total Billed Charges,1425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1254,88,,8.976,Percent of Total Billed Charges,88% of Total Billed Charges,1282.5,90,,9.184,Percent of Total Billed charges,90% of Total Billed Charges,628.43,1425,
SUPERCROSS 0.014 ST  130CM,2720002627,CDM,272,RC,C1887,HCPCS,Outpatient,,,1125.00,731.25,,1125,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,855,76,,19.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,810,72,,1886.4,Percent of Total Billed Charges,72% of Total Billed Charges,843.75,75,,1965,Percent of Total Billed charges,75% of Total Billed Charges,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,810,72,,1886.4,Percent of Total Billed Charges,72% of Total Billed Charges,675,60,,1572,Percent of Total Billed Charges,60% of Total Billed Charges,1012.5,90,,20.704,Percent of Total Billed Charges,90% of Total Billed Charges,506.25,45,,1.776,Percent of Total Billed Charges,45% of Total Billed Charges,1012.5,90,,22.68,Percent of Total Billed Charges,90% of Total billed Charges,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,731.25,65,,2.6,Percent of total Billed Charges,65% of Total Billed Charges,496.13,44.1,,1.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,1068.75,95,,23.944,Percent of Total Billed Charges,95% of Total Billed Charges,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,990,88,,22.176,Percent of Total Billed Charges,88% of Total Billed Charges,1012.5,90,,22.68,Percent of Total Billed charges,90% of Total Billed Charges,496.13,1125,
SUPERCROSS 0.014 ST  150CM,2720002628,CDM,272,RC,C1887,HCPCS,Outpatient,,,1125.00,731.25,,1125,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,855,76,,19.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,810,72,,4.744,Percent of Total Billed Charges,72% of Total Billed Charges,843.75,75,,4.936,Percent of Total Billed charges,75% of Total Billed Charges,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,810,72,,4.744,Percent of Total Billed Charges,72% of Total Billed Charges,675,60,,3.952,Percent of Total Billed Charges,60% of Total Billed Charges,1012.5,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,506.25,45,,4.672,Percent of Total Billed Charges,45% of Total Billed Charges,1012.5,90,,23.024,Percent of Total Billed Charges,90% of Total billed Charges,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,731.25,65,,2.56,Percent of total Billed Charges,65% of Total Billed Charges,496.13,44.1,,4.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,1068.75,95,,24.304,Percent of Total Billed Charges,95% of Total Billed Charges,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,990,88,,22.512,Percent of Total Billed Charges,88% of Total Billed Charges,1012.5,90,,23.024,Percent of Total Billed charges,90% of Total Billed Charges,496.13,1125,
GUIDELINER V3 RX 6F 150CM,2720002629,CDM,272,RC,C1887,HCPCS,Outpatient,,,1312.50,853.13,,1312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,997.5,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,945,72,,4.392,Percent of Total Billed Charges,72% of Total Billed Charges,984.38,75,,4.576,Percent of Total Billed charges,75% of Total Billed Charges,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,945,72,,4.392,Percent of Total Billed Charges,72% of Total Billed Charges,787.5,60,,3.664,Percent of Total Billed Charges,60% of Total Billed Charges,1181.25,90,,31.464,Percent of Total Billed Charges,90% of Total Billed Charges,590.63,45,,4.592,Percent of Total Billed Charges,45% of Total Billed Charges,1181.25,90,,3.6,Percent of Total Billed Charges,90% of Total billed Charges,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,853.13,65,,6.752,Percent of total Billed Charges,65% of Total Billed Charges,578.81,44.1,,4.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,1246.88,95,,3.8,Percent of Total Billed Charges,95% of Total Billed Charges,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1155,88,,3.52,Percent of Total Billed Charges,88% of Total Billed Charges,1181.25,90,,3.6,Percent of Total Billed charges,90% of Total Billed Charges,578.81,1312.5,
GUIDELINER V3 RX 7F 150CM,2720002630,CDM,272,RC,C1887,HCPCS,Outpatient,,,1312.50,853.13,,1312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,997.5,76,,3,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,945,72,,19.6,Percent of Total Billed Charges,72% of Total Billed Charges,984.38,75,,20.416,Percent of Total Billed charges,75% of Total Billed Charges,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,945,72,,19.6,Percent of Total Billed Charges,72% of Total Billed Charges,787.5,60,,16.336,Percent of Total Billed Charges,60% of Total Billed Charges,1181.25,90,,27.832,Percent of Total Billed Charges,90% of Total Billed Charges,590.63,45,,2.88,Percent of Total Billed Charges,45% of Total Billed Charges,1181.25,90,,3.552,Percent of Total Billed Charges,90% of Total billed Charges,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,853.13,65,,6.632,Percent of total Billed Charges,65% of Total Billed Charges,578.81,44.1,,2.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,1246.88,95,,3.744,Percent of Total Billed Charges,95% of Total Billed Charges,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1155,88,,3.472,Percent of Total Billed Charges,88% of Total Billed Charges,1181.25,90,,3.552,Percent of Total Billed charges,90% of Total Billed Charges,578.81,1312.5,
GUIDEZILLA II 6F,2720002631,CDM,272,RC,C1887,HCPCS,Outpatient,,,1000.00,650.00,,1000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,760,76,,7.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,720,72,,453.6,Percent of Total Billed Charges,72% of Total Billed Charges,750,75,,472.504,Percent of Total Billed charges,75% of Total Billed Charges,1000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,720,72,,453.6,Percent of Total Billed Charges,72% of Total Billed Charges,600,60,,378,Percent of Total Billed Charges,60% of Total Billed Charges,900,90,,5.328,Percent of Total Billed Charges,90% of Total Billed Charges,450,45,,4.768,Percent of Total Billed Charges,45% of Total Billed Charges,900,90,,9.344,Percent of Total Billed Charges,90% of Total billed Charges,1000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,650,65,,4.16,Percent of total Billed Charges,65% of Total Billed Charges,441,44.1,,4.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,950,95,,9.864,Percent of Total Billed Charges,95% of Total Billed Charges,1000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,880,88,,9.136,Percent of Total Billed Charges,88% of Total Billed Charges,900,90,,9.344,Percent of Total Billed charges,90% of Total Billed Charges,441,1000,
GUIDEZILLA II 7F,2720002632,CDM,272,RC,C1887,HCPCS,Outpatient,,,1000.00,650.00,,1000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,760,76,,7.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,720,72,,233.28,Percent of Total Billed Charges,72% of Total Billed Charges,750,75,,243,Percent of Total Billed charges,75% of Total Billed Charges,1000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,720,72,,233.28,Percent of Total Billed Charges,72% of Total Billed Charges,600,60,,194.4,Percent of Total Billed Charges,60% of Total Billed Charges,900,90,,0.76,Percent of Total Billed Charges,90% of Total Billed Charges,450,45,,7.648,Percent of Total Billed Charges,45% of Total Billed Charges,900,90,,9.184,Percent of Total Billed Charges,90% of Total billed Charges,1000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,650,65,,6.888,Percent of total Billed Charges,65% of Total Billed Charges,441,44.1,,7.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,950,95,,9.688,Percent of Total Billed Charges,95% of Total Billed Charges,1000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,880,88,,8.976,Percent of Total Billed Charges,88% of Total Billed Charges,900,90,,9.184,Percent of Total Billed charges,90% of Total Billed Charges,441,1000,
MAX-CORE BIOPSY INSTRUMENT,2720002633,CDM,272,RC,,,Outpatient,,,463.35,301.18,,463.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,352.15,76,,4.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,333.61,72,,344.16,Percent of Total Billed Charges,72% of Total Billed Charges,347.51,75,,358.504,Percent of Total Billed charges,75% of Total Billed Charges,463.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.61,72,,344.16,Percent of Total Billed Charges,72% of Total Billed Charges,278.01,60,,286.8,Percent of Total Billed Charges,60% of Total Billed Charges,417.02,90,,0.76,Percent of Total Billed Charges,90% of Total Billed Charges,208.51,45,,9.184,Percent of Total Billed Charges,45% of Total Billed Charges,417.02,90,,5.76,Percent of Total Billed Charges,90% of Total billed Charges,463.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,463.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,463.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.18,65,,11.048,Percent of total Billed Charges,65% of Total Billed Charges,204.34,44.1,,9,Percent of Total Billed Charges,44.1% of Total Billed Charges,440.18,95,,6.08,Percent of Total Billed Charges,95% of Total Billed Charges,463.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.75,88,,5.632,Percent of Total Billed Charges,88% of Total Billed Charges,417.02,90,,5.76,Percent of Total Billed charges,90% of Total Billed Charges,204.34,463.35,
BIOPENCE ULTRA DEVICE,2720002634,CDM,272,RC,,,Outpatient,,,185.00,120.25,,185,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,140.6,76,,8.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,133.2,72,,192.528,Percent of Total Billed Charges,72% of Total Billed Charges,138.75,75,,200.552,Percent of Total Billed charges,75% of Total Billed Charges,185,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.2,72,,192.528,Percent of Total Billed Charges,72% of Total Billed Charges,111,60,,160.44,Percent of Total Billed Charges,60% of Total Billed Charges,166.5,90,,0.616,Percent of Total Billed Charges,90% of Total Billed Charges,83.25,45,,10.352,Percent of Total Billed Charges,45% of Total Billed Charges,166.5,90,,9.544,Percent of Total Billed Charges,90% of Total billed Charges,185,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.25,65,,13.264,Percent of total Billed Charges,65% of Total Billed Charges,81.59,44.1,,10.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,175.75,95,,10.072,Percent of Total Billed Charges,95% of Total Billed Charges,185,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.8,88,,9.328,Percent of Total Billed Charges,88% of Total Billed Charges,166.5,90,,9.544,Percent of Total Billed charges,90% of Total Billed Charges,81.59,185,
KING AIRWAY SIZE 4,2720002635,CDM,272,RC,,,Outpatient,,,109.47,71.16,,109.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,83.2,76,,12.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,78.82,72,,17.248,Percent of Total Billed Charges,72% of Total Billed Charges,82.1,75,,17.968,Percent of Total Billed charges,75% of Total Billed Charges,109.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.82,72,,17.248,Percent of Total Billed Charges,72% of Total Billed Charges,65.68,60,,14.376,Percent of Total Billed Charges,60% of Total Billed Charges,98.52,90,,14.368,Percent of Total Billed Charges,90% of Total Billed Charges,49.26,45,,12.6,Percent of Total Billed Charges,45% of Total Billed Charges,98.52,90,,15.304,Percent of Total Billed Charges,90% of Total billed Charges,109.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.16,65,,14.952,Percent of total Billed Charges,65% of Total Billed Charges,48.28,44.1,,12.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,104,95,,16.152,Percent of Total Billed Charges,95% of Total Billed Charges,109.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.33,88,,14.96,Percent of Total Billed Charges,88% of Total Billed Charges,98.52,90,,15.304,Percent of Total Billed charges,90% of Total Billed Charges,48.28,109.47,
KING AIRWAY SIZE 5,2720002636,CDM,272,RC,,,Outpatient,,,103.22,67.09,,103.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,78.45,76,,15.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,74.32,72,,331.336,Percent of Total Billed Charges,72% of Total Billed Charges,77.42,75,,345.136,Percent of Total Billed charges,75% of Total Billed Charges,103.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.32,72,,331.336,Percent of Total Billed Charges,72% of Total Billed Charges,61.93,60,,276.112,Percent of Total Billed Charges,60% of Total Billed Charges,92.9,90,,24.48,Percent of Total Billed Charges,90% of Total Billed Charges,46.45,45,,15.736,Percent of Total Billed Charges,45% of Total Billed Charges,92.9,90,,18.36,Percent of Total Billed Charges,90% of Total billed Charges,103.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.09,65,,18.2,Percent of total Billed Charges,65% of Total Billed Charges,45.52,44.1,,15.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,98.06,95,,19.384,Percent of Total Billed Charges,95% of Total Billed Charges,103.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.83,88,,17.952,Percent of Total Billed Charges,88% of Total Billed Charges,92.9,90,,18.36,Percent of Total Billed charges,90% of Total Billed Charges,45.52,103.22,
WIPE CHG 2%,2720002637,CDM,272,RC,,,Outpatient,,,5.85,3.80,,5.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.45,76,,17.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.21,72,,1.6,Percent of Total Billed Charges,72% of Total Billed Charges,4.39,75,,1.672,Percent of Total Billed charges,75% of Total Billed Charges,5.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.21,72,,1.6,Percent of Total Billed Charges,72% of Total Billed Charges,3.51,60,,1.336,Percent of Total Billed Charges,60% of Total Billed Charges,5.27,90,,356.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.63,45,,13.912,Percent of Total Billed Charges,45% of Total Billed Charges,5.27,90,,20.704,Percent of Total Billed Charges,90% of Total billed Charges,5.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.8,65,,22.728,Percent of total Billed Charges,65% of Total Billed Charges,2.58,44.1,,13.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.56,95,,21.848,Percent of Total Billed Charges,95% of Total Billed Charges,5.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.15,88,,20.24,Percent of Total Billed Charges,88% of Total Billed Charges,5.27,90,,20.704,Percent of Total Billed charges,90% of Total Billed Charges,2.58,5.85,
LAP DISSECTOR 28-0801,2720002638,CDM,272,RC,,,Outpatient,,,58.42,37.97,,58.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,44.4,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.06,72,,123.176,Percent of Total Billed Charges,72% of Total Billed Charges,43.82,75,,128.312,Percent of Total Billed charges,75% of Total Billed Charges,58.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.06,72,,123.176,Percent of Total Billed Charges,72% of Total Billed Charges,35.05,60,,102.648,Percent of Total Billed Charges,60% of Total Billed Charges,52.58,90,,1271.16,Percent of Total Billed Charges,90% of Total Billed Charges,26.29,45,,2.664,Percent of Total Billed Charges,45% of Total Billed Charges,52.58,90,,25.2,Percent of Total Billed Charges,90% of Total billed Charges,58.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.97,65,,20.096,Percent of total Billed Charges,65% of Total Billed Charges,25.76,44.1,,2.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,55.5,95,,26.6,Percent of Total Billed Charges,95% of Total Billed Charges,58.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.41,88,,24.64,Percent of Total Billed Charges,88% of Total Billed Charges,52.58,90,,25.2,Percent of Total Billed charges,90% of Total Billed Charges,25.76,58.42,
ELEVIEW 5 AMP- 10ml,2720002639,CDM,272,RC,,,Outpatient,,,209.00,135.85,,209,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,158.84,76,,26.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.48,72,,819.504,Percent of Total Billed Charges,72% of Total Billed Charges,156.75,75,,853.648,Percent of Total Billed charges,75% of Total Billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.48,72,,819.504,Percent of Total Billed Charges,72% of Total Billed Charges,125.4,60,,682.92,Percent of Total Billed Charges,60% of Total Billed Charges,188.1,90,,342,Percent of Total Billed Charges,90% of Total Billed Charges,94.05,45,,0.376,Percent of Total Billed Charges,45% of Total Billed Charges,188.1,90,,31.464,Percent of Total Billed Charges,90% of Total billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.85,65,,3.848,Percent of total Billed Charges,65% of Total Billed Charges,92.17,44.1,,0.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,198.55,95,,33.216,Percent of Total Billed Charges,95% of Total Billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.92,88,,30.768,Percent of Total Billed Charges,88% of Total Billed Charges,188.1,90,,31.464,Percent of Total Billed charges,90% of Total Billed Charges,92.17,209,
Alexis Wound Protector,2720002640,CDM,272,RC,,,Outpatient,,,155.00,100.75,,155,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,117.8,76,,23.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.6,72,,351.216,Percent of Total Billed Charges,72% of Total Billed Charges,116.25,75,,365.848,Percent of Total Billed charges,75% of Total Billed Charges,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.6,72,,351.216,Percent of Total Billed Charges,72% of Total Billed Charges,93,60,,292.68,Percent of Total Billed Charges,60% of Total Billed Charges,139.5,90,,547.2,Percent of Total Billed Charges,90% of Total Billed Charges,69.75,45,,0.376,Percent of Total Billed Charges,45% of Total Billed Charges,139.5,90,,27.832,Percent of Total Billed Charges,90% of Total billed Charges,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.75,65,,0.544,Percent of total Billed Charges,65% of Total Billed Charges,68.36,44.1,,0.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,147.25,95,,29.376,Percent of Total Billed Charges,95% of Total Billed Charges,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.4,88,,27.208,Percent of Total Billed Charges,88% of Total Billed Charges,139.5,90,,27.832,Percent of Total Billed charges,90% of Total Billed Charges,68.36,155,
4.9 short Calib DB,2720002641,CDM,272,RC,,,Outpatient,,,361.55,235.01,,361.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,274.78,76,,4.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,260.32,72,,663.408,Percent of Total Billed Charges,72% of Total Billed Charges,271.16,75,,691.048,Percent of Total Billed charges,75% of Total Billed Charges,361.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.32,72,,663.408,Percent of Total Billed Charges,72% of Total Billed Charges,216.93,60,,552.84,Percent of Total Billed Charges,60% of Total Billed Charges,325.4,90,,380.488,Percent of Total Billed Charges,90% of Total Billed Charges,162.7,45,,0.304,Percent of Total Billed Charges,45% of Total Billed Charges,325.4,90,,5.328,Percent of Total Billed Charges,90% of Total billed Charges,361.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.01,65,,0.544,Percent of total Billed Charges,65% of Total Billed Charges,159.44,44.1,,0.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,343.47,95,,5.624,Percent of Total Billed Charges,95% of Total Billed Charges,361.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.16,88,,5.208,Percent of Total Billed Charges,88% of Total Billed Charges,325.4,90,,5.328,Percent of Total Billed charges,90% of Total Billed Charges,159.44,361.55,
4.3 short calib DB,2720002642,CDM,272,RC,,,Outpatient,,,268.85,174.75,,268.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,204.33,76,,0.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,193.57,72,,49.96,Percent of Total Billed Charges,72% of Total Billed Charges,201.64,75,,52.04,Percent of Total Billed charges,75% of Total Billed Charges,268.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.57,72,,49.96,Percent of Total Billed Charges,72% of Total Billed Charges,161.31,60,,41.632,Percent of Total Billed Charges,60% of Total Billed Charges,241.97,90,,48.784,Percent of Total Billed Charges,90% of Total Billed Charges,120.98,45,,7.184,Percent of Total Billed Charges,45% of Total Billed Charges,241.97,90,,0.76,Percent of Total Billed Charges,90% of Total billed Charges,268.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.75,65,,0.44,Percent of total Billed Charges,65% of Total Billed Charges,118.56,44.1,,7.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,255.41,95,,0.8,Percent of Total Billed Charges,95% of Total Billed Charges,268.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.59,88,,0.736,Percent of Total Billed Charges,88% of Total Billed Charges,241.97,90,,0.76,Percent of Total Billed charges,90% of Total Billed Charges,118.56,268.85,
VLOC 90 ABS SUT SZ 3-9?,2720002643,CDM,272,RC,,,Outpatient,,,76.32,49.61,,76.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58,76,,0.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,54.95,72,,49.96,Percent of Total Billed Charges,72% of Total Billed Charges,57.24,75,,52.04,Percent of Total Billed charges,75% of Total Billed Charges,76.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.95,72,,49.96,Percent of Total Billed Charges,72% of Total Billed Charges,45.79,60,,41.632,Percent of Total Billed Charges,60% of Total Billed Charges,68.69,90,,62.448,Percent of Total Billed Charges,90% of Total Billed Charges,34.34,45,,12.24,Percent of Total Billed Charges,45% of Total Billed Charges,68.69,90,,0.76,Percent of Total Billed Charges,90% of Total billed Charges,76.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,65,,10.376,Percent of total Billed Charges,65% of Total Billed Charges,33.66,44.1,,11.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,72.5,95,,0.8,Percent of Total Billed Charges,95% of Total Billed Charges,76.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.16,88,,0.736,Percent of Total Billed Charges,88% of Total Billed Charges,68.69,90,,0.76,Percent of Total Billed charges,90% of Total Billed Charges,33.66,76.32,
VLOC 90 ABS SUT SZ 3-6?,2720002644,CDM,272,RC,,,Outpatient,,,76.32,49.61,,76.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58,76,,0.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,54.95,72,,29.664,Percent of Total Billed Charges,72% of Total Billed Charges,57.24,75,,30.904,Percent of Total Billed charges,75% of Total Billed Charges,76.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.95,72,,29.664,Percent of Total Billed Charges,72% of Total Billed Charges,45.79,60,,24.72,Percent of Total Billed Charges,60% of Total Billed Charges,68.69,90,,5.472,Percent of Total Billed Charges,90% of Total Billed Charges,34.34,45,,178.2,Percent of Total Billed Charges,45% of Total Billed Charges,68.69,90,,0.616,Percent of Total Billed Charges,90% of Total billed Charges,76.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,65,,17.68,Percent of total Billed Charges,65% of Total Billed Charges,33.66,44.1,,174.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,72.5,95,,0.648,Percent of Total Billed Charges,95% of Total Billed Charges,76.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.16,88,,0.6,Percent of Total Billed Charges,88% of Total Billed Charges,68.69,90,,0.616,Percent of Total Billed charges,90% of Total Billed Charges,33.66,76.32,
Sterile Delivery Kit,2720002645,CDM,272,RC,,,Outpatient,,,305.40,198.51,,305.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,232.1,76,,12.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,219.89,72,,2403.88,Percent of Total Billed Charges,72% of Total Billed Charges,229.05,75,,2504.04,Percent of Total Billed charges,75% of Total Billed Charges,305.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.89,72,,2403.88,Percent of Total Billed Charges,72% of Total Billed Charges,183.24,60,,2003.232,Percent of Total Billed Charges,60% of Total Billed Charges,274.86,90,,558,Percent of Total Billed Charges,90% of Total Billed Charges,137.43,45,,635.584,Percent of Total Billed Charges,45% of Total Billed Charges,274.86,90,,14.368,Percent of Total Billed Charges,90% of Total billed Charges,305.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.51,65,,257.4,Percent of total Billed Charges,65% of Total Billed Charges,134.68,44.1,,622.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,290.13,95,,15.16,Percent of Total Billed Charges,95% of Total Billed Charges,305.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.75,88,,14.048,Percent of Total Billed Charges,88% of Total Billed Charges,274.86,90,,14.368,Percent of Total Billed charges,90% of Total Billed Charges,134.68,305.4,
Universal Flush 4F 65CM,2720002646,CDM,272,RC,C1887,HCPCS,Outpatient,,,33.75,21.94,,33.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.65,76,,20.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.3,72,,242.4,Percent of Total Billed Charges,72% of Total Billed Charges,25.31,75,,252.496,Percent of Total Billed charges,75% of Total Billed Charges,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.3,72,,242.4,Percent of Total Billed Charges,72% of Total Billed Charges,20.25,60,,202,Percent of Total Billed Charges,60% of Total Billed Charges,30.38,90,,567,Percent of Total Billed Charges,90% of Total Billed Charges,15.19,45,,171,Percent of Total Billed Charges,45% of Total Billed Charges,30.38,90,,24.48,Percent of Total Billed Charges,90% of Total billed Charges,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.94,65,,918.064,Percent of total Billed Charges,65% of Total Billed Charges,14.88,44.1,,167.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.06,95,,25.84,Percent of Total Billed Charges,95% of Total Billed Charges,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.7,88,,23.936,Percent of Total Billed Charges,88% of Total Billed Charges,30.38,90,,24.48,Percent of Total Billed charges,90% of Total Billed Charges,14.88,33.75,
Universal Flush 5F 65CM,2720002647,CDM,272,RC,C1887,HCPCS,Outpatient,,,33.75,21.94,,33.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.65,76,,300.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.3,72,,696,Percent of Total Billed Charges,72% of Total Billed Charges,25.31,75,,725,Percent of Total Billed charges,75% of Total Billed Charges,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.3,72,,696,Percent of Total Billed Charges,72% of Total Billed Charges,20.25,60,,580,Percent of Total Billed Charges,60% of Total Billed Charges,30.38,90,,24.792,Percent of Total Billed Charges,90% of Total Billed Charges,15.19,45,,273.6,Percent of Total Billed Charges,45% of Total Billed Charges,30.38,90,,356.4,Percent of Total Billed Charges,90% of Total billed Charges,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.94,65,,247,Percent of total Billed Charges,65% of Total Billed Charges,14.88,44.1,,268.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.06,95,,376.2,Percent of Total Billed Charges,95% of Total Billed Charges,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.7,88,,348.48,Percent of Total Billed Charges,88% of Total Billed Charges,30.38,90,,356.4,Percent of Total Billed charges,90% of Total Billed Charges,14.88,33.75,
J-Curve I 5F 65CM,2720002648,CDM,272,RC,C1887,HCPCS,Outpatient,,,33.75,21.94,,33.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.65,76,,1073.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.3,72,,2942.136,Percent of Total Billed Charges,72% of Total Billed Charges,25.31,75,,3064.728,Percent of Total Billed charges,75% of Total Billed Charges,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.3,72,,2942.136,Percent of Total Billed Charges,72% of Total Billed Charges,20.25,60,,2451.784,Percent of Total Billed Charges,60% of Total Billed Charges,30.38,90,,19.944,Percent of Total Billed Charges,90% of Total Billed Charges,15.19,45,,190.24,Percent of Total Billed Charges,45% of Total Billed Charges,30.38,90,,1271.16,Percent of Total Billed Charges,90% of Total billed Charges,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.94,65,,395.2,Percent of total Billed Charges,65% of Total Billed Charges,14.88,44.1,,186.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.06,95,,1341.784,Percent of Total Billed Charges,95% of Total Billed Charges,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.7,88,,1242.912,Percent of Total Billed Charges,88% of Total Billed Charges,30.38,90,,1271.16,Percent of Total Billed charges,90% of Total Billed Charges,14.88,33.75,
J-Curve II F 65CM,2720002649,CDM,272,RC,C1887,HCPCS,Outpatient,,,33.75,21.94,,33.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.65,76,,288.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.3,72,,208.928,Percent of Total Billed Charges,72% of Total Billed Charges,25.31,75,,208.928,Percent of Total Billed charges,75% of Total Billed Charges,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.3,72,,208.928,Percent of Total Billed Charges,72% of Total Billed Charges,20.25,60,,174.104,Percent of Total Billed Charges,60% of Total Billed Charges,30.38,90,,809.752,Percent of Total Billed Charges,90% of Total Billed Charges,15.19,45,,24.392,Percent of Total Billed Charges,45% of Total Billed Charges,30.38,90,,342,Percent of Total Billed Charges,90% of Total billed Charges,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.94,65,,274.792,Percent of total Billed Charges,65% of Total Billed Charges,14.88,44.1,,23.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.06,95,,361,Percent of Total Billed Charges,95% of Total Billed Charges,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.7,88,,334.4,Percent of Total Billed Charges,88% of Total Billed Charges,30.38,90,,342,Percent of Total Billed charges,90% of Total Billed Charges,14.88,33.75,
J-Curve III 5F 65CM,2720002650,CDM,272,RC,C1887,HCPCS,Outpatient,,,33.75,21.94,,33.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.65,76,,462.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.3,72,,218.456,Percent of Total Billed Charges,72% of Total Billed Charges,25.31,75,,218.456,Percent of Total Billed charges,75% of Total Billed Charges,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.3,72,,218.456,Percent of Total Billed Charges,72% of Total Billed Charges,20.25,60,,182.048,Percent of Total Billed Charges,60% of Total Billed Charges,30.38,90,,380.488,Percent of Total Billed Charges,90% of Total Billed Charges,15.19,45,,31.224,Percent of Total Billed Charges,45% of Total Billed Charges,30.38,90,,547.2,Percent of Total Billed Charges,90% of Total billed Charges,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.94,65,,35.232,Percent of total Billed Charges,65% of Total Billed Charges,14.88,44.1,,30.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.06,95,,577.6,Percent of Total Billed Charges,95% of Total Billed Charges,33.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.7,88,,535.04,Percent of Total Billed Charges,88% of Total Billed Charges,30.38,90,,547.2,Percent of Total Billed charges,90% of Total Billed Charges,14.88,33.75,
Brite Tip Radianz 6F 110CM,2720002651,CDM,272,RC,C1887,HCPCS,Outpatient,,,643.12,418.03,,643.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,488.77,76,,321.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,463.05,72,,71.76,Percent of Total Billed Charges,72% of Total Billed Charges,482.34,75,,71.76,Percent of Total Billed charges,75% of Total Billed Charges,643.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,463.05,72,,71.76,Percent of Total Billed Charges,72% of Total Billed Charges,385.87,60,,59.8,Percent of Total Billed Charges,60% of Total Billed Charges,578.81,90,,204.88,Percent of Total Billed Charges,90% of Total Billed Charges,289.4,45,,2.736,Percent of Total Billed Charges,45% of Total Billed Charges,578.81,90,,380.488,Percent of Total Billed Charges,90% of Total billed Charges,643.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,643.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,643.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,418.03,65,,45.096,Percent of total Billed Charges,65% of Total Billed Charges,283.62,44.1,,2.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,610.96,95,,401.624,Percent of Total Billed Charges,95% of Total Billed Charges,643.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,565.95,88,,372.032,Percent of Total Billed Charges,88% of Total Billed Charges,578.81,90,,380.488,Percent of Total Billed charges,90% of Total Billed Charges,283.62,643.12,
Brite Tip Radianz 6F 135CM,2720002652,CDM,272,RC,C1887,HCPCS,Outpatient,,,643.12,418.03,,643.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,488.77,76,,41.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,463.05,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,482.34,75,,41.28,Percent of Total Billed charges,75% of Total Billed Charges,643.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,463.05,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,385.87,60,,34.4,Percent of Total Billed Charges,60% of Total Billed Charges,578.81,90,,2934,Percent of Total Billed Charges,90% of Total Billed Charges,289.4,45,,279,Percent of Total Billed Charges,45% of Total Billed Charges,578.81,90,,48.784,Percent of Total Billed Charges,90% of Total billed Charges,643.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,643.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,643.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,418.03,65,,3.952,Percent of total Billed Charges,65% of Total Billed Charges,283.62,44.1,,273.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,610.96,95,,51.488,Percent of Total Billed Charges,95% of Total Billed Charges,643.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,565.95,88,,47.696,Percent of Total Billed Charges,88% of Total Billed Charges,578.81,90,,48.784,Percent of Total Billed charges,90% of Total Billed Charges,283.62,643.12,
PDS 2-0 Z317H Suture SH,2720002653,CDM,272,RC,,,Outpatient,,,7.22,4.69,,7.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.49,76,,52.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.2,72,,46.992,Percent of Total Billed Charges,72% of Total Billed Charges,5.42,75,,46.992,Percent of Total Billed charges,75% of Total Billed Charges,7.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.2,72,,46.992,Percent of Total Billed Charges,72% of Total Billed Charges,4.33,60,,39.16,Percent of Total Billed Charges,60% of Total Billed Charges,6.5,90,,2934,Percent of Total Billed Charges,90% of Total Billed Charges,3.25,45,,283.504,Percent of Total Billed Charges,45% of Total Billed Charges,6.5,90,,62.448,Percent of Total Billed Charges,90% of Total billed Charges,7.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.69,65,,403,Percent of total Billed Charges,65% of Total Billed Charges,3.18,44.1,,277.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.86,95,,65.912,Percent of Total Billed Charges,95% of Total Billed Charges,7.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,88,,61.056,Percent of Total Billed Charges,88% of Total Billed Charges,6.5,90,,62.448,Percent of Total Billed charges,90% of Total Billed Charges,3.18,7.22,
"Olympus Visiglide Gdwr .035,45",2720002654,CDM,272,RC,,,Outpatient,,,446.25,290.06,,446.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,339.15,76,,4.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,321.3,72,,35.56,Percent of Total Billed Charges,72% of Total Billed Charges,334.69,75,,35.56,Percent of Total Billed charges,75% of Total Billed Charges,446.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,321.3,72,,35.56,Percent of Total Billed Charges,72% of Total Billed Charges,267.75,60,,29.632,Percent of Total Billed Charges,60% of Total Billed Charges,401.63,90,,252.096,Percent of Total Billed Charges,90% of Total Billed Charges,200.81,45,,12.392,Percent of Total Billed Charges,45% of Total Billed Charges,401.63,90,,5.472,Percent of Total Billed Charges,90% of Total billed Charges,446.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290.06,65,,409.504,Percent of total Billed Charges,65% of Total Billed Charges,196.8,44.1,,12.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,423.94,95,,5.776,Percent of Total Billed Charges,95% of Total Billed Charges,446.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.7,88,,5.352,Percent of Total Billed Charges,88% of Total Billed Charges,401.63,90,,5.472,Percent of Total Billed charges,90% of Total Billed Charges,196.8,446.25,
MAILMAN S 0.014 X 182CM,2720002655,CDM,272,RC,C1769,HCPCS,Outpatient,,,212.17,137.91,,212.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.25,76,,471.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,152.76,72,,120.024,Percent of Total Billed Charges,72% of Total Billed Charges,159.13,75,,120.024,Percent of Total Billed charges,75% of Total Billed Charges,212.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.76,72,,120.024,Percent of Total Billed Charges,72% of Total Billed Charges,127.3,60,,100.016,Percent of Total Billed Charges,60% of Total Billed Charges,190.95,90,,75.48,Percent of Total Billed Charges,90% of Total Billed Charges,95.48,45,,9.976,Percent of Total Billed Charges,45% of Total Billed Charges,190.95,90,,558,Percent of Total Billed Charges,90% of Total billed Charges,212.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.91,65,,17.904,Percent of total Billed Charges,65% of Total Billed Charges,93.57,44.1,,9.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,201.56,95,,589,Percent of Total Billed Charges,95% of Total Billed Charges,212.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.71,88,,545.6,Percent of Total Billed Charges,88% of Total Billed Charges,190.95,90,,558,Percent of Total Billed charges,90% of Total Billed Charges,93.57,212.17,
MAILMAN S 0.014 X 300CM,2720002656,CDM,272,RC,C1769,HCPCS,Outpatient,,,212.17,137.91,,212.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.25,76,,478.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,152.76,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,159.13,75,,66.68,Percent of Total Billed charges,75% of Total Billed Charges,212.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.76,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,127.3,60,,55.568,Percent of Total Billed Charges,60% of Total Billed Charges,190.95,90,,248.744,Percent of Total Billed Charges,90% of Total Billed Charges,95.48,45,,404.872,Percent of Total Billed Charges,45% of Total Billed Charges,190.95,90,,567,Percent of Total Billed Charges,90% of Total billed Charges,212.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.91,65,,14.408,Percent of total Billed Charges,65% of Total Billed Charges,93.57,44.1,,396.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,201.56,95,,598.504,Percent of Total Billed Charges,95% of Total Billed Charges,212.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.71,88,,554.4,Percent of Total Billed Charges,88% of Total Billed Charges,190.95,90,,567,Percent of Total Billed charges,90% of Total Billed Charges,93.57,212.17,
Cath Foley 20FR 10cc 2,2720002657,CDM,272,RC,,,Outpatient,,,5.40,3.51,,5.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.1,76,,20.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.89,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,4.05,75,,109.864,Percent of Total Billed charges,75% of Total Billed Charges,5.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.89,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,3.24,60,,91.552,Percent of Total Billed Charges,60% of Total Billed Charges,4.86,90,,75.48,Percent of Total Billed Charges,90% of Total Billed Charges,2.43,45,,190.24,Percent of Total Billed Charges,45% of Total Billed Charges,4.86,90,,24.792,Percent of Total Billed Charges,90% of Total billed Charges,5.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.51,65,,584.816,Percent of total Billed Charges,65% of Total Billed Charges,2.38,44.1,,186.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.13,95,,26.168,Percent of Total Billed Charges,95% of Total Billed Charges,5.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.75,88,,24.24,Percent of Total Billed Charges,88% of Total Billed Charges,4.86,90,,24.792,Percent of Total Billed charges,90% of Total Billed Charges,2.38,5.4,
Osten-Site Bone Biopsy NDL Set,2720002658,CDM,272,RC,,,Outpatient,,,274.10,178.17,,274.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,208.32,76,,16.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,197.35,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,205.58,75,,70.488,Percent of Total Billed charges,75% of Total Billed Charges,274.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.35,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,164.46,60,,58.744,Percent of Total Billed Charges,60% of Total Billed Charges,246.69,90,,60.464,Percent of Total Billed Charges,90% of Total Billed Charges,123.35,45,,102.44,Percent of Total Billed Charges,45% of Total Billed Charges,246.69,90,,19.944,Percent of Total Billed Charges,90% of Total billed Charges,274.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.17,65,,274.792,Percent of total Billed Charges,65% of Total Billed Charges,120.88,44.1,,100.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,260.4,95,,21.056,Percent of Total Billed Charges,95% of Total Billed Charges,274.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.21,88,,19.504,Percent of Total Billed Charges,88% of Total Billed Charges,246.69,90,,19.944,Percent of Total Billed charges,90% of Total Billed Charges,120.88,274.1,
Olymp Retatbl Rat tth grsp 2.8,2720002659,CDM,272,RC,,,Outpatient,,,512.50,333.13,,512.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,389.5,76,,683.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,369,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,384.38,75,,91.448,Percent of Total Billed charges,75% of Total Billed Charges,512.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,307.5,60,,76.208,Percent of Total Billed Charges,60% of Total Billed Charges,461.25,90,,198.128,Percent of Total Billed Charges,90% of Total Billed Charges,230.63,45,,1467,Percent of Total Billed Charges,45% of Total Billed Charges,461.25,90,,809.752,Percent of Total Billed Charges,90% of Total billed Charges,512.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,512.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,512.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.13,65,,147.968,Percent of total Billed Charges,65% of Total Billed Charges,226.01,44.1,,1437.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,486.88,95,,854.736,Percent of Total Billed Charges,95% of Total Billed Charges,512.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,451,88,,791.752,Percent of Total Billed Charges,88% of Total Billed Charges,461.25,90,,809.752,Percent of Total Billed charges,90% of Total Billed Charges,226.01,512.5,
ZEPHYR LG RADIAL BAND,2720002660,CDM,272,RC,,,Outpatient,,,22.00,14.30,,22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.72,76,,321.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.84,72,,76.208,Percent of Total Billed Charges,72% of Total Billed Charges,16.5,75,,76.208,Percent of Total Billed charges,75% of Total Billed Charges,22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.84,72,,76.208,Percent of Total Billed Charges,72% of Total Billed Charges,13.2,60,,63.504,Percent of Total Billed Charges,60% of Total Billed Charges,19.8,90,,6.984,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,45,,1467,Percent of Total Billed Charges,45% of Total Billed Charges,19.8,90,,380.488,Percent of Total Billed Charges,90% of Total billed Charges,22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.3,65,,2119,Percent of total Billed Charges,65% of Total Billed Charges,9.7,44.1,,1437.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.9,95,,401.624,Percent of Total Billed Charges,95% of Total Billed Charges,22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.36,88,,372.032,Percent of Total Billed Charges,88% of Total Billed Charges,19.8,90,,380.488,Percent of Total Billed charges,90% of Total Billed Charges,9.7,22,
RAIN NITINOL R-SH 5F 10CM,2720002661,CDM,272,RC,C1894,HCPCS,Outpatient,,,137.50,89.38,,137.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,104.5,76,,173.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,99,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,103.13,75,,90.816,Percent of Total Billed charges,75% of Total Billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,82.5,60,,75.68,Percent of Total Billed Charges,60% of Total Billed Charges,123.75,90,,11.472,Percent of Total Billed Charges,90% of Total Billed Charges,61.88,45,,126.048,Percent of Total Billed Charges,45% of Total Billed Charges,123.75,90,,204.88,Percent of Total Billed Charges,90% of Total billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.38,65,,2119,Percent of total Billed Charges,65% of Total Billed Charges,60.64,44.1,,123.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,130.63,95,,216.256,Percent of Total Billed Charges,95% of Total Billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121,88,,200.32,Percent of Total Billed Charges,88% of Total Billed Charges,123.75,90,,204.88,Percent of Total Billed charges,90% of Total Billed Charges,60.64,137.5,
RAIN ANGIOCATH R-SH 5F 10CM,2720002662,CDM,272,RC,C1894,HCPCS,Outpatient,,,145.00,94.25,,145,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.2,76,,2477.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,104.4,72,,73.032,Percent of Total Billed Charges,72% of Total Billed Charges,108.75,75,,73.032,Percent of Total Billed charges,75% of Total Billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.4,72,,73.032,Percent of Total Billed Charges,72% of Total Billed Charges,87,60,,60.856,Percent of Total Billed Charges,60% of Total Billed Charges,130.5,90,,5.152,Percent of Total Billed Charges,90% of Total Billed Charges,65.25,45,,37.736,Percent of Total Billed Charges,45% of Total Billed Charges,130.5,90,,2934,Percent of Total Billed Charges,90% of Total billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.25,65,,182.064,Percent of total Billed Charges,65% of Total Billed Charges,63.95,44.1,,36.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,137.75,95,,3097,Percent of Total Billed Charges,95% of Total Billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.6,88,,2868.8,Percent of Total Billed Charges,88% of Total Billed Charges,130.5,90,,2934,Percent of Total Billed charges,90% of Total Billed Charges,63.95,145,
RAIN NITINOL R-SH 6F 10CM,2720002663,CDM,272,RC,C1894,HCPCS,Outpatient,,,137.50,89.38,,137.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,104.5,76,,2477.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,99,72,,106.056,Percent of Total Billed Charges,72% of Total Billed Charges,103.13,75,,106.056,Percent of Total Billed charges,75% of Total Billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,72,,106.056,Percent of Total Billed Charges,72% of Total Billed Charges,82.5,60,,88.376,Percent of Total Billed Charges,60% of Total Billed Charges,123.75,90,,341.464,Percent of Total Billed Charges,90% of Total Billed Charges,61.88,45,,124.376,Percent of Total Billed Charges,45% of Total Billed Charges,123.75,90,,2934,Percent of Total Billed Charges,90% of Total billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.38,65,,54.512,Percent of total Billed Charges,65% of Total Billed Charges,60.64,44.1,,121.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,130.63,95,,3097,Percent of Total Billed Charges,95% of Total Billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121,88,,2868.8,Percent of Total Billed Charges,88% of Total Billed Charges,123.75,90,,2934,Percent of Total Billed charges,90% of Total Billed Charges,60.64,137.5,
RAIN ANGIOCATH R-SH 6F 10CM,2720002664,CDM,272,RC,C1894,HCPCS,Outpatient,,,145.00,94.25,,145,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.2,76,,212.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,104.4,72,,106.056,Percent of Total Billed Charges,72% of Total Billed Charges,108.75,75,,106.056,Percent of Total Billed charges,75% of Total Billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.4,72,,106.056,Percent of Total Billed Charges,72% of Total Billed Charges,87,60,,88.376,Percent of Total Billed Charges,60% of Total Billed Charges,130.5,90,,87.808,Percent of Total Billed Charges,90% of Total Billed Charges,65.25,45,,37.736,Percent of Total Billed Charges,45% of Total Billed Charges,130.5,90,,252.096,Percent of Total Billed Charges,90% of Total billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.25,65,,179.648,Percent of total Billed Charges,65% of Total Billed Charges,63.95,44.1,,36.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,137.75,95,,266.096,Percent of Total Billed Charges,95% of Total Billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.6,88,,246.488,Percent of Total Billed Charges,88% of Total Billed Charges,130.5,90,,252.096,Percent of Total Billed charges,90% of Total Billed Charges,63.95,145,
RAIN NITINOL R-SH 6F 16CM,2720002665,CDM,272,RC,C1894,HCPCS,Outpatient,,,137.50,89.38,,137.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,104.5,76,,63.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,99,72,,106.056,Percent of Total Billed Charges,72% of Total Billed Charges,103.13,75,,106.056,Percent of Total Billed charges,75% of Total Billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,72,,106.056,Percent of Total Billed Charges,72% of Total Billed Charges,82.5,60,,88.376,Percent of Total Billed Charges,60% of Total Billed Charges,123.75,90,,458.536,Percent of Total Billed Charges,90% of Total Billed Charges,61.88,45,,30.232,Percent of Total Billed Charges,45% of Total Billed Charges,123.75,90,,75.48,Percent of Total Billed Charges,90% of Total billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.38,65,,54.512,Percent of total Billed Charges,65% of Total Billed Charges,60.64,44.1,,29.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,130.63,95,,79.672,Percent of Total Billed Charges,95% of Total Billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121,88,,73.8,Percent of Total Billed Charges,88% of Total Billed Charges,123.75,90,,75.48,Percent of Total Billed charges,90% of Total Billed Charges,60.64,137.5,
RAIN ANGIOCATH R-SH 6F 16CM,2720002666,CDM,272,RC,C1894,HCPCS,Outpatient,,,145.00,94.25,,145,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.2,76,,210.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,104.4,72,,106.056,Percent of Total Billed Charges,72% of Total Billed Charges,108.75,75,,106.056,Percent of Total Billed charges,75% of Total Billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.4,72,,106.056,Percent of Total Billed Charges,72% of Total Billed Charges,87,60,,88.376,Percent of Total Billed Charges,60% of Total Billed Charges,130.5,90,,388.296,Percent of Total Billed Charges,90% of Total Billed Charges,65.25,45,,99.064,Percent of Total Billed Charges,45% of Total Billed Charges,130.5,90,,248.744,Percent of Total Billed Charges,90% of Total billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.25,65,,43.672,Percent of total Billed Charges,65% of Total Billed Charges,63.95,44.1,,97.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,137.75,95,,262.568,Percent of Total Billed Charges,95% of Total Billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.6,88,,243.216,Percent of Total Billed Charges,88% of Total Billed Charges,130.5,90,,248.744,Percent of Total Billed charges,90% of Total Billed Charges,63.95,145,
RAIN NITINOL R-SH 7F 10CM,2720002667,CDM,272,RC,C1894,HCPCS,Outpatient,,,137.50,89.38,,137.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,104.5,76,,63.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,99,72,,106.056,Percent of Total Billed Charges,72% of Total Billed Charges,103.13,75,,106.056,Percent of Total Billed charges,75% of Total Billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,72,,106.056,Percent of Total Billed Charges,72% of Total Billed Charges,82.5,60,,88.376,Percent of Total Billed Charges,60% of Total Billed Charges,123.75,90,,197.064,Percent of Total Billed Charges,90% of Total Billed Charges,61.88,45,,3.496,Percent of Total Billed Charges,45% of Total Billed Charges,123.75,90,,75.48,Percent of Total Billed Charges,90% of Total billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.38,65,,143.096,Percent of total Billed Charges,65% of Total Billed Charges,60.64,44.1,,3.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,130.63,95,,79.672,Percent of Total Billed Charges,95% of Total Billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121,88,,73.8,Percent of Total Billed Charges,88% of Total Billed Charges,123.75,90,,75.48,Percent of Total Billed charges,90% of Total Billed Charges,60.64,137.5,
RAIN ANGIOCATH R-SH 7F 10CM,2720002668,CDM,272,RC,C1894,HCPCS,Outpatient,,,145.00,94.25,,145,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.2,76,,51.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,104.4,72,,106.056,Percent of Total Billed Charges,72% of Total Billed Charges,108.75,75,,106.056,Percent of Total Billed charges,75% of Total Billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.4,72,,106.056,Percent of Total Billed Charges,72% of Total Billed Charges,87,60,,88.376,Percent of Total Billed Charges,60% of Total Billed Charges,130.5,90,,115.128,Percent of Total Billed Charges,90% of Total Billed Charges,65.25,45,,5.736,Percent of Total Billed Charges,45% of Total Billed Charges,130.5,90,,60.464,Percent of Total Billed Charges,90% of Total billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.25,65,,5.048,Percent of total Billed Charges,65% of Total Billed Charges,63.95,44.1,,5.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,137.75,95,,63.824,Percent of Total Billed Charges,95% of Total Billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.6,88,,59.12,Percent of Total Billed Charges,88% of Total Billed Charges,130.5,90,,60.464,Percent of Total Billed charges,90% of Total Billed Charges,63.95,145,
RAIN NITINOL R-SH 7F 16CM,2720002669,CDM,272,RC,C1894,HCPCS,Outpatient,,,137.50,89.38,,137.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,104.5,76,,167.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,99,72,,106.056,Percent of Total Billed Charges,72% of Total Billed Charges,103.13,75,,106.056,Percent of Total Billed charges,75% of Total Billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,72,,106.056,Percent of Total Billed Charges,72% of Total Billed Charges,82.5,60,,88.376,Percent of Total Billed Charges,60% of Total Billed Charges,123.75,90,,197.064,Percent of Total Billed Charges,90% of Total Billed Charges,61.88,45,,2.576,Percent of Total Billed Charges,45% of Total Billed Charges,123.75,90,,198.128,Percent of Total Billed Charges,90% of Total billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.38,65,,8.28,Percent of total Billed Charges,65% of Total Billed Charges,60.64,44.1,,2.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,130.63,95,,209.136,Percent of Total Billed Charges,95% of Total Billed Charges,137.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121,88,,193.728,Percent of Total Billed Charges,88% of Total Billed Charges,123.75,90,,198.128,Percent of Total Billed charges,90% of Total Billed Charges,60.64,137.5,
RAIN ANGIOCATH R-SH 7F 16CM,2720002670,CDM,272,RC,C1894,HCPCS,Outpatient,,,145.00,94.25,,145,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.2,76,,5.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,104.4,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,108.75,75,,32.832,Percent of Total Billed charges,75% of Total Billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.4,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,87,60,,27.36,Percent of Total Billed Charges,60% of Total Billed Charges,130.5,90,,119.016,Percent of Total Billed Charges,90% of Total Billed Charges,65.25,45,,170.728,Percent of Total Billed Charges,45% of Total Billed Charges,130.5,90,,6.984,Percent of Total Billed Charges,90% of Total billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.25,65,,3.72,Percent of total Billed Charges,65% of Total Billed Charges,63.95,44.1,,167.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,137.75,95,,7.376,Percent of Total Billed Charges,95% of Total Billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.6,88,,6.832,Percent of Total Billed Charges,88% of Total Billed Charges,130.5,90,,6.984,Percent of Total Billed charges,90% of Total Billed Charges,63.95,145,
Quikelot Combat Gauze,2720002671,CDM,272,RC,,,Outpatient,,,156.20,101.53,,156.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,118.71,76,,9.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,112.46,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,117.15,75,,32.832,Percent of Total Billed charges,75% of Total Billed Charges,156.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.46,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,93.72,60,,27.36,Percent of Total Billed Charges,60% of Total Billed Charges,140.58,90,,78.048,Percent of Total Billed Charges,90% of Total Billed Charges,70.29,45,,43.904,Percent of Total Billed Charges,45% of Total Billed Charges,140.58,90,,11.472,Percent of Total Billed Charges,90% of Total billed Charges,156.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.53,65,,246.608,Percent of total Billed Charges,65% of Total Billed Charges,68.88,44.1,,43.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,148.39,95,,12.104,Percent of Total Billed Charges,95% of Total Billed Charges,156.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.46,88,,11.216,Percent of Total Billed Charges,88% of Total Billed Charges,140.58,90,,11.472,Percent of Total Billed charges,90% of Total Billed Charges,68.88,156.2,
Quikelot Combat Dressing,2720002672,CDM,272,RC,,,Outpatient,,,198.82,129.23,,198.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,151.1,76,,4.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,143.15,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,149.12,75,,32.832,Percent of Total Billed charges,75% of Total Billed Charges,198.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.15,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,119.29,60,,27.36,Percent of Total Billed Charges,60% of Total Billed Charges,178.94,90,,282.928,Percent of Total Billed Charges,90% of Total Billed Charges,89.47,45,,229.264,Percent of Total Billed Charges,45% of Total Billed Charges,178.94,90,,5.152,Percent of Total Billed Charges,90% of Total billed Charges,198.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.23,65,,63.416,Percent of total Billed Charges,65% of Total Billed Charges,87.68,44.1,,224.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,188.88,95,,5.432,Percent of Total Billed Charges,95% of Total Billed Charges,198.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.96,88,,5.032,Percent of Total Billed Charges,88% of Total Billed Charges,178.94,90,,5.152,Percent of Total Billed charges,90% of Total Billed Charges,87.68,198.82,
EMBOSPHERE 50-100 20ML SYRNGE,2720002673,CDM,272,RC,C1889,HCPCS,Outpatient,,,687.50,446.88,,687.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,522.5,76,,288.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,495,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,515.63,75,,32.832,Percent of Total Billed charges,75% of Total Billed Charges,687.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,412.5,60,,27.36,Percent of Total Billed Charges,60% of Total Billed Charges,618.75,90,,197.064,Percent of Total Billed Charges,90% of Total Billed Charges,309.38,45,,194.152,Percent of Total Billed Charges,45% of Total Billed Charges,618.75,90,,341.464,Percent of Total Billed Charges,90% of Total billed Charges,687.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,687.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,687.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,65,,331.16,Percent of total Billed Charges,65% of Total Billed Charges,303.19,44.1,,190.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,653.13,95,,360.432,Percent of Total Billed Charges,95% of Total Billed Charges,687.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,605,88,,333.872,Percent of Total Billed Charges,88% of Total Billed Charges,618.75,90,,341.464,Percent of Total Billed charges,90% of Total Billed Charges,303.19,687.5,
EMBOSPHERE 100-300 20ML SYRNGE,2720002674,CDM,272,RC,C1889,HCPCS,Outpatient,,,592.50,385.13,,592.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,450.3,76,,74.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,426.6,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,444.38,75,,32.832,Percent of Total Billed charges,75% of Total Billed Charges,592.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.6,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,355.5,60,,27.36,Percent of Total Billed Charges,60% of Total Billed Charges,533.25,90,,128.776,Percent of Total Billed Charges,90% of Total Billed Charges,266.63,45,,98.536,Percent of Total Billed Charges,45% of Total Billed Charges,533.25,90,,87.808,Percent of Total Billed Charges,90% of Total billed Charges,592.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.13,65,,280.44,Percent of total Billed Charges,65% of Total Billed Charges,261.29,44.1,,96.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,562.88,95,,92.68,Percent of Total Billed Charges,95% of Total Billed Charges,592.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521.4,88,,85.856,Percent of Total Billed Charges,88% of Total Billed Charges,533.25,90,,87.808,Percent of Total Billed charges,90% of Total Billed Charges,261.29,592.5,
BVI Custom Eye Pack,2720002675,CDM,272,RC,,,Outpatient,,,84.23,54.75,,84.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,64.01,76,,387.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,60.65,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,63.17,75,,32.832,Percent of Total Billed charges,75% of Total Billed Charges,84.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.65,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,50.54,60,,27.36,Percent of Total Billed Charges,60% of Total Billed Charges,75.81,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,37.9,45,,57.568,Percent of Total Billed Charges,45% of Total Billed Charges,75.81,90,,458.536,Percent of Total Billed Charges,90% of Total billed Charges,84.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.75,65,,142.328,Percent of total Billed Charges,65% of Total Billed Charges,37.15,44.1,,56.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,80.02,95,,484.008,Percent of Total Billed Charges,95% of Total Billed Charges,84.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.12,88,,448.344,Percent of Total Billed Charges,88% of Total Billed Charges,75.81,90,,458.536,Percent of Total Billed charges,90% of Total Billed Charges,37.15,84.23,
Clean Disp Bulb&Bladdr Assmbly,2720002676,CDM,272,RC,,,Outpatient,,,80.30,52.20,,80.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,61.03,76,,327.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.82,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,60.23,75,,32.832,Percent of Total Billed charges,75% of Total Billed Charges,80.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.82,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,48.18,60,,27.36,Percent of Total Billed Charges,60% of Total Billed Charges,72.27,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,36.14,45,,98.536,Percent of Total Billed Charges,45% of Total Billed Charges,72.27,90,,388.296,Percent of Total Billed Charges,90% of Total billed Charges,80.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.2,65,,83.152,Percent of total Billed Charges,65% of Total Billed Charges,35.41,44.1,,96.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,76.29,95,,409.872,Percent of Total Billed Charges,95% of Total Billed Charges,80.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.66,88,,379.664,Percent of Total Billed Charges,88% of Total Billed Charges,72.27,90,,388.296,Percent of Total Billed charges,90% of Total Billed Charges,35.41,80.3,
INPACT AV 7F 9MM X 60MM X 80CM,2720002677,CDM,272,RC,C2623,HCPCS,Outpatient,,,4075.00,2648.75,,4075,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3097,76,,166.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2934,72,,4302.4,Percent of Total Billed Charges,72% of Total Billed Charges,3056.25,75,,4302.4,Percent of Total Billed charges,75% of Total Billed Charges,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2934,72,,4302.4,Percent of Total Billed Charges,72% of Total Billed Charges,2445,60,,3585.328,Percent of Total Billed Charges,60% of Total Billed Charges,3667.5,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,1833.75,45,,59.512,Percent of Total Billed Charges,45% of Total Billed Charges,3667.5,90,,197.064,Percent of Total Billed Charges,90% of Total billed Charges,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2648.75,65,,142.328,Percent of total Billed Charges,65% of Total Billed Charges,1797.08,44.1,,58.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,3871.25,95,,208.016,Percent of Total Billed Charges,95% of Total Billed Charges,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3586,88,,192.688,Percent of Total Billed Charges,88% of Total Billed Charges,3667.5,90,,197.064,Percent of Total Billed charges,90% of Total Billed Charges,1797.08,4075,
INPACT AV 7F 10MM X 40MM X 80C,2720002678,CDM,272,RC,C2623,HCPCS,Outpatient,,,4075.00,2648.75,,4075,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3097,76,,97.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2934,72,,114.944,Percent of Total Billed Charges,72% of Total Billed Charges,3056.25,75,,114.944,Percent of Total Billed charges,75% of Total Billed Charges,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2934,72,,114.944,Percent of Total Billed Charges,72% of Total Billed Charges,2445,60,,95.784,Percent of Total Billed Charges,60% of Total Billed Charges,3667.5,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,1833.75,45,,39.024,Percent of Total Billed Charges,45% of Total Billed Charges,3667.5,90,,115.128,Percent of Total Billed Charges,90% of Total billed Charges,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2648.75,65,,85.96,Percent of total Billed Charges,65% of Total Billed Charges,1797.08,44.1,,38.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,3871.25,95,,121.528,Percent of Total Billed Charges,95% of Total Billed Charges,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3586,88,,112.568,Percent of Total Billed Charges,88% of Total Billed Charges,3667.5,90,,115.128,Percent of Total Billed charges,90% of Total Billed Charges,1797.08,4075,
"VLOC 90SZ2-0,9"" VLOCM2145",2720002679,CDM,272,RC,,,Outpatient,,,80.12,52.08,,80.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60.89,76,,166.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.69,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,60.09,75,,41.912,Percent of Total Billed charges,75% of Total Billed Charges,80.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.69,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,48.07,60,,34.928,Percent of Total Billed Charges,60% of Total Billed Charges,72.11,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,36.05,45,,141.464,Percent of Total Billed Charges,45% of Total Billed Charges,72.11,90,,197.064,Percent of Total Billed Charges,90% of Total billed Charges,80.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.08,65,,56.368,Percent of total Billed Charges,65% of Total Billed Charges,35.33,44.1,,138.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,76.11,95,,208.016,Percent of Total Billed Charges,95% of Total Billed Charges,80.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.51,88,,192.688,Percent of Total Billed Charges,88% of Total Billed Charges,72.11,90,,197.064,Percent of Total Billed charges,90% of Total Billed Charges,35.33,80.12,
Needle Decompression Kit,2720002680,CDM,272,RC,,,Outpatient,,,129.37,84.09,,129.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.32,76,,100.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,93.15,72,,685.208,Percent of Total Billed Charges,72% of Total Billed Charges,97.03,75,,685.208,Percent of Total Billed charges,75% of Total Billed Charges,129.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.15,72,,685.208,Percent of Total Billed Charges,72% of Total Billed Charges,77.62,60,,571.008,Percent of Total Billed Charges,60% of Total Billed Charges,116.43,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,58.22,45,,98.536,Percent of Total Billed Charges,45% of Total Billed Charges,116.43,90,,119.016,Percent of Total Billed Charges,90% of Total billed Charges,129.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.09,65,,204.336,Percent of total Billed Charges,65% of Total Billed Charges,57.05,44.1,,96.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,122.9,95,,125.632,Percent of Total Billed Charges,95% of Total Billed Charges,129.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.85,88,,116.368,Percent of Total Billed Charges,88% of Total Billed Charges,116.43,90,,119.016,Percent of Total Billed charges,90% of Total Billed Charges,57.05,129.37,
Pneumothorax Kit,2720002681,CDM,272,RC,,,Outpatient,,,470.45,305.79,,470.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,357.54,76,,65.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,338.72,72,,685.208,Percent of Total Billed Charges,72% of Total Billed Charges,352.84,75,,685.208,Percent of Total Billed charges,75% of Total Billed Charges,470.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,338.72,72,,685.208,Percent of Total Billed Charges,72% of Total Billed Charges,282.27,60,,571.008,Percent of Total Billed Charges,60% of Total Billed Charges,423.41,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,211.7,45,,64.384,Percent of Total Billed Charges,45% of Total Billed Charges,423.41,90,,78.048,Percent of Total Billed Charges,90% of Total billed Charges,470.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,470.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,470.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305.79,65,,142.328,Percent of total Billed Charges,65% of Total Billed Charges,207.47,44.1,,63.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,446.93,95,,82.384,Percent of Total Billed Charges,95% of Total Billed Charges,470.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414,88,,76.312,Percent of Total Billed Charges,88% of Total Billed Charges,423.41,90,,78.048,Percent of Total Billed charges,90% of Total Billed Charges,207.47,470.45,
G57716 Cook Blue Rhino KT,2720002682,CDM,272,RC,,,Outpatient,,,1330.00,864.50,,1330,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1010.8,76,,238.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,957.6,72,,475.008,Percent of Total Billed Charges,72% of Total Billed Charges,997.5,75,,475.008,Percent of Total Billed charges,75% of Total Billed Charges,1330,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,957.6,72,,475.008,Percent of Total Billed Charges,72% of Total Billed Charges,798,60,,395.84,Percent of Total Billed Charges,60% of Total Billed Charges,1197,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,598.5,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,1197,90,,282.928,Percent of Total Billed Charges,90% of Total billed Charges,1330,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1330,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1330,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,864.5,65,,93,Percent of total Billed Charges,65% of Total Billed Charges,586.53,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,1263.5,95,,298.64,Percent of Total Billed Charges,95% of Total Billed Charges,1330,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170.4,88,,276.64,Percent of Total Billed Charges,88% of Total Billed Charges,1197,90,,282.928,Percent of Total Billed charges,90% of Total Billed Charges,586.53,1330,
Microline Dolphin Nose Dis,2720002683,CDM,272,RC,,,Outpatient,,,152.95,99.42,,152.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,116.24,76,,166.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,110.12,72,,360.704,Percent of Total Billed Charges,72% of Total Billed Charges,114.71,75,,360.704,Percent of Total Billed charges,75% of Total Billed Charges,152.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.12,72,,360.704,Percent of Total Billed Charges,72% of Total Billed Charges,91.77,60,,300.584,Percent of Total Billed Charges,60% of Total Billed Charges,137.66,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,68.83,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,137.66,90,,197.064,Percent of Total Billed Charges,90% of Total billed Charges,152.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.42,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,67.45,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,145.3,95,,208.016,Percent of Total Billed Charges,95% of Total Billed Charges,152.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.6,88,,192.688,Percent of Total Billed Charges,88% of Total Billed Charges,137.66,90,,197.064,Percent of Total Billed charges,90% of Total Billed Charges,67.45,152.95,
"Gelpoint Mini Access, CNGL3",2720002684,CDM,272,RC,,,Outpatient,,,1875.00,1218.75,,1875,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1425,76,,108.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1350,72,,341.656,Percent of Total Billed Charges,72% of Total Billed Charges,1406.25,75,,341.656,Percent of Total Billed charges,75% of Total Billed Charges,1875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1350,72,,341.656,Percent of Total Billed Charges,72% of Total Billed Charges,1125,60,,284.712,Percent of Total Billed Charges,60% of Total Billed Charges,1687.5,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,843.75,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,1687.5,90,,128.776,Percent of Total Billed Charges,90% of Total billed Charges,1875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1218.75,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,826.88,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,1781.25,95,,135.928,Percent of Total Billed Charges,95% of Total Billed Charges,1875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1650,88,,125.912,Percent of Total Billed Charges,88% of Total Billed Charges,1687.5,90,,128.776,Percent of Total Billed charges,90% of Total Billed Charges,826.88,1875,
LF4418 Ligasure Impact,2720002685,CDM,272,RC,,,Outpatient,,,2785.32,1810.46,,2785.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2116.84,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2005.43,72,,360.704,Percent of Total Billed Charges,72% of Total Billed Charges,2088.99,75,,360.704,Percent of Total Billed charges,75% of Total Billed Charges,2785.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2005.43,72,,360.704,Percent of Total Billed Charges,72% of Total Billed Charges,1671.19,60,,300.584,Percent of Total Billed Charges,60% of Total Billed Charges,2506.79,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,1253.39,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,2506.79,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,2785.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2785.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2785.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1810.46,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,1228.33,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,2646.05,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,2785.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2451.08,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,2506.79,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,1228.33,2785.32,
LF1937 LAP Sealer/Divider 37cm,2720002686,CDM,272,RC,,,Outpatient,,,2136.12,1388.48,,2136.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1623.45,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1538.01,72,,341.656,Percent of Total Billed Charges,72% of Total Billed Charges,1602.09,75,,341.656,Percent of Total Billed charges,75% of Total Billed Charges,2136.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1538.01,72,,341.656,Percent of Total Billed Charges,72% of Total Billed Charges,1281.67,60,,284.712,Percent of Total Billed Charges,60% of Total Billed Charges,1922.51,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,961.25,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,1922.51,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,2136.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2136.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2136.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1388.48,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,942.03,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,2029.31,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,2136.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1879.79,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,1922.51,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,942.03,2136.12,
GUIDELINER COAST 6F,2720002687,CDM,272,RC,C1887,HCPCS,Outpatient,,,1312.50,853.13,,1312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,997.5,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,945,72,,341.656,Percent of Total Billed Charges,72% of Total Billed Charges,984.38,75,,341.656,Percent of Total Billed charges,75% of Total Billed Charges,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,945,72,,341.656,Percent of Total Billed Charges,72% of Total Billed Charges,787.5,60,,284.712,Percent of Total Billed Charges,60% of Total Billed Charges,1181.25,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,590.63,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,1181.25,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,853.13,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,578.81,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,1246.88,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1155,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,1181.25,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,578.81,1312.5,
AVANTI 4F 11CM SHEATH,2720002688,CDM,272,RC,C1894,HCPCS,Outpatient,,,18.50,12.03,,18.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.06,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.32,72,,360.704,Percent of Total Billed Charges,72% of Total Billed Charges,13.88,75,,360.704,Percent of Total Billed charges,75% of Total Billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.32,72,,360.704,Percent of Total Billed Charges,72% of Total Billed Charges,11.1,60,,300.584,Percent of Total Billed Charges,60% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,8.33,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.03,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,8.16,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.58,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.28,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,8.16,18.5,
AVANTI 4F 23CM SHEATH,2720002689,CDM,272,RC,C1894,HCPCS,Outpatient,,,40.00,26.00,,40,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,30.4,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.8,72,,341.656,Percent of Total Billed Charges,72% of Total Billed Charges,30,75,,341.656,Percent of Total Billed charges,75% of Total Billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.8,72,,341.656,Percent of Total Billed Charges,72% of Total Billed Charges,24,60,,284.712,Percent of Total Billed Charges,60% of Total Billed Charges,36,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,18,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,36,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,17.64,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,38,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.2,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,36,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,17.64,40,
AVANTI 5F 11CM SHEATH,2720002690,CDM,272,RC,C1894,HCPCS,Outpatient,,,18.50,12.03,,18.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.06,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.32,72,,360.704,Percent of Total Billed Charges,72% of Total Billed Charges,13.88,75,,360.704,Percent of Total Billed charges,75% of Total Billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.32,72,,360.704,Percent of Total Billed Charges,72% of Total Billed Charges,11.1,60,,300.584,Percent of Total Billed Charges,60% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,8.33,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.03,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,8.16,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.58,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.28,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,8.16,18.5,
AVANTI 5F 23CM SHEATH,2720002691,CDM,272,RC,C1894,HCPCS,Outpatient,,,40.00,26.00,,40,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,30.4,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.8,72,,532.8,Percent of Total Billed Charges,72% of Total Billed Charges,30,75,,532.8,Percent of Total Billed charges,75% of Total Billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.8,72,,532.8,Percent of Total Billed Charges,72% of Total Billed Charges,24,60,,444,Percent of Total Billed Charges,60% of Total Billed Charges,36,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,18,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,36,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,17.64,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,38,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.2,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,36,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,17.64,40,
AVANTI 6F 11CM SHEATH,2720002692,CDM,272,RC,C1894,HCPCS,Outpatient,,,18.50,12.03,,18.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.06,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.32,72,,532.8,Percent of Total Billed Charges,72% of Total Billed Charges,13.88,75,,532.8,Percent of Total Billed charges,75% of Total Billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.32,72,,532.8,Percent of Total Billed Charges,72% of Total Billed Charges,11.1,60,,444,Percent of Total Billed Charges,60% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,8.33,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.03,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,8.16,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.58,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.28,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,8.16,18.5,
AVANTI 6F 23CM SHEATH,2720002693,CDM,272,RC,C1894,HCPCS,Outpatient,,,40.00,26.00,,40,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,30.4,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.8,72,,507.4,Percent of Total Billed Charges,72% of Total Billed Charges,30,75,,507.4,Percent of Total Billed charges,75% of Total Billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.8,72,,507.4,Percent of Total Billed Charges,72% of Total Billed Charges,24,60,,422.832,Percent of Total Billed Charges,60% of Total Billed Charges,36,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,18,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,36,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,17.64,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,38,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.2,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,36,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,17.64,40,
AVANTI 7F 11CM SHEATH,2720002694,CDM,272,RC,C1894,HCPCS,Outpatient,,,18.50,12.03,,18.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.06,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.32,72,,532.8,Percent of Total Billed Charges,72% of Total Billed Charges,13.88,75,,532.8,Percent of Total Billed charges,75% of Total Billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.32,72,,532.8,Percent of Total Billed Charges,72% of Total Billed Charges,11.1,60,,444,Percent of Total Billed Charges,60% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,8.33,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.03,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,8.16,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.58,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.28,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,8.16,18.5,
AVANTI 7F 23CM SHEATH,2720002695,CDM,272,RC,C1894,HCPCS,Outpatient,,,40.00,26.00,,40,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,30.4,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.8,72,,748.712,Percent of Total Billed Charges,72% of Total Billed Charges,30,75,,748.712,Percent of Total Billed charges,75% of Total Billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.8,72,,748.712,Percent of Total Billed Charges,72% of Total Billed Charges,24,60,,623.928,Percent of Total Billed Charges,60% of Total Billed Charges,36,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,18,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,36,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,17.64,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,38,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.2,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,36,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,17.64,40,
AVANTI 8F 11CM SHEATH,2720002696,CDM,272,RC,C1894,HCPCS,Outpatient,,,18.50,12.03,,18.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.06,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.32,72,,3706.096,Percent of Total Billed Charges,72% of Total Billed Charges,13.88,75,,3706.096,Percent of Total Billed charges,75% of Total Billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.32,72,,3706.096,Percent of Total Billed Charges,72% of Total Billed Charges,11.1,60,,3088.408,Percent of Total Billed Charges,60% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,8.33,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.03,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,8.16,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.58,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.28,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,8.16,18.5,
AVANTI 8F 23CM SHEATH,2720002697,CDM,272,RC,C1894,HCPCS,Outpatient,,,40.00,26.00,,40,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,30.4,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.8,72,,532.8,Percent of Total Billed Charges,72% of Total Billed Charges,30,75,,532.8,Percent of Total Billed charges,75% of Total Billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.8,72,,532.8,Percent of Total Billed Charges,72% of Total Billed Charges,24,60,,444,Percent of Total Billed Charges,60% of Total Billed Charges,36,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,18,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,36,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,17.64,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,38,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.2,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,36,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,17.64,40,
AVANTI 9F 11CM SHEATH,2720002698,CDM,272,RC,C1894,HCPCS,Outpatient,,,18.50,12.03,,18.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.06,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.32,72,,545.504,Percent of Total Billed Charges,72% of Total Billed Charges,13.88,75,,545.504,Percent of Total Billed charges,75% of Total Billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.32,72,,545.504,Percent of Total Billed Charges,72% of Total Billed Charges,11.1,60,,454.584,Percent of Total Billed Charges,60% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,8.33,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.03,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,8.16,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.58,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.28,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,8.16,18.5,
AVANTI 10F 11CM SHEATH,2720002699,CDM,272,RC,C1894,HCPCS,Outpatient,,,18.50,12.03,,18.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.06,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.32,72,,492.16,Percent of Total Billed Charges,72% of Total Billed Charges,13.88,75,,492.16,Percent of Total Billed charges,75% of Total Billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.32,72,,492.16,Percent of Total Billed Charges,72% of Total Billed Charges,11.1,60,,410.128,Percent of Total Billed Charges,60% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,8.33,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.03,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,8.16,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.58,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.28,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,8.16,18.5,
AVANTI 10F 23CM SHEATH,2720002700,CDM,272,RC,C1894,HCPCS,Outpatient,,,40.00,26.00,,40,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,30.4,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.8,72,,359.432,Percent of Total Billed Charges,72% of Total Billed Charges,30,75,,359.432,Percent of Total Billed charges,75% of Total Billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.8,72,,359.432,Percent of Total Billed Charges,72% of Total Billed Charges,24,60,,299.528,Percent of Total Billed Charges,60% of Total Billed Charges,36,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,18,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,36,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,17.64,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,38,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.2,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,36,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,17.64,40,
AVANTI 11F 11CM SHEATH,2720002701,CDM,272,RC,C1894,HCPCS,Outpatient,,,18.50,12.03,,18.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.06,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.32,72,,2102.616,Percent of Total Billed Charges,72% of Total Billed Charges,13.88,75,,2102.616,Percent of Total Billed charges,75% of Total Billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.32,72,,2102.616,Percent of Total Billed Charges,72% of Total Billed Charges,11.1,60,,1752.184,Percent of Total Billed Charges,60% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,8.33,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.03,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,8.16,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.58,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,18.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.28,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,16.65,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,8.16,18.5,
ADMIRAL 6F OTW 5 X 60 X 130,2720002702,CDM,272,RC,C2623,HCPCS,Outpatient,,,3525.00,2291.25,,3525,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2679,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2538,72,,2103.888,Percent of Total Billed Charges,72% of Total Billed Charges,2643.75,75,,2103.888,Percent of Total Billed charges,75% of Total Billed Charges,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2538,72,,2103.888,Percent of Total Billed Charges,72% of Total Billed Charges,2115,60,,1753.24,Percent of Total Billed Charges,60% of Total Billed Charges,3172.5,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,1586.25,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,3172.5,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2291.25,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,1554.53,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,3348.75,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3102,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,3172.5,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,1554.53,3525,
Expiratory Muscle Strngth Trnr,2720002703,CDM,272,RC,,,Outpatient,,,101.52,65.99,,101.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,77.16,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,73.09,72,,359.432,Percent of Total Billed Charges,72% of Total Billed Charges,76.14,75,,359.432,Percent of Total Billed charges,75% of Total Billed Charges,101.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.09,72,,359.432,Percent of Total Billed Charges,72% of Total Billed Charges,60.91,60,,299.528,Percent of Total Billed Charges,60% of Total Billed Charges,91.37,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,45.68,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,91.37,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,101.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.99,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,44.77,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,96.44,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,101.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.34,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,91.37,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,44.77,101.52,
Classic T-Piece W/O Mask,2720002704,CDM,272,RC,,,Outpatient,,,17.25,11.21,,17.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.11,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.42,72,,449.608,Percent of Total Billed Charges,72% of Total Billed Charges,12.94,75,,449.608,Percent of Total Billed charges,75% of Total Billed Charges,17.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.42,72,,449.608,Percent of Total Billed Charges,72% of Total Billed Charges,10.35,60,,374.672,Percent of Total Billed Charges,60% of Total Billed Charges,15.53,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,7.76,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,15.53,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,17.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.21,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,7.61,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.39,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,17.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.18,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,15.53,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,7.61,17.25,
Micro Mask 35mm Single Use,2720002705,CDM,272,RC,,,Outpatient,,,15.62,10.15,,15.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.87,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.25,72,,2660.824,Percent of Total Billed Charges,72% of Total Billed Charges,11.72,75,,2660.824,Percent of Total Billed charges,75% of Total Billed Charges,15.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.25,72,,2660.824,Percent of Total Billed Charges,72% of Total Billed Charges,9.37,60,,2217.352,Percent of Total Billed Charges,60% of Total Billed Charges,14.06,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,7.03,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,14.06,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,15.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.15,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,6.89,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.84,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,15.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.75,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,14.06,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,6.89,15.62,
Premature Mask 42mm Single Use,2720002706,CDM,272,RC,,,Outpatient,,,15.62,10.15,,15.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.87,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.25,72,,449.608,Percent of Total Billed Charges,72% of Total Billed Charges,11.72,75,,449.608,Percent of Total Billed charges,75% of Total Billed Charges,15.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.25,72,,449.608,Percent of Total Billed Charges,72% of Total Billed Charges,9.37,60,,374.672,Percent of Total Billed Charges,60% of Total Billed Charges,14.06,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,7.03,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,14.06,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,15.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.15,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,6.89,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.84,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,15.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.75,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,14.06,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,6.89,15.62,
Neonatal Mask 50mm Single Use,2720002707,CDM,272,RC,,,Outpatient,,,15.62,10.15,,15.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.87,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.25,72,,449.608,Percent of Total Billed Charges,72% of Total Billed Charges,11.72,75,,449.608,Percent of Total Billed charges,75% of Total Billed Charges,15.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.25,72,,449.608,Percent of Total Billed Charges,72% of Total Billed Charges,9.37,60,,374.672,Percent of Total Billed Charges,60% of Total Billed Charges,14.06,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,7.03,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,14.06,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,15.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.15,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,6.89,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.84,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,15.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.75,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,14.06,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,6.89,15.62,
Infant Mask 60mm Single Use,2720002708,CDM,272,RC,,,Outpatient,,,16.52,10.74,,16.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.56,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.89,72,,449.608,Percent of Total Billed Charges,72% of Total Billed Charges,12.39,75,,449.608,Percent of Total Billed charges,75% of Total Billed Charges,16.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.89,72,,449.608,Percent of Total Billed Charges,72% of Total Billed Charges,9.91,60,,374.672,Percent of Total Billed Charges,60% of Total Billed Charges,14.87,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,7.43,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,14.87,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,16.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.74,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.69,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,16.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.54,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,14.87,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,7.29,16.52,
Gas Supply Line Long,2720002709,CDM,272,RC,,,Outpatient,,,14.00,9.10,,14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.64,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.08,72,,359.432,Percent of Total Billed Charges,72% of Total Billed Charges,10.5,75,,359.432,Percent of Total Billed charges,75% of Total Billed Charges,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.08,72,,359.432,Percent of Total Billed Charges,72% of Total Billed Charges,8.4,60,,299.528,Percent of Total Billed Charges,60% of Total Billed Charges,12.6,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,12.6,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.1,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,6.17,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.3,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.32,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,12.6,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,6.17,14,
BVI 2.2 Ready Pack,2720002710,CDM,272,RC,,,Outpatient,,,42.00,27.30,,42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31.92,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.24,72,,449.608,Percent of Total Billed Charges,72% of Total Billed Charges,31.5,75,,449.608,Percent of Total Billed charges,75% of Total Billed Charges,42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.24,72,,449.608,Percent of Total Billed Charges,72% of Total Billed Charges,25.2,60,,374.672,Percent of Total Billed Charges,60% of Total Billed Charges,37.8,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,18.9,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,37.8,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.3,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,18.52,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,39.9,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.96,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,37.8,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,18.52,42,
VLOCL0804 3-0 VLOC CV-23 NDLE,2720002711,CDM,272,RC,,,Outpatient,,,80.12,52.08,,80.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60.89,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.69,72,,359.432,Percent of Total Billed Charges,72% of Total Billed Charges,60.09,75,,359.432,Percent of Total Billed charges,75% of Total Billed Charges,80.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.69,72,,359.432,Percent of Total Billed Charges,72% of Total Billed Charges,48.07,60,,299.528,Percent of Total Billed Charges,60% of Total Billed Charges,72.11,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,36.05,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,72.11,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,80.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.08,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,35.33,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,76.11,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,80.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.51,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,72.11,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,35.33,80.12,
NC EUPHORA RX 3.75MM X 8MM,2720002712,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,449.608,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,449.608,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,449.608,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,374.672,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
G30361 Captura 3 Prong Grasper,2720002713,CDM,272,RC,,,Outpatient,,,691.25,449.31,,691.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,525.35,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,497.7,72,,449.608,Percent of Total Billed Charges,72% of Total Billed Charges,518.44,75,,449.608,Percent of Total Billed charges,75% of Total Billed Charges,691.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497.7,72,,449.608,Percent of Total Billed Charges,72% of Total Billed Charges,414.75,60,,374.672,Percent of Total Billed Charges,60% of Total Billed Charges,622.13,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,311.06,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,622.13,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,691.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,691.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,691.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,449.31,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,304.84,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,656.69,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,691.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,608.3,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,622.13,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,304.84,691.25,
BS Dakota Basket 1.9 x 120 x 8,2720002714,CDM,272,RC,,,Outpatient,,,496.12,322.48,,496.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.05,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.21,72,,449.608,Percent of Total Billed Charges,72% of Total Billed Charges,372.09,75,,449.608,Percent of Total Billed charges,75% of Total Billed Charges,496.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.21,72,,449.608,Percent of Total Billed Charges,72% of Total Billed Charges,297.67,60,,374.672,Percent of Total Billed Charges,60% of Total Billed Charges,446.51,90,,15.792,Percent of Total Billed Charges,90% of Total Billed Charges,223.25,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,446.51,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,496.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,496.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,496.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,322.48,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,218.79,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,471.31,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,496.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,436.59,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,446.51,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,218.79,496.12,
Word Bartholin Gland Catheter,2720002715,CDM,272,RC,,,Outpatient,,,105.22,68.39,,105.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.97,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75.76,72,,3690.856,Percent of Total Billed Charges,72% of Total Billed Charges,78.92,75,,3690.856,Percent of Total Billed charges,75% of Total Billed Charges,105.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.76,72,,3690.856,Percent of Total Billed Charges,72% of Total Billed Charges,63.13,60,,3075.712,Percent of Total Billed Charges,60% of Total Billed Charges,94.7,90,,27,Percent of Total Billed Charges,90% of Total Billed Charges,47.35,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,94.7,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,105.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.39,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,46.4,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,99.96,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,105.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.59,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,94.7,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,46.4,105.22,
Securmark for Eviva 13CM SHP 2,2720002716,CDM,272,RC,,,Outpatient,,,206.12,133.98,,206.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,156.65,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,148.41,72,,3021.52,Percent of Total Billed Charges,72% of Total Billed Charges,154.59,75,,3021.52,Percent of Total Billed charges,75% of Total Billed Charges,206.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.41,72,,3021.52,Percent of Total Billed Charges,72% of Total Billed Charges,123.67,60,,2517.936,Percent of Total Billed Charges,60% of Total Billed Charges,185.51,90,,27,Percent of Total Billed Charges,90% of Total Billed Charges,92.75,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,185.51,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,206.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.98,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,90.9,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,195.81,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,206.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.39,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,185.51,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,90.9,206.12,
Securmark for Eviva 13CM SHP 1,2720002717,CDM,272,RC,,,Outpatient,,,206.12,133.98,,206.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,156.65,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,148.41,72,,3023.424,Percent of Total Billed Charges,72% of Total Billed Charges,154.59,75,,3023.424,Percent of Total Billed charges,75% of Total Billed Charges,206.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.41,72,,3023.424,Percent of Total Billed Charges,72% of Total Billed Charges,123.67,60,,2519.52,Percent of Total Billed Charges,60% of Total Billed Charges,185.51,90,,27,Percent of Total Billed Charges,90% of Total Billed Charges,92.75,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,185.51,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,206.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.98,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,90.9,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,195.81,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,206.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.39,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,185.51,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,90.9,206.12,
Surg Retractr Lonestar 3307G,2720002718,CDM,272,RC,,,Outpatient,,,239.67,155.79,,239.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,182.15,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,172.56,72,,461.672,Percent of Total Billed Charges,72% of Total Billed Charges,179.75,75,,461.672,Percent of Total Billed charges,75% of Total Billed Charges,239.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.56,72,,461.672,Percent of Total Billed Charges,72% of Total Billed Charges,143.8,60,,384.728,Percent of Total Billed Charges,60% of Total Billed Charges,215.7,90,,27,Percent of Total Billed Charges,90% of Total Billed Charges,107.85,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,215.7,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,239.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.79,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,105.69,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,227.69,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,239.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,215.7,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,105.69,239.67,
PROLENE 0 CT-2  8412H,2720002719,CDM,272,RC,,,Outpatient,,,7.35,4.78,,7.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.59,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.29,72,,2627.8,Percent of Total Billed Charges,72% of Total Billed Charges,5.51,75,,2627.8,Percent of Total Billed charges,75% of Total Billed Charges,7.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.29,72,,2627.8,Percent of Total Billed Charges,72% of Total Billed Charges,4.41,60,,2189.832,Percent of Total Billed Charges,60% of Total Billed Charges,6.62,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,3.31,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,6.62,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,7.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.78,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,3.24,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.98,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,7.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.47,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,6.62,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,3.24,7.35,
PDS 3-0 Z316H SUTURE,2720002720,CDM,272,RC,,,Outpatient,,,7.60,4.94,,7.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.78,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.47,72,,2627.8,Percent of Total Billed Charges,72% of Total Billed Charges,5.7,75,,2627.8,Percent of Total Billed charges,75% of Total Billed Charges,7.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.47,72,,2627.8,Percent of Total Billed Charges,72% of Total Billed Charges,4.56,60,,2189.832,Percent of Total Billed Charges,60% of Total Billed Charges,6.84,90,,62.264,Percent of Total Billed Charges,90% of Total Billed Charges,3.42,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,6.84,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,7.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.94,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,3.35,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.22,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,7.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.69,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,6.84,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,3.35,7.6,
SUPRAPUBIC CATH INTRO KIT 16FR,2720002721,CDM,272,RC,,,Outpatient,,,117.87,76.62,,117.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,89.58,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.87,72,,487.08,Percent of Total Billed Charges,72% of Total Billed Charges,88.4,75,,487.08,Percent of Total Billed charges,75% of Total Billed Charges,117.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.87,72,,487.08,Percent of Total Billed Charges,72% of Total Billed Charges,70.72,60,,405.896,Percent of Total Billed Charges,60% of Total Billed Charges,106.08,90,,8460,Percent of Total Billed Charges,90% of Total Billed Charges,53.04,45,,7.896,Percent of Total Billed Charges,45% of Total Billed Charges,106.08,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,117.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.62,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,51.98,44.1,,7.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,111.98,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,117.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.73,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,106.08,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,51.98,117.87,
SUPRAPUBIC CATH INTRO KIT 18FR,2720002722,CDM,272,RC,,,Outpatient,,,117.87,76.62,,117.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,89.58,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.87,72,,657.264,Percent of Total Billed Charges,72% of Total Billed Charges,88.4,75,,657.264,Percent of Total Billed charges,75% of Total Billed Charges,117.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.87,72,,657.264,Percent of Total Billed Charges,72% of Total Billed Charges,70.72,60,,547.72,Percent of Total Billed Charges,60% of Total Billed Charges,106.08,90,,8460,Percent of Total Billed Charges,90% of Total Billed Charges,53.04,45,,13.504,Percent of Total Billed Charges,45% of Total Billed Charges,106.08,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,117.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.62,65,,11.4,Percent of total Billed Charges,65% of Total Billed Charges,51.98,44.1,,13.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,111.98,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,117.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.73,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,106.08,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,51.98,117.87,
ET TUIBE 2.5 CUFFED,2720002723,CDM,272,RC,,,Outpatient,,,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,72,,657.264,Percent of Total Billed Charges,72% of Total Billed Charges,7.44,75,,657.264,Percent of Total Billed charges,75% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,72,,657.264,Percent of Total Billed Charges,72% of Total Billed Charges,5.95,60,,547.72,Percent of Total Billed Charges,60% of Total Billed Charges,8.93,90,,8460,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,13.504,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,19.504,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,13.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,4.37,9.92,
ET TUIBE 3.0 CUFFED,2720002724,CDM,272,RC,,,Outpatient,,,4.57,2.97,,4.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.47,76,,13.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.29,72,,1917.184,Percent of Total Billed Charges,72% of Total Billed Charges,3.43,75,,1917.184,Percent of Total Billed charges,75% of Total Billed Charges,4.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.29,72,,1917.184,Percent of Total Billed Charges,72% of Total Billed Charges,2.74,60,,1597.656,Percent of Total Billed Charges,60% of Total Billed Charges,4.11,90,,8460,Percent of Total Billed Charges,90% of Total Billed Charges,2.06,45,,13.504,Percent of Total Billed Charges,45% of Total Billed Charges,4.11,90,,15.792,Percent of Total Billed Charges,90% of Total billed Charges,4.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.97,65,,19.504,Percent of total Billed Charges,65% of Total Billed Charges,2.02,44.1,,13.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.34,95,,16.664,Percent of Total Billed Charges,95% of Total Billed Charges,4.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.02,88,,15.44,Percent of Total Billed Charges,88% of Total Billed Charges,4.11,90,,15.792,Percent of Total Billed charges,90% of Total Billed Charges,2.02,4.57,
ET TUIBE 3.5 CUFFED,2720002725,CDM,272,RC,,,Outpatient,,,4.25,2.76,,4.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.23,76,,22.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.06,72,,657.264,Percent of Total Billed Charges,72% of Total Billed Charges,3.19,75,,657.264,Percent of Total Billed charges,75% of Total Billed Charges,4.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.06,72,,657.264,Percent of Total Billed Charges,72% of Total Billed Charges,2.55,60,,547.72,Percent of Total Billed Charges,60% of Total Billed Charges,3.83,90,,8460,Percent of Total Billed Charges,90% of Total Billed Charges,1.91,45,,13.504,Percent of Total Billed Charges,45% of Total Billed Charges,3.83,90,,27,Percent of Total Billed Charges,90% of Total billed Charges,4.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.76,65,,19.504,Percent of total Billed Charges,65% of Total Billed Charges,1.87,44.1,,13.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.04,95,,28.504,Percent of Total Billed Charges,95% of Total Billed Charges,4.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.74,88,,26.4,Percent of Total Billed Charges,88% of Total Billed Charges,3.83,90,,27,Percent of Total Billed charges,90% of Total Billed Charges,1.87,4.25,
ET TUIBE 4.0 CUFFED,2720002726,CDM,272,RC,,,Outpatient,,,4.47,2.91,,4.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.4,76,,22.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.22,72,,880.168,Percent of Total Billed Charges,72% of Total Billed Charges,3.35,75,,880.168,Percent of Total Billed charges,75% of Total Billed Charges,4.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.22,72,,880.168,Percent of Total Billed Charges,72% of Total Billed Charges,2.68,60,,733.472,Percent of Total Billed Charges,60% of Total Billed Charges,4.02,90,,8460,Percent of Total Billed Charges,90% of Total Billed Charges,2.01,45,,75.6,Percent of Total Billed Charges,45% of Total Billed Charges,4.02,90,,27,Percent of Total Billed Charges,90% of Total billed Charges,4.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,65,,19.504,Percent of total Billed Charges,65% of Total Billed Charges,1.97,44.1,,74.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.25,95,,28.504,Percent of Total Billed Charges,95% of Total Billed Charges,4.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.93,88,,26.4,Percent of Total Billed Charges,88% of Total Billed Charges,4.02,90,,27,Percent of Total Billed charges,90% of Total Billed Charges,1.97,4.47,
ET TUIBE 4.5 CUFFED,2720002727,CDM,272,RC,,,Outpatient,,,4.50,2.93,,4.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.42,76,,22.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.24,72,,880.168,Percent of Total Billed Charges,72% of Total Billed Charges,3.38,75,,880.168,Percent of Total Billed charges,75% of Total Billed Charges,4.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.24,72,,880.168,Percent of Total Billed Charges,72% of Total Billed Charges,2.7,60,,733.472,Percent of Total Billed Charges,60% of Total Billed Charges,4.05,90,,292.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.03,45,,31.136,Percent of Total Billed Charges,45% of Total Billed Charges,4.05,90,,27,Percent of Total Billed Charges,90% of Total billed Charges,4.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.93,65,,109.2,Percent of total Billed Charges,65% of Total Billed Charges,1.98,44.1,,30.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.28,95,,28.504,Percent of Total Billed Charges,95% of Total Billed Charges,4.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.96,88,,26.4,Percent of Total Billed Charges,88% of Total Billed Charges,4.05,90,,27,Percent of Total Billed charges,90% of Total Billed Charges,1.98,4.5,
ET TUIBE 5.0 CUFFED,2720002728,CDM,272,RC,,,Outpatient,,,4.55,2.96,,4.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.46,76,,22.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.28,72,,880.168,Percent of Total Billed Charges,72% of Total Billed Charges,3.41,75,,880.168,Percent of Total Billed charges,75% of Total Billed Charges,4.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.28,72,,880.168,Percent of Total Billed Charges,72% of Total Billed Charges,2.73,60,,733.472,Percent of Total Billed Charges,60% of Total Billed Charges,4.1,90,,23.856,Percent of Total Billed Charges,90% of Total Billed Charges,2.05,45,,4230,Percent of Total Billed Charges,45% of Total Billed Charges,4.1,90,,27,Percent of Total Billed Charges,90% of Total billed Charges,4.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.96,65,,44.968,Percent of total Billed Charges,65% of Total Billed Charges,2.01,44.1,,4145.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.32,95,,28.504,Percent of Total Billed Charges,95% of Total Billed Charges,4.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4,88,,26.4,Percent of Total Billed Charges,88% of Total Billed Charges,4.1,90,,27,Percent of Total Billed charges,90% of Total Billed Charges,2.01,4.55,
ZIMMR OSC BLADE 90/110X20X1.27,2720002729,CDM,272,RC,,,Outpatient,,,123.75,80.44,,123.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,94.05,76,,127.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,89.1,72,,575.984,Percent of Total Billed Charges,72% of Total Billed Charges,92.81,75,,575.984,Percent of Total Billed charges,75% of Total Billed Charges,123.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.1,72,,575.984,Percent of Total Billed Charges,72% of Total Billed Charges,74.25,60,,479.984,Percent of Total Billed Charges,60% of Total Billed Charges,111.38,90,,167.4,Percent of Total Billed Charges,90% of Total Billed Charges,55.69,45,,4230,Percent of Total Billed Charges,45% of Total Billed Charges,111.38,90,,151.2,Percent of Total Billed Charges,90% of Total billed Charges,123.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.44,65,,6110,Percent of total Billed Charges,65% of Total Billed Charges,54.57,44.1,,4145.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,117.56,95,,159.6,Percent of Total Billed Charges,95% of Total Billed Charges,123.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.9,88,,147.84,Percent of Total Billed Charges,88% of Total Billed Charges,111.38,90,,151.2,Percent of Total Billed charges,90% of Total Billed Charges,54.57,123.75,
XXL NC BALLOON 14 X 20 X 75,2720002730,CDM,272,RC,C1725,HCPCS,Outpatient,,,750.00,487.50,,750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,570,76,,52.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,540,72,,880.168,Percent of Total Billed Charges,72% of Total Billed Charges,562.5,75,,880.168,Percent of Total Billed charges,75% of Total Billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540,72,,880.168,Percent of Total Billed Charges,72% of Total Billed Charges,450,60,,733.472,Percent of Total Billed Charges,60% of Total Billed Charges,675,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,337.5,45,,4230,Percent of Total Billed Charges,45% of Total Billed Charges,675,90,,62.264,Percent of Total Billed Charges,90% of Total billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487.5,65,,6110,Percent of total Billed Charges,65% of Total Billed Charges,330.75,44.1,,4145.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,712.5,95,,65.728,Percent of Total Billed Charges,95% of Total Billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,660,88,,60.88,Percent of Total Billed Charges,88% of Total Billed Charges,675,90,,62.264,Percent of Total Billed charges,90% of Total Billed Charges,330.75,750,
XXL NC BALLOON 14 X 40 X 75,2720002731,CDM,272,RC,C1725,HCPCS,Outpatient,,,750.00,487.50,,750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,570,76,,7144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,540,72,,880.168,Percent of Total Billed Charges,72% of Total Billed Charges,562.5,75,,880.168,Percent of Total Billed charges,75% of Total Billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540,72,,880.168,Percent of Total Billed Charges,72% of Total Billed Charges,450,60,,733.472,Percent of Total Billed Charges,60% of Total Billed Charges,675,90,,1287,Percent of Total Billed Charges,90% of Total Billed Charges,337.5,45,,4230,Percent of Total Billed Charges,45% of Total Billed Charges,675,90,,8460,Percent of Total Billed Charges,90% of Total billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487.5,65,,6110,Percent of total Billed Charges,65% of Total Billed Charges,330.75,44.1,,4145.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,712.5,95,,8930,Percent of Total Billed Charges,95% of Total Billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,660,88,,8272,Percent of Total Billed Charges,88% of Total Billed Charges,675,90,,8460,Percent of Total Billed charges,90% of Total Billed Charges,330.75,750,
XXL NC BALLOON 14 X 60 X 75,2720002732,CDM,272,RC,C1725,HCPCS,Outpatient,,,750.00,487.50,,750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,570,76,,7144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,540,72,,880.168,Percent of Total Billed Charges,72% of Total Billed Charges,562.5,75,,880.168,Percent of Total Billed charges,75% of Total Billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540,72,,880.168,Percent of Total Billed Charges,72% of Total Billed Charges,450,60,,733.472,Percent of Total Billed Charges,60% of Total Billed Charges,675,90,,1170,Percent of Total Billed Charges,90% of Total Billed Charges,337.5,45,,4230,Percent of Total Billed Charges,45% of Total Billed Charges,675,90,,8460,Percent of Total Billed Charges,90% of Total billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487.5,65,,6110,Percent of total Billed Charges,65% of Total Billed Charges,330.75,44.1,,4145.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,712.5,95,,8930,Percent of Total Billed Charges,95% of Total Billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,660,88,,8272,Percent of Total Billed Charges,88% of Total Billed Charges,675,90,,8460,Percent of Total Billed charges,90% of Total Billed Charges,330.75,750,
SYRINGE 35ML ORAL FEED STERILE,2720002733,CDM,272,RC,,,Outpatient,,,8.05,5.23,,8.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.12,76,,7144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.8,72,,1202.128,Percent of Total Billed Charges,72% of Total Billed Charges,6.04,75,,1202.128,Percent of Total Billed charges,75% of Total Billed Charges,8.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.8,72,,1202.128,Percent of Total Billed Charges,72% of Total Billed Charges,4.83,60,,1001.776,Percent of Total Billed Charges,60% of Total Billed Charges,7.25,90,,2358,Percent of Total Billed Charges,90% of Total Billed Charges,3.62,45,,4230,Percent of Total Billed Charges,45% of Total Billed Charges,7.25,90,,8460,Percent of Total Billed Charges,90% of Total billed Charges,8.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.23,65,,6110,Percent of total Billed Charges,65% of Total Billed Charges,3.55,44.1,,4145.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.65,95,,8930,Percent of Total Billed Charges,95% of Total Billed Charges,8.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.08,88,,8272,Percent of Total Billed Charges,88% of Total Billed Charges,7.25,90,,8460,Percent of Total Billed charges,90% of Total Billed Charges,3.55,8.05,
SYRINGE 60ML ORAL FEED STERILE,2720002734,CDM,272,RC,,,Outpatient,,,5.62,3.65,,5.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.27,76,,7144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.05,72,,1425.032,Percent of Total Billed Charges,72% of Total Billed Charges,4.22,75,,1425.032,Percent of Total Billed charges,75% of Total Billed Charges,5.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.05,72,,1425.032,Percent of Total Billed Charges,72% of Total Billed Charges,3.37,60,,1187.528,Percent of Total Billed Charges,60% of Total Billed Charges,5.06,90,,5.928,Percent of Total Billed Charges,90% of Total Billed Charges,2.53,45,,146.344,Percent of Total Billed Charges,45% of Total Billed Charges,5.06,90,,8460,Percent of Total Billed Charges,90% of Total billed Charges,5.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.65,65,,6110,Percent of total Billed Charges,65% of Total Billed Charges,2.48,44.1,,143.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.34,95,,8930,Percent of Total Billed Charges,95% of Total Billed Charges,5.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.95,88,,8272,Percent of Total Billed Charges,88% of Total Billed Charges,5.06,90,,8460,Percent of Total Billed charges,90% of Total Billed Charges,2.48,5.62,
HEARTRAIL IKARI RIGHT 6F IR1.5,2720002735,CDM,272,RC,C1887,HCPCS,Outpatient,,,210.00,136.50,,210,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,159.6,76,,7144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,151.2,72,,1293.576,Percent of Total Billed Charges,72% of Total Billed Charges,157.5,75,,1293.576,Percent of Total Billed charges,75% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.2,72,,1293.576,Percent of Total Billed Charges,72% of Total Billed Charges,126,60,,1077.976,Percent of Total Billed Charges,60% of Total Billed Charges,189,90,,5.496,Percent of Total Billed Charges,90% of Total Billed Charges,94.5,45,,11.928,Percent of Total Billed Charges,45% of Total Billed Charges,189,90,,8460,Percent of Total Billed Charges,90% of Total billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.5,65,,211.384,Percent of total Billed Charges,65% of Total Billed Charges,92.61,44.1,,11.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,199.5,95,,8930,Percent of Total Billed Charges,95% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.8,88,,8272,Percent of Total Billed Charges,88% of Total Billed Charges,189,90,,8460,Percent of Total Billed charges,90% of Total Billed Charges,92.61,210,
G17551 STENT POSITIONER 6F,2720002736,CDM,272,RC,,,Outpatient,,,65.25,42.41,,65.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.59,76,,7144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.98,72,,1202.128,Percent of Total Billed Charges,72% of Total Billed Charges,48.94,75,,1202.128,Percent of Total Billed charges,75% of Total Billed Charges,65.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.98,72,,1202.128,Percent of Total Billed Charges,72% of Total Billed Charges,39.15,60,,1001.776,Percent of Total Billed Charges,60% of Total Billed Charges,58.73,90,,24.504,Percent of Total Billed Charges,90% of Total Billed Charges,29.36,45,,83.704,Percent of Total Billed Charges,45% of Total Billed Charges,58.73,90,,8460,Percent of Total Billed Charges,90% of Total billed Charges,65.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.41,65,,17.224,Percent of total Billed Charges,65% of Total Billed Charges,28.78,44.1,,82.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,61.99,95,,8930,Percent of Total Billed Charges,95% of Total Billed Charges,65.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.42,88,,8272,Percent of Total Billed Charges,88% of Total Billed Charges,58.73,90,,8460,Percent of Total Billed charges,90% of Total Billed Charges,28.78,65.25,
MICROPUNCTURE STIFF 5F G48008,2720002737,CDM,272,RC,C1894,HCPCS,Outpatient,,,136.25,88.56,,136.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,103.55,76,,247.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,98.1,72,,1202.128,Percent of Total Billed Charges,72% of Total Billed Charges,102.19,75,,1202.128,Percent of Total Billed charges,75% of Total Billed Charges,136.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.1,72,,1202.128,Percent of Total Billed Charges,72% of Total Billed Charges,81.75,60,,1001.776,Percent of Total Billed Charges,60% of Total Billed Charges,122.63,90,,567,Percent of Total Billed Charges,90% of Total Billed Charges,61.31,45,,4.68,Percent of Total Billed Charges,45% of Total Billed Charges,122.63,90,,292.68,Percent of Total Billed Charges,90% of Total billed Charges,136.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.56,65,,120.904,Percent of total Billed Charges,65% of Total Billed Charges,60.09,44.1,,4.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,129.44,95,,308.944,Percent of Total Billed Charges,95% of Total Billed Charges,136.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.9,88,,286.176,Percent of Total Billed Charges,88% of Total Billed Charges,122.63,90,,292.68,Percent of Total Billed charges,90% of Total Billed Charges,60.09,136.25,
ANGIO CATH 14G X 1.88,2720002738,CDM,272,RC,,,Outpatient,,,9.97,6.48,,9.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.58,76,,20.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.18,72,,1293.576,Percent of Total Billed Charges,72% of Total Billed Charges,7.48,75,,1293.576,Percent of Total Billed charges,75% of Total Billed Charges,9.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.18,72,,1293.576,Percent of Total Billed Charges,72% of Total Billed Charges,5.98,60,,1077.976,Percent of Total Billed Charges,60% of Total Billed Charges,8.97,90,,291.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.49,45,,643.504,Percent of Total Billed Charges,45% of Total Billed Charges,8.97,90,,23.856,Percent of Total Billed Charges,90% of Total billed Charges,9.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.48,65,,6.76,Percent of total Billed Charges,65% of Total Billed Charges,4.4,44.1,,630.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.47,95,,25.176,Percent of Total Billed Charges,95% of Total Billed Charges,9.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.77,88,,23.32,Percent of Total Billed Charges,88% of Total Billed Charges,8.97,90,,23.856,Percent of Total Billed charges,90% of Total Billed Charges,4.4,9.97,
ANGIO CATH 14G X 3.25,2720002739,CDM,272,RC,,,Outpatient,,,31.50,20.48,,31.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.94,76,,141.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.68,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,23.63,75,,91.448,Percent of Total Billed charges,75% of Total Billed Charges,31.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.68,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,18.9,60,,76.208,Percent of Total Billed Charges,60% of Total Billed Charges,28.35,90,,430.2,Percent of Total Billed Charges,90% of Total Billed Charges,14.18,45,,585,Percent of Total Billed Charges,45% of Total Billed Charges,28.35,90,,167.4,Percent of Total Billed Charges,90% of Total billed Charges,31.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.48,65,,929.504,Percent of total Billed Charges,65% of Total Billed Charges,13.89,44.1,,573.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.93,95,,176.704,Percent of Total Billed Charges,95% of Total Billed Charges,31.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.72,88,,163.68,Percent of Total Billed Charges,88% of Total Billed Charges,28.35,90,,167.4,Percent of Total Billed charges,90% of Total Billed Charges,13.89,31.5,
ANGIO CATH 12G X 3.00,2720002740,CDM,272,RC,,,Outpatient,,,31.50,20.48,,31.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.94,76,,7.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.68,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,23.63,75,,109.864,Percent of Total Billed charges,75% of Total Billed Charges,31.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.68,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,18.9,60,,91.552,Percent of Total Billed Charges,60% of Total Billed Charges,28.35,90,,240.664,Percent of Total Billed Charges,90% of Total Billed Charges,14.18,45,,1179,Percent of Total Billed Charges,45% of Total Billed Charges,28.35,90,,9.36,Percent of Total Billed Charges,90% of Total billed Charges,31.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.48,65,,845,Percent of total Billed Charges,65% of Total Billed Charges,13.89,44.1,,1155.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.93,95,,9.88,Percent of Total Billed Charges,95% of Total Billed Charges,31.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.72,88,,9.152,Percent of Total Billed Charges,88% of Total Billed Charges,28.35,90,,9.36,Percent of Total Billed charges,90% of Total Billed Charges,13.89,31.5,
B&L 25G ESA KIT-VALVED,2720002741,CDM,272,RC,,,Outpatient,,,320.00,208.00,,320,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,243.2,76,,1086.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,230.4,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,240,75,,109.864,Percent of Total Billed charges,75% of Total Billed Charges,320,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.4,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,192,60,,91.552,Percent of Total Billed Charges,60% of Total Billed Charges,288,90,,21.568,Percent of Total Billed Charges,90% of Total Billed Charges,144,45,,2.96,Percent of Total Billed Charges,45% of Total Billed Charges,288,90,,1287,Percent of Total Billed Charges,90% of Total billed Charges,320,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208,65,,1703,Percent of total Billed Charges,65% of Total Billed Charges,141.12,44.1,,2.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,304,95,,1358.504,Percent of Total Billed Charges,95% of Total Billed Charges,320,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,281.6,88,,1258.4,Percent of Total Billed Charges,88% of Total Billed Charges,288,90,,1287,Percent of Total Billed charges,90% of Total Billed Charges,141.12,320,
B&L ELITE 25G BIBLADE VIT CUT,2720002742,CDM,272,RC,,,Outpatient,,,583.32,379.16,,583.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,443.32,76,,988,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,419.99,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,437.49,75,,109.864,Percent of Total Billed charges,75% of Total Billed Charges,583.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.99,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,349.99,60,,91.552,Percent of Total Billed Charges,60% of Total Billed Charges,524.99,90,,414.168,Percent of Total Billed Charges,90% of Total Billed Charges,262.49,45,,2.744,Percent of Total Billed Charges,45% of Total Billed Charges,524.99,90,,1170,Percent of Total Billed Charges,90% of Total billed Charges,583.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.16,65,,4.28,Percent of total Billed Charges,65% of Total Billed Charges,257.24,44.1,,2.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,554.15,95,,1235,Percent of Total Billed Charges,95% of Total Billed Charges,583.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.32,88,,1144,Percent of Total Billed Charges,88% of Total Billed Charges,524.99,90,,1170,Percent of Total Billed charges,90% of Total Billed Charges,257.24,583.32,
B&L 25G BI-B COMB ELITE W WF,2720002743,CDM,272,RC,,,Outpatient,,,1721.67,1119.09,,1721.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1308.47,76,,1991.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1239.6,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,1291.25,75,,109.864,Percent of Total Billed charges,75% of Total Billed Charges,1721.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1239.6,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,1033,60,,91.552,Percent of Total Billed Charges,60% of Total Billed Charges,1549.5,90,,2,Percent of Total Billed Charges,90% of Total Billed Charges,774.75,45,,12.248,Percent of Total Billed Charges,45% of Total Billed Charges,1549.5,90,,2358,Percent of Total Billed Charges,90% of Total billed Charges,1721.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1721.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1721.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1119.09,65,,3.968,Percent of total Billed Charges,65% of Total Billed Charges,759.26,44.1,,12.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,1635.59,95,,2489,Percent of Total Billed Charges,95% of Total Billed Charges,1721.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1515.07,88,,2305.6,Percent of Total Billed Charges,88% of Total Billed Charges,1549.5,90,,2358,Percent of Total Billed charges,90% of Total Billed Charges,759.26,1721.67,
Tesio Cutting Trocar,2720002744,CDM,272,RC,,,Outpatient,,,15.00,9.75,,15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.4,76,,5,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.8,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,11.25,75,,109.864,Percent of Total Billed charges,75% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.8,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,9,60,,91.552,Percent of Total Billed Charges,60% of Total Billed Charges,13.5,90,,153.976,Percent of Total Billed Charges,90% of Total Billed Charges,6.75,45,,283.504,Percent of Total Billed Charges,45% of Total Billed Charges,13.5,90,,5.928,Percent of Total Billed Charges,90% of Total billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.75,65,,17.696,Percent of total Billed Charges,65% of Total Billed Charges,6.62,44.1,,277.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.25,95,,6.256,Percent of Total Billed Charges,95% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.2,88,,5.792,Percent of Total Billed Charges,88% of Total Billed Charges,13.5,90,,5.928,Percent of Total Billed charges,90% of Total Billed Charges,6.62,15,
ENCORE 40 INFLATOR DEVICE,2720002745,CDM,272,RC,,,Outpatient,,,125.00,81.25,,125,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95,76,,4.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,93.75,75,,91.448,Percent of Total Billed charges,75% of Total Billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,75,60,,76.208,Percent of Total Billed Charges,60% of Total Billed Charges,112.5,90,,1024.384,Percent of Total Billed Charges,90% of Total Billed Charges,56.25,45,,145.8,Percent of Total Billed Charges,45% of Total Billed Charges,112.5,90,,5.496,Percent of Total Billed Charges,90% of Total billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.25,65,,409.504,Percent of total Billed Charges,65% of Total Billed Charges,55.13,44.1,,142.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,118.75,95,,5.8,Percent of Total Billed Charges,95% of Total Billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110,88,,5.368,Percent of Total Billed Charges,88% of Total Billed Charges,112.5,90,,5.496,Percent of Total Billed charges,90% of Total Billed Charges,55.13,125,
B&L BIPOLAR PENCIL 18G STR,2720002746,CDM,272,RC,,,Outpatient,,,28.70,18.66,,28.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21.81,76,,20.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.66,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,21.53,75,,91.448,Percent of Total Billed charges,75% of Total Billed Charges,28.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.66,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,17.22,60,,76.208,Percent of Total Billed Charges,60% of Total Billed Charges,25.83,90,,439.024,Percent of Total Billed Charges,90% of Total Billed Charges,12.92,45,,215.104,Percent of Total Billed Charges,45% of Total Billed Charges,25.83,90,,24.504,Percent of Total Billed Charges,90% of Total billed Charges,28.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.66,65,,210.6,Percent of total Billed Charges,65% of Total Billed Charges,12.66,44.1,,210.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,27.27,95,,25.864,Percent of Total Billed Charges,95% of Total Billed Charges,28.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.26,88,,23.96,Percent of Total Billed Charges,88% of Total Billed Charges,25.83,90,,24.504,Percent of Total Billed charges,90% of Total Billed Charges,12.66,28.7,
LXMJ37L LIGASURE XP MARYLND JW,2720002747,CDM,272,RC,,,Outpatient,,,1250.62,812.90,,1250.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,950.47,76,,478.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,900.45,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,937.97,75,,91.448,Percent of Total Billed charges,75% of Total Billed Charges,1250.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,900.45,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,750.37,60,,76.208,Percent of Total Billed Charges,60% of Total Billed Charges,1125.56,90,,829.264,Percent of Total Billed Charges,90% of Total Billed Charges,562.78,45,,120.328,Percent of Total Billed Charges,45% of Total Billed Charges,1125.56,90,,567,Percent of Total Billed Charges,90% of Total billed Charges,1250.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1250.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1250.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,812.9,65,,310.704,Percent of total Billed Charges,65% of Total Billed Charges,551.52,44.1,,117.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,1188.09,95,,598.504,Percent of Total Billed Charges,95% of Total Billed Charges,1250.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1100.55,88,,554.4,Percent of Total Billed Charges,88% of Total Billed Charges,1125.56,90,,567,Percent of Total Billed charges,90% of Total Billed Charges,551.52,1250.62,
LF2019 LIGASURE EXACT DISSECTR,2720002748,CDM,272,RC,,,Outpatient,,,1239.97,805.98,,1239.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,942.38,76,,246.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,892.78,72,,1202.128,Percent of Total Billed Charges,72% of Total Billed Charges,929.98,75,,1202.128,Percent of Total Billed charges,75% of Total Billed Charges,1239.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,892.78,72,,1202.128,Percent of Total Billed Charges,72% of Total Billed Charges,743.98,60,,1001.776,Percent of Total Billed Charges,60% of Total Billed Charges,1115.97,90,,62.448,Percent of Total Billed Charges,90% of Total Billed Charges,557.99,45,,10.784,Percent of Total Billed Charges,45% of Total Billed Charges,1115.97,90,,291.6,Percent of Total Billed Charges,90% of Total billed Charges,1239.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1239.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1239.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,805.98,65,,173.808,Percent of total Billed Charges,65% of Total Billed Charges,546.83,44.1,,10.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,1177.97,95,,307.8,Percent of Total Billed Charges,95% of Total Billed Charges,1239.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1091.17,88,,285.12,Percent of Total Billed Charges,88% of Total Billed Charges,1115.97,90,,291.6,Percent of Total Billed charges,90% of Total Billed Charges,546.83,1239.97,
BVI ANTERIOR CHAMBER CANNULAS,2720002750,CDM,272,RC,,,Outpatient,,,10.47,6.81,,10.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.96,76,,363.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.54,72,,2176.28,Percent of Total Billed Charges,72% of Total Billed Charges,7.85,75,,2176.28,Percent of Total Billed charges,75% of Total Billed Charges,10.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.54,72,,2176.28,Percent of Total Billed Charges,72% of Total Billed Charges,6.28,60,,1813.568,Percent of Total Billed Charges,60% of Total Billed Charges,9.42,90,,62.448,Percent of Total Billed Charges,90% of Total Billed Charges,4.71,45,,207.08,Percent of Total Billed Charges,45% of Total Billed Charges,9.42,90,,430.2,Percent of Total Billed Charges,90% of Total billed Charges,10.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.81,65,,15.576,Percent of total Billed Charges,65% of Total Billed Charges,4.62,44.1,,202.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.95,95,,454.104,Percent of Total Billed Charges,95% of Total Billed Charges,10.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.21,88,,420.64,Percent of Total Billed Charges,88% of Total Billed Charges,9.42,90,,430.2,Percent of Total Billed charges,90% of Total Billed Charges,4.62,10.47,
PDS 0 Z334H SUTURE CT-2,2720002751,CDM,272,RC,,,Outpatient,,,7.62,4.95,,7.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.79,76,,203.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.49,72,,2354.096,Percent of Total Billed Charges,72% of Total Billed Charges,5.72,75,,2354.096,Percent of Total Billed charges,75% of Total Billed Charges,7.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.49,72,,2354.096,Percent of Total Billed Charges,72% of Total Billed Charges,4.57,60,,1961.744,Percent of Total Billed Charges,60% of Total Billed Charges,6.86,90,,37.08,Percent of Total Billed Charges,90% of Total Billed Charges,3.43,45,,1,Percent of Total Billed Charges,45% of Total Billed Charges,6.86,90,,240.664,Percent of Total Billed Charges,90% of Total billed Charges,7.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.95,65,,299.12,Percent of total Billed Charges,65% of Total Billed Charges,3.36,44.1,,0.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.24,95,,254.032,Percent of Total Billed Charges,95% of Total Billed Charges,7.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.71,88,,235.312,Percent of Total Billed Charges,88% of Total Billed Charges,6.86,90,,240.664,Percent of Total Billed charges,90% of Total Billed Charges,3.36,7.62,
PDS 3-0 Z311H SUTURE SH-1,2720002752,CDM,272,RC,,,Outpatient,,,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,18.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,2249.952,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,2249.952,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,2249.952,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,1874.96,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,3004.848,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,76.984,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,21.568,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,1.448,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,75.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,22.76,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,21.088,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,21.568,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
Guideliner Coast 7F,2720002753,CDM,272,RC,C1887,HCPCS,Outpatient,,,1312.50,853.13,,1312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,997.5,76,,349.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,945,72,,2354.096,Percent of Total Billed Charges,72% of Total Billed Charges,984.38,75,,2354.096,Percent of Total Billed charges,75% of Total Billed Charges,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,945,72,,2354.096,Percent of Total Billed Charges,72% of Total Billed Charges,787.5,60,,1961.744,Percent of Total Billed Charges,60% of Total Billed Charges,1181.25,90,,303,Percent of Total Billed Charges,90% of Total Billed Charges,590.63,45,,512.192,Percent of Total Billed Charges,45% of Total Billed Charges,1181.25,90,,414.168,Percent of Total Billed Charges,90% of Total billed Charges,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,853.13,65,,111.2,Percent of total Billed Charges,65% of Total Billed Charges,578.81,44.1,,501.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,1246.88,95,,437.176,Percent of Total Billed Charges,95% of Total Billed Charges,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1155,88,,404.96,Percent of Total Billed Charges,88% of Total Billed Charges,1181.25,90,,414.168,Percent of Total Billed charges,90% of Total Billed Charges,578.81,1312.5,
EMERALD WIRE ST 0.035 X 260,2720002754,CDM,272,RC,C1769,HCPCS,Outpatient,,,65.00,42.25,,65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.4,76,,1.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.8,72,,2249.952,Percent of Total Billed Charges,72% of Total Billed Charges,48.75,75,,2249.952,Percent of Total Billed charges,75% of Total Billed Charges,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.8,72,,2249.952,Percent of Total Billed Charges,72% of Total Billed Charges,39,60,,1874.96,Percent of Total Billed Charges,60% of Total Billed Charges,58.5,90,,870,Percent of Total Billed Charges,90% of Total Billed Charges,29.25,45,,219.512,Percent of Total Billed Charges,45% of Total Billed Charges,58.5,90,,2,Percent of Total Billed Charges,90% of Total billed Charges,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.25,65,,739.832,Percent of total Billed Charges,65% of Total Billed Charges,28.67,44.1,,215.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,61.75,95,,2.112,Percent of Total Billed Charges,95% of Total Billed Charges,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.2,88,,1.96,Percent of Total Billed Charges,88% of Total Billed Charges,58.5,90,,2,Percent of Total Billed charges,90% of Total Billed Charges,28.67,65,
EMERALD WIRE JT 0.035 X 175,2720002755,CDM,272,RC,C1769,HCPCS,Outpatient,,,65.00,42.25,,65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.4,76,,130.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.8,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,48.75,75,,227.344,Percent of Total Billed charges,75% of Total Billed Charges,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.8,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,39,60,,189.456,Percent of Total Billed Charges,60% of Total Billed Charges,58.5,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,29.25,45,,414.632,Percent of Total Billed Charges,45% of Total Billed Charges,58.5,90,,153.976,Percent of Total Billed Charges,90% of Total billed Charges,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.25,65,,317.072,Percent of total Billed Charges,65% of Total Billed Charges,28.67,44.1,,406.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,61.75,95,,162.528,Percent of Total Billed Charges,95% of Total Billed Charges,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.2,88,,150.552,Percent of Total Billed Charges,88% of Total Billed Charges,58.5,90,,153.976,Percent of Total Billed charges,90% of Total Billed Charges,28.67,65,
EMERALD WIRE JT 0.035 X 150,2720002756,CDM,272,RC,C1769,HCPCS,Outpatient,,,65.00,42.25,,65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.4,76,,865.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.8,72,,273.704,Percent of Total Billed Charges,72% of Total Billed Charges,48.75,75,,273.704,Percent of Total Billed charges,75% of Total Billed Charges,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.8,72,,273.704,Percent of Total Billed Charges,72% of Total Billed Charges,39,60,,228.088,Percent of Total Billed Charges,60% of Total Billed Charges,58.5,90,,3677.672,Percent of Total Billed Charges,90% of Total Billed Charges,29.25,45,,31.224,Percent of Total Billed Charges,45% of Total Billed Charges,58.5,90,,1024.384,Percent of Total Billed Charges,90% of Total billed Charges,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.25,65,,598.912,Percent of total Billed Charges,65% of Total Billed Charges,28.67,44.1,,30.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,61.75,95,,1081.288,Percent of Total Billed Charges,95% of Total Billed Charges,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.2,88,,1001.616,Percent of Total Billed Charges,88% of Total Billed Charges,58.5,90,,1024.384,Percent of Total Billed charges,90% of Total Billed Charges,28.67,65,
EMERALD WIRE JT 0.035 X 260,2720002757,CDM,272,RC,C1769,HCPCS,Outpatient,,,65.00,42.25,,65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.4,76,,370.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.8,72,,273.704,Percent of Total Billed Charges,72% of Total Billed Charges,48.75,75,,273.704,Percent of Total Billed charges,75% of Total Billed Charges,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.8,72,,273.704,Percent of Total Billed Charges,72% of Total Billed Charges,39,60,,228.088,Percent of Total Billed Charges,60% of Total Billed Charges,58.5,90,,261.16,Percent of Total Billed Charges,90% of Total Billed Charges,29.25,45,,31.224,Percent of Total Billed Charges,45% of Total Billed Charges,58.5,90,,439.024,Percent of Total Billed Charges,90% of Total billed Charges,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.25,65,,45.096,Percent of total Billed Charges,65% of Total Billed Charges,28.67,44.1,,30.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,61.75,95,,463.408,Percent of Total Billed Charges,95% of Total Billed Charges,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.2,88,,429.264,Percent of Total Billed Charges,88% of Total Billed Charges,58.5,90,,439.024,Percent of Total Billed charges,90% of Total Billed Charges,28.67,65,
SUTURE 5-0 MERSILNE S-14 1760G,2720002758,CDM,272,RC,,,Outpatient,,,38.75,25.19,,38.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.45,76,,700.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.9,72,,273.704,Percent of Total Billed Charges,72% of Total Billed Charges,29.06,75,,273.704,Percent of Total Billed charges,75% of Total Billed Charges,38.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.9,72,,273.704,Percent of Total Billed Charges,72% of Total Billed Charges,23.25,60,,228.088,Percent of Total Billed Charges,60% of Total Billed Charges,34.88,90,,273.064,Percent of Total Billed Charges,90% of Total Billed Charges,17.44,45,,18.544,Percent of Total Billed Charges,45% of Total Billed Charges,34.88,90,,829.264,Percent of Total Billed Charges,90% of Total billed Charges,38.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.19,65,,45.096,Percent of total Billed Charges,65% of Total Billed Charges,17.09,44.1,,18.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.81,95,,875.328,Percent of Total Billed Charges,95% of Total Billed Charges,38.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.1,88,,810.832,Percent of Total Billed Charges,88% of Total Billed Charges,34.88,90,,829.264,Percent of Total Billed charges,90% of Total Billed Charges,17.09,38.75,
SUTURE 7-0 VICRYL J546G,2720002759,CDM,272,RC,,,Outpatient,,,37.87,24.62,,37.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.78,76,,52.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.27,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,28.4,75,,281.96,Percent of Total Billed charges,75% of Total Billed Charges,37.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.27,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,22.72,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,34.08,90,,89.696,Percent of Total Billed Charges,90% of Total Billed Charges,17.04,45,,1502.424,Percent of Total Billed Charges,45% of Total Billed Charges,34.08,90,,62.448,Percent of Total Billed Charges,90% of Total billed Charges,37.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.62,65,,26.784,Percent of total Billed Charges,65% of Total Billed Charges,16.7,44.1,,1472.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.98,95,,65.912,Percent of Total Billed Charges,95% of Total Billed Charges,37.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.33,88,,61.056,Percent of Total Billed Charges,88% of Total Billed Charges,34.08,90,,62.448,Percent of Total Billed charges,90% of Total Billed Charges,16.7,37.87,
INFINITI 5F JK3.5 100CM,2720002760,CDM,272,RC,C1887,HCPCS,Outpatient,,,90.00,58.50,,90,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.4,76,,52.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.8,72,,226.072,Percent of Total Billed Charges,72% of Total Billed Charges,67.5,75,,226.072,Percent of Total Billed charges,75% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.8,72,,226.072,Percent of Total Billed Charges,72% of Total Billed Charges,54,60,,188.392,Percent of Total Billed Charges,60% of Total Billed Charges,81,90,,51.592,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,45,,151.496,Percent of Total Billed Charges,45% of Total Billed Charges,81,90,,62.448,Percent of Total Billed Charges,90% of Total billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.5,65,,2170.168,Percent of total Billed Charges,65% of Total Billed Charges,39.69,44.1,,148.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.5,95,,65.912,Percent of Total Billed Charges,95% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,88,,61.056,Percent of Total Billed Charges,88% of Total Billed Charges,81,90,,62.448,Percent of Total Billed charges,90% of Total Billed Charges,39.69,90,
INFINITI 5F JK3.5 125CM,2720002761,CDM,272,RC,C1887,HCPCS,Outpatient,,,96.87,62.97,,96.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.62,76,,31.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.75,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,72.65,75,,281.96,Percent of Total Billed charges,75% of Total Billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.75,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,58.12,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,87.18,90,,58.744,Percent of Total Billed Charges,90% of Total Billed Charges,43.59,45,,435,Percent of Total Billed Charges,45% of Total Billed Charges,87.18,90,,37.08,Percent of Total Billed Charges,90% of Total billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.97,65,,218.832,Percent of total Billed Charges,65% of Total Billed Charges,42.72,44.1,,426.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,92.03,95,,39.144,Percent of Total Billed Charges,95% of Total Billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.25,88,,36.256,Percent of Total Billed Charges,88% of Total Billed Charges,87.18,90,,37.08,Percent of Total Billed charges,90% of Total Billed Charges,42.72,96.87,
INFINITI 5F JK4.0 100CM,2720002762,CDM,272,RC,C1887,HCPCS,Outpatient,,,90.00,58.50,,90,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.4,76,,2537.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.8,72,,226.072,Percent of Total Billed Charges,72% of Total Billed Charges,67.5,75,,226.072,Percent of Total Billed charges,75% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.8,72,,226.072,Percent of Total Billed Charges,72% of Total Billed Charges,54,60,,188.392,Percent of Total Billed Charges,60% of Total Billed Charges,81,90,,44.456,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,45,,2.88,Percent of Total Billed Charges,45% of Total Billed Charges,81,90,,3004.848,Percent of Total Billed Charges,90% of Total billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.5,65,,628.328,Percent of total Billed Charges,65% of Total Billed Charges,39.69,44.1,,2.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.5,95,,3171.784,Percent of Total Billed Charges,95% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,88,,2938.072,Percent of Total Billed Charges,88% of Total Billed Charges,81,90,,3004.848,Percent of Total Billed charges,90% of Total Billed Charges,39.69,90,
INFINITI 5F JK4.0 125CM,2720002763,CDM,272,RC,C1887,HCPCS,Outpatient,,,96.87,62.97,,96.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.62,76,,255.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.75,72,,226.072,Percent of Total Billed Charges,72% of Total Billed Charges,72.65,75,,226.072,Percent of Total Billed charges,75% of Total Billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.75,72,,226.072,Percent of Total Billed Charges,72% of Total Billed Charges,58.12,60,,188.392,Percent of Total Billed Charges,60% of Total Billed Charges,87.18,90,,150.024,Percent of Total Billed Charges,90% of Total Billed Charges,43.59,45,,1838.84,Percent of Total Billed Charges,45% of Total Billed Charges,87.18,90,,303,Percent of Total Billed Charges,90% of Total billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.97,65,,4.16,Percent of total Billed Charges,65% of Total Billed Charges,42.72,44.1,,1802.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,92.03,95,,319.832,Percent of Total Billed Charges,95% of Total Billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.25,88,,296.264,Percent of Total Billed Charges,88% of Total Billed Charges,87.18,90,,303,Percent of Total Billed charges,90% of Total Billed Charges,42.72,96.87,
INFINITI 5F TG 4.0 100CM,2720002764,CDM,272,RC,C1887,HCPCS,Outpatient,,,90.00,58.50,,90,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.4,76,,734.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.8,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,67.5,75,,281.96,Percent of Total Billed charges,75% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.8,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,54,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,81,90,,83.344,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,45,,130.576,Percent of Total Billed Charges,45% of Total Billed Charges,81,90,,870,Percent of Total Billed Charges,90% of Total billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.5,65,,2656.096,Percent of total Billed Charges,65% of Total Billed Charges,39.69,44.1,,127.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.5,95,,918.328,Percent of Total Billed Charges,95% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,88,,850.664,Percent of Total Billed Charges,88% of Total Billed Charges,81,90,,870,Percent of Total Billed charges,90% of Total Billed Charges,39.69,90,
INFINITI 5F TG 4.0 125CM,2720002765,CDM,272,RC,C1887,HCPCS,Outpatient,,,96.87,62.97,,96.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.62,76,,4.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.75,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,72.65,75,,281.96,Percent of Total Billed charges,75% of Total Billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.75,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,58.12,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,87.18,90,,137.328,Percent of Total Billed Charges,90% of Total Billed Charges,43.59,45,,136.536,Percent of Total Billed Charges,45% of Total Billed Charges,87.18,90,,5.76,Percent of Total Billed Charges,90% of Total billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.97,65,,188.616,Percent of total Billed Charges,65% of Total Billed Charges,42.72,44.1,,133.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,92.03,95,,6.08,Percent of Total Billed Charges,95% of Total Billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.25,88,,5.632,Percent of Total Billed Charges,88% of Total Billed Charges,87.18,90,,5.76,Percent of Total Billed charges,90% of Total Billed Charges,42.72,96.87,
INFINITI 5F TG 4.5 100CM,2720002766,CDM,272,RC,C1887,HCPCS,Outpatient,,,90.00,58.50,,90,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.4,76,,3105.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.8,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,67.5,75,,281.96,Percent of Total Billed charges,75% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.8,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,54,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,81,90,,88.112,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,45,,44.848,Percent of Total Billed Charges,45% of Total Billed Charges,81,90,,3677.672,Percent of Total Billed Charges,90% of Total billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.5,65,,197.216,Percent of total Billed Charges,65% of Total Billed Charges,39.69,44.1,,43.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.5,95,,3881.992,Percent of Total Billed Charges,95% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,88,,3595.944,Percent of Total Billed Charges,88% of Total Billed Charges,81,90,,3677.672,Percent of Total Billed charges,90% of Total Billed Charges,39.69,90,
INFINITI 5F TG 4.5 125CM,2720002767,CDM,272,RC,C1887,HCPCS,Outpatient,,,96.87,62.97,,96.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.62,76,,220.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.75,72,,226.072,Percent of Total Billed Charges,72% of Total Billed Charges,72.65,75,,226.072,Percent of Total Billed charges,75% of Total Billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.75,72,,226.072,Percent of Total Billed Charges,72% of Total Billed Charges,58.12,60,,188.392,Percent of Total Billed Charges,60% of Total Billed Charges,87.18,90,,114.304,Percent of Total Billed Charges,90% of Total Billed Charges,43.59,45,,25.8,Percent of Total Billed Charges,45% of Total Billed Charges,87.18,90,,261.16,Percent of Total Billed Charges,90% of Total billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.97,65,,64.784,Percent of total Billed Charges,65% of Total Billed Charges,42.72,44.1,,25.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,92.03,95,,275.664,Percent of Total Billed Charges,95% of Total Billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.25,88,,255.352,Percent of Total Billed Charges,88% of Total Billed Charges,87.18,90,,261.16,Percent of Total Billed charges,90% of Total Billed Charges,42.72,96.87,
INFINITI 6F JK3.5 100CM,2720002768,CDM,272,RC,C1887,HCPCS,Outpatient,,,90.00,58.50,,90,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.4,76,,230.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.8,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,67.5,75,,281.96,Percent of Total Billed charges,75% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.8,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,54,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,81,90,,95.256,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,45,,29.376,Percent of Total Billed Charges,45% of Total Billed Charges,81,90,,273.064,Percent of Total Billed Charges,90% of Total billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.5,65,,37.264,Percent of total Billed Charges,65% of Total Billed Charges,39.69,44.1,,28.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.5,95,,288.24,Percent of Total Billed Charges,95% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,88,,267,Percent of Total Billed Charges,88% of Total Billed Charges,81,90,,273.064,Percent of Total Billed charges,90% of Total Billed Charges,39.69,90,
INFINITI 6F JK3.5 125CM,2720002769,CDM,272,RC,C1887,HCPCS,Outpatient,,,96.87,62.97,,96.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.62,76,,75.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.75,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,72.65,75,,281.96,Percent of Total Billed charges,75% of Total Billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.75,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,58.12,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,87.18,90,,113.512,Percent of Total Billed Charges,90% of Total Billed Charges,43.59,45,,22.224,Percent of Total Billed Charges,45% of Total Billed Charges,87.18,90,,89.696,Percent of Total Billed Charges,90% of Total billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.97,65,,42.424,Percent of total Billed Charges,65% of Total Billed Charges,42.72,44.1,,21.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,92.03,95,,94.68,Percent of Total Billed Charges,95% of Total Billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.25,88,,87.704,Percent of Total Billed Charges,88% of Total Billed Charges,87.18,90,,89.696,Percent of Total Billed charges,90% of Total Billed Charges,42.72,96.87,
INFINITI 6F JK4.0 100CM,2720002770,CDM,272,RC,C1887,HCPCS,Outpatient,,,90.00,58.50,,90,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.4,76,,43.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.8,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,67.5,75,,227.344,Percent of Total Billed charges,75% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.8,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,54,60,,189.456,Percent of Total Billed Charges,60% of Total Billed Charges,81,90,,91.288,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,45,,75.016,Percent of Total Billed Charges,45% of Total Billed Charges,81,90,,51.592,Percent of Total Billed Charges,90% of Total billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.5,65,,108.352,Percent of total Billed Charges,65% of Total Billed Charges,39.69,44.1,,73.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.5,95,,54.464,Percent of Total Billed Charges,95% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,88,,50.448,Percent of Total Billed Charges,88% of Total Billed Charges,81,90,,51.592,Percent of Total Billed charges,90% of Total Billed Charges,39.69,90,
INFINITI 6F JK4.0 125CM,2720002771,CDM,272,RC,C1887,HCPCS,Outpatient,,,96.87,62.97,,96.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.62,76,,49.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.75,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,72.65,75,,227.344,Percent of Total Billed charges,75% of Total Billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.75,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,58.12,60,,189.456,Percent of Total Billed Charges,60% of Total Billed Charges,87.18,90,,132.568,Percent of Total Billed Charges,90% of Total Billed Charges,43.59,45,,41.672,Percent of Total Billed Charges,45% of Total Billed Charges,87.18,90,,58.744,Percent of Total Billed Charges,90% of Total billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.97,65,,29.64,Percent of total Billed Charges,65% of Total Billed Charges,42.72,44.1,,40.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,92.03,95,,62.008,Percent of Total Billed Charges,95% of Total Billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.25,88,,57.44,Percent of Total Billed Charges,88% of Total Billed Charges,87.18,90,,58.744,Percent of Total Billed charges,90% of Total Billed Charges,42.72,96.87,
INFINITI 6F TG4.0 100CM,2720002772,CDM,272,RC,C1887,HCPCS,Outpatient,,,90.00,58.50,,90,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.4,76,,37.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.8,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,67.5,75,,227.344,Percent of Total Billed charges,75% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.8,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,54,60,,189.456,Percent of Total Billed Charges,60% of Total Billed Charges,81,90,,132.568,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,45,,68.664,Percent of Total Billed Charges,45% of Total Billed Charges,81,90,,44.456,Percent of Total Billed Charges,90% of Total billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.5,65,,3884.112,Percent of total Billed Charges,65% of Total Billed Charges,39.69,44.1,,67.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.5,95,,46.92,Percent of Total Billed Charges,95% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,88,,43.464,Percent of Total Billed Charges,88% of Total Billed Charges,81,90,,44.456,Percent of Total Billed charges,90% of Total Billed Charges,39.69,90,
INFINITI 6F TG4.0 125CM,2720002773,CDM,272,RC,C1887,HCPCS,Outpatient,,,96.87,62.97,,96.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.62,76,,126.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.75,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,72.65,75,,227.344,Percent of Total Billed charges,75% of Total Billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.75,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,58.12,60,,189.456,Percent of Total Billed Charges,60% of Total Billed Charges,87.18,90,,132.568,Percent of Total Billed Charges,90% of Total Billed Charges,43.59,45,,44.056,Percent of Total Billed Charges,45% of Total Billed Charges,87.18,90,,150.024,Percent of Total Billed Charges,90% of Total billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.97,65,,103.768,Percent of total Billed Charges,65% of Total Billed Charges,42.72,44.1,,43.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,92.03,95,,158.36,Percent of Total Billed Charges,95% of Total Billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.25,88,,146.696,Percent of Total Billed Charges,88% of Total Billed Charges,87.18,90,,150.024,Percent of Total Billed charges,90% of Total Billed Charges,42.72,96.87,
INFINITI 6F TG4.5 100CM,2720002774,CDM,272,RC,C1887,HCPCS,Outpatient,,,90.00,58.50,,90,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.4,76,,70.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.8,72,,165.112,Percent of Total Billed Charges,72% of Total Billed Charges,67.5,75,,165.112,Percent of Total Billed charges,75% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.8,72,,165.112,Percent of Total Billed Charges,72% of Total Billed Charges,54,60,,137.592,Percent of Total Billed Charges,60% of Total Billed Charges,81,90,,132.568,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,45,,57.152,Percent of Total Billed Charges,45% of Total Billed Charges,81,90,,83.344,Percent of Total Billed Charges,90% of Total billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.5,65,,37.84,Percent of total Billed Charges,65% of Total Billed Charges,39.69,44.1,,56.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.5,95,,87.976,Percent of Total Billed Charges,95% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,88,,81.496,Percent of Total Billed Charges,88% of Total Billed Charges,81,90,,83.344,Percent of Total Billed charges,90% of Total Billed Charges,39.69,90,
INFINITI 6F TG4.5 125CM,2720002775,CDM,272,RC,C1887,HCPCS,Outpatient,,,96.87,62.97,,96.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.62,76,,115.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.75,72,,165.112,Percent of Total Billed Charges,72% of Total Billed Charges,72.65,75,,165.112,Percent of Total Billed charges,75% of Total Billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.75,72,,165.112,Percent of Total Billed Charges,72% of Total Billed Charges,58.12,60,,137.592,Percent of Total Billed Charges,60% of Total Billed Charges,87.18,90,,132.568,Percent of Total Billed Charges,90% of Total Billed Charges,43.59,45,,47.632,Percent of Total Billed Charges,45% of Total Billed Charges,87.18,90,,137.328,Percent of Total Billed Charges,90% of Total billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.97,65,,618.592,Percent of total Billed Charges,65% of Total Billed Charges,42.72,44.1,,46.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,92.03,95,,144.952,Percent of Total Billed Charges,95% of Total Billed Charges,96.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.25,88,,134.272,Percent of Total Billed Charges,88% of Total Billed Charges,87.18,90,,137.328,Percent of Total Billed charges,90% of Total Billed Charges,42.72,96.87,
"ULTRAPLEX 360 NDLE 20GX6""",2720002776,CDM,272,RC,,,Outpatient,,,35.32,22.96,,35.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.84,76,,74.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.43,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,26.49,75,,91.448,Percent of Total Billed charges,75% of Total Billed Charges,35.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.43,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,21.19,60,,76.208,Percent of Total Billed Charges,60% of Total Billed Charges,31.79,90,,132.568,Percent of Total Billed Charges,90% of Total Billed Charges,15.89,45,,56.76,Percent of Total Billed Charges,45% of Total Billed Charges,31.79,90,,88.112,Percent of Total Billed Charges,90% of Total billed Charges,35.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.96,65,,618.592,Percent of total Billed Charges,65% of Total Billed Charges,15.58,44.1,,55.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.55,95,,93.008,Percent of Total Billed Charges,95% of Total Billed Charges,35.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.08,88,,86.152,Percent of Total Billed Charges,88% of Total Billed Charges,31.79,90,,88.112,Percent of Total Billed charges,90% of Total Billed Charges,15.58,35.32,
FILSHIE CLIPS,2720002777,CDM,272,RC,,,Outpatient,,,326.75,212.39,,326.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,248.33,76,,96.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,235.26,72,,165.112,Percent of Total Billed Charges,72% of Total Billed Charges,245.06,75,,165.112,Percent of Total Billed charges,75% of Total Billed Charges,326.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.26,72,,165.112,Percent of Total Billed Charges,72% of Total Billed Charges,196.05,60,,137.592,Percent of Total Billed Charges,60% of Total Billed Charges,294.08,90,,132.568,Percent of Total Billed Charges,90% of Total Billed Charges,147.04,45,,45.648,Percent of Total Billed Charges,45% of Total Billed Charges,294.08,90,,114.304,Percent of Total Billed Charges,90% of Total billed Charges,326.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.39,65,,428.832,Percent of total Billed Charges,65% of Total Billed Charges,144.1,44.1,,44.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,310.41,95,,120.656,Percent of Total Billed Charges,95% of Total Billed Charges,326.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,287.54,88,,111.768,Percent of Total Billed Charges,88% of Total Billed Charges,294.08,90,,114.304,Percent of Total Billed charges,90% of Total Billed Charges,144.1,326.75,
STERISHOT II-ELITE KIT,2720002778,CDM,272,RC,,,Outpatient,,,879.00,571.35,,879,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,668.04,76,,80.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,632.88,72,,165.112,Percent of Total Billed Charges,72% of Total Billed Charges,659.25,75,,165.112,Percent of Total Billed charges,75% of Total Billed Charges,879,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,632.88,72,,165.112,Percent of Total Billed Charges,72% of Total Billed Charges,527.4,60,,137.592,Percent of Total Billed Charges,60% of Total Billed Charges,791.1,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,395.55,45,,66.28,Percent of Total Billed Charges,45% of Total Billed Charges,791.1,90,,95.256,Percent of Total Billed Charges,90% of Total billed Charges,879,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,879,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,879,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,571.35,65,,325.632,Percent of total Billed Charges,65% of Total Billed Charges,387.64,44.1,,64.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,835.05,95,,100.552,Percent of Total Billed Charges,95% of Total Billed Charges,879,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,773.52,88,,93.136,Percent of Total Billed Charges,88% of Total Billed Charges,791.1,90,,95.256,Percent of Total Billed charges,90% of Total Billed Charges,387.64,879,
NANOCROSS E 4F 3 X 60 X 150,2720002779,CDM,272,RC,C1725,HCPCS,Outpatient,,,625.00,406.25,,625,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475,76,,95.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450,72,,165.112,Percent of Total Billed Charges,72% of Total Billed Charges,468.75,75,,165.112,Percent of Total Billed charges,75% of Total Billed Charges,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450,72,,165.112,Percent of Total Billed Charges,72% of Total Billed Charges,375,60,,137.592,Percent of Total Billed Charges,60% of Total Billed Charges,562.5,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,281.25,45,,66.28,Percent of Total Billed Charges,45% of Total Billed Charges,562.5,90,,113.512,Percent of Total Billed Charges,90% of Total billed Charges,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.25,65,,308.44,Percent of total Billed Charges,65% of Total Billed Charges,275.63,44.1,,64.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.75,95,,119.824,Percent of Total Billed Charges,95% of Total Billed Charges,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550,88,,110.992,Percent of Total Billed Charges,88% of Total Billed Charges,562.5,90,,113.512,Percent of Total Billed charges,90% of Total Billed Charges,275.63,625,
NANOCROSS E 4F 4 X 60 X 150,2720002780,CDM,272,RC,C1725,HCPCS,Outpatient,,,625.00,406.25,,625,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475,76,,77.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450,72,,165.112,Percent of Total Billed Charges,72% of Total Billed Charges,468.75,75,,165.112,Percent of Total Billed charges,75% of Total Billed Charges,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450,72,,165.112,Percent of Total Billed Charges,72% of Total Billed Charges,375,60,,137.592,Percent of Total Billed Charges,60% of Total Billed Charges,562.5,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,281.25,45,,66.28,Percent of Total Billed Charges,45% of Total Billed Charges,562.5,90,,91.288,Percent of Total Billed Charges,90% of Total billed Charges,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.25,65,,325.632,Percent of total Billed Charges,65% of Total Billed Charges,275.63,44.1,,64.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.75,95,,96.36,Percent of Total Billed Charges,95% of Total Billed Charges,625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550,88,,89.264,Percent of Total Billed Charges,88% of Total Billed Charges,562.5,90,,91.288,Percent of Total Billed charges,90% of Total Billed Charges,275.63,625,
C2A12 GELPOINT V-PATH PLATFORM,2720002781,CDM,272,RC,,,Outpatient,,,1875.00,1218.75,,1875,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1425,76,,111.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1350,72,,165.112,Percent of Total Billed Charges,72% of Total Billed Charges,1406.25,75,,165.112,Percent of Total Billed charges,75% of Total Billed Charges,1875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1350,72,,165.112,Percent of Total Billed Charges,72% of Total Billed Charges,1125,60,,137.592,Percent of Total Billed Charges,60% of Total Billed Charges,1687.5,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,843.75,45,,66.28,Percent of Total Billed Charges,45% of Total Billed Charges,1687.5,90,,132.568,Percent of Total Billed Charges,90% of Total billed Charges,1875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1218.75,65,,308.44,Percent of total Billed Charges,65% of Total Billed Charges,826.88,44.1,,64.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,1781.25,95,,139.928,Percent of Total Billed Charges,95% of Total Billed Charges,1875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1650,88,,129.624,Percent of Total Billed Charges,88% of Total Billed Charges,1687.5,90,,132.568,Percent of Total Billed charges,90% of Total Billed Charges,826.88,1875,
ENDOSTITCH 10MM SUTURE,2720002782,CDM,272,RC,,,Outpatient,,,1071.75,696.64,,1071.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,814.53,76,,111.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,771.66,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,803.81,75,,113.04,Percent of Total Billed charges,75% of Total Billed Charges,1071.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771.66,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,643.05,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,964.58,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,482.29,45,,66.28,Percent of Total Billed Charges,45% of Total Billed Charges,964.58,90,,132.568,Percent of Total Billed Charges,90% of Total billed Charges,1071.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1071.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1071.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,696.64,65,,308.44,Percent of total Billed Charges,65% of Total Billed Charges,472.64,44.1,,64.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,1018.16,95,,139.928,Percent of Total Billed Charges,95% of Total Billed Charges,1071.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,943.14,88,,129.624,Percent of Total Billed Charges,88% of Total Billed Charges,964.58,90,,132.568,Percent of Total Billed charges,90% of Total Billed Charges,472.64,1071.75,
ENDOSTITCH POLYSORB 0,2720002783,CDM,272,RC,,,Outpatient,,,170.32,110.71,,170.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.44,76,,111.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,122.63,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,127.74,75,,113.04,Percent of Total Billed charges,75% of Total Billed Charges,170.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.63,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,102.19,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,153.29,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,76.64,45,,66.28,Percent of Total Billed Charges,45% of Total Billed Charges,153.29,90,,132.568,Percent of Total Billed Charges,90% of Total billed Charges,170.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.71,65,,325.632,Percent of total Billed Charges,65% of Total Billed Charges,75.11,44.1,,64.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,161.8,95,,139.928,Percent of Total Billed Charges,95% of Total Billed Charges,170.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.88,88,,129.624,Percent of Total Billed Charges,88% of Total Billed Charges,153.29,90,,132.568,Percent of Total Billed charges,90% of Total Billed Charges,75.11,170.32,
NEONATE CLOSED SUCTION 8FR,2720002784,CDM,272,RC,,,Outpatient,,,32.47,21.11,,32.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.68,76,,111.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.38,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,24.35,75,,113.04,Percent of Total Billed charges,75% of Total Billed Charges,32.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.38,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,19.48,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,29.22,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,14.61,45,,66.28,Percent of Total Billed Charges,45% of Total Billed Charges,29.22,90,,132.568,Percent of Total Billed Charges,90% of Total billed Charges,32.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.11,65,,308.44,Percent of total Billed Charges,65% of Total Billed Charges,14.32,44.1,,64.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.85,95,,139.928,Percent of Total Billed Charges,95% of Total Billed Charges,32.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.57,88,,129.624,Percent of Total Billed Charges,88% of Total Billed Charges,29.22,90,,132.568,Percent of Total Billed charges,90% of Total Billed Charges,14.32,32.47,
NEONATE CLOSED SUCTION 6FR,2720002785,CDM,272,RC,,,Outpatient,,,32.47,21.11,,32.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.68,76,,111.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.38,72,,13422.208,Percent of Total Billed Charges,72% of Total Billed Charges,24.35,75,,13422.208,Percent of Total Billed charges,75% of Total Billed Charges,32.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.38,72,,13422.208,Percent of Total Billed Charges,72% of Total Billed Charges,19.48,60,,11185.168,Percent of Total Billed Charges,60% of Total Billed Charges,29.22,90,,5378,Percent of Total Billed Charges,90% of Total Billed Charges,14.61,45,,20.52,Percent of Total Billed Charges,45% of Total Billed Charges,29.22,90,,132.568,Percent of Total Billed Charges,90% of Total billed Charges,32.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.11,65,,325.632,Percent of total Billed Charges,65% of Total Billed Charges,14.32,44.1,,20.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.85,95,,139.928,Percent of Total Billed Charges,95% of Total Billed Charges,32.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.57,88,,129.624,Percent of Total Billed Charges,88% of Total Billed Charges,29.22,90,,132.568,Percent of Total Billed charges,90% of Total Billed Charges,14.32,32.47,
INPACT AV 5F 4MM X 150MM X 130,2720002786,CDM,272,RC,C2623,HCPCS,Outpatient,,,4075.00,2648.75,,4075,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3097,76,,111.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2934,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,3056.25,75,,327.68,Percent of Total Billed charges,75% of Total Billed Charges,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2934,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,2445,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,3667.5,90,,143.68,Percent of Total Billed Charges,90% of Total Billed Charges,1833.75,45,,20.52,Percent of Total Billed Charges,45% of Total Billed Charges,3667.5,90,,132.568,Percent of Total Billed Charges,90% of Total billed Charges,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2648.75,65,,481,Percent of total Billed Charges,65% of Total Billed Charges,1797.08,44.1,,20.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,3871.25,95,,139.928,Percent of Total Billed Charges,95% of Total Billed Charges,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3586,88,,129.624,Percent of Total Billed Charges,88% of Total Billed Charges,3667.5,90,,132.568,Percent of Total Billed charges,90% of Total Billed Charges,1797.08,4075,
INPA AV 5F 5MM X 150MM X 130CM,2720002787,CDM,272,RC,C2623,HCPCS,Outpatient,,,4075.00,2648.75,,4075,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3097,76,,111.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2934,72,,74.936,Percent of Total Billed Charges,72% of Total Billed Charges,3056.25,75,,74.936,Percent of Total Billed charges,75% of Total Billed Charges,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2934,72,,74.936,Percent of Total Billed Charges,72% of Total Billed Charges,2445,60,,62.448,Percent of Total Billed Charges,60% of Total Billed Charges,3667.5,90,,52.392,Percent of Total Billed Charges,90% of Total Billed Charges,1833.75,45,,20.52,Percent of Total Billed Charges,45% of Total Billed Charges,3667.5,90,,132.568,Percent of Total Billed Charges,90% of Total billed Charges,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2648.75,65,,481,Percent of total Billed Charges,65% of Total Billed Charges,1797.08,44.1,,20.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,3871.25,95,,139.928,Percent of Total Billed Charges,95% of Total Billed Charges,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3586,88,,129.624,Percent of Total Billed Charges,88% of Total Billed Charges,3667.5,90,,132.568,Percent of Total Billed charges,90% of Total Billed Charges,1797.08,4075,
INPACT AV 5F 4MM X 40MM X 130C,2720002788,CDM,272,RC,C2623,HCPCS,Outpatient,,,4075.00,2648.75,,4075,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3097,76,,34.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2934,72,,74.936,Percent of Total Billed Charges,72% of Total Billed Charges,3056.25,75,,74.936,Percent of Total Billed charges,75% of Total Billed Charges,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2934,72,,74.936,Percent of Total Billed Charges,72% of Total Billed Charges,2445,60,,62.448,Percent of Total Billed Charges,60% of Total Billed Charges,3667.5,90,,856.512,Percent of Total Billed Charges,90% of Total Billed Charges,1833.75,45,,20.52,Percent of Total Billed Charges,45% of Total Billed Charges,3667.5,90,,41.04,Percent of Total Billed Charges,90% of Total billed Charges,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2648.75,65,,458.072,Percent of total Billed Charges,65% of Total Billed Charges,1797.08,44.1,,20.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,3871.25,95,,43.32,Percent of Total Billed Charges,95% of Total Billed Charges,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3586,88,,40.128,Percent of Total Billed Charges,88% of Total Billed Charges,3667.5,90,,41.04,Percent of Total Billed charges,90% of Total Billed Charges,1797.08,4075,
"VCP335H VICRYL 1 CT-2,1X27",2720002789,CDM,272,RC,,,Outpatient,,,5.03,3.27,,5.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.82,76,,34.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.62,72,,74.936,Percent of Total Billed Charges,72% of Total Billed Charges,3.77,75,,74.936,Percent of Total Billed charges,75% of Total Billed Charges,5.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.62,72,,74.936,Percent of Total Billed Charges,72% of Total Billed Charges,3.02,60,,62.448,Percent of Total Billed Charges,60% of Total Billed Charges,4.53,90,,856.512,Percent of Total Billed Charges,90% of Total Billed Charges,2.26,45,,20.52,Percent of Total Billed Charges,45% of Total Billed Charges,4.53,90,,41.04,Percent of Total Billed Charges,90% of Total billed Charges,5.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.27,65,,481,Percent of total Billed Charges,65% of Total Billed Charges,2.22,44.1,,20.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.78,95,,43.32,Percent of Total Billed Charges,95% of Total Billed Charges,5.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.43,88,,40.128,Percent of Total Billed Charges,88% of Total Billed Charges,4.53,90,,41.04,Percent of Total Billed charges,90% of Total Billed Charges,2.22,5.03,
VCP496ZH VCL+UD 4-0 S/A PS-2,2720002790,CDM,272,RC,,,Outpatient,,,12.75,8.29,,12.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.69,76,,34.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.18,72,,55.248,Percent of Total Billed Charges,72% of Total Billed Charges,9.56,75,,55.248,Percent of Total Billed charges,75% of Total Billed Charges,12.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.18,72,,55.248,Percent of Total Billed Charges,72% of Total Billed Charges,7.65,60,,46.04,Percent of Total Billed Charges,60% of Total Billed Charges,11.48,90,,593.76,Percent of Total Billed Charges,90% of Total Billed Charges,5.74,45,,20.52,Percent of Total Billed Charges,45% of Total Billed Charges,11.48,90,,41.04,Percent of Total Billed Charges,90% of Total billed Charges,12.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.29,65,,675.92,Percent of total Billed Charges,65% of Total Billed Charges,5.62,44.1,,20.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.11,95,,43.32,Percent of Total Billed Charges,95% of Total Billed Charges,12.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.22,88,,40.128,Percent of Total Billed Charges,88% of Total Billed Charges,11.48,90,,41.04,Percent of Total Billed charges,90% of Total Billed Charges,5.62,12.75,
"ETHIBOND 0 CT-2 CR GRN, CX27D",2720002791,CDM,272,RC,,,Outpatient,,,31.50,20.48,,31.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.94,76,,34.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.68,72,,55.248,Percent of Total Billed Charges,72% of Total Billed Charges,23.63,75,,55.248,Percent of Total Billed charges,75% of Total Billed Charges,31.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.68,72,,55.248,Percent of Total Billed Charges,72% of Total Billed Charges,18.9,60,,46.04,Percent of Total Billed Charges,60% of Total Billed Charges,28.35,90,,450.88,Percent of Total Billed Charges,90% of Total Billed Charges,14.18,45,,20.52,Percent of Total Billed Charges,45% of Total Billed Charges,28.35,90,,41.04,Percent of Total Billed Charges,90% of Total billed Charges,31.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.48,65,,3345.776,Percent of total Billed Charges,65% of Total Billed Charges,13.89,44.1,,20.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.93,95,,43.32,Percent of Total Billed Charges,95% of Total Billed Charges,31.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.72,88,,40.128,Percent of Total Billed Charges,88% of Total Billed Charges,28.35,90,,41.04,Percent of Total Billed charges,90% of Total Billed Charges,13.89,31.5,
"ETHIBOND 0 CT-1 CR GREEN,CX21D",2720002792,CDM,272,RC,,,Outpatient,,,31.98,20.79,,31.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.3,76,,34.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.03,72,,55.248,Percent of Total Billed Charges,72% of Total Billed Charges,23.99,75,,55.248,Percent of Total Billed charges,75% of Total Billed Charges,31.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.03,72,,55.248,Percent of Total Billed Charges,72% of Total Billed Charges,19.19,60,,46.04,Percent of Total Billed Charges,60% of Total Billed Charges,28.78,90,,427.072,Percent of Total Billed Charges,90% of Total Billed Charges,14.39,45,,2689,Percent of Total Billed Charges,45% of Total Billed Charges,28.78,90,,41.04,Percent of Total Billed Charges,90% of Total billed Charges,31.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.79,65,,481,Percent of total Billed Charges,65% of Total Billed Charges,14.1,44.1,,2635.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.38,95,,43.32,Percent of Total Billed Charges,95% of Total Billed Charges,31.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.14,88,,40.128,Percent of Total Billed Charges,88% of Total Billed Charges,28.78,90,,41.04,Percent of Total Billed charges,90% of Total Billed Charges,14.1,31.98,
"VCP232H VICRYL 3-0 CT-2, 1X27",2720002793,CDM,272,RC,,,Outpatient,,,5.00,3.25,,5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.8,76,,34.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.6,72,,55.248,Percent of Total Billed Charges,72% of Total Billed Charges,3.75,75,,55.248,Percent of Total Billed charges,75% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.6,72,,55.248,Percent of Total Billed Charges,72% of Total Billed Charges,3,60,,46.04,Percent of Total Billed Charges,60% of Total Billed Charges,4.5,90,,450.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.25,45,,71.84,Percent of Total Billed Charges,45% of Total Billed Charges,4.5,90,,41.04,Percent of Total Billed Charges,90% of Total billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.25,65,,492.464,Percent of total Billed Charges,65% of Total Billed Charges,2.21,44.1,,70.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.75,95,,43.32,Percent of Total Billed Charges,95% of Total Billed Charges,5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.4,88,,40.128,Percent of Total Billed Charges,88% of Total Billed Charges,4.5,90,,41.04,Percent of Total Billed charges,90% of Total Billed Charges,2.21,5,
"VCP333H VICRYL 2-0 CT-2, 1X27",2720002794,CDM,272,RC,,,Outpatient,,,4.93,3.20,,4.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.75,76,,34.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.55,72,,55.248,Percent of Total Billed Charges,72% of Total Billed Charges,3.7,75,,55.248,Percent of Total Billed charges,75% of Total Billed Charges,4.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.55,72,,55.248,Percent of Total Billed Charges,72% of Total Billed Charges,2.96,60,,46.04,Percent of Total Billed Charges,60% of Total Billed Charges,4.44,90,,427.072,Percent of Total Billed Charges,90% of Total Billed Charges,2.22,45,,26.2,Percent of Total Billed Charges,45% of Total Billed Charges,4.44,90,,41.04,Percent of Total Billed Charges,90% of Total billed Charges,4.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.2,65,,444.312,Percent of total Billed Charges,65% of Total Billed Charges,2.17,44.1,,25.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.68,95,,43.32,Percent of Total Billed Charges,95% of Total Billed Charges,4.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.34,88,,40.128,Percent of Total Billed Charges,88% of Total Billed Charges,4.44,90,,41.04,Percent of Total Billed charges,90% of Total Billed Charges,2.17,4.93,
"VCP426H VICRYL 4-0 PS-2, 1X27",2720002795,CDM,272,RC,,,Outpatient,,,12.98,8.44,,12.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.86,76,,4541.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.35,72,,60.96,Percent of Total Billed Charges,72% of Total Billed Charges,9.74,75,,60.96,Percent of Total Billed charges,75% of Total Billed Charges,12.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.35,72,,60.96,Percent of Total Billed Charges,72% of Total Billed Charges,7.79,60,,50.8,Percent of Total Billed Charges,60% of Total Billed Charges,11.68,90,,427.072,Percent of Total Billed Charges,90% of Total Billed Charges,5.84,45,,428.256,Percent of Total Billed Charges,45% of Total Billed Charges,11.68,90,,5378,Percent of Total Billed Charges,90% of Total billed Charges,12.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.44,65,,324.488,Percent of total Billed Charges,65% of Total Billed Charges,5.72,44.1,,419.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.33,95,,5676.776,Percent of Total Billed Charges,95% of Total Billed Charges,12.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.42,88,,5258.488,Percent of Total Billed Charges,88% of Total Billed Charges,11.68,90,,5378,Percent of Total Billed charges,90% of Total Billed Charges,5.72,12.98,
"VCP428H VICRYL 2-0 PS-2, 1X27",2720002796,CDM,272,RC,,,Outpatient,,,12.75,8.29,,12.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.69,76,,121.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.18,72,,78.112,Percent of Total Billed Charges,72% of Total Billed Charges,9.56,75,,78.112,Percent of Total Billed charges,75% of Total Billed Charges,12.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.18,72,,78.112,Percent of Total Billed Charges,72% of Total Billed Charges,7.65,60,,65.096,Percent of Total Billed Charges,60% of Total Billed Charges,11.48,90,,450.88,Percent of Total Billed Charges,90% of Total Billed Charges,5.74,45,,428.256,Percent of Total Billed Charges,45% of Total Billed Charges,11.48,90,,143.68,Percent of Total Billed Charges,90% of Total billed Charges,12.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.29,65,,1898.2,Percent of total Billed Charges,65% of Total Billed Charges,5.62,44.1,,419.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.11,95,,151.656,Percent of Total Billed Charges,95% of Total Billed Charges,12.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.22,88,,140.48,Percent of Total Billed Charges,88% of Total Billed Charges,11.48,90,,143.68,Percent of Total Billed charges,90% of Total Billed Charges,5.62,12.75,
CELLONA 10CM X 3M,2720002797,CDM,272,RC,,,Outpatient,,,8.00,5.20,,8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.08,76,,44.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.76,72,,71.128,Percent of Total Billed Charges,72% of Total Billed Charges,6,75,,71.128,Percent of Total Billed charges,75% of Total Billed Charges,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.76,72,,71.128,Percent of Total Billed Charges,72% of Total Billed Charges,4.8,60,,59.272,Percent of Total Billed Charges,60% of Total Billed Charges,7.2,90,,427.072,Percent of Total Billed Charges,90% of Total Billed Charges,3.6,45,,296.88,Percent of Total Billed Charges,45% of Total Billed Charges,7.2,90,,52.392,Percent of Total Billed Charges,90% of Total billed Charges,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.2,65,,1899.344,Percent of total Billed Charges,65% of Total Billed Charges,3.53,44.1,,290.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.6,95,,55.304,Percent of Total Billed Charges,95% of Total Billed Charges,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.04,88,,51.232,Percent of Total Billed Charges,88% of Total Billed Charges,7.2,90,,52.392,Percent of Total Billed charges,90% of Total Billed Charges,3.53,8,
CELLONA 15CM X 3M,2720002798,CDM,272,RC,,,Outpatient,,,13.25,8.61,,13.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.07,76,,723.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.54,72,,55.248,Percent of Total Billed Charges,72% of Total Billed Charges,9.94,75,,55.248,Percent of Total Billed charges,75% of Total Billed Charges,13.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.54,72,,55.248,Percent of Total Billed Charges,72% of Total Billed Charges,7.95,60,,46.04,Percent of Total Billed Charges,60% of Total Billed Charges,11.93,90,,450.88,Percent of Total Billed Charges,90% of Total Billed Charges,5.96,45,,225.44,Percent of Total Billed Charges,45% of Total Billed Charges,11.93,90,,856.512,Percent of Total Billed Charges,90% of Total billed Charges,13.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.61,65,,324.488,Percent of total Billed Charges,65% of Total Billed Charges,5.84,44.1,,220.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.59,95,,904.096,Percent of Total Billed Charges,95% of Total Billed Charges,13.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.66,88,,837.48,Percent of Total Billed Charges,88% of Total Billed Charges,11.93,90,,856.512,Percent of Total Billed charges,90% of Total Billed Charges,5.84,13.25,
COMPRILAN 6CM X 5M,2720002799,CDM,272,RC,,,Outpatient,,,21.25,13.81,,21.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.15,76,,723.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.3,72,,78.112,Percent of Total Billed Charges,72% of Total Billed Charges,15.94,75,,78.112,Percent of Total Billed charges,75% of Total Billed Charges,21.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.3,72,,78.112,Percent of Total Billed Charges,72% of Total Billed Charges,12.75,60,,65.096,Percent of Total Billed Charges,60% of Total Billed Charges,19.13,90,,666,Percent of Total Billed Charges,90% of Total Billed Charges,9.56,45,,213.536,Percent of Total Billed Charges,45% of Total Billed Charges,19.13,90,,856.512,Percent of Total Billed Charges,90% of Total billed Charges,21.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.81,65,,405.896,Percent of total Billed Charges,65% of Total Billed Charges,9.37,44.1,,209.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.19,95,,904.096,Percent of Total Billed Charges,95% of Total Billed Charges,21.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.7,88,,837.48,Percent of Total Billed Charges,88% of Total Billed Charges,19.13,90,,856.512,Percent of Total Billed charges,90% of Total Billed Charges,9.37,21.25,
COMPRILAN 8CM X 5M,2720002800,CDM,272,RC,,,Outpatient,,,25.50,16.58,,25.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.38,76,,501.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.36,72,,78.112,Percent of Total Billed Charges,72% of Total Billed Charges,19.13,75,,78.112,Percent of Total Billed charges,75% of Total Billed Charges,25.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.36,72,,78.112,Percent of Total Billed Charges,72% of Total Billed Charges,15.3,60,,65.096,Percent of Total Billed Charges,60% of Total Billed Charges,22.95,90,,666,Percent of Total Billed Charges,90% of Total Billed Charges,11.48,45,,225.44,Percent of Total Billed Charges,45% of Total Billed Charges,22.95,90,,593.76,Percent of Total Billed Charges,90% of Total billed Charges,25.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.58,65,,2402.128,Percent of total Billed Charges,65% of Total Billed Charges,11.25,44.1,,220.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.23,95,,626.752,Percent of Total Billed Charges,95% of Total Billed Charges,25.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.44,88,,580.568,Percent of Total Billed Charges,88% of Total Billed Charges,22.95,90,,593.76,Percent of Total Billed charges,90% of Total Billed Charges,11.25,25.5,
COMPRILAN 10CM X 5M,2720002801,CDM,272,RC,,,Outpatient,,,28.75,18.69,,28.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21.85,76,,380.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.7,72,,78.112,Percent of Total Billed Charges,72% of Total Billed Charges,21.56,75,,78.112,Percent of Total Billed charges,75% of Total Billed Charges,28.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.7,72,,78.112,Percent of Total Billed Charges,72% of Total Billed Charges,17.25,60,,65.096,Percent of Total Billed Charges,60% of Total Billed Charges,25.88,90,,634.248,Percent of Total Billed Charges,90% of Total Billed Charges,12.94,45,,213.536,Percent of Total Billed Charges,45% of Total Billed Charges,25.88,90,,450.88,Percent of Total Billed Charges,90% of Total billed Charges,28.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.69,65,,405.896,Percent of total Billed Charges,65% of Total Billed Charges,12.68,44.1,,209.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,27.31,95,,475.928,Percent of Total Billed Charges,95% of Total Billed Charges,28.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.3,88,,440.856,Percent of Total Billed Charges,88% of Total Billed Charges,25.88,90,,450.88,Percent of Total Billed charges,90% of Total Billed Charges,12.68,28.75,
COMPRILAN 12CM X 5M,2720002802,CDM,272,RC,,,Outpatient,,,35.00,22.75,,35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.6,76,,360.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.2,72,,55.248,Percent of Total Billed Charges,72% of Total Billed Charges,26.25,75,,55.248,Percent of Total Billed charges,75% of Total Billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.2,72,,55.248,Percent of Total Billed Charges,72% of Total Billed Charges,21,60,,46.04,Percent of Total Billed Charges,60% of Total Billed Charges,31.5,90,,666,Percent of Total Billed Charges,90% of Total Billed Charges,15.75,45,,213.536,Percent of Total Billed Charges,45% of Total Billed Charges,31.5,90,,427.072,Percent of Total Billed Charges,90% of Total billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.75,65,,405.896,Percent of total Billed Charges,65% of Total Billed Charges,15.44,44.1,,209.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.25,95,,450.792,Percent of Total Billed Charges,95% of Total Billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.8,88,,417.576,Percent of Total Billed Charges,88% of Total Billed Charges,31.5,90,,427.072,Percent of Total Billed charges,90% of Total Billed Charges,15.44,35,
TG SZ9 - 8.5CM X 20M,2720002803,CDM,272,RC,,,Outpatient,,,43.70,28.41,,43.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33.21,76,,380.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,31.46,72,,806.504,Percent of Total Billed Charges,72% of Total Billed Charges,32.78,75,,806.504,Percent of Total Billed charges,75% of Total Billed Charges,43.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.46,72,,806.504,Percent of Total Billed Charges,72% of Total Billed Charges,26.22,60,,672.088,Percent of Total Billed Charges,60% of Total Billed Charges,39.33,90,,935.896,Percent of Total Billed Charges,90% of Total Billed Charges,19.67,45,,225.44,Percent of Total Billed Charges,45% of Total Billed Charges,39.33,90,,450.88,Percent of Total Billed Charges,90% of Total billed Charges,43.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.41,65,,405.896,Percent of total Billed Charges,65% of Total Billed Charges,19.27,44.1,,220.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.52,95,,475.928,Percent of Total Billed Charges,95% of Total Billed Charges,43.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.46,88,,440.856,Percent of Total Billed Charges,88% of Total Billed Charges,39.33,90,,450.88,Percent of Total Billed charges,90% of Total Billed Charges,19.27,43.7,
TG SZ6 - 6.5CM X 20M,2720002804,CDM,272,RC,,,Outpatient,,,38.65,25.12,,38.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.37,76,,360.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.83,72,,434.368,Percent of Total Billed Charges,72% of Total Billed Charges,28.99,75,,434.368,Percent of Total Billed charges,75% of Total Billed Charges,38.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.83,72,,434.368,Percent of Total Billed Charges,72% of Total Billed Charges,23.19,60,,361.976,Percent of Total Billed Charges,60% of Total Billed Charges,34.79,90,,4632.616,Percent of Total Billed Charges,90% of Total Billed Charges,17.39,45,,213.536,Percent of Total Billed Charges,45% of Total Billed Charges,34.79,90,,427.072,Percent of Total Billed Charges,90% of Total billed Charges,38.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.12,65,,324.488,Percent of total Billed Charges,65% of Total Billed Charges,17.04,44.1,,209.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.72,95,,450.792,Percent of Total Billed Charges,95% of Total Billed Charges,38.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.01,88,,417.576,Percent of Total Billed Charges,88% of Total Billed Charges,34.79,90,,427.072,Percent of Total Billed charges,90% of Total Billed Charges,17.04,38.65,
KOMPREX FOAM SM KIDNEY9CM X4CM,2720002805,CDM,272,RC,,,Outpatient,,,7.40,4.81,,7.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.62,76,,360.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.33,72,,732.84,Percent of Total Billed Charges,72% of Total Billed Charges,5.55,75,,732.84,Percent of Total Billed charges,75% of Total Billed Charges,7.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.33,72,,732.84,Percent of Total Billed Charges,72% of Total Billed Charges,4.44,60,,610.696,Percent of Total Billed Charges,60% of Total Billed Charges,6.66,90,,666,Percent of Total Billed Charges,90% of Total Billed Charges,3.33,45,,225.44,Percent of Total Billed Charges,45% of Total Billed Charges,6.66,90,,427.072,Percent of Total Billed Charges,90% of Total billed Charges,7.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.81,65,,405.896,Percent of total Billed Charges,65% of Total Billed Charges,3.26,44.1,,220.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.03,95,,450.792,Percent of Total Billed Charges,95% of Total Billed Charges,7.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.51,88,,417.576,Percent of Total Billed Charges,88% of Total Billed Charges,6.66,90,,427.072,Percent of Total Billed charges,90% of Total Billed Charges,3.26,7.4,
MOLLELAST 4CM X 4M,2720002806,CDM,272,RC,,,Outpatient,,,1.05,0.68,,1.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.8,76,,380.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.76,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,0.79,75,,360.072,Percent of Total Billed charges,75% of Total Billed Charges,1.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.76,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,0.63,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,0.95,90,,681.88,Percent of Total Billed Charges,90% of Total Billed Charges,0.47,45,,333,Percent of Total Billed Charges,45% of Total Billed Charges,0.95,90,,450.88,Percent of Total Billed Charges,90% of Total billed Charges,1.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.68,65,,324.488,Percent of total Billed Charges,65% of Total Billed Charges,0.46,44.1,,326.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,1,95,,475.928,Percent of Total Billed Charges,95% of Total Billed Charges,1.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.92,88,,440.856,Percent of Total Billed Charges,88% of Total Billed Charges,0.95,90,,450.88,Percent of Total Billed charges,90% of Total Billed Charges,0.46,1.05,
MOLLELAST 6CM X 4M,2720002807,CDM,272,RC,,,Outpatient,,,1.05,0.68,,1.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.8,76,,360.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.76,72,,706.168,Percent of Total Billed Charges,72% of Total Billed Charges,0.79,75,,706.168,Percent of Total Billed charges,75% of Total Billed Charges,1.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.76,72,,706.168,Percent of Total Billed Charges,72% of Total Billed Charges,0.63,60,,588.472,Percent of Total Billed Charges,60% of Total Billed Charges,0.95,90,,615.2,Percent of Total Billed Charges,90% of Total Billed Charges,0.47,45,,333,Percent of Total Billed Charges,45% of Total Billed Charges,0.95,90,,427.072,Percent of Total Billed Charges,90% of Total billed Charges,1.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.68,65,,405.896,Percent of total Billed Charges,65% of Total Billed Charges,0.46,44.1,,326.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,1,95,,450.792,Percent of Total Billed Charges,95% of Total Billed Charges,1.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.92,88,,417.576,Percent of Total Billed Charges,88% of Total Billed Charges,0.95,90,,427.072,Percent of Total Billed charges,90% of Total Billed Charges,0.46,1.05,
"ELASTO-SOFT 1"" X 4.1 YDS",2720002808,CDM,272,RC,,,Outpatient,,,0.85,0.55,,0.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.65,76,,380.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.61,72,,1185.624,Percent of Total Billed Charges,72% of Total Billed Charges,0.64,75,,1185.624,Percent of Total Billed charges,75% of Total Billed Charges,0.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.61,72,,1185.624,Percent of Total Billed Charges,72% of Total Billed Charges,0.51,60,,988.016,Percent of Total Billed Charges,60% of Total Billed Charges,0.77,90,,449.296,Percent of Total Billed Charges,90% of Total Billed Charges,0.38,45,,317.128,Percent of Total Billed Charges,45% of Total Billed Charges,0.77,90,,450.88,Percent of Total Billed Charges,90% of Total billed Charges,0.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.55,65,,405.896,Percent of total Billed Charges,65% of Total Billed Charges,0.37,44.1,,310.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.81,95,,475.928,Percent of Total Billed Charges,95% of Total Billed Charges,0.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.75,88,,440.856,Percent of Total Billed Charges,88% of Total Billed Charges,0.77,90,,450.88,Percent of Total Billed charges,90% of Total Billed Charges,0.37,0.85,
ROSIDAL SOFT 10CM X0.4CM X2.5M,2720002809,CDM,272,RC,,,Outpatient,,,19.95,12.97,,19.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.16,76,,562.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.36,72,,12393.44,Percent of Total Billed Charges,72% of Total Billed Charges,14.96,75,,12393.44,Percent of Total Billed charges,75% of Total Billed Charges,19.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.36,72,,12393.44,Percent of Total Billed Charges,72% of Total Billed Charges,11.97,60,,10327.864,Percent of Total Billed Charges,60% of Total Billed Charges,17.96,90,,2628.272,Percent of Total Billed Charges,90% of Total Billed Charges,8.98,45,,333,Percent of Total Billed Charges,45% of Total Billed Charges,17.96,90,,666,Percent of Total Billed Charges,90% of Total billed Charges,19.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.97,65,,405.896,Percent of total Billed Charges,65% of Total Billed Charges,8.8,44.1,,326.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.95,95,,703,Percent of Total Billed Charges,95% of Total Billed Charges,19.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.56,88,,651.2,Percent of Total Billed Charges,88% of Total Billed Charges,17.96,90,,666,Percent of Total Billed charges,90% of Total Billed Charges,8.8,19.95,
ROSIDAL SOFT15CM X 0.4CM X2.5M,2720002810,CDM,272,RC,,,Outpatient,,,34.00,22.10,,34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.84,76,,562.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.48,72,,428.656,Percent of Total Billed Charges,72% of Total Billed Charges,25.5,75,,428.656,Percent of Total Billed charges,75% of Total Billed Charges,34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.48,72,,428.656,Percent of Total Billed Charges,72% of Total Billed Charges,20.4,60,,357.208,Percent of Total Billed Charges,60% of Total Billed Charges,30.6,90,,2629.856,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,45,,467.944,Percent of Total Billed Charges,45% of Total Billed Charges,30.6,90,,666,Percent of Total Billed Charges,90% of Total billed Charges,34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.1,65,,3332.016,Percent of total Billed Charges,65% of Total Billed Charges,14.99,44.1,,458.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.3,95,,703,Percent of Total Billed Charges,95% of Total Billed Charges,34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.92,88,,651.2,Percent of Total Billed Charges,88% of Total Billed Charges,30.6,90,,666,Percent of Total Billed charges,90% of Total Billed Charges,14.99,34,
STRYKER 3.2X450MM K-WIRE,2720002811,CDM,272,RC,,,Outpatient,,,495.00,321.75,,495,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,376.2,76,,535.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,356.4,72,,428.656,Percent of Total Billed Charges,72% of Total Billed Charges,371.25,75,,428.656,Percent of Total Billed charges,75% of Total Billed Charges,495,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.4,72,,428.656,Percent of Total Billed Charges,72% of Total Billed Charges,297,60,,357.208,Percent of Total Billed Charges,60% of Total Billed Charges,445.5,90,,449.296,Percent of Total Billed Charges,90% of Total Billed Charges,222.75,45,,2316.312,Percent of Total Billed Charges,45% of Total Billed Charges,445.5,90,,634.248,Percent of Total Billed Charges,90% of Total billed Charges,495,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,321.75,65,,2727.768,Percent of total Billed Charges,65% of Total Billed Charges,218.3,44.1,,2269.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,470.25,95,,669.488,Percent of Total Billed Charges,95% of Total Billed Charges,495,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.6,88,,620.152,Percent of Total Billed Charges,88% of Total Billed Charges,445.5,90,,634.248,Percent of Total Billed charges,90% of Total Billed Charges,218.3,495,
STRYKER 8X510MM REAMER SHAFT,2720002812,CDM,272,RC,,,Outpatient,,,1765.50,1147.58,,1765.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1341.78,76,,562.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1271.16,72,,30.528,Percent of Total Billed Charges,72% of Total Billed Charges,1324.13,75,,30.528,Percent of Total Billed charges,75% of Total Billed Charges,1765.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1271.16,72,,30.528,Percent of Total Billed Charges,72% of Total Billed Charges,1059.3,60,,25.44,Percent of Total Billed Charges,60% of Total Billed Charges,1588.95,90,,562.008,Percent of Total Billed Charges,90% of Total Billed Charges,794.48,45,,333,Percent of Total Billed Charges,45% of Total Billed Charges,1588.95,90,,666,Percent of Total Billed Charges,90% of Total billed Charges,1765.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1765.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1765.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1147.58,65,,2729.48,Percent of total Billed Charges,65% of Total Billed Charges,778.59,44.1,,326.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,1677.23,95,,703,Percent of Total Billed Charges,95% of Total Billed Charges,1765.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1553.64,88,,651.2,Percent of Total Billed Charges,88% of Total Billed Charges,1588.95,90,,666,Percent of Total Billed charges,90% of Total Billed Charges,778.59,1765.5,
STRYKER 3X285MM WIRE,2720002813,CDM,272,RC,,,Outpatient,,,475.00,308.75,,475,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,361,76,,790.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,342,72,,102.96,Percent of Total Billed Charges,72% of Total Billed Charges,356.25,75,,102.96,Percent of Total Billed charges,75% of Total Billed Charges,475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342,72,,102.96,Percent of Total Billed Charges,72% of Total Billed Charges,285,60,,85.8,Percent of Total Billed Charges,60% of Total Billed Charges,427.5,90,,3326.024,Percent of Total Billed Charges,90% of Total Billed Charges,213.75,45,,340.936,Percent of Total Billed Charges,45% of Total Billed Charges,427.5,90,,935.896,Percent of Total Billed Charges,90% of Total billed Charges,475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.75,65,,416.792,Percent of total Billed Charges,65% of Total Billed Charges,209.48,44.1,,334.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,451.25,95,,987.888,Percent of Total Billed Charges,95% of Total Billed Charges,475,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,418,88,,915.096,Percent of Total Billed Charges,88% of Total Billed Charges,427.5,90,,935.896,Percent of Total Billed charges,90% of Total Billed Charges,209.48,475,
STRYKER 3X1000 BALL TIPPD WIRE,2720002814,CDM,272,RC,,,Outpatient,,,760.00,494.00,,760,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,577.6,76,,3911.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,547.2,72,,565.92,Percent of Total Billed Charges,72% of Total Billed Charges,570,75,,565.92,Percent of Total Billed charges,75% of Total Billed Charges,760,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.2,72,,565.92,Percent of Total Billed Charges,72% of Total Billed Charges,456,60,,471.6,Percent of Total Billed Charges,60% of Total Billed Charges,684,90,,562.008,Percent of Total Billed Charges,90% of Total Billed Charges,342,45,,307.6,Percent of Total Billed Charges,45% of Total Billed Charges,684,90,,4632.616,Percent of Total Billed Charges,90% of Total billed Charges,760,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,760,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,760,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,494,65,,2372.32,Percent of total Billed Charges,65% of Total Billed Charges,335.16,44.1,,301.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,722,95,,4889.984,Percent of Total Billed Charges,95% of Total Billed Charges,760,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,668.8,88,,4529.672,Percent of Total Billed Charges,88% of Total Billed Charges,684,90,,4632.616,Percent of Total Billed charges,90% of Total Billed Charges,335.16,760,
AR-13999HDN SCORPION NDLE,2720002815,CDM,272,RC,,,Outpatient,,,528.45,343.49,,528.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,401.62,76,,562.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,380.48,72,,3771.648,Percent of Total Billed Charges,72% of Total Billed Charges,396.34,75,,3771.648,Percent of Total Billed charges,75% of Total Billed Charges,528.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.48,72,,3771.648,Percent of Total Billed Charges,72% of Total Billed Charges,317.07,60,,3143.04,Percent of Total Billed Charges,60% of Total Billed Charges,475.61,90,,562.008,Percent of Total Billed Charges,90% of Total Billed Charges,237.8,45,,224.648,Percent of Total Billed Charges,45% of Total Billed Charges,475.61,90,,666,Percent of Total Billed Charges,90% of Total billed Charges,528.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,528.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,528.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.49,65,,2372.32,Percent of total Billed Charges,65% of Total Billed Charges,233.05,44.1,,220.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,502.03,95,,703,Percent of Total Billed Charges,95% of Total Billed Charges,528.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.04,88,,651.2,Percent of Total Billed Charges,88% of Total Billed Charges,475.61,90,,666,Percent of Total Billed charges,90% of Total Billed Charges,233.05,528.45,
"AR-6570 CANNULA, TWIST-IN",2720002816,CDM,272,RC,,,Outpatient,,,67.75,44.04,,67.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.49,76,,575.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,48.78,72,,15398.448,Percent of Total Billed Charges,72% of Total Billed Charges,50.81,75,,15398.448,Percent of Total Billed charges,75% of Total Billed Charges,67.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.78,72,,15398.448,Percent of Total Billed Charges,72% of Total Billed Charges,40.65,60,,12832.04,Percent of Total Billed Charges,60% of Total Billed Charges,60.98,90,,562.008,Percent of Total Billed Charges,90% of Total Billed Charges,30.49,45,,1314.136,Percent of Total Billed Charges,45% of Total Billed Charges,60.98,90,,681.88,Percent of Total Billed Charges,90% of Total billed Charges,67.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.04,65,,439.72,Percent of total Billed Charges,65% of Total Billed Charges,29.88,44.1,,1287.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,64.36,95,,719.76,Percent of Total Billed Charges,95% of Total Billed Charges,67.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.62,88,,666.72,Percent of Total Billed Charges,88% of Total Billed Charges,60.98,90,,681.88,Percent of Total Billed charges,90% of Total Billed Charges,29.88,67.75,
AR-6592-10-30 PASSPRT BTN CANN,2720002817,CDM,272,RC,,,Outpatient,,,86.73,56.37,,86.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,65.91,76,,519.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.45,72,,10252.088,Percent of Total Billed Charges,72% of Total Billed Charges,65.05,75,,10252.088,Percent of Total Billed charges,75% of Total Billed Charges,86.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.45,72,,10252.088,Percent of Total Billed Charges,72% of Total Billed Charges,52.04,60,,8543.408,Percent of Total Billed Charges,60% of Total Billed Charges,78.06,90,,449.296,Percent of Total Billed Charges,90% of Total Billed Charges,39.03,45,,1314.928,Percent of Total Billed Charges,45% of Total Billed Charges,78.06,90,,615.2,Percent of Total Billed Charges,90% of Total billed Charges,86.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.37,65,,593.368,Percent of total Billed Charges,65% of Total Billed Charges,38.25,44.1,,1288.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.39,95,,649.376,Percent of Total Billed Charges,95% of Total Billed Charges,86.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.32,88,,601.528,Percent of Total Billed Charges,88% of Total Billed Charges,78.06,90,,615.2,Percent of Total Billed charges,90% of Total Billed Charges,38.25,86.73,
PDS 3-0 Z316H  SUTURE,2720002820,CDM,272,RC,,,Outpatient,,,7.60,4.94,,7.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.78,76,,379.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.47,72,,11334.824,Percent of Total Billed Charges,72% of Total Billed Charges,5.7,75,,11334.824,Percent of Total Billed charges,75% of Total Billed Charges,7.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.47,72,,11334.824,Percent of Total Billed Charges,72% of Total Billed Charges,4.56,60,,9445.688,Percent of Total Billed Charges,60% of Total Billed Charges,6.84,90,,562.008,Percent of Total Billed Charges,90% of Total Billed Charges,3.42,45,,224.648,Percent of Total Billed Charges,45% of Total Billed Charges,6.84,90,,449.296,Percent of Total Billed Charges,90% of Total billed Charges,7.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.94,65,,593.368,Percent of total Billed Charges,65% of Total Billed Charges,3.35,44.1,,220.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.22,95,,474.256,Percent of Total Billed Charges,95% of Total Billed Charges,7.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.69,88,,439.312,Percent of Total Billed Charges,88% of Total Billed Charges,6.84,90,,449.296,Percent of Total Billed charges,90% of Total Billed Charges,3.35,7.6,
STRYKR 3.2/3.9X450 PRCISION PN,2720002821,CDM,272,RC,,,Outpatient,,,775.00,503.75,,775,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,589,76,,2219.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,558,72,,11892.392,Percent of Total Billed Charges,72% of Total Billed Charges,581.25,75,,11892.392,Percent of Total Billed charges,75% of Total Billed Charges,775,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558,72,,11892.392,Percent of Total Billed Charges,72% of Total Billed Charges,465,60,,9910.328,Percent of Total Billed Charges,60% of Total Billed Charges,697.5,90,,449.296,Percent of Total Billed Charges,90% of Total Billed Charges,348.75,45,,281.008,Percent of Total Billed Charges,45% of Total Billed Charges,697.5,90,,2628.272,Percent of Total Billed Charges,90% of Total billed Charges,775,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,775,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,775,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,503.75,65,,1730.792,Percent of total Billed Charges,65% of Total Billed Charges,341.78,44.1,,275.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,736.25,95,,2774.288,Percent of Total Billed Charges,95% of Total Billed Charges,775,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,682,88,,2569.864,Percent of Total Billed Charges,88% of Total Billed Charges,697.5,90,,2628.272,Percent of Total Billed charges,90% of Total Billed Charges,341.78,775,
STRYKER 4.2X360 LCK DRILL,2720002822,CDM,272,RC,,,Outpatient,,,787.50,511.88,,787.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,598.5,76,,2220.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,567,72,,34938.632,Percent of Total Billed Charges,72% of Total Billed Charges,590.63,75,,34938.632,Percent of Total Billed charges,75% of Total Billed Charges,787.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,567,72,,34938.632,Percent of Total Billed Charges,72% of Total Billed Charges,472.5,60,,29115.528,Percent of Total Billed Charges,60% of Total Billed Charges,708.75,90,,562.008,Percent of Total Billed Charges,90% of Total Billed Charges,354.38,45,,1663.016,Percent of Total Billed Charges,45% of Total Billed Charges,708.75,90,,2629.856,Percent of Total Billed Charges,90% of Total billed Charges,787.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,787.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,787.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511.88,65,,593.368,Percent of total Billed Charges,65% of Total Billed Charges,347.29,44.1,,1629.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,748.13,95,,2775.96,Percent of Total Billed Charges,95% of Total Billed Charges,787.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,693,88,,2571.416,Percent of Total Billed Charges,88% of Total Billed Charges,708.75,90,,2629.856,Percent of Total Billed charges,90% of Total Billed Charges,347.29,787.5,
FB-224U DISP BX FCP 3.2,2720002823,CDM,272,RC,,,Outpatient,,,34.43,22.38,,34.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.17,76,,379.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.79,72,,29173.736,Percent of Total Billed Charges,72% of Total Billed Charges,25.82,75,,29173.736,Percent of Total Billed charges,75% of Total Billed Charges,34.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.79,72,,29173.736,Percent of Total Billed Charges,72% of Total Billed Charges,20.66,60,,24311.448,Percent of Total Billed Charges,60% of Total Billed Charges,30.99,90,,562.008,Percent of Total Billed Charges,90% of Total Billed Charges,15.49,45,,281.008,Percent of Total Billed Charges,45% of Total Billed Charges,30.99,90,,449.296,Percent of Total Billed Charges,90% of Total billed Charges,34.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.38,65,,794.6,Percent of total Billed Charges,65% of Total Billed Charges,15.18,44.1,,275.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.71,95,,474.256,Percent of Total Billed Charges,95% of Total Billed Charges,34.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.3,88,,439.312,Percent of Total Billed Charges,88% of Total Billed Charges,30.99,90,,449.296,Percent of Total Billed charges,90% of Total Billed Charges,15.18,34.43,
"SUTURE, SILK 2-0 C012D 18"" SH",2720002824,CDM,272,RC,,,Outpatient,,,27.70,18.01,,27.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21.05,76,,474.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.94,72,,60149.72,Percent of Total Billed Charges,72% of Total Billed Charges,20.78,75,,60149.72,Percent of Total Billed charges,75% of Total Billed Charges,27.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.94,72,,60149.72,Percent of Total Billed Charges,72% of Total Billed Charges,16.62,60,,50124.768,Percent of Total Billed Charges,60% of Total Billed Charges,24.93,90,,562.008,Percent of Total Billed Charges,90% of Total Billed Charges,12.47,45,,281.008,Percent of Total Billed Charges,45% of Total Billed Charges,24.93,90,,562.008,Percent of Total Billed Charges,90% of Total billed Charges,27.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.01,65,,794.6,Percent of total Billed Charges,65% of Total Billed Charges,12.22,44.1,,275.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.32,95,,593.232,Percent of Total Billed Charges,95% of Total Billed Charges,27.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.38,88,,549.52,Percent of Total Billed Charges,88% of Total Billed Charges,24.93,90,,562.008,Percent of Total Billed charges,90% of Total Billed Charges,12.22,27.7,
AR-1204FF FLIPCUTTER III,2720002825,CDM,272,RC,,,Outpatient,,,1124.65,731.02,,1124.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,854.73,76,,2808.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,809.75,72,,46037.224,Percent of Total Billed Charges,72% of Total Billed Charges,843.49,75,,46037.224,Percent of Total Billed charges,75% of Total Billed Charges,1124.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,809.75,72,,46037.224,Percent of Total Billed Charges,72% of Total Billed Charges,674.79,60,,38364.352,Percent of Total Billed Charges,60% of Total Billed Charges,1012.19,90,,4613.568,Percent of Total Billed Charges,90% of Total Billed Charges,506.09,45,,281.008,Percent of Total Billed Charges,45% of Total Billed Charges,1012.19,90,,3326.024,Percent of Total Billed Charges,90% of Total billed Charges,1124.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1124.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1124.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,731.02,65,,794.6,Percent of total Billed Charges,65% of Total Billed Charges,495.97,44.1,,275.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,1068.42,95,,3510.808,Percent of Total Billed Charges,95% of Total Billed Charges,1124.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,989.69,88,,3252.112,Percent of Total Billed Charges,88% of Total Billed Charges,1012.19,90,,3326.024,Percent of Total Billed charges,90% of Total Billed Charges,495.97,1124.65,
"AR-12990N SCORPION NDLE,KNEE",2720002826,CDM,272,RC,,,Outpatient,,,528.45,343.49,,528.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,401.62,76,,474.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,380.48,72,,46037.224,Percent of Total Billed Charges,72% of Total Billed Charges,396.34,75,,46037.224,Percent of Total Billed charges,75% of Total Billed Charges,528.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.48,72,,46037.224,Percent of Total Billed Charges,72% of Total Billed Charges,317.07,60,,38364.352,Percent of Total Billed Charges,60% of Total Billed Charges,475.61,90,,3776.904,Percent of Total Billed Charges,90% of Total Billed Charges,237.8,45,,224.648,Percent of Total Billed Charges,45% of Total Billed Charges,475.61,90,,562.008,Percent of Total Billed Charges,90% of Total billed Charges,528.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,528.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,528.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.49,65,,519.984,Percent of total Billed Charges,65% of Total Billed Charges,233.05,44.1,,220.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,502.03,95,,593.232,Percent of Total Billed Charges,95% of Total Billed Charges,528.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.04,88,,549.52,Percent of Total Billed Charges,88% of Total Billed Charges,475.61,90,,562.008,Percent of Total Billed charges,90% of Total Billed Charges,233.05,528.45,
"AR-7209SN #2 FBRSNRE,#2 FBRWRE",2720002827,CDM,272,RC,,,Outpatient,,,284.55,184.96,,284.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,216.26,76,,474.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,204.88,72,,42910.92,Percent of Total Billed Charges,72% of Total Billed Charges,213.41,75,,42910.92,Percent of Total Billed charges,75% of Total Billed Charges,284.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.88,72,,42910.92,Percent of Total Billed Charges,72% of Total Billed Charges,170.73,60,,35759.104,Percent of Total Billed Charges,60% of Total Billed Charges,256.1,90,,3779.28,Percent of Total Billed Charges,90% of Total Billed Charges,128.05,45,,281.008,Percent of Total Billed Charges,45% of Total Billed Charges,256.1,90,,562.008,Percent of Total Billed Charges,90% of Total billed Charges,284.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.96,65,,794.6,Percent of total Billed Charges,65% of Total Billed Charges,125.49,44.1,,275.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,270.32,95,,593.232,Percent of Total Billed Charges,95% of Total Billed Charges,284.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.4,88,,549.52,Percent of Total Billed Charges,88% of Total Billed Charges,256.1,90,,562.008,Percent of Total Billed charges,90% of Total Billed Charges,125.49,284.55,
INPACT AV 7F 9MM X 80MM X 80CM,2720002828,CDM,272,RC,C2623,HCPCS,Outpatient,,,4075.00,2648.75,,4075,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3097,76,,474.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2934,72,,10658.512,Percent of Total Billed Charges,72% of Total Billed Charges,3056.25,75,,10658.512,Percent of Total Billed charges,75% of Total Billed Charges,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2934,72,,10658.512,Percent of Total Billed Charges,72% of Total Billed Charges,2445,60,,8882.096,Percent of Total Billed Charges,60% of Total Billed Charges,3667.5,90,,577.096,Percent of Total Billed Charges,90% of Total Billed Charges,1833.75,45,,224.648,Percent of Total Billed Charges,45% of Total Billed Charges,3667.5,90,,562.008,Percent of Total Billed Charges,90% of Total billed Charges,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2648.75,65,,794.6,Percent of total Billed Charges,65% of Total Billed Charges,1797.08,44.1,,220.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,3871.25,95,,593.232,Percent of Total Billed Charges,95% of Total Billed Charges,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3586,88,,549.52,Percent of Total Billed Charges,88% of Total Billed Charges,3667.5,90,,562.008,Percent of Total Billed charges,90% of Total Billed Charges,1797.08,4075,
INPCT AV 5F 5MM X 40MM X 130CM,2720002829,CDM,272,RC,C2623,HCPCS,Outpatient,,,4075.00,2648.75,,4075,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3097,76,,379.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2934,72,,17970.368,Percent of Total Billed Charges,72% of Total Billed Charges,3056.25,75,,17970.368,Percent of Total Billed charges,75% of Total Billed Charges,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2934,72,,17970.368,Percent of Total Billed Charges,72% of Total Billed Charges,2445,60,,14975.304,Percent of Total Billed Charges,60% of Total Billed Charges,3667.5,90,,3284.752,Percent of Total Billed Charges,90% of Total Billed Charges,1833.75,45,,281.008,Percent of Total Billed Charges,45% of Total Billed Charges,3667.5,90,,449.296,Percent of Total Billed Charges,90% of Total billed Charges,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2648.75,65,,794.6,Percent of total Billed Charges,65% of Total Billed Charges,1797.08,44.1,,275.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,3871.25,95,,474.256,Percent of Total Billed Charges,95% of Total Billed Charges,4075,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3586,88,,439.312,Percent of Total Billed Charges,88% of Total Billed Charges,3667.5,90,,449.296,Percent of Total Billed charges,90% of Total Billed Charges,1797.08,4075,
5400-031-171 CRESCENTIC BLADE,2720002830,CDM,272,RC,,,Outpatient,,,350.13,227.58,,350.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,266.1,76,,474.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,252.09,72,,9616.416,Percent of Total Billed Charges,72% of Total Billed Charges,262.6,75,,9616.416,Percent of Total Billed charges,75% of Total Billed Charges,350.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.09,72,,9616.416,Percent of Total Billed Charges,72% of Total Billed Charges,210.08,60,,8013.68,Percent of Total Billed Charges,60% of Total Billed Charges,315.12,90,,3284.752,Percent of Total Billed Charges,90% of Total Billed Charges,157.56,45,,281.008,Percent of Total Billed Charges,45% of Total Billed Charges,315.12,90,,562.008,Percent of Total Billed Charges,90% of Total billed Charges,350.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.58,65,,1085.256,Percent of total Billed Charges,65% of Total Billed Charges,154.41,44.1,,275.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,332.62,95,,593.232,Percent of Total Billed Charges,95% of Total Billed Charges,350.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.11,88,,549.52,Percent of Total Billed Charges,88% of Total Billed Charges,315.12,90,,562.008,Percent of Total Billed charges,90% of Total Billed Charges,154.41,350.13,
2296-003-111 PRECISION THIN BL,2720002831,CDM,272,RC,,,Outpatient,,,104.83,68.14,,104.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.67,76,,379.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75.48,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,78.62,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,104.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.48,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,62.9,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,94.35,90,,608.848,Percent of Total Billed Charges,90% of Total Billed Charges,47.17,45,,281.008,Percent of Total Billed Charges,45% of Total Billed Charges,94.35,90,,449.296,Percent of Total Billed Charges,90% of Total billed Charges,104.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.14,65,,1286.488,Percent of total Billed Charges,65% of Total Billed Charges,46.23,44.1,,275.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,99.59,95,,474.256,Percent of Total Billed Charges,95% of Total Billed Charges,104.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.25,88,,439.312,Percent of Total Billed Charges,88% of Total Billed Charges,94.35,90,,449.296,Percent of Total Billed charges,90% of Total Billed Charges,46.23,104.83,
5100-037-113 SM TEAR CROSS RAS,2720002832,CDM,272,RC,,,Outpatient,,,345.48,224.56,,345.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,262.56,76,,474.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,248.75,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,259.11,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,345.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.75,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,207.29,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,310.93,90,,821.584,Percent of Total Billed Charges,90% of Total Billed Charges,155.47,45,,2306.784,Percent of Total Billed Charges,45% of Total Billed Charges,310.93,90,,562.008,Percent of Total Billed Charges,90% of Total billed Charges,345.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.56,65,,1167.808,Percent of total Billed Charges,65% of Total Billed Charges,152.36,44.1,,2260.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,328.21,95,,593.232,Percent of Total Billed Charges,95% of Total Billed Charges,345.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.02,88,,549.52,Percent of Total Billed Charges,88% of Total Billed Charges,310.93,90,,562.008,Percent of Total Billed charges,90% of Total Billed Charges,152.36,345.48,
2296-003-115 PRECISION THIN BL,2720002833,CDM,272,RC,,,Outpatient,,,104.83,68.14,,104.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.67,76,,474.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75.48,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,78.62,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,104.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.48,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,62.9,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,94.35,90,,821.584,Percent of Total Billed Charges,90% of Total Billed Charges,47.17,45,,1888.456,Percent of Total Billed Charges,45% of Total Billed Charges,94.35,90,,562.008,Percent of Total Billed Charges,90% of Total billed Charges,104.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.14,65,,1085.256,Percent of total Billed Charges,65% of Total Billed Charges,46.23,44.1,,1850.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,99.59,95,,593.232,Percent of Total Billed Charges,95% of Total Billed Charges,104.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.25,88,,549.52,Percent of Total Billed Charges,88% of Total Billed Charges,94.35,90,,562.008,Percent of Total Billed charges,90% of Total Billed Charges,46.23,104.83,
VLOCN0604 NONABS 3-0 BL 6 V-20,2720002834,CDM,272,RC,,,Outpatient,,,83.98,54.59,,83.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,63.82,76,,474.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,60.47,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,62.99,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,83.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.47,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,50.39,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,75.58,90,,2396.488,Percent of Total Billed Charges,90% of Total Billed Charges,37.79,45,,1889.64,Percent of Total Billed Charges,45% of Total Billed Charges,75.58,90,,562.008,Percent of Total Billed Charges,90% of Total billed Charges,83.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.59,65,,1085.256,Percent of total Billed Charges,65% of Total Billed Charges,37.04,44.1,,1851.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,79.78,95,,593.232,Percent of Total Billed Charges,95% of Total Billed Charges,83.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.9,88,,549.52,Percent of Total Billed Charges,88% of Total Billed Charges,75.58,90,,562.008,Percent of Total Billed charges,90% of Total Billed Charges,37.04,83.98,
VLOCN008L ESTITCH NONABS 0 8,2720002835,CDM,272,RC,,,Outpatient,,,275.18,178.87,,275.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209.14,76,,3895.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198.13,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,206.39,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,275.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.13,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,165.11,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,247.66,90,,821.584,Percent of Total Billed Charges,90% of Total Billed Charges,123.83,45,,288.544,Percent of Total Billed Charges,45% of Total Billed Charges,247.66,90,,4613.568,Percent of Total Billed Charges,90% of Total billed Charges,275.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.87,65,,1167.808,Percent of total Billed Charges,65% of Total Billed Charges,121.35,44.1,,282.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.42,95,,4869.872,Percent of Total Billed Charges,95% of Total Billed Charges,275.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.16,88,,4511.04,Percent of Total Billed Charges,88% of Total Billed Charges,247.66,90,,4613.568,Percent of Total Billed charges,90% of Total Billed Charges,121.35,275.18,
SUT 8832H 3-0 PROLENE 1X30 SH,2720002836,CDM,272,RC,,,Outpatient,,,9.70,6.31,,9.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.37,76,,3189.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.98,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,9.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.98,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,5.82,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,8.73,90,,1100.208,Percent of Total Billed Charges,90% of Total Billed Charges,4.37,45,,1642.376,Percent of Total Billed Charges,45% of Total Billed Charges,8.73,90,,3776.904,Percent of Total Billed Charges,90% of Total billed Charges,9.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.31,65,,82.552,Percent of total Billed Charges,65% of Total Billed Charges,4.28,44.1,,1609.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.22,95,,3986.736,Percent of Total Billed Charges,95% of Total Billed Charges,9.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.54,88,,3692.976,Percent of Total Billed Charges,88% of Total Billed Charges,8.73,90,,3776.904,Percent of Total Billed charges,90% of Total Billed Charges,4.28,9.7,
SUT 8757H 4-0 PROLENE 1X18,2720002837,CDM,272,RC,,,Outpatient,,,15.93,10.35,,15.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.11,76,,3191.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.47,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,11.95,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,15.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.47,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,9.56,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,14.34,90,,1100.208,Percent of Total Billed Charges,90% of Total Billed Charges,7.17,45,,1642.376,Percent of Total Billed Charges,45% of Total Billed Charges,14.34,90,,3779.28,Percent of Total Billed Charges,90% of Total billed Charges,15.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.35,65,,99.176,Percent of total Billed Charges,65% of Total Billed Charges,7.03,44.1,,1609.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.13,95,,3989.24,Percent of Total Billed Charges,95% of Total Billed Charges,15.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.02,88,,3695.296,Percent of Total Billed Charges,88% of Total Billed Charges,14.34,90,,3779.28,Percent of Total Billed charges,90% of Total Billed Charges,7.03,15.93,
SUT Z340H 0 PDS II 1X27 CT-1,2720002838,CDM,272,RC,,,Outpatient,,,7.15,4.65,,7.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.43,76,,487.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.15,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,5.36,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,7.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.15,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,4.29,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,6.44,90,,1100.208,Percent of Total Billed Charges,90% of Total Billed Charges,3.22,45,,304.424,Percent of Total Billed Charges,45% of Total Billed Charges,6.44,90,,577.096,Percent of Total Billed Charges,90% of Total billed Charges,7.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.65,65,,99.176,Percent of total Billed Charges,65% of Total Billed Charges,3.15,44.1,,298.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.79,95,,609.152,Percent of Total Billed Charges,95% of Total Billed Charges,7.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.29,88,,564.272,Percent of Total Billed Charges,88% of Total Billed Charges,6.44,90,,577.096,Percent of Total Billed charges,90% of Total Billed Charges,3.15,7.15,
AR-5815 SUT TENSIONER/CUTTER,2720002839,CDM,272,RC,,,Outpatient,,,474.25,308.26,,474.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,360.43,76,,2773.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,341.46,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,355.69,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,474.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.46,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,284.55,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,426.83,90,,719.976,Percent of Total Billed Charges,90% of Total Billed Charges,213.41,45,,410.792,Percent of Total Billed Charges,45% of Total Billed Charges,426.83,90,,3284.752,Percent of Total Billed Charges,90% of Total billed Charges,474.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.26,65,,99.176,Percent of total Billed Charges,65% of Total Billed Charges,209.14,44.1,,402.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,450.54,95,,3467.232,Percent of Total Billed Charges,95% of Total Billed Charges,474.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.34,88,,3211.752,Percent of Total Billed Charges,88% of Total Billed Charges,426.83,90,,3284.752,Percent of Total Billed charges,90% of Total Billed Charges,209.14,474.25,
AR-4505 PORTAL SKID,2720002840,CDM,272,RC,,,Outpatient,,,121.95,79.27,,121.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,92.68,76,,2773.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,87.8,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,91.46,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,121.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.8,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,73.17,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,109.76,90,,1100.208,Percent of Total Billed Charges,90% of Total Billed Charges,54.88,45,,410.792,Percent of Total Billed Charges,45% of Total Billed Charges,109.76,90,,3284.752,Percent of Total Billed Charges,90% of Total billed Charges,121.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.27,65,,99.176,Percent of total Billed Charges,65% of Total Billed Charges,53.78,44.1,,402.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,115.85,95,,3467.232,Percent of Total Billed Charges,95% of Total Billed Charges,121.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.32,88,,3211.752,Percent of Total Billed Charges,88% of Total Billed Charges,109.76,90,,3284.752,Percent of Total Billed charges,90% of Total Billed Charges,53.78,121.95,
AR-9831 APOLLO ABLATOR 90,2720002841,CDM,272,RC,,,Outpatient,,,636.85,413.95,,636.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,484.01,76,,514.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,458.53,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,477.64,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,636.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,458.53,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,382.11,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,573.17,90,,1100.208,Percent of Total Billed Charges,90% of Total Billed Charges,286.58,45,,1198.24,Percent of Total Billed Charges,45% of Total Billed Charges,573.17,90,,608.848,Percent of Total Billed Charges,90% of Total billed Charges,636.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,636.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,636.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.95,65,,99.176,Percent of total Billed Charges,65% of Total Billed Charges,280.85,44.1,,1174.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,605.01,95,,642.672,Percent of Total Billed Charges,95% of Total Billed Charges,636.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,560.43,88,,595.32,Percent of Total Billed Charges,88% of Total Billed Charges,573.17,90,,608.848,Percent of Total Billed charges,90% of Total Billed Charges,280.85,636.85,
AR-9815 APOLLO RF 50,2720002842,CDM,272,RC,,,Outpatient,,,539.30,350.55,,539.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,409.87,76,,693.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,388.3,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,404.48,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,539.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,388.3,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,323.58,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,485.37,90,,1100.208,Percent of Total Billed Charges,90% of Total Billed Charges,242.69,45,,410.792,Percent of Total Billed Charges,45% of Total Billed Charges,485.37,90,,821.584,Percent of Total Billed Charges,90% of Total billed Charges,539.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,539.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,539.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.55,65,,82.552,Percent of total Billed Charges,65% of Total Billed Charges,237.83,44.1,,402.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,512.34,95,,867.232,Percent of Total Billed Charges,95% of Total Billed Charges,539.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.58,88,,803.328,Percent of Total Billed Charges,88% of Total Billed Charges,485.37,90,,821.584,Percent of Total Billed charges,90% of Total Billed Charges,237.83,539.3,
AR-8400TD TORPEDO 4.0MM X 13CM,2720002843,CDM,272,RC,,,Outpatient,,,273.70,177.91,,273.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,208.01,76,,693.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,197.06,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,205.28,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,273.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.06,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,164.22,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,246.33,90,,1502.664,Percent of Total Billed Charges,90% of Total Billed Charges,123.17,45,,550.104,Percent of Total Billed Charges,45% of Total Billed Charges,246.33,90,,821.584,Percent of Total Billed Charges,90% of Total billed Charges,273.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.91,65,,82.552,Percent of total Billed Charges,65% of Total Billed Charges,120.7,44.1,,539.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,260.02,95,,867.232,Percent of Total Billed Charges,95% of Total Billed Charges,273.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.86,88,,803.328,Percent of Total Billed Charges,88% of Total Billed Charges,246.33,90,,821.584,Percent of Total Billed charges,90% of Total Billed Charges,120.7,273.7,
AR-8400EX EXCALBR 4.0MM X 13CM,2720002844,CDM,272,RC,,,Outpatient,,,159.90,103.94,,159.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,121.52,76,,2023.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,115.13,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,119.93,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,159.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.13,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,95.94,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,143.91,90,,1781.288,Percent of Total Billed Charges,90% of Total Billed Charges,71.96,45,,550.104,Percent of Total Billed Charges,45% of Total Billed Charges,143.91,90,,2396.488,Percent of Total Billed Charges,90% of Total billed Charges,159.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.94,65,,82.552,Percent of total Billed Charges,65% of Total Billed Charges,70.52,44.1,,539.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,151.91,95,,2529.624,Percent of Total Billed Charges,95% of Total Billed Charges,159.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.71,88,,2343.232,Percent of Total Billed Charges,88% of Total Billed Charges,143.91,90,,2396.488,Percent of Total Billed charges,90% of Total Billed Charges,70.52,159.9,
AR-8400CTD TORPEDO CVD 4MM,2720002845,CDM,272,RC,,,Outpatient,,,273.70,177.91,,273.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,208.01,76,,693.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,197.06,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,205.28,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,273.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.06,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,164.22,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,246.33,90,,1616.968,Percent of Total Billed Charges,90% of Total Billed Charges,123.17,45,,550.104,Percent of Total Billed Charges,45% of Total Billed Charges,246.33,90,,821.584,Percent of Total Billed Charges,90% of Total billed Charges,273.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.91,65,,1085.256,Percent of total Billed Charges,65% of Total Billed Charges,120.7,44.1,,539.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,260.02,95,,867.232,Percent of Total Billed Charges,95% of Total Billed Charges,273.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.86,88,,803.328,Percent of Total Billed Charges,88% of Total Billed Charges,246.33,90,,821.584,Percent of Total Billed charges,90% of Total Billed Charges,120.7,273.7,
AR-6410 MAIN PUMP TUBING,2720002846,CDM,272,RC,,,Outpatient,,,165.30,107.45,,165.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,125.63,76,,929.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,119.02,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,123.98,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,165.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.02,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,99.18,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,148.77,90,,1502.664,Percent of Total Billed Charges,90% of Total Billed Charges,74.39,45,,359.992,Percent of Total Billed Charges,45% of Total Billed Charges,148.77,90,,1100.208,Percent of Total Billed Charges,90% of Total billed Charges,165.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.45,65,,1964.704,Percent of total Billed Charges,65% of Total Billed Charges,72.9,44.1,,352.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,157.04,95,,1161.336,Percent of Total Billed Charges,95% of Total Billed Charges,165.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.46,88,,1075.76,Percent of Total Billed Charges,88% of Total Billed Charges,148.77,90,,1100.208,Percent of Total Billed charges,90% of Total Billed Charges,72.9,165.3,
AR-6430 DW OUTFLW CSSTTE/TB ST,2720002847,CDM,272,RC,,,Outpatient,,,108.40,70.46,,108.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.38,76,,929.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,78.05,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,81.3,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,108.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.05,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,65.04,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,97.56,90,,1502.664,Percent of Total Billed Charges,90% of Total Billed Charges,48.78,45,,550.104,Percent of Total Billed Charges,45% of Total Billed Charges,97.56,90,,1100.208,Percent of Total Billed Charges,90% of Total billed Charges,108.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.46,65,,2125.224,Percent of total Billed Charges,65% of Total Billed Charges,47.8,44.1,,539.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.98,95,,1161.336,Percent of Total Billed Charges,95% of Total Billed Charges,108.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.39,88,,1075.76,Percent of Total Billed Charges,88% of Total Billed Charges,97.56,90,,1100.208,Percent of Total Billed charges,90% of Total Billed Charges,47.8,108.4,
AR-8550PR POWERASP 5.5MMX13CM,2720002848,CDM,272,RC,,,Outpatient,,,392.95,255.42,,392.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,298.64,76,,929.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,282.92,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,294.71,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,392.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.92,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,235.77,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,353.66,90,,1616.968,Percent of Total Billed Charges,90% of Total Billed Charges,176.83,45,,550.104,Percent of Total Billed Charges,45% of Total Billed Charges,353.66,90,,1100.208,Percent of Total Billed Charges,90% of Total billed Charges,392.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.42,65,,2031.2,Percent of total Billed Charges,65% of Total Billed Charges,173.29,44.1,,539.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,373.3,95,,1161.336,Percent of Total Billed Charges,95% of Total Billed Charges,392.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.8,88,,1075.76,Percent of Total Billed Charges,88% of Total Billed Charges,353.66,90,,1100.208,Percent of Total Billed charges,90% of Total Billed Charges,173.29,392.95,
AR-8150PP-45 POWERPICK 45 DEG,2720002849,CDM,272,RC,,,Outpatient,,,273.70,177.91,,273.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,208.01,76,,607.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,197.06,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,205.28,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,273.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.06,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,164.22,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,246.33,90,,114.304,Percent of Total Billed Charges,90% of Total Billed Charges,123.17,45,,550.104,Percent of Total Billed Charges,45% of Total Billed Charges,246.33,90,,719.976,Percent of Total Billed Charges,90% of Total billed Charges,273.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.91,65,,2125.224,Percent of total Billed Charges,65% of Total Billed Charges,120.7,44.1,,539.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,260.02,95,,759.976,Percent of Total Billed Charges,95% of Total Billed Charges,273.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.86,88,,703.976,Percent of Total Billed Charges,88% of Total Billed Charges,246.33,90,,719.976,Percent of Total Billed charges,90% of Total Billed Charges,120.7,273.7,
AR-8500COE BUR OVAL CLRCUT,2720002850,CDM,272,RC,,,Outpatient,,,178.85,116.25,,178.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,135.93,76,,929.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,128.77,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,134.14,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,178.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.77,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,107.31,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,160.97,90,,137.328,Percent of Total Billed Charges,90% of Total Billed Charges,80.48,45,,751.328,Percent of Total Billed Charges,45% of Total Billed Charges,160.97,90,,1100.208,Percent of Total Billed Charges,90% of Total billed Charges,178.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.25,65,,2031.2,Percent of total Billed Charges,65% of Total Billed Charges,78.87,44.1,,736.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,169.91,95,,1161.336,Percent of Total Billed Charges,95% of Total Billed Charges,178.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.39,88,,1075.76,Percent of Total Billed Charges,88% of Total Billed Charges,160.97,90,,1100.208,Percent of Total Billed charges,90% of Total Billed Charges,78.87,178.85,
INFINITI 5F JL 3.5,2720002851,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,929.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,137.328,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,890.64,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,1100.208,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,205.248,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,872.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,1161.336,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,1075.76,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,1100.208,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 5F JL 4,2720002852,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,929.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,137.328,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,808.488,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,1100.208,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,247.096,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,792.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,1161.336,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,1075.76,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,1100.208,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 5F JL 4.5,2720002853,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,1268.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,137.328,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,751.328,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,1502.664,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,247.096,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,736.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,1586.144,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,1469.272,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,1502.664,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 5F JL 5,2720002854,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,1504.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,137.328,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,751.328,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,1781.288,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,247.096,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,736.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,1880.248,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,1741.704,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,1781.288,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 5F JL 6,2720002855,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,1365.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,114.304,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,808.488,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,1616.968,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,792.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,1706.8,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,1581.04,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,1616.968,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 5F AL 1,2720002856,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,1268.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,114.304,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,57.152,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,1502.664,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,204.096,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,56.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,1586.144,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,1469.272,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,1502.664,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 5F AL 2,2720002857,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,1268.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,114.304,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,68.664,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,1502.664,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,67.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,1586.144,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,1469.272,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,1502.664,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 5F AL 3,2720002858,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,1365.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,1502.664,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,68.664,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,1616.968,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,204.096,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,67.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,1706.8,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,1581.04,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,1616.968,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 5F JR 3.5,2720002859,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,96.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,2720.352,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,68.664,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,114.304,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,204.096,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,67.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,120.656,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,111.768,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,114.304,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 5F JR 4,2720002860,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,115.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,2942.616,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,68.664,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,137.328,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,67.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,144.952,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,134.272,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,137.328,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 5F JR 4 MOD,2720002861,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,115.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,2812.432,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,68.664,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,137.328,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,67.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,144.952,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,134.272,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,137.328,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 5F JR 4 ST,2720002862,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,115.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,2942.616,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,57.152,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,137.328,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,56.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,144.952,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,134.272,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,137.328,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 5F JR 5,2720002863,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,115.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,2812.432,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,57.152,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,137.328,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,204.096,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,56.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,144.952,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,134.272,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,137.328,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 5F JR 6,2720002864,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,115.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,284.184,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,57.152,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,137.328,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,56.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,144.952,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,134.272,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,137.328,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 5F AR MOD,2720002865,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,96.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,342.128,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,751.328,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,114.304,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,736.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,120.656,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,111.768,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,114.304,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 5F AR 1 MOD,2720002866,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,96.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,342.128,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,1360.176,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,114.304,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,205.248,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,1332.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,120.656,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,111.768,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,114.304,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 5F AR 2 MOD,2720002867,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,96.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,342.128,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,1471.312,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,114.304,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,205.248,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,1441.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,120.656,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,111.768,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,114.304,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 5F 3 DRC,2720002868,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,1268.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,1406.216,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,1502.664,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,205.248,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,1378.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,1586.144,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,1469.272,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,1502.664,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 5F SRC,2720002869,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,2297.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,282.592,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,1471.312,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,2720.352,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,205.248,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,1441.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,2871.488,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,2659.904,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,2720.352,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 5F MPA 2 SH (100CM),2720002870,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,2484.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,1406.216,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,2942.616,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,149.056,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,1378.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,3106.096,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,2877.224,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,2942.616,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 6F JL 3.5,2720002871,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,2374.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,282.592,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,142.096,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,2812.432,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,149.056,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,139.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,2968.68,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,2749.936,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,2812.432,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 6F JL 4,2720002872,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,2484.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,282.592,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,171.064,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,2942.616,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,82.552,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,167.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,3106.096,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,2877.224,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,2942.616,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 6F JL 4.5,2720002873,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,2374.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,171.064,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,2812.432,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,149.056,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,167.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,2968.68,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,2749.936,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,2812.432,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 6F JL 5,2720002874,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,239.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,171.064,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,284.184,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,149.056,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,167.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,299.976,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,277.872,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,284.184,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 6F JL 6,2720002875,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,288.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,342.128,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,149.056,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,361.136,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,334.528,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,342.128,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 6F AL 1,2720002876,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,288.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,282.592,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,141.296,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,342.128,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,149.056,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,138.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,361.136,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,334.528,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,342.128,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 6F AL 2,2720002877,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,288.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,342.128,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,149.056,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,361.136,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,334.528,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,342.128,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 6F AL 3,2720002878,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,141.296,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,138.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 6F JR 3.5,2720002879,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,238.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,284.184,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,141.296,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,282.592,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,138.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,298.296,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,276.312,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,282.592,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 6F JR 4,2720002880,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,284.184,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 6F JR 4 MOD,2720002881,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,238.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,284.184,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,282.592,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,12117.272,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,298.296,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,276.312,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,282.592,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 6F JR 4 ST,2720002882,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,238.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,284.184,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,282.592,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,298.296,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,276.312,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,282.592,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 6F JR 5,2720002883,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,206.392,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,141.296,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,67.656,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,138.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 6F JR 6 (125CM),2720002884,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,206.392,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,67.656,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 6F AR MOD,2720002885,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,114.304,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,67.656,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 6F AR 1 MOD,2720002886,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,238.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,206.392,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,142.096,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,282.592,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,49.88,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,139.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,298.296,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,276.312,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,282.592,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 6F AR 2 MOD,2720002887,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,206.392,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,142.096,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,49.88,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,139.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 6F 3 DRC,2720002888,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,206.392,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,142.096,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,49.88,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,139.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 6F SRC,2720002889,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,239.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,206.392,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,142.096,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,284.184,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,49.88,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,139.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,299.976,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,277.872,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,284.184,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
INFINITI 6F MAP 2 SH (100CM),2720002890,CDM,272,RC,C1887,HCPCS,Outpatient,,,21.93,14.25,,21.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.67,76,,239.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,16.45,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,13.16,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,19.74,90,,206.392,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,45,,103.192,Percent of Total Billed Charges,45% of Total Billed Charges,19.74,90,,284.184,Percent of Total Billed Charges,90% of Total billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.25,65,,49.88,Percent of total Billed Charges,65% of Total Billed Charges,9.67,44.1,,101.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.83,95,,299.976,Percent of Total Billed Charges,95% of Total Billed Charges,21.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.3,88,,277.872,Percent of Total Billed Charges,88% of Total Billed Charges,19.74,90,,284.184,Percent of Total Billed charges,90% of Total Billed Charges,9.67,21.93,
IMPULSE 6F PIG 110CM,2720002891,CDM,272,RC,C1887,HCPCS,Outpatient,,,37.50,24.38,,37.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.5,76,,239.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,28.13,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,22.5,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,33.75,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,16.88,45,,103.192,Percent of Total Billed Charges,45% of Total Billed Charges,33.75,90,,284.184,Percent of Total Billed Charges,90% of Total billed Charges,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.38,65,,55.04,Percent of total Billed Charges,65% of Total Billed Charges,16.54,44.1,,101.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.63,95,,299.976,Percent of Total Billed Charges,95% of Total Billed Charges,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33,88,,277.872,Percent of Total Billed Charges,88% of Total Billed Charges,33.75,90,,284.184,Percent of Total Billed charges,90% of Total Billed Charges,16.54,37.5,
IMPULSE 6F RCB,2720002892,CDM,272,RC,C1887,HCPCS,Outpatient,,,37.50,24.38,,37.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.5,76,,239.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,28.13,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,22.5,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,33.75,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,16.88,45,,57.152,Percent of Total Billed Charges,45% of Total Billed Charges,33.75,90,,284.184,Percent of Total Billed Charges,90% of Total billed Charges,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.38,65,,70.52,Percent of total Billed Charges,65% of Total Billed Charges,16.54,44.1,,56.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.63,95,,299.976,Percent of Total Billed Charges,95% of Total Billed Charges,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33,88,,277.872,Percent of Total Billed Charges,88% of Total Billed Charges,33.75,90,,284.184,Percent of Total Billed charges,90% of Total Billed Charges,16.54,37.5,
IMPULSE 6F LCB,2720002893,CDM,272,RC,C1887,HCPCS,Outpatient,,,37.50,24.38,,37.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.5,76,,174.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,28.13,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,22.5,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,33.75,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,16.88,45,,103.192,Percent of Total Billed Charges,45% of Total Billed Charges,33.75,90,,206.392,Percent of Total Billed Charges,90% of Total billed Charges,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.38,65,,64.208,Percent of total Billed Charges,65% of Total Billed Charges,16.54,44.1,,101.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.63,95,,217.856,Percent of Total Billed Charges,95% of Total Billed Charges,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33,88,,201.8,Percent of Total Billed Charges,88% of Total Billed Charges,33.75,90,,206.392,Percent of Total Billed charges,90% of Total Billed Charges,16.54,37.5,
IMPULSE 5F IM,2720002894,CDM,272,RC,C1887,HCPCS,Outpatient,,,37.50,24.38,,37.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.5,76,,174.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,28.13,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,22.5,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,33.75,90,,16777.76,Percent of Total Billed Charges,90% of Total Billed Charges,16.88,45,,103.192,Percent of Total Billed Charges,45% of Total Billed Charges,33.75,90,,206.392,Percent of Total Billed Charges,90% of Total billed Charges,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.38,65,,49.88,Percent of total Billed Charges,65% of Total Billed Charges,16.54,44.1,,101.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.63,95,,217.856,Percent of Total Billed Charges,95% of Total Billed Charges,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33,88,,201.8,Percent of Total Billed Charges,88% of Total Billed Charges,33.75,90,,206.392,Percent of Total Billed charges,90% of Total Billed Charges,16.54,37.5,
HEARTRAIL IKARI RIGHT 6F IR1.5,2720002895,CDM,272,RC,C1887,HCPCS,Outpatient,,,210.00,136.50,,210,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,159.6,76,,96.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,151.2,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,157.5,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.2,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,126,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,189,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,94.5,45,,103.192,Percent of Total Billed Charges,45% of Total Billed Charges,189,90,,114.304,Percent of Total Billed Charges,90% of Total billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.5,65,,70.52,Percent of total Billed Charges,65% of Total Billed Charges,92.61,44.1,,101.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,199.5,95,,120.656,Percent of Total Billed Charges,95% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.8,88,,111.768,Percent of Total Billed Charges,88% of Total Billed Charges,189,90,,114.304,Percent of Total Billed charges,90% of Total Billed Charges,92.61,210,
VLOCL0014 180 ABS 3-0 CL 12,2720002896,CDM,272,RC,,,Outpatient,,,86.48,56.21,,86.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,65.72,76,,174.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.27,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,64.86,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,86.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.27,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,51.89,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,77.83,90,,93.672,Percent of Total Billed Charges,90% of Total Billed Charges,38.92,45,,103.192,Percent of Total Billed Charges,45% of Total Billed Charges,77.83,90,,206.392,Percent of Total Billed Charges,90% of Total billed Charges,86.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.21,65,,70.52,Percent of total Billed Charges,65% of Total Billed Charges,38.14,44.1,,101.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.16,95,,217.856,Percent of Total Billed Charges,95% of Total Billed Charges,86.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.1,88,,201.8,Percent of Total Billed Charges,88% of Total Billed Charges,77.83,90,,206.392,Percent of Total Billed charges,90% of Total Billed Charges,38.14,86.48,
IVL E8 6F 6MM X 80MM X 150CM,2720002900,CDM,272,RC,C1725,HCPCS,Outpatient,,,11750.00,7637.50,,11750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8930,76,,174.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8460,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,8812.5,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8460,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,7050,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,10575,90,,93.672,Percent of Total Billed Charges,90% of Total Billed Charges,5287.5,45,,103.192,Percent of Total Billed Charges,45% of Total Billed Charges,10575,90,,206.392,Percent of Total Billed Charges,90% of Total billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7637.5,65,,70.52,Percent of total Billed Charges,65% of Total Billed Charges,5181.75,44.1,,101.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,11162.5,95,,217.856,Percent of Total Billed Charges,95% of Total Billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10340,88,,201.8,Percent of Total Billed Charges,88% of Total Billed Charges,10575,90,,206.392,Percent of Total Billed charges,90% of Total Billed Charges,5181.75,11750,
IVL E8 6F 5MM X 80MM X 150CM,2720002901,CDM,272,RC,C1725,HCPCS,Outpatient,,,11750.00,7637.50,,11750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8930,76,,174.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8460,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,8812.5,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8460,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,7050,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,10575,90,,93.672,Percent of Total Billed Charges,90% of Total Billed Charges,5287.5,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,10575,90,,206.392,Percent of Total Billed Charges,90% of Total billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7637.5,65,,49.88,Percent of total Billed Charges,65% of Total Billed Charges,5181.75,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,11162.5,95,,217.856,Percent of Total Billed Charges,95% of Total Billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10340,88,,201.8,Percent of Total Billed Charges,88% of Total Billed Charges,10575,90,,206.392,Percent of Total Billed charges,90% of Total Billed Charges,5181.75,11750,
IVL E8 5F 4MM X 80MM X 150CM,2720002902,CDM,272,RC,C1725,HCPCS,Outpatient,,,11750.00,7637.50,,11750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8930,76,,174.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8460,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,8812.5,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8460,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,7050,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,10575,90,,69.064,Percent of Total Billed Charges,90% of Total Billed Charges,5287.5,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,10575,90,,206.392,Percent of Total Billed Charges,90% of Total billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7637.5,65,,728.096,Percent of total Billed Charges,65% of Total Billed Charges,5181.75,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,11162.5,95,,217.856,Percent of Total Billed Charges,95% of Total Billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10340,88,,201.8,Percent of Total Billed Charges,88% of Total Billed Charges,10575,90,,206.392,Percent of Total Billed charges,90% of Total Billed Charges,5181.75,11750,
IVL E8 5F 3.5MM X 80MM X 150CM,2720002903,CDM,272,RC,C1725,HCPCS,Outpatient,,,11750.00,7637.50,,11750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8930,76,,174.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8460,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,8812.5,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8460,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,7050,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,10575,90,,69.064,Percent of Total Billed Charges,90% of Total Billed Charges,5287.5,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,10575,90,,206.392,Percent of Total Billed Charges,90% of Total billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7637.5,65,,392.136,Percent of total Billed Charges,65% of Total Billed Charges,5181.75,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,11162.5,95,,217.856,Percent of Total Billed Charges,95% of Total Billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10340,88,,201.8,Percent of Total Billed Charges,88% of Total Billed Charges,10575,90,,206.392,Percent of Total Billed charges,90% of Total Billed Charges,5181.75,11750,
IVL E8 5F 3MM X 80MM X 150CM,2720002904,CDM,272,RC,C1725,HCPCS,Outpatient,,,11750.00,7637.50,,11750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8930,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8460,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,8812.5,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8460,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,7050,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,10575,90,,69.064,Percent of Total Billed Charges,90% of Total Billed Charges,5287.5,45,,8388.88,Percent of Total Billed Charges,45% of Total Billed Charges,10575,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7637.5,65,,661.592,Percent of total Billed Charges,65% of Total Billed Charges,5181.75,44.1,,8221.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,11162.5,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10340,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,10575,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,5181.75,11750,
IVL E8 5F 2.5MM X 60MM X 150CM,2720002905,CDM,272,RC,C1725,HCPCS,Outpatient,,,11750.00,7637.50,,11750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8930,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8460,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,8812.5,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8460,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,7050,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,10575,90,,69.064,Percent of Total Billed Charges,90% of Total Billed Charges,5287.5,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,10575,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7637.5,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,5181.75,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,11162.5,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,11750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10340,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,10575,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,5181.75,11750,
AR-8950-03 COUNTERSINK 3.5/4.0,2720002906,CDM,272,RC,,,Outpatient,,,406.50,264.23,,406.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.94,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.68,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,304.88,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,406.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.68,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,243.9,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,365.85,90,,69.064,Percent of Total Billed Charges,90% of Total Billed Charges,182.93,45,,46.84,Percent of Total Billed Charges,45% of Total Billed Charges,365.85,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,406.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.23,65,,637.512,Percent of total Billed Charges,65% of Total Billed Charges,179.27,44.1,,45.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,386.18,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,406.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.72,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,365.85,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,179.27,406.5,
CATH FOLEY 6FR 3CC,2720002907,CDM,272,RC,,,Outpatient,,,33.13,21.53,,33.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.18,76,,14167.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.85,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,24.85,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,33.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.85,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,19.88,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,29.82,90,,76.208,Percent of Total Billed Charges,90% of Total Billed Charges,14.91,45,,46.84,Percent of Total Billed Charges,45% of Total Billed Charges,29.82,90,,16777.76,Percent of Total Billed Charges,90% of Total billed Charges,33.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.53,65,,1070.352,Percent of total Billed Charges,65% of Total Billed Charges,14.61,44.1,,45.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.47,95,,17709.856,Percent of Total Billed Charges,95% of Total Billed Charges,33.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.15,88,,16404.92,Percent of Total Billed Charges,88% of Total Billed Charges,29.82,90,,16777.76,Percent of Total Billed charges,90% of Total Billed Charges,14.61,33.13,
AEROGEN SOLO NEB REPLACEMENT,2720002908,CDM,272,RC,,,Outpatient,,,232.50,151.13,,232.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,176.7,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,167.4,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,174.38,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,232.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.4,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,139.5,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,209.25,90,,97.64,Percent of Total Billed Charges,90% of Total Billed Charges,104.63,45,,46.84,Percent of Total Billed Charges,45% of Total Billed Charges,209.25,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,232.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.13,65,,11188.52,Percent of total Billed Charges,65% of Total Billed Charges,102.53,44.1,,45.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,220.88,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,232.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.6,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,209.25,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,102.53,232.5,
AEROGEN SOLO TEE PIECE ADAPTER,2720002909,CDM,272,RC,,,Outpatient,,,13.00,8.45,,13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.88,76,,79.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.36,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,9.75,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.36,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,7.8,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,11.7,90,,88.904,Percent of Total Billed Charges,90% of Total Billed Charges,5.85,45,,34.528,Percent of Total Billed Charges,45% of Total Billed Charges,11.7,90,,93.672,Percent of Total Billed Charges,90% of Total billed Charges,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.45,65,,386.976,Percent of total Billed Charges,65% of Total Billed Charges,5.73,44.1,,33.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.35,95,,98.88,Percent of Total Billed Charges,95% of Total Billed Charges,13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.44,88,,91.592,Percent of Total Billed Charges,88% of Total Billed Charges,11.7,90,,93.672,Percent of Total Billed charges,90% of Total Billed Charges,5.73,13,
VISIONS PV 5F 0.014 X 150CM RX,2720002910,CDM,272,RC,C1753,HCPCS,Outpatient,,,1787.50,1161.88,,1787.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1358.5,76,,79.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1287,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,1340.63,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,1787.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1287,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,1072.5,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,1608.75,90,,69.064,Percent of Total Billed Charges,90% of Total Billed Charges,804.38,45,,34.528,Percent of Total Billed Charges,45% of Total Billed Charges,1608.75,90,,93.672,Percent of Total Billed Charges,90% of Total billed Charges,1787.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1787.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1787.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1161.88,65,,386.976,Percent of total Billed Charges,65% of Total Billed Charges,788.29,44.1,,33.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,1698.13,95,,98.88,Percent of Total Billed Charges,95% of Total Billed Charges,1787.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1573,88,,91.592,Percent of Total Billed Charges,88% of Total Billed Charges,1608.75,90,,93.672,Percent of Total Billed charges,90% of Total Billed Charges,788.29,1787.5,
VISIONS PV 6F 0.018 X 135CM RX,2720002911,CDM,272,RC,C1753,HCPCS,Outpatient,,,1625.00,1056.25,,1625,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1235,76,,79.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1170,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,1218.75,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,1625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,975,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,1462.5,90,,97.64,Percent of Total Billed Charges,90% of Total Billed Charges,731.25,45,,34.528,Percent of Total Billed Charges,45% of Total Billed Charges,1462.5,90,,93.672,Percent of Total Billed Charges,90% of Total billed Charges,1625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1056.25,65,,27.56,Percent of total Billed Charges,65% of Total Billed Charges,716.63,44.1,,33.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,1543.75,95,,98.88,Percent of Total Billed Charges,95% of Total Billed Charges,1625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1430,88,,91.592,Percent of Total Billed Charges,88% of Total Billed Charges,1462.5,90,,93.672,Percent of Total Billed charges,90% of Total Billed Charges,716.63,1625,
VISIONS PV 8F 0.035 X 90CM OTW,2720002912,CDM,272,RC,C1753,HCPCS,Outpatient,,,3275.00,2128.75,,3275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2489,76,,58.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2358,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2456.25,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,3275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,1965,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,2947.5,90,,97.64,Percent of Total Billed Charges,90% of Total Billed Charges,1473.75,45,,34.528,Percent of Total Billed Charges,45% of Total Billed Charges,2947.5,90,,69.064,Percent of Total Billed Charges,90% of Total billed Charges,3275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2128.75,65,,92.952,Percent of total Billed Charges,65% of Total Billed Charges,1444.28,44.1,,33.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,3111.25,95,,72.896,Percent of Total Billed Charges,95% of Total Billed Charges,3275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2882,88,,67.528,Percent of Total Billed Charges,88% of Total Billed Charges,2947.5,90,,69.064,Percent of Total Billed charges,90% of Total Billed Charges,1444.28,3275,
PDP303H PDS+ VIO RB-1 SUTURE,2720002913,CDM,272,RC,,,Outpatient,,,8.23,5.35,,8.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.25,76,,58.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.93,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,6.17,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,8.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.93,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,4.94,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,7.41,90,,97.64,Percent of Total Billed Charges,90% of Total Billed Charges,3.7,45,,34.528,Percent of Total Billed Charges,45% of Total Billed Charges,7.41,90,,69.064,Percent of Total Billed Charges,90% of Total billed Charges,8.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.35,65,,510.904,Percent of total Billed Charges,65% of Total Billed Charges,3.63,44.1,,33.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.82,95,,72.896,Percent of Total Billed Charges,95% of Total Billed Charges,8.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.24,88,,67.528,Percent of Total Billed Charges,88% of Total Billed Charges,7.41,90,,69.064,Percent of Total Billed charges,90% of Total Billed Charges,3.63,8.23,
PDP304H PDS+ VIO RB-1 SUTURE,2720002914,CDM,272,RC,,,Outpatient,,,7.63,4.96,,7.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.8,76,,58.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.49,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,5.72,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,7.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.49,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,4.58,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,6.87,90,,69.064,Percent of Total Billed Charges,90% of Total Billed Charges,3.43,45,,38.104,Percent of Total Billed Charges,45% of Total Billed Charges,6.87,90,,69.064,Percent of Total Billed Charges,90% of Total billed Charges,7.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.96,65,,3404.96,Percent of total Billed Charges,65% of Total Billed Charges,3.36,44.1,,37.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.25,95,,72.896,Percent of Total Billed Charges,95% of Total Billed Charges,7.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.71,88,,67.528,Percent of Total Billed Charges,88% of Total Billed Charges,6.87,90,,69.064,Percent of Total Billed charges,90% of Total Billed Charges,3.36,7.63,
VCP864D VCL+ UD 3-0 SH SUTURE,2720002915,CDM,272,RC,,,Outpatient,,,34.03,22.12,,34.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.86,76,,58.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.5,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,25.52,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,34.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.5,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,20.42,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,30.63,90,,1008.128,Percent of Total Billed Charges,90% of Total Billed Charges,15.31,45,,48.816,Percent of Total Billed Charges,45% of Total Billed Charges,30.63,90,,69.064,Percent of Total Billed Charges,90% of Total billed Charges,34.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.12,65,,13901.376,Percent of total Billed Charges,65% of Total Billed Charges,15.01,44.1,,47.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.33,95,,72.896,Percent of Total Billed Charges,95% of Total Billed Charges,34.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.95,88,,67.528,Percent of Total Billed Charges,88% of Total Billed Charges,30.63,90,,69.064,Percent of Total Billed charges,90% of Total Billed Charges,15.01,34.03,
2351-4213S 4.2 X 135 DRILL,2720002916,CDM,272,RC,,,Outpatient,,,787.50,511.88,,787.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,598.5,76,,58.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,567,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,590.63,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,787.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,567,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,472.5,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,708.75,90,,542.96,Percent of Total Billed Charges,90% of Total Billed Charges,354.38,45,,44.456,Percent of Total Billed Charges,45% of Total Billed Charges,708.75,90,,69.064,Percent of Total Billed Charges,90% of Total billed Charges,787.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,787.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,787.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511.88,65,,9255.352,Percent of total Billed Charges,65% of Total Billed Charges,347.29,44.1,,43.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,748.13,95,,72.896,Percent of Total Billed Charges,95% of Total Billed Charges,787.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,693,88,,67.528,Percent of Total Billed Charges,88% of Total Billed Charges,708.75,90,,69.064,Percent of Total Billed charges,90% of Total Billed Charges,347.29,787.5,
60-19326 1.9X27 AO DRILL BIT,2720002917,CDM,272,RC,,,Outpatient,,,405.00,263.25,,405,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,307.8,76,,64.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,291.6,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,303.75,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,405,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291.6,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,243,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,364.5,90,,916.048,Percent of Total Billed Charges,90% of Total Billed Charges,182.25,45,,34.528,Percent of Total Billed Charges,45% of Total Billed Charges,364.5,90,,76.208,Percent of Total Billed Charges,90% of Total billed Charges,405,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.25,65,,10232.832,Percent of total Billed Charges,65% of Total Billed Charges,178.61,44.1,,33.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,384.75,95,,80.44,Percent of Total Billed Charges,95% of Total Billed Charges,405,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.4,88,,74.512,Percent of Total Billed Charges,88% of Total Billed Charges,364.5,90,,76.208,Percent of Total Billed charges,90% of Total Billed Charges,178.61,405,
705133 1.6X96MM AO DRILL BIT,2720002918,CDM,272,RC,,,Outpatient,,,597.50,388.38,,597.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,454.1,76,,82.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,430.2,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,448.13,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,597.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.2,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,358.5,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,537.75,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,268.88,45,,48.816,Percent of Total Billed Charges,45% of Total Billed Charges,537.75,90,,97.64,Percent of Total Billed Charges,90% of Total billed Charges,597.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,597.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,597.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,388.38,65,,10736.192,Percent of total Billed Charges,65% of Total Billed Charges,263.5,44.1,,47.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,567.63,95,,103.064,Percent of Total Billed Charges,95% of Total Billed Charges,597.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,525.8,88,,95.472,Percent of Total Billed Charges,88% of Total Billed Charges,537.75,90,,97.64,Percent of Total Billed charges,90% of Total Billed Charges,263.5,597.5,
"VLOCA008L 180 ABS RELOAD 8""-20",2720002919,CDM,272,RC,,,Outpatient,,,334.25,217.26,,334.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,254.03,76,,75.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,240.66,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,250.69,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,334.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.66,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,200.55,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,300.83,90,,882.704,Percent of Total Billed Charges,90% of Total Billed Charges,150.41,45,,48.816,Percent of Total Billed Charges,45% of Total Billed Charges,300.83,90,,88.904,Percent of Total Billed Charges,90% of Total billed Charges,334.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.26,65,,31541.824,Percent of total Billed Charges,65% of Total Billed Charges,147.4,44.1,,47.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,317.54,95,,93.848,Percent of Total Billed Charges,95% of Total Billed Charges,334.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.14,88,,86.928,Percent of Total Billed Charges,88% of Total Billed Charges,300.83,90,,88.904,Percent of Total Billed charges,90% of Total Billed Charges,147.4,334.25,
"GERTIE MARX SP NDLE 25G X 3.5""",2720002920,CDM,272,RC,,,Outpatient,,,29.95,19.47,,29.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.76,76,,58.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.56,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,22.46,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,29.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.56,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,17.97,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,26.96,90,,1482.024,Percent of Total Billed Charges,90% of Total Billed Charges,13.48,45,,48.816,Percent of Total Billed Charges,45% of Total Billed Charges,26.96,90,,69.064,Percent of Total Billed Charges,90% of Total billed Charges,29.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.47,65,,26337.4,Percent of total Billed Charges,65% of Total Billed Charges,13.21,44.1,,47.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.45,95,,72.896,Percent of Total Billed Charges,95% of Total Billed Charges,29.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.36,88,,67.528,Percent of Total Billed Charges,88% of Total Billed Charges,26.96,90,,69.064,Percent of Total Billed charges,90% of Total Billed Charges,13.21,29.95,
1946 SURGICEL NU-KNIT 6X9,2720002921,CDM,272,RC,,,Outpatient,,,575.23,373.90,,575.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,437.17,76,,82.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,414.17,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,431.42,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,575.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.17,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,345.14,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,517.71,90,,15491.8,Percent of Total Billed Charges,90% of Total Billed Charges,258.85,45,,34.528,Percent of Total Billed Charges,45% of Total Billed Charges,517.71,90,,97.64,Percent of Total Billed Charges,90% of Total billed Charges,575.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.9,65,,54301.832,Percent of total Billed Charges,65% of Total Billed Charges,253.68,44.1,,33.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,546.47,95,,103.064,Percent of Total Billed Charges,95% of Total Billed Charges,575.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.2,88,,95.472,Percent of Total Billed Charges,88% of Total Billed Charges,517.71,90,,97.64,Percent of Total Billed charges,90% of Total Billed Charges,253.68,575.23,
"SUCT CONNECTING TUB 3/16, 20""",2720002922,CDM,272,RC,,,Outpatient,,,2.78,1.81,,2.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.11,76,,82.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,2.09,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,2.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1.67,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,2.5,90,,535.816,Percent of Total Billed Charges,90% of Total Billed Charges,1.25,45,,504.064,Percent of Total Billed Charges,45% of Total Billed Charges,2.5,90,,97.64,Percent of Total Billed Charges,90% of Total billed Charges,2.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.81,65,,41561.384,Percent of total Billed Charges,65% of Total Billed Charges,1.23,44.1,,493.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.64,95,,103.064,Percent of Total Billed Charges,95% of Total Billed Charges,2.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.45,88,,95.472,Percent of Total Billed Charges,88% of Total Billed Charges,2.5,90,,97.64,Percent of Total Billed charges,90% of Total Billed Charges,1.23,2.78,
M00513372 JUMBO JAW FCPS 240CM,2720002923,CDM,272,RC,,,Outpatient,,,213.85,139.00,,213.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,162.53,76,,82.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153.97,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,160.39,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,213.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.97,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,128.31,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,192.47,90,,535.816,Percent of Total Billed Charges,90% of Total Billed Charges,96.23,45,,271.48,Percent of Total Billed Charges,45% of Total Billed Charges,192.47,90,,97.64,Percent of Total Billed Charges,90% of Total billed Charges,213.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139,65,,41561.384,Percent of total Billed Charges,65% of Total Billed Charges,94.31,44.1,,266.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,203.16,95,,103.064,Percent of Total Billed Charges,95% of Total Billed Charges,213.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.19,88,,95.472,Percent of Total Billed Charges,88% of Total Billed Charges,192.47,90,,97.64,Percent of Total Billed charges,90% of Total Billed Charges,94.31,213.85,
AR-8980DSC DISP KT DX SWLLCK,2720002924,CDM,272,RC,,,Outpatient,,,1422.75,924.79,,1422.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1081.29,76,,58.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1024.38,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1067.06,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,1422.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1024.38,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,853.65,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,1280.48,90,,38.16,Percent of Total Billed Charges,90% of Total Billed Charges,640.24,45,,458.024,Percent of Total Billed Charges,45% of Total Billed Charges,1280.48,90,,69.064,Percent of Total Billed Charges,90% of Total billed Charges,1422.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1422.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1422.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,924.79,65,,38739.024,Percent of total Billed Charges,65% of Total Billed Charges,627.43,44.1,,448.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,1351.61,95,,72.896,Percent of Total Billed Charges,95% of Total Billed Charges,1422.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1252.02,88,,67.528,Percent of Total Billed Charges,88% of Total Billed Charges,1280.48,90,,69.064,Percent of Total Billed charges,90% of Total Billed Charges,627.43,1422.75,
"AR-1897S DISP KIT,TRANS-TIB AC",2720002925,CDM,272,RC,,,Outpatient,,,609.75,396.34,,609.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,463.41,76,,851.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,439.02,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,457.31,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,609.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,439.02,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,365.85,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,548.78,90,,128.704,Percent of Total Billed Charges,90% of Total Billed Charges,274.39,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,548.78,90,,1008.128,Percent of Total Billed Charges,90% of Total billed Charges,609.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,609.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,609.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.34,65,,9622.264,Percent of total Billed Charges,65% of Total Billed Charges,268.9,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,579.26,95,,1064.136,Percent of Total Billed Charges,95% of Total Billed Charges,609.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,536.58,88,,985.728,Percent of Total Billed Charges,88% of Total Billed Charges,548.78,90,,1008.128,Percent of Total Billed charges,90% of Total Billed Charges,268.9,609.75,
AR-2386-10 QUADPRO HARVETR 10,2720002926,CDM,272,RC,,,Outpatient,,,1151.75,748.64,,1151.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,875.33,76,,458.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,829.26,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,863.81,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,1151.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,829.26,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,691.05,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,1036.58,90,,707.4,Percent of Total Billed Charges,90% of Total Billed Charges,518.29,45,,441.352,Percent of Total Billed Charges,45% of Total Billed Charges,1036.58,90,,542.96,Percent of Total Billed Charges,90% of Total billed Charges,1151.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1151.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1151.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,748.64,65,,16223.248,Percent of total Billed Charges,65% of Total Billed Charges,507.92,44.1,,432.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,1094.16,95,,573.12,Percent of Total Billed Charges,95% of Total Billed Charges,1151.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1013.54,88,,530.896,Percent of Total Billed Charges,88% of Total Billed Charges,1036.58,90,,542.96,Percent of Total Billed charges,90% of Total Billed Charges,507.92,1151.75,
AR-6592-08-30 PASSPRT BTN CANN,2720002927,CDM,272,RC,,,Outpatient,,,86.73,56.37,,86.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,65.91,76,,773.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.45,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,65.05,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,86.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.45,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,52.04,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,78.06,90,,4714.56,Percent of Total Billed Charges,90% of Total Billed Charges,39.03,45,,741.016,Percent of Total Billed Charges,45% of Total Billed Charges,78.06,90,,916.048,Percent of Total Billed Charges,90% of Total billed Charges,86.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.37,65,,8681.48,Percent of total Billed Charges,65% of Total Billed Charges,38.25,44.1,,726.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.39,95,,966.944,Percent of Total Billed Charges,95% of Total Billed Charges,86.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.32,88,,895.696,Percent of Total Billed Charges,88% of Total Billed Charges,78.06,90,,916.048,Percent of Total Billed charges,90% of Total Billed Charges,38.25,86.73,
AR-6592-10-50 PASSPRT BTN CANN,2720002928,CDM,272,RC,,,Outpatient,,,86.73,56.37,,86.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,65.91,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.45,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,65.05,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,86.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.45,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,52.04,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,78.06,90,,19248.064,Percent of Total Billed Charges,90% of Total Billed Charges,39.03,45,,7745.904,Percent of Total Billed Charges,45% of Total Billed Charges,78.06,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,86.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.37,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,38.25,44.1,,7590.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.39,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,86.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.32,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,78.06,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,38.25,86.73,
AR-7281 TAPERES CVD NDLE 26MM,2720002929,CDM,272,RC,,,Outpatient,,,51.50,33.48,,51.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,39.14,76,,745.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,37.08,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,38.63,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.08,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,30.9,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,46.35,90,,12815.104,Percent of Total Billed Charges,90% of Total Billed Charges,23.18,45,,267.912,Percent of Total Billed Charges,45% of Total Billed Charges,46.35,90,,882.704,Percent of Total Billed Charges,90% of Total billed Charges,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.48,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,22.71,44.1,,262.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.93,95,,931.744,Percent of Total Billed Charges,95% of Total Billed Charges,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.32,88,,863.088,Percent of Total Billed Charges,88% of Total Billed Charges,46.35,90,,882.704,Percent of Total Billed charges,90% of Total Billed Charges,22.71,51.5,
ARTHREX ABS-3005 QCKSET KT 5CC,2720002930,CDM,272,RC,,,Outpatient,,,4173.40,2712.71,,4173.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3171.78,76,,1251.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3004.85,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,3130.05,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,4173.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3004.85,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,2504.04,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,3756.06,90,,14168.536,Percent of Total Billed Charges,90% of Total Billed Charges,1878.03,45,,267.912,Percent of Total Billed Charges,45% of Total Billed Charges,3756.06,90,,1482.024,Percent of Total Billed Charges,90% of Total billed Charges,4173.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4173.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4173.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2712.71,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,1840.47,44.1,,262.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,3964.73,95,,1564.36,Percent of Total Billed Charges,95% of Total Billed Charges,4173.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3672.59,88,,1449.096,Percent of Total Billed Charges,88% of Total Billed Charges,3756.06,90,,1482.024,Percent of Total Billed charges,90% of Total Billed Charges,1840.47,4173.4,
9408-VC-006 BIOPSY SYS TRY 102,2720002931,CDM,272,RC,,,Outpatient,,,420.83,273.54,,420.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,319.83,76,,13081.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,303,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,315.62,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,420.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,252.5,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,378.75,90,,14865.496,Percent of Total Billed Charges,90% of Total Billed Charges,189.37,45,,19.08,Percent of Total Billed Charges,45% of Total Billed Charges,378.75,90,,15491.8,Percent of Total Billed Charges,90% of Total billed Charges,420.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,420.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,420.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.54,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,185.59,44.1,,18.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,399.79,95,,16352.456,Percent of Total Billed Charges,95% of Total Billed Charges,420.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.33,88,,15147.536,Percent of Total Billed Charges,88% of Total Billed Charges,378.75,90,,15491.8,Percent of Total Billed charges,90% of Total Billed Charges,185.59,420.83,
9463-VC-006 BIOPSY TRAY 10/12,2720002932,CDM,272,RC,,,Outpatient,,,1208.33,785.41,,1208.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,918.33,76,,452.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,870,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,906.25,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,1208.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,870,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,725,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,1087.5,90,,43673.296,Percent of Total Billed Charges,90% of Total Billed Charges,543.75,45,,64.352,Percent of Total Billed Charges,45% of Total Billed Charges,1087.5,90,,535.816,Percent of Total Billed Charges,90% of Total billed Charges,1208.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1208.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1208.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,785.41,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,532.87,44.1,,63.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,1147.91,95,,565.584,Percent of Total Billed Charges,95% of Total Billed Charges,1208.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1063.33,88,,523.912,Percent of Total Billed Charges,88% of Total Billed Charges,1087.5,90,,535.816,Percent of Total Billed charges,90% of Total Billed Charges,532.87,1208.33,
SILICONE FOLEY CATH 8FR 3CC,2740000001,CDM,270,RC,A4344,HCPCS,Outpatient,,,8.00,5.20,,8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.08,76,,452.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.62,350,,215.912,Fee Schedule,350% of BCBS fee schedule,53.62,350,,224.912,Fee Schedule,350% of BCBS fee schedule,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.62,350,,215.912,Fee Schedule,350% of BCBS PPO fee schedule,15.32,100,,179.928,Fee Schedule,100% of Blue ADV HMO fee schedule,7.2,90,,36467.176,Percent of Total Billed Charges,90% of Total Billed Charges,3.6,45,,353.704,Percent of Total Billed Charges,45% of Total Billed Charges,7.2,90,,535.816,Percent of Total Billed Charges,90% of Total billed Charges,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.2,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,3.53,44.1,,346.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.6,95,,565.584,Percent of Total Billed Charges,95% of Total Billed Charges,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.04,88,,523.912,Percent of Total Billed Charges,88% of Total Billed Charges,7.2,90,,535.816,Percent of Total Billed charges,90% of Total Billed Charges,3.53,53.62,
NOVASURE DEVICE,2740000002,CDM,270,RC,A4649,HCPCS,Outpatient,,,5107.88,3320.12,,5107.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3881.99,76,,32.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3677.67,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,3830.91,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,5107.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3677.67,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,3064.73,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,4597.09,90,,75187.152,Percent of Total Billed Charges,90% of Total Billed Charges,2298.55,45,,2357.28,Percent of Total Billed Charges,45% of Total Billed Charges,4597.09,90,,38.16,Percent of Total Billed Charges,90% of Total billed Charges,5107.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5107.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5107.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3320.12,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,2252.58,44.1,,2310.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,4852.49,95,,40.28,Percent of Total Billed Charges,95% of Total Billed Charges,5107.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4494.93,88,,37.312,Percent of Total Billed Charges,88% of Total Billed Charges,4597.09,90,,38.16,Percent of Total Billed charges,90% of Total Billed Charges,2252.58,5107.88,
QUILL RX-1059Q PDO SZ 1 SUTURE,2740000003,CDM,278,RC,C2626,HCPCS,Outpatient,,,362.72,235.77,,362.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,275.67,76,,108.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,261.16,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,261.16,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,362.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.16,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,217.63,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,326.45,90,,57546.536,Percent of Total Billed Charges,90% of Total Billed Charges,163.22,45,,9624.032,Percent of Total Billed Charges,45% of Total Billed Charges,326.45,90,,128.704,Percent of Total Billed Charges,90% of Total billed Charges,362.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,362.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,362.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.77,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,159.96,44.1,,9431.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,344.58,95,,135.848,Percent of Total Billed Charges,95% of Total Billed Charges,362.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319.19,88,,125.84,Percent of Total Billed Charges,88% of Total Billed Charges,326.45,90,,128.704,Percent of Total Billed charges,90% of Total Billed Charges,159.96,362.72,
QUILL RX1062Q PDO SZ 2 SUTURE,2740000004,CDM,278,RC,C2626,HCPCS,Outpatient,,,379.26,246.52,,379.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,288.24,76,,597.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,273.07,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,273.07,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,379.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.07,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,227.56,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,341.33,90,,57546.536,Percent of Total Billed Charges,90% of Total Billed Charges,170.67,45,,6407.552,Percent of Total Billed Charges,45% of Total Billed Charges,341.33,90,,707.4,Percent of Total Billed Charges,90% of Total billed Charges,379.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.52,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,167.25,44.1,,6279.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,360.3,95,,746.704,Percent of Total Billed Charges,95% of Total Billed Charges,379.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.75,88,,691.68,Percent of Total Billed Charges,88% of Total Billed Charges,341.33,90,,707.4,Percent of Total Billed charges,90% of Total Billed Charges,167.25,379.26,
ON Q 100ML PAIN PUMP,2740000005,CDM,278,RC,C2626,HCPCS,Outpatient,,,124.58,80.98,,124.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,94.68,76,,3981.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,89.7,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,89.7,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,124.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.7,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,74.75,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,112.12,90,,53638.656,Percent of Total Billed Charges,90% of Total Billed Charges,56.06,45,,7084.264,Percent of Total Billed Charges,45% of Total Billed Charges,112.12,90,,4714.56,Percent of Total Billed Charges,90% of Total billed Charges,124.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.98,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,54.94,44.1,,6942.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,118.35,95,,4976.48,Percent of Total Billed Charges,95% of Total Billed Charges,124.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.63,88,,4609.792,Percent of Total Billed Charges,88% of Total Billed Charges,112.12,90,,4714.56,Percent of Total Billed charges,90% of Total Billed Charges,54.94,124.58,
ON Q 2.5 SILVER SOAK,2740000006,CDM,278,RC,C2626,HCPCS,Outpatient,,,71.66,46.58,,71.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.46,76,,16253.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.6,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,51.6,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,43,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,64.49,90,,13323.136,Percent of Total Billed Charges,90% of Total Billed Charges,32.25,45,,7432.744,Percent of Total Billed Charges,45% of Total Billed Charges,64.49,90,,19248.064,Percent of Total Billed Charges,90% of Total billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.58,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,31.6,44.1,,7284.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.08,95,,20317.4,Percent of Total Billed Charges,95% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,88,,18820.328,Percent of Total Billed Charges,88% of Total Billed Charges,64.49,90,,19248.064,Percent of Total Billed charges,90% of Total Billed Charges,31.6,71.66,
ONQ5 SILVER SOAKER,2740000007,CDM,278,RC,C2626,HCPCS,Outpatient,,,81.59,53.03,,81.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.01,76,,10821.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,58.74,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,58.74,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.74,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,48.95,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,73.43,90,,22462.96,Percent of Total Billed Charges,90% of Total Billed Charges,36.72,45,,21836.648,Percent of Total Billed Charges,45% of Total Billed Charges,73.43,90,,12815.104,Percent of Total Billed Charges,90% of Total billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.03,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,35.98,44.1,,21399.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,77.51,95,,13527.056,Percent of Total Billed Charges,95% of Total Billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.8,88,,12530.328,Percent of Total Billed Charges,88% of Total Billed Charges,73.43,90,,12815.104,Percent of Total Billed charges,90% of Total Billed Charges,35.98,81.59,
CERV COLLAR FOAM MD,2740000008,CDM,274,RC,L0120,HCPCS,Outpatient,,,61.74,40.13,,37.38,125,,,Fee Schedule,125% of CMS OPPS Rate,46.92,76,,11964.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,44.45,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,44.45,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,29.9,100,,,Fee Schedule,100% of CMS OPPS Rate,44.45,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,37.04,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,55.57,90,,12020.512,Percent of Total Billed Charges,90% of Total Billed Charges,27.78,45,,18233.584,Percent of Total Billed Charges,45% of Total Billed Charges,55.57,90,,14168.536,Percent of Total Billed Charges,90% of Total billed Charges,29.9,100,,,Fee Schedule,100% of CMS OPPS Rate,29.9,100,,,Fee Schedule,100% of CMS OPPS Rate,29.9,100,,,Fee Schedule,100% of CMS OPPS Rate,59.8,200,,341.112,Fee Schedule,200% of CMS OPPS Rate,27.23,44.1,,17868.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,58.65,95,,14955.672,Percent of Total Billed Charges,95% of Total Billed Charges,22.43,75,,,Fee Schedule,75% of CMS OPPS Rate,54.33,88,,13853.68,Percent of Total Billed Charges,88% of Total Billed Charges,55.57,90,,14168.536,Percent of Total Billed charges,90% of Total Billed Charges,22.43,59.8,
CERV COLLAR FOAM SM,2740000009,CDM,274,RC,,,Outpatient,,,208.37,135.44,,208.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,158.36,76,,12553.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.03,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,150.03,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.03,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,125.02,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,187.53,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,93.77,45,,37593.576,Percent of Total Billed Charges,45% of Total Billed Charges,187.53,90,,14865.496,Percent of Total Billed Charges,90% of Total billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.44,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,91.89,44.1,,36841.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,197.95,95,,15691.352,Percent of Total Billed Charges,95% of Total Billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.37,88,,14535.152,Percent of Total Billed Charges,88% of Total Billed Charges,187.53,90,,14865.496,Percent of Total Billed charges,90% of Total Billed Charges,91.89,208.37,
KNEE IMMOB,2740000010,CDM,274,RC,L1830,HCPCS,Outpatient,,,115.76,75.24,,76.9,125,,,Fee Schedule,125% of CMS OPPS Rate,87.98,76,,36879.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,83.35,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,83.35,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,61.52,100,,,Fee Schedule,100% of CMS OPPS Rate,83.35,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,69.46,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,104.18,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,52.09,45,,28773.264,Percent of Total Billed Charges,45% of Total Billed Charges,104.18,90,,43673.296,Percent of Total Billed Charges,90% of Total billed Charges,61.52,100,,,Fee Schedule,100% of CMS OPPS Rate,61.52,100,,,Fee Schedule,100% of CMS OPPS Rate,61.52,100,,,Fee Schedule,100% of CMS OPPS Rate,123.04,200,,341.112,Fee Schedule,200% of CMS OPPS Rate,51.05,44.1,,28197.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,109.97,95,,46099.584,Percent of Total Billed Charges,95% of Total Billed Charges,46.14,75,,,Fee Schedule,75% of CMS OPPS Rate,101.87,88,,42702.776,Percent of Total Billed Charges,88% of Total Billed Charges,104.18,90,,43673.296,Percent of Total Billed charges,90% of Total Billed Charges,46.14,123.04,
ANKLE BRACE D/SM,2740000011,CDM,274,RC,L1902,HCPCS,Outpatient,,,190.73,123.97,,149.89,125,,,Fee Schedule,125% of CMS OPPS Rate,144.95,76,,30794.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,137.33,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,137.33,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,119.91,100,,,Fee Schedule,100% of CMS OPPS Rate,137.33,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,114.44,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,171.66,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,85.83,45,,28773.264,Percent of Total Billed Charges,45% of Total Billed Charges,171.66,90,,36467.176,Percent of Total Billed Charges,90% of Total billed Charges,119.91,100,,,Fee Schedule,100% of CMS OPPS Rate,119.91,100,,,Fee Schedule,100% of CMS OPPS Rate,119.91,100,,,Fee Schedule,100% of CMS OPPS Rate,239.82,200,,341.112,Fee Schedule,200% of CMS OPPS Rate,84.11,44.1,,28197.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,181.19,95,,38493.128,Percent of Total Billed Charges,95% of Total Billed Charges,89.93,75,,,Fee Schedule,75% of CMS OPPS Rate,167.84,88,,35656.792,Percent of Total Billed Charges,88% of Total Billed Charges,171.66,90,,36467.176,Percent of Total Billed charges,90% of Total Billed Charges,84.11,239.82,
ANKLE BRACE D/MED,2740000012,CDM,274,RC,L1902,HCPCS,Outpatient,,,122.38,79.55,,149.89,125,,,Fee Schedule,125% of CMS OPPS Rate,93.01,76,,63491.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.11,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,88.11,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,119.91,100,,,Fee Schedule,100% of CMS OPPS Rate,88.11,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,73.43,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,110.14,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,55.07,45,,26819.328,Percent of Total Billed Charges,45% of Total Billed Charges,110.14,90,,75187.152,Percent of Total Billed Charges,90% of Total billed Charges,119.91,100,,,Fee Schedule,100% of CMS OPPS Rate,119.91,100,,,Fee Schedule,100% of CMS OPPS Rate,119.91,100,,,Fee Schedule,100% of CMS OPPS Rate,239.82,200,,341.112,Fee Schedule,200% of CMS OPPS Rate,53.97,44.1,,26282.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.26,95,,79364.216,Percent of Total Billed Charges,95% of Total Billed Charges,89.93,75,,,Fee Schedule,75% of CMS OPPS Rate,107.69,88,,73516.328,Percent of Total Billed Charges,88% of Total Billed Charges,110.14,90,,75187.152,Percent of Total Billed charges,90% of Total Billed Charges,53.97,239.82,
ANKLE BRACE D/LRG,2740000013,CDM,274,RC,L1902,HCPCS,Outpatient,,,158.76,103.19,,149.89,125,,,Fee Schedule,125% of CMS OPPS Rate,120.66,76,,48594.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.31,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,114.31,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,119.91,100,,,Fee Schedule,100% of CMS OPPS Rate,114.31,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,95.26,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,142.88,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,71.44,45,,6661.568,Percent of Total Billed Charges,45% of Total Billed Charges,142.88,90,,57546.536,Percent of Total Billed Charges,90% of Total billed Charges,119.91,100,,,Fee Schedule,100% of CMS OPPS Rate,119.91,100,,,Fee Schedule,100% of CMS OPPS Rate,119.91,100,,,Fee Schedule,100% of CMS OPPS Rate,239.82,200,,341.112,Fee Schedule,200% of CMS OPPS Rate,70.01,44.1,,6528.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,150.82,95,,60743.56,Percent of Total Billed Charges,95% of Total Billed Charges,89.93,75,,,Fee Schedule,75% of CMS OPPS Rate,139.71,88,,56267.72,Percent of Total Billed Charges,88% of Total Billed Charges,142.88,90,,57546.536,Percent of Total Billed charges,90% of Total Billed Charges,70.01,239.82,
CLAV SPLNT PAD LG,2740000014,CDM,274,RC,L3650,HCPCS,Outpatient,,,132.30,86.00,,89.56,125,,,Fee Schedule,125% of CMS OPPS Rate,100.55,76,,48594.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.26,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,95.26,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,71.65,100,,,Fee Schedule,100% of CMS OPPS Rate,95.26,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,79.38,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,119.07,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,59.54,45,,11231.48,Percent of Total Billed Charges,45% of Total Billed Charges,119.07,90,,57546.536,Percent of Total Billed Charges,90% of Total billed Charges,71.65,100,,,Fee Schedule,100% of CMS OPPS Rate,71.65,100,,,Fee Schedule,100% of CMS OPPS Rate,71.65,100,,,Fee Schedule,100% of CMS OPPS Rate,143.3,200,,341.112,Fee Schedule,200% of CMS OPPS Rate,58.34,44.1,,11006.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.69,95,,60743.56,Percent of Total Billed Charges,95% of Total Billed Charges,53.74,75,,,Fee Schedule,75% of CMS OPPS Rate,116.42,88,,56267.72,Percent of Total Billed Charges,88% of Total Billed Charges,119.07,90,,57546.536,Percent of Total Billed charges,90% of Total Billed Charges,53.74,143.3,
CLAV SPLNT PAD INFNT,2740000015,CDM,274,RC,L3650,HCPCS,Outpatient,,,157.66,102.48,,89.56,125,,,Fee Schedule,125% of CMS OPPS Rate,119.82,76,,45294.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,113.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,113.52,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,71.65,100,,,Fee Schedule,100% of CMS OPPS Rate,113.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,94.6,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,141.89,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,70.95,45,,6010.256,Percent of Total Billed Charges,45% of Total Billed Charges,141.89,90,,53638.656,Percent of Total Billed Charges,90% of Total billed Charges,71.65,100,,,Fee Schedule,100% of CMS OPPS Rate,71.65,100,,,Fee Schedule,100% of CMS OPPS Rate,71.65,100,,,Fee Schedule,100% of CMS OPPS Rate,143.3,200,,341.112,Fee Schedule,200% of CMS OPPS Rate,69.53,44.1,,5890.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,149.78,95,,56618.576,Percent of Total Billed Charges,95% of Total Billed Charges,53.74,75,,,Fee Schedule,75% of CMS OPPS Rate,138.74,88,,52446.68,Percent of Total Billed Charges,88% of Total Billed Charges,141.89,90,,53638.656,Percent of Total Billed charges,90% of Total Billed Charges,53.74,149.78,
CLAV SPLNT XLG,2740000016,CDM,274,RC,L3650,HCPCS,Outpatient,,,126.79,82.41,,89.56,125,,,Fee Schedule,125% of CMS OPPS Rate,96.36,76,,11250.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.29,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,91.29,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,71.65,100,,,Fee Schedule,100% of CMS OPPS Rate,91.29,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,76.07,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,114.11,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,57.06,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,114.11,90,,13323.136,Percent of Total Billed Charges,90% of Total billed Charges,71.65,100,,,Fee Schedule,100% of CMS OPPS Rate,71.65,100,,,Fee Schedule,100% of CMS OPPS Rate,71.65,100,,,Fee Schedule,100% of CMS OPPS Rate,143.3,200,,341.112,Fee Schedule,200% of CMS OPPS Rate,55.91,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,120.45,95,,14063.312,Percent of Total Billed Charges,95% of Total Billed Charges,53.74,75,,,Fee Schedule,75% of CMS OPPS Rate,111.58,88,,13027.072,Percent of Total Billed Charges,88% of Total Billed Charges,114.11,90,,13323.136,Percent of Total Billed charges,90% of Total Billed Charges,53.74,143.3,
SPLINT WRIST MED/LFT,2740000017,CDM,274,RC,L3908,HCPCS,Outpatient,,,184.12,119.68,,82.56,125,,,Fee Schedule,125% of CMS OPPS Rate,139.93,76,,18968.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,132.57,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,132.57,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,132.57,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,110.47,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,165.71,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,82.85,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,165.71,90,,22462.96,Percent of Total Billed Charges,90% of Total billed Charges,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,132.1,200,,341.112,Fee Schedule,200% of CMS OPPS Rate,81.2,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,174.91,95,,23710.896,Percent of Total Billed Charges,95% of Total Billed Charges,49.54,75,,,Fee Schedule,75% of CMS OPPS Rate,162.03,88,,21963.776,Percent of Total Billed Charges,88% of Total Billed Charges,165.71,90,,22462.96,Percent of Total Billed charges,90% of Total Billed Charges,49.54,174.91,
SPLINT WRIST MED/RT,2740000018,CDM,274,RC,L3908,HCPCS,Outpatient,,,184.12,119.68,,82.56,125,,,Fee Schedule,125% of CMS OPPS Rate,139.93,76,,10150.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,132.57,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,132.57,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,132.57,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,110.47,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,165.71,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,82.85,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,165.71,90,,12020.512,Percent of Total Billed Charges,90% of Total billed Charges,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,132.1,200,,341.112,Fee Schedule,200% of CMS OPPS Rate,81.2,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,174.91,95,,12688.32,Percent of Total Billed Charges,95% of Total Billed Charges,49.54,75,,,Fee Schedule,75% of CMS OPPS Rate,162.03,88,,11753.392,Percent of Total Billed Charges,88% of Total Billed Charges,165.71,90,,12020.512,Percent of Total Billed charges,90% of Total Billed Charges,49.54,174.91,
SPLINT WRIST SM/LFT,2740000019,CDM,274,RC,L3908,HCPCS,Outpatient,,,184.12,119.68,,82.56,125,,,Fee Schedule,125% of CMS OPPS Rate,139.93,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,132.57,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,132.57,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,132.57,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,110.47,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,165.71,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,82.85,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,165.71,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,132.1,200,,341.112,Fee Schedule,200% of CMS OPPS Rate,81.2,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,174.91,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,49.54,75,,,Fee Schedule,75% of CMS OPPS Rate,162.03,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,165.71,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,49.54,174.91,
SPLINT WRIST SM RT,2740000020,CDM,274,RC,L3908,HCPCS,Outpatient,,,184.12,119.68,,82.56,125,,,Fee Schedule,125% of CMS OPPS Rate,139.93,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,132.57,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,132.57,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,132.57,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,110.47,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,165.71,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,82.85,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,165.71,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,132.1,200,,341.112,Fee Schedule,200% of CMS OPPS Rate,81.2,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,174.91,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,49.54,75,,,Fee Schedule,75% of CMS OPPS Rate,162.03,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,165.71,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,49.54,174.91,
SPLINT WRIST LG/LFT,2740000021,CDM,274,RC,L3908,HCPCS,Outpatient,,,184.12,119.68,,82.56,125,,,Fee Schedule,125% of CMS OPPS Rate,139.93,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,132.57,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,132.57,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,132.57,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,110.47,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,165.71,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,82.85,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,165.71,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,132.1,200,,341.112,Fee Schedule,200% of CMS OPPS Rate,81.2,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,174.91,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,49.54,75,,,Fee Schedule,75% of CMS OPPS Rate,162.03,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,165.71,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,49.54,174.91,
SPLINT WRIST LG/RT,2740000022,CDM,274,RC,L3908,HCPCS,Outpatient,,,184.12,119.68,,82.56,125,,,Fee Schedule,125% of CMS OPPS Rate,139.93,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,132.57,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,132.57,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,132.57,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,110.47,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,165.71,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,82.85,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,165.71,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,132.1,200,,341.112,Fee Schedule,200% of CMS OPPS Rate,81.2,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,174.91,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,49.54,75,,,Fee Schedule,75% of CMS OPPS Rate,162.03,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,165.71,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,49.54,174.91,
SPLINT WRIST XLG/LFT,2740000023,CDM,274,RC,L3908,HCPCS,Outpatient,,,184.12,119.68,,82.56,125,,,Fee Schedule,125% of CMS OPPS Rate,139.93,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,132.57,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,132.57,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,132.57,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,110.47,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,165.71,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,82.85,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,165.71,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,132.1,200,,341.112,Fee Schedule,200% of CMS OPPS Rate,81.2,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,174.91,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,49.54,75,,,Fee Schedule,75% of CMS OPPS Rate,162.03,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,165.71,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,49.54,174.91,
BRA POST XXL,2740000024,CDM,274,RC,L8000,HCPCS,Outpatient,,,57.00,37.05,,56.28,125,,,Fee Schedule,125% of CMS OPPS Rate,43.32,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.04,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,41.04,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,41.04,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,34.2,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,51.3,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,25.65,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,51.3,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,90.04,200,,341.112,Fee Schedule,200% of CMS OPPS Rate,25.14,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.15,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,33.77,75,,,Fee Schedule,75% of CMS OPPS Rate,50.16,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,51.3,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,25.14,90.04,
BRA POST SURG XXXL,2740000025,CDM,274,RC,L8000,HCPCS,Outpatient,,,57.00,37.05,,56.28,125,,,Fee Schedule,125% of CMS OPPS Rate,43.32,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.04,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,41.04,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,41.04,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,34.2,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,51.3,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,25.65,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,51.3,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,90.04,200,,341.112,Fee Schedule,200% of CMS OPPS Rate,25.14,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.15,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,33.77,75,,,Fee Schedule,75% of CMS OPPS Rate,50.16,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,51.3,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,25.14,90.04,
BRA POST SURG XL,2740000026,CDM,274,RC,L8000,HCPCS,Outpatient,,,57.00,37.05,,56.28,125,,,Fee Schedule,125% of CMS OPPS Rate,43.32,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.04,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,41.04,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,41.04,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,34.2,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,51.3,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,25.65,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,51.3,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,90.04,200,,341.112,Fee Schedule,200% of CMS OPPS Rate,25.14,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.15,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,33.77,75,,,Fee Schedule,75% of CMS OPPS Rate,50.16,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,51.3,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,25.14,90.04,
BRA POST 4XL,2740000027,CDM,274,RC,L8000,HCPCS,Outpatient,,,57.00,37.05,,56.28,125,,,Fee Schedule,125% of CMS OPPS Rate,43.32,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.04,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,41.04,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,41.04,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,34.2,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,51.3,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,25.65,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,51.3,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,90.04,200,,341.112,Fee Schedule,200% of CMS OPPS Rate,25.14,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.15,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,33.77,75,,,Fee Schedule,75% of CMS OPPS Rate,50.16,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,51.3,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,25.14,90.04,
BRA POST SURG SMALL,2740000028,CDM,274,RC,L8000,HCPCS,Outpatient,,,57.00,37.05,,56.28,125,,,Fee Schedule,125% of CMS OPPS Rate,43.32,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.04,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,41.04,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,41.04,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,34.2,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,51.3,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,25.65,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,51.3,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,90.04,200,,341.112,Fee Schedule,200% of CMS OPPS Rate,25.14,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.15,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,33.77,75,,,Fee Schedule,75% of CMS OPPS Rate,50.16,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,51.3,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,25.14,90.04,
BRA POST SURG MED,2740000029,CDM,274,RC,,,Outpatient,,,57.00,37.05,,57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.32,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.04,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,41.04,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.04,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,34.2,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,51.3,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,25.65,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,51.3,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.05,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,25.14,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.15,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.16,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,51.3,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,25.14,57,
BRA POST SURG LG,2740000030,CDM,274,RC,L8000,HCPCS,Outpatient,,,57.00,37.05,,56.28,125,,,Fee Schedule,125% of CMS OPPS Rate,43.32,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.04,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,41.04,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,41.04,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,34.2,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,51.3,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,25.65,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,51.3,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,45.02,100,,,Fee Schedule,100% of CMS OPPS Rate,90.04,200,,341.112,Fee Schedule,200% of CMS OPPS Rate,25.14,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.15,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,33.77,75,,,Fee Schedule,75% of CMS OPPS Rate,50.16,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,51.3,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,25.14,90.04,
PUROS MATRIX PUTTY,2740000031,CDM,274,RC,,,Outpatient,,,7469.44,4855.14,,7469.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5676.77,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5378,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,5378,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,7469.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5378,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,4481.66,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,6722.5,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,3361.25,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,6722.5,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,7469.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7469.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7469.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4855.14,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,3294.02,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,7095.97,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,7469.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6573.11,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,6722.5,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,3294.02,7469.44,
COLPO OCCLUDER,2740000032,CDM,274,RC,,,Outpatient,,,199.55,129.71,,199.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,151.66,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,143.68,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,143.68,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,199.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.68,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,119.73,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,179.6,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,89.8,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,179.6,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,199.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.71,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,88,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,189.57,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,199.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.6,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,179.6,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,88,199.55,
RUMI UTERINE TIPS,2740000033,CDM,278,RC,,,Outpatient,,,72.77,47.30,,72.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.31,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.39,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,52.39,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.39,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,65.49,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,32.75,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,65.49,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.3,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,32.09,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,69.13,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.04,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,65.49,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,32.09,72.77,
Z114707575 7.5 CAN,2740000034,CDM,274,RC,,,Outpatient,,,1189.60,773.24,,1189.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,904.1,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,856.51,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,856.51,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,1189.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,856.51,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,713.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,1070.64,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,535.32,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,1070.64,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,1189.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1189.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1189.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,773.24,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,524.61,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,1130.12,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,1189.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.85,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,1070.64,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,524.61,1189.6,
Z114708075 7.5 CAN,2740000035,CDM,278,RC,,,Outpatient,,,1189.60,773.24,,1189.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,904.1,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,856.51,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,856.51,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,1189.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,856.51,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,713.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,1070.64,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,535.32,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,1070.64,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,1189.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1189.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1189.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,773.24,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,524.61,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,1130.12,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,1189.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.85,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,1070.64,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,524.61,1189.6,
Z114710076 32MMTHD,2740000036,CDM,278,RC,,,Outpatient,,,824.67,536.04,,824.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,626.75,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,593.76,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,593.76,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,824.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,593.76,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,494.8,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,742.2,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,371.1,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,742.2,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,824.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,824.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,824.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,536.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,363.68,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,783.44,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,824.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,725.71,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,742.2,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,363.68,824.67,
Z11472640 4.0 CANC,2740000037,CDM,278,RC,,,Outpatient,,,626.22,407.04,,626.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.93,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.88,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,450.88,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.88,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,375.73,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,563.6,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,281.8,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,563.6,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,276.16,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,594.91,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,551.07,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,563.6,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,276.16,626.22,
Z11473235 3.5 CANN,2740000038,CDM,278,RC,,,Outpatient,,,593.15,385.55,,593.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,450.79,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,427.07,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,427.07,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.07,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,355.89,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,533.84,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,266.92,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,533.84,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.55,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,261.58,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,563.49,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521.97,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,533.84,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,261.58,593.15,
Z11473640 4.0 CANC,2740000039,CDM,278,RC,,,Outpatient,,,626.22,407.04,,626.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.93,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.88,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,450.88,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.88,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,375.73,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,563.6,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,281.8,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,563.6,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,276.16,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,594.91,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,551.07,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,563.6,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,276.16,626.22,
Z11473835 3.5 SCOR,2740000040,CDM,278,RC,,,Outpatient,,,593.15,385.55,,593.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,450.79,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,427.07,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,427.07,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.07,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,355.89,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,533.84,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,266.92,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,533.84,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.55,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,261.58,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,563.49,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521.97,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,533.84,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,261.58,593.15,
Z11474035 3.5 CANN,2740000041,CDM,278,RC,,,Outpatient,,,593.15,385.55,,593.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,450.79,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,427.07,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,427.07,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.07,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,355.89,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,533.84,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,266.92,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,533.84,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.55,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,261.58,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,563.49,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521.97,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,533.84,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,261.58,593.15,
Z11474040 4.0 CANC,2740000042,CDM,278,RC,,,Outpatient,,,626.22,407.04,,626.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.93,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.88,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,450.88,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.88,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,375.73,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,563.6,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,281.8,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,563.6,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,276.16,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,594.91,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,551.07,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,563.6,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,276.16,626.22,
Z11474235 3.5 SCOR,2740000043,CDM,278,RC,,,Outpatient,,,593.15,385.55,,593.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,450.79,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,427.07,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,427.07,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.07,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,355.89,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,533.84,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,266.92,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,533.84,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.55,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,261.58,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,563.49,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521.97,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,533.84,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,261.58,593.15,
Z11474641 4.0 CANN,2740000044,CDM,278,RC,,,Outpatient,,,626.22,407.04,,626.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.93,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.88,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,450.88,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.88,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,375.73,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,563.6,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,281.8,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,563.6,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,276.16,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,594.91,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,626.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,551.07,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,563.6,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,276.16,626.22,
Z11474841 4.0 CANN,2740000045,CDM,278,RC,,,Outpatient,,,925.00,601.25,,925,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,703,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,666,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,666,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,666,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,555,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,832.5,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,416.25,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,832.5,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,601.25,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,407.93,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,878.75,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,814,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,832.5,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,407.93,925,
Z11475040 4.0 CANN,2740000046,CDM,278,RC,,,Outpatient,,,925.00,601.25,,925,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,703,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,666,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,666,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,666,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,555,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,832.5,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,416.25,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,832.5,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,601.25,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,407.93,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,878.75,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,814,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,832.5,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,407.93,925,
Z11475035 3.5 CANN,2740000047,CDM,278,RC,,,Outpatient,,,880.90,572.59,,880.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,669.48,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,634.25,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,634.25,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,880.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,634.25,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,528.54,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,792.81,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,396.41,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,792.81,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,880.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,880.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,880.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,572.59,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,388.48,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,836.86,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,880.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,775.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,792.81,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,388.48,880.9,
Z11475041 4.0 CANN,2740000048,CDM,278,RC,,,Outpatient,,,925.00,601.25,,925,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,703,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,666,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,666,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,666,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,555,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,832.5,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,416.25,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,832.5,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,601.25,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,407.93,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,878.75,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,814,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,832.5,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,407.93,925,
Z22320518 CABLE GR,2740000049,CDM,278,RC,,,Outpatient,,,1299.85,844.90,,1299.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,987.89,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,935.89,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,935.89,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,1299.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,935.89,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,779.91,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,1169.87,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,584.93,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,1169.87,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,1299.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1299.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1299.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,844.9,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,573.23,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,1234.86,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,1299.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1143.87,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,1169.87,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,573.23,1299.85,
Z22401116 RETROFEM,2740000050,CDM,278,RC,,,Outpatient,,,6434.19,4182.22,,6434.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4889.98,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4632.62,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,4632.62,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,6434.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4632.62,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,3860.51,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,5790.77,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,2895.39,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,5790.77,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,6434.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6434.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6434.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4182.22,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,2837.48,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,6112.48,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,6434.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5662.09,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,5790.77,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,2837.48,6434.19,
Z225201 NAIL END CA,2740000051,CDM,278,RC,,,Outpatient,,,925.00,601.25,,925,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,703,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,666,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,666,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,666,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,555,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,832.5,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,416.25,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,832.5,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,601.25,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,407.93,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,878.75,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,925,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,814,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,832.5,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,407.93,925,
Z22520105 EXT NAIL,2740000052,CDM,278,RC,,,Outpatient,,,947.05,615.58,,947.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,719.76,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,681.88,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,681.88,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,947.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,681.88,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,568.23,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,852.35,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,426.17,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,852.35,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,947.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,947.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,947.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,615.58,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,417.65,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,899.7,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,947.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,833.4,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,852.35,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,417.65,947.05,
Z225203 HUMERAL LOC,2740000053,CDM,278,RC,,,Outpatient,,,854.44,555.39,,854.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,649.37,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,615.2,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,615.2,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,854.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,615.2,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,512.66,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,769,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,384.5,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,769,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,854.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,854.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,854.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.39,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,376.81,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,811.72,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,854.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,751.91,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,769,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,376.81,854.44,
Z22532542 4.2 CORT,2740000054,CDM,278,RC,,,Outpatient,,,624.02,405.61,,624.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,474.26,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,449.29,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,449.29,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,624.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,449.29,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,374.41,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,561.62,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,280.81,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,561.62,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,624.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,624.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,624.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.61,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,275.19,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,592.82,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,624.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.14,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,561.62,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,275.19,624.02,
Z225328009 TIBIAL,2740000055,CDM,278,RC,,,Outpatient,,,3650.38,2372.75,,3650.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2774.29,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2628.27,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,2628.27,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,3650.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2628.27,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,2190.23,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,3285.34,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,1642.67,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,3285.34,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,3650.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3650.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3650.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2372.75,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,1609.82,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,3467.86,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,3650.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3212.33,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,3285.34,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,1609.82,3650.38,
Z225330012 TIBIAL,2740000056,CDM,278,RC,,,Outpatient,,,3652.58,2374.18,,3652.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2775.96,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2629.86,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,2629.86,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,3652.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2629.86,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,2191.55,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,3287.32,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,1643.66,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,3287.32,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,3652.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3652.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3652.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2374.18,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,1610.79,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,3469.95,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,3652.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3214.27,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,3287.32,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,1610.79,3652.58,
Z22533042 4.2 CORT,2740000057,CDM,278,RC,,,Outpatient,,,624.02,405.61,,624.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,474.26,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,449.29,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,449.29,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,624.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,449.29,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,374.41,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,561.62,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,280.81,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,561.62,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,624.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,624.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,624.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.61,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,275.19,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,592.82,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,624.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.14,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,561.62,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,275.19,624.02,
Z22533055 5.5 SCOR,2740000058,CDM,278,RC,,,Outpatient,,,780.57,507.37,,780.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,593.23,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,562.01,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,562.01,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.01,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,468.34,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,351.26,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.37,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,344.23,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,741.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,686.9,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,344.23,780.57,
Z225334012 TIBIAL,2740000059,CDM,278,RC,,,Outpatient,,,4619.48,3002.66,,4619.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3510.8,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3326.03,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,3326.03,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,4619.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3326.03,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,2771.69,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,4157.53,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,2078.77,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,4157.53,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,4619.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4619.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4619.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3002.66,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,2037.19,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,4388.51,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,4619.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4065.14,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,4157.53,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,2037.19,4619.48,
Z22533542 4.2 CORT,2740000060,CDM,278,RC,,,Outpatient,,,780.57,507.37,,780.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,593.23,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,562.01,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,562.01,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.01,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,468.34,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,351.26,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.37,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,344.23,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,741.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,686.9,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,344.23,780.57,
Z22533555 5.5 CORT,2740000061,CDM,278,RC,,,Outpatient,,,780.57,507.37,,780.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,593.23,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,562.01,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,562.01,72,,224.912,Percent of Total Billed charges,72% of Total Billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.01,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,468.34,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,351.26,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.37,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,344.23,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,741.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,686.9,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,344.23,780.57,
Z22534042 4.2 CORT,2740000062,CDM,278,RC,,,Outpatient,,,780.57,507.37,,780.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,593.23,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,562.01,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,562.01,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.01,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,468.34,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,351.26,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.37,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,344.23,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,741.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,686.9,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,344.23,780.57,
Z22534542 4.2 CORT,2740000063,CDM,278,RC,,,Outpatient,,,624.02,405.61,,624.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,474.26,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,449.29,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,449.29,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,624.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,449.29,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,374.41,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,561.62,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,280.81,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,561.62,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,624.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,624.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,624.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.61,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,275.19,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,592.82,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,624.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.14,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,561.62,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,275.19,624.02,
Z22535042 4.2 CORT,2740000064,CDM,278,RC,,,Outpatient,,,780.57,507.37,,780.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,593.23,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,562.01,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,562.01,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.01,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,468.34,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,351.26,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.37,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,344.23,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,741.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,686.9,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,344.23,780.57,
Z22535542 4.2 CORT,2740000065,CDM,278,RC,,,Outpatient,,,624.02,405.61,,624.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,474.26,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,449.29,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,449.29,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,624.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,449.29,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,374.41,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,561.62,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,280.81,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,561.62,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,624.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,624.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,624.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.61,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,275.19,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,592.82,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,624.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.14,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,561.62,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,275.19,624.02,
Z22536555 5.5 CORT,2740000066,CDM,278,RC,,,Outpatient,,,780.57,507.37,,780.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,593.23,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,562.01,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,562.01,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.01,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,468.34,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,351.26,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.37,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,344.23,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,741.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,686.9,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,344.23,780.57,
Z22538055 5.5 CORT,2740000067,CDM,278,RC,,,Outpatient,,,780.57,507.37,,780.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,593.23,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,562.01,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,562.01,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.01,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,468.34,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,351.26,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.37,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,344.23,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,741.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,686.9,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,344.23,780.57,
Z22538555 5.5 CORT,2740000068,CDM,278,RC,,,Outpatient,,,780.57,507.37,,780.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,593.23,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,562.01,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,562.01,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.01,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,468.34,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,351.26,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.37,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,344.23,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,741.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,686.9,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,702.51,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,344.23,780.57,
Z225422510 HUM NAI,2740000069,CDM,278,RC,,,Outpatient,,,6407.73,4165.02,,6407.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4869.87,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4613.57,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,4613.57,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,6407.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4613.57,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,3844.64,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,5766.96,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,2883.48,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,5766.96,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,6407.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6407.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6407.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4165.02,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,2825.81,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,6087.34,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,6407.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5638.8,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,5766.96,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,2825.81,6407.73,
Z225424009 HUM NAI,2740000070,CDM,278,RC,,,Outpatient,,,5245.70,3409.71,,5245.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3986.73,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3776.9,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,3776.9,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,5245.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3776.9,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,3147.42,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,4721.13,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,2360.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,4721.13,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,5245.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5245.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5245.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3409.71,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,2313.35,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,4983.42,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,5245.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4616.22,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,4721.13,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,2313.35,5245.7,
Z225424010 HUM NAI,2740000071,CDM,278,RC,,,Outpatient,,,5249.00,3411.85,,5249,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3989.24,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3779.28,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,3779.28,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,5249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3779.28,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,3149.4,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,4724.1,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,2362.05,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,4724.1,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,5249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3411.85,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,2314.81,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,4986.55,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,5249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4619.12,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,4724.1,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,2314.81,5249,
75MM ANTI ROTATION S,2740000072,CDM,278,RC,,,Outpatient,,,801.52,520.99,,801.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,609.16,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,577.09,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,577.09,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,801.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.09,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,480.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,721.37,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,360.68,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,721.37,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,801.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,801.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,801.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520.99,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,353.47,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,761.44,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,801.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,705.34,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,721.37,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,353.47,801.52,
Z225718011 ITST NA,2740000073,CDM,278,RC,,,Outpatient,,,4562.15,2965.40,,4562.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3467.23,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3284.75,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,3284.75,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,4562.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3284.75,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,2737.29,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,4105.94,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,2052.97,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,4105.94,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,4562.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4562.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4562.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2965.4,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,2011.91,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,4334.04,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,4562.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4014.69,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,4105.94,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,2011.91,4562.15,
Z225718013 ITST NA,2740000074,CDM,278,RC,,,Outpatient,,,4562.15,2965.40,,4562.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3467.23,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3284.75,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,3284.75,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,4562.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3284.75,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,2737.29,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,4105.94,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,2052.97,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,4105.94,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,4562.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4562.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4562.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2965.4,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,2011.91,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,4334.04,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,4562.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4014.69,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,4105.94,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,2011.91,4562.15,
Z22577065 ANTIROT,2740000075,CDM,278,RC,,,Outpatient,,,845.62,549.65,,845.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,642.67,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,608.85,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,608.85,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,608.85,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,507.37,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,761.06,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,380.53,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,761.06,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.65,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,372.92,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,803.34,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,744.15,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,761.06,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,372.92,845.62,
Z22577565 ANTIROT,2740000076,CDM,278,RC,,,Outpatient,,,1141.09,741.71,,1141.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,867.23,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,821.58,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,821.58,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,1141.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,821.58,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,684.65,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,1026.98,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,513.49,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,1026.98,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,1141.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1141.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1141.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,741.71,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,503.22,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,1084.04,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,1141.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1004.16,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,1026.98,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,503.22,1141.09,
Z22578065 ANTIROT,2740000077,CDM,278,RC,,,Outpatient,,,1141.09,741.71,,1141.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,867.23,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,821.58,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,821.58,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,1141.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,821.58,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,684.65,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,1026.98,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,513.49,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,1026.98,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,1141.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1141.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1141.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,741.71,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,503.22,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,1084.04,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,1141.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1004.16,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,1026.98,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,503.22,1141.09,
Z225718010 ITST NA,2740000078,CDM,278,RC,,,Outpatient,,,3328.45,2163.49,,3328.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2529.62,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2396.48,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,2396.48,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,3328.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2396.48,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,1997.07,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,2995.61,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,1497.8,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,2995.61,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,3328.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3328.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3328.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2163.49,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,1467.85,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,3162.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,3328.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2929.04,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,2995.61,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,1467.85,3328.45,
Z22579565 ANTIROT,2740000079,CDM,278,RC,,,Outpatient,,,1141.09,741.71,,1141.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,867.23,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,821.58,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,821.58,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,1141.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,821.58,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,684.65,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,1026.98,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,513.49,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,1026.98,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,1141.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1141.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1141.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,741.71,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,503.22,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,1084.04,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,1141.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1004.16,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,1026.98,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,503.22,1141.09,
Z22590137 ITST LAG,2740000080,CDM,278,RC,,,Outpatient,,,1528.07,993.25,,1528.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1161.33,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1100.21,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,1100.21,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1100.21,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,916.84,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,1375.26,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,687.63,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,1375.26,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,993.25,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,673.88,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,1451.67,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1344.7,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,1375.26,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,673.88,1528.07,
Z22590140 ITST LAG,2740000081,CDM,278,RC,,,Outpatient,,,1528.07,993.25,,1528.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1161.33,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1100.21,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,1100.21,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1100.21,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,916.84,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,1375.26,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,687.63,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,1375.26,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,993.25,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,673.88,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,1451.67,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1344.7,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,1375.26,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,673.88,1528.07,
Z22590135 ITST LAG,2740000082,CDM,278,RC,,,Outpatient,,,1528.07,993.25,,1528.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1161.33,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1100.21,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,1100.21,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1100.21,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,916.84,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,1375.26,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,687.63,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,1375.26,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,993.25,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,673.88,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,1451.67,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1344.7,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,1375.26,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,673.88,1528.07,
Z22590805 LOCK NAI,2740000083,CDM,278,RC,,,Outpatient,,,999.97,649.98,,999.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,759.98,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,719.98,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,719.98,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,719.98,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,599.98,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,899.97,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,449.99,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,899.97,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649.98,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,440.99,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,949.97,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,879.97,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,899.97,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,440.99,999.97,
Z22590132 ITST LAG,2740000084,CDM,278,RC,,,Outpatient,,,1528.07,993.25,,1528.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1161.33,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1100.21,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,1100.21,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1100.21,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,916.84,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,1375.26,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,687.63,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,1375.26,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,993.25,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,673.88,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,1451.67,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1344.7,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,1375.26,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,673.88,1528.07,
Z22590145 ITST LAG,2740000085,CDM,278,RC,,,Outpatient,,,1528.07,993.25,,1528.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1161.33,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1100.21,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,1100.21,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1100.21,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,916.84,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,1375.26,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,687.63,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,1375.26,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,993.25,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,673.88,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,1451.67,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1344.7,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,1375.26,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,673.88,1528.07,
Z22590147 ITST LAG,2740000086,CDM,278,RC,,,Outpatient,,,1528.07,993.25,,1528.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1161.33,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1100.21,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,1100.21,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1100.21,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,916.84,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,1375.26,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,687.63,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,1375.26,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,993.25,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,673.88,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,1451.67,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,1528.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1344.7,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,1375.26,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,673.88,1528.07,
Z23471504 DISTALL,2740000087,CDM,278,RC,,,Outpatient,,,2087.03,1356.57,,2087.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1586.14,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1502.66,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,1502.66,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,2087.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1502.66,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,1252.22,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,1878.33,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,939.16,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,1878.33,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,2087.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2087.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2087.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1356.57,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,920.38,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,1982.68,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,2087.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1836.59,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,1878.33,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,920.38,2087.03,
Z23471508 DISTALL,2740000088,CDM,278,RC,,,Outpatient,,,2474.01,1608.11,,2474.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1880.25,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1781.29,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,1781.29,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,2474.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1781.29,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,1484.41,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,2226.61,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,1113.3,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,2226.61,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,2474.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2474.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2474.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.11,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,1091.04,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,2350.31,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,2474.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2177.13,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,2226.61,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,1091.04,2474.01,
Z23471706 DISTALL,2740000089,CDM,278,RC,,,Outpatient,,,2245.79,1459.76,,2245.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1706.8,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1616.97,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,1616.97,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,2245.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1616.97,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,1347.47,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,2021.21,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,1010.61,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,2021.21,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,2245.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2245.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2245.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1459.76,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,990.39,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,2133.5,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,2245.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1976.3,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,2021.21,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,990.39,2245.79,
Z23471704 DISTALL,2740000090,CDM,278,RC,,,Outpatient,,,2087.03,1356.57,,2087.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1586.14,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1502.66,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,1502.66,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,2087.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1502.66,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,1252.22,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,1878.33,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,939.16,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,1878.33,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,2087.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2087.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2087.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1356.57,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,920.38,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,1982.68,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,2087.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1836.59,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,1878.33,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,920.38,2087.03,
Z23471804 DISTALL,2740000091,CDM,278,RC,,,Outpatient,,,2087.03,1356.57,,2087.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1586.14,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1502.66,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,1502.66,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,2087.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1502.66,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,1252.22,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,1878.33,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,939.16,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,1878.33,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,2087.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2087.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2087.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1356.57,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,920.38,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,1982.68,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,2087.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1836.59,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,1878.33,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,920.38,2087.03,
Z23471806 DISTALA,2740000092,CDM,278,RC,,,Outpatient,,,2245.79,1459.76,,2245.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1706.8,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1616.97,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,1616.97,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,2245.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1616.97,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,1347.47,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,2021.21,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,1010.61,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,2021.21,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,2245.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2245.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2245.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1459.76,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,990.39,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,2133.5,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,2245.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1976.3,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,2021.21,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,990.39,2245.79,
Z23481035 3.5 CORT,2740000093,CDM,278,RC,,,Outpatient,,,158.76,103.19,,158.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.66,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.31,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,114.31,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.31,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,95.26,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,142.88,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,71.44,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,142.88,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.19,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,70.01,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,150.82,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.71,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,142.88,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,70.01,158.76,
Z23481235 3.5 CORT,2740000094,CDM,278,RC,,,Outpatient,,,190.73,123.97,,190.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.95,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,137.33,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,137.33,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.33,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,114.44,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,171.66,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,85.83,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,171.66,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.97,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,84.11,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,181.19,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.84,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,171.66,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,84.11,190.73,
Z23481635 3.5 CORT,2740000095,CDM,278,RC,,,Outpatient,,,190.73,123.97,,190.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.95,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,137.33,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,137.33,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.33,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,114.44,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,171.66,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,85.83,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,171.66,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.97,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,84.11,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,181.19,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.84,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,171.66,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,84.11,190.73,
Z23481835 3.5 SCOR,2740000096,CDM,278,RC,,,Outpatient,,,190.73,123.97,,190.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.95,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,137.33,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,137.33,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.33,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,114.44,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,171.66,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,85.83,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,171.66,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.97,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,84.11,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,181.19,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.84,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,171.66,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,84.11,190.73,
Z23482035 3.5 SCOR,2740000097,CDM,278,RC,,,Outpatient,,,190.73,123.97,,190.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.95,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,137.33,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,137.33,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.33,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,114.44,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,171.66,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,85.83,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,171.66,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.97,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,84.11,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,181.19,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.84,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,171.66,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,84.11,190.73,
Z23482235 3.5 SCOR,2740000098,CDM,278,RC,,,Outpatient,,,190.73,123.97,,190.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.95,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,137.33,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,137.33,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.33,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,114.44,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,171.66,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,85.83,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,171.66,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.97,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,84.11,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,181.19,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.84,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,171.66,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,84.11,190.73,
Z23482435 3.5 SCOR,2740000099,CDM,278,RC,,,Outpatient,,,158.76,103.19,,158.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.66,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.31,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,114.31,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.31,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,95.26,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,142.88,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,71.44,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,142.88,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.19,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,70.01,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,150.82,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.71,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,142.88,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,70.01,158.76,
Z23482635 3.5 SCOR,2740000100,CDM,278,RC,,,Outpatient,,,158.76,103.19,,158.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.66,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.31,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,114.31,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.31,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,95.26,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,142.88,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,71.44,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,142.88,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.19,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,70.01,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,150.82,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.71,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,142.88,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,70.01,158.76,
Z23482835 3.5 SCOR,2740000101,CDM,278,RC,,,Outpatient,,,158.76,103.19,,158.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.66,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.31,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,114.31,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.31,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,95.26,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,142.88,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,71.44,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,142.88,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.19,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,70.01,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,150.82,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.71,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,142.88,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,70.01,158.76,
Z23483235 3.5 SCOR,2740000102,CDM,278,RC,,,Outpatient,,,2087.03,1356.57,,2087.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1586.14,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1502.66,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,1502.66,72,,367.136,Percent of Total Billed charges,72% of Total Billed Charges,2087.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1502.66,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,1252.22,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,1878.33,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,939.16,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,1878.33,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,2087.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2087.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2087.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1356.57,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,920.38,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,1982.68,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,2087.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1836.59,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,1878.33,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,920.38,2087.03,
Z23581803 VOLARMC,2740000103,CDM,278,RC,,,Outpatient,,,3778.27,2455.88,,3778.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2871.49,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2720.35,72,,2270.272,Percent of Total Billed Charges,72% of Total Billed Charges,2720.35,72,,2364.864,Percent of Total Billed charges,72% of Total Billed Charges,3778.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2720.35,72,,2270.272,Percent of Total Billed Charges,72% of Total Billed Charges,2266.96,60,,1891.888,Percent of Total Billed Charges,60% of Total Billed Charges,3400.44,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,1700.22,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,3400.44,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,3778.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3778.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3778.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2455.88,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,1666.22,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,3589.36,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,3778.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3324.88,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,3400.44,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,1666.22,3778.27,
Z23582104 DORSALL,2740000104,CDM,278,RC,,,Outpatient,,,4086.97,2656.53,,4086.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3106.1,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2942.62,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,2942.62,72,,2397.936,Percent of Total Billed charges,72% of Total Billed Charges,4086.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2942.62,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,2452.18,60,,1918.352,Percent of Total Billed Charges,60% of Total Billed Charges,3678.27,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,1839.14,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,3678.27,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,4086.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4086.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4086.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2656.53,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,1802.35,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,3882.62,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,4086.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3596.53,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,3678.27,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,1802.35,4086.97,
Z23582103 DORSALT,2740000105,CDM,278,RC,,,Outpatient,,,3906.16,2539.00,,3906.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2968.68,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2812.44,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,2812.44,72,,2397.936,Percent of Total Billed charges,72% of Total Billed Charges,3906.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2812.44,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,2343.7,60,,1918.352,Percent of Total Billed Charges,60% of Total Billed Charges,3515.54,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,1757.77,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,3515.54,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,3906.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3906.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3906.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2539,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,1722.62,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,3710.85,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,3906.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3437.42,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,3515.54,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,1722.62,3906.16,
Z23582204 DORSALT,2740000106,CDM,278,RC,,,Outpatient,,,4086.97,2656.53,,4086.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3106.1,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2942.62,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,2942.62,72,,2397.936,Percent of Total Billed charges,72% of Total Billed Charges,4086.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2942.62,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,2452.18,60,,1918.352,Percent of Total Billed Charges,60% of Total Billed Charges,3678.27,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,1839.14,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,3678.27,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,4086.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4086.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4086.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2656.53,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,1802.35,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,3882.62,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,4086.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3596.53,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,3678.27,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,1802.35,4086.97,
Z23582203 DORSALT,2740000107,CDM,278,RC,,,Outpatient,,,3906.16,2539.00,,3906.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2968.68,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2812.44,72,,1273.256,Percent of Total Billed Charges,72% of Total Billed Charges,2812.44,72,,1326.304,Percent of Total Billed charges,72% of Total Billed Charges,3906.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2812.44,72,,1273.256,Percent of Total Billed Charges,72% of Total Billed Charges,2343.7,60,,1061.048,Percent of Total Billed Charges,60% of Total Billed Charges,3515.54,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,1757.77,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,3515.54,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,3906.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3906.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3906.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2539,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,1722.62,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,3710.85,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,3906.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3437.42,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,3515.54,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,1722.62,3906.16,
Z23591435 3.5 LOCK,2740000108,CDM,278,RC,,,Outpatient,,,394.70,256.56,,394.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.97,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.18,72,,1273.256,Percent of Total Billed Charges,72% of Total Billed Charges,284.18,72,,1326.304,Percent of Total Billed charges,72% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.18,72,,1273.256,Percent of Total Billed Charges,72% of Total Billed Charges,236.82,60,,1061.048,Percent of Total Billed Charges,60% of Total Billed Charges,355.23,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,177.62,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,355.23,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.56,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,174.06,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.97,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.34,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,355.23,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,174.06,394.7,
Z23591635 3.5 LOCK,2740000109,CDM,278,RC,,,Outpatient,,,475.18,308.87,,475.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,361.14,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,342.13,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,342.13,72,,2397.936,Percent of Total Billed charges,72% of Total Billed Charges,475.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.13,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,285.11,60,,1918.352,Percent of Total Billed Charges,60% of Total Billed Charges,427.66,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,213.83,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,427.66,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,475.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.87,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,209.55,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,451.42,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,475.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,418.16,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,427.66,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,209.55,475.18,
Z23591835 3.5 LOCK,2740000110,CDM,278,RC,,,Outpatient,,,475.18,308.87,,475.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,361.14,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,342.13,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,342.13,72,,2397.936,Percent of Total Billed charges,72% of Total Billed Charges,475.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.13,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,285.11,60,,1918.352,Percent of Total Billed Charges,60% of Total Billed Charges,427.66,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,213.83,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,427.66,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,475.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.87,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,209.55,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,451.42,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,475.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,418.16,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,427.66,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,209.55,475.18,
Z23592035 3.5 LOCK,2740000111,CDM,278,RC,,,Outpatient,,,475.18,308.87,,475.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,361.14,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,342.13,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,342.13,72,,2397.936,Percent of Total Billed charges,72% of Total Billed Charges,475.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.13,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,285.11,60,,1918.352,Percent of Total Billed Charges,60% of Total Billed Charges,427.66,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,213.83,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,427.66,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,475.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.87,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,209.55,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,451.42,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,475.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,418.16,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,427.66,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,209.55,475.18,
Z23591424 2.4 LOCK,2740000112,CDM,278,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,352.45,72,,2397.936,Percent of Total Billed charges,72% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,1918.352,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
Z23591425 2.4 CONI,2740000113,CDM,278,RC,,,Outpatient,,,392.49,255.12,,392.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,298.29,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,282.59,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,282.59,72,,2397.936,Percent of Total Billed charges,72% of Total Billed Charges,392.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.59,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,235.49,60,,1918.352,Percent of Total Billed Charges,60% of Total Billed Charges,353.24,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,176.62,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,353.24,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,392.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.12,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,173.09,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,372.87,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,392.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.39,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,353.24,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,173.09,392.49,
Z23591624 2.4 LOCK,2740000114,CDM,278,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,1273.256,Percent of Total Billed Charges,72% of Total Billed Charges,352.45,72,,1326.304,Percent of Total Billed charges,72% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,1273.256,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,1061.048,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
Z23591625 2.4 CONI,2740000115,CDM,278,RC,,,Outpatient,,,392.49,255.12,,392.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,298.29,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,282.59,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,282.59,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,392.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.59,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,235.49,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,353.24,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,176.62,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,353.24,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,392.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.12,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,173.09,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,372.87,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,392.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.39,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,353.24,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,173.09,392.49,
Z23591825 2.4 CONC,2740000116,CDM,278,RC,,,Outpatient,,,392.49,255.12,,392.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,298.29,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,282.59,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,282.59,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,392.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.59,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,235.49,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,353.24,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,176.62,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,353.24,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,392.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.12,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,173.09,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,372.87,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,392.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.39,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,353.24,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,173.09,392.49,
Z23591824 2.4 LOCK,2740000117,CDM,278,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,352.45,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
Z23592024 2.4 LOCK,2740000118,CDM,278,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,352.45,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
Z23592224 2.4 LOCK,2740000119,CDM,278,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,352.45,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
Z23592025 2.4 CONI,2740000120,CDM,278,RC,,,Outpatient,,,392.49,255.12,,392.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,298.29,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,282.59,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,282.59,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,392.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.59,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,235.49,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,353.24,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,176.62,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,353.24,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,392.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.12,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,173.09,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,372.87,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,392.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.39,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,353.24,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,173.09,392.49,
Z23592424 2.4 LOCK,2740000121,CDM,278,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,352.45,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
Z23592624 2.4 LOCK,2740000122,CDM,278,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,352.45,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
Z23593635 3.5 LOCK,2740000123,CDM,278,RC,,,Outpatient,,,394.70,256.56,,394.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.97,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.18,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,284.18,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.18,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,236.82,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,355.23,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,177.62,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,355.23,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.56,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,174.06,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.97,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.34,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,355.23,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,174.06,394.7,
Z23594035 3.5 LOCK,2740000124,CDM,278,RC,,,Outpatient,,,394.70,256.56,,394.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.97,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.18,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,284.18,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.18,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,236.82,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,355.23,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,177.62,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,355.23,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.56,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,174.06,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.97,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.34,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,355.23,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,174.06,394.7,
Z23594435 3.5 LOCK,2740000125,CDM,278,RC,,,Outpatient,,,394.70,256.56,,394.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.97,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.18,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,284.18,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.18,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,236.82,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,355.23,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,177.62,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,355.23,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.56,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,174.06,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.97,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.34,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,355.23,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,174.06,394.7,
Z23594835 3.5 LOCK,2740000126,CDM,278,RC,,,Outpatient,,,394.70,256.56,,394.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.97,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.18,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,284.18,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.18,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,236.82,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,355.23,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,177.62,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,355.23,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.56,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,174.06,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.97,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.34,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,355.23,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,174.06,394.7,
Z24801241 4.0 CANC,2740000127,CDM,278,RC,,,Outpatient,,,286.65,186.32,,286.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,217.85,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,206.39,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,206.39,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.39,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,171.99,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,257.99,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,128.99,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,257.99,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.32,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,126.41,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,272.32,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.25,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,257.99,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,126.41,286.65,
Z24801441 4.0 CANC,2740000128,CDM,278,RC,,,Outpatient,,,286.65,186.32,,286.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,217.85,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,206.39,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,206.39,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.39,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,171.99,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,257.99,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,128.99,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,257.99,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.32,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,126.41,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,272.32,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.25,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,257.99,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,126.41,286.65,
Z24801641 4.0 CANC,2740000129,CDM,278,RC,,,Outpatient,,,158.76,103.19,,158.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.66,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.31,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,114.31,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.31,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,95.26,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,142.88,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,71.44,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,142.88,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.19,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,70.01,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,150.82,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.71,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,142.88,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,70.01,158.76,
Z24801840 4.0 CANC,2740000130,CDM,278,RC,,,Outpatient,,,286.65,186.32,,286.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,217.85,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,206.39,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,206.39,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.39,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,171.99,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,257.99,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,128.99,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,257.99,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.32,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,126.41,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,272.32,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.25,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,257.99,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,126.41,286.65,
Z24801841 4.0 CANC,2740000131,CDM,278,RC,,,Outpatient,,,286.65,186.32,,286.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,217.85,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,206.39,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,206.39,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.39,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,171.99,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,257.99,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,128.99,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,257.99,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.32,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,126.41,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,272.32,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.25,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,257.99,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,126.41,286.65,
Z24802041 4.0 CANC,2740000132,CDM,278,RC,,,Outpatient,,,286.65,186.32,,286.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,217.85,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,206.39,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,206.39,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.39,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,171.99,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,257.99,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,128.99,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,257.99,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.32,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,126.41,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,272.32,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.25,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,257.99,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,126.41,286.65,
Z24802241 4.0 CANC,2740000133,CDM,278,RC,,,Outpatient,,,286.65,186.32,,286.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,217.85,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,206.39,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,206.39,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.39,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,171.99,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,257.99,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,128.99,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,257.99,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.32,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,126.41,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,272.32,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.25,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,257.99,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,126.41,286.65,
Z24802441 4.0 CANC,2740000134,CDM,278,RC,,,Outpatient,,,286.65,186.32,,286.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,217.85,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,206.39,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,206.39,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.39,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,171.99,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,257.99,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,128.99,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,257.99,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.32,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,126.41,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,272.32,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,286.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.25,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,257.99,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,126.41,286.65,
Z24803041 4.0 CANC,2740000135,CDM,278,RC,,,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,141.3,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
Z24803241 4.0 CANN,2740000136,CDM,278,RC,,,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,141.3,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
Z24804041 4.0 CANN,2740000137,CDM,278,RC,,,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,141.3,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
Z3281053506 HUM A,2740000138,CDM,278,RC,,,Outpatient,,,23302.44,15146.59,,23302.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17709.85,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16777.76,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,16777.76,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,23302.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16777.76,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,13981.46,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,20972.2,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,10486.1,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,20972.2,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,23302.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23302.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23302.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15146.59,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,10276.38,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,22137.32,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,23302.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20506.15,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,20972.2,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,10276.38,23302.44,
Z47223737 SM GDE W,2740000139,CDM,278,RC,,,Outpatient,,,568.89,369.78,,568.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.36,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,409.6,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,409.6,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.6,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,341.33,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,512,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,256,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,512,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.78,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,250.88,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,540.45,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.62,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,512,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,250.88,568.89,
Z48271801 2.7 CORT,2740000140,CDM,278,RC,,,Outpatient,,,130.10,84.57,,130.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.88,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,93.67,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,93.67,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.67,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,78.06,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,117.09,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,58.55,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,117.09,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.57,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,57.37,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,123.6,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.49,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,117.09,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,57.37,130.1,
Z48272001 2.7 CORT,2740000141,CDM,278,RC,,,Outpatient,,,130.10,84.57,,130.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.88,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,93.67,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,93.67,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.67,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,78.06,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,117.09,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,58.55,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,117.09,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.57,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,57.37,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,123.6,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.49,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,117.09,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,57.37,130.1,
Z48272201 2.7 CORT,2740000142,CDM,278,RC,,,Outpatient,,,130.10,84.57,,130.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.88,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,93.67,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,93.67,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.67,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,78.06,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,117.09,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,58.55,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,117.09,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.57,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,57.37,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,123.6,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.49,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,117.09,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,57.37,130.1,
Z48272401 2.7 CORT,2740000143,CDM,278,RC,,,Outpatient,,,95.92,62.35,,95.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.9,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.06,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,69.06,72,,375.072,Percent of Total Billed charges,72% of Total Billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.06,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,57.55,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,86.33,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,43.16,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,86.33,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.35,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,42.3,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.12,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.41,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,86.33,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,42.3,95.92,
Z48273001 2.7 CORT,2740000144,CDM,278,RC,,,Outpatient,,,95.92,62.35,,95.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.9,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.06,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,69.06,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.06,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,57.55,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,86.33,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,43.16,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,86.33,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.35,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,42.3,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.12,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.41,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,86.33,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,42.3,95.92,
Z48273401 2.7 CORT,2740000145,CDM,278,RC,,,Outpatient,,,95.92,62.35,,95.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.9,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.06,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,69.06,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.06,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,57.55,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,86.33,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,43.16,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,86.33,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.35,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,42.3,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.12,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.41,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,86.33,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,42.3,95.92,
Z48275001 2.7 CORT,2740000146,CDM,278,RC,,,Outpatient,,,95.92,62.35,,95.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.9,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.06,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,69.06,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.06,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,57.55,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,86.33,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,43.16,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,86.33,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.35,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,42.3,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.12,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.41,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,86.33,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,42.3,95.92,
Z48275401 2.7 CORT,2740000147,CDM,278,RC,,,Outpatient,,,95.92,62.35,,95.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.9,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.06,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,69.06,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.06,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,57.55,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,86.33,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,43.16,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,86.33,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.35,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,42.3,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.12,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.41,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,86.33,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,42.3,95.92,
Z48352601 3.5 CORT,2740000148,CDM,278,RC,,,Outpatient,,,105.84,68.80,,105.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,80.44,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,76.2,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,76.2,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,105.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.2,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,63.5,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,95.26,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,47.63,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,95.26,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,105.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.8,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,46.68,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,100.55,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,105.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.14,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,95.26,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,46.68,105.84,
Z48351601 3.5 CORT,2740000149,CDM,278,RC,,,Outpatient,,,135.61,88.15,,135.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,103.06,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,97.64,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,97.64,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.64,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,81.37,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,122.05,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,61.02,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,122.05,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.15,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,59.8,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,128.83,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.34,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,122.05,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,59.8,135.61,
Z48351801 3.5 CORT,2740000150,CDM,278,RC,,,Outpatient,,,123.48,80.26,,123.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.84,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.91,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,88.91,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.91,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,74.09,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,111.13,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,55.57,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,111.13,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.26,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,54.45,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,117.31,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.66,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,111.13,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,54.45,123.48,
Z4835-22-01 3.5 CORT,2740000151,CDM,278,RC,,,Outpatient,,,95.92,62.35,,95.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.9,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.06,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,69.06,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.06,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,57.55,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,86.33,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,43.16,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,86.33,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.35,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,42.3,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.12,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.41,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,86.33,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,42.3,95.92,
Z48352801 3.5 CORT,2740000152,CDM,278,RC,,,Outpatient,,,135.61,88.15,,135.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,103.06,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,97.64,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,97.64,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.64,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,81.37,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,122.05,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,61.02,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,122.05,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.15,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,59.8,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,128.83,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.34,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,122.05,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,59.8,135.61,
Z48353001 3.5 CORT,2740000153,CDM,278,RC,,,Outpatient,,,135.61,88.15,,135.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,103.06,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,97.64,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,97.64,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.64,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,81.37,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,122.05,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,61.02,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,122.05,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.15,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,59.8,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,128.83,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.34,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,122.05,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,59.8,135.61,
Z48353401 3.5 CORT,2740000154,CDM,278,RC,,,Outpatient,,,135.61,88.15,,135.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,103.06,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,97.64,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,97.64,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.64,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,81.37,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,122.05,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,61.02,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,122.05,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.15,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,59.8,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,128.83,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.34,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,122.05,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,59.8,135.61,
Z48354001 3.5 CORT,2740000155,CDM,278,RC,,,Outpatient,,,95.92,62.35,,95.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.9,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.06,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,69.06,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.06,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,57.55,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,86.33,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,43.16,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,86.33,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.35,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,42.3,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.12,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.41,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,86.33,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,42.3,95.92,
Z493600507 3.5 LOC,2740000156,CDM,278,RC,,,Outpatient,,,1400.18,910.12,,1400.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1064.14,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1008.13,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,1008.13,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,1400.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1008.13,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,840.11,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,1260.16,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,630.08,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,1260.16,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,1400.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1400.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1400.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,910.12,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,617.48,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,1330.17,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,1400.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1232.16,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,1260.16,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,617.48,1400.18,
Z493600603 3.5 LOC,2740000157,CDM,278,RC,,,Outpatient,,,754.11,490.17,,754.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,573.12,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,542.96,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,542.96,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,754.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,542.96,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,452.47,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,678.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,339.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,678.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,754.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,754.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,754.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.17,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,332.56,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,716.4,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,754.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,663.62,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,678.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,332.56,754.11,
Z493600707 3.5 LOC,2740000158,CDM,278,RC,,,Outpatient,,,1272.29,826.99,,1272.29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,966.94,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,916.05,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,916.05,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,1272.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.05,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,763.37,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,1145.06,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,572.53,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,1145.06,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,1272.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1272.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1272.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,561.08,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,1208.68,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,1272.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1119.62,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,1145.06,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,561.08,1272.29,
Z493600503 TUBULAR,2740000159,CDM,278,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,450.09,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
Z493600607 3.5 LOC,2740000160,CDM,278,RC,,,Outpatient,,,1225.98,796.89,,1225.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,931.74,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,882.71,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,882.71,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,1225.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,882.71,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,735.59,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,1103.38,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,551.69,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,1103.38,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,1225.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1225.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1225.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.89,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,540.66,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,1164.68,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,1225.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1078.86,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,1103.38,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,540.66,1225.98,
Z493600713 3.5 LOC,2740000161,CDM,278,RC,,,Outpatient,,,2058.37,1337.94,,2058.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1564.36,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1482.03,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,1482.03,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,2058.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1482.03,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,1235.02,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,1852.53,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,926.27,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,1852.53,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,2058.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2058.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2058.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1337.94,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,907.74,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,1955.45,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,2058.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1811.37,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,1852.53,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,907.74,2058.37,
Z00576401451 GSF,2740000162,CDM,278,RC,,,Outpatient,,,21516.39,13985.65,,21516.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16352.46,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15491.8,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,15491.8,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15491.8,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,12909.83,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,19364.75,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,9682.38,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,19364.75,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13985.65,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,9488.73,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,20440.57,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18934.42,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,19364.75,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,9488.73,21516.39,
Z62504535 4.5 BONE,2740000163,CDM,278,RC,,,Outpatient,,,744.19,483.72,,744.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,565.58,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,535.82,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,535.82,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,744.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,446.51,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,669.77,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,334.89,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,669.77,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,744.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,744.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,744.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,483.72,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,328.19,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,706.98,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,744.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,654.89,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,669.77,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,328.19,744.19,
Z62504540 4.5 BONE,2740000164,CDM,278,RC,,,Outpatient,,,744.19,483.72,,744.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,565.58,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,535.82,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,535.82,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,744.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,446.51,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,669.77,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,334.89,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,669.77,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,744.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,744.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,744.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,483.72,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,328.19,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,706.98,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,744.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,654.89,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,669.77,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,328.19,744.19,
DAVOL SUCTION/IRRIGATOR,2740000165,CDM,278,RC,,,Outpatient,,,53.00,34.45,,53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.28,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.16,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,38.16,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.16,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,31.8,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,47.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,23.85,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,47.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.45,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,23.37,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.35,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.64,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,47.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,23.37,53,
ARTHREX TIGERTAPE,2740000166,CDM,278,RC,,,Outpatient,,,178.75,116.19,,178.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,135.85,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,128.7,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,128.7,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,178.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.7,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,107.25,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,160.88,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,80.44,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,160.88,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,178.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.19,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,78.83,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,169.81,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,178.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.3,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,160.88,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,78.83,178.75,
ARTHEX DISP KT FOR DX SWIVLC,2740000167,CDM,278,RC,,,Outpatient,,,982.50,638.63,,982.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,746.7,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,707.4,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,707.4,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,982.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,707.4,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,589.5,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,884.25,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,442.13,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,884.25,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,982.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,982.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,982.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,638.63,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,433.28,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,933.38,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,982.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,864.6,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,884.25,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,433.28,982.5,
ACCOLADE MRI DR IS-1 (EL),2750000000,CDM,275,RC,,,Outpatient,,,6548.00,4256.20,,6548,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4976.48,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4714.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,4714.56,72,,321.496,Percent of Total Billed charges,72% of Total Billed Charges,6548,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4714.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,3928.8,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,5893.2,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,2946.6,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,5893.2,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,6548,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6548,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6548,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4256.2,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,2887.67,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,6220.6,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,6548,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5762.24,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,5893.2,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,2887.67,6548,
ACCOLADE MRI DR IS-1,2750000001,CDM,275,RC,C1785,HCPCS,Outpatient,,,26733.42,17376.72,,26733.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20317.4,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19248.06,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,19248.06,72,,2397.936,Percent of Total Billed charges,72% of Total Billed Charges,26733.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19248.06,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,16040.05,60,,1918.352,Percent of Total Billed Charges,60% of Total Billed Charges,24060.08,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,12030.04,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,24060.08,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,26733.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26733.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26733.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17376.72,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,11789.44,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,25396.75,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,26733.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23525.41,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,24060.08,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,11789.44,26733.42,
MOMENTUM CRT-D IS-1/DF-1/IS-1,2750000002,CDM,275,RC,C1882,HCPCS,Outpatient,,,17798.76,11569.19,,17798.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13527.06,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12815.11,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,12815.11,72,,2397.936,Percent of Total Billed charges,72% of Total Billed Charges,17798.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12815.11,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,10679.26,60,,1918.352,Percent of Total Billed Charges,60% of Total Billed Charges,16018.88,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,8009.44,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,16018.88,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,17798.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17798.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17798.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11569.19,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,7849.25,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,16908.82,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,17798.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15662.91,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,16018.88,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,7849.25,17798.76,
PCEMAKR DUAL CHAMB RTE RES DEV,2750000003,CDM,275,RC,,,Outpatient,,,19678.52,12791.04,,19678.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14955.68,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14168.53,72,,1273.256,Percent of Total Billed Charges,72% of Total Billed Charges,14168.53,72,,1326.304,Percent of Total Billed charges,72% of Total Billed Charges,19678.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14168.53,72,,1273.256,Percent of Total Billed Charges,72% of Total Billed Charges,11807.11,60,,1061.048,Percent of Total Billed Charges,60% of Total Billed Charges,17710.67,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,8855.33,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,17710.67,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,19678.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19678.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19678.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12791.04,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,8678.23,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,18694.59,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,19678.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17317.1,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,17710.67,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,8678.23,19678.52,
PCEMAKR DUAL CHAMB RTE RES DEV,2750000004,CDM,275,RC,,,Outpatient,,,20646.52,13420.24,,20646.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15691.36,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14865.49,72,,2213.752,Percent of Total Billed Charges,72% of Total Billed Charges,14865.49,72,,2305.992,Percent of Total Billed charges,72% of Total Billed Charges,20646.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14865.49,72,,2213.752,Percent of Total Billed Charges,72% of Total Billed Charges,12387.91,60,,1844.792,Percent of Total Billed Charges,60% of Total Billed Charges,18581.87,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,9290.93,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,18581.87,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,20646.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20646.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20646.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13420.24,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,9105.12,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,19614.19,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,20646.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18168.94,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,18581.87,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,9105.12,20646.52,
DEFIB/PACEMAK SINGLE,2750000005,CDM,275,RC,,,Outpatient,,,60657.35,39427.28,,60657.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46099.59,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43673.29,72,,2213.752,Percent of Total Billed Charges,72% of Total Billed Charges,43673.29,72,,2305.992,Percent of Total Billed charges,72% of Total Billed Charges,60657.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43673.29,72,,2213.752,Percent of Total Billed Charges,72% of Total Billed Charges,36394.41,60,,1844.792,Percent of Total Billed Charges,60% of Total Billed Charges,54591.62,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,27295.81,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,54591.62,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,60657.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60657.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60657.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39427.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,26749.89,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,57624.48,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,60657.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53378.47,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,54591.62,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,26749.89,60657.35,
BI V AICD INSERTION,2750000006,CDM,275,RC,,,Outpatient,,,50648.85,32921.75,,50648.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38493.13,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36467.17,72,,317.52,Percent of Total Billed Charges,72% of Total Billed Charges,36467.17,72,,330.752,Percent of Total Billed charges,72% of Total Billed Charges,50648.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36467.17,72,,317.52,Percent of Total Billed Charges,72% of Total Billed Charges,30389.31,60,,264.6,Percent of Total Billed Charges,60% of Total Billed Charges,45583.97,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,22791.98,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,45583.97,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,50648.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50648.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50648.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32921.75,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,22336.14,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,48116.41,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,50648.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44570.99,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,45583.97,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,22336.14,50648.85,
BI VENT AICD BATT CH,2750000007,CDM,275,RC,,,Outpatient,,,104426.60,67877.29,,104426.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79364.22,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75187.15,72,,283.864,Percent of Total Billed Charges,72% of Total Billed Charges,75187.15,72,,295.696,Percent of Total Billed charges,72% of Total Billed Charges,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75187.15,72,,283.864,Percent of Total Billed Charges,72% of Total Billed Charges,62655.96,60,,236.552,Percent of Total Billed Charges,60% of Total Billed Charges,93983.94,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,46991.97,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,93983.94,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67877.29,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,46052.13,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,99205.27,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91895.41,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,93983.94,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,46052.13,104426.6,
AICD DUAL CHAMB DEVI,2750000008,CDM,275,RC,,,Outpatient,,,79925.74,51951.73,,79925.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60743.56,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57546.53,72,,283.864,Percent of Total Billed Charges,72% of Total Billed Charges,57546.53,72,,295.696,Percent of Total Billed charges,72% of Total Billed Charges,79925.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57546.53,72,,283.864,Percent of Total Billed Charges,72% of Total Billed Charges,47955.44,60,,236.552,Percent of Total Billed Charges,60% of Total Billed Charges,71933.17,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,35966.58,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,71933.17,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,79925.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79925.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79925.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51951.73,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,35247.25,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,75929.45,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,79925.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70334.65,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,71933.17,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,35247.25,79925.74,
BI VENT AICD DEVICE,2750000009,CDM,275,RC,,,Outpatient,,,79925.74,51951.73,,79925.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,60743.56,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57546.53,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,57546.53,72,,1220.464,Percent of Total Billed charges,72% of Total Billed Charges,79925.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57546.53,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,47955.44,60,,976.376,Percent of Total Billed Charges,60% of Total Billed Charges,71933.17,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,35966.58,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,71933.17,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,79925.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79925.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79925.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51951.73,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,35247.25,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,75929.45,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,79925.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70334.65,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,71933.17,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,35247.25,79925.74,
AICD SINGL CHAM DEV,2750000010,CDM,275,RC,,,Outpatient,,,74498.13,48423.78,,74498.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56618.58,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53638.65,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,53638.65,72,,1220.464,Percent of Total Billed charges,72% of Total Billed Charges,74498.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53638.65,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,44698.88,60,,976.376,Percent of Total Billed Charges,60% of Total Billed Charges,67048.32,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,33524.16,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,67048.32,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,74498.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74498.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74498.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48423.78,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,32853.68,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,70773.22,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,74498.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65558.35,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,67048.32,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,32853.68,74498.13,
PACEMAKER SINGLE CHA,2750000011,CDM,275,RC,,,Outpatient,,,18504.36,12027.83,,18504.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14063.31,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13323.14,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,13323.14,72,,1220.464,Percent of Total Billed charges,72% of Total Billed Charges,18504.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13323.14,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,11102.62,60,,976.376,Percent of Total Billed Charges,60% of Total Billed Charges,16653.92,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,8326.96,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,16653.92,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,18504.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18504.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18504.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12027.83,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,8160.42,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,17579.14,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,18504.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16283.84,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,16653.92,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,8160.42,18504.36,
BI VENT PACEMKR DEVI,2750000012,CDM,275,RC,,,Outpatient,,,31198.55,20279.06,,31198.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23710.9,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22462.96,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,22462.96,72,,1220.464,Percent of Total Billed charges,72% of Total Billed Charges,31198.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22462.96,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,18719.13,60,,976.376,Percent of Total Billed Charges,60% of Total Billed Charges,28078.7,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,14039.35,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,28078.7,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,31198.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31198.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31198.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20279.06,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,13758.56,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,29638.62,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,31198.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27454.72,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,28078.7,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,13758.56,31198.55,
BI VENT LEAD REPLC L,2750000013,CDM,275,RC,,,Outpatient,,,16695.16,10851.85,,16695.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12688.32,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12020.52,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,12020.52,72,,1220.464,Percent of Total Billed charges,72% of Total Billed Charges,16695.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12020.52,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,10017.1,60,,976.376,Percent of Total Billed Charges,60% of Total Billed Charges,15025.64,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,7512.82,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,15025.64,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,16695.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16695.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16695.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10851.85,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,7362.57,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,15860.4,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,16695.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14691.74,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,15025.64,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,7362.57,16695.16,
ALCON SN60WF 10.0,2750000014,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,2118.496,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,2206.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,2118.496,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,1765.408,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 10.5,2750000015,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,1220.464,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,976.376,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 11.0,2750000016,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,1220.464,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,976.376,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 11.5,2750000017,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 12.0,2750000018,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 12.5,2750000019,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,1183.712,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,1233.04,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,1183.712,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,986.432,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 13.0,2750000020,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,2017.52,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,2101.584,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,2017.52,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,1681.264,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 13.5,2750000021,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 14.0,2750000022,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,2017.52,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,2101.584,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,2017.52,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,1681.264,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 14.5,2750000023,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,2017.52,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,2101.584,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,2017.52,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,1681.264,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 15.0,2750000024,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,2017.52,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,2101.584,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,2017.52,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,1681.264,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 15.5,2750000025,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,1921.448,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,2001.512,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,1921.448,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,1601.208,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 16.0,2750000026,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 16.5,2750000027,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 17.0,2750000028,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 17.5,2750000029,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,2049.552,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 18.0,2750000030,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,2078.208,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 18.5,2750000031,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,2078.208,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 19.0,2750000032,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,2078.208,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 19.5,2750000033,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,1149.464,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 20.0,2750000034,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,1149.464,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 20.5,2750000035,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,2078.208,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 21.0,2750000036,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,2078.208,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 21.5,2750000037,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,2078.208,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 22.0,2750000038,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,2078.208,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 22.5,2750000039,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,2078.208,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 23.0,2750000040,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,1149.464,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 23.5,2750000041,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 24.0,2750000042,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,2837.84,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 24.5,2750000043,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 25.0,2750000044,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 25.5,2750000045,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 26.0,2750000046,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,1591.568,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 26.5,2750000047,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.336,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,332.64,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.336,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.112,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,1591.568,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 27.0,2750000048,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 27.5,2750000049,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,1418.92,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,1390.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 28.0,2750000050,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,1127.344,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,1174.32,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,1127.344,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,939.456,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,1438.76,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,1409.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 28.5,2750000051,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,1438.76,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,1409.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 29.0,2750000052,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,2396.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,1438.76,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,2837.84,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,1409.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,2995.496,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,2774.776,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,2837.84,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 29.5,2750000053,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,2429.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,1591.568,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,795.784,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,779.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,3037.384,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,2813.576,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 30.0,2750000054,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,2429.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,1062.632,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,1106.912,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,1062.632,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,885.528,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,795.784,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,779.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,3037.384,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,2813.576,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 10.0,2750000055,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,2429.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,1438.76,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,1409.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,3037.384,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,2813.576,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 10.5,2750000056,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,1343.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,1438.76,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,1591.568,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,1409.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,1679.984,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,1556.2,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,1591.568,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 11.0,2750000057,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,1343.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,1438.76,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,1591.568,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,1409.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,1679.984,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,1556.2,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,1591.568,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 11.5,2750000058,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,2429.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,1438.76,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,1409.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,3037.384,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,2813.576,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 12.0,2750000059,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,2429.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,1438.76,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,1409.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,3037.384,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,2813.576,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 12.5,2750000060,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,2429.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,795.784,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,779.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,3037.384,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,2813.576,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 13.0,2750000061,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,2429.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,317.4,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,253.92,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,3037.384,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,2813.576,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 13.5,2750000062,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,2429.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,3037.384,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,2813.576,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 14.0,2750000063,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,1343.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,1829.952,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,1906.2,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,1829.952,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,1524.96,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,1591.568,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,1679.984,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,1556.2,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,1591.568,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 14.5,2750000064,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,1829.952,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,1906.2,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,1829.952,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,1524.96,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 15.0,2750000065,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,317.4,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,253.92,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 15.5,2750000066,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,173.952,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,181.2,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,173.952,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,144.96,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 16.0,2750000067,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,317.4,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,253.92,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 16.5,2750000068,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 17.0,2750000069,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 17.5,2750000070,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 18.0,2750000071,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 18.5,2750000072,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 19.0,2750000073,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 19.5,2750000074,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 20.0,2750000075,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 20.5,2750000076,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 21.0,2750000077,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 21.5,2750000078,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 22.0,2750000079,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 22.5,2750000080,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 23.0,2750000081,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 23.5,2750000082,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 24.0,2750000083,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 24.5,2750000084,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 25.0,2750000085,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 25.5,2750000086,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 26.0,2750000087,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 26.5,2750000088,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 27.0,2750000089,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 27.5,2750000090,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 28.0,2750000091,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 28.5,2750000092,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 29.0,2750000093,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,327.048,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,340.672,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,327.048,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,272.536,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 29.5,2750000094,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,327.048,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,340.672,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,327.048,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,272.536,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 30.0,2750000095,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,2078.208,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MTA3UO 10.0,2750000096,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,2078.208,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO,2750000097,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1149.464,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 11.0,2750000098,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1998.528,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 11.5,2750000099,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1998.528,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 12.0,2750000100,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,286.648,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 12.5,2750000101,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,256.264,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 13.0,2750000102,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,256.264,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 13.5,2750000103,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1057.736,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 14.0,2750000104,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1057.736,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 14.5,2750000105,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1057.736,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 15.0,2750000106,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1057.736,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 15.5,2750000107,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1057.736,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 16.0,2750000108,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2877.52,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1912.528,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 16.5,2750000109,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2877.52,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1057.736,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 17.0,2750000110,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1591.568,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1057.736,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 17.5,2750000111,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2767.192,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 18.0,2750000112,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2767.192,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 18.5,2750000113,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,396.904,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1068.632,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 19.0,2750000114,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,354.832,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1821.376,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 19.5,2750000115,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,341.336,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,354.832,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,1438.76,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,1409.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 20.0,2750000116,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,341.336,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,1438.76,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1821.376,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,1409.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 20.5,2750000117,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,341.336,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,795.784,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1821.376,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,779.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 21.0,2750000118,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,2429.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,341.336,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,1383.592,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,2877.52,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1821.376,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,1355.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,3037.384,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,2813.576,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,2877.52,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 21.5,2750000119,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,2429.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,341.336,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,1383.592,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,2877.52,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1734.64,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,1355.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,3037.384,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,2813.576,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,2877.52,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 22.0,2750000120,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1343.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,341.336,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,198.448,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1591.568,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,194.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1679.984,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1556.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1591.568,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 22.5,2750000121,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,2336.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,341.336,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2648.12,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,177.416,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,2767.192,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,173.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,2920.92,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,2705.696,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,2767.192,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 23.0,2750000122,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,2336.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,341.336,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,177.416,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,2767.192,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,173.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,2920.92,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,2705.696,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,2767.192,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 23.5,2750000123,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,335.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,732.28,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,396.904,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,717.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,418.952,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,388.08,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,396.904,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 24.0,2750000124,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,299.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,732.28,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,354.832,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,717.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,374.544,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,346.944,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,354.832,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 24.5,2750000125,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,299.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,732.28,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,354.832,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,717.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,374.544,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,346.944,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,354.832,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 25.0,2750000126,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1236.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1479.64,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,732.28,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,717.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1545.92,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1432.016,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 25.5,2750000127,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1236.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,732.28,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,717.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1545.92,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1432.016,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 26.0,2750000128,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1236.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,1324.056,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,1297.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1545.92,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1432.016,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 26.5,2750000129,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1236.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,732.28,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,717.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1545.92,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1432.016,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 27.0,2750000130,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1236.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,732.28,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,717.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1545.92,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1432.016,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 27.5,2750000131,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,2236.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,2648.12,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,2795.232,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,2589.272,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,2648.12,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 28.0,2750000132,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1236.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2401.816,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1545.92,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1432.016,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 29.0,2750000133,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1236.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,739.824,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,725.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1545.92,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1432.016,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 30.0,2750000134,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,1260.952,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,1235.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 10.0,2750000135,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 10.5,2750000136,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1249.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,1260.952,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1479.64,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,1235.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1561.848,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1446.76,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1479.64,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 11.0,2750000137,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,2129.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,1260.952,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,1235.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,2662.008,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,2465.856,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 11.5,2750000138,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,2017.52,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,2101.584,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,2017.52,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,1681.264,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,1260.952,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,1235.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 12.0,2750000139,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,2129.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,1200.904,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,1176.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,2662.008,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,2465.856,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 12.5,2750000140,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,2129.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,327.048,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,340.672,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,327.048,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,272.536,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,2662.008,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,2465.856,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 13.0,2750000141,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,2129.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.288,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,2662.008,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,2465.856,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 13.5,2750000142,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,2028.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,311.472,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,324.448,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,311.472,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,259.56,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,2401.816,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,2535.248,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,2348.44,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,2401.816,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 14.0,2750000143,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,311.472,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,324.448,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,311.472,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,259.56,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 14.5,2750000144,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1017.744,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 15.0,2750000145,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 15.5,2750000146,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 16.0,2750000147,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 16.5,2750000148,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,959.32,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 17.0,2750000149,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 17.5,2750000150,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 18.0,2750000151,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 18.5,2750000152,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 19.0,2750000153,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 19.5,2750000154,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.168,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 20.0,2750000155,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,275.08,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 20.5,2750000156,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 21.0,2750000157,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1409.184,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1652.04,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 21.5,2750000158,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1652.04,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 22.0,2750000159,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,275.08,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 22.5,2750000160,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,157.04,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 23.0,2750000161,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1328.296,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.584,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,275.08,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 23.5,2750000162,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 24.0,2750000163,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 24.5,2750000164,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,704.592,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.168,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,690.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,421.344,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,390.296,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.168,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 25.0,2750000165,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 25.5,2750000166,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 26.0,2750000167,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1189.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1409.184,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1487.472,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1377.872,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1409.184,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MAT4UO 26.5,2750000168,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,380.88,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,664.144,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,650.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 27.0,2750000169,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 27.5,2750000170,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2287.44,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 28.0,2750000171,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1121.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2287.44,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1328.296,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1402.088,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1298.776,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1328.296,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 29.0,2750000172,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,380.88,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 30.0,2750000173,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,217.44,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MA60AC 10.0,2750000174,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,380.88,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 10.5,2750000175,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,190.44,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,186.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 11.0,2750000176,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 11.5,2750000177,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1143.72,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1120.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 12.0,2750000178,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,321.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1143.72,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,380.88,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1120.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,402.04,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,372.416,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,380.88,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 12.5,2750000179,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,190.44,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,186.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 13.0,2750000180,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,1931.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,108.72,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,2287.44,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,106.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2414.52,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,2236.608,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,2287.44,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 13.5,2750000181,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,1931.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,190.44,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,2287.44,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,186.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2414.52,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,2236.608,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,2287.44,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 14.0,2750000182,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,321.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,380.88,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,402.04,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,372.416,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,380.88,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 14.5,2750000183,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,183.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,217.44,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,229.52,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,212.608,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,217.44,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 15.0,2750000184,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,321.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,331.496,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,345.304,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,331.496,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,276.248,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,380.88,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,402.04,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,372.416,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,380.88,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 15.5,2750000185,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,2213.752,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,2305.992,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,2213.752,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,1844.792,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 16.0,2750000186,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,2213.752,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,2305.992,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,2213.752,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,1844.792,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 16.5,2750000187,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,331.496,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,345.304,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,331.496,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,276.248,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,295.248,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 17.0,2750000188,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,317.4,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,253.92,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,295.248,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 17.5,2750000189,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,1256.112,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,1308.448,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,1256.112,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,1046.76,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 18.0,2750000190,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,13013.24,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,13555.456,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,13013.24,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,10844.368,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 18.5,2750000191,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,2787.832,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,2903.992,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,2787.832,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,2323.192,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 19.0,2750000192,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,4573.56,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,4764.128,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,4573.56,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,3811.304,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 19.5,2750000193,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,4351.928,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,4533.256,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,4351.928,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,3626.608,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 20.0,2750000194,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,324.504,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,338.032,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,324.504,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,270.424,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 20.5,2750000195,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,324.504,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,338.032,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,324.504,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,270.424,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 21.0,2750000196,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,324.504,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,338.032,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,324.504,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,270.424,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 21.5,2750000197,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,324.504,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,338.032,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,324.504,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,270.424,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 22.0,2750000198,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,444.528,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,463.048,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,444.528,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,370.44,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 22.5,2750000199,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,444.528,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,463.048,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,444.528,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,370.44,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 23.0,2750000200,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,444.528,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,463.048,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,444.528,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,370.44,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,408.808,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 23.5,2750000201,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,476.92,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,496.792,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,476.92,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,397.432,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,408.808,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 24.0,2750000202,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,1273.256,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,1326.304,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,1273.256,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,1061.048,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 24.5,2750000203,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,103.192,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,82.552,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 25.0,2750000204,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,69.456,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,55.568,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 25.5,2750000205,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 26.0,2750000206,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,33609.6,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,33609.6,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,33609.6,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,28008,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 26.5,2750000207,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,7404.48,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,7404.48,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,7404.48,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,6170.4,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,204.408,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,200.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 27.0,2750000208,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,204.408,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,200.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 27.5,2750000209,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 28.0,2750000210,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,345.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,408.808,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,431.52,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,399.728,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,408.808,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 28.5,2750000211,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,345.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,408.808,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,431.52,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,399.728,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,408.808,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 29.0,2750000212,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 29.5,2750000213,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 30.0,2750000214,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SN6AD1 17.5,2750000215,CDM,276,RC,,,Outpatient,,,3941.44,2561.94,,3941.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2995.49,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2837.84,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2956.08,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,3941.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2837.84,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2364.86,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,3547.3,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,1773.65,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,3547.3,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,3941.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3941.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3941.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2561.94,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,1738.18,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,3744.37,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,3941.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3468.47,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,3547.3,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,1738.18,3941.44,
ALCON SN6ADI 32.0 RE,2750000216,CDM,276,RC,,,Outpatient,,,3996.56,2597.76,,3996.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3037.39,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2877.52,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2997.42,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.52,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2397.94,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,1798.45,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2597.76,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,1762.48,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,3796.73,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3516.97,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,1762.48,3996.56,
ALCON SN6AD1 20.5 RE,2750000217,CDM,276,RC,,,Outpatient,,,3996.56,2597.76,,3996.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3037.39,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2877.52,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2997.42,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.52,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2397.94,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,1798.45,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2597.76,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,1762.48,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,3796.73,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3516.97,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,1762.48,3996.56,
ALCON SN6AD1 32.0,2750000218,CDM,276,RC,,,Outpatient,,,3996.56,2597.76,,3996.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3037.39,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2877.52,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2997.42,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.52,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2397.94,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,1798.45,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2597.76,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,1762.48,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,3796.73,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3516.97,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,1762.48,3996.56,
ALCON SN6AT5 17.5 TO,2750000219,CDM,276,RC,,,Outpatient,,,2210.51,1436.83,,2210.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1679.99,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1591.57,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,1657.88,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1591.57,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,1326.31,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,1989.46,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,994.73,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,1989.46,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1436.83,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,974.83,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,2099.98,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1945.25,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,1989.46,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,974.83,2210.51,
ALCON SN6AT5 18.0 TO,2750000220,CDM,276,RC,,,Outpatient,,,2210.51,1436.83,,2210.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1679.99,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1591.57,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,1657.88,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1591.57,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,1326.31,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,1989.46,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,994.73,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,1989.46,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1436.83,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,974.83,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,2099.98,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1945.25,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,1989.46,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,974.83,2210.51,
ALCON SN6AD1 31.0 RE,2750000221,CDM,276,RC,,,Outpatient,,,3996.56,2597.76,,3996.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3037.39,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2877.52,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2997.42,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.52,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2397.94,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,1798.45,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2597.76,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,1762.48,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,3796.73,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3516.97,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,1762.48,3996.56,
ALCON SN6AD1 21.5 RE,2750000222,CDM,276,RC,,,Outpatient,,,3996.56,2597.76,,3996.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3037.39,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2877.52,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2997.42,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.52,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2397.94,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,3596.9,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,1798.45,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2597.76,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,1762.48,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,3796.73,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3516.97,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,1762.48,3996.56,
ALCON SN6AD1 15.0 RE,2750000223,CDM,276,RC,,,Outpatient,,,3996.56,2597.76,,3996.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3037.39,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2877.52,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2997.42,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.52,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2397.94,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,3596.9,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,1798.45,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2597.76,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,1762.48,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,3796.73,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3516.97,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,1762.48,3996.56,
ALCON SN6AD1 12.0 RE,2750000224,CDM,276,RC,,,Outpatient,,,3996.56,2597.76,,3996.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3037.39,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2877.52,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2997.42,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.52,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2397.94,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,3596.9,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,1798.45,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2597.76,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,1762.48,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,3796.73,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3516.97,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,1762.48,3996.56,
ALCON SN6AD1 21.0 RE,2750000225,CDM,276,RC,,,Outpatient,,,3996.56,2597.76,,3996.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3037.39,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2877.52,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2997.42,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.52,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2397.94,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,3596.9,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,1798.45,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2597.76,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,1762.48,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,3796.73,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3516.97,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,1762.48,3996.56,
ALCON SN6AT3 20.5 TO,2750000226,CDM,276,RC,,,Outpatient,,,2210.51,1436.83,,2210.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1679.99,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1591.57,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,1657.88,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1591.57,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,1326.31,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,1989.46,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,994.73,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,1989.46,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1436.83,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,974.83,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,2099.98,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1945.25,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,1989.46,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,974.83,2210.51,
AMO ZCBOO 12.0,2750000227,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 12.5,2750000228,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 13.0,2750000229,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 13.5,2750000230,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 14.0,2750000231,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 14.5,2750000232,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,1821.376,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 15.0,2750000233,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 15.5,2750000234,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,295.248,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 16.0,2750000235,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 16.5,2750000236,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,281.192,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 17.0,2750000237,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,281.192,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 17.5,2750000238,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 18.0,2750000239,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 18.5,2750000240,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 19.0,2750000241,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 19.5,2750000242,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 20.0,2750000243,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 20.5,2750000244,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 21.0,2750000245,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,2521.904,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 21.5,2750000246,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 21.5,2750000247,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,408.808,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 22.5,2750000248,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 23.0,2750000249,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,389.344,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 23.5,2750000250,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,389.344,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 24.0,2750000251,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 24.5,2750000252,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,1260.952,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,1235.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 25.0,2750000253,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 25.5,2750000254,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,204.408,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,200.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 26.0,2750000255,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,2129.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,2521.904,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,2662.008,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,2465.856,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,2521.904,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZA9003.14.0,2750000256,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,194.672,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,190.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 14.5,2750000257,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,345.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,194.672,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,408.808,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,190.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,431.52,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,399.728,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,408.808,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 15.0,2750000258,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 15.5,2750000259,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,328.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,389.344,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,410.968,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,380.688,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,389.344,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 16.0,2750000260,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,328.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,389.344,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,410.968,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,380.688,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,389.344,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 16.5,2750000261,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 17.0,2750000262,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 17.5,2750000263,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 18.0,2750000264,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 18.5,2750000265,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 19.0,2750000266,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 19.5,2750000267,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 20.0,2750000268,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 20.5,2750000269,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 21.0,2750000270,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 21.5,2750000271,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 22.0,2750000272,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 22.5,2750000273,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 23.0,2750000274,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 23.5,2750000275,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 24.0,2750000276,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 24.5,2750000277,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 25.0,2750000278,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,299.264,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 25.5,2750000279,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,1998.528,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 26.0,2750000280,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,1998.528,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
ALCON SN6AD1 170D,2750000281,CDM,276,RC,,,Outpatient,,,3996.56,2597.76,,3996.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3037.39,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2877.52,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2997.42,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.52,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2397.94,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,3596.9,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,1798.45,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,3596.9,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2597.76,65,,299.264,Percent of total Billed Charges,65% of Total Billed Charges,1762.48,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,3796.73,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3516.97,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,3596.9,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,1762.48,3996.56,
ALCON SN6ADI 20.0 12,2750000282,CDM,276,RC,,,Outpatient,,,3996.56,2597.76,,3996.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3037.39,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2877.52,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2997.42,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.52,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2397.94,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,3596.9,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,1798.45,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,3596.9,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2597.76,65,,275.08,Percent of total Billed Charges,65% of Total Billed Charges,1762.48,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,3796.73,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3516.97,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,3596.9,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,1762.48,3996.56,
ALCON SN6AT3 16.0 TO,2750000283,CDM,276,RC,,,Outpatient,,,2210.51,1436.83,,2210.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1679.99,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1591.57,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,1657.88,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1591.57,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,1326.31,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,1989.46,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,994.73,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,1989.46,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1436.83,65,,1133.992,Percent of total Billed Charges,65% of Total Billed Charges,974.83,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,2099.98,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1945.25,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,1989.46,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,974.83,2210.51,
ALCON SN6AD1 18.0 RE,2750000284,CDM,276,RC,,,Outpatient,,,3843.32,2498.16,,3843.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2920.92,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2767.19,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2882.49,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2767.19,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2305.99,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,3458.99,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,1729.49,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,3458.99,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2498.16,65,,11748.064,Percent of total Billed Charges,65% of Total Billed Charges,1694.9,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,3651.15,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3382.12,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,3458.99,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,1694.9,3843.32,
ALCON SN6ADI 22.5,2750000285,CDM,276,RC,,,Outpatient,,,3843.32,2498.16,,3843.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2920.92,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2767.19,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2882.49,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2767.19,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,2305.99,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,3458.99,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,1729.49,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,3458.99,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2498.16,65,,2516.792,Percent of total Billed Charges,65% of Total Billed Charges,1694.9,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,3651.15,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3382.12,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,3458.99,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,1694.9,3843.32,
ALCON SN60WF 7.0,2750000286,CDM,276,RC,,,Outpatient,,,551.25,358.31,,551.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,418.95,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,396.9,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,413.44,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,551.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.9,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,330.75,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,496.13,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,248.06,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,496.13,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,551.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,551.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,551.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.31,65,,4128.912,Percent of total Billed Charges,65% of Total Billed Charges,243.1,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,523.69,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,551.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.1,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,496.13,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,243.1,551.25,
AMO ZA9003 27.0,2750000287,CDM,276,RC,,,Outpatient,,,492.82,320.33,,492.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,374.54,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,354.83,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,369.62,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,492.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.83,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,295.69,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,443.54,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,221.77,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,443.54,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,492.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320.33,65,,3928.824,Percent of total Billed Charges,65% of Total Billed Charges,217.33,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,468.18,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,492.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,433.68,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,443.54,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,217.33,492.82,
AMO ZA9003 28.0,2750000288,CDM,276,RC,,,Outpatient,,,492.82,320.33,,492.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,374.54,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,354.83,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,369.62,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,492.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.83,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,295.69,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,443.54,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,221.77,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,443.54,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,492.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320.33,65,,292.96,Percent of total Billed Charges,65% of Total Billed Charges,217.33,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,468.18,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,492.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,433.68,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,443.54,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,217.33,492.82,
ALCON SN6AT4 25.0 TO,2750000289,CDM,276,RC,,,Outpatient,,,2034.11,1322.17,,2034.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1545.92,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1464.56,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,1525.58,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1464.56,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,1220.47,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,915.35,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1322.17,65,,292.96,Percent of total Billed Charges,65% of Total Billed Charges,897.04,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,1932.4,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1790.02,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,897.04,2034.11,
ALCON SN6AT4 19.5 TO,2750000290,CDM,276,RC,,,Outpatient,,,2034.11,1322.17,,2034.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1545.92,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1464.56,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1525.58,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1464.56,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1220.47,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,915.35,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1322.17,65,,292.96,Percent of total Billed Charges,65% of Total Billed Charges,897.04,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,1932.4,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1790.02,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,897.04,2034.11,
ALCON SN6AT3 19.5 TO,2750000291,CDM,276,RC,,,Outpatient,,,2034.11,1322.17,,2034.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1545.92,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1464.56,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1525.58,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1464.56,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1220.47,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,1830.7,90,,414.368,Percent of Total Billed Charges,90% of Total Billed Charges,915.35,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1322.17,65,,292.96,Percent of total Billed Charges,65% of Total Billed Charges,897.04,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,1932.4,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1790.02,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,897.04,2034.11,
ALCON SN6AT6 22.0 TORIC,2750000292,CDM,276,RC,,,Outpatient,,,2034.11,1322.17,,2034.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1545.92,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1464.56,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1525.58,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1464.56,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1220.47,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,1830.7,90,,2767.192,Percent of Total Billed Charges,90% of Total Billed Charges,915.35,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1322.17,65,,401.312,Percent of total Billed Charges,65% of Total Billed Charges,897.04,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,1932.4,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1790.02,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,897.04,2034.11,
ALCON SN6AT3 19.0 TORIC,2750000293,CDM,276,RC,,,Outpatient,,,2034.11,1322.17,,2034.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1545.92,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1464.56,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1525.58,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1464.56,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1220.47,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,1830.7,90,,2767.192,Percent of Total Billed Charges,90% of Total Billed Charges,915.35,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1322.17,65,,401.312,Percent of total Billed Charges,65% of Total Billed Charges,897.04,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,1932.4,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1790.02,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,897.04,2034.11,
ALCON SN6AD1 19.5 RESTOR,2750000294,CDM,276,RC,,,Outpatient,,,3677.94,2390.66,,3677.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2795.23,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2648.12,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,2758.46,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,3677.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2648.12,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,2206.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,3310.15,90,,414.368,Percent of Total Billed Charges,90% of Total Billed Charges,1655.07,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,3310.15,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,3677.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3677.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3677.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2390.66,65,,401.312,Percent of total Billed Charges,65% of Total Billed Charges,1621.97,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,3494.04,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,3677.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3236.59,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,3310.15,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,1621.97,3677.94,
ALCON SN6A7721.0,2750000295,CDM,276,RC,,,Outpatient,,,2034.11,1322.17,,2034.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1545.92,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1464.56,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1525.58,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1464.56,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1220.47,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,1830.7,90,,380.88,Percent of Total Billed Charges,90% of Total Billed Charges,915.35,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1322.17,65,,430.552,Percent of total Billed Charges,65% of Total Billed Charges,897.04,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,1932.4,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1790.02,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,897.04,2034.11,
ALCON SN6AT6 9TORIC,2750000296,CDM,276,RC,,,Outpatient,,,2034.11,1322.17,,2034.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1545.92,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1464.56,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1525.58,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1464.56,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1220.47,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,1830.7,90,,1570.144,Percent of Total Billed Charges,90% of Total Billed Charges,915.35,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1322.17,65,,1149.464,Percent of total Billed Charges,65% of Total Billed Charges,897.04,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,1932.4,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1790.02,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,897.04,2034.11,
AMO ZCBOO 28.0,2750000297,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,16266.552,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,89.432,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
AMO ZCBOO 9.5,2750000298,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,3484.784,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,207.184,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,60.192,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,203.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
AMO ZCT 225 13.5 TORIC,2750000299,CDM,276,RC,,,Outpatient,,,2055.06,1335.79,,2055.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1561.85,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1479.64,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1541.3,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,2055.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1479.64,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1233.04,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,1849.55,90,,5716.952,Percent of Total Billed Charges,90% of Total Billed Charges,924.78,45,,1383.592,Percent of Total Billed Charges,45% of Total Billed Charges,1849.55,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,2055.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2055.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2055.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1335.79,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,906.28,44.1,,1355.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,1952.31,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,2055.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1808.45,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,1849.55,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,906.28,2055.06,
ALCON SN6AD1 19.0 RESTOR,2750000300,CDM,276,RC,,,Outpatient,,,3502.64,2276.72,,3502.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2662.01,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2521.9,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,2626.98,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.9,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,2101.58,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,3152.38,90,,5439.912,Percent of Total Billed Charges,90% of Total Billed Charges,1576.19,45,,1383.592,Percent of Total Billed Charges,45% of Total Billed Charges,3152.38,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2276.72,65,,30342,Percent of total Billed Charges,65% of Total Billed Charges,1544.66,44.1,,1355.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,3327.51,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3082.32,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,3152.38,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,1544.66,3502.64,
AMO ZCB OO 6.0,2750000301,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,349.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,405.632,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,207.184,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,414.368,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,6684.6,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,203.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,437.384,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,405.16,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,414.368,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
AMO ZMBOO 22.5 MULTI  FOCAL,2750000302,CDM,276,RC,,,Outpatient,,,3502.64,2276.72,,3502.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2662.01,76,,2336.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2521.9,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,2626.98,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.9,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,2101.58,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,3152.38,90,,405.632,Percent of Total Billed Charges,90% of Total Billed Charges,1576.19,45,,190.44,Percent of Total Billed Charges,45% of Total Billed Charges,3152.38,90,,2767.192,Percent of Total Billed Charges,90% of Total billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2276.72,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,1544.66,44.1,,186.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,3327.51,95,,2920.92,Percent of Total Billed Charges,95% of Total Billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3082.32,88,,2705.696,Percent of Total Billed Charges,88% of Total Billed Charges,3152.38,90,,2767.192,Percent of Total Billed charges,90% of Total Billed Charges,1544.66,3502.64,
AMO ZL BOO,2750000303,CDM,276,RC,,,Outpatient,,,3502.64,2276.72,,3502.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2662.01,76,,2336.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2521.9,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,2626.98,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.9,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,2101.58,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,3152.38,90,,405.632,Percent of Total Billed Charges,90% of Total Billed Charges,1576.19,45,,785.072,Percent of Total Billed Charges,45% of Total Billed Charges,3152.38,90,,2767.192,Percent of Total Billed Charges,90% of Total billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2276.72,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,1544.66,44.1,,769.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,3327.51,95,,2920.92,Percent of Total Billed Charges,95% of Total Billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3082.32,88,,2705.696,Percent of Total Billed Charges,88% of Total Billed Charges,3152.38,90,,2767.192,Percent of Total Billed charges,90% of Total Billed Charges,1544.66,3502.64,
AMO ZLB00 24.5 MULTIFOCAL,2750000304,CDM,276,RC,,,Outpatient,,,3502.64,2276.72,,3502.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2662.01,76,,349.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2521.9,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,2626.98,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.9,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,2101.58,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,3152.38,90,,405.632,Percent of Total Billed Charges,90% of Total Billed Charges,1576.19,45,,8133.272,Percent of Total Billed Charges,45% of Total Billed Charges,3152.38,90,,414.368,Percent of Total Billed Charges,90% of Total billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2276.72,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,1544.66,44.1,,7970.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,3327.51,95,,437.384,Percent of Total Billed Charges,95% of Total Billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3082.32,88,,405.16,Percent of Total Billed Charges,88% of Total Billed Charges,3152.38,90,,414.368,Percent of Total Billed charges,90% of Total Billed Charges,1544.66,3502.64,
AMO ZLBOO 19.0 MULTIFOCAL,2750000305,CDM,276,RC,,,Outpatient,,,3335.85,2168.30,,3335.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2535.25,76,,321.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2401.81,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,2501.89,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,3335.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2401.81,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,2001.51,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,3002.27,90,,555.664,Percent of Total Billed Charges,90% of Total Billed Charges,1501.13,45,,1742.392,Percent of Total Billed Charges,45% of Total Billed Charges,3002.27,90,,380.88,Percent of Total Billed Charges,90% of Total billed Charges,3335.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3335.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3335.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2168.3,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,1471.11,44.1,,1707.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,3169.06,95,,402.04,Percent of Total Billed Charges,95% of Total Billed Charges,3335.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2935.55,88,,372.416,Percent of Total Billed Charges,88% of Total Billed Charges,3002.27,90,,380.88,Percent of Total Billed charges,90% of Total Billed Charges,1471.11,3335.85,
AMO PCBOO 15.0,2750000306,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,1325.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,555.664,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,2858.472,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,1570.144,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,2801.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,1657.368,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,1535.248,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,1570.144,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 15.5,2750000307,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,13736.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,555.664,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,2719.952,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,16266.552,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,2665.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,17170.248,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,15905.072,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,16266.552,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 16.0,2750000308,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,2942.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,596.144,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,202.816,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,3484.784,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,198.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,3678.384,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,3407.344,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,3484.784,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 16.5,2750000309,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,4827.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,1591.568,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,202.816,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,5716.952,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,198.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,6034.56,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,5589.904,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,5716.952,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 17.0,2750000310,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,4593.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,123.832,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,202.816,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,5439.912,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,198.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,5742.128,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,5319.024,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,5439.912,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 17.5,2750000311,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,342.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,83.344,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,202.816,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,405.632,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,198.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,428.168,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,396.616,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,405.632,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 18.0,2750000312,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,342.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,277.832,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,405.632,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,272.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,428.168,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,396.616,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,405.632,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 18.5,2750000313,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,342.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,42012,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,277.832,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,405.632,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,272.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,428.168,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,396.616,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,405.632,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 19.0,2750000314,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,342.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,9255.6,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,277.832,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,405.632,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,272.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,428.168,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,396.616,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,405.632,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 20.0,2750000315,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,469.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,298.072,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,555.664,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,292.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,586.528,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,543.312,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,555.664,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 20.5,2750000316,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,469.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,795.784,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,555.664,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,779.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,586.528,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,543.312,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,555.664,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 21.0,2750000317,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,469.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,61.92,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,555.664,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,60.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,586.528,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,543.312,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,555.664,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 22.0,2750000318,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,503.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,41.672,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,596.144,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,40.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,629.264,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,582.896,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,596.144,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 22.5,2750000319,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,1343.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,1591.568,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,1679.984,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,1556.2,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,1591.568,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 23.0,2750000320,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,104.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,21006,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,123.832,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,20585.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,130.712,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,121.08,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,123.832,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 23.5,2750000321,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,70.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,4627.8,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,83.344,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,4535.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,87.976,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,81.496,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,83.344,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 24.0,2750000322,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 24.5,2750000323,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,35476.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,42012,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,44346,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,41078.4,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,42012,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 25.0,2750000324,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,7815.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,9255.6,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,9769.8,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,9049.92,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,9255.6,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 19.5,2750000325,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 21.5,2750000326,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 26.5,2750000327,CDM,276,RC,,,Outpatient,,,554.40,360.36,,554.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,421.34,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.17,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,415.8,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,554.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.17,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,332.64,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,498.96,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.48,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,498.96,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,554.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360.36,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.49,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,526.68,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,554.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487.87,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,498.96,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,244.49,554.4,
AMO PCBOO 13.5,2750000328,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 11.0,2750000329,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO ZCT300 16.5,2750000330,CDM,276,RC,,,Outpatient,,,1957.20,1272.18,,1957.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1487.47,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1409.18,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1467.9,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,1957.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1409.18,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1174.32,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,1761.48,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,880.74,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,1761.48,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,1957.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1957.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1957.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1272.18,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,863.13,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,1859.34,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,1957.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1722.34,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,1761.48,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,863.13,1957.2,
AMO PCBOO 6.0,2750000331,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 14.0,2750000332,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 27.0,2750000333,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
ALCON SN6AT4 13.5 TORIC,2750000334,CDM,276,RC,,,Outpatient,,,1844.85,1199.15,,1844.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1402.09,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1328.29,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1383.64,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1328.29,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1106.91,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,1660.37,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,830.18,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,1660.37,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1199.15,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,813.58,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,1752.61,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1623.47,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,1660.37,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,813.58,1844.85,
AMO PCB00 25.5,2750000335,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 14.5,2750000336,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 26.0,2750000337,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 13.0,2750000338,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 10.5,2750000339,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 28.0,2750000340,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 10.5,2750000341,CDM,276,RC,,,Outpatient,,,529.00,343.85,,529,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,402.04,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,380.88,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,396.75,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.88,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,317.4,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,476.1,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,238.05,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,476.1,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.85,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,233.29,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,502.55,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.52,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,476.1,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,233.29,529,
AMO PCBOO 11.5,2750000342,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
ALCON SND17S 20.0 TORIC,2750000343,CDM,276,RC,,,Outpatient,,,3177.00,2065.05,,3177,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2414.52,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2287.44,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,2382.75,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,3177,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2287.44,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1906.2,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,2859.3,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,1429.65,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,2859.3,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,3177,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2065.05,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,1401.06,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,3018.15,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,3177,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2795.76,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,2859.3,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,1401.06,3177,
ALCON SND1T3 18.0 TORIC,2750000344,CDM,276,RC,,,Outpatient,,,3177.00,2065.05,,3177,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2414.52,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2287.44,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,2382.75,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,3177,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2287.44,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,1906.2,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,2859.3,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,1429.65,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,2859.3,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,3177,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2065.05,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,1401.06,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,3018.15,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,3177,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2795.76,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,2859.3,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,1401.06,3177,
AMO PCBOO 32.0,2750000345,CDM,276,RC,,,Outpatient,,,529.00,343.85,,529,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,402.04,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,380.88,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,396.75,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.88,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,317.4,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,476.1,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,238.05,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,476.1,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.85,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,233.29,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,502.55,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.52,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,476.1,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,233.29,529,
ALCON MTA5U0 18.0,2750000346,CDM,276,RC,,,Outpatient,,,302.00,196.30,,302,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,229.52,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,217.44,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,226.5,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.44,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,181.2,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,271.8,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,135.9,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,271.8,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.3,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,133.18,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,286.9,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.76,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,271.8,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,133.18,302,
AMO PCBOO 7.5,2750000347,CDM,276,RC,,,Outpatient,,,529.00,343.85,,529,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,402.04,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,380.88,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,396.75,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.88,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,317.4,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,476.1,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,238.05,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,476.1,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.85,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,233.29,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,502.55,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.52,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,476.1,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,233.29,529,
BL M16OL 12.0,2750000348,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 12.5,2750000349,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 13.0,2750000350,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 13.5,2750000351,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 14.0,2750000352,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 14.5,2750000353,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 15.0,2750000354,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 15.5,2750000355,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 16.0,2750000356,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 16.5,2750000357,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 17.0,2750000358,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 17.5,2750000359,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 18.0,2750000360,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 18.5,2750000361,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 19.0,2750000362,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 19.5,2750000363,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 20.0,2750000364,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 20.5,2750000365,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 21.0,2750000366,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 21.5,2750000367,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,224.912,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,215.912,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,179.928,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 22.0,2750000368,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 22.5,2750000369,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 23.0,2750000370,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 23.5,2750000371,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 24.0,2750000372,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 18.5,2750000373,CDM,276,RC,,,Outpatient,,,567.79,369.06,,567.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,431.52,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,408.81,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,425.84,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,408.81,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,340.67,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,511.01,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,255.51,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,511.01,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.06,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,250.4,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,539.4,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,499.66,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,511.01,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,250.4,567.79,
BL M16OL 25.0,2750000374,CDM,276,RC,,,Outpatient,,,567.79,369.06,,567.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,431.52,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,408.81,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,425.84,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,408.81,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,340.67,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,511.01,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,255.51,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,511.01,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.06,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,250.4,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,539.4,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,499.66,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,511.01,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,250.4,567.79,
BL L161AO 16.0,2750000375,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 16.5,2750000376,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 17.0,2750000377,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 17.5,2750000378,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 18.0,2750000379,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 18.5,2750000380,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 19.0,2750000381,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 19.5,2750000382,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 20.0,2750000383,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 21.0,2750000384,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 21.5,2750000385,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 22.0,2750000386,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 22.5,2750000387,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 23.5,2750000388,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 23.0,2750000389,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 24.0,2750000390,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 24.5,2750000391,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 25.0,2750000392,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 25.5,2750000393,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 20.5,2750000394,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL M161OL 11.0,2750000395,CDM,276,RC,,,Outpatient,,,568.89,369.78,,568.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.36,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,409.6,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,426.67,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.6,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,341.33,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,512,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,256,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,512,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.78,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,250.88,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,540.45,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.62,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,512,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,250.88,568.89,
BL M16OL 11.5,2750000396,CDM,276,RC,,,Outpatient,,,568.89,369.78,,568.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.36,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,409.6,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,426.67,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.6,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,341.33,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,512,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,256,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,512,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.78,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,250.88,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,540.45,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.62,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,512,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,250.88,568.89,
BL M16OL 25.5,2750000397,CDM,276,RC,,,Outpatient,,,568.89,369.78,,568.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.36,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,409.6,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,426.67,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.6,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,341.33,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,512,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,256,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,512,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.78,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,250.88,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,540.45,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.62,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,512,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,250.88,568.89,
BL M16OL 26.0,2750000398,CDM,276,RC,,,Outpatient,,,568.89,369.78,,568.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.36,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,409.6,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,426.67,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.6,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,341.33,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,512,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,256,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,512,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.78,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,250.88,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,540.45,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.62,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,512,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,250.88,568.89,
BL M16OL 26.5,2750000399,CDM,276,RC,,,Outpatient,,,568.89,369.78,,568.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.36,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,409.6,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,426.67,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.6,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,341.33,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,512,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,256,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,512,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.78,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,250.88,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,540.45,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.62,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,512,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,250.88,568.89,
BL M16OL 27.0,2750000400,CDM,276,RC,,,Outpatient,,,568.89,369.78,,568.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.36,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,409.6,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,426.67,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.6,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,341.33,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,512,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,256,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,512,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.78,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,250.88,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,540.45,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.62,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,512,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,250.88,568.89,
BL M16OL 27.5,2750000401,CDM,276,RC,,,Outpatient,,,568.89,369.78,,568.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.36,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,409.6,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,426.67,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.6,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,341.33,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,512,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,256,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,512,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.78,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,250.88,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,540.45,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.62,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,512,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,250.88,568.89,
BL M16OL 28.0,2750000402,CDM,276,RC,,,Outpatient,,,568.89,369.78,,568.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.36,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,409.6,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,426.67,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.6,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,341.33,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,512,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,256,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,512,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.78,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,250.88,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,540.45,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.62,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,512,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,250.88,568.89,
BL L161AO 11.0,2750000403,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 11.5,2750000404,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 12.0,2750000405,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 12.5,2750000406,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 13.0,2750000407,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 13.5,2750000408,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 14.0,2750000409,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,2270.272,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,2364.864,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,2270.272,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,1891.888,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 14.5,2750000410,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,2397.936,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,1918.352,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 15.0,2750000411,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,2397.936,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,1918.352,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 15.5,2750000412,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,2397.936,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,1918.352,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 26.0,2750000413,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,1273.256,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,1326.304,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,1273.256,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,1061.048,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 26.5,2750000414,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,1273.256,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,1326.304,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,1273.256,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,1061.048,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 27.0,2750000415,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,2397.936,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,1918.352,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 27.5,2750000416,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,2397.936,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,1918.352,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 28.0,2750000417,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,2397.936,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,1918.352,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
AMO ZLBOO 19.5,2750000418,CDM,276,RC,,,Outpatient,,,3502.64,2276.72,,3502.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2662.01,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2521.9,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,2626.98,75,,2397.936,Percent of Total Billed charges,75% of Total Billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.9,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,2101.58,60,,1918.352,Percent of Total Billed Charges,60% of Total Billed Charges,3152.38,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,1576.19,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,3152.38,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2276.72,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,1544.66,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,3327.51,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3082.32,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,3152.38,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,1544.66,3502.64,
BL L161 AO 31.00,2750000419,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,2397.936,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,1918.352,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL M160L 28.5,2750000420,CDM,276,RC,,,Outpatient,,,567.79,369.06,,567.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,431.52,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,408.81,72,,1273.256,Percent of Total Billed Charges,72% of Total Billed Charges,425.84,75,,1326.304,Percent of Total Billed charges,75% of Total Billed Charges,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,408.81,72,,1273.256,Percent of Total Billed Charges,72% of Total Billed Charges,340.67,60,,1061.048,Percent of Total Billed Charges,60% of Total Billed Charges,511.01,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,255.51,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,511.01,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.06,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,250.4,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,539.4,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,499.66,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,511.01,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,250.4,567.79,
BL L161AO 34.0,2750000421,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL M160L 5.0,2750000422,CDM,276,RC,,,Outpatient,,,540.75,351.49,,540.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,410.97,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,389.34,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,405.56,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,540.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,389.34,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,324.45,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,486.68,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,243.34,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,486.68,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,540.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,351.49,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,238.47,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,513.71,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,540.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475.86,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,486.68,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,238.47,540.75,
BL M16OL 8.0,2750000423,CDM,276,RC,,,Outpatient,,,540.75,351.49,,540.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,410.97,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,389.34,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,405.56,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,540.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,389.34,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,324.45,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,486.68,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,243.34,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,486.68,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,540.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,351.49,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,238.47,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,513.71,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,540.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475.86,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,486.68,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,238.47,540.75,
ALCON SA60AT 10.0,2750000424,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 10.5,2750000425,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 11.5,2750000426,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 12.0,2750000427,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 12.5,2750000428,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 13.0,2750000429,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 13.5,2750000430,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 14.0,2750000431,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 14.5,2750000432,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 15.0,2750000433,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 15.5,2750000434,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 16.0,2750000435,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 16.5,2750000436,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 17.0,2750000437,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 17.5,2750000438,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 18.0,2750000439,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 18.5,2750000440,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 19.0,2750000441,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 19.5,2750000442,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 20.0,2750000443,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 20.5,2750000444,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 21.0,2750000445,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 21.5,2750000446,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 22.0,2750000447,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 22.5,2750000448,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 23.0,2750000449,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 23.5,2750000450,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 24.0,2750000451,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 24.5,2750000452,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 25.0,2750000453,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 25.5,2750000454,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 26.0,2750000455,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 26.5,2750000456,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 27.0,2750000457,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 27.5,2750000458,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 28.0,2750000459,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 28.5,2750000460,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 29.0,2750000461,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,194.92,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 29.5,2750000462,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 30.0,2750000463,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 6.0,2750000464,CDM,276,RC,,,Outpatient,,,575.51,374.08,,575.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,437.39,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,414.37,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,431.63,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.37,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,345.31,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,517.96,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,258.98,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,517.96,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.08,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,253.8,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,546.73,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.45,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,517.96,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,253.8,575.51,
ALCON SNEAD1 25.0 RE,2750000465,CDM,276,RC,,,Outpatient,,,3843.32,2498.16,,3843.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2920.92,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2767.19,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,2882.49,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2767.19,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,2305.99,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,3458.99,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,1729.49,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,3458.99,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2498.16,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,1694.9,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,3651.15,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3382.12,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,3458.99,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,1694.9,3843.32,
ALCON SN6AD1 23.0 RE,2750000466,CDM,276,RC,,,Outpatient,,,3843.32,2498.16,,3843.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2920.92,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2767.19,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,2882.49,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2767.19,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,2305.99,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,3458.99,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,1729.49,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,3458.99,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2498.16,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,1694.9,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,3651.15,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3382.12,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,3458.99,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,1694.9,3843.32,
ALCON SA60AT 34.0,2750000467,CDM,276,RC,,,Outpatient,,,575.51,374.08,,575.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,437.39,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,414.37,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,431.63,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.37,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,345.31,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,517.96,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,258.98,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,517.96,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.08,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,253.8,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,546.73,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.45,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,517.96,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,253.8,575.51,
AMO PCB00 27.5,2750000468,CDM,276,RC,,,Outpatient,,,529.00,343.85,,529,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,402.04,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,380.88,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,396.75,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.88,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,317.4,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,476.1,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,238.05,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,476.1,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.85,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,233.29,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,502.55,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.52,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,476.1,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,233.29,529,
ALCON SN6AT3 22.0,2750000469,CDM,276,RC,,,Outpatient,,,2180.75,1417.49,,2180.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1657.37,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1570.14,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,1635.56,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,2180.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1570.14,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,1308.45,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,1962.68,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,981.34,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,1962.68,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,2180.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2180.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2180.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1417.49,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,961.71,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,2071.71,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,2180.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1919.06,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,1962.68,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,961.71,2180.75,
Z00576401751 GSF,2750000470,CDM,276,RC,,,Outpatient,,,22592.43,14685.08,,22592.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17170.25,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16266.55,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,16944.32,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,22592.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16266.55,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,13555.46,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,20333.19,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,10166.59,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,20333.19,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,22592.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22592.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22592.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14685.08,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,9963.26,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,21462.81,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,22592.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19881.34,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,20333.19,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,9963.26,22592.43,
Z225236010 FEMREON,2750000471,CDM,276,RC,,,Outpatient,,,4839.98,3145.99,,4839.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3678.38,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3484.79,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,3629.99,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,4839.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3484.79,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,2903.99,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,4355.98,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,2177.99,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,4355.98,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,4839.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4839.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4839.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3145.99,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,2134.43,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,4597.98,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,4839.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4259.18,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,4355.98,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,2134.43,4839.98,
Z225730001 ITST NA,2750000472,CDM,276,RC,,,Outpatient,,,7940.21,5161.14,,7940.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6034.56,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5716.95,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,5955.16,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,7940.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5716.95,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,4764.13,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,7146.19,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,3573.09,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,7146.19,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,7940.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7940.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7940.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5161.14,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,3501.63,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,7543.2,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,7940.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6987.38,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,7146.19,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,3501.63,7940.21,
Z22261305 NCB TIBI,2750000473,CDM,276,RC,,,Outpatient,,,7555.43,4911.03,,7555.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5742.13,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5439.91,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,5666.57,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,7555.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5439.91,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,4533.26,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,6799.89,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,3399.94,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,6799.89,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,7555.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7555.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7555.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4911.03,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,3331.94,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,7177.66,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,7555.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6648.78,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,6799.89,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,3331.94,7555.43,
Z2315536 4.0 ST SC,2750000474,CDM,276,RC,,,Outpatient,,,563.38,366.20,,563.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,428.17,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,405.63,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,422.54,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.63,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,338.03,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,507.04,90,,269.896,Percent of Total Billed Charges,90% of Total Billed Charges,253.52,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,507.04,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.2,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,248.45,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,535.21,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,507.04,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,248.45,563.38,
Z2315528 4.0 ST SC,2750000475,CDM,276,RC,,,Outpatient,,,563.38,366.20,,563.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,428.17,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,405.63,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,422.54,75,,2397.936,Percent of Total Billed charges,75% of Total Billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.63,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,338.03,60,,1918.352,Percent of Total Billed Charges,60% of Total Billed Charges,507.04,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,253.52,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,507.04,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.2,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,248.45,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,535.21,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,507.04,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,248.45,563.38,
Z2315530 4.0 ST SC,2750000476,CDM,276,RC,,,Outpatient,,,563.38,366.20,,563.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,428.17,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,405.63,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,422.54,75,,2397.936,Percent of Total Billed charges,75% of Total Billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.63,72,,2302.016,Percent of Total Billed Charges,72% of Total Billed Charges,338.03,60,,1918.352,Percent of Total Billed Charges,60% of Total Billed Charges,507.04,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,253.52,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,507.04,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.2,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,248.45,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,535.21,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,507.04,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,248.45,563.38,
Z2315538 4.0 SCW 3,2750000477,CDM,276,RC,,,Outpatient,,,563.38,366.20,,563.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,428.17,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,405.63,72,,1273.256,Percent of Total Billed Charges,72% of Total Billed Charges,422.54,75,,1326.304,Percent of Total Billed charges,75% of Total Billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.63,72,,1273.256,Percent of Total Billed Charges,72% of Total Billed Charges,338.03,60,,1061.048,Percent of Total Billed Charges,60% of Total Billed Charges,507.04,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,253.52,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,507.04,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.2,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,248.45,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,535.21,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495.77,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,507.04,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,248.45,563.38,
Z2351270 5.0 CANC,2750000478,CDM,276,RC,,,Outpatient,,,771.75,501.64,,771.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,586.53,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,555.66,72,,2213.752,Percent of Total Billed Charges,72% of Total Billed Charges,578.81,75,,2305.992,Percent of Total Billed charges,75% of Total Billed Charges,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.66,72,,2213.752,Percent of Total Billed Charges,72% of Total Billed Charges,463.05,60,,1844.792,Percent of Total Billed Charges,60% of Total Billed Charges,694.58,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,347.29,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,694.58,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.64,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,340.34,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,733.16,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,679.14,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,694.58,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,340.34,771.75,
Z2351260 5.0 CANC,2750000479,CDM,276,RC,,,Outpatient,,,771.75,501.64,,771.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,586.53,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,555.66,72,,2213.752,Percent of Total Billed Charges,72% of Total Billed Charges,578.81,75,,2305.992,Percent of Total Billed charges,75% of Total Billed Charges,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.66,72,,2213.752,Percent of Total Billed Charges,72% of Total Billed Charges,463.05,60,,1844.792,Percent of Total Billed Charges,60% of Total Billed Charges,694.58,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,347.29,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,694.58,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.64,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,340.34,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,733.16,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,679.14,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,694.58,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,340.34,771.75,
Z2351265 5.0 CANC,2750000480,CDM,276,RC,,,Outpatient,,,771.75,501.64,,771.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,586.53,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,555.66,72,,317.52,Percent of Total Billed Charges,72% of Total Billed Charges,578.81,75,,330.752,Percent of Total Billed charges,75% of Total Billed Charges,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.66,72,,317.52,Percent of Total Billed Charges,72% of Total Billed Charges,463.05,60,,264.6,Percent of Total Billed Charges,60% of Total Billed Charges,694.58,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,347.29,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,694.58,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.64,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,340.34,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,733.16,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,679.14,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,694.58,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,340.34,771.75,
Z23150300 END LOCK,2750000481,CDM,276,RC,,,Outpatient,,,827.98,538.19,,827.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,629.26,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,596.15,72,,283.864,Percent of Total Billed Charges,72% of Total Billed Charges,620.99,75,,295.696,Percent of Total Billed charges,75% of Total Billed Charges,827.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,596.15,72,,283.864,Percent of Total Billed Charges,72% of Total Billed Charges,496.79,60,,236.552,Percent of Total Billed Charges,60% of Total Billed Charges,745.18,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,372.59,45,,134.944,Percent of Total Billed Charges,45% of Total Billed Charges,745.18,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,827.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,827.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,827.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.19,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,365.14,44.1,,132.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,786.58,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,827.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,728.62,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,745.18,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,365.14,827.98,
ALCON SN6AT3 21.5 TO,2750000482,CDM,276,RC,,,Outpatient,,,2210.51,1436.83,,2210.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1679.99,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1591.57,72,,283.864,Percent of Total Billed Charges,72% of Total Billed Charges,1657.88,75,,295.696,Percent of Total Billed charges,75% of Total Billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1591.57,72,,283.864,Percent of Total Billed Charges,72% of Total Billed Charges,1326.31,60,,236.552,Percent of Total Billed Charges,60% of Total Billed Charges,1989.46,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,994.73,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,1989.46,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1436.83,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,974.83,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,2099.98,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1945.25,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,1989.46,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,974.83,2210.51,
FLARED REVERSE,2750000483,CDM,276,RC,,,Outpatient,,,171.99,111.79,,171.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.71,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.83,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,128.99,75,,1220.464,Percent of Total Billed charges,75% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.83,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,103.19,60,,976.376,Percent of Total Billed Charges,60% of Total Billed Charges,154.79,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,77.4,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,154.79,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.79,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,75.85,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.39,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.35,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,154.79,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,75.85,171.99,
ALCON SLEEVE,2750000484,CDM,276,RC,,,Outpatient,,,115.76,75.24,,115.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.98,76,,227.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,83.35,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,86.82,75,,1220.464,Percent of Total Billed charges,75% of Total Billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.35,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,69.46,60,,976.376,Percent of Total Billed Charges,60% of Total Billed Charges,104.18,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,52.09,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,104.18,90,,269.896,Percent of Total Billed Charges,90% of Total billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.24,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,51.05,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,109.97,95,,284.888,Percent of Total Billed Charges,95% of Total Billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.87,88,,263.896,Percent of Total Billed Charges,88% of Total Billed Charges,104.18,90,,269.896,Percent of Total Billed charges,90% of Total Billed Charges,51.05,115.76,
AMO ZCBOO 22.0,2750000485,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,1220.464,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,976.376,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
ICD-DR DDMB1D1 EVERA MRI XT US,2750000486,CDM,275,RC,C1721,HCPCS,Outpatient,,,58350.00,37927.50,,58350,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,44346,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42012,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,42012,72,,1220.464,Percent of Total Billed charges,72% of Total Billed Charges,58350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42012,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,35010,60,,976.376,Percent of Total Billed Charges,60% of Total Billed Charges,52515,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,26257.5,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,52515,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,58350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37927.5,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,25732.35,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,55432.5,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,58350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51348,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,52515,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,25732.35,58350,
Accolade MRI SR IS-1,2750000487,CDM,275,RC,C1786,HCPCS,Outpatient,,,12855.00,8355.75,,12855,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9769.8,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9255.6,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,9255.6,72,,1220.464,Percent of Total Billed charges,72% of Total Billed Charges,12855,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9255.6,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,7713,60,,976.376,Percent of Total Billed Charges,60% of Total Billed Charges,11569.5,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,5784.75,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,11569.5,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,12855,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12855,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12855,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8355.75,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,5669.06,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,12212.25,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,12855,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11312.4,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,11569.5,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,5669.06,12855,
ALCON SN60WF 10.0,2760000001,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,2118.496,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,2206.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,2118.496,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,1765.408,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 10.5,2760000002,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,1220.464,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,976.376,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 11.0,2760000003,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,1220.464,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,1171.648,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,976.376,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 11.5,2760000004,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 12.0,2760000005,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 12.5,2760000006,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,1183.712,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,1233.04,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,1183.712,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,986.432,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 13.0,2760000007,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,2017.52,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,2101.584,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,2017.52,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,1681.264,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 13.5,2760000008,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 14.0,2760000009,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,2017.52,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,2101.584,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,2017.52,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,1681.264,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 14.5,2760000010,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,2017.52,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,2101.584,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,2017.52,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,1681.264,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 15.0,2760000011,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,2017.52,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,2101.584,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,2017.52,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,1681.264,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 15.5,2760000012,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,1921.448,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,2001.512,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,1921.448,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,1601.208,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 16.0,2760000013,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 16.5,2760000014,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 17.0,2760000015,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 17.5,2760000016,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,2049.552,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 18.0,2760000017,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,2078.208,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 18.5,2760000018,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,2078.208,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 19.0,2760000019,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,2078.208,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 19.5,2760000020,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,1149.464,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 20.0,2760000021,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,1149.464,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 20.5,2760000022,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,2078.208,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 21.0,2760000023,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,2078.208,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 21.5,2760000024,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,2078.208,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 22.0,2760000025,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,2078.208,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 22.5,2760000026,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,2078.208,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 23.0,2760000027,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,1149.464,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 23.5,2760000028,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 24.0,2760000029,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,2837.84,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 24.5,2760000030,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 25.0,2760000031,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 25.5,2760000032,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 26.0,2760000033,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,1591.568,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 26.5,2760000034,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.336,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,332.64,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.336,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.112,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,1591.568,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 27.0,2760000035,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 27.5,2760000036,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,1418.92,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,1390.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 28.0,2760000037,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,1127.344,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,1174.32,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,1127.344,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,939.456,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,1438.76,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,1409.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 28.5,2760000038,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,1438.76,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,1409.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 29.0,2760000039,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,2396.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,1438.76,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,2837.84,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,1409.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,2995.496,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,2774.776,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,2837.84,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 29.5,2760000040,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,2429.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,1591.568,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,795.784,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,779.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,3037.384,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,2813.576,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON SN60WF 30.0,2760000041,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,2429.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,1062.632,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,1106.912,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,1062.632,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,885.528,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,795.784,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,779.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,3037.384,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,2813.576,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 10.0,2760000042,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,2429.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,1438.76,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,1409.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,3037.384,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,2813.576,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 10.5,2760000043,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,1343.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,1438.76,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,1591.568,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,1409.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,1679.984,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,1556.2,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,1591.568,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 11.0,2760000044,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,1343.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,1438.76,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,1591.568,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,1409.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,1679.984,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,1556.2,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,1591.568,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 11.5,2760000045,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,2429.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,1438.76,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,1409.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,3037.384,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,2813.576,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 12.0,2760000046,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,2429.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,1438.76,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,1409.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,3037.384,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,2813.576,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 12.5,2760000047,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,2429.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,795.784,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,779.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,3037.384,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,2813.576,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 13.0,2760000048,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,2429.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,317.4,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,253.92,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,3037.384,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,2813.576,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 13.5,2760000049,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,2429.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,333.272,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,319.936,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,266.616,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,3037.384,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,2813.576,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,2877.52,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 14.0,2760000050,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,1343.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,1829.952,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,1906.2,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,1829.952,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,1524.96,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,1591.568,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,1679.984,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,1556.2,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,1591.568,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 14.5,2760000051,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,1829.952,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,1906.2,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,1829.952,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,1524.96,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 15.0,2760000052,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,317.4,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,253.92,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 15.5,2760000053,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,173.952,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,181.2,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,173.952,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,144.96,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 16.0,2760000054,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,317.4,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,253.92,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 16.5,2760000055,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 17.0,2760000056,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 17.5,2760000057,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 18.0,2760000058,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 18.5,2760000059,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 19.0,2760000060,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 19.5,2760000061,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 20.0,2760000062,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 20.5,2760000063,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 21.0,2760000064,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 21.5,2760000065,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 22.0,2760000066,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 22.5,2760000067,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 23.0,2760000068,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 23.5,2760000069,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 24.0,2760000070,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 24.5,2760000071,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 25.0,2760000072,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 25.5,2760000073,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 26.0,2760000074,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 26.5,2760000075,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 27.0,2760000076,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 27.5,2760000077,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 28.0,2760000078,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 28.5,2760000079,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,328.768,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,315.616,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,263.008,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 29.0,2760000080,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,327.048,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,340.672,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,327.048,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,272.536,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 29.5,2760000081,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,327.048,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,340.672,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,327.048,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,272.536,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MN60AC 30.0,2760000082,CDM,276,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,2078.208,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.27,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
ALCON MTA3UO 10.0,2760000083,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,2078.208,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO,2760000084,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1149.464,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 11.0,2760000085,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1998.528,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 11.5,2760000086,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1998.528,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 12.0,2760000087,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,286.648,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 12.5,2760000088,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,256.264,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 13.0,2760000089,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,256.264,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 13.5,2760000090,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1057.736,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 14.0,2760000091,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1057.736,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 14.5,2760000092,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1057.736,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 15.0,2760000093,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1057.736,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 15.5,2760000094,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1057.736,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 16.0,2760000095,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2877.52,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1912.528,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 16.5,2760000096,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2877.52,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1057.736,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 17.0,2760000097,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1591.568,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1057.736,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 17.5,2760000098,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2767.192,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 18.0,2760000099,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2767.192,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 18.5,2760000100,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,396.904,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1068.632,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 19.0,2760000101,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,354.832,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1821.376,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 19.5,2760000102,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,341.336,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,354.832,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,1438.76,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,1409.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 20.0,2760000103,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,341.336,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,1438.76,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1821.376,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,1409.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 20.5,2760000104,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,341.336,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,795.784,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1821.376,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,779.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 21.0,2760000105,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,2429.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,341.336,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,1383.592,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,2877.52,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1821.376,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,1355.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,3037.384,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,2813.576,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,2877.52,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 21.5,2760000106,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,2429.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,341.336,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,1383.592,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,2877.52,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1734.64,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,1355.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,3037.384,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,2813.576,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,2877.52,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 22.0,2760000107,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1343.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,341.336,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,198.448,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1591.568,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,194.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1679.984,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1556.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1591.568,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 22.5,2760000108,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,2336.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,341.336,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2648.12,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,177.416,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,2767.192,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,173.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,2920.92,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,2705.696,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,2767.192,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 23.0,2760000109,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,2336.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,341.336,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,177.416,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,2767.192,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,173.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,2920.92,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,2705.696,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,2767.192,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 23.5,2760000110,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,335.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,732.28,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,396.904,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,717.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,418.952,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,388.08,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,396.904,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 24.0,2760000111,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,299.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,732.28,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,354.832,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,717.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,374.544,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,346.944,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,354.832,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 24.5,2760000112,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,299.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,732.28,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,354.832,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,717.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,374.544,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,346.944,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,354.832,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 25.0,2760000113,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1236.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1479.64,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,732.28,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,717.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1545.92,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1432.016,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 25.5,2760000114,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1236.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,732.28,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,717.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1545.92,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1432.016,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 26.0,2760000115,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1236.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,1324.056,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,1297.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1545.92,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1432.016,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 26.5,2760000116,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1236.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,732.28,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,717.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1545.92,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1432.016,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 27.0,2760000117,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1236.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,732.28,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,717.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1545.92,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1432.016,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 27.5,2760000118,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,2236.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,2648.12,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,2795.232,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,2589.272,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,2648.12,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 28.0,2760000119,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1236.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2401.816,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1545.92,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1432.016,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 29.0,2760000120,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1236.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,739.824,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,725.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1545.92,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1432.016,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1464.56,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA3UO 30.0,2760000121,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,1260.952,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,1235.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 10.0,2760000122,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 10.5,2760000123,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1249.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,1260.952,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1479.64,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,1235.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1561.848,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1446.76,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1479.64,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 11.0,2760000124,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,2129.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,1260.952,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,1235.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,2662.008,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,2465.856,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 11.5,2760000125,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,2017.52,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,2101.584,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,2017.52,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,1681.264,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,1260.952,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,1235.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 12.0,2760000126,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,2129.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,1200.904,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,1176.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,2662.008,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,2465.856,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 12.5,2760000127,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,2129.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,327.048,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,340.672,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,327.048,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,272.536,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,2662.008,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,2465.856,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 13.0,2760000128,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,2129.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,293.704,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,281.96,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,234.968,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.288,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,2662.008,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,2465.856,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,2521.904,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 13.5,2760000129,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,2028.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,311.472,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,324.448,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,311.472,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,259.56,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,2401.816,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,2535.248,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,2348.44,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,2401.816,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 14.0,2760000130,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,311.472,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,324.448,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,311.472,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,259.56,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 14.5,2760000131,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1017.744,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 15.0,2760000132,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 15.5,2760000133,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 16.0,2760000134,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 16.5,2760000135,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,959.32,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 17.0,2760000136,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 17.5,2760000137,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 18.0,2760000138,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 18.5,2760000139,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 19.0,2760000140,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 19.5,2760000141,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.168,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 20.0,2760000142,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,275.08,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 20.5,2760000143,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,288.832,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 21.0,2760000144,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1409.184,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1652.04,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 21.5,2760000145,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,1652.04,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 22.0,2760000146,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,275.08,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 22.5,2760000147,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,157.04,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 23.0,2760000148,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,1328.296,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.584,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,275.08,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 23.5,2760000149,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 24.0,2760000150,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 24.5,2760000151,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,704.592,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.168,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,690.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,421.344,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,390.296,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.168,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 25.0,2760000152,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 25.5,2760000153,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 26.0,2760000154,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1189.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1409.184,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1487.472,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1377.872,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1409.184,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MAT4UO 26.5,2760000155,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,380.88,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,664.144,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,650.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 27.0,2760000156,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 27.5,2760000157,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2287.44,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 28.0,2760000158,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,1121.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,2287.44,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,1328.296,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,1402.088,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,1298.776,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,1328.296,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 29.0,2760000159,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,380.88,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MTA4UO 30.0,2760000160,CDM,276,RC,,,Outpatient,,,374.85,243.65,,374.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.89,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.37,90,,217.44,Percent of Total Billed Charges,90% of Total Billed Charges,168.68,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,165.31,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.11,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,374.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.87,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,337.37,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,165.31,374.85,
ALCON MA60AC 10.0,2760000161,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,380.88,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 10.5,2760000162,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,190.44,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,186.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 11.0,2760000163,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,199.96,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,195.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 11.5,2760000164,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1143.72,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1120.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 12.0,2760000165,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,321.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1143.72,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,380.88,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1120.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,402.04,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,372.416,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,380.88,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 12.5,2760000166,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,337.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,190.44,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,399.928,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,186.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,422.144,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,391.04,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,399.928,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 13.0,2760000167,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,1931.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,108.72,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,2287.44,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,106.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2414.52,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,2236.608,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,2287.44,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 13.5,2760000168,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,1931.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,190.44,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,2287.44,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,186.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2414.52,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,2236.608,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,2287.44,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 14.0,2760000169,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,321.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,380.88,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,402.04,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,372.416,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,380.88,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 14.5,2760000170,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,183.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,367.136,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,217.44,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,229.52,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,212.608,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,217.44,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 15.0,2760000171,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,321.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,331.496,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,345.304,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,331.496,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,276.248,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,380.88,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,402.04,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,372.416,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,380.88,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 15.5,2760000172,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,2213.752,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,2305.992,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,2213.752,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,1844.792,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 16.0,2760000173,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,2213.752,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,2305.992,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,2213.752,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,1844.792,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,284.928,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 16.5,2760000174,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,331.496,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,345.304,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,331.496,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,276.248,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,295.248,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 17.0,2760000175,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,317.4,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,253.92,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,295.248,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 17.5,2760000176,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,1256.112,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,1308.448,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,1256.112,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,1046.76,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 18.0,2760000177,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,13013.24,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,13555.456,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,13013.24,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,10844.368,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 18.5,2760000178,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,2787.832,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,2903.992,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,2787.832,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,2323.192,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 19.0,2760000179,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,4573.56,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,4764.128,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,4573.56,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,3811.304,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 19.5,2760000180,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,4351.928,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,4533.256,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,4351.928,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,3626.608,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 20.0,2760000181,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,324.504,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,338.032,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,324.504,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,270.424,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 20.5,2760000182,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,324.504,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,338.032,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,324.504,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,270.424,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 21.0,2760000183,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,324.504,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,338.032,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,324.504,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,270.424,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 21.5,2760000184,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,324.504,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,338.032,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,324.504,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,270.424,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 22.0,2760000185,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,444.528,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,463.048,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,444.528,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,370.44,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 22.5,2760000186,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,444.528,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,463.048,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,444.528,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,370.44,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 23.0,2760000187,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,444.528,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,463.048,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,444.528,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,370.44,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,408.808,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 23.5,2760000188,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,476.92,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,496.792,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,476.92,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,397.432,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,408.808,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 24.0,2760000189,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,1273.256,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,1326.304,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,1273.256,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,1061.048,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 24.5,2760000190,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,103.192,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,82.552,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 25.0,2760000191,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,69.456,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,55.568,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 25.5,2760000192,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,375.072,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,360.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,300.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 26.0,2760000193,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,197.256,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,193.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 26.5,2760000194,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,204.408,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,200.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 27.0,2760000195,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,204.408,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,200.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 27.5,2760000196,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,333.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,416.432,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,385.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,394.52,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 28.0,2760000197,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,345.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,408.808,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,431.52,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,399.728,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,408.808,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 28.5,2760000198,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,345.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,408.808,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,431.52,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,399.728,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,408.808,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 29.0,2760000199,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 29.5,2760000200,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON MA60AC 30.0,2760000201,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SN6AD1 17.5,2760000202,CDM,276,RC,,,Outpatient,,,3941.44,2561.94,,3941.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2995.49,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2837.84,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,2956.08,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,3941.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2837.84,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,2364.86,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,3547.3,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,1773.65,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,3547.3,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,3941.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3941.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3941.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2561.94,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,1738.18,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,3744.37,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,3941.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3468.47,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,3547.3,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,1738.18,3941.44,
ALCON SN6ADI 32.0 RE,2760000203,CDM,276,RC,,,Outpatient,,,3996.56,2597.76,,3996.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3037.39,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2877.52,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,2997.42,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.52,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,2397.94,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,1798.45,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2597.76,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,1762.48,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,3796.73,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3516.97,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,1762.48,3996.56,
ALCON SN6AD1 20.5 RE,2760000204,CDM,276,RC,,,Outpatient,,,3996.56,2597.76,,3996.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3037.39,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2877.52,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,2997.42,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.52,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,2397.94,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,1798.45,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2597.76,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,1762.48,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,3796.73,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3516.97,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,1762.48,3996.56,
ALCON SN6AD1 32.0,2760000205,CDM,276,RC,,,Outpatient,,,3996.56,2597.76,,3996.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3037.39,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2877.52,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,2997.42,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.52,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,2397.94,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,1798.45,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2597.76,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,1762.48,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,3796.73,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3516.97,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,1762.48,3996.56,
ALCON SN6AT5 17.5 TO,2760000206,CDM,276,RC,,,Outpatient,,,2210.51,1436.83,,2210.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1679.99,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1591.57,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,1657.88,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1591.57,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,1326.31,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,1989.46,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,994.73,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,1989.46,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1436.83,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,974.83,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,2099.98,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1945.25,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,1989.46,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,974.83,2210.51,
ALCON SN6AT5 18.0 TO,2760000207,CDM,276,RC,,,Outpatient,,,2210.51,1436.83,,2210.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1679.99,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1591.57,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,1657.88,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1591.57,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,1326.31,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,1989.46,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,994.73,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,1989.46,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1436.83,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,974.83,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,2099.98,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1945.25,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,1989.46,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,974.83,2210.51,
ALCON SN6AD1 31.0 RE,2760000208,CDM,276,RC,,,Outpatient,,,3996.56,2597.76,,3996.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3037.39,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2877.52,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,2997.42,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.52,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,2397.94,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,1798.45,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2597.76,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,1762.48,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,3796.73,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3516.97,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,1762.48,3996.56,
ALCON SN6AD1 21.5 RE,2760000209,CDM,276,RC,,,Outpatient,,,3996.56,2597.76,,3996.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3037.39,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2877.52,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,2997.42,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.52,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,2397.94,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,3596.9,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,1798.45,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2597.76,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,1762.48,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,3796.73,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3516.97,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,1762.48,3996.56,
ALCON SN6AD1 15.0 RE,2760000210,CDM,276,RC,,,Outpatient,,,3996.56,2597.76,,3996.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3037.39,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2877.52,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,2997.42,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.52,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,2397.94,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,3596.9,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,1798.45,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2597.76,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,1762.48,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,3796.73,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3516.97,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,1762.48,3996.56,
ALCON SN6AD1 12.0 RE,2760000211,CDM,276,RC,,,Outpatient,,,3996.56,2597.76,,3996.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3037.39,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2877.52,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,2997.42,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.52,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,2397.94,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,3596.9,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,1798.45,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2597.76,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,1762.48,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,3796.73,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3516.97,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,1762.48,3996.56,
ALCON SN6AD1 21.0 RE,2760000212,CDM,276,RC,,,Outpatient,,,3996.56,2597.76,,3996.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3037.39,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2877.52,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,2997.42,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.52,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,2397.94,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,3596.9,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,1798.45,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2597.76,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,1762.48,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,3796.73,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3516.97,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,3596.9,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,1762.48,3996.56,
ALCON SN6AT3 20.5 TO,2760000213,CDM,276,RC,,,Outpatient,,,2210.51,1436.83,,2210.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1679.99,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1591.57,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,1657.88,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1591.57,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,1326.31,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,1989.46,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,994.73,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,1989.46,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1436.83,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,974.83,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,2099.98,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1945.25,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,1989.46,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,974.83,2210.51,
AMO ZCBOO 12.0,2760000214,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 12.5,2760000215,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 13.0,2760000216,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 13.5,2760000217,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 14.0,2760000218,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 14.5,2760000219,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,1821.376,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 15.0,2760000220,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 15.5,2760000221,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,295.248,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 16.0,2760000222,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,254.544,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 16.5,2760000223,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,281.192,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 17.0,2760000224,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,281.192,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 17.5,2760000225,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 18.0,2760000226,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 18.5,2760000227,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 19.0,2760000228,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 19.5,2760000229,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 20.0,2760000230,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 20.5,2760000231,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 21.0,2760000232,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,2521.904,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 21.5,2760000233,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 21.5,2760000234,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,321.496,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,308.632,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,257.192,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,408.808,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 22.5,2760000235,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,298.2,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 23.0,2760000236,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,14.4,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,15,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,14.4,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,389.344,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 23.5,2760000237,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,28.224,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,29.4,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,28.224,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,23.52,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,389.344,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 24.0,2760000238,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,2.176,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,2.272,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,2.176,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,1.816,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 24.5,2760000239,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,2.712,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,2.824,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,2.712,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,2.264,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,1260.952,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,1235.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 25.0,2760000240,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,3.568,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,3.72,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,3.568,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,2.976,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 25.5,2760000241,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,0.752,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,0.784,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,0.752,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,0.632,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,204.408,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,200.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZCBOO 26.0,2760000242,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,2129.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,8.648,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,9.008,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,8.648,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,7.208,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,176.224,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,2521.904,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,172.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,2662.008,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,2465.856,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,2521.904,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
AMO ZA9003.14.0,2760000243,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,10.304,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,10.736,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,10.304,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,8.584,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,194.672,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,190.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 14.5,2760000244,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,345.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,194.672,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,408.808,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,190.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,431.52,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,399.728,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,408.808,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 15.0,2760000245,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,297.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,0.424,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,0.448,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,0.424,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,0.352,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,352.448,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,372.024,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,344.616,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,352.448,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 15.5,2760000246,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,328.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,9.144,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,9.52,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,9.144,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,7.616,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,389.344,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,410.968,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,380.688,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,389.344,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 16.0,2760000247,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,328.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,9,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,389.344,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,410.968,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,380.688,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,389.344,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 16.5,2760000248,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,9,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 17.0,2760000249,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 17.5,2760000250,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,19.848,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,15.88,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 18.0,2760000251,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,7.28,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 18.5,2760000252,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,2.176,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,2.272,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,2.176,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,1.816,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 19.0,2760000253,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,8.608,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,6.88,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 19.5,2760000254,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,205.632,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,205.632,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,205.632,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,171.36,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 20.0,2760000255,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,161.416,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,161.416,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,161.416,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,134.512,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 20.5,2760000256,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,161.416,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,161.416,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,161.416,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,134.512,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 21.0,2760000257,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,260.32,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,260.32,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,260.32,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,216.936,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 21.5,2760000258,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,192.072,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,192.072,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,192.072,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,160.064,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 22.0,2760000259,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,263.232,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,263.232,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,263.232,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,219.36,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 22.5,2760000260,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,104.144,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,108.488,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,104.144,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,86.792,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 23.0,2760000261,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 23.5,2760000262,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 24.0,2760000263,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,387.376,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,387.376,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,387.376,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,322.816,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 24.5,2760000264,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 25.0,2760000265,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,299.264,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 25.5,2760000266,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,1998.528,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
AMO ZA9003 26.0,2760000267,CDM,276,RC,,,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,1998.528,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
ALCON SN6AD1 170D,2760000268,CDM,276,RC,,,Outpatient,,,3996.56,2597.76,,3996.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3037.39,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2877.52,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,2997.42,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.52,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,2397.94,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,3596.9,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,1798.45,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,3596.9,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2597.76,65,,299.264,Percent of total Billed Charges,65% of Total Billed Charges,1762.48,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,3796.73,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3516.97,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,3596.9,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,1762.48,3996.56,
ALCON SN6ADI 20.0 12,2760000269,CDM,276,RC,,,Outpatient,,,3996.56,2597.76,,3996.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3037.39,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2877.52,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,2997.42,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.52,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,2397.94,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,3596.9,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,1798.45,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,3596.9,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2597.76,65,,275.08,Percent of total Billed Charges,65% of Total Billed Charges,1762.48,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,3796.73,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,3996.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3516.97,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,3596.9,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,1762.48,3996.56,
ALCON SN6AT3 16.0 TO,2760000270,CDM,276,RC,,,Outpatient,,,2210.51,1436.83,,2210.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1679.99,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1591.57,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,1657.88,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1591.57,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,1326.31,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,1989.46,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,994.73,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,1989.46,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1436.83,65,,1133.992,Percent of total Billed Charges,65% of Total Billed Charges,974.83,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,2099.98,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1945.25,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,1989.46,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,974.83,2210.51,
ALCON SN6AD1 18.0 RE,2760000271,CDM,276,RC,,,Outpatient,,,3843.32,2498.16,,3843.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2920.92,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2767.19,72,,387.376,Percent of Total Billed Charges,72% of Total Billed Charges,2882.49,75,,387.376,Percent of Total Billed charges,75% of Total Billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2767.19,72,,387.376,Percent of Total Billed Charges,72% of Total Billed Charges,2305.99,60,,322.816,Percent of Total Billed Charges,60% of Total Billed Charges,3458.99,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,1729.49,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,3458.99,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2498.16,65,,11748.064,Percent of total Billed Charges,65% of Total Billed Charges,1694.9,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,3651.15,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3382.12,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,3458.99,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,1694.9,3843.32,
ALCON SN6ADI 22.5,2760000272,CDM,276,RC,,,Outpatient,,,3843.32,2498.16,,3843.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2920.92,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2767.19,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,2882.49,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2767.19,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,2305.99,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,3458.99,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,1729.49,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,3458.99,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2498.16,65,,2516.792,Percent of total Billed Charges,65% of Total Billed Charges,1694.9,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,3651.15,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3382.12,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,3458.99,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,1694.9,3843.32,
ALCON SN60WF 7.0,2760000273,CDM,276,RC,,,Outpatient,,,551.25,358.31,,551.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,418.95,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,396.9,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,413.44,75,,2057.528,Percent of Total Billed charges,75% of Total Billed Charges,551.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.9,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,330.75,60,,1714.608,Percent of Total Billed Charges,60% of Total Billed Charges,496.13,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,248.06,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,496.13,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,551.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,551.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,551.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.31,65,,4128.912,Percent of total Billed Charges,65% of Total Billed Charges,243.1,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,523.69,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,551.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.1,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,496.13,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,243.1,551.25,
AMO ZA9003 27.0,2760000274,CDM,276,RC,,,Outpatient,,,492.82,320.33,,492.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,374.54,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,354.83,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,369.62,75,,2057.528,Percent of Total Billed charges,75% of Total Billed Charges,492.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.83,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,295.69,60,,1714.608,Percent of Total Billed Charges,60% of Total Billed Charges,443.54,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,221.77,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,443.54,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,492.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320.33,65,,3928.824,Percent of total Billed Charges,65% of Total Billed Charges,217.33,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,468.18,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,492.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,433.68,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,443.54,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,217.33,492.82,
AMO ZA9003 28.0,2760000275,CDM,276,RC,,,Outpatient,,,492.82,320.33,,492.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,374.54,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,354.83,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,369.62,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,492.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.83,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,295.69,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,443.54,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,221.77,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,443.54,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,492.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320.33,65,,292.96,Percent of total Billed Charges,65% of Total Billed Charges,217.33,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,468.18,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,492.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,433.68,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,443.54,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,217.33,492.82,
ALCON SN6AT4 25.0 TO,2760000276,CDM,276,RC,,,Outpatient,,,2034.11,1322.17,,2034.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1545.92,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1464.56,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,1525.58,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1464.56,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,1220.47,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,915.35,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1322.17,65,,292.96,Percent of total Billed Charges,65% of Total Billed Charges,897.04,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,1932.4,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1790.02,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,897.04,2034.11,
ALCON SN6AT4 19.5 TO,2760000277,CDM,276,RC,,,Outpatient,,,2034.11,1322.17,,2034.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1545.92,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1464.56,72,,387.376,Percent of Total Billed Charges,72% of Total Billed Charges,1525.58,75,,387.376,Percent of Total Billed charges,75% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1464.56,72,,387.376,Percent of Total Billed Charges,72% of Total Billed Charges,1220.47,60,,322.816,Percent of Total Billed Charges,60% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,915.35,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1322.17,65,,292.96,Percent of total Billed Charges,65% of Total Billed Charges,897.04,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,1932.4,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1790.02,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,897.04,2034.11,
ALCON SN6AT3 19.5 TO,2760000278,CDM,276,RC,,,Outpatient,,,2034.11,1322.17,,2034.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1545.92,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1464.56,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,1525.58,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1464.56,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,1220.47,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,1830.7,90,,414.368,Percent of Total Billed Charges,90% of Total Billed Charges,915.35,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1322.17,65,,292.96,Percent of total Billed Charges,65% of Total Billed Charges,897.04,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,1932.4,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1790.02,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,897.04,2034.11,
ALCON SN6AT6 22.0 TORIC,2760000279,CDM,276,RC,,,Outpatient,,,2034.11,1322.17,,2034.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1545.92,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1464.56,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,1525.58,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1464.56,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,1220.47,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,1830.7,90,,2767.192,Percent of Total Billed Charges,90% of Total Billed Charges,915.35,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1322.17,65,,401.312,Percent of total Billed Charges,65% of Total Billed Charges,897.04,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,1932.4,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1790.02,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,897.04,2034.11,
ALCON SN6AT3 19.0 TORIC,2760000280,CDM,276,RC,,,Outpatient,,,2034.11,1322.17,,2034.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1545.92,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1464.56,72,,387.376,Percent of Total Billed Charges,72% of Total Billed Charges,1525.58,75,,387.376,Percent of Total Billed charges,75% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1464.56,72,,387.376,Percent of Total Billed Charges,72% of Total Billed Charges,1220.47,60,,322.816,Percent of Total Billed Charges,60% of Total Billed Charges,1830.7,90,,2767.192,Percent of Total Billed Charges,90% of Total Billed Charges,915.35,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1322.17,65,,401.312,Percent of total Billed Charges,65% of Total Billed Charges,897.04,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,1932.4,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1790.02,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,897.04,2034.11,
ALCON SN6AD1 19.5 RESTOR,2760000281,CDM,276,RC,,,Outpatient,,,3677.94,2390.66,,3677.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2795.23,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2648.12,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,2758.46,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,3677.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2648.12,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,2206.76,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,3310.15,90,,414.368,Percent of Total Billed Charges,90% of Total Billed Charges,1655.07,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,3310.15,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,3677.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3677.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3677.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2390.66,65,,401.312,Percent of total Billed Charges,65% of Total Billed Charges,1621.97,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,3494.04,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,3677.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3236.59,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,3310.15,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,1621.97,3677.94,
ALCON SN6A7721.0,2760000282,CDM,276,RC,,,Outpatient,,,2034.11,1322.17,,2034.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1545.92,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1464.56,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,1525.58,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1464.56,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,1220.47,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,1830.7,90,,380.88,Percent of Total Billed Charges,90% of Total Billed Charges,915.35,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1322.17,65,,430.552,Percent of total Billed Charges,65% of Total Billed Charges,897.04,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,1932.4,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1790.02,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,897.04,2034.11,
ALCON SN6AT6 9TORIC,2760000283,CDM,276,RC,,,Outpatient,,,2034.11,1322.17,,2034.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1545.92,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1464.56,72,,387.376,Percent of Total Billed Charges,72% of Total Billed Charges,1525.58,75,,387.376,Percent of Total Billed charges,75% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1464.56,72,,387.376,Percent of Total Billed Charges,72% of Total Billed Charges,1220.47,60,,322.816,Percent of Total Billed Charges,60% of Total Billed Charges,1830.7,90,,1570.144,Percent of Total Billed Charges,90% of Total Billed Charges,915.35,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1322.17,65,,1149.464,Percent of total Billed Charges,65% of Total Billed Charges,897.04,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,1932.4,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,2034.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1790.02,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,1830.7,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,897.04,2034.11,
AMO ZCBOO 28.0,2760000284,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,16266.552,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,89.432,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
AMO ZCBOO 9.5,2760000285,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,3484.784,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,207.184,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,60.192,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,203.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
AMO ZCT 225 13.5 TORIC,2760000286,CDM,276,RC,,,Outpatient,,,2055.06,1335.79,,2055.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1561.85,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1479.64,72,,387.376,Percent of Total Billed Charges,72% of Total Billed Charges,1541.3,75,,387.376,Percent of Total Billed charges,75% of Total Billed Charges,2055.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1479.64,72,,387.376,Percent of Total Billed Charges,72% of Total Billed Charges,1233.04,60,,322.816,Percent of Total Billed Charges,60% of Total Billed Charges,1849.55,90,,5716.952,Percent of Total Billed Charges,90% of Total Billed Charges,924.78,45,,1383.592,Percent of Total Billed Charges,45% of Total Billed Charges,1849.55,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,2055.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2055.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2055.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1335.79,65,,325.064,Percent of total Billed Charges,65% of Total Billed Charges,906.28,44.1,,1355.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,1952.31,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,2055.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1808.45,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,1849.55,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,906.28,2055.06,
ALCON SN6AD1 19.0 RESTOR,2760000287,CDM,276,RC,,,Outpatient,,,3502.64,2276.72,,3502.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2662.01,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2521.9,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,2626.98,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.9,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,2101.58,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,3152.38,90,,5439.912,Percent of Total Billed Charges,90% of Total Billed Charges,1576.19,45,,1383.592,Percent of Total Billed Charges,45% of Total Billed Charges,3152.38,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2276.72,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,1544.66,44.1,,1355.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,3327.51,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3082.32,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,3152.38,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,1544.66,3502.64,
AMO ZCB OO 6.0,2760000288,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,349.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,405.632,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,207.184,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,414.368,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,203.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,437.384,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,405.16,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,414.368,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
AMO ZMBOO 22.5 MULTI  FOCAL,2760000289,CDM,276,RC,,,Outpatient,,,3502.64,2276.72,,3502.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2662.01,76,,2336.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2521.9,72,,387.376,Percent of Total Billed Charges,72% of Total Billed Charges,2626.98,75,,387.376,Percent of Total Billed charges,75% of Total Billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.9,72,,387.376,Percent of Total Billed Charges,72% of Total Billed Charges,2101.58,60,,322.816,Percent of Total Billed Charges,60% of Total Billed Charges,3152.38,90,,405.632,Percent of Total Billed Charges,90% of Total Billed Charges,1576.19,45,,190.44,Percent of Total Billed Charges,45% of Total Billed Charges,3152.38,90,,2767.192,Percent of Total Billed Charges,90% of Total billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2276.72,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,1544.66,44.1,,186.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,3327.51,95,,2920.92,Percent of Total Billed Charges,95% of Total Billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3082.32,88,,2705.696,Percent of Total Billed Charges,88% of Total Billed Charges,3152.38,90,,2767.192,Percent of Total Billed charges,90% of Total Billed Charges,1544.66,3502.64,
AMO ZL BOO,2760000290,CDM,276,RC,,,Outpatient,,,3502.64,2276.72,,3502.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2662.01,76,,2336.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2521.9,72,,73.016,Percent of Total Billed Charges,72% of Total Billed Charges,2626.98,75,,76.064,Percent of Total Billed charges,75% of Total Billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.9,72,,73.016,Percent of Total Billed Charges,72% of Total Billed Charges,2101.58,60,,60.848,Percent of Total Billed Charges,60% of Total Billed Charges,3152.38,90,,405.632,Percent of Total Billed Charges,90% of Total Billed Charges,1576.19,45,,785.072,Percent of Total Billed Charges,45% of Total Billed Charges,3152.38,90,,2767.192,Percent of Total Billed Charges,90% of Total billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2276.72,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,1544.66,44.1,,769.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,3327.51,95,,2920.92,Percent of Total Billed Charges,95% of Total Billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3082.32,88,,2705.696,Percent of Total Billed Charges,88% of Total Billed Charges,3152.38,90,,2767.192,Percent of Total Billed charges,90% of Total Billed Charges,1544.66,3502.64,
AMO ZLB00 24.5 MULTIFOCAL,2760000291,CDM,276,RC,,,Outpatient,,,3502.64,2276.72,,3502.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2662.01,76,,349.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2521.9,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,2626.98,75,,273.072,Percent of Total Billed charges,75% of Total Billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.9,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,2101.58,60,,227.56,Percent of Total Billed Charges,60% of Total Billed Charges,3152.38,90,,405.632,Percent of Total Billed Charges,90% of Total Billed Charges,1576.19,45,,8133.272,Percent of Total Billed Charges,45% of Total Billed Charges,3152.38,90,,414.368,Percent of Total Billed Charges,90% of Total billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2276.72,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,1544.66,44.1,,7970.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,3327.51,95,,437.384,Percent of Total Billed Charges,95% of Total Billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3082.32,88,,405.16,Percent of Total Billed Charges,88% of Total Billed Charges,3152.38,90,,414.368,Percent of Total Billed charges,90% of Total Billed Charges,1544.66,3502.64,
AMO ZLBOO 19.0 MULTIFOCAL,2760000292,CDM,276,RC,,,Outpatient,,,3335.85,2168.30,,3335.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2535.25,76,,321.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2401.81,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,2501.89,75,,1640.52,Percent of Total Billed charges,75% of Total Billed Charges,3335.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2401.81,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,2001.51,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,3002.27,90,,555.664,Percent of Total Billed Charges,90% of Total Billed Charges,1501.13,45,,1742.392,Percent of Total Billed Charges,45% of Total Billed Charges,3002.27,90,,380.88,Percent of Total Billed Charges,90% of Total billed Charges,3335.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3335.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3335.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2168.3,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,1471.11,44.1,,1707.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,3169.06,95,,402.04,Percent of Total Billed Charges,95% of Total Billed Charges,3335.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2935.55,88,,372.416,Percent of Total Billed Charges,88% of Total Billed Charges,3002.27,90,,380.88,Percent of Total Billed charges,90% of Total Billed Charges,1471.11,3335.85,
AMO PCBOO 15.0,2760000293,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,1325.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,555.664,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,2858.472,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,1570.144,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,2801.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,1657.368,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,1535.248,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,1570.144,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 15.5,2760000294,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,13736.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,1640.52,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,555.664,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,2719.952,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,16266.552,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,2665.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,17170.248,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,15905.072,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,16266.552,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 16.0,2760000295,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,2942.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,596.144,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,202.816,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,3484.784,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,198.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,3678.384,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,3407.344,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,3484.784,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 16.5,2760000296,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,4827.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,2143.264,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,1714.608,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,1591.568,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,202.816,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,5716.952,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,198.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,6034.56,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,5589.904,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,5716.952,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 17.0,2760000297,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,4593.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,2057.528,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,1714.608,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,123.832,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,202.816,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,5439.912,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,198.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,5742.128,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,5319.024,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,5439.912,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 17.5,2760000298,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,342.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,2143.264,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,1714.608,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,83.344,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,202.816,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,405.632,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,198.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,428.168,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,396.616,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,405.632,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 18.0,2760000299,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,342.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,2057.528,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,1714.608,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,450.088,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,277.832,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,405.632,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,272.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,428.168,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,396.616,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,405.632,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 18.5,2760000300,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,342.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,273.072,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,227.56,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,277.832,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,405.632,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,272.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,428.168,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,396.616,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,405.632,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 19.0,2760000301,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,342.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,277.832,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,405.632,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,272.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,428.168,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,396.616,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,405.632,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 20.0,2760000302,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,469.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,298.072,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,555.664,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,292.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,586.528,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,543.312,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,555.664,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 20.5,2760000303,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,469.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,1640.52,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,795.784,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,555.664,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,779.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,586.528,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,543.312,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,555.664,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 21.0,2760000304,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,469.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,61.92,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,555.664,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,60.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,586.528,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,543.312,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,555.664,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 22.0,2760000305,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,503.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,1640.52,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,41.672,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,596.144,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,40.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,629.264,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,582.896,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,596.144,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 22.5,2760000306,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,1343.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,225.04,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,1591.568,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,220.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,1679.984,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,1556.2,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,1591.568,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 23.0,2760000307,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,104.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,2143.264,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,1714.608,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,123.832,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,130.712,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,121.08,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,123.832,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 23.5,2760000308,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,70.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,2057.528,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,1714.608,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,83.344,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,87.976,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,81.496,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,83.344,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 24.0,2760000309,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,380.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,2143.264,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,1714.608,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,450.088,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,475.088,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,440.088,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,450.088,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 24.5,2760000310,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,2057.528,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,1714.608,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 25.0,2760000311,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,273.072,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,227.56,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 19.5,2760000312,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 21.5,2760000313,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,273.072,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,227.56,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 26.5,2760000314,CDM,276,RC,,,Outpatient,,,554.40,360.36,,554.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,421.34,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.17,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,415.8,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,554.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.17,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,332.64,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,498.96,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.48,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,498.96,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,554.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360.36,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.49,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,526.68,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,554.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487.87,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,498.96,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,244.49,554.4,
AMO PCBOO 13.5,2760000315,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,1574.896,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,1574.896,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,1312.416,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 11.0,2760000316,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,273.072,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,227.56,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO ZCT300 16.5,2760000317,CDM,276,RC,,,Outpatient,,,1957.20,1272.18,,1957.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1487.47,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1409.18,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,1467.9,75,,273.072,Percent of Total Billed charges,75% of Total Billed Charges,1957.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1409.18,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,1174.32,60,,227.56,Percent of Total Billed Charges,60% of Total Billed Charges,1761.48,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,880.74,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,1761.48,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,1957.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1957.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1957.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1272.18,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,863.13,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,1859.34,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,1957.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1722.34,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,1761.48,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,863.13,1957.2,
AMO PCBOO 6.0,2760000318,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,273.072,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,227.56,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 14.0,2760000319,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 27.0,2760000320,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
ALCON SN6AT4 13.5 TORIC,2760000321,CDM,276,RC,,,Outpatient,,,1844.85,1199.15,,1844.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1402.09,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1328.29,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,1383.64,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1328.29,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,1106.91,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,1660.37,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,830.18,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,1660.37,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1199.15,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,813.58,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,1752.61,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1623.47,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,1660.37,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,813.58,1844.85,
AMO PCB00 25.5,2760000322,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 14.5,2760000323,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 26.0,2760000324,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 13.0,2760000325,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 10.5,2760000326,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 28.0,2760000327,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
AMO PCBOO 10.5,2760000328,CDM,276,RC,,,Outpatient,,,529.00,343.85,,529,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,402.04,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,380.88,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,396.75,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.88,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,317.4,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,476.1,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,238.05,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,476.1,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.85,65,,278.624,Percent of total Billed Charges,65% of Total Billed Charges,233.29,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,502.55,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.52,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,476.1,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,233.29,529,
AMO PCBOO 11.5,2760000329,CDM,276,RC,,,Outpatient,,,555.45,361.04,,555.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.14,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.92,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,416.59,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.92,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,333.27,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,249.95,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.04,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,244.95,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.68,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,555.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.8,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,499.91,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,244.95,555.45,
ALCON SND17S 20.0 TORIC,2760000330,CDM,276,RC,,,Outpatient,,,3177.00,2065.05,,3177,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2414.52,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2287.44,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,2382.75,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,3177,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2287.44,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,1906.2,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,2859.3,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,1429.65,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,2859.3,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,3177,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2065.05,65,,13,Percent of total Billed Charges,65% of Total Billed Charges,1401.06,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,3018.15,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,3177,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2795.76,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,2859.3,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,1401.06,3177,
ALCON SND1T3 18.0 TORIC,2760000331,CDM,276,RC,,,Outpatient,,,3177.00,2065.05,,3177,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2414.52,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2287.44,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,2382.75,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,3177,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2287.44,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,1906.2,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,2859.3,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,1429.65,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,2859.3,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,3177,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2065.05,65,,25.48,Percent of total Billed Charges,65% of Total Billed Charges,1401.06,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,3018.15,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,3177,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2795.76,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,2859.3,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,1401.06,3177,
AMO PCBOO 32.0,2760000332,CDM,276,RC,,,Outpatient,,,529.00,343.85,,529,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,402.04,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,380.88,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,396.75,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.88,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,317.4,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,476.1,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,238.05,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,476.1,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.85,65,,1.968,Percent of total Billed Charges,65% of Total Billed Charges,233.29,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,502.55,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.52,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,476.1,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,233.29,529,
ALCON MTA5U0 18.0,2760000333,CDM,276,RC,,,Outpatient,,,302.00,196.30,,302,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,229.52,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,217.44,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,226.5,75,,3556.224,Percent of Total Billed charges,75% of Total Billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.44,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,181.2,60,,2963.52,Percent of Total Billed Charges,60% of Total Billed Charges,271.8,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,135.9,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,271.8,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.3,65,,2.448,Percent of total Billed Charges,65% of Total Billed Charges,133.18,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,286.9,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.76,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,271.8,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,133.18,302,
AMO PCBOO 7.5,2760000334,CDM,276,RC,,,Outpatient,,,529.00,343.85,,529,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,402.04,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,380.88,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,396.75,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.88,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,317.4,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,476.1,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,238.05,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,476.1,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.85,65,,3.224,Percent of total Billed Charges,65% of Total Billed Charges,233.29,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,502.55,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.52,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,476.1,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,233.29,529,
BL M16OL 12.0,2760000335,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,3556.224,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,2963.52,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,0.68,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 12.5,2760000336,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,7.808,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 13.0,2760000337,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,9.304,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 13.5,2760000338,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,3556.224,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,2963.52,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 14.0,2760000339,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,3556.224,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,2963.52,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,0.384,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 14.5,2760000340,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,3556.224,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,2963.52,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,8.256,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 15.0,2760000341,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,385.792,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,7.8,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 15.5,2760000342,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,3556.224,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,2963.52,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,7.8,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 16.0,2760000343,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 16.5,2760000344,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,3556.224,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,2963.52,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,35.28,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,17.2,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 17.0,2760000345,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,273.072,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,227.56,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,2.72,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 17.5,2760000346,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,1676.16,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,1746,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,1676.16,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,1396.8,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,3.392,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,1.968,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 18.0,2760000347,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,1676.16,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,1746,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,1676.16,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,1396.8,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,4.464,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,7.456,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 18.5,2760000348,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,1676.16,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,1746,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,1676.16,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,1396.8,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,0.944,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,192.896,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,185.64,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,189.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 19.0,2760000349,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,1676.16,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,1746,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,1676.16,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,1396.8,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,10.808,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,145.72,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 19.5,2760000350,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,1174.824,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,979.024,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,12.88,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,9,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,145.72,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,8.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 20.0,2760000351,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,325.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,1174.824,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,979.024,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,17.64,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,385.792,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,235.016,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,17.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,407.224,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,377.216,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,385.792,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 20.5,2760000352,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,1174.824,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,979.024,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,0.536,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,1.36,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,173.4,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,1.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 21.0,2760000353,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,1174.824,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,979.024,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,11.424,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,1.696,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,18,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,237.64,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,1.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,19,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,4.368,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,18,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 21.5,2760000354,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,29.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,1676.16,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,1746,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,1676.16,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,1396.8,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,2.232,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,35.28,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,94.024,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,2.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,37.24,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,0.92,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,35.28,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 22.0,2760000355,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,2.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,1174.824,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,979.024,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,0.472,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,2.72,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,0.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,2.872,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,10.568,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,2.72,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 22.5,2760000356,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,2.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,1174.824,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,979.024,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,5.4,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,3.392,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,5.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,3.576,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,12.592,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,3.392,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 23.0,2760000357,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,3.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,1174.824,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,979.024,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,23.816,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,6.44,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,4.464,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,349.712,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,6.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,4.712,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,4.464,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 23.5,2760000358,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,0.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,1174.824,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,979.024,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,0.944,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,0.992,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,0.52,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,0.944,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 24.0,2760000359,CDM,276,RC,,,Outpatient,,,547.94,356.16,,547.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,416.43,76,,9.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,394.52,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,410.96,75,,273.072,Percent of Total Billed charges,75% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.52,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,328.76,60,,227.56,Percent of Total Billed Charges,60% of Total Billed Charges,493.15,90,,2.72,Percent of Total Billed Charges,90% of Total Billed Charges,246.57,45,,0.264,Percent of Total Billed Charges,45% of Total Billed Charges,493.15,90,,10.808,Percent of Total Billed Charges,90% of Total billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.16,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,241.64,44.1,,0.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,520.54,95,,11.408,Percent of Total Billed Charges,95% of Total Billed Charges,547.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.19,88,,10.56,Percent of Total Billed Charges,88% of Total Billed Charges,493.15,90,,10.808,Percent of Total Billed charges,90% of Total Billed Charges,241.64,547.94,
BL M16OL 18.5,2760000360,CDM,276,RC,,,Outpatient,,,567.79,369.06,,567.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,431.52,76,,10.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,408.81,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,425.84,75,,1174.824,Percent of Total Billed charges,75% of Total Billed Charges,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,408.81,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,340.67,60,,979.024,Percent of Total Billed Charges,60% of Total Billed Charges,511.01,90,,10.328,Percent of Total Billed Charges,90% of Total Billed Charges,255.51,45,,5.712,Percent of Total Billed Charges,45% of Total Billed Charges,511.01,90,,12.88,Percent of Total Billed Charges,90% of Total billed Charges,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.06,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,250.4,44.1,,5.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,539.4,95,,13.6,Percent of Total Billed Charges,95% of Total Billed Charges,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,499.66,88,,10.56,Percent of Total Billed Charges,88% of Total Billed Charges,511.01,90,,12.88,Percent of Total Billed charges,90% of Total Billed Charges,250.4,567.79,
BL M16OL 25.0,2760000361,CDM,276,RC,,,Outpatient,,,567.79,369.06,,567.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,431.52,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,408.81,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,425.84,75,,1174.824,Percent of Total Billed charges,75% of Total Billed Charges,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,408.81,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,340.67,60,,979.024,Percent of Total Billed Charges,60% of Total Billed Charges,511.01,90,,257.04,Percent of Total Billed Charges,90% of Total Billed Charges,255.51,45,,5.4,Percent of Total Billed Charges,45% of Total Billed Charges,511.01,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.06,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,250.4,44.1,,5.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,539.4,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,499.66,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,511.01,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,250.4,567.79,
BL L161AO 16.0,2760000362,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,0.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,1174.824,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,979.024,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,201.768,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,5.4,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,0.536,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,5.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,0.56,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,23.288,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,0.536,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 16.5,2760000363,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,9.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,273.072,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,227.56,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,201.768,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,11.424,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,12.064,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,11.424,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 17.0,2760000364,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,1174.824,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,1174.824,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,979.024,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,325.408,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,11.912,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,10.8,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,11.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,11.4,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,2.664,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,10.8,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 17.5,2760000365,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,273.072,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,273.072,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,227.56,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,240.088,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,10.8,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,349.712,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,11.4,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,10.096,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,10.8,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 18.0,2760000366,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,329.04,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,1.36,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,1.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,251.328,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 18.5,2760000367,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,20.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,7415.36,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,7415.36,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,7415.36,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,6179.464,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,130.184,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,23.816,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1857.496,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,25.144,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,197.28,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,23.816,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 19.0,2760000368,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,7415.36,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,7415.36,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,7415.36,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,6179.464,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,128.52,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1857.496,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,125.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,197.28,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 19.5,2760000369,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,2.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,7415.36,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,7415.36,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,7415.36,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,6179.464,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,100.88,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,2.72,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,98.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,2.872,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,318.176,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,2.72,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 20.0,2760000370,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,8.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,7415.36,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,7415.36,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,7415.36,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,6179.464,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,484.224,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,100.88,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,10.328,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,98.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,10.896,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,234.752,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,10.328,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 21.0,2760000371,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,217.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,7415.36,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,7415.36,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,7415.36,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,6179.464,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,162.704,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,257.04,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,349.712,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,159.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,271.32,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,321.728,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,257.04,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 21.5,2760000372,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,170.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,3556.224,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,2963.52,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,120.048,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,201.768,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,117.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,212.976,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,127.288,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,201.768,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 22.0,2760000373,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,170.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,3556.224,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,2963.52,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,164.52,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,201.768,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,161.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,212.976,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,201.768,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 22.5,2760000374,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,274.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,3556.224,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,2963.52,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,65.088,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,325.408,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,349.712,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,63.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,343.48,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,325.408,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 23.5,2760000375,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,202.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,240.088,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,253.432,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,473.464,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,240.088,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 23.0,2760000376,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,277.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,329.04,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,347.32,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,329.04,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 24.0,2760000377,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,109.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,242.112,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,130.184,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,349.712,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,237.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,137.416,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,130.184,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 24.5,2760000378,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,7415.36,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,7415.36,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,7415.36,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,6179.464,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,484.224,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 25.0,2760000379,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,7415.36,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,7415.36,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,7415.36,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,6179.464,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 25.5,2760000380,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,408.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,7415.36,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,7415.36,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,7415.36,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,6179.464,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,2571.912,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,484.224,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,349.712,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,511.12,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,484.224,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 20.5,2760000381,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,3556.224,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,2963.52,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,2571.912,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL M161OL 11.0,2760000382,CDM,276,RC,,,Outpatient,,,568.89,369.78,,568.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.36,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,409.6,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,426.67,75,,3556.224,Percent of Total Billed charges,75% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.6,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,341.33,60,,2963.52,Percent of Total Billed Charges,60% of Total Billed Charges,512,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,256,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,512,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.78,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,250.88,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,540.45,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.62,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,512,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,250.88,568.89,
BL M16OL 11.5,2760000383,CDM,276,RC,,,Outpatient,,,568.89,369.78,,568.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.36,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,409.6,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,426.67,75,,3556.224,Percent of Total Billed charges,75% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.6,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,341.33,60,,2963.52,Percent of Total Billed Charges,60% of Total Billed Charges,512,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,256,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,512,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.78,65,,349.712,Percent of total Billed Charges,65% of Total Billed Charges,250.88,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,540.45,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.62,88,,473.464,Percent of Total Billed Charges,88% of Total Billed Charges,512,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,250.88,568.89,
BL M16OL 25.5,2760000384,CDM,276,RC,,,Outpatient,,,568.89,369.78,,568.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.36,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,409.6,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,426.67,75,,3556.224,Percent of Total Billed charges,75% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.6,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,341.33,60,,2963.52,Percent of Total Billed Charges,60% of Total Billed Charges,512,90,,484.224,Percent of Total Billed Charges,90% of Total Billed Charges,256,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,512,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.78,65,,65.92,Percent of total Billed Charges,65% of Total Billed Charges,250.88,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,540.45,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.62,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,512,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,250.88,568.89,
BL M16OL 26.0,2760000385,CDM,276,RC,,,Outpatient,,,568.89,369.78,,568.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.36,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,409.6,72,,7415.36,Percent of Total Billed Charges,72% of Total Billed Charges,426.67,75,,7415.36,Percent of Total Billed charges,75% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.6,72,,7415.36,Percent of Total Billed Charges,72% of Total Billed Charges,341.33,60,,6179.464,Percent of Total Billed Charges,60% of Total Billed Charges,512,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,256,45,,242.112,Percent of Total Billed Charges,45% of Total Billed Charges,512,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.78,65,,246.52,Percent of total Billed Charges,65% of Total Billed Charges,250.88,44.1,,237.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,540.45,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.62,88,,2514.76,Percent of Total Billed Charges,88% of Total Billed Charges,512,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,250.88,568.89,
BL M16OL 26.5,2760000386,CDM,276,RC,,,Outpatient,,,568.89,369.78,,568.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.36,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,409.6,72,,7415.36,Percent of Total Billed Charges,72% of Total Billed Charges,426.67,75,,7415.36,Percent of Total Billed charges,75% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.6,72,,7415.36,Percent of Total Billed Charges,72% of Total Billed Charges,341.33,60,,6179.464,Percent of Total Billed Charges,60% of Total Billed Charges,512,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,256,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,512,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.78,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,250.88,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,540.45,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.62,88,,2514.76,Percent of Total Billed Charges,88% of Total Billed Charges,512,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,250.88,568.89,
BL M16OL 27.0,2760000387,CDM,276,RC,,,Outpatient,,,568.89,369.78,,568.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.36,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,409.6,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,426.67,75,,3556.224,Percent of Total Billed charges,75% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.6,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,341.33,60,,2963.52,Percent of Total Billed Charges,60% of Total Billed Charges,512,90,,484.224,Percent of Total Billed Charges,90% of Total Billed Charges,256,45,,1285.96,Percent of Total Billed Charges,45% of Total Billed Charges,512,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.78,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,250.88,44.1,,1260.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,540.45,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.62,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,512,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,250.88,568.89,
BL M16OL 27.5,2760000388,CDM,276,RC,,,Outpatient,,,568.89,369.78,,568.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.36,76,,408.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,409.6,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,426.67,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.6,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,341.33,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,512,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,256,45,,1285.96,Percent of Total Billed Charges,45% of Total Billed Charges,512,90,,484.224,Percent of Total Billed Charges,90% of Total billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.78,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,250.88,44.1,,1260.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,540.45,95,,511.12,Percent of Total Billed Charges,95% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.62,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,512,90,,484.224,Percent of Total Billed charges,90% of Total Billed Charges,250.88,568.89,
BL M16OL 28.0,2760000389,CDM,276,RC,,,Outpatient,,,568.89,369.78,,568.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.36,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,409.6,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,426.67,75,,3556.224,Percent of Total Billed charges,75% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.6,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,341.33,60,,2963.52,Percent of Total Billed Charges,60% of Total Billed Charges,512,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,256,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,512,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.78,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,250.88,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,540.45,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.62,88,,473.464,Percent of Total Billed Charges,88% of Total Billed Charges,512,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,250.88,568.89,
BL L161AO 11.0,2760000390,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,2171.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,2857.68,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,2857.68,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,2857.68,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,2381.4,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,484.224,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,2571.912,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1857.496,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,2714.8,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,2571.912,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 11.5,2760000391,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,2171.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,242.112,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,2571.912,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1857.496,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,237.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,2714.8,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,2571.912,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 12.0,2760000392,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,2889.432,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1857.496,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,473.464,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 12.5,2760000393,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,3556.224,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,2963.52,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,484.224,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1857.496,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 13.0,2760000394,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,408.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,3556.224,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,3556.224,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,2963.52,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,242.112,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,484.224,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,246.52,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,237.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,511.12,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,484.224,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 13.5,2760000395,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,205.632,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,205.632,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,205.632,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,171.36,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,473.464,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 14.0,2760000396,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,2928.44,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,2928.44,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,2928.44,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,2440.368,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,484.224,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 14.5,2760000397,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,408.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,1335.168,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,1335.168,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,1335.168,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,1112.64,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,91.272,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,242.112,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,484.224,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,237.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,511.12,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,484.224,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 15.0,2760000398,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,3273.984,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,3273.984,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,3273.984,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,2728.32,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,341.336,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,473.464,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 15.5,2760000399,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,3836.736,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,3836.736,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,3836.736,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,3197.28,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 26.0,2760000400,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,408.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,2928.44,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,2928.44,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,2928.44,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,2440.368,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,242.112,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,484.224,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,237.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,511.12,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,484.224,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 26.5,2760000401,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,409.6,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,409.6,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,409.6,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,341.336,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1857.496,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,473.464,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 27.0,2760000402,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,238.776,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,238.776,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,238.776,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,198.976,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1857.496,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,89.248,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 27.5,2760000403,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,408.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,665.52,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,665.52,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,665.52,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,554.6,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,2571.912,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,242.112,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,484.224,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1857.496,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,237.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,511.12,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,333.752,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,484.224,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL L161AO 28.0,2760000404,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,237.312,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,237.312,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,237.312,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,197.76,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,2571.912,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,45.64,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1857.496,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,44.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
AMO ZLBOO 19.5,2760000405,CDM,276,RC,,,Outpatient,,,3502.64,2276.72,,3502.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2662.01,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2521.9,72,,1287.616,Percent of Total Billed Charges,72% of Total Billed Charges,2626.98,75,,1341.272,Percent of Total Billed charges,75% of Total Billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.9,72,,1287.616,Percent of Total Billed Charges,72% of Total Billed Charges,2101.58,60,,1073.016,Percent of Total Billed Charges,60% of Total Billed Charges,3152.38,90,,2571.912,Percent of Total Billed Charges,90% of Total Billed Charges,1576.19,45,,170.672,Percent of Total Billed Charges,45% of Total Billed Charges,3152.38,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2276.72,65,,246.52,Percent of total Billed Charges,65% of Total Billed Charges,1544.66,44.1,,167.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,3327.51,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,3502.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3082.32,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,3152.38,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,1544.66,3502.64,
BL L161 AO 31.00,2760000406,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,408.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,2082.928,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,2169.72,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,2082.928,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,1735.776,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,2571.912,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,484.224,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,511.12,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,484.224,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL M160L 28.5,2760000407,CDM,276,RC,,,Outpatient,,,567.79,369.06,,567.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,431.52,76,,77.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,408.81,72,,1242.136,Percent of Total Billed Charges,72% of Total Billed Charges,425.84,75,,1242.136,Percent of Total Billed charges,75% of Total Billed Charges,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,408.81,72,,1242.136,Percent of Total Billed Charges,72% of Total Billed Charges,340.67,60,,1035.112,Percent of Total Billed Charges,60% of Total Billed Charges,511.01,90,,341.336,Percent of Total Billed Charges,90% of Total Billed Charges,255.51,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,511.01,90,,91.272,Percent of Total Billed Charges,90% of Total billed Charges,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.06,65,,246.52,Percent of total Billed Charges,65% of Total Billed Charges,250.4,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,539.4,95,,96.344,Percent of Total Billed Charges,95% of Total Billed Charges,567.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,499.66,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,511.01,90,,91.272,Percent of Total Billed charges,90% of Total Billed Charges,250.4,567.79,
BL L161AO 34.0,2760000408,CDM,276,RC,,,Outpatient,,,489.51,318.18,,489.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.03,76,,288.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,352.45,72,,264.808,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,75,,264.808,Percent of Total Billed charges,75% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.45,72,,264.808,Percent of Total Billed Charges,72% of Total Billed Charges,293.71,60,,220.672,Percent of Total Billed Charges,60% of Total Billed Charges,440.56,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,220.28,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,440.56,90,,341.336,Percent of Total Billed Charges,90% of Total billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.18,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,215.87,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,465.03,95,,360.304,Percent of Total Billed Charges,95% of Total Billed Charges,489.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.77,88,,2514.76,Percent of Total Billed Charges,88% of Total Billed Charges,440.56,90,,341.336,Percent of Total Billed charges,90% of Total Billed Charges,215.87,489.51,
BL M160L 5.0,2760000409,CDM,276,RC,,,Outpatient,,,540.75,351.49,,540.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,410.97,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,389.34,72,,37.472,Percent of Total Billed Charges,72% of Total Billed Charges,405.56,75,,37.472,Percent of Total Billed charges,75% of Total Billed Charges,540.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,389.34,72,,37.472,Percent of Total Billed Charges,72% of Total Billed Charges,324.45,60,,31.224,Percent of Total Billed Charges,60% of Total Billed Charges,486.68,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,243.34,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,486.68,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,540.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,351.49,65,,1421.784,Percent of total Billed Charges,65% of Total Billed Charges,238.47,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,513.71,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,540.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475.86,88,,2514.76,Percent of Total Billed Charges,88% of Total Billed Charges,486.68,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,238.47,540.75,
BL M16OL 8.0,2760000410,CDM,276,RC,,,Outpatient,,,540.75,351.49,,540.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,410.97,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,389.34,72,,1438.312,Percent of Total Billed Charges,72% of Total Billed Charges,405.56,75,,1438.312,Percent of Total Billed charges,75% of Total Billed Charges,540.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,389.34,72,,1438.312,Percent of Total Billed Charges,72% of Total Billed Charges,324.45,60,,1133.2,Percent of Total Billed Charges,60% of Total Billed Charges,486.68,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,243.34,45,,1285.96,Percent of Total Billed Charges,45% of Total Billed Charges,486.68,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,540.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,351.49,65,,246.52,Percent of total Billed Charges,65% of Total Billed Charges,238.47,44.1,,1260.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,513.71,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,540.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475.86,88,,2514.76,Percent of Total Billed Charges,88% of Total Billed Charges,486.68,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,238.47,540.75,
ALCON SA60AT 10.0,2760000411,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,266.384,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,266.384,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,266.384,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,221.984,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1285.96,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,246.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1260.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,2514.76,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 10.5,2760000412,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,266.384,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,266.384,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,266.384,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,221.984,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1285.96,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,246.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1260.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,333.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 11.5,2760000413,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,2171.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,266.384,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,266.384,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,266.384,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,221.984,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1285.96,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,2571.912,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1260.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2714.8,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,2571.912,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 12.0,2760000414,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,2171.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,266.384,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,266.384,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,266.384,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,221.984,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,2571.912,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,170.672,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,2571.912,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,167.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2714.8,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,2571.912,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 12.5,2760000415,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,2171.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,266.384,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,266.384,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,266.384,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,221.984,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,2571.912,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,2571.912,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2714.8,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,2571.912,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 13.0,2760000416,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,2171.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,3451.392,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,3451.392,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,3451.392,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,2876.16,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,2571.912,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,2571.912,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2714.8,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,2571.912,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 13.5,2760000417,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,288.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,1799.424,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,1799.424,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,1799.424,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,1499.52,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,2571.912,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,341.336,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,360.304,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,341.336,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 14.0,2760000418,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,1169.856,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,1169.856,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,1169.856,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,974.88,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,341.336,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 14.5,2760000419,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,1169.856,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,1169.856,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,1169.856,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,974.88,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,2514.76,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 15.0,2760000420,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,137.664,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,137.664,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,137.664,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,114.72,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,341.336,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,2514.76,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 15.5,2760000421,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,2852.352,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,2852.352,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,2852.352,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,2376.96,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1285.96,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1260.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,2514.76,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 16.0,2760000422,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,439.488,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,439.488,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,439.488,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,366.24,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1285.96,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1260.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,2514.76,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 16.5,2760000423,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,4367.808,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,4367.808,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,4367.808,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,3639.84,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,341.336,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1285.96,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1260.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,333.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 17.0,2760000424,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,2171.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,3200.256,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,3200.256,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,3200.256,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,2666.88,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,341.336,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1285.96,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,2571.912,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1260.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2714.8,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,2571.912,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 17.5,2760000425,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,2171.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,286.272,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,286.272,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,238.56,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,341.336,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,170.672,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,2571.912,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,167.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2714.8,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,333.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,2571.912,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 18.0,2760000426,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,2171.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,4367.808,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,4367.808,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,4367.808,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,3639.84,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,2571.912,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2714.8,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,2571.912,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 18.5,2760000427,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,2171.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,3056.832,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,3056.832,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,3056.832,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,2547.36,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,170.672,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,2571.912,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,3210.48,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,167.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2714.8,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,1924.88,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,2571.912,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 19.0,2760000428,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,288.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,3056.832,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,3056.832,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,3056.832,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,2547.36,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,341.336,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,360.304,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,333.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,341.336,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 19.5,2760000429,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,950.976,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,950.976,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,950.976,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,792.48,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,984.312,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,3210.48,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,964.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,333.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 20.0,2760000430,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,288.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,1183.68,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,1183.68,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,1183.68,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,986.4,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,170.672,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,341.336,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,167.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,360.304,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,333.752,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,341.336,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 20.5,2760000431,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,439.488,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,439.488,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,439.488,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,366.24,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,170.672,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,167.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 21.0,2760000432,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,1662.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,439.488,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,439.488,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,439.488,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,366.24,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,170.672,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,3210.48,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,167.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,2077.992,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,1968.624,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 21.5,2760000433,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,288.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,408.96,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,408.96,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,408.96,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,340.8,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,341.336,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,3210.48,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,360.304,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,341.336,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 22.0,2760000434,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,288.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,393.728,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,410.128,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,393.728,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,328.104,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,341.336,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,3210.48,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,360.304,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,341.336,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 22.5,2760000435,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,288.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,393.728,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,410.128,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,393.728,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,328.104,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,341.336,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,360.304,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,341.336,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 23.0,2760000436,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,115.2,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,96,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,3210.48,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 23.5,2760000437,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,40.64,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,33.872,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 24.0,2760000438,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,26.032,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,21.696,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,3210.48,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 24.5,2760000439,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,182.888,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,182.888,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,182.888,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,152.408,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,246.52,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 25.0,2760000440,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,38.104,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,38.104,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,38.104,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,31.752,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,4445.28,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,1513.2,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 25.5,2760000441,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,145.264,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,145.264,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,145.264,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,121.056,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,1513.2,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 26.0,2760000442,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,2882.88,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,2882.88,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,2882.88,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,2402.4,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,4445.28,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,1513.2,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 26.5,2760000443,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,303.36,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,303.36,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,303.36,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,252.8,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,1513.2,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 27.0,2760000444,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,304.816,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,304.816,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,304.816,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,254.016,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,1060.608,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 27.5,2760000445,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,16.128,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,16.128,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,16.128,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,13.44,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,4445.28,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,1060.608,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,4346.496,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 28.0,2760000446,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,39.464,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,41.104,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,39.464,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,32.888,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,4445.28,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,1060.608,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 28.5,2760000447,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,661.712,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,689.288,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,661.712,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,551.432,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,4445.28,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,2222.64,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,1060.608,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,2178.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,4346.496,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 29.0,2760000448,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,661.712,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,689.288,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,661.712,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,551.432,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,1513.2,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 29.5,2760000449,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,218.696,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,218.696,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,218.696,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,182.248,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,4445.28,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,2222.64,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,1060.608,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,2178.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 30.0,2760000450,CDM,276,RC,,,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,3753.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,218.696,Percent of Total Billed Charges,72% of Total Billed Charges,458.92,75,,218.696,Percent of Total Billed charges,75% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,218.696,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,182.248,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,4445.28,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,1060.608,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,4692.24,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,4346.496,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,4445.28,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
ALCON SA60AT 6.0,2760000451,CDM,276,RC,,,Outpatient,,,575.51,374.08,,575.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,437.39,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,414.37,72,,302.976,Percent of Total Billed Charges,72% of Total Billed Charges,431.63,75,,302.976,Percent of Total Billed charges,75% of Total Billed Charges,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.37,72,,302.976,Percent of Total Billed Charges,72% of Total Billed Charges,345.31,60,,252.48,Percent of Total Billed Charges,60% of Total Billed Charges,517.96,90,,4445.28,Percent of Total Billed Charges,90% of Total Billed Charges,258.98,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,517.96,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.08,65,,1060.608,Percent of total Billed Charges,65% of Total Billed Charges,253.8,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,546.73,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.45,88,,4346.496,Percent of Total Billed Charges,88% of Total Billed Charges,517.96,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,253.8,575.51,
ALCON SNEAD1 25.0 RE,2760000452,CDM,276,RC,,,Outpatient,,,3843.32,2498.16,,3843.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2920.92,76,,3753.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2767.19,72,,1333.584,Percent of Total Billed Charges,72% of Total Billed Charges,2882.49,75,,1333.584,Percent of Total Billed charges,75% of Total Billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2767.19,72,,1333.584,Percent of Total Billed Charges,72% of Total Billed Charges,2305.99,60,,1111.32,Percent of Total Billed Charges,60% of Total Billed Charges,3458.99,90,,341.336,Percent of Total Billed Charges,90% of Total Billed Charges,1729.49,45,,2222.64,Percent of Total Billed Charges,45% of Total Billed Charges,3458.99,90,,4445.28,Percent of Total Billed Charges,90% of Total billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2498.16,65,,1060.608,Percent of total Billed Charges,65% of Total Billed Charges,1694.9,44.1,,2178.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,3651.15,95,,4692.24,Percent of Total Billed Charges,95% of Total Billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3382.12,88,,4346.496,Percent of Total Billed Charges,88% of Total Billed Charges,3458.99,90,,4445.28,Percent of Total Billed charges,90% of Total Billed Charges,1694.9,3843.32,
ALCON SN6AD1 23.0 RE,2760000453,CDM,276,RC,,,Outpatient,,,3843.32,2498.16,,3843.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2920.92,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2767.19,72,,1697.464,Percent of Total Billed Charges,72% of Total Billed Charges,2882.49,75,,1697.464,Percent of Total Billed charges,75% of Total Billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2767.19,72,,1697.464,Percent of Total Billed Charges,72% of Total Billed Charges,2305.99,60,,1414.552,Percent of Total Billed Charges,60% of Total Billed Charges,3458.99,90,,2095.2,Percent of Total Billed Charges,90% of Total Billed Charges,1729.49,45,,2222.64,Percent of Total Billed Charges,45% of Total Billed Charges,3458.99,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2498.16,65,,246.52,Percent of total Billed Charges,65% of Total Billed Charges,1694.9,44.1,,2178.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,3651.15,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,3843.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3382.12,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,3458.99,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,1694.9,3843.32,
ALCON SA60AT 34.0,2760000454,CDM,276,RC,,,Outpatient,,,575.51,374.08,,575.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,437.39,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,414.37,72,,163.584,Percent of Total Billed Charges,72% of Total Billed Charges,431.63,75,,163.584,Percent of Total Billed charges,75% of Total Billed Charges,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.37,72,,163.584,Percent of Total Billed Charges,72% of Total Billed Charges,345.31,60,,136.32,Percent of Total Billed Charges,60% of Total Billed Charges,517.96,90,,2095.2,Percent of Total Billed Charges,90% of Total Billed Charges,258.98,45,,2222.64,Percent of Total Billed Charges,45% of Total Billed Charges,517.96,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.08,65,,1060.608,Percent of total Billed Charges,65% of Total Billed Charges,253.8,44.1,,2178.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,546.73,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.45,88,,4346.496,Percent of Total Billed Charges,88% of Total Billed Charges,517.96,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,253.8,575.51,
AMO PCB00 27.5,2760000455,CDM,276,RC,,,Outpatient,,,529.00,343.85,,529,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,402.04,76,,3753.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,380.88,72,,39.464,Percent of Total Billed Charges,72% of Total Billed Charges,396.75,75,,41.104,Percent of Total Billed charges,75% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.88,72,,39.464,Percent of Total Billed Charges,72% of Total Billed Charges,317.4,60,,32.888,Percent of Total Billed Charges,60% of Total Billed Charges,476.1,90,,2095.2,Percent of Total Billed Charges,90% of Total Billed Charges,238.05,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,476.1,90,,4445.28,Percent of Total Billed Charges,90% of Total billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.85,65,,1060.608,Percent of total Billed Charges,65% of Total Billed Charges,233.29,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,502.55,95,,4692.24,Percent of Total Billed Charges,95% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.52,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,476.1,90,,4445.28,Percent of Total Billed charges,90% of Total Billed Charges,233.29,529,
ALCON SN6AT3 22.0,2760000456,CDM,276,RC,,,Outpatient,,,2180.75,1417.49,,2180.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1657.37,76,,3753.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1570.14,72,,59.856,Percent of Total Billed Charges,72% of Total Billed Charges,1635.56,75,,62.352,Percent of Total Billed charges,75% of Total Billed Charges,2180.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1570.14,72,,59.856,Percent of Total Billed Charges,72% of Total Billed Charges,1308.45,60,,49.88,Percent of Total Billed Charges,60% of Total Billed Charges,1962.68,90,,2095.2,Percent of Total Billed Charges,90% of Total Billed Charges,981.34,45,,2222.64,Percent of Total Billed Charges,45% of Total Billed Charges,1962.68,90,,4445.28,Percent of Total Billed Charges,90% of Total billed Charges,2180.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2180.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2180.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1417.49,65,,1060.608,Percent of total Billed Charges,65% of Total Billed Charges,961.71,44.1,,2178.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,2071.71,95,,4692.24,Percent of Total Billed Charges,95% of Total Billed Charges,2180.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1919.06,88,,4346.496,Percent of Total Billed Charges,88% of Total Billed Charges,1962.68,90,,4445.28,Percent of Total Billed charges,90% of Total Billed Charges,961.71,2180.75,
Z00576401751 GSF,2760000457,CDM,276,RC,,,Outpatient,,,22592.43,14685.08,,22592.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17170.25,76,,3753.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16266.55,72,,2082.928,Percent of Total Billed Charges,72% of Total Billed Charges,16944.32,75,,2169.72,Percent of Total Billed charges,75% of Total Billed Charges,22592.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16266.55,72,,2082.928,Percent of Total Billed Charges,72% of Total Billed Charges,13555.46,60,,1735.776,Percent of Total Billed Charges,60% of Total Billed Charges,20333.19,90,,1468.536,Percent of Total Billed Charges,90% of Total Billed Charges,10166.59,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,20333.19,90,,4445.28,Percent of Total Billed Charges,90% of Total billed Charges,22592.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22592.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22592.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14685.08,65,,246.52,Percent of total Billed Charges,65% of Total Billed Charges,9963.26,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,21462.81,95,,4692.24,Percent of Total Billed Charges,95% of Total Billed Charges,22592.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19881.34,88,,333.752,Percent of Total Billed Charges,88% of Total Billed Charges,20333.19,90,,4445.28,Percent of Total Billed charges,90% of Total Billed Charges,9963.26,22592.43,
Z225236010 FEMREON,2760000458,CDM,276,RC,,,Outpatient,,,4839.98,3145.99,,4839.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3678.38,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3484.79,72,,2082.928,Percent of Total Billed Charges,72% of Total Billed Charges,3629.99,75,,2082.928,Percent of Total Billed charges,75% of Total Billed Charges,4839.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3484.79,72,,2082.928,Percent of Total Billed Charges,72% of Total Billed Charges,2903.99,60,,1735.776,Percent of Total Billed Charges,60% of Total Billed Charges,4355.98,90,,1468.536,Percent of Total Billed Charges,90% of Total Billed Charges,2177.99,45,,2222.64,Percent of Total Billed Charges,45% of Total Billed Charges,4355.98,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,4839.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4839.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4839.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3145.99,65,,1060.608,Percent of total Billed Charges,65% of Total Billed Charges,2134.43,44.1,,2178.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,4597.98,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,4839.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4259.18,88,,2048.64,Percent of Total Billed Charges,88% of Total Billed Charges,4355.98,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,2134.43,4839.98,
Z225730001 ITST NA,2760000459,CDM,276,RC,,,Outpatient,,,7940.21,5161.14,,7940.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6034.56,76,,3753.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5716.95,72,,1892.416,Percent of Total Billed Charges,72% of Total Billed Charges,5955.16,75,,1971.272,Percent of Total Billed charges,75% of Total Billed Charges,7940.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5716.95,72,,1892.416,Percent of Total Billed Charges,72% of Total Billed Charges,4764.13,60,,1577.016,Percent of Total Billed Charges,60% of Total Billed Charges,7146.19,90,,1468.536,Percent of Total Billed Charges,90% of Total Billed Charges,3573.09,45,,170.672,Percent of Total Billed Charges,45% of Total Billed Charges,7146.19,90,,4445.28,Percent of Total Billed Charges,90% of Total billed Charges,7940.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7940.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7940.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5161.14,65,,246.52,Percent of total Billed Charges,65% of Total Billed Charges,3501.63,44.1,,167.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,7543.2,95,,4692.24,Percent of Total Billed Charges,95% of Total Billed Charges,7940.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6987.38,88,,2048.64,Percent of Total Billed Charges,88% of Total Billed Charges,7146.19,90,,4445.28,Percent of Total Billed charges,90% of Total Billed Charges,3501.63,7940.21,
Z22261305 NCB TIBI,2760000460,CDM,276,RC,,,Outpatient,,,7555.43,4911.03,,7555.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5742.13,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5439.91,72,,4367.808,Percent of Total Billed Charges,72% of Total Billed Charges,5666.57,75,,4367.808,Percent of Total Billed charges,75% of Total Billed Charges,7555.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5439.91,72,,4367.808,Percent of Total Billed Charges,72% of Total Billed Charges,4533.26,60,,3639.84,Percent of Total Billed Charges,60% of Total Billed Charges,6799.89,90,,1468.536,Percent of Total Billed Charges,90% of Total Billed Charges,3399.94,45,,1047.6,Percent of Total Billed Charges,45% of Total Billed Charges,6799.89,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,7555.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7555.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7555.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4911.03,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,3331.94,44.1,,1026.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,7177.66,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,7555.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6648.78,88,,2048.64,Percent of Total Billed Charges,88% of Total Billed Charges,6799.89,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,3331.94,7555.43,
Z2315536 4.0 ST SC,2760000461,CDM,276,RC,,,Outpatient,,,563.38,366.20,,563.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,428.17,76,,3753.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,405.63,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,422.54,75,,90.624,Percent of Total Billed charges,75% of Total Billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.63,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,338.03,60,,72.496,Percent of Total Billed Charges,60% of Total Billed Charges,507.04,90,,2095.2,Percent of Total Billed Charges,90% of Total Billed Charges,253.52,45,,1047.6,Percent of Total Billed Charges,45% of Total Billed Charges,507.04,90,,4445.28,Percent of Total Billed Charges,90% of Total billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.2,65,,6694.424,Percent of total Billed Charges,65% of Total Billed Charges,248.45,44.1,,1026.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,535.21,95,,4692.24,Percent of Total Billed Charges,95% of Total Billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495.77,88,,2048.64,Percent of Total Billed Charges,88% of Total Billed Charges,507.04,90,,4445.28,Percent of Total Billed charges,90% of Total Billed Charges,248.45,563.38,
Z2315528 4.0 ST SC,2760000462,CDM,276,RC,,,Outpatient,,,563.38,366.20,,563.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,428.17,76,,288.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,405.63,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,422.54,75,,90.624,Percent of Total Billed charges,75% of Total Billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.63,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,338.03,60,,72.496,Percent of Total Billed Charges,60% of Total Billed Charges,507.04,90,,1468.536,Percent of Total Billed Charges,90% of Total Billed Charges,253.52,45,,1047.6,Percent of Total Billed Charges,45% of Total Billed Charges,507.04,90,,341.336,Percent of Total Billed Charges,90% of Total billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.2,65,,6694.424,Percent of total Billed Charges,65% of Total Billed Charges,248.45,44.1,,1026.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,535.21,95,,360.304,Percent of Total Billed Charges,95% of Total Billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495.77,88,,1435.896,Percent of Total Billed Charges,88% of Total Billed Charges,507.04,90,,341.336,Percent of Total Billed charges,90% of Total Billed Charges,248.45,563.38,
Z2315530 4.0 ST SC,2760000463,CDM,276,RC,,,Outpatient,,,563.38,366.20,,563.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,428.17,76,,1769.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,405.63,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,422.54,75,,90.624,Percent of Total Billed charges,75% of Total Billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.63,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,338.03,60,,72.496,Percent of Total Billed Charges,60% of Total Billed Charges,507.04,90,,1468.536,Percent of Total Billed Charges,90% of Total Billed Charges,253.52,45,,1047.6,Percent of Total Billed Charges,45% of Total Billed Charges,507.04,90,,2095.2,Percent of Total Billed Charges,90% of Total billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.2,65,,6694.424,Percent of total Billed Charges,65% of Total Billed Charges,248.45,44.1,,1026.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,535.21,95,,2211.6,Percent of Total Billed Charges,95% of Total Billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495.77,88,,1435.896,Percent of Total Billed Charges,88% of Total Billed Charges,507.04,90,,2095.2,Percent of Total Billed charges,90% of Total Billed Charges,248.45,563.38,
Z2315538 4.0 SCW 3,2760000464,CDM,276,RC,,,Outpatient,,,563.38,366.20,,563.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,428.17,76,,1769.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,405.63,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,422.54,75,,90.624,Percent of Total Billed charges,75% of Total Billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.63,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,338.03,60,,72.496,Percent of Total Billed Charges,60% of Total Billed Charges,507.04,90,,1468.536,Percent of Total Billed Charges,90% of Total Billed Charges,253.52,45,,734.264,Percent of Total Billed Charges,45% of Total Billed Charges,507.04,90,,2095.2,Percent of Total Billed Charges,90% of Total billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.2,65,,6694.424,Percent of total Billed Charges,65% of Total Billed Charges,248.45,44.1,,719.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,535.21,95,,2211.6,Percent of Total Billed Charges,95% of Total Billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495.77,88,,1435.896,Percent of Total Billed Charges,88% of Total Billed Charges,507.04,90,,2095.2,Percent of Total Billed charges,90% of Total Billed Charges,248.45,563.38,
Z2351270 5.0 CANC,2760000465,CDM,276,RC,,,Outpatient,,,771.75,501.64,,771.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,586.53,76,,1769.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,555.66,72,,192.416,Percent of Total Billed Charges,72% of Total Billed Charges,578.81,75,,192.416,Percent of Total Billed charges,75% of Total Billed Charges,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.66,72,,192.416,Percent of Total Billed Charges,72% of Total Billed Charges,463.05,60,,160.352,Percent of Total Billed Charges,60% of Total Billed Charges,694.58,90,,1468.536,Percent of Total Billed Charges,90% of Total Billed Charges,347.29,45,,734.264,Percent of Total Billed Charges,45% of Total Billed Charges,694.58,90,,2095.2,Percent of Total Billed Charges,90% of Total billed Charges,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.64,65,,6694.424,Percent of total Billed Charges,65% of Total Billed Charges,340.34,44.1,,719.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,733.16,95,,2211.6,Percent of Total Billed Charges,95% of Total Billed Charges,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,679.14,88,,1435.896,Percent of Total Billed Charges,88% of Total Billed Charges,694.58,90,,2095.2,Percent of Total Billed charges,90% of Total Billed Charges,340.34,771.75,
Z2351260 5.0 CANC,2760000466,CDM,276,RC,,,Outpatient,,,771.75,501.64,,771.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,586.53,76,,1769.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,555.66,72,,252.112,Percent of Total Billed Charges,72% of Total Billed Charges,578.81,75,,252.112,Percent of Total Billed charges,75% of Total Billed Charges,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.66,72,,252.112,Percent of Total Billed Charges,72% of Total Billed Charges,463.05,60,,210.088,Percent of Total Billed Charges,60% of Total Billed Charges,694.58,90,,341.336,Percent of Total Billed Charges,90% of Total Billed Charges,347.29,45,,734.264,Percent of Total Billed Charges,45% of Total Billed Charges,694.58,90,,2095.2,Percent of Total Billed Charges,90% of Total billed Charges,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.64,65,,3210.48,Percent of total Billed Charges,65% of Total Billed Charges,340.34,44.1,,719.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,733.16,95,,2211.6,Percent of Total Billed Charges,95% of Total Billed Charges,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,679.14,88,,2048.64,Percent of Total Billed Charges,88% of Total Billed Charges,694.58,90,,2095.2,Percent of Total Billed charges,90% of Total Billed Charges,340.34,771.75,
Z2351265 5.0 CANC,2760000467,CDM,276,RC,,,Outpatient,,,771.75,501.64,,771.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,586.53,76,,1240.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,555.66,72,,192.416,Percent of Total Billed Charges,72% of Total Billed Charges,578.81,75,,192.416,Percent of Total Billed charges,75% of Total Billed Charges,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.66,72,,192.416,Percent of Total Billed Charges,72% of Total Billed Charges,463.05,60,,160.352,Percent of Total Billed Charges,60% of Total Billed Charges,694.58,90,,1468.536,Percent of Total Billed Charges,90% of Total Billed Charges,347.29,45,,734.264,Percent of Total Billed Charges,45% of Total Billed Charges,694.58,90,,1468.536,Percent of Total Billed Charges,90% of Total billed Charges,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.64,65,,3210.48,Percent of total Billed Charges,65% of Total Billed Charges,340.34,44.1,,719.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,733.16,95,,1550.12,Percent of Total Billed Charges,95% of Total Billed Charges,771.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,679.14,88,,1435.896,Percent of Total Billed Charges,88% of Total Billed Charges,694.58,90,,1468.536,Percent of Total Billed charges,90% of Total Billed Charges,340.34,771.75,
Z23150300 END LOCK,2760000468,CDM,276,RC,,,Outpatient,,,827.98,538.19,,827.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,629.26,76,,1240.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,596.15,72,,252.112,Percent of Total Billed Charges,72% of Total Billed Charges,620.99,75,,252.112,Percent of Total Billed charges,75% of Total Billed Charges,827.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,596.15,72,,252.112,Percent of Total Billed Charges,72% of Total Billed Charges,496.79,60,,210.088,Percent of Total Billed Charges,60% of Total Billed Charges,745.18,90,,1468.536,Percent of Total Billed Charges,90% of Total Billed Charges,372.59,45,,1047.6,Percent of Total Billed Charges,45% of Total Billed Charges,745.18,90,,1468.536,Percent of Total Billed Charges,90% of Total billed Charges,827.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,827.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,827.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.19,65,,3210.48,Percent of total Billed Charges,65% of Total Billed Charges,365.14,44.1,,1026.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,786.58,95,,1550.12,Percent of Total Billed Charges,95% of Total Billed Charges,827.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,728.62,88,,1435.896,Percent of Total Billed Charges,88% of Total Billed Charges,745.18,90,,1468.536,Percent of Total Billed charges,90% of Total Billed Charges,365.14,827.98,
ALCON SN6AT3 21.5 TO,2760000469,CDM,276,RC,,,Outpatient,,,2210.51,1436.83,,2210.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1679.99,76,,1240.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1591.57,72,,209.568,Percent of Total Billed Charges,72% of Total Billed Charges,1657.88,75,,209.568,Percent of Total Billed charges,75% of Total Billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1591.57,72,,209.568,Percent of Total Billed Charges,72% of Total Billed Charges,1326.31,60,,174.64,Percent of Total Billed Charges,60% of Total Billed Charges,1989.46,90,,1468.536,Percent of Total Billed Charges,90% of Total Billed Charges,994.73,45,,734.264,Percent of Total Billed Charges,45% of Total Billed Charges,1989.46,90,,1468.536,Percent of Total Billed Charges,90% of Total billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1436.83,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,974.83,44.1,,719.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,2099.98,95,,1550.12,Percent of Total Billed Charges,95% of Total Billed Charges,2210.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1945.25,88,,1435.896,Percent of Total Billed Charges,88% of Total Billed Charges,1989.46,90,,1468.536,Percent of Total Billed charges,90% of Total Billed Charges,974.83,2210.51,
FLARED REVERSE,2760000483,CDM,276,RC,,,Outpatient,,,171.99,111.79,,171.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.71,76,,1240.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.83,72,,269.256,Percent of Total Billed Charges,72% of Total Billed Charges,128.99,75,,269.256,Percent of Total Billed charges,75% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.83,72,,269.256,Percent of Total Billed Charges,72% of Total Billed Charges,103.19,60,,224.384,Percent of Total Billed Charges,60% of Total Billed Charges,154.79,90,,341.336,Percent of Total Billed Charges,90% of Total Billed Charges,77.4,45,,734.264,Percent of Total Billed Charges,45% of Total Billed Charges,154.79,90,,1468.536,Percent of Total Billed Charges,90% of Total billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.79,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,75.85,44.1,,719.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.39,95,,1550.12,Percent of Total Billed Charges,95% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.35,88,,1435.896,Percent of Total Billed Charges,88% of Total Billed Charges,154.79,90,,1468.536,Percent of Total Billed charges,90% of Total Billed Charges,75.85,171.99,
ALCON SLEEVE,2760000484,CDM,276,RC,,,Outpatient,,,115.76,75.24,,115.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.98,76,,1769.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,83.35,72,,2421.616,Percent of Total Billed Charges,72% of Total Billed Charges,86.82,75,,2421.616,Percent of Total Billed charges,75% of Total Billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.35,72,,2421.616,Percent of Total Billed Charges,72% of Total Billed Charges,69.46,60,,2018.016,Percent of Total Billed Charges,60% of Total Billed Charges,104.18,90,,1468.536,Percent of Total Billed Charges,90% of Total Billed Charges,52.09,45,,734.264,Percent of Total Billed Charges,45% of Total Billed Charges,104.18,90,,2095.2,Percent of Total Billed Charges,90% of Total billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.24,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,51.05,44.1,,719.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,109.97,95,,2211.6,Percent of Total Billed Charges,95% of Total Billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.87,88,,333.752,Percent of Total Billed Charges,88% of Total Billed Charges,104.18,90,,2095.2,Percent of Total Billed charges,90% of Total Billed Charges,51.05,115.76,
AMO ZCBOO 22.0,2760000485,CDM,276,RC,,,Outpatient,,,625.12,406.33,,625.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,475.09,76,,1240.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.09,72,,2421.616,Percent of Total Billed Charges,72% of Total Billed Charges,468.84,75,,2421.616,Percent of Total Billed charges,75% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.09,72,,2421.616,Percent of Total Billed Charges,72% of Total Billed Charges,375.07,60,,2018.016,Percent of Total Billed Charges,60% of Total Billed Charges,562.61,90,,341.336,Percent of Total Billed Charges,90% of Total Billed Charges,281.3,45,,734.264,Percent of Total Billed Charges,45% of Total Billed Charges,562.61,90,,1468.536,Percent of Total Billed Charges,90% of Total billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.33,65,,6694.424,Percent of total Billed Charges,65% of Total Billed Charges,275.68,44.1,,719.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,593.86,95,,1550.12,Percent of Total Billed Charges,95% of Total Billed Charges,625.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.11,88,,1435.896,Percent of Total Billed Charges,88% of Total Billed Charges,562.61,90,,1468.536,Percent of Total Billed charges,90% of Total Billed Charges,275.68,625.12,
ALCON ACUOTO 10.0,2760000486,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,1240.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,339,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,339,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,339,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,282.496,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,170.672,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,1468.536,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,6694.424,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,167.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,1550.12,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,1435.896,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,1468.536,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 10.5,2760000487,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,1240.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,64.136,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,64.136,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,64.136,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,53.448,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,734.264,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,1468.536,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,6694.424,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,719.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,1550.12,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,1435.896,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,1468.536,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 11.0,2760000488,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,1240.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,103.192,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,82.552,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,734.264,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,1468.536,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,3210.48,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,719.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,1550.12,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,333.752,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,1468.536,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 11.5,2760000489,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,288.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,2484.432,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,734.264,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,341.336,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,3210.48,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,719.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,360.304,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,1435.896,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,341.336,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 12.0,2760000490,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,1240.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,104.144,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,104.144,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,104.144,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,86.792,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,170.672,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,1468.536,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,3210.48,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,167.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,1550.12,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,333.752,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,1468.536,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 12.5,2760000491,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,1240.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,103.192,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,82.552,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,734.264,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,1468.536,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,3210.48,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,719.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,1550.12,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,1468.536,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 13.0,2760000492,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,1240.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,103.192,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,82.552,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,170.672,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,1468.536,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,6694.424,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,167.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,1550.12,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,9063.216,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,1468.536,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 13.5,2760000493,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,288.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,103.192,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,82.552,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,341.336,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,6694.424,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,360.304,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,9063.216,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,341.336,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 14.0,2760000494,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,1240.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,103.192,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,82.552,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,4634.6,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,1468.536,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,3210.48,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,4541.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,1550.12,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,9063.216,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,1468.536,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 14.5,2760000495,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,288.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,103.192,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,82.552,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,4634.6,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,341.336,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,4541.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,360.304,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,9063.216,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,341.336,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 15.0,2760000496,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,1157.68,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,1157.68,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,1157.68,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,964.736,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,4634.6,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,3210.48,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,4541.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,9063.216,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 15.5,2760000497,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,7827.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,1663.952,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,1663.952,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,1663.952,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,1386.632,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,4634.6,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,2579.848,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,4541.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,9784.16,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,4346.496,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 16.0,2760000498,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,7827.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,227.008,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,227.008,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,227.008,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,189.176,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,4634.6,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,4541.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,9784.16,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,4346.496,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 16.5,2760000499,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,7827.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,227.008,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,227.008,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,227.008,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,189.176,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,2222.64,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,2178.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,9784.16,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,4346.496,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 17.0,2760000500,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,7827.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,227.008,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,227.008,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,227.008,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,189.176,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,2222.64,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,3210.48,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,2178.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,9784.16,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 17.5,2760000501,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,7827.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,227.008,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,227.008,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,227.008,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,189.176,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,2222.64,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,3210.48,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,2178.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,9784.16,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 18.0,2760000502,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,3753.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,227.008,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,227.008,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,227.008,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,189.176,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,185.64,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,4692.24,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 18.5,2760000503,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,3753.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,217.656,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,217.656,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,217.656,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,181.384,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,2643.736,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,4692.24,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,9063.216,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 19.0,2760000504,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,3753.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,1079.568,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,1079.568,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,1079.568,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,899.64,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,1205.36,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,4692.24,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,9063.216,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 19.5,2760000505,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,1079.568,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,1079.568,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,1079.568,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,899.64,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,4634.6,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,2955.68,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,4541.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,9063.216,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 20.0,2760000506,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,83.824,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,83.824,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,83.824,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,69.856,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,4634.6,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,3463.72,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,4541.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,4346.496,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 20.5,2760000507,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,702.144,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,702.144,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,702.144,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,585.12,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,4634.6,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,2643.736,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,4541.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,4346.496,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 21.0,2760000508,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,7827.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,702.144,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,702.144,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,702.144,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,585.12,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,2222.64,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,369.776,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,2178.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,9784.16,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,4346.496,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 21.5,2760000509,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,7827.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,598.144,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,623.072,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,598.144,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,498.456,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,2222.64,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,215.56,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,2178.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,9784.16,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,4346.496,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 22.0,2760000510,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,7827.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,2382.192,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,2382.192,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,2382.192,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,1985.16,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,3572.104,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,2222.64,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,600.816,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,2178.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,9784.16,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,9063.216,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 22.5,2760000511,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,3753.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,6800.976,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,6800.976,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,6800.976,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,5667.48,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,2222.64,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,214.24,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,2178.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,4692.24,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,9063.216,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 23.0,2760000512,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,3753.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,2382.192,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,2382.192,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,2382.192,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,1985.16,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,4634.6,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,1162.432,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,4541.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,4692.24,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,4346.496,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 23.5,2760000513,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,3753.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,2227.68,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,2227.68,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,2227.68,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,1856.4,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,4634.6,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,1880.424,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,4541.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,4692.24,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 24.0,2760000514,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,3753.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,2382.192,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,2382.192,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,2382.192,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,1985.16,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,2222.64,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,1121.376,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,2178.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,4692.24,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,4346.496,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 24.5,2760000515,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,7827.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,2382.192,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,2382.192,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,2382.192,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,1985.16,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,257.04,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,239.064,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,9784.16,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,3492.72,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 25.0,2760000516,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,7827.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,3020.976,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,3020.976,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,3020.976,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,2517.48,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,3660.552,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,2222.64,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,33.824,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,2178.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,9784.16,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,9269.2,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 25.5,2760000517,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,3753.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,3020.976,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,3020.976,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,3020.976,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,2517.48,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,1668.96,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,1786.048,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,2510.704,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,1750.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,4692.24,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 26.0,2760000518,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,3020.976,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,3020.976,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,3020.976,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,2517.48,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,4092.48,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,240.488,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,4346.496,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 26.5,2760000519,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,3753.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,3020.976,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,3020.976,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,3020.976,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,2517.48,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,4795.92,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,240.488,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,4692.24,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,4346.496,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 27.0,2760000520,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,3016.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,3020.976,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,3020.976,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,3020.976,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,2517.48,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,3660.552,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,2222.64,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,3572.104,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,240.488,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,2178.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,3770.552,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,251.328,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,3572.104,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 27.5,2760000521,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,3020.976,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,3020.976,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,3020.976,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,2517.48,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,512,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,2222.64,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,240.488,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,2178.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,3579.208,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 28.0,2760000522,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,3020.976,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,3020.976,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,3020.976,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,2517.48,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,298.472,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,128.52,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,240.488,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,125.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,1631.872,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 28.5,2760000523,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,3753.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,1604.592,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,1604.592,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,1604.592,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,1337.16,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,831.904,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,1830.28,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,3115.84,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,1793.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,4692.24,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,4001.536,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 29.0,2760000524,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,3753.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,1604.592,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,1604.592,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,1604.592,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,1337.16,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,296.64,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,834.48,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,1624.48,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,817.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,4692.24,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,4689.344,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,4445.28,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 29.5,2760000525,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,217.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,1604.592,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,1604.592,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,1604.592,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,1337.16,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,1609.528,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,2046.24,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,257.04,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,1056.12,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,2005.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,271.32,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,3579.208,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,257.04,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ALCON ACUOTO 30.0,2760000526,CDM,276,RC,C1780,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,3091.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,109.224,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,109.224,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,109.224,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,91.024,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,2603.664,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,2397.96,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,3660.552,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,1056.12,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,2350,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,3863.92,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,500.624,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,3660.552,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
AMO ZA9003 26.5,2760000527,CDM,276,RC,C1780,HCPCS,Outpatient,,,535.82,348.28,,535.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,407.22,76,,1409.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,385.79,72,,6375.168,Percent of Total Billed Charges,72% of Total Billed Charges,401.87,75,,6375.168,Percent of Total Billed charges,75% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.79,72,,6375.168,Percent of Total Billed Charges,72% of Total Billed Charges,321.49,60,,5312.64,Percent of Total Billed Charges,60% of Total Billed Charges,482.24,90,,1552.672,Percent of Total Billed Charges,90% of Total Billed Charges,241.12,45,,1830.28,Percent of Total Billed Charges,45% of Total Billed Charges,482.24,90,,1668.96,Percent of Total Billed Charges,90% of Total billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.28,65,,124.28,Percent of total Billed Charges,65% of Total Billed Charges,236.3,44.1,,1793.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,509.03,95,,1761.68,Percent of Total Billed Charges,95% of Total Billed Charges,535.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.52,88,,291.84,Percent of Total Billed Charges,88% of Total Billed Charges,482.24,90,,1668.96,Percent of Total Billed charges,90% of Total Billed Charges,236.3,535.82,
ALCON ACU0T0 26.0,2760000528,CDM,276,RC,,,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,3455.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,372.75,75,,117.752,Percent of Total Billed charges,75% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,331.016,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,256,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,4092.48,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,2575.04,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,250.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,4319.84,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,813.416,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,4092.48,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
PERIFIX FX CONT EPID ST/CATH,2770000001,CDM,277,RC,,,Outpatient,,,25.00,16.25,,25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19,76,,4049.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,18.75,75,,933.512,Percent of Total Billed charges,75% of Total Billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,15,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,22.5,90,,46.84,Percent of Total Billed Charges,90% of Total Billed Charges,11.25,45,,149.232,Percent of Total Billed Charges,45% of Total Billed Charges,22.5,90,,4795.92,Percent of Total Billed Charges,90% of Total billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.25,65,,396.76,Percent of total Billed Charges,65% of Total Billed Charges,11.03,44.1,,146.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.75,95,,5062.36,Percent of Total Billed Charges,95% of Total Billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,22.5,90,,4795.92,Percent of Total Billed charges,90% of Total Billed Charges,11.03,25,
POLYANIDE PERIFIX EPID CATH,2770000002,CDM,277,RC,,,Outpatient,,,49.00,31.85,,49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,37.24,76,,3091.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,35.28,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,36.75,75,,933.512,Percent of Total Billed charges,75% of Total Billed Charges,49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,29.4,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,44.1,90,,1552.672,Percent of Total Billed Charges,90% of Total Billed Charges,22.05,45,,415.952,Percent of Total Billed Charges,45% of Total Billed Charges,44.1,90,,3660.552,Percent of Total Billed Charges,90% of Total billed Charges,49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.85,65,,3943.16,Percent of total Billed Charges,65% of Total Billed Charges,21.61,44.1,,407.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.55,95,,3863.92,Percent of Total Billed Charges,95% of Total Billed Charges,49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,44.1,90,,3660.552,Percent of Total Billed charges,90% of Total Billed Charges,21.61,49,
SOBRAVIEW 2000 4,2770000003,CDM,277,RC,,,Outpatient,,,3.78,2.46,,3.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.87,76,,432.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.72,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,2.84,75,,933.512,Percent of Total Billed charges,75% of Total Billed Charges,3.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.72,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,2.27,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,3.4,90,,332.976,Percent of Total Billed Charges,90% of Total Billed Charges,1.7,45,,148.32,Percent of Total Billed Charges,45% of Total Billed Charges,3.4,90,,512,Percent of Total Billed Charges,90% of Total billed Charges,3.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.46,65,,2889.12,Percent of total Billed Charges,65% of Total Billed Charges,1.67,44.1,,145.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.59,95,,540.44,Percent of Total Billed Charges,95% of Total Billed Charges,3.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,3.4,90,,512,Percent of Total Billed charges,90% of Total Billed Charges,1.67,3.78,
INTUBATING STYLET 6FR,2770000004,CDM,277,RC,,,Outpatient,,,4.71,3.06,,4.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.58,76,,252.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.39,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,3.53,75,,933.512,Percent of Total Billed charges,75% of Total Billed Charges,4.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.39,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,2.83,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,4.24,90,,332.976,Percent of Total Billed Charges,90% of Total Billed Charges,2.12,45,,804.76,Percent of Total Billed Charges,45% of Total Billed Charges,4.24,90,,298.472,Percent of Total Billed Charges,90% of Total billed Charges,4.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.06,65,,258.44,Percent of total Billed Charges,65% of Total Billed Charges,2.08,44.1,,788.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.47,95,,315.048,Percent of Total Billed Charges,95% of Total Billed Charges,4.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,4.24,90,,298.472,Percent of Total Billed charges,90% of Total Billed Charges,2.08,4.71,
INTUBATING STYLET 10FR,2770000005,CDM,272,RC,,,Outpatient,,,6.20,4.03,,6.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.71,76,,702.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.46,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,4.65,75,,933.512,Percent of Total Billed charges,75% of Total Billed Charges,6.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.46,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,3.72,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,5.58,90,,332.976,Percent of Total Billed Charges,90% of Total Billed Charges,2.79,45,,1301.832,Percent of Total Billed Charges,45% of Total Billed Charges,5.58,90,,831.904,Percent of Total Billed Charges,90% of Total billed Charges,6.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.03,65,,3943.16,Percent of total Billed Charges,65% of Total Billed Charges,2.73,44.1,,1275.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.89,95,,878.12,Percent of Total Billed Charges,95% of Total Billed Charges,6.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.46,88,,323.656,Percent of Total Billed Charges,88% of Total Billed Charges,5.58,90,,831.904,Percent of Total Billed charges,90% of Total Billed Charges,2.73,6.2,
SPINAL NEEDLE 18X 3.5,2770000006,CDM,271,RC,,,Outpatient,,,1.31,0.85,,1.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1,76,,250.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.94,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,0.98,75,,2000.376,Percent of Total Billed charges,75% of Total Billed Charges,1.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.94,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,0.79,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,1.18,90,,332.976,Percent of Total Billed Charges,90% of Total Billed Charges,0.59,45,,776.336,Percent of Total Billed Charges,45% of Total Billed Charges,1.18,90,,296.64,Percent of Total Billed Charges,90% of Total billed Charges,1.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.85,65,,2759.64,Percent of total Billed Charges,65% of Total Billed Charges,0.58,44.1,,760.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.24,95,,313.12,Percent of Total Billed Charges,95% of Total Billed Charges,1.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.15,88,,45.792,Percent of Total Billed Charges,88% of Total Billed Charges,1.18,90,,296.64,Percent of Total Billed charges,90% of Total Billed Charges,0.58,1.31,
LMA 3 UNIQUE PLUS PACK,2770000007,CDM,270,RC,,,Outpatient,,,15.01,9.76,,15.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.41,76,,1359.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.81,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,11.26,75,,2000.376,Percent of Total Billed charges,75% of Total Billed Charges,15.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.81,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,9.01,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,13.51,90,,332.976,Percent of Total Billed Charges,90% of Total Billed Charges,6.75,45,,165.504,Percent of Total Billed Charges,45% of Total Billed Charges,13.51,90,,1609.528,Percent of Total Billed Charges,90% of Total billed Charges,15.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.76,65,,2759.64,Percent of total Billed Charges,65% of Total Billed Charges,6.62,44.1,,162.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.26,95,,1698.944,Percent of Total Billed Charges,95% of Total Billed Charges,15.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.21,88,,1518.168,Percent of Total Billed Charges,88% of Total Billed Charges,13.51,90,,1609.528,Percent of Total Billed charges,90% of Total Billed Charges,6.62,15.01,
GERTIE MARX SP NDL 22GX 5,2770000008,CDM,271,RC,,,Outpatient,,,17.89,11.63,,17.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.6,76,,2198.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.88,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,13.42,75,,2000.376,Percent of Total Billed charges,75% of Total Billed Charges,17.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.88,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,10.73,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,16.1,90,,4314.24,Percent of Total Billed Charges,90% of Total Billed Charges,8.05,45,,23.416,Percent of Total Billed Charges,45% of Total Billed Charges,16.1,90,,2603.664,Percent of Total Billed Charges,90% of Total billed Charges,17.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.63,65,,858.52,Percent of total Billed Charges,65% of Total Billed Charges,7.89,44.1,,22.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,17,95,,2748.312,Percent of Total Billed Charges,95% of Total Billed Charges,17.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.74,88,,325.576,Percent of Total Billed Charges,88% of Total Billed Charges,16.1,90,,2603.664,Percent of Total Billed charges,90% of Total Billed Charges,7.89,17.89,
LMA 5 UNIQUE PLUS PACK,2770000009,CDM,270,RC,,,Outpatient,,,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,1311.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,2000.376,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,2249.28,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,776.336,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,1552.672,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,1068.6,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,760.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,1638.936,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,325.576,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,1552.672,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
CHLORAPREP 1 STEP 1.5ML FREPP,2770000010,CDM,272,RC,,,Outpatient,,,0.74,0.48,,0.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.56,76,,279.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.53,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,0.56,75,,2000.376,Percent of Total Billed charges,75% of Total Billed Charges,0.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.53,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,0.44,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,0.67,90,,1462.32,Percent of Total Billed Charges,90% of Total Billed Charges,0.33,45,,166.488,Percent of Total Billed Charges,45% of Total Billed Charges,0.67,90,,331.016,Percent of Total Billed Charges,90% of Total billed Charges,0.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.48,65,,396.76,Percent of total Billed Charges,65% of Total Billed Charges,0.33,44.1,,163.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.7,95,,349.4,Percent of Total Billed Charges,95% of Total Billed Charges,0.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.65,88,,325.576,Percent of Total Billed Charges,88% of Total Billed Charges,0.67,90,,331.016,Percent of Total Billed charges,90% of Total Billed Charges,0.33,0.74,
LMA 2 1/2 UNIQUE PLUS PACK,2770000011,CDM,277,RC,,,Outpatient,,,15.87,10.32,,15.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.06,76,,39.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.43,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,11.9,75,,2000.376,Percent of Total Billed charges,75% of Total Billed Charges,15.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.43,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,9.52,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,14.28,90,,1462.32,Percent of Total Billed Charges,90% of Total Billed Charges,7.14,45,,166.488,Percent of Total Billed Charges,45% of Total Billed Charges,14.28,90,,46.84,Percent of Total Billed Charges,90% of Total billed Charges,15.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,65,,396.76,Percent of total Billed Charges,65% of Total Billed Charges,7,44.1,,163.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.08,95,,49.44,Percent of Total Billed Charges,95% of Total Billed Charges,15.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,14.28,90,,46.84,Percent of Total Billed charges,90% of Total Billed Charges,7,15.87,
LMA 1 1/2,2770000012,CDM,272,RC,,,Outpatient,,,15.00,9.75,,15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.4,76,,1311.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.8,72,,92.72,Percent of Total Billed Charges,72% of Total Billed Charges,11.25,75,,92.72,Percent of Total Billed charges,75% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.8,72,,92.72,Percent of Total Billed Charges,72% of Total Billed Charges,9,60,,77.264,Percent of Total Billed Charges,60% of Total Billed Charges,13.5,90,,172.08,Percent of Total Billed Charges,90% of Total Billed Charges,6.75,45,,166.488,Percent of Total Billed Charges,45% of Total Billed Charges,13.5,90,,1552.672,Percent of Total Billed Charges,90% of Total billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.75,65,,369.2,Percent of total Billed Charges,65% of Total Billed Charges,6.62,44.1,,163.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.25,95,,1638.936,Percent of Total Billed Charges,95% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.2,88,,325.576,Percent of Total Billed Charges,88% of Total Billed Charges,13.5,90,,1552.672,Percent of Total Billed charges,90% of Total Billed Charges,6.62,15,
LMA 1,2770000013,CDM,272,RC,,,Outpatient,,,15.00,9.75,,15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.4,76,,281.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.8,72,,2453.76,Percent of Total Billed Charges,72% of Total Billed Charges,11.25,75,,2453.76,Percent of Total Billed charges,75% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.8,72,,2453.76,Percent of Total Billed Charges,72% of Total Billed Charges,9,60,,2044.8,Percent of Total Billed Charges,60% of Total Billed Charges,13.5,90,,3565.44,Percent of Total Billed Charges,90% of Total Billed Charges,6.75,45,,166.488,Percent of Total Billed Charges,45% of Total Billed Charges,13.5,90,,332.976,Percent of Total Billed Charges,90% of Total billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.75,65,,355.448,Percent of total Billed Charges,65% of Total Billed Charges,6.62,44.1,,163.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.25,95,,351.48,Percent of Total Billed Charges,95% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.2,88,,4218.368,Percent of Total Billed Charges,88% of Total Billed Charges,13.5,90,,332.976,Percent of Total Billed charges,90% of Total Billed Charges,6.62,15,
LMA 4 UNIQUE PLUS PACK,2770000014,CDM,270,RC,,,Outpatient,,,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,281.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,4261.12,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,4438.672,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,4261.12,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,3550.936,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,549.36,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,166.488,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,332.976,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,355.448,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,163.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,351.48,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,2199.296,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,332.976,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
GERTIE MARX CSE NDL 27G X 6.5,2770000015,CDM,272,RC,,,Outpatient,,,33.08,21.50,,33.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.14,76,,281.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.82,72,,1062.632,Percent of Total Billed Charges,72% of Total Billed Charges,24.81,75,,1062.632,Percent of Total Billed charges,75% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.82,72,,1062.632,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,60,,885.528,Percent of Total Billed Charges,60% of Total Billed Charges,29.77,90,,5459.76,Percent of Total Billed Charges,90% of Total Billed Charges,14.89,45,,2157.12,Percent of Total Billed Charges,45% of Total Billed Charges,29.77,90,,332.976,Percent of Total Billed Charges,90% of Total billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.5,65,,104,Percent of total Billed Charges,65% of Total Billed Charges,14.59,44.1,,2113.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.43,95,,351.48,Percent of Total Billed Charges,95% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.11,88,,1429.824,Percent of Total Billed Charges,88% of Total Billed Charges,29.77,90,,332.976,Percent of Total Billed charges,90% of Total Billed Charges,14.59,33.08,
LMA 2 UNIQUE PLUS PACK,2770000016,CDM,272,RC,,,Outpatient,,,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,281.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,1062.632,Percent of Total Billed Charges,72% of Total Billed Charges,9.1,75,,1062.632,Percent of Total Billed charges,75% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,1062.632,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,885.528,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,4000.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,1124.64,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,332.976,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,36.688,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,1102.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,351.48,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,1429.824,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,332.976,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
SORBRAVIEW 2000 4,2770000018,CDM,272,RC,,,Outpatient,,,3.78,2.46,,3.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.87,76,,281.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.72,72,,350.784,Percent of Total Billed Charges,72% of Total Billed Charges,2.84,75,,365.4,Percent of Total Billed charges,75% of Total Billed Charges,3.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.72,72,,350.784,Percent of Total Billed Charges,72% of Total Billed Charges,2.27,60,,292.32,Percent of Total Billed Charges,60% of Total Billed Charges,3.4,90,,357.84,Percent of Total Billed Charges,90% of Total Billed Charges,1.7,45,,731.16,Percent of Total Billed Charges,45% of Total Billed Charges,3.4,90,,332.976,Percent of Total Billed Charges,90% of Total billed Charges,3.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.46,65,,23.504,Percent of total Billed Charges,65% of Total Billed Charges,1.67,44.1,,716.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.59,95,,351.48,Percent of Total Billed Charges,95% of Total Billed Charges,3.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.33,88,,168.256,Percent of Total Billed Charges,88% of Total Billed Charges,3.4,90,,332.976,Percent of Total Billed charges,90% of Total Billed Charges,1.67,3.78,
ADULT HEAD POSITIONER PURPLE,2770000019,CDM,271,RC,,,Outpatient,,,14.34,9.32,,14.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.9,76,,3643.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.32,72,,241.344,Percent of Total Billed Charges,72% of Total Billed Charges,10.76,75,,241.344,Percent of Total Billed charges,75% of Total Billed Charges,14.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,72,,241.344,Percent of Total Billed Charges,72% of Total Billed Charges,8.6,60,,201.12,Percent of Total Billed Charges,60% of Total Billed Charges,12.91,90,,5459.76,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,731.16,Percent of Total Billed Charges,45% of Total Billed Charges,12.91,90,,4314.24,Percent of Total Billed Charges,90% of Total billed Charges,14.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.32,65,,165.112,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,716.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.62,95,,4553.92,Percent of Total Billed Charges,95% of Total Billed Charges,14.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.62,88,,3486.208,Percent of Total Billed Charges,88% of Total Billed Charges,12.91,90,,4314.24,Percent of Total Billed charges,90% of Total Billed Charges,6.32,14.34,
10.2F BILRY DRN CATH 40CM .038,2780000001,CDM,278,RC,C1729,HCPCS,Outpatient,,,357.00,232.05,,357,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,271.32,76,,1899.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,257.04,72,,444.096,Percent of Total Billed Charges,72% of Total Billed Charges,257.04,72,,444.096,Percent of Total Billed charges,72% of Total Billed Charges,357,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.04,72,,444.096,Percent of Total Billed Charges,72% of Total Billed Charges,214.2,60,,370.08,Percent of Total Billed Charges,60% of Total Billed Charges,321.3,90,,3821.04,Percent of Total Billed Charges,90% of Total Billed Charges,160.65,45,,86.04,Percent of Total Billed Charges,45% of Total Billed Charges,321.3,90,,2249.28,Percent of Total Billed Charges,90% of Total billed Charges,357,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.05,65,,34.4,Percent of total Billed Charges,65% of Total Billed Charges,157.44,44.1,,84.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,339.15,95,,2374.24,Percent of Total Billed Charges,95% of Total Billed Charges,357,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.16,88,,537.152,Percent of Total Billed Charges,88% of Total Billed Charges,321.3,90,,2249.28,Percent of Total Billed charges,90% of Total Billed Charges,157.44,357,
10.2FR 15CM DWSN MULR CATH DRN,2780000002,CDM,278,RC,C1729,HCPCS,Outpatient,,,280.23,182.15,,280.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,212.97,76,,1234.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,201.77,72,,444.096,Percent of Total Billed Charges,72% of Total Billed Charges,201.77,72,,444.096,Percent of Total Billed charges,72% of Total Billed Charges,280.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.77,72,,444.096,Percent of Total Billed Charges,72% of Total Billed Charges,168.14,60,,370.08,Percent of Total Billed Charges,60% of Total Billed Charges,252.21,90,,3821.04,Percent of Total Billed Charges,90% of Total Billed Charges,126.1,45,,1782.72,Percent of Total Billed Charges,45% of Total Billed Charges,252.21,90,,1462.32,Percent of Total Billed Charges,90% of Total billed Charges,280.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182.15,65,,131.144,Percent of total Billed Charges,65% of Total Billed Charges,123.58,44.1,,1747.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,266.22,95,,1543.56,Percent of Total Billed Charges,95% of Total Billed Charges,280.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.6,88,,5338.432,Percent of Total Billed Charges,88% of Total Billed Charges,252.21,90,,1462.32,Percent of Total Billed charges,90% of Total Billed Charges,123.58,280.23,
10F (25CM) DWSN MULR CATH DRN,2780000003,CDM,278,RC,C1729,HCPCS,Outpatient,,,280.23,182.15,,280.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,212.97,76,,1234.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,201.77,72,,444.096,Percent of Total Billed Charges,72% of Total Billed Charges,201.77,72,,444.096,Percent of Total Billed charges,72% of Total Billed Charges,280.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.77,72,,444.096,Percent of Total Billed Charges,72% of Total Billed Charges,168.14,60,,370.08,Percent of Total Billed Charges,60% of Total Billed Charges,252.21,90,,1188.72,Percent of Total Billed Charges,90% of Total Billed Charges,126.1,45,,274.68,Percent of Total Billed Charges,45% of Total Billed Charges,252.21,90,,1462.32,Percent of Total Billed Charges,90% of Total billed Charges,280.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182.15,65,,2602.6,Percent of total Billed Charges,65% of Total Billed Charges,123.58,44.1,,269.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,266.22,95,,1543.56,Percent of Total Billed Charges,95% of Total Billed Charges,280.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.6,88,,3911.424,Percent of Total Billed Charges,88% of Total Billed Charges,252.21,90,,1462.32,Percent of Total Billed charges,90% of Total Billed Charges,123.58,280.23,
12FR (15CM) DWSN MULR CATH DRN,2780000004,CDM,278,RC,C1729,HCPCS,Outpatient,,,451.95,293.77,,451.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,343.48,76,,145.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,325.4,72,,241.344,Percent of Total Billed Charges,72% of Total Billed Charges,325.4,72,,241.344,Percent of Total Billed charges,72% of Total Billed Charges,451.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.4,72,,241.344,Percent of Total Billed Charges,72% of Total Billed Charges,271.17,60,,201.12,Percent of Total Billed Charges,60% of Total Billed Charges,406.76,90,,1479.6,Percent of Total Billed Charges,90% of Total Billed Charges,203.38,45,,2729.88,Percent of Total Billed Charges,45% of Total Billed Charges,406.76,90,,172.08,Percent of Total Billed Charges,90% of Total billed Charges,451.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,451.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,451.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.77,65,,273.864,Percent of total Billed Charges,65% of Total Billed Charges,199.31,44.1,,2675.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,429.35,95,,181.64,Percent of Total Billed Charges,95% of Total Billed Charges,451.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.72,88,,349.888,Percent of Total Billed Charges,88% of Total Billed Charges,406.76,90,,172.08,Percent of Total Billed charges,90% of Total Billed Charges,199.31,451.95,
12FR (25CM) DWSN MULR CATH DRN,2780000005,CDM,278,RC,C1729,HCPCS,Outpatient,,,333.46,216.75,,333.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,253.43,76,,3010.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,240.09,72,,1542.528,Percent of Total Billed Charges,72% of Total Billed Charges,240.09,72,,1542.528,Percent of Total Billed charges,72% of Total Billed Charges,333.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.09,72,,1542.528,Percent of Total Billed Charges,72% of Total Billed Charges,200.08,60,,1285.44,Percent of Total Billed Charges,60% of Total Billed Charges,300.11,90,,549.36,Percent of Total Billed Charges,90% of Total Billed Charges,150.06,45,,2000.16,Percent of Total Billed Charges,45% of Total Billed Charges,300.11,90,,3565.44,Percent of Total Billed Charges,90% of Total billed Charges,333.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.75,65,,275.184,Percent of total Billed Charges,65% of Total Billed Charges,147.06,44.1,,1960.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,316.79,95,,3763.52,Percent of Total Billed Charges,95% of Total Billed Charges,333.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.44,88,,5338.432,Percent of Total Billed Charges,88% of Total Billed Charges,300.11,90,,3565.44,Percent of Total Billed charges,90% of Total Billed Charges,147.06,333.46,
14.0F BILRY DRN CATH (40CM),2780000006,CDM,278,RC,C1729,HCPCS,Outpatient,,,457.00,297.05,,457,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,347.32,76,,463.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,329.04,72,,838.256,Percent of Total Billed Charges,72% of Total Billed Charges,329.04,72,,838.256,Percent of Total Billed charges,72% of Total Billed Charges,457,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.04,72,,838.256,Percent of Total Billed Charges,72% of Total Billed Charges,274.2,60,,698.544,Percent of Total Billed Charges,60% of Total Billed Charges,411.3,90,,549.36,Percent of Total Billed Charges,90% of Total Billed Charges,205.65,45,,178.92,Percent of Total Billed Charges,45% of Total Billed Charges,411.3,90,,549.36,Percent of Total Billed Charges,90% of Total billed Charges,457,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,457,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,457,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.05,65,,14.56,Percent of total Billed Charges,65% of Total Billed Charges,201.54,44.1,,175.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,434.15,95,,579.88,Percent of Total Billed Charges,95% of Total Billed Charges,457,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,402.16,88,,3736.128,Percent of Total Billed Charges,88% of Total Billed Charges,411.3,90,,549.36,Percent of Total Billed charges,90% of Total Billed Charges,201.54,457,
JACKY 5F RADIAL 4.0 110CM,2780000007,CDM,272,RC,C1887,HCPCS,Outpatient,,,180.81,117.53,,180.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,137.42,76,,4610.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,130.18,72,,104.144,Percent of Total Billed Charges,72% of Total Billed Charges,135.61,75,,108.488,Percent of Total Billed charges,75% of Total Billed Charges,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.18,72,,104.144,Percent of Total Billed Charges,72% of Total Billed Charges,108.49,60,,86.792,Percent of Total Billed Charges,60% of Total Billed Charges,162.73,90,,511.2,Percent of Total Billed Charges,90% of Total Billed Charges,81.36,45,,2729.88,Percent of Total Billed Charges,45% of Total Billed Charges,162.73,90,,5459.76,Percent of Total Billed Charges,90% of Total billed Charges,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.53,65,,35.624,Percent of total Billed Charges,65% of Total Billed Charges,79.74,44.1,,2675.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,171.77,95,,5763.08,Percent of Total Billed Charges,95% of Total Billed Charges,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.11,88,,3736.128,Percent of Total Billed Charges,88% of Total Billed Charges,162.73,90,,5459.76,Percent of Total Billed charges,90% of Total Billed Charges,79.74,180.81,
4F 2.5X40X150 PWR CRS PTA BAL,2780000008,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,3378.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,104.144,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,108.488,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,104.144,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,86.792,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,492.16,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,1910.52,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,4000.32,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,597.384,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,1872.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,4222.56,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,1162.304,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,4000.32,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
4F 2X40X150 PWR CRS PTA BAL,2780000009,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,302.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,339.744,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,339.744,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,339.744,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,283.12,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,492.16,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,1910.52,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,357.84,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,597.384,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,1872.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,377.72,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,1446.72,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,357.84,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
4F 3X100X150 STRLG OTW PTA BAL,2780000010,CDM,278,RC,C1725,HCPCS,Outpatient,,,672.53,437.14,,672.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,511.12,76,,4610.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,484.22,72,,339.744,Percent of Total Billed Charges,72% of Total Billed Charges,484.22,72,,339.744,Percent of Total Billed charges,72% of Total Billed Charges,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484.22,72,,339.744,Percent of Total Billed Charges,72% of Total Billed Charges,403.52,60,,283.12,Percent of Total Billed Charges,60% of Total Billed Charges,605.28,90,,144,Percent of Total Billed Charges,90% of Total Billed Charges,302.64,45,,594.36,Percent of Total Billed Charges,45% of Total Billed Charges,605.28,90,,5459.76,Percent of Total Billed Charges,90% of Total billed Charges,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.14,65,,197.432,Percent of total Billed Charges,65% of Total Billed Charges,296.59,44.1,,582.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,638.9,95,,5763.08,Percent of Total Billed Charges,95% of Total Billed Charges,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,591.83,88,,537.152,Percent of Total Billed Charges,88% of Total Billed Charges,605.28,90,,5459.76,Percent of Total Billed charges,90% of Total Billed Charges,296.59,672.53,
4F 3X20X150 PWR CRS PTA BAL,2780000011,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,3226.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,339.744,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,339.744,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,339.744,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,283.12,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,50.8,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,739.8,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,3821.04,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,197.432,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,725.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,4033.32,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,537.152,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,3821.04,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
4F 3X20X90 PWR CRS PTA BAL,2780000012,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,3226.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,339.744,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,339.744,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,339.744,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,283.12,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,32.544,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,274.68,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,3821.04,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,273.52,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,269.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,4033.32,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,499.84,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,3821.04,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
4F 3X40X150 PWR CRS PTA BAL,2780000013,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,1003.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,2620.8,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,2620.8,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,2620.8,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,2184,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,228.616,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,274.68,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,1188.72,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,1203.928,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,269.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,1254.76,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,481.216,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,1188.72,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
4F 3X40X90 PWR CRS PTA BAL,2780000014,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,1249.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,110.024,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,110.024,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,110.024,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,91.688,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,47.632,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,255.6,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,1479.6,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,1532.432,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,250.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,1561.8,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,481.216,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,1479.6,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
4F 3X60X90 PWR CRS PTA BAL,2780000015,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,463.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,2122.848,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,2122.848,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,2122.848,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,1769.04,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,181.584,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,246.08,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,549.36,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,147.68,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,241.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,579.88,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,140.8,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,549.36,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
4F 3X80X150 PWR CRS PTA BAL,2780000016,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,463.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,3603.6,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,246.08,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,549.36,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,35.624,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,241.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,579.88,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,49.672,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,549.36,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
4F 4X100X150 PWR CRS PTA BAL,2780000017,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,431.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,379.192,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,72,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,511.2,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,54.04,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,70.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,539.6,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,31.824,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,511.2,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
4F 4X100X150 STRLG OTW PTA BAL,2780000018,CDM,278,RC,C1725,HCPCS,Outpatient,,,672.53,437.14,,672.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,511.12,76,,415.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,484.22,72,,2453.76,Percent of Total Billed Charges,72% of Total Billed Charges,484.22,72,,2453.76,Percent of Total Billed charges,72% of Total Billed Charges,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484.22,72,,2453.76,Percent of Total Billed Charges,72% of Total Billed Charges,403.52,60,,2044.8,Percent of Total Billed Charges,60% of Total Billed Charges,605.28,90,,381.024,Percent of Total Billed Charges,90% of Total Billed Charges,302.64,45,,25.4,Percent of Total Billed Charges,45% of Total Billed Charges,605.28,90,,492.16,Percent of Total Billed Charges,90% of Total billed Charges,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.14,65,,1880.424,Percent of total Billed Charges,65% of Total Billed Charges,296.59,44.1,,24.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,638.9,95,,519.496,Percent of Total Billed Charges,95% of Total Billed Charges,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,591.83,88,,223.536,Percent of Total Billed Charges,88% of Total Billed Charges,605.28,90,,492.16,Percent of Total Billed charges,90% of Total Billed Charges,296.59,672.53,
4F 4X120X150 PWR CRS PTA BAL,2780000019,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,415.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,1651.712,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,1651.712,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,1651.712,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,1376.424,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,16.272,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,492.16,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,1880.424,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,15.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,519.496,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,46.568,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,492.16,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
4F 4X150X150 PWR CRS PTA BAL,2780000020,CDM,278,RC,C1876,HCPCS,Outpatient,,,3572.10,2321.87,,3572.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2714.8,76,,121.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2571.91,72,,3824.064,Percent of Total Billed Charges,72% of Total Billed Charges,2571.91,72,,3824.064,Percent of Total Billed charges,72% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2571.91,72,,3824.064,Percent of Total Billed Charges,72% of Total Billed Charges,2143.26,60,,3186.72,Percent of Total Billed Charges,60% of Total Billed Charges,3214.89,90,,49.328,Percent of Total Billed Charges,90% of Total Billed Charges,1607.45,45,,114.304,Percent of Total Billed Charges,45% of Total Billed Charges,3214.89,90,,144,Percent of Total Billed Charges,90% of Total billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2321.87,65,,1708.432,Percent of total Billed Charges,65% of Total Billed Charges,1575.3,44.1,,112.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,3393.5,95,,152,Percent of Total Billed Charges,95% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3143.45,88,,177.552,Percent of Total Billed Charges,88% of Total Billed Charges,3214.89,90,,144,Percent of Total Billed charges,90% of Total Billed Charges,1575.3,3572.1,
4F 4X200X150 PWR CRS PTA BAL,2780000021,CDM,278,RC,C1876,HCPCS,Outpatient,,,3572.10,2321.87,,3572.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2714.8,76,,42.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2571.91,72,,192.328,Percent of Total Billed Charges,72% of Total Billed Charges,2571.91,72,,192.328,Percent of Total Billed charges,72% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2571.91,72,,192.328,Percent of Total Billed Charges,72% of Total Billed Charges,2143.26,60,,160.272,Percent of Total Billed Charges,60% of Total Billed Charges,3214.89,90,,827.144,Percent of Total Billed Charges,90% of Total Billed Charges,1607.45,45,,23.816,Percent of Total Billed Charges,45% of Total Billed Charges,3214.89,90,,50.8,Percent of Total Billed Charges,90% of Total billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2321.87,65,,3943.16,Percent of total Billed Charges,65% of Total Billed Charges,1575.3,44.1,,23.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,3393.5,95,,53.624,Percent of Total Billed Charges,95% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3143.45,88,,3523.52,Percent of Total Billed Charges,88% of Total Billed Charges,3214.89,90,,50.8,Percent of Total Billed charges,90% of Total Billed Charges,1575.3,3572.1,
4F 4X20X150 PWR CRS PTA BAL,2780000022,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,27.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,320.064,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,320.064,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,320.064,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,266.72,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,827.144,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,90.792,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,32.544,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,78.544,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,88.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,34.352,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,370.768,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,32.544,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
4F 4X20X90 PWR CRS PTA BAL,2780000023,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,193.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,320.064,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,320.064,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,320.064,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,266.72,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,273.368,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,1801.8,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,228.616,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,78.544,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,1765.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,241.312,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,372.56,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,228.616,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
4F 4X40X135 STRLG  OTW PTA BAL,2780000024,CDM,278,RC,C1725,HCPCS,Outpatient,,,672.53,437.14,,672.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,511.12,76,,40.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,484.22,72,,320.064,Percent of Total Billed Charges,72% of Total Billed Charges,484.22,72,,320.064,Percent of Total Billed charges,72% of Total Billed Charges,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484.22,72,,320.064,Percent of Total Billed Charges,72% of Total Billed Charges,403.52,60,,266.72,Percent of Total Billed Charges,60% of Total Billed Charges,605.28,90,,273.368,Percent of Total Billed Charges,90% of Total Billed Charges,302.64,45,,189.6,Percent of Total Billed Charges,45% of Total Billed Charges,605.28,90,,47.632,Percent of Total Billed Charges,90% of Total billed Charges,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.14,65,,78.544,Percent of total Billed Charges,65% of Total Billed Charges,296.59,44.1,,185.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,638.9,95,,50.272,Percent of Total Billed Charges,95% of Total Billed Charges,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,591.83,88,,19.712,Percent of Total Billed Charges,88% of Total Billed Charges,605.28,90,,47.632,Percent of Total Billed charges,90% of Total Billed Charges,296.59,672.53,
4F 4X40X150 PWR CRS PTA BAL,2780000025,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,153.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,348.968,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,348.968,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,348.968,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,290.808,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,378.72,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,190.512,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,181.584,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,78.544,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,186.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,191.672,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,48.232,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,181.584,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
4F 4X40X90 PWR CRS PTA BAL,2780000026,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,3043.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,418.176,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,418.176,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,418.176,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,348.48,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,1666.984,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,10.08,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,3603.6,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,173.712,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,9.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,3803.8,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,808.76,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,3603.6,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
4F 5X100X135 STRLG OTW PTA BAL,2780000027,CDM,278,RC,C1725,HCPCS,Outpatient,,,672.53,437.14,,672.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,511.12,76,,320.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,484.22,72,,418.176,Percent of Total Billed Charges,72% of Total Billed Charges,484.22,72,,418.176,Percent of Total Billed charges,72% of Total Billed Charges,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484.22,72,,418.176,Percent of Total Billed Charges,72% of Total Billed Charges,403.52,60,,348.48,Percent of Total Billed Charges,60% of Total Billed Charges,605.28,90,,2121.824,Percent of Total Billed Charges,90% of Total Billed Charges,302.64,45,,24.664,Percent of Total Billed Charges,45% of Total Billed Charges,605.28,90,,379.192,Percent of Total Billed Charges,90% of Total billed Charges,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.14,65,,227.6,Percent of total Billed Charges,65% of Total Billed Charges,296.59,44.1,,24.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,638.9,95,,400.264,Percent of Total Billed Charges,95% of Total Billed Charges,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,591.83,88,,808.76,Percent of Total Billed Charges,88% of Total Billed Charges,605.28,90,,379.192,Percent of Total Billed charges,90% of Total Billed Charges,296.59,672.53,
4F 5X20X150 PWR CRS PTA BAL,2780000028,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,321.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,511.488,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,511.488,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,511.488,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,426.24,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,204.48,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,413.568,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,381.024,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,173.712,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,405.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,402.192,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,267.296,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,381.024,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
4F 5X20X90 PWR CRS PTA BAL,2780000029,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,17.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,186.048,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,155.04,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,49.328,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,413.568,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,20.16,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,227.6,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,405.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,21.28,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,267.296,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,20.16,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
4F 5X40X135 STRLG OTW PTA BAL,2780000030,CDM,278,RC,C1725,HCPCS,Outpatient,,,672.53,437.14,,672.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,511.12,76,,41.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,484.22,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,484.22,72,,186.048,Percent of Total Billed charges,72% of Total Billed Charges,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484.22,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,403.52,60,,155.04,Percent of Total Billed Charges,60% of Total Billed Charges,605.28,90,,74.824,Percent of Total Billed Charges,90% of Total Billed Charges,302.64,45,,136.688,Percent of Total Billed Charges,45% of Total Billed Charges,605.28,90,,49.328,Percent of Total Billed Charges,90% of Total billed Charges,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.14,65,,189.192,Percent of total Billed Charges,65% of Total Billed Charges,296.59,44.1,,133.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,638.9,95,,52.064,Percent of Total Billed Charges,95% of Total Billed Charges,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,591.83,88,,370.304,Percent of Total Billed Charges,88% of Total Billed Charges,605.28,90,,49.328,Percent of Total Billed charges,90% of Total Billed Charges,296.59,672.53,
4F 5X40X150 PWR CRS PTA BAL,2780000031,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,698.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,186.048,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,155.04,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,2603.664,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,136.688,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,827.144,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,243.08,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,133.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,873.096,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,1629.936,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,827.144,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
4F 5X40X90 PWR CRS PTA BAL,2780000032,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,698.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,186.048,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,155.04,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,2603.664,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,189.36,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,827.144,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,2186.184,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,185.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,873.096,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,2074.672,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,827.144,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
4F 6X100X135 STRLG OTW PTA BAL,2780000033,CDM,278,RC,C1725,HCPCS,Outpatient,,,672.53,437.14,,672.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,511.12,76,,230.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,484.22,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,484.22,72,,186.048,Percent of Total Billed charges,72% of Total Billed Charges,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484.22,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,403.52,60,,155.04,Percent of Total Billed Charges,60% of Total Billed Charges,605.28,90,,2365.528,Percent of Total Billed Charges,90% of Total Billed Charges,302.64,45,,833.488,Percent of Total Billed Charges,45% of Total Billed Charges,605.28,90,,273.368,Percent of Total Billed Charges,90% of Total billed Charges,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.14,65,,2186.184,Percent of total Billed Charges,65% of Total Billed Charges,296.59,44.1,,816.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,638.9,95,,288.56,Percent of Total Billed Charges,95% of Total Billed Charges,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,591.83,88,,199.936,Percent of Total Billed Charges,88% of Total Billed Charges,605.28,90,,273.368,Percent of Total Billed charges,90% of Total Billed Charges,296.59,672.53,
4F 6X20X150 PWR CRS PTA BAL,2780000034,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,230.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,186.048,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,155.04,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,5459.76,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,1060.912,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,273.368,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,306.04,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,1039.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,288.56,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,48.232,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,273.368,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
4F 6X20X90 PWR CRS PTA BAL,2780000035,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,319.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,186.048,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,155.04,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,108.752,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,102.24,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,378.72,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,57.904,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,100.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,399.76,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,73.16,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,378.72,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
4F 6X40X135 STRLG OTW PTA BAL,2780000036,CDM,278,RC,C1725,HCPCS,Outpatient,,,672.53,437.14,,672.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,511.12,76,,1407.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,484.22,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,484.22,72,,186.048,Percent of Total Billed charges,72% of Total Billed Charges,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484.22,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,403.52,60,,155.04,Percent of Total Billed Charges,60% of Total Billed Charges,605.28,90,,108.752,Percent of Total Billed Charges,90% of Total Billed Charges,302.64,45,,24.664,Percent of Total Billed Charges,45% of Total Billed Charges,605.28,90,,1666.984,Percent of Total Billed Charges,90% of Total billed Charges,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.14,65,,89.432,Percent of total Billed Charges,65% of Total Billed Charges,296.59,44.1,,24.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,638.9,95,,1759.592,Percent of Total Billed Charges,95% of Total Billed Charges,672.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,591.83,88,,2545.808,Percent of Total Billed Charges,88% of Total Billed Charges,605.28,90,,1666.984,Percent of Total Billed charges,90% of Total Billed Charges,296.59,672.53,
4F STIFFEN VS 7CM MP NDLE KIT,2780000037,CDM,272,RC,C1894,HCPCS,Outpatient,,,126.77,82.40,,126.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,96.35,76,,1791.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.27,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,95.08,75,,186.048,Percent of Total Billed charges,75% of Total Billed Charges,126.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.27,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,76.06,60,,155.04,Percent of Total Billed Charges,60% of Total Billed Charges,114.09,90,,108.752,Percent of Total Billed Charges,90% of Total Billed Charges,57.05,45,,37.408,Percent of Total Billed Charges,45% of Total Billed Charges,114.09,90,,2121.824,Percent of Total Billed Charges,90% of Total billed Charges,126.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.4,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,55.91,44.1,,36.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,120.43,95,,2239.704,Percent of Total Billed Charges,95% of Total Billed Charges,126.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.56,88,,2545.808,Percent of Total Billed Charges,88% of Total Billed Charges,114.09,90,,2121.824,Percent of Total Billed charges,90% of Total Billed Charges,55.91,126.77,
5F 4X40X40 MUSTNG OTW PTA BAL,2780000038,CDM,278,RC,C1725,HCPCS,Outpatient,,,474.08,308.15,,474.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,360.3,76,,172.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,341.34,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,341.34,72,,186.048,Percent of Total Billed charges,72% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.34,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,284.45,60,,155.04,Percent of Total Billed Charges,60% of Total Billed Charges,426.67,90,,108.752,Percent of Total Billed Charges,90% of Total Billed Charges,213.34,45,,1301.832,Percent of Total Billed Charges,45% of Total Billed Charges,426.67,90,,204.48,Percent of Total Billed Charges,90% of Total billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.15,65,,94.024,Percent of total Billed Charges,65% of Total Billed Charges,209.07,44.1,,1275.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,450.38,95,,215.84,Percent of Total Billed Charges,95% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.19,88,,2312.96,Percent of Total Billed Charges,88% of Total Billed Charges,426.67,90,,204.48,Percent of Total Billed charges,90% of Total Billed Charges,209.07,474.08,
5F 5X100MMX135CM EVRC PTA BALL,2780000039,CDM,272,RC,C1725,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,41.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,97.92,Percent of Total Billed Charges,72% of Total Billed Charges,2050.65,75,,97.92,Percent of Total Billed charges,75% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,97.92,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,81.6,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,240.52,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,1301.832,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,49.328,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,89.432,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,1275.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,52.064,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,5338.432,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,49.328,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
5F 5X100X150 PWR CRS PTA BAL,2780000040,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,63.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,186.048,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,155.04,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,315.136,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,1182.76,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,74.824,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,89.432,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,1159.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,78.976,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,106.336,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,74.824,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
5F 5X120MMX135CM EVRC PTA BALL,2780000041,CDM,272,RC,C1725,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,2198.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,97.92,Percent of Total Billed Charges,72% of Total Billed Charges,2050.65,75,,97.92,Percent of Total Billed charges,75% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,97.92,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,81.6,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,240.52,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,2729.88,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,2603.664,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,89.432,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,2675.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,2748.312,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,106.336,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,2603.664,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
5F 5X120X150 PWR CRS PTA BAL,2780000042,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,2198.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,97.92,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,97.92,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,97.92,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,81.6,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,315.136,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,54.376,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,2603.664,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,89.432,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,53.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,2748.312,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,106.336,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,2603.664,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
5F 5X150MMX135CM EVRC PTA BALL,2780000043,CDM,272,RC,C1725,HCPCS,Outpatient,,,3572.10,2321.87,,3572.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2714.8,76,,1997.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2571.91,72,,97.92,Percent of Total Billed Charges,72% of Total Billed Charges,2679.08,75,,97.92,Percent of Total Billed charges,75% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2571.91,72,,97.92,Percent of Total Billed Charges,72% of Total Billed Charges,2143.26,60,,81.6,Percent of Total Billed Charges,60% of Total Billed Charges,3214.89,90,,261.96,Percent of Total Billed Charges,90% of Total Billed Charges,1607.45,45,,54.376,Percent of Total Billed Charges,45% of Total Billed Charges,3214.89,90,,2365.528,Percent of Total Billed Charges,90% of Total billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2321.87,65,,89.432,Percent of total Billed Charges,65% of Total Billed Charges,1575.3,44.1,,53.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,3393.5,95,,2496.944,Percent of Total Billed Charges,95% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3143.45,88,,106.336,Percent of Total Billed Charges,88% of Total Billed Charges,3214.89,90,,2365.528,Percent of Total Billed charges,90% of Total Billed Charges,1575.3,3572.1,
5F 5X150X150 PWR CRS PTA BAL,2780000044,CDM,278,RC,C1876,HCPCS,Outpatient,,,3572.10,2321.87,,3572.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2714.8,76,,4610.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2571.91,72,,1566.144,Percent of Total Billed Charges,72% of Total Billed Charges,2571.91,72,,1566.144,Percent of Total Billed charges,72% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2571.91,72,,1566.144,Percent of Total Billed Charges,72% of Total Billed Charges,2143.26,60,,1305.12,Percent of Total Billed Charges,60% of Total Billed Charges,3214.89,90,,336.568,Percent of Total Billed Charges,90% of Total Billed Charges,1607.45,45,,54.376,Percent of Total Billed Charges,45% of Total Billed Charges,3214.89,90,,5459.76,Percent of Total Billed Charges,90% of Total billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2321.87,65,,1045.128,Percent of total Billed Charges,65% of Total Billed Charges,1575.3,44.1,,53.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,3393.5,95,,5763.08,Percent of Total Billed Charges,95% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3143.45,88,,235.176,Percent of Total Billed Charges,88% of Total Billed Charges,3214.89,90,,5459.76,Percent of Total Billed charges,90% of Total Billed Charges,1575.3,3572.1,
5F 5X200MMX135CM EVRC PTA BALL,2780000045,CDM,272,RC,C1725,HCPCS,Outpatient,,,3572.10,2321.87,,3572.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2714.8,76,,91.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2571.91,72,,1566.144,Percent of Total Billed Charges,72% of Total Billed Charges,2679.08,75,,1566.144,Percent of Total Billed charges,75% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2571.91,72,,1566.144,Percent of Total Billed Charges,72% of Total Billed Charges,2143.26,60,,1305.12,Percent of Total Billed Charges,60% of Total Billed Charges,3214.89,90,,3027.024,Percent of Total Billed Charges,90% of Total Billed Charges,1607.45,45,,54.376,Percent of Total Billed Charges,45% of Total Billed Charges,3214.89,90,,108.752,Percent of Total Billed Charges,90% of Total billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2321.87,65,,1502.184,Percent of total Billed Charges,65% of Total Billed Charges,1575.3,44.1,,53.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,3393.5,95,,114.792,Percent of Total Billed Charges,95% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3143.45,88,,308.136,Percent of Total Billed Charges,88% of Total Billed Charges,3214.89,90,,108.752,Percent of Total Billed charges,90% of Total Billed Charges,1575.3,3572.1,
5F 5X200X150 PWR CRS PTA BAL,2780000046,CDM,278,RC,C1876,HCPCS,Outpatient,,,3572.10,2321.87,,3572.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2714.8,76,,91.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2571.91,72,,1566.144,Percent of Total Billed Charges,72% of Total Billed Charges,2571.91,72,,1566.144,Percent of Total Billed charges,72% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2571.91,72,,1566.144,Percent of Total Billed Charges,72% of Total Billed Charges,2143.26,60,,1305.12,Percent of Total Billed Charges,60% of Total Billed Charges,3214.89,90,,3027.024,Percent of Total Billed Charges,90% of Total Billed Charges,1607.45,45,,120.264,Percent of Total Billed Charges,45% of Total Billed Charges,3214.89,90,,108.752,Percent of Total Billed Charges,90% of Total billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2321.87,65,,204.936,Percent of total Billed Charges,65% of Total Billed Charges,1575.3,44.1,,117.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,3393.5,95,,114.792,Percent of Total Billed Charges,95% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3143.45,88,,235.176,Percent of Total Billed Charges,88% of Total Billed Charges,3214.89,90,,108.752,Percent of Total Billed charges,90% of Total Billed Charges,1575.3,3572.1,
5F 5X40X135 MUSTNG OTWPTA BAL,2780000047,CDM,278,RC,C1725,HCPCS,Outpatient,,,474.08,308.15,,474.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,360.3,76,,91.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,341.34,72,,1566.144,Percent of Total Billed Charges,72% of Total Billed Charges,341.34,72,,1566.144,Percent of Total Billed charges,72% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.34,72,,1566.144,Percent of Total Billed Charges,72% of Total Billed Charges,284.45,60,,1305.12,Percent of Total Billed Charges,60% of Total Billed Charges,426.67,90,,423.752,Percent of Total Billed Charges,90% of Total Billed Charges,213.34,45,,157.568,Percent of Total Billed Charges,45% of Total Billed Charges,426.67,90,,108.752,Percent of Total Billed Charges,90% of Total billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.15,65,,204.936,Percent of total Billed Charges,65% of Total Billed Charges,209.07,44.1,,154.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,450.38,95,,114.792,Percent of Total Billed Charges,95% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.19,88,,308.136,Percent of Total Billed Charges,88% of Total Billed Charges,426.67,90,,108.752,Percent of Total Billed charges,90% of Total Billed Charges,209.07,474.08,
5F 5X60X150 PWR CRS PTA BAL,2780000048,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,91.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,1566.144,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,1566.144,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,1566.144,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,1305.12,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,80.176,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,120.264,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,108.752,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,204.936,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,117.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,114.792,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,256.136,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,108.752,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
5F 5X80X150 PWR CRS PTA BAL,2780000049,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,203.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,1566.144,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,1566.144,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,1566.144,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,1305.12,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,123.832,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,157.568,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,240.52,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,204.936,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,154.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,253.888,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,329.088,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,240.52,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
5F 6X100MMX135CM EVRC PTA BALL,2780000050,CDM,272,RC,C1725,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,266.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,1566.144,Percent of Total Billed Charges,72% of Total Billed Charges,2050.65,75,,1566.144,Percent of Total Billed charges,75% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,1566.144,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,1305.12,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,130.976,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,315.136,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,204.936,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,128.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,332.648,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,2959.76,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,315.136,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
5F 6X100X150 PWR CRS PTA BAL,2780000051,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,203.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,43.544,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,43.544,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,43.544,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,36.288,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,130.184,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,168.288,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,240.52,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,196.496,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,164.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,253.888,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,2959.76,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,240.52,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
5F 6X120MMX135CM EVRC PTA BALL,2780000052,CDM,272,RC,C1725,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,266.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,24.192,Percent of Total Billed Charges,72% of Total Billed Charges,2050.65,75,,24.192,Percent of Total Billed charges,75% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,24.192,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,20.16,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,123.832,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,1513.512,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,315.136,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,974.608,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,1483.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,332.648,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,414.336,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,315.136,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
5F 6X120X150 PWR CRS PTA BAL,2780000053,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,221.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,1484.352,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,1484.352,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,1484.352,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,1236.96,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,123.832,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,1513.512,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,261.96,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,974.608,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,1483.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,276.512,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,78.392,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,261.96,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
5F 6X150MMX135CM EVRC PTA BALL,2780000054,CDM,272,RC,C1725,HCPCS,Outpatient,,,3572.10,2321.87,,3572.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2714.8,76,,284.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2571.91,72,,972.52,Percent of Total Billed Charges,72% of Total Billed Charges,2679.08,75,,972.52,Percent of Total Billed charges,75% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2571.91,72,,972.52,Percent of Total Billed Charges,72% of Total Billed Charges,2143.26,60,,810.432,Percent of Total Billed Charges,60% of Total Billed Charges,3214.89,90,,123.832,Percent of Total Billed Charges,90% of Total Billed Charges,1607.45,45,,211.872,Percent of Total Billed Charges,45% of Total Billed Charges,3214.89,90,,336.568,Percent of Total Billed Charges,90% of Total billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2321.87,65,,75.672,Percent of total Billed Charges,65% of Total Billed Charges,1575.3,44.1,,207.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,3393.5,95,,355.272,Percent of Total Billed Charges,95% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3143.45,88,,121.08,Percent of Total Billed Charges,88% of Total Billed Charges,3214.89,90,,336.568,Percent of Total Billed charges,90% of Total Billed Charges,1575.3,3572.1,
5F 6X150X150 PWR CRS PTA BAL,2780000055,CDM,278,RC,C1876,HCPCS,Outpatient,,,3572.10,2321.87,,3572.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2714.8,76,,2556.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2571.91,72,,2258.496,Percent of Total Billed Charges,72% of Total Billed Charges,2571.91,72,,2258.496,Percent of Total Billed charges,72% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2571.91,72,,2258.496,Percent of Total Billed Charges,72% of Total Billed Charges,2143.26,60,,1882.08,Percent of Total Billed Charges,60% of Total Billed Charges,3214.89,90,,123.832,Percent of Total Billed Charges,90% of Total Billed Charges,1607.45,45,,40.088,Percent of Total Billed Charges,45% of Total Billed Charges,3214.89,90,,3027.024,Percent of Total Billed Charges,90% of Total billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2321.87,65,,633.88,Percent of total Billed Charges,65% of Total Billed Charges,1575.3,44.1,,39.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,3393.5,95,,3195.192,Percent of Total Billed Charges,95% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3143.45,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3214.89,90,,3027.024,Percent of Total Billed charges,90% of Total Billed Charges,1575.3,3572.1,
5F 6X200MMX135CM EVRC PTA BALL,2780000056,CDM,272,RC,C1725,HCPCS,Outpatient,,,3572.10,2321.87,,3572.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2714.8,76,,2556.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2571.91,72,,2489.992,Percent of Total Billed Charges,72% of Total Billed Charges,2679.08,75,,2489.992,Percent of Total Billed charges,75% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2571.91,72,,2489.992,Percent of Total Billed Charges,72% of Total Billed Charges,2143.26,60,,2074.992,Percent of Total Billed Charges,60% of Total Billed Charges,3214.89,90,,123.832,Percent of Total Billed Charges,90% of Total Billed Charges,1607.45,45,,61.92,Percent of Total Billed Charges,45% of Total Billed Charges,3214.89,90,,3027.024,Percent of Total Billed Charges,90% of Total billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2321.87,65,,633.88,Percent of total Billed Charges,65% of Total Billed Charges,1575.3,44.1,,60.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,3393.5,95,,3195.192,Percent of Total Billed Charges,95% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3143.45,88,,127.288,Percent of Total Billed Charges,88% of Total Billed Charges,3214.89,90,,3027.024,Percent of Total Billed charges,90% of Total Billed Charges,1575.3,3572.1,
5F 6X200X150 PWR CRS PTA BAL,2780000057,CDM,278,RC,C1876,HCPCS,Outpatient,,,3572.10,2321.87,,3572.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2714.8,76,,357.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2571.91,72,,1733.664,Percent of Total Billed Charges,72% of Total Billed Charges,2571.91,72,,1733.664,Percent of Total Billed charges,72% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2571.91,72,,1733.664,Percent of Total Billed Charges,72% of Total Billed Charges,2143.26,60,,1444.72,Percent of Total Billed Charges,60% of Total Billed Charges,3214.89,90,,1447.096,Percent of Total Billed Charges,90% of Total Billed Charges,1607.45,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3214.89,90,,423.752,Percent of Total Billed Charges,90% of Total billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2321.87,65,,539.992,Percent of total Billed Charges,65% of Total Billed Charges,1575.3,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3393.5,95,,447.288,Percent of Total Billed Charges,95% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3143.45,88,,121.08,Percent of Total Billed Charges,88% of Total Billed Charges,3214.89,90,,423.752,Percent of Total Billed charges,90% of Total Billed Charges,1575.3,3572.1,
5F 6X40X135 MUSTNG OTWPTA BAL,2780000058,CDM,278,RC,C1725,HCPCS,Outpatient,,,474.08,308.15,,474.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,360.3,76,,67.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,341.34,72,,1929.84,Percent of Total Billed Charges,72% of Total Billed Charges,341.34,72,,1929.84,Percent of Total Billed charges,72% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.34,72,,1929.84,Percent of Total Billed Charges,72% of Total Billed Charges,284.45,60,,1542.808,Percent of Total Billed Charges,60% of Total Billed Charges,426.67,90,,2079.944,Percent of Total Billed Charges,90% of Total Billed Charges,213.34,45,,65.088,Percent of Total Billed Charges,45% of Total Billed Charges,426.67,90,,80.176,Percent of Total Billed Charges,90% of Total billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.15,65,,2150.592,Percent of total Billed Charges,65% of Total Billed Charges,209.07,44.1,,63.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,450.38,95,,84.624,Percent of Total Billed Charges,95% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.19,88,,121.08,Percent of Total Billed Charges,88% of Total Billed Charges,426.67,90,,80.176,Percent of Total Billed charges,90% of Total Billed Charges,209.07,474.08,
5F 6X40X150 PWR CRS PTA BAL,2780000059,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,104.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,1573.056,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,1573.056,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,1573.056,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,1310.88,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,283.76,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,61.92,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,123.832,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,6139.768,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,60.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,130.712,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,121.08,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,123.832,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
5F 6X40X40 MUSTNG OTW PTA BAL,2780000060,CDM,278,RC,C1725,HCPCS,Outpatient,,,474.08,308.15,,474.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,360.3,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,341.34,72,,1651.712,Percent of Total Billed Charges,72% of Total Billed Charges,341.34,72,,1651.712,Percent of Total Billed charges,72% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.34,72,,1651.712,Percent of Total Billed Charges,72% of Total Billed Charges,284.45,60,,1376.424,Percent of Total Billed Charges,60% of Total Billed Charges,426.67,90,,283.76,Percent of Total Billed Charges,90% of Total Billed Charges,213.34,45,,61.92,Percent of Total Billed Charges,45% of Total Billed Charges,426.67,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.15,65,,2150.592,Percent of total Billed Charges,65% of Total Billed Charges,209.07,44.1,,60.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,450.38,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.19,88,,121.08,Percent of Total Billed Charges,88% of Total Billed Charges,426.67,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,209.07,474.08,
5F 6X40X90 PWR CRS PTA BAL,2780000061,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,109.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,1733.664,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,1733.664,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,1733.664,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,1444.72,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,283.76,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,61.92,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,130.184,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,2011.104,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,60.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,137.416,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,121.08,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,130.184,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
5F 6X80X150 PWR CRS PTA BAL,2780000062,CDM,278,RC,C1876,HCPCS,Outpatient,,,2734.20,1777.23,,2734.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2077.99,76,,104.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1968.62,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,1968.62,72,,124.464,Percent of Total Billed charges,72% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.62,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,1640.52,60,,103.72,Percent of Total Billed Charges,60% of Total Billed Charges,2460.78,90,,283.76,Percent of Total Billed Charges,90% of Total Billed Charges,1230.39,45,,61.92,Percent of Total Billed Charges,45% of Total Billed Charges,2460.78,90,,123.832,Percent of Total Billed Charges,90% of Total billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.23,65,,2150.592,Percent of total Billed Charges,65% of Total Billed Charges,1205.78,44.1,,60.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,2597.49,95,,130.712,Percent of Total Billed Charges,95% of Total Billed Charges,2734.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.1,88,,1414.944,Percent of Total Billed Charges,88% of Total Billed Charges,2460.78,90,,123.832,Percent of Total Billed charges,90% of Total Billed Charges,1205.78,2734.2,
5F 7X40X135 MUSTNG OTWPTA BAL,2780000063,CDM,278,RC,C1725,HCPCS,Outpatient,,,474.08,308.15,,474.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,360.3,76,,104.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,341.34,72,,274.752,Percent of Total Billed Charges,72% of Total Billed Charges,341.34,72,,274.752,Percent of Total Billed charges,72% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.34,72,,274.752,Percent of Total Billed Charges,72% of Total Billed Charges,284.45,60,,228.96,Percent of Total Billed Charges,60% of Total Billed Charges,426.67,90,,283.76,Percent of Total Billed Charges,90% of Total Billed Charges,213.34,45,,61.92,Percent of Total Billed Charges,45% of Total Billed Charges,426.67,90,,123.832,Percent of Total Billed Charges,90% of Total billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.15,65,,2150.592,Percent of total Billed Charges,65% of Total Billed Charges,209.07,44.1,,60.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,450.38,95,,130.712,Percent of Total Billed Charges,95% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.19,88,,2033.72,Percent of Total Billed Charges,88% of Total Billed Charges,426.67,90,,123.832,Percent of Total Billed charges,90% of Total Billed Charges,209.07,474.08,
5F 7X40X40 MUSTNG OTW PTA BAL,2780000064,CDM,278,RC,C1725,HCPCS,Outpatient,,,474.08,308.15,,474.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,360.3,76,,104.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,341.34,72,,1702.512,Percent of Total Billed Charges,72% of Total Billed Charges,341.34,72,,1702.512,Percent of Total Billed charges,72% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.34,72,,1702.512,Percent of Total Billed Charges,72% of Total Billed Charges,284.45,60,,1418.76,Percent of Total Billed Charges,60% of Total Billed Charges,426.67,90,,272.072,Percent of Total Billed Charges,90% of Total Billed Charges,213.34,45,,723.552,Percent of Total Billed Charges,45% of Total Billed Charges,426.67,90,,123.832,Percent of Total Billed Charges,90% of Total billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.15,65,,2727.272,Percent of total Billed Charges,65% of Total Billed Charges,209.07,44.1,,709.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,450.38,95,,130.712,Percent of Total Billed Charges,95% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.19,88,,277.456,Percent of Total Billed Charges,88% of Total Billed Charges,426.67,90,,123.832,Percent of Total Billed charges,90% of Total Billed Charges,209.07,474.08,
5FR 4X40X135 MUSTNG OTWPTA BAL,2780000065,CDM,278,RC,C1725,HCPCS,Outpatient,,,474.08,308.15,,474.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,360.3,76,,104.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,341.34,72,,2479.832,Percent of Total Billed Charges,72% of Total Billed Charges,341.34,72,,2479.832,Percent of Total Billed charges,72% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.34,72,,2479.832,Percent of Total Billed Charges,72% of Total Billed Charges,284.45,60,,2066.528,Percent of Total Billed Charges,60% of Total Billed Charges,426.67,90,,1349.464,Percent of Total Billed Charges,90% of Total Billed Charges,213.34,45,,1039.968,Percent of Total Billed Charges,45% of Total Billed Charges,426.67,90,,123.832,Percent of Total Billed Charges,90% of Total billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.15,65,,2727.272,Percent of total Billed Charges,65% of Total Billed Charges,209.07,44.1,,1019.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,450.38,95,,130.712,Percent of Total Billed Charges,95% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.19,88,,277.456,Percent of Total Billed Charges,88% of Total Billed Charges,426.67,90,,123.832,Percent of Total Billed charges,90% of Total Billed Charges,209.07,474.08,
6F 035 10X40X80 P BIGGS STNT,2780000066,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,104.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,254.592,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,254.592,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,254.592,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,212.16,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,1349.464,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,141.88,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,123.832,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,2727.272,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,139.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,130.712,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,277.456,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,123.832,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6F 035 10X60X180 P BIGGS STNT,2780000067,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,1221.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,95.256,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,95.256,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,95.256,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,79.384,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,104.784,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,141.88,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,1447.096,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,2727.272,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,139.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,1527.496,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,277.456,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,1447.096,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6F 035 10X80X80 P BIGGS STNT,2780000068,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,1756.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,1366.24,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,1366.24,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,1366.24,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,1138.536,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,877.68,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,141.88,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,2079.944,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,2727.272,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,139.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,2195.496,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,277.456,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,2079.944,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6F 035 12X40X80 P P BIGGS STNT,2780000069,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,239.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,59.904,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,59.904,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,59.904,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,49.92,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,877.68,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,141.88,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,283.76,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,2727.272,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,139.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,299.52,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,266.024,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,283.76,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6F 035 12X60X80 P BIGGS STNT,2780000070,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,239.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,2238.912,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,2238.912,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,2238.912,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,1865.76,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,747.688,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,141.88,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,283.76,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,2727.272,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,139.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,299.52,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,1319.472,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,283.76,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6F 035 12X80X80 P BIGGS STNT,2780000071,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,239.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,2799.256,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,2799.256,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,2799.256,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,2332.712,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,2977.744,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,136.04,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,283.76,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,1448.592,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,133.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,299.52,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,1319.472,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,283.76,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6F 035 14X40X80 P BISS STNT,2780000072,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,239.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,2656.512,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,2656.512,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,2656.512,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,2213.76,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,8501.224,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,674.728,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,283.76,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,1448.592,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,661.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,299.52,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,102.456,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,283.76,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6F 035 14X60X80 P BIGGS STNT,2780000073,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,239.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,2592,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,2592,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,2592,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,2160,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,2977.744,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,674.728,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,283.76,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,1448.592,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,661.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,299.52,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,858.176,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,283.76,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6F 035 5X40X120 PRO EVRFX STNT,2780000074,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,229.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,2655.936,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,2655.936,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,2655.936,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,2213.28,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,2784.6,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,52.392,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,272.072,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,98.608,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,51.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,287.192,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,858.176,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,272.072,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6F 035 5X60X120 EVFLX STNT,2780000075,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,1139.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,1726.624,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,1726.624,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,1726.624,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,1373.464,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,2977.744,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,438.84,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,1349.464,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,5755.36,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,430.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,1424.432,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,731.072,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,1349.464,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6F 035 6X20X120  EVFLX STNT,2780000076,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,1139.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,2659.968,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,2659.968,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,2659.968,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,2216.64,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,2977.744,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,438.84,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,1349.464,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,430.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,1424.432,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,2911.568,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,1349.464,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6F 035 6X30X120 EVFLX SE STNT,2780000077,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,88.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,1736.2,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,1736.2,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,1736.2,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,1446.832,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,3776.224,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,373.84,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,104.784,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,366.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,110.6,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,8312.304,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,104.784,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6F 035 7X20X120 EVFLX SE STNT,2780000078,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,741.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,1721.544,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,1721.544,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,1721.544,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,1369.232,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,3776.224,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,1488.872,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,877.68,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,1459.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,926.44,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,2911.568,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,877.68,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6F 035 7X30X120 EVFLX SE STNT,2780000079,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,741.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,1778.696,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,1778.696,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,1778.696,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,1416.856,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,3776.224,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,4250.608,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,877.68,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,4165.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,926.44,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,2722.72,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,877.68,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6F 035 7X37X80 VISI PRO STNT,2780000080,CDM,278,RC,C1876,HCPCS,Outpatient,,,6174.00,4013.10,,6174,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4692.24,76,,631.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4445.28,72,,150.912,Percent of Total Billed Charges,72% of Total Billed Charges,4445.28,72,,150.912,Percent of Total Billed charges,72% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4445.28,72,,150.912,Percent of Total Billed Charges,72% of Total Billed Charges,3704.4,60,,125.76,Percent of Total Billed Charges,60% of Total Billed Charges,5556.6,90,,3776.224,Percent of Total Billed Charges,90% of Total Billed Charges,2778.3,45,,1488.872,Percent of Total Billed Charges,45% of Total Billed Charges,5556.6,90,,747.688,Percent of Total Billed Charges,90% of Total billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4013.1,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,2722.73,44.1,,1459.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,5865.3,95,,789.224,Percent of Total Billed Charges,95% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5433.12,88,,2911.568,Percent of Total Billed Charges,88% of Total Billed Charges,5556.6,90,,747.688,Percent of Total Billed charges,90% of Total Billed Charges,2722.73,6174,
6F 035 7X40X120  EVFLX STNT,2780000081,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,2514.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,150.912,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,150.912,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,150.912,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,125.76,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,3776.224,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,1392.304,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,2977.744,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,1364.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,3143.168,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,2911.568,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,2977.744,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6F 035 7X57X80 VISI PRO STNT,2780000082,CDM,278,RC,C1876,HCPCS,Outpatient,,,6174.00,4013.10,,6174,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4692.24,76,,7178.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4445.28,72,,150.912,Percent of Total Billed Charges,72% of Total Billed Charges,4445.28,72,,150.912,Percent of Total Billed charges,72% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4445.28,72,,150.912,Percent of Total Billed Charges,72% of Total Billed Charges,3704.4,60,,125.76,Percent of Total Billed Charges,60% of Total Billed Charges,5556.6,90,,3776.224,Percent of Total Billed Charges,90% of Total Billed Charges,2778.3,45,,1488.872,Percent of Total Billed Charges,45% of Total Billed Charges,5556.6,90,,8501.224,Percent of Total Billed Charges,90% of Total billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4013.1,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,2722.73,44.1,,1459.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,5865.3,95,,8973.512,Percent of Total Billed Charges,95% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5433.12,88,,3692.304,Percent of Total Billed Charges,88% of Total Billed Charges,5556.6,90,,8501.224,Percent of Total Billed charges,90% of Total Billed Charges,2722.73,6174,
6F 035 7X60X120  EVFLX STNT,2780000083,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,2514.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,150.912,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,150.912,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,150.912,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,125.76,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,3776.224,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,1488.872,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,2977.744,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,1459.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,3143.168,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,3692.304,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,2977.744,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6F 035 7X80X120 EVFLX SE STNT,2780000084,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,2351.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,150.912,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,150.912,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,150.912,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,125.76,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,2005.744,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,1888.112,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,2784.6,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,1850.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,2939.304,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,3692.304,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,2784.6,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6F 035 8X17X80 VISI PRO STNT,2780000085,CDM,278,RC,C1876,HCPCS,Outpatient,,,6174.00,4013.10,,6174,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4692.24,76,,2514.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4445.28,72,,176.256,Percent of Total Billed Charges,72% of Total Billed Charges,4445.28,72,,176.256,Percent of Total Billed charges,72% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4445.28,72,,176.256,Percent of Total Billed Charges,72% of Total Billed Charges,3704.4,60,,146.88,Percent of Total Billed Charges,60% of Total Billed Charges,5556.6,90,,2005.744,Percent of Total Billed Charges,90% of Total Billed Charges,2778.3,45,,1888.112,Percent of Total Billed Charges,45% of Total Billed Charges,5556.6,90,,2977.744,Percent of Total Billed Charges,90% of Total billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4013.1,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,2722.73,44.1,,1850.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,5865.3,95,,3143.168,Percent of Total Billed Charges,95% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5433.12,88,,3692.304,Percent of Total Billed Charges,88% of Total Billed Charges,5556.6,90,,2977.744,Percent of Total Billed charges,90% of Total Billed Charges,2722.73,6174,
6F 035 8X27X80 VISI PRO STNT,2780000086,CDM,278,RC,C1876,HCPCS,Outpatient,,,6174.00,4013.10,,6174,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4692.24,76,,2514.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4445.28,72,,62.208,Percent of Total Billed Charges,72% of Total Billed Charges,4445.28,72,,62.208,Percent of Total Billed charges,72% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4445.28,72,,62.208,Percent of Total Billed Charges,72% of Total Billed Charges,3704.4,60,,51.84,Percent of Total Billed Charges,60% of Total Billed Charges,5556.6,90,,2005.744,Percent of Total Billed Charges,90% of Total Billed Charges,2778.3,45,,1888.112,Percent of Total Billed Charges,45% of Total Billed Charges,5556.6,90,,2977.744,Percent of Total Billed Charges,90% of Total billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4013.1,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,2722.73,44.1,,1850.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,5865.3,95,,3143.168,Percent of Total Billed Charges,95% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5433.12,88,,3692.304,Percent of Total Billed Charges,88% of Total Billed Charges,5556.6,90,,2977.744,Percent of Total Billed charges,90% of Total Billed Charges,2722.73,6174,
6F 035 8X37X80 VISI PRO STNT,2780000087,CDM,278,RC,C1876,HCPCS,Outpatient,,,6174.00,4013.10,,6174,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4692.24,76,,3188.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4445.28,72,,11046.52,Percent of Total Billed Charges,72% of Total Billed Charges,4445.28,72,,11046.52,Percent of Total Billed charges,72% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4445.28,72,,11046.52,Percent of Total Billed Charges,72% of Total Billed Charges,3704.4,60,,9205.432,Percent of Total Billed Charges,60% of Total Billed Charges,5556.6,90,,136.536,Percent of Total Billed Charges,90% of Total Billed Charges,2778.3,45,,1888.112,Percent of Total Billed Charges,45% of Total Billed Charges,5556.6,90,,3776.224,Percent of Total Billed Charges,90% of Total billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4013.1,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,2722.73,44.1,,1850.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,5865.3,95,,3986.008,Percent of Total Billed Charges,95% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5433.12,88,,3692.304,Percent of Total Billed Charges,88% of Total Billed Charges,5556.6,90,,3776.224,Percent of Total Billed charges,90% of Total Billed Charges,2722.73,6174,
6F 035 8X40X120 EVFLX SE STNT,2780000088,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,3188.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,10280.024,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,10280.024,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,10280.024,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,8566.688,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,7968.96,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,1888.112,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,3776.224,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,83.704,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,1850.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,3986.008,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,3692.304,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,3776.224,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6F 035 8X57X80 VISI PRO STNT,2780000089,CDM,278,RC,C1876,HCPCS,Outpatient,,,6174.00,4013.10,,6174,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4692.24,76,,3188.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4445.28,72,,9790.504,Percent of Total Billed Charges,72% of Total Billed Charges,4445.28,72,,9790.504,Percent of Total Billed charges,72% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4445.28,72,,9790.504,Percent of Total Billed Charges,72% of Total Billed Charges,3704.4,60,,8158.752,Percent of Total Billed Charges,60% of Total Billed Charges,5556.6,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,2778.3,45,,1888.112,Percent of Total Billed Charges,45% of Total Billed Charges,5556.6,90,,3776.224,Percent of Total Billed Charges,90% of Total billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4013.1,65,,2215.2,Percent of total Billed Charges,65% of Total Billed Charges,2722.73,44.1,,1850.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,5865.3,95,,3986.008,Percent of Total Billed Charges,95% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5433.12,88,,1961.168,Percent of Total Billed Charges,88% of Total Billed Charges,5556.6,90,,3776.224,Percent of Total Billed charges,90% of Total Billed Charges,2722.73,6174,
6F 035 8X60X120 EVFLX SE STNT,2780000090,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,3188.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,11046.52,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,11046.52,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,11046.52,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,9205.432,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,1888.112,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,3776.224,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,3846.848,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,1850.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,3986.008,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,1961.168,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,3776.224,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6F 035 9X37X80 VISI PRO STNT,2780000091,CDM,278,RC,C1876,HCPCS,Outpatient,,,6174.00,4013.10,,6174,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4692.24,76,,3188.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4445.28,72,,10280.024,Percent of Total Billed Charges,72% of Total Billed Charges,4445.28,72,,10280.024,Percent of Total Billed charges,72% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4445.28,72,,10280.024,Percent of Total Billed Charges,72% of Total Billed Charges,3704.4,60,,8566.688,Percent of Total Billed Charges,60% of Total Billed Charges,5556.6,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,2778.3,45,,1002.872,Percent of Total Billed Charges,45% of Total Billed Charges,5556.6,90,,3776.224,Percent of Total Billed Charges,90% of Total billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4013.1,65,,959.32,Percent of total Billed Charges,65% of Total Billed Charges,2722.73,44.1,,982.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,5865.3,95,,3986.008,Percent of Total Billed Charges,95% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5433.12,88,,1961.168,Percent of Total Billed Charges,88% of Total Billed Charges,5556.6,90,,3776.224,Percent of Total Billed charges,90% of Total Billed Charges,2722.73,6174,
6F 10X40X135 MUSTNG OTWPTA BAL,2780000092,CDM,278,RC,C1725,HCPCS,Outpatient,,,474.08,308.15,,474.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,360.3,76,,3188.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,341.34,72,,9790.504,Percent of Total Billed Charges,72% of Total Billed Charges,341.34,72,,9790.504,Percent of Total Billed charges,72% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.34,72,,9790.504,Percent of Total Billed Charges,72% of Total Billed Charges,284.45,60,,8158.752,Percent of Total Billed Charges,60% of Total Billed Charges,426.67,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,213.34,45,,1002.872,Percent of Total Billed Charges,45% of Total Billed Charges,426.67,90,,3776.224,Percent of Total Billed Charges,90% of Total billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.15,65,,959.32,Percent of total Billed Charges,65% of Total Billed Charges,209.07,44.1,,982.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,450.38,95,,3986.008,Percent of Total Billed Charges,95% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.19,88,,133.496,Percent of Total Billed Charges,88% of Total Billed Charges,426.67,90,,3776.224,Percent of Total Billed charges,90% of Total Billed Charges,209.07,474.08,
6F 3MM DISTAL  EMBOL PRT DEV,2780000093,CDM,272,RC,C1884,HCPCS,Outpatient,,,2910.00,1891.50,,2910,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2211.6,76,,3188.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2095.2,72,,9790.504,Percent of Total Billed Charges,72% of Total Billed Charges,2182.5,75,,9790.504,Percent of Total Billed charges,75% of Total Billed Charges,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2095.2,72,,9790.504,Percent of Total Billed Charges,72% of Total Billed Charges,1746,60,,8158.752,Percent of Total Billed Charges,60% of Total Billed Charges,2619,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,1309.5,45,,1002.872,Percent of Total Billed Charges,45% of Total Billed Charges,2619,90,,3776.224,Percent of Total Billed Charges,90% of Total billed Charges,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1891.5,65,,316.68,Percent of total Billed Charges,65% of Total Billed Charges,1283.31,44.1,,982.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,2764.5,95,,3986.008,Percent of Total Billed Charges,95% of Total Billed Charges,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2560.8,88,,7791.872,Percent of Total Billed Charges,88% of Total Billed Charges,2619,90,,3776.224,Percent of Total Billed charges,90% of Total Billed Charges,1283.31,2910,
6F 4MM DISTAL EMBOL PRT DEV,2780000094,CDM,272,RC,C1884,HCPCS,Outpatient,,,2910.00,1891.50,,2910,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2211.6,76,,1693.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2095.2,72,,11046.52,Percent of Total Billed Charges,72% of Total Billed Charges,2182.5,75,,11046.52,Percent of Total Billed charges,75% of Total Billed Charges,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2095.2,72,,11046.52,Percent of Total Billed Charges,72% of Total Billed Charges,1746,60,,9205.432,Percent of Total Billed Charges,60% of Total Billed Charges,2619,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,1309.5,45,,68.264,Percent of Total Billed Charges,45% of Total Billed Charges,2619,90,,2005.744,Percent of Total Billed Charges,90% of Total billed Charges,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1891.5,65,,217.88,Percent of total Billed Charges,65% of Total Billed Charges,1283.31,44.1,,66.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,2764.5,95,,2117.168,Percent of Total Billed Charges,95% of Total Billed Charges,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2560.8,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,2619,90,,2005.744,Percent of Total Billed charges,90% of Total Billed Charges,1283.31,2910,
6F 5MM DISTAL EMBOL PRT DEV,2780000095,CDM,272,RC,C1884,HCPCS,Outpatient,,,2910.00,1891.50,,2910,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2211.6,76,,1693.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2095.2,72,,11046.52,Percent of Total Billed Charges,72% of Total Billed Charges,2182.5,75,,11046.52,Percent of Total Billed charges,75% of Total Billed Charges,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2095.2,72,,11046.52,Percent of Total Billed Charges,72% of Total Billed Charges,1746,60,,9205.432,Percent of Total Billed Charges,60% of Total Billed Charges,2619,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,1309.5,45,,3984.48,Percent of Total Billed Charges,45% of Total Billed Charges,2619,90,,2005.744,Percent of Total Billed Charges,90% of Total billed Charges,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1891.5,65,,400.92,Percent of total Billed Charges,65% of Total Billed Charges,1283.31,44.1,,3904.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,2764.5,95,,2117.168,Percent of Total Billed Charges,95% of Total Billed Charges,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2560.8,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,2619,90,,2005.744,Percent of Total Billed charges,90% of Total Billed Charges,1283.31,2910,
6F 6MM DISTAL EMBOL PRT DEV,2780000096,CDM,272,RC,C1884,HCPCS,Outpatient,,,2910.00,1891.50,,2910,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2211.6,76,,1693.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2095.2,72,,10280.024,Percent of Total Billed Charges,72% of Total Billed Charges,2182.5,75,,10280.024,Percent of Total Billed charges,75% of Total Billed Charges,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2095.2,72,,10280.024,Percent of Total Billed Charges,72% of Total Billed Charges,1746,60,,8566.688,Percent of Total Billed Charges,60% of Total Billed Charges,2619,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,1309.5,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,2619,90,,2005.744,Percent of Total Billed Charges,90% of Total billed Charges,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1891.5,65,,400.92,Percent of total Billed Charges,65% of Total Billed Charges,1283.31,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,2764.5,95,,2117.168,Percent of Total Billed Charges,95% of Total Billed Charges,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2560.8,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,2619,90,,2005.744,Percent of Total Billed charges,90% of Total Billed Charges,1283.31,2910,
6F 6X19MMX80CM OM EL ST OTW 35,2780000097,CDM,278,RC,C1876,HCPCS,Outpatient,,,2039.63,1325.76,,2039.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1550.12,76,,115.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1468.53,72,,9324.288,Percent of Total Billed Charges,72% of Total Billed Charges,1468.53,72,,9324.288,Percent of Total Billed charges,72% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1468.53,72,,9324.288,Percent of Total Billed Charges,72% of Total Billed Charges,1223.78,60,,7770.24,Percent of Total Billed Charges,60% of Total Billed Charges,1835.67,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,917.83,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,1835.67,90,,136.536,Percent of Total Billed Charges,90% of Total billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1325.76,65,,400.92,Percent of total Billed Charges,65% of Total Billed Charges,899.48,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,1937.65,95,,144.12,Percent of Total Billed Charges,95% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1794.87,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,1835.67,90,,136.536,Percent of Total Billed charges,90% of Total Billed Charges,899.48,2039.63,
6F 6X29MMX80CM OM EL ST OTW 35,2780000098,CDM,278,RC,C1876,HCPCS,Outpatient,,,2039.63,1325.76,,2039.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1550.12,76,,6729.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1468.53,72,,9790.504,Percent of Total Billed Charges,72% of Total Billed Charges,1468.53,72,,9790.504,Percent of Total Billed charges,72% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1468.53,72,,9790.504,Percent of Total Billed Charges,72% of Total Billed Charges,1223.78,60,,8158.752,Percent of Total Billed Charges,60% of Total Billed Charges,1835.67,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,917.83,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,1835.67,90,,7968.96,Percent of Total Billed Charges,90% of Total billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1325.76,65,,217.88,Percent of total Billed Charges,65% of Total Billed Charges,899.48,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,1937.65,95,,8411.68,Percent of Total Billed Charges,95% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1794.87,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,1835.67,90,,7968.96,Percent of Total Billed charges,90% of Total Billed Charges,899.48,2039.63,
6F 6X39MMX80CM OM EL ST OTW 35,2780000099,CDM,278,RC,C1876,HCPCS,Outpatient,,,2039.63,1325.76,,2039.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1550.12,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1468.53,72,,10280.024,Percent of Total Billed Charges,72% of Total Billed Charges,1468.53,72,,10280.024,Percent of Total Billed charges,72% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1468.53,72,,10280.024,Percent of Total Billed Charges,72% of Total Billed Charges,1223.78,60,,8566.688,Percent of Total Billed Charges,60% of Total Billed Charges,1835.67,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,917.83,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,1835.67,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1325.76,65,,1392.56,Percent of total Billed Charges,65% of Total Billed Charges,899.48,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,1937.65,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1794.87,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,1835.67,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,899.48,2039.63,
6F 6X59MMX80CM OM EL ST OTW 35,2780000100,CDM,278,RC,C1876,HCPCS,Outpatient,,,2039.63,1325.76,,2039.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1550.12,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1468.53,72,,11014.768,Percent of Total Billed Charges,72% of Total Billed Charges,1468.53,72,,11014.768,Percent of Total Billed charges,72% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1468.53,72,,11014.768,Percent of Total Billed Charges,72% of Total Billed Charges,1223.78,60,,9178.976,Percent of Total Billed Charges,60% of Total Billed Charges,1835.67,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,917.83,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,1835.67,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1325.76,65,,756.76,Percent of total Billed Charges,65% of Total Billed Charges,899.48,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,1937.65,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1794.87,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,1835.67,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,899.48,2039.63,
6F 7MM DISTAL EMBOL PRT DEV,2780000101,CDM,272,RC,C1884,HCPCS,Outpatient,,,2910.00,1891.50,,2910,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2211.6,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2095.2,72,,11046.52,Percent of Total Billed Charges,72% of Total Billed Charges,2182.5,75,,11046.52,Percent of Total Billed charges,75% of Total Billed Charges,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2095.2,72,,11046.52,Percent of Total Billed Charges,72% of Total Billed Charges,1746,60,,9205.432,Percent of Total Billed Charges,60% of Total Billed Charges,2619,90,,115.896,Percent of Total Billed Charges,90% of Total Billed Charges,1309.5,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,2619,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1891.5,65,,94.024,Percent of total Billed Charges,65% of Total Billed Charges,1283.31,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,2764.5,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,2910,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2560.8,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,2619,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,1283.31,2910,
6F 7X19MMX80CM OM EL ST OTW 35,2780000102,CDM,278,RC,C1876,HCPCS,Outpatient,,,2039.63,1325.76,,2039.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1550.12,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1468.53,72,,563.912,Percent of Total Billed Charges,72% of Total Billed Charges,1468.53,72,,563.912,Percent of Total Billed charges,72% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1468.53,72,,563.912,Percent of Total Billed Charges,72% of Total Billed Charges,1223.78,60,,469.928,Percent of Total Billed Charges,60% of Total Billed Charges,1835.67,90,,3067.2,Percent of Total Billed Charges,90% of Total Billed Charges,917.83,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,1835.67,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1325.76,65,,94.024,Percent of total Billed Charges,65% of Total Billed Charges,899.48,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,1937.65,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1794.87,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,1835.67,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,899.48,2039.63,
6F 7X29MMX80CM OM EL ST OTW 35,2780000103,CDM,278,RC,C1876,HCPCS,Outpatient,,,2039.63,1325.76,,2039.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1550.12,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1468.53,72,,563.912,Percent of Total Billed Charges,72% of Total Billed Charges,1468.53,72,,563.912,Percent of Total Billed charges,72% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1468.53,72,,563.912,Percent of Total Billed Charges,72% of Total Billed Charges,1223.78,60,,469.928,Percent of Total Billed Charges,60% of Total Billed Charges,1835.67,90,,5326.4,Percent of Total Billed Charges,90% of Total Billed Charges,917.83,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,1835.67,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1325.76,65,,306.72,Percent of total Billed Charges,65% of Total Billed Charges,899.48,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,1937.65,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1794.87,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,1835.67,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,899.48,2039.63,
6F 7X39MMX80CM OM EL ST OTW 35,2780000104,CDM,278,RC,C1876,HCPCS,Outpatient,,,2039.63,1325.76,,2039.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1550.12,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1468.53,72,,3945.504,Percent of Total Billed Charges,72% of Total Billed Charges,1468.53,72,,3945.504,Percent of Total Billed charges,72% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1468.53,72,,3945.504,Percent of Total Billed Charges,72% of Total Billed Charges,1223.78,60,,3287.92,Percent of Total Billed Charges,60% of Total Billed Charges,1835.67,90,,1328.296,Percent of Total Billed Charges,90% of Total Billed Charges,917.83,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,1835.67,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1325.76,65,,306.72,Percent of total Billed Charges,65% of Total Billed Charges,899.48,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,1937.65,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1794.87,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,1835.67,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,899.48,2039.63,
6F 7X59MMX80CM OM EL ST OTW 35,2780000105,CDM,278,RC,C1876,HCPCS,Outpatient,,,2039.63,1325.76,,2039.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1550.12,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1468.53,72,,3111.064,Percent of Total Billed Charges,72% of Total Billed Charges,1468.53,72,,3111.064,Percent of Total Billed charges,72% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1468.53,72,,3111.064,Percent of Total Billed Charges,72% of Total Billed Charges,1223.78,60,,2592.552,Percent of Total Billed Charges,60% of Total Billed Charges,1835.67,90,,1328.296,Percent of Total Billed Charges,90% of Total Billed Charges,917.83,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,1835.67,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1325.76,65,,306.72,Percent of total Billed Charges,65% of Total Billed Charges,899.48,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,1937.65,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1794.87,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,1835.67,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,899.48,2039.63,
6F8X40X135 MUST OTW PTA BAL DL,2780000106,CDM,278,RC,C1725,HCPCS,Outpatient,,,474.08,308.15,,474.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,360.3,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,341.34,72,,2962.912,Percent of Total Billed Charges,72% of Total Billed Charges,341.34,72,,2962.912,Percent of Total Billed charges,72% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.34,72,,2962.912,Percent of Total Billed Charges,72% of Total Billed Charges,284.45,60,,2469.096,Percent of Total Billed Charges,60% of Total Billed Charges,426.67,90,,438.48,Percent of Total Billed Charges,90% of Total Billed Charges,213.34,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,426.67,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.15,65,,306.72,Percent of total Billed Charges,65% of Total Billed Charges,209.07,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,450.38,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.19,88,,113.32,Percent of Total Billed Charges,88% of Total Billed Charges,426.67,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,209.07,474.08,
6F 8X19MMX80CM OM EL ST OTW 35,2780000107,CDM,278,RC,C1876,HCPCS,Outpatient,,,2039.63,1325.76,,2039.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1550.12,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1468.53,72,,2962.912,Percent of Total Billed Charges,72% of Total Billed Charges,1468.53,72,,2962.912,Percent of Total Billed charges,72% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1468.53,72,,2962.912,Percent of Total Billed Charges,72% of Total Billed Charges,1223.78,60,,2469.096,Percent of Total Billed Charges,60% of Total Billed Charges,1835.67,90,,301.68,Percent of Total Billed Charges,90% of Total Billed Charges,917.83,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,1835.67,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1325.76,65,,2366,Percent of total Billed Charges,65% of Total Billed Charges,899.48,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,1937.65,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1794.87,88,,2999.04,Percent of Total Billed Charges,88% of Total Billed Charges,1835.67,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,899.48,2039.63,
6F 8X29MMX80CM OM EL ST OTW 35,2780000108,CDM,278,RC,C1876,HCPCS,Outpatient,,,2039.63,1325.76,,2039.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1550.12,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1468.53,72,,3945.504,Percent of Total Billed Charges,72% of Total Billed Charges,1468.53,72,,3945.504,Percent of Total Billed charges,72% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1468.53,72,,3945.504,Percent of Total Billed Charges,72% of Total Billed Charges,1223.78,60,,3287.92,Percent of Total Billed Charges,60% of Total Billed Charges,1835.67,90,,555.12,Percent of Total Billed Charges,90% of Total Billed Charges,917.83,45,,57.952,Percent of Total Billed Charges,45% of Total Billed Charges,1835.67,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1325.76,65,,99.328,Percent of total Billed Charges,65% of Total Billed Charges,899.48,44.1,,56.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,1937.65,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1794.87,88,,5208.04,Percent of Total Billed Charges,88% of Total Billed Charges,1835.67,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,899.48,2039.63,
6F 8X39MMX80CM OM EL ST OTW 35,2780000109,CDM,278,RC,C1876,HCPCS,Outpatient,,,2039.63,1325.76,,2039.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1550.12,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1468.53,72,,3945.504,Percent of Total Billed Charges,72% of Total Billed Charges,1468.53,72,,3945.504,Percent of Total Billed charges,72% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1468.53,72,,3945.504,Percent of Total Billed Charges,72% of Total Billed Charges,1223.78,60,,3287.92,Percent of Total Billed Charges,60% of Total Billed Charges,1835.67,90,,555.12,Percent of Total Billed Charges,90% of Total Billed Charges,917.83,45,,1533.6,Percent of Total Billed Charges,45% of Total Billed Charges,1835.67,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1325.76,65,,1916.464,Percent of total Billed Charges,65% of Total Billed Charges,899.48,44.1,,1502.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,1937.65,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1794.87,88,,1298.776,Percent of Total Billed Charges,88% of Total Billed Charges,1835.67,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,899.48,2039.63,
6F 8X40X40 MUSTANG OTW PTA BAL,2780000110,CDM,278,RC,C1725,HCPCS,Outpatient,,,474.08,308.15,,474.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,360.3,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,341.34,72,,2821.824,Percent of Total Billed Charges,72% of Total Billed Charges,341.34,72,,2821.824,Percent of Total Billed charges,72% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.34,72,,2821.824,Percent of Total Billed Charges,72% of Total Billed Charges,284.45,60,,2351.52,Percent of Total Billed Charges,60% of Total Billed Charges,426.67,90,,555.12,Percent of Total Billed Charges,90% of Total Billed Charges,213.34,45,,2663.2,Percent of Total Billed Charges,45% of Total Billed Charges,426.67,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.15,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,209.07,44.1,,2609.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,450.38,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.19,88,,1298.776,Percent of Total Billed Charges,88% of Total Billed Charges,426.67,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,209.07,474.08,
6F 8X59MMX80CM OM EL ST OTW 35,2780000111,CDM,278,RC,C1876,HCPCS,Outpatient,,,2039.63,1325.76,,2039.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1550.12,76,,97.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1468.53,72,,3945.504,Percent of Total Billed Charges,72% of Total Billed Charges,1468.53,72,,3945.504,Percent of Total Billed charges,72% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1468.53,72,,3945.504,Percent of Total Billed Charges,72% of Total Billed Charges,1223.78,60,,3287.92,Percent of Total Billed Charges,60% of Total Billed Charges,1835.67,90,,301.68,Percent of Total Billed Charges,90% of Total Billed Charges,917.83,45,,664.144,Percent of Total Billed Charges,45% of Total Billed Charges,1835.67,90,,115.896,Percent of Total Billed Charges,90% of Total billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1325.76,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,899.48,44.1,,650.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,1937.65,95,,122.336,Percent of Total Billed Charges,95% of Total Billed Charges,2039.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1794.87,88,,428.736,Percent of Total Billed Charges,88% of Total Billed Charges,1835.67,90,,115.896,Percent of Total Billed charges,90% of Total Billed Charges,899.48,2039.63,
6F 9X40X135 MUSTNG OTW PTA BAL,2780000112,CDM,278,RC,C1725,HCPCS,Outpatient,,,474.08,308.15,,474.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,360.3,76,,2590.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,341.34,72,,3111.064,Percent of Total Billed Charges,72% of Total Billed Charges,341.34,72,,3111.064,Percent of Total Billed charges,72% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.34,72,,3111.064,Percent of Total Billed Charges,72% of Total Billed Charges,284.45,60,,2592.552,Percent of Total Billed Charges,60% of Total Billed Charges,426.67,90,,1928.16,Percent of Total Billed Charges,90% of Total Billed Charges,213.34,45,,664.144,Percent of Total Billed Charges,45% of Total Billed Charges,426.67,90,,3067.2,Percent of Total Billed Charges,90% of Total billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.15,65,,2215.2,Percent of total Billed Charges,65% of Total Billed Charges,209.07,44.1,,650.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,450.38,95,,3237.6,Percent of Total Billed Charges,95% of Total Billed Charges,474.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.19,88,,294.976,Percent of Total Billed Charges,88% of Total Billed Charges,426.67,90,,3067.2,Percent of Total Billed charges,90% of Total Billed Charges,209.07,474.08,
6FR 035 10X40X120  BIG SE STNT,2780000113,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,4497.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,2821.824,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,2821.824,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,2821.824,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,2351.52,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,1047.816,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,219.24,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,5326.4,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,1491.128,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,214.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,5622.312,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,542.784,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,5326.4,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6FR 035 5X100X120 PE LG SE STN,2780000114,CDM,278,RC,C1876,HCPCS,Outpatient,,,12873.89,8368.03,,12873.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9784.16,76,,1121.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9269.2,72,,2962.912,Percent of Total Billed Charges,72% of Total Billed Charges,9269.2,72,,2962.912,Percent of Total Billed charges,72% of Total Billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9269.2,72,,2962.912,Percent of Total Billed Charges,72% of Total Billed Charges,7724.33,60,,2469.096,Percent of Total Billed Charges,60% of Total Billed Charges,11586.5,90,,130.184,Percent of Total Billed Charges,90% of Total Billed Charges,5793.25,45,,150.84,Percent of Total Billed Charges,45% of Total Billed Charges,11586.5,90,,1328.296,Percent of Total Billed Charges,90% of Total billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8368.03,65,,3452.28,Percent of total Billed Charges,65% of Total Billed Charges,5677.39,44.1,,147.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,12230.2,95,,1402.088,Percent of Total Billed Charges,95% of Total Billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11329.02,88,,542.784,Percent of Total Billed Charges,88% of Total Billed Charges,11586.5,90,,1328.296,Percent of Total Billed charges,90% of Total Billed Charges,5677.39,12873.89,
6FR 035 5X120X120 PE LG SE STN,2780000115,CDM,278,RC,C1876,HCPCS,Outpatient,,,12873.89,8368.03,,12873.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9784.16,76,,1121.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9269.2,72,,3111.064,Percent of Total Billed Charges,72% of Total Billed Charges,9269.2,72,,3111.064,Percent of Total Billed charges,72% of Total Billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9269.2,72,,3111.064,Percent of Total Billed Charges,72% of Total Billed Charges,7724.33,60,,2592.552,Percent of Total Billed Charges,60% of Total Billed Charges,11586.5,90,,130.184,Percent of Total Billed Charges,90% of Total Billed Charges,5793.25,45,,277.56,Percent of Total Billed Charges,45% of Total Billed Charges,11586.5,90,,1328.296,Percent of Total Billed Charges,90% of Total billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8368.03,65,,173.632,Percent of total Billed Charges,65% of Total Billed Charges,5677.39,44.1,,272.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,12230.2,95,,1402.088,Percent of Total Billed Charges,95% of Total Billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11329.02,88,,542.784,Percent of Total Billed Charges,88% of Total Billed Charges,11586.5,90,,1328.296,Percent of Total Billed charges,90% of Total Billed Charges,5677.39,12873.89,
6FR 035 6X100X120 PE LG SE STN,2780000116,CDM,278,RC,C1876,HCPCS,Outpatient,,,12873.89,8368.03,,12873.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9784.16,76,,370.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9269.2,72,,2821.824,Percent of Total Billed Charges,72% of Total Billed Charges,9269.2,72,,2821.824,Percent of Total Billed charges,72% of Total Billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9269.2,72,,2821.824,Percent of Total Billed Charges,72% of Total Billed Charges,7724.33,60,,2351.52,Percent of Total Billed Charges,60% of Total Billed Charges,11586.5,90,,424.688,Percent of Total Billed Charges,90% of Total Billed Charges,5793.25,45,,277.56,Percent of Total Billed Charges,45% of Total Billed Charges,11586.5,90,,438.48,Percent of Total Billed Charges,90% of Total billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8368.03,65,,288.944,Percent of total Billed Charges,65% of Total Billed Charges,5677.39,44.1,,272.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,12230.2,95,,462.84,Percent of Total Billed Charges,95% of Total Billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11329.02,88,,294.976,Percent of Total Billed Charges,88% of Total Billed Charges,11586.5,90,,438.48,Percent of Total Billed charges,90% of Total Billed Charges,5677.39,12873.89,
6FR 035 6X120X120 PE LG SE STN,2780000117,CDM,278,RC,C1876,HCPCS,Outpatient,,,12873.89,8368.03,,12873.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9784.16,76,,254.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9269.2,72,,7341.12,Percent of Total Billed Charges,72% of Total Billed Charges,9269.2,72,,7341.12,Percent of Total Billed charges,72% of Total Billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9269.2,72,,7341.12,Percent of Total Billed Charges,72% of Total Billed Charges,7724.33,60,,6117.6,Percent of Total Billed Charges,60% of Total Billed Charges,11586.5,90,,424.688,Percent of Total Billed Charges,90% of Total Billed Charges,5793.25,45,,277.56,Percent of Total Billed Charges,45% of Total Billed Charges,11586.5,90,,301.68,Percent of Total Billed Charges,90% of Total billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8368.03,65,,288.944,Percent of total Billed Charges,65% of Total Billed Charges,5677.39,44.1,,272.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,12230.2,95,,318.44,Percent of Total Billed Charges,95% of Total Billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11329.02,88,,1885.312,Percent of Total Billed Charges,88% of Total Billed Charges,11586.5,90,,301.68,Percent of Total Billed charges,90% of Total Billed Charges,5677.39,12873.89,
6FR 035 6X150X120 PE LG SE STN,2780000118,CDM,278,RC,C1876,HCPCS,Outpatient,,,12873.89,8368.03,,12873.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9784.16,76,,468.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9269.2,72,,3399.552,Percent of Total Billed Charges,72% of Total Billed Charges,9269.2,72,,3399.552,Percent of Total Billed charges,72% of Total Billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9269.2,72,,3399.552,Percent of Total Billed Charges,72% of Total Billed Charges,7724.33,60,,2832.96,Percent of Total Billed Charges,60% of Total Billed Charges,11586.5,90,,424.688,Percent of Total Billed Charges,90% of Total Billed Charges,5793.25,45,,150.84,Percent of Total Billed Charges,45% of Total Billed Charges,11586.5,90,,555.12,Percent of Total Billed Charges,90% of Total billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8368.03,65,,288.944,Percent of total Billed Charges,65% of Total Billed Charges,5677.39,44.1,,147.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,12230.2,95,,585.96,Percent of Total Billed Charges,95% of Total Billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11329.02,88,,1024.528,Percent of Total Billed Charges,88% of Total Billed Charges,11586.5,90,,555.12,Percent of Total Billed charges,90% of Total Billed Charges,5677.39,12873.89,
6FR 035 6X17X80 VISI  EXP STNT,2780000119,CDM,278,RC,C1876,HCPCS,Outpatient,,,6174.00,4013.10,,6174,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4692.24,76,,468.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4445.28,72,,7341.12,Percent of Total Billed Charges,72% of Total Billed Charges,4445.28,72,,7341.12,Percent of Total Billed charges,72% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4445.28,72,,7341.12,Percent of Total Billed Charges,72% of Total Billed Charges,3704.4,60,,6117.6,Percent of Total Billed Charges,60% of Total Billed Charges,5556.6,90,,424.688,Percent of Total Billed Charges,90% of Total Billed Charges,2778.3,45,,964.08,Percent of Total Billed Charges,45% of Total Billed Charges,5556.6,90,,555.12,Percent of Total Billed Charges,90% of Total billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4013.1,65,,315.04,Percent of total Billed Charges,65% of Total Billed Charges,2722.73,44.1,,944.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,5865.3,95,,585.96,Percent of Total Billed Charges,95% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5433.12,88,,127.288,Percent of Total Billed Charges,88% of Total Billed Charges,5556.6,90,,555.12,Percent of Total Billed charges,90% of Total Billed Charges,2722.73,6174,
6FR 035 6X27X80  BAL EXP STNT,2780000120,CDM,278,RC,C1876,HCPCS,Outpatient,,,6174.00,4013.10,,6174,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4692.24,76,,468.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4445.28,72,,2962.912,Percent of Total Billed Charges,72% of Total Billed Charges,4445.28,72,,2962.912,Percent of Total Billed charges,72% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4445.28,72,,2962.912,Percent of Total Billed Charges,72% of Total Billed Charges,3704.4,60,,2469.096,Percent of Total Billed Charges,60% of Total Billed Charges,5556.6,90,,3276,Percent of Total Billed Charges,90% of Total Billed Charges,2778.3,45,,523.912,Percent of Total Billed Charges,45% of Total Billed Charges,5556.6,90,,555.12,Percent of Total Billed Charges,90% of Total billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4013.1,65,,377.52,Percent of total Billed Charges,65% of Total Billed Charges,2722.73,44.1,,513.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,5865.3,95,,585.96,Percent of Total Billed Charges,95% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5433.12,88,,127.288,Percent of Total Billed Charges,88% of Total Billed Charges,5556.6,90,,555.12,Percent of Total Billed charges,90% of Total Billed Charges,2722.73,6174,
6FR 035 6X37X80 BAL EXP STNT,2780000121,CDM,278,RC,C1876,HCPCS,Outpatient,,,6174.00,4013.10,,6174,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4692.24,76,,254.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4445.28,72,,4959.664,Percent of Total Billed Charges,72% of Total Billed Charges,4445.28,72,,4959.664,Percent of Total Billed charges,72% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4445.28,72,,4959.664,Percent of Total Billed Charges,72% of Total Billed Charges,3704.4,60,,4133.056,Percent of Total Billed Charges,60% of Total Billed Charges,5556.6,90,,137.528,Percent of Total Billed Charges,90% of Total Billed Charges,2778.3,45,,65.088,Percent of Total Billed Charges,45% of Total Billed Charges,5556.6,90,,301.68,Percent of Total Billed Charges,90% of Total billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4013.1,65,,377.52,Percent of total Billed Charges,65% of Total Billed Charges,2722.73,44.1,,63.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,5865.3,95,,318.44,Percent of Total Billed Charges,95% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5433.12,88,,415.248,Percent of Total Billed Charges,88% of Total Billed Charges,5556.6,90,,301.68,Percent of Total Billed charges,90% of Total Billed Charges,2722.73,6174,
6FR 035 6X40X120 P EVFLEX STNT,2780000122,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,1628.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,4048.704,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,4048.704,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,4048.704,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,3373.92,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,2653.56,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,65.088,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,1928.16,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,461.76,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,63.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,2035.28,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,415.248,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,1928.16,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6FR 035 6X60X120 P EVFLEX STNT,2780000123,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,884.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,4959.664,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,4959.664,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,4959.664,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,4133.056,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,212.344,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,1047.816,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,167.96,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,208.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,1106.032,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,415.248,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,1047.816,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6FR 035 6X80X120 P EVFLEX STNT,2780000124,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,109.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,4959.664,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,4959.664,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,4959.664,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,4133.056,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,212.344,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,130.184,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,167.96,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,208.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,137.416,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,415.248,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,130.184,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6FR 035 7X100X120 PE LG SE STN,2780000125,CDM,278,RC,C1876,HCPCS,Outpatient,,,12873.89,8368.03,,12873.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9784.16,76,,109.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9269.2,72,,4463.696,Percent of Total Billed Charges,72% of Total Billed Charges,9269.2,72,,4463.696,Percent of Total Billed charges,72% of Total Billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9269.2,72,,4463.696,Percent of Total Billed Charges,72% of Total Billed Charges,7724.33,60,,3719.744,Percent of Total Billed Charges,60% of Total Billed Charges,11586.5,90,,3067.2,Percent of Total Billed Charges,90% of Total Billed Charges,5793.25,45,,212.344,Percent of Total Billed Charges,45% of Total Billed Charges,11586.5,90,,130.184,Percent of Total Billed Charges,90% of Total billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8368.03,65,,167.96,Percent of total Billed Charges,65% of Total Billed Charges,5677.39,44.1,,208.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,12230.2,95,,137.416,Percent of Total Billed Charges,95% of Total Billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11329.02,88,,3203.2,Percent of Total Billed Charges,88% of Total Billed Charges,11586.5,90,,130.184,Percent of Total Billed charges,90% of Total Billed Charges,5677.39,12873.89,
6FR 035 7X120X120 PE LG SE STN,2780000126,CDM,278,RC,C1876,HCPCS,Outpatient,,,12873.89,8368.03,,12873.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9784.16,76,,358.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9269.2,72,,4959.664,Percent of Total Billed Charges,72% of Total Billed Charges,9269.2,72,,4959.664,Percent of Total Billed charges,72% of Total Billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9269.2,72,,4959.664,Percent of Total Billed Charges,72% of Total Billed Charges,7724.33,60,,4133.056,Percent of Total Billed Charges,60% of Total Billed Charges,11586.5,90,,2064.64,Percent of Total Billed Charges,90% of Total Billed Charges,5793.25,45,,212.344,Percent of Total Billed Charges,45% of Total Billed Charges,11586.5,90,,424.688,Percent of Total Billed Charges,90% of Total billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8368.03,65,,167.96,Percent of total Billed Charges,65% of Total Billed Charges,5677.39,44.1,,208.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,12230.2,95,,448.28,Percent of Total Billed Charges,95% of Total Billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11329.02,88,,134.472,Percent of Total Billed Charges,88% of Total Billed Charges,11586.5,90,,424.688,Percent of Total Billed charges,90% of Total Billed Charges,5677.39,12873.89,
6FR 035 7X150X120 PE LG SE STN,2780000127,CDM,278,RC,C1876,HCPCS,Outpatient,,,12873.89,8368.03,,12873.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9784.16,76,,358.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9269.2,72,,4959.664,Percent of Total Billed Charges,72% of Total Billed Charges,9269.2,72,,4959.664,Percent of Total Billed charges,72% of Total Billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9269.2,72,,4959.664,Percent of Total Billed Charges,72% of Total Billed Charges,7724.33,60,,4133.056,Percent of Total Billed Charges,60% of Total Billed Charges,11586.5,90,,4780.08,Percent of Total Billed Charges,90% of Total Billed Charges,5793.25,45,,1638,Percent of Total Billed Charges,45% of Total Billed Charges,11586.5,90,,424.688,Percent of Total Billed Charges,90% of Total billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8368.03,65,,167.96,Percent of total Billed Charges,65% of Total Billed Charges,5677.39,44.1,,1605.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,12230.2,95,,448.28,Percent of Total Billed Charges,95% of Total Billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11329.02,88,,2594.592,Percent of Total Billed Charges,88% of Total Billed Charges,11586.5,90,,424.688,Percent of Total Billed charges,90% of Total Billed Charges,5677.39,12873.89,
6FR 035 7X17X80  BAL EXPSTNT,2780000128,CDM,278,RC,C1876,HCPCS,Outpatient,,,6174.00,4013.10,,6174,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4692.24,76,,358.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4445.28,72,,1916.552,Percent of Total Billed Charges,72% of Total Billed Charges,4445.28,72,,1916.552,Percent of Total Billed charges,72% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4445.28,72,,1916.552,Percent of Total Billed Charges,72% of Total Billed Charges,3704.4,60,,1597.128,Percent of Total Billed Charges,60% of Total Billed Charges,5556.6,90,,240.408,Percent of Total Billed Charges,90% of Total Billed Charges,2778.3,45,,68.76,Percent of Total Billed Charges,45% of Total Billed Charges,5556.6,90,,424.688,Percent of Total Billed Charges,90% of Total billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4013.1,65,,167.96,Percent of total Billed Charges,65% of Total Billed Charges,2722.73,44.1,,67.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,5865.3,95,,448.28,Percent of Total Billed Charges,95% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5433.12,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,5556.6,90,,424.688,Percent of Total Billed charges,90% of Total Billed Charges,2722.73,6174,
6FR 035 7X27X135  BAL EXP STNT,2780000129,CDM,278,RC,C1876,HCPCS,Outpatient,,,6174.00,4013.10,,6174,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4692.24,76,,358.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4445.28,72,,1916.552,Percent of Total Billed Charges,72% of Total Billed Charges,4445.28,72,,1916.552,Percent of Total Billed charges,72% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4445.28,72,,1916.552,Percent of Total Billed Charges,72% of Total Billed Charges,3704.4,60,,1597.128,Percent of Total Billed Charges,60% of Total Billed Charges,5556.6,90,,400.072,Percent of Total Billed Charges,90% of Total Billed Charges,2778.3,45,,1326.784,Percent of Total Billed Charges,45% of Total Billed Charges,5556.6,90,,424.688,Percent of Total Billed Charges,90% of Total billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4013.1,65,,167.96,Percent of total Billed Charges,65% of Total Billed Charges,2722.73,44.1,,1300.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,5865.3,95,,448.28,Percent of Total Billed Charges,95% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5433.12,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,5556.6,90,,424.688,Percent of Total Billed charges,90% of Total Billed Charges,2722.73,6174,
6FR 035 7X27X80 P EVFLEX STNT,2780000130,CDM,278,RC,C1876,HCPCS,Outpatient,,,6174.00,4013.10,,6174,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4692.24,76,,2766.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4445.28,72,,106.448,Percent of Total Billed Charges,72% of Total Billed Charges,4445.28,72,,106.448,Percent of Total Billed charges,72% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4445.28,72,,106.448,Percent of Total Billed Charges,72% of Total Billed Charges,3704.4,60,,88.704,Percent of Total Billed Charges,60% of Total Billed Charges,5556.6,90,,400.072,Percent of Total Billed Charges,90% of Total Billed Charges,2778.3,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,5556.6,90,,3276,Percent of Total Billed Charges,90% of Total billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4013.1,65,,167.96,Percent of total Billed Charges,65% of Total Billed Charges,2722.73,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,5865.3,95,,3458,Percent of Total Billed Charges,95% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5433.12,88,,2999.04,Percent of Total Billed Charges,88% of Total Billed Charges,5556.6,90,,3276,Percent of Total Billed charges,90% of Total Billed Charges,2722.73,6174,
6FR 035 7X37X135  BAL EXP STNT,2780000131,CDM,278,RC,C1876,HCPCS,Outpatient,,,6174.00,4013.10,,6174,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4692.24,76,,116.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4445.28,72,,106.448,Percent of Total Billed Charges,72% of Total Billed Charges,4445.28,72,,106.448,Percent of Total Billed charges,72% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4445.28,72,,106.448,Percent of Total Billed Charges,72% of Total Billed Charges,3704.4,60,,88.704,Percent of Total Billed Charges,60% of Total Billed Charges,5556.6,90,,400.072,Percent of Total Billed Charges,90% of Total Billed Charges,2778.3,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,5556.6,90,,137.528,Percent of Total Billed Charges,90% of Total billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4013.1,65,,167.96,Percent of total Billed Charges,65% of Total Billed Charges,2722.73,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,5865.3,95,,145.168,Percent of Total Billed Charges,95% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5433.12,88,,2018.752,Percent of Total Billed Charges,88% of Total Billed Charges,5556.6,90,,137.528,Percent of Total Billed charges,90% of Total Billed Charges,2722.73,6174,
6FR 035 8X100X120 PE LG SE STN,2780000132,CDM,278,RC,C1876,HCPCS,Outpatient,,,12873.89,8368.03,,12873.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9784.16,76,,2240.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9269.2,72,,376.704,Percent of Total Billed Charges,72% of Total Billed Charges,9269.2,72,,376.704,Percent of Total Billed charges,72% of Total Billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9269.2,72,,376.704,Percent of Total Billed Charges,72% of Total Billed Charges,7724.33,60,,313.92,Percent of Total Billed Charges,60% of Total Billed Charges,11586.5,90,,436.216,Percent of Total Billed Charges,90% of Total Billed Charges,5793.25,45,,1533.6,Percent of Total Billed Charges,45% of Total Billed Charges,11586.5,90,,2653.56,Percent of Total Billed Charges,90% of Total billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8368.03,65,,167.96,Percent of total Billed Charges,65% of Total Billed Charges,5677.39,44.1,,1502.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,12230.2,95,,2800.984,Percent of Total Billed Charges,95% of Total Billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11329.02,88,,4673.856,Percent of Total Billed Charges,88% of Total Billed Charges,11586.5,90,,2653.56,Percent of Total Billed charges,90% of Total Billed Charges,5677.39,12873.89,
6FR 035 8X150X120 PE LG SE STN,2780000133,CDM,278,RC,C1876,HCPCS,Outpatient,,,12873.89,8368.03,,12873.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9784.16,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9269.2,72,,376.704,Percent of Total Billed Charges,72% of Total Billed Charges,9269.2,72,,376.704,Percent of Total Billed charges,72% of Total Billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9269.2,72,,376.704,Percent of Total Billed Charges,72% of Total Billed Charges,7724.33,60,,313.92,Percent of Total Billed Charges,60% of Total Billed Charges,11586.5,90,,522.72,Percent of Total Billed Charges,90% of Total Billed Charges,5793.25,45,,1032.32,Percent of Total Billed Charges,45% of Total Billed Charges,11586.5,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8368.03,65,,88.4,Percent of total Billed Charges,65% of Total Billed Charges,5677.39,44.1,,1011.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,12230.2,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,12873.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11329.02,88,,235.064,Percent of Total Billed Charges,88% of Total Billed Charges,11586.5,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,5677.39,12873.89,
6FR 035 8X27X135  BAL EXPA STN,2780000134,CDM,278,RC,C1876,HCPCS,Outpatient,,,6174.00,4013.10,,6174,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4692.24,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4445.28,72,,108.288,Percent of Total Billed Charges,72% of Total Billed Charges,4445.28,72,,108.288,Percent of Total Billed charges,72% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4445.28,72,,108.288,Percent of Total Billed Charges,72% of Total Billed Charges,3704.4,60,,90.24,Percent of Total Billed Charges,60% of Total Billed Charges,5556.6,90,,522.72,Percent of Total Billed Charges,90% of Total Billed Charges,2778.3,45,,2390.04,Percent of Total Billed Charges,45% of Total Billed Charges,5556.6,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4013.1,65,,167.96,Percent of total Billed Charges,65% of Total Billed Charges,2722.73,44.1,,2342.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,5865.3,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5433.12,88,,391.184,Percent of Total Billed Charges,88% of Total Billed Charges,5556.6,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,2722.73,6174,
6FR 035 8X30X120 EVF SE STD ST,2780000135,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,2590.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,270.344,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,270.344,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,270.344,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,225.288,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,639.36,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,120.208,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,3067.2,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,88.4,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,117.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,3237.6,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,391.184,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,3067.2,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6FR 035 8X37X135  BAL EXPA STN,2780000136,CDM,278,RC,C1876,HCPCS,Outpatient,,,6174.00,4013.10,,6174,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4692.24,76,,1743.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4445.28,72,,4405.824,Percent of Total Billed Charges,72% of Total Billed Charges,4445.28,72,,4405.824,Percent of Total Billed charges,72% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4445.28,72,,4405.824,Percent of Total Billed Charges,72% of Total Billed Charges,3704.4,60,,3671.52,Percent of Total Billed Charges,60% of Total Billed Charges,5556.6,90,,232.56,Percent of Total Billed Charges,90% of Total Billed Charges,2778.3,45,,200.04,Percent of Total Billed Charges,45% of Total Billed Charges,5556.6,90,,2064.64,Percent of Total Billed Charges,90% of Total billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4013.1,65,,88.4,Percent of total Billed Charges,65% of Total Billed Charges,2722.73,44.1,,196.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,5865.3,95,,2179.336,Percent of Total Billed Charges,95% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5433.12,88,,391.184,Percent of Total Billed Charges,88% of Total Billed Charges,5556.6,90,,2064.64,Percent of Total Billed charges,90% of Total Billed Charges,2722.73,6174,
6FR 035 8X80X120 P EVFLEX STNT,2780000137,CDM,278,RC,C1876,HCPCS,Outpatient,,,4961.25,3224.81,,4961.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3770.55,76,,4036.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3572.1,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,3572.1,72,,41.28,Percent of Total Billed charges,72% of Total Billed Charges,4961.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,2976.75,60,,34.4,Percent of Total Billed Charges,60% of Total Billed Charges,4465.13,90,,232.56,Percent of Total Billed Charges,90% of Total Billed Charges,2232.56,45,,200.04,Percent of Total Billed Charges,45% of Total Billed Charges,4465.13,90,,4780.08,Percent of Total Billed Charges,90% of Total billed Charges,4961.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4961.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4961.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3224.81,65,,88.4,Percent of total Billed Charges,65% of Total Billed Charges,2187.91,44.1,,196.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,4713.19,95,,5045.64,Percent of Total Billed Charges,95% of Total Billed Charges,4961.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4365.9,88,,426.52,Percent of Total Billed Charges,88% of Total Billed Charges,4465.13,90,,4780.08,Percent of Total Billed charges,90% of Total Billed Charges,2187.91,4961.25,
6FR 035 9X40X80 P BIGGS STNT,2780000138,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,203.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,38.592,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,38.592,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,38.592,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,232.56,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,200.04,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,240.408,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,1413.88,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,196.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,253.768,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,511.104,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,240.408,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
6FR 035 9X60X80 P BIGGS STNT,2780000139,CDM,278,RC,C1876,HCPCS,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,337.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,32.256,Percent of Total Billed Charges,72% of Total Billed Charges,3611.79,72,,32.256,Percent of Total Billed charges,72% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,32.256,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,26.88,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,232.56,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,218.104,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,400.072,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,1413.88,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,213.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,422.304,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,511.104,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,400.072,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
7F 035 9X27X80 VISI PRO STNT,2780000140,CDM,278,RC,C1876,HCPCS,Outpatient,,,6174.00,4013.10,,6174,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4692.24,76,,337.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4445.28,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,4445.28,72,,40.64,Percent of Total Billed charges,72% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4445.28,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,3704.4,60,,33.872,Percent of Total Billed Charges,60% of Total Billed Charges,5556.6,90,,232.56,Percent of Total Billed Charges,90% of Total Billed Charges,2778.3,45,,261.36,Percent of Total Billed Charges,45% of Total Billed Charges,5556.6,90,,400.072,Percent of Total Billed Charges,90% of Total billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4013.1,65,,1413.88,Percent of total Billed Charges,65% of Total Billed Charges,2722.73,44.1,,256.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,5865.3,95,,422.304,Percent of Total Billed Charges,95% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5433.12,88,,625.152,Percent of Total Billed Charges,88% of Total Billed Charges,5556.6,90,,400.072,Percent of Total Billed charges,90% of Total Billed Charges,2722.73,6174,
7FR 035 10X37X80 VISI PRO STNT,2780000141,CDM,278,RC,C1876,HCPCS,Outpatient,,,6174.00,4013.10,,6174,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4692.24,76,,337.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4445.28,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,4445.28,72,,36.192,Percent of Total Billed charges,72% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4445.28,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,3704.4,60,,30.16,Percent of Total Billed Charges,60% of Total Billed Charges,5556.6,90,,232.56,Percent of Total Billed Charges,90% of Total Billed Charges,2778.3,45,,261.36,Percent of Total Billed Charges,45% of Total Billed Charges,5556.6,90,,400.072,Percent of Total Billed Charges,90% of Total billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4013.1,65,,1413.88,Percent of total Billed Charges,65% of Total Billed Charges,2722.73,44.1,,256.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,5865.3,95,,422.304,Percent of Total Billed Charges,95% of Total Billed Charges,6174,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5433.12,88,,227.392,Percent of Total Billed Charges,88% of Total Billed Charges,5556.6,90,,400.072,Percent of Total Billed charges,90% of Total Billed Charges,2722.73,6174,
8F 40CM BILLIARY DRAIN CATH,2780000143,CDM,278,RC,C1729,HCPCS,Outpatient,,,357.00,232.05,,357,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,271.32,76,,368.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,257.04,72,,36.832,Percent of Total Billed Charges,72% of Total Billed Charges,257.04,72,,36.832,Percent of Total Billed charges,72% of Total Billed Charges,357,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.04,72,,36.832,Percent of Total Billed Charges,72% of Total Billed Charges,214.2,60,,30.696,Percent of Total Billed Charges,60% of Total Billed Charges,321.3,90,,232.56,Percent of Total Billed Charges,90% of Total Billed Charges,160.65,45,,319.68,Percent of Total Billed Charges,45% of Total Billed Charges,321.3,90,,436.216,Percent of Total Billed Charges,90% of Total billed Charges,357,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.05,65,,1413.88,Percent of total Billed Charges,65% of Total Billed Charges,157.44,44.1,,313.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,339.15,95,,460.448,Percent of Total Billed Charges,95% of Total Billed Charges,357,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.16,88,,227.392,Percent of Total Billed Charges,88% of Total Billed Charges,321.3,90,,436.216,Percent of Total Billed charges,90% of Total Billed Charges,157.44,357,
ACUM 700125 DIS CL PL RT 13,2780000144,CDM,278,RC,C1713,HCPCS,Outpatient,,,5084.10,3304.67,,5084.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3863.92,76,,441.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3660.55,72,,36.832,Percent of Total Billed Charges,72% of Total Billed Charges,3660.55,72,,36.832,Percent of Total Billed charges,72% of Total Billed Charges,5084.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3660.55,72,,36.832,Percent of Total Billed Charges,72% of Total Billed Charges,3050.46,60,,30.696,Percent of Total Billed Charges,60% of Total Billed Charges,4575.69,90,,232.56,Percent of Total Billed Charges,90% of Total Billed Charges,2287.85,45,,116.28,Percent of Total Billed Charges,45% of Total Billed Charges,4575.69,90,,522.72,Percent of Total Billed Charges,90% of Total billed Charges,5084.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5084.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5084.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3304.67,65,,1413.88,Percent of total Billed Charges,65% of Total Billed Charges,2242.09,44.1,,113.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,4829.9,95,,551.76,Percent of Total Billed Charges,95% of Total Billed Charges,5084.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4474.01,88,,227.392,Percent of Total Billed Charges,88% of Total Billed Charges,4575.69,90,,522.72,Percent of Total Billed charges,90% of Total Billed Charges,2242.09,5084.1,
ACUMD AT2C13S 13MM MICR SCRW,2780000145,CDM,278,RC,,,Outpatient,,,2318.00,1506.70,,2318,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1761.68,76,,441.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1668.96,72,,475.008,Percent of Total Billed Charges,72% of Total Billed Charges,1668.96,72,,475.008,Percent of Total Billed charges,72% of Total Billed Charges,2318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1668.96,72,,475.008,Percent of Total Billed Charges,72% of Total Billed Charges,1390.8,60,,395.84,Percent of Total Billed Charges,60% of Total Billed Charges,2086.2,90,,232.56,Percent of Total Billed Charges,90% of Total Billed Charges,1043.1,45,,116.28,Percent of Total Billed Charges,45% of Total Billed Charges,2086.2,90,,522.72,Percent of Total Billed Charges,90% of Total billed Charges,2318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1506.7,65,,1413.88,Percent of total Billed Charges,65% of Total Billed Charges,1022.24,44.1,,113.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,2202.1,95,,551.76,Percent of Total Billed Charges,95% of Total Billed Charges,2318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.84,88,,227.392,Percent of Total Billed Charges,88% of Total Billed Charges,2086.2,90,,522.72,Percent of Total Billed charges,90% of Total Billed Charges,1022.24,2318,
ACUMED 700296 CLAV 6HPLT LT,2780000146,CDM,278,RC,C1713,HCPCS,Outpatient,,,5684.00,3694.60,,5684,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4319.84,76,,539.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4092.48,72,,363.488,Percent of Total Billed Charges,72% of Total Billed Charges,4092.48,72,,363.488,Percent of Total Billed charges,72% of Total Billed Charges,5684,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4092.48,72,,363.488,Percent of Total Billed Charges,72% of Total Billed Charges,3410.4,60,,302.904,Percent of Total Billed Charges,60% of Total Billed Charges,5115.6,90,,232.56,Percent of Total Billed Charges,90% of Total Billed Charges,2557.8,45,,116.28,Percent of Total Billed Charges,45% of Total Billed Charges,5115.6,90,,639.36,Percent of Total Billed Charges,90% of Total billed Charges,5684,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5684,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5684,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3694.6,65,,39.312,Percent of total Billed Charges,65% of Total Billed Charges,2506.64,44.1,,113.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,5399.8,95,,674.88,Percent of Total Billed Charges,95% of Total Billed Charges,5684,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5001.92,88,,227.392,Percent of Total Billed Charges,88% of Total Billed Charges,5115.6,90,,639.36,Percent of Total Billed charges,90% of Total Billed Charges,2506.64,5684,
ACUMED 700299 CLAV PLT 8H RT,2780000147,CDM,278,RC,C1713,HCPCS,Outpatient,,,6661.00,4329.65,,6661,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5062.36,76,,196.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4795.92,72,,135.264,Percent of Total Billed Charges,72% of Total Billed Charges,4795.92,72,,135.264,Percent of Total Billed charges,72% of Total Billed Charges,6661,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4795.92,72,,135.264,Percent of Total Billed Charges,72% of Total Billed Charges,3996.6,60,,112.72,Percent of Total Billed Charges,60% of Total Billed Charges,5994.9,90,,122.4,Percent of Total Billed Charges,90% of Total Billed Charges,2997.45,45,,116.28,Percent of Total Billed Charges,45% of Total Billed Charges,5994.9,90,,232.56,Percent of Total Billed Charges,90% of Total billed Charges,6661,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6661,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6661,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4329.65,65,,21.84,Percent of total Billed Charges,65% of Total Billed Charges,2937.5,44.1,,113.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,6327.95,95,,245.48,Percent of Total Billed Charges,95% of Total Billed Charges,6661,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5861.68,88,,227.392,Percent of Total Billed Charges,88% of Total Billed Charges,5994.9,90,,232.56,Percent of Total Billed charges,90% of Total Billed Charges,2937.5,6661,
ACUMED 700319 CLAV J PLTE 8H,2780000148,CDM,278,RC,C1713,HCPCS,Outpatient,,,5084.10,3304.67,,5084.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3863.92,76,,196.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3660.55,72,,572.544,Percent of Total Billed Charges,72% of Total Billed Charges,3660.55,72,,572.544,Percent of Total Billed charges,72% of Total Billed Charges,5084.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3660.55,72,,572.544,Percent of Total Billed Charges,72% of Total Billed Charges,3050.46,60,,477.12,Percent of Total Billed Charges,60% of Total Billed Charges,4575.69,90,,232.56,Percent of Total Billed Charges,90% of Total Billed Charges,2287.85,45,,116.28,Percent of Total Billed Charges,45% of Total Billed Charges,4575.69,90,,232.56,Percent of Total Billed Charges,90% of Total billed Charges,5084.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5084.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5084.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3304.67,65,,1340.04,Percent of total Billed Charges,65% of Total Billed Charges,2242.09,44.1,,113.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,4829.9,95,,245.48,Percent of Total Billed Charges,95% of Total Billed Charges,5084.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4474.01,88,,227.392,Percent of Total Billed Charges,88% of Total Billed Charges,4575.69,90,,232.56,Percent of Total Billed charges,90% of Total Billed Charges,2242.09,5084.1,
ACUMED 800100 MICRO DRIL LG,2780000149,CDM,278,RC,C1713,HCPCS,Outpatient,,,711.11,462.22,,711.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,540.44,76,,196.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,512,72,,9949.808,Percent of Total Billed Charges,72% of Total Billed Charges,512,72,,9949.808,Percent of Total Billed charges,72% of Total Billed Charges,711.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,512,72,,9949.808,Percent of Total Billed Charges,72% of Total Billed Charges,426.67,60,,8291.504,Percent of Total Billed Charges,60% of Total Billed Charges,640,90,,122.4,Percent of Total Billed Charges,90% of Total Billed Charges,320,45,,116.28,Percent of Total Billed Charges,45% of Total Billed Charges,640,90,,232.56,Percent of Total Billed Charges,90% of Total billed Charges,711.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,711.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,711.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.22,65,,877.968,Percent of total Billed Charges,65% of Total Billed Charges,313.6,44.1,,113.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,675.55,95,,245.48,Percent of Total Billed Charges,95% of Total Billed Charges,711.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.78,88,,227.392,Percent of Total Billed Charges,88% of Total Billed Charges,640,90,,232.56,Percent of Total Billed charges,90% of Total Billed Charges,313.6,711.11,
ACUMED AT 2125 15 DRIL BIT LG,2780000150,CDM,278,RC,C1713,HCPCS,Outpatient,,,414.54,269.45,,414.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,315.05,76,,196.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,298.47,72,,2858.688,Percent of Total Billed Charges,72% of Total Billed Charges,298.47,72,,2858.688,Percent of Total Billed charges,72% of Total Billed Charges,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.47,72,,2858.688,Percent of Total Billed Charges,72% of Total Billed Charges,248.72,60,,2382.24,Percent of Total Billed Charges,60% of Total Billed Charges,373.09,90,,122.4,Percent of Total Billed Charges,90% of Total Billed Charges,186.54,45,,116.28,Percent of Total Billed Charges,45% of Total Billed Charges,373.09,90,,232.56,Percent of Total Billed Charges,90% of Total billed Charges,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.45,65,,2038.92,Percent of total Billed Charges,65% of Total Billed Charges,182.81,44.1,,113.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,393.81,95,,245.48,Percent of Total Billed Charges,95% of Total Billed Charges,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.8,88,,227.392,Percent of Total Billed Charges,88% of Total Billed Charges,373.09,90,,232.56,Percent of Total Billed charges,90% of Total Billed Charges,182.81,414.54,
ACUMED AT22515 DRIL BIT SHRT,2780000151,CDM,278,RC,C1713,HCPCS,Outpatient,,,1155.42,751.02,,1155.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,878.12,76,,196.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,831.9,72,,1262.592,Percent of Total Billed Charges,72% of Total Billed Charges,831.9,72,,1262.592,Percent of Total Billed charges,72% of Total Billed Charges,1155.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,831.9,72,,1262.592,Percent of Total Billed Charges,72% of Total Billed Charges,693.25,60,,1052.16,Percent of Total Billed Charges,60% of Total Billed Charges,1039.88,90,,122.4,Percent of Total Billed Charges,90% of Total Billed Charges,519.94,45,,116.28,Percent of Total Billed Charges,45% of Total Billed Charges,1039.88,90,,232.56,Percent of Total Billed Charges,90% of Total billed Charges,1155.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1155.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1155.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,751.02,65,,2247.912,Percent of total Billed Charges,65% of Total Billed Charges,509.54,44.1,,113.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,1097.65,95,,245.48,Percent of Total Billed Charges,95% of Total Billed Charges,1155.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1016.77,88,,227.392,Percent of Total Billed Charges,88% of Total Billed Charges,1039.88,90,,232.56,Percent of Total Billed charges,90% of Total Billed Charges,509.54,1155.42,
ACUMED CA 4120 40X12MM CAN SCW,2780000152,CDM,278,RC,C1773,HCPCS,Outpatient,,,412.00,267.80,,412,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,313.12,76,,196.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,296.64,72,,1352.448,Percent of Total Billed Charges,72% of Total Billed Charges,296.64,72,,1352.448,Percent of Total Billed charges,72% of Total Billed Charges,412,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.64,72,,1352.448,Percent of Total Billed Charges,72% of Total Billed Charges,247.2,60,,1127.04,Percent of Total Billed Charges,60% of Total Billed Charges,370.8,90,,1957.68,Percent of Total Billed Charges,90% of Total Billed Charges,185.4,45,,116.28,Percent of Total Billed Charges,45% of Total Billed Charges,370.8,90,,232.56,Percent of Total Billed Charges,90% of Total billed Charges,412,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.8,65,,1565.112,Percent of total Billed Charges,65% of Total Billed Charges,181.69,44.1,,113.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,391.4,95,,245.48,Percent of Total Billed Charges,95% of Total Billed Charges,412,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,362.56,88,,119.68,Percent of Total Billed Charges,88% of Total Billed Charges,370.8,90,,232.56,Percent of Total Billed charges,90% of Total Billed Charges,181.69,412,
ADMIRAL 6F 5X40X130 BALLOON,2780000153,CDM,272,RC,C2623,HCPCS,Outpatient,,,2235.45,1453.04,,2235.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1698.94,76,,196.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1609.52,72,,2667.168,Percent of Total Billed Charges,72% of Total Billed Charges,1676.59,75,,2667.168,Percent of Total Billed charges,75% of Total Billed Charges,2235.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1609.52,72,,2667.168,Percent of Total Billed Charges,72% of Total Billed Charges,1341.27,60,,2222.64,Percent of Total Billed Charges,60% of Total Billed Charges,2011.91,90,,1957.68,Percent of Total Billed Charges,90% of Total Billed Charges,1005.95,45,,116.28,Percent of Total Billed Charges,45% of Total Billed Charges,2011.91,90,,232.56,Percent of Total Billed Charges,90% of Total billed Charges,2235.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1453.04,65,,2954.44,Percent of total Billed Charges,65% of Total Billed Charges,985.83,44.1,,113.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,2123.68,95,,245.48,Percent of Total Billed Charges,95% of Total Billed Charges,2235.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.2,88,,227.392,Percent of Total Billed Charges,88% of Total Billed Charges,2011.91,90,,232.56,Percent of Total Billed charges,90% of Total Billed Charges,985.83,2235.45,
ADMRL 5F 4X150X130 0TW PTA BAL,2780000154,CDM,272,RC,C2623,HCPCS,Outpatient,,,3616.20,2350.53,,3616.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2748.31,76,,196.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2603.66,72,,2667.168,Percent of Total Billed Charges,72% of Total Billed Charges,2712.15,75,,2667.168,Percent of Total Billed charges,75% of Total Billed Charges,3616.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2603.66,72,,2667.168,Percent of Total Billed Charges,72% of Total Billed Charges,2169.72,60,,2222.64,Percent of Total Billed Charges,60% of Total Billed Charges,3254.58,90,,1957.68,Percent of Total Billed Charges,90% of Total Billed Charges,1627.29,45,,61.2,Percent of Total Billed Charges,45% of Total Billed Charges,3254.58,90,,232.56,Percent of Total Billed Charges,90% of Total billed Charges,3616.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3616.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3616.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2350.53,65,,1420.12,Percent of total Billed Charges,65% of Total Billed Charges,1594.74,44.1,,59.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,3435.39,95,,245.48,Percent of Total Billed Charges,95% of Total Billed Charges,3616.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3182.26,88,,119.68,Percent of Total Billed Charges,88% of Total Billed Charges,3254.58,90,,232.56,Percent of Total Billed charges,90% of Total Billed Charges,1594.74,3616.2,
AG IH 3016 HDLESS SCW 16MM 3.0,2780000155,CDM,278,RC,C1776,HCPCS,Outpatient,,,2156.49,1401.72,,2156.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1638.93,76,,196.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1552.67,72,,4251.632,Percent of Total Billed Charges,72% of Total Billed Charges,1552.67,72,,4428.784,Percent of Total Billed charges,72% of Total Billed Charges,2156.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1552.67,72,,4251.632,Percent of Total Billed Charges,72% of Total Billed Charges,1293.89,60,,3543.024,Percent of Total Billed Charges,60% of Total Billed Charges,1940.84,90,,1957.68,Percent of Total Billed Charges,90% of Total Billed Charges,970.42,45,,116.28,Percent of Total Billed Charges,45% of Total Billed Charges,1940.84,90,,232.56,Percent of Total Billed Charges,90% of Total billed Charges,2156.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2156.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2156.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1401.72,65,,1491.128,Percent of total Billed Charges,65% of Total Billed Charges,951.01,44.1,,113.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,2048.67,95,,245.48,Percent of Total Billed Charges,95% of Total Billed Charges,2156.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1897.71,88,,119.68,Percent of Total Billed Charges,88% of Total Billed Charges,1940.84,90,,232.56,Percent of Total Billed charges,90% of Total Billed Charges,951.01,2156.49,
AG IS1113 2.1 CANN DRL BIT 3.0,2780000156,CDM,278,RC,C1776,HCPCS,Outpatient,,,459.74,298.83,,459.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,349.4,76,,196.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,331.01,72,,7004.496,Percent of Total Billed Charges,72% of Total Billed Charges,331.01,72,,7296.352,Percent of Total Billed charges,72% of Total Billed Charges,459.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,331.01,72,,7004.496,Percent of Total Billed Charges,72% of Total Billed Charges,275.84,60,,5837.08,Percent of Total Billed Charges,60% of Total Billed Charges,413.77,90,,1957.68,Percent of Total Billed Charges,90% of Total Billed Charges,206.88,45,,61.2,Percent of Total Billed Charges,45% of Total Billed Charges,413.77,90,,232.56,Percent of Total Billed Charges,90% of Total billed Charges,459.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,459.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,459.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.83,65,,1565.112,Percent of total Billed Charges,65% of Total Billed Charges,202.75,44.1,,59.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,436.75,95,,245.48,Percent of Total Billed Charges,95% of Total Billed Charges,459.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404.57,88,,119.68,Percent of Total Billed Charges,88% of Total Billed Charges,413.77,90,,232.56,Percent of Total Billed charges,90% of Total Billed Charges,202.75,459.74,
AG KN1116 K-WIRE 1.15 NO-THRED,2780000157,CDM,278,RC,C1776,HCPCS,Outpatient,,,65.05,42.28,,65.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.44,76,,103.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.84,72,,1530.448,Percent of Total Billed Charges,72% of Total Billed Charges,46.84,72,,1594.216,Percent of Total Billed charges,72% of Total Billed Charges,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.84,72,,1530.448,Percent of Total Billed Charges,72% of Total Billed Charges,39.03,60,,1275.376,Percent of Total Billed Charges,60% of Total Billed Charges,58.55,90,,1957.68,Percent of Total Billed Charges,90% of Total Billed Charges,29.27,45,,61.2,Percent of Total Billed Charges,45% of Total Billed Charges,58.55,90,,122.4,Percent of Total Billed Charges,90% of Total billed Charges,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.28,65,,112.368,Percent of total Billed Charges,65% of Total Billed Charges,28.69,44.1,,59.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,61.8,95,,129.2,Percent of Total Billed Charges,95% of Total Billed Charges,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.24,88,,1914.176,Percent of Total Billed Charges,88% of Total Billed Charges,58.55,90,,122.4,Percent of Total Billed charges,90% of Total Billed Charges,28.69,65.05,
AGIH3014 HEADLS SCREW 14MM 3.0,2780000158,CDM,278,RC,C1716,HCPCS,Outpatient,,,2156.49,1401.72,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,1638.93,76,,196.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1797.89,72,,226.704,Percent of Total Billed Charges,72% of Total Billed Charges,1797.89,72,,236.152,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1797.89,72,,226.704,Percent of Total Billed Charges,72% of Total Billed Charges,1416.5,60,,188.92,Percent of Total Billed Charges,60% of Total Billed Charges,1940.84,90,,1957.68,Percent of Total Billed Charges,90% of Total Billed Charges,970.42,45,,61.2,Percent of Total Billed Charges,45% of Total Billed Charges,1940.84,90,,232.56,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3138.38,65,,248.04,Percent of total Billed Charges,65% of Total Billed Charges,951.01,44.1,,59.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,2048.67,95,,245.48,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,1897.71,88,,1914.176,Percent of Total Billed Charges,88% of Total Billed Charges,1940.84,90,,232.56,Percent of Total Billed charges,90% of Total Billed Charges,651.24,3138.38,
AMPLATZ 10.2F 22CM URET STENT,2780000159,CDM,278,RC,C2617,HCPCS,Outpatient,,,462.47,300.61,,462.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,351.48,76,,103.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,332.98,72,,99.696,Percent of Total Billed Charges,72% of Total Billed Charges,332.98,72,,103.856,Percent of Total Billed charges,72% of Total Billed Charges,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.98,72,,99.696,Percent of Total Billed Charges,72% of Total Billed Charges,277.48,60,,83.08,Percent of Total Billed Charges,60% of Total Billed Charges,416.22,90,,54.432,Percent of Total Billed Charges,90% of Total Billed Charges,208.11,45,,978.84,Percent of Total Billed Charges,45% of Total Billed Charges,416.22,90,,122.4,Percent of Total Billed Charges,90% of Total billed Charges,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.61,65,,1536.992,Percent of total Billed Charges,65% of Total Billed Charges,203.95,44.1,,959.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,439.35,95,,129.2,Percent of Total Billed Charges,95% of Total Billed Charges,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.97,88,,1914.176,Percent of Total Billed Charges,88% of Total Billed Charges,416.22,90,,122.4,Percent of Total Billed charges,90% of Total Billed Charges,203.95,462.47,
AMPLATZ 10.2F 24CM URET STENT,2780000160,CDM,278,RC,C2617,HCPCS,Outpatient,,,462.47,300.61,,462.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,351.48,76,,103.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,332.98,72,,99.696,Percent of Total Billed Charges,72% of Total Billed Charges,332.98,72,,103.856,Percent of Total Billed charges,72% of Total Billed Charges,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.98,72,,99.696,Percent of Total Billed Charges,72% of Total Billed Charges,277.48,60,,83.08,Percent of Total Billed Charges,60% of Total Billed Charges,416.22,90,,30.24,Percent of Total Billed Charges,90% of Total Billed Charges,208.11,45,,978.84,Percent of Total Billed Charges,45% of Total Billed Charges,416.22,90,,122.4,Percent of Total Billed Charges,90% of Total billed Charges,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.61,65,,2238.736,Percent of total Billed Charges,65% of Total Billed Charges,203.95,44.1,,959.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,439.35,95,,129.2,Percent of Total Billed Charges,95% of Total Billed Charges,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.97,88,,1914.176,Percent of Total Billed Charges,88% of Total Billed Charges,416.22,90,,122.4,Percent of Total Billed charges,90% of Total Billed Charges,203.95,462.47,
AMPLATZ 10.2F 26CM URET STENT,2780000161,CDM,278,RC,C2617,HCPCS,Outpatient,,,462.47,300.61,,462.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,351.48,76,,103.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,332.98,72,,76.208,Percent of Total Billed Charges,72% of Total Billed Charges,332.98,72,,79.384,Percent of Total Billed charges,72% of Total Billed Charges,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.98,72,,76.208,Percent of Total Billed Charges,72% of Total Billed Charges,277.48,60,,63.504,Percent of Total Billed Charges,60% of Total Billed Charges,416.22,90,,1855.44,Percent of Total Billed Charges,90% of Total Billed Charges,208.11,45,,978.84,Percent of Total Billed Charges,45% of Total Billed Charges,416.22,90,,122.4,Percent of Total Billed Charges,90% of Total billed Charges,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.61,65,,229.84,Percent of total Billed Charges,65% of Total Billed Charges,203.95,44.1,,959.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,439.35,95,,129.2,Percent of Total Billed Charges,95% of Total Billed Charges,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.97,88,,1914.176,Percent of Total Billed Charges,88% of Total Billed Charges,416.22,90,,122.4,Percent of Total Billed charges,90% of Total Billed Charges,203.95,462.47,
AMPLATZ 8.5F 20CM URET STENT,2780000162,CDM,278,RC,C2617,HCPCS,Outpatient,,,462.47,300.61,,462.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,351.48,76,,1653.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,332.98,72,,99.696,Percent of Total Billed Charges,72% of Total Billed Charges,332.98,72,,103.856,Percent of Total Billed charges,72% of Total Billed Charges,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.98,72,,99.696,Percent of Total Billed Charges,72% of Total Billed Charges,277.48,60,,83.08,Percent of Total Billed Charges,60% of Total Billed Charges,416.22,90,,1215.648,Percent of Total Billed Charges,90% of Total Billed Charges,208.11,45,,978.84,Percent of Total Billed Charges,45% of Total Billed Charges,416.22,90,,1957.68,Percent of Total Billed Charges,90% of Total billed Charges,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.61,65,,86,Percent of total Billed Charges,65% of Total Billed Charges,203.95,44.1,,959.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,439.35,95,,2066.44,Percent of Total Billed Charges,95% of Total Billed Charges,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.97,88,,1914.176,Percent of Total Billed Charges,88% of Total Billed Charges,416.22,90,,1957.68,Percent of Total Billed charges,90% of Total Billed Charges,203.95,462.47,
AMPLATZ 8.5F 22CM URET STENT,2780000163,CDM,278,RC,C2617,HCPCS,Outpatient,,,462.47,300.61,,462.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,351.48,76,,1653.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,332.98,72,,1075.12,Percent of Total Billed Charges,72% of Total Billed Charges,332.98,72,,1075.12,Percent of Total Billed charges,72% of Total Billed Charges,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.98,72,,1075.12,Percent of Total Billed Charges,72% of Total Billed Charges,277.48,60,,895.936,Percent of Total Billed Charges,60% of Total Billed Charges,416.22,90,,2823.12,Percent of Total Billed Charges,90% of Total Billed Charges,208.11,45,,978.84,Percent of Total Billed Charges,45% of Total Billed Charges,416.22,90,,1957.68,Percent of Total Billed Charges,90% of Total billed Charges,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.61,65,,1233.416,Percent of total Billed Charges,65% of Total Billed Charges,203.95,44.1,,959.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,439.35,95,,2066.44,Percent of Total Billed Charges,95% of Total Billed Charges,462.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.97,88,,1914.176,Percent of Total Billed Charges,88% of Total Billed Charges,416.22,90,,1957.68,Percent of Total Billed charges,90% of Total Billed Charges,203.95,462.47,
ARTHREX INTER BRACE LIGAMENT,2780000165,CDM,278,RC,C1713,HCPCS,Outpatient,,,5992.00,3894.80,,5992,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4553.92,76,,1653.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4314.24,72,,781.104,Percent of Total Billed Charges,72% of Total Billed Charges,4314.24,72,,781.104,Percent of Total Billed charges,72% of Total Billed Charges,5992,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4314.24,72,,781.104,Percent of Total Billed Charges,72% of Total Billed Charges,3595.2,60,,650.92,Percent of Total Billed Charges,60% of Total Billed Charges,5392.8,90,,3112.488,Percent of Total Billed Charges,90% of Total Billed Charges,2696.4,45,,978.84,Percent of Total Billed Charges,45% of Total Billed Charges,5392.8,90,,1957.68,Percent of Total Billed Charges,90% of Total billed Charges,5992,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5992,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5992,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3894.8,65,,54.08,Percent of total Billed Charges,65% of Total Billed Charges,2642.47,44.1,,959.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,5692.4,95,,2066.44,Percent of Total Billed Charges,95% of Total Billed Charges,5992,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5272.96,88,,53.224,Percent of Total Billed Charges,88% of Total Billed Charges,5392.8,90,,1957.68,Percent of Total Billed charges,90% of Total Billed Charges,2642.47,5992,
ARTHRX AR8926SS TIGTRPE IMPLT,2780000166,CDM,278,RC,C1713,HCPCS,Outpatient,,,3124.00,2030.60,,3124,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2374.24,76,,1653.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2249.28,72,,384.2,Percent of Total Billed Charges,72% of Total Billed Charges,2249.28,72,,384.2,Percent of Total Billed charges,72% of Total Billed Charges,3124,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2249.28,72,,384.2,Percent of Total Billed Charges,72% of Total Billed Charges,1874.4,60,,320.168,Percent of Total Billed Charges,60% of Total Billed Charges,2811.6,90,,2167.08,Percent of Total Billed Charges,90% of Total Billed Charges,1405.8,45,,978.84,Percent of Total Billed Charges,45% of Total Billed Charges,2811.6,90,,1957.68,Percent of Total Billed Charges,90% of Total billed Charges,3124,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3124,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3124,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2030.6,65,,2021.24,Percent of total Billed Charges,65% of Total Billed Charges,1377.68,44.1,,959.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,2967.8,95,,2066.44,Percent of Total Billed Charges,95% of Total Billed Charges,3124,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2749.12,88,,29.568,Percent of Total Billed Charges,88% of Total Billed Charges,2811.6,90,,1957.68,Percent of Total Billed charges,90% of Total Billed Charges,1377.68,3124,
ARTHRX BIO COMP CL 4.75X19.1MM,2780000167,CDM,278,RC,C1713,HCPCS,Outpatient,,,2031.00,1320.15,,2031,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1543.56,76,,1653.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1462.32,72,,800.784,Percent of Total Billed Charges,72% of Total Billed Charges,1462.32,72,,800.784,Percent of Total Billed charges,72% of Total Billed Charges,2031,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1462.32,72,,800.784,Percent of Total Billed Charges,72% of Total Billed Charges,1218.6,60,,667.32,Percent of Total Billed Charges,60% of Total Billed Charges,1827.9,90,,2167.08,Percent of Total Billed Charges,90% of Total Billed Charges,913.95,45,,27.216,Percent of Total Billed Charges,45% of Total Billed Charges,1827.9,90,,1957.68,Percent of Total Billed Charges,90% of Total billed Charges,2031,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2031,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2031,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1320.15,65,,2527.104,Percent of total Billed Charges,65% of Total Billed Charges,895.67,44.1,,26.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,1929.45,95,,2066.44,Percent of Total Billed Charges,95% of Total Billed Charges,2031,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1787.28,88,,1814.208,Percent of Total Billed Charges,88% of Total Billed Charges,1827.9,90,,1957.68,Percent of Total Billed charges,90% of Total Billed Charges,895.67,2031,
ARTHRX BIOCMP  3.5X15.8MM,2780000168,CDM,278,RC,C1713,HCPCS,Outpatient,,,2031.00,1320.15,,2031,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1543.56,76,,1653.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1462.32,72,,323.232,Percent of Total Billed Charges,72% of Total Billed Charges,1462.32,72,,323.232,Percent of Total Billed charges,72% of Total Billed Charges,2031,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1462.32,72,,323.232,Percent of Total Billed Charges,72% of Total Billed Charges,1218.6,60,,269.36,Percent of Total Billed Charges,60% of Total Billed Charges,1827.9,90,,1966.32,Percent of Total Billed Charges,90% of Total Billed Charges,913.95,45,,15.12,Percent of Total Billed Charges,45% of Total Billed Charges,1827.9,90,,1957.68,Percent of Total Billed Charges,90% of Total billed Charges,2031,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2031,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2031,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1320.15,65,,2398.24,Percent of total Billed Charges,65% of Total Billed Charges,895.67,44.1,,14.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,1929.45,95,,2066.44,Percent of Total Billed Charges,95% of Total Billed Charges,2031,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1787.28,88,,1188.632,Percent of Total Billed Charges,88% of Total Billed Charges,1827.9,90,,1957.68,Percent of Total Billed charges,90% of Total Billed Charges,895.67,2031,
ARTHRX DISP KT FOR SM JNT STAK,2780000169,CDM,278,RC,C1713,HCPCS,Outpatient,,,239.00,155.35,,239,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,181.64,76,,1653.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,172.08,72,,43.816,Percent of Total Billed Charges,72% of Total Billed Charges,172.08,72,,43.816,Percent of Total Billed charges,72% of Total Billed Charges,239,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.08,72,,43.816,Percent of Total Billed Charges,72% of Total Billed Charges,143.4,60,,36.512,Percent of Total Billed Charges,60% of Total Billed Charges,215.1,90,,2064.64,Percent of Total Billed Charges,90% of Total Billed Charges,107.55,45,,927.72,Percent of Total Billed Charges,45% of Total Billed Charges,215.1,90,,1957.68,Percent of Total Billed Charges,90% of Total billed Charges,239,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.35,65,,2340,Percent of total Billed Charges,65% of Total Billed Charges,105.4,44.1,,909.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,227.05,95,,2066.44,Percent of Total Billed Charges,95% of Total Billed Charges,239,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.32,88,,2760.384,Percent of Total Billed Charges,88% of Total Billed Charges,215.1,90,,1957.68,Percent of Total Billed charges,90% of Total Billed Charges,105.4,239,
"ARTHRX FREFT IB IMP SYS, PEEK",2780000170,CDM,278,RC,C1713,HCPCS,Outpatient,,,4952.00,3218.80,,4952,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3763.52,76,,45.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3565.44,72,,95.256,Percent of Total Billed Charges,72% of Total Billed Charges,3565.44,72,,95.256,Percent of Total Billed charges,72% of Total Billed Charges,4952,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3565.44,72,,95.256,Percent of Total Billed Charges,72% of Total Billed Charges,2971.2,60,,79.384,Percent of Total Billed Charges,60% of Total Billed Charges,4456.8,90,,2167.08,Percent of Total Billed Charges,90% of Total Billed Charges,2228.4,45,,607.824,Percent of Total Billed Charges,45% of Total Billed Charges,4456.8,90,,54.432,Percent of Total Billed Charges,90% of Total billed Charges,4952,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4952,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4952,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3218.8,65,,2397.72,Percent of total Billed Charges,65% of Total Billed Charges,2183.83,44.1,,595.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,4704.4,95,,57.456,Percent of Total Billed Charges,95% of Total Billed Charges,4952,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4357.76,88,,3043.32,Percent of Total Billed Charges,88% of Total Billed Charges,4456.8,90,,54.432,Percent of Total Billed charges,90% of Total Billed Charges,2183.83,4952,
ARTHRX LCK SCW TITAN 3.5X14MM,2780000171,CDM,278,RC,C1713,HCPCS,Outpatient,,,763.00,495.95,,763,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,579.88,76,,25.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,549.36,72,,437.544,Percent of Total Billed Charges,72% of Total Billed Charges,549.36,72,,437.544,Percent of Total Billed charges,72% of Total Billed Charges,763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.36,72,,437.544,Percent of Total Billed Charges,72% of Total Billed Charges,457.8,60,,364.616,Percent of Total Billed Charges,60% of Total Billed Charges,686.7,90,,155.584,Percent of Total Billed Charges,90% of Total Billed Charges,343.35,45,,1411.56,Percent of Total Billed Charges,45% of Total Billed Charges,686.7,90,,30.24,Percent of Total Billed Charges,90% of Total billed Charges,763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495.95,65,,2770.984,Percent of total Billed Charges,65% of Total Billed Charges,336.48,44.1,,1383.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,724.85,95,,31.92,Percent of Total Billed Charges,95% of Total Billed Charges,763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,671.44,88,,2118.92,Percent of Total Billed Charges,88% of Total Billed Charges,686.7,90,,30.24,Percent of Total Billed charges,90% of Total Billed Charges,336.48,763,
ARTHRX PARS SUT IMP KT SUT TPE,2780000172,CDM,278,RC,C1713,HCPCS,Outpatient,,,7583.00,4928.95,,7583,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5763.08,76,,1566.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5459.76,72,,1137.992,Percent of Total Billed Charges,72% of Total Billed Charges,5459.76,72,,1137.992,Percent of Total Billed charges,72% of Total Billed Charges,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5459.76,72,,1137.992,Percent of Total Billed Charges,72% of Total Billed Charges,4549.8,60,,948.328,Percent of Total Billed Charges,60% of Total Billed Charges,6824.7,90,,343.44,Percent of Total Billed Charges,90% of Total Billed Charges,3412.35,45,,1556.248,Percent of Total Billed Charges,45% of Total Billed Charges,6824.7,90,,1855.44,Percent of Total Billed Charges,90% of Total billed Charges,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4928.95,65,,2401.36,Percent of total Billed Charges,65% of Total Billed Charges,3344.1,44.1,,1525.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,7203.85,95,,1958.52,Percent of Total Billed Charges,95% of Total Billed Charges,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6673.04,88,,2118.92,Percent of Total Billed Charges,88% of Total Billed Charges,6824.7,90,,1855.44,Percent of Total Billed charges,90% of Total Billed Charges,3344.1,7583,
ARTHRX SUBT ARTHROEREISIS IMPL,2780000173,CDM,278,RC,C1713,HCPCS,Outpatient,,,5556.00,3611.40,,5556,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4222.56,76,,1026.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4000.32,72,,1242.136,Percent of Total Billed Charges,72% of Total Billed Charges,4000.32,72,,1242.136,Percent of Total Billed charges,72% of Total Billed Charges,5556,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4000.32,72,,1242.136,Percent of Total Billed Charges,72% of Total Billed Charges,3333.6,60,,1035.112,Percent of Total Billed Charges,60% of Total Billed Charges,5000.4,90,,2128.144,Percent of Total Billed Charges,90% of Total Billed Charges,2500.2,45,,1083.536,Percent of Total Billed Charges,45% of Total Billed Charges,5000.4,90,,1215.648,Percent of Total Billed Charges,90% of Total billed Charges,5556,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5556,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5556,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.4,65,,1567.408,Percent of total Billed Charges,65% of Total Billed Charges,2450.2,44.1,,1061.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,5278.2,95,,1283.184,Percent of Total Billed Charges,95% of Total Billed Charges,5556,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4889.28,88,,1922.624,Percent of Total Billed Charges,88% of Total Billed Charges,5000.4,90,,1215.648,Percent of Total Billed charges,90% of Total Billed Charges,2450.2,5556,
ARTRX MIINI TGHT RPE BUTT PLTE,2780000174,CDM,278,RC,C1713,HCPCS,Outpatient,,,497.00,323.05,,497,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,377.72,76,,2383.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,357.84,72,,328.952,Percent of Total Billed Charges,72% of Total Billed Charges,357.84,72,,328.952,Percent of Total Billed charges,72% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.84,72,,328.952,Percent of Total Billed Charges,72% of Total Billed Charges,298.2,60,,274.128,Percent of Total Billed Charges,60% of Total Billed Charges,447.3,90,,3099.784,Percent of Total Billed Charges,90% of Total Billed Charges,223.65,45,,1083.536,Percent of Total Billed Charges,45% of Total Billed Charges,447.3,90,,2823.12,Percent of Total Billed Charges,90% of Total billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,65,,2766.4,Percent of total Billed Charges,65% of Total Billed Charges,219.18,44.1,,1061.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.15,95,,2979.96,Percent of Total Billed Charges,95% of Total Billed Charges,497,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.36,88,,2018.752,Percent of Total Billed Charges,88% of Total Billed Charges,447.3,90,,2823.12,Percent of Total Billed charges,90% of Total Billed Charges,219.18,497,
ARTRX SUB ARTHROEREIS 1MP 14MM,2780000175,CDM,278,RC,C1713,HCPCS,Outpatient,,,7583.00,4928.95,,7583,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5763.08,76,,2628.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5459.76,72,,331.496,Percent of Total Billed Charges,72% of Total Billed Charges,5459.76,72,,331.496,Percent of Total Billed charges,72% of Total Billed Charges,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5459.76,72,,331.496,Percent of Total Billed Charges,72% of Total Billed Charges,4549.8,60,,276.248,Percent of Total Billed Charges,60% of Total Billed Charges,6824.7,90,,318.24,Percent of Total Billed Charges,90% of Total Billed Charges,3412.35,45,,983.16,Percent of Total Billed Charges,45% of Total Billed Charges,6824.7,90,,3112.488,Percent of Total Billed Charges,90% of Total billed Charges,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4928.95,65,,2817.992,Percent of total Billed Charges,65% of Total Billed Charges,3344.1,44.1,,963.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,7203.85,95,,3285.408,Percent of Total Billed Charges,95% of Total Billed Charges,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6673.04,88,,2118.92,Percent of Total Billed Charges,88% of Total Billed Charges,6824.7,90,,3112.488,Percent of Total Billed charges,90% of Total Billed Charges,3344.1,7583,
ARTRX SUB ARTHROEREIS IMP 12MM,2780000176,CDM,278,RC,C1713,HCPCS,Outpatient,,,5307.00,3449.55,,5307,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4033.32,76,,1829.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3821.04,72,,537.248,Percent of Total Billed Charges,72% of Total Billed Charges,3821.04,72,,537.248,Percent of Total Billed charges,72% of Total Billed Charges,5307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3821.04,72,,537.248,Percent of Total Billed Charges,72% of Total Billed Charges,3184.2,60,,447.704,Percent of Total Billed Charges,60% of Total Billed Charges,4776.3,90,,119.072,Percent of Total Billed Charges,90% of Total Billed Charges,2388.15,45,,1032.32,Percent of Total Billed Charges,45% of Total Billed Charges,4776.3,90,,2167.08,Percent of Total Billed Charges,90% of Total billed Charges,5307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3449.55,65,,136.24,Percent of total Billed Charges,65% of Total Billed Charges,2340.39,44.1,,1011.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,5041.65,95,,2287.472,Percent of Total Billed Charges,95% of Total Billed Charges,5307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4670.16,88,,152.128,Percent of Total Billed Charges,88% of Total Billed Charges,4776.3,90,,2167.08,Percent of Total Billed charges,90% of Total Billed Charges,2340.39,5307,
ARTRX SUBTALAR ARTHRO IMP 12MM,2780000177,CDM,278,RC,C1713,HCPCS,Outpatient,,,5307.00,3449.55,,5307,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4033.32,76,,1829.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3821.04,72,,311.176,Percent of Total Billed Charges,72% of Total Billed Charges,3821.04,72,,311.176,Percent of Total Billed charges,72% of Total Billed Charges,5307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3821.04,72,,311.176,Percent of Total Billed Charges,72% of Total Billed Charges,3184.2,60,,259.312,Percent of Total Billed Charges,60% of Total Billed Charges,4776.3,90,,1707.808,Percent of Total Billed Charges,90% of Total Billed Charges,2388.15,45,,1083.536,Percent of Total Billed Charges,45% of Total Billed Charges,4776.3,90,,2167.08,Percent of Total Billed Charges,90% of Total billed Charges,5307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3449.55,65,,136.24,Percent of total Billed Charges,65% of Total Billed Charges,2340.39,44.1,,1061.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,5041.65,95,,2287.472,Percent of Total Billed Charges,95% of Total Billed Charges,5307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4670.16,88,,335.808,Percent of Total Billed Charges,88% of Total Billed Charges,4776.3,90,,2167.08,Percent of Total Billed charges,90% of Total Billed Charges,2340.39,5307,
ARTRX SUT ANCHR BIOCOMP STAK,2780000178,CDM,278,RC,C1713,HCPCS,Outpatient,,,1651.00,1073.15,,1651,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1254.76,76,,1660.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1188.72,72,,1958.464,Percent of Total Billed Charges,72% of Total Billed Charges,1188.72,72,,1958.464,Percent of Total Billed charges,72% of Total Billed Charges,1651,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1188.72,72,,1958.464,Percent of Total Billed Charges,72% of Total Billed Charges,990.6,60,,1632.056,Percent of Total Billed Charges,60% of Total Billed Charges,1485.9,90,,74.88,Percent of Total Billed Charges,90% of Total Billed Charges,742.95,45,,77.792,Percent of Total Billed Charges,45% of Total Billed Charges,1485.9,90,,1966.32,Percent of Total Billed Charges,90% of Total billed Charges,1651,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1651,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1651,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1073.15,65,,136.24,Percent of total Billed Charges,65% of Total Billed Charges,728.09,44.1,,76.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,1568.45,95,,2075.56,Percent of Total Billed Charges,95% of Total Billed Charges,1651,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1452.88,88,,2080.848,Percent of Total Billed Charges,88% of Total Billed Charges,1485.9,90,,1966.32,Percent of Total Billed charges,90% of Total Billed Charges,728.09,1651,
ARTX BIOCOMPSWVLCK 4.75X15 VE5,2780000179,CDM,278,RC,C1713,HCPCS,Outpatient,,,2055.00,1335.75,,2055,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1561.8,76,,1743.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1479.6,72,,228.616,Percent of Total Billed Charges,72% of Total Billed Charges,1479.6,72,,228.616,Percent of Total Billed charges,72% of Total Billed Charges,2055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1479.6,72,,228.616,Percent of Total Billed Charges,72% of Total Billed Charges,1233,60,,190.512,Percent of Total Billed Charges,60% of Total Billed Charges,1849.5,90,,2798.64,Percent of Total Billed Charges,90% of Total Billed Charges,924.75,45,,171.72,Percent of Total Billed Charges,45% of Total Billed Charges,1849.5,90,,2064.64,Percent of Total Billed Charges,90% of Total billed Charges,2055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1335.75,65,,136.24,Percent of total Billed Charges,65% of Total Billed Charges,906.26,44.1,,168.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,1952.25,95,,2179.336,Percent of Total Billed Charges,95% of Total Billed Charges,2055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1808.4,88,,3030.904,Percent of Total Billed Charges,88% of Total Billed Charges,1849.5,90,,2064.64,Percent of Total Billed charges,90% of Total Billed Charges,906.26,2055,
ARTX QCKFIXSCW  CAN PT 3X18MM,2780000180,CDM,278,RC,C1713,HCPCS,Outpatient,,,763.00,495.95,,763,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,579.88,76,,1829.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,549.36,72,,184.8,Percent of Total Billed Charges,72% of Total Billed Charges,549.36,72,,184.8,Percent of Total Billed charges,72% of Total Billed Charges,763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.36,72,,184.8,Percent of Total Billed Charges,72% of Total Billed Charges,457.8,60,,154,Percent of Total Billed Charges,60% of Total Billed Charges,686.7,90,,3499.072,Percent of Total Billed Charges,90% of Total Billed Charges,343.35,45,,1064.072,Percent of Total Billed Charges,45% of Total Billed Charges,686.7,90,,2167.08,Percent of Total Billed Charges,90% of Total billed Charges,763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495.95,65,,136.24,Percent of total Billed Charges,65% of Total Billed Charges,336.48,44.1,,1042.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,724.85,95,,2287.472,Percent of Total Billed Charges,95% of Total Billed Charges,763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,671.44,88,,311.168,Percent of Total Billed Charges,88% of Total Billed Charges,686.7,90,,2167.08,Percent of Total Billed charges,90% of Total Billed Charges,336.48,763,
ARTX QCKFIXSCW  CAN PT 3X20MM,2780000181,CDM,278,RC,C1713,HCPCS,Outpatient,,,763.00,495.95,,763,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,579.88,76,,131.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,549.36,72,,69.856,Percent of Total Billed Charges,72% of Total Billed Charges,549.36,72,,69.856,Percent of Total Billed charges,72% of Total Billed Charges,763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.36,72,,69.856,Percent of Total Billed Charges,72% of Total Billed Charges,457.8,60,,58.216,Percent of Total Billed Charges,60% of Total Billed Charges,686.7,90,,3320.64,Percent of Total Billed Charges,90% of Total Billed Charges,343.35,45,,1549.896,Percent of Total Billed Charges,45% of Total Billed Charges,686.7,90,,155.584,Percent of Total Billed Charges,90% of Total billed Charges,763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495.95,65,,159.12,Percent of total Billed Charges,65% of Total Billed Charges,336.48,44.1,,1518.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,724.85,95,,164.232,Percent of Total Billed Charges,95% of Total Billed Charges,763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,671.44,88,,116.424,Percent of Total Billed Charges,88% of Total Billed Charges,686.7,90,,155.584,Percent of Total Billed charges,90% of Total Billed Charges,336.48,763,
ARTX QCKFIXSCW CAN PT 2X16MM,2780000182,CDM,278,RC,C1713,HCPCS,Outpatient,,,710.00,461.50,,710,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,539.6,76,,290.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,511.2,72,,62.24,Percent of Total Billed Charges,72% of Total Billed Charges,511.2,72,,62.24,Percent of Total Billed charges,72% of Total Billed Charges,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511.2,72,,62.24,Percent of Total Billed Charges,72% of Total Billed Charges,426,60,,51.864,Percent of Total Billed Charges,60% of Total Billed Charges,639,90,,3240,Percent of Total Billed Charges,90% of Total Billed Charges,319.5,45,,159.12,Percent of Total Billed Charges,45% of Total Billed Charges,639,90,,343.44,Percent of Total Billed Charges,90% of Total billed Charges,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,461.5,65,,56.16,Percent of total Billed Charges,65% of Total Billed Charges,313.11,44.1,,155.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,674.5,95,,362.52,Percent of Total Billed Charges,95% of Total Billed Charges,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,624.8,88,,1669.856,Percent of Total Billed Charges,88% of Total Billed Charges,639,90,,343.44,Percent of Total Billed charges,90% of Total Billed Charges,313.11,710,
ATRVE VAS SNR 1830MM 7F CATH,2780000183,CDM,272,RC,C1773,HCPCS,Outpatient,,,683.55,444.31,,683.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,519.5,76,,1797.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,492.16,72,,513.112,Percent of Total Billed Charges,72% of Total Billed Charges,512.66,75,,513.112,Percent of Total Billed charges,75% of Total Billed Charges,683.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.16,72,,513.112,Percent of Total Billed Charges,72% of Total Billed Charges,410.13,60,,427.592,Percent of Total Billed Charges,60% of Total Billed Charges,615.2,90,,3319.92,Percent of Total Billed Charges,90% of Total Billed Charges,307.6,45,,59.536,Percent of Total Billed Charges,45% of Total Billed Charges,615.2,90,,2128.144,Percent of Total Billed Charges,90% of Total billed Charges,683.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,683.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,683.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.31,65,,9972.552,Percent of total Billed Charges,65% of Total Billed Charges,301.45,44.1,,58.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,649.37,95,,2246.368,Percent of Total Billed Charges,95% of Total Billed Charges,683.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,601.52,88,,73.216,Percent of Total Billed Charges,88% of Total Billed Charges,615.2,90,,2128.144,Percent of Total Billed charges,90% of Total Billed Charges,301.45,683.55,
ATRVE VASC SNR 1220MM 6FCATH,2780000184,CDM,272,RC,C1773,HCPCS,Outpatient,,,683.55,444.31,,683.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,519.5,76,,2617.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,492.16,72,,889.056,Percent of Total Billed Charges,72% of Total Billed Charges,512.66,75,,889.056,Percent of Total Billed charges,75% of Total Billed Charges,683.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.16,72,,889.056,Percent of Total Billed Charges,72% of Total Billed Charges,410.13,60,,740.88,Percent of Total Billed Charges,60% of Total Billed Charges,615.2,90,,1913.064,Percent of Total Billed Charges,90% of Total Billed Charges,307.6,45,,853.904,Percent of Total Billed Charges,45% of Total Billed Charges,615.2,90,,3099.784,Percent of Total Billed Charges,90% of Total billed Charges,683.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,683.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,683.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.31,65,,9280.584,Percent of total Billed Charges,65% of Total Billed Charges,301.45,44.1,,836.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,649.37,95,,3272,Percent of Total Billed Charges,95% of Total Billed Charges,683.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,601.52,88,,2736.448,Percent of Total Billed Charges,88% of Total Billed Charges,615.2,90,,3099.784,Percent of Total Billed charges,90% of Total Billed Charges,301.45,683.55,
BROVIAC 6.6F SL CV CATHETER,2780000185,CDM,278,RC,C1751,HCPCS,Outpatient,,,200.00,130.00,,200,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152,76,,268.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144,72,,420.4,Percent of Total Billed Charges,72% of Total Billed Charges,144,72,,420.4,Percent of Total Billed charges,72% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144,72,,420.4,Percent of Total Billed Charges,72% of Total Billed Charges,120,60,,350.336,Percent of Total Billed Charges,60% of Total Billed Charges,180,90,,3324.96,Percent of Total Billed Charges,90% of Total Billed Charges,90,45,,37.44,Percent of Total Billed Charges,45% of Total Billed Charges,180,90,,318.24,Percent of Total Billed Charges,90% of Total billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130,65,,8838.648,Percent of total Billed Charges,65% of Total Billed Charges,88.2,44.1,,36.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,190,95,,335.92,Percent of Total Billed Charges,95% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,88,,3421.312,Percent of Total Billed Charges,88% of Total Billed Charges,180,90,,318.24,Percent of Total Billed charges,90% of Total Billed Charges,88.2,200,
BS .035 STIFF SHAFT ANG ZIPWRE,2780000186,CDM,278,RC,C1726,HCPCS,Outpatient,,,70.56,45.86,,70.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.63,76,,100.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.8,72,,804.6,Percent of Total Billed Charges,72% of Total Billed Charges,50.8,72,,804.6,Percent of Total Billed charges,72% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.8,72,,804.6,Percent of Total Billed Charges,72% of Total Billed Charges,42.34,60,,670.496,Percent of Total Billed Charges,60% of Total Billed Charges,63.5,90,,2170.256,Percent of Total Billed Charges,90% of Total Billed Charges,31.75,45,,1399.32,Percent of Total Billed Charges,45% of Total Billed Charges,63.5,90,,119.072,Percent of Total Billed Charges,90% of Total billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.86,65,,9972.552,Percent of total Billed Charges,65% of Total Billed Charges,31.12,44.1,,1371.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.03,95,,125.688,Percent of Total Billed Charges,95% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.09,88,,3246.848,Percent of Total Billed Charges,88% of Total Billed Charges,63.5,90,,119.072,Percent of Total Billed charges,90% of Total Billed Charges,31.12,70.56,
BS .035 STRAIGHT TIP AMPL WIRE,2780000187,CDM,278,RC,C1726,HCPCS,Outpatient,,,45.20,29.38,,45.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.35,76,,1442.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.54,72,,1169.104,Percent of Total Billed Charges,72% of Total Billed Charges,32.54,72,,1169.104,Percent of Total Billed charges,72% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.54,72,,1169.104,Percent of Total Billed Charges,72% of Total Billed Charges,27.12,60,,974.256,Percent of Total Billed Charges,60% of Total Billed Charges,40.68,90,,1906.712,Percent of Total Billed Charges,90% of Total Billed Charges,20.34,45,,1749.536,Percent of Total Billed Charges,45% of Total Billed Charges,40.68,90,,1707.808,Percent of Total Billed Charges,90% of Total billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.38,65,,9280.584,Percent of total Billed Charges,65% of Total Billed Charges,19.93,44.1,,1714.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.94,95,,1802.68,Percent of Total Billed Charges,95% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.78,88,,3168,Percent of Total Billed Charges,88% of Total Billed Charges,40.68,90,,1707.808,Percent of Total Billed charges,90% of Total Billed Charges,19.93,45.2,
BS 10CM  12FR UROMAX BAL KIT,2780000188,CDM,278,RC,C1726,HCPCS,Outpatient,,,317.52,206.39,,317.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,241.32,76,,63.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,228.61,72,,779.192,Percent of Total Billed Charges,72% of Total Billed Charges,228.61,72,,779.192,Percent of Total Billed charges,72% of Total Billed Charges,317.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.61,72,,779.192,Percent of Total Billed Charges,72% of Total Billed Charges,190.51,60,,649.328,Percent of Total Billed Charges,60% of Total Billed Charges,285.77,90,,1978.152,Percent of Total Billed Charges,90% of Total Billed Charges,142.88,45,,1660.32,Percent of Total Billed Charges,45% of Total Billed Charges,285.77,90,,74.88,Percent of Total Billed Charges,90% of Total billed Charges,317.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,317.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,317.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.39,65,,8838.648,Percent of total Billed Charges,65% of Total Billed Charges,140.03,44.1,,1627.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,301.64,95,,79.04,Percent of Total Billed Charges,95% of Total Billed Charges,317.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279.42,88,,3246.144,Percent of Total Billed Charges,88% of Total Billed Charges,285.77,90,,74.88,Percent of Total Billed charges,90% of Total Billed Charges,140.03,317.52,
BS SENSOR ANG .038 X 150 WIRE,2780000189,CDM,278,RC,C1726,HCPCS,Outpatient,,,66.15,43.00,,66.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,50.27,76,,2363.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47.63,72,,338.472,Percent of Total Billed Charges,72% of Total Billed Charges,47.63,72,,338.472,Percent of Total Billed charges,72% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.63,72,,338.472,Percent of Total Billed Charges,72% of Total Billed Charges,39.69,60,,282.064,Percent of Total Billed Charges,60% of Total Billed Charges,59.54,90,,188.64,Percent of Total Billed Charges,90% of Total Billed Charges,29.77,45,,1620,Percent of Total Billed Charges,45% of Total Billed Charges,59.54,90,,2798.64,Percent of Total Billed Charges,90% of Total billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,65,,8838.648,Percent of total Billed Charges,65% of Total Billed Charges,29.17,44.1,,1587.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.84,95,,2954.12,Percent of Total Billed Charges,95% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.21,88,,1870.552,Percent of Total Billed Charges,88% of Total Billed Charges,59.54,90,,2798.64,Percent of Total Billed charges,90% of Total Billed Charges,29.17,66.15,
CATH DRN 14FR 25CM DAWSN MUELR,2780000190,CDM,278,RC,C1729,HCPCS,Outpatient,,,252.20,163.93,,252.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,191.67,76,,2954.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,181.58,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,181.58,72,,91.448,Percent of Total Billed charges,72% of Total Billed Charges,252.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.58,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,151.32,60,,76.208,Percent of Total Billed Charges,60% of Total Billed Charges,226.98,90,,188.64,Percent of Total Billed Charges,90% of Total Billed Charges,113.49,45,,1659.96,Percent of Total Billed Charges,45% of Total Billed Charges,226.98,90,,3499.072,Percent of Total Billed Charges,90% of Total billed Charges,252.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.93,65,,9972.552,Percent of total Billed Charges,65% of Total Billed Charges,111.22,44.1,,1626.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,239.59,95,,3693.464,Percent of Total Billed Charges,95% of Total Billed Charges,252.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.94,88,,3251.072,Percent of Total Billed Charges,88% of Total Billed Charges,226.98,90,,3499.072,Percent of Total Billed charges,90% of Total Billed Charges,111.22,252.2,
CELECT PLATNIUM UNIST IVC FLTR,2780000191,CDM,278,RC,C1880,HCPCS,Outpatient,,,5005.00,3253.25,,5005,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3803.8,76,,2804.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3603.6,72,,109.224,Percent of Total Billed Charges,72% of Total Billed Charges,3603.6,72,,109.224,Percent of Total Billed charges,72% of Total Billed Charges,5005,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3603.6,72,,109.224,Percent of Total Billed Charges,72% of Total Billed Charges,3003,60,,91.024,Percent of Total Billed Charges,60% of Total Billed Charges,4504.5,90,,188.64,Percent of Total Billed Charges,90% of Total Billed Charges,2252.25,45,,956.528,Percent of Total Billed Charges,45% of Total Billed Charges,4504.5,90,,3320.64,Percent of Total Billed Charges,90% of Total billed Charges,5005,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5005,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5005,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3253.25,65,,9972.552,Percent of total Billed Charges,65% of Total Billed Charges,2207.21,44.1,,937.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,4754.75,95,,3505.12,Percent of Total Billed Charges,95% of Total Billed Charges,5005,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4404.4,88,,2122.024,Percent of Total Billed Charges,88% of Total Billed Charges,4504.5,90,,3320.64,Percent of Total Billed charges,90% of Total Billed Charges,2207.21,5005,
CEN LNE ST 3 LUMEN 7FR 20CM PI,2780000192,CDM,278,RC,C1751,HCPCS,Outpatient,,,526.66,342.33,,526.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,400.26,76,,2736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,379.2,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,379.2,72,,27.312,Percent of Total Billed charges,72% of Total Billed Charges,526.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.2,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,316,60,,22.76,Percent of Total Billed Charges,60% of Total Billed Charges,473.99,90,,188.64,Percent of Total Billed Charges,90% of Total Billed Charges,237,45,,1662.48,Percent of Total Billed Charges,45% of Total Billed Charges,473.99,90,,3240,Percent of Total Billed Charges,90% of Total billed Charges,526.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,526.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,526.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.33,65,,9280.584,Percent of total Billed Charges,65% of Total Billed Charges,232.26,44.1,,1629.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,500.33,95,,3420,Percent of Total Billed Charges,95% of Total Billed Charges,526.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,463.46,88,,1864.336,Percent of Total Billed Charges,88% of Total Billed Charges,473.99,90,,3240,Percent of Total Billed charges,90% of Total Billed Charges,232.26,526.66,
CK 3F SING LUMEN PIC LNE CATH,2780000193,CDM,278,RC,C1751,HCPCS,Outpatient,,,529.20,343.98,,529.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,402.19,76,,2803.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,381.02,72,,671.872,Percent of Total Billed Charges,72% of Total Billed Charges,381.02,72,,671.872,Percent of Total Billed charges,72% of Total Billed Charges,529.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.02,72,,671.872,Percent of Total Billed Charges,72% of Total Billed Charges,317.52,60,,559.896,Percent of Total Billed Charges,60% of Total Billed Charges,476.28,90,,188.64,Percent of Total Billed Charges,90% of Total Billed Charges,238.14,45,,1085.128,Percent of Total Billed Charges,45% of Total Billed Charges,476.28,90,,3319.92,Percent of Total Billed Charges,90% of Total billed Charges,529.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.98,65,,8417.76,Percent of total Billed Charges,65% of Total Billed Charges,233.38,44.1,,1063.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,502.74,95,,3504.36,Percent of Total Billed Charges,95% of Total Billed Charges,529.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.7,88,,1934.192,Percent of Total Billed Charges,88% of Total Billed Charges,476.28,90,,3319.92,Percent of Total Billed charges,90% of Total Billed Charges,233.38,529.2,
COLLART BUTTON VENT EAR TUBE,2780000194,CDM,278,RC,,,Outpatient,,,28.00,18.20,,28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21.28,76,,1615.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.16,72,,255.288,Percent of Total Billed Charges,72% of Total Billed Charges,20.16,72,,255.288,Percent of Total Billed charges,72% of Total Billed Charges,28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.16,72,,255.288,Percent of Total Billed Charges,72% of Total Billed Charges,16.8,60,,212.744,Percent of Total Billed Charges,60% of Total Billed Charges,25.2,90,,220.32,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,45,,953.352,Percent of Total Billed Charges,45% of Total Billed Charges,25.2,90,,1913.064,Percent of Total Billed Charges,90% of Total billed Charges,28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.2,65,,8838.648,Percent of total Billed Charges,65% of Total Billed Charges,12.35,44.1,,934.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.6,95,,2019.344,Percent of Total Billed Charges,95% of Total Billed Charges,28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.64,88,,184.448,Percent of Total Billed Charges,88% of Total Billed Charges,25.2,90,,1913.064,Percent of Total Billed charges,90% of Total Billed Charges,12.35,28,
CONTRALATERAL F 4F 65CM CATH,2780000195,CDM,272,RC,C1887,HCPCS,Outpatient,,,68.51,44.53,,68.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.07,76,,2807.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49.33,72,,509.304,Percent of Total Billed Charges,72% of Total Billed Charges,51.38,75,,509.304,Percent of Total Billed charges,75% of Total Billed Charges,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.33,72,,509.304,Percent of Total Billed Charges,72% of Total Billed Charges,41.11,60,,424.424,Percent of Total Billed Charges,60% of Total Billed Charges,61.66,90,,77.76,Percent of Total Billed Charges,90% of Total Billed Charges,30.83,45,,989.072,Percent of Total Billed Charges,45% of Total Billed Charges,61.66,90,,3324.96,Percent of Total Billed Charges,90% of Total billed Charges,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.53,65,,9280.584,Percent of total Billed Charges,65% of Total Billed Charges,30.21,44.1,,969.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.08,95,,3509.68,Percent of Total Billed Charges,95% of Total Billed Charges,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.29,88,,184.448,Percent of Total Billed Charges,88% of Total Billed Charges,61.66,90,,3324.96,Percent of Total Billed charges,90% of Total Billed Charges,30.21,68.51,
CONTRALATERAL F 4F 90CM CATH,2780000196,CDM,272,RC,C1887,HCPCS,Outpatient,,,1148.81,746.73,,1148.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,873.1,76,,1832.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,827.14,72,,109.224,Percent of Total Billed Charges,72% of Total Billed Charges,861.61,75,,109.224,Percent of Total Billed charges,75% of Total Billed Charges,1148.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,827.14,72,,109.224,Percent of Total Billed Charges,72% of Total Billed Charges,689.29,60,,91.024,Percent of Total Billed Charges,60% of Total Billed Charges,1033.93,90,,13808.152,Percent of Total Billed Charges,90% of Total Billed Charges,516.96,45,,94.32,Percent of Total Billed Charges,45% of Total Billed Charges,1033.93,90,,2170.256,Percent of Total Billed Charges,90% of Total billed Charges,1148.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1148.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1148.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,746.73,65,,9943.888,Percent of total Billed Charges,65% of Total Billed Charges,506.63,44.1,,92.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,1091.37,95,,2290.824,Percent of Total Billed Charges,95% of Total Billed Charges,1148.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1010.95,88,,184.448,Percent of Total Billed Charges,88% of Total Billed Charges,1033.93,90,,2170.256,Percent of Total Billed charges,90% of Total Billed Charges,506.63,1148.81,
CONTRALATERAL F 5F 90CM CATH,2780000197,CDM,272,RC,C1887,HCPCS,Outpatient,,,1148.81,746.73,,1148.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,873.1,76,,1610.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,827.14,72,,109.224,Percent of Total Billed Charges,72% of Total Billed Charges,861.61,75,,109.224,Percent of Total Billed charges,75% of Total Billed Charges,1148.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,827.14,72,,109.224,Percent of Total Billed Charges,72% of Total Billed Charges,689.29,60,,91.024,Percent of Total Billed Charges,60% of Total Billed Charges,1033.93,90,,12850.032,Percent of Total Billed Charges,90% of Total Billed Charges,516.96,45,,94.32,Percent of Total Billed Charges,45% of Total Billed Charges,1033.93,90,,1906.712,Percent of Total Billed Charges,90% of Total billed Charges,1148.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1148.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1148.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,746.73,65,,9972.552,Percent of total Billed Charges,65% of Total Billed Charges,506.63,44.1,,92.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,1091.37,95,,2012.64,Percent of Total Billed Charges,95% of Total Billed Charges,1148.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1010.95,88,,184.448,Percent of Total Billed Charges,88% of Total Billed Charges,1033.93,90,,1906.712,Percent of Total Billed charges,90% of Total Billed Charges,506.63,1148.81,
COPE NEPH U STNT 10.2X0.038X24,2780000198,CDM,278,RC,C2625,HCPCS,Outpatient,,,379.68,246.79,,379.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,288.56,76,,1670.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,273.37,72,,416.584,Percent of Total Billed Charges,72% of Total Billed Charges,273.37,72,,416.584,Percent of Total Billed charges,72% of Total Billed Charges,379.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.37,72,,416.584,Percent of Total Billed Charges,72% of Total Billed Charges,227.81,60,,347.152,Percent of Total Billed Charges,60% of Total Billed Charges,341.71,90,,12238.128,Percent of Total Billed Charges,90% of Total Billed Charges,170.86,45,,94.32,Percent of Total Billed Charges,45% of Total Billed Charges,341.71,90,,1978.152,Percent of Total Billed Charges,90% of Total billed Charges,379.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.79,65,,509.088,Percent of total Billed Charges,65% of Total Billed Charges,167.44,44.1,,92.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,360.7,95,,2088.048,Percent of Total Billed Charges,95% of Total Billed Charges,379.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.12,88,,184.448,Percent of Total Billed Charges,88% of Total Billed Charges,341.71,90,,1978.152,Percent of Total Billed charges,90% of Total Billed Charges,167.44,379.68,
COPE NEPH U STNT 10.2X0.038X28,2780000199,CDM,278,RC,C2625,HCPCS,Outpatient,,,379.68,246.79,,379.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,288.56,76,,159.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,273.37,72,,101.608,Percent of Total Billed Charges,72% of Total Billed Charges,273.37,72,,101.608,Percent of Total Billed charges,72% of Total Billed Charges,379.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.37,72,,101.608,Percent of Total Billed Charges,72% of Total Billed Charges,227.81,60,,84.672,Percent of Total Billed Charges,60% of Total Billed Charges,341.71,90,,13808.152,Percent of Total Billed Charges,90% of Total Billed Charges,170.86,45,,94.32,Percent of Total Billed Charges,45% of Total Billed Charges,341.71,90,,188.64,Percent of Total Billed Charges,90% of Total billed Charges,379.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.79,65,,509.088,Percent of total Billed Charges,65% of Total Billed Charges,167.44,44.1,,92.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,360.7,95,,199.12,Percent of Total Billed Charges,95% of Total Billed Charges,379.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.12,88,,215.424,Percent of Total Billed Charges,88% of Total Billed Charges,341.71,90,,188.64,Percent of Total Billed charges,90% of Total Billed Charges,167.44,379.68,
CTRL LNE SET4 LUM 8.5FR 20CMPI,2780000200,CDM,278,RC,C1751,HCPCS,Outpatient,,,526.00,341.90,,526,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,399.76,76,,159.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,378.72,72,,323.872,Percent of Total Billed Charges,72% of Total Billed Charges,378.72,72,,323.872,Percent of Total Billed charges,72% of Total Billed Charges,526,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.72,72,,323.872,Percent of Total Billed Charges,72% of Total Billed Charges,315.6,60,,269.896,Percent of Total Billed Charges,60% of Total Billed Charges,473.4,90,,12850.032,Percent of Total Billed Charges,90% of Total Billed Charges,236.7,45,,94.32,Percent of Total Billed Charges,45% of Total Billed Charges,473.4,90,,188.64,Percent of Total Billed Charges,90% of Total billed Charges,526,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,526,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,526,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.9,65,,3561.912,Percent of total Billed Charges,65% of Total Billed Charges,231.97,44.1,,92.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,499.7,95,,199.12,Percent of Total Billed Charges,95% of Total Billed Charges,526,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.88,88,,76.032,Percent of Total Billed Charges,88% of Total Billed Charges,473.4,90,,188.64,Percent of Total Billed charges,90% of Total Billed Charges,231.97,526,
ELITE 6FR RETR VENA CAVA FILT,2780000201,CDM,278,RC,C1880,HCPCS,Outpatient,,,2315.25,1504.91,,2315.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1759.59,76,,159.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1666.98,72,,456.592,Percent of Total Billed Charges,72% of Total Billed Charges,1666.98,72,,456.592,Percent of Total Billed charges,72% of Total Billed Charges,2315.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1666.98,72,,456.592,Percent of Total Billed Charges,72% of Total Billed Charges,1389.15,60,,380.496,Percent of Total Billed Charges,60% of Total Billed Charges,2083.73,90,,12238.128,Percent of Total Billed Charges,90% of Total Billed Charges,1041.86,45,,110.16,Percent of Total Billed Charges,45% of Total Billed Charges,2083.73,90,,188.64,Percent of Total Billed Charges,90% of Total billed Charges,2315.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2315.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2315.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1504.91,65,,2808.6,Percent of total Billed Charges,65% of Total Billed Charges,1021.03,44.1,,107.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,2199.49,95,,199.12,Percent of Total Billed Charges,95% of Total Billed Charges,2315.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2037.42,88,,13501.304,Percent of Total Billed Charges,88% of Total Billed Charges,2083.73,90,,188.64,Percent of Total Billed charges,90% of Total Billed Charges,1021.03,2315.25,
HASKAL 10F 38.5CM LIVER ACCESS,2780000202,CDM,278,RC,C1894,HCPCS,Outpatient,,,2946.98,1915.54,,2946.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2239.7,76,,159.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2121.83,72,,248.936,Percent of Total Billed Charges,72% of Total Billed Charges,2121.83,72,,248.936,Percent of Total Billed charges,72% of Total Billed Charges,2946.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2121.83,72,,248.936,Percent of Total Billed Charges,72% of Total Billed Charges,1768.19,60,,207.448,Percent of Total Billed Charges,60% of Total Billed Charges,2652.28,90,,12238.128,Percent of Total Billed Charges,90% of Total Billed Charges,1326.14,45,,38.88,Percent of Total Billed Charges,45% of Total Billed Charges,2652.28,90,,188.64,Percent of Total Billed Charges,90% of Total billed Charges,2946.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2946.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2946.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1915.54,65,,2674.856,Percent of total Billed Charges,65% of Total Billed Charges,1299.62,44.1,,38.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,2799.63,95,,199.12,Percent of Total Billed Charges,95% of Total Billed Charges,2946.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2593.34,88,,12564.48,Percent of Total Billed Charges,88% of Total Billed Charges,2652.28,90,,188.64,Percent of Total Billed charges,90% of Total Billed Charges,1299.62,2946.98,
HICKMAN 9.6F SL CV CATHETER,2780000203,CDM,278,RC,C1751,HCPCS,Outpatient,,,284.00,184.60,,284,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,215.84,76,,159.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,204.48,72,,142.248,Percent of Total Billed Charges,72% of Total Billed Charges,204.48,72,,142.248,Percent of Total Billed charges,72% of Total Billed Charges,284,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.48,72,,142.248,Percent of Total Billed Charges,72% of Total Billed Charges,170.4,60,,118.544,Percent of Total Billed Charges,60% of Total Billed Charges,255.6,90,,13808.152,Percent of Total Billed Charges,90% of Total Billed Charges,127.8,45,,6904.08,Percent of Total Billed Charges,45% of Total Billed Charges,255.6,90,,188.64,Percent of Total Billed Charges,90% of Total billed Charges,284,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.6,65,,2674.856,Percent of total Billed Charges,65% of Total Billed Charges,125.24,44.1,,6765.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,269.8,95,,199.12,Percent of Total Billed Charges,95% of Total Billed Charges,284,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.92,88,,11966.168,Percent of Total Billed Charges,88% of Total Billed Charges,255.6,90,,188.64,Percent of Total Billed charges,90% of Total Billed Charges,125.24,284,
IMPULSE 5F WILLIAMS RIGHT CATH,2780000204,CDM,272,RC,C1887,HCPCS,Outpatient,,,68.51,44.53,,68.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.07,76,,186.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49.33,72,,354.992,Percent of Total Billed Charges,72% of Total Billed Charges,51.38,75,,354.992,Percent of Total Billed charges,75% of Total Billed Charges,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.33,72,,354.992,Percent of Total Billed Charges,72% of Total Billed Charges,41.11,60,,295.824,Percent of Total Billed Charges,60% of Total Billed Charges,61.66,90,,13808.152,Percent of Total Billed Charges,90% of Total Billed Charges,30.83,45,,6425.016,Percent of Total Billed Charges,45% of Total Billed Charges,61.66,90,,220.32,Percent of Total Billed Charges,90% of Total billed Charges,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.53,65,,3561.912,Percent of total Billed Charges,65% of Total Billed Charges,30.21,44.1,,6296.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.08,95,,232.56,Percent of Total Billed Charges,95% of Total Billed Charges,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.29,88,,13501.304,Percent of Total Billed Charges,88% of Total Billed Charges,61.66,90,,220.32,Percent of Total Billed charges,90% of Total Billed Charges,30.21,68.51,
IMPULSE 6F MPA3 SH 125CM CATH,2780000205,CDM,272,RC,C1887,HCPCS,Outpatient,,,103.92,67.55,,103.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,78.98,76,,65.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,74.82,72,,448.976,Percent of Total Billed Charges,72% of Total Billed Charges,77.94,75,,448.976,Percent of Total Billed charges,75% of Total Billed Charges,103.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.82,72,,448.976,Percent of Total Billed Charges,72% of Total Billed Charges,62.35,60,,374.144,Percent of Total Billed Charges,60% of Total Billed Charges,93.53,90,,12850.032,Percent of Total Billed Charges,90% of Total Billed Charges,46.76,45,,6119.064,Percent of Total Billed Charges,45% of Total Billed Charges,93.53,90,,77.76,Percent of Total Billed Charges,90% of Total billed Charges,103.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.55,65,,3561.912,Percent of total Billed Charges,65% of Total Billed Charges,45.83,44.1,,5996.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,98.72,95,,82.08,Percent of Total Billed Charges,95% of Total Billed Charges,103.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.45,88,,12564.48,Percent of Total Billed Charges,88% of Total Billed Charges,93.53,90,,77.76,Percent of Total Billed charges,90% of Total Billed Charges,45.83,103.92,
IP ADM 5F 4X120X130CM PTA CATH,2780000206,CDM,272,RC,C2623,HCPCS,Outpatient,,,3616.20,2350.53,,3616.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2748.31,76,,11660.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2603.66,72,,429.92,Percent of Total Billed Charges,72% of Total Billed Charges,2712.15,75,,429.92,Percent of Total Billed charges,75% of Total Billed Charges,3616.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2603.66,72,,429.92,Percent of Total Billed Charges,72% of Total Billed Charges,2169.72,60,,358.264,Percent of Total Billed Charges,60% of Total Billed Charges,3254.58,90,,11655.36,Percent of Total Billed Charges,90% of Total Billed Charges,1627.29,45,,6904.08,Percent of Total Billed Charges,45% of Total Billed Charges,3254.58,90,,13808.152,Percent of Total Billed Charges,90% of Total billed Charges,3616.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3616.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3616.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2350.53,65,,2547.48,Percent of total Billed Charges,65% of Total Billed Charges,1594.74,44.1,,6765.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,3435.39,95,,14575.272,Percent of Total Billed Charges,95% of Total Billed Charges,3616.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3182.26,88,,11966.168,Percent of Total Billed Charges,88% of Total Billed Charges,3254.58,90,,13808.152,Percent of Total Billed charges,90% of Total Billed Charges,1594.74,3616.2,
IP ADM 6F 4X12X130CM PTA B CAT,2780000207,CDM,278,RC,C2623,HCPCS,Outpatient,,,3616.20,2350.53,,3616.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2748.31,76,,10851.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2603.66,72,,410.872,Percent of Total Billed Charges,72% of Total Billed Charges,2603.66,72,,410.872,Percent of Total Billed charges,72% of Total Billed Charges,3616.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2603.66,72,,410.872,Percent of Total Billed Charges,72% of Total Billed Charges,2169.72,60,,342.392,Percent of Total Billed Charges,60% of Total Billed Charges,3254.58,90,,12238.128,Percent of Total Billed Charges,90% of Total Billed Charges,1627.29,45,,6425.016,Percent of Total Billed Charges,45% of Total Billed Charges,3254.58,90,,12850.032,Percent of Total Billed Charges,90% of Total billed Charges,3616.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3616.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3616.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2350.53,65,,3561.912,Percent of total Billed Charges,65% of Total Billed Charges,1594.74,44.1,,6296.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,3435.39,95,,13563.928,Percent of Total Billed Charges,95% of Total Billed Charges,3616.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3182.26,88,,11966.168,Percent of Total Billed Charges,88% of Total Billed Charges,3254.58,90,,12850.032,Percent of Total Billed charges,90% of Total Billed Charges,1594.74,3616.2,
IP ADM 6F 5X80X130CM PTA B CTH,2780000208,CDM,272,RC,C2623,HCPCS,Outpatient,,,3285.45,2135.54,,3285.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2496.94,76,,10334.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2365.52,72,,429.92,Percent of Total Billed Charges,72% of Total Billed Charges,2464.09,75,,429.92,Percent of Total Billed charges,75% of Total Billed Charges,3285.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2365.52,72,,429.92,Percent of Total Billed Charges,72% of Total Billed Charges,1971.27,60,,358.264,Percent of Total Billed Charges,60% of Total Billed Charges,2956.91,90,,12850.032,Percent of Total Billed Charges,90% of Total Billed Charges,1478.45,45,,6119.064,Percent of Total Billed Charges,45% of Total Billed Charges,2956.91,90,,12238.128,Percent of Total Billed Charges,90% of Total billed Charges,3285.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3285.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3285.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2135.54,65,,2808.6,Percent of total Billed Charges,65% of Total Billed Charges,1448.88,44.1,,5996.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,3121.18,95,,12918.024,Percent of Total Billed Charges,95% of Total Billed Charges,3285.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2891.2,88,,13501.304,Percent of Total Billed Charges,88% of Total Billed Charges,2956.91,90,,12238.128,Percent of Total Billed charges,90% of Total Billed Charges,1448.88,3285.45,
K LESS T RPE W DRY SYN RPR T1,2780000209,CDM,278,RC,C1713,HCPCS,Outpatient,,,7583.00,4928.95,,7583,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5763.08,76,,11660.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5459.76,72,,219.088,Percent of Total Billed Charges,72% of Total Billed Charges,5459.76,72,,219.088,Percent of Total Billed charges,72% of Total Billed Charges,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5459.76,72,,219.088,Percent of Total Billed Charges,72% of Total Billed Charges,4549.8,60,,182.576,Percent of Total Billed Charges,60% of Total Billed Charges,6824.7,90,,13768.456,Percent of Total Billed Charges,90% of Total Billed Charges,3412.35,45,,6119.064,Percent of Total Billed Charges,45% of Total Billed Charges,6824.7,90,,13808.152,Percent of Total Billed Charges,90% of Total billed Charges,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4928.95,65,,2547.48,Percent of total Billed Charges,65% of Total Billed Charges,3344.1,44.1,,5996.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,7203.85,95,,14575.272,Percent of Total Billed Charges,95% of Total Billed Charges,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6673.04,88,,13501.304,Percent of Total Billed Charges,88% of Total Billed Charges,6824.7,90,,13808.152,Percent of Total Billed charges,90% of Total Billed Charges,3344.1,7583,
LAUNCHER EBU 6F 3.0 SH CATH,2780000210,CDM,272,RC,C1887,HCPCS,Outpatient,,,151.04,98.18,,151.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114.79,76,,10851.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.75,72,,354.992,Percent of Total Billed Charges,72% of Total Billed Charges,113.28,75,,354.992,Percent of Total Billed charges,75% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.75,72,,354.992,Percent of Total Billed Charges,72% of Total Billed Charges,90.62,60,,295.824,Percent of Total Billed Charges,60% of Total Billed Charges,135.94,90,,13808.152,Percent of Total Billed Charges,90% of Total Billed Charges,67.97,45,,6904.08,Percent of Total Billed Charges,45% of Total Billed Charges,135.94,90,,12850.032,Percent of Total Billed Charges,90% of Total billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.18,65,,2674.856,Percent of total Billed Charges,65% of Total Billed Charges,66.61,44.1,,6765.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,143.49,95,,13563.928,Percent of Total Billed Charges,95% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.92,88,,12564.48,Percent of Total Billed Charges,88% of Total Billed Charges,135.94,90,,12850.032,Percent of Total Billed charges,90% of Total Billed Charges,66.61,151.04,
LAUNCHER EBU 6F 3.5 SH CATH,2780000211,CDM,272,RC,C1887,HCPCS,Outpatient,,,151.04,98.18,,151.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114.79,76,,10334.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.75,72,,448.976,Percent of Total Billed Charges,72% of Total Billed Charges,113.28,75,,448.976,Percent of Total Billed charges,75% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.75,72,,448.976,Percent of Total Billed Charges,72% of Total Billed Charges,90.62,60,,374.144,Percent of Total Billed Charges,60% of Total Billed Charges,135.94,90,,704.896,Percent of Total Billed Charges,90% of Total Billed Charges,67.97,45,,6904.08,Percent of Total Billed Charges,45% of Total Billed Charges,135.94,90,,12238.128,Percent of Total Billed Charges,90% of Total billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.18,65,,2808.6,Percent of total Billed Charges,65% of Total Billed Charges,66.61,44.1,,6765.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,143.49,95,,12918.024,Percent of Total Billed Charges,95% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.92,88,,11396.352,Percent of Total Billed Charges,88% of Total Billed Charges,135.94,90,,12238.128,Percent of Total Billed charges,90% of Total Billed Charges,66.61,151.04,
LAUNCHER EBU 6F 4.0 SH CATH,2780000212,CDM,272,RC,C1887,HCPCS,Outpatient,,,151.04,98.18,,151.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114.79,76,,10334.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.75,72,,748.08,Percent of Total Billed Charges,72% of Total Billed Charges,113.28,75,,748.08,Percent of Total Billed charges,75% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.75,72,,748.08,Percent of Total Billed Charges,72% of Total Billed Charges,90.62,60,,623.4,Percent of Total Billed Charges,60% of Total Billed Charges,135.94,90,,704.896,Percent of Total Billed Charges,90% of Total Billed Charges,67.97,45,,6425.016,Percent of Total Billed Charges,45% of Total Billed Charges,135.94,90,,12238.128,Percent of Total Billed Charges,90% of Total billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.18,65,,2547.48,Percent of total Billed Charges,65% of Total Billed Charges,66.61,44.1,,6296.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,143.49,95,,12918.024,Percent of Total Billed Charges,95% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.92,88,,11966.168,Percent of Total Billed Charges,88% of Total Billed Charges,135.94,90,,12238.128,Percent of Total Billed charges,90% of Total Billed Charges,66.61,151.04,
LAUNCHER EBU 6F 4.5 SH CATH,2780000213,CDM,272,RC,C1887,HCPCS,Outpatient,,,151.04,98.18,,151.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114.79,76,,11660.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.75,72,,469.928,Percent of Total Billed Charges,72% of Total Billed Charges,113.28,75,,469.928,Percent of Total Billed charges,75% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.75,72,,469.928,Percent of Total Billed Charges,72% of Total Billed Charges,90.62,60,,391.608,Percent of Total Billed Charges,60% of Total Billed Charges,135.94,90,,4931.88,Percent of Total Billed Charges,90% of Total Billed Charges,67.97,45,,5827.68,Percent of Total Billed Charges,45% of Total Billed Charges,135.94,90,,13808.152,Percent of Total Billed Charges,90% of Total billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.18,65,,6627.4,Percent of total Billed Charges,65% of Total Billed Charges,66.61,44.1,,5711.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,143.49,95,,14575.272,Percent of Total Billed Charges,95% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.92,88,,12564.48,Percent of Total Billed Charges,88% of Total Billed Charges,135.94,90,,13808.152,Percent of Total Billed charges,90% of Total Billed Charges,66.61,151.04,
MAHURKAR 12FR X16CM KIT ACCESS,2780000214,CDM,278,RC,C1752,HCPCS,Outpatient,,,334.06,217.14,,334.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,253.89,76,,11660.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,240.52,72,,410.872,Percent of Total Billed Charges,72% of Total Billed Charges,240.52,72,,410.872,Percent of Total Billed charges,72% of Total Billed Charges,334.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.52,72,,410.872,Percent of Total Billed Charges,72% of Total Billed Charges,200.44,60,,342.392,Percent of Total Billed Charges,60% of Total Billed Charges,300.65,90,,3888.832,Percent of Total Billed Charges,90% of Total Billed Charges,150.33,45,,6119.064,Percent of Total Billed Charges,45% of Total Billed Charges,300.65,90,,13808.152,Percent of Total Billed Charges,90% of Total billed Charges,334.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.14,65,,3069.04,Percent of total Billed Charges,65% of Total Billed Charges,147.32,44.1,,5996.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,317.36,95,,14575.272,Percent of Total Billed Charges,95% of Total Billed Charges,334.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.97,88,,13462.496,Percent of Total Billed Charges,88% of Total Billed Charges,300.65,90,,13808.152,Percent of Total Billed charges,90% of Total Billed Charges,147.32,334.06,
MAHURKAR 12FR X16CM TRA ACCESS,2780000215,CDM,278,RC,C1752,HCPCS,Outpatient,,,437.69,284.50,,437.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,332.64,76,,10851.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,315.14,72,,762.68,Percent of Total Billed Charges,72% of Total Billed Charges,315.14,72,,762.68,Percent of Total Billed charges,72% of Total Billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.14,72,,762.68,Percent of Total Billed Charges,72% of Total Billed Charges,262.61,60,,635.568,Percent of Total Billed Charges,60% of Total Billed Charges,393.92,90,,3703.648,Percent of Total Billed Charges,90% of Total Billed Charges,196.96,45,,6425.016,Percent of Total Billed Charges,45% of Total Billed Charges,393.92,90,,12850.032,Percent of Total Billed Charges,90% of Total billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.5,65,,6627.4,Percent of total Billed Charges,65% of Total Billed Charges,193.02,44.1,,6296.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,415.81,95,,13563.928,Percent of Total Billed Charges,95% of Total Billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.17,88,,13501.304,Percent of Total Billed Charges,88% of Total Billed Charges,393.92,90,,12850.032,Percent of Total Billed charges,90% of Total Billed Charges,193.02,437.69,
MAHURKAR 12FR X20CM KIT ACCESS,2780000216,CDM,278,RC,C1752,HCPCS,Outpatient,,,334.06,217.14,,334.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,253.89,76,,9842.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,240.52,72,,240.68,Percent of Total Billed Charges,72% of Total Billed Charges,240.52,72,,240.68,Percent of Total Billed charges,72% of Total Billed Charges,334.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.52,72,,240.68,Percent of Total Billed Charges,72% of Total Billed Charges,200.44,60,,200.568,Percent of Total Billed Charges,60% of Total Billed Charges,300.65,90,,3703.648,Percent of Total Billed Charges,90% of Total Billed Charges,150.33,45,,6884.232,Percent of Total Billed Charges,45% of Total Billed Charges,300.65,90,,11655.36,Percent of Total Billed Charges,90% of Total billed Charges,334.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.14,65,,2674.856,Percent of total Billed Charges,65% of Total Billed Charges,147.32,44.1,,6746.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,317.36,95,,12302.88,Percent of Total Billed Charges,95% of Total Billed Charges,334.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.97,88,,689.232,Percent of Total Billed Charges,88% of Total Billed Charges,300.65,90,,11655.36,Percent of Total Billed charges,90% of Total Billed Charges,147.32,334.06,
MAHURKAR 12FR X20CM TRA ACCESS,2780000217,CDM,278,RC,C1752,HCPCS,Outpatient,,,437.69,284.50,,437.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,332.64,76,,10334.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,315.14,72,,539.784,Percent of Total Billed Charges,72% of Total Billed Charges,315.14,72,,539.784,Percent of Total Billed charges,72% of Total Billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.14,72,,539.784,Percent of Total Billed Charges,72% of Total Billed Charges,262.61,60,,449.824,Percent of Total Billed Charges,60% of Total Billed Charges,393.92,90,,4931.88,Percent of Total Billed Charges,90% of Total Billed Charges,196.96,45,,6904.08,Percent of Total Billed Charges,45% of Total Billed Charges,393.92,90,,12238.128,Percent of Total Billed Charges,90% of Total billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.5,65,,4477.472,Percent of total Billed Charges,65% of Total Billed Charges,193.02,44.1,,6765.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,415.81,95,,12918.024,Percent of Total Billed Charges,95% of Total Billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.17,88,,689.232,Percent of Total Billed Charges,88% of Total Billed Charges,393.92,90,,12238.128,Percent of Total Billed charges,90% of Total Billed Charges,193.02,437.69,
MAHURKAR 12FR X24CM  KIT FEM,2780000218,CDM,278,RC,C1752,HCPCS,Outpatient,,,363.83,236.49,,363.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,276.51,76,,10851.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,261.96,72,,392.456,Percent of Total Billed Charges,72% of Total Billed Charges,261.96,72,,392.456,Percent of Total Billed charges,72% of Total Billed Charges,363.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.96,72,,392.456,Percent of Total Billed Charges,72% of Total Billed Charges,218.3,60,,327.048,Percent of Total Billed Charges,60% of Total Billed Charges,327.45,90,,4931.88,Percent of Total Billed Charges,90% of Total Billed Charges,163.72,45,,352.448,Percent of Total Billed Charges,45% of Total Billed Charges,327.45,90,,12850.032,Percent of Total Billed Charges,90% of Total billed Charges,363.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.49,65,,3655.08,Percent of total Billed Charges,65% of Total Billed Charges,160.45,44.1,,345.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,345.64,95,,13563.928,Percent of Total Billed Charges,95% of Total Billed Charges,363.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320.17,88,,4822.28,Percent of Total Billed Charges,88% of Total Billed Charges,327.45,90,,12850.032,Percent of Total Billed charges,90% of Total Billed Charges,160.45,363.83,
MAHURKAR 12FR X24CM  TRA FEM,2780000219,CDM,278,RC,C1752,HCPCS,Outpatient,,,467.46,303.85,,467.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,355.27,76,,11626.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,336.57,72,,470.56,Percent of Total Billed Charges,72% of Total Billed Charges,336.57,72,,470.56,Percent of Total Billed charges,72% of Total Billed Charges,467.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,336.57,72,,470.56,Percent of Total Billed Charges,72% of Total Billed Charges,280.48,60,,392.136,Percent of Total Billed Charges,60% of Total Billed Charges,420.71,90,,3527.28,Percent of Total Billed Charges,90% of Total Billed Charges,210.36,45,,352.448,Percent of Total Billed Charges,45% of Total Billed Charges,420.71,90,,13768.456,Percent of Total Billed Charges,90% of Total billed Charges,467.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,467.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,467.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.85,65,,4477.472,Percent of total Billed Charges,65% of Total Billed Charges,206.15,44.1,,345.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,444.09,95,,14533.376,Percent of Total Billed Charges,95% of Total Billed Charges,467.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,88,,3802.408,Percent of Total Billed Charges,88% of Total Billed Charges,420.71,90,,13768.456,Percent of Total Billed charges,90% of Total Billed Charges,206.15,467.46,
MEGA 40CC BALLOON PUMP CATH,2780000220,CDM,278,RC,C1729,HCPCS,Outpatient,,,4204.20,2732.73,,4204.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3195.19,76,,11660.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3027.02,72,,429.92,Percent of Total Billed Charges,72% of Total Billed Charges,3027.02,72,,429.92,Percent of Total Billed charges,72% of Total Billed Charges,4204.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3027.02,72,,429.92,Percent of Total Billed Charges,72% of Total Billed Charges,2522.52,60,,358.264,Percent of Total Billed Charges,60% of Total Billed Charges,3783.78,90,,4931.88,Percent of Total Billed Charges,90% of Total Billed Charges,1891.89,45,,2465.936,Percent of Total Billed Charges,45% of Total Billed Charges,3783.78,90,,13808.152,Percent of Total Billed Charges,90% of Total billed Charges,4204.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4204.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4204.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2732.73,65,,4477.472,Percent of total Billed Charges,65% of Total Billed Charges,1854.05,44.1,,2416.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,3993.99,95,,14575.272,Percent of Total Billed Charges,95% of Total Billed Charges,4204.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3699.7,88,,3621.344,Percent of Total Billed Charges,88% of Total Billed Charges,3783.78,90,,13808.152,Percent of Total Billed charges,90% of Total Billed Charges,1854.05,4204.2,
MEGA 50CC BALLOON PUMP CATH,2780000221,CDM,278,RC,C1729,HCPCS,Outpatient,,,4204.20,2732.73,,4204.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3195.19,76,,595.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3027.02,72,,470.56,Percent of Total Billed Charges,72% of Total Billed Charges,3027.02,72,,470.56,Percent of Total Billed charges,72% of Total Billed Charges,4204.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3027.02,72,,470.56,Percent of Total Billed Charges,72% of Total Billed Charges,2522.52,60,,392.136,Percent of Total Billed Charges,60% of Total Billed Charges,3783.78,90,,3888.832,Percent of Total Billed Charges,90% of Total Billed Charges,1891.89,45,,1944.416,Percent of Total Billed Charges,45% of Total Billed Charges,3783.78,90,,704.896,Percent of Total Billed Charges,90% of Total billed Charges,4204.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4204.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4204.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2732.73,65,,4029.728,Percent of total Billed Charges,65% of Total Billed Charges,1854.05,44.1,,1905.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,3993.99,95,,744.056,Percent of Total Billed Charges,95% of Total Billed Charges,4204.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3699.7,88,,3621.344,Percent of Total Billed Charges,88% of Total Billed Charges,3783.78,90,,704.896,Percent of Total Billed charges,90% of Total Billed Charges,1854.05,4204.2,
MULTIPURP DRGE CATH 14F X 25CM,2780000222,CDM,278,RC,C1729,HCPCS,Outpatient,,,588.54,382.55,,588.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,447.29,76,,595.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,423.75,72,,429.92,Percent of Total Billed Charges,72% of Total Billed Charges,423.75,72,,429.92,Percent of Total Billed charges,72% of Total Billed Charges,588.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,423.75,72,,429.92,Percent of Total Billed Charges,72% of Total Billed Charges,353.12,60,,358.264,Percent of Total Billed Charges,60% of Total Billed Charges,529.69,90,,3527.28,Percent of Total Billed Charges,90% of Total Billed Charges,264.84,45,,1851.824,Percent of Total Billed Charges,45% of Total Billed Charges,529.69,90,,704.896,Percent of Total Billed Charges,90% of Total billed Charges,588.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,588.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,588.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.55,65,,4477.472,Percent of total Billed Charges,65% of Total Billed Charges,259.55,44.1,,1814.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,559.11,95,,744.056,Percent of Total Billed Charges,95% of Total Billed Charges,588.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,517.92,88,,4822.28,Percent of Total Billed Charges,88% of Total Billed Charges,529.69,90,,704.896,Percent of Total Billed charges,90% of Total Billed Charges,259.55,588.54,
NEEDLE 18GX2 TOUHY INSUL NERVE,2780000223,CDM,278,RC,,,Outpatient,,,111.35,72.38,,111.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,84.63,76,,4164.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,80.17,72,,921.448,Percent of Total Billed Charges,72% of Total Billed Charges,80.17,72,,921.448,Percent of Total Billed charges,72% of Total Billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.17,72,,921.448,Percent of Total Billed Charges,72% of Total Billed Charges,66.81,60,,767.872,Percent of Total Billed Charges,60% of Total Billed Charges,100.22,90,,3703.648,Percent of Total Billed Charges,90% of Total Billed Charges,50.11,45,,1851.824,Percent of Total Billed Charges,45% of Total Billed Charges,100.22,90,,4931.88,Percent of Total Billed Charges,90% of Total billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.38,65,,4477.472,Percent of total Billed Charges,65% of Total Billed Charges,49.11,44.1,,1814.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,105.78,95,,5205.872,Percent of Total Billed Charges,95% of Total Billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.99,88,,4822.28,Percent of Total Billed Charges,88% of Total Billed Charges,100.22,90,,4931.88,Percent of Total Billed charges,90% of Total Billed Charges,49.11,111.35,
OPTITORQUE 5F ST PIGTAIL 110CM,2780000224,CDM,272,RC,C1887,HCPCS,Outpatient,,,171.99,111.79,,171.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.71,76,,3283.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.83,72,,579.792,Percent of Total Billed Charges,72% of Total Billed Charges,128.99,75,,579.792,Percent of Total Billed charges,75% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.83,72,,579.792,Percent of Total Billed Charges,72% of Total Billed Charges,103.19,60,,483.16,Percent of Total Billed Charges,60% of Total Billed Charges,154.79,90,,3888.832,Percent of Total Billed Charges,90% of Total Billed Charges,77.4,45,,2465.936,Percent of Total Billed Charges,45% of Total Billed Charges,154.79,90,,3888.832,Percent of Total Billed Charges,90% of Total billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.79,65,,1730.224,Percent of total Billed Charges,65% of Total Billed Charges,75.85,44.1,,2416.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.39,95,,4104.872,Percent of Total Billed Charges,95% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.35,88,,3448.896,Percent of Total Billed Charges,88% of Total Billed Charges,154.79,90,,3888.832,Percent of Total Billed charges,90% of Total Billed Charges,75.85,171.99,
ONYX 2.5 X 22 DE STENT CATH,2780000225,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,3127.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,107.96,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,107.96,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,107.96,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,89.968,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,3527.28,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,2465.936,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,3703.648,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,1730.224,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,2416.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,3909.4,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,4822.28,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,3703.648,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
JACKY 5F RADIAL 4.0 100CM,2780000226,CDM,278,RC,C1887,HCPCS,Outpatient,,,180.81,117.53,,180.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,137.42,76,,3127.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,130.18,72,,539.784,Percent of Total Billed Charges,72% of Total Billed Charges,130.18,72,,539.784,Percent of Total Billed charges,72% of Total Billed Charges,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.18,72,,539.784,Percent of Total Billed Charges,72% of Total Billed Charges,108.49,60,,449.824,Percent of Total Billed Charges,60% of Total Billed Charges,162.73,90,,9176.4,Percent of Total Billed Charges,90% of Total Billed Charges,81.36,45,,1763.64,Percent of Total Billed Charges,45% of Total Billed Charges,162.73,90,,3703.648,Percent of Total Billed Charges,90% of Total billed Charges,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.53,65,,96.096,Percent of total Billed Charges,65% of Total Billed Charges,79.74,44.1,,1728.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,171.77,95,,3909.4,Percent of Total Billed Charges,95% of Total Billed Charges,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.11,88,,3802.408,Percent of Total Billed Charges,88% of Total Billed Charges,162.73,90,,3703.648,Percent of Total Billed charges,90% of Total Billed Charges,79.74,180.81,
OPTITORQUE 5F JL3.5 R CATHETER,2780000227,CDM,272,RC,C1887,HCPCS,Outpatient,,,171.99,111.79,,171.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.71,76,,4164.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.83,72,,392.456,Percent of Total Billed Charges,72% of Total Billed Charges,128.99,75,,392.456,Percent of Total Billed charges,75% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.83,72,,392.456,Percent of Total Billed Charges,72% of Total Billed Charges,103.19,60,,327.048,Percent of Total Billed Charges,60% of Total Billed Charges,154.79,90,,4249.44,Percent of Total Billed Charges,90% of Total Billed Charges,77.4,45,,2465.936,Percent of Total Billed Charges,45% of Total Billed Charges,154.79,90,,4931.88,Percent of Total Billed Charges,90% of Total billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.79,65,,96.096,Percent of total Billed Charges,65% of Total Billed Charges,75.85,44.1,,2416.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.39,95,,5205.872,Percent of Total Billed Charges,95% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.35,88,,3448.896,Percent of Total Billed Charges,88% of Total Billed Charges,154.79,90,,4931.88,Percent of Total Billed charges,90% of Total Billed Charges,75.85,171.99,
OPTITORQUE 5F JL4 R CATHETER,2780000228,CDM,272,RC,C1887,HCPCS,Outpatient,,,171.99,111.79,,171.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.71,76,,4164.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.83,72,,470.56,Percent of Total Billed Charges,72% of Total Billed Charges,128.99,75,,470.56,Percent of Total Billed charges,75% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.83,72,,470.56,Percent of Total Billed Charges,72% of Total Billed Charges,103.19,60,,392.136,Percent of Total Billed Charges,60% of Total Billed Charges,154.79,90,,9176.4,Percent of Total Billed Charges,90% of Total Billed Charges,77.4,45,,1944.416,Percent of Total Billed Charges,45% of Total Billed Charges,154.79,90,,4931.88,Percent of Total Billed Charges,90% of Total billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.79,65,,340.08,Percent of total Billed Charges,65% of Total Billed Charges,75.85,44.1,,1905.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.39,95,,5205.872,Percent of Total Billed Charges,95% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.35,88,,3621.344,Percent of Total Billed Charges,88% of Total Billed Charges,154.79,90,,4931.88,Percent of Total Billed charges,90% of Total Billed Charges,75.85,171.99,
OPTITORQUE 5F JR3.5 R CATHETER,2780000229,CDM,272,RC,C1887,HCPCS,Outpatient,,,171.99,111.79,,171.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.71,76,,2978.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.83,72,,429.92,Percent of Total Billed Charges,72% of Total Billed Charges,128.99,75,,429.92,Percent of Total Billed charges,75% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.83,72,,429.92,Percent of Total Billed Charges,72% of Total Billed Charges,103.19,60,,358.264,Percent of Total Billed Charges,60% of Total Billed Charges,154.79,90,,3703.648,Percent of Total Billed Charges,90% of Total Billed Charges,77.4,45,,1763.64,Percent of Total Billed Charges,45% of Total Billed Charges,154.79,90,,3527.28,Percent of Total Billed Charges,90% of Total billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.79,65,,340.08,Percent of total Billed Charges,65% of Total Billed Charges,75.85,44.1,,1728.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.39,95,,3723.24,Percent of Total Billed Charges,95% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.35,88,,3802.408,Percent of Total Billed Charges,88% of Total Billed Charges,154.79,90,,3527.28,Percent of Total Billed charges,90% of Total Billed Charges,75.85,171.99,
OPTITORQUE 5F JR4 R CATHETER,2780000230,CDM,272,RC,C1887,HCPCS,Outpatient,,,171.99,111.79,,171.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.71,76,,4164.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.83,72,,470.56,Percent of Total Billed Charges,72% of Total Billed Charges,128.99,75,,470.56,Percent of Total Billed charges,75% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.83,72,,470.56,Percent of Total Billed Charges,72% of Total Billed Charges,103.19,60,,392.136,Percent of Total Billed Charges,60% of Total Billed Charges,154.79,90,,6199.584,Percent of Total Billed Charges,90% of Total Billed Charges,77.4,45,,1851.824,Percent of Total Billed Charges,45% of Total Billed Charges,154.79,90,,4931.88,Percent of Total Billed Charges,90% of Total billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.79,65,,97.76,Percent of total Billed Charges,65% of Total Billed Charges,75.85,44.1,,1814.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.39,95,,5205.872,Percent of Total Billed Charges,95% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.35,88,,3448.896,Percent of Total Billed Charges,88% of Total Billed Charges,154.79,90,,4931.88,Percent of Total Billed charges,90% of Total Billed Charges,75.85,171.99,
OPTITORQUE 5F JR5 R CATHETER,2780000231,CDM,272,RC,C1887,HCPCS,Outpatient,,,171.99,111.79,,171.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.71,76,,3283.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.83,72,,429.92,Percent of Total Billed Charges,72% of Total Billed Charges,128.99,75,,429.92,Percent of Total Billed charges,75% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.83,72,,429.92,Percent of Total Billed Charges,72% of Total Billed Charges,103.19,60,,358.264,Percent of Total Billed Charges,60% of Total Billed Charges,154.79,90,,5060.88,Percent of Total Billed Charges,90% of Total Billed Charges,77.4,45,,1944.416,Percent of Total Billed Charges,45% of Total Billed Charges,154.79,90,,3888.832,Percent of Total Billed Charges,90% of Total billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.79,65,,244.064,Percent of total Billed Charges,65% of Total Billed Charges,75.85,44.1,,1905.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.39,95,,4104.872,Percent of Total Billed Charges,95% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.35,88,,8972.48,Percent of Total Billed Charges,88% of Total Billed Charges,154.79,90,,3888.832,Percent of Total Billed charges,90% of Total Billed Charges,75.85,171.99,
PALINDRO PREC HSI 28X45 SPRT,2780000232,CDM,278,RC,C1750,HCPCS,Outpatient,,,2009.86,1306.41,,2009.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1527.49,76,,2978.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1447.1,72,,507.4,Percent of Total Billed Charges,72% of Total Billed Charges,1447.1,72,,507.4,Percent of Total Billed charges,72% of Total Billed Charges,2009.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1447.1,72,,507.4,Percent of Total Billed Charges,72% of Total Billed Charges,1205.92,60,,422.832,Percent of Total Billed Charges,60% of Total Billed Charges,1808.87,90,,6199.584,Percent of Total Billed Charges,90% of Total Billed Charges,904.44,45,,1763.64,Percent of Total Billed Charges,45% of Total Billed Charges,1808.87,90,,3527.28,Percent of Total Billed Charges,90% of Total billed Charges,2009.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2009.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2009.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1306.41,65,,3977.48,Percent of total Billed Charges,65% of Total Billed Charges,886.35,44.1,,1728.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,1909.37,95,,3723.24,Percent of Total Billed Charges,95% of Total Billed Charges,2009.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1768.68,88,,4155.008,Percent of Total Billed Charges,88% of Total Billed Charges,1808.87,90,,3527.28,Percent of Total Billed charges,90% of Total Billed Charges,886.35,2009.86,
PARAM 5F 6X18X80 0.014 OTW GPS,2780000233,CDM,278,RC,C1876,HCPCS,Outpatient,,,2888.81,1877.73,,2888.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2195.5,76,,3127.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2079.94,72,,579.792,Percent of Total Billed Charges,72% of Total Billed Charges,2079.94,72,,579.792,Percent of Total Billed charges,72% of Total Billed Charges,2888.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2079.94,72,,579.792,Percent of Total Billed Charges,72% of Total Billed Charges,1733.29,60,,483.16,Percent of Total Billed Charges,60% of Total Billed Charges,2599.93,90,,6199.584,Percent of Total Billed Charges,90% of Total Billed Charges,1299.96,45,,4588.2,Percent of Total Billed Charges,45% of Total Billed Charges,2599.93,90,,3703.648,Percent of Total Billed Charges,90% of Total billed Charges,2888.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2888.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2888.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1877.73,65,,37.264,Percent of total Billed Charges,65% of Total Billed Charges,1273.97,44.1,,4496.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,2744.37,95,,3909.4,Percent of Total Billed Charges,95% of Total Billed Charges,2888.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2542.15,88,,8972.48,Percent of Total Billed Charges,88% of Total Billed Charges,2599.93,90,,3703.648,Percent of Total Billed charges,90% of Total Billed Charges,1273.97,2888.81,
PERCUFLEX PLUS 4.8X28CM URETER,2780000234,CDM,278,RC,C2617,HCPCS,Outpatient,,,394.11,256.17,,394.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.52,76,,3283.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,283.76,72,,321.968,Percent of Total Billed Charges,72% of Total Billed Charges,283.76,72,,321.968,Percent of Total Billed charges,72% of Total Billed Charges,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.76,72,,321.968,Percent of Total Billed Charges,72% of Total Billed Charges,236.47,60,,268.304,Percent of Total Billed Charges,60% of Total Billed Charges,354.7,90,,5579.616,Percent of Total Billed Charges,90% of Total Billed Charges,177.35,45,,2124.72,Percent of Total Billed Charges,45% of Total Billed Charges,354.7,90,,3888.832,Percent of Total Billed Charges,90% of Total billed Charges,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.17,65,,34.84,Percent of total Billed Charges,65% of Total Billed Charges,173.8,44.1,,2082.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.4,95,,4104.872,Percent of Total Billed Charges,95% of Total Billed Charges,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.82,88,,3621.344,Percent of Total Billed Charges,88% of Total Billed Charges,354.7,90,,3888.832,Percent of Total Billed charges,90% of Total Billed Charges,173.8,394.11,
PERCUFLEX PLUS 6FX28CM URETERL,2780000235,CDM,278,RC,C2617,HCPCS,Outpatient,,,394.11,256.17,,394.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.52,76,,2978.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,283.76,72,,429.92,Percent of Total Billed Charges,72% of Total Billed Charges,283.76,72,,429.92,Percent of Total Billed charges,72% of Total Billed Charges,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.76,72,,429.92,Percent of Total Billed Charges,72% of Total Billed Charges,236.47,60,,358.264,Percent of Total Billed Charges,60% of Total Billed Charges,354.7,90,,6199.584,Percent of Total Billed Charges,90% of Total Billed Charges,177.35,45,,4588.2,Percent of Total Billed Charges,45% of Total Billed Charges,354.7,90,,3527.28,Percent of Total Billed Charges,90% of Total billed Charges,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.17,65,,29.12,Percent of total Billed Charges,65% of Total Billed Charges,173.8,44.1,,4496.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.4,95,,3723.24,Percent of Total Billed Charges,95% of Total Billed Charges,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.82,88,,6061.816,Percent of Total Billed Charges,88% of Total Billed Charges,354.7,90,,3527.28,Percent of Total Billed charges,90% of Total Billed Charges,173.8,394.11,
PERCUFLEX PLUS 6FX30CM URETERL,2780000236,CDM,278,RC,C2617,HCPCS,Outpatient,,,394.11,256.17,,394.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.52,76,,7748.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,283.76,72,,507.4,Percent of Total Billed Charges,72% of Total Billed Charges,283.76,72,,507.4,Percent of Total Billed charges,72% of Total Billed Charges,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.76,72,,507.4,Percent of Total Billed Charges,72% of Total Billed Charges,236.47,60,,422.832,Percent of Total Billed Charges,60% of Total Billed Charges,354.7,90,,6199.584,Percent of Total Billed Charges,90% of Total Billed Charges,177.35,45,,1851.824,Percent of Total Billed Charges,45% of Total Billed Charges,354.7,90,,9176.4,Percent of Total Billed Charges,90% of Total billed Charges,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.17,65,,36.688,Percent of total Billed Charges,65% of Total Billed Charges,173.8,44.1,,1814.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.4,95,,9686.2,Percent of Total Billed Charges,95% of Total Billed Charges,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.82,88,,4948.416,Percent of Total Billed Charges,88% of Total Billed Charges,354.7,90,,9176.4,Percent of Total Billed charges,90% of Total Billed Charges,173.8,394.11,
PERCUFLEX PLUS 7FX28CM URETERL,2780000237,CDM,278,RC,C2617,HCPCS,Outpatient,,,394.11,256.17,,394.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.52,76,,3588.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,283.76,72,,483.904,Percent of Total Billed Charges,72% of Total Billed Charges,283.76,72,,483.904,Percent of Total Billed charges,72% of Total Billed Charges,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.76,72,,483.904,Percent of Total Billed Charges,72% of Total Billed Charges,236.47,60,,403.256,Percent of Total Billed Charges,60% of Total Billed Charges,354.7,90,,2395.696,Percent of Total Billed Charges,90% of Total Billed Charges,177.35,45,,3099.792,Percent of Total Billed Charges,45% of Total Billed Charges,354.7,90,,4249.44,Percent of Total Billed Charges,90% of Total billed Charges,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.17,65,,32.68,Percent of total Billed Charges,65% of Total Billed Charges,173.8,44.1,,3037.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.4,95,,4485.52,Percent of Total Billed Charges,95% of Total Billed Charges,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.82,88,,6061.816,Percent of Total Billed Charges,88% of Total Billed Charges,354.7,90,,4249.44,Percent of Total Billed charges,90% of Total Billed Charges,173.8,394.11,
PERCUFLEX PLUS 7FX30CM URETERL,2780000238,CDM,278,RC,C2617,HCPCS,Outpatient,,,394.11,256.17,,394.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.52,76,,7748.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,283.76,72,,515.016,Percent of Total Billed Charges,72% of Total Billed Charges,283.76,72,,515.016,Percent of Total Billed charges,72% of Total Billed Charges,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.76,72,,515.016,Percent of Total Billed Charges,72% of Total Billed Charges,236.47,60,,429.184,Percent of Total Billed Charges,60% of Total Billed Charges,354.7,90,,2395.696,Percent of Total Billed Charges,90% of Total Billed Charges,177.35,45,,2530.44,Percent of Total Billed Charges,45% of Total Billed Charges,354.7,90,,9176.4,Percent of Total Billed Charges,90% of Total billed Charges,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.17,65,,33.256,Percent of total Billed Charges,65% of Total Billed Charges,173.8,44.1,,2479.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.4,95,,9686.2,Percent of Total Billed Charges,95% of Total Billed Charges,394.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.82,88,,6061.816,Percent of Total Billed Charges,88% of Total Billed Charges,354.7,90,,9176.4,Percent of Total Billed charges,90% of Total Billed Charges,173.8,394.11,
PERCUFLX PL 6FX20CM URETE STNT,2780000239,CDM,278,RC,C2617,HCPCS,Outpatient,,,377.88,245.62,,377.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,287.19,76,,3127.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,272.07,72,,499.776,Percent of Total Billed Charges,72% of Total Billed Charges,272.07,72,,499.776,Percent of Total Billed charges,72% of Total Billed Charges,377.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.07,72,,499.776,Percent of Total Billed Charges,72% of Total Billed Charges,226.73,60,,416.48,Percent of Total Billed Charges,60% of Total Billed Charges,340.09,90,,133.056,Percent of Total Billed Charges,90% of Total Billed Charges,170.05,45,,3099.792,Percent of Total Billed Charges,45% of Total Billed Charges,340.09,90,,3703.648,Percent of Total Billed Charges,90% of Total billed Charges,377.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.62,65,,33.256,Percent of total Billed Charges,65% of Total Billed Charges,166.65,44.1,,3037.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,358.99,95,,3909.4,Percent of Total Billed Charges,95% of Total Billed Charges,377.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.53,88,,5455.624,Percent of Total Billed Charges,88% of Total Billed Charges,340.09,90,,3703.648,Percent of Total Billed charges,90% of Total Billed Charges,166.65,377.88,
POWERPORT 6F CV ISP PORT CATH,2780000241,CDM,278,RC,C1788,HCPCS,Outpatient,,,1874.25,1218.26,,1874.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1424.43,76,,5235.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1349.46,72,,567.088,Percent of Total Billed Charges,72% of Total Billed Charges,1349.46,72,,567.088,Percent of Total Billed charges,72% of Total Billed Charges,1874.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1349.46,72,,567.088,Percent of Total Billed Charges,72% of Total Billed Charges,1124.55,60,,472.576,Percent of Total Billed Charges,60% of Total Billed Charges,1686.83,90,,133.056,Percent of Total Billed Charges,90% of Total Billed Charges,843.41,45,,3099.792,Percent of Total Billed Charges,45% of Total Billed Charges,1686.83,90,,6199.584,Percent of Total Billed Charges,90% of Total billed Charges,1874.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1874.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1874.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1218.26,65,,428.832,Percent of total Billed Charges,65% of Total Billed Charges,826.54,44.1,,3037.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,1780.54,95,,6544,Percent of Total Billed Charges,95% of Total Billed Charges,1874.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1649.34,88,,6061.816,Percent of Total Billed Charges,88% of Total Billed Charges,1686.83,90,,6199.584,Percent of Total Billed charges,90% of Total Billed Charges,826.54,1874.25,
POWERPORT 8F CV ISP PORT CATH,2780000242,CDM,278,RC,C1788,HCPCS,Outpatient,,,1874.25,1218.26,,1874.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1424.43,76,,4273.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1349.46,72,,605.192,Percent of Total Billed Charges,72% of Total Billed Charges,1349.46,72,,605.192,Percent of Total Billed charges,72% of Total Billed Charges,1874.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1349.46,72,,605.192,Percent of Total Billed Charges,72% of Total Billed Charges,1124.55,60,,504.328,Percent of Total Billed Charges,60% of Total Billed Charges,1686.83,90,,470.88,Percent of Total Billed Charges,90% of Total Billed Charges,843.41,45,,2789.808,Percent of Total Billed Charges,45% of Total Billed Charges,1686.83,90,,5060.88,Percent of Total Billed Charges,90% of Total billed Charges,1874.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1874.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1874.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1218.26,65,,328.144,Percent of total Billed Charges,65% of Total Billed Charges,826.54,44.1,,2734.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,1780.54,95,,5342.04,Percent of Total Billed Charges,95% of Total Billed Charges,1874.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1649.34,88,,6061.816,Percent of Total Billed Charges,88% of Total Billed Charges,1686.83,90,,5060.88,Percent of Total Billed charges,90% of Total Billed Charges,826.54,1874.25,
PREFIX EPIDURAL CAT STYTED 20G,2780000243,CDM,278,RC,A4301,HCPCS,Outpatient,,,145.53,94.59,,145.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.6,76,,5235.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,104.78,72,,1470.752,Percent of Total Billed Charges,72% of Total Billed Charges,104.78,72,,1470.752,Percent of Total Billed charges,72% of Total Billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.78,72,,1470.752,Percent of Total Billed Charges,72% of Total Billed Charges,87.32,60,,1225.624,Percent of Total Billed Charges,60% of Total Billed Charges,130.98,90,,470.88,Percent of Total Billed Charges,90% of Total Billed Charges,65.49,45,,3099.792,Percent of Total Billed Charges,45% of Total Billed Charges,130.98,90,,6199.584,Percent of Total Billed Charges,90% of Total billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.59,65,,122.112,Percent of total Billed Charges,65% of Total Billed Charges,64.18,44.1,,3037.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,138.25,95,,6544,Percent of Total Billed Charges,95% of Total Billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.07,88,,2342.456,Percent of Total Billed Charges,88% of Total Billed Charges,130.98,90,,6199.584,Percent of Total Billed charges,90% of Total Billed Charges,64.18,145.53,
PROGRIP PARTX SLF FIX MESH RT,2780000244,CDM,278,RC,C1781,HCPCS,Outpatient,,,1219.00,792.35,,1219,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,926.44,76,,5235.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,877.68,72,,736.016,Percent of Total Billed Charges,72% of Total Billed Charges,877.68,72,,736.016,Percent of Total Billed charges,72% of Total Billed Charges,1219,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,877.68,72,,736.016,Percent of Total Billed Charges,72% of Total Billed Charges,731.4,60,,613.344,Percent of Total Billed Charges,60% of Total Billed Charges,1097.1,90,,135.36,Percent of Total Billed Charges,90% of Total Billed Charges,548.55,45,,3099.792,Percent of Total Billed Charges,45% of Total Billed Charges,1097.1,90,,6199.584,Percent of Total Billed Charges,90% of Total billed Charges,1219,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1219,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1219,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,792.35,65,,516.88,Percent of total Billed Charges,65% of Total Billed Charges,537.58,44.1,,3037.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,1158.05,95,,6544,Percent of Total Billed Charges,95% of Total Billed Charges,1219,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1072.72,88,,2342.456,Percent of Total Billed Charges,88% of Total Billed Charges,1097.1,90,,6199.584,Percent of Total Billed charges,90% of Total Billed Charges,537.58,1219,
PROGRP PARITX SLF FIX MESH LFT,2780000245,CDM,278,RC,C1781,HCPCS,Outpatient,,,1219.00,792.35,,1219,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,926.44,76,,4711.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,877.68,72,,469.928,Percent of Total Billed Charges,72% of Total Billed Charges,877.68,72,,469.928,Percent of Total Billed charges,72% of Total Billed Charges,1219,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,877.68,72,,469.928,Percent of Total Billed Charges,72% of Total Billed Charges,731.4,60,,391.608,Percent of Total Billed Charges,60% of Total Billed Charges,1097.1,90,,337.936,Percent of Total Billed Charges,90% of Total Billed Charges,548.55,45,,1197.848,Percent of Total Billed Charges,45% of Total Billed Charges,1097.1,90,,5579.616,Percent of Total Billed Charges,90% of Total billed Charges,1219,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1219,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1219,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,792.35,65,,8982.464,Percent of total Billed Charges,65% of Total Billed Charges,537.58,44.1,,1173.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,1158.05,95,,5889.6,Percent of Total Billed Charges,95% of Total Billed Charges,1219,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1072.72,88,,130.096,Percent of Total Billed Charges,88% of Total Billed Charges,1097.1,90,,5579.616,Percent of Total Billed charges,90% of Total Billed Charges,537.58,1219,
PRONTO LP 6F EXTRACTION CATH,2780000246,CDM,272,RC,C1729,HCPCS,Outpatient,,,1038.45,674.99,,1038.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,789.22,76,,5235.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,747.68,72,,2981.512,Percent of Total Billed Charges,72% of Total Billed Charges,778.84,75,,2981.512,Percent of Total Billed charges,75% of Total Billed Charges,1038.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,747.68,72,,2981.512,Percent of Total Billed Charges,72% of Total Billed Charges,623.07,60,,2484.592,Percent of Total Billed Charges,60% of Total Billed Charges,934.61,90,,5507.28,Percent of Total Billed Charges,90% of Total Billed Charges,467.3,45,,1197.848,Percent of Total Billed Charges,45% of Total Billed Charges,934.61,90,,6199.584,Percent of Total Billed Charges,90% of Total billed Charges,1038.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1038.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1038.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,674.99,65,,2580.76,Percent of total Billed Charges,65% of Total Billed Charges,457.96,44.1,,1173.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,986.53,95,,6544,Percent of Total Billed Charges,95% of Total Billed Charges,1038.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.84,88,,130.096,Percent of Total Billed Charges,88% of Total Billed Charges,934.61,90,,6199.584,Percent of Total Billed charges,90% of Total Billed Charges,457.96,1038.45,
PROT EF 6F 5X80X120 35 OTW SES,2780000247,CDM,278,RC,C1876,HCPCS,Outpatient,,,4135.75,2688.24,,4135.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3143.17,76,,5235.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2977.74,72,,594.4,Percent of Total Billed Charges,72% of Total Billed Charges,2977.74,72,,594.4,Percent of Total Billed charges,72% of Total Billed Charges,4135.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2977.74,72,,594.4,Percent of Total Billed Charges,72% of Total Billed Charges,2481.45,60,,495.328,Percent of Total Billed Charges,60% of Total Billed Charges,3722.18,90,,51.592,Percent of Total Billed Charges,90% of Total Billed Charges,1861.09,45,,66.528,Percent of Total Billed Charges,45% of Total Billed Charges,3722.18,90,,6199.584,Percent of Total Billed Charges,90% of Total billed Charges,4135.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4135.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4135.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2688.24,65,,1139.84,Percent of total Billed Charges,65% of Total Billed Charges,1823.87,44.1,,65.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,3928.96,95,,6544,Percent of Total Billed Charges,95% of Total Billed Charges,4135.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3639.46,88,,460.416,Percent of Total Billed Charges,88% of Total Billed Charges,3722.18,90,,6199.584,Percent of Total Billed charges,90% of Total Billed Charges,1823.87,4135.75,
PROT EVRFL STNT .035 6X200X120,2780000248,CDM,278,RC,C1876,HCPCS,Outpatient,,,11807.25,7674.71,,11807.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8973.51,76,,2023.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8501.22,72,,3113.6,Percent of Total Billed Charges,72% of Total Billed Charges,8501.22,72,,3113.6,Percent of Total Billed charges,72% of Total Billed Charges,11807.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8501.22,72,,3113.6,Percent of Total Billed Charges,72% of Total Billed Charges,7084.35,60,,2594.672,Percent of Total Billed Charges,60% of Total Billed Charges,10626.53,90,,48.24,Percent of Total Billed Charges,90% of Total Billed Charges,5313.26,45,,66.528,Percent of Total Billed Charges,45% of Total Billed Charges,10626.53,90,,2395.696,Percent of Total Billed Charges,90% of Total billed Charges,11807.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11807.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11807.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7674.71,65,,1220.96,Percent of total Billed Charges,65% of Total Billed Charges,5207,44.1,,65.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,11216.89,95,,2528.784,Percent of Total Billed Charges,95% of Total Billed Charges,11807.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10390.38,88,,460.416,Percent of Total Billed Charges,88% of Total Billed Charges,10626.53,90,,2395.696,Percent of Total Billed charges,90% of Total Billed Charges,5207,11807.25,
PROT GPS 6F 8X40X80 35 OTW SES,2780000249,CDM,278,RC,C1876,HCPCS,Outpatient,,,4135.75,2688.24,,4135.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3143.17,76,,2023.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2977.74,72,,488.984,Percent of Total Billed Charges,72% of Total Billed Charges,2977.74,72,,488.984,Percent of Total Billed charges,72% of Total Billed Charges,4135.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2977.74,72,,488.984,Percent of Total Billed Charges,72% of Total Billed Charges,2481.45,60,,407.488,Percent of Total Billed Charges,60% of Total Billed Charges,3722.18,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,1861.09,45,,235.44,Percent of Total Billed Charges,45% of Total Billed Charges,3722.18,90,,2395.696,Percent of Total Billed Charges,90% of Total billed Charges,4135.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4135.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4135.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2688.24,65,,2407.864,Percent of total Billed Charges,65% of Total Billed Charges,1823.87,44.1,,230.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,3928.96,95,,2528.784,Percent of Total Billed Charges,95% of Total Billed Charges,4135.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3639.46,88,,132.352,Percent of Total Billed Charges,88% of Total Billed Charges,3722.18,90,,2395.696,Percent of Total Billed charges,90% of Total Billed Charges,1823.87,4135.75,
PROTEG 6F 035 12X60 120CM STNT,2780000250,CDM,278,RC,C1876,HCPCS,Outpatient,,,3867.50,2513.88,,3867.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2939.3,76,,112.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2784.6,72,,147.328,Percent of Total Billed Charges,72% of Total Billed Charges,2784.6,72,,147.328,Percent of Total Billed charges,72% of Total Billed Charges,3867.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2784.6,72,,147.328,Percent of Total Billed Charges,72% of Total Billed Charges,2320.5,60,,122.776,Percent of Total Billed Charges,60% of Total Billed Charges,3480.75,90,,50.8,Percent of Total Billed Charges,90% of Total Billed Charges,1740.38,45,,235.44,Percent of Total Billed Charges,45% of Total Billed Charges,3480.75,90,,133.056,Percent of Total Billed Charges,90% of Total billed Charges,3867.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3867.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3867.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2513.88,65,,2407.864,Percent of total Billed Charges,65% of Total Billed Charges,1705.57,44.1,,230.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,3674.13,95,,140.448,Percent of Total Billed Charges,95% of Total Billed Charges,3867.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3403.4,88,,330.424,Percent of Total Billed Charges,88% of Total Billed Charges,3480.75,90,,133.056,Percent of Total Billed charges,90% of Total Billed Charges,1705.57,3867.5,
PROTEGE 6F 8X60X80  035,2780000251,CDM,278,RC,C1876,HCPCS,Outpatient,,,4135.75,2688.24,,4135.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3143.17,76,,112.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2977.74,72,,3113.6,Percent of Total Billed Charges,72% of Total Billed Charges,2977.74,72,,3113.6,Percent of Total Billed charges,72% of Total Billed Charges,4135.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2977.74,72,,3113.6,Percent of Total Billed Charges,72% of Total Billed Charges,2481.45,60,,2594.672,Percent of Total Billed Charges,60% of Total Billed Charges,3722.18,90,,45.248,Percent of Total Billed Charges,90% of Total Billed Charges,1861.09,45,,67.68,Percent of Total Billed Charges,45% of Total Billed Charges,3722.18,90,,133.056,Percent of Total Billed Charges,90% of Total billed Charges,4135.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4135.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4135.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2688.24,65,,3838.28,Percent of total Billed Charges,65% of Total Billed Charges,1823.87,44.1,,66.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,3928.96,95,,140.448,Percent of Total Billed Charges,95% of Total Billed Charges,4135.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3639.46,88,,5384.896,Percent of Total Billed Charges,88% of Total Billed Charges,3722.18,90,,133.056,Percent of Total Billed charges,90% of Total Billed Charges,1823.87,4135.75,
PROTEGE 6F 8X80X80  035,2780000252,CDM,278,RC,C1876,HCPCS,Outpatient,,,4135.75,2688.24,,4135.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3143.17,76,,397.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2977.74,72,,488.984,Percent of Total Billed Charges,72% of Total Billed Charges,2977.74,72,,488.984,Percent of Total Billed charges,72% of Total Billed Charges,4135.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2977.74,72,,488.984,Percent of Total Billed Charges,72% of Total Billed Charges,2481.45,60,,407.488,Percent of Total Billed Charges,60% of Total Billed Charges,3722.18,90,,46.048,Percent of Total Billed Charges,90% of Total Billed Charges,1861.09,45,,168.968,Percent of Total Billed Charges,45% of Total Billed Charges,3722.18,90,,470.88,Percent of Total Billed Charges,90% of Total billed Charges,4135.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4135.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4135.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2688.24,65,,6323.504,Percent of total Billed Charges,65% of Total Billed Charges,1823.87,44.1,,165.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,3928.96,95,,497.04,Percent of Total Billed Charges,95% of Total Billed Charges,4135.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3639.46,88,,50.448,Percent of Total Billed Charges,88% of Total Billed Charges,3722.18,90,,470.88,Percent of Total Billed charges,90% of Total Billed Charges,1823.87,4135.75,
PROTEGE 6F035 10X30 120CM STNT,2780000253,CDM,278,RC,C1876,HCPCS,Outpatient,,,5244.75,3409.09,,5244.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3986.01,76,,397.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3776.22,72,,2206.768,Percent of Total Billed Charges,72% of Total Billed Charges,3776.22,72,,2206.768,Percent of Total Billed charges,72% of Total Billed Charges,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3776.22,72,,2206.768,Percent of Total Billed Charges,72% of Total Billed Charges,3146.85,60,,1838.968,Percent of Total Billed Charges,60% of Total Billed Charges,4720.28,90,,46.048,Percent of Total Billed Charges,90% of Total Billed Charges,2360.14,45,,2753.64,Percent of Total Billed Charges,45% of Total Billed Charges,4720.28,90,,470.88,Percent of Total Billed Charges,90% of Total billed Charges,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3409.09,65,,1381.656,Percent of total Billed Charges,65% of Total Billed Charges,2312.93,44.1,,2698.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,4982.51,95,,497.04,Percent of Total Billed Charges,95% of Total Billed Charges,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4615.38,88,,47.168,Percent of Total Billed Charges,88% of Total Billed Charges,4720.28,90,,470.88,Percent of Total Billed charges,90% of Total Billed Charges,2312.93,5244.75,
PROTEGE 6F035 10X60 120CM STNT,2780000254,CDM,278,RC,C1876,HCPCS,Outpatient,,,5244.75,3409.09,,5244.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3986.01,76,,114.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3776.22,72,,875.72,Percent of Total Billed Charges,72% of Total Billed Charges,3776.22,72,,875.72,Percent of Total Billed charges,72% of Total Billed Charges,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3776.22,72,,875.72,Percent of Total Billed Charges,72% of Total Billed Charges,3146.85,60,,729.768,Percent of Total Billed Charges,60% of Total Billed Charges,4720.28,90,,593.76,Percent of Total Billed Charges,90% of Total Billed Charges,2360.14,45,,25.8,Percent of Total Billed Charges,45% of Total Billed Charges,4720.28,90,,135.36,Percent of Total Billed Charges,90% of Total billed Charges,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3409.09,65,,204.664,Percent of total Billed Charges,65% of Total Billed Charges,2312.93,44.1,,25.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,4982.51,95,,142.88,Percent of Total Billed Charges,95% of Total Billed Charges,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4615.38,88,,39.424,Percent of Total Billed Charges,88% of Total Billed Charges,4720.28,90,,135.36,Percent of Total Billed charges,90% of Total Billed Charges,2312.93,5244.75,
PROTEGE 6F035 12X30 120CM STNT,2780000255,CDM,278,RC,C1876,HCPCS,Outpatient,,,5244.75,3409.09,,5244.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3986.01,76,,285.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3776.22,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,3776.22,72,,109.864,Percent of Total Billed charges,72% of Total Billed Charges,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3776.22,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,3146.85,60,,91.552,Percent of Total Billed Charges,60% of Total Billed Charges,4720.28,90,,454.36,Percent of Total Billed Charges,90% of Total Billed Charges,2360.14,45,,24.12,Percent of Total Billed Charges,45% of Total Billed Charges,4720.28,90,,337.936,Percent of Total Billed Charges,90% of Total billed Charges,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3409.09,65,,970.592,Percent of total Billed Charges,65% of Total Billed Charges,2312.93,44.1,,23.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,4982.51,95,,356.704,Percent of Total Billed Charges,95% of Total Billed Charges,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4615.38,88,,49.672,Percent of Total Billed Charges,88% of Total Billed Charges,4720.28,90,,337.936,Percent of Total Billed charges,90% of Total Billed Charges,2312.93,5244.75,
PROTEGE 6F035 12X40 120CM STNT,2780000256,CDM,278,RC,C1876,HCPCS,Outpatient,,,5244.75,3409.09,,5244.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3986.01,76,,4650.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3776.22,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,3776.22,72,,227.344,Percent of Total Billed charges,72% of Total Billed Charges,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3776.22,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,3146.85,60,,189.456,Percent of Total Billed Charges,60% of Total Billed Charges,4720.28,90,,169.08,Percent of Total Billed Charges,90% of Total Billed Charges,2360.14,45,,20.16,Percent of Total Billed Charges,45% of Total Billed Charges,4720.28,90,,5507.28,Percent of Total Billed Charges,90% of Total billed Charges,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3409.09,65,,705.16,Percent of total Billed Charges,65% of Total Billed Charges,2312.93,44.1,,19.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,4982.51,95,,5813.24,Percent of Total Billed Charges,95% of Total Billed Charges,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4615.38,88,,44.24,Percent of Total Billed Charges,88% of Total Billed Charges,4720.28,90,,5507.28,Percent of Total Billed charges,90% of Total Billed Charges,2312.93,5244.75,
PROTEGE 6F035 14X30 120CM STNT,2780000257,CDM,278,RC,C1876,HCPCS,Outpatient,,,5244.75,3409.09,,5244.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3986.01,76,,43.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3776.22,72,,1360.256,Percent of Total Billed Charges,72% of Total Billed Charges,3776.22,72,,1360.256,Percent of Total Billed charges,72% of Total Billed Charges,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3776.22,72,,1360.256,Percent of Total Billed Charges,72% of Total Billed Charges,3146.85,60,,1133.552,Percent of Total Billed Charges,60% of Total Billed Charges,4720.28,90,,715.68,Percent of Total Billed Charges,90% of Total Billed Charges,2360.14,45,,25.4,Percent of Total Billed Charges,45% of Total Billed Charges,4720.28,90,,51.592,Percent of Total Billed Charges,90% of Total billed Charges,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3409.09,65,,346.848,Percent of total Billed Charges,65% of Total Billed Charges,2312.93,44.1,,24.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,4982.51,95,,54.464,Percent of Total Billed Charges,95% of Total Billed Charges,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4615.38,88,,45.024,Percent of Total Billed Charges,88% of Total Billed Charges,4720.28,90,,51.592,Percent of Total Billed charges,90% of Total Billed Charges,2312.93,5244.75,
PROTEGE 6F035 14X40 120CM STNT,2780000258,CDM,278,RC,C1876,HCPCS,Outpatient,,,5244.75,3409.09,,5244.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3986.01,76,,40.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3776.22,72,,8508.904,Percent of Total Billed Charges,72% of Total Billed Charges,3776.22,72,,8508.904,Percent of Total Billed charges,72% of Total Billed Charges,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3776.22,72,,8508.904,Percent of Total Billed Charges,72% of Total Billed Charges,3146.85,60,,7090.752,Percent of Total Billed Charges,60% of Total Billed Charges,4720.28,90,,12437.256,Percent of Total Billed Charges,90% of Total Billed Charges,2360.14,45,,22.624,Percent of Total Billed Charges,45% of Total Billed Charges,4720.28,90,,48.24,Percent of Total Billed Charges,90% of Total billed Charges,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3409.09,65,,722.928,Percent of total Billed Charges,65% of Total Billed Charges,2312.93,44.1,,22.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,4982.51,95,,50.92,Percent of Total Billed Charges,95% of Total Billed Charges,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4615.38,88,,45.024,Percent of Total Billed Charges,88% of Total Billed Charges,4720.28,90,,48.24,Percent of Total Billed charges,90% of Total Billed Charges,2312.93,5244.75,
PROTEGE 6F035 14X60 120CM STNT,2780000259,CDM,278,RC,C1876,HCPCS,Outpatient,,,5244.75,3409.09,,5244.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3986.01,76,,34.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3776.22,72,,69.856,Percent of Total Billed Charges,72% of Total Billed Charges,3776.22,72,,69.856,Percent of Total Billed charges,72% of Total Billed Charges,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3776.22,72,,69.856,Percent of Total Billed Charges,72% of Total Billed Charges,3146.85,60,,58.216,Percent of Total Billed Charges,60% of Total Billed Charges,4720.28,90,,3573.36,Percent of Total Billed Charges,90% of Total Billed Charges,2360.14,45,,23.024,Percent of Total Billed Charges,45% of Total Billed Charges,4720.28,90,,40.32,Percent of Total Billed Charges,90% of Total billed Charges,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3409.09,65,,291.808,Percent of total Billed Charges,65% of Total Billed Charges,2312.93,44.1,,22.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,4982.51,95,,42.56,Percent of Total Billed Charges,95% of Total Billed Charges,5244.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4615.38,88,,580.568,Percent of Total Billed Charges,88% of Total Billed Charges,4720.28,90,,40.32,Percent of Total Billed charges,90% of Total Billed Charges,2312.93,5244.75,
PROTG 6F 035 10X80 120 SE STNT,2780000260,CDM,278,RC,C1876,HCPCS,Outpatient,,,2785.75,1810.74,,2785.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2117.17,76,,42.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2005.74,72,,69.856,Percent of Total Billed Charges,72% of Total Billed Charges,2005.74,72,,69.856,Percent of Total Billed charges,72% of Total Billed Charges,2785.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2005.74,72,,69.856,Percent of Total Billed Charges,72% of Total Billed Charges,1671.45,60,,58.216,Percent of Total Billed Charges,60% of Total Billed Charges,2507.18,90,,1578.24,Percent of Total Billed Charges,90% of Total Billed Charges,1253.59,45,,23.024,Percent of Total Billed Charges,45% of Total Billed Charges,2507.18,90,,50.8,Percent of Total Billed Charges,90% of Total billed Charges,2785.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2785.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2785.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1810.74,65,,39.56,Percent of total Billed Charges,65% of Total Billed Charges,1228.52,44.1,,22.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,2646.46,95,,53.624,Percent of Total Billed Charges,95% of Total Billed Charges,2785.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2451.46,88,,444.256,Percent of Total Billed Charges,88% of Total Billed Charges,2507.18,90,,50.8,Percent of Total Billed charges,90% of Total Billed Charges,1228.52,2785.75,
PROTG 6F 035 12X80 120 SE STNT,2780000261,CDM,278,RC,C1876,HCPCS,Outpatient,,,2785.75,1810.74,,2785.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2117.17,76,,38.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2005.74,72,,111.768,Percent of Total Billed Charges,72% of Total Billed Charges,2005.74,72,,111.768,Percent of Total Billed charges,72% of Total Billed Charges,2785.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2005.74,72,,111.768,Percent of Total Billed Charges,72% of Total Billed Charges,1671.45,60,,93.136,Percent of Total Billed Charges,60% of Total Billed Charges,2507.18,90,,1690.56,Percent of Total Billed Charges,90% of Total Billed Charges,1253.59,45,,296.88,Percent of Total Billed Charges,45% of Total Billed Charges,2507.18,90,,45.248,Percent of Total Billed Charges,90% of Total billed Charges,2785.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2785.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2785.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1810.74,65,,86,Percent of total Billed Charges,65% of Total Billed Charges,1228.52,44.1,,290.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,2646.46,95,,47.76,Percent of Total Billed Charges,95% of Total Billed Charges,2785.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2451.46,88,,165.32,Percent of Total Billed Charges,88% of Total Billed Charges,2507.18,90,,45.248,Percent of Total Billed charges,90% of Total Billed Charges,1228.52,2785.75,
PROTG 6F 035 14X80 120 SE STNT,2780000262,CDM,278,RC,C1876,HCPCS,Outpatient,,,2785.75,1810.74,,2785.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2117.17,76,,38.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2005.74,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,2005.74,72,,14.608,Percent of Total Billed charges,72% of Total Billed Charges,2785.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2005.74,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,1671.45,60,,12.176,Percent of Total Billed Charges,60% of Total Billed Charges,2507.18,90,,3333.96,Percent of Total Billed Charges,90% of Total Billed Charges,1253.59,45,,227.176,Percent of Total Billed Charges,45% of Total Billed Charges,2507.18,90,,46.048,Percent of Total Billed Charges,90% of Total billed Charges,2785.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2785.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2785.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1810.74,65,,395,Percent of total Billed Charges,65% of Total Billed Charges,1228.52,44.1,,222.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,2646.46,95,,48.6,Percent of Total Billed Charges,95% of Total Billed Charges,2785.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2451.46,88,,699.776,Percent of Total Billed Charges,88% of Total Billed Charges,2507.18,90,,46.048,Percent of Total Billed charges,90% of Total Billed Charges,1228.52,2785.75,
RDRUN STIF 0.035X260CM ANG UNI,2780000263,CDM,278,RC,C1769,HCPCS,Outpatient,,,189.63,123.26,,189.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.12,76,,38.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,136.53,72,,1468.848,Percent of Total Billed Charges,72% of Total Billed Charges,136.53,72,,1468.848,Percent of Total Billed charges,72% of Total Billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.53,72,,1468.848,Percent of Total Billed Charges,72% of Total Billed Charges,113.78,60,,1224.04,Percent of Total Billed Charges,60% of Total Billed Charges,170.67,90,,3333.96,Percent of Total Billed Charges,90% of Total Billed Charges,85.33,45,,84.536,Percent of Total Billed Charges,45% of Total Billed Charges,170.67,90,,46.048,Percent of Total Billed Charges,90% of Total billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.26,65,,1027.352,Percent of total Billed Charges,65% of Total Billed Charges,83.63,44.1,,82.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,180.15,95,,48.6,Percent of Total Billed Charges,95% of Total Billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.87,88,,12160.872,Percent of Total Billed Charges,88% of Total Billed Charges,170.67,90,,46.048,Percent of Total Billed charges,90% of Total Billed Charges,83.63,189.63,
LNQ11 REVEAL INJ LOOP RECORDER,2780000265,CDM,278,RC,C1764,HCPCS,Outpatient,,,11068.00,7194.20,,11068,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8411.68,76,,501.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7968.96,72,,487.08,Percent of Total Billed Charges,72% of Total Billed Charges,7968.96,72,,487.08,Percent of Total Billed charges,72% of Total Billed Charges,11068,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7968.96,72,,487.08,Percent of Total Billed Charges,72% of Total Billed Charges,6640.8,60,,405.896,Percent of Total Billed Charges,60% of Total Billed Charges,9961.2,90,,5314.536,Percent of Total Billed Charges,90% of Total Billed Charges,4980.6,45,,357.84,Percent of Total Billed Charges,45% of Total Billed Charges,9961.2,90,,593.76,Percent of Total Billed Charges,90% of Total billed Charges,11068,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11068,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11068,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7194.2,65,,1121.376,Percent of total Billed Charges,65% of Total Billed Charges,4880.99,44.1,,350.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,10514.6,95,,626.752,Percent of Total Billed Charges,95% of Total Billed Charges,11068,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9739.84,88,,3493.952,Percent of Total Billed Charges,88% of Total Billed Charges,9961.2,90,,593.76,Percent of Total Billed charges,90% of Total Billed Charges,4880.99,11068,
RUNWAY GUIDE 6FR LFT BU 5 CATH,2780000266,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,383.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,487.08,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,487.08,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,487.08,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,405.896,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,8755.616,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,6218.632,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,454.36,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,296.976,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,6094.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,479.6,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,1543.168,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,454.36,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
RX ULTRA 4.5X28 MM BAREMETAL S,2780000269,CDM,278,RC,C1876,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,142.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,2874.192,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,2874.192,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,2874.192,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,2395.16,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,1913.064,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,1786.68,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,169.08,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,299.264,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,1750.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,178.472,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,1652.992,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,169.08,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX ULTRA 4.5X38MM BARMETAL STE,2780000270,CDM,278,RC,C1876,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,604.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,2792.912,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,2792.912,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,2792.912,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,2327.424,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,283.384,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,789.12,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,715.68,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,485.016,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,773.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,755.44,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,3259.872,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,715.68,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX ULTRA 5.0X13MM BAR MET STN,2780000271,CDM,278,RC,C1876,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,10502.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,3986.784,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,3986.784,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,3986.784,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,3322.32,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,124.624,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,845.28,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,12437.256,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,280.92,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,828.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,13128.216,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,3259.872,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,12437.256,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX ULTRA 5.0X18MM BARE METAL S,2780000272,CDM,278,RC,C1876,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,3017.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,487.08,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,487.08,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,487.08,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,405.896,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,124.624,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,1666.984,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,3573.36,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,1768.056,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,1633.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,3771.88,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,5196.432,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,3573.36,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX ULTRA 5.028MM BARE METAL ST,2780000273,CDM,278,RC,C1876,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,1332.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,487.08,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,487.08,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,487.08,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,405.896,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,95.256,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,1666.984,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,1578.24,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,206.392,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,1633.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,1665.92,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,8561.048,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,1578.24,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX X XPEDIT 3.25 X 8 D.E. STNT,2780000275,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,1427.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,751.256,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,751.256,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,751.256,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,626.048,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,124.624,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,2657.272,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,1690.56,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,166.832,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,2604.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,1784.48,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,1870.552,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,1690.56,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX X XPEDITION 3.25X12 DE STNT,2780000276,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,2815.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,751.256,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,751.256,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,751.256,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,626.048,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,1343.904,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,4377.808,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,3333.96,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,63.064,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,4290.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,3519.184,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,277.088,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,3333.96,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX X XPEDITION 3.25X15 DE STNT,2780000277,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,2815.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,12605.544,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,12605.544,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,12605.544,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,10504.624,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,976.376,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,956.528,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,3333.96,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,56.184,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,937.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,3519.184,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,121.856,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,3333.96,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX X XPEDITION 3.25X18 DE STNT,2780000278,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,4487.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,13840.696,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,13840.696,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,13840.696,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,11533.912,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,480.248,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,141.696,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,5314.536,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,463.224,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,138.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,5609.792,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,121.856,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,5314.536,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX X XPEDITION 3.25X23 DE STNT,2780000279,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,7393.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,270.528,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,270.528,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,270.528,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,225.44,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,1000.984,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,62.312,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,8755.616,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,802.624,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,61.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,9242.04,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,93.136,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,8755.616,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX X XPEDITION 3.25X28 DE STNT,2780000280,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,1615.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,751.256,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,751.256,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,751.256,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,626.048,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,404.04,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,62.312,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,1913.064,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,379.528,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,61.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,2019.344,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,121.856,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,1913.064,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
SCRUB STERILIUM RUB 1000 ML EA,2780000281,CDM,278,RC,,,Outpatient,,,160.97,104.63,,160.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,122.34,76,,239.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,115.9,72,,6637.44,Percent of Total Billed Charges,72% of Total Billed Charges,115.9,72,,6637.44,Percent of Total Billed charges,72% of Total Billed Charges,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.9,72,,6637.44,Percent of Total Billed Charges,72% of Total Billed Charges,96.58,60,,5531.2,Percent of Total Billed Charges,60% of Total Billed Charges,144.87,90,,54.768,Percent of Total Billed Charges,90% of Total Billed Charges,72.44,45,,47.632,Percent of Total Billed Charges,45% of Total Billed Charges,144.87,90,,283.384,Percent of Total Billed Charges,90% of Total billed Charges,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.63,65,,726.376,Percent of total Billed Charges,65% of Total Billed Charges,70.99,44.1,,46.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,152.92,95,,299.128,Percent of Total Billed Charges,95% of Total Billed Charges,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.65,88,,1314.04,Percent of Total Billed Charges,88% of Total Billed Charges,144.87,90,,283.384,Percent of Total Billed charges,90% of Total Billed Charges,70.99,160.97,
SEMITENDONO TENDN ALOGRFT 5.0,2780000282,CDM,278,RC,C1713,HCPCS,Outpatient,,,4260.00,2769.00,,4260,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3237.6,76,,105.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3067.2,72,,249.568,Percent of Total Billed Charges,72% of Total Billed Charges,3067.2,72,,249.568,Percent of Total Billed charges,72% of Total Billed Charges,4260,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3067.2,72,,249.568,Percent of Total Billed Charges,72% of Total Billed Charges,2556,60,,207.976,Percent of Total Billed Charges,60% of Total Billed Charges,3834,90,,119.072,Percent of Total Billed Charges,90% of Total Billed Charges,1917,45,,62.312,Percent of Total Billed Charges,45% of Total Billed Charges,3834,90,,124.624,Percent of Total Billed Charges,90% of Total billed Charges,4260,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4260,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4260,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2769,65,,1055.448,Percent of total Billed Charges,65% of Total Billed Charges,1878.66,44.1,,61.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,4047,95,,131.552,Percent of Total Billed Charges,95% of Total Billed Charges,4260,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3748.8,88,,954.68,Percent of Total Billed Charges,88% of Total Billed Charges,3834,90,,124.624,Percent of Total Billed charges,90% of Total Billed Charges,1878.66,4260,
SILVERHWK SH DS DIST VES TIP,2780000283,CDM,272,RC,C1714,HCPCS,Outpatient,,,7397.78,4808.56,,7397.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5622.31,76,,105.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5326.4,72,,8322.2,Percent of Total Billed Charges,72% of Total Billed Charges,5548.34,75,,8322.2,Percent of Total Billed charges,75% of Total Billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5326.4,72,,8322.2,Percent of Total Billed Charges,72% of Total Billed Charges,4438.67,60,,6935.168,Percent of Total Billed Charges,60% of Total Billed Charges,6658,90,,546.928,Percent of Total Billed Charges,90% of Total Billed Charges,3329,45,,671.952,Percent of Total Billed Charges,45% of Total Billed Charges,6658,90,,124.624,Percent of Total Billed Charges,90% of Total billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4808.56,65,,703.44,Percent of total Billed Charges,65% of Total Billed Charges,3262.42,44.1,,658.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,7027.89,95,,131.552,Percent of Total Billed Charges,95% of Total Billed Charges,7397.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6510.05,88,,469.576,Percent of Total Billed Charges,88% of Total Billed Charges,6658,90,,124.624,Percent of Total Billed charges,90% of Total Billed Charges,3262.42,7397.78,
S&N HEALCOIL 4.5 TAPE,2780000284,CDM,278,RC,C1713,HCPCS,Outpatient,,,1844.85,1199.15,,1844.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1402.09,76,,80.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1328.29,72,,437.544,Percent of Total Billed Charges,72% of Total Billed Charges,1328.29,72,,437.544,Percent of Total Billed charges,72% of Total Billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1328.29,72,,437.544,Percent of Total Billed Charges,72% of Total Billed Charges,1106.91,60,,364.616,Percent of Total Billed Charges,60% of Total Billed Charges,1660.37,90,,1422.488,Percent of Total Billed Charges,90% of Total Billed Charges,830.18,45,,488.192,Percent of Total Billed Charges,45% of Total Billed Charges,1660.37,90,,95.256,Percent of Total Billed Charges,90% of Total billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1199.15,65,,305.568,Percent of total Billed Charges,65% of Total Billed Charges,813.58,44.1,,478.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,1752.61,95,,100.552,Percent of Total Billed Charges,95% of Total Billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1623.47,88,,978.736,Percent of Total Billed Charges,88% of Total Billed Charges,1660.37,90,,95.256,Percent of Total Billed charges,90% of Total Billed Charges,813.58,1844.85,
S&N HEALCOIL 4.5 TAPE,2780000285,CDM,278,RC,C1713,HCPCS,Outpatient,,,1844.85,1199.15,,1844.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1402.09,76,,105.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1328.29,72,,1870.192,Percent of Total Billed Charges,72% of Total Billed Charges,1328.29,72,,1870.192,Percent of Total Billed charges,72% of Total Billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1328.29,72,,1870.192,Percent of Total Billed Charges,72% of Total Billed Charges,1106.91,60,,1558.496,Percent of Total Billed Charges,60% of Total Billed Charges,1660.37,90,,1552.672,Percent of Total Billed Charges,90% of Total Billed Charges,830.18,45,,240.12,Percent of Total Billed Charges,45% of Total Billed Charges,1660.37,90,,124.624,Percent of Total Billed Charges,90% of Total billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1199.15,65,,82.552,Percent of total Billed Charges,65% of Total Billed Charges,813.58,44.1,,235.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,1752.61,95,,131.552,Percent of Total Billed Charges,95% of Total Billed Charges,1844.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1623.47,88,,395.064,Percent of Total Billed Charges,88% of Total Billed Charges,1660.37,90,,124.624,Percent of Total Billed charges,90% of Total Billed Charges,813.58,1844.85,
SNARE 6F 15 LOOPS 120 GOOSENK,2780000286,CDM,272,RC,C1773,HCPCS,Outpatient,,,609.00,395.85,,609,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,462.84,76,,1134.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,438.48,72,,50.168,Percent of Total Billed Charges,72% of Total Billed Charges,456.75,75,,50.168,Percent of Total Billed charges,75% of Total Billed Charges,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,438.48,72,,50.168,Percent of Total Billed Charges,72% of Total Billed Charges,365.4,60,,41.808,Percent of Total Billed Charges,60% of Total Billed Charges,548.1,90,,411.192,Percent of Total Billed Charges,90% of Total Billed Charges,274.05,45,,500.488,Percent of Total Billed Charges,45% of Total Billed Charges,548.1,90,,1343.904,Percent of Total Billed Charges,90% of Total billed Charges,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,395.85,65,,98.608,Percent of total Billed Charges,65% of Total Billed Charges,268.57,44.1,,490.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,578.55,95,,1418.56,Percent of Total Billed Charges,95% of Total Billed Charges,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.92,88,,53.552,Percent of Total Billed Charges,88% of Total Billed Charges,548.1,90,,1343.904,Percent of Total Billed charges,90% of Total Billed Charges,268.57,609,
STKR BNE SCW T100 THD3.5MM/L30,2780000287,CDM,278,RC,C1713,HCPCS,Outpatient,,,419.00,272.35,,419,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,318.44,76,,824.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,301.68,72,,3885.176,Percent of Total Billed Charges,72% of Total Billed Charges,301.68,72,,3885.176,Percent of Total Billed charges,72% of Total Billed Charges,419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.68,72,,3885.176,Percent of Total Billed Charges,72% of Total Billed Charges,251.4,60,,3237.648,Percent of Total Billed Charges,60% of Total Billed Charges,377.1,90,,414.368,Percent of Total Billed Charges,90% of Total Billed Charges,188.55,45,,202.024,Percent of Total Billed Charges,45% of Total Billed Charges,377.1,90,,976.376,Percent of Total Billed Charges,90% of Total billed Charges,419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.35,65,,24.656,Percent of total Billed Charges,65% of Total Billed Charges,184.78,44.1,,197.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,398.05,95,,1030.624,Percent of Total Billed Charges,95% of Total Billed Charges,419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.72,88,,116.424,Percent of Total Billed Charges,88% of Total Billed Charges,377.1,90,,976.376,Percent of Total Billed charges,90% of Total Billed Charges,184.78,419,
STRKER SC T10 FTHD 3.5MM/L30MM,2780000288,CDM,278,RC,C1713,HCPCS,Outpatient,,,771.00,501.15,,771,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,585.96,76,,405.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,555.12,72,,396.264,Percent of Total Billed Charges,72% of Total Billed Charges,555.12,72,,396.264,Percent of Total Billed charges,72% of Total Billed Charges,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.12,72,,396.264,Percent of Total Billed Charges,72% of Total Billed Charges,462.6,60,,330.224,Percent of Total Billed Charges,60% of Total Billed Charges,693.9,90,,671.56,Percent of Total Billed Charges,90% of Total Billed Charges,346.95,45,,27.384,Percent of Total Billed Charges,45% of Total Billed Charges,693.9,90,,480.248,Percent of Total Billed Charges,90% of Total billed Charges,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.15,65,,606.552,Percent of total Billed Charges,65% of Total Billed Charges,340.01,44.1,,26.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,732.45,95,,506.928,Percent of Total Billed Charges,95% of Total Billed Charges,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678.48,88,,534.776,Percent of Total Billed Charges,88% of Total Billed Charges,693.9,90,,480.248,Percent of Total Billed charges,90% of Total Billed Charges,340.01,771,
STRKER SC T10 FTHD 3.5MM/L36MM,2780000289,CDM,278,RC,C1713,HCPCS,Outpatient,,,771.00,501.15,,771,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,585.96,76,,845.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,555.12,72,,396.264,Percent of Total Billed Charges,72% of Total Billed Charges,555.12,72,,396.264,Percent of Total Billed charges,72% of Total Billed Charges,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.12,72,,396.264,Percent of Total Billed Charges,72% of Total Billed Charges,462.6,60,,330.224,Percent of Total Billed Charges,60% of Total Billed Charges,693.9,90,,388.968,Percent of Total Billed Charges,90% of Total Billed Charges,346.95,45,,59.536,Percent of Total Billed Charges,45% of Total Billed Charges,693.9,90,,1000.984,Percent of Total Billed Charges,90% of Total billed Charges,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.15,65,,230.472,Percent of total Billed Charges,65% of Total Billed Charges,340.01,44.1,,58.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,732.45,95,,1056.592,Percent of Total Billed Charges,95% of Total Billed Charges,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678.48,88,,1390.88,Percent of Total Billed Charges,88% of Total Billed Charges,693.9,90,,1000.984,Percent of Total Billed charges,90% of Total Billed Charges,340.01,771,
STRKER SC T10 FTHD 3.5MM/L40MM,2780000290,CDM,278,RC,C1713,HCPCS,Outpatient,,,771.00,501.15,,771,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,585.96,76,,341.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,555.12,72,,288.944,Percent of Total Billed Charges,72% of Total Billed Charges,555.12,72,,288.944,Percent of Total Billed charges,72% of Total Billed Charges,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.12,72,,288.944,Percent of Total Billed Charges,72% of Total Billed Charges,462.6,60,,240.784,Percent of Total Billed Charges,60% of Total Billed Charges,693.9,90,,2448.08,Percent of Total Billed Charges,90% of Total Billed Charges,346.95,45,,273.464,Percent of Total Billed Charges,45% of Total Billed Charges,693.9,90,,404.04,Percent of Total Billed Charges,90% of Total billed Charges,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.15,65,,459.792,Percent of total Billed Charges,65% of Total Billed Charges,340.01,44.1,,267.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,732.45,95,,426.488,Percent of Total Billed Charges,95% of Total Billed Charges,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678.48,88,,1518.168,Percent of Total Billed Charges,88% of Total Billed Charges,693.9,90,,404.04,Percent of Total Billed charges,90% of Total Billed Charges,340.01,771,
STRKR BNESCW T10 THD 3.5MM/L36,2780000291,CDM,278,RC,C1713,HCPCS,Outpatient,,,419.00,272.35,,419,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,318.44,76,,46.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,301.68,72,,111.768,Percent of Total Billed Charges,72% of Total Billed Charges,301.68,72,,111.768,Percent of Total Billed charges,72% of Total Billed Charges,419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.68,72,,111.768,Percent of Total Billed Charges,72% of Total Billed Charges,251.4,60,,93.136,Percent of Total Billed Charges,60% of Total Billed Charges,377.1,90,,285.768,Percent of Total Billed Charges,90% of Total Billed Charges,188.55,45,,711.248,Percent of Total Billed Charges,45% of Total Billed Charges,377.1,90,,54.768,Percent of Total Billed Charges,90% of Total billed Charges,419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.35,65,,98.608,Percent of total Billed Charges,65% of Total Billed Charges,184.78,44.1,,697.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,398.05,95,,57.816,Percent of Total Billed Charges,95% of Total Billed Charges,419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.72,88,,402.056,Percent of Total Billed Charges,88% of Total Billed Charges,377.1,90,,54.768,Percent of Total Billed charges,90% of Total Billed Charges,184.78,419,
STRYKER DISTAL LAT FIB PLTE 4H,2780000292,CDM,278,RC,C1713,HCPCS,Outpatient,,,2678.00,1740.70,,2678,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2035.28,76,,100.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1928.16,72,,312.44,Percent of Total Billed Charges,72% of Total Billed Charges,1928.16,72,,312.44,Percent of Total Billed charges,72% of Total Billed Charges,2678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1928.16,72,,312.44,Percent of Total Billed Charges,72% of Total Billed Charges,1606.8,60,,260.368,Percent of Total Billed Charges,60% of Total Billed Charges,2410.2,90,,231,Percent of Total Billed Charges,90% of Total Billed Charges,1205.1,45,,776.336,Percent of Total Billed Charges,45% of Total Billed Charges,2410.2,90,,119.072,Percent of Total Billed Charges,90% of Total billed Charges,2678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1740.7,65,,98.608,Percent of total Billed Charges,65% of Total Billed Charges,1181,44.1,,760.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,2544.1,95,,125.688,Percent of Total Billed Charges,95% of Total Billed Charges,2678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2356.64,88,,405.16,Percent of Total Billed Charges,88% of Total Billed Charges,2410.2,90,,119.072,Percent of Total Billed charges,90% of Total Billed Charges,1181,2678,
TESIO 10FRX52CM DIALYSIS CATH,2780000295,CDM,278,RC,C1752,HCPCS,Outpatient,,,1455.30,945.95,,1455.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1106.03,76,,461.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1047.82,72,,1904.488,Percent of Total Billed Charges,72% of Total Billed Charges,1047.82,72,,1904.488,Percent of Total Billed charges,72% of Total Billed Charges,1455.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1047.82,72,,1904.488,Percent of Total Billed Charges,72% of Total Billed Charges,873.18,60,,1587.072,Percent of Total Billed Charges,60% of Total Billed Charges,1309.77,90,,87.32,Percent of Total Billed Charges,90% of Total Billed Charges,654.89,45,,205.6,Percent of Total Billed Charges,45% of Total Billed Charges,1309.77,90,,546.928,Percent of Total Billed Charges,90% of Total billed Charges,1455.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1455.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1455.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,945.95,65,,376.088,Percent of total Billed Charges,65% of Total Billed Charges,641.79,44.1,,201.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,1382.54,95,,577.312,Percent of Total Billed Charges,95% of Total Billed Charges,1455.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1280.66,88,,656.632,Percent of Total Billed Charges,88% of Total Billed Charges,1309.77,90,,546.928,Percent of Total Billed charges,90% of Total Billed Charges,641.79,1455.3,
TIGER 5F RADIAL 4.0 100CM,2780000296,CDM,272,RC,C1887,HCPCS,Outpatient,,,180.81,117.53,,180.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,137.42,76,,1201.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,130.18,72,,86.368,Percent of Total Billed Charges,72% of Total Billed Charges,135.61,75,,86.368,Percent of Total Billed charges,75% of Total Billed Charges,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.18,72,,86.368,Percent of Total Billed Charges,72% of Total Billed Charges,108.49,60,,71.968,Percent of Total Billed Charges,60% of Total Billed Charges,162.73,90,,77.8,Percent of Total Billed Charges,90% of Total Billed Charges,81.36,45,,207.184,Percent of Total Billed Charges,45% of Total Billed Charges,162.73,90,,1422.488,Percent of Total Billed Charges,90% of Total billed Charges,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.53,65,,91.728,Percent of total Billed Charges,65% of Total Billed Charges,79.74,44.1,,203.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,171.77,95,,1501.52,Percent of Total Billed Charges,95% of Total Billed Charges,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.11,88,,380.32,Percent of Total Billed Charges,88% of Total Billed Charges,162.73,90,,1422.488,Percent of Total Billed charges,90% of Total Billed Charges,79.74,180.81,
TIGER 5F RADIAL 4.0 110CM,2780000297,CDM,272,RC,C1887,HCPCS,Outpatient,,,180.81,117.53,,180.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,137.42,76,,1311.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,130.18,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,135.61,75,,6.352,Percent of Total Billed charges,75% of Total Billed Charges,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.18,72,,6.352,Percent of Total Billed Charges,72% of Total Billed Charges,108.49,60,,5.296,Percent of Total Billed Charges,60% of Total Billed Charges,162.73,90,,641.392,Percent of Total Billed Charges,90% of Total Billed Charges,81.36,45,,335.776,Percent of Total Billed Charges,45% of Total Billed Charges,162.73,90,,1552.672,Percent of Total Billed Charges,90% of Total billed Charges,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.53,65,,292.384,Percent of total Billed Charges,65% of Total Billed Charges,79.74,44.1,,329.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,171.77,95,,1638.936,Percent of Total Billed Charges,95% of Total Billed Charges,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.11,88,,2393.68,Percent of Total Billed Charges,88% of Total Billed Charges,162.73,90,,1552.672,Percent of Total Billed charges,90% of Total Billed Charges,79.74,180.81,
UN 7F 24CM URETER STNT W/C1769,2780000298,CDM,278,RC,C2617,HCPCS,Outpatient,,,589.84,383.40,,589.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,448.28,76,,347.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,424.68,72,,929.064,Percent of Total Billed Charges,72% of Total Billed Charges,424.68,72,,929.064,Percent of Total Billed charges,72% of Total Billed Charges,589.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.68,72,,929.064,Percent of Total Billed Charges,72% of Total Billed Charges,353.9,60,,774.224,Percent of Total Billed Charges,60% of Total Billed Charges,530.86,90,,1111.32,Percent of Total Billed Charges,90% of Total Billed Charges,265.43,45,,194.48,Percent of Total Billed Charges,45% of Total Billed Charges,530.86,90,,411.192,Percent of Total Billed Charges,90% of Total billed Charges,589.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,589.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,589.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,383.4,65,,412.208,Percent of total Billed Charges,65% of Total Billed Charges,260.12,44.1,,190.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,560.35,95,,434.04,Percent of Total Billed Charges,95% of Total Billed Charges,589.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,519.06,88,,279.416,Percent of Total Billed Charges,88% of Total Billed Charges,530.86,90,,411.192,Percent of Total Billed charges,90% of Total Billed Charges,260.12,589.84,
UN 7F 26CM URETER STNT W/C1769,2780000299,CDM,278,RC,C2617,HCPCS,Outpatient,,,589.84,383.40,,589.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,448.28,76,,349.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,424.68,72,,137.168,Percent of Total Billed Charges,72% of Total Billed Charges,424.68,72,,137.168,Percent of Total Billed charges,72% of Total Billed Charges,589.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.68,72,,137.168,Percent of Total Billed Charges,72% of Total Billed Charges,353.9,60,,114.304,Percent of Total Billed Charges,60% of Total Billed Charges,530.86,90,,525.496,Percent of Total Billed Charges,90% of Total Billed Charges,265.43,45,,1224.04,Percent of Total Billed Charges,45% of Total Billed Charges,530.86,90,,414.368,Percent of Total Billed Charges,90% of Total billed Charges,589.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,589.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,589.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,383.4,65,,224.736,Percent of total Billed Charges,65% of Total Billed Charges,260.12,44.1,,1199.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,560.35,95,,437.384,Percent of Total Billed Charges,95% of Total Billed Charges,589.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,519.06,88,,225.864,Percent of Total Billed Charges,88% of Total Billed Charges,530.86,90,,414.368,Percent of Total Billed charges,90% of Total Billed Charges,260.12,589.84,
UN 8F 24CM URETER STNT W/C1769,2780000300,CDM,278,RC,C2617,HCPCS,Outpatient,,,589.84,383.40,,589.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,448.28,76,,567.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,424.68,72,,55.88,Percent of Total Billed Charges,72% of Total Billed Charges,424.68,72,,55.88,Percent of Total Billed charges,72% of Total Billed Charges,589.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.68,72,,55.88,Percent of Total Billed Charges,72% of Total Billed Charges,353.9,60,,46.568,Percent of Total Billed Charges,60% of Total Billed Charges,530.86,90,,1005.744,Percent of Total Billed Charges,90% of Total Billed Charges,265.43,45,,142.888,Percent of Total Billed Charges,45% of Total Billed Charges,530.86,90,,671.56,Percent of Total Billed Charges,90% of Total billed Charges,589.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,589.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,589.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,383.4,65,,128.416,Percent of total Billed Charges,65% of Total Billed Charges,260.12,44.1,,140.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,560.35,95,,708.864,Percent of Total Billed Charges,95% of Total Billed Charges,589.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,519.06,88,,85.384,Percent of Total Billed Charges,88% of Total Billed Charges,530.86,90,,671.56,Percent of Total Billed charges,90% of Total Billed Charges,260.12,589.84,
UN 8F 26CM URETER STNT W/C1769,2780000301,CDM,278,RC,C2617,HCPCS,Outpatient,,,589.84,383.40,,589.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,448.28,76,,328.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,424.68,72,,55.88,Percent of Total Billed Charges,72% of Total Billed Charges,424.68,72,,55.88,Percent of Total Billed charges,72% of Total Billed Charges,589.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.68,72,,55.88,Percent of Total Billed Charges,72% of Total Billed Charges,353.9,60,,46.568,Percent of Total Billed Charges,60% of Total Billed Charges,530.86,90,,1461.384,Percent of Total Billed Charges,90% of Total Billed Charges,265.43,45,,115.496,Percent of Total Billed Charges,45% of Total Billed Charges,530.86,90,,388.968,Percent of Total Billed Charges,90% of Total billed Charges,589.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,589.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,589.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,383.4,65,,320.48,Percent of total Billed Charges,65% of Total Billed Charges,260.12,44.1,,113.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,560.35,95,,410.576,Percent of Total Billed Charges,95% of Total Billed Charges,589.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,519.06,88,,76.064,Percent of Total Billed Charges,88% of Total Billed Charges,530.86,90,,388.968,Percent of Total Billed charges,90% of Total Billed Charges,260.12,589.84,
VENA TECH LP 7F IVC FILTER IMP,2780000302,CDM,278,RC,C1880,HCPCS,Outpatient,,,4550.00,2957.50,,4550,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3458,76,,2067.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3276,72,,183.528,Percent of Total Billed Charges,72% of Total Billed Charges,3276,72,,183.528,Percent of Total Billed charges,72% of Total Billed Charges,4550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3276,72,,183.528,Percent of Total Billed Charges,72% of Total Billed Charges,2730,60,,152.936,Percent of Total Billed Charges,60% of Total Billed Charges,4095,90,,973.992,Percent of Total Billed Charges,90% of Total Billed Charges,2047.5,45,,43.664,Percent of Total Billed Charges,45% of Total Billed Charges,4095,90,,2448.08,Percent of Total Billed Charges,90% of Total billed Charges,4550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2957.5,65,,405.328,Percent of total Billed Charges,65% of Total Billed Charges,2006.55,44.1,,42.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,4322.5,95,,2584.08,Percent of Total Billed Charges,95% of Total Billed Charges,4550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4004,88,,627.136,Percent of Total Billed Charges,88% of Total Billed Charges,4095,90,,2448.08,Percent of Total Billed charges,90% of Total Billed Charges,2006.55,4550,
VENTRICULAR PAC W/ RT HRT CURV,2780000303,CDM,278,RC,,,Outpatient,,,191.01,124.16,,191.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,145.17,76,,241.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,137.53,72,,223.536,Percent of Total Billed Charges,72% of Total Billed Charges,137.53,72,,223.536,Percent of Total Billed charges,72% of Total Billed Charges,191.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.53,72,,223.536,Percent of Total Billed Charges,72% of Total Billed Charges,114.61,60,,186.28,Percent of Total Billed Charges,60% of Total Billed Charges,171.91,90,,423.096,Percent of Total Billed Charges,90% of Total Billed Charges,85.95,45,,38.896,Percent of Total Billed Charges,45% of Total Billed Charges,171.91,90,,285.768,Percent of Total Billed Charges,90% of Total billed Charges,191.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.16,65,,388.12,Percent of total Billed Charges,65% of Total Billed Charges,84.24,44.1,,38.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,181.46,95,,301.648,Percent of Total Billed Charges,95% of Total Billed Charges,191.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.09,88,,1086.624,Percent of Total Billed Charges,88% of Total Billed Charges,171.91,90,,285.768,Percent of Total Billed charges,90% of Total Billed Charges,84.24,191.01,
VISI BAL EXP STNT 035 6X27X135,2780000304,CDM,278,RC,C1876,HCPCS,Outpatient,,,3685.50,2395.58,,3685.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2800.98,76,,195.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2653.56,72,,575.984,Percent of Total Billed Charges,72% of Total Billed Charges,2653.56,72,,575.984,Percent of Total Billed charges,72% of Total Billed Charges,3685.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2653.56,72,,575.984,Percent of Total Billed Charges,72% of Total Billed Charges,2211.3,60,,479.984,Percent of Total Billed Charges,60% of Total Billed Charges,3316.95,90,,114.304,Percent of Total Billed Charges,90% of Total Billed Charges,1658.48,45,,320.696,Percent of Total Billed Charges,45% of Total Billed Charges,3316.95,90,,231,Percent of Total Billed Charges,90% of Total billed Charges,3685.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3685.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3685.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2395.58,65,,370.928,Percent of total Billed Charges,65% of Total Billed Charges,1625.31,44.1,,314.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,3501.23,95,,243.832,Percent of Total Billed Charges,95% of Total Billed Charges,3685.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3243.24,88,,513.824,Percent of Total Billed Charges,88% of Total Billed Charges,3316.95,90,,231,Percent of Total Billed charges,90% of Total Billed Charges,1625.31,3685.5,
VISTABRITE 6F XBLAD 3.5 CATH,2780000305,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,73.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,575.984,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,575.984,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,575.984,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,479.984,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,136.536,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,555.664,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,87.32,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,388.12,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,544.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,92.176,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,983.4,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,87.32,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
VISTABRITE 6F XBLAD 4.5 CATH,2780000306,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,65.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,575.984,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,575.984,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,575.984,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,479.984,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,34.136,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,262.752,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,77.8,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,197.784,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,257.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,82.12,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,1428.912,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,77.8,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
WM FLX HIN TOE IMPLSZ4 WGROMET,2780000307,CDM,278,RC,L8642,HCPCS,Outpatient,,,4260.00,2769.00,,4260,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3237.6,76,,541.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3067.2,72,,575.984,Percent of Total Billed Charges,72% of Total Billed Charges,3067.2,72,,575.984,Percent of Total Billed charges,72% of Total Billed Charges,4260,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3067.2,72,,575.984,Percent of Total Billed Charges,72% of Total Billed Charges,2556,60,,479.984,Percent of Total Billed Charges,60% of Total Billed Charges,3834,90,,839.848,Percent of Total Billed Charges,90% of Total Billed Charges,1917,45,,502.872,Percent of Total Billed Charges,45% of Total Billed Charges,3834,90,,641.392,Percent of Total Billed Charges,90% of Total billed Charges,4260,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4260,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4260,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2769,65,,320.48,Percent of total Billed Charges,65% of Total Billed Charges,1878.66,44.1,,492.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,4047,95,,677.024,Percent of Total Billed Charges,95% of Total Billed Charges,4260,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3748.8,88,,952.352,Percent of Total Billed Charges,88% of Total Billed Charges,3834,90,,641.392,Percent of Total Billed charges,90% of Total Billed Charges,1878.66,4260,
Z 225242012 FEMRECN NL 12X42,2780000308,CDM,278,RC,C1713,HCPCS,Outpatient,,,2867.55,1863.91,,2867.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2179.34,76,,938.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2064.64,72,,575.984,Percent of Total Billed Charges,72% of Total Billed Charges,2064.64,72,,575.984,Percent of Total Billed charges,72% of Total Billed Charges,2867.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2064.64,72,,575.984,Percent of Total Billed Charges,72% of Total Billed Charges,1720.53,60,,479.984,Percent of Total Billed Charges,60% of Total Billed Charges,2580.8,90,,319.112,Percent of Total Billed Charges,90% of Total Billed Charges,1290.4,45,,730.696,Percent of Total Billed Charges,45% of Total Billed Charges,2580.8,90,,1111.32,Percent of Total Billed Charges,90% of Total billed Charges,2867.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2867.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2867.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1863.91,65,,405.328,Percent of total Billed Charges,65% of Total Billed Charges,1264.59,44.1,,716.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,2724.17,95,,1173.064,Percent of Total Billed Charges,95% of Total Billed Charges,2867.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2523.44,88,,413.688,Percent of Total Billed Charges,88% of Total Billed Charges,2580.8,90,,1111.32,Percent of Total Billed charges,90% of Total Billed Charges,1264.59,2867.55,
Z00597000025 PSI PERS CRPINGDE,2780000309,CDM,278,RC,C1713,HCPCS,Outpatient,,,6639.00,4315.35,,6639,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5045.64,76,,443.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4780.08,72,,4887.264,Percent of Total Billed Charges,72% of Total Billed Charges,4780.08,72,,4887.264,Percent of Total Billed charges,72% of Total Billed Charges,6639,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4780.08,72,,4887.264,Percent of Total Billed Charges,72% of Total Billed Charges,3983.4,60,,4072.72,Percent of Total Billed Charges,60% of Total Billed Charges,5975.1,90,,636.632,Percent of Total Billed Charges,90% of Total Billed Charges,2987.55,45,,487,Percent of Total Billed Charges,45% of Total Billed Charges,5975.1,90,,525.496,Percent of Total Billed Charges,90% of Total billed Charges,6639,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6639,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6639,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4315.35,65,,675.352,Percent of total Billed Charges,65% of Total Billed Charges,2927.8,44.1,,477.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,6307.05,95,,554.696,Percent of Total Billed Charges,95% of Total Billed Charges,6639,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5842.32,88,,111.768,Percent of Total Billed Charges,88% of Total Billed Charges,5975.1,90,,525.496,Percent of Total Billed charges,90% of Total Billed Charges,2927.8,6639,
Z02.03155.042 NCB SLD SCW 42MM,2780000310,CDM,278,RC,C1713,HCPCS,Outpatient,,,333.90,217.04,,333.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,253.76,76,,849.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,240.41,72,,167.016,Percent of Total Billed Charges,72% of Total Billed Charges,240.41,72,,167.016,Percent of Total Billed charges,72% of Total Billed Charges,333.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.41,72,,167.016,Percent of Total Billed Charges,72% of Total Billed Charges,200.34,60,,139.184,Percent of Total Billed Charges,60% of Total Billed Charges,300.51,90,,136.536,Percent of Total Billed Charges,90% of Total Billed Charges,150.26,45,,211.544,Percent of Total Billed Charges,45% of Total Billed Charges,300.51,90,,1005.744,Percent of Total Billed Charges,90% of Total billed Charges,333.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.04,65,,424.24,Percent of total Billed Charges,65% of Total Billed Charges,147.25,44.1,,207.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,317.21,95,,1061.624,Percent of Total Billed Charges,95% of Total Billed Charges,333.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.83,88,,133.496,Percent of Total Billed Charges,88% of Total Billed Charges,300.51,90,,1005.744,Percent of Total Billed charges,90% of Total Billed Charges,147.25,333.9,
Z0203125044 5.0 CORT 44MM,2780000311,CDM,278,RC,C1776,HCPCS,Outpatient,,,555.66,361.18,,555.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.3,76,,1234.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,400.08,72,,3861.68,Percent of Total Billed Charges,72% of Total Billed Charges,400.08,72,,3861.68,Percent of Total Billed charges,72% of Total Billed Charges,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.08,72,,3861.68,Percent of Total Billed Charges,72% of Total Billed Charges,333.4,60,,3218.064,Percent of Total Billed Charges,60% of Total Billed Charges,500.09,90,,136.536,Percent of Total Billed Charges,90% of Total Billed Charges,250.05,45,,57.152,Percent of Total Billed Charges,45% of Total Billed Charges,500.09,90,,1461.384,Percent of Total Billed Charges,90% of Total billed Charges,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.18,65,,370.928,Percent of total Billed Charges,65% of Total Billed Charges,245.05,44.1,,56.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.88,95,,1542.576,Percent of Total Billed Charges,95% of Total Billed Charges,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.98,88,,33.376,Percent of Total Billed Charges,88% of Total Billed Charges,500.09,90,,1461.384,Percent of Total Billed charges,90% of Total Billed Charges,245.05,555.66,
Z0203150046 5.0 CORT 46MM,2780000312,CDM,278,RC,C1776,HCPCS,Outpatient,,,555.66,361.18,,555.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.3,76,,822.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,400.08,72,,342.288,Percent of Total Billed Charges,72% of Total Billed Charges,400.08,72,,342.288,Percent of Total Billed charges,72% of Total Billed Charges,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.08,72,,342.288,Percent of Total Billed Charges,72% of Total Billed Charges,333.4,60,,285.24,Percent of Total Billed Charges,60% of Total Billed Charges,500.09,90,,520.736,Percent of Total Billed Charges,90% of Total Billed Charges,250.05,45,,68.264,Percent of Total Billed Charges,45% of Total Billed Charges,500.09,90,,973.992,Percent of Total Billed Charges,90% of Total billed Charges,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.18,65,,688.536,Percent of total Billed Charges,65% of Total Billed Charges,245.05,44.1,,66.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.88,95,,1028.104,Percent of Total Billed Charges,95% of Total Billed Charges,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.98,88,,821.184,Percent of Total Billed Charges,88% of Total Billed Charges,500.09,90,,973.992,Percent of Total Billed charges,90% of Total Billed Charges,245.05,555.66,
Z0203150055 5.0 CORT 55MM,2780000313,CDM,278,RC,C1776,HCPCS,Outpatient,,,555.66,361.18,,555.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.3,76,,357.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,400.08,72,,273.704,Percent of Total Billed Charges,72% of Total Billed Charges,400.08,72,,273.704,Percent of Total Billed charges,72% of Total Billed Charges,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.08,72,,273.704,Percent of Total Billed Charges,72% of Total Billed Charges,333.4,60,,228.088,Percent of Total Billed Charges,60% of Total Billed Charges,500.09,90,,127.008,Percent of Total Billed Charges,90% of Total Billed Charges,250.05,45,,17.064,Percent of Total Billed Charges,45% of Total Billed Charges,500.09,90,,423.096,Percent of Total Billed Charges,90% of Total billed Charges,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.18,65,,217.28,Percent of total Billed Charges,65% of Total Billed Charges,245.05,44.1,,16.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.88,95,,446.6,Percent of Total Billed Charges,95% of Total Billed Charges,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.98,88,,312.016,Percent of Total Billed Charges,88% of Total Billed Charges,500.09,90,,423.096,Percent of Total Billed charges,90% of Total Billed Charges,245.05,555.66,
Z0203158065 NCB CANC SCW 65MM,2780000314,CDM,278,RC,C1713,HCPCS,Outpatient,,,605.85,393.80,,605.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,460.45,76,,96.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,436.21,72,,56.52,Percent of Total Billed Charges,72% of Total Billed Charges,436.21,72,,56.52,Percent of Total Billed charges,72% of Total Billed Charges,605.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,436.21,72,,56.52,Percent of Total Billed Charges,72% of Total Billed Charges,363.51,60,,47.096,Percent of Total Billed Charges,60% of Total Billed Charges,545.27,90,,404.84,Percent of Total Billed Charges,90% of Total Billed Charges,272.63,45,,419.92,Percent of Total Billed Charges,45% of Total Billed Charges,545.27,90,,114.304,Percent of Total Billed Charges,90% of Total billed Charges,605.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,605.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,605.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.8,65,,487.304,Percent of total Billed Charges,65% of Total Billed Charges,267.18,44.1,,411.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,575.56,95,,120.656,Percent of Total Billed Charges,95% of Total Billed Charges,605.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,533.15,88,,622.48,Percent of Total Billed Charges,88% of Total Billed Charges,545.27,90,,114.304,Percent of Total Billed charges,90% of Total Billed Charges,267.18,605.85,
Z114711575 16MM TD SCW 115MM,2780000315,CDM,278,RC,C1713,HCPCS,Outpatient,,,726.00,471.90,,726,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,551.76,76,,115.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,522.72,72,,56.52,Percent of Total Billed Charges,72% of Total Billed Charges,522.72,72,,56.52,Percent of Total Billed charges,72% of Total Billed Charges,726,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,522.72,72,,56.52,Percent of Total Billed Charges,72% of Total Billed Charges,435.6,60,,47.096,Percent of Total Billed Charges,60% of Total Billed Charges,653.4,90,,570.744,Percent of Total Billed Charges,90% of Total Billed Charges,326.7,45,,159.552,Percent of Total Billed Charges,45% of Total Billed Charges,653.4,90,,136.536,Percent of Total Billed Charges,90% of Total billed Charges,726,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,726,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,726,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.9,65,,354.304,Percent of total Billed Charges,65% of Total Billed Charges,320.17,44.1,,156.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,689.7,95,,144.12,Percent of Total Billed Charges,95% of Total Billed Charges,726,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,638.88,88,,133.496,Percent of Total Billed Charges,88% of Total Billed Charges,653.4,90,,136.536,Percent of Total Billed charges,90% of Total Billed Charges,320.17,726,
Z114712075 16MM THD SCW 120MM,2780000316,CDM,278,RC,C1713,HCPCS,Outpatient,,,726.00,471.90,,726,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,551.76,76,,28.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,522.72,72,,43.816,Percent of Total Billed Charges,72% of Total Billed Charges,522.72,72,,43.816,Percent of Total Billed charges,72% of Total Billed Charges,726,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,522.72,72,,43.816,Percent of Total Billed Charges,72% of Total Billed Charges,435.6,60,,36.512,Percent of Total Billed Charges,60% of Total Billed Charges,653.4,90,,311.168,Percent of Total Billed Charges,90% of Total Billed Charges,326.7,45,,318.312,Percent of Total Billed Charges,45% of Total Billed Charges,653.4,90,,34.136,Percent of Total Billed Charges,90% of Total billed Charges,726,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,726,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,726,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.9,65,,424.816,Percent of total Billed Charges,65% of Total Billed Charges,320.17,44.1,,311.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,689.7,95,,36.032,Percent of Total Billed Charges,95% of Total Billed Charges,726,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,638.88,88,,133.496,Percent of Total Billed Charges,88% of Total Billed Charges,653.4,90,,34.136,Percent of Total Billed charges,90% of Total Billed Charges,320.17,726,
Z114733 CAN CTRSNK FR 3.5/4.0,2780000317,CDM,278,RC,C1713,HCPCS,Outpatient,,,888.00,577.20,,888,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,674.88,76,,709.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,639.36,72,,43.816,Percent of Total Billed Charges,72% of Total Billed Charges,639.36,72,,43.816,Percent of Total Billed charges,72% of Total Billed Charges,888,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,639.36,72,,43.816,Percent of Total Billed Charges,72% of Total Billed Charges,532.8,60,,36.512,Percent of Total Billed Charges,60% of Total Billed Charges,799.2,90,,177.808,Percent of Total Billed Charges,90% of Total Billed Charges,399.6,45,,68.264,Percent of Total Billed Charges,45% of Total Billed Charges,799.2,90,,839.848,Percent of Total Billed Charges,90% of Total billed Charges,888,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,888,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,888,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.2,65,,388.12,Percent of total Billed Charges,65% of Total Billed Charges,391.61,44.1,,66.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,843.6,95,,886.504,Percent of Total Billed Charges,95% of Total Billed Charges,888,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,781.44,88,,509.16,Percent of Total Billed Charges,88% of Total Billed Charges,799.2,90,,839.848,Percent of Total Billed charges,90% of Total Billed Charges,391.61,888,
Z131227108 2.7MM LOCKNG SCW8,2780000318,CDM,278,RC,C1713,HCPCS,Outpatient,,,323.00,209.95,,323,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,245.48,76,,269.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,232.56,72,,43.816,Percent of Total Billed Charges,72% of Total Billed Charges,232.56,72,,43.816,Percent of Total Billed charges,72% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.56,72,,43.816,Percent of Total Billed Charges,72% of Total Billed Charges,193.8,60,,36.512,Percent of Total Billed Charges,60% of Total Billed Charges,290.7,90,,443.736,Percent of Total Billed Charges,90% of Total Billed Charges,145.35,45,,68.264,Percent of Total Billed Charges,45% of Total Billed Charges,290.7,90,,319.112,Percent of Total Billed Charges,90% of Total billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.95,65,,424.816,Percent of total Billed Charges,65% of Total Billed Charges,142.44,44.1,,66.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,306.85,95,,336.84,Percent of Total Billed Charges,95% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.24,88,,124.184,Percent of Total Billed Charges,88% of Total Billed Charges,290.7,90,,319.112,Percent of Total Billed charges,90% of Total Billed Charges,142.44,323,
Z131227110 2.7MM LCKNG SCW10,2780000319,CDM,278,RC,C1713,HCPCS,Outpatient,,,323.00,209.95,,323,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,245.48,76,,537.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,232.56,72,,437.544,Percent of Total Billed Charges,72% of Total Billed Charges,232.56,72,,437.544,Percent of Total Billed charges,72% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.56,72,,437.544,Percent of Total Billed Charges,72% of Total Billed Charges,193.8,60,,364.616,Percent of Total Billed Charges,60% of Total Billed Charges,290.7,90,,561.216,Percent of Total Billed Charges,90% of Total Billed Charges,145.35,45,,260.368,Percent of Total Billed Charges,45% of Total Billed Charges,290.7,90,,636.632,Percent of Total Billed Charges,90% of Total billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.95,65,,388.12,Percent of total Billed Charges,65% of Total Billed Charges,142.44,44.1,,255.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,306.85,95,,672,Percent of Total Billed Charges,95% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.24,88,,395.848,Percent of Total Billed Charges,88% of Total Billed Charges,290.7,90,,636.632,Percent of Total Billed charges,90% of Total Billed Charges,142.44,323,
Z131227112 2.7MM LCKNG SCW12,2780000320,CDM,278,RC,C1713,HCPCS,Outpatient,,,323.00,209.95,,323,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,245.48,76,,115.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,232.56,72,,437.544,Percent of Total Billed Charges,72% of Total Billed Charges,232.56,72,,437.544,Percent of Total Billed charges,72% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.56,72,,437.544,Percent of Total Billed Charges,72% of Total Billed Charges,193.8,60,,364.616,Percent of Total Billed Charges,60% of Total Billed Charges,290.7,90,,537.4,Percent of Total Billed Charges,90% of Total Billed Charges,145.35,45,,63.504,Percent of Total Billed Charges,45% of Total Billed Charges,290.7,90,,136.536,Percent of Total Billed Charges,90% of Total billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.95,65,,831.856,Percent of total Billed Charges,65% of Total Billed Charges,142.44,44.1,,62.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,306.85,95,,144.12,Percent of Total Billed Charges,95% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.24,88,,558.064,Percent of Total Billed Charges,88% of Total Billed Charges,290.7,90,,136.536,Percent of Total Billed charges,90% of Total Billed Charges,142.44,323,
Z131227114 2.7MM LCKNG SCW14,2780000321,CDM,278,RC,C1713,HCPCS,Outpatient,,,323.00,209.95,,323,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,245.48,76,,115.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,232.56,72,,93.984,Percent of Total Billed Charges,72% of Total Billed Charges,232.56,72,,93.984,Percent of Total Billed charges,72% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.56,72,,93.984,Percent of Total Billed Charges,72% of Total Billed Charges,193.8,60,,78.32,Percent of Total Billed Charges,60% of Total Billed Charges,290.7,90,,513.592,Percent of Total Billed Charges,90% of Total Billed Charges,145.35,45,,202.424,Percent of Total Billed Charges,45% of Total Billed Charges,290.7,90,,136.536,Percent of Total Billed Charges,90% of Total billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.95,65,,523.424,Percent of total Billed Charges,65% of Total Billed Charges,142.44,44.1,,198.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,306.85,95,,144.12,Percent of Total Billed Charges,95% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.24,88,,304.256,Percent of Total Billed Charges,88% of Total Billed Charges,290.7,90,,136.536,Percent of Total Billed charges,90% of Total Billed Charges,142.44,323,
Z131227115 2.7MM LCKNG SCW15,2780000322,CDM,278,RC,C1713,HCPCS,Outpatient,,,323.00,209.95,,323,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,245.48,76,,439.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,232.56,72,,224.808,Percent of Total Billed Charges,72% of Total Billed Charges,232.56,72,,224.808,Percent of Total Billed charges,72% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.56,72,,224.808,Percent of Total Billed Charges,72% of Total Billed Charges,193.8,60,,187.336,Percent of Total Billed Charges,60% of Total Billed Charges,290.7,90,,537.4,Percent of Total Billed Charges,90% of Total Billed Charges,145.35,45,,285.376,Percent of Total Billed Charges,45% of Total Billed Charges,290.7,90,,520.736,Percent of Total Billed Charges,90% of Total billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.95,65,,97.464,Percent of total Billed Charges,65% of Total Billed Charges,142.44,44.1,,279.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,306.85,95,,549.664,Percent of Total Billed Charges,95% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.24,88,,173.856,Percent of Total Billed Charges,88% of Total Billed Charges,290.7,90,,520.736,Percent of Total Billed charges,90% of Total Billed Charges,142.44,323,
Z131227116 2.7MM LCKNG SCW16,2780000323,CDM,278,RC,C1713,HCPCS,Outpatient,,,323.00,209.95,,323,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,245.48,76,,107.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,232.56,72,,328.952,Percent of Total Billed Charges,72% of Total Billed Charges,232.56,72,,328.952,Percent of Total Billed charges,72% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.56,72,,328.952,Percent of Total Billed Charges,72% of Total Billed Charges,193.8,60,,274.128,Percent of Total Billed Charges,60% of Total Billed Charges,290.7,90,,273.856,Percent of Total Billed Charges,90% of Total Billed Charges,145.35,45,,155.584,Percent of Total Billed Charges,45% of Total Billed Charges,290.7,90,,127.008,Percent of Total Billed Charges,90% of Total billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.95,65,,487.304,Percent of total Billed Charges,65% of Total Billed Charges,142.44,44.1,,152.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,306.85,95,,134.064,Percent of Total Billed Charges,95% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.24,88,,433.872,Percent of Total Billed Charges,88% of Total Billed Charges,290.7,90,,127.008,Percent of Total Billed charges,90% of Total Billed Charges,142.44,323,
Z131227118 2.7 MM LCKNG SCW18,2780000324,CDM,278,RC,C1713,HCPCS,Outpatient,,,323.00,209.95,,323,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,245.48,76,,341.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,232.56,72,,289.576,Percent of Total Billed Charges,72% of Total Billed Charges,232.56,72,,289.576,Percent of Total Billed charges,72% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.56,72,,289.576,Percent of Total Billed Charges,72% of Total Billed Charges,193.8,60,,241.312,Percent of Total Billed Charges,60% of Total Billed Charges,290.7,90,,443.736,Percent of Total Billed Charges,90% of Total Billed Charges,145.35,45,,88.904,Percent of Total Billed Charges,45% of Total Billed Charges,290.7,90,,404.84,Percent of Total Billed Charges,90% of Total billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.95,65,,354.304,Percent of total Billed Charges,65% of Total Billed Charges,142.44,44.1,,87.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,306.85,95,,427.336,Percent of Total Billed Charges,95% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.24,88,,548.744,Percent of Total Billed Charges,88% of Total Billed Charges,290.7,90,,404.84,Percent of Total Billed charges,90% of Total Billed Charges,142.44,323,
Z131227120 2.7MM LCKING SCW 20,2780000325,CDM,278,RC,C1713,HCPCS,Outpatient,,,323.00,209.95,,323,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,245.48,76,,481.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,232.56,72,,289.576,Percent of Total Billed Charges,72% of Total Billed Charges,232.56,72,,289.576,Percent of Total Billed charges,72% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.56,72,,289.576,Percent of Total Billed Charges,72% of Total Billed Charges,193.8,60,,241.312,Percent of Total Billed Charges,60% of Total Billed Charges,290.7,90,,561.216,Percent of Total Billed Charges,90% of Total Billed Charges,145.35,45,,221.872,Percent of Total Billed Charges,45% of Total Billed Charges,290.7,90,,570.744,Percent of Total Billed Charges,90% of Total billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.95,65,,424.816,Percent of total Billed Charges,65% of Total Billed Charges,142.44,44.1,,217.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,306.85,95,,602.456,Percent of Total Billed Charges,95% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.24,88,,525.456,Percent of Total Billed Charges,88% of Total Billed Charges,290.7,90,,570.744,Percent of Total Billed charges,90% of Total Billed Charges,142.44,323,
Z131227122 2.7MM LCKNG SCW 22,2780000326,CDM,278,RC,C1713,HCPCS,Outpatient,,,323.00,209.95,,323,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,245.48,76,,262.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,232.56,72,,289.576,Percent of Total Billed Charges,72% of Total Billed Charges,232.56,72,,289.576,Percent of Total Billed charges,72% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.56,72,,289.576,Percent of Total Billed Charges,72% of Total Billed Charges,193.8,60,,241.312,Percent of Total Billed Charges,60% of Total Billed Charges,290.7,90,,935.104,Percent of Total Billed Charges,90% of Total Billed Charges,145.35,45,,280.608,Percent of Total Billed Charges,45% of Total Billed Charges,290.7,90,,311.168,Percent of Total Billed Charges,90% of Total billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.95,65,,388.12,Percent of total Billed Charges,65% of Total Billed Charges,142.44,44.1,,275,Percent of Total Billed Charges,44.1% of Total Billed Charges,306.85,95,,328.456,Percent of Total Billed Charges,95% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.24,88,,502.176,Percent of Total Billed Charges,88% of Total Billed Charges,290.7,90,,311.168,Percent of Total Billed charges,90% of Total Billed Charges,142.44,323,
Z131227124 2.7MM LCKNG SCW 24,2780000327,CDM,278,RC,C1713,HCPCS,Outpatient,,,323.00,209.95,,323,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,245.48,76,,150.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,232.56,72,,2291.224,Percent of Total Billed Charges,72% of Total Billed Charges,232.56,72,,2291.224,Percent of Total Billed charges,72% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.56,72,,2291.224,Percent of Total Billed Charges,72% of Total Billed Charges,193.8,60,,1909.352,Percent of Total Billed Charges,60% of Total Billed Charges,290.7,90,,587.416,Percent of Total Billed Charges,90% of Total Billed Charges,145.35,45,,268.704,Percent of Total Billed Charges,45% of Total Billed Charges,290.7,90,,177.808,Percent of Total Billed Charges,90% of Total billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.95,65,,424.816,Percent of total Billed Charges,65% of Total Billed Charges,142.44,44.1,,263.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,306.85,95,,187.688,Percent of Total Billed Charges,95% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.24,88,,525.456,Percent of Total Billed Charges,88% of Total Billed Charges,290.7,90,,177.808,Percent of Total Billed charges,90% of Total Billed Charges,142.44,323,
Z131227212 2.7MM NLCKING SC 12,2780000328,CDM,278,RC,C1713,HCPCS,Outpatient,,,170.00,110.50,,170,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.2,76,,374.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,122.4,72,,262.272,Percent of Total Billed Charges,72% of Total Billed Charges,122.4,72,,262.272,Percent of Total Billed charges,72% of Total Billed Charges,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.4,72,,262.272,Percent of Total Billed Charges,72% of Total Billed Charges,102,60,,218.56,Percent of Total Billed Charges,60% of Total Billed Charges,153,90,,513.592,Percent of Total Billed Charges,90% of Total Billed Charges,76.5,45,,256.792,Percent of Total Billed Charges,45% of Total Billed Charges,153,90,,443.736,Percent of Total Billed Charges,90% of Total billed Charges,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.5,65,,388.12,Percent of total Billed Charges,65% of Total Billed Charges,74.97,44.1,,251.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,161.5,95,,468.392,Percent of Total Billed Charges,95% of Total Billed Charges,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.6,88,,267.776,Percent of Total Billed Charges,88% of Total Billed Charges,153,90,,443.736,Percent of Total Billed charges,90% of Total Billed Charges,74.97,170,
Z131227213 2.7MM SCRW 13,2780000329,CDM,278,RC,C1713,HCPCS,Outpatient,,,323.00,209.95,,323,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,245.48,76,,473.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,232.56,72,,2291.224,Percent of Total Billed Charges,72% of Total Billed Charges,232.56,72,,2291.224,Percent of Total Billed charges,72% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.56,72,,2291.224,Percent of Total Billed Charges,72% of Total Billed Charges,193.8,60,,1909.352,Percent of Total Billed Charges,60% of Total Billed Charges,290.7,90,,953.352,Percent of Total Billed Charges,90% of Total Billed Charges,145.35,45,,268.704,Percent of Total Billed Charges,45% of Total Billed Charges,290.7,90,,561.216,Percent of Total Billed Charges,90% of Total billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.95,65,,458.072,Percent of total Billed Charges,65% of Total Billed Charges,142.44,44.1,,263.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,306.85,95,,592.4,Percent of Total Billed Charges,95% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.24,88,,433.872,Percent of Total Billed Charges,88% of Total Billed Charges,290.7,90,,561.216,Percent of Total Billed charges,90% of Total Billed Charges,142.44,323,
Z131227214 2.7MM NLCKING SC 14,2780000330,CDM,278,RC,C1713,HCPCS,Outpatient,,,170.00,110.50,,170,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.2,76,,453.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,122.4,72,,262.272,Percent of Total Billed Charges,72% of Total Billed Charges,122.4,72,,262.272,Percent of Total Billed charges,72% of Total Billed Charges,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.4,72,,262.272,Percent of Total Billed Charges,72% of Total Billed Charges,102,60,,218.56,Percent of Total Billed Charges,60% of Total Billed Charges,153,90,,300.856,Percent of Total Billed Charges,90% of Total Billed Charges,76.5,45,,136.928,Percent of Total Billed Charges,45% of Total Billed Charges,153,90,,537.4,Percent of Total Billed Charges,90% of Total billed Charges,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.5,65,,523.424,Percent of total Billed Charges,65% of Total Billed Charges,74.97,44.1,,134.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,161.5,95,,567.256,Percent of Total Billed Charges,95% of Total Billed Charges,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.6,88,,548.744,Percent of Total Billed Charges,88% of Total Billed Charges,153,90,,537.4,Percent of Total Billed charges,90% of Total Billed Charges,74.97,170,
Z131227216 2.7MM NLCKING SC 16,2780000331,CDM,278,RC,C1713,HCPCS,Outpatient,,,170.00,110.50,,170,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.2,76,,433.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,122.4,72,,329.584,Percent of Total Billed Charges,72% of Total Billed Charges,122.4,72,,329.584,Percent of Total Billed charges,72% of Total Billed Charges,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.4,72,,329.584,Percent of Total Billed Charges,72% of Total Billed Charges,102,60,,274.656,Percent of Total Billed Charges,60% of Total Billed Charges,153,90,,674.736,Percent of Total Billed Charges,90% of Total Billed Charges,76.5,45,,221.872,Percent of Total Billed Charges,45% of Total Billed Charges,153,90,,513.592,Percent of Total Billed Charges,90% of Total billed Charges,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.5,65,,290.664,Percent of total Billed Charges,65% of Total Billed Charges,74.97,44.1,,217.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,161.5,95,,542.12,Percent of Total Billed Charges,95% of Total Billed Charges,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.6,88,,914.32,Percent of Total Billed Charges,88% of Total Billed Charges,153,90,,513.592,Percent of Total Billed charges,90% of Total Billed Charges,74.97,170,
Z131227218 2.7 MM SCW 18,2780000332,CDM,278,RC,C1713,HCPCS,Outpatient,,,170.00,110.50,,170,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.2,76,,453.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,122.4,72,,329.584,Percent of Total Billed Charges,72% of Total Billed Charges,122.4,72,,329.584,Percent of Total Billed charges,72% of Total Billed Charges,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.4,72,,329.584,Percent of Total Billed Charges,72% of Total Billed Charges,102,60,,274.656,Percent of Total Billed Charges,60% of Total Billed Charges,153,90,,490.576,Percent of Total Billed Charges,90% of Total Billed Charges,76.5,45,,280.608,Percent of Total Billed Charges,45% of Total Billed Charges,153,90,,537.4,Percent of Total Billed Charges,90% of Total billed Charges,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.5,65,,388.12,Percent of total Billed Charges,65% of Total Billed Charges,74.97,44.1,,275,Percent of Total Billed Charges,44.1% of Total Billed Charges,161.5,95,,567.256,Percent of Total Billed Charges,95% of Total Billed Charges,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.6,88,,574.36,Percent of Total Billed Charges,88% of Total Billed Charges,153,90,,537.4,Percent of Total Billed charges,90% of Total Billed Charges,74.97,170,
Z131812040 STD SHRT RT PLTE,2780000333,CDM,278,RC,C1713,HCPCS,Outpatient,,,2719.00,1767.35,,2719,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2066.44,76,,231.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1957.68,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,1957.68,72,,44.456,Percent of Total Billed charges,72% of Total Billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1957.68,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,1631.4,60,,37.048,Percent of Total Billed Charges,60% of Total Billed Charges,2447.1,90,,588.208,Percent of Total Billed Charges,90% of Total Billed Charges,1223.55,45,,467.552,Percent of Total Billed Charges,45% of Total Billed Charges,2447.1,90,,273.856,Percent of Total Billed Charges,90% of Total billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1767.35,65,,458.072,Percent of total Billed Charges,65% of Total Billed Charges,1199.08,44.1,,458.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,2583.05,95,,289.072,Percent of Total Billed Charges,95% of Total Billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2392.72,88,,502.176,Percent of Total Billed Charges,88% of Total Billed Charges,2447.1,90,,273.856,Percent of Total Billed charges,90% of Total Billed Charges,1199.08,2719,
Z131812050 STRD R PLTE PRPLE,2780000334,CDM,278,RC,C1713,HCPCS,Outpatient,,,2719.00,1767.35,,2719,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2066.44,76,,374.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1957.68,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,1957.68,72,,44.456,Percent of Total Billed charges,72% of Total Billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1957.68,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,1631.4,60,,37.048,Percent of Total Billed Charges,60% of Total Billed Charges,2447.1,90,,537.4,Percent of Total Billed Charges,90% of Total Billed Charges,1223.55,45,,293.704,Percent of Total Billed Charges,45% of Total Billed Charges,2447.1,90,,443.736,Percent of Total Billed Charges,90% of Total billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1767.35,65,,436.856,Percent of total Billed Charges,65% of Total Billed Charges,1199.08,44.1,,287.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,2583.05,95,,468.392,Percent of Total Billed Charges,95% of Total Billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2392.72,88,,932.168,Percent of Total Billed Charges,88% of Total Billed Charges,2447.1,90,,443.736,Percent of Total Billed charges,90% of Total Billed Charges,1199.08,2719,
Z131821040 NAROW SHT PLTE LT,2780000335,CDM,278,RC,C1713,HCPCS,Outpatient,,,2719.00,1767.35,,2719,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2066.44,76,,473.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1957.68,72,,2274.08,Percent of Total Billed Charges,72% of Total Billed Charges,1957.68,72,,2274.08,Percent of Total Billed charges,72% of Total Billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1957.68,72,,2274.08,Percent of Total Billed Charges,72% of Total Billed Charges,1631.4,60,,1895.064,Percent of Total Billed Charges,60% of Total Billed Charges,2447.1,90,,588.208,Percent of Total Billed Charges,90% of Total Billed Charges,1223.55,45,,256.792,Percent of Total Billed Charges,45% of Total Billed Charges,2447.1,90,,561.216,Percent of Total Billed Charges,90% of Total billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1767.35,65,,464.944,Percent of total Billed Charges,65% of Total Billed Charges,1199.08,44.1,,251.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,2583.05,95,,592.4,Percent of Total Billed Charges,95% of Total Billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2392.72,88,,294.168,Percent of Total Billed Charges,88% of Total Billed Charges,2447.1,90,,561.216,Percent of Total Billed charges,90% of Total Billed Charges,1199.08,2719,
Z131821050 NAROW PLTE LT GRN,2780000336,CDM,278,RC,C1713,HCPCS,Outpatient,,,2719.00,1767.35,,2719,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2066.44,76,,789.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1957.68,72,,8824.512,Percent of Total Billed Charges,72% of Total Billed Charges,1957.68,72,,8824.512,Percent of Total Billed charges,72% of Total Billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1957.68,72,,8824.512,Percent of Total Billed Charges,72% of Total Billed Charges,1631.4,60,,7353.76,Percent of Total Billed Charges,60% of Total Billed Charges,2447.1,90,,537.4,Percent of Total Billed Charges,90% of Total Billed Charges,1223.55,45,,476.68,Percent of Total Billed Charges,45% of Total Billed Charges,2447.1,90,,935.104,Percent of Total Billed Charges,90% of Total billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1767.35,65,,451.192,Percent of total Billed Charges,65% of Total Billed Charges,1199.08,44.1,,467.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,2583.05,95,,987.048,Percent of Total Billed Charges,95% of Total Billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2392.72,88,,659.736,Percent of Total Billed Charges,88% of Total Billed Charges,2447.1,90,,935.104,Percent of Total Billed charges,90% of Total Billed Charges,1199.08,2719,
Z131822040 MINI 9 GRN PEG LT,2780000337,CDM,278,RC,C1713,HCPCS,Outpatient,,,2719.00,1767.35,,2719,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2066.44,76,,496.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1957.68,72,,4848.528,Percent of Total Billed Charges,72% of Total Billed Charges,1957.68,72,,4848.528,Percent of Total Billed charges,72% of Total Billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1957.68,72,,4848.528,Percent of Total Billed Charges,72% of Total Billed Charges,1631.4,60,,4040.44,Percent of Total Billed Charges,60% of Total Billed Charges,2447.1,90,,1151.808,Percent of Total Billed Charges,90% of Total Billed Charges,1223.55,45,,150.424,Percent of Total Billed Charges,45% of Total Billed Charges,2447.1,90,,587.416,Percent of Total Billed Charges,90% of Total billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1767.35,65,,511.952,Percent of total Billed Charges,65% of Total Billed Charges,1199.08,44.1,,147.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,2583.05,95,,620.048,Percent of Total Billed Charges,95% of Total Billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2392.72,88,,479.672,Percent of Total Billed Charges,88% of Total Billed Charges,2447.1,90,,587.416,Percent of Total Billed charges,90% of Total Billed Charges,1199.08,2719,
Z131822050 STANDRD LG LT GRN,2780000338,CDM,278,RC,C1713,HCPCS,Outpatient,,,2719.00,1767.35,,2719,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2066.44,76,,433.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1957.68,72,,5768.072,Percent of Total Billed Charges,72% of Total Billed Charges,1957.68,72,,5768.072,Percent of Total Billed charges,72% of Total Billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1957.68,72,,5768.072,Percent of Total Billed Charges,72% of Total Billed Charges,1631.4,60,,4806.728,Percent of Total Billed Charges,60% of Total Billed Charges,2447.1,90,,724.736,Percent of Total Billed Charges,90% of Total Billed Charges,1223.55,45,,337.368,Percent of Total Billed Charges,45% of Total Billed Charges,2447.1,90,,513.592,Percent of Total Billed Charges,90% of Total billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1767.35,65,,546.352,Percent of total Billed Charges,65% of Total Billed Charges,1199.08,44.1,,330.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,2583.05,95,,542.12,Percent of Total Billed Charges,95% of Total Billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2392.72,88,,575.136,Percent of Total Billed Charges,88% of Total Billed Charges,2447.1,90,,513.592,Percent of Total Billed charges,90% of Total Billed Charges,1199.08,2719,
Z131823050 WIDE LG PLTE GRN,2780000339,CDM,278,RC,C1713,HCPCS,Outpatient,,,2719.00,1767.35,,2719,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2066.44,76,,805.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1957.68,72,,563.28,Percent of Total Billed Charges,72% of Total Billed Charges,1957.68,72,,563.28,Percent of Total Billed charges,72% of Total Billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1957.68,72,,563.28,Percent of Total Billed Charges,72% of Total Billed Charges,1631.4,60,,469.4,Percent of Total Billed Charges,60% of Total Billed Charges,2447.1,90,,134.952,Percent of Total Billed Charges,90% of Total Billed Charges,1223.55,45,,245.288,Percent of Total Billed Charges,45% of Total Billed Charges,2447.1,90,,953.352,Percent of Total Billed Charges,90% of Total billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1767.35,65,,1327.76,Percent of total Billed Charges,65% of Total Billed Charges,1199.08,44.1,,240.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,2583.05,95,,1006.32,Percent of Total Billed Charges,95% of Total Billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2392.72,88,,525.456,Percent of Total Billed Charges,88% of Total Billed Charges,2447.1,90,,953.352,Percent of Total Billed charges,90% of Total Billed Charges,1199.08,2719,
Z2001-00-000 DISP DRILL/PIN ST,2780000340,CDM,278,RC,C1713,HCPCS,Outpatient,,,75.60,49.14,,75.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,57.46,76,,254.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,54.43,72,,841.424,Percent of Total Billed Charges,72% of Total Billed Charges,54.43,72,,841.424,Percent of Total Billed charges,72% of Total Billed Charges,75.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.43,72,,841.424,Percent of Total Billed Charges,72% of Total Billed Charges,45.36,60,,701.192,Percent of Total Billed Charges,60% of Total Billed Charges,68.04,90,,674.736,Percent of Total Billed Charges,90% of Total Billed Charges,34.02,45,,294.104,Percent of Total Billed Charges,45% of Total Billed Charges,68.04,90,,300.856,Percent of Total Billed Charges,90% of Total billed Charges,75.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.14,65,,664.456,Percent of total Billed Charges,65% of Total Billed Charges,33.34,44.1,,288.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,71.82,95,,317.568,Percent of Total Billed Charges,95% of Total Billed Charges,75.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.53,88,,575.136,Percent of Total Billed Charges,88% of Total Billed Charges,68.04,90,,300.856,Percent of Total Billed charges,90% of Total Billed Charges,33.34,75.6,
Z212000010 BIOMT PL SZ TEMP ST,2780000341,CDM,278,RC,C1713,HCPCS,Outpatient,,,42.00,27.30,,42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31.92,76,,569.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.24,72,,55.88,Percent of Total Billed Charges,72% of Total Billed Charges,30.24,72,,55.88,Percent of Total Billed charges,72% of Total Billed Charges,42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.24,72,,55.88,Percent of Total Billed Charges,72% of Total Billed Charges,25.2,60,,46.568,Percent of Total Billed Charges,60% of Total Billed Charges,37.8,90,,490.576,Percent of Total Billed Charges,90% of Total Billed Charges,18.9,45,,268.704,Percent of Total Billed Charges,45% of Total Billed Charges,37.8,90,,674.736,Percent of Total Billed Charges,90% of Total billed Charges,42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.3,65,,424.24,Percent of total Billed Charges,65% of Total Billed Charges,18.52,44.1,,263.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,39.9,95,,712.216,Percent of Total Billed Charges,95% of Total Billed Charges,42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.96,88,,525.456,Percent of Total Billed Charges,88% of Total Billed Charges,37.8,90,,674.736,Percent of Total Billed charges,90% of Total Billed Charges,18.52,42,
Z22320302 CABLE PLTE 8HX246,2780000342,CDM,278,RC,C1773,HCPCS,Outpatient,,,2577.00,1675.05,,2577,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1958.52,76,,414.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1855.44,72,,55.88,Percent of Total Billed Charges,72% of Total Billed Charges,1855.44,72,,55.88,Percent of Total Billed charges,72% of Total Billed Charges,2577,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1855.44,72,,55.88,Percent of Total Billed Charges,72% of Total Billed Charges,1546.2,60,,46.568,Percent of Total Billed Charges,60% of Total Billed Charges,2319.3,90,,588.208,Percent of Total Billed Charges,90% of Total Billed Charges,1159.65,45,,294.104,Percent of Total Billed Charges,45% of Total Billed Charges,2319.3,90,,490.576,Percent of Total Billed Charges,90% of Total billed Charges,2577,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2577,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2577,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1675.05,65,,2691.648,Percent of total Billed Charges,65% of Total Billed Charges,1136.46,44.1,,288.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,2448.15,95,,517.824,Percent of Total Billed Charges,95% of Total Billed Charges,2577,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2267.76,88,,1126.208,Percent of Total Billed Charges,88% of Total Billed Charges,2319.3,90,,490.576,Percent of Total Billed charges,90% of Total Billed Charges,1136.46,2577,
Z22325021 CABLE READY PAT,2780000343,CDM,278,RC,C1713,HCPCS,Outpatient,,,1688.40,1097.46,,1688.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1283.18,76,,496.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1215.65,72,,55.88,Percent of Total Billed Charges,72% of Total Billed Charges,1215.65,72,,55.88,Percent of Total Billed charges,72% of Total Billed Charges,1688.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1215.65,72,,55.88,Percent of Total Billed Charges,72% of Total Billed Charges,1013.04,60,,46.568,Percent of Total Billed Charges,60% of Total Billed Charges,1519.56,90,,537.4,Percent of Total Billed Charges,90% of Total Billed Charges,759.78,45,,268.704,Percent of Total Billed Charges,45% of Total Billed Charges,1519.56,90,,588.208,Percent of Total Billed Charges,90% of Total billed Charges,1688.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1688.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1688.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1097.46,65,,536.608,Percent of total Billed Charges,65% of Total Billed Charges,744.58,44.1,,263.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,1603.98,95,,620.88,Percent of Total Billed Charges,95% of Total Billed Charges,1688.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1485.79,88,,708.632,Percent of Total Billed Charges,88% of Total Billed Charges,1519.56,90,,588.208,Percent of Total Billed charges,90% of Total Billed Charges,744.58,1688.4,
Z22401032 RETR FEM NLE 10X32,2780000344,CDM,278,RC,,,Outpatient,,,3921.00,2548.65,,3921,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2979.96,76,,453.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2823.12,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,2823.12,72,,44.456,Percent of Total Billed charges,72% of Total Billed Charges,3921,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2823.12,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,2352.6,60,,37.048,Percent of Total Billed Charges,60% of Total Billed Charges,3528.9,90,,588.208,Percent of Total Billed Charges,90% of Total Billed Charges,1764.45,45,,575.904,Percent of Total Billed Charges,45% of Total Billed Charges,3528.9,90,,537.4,Percent of Total Billed Charges,90% of Total billed Charges,3921,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3921,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3921,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2548.65,65,,2810.888,Percent of total Billed Charges,65% of Total Billed Charges,1729.16,44.1,,564.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,3724.95,95,,567.256,Percent of Total Billed Charges,95% of Total Billed Charges,3921,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3450.48,88,,131.952,Percent of Total Billed Charges,88% of Total Billed Charges,3528.9,90,,537.4,Percent of Total Billed charges,90% of Total Billed Charges,1729.16,3921,
Z224401336 RETROFEMNLE 13X36,2780000345,CDM,278,RC,C1713,HCPCS,Outpatient,,,4322.90,2809.89,,4322.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3285.4,76,,496.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3112.49,72,,165.744,Percent of Total Billed Charges,72% of Total Billed Charges,3112.49,72,,165.744,Percent of Total Billed charges,72% of Total Billed Charges,4322.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.49,72,,165.744,Percent of Total Billed Charges,72% of Total Billed Charges,2593.74,60,,138.12,Percent of Total Billed Charges,60% of Total Billed Charges,3890.61,90,,537.4,Percent of Total Billed Charges,90% of Total Billed Charges,1945.31,45,,362.368,Percent of Total Billed Charges,45% of Total Billed Charges,3890.61,90,,588.208,Percent of Total Billed Charges,90% of Total billed Charges,4322.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4322.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4322.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2809.89,65,,441.44,Percent of total Billed Charges,65% of Total Billed Charges,1906.4,44.1,,355.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,4106.76,95,,620.88,Percent of Total Billed Charges,95% of Total Billed Charges,4322.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3804.15,88,,659.736,Percent of Total Billed Charges,88% of Total Billed Charges,3890.61,90,,588.208,Percent of Total Billed charges,90% of Total Billed Charges,1906.4,4322.9,
Z225234010 FEMRECON 10X34,2780000346,CDM,278,RC,C1713,HCPCS,Outpatient,,,3009.83,1956.39,,3009.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2287.47,76,,453.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2167.08,72,,64.776,Percent of Total Billed Charges,72% of Total Billed Charges,2167.08,72,,64.776,Percent of Total Billed charges,72% of Total Billed Charges,3009.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2167.08,72,,64.776,Percent of Total Billed Charges,72% of Total Billed Charges,1805.9,60,,53.984,Percent of Total Billed Charges,60% of Total Billed Charges,2708.85,90,,634.248,Percent of Total Billed Charges,90% of Total Billed Charges,1354.42,45,,67.472,Percent of Total Billed Charges,45% of Total Billed Charges,2708.85,90,,537.4,Percent of Total Billed Charges,90% of Total billed Charges,3009.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3009.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3009.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1956.39,65,,133.008,Percent of total Billed Charges,65% of Total Billed Charges,1327.34,44.1,,66.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,2859.34,95,,567.256,Percent of Total Billed Charges,95% of Total Billed Charges,3009.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2648.65,88,,479.672,Percent of Total Billed Charges,88% of Total Billed Charges,2708.85,90,,537.4,Percent of Total Billed charges,90% of Total Billed Charges,1327.34,3009.83,
Z225234011 FEMRECON 11 X 34,2780000347,CDM,278,RC,C1716,HCPCS,Outpatient,,,3009.83,1956.39,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,2287.47,76,,972.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2412.3,72,,563.28,Percent of Total Billed Charges,72% of Total Billed Charges,2412.3,72,,563.28,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2412.3,72,,563.28,Percent of Total Billed Charges,72% of Total Billed Charges,1928.51,60,,469.4,Percent of Total Billed Charges,60% of Total Billed Charges,2708.85,90,,724.736,Percent of Total Billed Charges,90% of Total Billed Charges,1354.42,45,,337.368,Percent of Total Billed Charges,45% of Total Billed Charges,2708.85,90,,1151.808,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3693.05,65,,2810.888,Percent of total Billed Charges,65% of Total Billed Charges,1327.34,44.1,,330.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,2859.34,95,,1215.792,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,2648.65,88,,575.136,Percent of Total Billed Charges,88% of Total Billed Charges,2708.85,90,,1151.808,Percent of Total Billed charges,90% of Total Billed Charges,651.24,3693.05,
Z225238009 FEM RECNNAIL 9X38,2780000348,CDM,278,RC,C1713,HCPCS,Outpatient,,,2731.00,1775.15,,2731,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2075.56,76,,612,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1966.32,72,,156.224,Percent of Total Billed Charges,72% of Total Billed Charges,1966.32,72,,156.224,Percent of Total Billed charges,72% of Total Billed Charges,2731,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1966.32,72,,156.224,Percent of Total Billed Charges,72% of Total Billed Charges,1638.6,60,,130.184,Percent of Total Billed Charges,60% of Total Billed Charges,2457.9,90,,402.456,Percent of Total Billed Charges,90% of Total Billed Charges,1228.95,45,,245.288,Percent of Total Billed Charges,45% of Total Billed Charges,2457.9,90,,724.736,Percent of Total Billed Charges,90% of Total billed Charges,2731,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2731,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2731,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1775.15,65,,441.44,Percent of total Billed Charges,65% of Total Billed Charges,1204.37,44.1,,240.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,2594.45,95,,765,Percent of Total Billed Charges,95% of Total Billed Charges,2731,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2403.28,88,,525.456,Percent of Total Billed Charges,88% of Total Billed Charges,2457.9,90,,724.736,Percent of Total Billed charges,90% of Total Billed Charges,1204.37,2731,
Z225238013 FEMRECON NLE13X38,2780000349,CDM,278,RC,C1713,HCPCS,Outpatient,,,2867.55,1863.91,,2867.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2179.34,76,,113.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2064.64,72,,240.68,Percent of Total Billed Charges,72% of Total Billed Charges,2064.64,72,,240.68,Percent of Total Billed charges,72% of Total Billed Charges,2867.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2064.64,72,,240.68,Percent of Total Billed Charges,72% of Total Billed Charges,1720.53,60,,200.568,Percent of Total Billed Charges,60% of Total Billed Charges,2580.8,90,,537.4,Percent of Total Billed Charges,90% of Total Billed Charges,1290.4,45,,294.104,Percent of Total Billed Charges,45% of Total Billed Charges,2580.8,90,,134.952,Percent of Total Billed Charges,90% of Total billed Charges,2867.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2867.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2867.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1863.91,65,,1992.216,Percent of total Billed Charges,65% of Total Billed Charges,1264.59,44.1,,288.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,2724.17,95,,142.448,Percent of Total Billed Charges,95% of Total Billed Charges,2867.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2523.44,88,,575.136,Percent of Total Billed Charges,88% of Total Billed Charges,2580.8,90,,134.952,Percent of Total Billed charges,90% of Total Billed Charges,1264.59,2867.55,
Z225240013 FEMRECON 13 X 40,2780000350,CDM,278,RC,C1713,HCPCS,Outpatient,,,3009.83,1956.39,,3009.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2287.47,76,,569.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2167.08,72,,1146.888,Percent of Total Billed Charges,72% of Total Billed Charges,2167.08,72,,1146.888,Percent of Total Billed charges,72% of Total Billed Charges,3009.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2167.08,72,,1146.888,Percent of Total Billed Charges,72% of Total Billed Charges,1805.9,60,,955.736,Percent of Total Billed Charges,60% of Total Billed Charges,2708.85,90,,634.248,Percent of Total Billed Charges,90% of Total Billed Charges,1354.42,45,,268.704,Percent of Total Billed Charges,45% of Total Billed Charges,2708.85,90,,674.736,Percent of Total Billed Charges,90% of Total billed Charges,3009.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3009.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3009.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1956.39,65,,790.584,Percent of total Billed Charges,65% of Total Billed Charges,1327.34,44.1,,263.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,2859.34,95,,712.216,Percent of Total Billed Charges,95% of Total Billed Charges,3009.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2648.65,88,,525.456,Percent of Total Billed Charges,88% of Total Billed Charges,2708.85,90,,674.736,Percent of Total Billed charges,90% of Total Billed Charges,1327.34,3009.83,
Z22532042 4.2 CORT SCW 20,2780000351,CDM,278,RC,C1713,HCPCS,Outpatient,,,216.09,140.46,,216.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,164.23,76,,414.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,155.58,72,,977.328,Percent of Total Billed Charges,72% of Total Billed Charges,155.58,72,,977.328,Percent of Total Billed charges,72% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.58,72,,977.328,Percent of Total Billed Charges,72% of Total Billed Charges,129.65,60,,814.44,Percent of Total Billed Charges,60% of Total Billed Charges,194.48,90,,604.88,Percent of Total Billed Charges,90% of Total Billed Charges,97.24,45,,294.104,Percent of Total Billed Charges,45% of Total Billed Charges,194.48,90,,490.576,Percent of Total Billed Charges,90% of Total billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.46,65,,99.176,Percent of total Billed Charges,65% of Total Billed Charges,95.3,44.1,,288.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,205.29,95,,517.824,Percent of Total Billed Charges,95% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.16,88,,620.152,Percent of Total Billed Charges,88% of Total Billed Charges,194.48,90,,490.576,Percent of Total Billed charges,90% of Total Billed Charges,95.3,216.09,
Z22532737 3.7 CORTI SCW 27.5,2780000352,CDM,278,RC,C1713,HCPCS,Outpatient,,,477.00,310.05,,477,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,362.52,76,,496.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,343.44,72,,470.56,Percent of Total Billed Charges,72% of Total Billed Charges,343.44,72,,470.56,Percent of Total Billed charges,72% of Total Billed Charges,477,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.44,72,,470.56,Percent of Total Billed Charges,72% of Total Billed Charges,286.2,60,,392.136,Percent of Total Billed Charges,60% of Total Billed Charges,429.3,90,,643.776,Percent of Total Billed Charges,90% of Total Billed Charges,214.65,45,,268.704,Percent of Total Billed Charges,45% of Total Billed Charges,429.3,90,,588.208,Percent of Total Billed Charges,90% of Total billed Charges,477,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,477,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,477,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,310.05,65,,205.248,Percent of total Billed Charges,65% of Total Billed Charges,210.36,44.1,,263.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,453.15,95,,620.88,Percent of Total Billed Charges,95% of Total Billed Charges,477,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.76,88,,708.632,Percent of Total Billed Charges,88% of Total Billed Charges,429.3,90,,588.208,Percent of Total Billed charges,90% of Total Billed Charges,210.36,477,
Z225332009 TIBIAL NAIL 9X32,2780000353,CDM,278,RC,C1713,HCPCS,Outpatient,,,2955.75,1921.24,,2955.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2246.37,76,,453.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2128.14,72,,470.56,Percent of Total Billed Charges,72% of Total Billed Charges,2128.14,72,,470.56,Percent of Total Billed charges,72% of Total Billed Charges,2955.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2128.14,72,,470.56,Percent of Total Billed Charges,72% of Total Billed Charges,1773.45,60,,392.136,Percent of Total Billed Charges,60% of Total Billed Charges,2660.18,90,,624.72,Percent of Total Billed Charges,90% of Total Billed Charges,1330.09,45,,317.128,Percent of Total Billed Charges,45% of Total Billed Charges,2660.18,90,,537.4,Percent of Total Billed Charges,90% of Total billed Charges,2955.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2955.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2955.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1921.24,65,,1228.008,Percent of total Billed Charges,65% of Total Billed Charges,1303.49,44.1,,310.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,2807.96,95,,567.256,Percent of Total Billed Charges,95% of Total Billed Charges,2955.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2601.06,88,,393.512,Percent of Total Billed Charges,88% of Total Billed Charges,2660.18,90,,537.4,Percent of Total Billed charges,90% of Total Billed Charges,1303.49,2955.75,
Z225428510 HUM NAIL 10X28.5,2780000354,CDM,278,RC,C1713,HCPCS,Outpatient,,,4305.26,2798.42,,4305.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3272,76,,496.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3099.79,72,,470.56,Percent of Total Billed Charges,72% of Total Billed Charges,3099.79,72,,470.56,Percent of Total Billed charges,72% of Total Billed Charges,4305.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3099.79,72,,470.56,Percent of Total Billed Charges,72% of Total Billed Charges,2583.16,60,,392.136,Percent of Total Billed Charges,60% of Total Billed Charges,3874.73,90,,708.864,Percent of Total Billed Charges,90% of Total Billed Charges,1937.37,45,,362.368,Percent of Total Billed Charges,45% of Total Billed Charges,3874.73,90,,588.208,Percent of Total Billed Charges,90% of Total billed Charges,4305.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4305.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4305.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2798.42,65,,7681.648,Percent of total Billed Charges,65% of Total Billed Charges,1898.62,44.1,,355.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,4090,95,,620.88,Percent of Total Billed Charges,95% of Total Billed Charges,4305.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3788.63,88,,525.456,Percent of Total Billed Charges,88% of Total Billed Charges,3874.73,90,,588.208,Percent of Total Billed charges,90% of Total Billed Charges,1898.62,4305.26,
Z22553332 DST DRL BIT 3.2 IM,2780000355,CDM,278,RC,C1713,HCPCS,Outpatient,,,442.00,287.30,,442,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,335.92,76,,453.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,318.24,72,,2018.792,Percent of Total Billed Charges,72% of Total Billed Charges,318.24,72,,2018.792,Percent of Total Billed charges,72% of Total Billed Charges,442,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.24,72,,2018.792,Percent of Total Billed Charges,72% of Total Billed Charges,265.2,60,,1682.328,Percent of Total Billed Charges,60% of Total Billed Charges,397.8,90,,756.488,Percent of Total Billed Charges,90% of Total Billed Charges,198.9,45,,201.232,Percent of Total Billed Charges,45% of Total Billed Charges,397.8,90,,537.4,Percent of Total Billed Charges,90% of Total billed Charges,442,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,442,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,442,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,287.3,65,,63.064,Percent of total Billed Charges,65% of Total Billed Charges,194.92,44.1,,197.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,419.9,95,,567.256,Percent of Total Billed Charges,95% of Total Billed Charges,442,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,388.96,88,,620.152,Percent of Total Billed Charges,88% of Total Billed Charges,397.8,90,,537.4,Percent of Total Billed charges,90% of Total Billed Charges,194.92,442,
Z22553337 PILOT TIP DRIL BIT,2780000356,CDM,278,RC,C1713,HCPCS,Outpatient,,,165.38,107.50,,165.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,125.69,76,,535.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,119.07,72,,9959.968,Percent of Total Billed Charges,72% of Total Billed Charges,119.07,72,,9959.968,Percent of Total Billed charges,72% of Total Billed Charges,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.07,72,,9959.968,Percent of Total Billed Charges,72% of Total Billed Charges,99.23,60,,8299.976,Percent of Total Billed Charges,60% of Total Billed Charges,148.84,90,,1838.44,Percent of Total Billed Charges,90% of Total Billed Charges,74.42,45,,268.704,Percent of Total Billed Charges,45% of Total Billed Charges,148.84,90,,634.248,Percent of Total Billed Charges,90% of Total billed Charges,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,65,,63.064,Percent of total Billed Charges,65% of Total Billed Charges,72.93,44.1,,263.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,157.11,95,,669.488,Percent of Total Billed Charges,95% of Total Billed Charges,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,88,,591.44,Percent of Total Billed Charges,88% of Total Billed Charges,148.84,90,,634.248,Percent of Total Billed charges,90% of Total Billed Charges,72.93,165.38,
Z23481004 LFT PROX DORS UL PLT,2780000357,CDM,278,RC,C1776,HCPCS,Outpatient,,,2371.95,1541.77,,2371.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1802.68,76,,612,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1707.8,72,,8218.688,Percent of Total Billed Charges,72% of Total Billed Charges,1707.8,72,,8218.688,Percent of Total Billed charges,72% of Total Billed Charges,2371.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1707.8,72,,8218.688,Percent of Total Billed Charges,72% of Total Billed Charges,1423.17,60,,6848.912,Percent of Total Billed Charges,60% of Total Billed Charges,2134.76,90,,920.016,Percent of Total Billed Charges,90% of Total Billed Charges,1067.38,45,,317.128,Percent of Total Billed Charges,45% of Total Billed Charges,2134.76,90,,724.736,Percent of Total Billed Charges,90% of Total billed Charges,2371.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2371.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2371.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1541.77,65,,100.904,Percent of total Billed Charges,65% of Total Billed Charges,1046.03,44.1,,310.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,2253.35,95,,765,Percent of Total Billed Charges,95% of Total Billed Charges,2371.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2087.32,88,,629.464,Percent of Total Billed Charges,88% of Total Billed Charges,2134.76,90,,724.736,Percent of Total Billed charges,90% of Total Billed Charges,1046.03,2371.95,
Z23484035 3.5 CORTICAL SCW 40,2780000358,CDM,278,RC,C1713,HCPCS,Outpatient,,,104.00,67.60,,104,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.04,76,,339.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,74.88,72,,436.272,Percent of Total Billed Charges,72% of Total Billed Charges,74.88,72,,436.272,Percent of Total Billed charges,72% of Total Billed Charges,104,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.88,72,,436.272,Percent of Total Billed Charges,72% of Total Billed Charges,62.4,60,,363.56,Percent of Total Billed Charges,60% of Total Billed Charges,93.6,90,,587.416,Percent of Total Billed Charges,90% of Total Billed Charges,46.8,45,,302.44,Percent of Total Billed Charges,45% of Total Billed Charges,93.6,90,,402.456,Percent of Total Billed Charges,90% of Total billed Charges,104,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.6,65,,13.184,Percent of total Billed Charges,65% of Total Billed Charges,45.86,44.1,,296.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,98.8,95,,424.816,Percent of Total Billed Charges,95% of Total Billed Charges,104,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.52,88,,610.84,Percent of Total Billed Charges,88% of Total Billed Charges,93.6,90,,402.456,Percent of Total Billed charges,90% of Total Billed Charges,45.86,104,
Z23570306 TIBAL LCK PLT 6 RT,2780000359,CDM,278,RC,C1713,HCPCS,Outpatient,,,3887.00,2526.55,,3887,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2954.12,76,,453.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2798.64,72,,2018.792,Percent of Total Billed Charges,72% of Total Billed Charges,2798.64,72,,2018.792,Percent of Total Billed charges,72% of Total Billed Charges,3887,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2798.64,72,,2018.792,Percent of Total Billed Charges,72% of Total Billed Charges,2332.2,60,,1682.328,Percent of Total Billed Charges,60% of Total Billed Charges,3498.3,90,,3726.896,Percent of Total Billed Charges,90% of Total Billed Charges,1749.15,45,,321.888,Percent of Total Billed Charges,45% of Total Billed Charges,3498.3,90,,537.4,Percent of Total Billed Charges,90% of Total billed Charges,3887,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3887,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3887,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2526.55,65,,1326.04,Percent of total Billed Charges,65% of Total Billed Charges,1714.17,44.1,,315.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,3692.65,95,,567.256,Percent of Total Billed Charges,95% of Total Billed Charges,3887,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3420.56,88,,693.112,Percent of Total Billed Charges,88% of Total Billed Charges,3498.3,90,,537.4,Percent of Total Billed charges,90% of Total Billed Charges,1714.17,3887,
Z23570908 RT DIS LAT PLTE 8H,2780000360,CDM,278,RC,C1776,HCPCS,Outpatient,,,4859.82,3158.88,,4859.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3693.46,76,,535.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3499.07,72,,2273.44,Percent of Total Billed Charges,72% of Total Billed Charges,3499.07,72,,2273.44,Percent of Total Billed charges,72% of Total Billed Charges,4859.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3499.07,72,,2273.44,Percent of Total Billed Charges,72% of Total Billed Charges,2915.89,60,,1894.536,Percent of Total Billed Charges,60% of Total Billed Charges,4373.84,90,,743,Percent of Total Billed Charges,90% of Total Billed Charges,2186.92,45,,312.36,Percent of Total Billed Charges,45% of Total Billed Charges,4373.84,90,,634.248,Percent of Total Billed Charges,90% of Total billed Charges,4859.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4859.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4859.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3158.88,65,,439.72,Percent of total Billed Charges,65% of Total Billed Charges,2143.18,44.1,,306.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,4616.83,95,,669.488,Percent of Total Billed Charges,95% of Total Billed Charges,4859.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4276.64,88,,739.68,Percent of Total Billed Charges,88% of Total Billed Charges,4373.84,90,,634.248,Percent of Total Billed charges,90% of Total Billed Charges,2143.18,4859.82,
Z23580112 PROX LAT HUM 12HPLTE,2780000361,CDM,278,RC,C1773,HCPCS,Outpatient,,,4612.00,2997.80,,4612,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3505.12,76,,510.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3320.64,72,,160.664,Percent of Total Billed Charges,72% of Total Billed Charges,3320.64,72,,160.664,Percent of Total Billed charges,72% of Total Billed Charges,4612,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3320.64,72,,160.664,Percent of Total Billed Charges,72% of Total Billed Charges,2767.2,60,,133.888,Percent of Total Billed Charges,60% of Total Billed Charges,4150.8,90,,3892,Percent of Total Billed Charges,90% of Total Billed Charges,2075.4,45,,354.432,Percent of Total Billed Charges,45% of Total Billed Charges,4150.8,90,,604.88,Percent of Total Billed Charges,90% of Total billed Charges,4612,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4612,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4612,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2997.8,65,,439.72,Percent of total Billed Charges,65% of Total Billed Charges,2033.89,44.1,,347.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,4381.4,95,,638.48,Percent of Total Billed Charges,95% of Total Billed Charges,4612,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4058.56,88,,1797.584,Percent of Total Billed Charges,88% of Total Billed Charges,4150.8,90,,604.88,Percent of Total Billed charges,90% of Total Billed Charges,2033.89,4612,
Z23580208 HUM PLTE LT 8 HOLE,2780000362,CDM,278,RC,C1713,HCPCS,Outpatient,,,4500.00,2925.00,,4500,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3420,76,,543.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3240,72,,53.344,Percent of Total Billed Charges,72% of Total Billed Charges,3240,72,,53.344,Percent of Total Billed charges,72% of Total Billed Charges,4500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3240,72,,53.344,Percent of Total Billed Charges,72% of Total Billed Charges,2700,60,,44.456,Percent of Total Billed Charges,60% of Total Billed Charges,4050,90,,611.232,Percent of Total Billed Charges,90% of Total Billed Charges,2025,45,,378.248,Percent of Total Billed Charges,45% of Total Billed Charges,4050,90,,643.776,Percent of Total Billed Charges,90% of Total billed Charges,4500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2925,65,,2594.76,Percent of total Billed Charges,65% of Total Billed Charges,1984.5,44.1,,370.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,4275,95,,679.536,Percent of Total Billed Charges,95% of Total Billed Charges,4500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3960,88,,899.568,Percent of Total Billed Charges,88% of Total Billed Charges,4050,90,,643.776,Percent of Total Billed charges,90% of Total Billed Charges,1984.5,4500,
Z23580212 HUM PLTE LT 12HOLE,2780000363,CDM,278,RC,C1713,HCPCS,Outpatient,,,4611.00,2997.15,,4611,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3504.36,76,,527.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3319.92,72,,53.344,Percent of Total Billed Charges,72% of Total Billed Charges,3319.92,72,,53.344,Percent of Total Billed charges,72% of Total Billed Charges,4611,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3319.92,72,,53.344,Percent of Total Billed Charges,72% of Total Billed Charges,2766.6,60,,44.456,Percent of Total Billed Charges,60% of Total Billed Charges,4149.9,90,,184.16,Percent of Total Billed Charges,90% of Total Billed Charges,2074.95,45,,919.224,Percent of Total Billed Charges,45% of Total Billed Charges,4149.9,90,,624.72,Percent of Total Billed Charges,90% of Total billed Charges,4611,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4611,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4611,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2997.15,65,,2521.376,Percent of total Billed Charges,65% of Total Billed Charges,2033.45,44.1,,900.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,4380.45,95,,659.432,Percent of Total Billed Charges,95% of Total Billed Charges,4611,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4057.68,88,,574.36,Percent of Total Billed Charges,88% of Total Billed Charges,4149.9,90,,624.72,Percent of Total Billed charges,90% of Total Billed Charges,2033.45,4611,
Z23581704 VOL PLT 4 H9OLE RT,2780000364,CDM,278,RC,C1716,HCPCS,Outpatient,,,2657.03,1727.07,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,2019.34,76,,598.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2158.28,72,,50.168,Percent of Total Billed Charges,72% of Total Billed Charges,2158.28,72,,50.168,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2158.28,72,,50.168,Percent of Total Billed Charges,72% of Total Billed Charges,1716.83,60,,41.808,Percent of Total Billed Charges,60% of Total Billed Charges,2391.33,90,,3892,Percent of Total Billed Charges,90% of Total Billed Charges,1195.66,45,,460.008,Percent of Total Billed Charges,45% of Total Billed Charges,2391.33,90,,708.864,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.73,65,,3599.184,Percent of total Billed Charges,65% of Total Billed Charges,1171.75,44.1,,450.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,2524.18,95,,748.24,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,2338.19,88,,3644.072,Percent of Total Billed Charges,88% of Total Billed Charges,2391.33,90,,708.864,Percent of Total Billed charges,90% of Total Billed Charges,651.24,3463.73,
Z23582005 DIST PLAT 10H IGHT,2780000365,CDM,278,RC,C1713,HCPCS,Outpatient,,,4618.00,3001.70,,4618,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3509.68,76,,638.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3324.96,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,3324.96,72,,44.456,Percent of Total Billed charges,72% of Total Billed Charges,4618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3324.96,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,2770.8,60,,37.048,Percent of Total Billed Charges,60% of Total Billed Charges,4156.2,90,,611.232,Percent of Total Billed Charges,90% of Total Billed Charges,2078.1,45,,293.704,Percent of Total Billed Charges,45% of Total Billed Charges,4156.2,90,,756.488,Percent of Total Billed Charges,90% of Total billed Charges,4618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3001.7,65,,439.72,Percent of total Billed Charges,65% of Total Billed Charges,2036.54,44.1,,287.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,4387.1,95,,798.52,Percent of Total Billed Charges,95% of Total Billed Charges,4618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4063.84,88,,726.488,Percent of Total Billed Charges,88% of Total Billed Charges,4156.2,90,,756.488,Percent of Total Billed charges,90% of Total Billed Charges,2036.54,4618,
Z23582106 DORS T PLT 6 HOLE,2780000366,CDM,278,RC,,,Outpatient,,,3014.24,1959.26,,3014.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2290.82,76,,1552.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2170.25,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,2170.25,72,,44.456,Percent of Total Billed charges,72% of Total Billed Charges,3014.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2170.25,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,1808.54,60,,37.048,Percent of Total Billed Charges,60% of Total Billed Charges,2712.82,90,,2758.456,Percent of Total Billed Charges,90% of Total Billed Charges,1356.41,45,,1863.448,Percent of Total Billed Charges,45% of Total Billed Charges,2712.82,90,,1838.44,Percent of Total Billed Charges,90% of Total billed Charges,3014.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3014.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3014.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1959.26,65,,439.72,Percent of total Billed Charges,65% of Total Billed Charges,1329.28,44.1,,1826.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,2863.53,95,,1940.576,Percent of Total Billed Charges,95% of Total Billed Charges,3014.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2652.53,88,,3805.512,Percent of Total Billed Charges,88% of Total Billed Charges,2712.82,90,,1838.44,Percent of Total Billed charges,90% of Total Billed Charges,1329.28,3014.24,
Z23582602 LFT DORS DELTA 2H,2780000367,CDM,278,RC,C1716,HCPCS,Outpatient,,,2648.21,1721.34,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,2012.64,76,,776.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2151.93,72,,303.552,Percent of Total Billed Charges,72% of Total Billed Charges,2151.93,72,,303.552,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2151.93,72,,303.552,Percent of Total Billed Charges,72% of Total Billed Charges,1711.54,60,,252.96,Percent of Total Billed Charges,60% of Total Billed Charges,2383.39,90,,1094.656,Percent of Total Billed Charges,90% of Total Billed Charges,1191.69,45,,371.496,Percent of Total Billed Charges,45% of Total Billed Charges,2383.39,90,,920.016,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3458,65,,678.216,Percent of total Billed Charges,65% of Total Billed Charges,1167.86,44.1,,364.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,2515.8,95,,971.128,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,2330.42,88,,597.648,Percent of Total Billed Charges,88% of Total Billed Charges,2383.39,90,,920.016,Percent of Total Billed charges,90% of Total Billed Charges,651.24,3458,
Z23582604 LFT DORS DEL 4HOLE,2780000368,CDM,278,RC,C1716,HCPCS,Outpatient,,,2747.43,1785.83,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,2088.05,76,,496.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2223.37,72,,127.64,Percent of Total Billed Charges,72% of Total Billed Charges,2223.37,72,,127.64,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2223.37,72,,127.64,Percent of Total Billed Charges,72% of Total Billed Charges,1771.07,60,,106.368,Percent of Total Billed Charges,60% of Total Billed Charges,2472.69,90,,137.328,Percent of Total Billed Charges,90% of Total Billed Charges,1236.34,45,,1946,Percent of Total Billed Charges,45% of Total Billed Charges,2472.69,90,,587.416,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3522.49,65,,678.216,Percent of total Billed Charges,65% of Total Billed Charges,1211.62,44.1,,1907.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,2610.06,95,,620.048,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,2417.74,88,,180.072,Percent of Total Billed Charges,88% of Total Billed Charges,2472.69,90,,587.416,Percent of Total Billed charges,90% of Total Billed Charges,651.24,3522.49,
Z23592427 2.7 LOCKNG SCRW 24,2780000369,CDM,278,RC,C1713,HCPCS,Outpatient,,,262.00,170.30,,262,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,199.12,76,,3147.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,188.64,72,,86.368,Percent of Total Billed Charges,72% of Total Billed Charges,188.64,72,,86.368,Percent of Total Billed charges,72% of Total Billed Charges,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.64,72,,86.368,Percent of Total Billed Charges,72% of Total Billed Charges,157.2,60,,71.968,Percent of Total Billed Charges,60% of Total Billed Charges,235.8,90,,284.184,Percent of Total Billed Charges,90% of Total Billed Charges,117.9,45,,305.616,Percent of Total Billed Charges,45% of Total Billed Charges,235.8,90,,3726.896,Percent of Total Billed Charges,90% of Total billed Charges,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.3,65,,11380.008,Percent of total Billed Charges,65% of Total Billed Charges,115.54,44.1,,299.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,248.9,95,,3933.944,Percent of Total Billed Charges,95% of Total Billed Charges,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.56,88,,3805.512,Percent of Total Billed Charges,88% of Total Billed Charges,235.8,90,,3726.896,Percent of Total Billed charges,90% of Total Billed Charges,115.54,262,
Z23592627 2.7 LOCKNG SCRW 26,2780000370,CDM,278,RC,C1713,HCPCS,Outpatient,,,262.00,170.30,,262,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,199.12,76,,627.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,188.64,72,,380.392,Percent of Total Billed Charges,72% of Total Billed Charges,188.64,72,,380.392,Percent of Total Billed charges,72% of Total Billed Charges,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.64,72,,380.392,Percent of Total Billed Charges,72% of Total Billed Charges,157.2,60,,316.992,Percent of Total Billed Charges,60% of Total Billed Charges,235.8,90,,1700.32,Percent of Total Billed Charges,90% of Total Billed Charges,117.9,45,,92.08,Percent of Total Billed Charges,45% of Total Billed Charges,235.8,90,,743,Percent of Total Billed Charges,90% of Total billed Charges,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.3,65,,12495.072,Percent of total Billed Charges,65% of Total Billed Charges,115.54,44.1,,90.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,248.9,95,,784.272,Percent of Total Billed Charges,95% of Total Billed Charges,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.56,88,,597.648,Percent of Total Billed Charges,88% of Total Billed Charges,235.8,90,,743,Percent of Total Billed charges,90% of Total Billed Charges,115.54,262,
Z23593227 2.7 LOCKNG SCRW 32,2780000371,CDM,278,RC,C1713,HCPCS,Outpatient,,,262.00,170.30,,262,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,199.12,76,,3286.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,188.64,72,,274.336,Percent of Total Billed Charges,72% of Total Billed Charges,188.64,72,,274.336,Percent of Total Billed charges,72% of Total Billed Charges,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.64,72,,274.336,Percent of Total Billed Charges,72% of Total Billed Charges,157.2,60,,228.616,Percent of Total Billed Charges,60% of Total Billed Charges,235.8,90,,10636.128,Percent of Total Billed Charges,90% of Total Billed Charges,117.9,45,,1946,Percent of Total Billed Charges,45% of Total Billed Charges,235.8,90,,3892,Percent of Total Billed Charges,90% of Total billed Charges,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.3,65,,244.232,Percent of total Billed Charges,65% of Total Billed Charges,115.54,44.1,,1907.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,248.9,95,,4108.224,Percent of Total Billed Charges,95% of Total Billed Charges,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.56,88,,2697.16,Percent of Total Billed Charges,88% of Total Billed Charges,235.8,90,,3892,Percent of Total Billed charges,90% of Total Billed Charges,115.54,262,
Z23593827 2.7 LOCKNG SCRW 38,2780000372,CDM,278,RC,C1713,HCPCS,Outpatient,,,262.00,170.30,,262,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,199.12,76,,516.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,188.64,72,,2832.28,Percent of Total Billed Charges,72% of Total Billed Charges,188.64,72,,2832.28,Percent of Total Billed charges,72% of Total Billed Charges,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.64,72,,2832.28,Percent of Total Billed Charges,72% of Total Billed Charges,157.2,60,,2360.232,Percent of Total Billed Charges,60% of Total Billed Charges,235.8,90,,87.32,Percent of Total Billed Charges,90% of Total Billed Charges,117.9,45,,305.616,Percent of Total Billed Charges,45% of Total Billed Charges,235.8,90,,611.232,Percent of Total Billed Charges,90% of Total billed Charges,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.3,65,,678.216,Percent of total Billed Charges,65% of Total Billed Charges,115.54,44.1,,299.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,248.9,95,,645.184,Percent of Total Billed Charges,95% of Total Billed Charges,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.56,88,,1070.328,Percent of Total Billed Charges,88% of Total Billed Charges,235.8,90,,611.232,Percent of Total Billed charges,90% of Total Billed Charges,115.54,262,
Z23594027 2.7 LOCKNG SCRW 40,2780000373,CDM,278,RC,C1713,HCPCS,Outpatient,,,262.00,170.30,,262,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,199.12,76,,155.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,188.64,72,,563.28,Percent of Total Billed Charges,72% of Total Billed Charges,188.64,72,,563.28,Percent of Total Billed charges,72% of Total Billed Charges,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.64,72,,563.28,Percent of Total Billed Charges,72% of Total Billed Charges,157.2,60,,469.4,Percent of Total Billed Charges,60% of Total Billed Charges,235.8,90,,87.32,Percent of Total Billed Charges,90% of Total Billed Charges,117.9,45,,1379.232,Percent of Total Billed Charges,45% of Total Billed Charges,235.8,90,,184.16,Percent of Total Billed Charges,90% of Total billed Charges,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.3,65,,5992.128,Percent of total Billed Charges,65% of Total Billed Charges,115.54,44.1,,1351.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,248.9,95,,194.392,Percent of Total Billed Charges,95% of Total Billed Charges,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.56,88,,134.272,Percent of Total Billed Charges,88% of Total Billed Charges,235.8,90,,184.16,Percent of Total Billed charges,90% of Total Billed Charges,115.54,262,
Z23597036 3.5 CANN LCK SCW70,2780000374,CDM,278,RC,C1713,HCPCS,Outpatient,,,306.00,198.90,,306,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,232.56,76,,3286.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,220.32,72,,563.28,Percent of Total Billed Charges,72% of Total Billed Charges,220.32,72,,563.28,Percent of Total Billed charges,72% of Total Billed Charges,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.32,72,,563.28,Percent of Total Billed Charges,72% of Total Billed Charges,183.6,60,,469.4,Percent of Total Billed Charges,60% of Total Billed Charges,275.4,90,,139.712,Percent of Total Billed Charges,90% of Total Billed Charges,137.7,45,,547.328,Percent of Total Billed Charges,45% of Total Billed Charges,275.4,90,,3892,Percent of Total Billed Charges,90% of Total billed Charges,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.9,65,,225.304,Percent of total Billed Charges,65% of Total Billed Charges,134.95,44.1,,536.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,290.7,95,,4108.224,Percent of Total Billed Charges,95% of Total Billed Charges,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.28,88,,277.872,Percent of Total Billed Charges,88% of Total Billed Charges,275.4,90,,3892,Percent of Total Billed charges,90% of Total Billed Charges,134.95,306,
Z249001230 THD GUDE PIN 305M,2780000375,CDM,278,RC,C1713,HCPCS,Outpatient,,,108.00,70.20,,108,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.08,76,,516.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.76,72,,563.28,Percent of Total Billed Charges,72% of Total Billed Charges,77.76,72,,563.28,Percent of Total Billed charges,72% of Total Billed Charges,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.76,72,,563.28,Percent of Total Billed Charges,72% of Total Billed Charges,64.8,60,,469.4,Percent of Total Billed Charges,60% of Total Billed Charges,97.2,90,,18.256,Percent of Total Billed Charges,90% of Total Billed Charges,48.6,45,,68.664,Percent of Total Billed Charges,45% of Total Billed Charges,97.2,90,,611.232,Percent of Total Billed Charges,90% of Total billed Charges,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.2,65,,7513.096,Percent of total Billed Charges,65% of Total Billed Charges,47.63,44.1,,67.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.6,95,,645.184,Percent of Total Billed Charges,95% of Total Billed Charges,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.04,88,,1662.536,Percent of Total Billed Charges,88% of Total Billed Charges,97.2,90,,611.232,Percent of Total Billed charges,90% of Total Billed Charges,47.63,108,
Z42205006401 PERS FEM SZE LFT,2780000376,CDM,278,RC,C1776,HCPCS,Outpatient,,,19177.99,12465.69,,19177.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14575.27,76,,2329.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13808.15,72,,563.28,Percent of Total Billed Charges,72% of Total Billed Charges,13808.15,72,,563.28,Percent of Total Billed charges,72% of Total Billed Charges,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13808.15,72,,563.28,Percent of Total Billed Charges,72% of Total Billed Charges,11506.79,60,,469.4,Percent of Total Billed Charges,60% of Total Billed Charges,17260.19,90,,1836.056,Percent of Total Billed Charges,90% of Total Billed Charges,8630.1,45,,142.096,Percent of Total Billed Charges,45% of Total Billed Charges,17260.19,90,,2758.456,Percent of Total Billed Charges,90% of Total billed Charges,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12465.69,65,,395,Percent of total Billed Charges,65% of Total Billed Charges,8457.49,44.1,,139.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,18219.09,95,,2911.704,Percent of Total Billed Charges,95% of Total Billed Charges,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16876.63,88,,10399.768,Percent of Total Billed Charges,88% of Total Billed Charges,17260.19,90,,2758.456,Percent of Total Billed charges,90% of Total Billed Charges,8457.49,19177.99,
Z42500006402 PER FEM SZ8 RT,2780000377,CDM,278,RC,C1776,HCPCS,Outpatient,,,17847.27,11600.73,,17847.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13563.93,76,,924.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12850.03,72,,33.024,Percent of Total Billed Charges,72% of Total Billed Charges,12850.03,72,,33.024,Percent of Total Billed charges,72% of Total Billed Charges,17847.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12850.03,72,,33.024,Percent of Total Billed Charges,72% of Total Billed Charges,10708.36,60,,27.52,Percent of Total Billed Charges,60% of Total Billed Charges,16062.54,90,,608.848,Percent of Total Billed Charges,90% of Total Billed Charges,8031.27,45,,850.16,Percent of Total Billed Charges,45% of Total Billed Charges,16062.54,90,,1094.656,Percent of Total Billed Charges,90% of Total billed Charges,17847.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17847.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17847.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11600.73,65,,1688.368,Percent of total Billed Charges,65% of Total Billed Charges,7870.65,44.1,,833.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,16954.91,95,,1155.464,Percent of Total Billed Charges,95% of Total Billed Charges,17847.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15705.6,88,,85.384,Percent of Total Billed Charges,88% of Total Billed Charges,16062.54,90,,1094.656,Percent of Total Billed charges,90% of Total Billed Charges,7870.65,17847.27,
Z42500606002 PER FEM SZ6 RT,2780000378,CDM,278,RC,C1776,HCPCS,Outpatient,,,16997.40,11048.31,,16997.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12918.02,76,,115.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12238.13,72,,2530,Percent of Total Billed Charges,72% of Total Billed Charges,12238.13,72,,2530,Percent of Total Billed charges,72% of Total Billed Charges,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12238.13,72,,2530,Percent of Total Billed Charges,72% of Total Billed Charges,10198.44,60,,2108.336,Percent of Total Billed Charges,60% of Total Billed Charges,15297.66,90,,608.848,Percent of Total Billed Charges,90% of Total Billed Charges,7648.83,45,,5318.064,Percent of Total Billed Charges,45% of Total Billed Charges,15297.66,90,,137.328,Percent of Total Billed Charges,90% of Total billed Charges,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11048.31,65,,45.296,Percent of total Billed Charges,65% of Total Billed Charges,7495.85,44.1,,5211.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,16147.53,95,,144.952,Percent of Total Billed Charges,95% of Total Billed Charges,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14957.71,88,,85.384,Percent of Total Billed Charges,88% of Total Billed Charges,15297.66,90,,137.328,Percent of Total Billed charges,90% of Total Billed Charges,7495.85,16997.4,
Z42502006201 PERS FMR SZ 7 LFT,2780000379,CDM,278,RC,C1776,HCPCS,Outpatient,,,19177.99,12465.69,,19177.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14575.27,76,,239.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13808.15,72,,2918.008,Percent of Total Billed Charges,72% of Total Billed Charges,13808.15,72,,2918.008,Percent of Total Billed charges,72% of Total Billed Charges,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13808.15,72,,2918.008,Percent of Total Billed Charges,72% of Total Billed Charges,11506.79,60,,2431.672,Percent of Total Billed Charges,60% of Total Billed Charges,17260.19,90,,3592.744,Percent of Total Billed Charges,90% of Total Billed Charges,8630.1,45,,43.664,Percent of Total Billed Charges,45% of Total Billed Charges,17260.19,90,,284.184,Percent of Total Billed Charges,90% of Total billed Charges,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12465.69,65,,3507.456,Percent of total Billed Charges,65% of Total Billed Charges,8457.49,44.1,,42.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,18219.09,95,,299.976,Percent of Total Billed Charges,95% of Total Billed Charges,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16876.63,88,,136.608,Percent of Total Billed Charges,88% of Total Billed Charges,17260.19,90,,284.184,Percent of Total Billed charges,90% of Total Billed Charges,8457.49,19177.99,
Z42502605602 PERS FEM SZ 4 RT,2780000380,CDM,278,RC,C1713,HCPCS,Outpatient,,,17847.27,11600.73,,17847.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13563.93,76,,1435.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12850.03,72,,2918.008,Percent of Total Billed Charges,72% of Total Billed Charges,12850.03,72,,2918.008,Percent of Total Billed charges,72% of Total Billed Charges,17847.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12850.03,72,,2918.008,Percent of Total Billed Charges,72% of Total Billed Charges,10708.36,60,,2431.672,Percent of Total Billed Charges,60% of Total Billed Charges,16062.54,90,,3491.136,Percent of Total Billed Charges,90% of Total Billed Charges,8031.27,45,,43.664,Percent of Total Billed Charges,45% of Total Billed Charges,16062.54,90,,1700.32,Percent of Total Billed Charges,90% of Total billed Charges,17847.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17847.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17847.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11600.73,65,,357.736,Percent of total Billed Charges,65% of Total Billed Charges,7870.65,44.1,,42.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,16954.91,95,,1794.784,Percent of Total Billed Charges,95% of Total Billed Charges,17847.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15705.6,88,,17.856,Percent of Total Billed Charges,88% of Total Billed Charges,16062.54,90,,1700.32,Percent of Total Billed charges,90% of Total Billed Charges,7870.65,17847.27,
Z42502605801 PERS FEM SZ5 L,2780000381,CDM,278,RC,C1776,HCPCS,Outpatient,,,16997.40,11048.31,,16997.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12918.02,76,,8981.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12238.13,72,,3225.368,Percent of Total Billed Charges,72% of Total Billed Charges,12238.13,72,,3225.368,Percent of Total Billed charges,72% of Total Billed Charges,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12238.13,72,,3225.368,Percent of Total Billed Charges,72% of Total Billed Charges,10198.44,60,,2687.808,Percent of Total Billed Charges,60% of Total Billed Charges,15297.66,90,,4983.48,Percent of Total Billed Charges,90% of Total Billed Charges,7648.83,45,,69.856,Percent of Total Billed Charges,45% of Total Billed Charges,15297.66,90,,10636.128,Percent of Total Billed Charges,90% of Total billed Charges,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11048.31,65,,357.736,Percent of total Billed Charges,65% of Total Billed Charges,7495.85,44.1,,68.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,16147.53,95,,11227.024,Percent of Total Billed Charges,95% of Total Billed Charges,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14957.71,88,,1795.256,Percent of Total Billed Charges,88% of Total Billed Charges,15297.66,90,,10636.128,Percent of Total Billed charges,90% of Total Billed Charges,7495.85,16997.4,
Z42502606001 PERS FEM SZ 6 LT,2780000382,CDM,278,RC,C1713,HCPCS,Outpatient,,,16997.40,11048.31,,16997.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12918.02,76,,73.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12238.13,72,,2651.928,Percent of Total Billed Charges,72% of Total Billed Charges,12238.13,72,,2651.928,Percent of Total Billed charges,72% of Total Billed Charges,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12238.13,72,,2651.928,Percent of Total Billed Charges,72% of Total Billed Charges,10198.44,60,,2209.936,Percent of Total Billed Charges,60% of Total Billed Charges,15297.66,90,,608.848,Percent of Total Billed Charges,90% of Total Billed Charges,7648.83,45,,9.128,Percent of Total Billed Charges,45% of Total Billed Charges,15297.66,90,,87.32,Percent of Total Billed Charges,90% of Total billed Charges,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11048.31,65,,260.856,Percent of total Billed Charges,65% of Total Billed Charges,7495.85,44.1,,8.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,16147.53,95,,92.176,Percent of Total Billed Charges,95% of Total Billed Charges,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14957.71,88,,595.32,Percent of Total Billed Charges,88% of Total Billed Charges,15297.66,90,,87.32,Percent of Total Billed charges,90% of Total Billed Charges,7495.85,16997.4,
Z42502606002 PERS FEM SZ 6 RT,2780000383,CDM,278,RC,C1713,HCPCS,Outpatient,,,19177.99,12465.69,,19177.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14575.27,76,,73.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13808.15,72,,4595.152,Percent of Total Billed Charges,72% of Total Billed Charges,13808.15,72,,4595.152,Percent of Total Billed charges,72% of Total Billed Charges,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13808.15,72,,4595.152,Percent of Total Billed Charges,72% of Total Billed Charges,11506.79,60,,3829.288,Percent of Total Billed Charges,60% of Total Billed Charges,17260.19,90,,608.848,Percent of Total Billed Charges,90% of Total Billed Charges,8630.1,45,,918.032,Percent of Total Billed Charges,45% of Total Billed Charges,17260.19,90,,87.32,Percent of Total Billed Charges,90% of Total billed Charges,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12465.69,65,,100.904,Percent of total Billed Charges,65% of Total Billed Charges,8457.49,44.1,,899.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,18219.09,95,,92.176,Percent of Total Billed Charges,95% of Total Billed Charges,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16876.63,88,,595.32,Percent of Total Billed Charges,88% of Total Billed Charges,17260.19,90,,87.32,Percent of Total Billed charges,90% of Total Billed Charges,8457.49,19177.99,
Z42502606201 PERS FMUR SZ 7LFT,2780000384,CDM,278,RC,C1713,HCPCS,Outpatient,,,19177.99,12465.69,,19177.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14575.27,76,,117.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13808.15,72,,14492.888,Percent of Total Billed Charges,72% of Total Billed Charges,13808.15,72,,14492.888,Percent of Total Billed charges,72% of Total Billed Charges,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13808.15,72,,14492.888,Percent of Total Billed Charges,72% of Total Billed Charges,11506.79,60,,12077.408,Percent of Total Billed Charges,60% of Total Billed Charges,17260.19,90,,939.064,Percent of Total Billed Charges,90% of Total Billed Charges,8630.1,45,,304.424,Percent of Total Billed Charges,45% of Total Billed Charges,17260.19,90,,139.712,Percent of Total Billed Charges,90% of Total billed Charges,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12465.69,65,,282.064,Percent of total Billed Charges,65% of Total Billed Charges,8457.49,44.1,,298.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,18219.09,95,,147.472,Percent of Total Billed Charges,95% of Total Billed Charges,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16876.63,88,,3512.904,Percent of Total Billed Charges,88% of Total Billed Charges,17260.19,90,,139.712,Percent of Total Billed charges,90% of Total Billed Charges,8457.49,19177.99,
Z42502606202 PERS FEM SZ 7 RT,2780000385,CDM,278,RC,C1713,HCPCS,Outpatient,,,17847.27,11600.73,,17847.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13563.93,76,,15.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12850.03,72,,4684.056,Percent of Total Billed Charges,72% of Total Billed Charges,12850.03,72,,4684.056,Percent of Total Billed charges,72% of Total Billed Charges,17847.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12850.03,72,,4684.056,Percent of Total Billed Charges,72% of Total Billed Charges,10708.36,60,,3903.376,Percent of Total Billed Charges,60% of Total Billed Charges,16062.54,90,,939.064,Percent of Total Billed Charges,90% of Total Billed Charges,8031.27,45,,304.424,Percent of Total Billed Charges,45% of Total Billed Charges,16062.54,90,,18.256,Percent of Total Billed Charges,90% of Total billed Charges,17847.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17847.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17847.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11600.73,65,,1719.328,Percent of total Billed Charges,65% of Total Billed Charges,7870.65,44.1,,298.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,16954.91,95,,19.272,Percent of Total Billed Charges,95% of Total Billed Charges,17847.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15705.6,88,,3413.552,Percent of Total Billed Charges,88% of Total Billed Charges,16062.54,90,,18.256,Percent of Total Billed charges,90% of Total Billed Charges,7870.65,17847.27,
Z42502606401 PERS FEM S28LT,2780000386,CDM,278,RC,C1776,HCPCS,Outpatient,,,16188.00,10522.20,,16188,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12302.88,76,,1550.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11655.36,72,,3709.904,Percent of Total Billed Charges,72% of Total Billed Charges,11655.36,72,,3709.904,Percent of Total Billed charges,72% of Total Billed Charges,16188,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11655.36,72,,3709.904,Percent of Total Billed Charges,72% of Total Billed Charges,9712.8,60,,3091.592,Percent of Total Billed Charges,60% of Total Billed Charges,14569.2,90,,15756.936,Percent of Total Billed Charges,90% of Total Billed Charges,7284.6,45,,1796.368,Percent of Total Billed Charges,45% of Total Billed Charges,14569.2,90,,1836.056,Percent of Total Billed Charges,90% of Total billed Charges,16188,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16188,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16188,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10522.2,65,,77.968,Percent of total Billed Charges,65% of Total Billed Charges,7138.91,44.1,,1760.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,15378.6,95,,1938.064,Percent of Total Billed Charges,95% of Total Billed Charges,16188,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14245.44,88,,4872.736,Percent of Total Billed Charges,88% of Total Billed Charges,14569.2,90,,1836.056,Percent of Total Billed charges,90% of Total Billed Charges,7138.91,16188,
Z42502606402 PERS FEM SZ8 R,2780000387,CDM,278,RC,C1776,HCPCS,Outpatient,,,16997.40,11048.31,,16997.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12918.02,76,,514.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12238.13,72,,2832.912,Percent of Total Billed Charges,72% of Total Billed Charges,12238.13,72,,2832.912,Percent of Total Billed charges,72% of Total Billed Charges,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12238.13,72,,2832.912,Percent of Total Billed Charges,72% of Total Billed Charges,10198.44,60,,2360.76,Percent of Total Billed Charges,60% of Total Billed Charges,15297.66,90,,17300.872,Percent of Total Billed Charges,90% of Total Billed Charges,7648.83,45,,1745.568,Percent of Total Billed Charges,45% of Total Billed Charges,15297.66,90,,608.848,Percent of Total Billed Charges,90% of Total billed Charges,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11048.31,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,7495.85,44.1,,1710.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,16147.53,95,,642.672,Percent of Total Billed Charges,95% of Total Billed Charges,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14957.71,88,,595.32,Percent of Total Billed Charges,88% of Total Billed Charges,15297.66,90,,608.848,Percent of Total Billed charges,90% of Total Billed Charges,7495.85,16997.4,
Z42502606602 PERS FEM SZ 9 RT,2780000388,CDM,278,RC,C1713,HCPCS,Outpatient,,,17847.27,11600.73,,17847.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13563.93,76,,514.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12850.03,72,,563.28,Percent of Total Billed Charges,72% of Total Billed Charges,12850.03,72,,563.28,Percent of Total Billed charges,72% of Total Billed Charges,17847.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12850.03,72,,563.28,Percent of Total Billed Charges,72% of Total Billed Charges,10708.36,60,,469.4,Percent of Total Billed Charges,60% of Total Billed Charges,16062.54,90,,338.16,Percent of Total Billed Charges,90% of Total Billed Charges,8031.27,45,,2491.744,Percent of Total Billed Charges,45% of Total Billed Charges,16062.54,90,,608.848,Percent of Total Billed Charges,90% of Total billed Charges,17847.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17847.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17847.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11600.73,65,,838.736,Percent of total Billed Charges,65% of Total Billed Charges,7870.65,44.1,,2441.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,16954.91,95,,642.672,Percent of Total Billed Charges,95% of Total Billed Charges,17847.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15705.6,88,,595.32,Percent of Total Billed Charges,88% of Total Billed Charges,16062.54,90,,608.848,Percent of Total Billed charges,90% of Total Billed Charges,7870.65,17847.27,
Z42502606801 FEMUR LFT SZ10,2780000389,CDM,278,RC,C1776,HCPCS,Outpatient,,,19122.86,12429.86,,19122.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14533.37,76,,3033.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13768.46,72,,563.28,Percent of Total Billed Charges,72% of Total Billed Charges,13768.46,72,,563.28,Percent of Total Billed charges,72% of Total Billed Charges,19122.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13768.46,72,,563.28,Percent of Total Billed Charges,72% of Total Billed Charges,11473.72,60,,469.4,Percent of Total Billed Charges,60% of Total Billed Charges,17210.57,90,,939.064,Percent of Total Billed Charges,90% of Total Billed Charges,8605.29,45,,304.424,Percent of Total Billed Charges,45% of Total Billed Charges,17210.57,90,,3592.744,Percent of Total Billed Charges,90% of Total billed Charges,19122.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19122.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19122.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12429.86,65,,123.832,Percent of total Billed Charges,65% of Total Billed Charges,8433.18,44.1,,298.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,18166.72,95,,3792.336,Percent of Total Billed Charges,95% of Total Billed Charges,19122.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16828.12,88,,918.2,Percent of Total Billed Charges,88% of Total Billed Charges,17210.57,90,,3592.744,Percent of Total Billed charges,90% of Total Billed Charges,8433.18,19122.86,
Z42502607001 PERS FMR SZ11 LFT,2780000390,CDM,278,RC,C1713,HCPCS,Outpatient,,,19177.99,12465.69,,19177.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14575.27,76,,2948.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13808.15,72,,64.776,Percent of Total Billed Charges,72% of Total Billed Charges,13808.15,72,,64.776,Percent of Total Billed charges,72% of Total Billed Charges,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13808.15,72,,64.776,Percent of Total Billed Charges,72% of Total Billed Charges,11506.79,60,,53.984,Percent of Total Billed Charges,60% of Total Billed Charges,17260.19,90,,8296.8,Percent of Total Billed Charges,90% of Total Billed Charges,8630.1,45,,304.424,Percent of Total Billed Charges,45% of Total Billed Charges,17260.19,90,,3491.136,Percent of Total Billed Charges,90% of Total billed Charges,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12465.69,65,,50.448,Percent of total Billed Charges,65% of Total Billed Charges,8457.49,44.1,,298.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,18219.09,95,,3685.088,Percent of Total Billed Charges,95% of Total Billed Charges,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16876.63,88,,918.2,Percent of Total Billed Charges,88% of Total Billed Charges,17260.19,90,,3491.136,Percent of Total Billed charges,90% of Total Billed Charges,8457.49,19177.99,
Z42509902525 THRD PN 25MM,2780000391,CDM,278,RC,C1713,HCPCS,Outpatient,,,979.02,636.36,,979.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,744.06,76,,4208.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,704.89,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,704.89,72,,45.088,Percent of Total Billed charges,72% of Total Billed Charges,979.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704.89,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,587.41,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,881.12,90,,311.96,Percent of Total Billed Charges,90% of Total Billed Charges,440.56,45,,469.536,Percent of Total Billed Charges,45% of Total Billed Charges,881.12,90,,4983.48,Percent of Total Billed Charges,90% of Total billed Charges,979.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,979.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,979.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,636.36,65,,50.448,Percent of total Billed Charges,65% of Total Billed Charges,431.75,44.1,,460.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,930.07,95,,5260.344,Percent of Total Billed Charges,95% of Total Billed Charges,979.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,861.54,88,,15406.776,Percent of Total Billed Charges,88% of Total Billed Charges,881.12,90,,4983.48,Percent of Total Billed charges,90% of Total Billed Charges,431.75,979.02,
Z42509902548 THD PIN 48,2780000392,CDM,278,RC,C1713,HCPCS,Outpatient,,,979.02,636.36,,979.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,744.06,76,,514.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,704.89,72,,483.264,Percent of Total Billed Charges,72% of Total Billed Charges,704.89,72,,483.264,Percent of Total Billed charges,72% of Total Billed Charges,979.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704.89,72,,483.264,Percent of Total Billed Charges,72% of Total Billed Charges,587.41,60,,402.72,Percent of Total Billed Charges,60% of Total Billed Charges,881.12,90,,10402.744,Percent of Total Billed Charges,90% of Total Billed Charges,440.56,45,,469.536,Percent of Total Billed Charges,45% of Total Billed Charges,881.12,90,,608.848,Percent of Total Billed Charges,90% of Total billed Charges,979.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,979.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,979.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,636.36,65,,165.68,Percent of total Billed Charges,65% of Total Billed Charges,431.75,44.1,,460.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,930.07,95,,642.672,Percent of Total Billed Charges,95% of Total Billed Charges,979.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,861.54,88,,16916.408,Percent of Total Billed Charges,88% of Total Billed Charges,881.12,90,,608.848,Percent of Total Billed charges,90% of Total Billed Charges,431.75,979.02,
Z42511000412 PERS AS SZ12,2780000393,CDM,278,RC,C1713,HCPCS,Outpatient,,,6849.83,4452.39,,6849.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5205.87,76,,514.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4931.88,72,,483.264,Percent of Total Billed Charges,72% of Total Billed Charges,4931.88,72,,483.264,Percent of Total Billed charges,72% of Total Billed Charges,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4931.88,72,,483.264,Percent of Total Billed Charges,72% of Total Billed Charges,4109.9,60,,402.72,Percent of Total Billed Charges,60% of Total Billed Charges,6164.85,90,,546.928,Percent of Total Billed Charges,90% of Total Billed Charges,3082.42,45,,7878.464,Percent of Total Billed Charges,45% of Total Billed Charges,6164.85,90,,608.848,Percent of Total Billed Charges,90% of Total billed Charges,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4452.39,65,,201.8,Percent of total Billed Charges,65% of Total Billed Charges,3020.78,44.1,,7720.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,6507.34,95,,642.672,Percent of Total Billed Charges,95% of Total Billed Charges,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6027.85,88,,330.648,Percent of Total Billed Charges,88% of Total Billed Charges,6164.85,90,,608.848,Percent of Total Billed charges,90% of Total Billed Charges,3020.78,6849.83,
Z42511000510 PER AS SZ 311,2780000394,CDM,278,RC,C1713,HCPCS,Outpatient,,,5401.15,3510.75,,5401.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4104.87,76,,792.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3888.83,72,,483.264,Percent of Total Billed Charges,72% of Total Billed Charges,3888.83,72,,483.264,Percent of Total Billed charges,72% of Total Billed Charges,5401.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3888.83,72,,483.264,Percent of Total Billed Charges,72% of Total Billed Charges,3240.69,60,,402.72,Percent of Total Billed Charges,60% of Total Billed Charges,4861.04,90,,2337.736,Percent of Total Billed Charges,90% of Total Billed Charges,2430.52,45,,8650.44,Percent of Total Billed Charges,45% of Total Billed Charges,4861.04,90,,939.064,Percent of Total Billed Charges,90% of Total billed Charges,5401.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5401.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5401.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3510.75,65,,519.984,Percent of total Billed Charges,65% of Total Billed Charges,2381.91,44.1,,8477.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,5131.09,95,,991.24,Percent of Total Billed Charges,95% of Total Billed Charges,5401.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4753.01,88,,918.2,Percent of Total Billed Charges,88% of Total Billed Charges,4861.04,90,,939.064,Percent of Total Billed charges,90% of Total Billed Charges,2381.91,5401.15,
Z42511000512 PERS  SZ 12 LT,2780000395,CDM,278,RC,C1713,HCPCS,Outpatient,,,5143.95,3343.57,,5143.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3909.4,76,,792.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3703.64,72,,483.264,Percent of Total Billed Charges,72% of Total Billed Charges,3703.64,72,,483.264,Percent of Total Billed charges,72% of Total Billed Charges,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3703.64,72,,483.264,Percent of Total Billed Charges,72% of Total Billed Charges,3086.37,60,,402.72,Percent of Total Billed Charges,60% of Total Billed Charges,4629.56,90,,62.712,Percent of Total Billed Charges,90% of Total Billed Charges,2314.78,45,,169.08,Percent of Total Billed Charges,45% of Total Billed Charges,4629.56,90,,939.064,Percent of Total Billed Charges,90% of Total billed Charges,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3343.57,65,,519.984,Percent of total Billed Charges,65% of Total Billed Charges,2268.48,44.1,,165.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,4886.75,95,,991.24,Percent of Total Billed Charges,95% of Total Billed Charges,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4526.68,88,,8112.424,Percent of Total Billed Charges,88% of Total Billed Charges,4629.56,90,,939.064,Percent of Total Billed charges,90% of Total Billed Charges,2268.48,5143.95,
Z42511000514 PERS  AS 14L,2780000396,CDM,278,RC,C1776,HCPCS,Outpatient,,,5143.95,3343.57,,5143.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3909.4,76,,13305.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3703.64,72,,483.264,Percent of Total Billed Charges,72% of Total Billed Charges,3703.64,72,,483.264,Percent of Total Billed charges,72% of Total Billed Charges,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3703.64,72,,483.264,Percent of Total Billed Charges,72% of Total Billed Charges,3086.37,60,,402.72,Percent of Total Billed Charges,60% of Total Billed Charges,4629.56,90,,4856.472,Percent of Total Billed Charges,90% of Total Billed Charges,2314.78,45,,469.536,Percent of Total Billed Charges,45% of Total Billed Charges,4629.56,90,,15756.936,Percent of Total Billed Charges,90% of Total billed Charges,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3343.57,65,,519.984,Percent of total Billed Charges,65% of Total Billed Charges,2268.48,44.1,,460.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,4886.75,95,,16632.32,Percent of Total Billed Charges,95% of Total Billed Charges,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4526.68,88,,305.032,Percent of Total Billed Charges,88% of Total Billed Charges,4629.56,90,,15756.936,Percent of Total Billed charges,90% of Total Billed Charges,2268.48,5143.95,
Z42511000612 PERS  LFT 712,2780000397,CDM,278,RC,C1713,HCPCS,Outpatient,,,6849.83,4452.39,,6849.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5205.87,76,,14609.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4931.88,72,,483.264,Percent of Total Billed Charges,72% of Total Billed Charges,4931.88,72,,483.264,Percent of Total Billed charges,72% of Total Billed Charges,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4931.88,72,,483.264,Percent of Total Billed Charges,72% of Total Billed Charges,4109.9,60,,402.72,Percent of Total Billed Charges,60% of Total Billed Charges,6164.85,90,,495.328,Percent of Total Billed Charges,90% of Total Billed Charges,3082.42,45,,4148.4,Percent of Total Billed Charges,45% of Total Billed Charges,6164.85,90,,17300.872,Percent of Total Billed Charges,90% of Total billed Charges,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4452.39,65,,519.984,Percent of total Billed Charges,65% of Total Billed Charges,3020.78,44.1,,4065.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,6507.34,95,,18262.032,Percent of Total Billed Charges,95% of Total Billed Charges,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6027.85,88,,10171.576,Percent of Total Billed Charges,88% of Total Billed Charges,6164.85,90,,17300.872,Percent of Total Billed charges,90% of Total Billed Charges,3020.78,6849.83,
Z425111000410 PERS  LFT 39,2780000398,CDM,278,RC,C1776,HCPCS,Outpatient,,,6849.83,4452.39,,6849.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5205.87,76,,285.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4931.88,72,,483.264,Percent of Total Billed Charges,72% of Total Billed Charges,4931.88,72,,483.264,Percent of Total Billed charges,72% of Total Billed Charges,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4931.88,72,,483.264,Percent of Total Billed Charges,72% of Total Billed Charges,4109.9,60,,402.72,Percent of Total Billed Charges,60% of Total Billed Charges,6164.85,90,,495.328,Percent of Total Billed Charges,90% of Total Billed Charges,3082.42,45,,155.984,Percent of Total Billed Charges,45% of Total Billed Charges,6164.85,90,,338.16,Percent of Total Billed Charges,90% of Total billed Charges,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4452.39,65,,519.984,Percent of total Billed Charges,65% of Total Billed Charges,3020.78,44.1,,152.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,6507.34,95,,356.952,Percent of Total Billed Charges,95% of Total Billed Charges,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6027.85,88,,534.776,Percent of Total Billed Charges,88% of Total Billed Charges,6164.85,90,,338.16,Percent of Total Billed charges,90% of Total Billed Charges,3020.78,6849.83,
Z42512000513 PERS  SZ13 LT,2780000399,CDM,278,RC,C1776,HCPCS,Outpatient,,,4899.00,3184.35,,4899,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3723.24,76,,792.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3527.28,72,,80.648,Percent of Total Billed Charges,72% of Total Billed Charges,3527.28,72,,80.648,Percent of Total Billed charges,72% of Total Billed Charges,4899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3527.28,72,,80.648,Percent of Total Billed Charges,72% of Total Billed Charges,2939.4,60,,67.208,Percent of Total Billed Charges,60% of Total Billed Charges,4409.1,90,,361.184,Percent of Total Billed Charges,90% of Total Billed Charges,2204.55,45,,5201.376,Percent of Total Billed Charges,45% of Total Billed Charges,4409.1,90,,939.064,Percent of Total Billed Charges,90% of Total billed Charges,4899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3184.35,65,,4412.12,Percent of total Billed Charges,65% of Total Billed Charges,2160.46,44.1,,5097.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,4654.05,95,,991.24,Percent of Total Billed Charges,95% of Total Billed Charges,4899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4311.12,88,,2285.792,Percent of Total Billed Charges,88% of Total Billed Charges,4409.1,90,,939.064,Percent of Total Billed charges,90% of Total Billed Charges,2160.46,4899,
Z4252100005 13 PERS  SZ 13 RT,2780000400,CDM,278,RC,C1713,HCPCS,Outpatient,,,6849.83,4452.39,,6849.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5205.87,76,,7006.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4931.88,72,,3666.088,Percent of Total Billed Charges,72% of Total Billed Charges,4931.88,72,,3666.088,Percent of Total Billed charges,72% of Total Billed Charges,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4931.88,72,,3666.088,Percent of Total Billed Charges,72% of Total Billed Charges,4109.9,60,,3055.072,Percent of Total Billed Charges,60% of Total Billed Charges,6164.85,90,,139.712,Percent of Total Billed Charges,90% of Total Billed Charges,3082.42,45,,273.464,Percent of Total Billed Charges,45% of Total Billed Charges,6164.85,90,,8296.8,Percent of Total Billed Charges,90% of Total billed Charges,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4452.39,65,,150.776,Percent of total Billed Charges,65% of Total Billed Charges,3020.78,44.1,,267.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,6507.34,95,,8757.728,Percent of Total Billed Charges,95% of Total Billed Charges,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6027.85,88,,61.32,Percent of Total Billed Charges,88% of Total Billed Charges,6164.85,90,,8296.8,Percent of Total Billed charges,90% of Total Billed Charges,3020.78,6849.83,
Z42521000510 PERS AS SZ 10 RT,2780000401,CDM,278,RC,C1713,HCPCS,Outpatient,,,5401.15,3510.75,,5401.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4104.87,76,,263.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3888.83,72,,1301.832,Percent of Total Billed Charges,72% of Total Billed Charges,3888.83,72,,1301.832,Percent of Total Billed charges,72% of Total Billed Charges,5401.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3888.83,72,,1301.832,Percent of Total Billed Charges,72% of Total Billed Charges,3240.69,60,,1084.864,Percent of Total Billed Charges,60% of Total Billed Charges,4861.04,90,,390.552,Percent of Total Billed Charges,90% of Total Billed Charges,2430.52,45,,1168.872,Percent of Total Billed Charges,45% of Total Billed Charges,4861.04,90,,311.96,Percent of Total Billed Charges,90% of Total billed Charges,5401.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5401.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5401.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3510.75,65,,3486.24,Percent of total Billed Charges,65% of Total Billed Charges,2381.91,44.1,,1145.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,5131.09,95,,329.296,Percent of Total Billed Charges,95% of Total Billed Charges,5401.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4753.01,88,,4748.552,Percent of Total Billed Charges,88% of Total Billed Charges,4861.04,90,,311.96,Percent of Total Billed charges,90% of Total Billed Charges,2381.91,5401.15,
Z42521000514 PERS AS SZ 14 RT,2780000402,CDM,278,RC,C1713,HCPCS,Outpatient,,,4899.00,3184.35,,4899,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3723.24,76,,8784.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3527.28,72,,4686.592,Percent of Total Billed Charges,72% of Total Billed Charges,3527.28,72,,4686.592,Percent of Total Billed charges,72% of Total Billed Charges,4899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3527.28,72,,4686.592,Percent of Total Billed Charges,72% of Total Billed Charges,2939.4,60,,3905.496,Percent of Total Billed Charges,60% of Total Billed Charges,4409.1,90,,2380.608,Percent of Total Billed Charges,90% of Total Billed Charges,2204.55,45,,31.36,Percent of Total Billed Charges,45% of Total Billed Charges,4409.1,90,,10402.744,Percent of Total Billed Charges,90% of Total billed Charges,4899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3184.35,65,,309.008,Percent of total Billed Charges,65% of Total Billed Charges,2160.46,44.1,,30.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,4654.05,95,,10980.68,Percent of Total Billed Charges,95% of Total Billed Charges,4899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4311.12,88,,484.32,Percent of Total Billed Charges,88% of Total Billed Charges,4409.1,90,,10402.744,Percent of Total Billed charges,90% of Total Billed Charges,2160.46,4899,
Z42521400714 PERS  ASZ 14RT,2780000403,CDM,278,RC,C1776,HCPCS,Outpatient,,,5143.95,3343.57,,5143.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3909.4,76,,461.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3703.64,72,,4344.944,Percent of Total Billed Charges,72% of Total Billed Charges,3703.64,72,,4344.944,Percent of Total Billed charges,72% of Total Billed Charges,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3703.64,72,,4344.944,Percent of Total Billed Charges,72% of Total Billed Charges,3086.37,60,,3620.792,Percent of Total Billed Charges,60% of Total Billed Charges,4629.56,90,,107.96,Percent of Total Billed Charges,90% of Total Billed Charges,2314.78,45,,2428.24,Percent of Total Billed Charges,45% of Total Billed Charges,4629.56,90,,546.928,Percent of Total Billed Charges,90% of Total billed Charges,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3343.57,65,,247.096,Percent of total Billed Charges,65% of Total Billed Charges,2268.48,44.1,,2379.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,4886.75,95,,577.312,Percent of Total Billed Charges,95% of Total Billed Charges,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4526.68,88,,484.32,Percent of Total Billed Charges,88% of Total Billed Charges,4629.56,90,,546.928,Percent of Total Billed charges,90% of Total Billed Charges,2268.48,5143.95,
Z4252140710 PERS AS SZ10 RT,2780000404,CDM,278,RC,C1776,HCPCS,Outpatient,,,5401.15,3510.75,,5401.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4104.87,76,,1974.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3888.83,72,,334.664,Percent of Total Billed Charges,72% of Total Billed Charges,3888.83,72,,334.664,Percent of Total Billed charges,72% of Total Billed Charges,5401.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3888.83,72,,334.664,Percent of Total Billed Charges,72% of Total Billed Charges,3240.69,60,,278.888,Percent of Total Billed Charges,60% of Total Billed Charges,4861.04,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,2430.52,45,,247.664,Percent of Total Billed Charges,45% of Total Billed Charges,4861.04,90,,2337.736,Percent of Total Billed Charges,90% of Total billed Charges,5401.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5401.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5401.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3510.75,65,,51.024,Percent of total Billed Charges,65% of Total Billed Charges,2381.91,44.1,,242.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,5131.09,95,,2467.616,Percent of Total Billed Charges,95% of Total Billed Charges,5401.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4753.01,88,,353.152,Percent of Total Billed Charges,88% of Total Billed Charges,4861.04,90,,2337.736,Percent of Total Billed charges,90% of Total Billed Charges,2381.91,5401.15,
Z42522000410 PERS SZ 10 RT,2780000405,CDM,278,RC,C1776,HCPCS,Outpatient,,,4899.00,3184.35,,4899,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3723.24,76,,52.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3527.28,72,,334.664,Percent of Total Billed Charges,72% of Total Billed Charges,3527.28,72,,334.664,Percent of Total Billed charges,72% of Total Billed Charges,4899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3527.28,72,,334.664,Percent of Total Billed Charges,72% of Total Billed Charges,2939.4,60,,278.888,Percent of Total Billed Charges,60% of Total Billed Charges,4409.1,90,,1161.328,Percent of Total Billed Charges,90% of Total Billed Charges,2204.55,45,,247.664,Percent of Total Billed Charges,45% of Total Billed Charges,4409.1,90,,62.712,Percent of Total Billed Charges,90% of Total billed Charges,4899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3184.35,65,,51.024,Percent of total Billed Charges,65% of Total Billed Charges,2160.46,44.1,,242.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,4654.05,95,,66.2,Percent of Total Billed Charges,95% of Total Billed Charges,4899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4311.12,88,,136.608,Percent of Total Billed Charges,88% of Total Billed Charges,4409.1,90,,62.712,Percent of Total Billed charges,90% of Total Billed Charges,2160.46,4899,
Z42522000412 PERS ASSZ12RVE39,2780000406,CDM,278,RC,C1776,HCPCS,Outpatient,,,12745.00,8284.25,,12745,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9686.2,76,,4101.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9176.4,72,,334.664,Percent of Total Billed Charges,72% of Total Billed Charges,9176.4,72,,334.664,Percent of Total Billed charges,72% of Total Billed Charges,12745,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9176.4,72,,334.664,Percent of Total Billed Charges,72% of Total Billed Charges,7647,60,,278.888,Percent of Total Billed Charges,60% of Total Billed Charges,11470.5,90,,171.464,Percent of Total Billed Charges,90% of Total Billed Charges,5735.25,45,,180.592,Percent of Total Billed Charges,45% of Total Billed Charges,11470.5,90,,4856.472,Percent of Total Billed Charges,90% of Total billed Charges,12745,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12745,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12745,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8284.25,65,,39.56,Percent of total Billed Charges,65% of Total Billed Charges,5620.55,44.1,,176.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,12107.75,95,,5126.28,Percent of Total Billed Charges,95% of Total Billed Charges,12745,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11215.6,88,,381.872,Percent of Total Billed Charges,88% of Total Billed Charges,11470.5,90,,4856.472,Percent of Total Billed charges,90% of Total Billed Charges,5620.55,12745,
Z42522000610 PER  S210 RVE712,2780000407,CDM,278,RC,C1713,HCPCS,Outpatient,,,5902.00,3836.30,,5902,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4485.52,76,,418.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4249.44,72,,4125.216,Percent of Total Billed Charges,72% of Total Billed Charges,4249.44,72,,4125.216,Percent of Total Billed charges,72% of Total Billed Charges,5902,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4249.44,72,,4125.216,Percent of Total Billed Charges,72% of Total Billed Charges,3541.2,60,,3437.68,Percent of Total Billed Charges,60% of Total Billed Charges,5311.8,90,,69.856,Percent of Total Billed Charges,90% of Total Billed Charges,2655.9,45,,69.856,Percent of Total Billed Charges,45% of Total Billed Charges,5311.8,90,,495.328,Percent of Total Billed Charges,90% of Total billed Charges,5902,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5902,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5902,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3836.3,65,,39.56,Percent of total Billed Charges,65% of Total Billed Charges,2602.78,44.1,,68.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,5606.9,95,,522.848,Percent of Total Billed Charges,95% of Total Billed Charges,5902,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5193.76,88,,2327.704,Percent of Total Billed Charges,88% of Total Billed Charges,5311.8,90,,495.328,Percent of Total Billed charges,90% of Total Billed Charges,2602.78,5902,
Z42522000612 PERS AS SZ 12 RT,2780000408,CDM,278,RC,C1713,HCPCS,Outpatient,,,12745.00,8284.25,,12745,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9686.2,76,,418.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9176.4,72,,2417.6,Percent of Total Billed Charges,72% of Total Billed Charges,9176.4,72,,2417.6,Percent of Total Billed charges,72% of Total Billed Charges,12745,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9176.4,72,,2417.6,Percent of Total Billed Charges,72% of Total Billed Charges,7647,60,,2014.664,Percent of Total Billed Charges,60% of Total Billed Charges,11470.5,90,,69.856,Percent of Total Billed Charges,90% of Total Billed Charges,5735.25,45,,195.272,Percent of Total Billed Charges,45% of Total Billed Charges,11470.5,90,,495.328,Percent of Total Billed Charges,90% of Total billed Charges,12745,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12745,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12745,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8284.25,65,,39.56,Percent of total Billed Charges,65% of Total Billed Charges,5620.55,44.1,,191.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,12107.75,95,,522.848,Percent of Total Billed Charges,95% of Total Billed Charges,12745,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11215.6,88,,105.56,Percent of Total Billed Charges,88% of Total Billed Charges,11470.5,90,,495.328,Percent of Total Billed charges,90% of Total Billed Charges,5620.55,12745,
Z42531000512 PERS AS SZ12 R,2780000409,CDM,278,RC,C1776,HCPCS,Outpatient,,,5143.95,3343.57,,5143.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3909.4,76,,305,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3703.64,72,,334.664,Percent of Total Billed Charges,72% of Total Billed Charges,3703.64,72,,334.664,Percent of Total Billed charges,72% of Total Billed Charges,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3703.64,72,,334.664,Percent of Total Billed Charges,72% of Total Billed Charges,3086.37,60,,278.888,Percent of Total Billed Charges,60% of Total Billed Charges,4629.56,90,,229.408,Percent of Total Billed Charges,90% of Total Billed Charges,2314.78,45,,1190.304,Percent of Total Billed Charges,45% of Total Billed Charges,4629.56,90,,361.184,Percent of Total Billed Charges,90% of Total billed Charges,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3343.57,65,,395,Percent of total Billed Charges,65% of Total Billed Charges,2268.48,44.1,,1166.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,4886.75,95,,381.248,Percent of Total Billed Charges,95% of Total Billed Charges,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4526.68,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,4629.56,90,,361.184,Percent of Total Billed charges,90% of Total Billed Charges,2268.48,5143.95,
Z42532006401 PERS TIBA SZ CLFT,2780000410,CDM,278,RC,C1776,HCPCS,Outpatient,,,8610.53,5596.84,,8610.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6544,76,,117.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6199.58,72,,193.688,Percent of Total Billed Charges,72% of Total Billed Charges,6199.58,72,,193.688,Percent of Total Billed charges,72% of Total Billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6199.58,72,,193.688,Percent of Total Billed Charges,72% of Total Billed Charges,5166.32,60,,161.408,Percent of Total Billed Charges,60% of Total Billed Charges,7749.48,90,,279.416,Percent of Total Billed Charges,90% of Total Billed Charges,3874.74,45,,53.976,Percent of Total Billed Charges,45% of Total Billed Charges,7749.48,90,,139.712,Percent of Total Billed Charges,90% of Total billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5596.84,65,,395,Percent of total Billed Charges,65% of Total Billed Charges,3797.24,44.1,,52.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,8180,95,,147.472,Percent of Total Billed Charges,95% of Total Billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7577.27,88,,1135.52,Percent of Total Billed Charges,88% of Total Billed Charges,7749.48,90,,139.712,Percent of Total Billed charges,90% of Total Billed Charges,3797.24,8610.53,
Z42532006402 TIBIA SZ C RT,2780000411,CDM,278,RC,C1713,HCPCS,Outpatient,,,7029.00,4568.85,,7029,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5342.04,76,,329.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5060.88,72,,240.68,Percent of Total Billed Charges,72% of Total Billed Charges,5060.88,72,,240.68,Percent of Total Billed charges,72% of Total Billed Charges,7029,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5060.88,72,,240.68,Percent of Total Billed Charges,72% of Total Billed Charges,4217.4,60,,200.568,Percent of Total Billed Charges,60% of Total Billed Charges,6326.1,90,,719.976,Percent of Total Billed Charges,90% of Total Billed Charges,3163.05,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,6326.1,90,,390.552,Percent of Total Billed Charges,90% of Total billed Charges,7029,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7029,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7029,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4568.85,65,,84.848,Percent of total Billed Charges,65% of Total Billed Charges,3099.79,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,6677.55,95,,412.248,Percent of Total Billed Charges,95% of Total Billed Charges,7029,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6185.52,88,,167.648,Percent of Total Billed Charges,88% of Total Billed Charges,6326.1,90,,390.552,Percent of Total Billed charges,90% of Total Billed Charges,3099.79,7029,
Z42532006701 PERS TIBIA SZ LFT,2780000412,CDM,278,RC,C1713,HCPCS,Outpatient,,,8610.53,5596.84,,8610.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6544,76,,2010.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6199.58,72,,163.84,Percent of Total Billed Charges,72% of Total Billed Charges,6199.58,72,,163.84,Percent of Total Billed charges,72% of Total Billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6199.58,72,,163.84,Percent of Total Billed Charges,72% of Total Billed Charges,5166.32,60,,136.536,Percent of Total Billed Charges,60% of Total Billed Charges,7749.48,90,,719.976,Percent of Total Billed Charges,90% of Total Billed Charges,3874.74,45,,580.664,Percent of Total Billed Charges,45% of Total Billed Charges,7749.48,90,,2380.608,Percent of Total Billed Charges,90% of Total billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5596.84,65,,202.952,Percent of total Billed Charges,65% of Total Billed Charges,3797.24,44.1,,569.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,8180,95,,2512.864,Percent of Total Billed Charges,95% of Total Billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7577.27,88,,68.304,Percent of Total Billed Charges,88% of Total Billed Charges,7749.48,90,,2380.608,Percent of Total Billed charges,90% of Total Billed Charges,3797.24,8610.53,
Z42532007101 PERS TIBA SZE LFT,2780000413,CDM,278,RC,C1776,HCPCS,Outpatient,,,8610.53,5596.84,,8610.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6544,76,,91.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6199.58,72,,175.904,Percent of Total Billed Charges,72% of Total Billed Charges,6199.58,72,,175.904,Percent of Total Billed charges,72% of Total Billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6199.58,72,,175.904,Percent of Total Billed Charges,72% of Total Billed Charges,5166.32,60,,146.584,Percent of Total Billed Charges,60% of Total Billed Charges,7749.48,90,,719.976,Percent of Total Billed Charges,90% of Total Billed Charges,3874.74,45,,85.728,Percent of Total Billed Charges,45% of Total Billed Charges,7749.48,90,,107.96,Percent of Total Billed Charges,90% of Total billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5596.84,65,,296.976,Percent of total Billed Charges,65% of Total Billed Charges,3797.24,44.1,,84.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,8180,95,,113.952,Percent of Total Billed Charges,95% of Total Billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7577.27,88,,68.304,Percent of Total Billed Charges,88% of Total Billed Charges,7749.48,90,,107.96,Percent of Total Billed charges,90% of Total Billed Charges,3797.24,8610.53,
Z42532007102 PERS TIB SZ E RT,2780000414,CDM,278,RC,C1776,HCPCS,Outpatient,,,7749.47,5037.16,,7749.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5889.6,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5579.62,72,,2918.008,Percent of Total Billed Charges,72% of Total Billed Charges,5579.62,72,,2918.008,Percent of Total Billed charges,72% of Total Billed Charges,7749.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5579.62,72,,2918.008,Percent of Total Billed Charges,72% of Total Billed Charges,4649.68,60,,2431.672,Percent of Total Billed Charges,60% of Total Billed Charges,6974.52,90,,719.976,Percent of Total Billed Charges,90% of Total Billed Charges,3487.26,45,,34.928,Percent of Total Billed Charges,45% of Total Billed Charges,6974.52,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,7749.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7749.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7749.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5037.16,65,,261.424,Percent of total Billed Charges,65% of Total Billed Charges,3417.52,44.1,,34.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,7362,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,7749.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6819.53,88,,224.312,Percent of Total Billed Charges,88% of Total Billed Charges,6974.52,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,3417.52,7749.47,
Z42532007502 PERS TBIA SZ F RT,2780000415,CDM,278,RC,C1713,HCPCS,Outpatient,,,8610.53,5596.84,,8610.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6544,76,,980.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6199.58,72,,305.456,Percent of Total Billed Charges,72% of Total Billed Charges,6199.58,72,,305.456,Percent of Total Billed charges,72% of Total Billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6199.58,72,,305.456,Percent of Total Billed Charges,72% of Total Billed Charges,5166.32,60,,254.544,Percent of Total Billed Charges,60% of Total Billed Charges,7749.48,90,,719.976,Percent of Total Billed Charges,90% of Total Billed Charges,3874.74,45,,34.928,Percent of Total Billed Charges,45% of Total Billed Charges,7749.48,90,,1161.328,Percent of Total Billed Charges,90% of Total billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5596.84,65,,261.424,Percent of total Billed Charges,65% of Total Billed Charges,3797.24,44.1,,34.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,8180,95,,1225.848,Percent of Total Billed Charges,95% of Total Billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7577.27,88,,273.208,Percent of Total Billed Charges,88% of Total Billed Charges,7749.48,90,,1161.328,Percent of Total Billed charges,90% of Total Billed Charges,3797.24,8610.53,
Z42532008301 PERS TBIA SZH LFT,2780000416,CDM,278,RC,C1713,HCPCS,Outpatient,,,8610.53,5596.84,,8610.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6544,76,,144.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6199.58,72,,274.336,Percent of Total Billed Charges,72% of Total Billed Charges,6199.58,72,,274.336,Percent of Total Billed charges,72% of Total Billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6199.58,72,,274.336,Percent of Total Billed Charges,72% of Total Billed Charges,5166.32,60,,228.616,Percent of Total Billed Charges,60% of Total Billed Charges,7749.48,90,,6109.088,Percent of Total Billed Charges,90% of Total Billed Charges,3874.74,45,,114.704,Percent of Total Billed Charges,45% of Total Billed Charges,7749.48,90,,171.464,Percent of Total Billed Charges,90% of Total billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5596.84,65,,261.424,Percent of total Billed Charges,65% of Total Billed Charges,3797.24,44.1,,112.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,8180,95,,180.984,Percent of Total Billed Charges,95% of Total Billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7577.27,88,,703.976,Percent of Total Billed Charges,88% of Total Billed Charges,7749.48,90,,171.464,Percent of Total Billed charges,90% of Total Billed Charges,3797.24,8610.53,
Z42540000035 PERS PATELA 35,2780000417,CDM,278,RC,C1776,HCPCS,Outpatient,,,3327.35,2162.78,,3327.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2528.79,76,,58.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2395.69,72,,1223.088,Percent of Total Billed Charges,72% of Total Billed Charges,2395.69,72,,1223.088,Percent of Total Billed charges,72% of Total Billed Charges,3327.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2395.69,72,,1223.088,Percent of Total Billed Charges,72% of Total Billed Charges,1996.41,60,,1019.24,Percent of Total Billed Charges,60% of Total Billed Charges,2994.62,90,,208.768,Percent of Total Billed Charges,90% of Total Billed Charges,1497.31,45,,139.712,Percent of Total Billed Charges,45% of Total Billed Charges,2994.62,90,,69.856,Percent of Total Billed Charges,90% of Total billed Charges,3327.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3327.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3327.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2162.78,65,,2068.464,Percent of total Billed Charges,65% of Total Billed Charges,1467.36,44.1,,136.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,3160.98,95,,73.736,Percent of Total Billed Charges,95% of Total Billed Charges,3327.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2928.07,88,,703.976,Percent of Total Billed Charges,88% of Total Billed Charges,2994.62,90,,69.856,Percent of Total Billed charges,90% of Total Billed Charges,1467.36,3327.35,
Z42540000038 PERS PATELA 38,2780000418,CDM,278,RC,C1776,HCPCS,Outpatient,,,3327.35,2162.78,,3327.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2528.79,76,,58.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2395.69,72,,4344.944,Percent of Total Billed Charges,72% of Total Billed Charges,2395.69,72,,4344.944,Percent of Total Billed charges,72% of Total Billed Charges,3327.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2395.69,72,,4344.944,Percent of Total Billed Charges,72% of Total Billed Charges,1996.41,60,,3620.792,Percent of Total Billed Charges,60% of Total Billed Charges,2994.62,90,,4827.096,Percent of Total Billed Charges,90% of Total Billed Charges,1497.31,45,,359.992,Percent of Total Billed Charges,45% of Total Billed Charges,2994.62,90,,69.856,Percent of Total Billed Charges,90% of Total billed Charges,3327.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3327.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3327.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2162.78,65,,236.768,Percent of total Billed Charges,65% of Total Billed Charges,1467.36,44.1,,352.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,3160.98,95,,73.736,Percent of Total Billed Charges,95% of Total Billed Charges,3327.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2928.07,88,,703.976,Percent of Total Billed Charges,88% of Total Billed Charges,2994.62,90,,69.856,Percent of Total Billed charges,90% of Total Billed Charges,1467.36,3327.35,
Z44533008 THREAPIN 3.5X80X25,2780000419,CDM,278,RC,C1713,HCPCS,Outpatient,,,184.80,120.12,,184.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,140.45,76,,193.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,133.06,72,,11842.856,Percent of Total Billed Charges,72% of Total Billed Charges,133.06,72,,11842.856,Percent of Total Billed charges,72% of Total Billed Charges,184.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.06,72,,11842.856,Percent of Total Billed Charges,72% of Total Billed Charges,110.88,60,,9869.048,Percent of Total Billed Charges,60% of Total Billed Charges,166.32,90,,427.864,Percent of Total Billed Charges,90% of Total Billed Charges,83.16,45,,359.992,Percent of Total Billed Charges,45% of Total Billed Charges,166.32,90,,229.408,Percent of Total Billed Charges,90% of Total billed Charges,184.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.12,65,,2068.464,Percent of total Billed Charges,65% of Total Billed Charges,81.5,44.1,,352.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,175.56,95,,242.152,Percent of Total Billed Charges,95% of Total Billed Charges,184.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.62,88,,703.976,Percent of Total Billed Charges,88% of Total Billed Charges,166.32,90,,229.408,Percent of Total Billed charges,90% of Total Billed Charges,81.5,184.8,
Z44533408 THRD PIN 3.5X80X20,2780000420,CDM,278,RC,C1713,HCPCS,Outpatient,,,184.80,120.12,,184.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,140.45,76,,235.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,133.06,72,,11842.856,Percent of Total Billed Charges,72% of Total Billed Charges,133.06,72,,11842.856,Percent of Total Billed charges,72% of Total Billed Charges,184.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.06,72,,11842.856,Percent of Total Billed Charges,72% of Total Billed Charges,110.88,60,,9869.048,Percent of Total Billed Charges,60% of Total Billed Charges,166.32,90,,342.128,Percent of Total Billed Charges,90% of Total Billed Charges,83.16,45,,359.992,Percent of Total Billed Charges,45% of Total Billed Charges,166.32,90,,279.416,Percent of Total Billed Charges,90% of Total billed Charges,184.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.12,65,,236.768,Percent of total Billed Charges,65% of Total Billed Charges,81.5,44.1,,352.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,175.56,95,,294.944,Percent of Total Billed Charges,95% of Total Billed Charges,184.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.62,88,,703.976,Percent of Total Billed Charges,88% of Total Billed Charges,166.32,90,,279.416,Percent of Total Billed charges,90% of Total Billed Charges,81.5,184.8,
Z47248404750 CRTSCW 5.0X47.5,2780000421,CDM,278,RC,C1713,HCPCS,Outpatient,,,654.00,425.10,,654,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,497.04,76,,607.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,470.88,72,,4236.984,Percent of Total Billed Charges,72% of Total Billed Charges,470.88,72,,4236.984,Percent of Total Billed charges,72% of Total Billed Charges,654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,470.88,72,,4236.984,Percent of Total Billed Charges,72% of Total Billed Charges,392.4,60,,3530.824,Percent of Total Billed Charges,60% of Total Billed Charges,588.6,90,,70.648,Percent of Total Billed Charges,90% of Total Billed Charges,294.3,45,,359.992,Percent of Total Billed Charges,45% of Total Billed Charges,588.6,90,,719.976,Percent of Total Billed Charges,90% of Total billed Charges,654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,425.1,65,,297.544,Percent of total Billed Charges,65% of Total Billed Charges,288.41,44.1,,352.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,621.3,95,,759.976,Percent of Total Billed Charges,95% of Total Billed Charges,654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.52,88,,5973.328,Percent of Total Billed Charges,88% of Total Billed Charges,588.6,90,,719.976,Percent of Total Billed charges,90% of Total Billed Charges,288.41,654,
Z47248405750 CORT SCW 5.0X57.5,2780000422,CDM,278,RC,C1713,HCPCS,Outpatient,,,654.00,425.10,,654,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,497.04,76,,607.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,470.88,72,,4236.984,Percent of Total Billed Charges,72% of Total Billed Charges,470.88,72,,4236.984,Percent of Total Billed charges,72% of Total Billed Charges,654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,470.88,72,,4236.984,Percent of Total Billed Charges,72% of Total Billed Charges,392.4,60,,3530.824,Percent of Total Billed Charges,60% of Total Billed Charges,588.6,90,,70.648,Percent of Total Billed Charges,90% of Total Billed Charges,294.3,45,,359.992,Percent of Total Billed Charges,45% of Total Billed Charges,588.6,90,,719.976,Percent of Total Billed Charges,90% of Total billed Charges,654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,425.1,65,,297.544,Percent of total Billed Charges,65% of Total Billed Charges,288.41,44.1,,352.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,621.3,95,,759.976,Percent of Total Billed Charges,95% of Total Billed Charges,654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.52,88,,204.128,Percent of Total Billed Charges,88% of Total Billed Charges,588.6,90,,719.976,Percent of Total Billed charges,90% of Total Billed Charges,288.41,654,
Z47249009701 TD GUDEWR 2.4X100,2780000423,CDM,278,RC,C1713,HCPCS,Outpatient,,,188.00,122.20,,188,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,142.88,76,,607.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,135.36,72,,3297.76,Percent of Total Billed Charges,72% of Total Billed Charges,135.36,72,,3297.76,Percent of Total Billed charges,72% of Total Billed Charges,188,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.36,72,,3297.76,Percent of Total Billed Charges,72% of Total Billed Charges,112.8,60,,2748.136,Percent of Total Billed Charges,60% of Total Billed Charges,169.2,90,,54.768,Percent of Total Billed Charges,90% of Total Billed Charges,84.6,45,,3054.544,Percent of Total Billed Charges,45% of Total Billed Charges,169.2,90,,719.976,Percent of Total Billed Charges,90% of Total billed Charges,188,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.2,65,,40.136,Percent of total Billed Charges,65% of Total Billed Charges,82.91,44.1,,2993.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,178.6,95,,759.976,Percent of Total Billed Charges,95% of Total Billed Charges,188,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.44,88,,4719.824,Percent of Total Billed Charges,88% of Total Billed Charges,169.2,90,,719.976,Percent of Total Billed charges,90% of Total Billed Charges,82.91,188,
Z47249321210 FEM 10X21.5R,2780000424,CDM,278,RC,C1776,HCPCS,Outpatient,,,469.35,305.08,,469.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,356.71,76,,607.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,337.93,72,,607.096,Percent of Total Billed Charges,72% of Total Billed Charges,337.93,72,,607.096,Percent of Total Billed charges,72% of Total Billed Charges,469.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.93,72,,607.096,Percent of Total Billed Charges,72% of Total Billed Charges,281.61,60,,505.912,Percent of Total Billed Charges,60% of Total Billed Charges,422.42,90,,54.768,Percent of Total Billed Charges,90% of Total Billed Charges,211.21,45,,104.384,Percent of Total Billed Charges,45% of Total Billed Charges,422.42,90,,719.976,Percent of Total Billed Charges,90% of Total billed Charges,469.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,469.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,469.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305.08,65,,40.136,Percent of total Billed Charges,65% of Total Billed Charges,206.98,44.1,,102.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,445.88,95,,759.976,Percent of Total Billed Charges,95% of Total Billed Charges,469.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.03,88,,418.352,Percent of Total Billed Charges,88% of Total Billed Charges,422.42,90,,719.976,Percent of Total Billed charges,90% of Total Billed Charges,206.98,469.35,
Z47249334210 FEM 10X34 RT,2780000425,CDM,278,RC,C1713,HCPCS,Outpatient,,,7649.00,4971.85,,7649,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5813.24,76,,607.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5507.28,72,,334.664,Percent of Total Billed Charges,72% of Total Billed Charges,5507.28,72,,334.664,Percent of Total Billed charges,72% of Total Billed Charges,7649,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5507.28,72,,334.664,Percent of Total Billed Charges,72% of Total Billed Charges,4589.4,60,,278.888,Percent of Total Billed Charges,60% of Total Billed Charges,6884.1,90,,54.768,Percent of Total Billed Charges,90% of Total Billed Charges,3442.05,45,,2413.552,Percent of Total Billed Charges,45% of Total Billed Charges,6884.1,90,,719.976,Percent of Total Billed Charges,90% of Total billed Charges,7649,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7649,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7649,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4971.85,65,,2052.984,Percent of total Billed Charges,65% of Total Billed Charges,3373.21,44.1,,2365.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,7266.55,95,,759.976,Percent of Total Billed Charges,95% of Total Billed Charges,7649,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6731.12,88,,334.528,Percent of Total Billed Charges,88% of Total Billed Charges,6884.1,90,,719.976,Percent of Total Billed charges,90% of Total Billed Charges,3373.21,7649,
Z48151603 1.5 CORTKLE SCW 16,2780000426,CDM,278,RC,C1776,HCPCS,Outpatient,,,71.66,46.58,,71.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.46,76,,5158.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.6,72,,2651.928,Percent of Total Billed Charges,72% of Total Billed Charges,51.6,72,,2651.928,Percent of Total Billed charges,72% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,72,,2651.928,Percent of Total Billed Charges,72% of Total Billed Charges,43,60,,2209.936,Percent of Total Billed Charges,60% of Total Billed Charges,64.49,90,,546.928,Percent of Total Billed Charges,90% of Total Billed Charges,32.25,45,,213.928,Percent of Total Billed Charges,45% of Total Billed Charges,64.49,90,,6109.088,Percent of Total Billed Charges,90% of Total billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.58,65,,7966.576,Percent of total Billed Charges,65% of Total Billed Charges,31.6,44.1,,209.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.08,95,,6448.48,Percent of Total Billed Charges,95% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,88,,69.08,Percent of Total Billed Charges,88% of Total Billed Charges,64.49,90,,6109.088,Percent of Total Billed charges,90% of Total Billed Charges,31.6,71.66,
Z48202403 2.0 CORT SCW 24MM,2780000427,CDM,278,RC,C1713,HCPCS,Outpatient,,,67.00,43.55,,67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,50.92,76,,176.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,48.24,72,,2651.928,Percent of Total Billed Charges,72% of Total Billed Charges,48.24,72,,2651.928,Percent of Total Billed charges,72% of Total Billed Charges,67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.24,72,,2651.928,Percent of Total Billed Charges,72% of Total Billed Charges,40.2,60,,2209.936,Percent of Total Billed Charges,60% of Total Billed Charges,60.3,90,,546.928,Percent of Total Billed Charges,90% of Total Billed Charges,30.15,45,,171.064,Percent of Total Billed Charges,45% of Total Billed Charges,60.3,90,,208.768,Percent of Total Billed Charges,90% of Total billed Charges,67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.55,65,,4377.144,Percent of total Billed Charges,65% of Total Billed Charges,29.55,44.1,,167.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,63.65,95,,220.368,Percent of Total Billed Charges,95% of Total Billed Charges,67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.96,88,,69.08,Percent of Total Billed Charges,88% of Total Billed Charges,60.3,90,,208.768,Percent of Total Billed charges,90% of Total Billed Charges,29.55,67,
Z48270801 2.7 CORTICLE SCW 8MM,2780000428,CDM,278,RC,C1773,HCPCS,Outpatient,,,56.00,36.40,,56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.56,76,,4076.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.32,72,,4595.152,Percent of Total Billed Charges,72% of Total Billed Charges,40.32,72,,4595.152,Percent of Total Billed charges,72% of Total Billed Charges,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.32,72,,4595.152,Percent of Total Billed Charges,72% of Total Billed Charges,33.6,60,,3829.288,Percent of Total Billed Charges,60% of Total Billed Charges,50.4,90,,117.48,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,45,,35.32,Percent of Total Billed Charges,45% of Total Billed Charges,50.4,90,,4827.096,Percent of Total Billed Charges,90% of Total billed Charges,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.4,65,,5207.288,Percent of total Billed Charges,65% of Total Billed Charges,24.7,44.1,,34.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.2,95,,5095.272,Percent of Total Billed Charges,95% of Total Billed Charges,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.28,88,,53.552,Percent of Total Billed Charges,88% of Total Billed Charges,50.4,90,,4827.096,Percent of Total Billed charges,90% of Total Billed Charges,24.7,56,
Z48271001 2.7 CORT SCW 10,2780000429,CDM,278,RC,C1713,HCPCS,Outpatient,,,70.56,45.86,,70.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.63,76,,361.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.8,72,,2463.32,Percent of Total Billed Charges,72% of Total Billed Charges,50.8,72,,2463.32,Percent of Total Billed charges,72% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.8,72,,2463.32,Percent of Total Billed Charges,72% of Total Billed Charges,42.34,60,,2052.768,Percent of Total Billed Charges,60% of Total Billed Charges,63.5,90,,281.008,Percent of Total Billed Charges,90% of Total Billed Charges,31.75,45,,35.32,Percent of Total Billed Charges,45% of Total Billed Charges,63.5,90,,427.864,Percent of Total Billed Charges,90% of Total billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.86,65,,508.52,Percent of total Billed Charges,65% of Total Billed Charges,31.12,44.1,,34.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.03,95,,451.632,Percent of Total Billed Charges,95% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.09,88,,53.552,Percent of Total Billed Charges,88% of Total Billed Charges,63.5,90,,427.864,Percent of Total Billed charges,90% of Total Billed Charges,31.12,70.56,
Z48402801 CANCELLOUS SCRW 28,2780000430,CDM,278,RC,C1776,HCPCS,Outpatient,,,62.84,40.85,,62.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.76,76,,288.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.24,72,,14487.168,Percent of Total Billed Charges,72% of Total Billed Charges,45.24,72,,14487.168,Percent of Total Billed charges,72% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.24,72,,14487.168,Percent of Total Billed Charges,72% of Total Billed Charges,37.7,60,,12072.64,Percent of Total Billed Charges,60% of Total Billed Charges,56.56,90,,411.192,Percent of Total Billed Charges,90% of Total Billed Charges,28.28,45,,27.384,Percent of Total Billed Charges,45% of Total Billed Charges,56.56,90,,342.128,Percent of Total Billed Charges,90% of Total billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.85,65,,759.624,Percent of total Billed Charges,65% of Total Billed Charges,27.71,44.1,,26.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.7,95,,361.136,Percent of Total Billed Charges,95% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.3,88,,53.552,Percent of Total Billed Charges,88% of Total Billed Charges,56.56,90,,342.128,Percent of Total Billed charges,90% of Total Billed Charges,27.71,62.84,
Z48403001 CANCELOUS SCW 30MM,2780000431,CDM,278,RC,C1776,HCPCS,Outpatient,,,63.95,41.57,,63.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,48.6,76,,59.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.04,72,,47079.328,Percent of Total Billed Charges,72% of Total Billed Charges,46.04,72,,47079.328,Percent of Total Billed charges,72% of Total Billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.04,72,,47079.328,Percent of Total Billed Charges,72% of Total Billed Charges,38.37,60,,39232.768,Percent of Total Billed Charges,60% of Total Billed Charges,57.56,90,,361.976,Percent of Total Billed Charges,90% of Total Billed Charges,28.78,45,,27.384,Percent of Total Billed Charges,45% of Total Billed Charges,57.56,90,,70.648,Percent of Total Billed Charges,90% of Total billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.57,65,,50.448,Percent of total Billed Charges,65% of Total Billed Charges,28.2,44.1,,26.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,60.75,95,,74.568,Percent of Total Billed Charges,95% of Total Billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.28,88,,534.776,Percent of Total Billed Charges,88% of Total Billed Charges,57.56,90,,70.648,Percent of Total Billed charges,90% of Total Billed Charges,28.2,63.95,
Z48404001 CANCELOUS SCW 40MM,2780000432,CDM,278,RC,C1776,HCPCS,Outpatient,,,63.95,41.57,,63.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,48.6,76,,59.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.04,72,,149.232,Percent of Total Billed Charges,72% of Total Billed Charges,46.04,72,,149.232,Percent of Total Billed charges,72% of Total Billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.04,72,,149.232,Percent of Total Billed Charges,72% of Total Billed Charges,38.37,60,,124.36,Percent of Total Billed Charges,60% of Total Billed Charges,57.56,90,,361.976,Percent of Total Billed Charges,90% of Total Billed Charges,28.78,45,,27.384,Percent of Total Billed Charges,45% of Total Billed Charges,57.56,90,,70.648,Percent of Total Billed Charges,90% of Total billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.57,65,,50.448,Percent of total Billed Charges,65% of Total Billed Charges,28.2,44.1,,26.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,60.75,95,,74.568,Percent of Total Billed Charges,95% of Total Billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.28,88,,534.776,Percent of Total Billed Charges,88% of Total Billed Charges,57.56,90,,70.648,Percent of Total Billed charges,90% of Total Billed Charges,28.2,63.95,
Z49150119 1.5 COND PLTE LFT,2780000433,CDM,278,RC,C1776,HCPCS,Outpatient,,,824.67,536.04,,824.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,626.75,76,,46.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,593.76,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,593.76,72,,41.28,Percent of Total Billed charges,72% of Total Billed Charges,824.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,593.76,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,494.8,60,,34.4,Percent of Total Billed Charges,60% of Total Billed Charges,742.2,90,,361.976,Percent of Total Billed Charges,90% of Total Billed Charges,371.1,45,,273.464,Percent of Total Billed Charges,45% of Total Billed Charges,742.2,90,,54.768,Percent of Total Billed Charges,90% of Total billed Charges,824.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,824.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,824.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,536.04,65,,50.448,Percent of total Billed Charges,65% of Total Billed Charges,363.68,44.1,,267.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,783.44,95,,57.816,Percent of Total Billed Charges,95% of Total Billed Charges,824.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,725.71,88,,114.872,Percent of Total Billed Charges,88% of Total Billed Charges,742.2,90,,54.768,Percent of Total Billed charges,90% of Total Billed Charges,363.68,824.67,
Z491502002 MINI STRGHT PLTE,2780000434,CDM,278,RC,C1713,HCPCS,Outpatient,,,631.05,410.18,,631.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,479.6,76,,46.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,454.36,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,454.36,72,,41.28,Percent of Total Billed charges,72% of Total Billed Charges,631.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,454.36,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,378.63,60,,34.4,Percent of Total Billed Charges,60% of Total Billed Charges,567.95,90,,2864.032,Percent of Total Billed Charges,90% of Total Billed Charges,283.97,45,,273.464,Percent of Total Billed Charges,45% of Total Billed Charges,567.95,90,,54.768,Percent of Total Billed Charges,90% of Total billed Charges,631.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,631.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,631.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,410.18,65,,40.136,Percent of total Billed Charges,65% of Total Billed Charges,278.29,44.1,,267.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,599.5,95,,57.816,Percent of Total Billed Charges,95% of Total Billed Charges,631.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.32,88,,274.768,Percent of Total Billed Charges,88% of Total Billed Charges,567.95,90,,54.768,Percent of Total Billed charges,90% of Total Billed Charges,278.29,631.05,
Z49200602 ST PLT 2.0 / 6 HLE,2780000435,CDM,278,RC,C1713,HCPCS,Outpatient,,,234.83,152.64,,234.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,178.47,76,,46.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,169.08,72,,1042.736,Percent of Total Billed Charges,72% of Total Billed Charges,169.08,72,,1042.736,Percent of Total Billed charges,72% of Total Billed Charges,234.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.08,72,,1042.736,Percent of Total Billed Charges,72% of Total Billed Charges,140.9,60,,868.952,Percent of Total Billed Charges,60% of Total Billed Charges,211.35,90,,327.84,Percent of Total Billed Charges,90% of Total Billed Charges,105.67,45,,58.744,Percent of Total Billed Charges,45% of Total Billed Charges,211.35,90,,54.768,Percent of Total Billed Charges,90% of Total billed Charges,234.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.64,65,,149.632,Percent of total Billed Charges,65% of Total Billed Charges,103.56,44.1,,57.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,223.09,95,,57.816,Percent of Total Billed Charges,95% of Total Billed Charges,234.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.65,88,,402.056,Percent of Total Billed Charges,88% of Total Billed Charges,211.35,90,,54.768,Percent of Total Billed charges,90% of Total Billed Charges,103.56,234.83,
Z49350516 3.5MM CLVR LF PLT 5H,2780000436,CDM,278,RC,C1713,HCPCS,Outpatient,,,994.00,646.10,,994,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,755.44,76,,461.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,715.68,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,715.68,72,,8.256,Percent of Total Billed charges,72% of Total Billed Charges,994,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,715.68,72,,8.256,Percent of Total Billed Charges,72% of Total Billed Charges,596.4,60,,6.88,Percent of Total Billed Charges,60% of Total Billed Charges,894.6,90,,2864.032,Percent of Total Billed Charges,90% of Total Billed Charges,447.3,45,,140.504,Percent of Total Billed Charges,45% of Total Billed Charges,894.6,90,,546.928,Percent of Total Billed Charges,90% of Total billed Charges,994,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,646.1,65,,58.48,Percent of total Billed Charges,65% of Total Billed Charges,438.35,44.1,,137.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,944.3,95,,577.312,Percent of Total Billed Charges,95% of Total Billed Charges,994,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,874.72,88,,353.928,Percent of Total Billed Charges,88% of Total Billed Charges,894.6,90,,546.928,Percent of Total Billed charges,90% of Total Billed Charges,438.35,994,
Z59501702 FEMORAL CMP G RT,2780000437,CDM,278,RC,C1713,HCPCS,Outpatient,,,17273.97,11228.08,,17273.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13128.22,76,,461.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12437.26,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,12437.26,72,,90.816,Percent of Total Billed charges,72% of Total Billed Charges,17273.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12437.26,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,10364.38,60,,75.68,Percent of Total Billed Charges,60% of Total Billed Charges,15546.57,90,,327.84,Percent of Total Billed Charges,90% of Total Billed Charges,7773.29,45,,205.6,Percent of Total Billed Charges,45% of Total Billed Charges,15546.57,90,,546.928,Percent of Total Billed Charges,90% of Total billed Charges,17273.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17273.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17273.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11228.08,65,,508.52,Percent of total Billed Charges,65% of Total Billed Charges,7617.82,44.1,,201.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,16410.27,95,,577.312,Percent of Total Billed Charges,95% of Total Billed Charges,17273.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15201.09,88,,353.928,Percent of Total Billed Charges,88% of Total Billed Charges,15546.57,90,,546.928,Percent of Total Billed charges,90% of Total Billed Charges,7617.82,17273.97,
Z59524010 NEXG CR FLXPRO ART S,2780000438,CDM,278,RC,C1713,HCPCS,Outpatient,,,4963.00,3225.95,,4963,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3771.88,76,,99.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3573.36,72,,4344.944,Percent of Total Billed Charges,72% of Total Billed Charges,3573.36,72,,4344.944,Percent of Total Billed charges,72% of Total Billed Charges,4963,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3573.36,72,,4344.944,Percent of Total Billed Charges,72% of Total Billed Charges,2977.8,60,,3620.792,Percent of Total Billed Charges,60% of Total Billed Charges,4466.7,90,,411.984,Percent of Total Billed Charges,90% of Total Billed Charges,2233.35,45,,180.984,Percent of Total Billed Charges,45% of Total Billed Charges,4466.7,90,,117.48,Percent of Total Billed Charges,90% of Total billed Charges,4963,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4963,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4963,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3225.95,65,,141.032,Percent of total Billed Charges,65% of Total Billed Charges,2188.68,44.1,,177.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,4714.85,95,,124.008,Percent of Total Billed Charges,95% of Total Billed Charges,4963,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4367.44,88,,353.928,Percent of Total Billed Charges,88% of Total Billed Charges,4466.7,90,,117.48,Percent of Total Billed charges,90% of Total Billed Charges,2188.68,4963,
Z80182220 FEMOR HD 22MM 2.0,2780000439,CDM,278,RC,C1713,HCPCS,Outpatient,,,2192.00,1424.80,,2192,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1665.92,76,,237.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1578.24,72,,74.936,Percent of Total Billed Charges,72% of Total Billed Charges,1578.24,72,,74.936,Percent of Total Billed charges,72% of Total Billed Charges,2192,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1578.24,72,,74.936,Percent of Total Billed Charges,72% of Total Billed Charges,1315.2,60,,62.448,Percent of Total Billed Charges,60% of Total Billed Charges,1972.8,90,,411.984,Percent of Total Billed Charges,90% of Total Billed Charges,986.4,45,,180.984,Percent of Total Billed Charges,45% of Total Billed Charges,1972.8,90,,281.008,Percent of Total Billed Charges,90% of Total billed Charges,2192,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2192,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2192,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1424.8,65,,217.28,Percent of total Billed Charges,65% of Total Billed Charges,966.67,44.1,,177.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,2082.4,95,,296.624,Percent of Total Billed Charges,95% of Total Billed Charges,2192,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1928.96,88,,2800.384,Percent of Total Billed Charges,88% of Total Billed Charges,1972.8,90,,281.008,Percent of Total Billed charges,90% of Total Billed Charges,966.67,2192,
Z80182805 FEM HEAD 28MM 10.5,2780000440,CDM,278,RC,C1713,HCPCS,Outpatient,,,2348.00,1526.20,,2348,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1784.48,76,,347.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1690.56,72,,1661.264,Percent of Total Billed Charges,72% of Total Billed Charges,1690.56,72,,1661.264,Percent of Total Billed charges,72% of Total Billed Charges,2348,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1690.56,72,,1661.264,Percent of Total Billed Charges,72% of Total Billed Charges,1408.8,60,,1384.384,Percent of Total Billed Charges,60% of Total Billed Charges,2113.2,90,,55.568,Percent of Total Billed Charges,90% of Total Billed Charges,1056.6,45,,180.984,Percent of Total Billed Charges,45% of Total Billed Charges,2113.2,90,,411.192,Percent of Total Billed Charges,90% of Total billed Charges,2348,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2348,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2348,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1526.2,65,,1035.384,Percent of total Billed Charges,65% of Total Billed Charges,1035.47,44.1,,177.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,2230.6,95,,434.04,Percent of Total Billed Charges,95% of Total Billed Charges,2348,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2066.24,88,,320.552,Percent of Total Billed Charges,88% of Total Billed Charges,2113.2,90,,411.192,Percent of Total Billed charges,90% of Total Billed Charges,1035.47,2348,
ZILVR 635 12X40MM BILIARY STNT,2780000441,CDM,278,RC,C1876,HCPCS,Outpatient,,,4630.50,3009.83,,4630.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3519.18,76,,305.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3333.96,72,,127.64,Percent of Total Billed Charges,72% of Total Billed Charges,3333.96,72,,127.64,Percent of Total Billed charges,72% of Total Billed Charges,4630.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3333.96,72,,127.64,Percent of Total Billed Charges,72% of Total Billed Charges,2778.3,60,,106.368,Percent of Total Billed Charges,60% of Total Billed Charges,4167.45,90,,55.568,Percent of Total Billed Charges,90% of Total Billed Charges,2083.73,45,,1432.016,Percent of Total Billed Charges,45% of Total Billed Charges,4167.45,90,,361.976,Percent of Total Billed Charges,90% of Total billed Charges,4630.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4630.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4630.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3009.83,65,,882.312,Percent of total Billed Charges,65% of Total Billed Charges,2042.05,44.1,,1403.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,4398.98,95,,382.08,Percent of Total Billed Charges,95% of Total Billed Charges,4630.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4074.84,88,,2800.384,Percent of Total Billed Charges,88% of Total Billed Charges,4167.45,90,,361.976,Percent of Total Billed charges,90% of Total Billed Charges,2042.05,4630.5,
ZILVR 635 12X60MM BILIARY STNT,2780000442,CDM,278,RC,C1876,HCPCS,Outpatient,,,4630.50,3009.83,,4630.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3519.18,76,,305.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3333.96,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,3333.96,72,,41.28,Percent of Total Billed charges,72% of Total Billed Charges,4630.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3333.96,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,2778.3,60,,34.4,Percent of Total Billed Charges,60% of Total Billed Charges,4167.45,90,,2842.6,Percent of Total Billed Charges,90% of Total Billed Charges,2083.73,45,,163.92,Percent of Total Billed Charges,45% of Total Billed Charges,4167.45,90,,361.976,Percent of Total Billed Charges,90% of Total billed Charges,4630.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4630.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4630.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3009.83,65,,424.816,Percent of total Billed Charges,65% of Total Billed Charges,2042.05,44.1,,160.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,4398.98,95,,382.08,Percent of Total Billed Charges,95% of Total Billed Charges,4630.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4074.84,88,,320.552,Percent of Total Billed Charges,88% of Total Billed Charges,4167.45,90,,361.976,Percent of Total Billed charges,90% of Total Billed Charges,2042.05,4630.5,
MYOSURE TISSUE REMOV,2780000449,CDM,272,RC,,,Outpatient,,,7381.30,4797.85,,7381.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5609.79,76,,305.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5314.54,72,,3246.328,Percent of Total Billed Charges,72% of Total Billed Charges,5535.98,75,,3246.328,Percent of Total Billed charges,75% of Total Billed Charges,7381.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5314.54,72,,3246.328,Percent of Total Billed Charges,72% of Total Billed Charges,4428.78,60,,2705.272,Percent of Total Billed Charges,60% of Total Billed Charges,6643.17,90,,11030.648,Percent of Total Billed Charges,90% of Total Billed Charges,3321.59,45,,1432.016,Percent of Total Billed Charges,45% of Total Billed Charges,6643.17,90,,361.976,Percent of Total Billed Charges,90% of Total billed Charges,7381.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7381.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7381.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4797.85,65,,424.816,Percent of total Billed Charges,65% of Total Billed Charges,3255.15,44.1,,1403.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,7012.24,95,,382.08,Percent of Total Billed Charges,95% of Total Billed Charges,7381.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6495.54,88,,402.832,Percent of Total Billed Charges,88% of Total Billed Charges,6643.17,90,,361.976,Percent of Total Billed charges,90% of Total Billed Charges,3255.15,7381.3,
LAVH,2780000450,CDM,360,RC,,,Outpatient,,,12160.58,7904.38,,12160.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9242.04,76,,2418.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8755.62,72,,4630.712,Percent of Total Billed Charges,72% of Total Billed Charges,9120.44,75,,4630.712,Percent of Total Billed charges,75% of Total Billed Charges,12160.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8755.62,72,,4630.712,Percent of Total Billed Charges,72% of Total Billed Charges,7296.35,60,,3858.928,Percent of Total Billed Charges,60% of Total Billed Charges,10944.52,90,,6060.664,Percent of Total Billed Charges,90% of Total Billed Charges,5472.26,45,,163.92,Percent of Total Billed Charges,45% of Total Billed Charges,10944.52,90,,2864.032,Percent of Total Billed Charges,90% of Total billed Charges,12160.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12160.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12160.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7904.38,65,,424.816,Percent of total Billed Charges,65% of Total Billed Charges,5362.82,44.1,,160.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,11552.55,95,,3023.144,Percent of Total Billed Charges,95% of Total Billed Charges,12160.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10701.31,88,,402.832,Percent of Total Billed Charges,88% of Total Billed Charges,10944.52,90,,2864.032,Percent of Total Billed charges,90% of Total Billed Charges,5362.82,12160.58,
AMNIOGRAFT 2.0X1.5 C,2780000451,CDM,360,RC,,,Outpatient,,,2657.03,1727.07,,2657.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2019.34,76,,276.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1913.06,72,,267.352,Percent of Total Billed Charges,72% of Total Billed Charges,1992.77,75,,267.352,Percent of Total Billed charges,75% of Total Billed Charges,2657.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1913.06,72,,267.352,Percent of Total Billed Charges,72% of Total Billed Charges,1594.22,60,,222.792,Percent of Total Billed Charges,60% of Total Billed Charges,2391.33,90,,7210.088,Percent of Total Billed Charges,90% of Total Billed Charges,1195.66,45,,205.992,Percent of Total Billed Charges,45% of Total Billed Charges,2391.33,90,,327.84,Percent of Total Billed Charges,90% of Total billed Charges,2657.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2657.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2657.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1727.07,65,,1822.52,Percent of total Billed Charges,65% of Total Billed Charges,1171.75,44.1,,201.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,2524.18,95,,346.048,Percent of Total Billed Charges,95% of Total Billed Charges,2657.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2338.19,88,,54.336,Percent of Total Billed Charges,88% of Total Billed Charges,2391.33,90,,327.84,Percent of Total Billed charges,90% of Total Billed Charges,1171.75,2657.03,
TOPAZ WAND,2780000452,CDM,270,RC,A4649,HCPCS,Outpatient,,,393.59,255.83,,393.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.13,76,,2418.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,283.38,72,,6972.104,Percent of Total Billed Charges,72% of Total Billed Charges,295.19,75,,6972.104,Percent of Total Billed charges,75% of Total Billed Charges,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.38,72,,6972.104,Percent of Total Billed Charges,72% of Total Billed Charges,236.15,60,,5810.088,Percent of Total Billed Charges,60% of Total Billed Charges,354.23,90,,704.104,Percent of Total Billed Charges,90% of Total Billed Charges,177.12,45,,205.992,Percent of Total Billed Charges,45% of Total Billed Charges,354.23,90,,2864.032,Percent of Total Billed Charges,90% of Total billed Charges,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.83,65,,8991.64,Percent of total Billed Charges,65% of Total Billed Charges,173.57,44.1,,201.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,373.91,95,,3023.144,Percent of Total Billed Charges,95% of Total Billed Charges,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.36,88,,54.336,Percent of Total Billed Charges,88% of Total Billed Charges,354.23,90,,2864.032,Percent of Total Billed charges,90% of Total Billed Charges,173.57,393.59,
BARD 16FR TRI-FUNNEL GAS TUBE,2780000453,CDM,272,RC,B4087,HCPCS,Outpatient,,,173.09,112.51,,41.26,125,,,Fee Schedule,125% of CMS OPPS Rate,131.55,76,,276.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,124.62,72,,2662.72,Percent of Total Billed Charges,72% of Total Billed Charges,129.82,75,,2662.72,Percent of Total Billed charges,75% of Total Billed Charges,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,124.62,72,,2662.72,Percent of Total Billed Charges,72% of Total Billed Charges,103.85,60,,2218.936,Percent of Total Billed Charges,60% of Total Billed Charges,155.78,90,,1051.784,Percent of Total Billed Charges,90% of Total Billed Charges,77.89,45,,27.784,Percent of Total Billed Charges,45% of Total Billed Charges,155.78,90,,327.84,Percent of Total Billed Charges,90% of Total billed Charges,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,66.02,200,,7419.648,Fee Schedule,200% of CMS OPPS Rate,76.33,44.1,,27.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,164.44,95,,346.048,Percent of Total Billed Charges,95% of Total Billed Charges,24.76,75,,,Fee Schedule,75% of CMS OPPS Rate,152.32,88,,2779.424,Percent of Total Billed Charges,88% of Total Billed Charges,155.78,90,,327.84,Percent of Total Billed charges,90% of Total Billed Charges,24.76,164.44,
BARD 18FR TRI-FUNNEL GAST TUBE,2780000454,CDM,272,RC,B4087,HCPCS,Outpatient,,,173.09,112.51,,41.26,125,,,Fee Schedule,125% of CMS OPPS Rate,131.55,76,,347.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,124.62,72,,1748.904,Percent of Total Billed Charges,72% of Total Billed Charges,129.82,75,,1748.904,Percent of Total Billed charges,75% of Total Billed Charges,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,124.62,72,,1748.904,Percent of Total Billed Charges,72% of Total Billed Charges,103.85,60,,1457.416,Percent of Total Billed Charges,60% of Total Billed Charges,155.78,90,,69.856,Percent of Total Billed Charges,90% of Total Billed Charges,77.89,45,,27.784,Percent of Total Billed Charges,45% of Total Billed Charges,155.78,90,,411.984,Percent of Total Billed Charges,90% of Total billed Charges,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,66.02,200,,393.856,Fee Schedule,200% of CMS OPPS Rate,76.33,44.1,,27.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,164.44,95,,434.872,Percent of Total Billed Charges,95% of Total Billed Charges,24.76,75,,,Fee Schedule,75% of CMS OPPS Rate,152.32,88,,10785.52,Percent of Total Billed Charges,88% of Total Billed Charges,155.78,90,,411.984,Percent of Total Billed charges,90% of Total Billed Charges,24.76,164.44,
BARD 20 TRIFUNNEL TU,2780000455,CDM,272,RC,B4087,HCPCS,Outpatient,,,132.30,86.00,,41.26,125,,,Fee Schedule,125% of CMS OPPS Rate,100.55,76,,347.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.26,72,,174.64,Percent of Total Billed Charges,72% of Total Billed Charges,99.23,75,,174.64,Percent of Total Billed charges,75% of Total Billed Charges,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,95.26,72,,174.64,Percent of Total Billed Charges,72% of Total Billed Charges,79.38,60,,145.528,Percent of Total Billed Charges,60% of Total Billed Charges,119.07,90,,69.856,Percent of Total Billed Charges,90% of Total Billed Charges,59.54,45,,1421.296,Percent of Total Billed Charges,45% of Total Billed Charges,119.07,90,,411.984,Percent of Total Billed Charges,90% of Total billed Charges,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,66.02,200,,1822.52,Fee Schedule,200% of CMS OPPS Rate,58.34,44.1,,1392.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.69,95,,434.872,Percent of Total Billed Charges,95% of Total Billed Charges,24.76,75,,,Fee Schedule,75% of CMS OPPS Rate,116.42,88,,5925.984,Percent of Total Billed Charges,88% of Total Billed Charges,119.07,90,,411.984,Percent of Total Billed charges,90% of Total Billed Charges,24.76,125.69,
BARD 22FR TRI-FUNNEL GAST TUBE,2780000456,CDM,272,RC,B4087,HCPCS,Outpatient,,,173.09,112.51,,41.26,125,,,Fee Schedule,125% of CMS OPPS Rate,131.55,76,,46.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,124.62,72,,2651.928,Percent of Total Billed Charges,72% of Total Billed Charges,129.82,75,,2651.928,Percent of Total Billed charges,75% of Total Billed Charges,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,124.62,72,,2651.928,Percent of Total Billed Charges,72% of Total Billed Charges,103.85,60,,2209.936,Percent of Total Billed Charges,60% of Total Billed Charges,155.78,90,,69.856,Percent of Total Billed Charges,90% of Total Billed Charges,77.89,45,,5515.32,Percent of Total Billed Charges,45% of Total Billed Charges,155.78,90,,55.568,Percent of Total Billed Charges,90% of Total billed Charges,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,66.02,200,,2052.416,Fee Schedule,200% of CMS OPPS Rate,76.33,44.1,,5405.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,164.44,95,,58.656,Percent of Total Billed Charges,95% of Total Billed Charges,24.76,75,,,Fee Schedule,75% of CMS OPPS Rate,152.32,88,,7049.864,Percent of Total Billed Charges,88% of Total Billed Charges,155.78,90,,55.568,Percent of Total Billed charges,90% of Total Billed Charges,24.76,164.44,
BONE CHIPS 30 CC,2780000457,CDM,278,RC,C1713,HCPCS,Outpatient,,,1866.53,1213.24,,1866.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1418.56,76,,46.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1343.9,72,,21685.976,Percent of Total Billed Charges,72% of Total Billed Charges,1343.9,72,,21685.976,Percent of Total Billed charges,72% of Total Billed Charges,1866.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1343.9,72,,21685.976,Percent of Total Billed Charges,72% of Total Billed Charges,1119.92,60,,18071.648,Percent of Total Billed Charges,60% of Total Billed Charges,1679.88,90,,55.568,Percent of Total Billed Charges,90% of Total Billed Charges,839.94,45,,3030.336,Percent of Total Billed Charges,45% of Total Billed Charges,1679.88,90,,55.568,Percent of Total Billed Charges,90% of Total billed Charges,1866.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1866.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1866.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1213.24,65,,145.04,Percent of total Billed Charges,65% of Total Billed Charges,823.14,44.1,,2969.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,1773.2,95,,58.656,Percent of Total Billed Charges,95% of Total Billed Charges,1866.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1642.55,88,,688.456,Percent of Total Billed Charges,88% of Total Billed Charges,1679.88,90,,55.568,Percent of Total Billed charges,90% of Total Billed Charges,823.14,1866.53,
DPY GLL QUICK ANCHOR,2780000458,CDM,278,RC,C1713,HCPCS,Outpatient,,,1356.08,881.45,,1356.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1030.62,76,,2400.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,976.38,72,,4415.432,Percent of Total Billed Charges,72% of Total Billed Charges,976.38,72,,4415.432,Percent of Total Billed charges,72% of Total Billed Charges,1356.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,976.38,72,,4415.432,Percent of Total Billed Charges,72% of Total Billed Charges,813.65,60,,3679.528,Percent of Total Billed Charges,60% of Total Billed Charges,1220.47,90,,207.184,Percent of Total Billed Charges,90% of Total Billed Charges,610.24,45,,3605.04,Percent of Total Billed Charges,45% of Total Billed Charges,1220.47,90,,2842.6,Percent of Total Billed Charges,90% of Total billed Charges,1356.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1356.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1356.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,881.45,65,,48.16,Percent of total Billed Charges,65% of Total Billed Charges,598.03,44.1,,3532.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,1288.28,95,,3000.52,Percent of Total Billed Charges,95% of Total Billed Charges,1356.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1193.35,88,,1028.408,Percent of Total Billed Charges,88% of Total Billed Charges,1220.47,90,,2842.6,Percent of Total Billed charges,90% of Total Billed Charges,598.03,1356.08,
BONE SCREW 30MM,2780000459,CDM,278,RC,C1713,HCPCS,Outpatient,,,667.01,433.56,,667.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,506.93,76,,9314.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,480.25,72,,2651.928,Percent of Total Billed Charges,72% of Total Billed Charges,480.25,72,,2651.928,Percent of Total Billed charges,72% of Total Billed Charges,667.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.25,72,,2651.928,Percent of Total Billed Charges,72% of Total Billed Charges,400.21,60,,2209.936,Percent of Total Billed Charges,60% of Total Billed Charges,600.31,90,,80.968,Percent of Total Billed Charges,90% of Total Billed Charges,300.15,45,,352.048,Percent of Total Billed Charges,45% of Total Billed Charges,600.31,90,,11030.648,Percent of Total Billed Charges,90% of Total billed Charges,667.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,667.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,667.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,433.56,65,,48.16,Percent of total Billed Charges,65% of Total Billed Charges,294.15,44.1,,345.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,633.66,95,,11643.456,Percent of Total Billed Charges,95% of Total Billed Charges,667.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,586.97,88,,68.304,Percent of Total Billed Charges,88% of Total Billed Charges,600.31,90,,11030.648,Percent of Total Billed charges,90% of Total Billed Charges,294.15,667.01,
DPY MITEK 5 SPIRALOC,2780000460,CDM,278,RC,C1713,HCPCS,Outpatient,,,1390.25,903.66,,1390.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1056.59,76,,5117.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1000.98,72,,10092.688,Percent of Total Billed Charges,72% of Total Billed Charges,1000.98,72,,10092.688,Percent of Total Billed charges,72% of Total Billed Charges,1390.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1000.98,72,,10092.688,Percent of Total Billed Charges,72% of Total Billed Charges,834.15,60,,8410.576,Percent of Total Billed Charges,60% of Total Billed Charges,1251.23,90,,704.104,Percent of Total Billed Charges,90% of Total Billed Charges,625.61,45,,525.888,Percent of Total Billed Charges,45% of Total Billed Charges,1251.23,90,,6060.664,Percent of Total Billed Charges,90% of Total billed Charges,1390.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1390.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1390.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,903.66,65,,45.296,Percent of total Billed Charges,65% of Total Billed Charges,613.1,44.1,,515.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,1320.74,95,,6397.368,Percent of Total Billed Charges,95% of Total Billed Charges,1390.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1223.42,88,,68.304,Percent of Total Billed Charges,88% of Total Billed Charges,1251.23,90,,6060.664,Percent of Total Billed charges,90% of Total Billed Charges,613.1,1390.25,
DPY MITEK 2 ORTHO SU,2780000461,CDM,278,RC,C1713,HCPCS,Outpatient,,,561.17,364.76,,561.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,426.49,76,,6088.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,404.04,72,,344.832,Percent of Total Billed Charges,72% of Total Billed Charges,404.04,72,,344.832,Percent of Total Billed charges,72% of Total Billed Charges,561.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404.04,72,,344.832,Percent of Total Billed Charges,72% of Total Billed Charges,336.7,60,,287.36,Percent of Total Billed Charges,60% of Total Billed Charges,505.05,90,,195.28,Percent of Total Billed Charges,90% of Total Billed Charges,252.53,45,,34.928,Percent of Total Billed Charges,45% of Total Billed Charges,505.05,90,,7210.088,Percent of Total Billed Charges,90% of Total billed Charges,561.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.76,65,,40.136,Percent of total Billed Charges,65% of Total Billed Charges,247.48,44.1,,34.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,533.11,95,,7610.648,Percent of Total Billed Charges,95% of Total Billed Charges,561.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.83,88,,68.304,Percent of Total Billed Charges,88% of Total Billed Charges,505.05,90,,7210.088,Percent of Total Billed charges,90% of Total Billed Charges,247.48,561.17,
K-Wire .035 Smooth,2780000462,CDM,278,RC,C1713,HCPCS,Outpatient,,,76.07,49.45,,76.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,57.81,76,,594.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,54.77,72,,2841.808,Percent of Total Billed Charges,72% of Total Billed Charges,54.77,72,,2841.808,Percent of Total Billed charges,72% of Total Billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.77,72,,2841.808,Percent of Total Billed Charges,72% of Total Billed Charges,45.64,60,,2368.168,Percent of Total Billed Charges,60% of Total Billed Charges,68.46,90,,300.856,Percent of Total Billed Charges,90% of Total Billed Charges,34.23,45,,34.928,Percent of Total Billed Charges,45% of Total Billed Charges,68.46,90,,704.104,Percent of Total Billed Charges,90% of Total billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.45,65,,40.136,Percent of total Billed Charges,65% of Total Billed Charges,33.55,44.1,,34.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,72.27,95,,743.216,Percent of Total Billed Charges,95% of Total Billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.94,88,,54.336,Percent of Total Billed Charges,88% of Total Billed Charges,68.46,90,,704.104,Percent of Total Billed charges,90% of Total Billed Charges,33.55,76.07,
K-Wire threaded .035,2780000463,CDM,278,RC,C1713,HCPCS,Outpatient,,,165.38,107.50,,165.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,125.69,76,,888.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,119.07,72,,338.472,Percent of Total Billed Charges,72% of Total Billed Charges,119.07,72,,338.472,Percent of Total Billed charges,72% of Total Billed Charges,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.07,72,,338.472,Percent of Total Billed Charges,72% of Total Billed Charges,99.23,60,,282.064,Percent of Total Billed Charges,60% of Total Billed Charges,148.84,90,,1433.608,Percent of Total Billed Charges,90% of Total Billed Charges,74.42,45,,34.928,Percent of Total Billed Charges,45% of Total Billed Charges,148.84,90,,1051.784,Percent of Total Billed Charges,90% of Total billed Charges,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,65,,274.04,Percent of total Billed Charges,65% of Total Billed Charges,72.93,44.1,,34.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,157.11,95,,1110.216,Percent of Total Billed Charges,95% of Total Billed Charges,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,88,,202.576,Percent of Total Billed Charges,88% of Total Billed Charges,148.84,90,,1051.784,Percent of Total Billed charges,90% of Total Billed Charges,72.93,165.38,
GRAFTON PUTTY 2.5 CC,2780000464,CDM,278,RC,C1713,HCPCS,Outpatient,,,759.62,493.75,,759.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,577.31,76,,58.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,546.93,72,,2980.24,Percent of Total Billed Charges,72% of Total Billed Charges,546.93,72,,2980.24,Percent of Total Billed charges,72% of Total Billed Charges,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.93,72,,2980.24,Percent of Total Billed Charges,72% of Total Billed Charges,455.77,60,,2483.536,Percent of Total Billed Charges,60% of Total Billed Charges,683.66,90,,1221.664,Percent of Total Billed Charges,90% of Total Billed Charges,341.83,45,,27.784,Percent of Total Billed Charges,45% of Total Billed Charges,683.66,90,,69.856,Percent of Total Billed Charges,90% of Total billed Charges,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.75,65,,115.232,Percent of total Billed Charges,65% of Total Billed Charges,334.99,44.1,,27.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,721.64,95,,73.736,Percent of Total Billed Charges,95% of Total Billed Charges,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,668.47,88,,79.168,Percent of Total Billed Charges,88% of Total Billed Charges,683.66,90,,69.856,Percent of Total Billed charges,90% of Total Billed Charges,334.99,759.62,
GRAFTON DMF FLEX,2780000465,CDM,278,RC,C1713,HCPCS,Outpatient,,,1975.68,1284.19,,1975.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1501.52,76,,58.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1422.49,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,1422.49,72,,43.184,Percent of Total Billed charges,72% of Total Billed Charges,1975.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1422.49,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,1185.41,60,,35.984,Percent of Total Billed Charges,60% of Total Billed Charges,1778.11,90,,588.208,Percent of Total Billed Charges,90% of Total Billed Charges,889.06,45,,103.592,Percent of Total Billed Charges,45% of Total Billed Charges,1778.11,90,,69.856,Percent of Total Billed Charges,90% of Total billed Charges,1975.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1975.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1975.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1284.19,65,,77.968,Percent of total Billed Charges,65% of Total Billed Charges,871.27,44.1,,101.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,1876.9,95,,73.736,Percent of Total Billed Charges,95% of Total Billed Charges,1975.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1738.6,88,,688.456,Percent of Total Billed Charges,88% of Total Billed Charges,1778.11,90,,69.856,Percent of Total Billed charges,90% of Total Billed Charges,871.27,1975.68,
OPTEFORM GRAFT DISK,2780000466,CDM,278,RC,C1713,HCPCS,Outpatient,,,2156.49,1401.72,,2156.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1638.93,76,,58.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1552.67,72,,429.288,Percent of Total Billed Charges,72% of Total Billed Charges,1552.67,72,,429.288,Percent of Total Billed charges,72% of Total Billed Charges,2156.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1552.67,72,,429.288,Percent of Total Billed Charges,72% of Total Billed Charges,1293.89,60,,357.736,Percent of Total Billed Charges,60% of Total Billed Charges,1940.84,90,,588.208,Percent of Total Billed Charges,90% of Total Billed Charges,970.42,45,,40.488,Percent of Total Billed Charges,45% of Total Billed Charges,1940.84,90,,69.856,Percent of Total Billed Charges,90% of Total billed Charges,2156.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2156.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2156.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1401.72,65,,343.408,Percent of total Billed Charges,65% of Total Billed Charges,951.01,44.1,,39.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,2048.67,95,,73.736,Percent of Total Billed Charges,95% of Total Billed Charges,2156.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1897.71,88,,190.936,Percent of Total Billed Charges,88% of Total Billed Charges,1940.84,90,,69.856,Percent of Total Billed charges,90% of Total Billed Charges,951.01,2156.49,
STRYKER MAIN STAY AN,2780000467,CDM,278,RC,C1713,HCPCS,Outpatient,,,571.10,371.22,,571.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,434.04,76,,46.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,411.19,72,,186.704,Percent of Total Billed Charges,72% of Total Billed Charges,411.19,72,,186.704,Percent of Total Billed charges,72% of Total Billed Charges,571.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.19,72,,186.704,Percent of Total Billed Charges,72% of Total Billed Charges,342.66,60,,155.584,Percent of Total Billed Charges,60% of Total Billed Charges,513.99,90,,588.208,Percent of Total Billed Charges,90% of Total Billed Charges,257,45,,352.048,Percent of Total Billed Charges,45% of Total Billed Charges,513.99,90,,55.568,Percent of Total Billed Charges,90% of Total billed Charges,571.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,571.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,571.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.22,65,,247.664,Percent of total Billed Charges,65% of Total Billed Charges,251.86,44.1,,345.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,542.55,95,,58.656,Percent of Total Billed Charges,95% of Total Billed Charges,571.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.57,88,,294.168,Percent of Total Billed Charges,88% of Total Billed Charges,513.99,90,,55.568,Percent of Total Billed charges,90% of Total Billed Charges,251.86,571.1,
ZERO TIP BASKET 3X12,2780000468,CDM,278,RC,C1713,HCPCS,Outpatient,,,575.51,374.08,,575.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,437.39,76,,174.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,414.37,72,,186.704,Percent of Total Billed Charges,72% of Total Billed Charges,414.37,72,,186.704,Percent of Total Billed charges,72% of Total Billed Charges,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.37,72,,186.704,Percent of Total Billed Charges,72% of Total Billed Charges,345.31,60,,155.584,Percent of Total Billed Charges,60% of Total Billed Charges,517.96,90,,2523.496,Percent of Total Billed Charges,90% of Total Billed Charges,258.98,45,,97.64,Percent of Total Billed Charges,45% of Total Billed Charges,517.96,90,,207.184,Percent of Total Billed Charges,90% of Total billed Charges,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.08,65,,2556.92,Percent of total Billed Charges,65% of Total Billed Charges,253.8,44.1,,95.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,546.73,95,,218.688,Percent of Total Billed Charges,95% of Total Billed Charges,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.45,88,,1401.752,Percent of Total Billed Charges,88% of Total Billed Charges,517.96,90,,207.184,Percent of Total Billed charges,90% of Total Billed Charges,253.8,575.51,
RESORBABLE SCREW,2780000469,CDM,278,RC,C1713,HCPCS,Outpatient,,,932.72,606.27,,932.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,708.87,76,,68.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,671.56,72,,551.848,Percent of Total Billed Charges,72% of Total Billed Charges,671.56,72,,551.848,Percent of Total Billed charges,72% of Total Billed Charges,932.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,671.56,72,,551.848,Percent of Total Billed Charges,72% of Total Billed Charges,559.63,60,,459.872,Percent of Total Billed Charges,60% of Total Billed Charges,839.45,90,,12449.96,Percent of Total Billed Charges,90% of Total Billed Charges,419.72,45,,150.424,Percent of Total Billed Charges,45% of Total Billed Charges,839.45,90,,80.968,Percent of Total Billed Charges,90% of Total billed Charges,932.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,932.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,932.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,606.27,65,,508.52,Percent of total Billed Charges,65% of Total Billed Charges,411.33,44.1,,147.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,886.08,95,,85.472,Percent of Total Billed Charges,95% of Total Billed Charges,932.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,820.79,88,,1194.512,Percent of Total Billed Charges,88% of Total Billed Charges,839.45,90,,80.968,Percent of Total Billed charges,90% of Total Billed Charges,411.33,932.72,
RCI SCREW 10X25,2780000470,CDM,278,RC,C1713,HCPCS,Outpatient,,,540.23,351.15,,540.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,410.57,76,,594.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,388.97,72,,1468.216,Percent of Total Billed Charges,72% of Total Billed Charges,388.97,72,,1468.216,Percent of Total Billed charges,72% of Total Billed Charges,540.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,388.97,72,,1468.216,Percent of Total Billed Charges,72% of Total Billed Charges,324.14,60,,1223.512,Percent of Total Billed Charges,60% of Total Billed Charges,486.21,90,,10273.36,Percent of Total Billed Charges,90% of Total Billed Charges,243.1,45,,716.8,Percent of Total Billed Charges,45% of Total Billed Charges,486.21,90,,704.104,Percent of Total Billed Charges,90% of Total billed Charges,540.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,351.15,65,,508.52,Percent of total Billed Charges,65% of Total Billed Charges,238.24,44.1,,702.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,513.22,95,,743.216,Percent of Total Billed Charges,95% of Total Billed Charges,540.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475.4,88,,575.136,Percent of Total Billed Charges,88% of Total Billed Charges,486.21,90,,704.104,Percent of Total Billed charges,90% of Total Billed Charges,238.24,540.23,
DORSAL DELTA PLATE,2780000471,CDM,278,RC,C1713,HCPCS,Outpatient,,,3400.11,2210.07,,3400.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2584.08,76,,164.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2448.08,72,,319.424,Percent of Total Billed Charges,72% of Total Billed Charges,2448.08,72,,319.424,Percent of Total Billed charges,72% of Total Billed Charges,3400.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2448.08,72,,319.424,Percent of Total Billed Charges,72% of Total Billed Charges,2040.07,60,,266.192,Percent of Total Billed Charges,60% of Total Billed Charges,3060.1,90,,545.344,Percent of Total Billed Charges,90% of Total Billed Charges,1530.05,45,,610.832,Percent of Total Billed Charges,45% of Total Billed Charges,3060.1,90,,195.28,Percent of Total Billed Charges,90% of Total billed Charges,3400.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3400.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3400.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.07,65,,508.52,Percent of total Billed Charges,65% of Total Billed Charges,1499.45,44.1,,598.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,3230.1,95,,206.128,Percent of Total Billed Charges,95% of Total Billed Charges,3400.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2992.1,88,,575.136,Percent of Total Billed Charges,88% of Total Billed Charges,3060.1,90,,195.28,Percent of Total Billed charges,90% of Total Billed Charges,1499.45,3400.11,
LOCKING SCREWS,2780000472,CDM,278,RC,C1713,HCPCS,Outpatient,,,396.90,257.99,,396.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,301.64,76,,254.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,285.77,72,,50.168,Percent of Total Billed Charges,72% of Total Billed Charges,285.77,72,,50.168,Percent of Total Billed charges,72% of Total Billed Charges,396.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.77,72,,50.168,Percent of Total Billed Charges,72% of Total Billed Charges,238.14,60,,41.808,Percent of Total Billed Charges,60% of Total Billed Charges,357.21,90,,2523.496,Percent of Total Billed Charges,90% of Total Billed Charges,178.61,45,,294.104,Percent of Total Billed Charges,45% of Total Billed Charges,357.21,90,,300.856,Percent of Total Billed Charges,90% of Total billed Charges,396.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.99,65,,508.52,Percent of total Billed Charges,65% of Total Billed Charges,175.03,44.1,,288.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,377.06,95,,317.568,Percent of Total Billed Charges,95% of Total Billed Charges,396.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.27,88,,575.136,Percent of Total Billed Charges,88% of Total Billed Charges,357.21,90,,300.856,Percent of Total Billed charges,90% of Total Billed Charges,175.03,396.9,
CONICAL SCREWS,2780000473,CDM,278,RC,C1713,HCPCS,Outpatient,,,320.83,208.54,,320.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,243.83,76,,1210.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,231,72,,2731.944,Percent of Total Billed Charges,72% of Total Billed Charges,231,72,,2731.944,Percent of Total Billed charges,72% of Total Billed Charges,320.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231,72,,2731.944,Percent of Total Billed Charges,72% of Total Billed Charges,192.5,60,,2276.624,Percent of Total Billed Charges,60% of Total Billed Charges,288.75,90,,2841.808,Percent of Total Billed Charges,90% of Total Billed Charges,144.37,45,,294.104,Percent of Total Billed Charges,45% of Total Billed Charges,288.75,90,,1433.608,Percent of Total Billed Charges,90% of Total billed Charges,320.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.54,65,,29.808,Percent of total Billed Charges,65% of Total Billed Charges,141.49,44.1,,288.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,304.79,95,,1513.248,Percent of Total Billed Charges,95% of Total Billed Charges,320.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.33,88,,2467.416,Percent of Total Billed Charges,88% of Total Billed Charges,288.75,90,,1433.608,Percent of Total Billed charges,90% of Total Billed Charges,141.49,320.83,
DPY 4.0 CANC SCREWS,2780000474,CDM,278,RC,C1713,HCPCS,Outpatient,,,121.28,78.83,,121.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,92.17,76,,1031.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,87.32,72,,1901.944,Percent of Total Billed Charges,72% of Total Billed Charges,87.32,72,,1901.944,Percent of Total Billed charges,72% of Total Billed Charges,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.32,72,,1901.944,Percent of Total Billed Charges,72% of Total Billed Charges,72.77,60,,1584.952,Percent of Total Billed Charges,60% of Total Billed Charges,109.15,90,,200.832,Percent of Total Billed Charges,90% of Total Billed Charges,54.58,45,,294.104,Percent of Total Billed Charges,45% of Total Billed Charges,109.15,90,,1221.664,Percent of Total Billed Charges,90% of Total billed Charges,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.83,65,,2284.024,Percent of total Billed Charges,65% of Total Billed Charges,53.48,44.1,,288.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,115.22,95,,1289.528,Percent of Total Billed Charges,95% of Total Billed Charges,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.73,88,,12173.296,Percent of Total Billed Charges,88% of Total Billed Charges,109.15,90,,1221.664,Percent of Total Billed charges,90% of Total Billed Charges,53.48,121.28,
DPY 3.5 CORT SCREWS,2780000475,CDM,278,RC,C1713,HCPCS,Outpatient,,,108.05,70.23,,108.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.12,76,,496.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.8,72,,2559.848,Percent of Total Billed Charges,72% of Total Billed Charges,77.8,72,,2559.848,Percent of Total Billed charges,72% of Total Billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.8,72,,2559.848,Percent of Total Billed Charges,72% of Total Billed Charges,64.83,60,,2133.208,Percent of Total Billed Charges,60% of Total Billed Charges,97.25,90,,66.68,Percent of Total Billed Charges,90% of Total Billed Charges,48.62,45,,1261.744,Percent of Total Billed Charges,45% of Total Billed Charges,97.25,90,,588.208,Percent of Total Billed Charges,90% of Total billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.23,65,,2634.312,Percent of total Billed Charges,65% of Total Billed Charges,47.65,44.1,,1236.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.65,95,,620.88,Percent of Total Billed Charges,95% of Total Billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.08,88,,10045.064,Percent of Total Billed Charges,88% of Total Billed Charges,97.25,90,,588.208,Percent of Total Billed charges,90% of Total Billed Charges,47.65,108.05,
DPY 4.0 CANNUL SCREW,2780000476,CDM,278,RC,C1713,HCPCS,Outpatient,,,890.82,579.03,,890.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,677.02,76,,496.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,641.39,72,,2731.944,Percent of Total Billed Charges,72% of Total Billed Charges,641.39,72,,2731.944,Percent of Total Billed charges,72% of Total Billed Charges,890.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,641.39,72,,2731.944,Percent of Total Billed Charges,72% of Total Billed Charges,534.49,60,,2276.624,Percent of Total Billed Charges,60% of Total Billed Charges,801.74,90,,66.68,Percent of Total Billed Charges,90% of Total Billed Charges,400.87,45,,6224.976,Percent of Total Billed Charges,45% of Total Billed Charges,801.74,90,,588.208,Percent of Total Billed Charges,90% of Total billed Charges,890.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,890.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,890.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.03,65,,2634.312,Percent of total Billed Charges,65% of Total Billed Charges,392.85,44.1,,6100.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,846.28,95,,620.88,Percent of Total Billed Charges,95% of Total Billed Charges,890.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,783.92,88,,533.224,Percent of Total Billed Charges,88% of Total Billed Charges,801.74,90,,588.208,Percent of Total Billed charges,90% of Total Billed Charges,392.85,890.82,
Biorci Screw 8x25,2780000477,CDM,278,RC,C1713,HCPCS,Outpatient,,,1543.50,1003.28,,1543.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1173.06,76,,496.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1111.32,72,,3101.536,Percent of Total Billed Charges,72% of Total Billed Charges,1111.32,72,,3101.536,Percent of Total Billed charges,72% of Total Billed Charges,1543.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1111.32,72,,3101.536,Percent of Total Billed Charges,72% of Total Billed Charges,926.1,60,,2584.616,Percent of Total Billed Charges,60% of Total Billed Charges,1389.15,90,,62.712,Percent of Total Billed Charges,90% of Total Billed Charges,694.58,45,,5136.68,Percent of Total Billed Charges,45% of Total Billed Charges,1389.15,90,,588.208,Percent of Total Billed Charges,90% of Total billed Charges,1543.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1543.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1543.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1003.28,65,,2911.792,Percent of total Billed Charges,65% of Total Billed Charges,680.68,44.1,,5033.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,1466.33,95,,620.88,Percent of Total Billed Charges,95% of Total Billed Charges,1543.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1358.28,88,,2467.416,Percent of Total Billed Charges,88% of Total Billed Charges,1389.15,90,,588.208,Percent of Total Billed charges,90% of Total Billed Charges,680.68,1543.5,
RCI SCREW 89,2780000478,CDM,278,RC,C1713,HCPCS,Outpatient,,,729.86,474.41,,729.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,554.69,76,,2130.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,525.5,72,,3789.288,Percent of Total Billed Charges,72% of Total Billed Charges,525.5,72,,3789.288,Percent of Total Billed charges,72% of Total Billed Charges,729.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,525.5,72,,3789.288,Percent of Total Billed Charges,72% of Total Billed Charges,437.92,60,,3157.736,Percent of Total Billed Charges,60% of Total Billed Charges,656.87,90,,55.568,Percent of Total Billed Charges,90% of Total Billed Charges,328.44,45,,272.672,Percent of Total Billed Charges,45% of Total Billed Charges,656.87,90,,2523.496,Percent of Total Billed Charges,90% of Total billed Charges,729.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,729.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,729.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.41,65,,2394.104,Percent of total Billed Charges,65% of Total Billed Charges,321.87,44.1,,267.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,693.37,95,,2663.688,Percent of Total Billed Charges,95% of Total Billed Charges,729.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,642.28,88,,2778.656,Percent of Total Billed Charges,88% of Total Billed Charges,656.87,90,,2523.496,Percent of Total Billed charges,90% of Total Billed Charges,321.87,729.86,
PROMIMAL HUMERUS PLA,2780000479,CDM,278,RC,,,Outpatient,,,1396.87,907.97,,1396.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1061.62,76,,10513.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1005.75,72,,494.696,Percent of Total Billed Charges,72% of Total Billed Charges,1005.75,72,,494.696,Percent of Total Billed charges,72% of Total Billed Charges,1396.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1005.75,72,,494.696,Percent of Total Billed Charges,72% of Total Billed Charges,838.12,60,,412.248,Percent of Total Billed Charges,60% of Total Billed Charges,1257.18,90,,55.568,Percent of Total Billed Charges,90% of Total Billed Charges,628.59,45,,1261.744,Percent of Total Billed Charges,45% of Total Billed Charges,1257.18,90,,12449.96,Percent of Total Billed Charges,90% of Total billed Charges,1396.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1396.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1396.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,907.97,65,,4148.4,Percent of total Billed Charges,65% of Total Billed Charges,616.02,44.1,,1236.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,1327.03,95,,13141.624,Percent of Total Billed Charges,95% of Total Billed Charges,1396.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1229.25,88,,196.368,Percent of Total Billed Charges,88% of Total Billed Charges,1257.18,90,,12449.96,Percent of Total Billed charges,90% of Total Billed Charges,616.02,1396.87,
CALCANEAL PERIMETER,2780000483,CDM,278,RC,,,Outpatient,,,2029.70,1319.31,,2029.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1542.57,76,,8675.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1461.38,72,,1187.528,Percent of Total Billed Charges,72% of Total Billed Charges,1461.38,72,,1187.528,Percent of Total Billed charges,72% of Total Billed Charges,2029.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1461.38,72,,1187.528,Percent of Total Billed Charges,72% of Total Billed Charges,1217.82,60,,989.608,Percent of Total Billed Charges,60% of Total Billed Charges,1826.73,90,,379.44,Percent of Total Billed Charges,90% of Total Billed Charges,913.37,45,,1420.904,Percent of Total Billed Charges,45% of Total Billed Charges,1826.73,90,,10273.36,Percent of Total Billed Charges,90% of Total billed Charges,2029.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2029.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2029.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1319.31,65,,13083.856,Percent of total Billed Charges,65% of Total Billed Charges,895.1,44.1,,1392.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,1928.22,95,,10844.104,Percent of Total Billed Charges,95% of Total Billed Charges,2029.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1786.14,88,,65.2,Percent of Total Billed Charges,88% of Total Billed Charges,1826.73,90,,10273.36,Percent of Total Billed charges,90% of Total Billed Charges,895.1,2029.7,
DORSAL DISTAL RADIUS,2780000493,CDM,278,RC,C1713,HCPCS,Outpatient,,,1352.77,879.30,,1352.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1028.11,76,,460.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,973.99,72,,3789.288,Percent of Total Billed Charges,72% of Total Billed Charges,973.99,72,,3789.288,Percent of Total Billed charges,72% of Total Billed Charges,1352.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,973.99,72,,3789.288,Percent of Total Billed Charges,72% of Total Billed Charges,811.66,60,,3157.736,Percent of Total Billed Charges,60% of Total Billed Charges,1217.49,90,,159.552,Percent of Total Billed Charges,90% of Total Billed Charges,608.75,45,,100.416,Percent of Total Billed Charges,45% of Total Billed Charges,1217.49,90,,545.344,Percent of Total Billed Charges,90% of Total billed Charges,1352.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1352.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1352.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,879.3,65,,4228.664,Percent of total Billed Charges,65% of Total Billed Charges,596.57,44.1,,98.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,1285.13,95,,575.64,Percent of Total Billed Charges,95% of Total Billed Charges,1352.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1190.44,88,,65.2,Percent of Total Billed Charges,88% of Total Billed Charges,1217.49,90,,545.344,Percent of Total Billed charges,90% of Total Billed Charges,596.57,1352.77,
6.58.0 CAN CANC TAP,2780000498,CDM,278,RC,C1713,HCPCS,Outpatient,,,587.63,381.96,,587.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,446.6,76,,2130.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,423.09,72,,3789.288,Percent of Total Billed Charges,72% of Total Billed Charges,423.09,72,,3789.288,Percent of Total Billed charges,72% of Total Billed Charges,587.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,423.09,72,,3789.288,Percent of Total Billed Charges,72% of Total Billed Charges,352.58,60,,3157.736,Percent of Total Billed Charges,60% of Total Billed Charges,528.87,90,,107.96,Percent of Total Billed Charges,90% of Total Billed Charges,264.43,45,,33.336,Percent of Total Billed Charges,45% of Total Billed Charges,528.87,90,,2523.496,Percent of Total Billed Charges,90% of Total billed Charges,587.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,587.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,587.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.96,65,,3349.224,Percent of total Billed Charges,65% of Total Billed Charges,259.14,44.1,,32.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,558.25,95,,2663.688,Percent of Total Billed Charges,95% of Total Billed Charges,587.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,517.11,88,,61.32,Percent of Total Billed Charges,88% of Total Billed Charges,528.87,90,,2523.496,Percent of Total Billed charges,90% of Total Billed Charges,259.14,587.63,
6.5 FLAT WASHER,2780000499,CDM,278,RC,C1713,HCPCS,Outpatient,,,158.76,103.19,,158.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.66,76,,2399.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.31,72,,645.832,Percent of Total Billed Charges,72% of Total Billed Charges,114.31,72,,645.832,Percent of Total Billed charges,72% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.31,72,,645.832,Percent of Total Billed Charges,72% of Total Billed Charges,95.26,60,,538.192,Percent of Total Billed Charges,60% of Total Billed Charges,142.88,90,,475.488,Percent of Total Billed Charges,90% of Total Billed Charges,71.44,45,,33.336,Percent of Total Billed Charges,45% of Total Billed Charges,142.88,90,,2841.808,Percent of Total Billed Charges,90% of Total billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.19,65,,2557.488,Percent of total Billed Charges,65% of Total Billed Charges,70.01,44.1,,32.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,150.82,95,,2999.68,Percent of Total Billed Charges,95% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.71,88,,54.336,Percent of Total Billed Charges,88% of Total Billed Charges,142.88,90,,2841.808,Percent of Total Billed charges,90% of Total Billed Charges,70.01,158.76,
8.0 FLAT WASHER,2780000500,CDM,278,RC,C1713,HCPCS,Outpatient,,,189.63,123.26,,189.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.12,76,,169.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,136.53,72,,992.568,Percent of Total Billed Charges,72% of Total Billed Charges,136.53,72,,992.568,Percent of Total Billed charges,72% of Total Billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.53,72,,992.568,Percent of Total Billed Charges,72% of Total Billed Charges,113.78,60,,827.144,Percent of Total Billed Charges,60% of Total Billed Charges,170.67,90,,342.92,Percent of Total Billed Charges,90% of Total Billed Charges,85.33,45,,31.36,Percent of Total Billed Charges,45% of Total Billed Charges,170.67,90,,200.832,Percent of Total Billed Charges,90% of Total billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.26,65,,508.52,Percent of total Billed Charges,65% of Total Billed Charges,83.63,44.1,,30.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,180.15,95,,211.984,Percent of Total Billed Charges,95% of Total Billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.87,88,,54.336,Percent of Total Billed Charges,88% of Total Billed Charges,170.67,90,,200.832,Percent of Total Billed charges,90% of Total Billed Charges,83.63,189.63,
3.2X9 THREAD GUIDEPI,2780000501,CDM,278,RC,C1713,HCPCS,Outpatient,,,47.41,30.82,,47.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.03,76,,56.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.14,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,34.14,72,,36.192,Percent of Total Billed charges,72% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.14,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,28.45,60,,30.16,Percent of Total Billed Charges,60% of Total Billed Charges,42.67,90,,3540.352,Percent of Total Billed Charges,90% of Total Billed Charges,21.33,45,,27.784,Percent of Total Billed Charges,45% of Total Billed Charges,42.67,90,,66.68,Percent of Total Billed Charges,90% of Total billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.82,65,,508.52,Percent of total Billed Charges,65% of Total Billed Charges,20.91,44.1,,27.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.04,95,,70.384,Percent of Total Billed Charges,95% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.72,88,,371.008,Percent of Total Billed Charges,88% of Total Billed Charges,42.67,90,,66.68,Percent of Total Billed charges,90% of Total Billed Charges,20.91,47.41,
6.5 CANN CANC LAG SC,2780000502,CDM,278,RC,,,Outpatient,,,1166.45,758.19,,1166.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,886.5,76,,56.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,839.84,72,,3789.288,Percent of Total Billed Charges,72% of Total Billed Charges,839.84,72,,3789.288,Percent of Total Billed charges,72% of Total Billed Charges,1166.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,839.84,72,,3789.288,Percent of Total Billed Charges,72% of Total Billed Charges,699.87,60,,3157.736,Percent of Total Billed Charges,60% of Total Billed Charges,1049.81,90,,704.104,Percent of Total Billed Charges,90% of Total Billed Charges,524.9,45,,27.784,Percent of Total Billed Charges,45% of Total Billed Charges,1049.81,90,,66.68,Percent of Total Billed Charges,90% of Total billed Charges,1166.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,758.19,65,,58.48,Percent of total Billed Charges,65% of Total Billed Charges,514.4,44.1,,27.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,1108.13,95,,70.384,Percent of Total Billed Charges,95% of Total Billed Charges,1166.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1026.48,88,,156.008,Percent of Total Billed Charges,88% of Total Billed Charges,1049.81,90,,66.68,Percent of Total Billed charges,90% of Total Billed Charges,514.4,1166.45,
3.5 100 DEGREE TUBUL,2780000507,CDM,278,RC,,,Outpatient,,,443.21,288.09,,443.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,336.84,76,,52.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,319.11,72,,873.184,Percent of Total Billed Charges,72% of Total Billed Charges,319.11,72,,873.184,Percent of Total Billed charges,72% of Total Billed Charges,443.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319.11,72,,873.184,Percent of Total Billed Charges,72% of Total Billed Charges,265.93,60,,727.648,Percent of Total Billed Charges,60% of Total Billed Charges,398.89,90,,704.104,Percent of Total Billed Charges,90% of Total Billed Charges,199.44,45,,189.72,Percent of Total Billed Charges,45% of Total Billed Charges,398.89,90,,62.712,Percent of Total Billed Charges,90% of Total billed Charges,443.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,443.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,443.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.09,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,195.46,44.1,,185.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,421.05,95,,66.2,Percent of Total Billed Charges,95% of Total Billed Charges,443.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.02,88,,105.56,Percent of Total Billed Charges,88% of Total Billed Charges,398.89,90,,62.712,Percent of Total Billed charges,90% of Total Billed Charges,195.46,443.21,
3.5 ACTIVE COMP PLAT,2780000508,CDM,278,RC,,,Outpatient,,,884.21,574.74,,884.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,672,76,,46.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,636.63,72,,803.96,Percent of Total Billed Charges,72% of Total Billed Charges,636.63,72,,803.96,Percent of Total Billed charges,72% of Total Billed Charges,884.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,636.63,72,,803.96,Percent of Total Billed Charges,72% of Total Billed Charges,530.53,60,,669.968,Percent of Total Billed Charges,60% of Total Billed Charges,795.79,90,,704.104,Percent of Total Billed Charges,90% of Total Billed Charges,397.89,45,,79.776,Percent of Total Billed Charges,45% of Total Billed Charges,795.79,90,,55.568,Percent of Total Billed Charges,90% of Total billed Charges,884.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,884.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,884.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,574.74,65,,436.28,Percent of total Billed Charges,65% of Total Billed Charges,389.94,44.1,,78.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,840,95,,58.656,Percent of Total Billed Charges,95% of Total Billed Charges,884.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,778.1,88,,464.92,Percent of Total Billed Charges,88% of Total Billed Charges,795.79,90,,55.568,Percent of Total Billed charges,90% of Total Billed Charges,389.94,884.21,
4.0 SOLID CANC SCREW,2780000510,CDM,278,RC,,,Outpatient,,,189.63,123.26,,189.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.12,76,,46.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,136.53,72,,494.696,Percent of Total Billed Charges,72% of Total Billed Charges,136.53,72,,494.696,Percent of Total Billed charges,72% of Total Billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.53,72,,494.696,Percent of Total Billed Charges,72% of Total Billed Charges,113.78,60,,412.248,Percent of Total Billed Charges,60% of Total Billed Charges,170.67,90,,704.104,Percent of Total Billed Charges,90% of Total Billed Charges,85.33,45,,53.976,Percent of Total Billed Charges,45% of Total Billed Charges,170.67,90,,55.568,Percent of Total Billed Charges,90% of Total billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.26,65,,436.28,Percent of total Billed Charges,65% of Total Billed Charges,83.63,44.1,,52.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,180.15,95,,58.656,Percent of Total Billed Charges,95% of Total Billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.87,88,,335.304,Percent of Total Billed Charges,88% of Total Billed Charges,170.67,90,,55.568,Percent of Total Billed charges,90% of Total Billed Charges,83.63,189.63,
4.0 SOLID CANC LAG S,2780000511,CDM,278,RC,,,Outpatient,,,189.63,123.26,,189.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.12,76,,320.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,136.53,72,,33.024,Percent of Total Billed Charges,72% of Total Billed Charges,136.53,72,,33.024,Percent of Total Billed charges,72% of Total Billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.53,72,,33.024,Percent of Total Billed Charges,72% of Total Billed Charges,113.78,60,,27.52,Percent of Total Billed Charges,60% of Total Billed Charges,170.67,90,,41.28,Percent of Total Billed Charges,90% of Total Billed Charges,85.33,45,,237.744,Percent of Total Billed Charges,45% of Total Billed Charges,170.67,90,,379.44,Percent of Total Billed Charges,90% of Total billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.26,65,,436.28,Percent of total Billed Charges,65% of Total Billed Charges,83.63,44.1,,232.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,180.15,95,,400.52,Percent of Total Billed Charges,95% of Total Billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.87,88,,3461.672,Percent of Total Billed Charges,88% of Total Billed Charges,170.67,90,,379.44,Percent of Total Billed charges,90% of Total Billed Charges,83.63,189.63,
4.0 CANN CANC LAG SC,2780000512,CDM,278,RC,C1713,HCPCS,Outpatient,,,723.24,470.11,,723.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,549.66,76,,134.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,520.73,72,,252.112,Percent of Total Billed Charges,72% of Total Billed Charges,520.73,72,,252.112,Percent of Total Billed charges,72% of Total Billed Charges,723.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520.73,72,,252.112,Percent of Total Billed Charges,72% of Total Billed Charges,433.94,60,,210.088,Percent of Total Billed Charges,60% of Total Billed Charges,650.92,90,,3162.496,Percent of Total Billed Charges,90% of Total Billed Charges,325.46,45,,171.464,Percent of Total Billed Charges,45% of Total Billed Charges,650.92,90,,159.552,Percent of Total Billed Charges,90% of Total billed Charges,723.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,723.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,723.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,470.11,65,,436.28,Percent of total Billed Charges,65% of Total Billed Charges,318.95,44.1,,168.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,687.08,95,,168.416,Percent of Total Billed Charges,95% of Total Billed Charges,723.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,636.45,88,,688.456,Percent of Total Billed Charges,88% of Total Billed Charges,650.92,90,,159.552,Percent of Total Billed charges,90% of Total Billed Charges,318.95,723.24,
3.5 SOLID CORTICAL S,2780000513,CDM,278,RC,,,Outpatient,,,176.40,114.66,,176.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,134.06,76,,91.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,127.01,72,,506.128,Percent of Total Billed Charges,72% of Total Billed Charges,127.01,72,,506.128,Percent of Total Billed charges,72% of Total Billed Charges,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.01,72,,506.128,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,60,,421.768,Percent of Total Billed Charges,60% of Total Billed Charges,158.76,90,,3647.512,Percent of Total Billed Charges,90% of Total Billed Charges,79.38,45,,1770.176,Percent of Total Billed Charges,45% of Total Billed Charges,158.76,90,,107.96,Percent of Total Billed Charges,90% of Total billed Charges,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.66,65,,436.28,Percent of total Billed Charges,65% of Total Billed Charges,77.79,44.1,,1734.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,167.58,95,,113.952,Percent of Total Billed Charges,95% of Total Billed Charges,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.23,88,,688.456,Percent of Total Billed Charges,88% of Total Billed Charges,158.76,90,,107.96,Percent of Total Billed charges,90% of Total Billed Charges,77.79,176.4,
4.55.0 CANN CORTICA,2780000514,CDM,278,RC,C1713,HCPCS,Outpatient,,,562.28,365.48,,562.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,427.33,76,,401.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,404.84,72,,489.616,Percent of Total Billed Charges,72% of Total Billed Charges,404.84,72,,489.616,Percent of Total Billed charges,72% of Total Billed Charges,562.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404.84,72,,489.616,Percent of Total Billed Charges,72% of Total Billed Charges,337.37,60,,408.016,Percent of Total Billed Charges,60% of Total Billed Charges,506.05,90,,3647.512,Percent of Total Billed Charges,90% of Total Billed Charges,253.03,45,,352.048,Percent of Total Billed Charges,45% of Total Billed Charges,506.05,90,,475.488,Percent of Total Billed Charges,90% of Total billed Charges,562.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365.48,65,,436.28,Percent of total Billed Charges,65% of Total Billed Charges,247.97,44.1,,345.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,534.17,95,,501.904,Percent of Total Billed Charges,95% of Total Billed Charges,562.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,494.81,88,,688.456,Percent of Total Billed Charges,88% of Total Billed Charges,506.05,90,,475.488,Percent of Total Billed charges,90% of Total Billed Charges,247.97,562.28,
5.0 CANN CANC LAG SC,2780000517,CDM,278,RC,C1713,HCPCS,Outpatient,,,792.70,515.26,,792.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,602.45,76,,289.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,570.74,72,,6171.32,Percent of Total Billed Charges,72% of Total Billed Charges,570.74,72,,6171.32,Percent of Total Billed charges,72% of Total Billed Charges,792.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,570.74,72,,6171.32,Percent of Total Billed Charges,72% of Total Billed Charges,475.62,60,,5142.768,Percent of Total Billed Charges,60% of Total Billed Charges,713.43,90,,4031.712,Percent of Total Billed Charges,90% of Total Billed Charges,356.72,45,,352.048,Percent of Total Billed Charges,45% of Total Billed Charges,713.43,90,,342.92,Percent of Total Billed Charges,90% of Total billed Charges,792.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,792.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,792.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,515.26,65,,436.28,Percent of total Billed Charges,65% of Total Billed Charges,349.58,44.1,,345.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,753.07,95,,361.976,Percent of Total Billed Charges,95% of Total Billed Charges,792.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,697.58,88,,688.456,Percent of Total Billed Charges,88% of Total Billed Charges,713.43,90,,342.92,Percent of Total Billed charges,90% of Total Billed Charges,349.58,792.7,
1.0x6MM Cortex Screw,2780000518,CDM,278,RC,C1713,HCPCS,Outpatient,,,432.18,280.92,,432.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,328.46,76,,2989.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,311.17,72,,2549.688,Percent of Total Billed Charges,72% of Total Billed Charges,311.17,72,,2549.688,Percent of Total Billed charges,72% of Total Billed Charges,432.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,311.17,72,,2549.688,Percent of Total Billed Charges,72% of Total Billed Charges,259.31,60,,2124.736,Percent of Total Billed Charges,60% of Total Billed Charges,388.96,90,,3314.912,Percent of Total Billed Charges,90% of Total Billed Charges,194.48,45,,352.048,Percent of Total Billed Charges,45% of Total Billed Charges,388.96,90,,3540.352,Percent of Total Billed Charges,90% of Total billed Charges,432.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,432.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,432.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280.92,65,,72.808,Percent of total Billed Charges,65% of Total Billed Charges,190.59,44.1,,345.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,410.57,95,,3737.032,Percent of Total Billed Charges,95% of Total Billed Charges,432.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.32,88,,40.36,Percent of Total Billed Charges,88% of Total Billed Charges,388.96,90,,3540.352,Percent of Total Billed charges,90% of Total Billed Charges,190.59,432.18,
SYN1.3 CRTX SCR618M,2780000519,CDM,278,RC,C1713,HCPCS,Outpatient,,,246.96,160.52,,246.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,187.69,76,,594.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,177.81,72,,4245.88,Percent of Total Billed Charges,72% of Total Billed Charges,177.81,72,,4245.88,Percent of Total Billed charges,72% of Total Billed Charges,246.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.81,72,,4245.88,Percent of Total Billed Charges,72% of Total Billed Charges,148.18,60,,3538.232,Percent of Total Billed Charges,60% of Total Billed Charges,222.26,90,,5743.936,Percent of Total Billed Charges,90% of Total Billed Charges,111.13,45,,352.048,Percent of Total Billed Charges,45% of Total Billed Charges,222.26,90,,704.104,Percent of Total Billed Charges,90% of Total billed Charges,246.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.52,65,,3309.656,Percent of total Billed Charges,65% of Total Billed Charges,108.91,44.1,,345.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,234.61,95,,743.216,Percent of Total Billed Charges,95% of Total Billed Charges,246.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.32,88,,3092.224,Percent of Total Billed Charges,88% of Total Billed Charges,222.26,90,,704.104,Percent of Total Billed charges,90% of Total Billed Charges,108.91,246.96,
SYN1.3 STR PL 6 HOLE,2780000520,CDM,278,RC,C1713,HCPCS,Outpatient,,,616.30,400.60,,616.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,468.39,76,,594.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,443.74,72,,4245.88,Percent of Total Billed Charges,72% of Total Billed Charges,443.74,72,,4245.88,Percent of Total Billed charges,72% of Total Billed Charges,616.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,443.74,72,,4245.88,Percent of Total Billed Charges,72% of Total Billed Charges,369.78,60,,3538.232,Percent of Total Billed Charges,60% of Total Billed Charges,554.67,90,,18116.104,Percent of Total Billed Charges,90% of Total Billed Charges,277.34,45,,20.64,Percent of Total Billed Charges,45% of Total Billed Charges,554.67,90,,704.104,Percent of Total Billed Charges,90% of Total billed Charges,616.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,616.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,616.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.6,65,,1175.264,Percent of total Billed Charges,65% of Total Billed Charges,271.79,44.1,,20.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,585.49,95,,743.216,Percent of Total Billed Charges,95% of Total Billed Charges,616.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,542.34,88,,3566.456,Percent of Total Billed Charges,88% of Total Billed Charges,554.67,90,,704.104,Percent of Total Billed charges,90% of Total Billed Charges,271.79,616.3,
SYN1.3 STR PL 12 HOL,2780000521,CDM,278,RC,C1713,HCPCS,Outpatient,,,779.47,506.66,,779.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,592.4,76,,594.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,561.22,72,,33.024,Percent of Total Billed Charges,72% of Total Billed Charges,561.22,72,,33.024,Percent of Total Billed charges,72% of Total Billed Charges,779.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561.22,72,,33.024,Percent of Total Billed Charges,72% of Total Billed Charges,467.68,60,,27.52,Percent of Total Billed Charges,60% of Total Billed Charges,701.52,90,,5855.072,Percent of Total Billed Charges,90% of Total Billed Charges,350.76,45,,1581.248,Percent of Total Billed Charges,45% of Total Billed Charges,701.52,90,,704.104,Percent of Total Billed Charges,90% of Total billed Charges,779.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,779.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,779.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.66,65,,4230.952,Percent of total Billed Charges,65% of Total Billed Charges,343.75,44.1,,1549.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,740.5,95,,743.216,Percent of Total Billed Charges,95% of Total Billed Charges,779.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.93,88,,3566.456,Percent of Total Billed Charges,88% of Total Billed Charges,701.52,90,,704.104,Percent of Total Billed charges,90% of Total Billed Charges,343.75,779.47,
SYN1.3 EXT H PL 15MM,2780000522,CDM,278,RC,C1713,HCPCS,Outpatient,,,746.39,485.15,,746.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,567.26,76,,594.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,537.4,72,,3540.984,Percent of Total Billed Charges,72% of Total Billed Charges,537.4,72,,3540.984,Percent of Total Billed charges,72% of Total Billed Charges,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537.4,72,,3540.984,Percent of Total Billed Charges,72% of Total Billed Charges,447.83,60,,2950.816,Percent of Total Billed Charges,60% of Total Billed Charges,671.75,90,,4637.384,Percent of Total Billed Charges,90% of Total Billed Charges,335.88,45,,1823.76,Percent of Total Billed Charges,45% of Total Billed Charges,671.75,90,,704.104,Percent of Total Billed Charges,90% of Total billed Charges,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.15,65,,3922.52,Percent of total Billed Charges,65% of Total Billed Charges,329.16,44.1,,1787.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,709.07,95,,743.216,Percent of Total Billed Charges,95% of Total Billed Charges,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,656.82,88,,3942.12,Percent of Total Billed Charges,88% of Total Billed Charges,671.75,90,,704.104,Percent of Total Billed charges,90% of Total Billed Charges,329.16,746.39,
SYNTHES 1.3 T-PLT 3H,2780000523,CDM,278,RC,C1713,HCPCS,Outpatient,,,713.32,463.66,,713.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,542.12,76,,34.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,513.59,72,,948.752,Percent of Total Billed Charges,72% of Total Billed Charges,513.59,72,,948.752,Percent of Total Billed charges,72% of Total Billed Charges,713.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.59,72,,948.752,Percent of Total Billed Charges,72% of Total Billed Charges,427.99,60,,790.624,Percent of Total Billed Charges,60% of Total Billed Charges,641.99,90,,3541.144,Percent of Total Billed Charges,90% of Total Billed Charges,320.99,45,,1823.76,Percent of Total Billed Charges,45% of Total Billed Charges,641.99,90,,41.28,Percent of Total Billed Charges,90% of Total billed Charges,713.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,713.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,713.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,463.66,65,,302.128,Percent of total Billed Charges,65% of Total Billed Charges,314.57,44.1,,1787.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,677.65,95,,43.568,Percent of Total Billed Charges,95% of Total Billed Charges,713.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,627.72,88,,3241.248,Percent of Total Billed Charges,88% of Total Billed Charges,641.99,90,,41.28,Percent of Total Billed charges,90% of Total Billed Charges,314.57,713.32,
SYN1.3 TPL 4H/8H/32M,2780000524,CDM,278,RC,C1713,HCPCS,Outpatient,,,746.39,485.15,,746.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,567.26,76,,2670.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,537.4,72,,48.264,Percent of Total Billed Charges,72% of Total Billed Charges,537.4,72,,48.264,Percent of Total Billed charges,72% of Total Billed Charges,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537.4,72,,48.264,Percent of Total Billed Charges,72% of Total Billed Charges,447.83,60,,40.216,Percent of Total Billed Charges,60% of Total Billed Charges,671.75,90,,704.104,Percent of Total Billed Charges,90% of Total Billed Charges,335.88,45,,2015.856,Percent of Total Billed Charges,45% of Total Billed Charges,671.75,90,,3162.496,Percent of Total Billed Charges,90% of Total billed Charges,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.15,65,,302.128,Percent of total Billed Charges,65% of Total Billed Charges,329.16,44.1,,1975.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,709.07,95,,3338.192,Percent of Total Billed Charges,95% of Total Billed Charges,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,656.82,88,,5616.296,Percent of Total Billed Charges,88% of Total Billed Charges,671.75,90,,3162.496,Percent of Total Billed charges,90% of Total Billed Charges,329.16,746.39,
1.5X6MM CORTEX SCREW,2780000525,CDM,278,RC,C1713,HCPCS,Outpatient,,,380.36,247.23,,380.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,289.07,76,,3080.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,273.86,72,,160.032,Percent of Total Billed Charges,72% of Total Billed Charges,273.86,72,,160.032,Percent of Total Billed charges,72% of Total Billed Charges,380.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.86,72,,160.032,Percent of Total Billed Charges,72% of Total Billed Charges,228.22,60,,133.36,Percent of Total Billed Charges,60% of Total Billed Charges,342.32,90,,704.104,Percent of Total Billed Charges,90% of Total Billed Charges,171.16,45,,1657.456,Percent of Total Billed Charges,45% of Total Billed Charges,342.32,90,,3647.512,Percent of Total Billed Charges,90% of Total billed Charges,380.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.23,65,,302.128,Percent of total Billed Charges,65% of Total Billed Charges,167.74,44.1,,1624.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,361.34,95,,3850.152,Percent of Total Billed Charges,95% of Total Billed Charges,380.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.72,88,,17713.528,Percent of Total Billed Charges,88% of Total Billed Charges,342.32,90,,3647.512,Percent of Total Billed charges,90% of Total Billed Charges,167.74,380.36,
SYN1.5 STR PL 6H/29,2780000526,CDM,278,RC,C1713,HCPCS,Outpatient,,,616.30,400.60,,616.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,468.39,76,,3080.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,443.74,72,,1113.224,Percent of Total Billed Charges,72% of Total Billed Charges,443.74,72,,1113.224,Percent of Total Billed charges,72% of Total Billed Charges,616.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,443.74,72,,1113.224,Percent of Total Billed Charges,72% of Total Billed Charges,369.78,60,,927.688,Percent of Total Billed Charges,60% of Total Billed Charges,554.67,90,,80.968,Percent of Total Billed Charges,90% of Total Billed Charges,277.34,45,,2871.968,Percent of Total Billed Charges,45% of Total Billed Charges,554.67,90,,3647.512,Percent of Total Billed Charges,90% of Total billed Charges,616.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,616.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,616.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.6,65,,3724.16,Percent of total Billed Charges,65% of Total Billed Charges,271.79,44.1,,2814.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,585.49,95,,3850.152,Percent of Total Billed Charges,95% of Total Billed Charges,616.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,542.34,88,,5724.96,Percent of Total Billed Charges,88% of Total Billed Charges,554.67,90,,3647.512,Percent of Total Billed charges,90% of Total Billed Charges,271.79,616.3,
SYN1.5 STR PL 12H/59,2780000527,CDM,278,RC,C1713,HCPCS,Outpatient,,,779.47,506.66,,779.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,592.4,76,,3404.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,561.22,72,,99.696,Percent of Total Billed Charges,72% of Total Billed Charges,561.22,72,,99.696,Percent of Total Billed charges,72% of Total Billed Charges,779.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561.22,72,,99.696,Percent of Total Billed Charges,72% of Total Billed Charges,467.68,60,,83.08,Percent of Total Billed Charges,60% of Total Billed Charges,701.52,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,350.76,45,,9058.056,Percent of Total Billed Charges,45% of Total Billed Charges,701.52,90,,4031.712,Percent of Total Billed Charges,90% of Total billed Charges,779.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,779.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,779.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.66,65,,2182.552,Percent of total Billed Charges,65% of Total Billed Charges,343.75,44.1,,8876.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,740.5,95,,4255.696,Percent of Total Billed Charges,95% of Total Billed Charges,779.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.93,88,,4534.328,Percent of Total Billed Charges,88% of Total Billed Charges,701.52,90,,4031.712,Percent of Total Billed charges,90% of Total Billed Charges,343.75,779.47,
SYN1.5 TPL 3H/8H/40,2780000528,CDM,278,RC,C1713,HCPCS,Outpatient,,,1298.75,844.19,,1298.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,987.05,76,,2799.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,935.1,72,,4074.416,Percent of Total Billed Charges,72% of Total Billed Charges,935.1,72,,4074.416,Percent of Total Billed charges,72% of Total Billed Charges,1298.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,935.1,72,,4074.416,Percent of Total Billed Charges,72% of Total Billed Charges,779.25,60,,3395.344,Percent of Total Billed Charges,60% of Total Billed Charges,1168.88,90,,604.08,Percent of Total Billed Charges,90% of Total Billed Charges,584.44,45,,2927.536,Percent of Total Billed Charges,45% of Total Billed Charges,1168.88,90,,3314.912,Percent of Total Billed Charges,90% of Total billed Charges,1298.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1298.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1298.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,844.19,65,,302.128,Percent of total Billed Charges,65% of Total Billed Charges,572.75,44.1,,2868.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,1233.81,95,,3499.072,Percent of Total Billed Charges,95% of Total Billed Charges,1298.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1142.9,88,,3462.448,Percent of Total Billed Charges,88% of Total Billed Charges,1168.88,90,,3314.912,Percent of Total Billed charges,90% of Total Billed Charges,572.75,1298.75,
SYNTHES 1.5 EXT H-PLT R,2780000529,CDM,278,RC,C1713,HCPCS,Outpatient,,,815.85,530.30,,815.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,620.05,76,,4850.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,587.41,72,,3171.392,Percent of Total Billed Charges,72% of Total Billed Charges,587.41,72,,3171.392,Percent of Total Billed charges,72% of Total Billed Charges,815.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,587.41,72,,3171.392,Percent of Total Billed Charges,72% of Total Billed Charges,489.51,60,,2642.824,Percent of Total Billed Charges,60% of Total Billed Charges,734.27,90,,604.08,Percent of Total Billed Charges,90% of Total Billed Charges,367.13,45,,2318.688,Percent of Total Billed Charges,45% of Total Billed Charges,734.27,90,,5743.936,Percent of Total Billed Charges,90% of Total billed Charges,815.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,815.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,815.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.3,65,,174.856,Percent of total Billed Charges,65% of Total Billed Charges,359.79,44.1,,2272.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,775.06,95,,6063.048,Percent of Total Billed Charges,95% of Total Billed Charges,815.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,717.95,88,,688.456,Percent of Total Billed Charges,88% of Total Billed Charges,734.27,90,,5743.936,Percent of Total Billed charges,90% of Total Billed Charges,359.79,815.85,
SYN1.5 YPL 3X8 HOLE,2780000530,CDM,278,RC,C1713,HCPCS,Outpatient,,,713.32,463.66,,713.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,542.12,76,,15298.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,513.59,72,,321.968,Percent of Total Billed Charges,72% of Total Billed Charges,513.59,72,,321.968,Percent of Total Billed charges,72% of Total Billed Charges,713.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.59,72,,321.968,Percent of Total Billed Charges,72% of Total Billed Charges,427.99,60,,268.304,Percent of Total Billed Charges,60% of Total Billed Charges,641.99,90,,604.08,Percent of Total Billed Charges,90% of Total Billed Charges,320.99,45,,1770.568,Percent of Total Billed Charges,45% of Total Billed Charges,641.99,90,,18116.104,Percent of Total Billed Charges,90% of Total billed Charges,713.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,713.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,713.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,463.66,65,,217.28,Percent of total Billed Charges,65% of Total Billed Charges,314.57,44.1,,1735.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,677.65,95,,19122.56,Percent of Total Billed Charges,95% of Total Billed Charges,713.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,627.72,88,,688.456,Percent of Total Billed Charges,88% of Total Billed Charges,641.99,90,,18116.104,Percent of Total Billed charges,90% of Total Billed Charges,314.57,713.32,
SYN1.5 CONDYLAR PL 7,2780000531,CDM,278,RC,C1713,HCPCS,Outpatient,,,1324.10,860.67,,1324.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1006.32,76,,4944.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,953.35,72,,3171.392,Percent of Total Billed Charges,72% of Total Billed Charges,953.35,72,,3171.392,Percent of Total Billed charges,72% of Total Billed Charges,1324.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,953.35,72,,3171.392,Percent of Total Billed Charges,72% of Total Billed Charges,794.46,60,,2642.824,Percent of Total Billed Charges,60% of Total Billed Charges,1191.69,90,,604.08,Percent of Total Billed Charges,90% of Total Billed Charges,595.85,45,,352.048,Percent of Total Billed Charges,45% of Total Billed Charges,1191.69,90,,5855.072,Percent of Total Billed Charges,90% of Total billed Charges,1324.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1324.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1324.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,860.67,65,,147.912,Percent of total Billed Charges,65% of Total Billed Charges,583.93,44.1,,345.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,1257.9,95,,6180.352,Percent of Total Billed Charges,95% of Total Billed Charges,1324.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1165.21,88,,79.168,Percent of Total Billed Charges,88% of Total Billed Charges,1191.69,90,,5855.072,Percent of Total Billed charges,90% of Total Billed Charges,583.93,1324.1,
2.0X6MM CORTEX SCREW,2780000532,CDM,278,RC,C1713,HCPCS,Outpatient,,,417.85,271.60,,417.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,317.57,76,,3916.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,300.85,72,,4074.416,Percent of Total Billed Charges,72% of Total Billed Charges,300.85,72,,4074.416,Percent of Total Billed charges,72% of Total Billed Charges,417.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.85,72,,4074.416,Percent of Total Billed Charges,72% of Total Billed Charges,250.71,60,,3395.344,Percent of Total Billed Charges,60% of Total Billed Charges,376.07,90,,604.08,Percent of Total Billed Charges,90% of Total Billed Charges,188.03,45,,352.048,Percent of Total Billed Charges,45% of Total Billed Charges,376.07,90,,4637.384,Percent of Total Billed Charges,90% of Total billed Charges,417.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.6,65,,158.8,Percent of total Billed Charges,65% of Total Billed Charges,184.27,44.1,,345.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,396.96,95,,4895.016,Percent of Total Billed Charges,95% of Total Billed Charges,417.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,367.71,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,376.07,90,,4637.384,Percent of Total Billed charges,90% of Total Billed Charges,184.27,417.85,
SYN2.0 CONDYLAR PL 7,2780000533,CDM,278,RC,C1713,HCPCS,Outpatient,,,937.13,609.13,,937.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,712.22,76,,2990.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,674.73,72,,3965.192,Percent of Total Billed Charges,72% of Total Billed Charges,674.73,72,,3965.192,Percent of Total Billed charges,72% of Total Billed Charges,937.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,674.73,72,,3965.192,Percent of Total Billed Charges,72% of Total Billed Charges,562.28,60,,3304.328,Percent of Total Billed Charges,60% of Total Billed Charges,843.42,90,,604.08,Percent of Total Billed Charges,90% of Total Billed Charges,421.71,45,,40.488,Percent of Total Billed Charges,45% of Total Billed Charges,843.42,90,,3541.144,Percent of Total Billed Charges,90% of Total billed Charges,937.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,937.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,937.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,609.13,65,,2634.312,Percent of total Billed Charges,65% of Total Billed Charges,413.27,44.1,,39.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,890.27,95,,3737.872,Percent of Total Billed Charges,95% of Total Billed Charges,937.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,824.67,88,,590.656,Percent of Total Billed Charges,88% of Total Billed Charges,843.42,90,,3541.144,Percent of Total Billed charges,90% of Total Billed Charges,413.27,937.13,
SYNTHES 2.0 ST 6H,2780000534,CDM,278,RC,C1713,HCPCS,Outpatient,,,681.35,442.88,,681.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,517.83,76,,594.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,490.57,72,,12425.192,Percent of Total Billed Charges,72% of Total Billed Charges,490.57,72,,12425.192,Percent of Total Billed charges,72% of Total Billed Charges,681.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.57,72,,12425.192,Percent of Total Billed Charges,72% of Total Billed Charges,408.81,60,,10354.328,Percent of Total Billed Charges,60% of Total Billed Charges,613.22,90,,604.08,Percent of Total Billed Charges,90% of Total Billed Charges,306.61,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,613.22,90,,704.104,Percent of Total Billed Charges,90% of Total billed Charges,681.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,681.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,681.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,442.88,65,,275.76,Percent of total Billed Charges,65% of Total Billed Charges,300.48,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,647.28,95,,743.216,Percent of Total Billed Charges,95% of Total Billed Charges,681.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,599.59,88,,590.656,Percent of Total Billed Charges,88% of Total Billed Charges,613.22,90,,704.104,Percent of Total Billed charges,90% of Total Billed Charges,300.48,681.35,
SYN2.0 STR PL 12,2780000535,CDM,278,RC,C1713,HCPCS,Outpatient,,,816.95,531.02,,816.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,620.88,76,,594.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,588.2,72,,3427.312,Percent of Total Billed Charges,72% of Total Billed Charges,588.2,72,,3427.312,Percent of Total Billed charges,72% of Total Billed Charges,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,588.2,72,,3427.312,Percent of Total Billed Charges,72% of Total Billed Charges,490.17,60,,2856.088,Percent of Total Billed Charges,60% of Total Billed Charges,735.26,90,,100.816,Percent of Total Billed Charges,90% of Total Billed Charges,367.63,45,,302.04,Percent of Total Billed Charges,45% of Total Billed Charges,735.26,90,,704.104,Percent of Total Billed Charges,90% of Total billed Charges,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531.02,65,,247.664,Percent of total Billed Charges,65% of Total Billed Charges,360.27,44.1,,296,Percent of Total Billed Charges,44.1% of Total Billed Charges,776.1,95,,743.216,Percent of Total Billed Charges,95% of Total Billed Charges,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,718.92,88,,590.656,Percent of Total Billed Charges,88% of Total Billed Charges,735.26,90,,704.104,Percent of Total Billed charges,90% of Total Billed Charges,360.27,816.95,
SYN2.0 TPL 2H/8H/48,2780000536,CDM,278,RC,C1713,HCPCS,Outpatient,,,746.39,485.15,,746.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,567.26,76,,68.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,537.4,72,,2721.144,Percent of Total Billed Charges,72% of Total Billed Charges,537.4,72,,2721.144,Percent of Total Billed charges,72% of Total Billed Charges,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537.4,72,,2721.144,Percent of Total Billed Charges,72% of Total Billed Charges,447.83,60,,2267.624,Percent of Total Billed Charges,60% of Total Billed Charges,671.75,90,,4582.608,Percent of Total Billed Charges,90% of Total Billed Charges,335.88,45,,302.04,Percent of Total Billed Charges,45% of Total Billed Charges,671.75,90,,80.968,Percent of Total Billed Charges,90% of Total billed Charges,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.15,65,,1104.176,Percent of total Billed Charges,65% of Total Billed Charges,329.16,44.1,,296,Percent of Total Billed Charges,44.1% of Total Billed Charges,709.07,95,,85.472,Percent of Total Billed Charges,95% of Total Billed Charges,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,656.82,88,,590.656,Percent of Total Billed Charges,88% of Total Billed Charges,671.75,90,,80.968,Percent of Total Billed charges,90% of Total Billed Charges,329.16,746.39,
SYNTHES 2.0 T-PLT 3H,2780000537,CDM,278,RC,C1713,HCPCS,Outpatient,,,816.95,531.02,,816.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,620.88,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,588.2,72,,3427.312,Percent of Total Billed Charges,72% of Total Billed Charges,588.2,72,,3427.312,Percent of Total Billed charges,72% of Total Billed Charges,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,588.2,72,,3427.312,Percent of Total Billed Charges,72% of Total Billed Charges,490.17,60,,2856.088,Percent of Total Billed Charges,60% of Total Billed Charges,735.26,90,,1627.296,Percent of Total Billed Charges,90% of Total Billed Charges,367.63,45,,302.04,Percent of Total Billed Charges,45% of Total Billed Charges,735.26,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531.02,65,,3922.52,Percent of total Billed Charges,65% of Total Billed Charges,360.27,44.1,,296,Percent of Total Billed Charges,44.1% of Total Billed Charges,776.1,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,718.92,88,,590.656,Percent of Total Billed Charges,88% of Total Billed Charges,735.26,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,360.27,816.95,
SYN2.0 LCDCP PL 4H,2780000538,CDM,278,RC,C1713,HCPCS,Outpatient,,,746.39,485.15,,746.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,567.26,76,,510.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,537.4,72,,12249.928,Percent of Total Billed Charges,72% of Total Billed Charges,537.4,72,,12249.928,Percent of Total Billed charges,72% of Total Billed Charges,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537.4,72,,12249.928,Percent of Total Billed Charges,72% of Total Billed Charges,447.83,60,,10208.272,Percent of Total Billed Charges,60% of Total Billed Charges,671.75,90,,5858.248,Percent of Total Billed Charges,90% of Total Billed Charges,335.88,45,,302.04,Percent of Total Billed Charges,45% of Total Billed Charges,671.75,90,,604.08,Percent of Total Billed Charges,90% of Total billed Charges,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.15,65,,10691.472,Percent of total Billed Charges,65% of Total Billed Charges,329.16,44.1,,296,Percent of Total Billed Charges,44.1% of Total Billed Charges,709.07,95,,637.64,Percent of Total Billed Charges,95% of Total Billed Charges,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,656.82,88,,590.656,Percent of Total Billed Charges,88% of Total Billed Charges,671.75,90,,604.08,Percent of Total Billed charges,90% of Total Billed Charges,329.16,746.39,
SYN2.0 LCDCP PL 6H,2780000539,CDM,278,RC,C1713,HCPCS,Outpatient,,,1599.73,1039.82,,1599.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1215.79,76,,510.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1151.81,72,,3171.392,Percent of Total Billed Charges,72% of Total Billed Charges,1151.81,72,,3171.392,Percent of Total Billed charges,72% of Total Billed Charges,1599.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1151.81,72,,3171.392,Percent of Total Billed Charges,72% of Total Billed Charges,959.84,60,,2642.824,Percent of Total Billed Charges,60% of Total Billed Charges,1439.76,90,,5431.184,Percent of Total Billed Charges,90% of Total Billed Charges,719.88,45,,302.04,Percent of Total Billed Charges,45% of Total Billed Charges,1439.76,90,,604.08,Percent of Total Billed Charges,90% of Total billed Charges,1599.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1039.82,65,,10691.472,Percent of total Billed Charges,65% of Total Billed Charges,705.48,44.1,,296,Percent of Total Billed Charges,44.1% of Total Billed Charges,1519.74,95,,637.64,Percent of Total Billed Charges,95% of Total Billed Charges,1599.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1407.76,88,,590.656,Percent of Total Billed Charges,88% of Total Billed Charges,1439.76,90,,604.08,Percent of Total Billed charges,90% of Total Billed Charges,705.48,1599.73,
SYN2.0 LCDCP PL 8H,2780000540,CDM,278,RC,C1713,HCPCS,Outpatient,,,1006.58,654.28,,1006.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,765,76,,510.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,724.74,72,,5522.944,Percent of Total Billed Charges,72% of Total Billed Charges,724.74,72,,5522.944,Percent of Total Billed charges,72% of Total Billed Charges,1006.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,724.74,72,,5522.944,Percent of Total Billed Charges,72% of Total Billed Charges,603.95,60,,4602.448,Percent of Total Billed Charges,60% of Total Billed Charges,905.92,90,,418.336,Percent of Total Billed Charges,90% of Total Billed Charges,452.96,45,,302.04,Percent of Total Billed Charges,45% of Total Billed Charges,905.92,90,,604.08,Percent of Total Billed Charges,90% of Total billed Charges,1006.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1006.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1006.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,654.28,65,,3825.056,Percent of total Billed Charges,65% of Total Billed Charges,443.9,44.1,,296,Percent of Total Billed Charges,44.1% of Total Billed Charges,956.25,95,,637.64,Percent of Total Billed Charges,95% of Total Billed Charges,1006.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,885.79,88,,98.576,Percent of Total Billed Charges,88% of Total Billed Charges,905.92,90,,604.08,Percent of Total Billed charges,90% of Total Billed Charges,443.9,1006.58,
CORTEX SCREW 632MM,2780000541,CDM,278,RC,C1713,HCPCS,Outpatient,,,187.43,121.83,,187.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,142.45,76,,510.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,134.95,72,,1961.64,Percent of Total Billed Charges,72% of Total Billed Charges,134.95,72,,1961.64,Percent of Total Billed charges,72% of Total Billed Charges,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.95,72,,1961.64,Percent of Total Billed Charges,72% of Total Billed Charges,112.46,60,,1634.696,Percent of Total Billed Charges,60% of Total Billed Charges,168.69,90,,418.336,Percent of Total Billed Charges,90% of Total Billed Charges,84.34,45,,302.04,Percent of Total Billed Charges,45% of Total Billed Charges,168.69,90,,604.08,Percent of Total Billed Charges,90% of Total billed Charges,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.83,65,,3825.056,Percent of total Billed Charges,65% of Total Billed Charges,82.66,44.1,,296,Percent of Total Billed Charges,44.1% of Total Billed Charges,178.06,95,,637.64,Percent of Total Billed Charges,95% of Total Billed Charges,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.94,88,,4480.768,Percent of Total Billed Charges,88% of Total Billed Charges,168.69,90,,604.08,Percent of Total Billed charges,90% of Total Billed Charges,82.66,187.43,
2.0 CONDYLAR PLATE 7,2780000542,CDM,278,RC,C1713,HCPCS,Outpatient,,,937.13,609.13,,937.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,712.22,76,,510.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,674.73,72,,883.344,Percent of Total Billed Charges,72% of Total Billed Charges,674.73,72,,883.344,Percent of Total Billed charges,72% of Total Billed Charges,937.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,674.73,72,,883.344,Percent of Total Billed Charges,72% of Total Billed Charges,562.28,60,,736.12,Percent of Total Billed Charges,60% of Total Billed Charges,843.42,90,,418.336,Percent of Total Billed Charges,90% of Total Billed Charges,421.71,45,,50.408,Percent of Total Billed Charges,45% of Total Billed Charges,843.42,90,,604.08,Percent of Total Billed Charges,90% of Total billed Charges,937.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,937.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,937.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,609.13,65,,2977.144,Percent of total Billed Charges,65% of Total Billed Charges,413.27,44.1,,49.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,890.27,95,,637.64,Percent of Total Billed Charges,95% of Total Billed Charges,937.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,824.67,88,,1591.128,Percent of Total Billed Charges,88% of Total Billed Charges,843.42,90,,604.08,Percent of Total Billed charges,90% of Total Billed Charges,413.27,937.13,
2.0 STRAIGHT PLATE 6,2780000543,CDM,278,RC,C1713,HCPCS,Outpatient,,,681.35,442.88,,681.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,517.83,76,,510.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,490.57,72,,2731.944,Percent of Total Billed Charges,72% of Total Billed Charges,490.57,72,,2731.944,Percent of Total Billed charges,72% of Total Billed Charges,681.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.57,72,,2731.944,Percent of Total Billed Charges,72% of Total Billed Charges,408.81,60,,2276.624,Percent of Total Billed Charges,60% of Total Billed Charges,613.22,90,,5156.528,Percent of Total Billed Charges,90% of Total Billed Charges,306.61,45,,2291.304,Percent of Total Billed Charges,45% of Total Billed Charges,613.22,90,,604.08,Percent of Total Billed Charges,90% of Total billed Charges,681.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,681.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,681.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,442.88,65,,548.072,Percent of total Billed Charges,65% of Total Billed Charges,300.48,44.1,,2245.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,647.28,95,,637.64,Percent of Total Billed Charges,95% of Total Billed Charges,681.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,599.59,88,,5728.064,Percent of Total Billed Charges,88% of Total Billed Charges,613.22,90,,604.08,Percent of Total Billed charges,90% of Total Billed Charges,300.48,681.35,
2.0 STRAIGHT PLATE 1,2780000544,CDM,278,RC,C1713,HCPCS,Outpatient,,,816.95,531.02,,816.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,620.88,76,,510.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,588.2,72,,61.6,Percent of Total Billed Charges,72% of Total Billed Charges,588.2,72,,61.6,Percent of Total Billed charges,72% of Total Billed Charges,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,588.2,72,,61.6,Percent of Total Billed Charges,72% of Total Billed Charges,490.17,60,,51.328,Percent of Total Billed Charges,60% of Total Billed Charges,735.26,90,,3022,Percent of Total Billed Charges,90% of Total Billed Charges,367.63,45,,813.648,Percent of Total Billed Charges,45% of Total Billed Charges,735.26,90,,604.08,Percent of Total Billed Charges,90% of Total billed Charges,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531.02,65,,302.128,Percent of total Billed Charges,65% of Total Billed Charges,360.27,44.1,,797.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,776.1,95,,637.64,Percent of Total Billed Charges,95% of Total Billed Charges,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,718.92,88,,5310.488,Percent of Total Billed Charges,88% of Total Billed Charges,735.26,90,,604.08,Percent of Total Billed charges,90% of Total Billed Charges,360.27,816.95,
TPLATE 2HOLE/8HOLE,2780000545,CDM,278,RC,C1713,HCPCS,Outpatient,,,746.39,485.15,,746.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,567.26,76,,85.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,537.4,72,,3998.208,Percent of Total Billed Charges,72% of Total Billed Charges,537.4,72,,3998.208,Percent of Total Billed charges,72% of Total Billed Charges,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537.4,72,,3998.208,Percent of Total Billed Charges,72% of Total Billed Charges,447.83,60,,3331.84,Percent of Total Billed Charges,60% of Total Billed Charges,671.75,90,,418.336,Percent of Total Billed Charges,90% of Total Billed Charges,335.88,45,,2929.12,Percent of Total Billed Charges,45% of Total Billed Charges,671.75,90,,100.816,Percent of Total Billed Charges,90% of Total billed Charges,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.15,65,,2394.104,Percent of total Billed Charges,65% of Total Billed Charges,329.16,44.1,,2870.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,709.07,95,,106.416,Percent of Total Billed Charges,95% of Total Billed Charges,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,656.82,88,,409.04,Percent of Total Billed Charges,88% of Total Billed Charges,671.75,90,,100.816,Percent of Total Billed charges,90% of Total Billed Charges,329.16,746.39,
T&Y PLATE 3HOLE/8HOL,2780000546,CDM,278,RC,C1713,HCPCS,Outpatient,,,816.95,531.02,,816.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,620.88,76,,3869.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,588.2,72,,375.944,Percent of Total Billed Charges,72% of Total Billed Charges,588.2,72,,375.944,Percent of Total Billed charges,72% of Total Billed Charges,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,588.2,72,,375.944,Percent of Total Billed Charges,72% of Total Billed Charges,490.17,60,,313.288,Percent of Total Billed Charges,60% of Total Billed Charges,735.26,90,,242.104,Percent of Total Billed Charges,90% of Total Billed Charges,367.63,45,,2715.592,Percent of Total Billed Charges,45% of Total Billed Charges,735.26,90,,4582.608,Percent of Total Billed Charges,90% of Total billed Charges,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531.02,65,,2394.104,Percent of total Billed Charges,65% of Total Billed Charges,360.27,44.1,,2661.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,776.1,95,,4837.192,Percent of Total Billed Charges,95% of Total Billed Charges,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,718.92,88,,409.04,Percent of Total Billed Charges,88% of Total Billed Charges,735.26,90,,4582.608,Percent of Total Billed charges,90% of Total Billed Charges,360.27,816.95,
LC DCP PLATE 4HOLE,2780000547,CDM,278,RC,C1713,HCPCS,Outpatient,,,746.39,485.15,,746.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,567.26,76,,1374.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,537.4,72,,11077.64,Percent of Total Billed Charges,72% of Total Billed Charges,537.4,72,,11077.64,Percent of Total Billed charges,72% of Total Billed Charges,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537.4,72,,11077.64,Percent of Total Billed Charges,72% of Total Billed Charges,447.83,60,,9231.368,Percent of Total Billed Charges,60% of Total Billed Charges,671.75,90,,300.856,Percent of Total Billed Charges,90% of Total Billed Charges,335.88,45,,209.168,Percent of Total Billed Charges,45% of Total Billed Charges,671.75,90,,1627.296,Percent of Total Billed Charges,90% of Total billed Charges,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.15,65,,4148.4,Percent of total Billed Charges,65% of Total Billed Charges,329.16,44.1,,204.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,709.07,95,,1717.696,Percent of Total Billed Charges,95% of Total Billed Charges,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,656.82,88,,409.04,Percent of Total Billed Charges,88% of Total Billed Charges,671.75,90,,1627.296,Percent of Total Billed charges,90% of Total Billed Charges,329.16,746.39,
LC DCP PLATE 6HOLE,2780000548,CDM,278,RC,C1713,HCPCS,Outpatient,,,880.90,572.59,,880.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,669.48,76,,4946.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,634.25,72,,13330.76,Percent of Total Billed Charges,72% of Total Billed Charges,634.25,72,,13330.76,Percent of Total Billed charges,72% of Total Billed Charges,880.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,634.25,72,,13330.76,Percent of Total Billed Charges,72% of Total Billed Charges,528.54,60,,11108.968,Percent of Total Billed Charges,60% of Total Billed Charges,792.81,90,,204.808,Percent of Total Billed Charges,90% of Total Billed Charges,396.41,45,,209.168,Percent of Total Billed Charges,45% of Total Billed Charges,792.81,90,,5858.248,Percent of Total Billed Charges,90% of Total billed Charges,880.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,880.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,880.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,572.59,65,,2223.832,Percent of total Billed Charges,65% of Total Billed Charges,388.48,44.1,,204.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,836.86,95,,6183.704,Percent of Total Billed Charges,95% of Total Billed Charges,880.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,775.19,88,,5041.936,Percent of Total Billed Charges,88% of Total Billed Charges,792.81,90,,5858.248,Percent of Total Billed charges,90% of Total Billed Charges,388.48,880.9,
2.0LC DCP PLATE 8HOL,2780000549,CDM,278,RC,C1713,HCPCS,Outpatient,,,1006.58,654.28,,1006.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,765,76,,4586.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,724.74,72,,9998.072,Percent of Total Billed Charges,72% of Total Billed Charges,724.74,72,,9998.072,Percent of Total Billed charges,72% of Total Billed Charges,1006.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,724.74,72,,9998.072,Percent of Total Billed Charges,72% of Total Billed Charges,603.95,60,,8331.728,Percent of Total Billed Charges,60% of Total Billed Charges,905.92,90,,219.88,Percent of Total Billed Charges,90% of Total Billed Charges,452.96,45,,209.168,Percent of Total Billed Charges,45% of Total Billed Charges,905.92,90,,5431.184,Percent of Total Billed Charges,90% of Total billed Charges,1006.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1006.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1006.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,654.28,65,,13078.688,Percent of total Billed Charges,65% of Total Billed Charges,443.9,44.1,,204.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,956.25,95,,5732.912,Percent of Total Billed Charges,95% of Total Billed Charges,1006.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,885.79,88,,2954.84,Percent of Total Billed Charges,88% of Total Billed Charges,905.92,90,,5431.184,Percent of Total Billed charges,90% of Total Billed Charges,443.9,1006.58,
2.4 x6MM CORTEX SCREW,2780000550,CDM,278,RC,C1713,HCPCS,Outpatient,,,558.97,363.33,,558.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,424.82,76,,353.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,402.46,72,,4311.928,Percent of Total Billed Charges,72% of Total Billed Charges,402.46,72,,4311.928,Percent of Total Billed charges,72% of Total Billed Charges,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,402.46,72,,4311.928,Percent of Total Billed Charges,72% of Total Billed Charges,335.38,60,,3593.272,Percent of Total Billed Charges,60% of Total Billed Charges,503.07,90,,3647.512,Percent of Total Billed Charges,90% of Total Billed Charges,251.54,45,,2578.264,Percent of Total Billed Charges,45% of Total Billed Charges,503.07,90,,418.336,Percent of Total Billed Charges,90% of Total billed Charges,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.33,65,,42502.168,Percent of total Billed Charges,65% of Total Billed Charges,246.51,44.1,,2526.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,531.02,95,,441.576,Percent of Total Billed Charges,95% of Total Billed Charges,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.89,88,,409.04,Percent of Total Billed Charges,88% of Total Billed Charges,503.07,90,,418.336,Percent of Total Billed charges,90% of Total Billed Charges,246.51,558.97,
2.4 STRAIGHT PLATE 6,2780000551,CDM,278,RC,C1713,HCPCS,Outpatient,,,746.39,485.15,,746.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,567.26,76,,353.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,537.4,72,,3715.624,Percent of Total Billed Charges,72% of Total Billed Charges,537.4,72,,3715.624,Percent of Total Billed charges,72% of Total Billed Charges,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537.4,72,,3715.624,Percent of Total Billed Charges,72% of Total Billed Charges,447.83,60,,3096.352,Percent of Total Billed Charges,60% of Total Billed Charges,671.75,90,,381.816,Percent of Total Billed Charges,90% of Total Billed Charges,335.88,45,,1511,Percent of Total Billed Charges,45% of Total Billed Charges,671.75,90,,418.336,Percent of Total Billed Charges,90% of Total billed Charges,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.15,65,,134.728,Percent of total Billed Charges,65% of Total Billed Charges,329.16,44.1,,1480.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,709.07,95,,441.576,Percent of Total Billed Charges,95% of Total Billed Charges,746.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,656.82,88,,236.728,Percent of Total Billed Charges,88% of Total Billed Charges,671.75,90,,418.336,Percent of Total Billed charges,90% of Total Billed Charges,329.16,746.39,
2.4 STRAIGHT PLATE,2780000552,CDM,278,RC,C1713,HCPCS,Outpatient,,,880.90,572.59,,880.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,669.48,76,,353.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,634.25,72,,318.152,Percent of Total Billed Charges,72% of Total Billed Charges,634.25,72,,318.152,Percent of Total Billed charges,72% of Total Billed Charges,880.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,634.25,72,,318.152,Percent of Total Billed Charges,72% of Total Billed Charges,528.54,60,,265.128,Percent of Total Billed Charges,60% of Total Billed Charges,792.81,90,,342.92,Percent of Total Billed Charges,90% of Total Billed Charges,396.41,45,,209.168,Percent of Total Billed Charges,45% of Total Billed Charges,792.81,90,,418.336,Percent of Total Billed Charges,90% of Total billed Charges,880.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,880.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,880.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,572.59,65,,37.264,Percent of total Billed Charges,65% of Total Billed Charges,388.48,44.1,,204.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,836.86,95,,441.576,Percent of Total Billed Charges,95% of Total Billed Charges,880.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,775.19,88,,294.168,Percent of Total Billed Charges,88% of Total Billed Charges,792.81,90,,418.336,Percent of Total Billed charges,90% of Total Billed Charges,388.48,880.9,
2.4 T PLATE 2HOLE,2780000553,CDM,278,RC,C1713,HCPCS,Outpatient,,,840.11,546.07,,840.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,638.48,76,,4354.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,604.88,72,,318.152,Percent of Total Billed Charges,72% of Total Billed Charges,604.88,72,,318.152,Percent of Total Billed charges,72% of Total Billed Charges,840.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,604.88,72,,318.152,Percent of Total Billed Charges,72% of Total Billed Charges,504.07,60,,265.128,Percent of Total Billed Charges,60% of Total Billed Charges,756.1,90,,1528.864,Percent of Total Billed Charges,90% of Total Billed Charges,378.05,45,,121.056,Percent of Total Billed Charges,45% of Total Billed Charges,756.1,90,,5156.528,Percent of Total Billed Charges,90% of Total billed Charges,840.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,840.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,840.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.07,65,,37.264,Percent of total Billed Charges,65% of Total Billed Charges,370.49,44.1,,118.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,798.1,95,,5443,Percent of Total Billed Charges,95% of Total Billed Charges,840.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,739.3,88,,200.256,Percent of Total Billed Charges,88% of Total Billed Charges,756.1,90,,5156.528,Percent of Total Billed charges,90% of Total Billed Charges,370.49,840.11,
2.4 PLATE 3HOLE/8HOL,2780000554,CDM,278,RC,C1713,HCPCS,Outpatient,,,894.13,581.18,,894.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,679.54,76,,2551.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,643.77,72,,13330.76,Percent of Total Billed Charges,72% of Total Billed Charges,643.77,72,,13330.76,Percent of Total Billed charges,72% of Total Billed Charges,894.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,643.77,72,,13330.76,Percent of Total Billed Charges,72% of Total Billed Charges,536.48,60,,11108.968,Percent of Total Billed Charges,60% of Total Billed Charges,804.72,90,,5431.184,Percent of Total Billed Charges,90% of Total Billed Charges,402.36,45,,150.424,Percent of Total Billed Charges,45% of Total Billed Charges,804.72,90,,3022,Percent of Total Billed Charges,90% of Total billed Charges,894.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,894.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,894.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,581.18,65,,941.36,Percent of total Billed Charges,65% of Total Billed Charges,394.31,44.1,,147.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,849.42,95,,3189.888,Percent of Total Billed Charges,95% of Total Billed Charges,894.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,786.83,88,,214.992,Percent of Total Billed Charges,88% of Total Billed Charges,804.72,90,,3022,Percent of Total Billed charges,90% of Total Billed Charges,394.31,894.13,
2.4Y PLATE 3HOLE/8HO,2780000555,CDM,278,RC,C1713,HCPCS,Outpatient,,,867.67,563.99,,867.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,659.43,76,,353.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,624.72,72,,2684.952,Percent of Total Billed Charges,72% of Total Billed Charges,624.72,72,,2684.952,Percent of Total Billed charges,72% of Total Billed Charges,867.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,624.72,72,,2684.952,Percent of Total Billed Charges,72% of Total Billed Charges,520.6,60,,2237.456,Percent of Total Billed Charges,60% of Total Billed Charges,780.9,90,,14803.576,Percent of Total Billed Charges,90% of Total Billed Charges,390.45,45,,102.4,Percent of Total Billed Charges,45% of Total Billed Charges,780.9,90,,418.336,Percent of Total Billed Charges,90% of Total billed Charges,867.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,867.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,867.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.99,65,,7.448,Percent of total Billed Charges,65% of Total Billed Charges,382.64,44.1,,100.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,824.29,95,,441.576,Percent of Total Billed Charges,95% of Total Billed Charges,867.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,763.55,88,,3566.456,Percent of Total Billed Charges,88% of Total Billed Charges,780.9,90,,418.336,Percent of Total Billed charges,90% of Total Billed Charges,382.64,867.67,
SYNTHES 2.4 CONDY. PLT RT,2780000556,CDM,278,RC,C1713,HCPCS,Outpatient,,,984.53,639.94,,984.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,748.24,76,,204.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,708.86,72,,2439.824,Percent of Total Billed Charges,72% of Total Billed Charges,708.86,72,,2439.824,Percent of Total Billed charges,72% of Total Billed Charges,984.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,708.86,72,,2439.824,Percent of Total Billed Charges,72% of Total Billed Charges,590.72,60,,2033.192,Percent of Total Billed Charges,60% of Total Billed Charges,886.08,90,,14803.576,Percent of Total Billed Charges,90% of Total Billed Charges,443.04,45,,109.944,Percent of Total Billed Charges,45% of Total Billed Charges,886.08,90,,242.104,Percent of Total Billed Charges,90% of Total billed Charges,984.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,984.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,984.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,639.94,65,,81.984,Percent of total Billed Charges,65% of Total Billed Charges,434.18,44.1,,107.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,935.3,95,,255.56,Percent of Total Billed Charges,95% of Total Billed Charges,984.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,866.39,88,,373.328,Percent of Total Billed Charges,88% of Total Billed Charges,886.08,90,,242.104,Percent of Total Billed charges,90% of Total Billed Charges,434.18,984.53,
2.4 LC DC PLATE 4HOL,2780000557,CDM,278,RC,C1713,HCPCS,Outpatient,,,1050.68,682.94,,1050.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,798.52,76,,254.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,756.49,72,,3387.304,Percent of Total Billed Charges,72% of Total Billed Charges,756.49,72,,3387.304,Percent of Total Billed charges,72% of Total Billed Charges,1050.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.49,72,,3387.304,Percent of Total Billed Charges,72% of Total Billed Charges,630.41,60,,2822.752,Percent of Total Billed Charges,60% of Total Billed Charges,945.61,90,,5296.232,Percent of Total Billed Charges,90% of Total Billed Charges,472.81,45,,1823.76,Percent of Total Billed Charges,45% of Total Billed Charges,945.61,90,,300.856,Percent of Total Billed Charges,90% of Total billed Charges,1050.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,682.94,65,,3922.52,Percent of total Billed Charges,65% of Total Billed Charges,463.35,44.1,,1787.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,998.15,95,,317.568,Percent of Total Billed Charges,95% of Total Billed Charges,1050.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,924.6,88,,335.304,Percent of Total Billed Charges,88% of Total Billed Charges,945.61,90,,300.856,Percent of Total Billed charges,90% of Total Billed Charges,463.35,1050.68,
2.4 LC DCP PLATE 6HO,2780000558,CDM,278,RC,C1713,HCPCS,Outpatient,,,2553.39,1659.70,,2553.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1940.58,76,,172.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1838.44,72,,603.288,Percent of Total Billed Charges,72% of Total Billed Charges,1838.44,72,,603.288,Percent of Total Billed charges,72% of Total Billed Charges,2553.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1838.44,72,,603.288,Percent of Total Billed Charges,72% of Total Billed Charges,1532.03,60,,502.744,Percent of Total Billed Charges,60% of Total Billed Charges,2298.05,90,,5296.232,Percent of Total Billed Charges,90% of Total Billed Charges,1149.03,45,,190.912,Percent of Total Billed Charges,45% of Total Billed Charges,2298.05,90,,204.808,Percent of Total Billed Charges,90% of Total billed Charges,2553.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2553.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2553.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1659.7,65,,67.656,Percent of total Billed Charges,65% of Total Billed Charges,1126.04,44.1,,187.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,2425.72,95,,216.184,Percent of Total Billed Charges,95% of Total Billed Charges,2553.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2246.98,88,,1494.888,Percent of Total Billed Charges,88% of Total Billed Charges,2298.05,90,,204.808,Percent of Total Billed charges,90% of Total Billed Charges,1126.04,2553.39,
2.4 LC DCP PLATE 8,2780000559,CDM,278,RC,C1713,HCPCS,Outpatient,,,1277.80,830.57,,1277.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,971.13,76,,185.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,920.02,72,,8521.6,Percent of Total Billed Charges,72% of Total Billed Charges,920.02,72,,8521.6,Percent of Total Billed charges,72% of Total Billed Charges,1277.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,920.02,72,,8521.6,Percent of Total Billed Charges,72% of Total Billed Charges,766.68,60,,7101.336,Percent of Total Billed Charges,60% of Total Billed Charges,1150.02,90,,4122.2,Percent of Total Billed Charges,90% of Total Billed Charges,575.01,45,,171.464,Percent of Total Billed Charges,45% of Total Billed Charges,1150.02,90,,219.88,Percent of Total Billed Charges,90% of Total billed Charges,1277.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1277.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1277.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,830.57,65,,1499.752,Percent of total Billed Charges,65% of Total Billed Charges,563.51,44.1,,168.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,1213.91,95,,232.096,Percent of Total Billed Charges,95% of Total Billed Charges,1277.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1124.46,88,,5310.488,Percent of Total Billed Charges,88% of Total Billed Charges,1150.02,90,,219.88,Percent of Total Billed charges,90% of Total Billed Charges,563.51,1277.8,
SYN1.5 TPL 4H/8H/40M,2780000560,CDM,278,RC,C1713,HCPCS,Outpatient,,,815.85,530.30,,815.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,620.05,76,,3080.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,587.41,72,,4311.928,Percent of Total Billed Charges,72% of Total Billed Charges,587.41,72,,4311.928,Percent of Total Billed charges,72% of Total Billed Charges,815.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,587.41,72,,4311.928,Percent of Total Billed Charges,72% of Total Billed Charges,489.51,60,,3593.272,Percent of Total Billed Charges,60% of Total Billed Charges,734.27,90,,758.872,Percent of Total Billed Charges,90% of Total Billed Charges,367.13,45,,764.432,Percent of Total Billed Charges,45% of Total Billed Charges,734.27,90,,3647.512,Percent of Total Billed Charges,90% of Total billed Charges,815.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,815.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,815.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.3,65,,115.232,Percent of total Billed Charges,65% of Total Billed Charges,359.79,44.1,,749.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,775.06,95,,3850.152,Percent of Total Billed Charges,95% of Total Billed Charges,815.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,717.95,88,,14474.608,Percent of Total Billed Charges,88% of Total Billed Charges,734.27,90,,3647.512,Percent of Total Billed charges,90% of Total Billed Charges,359.79,815.85,
DPY CLAVICLE PIN,2780000561,CDM,278,RC,C1713,HCPCS,Outpatient,,,5176.24,3364.56,,5176.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3933.94,76,,322.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3726.89,72,,279.416,Percent of Total Billed Charges,72% of Total Billed Charges,3726.89,72,,279.416,Percent of Total Billed charges,72% of Total Billed Charges,5176.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3726.89,72,,279.416,Percent of Total Billed Charges,72% of Total Billed Charges,3105.74,60,,232.848,Percent of Total Billed Charges,60% of Total Billed Charges,4658.62,90,,418.336,Percent of Total Billed Charges,90% of Total Billed Charges,2329.31,45,,2715.592,Percent of Total Billed Charges,45% of Total Billed Charges,4658.62,90,,381.816,Percent of Total Billed Charges,90% of Total billed Charges,5176.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5176.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5176.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3364.56,65,,37.264,Percent of total Billed Charges,65% of Total Billed Charges,2282.72,44.1,,2661.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,4917.43,95,,403.032,Percent of Total Billed Charges,95% of Total Billed Charges,5176.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4555.09,88,,14474.608,Percent of Total Billed Charges,88% of Total Billed Charges,4658.62,90,,381.816,Percent of Total Billed charges,90% of Total Billed Charges,2282.72,5176.24,
SYN 7.3 SCREWS,2780000562,CDM,278,RC,C1713,HCPCS,Outpatient,,,1031.94,670.76,,1031.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,784.27,76,,289.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,743,72,,11077.64,Percent of Total Billed Charges,72% of Total Billed Charges,743,72,,11077.64,Percent of Total Billed charges,72% of Total Billed Charges,1031.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,743,72,,11077.64,Percent of Total Billed Charges,72% of Total Billed Charges,619.16,60,,9231.368,Percent of Total Billed Charges,60% of Total Billed Charges,928.75,90,,3314.912,Percent of Total Billed Charges,90% of Total Billed Charges,464.37,45,,7401.784,Percent of Total Billed Charges,45% of Total Billed Charges,928.75,90,,342.92,Percent of Total Billed Charges,90% of Total billed Charges,1031.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1031.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1031.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,670.76,65,,2930.712,Percent of total Billed Charges,65% of Total Billed Charges,455.09,44.1,,7253.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,980.34,95,,361.976,Percent of Total Billed Charges,95% of Total Billed Charges,1031.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,908.11,88,,5178.536,Percent of Total Billed Charges,88% of Total Billed Charges,928.75,90,,342.92,Percent of Total Billed charges,90% of Total Billed Charges,455.09,1031.94,
SYNT T CANN 170 NAIL,2780000563,CDM,278,RC,C1713,HCPCS,Outpatient,,,5405.56,3513.61,,5405.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4108.23,76,,1291.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3892,72,,162.568,Percent of Total Billed Charges,72% of Total Billed Charges,3892,72,,162.568,Percent of Total Billed charges,72% of Total Billed Charges,5405.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3892,72,,162.568,Percent of Total Billed Charges,72% of Total Billed Charges,3243.34,60,,135.472,Percent of Total Billed Charges,60% of Total Billed Charges,4865,90,,3314.912,Percent of Total Billed Charges,90% of Total Billed Charges,2432.5,45,,7401.784,Percent of Total Billed Charges,45% of Total Billed Charges,4865,90,,1528.864,Percent of Total Billed Charges,90% of Total billed Charges,5405.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5405.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5405.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3513.61,65,,4180.504,Percent of total Billed Charges,65% of Total Billed Charges,2383.85,44.1,,7253.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,5135.28,95,,1613.8,Percent of Total Billed Charges,95% of Total Billed Charges,5405.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4756.89,88,,5178.536,Percent of Total Billed Charges,88% of Total Billed Charges,4865,90,,1528.864,Percent of Total Billed charges,90% of Total Billed Charges,2383.85,5405.56,
SYNT 5.0 T LOCKING S,2780000564,CDM,278,RC,C1713,HCPCS,Outpatient,,,848.93,551.80,,848.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,645.19,76,,4586.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,611.23,72,,733.472,Percent of Total Billed Charges,72% of Total Billed Charges,611.23,72,,733.472,Percent of Total Billed charges,72% of Total Billed Charges,848.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.23,72,,733.472,Percent of Total Billed Charges,72% of Total Billed Charges,509.36,60,,611.224,Percent of Total Billed Charges,60% of Total Billed Charges,764.04,90,,5743.936,Percent of Total Billed Charges,90% of Total Billed Charges,382.02,45,,2648.12,Percent of Total Billed Charges,45% of Total Billed Charges,764.04,90,,5431.184,Percent of Total Billed Charges,90% of Total billed Charges,848.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,848.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,848.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,551.8,65,,241.36,Percent of total Billed Charges,65% of Total Billed Charges,374.38,44.1,,2595.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,806.48,95,,5732.912,Percent of Total Billed Charges,95% of Total Billed Charges,848.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,747.06,88,,4030.6,Percent of Total Billed Charges,88% of Total Billed Charges,764.04,90,,5431.184,Percent of Total Billed charges,90% of Total Billed Charges,374.38,848.93,
SYNT 4.0 3 FLUTED D,2780000565,CDM,278,RC,C1713,HCPCS,Outpatient,,,255.78,166.26,,255.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,194.39,76,,12500.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,184.16,72,,328.312,Percent of Total Billed Charges,72% of Total Billed Charges,184.16,72,,328.312,Percent of Total Billed charges,72% of Total Billed Charges,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.16,72,,328.312,Percent of Total Billed Charges,72% of Total Billed Charges,153.47,60,,273.592,Percent of Total Billed Charges,60% of Total Billed Charges,230.2,90,,3079.152,Percent of Total Billed Charges,90% of Total Billed Charges,115.1,45,,2648.12,Percent of Total Billed Charges,45% of Total Billed Charges,230.2,90,,14803.576,Percent of Total Billed Charges,90% of Total billed Charges,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.26,65,,6294.264,Percent of total Billed Charges,65% of Total Billed Charges,112.8,44.1,,2595.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,242.99,95,,15625.992,Percent of Total Billed Charges,95% of Total Billed Charges,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.09,88,,742.008,Percent of Total Billed Charges,88% of Total Billed Charges,230.2,90,,14803.576,Percent of Total Billed charges,90% of Total Billed Charges,112.8,255.78,
SYN CAN 170 MM NAIL,2780000566,CDM,278,RC,C1713,HCPCS,Outpatient,,,5405.56,3513.61,,5405.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4108.23,76,,12500.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3892,72,,3156.784,Percent of Total Billed Charges,72% of Total Billed Charges,3892,72,,3156.784,Percent of Total Billed charges,72% of Total Billed Charges,5405.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3892,72,,3156.784,Percent of Total Billed Charges,72% of Total Billed Charges,3243.34,60,,2630.656,Percent of Total Billed Charges,60% of Total Billed Charges,4865,90,,18108.96,Percent of Total Billed Charges,90% of Total Billed Charges,2432.5,45,,2061.104,Percent of Total Billed Charges,45% of Total Billed Charges,4865,90,,14803.576,Percent of Total Billed Charges,90% of Total billed Charges,5405.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5405.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5405.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3513.61,65,,2403.848,Percent of total Billed Charges,65% of Total Billed Charges,2383.85,44.1,,2019.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,5135.28,95,,15625.992,Percent of Total Billed Charges,95% of Total Billed Charges,5405.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4756.89,88,,409.04,Percent of Total Billed Charges,88% of Total Billed Charges,4865,90,,14803.576,Percent of Total Billed charges,90% of Total Billed Charges,2383.85,5405.56,
SYN 5 LOCKING SCREW,2780000567,CDM,278,RC,C1713,HCPCS,Outpatient,,,848.93,551.80,,848.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,645.19,76,,4472.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,611.23,72,,311.176,Percent of Total Billed Charges,72% of Total Billed Charges,611.23,72,,311.176,Percent of Total Billed charges,72% of Total Billed Charges,848.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.23,72,,311.176,Percent of Total Billed Charges,72% of Total Billed Charges,509.36,60,,259.312,Percent of Total Billed Charges,60% of Total Billed Charges,764.04,90,,58849.16,Percent of Total Billed Charges,90% of Total Billed Charges,382.02,45,,379.44,Percent of Total Billed Charges,45% of Total Billed Charges,764.04,90,,5296.232,Percent of Total Billed Charges,90% of Total billed Charges,848.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,848.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,848.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,551.8,65,,1578.872,Percent of total Billed Charges,65% of Total Billed Charges,374.38,44.1,,371.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,806.48,95,,5590.472,Percent of Total Billed Charges,95% of Total Billed Charges,848.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,747.06,88,,3241.248,Percent of Total Billed Charges,88% of Total Billed Charges,764.04,90,,5296.232,Percent of Total Billed charges,90% of Total Billed Charges,374.38,848.93,
Z00110301005 COPI,2780000568,CDM,278,RC,C1713,HCPCS,Outpatient,,,3831.19,2490.27,,3831.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2911.7,76,,4472.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2758.46,72,,319.424,Percent of Total Billed Charges,72% of Total Billed Charges,2758.46,72,,319.424,Percent of Total Billed charges,72% of Total Billed Charges,3831.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2758.46,72,,319.424,Percent of Total Billed Charges,72% of Total Billed Charges,2298.71,60,,266.192,Percent of Total Billed Charges,60% of Total Billed Charges,3448.07,90,,186.544,Percent of Total Billed Charges,90% of Total Billed Charges,1724.04,45,,209.168,Percent of Total Billed Charges,45% of Total Billed Charges,3448.07,90,,5296.232,Percent of Total Billed Charges,90% of Total billed Charges,3831.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3831.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3831.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2490.27,65,,157.656,Percent of total Billed Charges,65% of Total Billed Charges,1689.55,44.1,,204.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,3639.63,95,,5590.472,Percent of Total Billed Charges,95% of Total Billed Charges,3831.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3371.45,88,,3241.248,Percent of Total Billed Charges,88% of Total Billed Charges,3448.07,90,,5296.232,Percent of Total Billed charges,90% of Total Billed Charges,1689.55,3831.19,
Z00110301001 COPI,2780000569,CDM,278,RC,C1713,HCPCS,Outpatient,,,1520.35,988.23,,1520.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1155.47,76,,3480.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1094.65,72,,319.424,Percent of Total Billed Charges,72% of Total Billed Charges,1094.65,72,,319.424,Percent of Total Billed charges,72% of Total Billed Charges,1520.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1094.65,72,,319.424,Percent of Total Billed Charges,72% of Total Billed Charges,912.21,60,,266.192,Percent of Total Billed Charges,60% of Total Billed Charges,1368.32,90,,51.592,Percent of Total Billed Charges,90% of Total Billed Charges,684.16,45,,1657.456,Percent of Total Billed Charges,45% of Total Billed Charges,1368.32,90,,4122.2,Percent of Total Billed Charges,90% of Total billed Charges,1520.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1520.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1520.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,988.23,65,,2394.104,Percent of total Billed Charges,65% of Total Billed Charges,670.47,44.1,,1624.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,1444.33,95,,4351.216,Percent of Total Billed Charges,95% of Total Billed Charges,1520.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1337.91,88,,5616.296,Percent of Total Billed Charges,88% of Total Billed Charges,1368.32,90,,4122.2,Percent of Total Billed charges,90% of Total Billed Charges,670.47,1520.35,
Z23481435 3.5 CORT,2780000570,CDM,278,RC,C1713,HCPCS,Outpatient,,,190.73,123.97,,190.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.95,76,,640.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,137.33,72,,319.424,Percent of Total Billed Charges,72% of Total Billed Charges,137.33,72,,319.424,Percent of Total Billed charges,72% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.33,72,,319.424,Percent of Total Billed Charges,72% of Total Billed Charges,114.44,60,,266.192,Percent of Total Billed Charges,60% of Total Billed Charges,171.66,90,,51.592,Percent of Total Billed Charges,90% of Total Billed Charges,85.83,45,,1657.456,Percent of Total Billed Charges,45% of Total Billed Charges,171.66,90,,758.872,Percent of Total Billed Charges,90% of Total billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.97,65,,19577.624,Percent of total Billed Charges,65% of Total Billed Charges,84.11,44.1,,1624.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,181.19,95,,801.032,Percent of Total Billed Charges,95% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.84,88,,3010.728,Percent of Total Billed Charges,88% of Total Billed Charges,171.66,90,,758.872,Percent of Total Billed charges,90% of Total Billed Charges,84.11,190.73,
Z23592835 3.5 LOCK,2780000571,CDM,278,RC,C1713,HCPCS,Outpatient,,,394.70,256.56,,394.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.97,76,,353.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.18,72,,319.424,Percent of Total Billed Charges,72% of Total Billed Charges,284.18,72,,319.424,Percent of Total Billed charges,72% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.18,72,,319.424,Percent of Total Billed Charges,72% of Total Billed Charges,236.82,60,,266.192,Percent of Total Billed Charges,60% of Total Billed Charges,355.23,90,,1303.424,Percent of Total Billed Charges,90% of Total Billed Charges,177.62,45,,2871.968,Percent of Total Billed Charges,45% of Total Billed Charges,355.23,90,,418.336,Percent of Total Billed Charges,90% of Total billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.56,65,,3986.152,Percent of total Billed Charges,65% of Total Billed Charges,174.06,44.1,,2814.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.97,95,,441.576,Percent of Total Billed Charges,95% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.34,88,,17706.536,Percent of Total Billed Charges,88% of Total Billed Charges,355.23,90,,418.336,Percent of Total Billed charges,90% of Total Billed Charges,174.06,394.7,
Z23471508 DISTAL,2780000572,CDM,278,RC,C1713,HCPCS,Outpatient,,,2361.56,1535.01,,2361.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1794.79,76,,2799.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1700.32,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,1700.32,72,,212.104,Percent of Total Billed charges,72% of Total Billed Charges,2361.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1700.32,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,1416.94,60,,176.752,Percent of Total Billed Charges,60% of Total Billed Charges,2125.4,90,,10.32,Percent of Total Billed Charges,90% of Total Billed Charges,1062.7,45,,1539.576,Percent of Total Billed Charges,45% of Total Billed Charges,2125.4,90,,3314.912,Percent of Total Billed Charges,90% of Total billed Charges,2361.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2361.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2361.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1535.01,65,,2394.104,Percent of total Billed Charges,65% of Total Billed Charges,1041.45,44.1,,1508.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,2243.48,95,,3499.072,Percent of Total Billed Charges,95% of Total Billed Charges,2361.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2078.17,88,,57541.4,Percent of Total Billed Charges,88% of Total Billed Charges,2125.4,90,,3314.912,Percent of Total Billed charges,90% of Total Billed Charges,1041.45,2361.56,
MTF GRAFT,2780000573,CDM,278,RC,C1713,HCPCS,Outpatient,,,14772.40,9602.06,,14772.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11227.02,76,,2799.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10636.13,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,10636.13,72,,212.104,Percent of Total Billed charges,72% of Total Billed Charges,14772.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10636.13,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,8863.44,60,,176.752,Percent of Total Billed Charges,60% of Total Billed Charges,13295.16,90,,113.512,Percent of Total Billed Charges,90% of Total Billed Charges,6647.58,45,,9054.48,Percent of Total Billed Charges,45% of Total Billed Charges,13295.16,90,,3314.912,Percent of Total Billed Charges,90% of Total billed Charges,14772.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14772.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14772.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9602.06,65,,9111.456,Percent of total Billed Charges,65% of Total Billed Charges,6514.63,44.1,,8873.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,14033.78,95,,3499.072,Percent of Total Billed Charges,95% of Total Billed Charges,14772.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12999.71,88,,182.4,Percent of Total Billed Charges,88% of Total Billed Charges,13295.16,90,,3314.912,Percent of Total Billed charges,90% of Total Billed Charges,6514.63,14772.4,
Z490112151.25 KWI,2780000574,CDM,278,RC,C1713,HCPCS,Outpatient,,,121.28,78.83,,121.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,92.17,76,,4850.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,87.32,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,87.32,72,,212.104,Percent of Total Billed charges,72% of Total Billed Charges,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.32,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,72.77,60,,176.752,Percent of Total Billed Charges,60% of Total Billed Charges,109.15,90,,5431.184,Percent of Total Billed Charges,90% of Total Billed Charges,54.58,45,,29424.576,Percent of Total Billed Charges,45% of Total Billed Charges,109.15,90,,5743.936,Percent of Total Billed Charges,90% of Total billed Charges,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.83,65,,311.304,Percent of total Billed Charges,65% of Total Billed Charges,53.48,44.1,,28836.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,115.22,95,,6063.048,Percent of Total Billed Charges,95% of Total Billed Charges,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.73,88,,50.448,Percent of Total Billed Charges,88% of Total Billed Charges,109.15,90,,5743.936,Percent of Total Billed charges,90% of Total Billed Charges,53.48,121.28,
Z490116151.6 K WI,2780000575,CDM,278,RC,C1713,HCPCS,Outpatient,,,121.28,78.83,,121.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,92.17,76,,2600.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,87.32,72,,335.936,Percent of Total Billed Charges,72% of Total Billed Charges,87.32,72,,335.936,Percent of Total Billed charges,72% of Total Billed Charges,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.32,72,,335.936,Percent of Total Billed Charges,72% of Total Billed Charges,72.77,60,,279.944,Percent of Total Billed Charges,60% of Total Billed Charges,109.15,90,,93.672,Percent of Total Billed Charges,90% of Total Billed Charges,54.58,45,,93.272,Percent of Total Billed Charges,45% of Total Billed Charges,109.15,90,,3079.152,Percent of Total Billed Charges,90% of Total billed Charges,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.83,65,,2565.52,Percent of total Billed Charges,65% of Total Billed Charges,53.48,44.1,,91.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,115.22,95,,3250.216,Percent of Total Billed Charges,95% of Total Billed Charges,121.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.73,88,,50.448,Percent of Total Billed Charges,88% of Total Billed Charges,109.15,90,,3079.152,Percent of Total Billed charges,90% of Total Billed Charges,53.48,121.28,
Z114796WASHER,2780000576,CDM,278,RC,C1713,HCPCS,Outpatient,,,194.04,126.13,,194.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,147.47,76,,15292.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,139.71,72,,335.936,Percent of Total Billed Charges,72% of Total Billed Charges,139.71,72,,335.936,Percent of Total Billed charges,72% of Total Billed Charges,194.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.71,72,,335.936,Percent of Total Billed Charges,72% of Total Billed Charges,116.42,60,,279.944,Percent of Total Billed Charges,60% of Total Billed Charges,174.64,90,,2076.584,Percent of Total Billed Charges,90% of Total Billed Charges,87.32,45,,25.8,Percent of Total Billed Charges,45% of Total Billed Charges,174.64,90,,18108.96,Percent of Total Billed Charges,90% of Total billed Charges,194.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.13,65,,305.568,Percent of total Billed Charges,65% of Total Billed Charges,85.57,44.1,,25.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,184.34,95,,19115.008,Percent of Total Billed Charges,95% of Total Billed Charges,194.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.76,88,,1274.456,Percent of Total Billed Charges,88% of Total Billed Charges,174.64,90,,18108.96,Percent of Total Billed charges,90% of Total Billed Charges,85.57,194.04,
Z1147941.6 K WIRE,2780000577,CDM,278,RC,C1713,HCPCS,Outpatient,,,25.36,16.48,,25.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.27,76,,49694.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.26,72,,335.936,Percent of Total Billed Charges,72% of Total Billed Charges,18.26,72,,335.936,Percent of Total Billed charges,72% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.26,72,,335.936,Percent of Total Billed Charges,72% of Total Billed Charges,15.22,60,,279.944,Percent of Total Billed Charges,60% of Total Billed Charges,22.82,90,,159.552,Percent of Total Billed Charges,90% of Total Billed Charges,11.41,45,,25.8,Percent of Total Billed Charges,45% of Total Billed Charges,22.82,90,,58849.16,Percent of Total Billed Charges,90% of Total billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,65,,2690.496,Percent of total Billed Charges,65% of Total Billed Charges,11.18,44.1,,25.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.09,95,,62118.552,Percent of Total Billed Charges,95% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,88,,10.088,Percent of Total Billed Charges,88% of Total Billed Charges,22.82,90,,58849.16,Percent of Total Billed charges,90% of Total Billed Charges,11.18,25.36,
Z23471808 LAT FIB,2780000578,CDM,278,RC,C1713,HCPCS,Outpatient,,,2550.08,1657.55,,2550.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1938.06,76,,157.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1836.06,72,,335.936,Percent of Total Billed Charges,72% of Total Billed Charges,1836.06,72,,335.936,Percent of Total Billed charges,72% of Total Billed Charges,2550.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1836.06,72,,335.936,Percent of Total Billed Charges,72% of Total Billed Charges,1530.05,60,,279.944,Percent of Total Billed Charges,60% of Total Billed Charges,2295.07,90,,51.592,Percent of Total Billed Charges,90% of Total Billed Charges,1147.54,45,,651.712,Percent of Total Billed Charges,45% of Total Billed Charges,2295.07,90,,186.544,Percent of Total Billed Charges,90% of Total billed Charges,2550.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2550.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2550.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1657.55,65,,38.984,Percent of total Billed Charges,65% of Total Billed Charges,1124.59,44.1,,638.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,2422.58,95,,196.912,Percent of Total Billed Charges,95% of Total Billed Charges,2550.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2244.07,88,,110.992,Percent of Total Billed Charges,88% of Total Billed Charges,2295.07,90,,186.544,Percent of Total Billed charges,90% of Total Billed Charges,1124.59,2550.08,
Z22536055 5.5 CORT,2780000579,CDM,278,RC,C1713,HCPCS,Outpatient,,,845.62,549.65,,845.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,642.67,76,,43.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,608.85,72,,335.936,Percent of Total Billed Charges,72% of Total Billed Charges,608.85,72,,335.936,Percent of Total Billed charges,72% of Total Billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,608.85,72,,335.936,Percent of Total Billed Charges,72% of Total Billed Charges,507.37,60,,279.944,Percent of Total Billed Charges,60% of Total Billed Charges,761.06,90,,4057.904,Percent of Total Billed Charges,90% of Total Billed Charges,380.53,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,761.06,90,,51.592,Percent of Total Billed Charges,90% of Total billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.65,65,,387.552,Percent of total Billed Charges,65% of Total Billed Charges,372.92,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,803.34,95,,54.464,Percent of Total Billed Charges,95% of Total Billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,744.15,88,,5310.488,Percent of Total Billed Charges,88% of Total Billed Charges,761.06,90,,51.592,Percent of Total Billed charges,90% of Total Billed Charges,372.92,845.62,
Z22537055 5.5 CORT,2780000580,CDM,278,RC,C1713,HCPCS,Outpatient,,,845.62,549.65,,845.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,642.67,76,,43.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,608.85,72,,217.824,Percent of Total Billed Charges,72% of Total Billed Charges,608.85,72,,217.824,Percent of Total Billed charges,72% of Total Billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,608.85,72,,217.824,Percent of Total Billed Charges,72% of Total Billed Charges,507.37,60,,181.52,Percent of Total Billed Charges,60% of Total Billed Charges,761.06,90,,5788.392,Percent of Total Billed Charges,90% of Total Billed Charges,380.53,45,,56.76,Percent of Total Billed Charges,45% of Total Billed Charges,761.06,90,,51.592,Percent of Total Billed Charges,90% of Total billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.65,65,,168.552,Percent of total Billed Charges,65% of Total Billed Charges,372.92,44.1,,55.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,803.34,95,,54.464,Percent of Total Billed Charges,95% of Total Billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,744.15,88,,91.592,Percent of Total Billed Charges,88% of Total Billed Charges,761.06,90,,51.592,Percent of Total Billed charges,90% of Total Billed Charges,372.92,845.62,
Z225328010 TIBIAL,2780000581,CDM,278,RC,C1713,HCPCS,Outpatient,,,4989.92,3243.45,,4989.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3792.34,76,,1100.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3592.74,72,,2655.744,Percent of Total Billed Charges,72% of Total Billed Charges,3592.74,72,,2655.744,Percent of Total Billed charges,72% of Total Billed Charges,4989.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3592.74,72,,2655.744,Percent of Total Billed Charges,72% of Total Billed Charges,2993.95,60,,2213.12,Percent of Total Billed Charges,60% of Total Billed Charges,4490.93,90,,334.192,Percent of Total Billed Charges,90% of Total Billed Charges,2245.46,45,,2715.592,Percent of Total Billed Charges,45% of Total Billed Charges,4490.93,90,,1303.424,Percent of Total Billed Charges,90% of Total billed Charges,4989.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4989.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4989.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3243.45,65,,168.552,Percent of total Billed Charges,65% of Total Billed Charges,2200.55,44.1,,2661.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,4740.42,95,,1375.832,Percent of Total Billed Charges,95% of Total Billed Charges,4989.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4391.13,88,,2030.432,Percent of Total Billed Charges,88% of Total Billed Charges,4490.93,90,,1303.424,Percent of Total Billed charges,90% of Total Billed Charges,2200.55,4989.92,
Z59965014 ART SURF,2780000582,CDM,278,RC,C1713,HCPCS,Outpatient,,,4848.80,3151.72,,4848.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3685.09,76,,8.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3491.14,72,,182.256,Percent of Total Billed Charges,72% of Total Billed Charges,3491.14,72,,182.256,Percent of Total Billed charges,72% of Total Billed Charges,4848.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3491.14,72,,182.256,Percent of Total Billed Charges,72% of Total Billed Charges,2909.28,60,,151.88,Percent of Total Billed Charges,60% of Total Billed Charges,4363.92,90,,8715.136,Percent of Total Billed Charges,90% of Total Billed Charges,2181.96,45,,46.84,Percent of Total Billed Charges,45% of Total Billed Charges,4363.92,90,,10.32,Percent of Total Billed Charges,90% of Total billed Charges,4848.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4848.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4848.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3151.72,65,,498.2,Percent of total Billed Charges,65% of Total Billed Charges,2138.32,44.1,,45.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,4606.36,95,,10.888,Percent of Total Billed Charges,95% of Total Billed Charges,4848.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4266.94,88,,156.008,Percent of Total Billed Charges,88% of Total Billed Charges,4363.92,90,,10.32,Percent of Total Billed charges,90% of Total Billed Charges,2138.32,4848.8,
Z225422508 HUM NAI,2780000583,CDM,278,RC,C1713,HCPCS,Outpatient,,,6921.50,4498.98,,6921.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5260.34,76,,95.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4983.48,72,,182.256,Percent of Total Billed Charges,72% of Total Billed Charges,4983.48,72,,182.256,Percent of Total Billed charges,72% of Total Billed Charges,6921.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4983.48,72,,182.256,Percent of Total Billed Charges,72% of Total Billed Charges,4152.9,60,,151.88,Percent of Total Billed Charges,60% of Total Billed Charges,6229.35,90,,3328.4,Percent of Total Billed Charges,90% of Total Billed Charges,3114.68,45,,1038.288,Percent of Total Billed Charges,45% of Total Billed Charges,6229.35,90,,113.512,Percent of Total Billed Charges,90% of Total billed Charges,6921.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6921.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6921.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4498.98,65,,1325.472,Percent of total Billed Charges,65% of Total Billed Charges,3052.38,44.1,,1017.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,6575.43,95,,119.824,Percent of Total Billed Charges,95% of Total Billed Charges,6921.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6090.92,88,,50.448,Percent of Total Billed Charges,88% of Total Billed Charges,6229.35,90,,113.512,Percent of Total Billed charges,90% of Total Billed Charges,3052.38,6921.5,
Z22532537 3.7 CORT,2780000584,CDM,278,RC,C1713,HCPCS,Outpatient,,,845.62,549.65,,845.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,642.67,76,,4586.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,608.85,72,,177.176,Percent of Total Billed Charges,72% of Total Billed Charges,608.85,72,,177.176,Percent of Total Billed charges,72% of Total Billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,608.85,72,,177.176,Percent of Total Billed Charges,72% of Total Billed Charges,507.37,60,,147.648,Percent of Total Billed Charges,60% of Total Billed Charges,761.06,90,,2186.128,Percent of Total Billed Charges,90% of Total Billed Charges,380.53,45,,79.776,Percent of Total Billed Charges,45% of Total Billed Charges,761.06,90,,5431.184,Percent of Total Billed Charges,90% of Total billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.65,65,,288.368,Percent of total Billed Charges,65% of Total Billed Charges,372.92,44.1,,78.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,803.34,95,,5732.912,Percent of Total Billed Charges,95% of Total Billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,744.15,88,,3967.728,Percent of Total Billed Charges,88% of Total Billed Charges,761.06,90,,5431.184,Percent of Total Billed charges,90% of Total Billed Charges,372.92,845.62,
Z22533037 3.7 CORT,2780000585,CDM,278,RC,C1713,HCPCS,Outpatient,,,845.62,549.65,,845.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,642.67,76,,79.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,608.85,72,,191.784,Percent of Total Billed Charges,72% of Total Billed Charges,608.85,72,,191.784,Percent of Total Billed charges,72% of Total Billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,608.85,72,,191.784,Percent of Total Billed Charges,72% of Total Billed Charges,507.37,60,,159.824,Percent of Total Billed Charges,60% of Total Billed Charges,761.06,90,,218.296,Percent of Total Billed Charges,90% of Total Billed Charges,380.53,45,,25.8,Percent of Total Billed Charges,45% of Total Billed Charges,761.06,90,,93.672,Percent of Total Billed Charges,90% of Total billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.65,65,,45.296,Percent of total Billed Charges,65% of Total Billed Charges,372.92,44.1,,25.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,803.34,95,,98.88,Percent of Total Billed Charges,95% of Total Billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,744.15,88,,5659.76,Percent of Total Billed Charges,88% of Total Billed Charges,761.06,90,,93.672,Percent of Total Billed charges,90% of Total Billed Charges,372.92,845.62,
Z114707576 32MMTHD,2780000586,CDM,278,RC,C1713,HCPCS,Outpatient,,,1304.26,847.77,,1304.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,991.24,76,,1753.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,939.07,72,,117.48,Percent of Total Billed Charges,72% of Total Billed Charges,939.07,72,,117.48,Percent of Total Billed charges,72% of Total Billed Charges,1304.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,939.07,72,,117.48,Percent of Total Billed Charges,72% of Total Billed Charges,782.56,60,,97.904,Percent of Total Billed Charges,60% of Total Billed Charges,1173.83,90,,3314.912,Percent of Total Billed Charges,90% of Total Billed Charges,586.92,45,,2028.952,Percent of Total Billed Charges,45% of Total Billed Charges,1173.83,90,,2076.584,Percent of Total Billed Charges,90% of Total billed Charges,1304.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1304.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1304.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,847.77,65,,2466.336,Percent of total Billed Charges,65% of Total Billed Charges,575.18,44.1,,1988.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,1239.05,95,,2191.944,Percent of Total Billed Charges,95% of Total Billed Charges,1304.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1147.75,88,,326.76,Percent of Total Billed Charges,88% of Total Billed Charges,1173.83,90,,2076.584,Percent of Total Billed charges,90% of Total Billed Charges,575.18,1304.26,
Z114708075 32MMTHD,2780000587,CDM,278,RC,C1713,HCPCS,Outpatient,,,1304.26,847.77,,1304.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,991.24,76,,134.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,939.07,72,,1609.192,Percent of Total Billed Charges,72% of Total Billed Charges,939.07,72,,1609.192,Percent of Total Billed charges,72% of Total Billed Charges,1304.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,939.07,72,,1609.192,Percent of Total Billed Charges,72% of Total Billed Charges,782.56,60,,1340.992,Percent of Total Billed Charges,60% of Total Billed Charges,1173.83,90,,27107.472,Percent of Total Billed Charges,90% of Total Billed Charges,586.92,45,,2894.192,Percent of Total Billed Charges,45% of Total Billed Charges,1173.83,90,,159.552,Percent of Total Billed Charges,90% of Total billed Charges,1304.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1304.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1304.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,847.77,65,,1717.032,Percent of total Billed Charges,65% of Total Billed Charges,575.18,44.1,,2836.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,1239.05,95,,168.416,Percent of Total Billed Charges,95% of Total Billed Charges,1304.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1147.75,88,,8521.464,Percent of Total Billed Charges,88% of Total Billed Charges,1173.83,90,,159.552,Percent of Total Billed charges,90% of Total Billed Charges,575.18,1304.26,
Z3281056302 ULNAA,2780000588,CDM,278,RC,C1713,HCPCS,Outpatient,,,21884.63,14225.01,,21884.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16632.32,76,,43.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15756.93,72,,3626.08,Percent of Total Billed Charges,72% of Total Billed Charges,15756.93,72,,3626.08,Percent of Total Billed charges,72% of Total Billed Charges,21884.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15756.93,72,,3626.08,Percent of Total Billed Charges,72% of Total Billed Charges,13130.78,60,,3021.736,Percent of Total Billed Charges,60% of Total Billed Charges,19696.17,90,,5519.288,Percent of Total Billed Charges,90% of Total Billed Charges,9848.08,45,,167.096,Percent of Total Billed Charges,45% of Total Billed Charges,19696.17,90,,51.592,Percent of Total Billed Charges,90% of Total billed Charges,21884.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21884.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21884.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14225.01,65,,2310.976,Percent of total Billed Charges,65% of Total Billed Charges,9651.12,44.1,,163.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,20790.4,95,,54.464,Percent of Total Billed Charges,95% of Total Billed Charges,21884.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19258.47,88,,3254.44,Percent of Total Billed Charges,88% of Total Billed Charges,19696.17,90,,51.592,Percent of Total Billed charges,90% of Total Billed Charges,9651.12,21884.63,
Z3281052604 HUMI,2780000589,CDM,278,RC,C1713,HCPCS,Outpatient,,,24028.99,15618.84,,24028.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18262.03,76,,3426.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17300.87,72,,7931.656,Percent of Total Billed Charges,72% of Total Billed Charges,17300.87,72,,7931.656,Percent of Total Billed charges,72% of Total Billed Charges,24028.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17300.87,72,,7931.656,Percent of Total Billed Charges,72% of Total Billed Charges,14417.39,60,,6609.712,Percent of Total Billed Charges,60% of Total Billed Charges,21626.09,90,,3314.912,Percent of Total Billed Charges,90% of Total Billed Charges,10813.05,45,,4357.568,Percent of Total Billed Charges,45% of Total Billed Charges,21626.09,90,,4057.904,Percent of Total Billed Charges,90% of Total billed Charges,24028.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24028.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24028.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15618.84,65,,2466.336,Percent of total Billed Charges,65% of Total Billed Charges,10596.78,44.1,,4270.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,22827.54,95,,4283.344,Percent of Total Billed Charges,95% of Total Billed Charges,24028.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21145.51,88,,2137.552,Percent of Total Billed Charges,88% of Total Billed Charges,21626.09,90,,4057.904,Percent of Total Billed charges,90% of Total Billed Charges,10596.78,24028.99,
Z23592625 24 CONIC,2780000590,CDM,278,RC,C1713,HCPCS,Outpatient,,,469.67,305.29,,469.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,356.95,76,,4887.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,338.16,72,,2684.952,Percent of Total Billed Charges,72% of Total Billed Charges,338.16,72,,2684.952,Percent of Total Billed charges,72% of Total Billed Charges,469.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,338.16,72,,2684.952,Percent of Total Billed Charges,72% of Total Billed Charges,281.8,60,,2237.456,Percent of Total Billed Charges,60% of Total Billed Charges,422.7,90,,12615.864,Percent of Total Billed Charges,90% of Total Billed Charges,211.35,45,,1664.2,Percent of Total Billed Charges,45% of Total Billed Charges,422.7,90,,5788.392,Percent of Total Billed Charges,90% of Total billed Charges,469.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,469.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,469.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305.29,65,,2800,Percent of total Billed Charges,65% of Total Billed Charges,207.12,44.1,,1630.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,446.19,95,,6109.968,Percent of Total Billed Charges,95% of Total Billed Charges,469.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.31,88,,213.448,Percent of Total Billed Charges,88% of Total Billed Charges,422.7,90,,5788.392,Percent of Total Billed charges,90% of Total Billed Charges,207.12,469.67,
Z114708076 32MMTHD,2780000591,CDM,278,RC,C1713,HCPCS,Outpatient,,,1304.26,847.77,,1304.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,991.24,76,,282.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,939.07,72,,4782.488,Percent of Total Billed Charges,72% of Total Billed Charges,939.07,72,,4782.488,Percent of Total Billed charges,72% of Total Billed Charges,1304.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,939.07,72,,4782.488,Percent of Total Billed Charges,72% of Total Billed Charges,782.56,60,,3985.408,Percent of Total Billed Charges,60% of Total Billed Charges,1173.83,90,,431.032,Percent of Total Billed Charges,90% of Total Billed Charges,586.92,45,,1093.064,Percent of Total Billed Charges,45% of Total Billed Charges,1173.83,90,,334.192,Percent of Total Billed Charges,90% of Total billed Charges,1304.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1304.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1304.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,847.77,65,,3420.88,Percent of total Billed Charges,65% of Total Billed Charges,575.18,44.1,,1071.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,1239.05,95,,352.752,Percent of Total Billed Charges,95% of Total Billed Charges,1304.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1147.75,88,,3241.248,Percent of Total Billed Charges,88% of Total Billed Charges,1173.83,90,,334.192,Percent of Total Billed charges,90% of Total Billed Charges,575.18,1304.26,
Z59961751 FEMORAL,2780000592,CDM,278,RC,C1713,HCPCS,Outpatient,,,11523.33,7490.16,,11523.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8757.73,76,,7359.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8296.8,72,,2180.728,Percent of Total Billed Charges,72% of Total Billed Charges,8296.8,72,,2180.728,Percent of Total Billed charges,72% of Total Billed Charges,11523.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8296.8,72,,2180.728,Percent of Total Billed Charges,72% of Total Billed Charges,6914,60,,1817.272,Percent of Total Billed Charges,60% of Total Billed Charges,10371,90,,3552.256,Percent of Total Billed Charges,90% of Total Billed Charges,5185.5,45,,109.152,Percent of Total Billed Charges,45% of Total Billed Charges,10371,90,,8715.136,Percent of Total Billed Charges,90% of Total billed Charges,11523.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11523.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11523.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7490.16,65,,446.6,Percent of total Billed Charges,65% of Total Billed Charges,5081.79,44.1,,106.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,10947.16,95,,9199.304,Percent of Total Billed Charges,95% of Total Billed Charges,11523.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10140.53,88,,26505.088,Percent of Total Billed Charges,88% of Total Billed Charges,10371,90,,8715.136,Percent of Total Billed charges,90% of Total Billed Charges,5081.79,11523.33,
Z23592425 2.4 CONI,2780000593,CDM,278,RC,C1713,HCPCS,Outpatient,,,433.28,281.63,,433.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,329.29,76,,2810.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,311.96,72,,3773.408,Percent of Total Billed Charges,72% of Total Billed Charges,311.96,72,,3773.408,Percent of Total Billed charges,72% of Total Billed Charges,433.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,311.96,72,,3773.408,Percent of Total Billed Charges,72% of Total Billed Charges,259.97,60,,3144.512,Percent of Total Billed Charges,60% of Total Billed Charges,389.95,90,,423.096,Percent of Total Billed Charges,90% of Total Billed Charges,194.98,45,,1657.456,Percent of Total Billed Charges,45% of Total Billed Charges,389.95,90,,3328.4,Percent of Total Billed Charges,90% of Total billed Charges,433.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,433.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,433.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,281.63,65,,1072.072,Percent of total Billed Charges,65% of Total Billed Charges,191.08,44.1,,1624.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,411.62,95,,3513.312,Percent of Total Billed Charges,95% of Total Billed Charges,433.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.29,88,,5396.64,Percent of Total Billed Charges,88% of Total Billed Charges,389.95,90,,3328.4,Percent of Total Billed charges,90% of Total Billed Charges,191.08,433.28,
EXACTECH HIP SPACER,2780000594,CDM,278,RC,C1713,HCPCS,Outpatient,,,14448.26,9391.37,,14448.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10980.68,76,,1846.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10402.75,72,,3481.928,Percent of Total Billed Charges,72% of Total Billed Charges,10402.75,72,,3481.928,Percent of Total Billed charges,72% of Total Billed Charges,14448.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10402.75,72,,3481.928,Percent of Total Billed Charges,72% of Total Billed Charges,8668.96,60,,2901.608,Percent of Total Billed Charges,60% of Total Billed Charges,13003.43,90,,3725.304,Percent of Total Billed Charges,90% of Total Billed Charges,6501.72,45,,13553.736,Percent of Total Billed Charges,45% of Total Billed Charges,13003.43,90,,2186.128,Percent of Total Billed Charges,90% of Total billed Charges,14448.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14448.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14448.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9391.37,65,,3420.88,Percent of total Billed Charges,65% of Total Billed Charges,6371.68,44.1,,13282.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,13725.85,95,,2307.584,Percent of Total Billed Charges,95% of Total Billed Charges,14448.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12714.47,88,,3241.248,Percent of Total Billed Charges,88% of Total Billed Charges,13003.43,90,,2186.128,Percent of Total Billed charges,90% of Total Billed Charges,6371.68,14448.26,
Z11474440 4.0 CANN,2780000595,CDM,278,RC,C1713,HCPCS,Outpatient,,,759.62,493.75,,759.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,577.31,76,,184.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,546.93,72,,1038.928,Percent of Total Billed Charges,72% of Total Billed Charges,546.93,72,,1038.928,Percent of Total Billed charges,72% of Total Billed Charges,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.93,72,,1038.928,Percent of Total Billed Charges,72% of Total Billed Charges,455.77,60,,865.768,Percent of Total Billed Charges,60% of Total Billed Charges,683.66,90,,53.976,Percent of Total Billed Charges,90% of Total Billed Charges,341.83,45,,2759.648,Percent of Total Billed Charges,45% of Total Billed Charges,683.66,90,,218.296,Percent of Total Billed Charges,90% of Total billed Charges,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.75,65,,3420.88,Percent of total Billed Charges,65% of Total Billed Charges,334.99,44.1,,2704.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,721.64,95,,230.424,Percent of Total Billed Charges,95% of Total Billed Charges,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,668.47,88,,12335.512,Percent of Total Billed Charges,88% of Total Billed Charges,683.66,90,,218.296,Percent of Total Billed charges,90% of Total Billed Charges,334.99,759.62,
Z23480604 DIS PIL,2780000596,CDM,278,RC,C1713,HCPCS,Outpatient,,,3246.86,2110.46,,3246.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2467.61,76,,2799.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2337.74,72,,19953.592,Percent of Total Billed Charges,72% of Total Billed Charges,2337.74,72,,19953.592,Percent of Total Billed charges,72% of Total Billed Charges,3246.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2337.74,72,,19953.592,Percent of Total Billed Charges,72% of Total Billed Charges,1948.12,60,,16627.992,Percent of Total Billed Charges,60% of Total Billed Charges,2922.17,90,,536.608,Percent of Total Billed Charges,90% of Total Billed Charges,1461.09,45,,1657.456,Percent of Total Billed Charges,45% of Total Billed Charges,2922.17,90,,3314.912,Percent of Total Billed Charges,90% of Total billed Charges,3246.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3246.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3246.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2110.46,65,,583.048,Percent of total Billed Charges,65% of Total Billed Charges,1431.87,44.1,,1624.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,3084.52,95,,3499.072,Percent of Total Billed Charges,95% of Total Billed Charges,3246.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2857.24,88,,421.456,Percent of Total Billed Charges,88% of Total Billed Charges,2922.17,90,,3314.912,Percent of Total Billed charges,90% of Total Billed Charges,1431.87,3246.86,
Z48277001 2.7 CORT,2780000597,CDM,278,RC,C1713,HCPCS,Outpatient,,,87.10,56.62,,87.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.2,76,,22890.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.71,72,,3018.344,Percent of Total Billed Charges,72% of Total Billed Charges,62.71,72,,3018.344,Percent of Total Billed charges,72% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.71,72,,3018.344,Percent of Total Billed Charges,72% of Total Billed Charges,52.26,60,,2515.288,Percent of Total Billed Charges,60% of Total Billed Charges,78.39,90,,233.384,Percent of Total Billed Charges,90% of Total Billed Charges,39.2,45,,6307.928,Percent of Total Billed Charges,45% of Total Billed Charges,78.39,90,,27107.472,Percent of Total Billed Charges,90% of Total billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.62,65,,896.072,Percent of total Billed Charges,65% of Total Billed Charges,38.41,44.1,,6181.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.75,95,,28613.448,Percent of Total Billed Charges,95% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.65,88,,3473.32,Percent of Total Billed Charges,88% of Total Billed Charges,78.39,90,,27107.472,Percent of Total Billed charges,90% of Total Billed Charges,38.41,87.1,
Z02000261.309 NCB T,2780000598,CDM,278,RC,C1713,HCPCS,Outpatient,,,6745.10,4384.32,,6745.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5126.28,76,,4660.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4856.47,72,,3394.928,Percent of Total Billed Charges,72% of Total Billed Charges,4856.47,72,,3394.928,Percent of Total Billed charges,72% of Total Billed Charges,6745.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4856.47,72,,3394.928,Percent of Total Billed Charges,72% of Total Billed Charges,4047.06,60,,2829.104,Percent of Total Billed Charges,60% of Total Billed Charges,6070.59,90,,233.384,Percent of Total Billed Charges,90% of Total Billed Charges,3035.3,45,,215.52,Percent of Total Billed Charges,45% of Total Billed Charges,6070.59,90,,5519.288,Percent of Total Billed Charges,90% of Total billed Charges,6745.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6745.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6745.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4384.32,65,,32.68,Percent of total Billed Charges,65% of Total Billed Charges,2974.59,44.1,,211.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,6407.85,95,,5825.92,Percent of Total Billed Charges,95% of Total Billed Charges,6745.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5935.69,88,,413.688,Percent of Total Billed Charges,88% of Total Billed Charges,6070.59,90,,5519.288,Percent of Total Billed charges,90% of Total Billed Charges,2974.59,6745.1,
Z0203152.060 5.0 CA,2780000599,CDM,278,RC,C1713,HCPCS,Outpatient,,,687.96,447.17,,687.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,522.85,76,,2799.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,495.33,72,,331.2,Percent of Total Billed Charges,72% of Total Billed Charges,495.33,72,,331.2,Percent of Total Billed charges,72% of Total Billed Charges,687.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495.33,72,,331.2,Percent of Total Billed Charges,72% of Total Billed Charges,412.78,60,,276,Percent of Total Billed Charges,60% of Total Billed Charges,619.16,90,,689.808,Percent of Total Billed Charges,90% of Total Billed Charges,309.58,45,,1776.128,Percent of Total Billed Charges,45% of Total Billed Charges,619.16,90,,3314.912,Percent of Total Billed Charges,90% of Total billed Charges,687.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,687.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,687.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,447.17,65,,3420.88,Percent of total Billed Charges,65% of Total Billed Charges,303.39,44.1,,1740.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,653.56,95,,3499.072,Percent of Total Billed Charges,95% of Total Billed Charges,687.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,605.4,88,,3642.52,Percent of Total Billed Charges,88% of Total Billed Charges,619.16,90,,3314.912,Percent of Total Billed charges,90% of Total Billed Charges,303.39,687.96,
Z0203152.070 5.0 CA,2780000600,CDM,278,RC,C1713,HCPCS,Outpatient,,,687.96,447.17,,687.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,522.85,76,,10653.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,495.33,72,,51.264,Percent of Total Billed Charges,72% of Total Billed Charges,495.33,72,,51.264,Percent of Total Billed charges,72% of Total Billed Charges,687.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495.33,72,,51.264,Percent of Total Billed Charges,72% of Total Billed Charges,412.78,60,,42.72,Percent of Total Billed Charges,60% of Total Billed Charges,619.16,90,,1835.264,Percent of Total Billed Charges,90% of Total Billed Charges,309.58,45,,211.544,Percent of Total Billed Charges,45% of Total Billed Charges,619.16,90,,12615.864,Percent of Total Billed Charges,90% of Total billed Charges,687.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,687.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,687.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,447.17,65,,788.288,Percent of total Billed Charges,65% of Total Billed Charges,303.39,44.1,,207.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,653.56,95,,13316.744,Percent of Total Billed Charges,95% of Total Billed Charges,687.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,605.4,88,,52.776,Percent of Total Billed Charges,88% of Total Billed Charges,619.16,90,,12615.864,Percent of Total Billed charges,90% of Total Billed Charges,303.39,687.96,
Z0203155.046 4.0 CO,2780000601,CDM,278,RC,C1713,HCPCS,Outpatient,,,501.64,326.07,,501.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,381.25,76,,363.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,361.18,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,361.18,72,,15.872,Percent of Total Billed charges,72% of Total Billed Charges,501.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.18,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,300.98,60,,13.232,Percent of Total Billed Charges,60% of Total Billed Charges,451.48,90,,399.28,Percent of Total Billed Charges,90% of Total Billed Charges,225.74,45,,1862.648,Percent of Total Billed Charges,45% of Total Billed Charges,451.48,90,,431.032,Percent of Total Billed Charges,90% of Total billed Charges,501.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.07,65,,725.8,Percent of total Billed Charges,65% of Total Billed Charges,221.22,44.1,,1825.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,476.56,95,,454.984,Percent of Total Billed Charges,95% of Total Billed Charges,501.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,441.44,88,,524.688,Percent of Total Billed Charges,88% of Total Billed Charges,451.48,90,,431.032,Percent of Total Billed charges,90% of Total Billed Charges,221.22,501.64,
Z103.25.180 2.5 DRIL,2780000602,CDM,278,RC,C1713,HCPCS,Outpatient,,,194.04,126.13,,194.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,147.47,76,,2999.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,139.71,72,,341.656,Percent of Total Billed Charges,72% of Total Billed Charges,139.71,72,,341.656,Percent of Total Billed charges,72% of Total Billed Charges,194.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.71,72,,341.656,Percent of Total Billed Charges,72% of Total Billed Charges,116.42,60,,284.712,Percent of Total Billed Charges,60% of Total Billed Charges,174.64,90,,62.712,Percent of Total Billed Charges,90% of Total Billed Charges,87.32,45,,26.992,Percent of Total Billed Charges,45% of Total Billed Charges,174.64,90,,3552.256,Percent of Total Billed Charges,90% of Total billed Charges,194.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.13,65,,446.6,Percent of total Billed Charges,65% of Total Billed Charges,85.57,44.1,,26.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,184.34,95,,3749.608,Percent of Total Billed Charges,95% of Total Billed Charges,194.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.76,88,,228.192,Percent of Total Billed Charges,88% of Total Billed Charges,174.64,90,,3552.256,Percent of Total Billed charges,90% of Total Billed Charges,85.57,194.04,
ZD2.00024.133 3.3 DR,2780000603,CDM,278,RC,C1713,HCPCS,Outpatient,,,542.43,352.58,,542.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,412.25,76,,357.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,390.55,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,390.55,72,,11.432,Percent of Total Billed charges,72% of Total Billed Charges,542.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.55,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,325.46,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,488.19,90,,3414.928,Percent of Total Billed Charges,90% of Total Billed Charges,244.09,45,,268.304,Percent of Total Billed Charges,45% of Total Billed Charges,488.19,90,,423.096,Percent of Total Billed Charges,90% of Total billed Charges,542.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,542.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,542.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.58,65,,29.808,Percent of total Billed Charges,65% of Total Billed Charges,239.21,44.1,,262.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,515.31,95,,446.6,Percent of Total Billed Charges,95% of Total Billed Charges,542.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,477.34,88,,228.192,Percent of Total Billed Charges,88% of Total Billed Charges,488.19,90,,423.096,Percent of Total Billed charges,90% of Total Billed Charges,239.21,542.43,
Z23480906 ULNA PLA,2780000604,CDM,278,RC,C1713,HCPCS,Outpatient,,,3306.40,2149.16,,3306.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2512.86,76,,3145.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2380.61,72,,1227.528,Percent of Total Billed Charges,72% of Total Billed Charges,2380.61,72,,1227.528,Percent of Total Billed charges,72% of Total Billed Charges,3306.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2380.61,72,,1227.528,Percent of Total Billed Charges,72% of Total Billed Charges,1983.84,60,,1022.944,Percent of Total Billed Charges,60% of Total Billed Charges,2975.76,90,,2377.432,Percent of Total Billed Charges,90% of Total Billed Charges,1487.88,45,,116.688,Percent of Total Billed Charges,45% of Total Billed Charges,2975.76,90,,3725.304,Percent of Total Billed Charges,90% of Total billed Charges,3306.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3306.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3306.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2149.16,65,,227.6,Percent of total Billed Charges,65% of Total Billed Charges,1458.12,44.1,,114.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,3141.08,95,,3932.264,Percent of Total Billed Charges,95% of Total Billed Charges,3306.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2909.63,88,,674.48,Percent of Total Billed Charges,88% of Total Billed Charges,2975.76,90,,3725.304,Percent of Total Billed charges,90% of Total Billed Charges,1458.12,3306.4,
Z23483035 3.5 CORT,2780000605,CDM,278,RC,C1713,HCPCS,Outpatient,,,149.94,97.46,,149.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,113.95,76,,45.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,107.96,72,,482.632,Percent of Total Billed Charges,72% of Total Billed Charges,107.96,72,,482.632,Percent of Total Billed charges,72% of Total Billed Charges,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.96,72,,482.632,Percent of Total Billed Charges,72% of Total Billed Charges,89.96,60,,402.192,Percent of Total Billed Charges,60% of Total Billed Charges,134.95,90,,3199.808,Percent of Total Billed Charges,90% of Total Billed Charges,67.47,45,,116.688,Percent of Total Billed Charges,45% of Total Billed Charges,134.95,90,,53.976,Percent of Total Billed Charges,90% of Total billed Charges,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.46,65,,456.92,Percent of total Billed Charges,65% of Total Billed Charges,66.12,44.1,,114.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.44,95,,56.976,Percent of Total Billed Charges,95% of Total Billed Charges,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.95,88,,1794.48,Percent of Total Billed Charges,88% of Total Billed Charges,134.95,90,,53.976,Percent of Total Billed charges,90% of Total Billed Charges,66.12,149.94,
Z49012015,2780000606,CDM,278,RC,C1713,HCPCS,Outpatient,,,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,453.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.94,72,,349.912,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,72,,349.912,Percent of Total Billed charges,72% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.94,72,,349.912,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,60,,291.592,Percent of Total Billed Charges,60% of Total Billed Charges,9.93,90,,3414.928,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,344.904,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,536.608,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,442.016,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,338.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,566.424,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,390.408,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,536.608,Percent of Total Billed charges,90% of Total Billed Charges,4.86,11.03,
Z493601007 3.5 LOC,2780000607,CDM,278,RC,C1713,HCPCS,Outpatient,,,1612.96,1048.42,,1612.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1225.85,76,,197.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1161.33,72,,349.912,Percent of Total Billed Charges,72% of Total Billed Charges,1161.33,72,,349.912,Percent of Total Billed charges,72% of Total Billed Charges,1612.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1161.33,72,,349.912,Percent of Total Billed Charges,72% of Total Billed Charges,967.78,60,,291.592,Percent of Total Billed Charges,60% of Total Billed Charges,1451.66,90,,3876.92,Percent of Total Billed Charges,90% of Total Billed Charges,725.83,45,,917.632,Percent of Total Billed Charges,45% of Total Billed Charges,1451.66,90,,233.384,Percent of Total Billed Charges,90% of Total billed Charges,1612.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1612.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1612.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1048.42,65,,5571.336,Percent of total Billed Charges,65% of Total Billed Charges,711.32,44.1,,899.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,1532.31,95,,246.344,Percent of Total Billed Charges,95% of Total Billed Charges,1612.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1419.4,88,,61.32,Percent of Total Billed Charges,88% of Total Billed Charges,1451.66,90,,233.384,Percent of Total Billed charges,90% of Total Billed Charges,711.32,1612.96,
Z24802840 4.0 PT S,2780000608,CDM,278,RC,C1713,HCPCS,Outpatient,,,238.14,154.79,,238.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,180.99,76,,197.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,171.46,72,,349.912,Percent of Total Billed Charges,72% of Total Billed Charges,171.46,72,,349.912,Percent of Total Billed charges,72% of Total Billed Charges,238.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.46,72,,349.912,Percent of Total Billed Charges,72% of Total Billed Charges,142.88,60,,291.592,Percent of Total Billed Charges,60% of Total Billed Charges,214.33,90,,4736.608,Percent of Total Billed Charges,90% of Total Billed Charges,107.16,45,,199.64,Percent of Total Billed Charges,45% of Total Billed Charges,214.33,90,,233.384,Percent of Total Billed Charges,90% of Total billed Charges,238.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.79,65,,2301.8,Percent of total Billed Charges,65% of Total Billed Charges,105.02,44.1,,195.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,226.23,95,,246.344,Percent of Total Billed Charges,95% of Total Billed Charges,238.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.56,88,,3339.04,Percent of Total Billed Charges,88% of Total Billed Charges,214.33,90,,233.384,Percent of Total Billed charges,90% of Total Billed Charges,105.02,238.14,
Z483502001 3.5 COR,2780000609,CDM,278,RC,C1713,HCPCS,Outpatient,,,97.02,63.06,,97.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.74,76,,582.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.85,72,,372.096,Percent of Total Billed Charges,72% of Total Billed Charges,69.85,72,,372.096,Percent of Total Billed charges,72% of Total Billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.85,72,,372.096,Percent of Total Billed Charges,72% of Total Billed Charges,58.21,60,,310.08,Percent of Total Billed Charges,60% of Total Billed Charges,87.32,90,,618.376,Percent of Total Billed Charges,90% of Total Billed Charges,43.66,45,,31.36,Percent of Total Billed Charges,45% of Total Billed Charges,87.32,90,,689.808,Percent of Total Billed Charges,90% of Total billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,65,,3833.088,Percent of total Billed Charges,65% of Total Billed Charges,42.79,44.1,,30.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,92.17,95,,728.136,Percent of Total Billed Charges,95% of Total Billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.38,88,,2324.6,Percent of Total Billed Charges,88% of Total Billed Charges,87.32,90,,689.808,Percent of Total Billed charges,90% of Total Billed Charges,42.79,97.02,
Z483502201 3.5 COR,2780000610,CDM,278,RC,C1713,HCPCS,Outpatient,,,97.02,63.06,,97.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.74,76,,1549.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.85,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,69.85,72,,227.344,Percent of Total Billed charges,72% of Total Billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.85,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,58.21,60,,189.456,Percent of Total Billed Charges,60% of Total Billed Charges,87.32,90,,1484.408,Percent of Total Billed Charges,90% of Total Billed Charges,43.66,45,,1707.464,Percent of Total Billed Charges,45% of Total Billed Charges,87.32,90,,1835.264,Percent of Total Billed Charges,90% of Total billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,65,,3833.088,Percent of total Billed Charges,65% of Total Billed Charges,42.79,44.1,,1673.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,92.17,95,,1937.224,Percent of Total Billed Charges,95% of Total Billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.38,88,,3128.704,Percent of Total Billed Charges,88% of Total Billed Charges,87.32,90,,1835.264,Percent of Total Billed charges,90% of Total Billed Charges,42.79,97.02,
Z249005443 DRILL B,2780000611,CDM,278,RC,C1713,HCPCS,Outpatient,,,318.62,207.10,,318.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,242.15,76,,337.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,229.41,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,229.41,72,,227.344,Percent of Total Billed charges,72% of Total Billed Charges,318.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.41,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,191.17,60,,189.456,Percent of Total Billed Charges,60% of Total Billed Charges,286.76,90,,4736.608,Percent of Total Billed Charges,90% of Total Billed Charges,143.38,45,,1188.72,Percent of Total Billed Charges,45% of Total Billed Charges,286.76,90,,399.28,Percent of Total Billed Charges,90% of Total billed Charges,318.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.1,65,,29.808,Percent of total Billed Charges,65% of Total Billed Charges,140.51,44.1,,1164.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,302.69,95,,421.464,Percent of Total Billed Charges,95% of Total Billed Charges,318.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280.39,88,,3339.04,Percent of Total Billed Charges,88% of Total Billed Charges,286.76,90,,399.28,Percent of Total Billed charges,90% of Total Billed Charges,140.51,318.62,
Z249007243 DRILL B,2780000612,CDM,278,RC,C1713,HCPCS,Outpatient,,,388.08,252.25,,388.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,294.94,76,,52.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,279.42,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,279.42,72,,227.344,Percent of Total Billed charges,72% of Total Billed Charges,388.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279.42,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,232.85,60,,189.456,Percent of Total Billed Charges,60% of Total Billed Charges,349.27,90,,4736.608,Percent of Total Billed Charges,90% of Total Billed Charges,174.64,45,,1599.904,Percent of Total Billed Charges,45% of Total Billed Charges,349.27,90,,62.712,Percent of Total Billed Charges,90% of Total billed Charges,388.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,388.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,388.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.25,65,,3196.72,Percent of total Billed Charges,65% of Total Billed Charges,171.14,44.1,,1567.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,368.68,95,,66.2,Percent of Total Billed Charges,95% of Total Billed Charges,388.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.51,88,,3790.768,Percent of Total Billed Charges,88% of Total Billed Charges,349.27,90,,62.712,Percent of Total Billed charges,90% of Total Billed Charges,171.14,388.08,
Z47248403250 5.0X,2780000613,CDM,278,RC,C1713,HCPCS,Outpatient,,,999.97,649.98,,999.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,759.98,76,,2883.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,719.98,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,719.98,72,,227.344,Percent of Total Billed charges,72% of Total Billed Charges,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,719.98,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,599.98,60,,189.456,Percent of Total Billed Charges,60% of Total Billed Charges,899.97,90,,807.296,Percent of Total Billed Charges,90% of Total Billed Charges,449.99,45,,1707.464,Percent of Total Billed Charges,45% of Total Billed Charges,899.97,90,,3414.928,Percent of Total Billed Charges,90% of Total billed Charges,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649.98,65,,856.512,Percent of total Billed Charges,65% of Total Billed Charges,440.99,44.1,,1673.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,949.97,95,,3604.648,Percent of Total Billed Charges,95% of Total Billed Charges,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,879.97,88,,4631.352,Percent of Total Billed Charges,88% of Total Billed Charges,899.97,90,,3414.928,Percent of Total Billed charges,90% of Total Billed Charges,440.99,999.97,
Z47248403050 5.0X,2780000614,CDM,278,RC,C1713,HCPCS,Outpatient,,,999.97,649.98,,999.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,759.98,76,,2007.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,719.98,72,,4743.752,Percent of Total Billed Charges,72% of Total Billed Charges,719.98,72,,4743.752,Percent of Total Billed charges,72% of Total Billed Charges,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,719.98,72,,4743.752,Percent of Total Billed Charges,72% of Total Billed Charges,599.98,60,,3953.128,Percent of Total Billed Charges,60% of Total Billed Charges,899.97,90,,1240.712,Percent of Total Billed Charges,90% of Total Billed Charges,449.99,45,,1938.456,Percent of Total Billed Charges,45% of Total Billed Charges,899.97,90,,2377.432,Percent of Total Billed Charges,90% of Total billed Charges,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649.98,65,,43.568,Percent of total Billed Charges,65% of Total Billed Charges,440.99,44.1,,1899.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,949.97,95,,2509.512,Percent of Total Billed Charges,95% of Total Billed Charges,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,879.97,88,,604.632,Percent of Total Billed Charges,88% of Total Billed Charges,899.97,90,,2377.432,Percent of Total Billed charges,90% of Total Billed Charges,440.99,999.97,
Z47248402250 5.0X,2780000615,CDM,278,RC,C1713,HCPCS,Outpatient,,,999.97,649.98,,999.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,759.98,76,,2702.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,719.98,72,,7792.576,Percent of Total Billed Charges,72% of Total Billed Charges,719.98,72,,7792.576,Percent of Total Billed charges,72% of Total Billed Charges,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,719.98,72,,7792.576,Percent of Total Billed Charges,72% of Total Billed Charges,599.98,60,,6493.816,Percent of Total Billed Charges,60% of Total Billed Charges,899.97,90,,45.248,Percent of Total Billed Charges,90% of Total Billed Charges,449.99,45,,2368.304,Percent of Total Billed Charges,45% of Total Billed Charges,899.97,90,,3199.808,Percent of Total Billed Charges,90% of Total billed Charges,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649.98,65,,144.472,Percent of total Billed Charges,65% of Total Billed Charges,440.99,44.1,,2320.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,949.97,95,,3377.576,Percent of Total Billed Charges,95% of Total Billed Charges,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,879.97,88,,1451.424,Percent of Total Billed Charges,88% of Total Billed Charges,899.97,90,,3199.808,Percent of Total Billed charges,90% of Total Billed Charges,440.99,999.97,
Z47248403550 5.0X,2780000616,CDM,278,RC,C1713,HCPCS,Outpatient,,,999.97,649.98,,999.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,759.98,76,,2883.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,719.98,72,,3100.904,Percent of Total Billed Charges,72% of Total Billed Charges,719.98,72,,3100.904,Percent of Total Billed charges,72% of Total Billed Charges,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,719.98,72,,3100.904,Percent of Total Billed Charges,72% of Total Billed Charges,599.98,60,,2584.088,Percent of Total Billed Charges,60% of Total Billed Charges,899.97,90,,4736.608,Percent of Total Billed Charges,90% of Total Billed Charges,449.99,45,,309.184,Percent of Total Billed Charges,45% of Total Billed Charges,899.97,90,,3414.928,Percent of Total Billed Charges,90% of Total billed Charges,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649.98,65,,1004.992,Percent of total Billed Charges,65% of Total Billed Charges,440.99,44.1,,303,Percent of Total Billed Charges,44.1% of Total Billed Charges,949.97,95,,3604.648,Percent of Total Billed Charges,95% of Total Billed Charges,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,879.97,88,,4631.352,Percent of Total Billed Charges,88% of Total Billed Charges,899.97,90,,3414.928,Percent of Total Billed charges,90% of Total Billed Charges,440.99,999.97,
Z47248404550 5.0X,2780000617,CDM,278,RC,C1713,HCPCS,Outpatient,,,999.97,649.98,,999.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,759.98,76,,3273.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,719.98,72,,101.608,Percent of Total Billed Charges,72% of Total Billed Charges,719.98,72,,101.608,Percent of Total Billed charges,72% of Total Billed Charges,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,719.98,72,,101.608,Percent of Total Billed Charges,72% of Total Billed Charges,599.98,60,,84.672,Percent of Total Billed Charges,60% of Total Billed Charges,899.97,90,,1091.48,Percent of Total Billed Charges,90% of Total Billed Charges,449.99,45,,742.208,Percent of Total Billed Charges,45% of Total Billed Charges,899.97,90,,3876.92,Percent of Total Billed Charges,90% of Total billed Charges,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649.98,65,,90.008,Percent of total Billed Charges,65% of Total Billed Charges,440.99,44.1,,727.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,949.97,95,,4092.304,Percent of Total Billed Charges,95% of Total Billed Charges,999.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,879.97,88,,4631.352,Percent of Total Billed Charges,88% of Total Billed Charges,899.97,90,,3876.92,Percent of Total Billed charges,90% of Total Billed Charges,440.99,999.97,
Z47249530011 TIB.,2780000618,CDM,278,RC,C1713,HCPCS,Outpatient,,,8484.84,5515.15,,8484.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6448.48,76,,3999.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6109.08,72,,140.544,Percent of Total Billed Charges,72% of Total Billed Charges,6109.08,72,,140.544,Percent of Total Billed charges,72% of Total Billed Charges,8484.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6109.08,72,,140.544,Percent of Total Billed Charges,72% of Total Billed Charges,5090.9,60,,117.12,Percent of Total Billed Charges,60% of Total Billed Charges,7636.36,90,,1004.952,Percent of Total Billed Charges,90% of Total Billed Charges,3818.18,45,,2368.304,Percent of Total Billed Charges,45% of Total Billed Charges,7636.36,90,,4736.608,Percent of Total Billed Charges,90% of Total billed Charges,8484.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8484.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8484.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5515.15,65,,3678.296,Percent of total Billed Charges,65% of Total Billed Charges,3741.81,44.1,,2320.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,8060.6,95,,4999.752,Percent of Total Billed Charges,95% of Total Billed Charges,8484.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7466.66,88,,789.352,Percent of Total Billed Charges,88% of Total Billed Charges,7636.36,90,,4736.608,Percent of Total Billed charges,90% of Total Billed Charges,3741.81,8484.84,
Z49350803 TUB. PLA,2780000619,CDM,278,RC,C1713,HCPCS,Outpatient,,,289.96,188.47,,289.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,220.37,76,,522.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,208.77,72,,227.984,Percent of Total Billed Charges,72% of Total Billed Charges,208.77,72,,227.984,Percent of Total Billed charges,72% of Total Billed Charges,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.77,72,,227.984,Percent of Total Billed Charges,72% of Total Billed Charges,173.98,60,,189.984,Percent of Total Billed Charges,60% of Total Billed Charges,260.96,90,,618.376,Percent of Total Billed Charges,90% of Total Billed Charges,130.48,45,,2368.304,Percent of Total Billed Charges,45% of Total Billed Charges,260.96,90,,618.376,Percent of Total Billed Charges,90% of Total billed Charges,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.47,65,,2863.064,Percent of total Billed Charges,65% of Total Billed Charges,127.87,44.1,,2320.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,275.46,95,,652.728,Percent of Total Billed Charges,95% of Total Billed Charges,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.16,88,,1213.136,Percent of Total Billed Charges,88% of Total Billed Charges,260.96,90,,618.376,Percent of Total Billed charges,90% of Total Billed Charges,127.87,289.96,
Z23570710 DIS/MEDT,2780000620,CDM,278,RC,C1713,HCPCS,Outpatient,,,6704.30,4357.80,,6704.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5095.27,76,,1253.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4827.1,72,,2906.576,Percent of Total Billed Charges,72% of Total Billed Charges,4827.1,72,,2906.576,Percent of Total Billed charges,72% of Total Billed Charges,6704.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4827.1,72,,2906.576,Percent of Total Billed Charges,72% of Total Billed Charges,4022.58,60,,2422.144,Percent of Total Billed Charges,60% of Total Billed Charges,6033.87,90,,41.28,Percent of Total Billed Charges,90% of Total Billed Charges,3016.94,45,,403.648,Percent of Total Billed Charges,45% of Total Billed Charges,6033.87,90,,1484.408,Percent of Total Billed Charges,90% of Total billed Charges,6704.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6704.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6704.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4357.8,65,,290.664,Percent of total Billed Charges,65% of Total Billed Charges,2956.6,44.1,,395.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,6369.09,95,,1566.88,Percent of Total Billed Charges,95% of Total Billed Charges,6704.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5899.78,88,,44.24,Percent of Total Billed Charges,88% of Total Billed Charges,6033.87,90,,1484.408,Percent of Total Billed charges,90% of Total Billed Charges,2956.6,6704.3,
Z493510 3.5 COMP. P,2780000621,CDM,278,RC,C1713,HCPCS,Outpatient,,,594.25,386.26,,594.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,451.63,76,,3999.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,427.86,72,,335.936,Percent of Total Billed Charges,72% of Total Billed Charges,427.86,72,,335.936,Percent of Total Billed charges,72% of Total Billed Charges,594.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.86,72,,335.936,Percent of Total Billed Charges,72% of Total Billed Charges,356.55,60,,279.944,Percent of Total Billed Charges,60% of Total Billed Charges,534.83,90,,315.136,Percent of Total Billed Charges,90% of Total Billed Charges,267.41,45,,620.352,Percent of Total Billed Charges,45% of Total Billed Charges,534.83,90,,4736.608,Percent of Total Billed Charges,90% of Total billed Charges,594.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,594.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,594.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.26,65,,2863.064,Percent of total Billed Charges,65% of Total Billed Charges,262.06,44.1,,607.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,564.54,95,,4999.752,Percent of Total Billed Charges,95% of Total Billed Charges,594.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,522.94,88,,4631.352,Percent of Total Billed Charges,88% of Total Billed Charges,534.83,90,,4736.608,Percent of Total Billed charges,90% of Total Billed Charges,262.06,594.25,
Z23595035 3.5 LOCK,2780000622,CDM,278,RC,C1713,HCPCS,Outpatient,,,475.18,308.87,,475.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,361.14,76,,3999.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,342.13,72,,335.936,Percent of Total Billed Charges,72% of Total Billed Charges,342.13,72,,335.936,Percent of Total Billed charges,72% of Total Billed Charges,475.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.13,72,,335.936,Percent of Total Billed Charges,72% of Total Billed Charges,285.11,60,,279.944,Percent of Total Billed Charges,60% of Total Billed Charges,427.66,90,,632.656,Percent of Total Billed Charges,90% of Total Billed Charges,213.83,45,,22.624,Percent of Total Billed Charges,45% of Total Billed Charges,427.66,90,,4736.608,Percent of Total Billed Charges,90% of Total billed Charges,475.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.87,65,,3678.296,Percent of total Billed Charges,65% of Total Billed Charges,209.55,44.1,,22.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,451.42,95,,4999.752,Percent of Total Billed Charges,95% of Total Billed Charges,475.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,418.16,88,,1067.224,Percent of Total Billed Charges,88% of Total Billed Charges,427.66,90,,4736.608,Percent of Total Billed charges,90% of Total Billed Charges,209.55,475.18,
Z483501201 3.5 COR,2780000623,CDM,278,RC,C1713,HCPCS,Outpatient,,,98.12,63.78,,98.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,74.57,76,,681.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,70.65,72,,335.936,Percent of Total Billed Charges,72% of Total Billed Charges,70.65,72,,335.936,Percent of Total Billed charges,72% of Total Billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.65,72,,335.936,Percent of Total Billed Charges,72% of Total Billed Charges,58.87,60,,279.944,Percent of Total Billed Charges,60% of Total Billed Charges,88.31,90,,612.024,Percent of Total Billed Charges,90% of Total Billed Charges,44.15,45,,2368.304,Percent of Total Billed Charges,45% of Total Billed Charges,88.31,90,,807.296,Percent of Total Billed Charges,90% of Total billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.78,65,,3579.688,Percent of total Billed Charges,65% of Total Billed Charges,43.27,44.1,,2320.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,93.21,95,,852.144,Percent of Total Billed Charges,95% of Total Billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.35,88,,982.624,Percent of Total Billed Charges,88% of Total Billed Charges,88.31,90,,807.296,Percent of Total Billed charges,90% of Total Billed Charges,43.27,98.12,
Z483503201 3.5 COR,2780000624,CDM,278,RC,C1713,HCPCS,Outpatient,,,98.12,63.78,,98.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,74.57,76,,1047.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,70.65,72,,288.944,Percent of Total Billed Charges,72% of Total Billed Charges,70.65,72,,288.944,Percent of Total Billed charges,72% of Total Billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.65,72,,288.944,Percent of Total Billed Charges,72% of Total Billed Charges,58.87,60,,240.784,Percent of Total Billed Charges,60% of Total Billed Charges,88.31,90,,7714.152,Percent of Total Billed Charges,90% of Total Billed Charges,44.15,45,,545.736,Percent of Total Billed Charges,45% of Total Billed Charges,88.31,90,,1240.712,Percent of Total Billed Charges,90% of Total billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.78,65,,11217.192,Percent of total Billed Charges,65% of Total Billed Charges,43.27,44.1,,534.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,93.21,95,,1309.64,Percent of Total Billed Charges,95% of Total Billed Charges,98.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.35,88,,604.632,Percent of Total Billed Charges,88% of Total Billed Charges,88.31,90,,1240.712,Percent of Total Billed charges,90% of Total Billed Charges,43.27,98.12,
Z48400124.0 CANN S,2780000625,CDM,278,RC,C1713,HCPCS,Outpatient,,,76.07,49.45,,76.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,57.81,76,,38.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,54.77,72,,10447.048,Percent of Total Billed Charges,72% of Total Billed Charges,54.77,72,,10447.048,Percent of Total Billed charges,72% of Total Billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.77,72,,10447.048,Percent of Total Billed Charges,72% of Total Billed Charges,45.64,60,,8705.872,Percent of Total Billed Charges,60% of Total Billed Charges,68.46,90,,3187.112,Percent of Total Billed Charges,90% of Total Billed Charges,34.23,45,,502.48,Percent of Total Billed Charges,45% of Total Billed Charges,68.46,90,,45.248,Percent of Total Billed Charges,90% of Total billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.45,65,,3094.096,Percent of total Billed Charges,65% of Total Billed Charges,33.55,44.1,,492.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,72.27,95,,47.76,Percent of Total Billed Charges,95% of Total Billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.94,88,,40.36,Percent of Total Billed Charges,88% of Total Billed Charges,68.46,90,,45.248,Percent of Total Billed charges,90% of Total Billed Charges,33.55,76.07,
Z48400144.0 CANN.,2780000626,CDM,278,RC,C1713,HCPCS,Outpatient,,,76.07,49.45,,76.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,57.81,76,,3999.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,54.77,72,,657.904,Percent of Total Billed Charges,72% of Total Billed Charges,54.77,72,,657.904,Percent of Total Billed charges,72% of Total Billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.77,72,,657.904,Percent of Total Billed Charges,72% of Total Billed Charges,45.64,60,,548.248,Percent of Total Billed Charges,60% of Total Billed Charges,68.46,90,,5307.352,Percent of Total Billed Charges,90% of Total Billed Charges,34.23,45,,309.184,Percent of Total Billed Charges,45% of Total Billed Charges,68.46,90,,4736.608,Percent of Total Billed Charges,90% of Total billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.45,65,,2456.592,Percent of total Billed Charges,65% of Total Billed Charges,33.55,44.1,,303,Percent of Total Billed Charges,44.1% of Total Billed Charges,72.27,95,,4999.752,Percent of Total Billed Charges,95% of Total Billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.94,88,,308.136,Percent of Total Billed Charges,88% of Total Billed Charges,68.46,90,,4736.608,Percent of Total Billed charges,90% of Total Billed Charges,33.55,76.07,
Z48400164.0 CANN S,2780000627,CDM,278,RC,C1713,HCPCS,Outpatient,,,76.07,49.45,,76.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,57.81,76,,921.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,54.77,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,54.77,72,,14.608,Percent of Total Billed charges,72% of Total Billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.77,72,,14.608,Percent of Total Billed Charges,72% of Total Billed Charges,45.64,60,,12.176,Percent of Total Billed Charges,60% of Total Billed Charges,68.46,90,,5307.352,Percent of Total Billed Charges,90% of Total Billed Charges,34.23,45,,20.64,Percent of Total Billed Charges,45% of Total Billed Charges,68.46,90,,1091.48,Percent of Total Billed Charges,90% of Total billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.45,65,,3094.096,Percent of total Billed Charges,65% of Total Billed Charges,33.55,44.1,,20.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,72.27,95,,1152.112,Percent of Total Billed Charges,95% of Total Billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.94,88,,618.6,Percent of Total Billed Charges,88% of Total Billed Charges,68.46,90,,1091.48,Percent of Total Billed charges,90% of Total Billed Charges,33.55,76.07,
Z11473840 4.0 CANN,2780000628,CDM,278,RC,C1713,HCPCS,Outpatient,,,759.62,493.75,,759.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,577.31,76,,848.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,546.93,72,,1227.528,Percent of Total Billed Charges,72% of Total Billed Charges,546.93,72,,1227.528,Percent of Total Billed charges,72% of Total Billed Charges,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.93,72,,1227.528,Percent of Total Billed Charges,72% of Total Billed Charges,455.77,60,,1022.944,Percent of Total Billed Charges,60% of Total Billed Charges,683.66,90,,41.28,Percent of Total Billed Charges,90% of Total Billed Charges,341.83,45,,157.568,Percent of Total Billed Charges,45% of Total Billed Charges,683.66,90,,1004.952,Percent of Total Billed Charges,90% of Total billed Charges,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.75,65,,11058.96,Percent of total Billed Charges,65% of Total Billed Charges,334.99,44.1,,154.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,721.64,95,,1060.784,Percent of Total Billed Charges,95% of Total Billed Charges,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,668.47,88,,598.424,Percent of Total Billed Charges,88% of Total Billed Charges,683.66,90,,1004.952,Percent of Total Billed charges,90% of Total Billed Charges,334.99,759.62,
Z11474240 4.0CANN,2780000629,CDM,278,RC,C1713,HCPCS,Outpatient,,,759.62,493.75,,759.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,577.31,76,,522.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,546.93,72,,5284.808,Percent of Total Billed Charges,72% of Total Billed Charges,546.93,72,,5284.808,Percent of Total Billed charges,72% of Total Billed Charges,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.93,72,,5284.808,Percent of Total Billed Charges,72% of Total Billed Charges,455.77,60,,4404.008,Percent of Total Billed Charges,60% of Total Billed Charges,683.66,90,,4426.232,Percent of Total Billed Charges,90% of Total Billed Charges,341.83,45,,316.328,Percent of Total Billed Charges,45% of Total Billed Charges,683.66,90,,618.376,Percent of Total Billed Charges,90% of Total billed Charges,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.75,65,,2863.064,Percent of total Billed Charges,65% of Total Billed Charges,334.99,44.1,,310,Percent of Total Billed Charges,44.1% of Total Billed Charges,721.64,95,,652.728,Percent of Total Billed Charges,95% of Total Billed Charges,759.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,668.47,88,,7542.728,Percent of Total Billed Charges,88% of Total Billed Charges,683.66,90,,618.376,Percent of Total Billed charges,90% of Total Billed Charges,334.99,759.62,
SYNTHES OSCALATING,2780000630,CDM,278,RC,C1713,HCPCS,Outpatient,,,163.17,106.06,,163.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.01,76,,34.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,117.48,72,,3279.984,Percent of Total Billed Charges,72% of Total Billed Charges,117.48,72,,3279.984,Percent of Total Billed charges,72% of Total Billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.48,72,,3279.984,Percent of Total Billed Charges,72% of Total Billed Charges,97.9,60,,2733.32,Percent of Total Billed Charges,60% of Total Billed Charges,146.85,90,,1185.944,Percent of Total Billed Charges,90% of Total Billed Charges,73.43,45,,306.008,Percent of Total Billed Charges,45% of Total Billed Charges,146.85,90,,41.28,Percent of Total Billed Charges,90% of Total billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.06,65,,4985.992,Percent of total Billed Charges,65% of Total Billed Charges,71.96,44.1,,299.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,155.01,95,,43.568,Percent of Total Billed Charges,95% of Total Billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.59,88,,3116.288,Percent of Total Billed Charges,88% of Total Billed Charges,146.85,90,,41.28,Percent of Total Billed charges,90% of Total Billed Charges,71.96,163.17,
SYNTHES SAW BLADE,2780000631,CDM,278,RC,C1713,HCPCS,Outpatient,,,390.29,253.69,,390.29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,296.62,76,,266.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,281.01,72,,11890.488,Percent of Total Billed Charges,72% of Total Billed Charges,281.01,72,,11890.488,Percent of Total Billed charges,72% of Total Billed Charges,390.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,281.01,72,,11890.488,Percent of Total Billed Charges,72% of Total Billed Charges,234.17,60,,9908.744,Percent of Total Billed Charges,60% of Total Billed Charges,351.26,90,,60.328,Percent of Total Billed Charges,90% of Total Billed Charges,175.63,45,,3857.08,Percent of Total Billed Charges,45% of Total Billed Charges,351.26,90,,315.136,Percent of Total Billed Charges,90% of Total billed Charges,390.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,253.69,65,,1770.92,Percent of total Billed Charges,65% of Total Billed Charges,172.12,44.1,,3779.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,370.78,95,,332.648,Percent of Total Billed Charges,95% of Total Billed Charges,390.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.46,88,,5189.408,Percent of Total Billed Charges,88% of Total Billed Charges,351.26,90,,315.136,Percent of Total Billed charges,90% of Total Billed Charges,172.12,390.29,
SYNTHES RECIPROCATIN,2780000632,CDM,278,RC,C1713,HCPCS,Outpatient,,,571.10,371.22,,571.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,434.04,76,,534.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,411.19,72,,435.64,Percent of Total Billed Charges,72% of Total Billed Charges,411.19,72,,435.64,Percent of Total Billed charges,72% of Total Billed Charges,571.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.19,72,,435.64,Percent of Total Billed Charges,72% of Total Billed Charges,342.66,60,,363.032,Percent of Total Billed Charges,60% of Total Billed Charges,513.99,90,,200.04,Percent of Total Billed Charges,90% of Total Billed Charges,257,45,,1593.552,Percent of Total Billed Charges,45% of Total Billed Charges,513.99,90,,632.656,Percent of Total Billed Charges,90% of Total billed Charges,571.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,571.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,571.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.22,65,,797.464,Percent of total Billed Charges,65% of Total Billed Charges,251.86,44.1,,1561.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,542.55,95,,667.808,Percent of Total Billed Charges,95% of Total Billed Charges,571.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.57,88,,5189.408,Percent of Total Billed Charges,88% of Total Billed Charges,513.99,90,,632.656,Percent of Total Billed charges,90% of Total Billed Charges,251.86,571.1,
SYNTHES SAW BLADE 6X,2780000633,CDM,278,RC,C1713,HCPCS,Outpatient,,,502.74,326.78,,502.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,382.08,76,,516.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,361.97,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,361.97,72,,66.68,Percent of Total Billed charges,72% of Total Billed Charges,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.97,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,301.64,60,,55.568,Percent of Total Billed Charges,60% of Total Billed Charges,452.47,90,,1391.528,Percent of Total Billed Charges,90% of Total Billed Charges,226.23,45,,2653.672,Percent of Total Billed Charges,45% of Total Billed Charges,452.47,90,,612.024,Percent of Total Billed Charges,90% of Total billed Charges,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.78,65,,2466.336,Percent of total Billed Charges,65% of Total Billed Charges,221.71,44.1,,2600.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,477.6,95,,646.024,Percent of Total Billed Charges,95% of Total Billed Charges,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,442.41,88,,40.36,Percent of Total Billed Charges,88% of Total Billed Charges,452.47,90,,612.024,Percent of Total Billed charges,90% of Total Billed Charges,221.71,502.74,
SYNTHES SAW BLADE 10,2780000634,CDM,278,RC,C1713,HCPCS,Outpatient,,,502.74,326.78,,502.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,382.08,76,,6514.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,361.97,72,,349.912,Percent of Total Billed Charges,72% of Total Billed Charges,361.97,72,,349.912,Percent of Total Billed charges,72% of Total Billed Charges,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.97,72,,349.912,Percent of Total Billed Charges,72% of Total Billed Charges,301.64,60,,291.592,Percent of Total Billed Charges,60% of Total Billed Charges,452.47,90,,124.624,Percent of Total Billed Charges,90% of Total Billed Charges,226.23,45,,2653.672,Percent of Total Billed Charges,45% of Total Billed Charges,452.47,90,,7714.152,Percent of Total Billed Charges,90% of Total billed Charges,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.78,65,,55.608,Percent of total Billed Charges,65% of Total Billed Charges,221.71,44.1,,2600.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,477.6,95,,8142.72,Percent of Total Billed Charges,95% of Total Billed Charges,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,442.41,88,,4327.872,Percent of Total Billed Charges,88% of Total Billed Charges,452.47,90,,7714.152,Percent of Total Billed charges,90% of Total Billed Charges,221.71,502.74,
SYNTHES SMALL SAW BL,2780000635,CDM,278,RC,C1713,HCPCS,Outpatient,,,502.74,326.78,,502.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,382.08,76,,2691.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,361.97,72,,1877.176,Percent of Total Billed Charges,72% of Total Billed Charges,361.97,72,,1877.176,Percent of Total Billed charges,72% of Total Billed Charges,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.97,72,,1877.176,Percent of Total Billed Charges,72% of Total Billed Charges,301.64,60,,1564.312,Percent of Total Billed Charges,60% of Total Billed Charges,452.47,90,,5093.024,Percent of Total Billed Charges,90% of Total Billed Charges,226.23,45,,20.64,Percent of Total Billed Charges,45% of Total Billed Charges,452.47,90,,3187.112,Percent of Total Billed Charges,90% of Total billed Charges,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.78,65,,3609.496,Percent of total Billed Charges,65% of Total Billed Charges,221.71,44.1,,20.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,477.6,95,,3364.168,Percent of Total Billed Charges,95% of Total Billed Charges,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,442.41,88,,1159.584,Percent of Total Billed Charges,88% of Total Billed Charges,452.47,90,,3187.112,Percent of Total Billed charges,90% of Total Billed Charges,221.71,502.74,
Z23582206 DORSAL T,2780000636,CDM,278,RC,C1713,HCPCS,Outpatient,,,3977.82,2585.58,,3977.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3023.14,76,,4481.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2864.03,72,,1616.176,Percent of Total Billed Charges,72% of Total Billed Charges,2864.03,72,,1616.176,Percent of Total Billed charges,72% of Total Billed Charges,3977.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2864.03,72,,1616.176,Percent of Total Billed Charges,72% of Total Billed Charges,2386.69,60,,1346.816,Percent of Total Billed Charges,60% of Total Billed Charges,3580.04,90,,3964.24,Percent of Total Billed Charges,90% of Total Billed Charges,1790.02,45,,2213.112,Percent of Total Billed Charges,45% of Total Billed Charges,3580.04,90,,5307.352,Percent of Total Billed Charges,90% of Total billed Charges,3977.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3977.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3977.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2585.58,65,,339.392,Percent of total Billed Charges,65% of Total Billed Charges,1754.22,44.1,,2168.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,3778.93,95,,5602.2,Percent of Total Billed Charges,95% of Total Billed Charges,3977.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3500.48,88,,58.992,Percent of Total Billed Charges,88% of Total Billed Charges,3580.04,90,,5307.352,Percent of Total Billed charges,90% of Total Billed Charges,1754.22,3977.82,
Z23592824 2.4 LOCK,2780000637,CDM,278,RC,C1713,HCPCS,Outpatient,,,455.33,295.96,,455.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,346.05,76,,4481.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,327.84,72,,229.888,Percent of Total Billed Charges,72% of Total Billed Charges,327.84,72,,229.888,Percent of Total Billed charges,72% of Total Billed Charges,455.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.84,72,,229.888,Percent of Total Billed Charges,72% of Total Billed Charges,273.2,60,,191.576,Percent of Total Billed Charges,60% of Total Billed Charges,409.8,90,,402.456,Percent of Total Billed Charges,90% of Total Billed Charges,204.9,45,,592.968,Percent of Total Billed Charges,45% of Total Billed Charges,409.8,90,,5307.352,Percent of Total Billed Charges,90% of Total billed Charges,455.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,455.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,455.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.96,65,,10000.648,Percent of total Billed Charges,65% of Total Billed Charges,200.8,44.1,,581.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,432.56,95,,5602.2,Percent of Total Billed Charges,95% of Total Billed Charges,455.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.69,88,,195.592,Percent of Total Billed Charges,88% of Total Billed Charges,409.8,90,,5307.352,Percent of Total Billed charges,90% of Total Billed Charges,200.8,455.33,
Z23582206 DORSAL T,2780000638,CDM,278,RC,C1713,HCPCS,Outpatient,,,3977.82,2585.58,,3977.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3023.14,76,,34.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2864.03,72,,290.208,Percent of Total Billed Charges,72% of Total Billed Charges,2864.03,72,,290.208,Percent of Total Billed charges,72% of Total Billed Charges,3977.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2864.03,72,,290.208,Percent of Total Billed Charges,72% of Total Billed Charges,2386.69,60,,241.84,Percent of Total Billed Charges,60% of Total Billed Charges,3580.04,90,,3964.24,Percent of Total Billed Charges,90% of Total Billed Charges,1790.02,45,,30.168,Percent of Total Billed Charges,45% of Total Billed Charges,3580.04,90,,41.28,Percent of Total Billed Charges,90% of Total billed Charges,3977.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3977.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3977.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2585.58,65,,12034.712,Percent of total Billed Charges,65% of Total Billed Charges,1754.22,44.1,,29.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,3778.93,95,,43.568,Percent of Total Billed Charges,95% of Total Billed Charges,3977.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3500.48,88,,1360.608,Percent of Total Billed Charges,88% of Total Billed Charges,3580.04,90,,41.28,Percent of Total Billed charges,90% of Total Billed Charges,1754.22,3977.82,
Z23592824 2.4 LOCK,2780000639,CDM,278,RC,C1713,HCPCS,Outpatient,,,455.33,295.96,,455.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,346.05,76,,3737.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,327.84,72,,2843.072,Percent of Total Billed Charges,72% of Total Billed Charges,327.84,72,,2843.072,Percent of Total Billed charges,72% of Total Billed Charges,455.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.84,72,,2843.072,Percent of Total Billed Charges,72% of Total Billed Charges,273.2,60,,2369.224,Percent of Total Billed Charges,60% of Total Billed Charges,409.8,90,,5093.024,Percent of Total Billed Charges,90% of Total Billed Charges,204.9,45,,100.016,Percent of Total Billed Charges,45% of Total Billed Charges,409.8,90,,4426.232,Percent of Total Billed Charges,90% of Total billed Charges,455.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,455.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,455.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.96,65,,9026.032,Percent of total Billed Charges,65% of Total Billed Charges,200.8,44.1,,98.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,432.56,95,,4672.128,Percent of Total Billed Charges,95% of Total Billed Charges,455.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.69,88,,121.856,Percent of Total Billed Charges,88% of Total Billed Charges,409.8,90,,4426.232,Percent of Total Billed charges,90% of Total Billed Charges,200.8,455.33,
Z493503504 3.5LOCK,2780000640,CDM,278,RC,C1713,HCPCS,Outpatient,,,572.20,371.93,,572.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,434.87,76,,1001.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,411.98,72,,182.256,Percent of Total Billed Charges,72% of Total Billed Charges,411.98,72,,182.256,Percent of Total Billed charges,72% of Total Billed Charges,572.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.98,72,,182.256,Percent of Total Billed Charges,72% of Total Billed Charges,343.32,60,,151.88,Percent of Total Billed Charges,60% of Total Billed Charges,514.98,90,,4956.488,Percent of Total Billed Charges,90% of Total Billed Charges,257.49,45,,695.768,Percent of Total Billed Charges,45% of Total Billed Charges,514.98,90,,1185.944,Percent of Total Billed Charges,90% of Total billed Charges,572.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,572.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,572.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.93,65,,3892.712,Percent of total Billed Charges,65% of Total Billed Charges,252.34,44.1,,681.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,543.59,95,,1251.824,Percent of Total Billed Charges,95% of Total Billed Charges,572.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,503.54,88,,4979.84,Percent of Total Billed Charges,88% of Total Billed Charges,514.98,90,,1185.944,Percent of Total Billed charges,90% of Total Billed Charges,252.34,572.2,
Z493504604 3.5 LOC,2780000641,CDM,278,RC,C1713,HCPCS,Outpatient,,,572.20,371.93,,572.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,434.87,76,,50.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,411.98,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,411.98,72,,25.4,Percent of Total Billed charges,72% of Total Billed Charges,572.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.98,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,343.32,60,,21.168,Percent of Total Billed Charges,60% of Total Billed Charges,514.98,90,,15531.496,Percent of Total Billed Charges,90% of Total Billed Charges,257.49,45,,62.312,Percent of Total Billed Charges,45% of Total Billed Charges,514.98,90,,60.328,Percent of Total Billed Charges,90% of Total billed Charges,572.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,572.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,572.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.93,65,,3354.376,Percent of total Billed Charges,65% of Total Billed Charges,252.34,44.1,,61.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,543.59,95,,63.68,Percent of Total Billed Charges,95% of Total Billed Charges,572.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,503.54,88,,3876.144,Percent of Total Billed Charges,88% of Total Billed Charges,514.98,90,,60.328,Percent of Total Billed charges,90% of Total Billed Charges,252.34,572.2,
Z48401601 4.0 CANN,2780000642,CDM,278,RC,C1713,HCPCS,Outpatient,,,77.18,50.17,,77.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.66,76,,168.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.57,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,55.57,72,,212.104,Percent of Total Billed charges,72% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.57,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,60,,176.752,Percent of Total Billed Charges,60% of Total Billed Charges,69.46,90,,4284.136,Percent of Total Billed Charges,90% of Total Billed Charges,34.73,45,,2546.512,Percent of Total Billed Charges,45% of Total Billed Charges,69.46,90,,200.04,Percent of Total Billed Charges,90% of Total billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.17,65,,287.224,Percent of total Billed Charges,65% of Total Billed Charges,34.04,44.1,,2495.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.32,95,,211.152,Percent of Total Billed Charges,95% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.92,88,,393.512,Percent of Total Billed Charges,88% of Total Billed Charges,69.46,90,,200.04,Percent of Total Billed charges,90% of Total Billed Charges,34.04,77.18,
Z48401801 4.0 CANN,2780000643,CDM,278,RC,C1713,HCPCS,Outpatient,,,77.18,50.17,,77.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.66,76,,1175.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.57,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,55.57,72,,212.104,Percent of Total Billed charges,72% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.57,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,60,,176.752,Percent of Total Billed Charges,60% of Total Billed Charges,69.46,90,,3401.432,Percent of Total Billed Charges,90% of Total Billed Charges,34.73,45,,1982.12,Percent of Total Billed Charges,45% of Total Billed Charges,69.46,90,,1391.528,Percent of Total Billed Charges,90% of Total billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.17,65,,287.224,Percent of total Billed Charges,65% of Total Billed Charges,34.04,44.1,,1942.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.32,95,,1468.84,Percent of Total Billed Charges,95% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.92,88,,3876.144,Percent of Total Billed Charges,88% of Total Billed Charges,69.46,90,,1391.528,Percent of Total Billed charges,90% of Total Billed Charges,34.04,77.18,
Z225334011 TIBIAL,2780000644,CDM,278,RC,C1713,HCPCS,Outpatient,,,3948.05,2566.23,,3948.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3000.52,76,,105.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2842.6,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,2842.6,72,,212.104,Percent of Total Billed charges,72% of Total Billed Charges,3948.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2842.6,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,2368.83,60,,176.752,Percent of Total Billed Charges,60% of Total Billed Charges,3553.25,90,,4284.136,Percent of Total Billed Charges,90% of Total Billed Charges,1776.62,45,,201.232,Percent of Total Billed Charges,45% of Total Billed Charges,3553.25,90,,124.624,Percent of Total Billed Charges,90% of Total billed Charges,3948.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3948.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3948.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2566.23,65,,12034.712,Percent of total Billed Charges,65% of Total Billed Charges,1741.09,44.1,,197.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,3750.65,95,,131.552,Percent of Total Billed Charges,95% of Total Billed Charges,3948.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3474.28,88,,4979.84,Percent of Total Billed Charges,88% of Total Billed Charges,3553.25,90,,124.624,Percent of Total Billed charges,90% of Total Billed Charges,1741.09,3948.05,
EXACTECH KNEE SPACER,2780000645,CDM,278,RC,C1713,HCPCS,Outpatient,,,15320.34,9958.22,,15320.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11643.46,76,,4300.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11030.64,72,,2310.28,Percent of Total Billed Charges,72% of Total Billed Charges,11030.64,72,,2310.28,Percent of Total Billed charges,72% of Total Billed Charges,15320.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11030.64,72,,2310.28,Percent of Total Billed Charges,72% of Total Billed Charges,9192.2,60,,1925.232,Percent of Total Billed Charges,60% of Total Billed Charges,13788.31,90,,15312.408,Percent of Total Billed Charges,90% of Total Billed Charges,6894.15,45,,1982.12,Percent of Total Billed Charges,45% of Total Billed Charges,13788.31,90,,5093.024,Percent of Total Billed Charges,90% of Total billed Charges,15320.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15320.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15320.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9958.22,65,,2423.912,Percent of total Billed Charges,65% of Total Billed Charges,6756.27,44.1,,1942.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,14554.32,95,,5375.968,Percent of Total Billed Charges,95% of Total Billed Charges,15320.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13481.9,88,,4846.344,Percent of Total Billed Charges,88% of Total Billed Charges,13788.31,90,,5093.024,Percent of Total Billed charges,90% of Total Billed Charges,6756.27,15320.34,
WM EVOLVE HEAD 22MM,2780000646,CDM,278,RC,C1713,HCPCS,Outpatient,,,8417.59,5471.43,,8417.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6397.37,76,,3347.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6060.66,72,,3512.408,Percent of Total Billed Charges,72% of Total Billed Charges,6060.66,72,,3512.408,Percent of Total Billed charges,72% of Total Billed Charges,8417.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6060.66,72,,3512.408,Percent of Total Billed Charges,72% of Total Billed Charges,5050.55,60,,2927.008,Percent of Total Billed Charges,60% of Total Billed Charges,7575.83,90,,3964.24,Percent of Total Billed Charges,90% of Total Billed Charges,3787.92,45,,2546.512,Percent of Total Billed Charges,45% of Total Billed Charges,7575.83,90,,3964.24,Percent of Total Billed Charges,90% of Total billed Charges,8417.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8417.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8417.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5471.43,65,,2202.624,Percent of total Billed Charges,65% of Total Billed Charges,3712.16,44.1,,2495.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,7996.71,95,,4184.48,Percent of Total Billed Charges,95% of Total Billed Charges,8417.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7407.48,88,,15186.352,Percent of Total Billed Charges,88% of Total Billed Charges,7575.83,90,,3964.24,Percent of Total Billed charges,90% of Total Billed Charges,3712.16,8417.59,
WM EVOLVE STEM 7.5 M,2780000647,CDM,278,RC,C1713,HCPCS,Outpatient,,,10014.01,6509.11,,10014.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7610.65,76,,339.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7210.09,72,,4062.352,Percent of Total Billed Charges,72% of Total Billed Charges,7210.09,72,,4062.352,Percent of Total Billed charges,72% of Total Billed Charges,10014.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7210.09,72,,4062.352,Percent of Total Billed Charges,72% of Total Billed Charges,6008.41,60,,3385.288,Percent of Total Billed Charges,60% of Total Billed Charges,9012.61,90,,6903.68,Percent of Total Billed Charges,90% of Total Billed Charges,4506.3,45,,2478.24,Percent of Total Billed Charges,45% of Total Billed Charges,9012.61,90,,402.456,Percent of Total Billed Charges,90% of Total billed Charges,10014.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10014.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10014.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6509.11,65,,3057.984,Percent of total Billed Charges,65% of Total Billed Charges,4416.18,44.1,,2428.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,9513.31,95,,424.816,Percent of Total Billed Charges,95% of Total Billed Charges,10014.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8812.33,88,,4188.936,Percent of Total Billed Charges,88% of Total Billed Charges,9012.61,90,,402.456,Percent of Total Billed charges,90% of Total Billed Charges,4416.18,10014.01,
Z114706576 32 MMTH,2780000648,CDM,278,RC,C1713,HCPCS,Outpatient,,,977.92,635.65,,977.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,743.22,76,,3347.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,704.1,72,,48.264,Percent of Total Billed Charges,72% of Total Billed Charges,704.1,72,,48.264,Percent of Total Billed charges,72% of Total Billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704.1,72,,48.264,Percent of Total Billed Charges,72% of Total Billed Charges,586.75,60,,40.216,Percent of Total Billed Charges,60% of Total Billed Charges,880.13,90,,2452.048,Percent of Total Billed Charges,90% of Total Billed Charges,440.06,45,,7765.744,Percent of Total Billed Charges,45% of Total Billed Charges,880.13,90,,3964.24,Percent of Total Billed Charges,90% of Total billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,635.65,65,,544.64,Percent of total Billed Charges,65% of Total Billed Charges,431.26,44.1,,7610.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,929.02,95,,4184.48,Percent of Total Billed Charges,95% of Total Billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,860.57,88,,3325.84,Percent of Total Billed Charges,88% of Total Billed Charges,880.13,90,,3964.24,Percent of Total Billed charges,90% of Total Billed Charges,431.26,977.92,
Z49350616 CLOVERLE,2780000649,CDM,278,RC,C1713,HCPCS,Outpatient,,,1460.81,949.53,,1460.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1110.22,76,,4300.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1051.78,72,,2604.296,Percent of Total Billed Charges,72% of Total Billed Charges,1051.78,72,,2604.296,Percent of Total Billed charges,72% of Total Billed Charges,1460.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1051.78,72,,2604.296,Percent of Total Billed Charges,72% of Total Billed Charges,876.49,60,,2170.248,Percent of Total Billed Charges,60% of Total Billed Charges,1314.73,90,,1104.176,Percent of Total Billed Charges,90% of Total Billed Charges,657.36,45,,2142.072,Percent of Total Billed Charges,45% of Total Billed Charges,1314.73,90,,5093.024,Percent of Total Billed Charges,90% of Total billed Charges,1460.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1460.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1460.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,949.53,65,,7693.112,Percent of total Billed Charges,65% of Total Billed Charges,644.22,44.1,,2099.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,1387.77,95,,5375.968,Percent of Total Billed Charges,95% of Total Billed Charges,1460.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1285.51,88,,4188.936,Percent of Total Billed Charges,88% of Total Billed Charges,1314.73,90,,5093.024,Percent of Total Billed charges,90% of Total Billed Charges,644.22,1460.81,
Z483503601 3.5 COR,2780000650,CDM,278,RC,C1713,HCPCS,Outpatient,,,97.02,63.06,,97.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.74,76,,4185.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.85,72,,799.52,Percent of Total Billed Charges,72% of Total Billed Charges,69.85,72,,799.52,Percent of Total Billed charges,72% of Total Billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.85,72,,799.52,Percent of Total Billed Charges,72% of Total Billed Charges,58.21,60,,666.264,Percent of Total Billed Charges,60% of Total Billed Charges,87.32,90,,3414.928,Percent of Total Billed Charges,90% of Total Billed Charges,43.66,45,,1700.712,Percent of Total Billed Charges,45% of Total Billed Charges,87.32,90,,4956.488,Percent of Total Billed Charges,90% of Total billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,65,,3892.712,Percent of total Billed Charges,65% of Total Billed Charges,42.79,44.1,,1666.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,92.17,95,,5231.848,Percent of Total Billed Charges,95% of Total Billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.38,88,,14972.128,Percent of Total Billed Charges,88% of Total Billed Charges,87.32,90,,4956.488,Percent of Total Billed charges,90% of Total Billed Charges,42.79,97.02,
Z483503801 3.5 COR,2780000651,CDM,278,RC,C1713,HCPCS,Outpatient,,,97.02,63.06,,97.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.74,76,,13115.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.85,72,,1616.176,Percent of Total Billed Charges,72% of Total Billed Charges,69.85,72,,1616.176,Percent of Total Billed charges,72% of Total Billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.85,72,,1616.176,Percent of Total Billed Charges,72% of Total Billed Charges,58.21,60,,1346.816,Percent of Total Billed Charges,60% of Total Billed Charges,87.32,90,,77,Percent of Total Billed Charges,90% of Total Billed Charges,43.66,45,,2142.072,Percent of Total Billed Charges,45% of Total Billed Charges,87.32,90,,15531.496,Percent of Total Billed Charges,90% of Total billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,65,,252.256,Percent of total Billed Charges,65% of Total Billed Charges,42.79,44.1,,2099.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,92.17,95,,16394.352,Percent of Total Billed Charges,95% of Total Billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.38,88,,3876.144,Percent of Total Billed Charges,88% of Total Billed Charges,87.32,90,,15531.496,Percent of Total Billed charges,90% of Total Billed Charges,42.79,97.02,
Z483504501 3.5 COR,2780000652,CDM,278,RC,C1713,HCPCS,Outpatient,,,97.02,63.06,,97.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.74,76,,3617.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.85,72,,1857.488,Percent of Total Billed Charges,72% of Total Billed Charges,69.85,72,,1857.488,Percent of Total Billed charges,72% of Total Billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.85,72,,1857.488,Percent of Total Billed Charges,72% of Total Billed Charges,58.21,60,,1547.912,Percent of Total Billed Charges,60% of Total Billed Charges,87.32,90,,4997.768,Percent of Total Billed Charges,90% of Total Billed Charges,43.66,45,,7656.2,Percent of Total Billed Charges,45% of Total Billed Charges,87.32,90,,4284.136,Percent of Total Billed Charges,90% of Total billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,65,,10000.648,Percent of total Billed Charges,65% of Total Billed Charges,42.79,44.1,,7503.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,92.17,95,,4522.144,Percent of Total Billed Charges,95% of Total Billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.38,88,,6750.264,Percent of Total Billed Charges,88% of Total Billed Charges,87.32,90,,4284.136,Percent of Total Billed charges,90% of Total Billed Charges,42.79,97.02,
Z4840030 CANN SCW 3,2780000653,CDM,278,RC,C1713,HCPCS,Outpatient,,,77.18,50.17,,77.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.66,76,,2872.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.57,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,55.57,72,,47.632,Percent of Total Billed charges,72% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.57,72,,47.632,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,60,,39.688,Percent of Total Billed Charges,60% of Total Billed Charges,69.46,90,,469.928,Percent of Total Billed Charges,90% of Total Billed Charges,34.73,45,,1982.12,Percent of Total Billed Charges,45% of Total Billed Charges,69.46,90,,3401.432,Percent of Total Billed Charges,90% of Total billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.17,65,,146.768,Percent of total Billed Charges,65% of Total Billed Charges,34.04,44.1,,1942.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.32,95,,3590.4,Percent of Total Billed Charges,95% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.92,88,,2397.56,Percent of Total Billed Charges,88% of Total Billed Charges,69.46,90,,3401.432,Percent of Total Billed charges,90% of Total Billed Charges,34.04,77.18,
Z49351003 TUBULAR,2780000654,CDM,278,RC,C1713,HCPCS,Outpatient,,,287.75,187.04,,287.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,218.69,76,,3617.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,207.18,72,,2148.976,Percent of Total Billed Charges,72% of Total Billed Charges,207.18,72,,2148.976,Percent of Total Billed charges,72% of Total Billed Charges,287.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.18,72,,2148.976,Percent of Total Billed Charges,72% of Total Billed Charges,172.65,60,,1790.816,Percent of Total Billed Charges,60% of Total Billed Charges,258.98,90,,13847.048,Percent of Total Billed Charges,90% of Total Billed Charges,129.49,45,,3451.84,Percent of Total Billed Charges,45% of Total Billed Charges,258.98,90,,4284.136,Percent of Total Billed Charges,90% of Total billed Charges,287.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,287.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,287.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.04,65,,662.16,Percent of total Billed Charges,65% of Total Billed Charges,126.9,44.1,,3382.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,273.36,95,,4522.144,Percent of Total Billed Charges,95% of Total Billed Charges,287.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,253.22,88,,1079.64,Percent of Total Billed Charges,88% of Total Billed Charges,258.98,90,,4284.136,Percent of Total Billed charges,90% of Total Billed Charges,126.9,287.75,
Z11479901 GUIDE PI,2780000655,CDM,278,RC,C1713,HCPCS,Outpatient,,,112.46,73.10,,112.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,85.47,76,,12930.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,80.97,72,,3017.712,Percent of Total Billed Charges,72% of Total Billed Charges,80.97,72,,3017.712,Percent of Total Billed charges,72% of Total Billed Charges,112.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.97,72,,3017.712,Percent of Total Billed Charges,72% of Total Billed Charges,67.48,60,,2514.76,Percent of Total Billed Charges,60% of Total Billed Charges,101.21,90,,16663.448,Percent of Total Billed Charges,90% of Total Billed Charges,50.61,45,,1226.024,Percent of Total Billed Charges,45% of Total Billed Charges,101.21,90,,15312.408,Percent of Total Billed Charges,90% of Total billed Charges,112.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.1,65,,296.392,Percent of total Billed Charges,65% of Total Billed Charges,49.59,44.1,,1201.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,106.84,95,,16163.096,Percent of Total Billed Charges,95% of Total Billed Charges,112.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.96,88,,3339.04,Percent of Total Billed Charges,88% of Total Billed Charges,101.21,90,,15312.408,Percent of Total Billed charges,90% of Total Billed Charges,49.59,112.46,
Z114710576 32MM TH,2780000656,CDM,278,RC,C1713,HCPCS,Outpatient,,,977.92,635.65,,977.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,743.22,76,,3347.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,704.1,72,,3773.408,Percent of Total Billed Charges,72% of Total Billed Charges,704.1,72,,3773.408,Percent of Total Billed charges,72% of Total Billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704.1,72,,3773.408,Percent of Total Billed Charges,72% of Total Billed Charges,586.75,60,,3144.512,Percent of Total Billed Charges,60% of Total Billed Charges,880.13,90,,12497.584,Percent of Total Billed Charges,90% of Total Billed Charges,440.06,45,,552.088,Percent of Total Billed Charges,45% of Total Billed Charges,880.13,90,,3964.24,Percent of Total Billed Charges,90% of Total billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,635.65,65,,2849.872,Percent of total Billed Charges,65% of Total Billed Charges,431.26,44.1,,541.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,929.02,95,,4184.48,Percent of Total Billed Charges,95% of Total Billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,860.57,88,,75.288,Percent of Total Billed Charges,88% of Total Billed Charges,880.13,90,,3964.24,Percent of Total Billed charges,90% of Total Billed Charges,431.26,977.92,
Z44535015 TRANSFX,2780000657,CDM,278,RC,C1713,HCPCS,Outpatient,,,271.22,176.29,,271.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,206.13,76,,5829.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,195.28,72,,11665.048,Percent of Total Billed Charges,72% of Total Billed Charges,195.28,72,,11665.048,Percent of Total Billed charges,72% of Total Billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.28,72,,11665.048,Percent of Total Billed Charges,72% of Total Billed Charges,162.73,60,,9720.872,Percent of Total Billed Charges,60% of Total Billed Charges,244.1,90,,5389.904,Percent of Total Billed Charges,90% of Total Billed Charges,122.05,45,,1707.464,Percent of Total Billed Charges,45% of Total Billed Charges,244.1,90,,6903.68,Percent of Total Billed Charges,90% of Total billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.29,65,,280.92,Percent of total Billed Charges,65% of Total Billed Charges,119.61,44.1,,1673.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,257.66,95,,7287.216,Percent of Total Billed Charges,95% of Total Billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.67,88,,4886.704,Percent of Total Billed Charges,88% of Total Billed Charges,244.1,90,,6903.68,Percent of Total Billed charges,90% of Total Billed Charges,119.61,271.22,
Z44535031 TRANSFX,2780000658,CDM,278,RC,C1713,HCPCS,Outpatient,,,417.85,271.60,,417.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,317.57,76,,2070.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,300.85,72,,2733.848,Percent of Total Billed Charges,72% of Total Billed Charges,300.85,72,,2733.848,Percent of Total Billed charges,72% of Total Billed Charges,417.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.85,72,,2733.848,Percent of Total Billed Charges,72% of Total Billed Charges,250.71,60,,2278.208,Percent of Total Billed Charges,60% of Total Billed Charges,376.07,90,,4644.528,Percent of Total Billed Charges,90% of Total Billed Charges,188.03,45,,38.496,Percent of Total Billed Charges,45% of Total Billed Charges,376.07,90,,2452.048,Percent of Total Billed Charges,90% of Total billed Charges,417.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.6,65,,288.368,Percent of total Billed Charges,65% of Total Billed Charges,184.27,44.1,,37.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,396.96,95,,2588.272,Percent of Total Billed Charges,95% of Total Billed Charges,417.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,367.71,88,,459.488,Percent of Total Billed Charges,88% of Total Billed Charges,376.07,90,,2452.048,Percent of Total Billed charges,90% of Total Billed Charges,184.27,417.85,
Z44521511 TRANSFX,2780000659,CDM,278,RC,C1713,HCPCS,Outpatient,,,1991.12,1294.23,,1991.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1513.25,76,,932.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1433.61,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,1433.61,72,,227.344,Percent of Total Billed charges,72% of Total Billed Charges,1991.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1433.61,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,1194.67,60,,189.456,Percent of Total Billed Charges,60% of Total Billed Charges,1792.01,90,,397.696,Percent of Total Billed Charges,90% of Total Billed Charges,896,45,,2498.88,Percent of Total Billed Charges,45% of Total Billed Charges,1792.01,90,,1104.176,Percent of Total Billed Charges,90% of Total billed Charges,1991.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1991.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1991.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1294.23,65,,288.368,Percent of total Billed Charges,65% of Total Billed Charges,878.08,44.1,,2448.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,1891.56,95,,1165.52,Percent of Total Billed Charges,95% of Total Billed Charges,1991.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1752.19,88,,13539.336,Percent of Total Billed Charges,88% of Total Billed Charges,1792.01,90,,1104.176,Percent of Total Billed charges,90% of Total Billed Charges,878.08,1991.12,
Z44522551 TRANSFX,2780000660,CDM,278,RC,C1713,HCPCS,Outpatient,,,1696.75,1102.89,,1696.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1289.53,76,,2883.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1221.66,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,1221.66,72,,227.344,Percent of Total Billed charges,72% of Total Billed Charges,1696.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1221.66,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,1018.05,60,,189.456,Percent of Total Billed Charges,60% of Total Billed Charges,1527.08,90,,397.696,Percent of Total Billed Charges,90% of Total Billed Charges,763.54,45,,234.968,Percent of Total Billed Charges,45% of Total Billed Charges,1527.08,90,,3414.928,Percent of Total Billed Charges,90% of Total billed Charges,1696.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1696.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1696.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1102.89,65,,288.368,Percent of total Billed Charges,65% of Total Billed Charges,748.27,44.1,,230.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,1611.91,95,,3604.648,Percent of Total Billed Charges,95% of Total Billed Charges,1696.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1493.14,88,,16293.152,Percent of Total Billed Charges,88% of Total Billed Charges,1527.08,90,,3414.928,Percent of Total Billed charges,90% of Total Billed Charges,748.27,1696.75,
Z44510115 TRANSFX,2780000661,CDM,278,RC,C1713,HCPCS,Outpatient,,,816.95,531.02,,816.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,620.88,76,,65.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,588.2,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,588.2,72,,227.344,Percent of Total Billed charges,72% of Total Billed Charges,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,588.2,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,490.17,60,,189.456,Percent of Total Billed Charges,60% of Total Billed Charges,735.26,90,,16663.448,Percent of Total Billed Charges,90% of Total Billed Charges,367.63,45,,6923.52,Percent of Total Billed Charges,45% of Total Billed Charges,735.26,90,,77,Percent of Total Billed Charges,90% of Total billed Charges,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531.02,65,,288.368,Percent of total Billed Charges,65% of Total Billed Charges,360.27,44.1,,6785.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,776.1,95,,81.272,Percent of Total Billed Charges,95% of Total Billed Charges,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,718.92,88,,12219.864,Percent of Total Billed Charges,88% of Total Billed Charges,735.26,90,,77,Percent of Total Billed charges,90% of Total Billed Charges,360.27,816.95,
Z44510120 TRANSFX,2780000662,CDM,278,RC,C1713,HCPCS,Outpatient,,,816.95,531.02,,816.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,620.88,76,,4220.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,588.2,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,588.2,72,,227.344,Percent of Total Billed charges,72% of Total Billed Charges,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,588.2,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,490.17,60,,189.456,Percent of Total Billed Charges,60% of Total Billed Charges,735.26,90,,3356.184,Percent of Total Billed Charges,90% of Total Billed Charges,367.63,45,,8331.728,Percent of Total Billed Charges,45% of Total Billed Charges,735.26,90,,4997.768,Percent of Total Billed Charges,90% of Total billed Charges,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531.02,65,,191.488,Percent of total Billed Charges,65% of Total Billed Charges,360.27,44.1,,8165.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,776.1,95,,5275.416,Percent of Total Billed Charges,95% of Total Billed Charges,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,718.92,88,,5270.128,Percent of Total Billed Charges,88% of Total Billed Charges,735.26,90,,4997.768,Percent of Total Billed charges,90% of Total Billed Charges,360.27,816.95,
Z44510130 TRANSFX,2780000663,CDM,278,RC,C1713,HCPCS,Outpatient,,,816.95,531.02,,816.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,620.88,76,,396.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,588.2,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,588.2,72,,227.344,Percent of Total Billed charges,72% of Total Billed Charges,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,588.2,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,490.17,60,,189.456,Percent of Total Billed Charges,60% of Total Billed Charges,735.26,90,,3049.784,Percent of Total Billed Charges,90% of Total Billed Charges,367.63,45,,6248.792,Percent of Total Billed Charges,45% of Total Billed Charges,735.26,90,,469.928,Percent of Total Billed Charges,90% of Total billed Charges,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531.02,65,,191.488,Percent of total Billed Charges,65% of Total Billed Charges,360.27,44.1,,6123.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,776.1,95,,496.04,Percent of Total Billed Charges,95% of Total Billed Charges,816.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,718.92,88,,4541.312,Percent of Total Billed Charges,88% of Total Billed Charges,735.26,90,,469.928,Percent of Total Billed charges,90% of Total Billed Charges,360.27,816.95,
Z80183202 FEMORAL,2780000664,CDM,278,RC,C1713,HCPCS,Outpatient,,,3504.85,2278.15,,3504.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2663.69,76,,11693.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2523.49,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,2523.49,72,,227.344,Percent of Total Billed charges,72% of Total Billed Charges,3504.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2523.49,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,2102.91,60,,189.456,Percent of Total Billed Charges,60% of Total Billed Charges,3154.37,90,,4234.136,Percent of Total Billed Charges,90% of Total Billed Charges,1577.18,45,,2694.952,Percent of Total Billed Charges,45% of Total Billed Charges,3154.37,90,,13847.048,Percent of Total Billed Charges,90% of Total billed Charges,3504.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3504.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3504.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2278.15,65,,191.488,Percent of total Billed Charges,65% of Total Billed Charges,1545.64,44.1,,2641.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,3329.61,95,,14616.328,Percent of Total Billed Charges,95% of Total Billed Charges,3504.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3084.27,88,,388.856,Percent of Total Billed Charges,88% of Total Billed Charges,3154.37,90,,13847.048,Percent of Total Billed charges,90% of Total Billed Charges,1545.64,3504.85,
Z99931935 FEM BODY,2780000665,CDM,278,RC,C1713,HCPCS,Outpatient,,,17291.61,11239.55,,17291.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13141.62,76,,14071.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12449.96,72,,101.608,Percent of Total Billed Charges,72% of Total Billed Charges,12449.96,72,,101.608,Percent of Total Billed charges,72% of Total Billed Charges,17291.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12449.96,72,,101.608,Percent of Total Billed Charges,72% of Total Billed Charges,10374.97,60,,84.672,Percent of Total Billed Charges,60% of Total Billed Charges,15562.45,90,,754.112,Percent of Total Billed Charges,90% of Total Billed Charges,7781.22,45,,2322.264,Percent of Total Billed Charges,45% of Total Billed Charges,15562.45,90,,16663.448,Percent of Total Billed Charges,90% of Total billed Charges,17291.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17291.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17291.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11239.55,65,,303.272,Percent of total Billed Charges,65% of Total Billed Charges,7625.6,44.1,,2275.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,16427.03,95,,17589.2,Percent of Total Billed Charges,95% of Total Billed Charges,17291.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15216.62,88,,388.856,Percent of Total Billed Charges,88% of Total Billed Charges,15562.45,90,,16663.448,Percent of Total Billed charges,90% of Total Billed Charges,7625.6,17291.61,
Z99821923 FEMORAL,2780000666,CDM,278,RC,C1713,HCPCS,Outpatient,,,14268.56,9274.56,,14268.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10844.11,76,,10553.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10273.36,72,,2480.472,Percent of Total Billed Charges,72% of Total Billed Charges,10273.36,72,,2480.472,Percent of Total Billed charges,72% of Total Billed Charges,14268.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10273.36,72,,2480.472,Percent of Total Billed Charges,72% of Total Billed Charges,8561.14,60,,2067.056,Percent of Total Billed Charges,60% of Total Billed Charges,12841.7,90,,10652.008,Percent of Total Billed Charges,90% of Total Billed Charges,6420.85,45,,198.848,Percent of Total Billed Charges,45% of Total Billed Charges,12841.7,90,,12497.584,Percent of Total Billed Charges,90% of Total billed Charges,14268.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14268.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14268.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9274.56,65,,303.272,Percent of total Billed Charges,65% of Total Billed Charges,6292.43,44.1,,194.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,13555.13,95,,13191.896,Percent of Total Billed Charges,95% of Total Billed Charges,14268.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12556.33,88,,16293.152,Percent of Total Billed Charges,88% of Total Billed Charges,12841.7,90,,12497.584,Percent of Total Billed charges,90% of Total Billed Charges,6292.43,14268.56,
Z22320128 CABLE GR,2780000667,CDM,278,RC,C1713,HCPCS,Outpatient,,,757.42,492.32,,757.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,575.64,76,,4551.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,545.34,72,,191.784,Percent of Total Billed Charges,72% of Total Billed Charges,545.34,72,,191.784,Percent of Total Billed charges,72% of Total Billed Charges,757.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,545.34,72,,191.784,Percent of Total Billed Charges,72% of Total Billed Charges,454.45,60,,159.824,Percent of Total Billed Charges,60% of Total Billed Charges,681.68,90,,5389.904,Percent of Total Billed Charges,90% of Total Billed Charges,340.84,45,,198.848,Percent of Total Billed Charges,45% of Total Billed Charges,681.68,90,,5389.904,Percent of Total Billed Charges,90% of Total billed Charges,757.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,757.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,757.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.32,65,,303.272,Percent of total Billed Charges,65% of Total Billed Charges,334.02,44.1,,194.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,719.55,95,,5689.344,Percent of Total Billed Charges,95% of Total Billed Charges,757.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,666.53,88,,3281.608,Percent of Total Billed Charges,88% of Total Billed Charges,681.68,90,,5389.904,Percent of Total Billed charges,90% of Total Billed Charges,334.02,757.42,
Z80183201 FEMORAL,2780000668,CDM,278,RC,C1713,HCPCS,Outpatient,,,3504.85,2278.15,,3504.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2663.69,76,,3922.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2523.49,72,,191.784,Percent of Total Billed Charges,72% of Total Billed Charges,2523.49,72,,191.784,Percent of Total Billed charges,72% of Total Billed Charges,3504.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2523.49,72,,191.784,Percent of Total Billed Charges,72% of Total Billed Charges,2102.91,60,,159.824,Percent of Total Billed Charges,60% of Total Billed Charges,3154.37,90,,349.272,Percent of Total Billed Charges,90% of Total Billed Charges,1577.18,45,,8331.728,Percent of Total Billed Charges,45% of Total Billed Charges,3154.37,90,,4644.528,Percent of Total Billed Charges,90% of Total billed Charges,3504.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3504.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3504.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2278.15,65,,303.272,Percent of total Billed Charges,65% of Total Billed Charges,1545.64,44.1,,8165.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,3329.61,95,,4902.552,Percent of Total Billed Charges,95% of Total Billed Charges,3504.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3084.27,88,,2982.008,Percent of Total Billed Charges,88% of Total Billed Charges,3154.37,90,,4644.528,Percent of Total Billed charges,90% of Total Billed Charges,1545.64,3504.85,
Z225326012 TIBIAL,2780000669,CDM,278,RC,C1713,HCPCS,Outpatient,,,3946.95,2565.52,,3946.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2999.68,76,,335.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2841.8,72,,191.784,Percent of Total Billed Charges,72% of Total Billed Charges,2841.8,72,,191.784,Percent of Total Billed charges,72% of Total Billed Charges,3946.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2841.8,72,,191.784,Percent of Total Billed Charges,72% of Total Billed Charges,2368.17,60,,159.824,Percent of Total Billed Charges,60% of Total Billed Charges,3552.26,90,,13847.048,Percent of Total Billed Charges,90% of Total Billed Charges,1776.13,45,,1678.096,Percent of Total Billed Charges,45% of Total Billed Charges,3552.26,90,,397.696,Percent of Total Billed Charges,90% of Total billed Charges,3946.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3946.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3946.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2565.52,65,,303.272,Percent of total Billed Charges,65% of Total Billed Charges,1740.6,44.1,,1644.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,3749.6,95,,419.784,Percent of Total Billed Charges,95% of Total Billed Charges,3946.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3473.32,88,,4140.04,Percent of Total Billed Charges,88% of Total Billed Charges,3552.26,90,,397.696,Percent of Total Billed charges,90% of Total Billed Charges,1740.6,3946.95,
Z49350703 TUBULAR,2780000670,CDM,278,RC,C1713,HCPCS,Outpatient,,,278.93,181.30,,278.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,211.99,76,,335.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,200.83,72,,2788.464,Percent of Total Billed Charges,72% of Total Billed Charges,200.83,72,,2788.464,Percent of Total Billed charges,72% of Total Billed Charges,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.83,72,,2788.464,Percent of Total Billed Charges,72% of Total Billed Charges,167.36,60,,2323.72,Percent of Total Billed Charges,60% of Total Billed Charges,251.04,90,,203.216,Percent of Total Billed Charges,90% of Total Billed Charges,125.52,45,,1524.888,Percent of Total Billed Charges,45% of Total Billed Charges,251.04,90,,397.696,Percent of Total Billed Charges,90% of Total billed Charges,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.3,65,,196.64,Percent of total Billed Charges,65% of Total Billed Charges,123.01,44.1,,1494.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,264.98,95,,419.784,Percent of Total Billed Charges,95% of Total Billed Charges,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.46,88,,737.352,Percent of Total Billed Charges,88% of Total Billed Charges,251.04,90,,397.696,Percent of Total Billed charges,90% of Total Billed Charges,123.01,278.93,
Z49010607 0.6 KWI,2780000671,CDM,278,RC,C1713,HCPCS,Outpatient,,,92.61,60.20,,92.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,70.38,76,,14071.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,66.68,72,,191.784,Percent of Total Billed Charges,72% of Total Billed Charges,66.68,72,,191.784,Percent of Total Billed charges,72% of Total Billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.68,72,,191.784,Percent of Total Billed Charges,72% of Total Billed Charges,55.57,60,,159.824,Percent of Total Billed Charges,60% of Total Billed Charges,83.35,90,,916.84,Percent of Total Billed Charges,90% of Total Billed Charges,41.67,45,,2117.064,Percent of Total Billed Charges,45% of Total Billed Charges,83.35,90,,16663.448,Percent of Total Billed Charges,90% of Total billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.2,65,,2397.544,Percent of total Billed Charges,65% of Total Billed Charges,40.84,44.1,,2074.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,87.98,95,,17589.2,Percent of Total Billed Charges,95% of Total Billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.5,88,,10415.296,Percent of Total Billed Charges,88% of Total Billed Charges,83.35,90,,16663.448,Percent of Total Billed charges,90% of Total Billed Charges,40.84,92.61,
Z49010807 0.8 KWI,2780000672,CDM,278,RC,C1713,HCPCS,Outpatient,,,92.61,60.20,,92.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,70.38,76,,2834.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,66.68,72,,293.392,Percent of Total Billed Charges,72% of Total Billed Charges,66.68,72,,293.392,Percent of Total Billed charges,72% of Total Billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.68,72,,293.392,Percent of Total Billed Charges,72% of Total Billed Charges,55.57,60,,244.496,Percent of Total Billed Charges,60% of Total Billed Charges,83.35,90,,410.392,Percent of Total Billed Charges,90% of Total Billed Charges,41.67,45,,377.056,Percent of Total Billed Charges,45% of Total Billed Charges,83.35,90,,3356.184,Percent of Total Billed Charges,90% of Total billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.2,65,,164.536,Percent of total Billed Charges,65% of Total Billed Charges,40.84,44.1,,369.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,87.98,95,,3542.64,Percent of Total Billed Charges,95% of Total Billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.5,88,,5270.128,Percent of Total Billed Charges,88% of Total Billed Charges,83.35,90,,3356.184,Percent of Total Billed charges,90% of Total Billed Charges,40.84,92.61,
Z48271601 2.7 SCW,2780000673,CDM,278,RC,C1713,HCPCS,Outpatient,,,87.10,56.62,,87.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.2,76,,2575.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.71,72,,293.392,Percent of Total Billed Charges,72% of Total Billed Charges,62.71,72,,293.392,Percent of Total Billed charges,72% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.71,72,,293.392,Percent of Total Billed Charges,72% of Total Billed Charges,52.26,60,,244.496,Percent of Total Billed Charges,60% of Total Billed Charges,78.39,90,,3945.984,Percent of Total Billed Charges,90% of Total Billed Charges,39.2,45,,5326,Percent of Total Billed Charges,45% of Total Billed Charges,78.39,90,,3049.784,Percent of Total Billed Charges,90% of Total billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.62,65,,164.536,Percent of total Billed Charges,65% of Total Billed Charges,38.41,44.1,,5219.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.75,95,,3219.216,Percent of Total Billed Charges,95% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.65,88,,341.512,Percent of Total Billed Charges,88% of Total Billed Charges,78.39,90,,3049.784,Percent of Total Billed charges,90% of Total Billed Charges,38.41,87.1,
Z48400184.0 SCW18,2780000674,CDM,278,RC,C1713,HCPCS,Outpatient,,,77.18,50.17,,77.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.66,76,,3575.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.57,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,55.57,72,,15.872,Percent of Total Billed charges,72% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.57,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,60,,13.232,Percent of Total Billed Charges,60% of Total Billed Charges,69.46,90,,388.968,Percent of Total Billed Charges,90% of Total Billed Charges,34.73,45,,2694.952,Percent of Total Billed Charges,45% of Total Billed Charges,69.46,90,,4234.136,Percent of Total Billed Charges,90% of Total billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.17,65,,159.952,Percent of total Billed Charges,65% of Total Billed Charges,34.04,44.1,,2641.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.32,95,,4469.36,Percent of Total Billed Charges,95% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.92,88,,13539.336,Percent of Total Billed Charges,88% of Total Billed Charges,69.46,90,,4234.136,Percent of Total Billed charges,90% of Total Billed Charges,34.04,77.18,
Z48400204.0 SCW20,2780000675,CDM,278,RC,C1713,HCPCS,Outpatient,,,77.18,50.17,,77.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.66,76,,636.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.57,72,,235.6,Percent of Total Billed Charges,72% of Total Billed Charges,55.57,72,,235.6,Percent of Total Billed charges,72% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.57,72,,235.6,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,60,,196.336,Percent of Total Billed Charges,60% of Total Billed Charges,69.46,90,,399.28,Percent of Total Billed Charges,90% of Total Billed Charges,34.73,45,,174.64,Percent of Total Billed Charges,45% of Total Billed Charges,69.46,90,,754.112,Percent of Total Billed Charges,90% of Total billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.17,65,,173.136,Percent of total Billed Charges,65% of Total Billed Charges,34.04,44.1,,171.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.32,95,,796.008,Percent of Total Billed Charges,95% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.92,88,,198.696,Percent of Total Billed Charges,88% of Total Billed Charges,69.46,90,,754.112,Percent of Total Billed charges,90% of Total Billed Charges,34.04,77.18,
Z1147841.6 P7 GUID,2780000676,CDM,278,RC,C1713,HCPCS,Outpatient,,,527.00,342.55,,527,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,400.52,76,,8995.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,379.44,72,,1299.296,Percent of Total Billed Charges,72% of Total Billed Charges,379.44,72,,1299.296,Percent of Total Billed charges,72% of Total Billed Charges,527,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.44,72,,1299.296,Percent of Total Billed Charges,72% of Total Billed Charges,316.2,60,,1082.744,Percent of Total Billed Charges,60% of Total Billed Charges,474.3,90,,399.28,Percent of Total Billed Charges,90% of Total Billed Charges,237.15,45,,6923.52,Percent of Total Billed Charges,45% of Total Billed Charges,474.3,90,,10652.008,Percent of Total Billed Charges,90% of Total billed Charges,527,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,527,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,527,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.55,65,,106.056,Percent of total Billed Charges,65% of Total Billed Charges,232.41,44.1,,6785.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,500.65,95,,11243.784,Percent of Total Billed Charges,95% of Total Billed Charges,527,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,463.76,88,,896.464,Percent of Total Billed Charges,88% of Total Billed Charges,474.3,90,,10652.008,Percent of Total Billed charges,90% of Total Billed Charges,232.41,527,
Z493601003 1/3 TUB,2780000677,CDM,278,RC,C1713,HCPCS,Outpatient,,,221.60,144.04,,221.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,168.42,76,,4551.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,159.55,72,,2603.664,Percent of Total Billed Charges,72% of Total Billed Charges,159.55,72,,2603.664,Percent of Total Billed charges,72% of Total Billed Charges,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.55,72,,2603.664,Percent of Total Billed Charges,72% of Total Billed Charges,132.96,60,,2169.72,Percent of Total Billed Charges,60% of Total Billed Charges,199.44,90,,399.28,Percent of Total Billed Charges,90% of Total Billed Charges,99.72,45,,101.608,Percent of Total Billed Charges,45% of Total Billed Charges,199.44,90,,5389.904,Percent of Total Billed Charges,90% of Total billed Charges,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.04,65,,1452.744,Percent of total Billed Charges,65% of Total Billed Charges,97.73,44.1,,99.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,210.52,95,,5689.344,Percent of Total Billed Charges,95% of Total Billed Charges,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.01,88,,401.272,Percent of Total Billed Charges,88% of Total Billed Charges,199.44,90,,5389.904,Percent of Total Billed charges,90% of Total Billed Charges,97.73,221.6,
Z23485035 CORTICAL,2780000678,CDM,278,RC,C1713,HCPCS,Outpatient,,,149.94,97.46,,149.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,113.95,76,,294.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,107.96,72,,318.152,Percent of Total Billed Charges,72% of Total Billed Charges,107.96,72,,318.152,Percent of Total Billed charges,72% of Total Billed Charges,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.96,72,,318.152,Percent of Total Billed Charges,72% of Total Billed Charges,89.96,60,,265.128,Percent of Total Billed Charges,60% of Total Billed Charges,134.95,90,,399.28,Percent of Total Billed Charges,90% of Total Billed Charges,67.47,45,,458.424,Percent of Total Billed Charges,45% of Total Billed Charges,134.95,90,,349.272,Percent of Total Billed Charges,90% of Total billed Charges,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.46,65,,3273.544,Percent of total Billed Charges,65% of Total Billed Charges,66.12,44.1,,449.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.44,95,,368.68,Percent of Total Billed Charges,95% of Total Billed Charges,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.95,88,,3858.296,Percent of Total Billed Charges,88% of Total Billed Charges,134.95,90,,349.272,Percent of Total Billed charges,90% of Total Billed Charges,66.12,149.94,
Z78189901 FEMORAL,2780000679,CDM,278,RC,C1713,HCPCS,Outpatient,,,660.40,429.26,,660.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,501.9,76,,11693.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,475.49,72,,887.792,Percent of Total Billed Charges,72% of Total Billed Charges,475.49,72,,887.792,Percent of Total Billed charges,72% of Total Billed Charges,660.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475.49,72,,887.792,Percent of Total Billed Charges,72% of Total Billed Charges,396.24,60,,739.824,Percent of Total Billed Charges,60% of Total Billed Charges,594.36,90,,265.136,Percent of Total Billed Charges,90% of Total Billed Charges,297.18,45,,205.2,Percent of Total Billed Charges,45% of Total Billed Charges,594.36,90,,13847.048,Percent of Total Billed Charges,90% of Total billed Charges,660.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,660.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,660.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,429.26,65,,7160.52,Percent of total Billed Charges,65% of Total Billed Charges,291.24,44.1,,201.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,627.38,95,,14616.328,Percent of Total Billed Charges,95% of Total Billed Charges,660.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,581.15,88,,380.32,Percent of Total Billed Charges,88% of Total Billed Charges,594.36,90,,13847.048,Percent of Total Billed charges,90% of Total Billed Charges,291.24,660.4,
Z785909CENTRALIZER,2780000680,CDM,278,RC,C1713,HCPCS,Outpatient,,,476.28,309.58,,476.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,361.97,76,,171.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,342.92,72,,4355.744,Percent of Total Billed Charges,72% of Total Billed Charges,342.92,72,,4355.744,Percent of Total Billed charges,72% of Total Billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.92,72,,4355.744,Percent of Total Billed Charges,72% of Total Billed Charges,285.77,60,,3629.784,Percent of Total Billed Charges,60% of Total Billed Charges,428.65,90,,265.136,Percent of Total Billed Charges,90% of Total Billed Charges,214.33,45,,1972.992,Percent of Total Billed Charges,45% of Total Billed Charges,428.65,90,,203.216,Percent of Total Billed Charges,90% of Total billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.58,65,,2423.912,Percent of total Billed Charges,65% of Total Billed Charges,210.04,44.1,,1933.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,452.47,95,,214.504,Percent of Total Billed Charges,95% of Total Billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.13,88,,390.408,Percent of Total Billed Charges,88% of Total Billed Charges,428.65,90,,203.216,Percent of Total Billed charges,90% of Total Billed Charges,210.04,476.28,
Z59964017 ART SURF,2780000681,CDM,278,RC,C1713,HCPCS,Outpatient,,,4917.15,3196.15,,4917.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3737.03,76,,774.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3540.35,72,,14110.592,Percent of Total Billed Charges,72% of Total Billed Charges,3540.35,72,,14110.592,Percent of Total Billed charges,72% of Total Billed Charges,4917.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3540.35,72,,14110.592,Percent of Total Billed Charges,72% of Total Billed Charges,2950.29,60,,11758.824,Percent of Total Billed Charges,60% of Total Billed Charges,4425.44,90,,265.136,Percent of Total Billed Charges,90% of Total Billed Charges,2212.72,45,,194.48,Percent of Total Billed Charges,45% of Total Billed Charges,4425.44,90,,916.84,Percent of Total Billed Charges,90% of Total billed Charges,4917.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4917.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4917.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3196.15,65,,4317.52,Percent of total Billed Charges,65% of Total Billed Charges,2168.46,44.1,,190.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,4671.29,95,,967.776,Percent of Total Billed Charges,95% of Total Billed Charges,4917.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4327.09,88,,390.408,Percent of Total Billed Charges,88% of Total Billed Charges,4425.44,90,,916.84,Percent of Total Billed charges,90% of Total Billed Charges,2168.46,4917.15,
Z114709575 16MM TH,2780000682,CDM,278,RC,C1713,HCPCS,Outpatient,,,977.92,635.65,,977.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,743.22,76,,346.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,704.1,72,,657.904,Percent of Total Billed Charges,72% of Total Billed Charges,704.1,72,,657.904,Percent of Total Billed charges,72% of Total Billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704.1,72,,657.904,Percent of Total Billed Charges,72% of Total Billed Charges,586.75,60,,548.248,Percent of Total Billed Charges,60% of Total Billed Charges,880.13,90,,419.92,Percent of Total Billed Charges,90% of Total Billed Charges,440.06,45,,199.64,Percent of Total Billed Charges,45% of Total Billed Charges,880.13,90,,410.392,Percent of Total Billed Charges,90% of Total billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,635.65,65,,1968.712,Percent of total Billed Charges,65% of Total Billed Charges,431.26,44.1,,195.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,929.02,95,,433.192,Percent of Total Billed Charges,95% of Total Billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,860.57,88,,390.408,Percent of Total Billed Charges,88% of Total Billed Charges,880.13,90,,410.392,Percent of Total Billed charges,90% of Total Billed Charges,431.26,977.92,
Z114710075 16MM TH,2780000683,CDM,278,RC,C1713,HCPCS,Outpatient,,,977.92,635.65,,977.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,743.22,76,,3332.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,704.1,72,,11891.12,Percent of Total Billed Charges,72% of Total Billed Charges,704.1,72,,11891.12,Percent of Total Billed charges,72% of Total Billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704.1,72,,11891.12,Percent of Total Billed Charges,72% of Total Billed Charges,586.75,60,,9909.272,Percent of Total Billed Charges,60% of Total Billed Charges,880.13,90,,419.92,Percent of Total Billed Charges,90% of Total Billed Charges,440.06,45,,199.64,Percent of Total Billed Charges,45% of Total Billed Charges,880.13,90,,3945.984,Percent of Total Billed Charges,90% of Total billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,635.65,65,,3406.552,Percent of total Billed Charges,65% of Total Billed Charges,431.26,44.1,,195.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,929.02,95,,4165.2,Percent of Total Billed Charges,95% of Total Billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,860.57,88,,390.408,Percent of Total Billed Charges,88% of Total Billed Charges,880.13,90,,3945.984,Percent of Total Billed charges,90% of Total Billed Charges,431.26,977.92,
Z114710575 16MM TH,2780000684,CDM,278,RC,C1713,HCPCS,Outpatient,,,977.92,635.65,,977.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,743.22,76,,328.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,704.1,72,,3279.984,Percent of Total Billed Charges,72% of Total Billed Charges,704.1,72,,3279.984,Percent of Total Billed charges,72% of Total Billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704.1,72,,3279.984,Percent of Total Billed Charges,72% of Total Billed Charges,586.75,60,,2733.32,Percent of Total Billed Charges,60% of Total Billed Charges,880.13,90,,419.92,Percent of Total Billed Charges,90% of Total Billed Charges,440.06,45,,199.64,Percent of Total Billed Charges,45% of Total Billed Charges,880.13,90,,388.968,Percent of Total Billed Charges,90% of Total billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,635.65,65,,3143.408,Percent of total Billed Charges,65% of Total Billed Charges,431.26,44.1,,195.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,929.02,95,,410.576,Percent of Total Billed Charges,95% of Total Billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,860.57,88,,259.24,Percent of Total Billed Charges,88% of Total Billed Charges,880.13,90,,388.968,Percent of Total Billed charges,90% of Total Billed Charges,431.26,977.92,
Z114711075 16MM TH,2780000685,CDM,278,RC,C1713,HCPCS,Outpatient,,,977.92,635.65,,977.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,743.22,76,,337.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,704.1,72,,5100.008,Percent of Total Billed Charges,72% of Total Billed Charges,704.1,72,,5100.008,Percent of Total Billed charges,72% of Total Billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704.1,72,,5100.008,Percent of Total Billed Charges,72% of Total Billed Charges,586.75,60,,4250.008,Percent of Total Billed Charges,60% of Total Billed Charges,880.13,90,,419.92,Percent of Total Billed Charges,90% of Total Billed Charges,440.06,45,,199.64,Percent of Total Billed Charges,45% of Total Billed Charges,880.13,90,,399.28,Percent of Total Billed Charges,90% of Total billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,635.65,65,,937.92,Percent of total Billed Charges,65% of Total Billed Charges,431.26,44.1,,195.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,929.02,95,,421.464,Percent of Total Billed Charges,95% of Total Billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,860.57,88,,259.24,Percent of Total Billed Charges,88% of Total Billed Charges,880.13,90,,399.28,Percent of Total Billed charges,90% of Total Billed Charges,431.26,977.92,
Z114798 WASHER,2780000686,CDM,278,RC,C1713,HCPCS,Outpatient,,,57.33,37.26,,57.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.57,76,,337.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.28,72,,186.704,Percent of Total Billed Charges,72% of Total Billed Charges,41.28,72,,186.704,Percent of Total Billed charges,72% of Total Billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.28,72,,186.704,Percent of Total Billed Charges,72% of Total Billed Charges,34.4,60,,155.584,Percent of Total Billed Charges,60% of Total Billed Charges,51.6,90,,419.92,Percent of Total Billed Charges,90% of Total Billed Charges,25.8,45,,132.568,Percent of Total Billed Charges,45% of Total Billed Charges,51.6,90,,399.28,Percent of Total Billed Charges,90% of Total billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.26,65,,18013.656,Percent of total Billed Charges,65% of Total Billed Charges,25.28,44.1,,129.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.46,95,,421.464,Percent of Total Billed Charges,95% of Total Billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.45,88,,259.24,Percent of Total Billed Charges,88% of Total Billed Charges,51.6,90,,399.28,Percent of Total Billed charges,90% of Total Billed Charges,25.28,57.33,
Z59903431 REV AFA,2780000687,CDM,278,RC,C1713,HCPCS,Outpatient,,,4392.36,2855.03,,4392.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3338.19,76,,337.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3162.5,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,3162.5,72,,17.784,Percent of Total Billed charges,72% of Total Billed Charges,4392.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3162.5,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,2635.42,60,,14.816,Percent of Total Billed Charges,60% of Total Billed Charges,3953.12,90,,272.272,Percent of Total Billed Charges,90% of Total Billed Charges,1976.56,45,,132.568,Percent of Total Billed Charges,45% of Total Billed Charges,3953.12,90,,399.28,Percent of Total Billed Charges,90% of Total billed Charges,4392.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4392.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4392.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2855.03,65,,2724.896,Percent of total Billed Charges,65% of Total Billed Charges,1937.03,44.1,,129.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,4172.74,95,,421.464,Percent of Total Billed Charges,95% of Total Billed Charges,4392.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3865.28,88,,410.584,Percent of Total Billed Charges,88% of Total Billed Charges,3953.12,90,,399.28,Percent of Total Billed charges,90% of Total Billed Charges,1937.03,4392.36,
Z59903424 REV FAB,2780000688,CDM,278,RC,C1713,HCPCS,Outpatient,,,5065.99,3292.89,,5065.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3850.15,76,,337.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3647.51,72,,2764.328,Percent of Total Billed Charges,72% of Total Billed Charges,3647.51,72,,2764.328,Percent of Total Billed charges,72% of Total Billed Charges,5065.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3647.51,72,,2764.328,Percent of Total Billed Charges,72% of Total Billed Charges,3039.59,60,,2303.608,Percent of Total Billed Charges,60% of Total Billed Charges,4559.39,90,,3319.672,Percent of Total Billed Charges,90% of Total Billed Charges,2279.7,45,,132.568,Percent of Total Billed Charges,45% of Total Billed Charges,4559.39,90,,399.28,Percent of Total Billed Charges,90% of Total billed Charges,5065.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5065.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5065.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3292.89,65,,3064.864,Percent of total Billed Charges,65% of Total Billed Charges,2234.1,44.1,,129.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,4812.69,95,,421.464,Percent of Total Billed Charges,95% of Total Billed Charges,5065.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4458.07,88,,410.584,Percent of Total Billed Charges,88% of Total Billed Charges,4559.39,90,,399.28,Percent of Total Billed charges,90% of Total Billed Charges,2234.1,5065.99,
Z55903423 REV FAB,2780000689,CDM,278,RC,C1713,HCPCS,Outpatient,,,5065.99,3292.89,,5065.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3850.15,76,,223.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3647.51,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,3647.51,72,,212.104,Percent of Total Billed charges,72% of Total Billed Charges,5065.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3647.51,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,3039.59,60,,176.752,Percent of Total Billed Charges,60% of Total Billed Charges,4559.39,90,,227.824,Percent of Total Billed Charges,90% of Total Billed Charges,2279.7,45,,209.96,Percent of Total Billed Charges,45% of Total Billed Charges,4559.39,90,,265.136,Percent of Total Billed Charges,90% of Total billed Charges,5065.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5065.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5065.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3292.89,65,,299,Percent of total Billed Charges,65% of Total Billed Charges,2234.1,44.1,,205.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,4812.69,95,,279.864,Percent of Total Billed Charges,95% of Total Billed Charges,5065.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4458.07,88,,410.584,Percent of Total Billed Charges,88% of Total Billed Charges,4559.39,90,,265.136,Percent of Total Billed charges,90% of Total Billed Charges,2234.1,5065.99,
Z59880310 REV TIBI,2780000690,CDM,278,RC,C1713,HCPCS,Outpatient,,,5599.60,3639.74,,5599.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4255.7,76,,223.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4031.71,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,4031.71,72,,212.104,Percent of Total Billed charges,72% of Total Billed Charges,5599.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4031.71,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,3359.76,60,,176.752,Percent of Total Billed Charges,60% of Total Billed Charges,5039.64,90,,227.824,Percent of Total Billed Charges,90% of Total Billed Charges,2519.82,45,,209.96,Percent of Total Billed Charges,45% of Total Billed Charges,5039.64,90,,265.136,Percent of Total Billed Charges,90% of Total billed Charges,5599.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5599.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5599.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3639.74,65,,46.28,Percent of total Billed Charges,65% of Total Billed Charges,2469.42,44.1,,205.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,5319.62,95,,279.864,Percent of Total Billed Charges,95% of Total Billed Charges,5599.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4927.65,88,,410.584,Percent of Total Billed Charges,88% of Total Billed Charges,5039.64,90,,265.136,Percent of Total Billed charges,90% of Total Billed Charges,2469.42,5599.6,
Z59881113 REV STEM,2780000691,CDM,278,RC,C1713,HCPCS,Outpatient,,,4604.04,2992.63,,4604.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3499.07,76,,223.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3314.91,72,,261,Percent of Total Billed Charges,72% of Total Billed Charges,3314.91,72,,261,Percent of Total Billed charges,72% of Total Billed Charges,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3314.91,72,,261,Percent of Total Billed Charges,72% of Total Billed Charges,2762.42,60,,217.504,Percent of Total Billed Charges,60% of Total Billed Charges,4143.64,90,,221.472,Percent of Total Billed Charges,90% of Total Billed Charges,2071.82,45,,209.96,Percent of Total Billed Charges,45% of Total Billed Charges,4143.64,90,,265.136,Percent of Total Billed Charges,90% of Total billed Charges,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2992.63,65,,14.328,Percent of total Billed Charges,65% of Total Billed Charges,2030.38,44.1,,205.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,4373.84,95,,279.864,Percent of Total Billed Charges,95% of Total Billed Charges,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4051.56,88,,410.584,Percent of Total Billed Charges,88% of Total Billed Charges,4143.64,90,,265.136,Percent of Total Billed charges,90% of Total Billed Charges,2030.38,4604.04,
Z59803701 REV STEM,2780000692,CDM,278,RC,C1713,HCPCS,Outpatient,,,7977.69,5185.50,,7977.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6063.04,76,,354.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5743.94,72,,261,Percent of Total Billed Charges,72% of Total Billed Charges,5743.94,72,,261,Percent of Total Billed charges,72% of Total Billed Charges,7977.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5743.94,72,,261,Percent of Total Billed Charges,72% of Total Billed Charges,4786.61,60,,217.504,Percent of Total Billed Charges,60% of Total Billed Charges,7179.92,90,,239.728,Percent of Total Billed Charges,90% of Total Billed Charges,3589.96,45,,209.96,Percent of Total Billed Charges,45% of Total Billed Charges,7179.92,90,,419.92,Percent of Total Billed Charges,90% of Total billed Charges,7977.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7977.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7977.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5185.5,65,,308.44,Percent of total Billed Charges,65% of Total Billed Charges,3518.16,44.1,,205.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,7578.81,95,,443.248,Percent of Total Billed Charges,95% of Total Billed Charges,7977.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7020.37,88,,266.224,Percent of Total Billed Charges,88% of Total Billed Charges,7179.92,90,,419.92,Percent of Total Billed charges,90% of Total Billed Charges,3518.16,7977.69,
Z59941491 REV FEM/,2780000693,CDM,278,RC,C1713,HCPCS,Outpatient,,,25161.26,16354.82,,25161.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19122.56,76,,354.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18116.11,72,,261,Percent of Total Billed Charges,72% of Total Billed Charges,18116.11,72,,261,Percent of Total Billed charges,72% of Total Billed Charges,25161.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18116.11,72,,261,Percent of Total Billed Charges,72% of Total Billed Charges,15096.76,60,,217.504,Percent of Total Billed Charges,60% of Total Billed Charges,22645.13,90,,146.848,Percent of Total Billed Charges,90% of Total Billed Charges,11322.57,45,,209.96,Percent of Total Billed Charges,45% of Total Billed Charges,22645.13,90,,419.92,Percent of Total Billed Charges,90% of Total billed Charges,25161.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25161.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25161.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16354.82,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,11096.12,44.1,,205.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,23903.2,95,,443.248,Percent of Total Billed Charges,95% of Total Billed Charges,25161.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22141.91,88,,3245.904,Percent of Total Billed Charges,88% of Total Billed Charges,22645.13,90,,419.92,Percent of Total Billed charges,90% of Total Billed Charges,11096.12,25161.26,
Z59943017 REV ART,2780000694,CDM,278,RC,C1713,HCPCS,Outpatient,,,8132.04,5285.83,,8132.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6180.35,76,,354.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5855.07,72,,3716.256,Percent of Total Billed Charges,72% of Total Billed Charges,5855.07,72,,3716.256,Percent of Total Billed charges,72% of Total Billed Charges,8132.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5855.07,72,,3716.256,Percent of Total Billed Charges,72% of Total Billed Charges,4879.22,60,,3096.88,Percent of Total Billed Charges,60% of Total Billed Charges,7318.84,90,,2011.496,Percent of Total Billed Charges,90% of Total Billed Charges,3659.42,45,,136.136,Percent of Total Billed Charges,45% of Total Billed Charges,7318.84,90,,419.92,Percent of Total Billed Charges,90% of Total billed Charges,8132.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8132.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8132.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5285.83,65,,1108.184,Percent of total Billed Charges,65% of Total Billed Charges,3586.23,44.1,,133.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,7725.44,95,,443.248,Percent of Total Billed Charges,95% of Total Billed Charges,8132.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7156.2,88,,222.76,Percent of Total Billed Charges,88% of Total Billed Charges,7318.84,90,,419.92,Percent of Total Billed charges,90% of Total Billed Charges,3586.23,8132.04,
Z225736001 I7S7 11,2780000695,CDM,278,RC,C1713,HCPCS,Outpatient,,,6440.81,4186.53,,6440.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4895.02,76,,354.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4637.38,72,,1877.176,Percent of Total Billed Charges,72% of Total Billed Charges,4637.38,72,,1877.176,Percent of Total Billed charges,72% of Total Billed Charges,6440.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4637.38,72,,1877.176,Percent of Total Billed Charges,72% of Total Billed Charges,3864.49,60,,1564.312,Percent of Total Billed Charges,60% of Total Billed Charges,5796.73,90,,4532.6,Percent of Total Billed Charges,90% of Total Billed Charges,2898.36,45,,1659.84,Percent of Total Billed Charges,45% of Total Billed Charges,5796.73,90,,419.92,Percent of Total Billed Charges,90% of Total billed Charges,6440.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6440.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6440.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4186.53,65,,435.712,Percent of total Billed Charges,65% of Total Billed Charges,2840.4,44.1,,1626.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,6118.77,95,,443.248,Percent of Total Billed Charges,95% of Total Billed Charges,6440.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5667.91,88,,222.76,Percent of Total Billed Charges,88% of Total Billed Charges,5796.73,90,,419.92,Percent of Total Billed charges,90% of Total Billed Charges,2840.4,6440.81,
Z59963017 ART SURF,2780000696,CDM,278,RC,C1713,HCPCS,Outpatient,,,4918.25,3196.86,,4918.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3737.87,76,,354.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3541.14,72,,1686.032,Percent of Total Billed Charges,72% of Total Billed Charges,3541.14,72,,1686.032,Percent of Total Billed charges,72% of Total Billed Charges,4918.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3541.14,72,,1686.032,Percent of Total Billed Charges,72% of Total Billed Charges,2950.95,60,,1405.024,Percent of Total Billed Charges,60% of Total Billed Charges,4426.43,90,,9914.568,Percent of Total Billed Charges,90% of Total Billed Charges,2213.21,45,,113.912,Percent of Total Billed Charges,45% of Total Billed Charges,4426.43,90,,419.92,Percent of Total Billed Charges,90% of Total billed Charges,4918.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4918.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4918.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3196.86,65,,315.888,Percent of total Billed Charges,65% of Total Billed Charges,2168.95,44.1,,111.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,4672.34,95,,443.248,Percent of Total Billed Charges,95% of Total Billed Charges,4918.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4328.06,88,,216.552,Percent of Total Billed Charges,88% of Total Billed Charges,4426.43,90,,419.92,Percent of Total Billed charges,90% of Total Billed Charges,2168.95,4918.25,
Z1147757.5 SCW 65,2780000697,CDM,278,RC,C1713,HCPCS,Outpatient,,,977.92,635.65,,977.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,743.22,76,,229.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,704.1,72,,187.336,Percent of Total Billed Charges,72% of Total Billed Charges,704.1,72,,187.336,Percent of Total Billed charges,72% of Total Billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704.1,72,,187.336,Percent of Total Billed Charges,72% of Total Billed Charges,586.75,60,,156.112,Percent of Total Billed Charges,60% of Total Billed Charges,880.13,90,,3356.184,Percent of Total Billed Charges,90% of Total Billed Charges,440.06,45,,113.912,Percent of Total Billed Charges,45% of Total Billed Charges,880.13,90,,272.272,Percent of Total Billed Charges,90% of Total billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,635.65,65,,315.888,Percent of total Billed Charges,65% of Total Billed Charges,431.26,44.1,,111.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,929.02,95,,287.4,Percent of Total Billed Charges,95% of Total Billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,860.57,88,,234.4,Percent of Total Billed Charges,88% of Total Billed Charges,880.13,90,,272.272,Percent of Total Billed charges,90% of Total Billed Charges,431.26,977.92,
Z1147707.5 SCW 70,2780000698,CDM,278,RC,C1713,HCPCS,Outpatient,,,977.92,635.65,,977.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,743.22,76,,2803.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,704.1,72,,187.336,Percent of Total Billed Charges,72% of Total Billed Charges,704.1,72,,187.336,Percent of Total Billed charges,72% of Total Billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704.1,72,,187.336,Percent of Total Billed Charges,72% of Total Billed Charges,586.75,60,,156.112,Percent of Total Billed Charges,60% of Total Billed Charges,880.13,90,,5978.112,Percent of Total Billed Charges,90% of Total Billed Charges,440.06,45,,110.736,Percent of Total Billed Charges,45% of Total Billed Charges,880.13,90,,3319.672,Percent of Total Billed Charges,90% of Total billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,635.65,65,,315.888,Percent of total Billed Charges,65% of Total Billed Charges,431.26,44.1,,108.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,929.02,95,,3504.104,Percent of Total Billed Charges,95% of Total Billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,860.57,88,,143.584,Percent of Total Billed Charges,88% of Total Billed Charges,880.13,90,,3319.672,Percent of Total Billed charges,90% of Total Billed Charges,431.26,977.92,
Z114788GUIDE PIN 3,2780000699,CDM,278,RC,C1713,HCPCS,Outpatient,,,112.46,73.10,,112.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,85.47,76,,192.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,80.97,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,80.97,72,,212.104,Percent of Total Billed charges,72% of Total Billed Charges,112.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.97,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,67.48,60,,176.752,Percent of Total Billed Charges,60% of Total Billed Charges,101.21,90,,2725.912,Percent of Total Billed Charges,90% of Total Billed Charges,50.61,45,,119.864,Percent of Total Billed Charges,45% of Total Billed Charges,101.21,90,,227.824,Percent of Total Billed Charges,90% of Total billed Charges,112.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.1,65,,335.92,Percent of total Billed Charges,65% of Total Billed Charges,49.59,44.1,,117.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,106.84,95,,240.48,Percent of Total Billed Charges,95% of Total Billed Charges,112.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.96,88,,1966.792,Percent of Total Billed Charges,88% of Total Billed Charges,101.21,90,,227.824,Percent of Total Billed charges,90% of Total Billed Charges,49.59,112.46,
Z23603332 GUIDEWIRE,2780000700,CDM,278,RC,C1713,HCPCS,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,192.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,56.36,72,,212.104,Percent of Total Billed charges,72% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,212.104,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,176.752,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,4716.76,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,73.424,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,227.824,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,205.248,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,71.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,240.48,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,4431.88,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,227.824,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
Z23594055 5.5 CANN,2780000701,CDM,278,RC,C1713,HCPCS,Outpatient,,,839.00,545.35,,839,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,637.64,76,,187.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,604.08,72,,236.872,Percent of Total Billed Charges,72% of Total Billed Charges,604.08,72,,236.872,Percent of Total Billed charges,72% of Total Billed Charges,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,604.08,72,,236.872,Percent of Total Billed Charges,72% of Total Billed Charges,503.4,60,,197.392,Percent of Total Billed Charges,60% of Total Billed Charges,755.1,90,,4352.408,Percent of Total Billed Charges,90% of Total Billed Charges,377.55,45,,1005.744,Percent of Total Billed Charges,45% of Total Billed Charges,755.1,90,,221.472,Percent of Total Billed Charges,90% of Total billed Charges,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,545.35,65,,205.248,Percent of total Billed Charges,65% of Total Billed Charges,370,44.1,,985.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,797.05,95,,233.776,Percent of Total Billed Charges,95% of Total Billed Charges,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,738.32,88,,9694.24,Percent of Total Billed Charges,88% of Total Billed Charges,755.1,90,,221.472,Percent of Total Billed charges,90% of Total Billed Charges,370,839,
Z23594555 5.5 CANN,2780000702,CDM,278,RC,C1713,HCPCS,Outpatient,,,839.00,545.35,,839,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,637.64,76,,202.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,604.08,72,,2934.52,Percent of Total Billed Charges,72% of Total Billed Charges,604.08,72,,2934.52,Percent of Total Billed charges,72% of Total Billed Charges,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,604.08,72,,2934.52,Percent of Total Billed Charges,72% of Total Billed Charges,503.4,60,,2445.432,Percent of Total Billed Charges,60% of Total Billed Charges,755.1,90,,1298.656,Percent of Total Billed Charges,90% of Total Billed Charges,377.55,45,,2266.304,Percent of Total Billed Charges,45% of Total Billed Charges,755.1,90,,239.728,Percent of Total Billed Charges,90% of Total billed Charges,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,545.35,65,,205.248,Percent of total Billed Charges,65% of Total Billed Charges,370,44.1,,2220.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,797.05,95,,253.048,Percent of Total Billed Charges,95% of Total Billed Charges,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,738.32,88,,3281.608,Percent of Total Billed Charges,88% of Total Billed Charges,755.1,90,,239.728,Percent of Total Billed charges,90% of Total Billed Charges,370,839,
Z23595055 CANN/LCK,2780000703,CDM,278,RC,C1713,HCPCS,Outpatient,,,839.00,545.35,,839,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,637.64,76,,124.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,604.08,72,,6222.76,Percent of Total Billed Charges,72% of Total Billed Charges,604.08,72,,6222.76,Percent of Total Billed charges,72% of Total Billed Charges,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,604.08,72,,6222.76,Percent of Total Billed Charges,72% of Total Billed Charges,503.4,60,,5185.632,Percent of Total Billed Charges,60% of Total Billed Charges,755.1,90,,24941.992,Percent of Total Billed Charges,90% of Total Billed Charges,377.55,45,,4957.28,Percent of Total Billed Charges,45% of Total Billed Charges,755.1,90,,146.848,Percent of Total Billed Charges,90% of Total billed Charges,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,545.35,65,,205.248,Percent of total Billed Charges,65% of Total Billed Charges,370,44.1,,4858.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,797.05,95,,155.008,Percent of Total Billed Charges,95% of Total Billed Charges,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,738.32,88,,5845.264,Percent of Total Billed Charges,88% of Total Billed Charges,755.1,90,,146.848,Percent of Total Billed charges,90% of Total Billed Charges,370,839,
Z23596555 5.5 CANN,2780000704,CDM,278,RC,C1713,HCPCS,Outpatient,,,839.00,545.35,,839,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,637.64,76,,1698.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,604.08,72,,104.784,Percent of Total Billed Charges,72% of Total Billed Charges,604.08,72,,104.784,Percent of Total Billed charges,72% of Total Billed Charges,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,604.08,72,,104.784,Percent of Total Billed Charges,72% of Total Billed Charges,503.4,60,,87.32,Percent of Total Billed Charges,60% of Total Billed Charges,755.1,90,,3772.928,Percent of Total Billed Charges,90% of Total Billed Charges,377.55,45,,1678.096,Percent of Total Billed Charges,45% of Total Billed Charges,755.1,90,,2011.496,Percent of Total Billed Charges,90% of Total billed Charges,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,545.35,65,,4282.552,Percent of total Billed Charges,65% of Total Billed Charges,370,44.1,,1644.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,797.05,95,,2123.24,Percent of Total Billed Charges,95% of Total Billed Charges,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,738.32,88,,2665.336,Percent of Total Billed Charges,88% of Total Billed Charges,755.1,90,,2011.496,Percent of Total Billed charges,90% of Total Billed Charges,370,839,
Z23597055 5.5 CANN,2780000705,CDM,278,RC,C1713,HCPCS,Outpatient,,,839.00,545.35,,839,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,637.64,76,,3827.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,604.08,72,,104.784,Percent of Total Billed Charges,72% of Total Billed Charges,604.08,72,,104.784,Percent of Total Billed charges,72% of Total Billed Charges,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,604.08,72,,104.784,Percent of Total Billed Charges,72% of Total Billed Charges,503.4,60,,87.32,Percent of Total Billed Charges,60% of Total Billed Charges,755.1,90,,4243.656,Percent of Total Billed Charges,90% of Total Billed Charges,377.55,45,,2989.056,Percent of Total Billed Charges,45% of Total Billed Charges,755.1,90,,4532.6,Percent of Total Billed Charges,90% of Total billed Charges,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,545.35,65,,7034.968,Percent of total Billed Charges,65% of Total Billed Charges,370,44.1,,2929.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,797.05,95,,4784.416,Percent of Total Billed Charges,95% of Total Billed Charges,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,738.32,88,,4611.944,Percent of Total Billed Charges,88% of Total Billed Charges,755.1,90,,4532.6,Percent of Total Billed charges,90% of Total Billed Charges,370,839,
Z23597555 5.5 CANN,2780000706,CDM,278,RC,C1713,HCPCS,Outpatient,,,839.00,545.35,,839,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,637.64,76,,8372.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,604.08,72,,823.648,Percent of Total Billed Charges,72% of Total Billed Charges,604.08,72,,823.648,Percent of Total Billed charges,72% of Total Billed Charges,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,604.08,72,,823.648,Percent of Total Billed Charges,72% of Total Billed Charges,503.4,60,,686.368,Percent of Total Billed Charges,60% of Total Billed Charges,755.1,90,,414,Percent of Total Billed Charges,90% of Total Billed Charges,377.55,45,,1362.96,Percent of Total Billed Charges,45% of Total Billed Charges,755.1,90,,9914.568,Percent of Total Billed Charges,90% of Total billed Charges,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,545.35,65,,2799.424,Percent of total Billed Charges,65% of Total Billed Charges,370,44.1,,1335.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,797.05,95,,10465.376,Percent of Total Billed Charges,95% of Total Billed Charges,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,738.32,88,,4255.688,Percent of Total Billed Charges,88% of Total Billed Charges,755.1,90,,9914.568,Percent of Total Billed charges,90% of Total Billed Charges,370,839,
Z23598055 5.5 CANN,2780000707,CDM,278,RC,C1713,HCPCS,Outpatient,,,839.00,545.35,,839,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,637.64,76,,2834.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,604.08,72,,580.432,Percent of Total Billed Charges,72% of Total Billed Charges,604.08,72,,580.432,Percent of Total Billed charges,72% of Total Billed Charges,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,604.08,72,,580.432,Percent of Total Billed Charges,72% of Total Billed Charges,503.4,60,,483.688,Percent of Total Billed Charges,60% of Total Billed Charges,755.1,90,,64.08,Percent of Total Billed Charges,90% of Total Billed Charges,377.55,45,,2358.384,Percent of Total Billed Charges,45% of Total Billed Charges,755.1,90,,3356.184,Percent of Total Billed Charges,90% of Total billed Charges,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,545.35,65,,91.728,Percent of total Billed Charges,65% of Total Billed Charges,370,44.1,,2311.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,797.05,95,,3542.64,Percent of Total Billed Charges,95% of Total Billed Charges,839,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,738.32,88,,1269.8,Percent of Total Billed Charges,88% of Total Billed Charges,755.1,90,,3356.184,Percent of Total Billed charges,90% of Total Billed Charges,370,839,
Z23472338 4.5 CORT,2780000708,CDM,278,RC,C1713,HCPCS,Outpatient,,,140.02,91.01,,140.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.42,76,,5048.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.81,72,,85.728,Percent of Total Billed Charges,72% of Total Billed Charges,100.81,72,,85.728,Percent of Total Billed charges,72% of Total Billed Charges,140.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.81,72,,85.728,Percent of Total Billed Charges,72% of Total Billed Charges,84.01,60,,71.44,Percent of Total Billed Charges,60% of Total Billed Charges,126.02,90,,19.84,Percent of Total Billed Charges,90% of Total Billed Charges,63.01,45,,2176.2,Percent of Total Billed Charges,45% of Total Billed Charges,126.02,90,,5978.112,Percent of Total Billed Charges,90% of Total billed Charges,140.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.01,65,,126.88,Percent of total Billed Charges,65% of Total Billed Charges,61.75,44.1,,2132.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,133.02,95,,6310.224,Percent of Total Billed Charges,95% of Total Billed Charges,140.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.22,88,,24387.72,Percent of Total Billed Charges,88% of Total Billed Charges,126.02,90,,5978.112,Percent of Total Billed charges,90% of Total Billed Charges,61.75,140.02,
Z235710206 DIS/LAF,2780000709,CDM,278,RC,C1713,HCPCS,Outpatient,,,6364.73,4137.07,,6364.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4837.19,76,,2301.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4582.61,72,,1139.264,Percent of Total Billed Charges,72% of Total Billed Charges,4582.61,72,,1139.264,Percent of Total Billed charges,72% of Total Billed Charges,6364.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4582.61,72,,1139.264,Percent of Total Billed Charges,72% of Total Billed Charges,3818.84,60,,949.384,Percent of Total Billed Charges,60% of Total Billed Charges,5728.26,90,,427.072,Percent of Total Billed Charges,90% of Total Billed Charges,2864.13,45,,649.328,Percent of Total Billed Charges,45% of Total Billed Charges,5728.26,90,,2725.912,Percent of Total Billed Charges,90% of Total billed Charges,6364.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6364.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6364.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4137.07,65,,205.816,Percent of total Billed Charges,65% of Total Billed Charges,2806.85,44.1,,636.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,6046.49,95,,2877.352,Percent of Total Billed Charges,95% of Total Billed Charges,6364.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5600.96,88,,3689.088,Percent of Total Billed Charges,88% of Total Billed Charges,5728.26,90,,2725.912,Percent of Total Billed charges,90% of Total Billed Charges,2806.85,6364.73,
Z00110507016 COPI,2780000710,CDM,278,RC,C1713,HCPCS,Outpatient,,,2260.13,1469.08,,2260.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1717.7,76,,3983.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1627.29,72,,823.648,Percent of Total Billed Charges,72% of Total Billed Charges,1627.29,72,,823.648,Percent of Total Billed charges,72% of Total Billed Charges,2260.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1627.29,72,,823.648,Percent of Total Billed Charges,72% of Total Billed Charges,1356.08,60,,686.368,Percent of Total Billed Charges,60% of Total Billed Charges,2034.12,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,1017.06,45,,12470.992,Percent of Total Billed Charges,45% of Total Billed Charges,2034.12,90,,4716.76,Percent of Total Billed Charges,90% of Total billed Charges,2260.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2260.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2260.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1469.08,65,,2623.992,Percent of total Billed Charges,65% of Total Billed Charges,996.72,44.1,,12221.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,2147.12,95,,4978.808,Percent of Total Billed Charges,95% of Total Billed Charges,2260.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1988.91,88,,4149.352,Percent of Total Billed Charges,88% of Total Billed Charges,2034.12,90,,4716.76,Percent of Total Billed charges,90% of Total Billed Charges,996.72,2260.13,
Z00110301010 COPI,2780000711,CDM,278,RC,C1713,HCPCS,Outpatient,,,8136.45,5288.69,,8136.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6183.7,76,,3675.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5858.24,72,,120.664,Percent of Total Billed Charges,72% of Total Billed Charges,5858.24,72,,120.664,Percent of Total Billed charges,72% of Total Billed Charges,8136.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5858.24,72,,120.664,Percent of Total Billed Charges,72% of Total Billed Charges,4881.87,60,,100.552,Percent of Total Billed Charges,60% of Total Billed Charges,7322.81,90,,1534.416,Percent of Total Billed Charges,90% of Total Billed Charges,3661.4,45,,1886.464,Percent of Total Billed Charges,45% of Total Billed Charges,7322.81,90,,4352.408,Percent of Total Billed Charges,90% of Total billed Charges,8136.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8136.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8136.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5288.69,65,,303.272,Percent of total Billed Charges,65% of Total Billed Charges,3588.17,44.1,,1848.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,7729.63,95,,4594.208,Percent of Total Billed Charges,95% of Total Billed Charges,8136.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7160.08,88,,404.8,Percent of Total Billed Charges,88% of Total Billed Charges,7322.81,90,,4352.408,Percent of Total Billed charges,90% of Total Billed Charges,3588.17,8136.45,
Z783413 FEM STEM PR,2780000712,CDM,278,RC,C1713,HCPCS,Outpatient,,,7543.31,4903.15,,7543.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5732.92,76,,1096.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5431.18,72,,120.664,Percent of Total Billed Charges,72% of Total Billed Charges,5431.18,72,,120.664,Percent of Total Billed charges,72% of Total Billed Charges,7543.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5431.18,72,,120.664,Percent of Total Billed Charges,72% of Total Billed Charges,4525.99,60,,100.552,Percent of Total Billed Charges,60% of Total Billed Charges,6788.98,90,,603.288,Percent of Total Billed Charges,90% of Total Billed Charges,3394.49,45,,2121.832,Percent of Total Billed Charges,45% of Total Billed Charges,6788.98,90,,1298.656,Percent of Total Billed Charges,90% of Total billed Charges,7543.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7543.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7543.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4903.15,65,,303.272,Percent of total Billed Charges,65% of Total Billed Charges,3326.6,44.1,,2079.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,7166.14,95,,1370.808,Percent of Total Billed Charges,95% of Total Billed Charges,7543.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6638.11,88,,62.656,Percent of Total Billed Charges,88% of Total Billed Charges,6788.98,90,,1298.656,Percent of Total Billed charges,90% of Total Billed Charges,3326.6,7543.31,
Z62506540 BONE SCE,2780000713,CDM,278,RC,C1713,HCPCS,Outpatient,,,581.02,377.66,,581.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,441.58,76,,21062.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,418.33,72,,483.904,Percent of Total Billed Charges,72% of Total Billed Charges,418.33,72,,483.904,Percent of Total Billed charges,72% of Total Billed Charges,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,418.33,72,,483.904,Percent of Total Billed Charges,72% of Total Billed Charges,348.61,60,,403.256,Percent of Total Billed Charges,60% of Total Billed Charges,522.92,90,,437.384,Percent of Total Billed Charges,90% of Total Billed Charges,261.46,45,,207,Percent of Total Billed Charges,45% of Total Billed Charges,522.92,90,,24941.992,Percent of Total Billed Charges,90% of Total billed Charges,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.66,65,,303.272,Percent of total Billed Charges,65% of Total Billed Charges,256.23,44.1,,202.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,551.97,95,,26327.656,Percent of Total Billed Charges,95% of Total Billed Charges,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511.3,88,,19.4,Percent of Total Billed Charges,88% of Total Billed Charges,522.92,90,,24941.992,Percent of Total Billed charges,90% of Total Billed Charges,256.23,581.02,
Z62506560 BONE SCR,2780000714,CDM,278,RC,C1713,HCPCS,Outpatient,,,581.02,377.66,,581.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,441.58,76,,3186.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,418.33,72,,8802.928,Percent of Total Billed Charges,72% of Total Billed Charges,418.33,72,,8802.928,Percent of Total Billed charges,72% of Total Billed Charges,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,418.33,72,,8802.928,Percent of Total Billed Charges,72% of Total Billed Charges,348.61,60,,7335.776,Percent of Total Billed Charges,60% of Total Billed Charges,522.92,90,,437.384,Percent of Total Billed Charges,90% of Total Billed Charges,261.46,45,,32.04,Percent of Total Billed Charges,45% of Total Billed Charges,522.92,90,,3772.928,Percent of Total Billed Charges,90% of Total billed Charges,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.66,65,,260.856,Percent of total Billed Charges,65% of Total Billed Charges,256.23,44.1,,31.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,551.97,95,,3982.536,Percent of Total Billed Charges,95% of Total Billed Charges,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511.3,88,,417.576,Percent of Total Billed Charges,88% of Total Billed Charges,522.92,90,,3772.928,Percent of Total Billed charges,90% of Total Billed Charges,256.23,581.02,
Z62506530 BONE SCR,2780000715,CDM,278,RC,C1713,HCPCS,Outpatient,,,581.02,377.66,,581.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,441.58,76,,3583.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,418.33,72,,282.592,Percent of Total Billed Charges,72% of Total Billed Charges,418.33,72,,282.592,Percent of Total Billed charges,72% of Total Billed Charges,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,418.33,72,,282.592,Percent of Total Billed Charges,72% of Total Billed Charges,348.61,60,,235.496,Percent of Total Billed Charges,60% of Total Billed Charges,522.92,90,,437.384,Percent of Total Billed Charges,90% of Total Billed Charges,261.46,45,,9.92,Percent of Total Billed Charges,45% of Total Billed Charges,522.92,90,,4243.656,Percent of Total Billed Charges,90% of Total billed Charges,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.66,65,,9431.36,Percent of total Billed Charges,65% of Total Billed Charges,256.23,44.1,,9.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,551.97,95,,4479.416,Percent of Total Billed Charges,95% of Total Billed Charges,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511.3,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,522.92,90,,4243.656,Percent of Total Billed charges,90% of Total Billed Charges,256.23,581.02,
Z63056236 TRILOGY,2780000716,CDM,278,RC,C1713,HCPCS,Outpatient,,,7161.84,4655.20,,7161.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5443,76,,349.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5156.52,72,,245.128,Percent of Total Billed Charges,72% of Total Billed Charges,5156.52,72,,245.128,Percent of Total Billed charges,72% of Total Billed Charges,7161.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5156.52,72,,245.128,Percent of Total Billed Charges,72% of Total Billed Charges,4297.1,60,,204.272,Percent of Total Billed Charges,60% of Total Billed Charges,6445.66,90,,465.12,Percent of Total Billed Charges,90% of Total Billed Charges,3222.83,45,,213.536,Percent of Total Billed Charges,45% of Total Billed Charges,6445.66,90,,414,Percent of Total Billed Charges,90% of Total billed Charges,7161.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7161.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7161.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4655.2,65,,593.936,Percent of total Billed Charges,65% of Total Billed Charges,3158.37,44.1,,209.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,6803.75,95,,437,Percent of Total Billed Charges,95% of Total Billed Charges,7161.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6302.42,88,,1500.312,Percent of Total Billed Charges,88% of Total Billed Charges,6445.66,90,,414,Percent of Total Billed charges,90% of Total Billed Charges,3158.37,7161.84,
Z80183602 VERSYS F,2780000717,CDM,278,RC,C1713,HCPCS,Outpatient,,,4197.22,2728.19,,4197.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3189.89,76,,54.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3022,72,,1227.528,Percent of Total Billed Charges,72% of Total Billed Charges,3022,72,,1227.528,Percent of Total Billed charges,72% of Total Billed Charges,4197.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3022,72,,1227.528,Percent of Total Billed Charges,72% of Total Billed Charges,2518.33,60,,1022.944,Percent of Total Billed Charges,60% of Total Billed Charges,3777.5,90,,284.184,Percent of Total Billed Charges,90% of Total Billed Charges,1888.75,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,3777.5,90,,64.08,Percent of Total Billed Charges,90% of Total billed Charges,4197.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4197.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4197.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2728.19,65,,13.184,Percent of total Billed Charges,65% of Total Billed Charges,1850.97,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,3987.36,95,,67.64,Percent of Total Billed Charges,95% of Total Billed Charges,4197.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3693.55,88,,589.88,Percent of Total Billed Charges,88% of Total Billed Charges,3777.5,90,,64.08,Percent of Total Billed charges,90% of Total Billed Charges,1850.97,4197.22,
Z62506550 BONE SCR,2780000718,CDM,278,RC,C1713,HCPCS,Outpatient,,,581.02,377.66,,581.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,441.58,76,,16.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,418.33,72,,147.328,Percent of Total Billed Charges,72% of Total Billed Charges,418.33,72,,147.328,Percent of Total Billed charges,72% of Total Billed Charges,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,418.33,72,,147.328,Percent of Total Billed Charges,72% of Total Billed Charges,348.61,60,,122.776,Percent of Total Billed Charges,60% of Total Billed Charges,522.92,90,,284.184,Percent of Total Billed Charges,90% of Total Billed Charges,261.46,45,,767.208,Percent of Total Billed Charges,45% of Total Billed Charges,522.92,90,,19.84,Percent of Total Billed Charges,90% of Total billed Charges,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.66,65,,1108.184,Percent of total Billed Charges,65% of Total Billed Charges,256.23,44.1,,751.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,551.97,95,,20.944,Percent of Total Billed Charges,95% of Total Billed Charges,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511.3,88,,427.664,Percent of Total Billed Charges,88% of Total Billed Charges,522.92,90,,19.84,Percent of Total Billed charges,90% of Total Billed Charges,256.23,581.02,
Z44535020 TRANSFX,2780000719,CDM,278,RC,C1713,HCPCS,Outpatient,,,336.26,218.57,,336.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,255.56,76,,360.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,242.11,72,,5284.808,Percent of Total Billed Charges,72% of Total Billed Charges,242.11,72,,5284.808,Percent of Total Billed charges,72% of Total Billed Charges,336.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.11,72,,5284.808,Percent of Total Billed Charges,72% of Total Billed Charges,201.76,60,,4404.008,Percent of Total Billed Charges,60% of Total Billed Charges,302.63,90,,284.184,Percent of Total Billed Charges,90% of Total Billed Charges,151.32,45,,301.648,Percent of Total Billed Charges,45% of Total Billed Charges,302.63,90,,427.072,Percent of Total Billed Charges,90% of Total billed Charges,336.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,336.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,336.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.57,65,,4771.008,Percent of total Billed Charges,65% of Total Billed Charges,148.29,44.1,,295.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,319.45,95,,450.792,Percent of Total Billed Charges,95% of Total Billed Charges,336.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.91,88,,427.664,Percent of Total Billed Charges,88% of Total Billed Charges,302.63,90,,427.072,Percent of Total Billed charges,90% of Total Billed Charges,148.29,336.26,
Z44535630 TRANSFX,2780000720,CDM,278,RC,C1713,HCPCS,Outpatient,,,417.85,271.60,,417.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,317.57,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,300.85,72,,617.896,Percent of Total Billed Charges,72% of Total Billed Charges,300.85,72,,617.896,Percent of Total Billed charges,72% of Total Billed Charges,417.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.85,72,,617.896,Percent of Total Billed Charges,72% of Total Billed Charges,250.71,60,,514.912,Percent of Total Billed Charges,60% of Total Billed Charges,376.07,90,,284.184,Percent of Total Billed Charges,90% of Total Billed Charges,188.03,45,,218.696,Percent of Total Billed Charges,45% of Total Billed Charges,376.07,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,417.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.6,65,,2961.096,Percent of total Billed Charges,65% of Total Billed Charges,184.27,44.1,,214.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,396.96,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,417.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,367.71,88,,427.664,Percent of Total Billed Charges,88% of Total Billed Charges,376.07,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,184.27,417.85,
Z44510112 TRANSFX,2780000721,CDM,278,RC,C1713,HCPCS,Outpatient,,,284.45,184.89,,284.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,216.18,76,,1295.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,204.8,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,204.8,72,,34.928,Percent of Total Billed charges,72% of Total Billed Charges,284.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.8,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,170.67,60,,29.104,Percent of Total Billed Charges,60% of Total Billed Charges,256.01,90,,5929.688,Percent of Total Billed Charges,90% of Total Billed Charges,128,45,,218.696,Percent of Total Billed Charges,45% of Total Billed Charges,256.01,90,,1534.416,Percent of Total Billed Charges,90% of Total billed Charges,284.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.89,65,,10734.472,Percent of total Billed Charges,65% of Total Billed Charges,125.44,44.1,,214.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,270.23,95,,1619.656,Percent of Total Billed Charges,95% of Total Billed Charges,284.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.32,88,,454.784,Percent of Total Billed Charges,88% of Total Billed Charges,256.01,90,,1534.416,Percent of Total Billed charges,90% of Total Billed Charges,125.44,284.45,
Z44510135 TRANSFX,2780000722,CDM,278,RC,C1713,HCPCS,Outpatient,,,305.39,198.50,,305.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,232.1,76,,509.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,219.88,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,219.88,72,,34.928,Percent of Total Billed charges,72% of Total Billed Charges,305.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.88,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,183.23,60,,29.104,Percent of Total Billed Charges,60% of Total Billed Charges,274.85,90,,9740.72,Percent of Total Billed Charges,90% of Total Billed Charges,137.43,45,,218.696,Percent of Total Billed Charges,45% of Total Billed Charges,274.85,90,,603.288,Percent of Total Billed Charges,90% of Total billed Charges,305.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.5,65,,393.288,Percent of total Billed Charges,65% of Total Billed Charges,134.68,44.1,,214.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,290.12,95,,636.808,Percent of Total Billed Charges,95% of Total Billed Charges,305.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.74,88,,277.872,Percent of Total Billed Charges,88% of Total Billed Charges,274.85,90,,603.288,Percent of Total Billed charges,90% of Total Billed Charges,134.68,305.39,
Z59903423 REV FAB,2780000723,CDM,278,RC,C1713,HCPCS,Outpatient,,,5065.99,3292.89,,5065.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3850.15,76,,369.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3647.51,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,3647.51,72,,34.928,Percent of Total Billed charges,72% of Total Billed Charges,5065.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3647.51,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,3039.59,60,,29.104,Percent of Total Billed Charges,60% of Total Billed Charges,4559.39,90,,3876.128,Percent of Total Billed Charges,90% of Total Billed Charges,2279.7,45,,232.56,Percent of Total Billed Charges,45% of Total Billed Charges,4559.39,90,,437.384,Percent of Total Billed Charges,90% of Total billed Charges,5065.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5065.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5065.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3292.89,65,,60.192,Percent of total Billed Charges,65% of Total Billed Charges,2234.1,44.1,,227.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,4812.69,95,,461.688,Percent of Total Billed Charges,95% of Total Billed Charges,5065.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4458.07,88,,277.872,Percent of Total Billed Charges,88% of Total Billed Charges,4559.39,90,,437.384,Percent of Total Billed charges,90% of Total Billed Charges,2234.1,5065.99,
Z49350807 3.5COMP/,2780000724,CDM,278,RC,C1713,HCPCS,Outpatient,,,530.30,344.70,,530.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,403.03,76,,369.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,381.82,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,381.82,72,,34.928,Percent of Total Billed charges,72% of Total Billed Charges,530.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.82,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,318.18,60,,29.104,Percent of Total Billed Charges,60% of Total Billed Charges,477.27,90,,127.008,Percent of Total Billed Charges,90% of Total Billed Charges,238.64,45,,142.096,Percent of Total Billed Charges,45% of Total Billed Charges,477.27,90,,437.384,Percent of Total Billed Charges,90% of Total billed Charges,530.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,344.7,65,,315.888,Percent of total Billed Charges,65% of Total Billed Charges,233.86,44.1,,139.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,503.79,95,,461.688,Percent of Total Billed Charges,95% of Total Billed Charges,530.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,466.66,88,,277.872,Percent of Total Billed Charges,88% of Total Billed Charges,477.27,90,,437.384,Percent of Total Billed charges,90% of Total Billed Charges,233.86,530.3,
Z23591235 3.5 SCW,2780000725,CDM,278,RC,C1713,HCPCS,Outpatient,,,476.28,309.58,,476.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,361.97,76,,369.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,342.92,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,342.92,72,,34.928,Percent of Total Billed charges,72% of Total Billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.92,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,285.77,60,,29.104,Percent of Total Billed Charges,60% of Total Billed Charges,428.65,90,,175.68,Percent of Total Billed Charges,90% of Total Billed Charges,214.33,45,,142.096,Percent of Total Billed Charges,45% of Total Billed Charges,428.65,90,,437.384,Percent of Total Billed Charges,90% of Total billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.58,65,,1694.672,Percent of total Billed Charges,65% of Total Billed Charges,210.04,44.1,,139.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,452.47,95,,461.688,Percent of Total Billed Charges,95% of Total Billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.13,88,,277.872,Percent of Total Billed Charges,88% of Total Billed Charges,428.65,90,,437.384,Percent of Total Billed charges,90% of Total Billed Charges,210.04,476.28,
Z781852 FEMORAL HEA,2780000726,CDM,278,RC,C1713,HCPCS,Outpatient,,,2123.42,1380.22,,2123.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1613.8,76,,392.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1528.86,72,,1244.048,Percent of Total Billed Charges,72% of Total Billed Charges,1528.86,72,,1244.048,Percent of Total Billed charges,72% of Total Billed Charges,2123.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.86,72,,1244.048,Percent of Total Billed Charges,72% of Total Billed Charges,1274.05,60,,1036.704,Percent of Total Billed Charges,60% of Total Billed Charges,1911.08,90,,284.976,Percent of Total Billed Charges,90% of Total Billed Charges,955.54,45,,142.096,Percent of Total Billed Charges,45% of Total Billed Charges,1911.08,90,,465.12,Percent of Total Billed Charges,90% of Total billed Charges,2123.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2123.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2123.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1380.22,65,,1459.048,Percent of total Billed Charges,65% of Total Billed Charges,936.43,44.1,,139.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,2017.25,95,,490.96,Percent of Total Billed Charges,95% of Total Billed Charges,2123.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1868.61,88,,5797.92,Percent of Total Billed Charges,88% of Total Billed Charges,1911.08,90,,465.12,Percent of Total Billed charges,90% of Total Billed Charges,936.43,2123.42,
Z783311 FEMORAL STE,2780000727,CDM,278,RC,C1713,HCPCS,Outpatient,,,7543.31,4903.15,,7543.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5732.92,76,,239.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5431.18,72,,807.768,Percent of Total Billed Charges,72% of Total Billed Charges,5431.18,72,,807.768,Percent of Total Billed charges,72% of Total Billed Charges,7543.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5431.18,72,,807.768,Percent of Total Billed Charges,72% of Total Billed Charges,4525.99,60,,673.144,Percent of Total Billed Charges,60% of Total Billed Charges,6788.98,90,,3633.224,Percent of Total Billed Charges,90% of Total Billed Charges,3394.49,45,,142.096,Percent of Total Billed Charges,45% of Total Billed Charges,6788.98,90,,284.184,Percent of Total Billed Charges,90% of Total billed Charges,7543.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7543.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7543.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4903.15,65,,207.536,Percent of total Billed Charges,65% of Total Billed Charges,3326.6,44.1,,139.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,7166.14,95,,299.976,Percent of Total Billed Charges,95% of Total Billed Charges,7543.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6638.11,88,,9524.264,Percent of Total Billed Charges,88% of Total Billed Charges,6788.98,90,,284.184,Percent of Total Billed charges,90% of Total Billed Charges,3326.6,7543.31,
Z32855331161 NEFF,2780000728,CDM,278,RC,C1713,HCPCS,Outpatient,,,20560.52,13364.34,,20560.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15626,76,,239.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14803.57,72,,755.704,Percent of Total Billed Charges,72% of Total Billed Charges,14803.57,72,,755.704,Percent of Total Billed charges,72% of Total Billed Charges,20560.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14803.57,72,,755.704,Percent of Total Billed Charges,72% of Total Billed Charges,12336.31,60,,629.752,Percent of Total Billed Charges,60% of Total Billed Charges,18504.47,90,,419.92,Percent of Total Billed Charges,90% of Total Billed Charges,9252.23,45,,2964.848,Percent of Total Billed Charges,45% of Total Billed Charges,18504.47,90,,284.184,Percent of Total Billed Charges,90% of Total billed Charges,20560.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20560.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20560.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13364.34,65,,262,Percent of total Billed Charges,65% of Total Billed Charges,9067.19,44.1,,2905.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,19532.49,95,,299.976,Percent of Total Billed Charges,95% of Total Billed Charges,20560.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18093.26,88,,3789.992,Percent of Total Billed Charges,88% of Total Billed Charges,18504.47,90,,284.184,Percent of Total Billed charges,90% of Total Billed Charges,9067.19,20560.52,
Z32855331113 NEFF,2780000729,CDM,278,RC,C1713,HCPCS,Outpatient,,,20560.52,13364.34,,20560.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15626,76,,239.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14803.57,72,,130.824,Percent of Total Billed Charges,72% of Total Billed Charges,14803.57,72,,130.824,Percent of Total Billed charges,72% of Total Billed Charges,20560.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14803.57,72,,130.824,Percent of Total Billed Charges,72% of Total Billed Charges,12336.31,60,,109.016,Percent of Total Billed Charges,60% of Total Billed Charges,18504.47,90,,419.92,Percent of Total Billed Charges,90% of Total Billed Charges,9252.23,45,,4870.36,Percent of Total Billed Charges,45% of Total Billed Charges,18504.47,90,,284.184,Percent of Total Billed Charges,90% of Total billed Charges,20560.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20560.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20560.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13364.34,65,,2566.664,Percent of total Billed Charges,65% of Total Billed Charges,9067.19,44.1,,4772.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,19532.49,95,,299.976,Percent of Total Billed Charges,95% of Total Billed Charges,20560.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18093.26,88,,124.184,Percent of Total Billed Charges,88% of Total Billed Charges,18504.47,90,,284.184,Percent of Total Billed charges,90% of Total Billed Charges,9067.19,20560.52,
Z62006222 TRILOGY,2780000730,CDM,278,RC,C1713,HCPCS,Outpatient,,,7355.88,4781.32,,7355.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5590.47,76,,239.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5296.23,72,,807.768,Percent of Total Billed Charges,72% of Total Billed Charges,5296.23,72,,807.768,Percent of Total Billed charges,72% of Total Billed Charges,7355.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5296.23,72,,807.768,Percent of Total Billed Charges,72% of Total Billed Charges,4413.53,60,,673.144,Percent of Total Billed Charges,60% of Total Billed Charges,6620.29,90,,419.92,Percent of Total Billed Charges,90% of Total Billed Charges,3310.15,45,,1938.064,Percent of Total Billed Charges,45% of Total Billed Charges,6620.29,90,,284.184,Percent of Total Billed Charges,90% of Total billed Charges,7355.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7355.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7355.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4781.32,65,,164.536,Percent of total Billed Charges,65% of Total Billed Charges,3243.94,44.1,,1899.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,6988.09,95,,299.976,Percent of Total Billed Charges,95% of Total Billed Charges,7355.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6473.17,88,,171.776,Percent of Total Billed Charges,88% of Total Billed Charges,6620.29,90,,284.184,Percent of Total Billed charges,90% of Total Billed Charges,3243.94,7355.88,
Z62005822 TRILOGY,2780000731,CDM,278,RC,C1713,HCPCS,Outpatient,,,7355.88,4781.32,,7355.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5590.47,76,,5007.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5296.23,72,,866.192,Percent of Total Billed Charges,72% of Total Billed Charges,5296.23,72,,866.192,Percent of Total Billed charges,72% of Total Billed Charges,7355.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5296.23,72,,866.192,Percent of Total Billed Charges,72% of Total Billed Charges,4413.53,60,,721.832,Percent of Total Billed Charges,60% of Total Billed Charges,6620.29,90,,361.184,Percent of Total Billed Charges,90% of Total Billed Charges,3310.15,45,,63.504,Percent of Total Billed Charges,45% of Total Billed Charges,6620.29,90,,5929.688,Percent of Total Billed Charges,90% of Total billed Charges,7355.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7355.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7355.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4781.32,65,,22.936,Percent of total Billed Charges,65% of Total Billed Charges,3243.94,44.1,,62.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,6988.09,95,,6259.12,Percent of Total Billed Charges,95% of Total Billed Charges,7355.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6473.17,88,,278.64,Percent of Total Billed Charges,88% of Total Billed Charges,6620.29,90,,5929.688,Percent of Total Billed charges,90% of Total Billed Charges,3243.94,7355.88,
Z63205832 TRILOGY,2780000732,CDM,278,RC,C1713,HCPCS,Outpatient,,,5725.28,3721.43,,5725.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4351.21,76,,8225.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4122.2,72,,968.432,Percent of Total Billed Charges,72% of Total Billed Charges,4122.2,72,,968.432,Percent of Total Billed charges,72% of Total Billed Charges,5725.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4122.2,72,,968.432,Percent of Total Billed Charges,72% of Total Billed Charges,3435.17,60,,807.032,Percent of Total Billed Charges,60% of Total Billed Charges,5152.75,90,,13058.808,Percent of Total Billed Charges,90% of Total Billed Charges,2576.38,45,,87.84,Percent of Total Billed Charges,45% of Total Billed Charges,5152.75,90,,9740.72,Percent of Total Billed Charges,90% of Total billed Charges,5725.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5725.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5725.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3721.43,65,,191.488,Percent of total Billed Charges,65% of Total Billed Charges,2524.85,44.1,,86.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,5439.02,95,,10281.872,Percent of Total Billed Charges,95% of Total Billed Charges,5725.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5038.25,88,,3552.48,Percent of Total Billed Charges,88% of Total Billed Charges,5152.75,90,,9740.72,Percent of Total Billed charges,90% of Total Billed Charges,2524.85,5725.28,
CANCELLOUS BONE CHIP,2780000733,CDM,278,RC,C1713,HCPCS,Outpatient,,,1053.99,685.09,,1053.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,801.03,76,,3273.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,758.87,72,,243.856,Percent of Total Billed Charges,72% of Total Billed Charges,758.87,72,,243.856,Percent of Total Billed charges,72% of Total Billed Charges,1053.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,758.87,72,,243.856,Percent of Total Billed Charges,72% of Total Billed Charges,632.39,60,,203.216,Percent of Total Billed Charges,60% of Total Billed Charges,948.59,90,,822.376,Percent of Total Billed Charges,90% of Total Billed Charges,474.3,45,,142.488,Percent of Total Billed Charges,45% of Total Billed Charges,948.59,90,,3876.128,Percent of Total Billed Charges,90% of Total billed Charges,1053.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.09,65,,191.488,Percent of total Billed Charges,65% of Total Billed Charges,464.81,44.1,,139.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,1001.29,95,,4091.464,Percent of Total Billed Charges,95% of Total Billed Charges,1053.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,927.51,88,,410.584,Percent of Total Billed Charges,88% of Total Billed Charges,948.59,90,,3876.128,Percent of Total Billed charges,90% of Total Billed Charges,464.81,1053.99,
Z62506525 BONE SCW,2780000734,CDM,278,RC,C1713,HCPCS,Outpatient,,,581.02,377.66,,581.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,441.58,76,,107.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,418.33,72,,243.856,Percent of Total Billed Charges,72% of Total Billed Charges,418.33,72,,243.856,Percent of Total Billed charges,72% of Total Billed Charges,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,418.33,72,,243.856,Percent of Total Billed Charges,72% of Total Billed Charges,348.61,60,,203.216,Percent of Total Billed Charges,60% of Total Billed Charges,522.92,90,,18.256,Percent of Total Billed Charges,90% of Total Billed Charges,261.46,45,,1816.608,Percent of Total Billed Charges,45% of Total Billed Charges,522.92,90,,127.008,Percent of Total Billed Charges,90% of Total billed Charges,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.66,65,,191.488,Percent of total Billed Charges,65% of Total Billed Charges,256.23,44.1,,1780.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,551.97,95,,134.064,Percent of Total Billed Charges,95% of Total Billed Charges,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511.3,88,,410.584,Percent of Total Billed Charges,88% of Total Billed Charges,522.92,90,,127.008,Percent of Total Billed charges,90% of Total Billed Charges,256.23,581.02,
Z59881117 REV STEM,2780000735,CDM,278,RC,C1713,HCPCS,Outpatient,,,4604.04,2992.63,,4604.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3499.07,76,,148.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3314.91,72,,3716.256,Percent of Total Billed Charges,72% of Total Billed Charges,3314.91,72,,3716.256,Percent of Total Billed charges,72% of Total Billed Charges,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3314.91,72,,3716.256,Percent of Total Billed Charges,72% of Total Billed Charges,2762.42,60,,3096.88,Percent of Total Billed Charges,60% of Total Billed Charges,4143.64,90,,1534.416,Percent of Total Billed Charges,90% of Total Billed Charges,2071.82,45,,209.96,Percent of Total Billed Charges,45% of Total Billed Charges,4143.64,90,,175.68,Percent of Total Billed Charges,90% of Total billed Charges,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2992.63,65,,2085.672,Percent of total Billed Charges,65% of Total Billed Charges,2030.38,44.1,,205.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,4373.84,95,,185.44,Percent of Total Billed Charges,95% of Total Billed Charges,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4051.56,88,,410.584,Percent of Total Billed Charges,88% of Total Billed Charges,4143.64,90,,175.68,Percent of Total Billed charges,90% of Total Billed Charges,2030.38,4604.04,
Z59881114 REV STEM,2780000736,CDM,278,RC,C1713,HCPCS,Outpatient,,,4604.04,2992.63,,4604.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3499.07,76,,240.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3314.91,72,,3716.256,Percent of Total Billed Charges,72% of Total Billed Charges,3314.91,72,,3716.256,Percent of Total Billed charges,72% of Total Billed Charges,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3314.91,72,,3716.256,Percent of Total Billed Charges,72% of Total Billed Charges,2762.42,60,,3096.88,Percent of Total Billed Charges,60% of Total Billed Charges,4143.64,90,,6606.008,Percent of Total Billed Charges,90% of Total Billed Charges,2071.82,45,,209.96,Percent of Total Billed Charges,45% of Total Billed Charges,4143.64,90,,284.976,Percent of Total Billed Charges,90% of Total billed Charges,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2992.63,65,,3170.92,Percent of total Billed Charges,65% of Total Billed Charges,2030.38,44.1,,205.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,4373.84,95,,300.808,Percent of Total Billed Charges,95% of Total Billed Charges,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4051.56,88,,353.152,Percent of Total Billed Charges,88% of Total Billed Charges,4143.64,90,,284.976,Percent of Total Billed charges,90% of Total Billed Charges,2030.38,4604.04,
Z59804702 REV TIBI,2780000737,CDM,278,RC,C1713,HCPCS,Outpatient,,,7977.69,5185.50,,7977.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6063.04,76,,3068.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5743.94,72,,205.12,Percent of Total Billed Charges,72% of Total Billed Charges,5743.94,72,,205.12,Percent of Total Billed charges,72% of Total Billed Charges,7977.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5743.94,72,,205.12,Percent of Total Billed Charges,72% of Total Billed Charges,4786.61,60,,170.936,Percent of Total Billed Charges,60% of Total Billed Charges,7179.92,90,,4099.976,Percent of Total Billed Charges,90% of Total Billed Charges,3589.96,45,,209.96,Percent of Total Billed Charges,45% of Total Billed Charges,7179.92,90,,3633.224,Percent of Total Billed Charges,90% of Total billed Charges,7977.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7977.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7977.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5185.5,65,,3667.4,Percent of total Billed Charges,65% of Total Billed Charges,3518.16,44.1,,205.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,7578.81,95,,3835.064,Percent of Total Billed Charges,95% of Total Billed Charges,7977.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7020.37,88,,12768.608,Percent of Total Billed Charges,88% of Total Billed Charges,7179.92,90,,3633.224,Percent of Total Billed charges,90% of Total Billed Charges,3518.16,7977.69,
Z59880626 REV TIBI,2780000738,CDM,278,RC,C1713,HCPCS,Outpatient,,,4276.60,2779.79,,4276.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3250.22,76,,354.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3079.15,72,,205.12,Percent of Total Billed Charges,72% of Total Billed Charges,3079.15,72,,205.12,Percent of Total Billed charges,72% of Total Billed Charges,4276.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3079.15,72,,205.12,Percent of Total Billed Charges,72% of Total Billed Charges,2565.96,60,,170.936,Percent of Total Billed Charges,60% of Total Billed Charges,3848.94,90,,14863.112,Percent of Total Billed Charges,90% of Total Billed Charges,1924.47,45,,180.592,Percent of Total Billed Charges,45% of Total Billed Charges,3848.94,90,,419.92,Percent of Total Billed Charges,90% of Total billed Charges,4276.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4276.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4276.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2779.79,65,,43.568,Percent of total Billed Charges,65% of Total Billed Charges,1885.98,44.1,,176.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,4062.77,95,,443.248,Percent of Total Billed Charges,95% of Total Billed Charges,4276.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3763.41,88,,804.104,Percent of Total Billed Charges,88% of Total Billed Charges,3848.94,90,,419.92,Percent of Total Billed charges,90% of Total Billed Charges,1885.98,4276.6,
Z59941791 REV FEMO,2780000739,CDM,278,RC,C1713,HCPCS,Outpatient,,,25151.33,16348.36,,25151.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19115.01,76,,354.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18108.96,72,,205.12,Percent of Total Billed Charges,72% of Total Billed Charges,18108.96,72,,205.12,Percent of Total Billed charges,72% of Total Billed Charges,25151.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18108.96,72,,205.12,Percent of Total Billed Charges,72% of Total Billed Charges,15090.8,60,,170.936,Percent of Total Billed Charges,60% of Total Billed Charges,22636.2,90,,544.552,Percent of Total Billed Charges,90% of Total Billed Charges,11318.1,45,,6529.4,Percent of Total Billed Charges,45% of Total Billed Charges,22636.2,90,,419.92,Percent of Total Billed Charges,90% of Total billed Charges,25151.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25151.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25151.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16348.36,65,,2351.104,Percent of total Billed Charges,65% of Total Billed Charges,11091.74,44.1,,6398.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,23893.76,95,,443.248,Percent of Total Billed Charges,95% of Total Billed Charges,25151.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22133.17,88,,17.856,Percent of Total Billed Charges,88% of Total Billed Charges,22636.2,90,,419.92,Percent of Total Billed charges,90% of Total Billed Charges,11091.74,25151.33,
Z59944214 REV ARTI,2780000740,CDM,278,RC,C1713,HCPCS,Outpatient,,,81734.94,53127.71,,81734.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62118.55,76,,354.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,58849.16,72,,205.12,Percent of Total Billed Charges,72% of Total Billed Charges,58849.16,72,,205.12,Percent of Total Billed charges,72% of Total Billed Charges,81734.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58849.16,72,,205.12,Percent of Total Billed Charges,72% of Total Billed Charges,49040.96,60,,170.936,Percent of Total Billed Charges,60% of Total Billed Charges,73561.45,90,,83.344,Percent of Total Billed Charges,90% of Total Billed Charges,36780.72,45,,411.192,Percent of Total Billed Charges,45% of Total Billed Charges,73561.45,90,,419.92,Percent of Total Billed Charges,90% of Total billed Charges,81734.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81734.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81734.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53127.71,65,,721.784,Percent of total Billed Charges,65% of Total Billed Charges,36045.11,44.1,,402.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,77648.19,95,,443.248,Percent of Total Billed Charges,95% of Total Billed Charges,81734.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71926.75,88,,1500.312,Percent of Total Billed Charges,88% of Total Billed Charges,73561.45,90,,419.92,Percent of Total Billed charges,90% of Total Billed Charges,36045.11,81734.94,
Z49350603 TUB PLAT,2780000741,CDM,278,RC,C1713,HCPCS,Outpatient,,,259.09,168.41,,259.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,196.91,76,,305,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,186.54,72,,205.12,Percent of Total Billed Charges,72% of Total Billed Charges,186.54,72,,205.12,Percent of Total Billed charges,72% of Total Billed Charges,259.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.54,72,,205.12,Percent of Total Billed Charges,72% of Total Billed Charges,155.45,60,,170.936,Percent of Total Billed Charges,60% of Total Billed Charges,233.18,90,,437.384,Percent of Total Billed Charges,90% of Total Billed Charges,116.59,45,,9.128,Percent of Total Billed Charges,45% of Total Billed Charges,233.18,90,,361.184,Percent of Total Billed Charges,90% of Total billed Charges,259.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.41,65,,1459.048,Percent of total Billed Charges,65% of Total Billed Charges,114.26,44.1,,8.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,246.14,95,,381.248,Percent of Total Billed Charges,95% of Total Billed Charges,259.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228,88,,6459.208,Percent of Total Billed Charges,88% of Total Billed Charges,233.18,90,,361.184,Percent of Total Billed charges,90% of Total Billed Charges,114.26,259.09,
Z484014 4.0 CANN SC,2780000742,CDM,278,RC,C1713,HCPCS,Outpatient,,,71.66,46.58,,71.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.46,76,,11027.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.6,72,,4743.752,Percent of Total Billed Charges,72% of Total Billed Charges,51.6,72,,4743.752,Percent of Total Billed charges,72% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,72,,4743.752,Percent of Total Billed Charges,72% of Total Billed Charges,43,60,,3953.128,Percent of Total Billed Charges,60% of Total Billed Charges,64.49,90,,2346.472,Percent of Total Billed Charges,90% of Total Billed Charges,32.25,45,,767.208,Percent of Total Billed Charges,45% of Total Billed Charges,64.49,90,,13058.808,Percent of Total Billed Charges,90% of Total billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.58,65,,1676.904,Percent of total Billed Charges,65% of Total Billed Charges,31.6,44.1,,751.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.08,95,,13784.296,Percent of Total Billed Charges,95% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,88,,4008.864,Percent of Total Billed Charges,88% of Total Billed Charges,64.49,90,,13058.808,Percent of Total Billed charges,90% of Total Billed Charges,31.6,71.66,
Z484022 4.0 CANN SC,2780000743,CDM,278,RC,C1713,HCPCS,Outpatient,,,71.66,46.58,,71.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.46,76,,694.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.6,72,,4743.752,Percent of Total Billed Charges,72% of Total Billed Charges,51.6,72,,4743.752,Percent of Total Billed charges,72% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,72,,4743.752,Percent of Total Billed Charges,72% of Total Billed Charges,43,60,,3953.128,Percent of Total Billed Charges,60% of Total Billed Charges,64.49,90,,2020.216,Percent of Total Billed Charges,90% of Total Billed Charges,32.25,45,,3303,Percent of Total Billed Charges,45% of Total Billed Charges,64.49,90,,822.376,Percent of Total Billed Charges,90% of Total billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.58,65,,43,Percent of total Billed Charges,65% of Total Billed Charges,31.6,44.1,,3236.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.08,95,,868.064,Percent of Total Billed Charges,95% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,88,,14532.816,Percent of Total Billed Charges,88% of Total Billed Charges,64.49,90,,822.376,Percent of Total Billed charges,90% of Total Billed Charges,31.6,71.66,
Z44523551 TRANSFX,2780000744,CDM,278,RC,C1713,HCPCS,Outpatient,,,1810.31,1176.70,,1810.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1375.84,76,,15.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1303.42,72,,7792.576,Percent of Total Billed Charges,72% of Total Billed Charges,1303.42,72,,7792.576,Percent of Total Billed charges,72% of Total Billed Charges,1810.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1303.42,72,,7792.576,Percent of Total Billed Charges,72% of Total Billed Charges,1086.19,60,,6493.816,Percent of Total Billed Charges,60% of Total Billed Charges,1629.28,90,,287.36,Percent of Total Billed Charges,90% of Total Billed Charges,814.64,45,,2049.984,Percent of Total Billed Charges,45% of Total Billed Charges,1629.28,90,,18.256,Percent of Total Billed Charges,90% of Total billed Charges,1810.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1810.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1810.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1176.7,65,,1940.048,Percent of total Billed Charges,65% of Total Billed Charges,798.35,44.1,,2008.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,1719.79,95,,19.272,Percent of Total Billed Charges,95% of Total Billed Charges,1810.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1593.07,88,,532.448,Percent of Total Billed Charges,88% of Total Billed Charges,1629.28,90,,18.256,Percent of Total Billed charges,90% of Total Billed Charges,798.35,1810.31,
Z44529245 PROTECTI,2780000745,CDM,278,RC,C1713,HCPCS,Outpatient,,,14.33,9.31,,14.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.89,76,,1295.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.32,72,,1299.296,Percent of Total Billed Charges,72% of Total Billed Charges,10.32,72,,1299.296,Percent of Total Billed charges,72% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.32,72,,1299.296,Percent of Total Billed Charges,72% of Total Billed Charges,8.6,60,,1082.744,Percent of Total Billed Charges,60% of Total Billed Charges,12.9,90,,362.768,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,7431.552,Percent of Total Billed Charges,45% of Total Billed Charges,12.9,90,,1534.416,Percent of Total Billed Charges,90% of Total billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.31,65,,2724.32,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,7282.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.61,95,,1619.656,Percent of Total Billed Charges,95% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.61,88,,81.496,Percent of Total Billed Charges,88% of Total Billed Charges,12.9,90,,1534.416,Percent of Total Billed charges,90% of Total Billed Charges,6.32,14.33,
Z445067 TRANSFX DRI,2780000746,CDM,278,RC,C1713,HCPCS,Outpatient,,,157.66,102.48,,157.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,119.82,76,,5578.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,113.52,72,,210.2,Percent of Total Billed Charges,72% of Total Billed Charges,113.52,72,,210.2,Percent of Total Billed charges,72% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.52,72,,210.2,Percent of Total Billed Charges,72% of Total Billed Charges,94.6,60,,175.168,Percent of Total Billed Charges,60% of Total Billed Charges,141.89,90,,3553.84,Percent of Total Billed Charges,90% of Total Billed Charges,70.95,45,,272.272,Percent of Total Billed Charges,45% of Total Billed Charges,141.89,90,,6606.008,Percent of Total Billed Charges,90% of Total billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.48,65,,3406.552,Percent of total Billed Charges,65% of Total Billed Charges,69.53,44.1,,266.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,149.78,95,,6973.008,Percent of Total Billed Charges,95% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.74,88,,427.664,Percent of Total Billed Charges,88% of Total Billed Charges,141.89,90,,6606.008,Percent of Total Billed charges,90% of Total Billed Charges,69.53,157.66,
Z78341 FEMSTEM 11X1,2780000747,CDM,278,RC,C1713,HCPCS,Outpatient,,,7543.31,4903.15,,7543.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5732.92,76,,3462.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5431.18,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,5431.18,72,,17.144,Percent of Total Billed charges,72% of Total Billed Charges,7543.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5431.18,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,4525.99,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,6788.98,90,,227.824,Percent of Total Billed Charges,90% of Total Billed Charges,3394.49,45,,41.672,Percent of Total Billed Charges,45% of Total Billed Charges,6788.98,90,,4099.976,Percent of Total Billed Charges,90% of Total billed Charges,7543.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7543.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7543.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4903.15,65,,10530.944,Percent of total Billed Charges,65% of Total Billed Charges,3326.6,44.1,,40.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,7166.14,95,,4327.752,Percent of Total Billed Charges,95% of Total Billed Charges,7543.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6638.11,88,,2294.328,Percent of Total Billed Charges,88% of Total Billed Charges,6788.98,90,,4099.976,Percent of Total Billed charges,90% of Total Billed Charges,3326.6,7543.31,
Z23485435 35CORTIC,2780000748,CDM,278,RC,C1713,HCPCS,Outpatient,,,130.10,84.57,,130.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.88,76,,12551.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,93.67,72,,304.816,Percent of Total Billed Charges,72% of Total Billed Charges,93.67,72,,304.816,Percent of Total Billed charges,72% of Total Billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.67,72,,304.816,Percent of Total Billed Charges,72% of Total Billed Charges,78.06,60,,254.016,Percent of Total Billed Charges,60% of Total Billed Charges,117.09,90,,31.752,Percent of Total Billed Charges,90% of Total Billed Charges,58.55,45,,218.696,Percent of Total Billed Charges,45% of Total Billed Charges,117.09,90,,14863.112,Percent of Total Billed Charges,90% of Total billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.57,65,,2468.056,Percent of total Billed Charges,65% of Total Billed Charges,57.37,44.1,,214.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,123.6,95,,15688.84,Percent of Total Billed Charges,95% of Total Billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.49,88,,1975.328,Percent of Total Billed Charges,88% of Total Billed Charges,117.09,90,,14863.112,Percent of Total Billed charges,90% of Total Billed Charges,57.37,130.1,
Z23481006 ELBOW PL,2780000749,CDM,278,RC,C1713,HCPCS,Outpatient,,,2884.14,1874.69,,2884.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2191.95,76,,459.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2076.58,72,,304.816,Percent of Total Billed Charges,72% of Total Billed Charges,2076.58,72,,304.816,Percent of Total Billed charges,72% of Total Billed Charges,2884.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2076.58,72,,304.816,Percent of Total Billed Charges,72% of Total Billed Charges,1730.48,60,,254.016,Percent of Total Billed Charges,60% of Total Billed Charges,2595.73,90,,265.136,Percent of Total Billed Charges,90% of Total Billed Charges,1297.86,45,,1173.24,Percent of Total Billed Charges,45% of Total Billed Charges,2595.73,90,,544.552,Percent of Total Billed Charges,90% of Total billed Charges,2884.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2884.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2884.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1874.69,65,,205.248,Percent of total Billed Charges,65% of Total Billed Charges,1271.91,44.1,,1149.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,2739.93,95,,574.8,Percent of Total Billed Charges,95% of Total Billed Charges,2884.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2538.04,88,,280.976,Percent of Total Billed Charges,88% of Total Billed Charges,2595.73,90,,544.552,Percent of Total Billed charges,90% of Total Billed Charges,1271.91,2884.14,
Z24802641 4.0 CANN,2780000750,CDM,278,RC,C1713,HCPCS,Outpatient,,,221.60,144.04,,221.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,168.42,76,,70.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,159.55,72,,1420.584,Percent of Total Billed Charges,72% of Total Billed Charges,159.55,72,,1420.584,Percent of Total Billed charges,72% of Total Billed Charges,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.55,72,,1420.584,Percent of Total Billed Charges,72% of Total Billed Charges,132.96,60,,1183.816,Percent of Total Billed Charges,60% of Total Billed Charges,199.44,90,,265.136,Percent of Total Billed Charges,90% of Total Billed Charges,99.72,45,,1010.112,Percent of Total Billed Charges,45% of Total Billed Charges,199.44,90,,83.344,Percent of Total Billed Charges,90% of Total billed Charges,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.04,65,,205.248,Percent of total Billed Charges,65% of Total Billed Charges,97.73,44.1,,989.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,210.52,95,,87.976,Percent of Total Billed Charges,95% of Total Billed Charges,221.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.01,88,,354.704,Percent of Total Billed Charges,88% of Total Billed Charges,199.44,90,,83.344,Percent of Total Billed charges,90% of Total Billed Charges,97.73,221.6,
Z484045 4.0 CANN SC,2780000751,CDM,278,RC,C1713,HCPCS,Outpatient,,,71.66,46.58,,71.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.46,76,,369.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.6,72,,1420.584,Percent of Total Billed Charges,72% of Total Billed Charges,51.6,72,,1420.584,Percent of Total Billed charges,72% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,72,,1420.584,Percent of Total Billed Charges,72% of Total Billed Charges,43,60,,1183.816,Percent of Total Billed Charges,60% of Total Billed Charges,64.49,90,,265.136,Percent of Total Billed Charges,90% of Total Billed Charges,32.25,45,,143.68,Percent of Total Billed Charges,45% of Total Billed Charges,64.49,90,,437.384,Percent of Total Billed Charges,90% of Total billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.58,65,,205.248,Percent of total Billed Charges,65% of Total Billed Charges,31.6,44.1,,140.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.08,95,,461.688,Percent of Total Billed Charges,95% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,88,,3474.864,Percent of Total Billed Charges,88% of Total Billed Charges,64.49,90,,437.384,Percent of Total Billed charges,90% of Total Billed Charges,31.6,71.66,
Z225740001 ITST FE,2780000752,CDM,278,RC,C1713,HCPCS,Outpatient,,,5635.98,3663.39,,5635.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4283.34,76,,1981.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4057.91,72,,1420.584,Percent of Total Billed Charges,72% of Total Billed Charges,4057.91,72,,1420.584,Percent of Total Billed charges,72% of Total Billed Charges,5635.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4057.91,72,,1420.584,Percent of Total Billed Charges,72% of Total Billed Charges,3381.59,60,,1183.816,Percent of Total Billed Charges,60% of Total Billed Charges,5072.38,90,,2887.848,Percent of Total Billed Charges,90% of Total Billed Charges,2536.19,45,,181.384,Percent of Total Billed Charges,45% of Total Billed Charges,5072.38,90,,2346.472,Percent of Total Billed Charges,90% of Total billed Charges,5635.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5635.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5635.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3663.39,65,,205.248,Percent of total Billed Charges,65% of Total Billed Charges,2485.47,44.1,,177.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,5354.18,95,,2476.832,Percent of Total Billed Charges,95% of Total Billed Charges,5635.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4959.66,88,,222.76,Percent of Total Billed Charges,88% of Total Billed Charges,5072.38,90,,2346.472,Percent of Total Billed charges,90% of Total Billed Charges,2485.47,5635.98,
Z460001 WRISTORE,2780000753,CDM,278,RC,C1713,HCPCS,Outpatient,,,8039.43,5225.63,,8039.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6109.97,76,,1705.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5788.39,72,,53.344,Percent of Total Billed Charges,72% of Total Billed Charges,5788.39,72,,53.344,Percent of Total Billed charges,72% of Total Billed Charges,8039.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5788.39,72,,53.344,Percent of Total Billed Charges,72% of Total Billed Charges,4823.66,60,,44.456,Percent of Total Billed Charges,60% of Total Billed Charges,7235.49,90,,4390.512,Percent of Total Billed Charges,90% of Total Billed Charges,3617.74,45,,1776.92,Percent of Total Billed Charges,45% of Total Billed Charges,7235.49,90,,2020.216,Percent of Total Billed Charges,90% of Total billed Charges,8039.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8039.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8039.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5225.63,65,,205.248,Percent of total Billed Charges,65% of Total Billed Charges,3545.39,44.1,,1741.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,7637.46,95,,2132.456,Percent of Total Billed Charges,95% of Total Billed Charges,8039.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7074.7,88,,31.048,Percent of Total Billed Charges,88% of Total Billed Charges,7235.49,90,,2020.216,Percent of Total Billed charges,90% of Total Billed Charges,3545.39,8039.43,
Z51107030 MGII BON,2780000754,CDM,278,RC,C1713,HCPCS,Outpatient,,,464.15,301.70,,464.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,352.75,76,,242.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,334.19,72,,365.152,Percent of Total Billed Charges,72% of Total Billed Charges,334.19,72,,365.152,Percent of Total Billed charges,72% of Total Billed Charges,464.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.19,72,,365.152,Percent of Total Billed Charges,72% of Total Billed Charges,278.49,60,,304.288,Percent of Total Billed Charges,60% of Total Billed Charges,417.74,90,,5077.936,Percent of Total Billed Charges,90% of Total Billed Charges,208.87,45,,113.912,Percent of Total Billed Charges,45% of Total Billed Charges,417.74,90,,287.36,Percent of Total Billed Charges,90% of Total billed Charges,464.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,464.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,464.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.7,65,,205.248,Percent of total Billed Charges,65% of Total Billed Charges,204.69,44.1,,111.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,440.94,95,,303.32,Percent of Total Billed Charges,95% of Total Billed Charges,464.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,408.45,88,,259.24,Percent of Total Billed Charges,88% of Total Billed Charges,417.74,90,,287.36,Percent of Total Billed charges,90% of Total Billed Charges,204.69,464.15,
Z59701601 CRUC FEM,2780000755,CDM,278,RC,C1713,HCPCS,Outpatient,,,12104.35,7867.83,,12104.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9199.31,76,,306.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8715.13,72,,732.2,Percent of Total Billed Charges,72% of Total Billed Charges,8715.13,72,,732.2,Percent of Total Billed charges,72% of Total Billed Charges,12104.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8715.13,72,,732.2,Percent of Total Billed Charges,72% of Total Billed Charges,7262.61,60,,610.168,Percent of Total Billed Charges,60% of Total Billed Charges,10893.92,90,,60.328,Percent of Total Billed Charges,90% of Total Billed Charges,5446.96,45,,15.88,Percent of Total Billed Charges,45% of Total Billed Charges,10893.92,90,,362.768,Percent of Total Billed Charges,90% of Total billed Charges,12104.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12104.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12104.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7867.83,65,,91.728,Percent of total Billed Charges,65% of Total Billed Charges,5338.02,44.1,,15.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,11499.13,95,,382.92,Percent of Total Billed Charges,95% of Total Billed Charges,12104.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10651.83,88,,259.24,Percent of Total Billed Charges,88% of Total Billed Charges,10893.92,90,,362.768,Percent of Total Billed charges,90% of Total Billed Charges,5338.02,12104.35,
Z59764017 CRUC ART,2780000756,CDM,278,RC,C1713,HCPCS,Outpatient,,,4622.78,3004.81,,4622.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3513.31,76,,3001.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3328.4,72,,1299.296,Percent of Total Billed Charges,72% of Total Billed Charges,3328.4,72,,1299.296,Percent of Total Billed charges,72% of Total Billed Charges,4622.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3328.4,72,,1299.296,Percent of Total Billed Charges,72% of Total Billed Charges,2773.67,60,,1082.744,Percent of Total Billed Charges,60% of Total Billed Charges,4160.5,90,,3255.376,Percent of Total Billed Charges,90% of Total Billed Charges,2080.25,45,,132.568,Percent of Total Billed Charges,45% of Total Billed Charges,4160.5,90,,3553.84,Percent of Total Billed Charges,90% of Total billed Charges,4622.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4622.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4622.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3004.81,65,,2239.312,Percent of total Billed Charges,65% of Total Billed Charges,2038.65,44.1,,129.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,4391.64,95,,3751.28,Percent of Total Billed Charges,95% of Total Billed Charges,4622.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4068.05,88,,259.24,Percent of Total Billed Charges,88% of Total Billed Charges,4160.5,90,,3553.84,Percent of Total Billed charges,90% of Total Billed Charges,2038.65,4622.78,
Z23581804 DISTAL R,2780000757,CDM,278,RC,C1713,HCPCS,Outpatient,,,3036.29,1973.59,,3036.29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2307.58,76,,192.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2186.13,72,,1299.296,Percent of Total Billed Charges,72% of Total Billed Charges,2186.13,72,,1299.296,Percent of Total Billed charges,72% of Total Billed Charges,3036.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2186.13,72,,1299.296,Percent of Total Billed Charges,72% of Total Billed Charges,1821.77,60,,1082.744,Percent of Total Billed Charges,60% of Total Billed Charges,2732.66,90,,999.4,Percent of Total Billed Charges,90% of Total Billed Charges,1366.33,45,,132.568,Percent of Total Billed Charges,45% of Total Billed Charges,2732.66,90,,227.824,Percent of Total Billed Charges,90% of Total billed Charges,3036.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3036.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3036.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1973.59,65,,173.136,Percent of total Billed Charges,65% of Total Billed Charges,1339,44.1,,129.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,2884.48,95,,240.48,Percent of Total Billed Charges,95% of Total Billed Charges,3036.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2671.94,88,,2823.672,Percent of Total Billed Charges,88% of Total Billed Charges,2732.66,90,,227.824,Percent of Total Billed charges,90% of Total Billed Charges,1339,3036.29,
Z23593025 2.4 CONI,2780000758,CDM,278,RC,C1713,HCPCS,Outpatient,,,303.19,197.07,,303.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,230.42,76,,26.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,218.3,72,,1299.296,Percent of Total Billed Charges,72% of Total Billed Charges,218.3,72,,1299.296,Percent of Total Billed charges,72% of Total Billed Charges,303.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.3,72,,1299.296,Percent of Total Billed Charges,72% of Total Billed Charges,181.91,60,,1082.744,Percent of Total Billed Charges,60% of Total Billed Charges,272.87,90,,2020.216,Percent of Total Billed Charges,90% of Total Billed Charges,136.44,45,,132.568,Percent of Total Billed Charges,45% of Total Billed Charges,272.87,90,,31.752,Percent of Total Billed Charges,90% of Total billed Charges,303.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.07,65,,173.136,Percent of total Billed Charges,65% of Total Billed Charges,133.71,44.1,,129.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,288.03,95,,33.52,Percent of Total Billed Charges,95% of Total Billed Charges,303.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.81,88,,4292.944,Percent of Total Billed Charges,88% of Total Billed Charges,272.87,90,,31.752,Percent of Total Billed charges,90% of Total Billed Charges,133.71,303.19,
Z59881014 REV STEM,2780000759,CDM,278,RC,C1713,HCPCS,Outpatient,,,4604.04,2992.63,,4604.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3499.07,76,,223.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3314.91,72,,375.944,Percent of Total Billed Charges,72% of Total Billed Charges,3314.91,72,,375.944,Percent of Total Billed charges,72% of Total Billed Charges,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3314.91,72,,375.944,Percent of Total Billed Charges,72% of Total Billed Charges,2762.42,60,,313.288,Percent of Total Billed Charges,60% of Total Billed Charges,4143.64,90,,2321.864,Percent of Total Billed Charges,90% of Total Billed Charges,2071.82,45,,1443.928,Percent of Total Billed Charges,45% of Total Billed Charges,4143.64,90,,265.136,Percent of Total Billed Charges,90% of Total billed Charges,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2992.63,65,,173.136,Percent of total Billed Charges,65% of Total Billed Charges,2030.38,44.1,,1415.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,4373.84,95,,279.864,Percent of Total Billed Charges,95% of Total Billed Charges,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4051.56,88,,4965.096,Percent of Total Billed Charges,88% of Total Billed Charges,4143.64,90,,265.136,Percent of Total Billed charges,90% of Total Billed Charges,2030.38,4604.04,
Z58801501 REV FEMO,2780000760,CDM,278,RC,C1713,HCPCS,Outpatient,,,37649.27,24472.03,,37649.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28613.45,76,,223.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27107.47,72,,375.944,Percent of Total Billed Charges,72% of Total Billed Charges,27107.47,72,,375.944,Percent of Total Billed charges,72% of Total Billed Charges,37649.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27107.47,72,,375.944,Percent of Total Billed Charges,72% of Total Billed Charges,22589.56,60,,313.288,Percent of Total Billed Charges,60% of Total Billed Charges,33884.34,90,,59.536,Percent of Total Billed Charges,90% of Total Billed Charges,16942.17,45,,2195.256,Percent of Total Billed Charges,45% of Total Billed Charges,33884.34,90,,265.136,Percent of Total Billed Charges,90% of Total billed Charges,37649.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37649.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37649.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24472.03,65,,2517.36,Percent of total Billed Charges,65% of Total Billed Charges,16603.33,44.1,,2151.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,35766.81,95,,279.864,Percent of Total Billed Charges,95% of Total Billed Charges,37649.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33131.36,88,,58.992,Percent of Total Billed Charges,88% of Total Billed Charges,33884.34,90,,265.136,Percent of Total Billed charges,90% of Total Billed Charges,16603.33,37649.27,
Z58805017 REV ACCT,2780000761,CDM,278,RC,C1713,HCPCS,Outpatient,,,7665.68,4982.69,,7665.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5825.92,76,,223.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5519.29,72,,1820.664,Percent of Total Billed Charges,72% of Total Billed Charges,5519.29,72,,1820.664,Percent of Total Billed charges,72% of Total Billed Charges,7665.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5519.29,72,,1820.664,Percent of Total Billed Charges,72% of Total Billed Charges,4599.41,60,,1517.216,Percent of Total Billed Charges,60% of Total Billed Charges,6899.11,90,,2686.216,Percent of Total Billed Charges,90% of Total Billed Charges,3449.56,45,,2538.968,Percent of Total Billed Charges,45% of Total Billed Charges,6899.11,90,,265.136,Percent of Total Billed Charges,90% of Total billed Charges,7665.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7665.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7665.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4982.69,65,,173.136,Percent of total Billed Charges,65% of Total Billed Charges,3380.56,44.1,,2488.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,7282.4,95,,279.864,Percent of Total Billed Charges,95% of Total Billed Charges,7665.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6745.8,88,,3183.032,Percent of Total Billed Charges,88% of Total Billed Charges,6899.11,90,,265.136,Percent of Total Billed charges,90% of Total Billed Charges,3380.56,7665.68,
Z59881013 REV STEM,2780000762,CDM,278,RC,C1713,HCPCS,Outpatient,,,4604.04,2992.63,,4604.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3499.07,76,,2438.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3314.91,72,,883.976,Percent of Total Billed Charges,72% of Total Billed Charges,3314.91,72,,883.976,Percent of Total Billed charges,72% of Total Billed Charges,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3314.91,72,,883.976,Percent of Total Billed Charges,72% of Total Billed Charges,2762.42,60,,736.648,Percent of Total Billed Charges,60% of Total Billed Charges,4143.64,90,,3772.136,Percent of Total Billed Charges,90% of Total Billed Charges,2071.82,45,,30.168,Percent of Total Billed Charges,45% of Total Billed Charges,4143.64,90,,2887.848,Percent of Total Billed Charges,90% of Total billed Charges,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2992.63,65,,264.864,Percent of total Billed Charges,65% of Total Billed Charges,2030.38,44.1,,29.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,4373.84,95,,3048.288,Percent of Total Billed Charges,95% of Total Billed Charges,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4051.56,88,,977.184,Percent of Total Billed Charges,88% of Total Billed Charges,4143.64,90,,2887.848,Percent of Total Billed charges,90% of Total Billed Charges,2030.38,4604.04,
Z588004 REV TIBIAL,2780000763,CDM,278,RC,C1713,HCPCS,Outpatient,,,17522.03,11389.32,,17522.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13316.74,76,,3707.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12615.86,72,,341.016,Percent of Total Billed Charges,72% of Total Billed Charges,12615.86,72,,341.016,Percent of Total Billed charges,72% of Total Billed Charges,17522.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12615.86,72,,341.016,Percent of Total Billed Charges,72% of Total Billed Charges,10513.22,60,,284.176,Percent of Total Billed Charges,60% of Total Billed Charges,15769.83,90,,4716.76,Percent of Total Billed Charges,90% of Total Billed Charges,7884.91,45,,1627.688,Percent of Total Billed Charges,45% of Total Billed Charges,15769.83,90,,4390.512,Percent of Total Billed Charges,90% of Total billed Charges,17522.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17522.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17522.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11389.32,65,,264.864,Percent of total Billed Charges,65% of Total Billed Charges,7727.22,44.1,,1595.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,16645.93,95,,4634.424,Percent of Total Billed Charges,95% of Total Billed Charges,17522.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15419.39,88,,1975.328,Percent of Total Billed Charges,88% of Total Billed Charges,15769.83,90,,4390.512,Percent of Total Billed charges,90% of Total Billed Charges,7727.22,17522.03,
Z22539042 4.2 CORT,2780000764,CDM,278,RC,C1713,HCPCS,Outpatient,,,598.66,389.13,,598.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,454.98,76,,4288.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,431.04,72,,341.016,Percent of Total Billed Charges,72% of Total Billed Charges,431.04,72,,341.016,Percent of Total Billed charges,72% of Total Billed Charges,598.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,431.04,72,,341.016,Percent of Total Billed Charges,72% of Total Billed Charges,359.2,60,,284.176,Percent of Total Billed Charges,60% of Total Billed Charges,538.79,90,,14581.312,Percent of Total Billed Charges,90% of Total Billed Charges,269.4,45,,499.696,Percent of Total Billed Charges,45% of Total Billed Charges,538.79,90,,5077.936,Percent of Total Billed Charges,90% of Total billed Charges,598.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,598.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,598.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,389.13,65,,14.328,Percent of total Billed Charges,65% of Total Billed Charges,264.01,44.1,,489.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,568.73,95,,5360.048,Percent of Total Billed Charges,95% of Total Billed Charges,598.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,526.82,88,,2270.264,Percent of Total Billed Charges,88% of Total Billed Charges,538.79,90,,5077.936,Percent of Total Billed charges,90% of Total Billed Charges,264.01,598.66,
Z22401332 RETRO 13,2780000765,CDM,278,RC,C1713,HCPCS,Outpatient,,,4933.69,3206.90,,4933.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3749.6,76,,50.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3552.26,72,,341.016,Percent of Total Billed Charges,72% of Total Billed Charges,3552.26,72,,341.016,Percent of Total Billed charges,72% of Total Billed Charges,4933.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3552.26,72,,341.016,Percent of Total Billed Charges,72% of Total Billed Charges,2960.21,60,,284.176,Percent of Total Billed Charges,60% of Total Billed Charges,4440.32,90,,3417.304,Percent of Total Billed Charges,90% of Total Billed Charges,2220.16,45,,1010.112,Percent of Total Billed Charges,45% of Total Billed Charges,4440.32,90,,60.328,Percent of Total Billed Charges,90% of Total billed Charges,4933.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4933.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4933.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3206.9,65,,212.696,Percent of total Billed Charges,65% of Total Billed Charges,2175.76,44.1,,989.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,4687.01,95,,63.68,Percent of Total Billed Charges,95% of Total Billed Charges,4933.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4341.65,88,,58.216,Percent of Total Billed Charges,88% of Total Billed Charges,4440.32,90,,60.328,Percent of Total Billed charges,90% of Total Billed Charges,2175.76,4933.69,
Z47Z2553150 FEM 5,2780000766,CDM,278,RC,C1713,HCPCS,Outpatient,,,587.63,381.96,,587.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,446.6,76,,2748.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,423.09,72,,1517.752,Percent of Total Billed Charges,72% of Total Billed Charges,423.09,72,,1517.752,Percent of Total Billed charges,72% of Total Billed Charges,587.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,423.09,72,,1517.752,Percent of Total Billed Charges,72% of Total Billed Charges,352.58,60,,1264.792,Percent of Total Billed Charges,60% of Total Billed Charges,528.87,90,,284.184,Percent of Total Billed Charges,90% of Total Billed Charges,264.43,45,,1160.928,Percent of Total Billed Charges,45% of Total Billed Charges,528.87,90,,3255.376,Percent of Total Billed Charges,90% of Total billed Charges,587.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,587.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,587.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.96,65,,1172.976,Percent of total Billed Charges,65% of Total Billed Charges,259.14,44.1,,1137.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,558.25,95,,3436.224,Percent of Total Billed Charges,95% of Total Billed Charges,587.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,517.11,88,,2626.528,Percent of Total Billed Charges,88% of Total Billed Charges,528.87,90,,3255.376,Percent of Total Billed charges,90% of Total Billed Charges,259.14,587.63,
Z23580104 HUMERAL,2780000767,CDM,278,RC,C1713,HCPCS,Outpatient,,,5174.03,3363.12,,5174.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3932.26,76,,843.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3725.3,72,,3539.08,Percent of Total Billed Charges,72% of Total Billed Charges,3725.3,72,,3539.08,Percent of Total Billed charges,72% of Total Billed Charges,5174.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3725.3,72,,3539.08,Percent of Total Billed Charges,72% of Total Billed Charges,3104.42,60,,2949.232,Percent of Total Billed Charges,60% of Total Billed Charges,4656.63,90,,284.184,Percent of Total Billed Charges,90% of Total Billed Charges,2328.31,45,,29.768,Percent of Total Billed Charges,45% of Total Billed Charges,4656.63,90,,999.4,Percent of Total Billed Charges,90% of Total billed Charges,5174.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5174.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5174.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3363.12,65,,2350.528,Percent of total Billed Charges,65% of Total Billed Charges,2281.75,44.1,,29.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,4915.33,95,,1054.92,Percent of Total Billed Charges,95% of Total Billed Charges,5174.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4553.15,88,,3688.312,Percent of Total Billed Charges,88% of Total Billed Charges,4656.63,90,,999.4,Percent of Total Billed charges,90% of Total Billed Charges,2281.75,5174.03,
Z23603316 GUIDE WI,2780000768,CDM,278,RC,C1713,HCPCS,Outpatient,,,74.97,48.73,,74.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.98,76,,1705.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.98,72,,455.96,Percent of Total Billed Charges,72% of Total Billed Charges,53.98,72,,455.96,Percent of Total Billed charges,72% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.98,72,,455.96,Percent of Total Billed Charges,72% of Total Billed Charges,44.98,60,,379.968,Percent of Total Billed Charges,60% of Total Billed Charges,67.47,90,,284.184,Percent of Total Billed Charges,90% of Total Billed Charges,33.74,45,,1343.112,Percent of Total Billed Charges,45% of Total Billed Charges,67.47,90,,2020.216,Percent of Total Billed Charges,90% of Total billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.73,65,,287.224,Percent of total Billed Charges,65% of Total Billed Charges,33.06,44.1,,1316.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,71.22,95,,2132.456,Percent of Total Billed Charges,95% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.97,88,,4611.944,Percent of Total Billed Charges,88% of Total Billed Charges,67.47,90,,2020.216,Percent of Total Billed charges,90% of Total Billed Charges,33.06,74.97,
Z23594635 3.5 LOCK,2780000769,CDM,278,RC,C1713,HCPCS,Outpatient,,,745.29,484.44,,745.29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,566.42,76,,1960.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,536.61,72,,189.88,Percent of Total Billed Charges,72% of Total Billed Charges,536.61,72,,189.88,Percent of Total Billed charges,72% of Total Billed Charges,745.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,536.61,72,,189.88,Percent of Total Billed Charges,72% of Total Billed Charges,447.17,60,,158.232,Percent of Total Billed Charges,60% of Total Billed Charges,670.76,90,,284.184,Percent of Total Billed Charges,90% of Total Billed Charges,335.38,45,,1886.072,Percent of Total Billed Charges,45% of Total Billed Charges,670.76,90,,2321.864,Percent of Total Billed Charges,90% of Total billed Charges,745.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,745.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,745.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484.44,65,,801.48,Percent of total Billed Charges,65% of Total Billed Charges,328.67,44.1,,1848.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,708.03,95,,2450.856,Percent of Total Billed Charges,95% of Total Billed Charges,745.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.86,88,,14257.28,Percent of Total Billed Charges,88% of Total Billed Charges,670.76,90,,2321.864,Percent of Total Billed charges,90% of Total Billed Charges,328.67,745.29,
Z23593037 3.5 CANN,2780000770,CDM,278,RC,C1713,HCPCS,Outpatient,,,324.14,210.69,,324.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,246.35,76,,50.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,233.38,72,,54.616,Percent of Total Billed Charges,72% of Total Billed Charges,233.38,72,,54.616,Percent of Total Billed charges,72% of Total Billed Charges,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.38,72,,54.616,Percent of Total Billed Charges,72% of Total Billed Charges,194.48,60,,45.512,Percent of Total Billed Charges,60% of Total Billed Charges,291.73,90,,284.184,Percent of Total Billed Charges,90% of Total Billed Charges,145.86,45,,2358.384,Percent of Total Billed Charges,45% of Total Billed Charges,291.73,90,,59.536,Percent of Total Billed Charges,90% of Total billed Charges,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.69,65,,3932.264,Percent of total Billed Charges,65% of Total Billed Charges,142.95,44.1,,2311.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,307.93,95,,62.848,Percent of Total Billed Charges,95% of Total Billed Charges,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.24,88,,3341.368,Percent of Total Billed Charges,88% of Total Billed Charges,291.73,90,,59.536,Percent of Total Billed charges,90% of Total Billed Charges,142.95,324.14,
Z23595037 3.5 CANN,2780000771,CDM,278,RC,C1713,HCPCS,Outpatient,,,324.14,210.69,,324.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,246.35,76,,2268.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,233.38,72,,216.544,Percent of Total Billed Charges,72% of Total Billed Charges,233.38,72,,216.544,Percent of Total Billed charges,72% of Total Billed Charges,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.38,72,,216.544,Percent of Total Billed Charges,72% of Total Billed Charges,194.48,60,,180.456,Percent of Total Billed Charges,60% of Total Billed Charges,291.73,90,,284.184,Percent of Total Billed Charges,90% of Total Billed Charges,145.86,45,,7290.656,Percent of Total Billed Charges,45% of Total Billed Charges,291.73,90,,2686.216,Percent of Total Billed Charges,90% of Total billed Charges,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.69,65,,12738.728,Percent of total Billed Charges,65% of Total Billed Charges,142.95,44.1,,7144.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,307.93,95,,2835.456,Percent of Total Billed Charges,95% of Total Billed Charges,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.24,88,,277.872,Percent of Total Billed Charges,88% of Total Billed Charges,291.73,90,,2686.216,Percent of Total Billed charges,90% of Total Billed Charges,142.95,324.14,
Z22320318 CABLE GR,2780000772,CDM,278,RC,C1713,HCPCS,Outpatient,,,958.07,622.75,,958.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,728.13,76,,3185.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,689.81,72,,216.544,Percent of Total Billed Charges,72% of Total Billed Charges,689.81,72,,216.544,Percent of Total Billed charges,72% of Total Billed Charges,958.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,689.81,72,,216.544,Percent of Total Billed Charges,72% of Total Billed Charges,574.84,60,,180.456,Percent of Total Billed Charges,60% of Total Billed Charges,862.26,90,,127.008,Percent of Total Billed Charges,90% of Total Billed Charges,431.13,45,,1708.656,Percent of Total Billed Charges,45% of Total Billed Charges,862.26,90,,3772.136,Percent of Total Billed Charges,90% of Total billed Charges,958.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,958.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,958.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,622.75,65,,593.936,Percent of total Billed Charges,65% of Total Billed Charges,422.51,44.1,,1674.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,910.17,95,,3981.704,Percent of Total Billed Charges,95% of Total Billed Charges,958.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,843.1,88,,277.872,Percent of Total Billed Charges,88% of Total Billed Charges,862.26,90,,3772.136,Percent of Total Billed charges,90% of Total Billed Charges,422.51,958.07,
Z22320301 CABLE/PL,2780000773,CDM,278,RC,C1713,HCPCS,Outpatient,,,2548.98,1656.84,,2548.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1937.22,76,,3983.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1835.27,72,,446.432,Percent of Total Billed Charges,72% of Total Billed Charges,1835.27,72,,446.432,Percent of Total Billed charges,72% of Total Billed Charges,2548.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1835.27,72,,446.432,Percent of Total Billed Charges,72% of Total Billed Charges,1529.39,60,,372.032,Percent of Total Billed Charges,60% of Total Billed Charges,2294.08,90,,3100.584,Percent of Total Billed Charges,90% of Total Billed Charges,1147.04,45,,142.096,Percent of Total Billed Charges,45% of Total Billed Charges,2294.08,90,,4716.76,Percent of Total Billed Charges,90% of Total billed Charges,2548.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2548.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2548.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1656.84,65,,10735.04,Percent of total Billed Charges,65% of Total Billed Charges,1124.1,44.1,,139.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,2421.53,95,,4978.808,Percent of Total Billed Charges,95% of Total Billed Charges,2548.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2243.1,88,,277.872,Percent of Total Billed Charges,88% of Total Billed Charges,2294.08,90,,4716.76,Percent of Total Billed charges,90% of Total Billed Charges,1124.1,2548.98,
Z22535555 5.5 CORT,2780000774,CDM,278,RC,C1713,HCPCS,Outpatient,,,554.56,360.46,,554.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,421.47,76,,12313.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.28,72,,1262.456,Percent of Total Billed Charges,72% of Total Billed Charges,399.28,72,,1262.456,Percent of Total Billed charges,72% of Total Billed Charges,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.28,72,,1262.456,Percent of Total Billed Charges,72% of Total Billed Charges,332.74,60,,1052.048,Percent of Total Billed Charges,60% of Total Billed Charges,499.1,90,,239.728,Percent of Total Billed Charges,90% of Total Billed Charges,249.55,45,,142.096,Percent of Total Billed Charges,45% of Total Billed Charges,499.1,90,,14581.312,Percent of Total Billed Charges,90% of Total billed Charges,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360.46,65,,2961.096,Percent of total Billed Charges,65% of Total Billed Charges,244.56,44.1,,139.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,526.83,95,,15391.384,Percent of Total Billed Charges,95% of Total Billed Charges,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.01,88,,277.872,Percent of Total Billed Charges,88% of Total Billed Charges,499.1,90,,14581.312,Percent of Total Billed charges,90% of Total Billed Charges,244.56,554.56,
Z48355001 3.5 CORT,2780000775,CDM,278,RC,C1713,HCPCS,Outpatient,,,87.10,56.62,,87.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.2,76,,2885.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.71,72,,1262.456,Percent of Total Billed Charges,72% of Total Billed Charges,62.71,72,,1262.456,Percent of Total Billed charges,72% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.71,72,,1262.456,Percent of Total Billed Charges,72% of Total Billed Charges,52.26,60,,1052.048,Percent of Total Billed Charges,60% of Total Billed Charges,78.39,90,,239.728,Percent of Total Billed Charges,90% of Total Billed Charges,39.2,45,,142.096,Percent of Total Billed Charges,45% of Total Billed Charges,78.39,90,,3417.304,Percent of Total Billed Charges,90% of Total billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.62,65,,4604.176,Percent of total Billed Charges,65% of Total Billed Charges,38.41,44.1,,139.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.75,95,,3607.16,Percent of Total Billed Charges,95% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.65,88,,277.872,Percent of Total Billed Charges,88% of Total Billed Charges,78.39,90,,3417.304,Percent of Total Billed charges,90% of Total Billed Charges,38.41,87.1,
Z22401334 RETROFEM,2780000776,CDM,278,RC,C1713,HCPCS,Outpatient,,,4742.96,3082.92,,4742.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3604.65,76,,239.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3414.93,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,3414.93,72,,13.976,Percent of Total Billed charges,72% of Total Billed Charges,4742.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3414.93,72,,13.976,Percent of Total Billed Charges,72% of Total Billed Charges,2845.78,60,,11.648,Percent of Total Billed Charges,60% of Total Billed Charges,4268.66,90,,239.728,Percent of Total Billed Charges,90% of Total Billed Charges,2134.33,45,,142.096,Percent of Total Billed Charges,45% of Total Billed Charges,4268.66,90,,284.184,Percent of Total Billed Charges,90% of Total billed Charges,4742.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4742.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4742.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3082.92,65,,168.552,Percent of total Billed Charges,65% of Total Billed Charges,2091.65,44.1,,139.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,4505.81,95,,299.976,Percent of Total Billed Charges,95% of Total Billed Charges,4742.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4173.8,88,,277.872,Percent of Total Billed Charges,88% of Total Billed Charges,4268.66,90,,284.184,Percent of Total Billed charges,90% of Total Billed Charges,2091.65,4742.96,
Z225234013 FEMRECO,2780000777,CDM,278,RC,C1713,HCPCS,Outpatient,,,3301.99,2146.29,,3301.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2509.51,76,,239.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2377.43,72,,3554.96,Percent of Total Billed Charges,72% of Total Billed Charges,2377.43,72,,3554.96,Percent of Total Billed charges,72% of Total Billed Charges,3301.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2377.43,72,,3554.96,Percent of Total Billed Charges,72% of Total Billed Charges,1981.19,60,,2962.464,Percent of Total Billed Charges,60% of Total Billed Charges,2971.79,90,,3485.576,Percent of Total Billed Charges,90% of Total Billed Charges,1485.9,45,,142.096,Percent of Total Billed Charges,45% of Total Billed Charges,2971.79,90,,284.184,Percent of Total Billed Charges,90% of Total billed Charges,3301.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3301.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3301.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2146.29,65,,16.056,Percent of total Billed Charges,65% of Total Billed Charges,1456.18,44.1,,139.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,3136.89,95,,299.976,Percent of Total Billed Charges,95% of Total Billed Charges,3301.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2905.75,88,,124.184,Percent of Total Billed Charges,88% of Total Billed Charges,2971.79,90,,284.184,Percent of Total Billed charges,90% of Total Billed Charges,1456.18,3301.99,
Z59763014 CRUC 14M,2780000778,CDM,278,RC,C1713,HCPCS,Outpatient,,,4444.18,2888.72,,4444.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3377.58,76,,239.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3199.81,72,,114.304,Percent of Total Billed Charges,72% of Total Billed Charges,3199.81,72,,114.304,Percent of Total Billed charges,72% of Total Billed Charges,4444.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3199.81,72,,114.304,Percent of Total Billed Charges,72% of Total Billed Charges,2666.51,60,,95.256,Percent of Total Billed Charges,60% of Total Billed Charges,3999.76,90,,239.728,Percent of Total Billed Charges,90% of Total Billed Charges,1999.88,45,,142.096,Percent of Total Billed Charges,45% of Total Billed Charges,3999.76,90,,284.184,Percent of Total Billed Charges,90% of Total billed Charges,4444.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4444.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4444.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2888.72,65,,2495.576,Percent of total Billed Charges,65% of Total Billed Charges,1959.88,44.1,,139.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,4221.97,95,,299.976,Percent of Total Billed Charges,95% of Total Billed Charges,4444.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3910.88,88,,3031.688,Percent of Total Billed Charges,88% of Total Billed Charges,3999.76,90,,284.184,Percent of Total Billed charges,90% of Total Billed Charges,1959.88,4444.18,
Z59701402 FEM COMP,2780000779,CDM,278,RC,C1713,HCPCS,Outpatient,,,4742.96,3082.92,,4742.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3604.65,76,,239.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3414.93,72,,2683.04,Percent of Total Billed Charges,72% of Total Billed Charges,3414.93,72,,2683.04,Percent of Total Billed charges,72% of Total Billed Charges,4742.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3414.93,72,,2683.04,Percent of Total Billed Charges,72% of Total Billed Charges,2845.78,60,,2235.872,Percent of Total Billed Charges,60% of Total Billed Charges,4268.66,90,,366.736,Percent of Total Billed Charges,90% of Total Billed Charges,2134.33,45,,63.504,Percent of Total Billed Charges,45% of Total Billed Charges,4268.66,90,,284.184,Percent of Total Billed Charges,90% of Total billed Charges,4742.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4742.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4742.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3082.92,65,,191.488,Percent of total Billed Charges,65% of Total Billed Charges,2091.65,44.1,,62.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,4505.81,95,,299.976,Percent of Total Billed Charges,95% of Total Billed Charges,4742.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4173.8,88,,234.4,Percent of Total Billed Charges,88% of Total Billed Charges,4268.66,90,,284.184,Percent of Total Billed charges,90% of Total Billed Charges,2091.65,4742.96,
Z59880310 REV STEM,2780000780,CDM,278,RC,C1713,HCPCS,Outpatient,,,5384.61,3500.00,,5384.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4092.3,76,,239.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3876.92,72,,302.912,Percent of Total Billed Charges,72% of Total Billed Charges,3876.92,72,,302.912,Percent of Total Billed charges,72% of Total Billed Charges,5384.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3876.92,72,,302.912,Percent of Total Billed Charges,72% of Total Billed Charges,3230.77,60,,252.424,Percent of Total Billed Charges,60% of Total Billed Charges,4846.15,90,,366.736,Percent of Total Billed Charges,90% of Total Billed Charges,2423.07,45,,1550.296,Percent of Total Billed Charges,45% of Total Billed Charges,4846.15,90,,284.184,Percent of Total Billed Charges,90% of Total billed Charges,5384.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5384.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5384.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3500,65,,191.488,Percent of total Billed Charges,65% of Total Billed Charges,2374.61,44.1,,1519.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,5115.38,95,,299.976,Percent of Total Billed Charges,95% of Total Billed Charges,5384.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4738.46,88,,234.4,Percent of Total Billed Charges,88% of Total Billed Charges,4846.15,90,,284.184,Percent of Total Billed charges,90% of Total Billed Charges,2374.61,5384.61,
Z59643210 ART SURF,2780000781,CDM,278,RC,C1713,HCPCS,Outpatient,,,6578.62,4276.10,,6578.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4999.75,76,,239.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4736.61,72,,2254.392,Percent of Total Billed Charges,72% of Total Billed Charges,4736.61,72,,2254.392,Percent of Total Billed charges,72% of Total Billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4736.61,72,,2254.392,Percent of Total Billed Charges,72% of Total Billed Charges,3947.17,60,,1878.664,Percent of Total Billed Charges,60% of Total Billed Charges,5920.76,90,,19.84,Percent of Total Billed Charges,90% of Total Billed Charges,2960.38,45,,119.864,Percent of Total Billed Charges,45% of Total Billed Charges,5920.76,90,,284.184,Percent of Total Billed Charges,90% of Total billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4276.1,65,,235.624,Percent of total Billed Charges,65% of Total Billed Charges,2901.17,44.1,,117.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,6249.69,95,,299.976,Percent of Total Billed Charges,95% of Total Billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5789.19,88,,234.4,Percent of Total Billed Charges,88% of Total Billed Charges,5920.76,90,,284.184,Percent of Total Billed charges,90% of Total Billed Charges,2901.17,6578.62,
STRYKER RP 360 NEEDL,2780000782,CDM,278,RC,C1713,HCPCS,Outpatient,,,858.85,558.25,,858.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,652.73,76,,107.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,618.37,72,,9887.576,Percent of Total Billed Charges,72% of Total Billed Charges,618.37,72,,9887.576,Percent of Total Billed charges,72% of Total Billed Charges,858.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618.37,72,,9887.576,Percent of Total Billed Charges,72% of Total Billed Charges,515.31,60,,8239.648,Percent of Total Billed Charges,60% of Total Billed Charges,772.97,90,,294.504,Percent of Total Billed Charges,90% of Total Billed Charges,386.48,45,,119.864,Percent of Total Billed Charges,45% of Total Billed Charges,772.97,90,,127.008,Percent of Total Billed Charges,90% of Total billed Charges,858.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,858.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,858.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.25,65,,235.624,Percent of total Billed Charges,65% of Total Billed Charges,378.75,44.1,,117.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,815.91,95,,134.064,Percent of Total Billed Charges,95% of Total Billed Charges,858.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,755.79,88,,3408.12,Percent of Total Billed Charges,88% of Total Billed Charges,772.97,90,,127.008,Percent of Total Billed charges,90% of Total Billed Charges,378.75,858.85,
STRYKER REELXSTT 5.5,2780000783,CDM,278,RC,C1713,HCPCS,Outpatient,,,2061.68,1340.09,,2061.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1566.88,76,,2618.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1484.41,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,1484.41,72,,42.552,Percent of Total Billed charges,72% of Total Billed Charges,2061.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1484.41,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,1237.01,60,,35.456,Percent of Total Billed Charges,60% of Total Billed Charges,1855.51,90,,1624.12,Percent of Total Billed Charges,90% of Total Billed Charges,927.76,45,,119.864,Percent of Total Billed Charges,45% of Total Billed Charges,1855.51,90,,3100.584,Percent of Total Billed Charges,90% of Total billed Charges,2061.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2061.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2061.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1340.09,65,,235.624,Percent of total Billed Charges,65% of Total Billed Charges,909.2,44.1,,117.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,1958.6,95,,3272.84,Percent of Total Billed Charges,95% of Total Billed Charges,2061.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1814.28,88,,234.4,Percent of Total Billed Charges,88% of Total Billed Charges,1855.51,90,,3100.584,Percent of Total Billed charges,90% of Total Billed Charges,909.2,2061.68,
Z59643010 ART SUFA,2780000784,CDM,278,RC,C1713,HCPCS,Outpatient,,,6578.62,4276.10,,6578.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4999.75,76,,202.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4736.61,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,4736.61,72,,25.4,Percent of Total Billed charges,72% of Total Billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4736.61,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,3947.17,60,,21.168,Percent of Total Billed Charges,60% of Total Billed Charges,5920.76,90,,3254.584,Percent of Total Billed Charges,90% of Total Billed Charges,2960.38,45,,1742.792,Percent of Total Billed Charges,45% of Total Billed Charges,5920.76,90,,239.728,Percent of Total Billed Charges,90% of Total billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4276.1,65,,3354.952,Percent of total Billed Charges,65% of Total Billed Charges,2901.17,44.1,,1707.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,6249.69,95,,253.048,Percent of Total Billed Charges,95% of Total Billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5789.19,88,,358.592,Percent of Total Billed Charges,88% of Total Billed Charges,5920.76,90,,239.728,Percent of Total Billed charges,90% of Total Billed Charges,2901.17,6578.62,
Z59643012 ART SURF,2780000785,CDM,278,RC,C1713,HCPCS,Outpatient,,,6578.62,4276.10,,6578.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4999.75,76,,202.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4736.61,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,4736.61,72,,42.552,Percent of Total Billed charges,72% of Total Billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4736.61,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,3947.17,60,,35.456,Percent of Total Billed Charges,60% of Total Billed Charges,5920.76,90,,397.696,Percent of Total Billed Charges,90% of Total Billed Charges,2960.38,45,,119.864,Percent of Total Billed Charges,45% of Total Billed Charges,5920.76,90,,239.728,Percent of Total Billed Charges,90% of Total billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4276.1,65,,1694.672,Percent of total Billed Charges,65% of Total Billed Charges,2901.17,44.1,,117.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,6249.69,95,,253.048,Percent of Total Billed Charges,95% of Total Billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5789.19,88,,358.592,Percent of Total Billed Charges,88% of Total Billed Charges,5920.76,90,,239.728,Percent of Total Billed charges,90% of Total Billed Charges,2901.17,6578.62,
Z11811042 COMP LAG,2780000786,CDM,278,RC,C1713,HCPCS,Outpatient,,,1121.24,728.81,,1121.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,852.14,76,,202.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,807.29,72,,357.528,Percent of Total Billed Charges,72% of Total Billed Charges,807.29,72,,357.528,Percent of Total Billed charges,72% of Total Billed Charges,1121.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,807.29,72,,357.528,Percent of Total Billed Charges,72% of Total Billed Charges,672.74,60,,297.944,Percent of Total Billed Charges,60% of Total Billed Charges,1009.12,90,,1109.736,Percent of Total Billed Charges,90% of Total Billed Charges,504.56,45,,183.368,Percent of Total Billed Charges,45% of Total Billed Charges,1009.12,90,,239.728,Percent of Total Billed Charges,90% of Total billed Charges,1121.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1121.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1121.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,728.81,65,,1522.112,Percent of total Billed Charges,65% of Total Billed Charges,494.47,44.1,,179.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,1065.18,95,,253.048,Percent of Total Billed Charges,95% of Total Billed Charges,1121.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,986.69,88,,19.4,Percent of Total Billed Charges,88% of Total Billed Charges,1009.12,90,,239.728,Percent of Total Billed charges,90% of Total Billed Charges,494.47,1121.24,
Z118113506 COMP TU,2780000787,CDM,278,RC,C1713,HCPCS,Outpatient,,,1723.21,1120.09,,1723.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1309.64,76,,2943.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1240.71,72,,357.528,Percent of Total Billed Charges,72% of Total Billed Charges,1240.71,72,,357.528,Percent of Total Billed charges,72% of Total Billed Charges,1723.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1240.71,72,,357.528,Percent of Total Billed Charges,72% of Total Billed Charges,1033.93,60,,297.944,Percent of Total Billed Charges,60% of Total Billed Charges,1550.89,90,,5444.68,Percent of Total Billed Charges,90% of Total Billed Charges,775.44,45,,183.368,Percent of Total Billed Charges,45% of Total Billed Charges,1550.89,90,,3485.576,Percent of Total Billed Charges,90% of Total billed Charges,1723.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1723.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1723.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1120.09,65,,169.128,Percent of total Billed Charges,65% of Total Billed Charges,759.94,44.1,,179.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,1637.05,95,,3679.224,Percent of Total Billed Charges,95% of Total Billed Charges,1723.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1516.42,88,,287.96,Percent of Total Billed Charges,88% of Total Billed Charges,1550.89,90,,3485.576,Percent of Total Billed charges,90% of Total Billed Charges,759.94,1723.21,
Z48355501 3.5 CORT,2780000788,CDM,278,RC,C1713,HCPCS,Outpatient,,,62.84,40.85,,62.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.76,76,,202.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.24,72,,1262.456,Percent of Total Billed Charges,72% of Total Billed Charges,45.24,72,,1262.456,Percent of Total Billed charges,72% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.24,72,,1262.456,Percent of Total Billed Charges,72% of Total Billed Charges,37.7,60,,1052.048,Percent of Total Billed Charges,60% of Total Billed Charges,56.56,90,,17638.24,Percent of Total Billed Charges,90% of Total Billed Charges,28.28,45,,9.92,Percent of Total Billed Charges,45% of Total Billed Charges,56.56,90,,239.728,Percent of Total Billed Charges,90% of Total billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.85,65,,169.128,Percent of total Billed Charges,65% of Total Billed Charges,27.71,44.1,,9.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.7,95,,253.048,Percent of Total Billed Charges,95% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.3,88,,1588.024,Percent of Total Billed Charges,88% of Total Billed Charges,56.56,90,,239.728,Percent of Total Billed charges,90% of Total Billed Charges,27.71,62.84,
Z59644212 ART. SUR,2780000789,CDM,278,RC,C1713,HCPCS,Outpatient,,,6578.62,4276.10,,6578.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4999.75,76,,309.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4736.61,72,,1262.456,Percent of Total Billed Charges,72% of Total Billed Charges,4736.61,72,,1262.456,Percent of Total Billed charges,72% of Total Billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4736.61,72,,1262.456,Percent of Total Billed Charges,72% of Total Billed Charges,3947.17,60,,1052.048,Percent of Total Billed Charges,60% of Total Billed Charges,5920.76,90,,822.376,Percent of Total Billed Charges,90% of Total Billed Charges,2960.38,45,,147.248,Percent of Total Billed Charges,45% of Total Billed Charges,5920.76,90,,366.736,Percent of Total Billed Charges,90% of Total billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4276.1,65,,191.488,Percent of total Billed Charges,65% of Total Billed Charges,2901.17,44.1,,144.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,6249.69,95,,387.112,Percent of Total Billed Charges,95% of Total Billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5789.19,88,,3182.256,Percent of Total Billed Charges,88% of Total Billed Charges,5920.76,90,,366.736,Percent of Total Billed charges,90% of Total Billed Charges,2901.17,6578.62,
STRYKER 5.5 PEEK ZIP,2780000790,CDM,278,RC,C1713,HCPCS,Outpatient,,,1515.94,985.36,,1515.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1152.11,76,,309.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1091.48,72,,341.104,Percent of Total Billed Charges,72% of Total Billed Charges,1091.48,72,,341.104,Percent of Total Billed charges,72% of Total Billed Charges,1515.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1091.48,72,,341.104,Percent of Total Billed Charges,72% of Total Billed Charges,909.56,60,,284.256,Percent of Total Billed Charges,60% of Total Billed Charges,1364.35,90,,14863.904,Percent of Total Billed Charges,90% of Total Billed Charges,682.17,45,,812.056,Percent of Total Billed Charges,45% of Total Billed Charges,1364.35,90,,366.736,Percent of Total Billed Charges,90% of Total billed Charges,1515.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1515.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1515.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,985.36,65,,191.488,Percent of total Billed Charges,65% of Total Billed Charges,668.53,44.1,,795.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,1440.14,95,,387.112,Percent of Total Billed Charges,95% of Total Billed Charges,1515.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1334.03,88,,388.856,Percent of Total Billed Charges,88% of Total Billed Charges,1364.35,90,,366.736,Percent of Total Billed charges,90% of Total Billed Charges,668.53,1515.94,
STRYKER TWIN LOOP AN,2780000791,CDM,278,RC,C1713,HCPCS,Outpatient,,,1395.77,907.25,,1395.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1060.79,76,,16.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1004.95,72,,9790.504,Percent of Total Billed Charges,72% of Total Billed Charges,1004.95,72,,9790.504,Percent of Total Billed charges,72% of Total Billed Charges,1395.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1004.95,72,,9790.504,Percent of Total Billed Charges,72% of Total Billed Charges,837.46,60,,8158.752,Percent of Total Billed Charges,60% of Total Billed Charges,1256.19,90,,4099.976,Percent of Total Billed Charges,90% of Total Billed Charges,628.1,45,,1627.288,Percent of Total Billed Charges,45% of Total Billed Charges,1256.19,90,,19.84,Percent of Total Billed Charges,90% of Total billed Charges,1395.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1395.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1395.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,907.25,65,,213.84,Percent of total Billed Charges,65% of Total Billed Charges,615.53,44.1,,1594.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,1325.98,95,,20.944,Percent of Total Billed Charges,95% of Total Billed Charges,1395.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1228.28,88,,1085.072,Percent of Total Billed Charges,88% of Total Billed Charges,1256.19,90,,19.84,Percent of Total Billed charges,90% of Total Billed Charges,615.53,1395.77,
STRYKER TWIN LOOP DR,2780000792,CDM,278,RC,C1713,HCPCS,Outpatient,,,858.85,558.25,,858.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,652.73,76,,248.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,618.37,72,,394.936,Percent of Total Billed Charges,72% of Total Billed Charges,618.37,72,,394.936,Percent of Total Billed charges,72% of Total Billed Charges,858.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618.37,72,,394.936,Percent of Total Billed Charges,72% of Total Billed Charges,515.31,60,,329.112,Percent of Total Billed Charges,60% of Total Billed Charges,772.97,90,,6375.008,Percent of Total Billed Charges,90% of Total Billed Charges,386.48,45,,198.848,Percent of Total Billed Charges,45% of Total Billed Charges,772.97,90,,294.504,Percent of Total Billed Charges,90% of Total billed Charges,858.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,858.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,858.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.25,65,,2649.216,Percent of total Billed Charges,65% of Total Billed Charges,378.75,44.1,,194.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,815.91,95,,310.864,Percent of Total Billed Charges,95% of Total Billed Charges,858.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,755.79,88,,5323.68,Percent of Total Billed Charges,88% of Total Billed Charges,772.97,90,,294.504,Percent of Total Billed charges,90% of Total Billed Charges,378.75,858.85,
Z11479902 GUIDE PIN,2780000793,CDM,278,RC,C1713,HCPCS,Outpatient,,,57.33,37.26,,57.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.57,76,,1371.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.28,72,,324.776,Percent of Total Billed Charges,72% of Total Billed Charges,41.28,72,,324.776,Percent of Total Billed charges,72% of Total Billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.28,72,,324.776,Percent of Total Billed Charges,72% of Total Billed Charges,34.4,60,,270.648,Percent of Total Billed Charges,60% of Total Billed Charges,51.6,90,,233.384,Percent of Total Billed Charges,90% of Total Billed Charges,25.8,45,,554.872,Percent of Total Billed Charges,45% of Total Billed Charges,51.6,90,,1624.12,Percent of Total Billed Charges,90% of Total billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.26,65,,5617.768,Percent of total Billed Charges,65% of Total Billed Charges,25.28,44.1,,543.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.46,95,,1714.344,Percent of Total Billed Charges,95% of Total Billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.45,88,,17246.272,Percent of Total Billed Charges,88% of Total Billed Charges,51.6,90,,1624.12,Percent of Total Billed charges,90% of Total Billed Charges,25.28,57.33,
RUSH ROD M,2780000794,CDM,278,RC,C1713,HCPCS,Outpatient,,,437.69,284.50,,437.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,332.64,76,,2748.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,315.14,72,,324.776,Percent of Total Billed Charges,72% of Total Billed Charges,315.14,72,,324.776,Percent of Total Billed charges,72% of Total Billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.14,72,,324.776,Percent of Total Billed Charges,72% of Total Billed Charges,262.61,60,,270.648,Percent of Total Billed Charges,60% of Total Billed Charges,393.92,90,,22.224,Percent of Total Billed Charges,90% of Total Billed Charges,196.96,45,,2722.336,Percent of Total Billed Charges,45% of Total Billed Charges,393.92,90,,3254.584,Percent of Total Billed Charges,90% of Total billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.5,65,,94.592,Percent of total Billed Charges,65% of Total Billed Charges,193.02,44.1,,2667.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,415.81,95,,3435.392,Percent of Total Billed Charges,95% of Total Billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.17,88,,804.104,Percent of Total Billed Charges,88% of Total Billed Charges,393.92,90,,3254.584,Percent of Total Billed charges,90% of Total Billed Charges,193.02,437.69,
Z114709075 16MM TH,2780000795,CDM,278,RC,C1713,HCPCS,Outpatient,,,878.69,571.15,,878.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,667.8,76,,335.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,632.66,72,,84.064,Percent of Total Billed Charges,72% of Total Billed Charges,632.66,72,,84.064,Percent of Total Billed charges,72% of Total Billed Charges,878.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,632.66,72,,84.064,Percent of Total Billed Charges,72% of Total Billed Charges,527.21,60,,70.056,Percent of Total Billed Charges,60% of Total Billed Charges,790.82,90,,3455.408,Percent of Total Billed Charges,90% of Total Billed Charges,395.41,45,,8819.12,Percent of Total Billed Charges,45% of Total Billed Charges,790.82,90,,397.696,Percent of Total Billed Charges,90% of Total billed Charges,878.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,571.15,65,,94.592,Percent of total Billed Charges,65% of Total Billed Charges,387.5,44.1,,8642.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,834.76,95,,419.784,Percent of Total Billed Charges,95% of Total Billed Charges,878.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,773.25,88,,14533.592,Percent of Total Billed Charges,88% of Total Billed Charges,790.82,90,,397.696,Percent of Total Billed charges,90% of Total Billed Charges,387.5,878.69,
Z225212555 RECON S,2780000796,CDM,278,RC,C1713,HCPCS,Outpatient,,,850.03,552.52,,850.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,646.02,76,,937.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,612.02,72,,552.784,Percent of Total Billed Charges,72% of Total Billed Charges,612.02,72,,552.784,Percent of Total Billed charges,72% of Total Billed Charges,850.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.02,72,,552.784,Percent of Total Billed Charges,72% of Total Billed Charges,510.02,60,,460.656,Percent of Total Billed Charges,60% of Total Billed Charges,765.03,90,,265.136,Percent of Total Billed Charges,90% of Total Billed Charges,382.51,45,,411.192,Percent of Total Billed Charges,45% of Total Billed Charges,765.03,90,,1109.736,Percent of Total Billed Charges,90% of Total billed Charges,850.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,850.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,850.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.52,65,,743.568,Percent of total Billed Charges,65% of Total Billed Charges,374.86,44.1,,402.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,807.53,95,,1171.392,Percent of Total Billed Charges,95% of Total Billed Charges,850.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,748.03,88,,4008.864,Percent of Total Billed Charges,88% of Total Billed Charges,765.03,90,,1109.736,Percent of Total Billed charges,90% of Total Billed Charges,374.86,850.03,
STIMULAS KIT RAPID C,2780000797,CDM,278,RC,C1713,HCPCS,Outpatient,,,10714.10,6964.17,,10714.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8142.72,76,,4597.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7714.15,72,,110.072,Percent of Total Billed Charges,72% of Total Billed Charges,7714.15,72,,110.072,Percent of Total Billed charges,72% of Total Billed Charges,10714.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7714.15,72,,110.072,Percent of Total Billed Charges,72% of Total Billed Charges,6428.46,60,,91.728,Percent of Total Billed Charges,60% of Total Billed Charges,9642.69,90,,265.136,Percent of Total Billed Charges,90% of Total Billed Charges,4821.35,45,,7431.952,Percent of Total Billed Charges,45% of Total Billed Charges,9642.69,90,,5444.68,Percent of Total Billed Charges,90% of Total billed Charges,10714.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10714.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10714.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6964.17,65,,524,Percent of total Billed Charges,65% of Total Billed Charges,4724.92,44.1,,7283.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,10178.4,95,,5747.16,Percent of Total Billed Charges,95% of Total Billed Charges,10714.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9428.41,88,,6233.344,Percent of Total Billed Charges,88% of Total Billed Charges,9642.69,90,,5444.68,Percent of Total Billed charges,90% of Total Billed Charges,4724.92,10714.1,
Z59881015 REV STEM,2780000798,CDM,278,RC,C1713,HCPCS,Outpatient,,,4426.54,2877.25,,4426.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3364.17,76,,14894.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3187.11,72,,3001.624,Percent of Total Billed Charges,72% of Total Billed Charges,3187.11,72,,3001.624,Percent of Total Billed charges,72% of Total Billed Charges,4426.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3187.11,72,,3001.624,Percent of Total Billed Charges,72% of Total Billed Charges,2655.92,60,,2501.352,Percent of Total Billed Charges,60% of Total Billed Charges,3983.89,90,,326.256,Percent of Total Billed Charges,90% of Total Billed Charges,1991.94,45,,2049.984,Percent of Total Billed Charges,45% of Total Billed Charges,3983.89,90,,17638.24,Percent of Total Billed Charges,90% of Total billed Charges,4426.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4426.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4426.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.25,65,,77.4,Percent of total Billed Charges,65% of Total Billed Charges,1952.1,44.1,,2008.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,4205.21,95,,18618.136,Percent of Total Billed Charges,95% of Total Billed Charges,4426.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3895.36,88,,228.192,Percent of Total Billed Charges,88% of Total Billed Charges,3983.89,90,,17638.24,Percent of Total Billed charges,90% of Total Billed Charges,1952.1,4426.54,
Z58804012 REV. RHK,2780000799,CDM,278,RC,C1713,HCPCS,Outpatient,,,7371.32,4791.36,,7371.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5602.2,76,,694.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5307.35,72,,2924.208,Percent of Total Billed Charges,72% of Total Billed Charges,5307.35,72,,2924.208,Percent of Total Billed charges,72% of Total Billed Charges,7371.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5307.35,72,,2924.208,Percent of Total Billed Charges,72% of Total Billed Charges,4422.79,60,,2436.84,Percent of Total Billed Charges,60% of Total Billed Charges,6634.19,90,,326.256,Percent of Total Billed Charges,90% of Total Billed Charges,3317.09,45,,3187.504,Percent of Total Billed Charges,45% of Total Billed Charges,6634.19,90,,822.376,Percent of Total Billed Charges,90% of Total billed Charges,7371.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7371.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7371.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4791.36,65,,1028.504,Percent of total Billed Charges,65% of Total Billed Charges,3250.75,44.1,,3123.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,7002.75,95,,868.064,Percent of Total Billed Charges,95% of Total Billed Charges,7371.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6486.76,88,,21.736,Percent of Total Billed Charges,88% of Total Billed Charges,6634.19,90,,822.376,Percent of Total Billed charges,90% of Total Billed Charges,3250.75,7371.32,
Z58804023 REV ARTI,2780000800,CDM,278,RC,C1713,HCPCS,Outpatient,,,7371.32,4791.36,,7371.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5602.2,76,,12551.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5307.35,72,,14.512,Percent of Total Billed Charges,72% of Total Billed Charges,5307.35,72,,14.512,Percent of Total Billed charges,72% of Total Billed Charges,7371.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5307.35,72,,14.512,Percent of Total Billed Charges,72% of Total Billed Charges,4422.79,60,,12.096,Percent of Total Billed Charges,60% of Total Billed Charges,6634.19,90,,326.256,Percent of Total Billed Charges,90% of Total Billed Charges,3317.09,45,,116.688,Percent of Total Billed Charges,45% of Total Billed Charges,6634.19,90,,14863.904,Percent of Total Billed Charges,90% of Total billed Charges,7371.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7371.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7371.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4791.36,65,,743.568,Percent of total Billed Charges,65% of Total Billed Charges,3250.75,44.1,,114.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,7002.75,95,,15689.672,Percent of Total Billed Charges,95% of Total Billed Charges,7371.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6486.76,88,,3378.624,Percent of Total Billed Charges,88% of Total Billed Charges,6634.19,90,,14863.904,Percent of Total Billed charges,90% of Total Billed Charges,3250.75,7371.32,
Z11479903 GUIDE PI,2780000801,CDM,278,RC,C1713,HCPCS,Outpatient,,,57.33,37.26,,57.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.57,76,,3462.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.28,72,,222.912,Percent of Total Billed Charges,72% of Total Billed Charges,41.28,72,,222.912,Percent of Total Billed charges,72% of Total Billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.28,72,,222.912,Percent of Total Billed Charges,72% of Total Billed Charges,34.4,60,,185.76,Percent of Total Billed Charges,60% of Total Billed Charges,51.6,90,,4645.32,Percent of Total Billed Charges,90% of Total Billed Charges,25.8,45,,11.112,Percent of Total Billed Charges,45% of Total Billed Charges,51.6,90,,4099.976,Percent of Total Billed Charges,90% of Total billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.26,65,,108.928,Percent of total Billed Charges,65% of Total Billed Charges,25.28,44.1,,10.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.46,95,,4327.752,Percent of Total Billed Charges,95% of Total Billed Charges,57.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.45,88,,259.24,Percent of Total Billed Charges,88% of Total Billed Charges,51.6,90,,4099.976,Percent of Total Billed charges,90% of Total Billed Charges,25.28,57.33,
Z47249321211 FEMN,2780000802,CDM,278,RC,C1713,HCPCS,Outpatient,,,6147.54,3995.90,,6147.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4672.13,76,,5383.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4426.23,72,,367.112,Percent of Total Billed Charges,72% of Total Billed Charges,4426.23,72,,367.112,Percent of Total Billed charges,72% of Total Billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4426.23,72,,367.112,Percent of Total Billed Charges,72% of Total Billed Charges,3688.52,60,,305.928,Percent of Total Billed Charges,60% of Total Billed Charges,5532.79,90,,2346.472,Percent of Total Billed Charges,90% of Total Billed Charges,2766.39,45,,1727.704,Percent of Total Billed Charges,45% of Total Billed Charges,5532.79,90,,6375.008,Percent of Total Billed Charges,90% of Total billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3995.9,65,,108.928,Percent of total Billed Charges,65% of Total Billed Charges,2711.07,44.1,,1693.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,5840.16,95,,6729.176,Percent of Total Billed Charges,95% of Total Billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5409.84,88,,259.24,Percent of Total Billed Charges,88% of Total Billed Charges,5532.79,90,,6375.008,Percent of Total Billed charges,90% of Total Billed Charges,2711.07,6147.54,
Z23471506 DISTAL L,2780000803,CDM,278,RC,C1713,HCPCS,Outpatient,,,1647.14,1070.64,,1647.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1251.83,76,,197.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1185.94,72,,367.112,Percent of Total Billed Charges,72% of Total Billed Charges,1185.94,72,,367.112,Percent of Total Billed charges,72% of Total Billed Charges,1647.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1185.94,72,,367.112,Percent of Total Billed Charges,72% of Total Billed Charges,988.28,60,,305.928,Percent of Total Billed Charges,60% of Total Billed Charges,1482.43,90,,2107.544,Percent of Total Billed Charges,90% of Total Billed Charges,741.21,45,,132.568,Percent of Total Billed Charges,45% of Total Billed Charges,1482.43,90,,233.384,Percent of Total Billed Charges,90% of Total billed Charges,1647.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1647.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1647.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1070.64,65,,436.856,Percent of total Billed Charges,65% of Total Billed Charges,726.39,44.1,,129.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,1564.78,95,,246.344,Percent of Total Billed Charges,95% of Total Billed Charges,1647.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1449.48,88,,319,Percent of Total Billed Charges,88% of Total Billed Charges,1482.43,90,,233.384,Percent of Total Billed charges,90% of Total Billed Charges,726.39,1647.14,
ARTHREX SHORT GUIDE PIN 2.4,2780000804,CDM,278,RC,C1713,HCPCS,Outpatient,,,83.79,54.46,,83.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,63.68,76,,18.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,60.33,72,,341.104,Percent of Total Billed Charges,72% of Total Billed Charges,60.33,72,,341.104,Percent of Total Billed charges,72% of Total Billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.33,72,,341.104,Percent of Total Billed Charges,72% of Total Billed Charges,50.27,60,,284.256,Percent of Total Billed Charges,60% of Total Billed Charges,75.41,90,,234.176,Percent of Total Billed Charges,90% of Total Billed Charges,37.71,45,,132.568,Percent of Total Billed Charges,45% of Total Billed Charges,75.41,90,,22.224,Percent of Total Billed Charges,90% of Total billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.46,65,,7947.088,Percent of total Billed Charges,65% of Total Billed Charges,36.95,44.1,,129.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,79.6,95,,23.464,Percent of Total Billed Charges,95% of Total Billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.74,88,,319,Percent of Total Billed Charges,88% of Total Billed Charges,75.41,90,,22.224,Percent of Total Billed charges,90% of Total Billed Charges,36.95,83.79,
ARTHREX BUTTON INSER,2780000805,CDM,278,RC,C1713,HCPCS,Outpatient,,,277.83,180.59,,277.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,211.15,76,,2917.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,200.04,72,,37.496,Percent of Total Billed Charges,72% of Total Billed Charges,200.04,72,,37.496,Percent of Total Billed charges,72% of Total Billed Charges,277.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.04,72,,37.496,Percent of Total Billed Charges,72% of Total Billed Charges,166.7,60,,31.248,Percent of Total Billed Charges,60% of Total Billed Charges,250.05,90,,234.176,Percent of Total Billed Charges,90% of Total Billed Charges,125.02,45,,163.128,Percent of Total Billed Charges,45% of Total Billed Charges,250.05,90,,3455.408,Percent of Total Billed Charges,90% of Total billed Charges,277.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.59,65,,255.12,Percent of total Billed Charges,65% of Total Billed Charges,122.52,44.1,,159.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,263.94,95,,3647.376,Percent of Total Billed Charges,95% of Total Billed Charges,277.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.49,88,,319,Percent of Total Billed Charges,88% of Total Billed Charges,250.05,90,,3455.408,Percent of Total Billed charges,90% of Total Billed Charges,122.52,277.83,
ARTHREX AC TIGHT ROP,2780000806,CDM,278,RC,C1713,HCPCS,Outpatient,,,1932.68,1256.24,,1932.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1468.84,76,,223.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1391.53,72,,264.296,Percent of Total Billed Charges,72% of Total Billed Charges,1391.53,72,,264.296,Percent of Total Billed charges,72% of Total Billed Charges,1932.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1391.53,72,,264.296,Percent of Total Billed Charges,72% of Total Billed Charges,1159.61,60,,220.248,Percent of Total Billed Charges,60% of Total Billed Charges,1739.41,90,,265.136,Percent of Total Billed Charges,90% of Total Billed Charges,869.71,45,,163.128,Percent of Total Billed Charges,45% of Total Billed Charges,1739.41,90,,265.136,Percent of Total Billed Charges,90% of Total billed Charges,1932.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1932.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1932.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1256.24,65,,221.296,Percent of total Billed Charges,65% of Total Billed Charges,852.31,44.1,,159.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,1836.05,95,,279.864,Percent of Total Billed Charges,95% of Total Billed Charges,1932.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1700.76,88,,4542.088,Percent of Total Billed Charges,88% of Total Billed Charges,1739.41,90,,265.136,Percent of Total Billed charges,90% of Total Billed Charges,852.31,1932.68,
RADIOLUCENT DRILL BI,2780000807,CDM,278,RC,C1713,HCPCS,Outpatient,,,173.09,112.51,,173.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,131.55,76,,223.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,124.62,72,,264.296,Percent of Total Billed Charges,72% of Total Billed Charges,124.62,72,,264.296,Percent of Total Billed charges,72% of Total Billed Charges,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.62,72,,264.296,Percent of Total Billed Charges,72% of Total Billed Charges,103.85,60,,220.248,Percent of Total Billed Charges,60% of Total Billed Charges,155.78,90,,265.136,Percent of Total Billed Charges,90% of Total Billed Charges,77.89,45,,163.128,Percent of Total Billed Charges,45% of Total Billed Charges,155.78,90,,265.136,Percent of Total Billed Charges,90% of Total billed Charges,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.51,65,,1108.184,Percent of total Billed Charges,65% of Total Billed Charges,76.33,44.1,,159.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,164.44,95,,279.864,Percent of Total Billed Charges,95% of Total Billed Charges,173.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.32,88,,2294.328,Percent of Total Billed Charges,88% of Total Billed Charges,155.78,90,,265.136,Percent of Total Billed charges,90% of Total Billed Charges,76.33,173.09,
Z62005620 TRILOGY,2780000808,CDM,278,RC,C1713,HCPCS,Outpatient,,,7073.64,4597.87,,7073.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5375.97,76,,275.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5093.02,72,,264.296,Percent of Total Billed Charges,72% of Total Billed Charges,5093.02,72,,264.296,Percent of Total Billed charges,72% of Total Billed Charges,7073.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5093.02,72,,264.296,Percent of Total Billed Charges,72% of Total Billed Charges,4244.18,60,,220.248,Percent of Total Billed Charges,60% of Total Billed Charges,6366.28,90,,296.088,Percent of Total Billed Charges,90% of Total Billed Charges,3183.14,45,,2322.656,Percent of Total Billed Charges,45% of Total Billed Charges,6366.28,90,,326.256,Percent of Total Billed Charges,90% of Total billed Charges,7073.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7073.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7073.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4597.87,65,,133.008,Percent of total Billed Charges,65% of Total Billed Charges,3119.48,44.1,,2276.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,6719.96,95,,344.376,Percent of Total Billed Charges,95% of Total Billed Charges,7073.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6224.8,88,,2060.704,Percent of Total Billed Charges,88% of Total Billed Charges,6366.28,90,,326.256,Percent of Total Billed charges,90% of Total Billed Charges,3119.48,7073.64,
Z63205632 TRILOGY,2780000809,CDM,278,RC,C1713,HCPCS,Outpatient,,,5505.89,3578.83,,5505.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4184.48,76,,275.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3964.24,72,,341.104,Percent of Total Billed Charges,72% of Total Billed Charges,3964.24,72,,341.104,Percent of Total Billed charges,72% of Total Billed Charges,5505.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3964.24,72,,341.104,Percent of Total Billed Charges,72% of Total Billed Charges,3303.53,60,,284.256,Percent of Total Billed Charges,60% of Total Billed Charges,4955.3,90,,3668.152,Percent of Total Billed Charges,90% of Total Billed Charges,2477.65,45,,1173.24,Percent of Total Billed Charges,45% of Total Billed Charges,4955.3,90,,326.256,Percent of Total Billed Charges,90% of Total billed Charges,5505.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5505.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5505.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3578.83,65,,4771.008,Percent of total Billed Charges,65% of Total Billed Charges,2428.1,44.1,,1149.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,5230.6,95,,344.376,Percent of Total Billed Charges,95% of Total Billed Charges,5505.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4845.18,88,,228.968,Percent of Total Billed Charges,88% of Total Billed Charges,4955.3,90,,326.256,Percent of Total Billed charges,90% of Total Billed Charges,2428.1,5505.89,
Z62506520 BONE SCR,2780000810,CDM,278,RC,C1713,HCPCS,Outpatient,,,558.97,363.33,,558.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,424.82,76,,275.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,402.46,72,,2637.536,Percent of Total Billed Charges,72% of Total Billed Charges,402.46,72,,2637.536,Percent of Total Billed charges,72% of Total Billed Charges,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,402.46,72,,2637.536,Percent of Total Billed Charges,72% of Total Billed Charges,335.38,60,,2197.944,Percent of Total Billed Charges,60% of Total Billed Charges,503.07,90,,7778.448,Percent of Total Billed Charges,90% of Total Billed Charges,251.54,45,,1053.768,Percent of Total Billed Charges,45% of Total Billed Charges,503.07,90,,326.256,Percent of Total Billed Charges,90% of Total billed Charges,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.33,65,,557.816,Percent of total Billed Charges,65% of Total Billed Charges,246.51,44.1,,1032.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,531.02,95,,344.376,Percent of Total Billed Charges,95% of Total Billed Charges,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.89,88,,228.968,Percent of Total Billed Charges,88% of Total Billed Charges,503.07,90,,326.256,Percent of Total Billed charges,90% of Total Billed Charges,246.51,558.97,
Z63206232 LINEER 3,2780000811,CDM,278,RC,C1713,HCPCS,Outpatient,,,5505.89,3578.83,,5505.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4184.48,76,,3922.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3964.24,72,,263.088,Percent of Total Billed Charges,72% of Total Billed Charges,3964.24,72,,263.088,Percent of Total Billed charges,72% of Total Billed Charges,5505.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3964.24,72,,263.088,Percent of Total Billed Charges,72% of Total Billed Charges,3303.53,60,,219.24,Percent of Total Billed Charges,60% of Total Billed Charges,4955.3,90,,130.976,Percent of Total Billed Charges,90% of Total Billed Charges,2477.65,45,,117.088,Percent of Total Billed Charges,45% of Total Billed Charges,4955.3,90,,4645.32,Percent of Total Billed Charges,90% of Total billed Charges,5505.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5505.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5505.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3578.83,65,,31.536,Percent of total Billed Charges,65% of Total Billed Charges,2428.1,44.1,,114.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,5230.6,95,,4903.392,Percent of Total Billed Charges,95% of Total Billed Charges,5505.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4845.18,88,,259.24,Percent of Total Billed Charges,88% of Total Billed Charges,4955.3,90,,4645.32,Percent of Total Billed charges,90% of Total Billed Charges,2428.1,5505.89,
Z62006220 SHELL 62,2780000812,CDM,278,RC,C1713,HCPCS,Outpatient,,,7073.64,4597.87,,7073.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5375.97,76,,1981.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5093.02,72,,35.08,Percent of Total Billed Charges,72% of Total Billed Charges,5093.02,72,,35.08,Percent of Total Billed charges,72% of Total Billed Charges,7073.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5093.02,72,,35.08,Percent of Total Billed Charges,72% of Total Billed Charges,4244.18,60,,29.232,Percent of Total Billed Charges,60% of Total Billed Charges,6366.28,90,,130.976,Percent of Total Billed Charges,90% of Total Billed Charges,3183.14,45,,117.088,Percent of Total Billed Charges,45% of Total Billed Charges,6366.28,90,,2346.472,Percent of Total Billed Charges,90% of Total billed Charges,7073.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7073.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7073.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4597.87,65,,31.536,Percent of total Billed Charges,65% of Total Billed Charges,3119.48,44.1,,114.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,6719.96,95,,2476.832,Percent of Total Billed Charges,95% of Total Billed Charges,7073.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6224.8,88,,259.24,Percent of Total Billed Charges,88% of Total Billed Charges,6366.28,90,,2346.472,Percent of Total Billed charges,90% of Total Billed Charges,3119.48,7073.64,
Z63055636 LINER 36,2780000813,CDM,278,RC,C1713,HCPCS,Outpatient,,,6884.01,4474.61,,6884.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5231.85,76,,1779.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4956.49,72,,341.104,Percent of Total Billed Charges,72% of Total Billed Charges,4956.49,72,,341.104,Percent of Total Billed charges,72% of Total Billed Charges,6884.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4956.49,72,,341.104,Percent of Total Billed Charges,72% of Total Billed Charges,4130.41,60,,284.256,Percent of Total Billed Charges,60% of Total Billed Charges,6195.61,90,,1029.56,Percent of Total Billed Charges,90% of Total Billed Charges,3097.8,45,,132.568,Percent of Total Billed Charges,45% of Total Billed Charges,6195.61,90,,2107.544,Percent of Total Billed Charges,90% of Total billed Charges,6884.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6884.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6884.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4474.61,65,,31.536,Percent of total Billed Charges,65% of Total Billed Charges,3035.85,44.1,,129.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,6539.81,95,,2224.624,Percent of Total Billed Charges,95% of Total Billed Charges,6884.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6057.93,88,,289.504,Percent of Total Billed Charges,88% of Total Billed Charges,6195.61,90,,2107.544,Percent of Total Billed charges,90% of Total Billed Charges,3035.85,6884.01,
Z00771301500 FEM/,2780000814,CDM,278,RC,C1713,HCPCS,Outpatient,,,21571.52,14021.49,,21571.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16394.36,76,,197.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15531.49,72,,1288.224,Percent of Total Billed Charges,72% of Total Billed Charges,15531.49,72,,1288.224,Percent of Total Billed charges,72% of Total Billed Charges,21571.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15531.49,72,,1288.224,Percent of Total Billed Charges,72% of Total Billed Charges,12942.91,60,,1073.52,Percent of Total Billed Charges,60% of Total Billed Charges,19414.37,90,,725.536,Percent of Total Billed Charges,90% of Total Billed Charges,9707.18,45,,132.568,Percent of Total Billed Charges,45% of Total Billed Charges,19414.37,90,,234.176,Percent of Total Billed Charges,90% of Total billed Charges,21571.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21571.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21571.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14021.49,65,,31.536,Percent of total Billed Charges,65% of Total Billed Charges,9513.04,44.1,,129.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,20492.94,95,,247.184,Percent of Total Billed Charges,95% of Total Billed Charges,21571.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18982.94,88,,3586.632,Percent of Total Billed Charges,88% of Total Billed Charges,19414.37,90,,234.176,Percent of Total Billed charges,90% of Total Billed Charges,9513.04,21571.52,
Z00784804401 MOD/,2780000815,CDM,278,RC,C1713,HCPCS,Outpatient,,,5950.19,3867.62,,5950.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4522.14,76,,197.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4284.14,72,,78.016,Percent of Total Billed Charges,72% of Total Billed Charges,4284.14,72,,78.016,Percent of Total Billed charges,72% of Total Billed Charges,5950.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4284.14,72,,78.016,Percent of Total Billed Charges,72% of Total Billed Charges,3570.11,60,,65.016,Percent of Total Billed Charges,60% of Total Billed Charges,5355.17,90,,107.168,Percent of Total Billed Charges,90% of Total Billed Charges,2677.59,45,,148.04,Percent of Total Billed Charges,45% of Total Billed Charges,5355.17,90,,234.176,Percent of Total Billed Charges,90% of Total billed Charges,5950.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5950.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5950.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3867.62,65,,31.536,Percent of total Billed Charges,65% of Total Billed Charges,2624.03,44.1,,145.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,5652.68,95,,247.184,Percent of Total Billed Charges,95% of Total Billed Charges,5950.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5236.17,88,,7605.592,Percent of Total Billed Charges,88% of Total Billed Charges,5355.17,90,,234.176,Percent of Total Billed charges,90% of Total Billed Charges,2624.03,5950.19,
Z225428508 HUM NAI,2780000816,CDM,278,RC,C1713,HCPCS,Outpatient,,,4724.21,3070.74,,4724.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3590.4,76,,223.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3401.43,72,,48.384,Percent of Total Billed Charges,72% of Total Billed Charges,3401.43,72,,48.384,Percent of Total Billed charges,72% of Total Billed Charges,4724.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3401.43,72,,48.384,Percent of Total Billed Charges,72% of Total Billed Charges,2834.53,60,,40.32,Percent of Total Billed Charges,60% of Total Billed Charges,4251.79,90,,1424.08,Percent of Total Billed Charges,90% of Total Billed Charges,2125.89,45,,1834.072,Percent of Total Billed Charges,45% of Total Billed Charges,4251.79,90,,265.136,Percent of Total Billed Charges,90% of Total billed Charges,4724.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4724.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4724.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3070.74,65,,1123.096,Percent of total Billed Charges,65% of Total Billed Charges,2083.38,44.1,,1797.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,4488,95,,279.864,Percent of Total Billed Charges,95% of Total Billed Charges,4724.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4157.3,88,,128.064,Percent of Total Billed Charges,88% of Total Billed Charges,4251.79,90,,265.136,Percent of Total Billed charges,90% of Total Billed Charges,2083.38,4724.21,
Z00784802201 MOD/,2780000817,CDM,278,RC,C1713,HCPCS,Outpatient,,,5950.19,3867.62,,5950.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4522.14,76,,223.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4284.14,72,,29.952,Percent of Total Billed Charges,72% of Total Billed Charges,4284.14,72,,29.952,Percent of Total Billed charges,72% of Total Billed Charges,5950.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4284.14,72,,29.952,Percent of Total Billed Charges,72% of Total Billed Charges,3570.11,60,,24.96,Percent of Total Billed Charges,60% of Total Billed Charges,5355.17,90,,1029.56,Percent of Total Billed Charges,90% of Total Billed Charges,2677.59,45,,3889.224,Percent of Total Billed Charges,45% of Total Billed Charges,5355.17,90,,265.136,Percent of Total Billed Charges,90% of Total billed Charges,5950.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5950.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5950.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3867.62,65,,729.24,Percent of total Billed Charges,65% of Total Billed Charges,2624.03,44.1,,3811.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,5652.68,95,,279.864,Percent of Total Billed Charges,95% of Total Billed Charges,5950.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5236.17,88,,128.064,Percent of Total Billed Charges,88% of Total Billed Charges,5355.17,90,,265.136,Percent of Total Billed charges,90% of Total Billed Charges,2624.03,5950.19,
Z00771301200 FEM/,2780000818,CDM,278,RC,C1713,HCPCS,Outpatient,,,21267.23,13823.70,,21267.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16163.09,76,,250.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15312.41,72,,29.952,Percent of Total Billed Charges,72% of Total Billed Charges,15312.41,72,,29.952,Percent of Total Billed charges,72% of Total Billed Charges,21267.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15312.41,72,,29.952,Percent of Total Billed Charges,72% of Total Billed Charges,12760.34,60,,24.96,Percent of Total Billed Charges,60% of Total Billed Charges,19140.51,90,,150.824,Percent of Total Billed Charges,90% of Total Billed Charges,9570.25,45,,65.488,Percent of Total Billed Charges,45% of Total Billed Charges,19140.51,90,,296.088,Percent of Total Billed Charges,90% of Total billed Charges,21267.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21267.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21267.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13823.7,65,,682.232,Percent of total Billed Charges,65% of Total Billed Charges,9378.85,44.1,,64.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,20203.87,95,,312.536,Percent of Total Billed Charges,95% of Total Billed Charges,21267.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18715.16,88,,1006.68,Percent of Total Billed Charges,88% of Total Billed Charges,19140.51,90,,296.088,Percent of Total Billed charges,90% of Total Billed Charges,9378.85,21267.23,
Z63106232 TRILOGY,2780000819,CDM,278,RC,C1713,HCPCS,Outpatient,,,5505.89,3578.83,,5505.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4184.48,76,,3097.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3964.24,72,,122.112,Percent of Total Billed Charges,72% of Total Billed Charges,3964.24,72,,122.112,Percent of Total Billed charges,72% of Total Billed Charges,5505.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3964.24,72,,122.112,Percent of Total Billed Charges,72% of Total Billed Charges,3303.53,60,,101.76,Percent of Total Billed Charges,60% of Total Billed Charges,4955.3,90,,150.824,Percent of Total Billed Charges,90% of Total Billed Charges,2477.65,45,,65.488,Percent of Total Billed Charges,45% of Total Billed Charges,4955.3,90,,3668.152,Percent of Total Billed Charges,90% of Total billed Charges,5505.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5505.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5505.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3578.83,65,,118.104,Percent of total Billed Charges,65% of Total Billed Charges,2428.1,44.1,,64.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,5230.6,95,,3871.936,Percent of Total Billed Charges,95% of Total Billed Charges,5505.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4845.18,88,,709.416,Percent of Total Billed Charges,88% of Total Billed Charges,4955.3,90,,3668.152,Percent of Total Billed charges,90% of Total Billed Charges,2428.1,5505.89,
Z62026222 SHELL 62,2780000820,CDM,278,RC,C1713,HCPCS,Outpatient,,,9588.44,6232.49,,9588.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7287.21,76,,6568.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6903.68,72,,84.672,Percent of Total Billed Charges,72% of Total Billed Charges,6903.68,72,,84.672,Percent of Total Billed charges,72% of Total Billed Charges,9588.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6903.68,72,,84.672,Percent of Total Billed Charges,72% of Total Billed Charges,5753.06,60,,70.56,Percent of Total Billed Charges,60% of Total Billed Charges,8629.6,90,,604.88,Percent of Total Billed Charges,90% of Total Billed Charges,4314.8,45,,514.776,Percent of Total Billed Charges,45% of Total Billed Charges,8629.6,90,,7778.448,Percent of Total Billed Charges,90% of Total billed Charges,9588.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9588.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9588.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6232.49,65,,729.24,Percent of total Billed Charges,65% of Total Billed Charges,4228.5,44.1,,504.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,9109.02,95,,8210.584,Percent of Total Billed Charges,95% of Total Billed Charges,9588.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8437.83,88,,104.784,Percent of Total Billed Charges,88% of Total Billed Charges,8629.6,90,,7778.448,Percent of Total Billed charges,90% of Total Billed Charges,4228.5,9588.44,
Z225336012 TIBIAL,2780000821,CDM,278,RC,C1713,HCPCS,Outpatient,,,3405.62,2213.65,,3405.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2588.27,76,,110.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2452.05,72,,101.376,Percent of Total Billed Charges,72% of Total Billed Charges,2452.05,72,,101.376,Percent of Total Billed charges,72% of Total Billed Charges,3405.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2452.05,72,,101.376,Percent of Total Billed Charges,72% of Total Billed Charges,2043.37,60,,84.48,Percent of Total Billed Charges,60% of Total Billed Charges,3065.06,90,,11003.656,Percent of Total Billed Charges,90% of Total Billed Charges,1532.53,45,,362.768,Percent of Total Billed Charges,45% of Total Billed Charges,3065.06,90,,130.976,Percent of Total Billed Charges,90% of Total billed Charges,3405.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3405.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3405.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2213.65,65,,781.984,Percent of total Billed Charges,65% of Total Billed Charges,1501.88,44.1,,355.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,3235.34,95,,138.248,Percent of Total Billed Charges,95% of Total Billed Charges,3405.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2996.95,88,,1392.432,Percent of Total Billed Charges,88% of Total Billed Charges,3065.06,90,,130.976,Percent of Total Billed charges,90% of Total Billed Charges,1501.88,3405.62,
Z2434211513 HUM ST,2780000822,CDM,278,RC,C1713,HCPCS,Outpatient,,,1533.58,996.83,,1533.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1165.52,76,,110.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1104.18,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1104.18,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,1533.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1104.18,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,920.15,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,1380.22,90,,353.24,Percent of Total Billed Charges,90% of Total Billed Charges,690.11,45,,53.584,Percent of Total Billed Charges,45% of Total Billed Charges,1380.22,90,,130.976,Percent of Total Billed Charges,90% of Total billed Charges,1533.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1533.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1533.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,996.83,65,,874.28,Percent of total Billed Charges,65% of Total Billed Charges,676.31,44.1,,52.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,1456.9,95,,138.248,Percent of Total Billed Charges,95% of Total Billed Charges,1533.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1349.55,88,,1006.68,Percent of Total Billed Charges,88% of Total Billed Charges,1380.22,90,,130.976,Percent of Total Billed charges,90% of Total Billed Charges,676.31,1533.58,
Z22401016 RETROFEM,2780000823,CDM,278,RC,C1713,HCPCS,Outpatient,,,4742.96,3082.92,,4742.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3604.65,76,,869.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3414.93,72,,681.408,Percent of Total Billed Charges,72% of Total Billed Charges,3414.93,72,,681.408,Percent of Total Billed charges,72% of Total Billed Charges,4742.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3414.93,72,,681.408,Percent of Total Billed Charges,72% of Total Billed Charges,2845.78,60,,567.84,Percent of Total Billed Charges,60% of Total Billed Charges,4268.66,90,,306.408,Percent of Total Billed Charges,90% of Total Billed Charges,2134.33,45,,712.04,Percent of Total Billed Charges,45% of Total Billed Charges,4268.66,90,,1029.56,Percent of Total Billed Charges,90% of Total billed Charges,4742.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4742.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4742.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3082.92,65,,220.144,Percent of total Billed Charges,65% of Total Billed Charges,2091.65,44.1,,697.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,4505.81,95,,1086.752,Percent of Total Billed Charges,95% of Total Billed Charges,4742.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4173.8,88,,147.472,Percent of Total Billed Charges,88% of Total Billed Charges,4268.66,90,,1029.56,Percent of Total Billed charges,90% of Total Billed Charges,2091.65,4742.96,
Z23485235 3.5 CORT,2780000824,CDM,278,RC,C1713,HCPCS,Outpatient,,,106.94,69.51,,106.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.27,76,,612.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,77,72,,32.832,Percent of Total Billed charges,72% of Total Billed Charges,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,64.16,60,,27.36,Percent of Total Billed Charges,60% of Total Billed Charges,96.25,90,,1534.416,Percent of Total Billed Charges,90% of Total Billed Charges,48.12,45,,514.776,Percent of Total Billed Charges,45% of Total Billed Charges,96.25,90,,725.536,Percent of Total Billed Charges,90% of Total billed Charges,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.51,65,,220.144,Percent of total Billed Charges,65% of Total Billed Charges,47.16,44.1,,504.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,101.59,95,,765.848,Percent of Total Billed Charges,95% of Total Billed Charges,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.11,88,,147.472,Percent of Total Billed Charges,88% of Total Billed Charges,96.25,90,,725.536,Percent of Total Billed charges,90% of Total Billed Charges,47.16,106.94,
Z783416PRESSFIT ST,2780000825,CDM,278,RC,C1713,HCPCS,Outpatient,,,6941.34,4511.87,,6941.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5275.42,76,,90.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4997.76,72,,1335.168,Percent of Total Billed Charges,72% of Total Billed Charges,4997.76,72,,1335.168,Percent of Total Billed charges,72% of Total Billed Charges,6941.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4997.76,72,,1335.168,Percent of Total Billed Charges,72% of Total Billed Charges,4164.8,60,,1112.64,Percent of Total Billed Charges,60% of Total Billed Charges,6247.21,90,,184.16,Percent of Total Billed Charges,90% of Total Billed Charges,3123.6,45,,75.416,Percent of Total Billed Charges,45% of Total Billed Charges,6247.21,90,,107.168,Percent of Total Billed Charges,90% of Total billed Charges,6941.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6941.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6941.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4511.87,65,,3354.952,Percent of total Billed Charges,65% of Total Billed Charges,3061.13,44.1,,73.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,6594.27,95,,113.12,Percent of Total Billed Charges,95% of Total Billed Charges,6941.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6108.38,88,,591.44,Percent of Total Billed Charges,88% of Total Billed Charges,6247.21,90,,107.168,Percent of Total Billed charges,90% of Total Billed Charges,3061.13,6941.34,
Z11474441 4.0 CANN,2780000826,CDM,278,RC,C1713,HCPCS,Outpatient,,,652.68,424.24,,652.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,496.04,76,,1202.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,469.93,72,,151.488,Percent of Total Billed Charges,72% of Total Billed Charges,469.93,72,,151.488,Percent of Total Billed charges,72% of Total Billed Charges,652.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,469.93,72,,151.488,Percent of Total Billed Charges,72% of Total Billed Charges,391.61,60,,126.24,Percent of Total Billed Charges,60% of Total Billed Charges,587.41,90,,6606.008,Percent of Total Billed Charges,90% of Total Billed Charges,293.71,45,,75.416,Percent of Total Billed Charges,45% of Total Billed Charges,587.41,90,,1424.08,Percent of Total Billed Charges,90% of Total billed Charges,652.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,652.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,652.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.24,65,,3354.952,Percent of total Billed Charges,65% of Total Billed Charges,287.83,44.1,,73.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,620.05,95,,1503.2,Percent of Total Billed Charges,95% of Total Billed Charges,652.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,574.36,88,,10759.136,Percent of Total Billed Charges,88% of Total Billed Charges,587.41,90,,1424.08,Percent of Total Billed charges,90% of Total Billed Charges,287.83,652.68,
Z59501401 FEM COMP,2780000827,CDM,278,RC,C1713,HCPCS,Outpatient,,,19232.01,12500.81,,19232.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14616.33,76,,869.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13847.05,72,,151.488,Percent of Total Billed Charges,72% of Total Billed Charges,13847.05,72,,151.488,Percent of Total Billed charges,72% of Total Billed Charges,19232.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13847.05,72,,151.488,Percent of Total Billed Charges,72% of Total Billed Charges,11539.21,60,,126.24,Percent of Total Billed Charges,60% of Total Billed Charges,17308.81,90,,772.368,Percent of Total Billed Charges,90% of Total Billed Charges,8654.4,45,,302.44,Percent of Total Billed Charges,45% of Total Billed Charges,17308.81,90,,1029.56,Percent of Total Billed Charges,90% of Total billed Charges,19232.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19232.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19232.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12500.81,65,,185.176,Percent of total Billed Charges,65% of Total Billed Charges,8481.32,44.1,,296.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,18270.41,95,,1086.752,Percent of Total Billed Charges,95% of Total Billed Charges,19232.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16924.17,88,,345.392,Percent of Total Billed Charges,88% of Total Billed Charges,17308.81,90,,1029.56,Percent of Total Billed charges,90% of Total Billed Charges,8481.32,19232.01,
Z59941592,2780000828,CDM,278,RC,C1713,HCPCS,Outpatient,,,23143.68,15043.39,,23143.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17589.2,76,,127.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16663.45,72,,2505.024,Percent of Total Billed Charges,72% of Total Billed Charges,16663.45,72,,2505.024,Percent of Total Billed charges,72% of Total Billed Charges,23143.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16663.45,72,,2505.024,Percent of Total Billed Charges,72% of Total Billed Charges,13886.21,60,,2087.52,Percent of Total Billed Charges,60% of Total Billed Charges,20829.31,90,,43.664,Percent of Total Billed Charges,90% of Total Billed Charges,10414.66,45,,5501.832,Percent of Total Billed Charges,45% of Total Billed Charges,20829.31,90,,150.824,Percent of Total Billed Charges,90% of Total billed Charges,23143.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23143.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23143.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15043.39,65,,185.176,Percent of total Billed Charges,65% of Total Billed Charges,10206.36,44.1,,5391.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,21986.5,95,,159.208,Percent of Total Billed Charges,95% of Total Billed Charges,23143.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20366.44,88,,299.6,Percent of Total Billed Charges,88% of Total Billed Charges,20829.31,90,,150.824,Percent of Total Billed charges,90% of Total Billed Charges,10206.36,23143.68,
Z00545002236 FEM,2780000829,CDM,278,RC,C1713,HCPCS,Outpatient,,,17357.76,11282.54,,17357.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13191.9,76,,127.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12497.59,72,,151.488,Percent of Total Billed Charges,72% of Total Billed Charges,12497.59,72,,151.488,Percent of Total Billed charges,72% of Total Billed Charges,17357.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12497.59,72,,151.488,Percent of Total Billed Charges,72% of Total Billed Charges,10414.66,60,,126.24,Percent of Total Billed Charges,60% of Total Billed Charges,15621.98,90,,43.664,Percent of Total Billed Charges,90% of Total Billed Charges,7810.99,45,,176.616,Percent of Total Billed Charges,45% of Total Billed Charges,15621.98,90,,150.824,Percent of Total Billed Charges,90% of Total billed Charges,17357.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17357.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17357.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11282.54,65,,185.176,Percent of total Billed Charges,65% of Total Billed Charges,7654.77,44.1,,173.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,16489.87,95,,159.208,Percent of Total Billed Charges,95% of Total Billed Charges,17357.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15274.83,88,,1500.312,Percent of Total Billed Charges,88% of Total Billed Charges,15621.98,90,,150.824,Percent of Total Billed charges,90% of Total Billed Charges,7654.77,17357.76,
Z59943217 ART/SURF,2780000830,CDM,278,RC,C1713,HCPCS,Outpatient,,,7485.98,4865.89,,7485.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5689.34,76,,510.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5389.91,72,,122.112,Percent of Total Billed Charges,72% of Total Billed Charges,5389.91,72,,122.112,Percent of Total Billed charges,72% of Total Billed Charges,7485.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5389.91,72,,122.112,Percent of Total Billed Charges,72% of Total Billed Charges,4491.59,60,,101.76,Percent of Total Billed Charges,60% of Total Billed Charges,6737.38,90,,43.664,Percent of Total Billed Charges,90% of Total Billed Charges,3368.69,45,,153.208,Percent of Total Billed Charges,45% of Total Billed Charges,6737.38,90,,604.88,Percent of Total Billed Charges,90% of Total billed Charges,7485.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7485.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7485.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4865.89,65,,185.176,Percent of total Billed Charges,65% of Total Billed Charges,3301.32,44.1,,150.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,7111.68,95,,638.48,Percent of Total Billed Charges,95% of Total Billed Charges,7485.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6587.66,88,,180.072,Percent of Total Billed Charges,88% of Total Billed Charges,6737.38,90,,604.88,Percent of Total Billed charges,90% of Total Billed Charges,3301.32,7485.98,
Z59865702 TIBIAL C,2780000831,CDM,278,RC,C1713,HCPCS,Outpatient,,,6450.73,4192.97,,6450.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4902.55,76,,9291.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4644.53,72,,427.968,Percent of Total Billed Charges,72% of Total Billed Charges,4644.53,72,,427.968,Percent of Total Billed charges,72% of Total Billed Charges,6450.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4644.53,72,,427.968,Percent of Total Billed Charges,72% of Total Billed Charges,3870.44,60,,356.64,Percent of Total Billed Charges,60% of Total Billed Charges,5805.66,90,,43.664,Percent of Total Billed Charges,90% of Total Billed Charges,2902.83,45,,767.208,Percent of Total Billed Charges,45% of Total Billed Charges,5805.66,90,,11003.656,Percent of Total Billed Charges,90% of Total billed Charges,6450.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6450.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6450.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4192.97,65,,185.176,Percent of total Billed Charges,65% of Total Billed Charges,2844.77,44.1,,751.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,6128.19,95,,11614.976,Percent of Total Billed Charges,95% of Total Billed Charges,6450.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5676.64,88,,6459.208,Percent of Total Billed Charges,88% of Total Billed Charges,5805.66,90,,11003.656,Percent of Total Billed charges,90% of Total Billed Charges,2844.77,6450.73,
Z225310055 CORT 5X,2780000832,CDM,278,RC,C1713,HCPCS,Outpatient,,,552.35,359.03,,552.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,419.79,76,,298.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,397.69,72,,122.688,Percent of Total Billed Charges,72% of Total Billed Charges,397.69,72,,122.688,Percent of Total Billed charges,72% of Total Billed Charges,552.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.69,72,,122.688,Percent of Total Billed Charges,72% of Total Billed Charges,331.41,60,,102.24,Percent of Total Billed Charges,60% of Total Billed Charges,497.12,90,,43.664,Percent of Total Billed Charges,90% of Total Billed Charges,248.56,45,,92.08,Percent of Total Billed Charges,45% of Total Billed Charges,497.12,90,,353.24,Percent of Total Billed Charges,90% of Total billed Charges,552.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.03,65,,4282.552,Percent of total Billed Charges,65% of Total Billed Charges,243.59,44.1,,90.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,524.73,95,,372.864,Percent of Total Billed Charges,95% of Total Billed Charges,552.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,486.07,88,,755.2,Percent of Total Billed Charges,88% of Total Billed Charges,497.12,90,,353.24,Percent of Total Billed charges,90% of Total Billed Charges,243.59,552.35,
Z22538542 CORT 4.2,2780000833,CDM,278,RC,C1713,HCPCS,Outpatient,,,552.35,359.03,,552.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,419.79,76,,258.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,397.69,72,,309.312,Percent of Total Billed Charges,72% of Total Billed Charges,397.69,72,,309.312,Percent of Total Billed charges,72% of Total Billed Charges,552.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.69,72,,309.312,Percent of Total Billed Charges,72% of Total Billed Charges,331.41,60,,257.76,Percent of Total Billed Charges,60% of Total Billed Charges,497.12,90,,1555.056,Percent of Total Billed Charges,90% of Total Billed Charges,248.56,45,,3303,Percent of Total Billed Charges,45% of Total Billed Charges,497.12,90,,306.408,Percent of Total Billed Charges,90% of Total billed Charges,552.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.03,65,,4282.552,Percent of total Billed Charges,65% of Total Billed Charges,243.59,44.1,,3236.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,524.73,95,,323.432,Percent of Total Billed Charges,95% of Total Billed Charges,552.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,486.07,88,,42.688,Percent of Total Billed Charges,88% of Total Billed Charges,497.12,90,,306.408,Percent of Total Billed charges,90% of Total Billed Charges,243.59,552.35,
Z59941691 FEM/COMP,2780000834,CDM,278,RC,C1713,HCPCS,Outpatient,,,23143.68,15043.39,,23143.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17589.2,76,,1295.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16663.45,72,,4405.824,Percent of Total Billed Charges,72% of Total Billed Charges,16663.45,72,,4405.824,Percent of Total Billed charges,72% of Total Billed Charges,23143.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16663.45,72,,4405.824,Percent of Total Billed Charges,72% of Total Billed Charges,13886.21,60,,3671.52,Percent of Total Billed Charges,60% of Total Billed Charges,20829.31,90,,1009.712,Percent of Total Billed Charges,90% of Total Billed Charges,10414.66,45,,386.184,Percent of Total Billed Charges,45% of Total Billed Charges,20829.31,90,,1534.416,Percent of Total Billed Charges,90% of Total billed Charges,23143.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23143.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23143.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15043.39,65,,7034.968,Percent of total Billed Charges,65% of Total Billed Charges,10206.36,44.1,,378.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,21986.5,95,,1619.656,Percent of Total Billed Charges,95% of Total Billed Charges,23143.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20366.44,88,,42.688,Percent of Total Billed Charges,88% of Total Billed Charges,20829.31,90,,1534.416,Percent of Total Billed charges,90% of Total Billed Charges,10206.36,23143.68,
Z59903623 FEM AUG/,2780000835,CDM,278,RC,C1713,HCPCS,Outpatient,,,4661.37,3029.89,,4661.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3542.64,76,,155.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3356.19,72,,4367.808,Percent of Total Billed Charges,72% of Total Billed Charges,3356.19,72,,4367.808,Percent of Total Billed charges,72% of Total Billed Charges,4661.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3356.19,72,,4367.808,Percent of Total Billed Charges,72% of Total Billed Charges,2796.82,60,,3639.84,Percent of Total Billed Charges,60% of Total Billed Charges,4195.23,90,,944.624,Percent of Total Billed Charges,90% of Total Billed Charges,2097.62,45,,21.832,Percent of Total Billed Charges,45% of Total Billed Charges,4195.23,90,,184.16,Percent of Total Billed Charges,90% of Total billed Charges,4661.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4661.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4661.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3029.89,65,,1172.976,Percent of total Billed Charges,65% of Total Billed Charges,2055.66,44.1,,21.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,4428.3,95,,194.392,Percent of Total Billed Charges,95% of Total Billed Charges,4661.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4102.01,88,,42.688,Percent of Total Billed Charges,88% of Total Billed Charges,4195.23,90,,184.16,Percent of Total Billed charges,90% of Total Billed Charges,2055.66,4661.37,
Z59881012 STEM EXT,2780000836,CDM,278,RC,C1713,HCPCS,Outpatient,,,4235.81,2753.28,,4235.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3219.22,76,,5578.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3049.78,72,,235.584,Percent of Total Billed Charges,72% of Total Billed Charges,3049.78,72,,235.584,Percent of Total Billed charges,72% of Total Billed Charges,4235.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3049.78,72,,235.584,Percent of Total Billed Charges,72% of Total Billed Charges,2541.49,60,,196.32,Percent of Total Billed Charges,60% of Total Billed Charges,3812.23,90,,163.528,Percent of Total Billed Charges,90% of Total Billed Charges,1906.11,45,,21.832,Percent of Total Billed Charges,45% of Total Billed Charges,3812.23,90,,6606.008,Percent of Total Billed Charges,90% of Total billed Charges,4235.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4235.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4235.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2753.28,65,,189.76,Percent of total Billed Charges,65% of Total Billed Charges,1867.99,44.1,,21.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,4024.02,95,,6973.008,Percent of Total Billed Charges,95% of Total Billed Charges,4235.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3727.51,88,,42.688,Percent of Total Billed Charges,88% of Total Billed Charges,3812.23,90,,6606.008,Percent of Total Billed charges,90% of Total Billed Charges,1867.99,4235.81,
Z47249321013 FEMN,2780000838,CDM,278,RC,C1713,HCPCS,Outpatient,,,5880.74,3822.48,,5880.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4469.36,76,,652.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4234.13,72,,69.12,Percent of Total Billed Charges,72% of Total Billed Charges,4234.13,72,,69.12,Percent of Total Billed charges,72% of Total Billed Charges,5880.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4234.13,72,,69.12,Percent of Total Billed Charges,72% of Total Billed Charges,3528.44,60,,57.6,Percent of Total Billed Charges,60% of Total Billed Charges,5292.67,90,,1009.712,Percent of Total Billed Charges,90% of Total Billed Charges,2646.33,45,,21.832,Percent of Total Billed Charges,45% of Total Billed Charges,5292.67,90,,772.368,Percent of Total Billed Charges,90% of Total billed Charges,5880.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5880.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5880.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3822.48,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,2593.41,44.1,,21.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,5586.7,95,,815.272,Percent of Total Billed Charges,95% of Total Billed Charges,5880.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5175.05,88,,42.688,Percent of Total Billed Charges,88% of Total Billed Charges,5292.67,90,,772.368,Percent of Total Billed charges,90% of Total Billed Charges,2593.41,5880.74,
Z114706077 CANN/32,2780000839,CDM,278,RC,C1713,HCPCS,Outpatient,,,1047.38,680.80,,1047.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,796.01,76,,36.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,754.11,72,,117.504,Percent of Total Billed Charges,72% of Total Billed Charges,754.11,72,,117.504,Percent of Total Billed charges,72% of Total Billed Charges,1047.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,754.11,72,,117.504,Percent of Total Billed Charges,72% of Total Billed Charges,628.43,60,,97.92,Percent of Total Billed Charges,60% of Total Billed Charges,942.64,90,,1082.744,Percent of Total Billed Charges,90% of Total Billed Charges,471.32,45,,21.832,Percent of Total Billed Charges,45% of Total Billed Charges,942.64,90,,43.664,Percent of Total Billed Charges,90% of Total billed Charges,1047.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1047.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1047.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,680.8,65,,275.184,Percent of total Billed Charges,65% of Total Billed Charges,461.89,44.1,,21.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,995.01,95,,46.088,Percent of Total Billed Charges,95% of Total Billed Charges,1047.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,921.69,88,,1520.496,Percent of Total Billed Charges,88% of Total Billed Charges,942.64,90,,43.664,Percent of Total Billed charges,90% of Total Billed Charges,461.89,1047.38,
ZINFLATE FX FRACTURE,2780000840,CDM,278,RC,C1713,HCPCS,Outpatient,,,14794.45,9616.39,,14794.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11243.78,76,,36.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10652,72,,695.232,Percent of Total Billed Charges,72% of Total Billed Charges,10652,72,,695.232,Percent of Total Billed charges,72% of Total Billed Charges,14794.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10652,72,,695.232,Percent of Total Billed Charges,72% of Total Billed Charges,8876.67,60,,579.36,Percent of Total Billed Charges,60% of Total Billed Charges,13315.01,90,,1210.544,Percent of Total Billed Charges,90% of Total Billed Charges,6657.5,45,,21.832,Percent of Total Billed Charges,45% of Total Billed Charges,13315.01,90,,43.664,Percent of Total Billed Charges,90% of Total billed Charges,14794.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14794.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14794.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9616.39,65,,275.184,Percent of total Billed Charges,65% of Total Billed Charges,6524.35,44.1,,21.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,14054.73,95,,46.088,Percent of Total Billed Charges,95% of Total Billed Charges,14794.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13019.12,88,,987.272,Percent of Total Billed Charges,88% of Total Billed Charges,13315.01,90,,43.664,Percent of Total Billed charges,90% of Total Billed Charges,6524.35,14794.45,
Z59943220ART SUF 2,2780000841,CDM,278,RC,C1713,HCPCS,Outpatient,,,7485.98,4865.89,,7485.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5689.34,76,,36.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5389.91,72,,309.312,Percent of Total Billed Charges,72% of Total Billed Charges,5389.91,72,,309.312,Percent of Total Billed charges,72% of Total Billed Charges,7485.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5389.91,72,,309.312,Percent of Total Billed Charges,72% of Total Billed Charges,4491.59,60,,257.76,Percent of Total Billed Charges,60% of Total Billed Charges,6737.38,90,,304.816,Percent of Total Billed Charges,90% of Total Billed Charges,3368.69,45,,777.528,Percent of Total Billed Charges,45% of Total Billed Charges,6737.38,90,,43.664,Percent of Total Billed Charges,90% of Total billed Charges,7485.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7485.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7485.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4865.89,65,,1282.472,Percent of total Billed Charges,65% of Total Billed Charges,3301.32,44.1,,761.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,7111.68,95,,46.088,Percent of Total Billed Charges,95% of Total Billed Charges,7485.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6587.66,88,,923.632,Percent of Total Billed Charges,88% of Total Billed Charges,6737.38,90,,43.664,Percent of Total Billed charges,90% of Total Billed Charges,3301.32,7485.98,
Z020002418 DRILL B,2780000842,CDM,278,RC,C1713,HCPCS,Outpatient,,,485.10,315.32,,485.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,368.68,76,,36.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,349.27,72,,170.496,Percent of Total Billed Charges,72% of Total Billed Charges,349.27,72,,170.496,Percent of Total Billed charges,72% of Total Billed Charges,485.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.27,72,,170.496,Percent of Total Billed Charges,72% of Total Billed Charges,291.06,60,,142.08,Percent of Total Billed Charges,60% of Total Billed Charges,436.59,90,,304.816,Percent of Total Billed Charges,90% of Total Billed Charges,218.3,45,,504.856,Percent of Total Billed Charges,45% of Total Billed Charges,436.59,90,,43.664,Percent of Total Billed Charges,90% of Total billed Charges,485.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.32,65,,1282.472,Percent of total Billed Charges,65% of Total Billed Charges,213.93,44.1,,494.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,460.85,95,,46.088,Percent of Total Billed Charges,95% of Total Billed Charges,485.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.89,88,,159.896,Percent of Total Billed Charges,88% of Total Billed Charges,436.59,90,,43.664,Percent of Total Billed charges,90% of Total Billed Charges,213.93,485.1,
Z59501602 CR FEMCO,2780000843,CDM,278,RC,C1713,HCPCS,Outpatient,,,19232.01,12500.81,,19232.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14616.33,76,,36.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13847.05,72,,1764.864,Percent of Total Billed Charges,72% of Total Billed Charges,13847.05,72,,1764.864,Percent of Total Billed charges,72% of Total Billed Charges,19232.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13847.05,72,,1764.864,Percent of Total Billed Charges,72% of Total Billed Charges,11539.21,60,,1470.72,Percent of Total Billed Charges,60% of Total Billed Charges,17308.81,90,,4645.32,Percent of Total Billed Charges,90% of Total Billed Charges,8654.4,45,,472.312,Percent of Total Billed Charges,45% of Total Billed Charges,17308.81,90,,43.664,Percent of Total Billed Charges,90% of Total billed Charges,19232.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19232.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19232.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12500.81,65,,1282.472,Percent of total Billed Charges,65% of Total Billed Charges,8481.32,44.1,,462.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,18270.41,95,,46.088,Percent of Total Billed Charges,95% of Total Billed Charges,19232.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16924.17,88,,987.272,Percent of Total Billed Charges,88% of Total Billed Charges,17308.81,90,,43.664,Percent of Total Billed charges,90% of Total Billed Charges,8481.32,19232.01,
Z22320235 HEX BUTT,2780000844,CDM,278,RC,C1713,HCPCS,Outpatient,,,282.24,183.46,,282.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,214.5,76,,1313.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,203.21,72,,1764.864,Percent of Total Billed Charges,72% of Total Billed Charges,203.21,72,,1764.864,Percent of Total Billed charges,72% of Total Billed Charges,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.21,72,,1764.864,Percent of Total Billed Charges,72% of Total Billed Charges,169.34,60,,1470.72,Percent of Total Billed Charges,60% of Total Billed Charges,254.02,90,,4645.32,Percent of Total Billed Charges,90% of Total Billed Charges,127.01,45,,81.76,Percent of Total Billed Charges,45% of Total Billed Charges,254.02,90,,1555.056,Percent of Total Billed Charges,90% of Total billed Charges,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.46,65,,48.16,Percent of total Billed Charges,65% of Total Billed Charges,124.47,44.1,,80.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,268.13,95,,1641.448,Percent of Total Billed Charges,95% of Total Billed Charges,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.37,88,,1058.68,Percent of Total Billed Charges,88% of Total Billed Charges,254.02,90,,1555.056,Percent of Total Billed charges,90% of Total Billed Charges,124.47,282.24,
Z22320418 CERCLAGE,2780000845,CDM,278,RC,C1713,HCPCS,Outpatient,,,1273.39,827.70,,1273.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,967.78,76,,852.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,916.84,72,,1566.144,Percent of Total Billed Charges,72% of Total Billed Charges,916.84,72,,1566.144,Percent of Total Billed charges,72% of Total Billed Charges,1273.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.84,72,,1566.144,Percent of Total Billed Charges,72% of Total Billed Charges,764.03,60,,1305.12,Percent of Total Billed Charges,60% of Total Billed Charges,1146.05,90,,256.4,Percent of Total Billed Charges,90% of Total Billed Charges,573.03,45,,504.856,Percent of Total Billed Charges,45% of Total Billed Charges,1146.05,90,,1009.712,Percent of Total Billed Charges,90% of Total billed Charges,1273.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1273.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1273.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,827.7,65,,329.648,Percent of total Billed Charges,65% of Total Billed Charges,561.56,44.1,,494.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,1209.72,95,,1065.808,Percent of Total Billed Charges,95% of Total Billed Charges,1273.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1120.58,88,,1183.64,Percent of Total Billed Charges,88% of Total Billed Charges,1146.05,90,,1009.712,Percent of Total Billed charges,90% of Total Billed Charges,561.56,1273.39,
Z47223206000 CABL,2780000846,CDM,278,RC,C1713,HCPCS,Outpatient,,,569.99,370.49,,569.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,433.19,76,,797.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,410.39,72,,176.256,Percent of Total Billed Charges,72% of Total Billed Charges,410.39,72,,176.256,Percent of Total Billed charges,72% of Total Billed Charges,569.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,410.39,72,,176.256,Percent of Total Billed Charges,72% of Total Billed Charges,341.99,60,,146.88,Percent of Total Billed Charges,60% of Total Billed Charges,512.99,90,,256.4,Percent of Total Billed Charges,90% of Total Billed Charges,256.5,45,,541.368,Percent of Total Billed Charges,45% of Total Billed Charges,512.99,90,,944.624,Percent of Total Billed Charges,90% of Total billed Charges,569.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.49,65,,661.016,Percent of total Billed Charges,65% of Total Billed Charges,251.37,44.1,,530.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,541.49,95,,997.104,Percent of Total Billed Charges,95% of Total Billed Charges,569.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.59,88,,298.048,Percent of Total Billed Charges,88% of Total Billed Charges,512.99,90,,944.624,Percent of Total Billed charges,90% of Total Billed Charges,251.37,569.99,
Z0203263015 R 15H,2780000847,CDM,278,RC,C1713,HCPCS,Outpatient,,,5480.53,3562.34,,5480.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4165.2,76,,138.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3945.98,72,,1349.568,Percent of Total Billed Charges,72% of Total Billed Charges,3945.98,72,,1349.568,Percent of Total Billed charges,72% of Total Billed Charges,5480.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3945.98,72,,1349.568,Percent of Total Billed Charges,72% of Total Billed Charges,3288.32,60,,1124.64,Percent of Total Billed Charges,60% of Total Billed Charges,4932.48,90,,256.4,Percent of Total Billed Charges,90% of Total Billed Charges,2466.24,45,,605.272,Percent of Total Billed Charges,45% of Total Billed Charges,4932.48,90,,163.528,Percent of Total Billed Charges,90% of Total billed Charges,5480.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5480.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5480.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3562.34,65,,1172.976,Percent of total Billed Charges,65% of Total Billed Charges,2416.91,44.1,,593.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,5206.5,95,,172.608,Percent of Total Billed Charges,95% of Total Billed Charges,5480.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4822.87,88,,298.048,Percent of Total Billed Charges,88% of Total Billed Charges,4932.48,90,,163.528,Percent of Total Billed charges,90% of Total Billed Charges,2416.91,5480.53,
Z02-03150-300 LOCKIN,2780000848,CDM,278,RC,C1713,HCPCS,Outpatient,,,540.23,351.15,,540.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,410.57,76,,852.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,388.97,72,,309.312,Percent of Total Billed Charges,72% of Total Billed Charges,388.97,72,,309.312,Percent of Total Billed charges,72% of Total Billed Charges,540.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,388.97,72,,309.312,Percent of Total Billed Charges,72% of Total Billed Charges,324.14,60,,257.76,Percent of Total Billed Charges,60% of Total Billed Charges,486.21,90,,256.4,Percent of Total Billed Charges,90% of Total Billed Charges,243.1,45,,152.408,Percent of Total Billed Charges,45% of Total Billed Charges,486.21,90,,1009.712,Percent of Total Billed Charges,90% of Total billed Charges,540.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,351.15,65,,1172.976,Percent of total Billed Charges,65% of Total Billed Charges,238.24,44.1,,149.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,513.22,95,,1065.808,Percent of Total Billed Charges,95% of Total Billed Charges,540.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475.4,88,,4542.088,Percent of Total Billed Charges,88% of Total Billed Charges,486.21,90,,1009.712,Percent of Total Billed charges,90% of Total Billed Charges,238.24,540.23,
Z0203151010 UNICOR,2780000849,CDM,278,RC,C1713,HCPCS,Outpatient,,,554.56,360.46,,554.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,421.47,76,,914.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.28,72,,642.816,Percent of Total Billed Charges,72% of Total Billed Charges,399.28,72,,642.816,Percent of Total Billed charges,72% of Total Billed Charges,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.28,72,,642.816,Percent of Total Billed Charges,72% of Total Billed Charges,332.74,60,,535.68,Percent of Total Billed Charges,60% of Total Billed Charges,499.1,90,,256.4,Percent of Total Billed Charges,90% of Total Billed Charges,249.55,45,,152.408,Percent of Total Billed Charges,45% of Total Billed Charges,499.1,90,,1082.744,Percent of Total Billed Charges,90% of Total billed Charges,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360.46,65,,1172.976,Percent of total Billed Charges,65% of Total Billed Charges,244.56,44.1,,149.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,526.83,95,,1142.896,Percent of Total Billed Charges,95% of Total Billed Charges,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.01,88,,4542.088,Percent of Total Billed Charges,88% of Total Billed Charges,499.1,90,,1082.744,Percent of Total Billed charges,90% of Total Billed Charges,244.56,554.56,
Z0203151014 UNICOR,2780000850,CDM,278,RC,C1713,HCPCS,Outpatient,,,554.56,360.46,,554.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,421.47,76,,1022.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.28,72,,309.312,Percent of Total Billed Charges,72% of Total Billed Charges,399.28,72,,309.312,Percent of Total Billed charges,72% of Total Billed Charges,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.28,72,,309.312,Percent of Total Billed Charges,72% of Total Billed Charges,332.74,60,,257.76,Percent of Total Billed Charges,60% of Total Billed Charges,499.1,90,,5929.688,Percent of Total Billed Charges,90% of Total Billed Charges,249.55,45,,2322.656,Percent of Total Billed Charges,45% of Total Billed Charges,499.1,90,,1210.544,Percent of Total Billed Charges,90% of Total billed Charges,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360.46,65,,339.392,Percent of total Billed Charges,65% of Total Billed Charges,244.56,44.1,,2276.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,526.83,95,,1277.792,Percent of Total Billed Charges,95% of Total Billed Charges,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.01,88,,250.704,Percent of Total Billed Charges,88% of Total Billed Charges,499.1,90,,1210.544,Percent of Total Billed charges,90% of Total Billed Charges,244.56,554.56,
Z0203151018 UNICOR,2780000851,CDM,278,RC,C1713,HCPCS,Outpatient,,,554.56,360.46,,554.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,421.47,76,,257.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.28,72,,176.256,Percent of Total Billed Charges,72% of Total Billed Charges,399.28,72,,176.256,Percent of Total Billed charges,72% of Total Billed Charges,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.28,72,,176.256,Percent of Total Billed Charges,72% of Total Billed Charges,332.74,60,,146.88,Percent of Total Billed Charges,60% of Total Billed Charges,499.1,90,,5929.688,Percent of Total Billed Charges,90% of Total Billed Charges,249.55,45,,2322.656,Percent of Total Billed Charges,45% of Total Billed Charges,499.1,90,,304.816,Percent of Total Billed Charges,90% of Total billed Charges,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360.46,65,,339.392,Percent of total Billed Charges,65% of Total Billed Charges,244.56,44.1,,2276.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,526.83,95,,321.752,Percent of Total Billed Charges,95% of Total Billed Charges,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.01,88,,250.704,Percent of Total Billed Charges,88% of Total Billed Charges,499.1,90,,304.816,Percent of Total Billed charges,90% of Total Billed Charges,244.56,554.56,
Z02-03151-020 UNICOR,2780000852,CDM,278,RC,C1713,HCPCS,Outpatient,,,554.56,360.46,,554.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,421.47,76,,257.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.28,72,,267.84,Percent of Total Billed Charges,72% of Total Billed Charges,399.28,72,,267.84,Percent of Total Billed charges,72% of Total Billed Charges,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.28,72,,267.84,Percent of Total Billed Charges,72% of Total Billed Charges,332.74,60,,223.2,Percent of Total Billed Charges,60% of Total Billed Charges,499.1,90,,9740.72,Percent of Total Billed Charges,90% of Total Billed Charges,249.55,45,,128.2,Percent of Total Billed Charges,45% of Total Billed Charges,499.1,90,,304.816,Percent of Total Billed Charges,90% of Total billed Charges,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360.46,65,,1643.656,Percent of total Billed Charges,65% of Total Billed Charges,244.56,44.1,,125.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,526.83,95,,321.752,Percent of Total Billed Charges,95% of Total Billed Charges,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.01,88,,250.704,Percent of Total Billed Charges,88% of Total Billed Charges,499.1,90,,304.816,Percent of Total Billed charges,90% of Total Billed Charges,244.56,554.56,
Z0203155022 CORTIC,2780000853,CDM,278,RC,C1713,HCPCS,Outpatient,,,368.24,239.36,,368.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,279.86,76,,3922.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,265.13,72,,267.84,Percent of Total Billed Charges,72% of Total Billed Charges,265.13,72,,267.84,Percent of Total Billed charges,72% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.13,72,,267.84,Percent of Total Billed Charges,72% of Total Billed Charges,220.94,60,,223.2,Percent of Total Billed Charges,60% of Total Billed Charges,331.42,90,,1624.12,Percent of Total Billed Charges,90% of Total Billed Charges,165.71,45,,128.2,Percent of Total Billed Charges,45% of Total Billed Charges,331.42,90,,4645.32,Percent of Total Billed Charges,90% of Total billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.36,65,,798.032,Percent of total Billed Charges,65% of Total Billed Charges,162.39,44.1,,125.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,349.83,95,,4903.392,Percent of Total Billed Charges,95% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.05,88,,250.704,Percent of Total Billed Charges,88% of Total Billed Charges,331.42,90,,4645.32,Percent of Total Billed charges,90% of Total Billed Charges,162.39,368.24,
Z0203155036 CORTIC,2780000854,CDM,278,RC,C1713,HCPCS,Outpatient,,,368.24,239.36,,368.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,279.86,76,,3922.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,265.13,72,,267.84,Percent of Total Billed Charges,72% of Total Billed Charges,265.13,72,,267.84,Percent of Total Billed charges,72% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.13,72,,267.84,Percent of Total Billed Charges,72% of Total Billed Charges,220.94,60,,223.2,Percent of Total Billed Charges,60% of Total Billed Charges,331.42,90,,262.752,Percent of Total Billed Charges,90% of Total Billed Charges,165.71,45,,128.2,Percent of Total Billed Charges,45% of Total Billed Charges,331.42,90,,4645.32,Percent of Total Billed Charges,90% of Total billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.36,65,,307.864,Percent of total Billed Charges,65% of Total Billed Charges,162.39,44.1,,125.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,349.83,95,,4903.392,Percent of Total Billed Charges,95% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.05,88,,250.704,Percent of Total Billed Charges,88% of Total Billed Charges,331.42,90,,4645.32,Percent of Total Billed charges,90% of Total Billed Charges,162.39,368.24,
Z0203155040 CORTIC,2780000855,CDM,278,RC,C1713,HCPCS,Outpatient,,,368.24,239.36,,368.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,279.86,76,,216.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,265.13,72,,59.904,Percent of Total Billed Charges,72% of Total Billed Charges,265.13,72,,59.904,Percent of Total Billed charges,72% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.13,72,,59.904,Percent of Total Billed Charges,72% of Total Billed Charges,220.94,60,,49.92,Percent of Total Billed Charges,60% of Total Billed Charges,331.42,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,165.71,45,,128.2,Percent of Total Billed Charges,45% of Total Billed Charges,331.42,90,,256.4,Percent of Total Billed Charges,90% of Total billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.36,65,,307.864,Percent of total Billed Charges,65% of Total Billed Charges,162.39,44.1,,125.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,349.83,95,,270.64,Percent of Total Billed Charges,95% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.05,88,,5797.92,Percent of Total Billed Charges,88% of Total Billed Charges,331.42,90,,256.4,Percent of Total Billed charges,90% of Total Billed Charges,162.39,368.24,
Z02-03150-036 CORTIC,2780000856,CDM,278,RC,C1713,HCPCS,Outpatient,,,583.22,379.09,,583.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,443.25,76,,216.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,419.92,72,,1738.368,Percent of Total Billed Charges,72% of Total Billed Charges,419.92,72,,1738.368,Percent of Total Billed charges,72% of Total Billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.92,72,,1738.368,Percent of Total Billed Charges,72% of Total Billed Charges,349.93,60,,1448.64,Percent of Total Billed Charges,60% of Total Billed Charges,524.9,90,,381.024,Percent of Total Billed Charges,90% of Total Billed Charges,262.45,45,,128.2,Percent of Total Billed Charges,45% of Total Billed Charges,524.9,90,,256.4,Percent of Total Billed Charges,90% of Total billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.09,65,,307.864,Percent of total Billed Charges,65% of Total Billed Charges,257.2,44.1,,125.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,554.06,95,,270.64,Percent of Total Billed Charges,95% of Total Billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.23,88,,5797.92,Percent of Total Billed Charges,88% of Total Billed Charges,524.9,90,,256.4,Percent of Total Billed charges,90% of Total Billed Charges,257.2,583.22,
Z02-03150-038 CORTIC,2780000857,CDM,278,RC,C1713,HCPCS,Outpatient,,,583.22,379.09,,583.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,443.25,76,,216.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,419.92,72,,444.096,Percent of Total Billed Charges,72% of Total Billed Charges,419.92,72,,444.096,Percent of Total Billed charges,72% of Total Billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.92,72,,444.096,Percent of Total Billed Charges,72% of Total Billed Charges,349.93,60,,370.08,Percent of Total Billed Charges,60% of Total Billed Charges,524.9,90,,381.024,Percent of Total Billed Charges,90% of Total Billed Charges,262.45,45,,2964.848,Percent of Total Billed Charges,45% of Total Billed Charges,524.9,90,,256.4,Percent of Total Billed Charges,90% of Total billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.09,65,,1370.192,Percent of total Billed Charges,65% of Total Billed Charges,257.2,44.1,,2905.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,554.06,95,,270.64,Percent of Total Billed Charges,95% of Total Billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.23,88,,9524.264,Percent of Total Billed Charges,88% of Total Billed Charges,524.9,90,,256.4,Percent of Total Billed charges,90% of Total Billed Charges,257.2,583.22,
Z02-3150-044 CORTICA,2780000858,CDM,278,RC,C1713,HCPCS,Outpatient,,,583.22,379.09,,583.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,443.25,76,,216.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,419.92,72,,241.344,Percent of Total Billed Charges,72% of Total Billed Charges,419.92,72,,241.344,Percent of Total Billed charges,72% of Total Billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.92,72,,241.344,Percent of Total Billed Charges,72% of Total Billed Charges,349.93,60,,201.12,Percent of Total Billed Charges,60% of Total Billed Charges,524.9,90,,1775.728,Percent of Total Billed Charges,90% of Total Billed Charges,262.45,45,,2964.848,Percent of Total Billed Charges,45% of Total Billed Charges,524.9,90,,256.4,Percent of Total Billed Charges,90% of Total billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.09,65,,3195,Percent of total Billed Charges,65% of Total Billed Charges,257.2,44.1,,2905.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,554.06,95,,270.64,Percent of Total Billed Charges,95% of Total Billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.23,88,,1588.024,Percent of Total Billed Charges,88% of Total Billed Charges,524.9,90,,256.4,Percent of Total Billed charges,90% of Total Billed Charges,257.2,583.22,
Z02-03150-046 CORTIC,2780000859,CDM,278,RC,C1713,HCPCS,Outpatient,,,583.22,379.09,,583.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,443.25,76,,216.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,419.92,72,,444.096,Percent of Total Billed Charges,72% of Total Billed Charges,419.92,72,,444.096,Percent of Total Billed charges,72% of Total Billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.92,72,,444.096,Percent of Total Billed Charges,72% of Total Billed Charges,349.93,60,,370.08,Percent of Total Billed Charges,60% of Total Billed Charges,524.9,90,,1775.728,Percent of Total Billed Charges,90% of Total Billed Charges,262.45,45,,4870.36,Percent of Total Billed Charges,45% of Total Billed Charges,524.9,90,,256.4,Percent of Total Billed Charges,90% of Total billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.09,65,,411.632,Percent of total Billed Charges,65% of Total Billed Charges,257.2,44.1,,4772.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,554.06,95,,270.64,Percent of Total Billed Charges,95% of Total Billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.23,88,,256.912,Percent of Total Billed Charges,88% of Total Billed Charges,524.9,90,,256.4,Percent of Total Billed charges,90% of Total Billed Charges,257.2,583.22,
Z020315055 CORTICA,2780000860,CDM,278,RC,C1713,HCPCS,Outpatient,,,583.22,379.09,,583.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,443.25,76,,5007.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,419.92,72,,241.344,Percent of Total Billed Charges,72% of Total Billed Charges,419.92,72,,241.344,Percent of Total Billed charges,72% of Total Billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.92,72,,241.344,Percent of Total Billed Charges,72% of Total Billed Charges,349.93,60,,201.12,Percent of Total Billed Charges,60% of Total Billed Charges,524.9,90,,1775.728,Percent of Total Billed Charges,90% of Total Billed Charges,262.45,45,,812.056,Percent of Total Billed Charges,45% of Total Billed Charges,524.9,90,,5929.688,Percent of Total Billed Charges,90% of Total billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.09,65,,171.416,Percent of total Billed Charges,65% of Total Billed Charges,257.2,44.1,,795.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,554.06,95,,6259.12,Percent of Total Billed Charges,95% of Total Billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.23,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,524.9,90,,5929.688,Percent of Total Billed charges,90% of Total Billed Charges,257.2,583.22,
Z02-00024-002 DRILL,2780000861,CDM,278,RC,C1713,HCPCS,Outpatient,,,378.16,245.80,,378.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,287.4,76,,5007.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,272.28,72,,444.096,Percent of Total Billed Charges,72% of Total Billed Charges,272.28,72,,444.096,Percent of Total Billed charges,72% of Total Billed Charges,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.28,72,,444.096,Percent of Total Billed Charges,72% of Total Billed Charges,226.9,60,,370.08,Percent of Total Billed Charges,60% of Total Billed Charges,340.34,90,,66.68,Percent of Total Billed Charges,90% of Total Billed Charges,170.17,45,,131.376,Percent of Total Billed Charges,45% of Total Billed Charges,340.34,90,,5929.688,Percent of Total Billed Charges,90% of Total billed Charges,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.8,65,,49.304,Percent of total Billed Charges,65% of Total Billed Charges,166.77,44.1,,128.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,359.25,95,,6259.12,Percent of Total Billed Charges,95% of Total Billed Charges,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.78,88,,372.56,Percent of Total Billed Charges,88% of Total Billed Charges,340.34,90,,5929.688,Percent of Total Billed charges,90% of Total Billed Charges,166.77,378.16,
A700300 CLAVICLE PL,2780000862,CDM,278,RC,C1713,HCPCS,Outpatient,,,4610.66,2996.93,,4610.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3504.1,76,,8225.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3319.68,72,,1420.992,Percent of Total Billed Charges,72% of Total Billed Charges,3319.68,72,,1420.992,Percent of Total Billed charges,72% of Total Billed Charges,4610.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3319.68,72,,1420.992,Percent of Total Billed Charges,72% of Total Billed Charges,2766.4,60,,1184.16,Percent of Total Billed Charges,60% of Total Billed Charges,4149.59,90,,456.44,Percent of Total Billed Charges,90% of Total Billed Charges,2074.8,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,4149.59,90,,9740.72,Percent of Total Billed Charges,90% of Total billed Charges,4610.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4610.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4610.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2996.93,65,,195.496,Percent of total Billed Charges,65% of Total Billed Charges,2033.3,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,4380.13,95,,10281.872,Percent of Total Billed Charges,95% of Total Billed Charges,4610.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4057.38,88,,372.56,Percent of Total Billed Charges,88% of Total Billed Charges,4149.59,90,,9740.72,Percent of Total Billed charges,90% of Total Billed Charges,2033.3,4610.66,
AC03140 CORTICAL SC,2780000863,CDM,278,RC,C1713,HCPCS,Outpatient,,,316.42,205.67,,316.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,240.48,76,,1371.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,227.82,72,,1237.248,Percent of Total Billed Charges,72% of Total Billed Charges,227.82,72,,1237.248,Percent of Total Billed charges,72% of Total Billed Charges,316.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.82,72,,1237.248,Percent of Total Billed Charges,72% of Total Billed Charges,189.85,60,,1031.04,Percent of Total Billed Charges,60% of Total Billed Charges,284.78,90,,915.248,Percent of Total Billed Charges,90% of Total Billed Charges,142.39,45,,190.512,Percent of Total Billed Charges,45% of Total Billed Charges,284.78,90,,1624.12,Percent of Total Billed Charges,90% of Total billed Charges,316.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.67,65,,195.496,Percent of total Billed Charges,65% of Total Billed Charges,139.54,44.1,,186.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,300.6,95,,1714.344,Percent of Total Billed Charges,95% of Total Billed Charges,316.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.45,88,,1736.272,Percent of Total Billed Charges,88% of Total Billed Charges,284.78,90,,1624.12,Percent of Total Billed charges,90% of Total Billed Charges,139.54,316.42,
ACO 3120 CORTICAL SC,2780000864,CDM,278,RC,C1713,HCPCS,Outpatient,,,316.42,205.67,,316.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,240.48,76,,221.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,227.82,72,,444.096,Percent of Total Billed Charges,72% of Total Billed Charges,227.82,72,,444.096,Percent of Total Billed charges,72% of Total Billed Charges,316.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.82,72,,444.096,Percent of Total Billed Charges,72% of Total Billed Charges,189.85,60,,370.08,Percent of Total Billed Charges,60% of Total Billed Charges,284.78,90,,1624.12,Percent of Total Billed Charges,90% of Total Billed Charges,142.39,45,,190.512,Percent of Total Billed Charges,45% of Total Billed Charges,284.78,90,,262.752,Percent of Total Billed Charges,90% of Total billed Charges,316.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.67,65,,403.032,Percent of total Billed Charges,65% of Total Billed Charges,139.54,44.1,,186.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,300.6,95,,277.344,Percent of Total Billed Charges,95% of Total Billed Charges,316.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.45,88,,1736.272,Percent of Total Billed Charges,88% of Total Billed Charges,284.78,90,,262.752,Percent of Total Billed charges,90% of Total Billed Charges,139.54,316.42,
AMSDC28 DRILL BIT 2,2780000865,CDM,278,RC,C1713,HCPCS,Outpatient,,,307.60,199.94,,307.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,233.78,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,221.47,72,,1419.264,Percent of Total Billed Charges,72% of Total Billed Charges,221.47,72,,1419.264,Percent of Total Billed charges,72% of Total Billed Charges,307.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.47,72,,1419.264,Percent of Total Billed Charges,72% of Total Billed Charges,184.56,60,,1182.72,Percent of Total Billed Charges,60% of Total Billed Charges,276.84,90,,1624.12,Percent of Total Billed Charges,90% of Total Billed Charges,138.42,45,,887.864,Percent of Total Billed Charges,45% of Total Billed Charges,276.84,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,307.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.94,65,,1139.72,Percent of total Billed Charges,65% of Total Billed Charges,135.65,44.1,,870.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,292.22,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,307.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.69,88,,1736.272,Percent of Total Billed Charges,88% of Total Billed Charges,276.84,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,135.65,307.6,
AHPC0025 HEX DRIVER,2780000866,CDM,278,RC,C1713,HCPCS,Outpatient,,,332.96,216.42,,332.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,253.05,76,,321.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,239.73,72,,237.312,Percent of Total Billed Charges,72% of Total Billed Charges,239.73,72,,237.312,Percent of Total Billed charges,72% of Total Billed Charges,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.73,72,,237.312,Percent of Total Billed Charges,72% of Total Billed Charges,199.78,60,,197.76,Percent of Total Billed Charges,60% of Total Billed Charges,299.66,90,,1624.12,Percent of Total Billed Charges,90% of Total Billed Charges,149.83,45,,887.864,Percent of Total Billed Charges,45% of Total Billed Charges,299.66,90,,381.024,Percent of Total Billed Charges,90% of Total billed Charges,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.42,65,,1139.72,Percent of total Billed Charges,65% of Total Billed Charges,146.84,44.1,,870.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,316.31,95,,402.192,Percent of Total Billed Charges,95% of Total Billed Charges,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293,88,,65.2,Percent of Total Billed Charges,88% of Total Billed Charges,299.66,90,,381.024,Percent of Total Billed charges,90% of Total Billed Charges,146.84,332.96,
Z49270310 OBLIQUE,2780000867,CDM,278,RC,C1713,HCPCS,Outpatient,,,203.96,132.57,,203.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,155.01,76,,321.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,146.85,72,,390.528,Percent of Total Billed Charges,72% of Total Billed Charges,146.85,72,,390.528,Percent of Total Billed charges,72% of Total Billed Charges,203.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.85,72,,390.528,Percent of Total Billed Charges,72% of Total Billed Charges,122.38,60,,325.44,Percent of Total Billed Charges,60% of Total Billed Charges,183.56,90,,469.928,Percent of Total Billed Charges,90% of Total Billed Charges,91.78,45,,887.864,Percent of Total Billed Charges,45% of Total Billed Charges,183.56,90,,381.024,Percent of Total Billed Charges,90% of Total billed Charges,203.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.57,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,89.95,44.1,,870.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,193.76,95,,402.192,Percent of Total Billed Charges,95% of Total Billed Charges,203.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.48,88,,446.296,Percent of Total Billed Charges,88% of Total Billed Charges,183.56,90,,381.024,Percent of Total Billed charges,90% of Total Billed Charges,89.95,203.96,
Z123561304 VOLAR PL,2780000868,CDM,278,RC,C1713,HCPCS,Outpatient,,,2793.74,1815.93,,2793.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2123.24,76,,1499.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2011.49,72,,4367.808,Percent of Total Billed Charges,72% of Total Billed Charges,2011.49,72,,4367.808,Percent of Total Billed charges,72% of Total Billed Charges,2793.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2011.49,72,,4367.808,Percent of Total Billed Charges,72% of Total Billed Charges,1676.24,60,,3639.84,Percent of Total Billed Charges,60% of Total Billed Charges,2514.37,90,,469.928,Percent of Total Billed Charges,90% of Total Billed Charges,1257.18,45,,33.336,Percent of Total Billed Charges,45% of Total Billed Charges,2514.37,90,,1775.728,Percent of Total Billed Charges,90% of Total billed Charges,2793.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2793.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2793.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1815.93,65,,3209.336,Percent of total Billed Charges,65% of Total Billed Charges,1232.04,44.1,,32.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,2654.05,95,,1874.384,Percent of Total Billed Charges,95% of Total Billed Charges,2793.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2458.49,88,,894.912,Percent of Total Billed Charges,88% of Total Billed Charges,2514.37,90,,1775.728,Percent of Total Billed charges,90% of Total Billed Charges,1232.04,2793.74,
Z59645010 ART SURF,2780000869,CDM,278,RC,C1713,HCPCS,Outpatient,,,6295.28,4091.93,,6295.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4784.41,76,,1499.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4532.6,72,,2326.464,Percent of Total Billed Charges,72% of Total Billed Charges,4532.6,72,,2326.464,Percent of Total Billed charges,72% of Total Billed Charges,6295.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4532.6,72,,2326.464,Percent of Total Billed Charges,72% of Total Billed Charges,3777.17,60,,1938.72,Percent of Total Billed Charges,60% of Total Billed Charges,5665.75,90,,2275.824,Percent of Total Billed Charges,90% of Total Billed Charges,2832.88,45,,228.216,Percent of Total Billed Charges,45% of Total Billed Charges,5665.75,90,,1775.728,Percent of Total Billed Charges,90% of Total billed Charges,6295.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6295.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6295.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4091.93,65,,103.192,Percent of total Billed Charges,65% of Total Billed Charges,2776.22,44.1,,223.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,5980.52,95,,1874.384,Percent of Total Billed Charges,95% of Total Billed Charges,6295.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5539.85,88,,1588.024,Percent of Total Billed Charges,88% of Total Billed Charges,5665.75,90,,1775.728,Percent of Total Billed charges,90% of Total Billed Charges,2776.22,6295.28,
Z00545001352 REV,2780000870,CDM,278,RC,C1713,HCPCS,Outpatient,,,13770.23,8950.65,,13770.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10465.37,76,,1499.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9914.57,72,,3200.256,Percent of Total Billed Charges,72% of Total Billed Charges,9914.57,72,,3200.256,Percent of Total Billed charges,72% of Total Billed Charges,13770.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9914.57,72,,3200.256,Percent of Total Billed Charges,72% of Total Billed Charges,8262.14,60,,2666.88,Percent of Total Billed Charges,60% of Total Billed Charges,12393.21,90,,1104.968,Percent of Total Billed Charges,90% of Total Billed Charges,6196.6,45,,457.624,Percent of Total Billed Charges,45% of Total Billed Charges,12393.21,90,,1775.728,Percent of Total Billed Charges,90% of Total billed Charges,13770.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13770.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13770.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8950.65,65,,2422.192,Percent of total Billed Charges,65% of Total Billed Charges,6072.67,44.1,,448.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,13081.72,95,,1874.384,Percent of Total Billed Charges,95% of Total Billed Charges,13770.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12117.8,88,,1588.024,Percent of Total Billed Charges,88% of Total Billed Charges,12393.21,90,,1775.728,Percent of Total Billed charges,90% of Total Billed Charges,6072.67,13770.23,
Z59903524 FEM AUG/,2780000871,CDM,278,RC,C1713,HCPCS,Outpatient,,,4661.37,3029.89,,4661.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3542.64,76,,56.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3356.19,72,,701.568,Percent of Total Billed Charges,72% of Total Billed Charges,3356.19,72,,701.568,Percent of Total Billed charges,72% of Total Billed Charges,4661.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3356.19,72,,701.568,Percent of Total Billed Charges,72% of Total Billed Charges,2796.82,60,,584.64,Percent of Total Billed Charges,60% of Total Billed Charges,4195.23,90,,426.272,Percent of Total Billed Charges,90% of Total Billed Charges,2097.62,45,,812.056,Percent of Total Billed Charges,45% of Total Billed Charges,4195.23,90,,66.68,Percent of Total Billed Charges,90% of Total billed Charges,4661.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4661.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4661.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3029.89,65,,273.464,Percent of total Billed Charges,65% of Total Billed Charges,2055.66,44.1,,795.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,4428.3,95,,70.384,Percent of Total Billed Charges,95% of Total Billed Charges,4661.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4102.01,88,,1588.024,Percent of Total Billed Charges,88% of Total Billed Charges,4195.23,90,,66.68,Percent of Total Billed charges,90% of Total Billed Charges,2055.66,4661.37,
Z59805701 REV TIBIA,2780000872,CDM,278,RC,C1713,HCPCS,Outpatient,,,8302.93,5396.90,,8302.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6310.23,76,,385.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5978.11,72,,323.136,Percent of Total Billed Charges,72% of Total Billed Charges,5978.11,72,,323.136,Percent of Total Billed charges,72% of Total Billed Charges,8302.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5978.11,72,,323.136,Percent of Total Billed Charges,72% of Total Billed Charges,4981.76,60,,269.28,Percent of Total Billed Charges,60% of Total Billed Charges,7472.64,90,,426.272,Percent of Total Billed Charges,90% of Total Billed Charges,3736.32,45,,812.056,Percent of Total Billed Charges,45% of Total Billed Charges,7472.64,90,,456.44,Percent of Total Billed Charges,90% of Total billed Charges,8302.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8302.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8302.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5396.9,65,,2035.216,Percent of total Billed Charges,65% of Total Billed Charges,3661.59,44.1,,795.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,7887.78,95,,481.792,Percent of Total Billed Charges,95% of Total Billed Charges,8302.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7306.58,88,,459.488,Percent of Total Billed Charges,88% of Total Billed Charges,7472.64,90,,456.44,Percent of Total Billed charges,90% of Total Billed Charges,3661.59,8302.93,
Z59881118 REV STEM,2780000873,CDM,278,RC,C1713,HCPCS,Outpatient,,,3785.99,2460.89,,3785.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2877.35,76,,772.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2725.91,72,,323.136,Percent of Total Billed Charges,72% of Total Billed Charges,2725.91,72,,323.136,Percent of Total Billed charges,72% of Total Billed Charges,3785.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2725.91,72,,323.136,Percent of Total Billed Charges,72% of Total Billed Charges,2271.59,60,,269.28,Percent of Total Billed Charges,60% of Total Billed Charges,3407.39,90,,426.272,Percent of Total Billed Charges,90% of Total Billed Charges,1703.7,45,,812.056,Percent of Total Billed Charges,45% of Total Billed Charges,3407.39,90,,915.248,Percent of Total Billed Charges,90% of Total billed Charges,3785.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3785.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3785.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2460.89,65,,8926.28,Percent of total Billed Charges,65% of Total Billed Charges,1669.62,44.1,,795.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,3596.69,95,,966.096,Percent of Total Billed Charges,95% of Total Billed Charges,3785.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3331.67,88,,459.488,Percent of Total Billed Charges,88% of Total Billed Charges,3407.39,90,,915.248,Percent of Total Billed charges,90% of Total Billed Charges,1669.62,3785.99,
Z59945014 REV ART,2780000874,CDM,278,RC,C1713,HCPCS,Outpatient,,,6551.06,4258.19,,6551.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4978.81,76,,1371.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4716.76,72,,1542.528,Percent of Total Billed Charges,72% of Total Billed Charges,4716.76,72,,1542.528,Percent of Total Billed charges,72% of Total Billed Charges,6551.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4716.76,72,,1542.528,Percent of Total Billed Charges,72% of Total Billed Charges,3930.64,60,,1285.44,Percent of Total Billed Charges,60% of Total Billed Charges,5895.95,90,,1897.184,Percent of Total Billed Charges,90% of Total Billed Charges,2947.98,45,,234.968,Percent of Total Billed Charges,45% of Total Billed Charges,5895.95,90,,1624.12,Percent of Total Billed Charges,90% of Total billed Charges,6551.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6551.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6551.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4258.19,65,,38.416,Percent of total Billed Charges,65% of Total Billed Charges,2889.02,44.1,,230.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,6223.51,95,,1714.344,Percent of Total Billed Charges,95% of Total Billed Charges,6551.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5764.93,88,,2225.256,Percent of Total Billed Charges,88% of Total Billed Charges,5895.95,90,,1624.12,Percent of Total Billed charges,90% of Total Billed Charges,2889.02,6551.06,
Z59644210 ART SURF,2780000875,CDM,278,RC,C1713,HCPCS,Outpatient,,,6045.01,3929.26,,6045.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4594.21,76,,1371.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4352.41,72,,323.136,Percent of Total Billed Charges,72% of Total Billed Charges,4352.41,72,,323.136,Percent of Total Billed charges,72% of Total Billed Charges,6045.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4352.41,72,,323.136,Percent of Total Billed Charges,72% of Total Billed Charges,3627.01,60,,269.28,Percent of Total Billed Charges,60% of Total Billed Charges,5440.51,90,,4423.848,Percent of Total Billed Charges,90% of Total Billed Charges,2720.25,45,,234.968,Percent of Total Billed Charges,45% of Total Billed Charges,5440.51,90,,1624.12,Percent of Total Billed Charges,90% of Total billed Charges,6045.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6045.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6045.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3929.26,65,,22.936,Percent of total Billed Charges,65% of Total Billed Charges,2665.85,44.1,,230.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,5742.76,95,,1714.344,Percent of Total Billed Charges,95% of Total Billed Charges,6045.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5319.61,88,,1080.416,Percent of Total Billed Charges,88% of Total Billed Charges,5440.51,90,,1624.12,Percent of Total Billed charges,90% of Total Billed Charges,2665.85,6045.01,
SYNTHES ELASTIC NAIL,2780000876,CDM,278,RC,C1713,HCPCS,Outpatient,,,1803.69,1172.40,,1803.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1370.8,76,,1371.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1298.66,72,,163.584,Percent of Total Billed Charges,72% of Total Billed Charges,1298.66,72,,163.584,Percent of Total Billed charges,72% of Total Billed Charges,1803.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1298.66,72,,163.584,Percent of Total Billed Charges,72% of Total Billed Charges,1082.21,60,,136.32,Percent of Total Billed Charges,60% of Total Billed Charges,1623.32,90,,569.952,Percent of Total Billed Charges,90% of Total Billed Charges,811.66,45,,1137.912,Percent of Total Billed Charges,45% of Total Billed Charges,1623.32,90,,1624.12,Percent of Total Billed Charges,90% of Total billed Charges,1803.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1803.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1803.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1172.4,65,,38.416,Percent of total Billed Charges,65% of Total Billed Charges,795.43,44.1,,1115.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,1713.51,95,,1714.344,Percent of Total Billed Charges,95% of Total Billed Charges,1803.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1587.25,88,,416.8,Percent of Total Billed Charges,88% of Total Billed Charges,1623.32,90,,1624.12,Percent of Total Billed charges,90% of Total Billed Charges,795.43,1803.69,
Z58801302 REV FEM,2780000877,CDM,278,RC,C1713,HCPCS,Outpatient,,,34641.65,22517.07,,34641.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26327.65,76,,396.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24941.99,72,,163.584,Percent of Total Billed Charges,72% of Total Billed Charges,24941.99,72,,163.584,Percent of Total Billed charges,72% of Total Billed Charges,34641.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24941.99,72,,163.584,Percent of Total Billed Charges,72% of Total Billed Charges,20784.99,60,,136.32,Percent of Total Billed Charges,60% of Total Billed Charges,31177.49,90,,237.352,Percent of Total Billed Charges,90% of Total Billed Charges,15588.74,45,,552.488,Percent of Total Billed Charges,45% of Total Billed Charges,31177.49,90,,469.928,Percent of Total Billed Charges,90% of Total billed Charges,34641.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34641.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34641.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22517.07,65,,322.768,Percent of total Billed Charges,65% of Total Billed Charges,15276.97,44.1,,541.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,32909.57,95,,496.04,Percent of Total Billed Charges,95% of Total Billed Charges,34641.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30484.65,88,,416.8,Percent of Total Billed Charges,88% of Total Billed Charges,31177.49,90,,469.928,Percent of Total Billed charges,90% of Total Billed Charges,15276.97,34641.65,
Z59882113 STEM EXT,2780000878,CDM,278,RC,C1713,HCPCS,Outpatient,,,5240.18,3406.12,,5240.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3982.54,76,,396.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3772.93,72,,475.776,Percent of Total Billed Charges,72% of Total Billed Charges,3772.93,72,,475.776,Percent of Total Billed charges,72% of Total Billed Charges,5240.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3772.93,72,,475.776,Percent of Total Billed Charges,72% of Total Billed Charges,3144.11,60,,396.48,Percent of Total Billed Charges,60% of Total Billed Charges,4716.16,90,,68.272,Percent of Total Billed Charges,90% of Total Billed Charges,2358.08,45,,213.136,Percent of Total Billed Charges,45% of Total Billed Charges,4716.16,90,,469.928,Percent of Total Billed Charges,90% of Total billed Charges,5240.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5240.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5240.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3406.12,65,,322.768,Percent of total Billed Charges,65% of Total Billed Charges,2310.92,44.1,,208.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,4978.17,95,,496.04,Percent of Total Billed Charges,95% of Total Billed Charges,5240.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4611.36,88,,416.8,Percent of Total Billed Charges,88% of Total Billed Charges,4716.16,90,,469.928,Percent of Total Billed charges,90% of Total Billed Charges,2310.92,5240.18,
Z58803012 REV ART,2780000879,CDM,278,RC,C1713,HCPCS,Outpatient,,,5893.97,3831.08,,5893.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4479.42,76,,1921.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4243.66,72,,396.288,Percent of Total Billed Charges,72% of Total Billed Charges,4243.66,72,,396.288,Percent of Total Billed charges,72% of Total Billed Charges,5893.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4243.66,72,,396.288,Percent of Total Billed Charges,72% of Total Billed Charges,3536.38,60,,330.24,Percent of Total Billed Charges,60% of Total Billed Charges,5304.57,90,,270.688,Percent of Total Billed Charges,90% of Total Billed Charges,2652.29,45,,213.136,Percent of Total Billed Charges,45% of Total Billed Charges,5304.57,90,,2275.824,Percent of Total Billed Charges,90% of Total billed Charges,5893.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5893.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5893.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3831.08,65,,1139.72,Percent of total Billed Charges,65% of Total Billed Charges,2599.24,44.1,,208.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,5599.27,95,,2402.264,Percent of Total Billed Charges,95% of Total Billed Charges,5893.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5186.69,88,,1855.024,Percent of Total Billed Charges,88% of Total Billed Charges,5304.57,90,,2275.824,Percent of Total Billed charges,90% of Total Billed Charges,2599.24,5893.97,
ACCUMED T15 HEXALOBE,2780000880,CDM,278,RC,C1713,HCPCS,Outpatient,,,575.00,373.75,,575,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,437,76,,933.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,414,72,,828.288,Percent of Total Billed Charges,72% of Total Billed Charges,414,72,,828.288,Percent of Total Billed charges,72% of Total Billed Charges,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414,72,,828.288,Percent of Total Billed Charges,72% of Total Billed Charges,345,60,,690.24,Percent of Total Billed Charges,60% of Total Billed Charges,517.5,90,,270.688,Percent of Total Billed Charges,90% of Total Billed Charges,258.75,45,,213.136,Percent of Total Billed Charges,45% of Total Billed Charges,517.5,90,,1104.968,Percent of Total Billed Charges,90% of Total billed Charges,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.75,65,,1139.72,Percent of total Billed Charges,65% of Total Billed Charges,253.58,44.1,,208.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,546.25,95,,1166.36,Percent of Total Billed Charges,95% of Total Billed Charges,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506,88,,4325.536,Percent of Total Billed Charges,88% of Total Billed Charges,517.5,90,,1104.968,Percent of Total Billed charges,90% of Total Billed Charges,253.58,575,
ACUMED PLATE TACK,2780000881,CDM,278,RC,C1713,HCPCS,Outpatient,,,89.00,57.85,,89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.64,76,,359.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.08,72,,1388.16,Percent of Total Billed Charges,72% of Total Billed Charges,64.08,72,,1388.16,Percent of Total Billed charges,72% of Total Billed Charges,89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.08,72,,1388.16,Percent of Total Billed Charges,72% of Total Billed Charges,53.4,60,,1156.8,Percent of Total Billed Charges,60% of Total Billed Charges,80.1,90,,558.04,Percent of Total Billed Charges,90% of Total Billed Charges,40.05,45,,948.592,Percent of Total Billed Charges,45% of Total Billed Charges,80.1,90,,426.272,Percent of Total Billed Charges,90% of Total billed Charges,89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.85,65,,307.944,Percent of total Billed Charges,65% of Total Billed Charges,39.25,44.1,,929.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,84.55,95,,449.952,Percent of Total Billed Charges,95% of Total Billed Charges,89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.32,88,,557.288,Percent of Total Billed Charges,88% of Total Billed Charges,80.1,90,,426.272,Percent of Total Billed charges,90% of Total Billed Charges,39.25,89,
ACUMED GUIDE WIRE,2780000882,CDM,278,RC,C1713,HCPCS,Outpatient,,,27.56,17.91,,27.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.95,76,,359.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.84,72,,309.312,Percent of Total Billed Charges,72% of Total Billed Charges,19.84,72,,309.312,Percent of Total Billed charges,72% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.84,72,,309.312,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,60,,257.76,Percent of Total Billed Charges,60% of Total Billed Charges,24.8,90,,1578.072,Percent of Total Billed Charges,90% of Total Billed Charges,12.4,45,,2211.92,Percent of Total Billed Charges,45% of Total Billed Charges,24.8,90,,426.272,Percent of Total Billed Charges,90% of Total billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.91,65,,8838.648,Percent of total Billed Charges,65% of Total Billed Charges,12.15,44.1,,2167.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.18,95,,449.952,Percent of Total Billed Charges,95% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,88,,232.072,Percent of Total Billed Charges,88% of Total Billed Charges,24.8,90,,426.272,Percent of Total Billed charges,90% of Total Billed Charges,12.15,27.56,
Z11471831 CANN SCR,2780000883,CDM,278,RC,C1713,HCPCS,Outpatient,,,593.15,385.55,,593.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,450.79,76,,359.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,427.07,72,,1955.52,Percent of Total Billed Charges,72% of Total Billed Charges,427.07,72,,1955.52,Percent of Total Billed charges,72% of Total Billed Charges,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.07,72,,1955.52,Percent of Total Billed Charges,72% of Total Billed Charges,355.89,60,,1629.6,Percent of Total Billed Charges,60% of Total Billed Charges,533.84,90,,1578.072,Percent of Total Billed Charges,90% of Total Billed Charges,266.92,45,,284.976,Percent of Total Billed Charges,45% of Total Billed Charges,533.84,90,,426.272,Percent of Total Billed Charges,90% of Total billed Charges,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.55,65,,356.536,Percent of total Billed Charges,65% of Total Billed Charges,261.58,44.1,,279.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,563.49,95,,449.952,Percent of Total Billed Charges,95% of Total Billed Charges,593.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521.97,88,,66.752,Percent of Total Billed Charges,88% of Total Billed Charges,533.84,90,,426.272,Percent of Total Billed charges,90% of Total Billed Charges,261.58,593.15,
Z114789 GUIDE PIN 1,2780000884,CDM,278,RC,C1713,HCPCS,Outpatient,,,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,1602.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,309.312,Percent of Total Billed Charges,72% of Total Billed Charges,14.29,72,,309.312,Percent of Total Billed charges,72% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,309.312,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,257.76,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,118.672,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,1897.184,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,293.2,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,116.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,2002.584,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,264.672,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,1897.184,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
Z47248508010 LAG,2780000885,CDM,278,RC,C1713,HCPCS,Outpatient,,,2131.13,1385.23,,2131.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1619.66,76,,3735.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1534.41,72,,238.728,Percent of Total Billed Charges,72% of Total Billed Charges,1534.41,72,,238.728,Percent of Total Billed charges,72% of Total Billed Charges,2131.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1534.41,72,,238.728,Percent of Total Billed Charges,72% of Total Billed Charges,1278.68,60,,133.544,Percent of Total Billed Charges,60% of Total Billed Charges,1918.02,90,,4443.696,Percent of Total Billed Charges,90% of Total Billed Charges,959.01,45,,34.136,Percent of Total Billed Charges,45% of Total Billed Charges,1918.02,90,,4423.848,Percent of Total Billed Charges,90% of Total billed Charges,2131.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2131.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2131.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1385.23,65,,293.2,Percent of total Billed Charges,65% of Total Billed Charges,939.83,44.1,,33.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,2024.57,95,,4669.616,Percent of Total Billed Charges,95% of Total Billed Charges,2131.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1875.39,88,,264.672,Percent of Total Billed Charges,88% of Total Billed Charges,1918.02,90,,4423.848,Percent of Total Billed charges,90% of Total Billed Charges,939.83,2131.13,
Z114709076 32 MM T,2780000886,CDM,278,RC,C1713,HCPCS,Outpatient,,,837.90,544.64,,837.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,636.8,76,,481.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,603.29,72,,680.08,Percent of Total Billed Charges,72% of Total Billed Charges,603.29,72,,680.08,Percent of Total Billed charges,72% of Total Billed Charges,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,603.29,72,,680.08,Percent of Total Billed Charges,72% of Total Billed Charges,502.74,60,,501.344,Percent of Total Billed Charges,60% of Total Billed Charges,754.11,90,,142.888,Percent of Total Billed Charges,90% of Total Billed Charges,377.06,45,,135.344,Percent of Total Billed Charges,45% of Total Billed Charges,754.11,90,,569.952,Percent of Total Billed Charges,90% of Total billed Charges,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,544.64,65,,75.896,Percent of total Billed Charges,65% of Total Billed Charges,369.51,44.1,,132.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,796.01,95,,601.616,Percent of Total Billed Charges,95% of Total Billed Charges,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.35,88,,545.64,Percent of Total Billed Charges,88% of Total Billed Charges,754.11,90,,569.952,Percent of Total Billed charges,90% of Total Billed Charges,369.51,837.9,
ACUMED 2.7X14 LCK SC,2780000887,CDM,278,RC,C1713,HCPCS,Outpatient,,,607.48,394.86,,607.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,461.68,76,,200.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,437.39,72,,680.08,Percent of Total Billed Charges,72% of Total Billed Charges,437.39,72,,680.08,Percent of Total Billed charges,72% of Total Billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.39,72,,680.08,Percent of Total Billed Charges,72% of Total Billed Charges,364.49,60,,501.344,Percent of Total Billed Charges,60% of Total Billed Charges,546.73,90,,3353.8,Percent of Total Billed Charges,90% of Total Billed Charges,273.37,45,,135.344,Percent of Total Billed Charges,45% of Total Billed Charges,546.73,90,,237.352,Percent of Total Billed Charges,90% of Total billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.86,65,,499.048,Percent of total Billed Charges,65% of Total Billed Charges,267.9,44.1,,132.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,577.11,95,,250.536,Percent of Total Billed Charges,95% of Total Billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,534.58,88,,1543.008,Percent of Total Billed Charges,88% of Total Billed Charges,546.73,90,,237.352,Percent of Total Billed charges,90% of Total Billed Charges,267.9,607.48,
ACUMED 2.7X16 LCK SC,2780000888,CDM,278,RC,C1713,HCPCS,Outpatient,,,607.48,394.86,,607.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,461.68,76,,57.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,437.39,72,,3196.736,Percent of Total Billed Charges,72% of Total Billed Charges,437.39,72,,3196.736,Percent of Total Billed charges,72% of Total Billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.39,72,,3196.736,Percent of Total Billed Charges,72% of Total Billed Charges,364.49,60,,2598.56,Percent of Total Billed Charges,60% of Total Billed Charges,546.73,90,,378.64,Percent of Total Billed Charges,90% of Total Billed Charges,273.37,45,,279.024,Percent of Total Billed Charges,45% of Total Billed Charges,546.73,90,,68.272,Percent of Total Billed Charges,90% of Total billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.86,65,,99.376,Percent of total Billed Charges,65% of Total Billed Charges,267.9,44.1,,273.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,577.11,95,,72.064,Percent of Total Billed Charges,95% of Total Billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,534.58,88,,1543.008,Percent of Total Billed Charges,88% of Total Billed Charges,546.73,90,,68.272,Percent of Total Billed charges,90% of Total Billed Charges,267.9,607.48,
ACUMED 2.7X20 LCK SC,2780000889,CDM,278,RC,C1713,HCPCS,Outpatient,,,607.48,394.86,,607.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,461.68,76,,228.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,437.39,72,,3048.144,Percent of Total Billed Charges,72% of Total Billed Charges,437.39,72,,3048.144,Percent of Total Billed charges,72% of Total Billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.39,72,,3048.144,Percent of Total Billed Charges,72% of Total Billed Charges,364.49,60,,2474.728,Percent of Total Billed Charges,60% of Total Billed Charges,546.73,90,,2817.992,Percent of Total Billed Charges,90% of Total Billed Charges,273.37,45,,789.04,Percent of Total Billed Charges,45% of Total Billed Charges,546.73,90,,270.688,Percent of Total Billed Charges,90% of Total billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.86,65,,2709.8,Percent of total Billed Charges,65% of Total Billed Charges,267.9,44.1,,773.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,577.11,95,,285.72,Percent of Total Billed Charges,95% of Total Billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,534.58,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,546.73,90,,270.688,Percent of Total Billed charges,90% of Total Billed Charges,267.9,607.48,
ACUMED 3.5X12 NLCK S,2780000890,CDM,278,RC,C1713,HCPCS,Outpatient,,,646.00,419.90,,646,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,490.96,76,,228.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,465.12,72,,401.296,Percent of Total Billed Charges,72% of Total Billed Charges,465.12,72,,401.296,Percent of Total Billed charges,72% of Total Billed Charges,646,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.12,72,,401.296,Percent of Total Billed Charges,72% of Total Billed Charges,387.6,60,,269.024,Percent of Total Billed Charges,60% of Total Billed Charges,581.4,90,,12359.472,Percent of Total Billed Charges,90% of Total Billed Charges,290.7,45,,789.04,Percent of Total Billed Charges,45% of Total Billed Charges,581.4,90,,270.688,Percent of Total Billed Charges,90% of Total billed Charges,646,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,646,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,646,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.9,65,,2639.912,Percent of total Billed Charges,65% of Total Billed Charges,284.89,44.1,,773.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,613.7,95,,285.72,Percent of Total Billed Charges,95% of Total Billed Charges,646,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.48,88,,4344.944,Percent of Total Billed Charges,88% of Total Billed Charges,581.4,90,,270.688,Percent of Total Billed charges,90% of Total Billed Charges,284.89,646,
ACUMED 3.5X16 NLCK S,2780000891,CDM,278,RC,C1713,HCPCS,Outpatient,,,394.70,256.56,,394.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.97,76,,471.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.18,72,,401.296,Percent of Total Billed Charges,72% of Total Billed Charges,284.18,72,,401.296,Percent of Total Billed charges,72% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.18,72,,401.296,Percent of Total Billed Charges,72% of Total Billed Charges,236.82,60,,269.024,Percent of Total Billed Charges,60% of Total Billed Charges,355.23,90,,53.184,Percent of Total Billed Charges,90% of Total Billed Charges,177.62,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,355.23,90,,558.04,Percent of Total Billed Charges,90% of Total billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.56,65,,13.104,Percent of total Billed Charges,65% of Total Billed Charges,174.06,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.97,95,,589.048,Percent of Total Billed Charges,95% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.34,88,,139.712,Percent of Total Billed Charges,88% of Total Billed Charges,355.23,90,,558.04,Percent of Total Billed charges,90% of Total Billed Charges,174.06,394.7,
ACUMED 3.5X20 NLCK S,2780000892,CDM,278,RC,C1713,HCPCS,Outpatient,,,394.70,256.56,,394.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.97,76,,1332.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.18,72,,401.296,Percent of Total Billed Charges,72% of Total Billed Charges,284.18,72,,401.296,Percent of Total Billed charges,72% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.18,72,,401.296,Percent of Total Billed Charges,72% of Total Billed Charges,236.82,60,,269.024,Percent of Total Billed Charges,60% of Total Billed Charges,355.23,90,,31.752,Percent of Total Billed Charges,90% of Total Billed Charges,177.62,45,,2221.848,Percent of Total Billed Charges,45% of Total Billed Charges,355.23,90,,1578.072,Percent of Total Billed Charges,90% of Total billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.56,65,,201.24,Percent of total Billed Charges,65% of Total Billed Charges,174.06,44.1,,2177.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.97,95,,1665.744,Percent of Total Billed Charges,95% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.34,88,,3279.272,Percent of Total Billed Charges,88% of Total Billed Charges,355.23,90,,1578.072,Percent of Total Billed charges,90% of Total Billed Charges,174.06,394.7,
ACUMED 3.5X28 NLCK S,2780000893,CDM,278,RC,C1713,HCPCS,Outpatient,,,394.70,256.56,,394.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.97,76,,1332.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.18,72,,577.832,Percent of Total Billed Charges,72% of Total Billed Charges,284.18,72,,577.832,Percent of Total Billed charges,72% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.18,72,,577.832,Percent of Total Billed Charges,72% of Total Billed Charges,236.82,60,,416.136,Percent of Total Billed Charges,60% of Total Billed Charges,355.23,90,,53.184,Percent of Total Billed Charges,90% of Total Billed Charges,177.62,45,,71.44,Percent of Total Billed Charges,45% of Total Billed Charges,355.23,90,,1578.072,Percent of Total Billed Charges,90% of Total billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.56,65,,331.424,Percent of total Billed Charges,65% of Total Billed Charges,174.06,44.1,,70.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.97,95,,1665.744,Percent of Total Billed Charges,95% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.34,88,,370.224,Percent of Total Billed Charges,88% of Total Billed Charges,355.23,90,,1578.072,Percent of Total Billed charges,90% of Total Billed Charges,174.06,394.7,
ACUMED 3.5X36 NLCK S,2780000894,CDM,278,RC,C1713,HCPCS,Outpatient,,,394.70,256.56,,394.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.97,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.18,72,,655.944,Percent of Total Billed Charges,72% of Total Billed Charges,284.18,72,,655.944,Percent of Total Billed charges,72% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.18,72,,655.944,Percent of Total Billed Charges,72% of Total Billed Charges,236.82,60,,481.232,Percent of Total Billed Charges,60% of Total Billed Charges,355.23,90,,446.912,Percent of Total Billed Charges,90% of Total Billed Charges,177.62,45,,1676.904,Percent of Total Billed Charges,45% of Total Billed Charges,355.23,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.56,65,,331.424,Percent of total Billed Charges,65% of Total Billed Charges,174.06,44.1,,1643.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.97,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.34,88,,2755.368,Percent of Total Billed Charges,88% of Total Billed Charges,355.23,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,174.06,394.7,
ACUMED ELBOW STEM,2780000895,CDM,278,RC,C1713,HCPCS,Outpatient,,,8235.68,5353.19,,8235.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6259.12,76,,3752.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5929.69,72,,205.704,Percent of Total Billed Charges,72% of Total Billed Charges,5929.69,72,,205.704,Percent of Total Billed charges,72% of Total Billed Charges,8235.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5929.69,72,,205.704,Percent of Total Billed Charges,72% of Total Billed Charges,4941.41,60,,106.024,Percent of Total Billed Charges,60% of Total Billed Charges,7412.11,90,,446.912,Percent of Total Billed Charges,90% of Total Billed Charges,3706.06,45,,189.32,Percent of Total Billed Charges,45% of Total Billed Charges,7412.11,90,,4443.696,Percent of Total Billed Charges,90% of Total billed Charges,8235.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8235.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8235.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5353.19,65,,307.944,Percent of total Billed Charges,65% of Total Billed Charges,3631.93,44.1,,185.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,7823.9,95,,4690.568,Percent of Total Billed Charges,95% of Total Billed Charges,8235.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7247.4,88,,12084.816,Percent of Total Billed Charges,88% of Total Billed Charges,7412.11,90,,4443.696,Percent of Total Billed charges,90% of Total Billed Charges,3631.93,8235.68,
ACUMED ELBOW HEAD,2780000896,CDM,278,RC,C1713,HCPCS,Outpatient,,,13528.78,8793.71,,13528.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10281.87,76,,120.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9740.72,72,,2676.008,Percent of Total Billed Charges,72% of Total Billed Charges,9740.72,72,,2676.008,Percent of Total Billed charges,72% of Total Billed Charges,13528.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9740.72,72,,2676.008,Percent of Total Billed Charges,72% of Total Billed Charges,8117.27,60,,2164.616,Percent of Total Billed Charges,60% of Total Billed Charges,12175.9,90,,1578.072,Percent of Total Billed Charges,90% of Total Billed Charges,6087.95,45,,1409,Percent of Total Billed Charges,45% of Total Billed Charges,12175.9,90,,142.888,Percent of Total Billed Charges,90% of Total billed Charges,13528.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13528.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13528.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8793.71,65,,33.856,Percent of total Billed Charges,65% of Total Billed Charges,5966.19,44.1,,1380.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,12852.34,95,,150.824,Percent of Total Billed Charges,95% of Total Billed Charges,13528.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11905.33,88,,52.008,Percent of Total Billed Charges,88% of Total Billed Charges,12175.9,90,,142.888,Percent of Total Billed charges,90% of Total Billed Charges,5966.19,13528.78,
ACUMED OLECRANON PLA,2780000897,CDM,278,RC,C1713,HCPCS,Outpatient,,,5383.51,3499.28,,5383.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4091.47,76,,2832.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3876.13,72,,499.088,Percent of Total Billed Charges,72% of Total Billed Charges,3876.13,72,,499.088,Percent of Total Billed charges,72% of Total Billed Charges,5383.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3876.13,72,,499.088,Percent of Total Billed Charges,72% of Total Billed Charges,3230.11,60,,350.512,Percent of Total Billed Charges,60% of Total Billed Charges,4845.16,90,,1578.072,Percent of Total Billed Charges,90% of Total Billed Charges,2422.58,45,,6179.736,Percent of Total Billed Charges,45% of Total Billed Charges,4845.16,90,,3353.8,Percent of Total Billed Charges,90% of Total billed Charges,5383.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5383.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5383.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3499.28,65,,238.6,Percent of total Billed Charges,65% of Total Billed Charges,2374.13,44.1,,6056.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,5114.33,95,,3540.128,Percent of Total Billed Charges,95% of Total Billed Charges,5383.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4737.49,88,,31.048,Percent of Total Billed Charges,88% of Total Billed Charges,4845.16,90,,3353.8,Percent of Total Billed charges,90% of Total Billed Charges,2374.13,5383.51,
ACUMED DRILL BIT 2.0,2780000898,CDM,278,RC,C1713,HCPCS,Outpatient,,,176.40,114.66,,176.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,134.06,76,,319.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,127.01,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,127.01,72,,233.696,Percent of Total Billed charges,72% of Total Billed Charges,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.01,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,158.76,90,,426.384,Percent of Total Billed Charges,90% of Total Billed Charges,79.38,45,,26.592,Percent of Total Billed Charges,45% of Total Billed Charges,158.76,90,,378.64,Percent of Total Billed Charges,90% of Total billed Charges,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.66,65,,238.6,Percent of total Billed Charges,65% of Total Billed Charges,77.79,44.1,,26.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,167.58,95,,399.68,Percent of Total Billed Charges,95% of Total Billed Charges,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.23,88,,52.008,Percent of Total Billed Charges,88% of Total Billed Charges,158.76,90,,378.64,Percent of Total Billed charges,90% of Total Billed Charges,77.79,176.4,
ACUMED DRILL BIT 2.8,2780000899,CDM,278,RC,C1713,HCPCS,Outpatient,,,244.00,158.60,,244,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,185.44,76,,2379.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,175.68,72,,946.848,Percent of Total Billed Charges,72% of Total Billed Charges,175.68,72,,946.848,Percent of Total Billed charges,72% of Total Billed Charges,244,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.68,72,,946.848,Percent of Total Billed Charges,72% of Total Billed Charges,146.4,60,,789.04,Percent of Total Billed Charges,60% of Total Billed Charges,219.6,90,,12238.128,Percent of Total Billed Charges,90% of Total Billed Charges,109.8,45,,15.88,Percent of Total Billed Charges,45% of Total Billed Charges,219.6,90,,2817.992,Percent of Total Billed Charges,90% of Total billed Charges,244,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.6,65,,238.6,Percent of total Billed Charges,65% of Total Billed Charges,107.6,44.1,,15.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,231.8,95,,2974.552,Percent of Total Billed Charges,95% of Total Billed Charges,244,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.72,88,,436.976,Percent of Total Billed Charges,88% of Total Billed Charges,219.6,90,,2817.992,Percent of Total Billed charges,90% of Total Billed Charges,107.6,244,
ACUMED T8 HEXALOBE D,2780000900,CDM,278,RC,C1713,HCPCS,Outpatient,,,395.80,257.27,,395.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,300.81,76,,10436.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.98,72,,1537.432,Percent of Total Billed Charges,72% of Total Billed Charges,284.98,72,,1537.432,Percent of Total Billed charges,72% of Total Billed Charges,395.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.98,72,,1537.432,Percent of Total Billed Charges,72% of Total Billed Charges,237.48,60,,1281.192,Percent of Total Billed Charges,60% of Total Billed Charges,356.22,90,,493.672,Percent of Total Billed Charges,90% of Total Billed Charges,178.11,45,,26.592,Percent of Total Billed Charges,45% of Total Billed Charges,356.22,90,,12359.472,Percent of Total Billed Charges,90% of Total billed Charges,395.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,395.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,395.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.27,65,,307.944,Percent of total Billed Charges,65% of Total Billed Charges,174.55,44.1,,26.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,376.01,95,,13046.104,Percent of Total Billed Charges,95% of Total Billed Charges,395.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.3,88,,436.976,Percent of Total Billed Charges,88% of Total Billed Charges,356.22,90,,12359.472,Percent of Total Billed charges,90% of Total Billed Charges,174.55,395.8,
Z0203260105 TIBIAL,2780000901,CDM,278,RC,C1713,HCPCS,Outpatient,,,5046.14,3279.99,,5046.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3835.07,76,,44.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3633.22,72,,244.488,Percent of Total Billed Charges,72% of Total Billed Charges,3633.22,72,,244.488,Percent of Total Billed charges,72% of Total Billed Charges,5046.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3633.22,72,,244.488,Percent of Total Billed Charges,72% of Total Billed Charges,3027.68,60,,203.744,Percent of Total Billed Charges,60% of Total Billed Charges,4541.53,90,,405.976,Percent of Total Billed Charges,90% of Total Billed Charges,2270.76,45,,223.456,Percent of Total Billed Charges,45% of Total Billed Charges,4541.53,90,,53.184,Percent of Total Billed Charges,90% of Total billed Charges,5046.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5046.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5046.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3279.99,65,,2381.104,Percent of total Billed Charges,65% of Total Billed Charges,2225.35,44.1,,218.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,4793.83,95,,56.144,Percent of Total Billed Charges,95% of Total Billed Charges,5046.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4440.6,88,,1543.008,Percent of Total Billed Charges,88% of Total Billed Charges,4541.53,90,,53.184,Percent of Total Billed charges,90% of Total Billed Charges,2225.35,5046.14,
Z0203150040 5.0 CO,2780000902,CDM,278,RC,C1713,HCPCS,Outpatient,,,583.22,379.09,,583.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,443.25,76,,26.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,419.92,72,,321.968,Percent of Total Billed Charges,72% of Total Billed Charges,419.92,72,,321.968,Percent of Total Billed charges,72% of Total Billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.92,72,,321.968,Percent of Total Billed Charges,72% of Total Billed Charges,349.93,60,,268.304,Percent of Total Billed Charges,60% of Total Billed Charges,524.9,90,,405.976,Percent of Total Billed Charges,90% of Total Billed Charges,262.45,45,,223.456,Percent of Total Billed Charges,45% of Total Billed Charges,524.9,90,,31.752,Percent of Total Billed Charges,90% of Total billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.09,65,,237.512,Percent of total Billed Charges,65% of Total Billed Charges,257.2,44.1,,218.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,554.06,95,,33.52,Percent of Total Billed Charges,95% of Total Billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.23,88,,1543.008,Percent of Total Billed Charges,88% of Total Billed Charges,524.9,90,,31.752,Percent of Total Billed charges,90% of Total Billed Charges,257.2,583.22,
Z0203150048 5.0 CO,2780000903,CDM,278,RC,C1713,HCPCS,Outpatient,,,583.22,379.09,,583.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,443.25,76,,44.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,419.92,72,,517.56,Percent of Total Billed Charges,72% of Total Billed Charges,419.92,72,,517.56,Percent of Total Billed charges,72% of Total Billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.92,72,,517.56,Percent of Total Billed Charges,72% of Total Billed Charges,349.93,60,,431.296,Percent of Total Billed Charges,60% of Total Billed Charges,524.9,90,,105.088,Percent of Total Billed Charges,90% of Total Billed Charges,262.45,45,,789.04,Percent of Total Billed Charges,45% of Total Billed Charges,524.9,90,,53.184,Percent of Total Billed Charges,90% of Total billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.09,65,,31.672,Percent of total Billed Charges,65% of Total Billed Charges,257.2,44.1,,773.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,554.06,95,,56.144,Percent of Total Billed Charges,95% of Total Billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.23,88,,416.912,Percent of Total Billed Charges,88% of Total Billed Charges,524.9,90,,53.184,Percent of Total Billed charges,90% of Total Billed Charges,257.2,583.22,
Z0203150050 5.0 CO,2780000904,CDM,278,RC,C1713,HCPCS,Outpatient,,,583.22,379.09,,583.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,443.25,76,,377.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,419.92,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,419.92,72,,6.984,Percent of Total Billed charges,72% of Total Billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.92,72,,6.984,Percent of Total Billed Charges,72% of Total Billed Charges,349.93,60,,5.824,Percent of Total Billed Charges,60% of Total Billed Charges,524.9,90,,690.984,Percent of Total Billed Charges,90% of Total Billed Charges,262.45,45,,789.04,Percent of Total Billed Charges,45% of Total Billed Charges,524.9,90,,446.912,Percent of Total Billed Charges,90% of Total billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.09,65,,307.944,Percent of total Billed Charges,65% of Total Billed Charges,257.2,44.1,,773.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,554.06,95,,471.736,Percent of Total Billed Charges,95% of Total Billed Charges,583.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.23,88,,11966.168,Percent of Total Billed Charges,88% of Total Billed Charges,524.9,90,,446.912,Percent of Total Billed charges,90% of Total Billed Charges,257.2,583.22,
Z0203152065 5.0 CA,2780000905,CDM,278,RC,C1713,HCPCS,Outpatient,,,501.64,326.07,,501.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,381.25,76,,377.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,361.18,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,361.18,72,,40.64,Percent of Total Billed charges,72% of Total Billed Charges,501.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.18,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,300.98,60,,33.872,Percent of Total Billed Charges,60% of Total Billed Charges,451.48,90,,137.592,Percent of Total Billed Charges,90% of Total Billed Charges,225.74,45,,213.192,Percent of Total Billed Charges,45% of Total Billed Charges,451.48,90,,446.912,Percent of Total Billed Charges,90% of Total billed Charges,501.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.07,65,,1162.984,Percent of total Billed Charges,65% of Total Billed Charges,221.22,44.1,,208.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,476.56,95,,471.736,Percent of Total Billed Charges,95% of Total Billed Charges,501.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,441.44,88,,482.696,Percent of Total Billed Charges,88% of Total Billed Charges,451.48,90,,446.912,Percent of Total Billed charges,90% of Total Billed Charges,221.22,501.64,
Z59501502 FEM COMP,2780000906,CDM,278,RC,C1713,HCPCS,Outpatient,,,18137.23,11789.20,,18137.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13784.29,76,,1332.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13058.81,72,,137.168,Percent of Total Billed Charges,72% of Total Billed Charges,13058.81,72,,137.168,Percent of Total Billed charges,72% of Total Billed Charges,18137.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13058.81,72,,137.168,Percent of Total Billed Charges,72% of Total Billed Charges,10882.34,60,,114.304,Percent of Total Billed Charges,60% of Total Billed Charges,16323.51,90,,3752.032,Percent of Total Billed Charges,90% of Total Billed Charges,8161.75,45,,6119.064,Percent of Total Billed Charges,45% of Total Billed Charges,16323.51,90,,1578.072,Percent of Total Billed Charges,90% of Total billed Charges,18137.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18137.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18137.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11789.2,65,,70.432,Percent of total Billed Charges,65% of Total Billed Charges,7998.52,44.1,,5996.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,17230.37,95,,1665.744,Percent of Total Billed Charges,95% of Total Billed Charges,18137.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15960.76,88,,396.952,Percent of Total Billed Charges,88% of Total Billed Charges,16323.51,90,,1578.072,Percent of Total Billed charges,90% of Total Billed Charges,7998.52,18137.23,
TORNIER 3.0X14MM SCR,2780000907,CDM,278,RC,C1713,HCPCS,Outpatient,,,1142.19,742.42,,1142.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,868.06,76,,1332.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,822.38,72,,156.224,Percent of Total Billed Charges,72% of Total Billed Charges,822.38,72,,156.224,Percent of Total Billed charges,72% of Total Billed Charges,1142.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,822.38,72,,156.224,Percent of Total Billed Charges,72% of Total Billed Charges,685.31,60,,130.184,Percent of Total Billed Charges,60% of Total Billed Charges,1027.97,90,,3655.264,Percent of Total Billed Charges,90% of Total Billed Charges,513.99,45,,246.832,Percent of Total Billed Charges,45% of Total Billed Charges,1027.97,90,,1578.072,Percent of Total Billed Charges,90% of Total billed Charges,1142.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1142.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1142.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,742.42,65,,43.68,Percent of total Billed Charges,65% of Total Billed Charges,503.71,44.1,,241.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,1085.08,95,,1665.744,Percent of Total Billed Charges,95% of Total Billed Charges,1142.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1005.13,88,,396.952,Percent of Total Billed Charges,88% of Total Billed Charges,1027.97,90,,1578.072,Percent of Total Billed charges,90% of Total Billed Charges,503.71,1142.19,
TORNIER GUIDE WIRE,2780000908,CDM,278,RC,C1713,HCPCS,Outpatient,,,25.36,16.48,,25.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.27,76,,360.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.26,72,,156.224,Percent of Total Billed Charges,72% of Total Billed Charges,18.26,72,,156.224,Percent of Total Billed charges,72% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.26,72,,156.224,Percent of Total Billed Charges,72% of Total Billed Charges,15.22,60,,130.184,Percent of Total Billed Charges,60% of Total Billed Charges,22.82,90,,18.144,Percent of Total Billed Charges,90% of Total Billed Charges,11.41,45,,202.984,Percent of Total Billed Charges,45% of Total Billed Charges,22.82,90,,426.384,Percent of Total Billed Charges,90% of Total billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,65,,27.04,Percent of total Billed Charges,65% of Total Billed Charges,11.18,44.1,,198.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.09,95,,450.072,Percent of Total Billed Charges,95% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,88,,102.752,Percent of Total Billed Charges,88% of Total Billed Charges,22.82,90,,426.384,Percent of Total Billed charges,90% of Total Billed Charges,11.18,25.36,
Z47248507510 LAG,2780000909,CDM,278,RC,C1713,HCPCS,Outpatient,,,2131.13,1385.23,,2131.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1619.66,76,,10334.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1534.41,72,,94.92,Percent of Total Billed Charges,72% of Total Billed Charges,1534.41,72,,94.92,Percent of Total Billed charges,72% of Total Billed Charges,2131.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1534.41,72,,94.92,Percent of Total Billed Charges,72% of Total Billed Charges,1278.68,60,,79.096,Percent of Total Billed Charges,60% of Total Billed Charges,1918.02,90,,278.64,Percent of Total Billed Charges,90% of Total Billed Charges,959.01,45,,202.984,Percent of Total Billed Charges,45% of Total Billed Charges,1918.02,90,,12238.128,Percent of Total Billed Charges,90% of Total billed Charges,2131.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2131.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2131.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1385.23,65,,27.04,Percent of total Billed Charges,65% of Total Billed Charges,939.83,44.1,,198.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,2024.57,95,,12918.024,Percent of Total Billed Charges,95% of Total Billed Charges,2131.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1875.39,88,,675.632,Percent of Total Billed Charges,88% of Total Billed Charges,1918.02,90,,12238.128,Percent of Total Billed charges,90% of Total Billed Charges,939.83,2131.13,
Z62025622 SHELL W/,2780000910,CDM,278,RC,C1713,HCPCS,Outpatient,,,9175.01,5963.76,,9175.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6973.01,76,,416.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6606.01,72,,88.656,Percent of Total Billed Charges,72% of Total Billed Charges,6606.01,72,,88.656,Percent of Total Billed charges,72% of Total Billed Charges,9175.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6606.01,72,,88.656,Percent of Total Billed Charges,72% of Total Billed Charges,5505.01,60,,73.88,Percent of Total Billed Charges,60% of Total Billed Charges,8257.51,90,,458.896,Percent of Total Billed Charges,90% of Total Billed Charges,4128.75,45,,52.544,Percent of Total Billed Charges,45% of Total Billed Charges,8257.51,90,,493.672,Percent of Total Billed Charges,90% of Total billed Charges,9175.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9175.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9175.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5963.76,65,,110.24,Percent of total Billed Charges,65% of Total Billed Charges,4046.18,44.1,,51.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,8716.26,95,,521.096,Percent of Total Billed Charges,95% of Total Billed Charges,9175.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8074.01,88,,134.536,Percent of Total Billed Charges,88% of Total Billed Charges,8257.51,90,,493.672,Percent of Total Billed charges,90% of Total Billed Charges,4046.18,9175.01,
Z00744800301 MODN,2780000911,CDM,278,RC,C1713,HCPCS,Outpatient,,,5694.41,3701.37,,5694.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4327.75,76,,342.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4099.98,72,,232.424,Percent of Total Billed Charges,72% of Total Billed Charges,4099.98,72,,232.424,Percent of Total Billed charges,72% of Total Billed Charges,5694.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4099.98,72,,232.424,Percent of Total Billed Charges,72% of Total Billed Charges,3416.65,60,,193.688,Percent of Total Billed Charges,60% of Total Billed Charges,5124.97,90,,458.896,Percent of Total Billed Charges,90% of Total Billed Charges,2562.48,45,,345.496,Percent of Total Billed Charges,45% of Total Billed Charges,5124.97,90,,405.976,Percent of Total Billed Charges,90% of Total billed Charges,5694.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5694.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5694.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3701.37,65,,76.44,Percent of total Billed Charges,65% of Total Billed Charges,2511.23,44.1,,338.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,5409.69,95,,428.528,Percent of Total Billed Charges,95% of Total Billed Charges,5694.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5011.08,88,,3668.648,Percent of Total Billed Charges,88% of Total Billed Charges,5124.97,90,,405.976,Percent of Total Billed charges,90% of Total Billed Charges,2511.23,5694.41,
Z00771301300 STEM,2780000912,CDM,278,RC,C1713,HCPCS,Outpatient,,,20643.21,13418.09,,20643.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15688.84,76,,342.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14863.11,72,,736.232,Percent of Total Billed Charges,72% of Total Billed Charges,14863.11,72,,736.232,Percent of Total Billed charges,72% of Total Billed Charges,20643.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14863.11,72,,736.232,Percent of Total Billed Charges,72% of Total Billed Charges,12385.93,60,,613.528,Percent of Total Billed Charges,60% of Total Billed Charges,18578.89,90,,426.384,Percent of Total Billed Charges,90% of Total Billed Charges,9289.44,45,,68.8,Percent of Total Billed Charges,45% of Total Billed Charges,18578.89,90,,405.976,Percent of Total Billed Charges,90% of Total billed Charges,20643.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20643.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20643.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13418.09,65,,91.52,Percent of total Billed Charges,65% of Total Billed Charges,9103.66,44.1,,67.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,19611.05,95,,428.528,Percent of Total Billed Charges,95% of Total Billed Charges,20643.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18166.02,88,,3574.032,Percent of Total Billed Charges,88% of Total Billed Charges,18578.89,90,,405.976,Percent of Total Billed charges,90% of Total Billed Charges,9103.66,20643.21,
TORNIER RFS PIN 1.5X,2780000913,CDM,278,RC,C1713,HCPCS,Outpatient,,,756.32,491.61,,756.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,574.8,76,,88.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,544.55,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,544.55,72,,115.2,Percent of Total Billed charges,72% of Total Billed Charges,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,544.55,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,453.79,60,,96,Percent of Total Billed Charges,60% of Total Billed Charges,680.69,90,,46.872,Percent of Total Billed Charges,90% of Total Billed Charges,340.34,45,,1876.016,Percent of Total Billed Charges,45% of Total Billed Charges,680.69,90,,105.088,Percent of Total Billed Charges,90% of Total billed Charges,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.61,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,333.54,44.1,,1838.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,718.5,95,,110.92,Percent of Total Billed Charges,95% of Total Billed Charges,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,665.56,88,,17.744,Percent of Total Billed Charges,88% of Total Billed Charges,680.69,90,,105.088,Percent of Total Billed charges,90% of Total Billed Charges,333.54,756.32,
TORNIER RFS DISP. PI,2780000914,CDM,278,RC,C1713,HCPCS,Outpatient,,,115.76,75.24,,115.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.98,76,,583.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,83.35,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,83.35,72,,115.2,Percent of Total Billed charges,72% of Total Billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.35,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,69.46,60,,96,Percent of Total Billed Charges,60% of Total Billed Charges,104.18,90,,330.376,Percent of Total Billed Charges,90% of Total Billed Charges,52.09,45,,1827.632,Percent of Total Billed Charges,45% of Total Billed Charges,104.18,90,,690.984,Percent of Total Billed Charges,90% of Total billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.24,65,,615.16,Percent of total Billed Charges,65% of Total Billed Charges,51.05,44.1,,1791.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,109.97,95,,729.376,Percent of Total Billed Charges,95% of Total Billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.87,88,,272.448,Percent of Total Billed Charges,88% of Total Billed Charges,104.18,90,,690.984,Percent of Total Billed charges,90% of Total Billed Charges,51.05,115.76,
ACUMED 2.7X32 1 SCW,2780000915,CDM,278,RC,C1713,HCPCS,Outpatient,,,607.48,394.86,,607.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,461.68,76,,116.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,437.39,72,,402.192,Percent of Total Billed Charges,72% of Total Billed Charges,437.39,72,,402.192,Percent of Total Billed charges,72% of Total Billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.39,72,,402.192,Percent of Total Billed Charges,72% of Total Billed Charges,364.49,60,,335.16,Percent of Total Billed Charges,60% of Total Billed Charges,546.73,90,,330.376,Percent of Total Billed Charges,90% of Total Billed Charges,273.37,45,,9.072,Percent of Total Billed Charges,45% of Total Billed Charges,546.73,90,,137.592,Percent of Total Billed Charges,90% of Total billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.86,65,,29.64,Percent of total Billed Charges,65% of Total Billed Charges,267.9,44.1,,8.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,577.11,95,,145.24,Percent of Total Billed Charges,95% of Total Billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,534.58,88,,448.696,Percent of Total Billed Charges,88% of Total Billed Charges,546.73,90,,137.592,Percent of Total Billed charges,90% of Total Billed Charges,267.9,607.48,
Z225336011 TIBIAL,2780000916,CDM,278,RC,C1713,HCPCS,Outpatient,,,3258.99,2118.34,,3258.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2476.83,76,,3168.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2346.47,72,,424.392,Percent of Total Billed Charges,72% of Total Billed Charges,2346.47,72,,424.392,Percent of Total Billed charges,72% of Total Billed Charges,3258.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2346.47,72,,424.392,Percent of Total Billed Charges,72% of Total Billed Charges,1955.39,60,,353.656,Percent of Total Billed Charges,60% of Total Billed Charges,2933.09,90,,330.376,Percent of Total Billed Charges,90% of Total Billed Charges,1466.55,45,,139.32,Percent of Total Billed Charges,45% of Total Billed Charges,2933.09,90,,3752.032,Percent of Total Billed Charges,90% of Total billed Charges,3258.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3258.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3258.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2118.34,65,,1205.36,Percent of total Billed Charges,65% of Total Billed Charges,1437.21,44.1,,136.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,3096.04,95,,3960.472,Percent of Total Billed Charges,95% of Total Billed Charges,3258.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2867.91,88,,448.696,Percent of Total Billed Charges,88% of Total Billed Charges,2933.09,90,,3752.032,Percent of Total Billed charges,90% of Total Billed Charges,1437.21,3258.99,
Z500148BIPOLAR SHE,2780000917,CDM,278,RC,C1713,HCPCS,Outpatient,,,2805.86,1823.81,,2805.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2132.45,76,,3086.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2020.22,72,,486.624,Percent of Total Billed Charges,72% of Total Billed Charges,2020.22,72,,486.624,Percent of Total Billed charges,72% of Total Billed Charges,2805.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2020.22,72,,486.624,Percent of Total Billed Charges,72% of Total Billed Charges,1683.52,60,,405.52,Percent of Total Billed Charges,60% of Total Billed Charges,2525.27,90,,426.384,Percent of Total Billed Charges,90% of Total Billed Charges,1262.64,45,,229.448,Percent of Total Billed Charges,45% of Total Billed Charges,2525.27,90,,3655.264,Percent of Total Billed Charges,90% of Total billed Charges,2805.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2805.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2805.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1823.81,65,,136.76,Percent of total Billed Charges,65% of Total Billed Charges,1237.38,44.1,,224.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,2665.57,95,,3858.328,Percent of Total Billed Charges,95% of Total Billed Charges,2805.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2469.16,88,,416.912,Percent of Total Billed Charges,88% of Total Billed Charges,2525.27,90,,3655.264,Percent of Total Billed charges,90% of Total Billed Charges,1237.38,2805.86,
Z249004630 THREADE,2780000918,CDM,278,RC,C1713,HCPCS,Outpatient,,,399.11,259.42,,399.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,303.32,76,,15.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,287.36,72,,222.264,Percent of Total Billed Charges,72% of Total Billed Charges,287.36,72,,222.264,Percent of Total Billed charges,72% of Total Billed Charges,399.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,287.36,72,,222.264,Percent of Total Billed Charges,72% of Total Billed Charges,239.47,60,,185.224,Percent of Total Billed Charges,60% of Total Billed Charges,359.2,90,,3296.92,Percent of Total Billed Charges,90% of Total Billed Charges,179.6,45,,229.448,Percent of Total Billed Charges,45% of Total Billed Charges,359.2,90,,18.144,Percent of Total Billed Charges,90% of Total billed Charges,399.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.42,65,,136.76,Percent of total Billed Charges,65% of Total Billed Charges,176.01,44.1,,224.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,379.15,95,,19.152,Percent of Total Billed Charges,95% of Total Billed Charges,399.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,351.22,88,,45.832,Percent of Total Billed Charges,88% of Total Billed Charges,359.2,90,,18.144,Percent of Total Billed charges,90% of Total Billed Charges,176.01,399.11,
Z0203152050 CANC S,2780000919,CDM,278,RC,C1713,HCPCS,Outpatient,,,503.84,327.50,,503.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,382.92,76,,235.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,362.76,72,,106.28,Percent of Total Billed Charges,72% of Total Billed Charges,362.76,72,,106.28,Percent of Total Billed charges,72% of Total Billed Charges,503.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,362.76,72,,106.28,Percent of Total Billed Charges,72% of Total Billed Charges,302.3,60,,88.568,Percent of Total Billed Charges,60% of Total Billed Charges,453.46,90,,328.864,Percent of Total Billed Charges,90% of Total Billed Charges,226.73,45,,213.192,Percent of Total Billed Charges,45% of Total Billed Charges,453.46,90,,278.64,Percent of Total Billed Charges,90% of Total billed Charges,503.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,503.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,503.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.5,65,,2261.48,Percent of total Billed Charges,65% of Total Billed Charges,222.19,44.1,,208.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,478.65,95,,294.12,Percent of Total Billed Charges,95% of Total Billed Charges,503.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,443.38,88,,323.032,Percent of Total Billed Charges,88% of Total Billed Charges,453.46,90,,278.64,Percent of Total Billed charges,90% of Total Billed Charges,222.19,503.84,
Z0202261307 TIBIA,2780000920,CDM,278,RC,C1713,HCPCS,Outpatient,,,4935.89,3208.33,,4935.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3751.28,76,,387.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3553.84,72,,163.84,Percent of Total Billed Charges,72% of Total Billed Charges,3553.84,72,,163.84,Percent of Total Billed charges,72% of Total Billed Charges,4935.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3553.84,72,,163.84,Percent of Total Billed Charges,72% of Total Billed Charges,2961.53,60,,136.536,Percent of Total Billed Charges,60% of Total Billed Charges,4442.3,90,,43.848,Percent of Total Billed Charges,90% of Total Billed Charges,2221.15,45,,23.44,Percent of Total Billed Charges,45% of Total Billed Charges,4442.3,90,,458.896,Percent of Total Billed Charges,90% of Total billed Charges,4935.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4935.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4935.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3208.33,65,,136.76,Percent of total Billed Charges,65% of Total Billed Charges,2176.73,44.1,,22.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,4689.1,95,,484.384,Percent of Total Billed Charges,95% of Total Billed Charges,4935.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4343.58,88,,323.032,Percent of Total Billed Charges,88% of Total Billed Charges,4442.3,90,,458.896,Percent of Total Billed charges,90% of Total Billed Charges,2176.73,4935.89,
Z0203155016 4.0 ST,2780000921,CDM,278,RC,C1713,HCPCS,Outpatient,,,316.42,205.67,,316.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,240.48,76,,387.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,227.82,72,,1276.432,Percent of Total Billed Charges,72% of Total Billed Charges,227.82,72,,1276.432,Percent of Total Billed charges,72% of Total Billed Charges,316.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.82,72,,1276.432,Percent of Total Billed Charges,72% of Total Billed Charges,189.85,60,,1063.696,Percent of Total Billed Charges,60% of Total Billed Charges,284.78,90,,426.384,Percent of Total Billed Charges,90% of Total Billed Charges,142.39,45,,165.184,Percent of Total Billed Charges,45% of Total Billed Charges,284.78,90,,458.896,Percent of Total Billed Charges,90% of Total billed Charges,316.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.67,65,,110.24,Percent of total Billed Charges,65% of Total Billed Charges,139.54,44.1,,161.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,300.6,95,,484.384,Percent of Total Billed Charges,95% of Total Billed Charges,316.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.45,88,,323.032,Percent of Total Billed Charges,88% of Total Billed Charges,284.78,90,,458.896,Percent of Total Billed charges,90% of Total Billed Charges,139.54,316.42,
Z0203155020 4.0 ST,2780000922,CDM,278,RC,C1713,HCPCS,Outpatient,,,44.10,28.67,,44.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33.52,76,,360.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,31.75,72,,266.72,Percent of Total Billed Charges,72% of Total Billed Charges,31.75,72,,266.72,Percent of Total Billed charges,72% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.75,72,,266.72,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,60,,222.264,Percent of Total Billed Charges,60% of Total Billed Charges,39.69,90,,1610.28,Percent of Total Billed Charges,90% of Total Billed Charges,19.85,45,,165.184,Percent of Total Billed Charges,45% of Total Billed Charges,39.69,90,,426.384,Percent of Total Billed Charges,90% of Total billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,65,,386.36,Percent of total Billed Charges,65% of Total Billed Charges,19.45,44.1,,161.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.9,95,,450.072,Percent of Total Billed Charges,95% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.81,88,,416.912,Percent of Total Billed Charges,88% of Total Billed Charges,39.69,90,,426.384,Percent of Total Billed charges,90% of Total Billed Charges,19.45,44.1,
Z02-03155-044 4.0 ST,2780000923,CDM,278,RC,,,Outpatient,,,368.24,239.36,,368.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,279.86,76,,39.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,265.13,72,,324,Percent of Total Billed Charges,72% of Total Billed Charges,265.13,72,,324,Percent of Total Billed charges,72% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.13,72,,324,Percent of Total Billed Charges,72% of Total Billed Charges,220.94,60,,270,Percent of Total Billed Charges,60% of Total Billed Charges,331.42,90,,97.528,Percent of Total Billed Charges,90% of Total Billed Charges,165.71,45,,165.184,Percent of Total Billed Charges,45% of Total Billed Charges,331.42,90,,46.872,Percent of Total Billed Charges,90% of Total billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.36,65,,110.76,Percent of total Billed Charges,65% of Total Billed Charges,162.39,44.1,,161.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,349.83,95,,49.48,Percent of Total Billed Charges,95% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.05,88,,3223.648,Percent of Total Billed Charges,88% of Total Billed Charges,331.42,90,,46.872,Percent of Total Billed charges,90% of Total Billed Charges,162.39,368.24,
Z0203155050 4.0 ST,2780000924,CDM,278,RC,C1713,HCPCS,Outpatient,,,368.24,239.36,,368.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,279.86,76,,278.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,265.13,72,,324,Percent of Total Billed Charges,72% of Total Billed Charges,265.13,72,,324,Percent of Total Billed charges,72% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.13,72,,324,Percent of Total Billed Charges,72% of Total Billed Charges,220.94,60,,270,Percent of Total Billed Charges,60% of Total Billed Charges,331.42,90,,60.48,Percent of Total Billed Charges,90% of Total Billed Charges,165.71,45,,213.192,Percent of Total Billed Charges,45% of Total Billed Charges,331.42,90,,330.376,Percent of Total Billed Charges,90% of Total billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.36,65,,279.24,Percent of total Billed Charges,65% of Total Billed Charges,162.39,44.1,,208.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,349.83,95,,348.728,Percent of Total Billed Charges,95% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.05,88,,321.552,Percent of Total Billed Charges,88% of Total Billed Charges,331.42,90,,330.376,Percent of Total Billed charges,90% of Total Billed Charges,162.39,368.24,
Z0203155060 4.0 OS,2780000925,CDM,278,RC,C1713,HCPCS,Outpatient,,,368.24,239.36,,368.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,279.86,76,,278.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,265.13,72,,272.16,Percent of Total Billed Charges,72% of Total Billed Charges,265.13,72,,272.16,Percent of Total Billed charges,72% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.13,72,,272.16,Percent of Total Billed Charges,72% of Total Billed Charges,220.94,60,,226.8,Percent of Total Billed Charges,60% of Total Billed Charges,331.42,90,,37.44,Percent of Total Billed Charges,90% of Total Billed Charges,165.71,45,,1648.456,Percent of Total Billed Charges,45% of Total Billed Charges,331.42,90,,330.376,Percent of Total Billed Charges,90% of Total billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.36,65,,3977.48,Percent of total Billed Charges,65% of Total Billed Charges,162.39,44.1,,1615.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,349.83,95,,348.728,Percent of Total Billed Charges,95% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.05,88,,42.872,Percent of Total Billed Charges,88% of Total Billed Charges,331.42,90,,330.376,Percent of Total Billed charges,90% of Total Billed Charges,162.39,368.24,
Z59881112 STEM EXT,2780000926,CDM,278,RC,C1713,HCPCS,Outpatient,,,4010.90,2607.09,,4010.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3048.28,76,,278.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2887.85,72,,272.16,Percent of Total Billed Charges,72% of Total Billed Charges,2887.85,72,,272.16,Percent of Total Billed charges,72% of Total Billed Charges,4010.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2887.85,72,,272.16,Percent of Total Billed Charges,72% of Total Billed Charges,2406.54,60,,226.8,Percent of Total Billed Charges,60% of Total Billed Charges,3609.81,90,,37.44,Percent of Total Billed Charges,90% of Total Billed Charges,1804.91,45,,164.432,Percent of Total Billed Charges,45% of Total Billed Charges,3609.81,90,,330.376,Percent of Total Billed Charges,90% of Total billed Charges,4010.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4010.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4010.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2607.09,65,,3943.16,Percent of total Billed Charges,65% of Total Billed Charges,1768.81,44.1,,161.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,3810.36,95,,348.728,Percent of Total Billed Charges,95% of Total Billed Charges,4010.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3529.59,88,,416.912,Percent of Total Billed Charges,88% of Total Billed Charges,3609.81,90,,330.376,Percent of Total Billed charges,90% of Total Billed Charges,1768.81,4010.9,
Z58800310 TIBIAL F,2780000927,CDM,278,RC,C1713,HCPCS,Outpatient,,,6097.93,3963.65,,6097.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4634.43,76,,360.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4390.51,72,,4057.912,Percent of Total Billed Charges,72% of Total Billed Charges,4390.51,72,,4057.912,Percent of Total Billed charges,72% of Total Billed Charges,6097.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4390.51,72,,4057.912,Percent of Total Billed Charges,72% of Total Billed Charges,3658.76,60,,3381.592,Percent of Total Billed Charges,60% of Total Billed Charges,5488.14,90,,152.64,Percent of Total Billed Charges,90% of Total Billed Charges,2744.07,45,,21.928,Percent of Total Billed Charges,45% of Total Billed Charges,5488.14,90,,426.384,Percent of Total Billed Charges,90% of Total billed Charges,6097.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6097.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6097.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3963.65,65,,212.68,Percent of total Billed Charges,65% of Total Billed Charges,2689.19,44.1,,21.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,5793.03,95,,450.072,Percent of Total Billed Charges,95% of Total Billed Charges,6097.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5366.18,88,,1574.496,Percent of Total Billed Charges,88% of Total Billed Charges,5488.14,90,,426.384,Percent of Total Billed charges,90% of Total Billed Charges,2689.19,6097.93,
Z58803017 RH ART S,2780000928,CDM,278,RC,C1713,HCPCS,Outpatient,,,7052.69,4584.25,,7052.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5360.04,76,,2784.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5077.94,72,,8361.576,Percent of Total Billed Charges,72% of Total Billed Charges,5077.94,72,,8361.576,Percent of Total Billed charges,72% of Total Billed Charges,7052.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5077.94,72,,8361.576,Percent of Total Billed Charges,72% of Total Billed Charges,4231.61,60,,6967.976,Percent of Total Billed Charges,60% of Total Billed Charges,6347.42,90,,105.84,Percent of Total Billed Charges,90% of Total Billed Charges,3173.71,45,,213.192,Percent of Total Billed Charges,45% of Total Billed Charges,6347.42,90,,3296.92,Percent of Total Billed Charges,90% of Total billed Charges,7052.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7052.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7052.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4584.25,65,,62.4,Percent of total Billed Charges,65% of Total Billed Charges,3110.24,44.1,,208.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,6700.06,95,,3480.08,Percent of Total Billed Charges,95% of Total Billed Charges,7052.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6206.37,88,,95.36,Percent of Total Billed Charges,88% of Total Billed Charges,6347.42,90,,3296.92,Percent of Total Billed charges,90% of Total Billed Charges,3110.24,7052.69,
Z48351001 3.5 CORT,2780000929,CDM,278,RC,C1713,HCPCS,Outpatient,,,83.79,54.46,,83.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,63.68,76,,277.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,60.33,72,,7246.44,Percent of Total Billed Charges,72% of Total Billed Charges,60.33,72,,7246.44,Percent of Total Billed charges,72% of Total Billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.33,72,,7246.44,Percent of Total Billed Charges,72% of Total Billed Charges,50.27,60,,6038.704,Percent of Total Billed Charges,60% of Total Billed Charges,75.41,90,,126.72,Percent of Total Billed Charges,90% of Total Billed Charges,37.71,45,,805.144,Percent of Total Billed Charges,45% of Total Billed Charges,75.41,90,,328.864,Percent of Total Billed Charges,90% of Total billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.46,65,,106.08,Percent of total Billed Charges,65% of Total Billed Charges,36.95,44.1,,789.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,79.6,95,,347.128,Percent of Total Billed Charges,95% of Total Billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.74,88,,59.136,Percent of Total Billed Charges,88% of Total Billed Charges,75.41,90,,328.864,Percent of Total Billed charges,90% of Total Billed Charges,36.95,83.79,
Z225427010 HUMERAL,2780000930,CDM,278,RC,C1713,HCPCS,Outpatient,,,4521.35,2938.88,,4521.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3436.23,76,,37.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3255.37,72,,354.352,Percent of Total Billed Charges,72% of Total Billed Charges,3255.37,72,,354.352,Percent of Total Billed charges,72% of Total Billed Charges,4521.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3255.37,72,,354.352,Percent of Total Billed Charges,72% of Total Billed Charges,2712.81,60,,295.296,Percent of Total Billed Charges,60% of Total Billed Charges,4069.22,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,2034.61,45,,48.76,Percent of Total Billed Charges,45% of Total Billed Charges,4069.22,90,,43.848,Percent of Total Billed Charges,90% of Total billed Charges,4521.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4521.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4521.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2938.88,65,,627.64,Percent of total Billed Charges,65% of Total Billed Charges,1993.92,44.1,,47.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,4295.28,95,,46.288,Percent of Total Billed Charges,95% of Total Billed Charges,4521.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3978.79,88,,36.608,Percent of Total Billed Charges,88% of Total Billed Charges,4069.22,90,,43.848,Percent of Total Billed charges,90% of Total Billed Charges,1993.92,4521.35,
Z11790511 RCON 3.5,2780000931,CDM,278,RC,C1713,HCPCS,Outpatient,,,1388.05,902.23,,1388.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1054.92,76,,360.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,999.4,72,,113.672,Percent of Total Billed Charges,72% of Total Billed Charges,999.4,72,,118.408,Percent of Total Billed charges,72% of Total Billed Charges,1388.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,999.4,72,,113.672,Percent of Total Billed Charges,72% of Total Billed Charges,832.83,60,,94.728,Percent of Total Billed Charges,60% of Total Billed Charges,1249.25,90,,851.76,Percent of Total Billed Charges,90% of Total Billed Charges,624.62,45,,30.24,Percent of Total Billed Charges,45% of Total Billed Charges,1249.25,90,,426.384,Percent of Total Billed Charges,90% of Total billed Charges,1388.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1388.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1388.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,902.23,65,,279.24,Percent of total Billed Charges,65% of Total Billed Charges,612.13,44.1,,29.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,1318.65,95,,450.072,Percent of Total Billed Charges,95% of Total Billed Charges,1388.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1221.48,88,,36.608,Percent of Total Billed Charges,88% of Total Billed Charges,1249.25,90,,426.384,Percent of Total Billed charges,90% of Total Billed Charges,612.13,1388.05,
Z500144BIPOLAR SHE,2780000932,CDM,278,RC,C1713,HCPCS,Outpatient,,,2805.86,1823.81,,2805.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2132.45,76,,1359.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2020.22,72,,107.96,Percent of Total Billed Charges,72% of Total Billed Charges,2020.22,72,,112.456,Percent of Total Billed charges,72% of Total Billed Charges,2805.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2020.22,72,,107.96,Percent of Total Billed Charges,72% of Total Billed Charges,1683.52,60,,89.968,Percent of Total Billed Charges,60% of Total Billed Charges,2525.27,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,1262.64,45,,18.72,Percent of Total Billed Charges,45% of Total Billed Charges,2525.27,90,,1610.28,Percent of Total Billed Charges,90% of Total billed Charges,2805.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2805.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2805.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1823.81,65,,153.92,Percent of total Billed Charges,65% of Total Billed Charges,1237.38,44.1,,18.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,2665.57,95,,1699.744,Percent of Total Billed Charges,95% of Total Billed Charges,2805.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2469.16,88,,149.248,Percent of Total Billed Charges,88% of Total Billed Charges,2525.27,90,,1610.28,Percent of Total Billed charges,90% of Total Billed Charges,1237.38,2805.86,
Z80182814 FEMORAL,2780000933,CDM,278,RC,C1713,HCPCS,Outpatient,,,3224.81,2096.13,,3224.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2450.86,76,,82.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2321.86,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,2321.86,72,,103.192,Percent of Total Billed charges,72% of Total Billed Charges,3224.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2321.86,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,1934.89,60,,82.552,Percent of Total Billed Charges,60% of Total Billed Charges,2902.33,90,,1668.96,Percent of Total Billed Charges,90% of Total Billed Charges,1451.16,45,,18.72,Percent of Total Billed Charges,45% of Total Billed Charges,2902.33,90,,97.528,Percent of Total Billed Charges,90% of Total billed Charges,3224.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3224.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3224.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.13,65,,1593.28,Percent of total Billed Charges,65% of Total Billed Charges,1422.14,44.1,,18.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.57,95,,102.944,Percent of Total Billed Charges,95% of Total Billed Charges,3224.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2837.83,88,,103.488,Percent of Total Billed Charges,88% of Total Billed Charges,2902.33,90,,97.528,Percent of Total Billed charges,90% of Total Billed Charges,1422.14,3224.81,
Z480610020 DRILL B,2780000934,CDM,278,RC,C1713,HCPCS,Outpatient,,,82.69,53.75,,82.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.84,76,,51.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.54,72,,65.72,Percent of Total Billed Charges,72% of Total Billed Charges,59.54,72,,68.464,Percent of Total Billed charges,72% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,72,,65.72,Percent of Total Billed Charges,72% of Total Billed Charges,49.61,60,,54.768,Percent of Total Billed Charges,60% of Total Billed Charges,74.42,90,,189.36,Percent of Total Billed Charges,90% of Total Billed Charges,37.21,45,,76.32,Percent of Total Billed Charges,45% of Total Billed Charges,74.42,90,,60.48,Percent of Total Billed Charges,90% of Total billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.75,65,,1593.28,Percent of total Billed Charges,65% of Total Billed Charges,36.47,44.1,,74.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,78.56,95,,63.84,Percent of Total Billed Charges,95% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,88,,123.904,Percent of Total Billed Charges,88% of Total Billed Charges,74.42,90,,60.48,Percent of Total Billed charges,90% of Total Billed Charges,36.47,82.69,
Z59880327 TIBIAL B,2780000935,CDM,278,RC,C1713,HCPCS,Outpatient,,,3730.86,2425.06,,3730.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2835.45,76,,31.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2686.22,72,,65.72,Percent of Total Billed Charges,72% of Total Billed Charges,2686.22,72,,68.464,Percent of Total Billed charges,72% of Total Billed Charges,3730.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2686.22,72,,65.72,Percent of Total Billed Charges,72% of Total Billed Charges,2238.52,60,,54.768,Percent of Total Billed Charges,60% of Total Billed Charges,3357.77,90,,189.36,Percent of Total Billed Charges,90% of Total Billed Charges,1678.89,45,,52.92,Percent of Total Billed Charges,45% of Total Billed Charges,3357.77,90,,37.44,Percent of Total Billed Charges,90% of Total billed Charges,3730.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3730.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3730.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2425.06,65,,1413.88,Percent of total Billed Charges,65% of Total Billed Charges,1645.31,44.1,,51.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,3544.32,95,,39.52,Percent of Total Billed Charges,95% of Total Billed Charges,3730.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3283.16,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,3357.77,90,,37.44,Percent of Total Billed charges,90% of Total Billed Charges,1645.31,3730.86,
Z59882016 STEM EXT,2780000936,CDM,278,RC,C1713,HCPCS,Outpatient,,,5239.08,3405.40,,5239.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3981.7,76,,31.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3772.14,72,,65.72,Percent of Total Billed Charges,72% of Total Billed Charges,3772.14,72,,68.464,Percent of Total Billed charges,72% of Total Billed Charges,5239.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3772.14,72,,65.72,Percent of Total Billed Charges,72% of Total Billed Charges,3143.45,60,,54.768,Percent of Total Billed Charges,60% of Total Billed Charges,4715.17,90,,3131.28,Percent of Total Billed Charges,90% of Total Billed Charges,2357.59,45,,63.36,Percent of Total Billed Charges,45% of Total Billed Charges,4715.17,90,,37.44,Percent of Total Billed Charges,90% of Total billed Charges,5239.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5239.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5239.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3405.4,65,,159.12,Percent of total Billed Charges,65% of Total Billed Charges,2310.43,44.1,,62.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,4977.13,95,,39.52,Percent of Total Billed Charges,95% of Total Billed Charges,5239.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4610.39,88,,832.832,Percent of Total Billed Charges,88% of Total Billed Charges,4715.17,90,,37.44,Percent of Total Billed charges,90% of Total Billed Charges,2310.43,5239.08,
Z59943012 ART SURF,2780000937,CDM,278,RC,C1713,HCPCS,Outpatient,,,6551.06,4258.19,,6551.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4978.81,76,,128.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4716.76,72,,65.72,Percent of Total Billed Charges,72% of Total Billed Charges,4716.76,72,,68.464,Percent of Total Billed charges,72% of Total Billed Charges,6551.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4716.76,72,,65.72,Percent of Total Billed Charges,72% of Total Billed Charges,3930.64,60,,54.768,Percent of Total Billed Charges,60% of Total Billed Charges,5895.95,90,,189.36,Percent of Total Billed Charges,90% of Total Billed Charges,2947.98,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,5895.95,90,,152.64,Percent of Total Billed Charges,90% of Total billed Charges,6551.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6551.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6551.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4258.19,65,,1218.36,Percent of total Billed Charges,65% of Total Billed Charges,2889.02,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,6223.51,95,,161.12,Percent of Total Billed Charges,95% of Total Billed Charges,6551.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5764.93,88,,40.128,Percent of Total Billed Charges,88% of Total Billed Charges,5895.95,90,,152.64,Percent of Total Billed charges,90% of Total Billed Charges,2889.02,6551.06,
Z59941492 FEM COMP,2780000938,CDM,278,RC,C1713,HCPCS,Outpatient,,,20251.82,13163.68,,20251.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15391.38,76,,89.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14581.31,72,,37.848,Percent of Total Billed Charges,72% of Total Billed Charges,14581.31,72,,39.424,Percent of Total Billed charges,72% of Total Billed Charges,20251.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14581.31,72,,37.848,Percent of Total Billed Charges,72% of Total Billed Charges,12151.09,60,,31.544,Percent of Total Billed Charges,60% of Total Billed Charges,18226.64,90,,152.64,Percent of Total Billed Charges,90% of Total Billed Charges,9113.32,45,,425.88,Percent of Total Billed Charges,45% of Total Billed Charges,18226.64,90,,105.84,Percent of Total Billed Charges,90% of Total billed Charges,20251.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20251.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20251.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13163.68,65,,279.24,Percent of total Billed Charges,65% of Total Billed Charges,8931.05,44.1,,417.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,19239.23,95,,111.72,Percent of Total Billed Charges,95% of Total Billed Charges,20251.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17821.6,88,,1631.872,Percent of Total Billed Charges,88% of Total Billed Charges,18226.64,90,,105.84,Percent of Total Billed charges,90% of Total Billed Charges,8931.05,20251.82,
ACUMED OLECRANON PLA,2780000939,CDM,278,RC,C1713,HCPCS,Outpatient,,,4746.26,3085.07,,4746.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3607.16,76,,107.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3417.31,72,,22.256,Percent of Total Billed Charges,72% of Total Billed Charges,3417.31,72,,23.184,Percent of Total Billed charges,72% of Total Billed Charges,4746.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3417.31,72,,22.256,Percent of Total Billed Charges,72% of Total Billed Charges,2847.76,60,,18.544,Percent of Total Billed Charges,60% of Total Billed Charges,4271.63,90,,534.96,Percent of Total Billed Charges,90% of Total Billed Charges,2135.82,45,,20.52,Percent of Total Billed Charges,45% of Total Billed Charges,4271.63,90,,126.72,Percent of Total Billed Charges,90% of Total billed Charges,4746.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4746.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4746.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3085.07,65,,580.32,Percent of total Billed Charges,65% of Total Billed Charges,2093.1,44.1,,20.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,4508.95,95,,133.76,Percent of Total Billed Charges,95% of Total Billed Charges,4746.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4176.71,88,,185.152,Percent of Total Billed Charges,88% of Total Billed Charges,4271.63,90,,126.72,Percent of Total Billed charges,90% of Total Billed Charges,2093.1,4746.26,
ACUMED 2.7X20 CORT S,2780000940,CDM,278,RC,C1713,HCPCS,Outpatient,,,394.70,256.56,,394.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.97,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.18,72,,22.256,Percent of Total Billed Charges,72% of Total Billed Charges,284.18,72,,23.184,Percent of Total Billed charges,72% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.18,72,,22.256,Percent of Total Billed Charges,72% of Total Billed Charges,236.82,60,,18.544,Percent of Total Billed Charges,60% of Total Billed Charges,355.23,90,,153.36,Percent of Total Billed Charges,90% of Total Billed Charges,177.62,45,,834.48,Percent of Total Billed Charges,45% of Total Billed Charges,355.23,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.56,65,,279.24,Percent of total Billed Charges,65% of Total Billed Charges,174.06,44.1,,817.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.97,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.34,88,,185.152,Percent of Total Billed Charges,88% of Total Billed Charges,355.23,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,174.06,394.7,
ACUMED 2.7X22 CORT S,2780000941,CDM,278,RC,C1713,HCPCS,Outpatient,,,394.70,256.56,,394.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.97,76,,719.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.18,72,,22.256,Percent of Total Billed Charges,72% of Total Billed Charges,284.18,72,,23.184,Percent of Total Billed charges,72% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.18,72,,22.256,Percent of Total Billed Charges,72% of Total Billed Charges,236.82,60,,18.544,Percent of Total Billed Charges,60% of Total Billed Charges,355.23,90,,386.64,Percent of Total Billed Charges,90% of Total Billed Charges,177.62,45,,94.68,Percent of Total Billed Charges,45% of Total Billed Charges,355.23,90,,851.76,Percent of Total Billed Charges,90% of Total billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.56,65,,159.12,Percent of total Billed Charges,65% of Total Billed Charges,174.06,44.1,,92.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.97,95,,899.08,Percent of Total Billed Charges,95% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.34,88,,3061.696,Percent of Total Billed Charges,88% of Total Billed Charges,355.23,90,,851.76,Percent of Total Billed charges,90% of Total Billed Charges,174.06,394.7,
ACUMED 3.5X40 CORT S,2780000942,CDM,278,RC,C1713,HCPCS,Outpatient,,,394.70,256.56,,394.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.97,76,,34.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.18,72,,34.112,Percent of Total Billed Charges,72% of Total Billed Charges,284.18,72,,35.536,Percent of Total Billed charges,72% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.18,72,,34.112,Percent of Total Billed Charges,72% of Total Billed Charges,236.82,60,,28.424,Percent of Total Billed Charges,60% of Total Billed Charges,355.23,90,,5507.28,Percent of Total Billed Charges,90% of Total Billed Charges,177.62,45,,94.68,Percent of Total Billed Charges,45% of Total Billed Charges,355.23,90,,41.04,Percent of Total Billed Charges,90% of Total billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.56,65,,241.8,Percent of total Billed Charges,65% of Total Billed Charges,174.06,44.1,,92.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.97,95,,43.32,Percent of Total Billed Charges,95% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.34,88,,185.152,Percent of Total Billed Charges,88% of Total Billed Charges,355.23,90,,41.04,Percent of Total Billed charges,90% of Total Billed Charges,174.06,394.7,
ACUMED 3.5X32 CORT S,2780000943,CDM,278,RC,C1713,HCPCS,Outpatient,,,394.70,256.56,,394.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.97,76,,1409.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.18,72,,34.112,Percent of Total Billed Charges,72% of Total Billed Charges,284.18,72,,35.536,Percent of Total Billed charges,72% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.18,72,,34.112,Percent of Total Billed Charges,72% of Total Billed Charges,236.82,60,,28.424,Percent of Total Billed Charges,60% of Total Billed Charges,355.23,90,,5459.76,Percent of Total Billed Charges,90% of Total Billed Charges,177.62,45,,1565.64,Percent of Total Billed Charges,45% of Total Billed Charges,355.23,90,,1668.96,Percent of Total Billed Charges,90% of Total billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.56,65,,241.8,Percent of total Billed Charges,65% of Total Billed Charges,174.06,44.1,,1534.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.97,95,,1761.68,Percent of Total Billed Charges,95% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.34,88,,149.248,Percent of Total Billed Charges,88% of Total Billed Charges,355.23,90,,1668.96,Percent of Total Billed charges,90% of Total Billed Charges,174.06,394.7,
ACUMED 3.5X22 CORT S,2780000944,CDM,278,RC,C1713,HCPCS,Outpatient,,,394.70,256.56,,394.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.97,76,,159.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.18,72,,12182.608,Percent of Total Billed Charges,72% of Total Billed Charges,284.18,72,,12182.608,Percent of Total Billed charges,72% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.18,72,,12182.608,Percent of Total Billed Charges,72% of Total Billed Charges,236.82,60,,10152.176,Percent of Total Billed Charges,60% of Total Billed Charges,355.23,90,,294.48,Percent of Total Billed Charges,90% of Total Billed Charges,177.62,45,,94.68,Percent of Total Billed Charges,45% of Total Billed Charges,355.23,90,,189.36,Percent of Total Billed Charges,90% of Total billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.56,65,,241.8,Percent of total Billed Charges,65% of Total Billed Charges,174.06,44.1,,92.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.97,95,,199.88,Percent of Total Billed Charges,95% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.34,88,,523.072,Percent of Total Billed Charges,88% of Total Billed Charges,355.23,90,,189.36,Percent of Total Billed charges,90% of Total Billed Charges,174.06,394.7,
ACUMED 3.5X18 CORT S,2780000945,CDM,278,RC,C1713,HCPCS,Outpatient,,,394.70,256.56,,394.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.97,76,,159.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.18,72,,1205.944,Percent of Total Billed Charges,72% of Total Billed Charges,284.18,72,,1205.944,Percent of Total Billed charges,72% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.18,72,,1205.944,Percent of Total Billed Charges,72% of Total Billed Charges,236.82,60,,1004.952,Percent of Total Billed Charges,60% of Total Billed Charges,355.23,90,,86.4,Percent of Total Billed Charges,90% of Total Billed Charges,177.62,45,,76.32,Percent of Total Billed Charges,45% of Total Billed Charges,355.23,90,,189.36,Percent of Total Billed Charges,90% of Total billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.56,65,,54.08,Percent of total Billed Charges,65% of Total Billed Charges,174.06,44.1,,74.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.97,95,,199.88,Percent of Total Billed Charges,95% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.34,88,,149.952,Percent of Total Billed Charges,88% of Total Billed Charges,355.23,90,,189.36,Percent of Total Billed charges,90% of Total Billed Charges,174.06,394.7,
ACUMED 800386 DRILL,2780000946,CDM,278,RC,C1713,HCPCS,Outpatient,,,176.40,114.66,,176.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,134.06,76,,2644.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,127.01,72,,3586.704,Percent of Total Billed Charges,72% of Total Billed Charges,127.01,72,,3586.704,Percent of Total Billed charges,72% of Total Billed Charges,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.01,72,,3586.704,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,60,,2988.92,Percent of Total Billed Charges,60% of Total Billed Charges,158.76,90,,146.88,Percent of Total Billed Charges,90% of Total Billed Charges,79.38,45,,267.48,Percent of Total Billed Charges,45% of Total Billed Charges,158.76,90,,3131.28,Percent of Total Billed Charges,90% of Total billed Charges,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.66,65,,1569.36,Percent of total Billed Charges,65% of Total Billed Charges,77.79,44.1,,262.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,167.58,95,,3305.24,Percent of Total Billed Charges,95% of Total Billed Charges,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.23,88,,378.048,Percent of Total Billed Charges,88% of Total Billed Charges,158.76,90,,3131.28,Percent of Total Billed charges,90% of Total Billed Charges,77.79,176.4,
ACUMED 700717 LCK L,2780000947,CDM,278,RC,C1713,HCPCS,Outpatient,,,4306.37,2799.14,,4306.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3272.84,76,,159.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3100.59,72,,1372.32,Percent of Total Billed Charges,72% of Total Billed Charges,3100.59,72,,1372.32,Percent of Total Billed charges,72% of Total Billed Charges,4306.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3100.59,72,,1372.32,Percent of Total Billed Charges,72% of Total Billed Charges,2583.82,60,,1143.6,Percent of Total Billed Charges,60% of Total Billed Charges,3875.73,90,,869.04,Percent of Total Billed Charges,90% of Total Billed Charges,1937.87,45,,76.68,Percent of Total Billed Charges,45% of Total Billed Charges,3875.73,90,,189.36,Percent of Total Billed Charges,90% of Total billed Charges,4306.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4306.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4306.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2799.14,65,,400.92,Percent of total Billed Charges,65% of Total Billed Charges,1899.11,44.1,,75.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,4091.05,95,,199.88,Percent of Total Billed Charges,95% of Total Billed Charges,4306.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3789.61,88,,5384.896,Percent of Total Billed Charges,88% of Total Billed Charges,3875.73,90,,189.36,Percent of Total Billed charges,90% of Total Billed Charges,1899.11,4306.37,
ACUMED CO3160 3.5X1,2780000948,CDM,278,RC,C1713,HCPCS,Outpatient,,,332.96,216.42,,332.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,253.05,76,,128.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,239.73,72,,2091.824,Percent of Total Billed Charges,72% of Total Billed Charges,239.73,72,,2091.824,Percent of Total Billed charges,72% of Total Billed Charges,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.73,72,,2091.824,Percent of Total Billed Charges,72% of Total Billed Charges,199.78,60,,1743.184,Percent of Total Billed Charges,60% of Total Billed Charges,299.66,90,,386.64,Percent of Total Billed Charges,90% of Total Billed Charges,149.83,45,,193.32,Percent of Total Billed Charges,45% of Total Billed Charges,299.66,90,,152.64,Percent of Total Billed Charges,90% of Total billed Charges,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.42,65,,217.88,Percent of total Billed Charges,65% of Total Billed Charges,146.84,44.1,,189.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,316.31,95,,161.12,Percent of Total Billed Charges,95% of Total Billed Charges,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293,88,,5338.432,Percent of Total Billed Charges,88% of Total Billed Charges,299.66,90,,152.64,Percent of Total Billed charges,90% of Total Billed Charges,146.84,332.96,
ACUMED C02722 2.7X2,2780000949,CDM,278,RC,C1713,HCPCS,Outpatient,,,332.96,216.42,,332.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,253.05,76,,451.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,239.73,72,,3047.56,Percent of Total Billed Charges,72% of Total Billed Charges,239.73,72,,3047.56,Percent of Total Billed charges,72% of Total Billed Charges,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.73,72,,3047.56,Percent of Total Billed Charges,72% of Total Billed Charges,199.78,60,,2539.632,Percent of Total Billed Charges,60% of Total Billed Charges,299.66,90,,213.12,Percent of Total Billed Charges,90% of Total Billed Charges,149.83,45,,2753.64,Percent of Total Billed Charges,45% of Total Billed Charges,299.66,90,,534.96,Percent of Total Billed Charges,90% of Total billed Charges,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.42,65,,400.92,Percent of total Billed Charges,65% of Total Billed Charges,146.84,44.1,,2698.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,316.31,95,,564.68,Percent of Total Billed Charges,95% of Total Billed Charges,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293,88,,287.936,Percent of Total Billed Charges,88% of Total Billed Charges,299.66,90,,534.96,Percent of Total Billed charges,90% of Total Billed Charges,146.84,332.96,
ACUMED CO 2720 2.7X,2780000950,CDM,278,RC,C1713,HCPCS,Outpatient,,,332.96,216.42,,332.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,253.05,76,,129.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,239.73,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,239.73,72,,11.432,Percent of Total Billed charges,72% of Total Billed Charges,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.73,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,199.78,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,299.66,90,,2206.08,Percent of Total Billed Charges,90% of Total Billed Charges,149.83,45,,2729.88,Percent of Total Billed Charges,45% of Total Billed Charges,299.66,90,,153.36,Percent of Total Billed Charges,90% of Total billed Charges,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.42,65,,217.88,Percent of total Billed Charges,65% of Total Billed Charges,146.84,44.1,,2675.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,316.31,95,,161.88,Percent of Total Billed Charges,95% of Total Billed Charges,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293,88,,84.48,Percent of Total Billed Charges,88% of Total Billed Charges,299.66,90,,153.36,Percent of Total Billed charges,90% of Total Billed Charges,146.84,332.96,
ACUMED 700116 CLAVI,2780000951,CDM,278,RC,C1713,HCPCS,Outpatient,,,4841.08,3146.70,,4841.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3679.22,76,,326.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3485.58,72,,179.72,Percent of Total Billed Charges,72% of Total Billed Charges,3485.58,72,,179.72,Percent of Total Billed charges,72% of Total Billed Charges,4841.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3485.58,72,,179.72,Percent of Total Billed Charges,72% of Total Billed Charges,2904.65,60,,149.768,Percent of Total Billed Charges,60% of Total Billed Charges,4356.97,90,,2206.08,Percent of Total Billed Charges,90% of Total Billed Charges,2178.49,45,,147.24,Percent of Total Billed Charges,45% of Total Billed Charges,4356.97,90,,386.64,Percent of Total Billed Charges,90% of Total billed Charges,4841.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4841.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4841.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3146.7,65,,400.92,Percent of total Billed Charges,65% of Total Billed Charges,2134.92,44.1,,144.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,4599.03,95,,408.12,Percent of Total Billed Charges,95% of Total Billed Charges,4841.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4260.15,88,,143.616,Percent of Total Billed Charges,88% of Total Billed Charges,4356.97,90,,386.64,Percent of Total Billed charges,90% of Total Billed Charges,2134.92,4841.08,
ACUMED CO3100 3.5X1,2780000952,CDM,278,RC,C1713,HCPCS,Outpatient,,,332.96,216.42,,332.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,253.05,76,,4650.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,239.73,72,,215.28,Percent of Total Billed Charges,72% of Total Billed Charges,239.73,72,,215.28,Percent of Total Billed charges,72% of Total Billed Charges,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.73,72,,215.28,Percent of Total Billed Charges,72% of Total Billed Charges,199.78,60,,179.4,Percent of Total Billed Charges,60% of Total Billed Charges,299.66,90,,1957.68,Percent of Total Billed Charges,90% of Total Billed Charges,149.83,45,,43.2,Percent of Total Billed Charges,45% of Total Billed Charges,299.66,90,,5507.28,Percent of Total Billed Charges,90% of Total billed Charges,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.42,65,,1282.84,Percent of total Billed Charges,65% of Total Billed Charges,146.84,44.1,,42.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,316.31,95,,5813.24,Percent of Total Billed Charges,95% of Total Billed Charges,332.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293,88,,849.728,Percent of Total Billed Charges,88% of Total Billed Charges,299.66,90,,5507.28,Percent of Total Billed charges,90% of Total Billed Charges,146.84,332.96,
ACUMED COL3160 3.5X,2780000953,CDM,278,RC,C1713,HCPCS,Outpatient,,,509.36,331.08,,509.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,387.11,76,,4610.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,366.74,72,,795.92,Percent of Total Billed Charges,72% of Total Billed Charges,366.74,72,,795.92,Percent of Total Billed charges,72% of Total Billed Charges,509.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.74,72,,795.92,Percent of Total Billed Charges,72% of Total Billed Charges,305.62,60,,663.264,Percent of Total Billed Charges,60% of Total Billed Charges,458.42,90,,220.32,Percent of Total Billed Charges,90% of Total Billed Charges,229.21,45,,73.44,Percent of Total Billed Charges,45% of Total Billed Charges,458.42,90,,5459.76,Percent of Total Billed Charges,90% of Total billed Charges,509.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,509.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,509.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,331.08,65,,1116.96,Percent of total Billed Charges,65% of Total Billed Charges,224.63,44.1,,71.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,483.89,95,,5763.08,Percent of Total Billed Charges,95% of Total Billed Charges,509.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,448.24,88,,378.048,Percent of Total Billed Charges,88% of Total Billed Charges,458.42,90,,5459.76,Percent of Total Billed charges,90% of Total Billed Charges,224.63,509.36,
ACUMED COL3140 3.5X,2780000954,CDM,278,RC,C1713,HCPCS,Outpatient,,,509.36,331.08,,509.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,387.11,76,,248.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,366.74,72,,2901.312,Percent of Total Billed Charges,72% of Total Billed Charges,366.74,72,,2901.312,Percent of Total Billed charges,72% of Total Billed Charges,509.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.74,72,,2901.312,Percent of Total Billed Charges,72% of Total Billed Charges,305.62,60,,2417.76,Percent of Total Billed Charges,60% of Total Billed Charges,458.42,90,,1686.96,Percent of Total Billed Charges,90% of Total Billed Charges,229.21,45,,434.52,Percent of Total Billed Charges,45% of Total Billed Charges,458.42,90,,294.48,Percent of Total Billed Charges,90% of Total billed Charges,509.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,509.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,509.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,331.08,65,,400.92,Percent of total Billed Charges,65% of Total Billed Charges,224.63,44.1,,425.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,483.89,95,,310.84,Percent of Total Billed Charges,95% of Total Billed Charges,509.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,448.24,88,,208.384,Percent of Total Billed Charges,88% of Total Billed Charges,458.42,90,,294.48,Percent of Total Billed charges,90% of Total Billed Charges,224.63,509.36,
ACUMED WS-11065T K-WIRE.045,2780000955,CDM,278,RC,C1713,HCPCS,Outpatient,,,27.56,17.91,,27.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.95,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.84,72,,431.192,Percent of Total Billed Charges,72% of Total Billed Charges,19.84,72,,431.192,Percent of Total Billed charges,72% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.84,72,,431.192,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,60,,359.328,Percent of Total Billed Charges,60% of Total Billed Charges,24.8,90,,386.64,Percent of Total Billed Charges,90% of Total Billed Charges,12.4,45,,193.32,Percent of Total Billed Charges,45% of Total Billed Charges,24.8,90,,86.4,Percent of Total Billed Charges,90% of Total billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.91,65,,1281.28,Percent of total Billed Charges,65% of Total Billed Charges,12.15,44.1,,189.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.18,95,,91.2,Percent of Total Billed Charges,95% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,88,,2157.056,Percent of Total Billed Charges,88% of Total Billed Charges,24.8,90,,86.4,Percent of Total Billed charges,90% of Total Billed Charges,12.15,27.56,
ACUMED AT2ML 1813 MM,2780000956,CDM,278,RC,C1713,HCPCS,Outpatient,,,409.03,265.87,,409.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,310.86,76,,124.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,294.5,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,294.5,72,,40.64,Percent of Total Billed charges,72% of Total Billed Charges,409.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.5,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,245.42,60,,33.872,Percent of Total Billed Charges,60% of Total Billed Charges,368.13,90,,803.52,Percent of Total Billed Charges,90% of Total Billed Charges,184.06,45,,106.56,Percent of Total Billed Charges,45% of Total Billed Charges,368.13,90,,146.88,Percent of Total Billed Charges,90% of Total billed Charges,409.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.87,65,,214.24,Percent of total Billed Charges,65% of Total Billed Charges,180.38,44.1,,104.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,388.58,95,,155.04,Percent of Total Billed Charges,95% of Total Billed Charges,409.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.95,88,,2157.056,Percent of Total Billed Charges,88% of Total Billed Charges,368.13,90,,146.88,Percent of Total Billed charges,90% of Total Billed Charges,180.38,409.03,
ACUMED AT2M22S MINI,2780000957,CDM,278,RC,C1713,HCPCS,Outpatient,,,2255.72,1466.22,,2255.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1714.35,76,,733.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1624.12,72,,40.008,Percent of Total Billed Charges,72% of Total Billed Charges,1624.12,72,,40.008,Percent of Total Billed charges,72% of Total Billed Charges,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1624.12,72,,40.008,Percent of Total Billed Charges,72% of Total Billed Charges,1353.43,60,,33.344,Percent of Total Billed Charges,60% of Total Billed Charges,2030.15,90,,386.64,Percent of Total Billed Charges,90% of Total Billed Charges,1015.07,45,,1103.04,Percent of Total Billed Charges,45% of Total Billed Charges,2030.15,90,,869.04,Percent of Total Billed Charges,90% of Total billed Charges,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1466.22,65,,352.56,Percent of total Billed Charges,65% of Total Billed Charges,994.77,44.1,,1080.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,2142.93,95,,917.32,Percent of Total Billed Charges,95% of Total Billed Charges,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1985.03,88,,1914.176,Percent of Total Billed Charges,88% of Total Billed Charges,2030.15,90,,869.04,Percent of Total Billed charges,90% of Total Billed Charges,994.77,2255.72,
Z225425508 HUMERAL,2780000958,CDM,278,RC,C1713,HCPCS,Outpatient,,,4520.25,2938.16,,4520.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3435.39,76,,326.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3254.58,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,3254.58,72,,12.064,Percent of Total Billed charges,72% of Total Billed Charges,4520.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3254.58,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,2712.15,60,,10.056,Percent of Total Billed Charges,60% of Total Billed Charges,4068.23,90,,220.32,Percent of Total Billed Charges,90% of Total Billed Charges,2034.11,45,,1103.04,Percent of Total Billed Charges,45% of Total Billed Charges,4068.23,90,,386.64,Percent of Total Billed Charges,90% of Total billed Charges,4520.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4520.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4520.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2938.16,65,,3943.16,Percent of total Billed Charges,65% of Total Billed Charges,1993.43,44.1,,1080.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,4294.24,95,,408.12,Percent of Total Billed Charges,95% of Total Billed Charges,4520.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3977.82,88,,215.424,Percent of Total Billed Charges,88% of Total Billed Charges,4068.23,90,,386.64,Percent of Total Billed charges,90% of Total Billed Charges,1993.43,4520.25,
Z22532037 3.7 COR,2780000959,CDM,278,RC,C1713,HCPCS,Outpatient,,,552.35,359.03,,552.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,419.79,76,,179.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,397.69,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,397.69,72,,44.456,Percent of Total Billed charges,72% of Total Billed Charges,552.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.69,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,331.41,60,,37.048,Percent of Total Billed Charges,60% of Total Billed Charges,497.12,90,,334.8,Percent of Total Billed Charges,90% of Total Billed Charges,248.56,45,,978.84,Percent of Total Billed Charges,45% of Total Billed Charges,497.12,90,,213.12,Percent of Total Billed Charges,90% of Total billed Charges,552.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.03,65,,2100.28,Percent of total Billed Charges,65% of Total Billed Charges,243.59,44.1,,959.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,524.73,95,,224.96,Percent of Total Billed Charges,95% of Total Billed Charges,552.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,486.07,88,,1649.472,Percent of Total Billed Charges,88% of Total Billed Charges,497.12,90,,213.12,Percent of Total Billed charges,90% of Total Billed Charges,243.59,552.35,
STRYKER 5.5 BIOSTEON,2780000960,CDM,278,RC,C1713,HCPCS,Outpatient,,,1541.30,1001.85,,1541.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1171.39,76,,1862.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1109.74,72,,55.88,Percent of Total Billed Charges,72% of Total Billed Charges,1109.74,72,,55.88,Percent of Total Billed charges,72% of Total Billed Charges,1541.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1109.74,72,,55.88,Percent of Total Billed Charges,72% of Total Billed Charges,924.78,60,,46.568,Percent of Total Billed Charges,60% of Total Billed Charges,1387.17,90,,334.8,Percent of Total Billed Charges,90% of Total Billed Charges,693.59,45,,110.16,Percent of Total Billed Charges,45% of Total Billed Charges,1387.17,90,,2206.08,Percent of Total Billed Charges,90% of Total billed Charges,1541.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1541.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1541.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1001.85,65,,2889.12,Percent of total Billed Charges,65% of Total Billed Charges,679.71,44.1,,107.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,1464.24,95,,2328.64,Percent of Total Billed Charges,95% of Total Billed Charges,1541.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1356.34,88,,378.048,Percent of Total Billed Charges,88% of Total Billed Charges,1387.17,90,,2206.08,Percent of Total Billed charges,90% of Total Billed Charges,679.71,1541.3,
Z00877503201 CERA,2780000961,CDM,278,RC,C1713,HCPCS,Outpatient,,,7562.05,4915.33,,7562.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5747.16,76,,1862.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5444.68,72,,280.048,Percent of Total Billed Charges,72% of Total Billed Charges,5444.68,72,,291.72,Percent of Total Billed charges,72% of Total Billed Charges,7562.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5444.68,72,,280.048,Percent of Total Billed Charges,72% of Total Billed Charges,4537.23,60,,233.376,Percent of Total Billed Charges,60% of Total Billed Charges,6805.85,90,,334.8,Percent of Total Billed Charges,90% of Total Billed Charges,3402.92,45,,843.48,Percent of Total Billed Charges,45% of Total Billed Charges,6805.85,90,,2206.08,Percent of Total Billed Charges,90% of Total billed Charges,7562.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7562.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7562.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4915.33,65,,633.36,Percent of total Billed Charges,65% of Total Billed Charges,3334.86,44.1,,826.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,7183.95,95,,2328.64,Percent of Total Billed Charges,95% of Total Billed Charges,7562.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6654.6,88,,785.664,Percent of Total Billed Charges,88% of Total Billed Charges,6805.85,90,,2206.08,Percent of Total Billed charges,90% of Total Billed Charges,3334.86,7562.05,
Z01.00102.614 WAGNER,2780000962,CDM,278,RC,C1713,HCPCS,Outpatient,,,24497.55,15923.41,,24497.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18618.14,76,,1653.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17638.24,72,,33.872,Percent of Total Billed Charges,72% of Total Billed Charges,17638.24,72,,35.28,Percent of Total Billed charges,72% of Total Billed Charges,24497.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17638.24,72,,33.872,Percent of Total Billed Charges,72% of Total Billed Charges,14698.53,60,,28.224,Percent of Total Billed Charges,60% of Total Billed Charges,22047.8,90,,74.88,Percent of Total Billed Charges,90% of Total Billed Charges,11023.9,45,,193.32,Percent of Total Billed Charges,45% of Total Billed Charges,22047.8,90,,1957.68,Percent of Total Billed Charges,90% of Total billed Charges,24497.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24497.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24497.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15923.41,65,,291.72,Percent of total Billed Charges,65% of Total Billed Charges,10803.42,44.1,,189.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,23272.67,95,,2066.44,Percent of Total Billed Charges,95% of Total Billed Charges,24497.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21557.84,88,,378.048,Percent of Total Billed Charges,88% of Total Billed Charges,22047.8,90,,1957.68,Percent of Total Billed charges,90% of Total Billed Charges,10803.42,24497.55,
TOMIER 3.0X14MM SCRE,2780000963,CDM,278,RC,C1713,HCPCS,Outpatient,,,1142.19,742.42,,1142.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,868.06,76,,186.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,822.38,72,,33.872,Percent of Total Billed Charges,72% of Total Billed Charges,822.38,72,,33.872,Percent of Total Billed charges,72% of Total Billed Charges,1142.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,822.38,72,,33.872,Percent of Total Billed Charges,72% of Total Billed Charges,685.31,60,,28.224,Percent of Total Billed Charges,60% of Total Billed Charges,1027.97,90,,2172.96,Percent of Total Billed Charges,90% of Total Billed Charges,513.99,45,,401.76,Percent of Total Billed Charges,45% of Total Billed Charges,1027.97,90,,220.32,Percent of Total Billed Charges,90% of Total billed Charges,1142.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1142.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1142.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,742.42,65,,291.72,Percent of total Billed Charges,65% of Total Billed Charges,503.71,44.1,,393.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,1085.08,95,,232.56,Percent of Total Billed Charges,95% of Total Billed Charges,1142.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1005.13,88,,215.424,Percent of Total Billed Charges,88% of Total Billed Charges,1027.97,90,,220.32,Percent of Total Billed charges,90% of Total Billed Charges,503.71,1142.19,
Z00771300700 HIP,2780000964,CDM,278,RC,C1713,HCPCS,Outpatient,,,20644.31,13418.80,,20644.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15689.68,76,,1424.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14863.9,72,,84.096,Percent of Total Billed Charges,72% of Total Billed Charges,14863.9,72,,84.096,Percent of Total Billed charges,72% of Total Billed Charges,20644.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14863.9,72,,84.096,Percent of Total Billed Charges,72% of Total Billed Charges,12386.59,60,,70.08,Percent of Total Billed Charges,60% of Total Billed Charges,18579.88,90,,555.12,Percent of Total Billed Charges,90% of Total Billed Charges,9289.94,45,,193.32,Percent of Total Billed Charges,45% of Total Billed Charges,18579.88,90,,1686.96,Percent of Total Billed Charges,90% of Total billed Charges,20644.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20644.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20644.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13418.8,65,,1392.56,Percent of total Billed Charges,65% of Total Billed Charges,9104.14,44.1,,189.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,19612.09,95,,1780.68,Percent of Total Billed Charges,95% of Total Billed Charges,20644.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18166.99,88,,327.36,Percent of Total Billed Charges,88% of Total Billed Charges,18579.88,90,,1686.96,Percent of Total Billed charges,90% of Total Billed Charges,9104.14,20644.31,
Z00784803201 HIP,2780000965,CDM,278,RC,C1713,HCPCS,Outpatient,,,5694.41,3701.37,,5694.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4327.75,76,,326.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4099.98,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,4099.98,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,5694.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4099.98,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,3416.65,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,5124.97,90,,301.68,Percent of Total Billed Charges,90% of Total Billed Charges,2562.48,45,,110.16,Percent of Total Billed Charges,45% of Total Billed Charges,5124.97,90,,386.64,Percent of Total Billed Charges,90% of Total billed Charges,5694.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5694.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5694.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3701.37,65,,291.72,Percent of total Billed Charges,65% of Total Billed Charges,2511.23,44.1,,107.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,5409.69,95,,408.12,Percent of Total Billed Charges,95% of Total Billed Charges,5694.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5011.08,88,,327.36,Percent of Total Billed Charges,88% of Total Billed Charges,5124.97,90,,386.64,Percent of Total Billed charges,90% of Total Billed Charges,2511.23,5694.41,
Z47249336310 FEM,2780000966,CDM,278,RC,C1713,HCPCS,Outpatient,,,8854.18,5755.22,,8854.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6729.18,76,,678.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6375.01,72,,3492.72,Percent of Total Billed Charges,72% of Total Billed Charges,6375.01,72,,3492.72,Percent of Total Billed charges,72% of Total Billed Charges,8854.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6375.01,72,,3492.72,Percent of Total Billed Charges,72% of Total Billed Charges,5312.51,60,,2910.6,Percent of Total Billed Charges,60% of Total Billed Charges,7968.76,90,,555.12,Percent of Total Billed Charges,90% of Total Billed Charges,3984.38,45,,167.4,Percent of Total Billed Charges,45% of Total Billed Charges,7968.76,90,,803.52,Percent of Total Billed Charges,90% of Total billed Charges,8854.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8854.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8854.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5755.22,65,,147.68,Percent of total Billed Charges,65% of Total Billed Charges,3904.69,44.1,,164.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,8411.47,95,,848.16,Percent of Total Billed Charges,95% of Total Billed Charges,8854.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7791.68,88,,327.36,Percent of Total Billed Charges,88% of Total Billed Charges,7968.76,90,,803.52,Percent of Total Billed charges,90% of Total Billed Charges,3904.69,8854.18,
Z00236903635 LCK,2780000967,CDM,278,RC,C1713,HCPCS,Outpatient,,,324.14,210.69,,324.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,246.35,76,,326.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,233.38,72,,2027.048,Percent of Total Billed Charges,72% of Total Billed Charges,233.38,72,,2027.048,Percent of Total Billed charges,72% of Total Billed Charges,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.38,72,,2027.048,Percent of Total Billed Charges,72% of Total Billed Charges,194.48,60,,1689.208,Percent of Total Billed Charges,60% of Total Billed Charges,291.73,90,,301.68,Percent of Total Billed Charges,90% of Total Billed Charges,145.86,45,,167.4,Percent of Total Billed Charges,45% of Total Billed Charges,291.73,90,,386.64,Percent of Total Billed Charges,90% of Total billed Charges,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.69,65,,147.68,Percent of total Billed Charges,65% of Total Billed Charges,142.95,44.1,,164.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,307.93,95,,408.12,Percent of Total Billed Charges,95% of Total Billed Charges,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.24,88,,73.216,Percent of Total Billed Charges,88% of Total Billed Charges,291.73,90,,386.64,Percent of Total Billed charges,90% of Total Billed Charges,142.95,324.14,
Z229920150 KIRSCHN,2780000968,CDM,278,RC,C1713,HCPCS,Outpatient,,,30.87,20.07,,30.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.46,76,,186.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.23,72,,1743.552,Percent of Total Billed Charges,72% of Total Billed Charges,22.23,72,,1743.552,Percent of Total Billed charges,72% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.23,72,,1743.552,Percent of Total Billed Charges,72% of Total Billed Charges,18.52,60,,1452.96,Percent of Total Billed Charges,60% of Total Billed Charges,27.78,90,,555.12,Percent of Total Billed Charges,90% of Total Billed Charges,13.89,45,,167.4,Percent of Total Billed Charges,45% of Total Billed Charges,27.78,90,,220.32,Percent of Total Billed Charges,90% of Total billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.07,65,,429.52,Percent of total Billed Charges,65% of Total Billed Charges,13.61,44.1,,164.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.33,95,,232.56,Percent of Total Billed Charges,95% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.17,88,,2124.672,Percent of Total Billed Charges,88% of Total Billed Charges,27.78,90,,220.32,Percent of Total Billed charges,90% of Total Billed Charges,13.61,30.87,
Z0202262105 NCB P,2780000969,CDM,278,RC,C1713,HCPCS,Outpatient,,,4799.18,3119.47,,4799.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3647.38,76,,282.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3455.41,72,,3065.976,Percent of Total Billed Charges,72% of Total Billed Charges,3455.41,72,,3065.976,Percent of Total Billed charges,72% of Total Billed Charges,4799.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3455.41,72,,3065.976,Percent of Total Billed Charges,72% of Total Billed Charges,2879.51,60,,2554.976,Percent of Total Billed Charges,60% of Total Billed Charges,4319.26,90,,1776.24,Percent of Total Billed Charges,90% of Total Billed Charges,2159.63,45,,37.44,Percent of Total Billed Charges,45% of Total Billed Charges,4319.26,90,,334.8,Percent of Total Billed Charges,90% of Total billed Charges,4799.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4799.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4799.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3119.47,65,,357.76,Percent of total Billed Charges,65% of Total Billed Charges,2116.44,44.1,,36.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,4559.22,95,,353.4,Percent of Total Billed Charges,95% of Total Billed Charges,4799.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4223.28,88,,542.784,Percent of Total Billed Charges,88% of Total Billed Charges,4319.26,90,,334.8,Percent of Total Billed charges,90% of Total Billed Charges,2116.44,4799.18,
Z0203155032 NCB SC,2780000970,CDM,278,RC,C1713,HCPCS,Outpatient,,,368.24,239.36,,368.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,279.86,76,,282.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,265.13,72,,72.4,Percent of Total Billed Charges,72% of Total Billed Charges,265.13,72,,72.4,Percent of Total Billed charges,72% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.13,72,,72.4,Percent of Total Billed Charges,72% of Total Billed Charges,220.94,60,,60.328,Percent of Total Billed Charges,60% of Total Billed Charges,331.42,90,,1546.56,Percent of Total Billed Charges,90% of Total Billed Charges,165.71,45,,1086.48,Percent of Total Billed Charges,45% of Total Billed Charges,331.42,90,,334.8,Percent of Total Billed Charges,90% of Total billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.36,65,,747.76,Percent of total Billed Charges,65% of Total Billed Charges,162.39,44.1,,1064.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,349.83,95,,353.4,Percent of Total Billed Charges,95% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.05,88,,294.976,Percent of Total Billed Charges,88% of Total Billed Charges,331.42,90,,334.8,Percent of Total Billed charges,90% of Total Billed Charges,162.39,368.24,
Z0203155034 NCB SC,2780000971,CDM,278,RC,C1713,HCPCS,Outpatient,,,368.24,239.36,,368.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,279.86,76,,282.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,265.13,72,,212.736,Percent of Total Billed Charges,72% of Total Billed Charges,265.13,72,,212.736,Percent of Total Billed charges,72% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.13,72,,212.736,Percent of Total Billed Charges,72% of Total Billed Charges,220.94,60,,177.28,Percent of Total Billed Charges,60% of Total Billed Charges,331.42,90,,555.12,Percent of Total Billed Charges,90% of Total Billed Charges,165.71,45,,277.56,Percent of Total Billed Charges,45% of Total Billed Charges,331.42,90,,334.8,Percent of Total Billed Charges,90% of Total billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.36,65,,1253.2,Percent of total Billed Charges,65% of Total Billed Charges,162.39,44.1,,272.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,349.83,95,,353.4,Percent of Total Billed Charges,95% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.05,88,,542.784,Percent of Total Billed Charges,88% of Total Billed Charges,331.42,90,,334.8,Percent of Total Billed charges,90% of Total Billed Charges,162.39,368.24,
Z0203159036 NCB SC,2780000972,CDM,278,RC,C1713,HCPCS,Outpatient,,,453.13,294.53,,453.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,344.38,76,,63.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,326.25,72,,212.736,Percent of Total Billed Charges,72% of Total Billed Charges,326.25,72,,212.736,Percent of Total Billed charges,72% of Total Billed Charges,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.25,72,,212.736,Percent of Total Billed Charges,72% of Total Billed Charges,271.88,60,,177.28,Percent of Total Billed Charges,60% of Total Billed Charges,407.82,90,,1774.08,Percent of Total Billed Charges,90% of Total Billed Charges,203.91,45,,150.84,Percent of Total Billed Charges,45% of Total Billed Charges,407.82,90,,74.88,Percent of Total Billed Charges,90% of Total billed Charges,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.53,65,,279.24,Percent of total Billed Charges,65% of Total Billed Charges,199.83,44.1,,147.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,430.47,95,,79.04,Percent of Total Billed Charges,95% of Total Billed Charges,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.75,88,,294.976,Percent of Total Billed Charges,88% of Total Billed Charges,407.82,90,,74.88,Percent of Total Billed charges,90% of Total Billed Charges,199.83,453.13,
Z0203159044 NCB SC,2780000973,CDM,278,RC,C1713,HCPCS,Outpatient,,,453.13,294.53,,453.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,344.38,76,,1834.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,326.25,72,,242.592,Percent of Total Billed Charges,72% of Total Billed Charges,326.25,72,,242.592,Percent of Total Billed charges,72% of Total Billed Charges,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.25,72,,242.592,Percent of Total Billed Charges,72% of Total Billed Charges,271.88,60,,202.16,Percent of Total Billed Charges,60% of Total Billed Charges,407.82,90,,296.64,Percent of Total Billed Charges,90% of Total Billed Charges,203.91,45,,277.56,Percent of Total Billed Charges,45% of Total Billed Charges,407.82,90,,2172.96,Percent of Total Billed Charges,90% of Total billed Charges,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.53,65,,1765.4,Percent of total Billed Charges,65% of Total Billed Charges,199.83,44.1,,272.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,430.47,95,,2293.68,Percent of Total Billed Charges,95% of Total Billed Charges,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.75,88,,542.784,Percent of Total Billed Charges,88% of Total Billed Charges,407.82,90,,2172.96,Percent of Total Billed charges,90% of Total Billed Charges,199.83,453.13,
Z0203159046 NCB SC,2780000974,CDM,278,RC,C1713,HCPCS,Outpatient,,,453.13,294.53,,453.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,344.38,76,,468.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,326.25,72,,186.704,Percent of Total Billed Charges,72% of Total Billed Charges,326.25,72,,186.704,Percent of Total Billed charges,72% of Total Billed Charges,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.25,72,,186.704,Percent of Total Billed Charges,72% of Total Billed Charges,271.88,60,,155.584,Percent of Total Billed Charges,60% of Total Billed Charges,407.82,90,,488.16,Percent of Total Billed Charges,90% of Total Billed Charges,203.91,45,,150.84,Percent of Total Billed Charges,45% of Total Billed Charges,407.82,90,,555.12,Percent of Total Billed Charges,90% of Total billed Charges,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.53,65,,279.24,Percent of total Billed Charges,65% of Total Billed Charges,199.83,44.1,,147.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,430.47,95,,585.96,Percent of Total Billed Charges,95% of Total Billed Charges,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.75,88,,1736.768,Percent of Total Billed Charges,88% of Total Billed Charges,407.82,90,,555.12,Percent of Total Billed charges,90% of Total Billed Charges,199.83,453.13,
Z59524010 ART SURF,2780000975,CDM,278,RC,C1713,HCPCS,Outpatient,,,6451.83,4193.69,,6451.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4903.39,76,,254.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4645.32,72,,186.704,Percent of Total Billed Charges,72% of Total Billed Charges,4645.32,72,,186.704,Percent of Total Billed charges,72% of Total Billed Charges,6451.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4645.32,72,,186.704,Percent of Total Billed Charges,72% of Total Billed Charges,3871.1,60,,155.584,Percent of Total Billed Charges,60% of Total Billed Charges,5806.65,90,,5459.76,Percent of Total Billed Charges,90% of Total Billed Charges,2903.32,45,,277.56,Percent of Total Billed Charges,45% of Total Billed Charges,5806.65,90,,301.68,Percent of Total Billed Charges,90% of Total billed Charges,6451.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6451.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6451.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4193.69,65,,1427.744,Percent of total Billed Charges,65% of Total Billed Charges,2845.26,44.1,,272.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,6129.24,95,,318.44,Percent of Total Billed Charges,95% of Total Billed Charges,6451.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5677.61,88,,1512.192,Percent of Total Billed Charges,88% of Total Billed Charges,5806.65,90,,301.68,Percent of Total Billed charges,90% of Total Billed Charges,2845.26,6451.83,
Z225332010 TIBAIL,2780000976,CDM,278,RC,C1713,HCPCS,Outpatient,,,3258.99,2118.34,,3258.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2476.83,76,,468.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2346.47,72,,186.704,Percent of Total Billed Charges,72% of Total Billed Charges,2346.47,72,,186.704,Percent of Total Billed charges,72% of Total Billed Charges,3258.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2346.47,72,,186.704,Percent of Total Billed Charges,72% of Total Billed Charges,1955.39,60,,155.584,Percent of Total Billed Charges,60% of Total Billed Charges,2933.09,90,,2908.08,Percent of Total Billed Charges,90% of Total Billed Charges,1466.55,45,,888.12,Percent of Total Billed Charges,45% of Total Billed Charges,2933.09,90,,555.12,Percent of Total Billed Charges,90% of Total billed Charges,3258.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3258.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3258.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2118.34,65,,1826.184,Percent of total Billed Charges,65% of Total Billed Charges,1437.21,44.1,,870.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,3096.04,95,,585.96,Percent of Total Billed Charges,95% of Total Billed Charges,3258.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2867.91,88,,542.784,Percent of Total Billed Charges,88% of Total Billed Charges,2933.09,90,,555.12,Percent of Total Billed charges,90% of Total Billed Charges,1437.21,3258.99,
23581806 VOLAR MED,2780000977,CDM,278,RC,C1713,HCPCS,Outpatient,,,2927.14,1902.64,,2927.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2224.63,76,,254.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2107.54,72,,2706.544,Percent of Total Billed Charges,72% of Total Billed Charges,2107.54,72,,2706.544,Percent of Total Billed charges,72% of Total Billed Charges,2927.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2107.54,72,,2706.544,Percent of Total Billed Charges,72% of Total Billed Charges,1756.28,60,,2255.456,Percent of Total Billed Charges,60% of Total Billed Charges,2634.43,90,,4000.32,Percent of Total Billed Charges,90% of Total Billed Charges,1317.21,45,,773.28,Percent of Total Billed Charges,45% of Total Billed Charges,2634.43,90,,301.68,Percent of Total Billed Charges,90% of Total billed Charges,2927.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2927.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2927.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1902.64,65,,1826.184,Percent of total Billed Charges,65% of Total Billed Charges,1290.87,44.1,,757.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,2780.78,95,,318.44,Percent of Total Billed Charges,95% of Total Billed Charges,2927.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2575.88,88,,1734.656,Percent of Total Billed Charges,88% of Total Billed Charges,2634.43,90,,301.68,Percent of Total Billed charges,90% of Total Billed Charges,1290.87,2927.14,
Z236904435 LCK SCW,2780000978,CDM,278,RC,C1713,HCPCS,Outpatient,,,325.24,211.41,,325.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,247.18,76,,468.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,234.17,72,,2226.456,Percent of Total Billed Charges,72% of Total Billed Charges,234.17,72,,2226.456,Percent of Total Billed charges,72% of Total Billed Charges,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.17,72,,2226.456,Percent of Total Billed Charges,72% of Total Billed Charges,195.14,60,,1855.376,Percent of Total Billed Charges,60% of Total Billed Charges,292.72,90,,876.96,Percent of Total Billed Charges,90% of Total Billed Charges,146.36,45,,277.56,Percent of Total Billed Charges,45% of Total Billed Charges,292.72,90,,555.12,Percent of Total Billed Charges,90% of Total billed Charges,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.41,65,,4098.168,Percent of total Billed Charges,65% of Total Billed Charges,143.43,44.1,,272.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,308.98,95,,585.96,Percent of Total Billed Charges,95% of Total Billed Charges,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.21,88,,290.048,Percent of Total Billed Charges,88% of Total Billed Charges,292.72,90,,555.12,Percent of Total Billed charges,90% of Total Billed Charges,143.43,325.24,
Z236904635 LCK SCW,2780000979,CDM,278,RC,C1713,HCPCS,Outpatient,,,325.24,211.41,,325.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,247.18,76,,1499.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,234.17,72,,4244.608,Percent of Total Billed Charges,72% of Total Billed Charges,234.17,72,,4244.608,Percent of Total Billed charges,72% of Total Billed Charges,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.17,72,,4244.608,Percent of Total Billed Charges,72% of Total Billed Charges,195.14,60,,3537.176,Percent of Total Billed Charges,60% of Total Billed Charges,292.72,90,,403.92,Percent of Total Billed Charges,90% of Total Billed Charges,146.36,45,,887.04,Percent of Total Billed Charges,45% of Total Billed Charges,292.72,90,,1776.24,Percent of Total Billed Charges,90% of Total billed Charges,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.41,65,,3964.016,Percent of total Billed Charges,65% of Total Billed Charges,143.43,44.1,,869.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,308.98,95,,1874.92,Percent of Total Billed Charges,95% of Total Billed Charges,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.21,88,,477.312,Percent of Total Billed Charges,88% of Total Billed Charges,292.72,90,,1776.24,Percent of Total Billed charges,90% of Total Billed Charges,143.43,325.24,
Z0203155026 CORT 4,2780000980,CDM,278,RC,C1713,HCPCS,Outpatient,,,368.24,239.36,,368.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,279.86,76,,1305.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,265.13,72,,1961.64,Percent of Total Billed Charges,72% of Total Billed Charges,265.13,72,,1961.64,Percent of Total Billed charges,72% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.13,72,,1961.64,Percent of Total Billed Charges,72% of Total Billed Charges,220.94,60,,1634.696,Percent of Total Billed Charges,60% of Total Billed Charges,331.42,90,,403.92,Percent of Total Billed Charges,90% of Total Billed Charges,165.71,45,,148.32,Percent of Total Billed Charges,45% of Total Billed Charges,331.42,90,,1546.56,Percent of Total Billed Charges,90% of Total billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.36,65,,1574.504,Percent of total Billed Charges,65% of Total Billed Charges,162.39,44.1,,145.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,349.83,95,,1632.48,Percent of Total Billed Charges,95% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.05,88,,5338.432,Percent of Total Billed Charges,88% of Total Billed Charges,331.42,90,,1546.56,Percent of Total Billed charges,90% of Total Billed Charges,162.39,368.24,
Z0203155048 CORT 4,2780000981,CDM,278,RC,C1713,HCPCS,Outpatient,,,368.24,239.36,,368.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,279.86,76,,468.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,265.13,72,,331.496,Percent of Total Billed Charges,72% of Total Billed Charges,265.13,72,,331.496,Percent of Total Billed charges,72% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.13,72,,331.496,Percent of Total Billed Charges,72% of Total Billed Charges,220.94,60,,276.248,Percent of Total Billed Charges,60% of Total Billed Charges,331.42,90,,1928.16,Percent of Total Billed Charges,90% of Total Billed Charges,165.71,45,,244.08,Percent of Total Billed Charges,45% of Total Billed Charges,331.42,90,,555.12,Percent of Total Billed Charges,90% of Total billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.36,65,,1574.504,Percent of total Billed Charges,65% of Total Billed Charges,162.39,44.1,,239.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,349.83,95,,585.96,Percent of Total Billed Charges,95% of Total Billed Charges,368.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.05,88,,2843.456,Percent of Total Billed Charges,88% of Total Billed Charges,331.42,90,,555.12,Percent of Total Billed charges,90% of Total Billed Charges,162.39,368.24,
Z0203159048 CANC 4,2780000982,CDM,278,RC,C1713,HCPCS,Outpatient,,,411.23,267.30,,411.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,312.53,76,,1498.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,296.09,72,,1247.856,Percent of Total Billed Charges,72% of Total Billed Charges,296.09,72,,1247.856,Percent of Total Billed charges,72% of Total Billed Charges,411.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.09,72,,1247.856,Percent of Total Billed Charges,72% of Total Billed Charges,246.74,60,,1039.88,Percent of Total Billed Charges,60% of Total Billed Charges,370.11,90,,403.92,Percent of Total Billed Charges,90% of Total Billed Charges,185.05,45,,2729.88,Percent of Total Billed Charges,45% of Total Billed Charges,370.11,90,,1774.08,Percent of Total Billed Charges,90% of Total billed Charges,411.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.3,65,,1574.504,Percent of total Billed Charges,65% of Total Billed Charges,181.35,44.1,,2675.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,390.67,95,,1872.64,Percent of Total Billed Charges,95% of Total Billed Charges,411.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.88,88,,3911.424,Percent of Total Billed Charges,88% of Total Billed Charges,370.11,90,,1774.08,Percent of Total Billed charges,90% of Total Billed Charges,181.35,411.23,
Z43004624 MOD HUM,2780000983,CDM,278,RC,C1713,HCPCS,Outpatient,,,5094.65,3311.52,,5094.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3871.93,76,,250.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3668.15,72,,393.088,Percent of Total Billed Charges,72% of Total Billed Charges,3668.15,72,,393.088,Percent of Total Billed charges,72% of Total Billed Charges,5094.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3668.15,72,,393.088,Percent of Total Billed Charges,72% of Total Billed Charges,3056.79,60,,327.576,Percent of Total Billed Charges,60% of Total Billed Charges,4585.19,90,,204.48,Percent of Total Billed Charges,90% of Total Billed Charges,2292.59,45,,1454.04,Percent of Total Billed Charges,45% of Total Billed Charges,4585.19,90,,296.64,Percent of Total Billed Charges,90% of Total billed Charges,5094.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5094.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5094.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3311.52,65,,1733.88,Percent of total Billed Charges,65% of Total Billed Charges,2246.74,44.1,,1424.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,4839.92,95,,313.12,Percent of Total Billed Charges,95% of Total Billed Charges,5094.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4483.29,88,,857.472,Percent of Total Billed Charges,88% of Total Billed Charges,4585.19,90,,296.64,Percent of Total Billed charges,90% of Total Billed Charges,2246.74,5094.65,
Z43001413 MOD HUM,2780000984,CDM,278,RC,C1713,HCPCS,Outpatient,,,10803.40,7022.21,,10803.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8210.58,76,,412.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7778.45,72,,33.656,Percent of Total Billed Charges,72% of Total Billed Charges,7778.45,72,,33.656,Percent of Total Billed charges,72% of Total Billed Charges,10803.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7778.45,72,,33.656,Percent of Total Billed Charges,72% of Total Billed Charges,6482.04,60,,28.048,Percent of Total Billed Charges,60% of Total Billed Charges,9723.06,90,,204.48,Percent of Total Billed Charges,90% of Total Billed Charges,4861.53,45,,2000.16,Percent of Total Billed Charges,45% of Total Billed Charges,9723.06,90,,488.16,Percent of Total Billed Charges,90% of Total billed Charges,10803.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10803.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10803.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7022.21,65,,1804.4,Percent of total Billed Charges,65% of Total Billed Charges,4764.3,44.1,,1960.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,10263.23,95,,515.28,Percent of Total Billed Charges,95% of Total Billed Charges,10803.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9506.99,88,,394.944,Percent of Total Billed Charges,88% of Total Billed Charges,9723.06,90,,488.16,Percent of Total Billed charges,90% of Total Billed Charges,4764.3,10803.4,
Z484036 4.0 CANN SC,2780000985,CDM,278,RC,C1713,HCPCS,Outpatient,,,181.91,118.24,,181.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,138.25,76,,4610.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,130.98,72,,3540.984,Percent of Total Billed Charges,72% of Total Billed Charges,130.98,72,,3540.984,Percent of Total Billed charges,72% of Total Billed Charges,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.98,72,,3540.984,Percent of Total Billed Charges,72% of Total Billed Charges,109.15,60,,2950.816,Percent of Total Billed Charges,60% of Total Billed Charges,163.72,90,,594.72,Percent of Total Billed Charges,90% of Total Billed Charges,81.86,45,,438.48,Percent of Total Billed Charges,45% of Total Billed Charges,163.72,90,,5459.76,Percent of Total Billed Charges,90% of Total billed Charges,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.24,65,,1397.928,Percent of total Billed Charges,65% of Total Billed Charges,80.22,44.1,,429.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,172.81,95,,5763.08,Percent of Total Billed Charges,95% of Total Billed Charges,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.08,88,,394.944,Percent of Total Billed Charges,88% of Total Billed Charges,163.72,90,,5459.76,Percent of Total Billed charges,90% of Total Billed Charges,80.22,181.91,
Z484040 4.0 CANN SC,2780000986,CDM,278,RC,C1713,HCPCS,Outpatient,,,181.91,118.24,,181.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,138.25,76,,2455.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,130.98,72,,767.128,Percent of Total Billed Charges,72% of Total Billed Charges,130.98,72,,767.128,Percent of Total Billed charges,72% of Total Billed Charges,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.98,72,,767.128,Percent of Total Billed Charges,72% of Total Billed Charges,109.15,60,,639.272,Percent of Total Billed Charges,60% of Total Billed Charges,163.72,90,,495.36,Percent of Total Billed Charges,90% of Total Billed Charges,81.86,45,,201.96,Percent of Total Billed Charges,45% of Total Billed Charges,163.72,90,,2908.08,Percent of Total Billed Charges,90% of Total billed Charges,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.24,65,,3628.064,Percent of total Billed Charges,65% of Total Billed Charges,80.22,44.1,,197.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,172.81,95,,3069.64,Percent of Total Billed Charges,95% of Total Billed Charges,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.08,88,,1885.312,Percent of Total Billed Charges,88% of Total Billed Charges,163.72,90,,2908.08,Percent of Total Billed charges,90% of Total Billed Charges,80.22,181.91,
Z44523203 TRANSFX,2780000987,CDM,278,RC,C1713,HCPCS,Outpatient,,,1429.94,929.46,,1429.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1086.75,76,,3378.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1029.56,72,,6942.256,Percent of Total Billed Charges,72% of Total Billed Charges,1029.56,72,,6942.256,Percent of Total Billed charges,72% of Total Billed Charges,1429.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1029.56,72,,6942.256,Percent of Total Billed Charges,72% of Total Billed Charges,857.96,60,,5785.216,Percent of Total Billed Charges,60% of Total Billed Charges,1286.95,90,,1035.36,Percent of Total Billed Charges,90% of Total Billed Charges,643.47,45,,201.96,Percent of Total Billed Charges,45% of Total Billed Charges,1286.95,90,,4000.32,Percent of Total Billed Charges,90% of Total billed Charges,1429.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1429.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1429.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,929.46,65,,1662.792,Percent of total Billed Charges,65% of Total Billed Charges,630.6,44.1,,197.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,1358.44,95,,4222.56,Percent of Total Billed Charges,95% of Total Billed Charges,1429.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1258.35,88,,394.944,Percent of Total Billed Charges,88% of Total Billed Charges,1286.95,90,,4000.32,Percent of Total Billed charges,90% of Total Billed Charges,630.6,1429.94,
Z44531610 TRANSFX,2780000988,CDM,278,RC,C1713,HCPCS,Outpatient,,,1007.69,655.00,,1007.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,765.84,76,,740.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,725.54,72,,12425.832,Percent of Total Billed Charges,72% of Total Billed Charges,725.54,72,,12425.832,Percent of Total Billed charges,72% of Total Billed Charges,1007.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,725.54,72,,12425.832,Percent of Total Billed Charges,72% of Total Billed Charges,604.61,60,,10354.856,Percent of Total Billed Charges,60% of Total Billed Charges,906.92,90,,1735.2,Percent of Total Billed Charges,90% of Total Billed Charges,453.46,45,,964.08,Percent of Total Billed Charges,45% of Total Billed Charges,906.92,90,,876.96,Percent of Total Billed Charges,90% of Total billed Charges,1007.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1007.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1007.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,444.39,44.1,,944.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,957.31,95,,925.68,Percent of Total Billed Charges,95% of Total Billed Charges,1007.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,886.77,88,,199.936,Percent of Total Billed Charges,88% of Total Billed Charges,906.92,90,,876.96,Percent of Total Billed charges,90% of Total Billed Charges,444.39,1007.69,
Z44510307 TRANSFX,2780000989,CDM,278,RC,C1713,HCPCS,Outpatient,,,148.84,96.75,,148.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,113.12,76,,341.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,107.16,72,,3427.312,Percent of Total Billed Charges,72% of Total Billed Charges,107.16,72,,3427.312,Percent of Total Billed charges,72% of Total Billed Charges,148.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.16,72,,3427.312,Percent of Total Billed Charges,72% of Total Billed Charges,89.3,60,,2856.088,Percent of Total Billed Charges,60% of Total Billed Charges,133.96,90,,386.64,Percent of Total Billed Charges,90% of Total Billed Charges,66.98,45,,201.96,Percent of Total Billed Charges,45% of Total Billed Charges,133.96,90,,403.92,Percent of Total Billed Charges,90% of Total billed Charges,148.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.75,65,,854.792,Percent of total Billed Charges,65% of Total Billed Charges,65.64,44.1,,197.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,141.4,95,,426.36,Percent of Total Billed Charges,95% of Total Billed Charges,148.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.98,88,,199.936,Percent of Total Billed Charges,88% of Total Billed Charges,133.96,90,,403.92,Percent of Total Billed charges,90% of Total Billed Charges,65.64,148.84,
Z44521003 TRANSFX,2780000990,CDM,278,RC,C1713,HCPCS,Outpatient,,,1977.89,1285.63,,1977.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1503.2,76,,341.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1424.08,72,,504.224,Percent of Total Billed Charges,72% of Total Billed Charges,1424.08,72,,504.224,Percent of Total Billed charges,72% of Total Billed Charges,1977.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1424.08,72,,504.224,Percent of Total Billed Charges,72% of Total Billed Charges,1186.73,60,,420.184,Percent of Total Billed Charges,60% of Total Billed Charges,1780.1,90,,2444.4,Percent of Total Billed Charges,90% of Total Billed Charges,890.05,45,,102.24,Percent of Total Billed Charges,45% of Total Billed Charges,1780.1,90,,403.92,Percent of Total Billed Charges,90% of Total billed Charges,1977.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1977.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1977.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1285.63,65,,1387.96,Percent of total Billed Charges,65% of Total Billed Charges,872.25,44.1,,100.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,1879,95,,426.36,Percent of Total Billed Charges,95% of Total Billed Charges,1977.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1740.54,88,,581.504,Percent of Total Billed Charges,88% of Total Billed Charges,1780.1,90,,403.92,Percent of Total Billed charges,90% of Total Billed Charges,872.25,1977.89,
Z44523003 TRANSFX,2780000991,CDM,278,RC,C1713,HCPCS,Outpatient,,,1429.94,929.46,,1429.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1086.75,76,,1628.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1029.56,72,,147.328,Percent of Total Billed Charges,72% of Total Billed Charges,1029.56,72,,147.328,Percent of Total Billed charges,72% of Total Billed Charges,1429.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1029.56,72,,147.328,Percent of Total Billed Charges,72% of Total Billed Charges,857.96,60,,122.776,Percent of Total Billed Charges,60% of Total Billed Charges,1286.95,90,,386.64,Percent of Total Billed Charges,90% of Total Billed Charges,643.47,45,,102.24,Percent of Total Billed Charges,45% of Total Billed Charges,1286.95,90,,1928.16,Percent of Total Billed Charges,90% of Total billed Charges,1429.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1429.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1429.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,929.46,65,,220.72,Percent of total Billed Charges,65% of Total Billed Charges,630.6,44.1,,100.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,1358.44,95,,2035.28,Percent of Total Billed Charges,95% of Total Billed Charges,1429.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1258.35,88,,484.352,Percent of Total Billed Charges,88% of Total Billed Charges,1286.95,90,,1928.16,Percent of Total Billed charges,90% of Total Billed Charges,630.6,1429.94,
Z23592218 LCK PEG,2780000992,CDM,278,RC,C1713,HCPCS,Outpatient,,,209.48,136.16,,209.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,159.2,76,,341.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.83,72,,136.536,Percent of Total Billed Charges,72% of Total Billed Charges,150.83,72,,136.536,Percent of Total Billed charges,72% of Total Billed Charges,209.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.83,72,,136.536,Percent of Total Billed Charges,72% of Total Billed Charges,125.69,60,,113.776,Percent of Total Billed Charges,60% of Total Billed Charges,188.53,90,,53.184,Percent of Total Billed Charges,90% of Total Billed Charges,94.27,45,,297.36,Percent of Total Billed Charges,45% of Total Billed Charges,188.53,90,,403.92,Percent of Total Billed Charges,90% of Total billed Charges,209.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.16,65,,290.664,Percent of total Billed Charges,65% of Total Billed Charges,92.38,44.1,,291.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,199.01,95,,426.36,Percent of Total Billed Charges,95% of Total Billed Charges,209.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.34,88,,1012.352,Percent of Total Billed Charges,88% of Total Billed Charges,188.53,90,,403.92,Percent of Total Billed charges,90% of Total Billed Charges,92.38,209.48,
Z23592418 LCK PEG,2780000993,CDM,278,RC,C1713,HCPCS,Outpatient,,,209.48,136.16,,209.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,159.2,76,,172.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.83,72,,1903.216,Percent of Total Billed Charges,72% of Total Billed Charges,150.83,72,,1903.216,Percent of Total Billed charges,72% of Total Billed Charges,209.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.83,72,,1903.216,Percent of Total Billed Charges,72% of Total Billed Charges,125.69,60,,1586.008,Percent of Total Billed Charges,60% of Total Billed Charges,188.53,90,,604.88,Percent of Total Billed Charges,90% of Total Billed Charges,94.27,45,,247.68,Percent of Total Billed Charges,45% of Total Billed Charges,188.53,90,,204.48,Percent of Total Billed Charges,90% of Total billed Charges,209.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.16,65,,467.24,Percent of total Billed Charges,65% of Total Billed Charges,92.38,44.1,,242.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,199.01,95,,215.84,Percent of Total Billed Charges,95% of Total Billed Charges,209.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.34,88,,1696.64,Percent of Total Billed Charges,88% of Total Billed Charges,188.53,90,,204.48,Percent of Total Billed charges,90% of Total Billed Charges,92.38,209.48,
Z114708576 THD 32X,2780000994,CDM,278,RC,C1713,HCPCS,Outpatient,,,840.11,546.07,,840.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,638.48,76,,172.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,604.88,72,,1941.312,Percent of Total Billed Charges,72% of Total Billed Charges,604.88,72,,1941.312,Percent of Total Billed charges,72% of Total Billed Charges,840.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,604.88,72,,1941.312,Percent of Total Billed Charges,72% of Total Billed Charges,504.07,60,,1617.76,Percent of Total Billed Charges,60% of Total Billed Charges,756.1,90,,604.88,Percent of Total Billed Charges,90% of Total Billed Charges,378.05,45,,517.68,Percent of Total Billed Charges,45% of Total Billed Charges,756.1,90,,204.48,Percent of Total Billed Charges,90% of Total billed Charges,840.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,840.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,840.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.07,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,370.49,44.1,,507.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,798.1,95,,215.84,Percent of Total Billed Charges,95% of Total Billed Charges,840.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,739.3,88,,378.048,Percent of Total Billed Charges,88% of Total Billed Charges,756.1,90,,204.48,Percent of Total Billed charges,90% of Total Billed Charges,370.49,840.11,
Z43005227 MOD/HUM,2780000995,CDM,278,RC,C1713,HCPCS,Outpatient,,,15282.86,9933.86,,15282.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11614.97,76,,502.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11003.66,72,,1941.312,Percent of Total Billed Charges,72% of Total Billed Charges,11003.66,72,,1941.312,Percent of Total Billed charges,72% of Total Billed Charges,15282.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11003.66,72,,1941.312,Percent of Total Billed Charges,72% of Total Billed Charges,9169.72,60,,1617.76,Percent of Total Billed Charges,60% of Total Billed Charges,13754.57,90,,3750.704,Percent of Total Billed Charges,90% of Total Billed Charges,6877.29,45,,867.6,Percent of Total Billed Charges,45% of Total Billed Charges,13754.57,90,,594.72,Percent of Total Billed Charges,90% of Total billed Charges,15282.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15282.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15282.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9933.86,65,,36.688,Percent of total Billed Charges,65% of Total Billed Charges,6739.74,44.1,,850.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,14518.72,95,,627.76,Percent of Total Billed Charges,95% of Total Billed Charges,15282.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13448.92,88,,2390.08,Percent of Total Billed Charges,88% of Total Billed Charges,13754.57,90,,594.72,Percent of Total Billed charges,90% of Total Billed Charges,6739.74,15282.86,
Z493409 3.5 PLATE 9,2780000996,CDM,278,RC,C1713,HCPCS,Outpatient,,,490.61,318.90,,490.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.86,76,,418.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,353.24,72,,1689.208,Percent of Total Billed Charges,72% of Total Billed Charges,353.24,72,,1689.208,Percent of Total Billed charges,72% of Total Billed Charges,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.24,72,,1689.208,Percent of Total Billed Charges,72% of Total Billed Charges,294.37,60,,1407.672,Percent of Total Billed Charges,60% of Total Billed Charges,441.55,90,,3564.96,Percent of Total Billed Charges,90% of Total Billed Charges,220.77,45,,193.32,Percent of Total Billed Charges,45% of Total Billed Charges,441.55,90,,495.36,Percent of Total Billed Charges,90% of Total billed Charges,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.9,65,,123.832,Percent of total Billed Charges,65% of Total Billed Charges,216.36,44.1,,189.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,466.08,95,,522.88,Percent of Total Billed Charges,95% of Total Billed Charges,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,431.74,88,,378.048,Percent of Total Billed Charges,88% of Total Billed Charges,441.55,90,,495.36,Percent of Total Billed charges,90% of Total Billed Charges,216.36,490.61,
GOLD SUTURE 1.8,2780000997,CDM,278,RC,C1713,HCPCS,Outpatient,,,425.57,276.62,,425.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,323.43,76,,874.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,306.41,72,,103.512,Percent of Total Billed Charges,72% of Total Billed Charges,306.41,72,,103.512,Percent of Total Billed charges,72% of Total Billed Charges,425.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.41,72,,103.512,Percent of Total Billed Charges,72% of Total Billed Charges,255.34,60,,86.264,Percent of Total Billed Charges,60% of Total Billed Charges,383.01,90,,256.4,Percent of Total Billed Charges,90% of Total Billed Charges,191.51,45,,1222.2,Percent of Total Billed Charges,45% of Total Billed Charges,383.01,90,,1035.36,Percent of Total Billed Charges,90% of Total billed Charges,425.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,425.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,425.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.62,65,,141.032,Percent of total Billed Charges,65% of Total Billed Charges,187.68,44.1,,1197.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,404.29,95,,1092.88,Percent of Total Billed Charges,95% of Total Billed Charges,425.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.5,88,,52.008,Percent of Total Billed Charges,88% of Total Billed Charges,383.01,90,,1035.36,Percent of Total Billed charges,90% of Total Billed Charges,187.68,425.57,
Z47248507010 LAG,2780000998,CDM,278,RC,C1713,HCPCS,Outpatient,,,2131.13,1385.23,,2131.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1619.66,76,,1465.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1534.41,72,,3787.376,Percent of Total Billed Charges,72% of Total Billed Charges,1534.41,72,,3787.376,Percent of Total Billed charges,72% of Total Billed Charges,2131.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1534.41,72,,3787.376,Percent of Total Billed Charges,72% of Total Billed Charges,1278.68,60,,3156.152,Percent of Total Billed Charges,60% of Total Billed Charges,1918.02,90,,256.4,Percent of Total Billed Charges,90% of Total Billed Charges,959.01,45,,193.32,Percent of Total Billed Charges,45% of Total Billed Charges,1918.02,90,,1735.2,Percent of Total Billed Charges,90% of Total billed Charges,2131.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2131.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2131.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1385.23,65,,141.032,Percent of total Billed Charges,65% of Total Billed Charges,939.83,44.1,,189.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,2024.57,95,,1831.6,Percent of Total Billed Charges,95% of Total Billed Charges,2131.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1875.39,88,,591.44,Percent of Total Billed Charges,88% of Total Billed Charges,1918.02,90,,1735.2,Percent of Total Billed charges,90% of Total Billed Charges,939.83,2131.13,
Z49270503 MF 5,2780000999,CDM,278,RC,C1713,HCPCS,Outpatient,,,255.78,166.26,,255.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,194.39,76,,326.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,184.16,72,,287.04,Percent of Total Billed Charges,72% of Total Billed Charges,184.16,72,,287.04,Percent of Total Billed charges,72% of Total Billed Charges,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.16,72,,287.04,Percent of Total Billed Charges,72% of Total Billed Charges,153.47,60,,239.2,Percent of Total Billed Charges,60% of Total Billed Charges,230.2,90,,256.4,Percent of Total Billed Charges,90% of Total Billed Charges,115.1,45,,26.592,Percent of Total Billed Charges,45% of Total Billed Charges,230.2,90,,386.64,Percent of Total Billed Charges,90% of Total billed Charges,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.26,65,,85.688,Percent of total Billed Charges,65% of Total Billed Charges,112.8,44.1,,26.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,242.99,95,,408.12,Percent of Total Billed Charges,95% of Total Billed Charges,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.09,88,,591.44,Percent of Total Billed Charges,88% of Total Billed Charges,230.2,90,,386.64,Percent of Total Billed charges,90% of Total Billed Charges,112.8,255.78,
Z62025822 SHELL 58,2780001000,CDM,278,RC,C1713,HCPCS,Outpatient,,,9175.01,5963.76,,9175.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6973.01,76,,2064.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6606.01,72,,1689.208,Percent of Total Billed Charges,72% of Total Billed Charges,6606.01,72,,1689.208,Percent of Total Billed charges,72% of Total Billed Charges,9175.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6606.01,72,,1689.208,Percent of Total Billed Charges,72% of Total Billed Charges,5505.01,60,,1407.672,Percent of Total Billed Charges,60% of Total Billed Charges,8257.51,90,,477.072,Percent of Total Billed Charges,90% of Total Billed Charges,4128.75,45,,302.44,Percent of Total Billed Charges,45% of Total Billed Charges,8257.51,90,,2444.4,Percent of Total Billed Charges,90% of Total billed Charges,9175.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9175.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9175.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5963.76,65,,80.032,Percent of total Billed Charges,65% of Total Billed Charges,4046.18,44.1,,296.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,8716.26,95,,2580.2,Percent of Total Billed Charges,95% of Total Billed Charges,9175.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8074.01,88,,3667.352,Percent of Total Billed Charges,88% of Total Billed Charges,8257.51,90,,2444.4,Percent of Total Billed charges,90% of Total Billed Charges,4046.18,9175.01,
Z11811037 LAG SCW,2780001001,CDM,278,RC,C1713,HCPCS,Outpatient,,,1072.73,697.27,,1072.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,815.27,76,,326.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,772.37,72,,11576.144,Percent of Total Billed Charges,72% of Total Billed Charges,772.37,72,,11576.144,Percent of Total Billed charges,72% of Total Billed Charges,1072.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,772.37,72,,11576.144,Percent of Total Billed Charges,72% of Total Billed Charges,643.64,60,,9646.784,Percent of Total Billed Charges,60% of Total Billed Charges,965.46,90,,574.712,Percent of Total Billed Charges,90% of Total Billed Charges,482.73,45,,302.44,Percent of Total Billed Charges,45% of Total Billed Charges,965.46,90,,386.64,Percent of Total Billed Charges,90% of Total billed Charges,1072.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1072.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1072.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,697.27,65,,209.832,Percent of total Billed Charges,65% of Total Billed Charges,473.07,44.1,,296.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1019.09,95,,408.12,Percent of Total Billed Charges,95% of Total Billed Charges,1072.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,944,88,,3485.736,Percent of Total Billed Charges,88% of Total Billed Charges,965.46,90,,386.64,Percent of Total Billed charges,90% of Total Billed Charges,473.07,1072.73,
ECT SCREW 36MM 4.5,2780001002,CDM,278,RC,C1713,HCPCS,Outpatient,,,60.64,39.42,,60.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.09,76,,44.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.66,72,,122.56,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,72,,122.56,Percent of Total Billed charges,72% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,72,,122.56,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,60,,102.136,Percent of Total Billed Charges,60% of Total Billed Charges,54.58,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,27.29,45,,1875.352,Percent of Total Billed Charges,45% of Total Billed Charges,54.58,90,,53.184,Percent of Total Billed Charges,90% of Total billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.42,65,,664.656,Percent of total Billed Charges,65% of Total Billed Charges,26.74,44.1,,1837.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.61,95,,56.144,Percent of Total Billed Charges,95% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.36,88,,250.704,Percent of Total Billed Charges,88% of Total Billed Charges,54.58,90,,53.184,Percent of Total Billed charges,90% of Total Billed Charges,26.74,60.64,
ECT SCREW 38MM 4.5,2780001003,CDM,278,RC,C1713,HCPCS,Outpatient,,,60.64,39.42,,60.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.09,76,,510.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.66,72,,136.536,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,72,,136.536,Percent of Total Billed charges,72% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,72,,136.536,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,60,,113.776,Percent of Total Billed Charges,60% of Total Billed Charges,54.58,90,,3099.784,Percent of Total Billed Charges,90% of Total Billed Charges,27.29,45,,1782.48,Percent of Total Billed Charges,45% of Total Billed Charges,54.58,90,,604.88,Percent of Total Billed Charges,90% of Total billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.42,65,,104,Percent of total Billed Charges,65% of Total Billed Charges,26.74,44.1,,1746.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.61,95,,638.48,Percent of Total Billed Charges,95% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.36,88,,250.704,Percent of Total Billed Charges,88% of Total Billed Charges,54.58,90,,604.88,Percent of Total Billed charges,90% of Total Billed Charges,26.74,60.64,
ECT SCREW 42MM 4.5,2780001004,CDM,278,RC,C1713,HCPCS,Outpatient,,,60.64,39.42,,60.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.09,76,,510.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.66,72,,46.992,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,72,,46.992,Percent of Total Billed charges,72% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,72,,46.992,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,60,,39.16,Percent of Total Billed Charges,60% of Total Billed Charges,54.58,90,,378.64,Percent of Total Billed Charges,90% of Total Billed Charges,27.29,45,,128.2,Percent of Total Billed Charges,45% of Total Billed Charges,54.58,90,,604.88,Percent of Total Billed Charges,90% of Total billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.42,65,,104,Percent of total Billed Charges,65% of Total Billed Charges,26.74,44.1,,125.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.61,95,,638.48,Percent of Total Billed Charges,95% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.36,88,,250.704,Percent of Total Billed Charges,88% of Total Billed Charges,54.58,90,,604.88,Percent of Total Billed charges,90% of Total Billed Charges,26.74,60.64,
ECT SCREW 44MM 4.5,2780001005,CDM,278,RC,C1713,HCPCS,Outpatient,,,60.64,39.42,,60.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.09,76,,3167.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.66,72,,3540.984,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,72,,3540.984,Percent of Total Billed charges,72% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,72,,3540.984,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,60,,2950.816,Percent of Total Billed Charges,60% of Total Billed Charges,54.58,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,27.29,45,,128.2,Percent of Total Billed Charges,45% of Total Billed Charges,54.58,90,,3750.704,Percent of Total Billed Charges,90% of Total billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.42,65,,363.088,Percent of total Billed Charges,65% of Total Billed Charges,26.74,44.1,,125.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.61,95,,3959.072,Percent of Total Billed Charges,95% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.36,88,,466.472,Percent of Total Billed Charges,88% of Total Billed Charges,54.58,90,,3750.704,Percent of Total Billed charges,90% of Total Billed Charges,26.74,60.64,
ECT SCREW 48MM 4.5,2780001006,CDM,278,RC,C1713,HCPCS,Outpatient,,,60.64,39.42,,60.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.09,76,,3010.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.66,72,,472.472,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,72,,472.472,Percent of Total Billed charges,72% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,72,,472.472,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,60,,393.728,Percent of Total Billed Charges,60% of Total Billed Charges,54.58,90,,1183.56,Percent of Total Billed Charges,90% of Total Billed Charges,27.29,45,,128.2,Percent of Total Billed Charges,45% of Total Billed Charges,54.58,90,,3564.96,Percent of Total Billed Charges,90% of Total billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.42,65,,383.128,Percent of total Billed Charges,65% of Total Billed Charges,26.74,44.1,,125.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.61,95,,3763.008,Percent of Total Billed Charges,95% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.36,88,,561.936,Percent of Total Billed Charges,88% of Total Billed Charges,54.58,90,,3564.96,Percent of Total Billed charges,90% of Total Billed Charges,26.74,60.64,
Z118113510 COMP,2780001007,CDM,278,RC,C1713,HCPCS,Outpatient,,,2159.80,1403.87,,2159.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1641.45,76,,216.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1555.06,72,,6317.376,Percent of Total Billed Charges,72% of Total Billed Charges,1555.06,72,,6317.376,Percent of Total Billed charges,72% of Total Billed Charges,2159.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1555.06,72,,6317.376,Percent of Total Billed Charges,72% of Total Billed Charges,1295.88,60,,5264.48,Percent of Total Billed Charges,60% of Total Billed Charges,1943.82,90,,1921.792,Percent of Total Billed Charges,90% of Total Billed Charges,971.91,45,,238.536,Percent of Total Billed Charges,45% of Total Billed Charges,1943.82,90,,256.4,Percent of Total Billed Charges,90% of Total billed Charges,2159.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2159.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2159.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1403.87,65,,439.312,Percent of total Billed Charges,65% of Total Billed Charges,952.47,44.1,,233.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,2051.81,95,,270.64,Percent of Total Billed Charges,95% of Total Billed Charges,2159.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1900.62,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,1943.82,90,,256.4,Percent of Total Billed charges,90% of Total Billed Charges,952.47,2159.8,
SYNTHES ELASTIC NAIL 2.0,2780001008,CDM,278,RC,C1713,HCPCS,Outpatient,,,1402.38,911.55,,1402.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1065.81,76,,216.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1009.71,72,,13930.24,Percent of Total Billed Charges,72% of Total Billed Charges,1009.71,72,,13930.24,Percent of Total Billed charges,72% of Total Billed Charges,1402.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1009.71,72,,13930.24,Percent of Total Billed Charges,72% of Total Billed Charges,841.43,60,,11608.528,Percent of Total Billed Charges,60% of Total Billed Charges,1262.14,90,,305.608,Percent of Total Billed Charges,90% of Total Billed Charges,631.07,45,,287.352,Percent of Total Billed Charges,45% of Total Billed Charges,1262.14,90,,256.4,Percent of Total Billed Charges,90% of Total billed Charges,1402.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1402.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1402.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,911.55,65,,200.656,Percent of total Billed Charges,65% of Total Billed Charges,618.45,44.1,,281.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,1332.26,95,,270.64,Percent of Total Billed Charges,95% of Total Billed Charges,1402.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1234.09,88,,3030.904,Percent of Total Billed Charges,88% of Total Billed Charges,1262.14,90,,256.4,Percent of Total Billed charges,90% of Total Billed Charges,618.45,1402.38,
SYNTHES ELASTIC NAIL 1.5,2780001009,CDM,278,RC,C1713,HCPCS,Outpatient,,,1311.98,852.79,,1311.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,997.1,76,,216.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,944.63,72,,4506.24,Percent of Total Billed Charges,72% of Total Billed Charges,944.63,72,,4506.24,Percent of Total Billed charges,72% of Total Billed Charges,1311.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,944.63,72,,4506.24,Percent of Total Billed Charges,72% of Total Billed Charges,787.19,60,,3755.2,Percent of Total Billed Charges,60% of Total Billed Charges,1180.78,90,,402.456,Percent of Total Billed Charges,90% of Total Billed Charges,590.39,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,1180.78,90,,256.4,Percent of Total Billed Charges,90% of Total billed Charges,1311.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,852.79,65,,95.952,Percent of total Billed Charges,65% of Total Billed Charges,578.58,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,1246.38,95,,270.64,Percent of Total Billed Charges,95% of Total Billed Charges,1311.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1154.54,88,,370.224,Percent of Total Billed Charges,88% of Total Billed Charges,1180.78,90,,256.4,Percent of Total Billed charges,90% of Total Billed Charges,578.58,1311.98,
TORNIER 2.2 DRILL BIT,2780001010,CDM,278,RC,C1713,HCPCS,Outpatient,,,227.12,147.63,,227.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,172.61,76,,402.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,163.53,72,,2549.688,Percent of Total Billed Charges,72% of Total Billed Charges,163.53,72,,2549.688,Percent of Total Billed charges,72% of Total Billed Charges,227.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.53,72,,2549.688,Percent of Total Billed Charges,72% of Total Billed Charges,136.27,60,,2124.736,Percent of Total Billed Charges,60% of Total Billed Charges,204.41,90,,646.952,Percent of Total Billed Charges,90% of Total Billed Charges,102.2,45,,1549.896,Percent of Total Billed Charges,45% of Total Billed Charges,204.41,90,,477.072,Percent of Total Billed Charges,90% of Total billed Charges,227.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.63,65,,147.912,Percent of total Billed Charges,65% of Total Billed Charges,100.16,44.1,,1518.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,215.76,95,,503.576,Percent of Total Billed Charges,95% of Total Billed Charges,227.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.87,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,204.41,90,,477.072,Percent of Total Billed charges,90% of Total Billed Charges,100.16,227.12,
SYNTHES ELASTIC NAIL 2 X 440,2780001011,CDM,278,RC,C1713,HCPCS,Outpatient,,,1402.38,911.55,,1402.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1065.81,76,,485.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1009.71,72,,1283.416,Percent of Total Billed Charges,72% of Total Billed Charges,1009.71,72,,1283.416,Percent of Total Billed charges,72% of Total Billed Charges,1402.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1009.71,72,,1283.416,Percent of Total Billed Charges,72% of Total Billed Charges,841.43,60,,1069.512,Percent of Total Billed Charges,60% of Total Billed Charges,1262.14,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,631.07,45,,189.32,Percent of Total Billed Charges,45% of Total Billed Charges,1262.14,90,,574.712,Percent of Total Billed Charges,90% of Total billed Charges,1402.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1402.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1402.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,911.55,65,,1152.336,Percent of total Billed Charges,65% of Total Billed Charges,618.45,44.1,,185.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,1332.26,95,,606.64,Percent of Total Billed Charges,95% of Total Billed Charges,1402.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1234.09,88,,1157.256,Percent of Total Billed Charges,88% of Total Billed Charges,1262.14,90,,574.712,Percent of Total Billed charges,90% of Total Billed Charges,618.45,1402.38,
SYNTHES ELASTIC NAIL 3.0 X 440,2780001012,CDM,278,RC,C1713,HCPCS,Outpatient,,,1503.81,977.48,,1503.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1142.9,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1082.74,72,,3427.312,Percent of Total Billed Charges,72% of Total Billed Charges,1082.74,72,,3427.312,Percent of Total Billed charges,72% of Total Billed Charges,1503.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1082.74,72,,3427.312,Percent of Total Billed Charges,72% of Total Billed Charges,902.29,60,,2856.088,Percent of Total Billed Charges,60% of Total Billed Charges,1353.43,90,,50.8,Percent of Total Billed Charges,90% of Total Billed Charges,676.71,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,1353.43,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,1503.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1503.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1503.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,977.48,65,,240.784,Percent of total Billed Charges,65% of Total Billed Charges,663.18,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,1428.62,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,1503.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1323.35,88,,1879.08,Percent of Total Billed Charges,88% of Total Billed Charges,1353.43,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,663.18,1503.81,
SYNTHES ELASTIC NAIL 3.5 X 440,2780001013,CDM,278,RC,C1713,HCPCS,Outpatient,,,1681.31,1092.85,,1681.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1277.8,76,,2617.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1210.54,72,,5522.944,Percent of Total Billed Charges,72% of Total Billed Charges,1210.54,72,,5522.944,Percent of Total Billed charges,72% of Total Billed Charges,1681.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1210.54,72,,5522.944,Percent of Total Billed Charges,72% of Total Billed Charges,1008.79,60,,4602.448,Percent of Total Billed Charges,60% of Total Billed Charges,1513.18,90,,171.464,Percent of Total Billed Charges,90% of Total Billed Charges,756.59,45,,591.776,Percent of Total Billed Charges,45% of Total Billed Charges,1513.18,90,,3099.784,Percent of Total Billed Charges,90% of Total billed Charges,1681.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1681.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1681.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1092.85,65,,292.504,Percent of total Billed Charges,65% of Total Billed Charges,741.46,44.1,,579.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,1597.24,95,,3272,Percent of Total Billed Charges,95% of Total Billed Charges,1681.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1479.55,88,,298.816,Percent of Total Billed Charges,88% of Total Billed Charges,1513.18,90,,3099.784,Percent of Total Billed charges,90% of Total Billed Charges,741.46,1681.31,
SYNTHES ENDCAP 3.0  4.0,2780001014,CDM,278,RC,C1713,HCPCS,Outpatient,,,423.36,275.18,,423.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,321.75,76,,319.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,304.82,72,,12425.832,Percent of Total Billed Charges,72% of Total Billed Charges,304.82,72,,12425.832,Percent of Total Billed charges,72% of Total Billed Charges,423.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.82,72,,12425.832,Percent of Total Billed Charges,72% of Total Billed Charges,254.02,60,,10354.856,Percent of Total Billed Charges,60% of Total Billed Charges,381.02,90,,195.28,Percent of Total Billed Charges,90% of Total Billed Charges,190.51,45,,960.896,Percent of Total Billed Charges,45% of Total Billed Charges,381.02,90,,378.64,Percent of Total Billed Charges,90% of Total billed Charges,423.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,423.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,423.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.18,65,,292.504,Percent of total Billed Charges,65% of Total Billed Charges,186.7,44.1,,941.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,402.19,95,,399.68,Percent of Total Billed Charges,95% of Total Billed Charges,423.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,372.56,88,,393.512,Percent of Total Billed Charges,88% of Total Billed Charges,381.02,90,,378.64,Percent of Total Billed charges,90% of Total Billed Charges,186.7,423.36,
SYNTHES ENDCAP 1.5  2.5,2780001015,CDM,278,RC,C1713,HCPCS,Outpatient,,,423.36,275.18,,423.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,321.75,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,304.82,72,,3172.024,Percent of Total Billed Charges,72% of Total Billed Charges,304.82,72,,3172.024,Percent of Total Billed charges,72% of Total Billed Charges,423.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.82,72,,3172.024,Percent of Total Billed Charges,72% of Total Billed Charges,254.02,60,,2643.352,Percent of Total Billed Charges,60% of Total Billed Charges,381.02,90,,195.28,Percent of Total Billed Charges,90% of Total Billed Charges,190.51,45,,152.808,Percent of Total Billed Charges,45% of Total Billed Charges,381.02,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,423.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,423.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,423.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.18,65,,245.704,Percent of total Billed Charges,65% of Total Billed Charges,186.7,44.1,,149.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,402.19,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,423.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,372.56,88,,632.576,Percent of Total Billed Charges,88% of Total Billed Charges,381.02,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,186.7,423.36,
Z59523010 ART SURFACE,2780001016,CDM,278,RC,C1713,HCPCS,Outpatient,,,6451.83,4193.69,,6451.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4903.39,76,,999.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4645.32,72,,183.528,Percent of Total Billed Charges,72% of Total Billed Charges,4645.32,72,,183.528,Percent of Total Billed charges,72% of Total Billed Charges,6451.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4645.32,72,,183.528,Percent of Total Billed Charges,72% of Total Billed Charges,3871.1,60,,152.936,Percent of Total Billed Charges,60% of Total Billed Charges,5806.65,90,,118.648,Percent of Total Billed Charges,90% of Total Billed Charges,2903.32,45,,201.232,Percent of Total Billed Charges,45% of Total Billed Charges,5806.65,90,,1183.56,Percent of Total Billed Charges,90% of Total billed Charges,6451.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6451.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6451.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4193.69,65,,245.704,Percent of total Billed Charges,65% of Total Billed Charges,2845.26,44.1,,197.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,6129.24,95,,1249.312,Percent of Total Billed Charges,95% of Total Billed Charges,6451.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5677.61,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,5806.65,90,,1183.56,Percent of Total Billed charges,90% of Total Billed Charges,2845.26,6451.83,
Z59525014 ART SURFACE 14,2780001017,CDM,278,RC,C1713,HCPCS,Outpatient,,,6451.83,4193.69,,6451.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4903.39,76,,1622.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4645.32,72,,38.104,Percent of Total Billed Charges,72% of Total Billed Charges,4645.32,72,,38.104,Percent of Total Billed charges,72% of Total Billed Charges,6451.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4645.32,72,,38.104,Percent of Total Billed Charges,72% of Total Billed Charges,3871.1,60,,31.752,Percent of Total Billed Charges,60% of Total Billed Charges,5806.65,90,,110.816,Percent of Total Billed Charges,90% of Total Billed Charges,2903.32,45,,323.472,Percent of Total Billed Charges,45% of Total Billed Charges,5806.65,90,,1921.792,Percent of Total Billed Charges,90% of Total billed Charges,6451.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6451.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6451.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4193.69,65,,3663.392,Percent of total Billed Charges,65% of Total Billed Charges,2845.26,44.1,,317.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,6129.24,95,,2028.552,Percent of Total Billed Charges,95% of Total Billed Charges,6451.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5677.61,88,,49.672,Percent of Total Billed Charges,88% of Total Billed Charges,5806.65,90,,1921.792,Percent of Total Billed charges,90% of Total Billed Charges,2845.26,6451.83,
Z23592635 LCK SCW 26,2780001018,CDM,278,RC,C1713,HCPCS,Outpatient,,,356.11,231.47,,356.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,270.64,76,,258.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,256.4,72,,468.664,Percent of Total Billed Charges,72% of Total Billed Charges,256.4,72,,468.664,Percent of Total Billed charges,72% of Total Billed Charges,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.4,72,,468.664,Percent of Total Billed Charges,72% of Total Billed Charges,213.67,60,,390.552,Percent of Total Billed Charges,60% of Total Billed Charges,320.5,90,,290.536,Percent of Total Billed Charges,90% of Total Billed Charges,160.25,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,320.5,90,,305.608,Percent of Total Billed Charges,90% of Total billed Charges,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.47,65,,7548.64,Percent of total Billed Charges,65% of Total Billed Charges,157.04,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,338.3,95,,322.592,Percent of Total Billed Charges,95% of Total Billed Charges,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.38,88,,167.648,Percent of Total Billed Charges,88% of Total Billed Charges,320.5,90,,305.608,Percent of Total Billed charges,90% of Total Billed Charges,157.04,356.11,
Z23593235 LCK SCW 32,2780001019,CDM,278,RC,C1713,HCPCS,Outpatient,,,356.11,231.47,,356.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,270.64,76,,339.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,256.4,72,,8454.288,Percent of Total Billed Charges,72% of Total Billed Charges,256.4,72,,8454.288,Percent of Total Billed charges,72% of Total Billed Charges,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.4,72,,8454.288,Percent of Total Billed Charges,72% of Total Billed Charges,213.67,60,,7045.24,Percent of Total Billed Charges,60% of Total Billed Charges,320.5,90,,920.288,Percent of Total Billed Charges,90% of Total Billed Charges,160.25,45,,25.4,Percent of Total Billed Charges,45% of Total Billed Charges,320.5,90,,402.456,Percent of Total Billed Charges,90% of Total billed Charges,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.47,65,,6541.928,Percent of total Billed Charges,65% of Total Billed Charges,157.04,44.1,,24.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,338.3,95,,424.816,Percent of Total Billed Charges,95% of Total Billed Charges,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.38,88,,190.936,Percent of Total Billed Charges,88% of Total Billed Charges,320.5,90,,402.456,Percent of Total Billed charges,90% of Total Billed Charges,157.04,356.11,
Z23595036 LCK SCW 50,2780001020,CDM,278,RC,C1713,HCPCS,Outpatient,,,356.11,231.47,,356.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,270.64,76,,546.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,256.4,72,,1227.528,Percent of Total Billed Charges,72% of Total Billed Charges,256.4,72,,1227.528,Percent of Total Billed charges,72% of Total Billed Charges,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.4,72,,1227.528,Percent of Total Billed Charges,72% of Total Billed Charges,213.67,60,,1022.944,Percent of Total Billed Charges,60% of Total Billed Charges,320.5,90,,144,Percent of Total Billed Charges,90% of Total Billed Charges,160.25,45,,85.728,Percent of Total Billed Charges,45% of Total Billed Charges,320.5,90,,646.952,Percent of Total Billed Charges,90% of Total billed Charges,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.47,65,,319.904,Percent of total Billed Charges,65% of Total Billed Charges,157.04,44.1,,84.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,338.3,95,,682.888,Percent of Total Billed Charges,95% of Total Billed Charges,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.38,88,,190.936,Percent of Total Billed Charges,88% of Total Billed Charges,320.5,90,,646.952,Percent of Total Billed charges,90% of Total Billed Charges,157.04,356.11,
Z23595536 LCK SCW 55,2780001021,CDM,278,RC,C1713,HCPCS,Outpatient,,,356.11,231.47,,356.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,270.64,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,256.4,72,,1017.968,Percent of Total Billed Charges,72% of Total Billed Charges,256.4,72,,1017.968,Percent of Total Billed charges,72% of Total Billed Charges,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.4,72,,1017.968,Percent of Total Billed Charges,72% of Total Billed Charges,213.67,60,,848.312,Percent of Total Billed Charges,60% of Total Billed Charges,320.5,90,,144,Percent of Total Billed Charges,90% of Total Billed Charges,160.25,45,,97.64,Percent of Total Billed Charges,45% of Total Billed Charges,320.5,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.47,65,,102.624,Percent of total Billed Charges,65% of Total Billed Charges,157.04,44.1,,95.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,338.3,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.38,88,,116.016,Percent of Total Billed Charges,88% of Total Billed Charges,320.5,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,157.04,356.11,
Z23596036 LCK SCW 60,2780001022,CDM,278,RC,C1713,HCPCS,Outpatient,,,356.11,231.47,,356.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,270.64,76,,42.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,256.4,72,,11840.32,Percent of Total Billed Charges,72% of Total Billed Charges,256.4,72,,11840.32,Percent of Total Billed charges,72% of Total Billed Charges,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.4,72,,11840.32,Percent of Total Billed Charges,72% of Total Billed Charges,213.67,60,,9866.936,Percent of Total Billed Charges,60% of Total Billed Charges,320.5,90,,502.744,Percent of Total Billed Charges,90% of Total Billed Charges,160.25,45,,97.64,Percent of Total Billed Charges,45% of Total Billed Charges,320.5,90,,50.8,Percent of Total Billed Charges,90% of Total billed Charges,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.47,65,,97.464,Percent of total Billed Charges,65% of Total Billed Charges,157.04,44.1,,95.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,338.3,95,,53.624,Percent of Total Billed Charges,95% of Total Billed Charges,356.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.38,88,,108.352,Percent of Total Billed Charges,88% of Total Billed Charges,320.5,90,,50.8,Percent of Total Billed charges,90% of Total Billed Charges,157.04,356.11,
ACUMED TR-S0702 ELBOW STEM,2780001023,CDM,278,RC,C1713,HCPCS,Outpatient,,,8235.68,5353.19,,8235.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6259.12,76,,144.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5929.69,72,,1903.216,Percent of Total Billed Charges,72% of Total Billed Charges,5929.69,72,,1903.216,Percent of Total Billed charges,72% of Total Billed Charges,8235.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5929.69,72,,1903.216,Percent of Total Billed Charges,72% of Total Billed Charges,4941.41,60,,1586.008,Percent of Total Billed Charges,60% of Total Billed Charges,7412.11,90,,530.488,Percent of Total Billed Charges,90% of Total Billed Charges,3706.06,45,,59.328,Percent of Total Billed Charges,45% of Total Billed Charges,7412.11,90,,171.464,Percent of Total Billed Charges,90% of Total billed Charges,8235.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8235.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8235.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5353.19,65,,89.432,Percent of total Billed Charges,65% of Total Billed Charges,3631.93,44.1,,58.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,7823.9,95,,180.984,Percent of Total Billed Charges,95% of Total Billed Charges,8235.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7247.4,88,,284.08,Percent of Total Billed Charges,88% of Total Billed Charges,7412.11,90,,171.464,Percent of Total Billed charges,90% of Total Billed Charges,3631.93,8235.68,
ACUMED TR-S0704-S ELBOW STEM,2780001024,CDM,278,RC,C1713,HCPCS,Outpatient,,,8235.68,5353.19,,8235.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6259.12,76,,164.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5929.69,72,,489.616,Percent of Total Billed Charges,72% of Total Billed Charges,5929.69,72,,489.616,Percent of Total Billed charges,72% of Total Billed Charges,8235.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5929.69,72,,489.616,Percent of Total Billed Charges,72% of Total Billed Charges,4941.41,60,,408.016,Percent of Total Billed Charges,60% of Total Billed Charges,7412.11,90,,608.28,Percent of Total Billed Charges,90% of Total Billed Charges,3706.06,45,,55.408,Percent of Total Billed Charges,45% of Total Billed Charges,7412.11,90,,195.28,Percent of Total Billed Charges,90% of Total billed Charges,8235.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8235.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8235.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5353.19,65,,59.336,Percent of total Billed Charges,65% of Total Billed Charges,3631.93,44.1,,54.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,7823.9,95,,206.128,Percent of Total Billed Charges,95% of Total Billed Charges,8235.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7247.4,88,,899.84,Percent of Total Billed Charges,88% of Total Billed Charges,7412.11,90,,195.28,Percent of Total Billed charges,90% of Total Billed Charges,3631.93,8235.68,
ACUMED TRH200R HEAD RT,2780001025,CDM,278,RC,C1713,HCPCS,Outpatient,,,13528.78,8793.71,,13528.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10281.87,76,,164.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9740.72,72,,489.616,Percent of Total Billed Charges,72% of Total Billed Charges,9740.72,72,,489.616,Percent of Total Billed charges,72% of Total Billed Charges,13528.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9740.72,72,,489.616,Percent of Total Billed Charges,72% of Total Billed Charges,8117.27,60,,408.016,Percent of Total Billed Charges,60% of Total Billed Charges,12175.9,90,,277.832,Percent of Total Billed Charges,90% of Total Billed Charges,6087.95,45,,145.264,Percent of Total Billed Charges,45% of Total Billed Charges,12175.9,90,,195.28,Percent of Total Billed Charges,90% of Total billed Charges,13528.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13528.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13528.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8793.71,65,,59.336,Percent of total Billed Charges,65% of Total Billed Charges,5966.19,44.1,,142.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,12852.34,95,,206.128,Percent of Total Billed Charges,95% of Total Billed Charges,13528.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11905.33,88,,140.8,Percent of Total Billed Charges,88% of Total Billed Charges,12175.9,90,,195.28,Percent of Total Billed charges,90% of Total Billed Charges,5966.19,13528.78,
ACUMED AT2M245,2780001026,CDM,278,RC,C1713,HCPCS,Outpatient,,,2255.72,1466.22,,2255.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1714.35,76,,100.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1624.12,72,,468.664,Percent of Total Billed Charges,72% of Total Billed Charges,1624.12,72,,468.664,Percent of Total Billed charges,72% of Total Billed Charges,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1624.12,72,,468.664,Percent of Total Billed Charges,72% of Total Billed Charges,1353.43,60,,390.552,Percent of Total Billed Charges,60% of Total Billed Charges,2030.15,90,,132.856,Percent of Total Billed Charges,90% of Total Billed Charges,1015.07,45,,460.144,Percent of Total Billed Charges,45% of Total Billed Charges,2030.15,90,,118.648,Percent of Total Billed Charges,90% of Total billed Charges,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1466.22,65,,59.336,Percent of total Billed Charges,65% of Total Billed Charges,994.77,44.1,,450.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,2142.93,95,,125.24,Percent of Total Billed Charges,95% of Total Billed Charges,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1985.03,88,,140.8,Percent of Total Billed Charges,88% of Total Billed Charges,2030.15,90,,118.648,Percent of Total Billed charges,90% of Total Billed Charges,994.77,2255.72,
ACUMED AT2M1813 DRILLBIT,2780001027,CDM,278,RC,C1713,HCPCS,Outpatient,,,364.93,237.20,,364.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,277.35,76,,93.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,262.75,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,262.75,72,,36.192,Percent of Total Billed charges,72% of Total Billed Charges,364.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.75,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,218.96,60,,30.16,Percent of Total Billed Charges,60% of Total Billed Charges,328.44,90,,204.808,Percent of Total Billed Charges,90% of Total Billed Charges,164.22,45,,72,Percent of Total Billed Charges,45% of Total Billed Charges,328.44,90,,110.816,Percent of Total Billed Charges,90% of Total billed Charges,364.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.2,65,,59.336,Percent of total Billed Charges,65% of Total Billed Charges,160.93,44.1,,70.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,346.68,95,,116.968,Percent of Total Billed Charges,95% of Total Billed Charges,364.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,321.14,88,,491.568,Percent of Total Billed Charges,88% of Total Billed Charges,328.44,90,,110.816,Percent of Total Billed charges,90% of Total Billed Charges,160.93,364.93,
ACUMED 800971 GUIDEWIRE,2780001028,CDM,278,RC,C1713,HCPCS,Outpatient,,,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,245.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,21.43,72,,36.192,Percent of Total Billed charges,72% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,30.16,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,1595.544,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,72,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,290.536,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,34.168,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,70.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,306.672,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,518.704,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,290.536,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
ACUMED 800975 DRILL 7.5,2780001029,CDM,278,RC,C1713,HCPCS,Outpatient,,,529.20,343.98,,529.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,402.19,76,,777.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,381.02,72,,2780.84,Percent of Total Billed Charges,72% of Total Billed Charges,381.02,72,,2780.84,Percent of Total Billed charges,72% of Total Billed Charges,529.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.02,72,,2780.84,Percent of Total Billed Charges,72% of Total Billed Charges,317.52,60,,2317.368,Percent of Total Billed Charges,60% of Total Billed Charges,476.28,90,,333.4,Percent of Total Billed Charges,90% of Total Billed Charges,238.14,45,,251.368,Percent of Total Billed Charges,45% of Total Billed Charges,476.28,90,,920.288,Percent of Total Billed Charges,90% of Total billed Charges,529.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.98,65,,20.096,Percent of total Billed Charges,65% of Total Billed Charges,233.38,44.1,,246.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,502.74,95,,971.416,Percent of Total Billed Charges,95% of Total Billed Charges,529.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.7,88,,594.76,Percent of Total Billed Charges,88% of Total Billed Charges,476.28,90,,920.288,Percent of Total Billed charges,90% of Total Billed Charges,233.38,529.2,
ACUMED 800976 DRILL 7.5C,2780001030,CDM,278,RC,C1713,HCPCS,Outpatient,,,529.20,343.98,,529.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,402.19,76,,121.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,381.02,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,381.02,72,,36.192,Percent of Total Billed charges,72% of Total Billed Charges,529.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.02,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,317.52,60,,30.16,Percent of Total Billed Charges,60% of Total Billed Charges,476.28,90,,405,Percent of Total Billed Charges,90% of Total Billed Charges,238.14,45,,265.248,Percent of Total Billed Charges,45% of Total Billed Charges,476.28,90,,144,Percent of Total Billed Charges,90% of Total billed Charges,529.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.98,65,,20.096,Percent of total Billed Charges,65% of Total Billed Charges,233.38,44.1,,259.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,502.74,95,,152,Percent of Total Billed Charges,95% of Total Billed Charges,529.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.7,88,,271.656,Percent of Total Billed Charges,88% of Total Billed Charges,476.28,90,,144,Percent of Total Billed charges,90% of Total Billed Charges,233.38,529.2,
ACUMED 300775 SCW 85,2780001031,CDM,278,RC,C1713,HCPCS,Outpatient,,,2466.29,1603.09,,2466.29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1874.38,76,,121.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1775.73,72,,341.016,Percent of Total Billed Charges,72% of Total Billed Charges,1775.73,72,,341.016,Percent of Total Billed charges,72% of Total Billed Charges,2466.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1775.73,72,,341.016,Percent of Total Billed Charges,72% of Total Billed Charges,1479.77,60,,284.176,Percent of Total Billed Charges,60% of Total Billed Charges,2219.66,90,,405,Percent of Total Billed Charges,90% of Total Billed Charges,1109.83,45,,304.136,Percent of Total Billed Charges,45% of Total Billed Charges,2219.66,90,,144,Percent of Total Billed Charges,90% of Total billed Charges,2466.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2466.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2466.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1603.09,65,,20.096,Percent of total Billed Charges,65% of Total Billed Charges,1087.63,44.1,,298.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,2342.98,95,,152,Percent of Total Billed Charges,95% of Total Billed Charges,2466.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2170.34,88,,129.904,Percent of Total Billed Charges,88% of Total Billed Charges,2219.66,90,,144,Percent of Total Billed charges,90% of Total Billed Charges,1087.63,2466.29,
ACUMED 300785 SCW 75,2780001032,CDM,278,RC,C1713,HCPCS,Outpatient,,,2466.29,1603.09,,2466.29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1874.38,76,,424.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1775.73,72,,9810.096,Percent of Total Billed Charges,72% of Total Billed Charges,1775.73,72,,9810.096,Percent of Total Billed charges,72% of Total Billed Charges,2466.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1775.73,72,,9810.096,Percent of Total Billed Charges,72% of Total Billed Charges,1479.77,60,,8175.08,Percent of Total Billed Charges,60% of Total Billed Charges,2219.66,90,,340.2,Percent of Total Billed Charges,90% of Total Billed Charges,1109.83,45,,138.92,Percent of Total Billed Charges,45% of Total Billed Charges,2219.66,90,,502.744,Percent of Total Billed Charges,90% of Total billed Charges,2466.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2466.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2466.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1603.09,65,,30.792,Percent of total Billed Charges,65% of Total Billed Charges,1087.63,44.1,,136.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,2342.98,95,,530.672,Percent of Total Billed Charges,95% of Total Billed Charges,2466.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2170.34,88,,200.256,Percent of Total Billed Charges,88% of Total Billed Charges,2219.66,90,,502.744,Percent of Total Billed charges,90% of Total Billed Charges,1087.63,2466.29,
ACUMED 300795 SCW 95,2780001033,CDM,278,RC,C1713,HCPCS,Outpatient,,,2466.29,1603.09,,2466.29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1874.38,76,,447.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1775.73,72,,301.792,Percent of Total Billed Charges,72% of Total Billed Charges,1775.73,72,,301.792,Percent of Total Billed charges,72% of Total Billed Charges,2466.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1775.73,72,,301.792,Percent of Total Billed Charges,72% of Total Billed Charges,1479.77,60,,251.496,Percent of Total Billed Charges,60% of Total Billed Charges,2219.66,90,,340.2,Percent of Total Billed Charges,90% of Total Billed Charges,1109.83,45,,66.424,Percent of Total Billed Charges,45% of Total Billed Charges,2219.66,90,,530.488,Percent of Total Billed Charges,90% of Total billed Charges,2466.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2466.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2466.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1603.09,65,,30.792,Percent of total Billed Charges,65% of Total Billed Charges,1087.63,44.1,,65.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,2342.98,95,,559.96,Percent of Total Billed Charges,95% of Total Billed Charges,2466.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2170.34,88,,1560.088,Percent of Total Billed Charges,88% of Total Billed Charges,2219.66,90,,530.488,Percent of Total Billed charges,90% of Total Billed Charges,1087.63,2466.29,
ACUMED WS0906ST KWIRE,2780001034,CDM,278,RC,C1713,HCPCS,Outpatient,,,92.61,60.20,,92.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,70.38,76,,513.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,66.68,72,,3805.632,Percent of Total Billed Charges,72% of Total Billed Charges,66.68,72,,3805.632,Percent of Total Billed charges,72% of Total Billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.68,72,,3805.632,Percent of Total Billed Charges,72% of Total Billed Charges,55.57,60,,3171.36,Percent of Total Billed Charges,60% of Total Billed Charges,83.35,90,,5072.384,Percent of Total Billed Charges,90% of Total Billed Charges,41.67,45,,102.4,Percent of Total Billed Charges,45% of Total Billed Charges,83.35,90,,608.28,Percent of Total Billed Charges,90% of Total billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.2,65,,10998.184,Percent of total Billed Charges,65% of Total Billed Charges,40.84,44.1,,100.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,87.98,95,,642.072,Percent of Total Billed Charges,95% of Total Billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.5,88,,325.984,Percent of Total Billed Charges,88% of Total Billed Charges,83.35,90,,608.28,Percent of Total Billed charges,90% of Total Billed Charges,40.84,92.61,
ACUMED AT21509 MICRO DRILL,2780001035,CDM,278,RC,C1713,HCPCS,Outpatient,,,633.94,412.06,,633.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,481.79,76,,234.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,456.44,72,,393.728,Percent of Total Billed Charges,72% of Total Billed Charges,456.44,72,,410.128,Percent of Total Billed charges,72% of Total Billed Charges,633.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.44,72,,393.728,Percent of Total Billed Charges,72% of Total Billed Charges,380.36,60,,328.104,Percent of Total Billed Charges,60% of Total Billed Charges,570.55,90,,10451.968,Percent of Total Billed Charges,90% of Total Billed Charges,285.27,45,,797.768,Percent of Total Billed Charges,45% of Total Billed Charges,570.55,90,,277.832,Percent of Total Billed Charges,90% of Total billed Charges,633.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,633.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,633.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.06,65,,1088.696,Percent of total Billed Charges,65% of Total Billed Charges,279.57,44.1,,781.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,602.24,95,,293.272,Percent of Total Billed Charges,95% of Total Billed Charges,633.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,557.87,88,,396,Percent of Total Billed Charges,88% of Total Billed Charges,570.55,90,,277.832,Percent of Total Billed charges,90% of Total Billed Charges,279.57,633.94,
ACUMED AT2C11S SCW11.0,2780001036,CDM,278,RC,C1713,HCPCS,Outpatient,,,1271.18,826.27,,1271.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,966.1,76,,112.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,915.25,72,,393.728,Percent of Total Billed Charges,72% of Total Billed Charges,915.25,72,,393.728,Percent of Total Billed charges,72% of Total Billed Charges,1271.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,915.25,72,,393.728,Percent of Total Billed Charges,72% of Total Billed Charges,762.71,60,,328.104,Percent of Total Billed Charges,60% of Total Billed Charges,1144.06,90,,9058.056,Percent of Total Billed Charges,90% of Total Billed Charges,572.03,45,,166.696,Percent of Total Billed Charges,45% of Total Billed Charges,1144.06,90,,132.856,Percent of Total Billed Charges,90% of Total billed Charges,1271.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1271.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1271.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.27,65,,3238,Percent of total Billed Charges,65% of Total Billed Charges,560.59,44.1,,163.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,1207.62,95,,140.232,Percent of Total Billed Charges,95% of Total Billed Charges,1271.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1118.64,88,,396,Percent of Total Billed Charges,88% of Total Billed Charges,1144.06,90,,132.856,Percent of Total Billed charges,90% of Total Billed Charges,560.59,1271.18,
ACUMED AT2C18 MICROSCW,2780001037,CDM,278,RC,C1713,HCPCS,Outpatient,,,2255.72,1466.22,,2255.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1714.35,76,,172.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1624.12,72,,1638.4,Percent of Total Billed Charges,72% of Total Billed Charges,1624.12,72,,1706.672,Percent of Total Billed charges,72% of Total Billed Charges,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1624.12,72,,1638.4,Percent of Total Billed Charges,72% of Total Billed Charges,1353.43,60,,1365.336,Percent of Total Billed Charges,60% of Total Billed Charges,2030.15,90,,442.944,Percent of Total Billed Charges,90% of Total Billed Charges,1015.07,45,,202.504,Percent of Total Billed Charges,45% of Total Billed Charges,2030.15,90,,204.808,Percent of Total Billed Charges,90% of Total billed Charges,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1466.22,65,,1238.904,Percent of total Billed Charges,65% of Total Billed Charges,994.77,44.1,,198.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,2142.93,95,,216.184,Percent of Total Billed Charges,95% of Total Billed Charges,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1985.03,88,,332.64,Percent of Total Billed Charges,88% of Total Billed Charges,2030.15,90,,204.808,Percent of Total Billed charges,90% of Total Billed Charges,994.77,2255.72,
ACUMED AT2 M30 MINISCW,2780001038,CDM,278,RC,C1713,HCPCS,Outpatient,,,2255.72,1466.22,,2255.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1714.35,76,,1347.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1624.12,72,,350.784,Percent of Total Billed Charges,72% of Total Billed Charges,1624.12,72,,350.784,Percent of Total Billed charges,72% of Total Billed Charges,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1624.12,72,,350.784,Percent of Total Billed Charges,72% of Total Billed Charges,1353.43,60,,292.32,Percent of Total Billed Charges,60% of Total Billed Charges,2030.15,90,,142.096,Percent of Total Billed Charges,90% of Total Billed Charges,1015.07,45,,202.504,Percent of Total Billed Charges,45% of Total Billed Charges,2030.15,90,,1595.544,Percent of Total Billed Charges,90% of Total billed Charges,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1466.22,65,,1888.456,Percent of total Billed Charges,65% of Total Billed Charges,994.77,44.1,,198.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,2142.93,95,,1684.184,Percent of Total Billed Charges,95% of Total Billed Charges,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1985.03,88,,332.64,Percent of Total Billed Charges,88% of Total Billed Charges,2030.15,90,,1595.544,Percent of Total Billed charges,90% of Total Billed Charges,994.77,2255.72,
ACUMED AT2 M16 MINISCW,2780001039,CDM,278,RC,C1713,HCPCS,Outpatient,,,2255.72,1466.22,,2255.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1714.35,76,,281.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1624.12,72,,350.784,Percent of Total Billed Charges,72% of Total Billed Charges,1624.12,72,,365.4,Percent of Total Billed charges,72% of Total Billed Charges,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1624.12,72,,350.784,Percent of Total Billed Charges,72% of Total Billed Charges,1353.43,60,,292.32,Percent of Total Billed Charges,60% of Total Billed Charges,2030.15,90,,134.952,Percent of Total Billed Charges,90% of Total Billed Charges,1015.07,45,,170.104,Percent of Total Billed Charges,45% of Total Billed Charges,2030.15,90,,333.4,Percent of Total Billed Charges,90% of Total billed Charges,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1466.22,65,,2751.272,Percent of total Billed Charges,65% of Total Billed Charges,994.77,44.1,,166.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,2142.93,95,,351.92,Percent of Total Billed Charges,95% of Total Billed Charges,2255.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1985.03,88,,4959.664,Percent of Total Billed Charges,88% of Total Billed Charges,2030.15,90,,333.4,Percent of Total Billed charges,90% of Total Billed Charges,994.77,2255.72,
Z11473040 CANNU 4.,2780001040,CDM,278,RC,C1713,HCPCS,Outpatient,,,652.68,424.24,,652.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,496.04,76,,342,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,469.93,72,,350.784,Percent of Total Billed Charges,72% of Total Billed Charges,469.93,72,,365.4,Percent of Total Billed charges,72% of Total Billed Charges,652.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,469.93,72,,350.784,Percent of Total Billed Charges,72% of Total Billed Charges,391.61,60,,292.32,Percent of Total Billed Charges,60% of Total Billed Charges,587.41,90,,123.832,Percent of Total Billed Charges,90% of Total Billed Charges,293.71,45,,170.104,Percent of Total Billed Charges,45% of Total Billed Charges,587.41,90,,405,Percent of Total Billed Charges,90% of Total billed Charges,652.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,652.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,652.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.24,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,287.83,44.1,,166.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,620.05,95,,427.504,Percent of Total Billed Charges,95% of Total Billed Charges,652.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,574.36,88,,10219.704,Percent of Total Billed Charges,88% of Total Billed Charges,587.41,90,,405,Percent of Total Billed charges,90% of Total Billed Charges,287.83,652.68,
Z11473440 CANNU 4.,2780001041,CDM,278,RC,C1713,HCPCS,Outpatient,,,652.68,424.24,,652.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,496.04,76,,342,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,469.93,72,,350.784,Percent of Total Billed Charges,72% of Total Billed Charges,469.93,72,,350.784,Percent of Total Billed charges,72% of Total Billed Charges,652.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,469.93,72,,350.784,Percent of Total Billed Charges,72% of Total Billed Charges,391.61,60,,292.32,Percent of Total Billed Charges,60% of Total Billed Charges,587.41,90,,82.152,Percent of Total Billed Charges,90% of Total Billed Charges,293.71,45,,2536.192,Percent of Total Billed Charges,45% of Total Billed Charges,587.41,90,,405,Percent of Total Billed Charges,90% of Total billed Charges,652.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,652.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,652.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.24,65,,162.248,Percent of total Billed Charges,65% of Total Billed Charges,287.83,44.1,,2485.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,620.05,95,,427.504,Percent of Total Billed Charges,95% of Total Billed Charges,652.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,574.36,88,,8856.76,Percent of Total Billed Charges,88% of Total Billed Charges,587.41,90,,405,Percent of Total Billed charges,90% of Total Billed Charges,287.83,652.68,
Z225236009 FEMRECO,2780001042,CDM,278,RC,C1713,HCPCS,Outpatient,,,3160.87,2054.57,,3160.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2402.26,76,,287.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2275.83,72,,12759.224,Percent of Total Billed Charges,72% of Total Billed Charges,2275.83,72,,12759.224,Percent of Total Billed charges,72% of Total Billed Charges,3160.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2275.83,72,,12759.224,Percent of Total Billed Charges,72% of Total Billed Charges,1896.52,60,,10632.688,Percent of Total Billed Charges,60% of Total Billed Charges,2844.78,90,,82.152,Percent of Total Billed Charges,90% of Total Billed Charges,1422.39,45,,5225.984,Percent of Total Billed Charges,45% of Total Billed Charges,2844.78,90,,340.2,Percent of Total Billed Charges,90% of Total billed Charges,3160.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3160.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3160.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2054.57,65,,194.352,Percent of total Billed Charges,65% of Total Billed Charges,1393.94,44.1,,5121.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,3002.83,95,,359.104,Percent of Total Billed Charges,95% of Total Billed Charges,3160.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2781.57,88,,433.104,Percent of Total Billed Charges,88% of Total Billed Charges,2844.78,90,,340.2,Percent of Total Billed charges,90% of Total Billed Charges,1393.94,3160.87,
SYNTHES NAIL 2.5X440,2780001043,CDM,278,RC,C1713,HCPCS,Outpatient,,,1534.68,997.54,,1534.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1166.36,76,,287.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1104.97,72,,328.952,Percent of Total Billed Charges,72% of Total Billed Charges,1104.97,72,,328.952,Percent of Total Billed charges,72% of Total Billed Charges,1534.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1104.97,72,,328.952,Percent of Total Billed Charges,72% of Total Billed Charges,920.81,60,,274.128,Percent of Total Billed Charges,60% of Total Billed Charges,1381.21,90,,82.152,Percent of Total Billed Charges,90% of Total Billed Charges,690.61,45,,4529.024,Percent of Total Billed Charges,45% of Total Billed Charges,1381.21,90,,340.2,Percent of Total Billed Charges,90% of Total billed Charges,1534.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1534.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1534.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,997.54,65,,718.536,Percent of total Billed Charges,65% of Total Billed Charges,676.79,44.1,,4438.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,1457.95,95,,359.104,Percent of Total Billed Charges,95% of Total Billed Charges,1534.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1350.52,88,,138.936,Percent of Total Billed Charges,88% of Total Billed Charges,1381.21,90,,340.2,Percent of Total Billed charges,90% of Total Billed Charges,676.79,1534.68,
Z11472635 CANN SCFW 26,2780001044,CDM,278,RC,C1713,HCPCS,Outpatient,,,592.04,384.83,,592.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,449.95,76,,4283.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,426.27,72,,5379.424,Percent of Total Billed Charges,72% of Total Billed Charges,426.27,72,,5379.424,Percent of Total Billed charges,72% of Total Billed Charges,592.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.27,72,,5379.424,Percent of Total Billed Charges,72% of Total Billed Charges,355.22,60,,4482.856,Percent of Total Billed Charges,60% of Total Billed Charges,532.84,90,,82.152,Percent of Total Billed Charges,90% of Total Billed Charges,266.42,45,,221.472,Percent of Total Billed Charges,45% of Total Billed Charges,532.84,90,,5072.384,Percent of Total Billed Charges,90% of Total billed Charges,592.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.83,65,,2619.24,Percent of total Billed Charges,65% of Total Billed Charges,261.09,44.1,,217.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,562.44,95,,5354.184,Percent of Total Billed Charges,95% of Total Billed Charges,592.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521,88,,131.952,Percent of Total Billed Charges,88% of Total Billed Charges,532.84,90,,5072.384,Percent of Total Billed charges,90% of Total Billed Charges,261.09,592.04,
Z11473035 CANN SCW 30,2780001045,CDM,278,RC,C1713,HCPCS,Outpatient,,,592.04,384.83,,592.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,449.95,76,,8826.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,426.27,72,,162.568,Percent of Total Billed Charges,72% of Total Billed Charges,426.27,72,,162.568,Percent of Total Billed charges,72% of Total Billed Charges,592.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.27,72,,162.568,Percent of Total Billed Charges,72% of Total Billed Charges,355.22,60,,135.472,Percent of Total Billed Charges,60% of Total Billed Charges,532.84,90,,47.312,Percent of Total Billed Charges,90% of Total Billed Charges,266.42,45,,71.048,Percent of Total Billed Charges,45% of Total Billed Charges,532.84,90,,10451.968,Percent of Total Billed Charges,90% of Total billed Charges,592.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.83,65,,389.272,Percent of total Billed Charges,65% of Total Billed Charges,261.09,44.1,,69.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,562.44,95,,11032.632,Percent of Total Billed Charges,95% of Total Billed Charges,592.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521,88,,121.08,Percent of Total Billed Charges,88% of Total Billed Charges,532.84,90,,10451.968,Percent of Total Billed charges,90% of Total Billed Charges,261.09,592.04,
Z11473435 CANN SCW 24,2780001046,CDM,278,RC,C1713,HCPCS,Outpatient,,,592.04,384.83,,592.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,449.95,76,,7649.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,426.27,72,,10906.176,Percent of Total Billed Charges,72% of Total Billed Charges,426.27,72,,10906.176,Percent of Total Billed charges,72% of Total Billed Charges,592.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.27,72,,10906.176,Percent of Total Billed Charges,72% of Total Billed Charges,355.22,60,,9088.48,Percent of Total Billed Charges,60% of Total Billed Charges,532.84,90,,27.824,Percent of Total Billed Charges,90% of Total Billed Charges,266.42,45,,67.472,Percent of Total Billed Charges,45% of Total Billed Charges,532.84,90,,9058.056,Percent of Total Billed Charges,90% of Total billed Charges,592.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.83,65,,36.688,Percent of total Billed Charges,65% of Total Billed Charges,261.09,44.1,,66.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,562.44,95,,9561.28,Percent of Total Billed Charges,95% of Total Billed Charges,592.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521,88,,80.328,Percent of Total Billed Charges,88% of Total Billed Charges,532.84,90,,9058.056,Percent of Total Billed charges,90% of Total Billed Charges,261.09,592.04,
Z500142 BIPOLAR SHELL 42,2780001047,CDM,278,RC,C1713,HCPCS,Outpatient,,,2634.98,1712.74,,2634.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2002.58,76,,374.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1897.19,72,,11710.768,Percent of Total Billed Charges,72% of Total Billed Charges,1897.19,72,,11710.768,Percent of Total Billed charges,72% of Total Billed Charges,2634.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1897.19,72,,11710.768,Percent of Total Billed Charges,72% of Total Billed Charges,1580.99,60,,9758.976,Percent of Total Billed Charges,60% of Total Billed Charges,2371.48,90,,27.824,Percent of Total Billed Charges,90% of Total Billed Charges,1185.74,45,,61.92,Percent of Total Billed Charges,45% of Total Billed Charges,2371.48,90,,442.944,Percent of Total Billed Charges,90% of Total billed Charges,2634.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2634.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2634.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1712.74,65,,36.12,Percent of total Billed Charges,65% of Total Billed Charges,1162.03,44.1,,60.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,2503.23,95,,467.552,Percent of Total Billed Charges,95% of Total Billed Charges,2634.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2318.78,88,,80.328,Percent of Total Billed Charges,88% of Total Billed Charges,2371.48,90,,442.944,Percent of Total Billed charges,90% of Total Billed Charges,1162.03,2634.98,
Z59525012 ART SURFACE 12MM,2780001048,CDM,278,RC,C1713,HCPCS,Outpatient,,,6144.23,3993.75,,6144.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4669.61,76,,119.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4423.85,72,,4466.872,Percent of Total Billed Charges,72% of Total Billed Charges,4423.85,72,,4466.872,Percent of Total Billed charges,72% of Total Billed Charges,6144.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4423.85,72,,4466.872,Percent of Total Billed Charges,72% of Total Billed Charges,3686.54,60,,3722.392,Percent of Total Billed Charges,60% of Total Billed Charges,5529.81,90,,27.824,Percent of Total Billed Charges,90% of Total Billed Charges,2764.9,45,,41.08,Percent of Total Billed Charges,45% of Total Billed Charges,5529.81,90,,142.096,Percent of Total Billed Charges,90% of Total billed Charges,6144.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6144.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6144.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3993.75,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,2709.61,44.1,,40.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,5837.02,95,,149.984,Percent of Total Billed Charges,95% of Total Billed Charges,6144.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5406.92,88,,80.328,Percent of Total Billed Charges,88% of Total Billed Charges,5529.81,90,,142.096,Percent of Total Billed charges,90% of Total Billed Charges,2709.61,6144.23,
49200219 L PLATE 2.0 RIGHT,2780001049,CDM,278,RC,C1713,HCPCS,Outpatient,,,791.60,514.54,,791.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,601.62,76,,113.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,569.95,72,,4466.872,Percent of Total Billed Charges,72% of Total Billed Charges,569.95,72,,4466.872,Percent of Total Billed charges,72% of Total Billed Charges,791.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569.95,72,,4466.872,Percent of Total Billed Charges,72% of Total Billed Charges,474.96,60,,3722.392,Percent of Total Billed Charges,60% of Total Billed Charges,712.44,90,,42.64,Percent of Total Billed Charges,90% of Total Billed Charges,356.22,45,,41.08,Percent of Total Billed Charges,45% of Total Billed Charges,712.44,90,,134.952,Percent of Total Billed Charges,90% of Total billed Charges,791.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,791.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,791.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,514.54,65,,40.136,Percent of total Billed Charges,65% of Total Billed Charges,349.1,44.1,,40.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,752.02,95,,142.448,Percent of Total Billed Charges,95% of Total Billed Charges,791.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,696.61,88,,80.328,Percent of Total Billed Charges,88% of Total Billed Charges,712.44,90,,134.952,Percent of Total Billed charges,90% of Total Billed Charges,349.1,791.6,
Z23593424 2.4 LOCKING SCW 34,2780001050,CDM,278,RC,C1713,HCPCS,Outpatient,,,329.65,214.27,,329.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,250.53,76,,104.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,237.35,72,,4466.872,Percent of Total Billed Charges,72% of Total Billed Charges,237.35,72,,4466.872,Percent of Total Billed charges,72% of Total Billed Charges,329.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.35,72,,4466.872,Percent of Total Billed Charges,72% of Total Billed Charges,197.79,60,,3722.392,Percent of Total Billed Charges,60% of Total Billed Charges,296.69,90,,42.64,Percent of Total Billed Charges,90% of Total Billed Charges,148.34,45,,41.08,Percent of Total Billed Charges,45% of Total Billed Charges,296.69,90,,123.832,Percent of Total Billed Charges,90% of Total billed Charges,329.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.27,65,,50.448,Percent of total Billed Charges,65% of Total Billed Charges,145.38,44.1,,40.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,313.17,95,,130.712,Percent of Total Billed Charges,95% of Total Billed Charges,329.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290.09,88,,46.256,Percent of Total Billed Charges,88% of Total Billed Charges,296.69,90,,123.832,Percent of Total Billed charges,90% of Total Billed Charges,145.38,329.65,
Z CEMENT R,2780001051,CDM,278,RC,C1713,HCPCS,Outpatient,,,94.82,61.63,,94.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.06,76,,69.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,68.27,72,,5253.048,Percent of Total Billed Charges,72% of Total Billed Charges,68.27,72,,5253.048,Percent of Total Billed charges,72% of Total Billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.27,72,,5253.048,Percent of Total Billed Charges,72% of Total Billed Charges,56.89,60,,4377.544,Percent of Total Billed Charges,60% of Total Billed Charges,85.34,90,,15228.256,Percent of Total Billed Charges,90% of Total Billed Charges,42.67,45,,41.08,Percent of Total Billed Charges,45% of Total Billed Charges,85.34,90,,82.152,Percent of Total Billed Charges,90% of Total billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.63,65,,252.824,Percent of total Billed Charges,65% of Total Billed Charges,41.82,44.1,,40.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,90.08,95,,86.72,Percent of Total Billed Charges,95% of Total Billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.44,88,,27.2,Percent of Total Billed Charges,88% of Total Billed Charges,85.34,90,,82.152,Percent of Total Billed charges,90% of Total Billed Charges,41.82,94.82,
Z CEMENT RG,2780001052,CDM,278,RC,C1713,HCPCS,Outpatient,,,375.95,244.37,,375.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285.72,76,,69.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270.68,72,,11423.736,Percent of Total Billed Charges,72% of Total Billed Charges,270.68,72,,11423.736,Percent of Total Billed charges,72% of Total Billed Charges,375.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.68,72,,11423.736,Percent of Total Billed Charges,72% of Total Billed Charges,225.57,60,,9519.776,Percent of Total Billed Charges,60% of Total Billed Charges,338.36,90,,1507.432,Percent of Total Billed Charges,90% of Total Billed Charges,169.18,45,,23.656,Percent of Total Billed Charges,45% of Total Billed Charges,338.36,90,,82.152,Percent of Total Billed Charges,90% of Total billed Charges,375.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.37,65,,30.576,Percent of total Billed Charges,65% of Total Billed Charges,165.79,44.1,,23.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,357.15,95,,86.72,Percent of Total Billed Charges,95% of Total Billed Charges,375.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330.84,88,,27.2,Percent of Total Billed Charges,88% of Total Billed Charges,338.36,90,,82.152,Percent of Total Billed charges,90% of Total Billed Charges,165.79,375.95,
Z CEMENT LVG,2780001053,CDM,278,RC,C1713,HCPCS,Outpatient,,,375.95,244.37,,375.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285.72,76,,69.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270.68,72,,11423.736,Percent of Total Billed Charges,72% of Total Billed Charges,270.68,72,,11423.736,Percent of Total Billed charges,72% of Total Billed Charges,375.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.68,72,,11423.736,Percent of Total Billed Charges,72% of Total Billed Charges,225.57,60,,9519.776,Percent of Total Billed Charges,60% of Total Billed Charges,338.36,90,,4483.384,Percent of Total Billed Charges,90% of Total Billed Charges,169.18,45,,13.912,Percent of Total Billed Charges,45% of Total Billed Charges,338.36,90,,82.152,Percent of Total Billed Charges,90% of Total billed Charges,375.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.37,65,,30.576,Percent of total Billed Charges,65% of Total Billed Charges,165.79,44.1,,13.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,357.15,95,,86.72,Percent of Total Billed Charges,95% of Total Billed Charges,375.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330.84,88,,27.2,Percent of Total Billed Charges,88% of Total Billed Charges,338.36,90,,82.152,Percent of Total Billed charges,90% of Total Billed Charges,165.79,375.95,
Z225210055 RECON SCREW 100MM,2780001054,CDM,278,RC,C1713,HCPCS,Outpatient,,,775.06,503.79,,775.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,589.05,76,,69.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,558.04,72,,11423.736,Percent of Total Billed Charges,72% of Total Billed Charges,558.04,72,,11423.736,Percent of Total Billed charges,72% of Total Billed Charges,775.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.04,72,,11423.736,Percent of Total Billed Charges,72% of Total Billed Charges,465.04,60,,9519.776,Percent of Total Billed Charges,60% of Total Billed Charges,697.55,90,,1715.4,Percent of Total Billed Charges,90% of Total Billed Charges,348.78,45,,13.912,Percent of Total Billed Charges,45% of Total Billed Charges,697.55,90,,82.152,Percent of Total Billed Charges,90% of Total billed Charges,775.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,775.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,775.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,503.79,65,,75.92,Percent of total Billed Charges,65% of Total Billed Charges,341.8,44.1,,13.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,736.31,95,,86.72,Percent of Total Billed Charges,95% of Total Billed Charges,775.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,682.05,88,,41.688,Percent of Total Billed Charges,88% of Total Billed Charges,697.55,90,,82.152,Percent of Total Billed charges,90% of Total Billed Charges,341.8,775.06,
ACUMED AT 2S34S SCREW 34MM,2780001055,CDM,278,RC,C1713,HCPCS,Outpatient,,,2191.77,1424.65,,2191.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1665.75,76,,39.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1578.07,72,,11423.736,Percent of Total Billed Charges,72% of Total Billed Charges,1578.07,72,,11423.736,Percent of Total Billed charges,72% of Total Billed Charges,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1578.07,72,,11423.736,Percent of Total Billed Charges,72% of Total Billed Charges,1315.06,60,,9519.776,Percent of Total Billed Charges,60% of Total Billed Charges,1972.59,90,,2614.784,Percent of Total Billed Charges,90% of Total Billed Charges,986.3,45,,13.912,Percent of Total Billed Charges,45% of Total Billed Charges,1972.59,90,,47.312,Percent of Total Billed Charges,90% of Total billed Charges,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1424.65,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,966.57,44.1,,13.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,2082.18,95,,49.936,Percent of Total Billed Charges,95% of Total Billed Charges,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1928.76,88,,41.688,Percent of Total Billed Charges,88% of Total Billed Charges,1972.59,90,,47.312,Percent of Total Billed charges,90% of Total Billed Charges,966.57,2191.77,
ACUMED AT 2S34S SCREW 26MM,2780001056,CDM,278,RC,C1713,HCPCS,Outpatient,,,2191.77,1424.65,,2191.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1665.75,76,,23.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1578.07,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,1578.07,72,,327.68,Percent of Total Billed charges,72% of Total Billed Charges,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1578.07,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,1315.06,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,1972.59,90,,3809.448,Percent of Total Billed Charges,90% of Total Billed Charges,986.3,45,,21.32,Percent of Total Billed Charges,45% of Total Billed Charges,1972.59,90,,27.824,Percent of Total Billed Charges,90% of Total billed Charges,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1424.65,65,,3153.152,Percent of total Billed Charges,65% of Total Billed Charges,966.57,44.1,,20.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,2082.18,95,,29.368,Percent of Total Billed Charges,95% of Total Billed Charges,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1928.76,88,,14889.856,Percent of Total Billed Charges,88% of Total Billed Charges,1972.59,90,,27.824,Percent of Total Billed charges,90% of Total Billed Charges,966.57,2191.77,
ACUMED WS1407STK WIRE .054,2780001057,CDM,278,RC,C1713,HCPCS,Outpatient,,,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,23.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.47,72,,12393.44,Percent of Total Billed Charges,72% of Total Billed Charges,17.47,72,,12393.44,Percent of Total Billed charges,72% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,72,,12393.44,Percent of Total Billed Charges,72% of Total Billed Charges,14.56,60,,10327.864,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,21.32,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,27.824,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,1829.976,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,20.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,29.368,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,1473.928,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,27.824,Percent of Total Billed charges,90% of Total Billed Charges,10.7,24.26,
Z59623010 ART SURFACE 90,2780001058,CDM,278,RC,C1713,HCPCS,Outpatient,,,6171.80,4011.67,,6171.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4690.57,76,,23.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4443.7,72,,12393.44,Percent of Total Billed Charges,72% of Total Billed Charges,4443.7,72,,12393.44,Percent of Total Billed charges,72% of Total Billed Charges,6171.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4443.7,72,,12393.44,Percent of Total Billed Charges,72% of Total Billed Charges,3703.08,60,,10327.864,Percent of Total Billed Charges,60% of Total Billed Charges,5554.62,90,,224.648,Percent of Total Billed Charges,90% of Total Billed Charges,2777.31,45,,7614.128,Percent of Total Billed Charges,45% of Total Billed Charges,5554.62,90,,27.824,Percent of Total Billed Charges,90% of Total billed Charges,6171.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6171.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6171.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4011.67,65,,1574.04,Percent of total Billed Charges,65% of Total Billed Charges,2721.76,44.1,,7461.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,5863.21,95,,29.368,Percent of Total Billed Charges,95% of Total Billed Charges,6171.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5431.18,88,,4383.752,Percent of Total Billed Charges,88% of Total Billed Charges,5554.62,90,,27.824,Percent of Total Billed charges,90% of Total Billed Charges,2721.76,6171.8,
ZIMMER EQUIVABONE KIT,2780001059,CDM,278,RC,C1713,HCPCS,Outpatient,,,198.45,128.99,,198.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,150.82,76,,36.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,142.88,72,,12393.44,Percent of Total Billed Charges,72% of Total Billed Charges,142.88,72,,12393.44,Percent of Total Billed charges,72% of Total Billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.88,72,,12393.44,Percent of Total Billed Charges,72% of Total Billed Charges,119.07,60,,10327.864,Percent of Total Billed Charges,60% of Total Billed Charges,178.61,90,,269.104,Percent of Total Billed Charges,90% of Total Billed Charges,89.3,45,,753.712,Percent of Total Billed Charges,45% of Total Billed Charges,178.61,90,,42.64,Percent of Total Billed Charges,90% of Total billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.99,65,,2767.896,Percent of total Billed Charges,65% of Total Billed Charges,87.52,44.1,,738.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,188.53,95,,45.008,Percent of Total Billed Charges,95% of Total Billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.64,88,,1677.28,Percent of Total Billed Charges,88% of Total Billed Charges,178.61,90,,42.64,Percent of Total Billed charges,90% of Total Billed Charges,87.52,198.45,
ZIMMER EQUIVABONE GRAFT,2780001060,CDM,278,RC,C1713,HCPCS,Outpatient,,,4658.06,3027.74,,4658.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3540.13,76,,36.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3353.8,72,,12393.44,Percent of Total Billed Charges,72% of Total Billed Charges,3353.8,72,,12393.44,Percent of Total Billed charges,72% of Total Billed Charges,4658.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3353.8,72,,12393.44,Percent of Total Billed Charges,72% of Total Billed Charges,2794.84,60,,10327.864,Percent of Total Billed Charges,60% of Total Billed Charges,4192.25,90,,994.896,Percent of Total Billed Charges,90% of Total Billed Charges,2096.13,45,,2241.688,Percent of Total Billed Charges,45% of Total Billed Charges,4192.25,90,,42.64,Percent of Total Billed Charges,90% of Total billed Charges,4658.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4658.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4658.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3027.74,65,,65.36,Percent of total Billed Charges,65% of Total Billed Charges,2054.2,44.1,,2196.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,4425.16,95,,45.008,Percent of Total Billed Charges,95% of Total Billed Charges,4658.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4099.09,88,,2556.672,Percent of Total Billed Charges,88% of Total Billed Charges,4192.25,90,,42.64,Percent of Total Billed charges,90% of Total Billed Charges,2054.2,4658.06,
Z22553237 TIB/HUM DRILL BIT,2780001061,CDM,278,RC,C1713,HCPCS,Outpatient,,,525.89,341.83,,525.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,399.68,76,,12859.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,378.64,72,,71.76,Percent of Total Billed Charges,72% of Total Billed Charges,378.64,72,,71.76,Percent of Total Billed charges,72% of Total Billed Charges,525.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.64,72,,71.76,Percent of Total Billed Charges,72% of Total Billed Charges,315.53,60,,59.8,Percent of Total Billed Charges,60% of Total Billed Charges,473.3,90,,3626.64,Percent of Total Billed Charges,90% of Total Billed Charges,236.65,45,,857.704,Percent of Total Billed Charges,45% of Total Billed Charges,473.3,90,,15228.256,Percent of Total Billed Charges,90% of Total billed Charges,525.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,525.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,525.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.83,65,,192.056,Percent of total Billed Charges,65% of Total Billed Charges,231.92,44.1,,840.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,499.6,95,,16074.272,Percent of Total Billed Charges,95% of Total Billed Charges,525.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.78,88,,3724.792,Percent of Total Billed Charges,88% of Total Billed Charges,473.3,90,,15228.256,Percent of Total Billed charges,90% of Total Billed Charges,231.92,525.89,
Z PATIENT SPECIFIC BONE MODULE,2780001062,CDM,278,RC,C1713,HCPCS,Outpatient,,,3913.88,2544.02,,3913.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2974.55,76,,1272.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2817.99,72,,12393.44,Percent of Total Billed Charges,72% of Total Billed Charges,2817.99,72,,12393.44,Percent of Total Billed charges,72% of Total Billed Charges,3913.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2817.99,72,,12393.44,Percent of Total Billed Charges,72% of Total Billed Charges,2348.33,60,,10327.864,Percent of Total Billed Charges,60% of Total Billed Charges,3522.49,90,,538.992,Percent of Total Billed Charges,90% of Total Billed Charges,1761.25,45,,1307.392,Percent of Total Billed Charges,45% of Total Billed Charges,3522.49,90,,1507.432,Percent of Total Billed Charges,90% of Total billed Charges,3913.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3913.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3913.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2544.02,65,,192.056,Percent of total Billed Charges,65% of Total Billed Charges,1726.02,44.1,,1281.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,3718.19,95,,1591.176,Percent of Total Billed Charges,95% of Total Billed Charges,3913.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3444.21,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,3522.49,90,,1507.432,Percent of Total Billed charges,90% of Total Billed Charges,1726.02,3913.88,
Z 575001602 GSF FEM FRT,2780001063,CDM,278,RC,C1713,HCPCS,Outpatient,,,17165.93,11157.85,,17165.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13046.11,76,,3785.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12359.47,72,,950.016,Percent of Total Billed Charges,72% of Total Billed Charges,12359.47,72,,950.016,Percent of Total Billed charges,72% of Total Billed Charges,17165.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12359.47,72,,950.016,Percent of Total Billed Charges,72% of Total Billed Charges,10299.56,60,,791.68,Percent of Total Billed Charges,60% of Total Billed Charges,15449.34,90,,50.8,Percent of Total Billed Charges,90% of Total Billed Charges,7724.67,45,,1904.728,Percent of Total Billed Charges,45% of Total Billed Charges,15449.34,90,,4483.384,Percent of Total Billed Charges,90% of Total billed Charges,17165.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17165.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17165.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11157.85,65,,219,Percent of total Billed Charges,65% of Total Billed Charges,7570.18,44.1,,1866.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,16307.63,95,,4732.456,Percent of Total Billed Charges,95% of Total Billed Charges,17165.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15106.02,88,,219.656,Percent of Total Billed Charges,88% of Total Billed Charges,15449.34,90,,4483.384,Percent of Total Billed charges,90% of Total Billed Charges,7570.18,17165.93,
Z48202003 CORTICAL SCW 20,2780001064,CDM,278,RC,C1713,HCPCS,Outpatient,,,73.87,48.02,,73.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.14,76,,1448.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.19,72,,1662.536,Percent of Total Billed Charges,72% of Total Billed Charges,53.19,72,,1662.536,Percent of Total Billed charges,72% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.19,72,,1662.536,Percent of Total Billed Charges,72% of Total Billed Charges,44.32,60,,1385.448,Percent of Total Billed Charges,60% of Total Billed Charges,66.48,90,,50.008,Percent of Total Billed Charges,90% of Total Billed Charges,33.24,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,66.48,90,,1715.4,Percent of Total Billed Charges,90% of Total billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.02,65,,168.552,Percent of total Billed Charges,65% of Total Billed Charges,32.58,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,70.18,95,,1810.704,Percent of Total Billed Charges,95% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.01,88,,263.12,Percent of Total Billed Charges,88% of Total Billed Charges,66.48,90,,1715.4,Percent of Total Billed charges,90% of Total Billed Charges,32.58,73.87,
Z499011015 KWIRE 1.0,2780001065,CDM,278,RC,C1713,HCPCS,Outpatient,,,44.10,28.67,,44.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33.52,76,,2208.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,31.75,72,,1662.536,Percent of Total Billed Charges,72% of Total Billed Charges,31.75,72,,1662.536,Percent of Total Billed charges,72% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.75,72,,1662.536,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,60,,1385.448,Percent of Total Billed Charges,60% of Total Billed Charges,39.69,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,19.85,45,,112.32,Percent of Total Billed Charges,45% of Total Billed Charges,39.69,90,,2614.784,Percent of Total Billed Charges,90% of Total billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,65,,168.552,Percent of total Billed Charges,65% of Total Billed Charges,19.45,44.1,,110.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.9,95,,2760.048,Percent of Total Billed Charges,95% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.81,88,,972.784,Percent of Total Billed Charges,88% of Total Billed Charges,39.69,90,,2614.784,Percent of Total Billed charges,90% of Total Billed Charges,19.45,44.1,
Z48200803 CORTICAL 2.0 8MM,2780001066,CDM,278,RC,C1713,HCPCS,Outpatient,,,73.87,48.02,,73.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.14,76,,3216.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.19,72,,1662.536,Percent of Total Billed Charges,72% of Total Billed Charges,53.19,72,,1662.536,Percent of Total Billed charges,72% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.19,72,,1662.536,Percent of Total Billed Charges,72% of Total Billed Charges,44.32,60,,1385.448,Percent of Total Billed Charges,60% of Total Billed Charges,66.48,90,,55.568,Percent of Total Billed Charges,90% of Total Billed Charges,33.24,45,,134.552,Percent of Total Billed Charges,45% of Total Billed Charges,66.48,90,,3809.448,Percent of Total Billed Charges,90% of Total billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.02,65,,168.552,Percent of total Billed Charges,65% of Total Billed Charges,32.58,44.1,,131.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,70.18,95,,4021.088,Percent of Total Billed Charges,95% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.01,88,,3546.048,Percent of Total Billed Charges,88% of Total Billed Charges,66.48,90,,3809.448,Percent of Total Billed charges,90% of Total Billed Charges,32.58,73.87,
Z11473041 4.0 CANNU SCW 30,2780001067,CDM,278,RC,C1713,HCPCS,Outpatient,,,620.71,403.46,,620.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,471.74,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,446.91,72,,3792.456,Percent of Total Billed Charges,72% of Total Billed Charges,446.91,72,,3792.456,Percent of Total Billed charges,72% of Total Billed Charges,620.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.91,72,,3792.456,Percent of Total Billed Charges,72% of Total Billed Charges,372.43,60,,3160.384,Percent of Total Billed Charges,60% of Total Billed Charges,558.64,90,,69.856,Percent of Total Billed Charges,90% of Total Billed Charges,279.32,45,,497.448,Percent of Total Billed Charges,45% of Total Billed Charges,558.64,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,620.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,620.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,620.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,403.46,65,,2443.408,Percent of total Billed Charges,65% of Total Billed Charges,273.73,44.1,,487.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,589.67,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,620.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.22,88,,527.016,Percent of Total Billed Charges,88% of Total Billed Charges,558.64,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,273.73,620.71,
Z11473441 4.0 CANNU SCW 34,2780001068,CDM,278,RC,C1713,HCPCS,Outpatient,,,620.71,403.46,,620.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,471.74,76,,189.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,446.91,72,,3792.456,Percent of Total Billed Charges,72% of Total Billed Charges,446.91,72,,3792.456,Percent of Total Billed charges,72% of Total Billed Charges,620.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.91,72,,3792.456,Percent of Total Billed Charges,72% of Total Billed Charges,372.43,60,,3160.384,Percent of Total Billed Charges,60% of Total Billed Charges,558.64,90,,350.064,Percent of Total Billed Charges,90% of Total Billed Charges,279.32,45,,1813.32,Percent of Total Billed Charges,45% of Total Billed Charges,558.64,90,,224.648,Percent of Total Billed Charges,90% of Total billed Charges,620.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,620.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,620.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,403.46,65,,2009.992,Percent of total Billed Charges,65% of Total Billed Charges,273.73,44.1,,1777.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,589.67,95,,237.128,Percent of Total Billed Charges,95% of Total Billed Charges,620.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.22,88,,49.672,Percent of Total Billed Charges,88% of Total Billed Charges,558.64,90,,224.648,Percent of Total Billed charges,90% of Total Billed Charges,273.73,620.71,
ACUMED AT 2S28S SCW 28MM,2780001069,CDM,278,RC,C1713,HCPCS,Outpatient,,,2191.77,1424.65,,2191.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1665.75,76,,227.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1578.07,72,,3792.456,Percent of Total Billed Charges,72% of Total Billed Charges,1578.07,72,,3792.456,Percent of Total Billed charges,72% of Total Billed Charges,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1578.07,72,,3792.456,Percent of Total Billed Charges,72% of Total Billed Charges,1315.06,60,,3160.384,Percent of Total Billed Charges,60% of Total Billed Charges,1972.59,90,,42.336,Percent of Total Billed Charges,90% of Total Billed Charges,986.3,45,,269.496,Percent of Total Billed Charges,45% of Total Billed Charges,1972.59,90,,269.104,Percent of Total Billed Charges,90% of Total billed Charges,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1424.65,65,,3831.936,Percent of total Billed Charges,65% of Total Billed Charges,966.57,44.1,,264.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,2082.18,95,,284.048,Percent of Total Billed Charges,95% of Total Billed Charges,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1928.76,88,,48.896,Percent of Total Billed Charges,88% of Total Billed Charges,1972.59,90,,269.104,Percent of Total Billed charges,90% of Total Billed Charges,966.57,2191.77,
ACUMED AT2S32S SCW 32MM,2780001070,CDM,278,RC,C1713,HCPCS,Outpatient,,,2191.77,1424.65,,2191.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1665.75,76,,840.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1578.07,72,,3792.456,Percent of Total Billed Charges,72% of Total Billed Charges,1578.07,72,,3792.456,Percent of Total Billed charges,72% of Total Billed Charges,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1578.07,72,,3792.456,Percent of Total Billed Charges,72% of Total Billed Charges,1315.06,60,,3160.384,Percent of Total Billed Charges,60% of Total Billed Charges,1972.59,90,,42.336,Percent of Total Billed Charges,90% of Total Billed Charges,986.3,45,,25.4,Percent of Total Billed Charges,45% of Total Billed Charges,1972.59,90,,994.896,Percent of Total Billed Charges,90% of Total billed Charges,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1424.65,65,,1770.92,Percent of total Billed Charges,65% of Total Billed Charges,966.57,44.1,,24.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,2082.18,95,,1050.168,Percent of Total Billed Charges,95% of Total Billed Charges,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1928.76,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,1972.59,90,,994.896,Percent of Total Billed charges,90% of Total Billed Charges,966.57,2191.77,
Z11473641 CANN SCW 36MM,2780001071,CDM,278,RC,C1713,HCPCS,Outpatient,,,592.20,384.93,,592.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,450.07,76,,3062.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,426.38,72,,3792.456,Percent of Total Billed Charges,72% of Total Billed Charges,426.38,72,,3792.456,Percent of Total Billed charges,72% of Total Billed Charges,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.38,72,,3792.456,Percent of Total Billed Charges,72% of Total Billed Charges,355.32,60,,3160.384,Percent of Total Billed Charges,60% of Total Billed Charges,532.98,90,,105.12,Percent of Total Billed Charges,90% of Total Billed Charges,266.49,45,,25.008,Percent of Total Billed Charges,45% of Total Billed Charges,532.98,90,,3626.64,Percent of Total Billed Charges,90% of Total billed Charges,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.93,65,,299.264,Percent of total Billed Charges,65% of Total Billed Charges,261.16,44.1,,24.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,562.59,95,,3828.12,Percent of Total Billed Charges,95% of Total Billed Charges,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521.14,88,,54.336,Percent of Total Billed Charges,88% of Total Billed Charges,532.98,90,,3626.64,Percent of Total Billed charges,90% of Total Billed Charges,261.16,592.2,
Z42500606401 FEMUR SZ 8,2780001072,CDM,278,RC,C1713,HCPCS,Outpatient,,,16997.40,11048.31,,16997.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12918.02,76,,455.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12238.13,72,,6231.648,Percent of Total Billed Charges,72% of Total Billed Charges,12238.13,72,,6231.648,Percent of Total Billed charges,72% of Total Billed Charges,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12238.13,72,,6231.648,Percent of Total Billed Charges,72% of Total Billed Charges,10198.44,60,,5193.04,Percent of Total Billed Charges,60% of Total Billed Charges,15297.66,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,7648.83,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,15297.66,90,,538.992,Percent of Total Billed Charges,90% of Total billed Charges,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11048.31,65,,1126.536,Percent of total Billed Charges,65% of Total Billed Charges,7495.85,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,16147.53,95,,568.936,Percent of Total Billed Charges,95% of Total Billed Charges,16997.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14957.71,88,,68.304,Percent of Total Billed Charges,88% of Total Billed Charges,15297.66,90,,538.992,Percent of Total Billed charges,90% of Total Billed Charges,7495.85,16997.4,
Z47248403750 5.0X37.5 CORT,2780001073,CDM,278,RC,C1713,HCPCS,Outpatient,,,685.65,445.67,,685.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,521.09,76,,42.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,493.67,72,,6231.648,Percent of Total Billed Charges,72% of Total Billed Charges,493.67,72,,6231.648,Percent of Total Billed charges,72% of Total Billed Charges,685.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.67,72,,6231.648,Percent of Total Billed Charges,72% of Total Billed Charges,411.39,60,,5193.04,Percent of Total Billed Charges,60% of Total Billed Charges,617.09,90,,4365.904,Percent of Total Billed Charges,90% of Total Billed Charges,308.54,45,,27.784,Percent of Total Billed Charges,45% of Total Billed Charges,617.09,90,,50.8,Percent of Total Billed Charges,90% of Total billed Charges,685.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,445.67,65,,354.872,Percent of total Billed Charges,65% of Total Billed Charges,302.37,44.1,,27.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,651.37,95,,53.624,Percent of Total Billed Charges,95% of Total Billed Charges,685.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,603.37,88,,342.288,Percent of Total Billed Charges,88% of Total Billed Charges,617.09,90,,50.8,Percent of Total Billed charges,90% of Total Billed Charges,302.37,685.65,
Z11472235 CANN SCW 3.5 X 22,2780001074,CDM,278,RC,C1713,HCPCS,Outpatient,,,563.85,366.50,,563.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,428.53,76,,42.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,405.97,72,,6231.648,Percent of Total Billed Charges,72% of Total Billed Charges,405.97,72,,6231.648,Percent of Total Billed charges,72% of Total Billed Charges,563.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.97,72,,6231.648,Percent of Total Billed Charges,72% of Total Billed Charges,338.31,60,,5193.04,Percent of Total Billed Charges,60% of Total Billed Charges,507.47,90,,2533.808,Percent of Total Billed Charges,90% of Total Billed Charges,253.73,45,,34.928,Percent of Total Billed Charges,45% of Total Billed Charges,507.47,90,,50.008,Percent of Total Billed Charges,90% of Total billed Charges,563.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.5,65,,30.384,Percent of total Billed Charges,65% of Total Billed Charges,248.66,44.1,,34.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,535.66,95,,52.792,Percent of Total Billed Charges,95% of Total Billed Charges,563.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,496.19,88,,41.392,Percent of Total Billed Charges,88% of Total Billed Charges,507.47,90,,50.008,Percent of Total Billed charges,90% of Total Billed Charges,248.66,563.85,
Z11472636 CANN SCW 3.5 X 26,2780001075,CDM,278,RC,C1713,HCPCS,Outpatient,,,563.85,366.50,,563.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,428.53,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,405.97,72,,6231.648,Percent of Total Billed Charges,72% of Total Billed Charges,405.97,72,,6231.648,Percent of Total Billed charges,72% of Total Billed Charges,563.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.97,72,,6231.648,Percent of Total Billed Charges,72% of Total Billed Charges,338.31,60,,5193.04,Percent of Total Billed Charges,60% of Total Billed Charges,507.47,90,,2179.44,Percent of Total Billed Charges,90% of Total Billed Charges,253.73,45,,175.032,Percent of Total Billed Charges,45% of Total Billed Charges,507.47,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,563.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.5,65,,3196.72,Percent of total Billed Charges,65% of Total Billed Charges,248.66,44.1,,171.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,535.66,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,563.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,496.19,88,,41.392,Percent of Total Billed Charges,88% of Total Billed Charges,507.47,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,248.66,563.85,
Z44510420 4MM X 200 ROD,2780001076,CDM,278,RC,C1713,HCPCS,Outpatient,,,145.95,94.87,,145.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.92,76,,46.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,105.08,72,,6231.648,Percent of Total Billed Charges,72% of Total Billed Charges,105.08,72,,6231.648,Percent of Total Billed charges,72% of Total Billed Charges,145.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.08,72,,6231.648,Percent of Total Billed Charges,72% of Total Billed Charges,87.57,60,,5193.04,Percent of Total Billed Charges,60% of Total Billed Charges,131.36,90,,3832.464,Percent of Total Billed Charges,90% of Total Billed Charges,65.68,45,,21.168,Percent of Total Billed Charges,45% of Total Billed Charges,131.36,90,,55.568,Percent of Total Billed Charges,90% of Total billed Charges,145.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.87,65,,692.544,Percent of total Billed Charges,65% of Total Billed Charges,64.36,44.1,,20.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,138.65,95,,58.656,Percent of Total Billed Charges,95% of Total Billed Charges,145.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.44,88,,102.784,Percent of Total Billed Charges,88% of Total Billed Charges,131.36,90,,55.568,Percent of Total Billed charges,90% of Total Billed Charges,64.36,145.95,
Z44522524 OPEN PIN TO ROD,2780001077,CDM,278,RC,C1713,HCPCS,Outpatient,,,959.70,623.81,,959.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,729.37,76,,58.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,690.98,72,,6231.648,Percent of Total Billed Charges,72% of Total Billed Charges,690.98,72,,6231.648,Percent of Total Billed charges,72% of Total Billed Charges,959.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,690.98,72,,6231.648,Percent of Total Billed Charges,72% of Total Billed Charges,575.82,60,,5193.04,Percent of Total Billed Charges,60% of Total Billed Charges,863.73,90,,90.496,Percent of Total Billed Charges,90% of Total Billed Charges,431.87,45,,21.168,Percent of Total Billed Charges,45% of Total Billed Charges,863.73,90,,69.856,Percent of Total Billed Charges,90% of Total billed Charges,959.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,959.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,959.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,623.81,65,,6267.312,Percent of total Billed Charges,65% of Total Billed Charges,423.23,44.1,,20.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,911.72,95,,73.736,Percent of Total Billed Charges,95% of Total Billed Charges,959.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,844.54,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,863.73,90,,69.856,Percent of Total Billed charges,90% of Total Billed Charges,423.23,959.7,
Z445056 DRILL BIT 2.5,2780001078,CDM,278,RC,C1713,HCPCS,Outpatient,,,191.10,124.22,,191.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,145.24,76,,295.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,137.59,72,,6231.648,Percent of Total Billed Charges,72% of Total Billed Charges,137.59,72,,6231.648,Percent of Total Billed charges,72% of Total Billed Charges,191.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.59,72,,6231.648,Percent of Total Billed Charges,72% of Total Billed Charges,114.66,60,,5193.04,Percent of Total Billed Charges,60% of Total Billed Charges,171.99,90,,265.928,Percent of Total Billed Charges,90% of Total Billed Charges,86,45,,52.56,Percent of Total Billed Charges,45% of Total Billed Charges,171.99,90,,350.064,Percent of Total Billed Charges,90% of Total billed Charges,191.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.22,65,,11217.76,Percent of total Billed Charges,65% of Total Billed Charges,84.28,44.1,,51.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,181.55,95,,369.512,Percent of Total Billed Charges,95% of Total Billed Charges,191.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.17,88,,4268.88,Percent of Total Billed Charges,88% of Total Billed Charges,171.99,90,,350.064,Percent of Total Billed charges,90% of Total Billed Charges,84.28,191.1,
Z9059523017 NEXGEN AS 17MM,2780001079,CDM,278,RC,C1713,HCPCS,Outpatient,,,5211.15,3387.25,,5211.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3960.47,76,,35.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3752.03,72,,6231.648,Percent of Total Billed Charges,72% of Total Billed Charges,3752.03,72,,6231.648,Percent of Total Billed charges,72% of Total Billed Charges,5211.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3752.03,72,,6231.648,Percent of Total Billed Charges,72% of Total Billed Charges,3126.69,60,,5193.04,Percent of Total Billed Charges,60% of Total Billed Charges,4690.04,90,,265.928,Percent of Total Billed Charges,90% of Total Billed Charges,2345.02,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,4690.04,90,,42.336,Percent of Total Billed Charges,90% of Total billed Charges,5211.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5211.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5211.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3387.25,65,,3094.096,Percent of total Billed Charges,65% of Total Billed Charges,2298.12,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,4950.59,95,,44.688,Percent of Total Billed Charges,95% of Total Billed Charges,5211.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4585.81,88,,2477.504,Percent of Total Billed Charges,88% of Total Billed Charges,4690.04,90,,42.336,Percent of Total Billed charges,90% of Total Billed Charges,2298.12,5211.15,
ACUMED ACU SINCH REPAIR,2780001080,CDM,278,RC,C1713,HCPCS,Outpatient,,,5076.75,3299.89,,5076.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3858.33,76,,35.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3655.26,72,,6231.648,Percent of Total Billed Charges,72% of Total Billed Charges,3655.26,72,,6231.648,Percent of Total Billed charges,72% of Total Billed Charges,5076.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3655.26,72,,6231.648,Percent of Total Billed Charges,72% of Total Billed Charges,3046.05,60,,5193.04,Percent of Total Billed Charges,60% of Total Billed Charges,4569.08,90,,303.232,Percent of Total Billed Charges,90% of Total Billed Charges,2284.54,45,,2182.952,Percent of Total Billed Charges,45% of Total Billed Charges,4569.08,90,,42.336,Percent of Total Billed Charges,90% of Total billed Charges,5076.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5076.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5076.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3299.89,65,,455.2,Percent of total Billed Charges,65% of Total Billed Charges,2238.85,44.1,,2139.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,4822.91,95,,44.688,Percent of Total Billed Charges,95% of Total Billed Charges,5076.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4467.54,88,,2131.008,Percent of Total Billed Charges,88% of Total Billed Charges,4569.08,90,,42.336,Percent of Total Billed charges,90% of Total Billed Charges,2238.85,5076.75,
ACUMED 2S16065.062 KWIRE,2780001081,CDM,278,RC,C1713,HCPCS,Outpatient,,,25.20,16.38,,25.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.15,76,,88.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.14,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,18.14,72,,2660.184,Percent of Total Billed charges,72% of Total Billed Charges,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.14,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,15.12,60,,2216.816,Percent of Total Billed Charges,60% of Total Billed Charges,22.68,90,,233.384,Percent of Total Billed Charges,90% of Total Billed Charges,11.34,45,,1266.904,Percent of Total Billed Charges,45% of Total Billed Charges,22.68,90,,105.12,Percent of Total Billed Charges,90% of Total billed Charges,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.38,65,,133.008,Percent of total Billed Charges,65% of Total Billed Charges,11.11,44.1,,1241.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.94,95,,110.96,Percent of Total Billed Charges,95% of Total Billed Charges,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.18,88,,3747.304,Percent of Total Billed Charges,88% of Total Billed Charges,22.68,90,,105.12,Percent of Total Billed charges,90% of Total Billed Charges,11.11,25.2,
ACUMED 3.5 X 14 NLCK SCW,2780001082,CDM,278,RC,C1713,HCPCS,Outpatient,,,387.00,251.55,,387,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,294.12,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,278.64,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,278.64,72,,2660.184,Percent of Total Billed charges,72% of Total Billed Charges,387,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.64,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,232.2,60,,2216.816,Percent of Total Billed Charges,60% of Total Billed Charges,348.3,90,,233.384,Percent of Total Billed Charges,90% of Total Billed Charges,174.15,45,,1089.72,Percent of Total Billed Charges,45% of Total Billed Charges,348.3,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,387,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,387,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,387,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.55,65,,123.264,Percent of total Billed Charges,65% of Total Billed Charges,170.67,44.1,,1067.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,367.65,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,387,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.56,88,,88.488,Percent of Total Billed Charges,88% of Total Billed Charges,348.3,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,170.67,387,
ACUMED 3.5 X 12 LOCK SCW,2780001083,CDM,278,RC,C1713,HCPCS,Outpatient,,,637.35,414.28,,637.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,484.39,76,,3686.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,458.89,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,458.89,72,,2660.184,Percent of Total Billed charges,72% of Total Billed Charges,637.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,458.89,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,382.41,60,,2216.816,Percent of Total Billed Charges,60% of Total Billed Charges,573.62,90,,233.384,Percent of Total Billed Charges,90% of Total Billed Charges,286.81,45,,1916.232,Percent of Total Billed Charges,45% of Total Billed Charges,573.62,90,,4365.904,Percent of Total Billed Charges,90% of Total billed Charges,637.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,637.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,637.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.28,65,,1718.176,Percent of total Billed Charges,65% of Total Billed Charges,281.07,44.1,,1877.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,605.48,95,,4608.448,Percent of Total Billed Charges,95% of Total Billed Charges,637.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,560.87,88,,260.016,Percent of Total Billed Charges,88% of Total Billed Charges,573.62,90,,4365.904,Percent of Total Billed charges,90% of Total Billed Charges,281.07,637.35,
ACUMED 3.5 X 14 LOCK SCW,2780001084,CDM,278,RC,C1713,HCPCS,Outpatient,,,637.35,414.28,,637.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,484.39,76,,2139.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,458.89,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,458.89,72,,2660.184,Percent of Total Billed charges,72% of Total Billed Charges,637.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,458.89,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,382.41,60,,2216.816,Percent of Total Billed Charges,60% of Total Billed Charges,573.62,90,,3383.176,Percent of Total Billed Charges,90% of Total Billed Charges,286.81,45,,45.248,Percent of Total Billed Charges,45% of Total Billed Charges,573.62,90,,2533.808,Percent of Total Billed Charges,90% of Total billed Charges,637.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,637.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,637.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.28,65,,1752.576,Percent of total Billed Charges,65% of Total Billed Charges,281.07,44.1,,44.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,605.48,95,,2674.576,Percent of Total Billed Charges,95% of Total Billed Charges,637.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,560.87,88,,260.016,Percent of Total Billed Charges,88% of Total Billed Charges,573.62,90,,2533.808,Percent of Total Billed charges,90% of Total Billed Charges,281.07,637.35,
Z11476040 4.0 CANNU SCW 60MM,2780001085,CDM,278,RC,C1713,HCPCS,Outpatient,,,592.20,384.93,,592.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,450.07,76,,1840.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,426.38,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,426.38,72,,2660.184,Percent of Total Billed charges,72% of Total Billed Charges,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.38,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,355.32,60,,2216.816,Percent of Total Billed Charges,60% of Total Billed Charges,532.98,90,,2783.064,Percent of Total Billed Charges,90% of Total Billed Charges,266.49,45,,132.96,Percent of Total Billed Charges,45% of Total Billed Charges,532.98,90,,2179.44,Percent of Total Billed Charges,90% of Total billed Charges,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.93,65,,1752.576,Percent of total Billed Charges,65% of Total Billed Charges,261.16,44.1,,130.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,562.59,95,,2300.52,Percent of Total Billed Charges,95% of Total Billed Charges,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521.14,88,,296.496,Percent of Total Billed Charges,88% of Total Billed Charges,532.98,90,,2179.44,Percent of Total Billed charges,90% of Total Billed Charges,261.16,592.2,
Z02.01362.116 SMOOTH GUIDE PIN,2780001086,CDM,278,RC,C1713,HCPCS,Outpatient,,,65.10,42.32,,65.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.48,76,,3236.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.87,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,46.87,72,,2660.184,Percent of Total Billed charges,72% of Total Billed Charges,65.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.87,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,39.06,60,,2216.816,Percent of Total Billed Charges,60% of Total Billed Charges,58.59,90,,5305.76,Percent of Total Billed Charges,90% of Total Billed Charges,29.3,45,,132.96,Percent of Total Billed Charges,45% of Total Billed Charges,58.59,90,,3832.464,Percent of Total Billed Charges,90% of Total billed Charges,65.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.32,65,,1524.976,Percent of total Billed Charges,65% of Total Billed Charges,28.71,44.1,,130.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,61.85,95,,4045.384,Percent of Total Billed Charges,95% of Total Billed Charges,65.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.29,88,,228.192,Percent of Total Billed Charges,88% of Total Billed Charges,58.59,90,,3832.464,Percent of Total Billed charges,90% of Total Billed Charges,28.71,65.1,
ACUMED CO T2316 2.3X16 LCK SCW,2780001087,CDM,278,RC,C1713,HCPCS,Outpatient,,,458.85,298.25,,458.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,348.73,76,,76.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,330.37,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,330.37,72,,2660.184,Percent of Total Billed charges,72% of Total Billed Charges,458.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330.37,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,275.31,60,,2216.816,Percent of Total Billed Charges,60% of Total Billed Charges,412.97,90,,2452.048,Percent of Total Billed Charges,90% of Total Billed Charges,206.48,45,,151.616,Percent of Total Billed Charges,45% of Total Billed Charges,412.97,90,,90.496,Percent of Total Billed Charges,90% of Total billed Charges,458.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,458.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,458.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.25,65,,93.448,Percent of total Billed Charges,65% of Total Billed Charges,202.35,44.1,,148.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,435.91,95,,95.528,Percent of Total Billed Charges,95% of Total Billed Charges,458.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,403.79,88,,228.192,Percent of Total Billed Charges,88% of Total Billed Charges,412.97,90,,90.496,Percent of Total Billed charges,90% of Total Billed Charges,202.35,458.85,
ACUMED CO T2314 2.3X14 LCK SCW,2780001088,CDM,278,RC,C1713,HCPCS,Outpatient,,,458.85,298.25,,458.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,348.73,76,,224.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,330.37,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,330.37,72,,2660.184,Percent of Total Billed charges,72% of Total Billed Charges,458.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330.37,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,275.31,60,,2216.816,Percent of Total Billed Charges,60% of Total Billed Charges,412.97,90,,414.368,Percent of Total Billed Charges,90% of Total Billed Charges,206.48,45,,116.688,Percent of Total Billed Charges,45% of Total Billed Charges,412.97,90,,265.928,Percent of Total Billed Charges,90% of Total billed Charges,458.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,458.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,458.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.25,65,,3419.16,Percent of total Billed Charges,65% of Total Billed Charges,202.35,44.1,,114.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,435.91,95,,280.696,Percent of Total Billed Charges,95% of Total Billed Charges,458.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,403.79,88,,228.192,Percent of Total Billed Charges,88% of Total Billed Charges,412.97,90,,265.928,Percent of Total Billed charges,90% of Total Billed Charges,202.35,458.85,
ACUMED CO T2312 2.3XAS LCK SCW,2780001089,CDM,278,RC,C1713,HCPCS,Outpatient,,,458.85,298.25,,458.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,348.73,76,,224.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,330.37,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,330.37,72,,2660.184,Percent of Total Billed charges,72% of Total Billed Charges,458.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330.37,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,275.31,60,,2216.816,Percent of Total Billed Charges,60% of Total Billed Charges,412.97,90,,1559.816,Percent of Total Billed Charges,90% of Total Billed Charges,206.48,45,,116.688,Percent of Total Billed Charges,45% of Total Billed Charges,412.97,90,,265.928,Percent of Total Billed Charges,90% of Total billed Charges,458.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,458.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,458.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.25,65,,259.128,Percent of total Billed Charges,65% of Total Billed Charges,202.35,44.1,,114.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,435.91,95,,280.696,Percent of Total Billed Charges,95% of Total Billed Charges,458.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,403.79,88,,3308,Percent of Total Billed Charges,88% of Total Billed Charges,412.97,90,,265.928,Percent of Total Billed charges,90% of Total Billed Charges,202.35,458.85,
Z11473841 4.0 CANN SCW 38MM,2780001090,CDM,278,RC,C1713,HCPCS,Outpatient,,,592.20,384.93,,592.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,450.07,76,,256.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,426.38,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,426.38,72,,2660.184,Percent of Total Billed charges,72% of Total Billed Charges,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.38,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,355.32,60,,2216.816,Percent of Total Billed Charges,60% of Total Billed Charges,532.98,90,,491.368,Percent of Total Billed Charges,90% of Total Billed Charges,266.49,45,,116.688,Percent of Total Billed Charges,45% of Total Billed Charges,532.98,90,,303.232,Percent of Total Billed Charges,90% of Total billed Charges,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.93,65,,1524.976,Percent of total Billed Charges,65% of Total Billed Charges,261.16,44.1,,114.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,562.59,95,,320.08,Percent of Total Billed Charges,95% of Total Billed Charges,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521.14,88,,2721.224,Percent of Total Billed Charges,88% of Total Billed Charges,532.98,90,,303.232,Percent of Total Billed charges,90% of Total Billed Charges,261.16,592.2,
Z02.3260.009 FEMUR PLATE R 9H,2780001091,CDM,278,RC,C1713,HCPCS,Outpatient,,,4579.05,2976.38,,4579.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3480.08,76,,197.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3296.92,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,3296.92,72,,2660.184,Percent of Total Billed charges,72% of Total Billed Charges,4579.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3296.92,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,2747.43,60,,2216.816,Percent of Total Billed Charges,60% of Total Billed Charges,4121.15,90,,42.072,Percent of Total Billed Charges,90% of Total Billed Charges,2060.57,45,,1691.592,Percent of Total Billed Charges,45% of Total Billed Charges,4121.15,90,,233.384,Percent of Total Billed Charges,90% of Total billed Charges,4579.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4579.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4579.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2976.38,65,,10450.688,Percent of total Billed Charges,65% of Total Billed Charges,2019.36,44.1,,1657.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,4350.1,95,,246.344,Percent of Total Billed Charges,95% of Total Billed Charges,4579.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4029.56,88,,5187.856,Percent of Total Billed Charges,88% of Total Billed Charges,4121.15,90,,233.384,Percent of Total Billed charges,90% of Total Billed Charges,2019.36,4579.05,
Z02.03152.055 2.5 CANC SCW 55,2780001092,CDM,278,RC,C1713,HCPCS,Outpatient,,,456.75,296.89,,456.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,347.13,76,,197.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,328.86,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,328.86,72,,2660.184,Percent of Total Billed charges,72% of Total Billed Charges,456.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.86,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,274.05,60,,2216.816,Percent of Total Billed Charges,60% of Total Billed Charges,411.08,90,,4426.232,Percent of Total Billed Charges,90% of Total Billed Charges,205.54,45,,1391.536,Percent of Total Billed Charges,45% of Total Billed Charges,411.08,90,,233.384,Percent of Total Billed Charges,90% of Total billed Charges,456.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.89,65,,110.648,Percent of total Billed Charges,65% of Total Billed Charges,201.43,44.1,,1363.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,433.91,95,,246.344,Percent of Total Billed Charges,95% of Total Billed Charges,456.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.94,88,,2397.56,Percent of Total Billed Charges,88% of Total Billed Charges,411.08,90,,233.384,Percent of Total Billed charges,90% of Total Billed Charges,201.43,456.75,
Z4804501 CANC SCW 45,2780001093,CDM,278,RC,C1713,HCPCS,Outpatient,,,60.90,39.59,,60.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.28,76,,197.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.85,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,43.85,72,,2660.184,Percent of Total Billed charges,72% of Total Billed Charges,60.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.85,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,36.54,60,,2216.816,Percent of Total Billed Charges,60% of Total Billed Charges,54.81,90,,958.912,Percent of Total Billed Charges,90% of Total Billed Charges,27.41,45,,2652.88,Percent of Total Billed Charges,45% of Total Billed Charges,54.81,90,,233.384,Percent of Total Billed Charges,90% of Total billed Charges,60.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.59,65,,123.264,Percent of total Billed Charges,65% of Total Billed Charges,26.86,44.1,,2599.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.86,95,,246.344,Percent of Total Billed Charges,95% of Total Billed Charges,60.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.59,88,,405.16,Percent of Total Billed Charges,88% of Total Billed Charges,54.81,90,,233.384,Percent of Total Billed charges,90% of Total Billed Charges,26.86,60.9,
Z11475540 CANN 4.0 55MM,2780001094,CDM,278,RC,C1713,HCPCS,Outpatient,,,592.20,384.93,,592.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,450.07,76,,2856.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,426.38,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,426.38,72,,2660.184,Percent of Total Billed charges,72% of Total Billed Charges,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.38,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,355.32,60,,2216.816,Percent of Total Billed Charges,60% of Total Billed Charges,532.98,90,,8677.824,Percent of Total Billed Charges,90% of Total Billed Charges,266.49,45,,1226.024,Percent of Total Billed Charges,45% of Total Billed Charges,532.98,90,,3383.176,Percent of Total Billed Charges,90% of Total billed Charges,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.93,65,,42.424,Percent of total Billed Charges,65% of Total Billed Charges,261.16,44.1,,1201.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,562.59,95,,3571.136,Percent of Total Billed Charges,95% of Total Billed Charges,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521.14,88,,1525.152,Percent of Total Billed Charges,88% of Total Billed Charges,532.98,90,,3383.176,Percent of Total Billed charges,90% of Total Billed Charges,261.16,592.2,
ACUMED AT2C14S 14MM MICRO SCRW,2780001095,CDM,278,RC,C1713,HCPCS,Outpatient,,,2236.50,1453.73,,2236.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1699.74,76,,2350.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1610.28,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,1610.28,72,,2660.184,Percent of Total Billed charges,72% of Total Billed Charges,2236.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1610.28,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,1341.9,60,,2216.816,Percent of Total Billed Charges,60% of Total Billed Charges,2012.85,90,,15532.288,Percent of Total Billed Charges,90% of Total Billed Charges,1006.43,45,,207.184,Percent of Total Billed Charges,45% of Total Billed Charges,2012.85,90,,2783.064,Percent of Total Billed Charges,90% of Total billed Charges,2236.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2236.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2236.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1453.73,65,,3196.72,Percent of total Billed Charges,65% of Total Billed Charges,986.3,44.1,,203.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,2124.68,95,,2937.68,Percent of Total Billed Charges,95% of Total Billed Charges,2236.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.12,88,,480.448,Percent of Total Billed Charges,88% of Total Billed Charges,2012.85,90,,2783.064,Percent of Total Billed charges,90% of Total Billed Charges,986.3,2236.5,
Z249004732 THREADED PIN 3.2,2780001096,CDM,278,RC,C1713,HCPCS,Outpatient,,,135.45,88.04,,135.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,102.94,76,,4480.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,97.52,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,97.52,72,,2660.184,Percent of Total Billed charges,72% of Total Billed Charges,135.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.52,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,81.27,60,,2216.816,Percent of Total Billed Charges,60% of Total Billed Charges,121.91,90,,4284.136,Percent of Total Billed Charges,90% of Total Billed Charges,60.95,45,,779.904,Percent of Total Billed Charges,45% of Total Billed Charges,121.91,90,,5305.76,Percent of Total Billed Charges,90% of Total billed Charges,135.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.04,65,,426.536,Percent of total Billed Charges,65% of Total Billed Charges,59.73,44.1,,764.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,128.68,95,,5600.52,Percent of Total Billed Charges,95% of Total Billed Charges,135.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.2,88,,41.136,Percent of Total Billed Charges,88% of Total Billed Charges,121.91,90,,5305.76,Percent of Total Billed charges,90% of Total Billed Charges,59.73,135.45,
Z241033 DRILL BIT 3.2 ECT,2780001097,CDM,278,RC,C1713,HCPCS,Outpatient,,,84.00,54.60,,84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,63.84,76,,2070.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,60.48,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,60.48,72,,2660.184,Percent of Total Billed charges,72% of Total Billed Charges,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.48,72,,2660.184,Percent of Total Billed Charges,72% of Total Billed Charges,50.4,60,,2216.816,Percent of Total Billed Charges,60% of Total Billed Charges,75.6,90,,630.28,Percent of Total Billed Charges,90% of Total Billed Charges,37.8,45,,245.68,Percent of Total Billed Charges,45% of Total Billed Charges,75.6,90,,2452.048,Percent of Total Billed Charges,90% of Total billed Charges,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.6,65,,5703.192,Percent of total Billed Charges,65% of Total Billed Charges,37.04,44.1,,240.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,79.8,95,,2588.272,Percent of Total Billed Charges,95% of Total Billed Charges,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.92,88,,4327.872,Percent of Total Billed Charges,88% of Total Billed Charges,75.6,90,,2452.048,Percent of Total Billed charges,90% of Total Billed Charges,37.04,84,
ECT SCREW 56 MM 4.5,2780001098,CDM,278,RC,C1713,HCPCS,Outpatient,,,52.00,33.80,,52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,39.52,76,,349.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,37.44,72,,428.656,Percent of Total Billed Charges,72% of Total Billed Charges,37.44,72,,428.656,Percent of Total Billed charges,72% of Total Billed Charges,52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.44,72,,428.656,Percent of Total Billed Charges,72% of Total Billed Charges,31.2,60,,357.208,Percent of Total Billed Charges,60% of Total Billed Charges,46.8,90,,184.16,Percent of Total Billed Charges,90% of Total Billed Charges,23.4,45,,21.032,Percent of Total Billed Charges,45% of Total Billed Charges,46.8,90,,414.368,Percent of Total Billed Charges,90% of Total billed Charges,52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.8,65,,12575.912,Percent of total Billed Charges,65% of Total Billed Charges,22.93,44.1,,20.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,49.4,95,,437.384,Percent of Total Billed Charges,95% of Total Billed Charges,52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.76,88,,937.6,Percent of Total Billed Charges,88% of Total Billed Charges,46.8,90,,414.368,Percent of Total Billed charges,90% of Total Billed Charges,22.93,52,
ECT SCREW 32 MM 4.5,2780001099,CDM,278,RC,C1713,HCPCS,Outpatient,,,52.00,33.80,,52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,39.52,76,,1317.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,37.44,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,37.44,72,,1633.32,Percent of Total Billed charges,72% of Total Billed Charges,52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.44,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,31.2,60,,1361.104,Percent of Total Billed Charges,60% of Total Billed Charges,46.8,90,,170.672,Percent of Total Billed Charges,90% of Total Billed Charges,23.4,45,,2213.112,Percent of Total Billed Charges,45% of Total Billed Charges,46.8,90,,1559.816,Percent of Total Billed Charges,90% of Total billed Charges,52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.8,65,,4068.136,Percent of total Billed Charges,65% of Total Billed Charges,22.93,44.1,,2168.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,49.4,95,,1646.472,Percent of Total Billed Charges,95% of Total Billed Charges,52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.76,88,,8484.984,Percent of Total Billed Charges,88% of Total Billed Charges,46.8,90,,1559.816,Percent of Total Billed charges,90% of Total Billed Charges,22.93,52,
Z22553550 DRILL BIT FEMORAL,2780001100,CDM,278,RC,C1713,HCPCS,Outpatient,,,212.00,137.80,,212,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.12,76,,414.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,152.64,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,152.64,72,,1633.32,Percent of Total Billed charges,72% of Total Billed Charges,212,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.64,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,127.2,60,,1361.104,Percent of Total Billed Charges,60% of Total Billed Charges,190.8,90,,2379.016,Percent of Total Billed Charges,90% of Total Billed Charges,95.4,45,,479.456,Percent of Total Billed Charges,45% of Total Billed Charges,190.8,90,,491.368,Percent of Total Billed Charges,90% of Total billed Charges,212,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.8,65,,2301.8,Percent of total Billed Charges,65% of Total Billed Charges,93.49,44.1,,469.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,201.4,95,,518.664,Percent of Total Billed Charges,95% of Total Billed Charges,212,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.56,88,,15187.128,Percent of Total Billed Charges,88% of Total Billed Charges,190.8,90,,491.368,Percent of Total Billed charges,90% of Total Billed Charges,93.49,212,
Z22553137 DRILL BIT 3.7,2780001101,CDM,278,RC,C1713,HCPCS,Outpatient,,,147.00,95.55,,147,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,111.72,76,,35.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,105.84,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,72,,1633.32,Percent of Total Billed charges,72% of Total Billed Charges,147,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.84,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,88.2,60,,1361.104,Percent of Total Billed Charges,60% of Total Billed Charges,132.3,90,,2426.648,Percent of Total Billed Charges,90% of Total Billed Charges,66.15,45,,4338.912,Percent of Total Billed Charges,45% of Total Billed Charges,132.3,90,,42.072,Percent of Total Billed Charges,90% of Total billed Charges,147,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.55,65,,1158.64,Percent of total Billed Charges,65% of Total Billed Charges,64.83,44.1,,4252.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,139.65,95,,44.408,Percent of Total Billed Charges,95% of Total Billed Charges,147,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.36,88,,4188.936,Percent of Total Billed Charges,88% of Total Billed Charges,132.3,90,,42.072,Percent of Total Billed charges,90% of Total Billed Charges,64.83,147,
Z225867 THD GUIDE PIN,2780001102,CDM,278,RC,C1713,HCPCS,Outpatient,,,176.00,114.40,,176,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,133.76,76,,3737.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,126.72,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,126.72,72,,1633.32,Percent of Total Billed charges,72% of Total Billed Charges,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.72,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,105.6,60,,1361.104,Percent of Total Billed Charges,60% of Total Billed Charges,158.4,90,,2426.648,Percent of Total Billed Charges,90% of Total Billed Charges,79.2,45,,7766.144,Percent of Total Billed Charges,45% of Total Billed Charges,158.4,90,,4426.232,Percent of Total Billed Charges,90% of Total billed Charges,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.4,65,,3094.096,Percent of total Billed Charges,65% of Total Billed Charges,77.62,44.1,,7610.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,167.2,95,,4672.128,Percent of Total Billed Charges,95% of Total Billed Charges,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.88,88,,616.272,Percent of Total Billed Charges,88% of Total Billed Charges,158.4,90,,4426.232,Percent of Total Billed charges,90% of Total Billed Charges,77.62,176,
Z22553350 DISTAL DRILL BIT,2780001103,CDM,278,RC,C1713,HCPCS,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,809.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,1633.32,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,1361.104,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,2111.512,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,2142.072,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,958.912,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,4985.992,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,2099.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,1012.184,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,180.072,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,958.912,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
Z114726 CANN DRILL BIT 2.7,2780001104,CDM,278,RC,C1713,HCPCS,Outpatient,,,1183.00,768.95,,1183,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,899.08,76,,7327.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,851.76,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,851.76,72,,1633.32,Percent of Total Billed charges,72% of Total Billed Charges,1183,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,851.76,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,709.8,60,,1361.104,Percent of Total Billed Charges,60% of Total Billed Charges,1064.7,90,,129.392,Percent of Total Billed Charges,90% of Total Billed Charges,532.35,45,,315.144,Percent of Total Billed Charges,45% of Total Billed Charges,1064.7,90,,8677.824,Percent of Total Billed Charges,90% of Total billed Charges,1183,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1183,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1183,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,768.95,65,,11217.76,Percent of total Billed Charges,65% of Total Billed Charges,521.7,44.1,,308.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,1123.85,95,,9159.92,Percent of Total Billed Charges,95% of Total Billed Charges,1183,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1041.04,88,,166.88,Percent of Total Billed Charges,88% of Total Billed Charges,1064.7,90,,8677.824,Percent of Total Billed charges,90% of Total Billed Charges,521.7,1183,
Z48402601 CANC 4.0 X 26,2780001105,CDM,278,RC,C1713,HCPCS,Outpatient,,,57.00,37.05,,57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.32,76,,13116.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.04,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,41.04,72,,1633.32,Percent of Total Billed charges,72% of Total Billed Charges,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.04,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,34.2,60,,1361.104,Percent of Total Billed Charges,60% of Total Billed Charges,51.3,90,,4734.224,Percent of Total Billed Charges,90% of Total Billed Charges,25.65,45,,92.08,Percent of Total Billed Charges,45% of Total Billed Charges,51.3,90,,15532.288,Percent of Total Billed Charges,90% of Total billed Charges,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.05,65,,2863.632,Percent of total Billed Charges,65% of Total Billed Charges,25.14,44.1,,90.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.15,95,,16395.192,Percent of Total Billed Charges,95% of Total Billed Charges,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.16,88,,2326.152,Percent of Total Billed Charges,88% of Total Billed Charges,51.3,90,,15532.288,Percent of Total Billed charges,90% of Total Billed Charges,25.14,57,
ACUMED AT2C 12S MICROSCW,2780001106,CDM,278,RC,C1713,HCPCS,Outpatient,,,2318.00,1506.70,,2318,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1761.68,76,,3617.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1668.96,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,1668.96,72,,1633.32,Percent of Total Billed charges,72% of Total Billed Charges,2318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1668.96,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,1390.8,60,,1361.104,Percent of Total Billed Charges,60% of Total Billed Charges,2086.2,90,,358.8,Percent of Total Billed Charges,90% of Total Billed Charges,1043.1,45,,85.336,Percent of Total Billed Charges,45% of Total Billed Charges,2086.2,90,,4284.136,Percent of Total Billed Charges,90% of Total billed Charges,2318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1506.7,65,,165.68,Percent of total Billed Charges,65% of Total Billed Charges,1022.24,44.1,,83.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,2202.1,95,,4522.144,Percent of Total Billed Charges,95% of Total Billed Charges,2318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2039.84,88,,2372.72,Percent of Total Billed Charges,88% of Total Billed Charges,2086.2,90,,4284.136,Percent of Total Billed charges,90% of Total Billed Charges,1022.24,2318,
Z23593027 2.7 CORTICAL SCW,2780001107,CDM,278,RC,C1713,HCPCS,Outpatient,,,263.00,170.95,,263,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,199.88,76,,532.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,189.36,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,189.36,72,,1633.32,Percent of Total Billed charges,72% of Total Billed Charges,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.36,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,157.8,60,,1361.104,Percent of Total Billed Charges,60% of Total Billed Charges,236.7,90,,2111.512,Percent of Total Billed Charges,90% of Total Billed Charges,118.35,45,,1189.512,Percent of Total Billed Charges,45% of Total Billed Charges,236.7,90,,630.28,Percent of Total Billed Charges,90% of Total billed Charges,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.95,65,,34.4,Percent of total Billed Charges,65% of Total Billed Charges,115.98,44.1,,1165.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,249.85,95,,665.296,Percent of Total Billed Charges,95% of Total Billed Charges,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.44,88,,2372.72,Percent of Total Billed Charges,88% of Total Billed Charges,236.7,90,,630.28,Percent of Total Billed charges,90% of Total Billed Charges,115.98,263,
Z23594227 2.7 CORTICAL SCW,2780001108,CDM,278,RC,C1713,HCPCS,Outpatient,,,263.00,170.95,,263,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,199.88,76,,155.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,189.36,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,189.36,72,,1633.32,Percent of Total Billed charges,72% of Total Billed Charges,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.36,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,157.8,60,,1361.104,Percent of Total Billed Charges,60% of Total Billed Charges,236.7,90,,14470.176,Percent of Total Billed Charges,90% of Total Billed Charges,118.35,45,,1213.32,Percent of Total Billed Charges,45% of Total Billed Charges,236.7,90,,184.16,Percent of Total Billed Charges,90% of Total billed Charges,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.95,65,,423.096,Percent of total Billed Charges,65% of Total Billed Charges,115.98,44.1,,1189.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,249.85,95,,194.392,Percent of Total Billed Charges,95% of Total Billed Charges,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.44,88,,2064.584,Percent of Total Billed Charges,88% of Total Billed Charges,236.7,90,,184.16,Percent of Total Billed charges,90% of Total Billed Charges,115.98,263,
Z235701006,2780001109,CDM,278,RC,C1713,HCPCS,Outpatient,,,4349.00,2826.85,,4349,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3305.24,76,,144.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3131.28,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,3131.28,72,,1633.32,Percent of Total Billed charges,72% of Total Billed Charges,4349,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3131.28,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,2609.4,60,,1361.104,Percent of Total Billed Charges,60% of Total Billed Charges,3914.1,90,,153.2,Percent of Total Billed Charges,90% of Total Billed Charges,1957.05,45,,1213.32,Percent of Total Billed Charges,45% of Total Billed Charges,3914.1,90,,170.672,Percent of Total Billed Charges,90% of Total billed Charges,4349,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4349,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4349,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2826.85,65,,7632.344,Percent of total Billed Charges,65% of Total Billed Charges,1917.91,44.1,,1189.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,4131.55,95,,180.152,Percent of Total Billed Charges,95% of Total Billed Charges,4349,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3827.12,88,,126.512,Percent of Total Billed Charges,88% of Total Billed Charges,3914.1,90,,170.672,Percent of Total Billed charges,90% of Total Billed Charges,1917.91,4349,
Z23583427 2.7 CORTICAL SCW,2780001110,CDM,278,RC,C1713,HCPCS,Outpatient,,,263.00,170.95,,263,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,199.88,76,,2008.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,189.36,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,189.36,72,,1633.32,Percent of Total Billed charges,72% of Total Billed Charges,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.36,72,,1633.32,Percent of Total Billed Charges,72% of Total Billed Charges,157.8,60,,1361.104,Percent of Total Billed Charges,60% of Total Billed Charges,236.7,90,,170.672,Percent of Total Billed Charges,90% of Total Billed Charges,118.35,45,,1055.752,Percent of Total Billed Charges,45% of Total Billed Charges,236.7,90,,2379.016,Percent of Total Billed Charges,90% of Total billed Charges,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.95,65,,1108.184,Percent of total Billed Charges,65% of Total Billed Charges,115.98,44.1,,1034.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,249.85,95,,2511.184,Percent of Total Billed Charges,95% of Total Billed Charges,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.44,88,,4629.016,Percent of Total Billed Charges,88% of Total Billed Charges,236.7,90,,2379.016,Percent of Total Billed charges,90% of Total Billed Charges,115.98,263,
ARTHREX CANNULATED DRILL 4MM,2780001111,CDM,278,RC,C1713,HCPCS,Outpatient,,,212.00,137.80,,212,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.12,76,,2049.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,152.64,72,,426.112,Percent of Total Billed Charges,72% of Total Billed Charges,152.64,72,,426.112,Percent of Total Billed charges,72% of Total Billed Charges,212,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.64,72,,426.112,Percent of Total Billed Charges,72% of Total Billed Charges,127.2,60,,355.096,Percent of Total Billed Charges,60% of Total Billed Charges,190.8,90,,58.744,Percent of Total Billed Charges,90% of Total Billed Charges,95.4,45,,64.696,Percent of Total Billed Charges,45% of Total Billed Charges,190.8,90,,2426.648,Percent of Total Billed Charges,90% of Total billed Charges,212,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.8,65,,919,Percent of total Billed Charges,65% of Total Billed Charges,93.49,44.1,,63.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,201.4,95,,2561.456,Percent of Total Billed Charges,95% of Total Billed Charges,212,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.56,88,,350.824,Percent of Total Billed Charges,88% of Total Billed Charges,190.8,90,,2426.648,Percent of Total Billed charges,90% of Total Billed Charges,93.49,212,
Z236017520 DRILL BIT 2.0,2780001112,CDM,278,RC,C1713,HCPCS,Outpatient,,,743.00,482.95,,743,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,564.68,76,,2049.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,534.96,72,,5554.696,Percent of Total Billed Charges,72% of Total Billed Charges,534.96,72,,5554.696,Percent of Total Billed charges,72% of Total Billed Charges,743,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,534.96,72,,5554.696,Percent of Total Billed Charges,72% of Total Billed Charges,445.8,60,,4628.912,Percent of Total Billed Charges,60% of Total Billed Charges,668.7,90,,4426.232,Percent of Total Billed Charges,90% of Total Billed Charges,334.35,45,,2367.112,Percent of Total Billed Charges,45% of Total Billed Charges,668.7,90,,2426.648,Percent of Total Billed Charges,90% of Total billed Charges,743,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,743,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,743,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.95,65,,10689.176,Percent of total Billed Charges,65% of Total Billed Charges,327.66,44.1,,2319.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,705.85,95,,2561.456,Percent of Total Billed Charges,95% of Total Billed Charges,743,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,653.84,88,,2064.584,Percent of Total Billed Charges,88% of Total Billed Charges,668.7,90,,2426.648,Percent of Total Billed charges,90% of Total Billed Charges,327.66,743,
Z480610027 DRILL BIT 2.7,2780001113,CDM,278,RC,C1713,HCPCS,Outpatient,,,213.00,138.45,,213,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.88,76,,1783.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153.36,72,,5554.696,Percent of Total Billed Charges,72% of Total Billed Charges,153.36,72,,5554.696,Percent of Total Billed charges,72% of Total Billed Charges,213,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.36,72,,5554.696,Percent of Total Billed Charges,72% of Total Billed Charges,127.8,60,,4628.912,Percent of Total Billed Charges,60% of Total Billed Charges,191.7,90,,590.584,Percent of Total Billed Charges,90% of Total Billed Charges,95.85,45,,179.4,Percent of Total Billed Charges,45% of Total Billed Charges,191.7,90,,2111.512,Percent of Total Billed Charges,90% of Total billed Charges,213,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.45,65,,1718.176,Percent of total Billed Charges,65% of Total Billed Charges,93.93,44.1,,175.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,202.35,95,,2228.816,Percent of Total Billed Charges,95% of Total Billed Charges,213,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.44,88,,14148.616,Percent of Total Billed Charges,88% of Total Billed Charges,191.7,90,,2111.512,Percent of Total Billed charges,90% of Total Billed Charges,93.93,213,
Z11472434 3.5 CANN SCW 24MM,2780001114,CDM,278,RC,C1713,HCPCS,Outpatient,,,537.00,349.05,,537,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,408.12,76,,109.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,386.64,72,,5554.696,Percent of Total Billed Charges,72% of Total Billed Charges,386.64,72,,5554.696,Percent of Total Billed charges,72% of Total Billed Charges,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.64,72,,5554.696,Percent of Total Billed Charges,72% of Total Billed Charges,322.2,60,,4628.912,Percent of Total Billed Charges,60% of Total Billed Charges,483.3,90,,7896.72,Percent of Total Billed Charges,90% of Total Billed Charges,241.65,45,,1055.752,Percent of Total Billed Charges,45% of Total Billed Charges,483.3,90,,129.392,Percent of Total Billed Charges,90% of Total billed Charges,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.05,65,,442.016,Percent of total Billed Charges,65% of Total Billed Charges,236.82,44.1,,1034.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,510.15,95,,136.576,Percent of Total Billed Charges,95% of Total Billed Charges,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.56,88,,149.8,Percent of Total Billed Charges,88% of Total Billed Charges,483.3,90,,129.392,Percent of Total Billed charges,90% of Total Billed Charges,236.82,537,
Z47249340313NLCPM13MMX40CM130L,2780001115,CDM,278,RC,C1713,HCPCS,Outpatient,,,7649.00,4971.85,,7649,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5813.24,76,,3997.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5507.28,72,,349.912,Percent of Total Billed Charges,72% of Total Billed Charges,5507.28,72,,349.912,Percent of Total Billed charges,72% of Total Billed Charges,7649,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5507.28,72,,349.912,Percent of Total Billed Charges,72% of Total Billed Charges,4589.4,60,,291.592,Percent of Total Billed Charges,60% of Total Billed Charges,6884.1,90,,17412.8,Percent of Total Billed Charges,90% of Total Billed Charges,3442.05,45,,7235.088,Percent of Total Billed Charges,45% of Total Billed Charges,6884.1,90,,4734.224,Percent of Total Billed Charges,90% of Total billed Charges,7649,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7649,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7649,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4971.85,65,,442.016,Percent of total Billed Charges,65% of Total Billed Charges,3373.21,44.1,,7090.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,7266.55,95,,4997.232,Percent of Total Billed Charges,95% of Total Billed Charges,7649,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6731.12,88,,166.88,Percent of Total Billed Charges,88% of Total Billed Charges,6884.1,90,,4734.224,Percent of Total Billed charges,90% of Total Billed Charges,3373.21,7649,
ARTHREX AR 8925SS TIGHTROPE XP,2780001116,CDM,278,RC,C1713,HCPCS,Outpatient,,,7583.00,4928.95,,7583,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5763.08,76,,302.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5459.76,72,,349.912,Percent of Total Billed Charges,72% of Total Billed Charges,5459.76,72,,349.912,Percent of Total Billed charges,72% of Total Billed Charges,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5459.76,72,,349.912,Percent of Total Billed Charges,72% of Total Billed Charges,4549.8,60,,291.592,Percent of Total Billed Charges,60% of Total Billed Charges,6824.7,90,,5632.808,Percent of Total Billed Charges,90% of Total Billed Charges,3412.35,45,,76.6,Percent of Total Billed Charges,45% of Total Billed Charges,6824.7,90,,358.8,Percent of Total Billed Charges,90% of Total billed Charges,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4928.95,65,,423.096,Percent of total Billed Charges,65% of Total Billed Charges,3344.1,44.1,,75.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,7203.85,95,,378.728,Percent of Total Billed Charges,95% of Total Billed Charges,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6673.04,88,,57.44,Percent of Total Billed Charges,88% of Total Billed Charges,6824.7,90,,358.8,Percent of Total Billed charges,90% of Total Billed Charges,3344.1,7583,
Z22320228 CERCLAGE CABLE,2780001117,CDM,278,RC,C1713,HCPCS,Outpatient,,,409.00,265.85,,409,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,310.84,76,,1783.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,294.48,72,,349.912,Percent of Total Billed Charges,72% of Total Billed Charges,294.48,72,,349.912,Percent of Total Billed charges,72% of Total Billed Charges,409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.48,72,,349.912,Percent of Total Billed Charges,72% of Total Billed Charges,245.4,60,,291.592,Percent of Total Billed Charges,60% of Total Billed Charges,368.1,90,,3187.112,Percent of Total Billed Charges,90% of Total Billed Charges,184.05,45,,85.336,Percent of Total Billed Charges,45% of Total Billed Charges,368.1,90,,2111.512,Percent of Total Billed Charges,90% of Total billed Charges,409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.85,65,,32.68,Percent of total Billed Charges,65% of Total Billed Charges,180.37,44.1,,83.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,388.55,95,,2228.816,Percent of Total Billed Charges,95% of Total Billed Charges,409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.92,88,,4327.872,Percent of Total Billed Charges,88% of Total Billed Charges,368.1,90,,2111.512,Percent of Total Billed charges,90% of Total Billed Charges,180.37,409,
Z249007543 DRILL BIT 4.3,2780001118,CDM,278,RC,C1713,HCPCS,Outpatient,,,120.00,78.00,,120,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,91.2,76,,12219.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,86.4,72,,349.912,Percent of Total Billed Charges,72% of Total Billed Charges,86.4,72,,349.912,Percent of Total Billed charges,72% of Total Billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.4,72,,349.912,Percent of Total Billed Charges,72% of Total Billed Charges,72,60,,291.592,Percent of Total Billed Charges,60% of Total Billed Charges,108,90,,1604.272,Percent of Total Billed Charges,90% of Total Billed Charges,54,45,,29.376,Percent of Total Billed Charges,45% of Total Billed Charges,108,90,,14470.176,Percent of Total Billed Charges,90% of Total billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78,65,,32.68,Percent of total Billed Charges,65% of Total Billed Charges,52.92,44.1,,28.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,114,95,,15274.08,Percent of Total Billed Charges,95% of Total Billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.6,88,,577.464,Percent of Total Billed Charges,88% of Total Billed Charges,108,90,,14470.176,Percent of Total Billed charges,90% of Total Billed Charges,52.92,120,
Z20090127AGC,2780001119,CDM,278,RC,C1713,HCPCS,Outpatient,,,204.00,132.60,,204,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,155.04,76,,129.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,146.88,72,,349.912,Percent of Total Billed Charges,72% of Total Billed Charges,146.88,72,,349.912,Percent of Total Billed charges,72% of Total Billed Charges,204,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.88,72,,349.912,Percent of Total Billed Charges,72% of Total Billed Charges,122.4,60,,291.592,Percent of Total Billed Charges,60% of Total Billed Charges,183.6,90,,4284.136,Percent of Total Billed Charges,90% of Total Billed Charges,91.8,45,,2213.112,Percent of Total Billed Charges,45% of Total Billed Charges,183.6,90,,153.2,Percent of Total Billed Charges,90% of Total billed Charges,204,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.6,65,,2510.48,Percent of total Billed Charges,65% of Total Billed Charges,89.96,44.1,,2168.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,193.8,95,,161.712,Percent of Total Billed Charges,95% of Total Billed Charges,204,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.52,88,,7721.24,Percent of Total Billed Charges,88% of Total Billed Charges,183.6,90,,153.2,Percent of Total Billed charges,90% of Total Billed Charges,89.96,204,
S&N HEALCOIL DOUBLE STRAND 4.5,2780001120,CDM,278,RC,C1713,HCPCS,Outpatient,,,1207.00,784.55,,1207,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,917.32,76,,144.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,869.04,72,,5275.912,Percent of Total Billed Charges,72% of Total Billed Charges,869.04,72,,5275.912,Percent of Total Billed charges,72% of Total Billed Charges,1207,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,869.04,72,,5275.912,Percent of Total Billed Charges,72% of Total Billed Charges,724.2,60,,4396.592,Percent of Total Billed Charges,60% of Total Billed Charges,1086.3,90,,6903.68,Percent of Total Billed Charges,90% of Total Billed Charges,543.15,45,,295.296,Percent of Total Billed Charges,45% of Total Billed Charges,1086.3,90,,170.672,Percent of Total Billed Charges,90% of Total billed Charges,1207,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1207,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1207,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,784.55,65,,32.68,Percent of total Billed Charges,65% of Total Billed Charges,532.29,44.1,,289.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,1146.65,95,,180.152,Percent of Total Billed Charges,95% of Total Billed Charges,1207,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1062.16,88,,17025.848,Percent of Total Billed Charges,88% of Total Billed Charges,1086.3,90,,170.672,Percent of Total Billed charges,90% of Total Billed Charges,532.29,1207,
Z11472435,2780001121,CDM,278,RC,C1713,HCPCS,Outpatient,,,537.00,349.05,,537,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,408.12,76,,49.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,386.64,72,,626.784,Percent of Total Billed Charges,72% of Total Billed Charges,386.64,72,,626.784,Percent of Total Billed charges,72% of Total Billed Charges,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.64,72,,626.784,Percent of Total Billed Charges,72% of Total Billed Charges,322.2,60,,522.32,Percent of Total Billed Charges,60% of Total Billed Charges,483.3,90,,15532.288,Percent of Total Billed Charges,90% of Total Billed Charges,241.65,45,,3948.36,Percent of Total Billed Charges,45% of Total Billed Charges,483.3,90,,58.744,Percent of Total Billed Charges,90% of Total billed Charges,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.05,65,,307.864,Percent of total Billed Charges,65% of Total Billed Charges,236.82,44.1,,3869.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,510.15,95,,62.008,Percent of Total Billed Charges,95% of Total Billed Charges,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.56,88,,5507.632,Percent of Total Billed Charges,88% of Total Billed Charges,483.3,90,,58.744,Percent of Total Billed charges,90% of Total Billed Charges,236.82,537,
Z231200200 2.2MM DRILL BIT,2780001122,CDM,278,RC,C1713,HCPCS,Outpatient,,,296.00,192.40,,296,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,224.96,76,,3737.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,213.12,72,,840.16,Percent of Total Billed Charges,72% of Total Billed Charges,213.12,72,,840.16,Percent of Total Billed charges,72% of Total Billed Charges,296,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.12,72,,840.16,Percent of Total Billed Charges,72% of Total Billed Charges,177.6,60,,700.136,Percent of Total Billed Charges,60% of Total Billed Charges,266.4,90,,3965.032,Percent of Total Billed Charges,90% of Total Billed Charges,133.2,45,,8706.4,Percent of Total Billed Charges,45% of Total Billed Charges,266.4,90,,4426.232,Percent of Total Billed Charges,90% of Total billed Charges,296,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.4,65,,8856.336,Percent of total Billed Charges,65% of Total Billed Charges,130.54,44.1,,8532.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,281.2,95,,4672.128,Percent of Total Billed Charges,95% of Total Billed Charges,296,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.48,88,,3116.288,Percent of Total Billed Charges,88% of Total Billed Charges,266.4,90,,4426.232,Percent of Total Billed charges,90% of Total Billed Charges,130.54,296,
Z131812060 MED PLATE,2780001123,CDM,278,RC,C1713,HCPCS,Outpatient,,,3064.00,1991.60,,3064,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2328.64,76,,498.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2206.08,72,,2428.392,Percent of Total Billed Charges,72% of Total Billed Charges,2206.08,72,,2428.392,Percent of Total Billed charges,72% of Total Billed Charges,3064,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2206.08,72,,2428.392,Percent of Total Billed Charges,72% of Total Billed Charges,1838.4,60,,2023.664,Percent of Total Billed Charges,60% of Total Billed Charges,2757.6,90,,229.408,Percent of Total Billed Charges,90% of Total Billed Charges,1378.8,45,,2816.4,Percent of Total Billed Charges,45% of Total Billed Charges,2757.6,90,,590.584,Percent of Total Billed Charges,90% of Total billed Charges,3064,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3064,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3064,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1991.6,65,,272.456,Percent of total Billed Charges,65% of Total Billed Charges,1351.22,44.1,,2760.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,2910.8,95,,623.4,Percent of Total Billed Charges,95% of Total Billed Charges,3064,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2696.32,88,,1568.616,Percent of Total Billed Charges,88% of Total Billed Charges,2757.6,90,,590.584,Percent of Total Billed charges,90% of Total Billed Charges,1351.22,3064,
Z131822060 MED PLATE,2780001124,CDM,278,RC,C1713,HCPCS,Outpatient,,,3064.00,1991.60,,3064,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2328.64,76,,6668.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2206.08,72,,4618.648,Percent of Total Billed Charges,72% of Total Billed Charges,2206.08,72,,4618.648,Percent of Total Billed charges,72% of Total Billed Charges,3064,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2206.08,72,,4618.648,Percent of Total Billed Charges,72% of Total Billed Charges,1838.4,60,,3848.872,Percent of Total Billed Charges,60% of Total Billed Charges,2757.6,90,,47.632,Percent of Total Billed Charges,90% of Total Billed Charges,1378.8,45,,1593.552,Percent of Total Billed Charges,45% of Total Billed Charges,2757.6,90,,7896.72,Percent of Total Billed Charges,90% of Total billed Charges,3064,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3064,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3064,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1991.6,65,,3435.64,Percent of total Billed Charges,65% of Total Billed Charges,1351.22,44.1,,1561.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,2910.8,95,,8335.432,Percent of Total Billed Charges,95% of Total Billed Charges,3064,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2696.32,88,,4188.936,Percent of Total Billed Charges,88% of Total Billed Charges,2757.6,90,,7896.72,Percent of Total Billed charges,90% of Total Billed Charges,1351.22,3064,
Z131813050 RIGHT WIDE PLATE,2780001125,CDM,278,RC,C1713,HCPCS,Outpatient,,,2719.00,1767.35,,2719,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2066.44,76,,14704.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1957.68,72,,2428.392,Percent of Total Billed Charges,72% of Total Billed Charges,1957.68,72,,2428.392,Percent of Total Billed charges,72% of Total Billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1957.68,72,,2428.392,Percent of Total Billed Charges,72% of Total Billed Charges,1631.4,60,,2023.664,Percent of Total Billed Charges,60% of Total Billed Charges,2447.1,90,,585.832,Percent of Total Billed Charges,90% of Total Billed Charges,1223.55,45,,802.136,Percent of Total Billed Charges,45% of Total Billed Charges,2447.1,90,,17412.8,Percent of Total Billed Charges,90% of Total billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1767.35,65,,355.448,Percent of total Billed Charges,65% of Total Billed Charges,1199.08,44.1,,786.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,2583.05,95,,18380.176,Percent of Total Billed Charges,95% of Total Billed Charges,2719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2392.72,88,,6750.264,Percent of Total Billed Charges,88% of Total Billed Charges,2447.1,90,,17412.8,Percent of Total Billed charges,90% of Total Billed Charges,1199.08,2719,
Z23597536 3.5CANN LCK SCW 75,2780001126,CDM,278,RC,C1713,HCPCS,Outpatient,,,306.00,198.90,,306,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,232.56,76,,4756.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,220.32,72,,14282.056,Percent of Total Billed Charges,72% of Total Billed Charges,220.32,72,,14282.056,Percent of Total Billed charges,72% of Total Billed Charges,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.32,72,,14282.056,Percent of Total Billed Charges,72% of Total Billed Charges,183.6,60,,11901.712,Percent of Total Billed Charges,60% of Total Billed Charges,275.4,90,,10567.856,Percent of Total Billed Charges,90% of Total Billed Charges,137.7,45,,2142.072,Percent of Total Billed Charges,45% of Total Billed Charges,275.4,90,,5632.808,Percent of Total Billed Charges,90% of Total billed Charges,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.9,65,,355.448,Percent of total Billed Charges,65% of Total Billed Charges,134.95,44.1,,2099.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,290.7,95,,5945.736,Percent of Total Billed Charges,95% of Total Billed Charges,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.28,88,,15187.128,Percent of Total Billed Charges,88% of Total Billed Charges,275.4,90,,5632.808,Percent of Total Billed charges,90% of Total Billed Charges,134.95,306,
Z00590102000 NEXGEN,2780001127,CDM,278,RC,C1713,HCPCS,Outpatient,,,2343.00,1522.95,,2343,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1780.68,76,,2691.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1686.96,72,,4529.736,Percent of Total Billed Charges,72% of Total Billed Charges,1686.96,72,,4529.736,Percent of Total Billed charges,72% of Total Billed Charges,2343,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1686.96,72,,4529.736,Percent of Total Billed Charges,72% of Total Billed Charges,1405.8,60,,3774.784,Percent of Total Billed Charges,60% of Total Billed Charges,2108.7,90,,1534.416,Percent of Total Billed Charges,90% of Total Billed Charges,1054.35,45,,3451.84,Percent of Total Billed Charges,45% of Total Billed Charges,2108.7,90,,3187.112,Percent of Total Billed Charges,90% of Total billed Charges,2343,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2343,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2343,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1522.95,65,,1479.112,Percent of total Billed Charges,65% of Total Billed Charges,1033.26,44.1,,3382.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,2225.85,95,,3364.168,Percent of Total Billed Charges,95% of Total Billed Charges,2343,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2061.84,88,,3876.92,Percent of Total Billed Charges,88% of Total Billed Charges,2108.7,90,,3187.112,Percent of Total Billed charges,90% of Total Billed Charges,1033.26,2343,
Z11473635 CANN SCW 36,2780001128,CDM,278,RC,C1713,HCPCS,Outpatient,,,537.00,349.05,,537,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,408.12,76,,1354.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,386.64,72,,2428.392,Percent of Total Billed Charges,72% of Total Billed Charges,386.64,72,,2428.392,Percent of Total Billed charges,72% of Total Billed Charges,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.64,72,,2428.392,Percent of Total Billed Charges,72% of Total Billed Charges,322.2,60,,2023.664,Percent of Total Billed Charges,60% of Total Billed Charges,483.3,90,,1272.464,Percent of Total Billed Charges,90% of Total Billed Charges,241.65,45,,7766.144,Percent of Total Billed Charges,45% of Total Billed Charges,483.3,90,,1604.272,Percent of Total Billed Charges,90% of Total billed Charges,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.05,65,,316.68,Percent of total Billed Charges,65% of Total Billed Charges,236.82,44.1,,7610.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,510.15,95,,1693.392,Percent of Total Billed Charges,95% of Total Billed Charges,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.56,88,,224.312,Percent of Total Billed Charges,88% of Total Billed Charges,483.3,90,,1604.272,Percent of Total Billed charges,90% of Total Billed Charges,236.82,537,
Z114737 CANN TAP 3.5MM,2780001129,CDM,278,RC,C1713,HCPCS,Outpatient,,,1116.00,725.40,,1116,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,848.16,76,,3617.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,803.52,72,,3413.976,Percent of Total Billed Charges,72% of Total Billed Charges,803.52,72,,3413.976,Percent of Total Billed charges,72% of Total Billed Charges,1116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,803.52,72,,3413.976,Percent of Total Billed Charges,72% of Total Billed Charges,669.6,60,,2844.976,Percent of Total Billed Charges,60% of Total Billed Charges,1004.4,90,,14800.4,Percent of Total Billed Charges,90% of Total Billed Charges,502.2,45,,1982.52,Percent of Total Billed Charges,45% of Total Billed Charges,1004.4,90,,4284.136,Percent of Total Billed Charges,90% of Total billed Charges,1116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,725.4,65,,316.68,Percent of total Billed Charges,65% of Total Billed Charges,492.16,44.1,,1942.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,1060.2,95,,4522.144,Percent of Total Billed Charges,95% of Total Billed Charges,1116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,982.08,88,,46.568,Percent of Total Billed Charges,88% of Total Billed Charges,1004.4,90,,4284.136,Percent of Total Billed charges,90% of Total Billed Charges,492.16,1116,
Z11474635 CANN SCW 46,2780001130,CDM,278,RC,C1713,HCPCS,Outpatient,,,537.00,349.05,,537,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,408.12,76,,5829.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,386.64,72,,2351.552,Percent of Total Billed Charges,72% of Total Billed Charges,386.64,72,,2351.552,Percent of Total Billed charges,72% of Total Billed Charges,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.64,72,,2351.552,Percent of Total Billed Charges,72% of Total Billed Charges,322.2,60,,1959.632,Percent of Total Billed Charges,60% of Total Billed Charges,483.3,90,,2379.016,Percent of Total Billed Charges,90% of Total Billed Charges,241.65,45,,114.704,Percent of Total Billed Charges,45% of Total Billed Charges,483.3,90,,6903.68,Percent of Total Billed Charges,90% of Total billed Charges,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.05,65,,316.68,Percent of total Billed Charges,65% of Total Billed Charges,236.82,44.1,,112.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,510.15,95,,7287.216,Percent of Total Billed Charges,95% of Total Billed Charges,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.56,88,,572.808,Percent of Total Billed Charges,88% of Total Billed Charges,483.3,90,,6903.68,Percent of Total Billed charges,90% of Total Billed Charges,236.82,537,
Z23596536 3.5CANN LCK SCW 65,2780001131,CDM,278,RC,C1713,HCPCS,Outpatient,,,306.00,198.90,,306,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,232.56,76,,13116.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,220.32,72,,1745.088,Percent of Total Billed Charges,72% of Total Billed Charges,220.32,72,,1745.088,Percent of Total Billed charges,72% of Total Billed Charges,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.32,72,,1745.088,Percent of Total Billed Charges,72% of Total Billed Charges,183.6,60,,1454.24,Percent of Total Billed Charges,60% of Total Billed Charges,275.4,90,,612.024,Percent of Total Billed Charges,90% of Total Billed Charges,137.7,45,,23.816,Percent of Total Billed Charges,45% of Total Billed Charges,275.4,90,,15532.288,Percent of Total Billed Charges,90% of Total billed Charges,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.9,65,,316.68,Percent of total Billed Charges,65% of Total Billed Charges,134.95,44.1,,23.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,290.7,95,,16395.192,Percent of Total Billed Charges,95% of Total Billed Charges,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.28,88,,10333.016,Percent of Total Billed Charges,88% of Total Billed Charges,275.4,90,,15532.288,Percent of Total Billed charges,90% of Total Billed Charges,134.95,306,
ACUMED 2.3X8MM LCK SCW,2780001132,CDM,278,RC,C1713,HCPCS,Outpatient,,,465.00,302.25,,465,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,353.4,76,,3348.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,334.8,72,,4223.016,Percent of Total Billed Charges,72% of Total Billed Charges,334.8,72,,4223.016,Percent of Total Billed charges,72% of Total Billed Charges,465,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.8,72,,4223.016,Percent of Total Billed Charges,72% of Total Billed Charges,279,60,,3519.184,Percent of Total Billed Charges,60% of Total Billed Charges,418.5,90,,612.024,Percent of Total Billed Charges,90% of Total Billed Charges,209.25,45,,292.912,Percent of Total Billed Charges,45% of Total Billed Charges,418.5,90,,3965.032,Percent of Total Billed Charges,90% of Total billed Charges,465,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.25,65,,11518.744,Percent of total Billed Charges,65% of Total Billed Charges,205.07,44.1,,287.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,441.75,95,,4185.312,Percent of Total Billed Charges,95% of Total Billed Charges,465,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.2,88,,1500.312,Percent of Total Billed Charges,88% of Total Billed Charges,418.5,90,,3965.032,Percent of Total Billed charges,90% of Total Billed Charges,205.07,465,
ACUMED 2.3X10MM LCK SCW,2780001133,CDM,278,RC,C1713,HCPCS,Outpatient,,,465.00,302.25,,465,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,353.4,76,,193.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,334.8,72,,246.392,Percent of Total Billed Charges,72% of Total Billed Charges,334.8,72,,246.392,Percent of Total Billed charges,72% of Total Billed Charges,465,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.8,72,,246.392,Percent of Total Billed Charges,72% of Total Billed Charges,279,60,,205.328,Percent of Total Billed Charges,60% of Total Billed Charges,418.5,90,,585.832,Percent of Total Billed Charges,90% of Total Billed Charges,209.25,45,,5283.928,Percent of Total Billed Charges,45% of Total Billed Charges,418.5,90,,229.408,Percent of Total Billed Charges,90% of Total billed Charges,465,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.25,65,,296.976,Percent of total Billed Charges,65% of Total Billed Charges,205.07,44.1,,5178.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,441.75,95,,242.152,Percent of Total Billed Charges,95% of Total Billed Charges,465,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.2,88,,1244.184,Percent of Total Billed Charges,88% of Total Billed Charges,418.5,90,,229.408,Percent of Total Billed charges,90% of Total Billed Charges,205.07,465,
ACUMED 2.3X16MM CORT SCW,2780001134,CDM,278,RC,C1713,HCPCS,Outpatient,,,465.00,302.25,,465,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,353.4,76,,40.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,334.8,72,,2383.944,Percent of Total Billed Charges,72% of Total Billed Charges,334.8,72,,2383.944,Percent of Total Billed charges,72% of Total Billed Charges,465,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.8,72,,2383.944,Percent of Total Billed Charges,72% of Total Billed Charges,279,60,,1986.616,Percent of Total Billed Charges,60% of Total Billed Charges,418.5,90,,45.248,Percent of Total Billed Charges,90% of Total Billed Charges,209.25,45,,767.208,Percent of Total Billed Charges,45% of Total Billed Charges,418.5,90,,47.632,Percent of Total Billed Charges,90% of Total billed Charges,465,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.25,65,,4856.424,Percent of total Billed Charges,65% of Total Billed Charges,205.07,44.1,,751.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,441.75,95,,50.272,Percent of Total Billed Charges,95% of Total Billed Charges,465,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.2,88,,14471.504,Percent of Total Billed Charges,88% of Total Billed Charges,418.5,90,,47.632,Percent of Total Billed charges,90% of Total Billed Charges,205.07,465,
Z23488035 3.5CORTICAL SCW 80,2780001135,CDM,278,RC,C1713,HCPCS,Outpatient,,,104.00,67.60,,104,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.04,76,,494.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,74.88,72,,1141.168,Percent of Total Billed Charges,72% of Total Billed Charges,74.88,72,,1141.168,Percent of Total Billed charges,72% of Total Billed Charges,104,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.88,72,,1141.168,Percent of Total Billed Charges,72% of Total Billed Charges,62.4,60,,950.968,Percent of Total Billed Charges,60% of Total Billed Charges,93.6,90,,45.248,Percent of Total Billed Charges,90% of Total Billed Charges,46.8,45,,636.232,Percent of Total Billed Charges,45% of Total Billed Charges,93.6,90,,585.832,Percent of Total Billed Charges,90% of Total billed Charges,104,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.6,65,,146.768,Percent of total Billed Charges,65% of Total Billed Charges,45.86,44.1,,623.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,98.8,95,,618.376,Percent of Total Billed Charges,95% of Total Billed Charges,104,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.52,88,,2326.152,Percent of Total Billed Charges,88% of Total Billed Charges,93.6,90,,585.832,Percent of Total Billed charges,90% of Total Billed Charges,45.86,104,
STRYKER DISTAL LAT FIB PLAT 9H,2780001136,CDM,278,RC,C1713,HCPCS,Outpatient,,,3018.00,1961.70,,3018,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2293.68,76,,8923.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2172.96,72,,485.168,Percent of Total Billed Charges,72% of Total Billed Charges,2172.96,72,,485.168,Percent of Total Billed charges,72% of Total Billed Charges,3018,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2172.96,72,,485.168,Percent of Total Billed Charges,72% of Total Billed Charges,1810.8,60,,404.312,Percent of Total Billed Charges,60% of Total Billed Charges,2716.2,90,,3476.056,Percent of Total Billed Charges,90% of Total Billed Charges,1358.1,45,,7400.2,Percent of Total Billed Charges,45% of Total Billed Charges,2716.2,90,,10567.856,Percent of Total Billed Charges,90% of Total billed Charges,3018,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3018,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3018,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1961.7,65,,9845.856,Percent of total Billed Charges,65% of Total Billed Charges,1330.94,44.1,,7252.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,2867.1,95,,11154.96,Percent of Total Billed Charges,95% of Total Billed Charges,3018,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2655.84,88,,598.424,Percent of Total Billed Charges,88% of Total Billed Charges,2716.2,90,,10567.856,Percent of Total Billed charges,90% of Total Billed Charges,1330.94,3018,
STRYKER 3.5 LOCK SCW FT 12MM,2780001137,CDM,278,RC,C1713,HCPCS,Outpatient,,,771.00,501.15,,771,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,585.96,76,,1295.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,555.12,72,,94.616,Percent of Total Billed Charges,72% of Total Billed Charges,555.12,72,,94.616,Percent of Total Billed charges,72% of Total Billed Charges,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.12,72,,94.616,Percent of Total Billed Charges,72% of Total Billed Charges,462.6,60,,78.848,Percent of Total Billed Charges,60% of Total Billed Charges,693.9,90,,45.248,Percent of Total Billed Charges,90% of Total Billed Charges,346.95,45,,1189.512,Percent of Total Billed Charges,45% of Total Billed Charges,693.9,90,,1534.416,Percent of Total Billed Charges,90% of Total billed Charges,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.15,65,,10572.224,Percent of total Billed Charges,65% of Total Billed Charges,340.01,44.1,,1165.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,732.45,95,,1619.656,Percent of Total Billed Charges,95% of Total Billed Charges,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678.48,88,,598.424,Percent of Total Billed Charges,88% of Total Billed Charges,693.9,90,,1534.416,Percent of Total Billed charges,90% of Total Billed Charges,340.01,771,
STRYKER 3.5 BONE SCW FT 12MM,2780001138,CDM,278,RC,C1713,HCPCS,Outpatient,,,419.00,272.35,,419,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,318.44,76,,1074.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,301.68,72,,97.16,Percent of Total Billed Charges,72% of Total Billed Charges,301.68,72,,97.16,Percent of Total Billed charges,72% of Total Billed Charges,419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.68,72,,97.16,Percent of Total Billed Charges,72% of Total Billed Charges,251.4,60,,80.968,Percent of Total Billed Charges,60% of Total Billed Charges,377.1,90,,426.272,Percent of Total Billed Charges,90% of Total Billed Charges,188.55,45,,306.008,Percent of Total Billed Charges,45% of Total Billed Charges,377.1,90,,1272.464,Percent of Total Billed Charges,90% of Total billed Charges,419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.35,65,,4032.592,Percent of total Billed Charges,65% of Total Billed Charges,184.78,44.1,,299.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,398.05,95,,1343.152,Percent of Total Billed Charges,95% of Total Billed Charges,419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.72,88,,572.808,Percent of Total Billed Charges,88% of Total Billed Charges,377.1,90,,1272.464,Percent of Total Billed charges,90% of Total Billed Charges,184.78,419,
STRYKER 3.5 LOCK SCW FT 10MM,2780001139,CDM,278,RC,C1713,HCPCS,Outpatient,,,771.00,501.15,,771,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,585.96,76,,12498.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,555.12,72,,12225.16,Percent of Total Billed Charges,72% of Total Billed Charges,555.12,72,,12225.16,Percent of Total Billed charges,72% of Total Billed Charges,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.12,72,,12225.16,Percent of Total Billed Charges,72% of Total Billed Charges,462.6,60,,10187.632,Percent of Total Billed Charges,60% of Total Billed Charges,693.9,90,,12262.624,Percent of Total Billed Charges,90% of Total Billed Charges,346.95,45,,306.008,Percent of Total Billed Charges,45% of Total Billed Charges,693.9,90,,14800.4,Percent of Total Billed Charges,90% of Total billed Charges,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.15,65,,4032.592,Percent of total Billed Charges,65% of Total Billed Charges,340.01,44.1,,299.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,732.45,95,,15622.64,Percent of Total Billed Charges,95% of Total Billed Charges,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678.48,88,,44.24,Percent of Total Billed Charges,88% of Total Billed Charges,693.9,90,,14800.4,Percent of Total Billed charges,90% of Total Billed Charges,340.01,771,
STRYKER 3.5 BONE SCW FT 14MM,2780001140,CDM,278,RC,C1713,HCPCS,Outpatient,,,419.00,272.35,,419,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,318.44,76,,2008.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,301.68,72,,5580.096,Percent of Total Billed Charges,72% of Total Billed Charges,301.68,72,,5580.096,Percent of Total Billed charges,72% of Total Billed Charges,419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.68,72,,5580.096,Percent of Total Billed Charges,72% of Total Billed Charges,251.4,60,,4650.08,Percent of Total Billed Charges,60% of Total Billed Charges,377.1,90,,377.248,Percent of Total Billed Charges,90% of Total Billed Charges,188.55,45,,292.912,Percent of Total Billed Charges,45% of Total Billed Charges,377.1,90,,2379.016,Percent of Total Billed Charges,90% of Total billed Charges,419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.35,65,,4032.592,Percent of total Billed Charges,65% of Total Billed Charges,184.78,44.1,,287.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,398.05,95,,2511.184,Percent of Total Billed Charges,95% of Total Billed Charges,419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.72,88,,44.24,Percent of Total Billed Charges,88% of Total Billed Charges,377.1,90,,2379.016,Percent of Total Billed charges,90% of Total Billed Charges,184.78,419,
STRYKER 3.5 LOCK SCW FT 14MM,2780001141,CDM,278,RC,C1713,HCPCS,Outpatient,,,771.00,501.15,,771,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,585.96,76,,516.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,555.12,72,,12393.44,Percent of Total Billed Charges,72% of Total Billed Charges,555.12,72,,12393.44,Percent of Total Billed charges,72% of Total Billed Charges,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.12,72,,12393.44,Percent of Total Billed Charges,72% of Total Billed Charges,462.6,60,,10327.864,Percent of Total Billed Charges,60% of Total Billed Charges,693.9,90,,4757.04,Percent of Total Billed Charges,90% of Total Billed Charges,346.95,45,,22.624,Percent of Total Billed Charges,45% of Total Billed Charges,693.9,90,,612.024,Percent of Total Billed Charges,90% of Total billed Charges,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.15,65,,4742.336,Percent of total Billed Charges,65% of Total Billed Charges,340.01,44.1,,22.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,732.45,95,,646.024,Percent of Total Billed Charges,95% of Total Billed Charges,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678.48,88,,3398.808,Percent of Total Billed Charges,88% of Total Billed Charges,693.9,90,,612.024,Percent of Total Billed charges,90% of Total Billed Charges,340.01,771,
ARTHREX MINI TIGHTROPE 1.1MM,2780001142,CDM,278,RC,C1713,HCPCS,Outpatient,,,2467.00,1603.55,,2467,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1874.92,76,,516.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1776.24,72,,4002.656,Percent of Total Billed Charges,72% of Total Billed Charges,1776.24,72,,4002.656,Percent of Total Billed charges,72% of Total Billed Charges,2467,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1776.24,72,,4002.656,Percent of Total Billed Charges,72% of Total Billed Charges,1480.2,60,,3335.552,Percent of Total Billed Charges,60% of Total Billed Charges,2220.3,90,,492.16,Percent of Total Billed Charges,90% of Total Billed Charges,1110.15,45,,22.624,Percent of Total Billed Charges,45% of Total Billed Charges,2220.3,90,,612.024,Percent of Total Billed Charges,90% of Total billed Charges,2467,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2467,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2467,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1603.55,65,,10313.096,Percent of total Billed Charges,65% of Total Billed Charges,1087.95,44.1,,22.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,2343.65,95,,646.024,Percent of Total Billed Charges,95% of Total Billed Charges,2467,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2170.96,88,,44.24,Percent of Total Billed Charges,88% of Total Billed Charges,2220.3,90,,612.024,Percent of Total Billed charges,90% of Total Billed Charges,1087.95,2467,
MINI QUICK ANCHOR 1.8,2780001143,CDM,278,RC,C1713,HCPCS,Outpatient,,,2148.00,1396.20,,2148,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1632.48,76,,494.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1546.56,72,,2787.192,Percent of Total Billed Charges,72% of Total Billed Charges,1546.56,72,,2787.192,Percent of Total Billed charges,72% of Total Billed Charges,2148,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1546.56,72,,2787.192,Percent of Total Billed Charges,72% of Total Billed Charges,1288.8,60,,2322.656,Percent of Total Billed Charges,60% of Total Billed Charges,1933.2,90,,492.16,Percent of Total Billed Charges,90% of Total Billed Charges,966.6,45,,1738.024,Percent of Total Billed Charges,45% of Total Billed Charges,1933.2,90,,585.832,Percent of Total Billed Charges,90% of Total billed Charges,2148,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2148,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2148,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1396.2,65,,10313.096,Percent of total Billed Charges,65% of Total Billed Charges,947.27,44.1,,1703.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,2040.6,95,,618.376,Percent of Total Billed Charges,95% of Total Billed Charges,2148,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1890.24,88,,416.8,Percent of Total Billed Charges,88% of Total Billed Charges,1933.2,90,,585.832,Percent of Total Billed charges,90% of Total Billed Charges,947.27,2148,
STRYKER  3.5 LCK SCW FT 16MM,2780001144,CDM,278,RC,C1713,HCPCS,Outpatient,,,771.00,501.15,,771,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,585.96,76,,38.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,555.12,72,,487.08,Percent of Total Billed Charges,72% of Total Billed Charges,555.12,72,,487.08,Percent of Total Billed charges,72% of Total Billed Charges,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.12,72,,487.08,Percent of Total Billed Charges,72% of Total Billed Charges,462.6,60,,405.896,Percent of Total Billed Charges,60% of Total Billed Charges,693.9,90,,2048.008,Percent of Total Billed Charges,90% of Total Billed Charges,346.95,45,,22.624,Percent of Total Billed Charges,45% of Total Billed Charges,693.9,90,,45.248,Percent of Total Billed Charges,90% of Total billed Charges,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.15,65,,10313.096,Percent of total Billed Charges,65% of Total Billed Charges,340.01,44.1,,22.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,732.45,95,,47.76,Percent of Total Billed Charges,95% of Total Billed Charges,771,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678.48,88,,11990.12,Percent of Total Billed Charges,88% of Total Billed Charges,693.9,90,,45.248,Percent of Total Billed charges,90% of Total Billed Charges,340.01,771,
ACUMED AT2C16S 16MM MICROSCW,2780001145,CDM,278,RC,C1713,HCPCS,Outpatient,,,2464.00,1601.60,,2464,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1872.64,76,,38.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1774.08,72,,487.08,Percent of Total Billed Charges,72% of Total Billed Charges,1774.08,72,,487.08,Percent of Total Billed charges,72% of Total Billed Charges,2464,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1774.08,72,,487.08,Percent of Total Billed Charges,72% of Total Billed Charges,1478.4,60,,405.896,Percent of Total Billed Charges,60% of Total Billed Charges,2217.6,90,,438.48,Percent of Total Billed Charges,90% of Total Billed Charges,1108.8,45,,213.136,Percent of Total Billed Charges,45% of Total Billed Charges,2217.6,90,,45.248,Percent of Total Billed Charges,90% of Total billed Charges,2464,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2464,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2464,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1601.6,65,,10313.096,Percent of total Billed Charges,65% of Total Billed Charges,1086.62,44.1,,208.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,2340.8,95,,47.76,Percent of Total Billed Charges,95% of Total Billed Charges,2464,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2168.32,88,,368.864,Percent of Total Billed Charges,88% of Total Billed Charges,2217.6,90,,45.248,Percent of Total Billed charges,90% of Total Billed Charges,1086.62,2464,
ACUMED 3.5X8 CORTICAL SCW,2780001146,CDM,278,RC,C1713,HCPCS,Outpatient,,,412.00,267.80,,412,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,313.12,76,,2935.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,296.64,72,,246.392,Percent of Total Billed Charges,72% of Total Billed Charges,296.64,72,,246.392,Percent of Total Billed charges,72% of Total Billed Charges,412,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.64,72,,246.392,Percent of Total Billed Charges,72% of Total Billed Charges,247.2,60,,205.328,Percent of Total Billed Charges,60% of Total Billed Charges,370.8,90,,438.48,Percent of Total Billed Charges,90% of Total Billed Charges,185.4,45,,6131.312,Percent of Total Billed Charges,45% of Total Billed Charges,370.8,90,,3476.056,Percent of Total Billed Charges,90% of Total billed Charges,412,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.8,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,181.69,44.1,,6008.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,391.4,95,,3669.168,Percent of Total Billed Charges,95% of Total Billed Charges,412,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,362.56,88,,4651.328,Percent of Total Billed Charges,88% of Total Billed Charges,370.8,90,,3476.056,Percent of Total Billed charges,90% of Total Billed Charges,181.69,412,
ACUMED 300233 3.5X10LCK SCW,2780001147,CDM,278,RC,C1713,HCPCS,Outpatient,,,678.00,440.70,,678,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,515.28,76,,38.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,488.16,72,,487.08,Percent of Total Billed Charges,72% of Total Billed Charges,488.16,72,,487.08,Percent of Total Billed charges,72% of Total Billed Charges,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.16,72,,487.08,Percent of Total Billed Charges,72% of Total Billed Charges,406.8,60,,405.896,Percent of Total Billed Charges,60% of Total Billed Charges,610.2,90,,438.48,Percent of Total Billed Charges,90% of Total Billed Charges,305.1,45,,188.624,Percent of Total Billed Charges,45% of Total Billed Charges,610.2,90,,45.248,Percent of Total Billed Charges,90% of Total billed Charges,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.7,65,,11188.52,Percent of total Billed Charges,65% of Total Billed Charges,299,44.1,,184.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,644.1,95,,47.76,Percent of Total Billed Charges,95% of Total Billed Charges,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,596.64,88,,481.216,Percent of Total Billed Charges,88% of Total Billed Charges,610.2,90,,45.248,Percent of Total Billed charges,90% of Total Billed Charges,299,678,
ARTHREX DYNAMITE STAPLE 9WX10L,2780001148,CDM,278,RC,C1713,HCPCS,Outpatient,,,7583.00,4928.95,,7583,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5763.08,76,,359.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5459.76,72,,386.104,Percent of Total Billed Charges,72% of Total Billed Charges,5459.76,72,,386.104,Percent of Total Billed charges,72% of Total Billed Charges,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5459.76,72,,386.104,Percent of Total Billed Charges,72% of Total Billed Charges,4549.8,60,,321.752,Percent of Total Billed Charges,60% of Total Billed Charges,6824.7,90,,438.48,Percent of Total Billed Charges,90% of Total Billed Charges,3412.35,45,,2378.52,Percent of Total Billed Charges,45% of Total Billed Charges,6824.7,90,,426.272,Percent of Total Billed Charges,90% of Total billed Charges,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4928.95,65,,11188.52,Percent of total Billed Charges,65% of Total Billed Charges,3344.1,44.1,,2330.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,7203.85,95,,449.952,Percent of Total Billed Charges,95% of Total Billed Charges,7583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6673.04,88,,481.216,Percent of Total Billed Charges,88% of Total Billed Charges,6824.7,90,,426.272,Percent of Total Billed charges,90% of Total Billed Charges,3344.1,7583,
ARTHREX PT SCW 5.5X40,2780001149,CDM,278,RC,C1713,HCPCS,Outpatient,,,4039.00,2625.35,,4039,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3069.64,76,,10355.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2908.08,72,,1450.432,Percent of Total Billed Charges,72% of Total Billed Charges,2908.08,72,,1450.432,Percent of Total Billed charges,72% of Total Billed Charges,4039,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2908.08,72,,1450.432,Percent of Total Billed Charges,72% of Total Billed Charges,2423.4,60,,1208.696,Percent of Total Billed Charges,60% of Total Billed Charges,3635.1,90,,15949.032,Percent of Total Billed Charges,90% of Total Billed Charges,1817.55,45,,246.08,Percent of Total Billed Charges,45% of Total Billed Charges,3635.1,90,,12262.624,Percent of Total Billed Charges,90% of Total billed Charges,4039,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4039,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4039,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2625.35,65,,11188.52,Percent of total Billed Charges,65% of Total Billed Charges,1781.2,44.1,,241.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,3837.05,95,,12943.88,Percent of Total Billed Charges,95% of Total Billed Charges,4039,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3554.32,88,,2002.496,Percent of Total Billed Charges,88% of Total Billed Charges,3635.1,90,,12262.624,Percent of Total Billed charges,90% of Total Billed Charges,1781.2,4039,
ARTHREX IMP SYS CPR VIPER,2780001150,CDM,278,RC,C1713,HCPCS,Outpatient,,,5556.00,3611.40,,5556,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4222.56,76,,318.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4000.32,72,,829.368,Percent of Total Billed Charges,72% of Total Billed Charges,4000.32,72,,829.368,Percent of Total Billed charges,72% of Total Billed Charges,5556,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4000.32,72,,829.368,Percent of Total Billed Charges,72% of Total Billed Charges,3333.6,60,,691.136,Percent of Total Billed Charges,60% of Total Billed Charges,5000.4,90,,411.192,Percent of Total Billed Charges,90% of Total Billed Charges,2500.2,45,,246.08,Percent of Total Billed Charges,45% of Total Billed Charges,5000.4,90,,377.248,Percent of Total Billed Charges,90% of Total billed Charges,5556,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5556,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5556,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.4,65,,11188.52,Percent of total Billed Charges,65% of Total Billed Charges,2450.2,44.1,,241.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,5278.2,95,,398.2,Percent of Total Billed Charges,95% of Total Billed Charges,5556,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4889.28,88,,428.736,Percent of Total Billed Charges,88% of Total Billed Charges,5000.4,90,,377.248,Percent of Total Billed charges,90% of Total Billed Charges,2450.2,5556,
ARTHREX QCKFIX SCW 2X11MM,2780001151,CDM,278,RC,C1713,HCPCS,Outpatient,,,1218.00,791.70,,1218,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,925.68,76,,4017.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,876.96,72,,2651.928,Percent of Total Billed Charges,72% of Total Billed Charges,876.96,72,,2651.928,Percent of Total Billed charges,72% of Total Billed Charges,1218,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,876.96,72,,2651.928,Percent of Total Billed Charges,72% of Total Billed Charges,730.8,60,,2209.936,Percent of Total Billed Charges,60% of Total Billed Charges,1096.2,90,,6724.28,Percent of Total Billed Charges,90% of Total Billed Charges,548.1,45,,1024,Percent of Total Billed Charges,45% of Total Billed Charges,1096.2,90,,4757.04,Percent of Total Billed Charges,90% of Total billed Charges,1218,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1218,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1218,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,791.7,65,,64.784,Percent of total Billed Charges,65% of Total Billed Charges,537.14,44.1,,1003.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,1157.1,95,,5021.32,Percent of Total Billed Charges,95% of Total Billed Charges,1218,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1071.84,88,,428.736,Percent of Total Billed Charges,88% of Total Billed Charges,1096.2,90,,4757.04,Percent of Total Billed charges,90% of Total Billed Charges,537.14,1218,
STRYKER LCK SCW T10 3.5X10MM,2780001152,CDM,278,RC,C1713,HCPCS,Outpatient,,,561.00,364.65,,561,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,426.36,76,,415.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,403.92,72,,3225.368,Percent of Total Billed Charges,72% of Total Billed Charges,403.92,72,,3225.368,Percent of Total Billed charges,72% of Total Billed Charges,561,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,403.92,72,,3225.368,Percent of Total Billed Charges,72% of Total Billed Charges,336.6,60,,2687.808,Percent of Total Billed Charges,60% of Total Billed Charges,504.9,90,,203.216,Percent of Total Billed Charges,90% of Total Billed Charges,252.45,45,,219.24,Percent of Total Billed Charges,45% of Total Billed Charges,504.9,90,,492.16,Percent of Total Billed Charges,90% of Total billed Charges,561,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.65,65,,11188.52,Percent of total Billed Charges,65% of Total Billed Charges,247.4,44.1,,214.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,532.95,95,,519.496,Percent of Total Billed Charges,95% of Total Billed Charges,561,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.68,88,,428.736,Percent of Total Billed Charges,88% of Total Billed Charges,504.9,90,,492.16,Percent of Total Billed charges,90% of Total Billed Charges,247.4,561,
STRYKER LCK SCW T10 3.5X12MM,2780001153,CDM,278,RC,C1713,HCPCS,Outpatient,,,561.00,364.65,,561,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,426.36,76,,415.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,403.92,72,,4595.152,Percent of Total Billed Charges,72% of Total Billed Charges,403.92,72,,4595.152,Percent of Total Billed charges,72% of Total Billed Charges,561,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,403.92,72,,4595.152,Percent of Total Billed Charges,72% of Total Billed Charges,336.6,60,,3829.288,Percent of Total Billed Charges,60% of Total Billed Charges,504.9,90,,13632.728,Percent of Total Billed Charges,90% of Total Billed Charges,252.45,45,,219.24,Percent of Total Billed Charges,45% of Total Billed Charges,504.9,90,,492.16,Percent of Total Billed Charges,90% of Total billed Charges,561,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.65,65,,857.656,Percent of total Billed Charges,65% of Total Billed Charges,247.4,44.1,,214.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,532.95,95,,519.496,Percent of Total Billed Charges,95% of Total Billed Charges,561,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.68,88,,428.736,Percent of Total Billed Charges,88% of Total Billed Charges,504.9,90,,492.16,Percent of Total Billed charges,90% of Total Billed Charges,247.4,561,
STRYKER DISTAL LAT FIB PLT 5H,2780001154,CDM,278,RC,C1713,HCPCS,Outpatient,,,2678.00,1740.70,,2678,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2035.28,76,,1729.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1928.16,72,,14487.168,Percent of Total Billed Charges,72% of Total Billed Charges,1928.16,72,,14487.168,Percent of Total Billed charges,72% of Total Billed Charges,2678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1928.16,72,,14487.168,Percent of Total Billed Charges,72% of Total Billed Charges,1606.8,60,,12072.64,Percent of Total Billed Charges,60% of Total Billed Charges,2410.2,90,,14638.464,Percent of Total Billed Charges,90% of Total Billed Charges,1205.1,45,,219.24,Percent of Total Billed Charges,45% of Total Billed Charges,2410.2,90,,2048.008,Percent of Total Billed Charges,90% of Total billed Charges,2678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1740.7,65,,1500.904,Percent of total Billed Charges,65% of Total Billed Charges,1181,44.1,,214.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,2544.1,95,,2161.784,Percent of Total Billed Charges,95% of Total Billed Charges,2678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2356.64,88,,15594.608,Percent of Total Billed Charges,88% of Total Billed Charges,2410.2,90,,2048.008,Percent of Total Billed charges,90% of Total Billed Charges,1181,2678,
STRYKER LCK SCW T10 3.5X16MM,2780001155,CDM,278,RC,C1713,HCPCS,Outpatient,,,561.00,364.65,,561,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,426.36,76,,370.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,403.92,72,,2833.552,Percent of Total Billed Charges,72% of Total Billed Charges,403.92,72,,2833.552,Percent of Total Billed charges,72% of Total Billed Charges,561,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,403.92,72,,2833.552,Percent of Total Billed Charges,72% of Total Billed Charges,336.6,60,,2361.296,Percent of Total Billed Charges,60% of Total Billed Charges,504.9,90,,5583.592,Percent of Total Billed Charges,90% of Total Billed Charges,252.45,45,,219.24,Percent of Total Billed Charges,45% of Total Billed Charges,504.9,90,,438.48,Percent of Total Billed Charges,90% of Total billed Charges,561,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.65,65,,1500.904,Percent of total Billed Charges,65% of Total Billed Charges,247.4,44.1,,214.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,532.95,95,,462.84,Percent of Total Billed Charges,95% of Total Billed Charges,561,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.68,88,,402.056,Percent of Total Billed Charges,88% of Total Billed Charges,504.9,90,,438.48,Percent of Total Billed charges,90% of Total Billed Charges,247.4,561,
STRYKER BONE SCW T10 3.5X18MM,2780001156,CDM,278,RC,C1713,HCPCS,Outpatient,,,284.00,184.60,,284,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,215.84,76,,370.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,204.48,72,,2832.912,Percent of Total Billed Charges,72% of Total Billed Charges,204.48,72,,2832.912,Percent of Total Billed charges,72% of Total Billed Charges,284,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.48,72,,2832.912,Percent of Total Billed Charges,72% of Total Billed Charges,170.4,60,,2360.76,Percent of Total Billed Charges,60% of Total Billed Charges,255.6,90,,5583.592,Percent of Total Billed Charges,90% of Total Billed Charges,127.8,45,,7974.512,Percent of Total Billed Charges,45% of Total Billed Charges,255.6,90,,438.48,Percent of Total Billed Charges,90% of Total billed Charges,284,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.6,65,,1500.904,Percent of total Billed Charges,65% of Total Billed Charges,125.24,44.1,,7815.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,269.8,95,,462.84,Percent of Total Billed Charges,95% of Total Billed Charges,284,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.92,88,,6574.856,Percent of Total Billed Charges,88% of Total Billed Charges,255.6,90,,438.48,Percent of Total Billed charges,90% of Total Billed Charges,125.24,284,
STRYKER BONE SCW T10 3.5X60MM,2780001157,CDM,278,RC,C1713,HCPCS,Outpatient,,,284.00,184.60,,284,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,215.84,76,,370.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,204.48,72,,6634.264,Percent of Total Billed Charges,72% of Total Billed Charges,204.48,72,,6634.264,Percent of Total Billed charges,72% of Total Billed Charges,284,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.48,72,,6634.264,Percent of Total Billed Charges,72% of Total Billed Charges,170.4,60,,5528.552,Percent of Total Billed Charges,60% of Total Billed Charges,255.6,90,,5583.592,Percent of Total Billed Charges,90% of Total Billed Charges,127.8,45,,205.6,Percent of Total Billed Charges,45% of Total Billed Charges,255.6,90,,438.48,Percent of Total Billed Charges,90% of Total billed Charges,284,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.6,65,,3423.744,Percent of total Billed Charges,65% of Total Billed Charges,125.24,44.1,,201.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,269.8,95,,462.84,Percent of Total Billed Charges,95% of Total Billed Charges,284,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.92,88,,198.696,Percent of Total Billed Charges,88% of Total Billed Charges,255.6,90,,438.48,Percent of Total Billed charges,90% of Total Billed Charges,125.24,284,
STRYKER CANN SCW 4.0X20MM,2780001158,CDM,278,RC,C1713,HCPCS,Outpatient,,,826.00,536.90,,826,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,627.76,76,,370.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,594.72,72,,84.456,Percent of Total Billed Charges,72% of Total Billed Charges,594.72,72,,84.456,Percent of Total Billed charges,72% of Total Billed Charges,826,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,594.72,72,,84.456,Percent of Total Billed Charges,72% of Total Billed Charges,495.6,60,,70.384,Percent of Total Billed Charges,60% of Total Billed Charges,743.4,90,,6566.312,Percent of Total Billed Charges,90% of Total Billed Charges,371.7,45,,3362.144,Percent of Total Billed Charges,45% of Total Billed Charges,743.4,90,,438.48,Percent of Total Billed Charges,90% of Total billed Charges,826,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,536.9,65,,3423.744,Percent of total Billed Charges,65% of Total Billed Charges,364.27,44.1,,3294.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,784.7,95,,462.84,Percent of Total Billed Charges,95% of Total Billed Charges,826,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,726.88,88,,13329.776,Percent of Total Billed Charges,88% of Total Billed Charges,743.4,90,,438.48,Percent of Total Billed charges,90% of Total Billed Charges,364.27,826,
STRYKER 4.0X46MM T1 CANN SCW,2780001159,CDM,278,RC,C1713,HCPCS,Outpatient,,,688.00,447.20,,688,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,522.88,76,,13468.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,495.36,72,,238.776,Percent of Total Billed Charges,72% of Total Billed Charges,495.36,72,,238.776,Percent of Total Billed charges,72% of Total Billed Charges,688,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495.36,72,,238.776,Percent of Total Billed Charges,72% of Total Billed Charges,412.8,60,,198.976,Percent of Total Billed Charges,60% of Total Billed Charges,619.2,90,,14279.664,Percent of Total Billed Charges,90% of Total Billed Charges,309.6,45,,101.608,Percent of Total Billed Charges,45% of Total Billed Charges,619.2,90,,15949.032,Percent of Total Billed Charges,90% of Total billed Charges,688,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,688,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,688,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,447.2,65,,3423.744,Percent of total Billed Charges,65% of Total Billed Charges,303.41,44.1,,99.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,653.6,95,,16835.088,Percent of Total Billed Charges,95% of Total Billed Charges,688,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,605.44,88,,14313.168,Percent of Total Billed Charges,88% of Total Billed Charges,619.2,90,,15949.032,Percent of Total Billed charges,90% of Total Billed Charges,303.41,688,
"ARTHREX TENO SCW, BIOCOMP",2780001160,CDM,278,RC,C1713,HCPCS,Outpatient,,,1438.00,934.70,,1438,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1092.88,76,,347.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1035.36,72,,4514.496,Percent of Total Billed Charges,72% of Total Billed Charges,1035.36,72,,4514.496,Percent of Total Billed charges,72% of Total Billed Charges,1438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1035.36,72,,4514.496,Percent of Total Billed Charges,72% of Total Billed Charges,862.8,60,,3762.08,Percent of Total Billed Charges,60% of Total Billed Charges,1294.2,90,,14279.664,Percent of Total Billed Charges,90% of Total Billed Charges,647.1,45,,6816.36,Percent of Total Billed Charges,45% of Total Billed Charges,1294.2,90,,411.192,Percent of Total Billed Charges,90% of Total billed Charges,1438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,934.7,65,,3423.744,Percent of total Billed Charges,65% of Total Billed Charges,634.16,44.1,,6680.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,1366.1,95,,434.04,Percent of Total Billed Charges,95% of Total Billed Charges,1438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1265.44,88,,5459.512,Percent of Total Billed Charges,88% of Total Billed Charges,1294.2,90,,411.192,Percent of Total Billed charges,90% of Total Billed Charges,634.16,1438,
ARTHREX LCK ST PLATE TI 6H,2780001161,CDM,278,RC,C1713,HCPCS,Outpatient,,,2410.00,1566.50,,2410,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1831.6,76,,5678.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1735.2,72,,450.24,Percent of Total Billed Charges,72% of Total Billed Charges,1735.2,72,,450.24,Percent of Total Billed charges,72% of Total Billed Charges,2410,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1735.2,72,,450.24,Percent of Total Billed Charges,72% of Total Billed Charges,1446,60,,375.2,Percent of Total Billed Charges,60% of Total Billed Charges,2169,90,,14279.664,Percent of Total Billed Charges,90% of Total Billed Charges,1084.5,45,,7319.232,Percent of Total Billed Charges,45% of Total Billed Charges,2169,90,,6724.28,Percent of Total Billed Charges,90% of Total billed Charges,2410,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2410,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2410,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1566.5,65,,3423.744,Percent of total Billed Charges,65% of Total Billed Charges,1062.81,44.1,,7172.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,2289.5,95,,7097.856,Percent of Total Billed Charges,95% of Total Billed Charges,2410,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2120.8,88,,5459.512,Percent of Total Billed Charges,88% of Total Billed Charges,2169,90,,6724.28,Percent of Total Billed charges,90% of Total Billed Charges,1062.81,2410,
Z11473036 CANN SCW FT 3.5X30,2780001162,CDM,278,RC,C1713,HCPCS,Outpatient,,,537.00,349.05,,537,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,408.12,76,,171.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,386.64,72,,450.24,Percent of Total Billed Charges,72% of Total Billed Charges,386.64,72,,450.24,Percent of Total Billed charges,72% of Total Billed Charges,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.64,72,,450.24,Percent of Total Billed Charges,72% of Total Billed Charges,322.2,60,,375.2,Percent of Total Billed Charges,60% of Total Billed Charges,483.3,90,,14279.664,Percent of Total Billed Charges,90% of Total Billed Charges,241.65,45,,2791.8,Percent of Total Billed Charges,45% of Total Billed Charges,483.3,90,,203.216,Percent of Total Billed Charges,90% of Total billed Charges,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.05,65,,5625.792,Percent of total Billed Charges,65% of Total Billed Charges,236.82,44.1,,2735.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,510.15,95,,214.504,Percent of Total Billed Charges,95% of Total Billed Charges,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.56,88,,5459.512,Percent of Total Billed Charges,88% of Total Billed Charges,483.3,90,,203.216,Percent of Total Billed charges,90% of Total Billed Charges,236.82,537,
STRYKER CALC STD PLT LG,2780001163,CDM,278,RC,C1713,HCPCS,Outpatient,,,3395.00,2206.75,,3395,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2580.2,76,,11512.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2444.4,72,,522.64,Percent of Total Billed Charges,72% of Total Billed Charges,2444.4,72,,522.64,Percent of Total Billed charges,72% of Total Billed Charges,3395,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2444.4,72,,522.64,Percent of Total Billed Charges,72% of Total Billed Charges,2037,60,,435.536,Percent of Total Billed Charges,60% of Total Billed Charges,3055.5,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,1527.75,45,,2791.8,Percent of Total Billed Charges,45% of Total Billed Charges,3055.5,90,,13632.728,Percent of Total Billed Charges,90% of Total billed Charges,3395,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3395,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3395,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2206.75,65,,5625.792,Percent of total Billed Charges,65% of Total Billed Charges,1497.2,44.1,,2735.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,3225.25,95,,14390.096,Percent of Total Billed Charges,95% of Total Billed Charges,3395,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2987.6,88,,6420.392,Percent of Total Billed Charges,88% of Total Billed Charges,3055.5,90,,13632.728,Percent of Total Billed charges,90% of Total Billed Charges,1497.2,3395,
Z11475536 CANN SCW FT 3.5X55,2780001164,CDM,278,RC,C1713,HCPCS,Outpatient,,,537.00,349.05,,537,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,408.12,76,,12361.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,386.64,72,,522.64,Percent of Total Billed Charges,72% of Total Billed Charges,386.64,72,,522.64,Percent of Total Billed charges,72% of Total Billed Charges,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.64,72,,522.64,Percent of Total Billed Charges,72% of Total Billed Charges,322.2,60,,435.536,Percent of Total Billed Charges,60% of Total Billed Charges,483.3,90,,15491.8,Percent of Total Billed Charges,90% of Total Billed Charges,241.65,45,,2791.8,Percent of Total Billed Charges,45% of Total Billed Charges,483.3,90,,14638.464,Percent of Total Billed Charges,90% of Total billed Charges,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.05,65,,5625.792,Percent of total Billed Charges,65% of Total Billed Charges,236.82,44.1,,2735.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,510.15,95,,15451.712,Percent of Total Billed Charges,95% of Total Billed Charges,537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.56,88,,13962.344,Percent of Total Billed Charges,88% of Total Billed Charges,483.3,90,,14638.464,Percent of Total Billed charges,90% of Total Billed Charges,236.82,537,
Z48151003 MINI 10MM,2780001172,CDM,278,RC,C1716,HCPCS,Outpatient,,,73.87,48.02,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,56.14,76,,4715.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,298.41,72,,522.64,Percent of Total Billed Charges,72% of Total Billed Charges,298.41,72,,522.64,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,298.41,72,,522.64,Percent of Total Billed Charges,72% of Total Billed Charges,166.93,60,,435.536,Percent of Total Billed Charges,60% of Total Billed Charges,66.48,90,,15491.8,Percent of Total Billed Charges,90% of Total Billed Charges,33.24,45,,3283.16,Percent of Total Billed Charges,45% of Total Billed Charges,66.48,90,,5583.592,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1784.68,65,,5625.792,Percent of total Billed Charges,65% of Total Billed Charges,32.58,44.1,,3217.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,70.18,95,,5893.792,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,65.01,88,,13962.344,Percent of Total Billed Charges,88% of Total Billed Charges,66.48,90,,5583.592,Percent of Total Billed charges,90% of Total Billed Charges,32.58,1784.68,
Z11478575 16THDSCW 85,2780001173,CDM,278,RC,C1716,HCPCS,Outpatient,,,840.11,546.07,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,638.48,76,,4715.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,850.1,72,,522.64,Percent of Total Billed Charges,72% of Total Billed Charges,850.1,72,,522.64,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,850.1,72,,522.64,Percent of Total Billed Charges,72% of Total Billed Charges,626.68,60,,435.536,Percent of Total Billed Charges,60% of Total Billed Charges,756.1,90,,15491.8,Percent of Total Billed Charges,90% of Total Billed Charges,378.05,45,,7139.832,Percent of Total Billed Charges,45% of Total Billed Charges,756.1,90,,5583.592,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2282.73,65,,5625.792,Percent of total Billed Charges,65% of Total Billed Charges,370.49,44.1,,6997.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,798.1,95,,5893.792,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,739.3,88,,13962.344,Percent of Total Billed Charges,88% of Total Billed Charges,756.1,90,,5583.592,Percent of Total Billed charges,90% of Total Billed Charges,370.49,2282.73,
Z11479575 16MM THD SCW 95,2780001174,CDM,278,RC,C1716,HCPCS,Outpatient,,,840.11,546.07,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,638.48,76,,4715.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,850.1,72,,238.776,Percent of Total Billed Charges,72% of Total Billed Charges,850.1,72,,238.776,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,850.1,72,,238.776,Percent of Total Billed Charges,72% of Total Billed Charges,626.68,60,,198.976,Percent of Total Billed Charges,60% of Total Billed Charges,756.1,90,,15491.8,Percent of Total Billed Charges,90% of Total Billed Charges,378.05,45,,7139.832,Percent of Total Billed Charges,45% of Total Billed Charges,756.1,90,,5583.592,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2282.73,65,,5625.792,Percent of total Billed Charges,65% of Total Billed Charges,370.49,44.1,,6997.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,798.1,95,,5893.792,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,739.3,88,,13962.344,Percent of Total Billed Charges,88% of Total Billed Charges,756.1,90,,5583.592,Percent of Total Billed charges,90% of Total Billed Charges,370.49,2282.73,
Z23580108 PLT/R8H,2780001175,CDM,278,RC,C1716,HCPCS,Outpatient,,,5209.31,3386.05,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,3959.08,76,,5544.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3995.92,72,,1120.208,Percent of Total Billed Charges,72% of Total Billed Charges,3995.92,72,,1120.208,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3995.92,72,,1120.208,Percent of Total Billed Charges,72% of Total Billed Charges,3248.2,60,,933.512,Percent of Total Billed Charges,60% of Total Billed Charges,4688.38,90,,89.696,Percent of Total Billed Charges,90% of Total Billed Charges,2344.19,45,,7139.832,Percent of Total Billed Charges,45% of Total Billed Charges,4688.38,90,,6566.312,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,5122.71,65,,5625.792,Percent of total Billed Charges,65% of Total Billed Charges,2297.31,44.1,,6997.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,4948.84,95,,6931.112,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,4584.19,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,4688.38,90,,6566.312,Percent of Total Billed charges,90% of Total Billed Charges,651.24,5122.71,
Z23580204 PLT 4H,2780001176,CDM,278,RC,C1716,HCPCS,Outpatient,,,4951.33,3218.36,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,3763.01,76,,12058.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3810.18,72,,40.008,Percent of Total Billed Charges,72% of Total Billed Charges,3810.18,72,,40.008,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3810.18,72,,40.008,Percent of Total Billed Charges,72% of Total Billed Charges,3093.41,60,,33.344,Percent of Total Billed Charges,60% of Total Billed Charges,4456.2,90,,15491.8,Percent of Total Billed Charges,90% of Total Billed Charges,2228.1,45,,7139.832,Percent of Total Billed Charges,45% of Total Billed Charges,4456.2,90,,14279.664,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,4955.02,65,,5625.792,Percent of total Billed Charges,65% of Total Billed Charges,2183.54,44.1,,6997.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,4703.76,95,,15072.984,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,4357.17,88,,15147.536,Percent of Total Billed Charges,88% of Total Billed Charges,4456.2,90,,14279.664,Percent of Total Billed charges,90% of Total Billed Charges,651.24,4955.02,
Z23592435 SCW 24,2780001177,CDM,278,RC,C1716,HCPCS,Outpatient,,,356.11,231.47,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,270.64,76,,12058.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,501.62,72,,649.648,Percent of Total Billed Charges,72% of Total Billed Charges,501.62,72,,649.648,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,501.62,72,,649.648,Percent of Total Billed Charges,72% of Total Billed Charges,336.28,60,,541.376,Percent of Total Billed Charges,60% of Total Billed Charges,320.5,90,,1187.528,Percent of Total Billed Charges,90% of Total Billed Charges,160.25,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,320.5,90,,14279.664,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1968.13,65,,5625.792,Percent of total Billed Charges,65% of Total Billed Charges,157.04,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,338.3,95,,15072.984,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,313.38,88,,15147.536,Percent of Total Billed Charges,88% of Total Billed Charges,320.5,90,,14279.664,Percent of Total Billed charges,90% of Total Billed Charges,157.04,1968.13,
Z23593435 SCW 35,2780001178,CDM,278,RC,C1716,HCPCS,Outpatient,,,356.11,231.47,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,270.64,76,,12058.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,501.62,72,,896.68,Percent of Total Billed Charges,72% of Total Billed Charges,501.62,72,,896.68,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,501.62,72,,896.68,Percent of Total Billed Charges,72% of Total Billed Charges,336.28,60,,747.232,Percent of Total Billed Charges,60% of Total Billed Charges,320.5,90,,2078.176,Percent of Total Billed Charges,90% of Total Billed Charges,160.25,45,,7745.904,Percent of Total Billed Charges,45% of Total Billed Charges,320.5,90,,14279.664,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1968.13,65,,2401.552,Percent of total Billed Charges,65% of Total Billed Charges,157.04,44.1,,7590.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,338.3,95,,15072.984,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,313.38,88,,15147.536,Percent of Total Billed Charges,88% of Total Billed Charges,320.5,90,,14279.664,Percent of Total Billed charges,90% of Total Billed Charges,157.04,1968.13,
Z23593036 SCW 30,2780001179,CDM,278,RC,C1716,HCPCS,Outpatient,,,356.11,231.47,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,270.64,76,,12058.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,501.62,72,,197.496,Percent of Total Billed Charges,72% of Total Billed Charges,501.62,72,,197.496,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,501.62,72,,197.496,Percent of Total Billed Charges,72% of Total Billed Charges,336.28,60,,164.584,Percent of Total Billed Charges,60% of Total Billed Charges,320.5,90,,2078.176,Percent of Total Billed Charges,90% of Total Billed Charges,160.25,45,,7745.904,Percent of Total Billed Charges,45% of Total Billed Charges,320.5,90,,14279.664,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1968.13,65,,2401.552,Percent of total Billed Charges,65% of Total Billed Charges,157.04,44.1,,7590.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,338.3,95,,15072.984,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,313.38,88,,15147.536,Percent of Total Billed Charges,88% of Total Billed Charges,320.5,90,,14279.664,Percent of Total Billed charges,90% of Total Billed Charges,157.04,1968.13,
Z484024SCW24,2780001180,CDM,278,RC,C1716,HCPCS,Outpatient,,,662.60,430.69,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,503.58,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,722.29,72,,197.496,Percent of Total Billed Charges,72% of Total Billed Charges,722.29,72,,197.496,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,722.29,72,,197.496,Percent of Total Billed Charges,72% of Total Billed Charges,520.17,60,,164.584,Percent of Total Billed Charges,60% of Total Billed Charges,596.34,90,,2078.176,Percent of Total Billed Charges,90% of Total Billed Charges,298.17,45,,7745.904,Percent of Total Billed Charges,45% of Total Billed Charges,596.34,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2167.35,65,,2401.552,Percent of total Billed Charges,65% of Total Billed Charges,292.21,44.1,,7590.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,629.47,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,583.09,88,,87.704,Percent of Total Billed Charges,88% of Total Billed Charges,596.34,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,292.21,2167.35,
Z114708576 THD SCW 32X85,2780001181,CDM,278,RC,C1716,HCPCS,Outpatient,,,798.21,518.84,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,606.64,76,,13081.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,819.93,72,,279.416,Percent of Total Billed Charges,72% of Total Billed Charges,819.93,72,,279.416,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,819.93,72,,279.416,Percent of Total Billed Charges,72% of Total Billed Charges,601.54,60,,232.848,Percent of Total Billed Charges,60% of Total Billed Charges,718.39,90,,4740.576,Percent of Total Billed Charges,90% of Total Billed Charges,359.19,45,,7745.904,Percent of Total Billed Charges,45% of Total Billed Charges,718.39,90,,15491.8,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2255.5,65,,2401.552,Percent of total Billed Charges,65% of Total Billed Charges,352.01,44.1,,7590.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,758.3,95,,16352.456,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,702.42,88,,15147.536,Percent of Total Billed Charges,88% of Total Billed Charges,718.39,90,,15491.8,Percent of Total Billed charges,90% of Total Billed Charges,352.01,2255.5,
CERCLAGE WIRE  EYE,2780001182,CDM,278,RC,C1716,HCPCS,Outpatient,,,16.54,10.75,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,12.57,76,,13081.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,257.13,72,,850.952,Percent of Total Billed Charges,72% of Total Billed Charges,257.13,72,,850.952,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,257.13,72,,850.952,Percent of Total Billed Charges,72% of Total Billed Charges,132.53,60,,709.128,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,90,,4740.576,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,44.848,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,15491.8,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1747.41,65,,2401.552,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,43.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,16352.456,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,14.56,88,,1161.136,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,15491.8,Percent of Total Billed charges,90% of Total Billed Charges,7.29,1747.41,
Z225419508 HUMERAL NAIL,2780001183,CDM,278,RC,C1716,HCPCS,Outpatient,,,4305.26,2798.42,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,3272,76,,13081.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3345.01,72,,972.248,Percent of Total Billed Charges,72% of Total Billed Charges,3345.01,72,,972.248,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3345.01,72,,972.248,Percent of Total Billed Charges,72% of Total Billed Charges,2705.77,60,,810.208,Percent of Total Billed Charges,60% of Total Billed Charges,3874.73,90,,4740.576,Percent of Total Billed Charges,90% of Total Billed Charges,1937.37,45,,7745.904,Percent of Total Billed Charges,45% of Total Billed Charges,3874.73,90,,15491.8,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,4535.08,65,,2401.552,Percent of total Billed Charges,65% of Total Billed Charges,1898.62,44.1,,7590.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,4090,95,,16352.456,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,3788.63,88,,2031.992,Percent of Total Billed Charges,88% of Total Billed Charges,3874.73,90,,15491.8,Percent of Total Billed charges,90% of Total Billed Charges,651.24,4535.08,
Z22533537 CORTICAL SCW,2780001184,CDM,278,RC,C1716,HCPCS,Outpatient,,,525.89,341.83,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,399.68,76,,13081.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,623.86,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,623.86,72,,12.064,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,623.86,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,438.14,60,,10.056,Percent of Total Billed Charges,60% of Total Billed Charges,473.3,90,,4740.576,Percent of Total Billed Charges,90% of Total Billed Charges,236.65,45,,593.76,Percent of Total Billed Charges,45% of Total Billed Charges,473.3,90,,15491.8,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2078.49,65,,2401.552,Percent of total Billed Charges,65% of Total Billed Charges,231.92,44.1,,581.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,499.6,95,,16352.456,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,462.78,88,,2031.992,Percent of Total Billed Charges,88% of Total Billed Charges,473.3,90,,15491.8,Percent of Total Billed charges,90% of Total Billed Charges,231.92,2078.49,
RX TREK 2.5X12,2780001185,CDM,278,RC,C1725,HCPCS,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,75.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,1762.24,Percent of Total Billed Charges,72% of Total Billed Charges,292.12,72,,1762.24,Percent of Total Billed charges,72% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,1762.24,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,1468.528,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,4740.576,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,1039.088,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,89.696,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,2401.552,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,1018.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,94.68,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,2031.992,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,89.696,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
Z50015328 BIPOLAR LINER 28MM,2780001270,CDM,278,RC,C1726,HCPCS,Outpatient,,,1643.83,1068.49,,1643.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1249.31,76,,13081.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1183.56,72,,266.72,Percent of Total Billed Charges,72% of Total Billed Charges,1183.56,72,,266.72,Percent of Total Billed charges,72% of Total Billed Charges,1643.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1183.56,72,,266.72,Percent of Total Billed Charges,72% of Total Billed Charges,986.3,60,,222.264,Percent of Total Billed Charges,60% of Total Billed Charges,1479.45,90,,7789.56,Percent of Total Billed Charges,90% of Total Billed Charges,739.72,45,,1039.088,Percent of Total Billed Charges,45% of Total Billed Charges,1479.45,90,,15491.8,Percent of Total Billed Charges,90% of Total billed Charges,1643.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1643.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1643.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1068.49,65,,2401.552,Percent of total Billed Charges,65% of Total Billed Charges,724.93,44.1,,1018.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,1561.64,95,,16352.456,Percent of Total Billed Charges,95% of Total Billed Charges,1643.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1446.57,88,,4635.224,Percent of Total Billed Charges,88% of Total Billed Charges,1479.45,90,,15491.8,Percent of Total Billed charges,90% of Total Billed Charges,724.93,1643.83,
Z500155 BIPOLAR SHELL 55MM,2780001271,CDM,278,RC,C1726,HCPCS,Outpatient,,,2669.15,1734.95,,2669.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2028.55,76,,1002.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1921.79,72,,5574.384,Percent of Total Billed Charges,72% of Total Billed Charges,1921.79,72,,5574.384,Percent of Total Billed charges,72% of Total Billed Charges,2669.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1921.79,72,,5574.384,Percent of Total Billed Charges,72% of Total Billed Charges,1601.49,60,,4645.32,Percent of Total Billed Charges,60% of Total Billed Charges,2402.24,90,,7789.56,Percent of Total Billed Charges,90% of Total Billed Charges,1201.12,45,,1039.088,Percent of Total Billed Charges,45% of Total Billed Charges,2402.24,90,,1187.528,Percent of Total Billed Charges,90% of Total billed Charges,2669.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2669.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2669.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1734.95,65,,2401.552,Percent of total Billed Charges,65% of Total Billed Charges,1177.1,44.1,,1018.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2535.69,95,,1253.496,Percent of Total Billed Charges,95% of Total Billed Charges,2669.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2348.85,88,,4635.224,Percent of Total Billed Charges,88% of Total Billed Charges,2402.24,90,,1187.528,Percent of Total Billed charges,90% of Total Billed Charges,1177.1,2669.15,
BS FLEXIVA 365 LASER FIBER,2780001272,CDM,278,RC,C1726,HCPCS,Outpatient,,,424.46,275.90,,424.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,322.59,76,,1754.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,305.61,72,,136.536,Percent of Total Billed Charges,72% of Total Billed Charges,305.61,72,,136.536,Percent of Total Billed charges,72% of Total Billed Charges,424.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305.61,72,,136.536,Percent of Total Billed Charges,72% of Total Billed Charges,254.68,60,,113.776,Percent of Total Billed Charges,60% of Total Billed Charges,382.01,90,,7789.56,Percent of Total Billed Charges,90% of Total Billed Charges,191.01,45,,2370.288,Percent of Total Billed Charges,45% of Total Billed Charges,382.01,90,,2078.176,Percent of Total Billed Charges,90% of Total billed Charges,424.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.9,65,,2401.552,Percent of total Billed Charges,65% of Total Billed Charges,187.19,44.1,,2322.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,403.24,95,,2193.624,Percent of Total Billed Charges,95% of Total Billed Charges,424.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.52,88,,4635.224,Percent of Total Billed Charges,88% of Total Billed Charges,382.01,90,,2078.176,Percent of Total Billed charges,90% of Total Billed Charges,187.19,424.46,
BS FLEXIVA 550 LASER FIBER,2780001273,CDM,278,RC,C1726,HCPCS,Outpatient,,,558.97,363.33,,558.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,424.82,76,,1754.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,402.46,72,,3111.696,Percent of Total Billed Charges,72% of Total Billed Charges,402.46,72,,3111.696,Percent of Total Billed charges,72% of Total Billed Charges,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,402.46,72,,3111.696,Percent of Total Billed Charges,72% of Total Billed Charges,335.38,60,,2593.08,Percent of Total Billed Charges,60% of Total Billed Charges,503.07,90,,7789.56,Percent of Total Billed Charges,90% of Total Billed Charges,251.54,45,,2370.288,Percent of Total Billed Charges,45% of Total Billed Charges,503.07,90,,2078.176,Percent of Total Billed Charges,90% of Total billed Charges,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.33,65,,2401.552,Percent of total Billed Charges,65% of Total Billed Charges,246.51,44.1,,2322.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,531.02,95,,2193.624,Percent of Total Billed Charges,95% of Total Billed Charges,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.89,88,,4635.224,Percent of Total Billed Charges,88% of Total Billed Charges,503.07,90,,2078.176,Percent of Total Billed charges,90% of Total Billed Charges,246.51,558.97,
BS FLEXIVA Pulse 910,2780001274,CDM,278,RC,C1726,HCPCS,Outpatient,,,898.54,584.05,,898.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,682.89,76,,1754.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,646.95,72,,213.376,Percent of Total Billed Charges,72% of Total Billed Charges,646.95,72,,213.376,Percent of Total Billed charges,72% of Total Billed Charges,898.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,646.95,72,,213.376,Percent of Total Billed Charges,72% of Total Billed Charges,539.12,60,,177.808,Percent of Total Billed Charges,60% of Total Billed Charges,808.69,90,,7789.56,Percent of Total Billed Charges,90% of Total Billed Charges,404.34,45,,2370.288,Percent of Total Billed Charges,45% of Total Billed Charges,808.69,90,,2078.176,Percent of Total Billed Charges,90% of Total billed Charges,898.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,584.05,65,,2401.552,Percent of total Billed Charges,65% of Total Billed Charges,396.26,44.1,,2322.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,853.61,95,,2193.624,Percent of Total Billed Charges,95% of Total Billed Charges,898.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,790.72,88,,4635.224,Percent of Total Billed Charges,88% of Total Billed Charges,808.69,90,,2078.176,Percent of Total Billed charges,90% of Total Billed Charges,396.26,898.54,
BS OPEN END URETERAL CATHETER,2780001275,CDM,278,RC,C1726,HCPCS,Outpatient,,,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,4003.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.73,72,,213.376,Percent of Total Billed Charges,72% of Total Billed Charges,8.73,72,,213.376,Percent of Total Billed charges,72% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,72,,213.376,Percent of Total Billed Charges,72% of Total Billed Charges,7.28,60,,177.808,Percent of Total Billed Charges,60% of Total Billed Charges,10.92,90,,7789.56,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,2370.288,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,4740.576,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,2401.552,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,2322.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,5003.936,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,7616.456,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,4740.576,Percent of Total Billed charges,90% of Total Billed Charges,5.35,12.13,
BS .025 STIFF SHAFT ZIPWIRE,2780001276,CDM,278,RC,C1726,HCPCS,Outpatient,,,70.56,45.86,,70.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.63,76,,4003.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.8,72,,3789.288,Percent of Total Billed Charges,72% of Total Billed Charges,50.8,72,,3789.288,Percent of Total Billed charges,72% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.8,72,,3789.288,Percent of Total Billed Charges,72% of Total Billed Charges,42.34,60,,3157.736,Percent of Total Billed Charges,60% of Total Billed Charges,63.5,90,,7789.56,Percent of Total Billed Charges,90% of Total Billed Charges,31.75,45,,2370.288,Percent of Total Billed Charges,45% of Total Billed Charges,63.5,90,,4740.576,Percent of Total Billed Charges,90% of Total billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.86,65,,2401.552,Percent of total Billed Charges,65% of Total Billed Charges,31.12,44.1,,2322.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.03,95,,5003.936,Percent of Total Billed Charges,95% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.09,88,,7616.456,Percent of Total Billed Charges,88% of Total Billed Charges,63.5,90,,4740.576,Percent of Total Billed charges,90% of Total Billed Charges,31.12,70.56,
BS 1.9 FR ZEROTIP BASKET,2780001277,CDM,278,RC,C1726,HCPCS,Outpatient,,,238.14,154.79,,238.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,180.99,76,,4003.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,171.46,72,,3789.288,Percent of Total Billed Charges,72% of Total Billed Charges,171.46,72,,3789.288,Percent of Total Billed charges,72% of Total Billed Charges,238.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.46,72,,3789.288,Percent of Total Billed Charges,72% of Total Billed Charges,142.88,60,,3157.736,Percent of Total Billed Charges,60% of Total Billed Charges,214.33,90,,7789.56,Percent of Total Billed Charges,90% of Total Billed Charges,107.16,45,,3894.776,Percent of Total Billed Charges,45% of Total Billed Charges,214.33,90,,4740.576,Percent of Total Billed Charges,90% of Total billed Charges,238.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.79,65,,2401.552,Percent of total Billed Charges,65% of Total Billed Charges,105.02,44.1,,3816.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,226.23,95,,5003.936,Percent of Total Billed Charges,95% of Total Billed Charges,238.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.56,88,,7616.456,Percent of Total Billed Charges,88% of Total Billed Charges,214.33,90,,4740.576,Percent of Total Billed charges,90% of Total Billed Charges,105.02,238.14,
BS SEGURA BASKET 2.4 X 90,2780001278,CDM,278,RC,C1726,HCPCS,Outpatient,,,271.22,176.29,,271.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,206.13,76,,4003.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,195.28,72,,3789.288,Percent of Total Billed Charges,72% of Total Billed Charges,195.28,72,,3789.288,Percent of Total Billed charges,72% of Total Billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.28,72,,3789.288,Percent of Total Billed Charges,72% of Total Billed Charges,162.73,60,,3157.736,Percent of Total Billed Charges,60% of Total Billed Charges,244.1,90,,7789.56,Percent of Total Billed Charges,90% of Total Billed Charges,122.05,45,,3894.776,Percent of Total Billed Charges,45% of Total Billed Charges,244.1,90,,4740.576,Percent of Total Billed Charges,90% of Total billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.29,65,,2401.552,Percent of total Billed Charges,65% of Total Billed Charges,119.61,44.1,,3816.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,257.66,95,,5003.936,Percent of Total Billed Charges,95% of Total Billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.67,88,,7616.456,Percent of Total Billed Charges,88% of Total Billed Charges,244.1,90,,4740.576,Percent of Total Billed charges,90% of Total Billed Charges,119.61,271.22,
BS SEGURA BASKET 2.4 X 120,2780001279,CDM,278,RC,C1726,HCPCS,Outpatient,,,271.22,176.29,,271.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,206.13,76,,4003.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,195.28,72,,2721.144,Percent of Total Billed Charges,72% of Total Billed Charges,195.28,72,,2721.144,Percent of Total Billed charges,72% of Total Billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.28,72,,2721.144,Percent of Total Billed Charges,72% of Total Billed Charges,162.73,60,,2267.624,Percent of Total Billed Charges,60% of Total Billed Charges,244.1,90,,3325.224,Percent of Total Billed Charges,90% of Total Billed Charges,122.05,45,,3894.776,Percent of Total Billed Charges,45% of Total Billed Charges,244.1,90,,4740.576,Percent of Total Billed Charges,90% of Total billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.29,65,,386.976,Percent of total Billed Charges,65% of Total Billed Charges,119.61,44.1,,3816.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,257.66,95,,5003.936,Percent of Total Billed Charges,95% of Total Billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.67,88,,7616.456,Percent of Total Billed Charges,88% of Total Billed Charges,244.1,90,,4740.576,Percent of Total Billed charges,90% of Total Billed Charges,119.61,271.22,
12F BILIARY DRAINAGE CATHETER,2780001280,CDM,278,RC,C1729,HCPCS,Outpatient,,,164.79,107.11,,164.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,125.24,76,,6577.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,118.65,72,,3789.288,Percent of Total Billed Charges,72% of Total Billed Charges,118.65,72,,3789.288,Percent of Total Billed charges,72% of Total Billed Charges,164.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.65,72,,3789.288,Percent of Total Billed Charges,72% of Total Billed Charges,98.87,60,,3157.736,Percent of Total Billed Charges,60% of Total Billed Charges,148.31,90,,3325.224,Percent of Total Billed Charges,90% of Total Billed Charges,74.16,45,,3894.776,Percent of Total Billed Charges,45% of Total Billed Charges,148.31,90,,7789.56,Percent of Total Billed Charges,90% of Total billed Charges,164.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.11,65,,1474.528,Percent of total Billed Charges,65% of Total Billed Charges,72.67,44.1,,3816.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,156.55,95,,8222.312,Percent of Total Billed Charges,95% of Total Billed Charges,164.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.02,88,,7616.456,Percent of Total Billed Charges,88% of Total Billed Charges,148.31,90,,7789.56,Percent of Total Billed charges,90% of Total Billed Charges,72.67,164.79,
DAWSONMUELLER 8.5F X 15CM,2780001281,CDM,278,RC,C1729,HCPCS,Outpatient,,,153.91,100.04,,153.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,116.97,76,,6577.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,110.82,72,,2730.672,Percent of Total Billed Charges,72% of Total Billed Charges,110.82,72,,2730.672,Percent of Total Billed charges,72% of Total Billed Charges,153.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.82,72,,2730.672,Percent of Total Billed Charges,72% of Total Billed Charges,92.35,60,,2275.56,Percent of Total Billed Charges,60% of Total Billed Charges,138.52,90,,3325.224,Percent of Total Billed Charges,90% of Total Billed Charges,69.26,45,,3894.776,Percent of Total Billed Charges,45% of Total Billed Charges,138.52,90,,7789.56,Percent of Total Billed Charges,90% of Total billed Charges,153.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.04,65,,1474.528,Percent of total Billed Charges,65% of Total Billed Charges,67.87,44.1,,3816.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,146.21,95,,8222.312,Percent of Total Billed Charges,95% of Total Billed Charges,153.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.44,88,,7616.456,Percent of Total Billed Charges,88% of Total Billed Charges,138.52,90,,7789.56,Percent of Total Billed charges,90% of Total Billed Charges,67.87,153.91,
QUINTON CATHETER,2780001282,CDM,278,RC,C1750,HCPCS,Outpatient,,,403.52,262.29,,403.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,306.68,76,,6577.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,290.53,72,,3789.288,Percent of Total Billed Charges,72% of Total Billed Charges,290.53,72,,3789.288,Percent of Total Billed charges,72% of Total Billed Charges,403.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290.53,72,,3789.288,Percent of Total Billed Charges,72% of Total Billed Charges,242.11,60,,3157.736,Percent of Total Billed Charges,60% of Total Billed Charges,363.17,90,,3325.224,Percent of Total Billed Charges,90% of Total Billed Charges,181.58,45,,3894.776,Percent of Total Billed Charges,45% of Total Billed Charges,363.17,90,,7789.56,Percent of Total Billed Charges,90% of Total billed Charges,403.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,403.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,403.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.29,65,,1474.528,Percent of total Billed Charges,65% of Total Billed Charges,177.95,44.1,,3816.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,383.34,95,,8222.312,Percent of Total Billed Charges,95% of Total Billed Charges,403.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.1,88,,7616.456,Percent of Total Billed Charges,88% of Total Billed Charges,363.17,90,,7789.56,Percent of Total Billed charges,90% of Total Billed Charges,177.95,403.52,
CATHETER PICC 6FR TRIPLE LUMEN,2780001283,CDM,278,RC,C1751,HCPCS,Outpatient,,,1278.18,830.82,,1278.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,971.42,76,,6577.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,920.29,72,,1282.784,Percent of Total Billed Charges,72% of Total Billed Charges,920.29,72,,1282.784,Percent of Total Billed charges,72% of Total Billed Charges,1278.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,920.29,72,,1282.784,Percent of Total Billed Charges,72% of Total Billed Charges,766.91,60,,1068.984,Percent of Total Billed Charges,60% of Total Billed Charges,1150.36,90,,3325.224,Percent of Total Billed Charges,90% of Total Billed Charges,575.18,45,,3894.776,Percent of Total Billed Charges,45% of Total Billed Charges,1150.36,90,,7789.56,Percent of Total Billed Charges,90% of Total billed Charges,1278.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1278.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1278.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,830.82,65,,1474.528,Percent of total Billed Charges,65% of Total Billed Charges,563.68,44.1,,3816.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,1214.27,95,,8222.312,Percent of Total Billed Charges,95% of Total Billed Charges,1278.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1124.8,88,,7616.456,Percent of Total Billed Charges,88% of Total Billed Charges,1150.36,90,,7789.56,Percent of Total Billed charges,90% of Total Billed Charges,563.68,1278.18,
TURBOJECT 3F PICC SL OTW,2780001284,CDM,278,RC,C1751,HCPCS,Outpatient,,,200.00,130.00,,200,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152,76,,6577.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144,72,,3540.984,Percent of Total Billed Charges,72% of Total Billed Charges,144,72,,3540.984,Percent of Total Billed charges,72% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144,72,,3540.984,Percent of Total Billed Charges,72% of Total Billed Charges,120,60,,2950.816,Percent of Total Billed Charges,60% of Total Billed Charges,180,90,,3325.224,Percent of Total Billed Charges,90% of Total Billed Charges,90,45,,3894.776,Percent of Total Billed Charges,45% of Total Billed Charges,180,90,,7789.56,Percent of Total Billed Charges,90% of Total billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130,65,,1474.528,Percent of total Billed Charges,65% of Total Billed Charges,88.2,44.1,,3816.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,190,95,,8222.312,Percent of Total Billed Charges,95% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,88,,3251.336,Percent of Total Billed Charges,88% of Total Billed Charges,180,90,,7789.56,Percent of Total Billed charges,90% of Total Billed Charges,88.2,200,
TURBOJECT 4F PICC SL CATHETER,2780001285,CDM,278,RC,C1751,HCPCS,Outpatient,,,200.00,130.00,,200,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152,76,,6577.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,144,72,,45.088,Percent of Total Billed charges,72% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,120,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,180,90,,3325.224,Percent of Total Billed Charges,90% of Total Billed Charges,90,45,,3894.776,Percent of Total Billed Charges,45% of Total Billed Charges,180,90,,7789.56,Percent of Total Billed Charges,90% of Total billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130,65,,1474.528,Percent of total Billed Charges,65% of Total Billed Charges,88.2,44.1,,3816.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,190,95,,8222.312,Percent of Total Billed Charges,95% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,88,,3251.336,Percent of Total Billed Charges,88% of Total Billed Charges,180,90,,7789.56,Percent of Total Billed charges,90% of Total Billed Charges,88.2,200,
PICC 4F SINGLE LUMEN,2780001286,CDM,278,RC,C1751,HCPCS,Outpatient,,,698.25,453.86,,698.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,530.67,76,,6577.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,502.74,72,,1282.784,Percent of Total Billed Charges,72% of Total Billed Charges,502.74,72,,1282.784,Percent of Total Billed charges,72% of Total Billed Charges,698.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.74,72,,1282.784,Percent of Total Billed Charges,72% of Total Billed Charges,418.95,60,,1068.984,Percent of Total Billed Charges,60% of Total Billed Charges,628.43,90,,3325.224,Percent of Total Billed Charges,90% of Total Billed Charges,314.21,45,,1662.616,Percent of Total Billed Charges,45% of Total Billed Charges,628.43,90,,7789.56,Percent of Total Billed Charges,90% of Total billed Charges,698.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,698.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,698.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.86,65,,1474.528,Percent of total Billed Charges,65% of Total Billed Charges,307.93,44.1,,1629.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,663.34,95,,8222.312,Percent of Total Billed Charges,95% of Total Billed Charges,698.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,614.46,88,,3251.336,Percent of Total Billed Charges,88% of Total Billed Charges,628.43,90,,7789.56,Percent of Total Billed charges,90% of Total Billed Charges,307.93,698.25,
PICC 5F DUAL LUMEN,2780001287,CDM,278,RC,C1751,HCPCS,Outpatient,,,736.79,478.91,,736.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,559.96,76,,6577.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,530.49,72,,3540.984,Percent of Total Billed Charges,72% of Total Billed Charges,530.49,72,,3540.984,Percent of Total Billed charges,72% of Total Billed Charges,736.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.49,72,,3540.984,Percent of Total Billed Charges,72% of Total Billed Charges,442.07,60,,2950.816,Percent of Total Billed Charges,60% of Total Billed Charges,663.11,90,,3325.224,Percent of Total Billed Charges,90% of Total Billed Charges,331.56,45,,1662.616,Percent of Total Billed Charges,45% of Total Billed Charges,663.11,90,,7789.56,Percent of Total Billed Charges,90% of Total billed Charges,736.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,736.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,736.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,478.91,65,,1474.528,Percent of total Billed Charges,65% of Total Billed Charges,324.92,44.1,,1629.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,699.95,95,,8222.312,Percent of Total Billed Charges,95% of Total Billed Charges,736.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,648.38,88,,3251.336,Percent of Total Billed Charges,88% of Total Billed Charges,663.11,90,,7789.56,Percent of Total Billed charges,90% of Total Billed Charges,324.92,736.79,
PICC 5F TRIPLE LUMEN,2780001288,CDM,278,RC,C1751,HCPCS,Outpatient,,,844.83,549.14,,844.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,642.07,76,,6577.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,608.28,72,,136.536,Percent of Total Billed Charges,72% of Total Billed Charges,608.28,72,,136.536,Percent of Total Billed charges,72% of Total Billed Charges,844.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,608.28,72,,136.536,Percent of Total Billed Charges,72% of Total Billed Charges,506.9,60,,113.776,Percent of Total Billed Charges,60% of Total Billed Charges,760.35,90,,3325.224,Percent of Total Billed Charges,90% of Total Billed Charges,380.17,45,,1662.616,Percent of Total Billed Charges,45% of Total Billed Charges,760.35,90,,7789.56,Percent of Total Billed Charges,90% of Total billed Charges,844.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,844.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,844.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.14,65,,1474.528,Percent of total Billed Charges,65% of Total Billed Charges,372.57,44.1,,1629.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,802.59,95,,8222.312,Percent of Total Billed Charges,95% of Total Billed Charges,844.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,743.45,88,,3251.336,Percent of Total Billed Charges,88% of Total Billed Charges,760.35,90,,7789.56,Percent of Total Billed charges,90% of Total Billed Charges,372.57,844.83,
CVC 7F 16CM TRIPLE,2780001289,CDM,278,RC,C1751,HCPCS,Outpatient,,,385.88,250.82,,385.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,293.27,76,,2807.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,277.83,72,,2368.704,Percent of Total Billed Charges,72% of Total Billed Charges,277.83,72,,2368.704,Percent of Total Billed charges,72% of Total Billed Charges,385.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.83,72,,2368.704,Percent of Total Billed Charges,72% of Total Billed Charges,231.53,60,,1973.92,Percent of Total Billed Charges,60% of Total Billed Charges,347.29,90,,3325.224,Percent of Total Billed Charges,90% of Total Billed Charges,173.65,45,,1662.616,Percent of Total Billed Charges,45% of Total Billed Charges,347.29,90,,3325.224,Percent of Total Billed Charges,90% of Total billed Charges,385.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.82,65,,1474.528,Percent of total Billed Charges,65% of Total Billed Charges,170.17,44.1,,1629.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,366.59,95,,3509.96,Percent of Total Billed Charges,95% of Total Billed Charges,385.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,339.57,88,,3251.336,Percent of Total Billed Charges,88% of Total Billed Charges,347.29,90,,3325.224,Percent of Total Billed charges,90% of Total Billed Charges,170.17,385.88,
PACEL 5F PACING CATHETER,2780001290,CDM,278,RC,C1756,HCPCS,Outpatient,,,184.52,119.94,,184.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,140.24,76,,2807.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,132.85,72,,4244.608,Percent of Total Billed Charges,72% of Total Billed Charges,132.85,72,,4244.608,Percent of Total Billed charges,72% of Total Billed Charges,184.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.85,72,,4244.608,Percent of Total Billed Charges,72% of Total Billed Charges,110.71,60,,3537.176,Percent of Total Billed Charges,60% of Total Billed Charges,166.07,90,,3325.224,Percent of Total Billed Charges,90% of Total Billed Charges,83.03,45,,1662.616,Percent of Total Billed Charges,45% of Total Billed Charges,166.07,90,,3325.224,Percent of Total Billed Charges,90% of Total billed Charges,184.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.94,65,,1474.528,Percent of total Billed Charges,65% of Total Billed Charges,81.37,44.1,,1629.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,175.29,95,,3509.96,Percent of Total Billed Charges,95% of Total Billed Charges,184.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.38,88,,3251.336,Percent of Total Billed Charges,88% of Total Billed Charges,166.07,90,,3325.224,Percent of Total Billed charges,90% of Total Billed Charges,81.37,184.52,
6 FR MYNX GRIP,2780001291,CDM,278,RC,C1760,HCPCS,Outpatient,,,284.45,184.89,,284.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,216.18,76,,2807.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,204.8,72,,1689.208,Percent of Total Billed Charges,72% of Total Billed Charges,204.8,72,,1689.208,Percent of Total Billed charges,72% of Total Billed Charges,284.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.8,72,,1689.208,Percent of Total Billed Charges,72% of Total Billed Charges,170.67,60,,1407.672,Percent of Total Billed Charges,60% of Total Billed Charges,256.01,90,,3325.224,Percent of Total Billed Charges,90% of Total Billed Charges,128,45,,1662.616,Percent of Total Billed Charges,45% of Total Billed Charges,256.01,90,,3325.224,Percent of Total Billed Charges,90% of Total billed Charges,284.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.89,65,,1474.528,Percent of total Billed Charges,65% of Total Billed Charges,125.44,44.1,,1629.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,270.23,95,,3509.96,Percent of Total Billed Charges,95% of Total Billed Charges,284.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.32,88,,3251.336,Percent of Total Billed Charges,88% of Total Billed Charges,256.01,90,,3325.224,Percent of Total Billed charges,90% of Total Billed Charges,125.44,284.45,
5FR MYNX GRIP,2780001292,CDM,278,RC,C1760,HCPCS,Outpatient,,,2216.03,1440.42,,2216.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1684.18,76,,2807.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1595.54,72,,1038.928,Percent of Total Billed Charges,72% of Total Billed Charges,1595.54,72,,1038.928,Percent of Total Billed charges,72% of Total Billed Charges,2216.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1595.54,72,,1038.928,Percent of Total Billed Charges,72% of Total Billed Charges,1329.62,60,,865.768,Percent of Total Billed Charges,60% of Total Billed Charges,1994.43,90,,3325.224,Percent of Total Billed Charges,90% of Total Billed Charges,997.21,45,,1662.616,Percent of Total Billed Charges,45% of Total Billed Charges,1994.43,90,,3325.224,Percent of Total Billed Charges,90% of Total billed Charges,2216.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2216.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2216.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440.42,65,,384.688,Percent of total Billed Charges,65% of Total Billed Charges,977.27,44.1,,1629.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,2105.23,95,,3509.96,Percent of Total Billed Charges,95% of Total Billed Charges,2216.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1950.11,88,,3251.336,Percent of Total Billed Charges,88% of Total Billed Charges,1994.43,90,,3325.224,Percent of Total Billed charges,90% of Total Billed Charges,977.27,2216.03,
STARCLOSE CLOSURE DE,2780001293,CDM,278,RC,C1760,HCPCS,Outpatient,,,463.05,300.98,,463.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,351.92,76,,2807.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,333.4,72,,1941.312,Percent of Total Billed Charges,72% of Total Billed Charges,333.4,72,,1941.312,Percent of Total Billed charges,72% of Total Billed Charges,463.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.4,72,,1941.312,Percent of Total Billed Charges,72% of Total Billed Charges,277.83,60,,1617.76,Percent of Total Billed Charges,60% of Total Billed Charges,416.75,90,,3325.224,Percent of Total Billed Charges,90% of Total Billed Charges,208.37,45,,1662.616,Percent of Total Billed Charges,45% of Total Billed Charges,416.75,90,,3325.224,Percent of Total Billed Charges,90% of Total billed Charges,463.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,463.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,463.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.98,65,,5014.656,Percent of total Billed Charges,65% of Total Billed Charges,204.21,44.1,,1629.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,439.9,95,,3509.96,Percent of Total Billed Charges,95% of Total Billed Charges,463.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.48,88,,3251.336,Percent of Total Billed Charges,88% of Total Billed Charges,416.75,90,,3325.224,Percent of Total Billed charges,90% of Total Billed Charges,204.21,463.05,
ANGIOSEAL VIP 6F DEVICE,2780001294,CDM,278,RC,C1760,HCPCS,Outpatient,,,562.50,365.63,,562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,427.5,76,,2807.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,405,72,,2721.784,Percent of Total Billed Charges,72% of Total Billed Charges,405,72,,2721.784,Percent of Total Billed charges,72% of Total Billed Charges,562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405,72,,2721.784,Percent of Total Billed Charges,72% of Total Billed Charges,337.5,60,,2268.152,Percent of Total Billed Charges,60% of Total Billed Charges,506.25,90,,3325.224,Percent of Total Billed Charges,90% of Total Billed Charges,253.13,45,,1662.616,Percent of Total Billed Charges,45% of Total Billed Charges,506.25,90,,3325.224,Percent of Total Billed Charges,90% of Total billed Charges,562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365.63,65,,5014.656,Percent of total Billed Charges,65% of Total Billed Charges,248.06,44.1,,1629.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,534.38,95,,3509.96,Percent of Total Billed Charges,95% of Total Billed Charges,562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495,88,,3251.336,Percent of Total Billed Charges,88% of Total Billed Charges,506.25,90,,3325.224,Percent of Total Billed charges,90% of Total Billed Charges,248.06,562.5,
ANGIOSEAL EVOLUTION 6F DEVICE,2780001295,CDM,278,RC,C1760,HCPCS,Outpatient,,,562.50,365.63,,562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,427.5,76,,2807.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,405,72,,455.32,Percent of Total Billed Charges,72% of Total Billed Charges,405,72,,455.32,Percent of Total Billed charges,72% of Total Billed Charges,562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405,72,,455.32,Percent of Total Billed Charges,72% of Total Billed Charges,337.5,60,,379.432,Percent of Total Billed Charges,60% of Total Billed Charges,506.25,90,,3325.224,Percent of Total Billed Charges,90% of Total Billed Charges,253.13,45,,1662.616,Percent of Total Billed Charges,45% of Total Billed Charges,506.25,90,,3325.224,Percent of Total Billed Charges,90% of Total billed Charges,562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365.63,65,,5014.656,Percent of total Billed Charges,65% of Total Billed Charges,248.06,44.1,,1629.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,534.38,95,,3509.96,Percent of Total Billed Charges,95% of Total Billed Charges,562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495,88,,3251.336,Percent of Total Billed Charges,88% of Total Billed Charges,506.25,90,,3325.224,Percent of Total Billed charges,90% of Total Billed Charges,248.06,562.5,
VASCADE 6/7 CLOSURE DEVICE,2780001296,CDM,278,RC,C1760,HCPCS,Outpatient,,,472.50,307.13,,472.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,359.1,76,,2807.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,340.2,72,,3539.712,Percent of Total Billed Charges,72% of Total Billed Charges,340.2,72,,3539.712,Percent of Total Billed charges,72% of Total Billed Charges,472.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.2,72,,3539.712,Percent of Total Billed Charges,72% of Total Billed Charges,283.5,60,,2949.76,Percent of Total Billed Charges,60% of Total Billed Charges,425.25,90,,535.816,Percent of Total Billed Charges,90% of Total Billed Charges,212.63,45,,1662.616,Percent of Total Billed Charges,45% of Total Billed Charges,425.25,90,,3325.224,Percent of Total Billed Charges,90% of Total billed Charges,472.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.13,65,,315.888,Percent of total Billed Charges,65% of Total Billed Charges,208.37,44.1,,1629.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,448.88,95,,3509.96,Percent of Total Billed Charges,95% of Total Billed Charges,472.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.8,88,,3251.336,Percent of Total Billed Charges,88% of Total Billed Charges,425.25,90,,3325.224,Percent of Total Billed charges,90% of Total Billed Charges,208.37,472.5,
VASCADE 5F CLOSURE DEVICE,2780001297,CDM,278,RC,C1760,HCPCS,Outpatient,,,472.50,307.13,,472.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,359.1,76,,2807.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,340.2,72,,6703.48,Percent of Total Billed Charges,72% of Total Billed Charges,340.2,72,,6703.48,Percent of Total Billed charges,72% of Total Billed Charges,472.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.2,72,,6703.48,Percent of Total Billed Charges,72% of Total Billed Charges,283.5,60,,5586.232,Percent of Total Billed Charges,60% of Total Billed Charges,425.25,90,,2041.656,Percent of Total Billed Charges,90% of Total Billed Charges,212.63,45,,1662.616,Percent of Total Billed Charges,45% of Total Billed Charges,425.25,90,,3325.224,Percent of Total Billed Charges,90% of Total billed Charges,472.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.13,65,,315.888,Percent of total Billed Charges,65% of Total Billed Charges,208.37,44.1,,1629.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,448.88,95,,3509.96,Percent of Total Billed Charges,95% of Total Billed Charges,472.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.8,88,,3251.336,Percent of Total Billed Charges,88% of Total Billed Charges,425.25,90,,3325.224,Percent of Total Billed charges,90% of Total Billed Charges,208.37,472.5,
SURGISIS GOLD 13X15,2780001298,CDM,278,RC,C1763,HCPCS,Outpatient,,,7044.98,4579.24,,7044.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5354.18,76,,2807.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5072.39,72,,4040.76,Percent of Total Billed Charges,72% of Total Billed Charges,5072.39,72,,4040.76,Percent of Total Billed charges,72% of Total Billed Charges,7044.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5072.39,72,,4040.76,Percent of Total Billed Charges,72% of Total Billed Charges,4226.99,60,,3367.304,Percent of Total Billed Charges,60% of Total Billed Charges,6340.48,90,,2041.656,Percent of Total Billed Charges,90% of Total Billed Charges,3170.24,45,,1662.616,Percent of Total Billed Charges,45% of Total Billed Charges,6340.48,90,,3325.224,Percent of Total Billed Charges,90% of Total billed Charges,7044.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7044.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7044.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4579.24,65,,315.888,Percent of total Billed Charges,65% of Total Billed Charges,3106.84,44.1,,1629.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,6692.73,95,,3509.96,Percent of Total Billed Charges,95% of Total Billed Charges,7044.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6199.58,88,,3251.336,Percent of Total Billed Charges,88% of Total Billed Charges,6340.48,90,,3325.224,Percent of Total Billed charges,90% of Total Billed Charges,3106.84,7044.98,
SURGISIS GOLD 13X22,2780001299,CDM,278,RC,C1763,HCPCS,Outpatient,,,14516.62,9435.80,,14516.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11032.63,76,,2807.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10451.97,72,,1283.416,Percent of Total Billed Charges,72% of Total Billed Charges,10451.97,72,,1283.416,Percent of Total Billed charges,72% of Total Billed Charges,14516.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10451.97,72,,1283.416,Percent of Total Billed Charges,72% of Total Billed Charges,8709.97,60,,1069.512,Percent of Total Billed Charges,60% of Total Billed Charges,13064.96,90,,2041.656,Percent of Total Billed Charges,90% of Total Billed Charges,6532.48,45,,1662.616,Percent of Total Billed Charges,45% of Total Billed Charges,13064.96,90,,3325.224,Percent of Total Billed Charges,90% of Total billed Charges,14516.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14516.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14516.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9435.8,65,,315.888,Percent of total Billed Charges,65% of Total Billed Charges,6401.83,44.1,,1629.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,13790.79,95,,3509.96,Percent of Total Billed Charges,95% of Total Billed Charges,14516.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12774.63,88,,3251.336,Percent of Total Billed Charges,88% of Total Billed Charges,13064.96,90,,3325.224,Percent of Total Billed charges,90% of Total Billed Charges,6401.83,14516.62,
SURGISIS GOID 20X20,2780001300,CDM,278,RC,C1763,HCPCS,Outpatient,,,12580.63,8177.41,,12580.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9561.28,76,,2807.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9058.05,72,,455.96,Percent of Total Billed Charges,72% of Total Billed Charges,9058.05,72,,455.96,Percent of Total Billed charges,72% of Total Billed Charges,12580.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9058.05,72,,455.96,Percent of Total Billed Charges,72% of Total Billed Charges,7548.38,60,,379.968,Percent of Total Billed Charges,60% of Total Billed Charges,11322.57,90,,2041.656,Percent of Total Billed Charges,90% of Total Billed Charges,5661.28,45,,1662.616,Percent of Total Billed Charges,45% of Total Billed Charges,11322.57,90,,3325.224,Percent of Total Billed Charges,90% of Total billed Charges,12580.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12580.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12580.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8177.41,65,,315.888,Percent of total Billed Charges,65% of Total Billed Charges,5548.06,44.1,,1629.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,11951.6,95,,3509.96,Percent of Total Billed Charges,95% of Total Billed Charges,12580.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11070.95,88,,3251.336,Percent of Total Billed Charges,88% of Total Billed Charges,11322.57,90,,3325.224,Percent of Total Billed charges,90% of Total Billed Charges,5548.06,12580.63,
INTERCEED 3X4,2780001302,CDM,278,RC,C1765,HCPCS,Outpatient,,,615.20,399.88,,615.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,467.55,76,,2807.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,442.94,72,,4074.416,Percent of Total Billed Charges,72% of Total Billed Charges,442.94,72,,4074.416,Percent of Total Billed charges,72% of Total Billed Charges,615.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,442.94,72,,4074.416,Percent of Total Billed Charges,72% of Total Billed Charges,369.12,60,,3395.344,Percent of Total Billed Charges,60% of Total Billed Charges,553.68,90,,2041.656,Percent of Total Billed Charges,90% of Total Billed Charges,276.84,45,,1662.616,Percent of Total Billed Charges,45% of Total Billed Charges,553.68,90,,3325.224,Percent of Total Billed Charges,90% of Total billed Charges,615.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,615.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,615.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.88,65,,4762.976,Percent of total Billed Charges,65% of Total Billed Charges,271.3,44.1,,1629.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,584.44,95,,3509.96,Percent of Total Billed Charges,95% of Total Billed Charges,615.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,541.38,88,,523.912,Percent of Total Billed Charges,88% of Total Billed Charges,553.68,90,,3325.224,Percent of Total Billed charges,90% of Total Billed Charges,271.3,615.2,
6F GLIDESHEATH NK,2780001303,CDM,272,RC,C1894,HCPCS,Outpatient,,,197.35,128.28,,197.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.99,76,,2807.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,142.09,72,,12162.288,Percent of Total Billed Charges,72% of Total Billed Charges,148.01,75,,12162.288,Percent of Total Billed charges,75% of Total Billed Charges,197.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.09,72,,12162.288,Percent of Total Billed Charges,72% of Total Billed Charges,118.41,60,,10135.24,Percent of Total Billed Charges,60% of Total Billed Charges,177.62,90,,2041.656,Percent of Total Billed Charges,90% of Total Billed Charges,88.81,45,,1662.616,Percent of Total Billed Charges,45% of Total Billed Charges,177.62,90,,3325.224,Percent of Total Billed Charges,90% of Total billed Charges,197.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.28,65,,565.848,Percent of total Billed Charges,65% of Total Billed Charges,87.03,44.1,,1629.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,187.48,95,,3509.96,Percent of Total Billed Charges,95% of Total Billed Charges,197.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.67,88,,1996.28,Percent of Total Billed Charges,88% of Total Billed Charges,177.62,90,,3325.224,Percent of Total Billed charges,90% of Total Billed Charges,87.03,197.35,
4F GLIDESHEATH NK,2780001304,CDM,272,RC,C1894,HCPCS,Outpatient,,,187.43,121.83,,187.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,142.45,76,,2807.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,134.95,72,,40.008,Percent of Total Billed Charges,72% of Total Billed Charges,140.57,75,,40.008,Percent of Total Billed charges,75% of Total Billed Charges,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.95,72,,40.008,Percent of Total Billed Charges,72% of Total Billed Charges,112.46,60,,33.344,Percent of Total Billed Charges,60% of Total Billed Charges,168.69,90,,2041.656,Percent of Total Billed Charges,90% of Total Billed Charges,84.34,45,,267.912,Percent of Total Billed Charges,45% of Total Billed Charges,168.69,90,,3325.224,Percent of Total Billed Charges,90% of Total billed Charges,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.83,65,,758.48,Percent of total Billed Charges,65% of Total Billed Charges,82.66,44.1,,262.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,178.06,95,,3509.96,Percent of Total Billed Charges,95% of Total Billed Charges,187.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.94,88,,1996.28,Percent of Total Billed Charges,88% of Total Billed Charges,168.69,90,,3325.224,Percent of Total Billed charges,90% of Total Billed Charges,82.66,187.43,
OPTITORQUE 5F JL5 R CATHETER,2780001305,CDM,272,RC,C1887,HCPCS,Outpatient,,,171.99,111.79,,171.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.71,76,,2807.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.83,72,,321.968,Percent of Total Billed Charges,72% of Total Billed Charges,128.99,75,,321.968,Percent of Total Billed charges,75% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.83,72,,321.968,Percent of Total Billed Charges,72% of Total Billed Charges,103.19,60,,268.304,Percent of Total Billed Charges,60% of Total Billed Charges,154.79,90,,2041.656,Percent of Total Billed Charges,90% of Total Billed Charges,77.4,45,,1020.824,Percent of Total Billed Charges,45% of Total Billed Charges,154.79,90,,3325.224,Percent of Total Billed Charges,90% of Total billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.79,65,,2192.296,Percent of total Billed Charges,65% of Total Billed Charges,75.85,44.1,,1000.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.39,95,,3509.96,Percent of Total Billed Charges,95% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.35,88,,1996.28,Percent of Total Billed Charges,88% of Total Billed Charges,154.79,90,,3325.224,Percent of Total Billed charges,90% of Total Billed Charges,75.85,171.99,
PINNACLE R/O 6F 10CM SHEATH,2780001306,CDM,272,RC,C1894,HCPCS,Outpatient,,,114.10,74.17,,114.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,86.72,76,,2807.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.15,72,,4074.416,Percent of Total Billed Charges,72% of Total Billed Charges,85.58,75,,4074.416,Percent of Total Billed charges,75% of Total Billed Charges,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.15,72,,4074.416,Percent of Total Billed Charges,72% of Total Billed Charges,68.46,60,,3395.344,Percent of Total Billed Charges,60% of Total Billed Charges,102.69,90,,2041.656,Percent of Total Billed Charges,90% of Total Billed Charges,51.35,45,,1020.824,Percent of Total Billed Charges,45% of Total Billed Charges,102.69,90,,3325.224,Percent of Total Billed Charges,90% of Total billed Charges,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.17,65,,4169.608,Percent of total Billed Charges,65% of Total Billed Charges,50.32,44.1,,1000.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,108.4,95,,3509.96,Percent of Total Billed Charges,95% of Total Billed Charges,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.41,88,,1996.28,Percent of Total Billed Charges,88% of Total Billed Charges,102.69,90,,3325.224,Percent of Total Billed charges,90% of Total Billed Charges,50.32,114.1,
PINNACLE R/O 7F 10CM SHEATH,2780001307,CDM,272,RC,C1894,HCPCS,Outpatient,,,114.10,74.17,,114.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,86.72,76,,452.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.15,72,,12162.288,Percent of Total Billed Charges,72% of Total Billed Charges,85.58,75,,12162.288,Percent of Total Billed charges,75% of Total Billed Charges,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.15,72,,12162.288,Percent of Total Billed Charges,72% of Total Billed Charges,68.46,60,,10135.24,Percent of Total Billed Charges,60% of Total Billed Charges,102.69,90,,2041.656,Percent of Total Billed Charges,90% of Total Billed Charges,51.35,45,,1020.824,Percent of Total Billed Charges,45% of Total Billed Charges,102.69,90,,535.816,Percent of Total Billed Charges,90% of Total billed Charges,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.17,65,,2192.296,Percent of total Billed Charges,65% of Total Billed Charges,50.32,44.1,,1000.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,108.4,95,,565.584,Percent of Total Billed Charges,95% of Total Billed Charges,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.41,88,,1996.28,Percent of Total Billed Charges,88% of Total Billed Charges,102.69,90,,535.816,Percent of Total Billed charges,90% of Total Billed Charges,50.32,114.1,
PINNACLE R/O 5F 25CM SHEATH,2780001308,CDM,272,RC,C1894,HCPCS,Outpatient,,,114.10,74.17,,114.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,86.72,76,,1724.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.15,72,,1597.76,Percent of Total Billed Charges,72% of Total Billed Charges,85.58,75,,1597.76,Percent of Total Billed charges,75% of Total Billed Charges,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.15,72,,1597.76,Percent of Total Billed Charges,72% of Total Billed Charges,68.46,60,,1331.464,Percent of Total Billed Charges,60% of Total Billed Charges,102.69,90,,2041.656,Percent of Total Billed Charges,90% of Total Billed Charges,51.35,45,,1020.824,Percent of Total Billed Charges,45% of Total Billed Charges,102.69,90,,2041.656,Percent of Total Billed Charges,90% of Total billed Charges,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.17,65,,12893.52,Percent of total Billed Charges,65% of Total Billed Charges,50.32,44.1,,1000.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,108.4,95,,2155.08,Percent of Total Billed Charges,95% of Total Billed Charges,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.41,88,,1996.28,Percent of Total Billed Charges,88% of Total Billed Charges,102.69,90,,2041.656,Percent of Total Billed charges,90% of Total Billed Charges,50.32,114.1,
PINNACLE R/O 6F 25CM SHEATH,2780001309,CDM,272,RC,C1894,HCPCS,Outpatient,,,114.10,74.17,,114.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,86.72,76,,1724.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.15,72,,1085.92,Percent of Total Billed Charges,72% of Total Billed Charges,85.58,75,,1085.92,Percent of Total Billed charges,75% of Total Billed Charges,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.15,72,,1085.92,Percent of Total Billed Charges,72% of Total Billed Charges,68.46,60,,904.936,Percent of Total Billed Charges,60% of Total Billed Charges,102.69,90,,2041.656,Percent of Total Billed Charges,90% of Total Billed Charges,51.35,45,,1020.824,Percent of Total Billed Charges,45% of Total Billed Charges,102.69,90,,2041.656,Percent of Total Billed Charges,90% of Total billed Charges,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.17,65,,4089.344,Percent of total Billed Charges,65% of Total Billed Charges,50.32,44.1,,1000.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,108.4,95,,2155.08,Percent of Total Billed Charges,95% of Total Billed Charges,114.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.41,88,,1996.28,Percent of Total Billed Charges,88% of Total Billed Charges,102.69,90,,2041.656,Percent of Total Billed charges,90% of Total Billed Charges,50.32,114.1,
6F 7CM RO SHEATH,2780001310,CDM,272,RC,C1894,HCPCS,Outpatient,,,65.71,42.71,,65.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.94,76,,1724.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47.31,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,49.28,75,,43.184,Percent of Total Billed charges,75% of Total Billed Charges,65.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.31,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,39.43,60,,35.984,Percent of Total Billed Charges,60% of Total Billed Charges,59.14,90,,532.64,Percent of Total Billed Charges,90% of Total Billed Charges,29.57,45,,1020.824,Percent of Total Billed Charges,45% of Total Billed Charges,59.14,90,,2041.656,Percent of Total Billed Charges,90% of Total billed Charges,65.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.71,65,,2192.296,Percent of total Billed Charges,65% of Total Billed Charges,28.98,44.1,,1000.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.42,95,,2155.08,Percent of Total Billed Charges,95% of Total Billed Charges,65.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.82,88,,1996.28,Percent of Total Billed Charges,88% of Total Billed Charges,59.14,90,,2041.656,Percent of Total Billed charges,90% of Total Billed Charges,28.98,65.71,
5F 11CM R/O SUPER SHEATH,2780001311,CDM,272,RC,C1894,HCPCS,Outpatient,,,38.64,25.12,,38.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.37,76,,1724.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.82,72,,72.4,Percent of Total Billed Charges,72% of Total Billed Charges,28.98,75,,72.4,Percent of Total Billed charges,75% of Total Billed Charges,38.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.82,72,,72.4,Percent of Total Billed Charges,72% of Total Billed Charges,23.18,60,,60.328,Percent of Total Billed Charges,60% of Total Billed Charges,34.78,90,,6943.368,Percent of Total Billed Charges,90% of Total Billed Charges,17.39,45,,1020.824,Percent of Total Billed Charges,45% of Total Billed Charges,34.78,90,,2041.656,Percent of Total Billed Charges,90% of Total billed Charges,38.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.12,65,,3082.064,Percent of total Billed Charges,65% of Total Billed Charges,17.04,44.1,,1000.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.71,95,,2155.08,Percent of Total Billed Charges,95% of Total Billed Charges,38.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34,88,,1996.28,Percent of Total Billed Charges,88% of Total Billed Charges,34.78,90,,2041.656,Percent of Total Billed charges,90% of Total Billed Charges,17.04,38.64,
6F 11CM R/O SUPER SHEATH,2780001312,CDM,272,RC,C1894,HCPCS,Outpatient,,,38.64,25.12,,38.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.37,76,,1724.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.82,72,,72.4,Percent of Total Billed Charges,72% of Total Billed Charges,28.98,75,,72.4,Percent of Total Billed charges,75% of Total Billed Charges,38.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.82,72,,72.4,Percent of Total Billed Charges,72% of Total Billed Charges,23.18,60,,60.328,Percent of Total Billed Charges,60% of Total Billed Charges,34.78,90,,6943.368,Percent of Total Billed Charges,90% of Total Billed Charges,17.39,45,,1020.824,Percent of Total Billed Charges,45% of Total Billed Charges,34.78,90,,2041.656,Percent of Total Billed Charges,90% of Total billed Charges,38.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.12,65,,2122.928,Percent of total Billed Charges,65% of Total Billed Charges,17.04,44.1,,1000.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.71,95,,2155.08,Percent of Total Billed Charges,95% of Total Billed Charges,38.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34,88,,1996.28,Percent of Total Billed Charges,88% of Total Billed Charges,34.78,90,,2041.656,Percent of Total Billed charges,90% of Total Billed Charges,17.04,38.64,
7F 11CM R/O SUPER SHEATH,2780001313,CDM,272,RC,C1894,HCPCS,Outpatient,,,38.64,25.12,,38.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.37,76,,1724.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.82,72,,122.56,Percent of Total Billed Charges,72% of Total Billed Charges,28.98,75,,122.56,Percent of Total Billed charges,75% of Total Billed Charges,38.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.82,72,,122.56,Percent of Total Billed Charges,72% of Total Billed Charges,23.18,60,,102.136,Percent of Total Billed Charges,60% of Total Billed Charges,34.78,90,,6943.368,Percent of Total Billed Charges,90% of Total Billed Charges,17.39,45,,1020.824,Percent of Total Billed Charges,45% of Total Billed Charges,34.78,90,,2041.656,Percent of Total Billed Charges,90% of Total billed Charges,38.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.12,65,,1575.432,Percent of total Billed Charges,65% of Total Billed Charges,17.04,44.1,,1000.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.71,95,,2155.08,Percent of Total Billed Charges,95% of Total Billed Charges,38.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34,88,,1996.28,Percent of Total Billed Charges,88% of Total Billed Charges,34.78,90,,2041.656,Percent of Total Billed charges,90% of Total Billed Charges,17.04,38.64,
6F 25CM R/O SUPER SHEATH,2780001314,CDM,272,RC,C1766,HCPCS,Outpatient,,,59.22,38.49,,59.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.01,76,,1724.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.64,72,,122.56,Percent of Total Billed Charges,72% of Total Billed Charges,44.42,75,,122.56,Percent of Total Billed charges,75% of Total Billed Charges,59.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.64,72,,122.56,Percent of Total Billed Charges,72% of Total Billed Charges,35.53,60,,102.136,Percent of Total Billed Charges,60% of Total Billed Charges,53.3,90,,437.384,Percent of Total Billed Charges,90% of Total Billed Charges,26.65,45,,1020.824,Percent of Total Billed Charges,45% of Total Billed Charges,53.3,90,,2041.656,Percent of Total Billed Charges,90% of Total billed Charges,59.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.49,65,,3812.448,Percent of total Billed Charges,65% of Total Billed Charges,26.12,44.1,,1000.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,56.26,95,,2155.08,Percent of Total Billed Charges,95% of Total Billed Charges,59.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.11,88,,1996.28,Percent of Total Billed Charges,88% of Total Billed Charges,53.3,90,,2041.656,Percent of Total Billed charges,90% of Total Billed Charges,26.12,59.22,
7F 25CM R/O SUPER SHEATH,2780001315,CDM,272,RC,C1766,HCPCS,Outpatient,,,59.22,38.49,,59.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.01,76,,1724.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.64,72,,147.328,Percent of Total Billed Charges,72% of Total Billed Charges,44.42,75,,147.328,Percent of Total Billed charges,75% of Total Billed Charges,59.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.64,72,,147.328,Percent of Total Billed Charges,72% of Total Billed Charges,35.53,60,,122.776,Percent of Total Billed Charges,60% of Total Billed Charges,53.3,90,,437.384,Percent of Total Billed Charges,90% of Total Billed Charges,26.65,45,,1020.824,Percent of Total Billed Charges,45% of Total Billed Charges,53.3,90,,2041.656,Percent of Total Billed Charges,90% of Total billed Charges,59.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.49,65,,222.44,Percent of total Billed Charges,65% of Total Billed Charges,26.12,44.1,,1000.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,56.26,95,,2155.08,Percent of Total Billed Charges,95% of Total Billed Charges,59.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.11,88,,520.808,Percent of Total Billed Charges,88% of Total Billed Charges,53.3,90,,2041.656,Percent of Total Billed charges,90% of Total Billed Charges,26.12,59.22,
GENERAT NEUR NONREC,2780001316,CDM,278,RC,C1767,HCPCS,Outpatient,,,21150.36,13747.73,,21150.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16074.27,76,,1724.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15228.26,72,,1941.312,Percent of Total Billed Charges,72% of Total Billed Charges,15228.26,72,,1941.312,Percent of Total Billed charges,72% of Total Billed Charges,21150.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15228.26,72,,1941.312,Percent of Total Billed Charges,72% of Total Billed Charges,12690.22,60,,1617.76,Percent of Total Billed Charges,60% of Total Billed Charges,19035.32,90,,437.384,Percent of Total Billed Charges,90% of Total Billed Charges,9517.66,45,,1020.824,Percent of Total Billed Charges,45% of Total Billed Charges,19035.32,90,,2041.656,Percent of Total Billed Charges,90% of Total billed Charges,21150.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21150.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21150.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13747.73,65,,2152.168,Percent of total Billed Charges,65% of Total Billed Charges,9327.31,44.1,,1000.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,20092.84,95,,2155.08,Percent of Total Billed Charges,95% of Total Billed Charges,21150.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18612.32,88,,6789.072,Percent of Total Billed Charges,88% of Total Billed Charges,19035.32,90,,2041.656,Percent of Total Billed charges,90% of Total Billed Charges,9327.31,21150.36,
GRFT HEMSHIELD 14X7,2780001317,CDM,278,RC,C1768,HCPCS,Outpatient,,,2093.65,1360.87,,2093.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1591.17,76,,1724.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1507.43,72,,1038.928,Percent of Total Billed Charges,72% of Total Billed Charges,1507.43,72,,1038.928,Percent of Total Billed charges,72% of Total Billed Charges,2093.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1507.43,72,,1038.928,Percent of Total Billed Charges,72% of Total Billed Charges,1256.19,60,,865.768,Percent of Total Billed Charges,60% of Total Billed Charges,1884.29,90,,437.384,Percent of Total Billed Charges,90% of Total Billed Charges,942.14,45,,266.32,Percent of Total Billed Charges,45% of Total Billed Charges,1884.29,90,,2041.656,Percent of Total Billed Charges,90% of Total billed Charges,2093.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2093.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2093.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1360.87,65,,1030.216,Percent of total Billed Charges,65% of Total Billed Charges,923.3,44.1,,260.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,1988.97,95,,2155.08,Percent of Total Billed Charges,95% of Total Billed Charges,2093.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1842.41,88,,6789.072,Percent of Total Billed Charges,88% of Total Billed Charges,1884.29,90,,2041.656,Percent of Total Billed charges,90% of Total Billed Charges,923.3,2093.65,
ARTEGRAFT 6X30 VASCULAR,2780001318,CDM,278,RC,C1768,HCPCS,Outpatient,,,6226.92,4047.50,,6226.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4732.46,76,,1724.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4483.38,72,,1689.208,Percent of Total Billed Charges,72% of Total Billed Charges,4483.38,72,,1689.208,Percent of Total Billed charges,72% of Total Billed Charges,6226.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4483.38,72,,1689.208,Percent of Total Billed Charges,72% of Total Billed Charges,3736.15,60,,1407.672,Percent of Total Billed Charges,60% of Total Billed Charges,5604.23,90,,437.384,Percent of Total Billed Charges,90% of Total Billed Charges,2802.11,45,,3471.688,Percent of Total Billed Charges,45% of Total Billed Charges,5604.23,90,,2041.656,Percent of Total Billed Charges,90% of Total billed Charges,6226.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6226.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6226.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4047.5,65,,438,Percent of total Billed Charges,65% of Total Billed Charges,2746.07,44.1,,3402.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,5915.57,95,,2155.08,Percent of Total Billed Charges,95% of Total Billed Charges,6226.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5479.69,88,,6789.072,Percent of Total Billed Charges,88% of Total Billed Charges,5604.23,90,,2041.656,Percent of Total Billed charges,90% of Total Billed Charges,2746.07,6226.92,
BOVINE GRAFT #7,2780001319,CDM,278,RC,C1768,HCPCS,Outpatient,,,2382.50,1548.63,,2382.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1810.7,76,,1724.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1715.4,72,,504.224,Percent of Total Billed Charges,72% of Total Billed Charges,1715.4,72,,504.224,Percent of Total Billed charges,72% of Total Billed Charges,2382.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1715.4,72,,504.224,Percent of Total Billed Charges,72% of Total Billed Charges,1429.5,60,,420.184,Percent of Total Billed Charges,60% of Total Billed Charges,2144.25,90,,6594.888,Percent of Total Billed Charges,90% of Total Billed Charges,1072.13,45,,3471.688,Percent of Total Billed Charges,45% of Total Billed Charges,2144.25,90,,2041.656,Percent of Total Billed Charges,90% of Total billed Charges,2382.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2382.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2382.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1548.63,65,,85.424,Percent of total Billed Charges,65% of Total Billed Charges,1050.68,44.1,,3402.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,2263.38,95,,2155.08,Percent of Total Billed Charges,95% of Total Billed Charges,2382.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.6,88,,427.664,Percent of Total Billed Charges,88% of Total Billed Charges,2144.25,90,,2041.656,Percent of Total Billed charges,90% of Total Billed Charges,1050.68,2382.5,
GORETEX 6X40 STRETCH GRAFT,2780001320,CDM,278,RC,,,Outpatient,,,3631.64,2360.57,,3631.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2760.05,76,,449.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2614.78,72,,786.816,Percent of Total Billed Charges,72% of Total Billed Charges,2614.78,72,,786.816,Percent of Total Billed charges,72% of Total Billed Charges,3631.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2614.78,72,,786.816,Percent of Total Billed Charges,72% of Total Billed Charges,2178.98,60,,655.68,Percent of Total Billed Charges,60% of Total Billed Charges,3268.48,90,,783.48,Percent of Total Billed Charges,90% of Total Billed Charges,1634.24,45,,3471.688,Percent of Total Billed Charges,45% of Total Billed Charges,3268.48,90,,532.64,Percent of Total Billed Charges,90% of Total billed Charges,3631.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3631.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3631.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2360.57,65,,87.712,Percent of total Billed Charges,65% of Total Billed Charges,1601.55,44.1,,3402.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,3450.06,95,,562.232,Percent of Total Billed Charges,95% of Total Billed Charges,3631.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3195.84,88,,427.664,Percent of Total Billed Charges,88% of Total Billed Charges,3268.48,90,,532.64,Percent of Total Billed charges,90% of Total Billed Charges,1601.55,3631.64,
VASCULAR GRAF INTERI,2780001321,CDM,278,RC,C1768,HCPCS,Outpatient,,,5290.90,3439.09,,5290.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4021.08,76,,5863.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3809.45,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,3809.45,72,,43.184,Percent of Total Billed charges,72% of Total Billed Charges,5290.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3809.45,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,3174.54,60,,35.984,Percent of Total Billed Charges,60% of Total Billed Charges,4761.81,90,,1050.2,Percent of Total Billed Charges,90% of Total Billed Charges,2380.91,45,,218.696,Percent of Total Billed Charges,45% of Total Billed Charges,4761.81,90,,6943.368,Percent of Total Billed Charges,90% of Total billed Charges,5290.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5290.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5290.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3439.09,65,,11036.6,Percent of total Billed Charges,65% of Total Billed Charges,2333.29,44.1,,214.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,5026.36,95,,7329.112,Percent of Total Billed Charges,95% of Total Billed Charges,5290.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4655.99,88,,427.664,Percent of Total Billed Charges,88% of Total Billed Charges,4761.81,90,,6943.368,Percent of Total Billed charges,90% of Total Billed Charges,2333.29,5290.9,
ALCON SHEATH GLIDE,2780001322,CDM,278,RC,C1768,HCPCS,Outpatient,,,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,5863.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,2023.24,Percent of Total Billed Charges,72% of Total Billed Charges,14.29,72,,2023.24,Percent of Total Billed charges,72% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,2023.24,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,1686.032,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,3035.488,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,218.696,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,6943.368,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,5037.592,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,214.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,7329.112,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,427.664,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,6943.368,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
HEMASHIELD PATCH 3X3,2780001323,CDM,278,RC,C1768,HCPCS,Outpatient,,,312.01,202.81,,312.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.13,76,,5863.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,224.65,72,,3243.152,Percent of Total Billed Charges,72% of Total Billed Charges,224.65,72,,3243.152,Percent of Total Billed charges,72% of Total Billed Charges,312.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.65,72,,3243.152,Percent of Total Billed Charges,72% of Total Billed Charges,187.21,60,,2702.624,Percent of Total Billed Charges,60% of Total Billed Charges,280.81,90,,5773.304,Percent of Total Billed Charges,90% of Total Billed Charges,140.4,45,,218.696,Percent of Total Billed Charges,45% of Total Billed Charges,280.81,90,,6943.368,Percent of Total Billed Charges,90% of Total billed Charges,312.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.81,65,,11188.52,Percent of total Billed Charges,65% of Total Billed Charges,137.6,44.1,,214.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.41,95,,7329.112,Percent of Total Billed Charges,95% of Total Billed Charges,312.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.57,88,,427.664,Percent of Total Billed Charges,88% of Total Billed Charges,280.81,90,,6943.368,Percent of Total Billed charges,90% of Total Billed Charges,137.6,312.01,
HEMASHIELD PATCH 1X3,2780001324,CDM,278,RC,C1768,HCPCS,Outpatient,,,373.75,242.94,,373.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.05,76,,369.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.1,72,,6246.256,Percent of Total Billed Charges,72% of Total Billed Charges,269.1,72,,6246.256,Percent of Total Billed charges,72% of Total Billed Charges,373.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.1,72,,6246.256,Percent of Total Billed Charges,72% of Total Billed Charges,224.25,60,,5205.208,Percent of Total Billed Charges,60% of Total Billed Charges,336.38,90,,3035.488,Percent of Total Billed Charges,90% of Total Billed Charges,168.19,45,,218.696,Percent of Total Billed Charges,45% of Total Billed Charges,336.38,90,,437.384,Percent of Total Billed Charges,90% of Total billed Charges,373.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.94,65,,3613.512,Percent of total Billed Charges,65% of Total Billed Charges,164.82,44.1,,214.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,355.06,95,,461.688,Percent of Total Billed Charges,95% of Total Billed Charges,373.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.9,88,,6448.336,Percent of Total Billed Charges,88% of Total Billed Charges,336.38,90,,437.384,Percent of Total Billed charges,90% of Total Billed Charges,164.82,373.75,
HEMASHIELD ST GRAFT 10 X 30,2780001325,CDM,278,RC,C1768,HCPCS,Outpatient,,,1381.80,898.17,,1381.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1050.17,76,,369.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,994.9,72,,8967.4,Percent of Total Billed Charges,72% of Total Billed Charges,994.9,72,,8967.4,Percent of Total Billed charges,72% of Total Billed Charges,1381.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.9,72,,8967.4,Percent of Total Billed Charges,72% of Total Billed Charges,829.08,60,,7472.832,Percent of Total Billed Charges,60% of Total Billed Charges,1243.62,90,,17852.568,Percent of Total Billed Charges,90% of Total Billed Charges,621.81,45,,218.696,Percent of Total Billed Charges,45% of Total Billed Charges,1243.62,90,,437.384,Percent of Total Billed Charges,90% of Total billed Charges,1381.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1381.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1381.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.17,65,,2516.216,Percent of total Billed Charges,65% of Total Billed Charges,609.37,44.1,,214.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,1312.71,95,,461.688,Percent of Total Billed Charges,95% of Total Billed Charges,1381.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1215.98,88,,766.072,Percent of Total Billed Charges,88% of Total Billed Charges,1243.62,90,,437.384,Percent of Total Billed charges,90% of Total Billed Charges,609.37,1381.8,
ARTEGRAFT 5X40 VASCULAR,2780001326,CDM,278,RC,C1768,HCPCS,Outpatient,,,5037.00,3274.05,,5037,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3828.12,76,,369.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3626.64,72,,3539.712,Percent of Total Billed Charges,72% of Total Billed Charges,3626.64,72,,3539.712,Percent of Total Billed charges,72% of Total Billed Charges,5037,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3626.64,72,,3539.712,Percent of Total Billed Charges,72% of Total Billed Charges,3022.2,60,,2949.76,Percent of Total Billed Charges,60% of Total Billed Charges,4533.3,90,,5662.176,Percent of Total Billed Charges,90% of Total Billed Charges,2266.65,45,,3297.448,Percent of Total Billed Charges,45% of Total Billed Charges,4533.3,90,,437.384,Percent of Total Billed Charges,90% of Total billed Charges,5037,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5037,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5037,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3274.05,65,,439.72,Percent of total Billed Charges,65% of Total Billed Charges,2221.32,44.1,,3231.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,4785.15,95,,461.688,Percent of Total Billed Charges,95% of Total Billed Charges,5037,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4432.56,88,,1026.864,Percent of Total Billed Charges,88% of Total Billed Charges,4533.3,90,,437.384,Percent of Total Billed charges,90% of Total Billed Charges,2221.32,5037,
Z4722550801 SG WI,2780001327,CDM,278,RC,C1769,HCPCS,Outpatient,,,748.60,486.59,,748.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,568.94,76,,369.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,538.99,72,,1659.36,Percent of Total Billed Charges,72% of Total Billed Charges,538.99,72,,1659.36,Percent of Total Billed charges,72% of Total Billed Charges,748.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.99,72,,1659.36,Percent of Total Billed Charges,72% of Total Billed Charges,449.16,60,,1382.8,Percent of Total Billed Charges,60% of Total Billed Charges,673.74,90,,3035.488,Percent of Total Billed Charges,90% of Total Billed Charges,336.87,45,,391.744,Percent of Total Billed Charges,45% of Total Billed Charges,673.74,90,,437.384,Percent of Total Billed Charges,90% of Total billed Charges,748.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,748.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,748.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,486.59,65,,439.72,Percent of total Billed Charges,65% of Total Billed Charges,330.13,44.1,,383.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,711.17,95,,461.688,Percent of Total Billed Charges,95% of Total Billed Charges,748.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658.77,88,,2968.032,Percent of Total Billed Charges,88% of Total Billed Charges,673.74,90,,437.384,Percent of Total Billed charges,90% of Total Billed Charges,330.13,748.6,
COOK ROADRUNNER WIRE GUIDE,2780001328,CDM,278,RC,C1769,HCPCS,Outpatient,,,70.56,45.86,,70.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.63,76,,369.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.8,72,,10446.408,Percent of Total Billed Charges,72% of Total Billed Charges,50.8,72,,10446.408,Percent of Total Billed charges,72% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.8,72,,10446.408,Percent of Total Billed Charges,72% of Total Billed Charges,42.34,60,,8705.344,Percent of Total Billed Charges,60% of Total Billed Charges,63.5,90,,4267.472,Percent of Total Billed Charges,90% of Total Billed Charges,31.75,45,,525.096,Percent of Total Billed Charges,45% of Total Billed Charges,63.5,90,,437.384,Percent of Total Billed Charges,90% of Total billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.86,65,,222.44,Percent of total Billed Charges,65% of Total Billed Charges,31.12,44.1,,514.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.03,95,,461.688,Percent of Total Billed Charges,95% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.09,88,,5645.008,Percent of Total Billed Charges,88% of Total Billed Charges,63.5,90,,437.384,Percent of Total Billed charges,90% of Total Billed Charges,31.12,70.56,
COOK HUWIU ANGLED,2780001329,CDM,278,RC,C1769,HCPCS,Outpatient,,,69.46,45.15,,69.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.79,76,,5569.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.01,72,,8287.272,Percent of Total Billed Charges,72% of Total Billed Charges,50.01,72,,8287.272,Percent of Total Billed charges,72% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.01,72,,8287.272,Percent of Total Billed Charges,72% of Total Billed Charges,41.68,60,,6906.064,Percent of Total Billed Charges,60% of Total Billed Charges,62.51,90,,2939.44,Percent of Total Billed Charges,90% of Total Billed Charges,31.26,45,,1517.744,Percent of Total Billed Charges,45% of Total Billed Charges,62.51,90,,6594.888,Percent of Total Billed Charges,90% of Total billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.15,65,,439.72,Percent of total Billed Charges,65% of Total Billed Charges,30.63,44.1,,1487.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.99,95,,6961.272,Percent of Total Billed Charges,95% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,88,,2968.032,Percent of Total Billed Charges,88% of Total Billed Charges,62.51,90,,6594.888,Percent of Total Billed charges,90% of Total Billed Charges,30.63,69.46,
COOK TUOHY ADAPTER,2780001330,CDM,278,RC,C1769,HCPCS,Outpatient,,,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,661.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,2549.688,Percent of Total Billed Charges,72% of Total Billed Charges,15.08,72,,2549.688,Percent of Total Billed charges,72% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,2549.688,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,2124.736,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,2181.36,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,2886.656,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,783.48,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,348.568,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,2828.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,827.008,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,17455.84,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,783.48,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
COOK HIWIE STRAIGHT,2780001331,CDM,278,RC,C1769,HCPCS,Outpatient,,,77.18,50.17,,77.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.66,76,,886.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.57,72,,9704.048,Percent of Total Billed Charges,72% of Total Billed Charges,55.57,72,,9704.048,Percent of Total Billed charges,72% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.57,72,,9704.048,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,60,,8086.704,Percent of Total Billed Charges,60% of Total Billed Charges,69.46,90,,5278.776,Percent of Total Billed Charges,90% of Total Billed Charges,34.73,45,,1517.744,Percent of Total Billed Charges,45% of Total Billed Charges,69.46,90,,1050.2,Percent of Total Billed Charges,90% of Total billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.17,65,,1309.416,Percent of total Billed Charges,65% of Total Billed Charges,34.04,44.1,,1487.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.32,95,,1108.544,Percent of Total Billed Charges,95% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.92,88,,5536.344,Percent of Total Billed Charges,88% of Total Billed Charges,69.46,90,,1050.2,Percent of Total Billed charges,90% of Total Billed Charges,34.04,77.18,
COOK CATHETER PUNCH,2780001332,CDM,278,RC,C1769,HCPCS,Outpatient,,,97.02,63.06,,97.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.74,76,,2563.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.85,72,,20851.536,Percent of Total Billed Charges,72% of Total Billed Charges,69.85,72,,20851.536,Percent of Total Billed charges,72% of Total Billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.85,72,,20851.536,Percent of Total Billed Charges,72% of Total Billed Charges,58.21,60,,17376.28,Percent of Total Billed Charges,60% of Total Billed Charges,87.32,90,,307.992,Percent of Total Billed Charges,90% of Total Billed Charges,43.66,45,,8926.28,Percent of Total Billed Charges,45% of Total Billed Charges,87.32,90,,3035.488,Percent of Total Billed Charges,90% of Total billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,65,,748.736,Percent of total Billed Charges,65% of Total Billed Charges,42.79,44.1,,8747.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,92.17,95,,3204.128,Percent of Total Billed Charges,95% of Total Billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.38,88,,2968.032,Percent of Total Billed Charges,88% of Total Billed Charges,87.32,90,,3035.488,Percent of Total Billed charges,90% of Total Billed Charges,42.79,97.02,
WHOLLEY WIRE 0.035 X 260CM,2780001333,CDM,272,RC,C1769,HCPCS,Outpatient,,,486.20,316.03,,486.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,369.51,76,,4875.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,350.06,72,,4244.608,Percent of Total Billed Charges,72% of Total Billed Charges,364.65,75,,4244.608,Percent of Total Billed charges,75% of Total Billed Charges,486.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.06,72,,4244.608,Percent of Total Billed Charges,72% of Total Billed Charges,291.72,60,,3537.176,Percent of Total Billed Charges,60% of Total Billed Charges,437.58,90,,2979.928,Percent of Total Billed Charges,90% of Total Billed Charges,218.79,45,,2831.088,Percent of Total Billed Charges,45% of Total Billed Charges,437.58,90,,5773.304,Percent of Total Billed Charges,90% of Total billed Charges,486.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,486.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,486.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.03,65,,2394.104,Percent of total Billed Charges,65% of Total Billed Charges,214.41,44.1,,2774.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,461.89,95,,6094.048,Percent of Total Billed Charges,95% of Total Billed Charges,486.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.86,88,,4172.64,Percent of Total Billed Charges,88% of Total Billed Charges,437.58,90,,5773.304,Percent of Total Billed charges,90% of Total Billed Charges,214.41,486.2,
RIM 5F 65CM COOK CATHETER,2780001334,CDM,272,RC,C1769,HCPCS,Outpatient,,,58.80,38.22,,58.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,44.69,76,,2563.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.34,72,,129.552,Percent of Total Billed Charges,72% of Total Billed Charges,44.1,75,,129.552,Percent of Total Billed charges,75% of Total Billed Charges,58.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.34,72,,129.552,Percent of Total Billed Charges,72% of Total Billed Charges,35.28,60,,107.96,Percent of Total Billed Charges,60% of Total Billed Charges,52.92,90,,1426.456,Percent of Total Billed Charges,90% of Total Billed Charges,26.46,45,,1517.744,Percent of Total Billed Charges,45% of Total Billed Charges,52.92,90,,3035.488,Percent of Total Billed Charges,90% of Total billed Charges,58.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.22,65,,2911.792,Percent of total Billed Charges,65% of Total Billed Charges,25.93,44.1,,1487.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,55.86,95,,3204.128,Percent of Total Billed Charges,95% of Total Billed Charges,58.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.74,88,,2874.12,Percent of Total Billed Charges,88% of Total Billed Charges,52.92,90,,3035.488,Percent of Total Billed charges,90% of Total Billed Charges,25.93,58.8,
RIM 5F 80CM COOK CATHETER,2780001335,CDM,278,RC,C1769,HCPCS,Outpatient,,,58.80,38.22,,58.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,44.69,76,,15075.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.34,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,42.34,72,,45.088,Percent of Total Billed charges,72% of Total Billed Charges,58.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.34,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,35.28,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,52.92,90,,606.464,Percent of Total Billed Charges,90% of Total Billed Charges,26.46,45,,2133.736,Percent of Total Billed Charges,45% of Total Billed Charges,52.92,90,,17852.568,Percent of Total Billed Charges,90% of Total billed Charges,58.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.22,65,,4148.4,Percent of total Billed Charges,65% of Total Billed Charges,25.93,44.1,,2091.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,55.86,95,,18844.376,Percent of Total Billed Charges,95% of Total Billed Charges,58.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.74,88,,2132.888,Percent of Total Billed Charges,88% of Total Billed Charges,52.92,90,,17852.568,Percent of Total Billed charges,90% of Total Billed Charges,25.93,58.8,
TURBOJECT 3F PICC WIREGUIDE,2780001336,CDM,278,RC,C1769,HCPCS,Outpatient,,,146.00,94.90,,146,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.96,76,,4781.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,105.12,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,105.12,72,,45.088,Percent of Total Billed charges,72% of Total Billed Charges,146,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.12,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,87.6,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,131.4,90,,118.272,Percent of Total Billed Charges,90% of Total Billed Charges,65.7,45,,1469.72,Percent of Total Billed Charges,45% of Total Billed Charges,131.4,90,,5662.176,Percent of Total Billed Charges,90% of Total billed Charges,146,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.9,65,,13078.688,Percent of total Billed Charges,65% of Total Billed Charges,64.39,44.1,,1440.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,138.7,95,,5976.736,Percent of Total Billed Charges,95% of Total Billed Charges,146,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.48,88,,5161.464,Percent of Total Billed Charges,88% of Total Billed Charges,131.4,90,,5662.176,Percent of Total Billed charges,90% of Total Billed Charges,64.39,146,
TURBOJECT 4F PICC GUIDEWIRE,2780001337,CDM,278,RC,C1769,HCPCS,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,2563.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,45.088,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,121.448,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,1090.68,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,3035.488,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,2558.064,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,1068.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,3204.128,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,301.152,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,3035.488,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
GYNECARE TVT DEVICE,2780001338,CDM,278,RC,C1771,HCPCS,Outpatient,,,6063.75,3941.44,,6063.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4608.45,76,,3603.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4365.9,72,,1282.784,Percent of Total Billed Charges,72% of Total Billed Charges,4365.9,72,,1282.784,Percent of Total Billed charges,72% of Total Billed Charges,6063.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4365.9,72,,1282.784,Percent of Total Billed Charges,72% of Total Billed Charges,3638.25,60,,1068.984,Percent of Total Billed Charges,60% of Total Billed Charges,5457.38,90,,15281.448,Percent of Total Billed Charges,90% of Total Billed Charges,2728.69,45,,2639.384,Percent of Total Billed Charges,45% of Total Billed Charges,5457.38,90,,4267.472,Percent of Total Billed Charges,90% of Total billed Charges,6063.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6063.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6063.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3941.44,65,,2557.488,Percent of total Billed Charges,65% of Total Billed Charges,2674.11,44.1,,2586.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,5760.56,95,,4504.552,Percent of Total Billed Charges,95% of Total Billed Charges,6063.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5336.1,88,,2913.712,Percent of Total Billed Charges,88% of Total Billed Charges,5457.38,90,,4267.472,Percent of Total Billed charges,90% of Total Billed Charges,2674.11,6063.75,
T SLING COLOPLAST,2780001339,CDM,278,RC,C1771,HCPCS,Outpatient,,,3519.18,2287.47,,3519.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2674.58,76,,2482.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2533.81,72,,3540.984,Percent of Total Billed Charges,72% of Total Billed Charges,2533.81,72,,3540.984,Percent of Total Billed charges,72% of Total Billed Charges,3519.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2533.81,72,,3540.984,Percent of Total Billed Charges,72% of Total Billed Charges,2111.51,60,,2950.816,Percent of Total Billed Charges,60% of Total Billed Charges,3167.26,90,,6975.12,Percent of Total Billed Charges,90% of Total Billed Charges,1583.63,45,,154,Percent of Total Billed Charges,45% of Total Billed Charges,3167.26,90,,2939.44,Percent of Total Billed Charges,90% of Total billed Charges,3519.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3519.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3519.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2287.47,65,,5989.264,Percent of total Billed Charges,65% of Total Billed Charges,1551.96,44.1,,150.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,3343.22,95,,3102.744,Percent of Total Billed Charges,95% of Total Billed Charges,3519.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3096.88,88,,1394.76,Percent of Total Billed Charges,88% of Total Billed Charges,3167.26,90,,2939.44,Percent of Total Billed charges,90% of Total Billed Charges,1551.96,3519.18,
OBTRYXII TOT HALO TROCAR,2780001341,CDM,278,RC,C1771,HCPCS,Outpatient,,,3027.00,1967.55,,3027,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2300.52,76,,1842.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2179.44,72,,1281.512,Percent of Total Billed Charges,72% of Total Billed Charges,2179.44,72,,1281.512,Percent of Total Billed charges,72% of Total Billed Charges,3027,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2179.44,72,,1281.512,Percent of Total Billed Charges,72% of Total Billed Charges,1816.2,60,,1067.928,Percent of Total Billed Charges,60% of Total Billed Charges,2724.3,90,,15491.8,Percent of Total Billed Charges,90% of Total Billed Charges,1362.15,45,,1489.968,Percent of Total Billed Charges,45% of Total Billed Charges,2724.3,90,,2181.36,Percent of Total Billed Charges,90% of Total billed Charges,3027,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3027,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3027,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.55,65,,76.248,Percent of total Billed Charges,65% of Total Billed Charges,1334.91,44.1,,1460.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,2875.65,95,,2302.552,Percent of Total Billed Charges,95% of Total Billed Charges,3027,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2663.76,88,,592.984,Percent of Total Billed Charges,88% of Total Billed Charges,2724.3,90,,2181.36,Percent of Total Billed charges,90% of Total Billed Charges,1334.91,3027,
Z434211513 HUM,2780001342,CDM,278,RC,C1773,HCPCS,Outpatient,,,5322.87,3459.87,,5322.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4045.38,76,,4457.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3832.47,72,,482.632,Percent of Total Billed Charges,72% of Total Billed Charges,3832.47,72,,482.632,Percent of Total Billed charges,72% of Total Billed Charges,5322.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3832.47,72,,482.632,Percent of Total Billed Charges,72% of Total Billed Charges,3193.72,60,,402.192,Percent of Total Billed Charges,60% of Total Billed Charges,4790.58,90,,5003.32,Percent of Total Billed Charges,90% of Total Billed Charges,2395.29,45,,713.232,Percent of Total Billed Charges,45% of Total Billed Charges,4790.58,90,,5278.776,Percent of Total Billed Charges,90% of Total billed Charges,5322.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5322.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5322.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3459.87,65,,215.56,Percent of total Billed Charges,65% of Total Billed Charges,2347.39,44.1,,698.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,5056.73,95,,5572.04,Percent of Total Billed Charges,95% of Total Billed Charges,5322.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4684.13,88,,115.648,Percent of Total Billed Charges,88% of Total Billed Charges,4790.58,90,,5278.776,Percent of Total Billed charges,90% of Total Billed Charges,2347.39,5322.87,
Z23483835 PERI SCW,2780001343,CDM,278,RC,C1773,HCPCS,Outpatient,,,125.69,81.70,,125.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95.52,76,,260.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90.5,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,90.5,72,,45.088,Percent of Total Billed charges,72% of Total Billed Charges,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.5,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,75.41,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,113.12,90,,3483.984,Percent of Total Billed Charges,90% of Total Billed Charges,56.56,45,,303.232,Percent of Total Billed Charges,45% of Total Billed Charges,113.12,90,,307.992,Percent of Total Billed Charges,90% of Total billed Charges,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.7,65,,4075.592,Percent of total Billed Charges,65% of Total Billed Charges,55.43,44.1,,297.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,119.41,95,,325.104,Percent of Total Billed Charges,95% of Total Billed Charges,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.61,88,,118.752,Percent of Total Billed Charges,88% of Total Billed Charges,113.12,90,,307.992,Percent of Total Billed charges,90% of Total Billed Charges,55.43,125.69,
Z23598036 CAM LCK/,2780001344,CDM,278,RC,C1773,HCPCS,Outpatient,,,369.34,240.07,,369.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,280.7,76,,2516.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,265.92,72,,176.544,Percent of Total Billed Charges,72% of Total Billed Charges,265.92,72,,176.544,Percent of Total Billed charges,72% of Total Billed Charges,369.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.92,72,,176.544,Percent of Total Billed Charges,72% of Total Billed Charges,221.6,60,,147.12,Percent of Total Billed Charges,60% of Total Billed Charges,332.41,90,,608.848,Percent of Total Billed Charges,90% of Total Billed Charges,166.2,45,,59.136,Percent of Total Billed Charges,45% of Total Billed Charges,332.41,90,,2979.928,Percent of Total Billed Charges,90% of Total billed Charges,369.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.07,65,,406.472,Percent of total Billed Charges,65% of Total Billed Charges,162.88,44.1,,57.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,350.87,95,,3145.48,Percent of Total Billed Charges,95% of Total Billed Charges,369.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.02,88,,14941.856,Percent of Total Billed Charges,88% of Total Billed Charges,332.41,90,,2979.928,Percent of Total Billed charges,90% of Total Billed Charges,162.88,369.34,
Z23596035 PERI/LCK,2780001345,CDM,278,RC,C1773,HCPCS,Outpatient,,,369.34,240.07,,369.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,280.7,76,,1204.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,265.92,72,,123.832,Percent of Total Billed Charges,72% of Total Billed Charges,265.92,72,,123.832,Percent of Total Billed charges,72% of Total Billed Charges,369.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.92,72,,123.832,Percent of Total Billed Charges,72% of Total Billed Charges,221.6,60,,103.192,Percent of Total Billed Charges,60% of Total Billed Charges,332.41,90,,608.848,Percent of Total Billed Charges,90% of Total Billed Charges,166.2,45,,60.728,Percent of Total Billed Charges,45% of Total Billed Charges,332.41,90,,1426.456,Percent of Total Billed Charges,90% of Total billed Charges,369.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.07,65,,406.472,Percent of total Billed Charges,65% of Total Billed Charges,162.88,44.1,,59.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,350.87,95,,1505.704,Percent of Total Billed Charges,95% of Total Billed Charges,369.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.02,88,,6820.12,Percent of Total Billed Charges,88% of Total Billed Charges,332.41,90,,1426.456,Percent of Total Billed charges,90% of Total Billed Charges,162.88,369.34,
Z23597035 PERI/LCK,2780001346,CDM,278,RC,C1773,HCPCS,Outpatient,,,421.16,273.75,,421.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,320.08,76,,512.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,303.24,72,,3450.808,Percent of Total Billed Charges,72% of Total Billed Charges,303.24,72,,3450.808,Percent of Total Billed charges,72% of Total Billed Charges,421.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.24,72,,3450.808,Percent of Total Billed Charges,72% of Total Billed Charges,252.7,60,,2875.672,Percent of Total Billed Charges,60% of Total Billed Charges,379.04,90,,307.992,Percent of Total Billed Charges,90% of Total Billed Charges,189.52,45,,7640.72,Percent of Total Billed Charges,45% of Total Billed Charges,379.04,90,,606.464,Percent of Total Billed Charges,90% of Total billed Charges,421.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,421.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,421.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.75,65,,471.824,Percent of total Billed Charges,65% of Total Billed Charges,185.73,44.1,,7487.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,400.1,95,,640.152,Percent of Total Billed Charges,95% of Total Billed Charges,421.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.62,88,,15147.536,Percent of Total Billed Charges,88% of Total Billed Charges,379.04,90,,606.464,Percent of Total Billed charges,90% of Total Billed Charges,185.73,421.16,
Z23597037 CANN/CON,2780001347,CDM,278,RC,C1773,HCPCS,Outpatient,,,324.14,210.69,,324.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,246.35,76,,99.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,233.38,72,,2708.448,Percent of Total Billed Charges,72% of Total Billed Charges,233.38,72,,2708.448,Percent of Total Billed charges,72% of Total Billed Charges,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.38,72,,2708.448,Percent of Total Billed Charges,72% of Total Billed Charges,194.48,60,,2257.04,Percent of Total Billed Charges,60% of Total Billed Charges,291.73,90,,608.848,Percent of Total Billed Charges,90% of Total Billed Charges,145.86,45,,3487.56,Percent of Total Billed Charges,45% of Total Billed Charges,291.73,90,,118.272,Percent of Total Billed Charges,90% of Total billed Charges,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.69,65,,471.824,Percent of total Billed Charges,65% of Total Billed Charges,142.95,44.1,,3417.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,307.93,95,,124.848,Percent of Total Billed Charges,95% of Total Billed Charges,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.24,88,,4892.136,Percent of Total Billed Charges,88% of Total Billed Charges,291.73,90,,118.272,Percent of Total Billed charges,90% of Total Billed Charges,142.95,324.14,
Z23596037 CANN/CON,2780001348,CDM,278,RC,C1773,HCPCS,Outpatient,,,324.14,210.69,,324.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,246.35,76,,102.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,233.38,72,,2980.24,Percent of Total Billed Charges,72% of Total Billed Charges,233.38,72,,2980.24,Percent of Total Billed charges,72% of Total Billed Charges,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.38,72,,2980.24,Percent of Total Billed Charges,72% of Total Billed Charges,194.48,60,,2483.536,Percent of Total Billed Charges,60% of Total Billed Charges,291.73,90,,482.632,Percent of Total Billed Charges,90% of Total Billed Charges,145.86,45,,7745.904,Percent of Total Billed Charges,45% of Total Billed Charges,291.73,90,,121.448,Percent of Total Billed Charges,90% of Total billed Charges,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.69,65,,471.824,Percent of total Billed Charges,65% of Total Billed Charges,142.95,44.1,,7590.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,307.93,95,,128.2,Percent of Total Billed Charges,95% of Total Billed Charges,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.24,88,,3406.568,Percent of Total Billed Charges,88% of Total Billed Charges,291.73,90,,121.448,Percent of Total Billed charges,90% of Total Billed Charges,142.95,324.14,
Z23594537 CANN/CON,2780001349,CDM,278,RC,C1773,HCPCS,Outpatient,,,324.14,210.69,,324.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,246.35,76,,12904.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,233.38,72,,214.648,Percent of Total Billed Charges,72% of Total Billed Charges,233.38,72,,214.648,Percent of Total Billed charges,72% of Total Billed Charges,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.38,72,,214.648,Percent of Total Billed Charges,72% of Total Billed Charges,194.48,60,,178.872,Percent of Total Billed Charges,60% of Total Billed Charges,291.73,90,,1813.04,Percent of Total Billed Charges,90% of Total Billed Charges,145.86,45,,2501.664,Percent of Total Billed Charges,45% of Total Billed Charges,291.73,90,,15281.448,Percent of Total Billed Charges,90% of Total billed Charges,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.69,65,,471.824,Percent of total Billed Charges,65% of Total Billed Charges,142.95,44.1,,2451.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,307.93,95,,16130.416,Percent of Total Billed Charges,95% of Total Billed Charges,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.24,88,,595.32,Percent of Total Billed Charges,88% of Total Billed Charges,291.73,90,,15281.448,Percent of Total Billed charges,90% of Total Billed Charges,142.95,324.14,
Z23570406 TIBIAL L,2780001350,CDM,278,RC,C1773,HCPCS,Outpatient,,,4698.86,3054.26,,4698.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3571.13,76,,5890.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3383.18,72,,187.336,Percent of Total Billed Charges,72% of Total Billed Charges,3383.18,72,,187.336,Percent of Total Billed charges,72% of Total Billed Charges,4698.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3383.18,72,,187.336,Percent of Total Billed Charges,72% of Total Billed Charges,2819.32,60,,156.112,Percent of Total Billed Charges,60% of Total Billed Charges,4228.97,90,,1036.704,Percent of Total Billed Charges,90% of Total Billed Charges,2114.49,45,,1741.992,Percent of Total Billed Charges,45% of Total Billed Charges,4228.97,90,,6975.12,Percent of Total Billed Charges,90% of Total billed Charges,4698.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4698.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4698.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3054.26,65,,215.56,Percent of total Billed Charges,65% of Total Billed Charges,2072.2,44.1,,1707.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,4463.92,95,,7362.632,Percent of Total Billed Charges,95% of Total Billed Charges,4698.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4135,88,,595.32,Percent of Total Billed Charges,88% of Total Billed Charges,4228.97,90,,6975.12,Percent of Total Billed charges,90% of Total Billed Charges,2072.2,4698.86,
Z PATIENT SPECIAL LU,2780001351,CDM,278,RC,C1773,HCPCS,Outpatient,,,3865.37,2512.49,,3865.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2937.68,76,,13081.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2783.07,72,,187.336,Percent of Total Billed Charges,72% of Total Billed Charges,2783.07,72,,187.336,Percent of Total Billed charges,72% of Total Billed Charges,3865.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2783.07,72,,187.336,Percent of Total Billed Charges,72% of Total Billed Charges,2319.22,60,,156.112,Percent of Total Billed Charges,60% of Total Billed Charges,3478.83,90,,3314.912,Percent of Total Billed Charges,90% of Total Billed Charges,1739.42,45,,304.424,Percent of Total Billed Charges,45% of Total Billed Charges,3478.83,90,,15491.8,Percent of Total Billed Charges,90% of Total billed Charges,3865.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3865.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3865.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2512.49,65,,1011.304,Percent of total Billed Charges,65% of Total Billed Charges,1704.63,44.1,,298.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,3672.1,95,,16352.456,Percent of Total Billed Charges,95% of Total Billed Charges,3865.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3401.53,88,,301.152,Percent of Total Billed Charges,88% of Total Billed Charges,3478.83,90,,15491.8,Percent of Total Billed charges,90% of Total Billed Charges,1704.63,3865.37,
Z58805014 REV ACET,2780001352,CDM,278,RC,C1773,HCPCS,Outpatient,,,7369.11,4789.92,,7369.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5600.52,76,,4225.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5305.76,72,,3540.984,Percent of Total Billed Charges,72% of Total Billed Charges,5305.76,72,,3540.984,Percent of Total Billed charges,72% of Total Billed Charges,7369.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5305.76,72,,3540.984,Percent of Total Billed Charges,72% of Total Billed Charges,4421.47,60,,2950.816,Percent of Total Billed Charges,60% of Total Billed Charges,6632.2,90,,4031.712,Percent of Total Billed Charges,90% of Total Billed Charges,3316.1,45,,304.424,Percent of Total Billed Charges,45% of Total Billed Charges,6632.2,90,,5003.32,Percent of Total Billed Charges,90% of Total billed Charges,7369.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7369.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7369.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4789.92,65,,36.12,Percent of total Billed Charges,65% of Total Billed Charges,3249.78,44.1,,298.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,7000.65,95,,5281.288,Percent of Total Billed Charges,95% of Total Billed Charges,7369.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6484.82,88,,595.32,Percent of Total Billed Charges,88% of Total Billed Charges,6632.2,90,,5003.32,Percent of Total Billed charges,90% of Total Billed Charges,3249.78,7369.11,
Z225334009 TIBIAL,2780001353,CDM,278,RC,C1773,HCPCS,Outpatient,,,3405.62,2213.65,,3405.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2588.27,76,,2942.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2452.05,72,,40.008,Percent of Total Billed Charges,72% of Total Billed Charges,2452.05,72,,40.008,Percent of Total Billed charges,72% of Total Billed Charges,3405.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2452.05,72,,40.008,Percent of Total Billed Charges,72% of Total Billed Charges,2043.37,60,,33.344,Percent of Total Billed Charges,60% of Total Billed Charges,3065.06,90,,5743.936,Percent of Total Billed Charges,90% of Total Billed Charges,1532.53,45,,154,Percent of Total Billed Charges,45% of Total Billed Charges,3065.06,90,,3483.984,Percent of Total Billed Charges,90% of Total billed Charges,3405.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3405.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3405.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2213.65,65,,586.488,Percent of total Billed Charges,65% of Total Billed Charges,1501.88,44.1,,150.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,3235.34,95,,3677.544,Percent of Total Billed Charges,95% of Total Billed Charges,3405.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2996.95,88,,471.904,Percent of Total Billed Charges,88% of Total Billed Charges,3065.06,90,,3483.984,Percent of Total Billed charges,90% of Total Billed Charges,1501.88,3405.62,
Z22536042 CORTICAL,2780001354,CDM,278,RC,C1773,HCPCS,Outpatient,,,575.51,374.08,,575.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,437.39,76,,514.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,414.37,72,,2548.416,Percent of Total Billed Charges,72% of Total Billed Charges,414.37,72,,2548.416,Percent of Total Billed charges,72% of Total Billed Charges,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.37,72,,2548.416,Percent of Total Billed Charges,72% of Total Billed Charges,345.31,60,,2123.68,Percent of Total Billed Charges,60% of Total Billed Charges,517.96,90,,18108.96,Percent of Total Billed Charges,90% of Total Billed Charges,258.98,45,,304.424,Percent of Total Billed Charges,45% of Total Billed Charges,517.96,90,,608.848,Percent of Total Billed Charges,90% of Total billed Charges,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.08,65,,809.496,Percent of total Billed Charges,65% of Total Billed Charges,253.8,44.1,,298.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,546.73,95,,642.672,Percent of Total Billed Charges,95% of Total Billed Charges,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.45,88,,1772.752,Percent of Total Billed Charges,88% of Total Billed Charges,517.96,90,,608.848,Percent of Total Billed charges,90% of Total Billed Charges,253.8,575.51,
Z781851 FEMORAL HEA,2780001355,CDM,278,RC,C1773,HCPCS,Outpatient,,,2166.41,1408.17,,2166.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1646.47,76,,514.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1559.82,72,,441.352,Percent of Total Billed Charges,72% of Total Billed Charges,1559.82,72,,441.352,Percent of Total Billed charges,72% of Total Billed Charges,2166.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1559.82,72,,441.352,Percent of Total Billed Charges,72% of Total Billed Charges,1299.85,60,,367.792,Percent of Total Billed Charges,60% of Total Billed Charges,1949.77,90,,3541.936,Percent of Total Billed Charges,90% of Total Billed Charges,974.88,45,,241.312,Percent of Total Billed Charges,45% of Total Billed Charges,1949.77,90,,608.848,Percent of Total Billed Charges,90% of Total billed Charges,2166.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2166.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2166.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1408.17,65,,178.296,Percent of total Billed Charges,65% of Total Billed Charges,955.39,44.1,,236.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,2058.09,95,,642.672,Percent of Total Billed Charges,95% of Total Billed Charges,2166.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1906.44,88,,1013.672,Percent of Total Billed Charges,88% of Total Billed Charges,1949.77,90,,608.848,Percent of Total Billed charges,90% of Total Billed Charges,955.39,2166.41,
Z11475541 CANN SCW,2780001356,CDM,278,RC,C1773,HCPCS,Outpatient,,,682.45,443.59,,682.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,518.66,76,,260.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,491.36,72,,80.016,Percent of Total Billed Charges,72% of Total Billed Charges,491.36,72,,80.016,Percent of Total Billed charges,72% of Total Billed Charges,682.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.36,72,,80.016,Percent of Total Billed Charges,72% of Total Billed Charges,409.47,60,,66.68,Percent of Total Billed Charges,60% of Total Billed Charges,614.21,90,,3541.144,Percent of Total Billed Charges,90% of Total Billed Charges,307.1,45,,906.52,Percent of Total Billed Charges,45% of Total Billed Charges,614.21,90,,307.992,Percent of Total Billed Charges,90% of Total billed Charges,682.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,682.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,682.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,443.59,65,,178.296,Percent of total Billed Charges,65% of Total Billed Charges,300.96,44.1,,888.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,648.33,95,,325.104,Percent of Total Billed Charges,95% of Total Billed Charges,682.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,600.56,88,,3241.248,Percent of Total Billed Charges,88% of Total Billed Charges,614.21,90,,307.992,Percent of Total Billed charges,90% of Total Billed Charges,300.96,682.45,
Z114786 GUIDE PIN 1,2780001357,CDM,278,RC,C1773,HCPCS,Outpatient,,,58.43,37.98,,58.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,44.41,76,,514.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.07,72,,2782.752,Percent of Total Billed Charges,72% of Total Billed Charges,42.07,72,,2782.752,Percent of Total Billed charges,72% of Total Billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.07,72,,2782.752,Percent of Total Billed Charges,72% of Total Billed Charges,35.06,60,,2318.96,Percent of Total Billed Charges,60% of Total Billed Charges,52.59,90,,8292.832,Percent of Total Billed Charges,90% of Total Billed Charges,26.29,45,,518.352,Percent of Total Billed Charges,45% of Total Billed Charges,52.59,90,,608.848,Percent of Total Billed Charges,90% of Total billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.98,65,,252.256,Percent of total Billed Charges,65% of Total Billed Charges,25.77,44.1,,507.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,55.51,95,,642.672,Percent of Total Billed Charges,95% of Total Billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.42,88,,3942.12,Percent of Total Billed Charges,88% of Total Billed Charges,52.59,90,,608.848,Percent of Total Billed charges,90% of Total Billed Charges,25.77,58.43,
Z47249321110 FEMN,2780001358,CDM,278,RC,C1773,HCPCS,Outpatient,,,6147.54,3995.90,,6147.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4672.13,76,,407.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4426.23,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,4426.23,72,,352.448,Percent of Total Billed charges,72% of Total Billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4426.23,72,,352.448,Percent of Total Billed Charges,72% of Total Billed Charges,3688.52,60,,293.704,Percent of Total Billed Charges,60% of Total Billed Charges,5532.79,90,,105.576,Percent of Total Billed Charges,90% of Total Billed Charges,2766.39,45,,1657.456,Percent of Total Billed Charges,45% of Total Billed Charges,5532.79,90,,482.632,Percent of Total Billed Charges,90% of Total billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3995.9,65,,768.224,Percent of total Billed Charges,65% of Total Billed Charges,2711.07,44.1,,1624.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,5840.16,95,,509.44,Percent of Total Billed Charges,95% of Total Billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5409.84,88,,5616.296,Percent of Total Billed Charges,88% of Total Billed Charges,5532.79,90,,482.632,Percent of Total Billed charges,90% of Total Billed Charges,2711.07,6147.54,
Z22320118 CABLE GR,2780001359,CDM,278,RC,C1773,HCPCS,Outpatient,,,1331.82,865.68,,1331.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1012.18,76,,1531.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,958.91,72,,2755.44,Percent of Total Billed Charges,72% of Total Billed Charges,958.91,72,,2755.44,Percent of Total Billed charges,72% of Total Billed Charges,1331.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,958.91,72,,2755.44,Percent of Total Billed Charges,72% of Total Billed Charges,799.09,60,,2296.2,Percent of Total Billed Charges,60% of Total Billed Charges,1198.64,90,,298.472,Percent of Total Billed Charges,90% of Total Billed Charges,599.32,45,,2015.856,Percent of Total Billed Charges,45% of Total Billed Charges,1198.64,90,,1813.04,Percent of Total Billed Charges,90% of Total billed Charges,1331.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1331.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1331.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,865.68,65,,877.72,Percent of total Billed Charges,65% of Total Billed Charges,587.33,44.1,,1975.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,1265.23,95,,1913.76,Percent of Total Billed Charges,95% of Total Billed Charges,1331.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1172,88,,17706.536,Percent of Total Billed Charges,88% of Total Billed Charges,1198.64,90,,1813.04,Percent of Total Billed charges,90% of Total Billed Charges,587.33,1331.82,
Z62025220 SHELL 52,2780001360,CDM,278,RC,C1773,HCPCS,Outpatient,,,12052.53,7834.14,,12052.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9159.92,76,,875.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8677.82,72,,7183.576,Percent of Total Billed Charges,72% of Total Billed Charges,8677.82,72,,7183.576,Percent of Total Billed charges,72% of Total Billed Charges,12052.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8677.82,72,,7183.576,Percent of Total Billed Charges,72% of Total Billed Charges,7231.52,60,,5986.312,Percent of Total Billed Charges,60% of Total Billed Charges,10847.28,90,,5643.12,Percent of Total Billed Charges,90% of Total Billed Charges,5423.64,45,,2871.968,Percent of Total Billed Charges,45% of Total Billed Charges,10847.28,90,,1036.704,Percent of Total Billed Charges,90% of Total billed Charges,12052.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12052.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12052.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7834.14,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,5315.17,44.1,,2814.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,11449.9,95,,1094.304,Percent of Total Billed Charges,95% of Total Billed Charges,12052.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10606.23,88,,3463.232,Percent of Total Billed Charges,88% of Total Billed Charges,10847.28,90,,1036.704,Percent of Total Billed charges,90% of Total Billed Charges,5315.17,12052.53,
Z00771301100 FEM,2780001361,CDM,278,RC,C1773,HCPCS,Outpatient,,,21572.62,14022.20,,21572.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16395.19,76,,2799.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15532.29,72,,5049.208,Percent of Total Billed Charges,72% of Total Billed Charges,15532.29,72,,5049.208,Percent of Total Billed charges,72% of Total Billed Charges,21572.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15532.29,72,,5049.208,Percent of Total Billed Charges,72% of Total Billed Charges,12943.57,60,,4207.672,Percent of Total Billed Charges,60% of Total Billed Charges,19415.36,90,,562.8,Percent of Total Billed Charges,90% of Total Billed Charges,9707.68,45,,9054.48,Percent of Total Billed Charges,45% of Total Billed Charges,19415.36,90,,3314.912,Percent of Total Billed Charges,90% of Total billed Charges,21572.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21572.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21572.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14022.2,65,,1590.912,Percent of total Billed Charges,65% of Total Billed Charges,9513.53,44.1,,8873.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,20493.99,95,,3499.072,Percent of Total Billed Charges,95% of Total Billed Charges,21572.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18983.91,88,,3462.448,Percent of Total Billed Charges,88% of Total Billed Charges,19415.36,90,,3314.912,Percent of Total Billed charges,90% of Total Billed Charges,9513.53,21572.62,
Z00754802200 MOD,2780001362,CDM,278,RC,C1773,HCPCS,Outpatient,,,5950.19,3867.62,,5950.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4522.14,76,,3404.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4284.14,72,,5522.944,Percent of Total Billed Charges,72% of Total Billed Charges,4284.14,72,,5522.944,Percent of Total Billed charges,72% of Total Billed Charges,5950.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4284.14,72,,5522.944,Percent of Total Billed Charges,72% of Total Billed Charges,3570.11,60,,4602.448,Percent of Total Billed Charges,60% of Total Billed Charges,5355.17,90,,562.8,Percent of Total Billed Charges,90% of Total Billed Charges,2677.59,45,,1770.968,Percent of Total Billed Charges,45% of Total Billed Charges,5355.17,90,,4031.712,Percent of Total Billed Charges,90% of Total billed Charges,5950.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5950.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5950.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3867.62,65,,240.784,Percent of total Billed Charges,65% of Total Billed Charges,2624.03,44.1,,1735.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,5652.68,95,,4255.696,Percent of Total Billed Charges,95% of Total Billed Charges,5950.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5236.17,88,,8108.544,Percent of Total Billed Charges,88% of Total Billed Charges,5355.17,90,,4031.712,Percent of Total Billed charges,90% of Total Billed Charges,2624.03,5950.19,
Z114708575 16MM TH,2780001363,CDM,278,RC,C1773,HCPCS,Outpatient,,,875.39,569.00,,875.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,665.3,76,,4850.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,630.28,72,,2514.76,Percent of Total Billed Charges,72% of Total Billed Charges,630.28,72,,2514.76,Percent of Total Billed charges,72% of Total Billed Charges,875.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,630.28,72,,2514.76,Percent of Total Billed Charges,72% of Total Billed Charges,525.23,60,,2095.632,Percent of Total Billed Charges,60% of Total Billed Charges,787.85,90,,653.296,Percent of Total Billed Charges,90% of Total Billed Charges,393.93,45,,1770.568,Percent of Total Billed Charges,45% of Total Billed Charges,787.85,90,,5743.936,Percent of Total Billed Charges,90% of Total billed Charges,875.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,875.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,875.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569,65,,5032.432,Percent of total Billed Charges,65% of Total Billed Charges,386.05,44.1,,1735.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,831.62,95,,6063.048,Percent of Total Billed Charges,95% of Total Billed Charges,875.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770.34,88,,103.224,Percent of Total Billed Charges,88% of Total Billed Charges,787.85,90,,5743.936,Percent of Total Billed charges,90% of Total Billed Charges,386.05,875.39,
Z48068515 1.5 DRIL,2780001364,CDM,278,RC,C1773,HCPCS,Outpatient,,,255.78,166.26,,255.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,194.39,76,,15292.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,184.16,72,,2514.76,Percent of Total Billed Charges,72% of Total Billed Charges,184.16,72,,2514.76,Percent of Total Billed charges,72% of Total Billed Charges,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.16,72,,2514.76,Percent of Total Billed Charges,72% of Total Billed Charges,153.47,60,,2095.632,Percent of Total Billed Charges,60% of Total Billed Charges,230.2,90,,653.296,Percent of Total Billed Charges,90% of Total Billed Charges,115.1,45,,4146.416,Percent of Total Billed Charges,45% of Total Billed Charges,230.2,90,,18108.96,Percent of Total Billed Charges,90% of Total billed Charges,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.26,65,,123.264,Percent of total Billed Charges,65% of Total Billed Charges,112.8,44.1,,4063.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,242.99,95,,19115.008,Percent of Total Billed Charges,95% of Total Billed Charges,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.09,88,,291.84,Percent of Total Billed Charges,88% of Total Billed Charges,230.2,90,,18108.96,Percent of Total Billed charges,90% of Total Billed Charges,112.8,255.78,
Z49200502 ST PLT 2,2780001365,CDM,278,RC,C1773,HCPCS,Outpatient,,,237.04,154.08,,237.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,180.15,76,,2990.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,170.67,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,170.67,72,,332.128,Percent of Total Billed charges,72% of Total Billed Charges,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.67,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,142.22,60,,276.776,Percent of Total Billed Charges,60% of Total Billed Charges,213.34,90,,653.296,Percent of Total Billed Charges,90% of Total Billed Charges,106.67,45,,52.784,Percent of Total Billed Charges,45% of Total Billed Charges,213.34,90,,3541.936,Percent of Total Billed Charges,90% of Total billed Charges,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.08,65,,2809.168,Percent of total Billed Charges,65% of Total Billed Charges,104.53,44.1,,51.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,225.19,95,,3738.712,Percent of Total Billed Charges,95% of Total Billed Charges,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.6,88,,5517.72,Percent of Total Billed Charges,88% of Total Billed Charges,213.34,90,,3541.936,Percent of Total Billed charges,90% of Total Billed Charges,104.53,237.04,
Z225240011 FEM REC,2780001366,CDM,278,RC,C1773,HCPCS,Outpatient,,,3304.19,2147.72,,3304.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2511.18,76,,2990.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2379.02,72,,40.008,Percent of Total Billed Charges,72% of Total Billed Charges,2379.02,72,,40.008,Percent of Total Billed charges,72% of Total Billed Charges,3304.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2379.02,72,,40.008,Percent of Total Billed Charges,72% of Total Billed Charges,1982.51,60,,33.344,Percent of Total Billed Charges,60% of Total Billed Charges,2973.77,90,,653.296,Percent of Total Billed Charges,90% of Total Billed Charges,1486.89,45,,149.232,Percent of Total Billed Charges,45% of Total Billed Charges,2973.77,90,,3541.144,Percent of Total Billed Charges,90% of Total billed Charges,3304.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3304.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3304.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2147.72,65,,192.632,Percent of total Billed Charges,65% of Total Billed Charges,1457.15,44.1,,146.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,3138.98,95,,3737.872,Percent of Total Billed Charges,95% of Total Billed Charges,3304.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2907.69,88,,550.296,Percent of Total Billed Charges,88% of Total Billed Charges,2973.77,90,,3541.144,Percent of Total Billed charges,90% of Total Billed Charges,1457.15,3304.19,
Z80182801 FEM/HEAD,2780001367,CDM,278,RC,C1773,HCPCS,Outpatient,,,3370.34,2190.72,,3370.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2561.46,76,,7002.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2426.64,72,,332.76,Percent of Total Billed Charges,72% of Total Billed Charges,2426.64,72,,332.76,Percent of Total Billed charges,72% of Total Billed Charges,3370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2426.64,72,,332.76,Percent of Total Billed Charges,72% of Total Billed Charges,2022.2,60,,277.304,Percent of Total Billed Charges,60% of Total Billed Charges,3033.31,90,,298.472,Percent of Total Billed Charges,90% of Total Billed Charges,1516.65,45,,2821.56,Percent of Total Billed Charges,45% of Total Billed Charges,3033.31,90,,8292.832,Percent of Total Billed Charges,90% of Total billed Charges,3370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2190.72,65,,192.632,Percent of total Billed Charges,65% of Total Billed Charges,1486.32,44.1,,2765.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,3201.82,95,,8753.544,Percent of Total Billed Charges,95% of Total Billed Charges,3370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2965.9,88,,550.296,Percent of Total Billed Charges,88% of Total Billed Charges,3033.31,90,,8292.832,Percent of Total Billed charges,90% of Total Billed Charges,1486.32,3370.34,
Z80182803 FEM/HEAD,2780001368,CDM,278,RC,C1773,HCPCS,Outpatient,,,3370.34,2190.72,,3370.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2561.46,76,,89.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2426.64,72,,871.912,Percent of Total Billed Charges,72% of Total Billed Charges,2426.64,72,,871.912,Percent of Total Billed charges,72% of Total Billed Charges,3370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2426.64,72,,871.912,Percent of Total Billed Charges,72% of Total Billed Charges,2022.2,60,,726.592,Percent of Total Billed Charges,60% of Total Billed Charges,3033.31,90,,1400.264,Percent of Total Billed Charges,90% of Total Billed Charges,1516.65,45,,281.4,Percent of Total Billed Charges,45% of Total Billed Charges,3033.31,90,,105.576,Percent of Total Billed Charges,90% of Total billed Charges,3370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2190.72,65,,3420.88,Percent of total Billed Charges,65% of Total Billed Charges,1486.32,44.1,,275.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3201.82,95,,111.44,Percent of Total Billed Charges,95% of Total Billed Charges,3370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2965.9,88,,638.784,Percent of Total Billed Charges,88% of Total Billed Charges,3033.31,90,,105.576,Percent of Total Billed charges,90% of Total Billed Charges,1486.32,3370.34,
Z500149 BIPOLAR SHE,2780001369,CDM,278,RC,C1773,HCPCS,Outpatient,,,2932.65,1906.22,,2932.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2228.81,76,,252.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2111.51,72,,1001.456,Percent of Total Billed Charges,72% of Total Billed Charges,2111.51,72,,1001.456,Percent of Total Billed charges,72% of Total Billed Charges,2932.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2111.51,72,,1001.456,Percent of Total Billed Charges,72% of Total Billed Charges,1759.59,60,,834.544,Percent of Total Billed Charges,60% of Total Billed Charges,2639.39,90,,50.008,Percent of Total Billed Charges,90% of Total Billed Charges,1319.69,45,,281.4,Percent of Total Billed Charges,45% of Total Billed Charges,2639.39,90,,298.472,Percent of Total Billed Charges,90% of Total billed Charges,2932.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2932.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2932.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1906.22,65,,3420.88,Percent of total Billed Charges,65% of Total Billed Charges,1293.3,44.1,,275.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,2786.02,95,,315.048,Percent of Total Billed Charges,95% of Total Billed Charges,2932.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2580.73,88,,638.784,Percent of Total Billed Charges,88% of Total Billed Charges,2639.39,90,,298.472,Percent of Total Billed charges,90% of Total Billed Charges,1293.3,2932.65,
Z50014728 BIPOLAR,2780001370,CDM,278,RC,C1773,HCPCS,Outpatient,,,179.71,116.81,,179.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,136.58,76,,4765.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,129.39,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,129.39,72,,51.44,Percent of Total Billed charges,72% of Total Billed Charges,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.39,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,107.83,60,,42.864,Percent of Total Billed Charges,60% of Total Billed Charges,161.74,90,,812.056,Percent of Total Billed Charges,90% of Total Billed Charges,80.87,45,,326.648,Percent of Total Billed Charges,45% of Total Billed Charges,161.74,90,,5643.12,Percent of Total Billed Charges,90% of Total billed Charges,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.81,65,,3420.88,Percent of total Billed Charges,65% of Total Billed Charges,79.25,44.1,,320.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,170.72,95,,5956.632,Percent of Total Billed Charges,95% of Total Billed Charges,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.14,88,,638.784,Percent of Total Billed Charges,88% of Total Billed Charges,161.74,90,,5643.12,Percent of Total Billed charges,90% of Total Billed Charges,79.25,179.71,
Z58420402 TIBIAL C,2780001371,CDM,278,RC,C1773,HCPCS,Outpatient,,,6575.31,4273.95,,6575.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4997.24,76,,475.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4734.22,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,4734.22,72,,66.68,Percent of Total Billed charges,72% of Total Billed Charges,6575.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4734.22,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,3945.19,60,,55.568,Percent of Total Billed Charges,60% of Total Billed Charges,5917.78,90,,1120.848,Percent of Total Billed Charges,90% of Total Billed Charges,2958.89,45,,326.648,Percent of Total Billed Charges,45% of Total Billed Charges,5917.78,90,,562.8,Percent of Total Billed Charges,90% of Total billed Charges,6575.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6575.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6575.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4273.95,65,,2456.592,Percent of total Billed Charges,65% of Total Billed Charges,2899.71,44.1,,320.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,6246.54,95,,594.072,Percent of Total Billed Charges,95% of Total Billed Charges,6575.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5786.27,88,,638.784,Percent of Total Billed Charges,88% of Total Billed Charges,5917.78,90,,562.8,Percent of Total Billed charges,90% of Total Billed Charges,2899.71,6575.31,
Z59834048 HEADED S,2780001372,CDM,278,RC,C1773,HCPCS,Outpatient,,,498.33,323.91,,498.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,378.73,76,,475.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,358.8,72,,742.36,Percent of Total Billed Charges,72% of Total Billed Charges,358.8,72,,742.36,Percent of Total Billed charges,72% of Total Billed Charges,498.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.8,72,,742.36,Percent of Total Billed Charges,72% of Total Billed Charges,299,60,,618.632,Percent of Total Billed Charges,60% of Total Billed Charges,448.5,90,,246.872,Percent of Total Billed Charges,90% of Total Billed Charges,224.25,45,,326.648,Percent of Total Billed Charges,45% of Total Billed Charges,448.5,90,,562.8,Percent of Total Billed Charges,90% of Total billed Charges,498.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.91,65,,3420.88,Percent of total Billed Charges,65% of Total Billed Charges,219.76,44.1,,320.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,473.41,95,,594.072,Percent of Total Billed Charges,95% of Total Billed Charges,498.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,438.53,88,,291.84,Percent of Total Billed Charges,88% of Total Billed Charges,448.5,90,,562.8,Percent of Total Billed charges,90% of Total Billed Charges,219.76,498.33,
Z58422409 ART SURF,2780001373,CDM,278,RC,C1773,HCPCS,Outpatient,,,2932.65,1906.22,,2932.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2228.81,76,,551.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2111.51,72,,1103.064,Percent of Total Billed Charges,72% of Total Billed Charges,2111.51,72,,1103.064,Percent of Total Billed charges,72% of Total Billed Charges,2932.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2111.51,72,,1103.064,Percent of Total Billed Charges,72% of Total Billed Charges,1759.59,60,,919.216,Percent of Total Billed Charges,60% of Total Billed Charges,2639.39,90,,246.872,Percent of Total Billed Charges,90% of Total Billed Charges,1319.69,45,,326.648,Percent of Total Billed Charges,45% of Total Billed Charges,2639.39,90,,653.296,Percent of Total Billed Charges,90% of Total billed Charges,2932.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2932.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2932.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1906.22,65,,2465.192,Percent of total Billed Charges,65% of Total Billed Charges,1293.3,44.1,,320.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,2786.02,95,,689.592,Percent of Total Billed Charges,95% of Total Billed Charges,2932.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2580.73,88,,1369.144,Percent of Total Billed Charges,88% of Total Billed Charges,2639.39,90,,653.296,Percent of Total Billed charges,90% of Total Billed Charges,1293.3,2932.65,
Z59501601 FEM/COMP,2780001374,CDM,278,RC,C1773,HCPCS,Outpatient,,,20097.47,13063.36,,20097.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15274.08,76,,551.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14470.18,72,,563.28,Percent of Total Billed Charges,72% of Total Billed Charges,14470.18,72,,563.28,Percent of Total Billed charges,72% of Total Billed Charges,20097.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14470.18,72,,563.28,Percent of Total Billed Charges,72% of Total Billed Charges,12058.48,60,,469.4,Percent of Total Billed Charges,60% of Total Billed Charges,18087.72,90,,349.272,Percent of Total Billed Charges,90% of Total Billed Charges,9043.86,45,,149.232,Percent of Total Billed Charges,45% of Total Billed Charges,18087.72,90,,653.296,Percent of Total Billed Charges,90% of Total billed Charges,20097.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20097.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20097.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13063.36,65,,3420.88,Percent of total Billed Charges,65% of Total Billed Charges,8862.98,44.1,,146.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,19092.6,95,,689.592,Percent of Total Billed Charges,95% of Total Billed Charges,20097.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17685.77,88,,48.896,Percent of Total Billed Charges,88% of Total Billed Charges,18087.72,90,,653.296,Percent of Total Billed charges,90% of Total Billed Charges,8862.98,20097.47,
Z49200204  7 PLATE,2780001375,CDM,278,RC,C1773,HCPCS,Outpatient,,,212.78,138.31,,212.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.71,76,,551.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153.2,72,,4811.064,Percent of Total Billed Charges,72% of Total Billed Charges,153.2,72,,4811.064,Percent of Total Billed charges,72% of Total Billed Charges,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.2,72,,4811.064,Percent of Total Billed Charges,72% of Total Billed Charges,127.67,60,,4009.216,Percent of Total Billed Charges,60% of Total Billed Charges,191.5,90,,1063.696,Percent of Total Billed Charges,90% of Total Billed Charges,95.75,45,,700.128,Percent of Total Billed Charges,45% of Total Billed Charges,191.5,90,,653.296,Percent of Total Billed Charges,90% of Total billed Charges,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.31,65,,1158.064,Percent of total Billed Charges,65% of Total Billed Charges,93.84,44.1,,686.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,202.14,95,,689.592,Percent of Total Billed Charges,95% of Total Billed Charges,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.25,88,,794.016,Percent of Total Billed Charges,88% of Total Billed Charges,191.5,90,,653.296,Percent of Total Billed charges,90% of Total Billed Charges,93.84,212.78,
Z49200502  57 PLATE,2780001376,CDM,278,RC,C1773,HCPCS,Outpatient,,,237.04,154.08,,237.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,180.15,76,,551.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,170.67,72,,1901.944,Percent of Total Billed Charges,72% of Total Billed Charges,170.67,72,,1901.944,Percent of Total Billed charges,72% of Total Billed Charges,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.67,72,,1901.944,Percent of Total Billed Charges,72% of Total Billed Charges,142.22,60,,1584.952,Percent of Total Billed Charges,60% of Total Billed Charges,213.34,90,,1215.312,Percent of Total Billed Charges,90% of Total Billed Charges,106.67,45,,25.008,Percent of Total Billed Charges,45% of Total Billed Charges,213.34,90,,653.296,Percent of Total Billed Charges,90% of Total billed Charges,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.08,65,,3196.72,Percent of total Billed Charges,65% of Total Billed Charges,104.53,44.1,,24.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,225.19,95,,689.592,Percent of Total Billed Charges,95% of Total Billed Charges,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.6,88,,1095.936,Percent of Total Billed Charges,88% of Total Billed Charges,213.34,90,,653.296,Percent of Total Billed charges,90% of Total Billed Charges,104.53,237.04,
Z48201003 CORTIUM,2780001377,CDM,278,RC,C1773,HCPCS,Outpatient,,,81.59,53.03,,81.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.01,76,,252.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,58.74,72,,482.632,Percent of Total Billed Charges,72% of Total Billed Charges,58.74,72,,482.632,Percent of Total Billed charges,72% of Total Billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.74,72,,482.632,Percent of Total Billed Charges,72% of Total Billed Charges,48.95,60,,402.192,Percent of Total Billed Charges,60% of Total Billed Charges,73.43,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,36.72,45,,406.032,Percent of Total Billed Charges,45% of Total Billed Charges,73.43,90,,298.472,Percent of Total Billed Charges,90% of Total billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.03,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,35.98,44.1,,397.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,77.51,95,,315.048,Percent of Total Billed Charges,95% of Total Billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.8,88,,241.384,Percent of Total Billed Charges,88% of Total Billed Charges,73.43,90,,298.472,Percent of Total Billed charges,90% of Total Billed Charges,35.98,81.59,
Z47249321111 FEMA,2780001378,CDM,278,RC,C1773,HCPCS,Outpatient,,,6147.54,3995.90,,6147.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4672.13,76,,1182.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4426.23,72,,482.632,Percent of Total Billed Charges,72% of Total Billed Charges,4426.23,72,,482.632,Percent of Total Billed charges,72% of Total Billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4426.23,72,,482.632,Percent of Total Billed Charges,72% of Total Billed Charges,3688.52,60,,402.192,Percent of Total Billed Charges,60% of Total Billed Charges,5532.79,90,,2202.8,Percent of Total Billed Charges,90% of Total Billed Charges,2766.39,45,,560.424,Percent of Total Billed Charges,45% of Total Billed Charges,5532.79,90,,1400.264,Percent of Total Billed Charges,90% of Total billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3995.9,65,,1158.064,Percent of total Billed Charges,65% of Total Billed Charges,2711.07,44.1,,549.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,5840.16,95,,1478.056,Percent of Total Billed Charges,95% of Total Billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5409.84,88,,241.384,Percent of Total Billed Charges,88% of Total Billed Charges,5532.79,90,,1400.264,Percent of Total Billed charges,90% of Total Billed Charges,2711.07,6147.54,
Z47248700210 NAIL,2780001379,CDM,278,RC,C1773,HCPCS,Outpatient,,,820.26,533.17,,820.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,623.4,76,,42.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,590.59,72,,35.136,Percent of Total Billed Charges,72% of Total Billed Charges,590.59,72,,35.136,Percent of Total Billed charges,72% of Total Billed Charges,820.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,590.59,72,,35.136,Percent of Total Billed Charges,72% of Total Billed Charges,492.16,60,,29.28,Percent of Total Billed Charges,60% of Total Billed Charges,738.23,90,,333.4,Percent of Total Billed Charges,90% of Total Billed Charges,369.12,45,,123.44,Percent of Total Billed Charges,45% of Total Billed Charges,738.23,90,,50.008,Percent of Total Billed Charges,90% of Total billed Charges,820.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,820.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,820.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,533.17,65,,3196.72,Percent of total Billed Charges,65% of Total Billed Charges,361.73,44.1,,120.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,779.25,95,,52.792,Percent of Total Billed Charges,95% of Total Billed Charges,820.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,721.83,88,,341.512,Percent of Total Billed Charges,88% of Total Billed Charges,738.23,90,,50.008,Percent of Total Billed charges,90% of Total Billed Charges,361.73,820.26,
Z59880610 REV TIBI,2780001380,CDM,278,RC,C1773,HCPCS,Outpatient,,,10967.67,7128.99,,10967.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8335.43,76,,685.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7896.72,72,,120.024,Percent of Total Billed Charges,72% of Total Billed Charges,7896.72,72,,120.024,Percent of Total Billed charges,72% of Total Billed Charges,10967.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7896.72,72,,120.024,Percent of Total Billed Charges,72% of Total Billed Charges,6580.6,60,,100.016,Percent of Total Billed Charges,60% of Total Billed Charges,9870.9,90,,6967.984,Percent of Total Billed Charges,90% of Total Billed Charges,4935.45,45,,123.44,Percent of Total Billed Charges,45% of Total Billed Charges,9870.9,90,,812.056,Percent of Total Billed Charges,90% of Total billed Charges,10967.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10967.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10967.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7128.99,65,,123.264,Percent of total Billed Charges,65% of Total Billed Charges,4836.74,44.1,,120.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,10419.29,95,,857.176,Percent of Total Billed Charges,95% of Total Billed Charges,10967.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9651.55,88,,1040.056,Percent of Total Billed Charges,88% of Total Billed Charges,9870.9,90,,812.056,Percent of Total Billed charges,90% of Total Billed Charges,4836.74,10967.67,
Z59941692 REV FEMO,2780001381,CDM,278,RC,C1773,HCPCS,Outpatient,,,24184.44,15719.89,,24184.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18380.17,76,,946.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17412.8,72,,46.992,Percent of Total Billed Charges,72% of Total Billed Charges,17412.8,72,,46.992,Percent of Total Billed charges,72% of Total Billed Charges,24184.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17412.8,72,,46.992,Percent of Total Billed Charges,72% of Total Billed Charges,14510.66,60,,39.16,Percent of Total Billed Charges,60% of Total Billed Charges,21766,90,,170.672,Percent of Total Billed Charges,90% of Total Billed Charges,10883,45,,174.64,Percent of Total Billed Charges,45% of Total Billed Charges,21766,90,,1120.848,Percent of Total Billed Charges,90% of Total billed Charges,24184.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24184.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24184.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15719.89,65,,2138.408,Percent of total Billed Charges,65% of Total Billed Charges,10665.34,44.1,,171.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,22975.22,95,,1183.112,Percent of Total Billed Charges,95% of Total Billed Charges,24184.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21282.31,88,,1188.304,Percent of Total Billed Charges,88% of Total Billed Charges,21766,90,,1120.848,Percent of Total Billed charges,90% of Total Billed Charges,10665.34,24184.44,
Z59944010 REV ARTI,2780001382,CDM,278,RC,C1773,HCPCS,Outpatient,,,7823.34,5085.17,,7823.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5945.74,76,,208.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5632.8,72,,46.992,Percent of Total Billed Charges,72% of Total Billed Charges,5632.8,72,,46.992,Percent of Total Billed charges,72% of Total Billed Charges,7823.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5632.8,72,,46.992,Percent of Total Billed Charges,72% of Total Billed Charges,4694,60,,39.16,Percent of Total Billed Charges,60% of Total Billed Charges,7041.01,90,,3889.624,Percent of Total Billed Charges,90% of Total Billed Charges,3520.5,45,,531.848,Percent of Total Billed Charges,45% of Total Billed Charges,7041.01,90,,246.872,Percent of Total Billed Charges,90% of Total billed Charges,7823.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7823.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7823.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5085.17,65,,3831.936,Percent of total Billed Charges,65% of Total Billed Charges,3450.09,44.1,,521.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,7432.17,95,,260.592,Percent of Total Billed Charges,95% of Total Billed Charges,7823.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6884.54,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,7041.01,90,,246.872,Percent of Total Billed charges,90% of Total Billed Charges,3450.09,7823.34,
Z59881018 REV STEM,2780001383,CDM,278,RC,C1773,HCPCS,Outpatient,,,4426.54,2877.25,,4426.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3364.17,76,,208.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3187.11,72,,46.992,Percent of Total Billed Charges,72% of Total Billed Charges,3187.11,72,,46.992,Percent of Total Billed charges,72% of Total Billed Charges,4426.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3187.11,72,,46.992,Percent of Total Billed Charges,72% of Total Billed Charges,2655.92,60,,39.16,Percent of Total Billed Charges,60% of Total Billed Charges,3983.89,90,,266.72,Percent of Total Billed Charges,90% of Total Billed Charges,1991.94,45,,607.656,Percent of Total Billed Charges,45% of Total Billed Charges,3983.89,90,,246.872,Percent of Total Billed Charges,90% of Total billed Charges,4426.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4426.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4426.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.25,65,,1524.976,Percent of total Billed Charges,65% of Total Billed Charges,1952.1,44.1,,595.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,4205.21,95,,260.592,Percent of Total Billed Charges,95% of Total Billed Charges,4426.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3895.36,88,,2153.848,Percent of Total Billed Charges,88% of Total Billed Charges,3983.89,90,,246.872,Percent of Total Billed charges,90% of Total Billed Charges,1952.1,4426.54,
Z47248510510 LAGS,2780001384,CDM,278,RC,C1773,HCPCS,Outpatient,,,2228.15,1448.30,,2228.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1693.39,76,,294.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1604.27,72,,46.992,Percent of Total Billed Charges,72% of Total Billed Charges,1604.27,72,,46.992,Percent of Total Billed charges,72% of Total Billed Charges,2228.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1604.27,72,,46.992,Percent of Total Billed Charges,72% of Total Billed Charges,1336.89,60,,39.16,Percent of Total Billed Charges,60% of Total Billed Charges,2005.34,90,,266.72,Percent of Total Billed Charges,90% of Total Billed Charges,1002.67,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,2005.34,90,,349.272,Percent of Total Billed Charges,90% of Total billed Charges,2228.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2228.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2228.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1448.3,65,,937.92,Percent of total Billed Charges,65% of Total Billed Charges,982.61,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,2116.74,95,,368.68,Percent of Total Billed Charges,95% of Total Billed Charges,2228.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1960.77,88,,325.984,Percent of Total Billed Charges,88% of Total Billed Charges,2005.34,90,,349.272,Percent of Total Billed charges,90% of Total Billed Charges,982.61,2228.15,
Z00784804201 MED,2780001385,CDM,278,RC,C1773,HCPCS,Outpatient,,,5950.19,3867.62,,5950.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4522.14,76,,898.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4284.14,72,,681.4,Percent of Total Billed Charges,72% of Total Billed Charges,4284.14,72,,681.4,Percent of Total Billed charges,72% of Total Billed Charges,5950.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4284.14,72,,681.4,Percent of Total Billed Charges,72% of Total Billed Charges,3570.11,60,,567.832,Percent of Total Billed Charges,60% of Total Billed Charges,5355.17,90,,4736.608,Percent of Total Billed Charges,90% of Total Billed Charges,2677.59,45,,1101.4,Percent of Total Billed Charges,45% of Total Billed Charges,5355.17,90,,1063.696,Percent of Total Billed Charges,90% of Total billed Charges,5950.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5950.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5950.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3867.62,65,,1752.576,Percent of total Billed Charges,65% of Total Billed Charges,2624.03,44.1,,1079.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,5652.68,95,,1122.784,Percent of Total Billed Charges,95% of Total Billed Charges,5950.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5236.17,88,,6813.136,Percent of Total Billed Charges,88% of Total Billed Charges,5355.17,90,,1063.696,Percent of Total Billed charges,90% of Total Billed Charges,2624.03,5950.19,
Z62025022 SHELL W,2780001386,CDM,278,RC,C1773,HCPCS,Outpatient,,,9588.44,6232.49,,9588.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7287.21,76,,1026.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6903.68,72,,998.92,Percent of Total Billed Charges,72% of Total Billed Charges,6903.68,72,,998.92,Percent of Total Billed charges,72% of Total Billed Charges,9588.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6903.68,72,,998.92,Percent of Total Billed Charges,72% of Total Billed Charges,5753.06,60,,832.432,Percent of Total Billed Charges,60% of Total Billed Charges,8629.6,90,,4736.608,Percent of Total Billed Charges,90% of Total Billed Charges,4314.8,45,,166.696,Percent of Total Billed Charges,45% of Total Billed Charges,8629.6,90,,1215.312,Percent of Total Billed Charges,90% of Total billed Charges,9588.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9588.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9588.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6232.49,65,,2457.168,Percent of total Billed Charges,65% of Total Billed Charges,4228.5,44.1,,163.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,9109.02,95,,1282.824,Percent of Total Billed Charges,95% of Total Billed Charges,9588.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8437.83,88,,166.88,Percent of Total Billed Charges,88% of Total Billed Charges,8629.6,90,,1215.312,Percent of Total Billed charges,90% of Total Billed Charges,4228.5,9588.44,
Z00771300600 FEM,2780001387,CDM,278,RC,C1773,HCPCS,Outpatient,,,21572.62,14022.20,,21572.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16395.19,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15532.29,72,,1542.512,Percent of Total Billed Charges,72% of Total Billed Charges,15532.29,72,,1542.512,Percent of Total Billed charges,72% of Total Billed Charges,21572.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15532.29,72,,1542.512,Percent of Total Billed Charges,72% of Total Billed Charges,12943.57,60,,1285.424,Percent of Total Billed Charges,60% of Total Billed Charges,19415.36,90,,4736.608,Percent of Total Billed Charges,90% of Total Billed Charges,9707.68,45,,3483.992,Percent of Total Billed Charges,45% of Total Billed Charges,19415.36,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,21572.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21572.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21572.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14022.2,65,,411.056,Percent of total Billed Charges,65% of Total Billed Charges,9513.53,44.1,,3414.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,20493.99,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,21572.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18983.91,88,,3803.184,Percent of Total Billed Charges,88% of Total Billed Charges,19415.36,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,9513.53,21572.62,
Z63105032 TILOGY L,2780001388,CDM,278,RC,C1773,HCPCS,Outpatient,,,5506.99,3579.54,,5506.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4185.31,76,,1860.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3965.03,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,3965.03,72,,45.088,Percent of Total Billed charges,72% of Total Billed Charges,5506.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3965.03,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,3304.19,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,4956.29,90,,3401.432,Percent of Total Billed Charges,90% of Total Billed Charges,2478.15,45,,85.336,Percent of Total Billed Charges,45% of Total Billed Charges,4956.29,90,,2202.8,Percent of Total Billed Charges,90% of Total billed Charges,5506.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5506.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5506.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3579.54,65,,3195.576,Percent of total Billed Charges,65% of Total Billed Charges,2428.58,44.1,,83.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,5231.64,95,,2325.176,Percent of Total Billed Charges,95% of Total Billed Charges,5506.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4846.15,88,,260.792,Percent of Total Billed Charges,88% of Total Billed Charges,4956.29,90,,2202.8,Percent of Total Billed charges,90% of Total Billed Charges,2428.58,5506.99,
Z49270803 TUBULAR,2780001389,CDM,278,RC,C1773,HCPCS,Outpatient,,,318.62,207.10,,318.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,242.15,76,,281.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,229.41,72,,122.56,Percent of Total Billed Charges,72% of Total Billed Charges,229.41,72,,122.56,Percent of Total Billed charges,72% of Total Billed Charges,318.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.41,72,,122.56,Percent of Total Billed Charges,72% of Total Billed Charges,191.17,60,,102.136,Percent of Total Billed Charges,60% of Total Billed Charges,286.76,90,,4736.608,Percent of Total Billed Charges,90% of Total Billed Charges,143.38,45,,1944.808,Percent of Total Billed Charges,45% of Total Billed Charges,286.76,90,,333.4,Percent of Total Billed Charges,90% of Total billed Charges,318.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.1,65,,6051.752,Percent of total Billed Charges,65% of Total Billed Charges,140.51,44.1,,1905.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,302.69,95,,351.92,Percent of Total Billed Charges,95% of Total Billed Charges,318.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280.39,88,,260.792,Percent of Total Billed Charges,88% of Total Billed Charges,286.76,90,,333.4,Percent of Total Billed charges,90% of Total Billed Charges,140.51,318.62,
Z48402001 CANN 4.0,2780001390,CDM,278,RC,C1773,HCPCS,Outpatient,,,66.15,43.00,,66.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,50.27,76,,5884.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47.63,72,,1282.784,Percent of Total Billed Charges,72% of Total Billed Charges,47.63,72,,1282.784,Percent of Total Billed charges,72% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.63,72,,1282.784,Percent of Total Billed Charges,72% of Total Billed Charges,39.69,60,,1068.984,Percent of Total Billed Charges,60% of Total Billed Charges,59.54,90,,3413.344,Percent of Total Billed Charges,90% of Total Billed Charges,29.77,45,,133.36,Percent of Total Billed Charges,45% of Total Billed Charges,59.54,90,,6967.984,Percent of Total Billed Charges,90% of Total billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,65,,3647.912,Percent of total Billed Charges,65% of Total Billed Charges,29.17,44.1,,130.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.84,95,,7355.088,Percent of Total Billed Charges,95% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.21,88,,4631.352,Percent of Total Billed Charges,88% of Total Billed Charges,59.54,90,,6967.984,Percent of Total Billed charges,90% of Total Billed Charges,29.17,66.15,
Z22526555 RECON SC,2780001391,CDM,278,RC,C1773,HCPCS,Outpatient,,,813.65,528.87,,813.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,618.37,76,,144.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,585.83,72,,3540.984,Percent of Total Billed Charges,72% of Total Billed Charges,585.83,72,,3540.984,Percent of Total Billed charges,72% of Total Billed Charges,813.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,585.83,72,,3540.984,Percent of Total Billed Charges,72% of Total Billed Charges,488.19,60,,2950.816,Percent of Total Billed Charges,60% of Total Billed Charges,732.29,90,,4736.608,Percent of Total Billed Charges,90% of Total Billed Charges,366.14,45,,133.36,Percent of Total Billed Charges,45% of Total Billed Charges,732.29,90,,170.672,Percent of Total Billed Charges,90% of Total billed Charges,813.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,813.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,813.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,528.87,65,,1158.64,Percent of total Billed Charges,65% of Total Billed Charges,358.82,44.1,,130.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,772.97,95,,180.152,Percent of Total Billed Charges,95% of Total Billed Charges,813.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,716.01,88,,4631.352,Percent of Total Billed Charges,88% of Total Billed Charges,732.29,90,,170.672,Percent of Total Billed charges,90% of Total Billed Charges,358.82,813.65,
Z434810913 HUM STE,2780001392,CDM,278,RC,C1773,HCPCS,Outpatient,,,14677.58,9540.43,,14677.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11154.96,76,,3284.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10567.86,72,,472.472,Percent of Total Billed Charges,72% of Total Billed Charges,10567.86,72,,472.472,Percent of Total Billed charges,72% of Total Billed Charges,14677.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10567.86,72,,472.472,Percent of Total Billed Charges,72% of Total Billed Charges,8806.55,60,,393.728,Percent of Total Billed Charges,60% of Total Billed Charges,13209.82,90,,1603.48,Percent of Total Billed Charges,90% of Total Billed Charges,6604.91,45,,2368.304,Percent of Total Billed Charges,45% of Total Billed Charges,13209.82,90,,3889.624,Percent of Total Billed Charges,90% of Total billed Charges,14677.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14677.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14677.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9540.43,65,,411.632,Percent of total Billed Charges,65% of Total Billed Charges,6472.81,44.1,,2320.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,13943.7,95,,4105.712,Percent of Total Billed Charges,95% of Total Billed Charges,14677.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12916.27,88,,4631.352,Percent of Total Billed Charges,88% of Total Billed Charges,13209.82,90,,3889.624,Percent of Total Billed charges,90% of Total Billed Charges,6472.81,14677.58,
Z472485110 LAG SCW,2780001393,CDM,278,RC,C1773,HCPCS,Outpatient,,,2131.13,1385.23,,2131.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1619.66,76,,225.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1534.41,72,,319.424,Percent of Total Billed Charges,72% of Total Billed Charges,1534.41,72,,319.424,Percent of Total Billed charges,72% of Total Billed Charges,2131.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1534.41,72,,319.424,Percent of Total Billed Charges,72% of Total Billed Charges,1278.68,60,,266.192,Percent of Total Billed Charges,60% of Total Billed Charges,1918.02,90,,4426.232,Percent of Total Billed Charges,90% of Total Billed Charges,959.01,45,,2368.304,Percent of Total Billed Charges,45% of Total Billed Charges,1918.02,90,,266.72,Percent of Total Billed Charges,90% of Total billed Charges,2131.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2131.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2131.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1385.23,65,,3678.296,Percent of total Billed Charges,65% of Total Billed Charges,939.83,44.1,,2320.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,2024.57,95,,281.536,Percent of Total Billed Charges,95% of Total Billed Charges,2131.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1875.39,88,,3325.84,Percent of Total Billed Charges,88% of Total Billed Charges,1918.02,90,,266.72,Percent of Total Billed charges,90% of Total Billed Charges,939.83,2131.13,
ARTHROCARE SPEED SCREW 5.5,2780001394,CDM,278,RC,C1773,HCPCS,Outpatient,,,1767.31,1148.75,,1767.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1343.16,76,,225.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1272.46,72,,393.088,Percent of Total Billed Charges,72% of Total Billed Charges,1272.46,72,,393.088,Percent of Total Billed charges,72% of Total Billed Charges,1767.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1272.46,72,,393.088,Percent of Total Billed Charges,72% of Total Billed Charges,1060.39,60,,327.576,Percent of Total Billed Charges,60% of Total Billed Charges,1590.58,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,795.29,45,,2368.304,Percent of Total Billed Charges,45% of Total Billed Charges,1590.58,90,,266.72,Percent of Total Billed Charges,90% of Total billed Charges,1767.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1767.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1767.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1148.75,65,,10979.84,Percent of total Billed Charges,65% of Total Billed Charges,779.38,44.1,,2320.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,1678.94,95,,281.536,Percent of Total Billed Charges,95% of Total Billed Charges,1767.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1555.23,88,,4631.352,Percent of Total Billed Charges,88% of Total Billed Charges,1590.58,90,,266.72,Percent of Total Billed charges,90% of Total Billed Charges,779.38,1767.31,
Z00575001401 GSF FEM DLT,2780001395,CDM,278,RC,C1773,HCPCS,Outpatient,,,20556.11,13361.47,,20556.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15622.64,76,,3999.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14800.4,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,14800.4,72,,23.496,Percent of Total Billed charges,72% of Total Billed Charges,20556.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14800.4,72,,23.496,Percent of Total Billed Charges,72% of Total Billed Charges,12333.67,60,,19.576,Percent of Total Billed Charges,60% of Total Billed Charges,18500.5,90,,1603.48,Percent of Total Billed Charges,90% of Total Billed Charges,9250.25,45,,1700.712,Percent of Total Billed Charges,45% of Total Billed Charges,18500.5,90,,4736.608,Percent of Total Billed Charges,90% of Total billed Charges,20556.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20556.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20556.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13361.47,65,,36.12,Percent of total Billed Charges,65% of Total Billed Charges,9065.24,44.1,,1666.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,19528.3,95,,4999.752,Percent of Total Billed Charges,95% of Total Billed Charges,20556.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18089.38,88,,3337.488,Percent of Total Billed Charges,88% of Total Billed Charges,18500.5,90,,4736.608,Percent of Total Billed charges,90% of Total Billed Charges,9065.24,20556.11,
Z225236014,2780001396,CDM,278,RC,C1773,HCPCS,Outpatient,,,3304.19,2147.72,,3304.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2511.18,76,,3999.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2379.02,72,,3481.928,Percent of Total Billed Charges,72% of Total Billed Charges,2379.02,72,,3481.928,Percent of Total Billed charges,72% of Total Billed Charges,3304.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2379.02,72,,3481.928,Percent of Total Billed Charges,72% of Total Billed Charges,1982.51,60,,2901.608,Percent of Total Billed Charges,60% of Total Billed Charges,2973.77,90,,4426.232,Percent of Total Billed Charges,90% of Total Billed Charges,1486.89,45,,2368.304,Percent of Total Billed Charges,45% of Total Billed Charges,2973.77,90,,4736.608,Percent of Total Billed Charges,90% of Total billed Charges,3304.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3304.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3304.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2147.72,65,,290.664,Percent of total Billed Charges,65% of Total Billed Charges,1457.15,44.1,,2320.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,3138.98,95,,4999.752,Percent of Total Billed Charges,95% of Total Billed Charges,3304.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2907.69,88,,4631.352,Percent of Total Billed Charges,88% of Total Billed Charges,2973.77,90,,4736.608,Percent of Total Billed charges,90% of Total Billed Charges,1457.15,3304.19,
Z225211555,2780001397,CDM,278,RC,C1773,HCPCS,Outpatient,,,850.03,552.52,,850.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,646.02,76,,3999.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,612.02,72,,1857.488,Percent of Total Billed Charges,72% of Total Billed Charges,612.02,72,,1857.488,Percent of Total Billed charges,72% of Total Billed Charges,850.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.02,72,,1857.488,Percent of Total Billed Charges,72% of Total Billed Charges,510.02,60,,1547.912,Percent of Total Billed Charges,60% of Total Billed Charges,765.03,90,,170.672,Percent of Total Billed Charges,90% of Total Billed Charges,382.51,45,,1706.672,Percent of Total Billed Charges,45% of Total Billed Charges,765.03,90,,4736.608,Percent of Total Billed Charges,90% of Total billed Charges,850.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,850.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,850.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.52,65,,3678.296,Percent of total Billed Charges,65% of Total Billed Charges,374.86,44.1,,1672.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,807.53,95,,4999.752,Percent of Total Billed Charges,95% of Total Billed Charges,850.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,748.03,88,,1567.84,Percent of Total Billed Charges,88% of Total Billed Charges,765.03,90,,4736.608,Percent of Total Billed charges,90% of Total Billed Charges,374.86,850.03,
Z22529555,2780001398,CDM,278,RC,C1773,HCPCS,Outpatient,,,850.03,552.52,,850.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,646.02,76,,2872.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,612.02,72,,38.104,Percent of Total Billed Charges,72% of Total Billed Charges,612.02,72,,38.104,Percent of Total Billed charges,72% of Total Billed Charges,850.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.02,72,,38.104,Percent of Total Billed Charges,72% of Total Billed Charges,510.02,60,,31.752,Percent of Total Billed Charges,60% of Total Billed Charges,765.03,90,,2960.88,Percent of Total Billed Charges,90% of Total Billed Charges,382.51,45,,2368.304,Percent of Total Billed Charges,45% of Total Billed Charges,765.03,90,,3401.432,Percent of Total Billed Charges,90% of Total billed Charges,850.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,850.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,850.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.52,65,,10979.84,Percent of total Billed Charges,65% of Total Billed Charges,374.86,44.1,,2320.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,807.53,95,,3590.4,Percent of Total Billed Charges,95% of Total Billed Charges,850.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,748.03,88,,4327.872,Percent of Total Billed Charges,88% of Total Billed Charges,765.03,90,,3401.432,Percent of Total Billed charges,90% of Total Billed Charges,374.86,850.03,
Z22526055 SCW,2780001399,CDM,278,RC,C1773,HCPCS,Outpatient,,,813.65,528.87,,813.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,618.37,76,,3999.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,585.83,72,,320.064,Percent of Total Billed Charges,72% of Total Billed Charges,585.83,72,,320.064,Percent of Total Billed charges,72% of Total Billed Charges,813.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,585.83,72,,320.064,Percent of Total Billed Charges,72% of Total Billed Charges,488.19,60,,266.72,Percent of Total Billed Charges,60% of Total Billed Charges,732.29,90,,5305.76,Percent of Total Billed Charges,90% of Total Billed Charges,366.14,45,,801.736,Percent of Total Billed Charges,45% of Total Billed Charges,732.29,90,,4736.608,Percent of Total Billed Charges,90% of Total billed Charges,813.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,813.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,813.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,528.87,65,,1442.424,Percent of total Billed Charges,65% of Total Billed Charges,358.82,44.1,,785.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,772.97,95,,4999.752,Percent of Total Billed Charges,95% of Total Billed Charges,813.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,716.01,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,732.29,90,,4736.608,Percent of Total Billed charges,90% of Total Billed Charges,358.82,813.65,
Z4840104.0 CANN SCW 10,2780001400,CDM,278,RC,C1773,HCPCS,Outpatient,,,62.84,40.85,,62.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.76,76,,2882.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.24,72,,320.064,Percent of Total Billed Charges,72% of Total Billed Charges,45.24,72,,320.064,Percent of Total Billed charges,72% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.24,72,,320.064,Percent of Total Billed Charges,72% of Total Billed Charges,37.7,60,,266.72,Percent of Total Billed Charges,60% of Total Billed Charges,56.56,90,,2111.512,Percent of Total Billed Charges,90% of Total Billed Charges,28.28,45,,2213.112,Percent of Total Billed Charges,45% of Total Billed Charges,56.56,90,,3413.344,Percent of Total Billed Charges,90% of Total billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.85,65,,980.344,Percent of total Billed Charges,65% of Total Billed Charges,27.71,44.1,,2168.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.7,95,,3602.968,Percent of Total Billed Charges,95% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.3,88,,1567.84,Percent of Total Billed Charges,88% of Total Billed Charges,56.56,90,,3413.344,Percent of Total Billed charges,90% of Total Billed Charges,27.71,62.84,
Z48403501 4.0 CANN SCW 35,2780001401,CDM,278,RC,C1773,HCPCS,Outpatient,,,62.84,40.85,,62.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.76,76,,3999.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.24,72,,320.064,Percent of Total Billed Charges,72% of Total Billed Charges,45.24,72,,320.064,Percent of Total Billed charges,72% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.24,72,,320.064,Percent of Total Billed Charges,72% of Total Billed Charges,37.7,60,,266.72,Percent of Total Billed Charges,60% of Total Billed Charges,56.56,90,,1298.656,Percent of Total Billed Charges,90% of Total Billed Charges,28.28,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,56.56,90,,4736.608,Percent of Total Billed Charges,90% of Total billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.85,65,,38.984,Percent of total Billed Charges,65% of Total Billed Charges,27.71,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.7,95,,4999.752,Percent of Total Billed Charges,95% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.3,88,,4327.872,Percent of Total Billed Charges,88% of Total Billed Charges,56.56,90,,4736.608,Percent of Total Billed charges,90% of Total Billed Charges,27.71,62.84,
Z23580106 HUMERAL PLT R6H,2780001402,CDM,278,RC,C1773,HCPCS,Outpatient,,,4827.85,3138.10,,4827.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3669.17,76,,1354.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3476.05,72,,81.92,Percent of Total Billed Charges,72% of Total Billed Charges,3476.05,72,,81.92,Percent of Total Billed charges,72% of Total Billed Charges,4827.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3476.05,72,,81.92,Percent of Total Billed Charges,72% of Total Billed Charges,2896.71,60,,68.264,Percent of Total Billed Charges,60% of Total Billed Charges,4345.07,90,,2426.648,Percent of Total Billed Charges,90% of Total Billed Charges,2172.53,45,,801.736,Percent of Total Billed Charges,45% of Total Billed Charges,4345.07,90,,1603.48,Percent of Total Billed Charges,90% of Total billed Charges,4827.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4827.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4827.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3138.1,65,,65.36,Percent of total Billed Charges,65% of Total Billed Charges,2129.08,44.1,,785.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,4586.46,95,,1692.56,Percent of Total Billed Charges,95% of Total Billed Charges,4827.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4248.51,88,,166.88,Percent of Total Billed Charges,88% of Total Billed Charges,4345.07,90,,1603.48,Percent of Total Billed charges,90% of Total Billed Charges,2129.08,4827.85,
Z48405001 CANC SCW 50,2780001403,CDM,278,RC,C1773,HCPCS,Outpatient,,,62.84,40.85,,62.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.76,76,,3737.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.24,72,,320.064,Percent of Total Billed Charges,72% of Total Billed Charges,45.24,72,,320.064,Percent of Total Billed charges,72% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.24,72,,320.064,Percent of Total Billed Charges,72% of Total Billed Charges,37.7,60,,266.72,Percent of Total Billed Charges,60% of Total Billed Charges,56.56,90,,3402.232,Percent of Total Billed Charges,90% of Total Billed Charges,28.28,45,,2213.112,Percent of Total Billed Charges,45% of Total Billed Charges,56.56,90,,4426.232,Percent of Total Billed Charges,90% of Total billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.85,65,,65.36,Percent of total Billed Charges,65% of Total Billed Charges,27.71,44.1,,2168.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.7,95,,4672.128,Percent of Total Billed Charges,95% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.3,88,,2895.08,Percent of Total Billed Charges,88% of Total Billed Charges,56.56,90,,4426.232,Percent of Total Billed charges,90% of Total Billed Charges,27.71,62.84,
Z11474435 CANN SCW 44,2780001404,CDM,278,RC,C1773,HCPCS,Outpatient,,,592.04,384.83,,592.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,449.95,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,426.27,72,,189.248,Percent of Total Billed Charges,72% of Total Billed Charges,426.27,72,,189.248,Percent of Total Billed charges,72% of Total Billed Charges,592.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.27,72,,189.248,Percent of Total Billed Charges,72% of Total Billed Charges,355.22,60,,157.704,Percent of Total Billed Charges,60% of Total Billed Charges,532.84,90,,569.152,Percent of Total Billed Charges,90% of Total Billed Charges,266.42,45,,85.336,Percent of Total Billed Charges,45% of Total Billed Charges,532.84,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,592.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.83,65,,110.648,Percent of total Billed Charges,65% of Total Billed Charges,261.09,44.1,,83.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,562.44,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,592.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521,88,,5187.856,Percent of Total Billed Charges,88% of Total Billed Charges,532.84,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,261.09,592.04,
Z59501501 NEXGEN E LEFT,2780001405,CDM,278,RC,C1773,HCPCS,Outpatient,,,17031.42,11070.42,,17031.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12943.88,76,,1354.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12262.62,72,,2787.192,Percent of Total Billed Charges,72% of Total Billed Charges,12262.62,72,,2787.192,Percent of Total Billed charges,72% of Total Billed Charges,17031.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12262.62,72,,2787.192,Percent of Total Billed Charges,72% of Total Billed Charges,10218.85,60,,2322.656,Percent of Total Billed Charges,60% of Total Billed Charges,15328.28,90,,4424.648,Percent of Total Billed Charges,90% of Total Billed Charges,7664.14,45,,1480.44,Percent of Total Billed Charges,45% of Total Billed Charges,15328.28,90,,1603.48,Percent of Total Billed Charges,90% of Total billed Charges,17031.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17031.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17031.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11070.42,65,,110.648,Percent of total Billed Charges,65% of Total Billed Charges,7510.86,44.1,,1450.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,16179.85,95,,1692.56,Percent of Total Billed Charges,95% of Total Billed Charges,17031.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14987.65,88,,2064.584,Percent of Total Billed Charges,88% of Total Billed Charges,15328.28,90,,1603.48,Percent of Total Billed charges,90% of Total Billed Charges,7510.86,17031.42,
Z492007COMP PLATE 2.04,2780001406,CDM,278,RC,C1773,HCPCS,Outpatient,,,523.95,340.57,,523.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,398.2,76,,3737.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,377.24,72,,170.192,Percent of Total Billed Charges,72% of Total Billed Charges,377.24,72,,170.192,Percent of Total Billed charges,72% of Total Billed Charges,523.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.24,72,,170.192,Percent of Total Billed Charges,72% of Total Billed Charges,314.37,60,,141.824,Percent of Total Billed Charges,60% of Total Billed Charges,471.56,90,,8379.352,Percent of Total Billed Charges,90% of Total Billed Charges,235.78,45,,2652.88,Percent of Total Billed Charges,45% of Total Billed Charges,471.56,90,,4426.232,Percent of Total Billed Charges,90% of Total billed Charges,523.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,523.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,523.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.57,65,,133.008,Percent of total Billed Charges,65% of Total Billed Charges,231.06,44.1,,2599.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,497.75,95,,4672.128,Percent of Total Billed Charges,95% of Total Billed Charges,523.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,461.08,88,,1269.8,Percent of Total Billed Charges,88% of Total Billed Charges,471.56,90,,4426.232,Percent of Total Billed charges,90% of Total Billed Charges,231.06,523.95,
ACUMED 700297 CLAVICLE,2780001407,CDM,278,RC,C1773,HCPCS,Outpatient,,,6607.00,4294.55,,6607,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5021.32,76,,144.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4757.04,72,,3537.176,Percent of Total Billed Charges,72% of Total Billed Charges,4757.04,72,,3537.176,Percent of Total Billed charges,72% of Total Billed Charges,6607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4757.04,72,,3537.176,Percent of Total Billed Charges,72% of Total Billed Charges,3964.2,60,,2947.648,Percent of Total Billed Charges,60% of Total Billed Charges,5946.3,90,,5050.952,Percent of Total Billed Charges,90% of Total Billed Charges,2973.15,45,,1055.752,Percent of Total Billed Charges,45% of Total Billed Charges,5946.3,90,,170.672,Percent of Total Billed Charges,90% of Total billed Charges,6607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4294.55,65,,1752.576,Percent of total Billed Charges,65% of Total Billed Charges,2913.69,44.1,,1034.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,6276.65,95,,180.152,Percent of Total Billed Charges,95% of Total Billed Charges,6607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5814.16,88,,2372.72,Percent of Total Billed Charges,88% of Total Billed Charges,5946.3,90,,170.672,Percent of Total Billed charges,90% of Total Billed Charges,2913.69,6607,
ATRIEVE VASC SNR 1220MM 6 FR,2780001408,CDM,272,RC,C1773,HCPCS,Outpatient,,,683.55,444.31,,683.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,519.5,76,,2500.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,492.16,72,,1539.968,Percent of Total Billed Charges,72% of Total Billed Charges,512.66,75,,1539.968,Percent of Total Billed charges,75% of Total Billed Charges,683.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.16,72,,1539.968,Percent of Total Billed Charges,72% of Total Billed Charges,410.13,60,,1283.312,Percent of Total Billed Charges,60% of Total Billed Charges,615.2,90,,1604.272,Percent of Total Billed Charges,90% of Total Billed Charges,307.6,45,,649.328,Percent of Total Billed Charges,45% of Total Billed Charges,615.2,90,,2960.88,Percent of Total Billed Charges,90% of Total billed Charges,683.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,683.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,683.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.31,65,,937.92,Percent of total Billed Charges,65% of Total Billed Charges,301.45,44.1,,636.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,649.37,95,,3125.368,Percent of Total Billed Charges,95% of Total Billed Charges,683.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,601.52,88,,3326.624,Percent of Total Billed Charges,88% of Total Billed Charges,615.2,90,,2960.88,Percent of Total Billed charges,90% of Total Billed Charges,301.45,683.55,
ATRIEVE VASC SNR 1830MM 7FR,2780001409,CDM,278,RC,C1773,HCPCS,Outpatient,,,683.55,444.31,,683.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,519.5,76,,4480.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,492.16,72,,1539.968,Percent of Total Billed Charges,72% of Total Billed Charges,492.16,72,,1539.968,Percent of Total Billed charges,72% of Total Billed Charges,683.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.16,72,,1539.968,Percent of Total Billed Charges,72% of Total Billed Charges,410.13,60,,1283.312,Percent of Total Billed Charges,60% of Total Billed Charges,615.2,90,,569.952,Percent of Total Billed Charges,90% of Total Billed Charges,307.6,45,,1213.32,Percent of Total Billed Charges,45% of Total Billed Charges,615.2,90,,5305.76,Percent of Total Billed Charges,90% of Total billed Charges,683.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,683.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,683.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.31,65,,1524.976,Percent of total Billed Charges,65% of Total Billed Charges,301.45,44.1,,1189.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,649.37,95,,5600.52,Percent of Total Billed Charges,95% of Total Billed Charges,683.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,601.52,88,,556.504,Percent of Total Billed Charges,88% of Total Billed Charges,615.2,90,,5305.76,Percent of Total Billed charges,90% of Total Billed Charges,301.45,683.55,
IVC FILTER RETRIEVAL SET,2780001410,CDM,272,RC,C1773,HCPCS,Outpatient,,,2844.45,1848.89,,2844.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2161.78,76,,1783.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2048,72,,276.24,Percent of Total Billed Charges,72% of Total Billed Charges,2133.34,75,,276.24,Percent of Total Billed charges,75% of Total Billed Charges,2844.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2048,72,,276.24,Percent of Total Billed Charges,72% of Total Billed Charges,1706.67,60,,230.2,Percent of Total Billed Charges,60% of Total Billed Charges,2560.01,90,,5093.024,Percent of Total Billed Charges,90% of Total Billed Charges,1280,45,,1701.112,Percent of Total Billed Charges,45% of Total Billed Charges,2560.01,90,,2111.512,Percent of Total Billed Charges,90% of Total billed Charges,2844.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2844.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2844.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1848.89,65,,455.2,Percent of total Billed Charges,65% of Total Billed Charges,1254.4,44.1,,1667.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,2702.23,95,,2228.816,Percent of Total Billed Charges,95% of Total Billed Charges,2844.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2503.12,88,,4326.32,Percent of Total Billed Charges,88% of Total Billed Charges,2560.01,90,,2111.512,Percent of Total Billed charges,90% of Total Billed Charges,1254.4,2844.45,
SNARE 4F 5 LOOPS 120 GOOSENECK,2780001411,CDM,278,RC,C1773,HCPCS,Outpatient,,,609.00,395.85,,609,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,462.84,76,,1096.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,438.48,72,,1262.456,Percent of Total Billed Charges,72% of Total Billed Charges,438.48,72,,1262.456,Percent of Total Billed charges,72% of Total Billed Charges,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,438.48,72,,1262.456,Percent of Total Billed Charges,72% of Total Billed Charges,365.4,60,,1052.048,Percent of Total Billed Charges,60% of Total Billed Charges,548.1,90,,15202.856,Percent of Total Billed Charges,90% of Total Billed Charges,274.05,45,,284.576,Percent of Total Billed Charges,45% of Total Billed Charges,548.1,90,,1298.656,Percent of Total Billed Charges,90% of Total billed Charges,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,395.85,65,,710.32,Percent of total Billed Charges,65% of Total Billed Charges,268.57,44.1,,278.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,578.55,95,,1370.808,Percent of Total Billed Charges,95% of Total Billed Charges,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.92,88,,8193.144,Percent of Total Billed Charges,88% of Total Billed Charges,548.1,90,,1298.656,Percent of Total Billed charges,90% of Total Billed Charges,268.57,609,
SNARE 4F 10 LOOPS 65 GOOSENECK,2780001412,CDM,272,RC,C1773,HCPCS,Outpatient,,,609.00,395.85,,609,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,462.84,76,,2049.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,438.48,72,,2837.992,Percent of Total Billed Charges,72% of Total Billed Charges,456.75,75,,2837.992,Percent of Total Billed charges,75% of Total Billed Charges,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,438.48,72,,2837.992,Percent of Total Billed Charges,72% of Total Billed Charges,365.4,60,,2364.992,Percent of Total Billed Charges,60% of Total Billed Charges,548.1,90,,50.008,Percent of Total Billed Charges,90% of Total Billed Charges,274.05,45,,2212.32,Percent of Total Billed Charges,45% of Total Billed Charges,548.1,90,,2426.648,Percent of Total Billed Charges,90% of Total billed Charges,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,395.85,65,,38.984,Percent of total Billed Charges,65% of Total Billed Charges,268.57,44.1,,2168.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,578.55,95,,2561.456,Percent of Total Billed Charges,95% of Total Billed Charges,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.92,88,,4938.704,Percent of Total Billed Charges,88% of Total Billed Charges,548.1,90,,2426.648,Percent of Total Billed charges,90% of Total Billed Charges,268.57,609,
SNARE 6F 20LOOPS 120 GOOSENECK,2780001413,CDM,272,RC,C1773,HCPCS,Outpatient,,,609.00,395.85,,609,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,462.84,76,,2872.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,438.48,72,,551.216,Percent of Total Billed Charges,72% of Total Billed Charges,456.75,75,,551.216,Percent of Total Billed charges,75% of Total Billed Charges,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,438.48,72,,551.216,Percent of Total Billed Charges,72% of Total Billed Charges,365.4,60,,459.344,Percent of Total Billed Charges,60% of Total Billed Charges,548.1,90,,402.456,Percent of Total Billed Charges,90% of Total Billed Charges,274.05,45,,4189.68,Percent of Total Billed Charges,45% of Total Billed Charges,548.1,90,,3402.232,Percent of Total Billed Charges,90% of Total billed Charges,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,395.85,65,,1826.536,Percent of total Billed Charges,65% of Total Billed Charges,268.57,44.1,,4105.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,578.55,95,,3591.24,Percent of Total Billed Charges,95% of Total Billed Charges,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.92,88,,1568.616,Percent of Total Billed Charges,88% of Total Billed Charges,548.1,90,,3402.232,Percent of Total Billed charges,90% of Total Billed Charges,268.57,609,
SNARE 6F 25 LOOPS GOOSENECK,2780001414,CDM,278,RC,C1773,HCPCS,Outpatient,,,609.00,395.85,,609,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,462.84,76,,480.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,438.48,72,,1916.552,Percent of Total Billed Charges,72% of Total Billed Charges,438.48,72,,1916.552,Percent of Total Billed charges,72% of Total Billed Charges,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,438.48,72,,1916.552,Percent of Total Billed Charges,72% of Total Billed Charges,365.4,60,,1597.128,Percent of Total Billed Charges,60% of Total Billed Charges,548.1,90,,5093.024,Percent of Total Billed Charges,90% of Total Billed Charges,274.05,45,,2525.472,Percent of Total Billed Charges,45% of Total Billed Charges,548.1,90,,569.152,Percent of Total Billed Charges,90% of Total billed Charges,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,395.85,65,,2927.848,Percent of total Billed Charges,65% of Total Billed Charges,268.57,44.1,,2474.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,578.55,95,,600.776,Percent of Total Billed Charges,95% of Total Billed Charges,609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.92,88,,557.288,Percent of Total Billed Charges,88% of Total Billed Charges,548.1,90,,569.152,Percent of Total Billed charges,90% of Total Billed Charges,268.57,609,
DPY UNIFEMORAL SZ53,2780001415,CDM,278,RC,C1776,HCPCS,Outpatient,,,22151.43,14398.43,,22151.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16835.09,76,,3736.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15949.03,72,,3945.504,Percent of Total Billed Charges,72% of Total Billed Charges,15949.03,72,,3945.504,Percent of Total Billed charges,72% of Total Billed Charges,22151.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15949.03,72,,3945.504,Percent of Total Billed Charges,72% of Total Billed Charges,13290.86,60,,3287.92,Percent of Total Billed Charges,60% of Total Billed Charges,19936.29,90,,15202.856,Percent of Total Billed Charges,90% of Total Billed Charges,9968.14,45,,802.136,Percent of Total Billed Charges,45% of Total Billed Charges,19936.29,90,,4424.648,Percent of Total Billed Charges,90% of Total billed Charges,22151.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22151.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22151.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14398.43,65,,5638.976,Percent of total Billed Charges,65% of Total Billed Charges,9768.78,44.1,,786.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,21043.86,95,,4670.456,Percent of Total Billed Charges,95% of Total Billed Charges,22151.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19493.26,88,,4979.84,Percent of Total Billed Charges,88% of Total Billed Charges,19936.29,90,,4424.648,Percent of Total Billed charges,90% of Total Billed Charges,9768.78,22151.43,
DPY TAPER SLV 11/13,2780001416,CDM,278,RC,C1776,HCPCS,Outpatient,,,571.10,371.22,,571.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,434.04,76,,7075.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,411.19,72,,4959.664,Percent of Total Billed Charges,72% of Total Billed Charges,411.19,72,,4959.664,Percent of Total Billed charges,72% of Total Billed Charges,571.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.19,72,,4959.664,Percent of Total Billed Charges,72% of Total Billed Charges,342.66,60,,4133.056,Percent of Total Billed Charges,60% of Total Billed Charges,513.99,90,,1997.2,Percent of Total Billed Charges,90% of Total Billed Charges,257,45,,284.976,Percent of Total Billed Charges,45% of Total Billed Charges,513.99,90,,8379.352,Percent of Total Billed Charges,90% of Total billed Charges,571.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,571.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,571.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.22,65,,8095.568,Percent of total Billed Charges,65% of Total Billed Charges,251.86,44.1,,279.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,542.55,95,,8844.872,Percent of Total Billed Charges,95% of Total Billed Charges,571.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.57,88,,14865.016,Percent of Total Billed Charges,88% of Total Billed Charges,513.99,90,,8379.352,Percent of Total Billed charges,90% of Total Billed Charges,251.86,571.1,
DPY FEMORAL STEM 18X,2780001417,CDM,278,RC,C1776,HCPCS,Outpatient,,,9339.28,6070.53,,9339.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7097.85,76,,4265.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6724.28,72,,9950.44,Percent of Total Billed Charges,72% of Total Billed Charges,6724.28,72,,9950.44,Percent of Total Billed charges,72% of Total Billed Charges,9339.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6724.28,72,,9950.44,Percent of Total Billed Charges,72% of Total Billed Charges,5603.57,60,,8292.032,Percent of Total Billed Charges,60% of Total Billed Charges,8405.35,90,,1357.4,Percent of Total Billed Charges,90% of Total Billed Charges,4202.68,45,,2546.512,Percent of Total Billed Charges,45% of Total Billed Charges,8405.35,90,,5050.952,Percent of Total Billed Charges,90% of Total billed Charges,9339.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9339.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9339.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6070.53,65,,3195.576,Percent of total Billed Charges,65% of Total Billed Charges,4118.62,44.1,,2495.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,8872.32,95,,5331.56,Percent of Total Billed Charges,95% of Total Billed Charges,9339.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8218.57,88,,48.896,Percent of Total Billed Charges,88% of Total Billed Charges,8405.35,90,,5050.952,Percent of Total Billed charges,90% of Total Billed Charges,4118.62,9339.28,
DEPUY PFC SIGMA,2780001418,CDM,278,RC,C1776,HCPCS,Outpatient,,,282.24,183.46,,282.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,214.5,76,,1354.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,203.21,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,203.21,72,,41.28,Percent of Total Billed charges,72% of Total Billed Charges,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.21,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,169.34,60,,34.4,Percent of Total Billed Charges,60% of Total Billed Charges,254.02,90,,53.976,Percent of Total Billed Charges,90% of Total Billed Charges,127.01,45,,7601.432,Percent of Total Billed Charges,45% of Total Billed Charges,254.02,90,,1604.272,Percent of Total Billed Charges,90% of Total billed Charges,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.46,65,,1498.032,Percent of total Billed Charges,65% of Total Billed Charges,124.47,44.1,,7449.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,268.13,95,,1693.392,Percent of Total Billed Charges,95% of Total Billed Charges,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.37,88,,393.512,Percent of Total Billed Charges,88% of Total Billed Charges,254.02,90,,1604.272,Percent of Total Billed charges,90% of Total Billed Charges,124.47,282.24,
Z22320207 EXT 5H G,2780001419,CDM,278,RC,C1776,HCPCS,Outpatient,,,18934.34,12307.32,,18934.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14390.1,76,,481.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13632.72,72,,847.776,Percent of Total Billed Charges,72% of Total Billed Charges,13632.72,72,,847.776,Percent of Total Billed charges,72% of Total Billed Charges,18934.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13632.72,72,,847.776,Percent of Total Billed Charges,72% of Total Billed Charges,11360.6,60,,706.48,Percent of Total Billed Charges,60% of Total Billed Charges,17040.91,90,,90.496,Percent of Total Billed Charges,90% of Total Billed Charges,8520.45,45,,25.008,Percent of Total Billed Charges,45% of Total Billed Charges,17040.91,90,,569.952,Percent of Total Billed Charges,90% of Total billed Charges,18934.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18934.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18934.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12307.32,65,,9430.784,Percent of total Billed Charges,65% of Total Billed Charges,8350.04,44.1,,24.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,17987.62,95,,601.616,Percent of Total Billed Charges,95% of Total Billed Charges,18934.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16662.22,88,,4979.84,Percent of Total Billed Charges,88% of Total Billed Charges,17040.91,90,,569.952,Percent of Total Billed charges,90% of Total Billed Charges,8350.04,18934.34,
Z3281055302 ULNA,2780001420,CDM,278,RC,C1776,HCPCS,Outpatient,,,20331.20,13215.28,,20331.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15451.71,76,,4300.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14638.46,72,,3945.504,Percent of Total Billed Charges,72% of Total Billed Charges,14638.46,72,,3945.504,Percent of Total Billed charges,72% of Total Billed Charges,20331.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14638.46,72,,3945.504,Percent of Total Billed Charges,72% of Total Billed Charges,12198.72,60,,3287.92,Percent of Total Billed Charges,60% of Total Billed Charges,18298.08,90,,90.496,Percent of Total Billed Charges,90% of Total Billed Charges,9149.04,45,,201.232,Percent of Total Billed Charges,45% of Total Billed Charges,18298.08,90,,5093.024,Percent of Total Billed Charges,90% of Total billed Charges,20331.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20331.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20331.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13215.28,65,,7481.568,Percent of total Billed Charges,65% of Total Billed Charges,8966.06,44.1,,197.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,19314.64,95,,5375.968,Percent of Total Billed Charges,95% of Total Billed Charges,20331.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17891.46,88,,14865.016,Percent of Total Billed Charges,88% of Total Billed Charges,18298.08,90,,5093.024,Percent of Total Billed charges,90% of Total Billed Charges,8966.06,20331.2,
Z43004627 MOD HUM,2780001421,CDM,278,RC,C1776,HCPCS,Outpatient,,,7754.99,5040.74,,7754.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5893.79,76,,12837.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5583.59,72,,4959.664,Percent of Total Billed Charges,72% of Total Billed Charges,5583.59,72,,4959.664,Percent of Total Billed charges,72% of Total Billed Charges,7754.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5583.59,72,,4959.664,Percent of Total Billed Charges,72% of Total Billed Charges,4652.99,60,,4133.056,Percent of Total Billed Charges,60% of Total Billed Charges,6979.49,90,,153.2,Percent of Total Billed Charges,90% of Total Billed Charges,3489.75,45,,2546.512,Percent of Total Billed Charges,45% of Total Billed Charges,6979.49,90,,15202.856,Percent of Total Billed Charges,90% of Total billed Charges,7754.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7754.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7754.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5040.74,65,,2301.8,Percent of total Billed Charges,65% of Total Billed Charges,3419.95,44.1,,2495.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,7367.24,95,,16047.464,Percent of Total Billed Charges,95% of Total Billed Charges,7754.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6824.39,88,,1952.816,Percent of Total Billed Charges,88% of Total Billed Charges,6979.49,90,,15202.856,Percent of Total Billed charges,90% of Total Billed Charges,3419.95,7754.99,
Z43004630 MOD HUM,2780001422,CDM,278,RC,C1776,HCPCS,Outpatient,,,7754.99,5040.74,,7754.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5893.79,76,,42.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5583.59,72,,11046.52,Percent of Total Billed Charges,72% of Total Billed Charges,5583.59,72,,11046.52,Percent of Total Billed charges,72% of Total Billed Charges,7754.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5583.59,72,,11046.52,Percent of Total Billed Charges,72% of Total Billed Charges,4652.99,60,,9205.432,Percent of Total Billed Charges,60% of Total Billed Charges,6979.49,90,,153.2,Percent of Total Billed Charges,90% of Total Billed Charges,3489.75,45,,7601.432,Percent of Total Billed Charges,45% of Total Billed Charges,6979.49,90,,50.008,Percent of Total Billed Charges,90% of Total billed Charges,7754.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7754.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7754.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5040.74,65,,8760.6,Percent of total Billed Charges,65% of Total Billed Charges,3419.95,44.1,,7449.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,7367.24,95,,52.792,Percent of Total Billed Charges,95% of Total Billed Charges,7754.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6824.39,88,,1327.24,Percent of Total Billed Charges,88% of Total Billed Charges,6979.49,90,,50.008,Percent of Total Billed charges,90% of Total Billed Charges,3419.95,7754.99,
Z43005221 MOD HUM,2780001423,CDM,278,RC,C1776,HCPCS,Outpatient,,,7754.99,5040.74,,7754.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5893.79,76,,339.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5583.59,72,,3945.504,Percent of Total Billed Charges,72% of Total Billed Charges,5583.59,72,,3945.504,Percent of Total Billed charges,72% of Total Billed Charges,7754.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5583.59,72,,3945.504,Percent of Total Billed Charges,72% of Total Billed Charges,4652.99,60,,3287.92,Percent of Total Billed Charges,60% of Total Billed Charges,6979.49,90,,184.16,Percent of Total Billed Charges,90% of Total Billed Charges,3489.75,45,,998.6,Percent of Total Billed Charges,45% of Total Billed Charges,6979.49,90,,402.456,Percent of Total Billed Charges,90% of Total billed Charges,7754.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7754.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7754.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5040.74,65,,18824.304,Percent of total Billed Charges,65% of Total Billed Charges,3419.95,44.1,,978.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,7367.24,95,,424.816,Percent of Total Billed Charges,95% of Total Billed Charges,7754.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6824.39,88,,52.776,Percent of Total Billed Charges,88% of Total Billed Charges,6979.49,90,,402.456,Percent of Total Billed charges,90% of Total Billed Charges,3419.95,7754.99,
Z43025230 MOD HUM,2780001424,CDM,278,RC,C1776,HCPCS,Outpatient,,,9119.88,5927.92,,9119.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6931.11,76,,4300.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6566.31,72,,4959.664,Percent of Total Billed Charges,72% of Total Billed Charges,6566.31,72,,4959.664,Percent of Total Billed charges,72% of Total Billed Charges,9119.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6566.31,72,,4959.664,Percent of Total Billed Charges,72% of Total Billed Charges,5471.93,60,,4133.056,Percent of Total Billed Charges,60% of Total Billed Charges,8207.89,90,,2426.648,Percent of Total Billed Charges,90% of Total Billed Charges,4103.95,45,,678.704,Percent of Total Billed Charges,45% of Total Billed Charges,8207.89,90,,5093.024,Percent of Total Billed Charges,90% of Total billed Charges,9119.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9119.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9119.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5927.92,65,,3831.936,Percent of total Billed Charges,65% of Total Billed Charges,4021.87,44.1,,665.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,8663.89,95,,5375.968,Percent of Total Billed Charges,95% of Total Billed Charges,9119.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8025.49,88,,88.488,Percent of Total Billed Charges,88% of Total Billed Charges,8207.89,90,,5093.024,Percent of Total Billed charges,90% of Total Billed Charges,4021.87,9119.88,
Z434211113 HUM STE,2780001425,CDM,278,RC,C1776,HCPCS,Outpatient,,,19832.87,12891.37,,19832.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15072.98,76,,12837.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14279.67,72,,11046.52,Percent of Total Billed Charges,72% of Total Billed Charges,14279.67,72,,11046.52,Percent of Total Billed charges,72% of Total Billed Charges,19832.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14279.67,72,,11046.52,Percent of Total Billed Charges,72% of Total Billed Charges,11899.72,60,,9205.432,Percent of Total Billed Charges,60% of Total Billed Charges,17849.58,90,,1298.656,Percent of Total Billed Charges,90% of Total Billed Charges,8924.79,45,,26.992,Percent of Total Billed Charges,45% of Total Billed Charges,17849.58,90,,15202.856,Percent of Total Billed Charges,90% of Total billed Charges,19832.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19832.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19832.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12891.37,65,,116.952,Percent of total Billed Charges,65% of Total Billed Charges,8746.3,44.1,,26.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,18841.23,95,,16047.464,Percent of Total Billed Charges,95% of Total Billed Charges,19832.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17452.93,88,,88.488,Percent of Total Billed Charges,88% of Total Billed Charges,17849.58,90,,15202.856,Percent of Total Billed charges,90% of Total Billed Charges,8746.3,19832.87,
Z434211313 HUM STE,2780001426,CDM,278,RC,C1776,HCPCS,Outpatient,,,19832.87,12891.37,,19832.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15072.98,76,,1686.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14279.67,72,,189.248,Percent of Total Billed Charges,72% of Total Billed Charges,14279.67,72,,189.248,Percent of Total Billed charges,72% of Total Billed Charges,19832.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14279.67,72,,189.248,Percent of Total Billed Charges,72% of Total Billed Charges,11899.72,60,,157.704,Percent of Total Billed Charges,60% of Total Billed Charges,17849.58,90,,2111.512,Percent of Total Billed Charges,90% of Total Billed Charges,8924.79,45,,45.248,Percent of Total Billed Charges,45% of Total Billed Charges,17849.58,90,,1997.2,Percent of Total Billed Charges,90% of Total billed Charges,19832.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19832.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19832.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12891.37,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,8746.3,44.1,,44.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,18841.23,95,,2108.16,Percent of Total Billed Charges,95% of Total Billed Charges,19832.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17452.93,88,,149.8,Percent of Total Billed Charges,88% of Total Billed Charges,17849.58,90,,1997.2,Percent of Total Billed charges,90% of Total Billed Charges,8746.3,19832.87,
Z434211413 HUM STE,2780001427,CDM,278,RC,C1776,HCPCS,Outpatient,,,19832.87,12891.37,,19832.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15072.98,76,,1146.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14279.67,72,,946.848,Percent of Total Billed Charges,72% of Total Billed Charges,14279.67,72,,946.848,Percent of Total Billed charges,72% of Total Billed Charges,19832.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14279.67,72,,946.848,Percent of Total Billed Charges,72% of Total Billed Charges,11899.72,60,,789.04,Percent of Total Billed Charges,60% of Total Billed Charges,17849.58,90,,630.28,Percent of Total Billed Charges,90% of Total Billed Charges,8924.79,45,,45.248,Percent of Total Billed Charges,45% of Total Billed Charges,17849.58,90,,1357.4,Percent of Total Billed Charges,90% of Total billed Charges,19832.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19832.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19832.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12891.37,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,8746.3,44.1,,44.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,18841.23,95,,1432.816,Percent of Total Billed Charges,95% of Total Billed Charges,19832.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17452.93,88,,149.8,Percent of Total Billed Charges,88% of Total Billed Charges,17849.58,90,,1357.4,Percent of Total Billed charges,90% of Total Billed Charges,8746.3,19832.87,
Z434211613 HUM STE,2780001428,CDM,278,RC,C1776,HCPCS,Outpatient,,,19832.87,12891.37,,19832.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15072.98,76,,45.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14279.67,72,,1537.432,Percent of Total Billed Charges,72% of Total Billed Charges,14279.67,72,,1537.432,Percent of Total Billed charges,72% of Total Billed Charges,19832.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14279.67,72,,1537.432,Percent of Total Billed Charges,72% of Total Billed Charges,11899.72,60,,1281.192,Percent of Total Billed Charges,60% of Total Billed Charges,17849.58,90,,983.52,Percent of Total Billed Charges,90% of Total Billed Charges,8924.79,45,,76.6,Percent of Total Billed Charges,45% of Total Billed Charges,17849.58,90,,53.976,Percent of Total Billed Charges,90% of Total billed Charges,19832.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19832.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19832.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12891.37,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,8746.3,44.1,,75.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,18841.23,95,,56.976,Percent of Total Billed Charges,95% of Total Billed Charges,19832.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17452.93,88,,180.072,Percent of Total Billed Charges,88% of Total Billed Charges,17849.58,90,,53.976,Percent of Total Billed charges,90% of Total Billed Charges,8746.3,19832.87,
Z47223733 SM GDEWI,2780001429,CDM,278,RC,C1776,HCPCS,Outpatient,,,568.89,369.78,,568.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.36,76,,76.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,409.6,72,,2962.912,Percent of Total Billed Charges,72% of Total Billed Charges,409.6,72,,2962.912,Percent of Total Billed charges,72% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.6,72,,2962.912,Percent of Total Billed Charges,72% of Total Billed Charges,341.33,60,,2469.096,Percent of Total Billed Charges,60% of Total Billed Charges,512,90,,53.976,Percent of Total Billed Charges,90% of Total Billed Charges,256,45,,76.6,Percent of Total Billed Charges,45% of Total Billed Charges,512,90,,90.496,Percent of Total Billed Charges,90% of Total billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.78,65,,1158.064,Percent of total Billed Charges,65% of Total Billed Charges,250.88,44.1,,75.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,540.45,95,,95.528,Percent of Total Billed Charges,95% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.62,88,,2372.72,Percent of Total Billed Charges,88% of Total Billed Charges,512,90,,90.496,Percent of Total Billed charges,90% of Total Billed Charges,250.88,568.89,
Z00576401552 GSF,2780001430,CDM,278,RC,C1776,HCPCS,Outpatient,,,21516.39,13985.65,,21516.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16352.46,76,,76.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15491.8,72,,4626.112,Percent of Total Billed Charges,72% of Total Billed Charges,15491.8,72,,4626.112,Percent of Total Billed charges,72% of Total Billed Charges,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15491.8,72,,4626.112,Percent of Total Billed Charges,72% of Total Billed Charges,12909.83,60,,3855.096,Percent of Total Billed Charges,60% of Total Billed Charges,19364.75,90,,2529.048,Percent of Total Billed Charges,90% of Total Billed Charges,9682.38,45,,92.08,Percent of Total Billed Charges,45% of Total Billed Charges,19364.75,90,,90.496,Percent of Total Billed Charges,90% of Total billed Charges,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13985.65,65,,3196.72,Percent of total Billed Charges,65% of Total Billed Charges,9488.73,44.1,,90.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,20440.57,95,,95.528,Percent of Total Billed Charges,95% of Total Billed Charges,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18934.42,88,,1269.8,Percent of Total Billed Charges,88% of Total Billed Charges,19364.75,90,,90.496,Percent of Total Billed charges,90% of Total Billed Charges,9488.73,21516.39,
Z00576401651 GSF,2780001431,CDM,278,RC,C1776,HCPCS,Outpatient,,,21516.39,13985.65,,21516.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16352.46,76,,129.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15491.8,72,,1393.456,Percent of Total Billed Charges,72% of Total Billed Charges,15491.8,72,,1393.456,Percent of Total Billed charges,72% of Total Billed Charges,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15491.8,72,,1393.456,Percent of Total Billed Charges,72% of Total Billed Charges,12909.83,60,,1161.216,Percent of Total Billed Charges,60% of Total Billed Charges,19364.75,90,,4053.936,Percent of Total Billed Charges,90% of Total Billed Charges,9682.38,45,,1213.32,Percent of Total Billed Charges,45% of Total Billed Charges,19364.75,90,,153.2,Percent of Total Billed Charges,90% of Total billed Charges,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13985.65,65,,1156.92,Percent of total Billed Charges,65% of Total Billed Charges,9488.73,44.1,,1189.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,20440.57,95,,161.712,Percent of Total Billed Charges,95% of Total Billed Charges,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18934.42,88,,2064.584,Percent of Total Billed Charges,88% of Total Billed Charges,19364.75,90,,153.2,Percent of Total Billed charges,90% of Total Billed Charges,9488.73,21516.39,
Z00576401752 GSF,2780001432,CDM,278,RC,C1776,HCPCS,Outpatient,,,21516.39,13985.65,,21516.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16352.46,76,,129.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15491.8,72,,834.624,Percent of Total Billed Charges,72% of Total Billed Charges,15491.8,72,,834.624,Percent of Total Billed charges,72% of Total Billed Charges,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15491.8,72,,834.624,Percent of Total Billed Charges,72% of Total Billed Charges,12909.83,60,,695.52,Percent of Total Billed Charges,60% of Total Billed Charges,19364.75,90,,7807.816,Percent of Total Billed Charges,90% of Total Billed Charges,9682.38,45,,649.328,Percent of Total Billed Charges,45% of Total Billed Charges,19364.75,90,,153.2,Percent of Total Billed Charges,90% of Total billed Charges,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13985.65,65,,435.712,Percent of total Billed Charges,65% of Total Billed Charges,9488.73,44.1,,636.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,20440.57,95,,161.712,Percent of Total Billed Charges,95% of Total Billed Charges,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18934.42,88,,616.272,Percent of Total Billed Charges,88% of Total Billed Charges,19364.75,90,,153.2,Percent of Total Billed charges,90% of Total Billed Charges,9488.73,21516.39,
Z00576401551 GSF,2780001433,CDM,278,RC,C1776,HCPCS,Outpatient,,,21516.39,13985.65,,21516.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16352.46,76,,155.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15491.8,72,,1394.064,Percent of Total Billed Charges,72% of Total Billed Charges,15491.8,72,,1394.064,Percent of Total Billed charges,72% of Total Billed Charges,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15491.8,72,,1394.064,Percent of Total Billed Charges,72% of Total Billed Charges,12909.83,60,,1161.72,Percent of Total Billed Charges,60% of Total Billed Charges,19364.75,90,,11209.248,Percent of Total Billed Charges,90% of Total Billed Charges,9682.38,45,,1055.752,Percent of Total Billed Charges,45% of Total Billed Charges,19364.75,90,,184.16,Percent of Total Billed Charges,90% of Total billed Charges,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13985.65,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,9488.73,44.1,,1034.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,20440.57,95,,194.392,Percent of Total Billed Charges,95% of Total Billed Charges,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18934.42,88,,961.664,Percent of Total Billed Charges,88% of Total Billed Charges,19364.75,90,,184.16,Percent of Total Billed charges,90% of Total Billed Charges,9488.73,21516.39,
Z24801640 4.0 CANC,2780001434,CDM,278,RC,C1776,HCPCS,Outpatient,,,124.58,80.98,,124.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,94.68,76,,2049.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,89.7,72,,834.624,Percent of Total Billed Charges,72% of Total Billed Charges,89.7,72,,834.624,Percent of Total Billed charges,72% of Total Billed Charges,124.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.7,72,,834.624,Percent of Total Billed Charges,72% of Total Billed Charges,74.75,60,,695.52,Percent of Total Billed Charges,60% of Total Billed Charges,112.12,90,,4424.648,Percent of Total Billed Charges,90% of Total Billed Charges,56.06,45,,315.144,Percent of Total Billed Charges,45% of Total Billed Charges,112.12,90,,2426.648,Percent of Total Billed Charges,90% of Total billed Charges,124.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.98,65,,159.384,Percent of total Billed Charges,65% of Total Billed Charges,54.94,44.1,,308.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,118.35,95,,2561.456,Percent of Total Billed Charges,95% of Total Billed Charges,124.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.63,88,,52.776,Percent of Total Billed Charges,88% of Total Billed Charges,112.12,90,,2426.648,Percent of Total Billed charges,90% of Total Billed Charges,54.94,124.58,
Z00576401652 GSF,2780001435,CDM,278,RC,C1776,HCPCS,Outpatient,,,21516.39,13985.65,,21516.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16352.46,76,,1096.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15491.8,72,,1394.064,Percent of Total Billed Charges,72% of Total Billed Charges,15491.8,72,,1394.064,Percent of Total Billed charges,72% of Total Billed Charges,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15491.8,72,,1394.064,Percent of Total Billed Charges,72% of Total Billed Charges,12909.83,60,,1161.72,Percent of Total Billed Charges,60% of Total Billed Charges,19364.75,90,,2074.2,Percent of Total Billed Charges,90% of Total Billed Charges,9682.38,45,,491.76,Percent of Total Billed Charges,45% of Total Billed Charges,19364.75,90,,1298.656,Percent of Total Billed Charges,90% of Total billed Charges,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13985.65,65,,111.792,Percent of total Billed Charges,65% of Total Billed Charges,9488.73,44.1,,481.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,20440.57,95,,1370.808,Percent of Total Billed Charges,95% of Total Billed Charges,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18934.42,88,,2472.848,Percent of Total Billed Charges,88% of Total Billed Charges,19364.75,90,,1298.656,Percent of Total Billed charges,90% of Total Billed Charges,9488.73,21516.39,
Z59726532 PATELLA,2780001436,CDM,278,RC,C1776,HCPCS,Outpatient,,,1649.34,1072.07,,1649.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1253.5,76,,1783.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1187.52,72,,1717.632,Percent of Total Billed Charges,72% of Total Billed Charges,1187.52,72,,1717.632,Percent of Total Billed charges,72% of Total Billed Charges,1649.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1187.52,72,,1717.632,Percent of Total Billed Charges,72% of Total Billed Charges,989.6,60,,1431.36,Percent of Total Billed Charges,60% of Total Billed Charges,1484.41,90,,13058.016,Percent of Total Billed Charges,90% of Total Billed Charges,742.2,45,,26.992,Percent of Total Billed Charges,45% of Total Billed Charges,1484.41,90,,2111.512,Percent of Total Billed Charges,90% of Total billed Charges,1649.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1649.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1649.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1072.07,65,,3115.312,Percent of total Billed Charges,65% of Total Billed Charges,727.36,44.1,,26.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,1566.87,95,,2228.816,Percent of Total Billed Charges,95% of Total Billed Charges,1649.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1451.42,88,,3963.848,Percent of Total Billed Charges,88% of Total Billed Charges,1484.41,90,,2111.512,Percent of Total Billed charges,90% of Total Billed Charges,727.36,1649.34,
Z59726529 PATELLA,2780001437,CDM,278,RC,C1776,HCPCS,Outpatient,,,2886.35,1876.13,,2886.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2193.63,76,,532.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2078.17,72,,1389.888,Percent of Total Billed Charges,72% of Total Billed Charges,2078.17,72,,1389.888,Percent of Total Billed charges,72% of Total Billed Charges,2886.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2078.17,72,,1389.888,Percent of Total Billed Charges,72% of Total Billed Charges,1731.81,60,,1158.24,Percent of Total Billed Charges,60% of Total Billed Charges,2597.72,90,,10359.096,Percent of Total Billed Charges,90% of Total Billed Charges,1298.86,45,,1264.528,Percent of Total Billed Charges,45% of Total Billed Charges,2597.72,90,,630.28,Percent of Total Billed Charges,90% of Total billed Charges,2886.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2886.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2886.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1876.13,65,,2445.12,Percent of total Billed Charges,65% of Total Billed Charges,1272.88,44.1,,1239.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,2742.03,95,,665.296,Percent of Total Billed Charges,95% of Total Billed Charges,2886.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2539.99,88,,7634.312,Percent of Total Billed Charges,88% of Total Billed Charges,2597.72,90,,630.28,Percent of Total Billed charges,90% of Total Billed Charges,1272.88,2886.35,
Z59726535 PATELLA,2780001438,CDM,278,RC,C1776,HCPCS,Outpatient,,,2886.35,1876.13,,2886.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2193.63,76,,830.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2078.17,72,,37.44,Percent of Total Billed Charges,72% of Total Billed Charges,2078.17,72,,37.44,Percent of Total Billed charges,72% of Total Billed Charges,2886.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2078.17,72,,37.44,Percent of Total Billed Charges,72% of Total Billed Charges,1731.81,60,,31.2,Percent of Total Billed Charges,60% of Total Billed Charges,2597.72,90,,3187.112,Percent of Total Billed Charges,90% of Total Billed Charges,1298.86,45,,2026.968,Percent of Total Billed Charges,45% of Total Billed Charges,2597.72,90,,983.52,Percent of Total Billed Charges,90% of Total billed Charges,2886.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2886.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2886.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1876.13,65,,2690.496,Percent of total Billed Charges,65% of Total Billed Charges,1272.88,44.1,,1986.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,2742.03,95,,1038.16,Percent of Total Billed Charges,95% of Total Billed Charges,2886.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2539.99,88,,10960.152,Percent of Total Billed Charges,88% of Total Billed Charges,2597.72,90,,983.52,Percent of Total Billed charges,90% of Total Billed Charges,1272.88,2886.35,
Z59726538 PATELLA,2780001439,CDM,278,RC,C1776,HCPCS,Outpatient,,,2886.35,1876.13,,2886.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2193.63,76,,45.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2078.17,72,,229.248,Percent of Total Billed Charges,72% of Total Billed Charges,2078.17,72,,229.248,Percent of Total Billed charges,72% of Total Billed Charges,2886.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2078.17,72,,229.248,Percent of Total Billed Charges,72% of Total Billed Charges,1731.81,60,,191.04,Percent of Total Billed Charges,60% of Total Billed Charges,2597.72,90,,12130.056,Percent of Total Billed Charges,90% of Total Billed Charges,1298.86,45,,3903.912,Percent of Total Billed Charges,45% of Total Billed Charges,2597.72,90,,53.976,Percent of Total Billed Charges,90% of Total billed Charges,2886.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2886.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2886.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1876.13,65,,193.776,Percent of total Billed Charges,65% of Total Billed Charges,1272.88,44.1,,3825.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,2742.03,95,,56.976,Percent of Total Billed Charges,95% of Total Billed Charges,2886.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2539.99,88,,4326.32,Percent of Total Billed Charges,88% of Total Billed Charges,2597.72,90,,53.976,Percent of Total Billed charges,90% of Total Billed Charges,1272.88,2886.35,
Z59863702 TIBIAL C,2780001440,CDM,278,RC,C1776,HCPCS,Outpatient,,,6584.13,4279.68,,6584.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5003.94,76,,2135.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4740.57,72,,171.648,Percent of Total Billed Charges,72% of Total Billed Charges,4740.57,72,,171.648,Percent of Total Billed charges,72% of Total Billed Charges,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4740.57,72,,171.648,Percent of Total Billed Charges,72% of Total Billed Charges,3950.48,60,,143.04,Percent of Total Billed Charges,60% of Total Billed Charges,5925.72,90,,26064.424,Percent of Total Billed Charges,90% of Total Billed Charges,2962.86,45,,5604.624,Percent of Total Billed Charges,45% of Total Billed Charges,5925.72,90,,2529.048,Percent of Total Billed Charges,90% of Total billed Charges,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4279.68,65,,169.128,Percent of total Billed Charges,65% of Total Billed Charges,2903.6,44.1,,5492.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,6254.92,95,,2669.552,Percent of Total Billed Charges,95% of Total Billed Charges,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5794.03,88,,2028.104,Percent of Total Billed Charges,88% of Total Billed Charges,5925.72,90,,2529.048,Percent of Total Billed charges,90% of Total Billed Charges,2903.6,6584.13,
Z59863701 TIBIAL C,2780001441,CDM,278,RC,C1776,HCPCS,Outpatient,,,6584.13,4279.68,,6584.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5003.94,76,,3423.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4740.57,72,,171.648,Percent of Total Billed Charges,72% of Total Billed Charges,4740.57,72,,171.648,Percent of Total Billed charges,72% of Total Billed Charges,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4740.57,72,,171.648,Percent of Total Billed Charges,72% of Total Billed Charges,3950.48,60,,143.04,Percent of Total Billed Charges,60% of Total Billed Charges,5925.72,90,,5305.76,Percent of Total Billed Charges,90% of Total Billed Charges,2962.86,45,,2212.32,Percent of Total Billed Charges,45% of Total Billed Charges,5925.72,90,,4053.936,Percent of Total Billed Charges,90% of Total billed Charges,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4279.68,65,,169.128,Percent of total Billed Charges,65% of Total Billed Charges,2903.6,44.1,,2168.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,6254.92,95,,4279.16,Percent of Total Billed Charges,95% of Total Billed Charges,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5794.03,88,,12767.832,Percent of Total Billed Charges,88% of Total Billed Charges,5925.72,90,,4053.936,Percent of Total Billed charges,90% of Total Billed Charges,2903.6,6584.13,
Z59864702 TIBIAL C,2780001442,CDM,278,RC,C1776,HCPCS,Outpatient,,,6584.13,4279.68,,6584.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5003.94,76,,6593.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4740.57,72,,204.48,Percent of Total Billed Charges,72% of Total Billed Charges,4740.57,72,,204.48,Percent of Total Billed charges,72% of Total Billed Charges,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4740.57,72,,204.48,Percent of Total Billed Charges,72% of Total Billed Charges,3950.48,60,,170.4,Percent of Total Billed Charges,60% of Total Billed Charges,5925.72,90,,161.936,Percent of Total Billed Charges,90% of Total Billed Charges,2962.86,45,,1037.096,Percent of Total Billed Charges,45% of Total Billed Charges,5925.72,90,,7807.816,Percent of Total Billed Charges,90% of Total billed Charges,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4279.68,65,,3196.72,Percent of total Billed Charges,65% of Total Billed Charges,2903.6,44.1,,1016.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,6254.92,95,,8241.584,Percent of Total Billed Charges,95% of Total Billed Charges,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5794.03,88,,10128.888,Percent of Total Billed Charges,88% of Total Billed Charges,5925.72,90,,7807.816,Percent of Total Billed charges,90% of Total Billed Charges,2903.6,6584.13,
Z59864701 TIBIAL C,2780001443,CDM,278,RC,C1776,HCPCS,Outpatient,,,6584.13,4279.68,,6584.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5003.94,76,,9465.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4740.57,72,,375.552,Percent of Total Billed Charges,72% of Total Billed Charges,4740.57,72,,375.552,Percent of Total Billed charges,72% of Total Billed Charges,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4740.57,72,,375.552,Percent of Total Billed Charges,72% of Total Billed Charges,3950.48,60,,312.96,Percent of Total Billed Charges,60% of Total Billed Charges,5925.72,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,2962.86,45,,6529.008,Percent of Total Billed Charges,45% of Total Billed Charges,5925.72,90,,11209.248,Percent of Total Billed Charges,90% of Total billed Charges,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4279.68,65,,36.12,Percent of total Billed Charges,65% of Total Billed Charges,2903.6,44.1,,6398.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,6254.92,95,,11831.984,Percent of Total Billed Charges,95% of Total Billed Charges,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5794.03,88,,3116.288,Percent of Total Billed Charges,88% of Total Billed Charges,5925.72,90,,11209.248,Percent of Total Billed charges,90% of Total Billed Charges,2903.6,6584.13,
Z59865701 TIBIAL C,2780001444,CDM,278,RC,C1776,HCPCS,Outpatient,,,6584.13,4279.68,,6584.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5003.94,76,,3736.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4740.57,72,,1978.784,Percent of Total Billed Charges,72% of Total Billed Charges,4740.57,72,,1978.784,Percent of Total Billed charges,72% of Total Billed Charges,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4740.57,72,,1978.784,Percent of Total Billed Charges,72% of Total Billed Charges,3950.48,60,,1648.984,Percent of Total Billed Charges,60% of Total Billed Charges,5925.72,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,2962.86,45,,5179.544,Percent of Total Billed Charges,45% of Total Billed Charges,5925.72,90,,4424.648,Percent of Total Billed Charges,90% of Total billed Charges,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4279.68,65,,2300.648,Percent of total Billed Charges,65% of Total Billed Charges,2903.6,44.1,,5075.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,6254.92,95,,4670.456,Percent of Total Billed Charges,95% of Total Billed Charges,6584.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5794.03,88,,11860.496,Percent of Total Billed Charges,88% of Total Billed Charges,5925.72,90,,4424.648,Percent of Total Billed charges,90% of Total Billed Charges,2903.6,6584.13,
Z59961332 FEMORAL,2780001445,CDM,278,RC,C1776,HCPCS,Outpatient,,,10818.83,7032.24,,10818.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8222.31,76,,1751.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7789.56,72,,7698.592,Percent of Total Billed Charges,72% of Total Billed Charges,7789.56,72,,7698.592,Percent of Total Billed charges,72% of Total Billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7789.56,72,,7698.592,Percent of Total Billed Charges,72% of Total Billed Charges,6491.3,60,,6415.496,Percent of Total Billed Charges,60% of Total Billed Charges,9736.95,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,4868.47,45,,1593.552,Percent of Total Billed Charges,45% of Total Billed Charges,9736.95,90,,2074.2,Percent of Total Billed Charges,90% of Total billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7032.24,65,,398.448,Percent of total Billed Charges,65% of Total Billed Charges,4771.1,44.1,,1561.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,10277.89,95,,2189.432,Percent of Total Billed Charges,95% of Total Billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9520.57,88,,25485.216,Percent of Total Billed Charges,88% of Total Billed Charges,9736.95,90,,2074.2,Percent of Total Billed charges,90% of Total Billed Charges,4771.1,10818.83,
Z59961351 FEMORAL,2780001446,CDM,278,RC,C1776,HCPCS,Outpatient,,,10818.83,7032.24,,10818.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8222.31,76,,11026.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7789.56,72,,1461.224,Percent of Total Billed Charges,72% of Total Billed Charges,7789.56,72,,1461.224,Percent of Total Billed charges,72% of Total Billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7789.56,72,,1461.224,Percent of Total Billed Charges,72% of Total Billed Charges,6491.3,60,,1217.688,Percent of Total Billed Charges,60% of Total Billed Charges,9736.95,90,,1603.48,Percent of Total Billed Charges,90% of Total Billed Charges,4868.47,45,,6065.032,Percent of Total Billed Charges,45% of Total Billed Charges,9736.95,90,,13058.016,Percent of Total Billed Charges,90% of Total billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7032.24,65,,72.24,Percent of total Billed Charges,65% of Total Billed Charges,4771.1,44.1,,5943.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,10277.89,95,,13783.456,Percent of Total Billed Charges,95% of Total Billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9520.57,88,,5187.856,Percent of Total Billed Charges,88% of Total Billed Charges,9736.95,90,,13058.016,Percent of Total Billed charges,90% of Total Billed Charges,4771.1,10818.83,
Z59961452 FEMORAL,2780001447,CDM,278,RC,C1776,HCPCS,Outpatient,,,10818.83,7032.24,,10818.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8222.31,76,,8747.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7789.56,72,,556.296,Percent of Total Billed Charges,72% of Total Billed Charges,7789.56,72,,556.296,Percent of Total Billed charges,72% of Total Billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7789.56,72,,556.296,Percent of Total Billed Charges,72% of Total Billed Charges,6491.3,60,,463.576,Percent of Total Billed Charges,60% of Total Billed Charges,9736.95,90,,4426.232,Percent of Total Billed Charges,90% of Total Billed Charges,4868.47,45,,13032.216,Percent of Total Billed Charges,45% of Total Billed Charges,9736.95,90,,10359.096,Percent of Total Billed Charges,90% of Total billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7032.24,65,,2512.2,Percent of total Billed Charges,65% of Total Billed Charges,4771.1,44.1,,12771.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,10277.89,95,,10934.6,Percent of Total Billed Charges,95% of Total Billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9520.57,88,,158.336,Percent of Total Billed Charges,88% of Total Billed Charges,9736.95,90,,10359.096,Percent of Total Billed charges,90% of Total Billed Charges,4771.1,10818.83,
Z59961451 FEMORAL,2780001448,CDM,278,RC,C1776,HCPCS,Outpatient,,,10818.83,7032.24,,10818.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8222.31,76,,2691.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7789.56,72,,1425.032,Percent of Total Billed Charges,72% of Total Billed Charges,7789.56,72,,1425.032,Percent of Total Billed charges,72% of Total Billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7789.56,72,,1425.032,Percent of Total Billed Charges,72% of Total Billed Charges,6491.3,60,,1187.528,Percent of Total Billed Charges,60% of Total Billed Charges,9736.95,90,,1601.896,Percent of Total Billed Charges,90% of Total Billed Charges,4868.47,45,,2652.88,Percent of Total Billed Charges,45% of Total Billed Charges,9736.95,90,,3187.112,Percent of Total Billed Charges,90% of Total billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7032.24,65,,318.184,Percent of total Billed Charges,65% of Total Billed Charges,4771.1,44.1,,2599.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,10277.89,95,,3364.168,Percent of Total Billed Charges,95% of Total Billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9520.57,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,9736.95,90,,3187.112,Percent of Total Billed charges,90% of Total Billed Charges,4771.1,10818.83,
Z59961552 FEMORAL,2780001449,CDM,278,RC,C1776,HCPCS,Outpatient,,,10818.83,7032.24,,10818.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8222.31,76,,10243.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7789.56,72,,2879.272,Percent of Total Billed Charges,72% of Total Billed Charges,7789.56,72,,2879.272,Percent of Total Billed charges,72% of Total Billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7789.56,72,,2879.272,Percent of Total Billed Charges,72% of Total Billed Charges,6491.3,60,,2399.392,Percent of Total Billed Charges,60% of Total Billed Charges,9736.95,90,,603.288,Percent of Total Billed Charges,90% of Total Billed Charges,4868.47,45,,80.968,Percent of Total Billed Charges,45% of Total Billed Charges,9736.95,90,,12130.056,Percent of Total Billed Charges,90% of Total billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7032.24,65,,2487.552,Percent of total Billed Charges,65% of Total Billed Charges,4771.1,44.1,,79.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,10277.89,95,,12803.952,Percent of Total Billed Charges,95% of Total Billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9520.57,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,9736.95,90,,12130.056,Percent of Total Billed charges,90% of Total Billed Charges,4771.1,10818.83,
Z59961551 FEMORAL,2780001450,CDM,278,RC,C1776,HCPCS,Outpatient,,,10818.83,7032.24,,10818.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8222.31,76,,22009.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7789.56,72,,1619.352,Percent of Total Billed Charges,72% of Total Billed Charges,7789.56,72,,1619.352,Percent of Total Billed charges,72% of Total Billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7789.56,72,,1619.352,Percent of Total Billed Charges,72% of Total Billed Charges,6491.3,60,,1349.464,Percent of Total Billed Charges,60% of Total Billed Charges,9736.95,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,4868.47,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,9736.95,90,,26064.424,Percent of Total Billed Charges,90% of Total billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7032.24,65,,6485.168,Percent of total Billed Charges,65% of Total Billed Charges,4771.1,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,10277.89,95,,27512.448,Percent of Total Billed Charges,95% of Total Billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9520.57,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,9736.95,90,,26064.424,Percent of Total Billed charges,90% of Total Billed Charges,4771.1,10818.83,
Z59961652 FEMORAL,2780001451,CDM,278,RC,C1776,HCPCS,Outpatient,,,10818.83,7032.24,,10818.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8222.31,76,,4480.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7789.56,72,,5462.784,Percent of Total Billed Charges,72% of Total Billed Charges,7789.56,72,,5462.784,Percent of Total Billed charges,72% of Total Billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7789.56,72,,5462.784,Percent of Total Billed Charges,72% of Total Billed Charges,6491.3,60,,4552.32,Percent of Total Billed Charges,60% of Total Billed Charges,9736.95,90,,220.68,Percent of Total Billed Charges,90% of Total Billed Charges,4868.47,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,9736.95,90,,5305.76,Percent of Total Billed Charges,90% of Total billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7032.24,65,,4558.312,Percent of total Billed Charges,65% of Total Billed Charges,4771.1,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,10277.89,95,,5600.52,Percent of Total Billed Charges,95% of Total Billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9520.57,88,,1567.84,Percent of Total Billed Charges,88% of Total Billed Charges,9736.95,90,,5305.76,Percent of Total Billed charges,90% of Total Billed Charges,4771.1,10818.83,
Z59961651 FEMORAL,2780001452,CDM,278,RC,C1776,HCPCS,Outpatient,,,10818.83,7032.24,,10818.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8222.31,76,,136.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7789.56,72,,1682.856,Percent of Total Billed Charges,72% of Total Billed Charges,7789.56,72,,1682.856,Percent of Total Billed charges,72% of Total Billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7789.56,72,,1682.856,Percent of Total Billed Charges,72% of Total Billed Charges,6491.3,60,,1402.384,Percent of Total Billed Charges,60% of Total Billed Charges,9736.95,90,,154.792,Percent of Total Billed Charges,90% of Total Billed Charges,4868.47,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,9736.95,90,,161.936,Percent of Total Billed Charges,90% of Total billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7032.24,65,,4985.992,Percent of total Billed Charges,65% of Total Billed Charges,4771.1,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,10277.89,95,,170.928,Percent of Total Billed Charges,95% of Total Billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9520.57,88,,4327.872,Percent of Total Billed Charges,88% of Total Billed Charges,9736.95,90,,161.936,Percent of Total Billed charges,90% of Total Billed Charges,4771.1,10818.83,
Z59961752 FEMORAL,2780001453,CDM,278,RC,C1776,HCPCS,Outpatient,,,10818.83,7032.24,,10818.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8222.31,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7789.56,72,,2187.712,Percent of Total Billed Charges,72% of Total Billed Charges,7789.56,72,,2187.712,Percent of Total Billed charges,72% of Total Billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7789.56,72,,2187.712,Percent of Total Billed Charges,72% of Total Billed Charges,6491.3,60,,1823.096,Percent of Total Billed Charges,60% of Total Billed Charges,9736.95,90,,4313.512,Percent of Total Billed Charges,90% of Total Billed Charges,4868.47,45,,801.736,Percent of Total Billed Charges,45% of Total Billed Charges,9736.95,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7032.24,65,,2270.272,Percent of total Billed Charges,65% of Total Billed Charges,4771.1,44.1,,785.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,10277.89,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,10818.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9520.57,88,,1566.296,Percent of Total Billed Charges,88% of Total Billed Charges,9736.95,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,4771.1,10818.83,
Z59963010 ART SURF,2780001454,CDM,278,RC,C1776,HCPCS,Outpatient,,,4618.37,3001.94,,4618.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3509.96,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3325.23,72,,1725.4,Percent of Total Billed Charges,72% of Total Billed Charges,3325.23,72,,1725.4,Percent of Total Billed charges,72% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3325.23,72,,1725.4,Percent of Total Billed Charges,72% of Total Billed Charges,2771.02,60,,1437.832,Percent of Total Billed Charges,60% of Total Billed Charges,4156.53,90,,3385.552,Percent of Total Billed Charges,90% of Total Billed Charges,2078.27,45,,2213.112,Percent of Total Billed Charges,45% of Total Billed Charges,4156.53,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3001.94,65,,2270.272,Percent of total Billed Charges,65% of Total Billed Charges,2036.7,44.1,,2168.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,4387.45,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4064.17,88,,589.88,Percent of Total Billed Charges,88% of Total Billed Charges,4156.53,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,2036.7,4618.37,
Z59963112 ART SURF,2780001455,CDM,278,RC,C1776,HCPCS,Outpatient,,,4618.37,3001.94,,4618.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3509.96,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3325.23,72,,2353.464,Percent of Total Billed Charges,72% of Total Billed Charges,3325.23,72,,2353.464,Percent of Total Billed charges,72% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3325.23,72,,2353.464,Percent of Total Billed Charges,72% of Total Billed Charges,2771.02,60,,1961.216,Percent of Total Billed Charges,60% of Total Billed Charges,4156.53,90,,3725.304,Percent of Total Billed Charges,90% of Total Billed Charges,2078.27,45,,800.944,Percent of Total Billed Charges,45% of Total Billed Charges,4156.53,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3001.94,65,,299.84,Percent of total Billed Charges,65% of Total Billed Charges,2036.7,44.1,,784.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,4387.45,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4064.17,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,4156.53,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,2036.7,4618.37,
Z59963020 ART SURF,2780001456,CDM,278,RC,C1776,HCPCS,Outpatient,,,4618.37,3001.94,,4618.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3509.96,76,,1354.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3325.23,72,,2058.16,Percent of Total Billed Charges,72% of Total Billed Charges,3325.23,72,,2058.16,Percent of Total Billed charges,72% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3325.23,72,,2058.16,Percent of Total Billed Charges,72% of Total Billed Charges,2771.02,60,,1715.136,Percent of Total Billed Charges,60% of Total Billed Charges,4156.53,90,,268.312,Percent of Total Billed Charges,90% of Total Billed Charges,2078.27,45,,301.648,Percent of Total Billed Charges,45% of Total Billed Charges,4156.53,90,,1603.48,Percent of Total Billed Charges,90% of Total billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3001.94,65,,36.12,Percent of total Billed Charges,65% of Total Billed Charges,2036.7,44.1,,295.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,4387.45,95,,1692.56,Percent of Total Billed Charges,95% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4064.17,88,,215.776,Percent of Total Billed Charges,88% of Total Billed Charges,4156.53,90,,1603.48,Percent of Total Billed charges,90% of Total Billed Charges,2036.7,4618.37,
Z59963014 ART SURF,2780001457,CDM,278,RC,C1776,HCPCS,Outpatient,,,4618.37,3001.94,,4618.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3509.96,76,,3737.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3325.23,72,,7830.68,Percent of Total Billed Charges,72% of Total Billed Charges,3325.23,72,,7830.68,Percent of Total Billed charges,72% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3325.23,72,,7830.68,Percent of Total Billed Charges,72% of Total Billed Charges,2771.02,60,,6525.568,Percent of Total Billed Charges,60% of Total Billed Charges,4156.53,90,,234.176,Percent of Total Billed Charges,90% of Total Billed Charges,2078.27,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,4156.53,90,,4426.232,Percent of Total Billed Charges,90% of Total billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3001.94,65,,300.408,Percent of total Billed Charges,65% of Total Billed Charges,2036.7,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,4387.45,95,,4672.128,Percent of Total Billed Charges,95% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4064.17,88,,151.352,Percent of Total Billed Charges,88% of Total Billed Charges,4156.53,90,,4426.232,Percent of Total Billed charges,90% of Total Billed Charges,2036.7,4618.37,
Z59963012 ART SURF,2780001458,CDM,278,RC,C1776,HCPCS,Outpatient,,,4618.37,3001.94,,4618.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3509.96,76,,1352.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3325.23,72,,585.512,Percent of Total Billed Charges,72% of Total Billed Charges,3325.23,72,,585.512,Percent of Total Billed charges,72% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3325.23,72,,585.512,Percent of Total Billed Charges,72% of Total Billed Charges,2771.02,60,,487.928,Percent of Total Billed Charges,60% of Total Billed Charges,4156.53,90,,234.176,Percent of Total Billed Charges,90% of Total Billed Charges,2078.27,45,,110.344,Percent of Total Billed Charges,45% of Total Billed Charges,4156.53,90,,1601.896,Percent of Total Billed Charges,90% of Total billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3001.94,65,,787.136,Percent of total Billed Charges,65% of Total Billed Charges,2036.7,44.1,,108.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,4387.45,95,,1690.888,Percent of Total Billed Charges,95% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4064.17,88,,4217.656,Percent of Total Billed Charges,88% of Total Billed Charges,4156.53,90,,1601.896,Percent of Total Billed charges,90% of Total Billed Charges,2036.7,4618.37,
Z59963210 ART SURF,2780001459,CDM,278,RC,C1776,HCPCS,Outpatient,,,4618.37,3001.94,,4618.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3509.96,76,,509.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3325.23,72,,853.496,Percent of Total Billed Charges,72% of Total Billed Charges,3325.23,72,,853.496,Percent of Total Billed charges,72% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3325.23,72,,853.496,Percent of Total Billed Charges,72% of Total Billed Charges,2771.02,60,,711.248,Percent of Total Billed Charges,60% of Total Billed Charges,4156.53,90,,4426.232,Percent of Total Billed Charges,90% of Total Billed Charges,2078.27,45,,77.4,Percent of Total Billed Charges,45% of Total Billed Charges,4156.53,90,,603.288,Percent of Total Billed Charges,90% of Total billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3001.94,65,,904.096,Percent of total Billed Charges,65% of Total Billed Charges,2036.7,44.1,,75.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,4387.45,95,,636.808,Percent of Total Billed Charges,95% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4064.17,88,,3310.32,Percent of Total Billed Charges,88% of Total Billed Charges,4156.53,90,,603.288,Percent of Total Billed charges,90% of Total Billed Charges,2036.7,4618.37,
Z59963212 ART SURF,2780001460,CDM,278,RC,C1776,HCPCS,Outpatient,,,4618.37,3001.94,,4618.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3509.96,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3325.23,72,,314.976,Percent of Total Billed Charges,72% of Total Billed Charges,3325.23,72,,314.976,Percent of Total Billed charges,72% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3325.23,72,,314.976,Percent of Total Billed Charges,72% of Total Billed Charges,2771.02,60,,262.48,Percent of Total Billed Charges,60% of Total Billed Charges,4156.53,90,,50.008,Percent of Total Billed Charges,90% of Total Billed Charges,2078.27,45,,2156.76,Percent of Total Billed Charges,45% of Total Billed Charges,4156.53,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3001.94,65,,46.44,Percent of total Billed Charges,65% of Total Billed Charges,2036.7,44.1,,2113.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,4387.45,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4064.17,88,,3642.52,Percent of Total Billed Charges,88% of Total Billed Charges,4156.53,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,2036.7,4618.37,
Z59963214 ART SURF,2780001461,CDM,278,RC,C1776,HCPCS,Outpatient,,,4618.37,3001.94,,4618.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3509.96,76,,186.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3325.23,72,,2566.08,Percent of Total Billed Charges,72% of Total Billed Charges,3325.23,72,,2566.08,Percent of Total Billed charges,72% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3325.23,72,,2566.08,Percent of Total Billed Charges,72% of Total Billed Charges,2771.02,60,,2138.4,Percent of Total Billed Charges,60% of Total Billed Charges,4156.53,90,,3185.52,Percent of Total Billed Charges,90% of Total Billed Charges,2078.27,45,,1692.776,Percent of Total Billed Charges,45% of Total Billed Charges,4156.53,90,,220.68,Percent of Total Billed Charges,90% of Total billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3001.94,65,,60.192,Percent of total Billed Charges,65% of Total Billed Charges,2036.7,44.1,,1658.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,4387.45,95,,232.944,Percent of Total Billed Charges,95% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4064.17,88,,262.344,Percent of Total Billed Charges,88% of Total Billed Charges,4156.53,90,,220.68,Percent of Total Billed charges,90% of Total Billed Charges,2036.7,4618.37,
Z59964010 ART SURF,2780001462,CDM,278,RC,C1776,HCPCS,Outpatient,,,4618.37,3001.94,,4618.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3509.96,76,,130.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3325.23,72,,120.024,Percent of Total Billed Charges,72% of Total Billed Charges,3325.23,72,,120.024,Percent of Total Billed charges,72% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3325.23,72,,120.024,Percent of Total Billed Charges,72% of Total Billed Charges,2771.02,60,,100.016,Percent of Total Billed Charges,60% of Total Billed Charges,4156.53,90,,551.696,Percent of Total Billed Charges,90% of Total Billed Charges,2078.27,45,,1862.648,Percent of Total Billed Charges,45% of Total Billed Charges,4156.53,90,,154.792,Percent of Total Billed Charges,90% of Total billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3001.94,65,,670.184,Percent of total Billed Charges,65% of Total Billed Charges,2036.7,44.1,,1825.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,4387.45,95,,163.392,Percent of Total Billed Charges,95% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4064.17,88,,228.968,Percent of Total Billed Charges,88% of Total Billed Charges,4156.53,90,,154.792,Percent of Total Billed charges,90% of Total Billed Charges,2036.7,4618.37,
Z59964110 ART SURF,2780001463,CDM,278,RC,C1776,HCPCS,Outpatient,,,4618.37,3001.94,,4618.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3509.96,76,,3642.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3325.23,72,,9799.936,Percent of Total Billed Charges,72% of Total Billed Charges,3325.23,72,,9799.936,Percent of Total Billed charges,72% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3325.23,72,,9799.936,Percent of Total Billed Charges,72% of Total Billed Charges,2771.02,60,,8166.616,Percent of Total Billed Charges,60% of Total Billed Charges,4156.53,90,,100.024,Percent of Total Billed Charges,90% of Total Billed Charges,2078.27,45,,134.152,Percent of Total Billed Charges,45% of Total Billed Charges,4156.53,90,,4313.512,Percent of Total Billed Charges,90% of Total billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3001.94,65,,995.824,Percent of total Billed Charges,65% of Total Billed Charges,2036.7,44.1,,131.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,4387.45,95,,4553.152,Percent of Total Billed Charges,95% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4064.17,88,,228.968,Percent of Total Billed Charges,88% of Total Billed Charges,4156.53,90,,4313.512,Percent of Total Billed charges,90% of Total Billed Charges,2036.7,4618.37,
Z59964012 ART SURF,2780001464,CDM,278,RC,C1776,HCPCS,Outpatient,,,4618.37,3001.94,,4618.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3509.96,76,,2858.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3325.23,72,,2556.288,Percent of Total Billed Charges,72% of Total Billed Charges,3325.23,72,,2556.288,Percent of Total Billed charges,72% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3325.23,72,,2556.288,Percent of Total Billed Charges,72% of Total Billed Charges,2771.02,60,,2130.24,Percent of Total Billed Charges,60% of Total Billed Charges,4156.53,90,,3478.432,Percent of Total Billed Charges,90% of Total Billed Charges,2078.27,45,,117.088,Percent of Total Billed Charges,45% of Total Billed Charges,4156.53,90,,3385.552,Percent of Total Billed Charges,90% of Total billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3001.94,65,,508.52,Percent of total Billed Charges,65% of Total Billed Charges,2036.7,44.1,,114.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,4387.45,95,,3573.64,Percent of Total Billed Charges,95% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4064.17,88,,4327.872,Percent of Total Billed Charges,88% of Total Billed Charges,4156.53,90,,3385.552,Percent of Total Billed charges,90% of Total Billed Charges,2036.7,4618.37,
Z59964014 ART SURF,2780001465,CDM,278,RC,C1776,HCPCS,Outpatient,,,4618.37,3001.94,,4618.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3509.96,76,,3145.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3325.23,72,,2616.192,Percent of Total Billed Charges,72% of Total Billed Charges,3325.23,72,,2616.192,Percent of Total Billed charges,72% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3325.23,72,,2616.192,Percent of Total Billed Charges,72% of Total Billed Charges,2771.02,60,,2180.16,Percent of Total Billed Charges,60% of Total Billed Charges,4156.53,90,,440.56,Percent of Total Billed Charges,90% of Total Billed Charges,2078.27,45,,117.088,Percent of Total Billed Charges,45% of Total Billed Charges,4156.53,90,,3725.304,Percent of Total Billed Charges,90% of Total billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3001.94,65,,4343.32,Percent of total Billed Charges,65% of Total Billed Charges,2036.7,44.1,,114.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,4387.45,95,,3932.264,Percent of Total Billed Charges,95% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4064.17,88,,48.896,Percent of Total Billed Charges,88% of Total Billed Charges,4156.53,90,,3725.304,Percent of Total Billed charges,90% of Total Billed Charges,2036.7,4618.37,
Z59964210 ART SURF,2780001466,CDM,278,RC,C1776,HCPCS,Outpatient,,,4618.37,3001.94,,4618.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3509.96,76,,226.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3325.23,72,,1758.528,Percent of Total Billed Charges,72% of Total Billed Charges,3325.23,72,,1758.528,Percent of Total Billed charges,72% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3325.23,72,,1758.528,Percent of Total Billed Charges,72% of Total Billed Charges,2771.02,60,,1465.44,Percent of Total Billed Charges,60% of Total Billed Charges,4156.53,90,,3444.304,Percent of Total Billed Charges,90% of Total Billed Charges,2078.27,45,,2213.112,Percent of Total Billed Charges,45% of Total Billed Charges,4156.53,90,,268.312,Percent of Total Billed Charges,90% of Total billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3001.94,65,,1717.032,Percent of total Billed Charges,65% of Total Billed Charges,2036.7,44.1,,2168.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,4387.45,95,,283.216,Percent of Total Billed Charges,95% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4064.17,88,,3114.728,Percent of Total Billed Charges,88% of Total Billed Charges,4156.53,90,,268.312,Percent of Total Billed charges,90% of Total Billed Charges,2036.7,4618.37,
Z59964212 ART SURF,2780001467,CDM,278,RC,C1776,HCPCS,Outpatient,,,4618.37,3001.94,,4618.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3509.96,76,,197.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3325.23,72,,3296.448,Percent of Total Billed Charges,72% of Total Billed Charges,3325.23,72,,3296.448,Percent of Total Billed charges,72% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3325.23,72,,3296.448,Percent of Total Billed Charges,72% of Total Billed Charges,2771.02,60,,2747.04,Percent of Total Billed Charges,60% of Total Billed Charges,4156.53,90,,8979.464,Percent of Total Billed Charges,90% of Total Billed Charges,2078.27,45,,25.008,Percent of Total Billed Charges,45% of Total Billed Charges,4156.53,90,,234.176,Percent of Total Billed Charges,90% of Total billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3001.94,65,,435.712,Percent of total Billed Charges,65% of Total Billed Charges,2036.7,44.1,,24.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,4387.45,95,,247.184,Percent of Total Billed Charges,95% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4064.17,88,,539.432,Percent of Total Billed Charges,88% of Total Billed Charges,4156.53,90,,234.176,Percent of Total Billed charges,90% of Total Billed Charges,2036.7,4618.37,
Z59964214 ART SURF,2780001468,CDM,278,RC,C1776,HCPCS,Outpatient,,,4618.37,3001.94,,4618.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3509.96,76,,197.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3325.23,72,,1738.368,Percent of Total Billed Charges,72% of Total Billed Charges,3325.23,72,,1738.368,Percent of Total Billed charges,72% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3325.23,72,,1738.368,Percent of Total Billed Charges,72% of Total Billed Charges,2771.02,60,,1448.64,Percent of Total Billed Charges,60% of Total Billed Charges,4156.53,90,,6311.504,Percent of Total Billed Charges,90% of Total Billed Charges,2078.27,45,,1592.76,Percent of Total Billed Charges,45% of Total Billed Charges,4156.53,90,,234.176,Percent of Total Billed Charges,90% of Total billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3001.94,65,,435.712,Percent of total Billed Charges,65% of Total Billed Charges,2036.7,44.1,,1560.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,4387.45,95,,247.184,Percent of Total Billed Charges,95% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4064.17,88,,97.8,Percent of Total Billed Charges,88% of Total Billed Charges,4156.53,90,,234.176,Percent of Total Billed charges,90% of Total Billed Charges,2036.7,4618.37,
Z59965010 ART SURF,2780001469,CDM,278,RC,C1776,HCPCS,Outpatient,,,4618.37,3001.94,,4618.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3509.96,76,,3737.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3325.23,72,,1439.64,Percent of Total Billed Charges,72% of Total Billed Charges,3325.23,72,,1439.64,Percent of Total Billed charges,72% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3325.23,72,,1439.64,Percent of Total Billed Charges,72% of Total Billed Charges,2771.02,60,,1199.696,Percent of Total Billed Charges,60% of Total Billed Charges,4156.53,90,,6903.68,Percent of Total Billed Charges,90% of Total Billed Charges,2078.27,45,,275.848,Percent of Total Billed Charges,45% of Total Billed Charges,4156.53,90,,4426.232,Percent of Total Billed Charges,90% of Total billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3001.94,65,,31.72,Percent of total Billed Charges,65% of Total Billed Charges,2036.7,44.1,,270.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,4387.45,95,,4672.128,Percent of Total Billed Charges,95% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4064.17,88,,3401.136,Percent of Total Billed Charges,88% of Total Billed Charges,4156.53,90,,4426.232,Percent of Total Billed charges,90% of Total Billed Charges,2036.7,4618.37,
Z59965110 ART SURF,2780001470,CDM,278,RC,C1776,HCPCS,Outpatient,,,4618.37,3001.94,,4618.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3509.96,76,,42.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3325.23,72,,3476.16,Percent of Total Billed Charges,72% of Total Billed Charges,3325.23,72,,3476.16,Percent of Total Billed charges,72% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3325.23,72,,3476.16,Percent of Total Billed Charges,72% of Total Billed Charges,2771.02,60,,2896.8,Percent of Total Billed Charges,60% of Total Billed Charges,4156.53,90,,3143.448,Percent of Total Billed Charges,90% of Total Billed Charges,2078.27,45,,50.008,Percent of Total Billed Charges,45% of Total Billed Charges,4156.53,90,,50.008,Percent of Total Billed Charges,90% of Total billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3001.94,65,,108.352,Percent of total Billed Charges,65% of Total Billed Charges,2036.7,44.1,,49.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,4387.45,95,,52.792,Percent of Total Billed Charges,95% of Total Billed Charges,4618.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4064.17,88,,430.768,Percent of Total Billed Charges,88% of Total Billed Charges,4156.53,90,,50.008,Percent of Total Billed charges,90% of Total Billed Charges,2036.7,4618.37,
Z62504530 4.5 BONE,2780001471,CDM,278,RC,C1776,HCPCS,Outpatient,,,744.19,483.72,,744.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,565.58,76,,2689.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,535.82,72,,2198.016,Percent of Total Billed Charges,72% of Total Billed Charges,535.82,72,,2198.016,Percent of Total Billed charges,72% of Total Billed Charges,744.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.82,72,,2198.016,Percent of Total Billed Charges,72% of Total Billed Charges,446.51,60,,1831.68,Percent of Total Billed Charges,60% of Total Billed Charges,669.77,90,,3143.448,Percent of Total Billed Charges,90% of Total Billed Charges,334.89,45,,1739.216,Percent of Total Billed Charges,45% of Total Billed Charges,669.77,90,,3185.52,Percent of Total Billed Charges,90% of Total billed Charges,744.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,744.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,744.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,483.72,65,,42.424,Percent of total Billed Charges,65% of Total Billed Charges,328.19,44.1,,1704.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,706.98,95,,3362.488,Percent of Total Billed Charges,95% of Total Billed Charges,744.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,654.89,88,,3367.76,Percent of Total Billed Charges,88% of Total Billed Charges,669.77,90,,3185.52,Percent of Total Billed charges,90% of Total Billed Charges,328.19,744.19,
Z781841 FEMORAL HEA,2780001472,CDM,278,RC,C1776,HCPCS,Outpatient,,,2835.63,1843.16,,2835.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2155.08,76,,465.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2041.65,72,,2717.336,Percent of Total Billed Charges,72% of Total Billed Charges,2041.65,72,,2717.336,Percent of Total Billed charges,72% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2041.65,72,,2717.336,Percent of Total Billed Charges,72% of Total Billed Charges,1701.38,60,,2264.448,Percent of Total Billed Charges,60% of Total Billed Charges,2552.07,90,,415.16,Percent of Total Billed Charges,90% of Total Billed Charges,1276.03,45,,220.28,Percent of Total Billed Charges,45% of Total Billed Charges,2552.07,90,,551.696,Percent of Total Billed Charges,90% of Total billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1843.16,65,,42.424,Percent of total Billed Charges,65% of Total Billed Charges,1250.51,44.1,,215.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,2693.85,95,,582.344,Percent of Total Billed Charges,95% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2495.35,88,,8779.92,Percent of Total Billed Charges,88% of Total Billed Charges,2552.07,90,,551.696,Percent of Total Billed charges,90% of Total Billed Charges,1250.51,2835.63,
Z781842 FEMORAL HEA,2780001473,CDM,278,RC,C1776,HCPCS,Outpatient,,,2835.63,1843.16,,2835.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2155.08,76,,84.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2041.65,72,,1063.696,Percent of Total Billed Charges,72% of Total Billed Charges,2041.65,72,,1063.696,Percent of Total Billed charges,72% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2041.65,72,,1063.696,Percent of Total Billed Charges,72% of Total Billed Charges,1701.38,60,,886.408,Percent of Total Billed Charges,60% of Total Billed Charges,2552.07,90,,50.008,Percent of Total Billed Charges,90% of Total Billed Charges,1276.03,45,,1722.152,Percent of Total Billed Charges,45% of Total Billed Charges,2552.07,90,,100.024,Percent of Total Billed Charges,90% of Total billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1843.16,65,,42.424,Percent of total Billed Charges,65% of Total Billed Charges,1250.51,44.1,,1687.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,2693.85,95,,105.576,Percent of Total Billed Charges,95% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2495.35,88,,6171.248,Percent of Total Billed Charges,88% of Total Billed Charges,2552.07,90,,100.024,Percent of Total Billed charges,90% of Total Billed Charges,1250.51,2835.63,
Z781843 FEMORAL HEA,2780001474,CDM,278,RC,C1776,HCPCS,Outpatient,,,2835.63,1843.16,,2835.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2155.08,76,,2937.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2041.65,72,,732.096,Percent of Total Billed Charges,72% of Total Billed Charges,2041.65,72,,732.096,Percent of Total Billed charges,72% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2041.65,72,,732.096,Percent of Total Billed Charges,72% of Total Billed Charges,1701.38,60,,610.08,Percent of Total Billed Charges,60% of Total Billed Charges,2552.07,90,,415.952,Percent of Total Billed Charges,90% of Total Billed Charges,1276.03,45,,4489.736,Percent of Total Billed Charges,45% of Total Billed Charges,2552.07,90,,3478.432,Percent of Total Billed Charges,90% of Total billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1843.16,65,,42.424,Percent of total Billed Charges,65% of Total Billed Charges,1250.51,44.1,,4399.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,2693.85,95,,3671.68,Percent of Total Billed Charges,95% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2495.35,88,,6750.264,Percent of Total Billed Charges,88% of Total Billed Charges,2552.07,90,,3478.432,Percent of Total Billed charges,90% of Total Billed Charges,1250.51,2835.63,
Z781844 FEMORAL HEA,2780001475,CDM,278,RC,C1776,HCPCS,Outpatient,,,2835.63,1843.16,,2835.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2155.08,76,,372.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2041.65,72,,572.168,Percent of Total Billed Charges,72% of Total Billed Charges,2041.65,72,,572.168,Percent of Total Billed charges,72% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2041.65,72,,572.168,Percent of Total Billed Charges,72% of Total Billed Charges,1701.38,60,,476.808,Percent of Total Billed Charges,60% of Total Billed Charges,2552.07,90,,1089.888,Percent of Total Billed Charges,90% of Total Billed Charges,1276.03,45,,3155.752,Percent of Total Billed Charges,45% of Total Billed Charges,2552.07,90,,440.56,Percent of Total Billed Charges,90% of Total billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1843.16,65,,615.152,Percent of total Billed Charges,65% of Total Billed Charges,1250.51,44.1,,3092.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,2693.85,95,,465.04,Percent of Total Billed Charges,95% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2495.35,88,,3073.592,Percent of Total Billed Charges,88% of Total Billed Charges,2552.07,90,,440.56,Percent of Total Billed charges,90% of Total Billed Charges,1250.51,2835.63,
Z781845 FEMORAL HEA,2780001476,CDM,278,RC,C1776,HCPCS,Outpatient,,,2835.63,1843.16,,2835.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2155.08,76,,2908.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2041.65,72,,527.088,Percent of Total Billed Charges,72% of Total Billed Charges,2041.65,72,,527.088,Percent of Total Billed charges,72% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2041.65,72,,527.088,Percent of Total Billed Charges,72% of Total Billed Charges,1701.38,60,,439.24,Percent of Total Billed Charges,60% of Total Billed Charges,2552.07,90,,1251.824,Percent of Total Billed Charges,90% of Total Billed Charges,1276.03,45,,3451.84,Percent of Total Billed Charges,45% of Total Billed Charges,2552.07,90,,3444.304,Percent of Total Billed Charges,90% of Total billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1843.16,65,,901.8,Percent of total Billed Charges,65% of Total Billed Charges,1250.51,44.1,,3382.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,2693.85,95,,3635.648,Percent of Total Billed Charges,95% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2495.35,88,,3073.592,Percent of Total Billed Charges,88% of Total Billed Charges,2552.07,90,,3444.304,Percent of Total Billed charges,90% of Total Billed Charges,1250.51,2835.63,
Z781847 FEMORAL HEA,2780001477,CDM,278,RC,C1776,HCPCS,Outpatient,,,2835.63,1843.16,,2835.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2155.08,76,,7582.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2041.65,72,,738.552,Percent of Total Billed Charges,72% of Total Billed Charges,2041.65,72,,738.552,Percent of Total Billed charges,72% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2041.65,72,,738.552,Percent of Total Billed Charges,72% of Total Billed Charges,1701.38,60,,615.464,Percent of Total Billed Charges,60% of Total Billed Charges,2552.07,90,,64.296,Percent of Total Billed Charges,90% of Total Billed Charges,1276.03,45,,1571.728,Percent of Total Billed Charges,45% of Total Billed Charges,2552.07,90,,8979.464,Percent of Total Billed Charges,90% of Total billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1843.16,65,,1392.544,Percent of total Billed Charges,65% of Total Billed Charges,1250.51,44.1,,1540.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,2693.85,95,,9478.328,Percent of Total Billed Charges,95% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2495.35,88,,405.936,Percent of Total Billed Charges,88% of Total Billed Charges,2552.07,90,,8979.464,Percent of Total Billed charges,90% of Total Billed Charges,1250.51,2835.63,
Z781848 FEMORAL HEA,2780001478,CDM,278,RC,C1776,HCPCS,Outpatient,,,2835.63,1843.16,,2835.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2155.08,76,,5329.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2041.65,72,,455.32,Percent of Total Billed Charges,72% of Total Billed Charges,2041.65,72,,455.32,Percent of Total Billed charges,72% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2041.65,72,,455.32,Percent of Total Billed Charges,72% of Total Billed Charges,1701.38,60,,379.432,Percent of Total Billed Charges,60% of Total Billed Charges,2552.07,90,,83.344,Percent of Total Billed Charges,90% of Total Billed Charges,1276.03,45,,1571.728,Percent of Total Billed Charges,45% of Total Billed Charges,2552.07,90,,6311.504,Percent of Total Billed Charges,90% of Total billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1843.16,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,1250.51,44.1,,1540.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,2693.85,95,,6662.144,Percent of Total Billed Charges,95% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2495.35,88,,48.896,Percent of Total Billed Charges,88% of Total Billed Charges,2552.07,90,,6311.504,Percent of Total Billed charges,90% of Total Billed Charges,1250.51,2835.63,
Z781849 FEMORAL HEA,2780001479,CDM,278,RC,C1776,HCPCS,Outpatient,,,2835.63,1843.16,,2835.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2155.08,76,,5829.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2041.65,72,,455.32,Percent of Total Billed Charges,72% of Total Billed Charges,2041.65,72,,455.32,Percent of Total Billed charges,72% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2041.65,72,,455.32,Percent of Total Billed Charges,72% of Total Billed Charges,1701.38,60,,379.432,Percent of Total Billed Charges,60% of Total Billed Charges,2552.07,90,,927.952,Percent of Total Billed Charges,90% of Total Billed Charges,1276.03,45,,207.576,Percent of Total Billed Charges,45% of Total Billed Charges,2552.07,90,,6903.68,Percent of Total Billed Charges,90% of Total billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1843.16,65,,110.648,Percent of total Billed Charges,65% of Total Billed Charges,1250.51,44.1,,203.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,2693.85,95,,7287.216,Percent of Total Billed Charges,95% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2495.35,88,,406.704,Percent of Total Billed Charges,88% of Total Billed Charges,2552.07,90,,6903.68,Percent of Total Billed charges,90% of Total Billed Charges,1250.51,2835.63,
Z781850 FEMORAL HEA,2780001480,CDM,278,RC,C1776,HCPCS,Outpatient,,,2835.63,1843.16,,2835.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2155.08,76,,2654.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2041.65,72,,455.32,Percent of Total Billed Charges,72% of Total Billed Charges,2041.65,72,,455.32,Percent of Total Billed charges,72% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2041.65,72,,455.32,Percent of Total Billed Charges,72% of Total Billed Charges,1701.38,60,,379.432,Percent of Total Billed Charges,60% of Total Billed Charges,2552.07,90,,1378.832,Percent of Total Billed Charges,90% of Total Billed Charges,1276.03,45,,25.008,Percent of Total Billed Charges,45% of Total Billed Charges,2552.07,90,,3143.448,Percent of Total Billed Charges,90% of Total billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1843.16,65,,1158.064,Percent of total Billed Charges,65% of Total Billed Charges,1250.51,44.1,,24.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,2693.85,95,,3318.088,Percent of Total Billed Charges,95% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2495.35,88,,1065.664,Percent of Total Billed Charges,88% of Total Billed Charges,2552.07,90,,3143.448,Percent of Total Billed charges,90% of Total Billed Charges,1250.51,2835.63,
Z781853 FEMORAL HEA,2780001481,CDM,278,RC,C1776,HCPCS,Outpatient,,,2835.63,1843.16,,2835.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2155.08,76,,2654.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2041.65,72,,455.32,Percent of Total Billed Charges,72% of Total Billed Charges,2041.65,72,,455.32,Percent of Total Billed charges,72% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2041.65,72,,455.32,Percent of Total Billed Charges,72% of Total Billed Charges,1701.38,60,,379.432,Percent of Total Billed Charges,60% of Total Billed Charges,2552.07,90,,704.104,Percent of Total Billed Charges,90% of Total Billed Charges,1276.03,45,,207.976,Percent of Total Billed Charges,45% of Total Billed Charges,2552.07,90,,3143.448,Percent of Total Billed Charges,90% of Total billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1843.16,65,,3196.72,Percent of total Billed Charges,65% of Total Billed Charges,1250.51,44.1,,203.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,2693.85,95,,3318.088,Percent of Total Billed Charges,95% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2495.35,88,,1224,Percent of Total Billed Charges,88% of Total Billed Charges,2552.07,90,,3143.448,Percent of Total Billed charges,90% of Total Billed Charges,1250.51,2835.63,
Z781854 FEMORAL HEA,2780001482,CDM,278,RC,C1776,HCPCS,Outpatient,,,2835.63,1843.16,,2835.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2155.08,76,,350.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2041.65,72,,455.32,Percent of Total Billed Charges,72% of Total Billed Charges,2041.65,72,,455.32,Percent of Total Billed charges,72% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2041.65,72,,455.32,Percent of Total Billed Charges,72% of Total Billed Charges,1701.38,60,,379.432,Percent of Total Billed Charges,60% of Total Billed Charges,2552.07,90,,6013.832,Percent of Total Billed Charges,90% of Total Billed Charges,1276.03,45,,544.944,Percent of Total Billed Charges,45% of Total Billed Charges,2552.07,90,,415.16,Percent of Total Billed Charges,90% of Total billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1843.16,65,,426.536,Percent of total Billed Charges,65% of Total Billed Charges,1250.51,44.1,,534.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,2693.85,95,,438.224,Percent of Total Billed Charges,95% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2495.35,88,,62.864,Percent of Total Billed Charges,88% of Total Billed Charges,2552.07,90,,415.16,Percent of Total Billed charges,90% of Total Billed Charges,1250.51,2835.63,
Z781860 FEMORAL HEA,2780001483,CDM,278,RC,C1776,HCPCS,Outpatient,,,2835.63,1843.16,,2835.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2155.08,76,,42.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2041.65,72,,455.32,Percent of Total Billed Charges,72% of Total Billed Charges,2041.65,72,,455.32,Percent of Total Billed charges,72% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2041.65,72,,455.32,Percent of Total Billed Charges,72% of Total Billed Charges,1701.38,60,,379.432,Percent of Total Billed Charges,60% of Total Billed Charges,2552.07,90,,2377.432,Percent of Total Billed Charges,90% of Total Billed Charges,1276.03,45,,625.912,Percent of Total Billed Charges,45% of Total Billed Charges,2552.07,90,,50.008,Percent of Total Billed Charges,90% of Total billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1843.16,65,,288.368,Percent of total Billed Charges,65% of Total Billed Charges,1250.51,44.1,,613.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,2693.85,95,,52.792,Percent of Total Billed Charges,95% of Total Billed Charges,2835.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2495.35,88,,81.496,Percent of Total Billed Charges,88% of Total Billed Charges,2552.07,90,,50.008,Percent of Total Billed charges,90% of Total Billed Charges,1250.51,2835.63,
Z781899 FEMORAL HEA,2780001484,CDM,278,RC,C1776,HCPCS,Outpatient,,,739.78,480.86,,739.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,562.23,76,,351.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,532.64,72,,238.144,Percent of Total Billed Charges,72% of Total Billed Charges,532.64,72,,238.144,Percent of Total Billed charges,72% of Total Billed Charges,739.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,532.64,72,,238.144,Percent of Total Billed Charges,72% of Total Billed Charges,443.87,60,,198.448,Percent of Total Billed Charges,60% of Total Billed Charges,665.8,90,,603.288,Percent of Total Billed Charges,90% of Total Billed Charges,332.9,45,,32.152,Percent of Total Billed Charges,45% of Total Billed Charges,665.8,90,,415.952,Percent of Total Billed Charges,90% of Total billed Charges,739.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,739.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,739.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.86,65,,354.872,Percent of total Billed Charges,65% of Total Billed Charges,326.24,44.1,,31.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,702.79,95,,439.056,Percent of Total Billed Charges,95% of Total Billed Charges,739.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,651.01,88,,907.328,Percent of Total Billed Charges,88% of Total Billed Charges,665.8,90,,415.952,Percent of Total Billed charges,90% of Total Billed Charges,326.24,739.78,
Z783312 FEMORAL STE,2780001485,CDM,278,RC,C1776,HCPCS,Outpatient,,,9643.57,6268.32,,9643.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7329.11,76,,920.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6943.37,72,,238.144,Percent of Total Billed Charges,72% of Total Billed Charges,6943.37,72,,238.144,Percent of Total Billed charges,72% of Total Billed Charges,9643.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6943.37,72,,238.144,Percent of Total Billed Charges,72% of Total Billed Charges,5786.14,60,,198.448,Percent of Total Billed Charges,60% of Total Billed Charges,8679.21,90,,603.288,Percent of Total Billed Charges,90% of Total Billed Charges,4339.61,45,,41.672,Percent of Total Billed Charges,45% of Total Billed Charges,8679.21,90,,1089.888,Percent of Total Billed Charges,90% of Total billed Charges,9643.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9643.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9643.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6268.32,65,,21.208,Percent of total Billed Charges,65% of Total Billed Charges,4252.81,44.1,,40.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,9161.39,95,,1150.432,Percent of Total Billed Charges,95% of Total Billed Charges,9643.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8486.34,88,,1348.192,Percent of Total Billed Charges,88% of Total Billed Charges,8679.21,90,,1089.888,Percent of Total Billed charges,90% of Total Billed Charges,4252.81,9643.57,
Z783314 FEMORAL STE,2780001486,CDM,278,RC,C1776,HCPCS,Outpatient,,,9643.57,6268.32,,9643.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7329.11,76,,1057.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6943.37,72,,238.144,Percent of Total Billed Charges,72% of Total Billed Charges,6943.37,72,,238.144,Percent of Total Billed charges,72% of Total Billed Charges,9643.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6943.37,72,,238.144,Percent of Total Billed Charges,72% of Total Billed Charges,5786.14,60,,198.448,Percent of Total Billed Charges,60% of Total Billed Charges,8679.21,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,4339.61,45,,463.976,Percent of Total Billed Charges,45% of Total Billed Charges,8679.21,90,,1251.824,Percent of Total Billed Charges,90% of Total billed Charges,9643.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9643.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9643.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6268.32,65,,3143.408,Percent of total Billed Charges,65% of Total Billed Charges,4252.81,44.1,,454.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,9161.39,95,,1321.368,Percent of Total Billed Charges,95% of Total Billed Charges,9643.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8486.34,88,,688.456,Percent of Total Billed Charges,88% of Total Billed Charges,8679.21,90,,1251.824,Percent of Total Billed charges,90% of Total Billed Charges,4252.81,9643.57,
Z783316 FEMORAL STE,2780001487,CDM,278,RC,C1776,HCPCS,Outpatient,,,9643.57,6268.32,,9643.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7329.11,76,,54.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6943.37,72,,238.144,Percent of Total Billed Charges,72% of Total Billed Charges,6943.37,72,,238.144,Percent of Total Billed charges,72% of Total Billed Charges,9643.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6943.37,72,,238.144,Percent of Total Billed Charges,72% of Total Billed Charges,5786.14,60,,198.448,Percent of Total Billed Charges,60% of Total Billed Charges,8679.21,90,,150.024,Percent of Total Billed Charges,90% of Total Billed Charges,4339.61,45,,689.416,Percent of Total Billed Charges,45% of Total Billed Charges,8679.21,90,,64.296,Percent of Total Billed Charges,90% of Total billed Charges,9643.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9643.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9643.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6268.32,65,,1676.904,Percent of total Billed Charges,65% of Total Billed Charges,4252.81,44.1,,675.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,9161.39,95,,67.872,Percent of Total Billed Charges,95% of Total Billed Charges,9643.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8486.34,88,,5880.192,Percent of Total Billed Charges,88% of Total Billed Charges,8679.21,90,,64.296,Percent of Total Billed charges,90% of Total Billed Charges,4252.81,9643.57,
Z785901000 CENTRAL,2780001488,CDM,278,RC,C1776,HCPCS,Outpatient,,,607.48,394.86,,607.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,461.68,76,,70.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,437.39,72,,238.144,Percent of Total Billed Charges,72% of Total Billed Charges,437.39,72,,238.144,Percent of Total Billed charges,72% of Total Billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.39,72,,238.144,Percent of Total Billed Charges,72% of Total Billed Charges,364.49,60,,198.448,Percent of Total Billed Charges,60% of Total Billed Charges,546.73,90,,58.744,Percent of Total Billed Charges,90% of Total Billed Charges,273.37,45,,352.048,Percent of Total Billed Charges,45% of Total Billed Charges,546.73,90,,83.344,Percent of Total Billed Charges,90% of Total billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.86,65,,34.4,Percent of total Billed Charges,65% of Total Billed Charges,267.9,44.1,,345.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,577.11,95,,87.976,Percent of Total Billed Charges,95% of Total Billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,534.58,88,,2324.6,Percent of Total Billed Charges,88% of Total Billed Charges,546.73,90,,83.344,Percent of Total Billed charges,90% of Total Billed Charges,267.9,607.48,
Z785910 CENTRALIZER,2780001489,CDM,278,RC,C1776,HCPCS,Outpatient,,,607.48,394.86,,607.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,461.68,76,,783.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,437.39,72,,238.144,Percent of Total Billed Charges,72% of Total Billed Charges,437.39,72,,238.144,Percent of Total Billed charges,72% of Total Billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.39,72,,238.144,Percent of Total Billed Charges,72% of Total Billed Charges,364.49,60,,198.448,Percent of Total Billed Charges,60% of Total Billed Charges,546.73,90,,58.744,Percent of Total Billed Charges,90% of Total Billed Charges,273.37,45,,3006.912,Percent of Total Billed Charges,45% of Total Billed Charges,546.73,90,,927.952,Percent of Total Billed Charges,90% of Total billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.86,65,,288.944,Percent of total Billed Charges,65% of Total Billed Charges,267.9,44.1,,2946.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,577.11,95,,979.504,Percent of Total Billed Charges,95% of Total Billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,534.58,88,,589.88,Percent of Total Billed Charges,88% of Total Billed Charges,546.73,90,,927.952,Percent of Total Billed charges,90% of Total Billed Charges,267.9,607.48,
Z785912 CENTRALIZER,2780001490,CDM,278,RC,C1776,HCPCS,Outpatient,,,607.48,394.86,,607.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,461.68,76,,1164.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,437.39,72,,238.144,Percent of Total Billed Charges,72% of Total Billed Charges,437.39,72,,238.144,Percent of Total Billed charges,72% of Total Billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.39,72,,238.144,Percent of Total Billed Charges,72% of Total Billed Charges,364.49,60,,198.448,Percent of Total Billed Charges,60% of Total Billed Charges,546.73,90,,58.744,Percent of Total Billed Charges,90% of Total Billed Charges,273.37,45,,1188.72,Percent of Total Billed Charges,45% of Total Billed Charges,546.73,90,,1378.832,Percent of Total Billed Charges,90% of Total billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.86,65,,288.944,Percent of total Billed Charges,65% of Total Billed Charges,267.9,44.1,,1164.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,577.11,95,,1455.432,Percent of Total Billed Charges,95% of Total Billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,534.58,88,,589.88,Percent of Total Billed Charges,88% of Total Billed Charges,546.73,90,,1378.832,Percent of Total Billed charges,90% of Total Billed Charges,267.9,607.48,
Z785913 CENTRALIZER,2780001491,CDM,278,RC,C1776,HCPCS,Outpatient,,,607.48,394.86,,607.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,461.68,76,,594.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,437.39,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,437.39,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.39,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,364.49,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,546.73,90,,58.744,Percent of Total Billed Charges,90% of Total Billed Charges,273.37,45,,301.648,Percent of Total Billed Charges,45% of Total Billed Charges,546.73,90,,704.104,Percent of Total Billed Charges,90% of Total billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.86,65,,288.944,Percent of total Billed Charges,65% of Total Billed Charges,267.9,44.1,,295.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,577.11,95,,743.216,Percent of Total Billed Charges,95% of Total Billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,534.58,88,,42.944,Percent of Total Billed Charges,88% of Total Billed Charges,546.73,90,,704.104,Percent of Total Billed charges,90% of Total Billed Charges,267.9,607.48,
Z785914 CENTRALIZER,2780001492,CDM,278,RC,C1776,HCPCS,Outpatient,,,607.48,394.86,,607.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,461.68,76,,5078.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,437.39,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,437.39,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.39,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,364.49,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,546.73,90,,851.744,Percent of Total Billed Charges,90% of Total Billed Charges,273.37,45,,301.648,Percent of Total Billed Charges,45% of Total Billed Charges,546.73,90,,6013.832,Percent of Total Billed Charges,90% of Total billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.86,65,,73.952,Percent of total Billed Charges,65% of Total Billed Charges,267.9,44.1,,295.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,577.11,95,,6347.928,Percent of Total Billed Charges,95% of Total Billed Charges,607.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,534.58,88,,146.696,Percent of Total Billed Charges,88% of Total Billed Charges,546.73,90,,6013.832,Percent of Total Billed charges,90% of Total Billed Charges,267.9,607.48,
Z783414 STEM PF14X,2780001493,CDM,278,RC,C1776,HCPCS,Outpatient,,,9159.57,5953.72,,9159.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6961.27,76,,2007.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6594.89,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,6594.89,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,9159.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6594.89,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,5495.74,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,8243.61,90,,1248.648,Percent of Total Billed Charges,90% of Total Billed Charges,4121.81,45,,21.96,Percent of Total Billed Charges,45% of Total Billed Charges,8243.61,90,,2377.432,Percent of Total Billed Charges,90% of Total billed Charges,9159.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9159.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9159.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5953.72,65,,288.944,Percent of total Billed Charges,65% of Total Billed Charges,4039.37,44.1,,21.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,8701.59,95,,2509.512,Percent of Total Billed Charges,95% of Total Billed Charges,9159.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8060.42,88,,57.44,Percent of Total Billed Charges,88% of Total Billed Charges,8243.61,90,,2377.432,Percent of Total Billed charges,90% of Total Billed Charges,4039.37,9159.57,
Z22578565 ANTIROT,2780001494,CDM,278,RC,C1776,HCPCS,Outpatient,,,1088.17,707.31,,1088.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,827.01,76,,509.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,783.48,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,783.48,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,1088.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,783.48,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,652.9,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,979.35,90,,1928.136,Percent of Total Billed Charges,90% of Total Billed Charges,489.68,45,,75.016,Percent of Total Billed Charges,45% of Total Billed Charges,979.35,90,,603.288,Percent of Total Billed Charges,90% of Total billed Charges,1088.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1088.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1088.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,707.31,65,,170.848,Percent of total Billed Charges,65% of Total Billed Charges,479.88,44.1,,73.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,1033.76,95,,636.808,Percent of Total Billed Charges,95% of Total Billed Charges,1088.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,957.59,88,,57.44,Percent of Total Billed Charges,88% of Total Billed Charges,979.35,90,,603.288,Percent of Total Billed charges,90% of Total Billed Charges,479.88,1088.17,
Z22590142 ITST LAG,2780001495,CDM,278,RC,C1776,HCPCS,Outpatient,,,1458.61,948.10,,1458.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1108.54,76,,509.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1050.2,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,1050.2,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,1458.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.2,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,875.17,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,1312.75,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,656.37,45,,29.376,Percent of Total Billed Charges,45% of Total Billed Charges,1312.75,90,,603.288,Percent of Total Billed Charges,90% of Total billed Charges,1458.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1458.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1458.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,948.1,65,,2516.216,Percent of total Billed Charges,65% of Total Billed Charges,643.25,44.1,,28.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,1385.68,95,,636.808,Percent of Total Billed Charges,95% of Total Billed Charges,1458.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1283.58,88,,57.44,Percent of Total Billed Charges,88% of Total Billed Charges,1312.75,90,,603.288,Percent of Total Billed charges,90% of Total Billed Charges,643.25,1458.61,
Z59880526 REVTIBIAL,2780001496,CDM,278,RC,C1776,HCPCS,Outpatient,,,4215.96,2740.37,,4215.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3204.13,76,,37.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3035.49,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,3035.49,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,4215.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3035.49,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,2529.58,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,3794.36,90,,153.2,Percent of Total Billed Charges,90% of Total Billed Charges,1897.18,45,,29.376,Percent of Total Billed Charges,45% of Total Billed Charges,3794.36,90,,43.92,Percent of Total Billed Charges,90% of Total billed Charges,4215.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4215.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4215.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2740.37,65,,153.648,Percent of total Billed Charges,65% of Total Billed Charges,1859.24,44.1,,28.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,4005.16,95,,46.36,Percent of Total Billed Charges,95% of Total Billed Charges,4215.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3710.04,88,,57.44,Percent of Total Billed Charges,88% of Total Billed Charges,3794.36,90,,43.92,Percent of Total Billed charges,90% of Total Billed Charges,1859.24,4215.96,
Z59944217 REV ARTIC,2780001497,CDM,278,RC,C1776,HCPCS,Outpatient,,,8018.48,5212.01,,8018.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6094.04,76,,126.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5773.31,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,5773.31,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,8018.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5773.31,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,4811.09,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,7216.63,90,,1603.48,Percent of Total Billed Charges,90% of Total Billed Charges,3608.32,45,,29.376,Percent of Total Billed Charges,45% of Total Billed Charges,7216.63,90,,150.024,Percent of Total Billed Charges,90% of Total billed Charges,8018.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8018.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8018.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5212.01,65,,3193.28,Percent of total Billed Charges,65% of Total Billed Charges,3536.15,44.1,,28.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,7617.56,95,,158.36,Percent of Total Billed Charges,95% of Total Billed Charges,8018.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7056.26,88,,832.816,Percent of Total Billed Charges,88% of Total Billed Charges,7216.63,90,,150.024,Percent of Total Billed charges,90% of Total Billed Charges,3536.15,8018.48,
Z59903701 REV POST,2780001498,CDM,278,RC,C1776,HCPCS,Outpatient,,,4215.96,2740.37,,4215.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3204.13,76,,49.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3035.49,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,3035.49,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,4215.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3035.49,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,2529.58,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,3794.36,90,,4426.232,Percent of Total Billed Charges,90% of Total Billed Charges,1897.18,45,,29.376,Percent of Total Billed Charges,45% of Total Billed Charges,3794.36,90,,58.744,Percent of Total Billed Charges,90% of Total billed Charges,4215.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4215.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4215.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2740.37,65,,1390.248,Percent of total Billed Charges,65% of Total Billed Charges,1859.24,44.1,,28.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,4005.16,95,,62.008,Percent of Total Billed Charges,95% of Total Billed Charges,4215.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3710.04,88,,1220.896,Percent of Total Billed Charges,88% of Total Billed Charges,3794.36,90,,58.744,Percent of Total Billed charges,90% of Total Billed Charges,1859.24,4215.96,
Z59941792 REV FEMOR,2780001499,CDM,278,RC,C1776,HCPCS,Outpatient,,,24795.23,16116.90,,24795.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18844.37,76,,49.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17852.57,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,17852.57,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,24795.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17852.57,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,14877.14,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,22315.71,90,,590.584,Percent of Total Billed Charges,90% of Total Billed Charges,11157.85,45,,425.872,Percent of Total Billed Charges,45% of Total Billed Charges,22315.71,90,,58.744,Percent of Total Billed Charges,90% of Total billed Charges,24795.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24795.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24795.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16116.9,65,,1390.248,Percent of total Billed Charges,65% of Total Billed Charges,10934.7,44.1,,417.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,23555.47,95,,62.008,Percent of Total Billed Charges,95% of Total Billed Charges,24795.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21819.8,88,,1885.288,Percent of Total Billed Charges,88% of Total Billed Charges,22315.71,90,,58.744,Percent of Total Billed charges,90% of Total Billed Charges,10934.7,24795.23,
Z59804701 REV TIBIA,2780001500,CDM,278,RC,C1776,HCPCS,Outpatient,,,7864.13,5111.68,,7864.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5976.74,76,,49.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5662.17,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,5662.17,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,7864.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5662.17,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,4718.48,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,7077.72,90,,399.28,Percent of Total Billed Charges,90% of Total Billed Charges,3538.86,45,,624.32,Percent of Total Billed Charges,45% of Total Billed Charges,7077.72,90,,58.744,Percent of Total Billed Charges,90% of Total billed Charges,7864.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7864.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7864.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5111.68,65,,249.384,Percent of total Billed Charges,65% of Total Billed Charges,3468.08,44.1,,611.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,7470.92,95,,62.008,Percent of Total Billed Charges,95% of Total Billed Charges,7864.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6920.43,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,7077.72,90,,58.744,Percent of Total Billed charges,90% of Total Billed Charges,3468.08,7864.13,
Z59903710 REV DIST,2780001501,CDM,278,RC,C1776,HCPCS,Outpatient,,,4215.96,2740.37,,4215.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3204.13,76,,49.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3035.49,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,3035.49,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,4215.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3035.49,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,2529.58,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,3794.36,90,,491.368,Percent of Total Billed Charges,90% of Total Billed Charges,1897.18,45,,964.072,Percent of Total Billed Charges,45% of Total Billed Charges,3794.36,90,,58.744,Percent of Total Billed Charges,90% of Total billed Charges,4215.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4215.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4215.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2740.37,65,,1139.72,Percent of total Billed Charges,65% of Total Billed Charges,1859.24,44.1,,944.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,4005.16,95,,62.008,Percent of Total Billed Charges,95% of Total Billed Charges,4215.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3710.04,88,,149.8,Percent of Total Billed Charges,88% of Total Billed Charges,3794.36,90,,58.744,Percent of Total Billed charges,90% of Total Billed Charges,1859.24,4215.96,
Z59882012REV STEM,2780001502,CDM,278,RC,C1776,HCPCS,Outpatient,,,5927.04,3852.58,,5927.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4504.55,76,,719.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4267.47,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,4267.47,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,5927.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4267.47,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,3556.22,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,5334.34,90,,29.368,Percent of Total Billed Charges,90% of Total Billed Charges,2667.17,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,5334.34,90,,851.744,Percent of Total Billed Charges,90% of Total billed Charges,5927.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5927.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5927.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3852.58,65,,2562.08,Percent of total Billed Charges,65% of Total Billed Charges,2613.82,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,5630.69,95,,899.064,Percent of Total Billed Charges,95% of Total Billed Charges,5927.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5215.8,88,,1567.84,Percent of Total Billed Charges,88% of Total Billed Charges,5334.34,90,,851.744,Percent of Total Billed charges,90% of Total Billed Charges,2613.82,5927.04,
Z23581703VOLAR3HO,2780001503,CDM,278,RC,C1776,HCPCS,Outpatient,,,4082.56,2653.66,,4082.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3102.75,76,,1054.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2939.44,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,2939.44,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,4082.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2939.44,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,2449.54,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,3674.3,90,,4352.408,Percent of Total Billed Charges,90% of Total Billed Charges,1837.15,45,,76.6,Percent of Total Billed Charges,45% of Total Billed Charges,3674.3,90,,1248.648,Percent of Total Billed Charges,90% of Total billed Charges,4082.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4082.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4082.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2653.66,65,,497.624,Percent of total Billed Charges,65% of Total Billed Charges,1800.41,44.1,,75.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,3878.43,95,,1318.016,Percent of Total Billed Charges,95% of Total Billed Charges,4082.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3592.65,88,,4327.872,Percent of Total Billed Charges,88% of Total Billed Charges,3674.3,90,,1248.648,Percent of Total Billed charges,90% of Total Billed Charges,1800.41,4082.56,
Z59726541 PATELLA,2780001504,CDM,278,RC,C1776,HCPCS,Outpatient,,,3029.67,1969.29,,3029.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2302.55,76,,1628.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2181.36,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,2181.36,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,3029.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2181.36,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,1817.8,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,2726.7,90,,2321.864,Percent of Total Billed Charges,90% of Total Billed Charges,1363.35,45,,801.736,Percent of Total Billed Charges,45% of Total Billed Charges,2726.7,90,,1928.136,Percent of Total Billed Charges,90% of Total billed Charges,3029.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3029.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3029.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1969.29,65,,1730.224,Percent of total Billed Charges,65% of Total Billed Charges,1336.08,44.1,,785.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,2878.19,95,,2035.256,Percent of Total Billed Charges,95% of Total Billed Charges,3029.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2666.11,88,,577.464,Percent of Total Billed Charges,88% of Total Billed Charges,2726.7,90,,1928.136,Percent of Total Billed charges,90% of Total Billed Charges,1336.08,3029.67,
Z225425510 HUM NAI,2780001505,CDM,278,RC,C1776,HCPCS,Outpatient,,,7331.63,4765.56,,7331.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5572.04,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5278.77,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,5278.77,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,7331.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5278.77,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,4398.98,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,6598.47,90,,47.632,Percent of Total Billed Charges,90% of Total Billed Charges,3299.23,45,,2213.112,Percent of Total Billed Charges,45% of Total Billed Charges,6598.47,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,7331.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7331.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7331.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4765.56,65,,3561.912,Percent of total Billed Charges,65% of Total Billed Charges,3233.25,44.1,,2168.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,6965.05,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,7331.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6451.83,88,,390.408,Percent of Total Billed Charges,88% of Total Billed Charges,6598.47,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,3233.25,7331.63,
Z23592225 2.4 CONI,2780001506,CDM,278,RC,C1776,HCPCS,Outpatient,,,427.77,278.05,,427.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,325.11,76,,129.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,307.99,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,307.99,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,427.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.99,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,256.66,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,384.99,90,,400.072,Percent of Total Billed Charges,90% of Total Billed Charges,192.5,45,,295.296,Percent of Total Billed Charges,45% of Total Billed Charges,384.99,90,,153.2,Percent of Total Billed Charges,90% of Total billed Charges,427.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.05,65,,4477.472,Percent of total Billed Charges,65% of Total Billed Charges,188.65,44.1,,289.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,406.38,95,,161.712,Percent of Total Billed Charges,95% of Total Billed Charges,427.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.44,88,,480.448,Percent of Total Billed Charges,88% of Total Billed Charges,384.99,90,,153.2,Percent of Total Billed charges,90% of Total Billed Charges,188.65,427.77,
PUROS 5CC DBM,2780001507,CDM,278,RC,C1776,HCPCS,Outpatient,,,4138.79,2690.21,,4138.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3145.48,76,,1354.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2979.93,72,,4388.76,Percent of Total Billed Charges,72% of Total Billed Charges,2979.93,72,,4388.76,Percent of Total Billed charges,72% of Total Billed Charges,4138.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2979.93,72,,4388.76,Percent of Total Billed Charges,72% of Total Billed Charges,2483.27,60,,3657.304,Percent of Total Billed Charges,60% of Total Billed Charges,3724.91,90,,400.072,Percent of Total Billed Charges,90% of Total Billed Charges,1862.46,45,,199.64,Percent of Total Billed Charges,45% of Total Billed Charges,3724.91,90,,1603.48,Percent of Total Billed Charges,90% of Total billed Charges,4138.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4138.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4138.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2690.21,65,,8983.04,Percent of total Billed Charges,65% of Total Billed Charges,1825.21,44.1,,195.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,3931.85,95,,1692.56,Percent of Total Billed Charges,95% of Total Billed Charges,4138.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3642.14,88,,28.72,Percent of Total Billed Charges,88% of Total Billed Charges,3724.91,90,,1603.48,Percent of Total Billed charges,90% of Total Billed Charges,1825.21,4138.79,
PUROS 2CC DBM,2780001508,CDM,278,RC,C1776,HCPCS,Outpatient,,,1981.19,1287.77,,1981.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1505.7,76,,3737.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1426.46,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,1426.46,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,1981.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.46,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,1188.71,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,1783.07,90,,400.072,Percent of Total Billed Charges,90% of Total Billed Charges,891.54,45,,245.68,Percent of Total Billed Charges,45% of Total Billed Charges,1783.07,90,,4426.232,Percent of Total Billed Charges,90% of Total billed Charges,1981.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1981.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1981.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1287.77,65,,37.264,Percent of total Billed Charges,65% of Total Billed Charges,873.7,44.1,,240.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,1882.13,95,,4672.128,Percent of Total Billed Charges,95% of Total Billed Charges,1981.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1743.45,88,,4255.688,Percent of Total Billed Charges,88% of Total Billed Charges,1783.07,90,,4426.232,Percent of Total Billed charges,90% of Total Billed Charges,873.7,1981.19,
Z493600703 TUBULAR,2780001509,CDM,278,RC,C1776,HCPCS,Outpatient,,,842.31,547.50,,842.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,640.16,76,,498.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,606.46,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,606.46,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,842.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,606.46,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,505.39,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,758.08,90,,102.4,Percent of Total Billed Charges,90% of Total Billed Charges,379.04,45,,14.688,Percent of Total Billed Charges,45% of Total Billed Charges,758.08,90,,590.584,Percent of Total Billed Charges,90% of Total billed Charges,842.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,842.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,842.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547.5,65,,765.36,Percent of total Billed Charges,65% of Total Billed Charges,371.46,44.1,,14.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,800.19,95,,623.4,Percent of Total Billed Charges,95% of Total Billed Charges,842.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,741.23,88,,2270.264,Percent of Total Billed Charges,88% of Total Billed Charges,758.08,90,,590.584,Percent of Total Billed charges,90% of Total Billed Charges,371.46,842.31,
Z483501401 3.5 SCO,2780001510,CDM,278,RC,C1776,HCPCS,Outpatient,,,164.27,106.78,,164.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.85,76,,337.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,118.27,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,118.27,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.27,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,98.56,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,147.84,90,,400.072,Percent of Total Billed Charges,90% of Total Billed Charges,73.92,45,,2176.2,Percent of Total Billed Charges,45% of Total Billed Charges,147.84,90,,399.28,Percent of Total Billed Charges,90% of Total billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.78,65,,3561.912,Percent of total Billed Charges,65% of Total Billed Charges,72.44,44.1,,2132.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,156.06,95,,421.464,Percent of Total Billed Charges,95% of Total Billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.56,88,,46.568,Percent of Total Billed Charges,88% of Total Billed Charges,147.84,90,,399.28,Percent of Total Billed charges,90% of Total Billed Charges,72.44,164.27,
ECT SCW 38MM  4.5 CORT BN,2780001511,CDM,278,RC,C1776,HCPCS,Outpatient,,,168.68,109.64,,168.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,128.2,76,,414.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,121.45,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,121.45,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.45,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,101.21,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,151.81,90,,236.56,Percent of Total Billed Charges,90% of Total Billed Charges,75.91,45,,1160.928,Percent of Total Billed Charges,45% of Total Billed Charges,151.81,90,,491.368,Percent of Total Billed Charges,90% of Total billed Charges,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.64,65,,4477.472,Percent of total Billed Charges,65% of Total Billed Charges,74.39,44.1,,1137.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,160.25,95,,518.664,Percent of Total Billed Charges,95% of Total Billed Charges,168.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.44,88,,391.184,Percent of Total Billed Charges,88% of Total Billed Charges,151.81,90,,491.368,Percent of Total Billed charges,90% of Total Billed Charges,74.39,168.68,
Z434211213 HUM STE,2780001512,CDM,278,RC,C1776,HCPCS,Outpatient,,,21224.23,13795.75,,21224.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16130.41,76,,24.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15281.45,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,15281.45,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,21224.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15281.45,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,12734.54,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,19101.81,90,,3483.984,Percent of Total Billed Charges,90% of Total Billed Charges,9550.9,45,,23.816,Percent of Total Billed Charges,45% of Total Billed Charges,19101.81,90,,29.368,Percent of Total Billed Charges,90% of Total billed Charges,21224.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21224.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21224.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13795.75,65,,9972.552,Percent of total Billed Charges,65% of Total Billed Charges,9359.89,44.1,,23.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,20163.02,95,,31,Percent of Total Billed Charges,95% of Total Billed Charges,21224.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18677.32,88,,391.184,Percent of Total Billed Charges,88% of Total Billed Charges,19101.81,90,,29.368,Percent of Total Billed charges,90% of Total Billed Charges,9359.89,21224.23,
X43025224 MOD. HUM,2780001513,CDM,278,RC,C1776,HCPCS,Outpatient,,,9687.67,6296.99,,9687.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7362.63,76,,3675.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6975.12,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,6975.12,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,9687.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6975.12,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,5812.6,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,8718.9,90,,212.736,Percent of Total Billed Charges,90% of Total Billed Charges,4359.45,45,,200.04,Percent of Total Billed Charges,45% of Total Billed Charges,8718.9,90,,4352.408,Percent of Total Billed Charges,90% of Total billed Charges,9687.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9687.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9687.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6296.99,65,,3561.912,Percent of total Billed Charges,65% of Total Billed Charges,4272.26,44.1,,196.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,9203.29,95,,4594.208,Percent of Total Billed Charges,95% of Total Billed Charges,9687.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8525.15,88,,391.184,Percent of Total Billed Charges,88% of Total Billed Charges,8718.9,90,,4352.408,Percent of Total Billed charges,90% of Total Billed Charges,4272.26,9687.67,
ZOO576401452 GSF,2780001514,CDM,278,RC,C1776,HCPCS,Outpatient,,,21516.39,13985.65,,21516.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16352.46,76,,1960.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15491.8,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,15491.8,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15491.8,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,12909.83,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,19364.75,90,,4421.472,Percent of Total Billed Charges,90% of Total Billed Charges,9682.38,45,,200.04,Percent of Total Billed Charges,45% of Total Billed Charges,19364.75,90,,2321.864,Percent of Total Billed Charges,90% of Total billed Charges,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13985.65,65,,4477.472,Percent of total Billed Charges,65% of Total Billed Charges,9488.73,44.1,,196.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,20440.57,95,,2450.856,Percent of Total Billed Charges,95% of Total Billed Charges,21516.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18934.42,88,,100.12,Percent of Total Billed Charges,88% of Total Billed Charges,19364.75,90,,2321.864,Percent of Total Billed charges,90% of Total Billed Charges,9488.73,21516.39,
Z22401238 RETROFEM,2780001515,CDM,278,RC,C1776,HCPCS,Outpatient,,,6949.06,4516.89,,6949.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5281.29,76,,40.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5003.32,72,,1000.192,Percent of Total Billed Charges,72% of Total Billed Charges,5003.32,72,,1000.192,Percent of Total Billed charges,72% of Total Billed Charges,6949.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5003.32,72,,1000.192,Percent of Total Billed Charges,72% of Total Billed Charges,4169.44,60,,833.488,Percent of Total Billed Charges,60% of Total Billed Charges,6254.15,90,,1924.96,Percent of Total Billed Charges,90% of Total Billed Charges,3127.08,45,,200.04,Percent of Total Billed Charges,45% of Total Billed Charges,6254.15,90,,47.632,Percent of Total Billed Charges,90% of Total billed Charges,6949.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6949.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6949.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4516.89,65,,9972.552,Percent of total Billed Charges,65% of Total Billed Charges,3064.54,44.1,,196.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,6601.61,95,,50.272,Percent of Total Billed Charges,95% of Total Billed Charges,6949.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6115.17,88,,391.184,Percent of Total Billed Charges,88% of Total Billed Charges,6254.15,90,,47.632,Percent of Total Billed charges,90% of Total Billed Charges,3064.54,6949.06,
Z225238012 FEMRECO,2780001516,CDM,278,RC,C1776,HCPCS,Outpatient,,,4838.87,3145.27,,4838.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3677.54,76,,337.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3483.99,72,,1000.192,Percent of Total Billed Charges,72% of Total Billed Charges,3483.99,72,,1000.192,Percent of Total Billed charges,72% of Total Billed Charges,4838.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3483.99,72,,1000.192,Percent of Total Billed Charges,72% of Total Billed Charges,2903.32,60,,833.488,Percent of Total Billed Charges,60% of Total Billed Charges,4354.98,90,,1924.96,Percent of Total Billed Charges,90% of Total Billed Charges,2177.49,45,,51.2,Percent of Total Billed Charges,45% of Total Billed Charges,4354.98,90,,400.072,Percent of Total Billed Charges,90% of Total billed Charges,4838.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4838.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4838.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3145.27,65,,170.848,Percent of total Billed Charges,65% of Total Billed Charges,2133.94,44.1,,50.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,4596.93,95,,422.304,Percent of Total Billed Charges,95% of Total Billed Charges,4838.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4258.21,88,,231.296,Percent of Total Billed Charges,88% of Total Billed Charges,4354.98,90,,400.072,Percent of Total Billed charges,90% of Total Billed Charges,2133.94,4838.87,
Z22534555 5.5 CORT,2780001517,CDM,278,RC,C1776,HCPCS,Outpatient,,,845.62,549.65,,845.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,642.67,76,,337.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,608.85,72,,1000.192,Percent of Total Billed Charges,72% of Total Billed Charges,608.85,72,,1000.192,Percent of Total Billed charges,72% of Total Billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,608.85,72,,1000.192,Percent of Total Billed Charges,72% of Total Billed Charges,507.37,60,,833.488,Percent of Total Billed Charges,60% of Total Billed Charges,761.06,90,,345.304,Percent of Total Billed Charges,90% of Total Billed Charges,380.53,45,,200.04,Percent of Total Billed Charges,45% of Total Billed Charges,761.06,90,,400.072,Percent of Total Billed Charges,90% of Total billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.65,65,,854.792,Percent of total Billed Charges,65% of Total Billed Charges,372.92,44.1,,196.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,803.34,95,,422.304,Percent of Total Billed Charges,95% of Total Billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,744.15,88,,3406.568,Percent of Total Billed Charges,88% of Total Billed Charges,761.06,90,,400.072,Percent of Total Billed charges,90% of Total Billed Charges,372.92,845.62,
Z22535055 5.5 CORT,2780001518,CDM,278,RC,C1776,HCPCS,Outpatient,,,845.62,549.65,,845.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,642.67,76,,337.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,608.85,72,,1000.192,Percent of Total Billed Charges,72% of Total Billed Charges,608.85,72,,1000.192,Percent of Total Billed charges,72% of Total Billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,608.85,72,,1000.192,Percent of Total Billed Charges,72% of Total Billed Charges,507.37,60,,833.488,Percent of Total Billed Charges,60% of Total Billed Charges,761.06,90,,1578.072,Percent of Total Billed Charges,90% of Total Billed Charges,380.53,45,,118.28,Percent of Total Billed Charges,45% of Total Billed Charges,761.06,90,,400.072,Percent of Total Billed Charges,90% of Total billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.65,65,,1387.96,Percent of total Billed Charges,65% of Total Billed Charges,372.92,44.1,,115.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,803.34,95,,422.304,Percent of Total Billed Charges,95% of Total Billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,744.15,88,,208.008,Percent of Total Billed Charges,88% of Total Billed Charges,761.06,90,,400.072,Percent of Total Billed charges,90% of Total Billed Charges,372.92,845.62,
Z23591225 2.4 CONI,2780001519,CDM,278,RC,C1776,HCPCS,Outpatient,,,427.77,278.05,,427.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,325.11,76,,86.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,307.99,72,,1000.192,Percent of Total Billed Charges,72% of Total Billed Charges,307.99,72,,1000.192,Percent of Total Billed charges,72% of Total Billed Charges,427.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.99,72,,1000.192,Percent of Total Billed Charges,72% of Total Billed Charges,256.66,60,,833.488,Percent of Total Billed Charges,60% of Total Billed Charges,384.99,90,,3547.488,Percent of Total Billed Charges,90% of Total Billed Charges,192.5,45,,1741.992,Percent of Total Billed Charges,45% of Total Billed Charges,384.99,90,,102.4,Percent of Total Billed Charges,90% of Total billed Charges,427.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.05,65,,2674.856,Percent of total Billed Charges,65% of Total Billed Charges,188.65,44.1,,1707.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,406.38,95,,108.088,Percent of Total Billed Charges,95% of Total Billed Charges,427.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.44,88,,4323.216,Percent of Total Billed Charges,88% of Total Billed Charges,384.99,90,,102.4,Percent of Total Billed charges,90% of Total Billed Charges,188.65,427.77,
Z22533545 4.5 CORT,2780001520,CDM,278,RC,C1776,HCPCS,Outpatient,,,845.62,549.65,,845.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,642.67,76,,337.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,608.85,72,,1000.192,Percent of Total Billed Charges,72% of Total Billed Charges,608.85,72,,1000.192,Percent of Total Billed charges,72% of Total Billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,608.85,72,,1000.192,Percent of Total Billed Charges,72% of Total Billed Charges,507.37,60,,833.488,Percent of Total Billed Charges,60% of Total Billed Charges,761.06,90,,689.016,Percent of Total Billed Charges,90% of Total Billed Charges,380.53,45,,106.368,Percent of Total Billed Charges,45% of Total Billed Charges,761.06,90,,400.072,Percent of Total Billed Charges,90% of Total billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.65,65,,4176.352,Percent of total Billed Charges,65% of Total Billed Charges,372.92,44.1,,104.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,803.34,95,,422.304,Percent of Total Billed Charges,95% of Total Billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,744.15,88,,1882.184,Percent of Total Billed Charges,88% of Total Billed Charges,761.06,90,,400.072,Percent of Total Billed charges,90% of Total Billed Charges,372.92,845.62,
Z785911 CENTRALIZER,2780001521,CDM,278,RC,C1776,HCPCS,Outpatient,,,670.32,435.71,,670.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,509.44,76,,199.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,482.63,72,,1000.192,Percent of Total Billed Charges,72% of Total Billed Charges,482.63,72,,1000.192,Percent of Total Billed charges,72% of Total Billed Charges,670.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.63,72,,1000.192,Percent of Total Billed Charges,72% of Total Billed Charges,402.19,60,,833.488,Percent of Total Billed Charges,60% of Total Billed Charges,603.29,90,,2395.696,Percent of Total Billed Charges,90% of Total Billed Charges,301.64,45,,2210.736,Percent of Total Billed Charges,45% of Total Billed Charges,603.29,90,,236.56,Percent of Total Billed Charges,90% of Total billed Charges,670.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,670.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,670.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.71,65,,1257.984,Percent of total Billed Charges,65% of Total Billed Charges,295.61,44.1,,2166.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,636.8,95,,249.696,Percent of Total Billed Charges,95% of Total Billed Charges,670.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,589.88,88,,1882.184,Percent of Total Billed Charges,88% of Total Billed Charges,603.29,90,,236.56,Percent of Total Billed charges,90% of Total Billed Charges,295.61,670.32,
Z4711553505 HERBE,2780001522,CDM,278,RC,C1776,HCPCS,Outpatient,,,2518.11,1636.77,,2518.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1913.76,76,,2942.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1813.04,72,,1000.192,Percent of Total Billed Charges,72% of Total Billed Charges,1813.04,72,,1000.192,Percent of Total Billed charges,72% of Total Billed Charges,2518.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1813.04,72,,1000.192,Percent of Total Billed Charges,72% of Total Billed Charges,1510.87,60,,833.488,Percent of Total Billed Charges,60% of Total Billed Charges,2266.3,90,,4931.88,Percent of Total Billed Charges,90% of Total Billed Charges,1133.15,45,,962.48,Percent of Total Billed Charges,45% of Total Billed Charges,2266.3,90,,3483.984,Percent of Total Billed Charges,90% of Total billed Charges,2518.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2518.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2518.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1636.77,65,,753.48,Percent of total Billed Charges,65% of Total Billed Charges,1110.49,44.1,,943.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,2392.2,95,,3677.544,Percent of Total Billed Charges,95% of Total Billed Charges,2518.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2215.94,88,,337.632,Percent of Total Billed Charges,88% of Total Billed Charges,2266.3,90,,3483.984,Percent of Total Billed charges,90% of Total Billed Charges,1110.49,2518.11,
Z115230HERBERT 3.0,2780001523,CDM,278,RC,C1776,HCPCS,Outpatient,,,1439.87,935.92,,1439.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1094.3,76,,179.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1036.71,72,,1000.192,Percent of Total Billed Charges,72% of Total Billed Charges,1036.71,72,,1000.192,Percent of Total Billed charges,72% of Total Billed Charges,1439.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1036.71,72,,1000.192,Percent of Total Billed Charges,72% of Total Billed Charges,863.92,60,,833.488,Percent of Total Billed Charges,60% of Total Billed Charges,1295.88,90,,6199.584,Percent of Total Billed Charges,90% of Total Billed Charges,647.94,45,,962.48,Percent of Total Billed Charges,45% of Total Billed Charges,1295.88,90,,212.736,Percent of Total Billed Charges,90% of Total billed Charges,1439.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1439.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1439.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,935.92,65,,1258.528,Percent of total Billed Charges,65% of Total Billed Charges,634.98,44.1,,943.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,1367.88,95,,224.56,Percent of Total Billed Charges,95% of Total Billed Charges,1439.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1267.09,88,,1543.008,Percent of Total Billed Charges,88% of Total Billed Charges,1295.88,90,,212.736,Percent of Total Billed charges,90% of Total Billed Charges,634.98,1439.87,
Z59881017 REV STEM,2780001524,CDM,278,RC,C1776,HCPCS,Outpatient,,,4604.04,2992.63,,4604.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3499.07,76,,3733.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3314.91,72,,1868.288,Percent of Total Billed Charges,72% of Total Billed Charges,3314.91,72,,1868.288,Percent of Total Billed charges,72% of Total Billed Charges,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3314.91,72,,1868.288,Percent of Total Billed Charges,72% of Total Billed Charges,2762.42,60,,1556.912,Percent of Total Billed Charges,60% of Total Billed Charges,4143.64,90,,12438.048,Percent of Total Billed Charges,90% of Total Billed Charges,2071.82,45,,172.656,Percent of Total Billed Charges,45% of Total Billed Charges,4143.64,90,,4421.472,Percent of Total Billed Charges,90% of Total billed Charges,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2992.63,65,,753.48,Percent of total Billed Charges,65% of Total Billed Charges,2030.38,44.1,,169.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,4373.84,95,,4667.104,Percent of Total Billed Charges,95% of Total Billed Charges,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4051.56,88,,3468.656,Percent of Total Billed Charges,88% of Total Billed Charges,4143.64,90,,4421.472,Percent of Total Billed charges,90% of Total Billed Charges,2030.38,4604.04,
Z59880410 REV TIBI,2780001525,CDM,278,RC,C1776,HCPCS,Outpatient,,,5599.60,3639.74,,5599.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4255.7,76,,1625.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4031.71,72,,1868.288,Percent of Total Billed Charges,72% of Total Billed Charges,4031.71,72,,1868.288,Percent of Total Billed charges,72% of Total Billed Charges,5599.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4031.71,72,,1868.288,Percent of Total Billed Charges,72% of Total Billed Charges,3359.76,60,,1556.912,Percent of Total Billed Charges,60% of Total Billed Charges,5039.64,90,,51.592,Percent of Total Billed Charges,90% of Total Billed Charges,2519.82,45,,789.04,Percent of Total Billed Charges,45% of Total Billed Charges,5039.64,90,,1924.96,Percent of Total Billed Charges,90% of Total billed Charges,5599.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5599.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5599.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3639.74,65,,1258.528,Percent of total Billed Charges,65% of Total Billed Charges,2469.42,44.1,,773.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,5319.62,95,,2031.904,Percent of Total Billed Charges,95% of Total Billed Charges,5599.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4927.65,88,,673.704,Percent of Total Billed Charges,88% of Total Billed Charges,5039.64,90,,1924.96,Percent of Total Billed charges,90% of Total Billed Charges,2469.42,5599.6,
Z59803702 REV TIBI,2780001526,CDM,278,RC,C1776,HCPCS,Outpatient,,,7977.69,5185.50,,7977.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6063.04,76,,1625.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5743.94,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,5743.94,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,7977.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5743.94,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,4786.61,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,7179.92,90,,1059.728,Percent of Total Billed Charges,90% of Total Billed Charges,3589.96,45,,1773.744,Percent of Total Billed Charges,45% of Total Billed Charges,7179.92,90,,1924.96,Percent of Total Billed Charges,90% of Total billed Charges,7977.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7977.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7977.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5185.5,65,,1550.64,Percent of total Billed Charges,65% of Total Billed Charges,3518.16,44.1,,1738.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,7578.81,95,,2031.904,Percent of Total Billed Charges,95% of Total Billed Charges,7977.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7020.37,88,,2342.456,Percent of Total Billed Charges,88% of Total Billed Charges,7179.92,90,,1924.96,Percent of Total Billed charges,90% of Total Billed Charges,3518.16,7977.69,
Z59941591 REV FEMO,2780001527,CDM,278,RC,C1776,HCPCS,Outpatient,,,25151.33,16348.36,,25151.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19115.01,76,,291.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18108.96,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,18108.96,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,25151.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18108.96,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,15090.8,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,22636.2,90,,4931.88,Percent of Total Billed Charges,90% of Total Billed Charges,11318.1,45,,344.512,Percent of Total Billed Charges,45% of Total Billed Charges,22636.2,90,,345.304,Percent of Total Billed Charges,90% of Total billed Charges,25151.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25151.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25151.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16348.36,65,,1254.76,Percent of total Billed Charges,65% of Total Billed Charges,11091.74,44.1,,337.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,23893.76,95,,364.488,Percent of Total Billed Charges,95% of Total Billed Charges,25151.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22133.17,88,,4822.28,Percent of Total Billed Charges,88% of Total Billed Charges,22636.2,90,,345.304,Percent of Total Billed charges,90% of Total Billed Charges,11091.74,25151.33,
Z59963217 REV ARTI,2780001528,CDM,278,RC,C1776,HCPCS,Outpatient,,,4919.36,3197.58,,4919.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3738.71,76,,1332.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3541.94,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,3541.94,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,4919.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3541.94,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,2951.62,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,4427.42,90,,6199.584,Percent of Total Billed Charges,90% of Total Billed Charges,2213.71,45,,1197.848,Percent of Total Billed Charges,45% of Total Billed Charges,4427.42,90,,1578.072,Percent of Total Billed Charges,90% of Total billed Charges,4919.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4919.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4919.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3197.58,65,,33.8,Percent of total Billed Charges,65% of Total Billed Charges,2169.44,44.1,,1173.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,4673.39,95,,1665.744,Percent of Total Billed Charges,95% of Total Billed Charges,4919.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4329.04,88,,6061.816,Percent of Total Billed Charges,88% of Total Billed Charges,4427.42,90,,1578.072,Percent of Total Billed charges,90% of Total Billed Charges,2169.44,4919.36,
Z59965012 ART SURF,2780001529,CDM,278,RC,C1776,HCPCS,Outpatient,,,4918.25,3196.86,,4918.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3737.87,76,,2995.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3541.14,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,3541.14,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,4918.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3541.14,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,2950.95,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,4426.43,90,,13808.152,Percent of Total Billed Charges,90% of Total Billed Charges,2213.21,45,,2465.936,Percent of Total Billed Charges,45% of Total Billed Charges,4426.43,90,,3547.488,Percent of Total Billed Charges,90% of Total billed Charges,4918.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4918.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4918.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3196.86,65,,206.96,Percent of total Billed Charges,65% of Total Billed Charges,2168.95,44.1,,2416.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,4672.34,95,,3744.576,Percent of Total Billed Charges,95% of Total Billed Charges,4918.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4328.06,88,,12161.648,Percent of Total Billed Charges,88% of Total Billed Charges,4426.43,90,,3547.488,Percent of Total Billed charges,90% of Total Billed Charges,2168.95,4918.25,
Z59961352 FEMORAL,2780001530,CDM,278,RC,C1776,HCPCS,Outpatient,,,11517.82,7486.58,,11517.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8753.54,76,,581.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8292.83,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,8292.83,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,11517.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8292.83,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,6910.69,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,10366.04,90,,4931.88,Percent of Total Billed Charges,90% of Total Billed Charges,5183.02,45,,3099.792,Percent of Total Billed Charges,45% of Total Billed Charges,10366.04,90,,689.016,Percent of Total Billed Charges,90% of Total billed Charges,11517.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11517.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11517.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7486.58,65,,154.96,Percent of total Billed Charges,65% of Total Billed Charges,5079.36,44.1,,3037.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,10941.93,95,,727.296,Percent of Total Billed Charges,95% of Total Billed Charges,11517.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10135.68,88,,50.448,Percent of Total Billed Charges,88% of Total Billed Charges,10366.04,90,,689.016,Percent of Total Billed charges,90% of Total Billed Charges,5079.36,11517.82,
Z29020280 GUIDE PI,2780001531,CDM,278,RC,C1776,HCPCS,Outpatient,,,146.63,95.31,,146.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,111.44,76,,2023.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,105.57,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,105.57,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.57,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,87.98,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,131.97,90,,6199.584,Percent of Total Billed Charges,90% of Total Billed Charges,65.98,45,,6219.024,Percent of Total Billed Charges,45% of Total Billed Charges,131.97,90,,2395.696,Percent of Total Billed Charges,90% of Total billed Charges,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.31,65,,154.96,Percent of total Billed Charges,65% of Total Billed Charges,64.66,44.1,,6094.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,139.3,95,,2528.784,Percent of Total Billed Charges,95% of Total Billed Charges,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.03,88,,1036.176,Percent of Total Billed Charges,88% of Total Billed Charges,131.97,90,,2395.696,Percent of Total Billed charges,90% of Total Billed Charges,64.66,146.63,
Z0200024003 4.3 DR,2780001532,CDM,278,RC,C1776,HCPCS,Outpatient,,,414.54,269.45,,414.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,315.05,76,,4164.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,298.47,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,298.47,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.47,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,248.72,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,373.09,90,,13808.152,Percent of Total Billed Charges,90% of Total Billed Charges,186.54,45,,25.8,Percent of Total Billed Charges,45% of Total Billed Charges,373.09,90,,4931.88,Percent of Total Billed Charges,90% of Total billed Charges,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.45,65,,184.6,Percent of total Billed Charges,65% of Total Billed Charges,182.81,44.1,,25.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,393.81,95,,5205.872,Percent of Total Billed Charges,95% of Total Billed Charges,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.8,88,,4822.28,Percent of Total Billed Charges,88% of Total Billed Charges,373.09,90,,4931.88,Percent of Total Billed charges,90% of Total Billed Charges,182.81,414.54,
Z0203260109 DFNCB,2780001533,CDM,278,RC,C1776,HCPCS,Outpatient,,,7837.67,5094.49,,7837.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5956.63,76,,5235.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5643.12,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,5643.12,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,7837.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5643.12,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,4702.6,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,7053.9,90,,236.56,Percent of Total Billed Charges,90% of Total Billed Charges,3526.95,45,,529.864,Percent of Total Billed Charges,45% of Total Billed Charges,7053.9,90,,6199.584,Percent of Total Billed Charges,90% of Total billed Charges,7837.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7837.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7837.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5094.49,65,,339.04,Percent of total Billed Charges,65% of Total Billed Charges,3456.41,44.1,,519.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,7445.79,95,,6544,Percent of Total Billed Charges,95% of Total Billed Charges,7837.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6897.15,88,,6061.816,Percent of Total Billed Charges,88% of Total Billed Charges,7053.9,90,,6199.584,Percent of Total Billed charges,90% of Total Billed Charges,3456.41,7837.67,
Z0203152075 5.0 CA,2780001534,CDM,278,RC,C1776,HCPCS,Outpatient,,,781.67,508.09,,781.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,594.07,76,,10503.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,562.8,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,562.8,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,781.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.8,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,469,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,703.5,90,,1183.56,Percent of Total Billed Charges,90% of Total Billed Charges,351.75,45,,2465.936,Percent of Total Billed Charges,45% of Total Billed Charges,703.5,90,,12438.048,Percent of Total Billed Charges,90% of Total billed Charges,781.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,781.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,781.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.09,65,,1786.4,Percent of total Billed Charges,65% of Total Billed Charges,344.72,44.1,,2416.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,742.59,95,,13129.056,Percent of Total Billed Charges,95% of Total Billed Charges,781.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,687.87,88,,13501.304,Percent of Total Billed Charges,88% of Total Billed Charges,703.5,90,,12438.048,Percent of Total Billed charges,90% of Total Billed Charges,344.72,781.67,
Z0203152080 5.0 CA,2780001535,CDM,278,RC,C1776,HCPCS,Outpatient,,,781.67,508.09,,781.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,594.07,76,,43.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,562.8,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,562.8,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,781.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.8,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,469,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,703.5,90,,1921.792,Percent of Total Billed Charges,90% of Total Billed Charges,351.75,45,,3099.792,Percent of Total Billed Charges,45% of Total Billed Charges,703.5,90,,51.592,Percent of Total Billed Charges,90% of Total billed Charges,781.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,781.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,781.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.09,65,,6950.12,Percent of total Billed Charges,65% of Total Billed Charges,344.72,44.1,,3037.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,742.59,95,,54.464,Percent of Total Billed Charges,95% of Total Billed Charges,781.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,687.87,88,,4822.28,Percent of Total Billed Charges,88% of Total Billed Charges,703.5,90,,51.592,Percent of Total Billed charges,90% of Total Billed Charges,344.72,781.67,
Z023150034 34X50,2780001537,CDM,278,RC,C1776,HCPCS,Outpatient,,,907.36,589.78,,907.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,689.59,76,,894.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,653.3,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,653.3,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,653.3,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,544.42,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,816.62,90,,3703.648,Percent of Total Billed Charges,90% of Total Billed Charges,408.31,45,,6904.08,Percent of Total Billed Charges,45% of Total Billed Charges,816.62,90,,1059.728,Percent of Total Billed Charges,90% of Total billed Charges,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,589.78,65,,1319.16,Percent of total Billed Charges,65% of Total Billed Charges,400.15,44.1,,6765.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,861.99,95,,1118.6,Percent of Total Billed Charges,95% of Total Billed Charges,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,798.48,88,,6061.816,Percent of Total Billed Charges,88% of Total Billed Charges,816.62,90,,1059.728,Percent of Total Billed charges,90% of Total Billed Charges,400.15,907.36,
Z0203150036 36X50,2780001538,CDM,278,RC,C1776,HCPCS,Outpatient,,,907.36,589.78,,907.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,689.59,76,,4164.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,653.3,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,653.3,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,653.3,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,544.42,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,816.62,90,,5782.648,Percent of Total Billed Charges,90% of Total Billed Charges,408.31,45,,2465.936,Percent of Total Billed Charges,45% of Total Billed Charges,816.62,90,,4931.88,Percent of Total Billed Charges,90% of Total billed Charges,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,589.78,65,,502.208,Percent of total Billed Charges,65% of Total Billed Charges,400.15,44.1,,2416.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,861.99,95,,5205.872,Percent of Total Billed Charges,95% of Total Billed Charges,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,798.48,88,,13501.304,Percent of Total Billed Charges,88% of Total Billed Charges,816.62,90,,4931.88,Percent of Total Billed charges,90% of Total Billed Charges,400.15,907.36,
Z0203150038 38X50,2780001539,CDM,278,RC,C1776,HCPCS,Outpatient,,,907.36,589.78,,907.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,689.59,76,,5235.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,653.3,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,653.3,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,653.3,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,544.42,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,816.62,90,,1741.824,Percent of Total Billed Charges,90% of Total Billed Charges,408.31,45,,3099.792,Percent of Total Billed Charges,45% of Total Billed Charges,816.62,90,,6199.584,Percent of Total Billed Charges,90% of Total billed Charges,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,589.78,65,,1286.488,Percent of total Billed Charges,65% of Total Billed Charges,400.15,44.1,,3037.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,861.99,95,,6544,Percent of Total Billed Charges,95% of Total Billed Charges,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,798.48,88,,231.296,Percent of Total Billed Charges,88% of Total Billed Charges,816.62,90,,6199.584,Percent of Total Billed charges,90% of Total Billed Charges,400.15,907.36,
Z0203150042 42X50,2780001540,CDM,278,RC,C1776,HCPCS,Outpatient,,,907.36,589.78,,907.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,689.59,76,,11660.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,653.3,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,653.3,72,,2000.376,Percent of Total Billed charges,72% of Total Billed Charges,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,653.3,72,,2000.376,Percent of Total Billed Charges,72% of Total Billed Charges,544.42,60,,1666.984,Percent of Total Billed Charges,60% of Total Billed Charges,816.62,90,,1043.28,Percent of Total Billed Charges,90% of Total Billed Charges,408.31,45,,6904.08,Percent of Total Billed Charges,45% of Total Billed Charges,816.62,90,,13808.152,Percent of Total Billed Charges,90% of Total billed Charges,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,589.78,65,,2599.344,Percent of total Billed Charges,65% of Total Billed Charges,400.15,44.1,,6765.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,861.99,95,,14575.272,Percent of Total Billed Charges,95% of Total Billed Charges,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,798.48,88,,1157.256,Percent of Total Billed Charges,88% of Total Billed Charges,816.62,90,,13808.152,Percent of Total Billed charges,90% of Total Billed Charges,400.15,907.36,
Z10325180 2.5 DRIL,2780001541,CDM,278,RC,C1776,HCPCS,Outpatient,,,414.54,269.45,,414.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,315.05,76,,4164.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,298.47,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,298.47,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.47,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,248.72,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,373.09,90,,1742.584,Percent of Total Billed Charges,90% of Total Billed Charges,186.54,45,,118.28,Percent of Total Billed Charges,45% of Total Billed Charges,373.09,90,,4931.88,Percent of Total Billed Charges,90% of Total billed Charges,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.45,65,,1461.92,Percent of total Billed Charges,65% of Total Billed Charges,182.81,44.1,,115.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,393.81,95,,5205.872,Percent of Total Billed Charges,95% of Total Billed Charges,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.8,88,,1879.08,Percent of Total Billed Charges,88% of Total Billed Charges,373.09,90,,4931.88,Percent of Total Billed charges,90% of Total Billed Charges,182.81,414.54,
Z22325018 CABLE RE,2780001542,CDM,278,RC,C1776,HCPCS,Outpatient,,,1944.81,1264.13,,1944.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1478.06,76,,5235.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1400.26,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,1400.26,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,1944.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1400.26,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,1750.33,90,,1043.28,Percent of Total Billed Charges,90% of Total Billed Charges,875.16,45,,591.776,Percent of Total Billed Charges,45% of Total Billed Charges,1750.33,90,,6199.584,Percent of Total Billed Charges,90% of Total billed Charges,1944.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1944.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1944.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1264.13,65,,4931.68,Percent of total Billed Charges,65% of Total Billed Charges,857.66,44.1,,579.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,1847.57,95,,6544,Percent of Total Billed Charges,95% of Total Billed Charges,1944.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1711.43,88,,3621.344,Percent of Total Billed Charges,88% of Total Billed Charges,1750.33,90,,6199.584,Percent of Total Billed charges,90% of Total Billed Charges,857.66,1944.81,
Z484026  4.0 CANN SC,2780001543,CDM,278,RC,C1776,HCPCS,Outpatient,,,69.46,45.15,,69.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.79,76,,11660.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.01,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,50.01,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.01,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,41.68,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,62.51,90,,1742.584,Percent of Total Billed Charges,90% of Total Billed Charges,31.26,45,,960.896,Percent of Total Billed Charges,45% of Total Billed Charges,62.51,90,,13808.152,Percent of Total Billed Charges,90% of Total billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.15,65,,1519.248,Percent of total Billed Charges,65% of Total Billed Charges,30.63,44.1,,941.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.99,95,,14575.272,Percent of Total Billed Charges,95% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,88,,5654.144,Percent of Total Billed Charges,88% of Total Billed Charges,62.51,90,,13808.152,Percent of Total Billed charges,90% of Total Billed Charges,30.63,69.46,
Z22590150 I757 LAG,2780001544,CDM,278,RC,C1776,HCPCS,Outpatient,,,1127.86,733.11,,1127.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,857.17,76,,199.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,812.06,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,812.06,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,1127.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,812.06,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,676.72,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,1015.07,90,,2147.04,Percent of Total Billed Charges,90% of Total Billed Charges,507.54,45,,1851.824,Percent of Total Billed Charges,45% of Total Billed Charges,1015.07,90,,236.56,Percent of Total Billed Charges,90% of Total billed Charges,1127.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1127.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1127.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,733.11,65,,1975.016,Percent of total Billed Charges,65% of Total Billed Charges,497.39,44.1,,1814.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,1071.47,95,,249.696,Percent of Total Billed Charges,95% of Total Billed Charges,1127.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,992.52,88,,1703.12,Percent of Total Billed Charges,88% of Total Billed Charges,1015.07,90,,236.56,Percent of Total Billed charges,90% of Total Billed Charges,497.39,1127.86,
Z49356017 CALCANEA,2780001545,CDM,278,RC,C1776,HCPCS,Outpatient,,,1556.73,1011.87,,1556.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1183.11,76,,999.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1120.85,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,1120.85,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,1556.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1120.85,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,934.04,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,1401.06,90,,1737.36,Percent of Total Billed Charges,90% of Total Billed Charges,700.53,45,,2891.32,Percent of Total Billed Charges,45% of Total Billed Charges,1401.06,90,,1183.56,Percent of Total Billed Charges,90% of Total billed Charges,1556.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1556.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1556.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1011.87,65,,1557.656,Percent of total Billed Charges,65% of Total Billed Charges,686.52,44.1,,2833.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,1478.89,95,,1249.312,Percent of Total Billed Charges,95% of Total Billed Charges,1556.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1369.92,88,,1020.096,Percent of Total Billed Charges,88% of Total Billed Charges,1401.06,90,,1183.56,Percent of Total Billed charges,90% of Total Billed Charges,686.52,1556.73,
Z44543008 TRANSFX,2780001546,CDM,278,RC,C1776,HCPCS,Outpatient,,,342.88,222.87,,342.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,260.59,76,,1622.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,246.87,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,246.87,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,342.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.87,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,205.73,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,308.59,90,,46.8,Percent of Total Billed Charges,90% of Total Billed Charges,154.3,45,,870.912,Percent of Total Billed Charges,45% of Total Billed Charges,308.59,90,,1921.792,Percent of Total Billed Charges,90% of Total billed Charges,342.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.87,65,,2124.656,Percent of total Billed Charges,65% of Total Billed Charges,151.21,44.1,,853.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,325.74,95,,2028.552,Percent of Total Billed Charges,95% of Total Billed Charges,342.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.73,88,,1703.856,Percent of Total Billed Charges,88% of Total Billed Charges,308.59,90,,1921.792,Percent of Total Billed charges,90% of Total Billed Charges,151.21,342.88,
Z44542390 TRANSFX,2780001547,CDM,278,RC,C1776,HCPCS,Outpatient,,,342.88,222.87,,342.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,260.59,76,,3127.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,246.87,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,246.87,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,342.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.87,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,205.73,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,308.59,90,,286.56,Percent of Total Billed Charges,90% of Total Billed Charges,154.3,45,,521.64,Percent of Total Billed Charges,45% of Total Billed Charges,308.59,90,,3703.648,Percent of Total Billed Charges,90% of Total billed Charges,342.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.87,65,,1858.064,Percent of total Billed Charges,65% of Total Billed Charges,151.21,44.1,,511.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,325.74,95,,3909.4,Percent of Total Billed Charges,95% of Total Billed Charges,342.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.73,88,,1020.096,Percent of Total Billed Charges,88% of Total Billed Charges,308.59,90,,3703.648,Percent of Total Billed charges,90% of Total Billed Charges,151.21,342.88,
Z4450820 TRANSFX R,2780001548,CDM,278,RC,C1776,HCPCS,Outpatient,,,485.10,315.32,,485.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,368.68,76,,4883.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,349.27,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,349.27,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,485.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.27,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,291.06,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,436.59,90,,214.56,Percent of Total Billed Charges,90% of Total Billed Charges,218.3,45,,871.288,Percent of Total Billed Charges,45% of Total Billed Charges,436.59,90,,5782.648,Percent of Total Billed Charges,90% of Total billed Charges,485.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.32,65,,7069.36,Percent of total Billed Charges,65% of Total Billed Charges,213.93,44.1,,853.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,460.85,95,,6103.904,Percent of Total Billed Charges,95% of Total Billed Charges,485.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.89,88,,1703.856,Percent of Total Billed Charges,88% of Total Billed Charges,436.59,90,,5782.648,Percent of Total Billed charges,90% of Total Billed Charges,213.93,485.1,
Z44521588 TRANSFX,2780001549,CDM,278,RC,C1776,HCPCS,Outpatient,,,1477.35,960.28,,1477.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1122.79,76,,1470.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1063.69,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,1063.69,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,1477.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1063.69,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,886.41,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,1329.62,90,,214.56,Percent of Total Billed Charges,90% of Total Billed Charges,664.81,45,,521.64,Percent of Total Billed Charges,45% of Total Billed Charges,1329.62,90,,1741.824,Percent of Total Billed Charges,90% of Total billed Charges,1477.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1477.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1477.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,960.28,65,,528.584,Percent of total Billed Charges,65% of Total Billed Charges,651.51,44.1,,511.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,1403.48,95,,1838.592,Percent of Total Billed Charges,95% of Total Billed Charges,1477.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300.07,88,,2099.328,Percent of Total Billed Charges,88% of Total Billed Charges,1329.62,90,,1741.824,Percent of Total Billed charges,90% of Total Billed Charges,651.51,1477.35,
Z44523008 TRANSFX,2780001550,CDM,278,RC,C1776,HCPCS,Outpatient,,,1687.93,1097.15,,1687.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1282.83,76,,880.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1215.31,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,1215.31,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,1687.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1215.31,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,1012.76,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,1519.14,90,,255.6,Percent of Total Billed Charges,90% of Total Billed Charges,759.57,45,,871.288,Percent of Total Billed Charges,45% of Total Billed Charges,1519.14,90,,1043.28,Percent of Total Billed Charges,90% of Total billed Charges,1687.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1687.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1687.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1097.15,65,,770.512,Percent of total Billed Charges,65% of Total Billed Charges,744.38,44.1,,853.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,1603.53,95,,1101.24,Percent of Total Billed Charges,95% of Total Billed Charges,1687.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1485.38,88,,1698.752,Percent of Total Billed Charges,88% of Total Billed Charges,1519.14,90,,1043.28,Percent of Total Billed charges,90% of Total Billed Charges,744.38,1687.93,
Z44529225 PROTECTI,2780001551,CDM,278,RC,C1776,HCPCS,Outpatient,,,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,1471.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,15.08,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,469.44,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,1073.52,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,1742.584,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,284.36,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,1052.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,1839.392,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,45.76,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,1742.584,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
Z23581406 VOLAR LT,2780001552,CDM,278,RC,C1776,HCPCS,Outpatient,,,3059.44,1988.64,,3059.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2325.17,76,,880.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2202.8,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,2202.8,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,3059.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2202.8,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,1835.66,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,2753.5,90,,2473.48,Percent of Total Billed Charges,90% of Total Billed Charges,1376.75,45,,868.68,Percent of Total Billed Charges,45% of Total Billed Charges,2753.5,90,,1043.28,Percent of Total Billed Charges,90% of Total billed Charges,3059.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3059.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3059.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1988.64,65,,2316.6,Percent of total Billed Charges,65% of Total Billed Charges,1349.21,44.1,,851.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2906.47,95,,1101.24,Percent of Total Billed Charges,95% of Total Billed Charges,3059.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2692.31,88,,280.192,Percent of Total Billed Charges,88% of Total Billed Charges,2753.5,90,,1043.28,Percent of Total Billed charges,90% of Total Billed Charges,1349.21,3059.44,
Z493506 COMPLPLATE,2780001553,CDM,278,RC,C1776,HCPCS,Outpatient,,,463.05,300.98,,463.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,351.92,76,,1471.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,333.4,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,333.4,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,463.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.4,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,277.83,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,416.75,90,,9623.24,Percent of Total Billed Charges,90% of Total Billed Charges,208.37,45,,23.4,Percent of Total Billed Charges,45% of Total Billed Charges,416.75,90,,1742.584,Percent of Total Billed Charges,90% of Total billed Charges,463.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,463.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,463.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.98,65,,108.352,Percent of total Billed Charges,65% of Total Billed Charges,204.21,44.1,,22.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,439.9,95,,1839.392,Percent of Total Billed Charges,95% of Total Billed Charges,463.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.48,88,,209.792,Percent of Total Billed Charges,88% of Total Billed Charges,416.75,90,,1742.584,Percent of Total Billed charges,90% of Total Billed Charges,204.21,463.05,
Z595230 12 CRUC DRT,2780001554,CDM,278,RC,C1776,HCPCS,Outpatient,,,9677.75,6290.54,,9677.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7355.09,76,,1813.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6967.98,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,6967.98,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,9677.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6967.98,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,5806.65,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,8709.98,90,,1826.536,Percent of Total Billed Charges,90% of Total Billed Charges,4354.99,45,,143.28,Percent of Total Billed Charges,45% of Total Billed Charges,8709.98,90,,2147.04,Percent of Total Billed Charges,90% of Total billed Charges,9677.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9677.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9677.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6290.54,65,,8847.168,Percent of total Billed Charges,65% of Total Billed Charges,4267.89,44.1,,140.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,9193.86,95,,2266.32,Percent of Total Billed Charges,95% of Total Billed Charges,9677.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8516.42,88,,209.792,Percent of Total Billed Charges,88% of Total Billed Charges,8709.98,90,,2147.04,Percent of Total Billed charges,90% of Total Billed Charges,4267.89,9677.75,
Z49350403 TUB PLATE 4H,2780001555,CDM,278,RC,C1776,HCPCS,Outpatient,,,237.04,154.08,,237.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,180.15,76,,1467.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,170.67,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,170.67,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.67,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,142.22,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,213.34,90,,695.368,Percent of Total Billed Charges,90% of Total Billed Charges,106.67,45,,107.28,Percent of Total Billed Charges,45% of Total Billed Charges,213.34,90,,1737.36,Percent of Total Billed Charges,90% of Total billed Charges,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.08,65,,2307.76,Percent of total Billed Charges,65% of Total Billed Charges,104.53,44.1,,105.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,225.19,95,,1833.88,Percent of Total Billed Charges,95% of Total Billed Charges,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.6,88,,249.92,Percent of Total Billed Charges,88% of Total Billed Charges,213.34,90,,1737.36,Percent of Total Billed charges,90% of Total Billed Charges,104.53,237.04,
Z23570910 DIS TIB,2780001556,CDM,278,RC,C1776,HCPCS,Outpatient,,,5402.25,3511.46,,5402.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4105.71,76,,39.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3889.62,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,3889.62,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,5402.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3889.62,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,3241.35,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,4862.03,90,,1781.288,Percent of Total Billed Charges,90% of Total Billed Charges,2431.01,45,,107.28,Percent of Total Billed Charges,45% of Total Billed Charges,4862.03,90,,46.8,Percent of Total Billed Charges,90% of Total billed Charges,5402.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5402.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5402.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3511.46,65,,2361.84,Percent of total Billed Charges,65% of Total Billed Charges,2382.39,44.1,,105.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,5132.14,95,,49.4,Percent of Total Billed Charges,95% of Total Billed Charges,5402.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4753.98,88,,459.008,Percent of Total Billed Charges,88% of Total Billed Charges,4862.03,90,,46.8,Percent of Total Billed charges,90% of Total Billed Charges,2382.39,5402.25,
Z23591036 CANN LCK,2780001557,CDM,278,RC,C1776,HCPCS,Outpatient,,,370.44,240.79,,370.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,281.53,76,,241.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,266.72,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,266.72,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.72,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,222.26,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,333.4,90,,3599.096,Percent of Total Billed Charges,90% of Total Billed Charges,166.7,45,,127.8,Percent of Total Billed Charges,45% of Total Billed Charges,333.4,90,,286.56,Percent of Total Billed Charges,90% of Total billed Charges,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.79,65,,1587.56,Percent of total Billed Charges,65% of Total Billed Charges,163.36,44.1,,125.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,351.92,95,,302.48,Percent of Total Billed Charges,95% of Total Billed Charges,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.99,88,,2418.512,Percent of Total Billed Charges,88% of Total Billed Charges,333.4,90,,286.56,Percent of Total Billed charges,90% of Total Billed Charges,163.36,370.44,
Z23594536 CANN LCK,2780001558,CDM,278,RC,C1776,HCPCS,Outpatient,,,370.44,240.79,,370.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,281.53,76,,181.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,266.72,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,266.72,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.72,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,222.26,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,333.4,90,,2024.192,Percent of Total Billed Charges,90% of Total Billed Charges,166.7,45,,234.72,Percent of Total Billed Charges,45% of Total Billed Charges,333.4,90,,214.56,Percent of Total Billed Charges,90% of Total billed Charges,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.79,65,,2975.96,Percent of total Billed Charges,65% of Total Billed Charges,163.36,44.1,,230.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,351.92,95,,226.48,Percent of Total Billed Charges,95% of Total Billed Charges,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.99,88,,9409.392,Percent of Total Billed Charges,88% of Total Billed Charges,333.4,90,,214.56,Percent of Total Billed charges,90% of Total Billed Charges,163.36,370.44,
Z59644012 ART SURF,2780001559,CDM,278,RC,C1776,HCPCS,Outpatient,,,6578.62,4276.10,,6578.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4999.75,76,,181.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4736.61,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,4736.61,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4736.61,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,3947.17,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,5920.76,90,,6828.48,Percent of Total Billed Charges,90% of Total Billed Charges,2960.38,45,,1236.744,Percent of Total Billed Charges,45% of Total Billed Charges,5920.76,90,,214.56,Percent of Total Billed Charges,90% of Total billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4276.1,65,,1569.36,Percent of total Billed Charges,65% of Total Billed Charges,2901.17,44.1,,1212.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,6249.69,95,,226.48,Percent of Total Billed Charges,95% of Total Billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5789.19,88,,1785.944,Percent of Total Billed Charges,88% of Total Billed Charges,5920.76,90,,214.56,Percent of Total Billed charges,90% of Total Billed Charges,2901.17,6578.62,
Z59643212 ART SURF,2780001560,CDM,278,RC,C1776,HCPCS,Outpatient,,,6578.62,4276.10,,6578.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4999.75,76,,215.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4736.61,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,4736.61,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4736.61,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,3947.17,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,5920.76,90,,2103.576,Percent of Total Billed Charges,90% of Total Billed Charges,2960.38,45,,4811.616,Percent of Total Billed Charges,45% of Total Billed Charges,5920.76,90,,255.6,Percent of Total Billed Charges,90% of Total billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4276.1,65,,1299.672,Percent of total Billed Charges,65% of Total Billed Charges,2901.17,44.1,,4715.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,6249.69,95,,269.8,Percent of Total Billed Charges,95% of Total Billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5789.19,88,,679.92,Percent of Total Billed Charges,88% of Total Billed Charges,5920.76,90,,255.6,Percent of Total Billed charges,90% of Total Billed Charges,2901.17,6578.62,
Z59644010 AR7 SURF,2780001561,CDM,278,RC,C1776,HCPCS,Outpatient,,,6578.62,4276.10,,6578.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4999.75,76,,396.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4736.61,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,4736.61,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4736.61,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,3947.17,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,5920.76,90,,2734.64,Percent of Total Billed Charges,90% of Total Billed Charges,2960.38,45,,913.264,Percent of Total Billed Charges,45% of Total Billed Charges,5920.76,90,,469.44,Percent of Total Billed Charges,90% of Total billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4276.1,65,,3138.2,Percent of total Billed Charges,65% of Total Billed Charges,2901.17,44.1,,895,Percent of Total Billed Charges,44.1% of Total Billed Charges,6249.69,95,,495.52,Percent of Total Billed Charges,95% of Total Billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5789.19,88,,1741.704,Percent of Total Billed Charges,88% of Total Billed Charges,5920.76,90,,469.44,Percent of Total Billed charges,90% of Total Billed Charges,2901.17,6578.62,
Z225424008 NAIL 8X,2780001562,CDM,278,RC,C1776,HCPCS,Outpatient,,,4724.21,3070.74,,4724.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3590.4,76,,2088.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3401.43,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,3401.43,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,4724.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3401.43,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,2834.53,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,4251.79,90,,2156.752,Percent of Total Billed Charges,90% of Total Billed Charges,2125.89,45,,347.688,Percent of Total Billed Charges,45% of Total Billed Charges,4251.79,90,,2473.48,Percent of Total Billed Charges,90% of Total billed Charges,4724.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4724.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4724.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3070.74,65,,1984.32,Percent of total Billed Charges,65% of Total Billed Charges,2083.38,44.1,,340.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,4488,95,,2610.896,Percent of Total Billed Charges,95% of Total Billed Charges,4724.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4157.3,88,,3519.112,Percent of Total Billed Charges,88% of Total Billed Charges,4251.79,90,,2473.48,Percent of Total Billed charges,90% of Total Billed Charges,2083.38,4724.21,
Z59643014 ART SURF,2780001563,CDM,278,RC,C1776,HCPCS,Outpatient,,,6578.62,4276.10,,6578.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4999.75,76,,8126.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4736.61,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,4736.61,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4736.61,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,3947.17,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,5920.76,90,,2941.824,Percent of Total Billed Charges,90% of Total Billed Charges,2960.38,45,,890.64,Percent of Total Billed Charges,45% of Total Billed Charges,5920.76,90,,9623.24,Percent of Total Billed Charges,90% of Total billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4276.1,65,,2453.152,Percent of total Billed Charges,65% of Total Billed Charges,2901.17,44.1,,872.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,6249.69,95,,10157.864,Percent of Total Billed Charges,95% of Total Billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5789.19,88,,1979.208,Percent of Total Billed Charges,88% of Total Billed Charges,5920.76,90,,9623.24,Percent of Total Billed charges,90% of Total Billed Charges,2901.17,6578.62,
Z22401318 NAIL 13X,2780001564,CDM,278,RC,C1776,HCPCS,Outpatient,,,4740.75,3081.49,,4740.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3602.97,76,,1542.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3413.34,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,3413.34,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,4740.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3413.34,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,2844.45,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,4266.68,90,,2572.704,Percent of Total Billed Charges,90% of Total Billed Charges,2133.34,45,,1799.544,Percent of Total Billed Charges,45% of Total Billed Charges,4266.68,90,,1826.536,Percent of Total Billed Charges,90% of Total billed Charges,4740.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4740.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4740.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3081.49,65,,960.28,Percent of total Billed Charges,65% of Total Billed Charges,2090.67,44.1,,1763.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,4503.71,95,,1928.008,Percent of Total Billed Charges,95% of Total Billed Charges,4740.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4171.86,88,,6676.736,Percent of Total Billed Charges,88% of Total Billed Charges,4266.68,90,,1826.536,Percent of Total Billed charges,90% of Total Billed Charges,2090.67,4740.75,
Z59645012 ART  SUR,2780001565,CDM,278,RC,C1776,HCPCS,Outpatient,,,6578.62,4276.10,,6578.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4999.75,76,,587.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4736.61,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,4736.61,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4736.61,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,3947.17,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,5920.76,90,,9788.352,Percent of Total Billed Charges,90% of Total Billed Charges,2960.38,45,,1012.096,Percent of Total Billed Charges,45% of Total Billed Charges,5920.76,90,,695.368,Percent of Total Billed Charges,90% of Total billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4276.1,65,,660.92,Percent of total Billed Charges,65% of Total Billed Charges,2901.17,44.1,,991.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,6249.69,95,,734,Percent of Total Billed Charges,95% of Total Billed Charges,6578.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5789.19,88,,2056.824,Percent of Total Billed Charges,88% of Total Billed Charges,5920.76,90,,695.368,Percent of Total Billed charges,90% of Total Billed Charges,2901.17,6578.62,
Z47248510010 LAG,2780001566,CDM,278,RC,C1776,HCPCS,Outpatient,,,2227.05,1447.58,,2227.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1692.56,76,,1504.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1603.48,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,1603.48,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,2227.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1603.48,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,1336.23,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,2004.35,90,,731.888,Percent of Total Billed Charges,90% of Total Billed Charges,1002.17,45,,3414.24,Percent of Total Billed Charges,45% of Total Billed Charges,2004.35,90,,1781.288,Percent of Total Billed Charges,90% of Total billed Charges,2227.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2227.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2227.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1447.58,65,,516.544,Percent of total Billed Charges,65% of Total Billed Charges,982.13,44.1,,3345.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,2115.7,95,,1880.248,Percent of Total Billed Charges,95% of Total Billed Charges,2227.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1959.8,88,,2673.872,Percent of Total Billed Charges,88% of Total Billed Charges,2004.35,90,,1781.288,Percent of Total Billed charges,90% of Total Billed Charges,982.13,2227.05,
Z47249321313 FEMI,2780001567,CDM,278,RC,C1776,HCPCS,Outpatient,,,6147.54,3995.90,,6147.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4672.13,76,,3039.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4426.23,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,4426.23,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4426.23,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,3688.52,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,5532.79,90,,1066.864,Percent of Total Billed Charges,90% of Total Billed Charges,2766.39,45,,1051.784,Percent of Total Billed Charges,45% of Total Billed Charges,5532.79,90,,3599.096,Percent of Total Billed Charges,90% of Total billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3995.9,65,,475.84,Percent of total Billed Charges,65% of Total Billed Charges,2711.07,44.1,,1030.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,5840.16,95,,3799.04,Percent of Total Billed Charges,95% of Total Billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5409.84,88,,2108.824,Percent of Total Billed Charges,88% of Total Billed Charges,5532.79,90,,3599.096,Percent of Total Billed charges,90% of Total Billed Charges,2711.07,6147.54,
Z48271401 2.7 CORT,2780001568,CDM,278,RC,C1776,HCPCS,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,1709.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,56.36,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,393.728,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,1367.32,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,2024.192,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,666.752,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,1339.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,2136.648,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,2876.456,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,2024.192,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
Z47248509010 LAG,2780001569,CDM,278,RC,C1776,HCPCS,Outpatient,,,2227.05,1447.58,,2227.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1692.56,76,,5766.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1603.48,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,1603.48,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,2227.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1603.48,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,1336.23,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,2004.35,90,,3207.6,Percent of Total Billed Charges,90% of Total Billed Charges,1002.17,45,,1078.376,Percent of Total Billed Charges,45% of Total Billed Charges,2004.35,90,,6828.48,Percent of Total Billed Charges,90% of Total billed Charges,2227.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2227.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2227.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1447.58,65,,411.056,Percent of total Billed Charges,65% of Total Billed Charges,982.13,44.1,,1056.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,2115.7,95,,7207.84,Percent of Total Billed Charges,95% of Total Billed Charges,2227.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1959.8,88,,2515.536,Percent of Total Billed Charges,88% of Total Billed Charges,2004.35,90,,6828.48,Percent of Total Billed charges,90% of Total Billed Charges,982.13,2227.05,
Z47249321311 FEMN,2780001570,CDM,278,RC,C1776,HCPCS,Outpatient,,,6147.54,3995.90,,6147.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4672.13,76,,1776.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4426.23,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,4426.23,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4426.23,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,3688.52,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,5532.79,90,,150.024,Percent of Total Billed Charges,90% of Total Billed Charges,2766.39,45,,1470.912,Percent of Total Billed Charges,45% of Total Billed Charges,5532.79,90,,2103.576,Percent of Total Billed Charges,90% of Total billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3995.9,65,,411.056,Percent of total Billed Charges,65% of Total Billed Charges,2711.07,44.1,,1441.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,5840.16,95,,2220.44,Percent of Total Billed Charges,95% of Total Billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5409.84,88,,9570.832,Percent of Total Billed Charges,88% of Total Billed Charges,5532.79,90,,2103.576,Percent of Total Billed charges,90% of Total Billed Charges,2711.07,6147.54,
Z49350503 TUB PLAT,2780001571,CDM,278,RC,C1776,HCPCS,Outpatient,,,237.04,154.08,,237.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,180.15,76,,2309.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,170.67,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,170.67,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.67,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,142.22,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,213.34,90,,12249.92,Percent of Total Billed Charges,90% of Total Billed Charges,106.67,45,,1286.352,Percent of Total Billed Charges,45% of Total Billed Charges,213.34,90,,2734.64,Percent of Total Billed Charges,90% of Total billed Charges,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.08,65,,411.056,Percent of total Billed Charges,65% of Total Billed Charges,104.53,44.1,,1260.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,225.19,95,,2886.56,Percent of Total Billed Charges,95% of Total Billed Charges,237.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.6,88,,715.624,Percent of Total Billed Charges,88% of Total Billed Charges,213.34,90,,2734.64,Percent of Total Billed charges,90% of Total Billed Charges,104.53,237.04,
Z55903521 REV FEM/,2780001572,CDM,278,RC,C1776,HCPCS,Outpatient,,,4112.33,2673.01,,4112.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3125.37,76,,1821.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2960.88,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,2960.88,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,4112.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2960.88,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,2467.4,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,3701.1,90,,3195.36,Percent of Total Billed Charges,90% of Total Billed Charges,1850.55,45,,4894.176,Percent of Total Billed Charges,45% of Total Billed Charges,3701.1,90,,2156.752,Percent of Total Billed Charges,90% of Total billed Charges,4112.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4112.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4112.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2673.01,65,,411.056,Percent of total Billed Charges,65% of Total Billed Charges,1813.54,44.1,,4796.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,3906.71,95,,2276.576,Percent of Total Billed Charges,95% of Total Billed Charges,4112.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3618.85,88,,1043.16,Percent of Total Billed Charges,88% of Total Billed Charges,3701.1,90,,2156.752,Percent of Total Billed charges,90% of Total Billed Charges,1813.54,4112.33,
Z58805012 REV ARTI,2780001573,CDM,278,RC,C1776,HCPCS,Outpatient,,,7369.11,4789.92,,7369.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5600.52,76,,2484.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5305.76,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,5305.76,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,7369.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5305.76,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,4421.47,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,6632.2,90,,3270.24,Percent of Total Billed Charges,90% of Total Billed Charges,3316.1,45,,365.944,Percent of Total Billed Charges,45% of Total Billed Charges,6632.2,90,,2941.824,Percent of Total Billed Charges,90% of Total billed Charges,7369.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7369.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7369.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4789.92,65,,411.056,Percent of total Billed Charges,65% of Total Billed Charges,3249.78,44.1,,358.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,7000.65,95,,3105.264,Percent of Total Billed Charges,95% of Total Billed Charges,7369.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6484.82,88,,384.976,Percent of Total Billed Charges,88% of Total Billed Charges,6632.2,90,,2941.824,Percent of Total Billed charges,90% of Total Billed Charges,3249.78,7369.11,
Z500145 BIPOLAR CUP,2780001574,CDM,278,RC,C1776,HCPCS,Outpatient,,,2932.65,1906.22,,2932.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2228.81,76,,2172.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2111.51,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,2111.51,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,2932.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2111.51,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,1759.59,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,2639.39,90,,2198.16,Percent of Total Billed Charges,90% of Total Billed Charges,1319.69,45,,533.432,Percent of Total Billed Charges,45% of Total Billed Charges,2639.39,90,,2572.704,Percent of Total Billed Charges,90% of Total billed Charges,2932.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2932.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2932.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1906.22,65,,411.056,Percent of total Billed Charges,65% of Total Billed Charges,1293.3,44.1,,522.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,2786.02,95,,2715.632,Percent of Total Billed Charges,95% of Total Billed Charges,2932.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2580.73,88,,3136.32,Percent of Total Billed Charges,88% of Total Billed Charges,2639.39,90,,2572.704,Percent of Total Billed charges,90% of Total Billed Charges,1293.3,2932.65,
Z50014428 BIPOLAR,2780001575,CDM,278,RC,C1776,HCPCS,Outpatient,,,1803.69,1172.40,,1803.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1370.8,76,,8265.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1298.66,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,1298.66,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,1803.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1298.66,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,1082.21,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,1623.32,90,,4120.56,Percent of Total Billed Charges,90% of Total Billed Charges,811.66,45,,196.864,Percent of Total Billed Charges,45% of Total Billed Charges,1623.32,90,,9788.352,Percent of Total Billed Charges,90% of Total billed Charges,1803.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1803.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1803.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1172.4,65,,214.992,Percent of total Billed Charges,65% of Total Billed Charges,795.43,44.1,,192.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,1713.51,95,,10332.144,Percent of Total Billed Charges,95% of Total Billed Charges,1803.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1587.25,88,,146.696,Percent of Total Billed Charges,88% of Total Billed Charges,1623.32,90,,9788.352,Percent of Total Billed charges,90% of Total Billed Charges,795.43,1803.69,
Z80182802 FEM HEAD,2780001576,CDM,278,RC,C1776,HCPCS,Outpatient,,,3370.34,2190.72,,3370.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2561.46,76,,618.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2426.64,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,2426.64,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,3370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2426.64,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,2022.2,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,3033.31,90,,2172.96,Percent of Total Billed Charges,90% of Total Billed Charges,1516.65,45,,1603.8,Percent of Total Billed Charges,45% of Total Billed Charges,3033.31,90,,731.888,Percent of Total Billed Charges,90% of Total billed Charges,3370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2190.72,65,,214.992,Percent of total Billed Charges,65% of Total Billed Charges,1486.32,44.1,,1571.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,3201.82,95,,772.544,Percent of Total Billed Charges,95% of Total Billed Charges,3370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2965.9,88,,11977.704,Percent of Total Billed Charges,88% of Total Billed Charges,3033.31,90,,731.888,Percent of Total Billed charges,90% of Total Billed Charges,1486.32,3370.34,
Z225425509 HUM NAI,2780001577,CDM,278,RC,C1776,HCPCS,Outpatient,,,4725.32,3071.46,,4725.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3591.24,76,,900.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3402.23,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,3402.23,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,4725.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3402.23,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,2835.19,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,4252.79,90,,1799.544,Percent of Total Billed Charges,90% of Total Billed Charges,2126.39,45,,75.016,Percent of Total Billed Charges,45% of Total Billed Charges,4252.79,90,,1066.864,Percent of Total Billed Charges,90% of Total billed Charges,4725.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4725.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4725.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3071.46,65,,214.992,Percent of total Billed Charges,65% of Total Billed Charges,2083.87,44.1,,73.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,4489.05,95,,1126.136,Percent of Total Billed Charges,95% of Total Billed Charges,4725.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4158.28,88,,3124.352,Percent of Total Billed Charges,88% of Total Billed Charges,4252.79,90,,1066.864,Percent of Total Billed charges,90% of Total Billed Charges,2083.87,4725.32,
Z47248402550 5.0X,2780001578,CDM,278,RC,C1776,HCPCS,Outpatient,,,790.49,513.82,,790.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,600.77,76,,332.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,569.15,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,569.15,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569.15,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,474.29,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,711.44,90,,4345.2,Percent of Total Billed Charges,90% of Total Billed Charges,355.72,45,,6124.96,Percent of Total Billed Charges,45% of Total Billed Charges,711.44,90,,393.728,Percent of Total Billed Charges,90% of Total billed Charges,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.82,65,,214.992,Percent of total Billed Charges,65% of Total Billed Charges,348.61,44.1,,6002.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,750.97,95,,415.6,Percent of Total Billed Charges,95% of Total Billed Charges,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.63,88,,3197.568,Percent of Total Billed Charges,88% of Total Billed Charges,711.44,90,,393.728,Percent of Total Billed charges,90% of Total Billed Charges,348.61,790.49,
Z47249321010 FEMN,2780001579,CDM,278,RC,C1776,HCPCS,Outpatient,,,6145.34,3994.47,,6145.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4670.46,76,,2708.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4424.64,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,4424.64,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,6145.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4424.64,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,3687.2,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,5530.81,90,,2747.52,Percent of Total Billed Charges,90% of Total Billed Charges,2765.4,45,,1597.68,Percent of Total Billed Charges,45% of Total Billed Charges,5530.81,90,,3207.6,Percent of Total Billed Charges,90% of Total billed Charges,6145.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6145.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6145.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3994.47,65,,214.992,Percent of total Billed Charges,65% of Total Billed Charges,2710.09,44.1,,1565.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,5838.07,95,,3385.8,Percent of Total Billed Charges,95% of Total Billed Charges,6145.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.9,88,,2149.312,Percent of Total Billed Charges,88% of Total Billed Charges,5530.81,90,,3207.6,Percent of Total Billed charges,90% of Total Billed Charges,2710.09,6145.34,
Z59701501 CRUC FEM,2780001580,CDM,278,RC,C1776,HCPCS,Outpatient,,,11637.99,7564.69,,11637.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8844.87,76,,126.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8379.35,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,8379.35,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,11637.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8379.35,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,6982.79,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,10474.19,90,,3396.672,Percent of Total Billed Charges,90% of Total Billed Charges,5237.1,45,,1635.12,Percent of Total Billed Charges,45% of Total Billed Charges,10474.19,90,,150.024,Percent of Total Billed Charges,90% of Total billed Charges,11637.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11637.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11637.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7564.69,65,,214.992,Percent of total Billed Charges,65% of Total Billed Charges,5132.35,44.1,,1602.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,11056.09,95,,158.36,Percent of Total Billed Charges,95% of Total Billed Charges,11637.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10241.43,88,,4028.992,Percent of Total Billed Charges,88% of Total Billed Charges,10474.19,90,,150.024,Percent of Total Billed charges,90% of Total Billed Charges,5132.35,11637.99,
Z59524012 ART SURF,2780001581,CDM,278,RC,C1776,HCPCS,Outpatient,,,7015.21,4559.89,,7015.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5331.56,76,,10344.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5050.95,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,5050.95,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,7015.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5050.95,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,4209.13,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,6313.69,90,,1329.616,Percent of Total Billed Charges,90% of Total Billed Charges,3156.84,45,,1099.08,Percent of Total Billed Charges,45% of Total Billed Charges,6313.69,90,,12249.92,Percent of Total Billed Charges,90% of Total billed Charges,7015.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7015.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7015.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4559.89,65,,214.992,Percent of total Billed Charges,65% of Total Billed Charges,3093.71,44.1,,1077.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,6664.45,95,,12930.472,Percent of Total Billed Charges,95% of Total Billed Charges,7015.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6173.38,88,,2124.672,Percent of Total Billed Charges,88% of Total Billed Charges,6313.69,90,,12249.92,Percent of Total Billed charges,90% of Total Billed Charges,3093.71,7015.21,
Z4724934010 LAGSC,2780001582,CDM,278,RC,C1776,HCPCS,Outpatient,,,2228.15,1448.30,,2228.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1693.39,76,,2698.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1604.27,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,1604.27,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,2228.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1604.27,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,1336.89,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,2005.34,90,,915.12,Percent of Total Billed Charges,90% of Total Billed Charges,1002.67,45,,2060.28,Percent of Total Billed Charges,45% of Total Billed Charges,2005.34,90,,3195.36,Percent of Total Billed Charges,90% of Total billed Charges,2228.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2228.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2228.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1448.3,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,982.61,44.1,,2019.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,2116.74,95,,3372.88,Percent of Total Billed Charges,95% of Total Billed Charges,2228.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1960.77,88,,1759.56,Percent of Total Billed Charges,88% of Total Billed Charges,2005.34,90,,3195.36,Percent of Total Billed charges,90% of Total Billed Charges,982.61,2228.15,
Z47248404050 5.0X,2780001583,CDM,278,RC,C1776,HCPCS,Outpatient,,,791.60,514.54,,791.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,601.62,76,,2761.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,569.95,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,569.95,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,791.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569.95,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,474.96,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,712.44,90,,715.216,Percent of Total Billed Charges,90% of Total Billed Charges,356.22,45,,1086.48,Percent of Total Billed Charges,45% of Total Billed Charges,712.44,90,,3270.24,Percent of Total Billed Charges,90% of Total billed Charges,791.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,791.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,791.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,514.54,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,349.1,44.1,,1064.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,752.02,95,,3451.92,Percent of Total Billed Charges,95% of Total Billed Charges,791.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,696.61,88,,4248.64,Percent of Total Billed Charges,88% of Total Billed Charges,712.44,90,,3270.24,Percent of Total Billed charges,90% of Total Billed Charges,349.1,791.6,
Z62005422 TRILOGY,2780001584,CDM,278,RC,C1776,HCPCS,Outpatient,,,7073.64,4597.87,,7073.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5375.97,76,,1856.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5093.02,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,5093.02,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,7073.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5093.02,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,4244.18,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,6366.28,90,,658.856,Percent of Total Billed Charges,90% of Total Billed Charges,3183.14,45,,899.776,Percent of Total Billed Charges,45% of Total Billed Charges,6366.28,90,,2198.16,Percent of Total Billed Charges,90% of Total billed Charges,7073.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7073.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7073.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4597.87,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,3119.48,44.1,,881.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,6719.96,95,,2320.28,Percent of Total Billed Charges,95% of Total Billed Charges,7073.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6224.8,88,,2686.464,Percent of Total Billed Charges,88% of Total Billed Charges,6366.28,90,,2198.16,Percent of Total Billed charges,90% of Total Billed Charges,3119.48,7073.64,
Z784116 FEM STEM SZ,2780001585,CDM,278,RC,C1776,HCPCS,Outpatient,,,21115.08,13724.80,,21115.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16047.46,76,,3479.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15202.86,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,15202.86,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,21115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15202.86,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,12669.05,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,19003.57,90,,923.192,Percent of Total Billed Charges,90% of Total Billed Charges,9501.79,45,,2172.6,Percent of Total Billed Charges,45% of Total Billed Charges,19003.57,90,,4120.56,Percent of Total Billed Charges,90% of Total billed Charges,21115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13724.8,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,9311.75,44.1,,2129.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,20059.33,95,,4349.48,Percent of Total Billed Charges,95% of Total Billed Charges,21115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18581.27,88,,3321.192,Percent of Total Billed Charges,88% of Total Billed Charges,19003.57,90,,4120.56,Percent of Total Billed charges,90% of Total Billed Charges,9311.75,21115.08,
Z484050 4.0 CANN SC,2780001586,CDM,278,RC,C1776,HCPCS,Outpatient,,,69.46,45.15,,69.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.79,76,,1834.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.01,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,50.01,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.01,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,41.68,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,62.51,90,,569.152,Percent of Total Billed Charges,90% of Total Billed Charges,31.26,45,,1373.76,Percent of Total Billed Charges,45% of Total Billed Charges,62.51,90,,2172.96,Percent of Total Billed Charges,90% of Total billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.15,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,30.63,44.1,,1346.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.99,95,,2293.68,Percent of Total Billed Charges,95% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,88,,1300.072,Percent of Total Billed Charges,88% of Total Billed Charges,62.51,90,,2172.96,Percent of Total Billed charges,90% of Total Billed Charges,30.63,69.46,
Z62506535 BONESCRE,2780001587,CDM,278,RC,C1776,HCPCS,Outpatient,,,558.97,363.33,,558.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,424.82,76,,1519.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,402.46,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,402.46,72,,2089.92,Percent of Total Billed charges,72% of Total Billed Charges,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,402.46,72,,2089.92,Percent of Total Billed Charges,72% of Total Billed Charges,335.38,60,,1741.6,Percent of Total Billed Charges,60% of Total Billed Charges,503.07,90,,569.152,Percent of Total Billed Charges,90% of Total Billed Charges,251.54,45,,1698.336,Percent of Total Billed Charges,45% of Total Billed Charges,503.07,90,,1799.544,Percent of Total Billed Charges,90% of Total billed Charges,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.33,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,246.51,44.1,,1664.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,531.02,95,,1899.52,Percent of Total Billed Charges,95% of Total Billed Charges,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.89,88,,894.784,Percent of Total Billed Charges,88% of Total Billed Charges,503.07,90,,1799.544,Percent of Total Billed charges,90% of Total Billed Charges,246.51,558.97,
Z62005222 TRIOLOGY,2780001588,CDM,278,RC,C1776,HCPCS,Outpatient,,,7073.64,4597.87,,7073.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5375.97,76,,3669.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5093.02,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,5093.02,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,7073.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5093.02,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,4244.18,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,6366.28,90,,569.152,Percent of Total Billed Charges,90% of Total Billed Charges,3183.14,45,,664.808,Percent of Total Billed Charges,45% of Total Billed Charges,6366.28,90,,4345.2,Percent of Total Billed Charges,90% of Total billed Charges,7073.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7073.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7073.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4597.87,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,3119.48,44.1,,651.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,6719.96,95,,4586.6,Percent of Total Billed Charges,95% of Total Billed Charges,7073.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6224.8,88,,699.32,Percent of Total Billed Charges,88% of Total Billed Charges,6366.28,90,,4345.2,Percent of Total Billed charges,90% of Total Billed Charges,3119.48,7073.64,
Z784114 FEM STEM SZ,2780001589,CDM,278,RC,C1776,HCPCS,Outpatient,,,21115.08,13724.80,,21115.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16047.46,76,,2320.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15202.86,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,15202.86,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,21115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15202.86,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,12669.05,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,19003.57,90,,569.152,Percent of Total Billed Charges,90% of Total Billed Charges,9501.79,45,,457.56,Percent of Total Billed Charges,45% of Total Billed Charges,19003.57,90,,2747.52,Percent of Total Billed Charges,90% of Total billed Charges,21115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13724.8,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,9311.75,44.1,,448.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,20059.33,95,,2900.16,Percent of Total Billed Charges,95% of Total Billed Charges,21115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18581.27,88,,644.216,Percent of Total Billed Charges,88% of Total Billed Charges,19003.57,90,,2747.52,Percent of Total Billed charges,90% of Total Billed Charges,9311.75,21115.08,
Z23480606 HUMERAL,2780001590,CDM,278,RC,C1776,HCPCS,Outpatient,,,2773.89,1803.03,,2773.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2108.16,76,,2868.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1997.2,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,1997.2,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,2773.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1997.2,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,1664.33,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,2496.5,90,,569.152,Percent of Total Billed Charges,90% of Total Billed Charges,1248.25,45,,357.608,Percent of Total Billed Charges,45% of Total Billed Charges,2496.5,90,,3396.672,Percent of Total Billed Charges,90% of Total billed Charges,2773.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2773.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2773.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1803.03,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,1223.29,44.1,,350.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,2635.2,95,,3585.376,Percent of Total Billed Charges,95% of Total Billed Charges,2773.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2441.02,88,,902.672,Percent of Total Billed Charges,88% of Total Billed Charges,2496.5,90,,3396.672,Percent of Total Billed charges,90% of Total Billed Charges,1223.29,2773.89,
Z23480716 HUMERAL,2780001591,CDM,278,RC,C1776,HCPCS,Outpatient,,,1885.28,1225.43,,1885.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1432.81,76,,1122.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1357.4,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,1357.4,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,1885.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1357.4,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,1131.17,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,1696.75,90,,569.152,Percent of Total Billed Charges,90% of Total Billed Charges,848.38,45,,329.432,Percent of Total Billed Charges,45% of Total Billed Charges,1696.75,90,,1329.616,Percent of Total Billed Charges,90% of Total billed Charges,1885.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1885.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1885.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1225.43,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,831.41,44.1,,322.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,1791.02,95,,1403.488,Percent of Total Billed Charges,95% of Total Billed Charges,1885.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1659.05,88,,556.504,Percent of Total Billed Charges,88% of Total Billed Charges,1696.75,90,,1329.616,Percent of Total Billed charges,90% of Total Billed Charges,831.41,1885.28,
Z114793 GUIDE PIN 3,2780001592,CDM,278,RC,C1776,HCPCS,Outpatient,,,74.97,48.73,,74.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.98,76,,772.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.98,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,53.98,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.98,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,44.98,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,67.47,90,,297.68,Percent of Total Billed Charges,90% of Total Billed Charges,33.74,45,,461.592,Percent of Total Billed Charges,45% of Total Billed Charges,67.47,90,,915.12,Percent of Total Billed Charges,90% of Total billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.73,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,33.06,44.1,,452.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,71.22,95,,965.96,Percent of Total Billed Charges,95% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.97,88,,556.504,Percent of Total Billed Charges,88% of Total Billed Charges,67.47,90,,915.12,Percent of Total Billed charges,90% of Total Billed Charges,33.06,74.97,
Z23483635 3.5 CORT,2780001593,CDM,278,RC,C1776,HCPCS,Outpatient,,,125.69,81.70,,125.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95.52,76,,603.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90.5,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,90.5,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.5,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,75.41,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,113.12,90,,297.68,Percent of Total Billed Charges,90% of Total Billed Charges,56.56,45,,284.576,Percent of Total Billed Charges,45% of Total Billed Charges,113.12,90,,715.216,Percent of Total Billed Charges,90% of Total billed Charges,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.7,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,55.43,44.1,,278.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,119.41,95,,754.944,Percent of Total Billed Charges,95% of Total Billed Charges,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.61,88,,556.504,Percent of Total Billed Charges,88% of Total Billed Charges,113.12,90,,715.216,Percent of Total Billed charges,90% of Total Billed Charges,55.43,125.69,
Z23487535 3.5 CORT,2780001594,CDM,278,RC,C1776,HCPCS,Outpatient,,,125.69,81.70,,125.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95.52,76,,556.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90.5,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,90.5,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.5,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,75.41,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,113.12,90,,297.68,Percent of Total Billed Charges,90% of Total Billed Charges,56.56,45,,284.576,Percent of Total Billed Charges,45% of Total Billed Charges,113.12,90,,658.856,Percent of Total Billed Charges,90% of Total billed Charges,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.7,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,55.43,44.1,,278.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,119.41,95,,695.464,Percent of Total Billed Charges,95% of Total Billed Charges,125.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.61,88,,556.504,Percent of Total Billed Charges,88% of Total Billed Charges,113.12,90,,658.856,Percent of Total Billed charges,90% of Total Billed Charges,55.43,125.69,
Z24484040 4.0 CANN,2780001595,CDM,278,RC,C1776,HCPCS,Outpatient,,,212.78,138.31,,212.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.71,76,,779.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153.2,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,153.2,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.2,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,127.67,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,191.5,90,,297.68,Percent of Total Billed Charges,90% of Total Billed Charges,95.75,45,,284.576,Percent of Total Billed Charges,45% of Total Billed Charges,191.5,90,,923.192,Percent of Total Billed Charges,90% of Total billed Charges,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.31,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,93.84,44.1,,278.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,202.14,95,,974.48,Percent of Total Billed Charges,95% of Total Billed Charges,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.25,88,,556.504,Percent of Total Billed Charges,88% of Total Billed Charges,191.5,90,,923.192,Percent of Total Billed charges,90% of Total Billed Charges,93.84,212.78,
Z24803441 4.0 CANN,2780001596,CDM,278,RC,C1776,HCPCS,Outpatient,,,212.78,138.31,,212.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.71,76,,480.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153.2,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,153.2,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.2,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,127.67,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,191.5,90,,297.68,Percent of Total Billed Charges,90% of Total Billed Charges,95.75,45,,284.576,Percent of Total Billed Charges,45% of Total Billed Charges,191.5,90,,569.152,Percent of Total Billed Charges,90% of Total billed Charges,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.31,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,93.84,44.1,,278.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,202.14,95,,600.776,Percent of Total Billed Charges,95% of Total Billed Charges,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.25,88,,556.504,Percent of Total Billed Charges,88% of Total Billed Charges,191.5,90,,569.152,Percent of Total Billed charges,90% of Total Billed Charges,93.84,212.78,
Z480611025 DRILL B,2780001597,CDM,278,RC,C1776,HCPCS,Outpatient,,,255.78,166.26,,255.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,194.39,76,,480.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,184.16,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,184.16,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.16,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,153.47,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,230.2,90,,297.68,Percent of Total Billed Charges,90% of Total Billed Charges,115.1,45,,284.576,Percent of Total Billed Charges,45% of Total Billed Charges,230.2,90,,569.152,Percent of Total Billed Charges,90% of Total billed Charges,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.26,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,112.8,44.1,,278.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,242.99,95,,600.776,Percent of Total Billed Charges,95% of Total Billed Charges,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.09,88,,291.064,Percent of Total Billed Charges,88% of Total Billed Charges,230.2,90,,569.152,Percent of Total Billed charges,90% of Total Billed Charges,112.8,255.78,
Z80182202 FEM/HEAD,2780001599,CDM,278,RC,C1776,HCPCS,Outpatient,,,3370.34,2190.72,,3370.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2561.46,76,,480.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2426.64,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,2426.64,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,3370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2426.64,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,2022.2,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,3033.31,90,,297.68,Percent of Total Billed Charges,90% of Total Billed Charges,1516.65,45,,284.576,Percent of Total Billed Charges,45% of Total Billed Charges,3033.31,90,,569.152,Percent of Total Billed Charges,90% of Total billed Charges,3370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2190.72,65,,3962.08,Percent of total Billed Charges,65% of Total Billed Charges,1486.32,44.1,,278.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3201.82,95,,600.776,Percent of Total Billed Charges,95% of Total Billed Charges,3370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2965.9,88,,291.064,Percent of Total Billed Charges,88% of Total Billed Charges,3033.31,90,,569.152,Percent of Total Billed charges,90% of Total Billed Charges,1486.32,3370.34,
Z50014222 BIPOLAR,2780001600,CDM,278,RC,C1776,HCPCS,Outpatient,,,1803.69,1172.40,,1803.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1370.8,76,,480.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1298.66,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,1298.66,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,1803.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1298.66,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,1082.21,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,1623.32,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,811.66,45,,148.84,Percent of Total Billed Charges,45% of Total Billed Charges,1623.32,90,,569.152,Percent of Total Billed Charges,90% of Total billed Charges,1803.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1803.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1803.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1172.4,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,795.43,44.1,,145.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,1713.51,95,,600.776,Percent of Total Billed Charges,95% of Total Billed Charges,1803.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1587.25,88,,291.064,Percent of Total Billed Charges,88% of Total Billed Charges,1623.32,90,,569.152,Percent of Total Billed charges,90% of Total Billed Charges,795.43,1803.69,
Z500143 BIPOLAR SHE,2780001601,CDM,278,RC,C1776,HCPCS,Outpatient,,,2932.65,1906.22,,2932.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2228.81,76,,480.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2111.51,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,2111.51,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,2932.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2111.51,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,1759.59,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,2639.39,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,1319.69,45,,148.84,Percent of Total Billed Charges,45% of Total Billed Charges,2639.39,90,,569.152,Percent of Total Billed Charges,90% of Total billed Charges,2932.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2932.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2932.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1906.22,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,1293.3,44.1,,145.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,2786.02,95,,600.776,Percent of Total Billed Charges,95% of Total Billed Charges,2932.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2580.73,88,,291.064,Percent of Total Billed Charges,88% of Total Billed Charges,2639.39,90,,569.152,Percent of Total Billed charges,90% of Total Billed Charges,1293.3,2932.65,
Z11479576 32MMTHD,2780001602,CDM,278,RC,C1776,HCPCS,Outpatient,,,875.39,569.00,,875.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,665.3,76,,480.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,630.28,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,630.28,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,875.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,630.28,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,525.23,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,787.85,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,393.93,45,,148.84,Percent of Total Billed Charges,45% of Total Billed Charges,787.85,90,,569.152,Percent of Total Billed Charges,90% of Total billed Charges,875.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,875.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,875.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,386.05,44.1,,145.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,831.62,95,,600.776,Percent of Total Billed Charges,95% of Total Billed Charges,875.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770.34,88,,291.064,Percent of Total Billed Charges,88% of Total Billed Charges,787.85,90,,569.152,Percent of Total Billed charges,90% of Total Billed Charges,386.05,875.39,
Z114715076 32MTHD,2780001603,CDM,278,RC,C1776,HCPCS,Outpatient,,,1366.00,887.90,,1366,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1038.16,76,,251.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,983.52,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,983.52,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,1366,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,983.52,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,819.6,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,1229.4,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,614.7,45,,148.84,Percent of Total Billed Charges,45% of Total Billed Charges,1229.4,90,,297.68,Percent of Total Billed Charges,90% of Total billed Charges,1366,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1366,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1366,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,887.9,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,602.41,44.1,,145.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,1297.7,95,,314.216,Percent of Total Billed Charges,95% of Total Billed Charges,1366,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1202.08,88,,291.064,Percent of Total Billed Charges,88% of Total Billed Charges,1229.4,90,,297.68,Percent of Total Billed charges,90% of Total Billed Charges,602.41,1366,
Z114792 GUIDE PIN 3,2780001604,CDM,278,RC,C1776,HCPCS,Outpatient,,,74.97,48.73,,74.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.98,76,,251.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.98,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,53.98,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.98,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,44.98,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,67.47,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,33.74,45,,148.84,Percent of Total Billed Charges,45% of Total Billed Charges,67.47,90,,297.68,Percent of Total Billed Charges,90% of Total billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.73,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,33.06,44.1,,145.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,71.22,95,,314.216,Percent of Total Billed Charges,95% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.97,88,,291.064,Percent of Total Billed Charges,88% of Total Billed Charges,67.47,90,,297.68,Percent of Total Billed charges,90% of Total Billed Charges,33.06,74.97,
HYDROSET 3CC,2780001605,CDM,278,RC,C1776,HCPCS,Outpatient,,,3512.57,2283.17,,3512.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2669.55,76,,251.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2529.05,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,2529.05,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,3512.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2529.05,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,2107.54,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,3161.31,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,1580.66,45,,148.84,Percent of Total Billed Charges,45% of Total Billed Charges,3161.31,90,,297.68,Percent of Total Billed Charges,90% of Total billed Charges,3512.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3512.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3512.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2283.17,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,1549.04,44.1,,145.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,3336.94,95,,314.216,Percent of Total Billed Charges,95% of Total Billed Charges,3512.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3091.06,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,3161.31,90,,297.68,Percent of Total Billed charges,90% of Total Billed Charges,1549.04,3512.57,
HYDROSET 5CC,2780001606,CDM,278,RC,C1776,HCPCS,Outpatient,,,5630.47,3659.81,,5630.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4279.16,76,,251.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4053.94,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,4053.94,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,5630.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4053.94,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,3378.28,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,5067.42,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,2533.71,45,,148.84,Percent of Total Billed Charges,45% of Total Billed Charges,5067.42,90,,297.68,Percent of Total Billed Charges,90% of Total billed Charges,5630.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5630.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5630.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3659.81,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,2483.04,44.1,,145.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,5348.95,95,,314.216,Percent of Total Billed Charges,95% of Total Billed Charges,5630.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4954.81,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,5067.42,90,,297.68,Percent of Total Billed charges,90% of Total Billed Charges,2483.04,5630.47,
HYDROSET 10CC,2780001607,CDM,278,RC,C1776,HCPCS,Outpatient,,,10844.19,7048.72,,10844.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8241.58,76,,251.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7807.82,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,7807.82,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,10844.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7807.82,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,6506.51,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,9759.77,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,4879.89,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,9759.77,90,,297.68,Percent of Total Billed Charges,90% of Total billed Charges,10844.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10844.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10844.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7048.72,65,,902.952,Percent of total Billed Charges,65% of Total Billed Charges,4782.29,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,10301.98,95,,314.216,Percent of Total Billed Charges,95% of Total Billed Charges,10844.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9542.89,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,9759.77,90,,297.68,Percent of Total Billed charges,90% of Total Billed Charges,4782.29,10844.19,
HYDROSET 15CC,2780001608,CDM,278,RC,C1776,HCPCS,Outpatient,,,15568.40,10119.46,,15568.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11831.98,76,,251.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11209.25,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,11209.25,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,15568.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11209.25,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,9341.04,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,14011.56,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,7005.78,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,14011.56,90,,297.68,Percent of Total Billed Charges,90% of Total billed Charges,15568.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15568.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15568.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10119.46,65,,902.952,Percent of total Billed Charges,65% of Total Billed Charges,6865.66,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,14789.98,95,,314.216,Percent of Total Billed Charges,95% of Total Billed Charges,15568.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13700.19,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,14011.56,90,,297.68,Percent of Total Billed charges,90% of Total Billed Charges,6865.66,15568.4,
Z47249321011 FEMN,2780001609,CDM,278,RC,C1776,HCPCS,Outpatient,,,6145.34,3994.47,,6145.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4670.46,76,,251.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4424.64,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,4424.64,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,6145.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4424.64,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,3687.2,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,5530.81,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,2765.4,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,5530.81,90,,297.68,Percent of Total Billed Charges,90% of Total billed Charges,6145.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6145.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6145.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3994.47,65,,902.952,Percent of total Billed Charges,65% of Total Billed Charges,2710.09,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,5838.07,95,,314.216,Percent of Total Billed Charges,95% of Total Billed Charges,6145.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.9,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,5530.81,90,,297.68,Percent of Total Billed charges,90% of Total Billed Charges,2710.09,6145.34,
Z23582502 DORSAL D,2780001610,CDM,278,RC,C1776,HCPCS,Outpatient,,,2880.83,1872.54,,2880.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2189.43,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2074.2,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,2074.2,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,2880.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2074.2,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,1728.5,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,2592.75,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,1296.37,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,2592.75,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,2880.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2880.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2880.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1872.54,65,,902.952,Percent of total Billed Charges,65% of Total Billed Charges,1270.45,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,2736.79,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,2880.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2535.13,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,2592.75,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,1270.45,2880.83,
Z00545002036 REV,2780001611,CDM,278,RC,C1776,HCPCS,Outpatient,,,18136.13,11788.48,,18136.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13783.46,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13058.01,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,13058.01,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,18136.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13058.01,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,10881.68,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,16322.52,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,8161.26,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,16322.52,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,18136.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18136.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18136.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11788.48,65,,902.952,Percent of total Billed Charges,65% of Total Billed Charges,7998.03,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,17229.32,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,18136.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15959.79,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,16322.52,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,7998.03,18136.13,
Z00545001356 REV,2780001612,CDM,278,RC,C1776,HCPCS,Outpatient,,,14387.63,9351.96,,14387.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10934.6,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10359.09,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,10359.09,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,14387.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10359.09,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,8632.58,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,12948.87,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,6474.43,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,12948.87,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,14387.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14387.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14387.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9351.96,65,,902.952,Percent of total Billed Charges,65% of Total Billed Charges,6344.94,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,13668.25,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,14387.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12661.11,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,12948.87,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,6344.94,14387.63,
Z59881011 REV STE,2780001613,CDM,278,RC,C1776,HCPCS,Outpatient,,,4426.54,2877.25,,4426.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3364.17,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3187.11,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,3187.11,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,4426.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3187.11,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,2655.92,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,3983.89,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,1991.94,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,3983.89,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,4426.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4426.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4426.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2877.25,65,,902.952,Percent of total Billed Charges,65% of Total Billed Charges,1952.1,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,4205.21,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,4426.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3895.36,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,3983.89,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,1952.1,4426.54,
Z588003 REV RHK TIB,2780001614,CDM,278,RC,C1776,HCPCS,Outpatient,,,16847.30,10950.75,,16847.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12803.95,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12130.06,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,12130.06,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,16847.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12130.06,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,10108.38,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,15162.57,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,7581.29,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,15162.57,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,16847.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16847.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16847.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.75,65,,902.952,Percent of total Billed Charges,65% of Total Billed Charges,7429.66,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,16004.94,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,16847.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14825.62,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,15162.57,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,7429.66,16847.3,
Z58801402 REV RHK,2780001615,CDM,278,RC,C1776,HCPCS,Outpatient,,,36200.59,23530.38,,36200.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27512.45,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26064.42,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,26064.42,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,36200.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26064.42,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,21720.35,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,32580.53,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,16290.27,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,32580.53,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,36200.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36200.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36200.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23530.38,65,,902.952,Percent of total Billed Charges,65% of Total Billed Charges,15964.46,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,34390.56,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,36200.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31856.52,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,32580.53,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,15964.46,36200.59,
Z58804017 REV RHK,2780001616,CDM,278,RC,C1776,HCPCS,Outpatient,,,7369.11,4789.92,,7369.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5600.52,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5305.76,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,5305.76,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,7369.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5305.76,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,4421.47,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,6632.2,90,,5485.952,Percent of Total Billed Charges,90% of Total Billed Charges,3316.1,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,6632.2,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,7369.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7369.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7369.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4789.92,65,,1686.648,Percent of total Billed Charges,65% of Total Billed Charges,3249.78,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,7000.65,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,7369.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6484.82,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,6632.2,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,3249.78,7369.11,
Z49200402 ST/PLT 4,2780001617,CDM,278,RC,C1776,HCPCS,Outpatient,,,224.91,146.19,,224.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,170.93,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,161.94,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,161.94,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.94,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,134.95,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,202.42,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,101.21,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,202.42,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.19,65,,1686.648,Percent of total Billed Charges,65% of Total Billed Charges,99.19,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.66,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,224.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.92,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,202.42,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,99.19,224.91,
Z48150603 MINI COR,2780001618,CDM,278,RC,C1776,HCPCS,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,56.36,72,,3005.856,Percent of Total Billed charges,72% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,3005.856,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,2504.88,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
Z48151203 MINI 12M,2780001619,CDM,278,RC,C1776,HCPCS,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,2862.72,Percent of Total Billed Charges,72% of Total Billed Charges,56.36,72,,2862.72,Percent of Total Billed charges,72% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,2862.72,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,2385.6,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
Z48151403 MINI 14M,2780001620,CDM,278,RC,C1776,HCPCS,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,56.36,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
Z47248509510 LAB,2780001621,CDM,278,RC,C1776,HCPCS,Outpatient,,,2227.05,1447.58,,2227.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1692.56,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1603.48,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1603.48,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,2227.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1603.48,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1336.23,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,2004.35,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,1002.17,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,2004.35,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,2227.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2227.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2227.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1447.58,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,982.13,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,2115.7,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,2227.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1959.8,88,,5364.04,Percent of Total Billed Charges,88% of Total Billed Charges,2004.35,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,982.13,2227.05,
Z47249321113 FEMN,2780001622,CDM,278,RC,C1776,HCPCS,Outpatient,,,6147.54,3995.90,,6147.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4672.13,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4426.23,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,4426.23,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4426.23,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,3688.52,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,5532.79,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,2766.39,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,5532.79,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3995.9,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,2711.07,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,5840.16,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5409.84,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,5532.79,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,2711.07,6147.54,
Z47248508510 LAG,2780001623,CDM,278,RC,C1776,HCPCS,Outpatient,,,2224.85,1446.15,,2224.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1690.89,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1601.89,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1601.89,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,2224.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1601.89,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1334.91,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,2002.37,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,1001.18,45,,2742.976,Percent of Total Billed Charges,45% of Total Billed Charges,2002.37,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,2224.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2224.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2224.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1446.15,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,981.16,44.1,,2688.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,2113.61,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,2224.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1957.87,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,2002.37,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,981.16,2224.85,
ENSEAL SUPERJAW,2780001624,CDM,278,RC,C1776,HCPCS,Outpatient,,,837.90,544.64,,837.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,636.8,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,603.29,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,603.29,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,603.29,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,502.74,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,754.11,90,,1250.24,Percent of Total Billed Charges,90% of Total Billed Charges,377.06,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,754.11,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,544.64,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,369.51,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,796.01,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.35,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,754.11,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,369.51,837.9,
Z48271201 2.7 CORT,2780001625,CDM,278,RC,C1776,HCPCS,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,56.36,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,1250.24,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
Z49270703 TUBULAR,2780001626,CDM,278,RC,C1776,HCPCS,Outpatient,,,306.50,199.23,,306.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,232.94,76,,4632.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,220.68,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,220.68,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,306.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.68,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,183.9,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,275.85,90,,1250.24,Percent of Total Billed Charges,90% of Total Billed Charges,137.93,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,275.85,90,,5485.952,Percent of Total Billed Charges,90% of Total billed Charges,306.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.23,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,135.17,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,291.18,95,,5790.728,Percent of Total Billed Charges,95% of Total Billed Charges,306.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.72,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,275.85,90,,5485.952,Percent of Total Billed charges,90% of Total Billed Charges,135.17,306.5,
SEQUENT DISP SUTURE,2780001627,CDM,278,RC,C1776,HCPCS,Outpatient,,,214.99,139.74,,214.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,163.39,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,154.79,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,154.79,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,214.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.79,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,128.99,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,193.49,90,,1250.24,Percent of Total Billed Charges,90% of Total Billed Charges,96.75,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,193.49,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,214.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.74,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,94.81,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,204.24,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,214.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.19,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,193.49,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,94.81,214.99,
SEQUENT MENISEAL CU,2780001628,CDM,278,RC,C1776,HCPCS,Outpatient,,,5990.99,3894.14,,5990.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4553.15,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4313.51,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,4313.51,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,5990.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.51,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,3594.59,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,5391.89,90,,1250.24,Percent of Total Billed Charges,90% of Total Billed Charges,2695.95,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,5391.89,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,5990.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5990.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5990.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3894.14,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,2642.03,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,5691.44,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,5990.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5272.07,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,5391.89,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,2642.03,5990.99,
SEQUENT MENISEAL CU,2780001629,CDM,278,RC,C1776,HCPCS,Outpatient,,,4702.16,3056.40,,4702.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3573.64,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3385.56,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,3385.56,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,4702.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3385.56,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,2821.3,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,4231.94,90,,1250.24,Percent of Total Billed Charges,90% of Total Billed Charges,2115.97,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,4231.94,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,4702.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4702.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4702.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.4,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,2073.65,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,4467.05,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,4702.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4137.9,88,,1222.456,Percent of Total Billed Charges,88% of Total Billed Charges,4231.94,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,2073.65,4702.16,
Z23570806 DIS TIB,2780001630,CDM,278,RC,C1776,HCPCS,Outpatient,,,5174.03,3363.12,,5174.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3932.26,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3725.3,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,3725.3,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,5174.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3725.3,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,3104.42,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,4656.63,90,,1250.24,Percent of Total Billed Charges,90% of Total Billed Charges,2328.31,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,4656.63,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,5174.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5174.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5174.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3363.12,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,2281.75,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,4915.33,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,5174.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4553.15,88,,1222.456,Percent of Total Billed Charges,88% of Total Billed Charges,4656.63,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,2281.75,5174.03,
Z23593835 3.5 LOCK,2780001631,CDM,278,RC,C1776,HCPCS,Outpatient,,,372.65,242.22,,372.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,283.21,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,268.31,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,268.31,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,372.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.31,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,223.59,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,335.39,90,,1250.24,Percent of Total Billed Charges,90% of Total Billed Charges,167.69,45,,625.12,Percent of Total Billed Charges,45% of Total Billed Charges,335.39,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,372.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,372.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,372.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.22,65,,1805.896,Percent of total Billed Charges,65% of Total Billed Charges,164.34,44.1,,612.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,354.02,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,372.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.93,88,,1222.456,Percent of Total Billed Charges,88% of Total Billed Charges,335.39,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,164.34,372.65,
Z23593537 CANN CON,2780001632,CDM,278,RC,C1776,HCPCS,Outpatient,,,325.24,211.41,,325.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,247.18,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,234.17,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,234.17,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.17,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,195.14,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,292.72,90,,1250.24,Percent of Total Billed Charges,90% of Total Billed Charges,146.36,45,,625.12,Percent of Total Billed Charges,45% of Total Billed Charges,292.72,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.41,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,143.43,44.1,,612.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,308.98,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.21,88,,1222.456,Percent of Total Billed Charges,88% of Total Billed Charges,292.72,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,143.43,325.24,
Z23594037 CANN CON,2780001633,CDM,278,RC,C1776,HCPCS,Outpatient,,,325.24,211.41,,325.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,247.18,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,234.17,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,234.17,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.17,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,195.14,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,292.72,90,,2335.36,Percent of Total Billed Charges,90% of Total Billed Charges,146.36,45,,625.12,Percent of Total Billed Charges,45% of Total Billed Charges,292.72,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.41,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,143.43,44.1,,612.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,308.98,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,325.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.21,88,,1222.456,Percent of Total Billed Charges,88% of Total Billed Charges,292.72,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,143.43,325.24,
Z47249321310 FEMN,2780001634,CDM,278,RC,C1776,HCPCS,Outpatient,,,6147.54,3995.90,,6147.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4672.13,76,,1055.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4426.23,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,4426.23,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4426.23,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,3688.52,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,5532.79,90,,2335.36,Percent of Total Billed Charges,90% of Total Billed Charges,2766.39,45,,625.12,Percent of Total Billed Charges,45% of Total Billed Charges,5532.79,90,,1250.24,Percent of Total Billed Charges,90% of Total billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3995.9,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,2711.07,44.1,,612.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,5840.16,95,,1319.696,Percent of Total Billed Charges,95% of Total Billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5409.84,88,,1222.456,Percent of Total Billed Charges,88% of Total Billed Charges,5532.79,90,,1250.24,Percent of Total Billed charges,90% of Total Billed Charges,2711.07,6147.54,
Z484050 4.0 CANN,2780001635,CDM,278,RC,C1776,HCPCS,Outpatient,,,69.46,45.15,,69.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.79,76,,1055.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.01,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,50.01,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.01,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,41.68,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,62.51,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,31.26,45,,625.12,Percent of Total Billed Charges,45% of Total Billed Charges,62.51,90,,1250.24,Percent of Total Billed Charges,90% of Total billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.15,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,30.63,44.1,,612.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.99,95,,1319.696,Percent of Total Billed Charges,95% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,88,,1222.456,Percent of Total Billed Charges,88% of Total Billed Charges,62.51,90,,1250.24,Percent of Total Billed charges,90% of Total Billed Charges,30.63,69.46,
Z59764012 CRUC AR,2780001636,CDM,278,RC,C1776,HCPCS,Outpatient,,,4424.33,2875.81,,4424.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3362.49,76,,1055.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3185.52,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,3185.52,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,4424.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3185.52,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,2654.6,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,3981.9,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,1990.95,45,,625.12,Percent of Total Billed Charges,45% of Total Billed Charges,3981.9,90,,1250.24,Percent of Total Billed Charges,90% of Total billed Charges,4424.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4424.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4424.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2875.81,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,1951.13,44.1,,612.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,4203.11,95,,1319.696,Percent of Total Billed Charges,95% of Total Billed Charges,4424.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3893.41,88,,1222.456,Percent of Total Billed Charges,88% of Total Billed Charges,3981.9,90,,1250.24,Percent of Total Billed charges,90% of Total Billed Charges,1951.13,4424.33,
STRYKER 40301205 3,2780001637,CDM,278,RC,C1776,HCPCS,Outpatient,,,766.24,498.06,,766.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,582.34,76,,1055.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,551.69,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,551.69,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,766.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,551.69,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,459.74,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,689.62,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,344.81,45,,625.12,Percent of Total Billed Charges,45% of Total Billed Charges,689.62,90,,1250.24,Percent of Total Billed Charges,90% of Total billed Charges,766.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,766.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,766.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.06,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,337.91,44.1,,612.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,727.93,95,,1319.696,Percent of Total Billed Charges,95% of Total Billed Charges,766.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,674.29,88,,1222.456,Percent of Total Billed Charges,88% of Total Billed Charges,689.62,90,,1250.24,Percent of Total Billed charges,90% of Total Billed Charges,337.91,766.24,
STRYKER 45300155 1,2780001638,CDM,278,RC,C1776,HCPCS,Outpatient,,,138.92,90.30,,138.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,105.58,76,,1055.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.02,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,100.02,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.02,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,83.35,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,125.03,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,62.51,45,,625.12,Percent of Total Billed Charges,45% of Total Billed Charges,125.03,90,,1250.24,Percent of Total Billed Charges,90% of Total billed Charges,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.3,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,61.26,44.1,,612.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,131.97,95,,1319.696,Percent of Total Billed Charges,95% of Total Billed Charges,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.25,88,,2283.464,Percent of Total Billed Charges,88% of Total Billed Charges,125.03,90,,1250.24,Percent of Total Billed charges,90% of Total Billed Charges,61.26,138.92,
STRYKER STD 16 16MM,2780001639,CDM,278,RC,C1776,HCPCS,Outpatient,,,4831.16,3140.25,,4831.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3671.68,76,,1055.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3478.44,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,3478.44,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,4831.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3478.44,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,2898.7,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,4348.04,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,2174.02,45,,625.12,Percent of Total Billed Charges,45% of Total Billed Charges,4348.04,90,,1250.24,Percent of Total Billed Charges,90% of Total billed Charges,4831.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4831.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4831.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3140.25,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,2130.54,44.1,,612.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,4589.6,95,,1319.696,Percent of Total Billed Charges,95% of Total Billed Charges,4831.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4251.42,88,,2283.464,Percent of Total Billed Charges,88% of Total Billed Charges,4348.04,90,,1250.24,Percent of Total Billed charges,90% of Total Billed Charges,2130.54,4831.16,
STRYKER 45300055 2,2780001640,CDM,278,RC,C1776,HCPCS,Outpatient,,,611.89,397.73,,611.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.04,76,,1055.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,440.56,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,440.56,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,367.13,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,550.7,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,275.35,45,,1167.68,Percent of Total Billed Charges,45% of Total Billed Charges,550.7,90,,1250.24,Percent of Total Billed Charges,90% of Total billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.73,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,269.84,44.1,,1144.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,581.3,95,,1319.696,Percent of Total Billed Charges,95% of Total Billed Charges,611.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.46,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,550.7,90,,1250.24,Percent of Total Billed charges,90% of Total Billed Charges,269.84,611.89,
STRYKER ST STOA 16 1,2780001641,CDM,278,RC,C1776,HCPCS,Outpatient,,,4783.75,3109.44,,4783.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3635.65,76,,1055.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3444.3,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,3444.3,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,4783.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3444.3,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,2870.25,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,4305.38,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,2152.69,45,,1167.68,Percent of Total Billed Charges,45% of Total Billed Charges,4305.38,90,,1250.24,Percent of Total Billed Charges,90% of Total billed Charges,4783.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4783.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4783.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3109.44,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,2109.63,44.1,,1144.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,4544.56,95,,1319.696,Percent of Total Billed Charges,95% of Total Billed Charges,4783.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4209.7,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,4305.38,90,,1250.24,Percent of Total Billed charges,90% of Total Billed Charges,2109.63,4783.75,
Z99521618 REV/FEM,2780001642,CDM,278,RC,C1776,HCPCS,Outpatient,,,12471.48,8106.46,,12471.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9478.32,76,,1055.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8979.47,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,8979.47,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,12471.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8979.47,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,7482.89,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,11224.33,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,5612.17,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,11224.33,90,,1250.24,Percent of Total Billed Charges,90% of Total billed Charges,12471.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12471.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12471.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8106.46,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,5499.92,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,11847.91,95,,1319.696,Percent of Total Billed Charges,95% of Total Billed Charges,12471.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10974.9,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,11224.33,90,,1250.24,Percent of Total Billed charges,90% of Total Billed Charges,5499.92,12471.48,
Z22320205 REATTACH,2780001643,CDM,278,RC,C1776,HCPCS,Outpatient,,,8765.98,5697.89,,8765.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6662.14,76,,1972.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6311.51,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,6311.51,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,8765.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6311.51,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,5259.59,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,7889.38,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,3944.69,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,7889.38,90,,2335.36,Percent of Total Billed Charges,90% of Total billed Charges,8765.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8765.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8765.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5697.89,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,3865.8,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,8327.68,95,,2465.104,Percent of Total Billed Charges,95% of Total Billed Charges,8765.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7714.06,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,7889.38,90,,2335.36,Percent of Total Billed charges,90% of Total Billed Charges,3865.8,8765.98,
Z62025422 MODULAR,2780001644,CDM,278,RC,C1776,HCPCS,Outpatient,,,9588.44,6232.49,,9588.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7287.21,76,,1972.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6903.68,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,6903.68,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,9588.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6903.68,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,5753.06,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,8629.6,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,4314.8,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,8629.6,90,,2335.36,Percent of Total Billed Charges,90% of Total billed Charges,9588.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9588.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9588.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6232.49,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,4228.5,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,9109.02,95,,2465.104,Percent of Total Billed Charges,95% of Total Billed Charges,9588.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8437.83,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,8629.6,90,,2335.36,Percent of Total Billed charges,90% of Total Billed Charges,4228.5,9588.44,
Z225334008 TIBIAL,2780001645,CDM,278,RC,C1776,HCPCS,Outpatient,,,4365.90,2837.84,,4365.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3318.08,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3143.45,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,3143.45,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,4365.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3143.45,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,2619.54,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,3929.31,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,1964.66,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,3929.31,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,4365.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4365.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4365.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2837.84,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,1925.36,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,4147.61,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,4365.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3841.99,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,3929.31,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,1925.36,4365.9,
Z225338008 TIBIAL,2780001646,CDM,278,RC,C1776,HCPCS,Outpatient,,,4365.90,2837.84,,4365.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3318.08,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3143.45,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,3143.45,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,4365.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3143.45,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,2619.54,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,3929.31,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,1964.66,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,3929.31,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,4365.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4365.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4365.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2837.84,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,1925.36,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,4147.61,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,4365.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3841.99,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,3929.31,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,1925.36,4365.9,
Z22536542 CORTICAL,2780001647,CDM,278,RC,C1776,HCPCS,Outpatient,,,576.61,374.80,,576.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,438.22,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.16,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,415.16,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.16,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,345.97,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,518.95,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,259.47,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,518.95,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.8,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,254.29,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,547.78,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.42,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,518.95,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,254.29,576.61,
Z484055 4.0 D CANN,2780001648,CDM,278,RC,C1776,HCPCS,Outpatient,,,69.46,45.15,,69.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.79,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.01,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,50.01,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.01,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,41.68,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,62.51,90,,2500.472,Percent of Total Billed Charges,90% of Total Billed Charges,31.26,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,62.51,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.15,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,30.63,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.99,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,62.51,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,30.63,69.46,
Z225305555 CORTICA,2780001649,CDM,278,RC,C1776,HCPCS,Outpatient,,,577.71,375.51,,577.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,439.06,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.95,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,415.95,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.95,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,346.63,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,519.94,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,259.97,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,519.94,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.51,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,254.77,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,548.82,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.38,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,519.94,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,254.77,577.71,
STRYKER 234020290A,2780001650,CDM,278,RC,C1776,HCPCS,Outpatient,,,1513.73,983.92,,1513.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1150.43,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1089.89,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1089.89,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,1513.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1089.89,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,908.24,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,1362.36,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,681.18,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,1362.36,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,1513.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1513.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1513.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,983.92,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,667.55,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,1438.04,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,1513.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1332.08,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,1362.36,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,667.55,1513.73,
STRYKER 234108020,2780001651,CDM,278,RC,C1776,HCPCS,Outpatient,,,1738.64,1130.12,,1738.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1321.37,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1251.82,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1251.82,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,1738.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1251.82,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1043.18,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,1564.78,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,782.39,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,1564.78,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,1738.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1738.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1738.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1130.12,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,766.74,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,1651.71,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,1738.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,1564.78,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,766.74,1738.64,
STRYKER 3910900020,2780001652,CDM,278,RC,C1776,HCPCS,Outpatient,,,89.30,58.05,,89.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.87,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.3,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,64.3,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.3,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,53.58,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,80.37,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,40.19,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,80.37,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.05,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,39.38,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,84.84,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.58,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,80.37,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,39.38,89.3,
STRYKER 3910900050,2780001653,CDM,278,RC,C1776,HCPCS,Outpatient,,,115.76,75.24,,115.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.98,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,83.35,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,83.35,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.35,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,69.46,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,104.18,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,52.09,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,104.18,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.24,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,51.05,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,109.97,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.87,88,,2444.904,Percent of Total Billed Charges,88% of Total Billed Charges,104.18,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,51.05,115.76,
STRYKER 234108070,2780001654,CDM,278,RC,C1776,HCPCS,Outpatient,,,1288.82,837.73,,1288.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,979.5,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,927.95,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,927.95,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,1288.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,927.95,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,773.29,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,1159.94,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,579.97,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,1159.94,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,1288.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1288.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1288.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,837.73,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,568.37,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,1224.38,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,1288.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1134.16,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,1159.94,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,568.37,1288.82,
STRYKER 234101015,2780001655,CDM,278,RC,C1776,HCPCS,Outpatient,,,1915.04,1244.78,,1915.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1455.43,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1378.83,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1378.83,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,1915.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1378.83,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1149.02,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,1723.54,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,861.77,45,,1250.24,Percent of Total Billed Charges,45% of Total Billed Charges,1723.54,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,1915.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1915.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1915.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1244.78,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,844.53,44.1,,1225.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,1819.29,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,1915.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1685.24,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,1723.54,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,844.53,1915.04,
STRYKER 234010162,2780001656,CDM,278,RC,C1776,HCPCS,Outpatient,,,977.92,635.65,,977.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,743.22,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,704.1,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,704.1,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704.1,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,586.75,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,880.13,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,440.06,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,880.13,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,635.65,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,431.26,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,929.02,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,977.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,860.57,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,880.13,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,431.26,977.92,
ANTERIOR TIBIALIS TE,2780001657,CDM,278,RC,C1776,HCPCS,Outpatient,,,8352.54,5429.15,,8352.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6347.93,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6013.83,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,6013.83,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,8352.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6013.83,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,5011.52,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,7517.29,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,3758.64,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,7517.29,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,8352.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8352.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8352.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5429.15,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,3683.47,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,7934.91,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,8352.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7350.24,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,7517.29,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,3683.47,8352.54,
Z225232010 FEMNAIL,2780001658,CDM,278,RC,C1776,HCPCS,Outpatient,,,3301.99,2146.29,,3301.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2509.51,76,,2111.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2377.43,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,2377.43,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,3301.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2377.43,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1981.19,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,2971.79,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,1485.9,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,2971.79,90,,2500.472,Percent of Total Billed Charges,90% of Total billed Charges,3301.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3301.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3301.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2146.29,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,1456.18,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,3136.89,95,,2639.392,Percent of Total Billed Charges,95% of Total Billed Charges,3301.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2905.75,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,2971.79,90,,2500.472,Percent of Total Billed charges,90% of Total Billed Charges,1456.18,3301.99,
Z22528055 SCW 80,2780001659,CDM,278,RC,C1776,HCPCS,Outpatient,,,837.90,544.64,,837.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,636.8,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,603.29,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,603.29,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,603.29,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,502.74,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,754.11,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,377.06,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,754.11,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,544.64,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,369.51,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,796.01,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.35,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,754.11,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,369.51,837.9,
Z22528555 SCW 85,2780001660,CDM,278,RC,C1776,HCPCS,Outpatient,,,837.90,544.64,,837.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,636.8,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,603.29,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,603.29,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,603.29,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,502.74,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,754.11,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,377.06,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,754.11,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,544.64,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,369.51,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,796.01,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.35,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,754.11,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,369.51,837.9,
CONMED DOUBLE ARMED,2780001661,CDM,278,RC,C1776,HCPCS,Outpatient,,,61.00,39.65,,61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.36,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.92,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,43.92,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.92,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,36.6,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,54.9,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,27.45,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,54.9,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.65,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,26.9,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.95,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.68,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,54.9,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,26.9,61,
Z49200209 LEFT OBL,2780001662,CDM,278,RC,C1776,HCPCS,Outpatient,,,208.37,135.44,,208.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,158.36,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.03,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,150.03,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.03,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,125.02,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,187.53,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,93.77,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,187.53,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.44,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,91.89,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,197.95,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.37,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,187.53,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,91.89,208.37,
Z48201203 CORTICAL,2780001663,CDM,278,RC,C1776,HCPCS,Outpatient,,,81.59,53.03,,81.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.01,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,58.74,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,58.74,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.74,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,48.95,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,73.43,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,36.72,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,73.43,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.03,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,35.98,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,77.51,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.8,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,73.43,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,35.98,81.59,
Z48201403 CORTICAL,2780001664,CDM,278,RC,C1776,HCPCS,Outpatient,,,81.59,53.03,,81.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.01,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,58.74,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,58.74,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.74,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,48.95,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,73.43,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,36.72,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,73.43,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.03,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,35.98,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,77.51,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.8,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,73.43,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,35.98,81.59,
Z48201603 CORTICAL,2780001665,CDM,278,RC,C1776,HCPCS,Outpatient,,,81.59,53.03,,81.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.01,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,58.74,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,58.74,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.74,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,48.95,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,73.43,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,36.72,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,73.43,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.03,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,35.98,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,77.51,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.8,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,73.43,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,35.98,81.59,
Z48201803 CORTICAL,2780001666,CDM,278,RC,C1776,HCPCS,Outpatient,,,81.59,53.03,,81.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.01,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,58.74,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,58.74,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.74,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,48.95,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,73.43,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,36.72,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,73.43,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.03,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,35.98,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,77.51,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,81.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.8,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,73.43,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,35.98,81.59,
HUMAN SCLERA MODEL T,2780001667,CDM,278,RC,C1776,HCPCS,Outpatient,,,1182.98,768.94,,1182.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,899.06,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,851.75,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,851.75,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,1182.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,851.75,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,709.79,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,1064.68,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,532.34,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,1064.68,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,1182.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1182.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1182.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,768.94,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,521.69,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,1123.83,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,1182.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1041.02,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,1064.68,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,521.69,1182.98,
Z23480712 DISTAL H,2780001668,CDM,278,RC,C1776,HCPCS,Outpatient,,,1734.23,1127.25,,1734.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1318.01,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1248.65,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1248.65,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,1734.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1248.65,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1040.54,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,1560.81,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,780.4,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,1560.81,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,1734.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1734.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1734.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1127.25,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,764.8,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,1647.52,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,1734.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1526.12,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,1560.81,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,764.8,1734.23,
Z23480502 DISTAL H,2780001669,CDM,278,RC,C1776,HCPCS,Outpatient,,,2677.97,1740.68,,2677.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2035.26,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1928.14,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1928.14,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,2677.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1928.14,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1606.78,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,2410.17,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,1205.09,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,2410.17,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,2677.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2677.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2677.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1740.68,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,1180.98,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,2544.07,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,2677.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2356.61,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,2410.17,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,1180.98,2677.97,
Z48274401 CORTICAL,2780001670,CDM,278,RC,C1776,HCPCS,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,56.36,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
Z24803640 CANN 4.0,2780001671,CDM,278,RC,C1776,HCPCS,Outpatient,,,212.78,138.31,,212.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.71,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153.2,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,153.2,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.2,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,127.67,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,191.5,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,95.75,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,191.5,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.31,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,93.84,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,202.14,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,212.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.25,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,191.5,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,93.84,212.78,
Z47248512010 LAG,2780001672,CDM,278,RC,C1776,HCPCS,Outpatient,,,2227.05,1447.58,,2227.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1692.56,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1603.48,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1603.48,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,2227.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1603.48,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1336.23,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,2004.35,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,1002.17,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,2004.35,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,2227.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2227.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2227.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1447.58,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,982.13,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,2115.7,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,2227.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1959.8,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,2004.35,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,982.13,2227.05,
Z47249321213 FEMN,2780001673,CDM,278,RC,C1776,HCPCS,Outpatient,,,6147.54,3995.90,,6147.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4672.13,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4426.23,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,4426.23,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4426.23,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,3688.52,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,5532.79,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,2766.39,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,5532.79,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3995.9,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,2711.07,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,5840.16,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,6147.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5409.84,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,5532.79,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,2711.07,6147.54,
Z47248700215 NAIL,2780001674,CDM,278,RC,C1776,HCPCS,Outpatient,,,820.26,533.17,,820.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,623.4,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,590.59,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,590.59,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,820.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,590.59,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,492.16,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,738.23,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,369.12,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,738.23,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,820.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,820.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,820.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,533.17,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,361.73,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,779.25,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,820.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,721.83,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,738.23,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,361.73,820.26,
ALCON SA60AT 33.0,2780001675,CDM,278,RC,C1776,HCPCS,Outpatient,,,554.56,360.46,,554.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,421.47,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,399.28,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,399.28,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.28,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,332.74,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,499.1,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,249.55,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,499.1,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360.46,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,244.56,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,526.83,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,554.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.01,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,499.1,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,244.56,554.56,
Z11476041 CANNU S,2780001676,CDM,278,RC,C1776,HCPCS,Outpatient,,,682.45,443.59,,682.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,518.66,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,491.36,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,491.36,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,682.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.36,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,409.47,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,614.21,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,307.1,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,614.21,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,682.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,682.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,682.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,443.59,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,300.96,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,648.33,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,682.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,600.56,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,614.21,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,300.96,682.45,
Z114790 GUIDE PIN 1,2780001677,CDM,278,RC,C1776,HCPCS,Outpatient,,,40.79,26.51,,40.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.37,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,29.37,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.37,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,24.47,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,36.71,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,18.36,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,36.71,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.51,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,17.99,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.75,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.9,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,36.71,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,17.99,40.79,
Z59645112,2780001678,CDM,278,RC,C1776,HCPCS,Outpatient,,,6045.01,3929.26,,6045.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4594.21,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4352.41,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,4352.41,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,6045.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4352.41,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,3627.01,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,5440.51,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,2720.25,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,5440.51,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,6045.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6045.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6045.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3929.26,65,,1886.728,Percent of total Billed Charges,65% of Total Billed Charges,2665.85,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,5742.76,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,6045.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5319.61,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,5440.51,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,2665.85,6045.01,
Z80182230 FEM HEAD 22,2780001679,CDM,278,RC,C1776,HCPCS,Outpatient,,,3224.81,2096.13,,3224.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2450.86,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2321.86,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,2321.86,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,3224.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2321.86,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1934.89,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,2902.33,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,1451.16,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,2902.33,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,3224.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3224.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3224.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.13,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,1422.14,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,3063.57,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,3224.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2837.83,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,2902.33,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,1422.14,3224.81,
Z484038 SCW 38,2780001680,CDM,278,RC,C1776,HCPCS,Outpatient,,,66.15,43.00,,66.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,50.27,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47.63,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,47.63,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.63,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,39.69,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,59.54,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,29.77,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,59.54,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,29.17,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.84,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.21,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,59.54,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,29.17,66.15,
Z020315026 NCB 5.0SCW,2780001681,CDM,278,RC,C1776,HCPCS,Outpatient,,,555.66,361.18,,555.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.3,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,400.08,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,400.08,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.08,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,333.4,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,500.09,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,250.05,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,500.09,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.18,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,245.05,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.88,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.98,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,500.09,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,245.05,555.66,
Z020315028 NCB 5.0 SCW,2780001682,CDM,278,RC,C1776,HCPCS,Outpatient,,,555.66,361.18,,555.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.3,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,400.08,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,400.08,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.08,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,333.4,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,500.09,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,250.05,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,500.09,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.18,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,245.05,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.88,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.98,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,500.09,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,245.05,555.66,
Z020315030 NCB 5.0SCW,2780001683,CDM,278,RC,C1776,HCPCS,Outpatient,,,555.66,361.18,,555.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.3,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,400.08,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,400.08,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.08,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,333.4,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,500.09,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,250.05,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,500.09,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.18,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,245.05,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.88,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.98,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,500.09,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,245.05,555.66,
Z0200024002 NCB DRILL BIT,2780001684,CDM,278,RC,C1776,HCPCS,Outpatient,,,142.22,92.44,,142.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,108.09,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,102.4,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,102.4,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,142.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.4,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,85.33,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,128,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,64,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,128,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,142.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.44,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,62.72,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,135.11,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,142.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.15,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,128,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,62.72,142.22,
Z020315032 NCB 5.0SCW,2780001685,CDM,278,RC,C1776,HCPCS,Outpatient,,,555.66,361.18,,555.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.3,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,400.08,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,400.08,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.08,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,333.4,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,500.09,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,250.05,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,500.09,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.18,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,245.05,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.88,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,555.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.98,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,500.09,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,245.05,555.66,
Z020313180 NCB 3.5 SCW,2780001686,CDM,278,RC,C1776,HCPCS,Outpatient,,,328.55,213.56,,328.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,249.7,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,236.56,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,236.56,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.56,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,197.13,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,295.7,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,147.85,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,295.7,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.56,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,144.89,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,312.12,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.12,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,295.7,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,144.89,328.55,
Z23580206 PH 6HL,2780001687,CDM,278,RC,C1776,HCPCS,Outpatient,,,4838.87,3145.27,,4838.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3677.54,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3483.99,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,3483.99,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,4838.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3483.99,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,2903.32,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,4354.98,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,2177.49,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,4354.98,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,4838.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4838.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4838.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3145.27,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,2133.94,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,4596.93,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,4838.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4258.21,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,4354.98,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,2133.94,4838.87,
Z23593035 LCK SCW 30,2780001688,CDM,278,RC,C1776,HCPCS,Outpatient,,,295.47,192.06,,295.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,224.56,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,212.74,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,212.74,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.74,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,177.28,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,265.92,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,132.96,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,265.92,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.06,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,130.3,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,280.7,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.01,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,265.92,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,130.3,295.47,
Z59524014 ART SURFACE 14,2780001689,CDM,278,RC,C1776,HCPCS,Outpatient,,,6140.93,3991.60,,6140.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4667.11,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4421.47,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,4421.47,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,6140.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4421.47,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,3684.56,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,5526.84,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,2763.42,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,5526.84,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,6140.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6140.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6140.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3991.6,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,2708.15,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,5833.88,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,6140.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5404.02,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,5526.84,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,2708.15,6140.93,
Z500147 BIPOLAR SHELL 47MM,2780001690,CDM,278,RC,C1776,HCPCS,Outpatient,,,2673.56,1737.81,,2673.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2031.91,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1924.96,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1924.96,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,2673.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1924.96,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1604.14,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,2406.2,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,1203.1,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,2406.2,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,2673.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2673.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2673.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1737.81,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,1179.04,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,2539.88,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,2673.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2352.73,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,2406.2,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,1179.04,2673.56,
Z500146 BIPOLAR SHELL 46MM,2780001691,CDM,278,RC,C1776,HCPCS,Outpatient,,,2673.56,1737.81,,2673.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2031.91,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1924.96,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1924.96,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,2673.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1924.96,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1604.14,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,2406.2,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,1203.1,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,2406.2,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,2673.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2673.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2673.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1737.81,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,1179.04,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,2539.88,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,2673.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2352.73,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,2406.2,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,1179.04,2673.56,
Z0203152085 50 CANC 85MM,2780001692,CDM,278,RC,C1776,HCPCS,Outpatient,,,479.59,311.73,,479.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,364.49,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,345.3,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,345.3,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,479.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.3,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,287.75,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,431.63,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,215.82,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,431.63,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,479.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,311.73,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,211.5,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,455.61,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,479.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.04,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,431.63,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,211.5,479.59,
ACUMED AT2M16SMINI SCW 16,2780001693,CDM,278,RC,C1776,HCPCS,Outpatient,,,2191.77,1424.65,,2191.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1665.75,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1578.07,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1578.07,72,,2484.432,Percent of Total Billed charges,72% of Total Billed Charges,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1578.07,72,,2484.432,Percent of Total Billed Charges,72% of Total Billed Charges,1315.06,60,,2070.36,Percent of Total Billed Charges,60% of Total Billed Charges,1972.59,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,986.3,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,1972.59,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1424.65,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,966.57,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,2082.18,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,2191.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1928.76,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,1972.59,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,966.57,2191.77,
WM FLEX HINGE OE IMPLANT,2780001694,CDM,278,RC,C1776,HCPCS,Outpatient,,,4927.07,3202.60,,4927.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3744.57,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3547.49,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,3547.49,72,,233.696,Percent of Total Billed charges,72% of Total Billed Charges,4927.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3547.49,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,2956.24,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,4434.36,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,2217.18,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,4434.36,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,4927.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4927.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4927.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3202.6,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,2172.84,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,4680.72,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,4927.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4335.82,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,4434.36,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,2172.84,4927.07,
WM COLOR CODE SET,2780001695,CDM,278,RC,C1776,HCPCS,Outpatient,,,956.97,622.03,,956.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,727.3,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,689.02,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,689.02,72,,339.952,Percent of Total Billed charges,72% of Total Billed Charges,956.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,689.02,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,574.18,60,,271.96,Percent of Total Billed Charges,60% of Total Billed Charges,861.27,90,,2612.4,Percent of Total Billed Charges,90% of Total Billed Charges,430.64,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,861.27,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,956.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,956.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,956.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,622.03,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,422.02,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,909.12,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,956.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,842.13,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,861.27,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,422.02,956.97,
Z42540000041 PATELLA 41,2780001696,CDM,278,RC,C1776,HCPCS,Outpatient,,,3327.35,2162.78,,3327.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2528.79,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2395.69,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,2395.69,72,,339.952,Percent of Total Billed charges,72% of Total Billed Charges,3327.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2395.69,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,1996.41,60,,271.96,Percent of Total Billed Charges,60% of Total Billed Charges,2994.62,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,1497.31,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,2994.62,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,3327.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3327.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3327.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2162.78,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,1467.36,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,3160.98,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,3327.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2928.07,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,2994.62,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,1467.36,3327.35,
Z42511200516 AS LEFT 16,2780001697,CDM,278,RC,C1776,HCPCS,Outpatient,,,6849.83,4452.39,,6849.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5205.87,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4931.88,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,4931.88,72,,339.952,Percent of Total Billed charges,72% of Total Billed Charges,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4931.88,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,4109.9,60,,271.96,Percent of Total Billed Charges,60% of Total Billed Charges,6164.85,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,3082.42,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,6164.85,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4452.39,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,3020.78,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,6507.34,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6027.85,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,6164.85,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,3020.78,6849.83,
Z42532007501 TIBIA L SZF,2780001698,CDM,278,RC,C1776,HCPCS,Outpatient,,,8610.53,5596.84,,8610.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6544,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6199.58,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,6199.58,72,,339.952,Percent of Total Billed charges,72% of Total Billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6199.58,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,5166.32,60,,271.96,Percent of Total Billed Charges,60% of Total Billed Charges,7749.48,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,3874.74,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,7749.48,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5596.84,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,3797.24,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,8180,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7577.27,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,7749.48,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,3797.24,8610.53,
Z59501505 NEXGEN FEMORAL,2780001699,CDM,278,RC,C1776,HCPCS,Outpatient,,,17275.07,11228.80,,17275.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13129.05,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12438.05,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,12438.05,72,,339.952,Percent of Total Billed charges,72% of Total Billed Charges,17275.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12438.05,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,10365.04,60,,271.96,Percent of Total Billed Charges,60% of Total Billed Charges,15547.56,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,7773.78,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,15547.56,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,17275.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17275.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17275.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11228.8,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,7618.31,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,16411.32,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,17275.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15202.06,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,15547.56,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,7618.31,17275.07,
Z48151803 CORTICAL SCW 18,2780001700,CDM,278,RC,C1776,HCPCS,Outpatient,,,71.66,46.58,,71.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54.46,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.6,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,51.6,72,,339.952,Percent of Total Billed charges,72% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.6,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,43,60,,271.96,Percent of Total Billed Charges,60% of Total Billed Charges,64.49,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,32.25,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,64.49,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.58,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,31.6,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.08,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,71.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,88,,2554.344,Percent of Total Billed Charges,88% of Total Billed Charges,64.49,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,31.6,71.66,
AG IC 3014 HEADED SCW 14 3.0,2780001701,CDM,278,RC,C1776,HCPCS,Outpatient,,,1471.84,956.70,,1471.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1118.6,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1059.72,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,1059.72,72,,339.952,Percent of Total Billed charges,72% of Total Billed Charges,1471.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1059.72,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,883.1,60,,271.96,Percent of Total Billed Charges,60% of Total Billed Charges,1324.66,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,662.33,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,1324.66,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,1471.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1471.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1471.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,956.7,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,649.08,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,1398.25,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,1471.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1295.22,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,1324.66,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,649.08,1471.84,
Z42521000612 PERSONA AS,2780001702,CDM,278,RC,C1776,HCPCS,Outpatient,,,6849.83,4452.39,,6849.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5205.87,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4931.88,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,4931.88,72,,339.952,Percent of Total Billed charges,72% of Total Billed Charges,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4931.88,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,4109.9,60,,271.96,Percent of Total Billed Charges,60% of Total Billed Charges,6164.85,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,3082.42,45,,1306.2,Percent of Total Billed Charges,45% of Total Billed Charges,6164.85,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4452.39,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,3020.78,44.1,,1280.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,6507.34,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6027.85,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,6164.85,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,3020.78,6849.83,
Z42532007902 PERSONA TIBIA,2780001703,CDM,278,RC,C1776,HCPCS,Outpatient,,,8610.53,5596.84,,8610.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6544,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6199.58,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,6199.58,72,,339.952,Percent of Total Billed charges,72% of Total Billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6199.58,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,5166.32,60,,271.96,Percent of Total Billed Charges,60% of Total Billed Charges,7749.48,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,3874.74,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,7749.48,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5596.84,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,3797.24,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,8180,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7577.27,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,7749.48,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,3797.24,8610.53,
Z42502607002 PERSONA FEMUR,2780001704,CDM,278,RC,C1776,HCPCS,Outpatient,,,19177.99,12465.69,,19177.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14575.27,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13808.15,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,13808.15,72,,339.952,Percent of Total Billed charges,72% of Total Billed Charges,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13808.15,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,11506.79,60,,271.96,Percent of Total Billed Charges,60% of Total Billed Charges,17260.19,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,8630.1,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,17260.19,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12465.69,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,8457.49,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,18219.09,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16876.63,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,17260.19,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,8457.49,19177.99,
Z42521000412 PERSONA AS,2780001705,CDM,278,RC,C1776,HCPCS,Outpatient,,,6849.83,4452.39,,6849.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5205.87,76,,2206.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4931.88,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,4931.88,72,,339.952,Percent of Total Billed charges,72% of Total Billed Charges,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4931.88,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,4109.9,60,,271.96,Percent of Total Billed Charges,60% of Total Billed Charges,6164.85,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,3082.42,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,6164.85,90,,2612.4,Percent of Total Billed Charges,90% of Total billed Charges,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4452.39,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,3020.78,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,6507.34,95,,2757.528,Percent of Total Billed Charges,95% of Total Billed Charges,6849.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6027.85,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,6164.85,90,,2612.4,Percent of Total Billed charges,90% of Total Billed Charges,3020.78,6849.83,
Z42532006702 PERSONA TIBIA,2780001706,CDM,278,RC,C1776,HCPCS,Outpatient,,,8610.53,5596.84,,8610.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6544,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6199.58,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,6199.58,72,,339.952,Percent of Total Billed charges,72% of Total Billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6199.58,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,5166.32,60,,271.96,Percent of Total Billed Charges,60% of Total Billed Charges,7749.48,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,3874.74,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,7749.48,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5596.84,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,3797.24,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,8180,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,8610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7577.27,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,7749.48,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,3797.24,8610.53,
Z42502006202 PERSONA FEMUR,2780001707,CDM,278,RC,C1776,HCPCS,Outpatient,,,19177.99,12465.69,,19177.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14575.27,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13808.15,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,13808.15,72,,339.952,Percent of Total Billed charges,72% of Total Billed Charges,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13808.15,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,11506.79,60,,271.96,Percent of Total Billed Charges,60% of Total Billed Charges,17260.19,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,8630.1,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,17260.19,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12465.69,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,8457.49,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,18219.09,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,19177.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16876.63,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,17260.19,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,8457.49,19177.99,
Z23591024 2.4 LOCKING SCW 10,2780001708,CDM,278,RC,C1776,HCPCS,Outpatient,,,328.55,213.56,,328.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,249.7,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,236.56,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,236.56,72,,339.952,Percent of Total Billed charges,72% of Total Billed Charges,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.56,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,197.13,60,,271.96,Percent of Total Billed Charges,60% of Total Billed Charges,295.7,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,147.85,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,295.7,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.56,65,,2713.624,Percent of total Billed Charges,65% of Total Billed Charges,144.89,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,312.12,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.12,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,295.7,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,144.89,328.55,
Z50015328 BIPOLAR LINER 28MM,2780001709,CDM,278,RC,C1776,HCPCS,Outpatient,,,1643.83,1068.49,,1643.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1249.31,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1183.56,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,1183.56,72,,339.952,Percent of Total Billed charges,72% of Total Billed Charges,1643.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1183.56,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,986.3,60,,271.96,Percent of Total Billed Charges,60% of Total Billed Charges,1479.45,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,739.72,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,1479.45,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,1643.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1643.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1643.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1068.49,65,,2584.4,Percent of total Billed Charges,65% of Total Billed Charges,724.93,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,1561.64,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,1643.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1446.57,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,1479.45,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,724.93,1643.83,
Z500155 BIPOLAR SHELL 55MM,2780001710,CDM,278,RC,C1776,HCPCS,Outpatient,,,2669.15,1734.95,,2669.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2028.55,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1921.79,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,1921.79,72,,339.952,Percent of Total Billed charges,72% of Total Billed Charges,2669.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1921.79,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,1601.49,60,,271.96,Percent of Total Billed Charges,60% of Total Billed Charges,2402.24,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,1201.12,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,2402.24,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,2669.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2669.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2669.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1734.95,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1177.1,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,2535.69,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,2669.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2348.85,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,2402.24,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,1177.1,2669.15,
Z4251400712 AS SZ 12,2780001711,CDM,278,RC,C1776,HCPCS,Outpatient,,,5143.95,3343.57,,5143.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3909.4,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3703.64,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,3703.64,72,,339.952,Percent of Total Billed charges,72% of Total Billed Charges,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3703.64,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,3086.37,60,,271.96,Percent of Total Billed Charges,60% of Total Billed Charges,4629.56,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,2314.78,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,4629.56,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3343.57,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,2268.48,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,4886.75,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,5143.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4526.68,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,4629.56,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,2268.48,5143.95,
Z47249334211 FEMNAIL 34R,2780001712,CDM,278,RC,C1776,HCPCS,Outpatient,,,8031.45,5220.44,,8031.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6103.9,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5782.64,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,5782.64,72,,339.952,Percent of Total Billed charges,72% of Total Billed Charges,8031.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5782.64,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,4818.87,60,,271.96,Percent of Total Billed Charges,60% of Total Billed Charges,7228.31,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,3614.15,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,7228.31,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,8031.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8031.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8031.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5220.44,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,3541.87,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,7629.88,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,8031.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7067.68,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,7228.31,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,3541.87,8031.45,
Z500151 BIPOLAR SHELL 51MM,2780001713,CDM,278,RC,C1776,HCPCS,Outpatient,,,2419.20,1572.48,,2419.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1838.59,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1741.82,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,1741.82,72,,339.952,Percent of Total Billed charges,72% of Total Billed Charges,2419.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1741.82,72,,326.352,Percent of Total Billed Charges,72% of Total Billed Charges,1451.52,60,,271.96,Percent of Total Billed Charges,60% of Total Billed Charges,2177.28,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,1088.64,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,2177.28,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,2419.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2419.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2419.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1572.48,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1066.87,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,2298.24,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,2419.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2128.9,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,2177.28,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,1066.87,2419.2,
Z50015028 BIPOLAR LINER 28MM,2780001714,CDM,278,RC,C1776,HCPCS,Outpatient,,,1449.00,941.85,,1449,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1101.24,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1043.28,72,,101.608,Percent of Total Billed Charges,72% of Total Billed Charges,1043.28,72,,101.608,Percent of Total Billed charges,72% of Total Billed Charges,1449,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1043.28,72,,101.608,Percent of Total Billed Charges,72% of Total Billed Charges,869.4,60,,84.672,Percent of Total Billed Charges,60% of Total Billed Charges,1304.1,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,652.05,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,1304.1,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,1449,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1449,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1449,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,941.85,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,639.01,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,1376.55,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,1449,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1275.12,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,1304.1,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,639.01,1449,
Z500141 BIPOLAR SHELL 41MM,2780001715,CDM,278,RC,C1776,HCPCS,Outpatient,,,2420.25,1573.16,,2420.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1839.39,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1742.58,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,1742.58,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,2420.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1742.58,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,1452.15,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,2178.23,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,1089.11,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,2178.23,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,2420.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2420.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2420.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1573.16,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1067.33,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,2299.24,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,2420.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2129.82,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,2178.23,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,1067.33,2420.25,
Z50014022 BIPOLAR LINER 22MM,2780001716,CDM,278,RC,C1776,HCPCS,Outpatient,,,1449.00,941.85,,1449,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1101.24,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1043.28,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,1043.28,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,1449,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1043.28,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,869.4,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,1304.1,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,652.05,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,1304.1,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,1449,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1449,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1449,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,941.85,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,639.01,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,1376.55,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,1449,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1275.12,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,1304.1,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,639.01,1449,
Z500150 BIPOLAR SHELL 50MM,2780001717,CDM,278,RC,C1776,HCPCS,Outpatient,,,2420.25,1573.16,,2420.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1839.39,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1742.58,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,1742.58,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,2420.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1742.58,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,1452.15,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,2178.23,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,1089.11,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,2178.23,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,2420.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2420.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2420.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1573.16,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1067.33,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,2299.24,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,2420.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2129.82,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,2178.23,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,1067.33,2420.25,
Z42540000032 PATELLA,2780001718,CDM,278,RC,C1776,HCPCS,Outpatient,,,2982.00,1938.30,,2982,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2266.32,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2147.04,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,2147.04,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,2982,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2147.04,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,1789.2,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,2683.8,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,1341.9,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,2683.8,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,2982,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2982,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2982,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1938.3,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1315.06,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,2832.9,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,2982,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2624.16,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,2683.8,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,1315.06,2982,
Z23581404 VOLAR LEFT LAT 4H,2780001719,CDM,278,RC,C1776,HCPCS,Outpatient,,,2413.00,1568.45,,2413,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1833.88,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1737.36,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,1737.36,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,2413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1737.36,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,1447.8,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,2171.7,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,1085.85,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,2171.7,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,2413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1568.45,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1064.13,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,2292.35,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,2413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2123.44,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,2171.7,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,1064.13,2413,
Z48150803 MINI CORTICAL 8MM,2780001720,CDM,278,RC,C1776,HCPCS,Outpatient,,,65.00,42.25,,65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.4,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.8,72,,9335.088,Percent of Total Billed Charges,72% of Total Billed Charges,46.8,72,,9335.088,Percent of Total Billed charges,72% of Total Billed Charges,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.8,72,,9335.088,Percent of Total Billed Charges,72% of Total Billed Charges,39,60,,7779.24,Percent of Total Billed Charges,60% of Total Billed Charges,58.5,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,29.25,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,58.5,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.25,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,28.67,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,61.75,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.2,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,58.5,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,28.67,65,
Z480920 CUNTERSINK 2.0 MM,2780001721,CDM,278,RC,C1776,HCPCS,Outpatient,,,398.00,258.70,,398,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,302.48,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,286.56,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,286.56,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,398,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.56,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,238.8,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,358.2,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,179.1,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,358.2,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,398,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258.7,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,175.52,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,378.1,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,398,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.24,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,358.2,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,175.52,398,
Z23593224 LOCKING SCW32,2780001722,CDM,278,RC,C1776,HCPCS,Outpatient,,,298.00,193.70,,298,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,226.48,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,214.56,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,214.56,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,298,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.56,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,178.8,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,268.2,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,134.1,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,268.2,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,298,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.7,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,131.42,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,283.1,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,298,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.24,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,268.2,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,131.42,298,
Z23593824 LOCKING SCW38,2780001723,CDM,278,RC,C1776,HCPCS,Outpatient,,,298.00,193.70,,298,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,226.48,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,214.56,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,214.56,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,298,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.56,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,178.8,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,268.2,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,134.1,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,268.2,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,298,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.7,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,131.42,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,283.1,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,298,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.24,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,268.2,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,131.42,298,
Z225210555 RECON SCW 105,2780001724,CDM,278,RC,C1776,HCPCS,Outpatient,,,355.00,230.75,,355,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,269.8,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,255.6,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,255.6,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,355,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.6,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,213,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,319.5,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,159.75,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,319.5,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,355,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.75,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,156.56,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,337.25,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,355,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.4,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,319.5,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,156.56,355,
ENSEAL XL LG JAW SEALER,2780001725,CDM,278,RC,C1776,HCPCS,Outpatient,,,652.00,423.80,,652,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,495.52,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,469.44,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,469.44,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,652,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,469.44,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,391.2,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,586.8,90,,3757.32,Percent of Total Billed Charges,90% of Total Billed Charges,293.4,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,586.8,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,652,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,652,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,652,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,423.8,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,287.53,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,619.4,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,652,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,573.76,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,586.8,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,287.53,652,
LEAD CARIOVERTERDE,2780001726,CDM,278,RC,C1777,HCPCS,Outpatient,,,3435.39,2233.00,,3435.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2610.9,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2473.48,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,2473.48,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,3435.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2473.48,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,2061.23,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,3091.85,90,,3578.4,Percent of Total Billed Charges,90% of Total Billed Charges,1545.93,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,3091.85,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,3435.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3435.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3435.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2233,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1515.01,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,3263.62,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,3435.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3023.14,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,3091.85,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,1515.01,3435.39,
MEDTRONIC TINED LEAD IMPLANT,2780001727,CDM,278,RC,C1778,HCPCS,Outpatient,,,13365.61,8687.65,,13365.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10157.86,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9623.24,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,9623.24,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,13365.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9623.24,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,8019.37,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,12029.05,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,6014.52,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,12029.05,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,13365.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13365.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13365.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8687.65,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,5894.23,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,12697.33,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,13365.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11761.74,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,12029.05,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,5894.23,13365.61,
LEAD PACEMAKR TRAN,2780001728,CDM,278,RC,C1779,HCPCS,Outpatient,,,2536.85,1648.95,,2536.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1928.01,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1826.53,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,1826.53,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,2536.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1826.53,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,1522.11,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,2283.17,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1141.58,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,2283.17,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,2536.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2536.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2536.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1648.95,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1118.75,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,2410.01,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,2536.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2232.43,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,2283.17,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,1118.75,2536.85,
BARD MESH LG/PLUG,2780001729,CDM,278,RC,C1781,HCPCS,Outpatient,,,965.79,627.76,,965.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,734,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,695.37,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,695.37,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,965.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.37,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,579.47,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,869.21,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,434.61,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,869.21,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,965.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,965.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,965.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,627.76,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,425.91,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,917.5,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,965.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,849.9,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,869.21,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,425.91,965.79,
BARD MESH XLG PLUG,2780001730,CDM,278,RC,C1781,HCPCS,Outpatient,,,2474.01,1608.11,,2474.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1880.25,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1781.29,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,1781.29,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,2474.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1781.29,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,1484.41,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,2226.61,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1113.3,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,2226.61,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,2474.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2474.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2474.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1608.11,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1091.04,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,2350.31,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,2474.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2177.13,88,,3673.824,Percent of Total Billed Charges,88% of Total Billed Charges,2226.61,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,1091.04,2474.01,
GORTEX DUAL MESH 15X,2780001731,CDM,278,RC,C1781,HCPCS,Outpatient,,,4998.74,3249.18,,4998.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3799.04,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3599.09,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,3599.09,72,,933.512,Percent of Total Billed charges,72% of Total Billed Charges,4998.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3599.09,72,,933.512,Percent of Total Billed Charges,72% of Total Billed Charges,2999.24,60,,777.928,Percent of Total Billed Charges,60% of Total Billed Charges,4498.87,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,2249.43,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,4498.87,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,4998.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4998.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4998.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3249.18,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,2204.44,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,4748.8,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,4998.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4398.89,88,,3498.88,Percent of Total Billed Charges,88% of Total Billed Charges,4498.87,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,2204.44,4998.74,
GORTEX DUAL MESH 10X,2780001732,CDM,278,RC,C1781,HCPCS,Outpatient,,,2811.38,1827.40,,2811.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2136.65,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2024.19,72,,2096.64,Percent of Total Billed Charges,72% of Total Billed Charges,2024.19,72,,2096.64,Percent of Total Billed charges,72% of Total Billed Charges,2811.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2024.19,72,,2096.64,Percent of Total Billed Charges,72% of Total Billed Charges,1686.83,60,,1747.2,Percent of Total Billed Charges,60% of Total Billed Charges,2530.24,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1265.12,45,,1878.664,Percent of Total Billed Charges,45% of Total Billed Charges,2530.24,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,2811.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2811.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2811.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1827.4,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1239.82,44.1,,1841.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,2670.81,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,2811.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2474.01,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,2530.24,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,1239.82,2811.38,
VICRYL KNITTED MESH 12X12,2780001733,CDM,278,RC,C1781,HCPCS,Outpatient,,,9484.00,6164.60,,9484,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7207.84,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6828.48,72,,1995.296,Percent of Total Billed Charges,72% of Total Billed Charges,6828.48,72,,2078.44,Percent of Total Billed charges,72% of Total Billed Charges,9484,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6828.48,72,,1995.296,Percent of Total Billed Charges,72% of Total Billed Charges,5690.4,60,,1662.752,Percent of Total Billed Charges,60% of Total Billed Charges,8535.6,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,4267.8,45,,1789.2,Percent of Total Billed Charges,45% of Total Billed Charges,8535.6,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,9484,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9484,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9484,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6164.6,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,4182.44,44.1,,1753.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,9009.8,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,9484,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8345.92,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,8535.6,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,4182.44,9484,
BARD COMPOSIX KUGEL,2780001734,CDM,278,RC,C1781,HCPCS,Outpatient,,,2921.63,1899.06,,2921.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2220.44,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2103.57,72,,1560.288,Percent of Total Billed Charges,72% of Total Billed Charges,2103.57,72,,1560.288,Percent of Total Billed charges,72% of Total Billed Charges,2921.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2103.57,72,,1560.288,Percent of Total Billed Charges,72% of Total Billed Charges,1752.98,60,,1300.24,Percent of Total Billed Charges,60% of Total Billed Charges,2629.47,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1314.73,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,2629.47,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,2921.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2921.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2921.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1899.06,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1288.44,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,2775.55,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,2921.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2571.03,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,2629.47,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,1288.44,2921.63,
VENTRLX HER PTCH 1.7X1.7,2780001735,CDM,278,RC,C1781,HCPCS,Outpatient,,,3798.11,2468.77,,3798.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2886.56,76,,3172.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2734.64,72,,2514.76,Percent of Total Billed Charges,72% of Total Billed Charges,2734.64,72,,2514.76,Percent of Total Billed charges,72% of Total Billed Charges,3798.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2734.64,72,,2514.76,Percent of Total Billed Charges,72% of Total Billed Charges,2278.87,60,,2095.632,Percent of Total Billed Charges,60% of Total Billed Charges,3418.3,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1709.15,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3418.3,90,,3757.32,Percent of Total Billed Charges,90% of Total billed Charges,3798.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3798.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3798.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2468.77,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1674.97,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3608.2,95,,3966.064,Percent of Total Billed Charges,95% of Total Billed Charges,3798.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3342.34,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3418.3,90,,3757.32,Percent of Total Billed charges,90% of Total Billed Charges,1674.97,3798.11,
BARD COMPOSIX KUGEL,2780001736,CDM,278,RC,C1781,HCPCS,Outpatient,,,2995.49,1947.07,,2995.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2276.57,76,,3021.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2156.75,72,,2882.88,Percent of Total Billed Charges,72% of Total Billed Charges,2156.75,72,,2882.88,Percent of Total Billed charges,72% of Total Billed Charges,2995.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2156.75,72,,2882.88,Percent of Total Billed Charges,72% of Total Billed Charges,1797.29,60,,2402.4,Percent of Total Billed Charges,60% of Total Billed Charges,2695.94,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1347.97,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,2695.94,90,,3578.4,Percent of Total Billed Charges,90% of Total billed Charges,2995.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2995.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2995.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1947.07,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1321.01,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,2845.72,95,,3777.2,Percent of Total Billed Charges,95% of Total Billed Charges,2995.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2636.03,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,2695.94,90,,3578.4,Percent of Total Billed charges,90% of Total Billed Charges,1321.01,2995.49,
BARD COMPOSIX 6X8,2780001737,CDM,278,RC,C1781,HCPCS,Outpatient,,,4085.87,2655.82,,4085.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3105.26,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2941.83,72,,2882.88,Percent of Total Billed Charges,72% of Total Billed Charges,2941.83,72,,2882.88,Percent of Total Billed charges,72% of Total Billed Charges,4085.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2941.83,72,,2882.88,Percent of Total Billed Charges,72% of Total Billed Charges,2451.52,60,,2402.4,Percent of Total Billed Charges,60% of Total Billed Charges,3677.28,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1838.64,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3677.28,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,4085.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4085.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4085.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2655.82,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1801.87,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3881.58,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,4085.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3595.57,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3677.28,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1801.87,4085.87,
BARD COMPOSIX MESH 4,2780001738,CDM,278,RC,C1781,HCPCS,Outpatient,,,3573.20,2322.58,,3573.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2715.63,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2572.7,72,,13526.352,Percent of Total Billed Charges,72% of Total Billed Charges,2572.7,72,,13526.352,Percent of Total Billed charges,72% of Total Billed Charges,3573.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2572.7,72,,13526.352,Percent of Total Billed Charges,72% of Total Billed Charges,2143.92,60,,11271.96,Percent of Total Billed Charges,60% of Total Billed Charges,3215.88,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1607.94,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3215.88,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3573.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3573.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3573.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322.58,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1575.78,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3394.54,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3573.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3144.42,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3215.88,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1575.78,3573.2,
BARD COMPOSIX 10X13,2780001739,CDM,278,RC,C1781,HCPCS,Outpatient,,,13594.93,8836.70,,13594.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10332.15,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9788.35,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,9788.35,72,,113.04,Percent of Total Billed charges,72% of Total Billed Charges,13594.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9788.35,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,8156.96,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,12235.44,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,6117.72,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,12235.44,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,13594.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13594.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13594.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8836.7,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,5995.36,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,12915.18,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,13594.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11963.54,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,12235.44,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,5995.36,13594.93,
BARD MESH 3X6,2780001740,CDM,278,RC,,,Outpatient,,,1016.51,660.73,,1016.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,772.55,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,731.89,72,,149.232,Percent of Total Billed Charges,72% of Total Billed Charges,731.89,72,,155.456,Percent of Total Billed charges,72% of Total Billed Charges,1016.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,731.89,72,,149.232,Percent of Total Billed Charges,72% of Total Billed Charges,609.91,60,,124.36,Percent of Total Billed Charges,60% of Total Billed Charges,914.86,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,457.43,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,914.86,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,1016.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1016.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1016.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,660.73,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,448.28,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,965.68,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,1016.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,894.53,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,914.86,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,448.28,1016.51,
BARD MESH 10X14,2780001741,CDM,278,RC,C1781,HCPCS,Outpatient,,,1481.76,963.14,,1481.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1126.14,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1066.87,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,1066.87,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,1481.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1066.87,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,889.06,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,1333.58,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,666.79,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,1333.58,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,1481.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1481.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1481.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,963.14,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,653.46,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1407.67,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,1481.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1303.95,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,1333.58,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,653.46,1481.76,
MOTIFMESH 6X11,2780001742,CDM,278,RC,C1781,HCPCS,Outpatient,,,546.84,355.45,,546.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,415.6,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.72,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,393.72,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,546.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.72,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,328.1,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,492.16,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,246.08,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,492.16,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,546.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.45,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,241.16,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,519.5,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,546.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,481.22,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,492.16,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,241.16,546.84,
VICRYL KNITTED MESH 6X6,2780001743,CDM,278,RC,C1781,HCPCS,Outpatient,,,4455.00,2895.75,,4455,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3385.8,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3207.6,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,3207.6,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,4455,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3207.6,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,2673,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,4009.5,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,2004.75,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,4009.5,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,4455,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4455,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4455,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2895.75,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1964.66,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,4232.25,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,4455,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3920.4,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,4009.5,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1964.66,4455,
BARD MAX CORE 20,2780001744,CDM,278,RC,C1781,HCPCS,Outpatient,,,208.37,135.44,,208.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,158.36,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.03,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,150.03,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.03,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,125.02,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,187.53,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,93.77,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,187.53,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.44,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,91.89,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,197.95,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.37,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,187.53,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,91.89,208.37,
SURGICAL MATRIX PLUS 10CMX15CM,2780001748,CDM,278,RC,C1781,HCPCS,Outpatient,,,17013.78,11058.96,,17013.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12930.47,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12249.92,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,12249.92,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,17013.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12249.92,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,10208.27,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,15312.4,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,7656.2,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,15312.4,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,17013.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17013.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17013.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11058.96,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,7503.08,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,16163.09,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,17013.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14972.13,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,15312.4,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,7503.08,17013.78,
SURGIMESH XB CIRCLE 10MM,2780001749,CDM,278,RC,C1781,HCPCS,Outpatient,,,4438.00,2884.70,,4438,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3372.88,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3195.36,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,3195.36,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,4438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3195.36,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,2662.8,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,3994.2,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1997.1,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3994.2,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,4438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2884.7,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1957.16,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,4216.1,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,4438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3905.44,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3994.2,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1957.16,4438,
VENTRIO HERNIA PATCH MD,2780001750,CDM,278,RC,C1781,HCPCS,Outpatient,,,4542.00,2952.30,,4542,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3451.92,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3270.24,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,3270.24,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,4542,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3270.24,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,2725.2,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,4087.8,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,2043.9,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,4087.8,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,4542,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4542,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4542,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2952.3,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,2003.02,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,4314.9,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,4542,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3996.96,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,4087.8,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,2003.02,4542,
VENTRIO HERNIA PATCH,2780001751,CDM,278,RC,C1781,HCPCS,Outpatient,,,3053.00,1984.45,,3053,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2320.28,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2198.16,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,2198.16,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,3053,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2198.16,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,1831.8,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,2747.7,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1373.85,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,2747.7,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3053,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3053,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3053,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1984.45,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1346.37,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,2900.35,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3053,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2686.64,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,2747.7,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1346.37,3053,
VENTRIO HERNIA PATCH LG,2780001752,CDM,278,RC,C1781,HCPCS,Outpatient,,,5723.00,3719.95,,5723,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4349.48,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4120.56,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,4120.56,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,5723,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4120.56,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,3433.8,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,5150.7,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,2575.35,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,5150.7,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,5723,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5723,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5723,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3719.95,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,2523.84,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,5436.85,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,5723,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5036.24,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,5150.7,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,2523.84,5723,
SURGIMESH XB7,2780001753,CDM,278,RC,C1781,HCPCS,Outpatient,,,3018.00,1961.70,,3018,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2293.68,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2172.96,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,2172.96,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,3018,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2172.96,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,1810.8,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,2716.2,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1358.1,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,2716.2,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3018,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3018,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3018,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1961.7,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1330.94,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,2867.1,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3018,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2655.84,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,2716.2,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1330.94,3018,
AHMED VALVE FP7,2780001754,CDM,278,RC,C1783,HCPCS,Outpatient,,,2499.37,1624.59,,2499.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1899.52,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1799.55,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,1799.55,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,2499.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1799.55,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,1499.62,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,2249.43,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1124.72,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,2249.43,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,2499.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2499.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2499.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1624.59,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1102.22,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,2374.4,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,2499.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2199.45,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,2249.43,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1102.22,2499.37,
ALCON CYPASS SYSTEM STENT,2780001755,CDM,278,RC,C1783,HCPCS,Outpatient,,,6035.00,3922.75,,6035,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4586.6,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4345.2,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,4345.2,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,6035,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4345.2,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,3621,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,5431.5,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,2715.75,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,5431.5,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,6035,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6035,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6035,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3922.75,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,2661.44,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,5733.25,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,6035,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5310.8,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,5431.5,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,2661.44,6035,
ISTENT INJECT DELIVERY SYSTEM,2780001756,CDM,278,RC,C1783,HCPCS,Outpatient,,,3816.00,2480.40,,3816,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2900.16,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2747.52,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,2747.52,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,3816,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2747.52,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,2289.6,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,3434.4,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1717.2,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3434.4,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3816,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3816,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3816,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2480.4,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1682.86,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3625.2,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3816,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3358.08,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3434.4,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1682.86,3816,
INDWELLING PORT IMPLANT,2780001757,CDM,278,RC,C1788,HCPCS,Outpatient,,,4717.60,3066.44,,4717.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3585.38,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3396.67,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,3396.67,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,4717.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3396.67,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,2830.56,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,4245.84,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,2122.92,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,4245.84,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,4717.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4717.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4717.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3066.44,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,2080.46,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,4481.72,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,4717.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4151.49,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,4245.84,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,2080.46,4717.6,
BARD POWERPORT ISP,2780001758,CDM,278,RC,C1788,HCPCS,Outpatient,,,1846.69,1200.35,,1846.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1403.48,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1329.62,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,1329.62,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,1846.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1329.62,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,1108.01,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,1662.02,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,831.01,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,1662.02,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,1846.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1846.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1846.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1200.35,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,814.39,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1754.36,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,1846.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1625.09,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,1662.02,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,814.39,1846.69,
POWERPOINT 8F CV LSP CATHETER,2780001759,CDM,278,RC,C1788,HCPCS,Outpatient,,,1271.00,826.15,,1271,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,965.96,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,915.12,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,915.12,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,1271,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,915.12,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,762.6,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,1143.9,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,571.95,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,1143.9,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,1271,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1271,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1271,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.15,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,560.51,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1207.45,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,1271,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1118.48,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,1143.9,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,560.51,1271,
POLARIS STENTS,2780001760,CDM,278,RC,C1874,HCPCS,Outpatient,,,993.35,645.68,,993.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,754.95,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,715.21,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,715.21,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,993.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,715.21,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,596.01,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,894.02,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,447.01,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,894.02,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,993.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,993.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,993.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,645.68,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,438.07,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,943.68,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,993.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,874.15,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,894.02,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,438.07,993.35,
PERCUFLEX PLUS STENT 6X28,2780001761,CDM,278,RC,C1874,HCPCS,Outpatient,,,915.08,594.80,,915.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,695.46,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,658.86,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,658.86,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,915.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658.86,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,549.05,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,823.57,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,411.79,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,823.57,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,915.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,915.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,915.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,594.8,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,403.55,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,869.33,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,915.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,805.27,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,823.57,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,403.55,915.08,
POLARIS STENT 5X20CM,2780001762,CDM,278,RC,C1874,HCPCS,Outpatient,,,1282.21,833.44,,1282.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,974.48,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,923.19,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,923.19,72,,90.624,Percent of Total Billed charges,72% of Total Billed Charges,1282.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.19,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,769.33,60,,72.496,Percent of Total Billed Charges,60% of Total Billed Charges,1153.99,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,576.99,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,1153.99,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,1282.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1282.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1282.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,833.44,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,565.45,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1218.1,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,1282.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1128.34,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,1153.99,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,565.45,1282.21,
POLARIS STENT 8FRX20,2780001763,CDM,278,RC,C1874,HCPCS,Outpatient,,,790.49,513.82,,790.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,600.77,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,569.15,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,569.15,72,,90.624,Percent of Total Billed charges,72% of Total Billed Charges,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569.15,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,474.29,60,,72.496,Percent of Total Billed Charges,60% of Total Billed Charges,711.44,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,355.72,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,711.44,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.82,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,348.61,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,750.97,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.63,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,711.44,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,348.61,790.49,
POLARIS STENT 8FRX22,2780001764,CDM,278,RC,C1874,HCPCS,Outpatient,,,790.49,513.82,,790.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,600.77,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,569.15,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,569.15,72,,90.624,Percent of Total Billed charges,72% of Total Billed Charges,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569.15,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,474.29,60,,72.496,Percent of Total Billed Charges,60% of Total Billed Charges,711.44,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,355.72,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,711.44,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.82,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,348.61,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,750.97,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.63,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,711.44,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,348.61,790.49,
POLARIS STENT 8FRX24,2780001765,CDM,278,RC,C1874,HCPCS,Outpatient,,,790.49,513.82,,790.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,600.77,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,569.15,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,569.15,72,,90.624,Percent of Total Billed charges,72% of Total Billed Charges,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569.15,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,474.29,60,,72.496,Percent of Total Billed Charges,60% of Total Billed Charges,711.44,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,355.72,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,711.44,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.82,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,348.61,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,750.97,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.63,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,711.44,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,348.61,790.49,
POLARIS STENT 8FRX26,2780001766,CDM,278,RC,C1874,HCPCS,Outpatient,,,790.49,513.82,,790.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,600.77,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,569.15,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,569.15,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569.15,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,474.29,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,711.44,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,355.72,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,711.44,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.82,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,348.61,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,750.97,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.63,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,711.44,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,348.61,790.49,
POLARIS STENT 8FRX28,2780001767,CDM,278,RC,C1874,HCPCS,Outpatient,,,790.49,513.82,,790.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,600.77,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,569.15,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,569.15,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569.15,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,474.29,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,711.44,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,355.72,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,711.44,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.82,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,348.61,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,750.97,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.63,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,711.44,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,348.61,790.49,
POLARIS STENT 8FRX30,2780001768,CDM,278,RC,C1874,HCPCS,Outpatient,,,790.49,513.82,,790.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,600.77,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,569.15,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,569.15,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569.15,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,474.29,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,711.44,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,355.72,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,711.44,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.82,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,348.61,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,750.97,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,790.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.63,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,711.44,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,348.61,790.49,
PERCUFLEX PLUS STENT 4.8 X 22,2780001769,CDM,278,RC,C1874,HCPCS,Outpatient,,,413.44,268.74,,413.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,314.21,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297.68,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,297.68,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,248.06,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,372.1,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,186.05,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,372.1,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.74,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,182.33,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,392.77,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.83,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,372.1,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,182.33,413.44,
PERCUFLEX PLUS STENT 4.8 X 24,2780001770,CDM,278,RC,C1874,HCPCS,Outpatient,,,413.44,268.74,,413.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,314.21,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297.68,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,297.68,72,,90.624,Percent of Total Billed charges,72% of Total Billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,248.06,60,,72.496,Percent of Total Billed Charges,60% of Total Billed Charges,372.1,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,186.05,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,372.1,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.74,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,182.33,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,392.77,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.83,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,372.1,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,182.33,413.44,
PERCUFLEX PLUS STENT 4.8 X 26,2780001771,CDM,278,RC,C1874,HCPCS,Outpatient,,,413.44,268.74,,413.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,314.21,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297.68,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,297.68,72,,90.624,Percent of Total Billed charges,72% of Total Billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,248.06,60,,72.496,Percent of Total Billed Charges,60% of Total Billed Charges,372.1,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,186.05,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,372.1,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.74,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,182.33,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,392.77,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.83,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,372.1,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,182.33,413.44,
PERCUFLEX PLUS STENT 4.8 X 28,2780001772,CDM,278,RC,C1874,HCPCS,Outpatient,,,413.44,268.74,,413.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,314.21,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297.68,72,,213.376,Percent of Total Billed Charges,72% of Total Billed Charges,297.68,72,,222.264,Percent of Total Billed charges,72% of Total Billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,72,,213.376,Percent of Total Billed Charges,72% of Total Billed Charges,248.06,60,,177.808,Percent of Total Billed Charges,60% of Total Billed Charges,372.1,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,186.05,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,372.1,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.74,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,182.33,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,392.77,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.83,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,372.1,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,182.33,413.44,
PERCUFLEX PLUS STENT 6 X 22,2780001773,CDM,278,RC,C1874,HCPCS,Outpatient,,,413.44,268.74,,413.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,314.21,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297.68,72,,213.376,Percent of Total Billed Charges,72% of Total Billed Charges,297.68,72,,222.264,Percent of Total Billed charges,72% of Total Billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,72,,213.376,Percent of Total Billed Charges,72% of Total Billed Charges,248.06,60,,177.808,Percent of Total Billed Charges,60% of Total Billed Charges,372.1,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,186.05,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,372.1,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.74,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,182.33,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,392.77,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.83,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,372.1,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,182.33,413.44,
PERCUFLEX PLUS STENT 6 X 24,2780001774,CDM,278,RC,C1874,HCPCS,Outpatient,,,413.44,268.74,,413.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,314.21,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297.68,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,297.68,72,,117.752,Percent of Total Billed charges,72% of Total Billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,72,,113.04,Percent of Total Billed Charges,72% of Total Billed Charges,248.06,60,,94.2,Percent of Total Billed Charges,60% of Total Billed Charges,372.1,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,186.05,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,372.1,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.74,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,182.33,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,392.77,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.83,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,372.1,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,182.33,413.44,
PERCUFLEX PLUS STENT 6 X 26,2780001775,CDM,278,RC,C1874,HCPCS,Outpatient,,,413.44,268.74,,413.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,314.21,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297.68,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,297.68,72,,33.08,Percent of Total Billed charges,72% of Total Billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,248.06,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,372.1,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,186.05,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,372.1,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.74,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,182.33,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,392.77,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,413.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.83,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,372.1,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,182.33,413.44,
RX XIENCE NANO 2.25X,2780001777,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,33.08,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX XIENCE NANO 2.25X,2780001778,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,33.08,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX XIENCE V 2.5X8,2780001781,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,33.08,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX XIENCE V 2.5X15,2780001783,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,33.08,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX XIENCE V 2.75X18,2780001789,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,33.08,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX XIENCE V 3X15,2780001793,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,33.08,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX XIENCE V 3X18,2780001794,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,33.08,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX XIENCE V 3X23,2780001795,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,33.08,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX XIENCE V 3.5X12,2780001797,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,33.08,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX XIENCE V 3.5X15,2780001798,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,33.08,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX XIENCE V 3.5X18,2780001799,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,99.064,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,99.064,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,82.552,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,2242.888,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX XIENCE V 4X8,2780001801,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,59.856,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,62.352,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,59.856,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,49.88,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX XIENCE V 4X12,2780001802,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,59.856,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,62.352,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,59.856,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,49.88,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,294.624,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX XIENCE V 4X15,2780001803,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,208.048,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,216.72,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,208.048,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,173.376,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,294.624,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX XIENCE V 4X18,2780001804,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,29.128,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,30.344,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,29.128,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,24.272,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,294.624,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX XIENCE V 4X23,2780001805,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,29.128,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,30.344,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,29.128,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,24.272,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,294.624,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
PROMUS EP 2.5X32 DE,2780001806,CDM,278,RC,C1874,HCPCS,Outpatient,,,7619.38,4952.60,,7619.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5790.73,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5485.95,72,,29.128,Percent of Total Billed Charges,72% of Total Billed Charges,5485.95,72,,30.344,Percent of Total Billed charges,72% of Total Billed Charges,7619.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5485.95,72,,29.128,Percent of Total Billed Charges,72% of Total Billed Charges,4571.63,60,,24.272,Percent of Total Billed Charges,60% of Total Billed Charges,6857.44,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,3428.72,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,6857.44,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,7619.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7619.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7619.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4952.6,65,,294.624,Percent of total Billed Charges,65% of Total Billed Charges,3360.15,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,7238.41,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,7619.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6705.05,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,6857.44,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,3360.15,7619.38,
RX ULTRA 4.5 X 13 STENT,2780001807,CDM,278,RC,C1874,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,118.392,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,123.328,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,118.392,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,98.656,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,294.624,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX ULTRA 4.5 X 18 STENT,2780001808,CDM,278,RC,C1874,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,118.392,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,123.328,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,118.392,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,98.656,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,294.624,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX ULTRA 4.5 X 28 STENT,2780001809,CDM,278,RC,C1874,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,39.464,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,41.104,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,39.464,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,32.888,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,294.624,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX ULTRA 4.5 X 38 STENT,2780001810,CDM,278,RC,C1874,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,39.464,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,41.104,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,39.464,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,32.888,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,294.624,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX ULTRA 5 X 18 STENT,2780001812,CDM,278,RC,C1874,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,39.464,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,41.104,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,39.464,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,32.888,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,294.624,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX ULTRA 5 X 28 STENT,2780001813,CDM,278,RC,C1874,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,39.464,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,41.104,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,39.464,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,32.888,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,294.624,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX ULTRA 5 X 38 STENT,2780001814,CDM,278,RC,C1874,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,18.088,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,18.84,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,18.088,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,15.072,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,294.624,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
XXPEDTION 2.25X8,2780001815,CDM,278,RC,C1874,HCPCS,Outpatient,,,1736.44,1128.69,,1736.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1319.69,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1250.24,72,,18.088,Percent of Total Billed Charges,72% of Total Billed Charges,1250.24,72,,18.84,Percent of Total Billed charges,72% of Total Billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1250.24,72,,18.088,Percent of Total Billed Charges,72% of Total Billed Charges,1041.86,60,,15.072,Percent of Total Billed Charges,60% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,781.4,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1128.69,65,,294.624,Percent of total Billed Charges,65% of Total Billed Charges,765.77,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1649.62,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.07,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,765.77,1736.44,
XXPEDITION 2.25X18,2780001818,CDM,278,RC,C1874,HCPCS,Outpatient,,,1736.44,1128.69,,1736.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1319.69,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1250.24,72,,18.088,Percent of Total Billed Charges,72% of Total Billed Charges,1250.24,72,,18.84,Percent of Total Billed charges,72% of Total Billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1250.24,72,,18.088,Percent of Total Billed Charges,72% of Total Billed Charges,1041.86,60,,15.072,Percent of Total Billed Charges,60% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,781.4,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1128.69,65,,294.624,Percent of total Billed Charges,65% of Total Billed Charges,765.77,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1649.62,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.07,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,765.77,1736.44,
XXPEDITION 2.5X12,2780001821,CDM,278,RC,C1874,HCPCS,Outpatient,,,1736.44,1128.69,,1736.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1319.69,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1250.24,72,,18.088,Percent of Total Billed Charges,72% of Total Billed Charges,1250.24,72,,18.84,Percent of Total Billed charges,72% of Total Billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1250.24,72,,18.088,Percent of Total Billed Charges,72% of Total Billed Charges,1041.86,60,,15.072,Percent of Total Billed Charges,60% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,781.4,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1128.69,65,,294.624,Percent of total Billed Charges,65% of Total Billed Charges,765.77,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1649.62,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.07,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,765.77,1736.44,
X XPEDITION 2.5X 18,2780001823,CDM,278,RC,C1874,HCPCS,Outpatient,,,1736.44,1128.69,,1736.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1319.69,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1250.24,72,,18.088,Percent of Total Billed Charges,72% of Total Billed Charges,1250.24,72,,18.84,Percent of Total Billed charges,72% of Total Billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1250.24,72,,18.088,Percent of Total Billed Charges,72% of Total Billed Charges,1041.86,60,,15.072,Percent of Total Billed Charges,60% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed Charges,90% of Total Billed Charges,781.4,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1128.69,65,,294.624,Percent of total Billed Charges,65% of Total Billed Charges,765.77,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1649.62,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.07,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,765.77,1736.44,
XXPEDITION 2.75X8,2780001825,CDM,278,RC,C1874,HCPCS,Outpatient,,,1736.44,1128.69,,1736.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1319.69,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1250.24,72,,18.088,Percent of Total Billed Charges,72% of Total Billed Charges,1250.24,72,,18.84,Percent of Total Billed charges,72% of Total Billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1250.24,72,,18.088,Percent of Total Billed Charges,72% of Total Billed Charges,1041.86,60,,15.072,Percent of Total Billed Charges,60% of Total Billed Charges,1562.8,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,781.4,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1128.69,65,,294.624,Percent of total Billed Charges,65% of Total Billed Charges,765.77,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1649.62,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.07,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,765.77,1736.44,
X XPEDITION 2.75 X15,2780001827,CDM,278,RC,C1874,HCPCS,Outpatient,,,1736.44,1128.69,,1736.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1319.69,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1250.24,72,,18.088,Percent of Total Billed Charges,72% of Total Billed Charges,1250.24,72,,18.84,Percent of Total Billed charges,72% of Total Billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1250.24,72,,18.088,Percent of Total Billed Charges,72% of Total Billed Charges,1041.86,60,,15.072,Percent of Total Billed Charges,60% of Total Billed Charges,1562.8,90,,407.936,Percent of Total Billed Charges,90% of Total Billed Charges,781.4,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1128.69,65,,294.624,Percent of total Billed Charges,65% of Total Billed Charges,765.77,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1649.62,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.07,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,765.77,1736.44,
XXPEDITION 3.0X15,2780001837,CDM,278,RC,C1874,HCPCS,Outpatient,,,1736.44,1128.69,,1736.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1319.69,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1250.24,72,,406.424,Percent of Total Billed Charges,72% of Total Billed Charges,1250.24,72,,423.36,Percent of Total Billed charges,72% of Total Billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1250.24,72,,406.424,Percent of Total Billed Charges,72% of Total Billed Charges,1041.86,60,,338.688,Percent of Total Billed Charges,60% of Total Billed Charges,1562.8,90,,407.936,Percent of Total Billed Charges,90% of Total Billed Charges,781.4,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1128.69,65,,294.624,Percent of total Billed Charges,65% of Total Billed Charges,765.77,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1649.62,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.07,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,765.77,1736.44,
XXPEDITION 3.5X15,2780001842,CDM,278,RC,C1874,HCPCS,Outpatient,,,1736.44,1128.69,,1736.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1319.69,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1250.24,72,,406.424,Percent of Total Billed Charges,72% of Total Billed Charges,1250.24,72,,423.36,Percent of Total Billed charges,72% of Total Billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1250.24,72,,406.424,Percent of Total Billed Charges,72% of Total Billed Charges,1041.86,60,,338.688,Percent of Total Billed Charges,60% of Total Billed Charges,1562.8,90,,407.936,Percent of Total Billed Charges,90% of Total Billed Charges,781.4,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1128.69,65,,91.728,Percent of total Billed Charges,65% of Total Billed Charges,765.77,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1649.62,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.07,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,765.77,1736.44,
X XPEDITION 3.5 X 23,2780001844,CDM,278,RC,C1874,HCPCS,Outpatient,,,1736.44,1128.69,,1736.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1319.69,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1250.24,72,,169.344,Percent of Total Billed Charges,72% of Total Billed Charges,1250.24,72,,169.344,Percent of Total Billed charges,72% of Total Billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1250.24,72,,169.344,Percent of Total Billed Charges,72% of Total Billed Charges,1041.86,60,,141.12,Percent of Total Billed Charges,60% of Total Billed Charges,1562.8,90,,407.936,Percent of Total Billed Charges,90% of Total Billed Charges,781.4,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1128.69,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,765.77,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1649.62,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,1736.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.07,88,,3036.528,Percent of Total Billed Charges,88% of Total Billed Charges,1562.8,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,765.77,1736.44,
6FR VIABAHN 5MM X 5CM 0.018,2780001845,CDM,278,RC,C1874,HCPCS,Outpatient,,,3243.56,2108.31,,3243.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2465.11,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2335.36,72,,169.344,Percent of Total Billed Charges,72% of Total Billed Charges,2335.36,72,,169.344,Percent of Total Billed charges,72% of Total Billed Charges,3243.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2335.36,72,,169.344,Percent of Total Billed Charges,72% of Total Billed Charges,1946.14,60,,141.12,Percent of Total Billed Charges,60% of Total Billed Charges,2919.2,90,,407.936,Percent of Total Billed Charges,90% of Total Billed Charges,1459.6,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,2919.2,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3243.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3243.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3243.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2108.31,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,1430.41,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3081.38,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3243.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2854.33,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,2919.2,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1430.41,3243.56,
6FR VIABAHN 6MM X 5CM 0.018,2780001846,CDM,278,RC,C1874,HCPCS,Outpatient,,,3243.56,2108.31,,3243.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2465.11,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2335.36,72,,36.864,Percent of Total Billed Charges,72% of Total Billed Charges,2335.36,72,,38.4,Percent of Total Billed charges,72% of Total Billed Charges,3243.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2335.36,72,,36.864,Percent of Total Billed Charges,72% of Total Billed Charges,1946.14,60,,30.72,Percent of Total Billed Charges,60% of Total Billed Charges,2919.2,90,,407.936,Percent of Total Billed Charges,90% of Total Billed Charges,1459.6,45,,1552.768,Percent of Total Billed Charges,45% of Total Billed Charges,2919.2,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3243.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3243.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3243.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2108.31,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,1430.41,44.1,,1521.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3081.38,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3243.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2854.33,88,,398.872,Percent of Total Billed Charges,88% of Total Billed Charges,2919.2,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1430.41,3243.56,
RX X XPEDITION 2.25X28,2780001847,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,12.064,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,10.056,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,398.872,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX X XPEDITION 2.5X28,2780001848,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,52.712,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,52.712,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,52.712,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,43.928,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,203.968,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,199.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,398.872,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX X XPEDITION 2.5X33,2780001849,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,2622.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,78.112,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,78.112,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,78.112,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,65.096,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,203.968,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,8427.512,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,199.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,3278.072,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,398.872,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,3105.544,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX X XPEDITION 2.75X28,2780001850,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,78.112,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,78.112,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,78.112,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,65.096,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,203.968,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,199.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,398.872,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX X XPEDITION 2.75X33,2780001851,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,344.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,3609.568,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,3759.968,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,3609.568,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,3007.976,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,203.968,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,199.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,430.6,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,398.872,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX X XPEDITION 3X28,2780001852,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,344.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,3609.568,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,3759.968,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,3609.568,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,3007.976,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,203.968,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,199.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,430.6,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,398.872,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX X XPEDITION 3X33,2780001853,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,344.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,371.496,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,386.976,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,371.496,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,309.584,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,203.968,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,199.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,430.6,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,398.872,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX X XPEDITION 3X38,2780001854,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,344.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,1463.136,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,1524.096,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,1463.136,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,1219.28,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,203.968,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,199.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,430.6,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,398.872,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX X XPEDITION 3.5X28,2780001855,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,344.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,1463.136,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,1524.096,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,1463.136,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,1219.28,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,203.968,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,199.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,430.6,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,398.872,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX X XPEDITION 3.5X33,2780001856,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,344.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,2508.408,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,2612.928,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,2508.408,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,2090.344,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,203.968,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,199.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,430.6,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,398.872,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX X XPEDITION 3.5X38,2780001857,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,344.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,2508.408,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,2508.408,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,2508.408,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,2090.344,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,203.968,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,199.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,430.6,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,398.872,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX X XPEDITION 4X28,2780001858,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,344.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,203.968,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,199.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,430.6,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,398.872,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX X XPEDITION 4X33,2780001859,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,344.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,84.096,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,84.096,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,84.096,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,70.08,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,203.968,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,199.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,430.6,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,398.872,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
RX X XPEDITION 4X38,2780001860,CDM,278,RC,C1874,HCPCS,Outpatient,,,3472.88,2257.37,,3472.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2639.39,76,,344.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2500.47,72,,1978.784,Percent of Total Billed Charges,72% of Total Billed Charges,2500.47,72,,1978.784,Percent of Total Billed charges,72% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.47,72,,1978.784,Percent of Total Billed Charges,72% of Total Billed Charges,2083.73,60,,1648.984,Percent of Total Billed Charges,60% of Total Billed Charges,3125.59,90,,127.008,Percent of Total Billed Charges,90% of Total Billed Charges,1562.8,45,,203.968,Percent of Total Billed Charges,45% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed Charges,90% of Total billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.37,65,,842.752,Percent of total Billed Charges,65% of Total Billed Charges,1531.54,44.1,,199.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3299.24,95,,430.6,Percent of Total Billed Charges,95% of Total Billed Charges,3472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3056.13,88,,398.872,Percent of Total Billed Charges,88% of Total Billed Charges,3125.59,90,,407.936,Percent of Total Billed charges,90% of Total Billed Charges,1531.54,3472.88,
P PREMIER 2.25X8 RX DES,2780001861,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,344.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,1978.784,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,1978.784,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,1978.784,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,1648.984,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,203.968,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,407.936,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,1892.8,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,199.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,430.6,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,398.872,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,407.936,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.5X8 RX DES,2780001862,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,344.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,1536.16,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,1536.16,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,1536.16,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,1280.136,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,203.968,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,407.936,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,1801.312,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,199.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,430.6,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,398.872,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,407.936,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.75X8 RX DES,2780001863,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,344.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,1617.448,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,1617.448,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,1617.448,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,1347.872,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,203.968,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,407.936,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,1408.6,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,199.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,430.6,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,398.872,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,407.936,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 3X8 RX DES,2780001864,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,344.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,332.128,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,276.776,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,203.968,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,407.936,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,2270.272,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,199.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,430.6,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,398.872,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,407.936,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 3.5X8 RX DES,2780001865,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,344.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,332.128,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,276.776,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,203.968,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,407.936,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,2602.6,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,199.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,430.6,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,124.184,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,407.936,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 4X8 RX DES,2780001866,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,344.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,332.128,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,276.776,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,11668.864,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,203.968,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,407.936,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,2602.6,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,199.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,430.6,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,407.936,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.25X12 RX DES,2780001867,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,344.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,332.128,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,276.776,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,63.504,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,407.936,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,12211.288,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,62.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,430.6,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,407.936,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.5X12 RX DES,2780001868,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,344.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,332.128,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,276.776,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,407.936,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,430.6,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,407.936,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.75X12 RX DES,2780001869,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,344.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,332.128,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,276.776,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,407.936,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,134.728,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,430.6,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,407.936,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 3X12 RX DES,2780001870,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,107.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,332.128,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,276.776,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,127.008,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,134.064,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,127.008,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 3.5X12 RX DES,2780001871,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,332.128,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,276.776,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,11409.552,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 4X12 RX DES,2780001872,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,332.128,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,276.776,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.25X16 RX DES,2780001873,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,332.128,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,276.776,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,5834.432,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,5717.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.5X16 RX DES,2780001874,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,332.128,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,276.776,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.75X16 RX DES,2780001875,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,332.128,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,276.776,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 3X16 RX DES,2780001876,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,9853.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,332.128,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,332.128,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,276.776,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,11668.864,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,12317.128,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,11668.864,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 3.5X16 RX DES,2780001877,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,666.152,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,666.152,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,666.152,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,555.128,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 4X16 RX DES,2780001878,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,2198.016,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,2198.016,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,2198.016,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,1831.68,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,2620.8,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.25X20 RX DES,2780001879,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,3626.08,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,3626.08,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,3626.08,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,3021.736,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,2494.12,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.5X20 RX DES,2780001880,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,842.696,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,842.696,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,842.696,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,702.248,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,1950.368,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.75X20 RX DES,2780001881,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,842.696,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,842.696,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,842.696,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,702.248,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,3143.448,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 3X20 RX DES,2780001882,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,1954.016,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,1954.016,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,1954.016,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,1628.344,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,3603.6,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,1140.96,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 3.5X20 RX DES,2780001883,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,507.4,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,507.4,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,507.4,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,422.832,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,3603.6,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,2562.56,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 4X20 RX DES,2780001884,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,2592.24,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,2592.24,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,2592.24,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,2160.2,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,16907.944,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,583.448,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,571.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,2438.696,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.25X24 RX DES,2780001885,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,6221.488,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,6221.488,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,6221.488,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,5184.568,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,1310.4,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,1284.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,1907.024,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.5X24 RX DES,2780001886,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,490.888,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,490.888,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,490.888,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,409.072,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,186.544,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,1247.064,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,1222.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,3073.592,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.75X24 RX DES,2780001887,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,985.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,48.264,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,48.264,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,48.264,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,40.216,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,975.184,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,955.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,1231.72,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,3523.52,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,1166.888,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 3X24 RX DES,2780001888,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,2213.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,2968.816,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,2968.816,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,2968.816,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,2474.008,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,1571.728,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,2620.8,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,78.544,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,1540.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,2766.4,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,3523.52,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,2620.8,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 3.5X24 RX DES,2780001889,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,2106.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,682.672,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,682.672,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,682.672,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,568.888,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,1801.8,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,2494.12,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,78.544,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,1765.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,2632.688,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,16532.208,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,2494.12,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 4X24 RX DES,2780001890,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,1646.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,7522.688,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,7522.688,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,7522.688,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,6268.904,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,1801.8,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,1950.368,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,78.544,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,1765.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,2058.72,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,1950.368,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.25X28 RX DES,2780001891,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,2654.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,443.264,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,443.264,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,443.264,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,369.384,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,8453.968,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,3143.448,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,78.544,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,8284.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,3318.088,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,182.4,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,3143.448,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.5X28 RX DES,2780001892,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,3043.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,831.264,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,831.264,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,831.264,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,692.72,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,3603.6,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,3803.8,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,3603.6,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.75X28 RX DES,2780001893,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,3043.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,25305.704,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,25305.704,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,25305.704,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,21088.088,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,93.272,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,3603.6,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,91.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,3803.8,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,3603.6,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 3X28 RX DES,2780001894,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,14277.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,204.488,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,204.488,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,204.488,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,170.408,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,16907.944,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,17847.272,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,16907.944,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 3.5X28 RX DES,2780001895,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,1019.056,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,1019.056,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,1019.056,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,849.216,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 4X28 RX DES,2780001896,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,157.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,404.928,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,404.928,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,404.928,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,337.44,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,186.544,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,78.544,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,196.912,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,186.544,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.25X32 RX DES,2780001897,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,1060.416,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,1060.416,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,1060.416,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,883.68,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,78.544,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.5X32 RX DES,2780001898,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,7303.104,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,7303.104,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,7303.104,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,6085.92,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,192.632,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.75X32 RX DES,2780001899,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,32.832,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,27.36,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,192.632,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 3X32 RX DES,2780001900,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,2817.04,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,2817.04,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,2817.04,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,2347.528,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,102.048,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 3.5X32 RX DES,2780001901,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,2777.664,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,2777.664,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,2777.664,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,2314.72,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 4X32 RX DES,2780001902,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,1262.592,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,1262.592,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,1262.592,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,1052.16,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.5X38 RX DES,2780001903,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,3298.4,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,3298.4,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,3298.4,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,2748.664,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 2.75X38 RX DES,2780001904,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,334.664,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,334.664,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,334.664,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,278.888,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 3X38 RX DES,2780001905,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,5743.936,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,5743.936,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,5743.936,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,4786.616,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,108.752,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 3.5X38 RX DES,2780001906,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,8677.184,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,8677.184,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,8677.184,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,7230.992,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,108.752,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
P PREMIER 4X38 RX DES,2780001907,CDM,278,RC,C1874,HCPCS,Outpatient,,,3628.33,2358.41,,3628.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2757.53,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.4,72,,2841.808,Percent of Total Billed Charges,72% of Total Billed Charges,2612.4,72,,2841.808,Percent of Total Billed charges,72% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.4,72,,2841.808,Percent of Total Billed Charges,72% of Total Billed Charges,2177,60,,2368.168,Percent of Total Billed Charges,60% of Total Billed Charges,3265.5,90,,108.752,Percent of Total Billed Charges,90% of Total Billed Charges,1632.75,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.41,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,1600.09,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,3446.91,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,3628.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3192.93,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,3265.5,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,1600.09,3628.33,
RX RESOLUTE 2.25 X 12 DES,2780001908,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,272.432,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,272.432,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,272.432,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,227.024,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,108.752,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 2.25 X 18 DES,2780001909,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,213.376,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,213.376,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,213.376,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,177.808,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 2.5 X 8 DES,2780001910,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,2731.944,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,2731.944,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,2731.944,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,2276.624,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,106.336,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 2.5 X 12 DES,2780001911,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,1736.2,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,1736.2,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,1736.2,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,1446.832,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,106.336,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 2.5 X 14 DES,2780001912,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,499.144,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,499.144,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,499.144,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,415.952,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,54.376,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,89.432,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,53.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,106.336,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 2.5 X 18 DES,2780001913,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,321.968,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,321.968,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,321.968,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,268.304,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,108.752,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,54.376,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,54.04,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,53.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,106.336,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 2.5 X 22 DES,2780001914,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,482.632,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,482.632,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,482.632,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,402.192,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,108.752,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,54.376,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,54.04,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,53.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 2.5 X 26 DES,2780001915,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,91.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,8905.168,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,8905.168,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,8905.168,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,7420.976,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,266.72,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,54.376,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,108.752,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,187.824,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,53.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,114.792,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,108.752,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 2.5 X 30 DES,2780001916,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,91.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,1120.208,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,1120.208,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,1120.208,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,933.512,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,266.72,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,108.752,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,26.296,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,114.792,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,108.752,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 3 X 12 DES,2780001917,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,91.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,3866.76,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,3866.76,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,3866.76,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,3222.296,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,108.752,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,26.296,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,114.792,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,108.752,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 3 X 15 DES,2780001918,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,91.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,3388.576,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,3388.576,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,3388.576,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,2823.808,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,108.752,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,26.296,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,114.792,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,106.336,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,108.752,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 3 X 18 DES,2780001919,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,435.64,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,435.64,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,435.64,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,363.032,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,106.88,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,106.336,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 3 X 22 DES,2780001920,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,2310.28,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,2310.28,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,2310.28,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,1925.232,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,54.376,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,106.88,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,53.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,260.792,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 3 X 26 DES,2780001921,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,3512.408,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,3512.408,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,3512.408,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,2927.008,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,54.376,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,35.624,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,53.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,260.792,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 3.5 X 12 DES,2780001922,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,19952.32,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,19952.32,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,19952.32,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,16626.936,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,133.36,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,35.624,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,130.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,138.16,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 3.5 X 15 DES,2780001923,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,91.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,1155.136,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,1155.136,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,1155.136,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,962.616,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,133.36,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,108.752,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,35.624,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,130.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,114.792,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,108.752,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 3.5 X 18 DES,2780001924,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,91.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,7930.376,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,7930.376,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,7930.376,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,6608.648,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,70.648,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,108.752,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,35.624,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,69.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,114.792,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,108.752,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 3.5 X 22 DES,2780001925,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,225.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,227.344,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,227.344,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,189.456,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,266.72,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,16.328,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,281.536,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,266.72,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 3.5 X 26 DES,2780001926,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,225.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,34.928,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,29.104,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,266.72,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,16.328,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,281.536,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,266.72,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 4 X 12 DES,2780001927,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,119.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,198.768,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,198.768,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,198.768,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,165.64,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,16.328,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,149.152,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,141.304,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 4 X 15 DES,2780001928,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,158.76,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,158.76,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,158.76,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,132.304,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,16.328,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 4 X 22 DES,2780001929,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,958.272,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,958.272,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,958.272,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,798.56,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,123.832,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,16.328,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 2.75 X 12 DES,2780001930,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,378.432,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,378.432,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,378.432,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,315.36,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,74.824,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,16.328,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 2.75 X 14 DES,2780001931,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,192.96,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,192.96,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,192.96,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,160.8,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,74.824,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,16.328,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 2.75 X 18 DES,2780001932,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,23.04,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,23.04,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,23.04,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,19.2,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,260.064,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,366.912,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 2.75 X 22 DES,2780001933,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,32.256,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,32.256,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,32.256,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,26.88,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,36.408,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,366.912,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 2.75 X 30 DES,2780001934,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,46.656,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,46.656,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,46.656,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,38.88,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,36.408,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,152.88,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,121.08,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 2.75 X 26 DES,2780001935,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,115.776,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,115.776,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,115.776,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,96.48,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,36.408,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,152.88,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,73.16,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 3 X 38 DES,2780001936,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,28.224,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,28.224,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,28.224,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,23.52,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,147.992,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,61.92,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,33.28,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,60.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,73.16,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 3 X 34 DES,2780001937,CDM,278,RC,C1874,HCPCS,Outpatient,,,5218.50,3392.03,,5218.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3966.06,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3757.32,72,,115.776,Percent of Total Billed Charges,72% of Total Billed Charges,3757.32,72,,115.776,Percent of Total Billed charges,72% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.32,72,,115.776,Percent of Total Billed Charges,72% of Total Billed Charges,3131.1,60,,96.48,Percent of Total Billed Charges,60% of Total Billed Charges,4696.65,90,,147.992,Percent of Total Billed Charges,90% of Total Billed Charges,2348.33,45,,37.408,Percent of Total Billed Charges,45% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.03,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,2301.36,44.1,,36.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,4957.58,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,5218.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4592.28,88,,254.288,Percent of Total Billed Charges,88% of Total Billed Charges,4696.65,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,2301.36,5218.5,
RX RESOLUTE 4 X 18 DES,2780001938,CDM,278,RC,C1874,HCPCS,Outpatient,,,4970.00,3230.50,,4970,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3777.2,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3578.4,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,3578.4,72,,25.4,Percent of Total Billed charges,72% of Total Billed Charges,4970,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3578.4,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,2982,60,,21.168,Percent of Total Billed Charges,60% of Total Billed Charges,4473,90,,49.328,Percent of Total Billed Charges,90% of Total Billed Charges,2236.5,45,,37.408,Percent of Total Billed Charges,45% of Total Billed Charges,4473,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,4970,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4970,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4970,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3230.5,65,,47.584,Percent of total Billed Charges,65% of Total Billed Charges,2191.77,44.1,,36.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,4721.5,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,4970,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4373.6,88,,35.6,Percent of Total Billed Charges,88% of Total Billed Charges,4473,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,2191.77,4970,
ONYX 3 X 15 DE STENT CATHETER,2780001939,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,104.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,29.216,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,29.216,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,29.216,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,24.344,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,49.328,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,130.032,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,123.832,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,70.52,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,127.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,130.712,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,35.6,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,123.832,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 4 X 22 RX DES,2780001940,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,63.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,36.832,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,36.832,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,36.832,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,30.696,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,49.328,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,18.208,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,74.824,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,70.52,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,17.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,78.976,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,35.6,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,74.824,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.75 X 30  RX DES,2780001941,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,63.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,77.32,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,77.32,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,77.32,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,64.432,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,49.328,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,18.208,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,74.824,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,3258.64,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,17.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,78.976,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,144.704,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,74.824,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2 X 15  RX DES,2780001942,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,219.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,37.688,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,37.688,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,37.688,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,31.408,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,22.608,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,18.208,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,260.064,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,3258.64,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,17.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,274.512,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,144.704,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,260.064,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 3.5 X 18 RX DES,2780001943,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,30.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,29.376,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,29.376,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,29.376,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,24.48,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,22.608,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,73.992,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,36.408,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,335.376,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,72.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,38.432,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,48.232,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,36.408,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.5 X 22 RX DES,2780001944,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,30.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,0.288,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,0.304,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,0.288,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,0.24,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,22.608,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,73.992,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,36.408,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,1320.88,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,72.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,38.432,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,48.232,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,36.408,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 3 X 38 RX DES,2780001945,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,30.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,186.704,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,186.704,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,186.704,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,155.584,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,22.608,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,24.664,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,36.408,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,1320.88,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,24.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,38.432,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,48.232,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,36.408,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.25 X 26  RX DES,2780001946,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,124.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,109.224,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,109.224,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,109.224,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,91.024,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,22.608,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,24.664,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,147.992,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,2264.536,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,24.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,156.208,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,48.232,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,147.992,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2 X 8 RX DES,2780001947,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,124.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,109.224,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,109.224,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,109.224,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,91.024,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,22.608,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,24.664,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,147.992,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,2264.536,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,24.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,156.208,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,22.104,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,147.992,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.5 X 34 RX DES,2780001948,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,41.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,94.6,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,75.68,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,22.608,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,24.664,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,49.328,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,24.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,52.064,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,22.104,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,49.328,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.75 X 38  RX DES,2780001949,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,41.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,12.064,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,12.064,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,10.056,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,508.032,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,11.304,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,49.328,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,75.92,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,11.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,52.064,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,22.104,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,49.328,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 3.5 X 34 RX DES,2780001950,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,41.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,10.792,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,8.992,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,508.032,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,11.304,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,49.328,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,1786.4,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,11.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,52.064,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,22.104,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,49.328,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2 X 26  RX DES,2780001951,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,41.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,106.688,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,106.688,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,106.688,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,88.904,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,211.68,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,11.304,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,49.328,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,1786.4,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,11.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,52.064,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,22.104,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,49.328,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 3 X 8 RX DES,2780001952,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,19.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,91.448,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,91.448,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,76.208,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,211.68,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,11.304,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,22.608,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,1386.816,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,11.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,23.864,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,22.104,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,22.608,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 3.5 X 12 RX DES,2780001953,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,19.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,17.144,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,11.304,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,22.608,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,1460.2,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,11.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,23.864,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,22.104,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,22.608,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 4 X 18 RX DES,2780001954,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,19.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,445.768,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,445.768,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,445.768,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,371.472,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,11.304,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,22.608,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,299.84,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,11.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,23.864,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,496.744,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,22.608,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 4.5 X 26 RX DES,2780001955,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,19.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,130.864,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,130.864,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,130.864,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,109.056,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,65.888,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,11.304,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,22.608,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,299.84,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,11.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,23.864,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,496.744,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,22.608,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 4.5 X 30 RX DES,2780001956,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,19.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,445.768,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,445.768,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,445.768,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,371.472,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,97.64,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,254.016,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,22.608,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,299.84,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,248.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,23.864,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,206.976,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,22.608,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.25 X 15  RX DES,2780001957,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,19.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,130.864,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,130.864,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,130.864,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,109.056,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,97.64,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,254.016,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,22.608,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,299.84,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,248.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,23.864,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,206.976,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,22.608,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.25 X 8  RX DES,2780001958,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,19.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,130.864,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,130.864,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,130.864,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,109.056,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,4511.96,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,105.84,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,22.608,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,299.84,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,103.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,23.864,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,45.056,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,22.608,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 3.5 X 26 RX DES,2780001959,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,429.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,222.264,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,222.264,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,222.264,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,185.224,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,4511.96,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,105.84,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,508.032,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,299.84,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,103.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,536.256,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,508.032,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.25 X 12  RX DES,2780001960,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,429.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,65,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,65,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,65,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,54.168,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,464.368,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,23.04,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,508.032,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,299.84,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,22.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,536.256,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,64.424,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,508.032,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 3 X 22 RX DES,2780001961,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,178.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,11.48,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,11.48,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,11.48,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,9.568,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,1828.912,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,211.68,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,299.84,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,223.44,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,95.472,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,211.68,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.25 X 22  RX DES,2780001962,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,178.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,19.584,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,19.584,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,19.584,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,16.32,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,1828.912,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,32.944,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,211.68,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,299.84,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,32.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,223.44,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,95.472,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,211.68,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.25 X 34  RX DES,2780001963,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,38.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,170.192,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,170.192,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,170.192,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,141.824,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,3135.512,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,48.816,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,46.08,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,299.84,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,47.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,48.64,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,4411.696,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,46.08,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.5 X 8  RX DES,2780001964,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,120.024,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,120.024,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,120.024,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,100.016,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,3135.512,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,48.816,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,299.84,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,47.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,4411.696,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 4 X 34 RX DES,2780001965,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,55.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,7239.456,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,7239.456,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,7239.456,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,6032.88,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,2255.976,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,65.888,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,299.84,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,2210.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,69.544,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,454.048,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,65.888,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 3 X 18 RX DES,2780001966,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,82.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,55.248,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,55.248,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,55.248,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,46.04,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,105.12,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,2255.976,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,97.64,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,299.84,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,2210.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,103.064,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,1788.272,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,97.64,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 5 X 12 RX DES,2780001967,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,82.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,4743.112,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,4743.112,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,4743.112,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,3952.592,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,2473.48,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,232.184,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,97.64,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,601.392,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,227.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,103.064,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,1788.272,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,97.64,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.75 X 15 RX DES,2780001968,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,3810.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,4002.656,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,4002.656,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,4002.656,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,3335.552,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,2473.48,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,914.456,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,4511.96,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,1984.32,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,896.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,4762.624,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,3065.832,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,4511.96,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 4 X 12 RX DES,2780001969,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,3810.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,487.08,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,487.08,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,487.08,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,405.896,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,1920.208,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,914.456,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,4511.96,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,3273.544,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,896.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,4762.624,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,3065.832,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,4511.96,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 4.5 X 12 RX DES,2780001970,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,392.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,546.768,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,546.768,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,546.768,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,455.64,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,2021.808,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,1567.76,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,464.368,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,760.768,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,1536.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,490.168,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,464.368,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 4 X 38 RX DES,2780001971,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,1544.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,751.256,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,751.256,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,751.256,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,626.048,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,1567.76,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,1828.912,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,760.768,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,1536.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,1930.52,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,102.784,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,1828.912,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 3 X 12 RX DES,2780001972,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,1544.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,2651.928,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,2651.928,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,2651.928,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,2209.936,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,1828.912,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,1764.04,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,1930.52,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,2418.512,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,1828.912,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 4 X 26 RX DES,2780001973,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,2647.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,984.312,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,984.312,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,984.312,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,820.264,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,52.56,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,3135.512,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,458.072,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,51.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,3309.712,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,2418.512,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,3135.512,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.25 X 38  RX DES,2780001974,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,2647.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,1315.168,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,1315.168,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,1315.168,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,1095.976,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,1236.744,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,3135.512,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,2340.216,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,1212.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,3309.712,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,1877.536,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,3135.512,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.25 X 18  RX DES,2780001975,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,4142.368,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,4142.368,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,4142.368,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,3451.976,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,1236.744,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,5616.616,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,1212.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,1976.88,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 3 X 34 RX DES,2780001976,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,88.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,1738.368,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,1738.368,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,1738.368,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,1448.64,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,960.104,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,105.12,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,443.16,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,940.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,110.96,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,405.936,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,105.12,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 5 X 18 RX DES,2780001977,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,2088.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,1068.48,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,1068.48,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,1068.48,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,890.4,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,1010.904,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,2473.48,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,43.568,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,990.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,2610.896,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,405.936,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,2473.48,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.75 X 22 RX DES,2780001978,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,2088.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,324.864,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,324.864,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,324.864,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,270.72,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,207.576,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,2473.48,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,2680.176,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,203.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,2610.896,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,405.936,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,2473.48,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 4 X 30 RX DES,2780001979,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,1621.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,324.864,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,324.864,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,324.864,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,270.72,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,207.576,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,1920.208,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,616.296,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,203.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,2026.88,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,405.936,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,1920.208,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2 X 22  RX DES,2780001980,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,1707.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,324.864,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,324.864,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,324.864,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,270.72,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,207.576,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,2021.808,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,6791.312,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,203.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,2134.136,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,405.936,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,2021.808,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2 X 12 RX DES,2780001981,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,350.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,3384.576,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,3384.576,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,3384.576,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,2820.48,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,207.576,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,400.168,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,203.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,438.224,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,405.936,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 3.5 X 22 RX DES,2780001982,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,350.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,5.408,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,5.632,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,5.408,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,4.504,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,207.576,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,750.448,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,203.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,438.224,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,405.936,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.75 X 8 RX DES,2780001983,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,350.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,2143.264,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,2057.528,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,1714.608,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,207.576,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,22845.432,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,203.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,438.224,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,405.936,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.5 X 30 RX DES,2780001984,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,350.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,250.896,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,250.896,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,250.896,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,143.688,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,832.696,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,207.576,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,184.608,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,203.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,438.224,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,405.936,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 5 X 26 RX DES,2780001985,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,350.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,4021.968,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,4021.968,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,4021.968,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,3286.248,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,2747.52,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,207.576,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,919.984,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,203.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,438.224,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,405.936,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 3 X 26 RX DES,2780001986,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,350.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,3396.432,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,3396.432,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,3396.432,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,2764.968,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,4532.6,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,207.576,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,365.56,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,203.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,438.224,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,405.936,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2 X 18  RX DES,2780001987,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,350.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,371.856,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,371.856,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,371.856,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,244.488,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,1053.376,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,207.576,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,957.32,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,203.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,438.224,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,405.936,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.75 X 18 RX DES,2780001988,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,350.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,635.664,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,635.664,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,635.664,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,464.328,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,1053.376,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,207.576,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,6593.08,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,203.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,438.224,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,405.936,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 3.5 X 30 RX DES,2780001989,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,350.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,371.856,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,371.856,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,371.856,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,244.488,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,2442.52,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,207.576,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,29.64,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,203.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,438.224,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,814.192,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 5 X 22 RX DES,2780001990,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,350.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,36.864,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,36.864,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,36.864,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,30.72,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,634.248,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,207.576,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,2543.16,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,203.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,438.224,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,2686.464,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 3.5 X 8 RX DES,2780001991,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,350.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,36.864,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,36.864,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,36.864,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,30.72,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,3240.296,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,416.344,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,2507.616,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,408.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,438.224,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,4431.88,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.5 X 15   RX DES,2780001992,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,350.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,274.176,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,274.176,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,274.176,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,228.48,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,7776.856,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,1373.76,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,1139.84,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,1346.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,438.224,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,1029.968,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 5 X 15 RX DES,2780001993,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,350.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,38.592,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,38.592,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,38.592,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,613.608,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,2266.304,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,2977.72,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,2220.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,438.224,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,1029.968,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,415.16,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 4.5 X 22 RX DES,2780001994,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,703.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,2238.912,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,2238.912,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,2238.912,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,1865.76,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,60.328,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,526.688,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,832.696,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,302.128,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,516.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,878.952,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,2388.24,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,832.696,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 4 X 8 RX DES,2780001995,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,2320.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,4079.232,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,4079.232,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,4079.232,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,3399.36,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,3711.016,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,526.688,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,2747.52,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,5185.496,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,516.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,2900.16,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,620.152,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,2747.52,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.75 X 12 RX DES,2780001996,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,3827.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,404.352,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,404.352,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,404.352,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,336.96,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,853.336,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,1221.264,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,4532.6,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,7833.568,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,1196.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,4784.416,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,3168.288,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,4532.6,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.25 X 30  RX DES,2780001997,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,889.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,176.832,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,176.832,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,176.832,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,147.36,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,9403.36,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,317.128,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,1053.376,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,2565.52,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,310.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,1111.896,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,7604.04,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,1053.376,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2 X 30  RX DES,2780001998,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,889.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,1022.4,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,1022.4,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,1022.4,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,852,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,554.08,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,1620.144,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,1053.376,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,245.944,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,1587.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,1111.896,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,599.968,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,1053.376,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 4.5 X 18 RX DES,2780001999,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,2062.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,1022.4,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,1022.4,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,1022.4,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,852,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,1039.08,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,3888.432,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,2442.52,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,192.632,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,3810.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,2578.216,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,58.992,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,2442.52,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.75 X 26  RX DES,2780002000,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,535.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,1022.4,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,1022.4,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,1022.4,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,852,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,31632.136,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,306.8,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,634.248,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,2466.336,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,300.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,669.488,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,3628.552,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,634.248,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2 X 8 RX DES,2780002001,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,2736.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,482.688,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,482.688,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,482.688,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,402.24,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,255.608,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,30.168,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,3240.296,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,1567.408,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,29.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,3420.312,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,834.376,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,3240.296,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 4.5 X 15 RX DES,2780002002,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,6567.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,357.696,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,357.696,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,357.696,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,298.08,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,1273.824,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,1855.512,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,7776.856,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,450.616,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,1818.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,8208.904,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,9194.392,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,7776.856,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.5 X 12   RX DES,2780002003,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,518.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,186.048,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,186.048,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,155.04,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,506.16,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,426.672,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,613.608,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,290.664,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,418.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,647.696,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,541.76,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,613.608,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 5 X 30 RX DES,2780002004,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,50.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,97.92,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,97.92,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,97.92,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,81.6,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,1325.52,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,4701.68,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,60.328,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,435.712,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,4607.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,63.68,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,1015.992,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,60.328,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 3.5 X 15 RX DES,2780002005,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,3133.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,274.752,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,274.752,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,274.752,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,228.96,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,9128.88,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,277.04,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,3711.016,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,8039.384,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,271.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,3917.184,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,30929.2,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,3711.016,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.5 X 26 RX DES,2780002006,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,720.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,1622.016,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,1622.016,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,1622.016,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,1351.68,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,519.544,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,853.336,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,1011.304,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,509.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,900.744,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,249.928,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,853.336,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.5 X 18   RX DES,2780002007,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,7940.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,1570.176,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,1570.176,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,1570.176,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,1308.48,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,3521.296,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,15816.064,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,9403.36,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,3490.824,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,15499.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,9925.768,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,1245.52,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,9403.36,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 4 X 15 RX DES,2780002008,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,467.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,167.04,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,167.04,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,167.04,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,139.2,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,3472.088,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,127.8,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,554.08,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,3059.128,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,125.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,584.856,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,494.912,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,554.08,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 3.5 X 38 RX DES,2780002009,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,877.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,167.04,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,167.04,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,167.04,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,139.2,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,1578.24,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,636.912,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,1039.08,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,393.288,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,624.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,1096.808,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,1296.064,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,1039.08,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 3 X 30 RX DES,2780002010,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,26711.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,329.472,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,329.472,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,329.472,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,274.56,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,4123,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,253.08,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,31632.136,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,2085.672,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,248.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,33389.472,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,8926.016,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,31632.136,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.75 X 34  RX DES,2780002011,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,215.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,1776.384,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,1776.384,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,1776.384,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,1480.32,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,418.336,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,662.76,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,255.608,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,3170.92,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,649.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,269.808,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,40.128,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,255.608,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
ONYX 5F 2.5 X 38 RX DES,2780002012,CDM,278,RC,C1874,HCPCS,Outpatient,,,4313.25,2803.61,,4313.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3278.07,76,,1075.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3105.54,72,,390.528,Percent of Total Billed Charges,72% of Total Billed Charges,3105.54,72,,390.528,Percent of Total Billed charges,72% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.54,72,,390.528,Percent of Total Billed Charges,72% of Total Billed Charges,2587.95,60,,325.44,Percent of Total Billed Charges,60% of Total Billed Charges,3881.93,90,,7179.92,Percent of Total Billed Charges,90% of Total Billed Charges,1940.96,45,,4564.44,Percent of Total Billed Charges,45% of Total Billed Charges,3881.93,90,,1273.824,Percent of Total Billed Charges,90% of Total billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2803.61,65,,18012.512,Percent of total Billed Charges,65% of Total Billed Charges,1902.14,44.1,,4473.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,4097.59,95,,1344.592,Percent of Total Billed Charges,95% of Total Billed Charges,4313.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3795.66,88,,3443.048,Percent of Total Billed Charges,88% of Total Billed Charges,3881.93,90,,1273.824,Percent of Total Billed charges,90% of Total Billed Charges,1902.14,4313.25,
RX TREK 5 MM X 15 MM BALLOON,2780002017,CDM,278,RC,C1875,HCPCS,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,427.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,1830.528,Percent of Total Billed Charges,72% of Total Billed Charges,292.12,72,,1830.528,Percent of Total Billed charges,72% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,1830.528,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,1525.44,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,10846.48,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,20.52,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,506.16,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,1042.832,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,20.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,534.28,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,3394.928,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,506.16,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
RX EUPHORA 1.5 X 12 BALLOON,2780002018,CDM,272,RC,C1725,HCPCS,Outpatient,,,566.58,368.28,,566.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.6,76,,1119.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,407.94,72,,2026.944,Percent of Total Billed Charges,72% of Total Billed Charges,424.94,75,,2026.944,Percent of Total Billed charges,75% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.94,72,,2026.944,Percent of Total Billed Charges,72% of Total Billed Charges,339.95,60,,1689.12,Percent of Total Billed Charges,60% of Total Billed Charges,509.92,90,,3552.256,Percent of Total Billed Charges,90% of Total Billed Charges,254.96,45,,1760.648,Percent of Total Billed Charges,45% of Total Billed Charges,509.92,90,,1325.52,Percent of Total Billed Charges,90% of Total billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.28,65,,7159.368,Percent of total Billed Charges,65% of Total Billed Charges,249.86,44.1,,1725.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.25,95,,1399.16,Percent of Total Billed Charges,95% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.59,88,,1543.168,Percent of Total Billed Charges,88% of Total Billed Charges,509.92,90,,1325.52,Percent of Total Billed charges,90% of Total Billed Charges,249.86,566.58,
RX EUPHORA 2 X 12 BALLOON,2780002019,CDM,272,RC,C1725,HCPCS,Outpatient,,,566.58,368.28,,566.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.6,76,,7708.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,407.94,72,,2022.912,Percent of Total Billed Charges,72% of Total Billed Charges,424.94,75,,2022.912,Percent of Total Billed charges,75% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.94,72,,2022.912,Percent of Total Billed Charges,72% of Total Billed Charges,339.95,60,,1685.76,Percent of Total Billed Charges,60% of Total Billed Charges,509.92,90,,340.536,Percent of Total Billed Charges,90% of Total Billed Charges,254.96,45,,1736.04,Percent of Total Billed Charges,45% of Total Billed Charges,509.92,90,,9128.88,Percent of Total Billed Charges,90% of Total billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.28,65,,205.248,Percent of total Billed Charges,65% of Total Billed Charges,249.86,44.1,,1701.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.25,95,,9636.04,Percent of Total Billed Charges,95% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.59,88,,4031.376,Percent of Total Billed Charges,88% of Total Billed Charges,509.92,90,,9128.88,Percent of Total Billed charges,90% of Total Billed Charges,249.86,566.58,
RX EUPHORA 2 X 15 BALLOON,2780002020,CDM,272,RC,C1725,HCPCS,Outpatient,,,566.58,368.28,,566.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.6,76,,34.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,407.94,72,,1179.072,Percent of Total Billed Charges,72% of Total Billed Charges,424.94,75,,1179.072,Percent of Total Billed charges,75% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.94,72,,1179.072,Percent of Total Billed Charges,72% of Total Billed Charges,339.95,60,,982.56,Percent of Total Billed Charges,60% of Total Billed Charges,509.92,90,,266.72,Percent of Total Billed Charges,90% of Total Billed Charges,254.96,45,,789.12,Percent of Total Billed Charges,45% of Total Billed Charges,509.92,90,,41.04,Percent of Total Billed Charges,90% of Total billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.28,65,,31.536,Percent of total Billed Charges,65% of Total Billed Charges,249.86,44.1,,773.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.25,95,,43.32,Percent of Total Billed Charges,95% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.59,88,,409.04,Percent of Total Billed Charges,88% of Total Billed Charges,509.92,90,,41.04,Percent of Total Billed charges,90% of Total Billed Charges,249.86,566.58,
RX EUPHORA 2 X 20 BALLOON,2780002021,CDM,272,RC,C1725,HCPCS,Outpatient,,,566.58,368.28,,566.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.6,76,,2973.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,407.94,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,424.94,75,,881.28,Percent of Total Billed charges,75% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.94,72,,881.28,Percent of Total Billed Charges,72% of Total Billed Charges,339.95,60,,734.4,Percent of Total Billed Charges,60% of Total Billed Charges,509.92,90,,3414.928,Percent of Total Billed Charges,90% of Total Billed Charges,254.96,45,,2061.504,Percent of Total Billed Charges,45% of Total Billed Charges,509.92,90,,3521.296,Percent of Total Billed Charges,90% of Total billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.28,65,,179.44,Percent of total Billed Charges,65% of Total Billed Charges,249.86,44.1,,2020.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.25,95,,3716.928,Percent of Total Billed Charges,95% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.59,88,,7020.368,Percent of Total Billed Charges,88% of Total Billed Charges,509.92,90,,3521.296,Percent of Total Billed charges,90% of Total Billed Charges,249.86,566.58,
RX EUPHORA 2.5 X 12 BALLOON,2780002022,CDM,272,RC,C1725,HCPCS,Outpatient,,,566.58,368.28,,566.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.6,76,,2931.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,407.94,72,,1060.992,Percent of Total Billed Charges,72% of Total Billed Charges,424.94,75,,1060.992,Percent of Total Billed charges,75% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.94,72,,1060.992,Percent of Total Billed Charges,72% of Total Billed Charges,339.95,60,,884.16,Percent of Total Billed Charges,60% of Total Billed Charges,509.92,90,,2170.256,Percent of Total Billed Charges,90% of Total Billed Charges,254.96,45,,209.168,Percent of Total Billed Charges,45% of Total Billed Charges,509.92,90,,3472.088,Percent of Total Billed Charges,90% of Total billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.28,65,,143.328,Percent of total Billed Charges,65% of Total Billed Charges,249.86,44.1,,204.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.25,95,,3664.976,Percent of Total Billed Charges,95% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.59,88,,10605.448,Percent of Total Billed Charges,88% of Total Billed Charges,509.92,90,,3472.088,Percent of Total Billed charges,90% of Total Billed Charges,249.86,566.58,
RX EUPHORA 2.5 X 20 BALLOON,2780002023,CDM,272,RC,C1725,HCPCS,Outpatient,,,566.58,368.28,,566.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.6,76,,1332.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,407.94,72,,337.536,Percent of Total Billed Charges,72% of Total Billed Charges,424.94,75,,337.536,Percent of Total Billed charges,75% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.94,72,,337.536,Percent of Total Billed Charges,72% of Total Billed Charges,339.95,60,,281.28,Percent of Total Billed Charges,60% of Total Billed Charges,509.92,90,,623.928,Percent of Total Billed Charges,90% of Total Billed Charges,254.96,45,,3589.96,Percent of Total Billed Charges,45% of Total Billed Charges,509.92,90,,1578.24,Percent of Total Billed Charges,90% of Total billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.28,65,,865.112,Percent of total Billed Charges,65% of Total Billed Charges,249.86,44.1,,3518.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.25,95,,1665.92,Percent of Total Billed Charges,95% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.59,88,,3473.32,Percent of Total Billed Charges,88% of Total Billed Charges,509.92,90,,1578.24,Percent of Total Billed charges,90% of Total Billed Charges,249.86,566.58,
RX EUPHORA 2.75 X 12 BALLOON,2780002024,CDM,272,RC,C1725,HCPCS,Outpatient,,,566.58,368.28,,566.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.6,76,,3481.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,407.94,72,,312.768,Percent of Total Billed Charges,72% of Total Billed Charges,424.94,75,,312.768,Percent of Total Billed charges,75% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.94,72,,312.768,Percent of Total Billed Charges,72% of Total Billed Charges,339.95,60,,260.64,Percent of Total Billed Charges,60% of Total Billed Charges,509.92,90,,402.456,Percent of Total Billed Charges,90% of Total Billed Charges,254.96,45,,5423.24,Percent of Total Billed Charges,45% of Total Billed Charges,509.92,90,,4123,Percent of Total Billed Charges,90% of Total billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.28,65,,341.64,Percent of total Billed Charges,65% of Total Billed Charges,249.86,44.1,,5314.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.25,95,,4352.056,Percent of Total Billed Charges,95% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.59,88,,332.968,Percent of Total Billed Charges,88% of Total Billed Charges,509.92,90,,4123,Percent of Total Billed charges,90% of Total Billed Charges,249.86,566.58,
RX EUPHORA 2.75 X 15 BALLOON,2780002025,CDM,272,RC,C1725,HCPCS,Outpatient,,,566.58,368.28,,566.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.6,76,,353.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,407.94,72,,324.864,Percent of Total Billed Charges,72% of Total Billed Charges,424.94,75,,324.864,Percent of Total Billed charges,75% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.94,72,,324.864,Percent of Total Billed Charges,72% of Total Billed Charges,339.95,60,,270.72,Percent of Total Billed Charges,60% of Total Billed Charges,509.92,90,,603.288,Percent of Total Billed Charges,90% of Total Billed Charges,254.96,45,,1776.128,Percent of Total Billed Charges,45% of Total Billed Charges,509.92,90,,418.336,Percent of Total Billed Charges,90% of Total billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.28,65,,174.2,Percent of total Billed Charges,65% of Total Billed Charges,249.86,44.1,,1740.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.25,95,,441.576,Percent of Total Billed Charges,95% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.59,88,,260.792,Percent of Total Billed Charges,88% of Total Billed Charges,509.92,90,,418.336,Percent of Total Billed charges,90% of Total Billed Charges,249.86,566.58,
RX EUPHORA 2.75 X 25 BALLOON,2780002027,CDM,272,RC,C1725,HCPCS,Outpatient,,,566.58,368.28,,566.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.6,76,,6063.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,407.94,72,,3399.552,Percent of Total Billed Charges,72% of Total Billed Charges,424.94,75,,3399.552,Percent of Total Billed charges,75% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.94,72,,3399.552,Percent of Total Billed Charges,72% of Total Billed Charges,339.95,60,,2832.96,Percent of Total Billed Charges,60% of Total Billed Charges,509.92,90,,11131.456,Percent of Total Billed Charges,90% of Total Billed Charges,254.96,45,,170.272,Percent of Total Billed Charges,45% of Total Billed Charges,509.92,90,,7179.92,Percent of Total Billed Charges,90% of Total billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.28,65,,20.8,Percent of total Billed Charges,65% of Total Billed Charges,249.86,44.1,,166.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.25,95,,7578.8,Percent of Total Billed Charges,95% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.59,88,,3339.04,Percent of Total Billed Charges,88% of Total Billed Charges,509.92,90,,7179.92,Percent of Total Billed charges,90% of Total Billed Charges,249.86,566.58,
RX EUPHORA 3.0 X 12 BALLOON,2780002028,CDM,272,RC,C1725,HCPCS,Outpatient,,,566.58,368.28,,566.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.6,76,,9159.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,407.94,72,,779.328,Percent of Total Billed Charges,72% of Total Billed Charges,424.94,75,,779.328,Percent of Total Billed charges,75% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.94,72,,779.328,Percent of Total Billed Charges,72% of Total Billed Charges,339.95,60,,649.44,Percent of Total Billed Charges,60% of Total Billed Charges,509.92,90,,1400.264,Percent of Total Billed Charges,90% of Total Billed Charges,254.96,45,,133.36,Percent of Total Billed Charges,45% of Total Billed Charges,509.92,90,,10846.48,Percent of Total Billed Charges,90% of Total billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.28,65,,29.12,Percent of total Billed Charges,65% of Total Billed Charges,249.86,44.1,,130.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.25,95,,11449.064,Percent of Total Billed Charges,95% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.59,88,,2122.024,Percent of Total Billed Charges,88% of Total Billed Charges,509.92,90,,10846.48,Percent of Total Billed charges,90% of Total Billed Charges,249.86,566.58,
RX EUPHORA 3.0 X 15 BALLOON,2780002029,CDM,272,RC,C1725,HCPCS,Outpatient,,,566.58,368.28,,566.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.6,76,,2999.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,407.94,72,,3056.832,Percent of Total Billed Charges,72% of Total Billed Charges,424.94,75,,3056.832,Percent of Total Billed charges,75% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.94,72,,3056.832,Percent of Total Billed Charges,72% of Total Billed Charges,339.95,60,,2547.36,Percent of Total Billed Charges,60% of Total Billed Charges,509.92,90,,4833.448,Percent of Total Billed Charges,90% of Total Billed Charges,254.96,45,,1707.464,Percent of Total Billed Charges,45% of Total Billed Charges,509.92,90,,3552.256,Percent of Total Billed Charges,90% of Total billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.28,65,,42.12,Percent of total Billed Charges,65% of Total Billed Charges,249.86,44.1,,1673.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.25,95,,3749.608,Percent of Total Billed Charges,95% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.59,88,,610.064,Percent of Total Billed Charges,88% of Total Billed Charges,509.92,90,,3552.256,Percent of Total Billed charges,90% of Total Billed Charges,249.86,566.58,
RX EUPHORA 3.0 X 20 BALLOON,2780002030,CDM,272,RC,C1725,HCPCS,Outpatient,,,566.58,368.28,,566.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.6,76,,287.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,407.94,72,,288,Percent of Total Billed Charges,72% of Total Billed Charges,424.94,75,,288,Percent of Total Billed charges,75% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.94,72,,288,Percent of Total Billed Charges,72% of Total Billed Charges,339.95,60,,240,Percent of Total Billed Charges,60% of Total Billed Charges,509.92,90,,4235.72,Percent of Total Billed Charges,90% of Total Billed Charges,254.96,45,,1085.128,Percent of Total Billed Charges,45% of Total Billed Charges,509.92,90,,340.536,Percent of Total Billed Charges,90% of Total billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.28,65,,104.52,Percent of total Billed Charges,65% of Total Billed Charges,249.86,44.1,,1063.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.25,95,,359.456,Percent of Total Billed Charges,95% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.59,88,,393.512,Percent of Total Billed Charges,88% of Total Billed Charges,509.92,90,,340.536,Percent of Total Billed charges,90% of Total Billed Charges,249.86,566.58,
RX EUPHORA 3.5 X 12 BALLOON,2780002031,CDM,272,RC,C1725,HCPCS,Outpatient,,,566.58,368.28,,566.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.6,76,,225.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,407.94,72,,2077.632,Percent of Total Billed Charges,72% of Total Billed Charges,424.94,75,,2077.632,Percent of Total Billed charges,75% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.94,72,,2077.632,Percent of Total Billed Charges,72% of Total Billed Charges,339.95,60,,1731.36,Percent of Total Billed Charges,60% of Total Billed Charges,509.92,90,,544.552,Percent of Total Billed Charges,90% of Total Billed Charges,254.96,45,,311.968,Percent of Total Billed Charges,45% of Total Billed Charges,509.92,90,,266.72,Percent of Total Billed Charges,90% of Total billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.28,65,,25.48,Percent of total Billed Charges,65% of Total Billed Charges,249.86,44.1,,305.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.25,95,,281.536,Percent of Total Billed Charges,95% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.59,88,,589.88,Percent of Total Billed Charges,88% of Total Billed Charges,509.92,90,,266.72,Percent of Total Billed charges,90% of Total Billed Charges,249.86,566.58,
RX EUPHORA 3.5 X 15 BALLOON,2780002032,CDM,272,RC,C1725,HCPCS,Outpatient,,,566.58,368.28,,566.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.6,76,,2883.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,407.94,72,,1748.736,Percent of Total Billed Charges,72% of Total Billed Charges,424.94,75,,1748.736,Percent of Total Billed charges,75% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.94,72,,1748.736,Percent of Total Billed Charges,72% of Total Billed Charges,339.95,60,,1457.28,Percent of Total Billed Charges,60% of Total Billed Charges,509.92,90,,2887.848,Percent of Total Billed Charges,90% of Total Billed Charges,254.96,45,,201.232,Percent of Total Billed Charges,45% of Total Billed Charges,509.92,90,,3414.928,Percent of Total Billed Charges,90% of Total billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.28,65,,104.52,Percent of total Billed Charges,65% of Total Billed Charges,249.86,44.1,,197.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.25,95,,3604.648,Percent of Total Billed Charges,95% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.59,88,,10884.096,Percent of Total Billed Charges,88% of Total Billed Charges,509.92,90,,3414.928,Percent of Total Billed charges,90% of Total Billed Charges,249.86,566.58,
RX EUPHORA 3.5 X 20 BALLOON,2780002033,CDM,272,RC,C1725,HCPCS,Outpatient,,,566.58,368.28,,566.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.6,76,,1832.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,407.94,72,,3184.704,Percent of Total Billed Charges,72% of Total Billed Charges,424.94,75,,3184.704,Percent of Total Billed charges,75% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.94,72,,3184.704,Percent of Total Billed Charges,72% of Total Billed Charges,339.95,60,,2653.92,Percent of Total Billed Charges,60% of Total Billed Charges,509.92,90,,4390.512,Percent of Total Billed Charges,90% of Total Billed Charges,254.96,45,,301.648,Percent of Total Billed Charges,45% of Total Billed Charges,509.92,90,,2170.256,Percent of Total Billed Charges,90% of Total billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.28,65,,22.936,Percent of total Billed Charges,65% of Total Billed Charges,249.86,44.1,,295.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.25,95,,2290.824,Percent of Total Billed Charges,95% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.59,88,,1369.144,Percent of Total Billed Charges,88% of Total Billed Charges,509.92,90,,2170.256,Percent of Total Billed charges,90% of Total Billed Charges,249.86,566.58,
RX EUPHORA 4.0 X 12 BALLOON,2780002034,CDM,272,RC,C1725,HCPCS,Outpatient,,,566.58,368.28,,566.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.6,76,,526.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,407.94,72,,1069.632,Percent of Total Billed Charges,72% of Total Billed Charges,424.94,75,,1069.632,Percent of Total Billed charges,75% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.94,72,,1069.632,Percent of Total Billed Charges,72% of Total Billed Charges,339.95,60,,891.36,Percent of Total Billed Charges,60% of Total Billed Charges,509.92,90,,24940.408,Percent of Total Billed Charges,90% of Total Billed Charges,254.96,45,,5565.728,Percent of Total Billed Charges,45% of Total Billed Charges,509.92,90,,623.928,Percent of Total Billed Charges,90% of Total billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.28,65,,26.376,Percent of total Billed Charges,65% of Total Billed Charges,249.86,44.1,,5454.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.25,95,,658.592,Percent of Total Billed Charges,95% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.59,88,,4726.04,Percent of Total Billed Charges,88% of Total Billed Charges,509.92,90,,623.928,Percent of Total Billed charges,90% of Total Billed Charges,249.86,566.58,
RX EUPHORA 4.0 X 15 BALLOON,2780002035,CDM,272,RC,C1725,HCPCS,Outpatient,,,566.58,368.28,,566.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.6,76,,339.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,407.94,72,,570.24,Percent of Total Billed Charges,72% of Total Billed Charges,424.94,75,,570.24,Percent of Total Billed charges,75% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.94,72,,570.24,Percent of Total Billed Charges,72% of Total Billed Charges,339.95,60,,475.2,Percent of Total Billed Charges,60% of Total Billed Charges,509.92,90,,1443.928,Percent of Total Billed Charges,90% of Total Billed Charges,254.96,45,,700.128,Percent of Total Billed Charges,45% of Total Billed Charges,509.92,90,,402.456,Percent of Total Billed Charges,90% of Total billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.28,65,,33.256,Percent of total Billed Charges,65% of Total Billed Charges,249.86,44.1,,686.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.25,95,,424.816,Percent of Total Billed Charges,95% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.59,88,,4141.592,Percent of Total Billed Charges,88% of Total Billed Charges,509.92,90,,402.456,Percent of Total Billed charges,90% of Total Billed Charges,249.86,566.58,
RX EUPHORA 4.0 X 20 BALLOON,2780002036,CDM,272,RC,C1725,HCPCS,Outpatient,,,566.58,368.28,,566.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.6,76,,509.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,407.94,72,,346.752,Percent of Total Billed Charges,72% of Total Billed Charges,424.94,75,,346.752,Percent of Total Billed charges,75% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.94,72,,346.752,Percent of Total Billed Charges,72% of Total Billed Charges,339.95,60,,288.96,Percent of Total Billed Charges,60% of Total Billed Charges,509.92,90,,9912.976,Percent of Total Billed Charges,90% of Total Billed Charges,254.96,45,,2416.72,Percent of Total Billed Charges,45% of Total Billed Charges,509.92,90,,603.288,Percent of Total Billed Charges,90% of Total billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.28,65,,69.8,Percent of total Billed Charges,65% of Total Billed Charges,249.86,44.1,,2368.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.25,95,,636.808,Percent of Total Billed Charges,95% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.59,88,,532.448,Percent of Total Billed Charges,88% of Total Billed Charges,509.92,90,,603.288,Percent of Total Billed charges,90% of Total Billed Charges,249.86,566.58,
RX EUPHORA 2.5 X 15 BALLOON,2780002037,CDM,272,RC,C1725,HCPCS,Outpatient,,,566.58,368.28,,566.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.6,76,,9399.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,407.94,72,,274.752,Percent of Total Billed Charges,72% of Total Billed Charges,424.94,75,,274.752,Percent of Total Billed charges,75% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.94,72,,274.752,Percent of Total Billed Charges,72% of Total Billed Charges,339.95,60,,228.96,Percent of Total Billed Charges,60% of Total Billed Charges,509.92,90,,284.184,Percent of Total Billed Charges,90% of Total Billed Charges,254.96,45,,2117.856,Percent of Total Billed Charges,45% of Total Billed Charges,509.92,90,,11131.456,Percent of Total Billed Charges,90% of Total billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.28,65,,34.024,Percent of total Billed Charges,65% of Total Billed Charges,249.86,44.1,,2075.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.25,95,,11749.872,Percent of Total Billed Charges,95% of Total Billed Charges,566.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.59,88,,2823.672,Percent of Total Billed Charges,88% of Total Billed Charges,509.92,90,,11131.456,Percent of Total Billed charges,90% of Total Billed Charges,249.86,566.58,
BENGAL RADIAL COMPRE,2780002038,CDM,278,RC,C1876,HCPCS,Outpatient,,,176.40,114.66,,176.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,134.06,76,,1182.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,127.01,72,,255.744,Percent of Total Billed Charges,72% of Total Billed Charges,127.01,72,,255.744,Percent of Total Billed charges,72% of Total Billed Charges,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.01,72,,255.744,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,60,,213.12,Percent of Total Billed Charges,60% of Total Billed Charges,158.76,90,,43.664,Percent of Total Billed Charges,90% of Total Billed Charges,79.38,45,,272.272,Percent of Total Billed Charges,45% of Total Billed Charges,158.76,90,,1400.264,Percent of Total Billed Charges,90% of Total billed Charges,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.66,65,,26.52,Percent of total Billed Charges,65% of Total Billed Charges,77.79,44.1,,266.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,167.58,95,,1478.056,Percent of Total Billed Charges,95% of Total Billed Charges,176.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.23,88,,4292.944,Percent of Total Billed Charges,88% of Total Billed Charges,158.76,90,,1400.264,Percent of Total Billed charges,90% of Total Billed Charges,77.79,176.4,
RX MINI VISION 2X12,2780002040,CDM,278,RC,C1876,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,4081.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,390.528,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,390.528,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,390.528,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,325.44,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,248.456,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,1443.928,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,4833.448,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,0.264,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,1415.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,5101.968,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,24386.176,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,4833.448,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX MINI VISION 2.25X,2780002047,CDM,278,RC,C1876,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,3576.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,1085.76,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,1085.76,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,1085.76,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,904.8,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,198.456,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,2195.256,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,4235.72,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,168.552,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,2151.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,4471.032,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,1411.84,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,4235.72,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX MINI VISION 2.25X,2780002048,CDM,278,RC,C1876,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,459.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,390.528,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,390.528,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,390.528,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,325.44,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,1197.84,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,12470.2,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,544.552,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,98.608,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,12220.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,574.8,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,9692.688,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,544.552,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX MINI VISION 2.5X1,2780002051,CDM,278,RC,C1876,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,2438.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,4163.904,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,4163.904,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,4163.904,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,3469.92,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,473.04,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,721.96,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,2887.848,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,98.608,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,707.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,3048.288,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,277.872,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,2887.848,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX VISION 3X8,2780002058,CDM,278,RC,C1876,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,3707.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,842.688,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,842.688,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,842.688,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,702.24,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,241.2,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,4956.488,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,4390.512,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,81.984,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,4857.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,4634.424,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,42.688,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,4390.512,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX VISION 3X12,2780002059,CDM,278,RC,C1876,HCPCS,Outpatient,,,16206.75,10534.39,,16206.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12317.13,76,,21060.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11668.86,72,,390.528,Percent of Total Billed Charges,72% of Total Billed Charges,11668.86,72,,390.528,Percent of Total Billed charges,72% of Total Billed Charges,16206.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11668.86,72,,390.528,Percent of Total Billed Charges,72% of Total Billed Charges,9724.05,60,,325.44,Percent of Total Billed Charges,60% of Total Billed Charges,14586.08,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,7293.04,45,,142.096,Percent of Total Billed Charges,45% of Total Billed Charges,14586.08,90,,24940.408,Percent of Total Billed Charges,90% of Total billed Charges,16206.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16206.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16206.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10534.39,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,7147.18,44.1,,139.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,15396.41,95,,26325.984,Percent of Total Billed Charges,95% of Total Billed Charges,16206.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14261.94,88,,242.936,Percent of Total Billed Charges,88% of Total Billed Charges,14586.08,90,,24940.408,Percent of Total Billed charges,90% of Total Billed Charges,7147.18,16206.75,
RX VISION 3X15,2780002060,CDM,278,RC,C1876,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,1219.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,195.264,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,195.264,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,195.264,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,162.72,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,21.832,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,1443.928,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,9.744,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,21.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,1524.144,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,194.04,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,1443.928,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX VISION 3X18,2780002061,CDM,278,RC,C1876,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,8370.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,390.528,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,390.528,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,390.528,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,325.44,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,58.32,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,124.232,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,9912.976,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,96.312,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,121.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,10463.696,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,1171.224,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,9912.976,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX VISION 3.5X8,2780002063,CDM,278,RC,C1876,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,239.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,102.528,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,102.528,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,102.528,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,85.44,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,144.72,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,99.224,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,284.184,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,82.552,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,97.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,299.976,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,462.528,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,284.184,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX VISION 3.5X12,2780002064,CDM,278,RC,C1876,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,36.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,408.96,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,408.96,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,408.96,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,340.8,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,35.28,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,598.92,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,43.664,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,586.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,46.088,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,235.84,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,43.664,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX VISION 3.5X15,2780002065,CDM,278,RC,C1876,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,209.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,8749.44,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,8749.44,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,8749.44,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,7291.2,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,144.72,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,236.52,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,248.456,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,402.432,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,231.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,262.264,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,28.16,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,248.456,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX VISION 3.5X18,2780002066,CDM,278,RC,C1876,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,167.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,102.528,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,102.528,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,102.528,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,85.44,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,31.752,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,120.6,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,198.456,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,118.144,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,118.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,209.48,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,39.424,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,198.456,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX VISION 3.5X23,2780002067,CDM,278,RC,C1876,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,1011.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,175.68,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,175.68,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,175.68,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,146.4,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,36.52,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,14.4,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,1197.84,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,402.432,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,14.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,1264.392,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,57.024,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,1197.84,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX VISION 4X8,2780002068,CDM,278,RC,C1876,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,399.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,102.528,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,102.528,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,102.528,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,85.44,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,46.048,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,20.16,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,473.04,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,118.144,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,19.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,499.32,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,141.504,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,473.04,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX VISION 4X12,2780002069,CDM,278,RC,C1876,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,203.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,8749.44,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,8749.44,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,8749.44,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,7291.2,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,96.648,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,29.16,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,241.2,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,118.144,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,28.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,254.6,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,34.496,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,241.2,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX VISION 4X15,2780002070,CDM,278,RC,C1876,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,102.528,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,102.528,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,102.528,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,85.44,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,47.112,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,72.36,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,28.8,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,200.656,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,70.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,30.4,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,141.504,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,28.8,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
RX VISION 4X18,2780002071,CDM,278,RC,C1876,HCPCS,Outpatient,,,1620.68,1053.44,,1620.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1231.72,76,,34.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1166.89,72,,2323.008,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,72,,2323.008,Percent of Total Billed charges,72% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1166.89,72,,2323.008,Percent of Total Billed Charges,72% of Total Billed Charges,972.41,60,,1935.84,Percent of Total Billed Charges,60% of Total Billed Charges,1458.61,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,729.31,45,,17.64,Percent of Total Billed Charges,45% of Total Billed Charges,1458.61,90,,40.32,Percent of Total Billed Charges,90% of Total billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.44,65,,58.68,Percent of total Billed Charges,65% of Total Billed Charges,714.72,44.1,,17.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,1539.65,95,,42.56,Percent of Total Billed Charges,95% of Total Billed Charges,1620.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1426.2,88,,31.048,Percent of Total Billed Charges,88% of Total Billed Charges,1458.61,90,,40.32,Percent of Total Billed charges,90% of Total Billed Charges,714.72,1620.68,
VISI PRO 6F 6X27X135 STENT,2780002073,CDM,278,RC,C1876,HCPCS,Outpatient,,,3640.00,2366.00,,3640,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2766.4,76,,49.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2620.8,72,,102.528,Percent of Total Billed Charges,72% of Total Billed Charges,2620.8,72,,102.528,Percent of Total Billed charges,72% of Total Billed Charges,3640,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2620.8,72,,102.528,Percent of Total Billed Charges,72% of Total Billed Charges,2184,60,,85.44,Percent of Total Billed Charges,60% of Total Billed Charges,3276,90,,0.36,Percent of Total Billed Charges,90% of Total Billed Charges,1638,45,,72.36,Percent of Total Billed Charges,45% of Total Billed Charges,3276,90,,58.32,Percent of Total Billed Charges,90% of Total billed Charges,3640,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3640,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3640,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2366,65,,10.36,Percent of total Billed Charges,65% of Total Billed Charges,1605.24,44.1,,70.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,3458,95,,61.56,Percent of Total Billed Charges,95% of Total Billed Charges,3640,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3203.2,88,,35.704,Percent of Total Billed Charges,88% of Total Billed Charges,3276,90,,58.32,Percent of Total Billed charges,90% of Total Billed Charges,1605.24,3640,
OPTEASE RET VCF,2780002074,CDM,272,RC,C1773,HCPCS,Outpatient,,,3464.06,2251.64,,3464.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2632.69,76,,122.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2494.12,72,,408.96,Percent of Total Billed Charges,72% of Total Billed Charges,2598.05,75,,408.96,Percent of Total Billed charges,75% of Total Billed Charges,3464.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2494.12,72,,408.96,Percent of Total Billed Charges,72% of Total Billed Charges,2078.44,60,,340.8,Percent of Total Billed Charges,60% of Total Billed Charges,3117.65,90,,233.384,Percent of Total Billed Charges,90% of Total Billed Charges,1558.83,45,,15.88,Percent of Total Billed Charges,45% of Total Billed Charges,3117.65,90,,144.72,Percent of Total Billed Charges,90% of Total billed Charges,3464.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3464.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3464.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2251.64,65,,17.68,Percent of total Billed Charges,65% of Total Billed Charges,1527.65,44.1,,15.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,3290.86,95,,152.76,Percent of Total Billed Charges,95% of Total Billed Charges,3464.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3048.37,88,,45.024,Percent of Total Billed Charges,88% of Total Billed Charges,3117.65,90,,144.72,Percent of Total Billed charges,90% of Total Billed Charges,1527.65,3464.06,
TRAPEASE PERM VCF,2780002075,CDM,278,RC,C1880,HCPCS,Outpatient,,,2708.84,1760.75,,2708.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2058.72,76,,29.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1950.36,72,,408.96,Percent of Total Billed Charges,72% of Total Billed Charges,1950.36,72,,408.96,Percent of Total Billed charges,72% of Total Billed Charges,2708.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1950.36,72,,408.96,Percent of Total Billed Charges,72% of Total Billed Charges,1625.3,60,,340.8,Percent of Total Billed Charges,60% of Total Billed Charges,2437.96,90,,136.536,Percent of Total Billed Charges,90% of Total Billed Charges,1218.98,45,,18.256,Percent of Total Billed Charges,45% of Total Billed Charges,2437.96,90,,35.28,Percent of Total Billed Charges,90% of Total billed Charges,2708.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2708.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2708.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760.75,65,,153.648,Percent of total Billed Charges,65% of Total Billed Charges,1194.6,44.1,,17.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,2573.4,95,,37.24,Percent of Total Billed Charges,95% of Total Billed Charges,2708.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2383.78,88,,94.496,Percent of Total Billed Charges,88% of Total Billed Charges,2437.96,90,,35.28,Percent of Total Billed charges,90% of Total Billed Charges,1194.6,2708.84,
TULIP IVC FILTER JUGULAR,2780002076,CDM,278,RC,C1880,HCPCS,Outpatient,,,4365.90,2837.84,,4365.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3318.08,76,,122.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3143.45,72,,120.824,Percent of Total Billed Charges,72% of Total Billed Charges,3143.45,72,,120.824,Percent of Total Billed charges,72% of Total Billed Charges,4365.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3143.45,72,,120.824,Percent of Total Billed Charges,72% of Total Billed Charges,2619.54,60,,100.688,Percent of Total Billed Charges,60% of Total Billed Charges,3929.31,90,,136.536,Percent of Total Billed Charges,90% of Total Billed Charges,1964.66,45,,23.024,Percent of Total Billed Charges,45% of Total Billed Charges,3929.31,90,,144.72,Percent of Total Billed Charges,90% of Total billed Charges,4365.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4365.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4365.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2837.84,65,,108.352,Percent of total Billed Charges,65% of Total Billed Charges,1925.36,44.1,,22.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,4147.61,95,,152.76,Percent of Total Billed Charges,95% of Total Billed Charges,4365.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3841.99,88,,46.064,Percent of Total Billed Charges,88% of Total Billed Charges,3929.31,90,,144.72,Percent of Total Billed charges,90% of Total Billed Charges,1925.36,4365.9,
CELECT PLATNIUM JUG IVC FILTER,2780002077,CDM,278,RC,C1880,HCPCS,Outpatient,,,5005.00,3253.25,,5005,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3803.8,76,,26.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3603.6,72,,81.488,Percent of Total Billed Charges,72% of Total Billed Charges,3603.6,72,,81.488,Percent of Total Billed charges,72% of Total Billed Charges,5005,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3603.6,72,,81.488,Percent of Total Billed Charges,72% of Total Billed Charges,3003,60,,67.904,Percent of Total Billed Charges,60% of Total Billed Charges,4504.5,90,,113.512,Percent of Total Billed Charges,90% of Total Billed Charges,2252.25,45,,48.32,Percent of Total Billed Charges,45% of Total Billed Charges,4504.5,90,,31.752,Percent of Total Billed Charges,90% of Total billed Charges,5005,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5005,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5005,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3253.25,65,,6535.624,Percent of total Billed Charges,65% of Total Billed Charges,2207.21,44.1,,47.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,4754.75,95,,33.52,Percent of Total Billed Charges,95% of Total Billed Charges,5005,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4404.4,88,,35.904,Percent of Total Billed Charges,88% of Total Billed Charges,4504.5,90,,31.752,Percent of Total Billed charges,90% of Total Billed Charges,2207.21,5005,
CELECT PLATNIUM FEM IVC FILTER,2780002078,CDM,278,RC,C1880,HCPCS,Outpatient,,,5005.00,3253.25,,5005,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3803.8,76,,30.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3603.6,72,,22.248,Percent of Total Billed Charges,72% of Total Billed Charges,3603.6,72,,22.248,Percent of Total Billed charges,72% of Total Billed Charges,5005,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3603.6,72,,22.248,Percent of Total Billed Charges,72% of Total Billed Charges,3003,60,,18.544,Percent of Total Billed Charges,60% of Total Billed Charges,4504.5,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,2252.25,45,,23.552,Percent of Total Billed Charges,45% of Total Billed Charges,4504.5,90,,36.52,Percent of Total Billed Charges,90% of Total billed Charges,5005,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5005,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5005,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3253.25,65,,49.88,Percent of total Billed Charges,65% of Total Billed Charges,2207.21,44.1,,23.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,4754.75,95,,38.544,Percent of Total Billed Charges,95% of Total Billed Charges,5005,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4404.4,88,,0.352,Percent of Total Billed Charges,88% of Total Billed Charges,4504.5,90,,36.52,Percent of Total Billed charges,90% of Total Billed Charges,2207.21,5005,
BIV GEN DEVICE  MULTI LEAD,2780002079,CDM,278,RC,C1882,HCPCS,Outpatient,,,23483.25,15264.11,,23483.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17847.27,76,,38.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16907.94,72,,3056.832,Percent of Total Billed Charges,72% of Total Billed Charges,16907.94,72,,3056.832,Percent of Total Billed charges,72% of Total Billed Charges,23483.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16907.94,72,,3056.832,Percent of Total Billed Charges,72% of Total Billed Charges,14089.95,60,,2547.36,Percent of Total Billed Charges,60% of Total Billed Charges,21134.93,90,,13.496,Percent of Total Billed Charges,90% of Total Billed Charges,10567.46,45,,18.36,Percent of Total Billed Charges,45% of Total Billed Charges,21134.93,90,,46.048,Percent of Total Billed Charges,90% of Total billed Charges,23483.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23483.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23483.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15264.11,65,,4281.976,Percent of total Billed Charges,65% of Total Billed Charges,10356.11,44.1,,17.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,22309.09,95,,48.6,Percent of Total Billed Charges,95% of Total Billed Charges,23483.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20665.26,88,,228.192,Percent of Total Billed Charges,88% of Total Billed Charges,21134.93,90,,46.048,Percent of Total Billed charges,90% of Total Billed Charges,10356.11,23483.25,
RUNWAY GUIDE AL2,2780002080,CDM,278,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,81.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,172.592,Percent of Total Billed Charges,72% of Total Billed Charges,141.3,72,,172.592,Percent of Total Billed charges,72% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,172.592,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,143.824,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,133.36,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,0.184,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,96.648,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,3613.512,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,0.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,102.016,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,133.496,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,96.648,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
90CM STRAIGHT DESTIN,2780002081,CDM,272,RC,C1887,HCPCS,Outpatient,,,259.09,168.41,,259.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,196.91,76,,39.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,186.54,72,,1748.736,Percent of Total Billed Charges,72% of Total Billed Charges,194.32,75,,1748.736,Percent of Total Billed charges,75% of Total Billed Charges,259.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.54,72,,1748.736,Percent of Total Billed Charges,72% of Total Billed Charges,155.45,60,,1457.28,Percent of Total Billed Charges,60% of Total Billed Charges,233.18,90,,114.304,Percent of Total Billed Charges,90% of Total Billed Charges,116.59,45,,116.688,Percent of Total Billed Charges,45% of Total Billed Charges,233.18,90,,47.112,Percent of Total Billed Charges,90% of Total billed Charges,259.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.41,65,,439.72,Percent of total Billed Charges,65% of Total Billed Charges,114.26,44.1,,114.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,246.14,95,,49.728,Percent of Total Billed Charges,95% of Total Billed Charges,259.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228,88,,133.496,Percent of Total Billed Charges,88% of Total Billed Charges,233.18,90,,47.112,Percent of Total Billed charges,90% of Total Billed Charges,114.26,259.09,
RUNWAY GUIDE 6F AR2,2780002082,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,31.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,5316.48,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,5316.48,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,5316.48,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,4430.4,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,68.264,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,36.72,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,493.608,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,66.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,38.76,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,110.992,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,36.72,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
RUNWAY GUIDE 6F RCB,2780002083,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,0.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,439.488,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,439.488,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,439.488,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,366.24,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,557.208,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,68.264,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,0.36,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,678.216,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,66.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,0.384,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,0.36,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
RUNWAY GUIDE 6F FL4 SH,2780002084,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,197.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,2784.96,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,2784.96,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,2784.96,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,2320.8,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,163.584,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,56.76,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,233.384,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,2394.104,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,55.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,246.344,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,13.192,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,233.384,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
RUNWAY GUIDE 6F FR4 SH,2780002085,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,115.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,331.2,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,331.2,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,331.2,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,276,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,557.208,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,136.536,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,888.616,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,144.12,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,130.392,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,136.536,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
RUNWAY GUIDE 6F WRP,2780002086,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,115.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,3113.28,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,3113.28,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,3113.28,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,2594.4,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,163.584,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,6.744,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,136.536,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,1187.304,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,6.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,144.12,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,111.768,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,136.536,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
RUNWAY GUIDE FL 3.5,2780002087,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,95.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,331.2,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,331.2,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,331.2,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,276,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,163.584,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,66.68,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,113.512,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,3739.64,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,65.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,119.824,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,113.512,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
RUNWAY GUIDE FL4,2780002088,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,373.936,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,373.936,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,373.936,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,311.616,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,277.832,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,57.152,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,1569.36,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,56.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,544.824,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
RUNWAY GUIDE FL4.5,2780002089,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,11.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,331.2,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,331.2,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,331.2,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,276,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,81.256,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,13.496,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,964.6,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,14.24,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,159.952,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,13.496,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
RUNWAY GUIDE FL5,2780002090,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,112.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,712.048,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,712.048,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,712.048,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,593.376,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,14.352,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,278.608,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,133.36,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,293.28,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,273.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,140.768,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,544.824,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,133.36,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
RUNWAY GUIDE 6F IMA,2780002091,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,96.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,42.736,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,42.736,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,42.736,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,35.616,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,24.48,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,81.792,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,114.304,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,293.28,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,80.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,120.656,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,159.952,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,114.304,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
RUNWAY GUIDE 6F AL1,2780002092,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,169.344,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,169.344,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,169.344,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,141.12,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,212.736,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,278.608,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,293.28,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,273.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,159.952,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
RUNWAY GUIDE 6F AL2,2780002093,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,470.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,8.936,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,8.936,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,8.936,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,7.448,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,150.024,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,81.792,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,557.208,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,3055.52,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,80.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,588.168,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,271.656,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,557.208,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
RUNWAY GUIDE 6F LCB,2780002094,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,138.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,87.184,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,90.816,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,87.184,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,72.656,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,9049.32,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,81.792,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,163.584,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,4.88,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,80.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,172.672,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,79.448,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,163.584,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
RUNWAY GUIDE 6F FR3.0,2780002095,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,470.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,87.184,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,90.816,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,87.184,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,72.656,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,69.064,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,138.92,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,557.208,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,1857.496,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,136.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,588.168,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,14.032,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,557.208,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
RUNWAY GUIDE 6F FR3.5,2780002096,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,138.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,120.096,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,125.104,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,120.096,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,100.08,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,5928.888,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,40.624,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,163.584,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,1438.728,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,39.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,172.672,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,23.936,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,163.584,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
RUNWAY GUIDE 6F FR4,2780002097,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,138.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,70.848,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,70.848,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,70.848,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,59.04,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,5003.32,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,7.176,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,163.584,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,4843.168,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,7.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,172.672,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,208.008,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,163.584,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
RUNWAY GUIDE 5F FR5,2780002098,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,234.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,53.416,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,53.416,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,53.416,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,44.512,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,608.848,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,12.24,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,277.832,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,4278.448,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,11.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,293.272,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,146.696,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,277.832,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
RUNWAY GUIDE 6F AR1,2780002099,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,68.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,10.48,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,10.48,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,10.48,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,8.736,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,683.464,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,106.368,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,81.256,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,1547.928,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,104.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,85.768,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,8848.224,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,81.256,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
LAUNCHER EBU 6F 3.0 CATHETER,2780002100,CDM,272,RC,C1887,HCPCS,Outpatient,,,151.04,98.18,,151.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114.79,76,,12.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.75,72,,21.6,Percent of Total Billed Charges,72% of Total Billed Charges,113.28,75,,22.504,Percent of Total Billed charges,75% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.75,72,,21.6,Percent of Total Billed Charges,72% of Total Billed Charges,90.62,60,,18,Percent of Total Billed Charges,60% of Total Billed Charges,135.94,90,,939.064,Percent of Total Billed Charges,90% of Total Billed Charges,67.97,45,,75.016,Percent of Total Billed Charges,45% of Total Billed Charges,135.94,90,,14.352,Percent of Total Billed Charges,90% of Total billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.18,65,,1786.088,Percent of total Billed Charges,65% of Total Billed Charges,66.61,44.1,,73.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,143.49,95,,15.144,Percent of Total Billed Charges,95% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.92,88,,67.528,Percent of Total Billed Charges,88% of Total Billed Charges,135.94,90,,14.352,Percent of Total Billed charges,90% of Total Billed Charges,66.61,151.04,
LAUNCHER EBU 6F 3.5 CATHETER,2780002101,CDM,272,RC,C1887,HCPCS,Outpatient,,,151.04,98.18,,151.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114.79,76,,20.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.75,72,,6566.4,Percent of Total Billed Charges,72% of Total Billed Charges,113.28,75,,6566.4,Percent of Total Billed charges,75% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.75,72,,6566.4,Percent of Total Billed Charges,72% of Total Billed Charges,90.62,60,,5472,Percent of Total Billed Charges,60% of Total Billed Charges,135.94,90,,3314.912,Percent of Total Billed Charges,90% of Total Billed Charges,67.97,45,,4524.664,Percent of Total Billed Charges,45% of Total Billed Charges,135.94,90,,24.48,Percent of Total Billed Charges,90% of Total billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.18,65,,1547.928,Percent of total Billed Charges,65% of Total Billed Charges,66.61,44.1,,4434.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,143.49,95,,25.84,Percent of Total Billed Charges,95% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.92,88,,5797.136,Percent of Total Billed Charges,88% of Total Billed Charges,135.94,90,,24.48,Percent of Total Billed charges,90% of Total Billed Charges,66.61,151.04,
LAUNCHER EBU 6F 3.75 CATHETER,2780002102,CDM,272,RC,C1887,HCPCS,Outpatient,,,151.04,98.18,,151.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114.79,76,,179.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.75,72,,684,Percent of Total Billed Charges,72% of Total Billed Charges,113.28,75,,684,Percent of Total Billed charges,75% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.75,72,,684,Percent of Total Billed Charges,72% of Total Billed Charges,90.62,60,,570,Percent of Total Billed Charges,60% of Total Billed Charges,135.94,90,,1230.392,Percent of Total Billed Charges,90% of Total Billed Charges,67.97,45,,34.528,Percent of Total Billed Charges,45% of Total Billed Charges,135.94,90,,212.736,Percent of Total Billed Charges,90% of Total billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.18,65,,33.28,Percent of total Billed Charges,65% of Total Billed Charges,66.61,44.1,,33.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,143.49,95,,224.56,Percent of Total Billed Charges,95% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.92,88,,4892.136,Percent of Total Billed Charges,88% of Total Billed Charges,135.94,90,,212.736,Percent of Total Billed charges,90% of Total Billed Charges,66.61,151.04,
6FR EBU 3.75 SH GUIDE CATHETER,2780002103,CDM,272,RC,C1887,HCPCS,Outpatient,,,151.04,98.18,,151.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114.79,76,,126.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.75,72,,642.24,Percent of Total Billed Charges,72% of Total Billed Charges,113.28,75,,642.24,Percent of Total Billed charges,75% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.75,72,,642.24,Percent of Total Billed Charges,72% of Total Billed Charges,90.62,60,,535.2,Percent of Total Billed Charges,60% of Total Billed Charges,135.94,90,,1643.96,Percent of Total Billed Charges,90% of Total Billed Charges,67.97,45,,2964.448,Percent of Total Billed Charges,45% of Total Billed Charges,135.94,90,,150.024,Percent of Total Billed Charges,90% of Total billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.18,65,,33.28,Percent of total Billed Charges,65% of Total Billed Charges,66.61,44.1,,2905.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,143.49,95,,158.36,Percent of Total Billed Charges,95% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.92,88,,595.32,Percent of Total Billed Charges,88% of Total Billed Charges,135.94,90,,150.024,Percent of Total Billed charges,90% of Total Billed Charges,66.61,151.04,
VISTABRITE 6F XB 4 CATHETER,2780002104,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,7641.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,1163.52,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,1163.52,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,1163.52,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,969.6,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,5177.96,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,2501.664,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,9049.32,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,247.52,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,2451.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,9552.064,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,668.272,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,9049.32,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
VISTABRITE 6F XBRCA CATHETER,2780002105,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,58.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,1163.52,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,1163.52,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,1163.52,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,969.6,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,2172.96,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,304.424,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,69.064,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,34.84,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,298.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,72.896,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,918.2,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,69.064,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
VISTABRITE 6F XB3.0 CATHETER,2780002106,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,5006.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,339.952,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,339.952,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,339.952,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,283.296,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,1335.6,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,341.728,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,5928.888,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,2021.24,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,334.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,6258.272,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,3241.248,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,5928.888,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
VISTABRITE 6F XB 3.5 CATHETER,2780002107,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,4225.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,341.104,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,341.104,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,341.104,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,284.256,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,406.08,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,469.536,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,5003.32,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,3682.64,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,460.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,5281.288,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,1203.048,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,5003.32,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
LAUNCHER EBU 6F 4.0 CATHETER,2780002108,CDM,272,RC,C1887,HCPCS,Outpatient,,,151.04,98.18,,151.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114.79,76,,514.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.75,72,,339.952,Percent of Total Billed Charges,72% of Total Billed Charges,113.28,75,,339.952,Percent of Total Billed charges,75% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.75,72,,339.952,Percent of Total Billed Charges,72% of Total Billed Charges,90.62,60,,283.296,Percent of Total Billed Charges,60% of Total Billed Charges,135.94,90,,406.08,Percent of Total Billed Charges,90% of Total Billed Charges,67.97,45,,1657.456,Percent of Total Billed Charges,45% of Total Billed Charges,135.94,90,,608.848,Percent of Total Billed Charges,90% of Total billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.18,65,,365.04,Percent of total Billed Charges,65% of Total Billed Charges,66.61,44.1,,1624.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,143.49,95,,642.672,Percent of Total Billed Charges,95% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.92,88,,1607.432,Percent of Total Billed Charges,88% of Total Billed Charges,135.94,90,,608.848,Percent of Total Billed charges,90% of Total Billed Charges,66.61,151.04,
VISTABRITE EBU 6F 4.5 CATHETER,2780002109,CDM,272,RC,C1887,HCPCS,Outpatient,,,151.04,98.18,,151.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114.79,76,,577.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.75,72,,806.4,Percent of Total Billed Charges,72% of Total Billed Charges,113.28,75,,806.4,Percent of Total Billed charges,75% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.75,72,,806.4,Percent of Total Billed Charges,72% of Total Billed Charges,90.62,60,,672,Percent of Total Billed Charges,60% of Total Billed Charges,135.94,90,,406.08,Percent of Total Billed Charges,90% of Total Billed Charges,67.97,45,,615.2,Percent of Total Billed Charges,45% of Total Billed Charges,135.94,90,,683.464,Percent of Total Billed Charges,90% of Total billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.18,65,,159.64,Percent of total Billed Charges,65% of Total Billed Charges,66.61,44.1,,602.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,143.49,95,,721.432,Percent of Total Billed Charges,95% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.92,88,,5062.896,Percent of Total Billed Charges,88% of Total Billed Charges,135.94,90,,683.464,Percent of Total Billed charges,90% of Total Billed Charges,66.61,151.04,
RUNWAY GUIDE 6F FR4.5,2780002110,CDM,272,RC,C1887,HCPCS,Outpatient,,,370.44,240.79,,370.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,281.53,76,,792.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,266.72,72,,790.56,Percent of Total Billed Charges,72% of Total Billed Charges,277.83,75,,790.56,Percent of Total Billed charges,75% of Total Billed Charges,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.72,72,,790.56,Percent of Total Billed Charges,72% of Total Billed Charges,222.26,60,,658.8,Percent of Total Billed Charges,60% of Total Billed Charges,333.4,90,,4230.72,Percent of Total Billed Charges,90% of Total Billed Charges,166.7,45,,821.984,Percent of Total Billed Charges,45% of Total Billed Charges,333.4,90,,939.064,Percent of Total Billed Charges,90% of Total billed Charges,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.79,65,,923,Percent of total Billed Charges,65% of Total Billed Charges,163.36,44.1,,805.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,351.92,95,,991.24,Percent of Total Billed Charges,95% of Total Billed Charges,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.99,88,,2124.672,Percent of Total Billed Charges,88% of Total Billed Charges,333.4,90,,939.064,Percent of Total Billed charges,90% of Total Billed Charges,163.36,370.44,
RUNWAY GUIDE 6F FR6,2780002111,CDM,272,RC,C1887,HCPCS,Outpatient,,,370.44,240.79,,370.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,281.53,76,,2799.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,266.72,72,,790.56,Percent of Total Billed Charges,72% of Total Billed Charges,277.83,75,,790.56,Percent of Total Billed charges,75% of Total Billed Charges,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.72,72,,790.56,Percent of Total Billed Charges,72% of Total Billed Charges,222.26,60,,658.8,Percent of Total Billed Charges,60% of Total Billed Charges,333.4,90,,6.76,Percent of Total Billed Charges,90% of Total Billed Charges,166.7,45,,2588.976,Percent of Total Billed Charges,45% of Total Billed Charges,333.4,90,,3314.912,Percent of Total Billed Charges,90% of Total billed Charges,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.79,65,,923,Percent of total Billed Charges,65% of Total Billed Charges,163.36,44.1,,2537.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,351.92,95,,3499.072,Percent of Total Billed Charges,95% of Total Billed Charges,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.99,88,,1305.92,Percent of Total Billed Charges,88% of Total Billed Charges,333.4,90,,3314.912,Percent of Total Billed charges,90% of Total Billed Charges,163.36,370.44,
VISTABRITE 6F XB 4.5 CATHETER,2780002112,CDM,272,RC,C1887,HCPCS,Outpatient,,,196.25,127.56,,196.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,149.15,76,,1039,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,141.3,72,,2446.56,Percent of Total Billed Charges,72% of Total Billed Charges,147.19,75,,2446.56,Percent of Total Billed charges,75% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,72,,2446.56,Percent of Total Billed Charges,72% of Total Billed Charges,117.75,60,,2038.8,Percent of Total Billed Charges,60% of Total Billed Charges,176.63,90,,2571.912,Percent of Total Billed Charges,90% of Total Billed Charges,88.31,45,,1086.48,Percent of Total Billed Charges,45% of Total Billed Charges,176.63,90,,1230.392,Percent of Total Billed Charges,90% of Total billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.56,65,,923,Percent of total Billed Charges,65% of Total Billed Charges,86.55,44.1,,1064.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,186.44,95,,1298.752,Percent of Total Billed Charges,95% of Total Billed Charges,196.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.7,88,,397.056,Percent of Total Billed Charges,88% of Total Billed Charges,176.63,90,,1230.392,Percent of Total Billed charges,90% of Total Billed Charges,86.55,196.25,
IMPULSE 6F FR3.5 CATHETER,2780002113,CDM,272,RC,C1887,HCPCS,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,1388.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,228.816,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,228.816,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,228.816,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,190.68,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,68.4,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,667.8,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,1643.96,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,435.76,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,654.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,1735.296,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,397.056,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,1643.96,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
IMPULSE 6F FR4 CATHETER,2780002114,CDM,272,RC,C1887,HCPCS,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,4372.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,131.04,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,131.04,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,131.04,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,109.2,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,4782.24,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,203.04,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,5177.96,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,322.92,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,198.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,5465.624,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,397.056,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,5177.96,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
IMPULSE 5F FR5 CATHETER,2780002115,CDM,272,RC,C1887,HCPCS,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,1834.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,401.76,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,401.76,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,401.76,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,334.8,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,4000.32,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,203.04,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,2172.96,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,167.96,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,198.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,2293.68,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,4136.704,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,2172.96,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
IMPULSE 6F IM CATHETER,2780002116,CDM,272,RC,C1887,HCPCS,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,1127.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,387.36,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,387.36,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,387.36,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,322.8,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,219.6,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,203.04,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,1335.6,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,88.4,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,198.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,1409.8,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,6.608,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,1335.6,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
IMPULSE 6F FL3.5 CATHETER,2780002117,CDM,272,RC,C1887,HCPCS,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,342.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,387.36,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,387.36,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,387.36,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,322.8,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,549.36,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,2115.36,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,406.08,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,248.04,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,2073.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,428.64,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,2514.76,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,406.08,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
IMPULSE 6F FL4.5 CATHETER,2780002118,CDM,272,RC,C1887,HCPCS,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,342.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,1715.04,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,1715.04,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,1715.04,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,1429.2,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,219.6,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,3.384,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,406.08,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,1464.32,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,3.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,428.64,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,66.88,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,406.08,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
IMPULSE 6F FL5 CATHETER,2780002119,CDM,272,RC,C1887,HCPCS,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,342.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,8.744,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,8.744,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,8.744,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,7.288,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,1285.96,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,406.08,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,1417.52,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,1260.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,428.64,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,4675.968,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,406.08,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
IMPULSE 6F AR1 CATHETER,2780002120,CDM,272,RC,C1887,HCPCS,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,3572.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,9.904,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,9.904,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,9.904,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,8.256,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,34.2,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,4230.72,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,150.8,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,33.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,4465.76,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,3911.424,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,4230.72,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
IMPULSE 6F AR2 CATHETER,2780002121,CDM,272,RC,C1887,HCPCS,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,5.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,9.904,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,9.904,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,9.904,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,8.256,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,342.72,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,2391.12,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,6.76,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,150.8,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,2343.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,7.136,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,214.72,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,6.76,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
IMPULSE 6F AL1 CATHETER,2780002122,CDM,272,RC,C1887,HCPCS,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,2171.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,9.904,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,9.904,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,9.904,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,8.256,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,48.24,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,2000.16,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,2571.912,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,297.44,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,1960.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,2714.8,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,537.152,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,2571.912,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
IMPULSE 6F AL2 CATHETER,2780002123,CDM,272,RC,C1887,HCPCS,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,57.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,8.744,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,8.744,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,8.744,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,7.288,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,2798.64,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,109.8,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,68.4,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,1603.68,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,107.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,72.2,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,214.72,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,68.4,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
OPTITORQUE 5F IM R CATHETER,2780002124,CDM,278,RC,C1887,HCPCS,Outpatient,,,171.99,111.79,,171.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.71,76,,4038.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.83,72,,4,Percent of Total Billed Charges,72% of Total Billed Charges,123.83,72,,4,Percent of Total Billed charges,72% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.83,72,,4,Percent of Total Billed Charges,72% of Total Billed Charges,103.19,60,,3.336,Percent of Total Billed Charges,60% of Total Billed Charges,154.79,90,,5099.04,Percent of Total Billed Charges,90% of Total Billed Charges,77.4,45,,274.68,Percent of Total Billed Charges,45% of Total Billed Charges,154.79,90,,4782.24,Percent of Total Billed Charges,90% of Total billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.79,65,,352.56,Percent of total Billed Charges,65% of Total Billed Charges,75.85,44.1,,269.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.39,95,,5047.92,Percent of Total Billed Charges,95% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.35,88,,45.056,Percent of Total Billed Charges,88% of Total Billed Charges,154.79,90,,4782.24,Percent of Total Billed charges,90% of Total Billed Charges,75.85,171.99,
IMPULSE 6F MPA1 CATHETER,2780002125,CDM,272,RC,C1887,HCPCS,Outpatient,,,103.92,67.55,,103.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,78.98,76,,3378.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,74.82,72,,4,Percent of Total Billed Charges,72% of Total Billed Charges,77.94,75,,4,Percent of Total Billed charges,75% of Total Billed Charges,103.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.82,72,,4,Percent of Total Billed Charges,72% of Total Billed Charges,62.35,60,,3.336,Percent of Total Billed Charges,60% of Total Billed Charges,93.53,90,,505.44,Percent of Total Billed Charges,90% of Total Billed Charges,46.76,45,,109.8,Percent of Total Billed Charges,45% of Total Billed Charges,93.53,90,,4000.32,Percent of Total Billed Charges,90% of Total billed Charges,103.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.55,65,,1652.56,Percent of total Billed Charges,65% of Total Billed Charges,45.83,44.1,,107.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,98.72,95,,4222.56,Percent of Total Billed Charges,95% of Total Billed Charges,103.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.45,88,,45.056,Percent of Total Billed Charges,88% of Total Billed Charges,93.53,90,,4000.32,Percent of Total Billed charges,90% of Total Billed Charges,45.83,103.92,
IMPULSE 6F MPA2 SH CATHETER,2780002126,CDM,272,RC,C1887,HCPCS,Outpatient,,,103.92,67.55,,103.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,78.98,76,,185.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,74.82,72,,12.432,Percent of Total Billed Charges,72% of Total Billed Charges,77.94,75,,12.432,Percent of Total Billed charges,75% of Total Billed Charges,103.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.82,72,,12.432,Percent of Total Billed Charges,72% of Total Billed Charges,62.35,60,,10.36,Percent of Total Billed Charges,60% of Total Billed Charges,93.53,90,,221.04,Percent of Total Billed Charges,90% of Total Billed Charges,46.76,45,,23.04,Percent of Total Billed Charges,45% of Total Billed Charges,93.53,90,,219.6,Percent of Total Billed Charges,90% of Total billed Charges,103.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.55,65,,1829.88,Percent of total Billed Charges,65% of Total Billed Charges,45.83,44.1,,22.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,98.72,95,,231.8,Percent of Total Billed Charges,95% of Total Billed Charges,103.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.45,88,,335.104,Percent of Total Billed Charges,88% of Total Billed Charges,93.53,90,,219.6,Percent of Total Billed charges,90% of Total Billed Charges,45.83,103.92,
RUNWAY 6F AL3 GUIDE CATHETER,2780002127,CDM,272,RC,C1887,HCPCS,Outpatient,,,361.20,234.78,,361.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,274.51,76,,463.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,260.06,72,,4,Percent of Total Billed Charges,72% of Total Billed Charges,270.9,75,,4,Percent of Total Billed charges,75% of Total Billed Charges,361.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.06,72,,4,Percent of Total Billed Charges,72% of Total Billed Charges,216.72,60,,3.336,Percent of Total Billed Charges,60% of Total Billed Charges,325.08,90,,1278,Percent of Total Billed Charges,90% of Total Billed Charges,162.54,45,,23.04,Percent of Total Billed Charges,45% of Total Billed Charges,325.08,90,,549.36,Percent of Total Billed Charges,90% of Total billed Charges,361.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.78,65,,1826.24,Percent of total Billed Charges,65% of Total Billed Charges,159.29,44.1,,22.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,343.14,95,,579.88,Percent of Total Billed Charges,95% of Total Billed Charges,361.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,317.86,88,,47.168,Percent of Total Billed Charges,88% of Total Billed Charges,325.08,90,,549.36,Percent of Total Billed charges,90% of Total Billed Charges,159.29,361.2,
IMPULSE 5F AL3 CATHETER,2780002128,CDM,272,RC,C1887,HCPCS,Outpatient,,,50.57,32.87,,50.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38.43,76,,185.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36.41,72,,10.048,Percent of Total Billed Charges,72% of Total Billed Charges,37.93,75,,10.048,Percent of Total Billed charges,75% of Total Billed Charges,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.41,72,,10.048,Percent of Total Billed Charges,72% of Total Billed Charges,30.34,60,,8.376,Percent of Total Billed Charges,60% of Total Billed Charges,45.51,90,,1278,Percent of Total Billed Charges,90% of Total Billed Charges,22.76,45,,171.36,Percent of Total Billed Charges,45% of Total Billed Charges,45.51,90,,219.6,Percent of Total Billed Charges,90% of Total billed Charges,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.87,65,,1064.44,Percent of total Billed Charges,65% of Total Billed Charges,22.3,44.1,,167.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.04,95,,231.8,Percent of Total Billed Charges,95% of Total Billed Charges,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.5,88,,2736.448,Percent of Total Billed Charges,88% of Total Billed Charges,45.51,90,,219.6,Percent of Total Billed charges,90% of Total Billed Charges,22.3,50.57,
IMPULSE 6F AL3 CATHETER,2780002129,CDM,272,RC,C1887,HCPCS,Outpatient,,,50.57,32.87,,50.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38.43,76,,38.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36.41,72,,11.912,Percent of Total Billed Charges,72% of Total Billed Charges,37.93,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.41,72,,11.912,Percent of Total Billed Charges,72% of Total Billed Charges,30.34,60,,9.928,Percent of Total Billed Charges,60% of Total Billed Charges,45.51,90,,1278,Percent of Total Billed Charges,90% of Total Billed Charges,22.76,45,,24.12,Percent of Total Billed Charges,45% of Total Billed Charges,45.51,90,,46.08,Percent of Total Billed Charges,90% of Total billed Charges,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.87,65,,795.6,Percent of total Billed Charges,65% of Total Billed Charges,22.3,44.1,,23.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.04,95,,48.64,Percent of Total Billed Charges,95% of Total Billed Charges,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.5,88,,4985.728,Percent of Total Billed Charges,88% of Total Billed Charges,45.51,90,,46.08,Percent of Total Billed charges,90% of Total Billed Charges,22.3,50.57,
IMPULSE 6F FL6 CATHETER,2780002130,CDM,272,RC,C1887,HCPCS,Outpatient,,,50.57,32.87,,50.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38.43,76,,38.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36.41,72,,10.072,Percent of Total Billed Charges,72% of Total Billed Charges,37.93,75,,10.072,Percent of Total Billed charges,75% of Total Billed Charges,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.41,72,,10.072,Percent of Total Billed Charges,72% of Total Billed Charges,30.34,60,,8.392,Percent of Total Billed Charges,60% of Total Billed Charges,45.51,90,,603.36,Percent of Total Billed Charges,90% of Total Billed Charges,22.76,45,,1399.32,Percent of Total Billed Charges,45% of Total Billed Charges,45.51,90,,46.08,Percent of Total Billed Charges,90% of Total billed Charges,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.87,65,,957.84,Percent of total Billed Charges,65% of Total Billed Charges,22.3,44.1,,1371.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.04,95,,48.64,Percent of Total Billed Charges,95% of Total Billed Charges,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.5,88,,494.208,Percent of Total Billed Charges,88% of Total Billed Charges,45.51,90,,46.08,Percent of Total Billed charges,90% of Total Billed Charges,22.3,50.57,
IMPULSE 6F MULTIPACK (300),2780002131,CDM,272,RC,C1887,HCPCS,Outpatient,,,205.54,133.60,,205.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,156.21,76,,289.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,147.99,72,,10.072,Percent of Total Billed Charges,72% of Total Billed Charges,154.16,75,,10.072,Percent of Total Billed charges,75% of Total Billed Charges,205.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.99,72,,10.072,Percent of Total Billed Charges,72% of Total Billed Charges,123.32,60,,8.392,Percent of Total Billed Charges,60% of Total Billed Charges,184.99,90,,447.12,Percent of Total Billed Charges,90% of Total Billed Charges,92.49,45,,2549.52,Percent of Total Billed Charges,45% of Total Billed Charges,184.99,90,,342.72,Percent of Total Billed Charges,90% of Total billed Charges,205.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.6,65,,304.72,Percent of total Billed Charges,65% of Total Billed Charges,90.64,44.1,,2498.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,195.26,95,,361.76,Percent of Total Billed Charges,95% of Total Billed Charges,205.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.88,88,,216.128,Percent of Total Billed Charges,88% of Total Billed Charges,184.99,90,,342.72,Percent of Total Billed charges,90% of Total Billed Charges,90.64,205.54,
IMPULSE 6F MULTIPACK (301),2780002132,CDM,272,RC,C1887,HCPCS,Outpatient,,,205.54,133.60,,205.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,156.21,76,,40.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,147.99,72,,10.072,Percent of Total Billed Charges,72% of Total Billed Charges,154.16,75,,10.072,Percent of Total Billed charges,75% of Total Billed Charges,205.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.99,72,,10.072,Percent of Total Billed Charges,72% of Total Billed Charges,123.32,60,,8.392,Percent of Total Billed Charges,60% of Total Billed Charges,184.99,90,,232.56,Percent of Total Billed Charges,90% of Total Billed Charges,92.49,45,,252.72,Percent of Total Billed Charges,45% of Total Billed Charges,184.99,90,,48.24,Percent of Total Billed Charges,90% of Total billed Charges,205.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.6,65,,282.36,Percent of total Billed Charges,65% of Total Billed Charges,90.64,44.1,,247.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,195.26,95,,50.92,Percent of Total Billed Charges,95% of Total Billed Charges,205.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.88,88,,1249.6,Percent of Total Billed Charges,88% of Total Billed Charges,184.99,90,,48.24,Percent of Total Billed charges,90% of Total Billed Charges,90.64,205.54,
IMPULSE 6F W RIGHT CATHETER,2780002133,CDM,272,RC,C1887,HCPCS,Outpatient,,,68.51,44.53,,68.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.07,76,,2363.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49.33,72,,10.072,Percent of Total Billed Charges,72% of Total Billed Charges,51.38,75,,10.072,Percent of Total Billed charges,75% of Total Billed Charges,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.33,72,,10.072,Percent of Total Billed Charges,72% of Total Billed Charges,41.11,60,,8.392,Percent of Total Billed Charges,60% of Total Billed Charges,61.66,90,,122.4,Percent of Total Billed Charges,90% of Total Billed Charges,30.83,45,,110.52,Percent of Total Billed Charges,45% of Total Billed Charges,61.66,90,,2798.64,Percent of Total Billed Charges,90% of Total billed Charges,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.53,65,,293.28,Percent of total Billed Charges,65% of Total Billed Charges,30.21,44.1,,108.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.08,95,,2954.12,Percent of Total Billed Charges,95% of Total Billed Charges,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.29,88,,1249.6,Percent of Total Billed Charges,88% of Total Billed Charges,61.66,90,,2798.64,Percent of Total Billed charges,90% of Total Billed Charges,30.21,68.51,
IMPULSE 6F WRP CATHETER,2780002134,CDM,272,RC,C1887,HCPCS,Outpatient,,,68.51,44.53,,68.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.07,76,,4305.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49.33,72,,10.072,Percent of Total Billed Charges,72% of Total Billed Charges,51.38,75,,10.072,Percent of Total Billed charges,75% of Total Billed Charges,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.33,72,,10.072,Percent of Total Billed Charges,72% of Total Billed Charges,41.11,60,,8.392,Percent of Total Billed Charges,60% of Total Billed Charges,61.66,90,,343.44,Percent of Total Billed Charges,90% of Total Billed Charges,30.83,45,,639,Percent of Total Billed Charges,45% of Total Billed Charges,61.66,90,,5099.04,Percent of Total Billed Charges,90% of Total billed Charges,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.53,65,,3069.04,Percent of total Billed Charges,65% of Total Billed Charges,30.21,44.1,,626.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.08,95,,5382.32,Percent of Total Billed Charges,95% of Total Billed Charges,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.29,88,,1249.6,Percent of Total Billed Charges,88% of Total Billed Charges,61.66,90,,5099.04,Percent of Total Billed charges,90% of Total Billed Charges,30.21,68.51,
5F FL4 125CM IMPULSE CATHETER,2780002135,CDM,272,RC,C1887,HCPCS,Outpatient,,,68.51,44.53,,68.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.07,76,,426.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49.33,72,,11.912,Percent of Total Billed Charges,72% of Total Billed Charges,51.38,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.33,72,,11.912,Percent of Total Billed Charges,72% of Total Billed Charges,41.11,60,,9.928,Percent of Total Billed Charges,60% of Total Billed Charges,61.66,90,,2027.52,Percent of Total Billed Charges,90% of Total Billed Charges,30.83,45,,639,Percent of Total Billed Charges,45% of Total Billed Charges,61.66,90,,505.44,Percent of Total Billed Charges,90% of Total billed Charges,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.53,65,,703.56,Percent of total Billed Charges,65% of Total Billed Charges,30.21,44.1,,626.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.08,95,,533.52,Percent of Total Billed Charges,95% of Total Billed Charges,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.29,88,,589.952,Percent of Total Billed Charges,88% of Total Billed Charges,61.66,90,,505.44,Percent of Total Billed charges,90% of Total Billed Charges,30.21,68.51,
5F FL5 125CM IMPULSE CATHETER,2780002136,CDM,272,RC,C1887,HCPCS,Outpatient,,,68.51,44.53,,68.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.07,76,,186.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49.33,72,,294.584,Percent of Total Billed Charges,72% of Total Billed Charges,51.38,75,,294.584,Percent of Total Billed charges,75% of Total Billed Charges,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.33,72,,294.584,Percent of Total Billed Charges,72% of Total Billed Charges,41.11,60,,245.488,Percent of Total Billed Charges,60% of Total Billed Charges,61.66,90,,1962.72,Percent of Total Billed Charges,90% of Total Billed Charges,30.83,45,,639,Percent of Total Billed Charges,45% of Total Billed Charges,61.66,90,,221.04,Percent of Total Billed Charges,90% of Total billed Charges,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.53,65,,2759.64,Percent of total Billed Charges,65% of Total Billed Charges,30.21,44.1,,626.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.08,95,,233.32,Percent of Total Billed Charges,95% of Total Billed Charges,68.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.29,88,,437.184,Percent of Total Billed Charges,88% of Total Billed Charges,61.66,90,,221.04,Percent of Total Billed charges,90% of Total Billed Charges,30.21,68.51,
UNIVERSAL 4F 65CM CATHETER,2780002137,CDM,272,RC,C1887,HCPCS,Outpatient,,,31.40,20.41,,31.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.86,76,,1079.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.61,72,,188.112,Percent of Total Billed Charges,72% of Total Billed Charges,23.55,75,,188.112,Percent of Total Billed charges,75% of Total Billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.61,72,,188.112,Percent of Total Billed Charges,72% of Total Billed Charges,18.84,60,,156.76,Percent of Total Billed Charges,60% of Total Billed Charges,28.26,90,,208.8,Percent of Total Billed Charges,90% of Total Billed Charges,14.13,45,,301.68,Percent of Total Billed Charges,45% of Total Billed Charges,28.26,90,,1278,Percent of Total Billed Charges,90% of Total billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.41,65,,260,Percent of total Billed Charges,65% of Total Billed Charges,13.85,44.1,,295.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.83,95,,1349,Percent of Total Billed Charges,95% of Total Billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.63,88,,227.392,Percent of Total Billed Charges,88% of Total Billed Charges,28.26,90,,1278,Percent of Total Billed charges,90% of Total Billed Charges,13.85,31.4,
UNIVERSAL 4F 90CM CATHETER,2780002138,CDM,272,RC,C1887,HCPCS,Outpatient,,,31.40,20.41,,31.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.86,76,,1079.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.61,72,,159.944,Percent of Total Billed Charges,72% of Total Billed Charges,23.55,75,,159.944,Percent of Total Billed charges,75% of Total Billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.61,72,,159.944,Percent of Total Billed Charges,72% of Total Billed Charges,18.84,60,,133.288,Percent of Total Billed Charges,60% of Total Billed Charges,28.26,90,,208.8,Percent of Total Billed Charges,90% of Total Billed Charges,14.13,45,,223.56,Percent of Total Billed Charges,45% of Total Billed Charges,28.26,90,,1278,Percent of Total Billed Charges,90% of Total billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.41,65,,1875.64,Percent of total Billed Charges,65% of Total Billed Charges,13.85,44.1,,219.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.83,95,,1349,Percent of Total Billed Charges,95% of Total Billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.63,88,,119.68,Percent of Total Billed Charges,88% of Total Billed Charges,28.26,90,,1278,Percent of Total Billed charges,90% of Total Billed Charges,13.85,31.4,
UNIVERSAL 5F 90CM CATHETER,2780002139,CDM,272,RC,C1887,HCPCS,Outpatient,,,31.40,20.41,,31.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.86,76,,1079.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.61,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,23.55,75,,80.64,Percent of Total Billed charges,75% of Total Billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.61,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,18.84,60,,67.2,Percent of Total Billed Charges,60% of Total Billed Charges,28.26,90,,411.84,Percent of Total Billed Charges,90% of Total Billed Charges,14.13,45,,116.28,Percent of Total Billed Charges,45% of Total Billed Charges,28.26,90,,1278,Percent of Total Billed Charges,90% of Total billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.41,65,,1578.72,Percent of total Billed Charges,65% of Total Billed Charges,13.85,44.1,,113.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.83,95,,1349,Percent of Total Billed Charges,95% of Total Billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.63,88,,335.808,Percent of Total Billed Charges,88% of Total Billed Charges,28.26,90,,1278,Percent of Total Billed charges,90% of Total Billed Charges,13.85,31.4,
TEMPO SIM 1 4F CATHETER,2780002140,CDM,272,RC,C1887,HCPCS,Outpatient,,,31.40,20.41,,31.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.86,76,,509.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.61,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,23.55,75,,80.64,Percent of Total Billed charges,75% of Total Billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.61,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,18.84,60,,67.2,Percent of Total Billed Charges,60% of Total Billed Charges,28.26,90,,2220.48,Percent of Total Billed Charges,90% of Total Billed Charges,14.13,45,,61.2,Percent of Total Billed Charges,45% of Total Billed Charges,28.26,90,,603.36,Percent of Total Billed Charges,90% of Total billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.41,65,,2875.08,Percent of total Billed Charges,65% of Total Billed Charges,13.85,44.1,,59.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.83,95,,636.88,Percent of Total Billed Charges,95% of Total Billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.63,88,,1982.464,Percent of Total Billed Charges,88% of Total Billed Charges,28.26,90,,603.36,Percent of Total Billed charges,90% of Total Billed Charges,13.85,31.4,
TEMPO SIM 1 5F CATHETER,2780002141,CDM,272,RC,C1887,HCPCS,Outpatient,,,31.40,20.41,,31.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.86,76,,377.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.61,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,23.55,75,,80.64,Percent of Total Billed charges,75% of Total Billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.61,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,18.84,60,,67.2,Percent of Total Billed Charges,60% of Total Billed Charges,28.26,90,,488.16,Percent of Total Billed Charges,90% of Total Billed Charges,14.13,45,,171.72,Percent of Total Billed Charges,45% of Total Billed Charges,28.26,90,,447.12,Percent of Total Billed Charges,90% of Total billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.41,65,,965.64,Percent of total Billed Charges,65% of Total Billed Charges,13.85,44.1,,168.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.83,95,,471.96,Percent of Total Billed Charges,95% of Total Billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.63,88,,1919.104,Percent of Total Billed Charges,88% of Total Billed Charges,28.26,90,,447.12,Percent of Total Billed charges,90% of Total Billed Charges,13.85,31.4,
TEMPO SIM 2 4F CATHETER,2780002142,CDM,272,RC,C1887,HCPCS,Outpatient,,,31.40,20.41,,31.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.86,76,,196.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.61,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,23.55,75,,80.64,Percent of Total Billed charges,75% of Total Billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.61,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,18.84,60,,67.2,Percent of Total Billed Charges,60% of Total Billed Charges,28.26,90,,2288.16,Percent of Total Billed Charges,90% of Total Billed Charges,14.13,45,,1013.76,Percent of Total Billed Charges,45% of Total Billed Charges,28.26,90,,232.56,Percent of Total Billed Charges,90% of Total billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.41,65,,514.8,Percent of total Billed Charges,65% of Total Billed Charges,13.85,44.1,,993.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.83,95,,245.48,Percent of Total Billed Charges,95% of Total Billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.63,88,,204.16,Percent of Total Billed Charges,88% of Total Billed Charges,28.26,90,,232.56,Percent of Total Billed charges,90% of Total Billed Charges,13.85,31.4,
TEMPO RC3 5F (RIM) CATHETER,2780002143,CDM,272,RC,C1887,HCPCS,Outpatient,,,31.40,20.41,,31.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.86,76,,103.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.61,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,23.55,75,,80.64,Percent of Total Billed charges,75% of Total Billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.61,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,18.84,60,,67.2,Percent of Total Billed Charges,60% of Total Billed Charges,28.26,90,,2533.68,Percent of Total Billed Charges,90% of Total Billed Charges,14.13,45,,981.36,Percent of Total Billed Charges,45% of Total Billed Charges,28.26,90,,122.4,Percent of Total Billed Charges,90% of Total billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.41,65,,313.04,Percent of total Billed Charges,65% of Total Billed Charges,13.85,44.1,,961.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.83,95,,129.2,Percent of Total Billed Charges,95% of Total Billed Charges,31.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.63,88,,204.16,Percent of Total Billed Charges,88% of Total Billed Charges,28.26,90,,122.4,Percent of Total Billed charges,90% of Total Billed Charges,13.85,31.4,
IMPULSE 5F MPA (SH) CATHETER,2780002144,CDM,272,RC,C1887,HCPCS,Outpatient,,,705.60,458.64,,705.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,536.26,76,,290.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,508.03,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,529.2,75,,80.64,Percent of Total Billed charges,75% of Total Billed Charges,705.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.03,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,423.36,60,,67.2,Percent of Total Billed Charges,60% of Total Billed Charges,635.04,90,,2528.64,Percent of Total Billed Charges,90% of Total Billed Charges,317.52,45,,104.4,Percent of Total Billed Charges,45% of Total Billed Charges,635.04,90,,343.44,Percent of Total Billed Charges,90% of Total billed Charges,705.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,705.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,705.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,458.64,65,,248.04,Percent of total Billed Charges,65% of Total Billed Charges,311.17,44.1,,102.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,670.32,95,,362.52,Percent of Total Billed Charges,95% of Total Billed Charges,705.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,620.93,88,,402.688,Percent of Total Billed Charges,88% of Total Billed Charges,635.04,90,,343.44,Percent of Total Billed charges,90% of Total Billed Charges,311.17,705.6,
IMPULSE 5F FL5 CATHETER,2780002145,CDM,272,RC,C1887,HCPCS,Outpatient,,,705.60,458.64,,705.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,536.26,76,,1712.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,508.03,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,529.2,75,,80.64,Percent of Total Billed charges,75% of Total Billed Charges,705.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.03,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,423.36,60,,67.2,Percent of Total Billed Charges,60% of Total Billed Charges,635.04,90,,1473.84,Percent of Total Billed Charges,90% of Total Billed Charges,317.52,45,,104.4,Percent of Total Billed Charges,45% of Total Billed Charges,635.04,90,,2027.52,Percent of Total Billed Charges,90% of Total billed Charges,705.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,705.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,705.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,458.64,65,,230.88,Percent of total Billed Charges,65% of Total Billed Charges,311.17,44.1,,102.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,670.32,95,,2140.16,Percent of Total Billed Charges,95% of Total Billed Charges,705.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,620.93,88,,2171.136,Percent of Total Billed Charges,88% of Total Billed Charges,635.04,90,,2027.52,Percent of Total Billed charges,90% of Total Billed Charges,311.17,705.6,
COBRA 2 65CM CATHETER,2780002146,CDM,278,RC,C1887,HCPCS,Outpatient,,,294.00,191.10,,294,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,223.44,76,,1657.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,211.68,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,211.68,72,,80.64,Percent of Total Billed charges,72% of Total Billed Charges,294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.68,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,176.4,60,,67.2,Percent of Total Billed Charges,60% of Total Billed Charges,264.6,90,,1101.6,Percent of Total Billed Charges,90% of Total Billed Charges,132.3,45,,205.92,Percent of Total Billed Charges,45% of Total Billed Charges,264.6,90,,1962.72,Percent of Total Billed Charges,90% of Total billed Charges,294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.1,65,,352.56,Percent of total Billed Charges,65% of Total Billed Charges,129.65,44.1,,201.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,279.3,95,,2071.76,Percent of Total Billed Charges,95% of Total Billed Charges,294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258.72,88,,477.312,Percent of Total Billed Charges,88% of Total Billed Charges,264.6,90,,1962.72,Percent of Total Billed charges,90% of Total Billed Charges,129.65,294,
COBRA 2 100CM CATHETER,2780002147,CDM,278,RC,C1887,HCPCS,Outpatient,,,294.00,191.10,,294,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,223.44,76,,176.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,211.68,72,,131.76,Percent of Total Billed Charges,72% of Total Billed Charges,211.68,72,,131.76,Percent of Total Billed charges,72% of Total Billed Charges,294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.68,72,,131.76,Percent of Total Billed Charges,72% of Total Billed Charges,176.4,60,,109.8,Percent of Total Billed Charges,60% of Total Billed Charges,264.6,90,,1326.24,Percent of Total Billed Charges,90% of Total Billed Charges,132.3,45,,1110.24,Percent of Total Billed Charges,45% of Total Billed Charges,264.6,90,,208.8,Percent of Total Billed Charges,90% of Total billed Charges,294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.1,65,,980.2,Percent of total Billed Charges,65% of Total Billed Charges,129.65,44.1,,1088.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,279.3,95,,220.4,Percent of Total Billed Charges,95% of Total Billed Charges,294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258.72,88,,2237.312,Percent of Total Billed Charges,88% of Total Billed Charges,264.6,90,,208.8,Percent of Total Billed charges,90% of Total Billed Charges,129.65,294,
5F FR4 125CM IMPULSE CATHETER,2780002148,CDM,272,RC,C1887,HCPCS,Outpatient,,,64.00,41.60,,64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,48.64,76,,176.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.08,72,,126.216,Percent of Total Billed Charges,72% of Total Billed Charges,48,75,,126.216,Percent of Total Billed charges,75% of Total Billed Charges,64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.08,72,,126.216,Percent of Total Billed Charges,72% of Total Billed Charges,38.4,60,,105.184,Percent of Total Billed Charges,60% of Total Billed Charges,57.6,90,,421.92,Percent of Total Billed Charges,90% of Total Billed Charges,28.8,45,,244.08,Percent of Total Billed Charges,45% of Total Billed Charges,57.6,90,,208.8,Percent of Total Billed Charges,90% of Total billed Charges,64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.6,65,,352.56,Percent of total Billed Charges,65% of Total Billed Charges,28.22,44.1,,239.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,60.8,95,,220.4,Percent of Total Billed Charges,95% of Total Billed Charges,64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.32,88,,2477.376,Percent of Total Billed Charges,88% of Total Billed Charges,57.6,90,,208.8,Percent of Total Billed charges,90% of Total Billed Charges,28.22,64,
COOK CONE TIP CATH,2780002149,CDM,278,RC,C1892,HCPCS,Outpatient,,,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,347.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,131.76,Percent of Total Billed Charges,72% of Total Billed Charges,15.08,72,,131.76,Percent of Total Billed charges,72% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,131.76,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,109.8,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,390.96,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,1144.08,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,411.84,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,3759.08,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,1121.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,434.72,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,2472.448,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,411.84,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
COOK DILATOR SHEATH 8/10,2780002150,CDM,278,RC,C1892,HCPCS,Outpatient,,,91.51,59.48,,91.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,69.55,76,,1875.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.89,72,,76.32,Percent of Total Billed Charges,72% of Total Billed Charges,65.89,72,,76.32,Percent of Total Billed charges,72% of Total Billed Charges,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.89,72,,76.32,Percent of Total Billed Charges,72% of Total Billed Charges,54.91,60,,63.6,Percent of Total Billed Charges,60% of Total Billed Charges,82.36,90,,406.08,Percent of Total Billed Charges,90% of Total Billed Charges,41.18,45,,1266.84,Percent of Total Billed Charges,45% of Total Billed Charges,82.36,90,,2220.48,Percent of Total Billed Charges,90% of Total billed Charges,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.48,65,,760.76,Percent of total Billed Charges,65% of Total Billed Charges,40.36,44.1,,1241.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,86.93,95,,2343.84,Percent of Total Billed Charges,95% of Total Billed Charges,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.53,88,,1441.088,Percent of Total Billed Charges,88% of Total Billed Charges,82.36,90,,2220.48,Percent of Total Billed charges,90% of Total Billed Charges,40.36,91.51,
BS URETERAL SHEATH 11/28,2780002151,CDM,278,RC,C1892,HCPCS,Outpatient,,,135.61,88.15,,135.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,103.06,76,,412.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,97.64,72,,76.32,Percent of Total Billed Charges,72% of Total Billed Charges,97.64,72,,76.32,Percent of Total Billed charges,72% of Total Billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.64,72,,76.32,Percent of Total Billed Charges,72% of Total Billed Charges,81.37,60,,63.6,Percent of Total Billed Charges,60% of Total Billed Charges,122.05,90,,4249.44,Percent of Total Billed Charges,90% of Total Billed Charges,61.02,45,,1264.32,Percent of Total Billed Charges,45% of Total Billed Charges,122.05,90,,488.16,Percent of Total Billed Charges,90% of Total billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.15,65,,352.56,Percent of total Billed Charges,65% of Total Billed Charges,59.8,44.1,,1239.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,128.83,95,,515.28,Percent of Total Billed Charges,95% of Total Billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.34,88,,1077.12,Percent of Total Billed Charges,88% of Total Billed Charges,122.05,90,,488.16,Percent of Total Billed charges,90% of Total Billed Charges,59.8,135.61,
BS URETERAL SHEATH 11/36,2780002152,CDM,278,RC,C1892,HCPCS,Outpatient,,,135.61,88.15,,135.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,103.06,76,,1932.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,97.64,72,,76.32,Percent of Total Billed Charges,72% of Total Billed Charges,97.64,72,,76.32,Percent of Total Billed charges,72% of Total Billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.64,72,,76.32,Percent of Total Billed Charges,72% of Total Billed Charges,81.37,60,,63.6,Percent of Total Billed Charges,60% of Total Billed Charges,122.05,90,,974.16,Percent of Total Billed Charges,90% of Total Billed Charges,61.02,45,,736.92,Percent of Total Billed Charges,45% of Total Billed Charges,122.05,90,,2288.16,Percent of Total Billed Charges,90% of Total billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.15,65,,176.28,Percent of total Billed Charges,65% of Total Billed Charges,59.8,44.1,,722.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,128.83,95,,2415.28,Percent of Total Billed Charges,95% of Total Billed Charges,135.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.34,88,,1296.768,Percent of Total Billed Charges,88% of Total Billed Charges,122.05,90,,2288.16,Percent of Total Billed charges,90% of Total Billed Charges,59.8,135.61,
5F COOK MP SOFT,2780002153,CDM,272,RC,C1894,HCPCS,Outpatient,,,6266.61,4073.30,,6266.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4762.62,76,,2139.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4511.96,72,,76.32,Percent of Total Billed Charges,72% of Total Billed Charges,4699.96,75,,76.32,Percent of Total Billed charges,75% of Total Billed Charges,6266.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4511.96,72,,76.32,Percent of Total Billed Charges,72% of Total Billed Charges,3759.97,60,,63.6,Percent of Total Billed Charges,60% of Total Billed Charges,5639.95,90,,3821.04,Percent of Total Billed Charges,90% of Total Billed Charges,2819.97,45,,550.8,Percent of Total Billed Charges,45% of Total Billed Charges,5639.95,90,,2533.68,Percent of Total Billed Charges,90% of Total billed Charges,6266.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6266.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6266.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4073.3,65,,352.56,Percent of total Billed Charges,65% of Total Billed Charges,2763.58,44.1,,539.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,5953.28,95,,2674.44,Percent of Total Billed Charges,95% of Total Billed Charges,6266.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5514.62,88,,412.544,Percent of Total Billed Charges,88% of Total Billed Charges,5639.95,90,,2533.68,Percent of Total Billed charges,90% of Total Billed Charges,2763.58,6266.61,
4F COOK MP STIFF,2780002154,CDM,272,RC,C1894,HCPCS,Outpatient,,,6266.61,4073.30,,6266.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4762.62,76,,2135.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4511.96,72,,76.32,Percent of Total Billed Charges,72% of Total Billed Charges,4699.96,75,,76.32,Percent of Total Billed charges,75% of Total Billed Charges,6266.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4511.96,72,,76.32,Percent of Total Billed Charges,72% of Total Billed Charges,3759.97,60,,63.6,Percent of Total Billed Charges,60% of Total Billed Charges,5639.95,90,,360,Percent of Total Billed Charges,90% of Total Billed Charges,2819.97,45,,663.12,Percent of Total Billed Charges,45% of Total Billed Charges,5639.95,90,,2528.64,Percent of Total Billed Charges,90% of Total billed Charges,6266.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6266.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6266.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4073.3,65,,92.56,Percent of total Billed Charges,65% of Total Billed Charges,2763.58,44.1,,649.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,5953.28,95,,2669.12,Percent of Total Billed Charges,95% of Total Billed Charges,6266.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5514.62,88,,382.272,Percent of Total Billed Charges,88% of Total Billed Charges,5639.95,90,,2528.64,Percent of Total Billed charges,90% of Total Billed Charges,2763.58,6266.61,
5F COOK MP STIFF,2780002155,CDM,272,RC,C1894,HCPCS,Outpatient,,,644.96,419.22,,644.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,490.17,76,,1244.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,464.37,72,,76.32,Percent of Total Billed Charges,72% of Total Billed Charges,483.72,75,,76.32,Percent of Total Billed charges,75% of Total Billed Charges,644.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,464.37,72,,76.32,Percent of Total Billed Charges,72% of Total Billed Charges,386.98,60,,63.6,Percent of Total Billed Charges,60% of Total Billed Charges,580.46,90,,2597.04,Percent of Total Billed Charges,90% of Total Billed Charges,290.23,45,,210.96,Percent of Total Billed Charges,45% of Total Billed Charges,580.46,90,,1473.84,Percent of Total Billed Charges,90% of Total billed Charges,644.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,644.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,644.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.22,65,,369.2,Percent of total Billed Charges,65% of Total Billed Charges,284.43,44.1,,206.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,612.71,95,,1555.72,Percent of Total Billed Charges,95% of Total Billed Charges,644.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,567.56,88,,397.056,Percent of Total Billed Charges,88% of Total Billed Charges,580.46,90,,1473.84,Percent of Total Billed charges,90% of Total Billed Charges,284.43,644.96,
5F MERIT MP SOFT,2780002156,CDM,272,RC,C1894,HCPCS,Outpatient,,,2540.16,1651.10,,2540.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1930.52,76,,930.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1828.92,72,,76.32,Percent of Total Billed Charges,72% of Total Billed Charges,1905.12,75,,76.32,Percent of Total Billed charges,75% of Total Billed Charges,2540.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1828.92,72,,76.32,Percent of Total Billed Charges,72% of Total Billed Charges,1524.1,60,,63.6,Percent of Total Billed Charges,60% of Total Billed Charges,2286.14,90,,2185.92,Percent of Total Billed Charges,90% of Total Billed Charges,1143.07,45,,195.48,Percent of Total Billed Charges,45% of Total Billed Charges,2286.14,90,,1101.6,Percent of Total Billed Charges,90% of Total billed Charges,2540.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2540.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2540.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1651.1,65,,7898.8,Percent of total Billed Charges,65% of Total Billed Charges,1120.21,44.1,,191.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,2413.15,95,,1162.8,Percent of Total Billed Charges,95% of Total Billed Charges,2540.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.34,88,,4155.008,Percent of Total Billed Charges,88% of Total Billed Charges,2286.14,90,,1101.6,Percent of Total Billed charges,90% of Total Billed Charges,1120.21,2540.16,
4F MERIT MP SOFT,2780002157,CDM,272,RC,C1894,HCPCS,Outpatient,,,2540.16,1651.10,,2540.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1930.52,76,,1119.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1828.92,72,,230.4,Percent of Total Billed Charges,72% of Total Billed Charges,1905.12,75,,230.4,Percent of Total Billed charges,75% of Total Billed Charges,2540.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1828.92,72,,230.4,Percent of Total Billed Charges,72% of Total Billed Charges,1524.1,60,,192,Percent of Total Billed Charges,60% of Total Billed Charges,2286.14,90,,3980.88,Percent of Total Billed Charges,90% of Total Billed Charges,1143.07,45,,203.04,Percent of Total Billed Charges,45% of Total Billed Charges,2286.14,90,,1326.24,Percent of Total Billed Charges,90% of Total billed Charges,2540.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2540.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2540.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1651.1,65,,92.56,Percent of total Billed Charges,65% of Total Billed Charges,1120.21,44.1,,198.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,2413.15,95,,1399.92,Percent of Total Billed Charges,95% of Total Billed Charges,2540.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.34,88,,952.512,Percent of Total Billed Charges,88% of Total Billed Charges,2286.14,90,,1326.24,Percent of Total Billed charges,90% of Total Billed Charges,1120.21,2540.16,
4F MERIT MP STIFF,2780002158,CDM,272,RC,C1894,HCPCS,Outpatient,,,4354.88,2830.67,,4354.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3309.71,76,,356.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3135.51,72,,220.32,Percent of Total Billed Charges,72% of Total Billed Charges,3266.16,75,,220.32,Percent of Total Billed charges,75% of Total Billed Charges,4354.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.51,72,,220.32,Percent of Total Billed Charges,72% of Total Billed Charges,2612.93,60,,183.6,Percent of Total Billed Charges,60% of Total Billed Charges,3919.39,90,,1337.04,Percent of Total Billed Charges,90% of Total Billed Charges,1959.7,45,,2124.72,Percent of Total Billed Charges,45% of Total Billed Charges,3919.39,90,,421.92,Percent of Total Billed Charges,90% of Total billed Charges,4354.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4354.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4354.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2830.67,65,,158.6,Percent of total Billed Charges,65% of Total Billed Charges,1920.5,44.1,,2082.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,4137.14,95,,445.36,Percent of Total Billed Charges,95% of Total Billed Charges,4354.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3832.29,88,,3736.128,Percent of Total Billed Charges,88% of Total Billed Charges,3919.39,90,,421.92,Percent of Total Billed charges,90% of Total Billed Charges,1920.5,4354.88,
5F MERIT MP STIFF,2780002159,CDM,278,RC,C1894,HCPCS,Outpatient,,,4354.88,2830.67,,4354.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3309.71,76,,330.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3135.51,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,3135.51,72,,51.84,Percent of Total Billed charges,72% of Total Billed Charges,4354.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.51,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,2612.93,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,3919.39,90,,712.8,Percent of Total Billed Charges,90% of Total Billed Charges,1959.7,45,,487.08,Percent of Total Billed Charges,45% of Total Billed Charges,3919.39,90,,390.96,Percent of Total Billed Charges,90% of Total billed Charges,4354.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4354.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4354.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2830.67,65,,92.56,Percent of total Billed Charges,65% of Total Billed Charges,1920.5,44.1,,477.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,4137.14,95,,412.68,Percent of Total Billed Charges,95% of Total Billed Charges,4354.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3832.29,88,,352,Percent of Total Billed Charges,88% of Total Billed Charges,3919.39,90,,390.96,Percent of Total Billed charges,90% of Total Billed Charges,1920.5,4354.88,
TURBOJECT 4F PICC INTRO SHEATH,2780002160,CDM,278,RC,C1894,HCPCS,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,342.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,81.392,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,81.392,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,81.392,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,67.824,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,433.44,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,1910.52,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,406.08,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,7898.8,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,1872.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,428.64,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,2539.328,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,406.08,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
TURBOJECT 3F PICC INTRO SHEATH,2780002161,CDM,278,RC,C1894,HCPCS,Outpatient,,,146.00,94.90,,146,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.96,76,,3588.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,105.12,72,,74.16,Percent of Total Billed Charges,72% of Total Billed Charges,105.12,72,,74.16,Percent of Total Billed charges,72% of Total Billed Charges,146,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.12,72,,74.16,Percent of Total Billed Charges,72% of Total Billed Charges,87.6,60,,61.8,Percent of Total Billed Charges,60% of Total Billed Charges,131.4,90,,343.44,Percent of Total Billed Charges,90% of Total Billed Charges,65.7,45,,180,Percent of Total Billed Charges,45% of Total Billed Charges,131.4,90,,4249.44,Percent of Total Billed Charges,90% of Total billed Charges,146,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.9,65,,92.56,Percent of total Billed Charges,65% of Total Billed Charges,64.39,44.1,,176.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,138.7,95,,4485.52,Percent of Total Billed Charges,95% of Total Billed Charges,146,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.48,88,,2137.344,Percent of Total Billed Charges,88% of Total Billed Charges,131.4,90,,4249.44,Percent of Total Billed charges,90% of Total Billed Charges,64.39,146,
LEAD CARDIOVERTERD,2780002162,CDM,278,RC,C1895,HCPCS,Outpatient,,,3435.39,2233.00,,3435.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2610.9,76,,822.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2473.48,72,,62.64,Percent of Total Billed Charges,72% of Total Billed Charges,2473.48,72,,62.64,Percent of Total Billed charges,72% of Total Billed Charges,3435.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2473.48,72,,62.64,Percent of Total Billed Charges,72% of Total Billed Charges,2061.23,60,,52.2,Percent of Total Billed Charges,60% of Total Billed Charges,3091.85,90,,319.68,Percent of Total Billed Charges,90% of Total Billed Charges,1545.93,45,,1298.52,Percent of Total Billed Charges,45% of Total Billed Charges,3091.85,90,,974.16,Percent of Total Billed Charges,90% of Total billed Charges,3435.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3435.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3435.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2233,65,,2097.16,Percent of total Billed Charges,65% of Total Billed Charges,1515.01,44.1,,1272.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,3263.62,95,,1028.28,Percent of Total Billed Charges,95% of Total Billed Charges,3435.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3023.14,88,,3892.416,Percent of Total Billed Charges,88% of Total Billed Charges,3091.85,90,,974.16,Percent of Total Billed charges,90% of Total Billed Charges,1515.01,3435.39,
LEAD CARIODEFIB OT,2780002163,CDM,278,RC,C1896,HCPCS,Outpatient,,,3435.39,2233.00,,3435.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2610.9,76,,3226.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2473.48,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,2473.48,72,,51.84,Percent of Total Billed charges,72% of Total Billed Charges,3435.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2473.48,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,2061.23,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,3091.85,90,,488.16,Percent of Total Billed Charges,90% of Total Billed Charges,1545.93,45,,1092.96,Percent of Total Billed Charges,45% of Total Billed Charges,3091.85,90,,3821.04,Percent of Total Billed Charges,90% of Total billed Charges,3435.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3435.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3435.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2233,65,,92.56,Percent of total Billed Charges,65% of Total Billed Charges,1515.01,44.1,,1071.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,3263.62,95,,4033.32,Percent of Total Billed Charges,95% of Total Billed Charges,3435.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3023.14,88,,1307.328,Percent of Total Billed Charges,88% of Total Billed Charges,3091.85,90,,3821.04,Percent of Total Billed charges,90% of Total Billed Charges,1515.01,3435.39,
LEAD PACEMAKR OTHR,2780002164,CDM,278,RC,C1898,HCPCS,Outpatient,,,2666.95,1733.52,,2666.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2026.88,76,,304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1920.2,72,,62.64,Percent of Total Billed Charges,72% of Total Billed Charges,1920.2,72,,62.64,Percent of Total Billed charges,72% of Total Billed Charges,2666.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1920.2,72,,62.64,Percent of Total Billed Charges,72% of Total Billed Charges,1600.17,60,,52.2,Percent of Total Billed Charges,60% of Total Billed Charges,2400.26,90,,1357.2,Percent of Total Billed Charges,90% of Total Billed Charges,1200.13,45,,1990.44,Percent of Total Billed Charges,45% of Total Billed Charges,2400.26,90,,360,Percent of Total Billed Charges,90% of Total billed Charges,2666.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2666.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2666.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1733.52,65,,369.2,Percent of total Billed Charges,65% of Total Billed Charges,1176.12,44.1,,1950.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,2533.6,95,,380,Percent of Total Billed Charges,95% of Total Billed Charges,2666.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2346.92,88,,696.96,Percent of Total Billed Charges,88% of Total Billed Charges,2400.26,90,,360,Percent of Total Billed charges,90% of Total Billed Charges,1176.12,2666.95,
LEAD PACEMAKR/AICD,2780002165,CDM,278,RC,C1899,HCPCS,Outpatient,,,2808.07,1825.25,,2808.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2134.13,76,,2193.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2021.81,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,2021.81,72,,51.84,Percent of Total Billed charges,72% of Total Billed Charges,2808.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2021.81,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,1684.84,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,2527.26,90,,488.16,Percent of Total Billed Charges,90% of Total Billed Charges,1263.63,45,,668.52,Percent of Total Billed Charges,45% of Total Billed Charges,2527.26,90,,2597.04,Percent of Total Billed Charges,90% of Total billed Charges,2808.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2808.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2808.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1825.25,65,,369.2,Percent of total Billed Charges,65% of Total Billed Charges,1238.36,44.1,,655.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,2667.67,95,,2741.32,Percent of Total Billed Charges,95% of Total Billed Charges,2808.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2471.1,88,,423.808,Percent of Total Billed Charges,88% of Total Billed Charges,2527.26,90,,2597.04,Percent of Total Billed charges,90% of Total Billed Charges,1238.36,2808.07,
PERCUFLEX PLUS STENT 6 X 20,2780002166,CDM,278,RC,C2617,HCPCS,Outpatient,,,576.61,374.80,,576.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,438.22,76,,1845.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.16,72,,74.16,Percent of Total Billed Charges,72% of Total Billed Charges,415.16,72,,74.16,Percent of Total Billed charges,72% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.16,72,,74.16,Percent of Total Billed Charges,72% of Total Billed Charges,345.97,60,,61.8,Percent of Total Billed Charges,60% of Total Billed Charges,518.95,90,,5204.88,Percent of Total Billed Charges,90% of Total Billed Charges,259.47,45,,356.4,Percent of Total Billed Charges,45% of Total Billed Charges,518.95,90,,2185.92,Percent of Total Billed Charges,90% of Total billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.8,65,,109.072,Percent of total Billed Charges,65% of Total Billed Charges,254.29,44.1,,349.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,547.78,95,,2307.36,Percent of Total Billed Charges,95% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.42,88,,335.808,Percent of Total Billed Charges,88% of Total Billed Charges,518.95,90,,2185.92,Percent of Total Billed charges,90% of Total Billed Charges,254.29,576.61,
PERCUFLEX PLUS STENT 7 X 20,2780002167,CDM,278,RC,C2617,HCPCS,Outpatient,,,576.61,374.80,,576.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,438.22,76,,3361.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.16,72,,81.392,Percent of Total Billed Charges,72% of Total Billed Charges,415.16,72,,81.392,Percent of Total Billed charges,72% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.16,72,,81.392,Percent of Total Billed Charges,72% of Total Billed Charges,345.97,60,,67.824,Percent of Total Billed Charges,60% of Total Billed Charges,518.95,90,,1053.36,Percent of Total Billed Charges,90% of Total Billed Charges,259.47,45,,216.72,Percent of Total Billed Charges,45% of Total Billed Charges,518.95,90,,3980.88,Percent of Total Billed Charges,90% of Total billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.8,65,,73.568,Percent of total Billed Charges,65% of Total Billed Charges,254.29,44.1,,212.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,547.78,95,,4202.04,Percent of Total Billed Charges,95% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.42,88,,312.576,Percent of Total Billed Charges,88% of Total Billed Charges,518.95,90,,3980.88,Percent of Total Billed charges,90% of Total Billed Charges,254.29,576.61,
PERCUFLEX PLUS STENT 7 X 22,2780002168,CDM,278,RC,C2617,HCPCS,Outpatient,,,576.61,374.80,,576.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,438.22,76,,1129.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.16,72,,81.36,Percent of Total Billed Charges,72% of Total Billed Charges,415.16,72,,81.36,Percent of Total Billed charges,72% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.16,72,,81.36,Percent of Total Billed Charges,72% of Total Billed Charges,345.97,60,,67.8,Percent of Total Billed Charges,60% of Total Billed Charges,518.95,90,,488.16,Percent of Total Billed Charges,90% of Total Billed Charges,259.47,45,,171.72,Percent of Total Billed Charges,45% of Total Billed Charges,518.95,90,,1337.04,Percent of Total Billed Charges,90% of Total billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.8,65,,20.088,Percent of total Billed Charges,65% of Total Billed Charges,254.29,44.1,,168.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,547.78,95,,1411.32,Percent of Total Billed Charges,95% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.42,88,,477.312,Percent of Total Billed Charges,88% of Total Billed Charges,518.95,90,,1337.04,Percent of Total Billed charges,90% of Total Billed Charges,254.29,576.61,
PERCUFLEX PLUS STENT 7 X 24,2780002169,CDM,278,RC,C2617,HCPCS,Outpatient,,,576.61,374.80,,576.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,438.22,76,,601.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.16,72,,81.36,Percent of Total Billed Charges,72% of Total Billed Charges,415.16,72,,81.36,Percent of Total Billed charges,72% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.16,72,,81.36,Percent of Total Billed Charges,72% of Total Billed Charges,345.97,60,,67.8,Percent of Total Billed Charges,60% of Total Billed Charges,518.95,90,,244.08,Percent of Total Billed Charges,90% of Total Billed Charges,259.47,45,,159.84,Percent of Total Billed Charges,45% of Total Billed Charges,518.95,90,,712.8,Percent of Total Billed Charges,90% of Total billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.8,65,,2759.64,Percent of total Billed Charges,65% of Total Billed Charges,254.29,44.1,,156.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,547.78,95,,752.4,Percent of Total Billed Charges,95% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.42,88,,1327.04,Percent of Total Billed Charges,88% of Total Billed Charges,518.95,90,,712.8,Percent of Total Billed charges,90% of Total Billed Charges,254.29,576.61,
PERCUFLEX PLUS STENT 7 X 26,2780002170,CDM,278,RC,C2617,HCPCS,Outpatient,,,576.61,374.80,,576.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,438.22,76,,366.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.16,72,,68.04,Percent of Total Billed Charges,72% of Total Billed Charges,415.16,72,,68.04,Percent of Total Billed charges,72% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.16,72,,68.04,Percent of Total Billed Charges,72% of Total Billed Charges,345.97,60,,56.704,Percent of Total Billed Charges,60% of Total Billed Charges,518.95,90,,488.16,Percent of Total Billed Charges,90% of Total Billed Charges,259.47,45,,244.08,Percent of Total Billed Charges,45% of Total Billed Charges,518.95,90,,433.44,Percent of Total Billed Charges,90% of Total billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.8,65,,155.816,Percent of total Billed Charges,65% of Total Billed Charges,254.29,44.1,,239.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,547.78,95,,457.52,Percent of Total Billed Charges,95% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.42,88,,477.312,Percent of Total Billed Charges,88% of Total Billed Charges,518.95,90,,433.44,Percent of Total Billed charges,90% of Total Billed Charges,254.29,576.61,
PERCUFLEX PLUS STENT 7 X 28,2780002171,CDM,278,RC,C2617,HCPCS,Outpatient,,,576.61,374.80,,576.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,438.22,76,,290.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.16,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,415.16,72,,51.84,Percent of Total Billed charges,72% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.16,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,345.97,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,518.95,90,,128.16,Percent of Total Billed Charges,90% of Total Billed Charges,259.47,45,,678.6,Percent of Total Billed Charges,45% of Total Billed Charges,518.95,90,,343.44,Percent of Total Billed Charges,90% of Total billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.8,65,,1578.72,Percent of total Billed Charges,65% of Total Billed Charges,254.29,44.1,,665.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,547.78,95,,362.52,Percent of Total Billed Charges,95% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.42,88,,5089.216,Percent of Total Billed Charges,88% of Total Billed Charges,518.95,90,,343.44,Percent of Total Billed charges,90% of Total Billed Charges,254.29,576.61,
PERCUFLEX PLUS STENT 7 X 30,2780002172,CDM,278,RC,C2617,HCPCS,Outpatient,,,576.61,374.80,,576.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,438.22,76,,269.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.16,72,,293.76,Percent of Total Billed Charges,72% of Total Billed Charges,415.16,72,,293.76,Percent of Total Billed charges,72% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.16,72,,293.76,Percent of Total Billed Charges,72% of Total Billed Charges,345.97,60,,244.8,Percent of Total Billed Charges,60% of Total Billed Charges,518.95,90,,511.2,Percent of Total Billed Charges,90% of Total Billed Charges,259.47,45,,244.08,Percent of Total Billed Charges,45% of Total Billed Charges,518.95,90,,319.68,Percent of Total Billed Charges,90% of Total billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.8,65,,4799.6,Percent of total Billed Charges,65% of Total Billed Charges,254.29,44.1,,239.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,547.78,95,,337.44,Percent of Total Billed Charges,95% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.42,88,,1029.952,Percent of Total Billed Charges,88% of Total Billed Charges,518.95,90,,319.68,Percent of Total Billed charges,90% of Total Billed Charges,254.29,576.61,
PERCUFLEX PLUS STENT 8 X 20,2780002173,CDM,278,RC,C2617,HCPCS,Outpatient,,,576.61,374.80,,576.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,438.22,76,,412.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.16,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,415.16,72,,57.6,Percent of Total Billed charges,72% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.16,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,345.97,60,,48,Percent of Total Billed Charges,60% of Total Billed Charges,518.95,90,,10936.8,Percent of Total Billed Charges,90% of Total Billed Charges,259.47,45,,2602.44,Percent of Total Billed Charges,45% of Total Billed Charges,518.95,90,,488.16,Percent of Total Billed Charges,90% of Total billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.8,65,,396.76,Percent of total Billed Charges,65% of Total Billed Charges,254.29,44.1,,2550.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,547.78,95,,515.28,Percent of Total Billed Charges,95% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.42,88,,477.312,Percent of Total Billed Charges,88% of Total Billed Charges,518.95,90,,488.16,Percent of Total Billed charges,90% of Total Billed Charges,254.29,576.61,
PERCUFLEX PLUS STENT 8 X 22,2780002174,CDM,278,RC,C2617,HCPCS,Outpatient,,,576.61,374.80,,576.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,438.22,76,,1146.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.16,72,,62.096,Percent of Total Billed Charges,72% of Total Billed Charges,415.16,72,,62.096,Percent of Total Billed charges,72% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.16,72,,62.096,Percent of Total Billed Charges,72% of Total Billed Charges,345.97,60,,51.744,Percent of Total Billed Charges,60% of Total Billed Charges,518.95,90,,128.16,Percent of Total Billed Charges,90% of Total Billed Charges,259.47,45,,526.68,Percent of Total Billed Charges,45% of Total Billed Charges,518.95,90,,1357.2,Percent of Total Billed Charges,90% of Total billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.8,65,,2514.2,Percent of total Billed Charges,65% of Total Billed Charges,254.29,44.1,,516.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,547.78,95,,1432.6,Percent of Total Billed Charges,95% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.42,88,,238.656,Percent of Total Billed Charges,88% of Total Billed Charges,518.95,90,,1357.2,Percent of Total Billed charges,90% of Total Billed Charges,254.29,576.61,
PERCUFLEX PLUS STENT 8 X 24,2780002175,CDM,278,RC,C2617,HCPCS,Outpatient,,,576.61,374.80,,576.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,438.22,76,,412.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.16,72,,62.096,Percent of Total Billed Charges,72% of Total Billed Charges,415.16,72,,62.096,Percent of Total Billed charges,72% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.16,72,,62.096,Percent of Total Billed Charges,72% of Total Billed Charges,345.97,60,,51.744,Percent of Total Billed Charges,60% of Total Billed Charges,518.95,90,,219.6,Percent of Total Billed Charges,90% of Total Billed Charges,259.47,45,,244.08,Percent of Total Billed Charges,45% of Total Billed Charges,518.95,90,,488.16,Percent of Total Billed Charges,90% of Total billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.8,65,,299,Percent of total Billed Charges,65% of Total Billed Charges,254.29,44.1,,239.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,547.78,95,,515.28,Percent of Total Billed Charges,95% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.42,88,,477.312,Percent of Total Billed Charges,88% of Total Billed Charges,518.95,90,,488.16,Percent of Total Billed charges,90% of Total Billed Charges,254.29,576.61,
PERCUFLEX PLUS STENT 8 X 26,2780002176,CDM,278,RC,C2617,HCPCS,Outpatient,,,576.61,374.80,,576.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,438.22,76,,4395.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.16,72,,62.096,Percent of Total Billed Charges,72% of Total Billed Charges,415.16,72,,62.096,Percent of Total Billed charges,72% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.16,72,,62.096,Percent of Total Billed Charges,72% of Total Billed Charges,345.97,60,,51.744,Percent of Total Billed Charges,60% of Total Billed Charges,518.95,90,,128.16,Percent of Total Billed Charges,90% of Total Billed Charges,259.47,45,,122.04,Percent of Total Billed Charges,45% of Total Billed Charges,518.95,90,,5204.88,Percent of Total Billed Charges,90% of Total billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.8,65,,2810.6,Percent of total Billed Charges,65% of Total Billed Charges,254.29,44.1,,119.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,547.78,95,,5494.04,Percent of Total Billed Charges,95% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.42,88,,125.312,Percent of Total Billed Charges,88% of Total Billed Charges,518.95,90,,5204.88,Percent of Total Billed charges,90% of Total Billed Charges,254.29,576.61,
PERCUFLEX PLUS STENT 8 X 28,2780002177,CDM,278,RC,C2617,HCPCS,Outpatient,,,576.61,374.80,,576.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,438.22,76,,889.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.16,72,,62.096,Percent of Total Billed Charges,72% of Total Billed Charges,415.16,72,,62.096,Percent of Total Billed charges,72% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.16,72,,62.096,Percent of Total Billed Charges,72% of Total Billed Charges,345.97,60,,51.744,Percent of Total Billed Charges,60% of Total Billed Charges,518.95,90,,10936.8,Percent of Total Billed Charges,90% of Total Billed Charges,259.47,45,,244.08,Percent of Total Billed Charges,45% of Total Billed Charges,518.95,90,,1053.36,Percent of Total Billed Charges,90% of Total billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.8,65,,299,Percent of total Billed Charges,65% of Total Billed Charges,254.29,44.1,,239.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,547.78,95,,1111.88,Percent of Total Billed Charges,95% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.42,88,,499.84,Percent of Total Billed Charges,88% of Total Billed Charges,518.95,90,,1053.36,Percent of Total Billed charges,90% of Total Billed Charges,254.29,576.61,
PERCUFLEX PLUS STENT 8 X 30,2780002178,CDM,278,RC,C2617,HCPCS,Outpatient,,,576.61,374.80,,576.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,438.22,76,,412.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.16,72,,62.096,Percent of Total Billed Charges,72% of Total Billed Charges,415.16,72,,62.096,Percent of Total Billed charges,72% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.16,72,,62.096,Percent of Total Billed Charges,72% of Total Billed Charges,345.97,60,,51.744,Percent of Total Billed Charges,60% of Total Billed Charges,518.95,90,,128.16,Percent of Total Billed Charges,90% of Total Billed Charges,259.47,45,,64.08,Percent of Total Billed Charges,45% of Total Billed Charges,518.95,90,,488.16,Percent of Total Billed Charges,90% of Total billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.8,65,,337.584,Percent of total Billed Charges,65% of Total Billed Charges,254.29,44.1,,62.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,547.78,95,,515.28,Percent of Total Billed Charges,95% of Total Billed Charges,576.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.42,88,,10693.76,Percent of Total Billed Charges,88% of Total Billed Charges,518.95,90,,488.16,Percent of Total Billed charges,90% of Total Billed Charges,254.29,576.61,
TRAN Z GRAFT TPD,2780002179,CDM,278,RC,L8610,HCPCS,Outpatient,,,1156.52,751.74,,1156.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,878.96,76,,206.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,832.69,72,,89.28,Percent of Total Billed Charges,72% of Total Billed Charges,832.69,72,,89.28,Percent of Total Billed charges,72% of Total Billed Charges,1156.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,832.69,72,,89.28,Percent of Total Billed Charges,72% of Total Billed Charges,693.91,60,,74.4,Percent of Total Billed Charges,60% of Total Billed Charges,1040.87,90,,2903.76,Percent of Total Billed Charges,90% of Total Billed Charges,520.43,45,,255.6,Percent of Total Billed Charges,45% of Total Billed Charges,1040.87,90,,244.08,Percent of Total Billed Charges,90% of Total billed Charges,1156.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1156.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1156.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,751.74,65,,299,Percent of total Billed Charges,65% of Total Billed Charges,510.03,44.1,,250.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,1098.69,95,,257.64,Percent of Total Billed Charges,95% of Total Billed Charges,1156.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1017.74,88,,125.312,Percent of Total Billed Charges,88% of Total Billed Charges,1040.87,90,,244.08,Percent of Total Billed charges,90% of Total Billed Charges,510.03,1156.52,
ISTENT INJECT IMPLANT,2780002180,CDM,278,RC,L8612,HCPCS,Outpatient,,,3816.00,2480.40,,3816,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2900.16,76,,412.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2747.52,72,,88.92,Percent of Total Billed Charges,72% of Total Billed Charges,2747.52,72,,88.92,Percent of Total Billed charges,72% of Total Billed Charges,3816,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2747.52,72,,88.92,Percent of Total Billed Charges,72% of Total Billed Charges,2289.6,60,,74.104,Percent of Total Billed Charges,60% of Total Billed Charges,3434.4,90,,128.16,Percent of Total Billed Charges,90% of Total Billed Charges,1717.2,45,,5468.4,Percent of Total Billed Charges,45% of Total Billed Charges,3434.4,90,,488.16,Percent of Total Billed Charges,90% of Total billed Charges,3816,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3816,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3816,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2480.4,65,,642.824,Percent of total Billed Charges,65% of Total Billed Charges,1682.86,44.1,,5359.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,3625.2,95,,515.28,Percent of Total Billed Charges,95% of Total Billed Charges,3816,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3358.08,88,,214.72,Percent of Total Billed Charges,88% of Total Billed Charges,3434.4,90,,488.16,Percent of Total Billed charges,90% of Total Billed Charges,1682.86,3816,
Z59645010 ART SURF,2780002181,CDM,278,RC,,,Outpatient,,,6295.28,4091.93,,6295.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4784.41,76,,108.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4532.6,72,,71.536,Percent of Total Billed Charges,72% of Total Billed Charges,4532.6,72,,71.536,Percent of Total Billed charges,72% of Total Billed Charges,6295.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4532.6,72,,71.536,Percent of Total Billed Charges,72% of Total Billed Charges,3777.17,60,,59.616,Percent of Total Billed Charges,60% of Total Billed Charges,5665.75,90,,511.2,Percent of Total Billed Charges,90% of Total Billed Charges,2832.88,45,,64.08,Percent of Total Billed Charges,45% of Total Billed Charges,5665.75,90,,128.16,Percent of Total Billed Charges,90% of Total billed Charges,6295.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6295.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6295.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4091.93,65,,38.584,Percent of total Billed Charges,65% of Total Billed Charges,2776.22,44.1,,62.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,5980.52,95,,135.28,Percent of Total Billed Charges,95% of Total Billed Charges,6295.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5539.85,88,,125.312,Percent of Total Billed Charges,88% of Total Billed Charges,5665.75,90,,128.16,Percent of Total Billed charges,90% of Total Billed Charges,2776.22,6295.28,
ANASTOCLIP LARGE,2780002182,CDM,278,RC,,,Outpatient,,,1463.02,950.96,,1463.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1111.9,76,,431.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1053.37,72,,81.36,Percent of Total Billed Charges,72% of Total Billed Charges,1053.37,72,,81.36,Percent of Total Billed charges,72% of Total Billed Charges,1463.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.37,72,,81.36,Percent of Total Billed Charges,72% of Total Billed Charges,877.81,60,,67.8,Percent of Total Billed Charges,60% of Total Billed Charges,1316.72,90,,511.2,Percent of Total Billed Charges,90% of Total Billed Charges,658.36,45,,109.8,Percent of Total Billed Charges,45% of Total Billed Charges,1316.72,90,,511.2,Percent of Total Billed Charges,90% of Total billed Charges,1463.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1463.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1463.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,950.96,65,,152.88,Percent of total Billed Charges,65% of Total Billed Charges,645.19,44.1,,107.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,1389.87,95,,539.6,Percent of Total Billed Charges,95% of Total Billed Charges,1463.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1287.46,88,,10693.76,Percent of Total Billed Charges,88% of Total Billed Charges,1316.72,90,,511.2,Percent of Total Billed charges,90% of Total Billed Charges,645.19,1463.02,
ANASTOCLIP MEDIUM,2780002183,CDM,278,RC,,,Outpatient,,,1463.02,950.96,,1463.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1111.9,76,,9235.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1053.37,72,,89.28,Percent of Total Billed Charges,72% of Total Billed Charges,1053.37,72,,89.28,Percent of Total Billed charges,72% of Total Billed Charges,1463.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.37,72,,89.28,Percent of Total Billed Charges,72% of Total Billed Charges,877.81,60,,74.4,Percent of Total Billed Charges,60% of Total Billed Charges,1316.72,90,,151.024,Percent of Total Billed Charges,90% of Total Billed Charges,658.36,45,,64.08,Percent of Total Billed Charges,45% of Total Billed Charges,1316.72,90,,10936.8,Percent of Total Billed Charges,90% of Total billed Charges,1463.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1463.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1463.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,950.96,65,,8.072,Percent of total Billed Charges,65% of Total Billed Charges,645.19,44.1,,62.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,1389.87,95,,11544.4,Percent of Total Billed Charges,95% of Total Billed Charges,1463.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1287.46,88,,125.312,Percent of Total Billed Charges,88% of Total Billed Charges,1316.72,90,,10936.8,Percent of Total Billed charges,90% of Total Billed Charges,645.19,1463.02,
OATS GRAFT,2780002184,CDM,278,RC,,,Outpatient,,,3392.39,2205.05,,3392.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2578.22,76,,108.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2442.52,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,2442.52,72,,57.6,Percent of Total Billed charges,72% of Total Billed Charges,3392.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2442.52,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,2035.43,60,,48,Percent of Total Billed Charges,60% of Total Billed Charges,3053.15,90,,101.856,Percent of Total Billed Charges,90% of Total Billed Charges,1526.58,45,,5468.4,Percent of Total Billed Charges,45% of Total Billed Charges,3053.15,90,,128.16,Percent of Total Billed Charges,90% of Total billed Charges,3392.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3392.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2205.05,65,,63.96,Percent of total Billed Charges,65% of Total Billed Charges,1496.04,44.1,,5359.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,3222.77,95,,135.28,Percent of Total Billed Charges,95% of Total Billed Charges,3392.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2985.3,88,,2839.232,Percent of Total Billed Charges,88% of Total Billed Charges,3053.15,90,,128.16,Percent of Total Billed charges,90% of Total Billed Charges,1496.04,3392.39,
GAMMA GRAFT,2780002185,CDM,278,RC,,,Outpatient,,,880.90,572.59,,880.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,669.48,76,,185.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,634.25,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,634.25,72,,57.6,Percent of Total Billed charges,72% of Total Billed Charges,880.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,634.25,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,528.54,60,,48,Percent of Total Billed Charges,60% of Total Billed Charges,792.81,90,,27.816,Percent of Total Billed Charges,90% of Total Billed Charges,396.41,45,,64.08,Percent of Total Billed Charges,45% of Total Billed Charges,792.81,90,,219.6,Percent of Total Billed Charges,90% of Total billed Charges,880.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,880.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,880.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,572.59,65,,48.216,Percent of total Billed Charges,65% of Total Billed Charges,388.48,44.1,,62.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,836.86,95,,231.8,Percent of Total Billed Charges,95% of Total Billed Charges,880.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,775.19,88,,125.312,Percent of Total Billed Charges,88% of Total Billed Charges,792.81,90,,219.6,Percent of Total Billed charges,90% of Total Billed Charges,388.48,880.9,
METALLIC STENT,2780002186,CDM,278,RC,,,Outpatient,,,4500.41,2925.27,,4500.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3420.31,76,,108.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3240.3,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,3240.3,72,,57.6,Percent of Total Billed charges,72% of Total Billed Charges,4500.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3240.3,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,2700.25,60,,48,Percent of Total Billed Charges,60% of Total Billed Charges,4050.37,90,,3821.04,Percent of Total Billed Charges,90% of Total Billed Charges,2025.18,45,,1451.88,Percent of Total Billed Charges,45% of Total Billed Charges,4050.37,90,,128.16,Percent of Total Billed Charges,90% of Total billed Charges,4500.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4500.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4500.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2925.27,65,,9.464,Percent of total Billed Charges,65% of Total Billed Charges,1984.68,44.1,,1422.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,4275.39,95,,135.28,Percent of Total Billed Charges,95% of Total Billed Charges,4500.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3960.36,88,,499.84,Percent of Total Billed Charges,88% of Total Billed Charges,4050.37,90,,128.16,Percent of Total Billed charges,90% of Total Billed Charges,1984.68,4500.41,
BONE TENDON GRAFT,2780002187,CDM,278,RC,,,Outpatient,,,10801.19,7020.77,,10801.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8208.9,76,,9235.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7776.86,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,7776.86,72,,57.6,Percent of Total Billed charges,72% of Total Billed Charges,10801.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7776.86,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,6480.71,60,,48,Percent of Total Billed Charges,60% of Total Billed Charges,9721.07,90,,215.744,Percent of Total Billed Charges,90% of Total Billed Charges,4860.54,45,,64.08,Percent of Total Billed Charges,45% of Total Billed Charges,9721.07,90,,10936.8,Percent of Total Billed Charges,90% of Total billed Charges,10801.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10801.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10801.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7020.77,65,,19.504,Percent of total Billed Charges,65% of Total Billed Charges,4763.32,44.1,,62.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,10261.13,95,,11544.4,Percent of Total Billed Charges,95% of Total Billed Charges,10801.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9505.05,88,,499.84,Percent of Total Billed Charges,88% of Total Billed Charges,9721.07,90,,10936.8,Percent of Total Billed charges,90% of Total Billed Charges,4763.32,10801.19,
CAPSLR TNSION RNG 10MM,2780002188,CDM,278,RC,,,Outpatient,,,852.23,553.95,,852.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,647.69,76,,108.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,613.61,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,613.61,72,,57.6,Percent of Total Billed charges,72% of Total Billed Charges,852.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,613.61,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,511.34,60,,48,Percent of Total Billed Charges,60% of Total Billed Charges,767.01,90,,2185.92,Percent of Total Billed Charges,90% of Total Billed Charges,383.5,45,,255.6,Percent of Total Billed Charges,45% of Total Billed Charges,767.01,90,,128.16,Percent of Total Billed Charges,90% of Total billed Charges,852.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,852.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,852.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,553.95,65,,5928,Percent of total Billed Charges,65% of Total Billed Charges,375.83,44.1,,250.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,809.62,95,,135.28,Percent of Total Billed Charges,95% of Total Billed Charges,852.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,749.96,88,,147.672,Percent of Total Billed Charges,88% of Total Billed Charges,767.01,90,,128.16,Percent of Total Billed charges,90% of Total Billed Charges,375.83,852.23,
PARHAM BAND,2780002189,CDM,278,RC,,,Outpatient,,,83.79,54.46,,83.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,63.68,76,,2452.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,60.33,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,60.33,72,,57.6,Percent of Total Billed charges,72% of Total Billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.33,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,50.27,60,,48,Percent of Total Billed Charges,60% of Total Billed Charges,75.41,90,,6645.6,Percent of Total Billed Charges,90% of Total Billed Charges,37.71,45,,255.6,Percent of Total Billed Charges,45% of Total Billed Charges,75.41,90,,2903.76,Percent of Total Billed Charges,90% of Total billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.46,65,,617.504,Percent of total Billed Charges,65% of Total Billed Charges,36.95,44.1,,250.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,79.6,95,,3065.08,Percent of Total Billed Charges,95% of Total Billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.74,88,,99.592,Percent of Total Billed Charges,88% of Total Billed Charges,75.41,90,,2903.76,Percent of Total Billed charges,90% of Total Billed Charges,36.95,83.79,
RESTORE ORTHO SFT TI,2780002190,CDM,278,RC,,,Outpatient,,,5154.19,3350.22,,5154.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3917.18,76,,108.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3711.02,72,,289.44,Percent of Total Billed Charges,72% of Total Billed Charges,3711.02,72,,289.44,Percent of Total Billed charges,72% of Total Billed Charges,5154.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3711.02,72,,289.44,Percent of Total Billed Charges,72% of Total Billed Charges,3092.51,60,,241.2,Percent of Total Billed Charges,60% of Total Billed Charges,4638.77,90,,549.36,Percent of Total Billed Charges,90% of Total Billed Charges,2319.39,45,,75.512,Percent of Total Billed Charges,45% of Total Billed Charges,4638.77,90,,128.16,Percent of Total Billed Charges,90% of Total billed Charges,5154.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5154.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5154.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3350.22,65,,579.8,Percent of total Billed Charges,65% of Total Billed Charges,2273,44.1,,74,Percent of Total Billed Charges,44.1% of Total Billed Charges,4896.48,95,,135.28,Percent of Total Billed Charges,95% of Total Billed Charges,5154.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4535.69,88,,27.192,Percent of Total Billed Charges,88% of Total Billed Charges,4638.77,90,,128.16,Percent of Total Billed charges,90% of Total Billed Charges,2273,5154.19,
PROTACK,2780002191,CDM,278,RC,,,Outpatient,,,1185.19,770.37,,1185.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,900.74,76,,431.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,853.34,72,,347.04,Percent of Total Billed Charges,72% of Total Billed Charges,853.34,72,,347.04,Percent of Total Billed charges,72% of Total Billed Charges,1185.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,853.34,72,,347.04,Percent of Total Billed Charges,72% of Total Billed Charges,711.11,60,,289.2,Percent of Total Billed Charges,60% of Total Billed Charges,1066.67,90,,3481.2,Percent of Total Billed Charges,90% of Total Billed Charges,533.34,45,,50.928,Percent of Total Billed Charges,45% of Total Billed Charges,1066.67,90,,511.2,Percent of Total Billed Charges,90% of Total billed Charges,1185.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1185.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1185.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770.37,65,,1050.4,Percent of total Billed Charges,65% of Total Billed Charges,522.67,44.1,,49.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,1125.93,95,,539.6,Percent of Total Billed Charges,95% of Total Billed Charges,1185.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1042.97,88,,3736.128,Percent of Total Billed Charges,88% of Total Billed Charges,1066.67,90,,511.2,Percent of Total Billed charges,90% of Total Billed Charges,522.67,1185.19,
ALLOGRAFT,2780002192,CDM,278,RC,,,Outpatient,,,13060.22,8489.14,,13060.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9925.77,76,,431.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9403.36,72,,856.8,Percent of Total Billed Charges,72% of Total Billed Charges,9403.36,72,,856.8,Percent of Total Billed charges,72% of Total Billed Charges,13060.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9403.36,72,,856.8,Percent of Total Billed Charges,72% of Total Billed Charges,7836.13,60,,714,Percent of Total Billed Charges,60% of Total Billed Charges,11754.2,90,,414,Percent of Total Billed Charges,90% of Total Billed Charges,5877.1,45,,13.904,Percent of Total Billed Charges,45% of Total Billed Charges,11754.2,90,,511.2,Percent of Total Billed Charges,90% of Total billed Charges,13060.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13060.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13060.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8489.14,65,,1050.4,Percent of total Billed Charges,65% of Total Billed Charges,5759.56,44.1,,13.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,12407.21,95,,539.6,Percent of Total Billed Charges,95% of Total Billed Charges,13060.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11492.99,88,,210.944,Percent of Total Billed Charges,88% of Total Billed Charges,11754.2,90,,511.2,Percent of Total Billed charges,90% of Total Billed Charges,5759.56,13060.22,
FIBULAR COMPOSITE PL,2780002193,CDM,278,RC,,,Outpatient,,,769.55,500.21,,769.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,584.86,76,,127.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,554.08,72,,82.08,Percent of Total Billed Charges,72% of Total Billed Charges,554.08,72,,82.08,Percent of Total Billed charges,72% of Total Billed Charges,769.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.08,72,,82.08,Percent of Total Billed Charges,72% of Total Billed Charges,461.73,60,,68.4,Percent of Total Billed Charges,60% of Total Billed Charges,692.6,90,,3891.6,Percent of Total Billed Charges,90% of Total Billed Charges,346.3,45,,1910.52,Percent of Total Billed Charges,45% of Total Billed Charges,692.6,90,,151.024,Percent of Total Billed Charges,90% of Total billed Charges,769.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,769.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,769.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.21,65,,306.904,Percent of total Billed Charges,65% of Total Billed Charges,339.37,44.1,,1872.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,731.07,95,,159.416,Percent of Total Billed Charges,95% of Total Billed Charges,769.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.2,88,,2137.344,Percent of Total Billed Charges,88% of Total Billed Charges,692.6,90,,151.024,Percent of Total Billed charges,90% of Total Billed Charges,339.37,769.55,
MEDTRONIC ICON PROGRAMMER,2780002194,CDM,278,RC,,,Outpatient,,,1443.17,938.06,,1443.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1096.81,76,,86.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1039.08,72,,120.384,Percent of Total Billed Charges,72% of Total Billed Charges,1039.08,72,,120.384,Percent of Total Billed charges,72% of Total Billed Charges,1443.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1039.08,72,,120.384,Percent of Total Billed Charges,72% of Total Billed Charges,865.9,60,,100.32,Percent of Total Billed Charges,60% of Total Billed Charges,1298.85,90,,414,Percent of Total Billed Charges,90% of Total Billed Charges,649.43,45,,107.872,Percent of Total Billed Charges,45% of Total Billed Charges,1298.85,90,,101.856,Percent of Total Billed Charges,90% of Total billed Charges,1443.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1443.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1443.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,938.06,65,,307.944,Percent of total Billed Charges,65% of Total Billed Charges,636.44,44.1,,105.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1371.01,95,,107.52,Percent of Total Billed Charges,95% of Total Billed Charges,1443.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1269.99,88,,6497.92,Percent of Total Billed Charges,88% of Total Billed Charges,1298.85,90,,101.856,Percent of Total Billed charges,90% of Total Billed Charges,636.44,1443.17,
MEDTRONIC INTERS II NEUROSTIM,2780002195,CDM,278,RC,,,Outpatient,,,43933.52,28556.79,,43933.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33389.48,76,,23.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,31632.13,72,,120.384,Percent of Total Billed Charges,72% of Total Billed Charges,31632.13,72,,120.384,Percent of Total Billed charges,72% of Total Billed Charges,43933.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31632.13,72,,120.384,Percent of Total Billed Charges,72% of Total Billed Charges,26360.11,60,,100.32,Percent of Total Billed Charges,60% of Total Billed Charges,39540.17,90,,467.424,Percent of Total Billed Charges,90% of Total Billed Charges,19770.08,45,,1092.96,Percent of Total Billed Charges,45% of Total Billed Charges,39540.17,90,,27.816,Percent of Total Billed Charges,90% of Total billed Charges,43933.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43933.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43933.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28556.79,65,,306.904,Percent of total Billed Charges,65% of Total Billed Charges,19374.68,44.1,,1071.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,41736.84,95,,29.36,Percent of Total Billed Charges,95% of Total Billed Charges,43933.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38661.5,88,,537.152,Percent of Total Billed Charges,88% of Total Billed Charges,39540.17,90,,27.816,Percent of Total Billed charges,90% of Total Billed Charges,19374.68,43933.52,
MEDTRONIC LEAD INTRODUCER K,2780002196,CDM,278,RC,,,Outpatient,,,355.01,230.76,,355.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,269.81,76,,3226.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,255.61,72,,120.384,Percent of Total Billed Charges,72% of Total Billed Charges,255.61,72,,120.384,Percent of Total Billed charges,72% of Total Billed Charges,355.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.61,72,,120.384,Percent of Total Billed Charges,72% of Total Billed Charges,213.01,60,,100.32,Percent of Total Billed Charges,60% of Total Billed Charges,319.51,90,,414,Percent of Total Billed Charges,90% of Total Billed Charges,159.75,45,,3322.8,Percent of Total Billed Charges,45% of Total Billed Charges,319.51,90,,3821.04,Percent of Total Billed Charges,90% of Total billed Charges,355.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.76,65,,728,Percent of total Billed Charges,65% of Total Billed Charges,156.56,44.1,,3256.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,337.26,95,,4033.32,Percent of Total Billed Charges,95% of Total Billed Charges,355.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.41,88,,3403.84,Percent of Total Billed Charges,88% of Total Billed Charges,319.51,90,,3821.04,Percent of Total Billed charges,90% of Total Billed Charges,156.56,355.01,
ILIUM TRICORTICA BLOCK 12X27M,2780002197,CDM,278,RC,,,Outpatient,,,1769.20,1149.98,,1769.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1344.59,76,,182.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1273.82,72,,120.384,Percent of Total Billed Charges,72% of Total Billed Charges,1273.82,72,,120.384,Percent of Total Billed charges,72% of Total Billed Charges,1769.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1273.82,72,,120.384,Percent of Total Billed Charges,72% of Total Billed Charges,1061.52,60,,100.32,Percent of Total Billed Charges,60% of Total Billed Charges,1592.28,90,,890.064,Percent of Total Billed Charges,90% of Total Billed Charges,796.14,45,,274.68,Percent of Total Billed Charges,45% of Total Billed Charges,1592.28,90,,215.744,Percent of Total Billed Charges,90% of Total billed Charges,1769.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1769.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1769.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1149.98,65,,713.704,Percent of total Billed Charges,65% of Total Billed Charges,780.22,44.1,,269.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,1680.74,95,,227.728,Percent of Total Billed Charges,95% of Total Billed Charges,1769.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1556.9,88,,404.8,Percent of Total Billed Charges,88% of Total Billed Charges,1592.28,90,,215.744,Percent of Total Billed charges,90% of Total Billed Charges,780.22,1769.2,
Z2252-65-55 RECO SCREW 65MM,2780002198,CDM,278,RC,,,Outpatient,,,703.00,456.95,,703,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,534.28,76,,1845.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,506.16,72,,133.2,Percent of Total Billed Charges,72% of Total Billed Charges,506.16,72,,133.2,Percent of Total Billed charges,72% of Total Billed Charges,703,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.16,72,,133.2,Percent of Total Billed Charges,72% of Total Billed Charges,421.8,60,,111,Percent of Total Billed Charges,60% of Total Billed Charges,632.7,90,,53.424,Percent of Total Billed Charges,90% of Total Billed Charges,316.35,45,,1740.6,Percent of Total Billed Charges,45% of Total Billed Charges,632.7,90,,2185.92,Percent of Total Billed Charges,90% of Total billed Charges,703,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,703,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,703,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.95,65,,713.704,Percent of total Billed Charges,65% of Total Billed Charges,310.02,44.1,,1705.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,667.85,95,,2307.36,Percent of Total Billed Charges,95% of Total Billed Charges,703,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618.64,88,,3805.12,Percent of Total Billed Charges,88% of Total Billed Charges,632.7,90,,2185.92,Percent of Total Billed charges,90% of Total Billed Charges,310.02,703,
Z47-248511010 LAGSCW10.5X110,2780002199,CDM,278,RC,,,Outpatient,,,1841.00,1196.65,,1841,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1399.16,76,,5611.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1325.52,72,,133.2,Percent of Total Billed Charges,72% of Total Billed Charges,1325.52,72,,133.2,Percent of Total Billed charges,72% of Total Billed Charges,1841,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1325.52,72,,133.2,Percent of Total Billed Charges,72% of Total Billed Charges,1104.6,60,,111,Percent of Total Billed Charges,60% of Total Billed Charges,1656.9,90,,211.68,Percent of Total Billed Charges,90% of Total Billed Charges,828.45,45,,207,Percent of Total Billed Charges,45% of Total Billed Charges,1656.9,90,,6645.6,Percent of Total Billed Charges,90% of Total billed Charges,1841,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1841,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1841,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1196.65,65,,2208.704,Percent of total Billed Charges,65% of Total Billed Charges,811.88,44.1,,202.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,1748.95,95,,7014.8,Percent of Total Billed Charges,95% of Total Billed Charges,1841,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.08,88,,404.8,Percent of Total Billed Charges,88% of Total Billed Charges,1656.9,90,,6645.6,Percent of Total Billed charges,90% of Total Billed Charges,811.88,1841,
Z4348-109-13 HUM.STEM 9X130,2780002200,CDM,278,RC,,,Outpatient,,,12679.00,8241.35,,12679,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9636.04,76,,463.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9128.88,72,,133.2,Percent of Total Billed Charges,72% of Total Billed Charges,9128.88,72,,133.2,Percent of Total Billed charges,72% of Total Billed Charges,12679,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9128.88,72,,133.2,Percent of Total Billed Charges,72% of Total Billed Charges,7607.4,60,,111,Percent of Total Billed Charges,60% of Total Billed Charges,11411.1,90,,11.176,Percent of Total Billed Charges,90% of Total Billed Charges,5705.55,45,,1945.8,Percent of Total Billed Charges,45% of Total Billed Charges,11411.1,90,,549.36,Percent of Total Billed Charges,90% of Total billed Charges,12679,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12679,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12679,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8241.35,65,,206.568,Percent of total Billed Charges,65% of Total Billed Charges,5591.44,44.1,,1906.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,12045.05,95,,579.88,Percent of Total Billed Charges,95% of Total Billed Charges,12679,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11157.52,88,,457.04,Percent of Total Billed Charges,88% of Total Billed Charges,11411.1,90,,549.36,Percent of Total Billed charges,90% of Total Billed Charges,5591.44,12679,
Z4840-20-01 CANN 4.0 X 20MM,2780002201,CDM,278,RC,,,Outpatient,,,57.00,37.05,,57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.32,76,,2939.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.04,72,,133.2,Percent of Total Billed Charges,72% of Total Billed Charges,41.04,72,,133.2,Percent of Total Billed charges,72% of Total Billed Charges,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.04,72,,133.2,Percent of Total Billed Charges,72% of Total Billed Charges,34.2,60,,111,Percent of Total Billed Charges,60% of Total Billed Charges,51.3,90,,108.976,Percent of Total Billed Charges,90% of Total Billed Charges,25.65,45,,207,Percent of Total Billed Charges,45% of Total Billed Charges,51.3,90,,3481.2,Percent of Total Billed Charges,90% of Total billed Charges,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.05,65,,118.304,Percent of total Billed Charges,65% of Total Billed Charges,25.14,44.1,,202.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.15,95,,3674.6,Percent of Total Billed Charges,95% of Total Billed Charges,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.16,88,,404.8,Percent of Total Billed Charges,88% of Total Billed Charges,51.3,90,,3481.2,Percent of Total Billed charges,90% of Total Billed Charges,25.14,57,
EX-PRESS MINI-SHUNT P-50,2780002202,CDM,278,RC,,,Outpatient,,,4890.69,3178.95,,4890.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3716.92,76,,349.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3521.3,72,,133.2,Percent of Total Billed Charges,72% of Total Billed Charges,3521.3,72,,133.2,Percent of Total Billed charges,72% of Total Billed Charges,4890.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3521.3,72,,133.2,Percent of Total Billed Charges,72% of Total Billed Charges,2934.41,60,,111,Percent of Total Billed Charges,60% of Total Billed Charges,4401.62,90,,108.976,Percent of Total Billed Charges,90% of Total Billed Charges,2200.81,45,,233.712,Percent of Total Billed Charges,45% of Total Billed Charges,4401.62,90,,414,Percent of Total Billed Charges,90% of Total billed Charges,4890.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4890.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4890.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3178.95,65,,362.704,Percent of total Billed Charges,65% of Total Billed Charges,2156.79,44.1,,229.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,4646.16,95,,437,Percent of Total Billed Charges,95% of Total Billed Charges,4890.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4303.81,88,,870.288,Percent of Total Billed Charges,88% of Total Billed Charges,4401.62,90,,414,Percent of Total Billed charges,90% of Total Billed Charges,2156.79,4890.69,
EX-PRESS MINI-SHUNT R-50,2780002203,CDM,278,RC,,,Outpatient,,,4822.34,3134.52,,4822.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3664.98,76,,3286.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3472.08,72,,133.2,Percent of Total Billed Charges,72% of Total Billed Charges,3472.08,72,,133.2,Percent of Total Billed charges,72% of Total Billed Charges,4822.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3472.08,72,,133.2,Percent of Total Billed Charges,72% of Total Billed Charges,2893.4,60,,111,Percent of Total Billed Charges,60% of Total Billed Charges,4340.11,90,,150.12,Percent of Total Billed Charges,90% of Total Billed Charges,2170.05,45,,207,Percent of Total Billed Charges,45% of Total Billed Charges,4340.11,90,,3891.6,Percent of Total Billed Charges,90% of Total billed Charges,4822.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4822.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4822.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3134.52,65,,349.704,Percent of total Billed Charges,65% of Total Billed Charges,2126.65,44.1,,202.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,4581.22,95,,4107.8,Percent of Total Billed Charges,95% of Total Billed Charges,4822.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4243.66,88,,52.24,Percent of Total Billed Charges,88% of Total Billed Charges,4340.11,90,,3891.6,Percent of Total Billed charges,90% of Total Billed Charges,2126.65,4822.34,
Z80182220 FEMO HEAD 22MM2.0,2780002204,CDM,278,RC,,,Outpatient,,,2192.00,1424.80,,2192,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1665.92,76,,349.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1578.24,72,,108.72,Percent of Total Billed Charges,72% of Total Billed Charges,1578.24,72,,108.72,Percent of Total Billed charges,72% of Total Billed Charges,2192,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1578.24,72,,108.72,Percent of Total Billed Charges,72% of Total Billed Charges,1315.2,60,,90.6,Percent of Total Billed Charges,60% of Total Billed Charges,1972.8,90,,88.56,Percent of Total Billed Charges,90% of Total Billed Charges,986.4,45,,445.032,Percent of Total Billed Charges,45% of Total Billed Charges,1972.8,90,,414,Percent of Total Billed Charges,90% of Total billed Charges,2192,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2192,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2192,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1424.8,65,,349.704,Percent of total Billed Charges,65% of Total Billed Charges,966.67,44.1,,436.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,2082.4,95,,437,Percent of Total Billed Charges,95% of Total Billed Charges,2192,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1928.96,88,,206.976,Percent of Total Billed Charges,88% of Total Billed Charges,1972.8,90,,414,Percent of Total Billed charges,90% of Total Billed Charges,966.67,2192,
Z63205032 TRILOGY,2780002205,CDM,278,RC,,,Outpatient,,,5726.39,3722.15,,5726.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4352.06,76,,394.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4123,72,,82.08,Percent of Total Billed Charges,72% of Total Billed Charges,4123,72,,82.08,Percent of Total Billed charges,72% of Total Billed Charges,5726.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4123,72,,82.08,Percent of Total Billed Charges,72% of Total Billed Charges,3435.83,60,,68.4,Percent of Total Billed Charges,60% of Total Billed Charges,5153.75,90,,66.768,Percent of Total Billed Charges,90% of Total Billed Charges,2576.88,45,,26.712,Percent of Total Billed Charges,45% of Total Billed Charges,5153.75,90,,467.424,Percent of Total Billed Charges,90% of Total billed Charges,5726.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3722.15,65,,1548.304,Percent of total Billed Charges,65% of Total Billed Charges,2525.34,44.1,,26.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,5440.07,95,,493.392,Percent of Total Billed Charges,95% of Total Billed Charges,5726.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5039.22,88,,10.928,Percent of Total Billed Charges,88% of Total Billed Charges,5153.75,90,,467.424,Percent of Total Billed charges,90% of Total Billed Charges,2525.34,5726.39,
Z62506515 BONE SCR,2780002206,CDM,278,RC,,,Outpatient,,,581.02,377.66,,581.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,441.58,76,,349.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,418.33,72,,82.08,Percent of Total Billed Charges,72% of Total Billed Charges,418.33,72,,82.08,Percent of Total Billed charges,72% of Total Billed Charges,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,418.33,72,,82.08,Percent of Total Billed Charges,72% of Total Billed Charges,348.61,60,,68.4,Percent of Total Billed Charges,60% of Total Billed Charges,522.92,90,,13.104,Percent of Total Billed Charges,90% of Total Billed Charges,261.46,45,,105.84,Percent of Total Billed Charges,45% of Total Billed Charges,522.92,90,,414,Percent of Total Billed Charges,90% of Total billed Charges,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.66,65,,7.896,Percent of total Billed Charges,65% of Total Billed Charges,256.23,44.1,,103.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,551.97,95,,437,Percent of Total Billed Charges,95% of Total Billed Charges,581.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511.3,88,,106.56,Percent of Total Billed Charges,88% of Total Billed Charges,522.92,90,,414,Percent of Total Billed charges,90% of Total Billed Charges,256.23,581.02,
Z62025222 SHELL CL,2780002207,CDM,278,RC,,,Outpatient,,,9972.11,6481.87,,9972.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7578.8,76,,751.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7179.92,72,,108.72,Percent of Total Billed Charges,72% of Total Billed Charges,7179.92,72,,108.72,Percent of Total Billed charges,72% of Total Billed Charges,9972.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7179.92,72,,108.72,Percent of Total Billed Charges,72% of Total Billed Charges,5983.27,60,,90.6,Percent of Total Billed Charges,60% of Total Billed Charges,8974.9,90,,27,Percent of Total Billed Charges,90% of Total Billed Charges,4487.45,45,,5.584,Percent of Total Billed Charges,45% of Total Billed Charges,8974.9,90,,890.064,Percent of Total Billed Charges,90% of Total billed Charges,9972.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9972.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9972.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6481.87,65,,8.944,Percent of total Billed Charges,65% of Total Billed Charges,4397.7,44.1,,5.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,9473.5,95,,939.512,Percent of Total Billed Charges,95% of Total Billed Charges,9972.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8775.46,88,,106.56,Percent of Total Billed Charges,88% of Total Billed Charges,8974.9,90,,890.064,Percent of Total Billed charges,90% of Total Billed Charges,4397.7,9972.11,
Z785014 FEM STEM CE,2780002208,CDM,278,RC,,,Outpatient,,,15064.56,9791.96,,15064.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11449.07,76,,45.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10846.48,72,,82.08,Percent of Total Billed Charges,72% of Total Billed Charges,10846.48,72,,82.08,Percent of Total Billed charges,72% of Total Billed Charges,15064.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10846.48,72,,82.08,Percent of Total Billed Charges,72% of Total Billed Charges,9038.74,60,,68.4,Percent of Total Billed Charges,60% of Total Billed Charges,13558.1,90,,8208,Percent of Total Billed Charges,90% of Total Billed Charges,6779.05,45,,54.488,Percent of Total Billed Charges,45% of Total Billed Charges,13558.1,90,,53.424,Percent of Total Billed Charges,90% of Total billed Charges,15064.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15064.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15064.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9791.96,65,,8.944,Percent of total Billed Charges,65% of Total Billed Charges,6643.47,44.1,,53.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,14311.33,95,,56.392,Percent of Total Billed Charges,95% of Total Billed Charges,15064.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13256.81,88,,146.784,Percent of Total Billed Charges,88% of Total Billed Charges,13558.1,90,,53.424,Percent of Total Billed charges,90% of Total Billed Charges,6643.47,15064.56,
Z22401218 RETRO FO,2780002209,CDM,278,RC,,,Outpatient,,,4933.69,3206.90,,4933.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3749.6,76,,178.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3552.26,72,,82.08,Percent of Total Billed Charges,72% of Total Billed Charges,3552.26,72,,82.08,Percent of Total Billed charges,72% of Total Billed Charges,4933.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3552.26,72,,82.08,Percent of Total Billed Charges,72% of Total Billed Charges,2960.21,60,,68.4,Percent of Total Billed Charges,60% of Total Billed Charges,4440.32,90,,855,Percent of Total Billed Charges,90% of Total Billed Charges,2220.16,45,,54.488,Percent of Total Billed Charges,45% of Total Billed Charges,4440.32,90,,211.68,Percent of Total Billed Charges,90% of Total billed Charges,4933.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4933.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4933.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3206.9,65,,8.944,Percent of total Billed Charges,65% of Total Billed Charges,2175.76,44.1,,53.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,4687.01,95,,223.44,Percent of Total Billed Charges,95% of Total Billed Charges,4933.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4341.65,88,,86.592,Percent of Total Billed Charges,88% of Total Billed Charges,4440.32,90,,211.68,Percent of Total Billed charges,90% of Total Billed Charges,2175.76,4933.69,
Z493507COMPLPLATE,2780002210,CDM,278,RC,,,Outpatient,,,472.97,307.43,,472.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,359.46,76,,9.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,340.54,72,,303.84,Percent of Total Billed Charges,72% of Total Billed Charges,340.54,72,,303.84,Percent of Total Billed charges,72% of Total Billed Charges,472.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.54,72,,303.84,Percent of Total Billed Charges,72% of Total Billed Charges,283.78,60,,253.2,Percent of Total Billed Charges,60% of Total Billed Charges,425.67,90,,802.8,Percent of Total Billed Charges,90% of Total Billed Charges,212.84,45,,75.064,Percent of Total Billed Charges,45% of Total Billed Charges,425.67,90,,11.176,Percent of Total Billed Charges,90% of Total billed Charges,472.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.43,65,,7.896,Percent of total Billed Charges,65% of Total Billed Charges,208.58,44.1,,73.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,449.32,95,,11.792,Percent of Total Billed Charges,95% of Total Billed Charges,472.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,416.21,88,,65.28,Percent of Total Billed Charges,88% of Total Billed Charges,425.67,90,,11.176,Percent of Total Billed charges,90% of Total Billed Charges,208.58,472.97,
Z23563536 CANN LCK,2780002211,CDM,278,RC,,,Outpatient,,,370.44,240.79,,370.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,281.53,76,,92.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,266.72,72,,828,Percent of Total Billed Charges,72% of Total Billed Charges,266.72,72,,828,Percent of Total Billed charges,72% of Total Billed Charges,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.72,72,,828,Percent of Total Billed Charges,72% of Total Billed Charges,222.26,60,,690,Percent of Total Billed Charges,60% of Total Billed Charges,333.4,90,,1454.4,Percent of Total Billed Charges,90% of Total Billed Charges,166.7,45,,44.28,Percent of Total Billed Charges,45% of Total Billed Charges,333.4,90,,108.976,Percent of Total Billed Charges,90% of Total billed Charges,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.79,65,,3.616,Percent of total Billed Charges,65% of Total Billed Charges,163.36,44.1,,43.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,351.92,95,,115.032,Percent of Total Billed Charges,95% of Total Billed Charges,370.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.99,88,,12.816,Percent of Total Billed Charges,88% of Total Billed Charges,333.4,90,,108.976,Percent of Total Billed charges,90% of Total Billed Charges,163.36,370.44,
Z22401232 RETROFEM,2780002212,CDM,278,RC,,,Outpatient,,,4742.96,3082.92,,4742.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3604.65,76,,92.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3414.93,72,,1228.32,Percent of Total Billed Charges,72% of Total Billed Charges,3414.93,72,,1228.32,Percent of Total Billed charges,72% of Total Billed Charges,4742.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3414.93,72,,1228.32,Percent of Total Billed Charges,72% of Total Billed Charges,2845.78,60,,1023.6,Percent of Total Billed Charges,60% of Total Billed Charges,4268.66,90,,1454.4,Percent of Total Billed Charges,90% of Total Billed Charges,2134.33,45,,33.384,Percent of Total Billed Charges,45% of Total Billed Charges,4268.66,90,,108.976,Percent of Total Billed Charges,90% of Total billed Charges,4742.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4742.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4742.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3082.92,65,,3.616,Percent of total Billed Charges,65% of Total Billed Charges,2091.65,44.1,,32.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,4505.81,95,,115.032,Percent of Total Billed Charges,95% of Total Billed Charges,4742.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4173.8,88,,26.4,Percent of Total Billed Charges,88% of Total Billed Charges,4268.66,90,,108.976,Percent of Total Billed charges,90% of Total Billed Charges,2091.65,4742.96,
Z23582504 DORSALDE,2780002213,CDM,278,RC,,,Outpatient,,,3014.24,1959.26,,3014.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2290.82,76,,126.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2170.25,72,,21.168,Percent of Total Billed Charges,72% of Total Billed Charges,2170.25,72,,21.168,Percent of Total Billed charges,72% of Total Billed Charges,3014.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2170.25,72,,21.168,Percent of Total Billed Charges,72% of Total Billed Charges,1808.54,60,,17.64,Percent of Total Billed Charges,60% of Total Billed Charges,2712.82,90,,424.944,Percent of Total Billed Charges,90% of Total Billed Charges,1356.41,45,,6.552,Percent of Total Billed Charges,45% of Total Billed Charges,2712.82,90,,150.12,Percent of Total Billed Charges,90% of Total billed Charges,3014.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3014.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3014.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1959.26,65,,11.224,Percent of total Billed Charges,65% of Total Billed Charges,1329.28,44.1,,6.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,2863.53,95,,158.464,Percent of Total Billed Charges,95% of Total Billed Charges,3014.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2652.53,88,,8025.6,Percent of Total Billed Charges,88% of Total Billed Charges,2712.82,90,,150.12,Percent of Total Billed charges,90% of Total Billed Charges,1329.28,3014.24,
Z236011518 DRILL B,2780002214,CDM,278,RC,,,Outpatient,,,866.57,563.27,,866.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,658.59,76,,74.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,623.93,72,,1990.368,Percent of Total Billed Charges,72% of Total Billed Charges,623.93,72,,1990.368,Percent of Total Billed charges,72% of Total Billed Charges,866.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,623.93,72,,1990.368,Percent of Total Billed Charges,72% of Total Billed Charges,519.94,60,,1658.64,Percent of Total Billed Charges,60% of Total Billed Charges,779.91,90,,426.384,Percent of Total Billed Charges,90% of Total Billed Charges,389.96,45,,13.504,Percent of Total Billed Charges,45% of Total Billed Charges,779.91,90,,88.56,Percent of Total Billed Charges,90% of Total billed Charges,866.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,866.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,866.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.27,65,,3.616,Percent of total Billed Charges,65% of Total Billed Charges,382.16,44.1,,13.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,823.24,95,,93.48,Percent of Total Billed Charges,95% of Total Billed Charges,866.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,762.58,88,,836,Percent of Total Billed Charges,88% of Total Billed Charges,779.91,90,,88.56,Percent of Total Billed charges,90% of Total Billed Charges,382.16,866.57,
Z62506525 BONE SCR,2780002215,CDM,278,RC,,,Outpatient,,,558.97,363.33,,558.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,424.82,76,,56.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,402.46,72,,148.456,Percent of Total Billed Charges,72% of Total Billed Charges,402.46,72,,148.456,Percent of Total Billed charges,72% of Total Billed Charges,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,402.46,72,,148.456,Percent of Total Billed Charges,72% of Total Billed Charges,335.38,60,,123.712,Percent of Total Billed Charges,60% of Total Billed Charges,503.07,90,,424.944,Percent of Total Billed Charges,90% of Total Billed Charges,251.54,45,,4104,Percent of Total Billed Charges,45% of Total Billed Charges,503.07,90,,66.768,Percent of Total Billed Charges,90% of Total billed Charges,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.33,65,,9.072,Percent of total Billed Charges,65% of Total Billed Charges,246.51,44.1,,4021.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,531.02,95,,70.472,Percent of Total Billed Charges,95% of Total Billed Charges,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.89,88,,784.96,Percent of Total Billed Charges,88% of Total Billed Charges,503.07,90,,66.768,Percent of Total Billed charges,90% of Total Billed Charges,246.51,558.97,
Z22529055 SCW 90,2780002216,CDM,278,RC,,,Outpatient,,,837.90,544.64,,837.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,636.8,76,,11.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,603.29,72,,286.56,Percent of Total Billed Charges,72% of Total Billed Charges,603.29,72,,286.56,Percent of Total Billed charges,72% of Total Billed Charges,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,603.29,72,,286.56,Percent of Total Billed Charges,72% of Total Billed Charges,502.74,60,,238.8,Percent of Total Billed Charges,60% of Total Billed Charges,754.11,90,,1008,Percent of Total Billed Charges,90% of Total Billed Charges,377.06,45,,427.504,Percent of Total Billed Charges,45% of Total Billed Charges,754.11,90,,13.104,Percent of Total Billed Charges,90% of Total billed Charges,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,544.64,65,,10.752,Percent of total Billed Charges,65% of Total Billed Charges,369.51,44.1,,418.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,796.01,95,,13.832,Percent of Total Billed Charges,95% of Total Billed Charges,837.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.35,88,,1422.08,Percent of Total Billed Charges,88% of Total Billed Charges,754.11,90,,13.104,Percent of Total Billed charges,90% of Total Billed Charges,369.51,837.9,
EXACTECH HIP SPACER,2780002217,CDM,278,RC,,,Outpatient,,,15460.36,10049.23,,15460.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11749.87,76,,22.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11131.46,72,,102.24,Percent of Total Billed Charges,72% of Total Billed Charges,11131.46,72,,102.24,Percent of Total Billed charges,72% of Total Billed Charges,15460.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11131.46,72,,102.24,Percent of Total Billed Charges,72% of Total Billed Charges,9276.22,60,,85.2,Percent of Total Billed Charges,60% of Total Billed Charges,13914.32,90,,988.2,Percent of Total Billed Charges,90% of Total Billed Charges,6957.16,45,,401.4,Percent of Total Billed Charges,45% of Total Billed Charges,13914.32,90,,27,Percent of Total Billed Charges,90% of Total billed Charges,15460.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15460.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15460.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10049.23,65,,9.088,Percent of total Billed Charges,65% of Total Billed Charges,6818.02,44.1,,393.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,14687.34,95,,28.504,Percent of Total Billed Charges,95% of Total Billed Charges,15460.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13605.12,88,,1422.08,Percent of Total Billed Charges,88% of Total Billed Charges,13914.32,90,,27,Percent of Total Billed charges,90% of Total Billed Charges,6818.02,15460.36,
Z22325020 CABLE RE,2780002218,CDM,278,RC,,,Outpatient,,,1944.81,1264.13,,1944.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1478.06,76,,6931.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1400.26,72,,1044,Percent of Total Billed Charges,72% of Total Billed Charges,1400.26,72,,1044,Percent of Total Billed charges,72% of Total Billed Charges,1944.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1400.26,72,,1044,Percent of Total Billed Charges,72% of Total Billed Charges,1166.89,60,,870,Percent of Total Billed Charges,60% of Total Billed Charges,1750.33,90,,988.2,Percent of Total Billed Charges,90% of Total Billed Charges,875.16,45,,727.2,Percent of Total Billed Charges,45% of Total Billed Charges,1750.33,90,,8208,Percent of Total Billed Charges,90% of Total billed Charges,1944.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1944.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1944.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1264.13,65,,9.088,Percent of total Billed Charges,65% of Total Billed Charges,857.66,44.1,,712.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,1847.57,95,,8664,Percent of Total Billed Charges,95% of Total Billed Charges,1944.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1711.43,88,,415.504,Percent of Total Billed Charges,88% of Total Billed Charges,1750.33,90,,8208,Percent of Total Billed charges,90% of Total Billed Charges,857.66,1944.81,
Z59523014 ART SURF,2780002219,CDM,278,RC,,,Outpatient,,,6713.12,4363.53,,6713.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5101.97,76,,722,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4833.45,72,,4320,Percent of Total Billed Charges,72% of Total Billed Charges,4833.45,72,,4320,Percent of Total Billed charges,72% of Total Billed Charges,6713.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4833.45,72,,4320,Percent of Total Billed Charges,72% of Total Billed Charges,4027.87,60,,3600,Percent of Total Billed Charges,60% of Total Billed Charges,6041.81,90,,3058.2,Percent of Total Billed Charges,90% of Total Billed Charges,3020.9,45,,727.2,Percent of Total Billed Charges,45% of Total Billed Charges,6041.81,90,,855,Percent of Total Billed Charges,90% of Total billed Charges,6713.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6713.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6713.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4363.53,65,,9.088,Percent of total Billed Charges,65% of Total Billed Charges,2960.49,44.1,,712.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,6377.46,95,,902.504,Percent of Total Billed Charges,95% of Total Billed Charges,6713.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5907.55,88,,416.912,Percent of Total Billed Charges,88% of Total Billed Charges,6041.81,90,,855,Percent of Total Billed charges,90% of Total Billed Charges,2960.49,6713.12,
Z47249331210 FEM,2780002220,CDM,278,RC,,,Outpatient,,,5882.94,3823.91,,5882.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4471.03,76,,677.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4235.72,72,,4320,Percent of Total Billed Charges,72% of Total Billed Charges,4235.72,72,,4320,Percent of Total Billed charges,72% of Total Billed Charges,5882.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4235.72,72,,4320,Percent of Total Billed Charges,72% of Total Billed Charges,3529.76,60,,3600,Percent of Total Billed Charges,60% of Total Billed Charges,5294.65,90,,286.024,Percent of Total Billed Charges,90% of Total Billed Charges,2647.32,45,,212.472,Percent of Total Billed Charges,45% of Total Billed Charges,5294.65,90,,802.8,Percent of Total Billed Charges,90% of Total billed Charges,5882.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5882.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5882.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3823.91,65,,9.088,Percent of total Billed Charges,65% of Total Billed Charges,2594.38,44.1,,208.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,5588.79,95,,847.4,Percent of Total Billed Charges,95% of Total Billed Charges,5882.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5176.99,88,,415.504,Percent of Total Billed Charges,88% of Total Billed Charges,5294.65,90,,802.8,Percent of Total Billed charges,90% of Total Billed Charges,2594.38,5882.94,
Z47248409050 CORT,2780002221,CDM,278,RC,,,Outpatient,,,756.32,491.61,,756.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,574.8,76,,1228.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,544.55,72,,4320,Percent of Total Billed Charges,72% of Total Billed Charges,544.55,72,,4320,Percent of Total Billed charges,72% of Total Billed Charges,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,544.55,72,,4320,Percent of Total Billed Charges,72% of Total Billed Charges,453.79,60,,3600,Percent of Total Billed Charges,60% of Total Billed Charges,680.69,90,,163.8,Percent of Total Billed Charges,90% of Total Billed Charges,340.34,45,,213.192,Percent of Total Billed Charges,45% of Total Billed Charges,680.69,90,,1454.4,Percent of Total Billed Charges,90% of Total billed Charges,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.61,65,,9.088,Percent of total Billed Charges,65% of Total Billed Charges,333.54,44.1,,208.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,718.5,95,,1535.2,Percent of Total Billed Charges,95% of Total Billed Charges,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,665.56,88,,985.6,Percent of Total Billed Charges,88% of Total Billed Charges,680.69,90,,1454.4,Percent of Total Billed charges,90% of Total Billed Charges,333.54,756.32,
Z59881016 STEM EXT,2780002222,CDM,278,RC,,,Outpatient,,,4010.90,2607.09,,4010.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3048.28,76,,1228.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2887.85,72,,4320,Percent of Total Billed Charges,72% of Total Billed Charges,2887.85,72,,4320,Percent of Total Billed charges,72% of Total Billed Charges,4010.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2887.85,72,,4320,Percent of Total Billed Charges,72% of Total Billed Charges,2406.54,60,,3600,Percent of Total Billed Charges,60% of Total Billed Charges,3609.81,90,,502.2,Percent of Total Billed Charges,90% of Total Billed Charges,1804.91,45,,212.472,Percent of Total Billed Charges,45% of Total Billed Charges,3609.81,90,,1454.4,Percent of Total Billed Charges,90% of Total billed Charges,4010.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4010.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4010.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2607.09,65,,10.752,Percent of total Billed Charges,65% of Total Billed Charges,1768.81,44.1,,208.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,3810.36,95,,1535.2,Percent of Total Billed Charges,95% of Total Billed Charges,4010.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3529.59,88,,966.24,Percent of Total Billed Charges,88% of Total Billed Charges,3609.81,90,,1454.4,Percent of Total Billed charges,90% of Total Billed Charges,1768.81,4010.9,
Z58800410 TIBIAL A,2780002223,CDM,278,RC,,,Outpatient,,,6097.93,3963.65,,6097.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4634.43,76,,358.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4390.51,72,,195.84,Percent of Total Billed Charges,72% of Total Billed Charges,4390.51,72,,195.84,Percent of Total Billed charges,72% of Total Billed Charges,6097.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4390.51,72,,195.84,Percent of Total Billed Charges,72% of Total Billed Charges,3658.76,60,,163.2,Percent of Total Billed Charges,60% of Total Billed Charges,5488.14,90,,484.2,Percent of Total Billed Charges,90% of Total Billed Charges,2744.07,45,,504,Percent of Total Billed Charges,45% of Total Billed Charges,5488.14,90,,424.944,Percent of Total Billed Charges,90% of Total billed Charges,6097.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6097.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6097.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3963.65,65,,265.944,Percent of total Billed Charges,65% of Total Billed Charges,2689.19,44.1,,493.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,5793.03,95,,448.552,Percent of Total Billed Charges,95% of Total Billed Charges,6097.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5366.18,88,,966.24,Percent of Total Billed Charges,88% of Total Billed Charges,5488.14,90,,424.944,Percent of Total Billed charges,90% of Total Billed Charges,2689.19,6097.93,
Z5880-15-02 RHK FEM/,2780002224,CDM,278,RC,,,Outpatient,,,34639.45,22515.64,,34639.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26325.98,76,,360.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24940.4,72,,131.04,Percent of Total Billed Charges,72% of Total Billed Charges,24940.4,72,,131.04,Percent of Total Billed charges,72% of Total Billed Charges,34639.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24940.4,72,,131.04,Percent of Total Billed Charges,72% of Total Billed Charges,20783.67,60,,109.2,Percent of Total Billed Charges,60% of Total Billed Charges,31175.51,90,,484.2,Percent of Total Billed Charges,90% of Total Billed Charges,15587.75,45,,494.104,Percent of Total Billed Charges,45% of Total Billed Charges,31175.51,90,,426.384,Percent of Total Billed Charges,90% of Total billed Charges,34639.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34639.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34639.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22515.64,65,,169.824,Percent of total Billed Charges,65% of Total Billed Charges,15276,44.1,,484.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,32907.48,95,,450.072,Percent of Total Billed Charges,95% of Total Billed Charges,34639.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30482.72,88,,2990.24,Percent of Total Billed Charges,88% of Total Billed Charges,31175.51,90,,426.384,Percent of Total Billed charges,90% of Total Billed Charges,15276,34639.45,
STRYKER FLEX OSTEDFU,2780002225,CDM,278,RC,,,Outpatient,,,2005.45,1303.54,,2005.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1524.14,76,,358.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1443.92,72,,7283.52,Percent of Total Billed Charges,72% of Total Billed Charges,1443.92,72,,7283.52,Percent of Total Billed charges,72% of Total Billed Charges,2005.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1443.92,72,,7283.52,Percent of Total Billed Charges,72% of Total Billed Charges,1203.27,60,,6069.6,Percent of Total Billed Charges,60% of Total Billed Charges,1804.91,90,,2143.8,Percent of Total Billed Charges,90% of Total Billed Charges,902.45,45,,494.104,Percent of Total Billed Charges,45% of Total Billed Charges,1804.91,90,,424.944,Percent of Total Billed Charges,90% of Total billed Charges,2005.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2005.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2005.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1303.54,65,,144.392,Percent of total Billed Charges,65% of Total Billed Charges,884.4,44.1,,484.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,1905.18,95,,448.552,Percent of Total Billed Charges,95% of Total Billed Charges,2005.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1764.8,88,,279.664,Percent of Total Billed Charges,88% of Total Billed Charges,1804.91,90,,424.944,Percent of Total Billed charges,90% of Total Billed Charges,884.4,2005.45,
Z00545001368 REVT,2780002226,CDM,278,RC,,,Outpatient,,,13768.02,8949.21,,13768.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10463.7,76,,851.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9912.97,72,,193.536,Percent of Total Billed Charges,72% of Total Billed Charges,9912.97,72,,193.536,Percent of Total Billed charges,72% of Total Billed Charges,13768.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9912.97,72,,193.536,Percent of Total Billed Charges,72% of Total Billed Charges,8260.81,60,,161.28,Percent of Total Billed Charges,60% of Total Billed Charges,12391.22,90,,10.928,Percent of Total Billed Charges,90% of Total Billed Charges,6195.61,45,,1529.104,Percent of Total Billed Charges,45% of Total Billed Charges,12391.22,90,,1008,Percent of Total Billed Charges,90% of Total billed Charges,13768.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13768.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13768.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8949.21,65,,72.8,Percent of total Billed Charges,65% of Total Billed Charges,6071.7,44.1,,1498.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,13079.62,95,,1064,Percent of Total Billed Charges,95% of Total Billed Charges,13768.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12115.86,88,,160.16,Percent of Total Billed Charges,88% of Total Billed Charges,12391.22,90,,1008,Percent of Total Billed charges,90% of Total Billed Charges,6071.7,13768.02,
ACUMED 3.5X24 NLCK S,2780002227,CDM,278,RC,,,Outpatient,,,394.70,256.56,,394.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.97,76,,834.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.18,72,,1510.56,Percent of Total Billed Charges,72% of Total Billed Charges,284.18,72,,1510.56,Percent of Total Billed charges,72% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.18,72,,1510.56,Percent of Total Billed Charges,72% of Total Billed Charges,236.82,60,,1258.8,Percent of Total Billed Charges,60% of Total Billed Charges,355.23,90,,12.384,Percent of Total Billed Charges,90% of Total Billed Charges,177.62,45,,143.008,Percent of Total Billed Charges,45% of Total Billed Charges,355.23,90,,988.2,Percent of Total Billed Charges,90% of Total billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.56,65,,72.8,Percent of total Billed Charges,65% of Total Billed Charges,174.06,44.1,,140.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.97,95,,1043.104,Percent of Total Billed Charges,95% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.34,88,,491.04,Percent of Total Billed Charges,88% of Total Billed Charges,355.23,90,,988.2,Percent of Total Billed charges,90% of Total Billed Charges,174.06,394.7,
ECT SCREW 46MM 4.5,2780002228,CDM,278,RC,,,Outpatient,,,60.64,39.42,,60.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.09,76,,834.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.66,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,54.58,90,,12.384,Percent of Total Billed Charges,90% of Total Billed Charges,27.29,45,,81.904,Percent of Total Billed Charges,45% of Total Billed Charges,54.58,90,,988.2,Percent of Total Billed Charges,90% of Total billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.42,65,,72.8,Percent of total Billed Charges,65% of Total Billed Charges,26.74,44.1,,80.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.61,95,,1043.104,Percent of Total Billed Charges,95% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.36,88,,473.44,Percent of Total Billed Charges,88% of Total Billed Charges,54.58,90,,988.2,Percent of Total Billed charges,90% of Total Billed Charges,26.74,60.64,
Z23593024 CORTICAL SCW 30,2780002229,CDM,278,RC,,,Outpatient,,,345.08,224.30,,345.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,262.26,76,,2582.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,248.46,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,248.46,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,345.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.46,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,207.05,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,310.57,90,,12.384,Percent of Total Billed Charges,90% of Total Billed Charges,155.29,45,,251.104,Percent of Total Billed Charges,45% of Total Billed Charges,310.57,90,,3058.2,Percent of Total Billed Charges,90% of Total billed Charges,345.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.3,65,,72.8,Percent of total Billed Charges,65% of Total Billed Charges,152.18,44.1,,246.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,327.83,95,,3228.104,Percent of Total Billed Charges,95% of Total Billed Charges,345.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.67,88,,473.44,Percent of Total Billed Charges,88% of Total Billed Charges,310.57,90,,3058.2,Percent of Total Billed charges,90% of Total Billed Charges,152.18,345.08,
Z23593225 CONICAL SCW 32,2780002230,CDM,278,RC,,,Outpatient,,,275.63,179.16,,275.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209.48,76,,241.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198.45,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,198.45,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,275.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.45,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,165.38,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,248.07,90,,10.928,Percent of Total Billed Charges,90% of Total Billed Charges,124.03,45,,242.104,Percent of Total Billed Charges,45% of Total Billed Charges,248.07,90,,286.024,Percent of Total Billed Charges,90% of Total billed Charges,275.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.16,65,,72.8,Percent of total Billed Charges,65% of Total Billed Charges,121.55,44.1,,237.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.85,95,,301.912,Percent of Total Billed Charges,95% of Total Billed Charges,275.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.55,88,,2096.16,Percent of Total Billed Charges,88% of Total Billed Charges,248.07,90,,286.024,Percent of Total Billed charges,90% of Total Billed Charges,121.55,275.63,
ARTHROCARE SPEED LOCK IMPLANT,2780002231,CDM,278,RC,,,Outpatient,,,1663.67,1081.39,,1663.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1264.39,76,,138.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1197.84,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,1197.84,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,1663.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1197.84,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,998.2,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,1497.3,90,,5.008,Percent of Total Billed Charges,90% of Total Billed Charges,748.65,45,,242.104,Percent of Total Billed Charges,45% of Total Billed Charges,1497.3,90,,163.8,Percent of Total Billed Charges,90% of Total billed Charges,1663.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1663.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1663.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1081.39,65,,72.8,Percent of total Billed Charges,65% of Total Billed Charges,733.68,44.1,,237.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,1580.49,95,,172.904,Percent of Total Billed Charges,95% of Total Billed Charges,1663.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1464.03,88,,10.688,Percent of Total Billed Charges,88% of Total Billed Charges,1497.3,90,,163.8,Percent of Total Billed charges,90% of Total Billed Charges,733.68,1663.67,
BOVINE VASCULAR PATCH 0.8X8,2780002232,CDM,278,RC,,,Outpatient,,,657.00,427.05,,657,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,499.32,76,,424.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,473.04,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,473.04,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,657,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.04,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,394.2,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,591.3,90,,5.008,Percent of Total Billed Charges,90% of Total Billed Charges,295.65,45,,1071.904,Percent of Total Billed Charges,45% of Total Billed Charges,591.3,90,,502.2,Percent of Total Billed Charges,90% of Total billed Charges,657,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,657,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,657,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.05,65,,72.8,Percent of total Billed Charges,65% of Total Billed Charges,289.74,44.1,,1050.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,624.15,95,,530.104,Percent of Total Billed Charges,95% of Total Billed Charges,657,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,578.16,88,,12.112,Percent of Total Billed Charges,88% of Total Billed Charges,591.3,90,,502.2,Percent of Total Billed charges,90% of Total Billed Charges,289.74,657,
SEPRAFLIM SM INCISION,2780002233,CDM,278,RC,,,Outpatient,,,335.00,217.75,,335,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,254.6,76,,408.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,241.2,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,241.2,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,335,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.2,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,201,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,301.5,90,,15.536,Percent of Total Billed Charges,90% of Total Billed Charges,150.75,45,,5.464,Percent of Total Billed Charges,45% of Total Billed Charges,301.5,90,,484.2,Percent of Total Billed Charges,90% of Total billed Charges,335,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,335,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,335,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.75,65,,72.8,Percent of total Billed Charges,65% of Total Billed Charges,147.74,44.1,,5.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,318.25,95,,511.104,Percent of Total Billed Charges,95% of Total Billed Charges,335,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.8,88,,12.112,Percent of Total Billed Charges,88% of Total Billed Charges,301.5,90,,484.2,Percent of Total Billed charges,90% of Total Billed Charges,147.74,335,
ARTHREX GUIDEWIRE 0.078 DIA,2780002234,CDM,278,RC,,,Outpatient,,,40.00,26.00,,40,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,30.4,76,,408.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.8,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,28.8,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.8,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,24,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,36,90,,5.008,Percent of Total Billed Charges,90% of Total Billed Charges,18,45,,6.192,Percent of Total Billed Charges,45% of Total Billed Charges,36,90,,484.2,Percent of Total Billed Charges,90% of Total billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26,65,,118.952,Percent of total Billed Charges,65% of Total Billed Charges,17.64,44.1,,6.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,38,95,,511.104,Percent of Total Billed Charges,95% of Total Billed Charges,40,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.2,88,,12.112,Percent of Total Billed Charges,88% of Total Billed Charges,36,90,,484.2,Percent of Total Billed charges,90% of Total Billed Charges,17.64,40,
ARMSTRONG VENTILATION EAR TUBE,2780002235,CDM,278,RC,,,Outpatient,,,56.00,36.40,,56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.56,76,,1810.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.32,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,40.32,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.32,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,33.6,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,50.4,90,,12.568,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,45,,6.192,Percent of Total Billed Charges,45% of Total Billed Charges,50.4,90,,2143.8,Percent of Total Billed Charges,90% of Total billed Charges,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.4,65,,113.944,Percent of total Billed Charges,65% of Total Billed Charges,24.7,44.1,,6.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.2,95,,2262.904,Percent of Total Billed Charges,95% of Total Billed Charges,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.28,88,,10.688,Percent of Total Billed Charges,88% of Total Billed Charges,50.4,90,,2143.8,Percent of Total Billed charges,90% of Total Billed Charges,24.7,56,
RICHARDS MODIFIED EAR TTUBE,2780002236,CDM,278,RC,,,Outpatient,,,81.00,52.65,,81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,61.56,76,,9.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,58.32,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,58.32,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.32,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,48.6,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,72.9,90,,14.888,Percent of Total Billed Charges,90% of Total Billed Charges,36.45,45,,6.192,Percent of Total Billed Charges,45% of Total Billed Charges,72.9,90,,10.928,Percent of Total Billed Charges,90% of Total billed Charges,81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.65,65,,118.952,Percent of total Billed Charges,65% of Total Billed Charges,35.72,44.1,,6.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,76.95,95,,11.536,Percent of Total Billed Charges,95% of Total Billed Charges,81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.28,88,,4.896,Percent of Total Billed Charges,88% of Total Billed Charges,72.9,90,,10.928,Percent of Total Billed charges,90% of Total Billed Charges,35.72,81,
ARTHREX  CANN BONE TAP 5.5MM,2780002237,CDM,278,RC,,,Outpatient,,,201.00,130.65,,201,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152.76,76,,10.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144.72,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,144.72,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.72,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,120.6,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,180.9,90,,12.584,Percent of Total Billed Charges,90% of Total Billed Charges,90.45,45,,5.464,Percent of Total Billed Charges,45% of Total Billed Charges,180.9,90,,12.384,Percent of Total Billed Charges,90% of Total billed Charges,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.65,65,,68.904,Percent of total Billed Charges,65% of Total Billed Charges,88.64,44.1,,5.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,190.95,95,,13.072,Percent of Total Billed Charges,95% of Total Billed Charges,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.88,88,,4.896,Percent of Total Billed Charges,88% of Total Billed Charges,180.9,90,,12.384,Percent of Total Billed charges,90% of Total Billed Charges,88.64,201,
ARTHREX GUIDEWIRE 2.0MM,2780002238,CDM,278,RC,,,Outpatient,,,49.00,31.85,,49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,37.24,76,,10.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,35.28,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,35.28,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,29.4,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,44.1,90,,12.584,Percent of Total Billed Charges,90% of Total Billed Charges,22.05,45,,2.504,Percent of Total Billed Charges,45% of Total Billed Charges,44.1,90,,12.384,Percent of Total Billed Charges,90% of Total billed Charges,49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.85,65,,68.904,Percent of total Billed Charges,65% of Total Billed Charges,21.61,44.1,,2.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.55,95,,13.072,Percent of Total Billed Charges,95% of Total Billed Charges,49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.12,88,,15.192,Percent of Total Billed Charges,88% of Total Billed Charges,44.1,90,,12.384,Percent of Total Billed charges,90% of Total Billed Charges,21.61,49,
ARTHREX  CANN DRILL BIT 4.0MM,2780002239,CDM,278,RC,,,Outpatient,,,201.00,130.65,,201,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152.76,76,,10.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144.72,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,144.72,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.72,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,120.6,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,180.9,90,,12.584,Percent of Total Billed Charges,90% of Total Billed Charges,90.45,45,,2.504,Percent of Total Billed Charges,45% of Total Billed Charges,180.9,90,,12.384,Percent of Total Billed Charges,90% of Total billed Charges,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.65,65,,68.904,Percent of total Billed Charges,65% of Total Billed Charges,88.64,44.1,,2.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,190.95,95,,13.072,Percent of Total Billed Charges,95% of Total Billed Charges,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.88,88,,4.896,Percent of Total Billed Charges,88% of Total Billed Charges,180.9,90,,12.384,Percent of Total Billed charges,90% of Total Billed Charges,88.64,201,
TOUHY NEEDLE 20G X 4,2780002240,CDM,278,RC,,,Outpatient,,,44.10,28.67,,44.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33.52,76,,9.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,31.75,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,31.75,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.75,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,39.69,90,,12.584,Percent of Total Billed Charges,90% of Total Billed Charges,19.85,45,,7.768,Percent of Total Billed Charges,45% of Total Billed Charges,39.69,90,,10.928,Percent of Total Billed Charges,90% of Total billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,65,,68.904,Percent of total Billed Charges,65% of Total Billed Charges,19.45,44.1,,7.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.9,95,,11.536,Percent of Total Billed Charges,95% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.81,88,,12.288,Percent of Total Billed Charges,88% of Total Billed Charges,39.69,90,,10.928,Percent of Total Billed charges,90% of Total Billed Charges,19.45,44.1,
STIMUPLEX 21G X 4 NEEDLE,2780002241,CDM,278,RC,,,Outpatient,,,50.72,32.97,,50.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38.55,76,,4.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36.52,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,36.52,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.52,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,30.43,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,45.65,90,,12.584,Percent of Total Billed Charges,90% of Total Billed Charges,22.82,45,,2.504,Percent of Total Billed Charges,45% of Total Billed Charges,45.65,90,,5.008,Percent of Total Billed Charges,90% of Total billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.97,65,,68.904,Percent of total Billed Charges,65% of Total Billed Charges,22.37,44.1,,2.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.18,95,,5.28,Percent of Total Billed Charges,95% of Total Billed Charges,50.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.63,88,,14.56,Percent of Total Billed Charges,88% of Total Billed Charges,45.65,90,,5.008,Percent of Total Billed charges,90% of Total Billed Charges,22.37,50.72,
STIMUPLEX 22G X 2 NEEDLE,2780002242,CDM,278,RC,,,Outpatient,,,63.95,41.57,,63.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,48.6,76,,4.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.04,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,46.04,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.04,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,38.37,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,57.56,90,,14.888,Percent of Total Billed Charges,90% of Total Billed Charges,28.78,45,,6.28,Percent of Total Billed Charges,45% of Total Billed Charges,57.56,90,,5.008,Percent of Total Billed Charges,90% of Total billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.57,65,,68.904,Percent of total Billed Charges,65% of Total Billed Charges,28.2,44.1,,6.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,60.75,95,,5.28,Percent of Total Billed Charges,95% of Total Billed Charges,63.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.28,88,,12.304,Percent of Total Billed Charges,88% of Total Billed Charges,57.56,90,,5.008,Percent of Total Billed charges,90% of Total Billed Charges,28.2,63.95,
COMBINED SPINAL/EPIDURAL TRAY,2780002243,CDM,278,RC,,,Outpatient,,,134.23,87.25,,134.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,102.01,76,,13.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,96.65,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,96.65,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,134.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.65,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,80.54,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,120.81,90,,368.232,Percent of Total Billed Charges,90% of Total Billed Charges,60.4,45,,7.448,Percent of Total Billed Charges,45% of Total Billed Charges,120.81,90,,15.536,Percent of Total Billed Charges,90% of Total billed Charges,134.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.25,65,,68.904,Percent of total Billed Charges,65% of Total Billed Charges,59.2,44.1,,7.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,127.52,95,,16.4,Percent of Total Billed Charges,95% of Total Billed Charges,134.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.12,88,,12.304,Percent of Total Billed Charges,88% of Total Billed Charges,120.81,90,,15.536,Percent of Total Billed charges,90% of Total Billed Charges,59.2,134.23,
SPINAL TRAY,2780002244,CDM,278,RC,,,Outpatient,,,65.43,42.53,,65.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.73,76,,4.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47.11,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,47.11,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,65.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.11,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,39.26,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,58.89,90,,235.136,Percent of Total Billed Charges,90% of Total Billed Charges,29.44,45,,6.296,Percent of Total Billed Charges,45% of Total Billed Charges,58.89,90,,5.008,Percent of Total Billed Charges,90% of Total billed Charges,65.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.53,65,,208,Percent of total Billed Charges,65% of Total Billed Charges,28.85,44.1,,6.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.16,95,,5.28,Percent of Total Billed Charges,95% of Total Billed Charges,65.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.58,88,,12.304,Percent of Total Billed Charges,88% of Total Billed Charges,58.89,90,,5.008,Percent of Total Billed charges,90% of Total Billed Charges,28.85,65.43,
HEMORHOID MULTIBAND LIGATOR,2780002245,CDM,278,RC,,,Outpatient,,,51.00,33.15,,51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38.76,76,,10.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36.72,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,36.72,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.72,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,30.6,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,45.9,90,,199.928,Percent of Total Billed Charges,90% of Total Billed Charges,22.95,45,,6.296,Percent of Total Billed Charges,45% of Total Billed Charges,45.9,90,,12.568,Percent of Total Billed Charges,90% of Total billed Charges,51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.15,65,,198.904,Percent of total Billed Charges,65% of Total Billed Charges,22.49,44.1,,6.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.45,95,,13.264,Percent of Total Billed Charges,95% of Total Billed Charges,51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.88,88,,12.304,Percent of Total Billed Charges,88% of Total Billed Charges,45.9,90,,12.568,Percent of Total Billed charges,90% of Total Billed Charges,22.49,51,
XEROFORM PETROLEUM GAUZE,2780002246,CDM,272,RC,,,Outpatient,,,0.50,0.33,,0.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.38,76,,12.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.36,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,0.38,75,,1152,Percent of Total Billed charges,75% of Total Billed Charges,0.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.36,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,0.3,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,0.45,90,,100.8,Percent of Total Billed Charges,90% of Total Billed Charges,0.23,45,,6.296,Percent of Total Billed Charges,45% of Total Billed Charges,0.45,90,,14.888,Percent of Total Billed Charges,90% of Total billed Charges,0.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.33,65,,46.8,Percent of total Billed Charges,65% of Total Billed Charges,0.22,44.1,,6.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,0.48,95,,15.72,Percent of Total Billed Charges,95% of Total Billed Charges,0.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.44,88,,12.304,Percent of Total Billed Charges,88% of Total Billed Charges,0.45,90,,14.888,Percent of Total Billed charges,90% of Total Billed Charges,0.22,0.5,
VC RETRIEVAL KIT,2780002248,CDM,278,RC,,,Outpatient,,,324.14,210.69,,324.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,246.35,76,,10.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,233.38,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,233.38,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.38,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,194.48,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,291.73,90,,100.8,Percent of Total Billed Charges,90% of Total Billed Charges,145.86,45,,6.296,Percent of Total Billed Charges,45% of Total Billed Charges,291.73,90,,12.584,Percent of Total Billed Charges,90% of Total billed Charges,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.69,65,,73.48,Percent of total Billed Charges,65% of Total Billed Charges,142.95,44.1,,6.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,307.93,95,,13.288,Percent of Total Billed Charges,95% of Total Billed Charges,324.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.24,88,,14.56,Percent of Total Billed Charges,88% of Total Billed Charges,291.73,90,,12.584,Percent of Total Billed charges,90% of Total Billed Charges,142.95,324.14,
TR BAND REGULAR LENGTH,2780002249,CDM,278,RC,,,Outpatient,,,189.63,123.26,,189.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.12,76,,10.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,136.53,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,136.53,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.53,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,113.78,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,170.67,90,,100.8,Percent of Total Billed Charges,90% of Total Billed Charges,85.33,45,,6.296,Percent of Total Billed Charges,45% of Total Billed Charges,170.67,90,,12.584,Percent of Total Billed Charges,90% of Total billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.26,65,,66.952,Percent of total Billed Charges,65% of Total Billed Charges,83.63,44.1,,6.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,180.15,95,,13.288,Percent of Total Billed Charges,95% of Total Billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.87,88,,360.048,Percent of Total Billed Charges,88% of Total Billed Charges,170.67,90,,12.584,Percent of Total Billed charges,90% of Total Billed Charges,83.63,189.63,
TR BAND XL LENGTH,2780002250,CDM,278,RC,,,Outpatient,,,189.63,123.26,,189.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.12,76,,10.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,136.53,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,136.53,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.53,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,113.78,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,170.67,90,,100.8,Percent of Total Billed Charges,90% of Total Billed Charges,85.33,45,,7.448,Percent of Total Billed Charges,45% of Total Billed Charges,170.67,90,,12.584,Percent of Total Billed Charges,90% of Total billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.26,65,,56.552,Percent of total Billed Charges,65% of Total Billed Charges,83.63,44.1,,7.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,180.15,95,,13.288,Percent of Total Billed Charges,95% of Total Billed Charges,189.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.87,88,,229.912,Percent of Total Billed Charges,88% of Total Billed Charges,170.67,90,,12.584,Percent of Total Billed charges,90% of Total Billed Charges,83.63,189.63,
MONARCH INFLATION DE,2780002251,CDM,272,RC,,,Outpatient,,,157.66,102.48,,157.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,119.82,76,,10.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,113.52,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,118.25,75,,1152,Percent of Total Billed charges,75% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.52,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,94.6,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,141.89,90,,100.8,Percent of Total Billed Charges,90% of Total Billed Charges,70.95,45,,184.112,Percent of Total Billed Charges,45% of Total Billed Charges,141.89,90,,12.584,Percent of Total Billed Charges,90% of Total billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.48,65,,46.8,Percent of total Billed Charges,65% of Total Billed Charges,69.53,44.1,,180.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,149.78,95,,13.288,Percent of Total Billed Charges,95% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.74,88,,195.488,Percent of Total Billed Charges,88% of Total Billed Charges,141.89,90,,12.584,Percent of Total Billed charges,90% of Total Billed Charges,69.53,157.66,
20 MONOCRYL + MCP94,2780002253,CDM,278,RC,,,Outpatient,,,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,10.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.08,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,15.08,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.08,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,12.57,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,18.86,90,,100.8,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,117.568,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,12.584,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,56.552,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,115.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,13.288,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,98.56,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,12.584,Percent of Total Billed charges,90% of Total Billed Charges,9.24,20.95,
ETHIBAND EXCEL X424,2780002254,CDM,278,RC,,,Outpatient,,,18.74,12.18,,18.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.24,76,,12.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.49,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,13.49,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.49,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,11.24,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,16.87,90,,100.8,Percent of Total Billed Charges,90% of Total Billed Charges,8.43,45,,99.968,Percent of Total Billed Charges,45% of Total Billed Charges,16.87,90,,14.888,Percent of Total Billed Charges,90% of Total billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.18,65,,46.8,Percent of total Billed Charges,65% of Total Billed Charges,8.26,44.1,,97.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.8,95,,15.72,Percent of Total Billed Charges,95% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,88,,98.56,Percent of Total Billed Charges,88% of Total Billed Charges,16.87,90,,14.888,Percent of Total Billed charges,90% of Total Billed Charges,8.26,18.74,
COPILOT TOUHY,2780002256,CDM,278,RC,,,Outpatient,,,185.22,120.39,,185.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,140.77,76,,310.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,133.36,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,133.36,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.36,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,111.13,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,166.7,90,,100.8,Percent of Total Billed Charges,90% of Total Billed Charges,83.35,45,,50.4,Percent of Total Billed Charges,45% of Total Billed Charges,166.7,90,,368.232,Percent of Total Billed Charges,90% of Total billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.39,65,,66.952,Percent of total Billed Charges,65% of Total Billed Charges,81.68,44.1,,49.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,175.96,95,,388.688,Percent of Total Billed Charges,95% of Total Billed Charges,185.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.99,88,,98.56,Percent of Total Billed Charges,88% of Total Billed Charges,166.7,90,,368.232,Percent of Total Billed charges,90% of Total Billed Charges,81.68,185.22,
PRIORITY PAK INFLATION DEVICE,2780002257,CDM,278,RC,,,Outpatient,,,158.76,103.19,,158.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.66,76,,198.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.31,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,114.31,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.31,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,95.26,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,142.88,90,,164.704,Percent of Total Billed Charges,90% of Total Billed Charges,71.44,45,,50.4,Percent of Total Billed Charges,45% of Total Billed Charges,142.88,90,,235.136,Percent of Total Billed Charges,90% of Total billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.19,65,,73.48,Percent of total Billed Charges,65% of Total Billed Charges,70.01,44.1,,49.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,150.82,95,,248.2,Percent of Total Billed Charges,95% of Total Billed Charges,158.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.71,88,,98.56,Percent of Total Billed Charges,88% of Total Billed Charges,142.88,90,,235.136,Percent of Total Billed charges,90% of Total Billed Charges,70.01,158.76,
COOK 18F 20CM DILATOR,2780002258,CDM,278,RC,C1889,HCPCS,Outpatient,,,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,168.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,21.43,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,157.776,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,50.4,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,199.928,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,73.448,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,49.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,211.04,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,98.56,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,199.928,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
MIC 18FX30CM GJTUBE,2780002259,CDM,278,RC,,,Outpatient,,,773.90,503.04,,773.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,588.16,76,,85.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,557.21,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,557.21,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,773.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,557.21,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,464.34,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,696.51,90,,164.704,Percent of Total Billed Charges,90% of Total Billed Charges,348.26,45,,50.4,Percent of Total Billed Charges,45% of Total Billed Charges,696.51,90,,100.8,Percent of Total Billed Charges,90% of Total billed Charges,773.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,773.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,773.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,503.04,65,,73.448,Percent of total Billed Charges,65% of Total Billed Charges,341.29,44.1,,49.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,735.21,95,,106.4,Percent of Total Billed Charges,95% of Total Billed Charges,773.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,681.03,88,,98.56,Percent of Total Billed Charges,88% of Total Billed Charges,696.51,90,,100.8,Percent of Total Billed charges,90% of Total Billed Charges,341.29,773.9,
PEG 18F REPL GT TUBE BRTTRI,2780002260,CDM,278,RC,,,Outpatient,,,227.20,147.68,,227.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,172.67,76,,85.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,163.58,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,163.58,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,227.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.58,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,136.32,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,204.48,90,,95.4,Percent of Total Billed Charges,90% of Total Billed Charges,102.24,45,,50.4,Percent of Total Billed Charges,45% of Total Billed Charges,204.48,90,,100.8,Percent of Total Billed Charges,90% of Total billed Charges,227.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.68,65,,61.424,Percent of total Billed Charges,65% of Total Billed Charges,100.2,44.1,,49.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,215.84,95,,106.4,Percent of Total Billed Charges,95% of Total Billed Charges,227.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.94,88,,98.56,Percent of Total Billed Charges,88% of Total Billed Charges,204.48,90,,100.8,Percent of Total Billed charges,90% of Total Billed Charges,100.2,227.2,
MIC 22FX45CM GJTUBE,2780002261,CDM,278,RC,,,Outpatient,,,773.90,503.04,,773.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,588.16,76,,85.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,557.21,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,557.21,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,773.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,557.21,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,464.34,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,696.51,90,,95.4,Percent of Total Billed Charges,90% of Total Billed Charges,348.26,45,,50.4,Percent of Total Billed Charges,45% of Total Billed Charges,696.51,90,,100.8,Percent of Total Billed Charges,90% of Total billed Charges,773.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,773.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,773.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,503.04,65,,46.8,Percent of total Billed Charges,65% of Total Billed Charges,341.29,44.1,,49.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,735.21,95,,106.4,Percent of Total Billed Charges,95% of Total Billed Charges,773.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,681.03,88,,98.56,Percent of Total Billed Charges,88% of Total Billed Charges,696.51,90,,100.8,Percent of Total Billed charges,90% of Total Billed Charges,341.29,773.9,
PEG 24F REPL GT TUBE BRTTRI,2780002262,CDM,278,RC,,,Outpatient,,,227.20,147.68,,227.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,172.67,76,,85.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,163.58,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,163.58,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,227.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.58,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,136.32,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,204.48,90,,95.4,Percent of Total Billed Charges,90% of Total Billed Charges,102.24,45,,50.4,Percent of Total Billed Charges,45% of Total Billed Charges,204.48,90,,100.8,Percent of Total Billed Charges,90% of Total billed Charges,227.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.68,65,,265.2,Percent of total Billed Charges,65% of Total Billed Charges,100.2,44.1,,49.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,215.84,95,,106.4,Percent of Total Billed Charges,95% of Total Billed Charges,227.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.94,88,,161.04,Percent of Total Billed Charges,88% of Total Billed Charges,204.48,90,,100.8,Percent of Total Billed charges,90% of Total Billed Charges,100.2,227.2,
PEG 22F REPL GT TUBE BRTTRI,2780002263,CDM,278,RC,,,Outpatient,,,227.20,147.68,,227.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,172.67,76,,85.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,163.58,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,163.58,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,227.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.58,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,136.32,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,204.48,90,,95.4,Percent of Total Billed Charges,90% of Total Billed Charges,102.24,45,,50.4,Percent of Total Billed Charges,45% of Total Billed Charges,204.48,90,,100.8,Percent of Total Billed Charges,90% of Total billed Charges,227.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.68,65,,52,Percent of total Billed Charges,65% of Total Billed Charges,100.2,44.1,,49.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,215.84,95,,106.4,Percent of Total Billed Charges,95% of Total Billed Charges,227.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.94,88,,154.264,Percent of Total Billed Charges,88% of Total Billed Charges,204.48,90,,100.8,Percent of Total Billed charges,90% of Total Billed Charges,100.2,227.2,
CVC 7F 20CM TRIPLE,2780002264,CDM,278,RC,,,Outpatient,,,385.88,250.82,,385.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,293.27,76,,85.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,277.83,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,277.83,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,385.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.83,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,231.53,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,347.29,90,,95.4,Percent of Total Billed Charges,90% of Total Billed Charges,173.65,45,,82.352,Percent of Total Billed Charges,45% of Total Billed Charges,347.29,90,,100.8,Percent of Total Billed Charges,90% of Total billed Charges,385.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.82,65,,56.056,Percent of total Billed Charges,65% of Total Billed Charges,170.17,44.1,,80.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,366.59,95,,106.4,Percent of Total Billed Charges,95% of Total Billed Charges,385.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,339.57,88,,161.04,Percent of Total Billed Charges,88% of Total Billed Charges,347.29,90,,100.8,Percent of Total Billed charges,90% of Total Billed Charges,170.17,385.88,
ER SUPPLIES,2780002265,CDM,278,RC,,,Outpatient,,,112.85,73.35,,112.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,85.77,76,,85.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,81.25,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,81.25,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,112.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.25,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,67.71,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,101.57,90,,95.4,Percent of Total Billed Charges,90% of Total Billed Charges,50.78,45,,78.888,Percent of Total Billed Charges,45% of Total Billed Charges,101.57,90,,100.8,Percent of Total Billed Charges,90% of Total billed Charges,112.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.35,65,,56.056,Percent of total Billed Charges,65% of Total Billed Charges,49.77,44.1,,77.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,107.21,95,,106.4,Percent of Total Billed Charges,95% of Total Billed Charges,112.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.31,88,,93.28,Percent of Total Billed Charges,88% of Total Billed Charges,101.57,90,,100.8,Percent of Total Billed charges,90% of Total Billed Charges,49.77,112.85,
SYRINGE TUBING,2780002266,CDM,278,RC,,,Outpatient,,,19.93,12.95,,19.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.15,76,,85.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.35,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,14.35,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,19.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.35,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,11.96,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,17.94,90,,95.4,Percent of Total Billed Charges,90% of Total Billed Charges,8.97,45,,82.352,Percent of Total Billed Charges,45% of Total Billed Charges,17.94,90,,100.8,Percent of Total Billed Charges,90% of Total billed Charges,19.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.95,65,,56.056,Percent of total Billed Charges,65% of Total Billed Charges,8.79,44.1,,80.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.93,95,,106.4,Percent of Total Billed Charges,95% of Total Billed Charges,19.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.54,88,,93.28,Percent of Total Billed Charges,88% of Total Billed Charges,17.94,90,,100.8,Percent of Total Billed charges,90% of Total Billed Charges,8.79,19.93,
BURETTE SMARTSITE TUBING,2780002267,CDM,278,RC,,,Outpatient,,,34.00,22.10,,34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.84,76,,139.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.48,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,24.48,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.48,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,20.4,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,30.6,90,,288,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,45,,47.704,Percent of Total Billed Charges,45% of Total Billed Charges,30.6,90,,164.704,Percent of Total Billed Charges,90% of Total billed Charges,34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.1,65,,56.056,Percent of total Billed Charges,65% of Total Billed Charges,14.99,44.1,,46.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.3,95,,173.848,Percent of Total Billed Charges,95% of Total Billed Charges,34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.92,88,,93.28,Percent of Total Billed Charges,88% of Total Billed Charges,30.6,90,,164.704,Percent of Total Billed charges,90% of Total Billed Charges,14.99,34,
KATZ EXTRACTOR #1021,2780002268,CDM,278,RC,,,Outpatient,,,295.47,192.06,,295.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,224.56,76,,133.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,212.74,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,212.74,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.74,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,177.28,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,265.92,90,,275.4,Percent of Total Billed Charges,90% of Total Billed Charges,132.96,45,,47.704,Percent of Total Billed Charges,45% of Total Billed Charges,265.92,90,,157.776,Percent of Total Billed Charges,90% of Total billed Charges,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.06,65,,56.056,Percent of total Billed Charges,65% of Total Billed Charges,130.3,44.1,,46.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,280.7,95,,166.536,Percent of Total Billed Charges,95% of Total Billed Charges,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.01,88,,93.28,Percent of Total Billed Charges,88% of Total Billed Charges,265.92,90,,157.776,Percent of Total Billed charges,90% of Total Billed Charges,130.3,295.47,
GASTROSTOMY TUBE,2780002269,CDM,278,RC,,,Outpatient,,,208.37,135.44,,208.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,158.36,76,,139.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.03,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,150.03,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.03,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,125.02,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,187.53,90,,64.8,Percent of Total Billed Charges,90% of Total Billed Charges,93.77,45,,47.704,Percent of Total Billed Charges,45% of Total Billed Charges,187.53,90,,164.704,Percent of Total Billed Charges,90% of Total billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.44,65,,80.6,Percent of total Billed Charges,65% of Total Billed Charges,91.89,44.1,,46.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,197.95,95,,173.848,Percent of Total Billed Charges,95% of Total Billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.37,88,,93.28,Percent of Total Billed Charges,88% of Total Billed Charges,187.53,90,,164.704,Percent of Total Billed charges,90% of Total Billed Charges,91.89,208.37,
INTERSPACE SM-LARGE,2780002270,CDM,278,RC,,,Outpatient,,,12568.50,8169.53,,12568.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9552.06,76,,80.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9049.32,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,9049.32,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,12568.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9049.32,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,7541.1,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,11311.65,90,,101.736,Percent of Total Billed Charges,90% of Total Billed Charges,5655.83,45,,47.704,Percent of Total Billed Charges,45% of Total Billed Charges,11311.65,90,,95.4,Percent of Total Billed Charges,90% of Total billed Charges,12568.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12568.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12568.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8169.53,65,,80.28,Percent of total Billed Charges,65% of Total Billed Charges,5542.71,44.1,,46.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,11940.08,95,,100.704,Percent of Total Billed Charges,95% of Total Billed Charges,12568.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11060.28,88,,93.28,Percent of Total Billed Charges,88% of Total Billed Charges,11311.65,90,,95.4,Percent of Total Billed charges,90% of Total Billed Charges,5542.71,12568.5,
Z4827-22-012.7 CORTI,2780002271,CDM,278,RC,,,Outpatient,,,95.92,62.35,,95.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.9,76,,80.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.06,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,69.06,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.06,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,57.55,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,86.33,90,,92.704,Percent of Total Billed Charges,90% of Total Billed Charges,43.16,45,,47.704,Percent of Total Billed Charges,45% of Total Billed Charges,86.33,90,,95.4,Percent of Total Billed Charges,90% of Total billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.35,65,,64.584,Percent of total Billed Charges,65% of Total Billed Charges,42.3,44.1,,46.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.12,95,,100.704,Percent of Total Billed Charges,95% of Total Billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.41,88,,93.28,Percent of Total Billed Charges,88% of Total Billed Charges,86.33,90,,95.4,Percent of Total Billed charges,90% of Total Billed Charges,42.3,95.92,
Z4300-46-18 MOD HUM,2780002272,CDM,278,RC,,,Outpatient,,,8234.57,5352.47,,8234.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6258.27,76,,80.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5928.89,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,5928.89,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,8234.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5928.89,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,4940.74,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,7411.11,90,,78.304,Percent of Total Billed Charges,90% of Total Billed Charges,3705.56,45,,47.704,Percent of Total Billed Charges,45% of Total Billed Charges,7411.11,90,,95.4,Percent of Total Billed Charges,90% of Total billed Charges,8234.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8234.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8234.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5352.47,65,,73.448,Percent of total Billed Charges,65% of Total Billed Charges,3631.45,44.1,,46.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,7822.84,95,,100.704,Percent of Total Billed Charges,95% of Total Billed Charges,8234.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7246.42,88,,281.6,Percent of Total Billed Charges,88% of Total Billed Charges,7411.11,90,,95.4,Percent of Total Billed charges,90% of Total Billed Charges,3631.45,8234.57,
Z2240-13-16 RETROFEM,2780002273,CDM,278,RC,,,Outpatient,,,6949.06,4516.89,,6949.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5281.29,76,,80.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5003.32,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,5003.32,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,6949.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5003.32,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,4169.44,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,6254.15,90,,64.8,Percent of Total Billed Charges,90% of Total Billed Charges,3127.08,45,,47.704,Percent of Total Billed Charges,45% of Total Billed Charges,6254.15,90,,95.4,Percent of Total Billed Charges,90% of Total billed Charges,6949.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6949.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6949.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4516.89,65,,80.6,Percent of total Billed Charges,65% of Total Billed Charges,3064.54,44.1,,46.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,6601.61,95,,100.704,Percent of Total Billed Charges,95% of Total Billed Charges,6949.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6115.17,88,,269.28,Percent of Total Billed Charges,88% of Total Billed Charges,6254.15,90,,95.4,Percent of Total Billed charges,90% of Total Billed Charges,3064.54,6949.06,
Z2253-90-55 5.5 CORT,2780002274,CDM,278,RC,,,Outpatient,,,845.62,549.65,,845.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,642.67,76,,80.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,608.85,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,608.85,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,608.85,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,507.37,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,761.06,90,,78.304,Percent of Total Billed Charges,90% of Total Billed Charges,380.53,45,,144,Percent of Total Billed Charges,45% of Total Billed Charges,761.06,90,,95.4,Percent of Total Billed Charges,90% of Total billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.65,65,,52,Percent of total Billed Charges,65% of Total Billed Charges,372.92,44.1,,141.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,803.34,95,,100.704,Percent of Total Billed Charges,95% of Total Billed Charges,845.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,744.15,88,,63.36,Percent of Total Billed Charges,88% of Total Billed Charges,761.06,90,,95.4,Percent of Total Billed charges,90% of Total Billed Charges,372.92,845.62,
GOLD WEIGHT 0.8,2780002275,CDM,278,RC,,,Outpatient,,,949.25,617.01,,949.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,721.43,76,,80.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,683.46,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,683.46,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,949.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,683.46,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,569.55,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,854.33,90,,64.8,Percent of Total Billed Charges,90% of Total Billed Charges,427.16,45,,137.704,Percent of Total Billed Charges,45% of Total Billed Charges,854.33,90,,95.4,Percent of Total Billed Charges,90% of Total billed Charges,949.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,949.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,949.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,617.01,65,,52,Percent of total Billed Charges,65% of Total Billed Charges,418.62,44.1,,134.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,901.79,95,,100.704,Percent of Total Billed Charges,95% of Total Billed Charges,949.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,835.34,88,,99.472,Percent of Total Billed Charges,88% of Total Billed Charges,854.33,90,,95.4,Percent of Total Billed charges,90% of Total Billed Charges,418.62,949.25,
Z1147-070-76 32MM TH,2780002276,CDM,278,RC,,,Outpatient,,,1304.26,847.77,,1304.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,991.24,76,,80.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,939.07,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,939.07,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,1304.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,939.07,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,782.56,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,1173.83,90,,92.704,Percent of Total Billed Charges,90% of Total Billed Charges,586.92,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,1173.83,90,,95.4,Percent of Total Billed Charges,90% of Total billed Charges,1304.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1304.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1304.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,847.77,65,,52,Percent of total Billed Charges,65% of Total Billed Charges,575.18,44.1,,31.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,1239.05,95,,100.704,Percent of Total Billed Charges,95% of Total Billed Charges,1304.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1147.75,88,,90.64,Percent of Total Billed Charges,88% of Total Billed Charges,1173.83,90,,95.4,Percent of Total Billed charges,90% of Total Billed Charges,575.18,1304.26,
Z5988-10-10 REV STEM,2780002277,CDM,278,RC,,,Outpatient,,,4604.04,2992.63,,4604.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3499.07,76,,243.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3314.91,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,3314.91,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3314.91,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,2762.42,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,4143.64,90,,101.736,Percent of Total Billed Charges,90% of Total Billed Charges,2071.82,45,,50.872,Percent of Total Billed Charges,45% of Total Billed Charges,4143.64,90,,288,Percent of Total Billed Charges,90% of Total billed Charges,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2992.63,65,,52,Percent of total Billed Charges,65% of Total Billed Charges,2030.38,44.1,,49.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,4373.84,95,,304,Percent of Total Billed Charges,95% of Total Billed Charges,4604.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4051.56,88,,76.56,Percent of Total Billed Charges,88% of Total Billed Charges,4143.64,90,,288,Percent of Total Billed charges,90% of Total Billed Charges,2030.38,4604.04,
DPY SMALL BONE 1.6 F,2780002278,CDM,278,RC,,,Outpatient,,,1708.88,1110.77,,1708.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1298.75,76,,232.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1230.39,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,1230.39,72,,1152,Percent of Total Billed charges,72% of Total Billed Charges,1708.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1230.39,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,1025.33,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,1537.99,90,,101.704,Percent of Total Billed Charges,90% of Total Billed Charges,769,45,,46.352,Percent of Total Billed Charges,45% of Total Billed Charges,1537.99,90,,275.4,Percent of Total Billed Charges,90% of Total billed Charges,1708.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1708.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1708.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1110.77,65,,52,Percent of total Billed Charges,65% of Total Billed Charges,753.62,44.1,,45.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,1623.44,95,,290.704,Percent of Total Billed Charges,95% of Total Billed Charges,1708.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1503.81,88,,63.36,Percent of Total Billed Charges,88% of Total Billed Charges,1537.99,90,,275.4,Percent of Total Billed charges,90% of Total Billed Charges,753.62,1708.88,
Z2232-50-19CABLE-REA,2780002279,CDM,278,RC,,,Outpatient,,,2283.28,1484.13,,2283.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1735.29,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1643.96,72,,26006.4,Percent of Total Billed Charges,72% of Total Billed Charges,1643.96,72,,26006.4,Percent of Total Billed charges,72% of Total Billed Charges,2283.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1643.96,72,,26006.4,Percent of Total Billed Charges,72% of Total Billed Charges,1369.97,60,,21672,Percent of Total Billed Charges,60% of Total Billed Charges,2054.95,90,,101.704,Percent of Total Billed Charges,90% of Total Billed Charges,1027.48,45,,39.152,Percent of Total Billed Charges,45% of Total Billed Charges,2054.95,90,,64.8,Percent of Total Billed Charges,90% of Total billed Charges,2283.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2283.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2283.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1484.13,65,,52,Percent of total Billed Charges,65% of Total Billed Charges,1006.93,44.1,,38.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,2169.12,95,,68.4,Percent of Total Billed Charges,95% of Total Billed Charges,2283.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2009.29,88,,76.56,Percent of Total Billed Charges,88% of Total Billed Charges,2054.95,90,,64.8,Percent of Total Billed charges,90% of Total Billed Charges,1006.93,2283.28,
Z5994-40-17 ART/SURF,2780002280,CDM,278,RC,,,Outpatient,,,7191.61,4674.55,,7191.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5465.62,76,,85.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5177.96,72,,7424.64,Percent of Total Billed Charges,72% of Total Billed Charges,5177.96,72,,7424.64,Percent of Total Billed charges,72% of Total Billed Charges,7191.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5177.96,72,,7424.64,Percent of Total Billed Charges,72% of Total Billed Charges,4314.97,60,,6187.2,Percent of Total Billed Charges,60% of Total Billed Charges,6472.45,90,,85.056,Percent of Total Billed Charges,90% of Total Billed Charges,3236.22,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,6472.45,90,,101.736,Percent of Total Billed Charges,90% of Total billed Charges,7191.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7191.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7191.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4674.55,65,,261.304,Percent of total Billed Charges,65% of Total Billed Charges,3171.5,44.1,,31.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,6832.03,95,,107.392,Percent of Total Billed Charges,95% of Total Billed Charges,7191.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6328.62,88,,63.36,Percent of Total Billed Charges,88% of Total Billed Charges,6472.45,90,,101.736,Percent of Total Billed charges,90% of Total Billed Charges,3171.5,7191.61,
SURGIMESH XB7,2780002281,CDM,278,RC,C1781,HCPCS,Outpatient,,,3018.00,1961.70,,3018,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2293.68,76,,78.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2172.96,72,,7424.64,Percent of Total Billed Charges,72% of Total Billed Charges,2172.96,72,,7424.64,Percent of Total Billed charges,72% of Total Billed Charges,3018,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2172.96,72,,7424.64,Percent of Total Billed Charges,72% of Total Billed Charges,1810.8,60,,6187.2,Percent of Total Billed Charges,60% of Total Billed Charges,2716.2,90,,64.8,Percent of Total Billed Charges,90% of Total Billed Charges,1358.1,45,,39.152,Percent of Total Billed Charges,45% of Total Billed Charges,2716.2,90,,92.704,Percent of Total Billed Charges,90% of Total billed Charges,3018,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3018,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3018,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1961.7,65,,313.304,Percent of total Billed Charges,65% of Total Billed Charges,1330.94,44.1,,38.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,2867.1,95,,97.848,Percent of Total Billed Charges,95% of Total Billed Charges,3018,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2655.84,88,,90.64,Percent of Total Billed Charges,88% of Total Billed Charges,2716.2,90,,92.704,Percent of Total Billed charges,90% of Total Billed Charges,1330.94,3018,
Z500153 BIPOLAR SHELL 53MM,2780002282,CDM,278,RC,C1726,HCPCS,Outpatient,,,1855.00,1205.75,,1855,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1409.8,76,,66.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1335.6,72,,6480,Percent of Total Billed Charges,72% of Total Billed Charges,1335.6,72,,6480,Percent of Total Billed charges,72% of Total Billed Charges,1855,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1335.6,72,,6480,Percent of Total Billed Charges,72% of Total Billed Charges,1113,60,,5400,Percent of Total Billed Charges,60% of Total Billed Charges,1669.5,90,,367.2,Percent of Total Billed Charges,90% of Total Billed Charges,834.75,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,1669.5,90,,78.304,Percent of Total Billed Charges,90% of Total billed Charges,1855,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1855,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1855,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1205.75,65,,773.504,Percent of total Billed Charges,65% of Total Billed Charges,818.06,44.1,,31.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,1762.25,95,,82.648,Percent of Total Billed Charges,95% of Total Billed Charges,1855,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1632.4,88,,99.472,Percent of Total Billed Charges,88% of Total Billed Charges,1669.5,90,,78.304,Percent of Total Billed charges,90% of Total Billed Charges,818.06,1855,
Z11471441 4.0 CANN SCW 14,2780002283,CDM,278,RC,C1713,HCPCS,Outpatient,,,564.00,366.60,,564,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,428.64,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,406.08,72,,5410.08,Percent of Total Billed Charges,72% of Total Billed Charges,406.08,72,,5410.08,Percent of Total Billed charges,72% of Total Billed Charges,564,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.08,72,,5410.08,Percent of Total Billed Charges,72% of Total Billed Charges,338.4,60,,4508.4,Percent of Total Billed Charges,60% of Total Billed Charges,507.6,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,253.8,45,,46.352,Percent of Total Billed Charges,45% of Total Billed Charges,507.6,90,,64.8,Percent of Total Billed Charges,90% of Total billed Charges,564,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,564,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,564,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.6,65,,74.104,Percent of total Billed Charges,65% of Total Billed Charges,248.72,44.1,,45.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,535.8,95,,68.4,Percent of Total Billed Charges,95% of Total Billed Charges,564,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,496.32,88,,99.44,Percent of Total Billed Charges,88% of Total Billed Charges,507.6,90,,64.8,Percent of Total Billed charges,90% of Total Billed Charges,248.72,564,
Z11471041 4.0 CANN SCW 10,2780002284,CDM,278,RC,C1713,HCPCS,Outpatient,,,564.00,366.60,,564,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,428.64,76,,66.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,406.08,72,,5410.08,Percent of Total Billed Charges,72% of Total Billed Charges,406.08,72,,5410.08,Percent of Total Billed charges,72% of Total Billed Charges,564,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.08,72,,5410.08,Percent of Total Billed Charges,72% of Total Billed Charges,338.4,60,,4508.4,Percent of Total Billed Charges,60% of Total Billed Charges,507.6,90,,77.616,Percent of Total Billed Charges,90% of Total Billed Charges,253.8,45,,50.872,Percent of Total Billed Charges,45% of Total Billed Charges,507.6,90,,78.304,Percent of Total Billed Charges,90% of Total billed Charges,564,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,564,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,564,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.6,65,,108.68,Percent of total Billed Charges,65% of Total Billed Charges,248.72,44.1,,49.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,535.8,95,,82.648,Percent of Total Billed Charges,95% of Total Billed Charges,564,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,496.32,88,,99.44,Percent of Total Billed Charges,88% of Total Billed Charges,507.6,90,,78.304,Percent of Total Billed charges,90% of Total Billed Charges,248.72,564,
Z11471241 4.0 CANN SCW 12,2780002285,CDM,278,RC,C1713,HCPCS,Outpatient,,,564.00,366.60,,564,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,428.64,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,406.08,72,,5918.4,Percent of Total Billed Charges,72% of Total Billed Charges,406.08,72,,5918.4,Percent of Total Billed charges,72% of Total Billed Charges,564,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.08,72,,5918.4,Percent of Total Billed Charges,72% of Total Billed Charges,338.4,60,,4932,Percent of Total Billed Charges,60% of Total Billed Charges,507.6,90,,77.616,Percent of Total Billed Charges,90% of Total Billed Charges,253.8,45,,50.848,Percent of Total Billed Charges,45% of Total Billed Charges,507.6,90,,64.8,Percent of Total Billed Charges,90% of Total billed Charges,564,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,564,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,564,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.6,65,,108.68,Percent of total Billed Charges,65% of Total Billed Charges,248.72,44.1,,49.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,535.8,95,,68.4,Percent of Total Billed Charges,95% of Total Billed Charges,564,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,496.32,88,,83.16,Percent of Total Billed Charges,88% of Total Billed Charges,507.6,90,,64.8,Percent of Total Billed charges,90% of Total Billed Charges,248.72,564,
SURGIMESH XB OVAL 10X15CM,2780002287,CDM,278,RC,C1781,HCPCS,Outpatient,,,5876.00,3819.40,,5876,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4465.76,76,,78.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4230.72,72,,5918.4,Percent of Total Billed Charges,72% of Total Billed Charges,4230.72,72,,5918.4,Percent of Total Billed charges,72% of Total Billed Charges,5876,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4230.72,72,,5918.4,Percent of Total Billed Charges,72% of Total Billed Charges,3525.6,60,,4932,Percent of Total Billed Charges,60% of Total Billed Charges,5288.4,90,,77.616,Percent of Total Billed Charges,90% of Total Billed Charges,2644.2,45,,50.848,Percent of Total Billed Charges,45% of Total Billed Charges,5288.4,90,,92.704,Percent of Total Billed Charges,90% of Total billed Charges,5876,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5876,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5876,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3819.4,65,,108.68,Percent of total Billed Charges,65% of Total Billed Charges,2591.32,44.1,,49.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,5582.2,95,,97.848,Percent of Total Billed Charges,95% of Total Billed Charges,5876,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5170.88,88,,63.36,Percent of Total Billed Charges,88% of Total Billed Charges,5288.4,90,,92.704,Percent of Total Billed charges,90% of Total Billed Charges,2591.32,5876,
MODIFIED JACKSON REES 2L LF,2780002288,CDM,272,RC,,,Outpatient,,,9.39,6.10,,9.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.14,76,,85.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.76,72,,6595.2,Percent of Total Billed Charges,72% of Total Billed Charges,7.04,75,,6595.2,Percent of Total Billed charges,75% of Total Billed Charges,9.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.76,72,,6595.2,Percent of Total Billed Charges,72% of Total Billed Charges,5.63,60,,5496,Percent of Total Billed Charges,60% of Total Billed Charges,8.45,90,,77.616,Percent of Total Billed Charges,90% of Total Billed Charges,4.23,45,,42.528,Percent of Total Billed Charges,45% of Total Billed Charges,8.45,90,,101.736,Percent of Total Billed Charges,90% of Total billed Charges,9.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.1,65,,108.68,Percent of total Billed Charges,65% of Total Billed Charges,4.14,44.1,,41.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.92,95,,107.392,Percent of Total Billed Charges,95% of Total Billed Charges,9.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.26,88,,359.04,Percent of Total Billed Charges,88% of Total Billed Charges,8.45,90,,101.736,Percent of Total Billed charges,90% of Total Billed Charges,4.14,9.39,
4F 2.0X150X150 NANO CRS PTA BA,2780002289,CDM,272,RC,C1725,HCPCS,Outpatient,,,3572.10,2321.87,,3572.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2714.8,76,,85.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2571.91,72,,10840.32,Percent of Total Billed Charges,72% of Total Billed Charges,2679.08,75,,10840.32,Percent of Total Billed charges,75% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2571.91,72,,10840.32,Percent of Total Billed Charges,72% of Total Billed Charges,2143.26,60,,9033.6,Percent of Total Billed Charges,60% of Total Billed Charges,3214.89,90,,77.616,Percent of Total Billed Charges,90% of Total Billed Charges,1607.45,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,3214.89,90,,101.704,Percent of Total Billed Charges,90% of Total billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2321.87,65,,120.248,Percent of total Billed Charges,65% of Total Billed Charges,1575.3,44.1,,31.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,3393.5,95,,107.352,Percent of Total Billed Charges,95% of Total Billed Charges,3572.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3143.45,88,,70.4,Percent of Total Billed Charges,88% of Total Billed Charges,3214.89,90,,101.704,Percent of Total Billed charges,90% of Total Billed Charges,1575.3,3572.1,
ARTHREX DB 3.5MM,2780002290,CDM,278,RC,C1716,HCPCS,Outpatient,,,95.00,61.75,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,72.2,76,,85.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,313.62,72,,5410.08,Percent of Total Billed Charges,72% of Total Billed Charges,313.62,72,,5410.08,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,313.62,72,,5410.08,Percent of Total Billed Charges,72% of Total Billed Charges,179.61,60,,4508.4,Percent of Total Billed Charges,60% of Total Billed Charges,85.5,90,,111.6,Percent of Total Billed Charges,90% of Total Billed Charges,42.75,45,,183.6,Percent of Total Billed Charges,45% of Total Billed Charges,85.5,90,,101.704,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1798.41,65,,120.248,Percent of total Billed Charges,65% of Total Billed Charges,41.9,44.1,,179.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,90.25,95,,107.352,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,83.6,88,,75.888,Percent of Total Billed Charges,88% of Total Billed Charges,85.5,90,,101.704,Percent of Total Billed charges,90% of Total Billed Charges,41.9,1798.41,
ACUMED DIS CLA PLT 3.5 9 LEFT,2780002291,CDM,278,RC,C1716,HCPCS,Outpatient,,,6642.00,4317.30,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,5047.92,76,,71.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5027.46,72,,5410.08,Percent of Total Billed Charges,72% of Total Billed Charges,5027.46,72,,5410.08,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,5027.46,72,,5410.08,Percent of Total Billed Charges,72% of Total Billed Charges,4107.81,60,,4508.4,Percent of Total Billed Charges,60% of Total Billed Charges,5977.8,90,,111.152,Percent of Total Billed Charges,90% of Total Billed Charges,2988.9,45,,36,Percent of Total Billed Charges,45% of Total Billed Charges,5977.8,90,,85.056,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6053.96,65,,120.248,Percent of total Billed Charges,65% of Total Billed Charges,2929.12,44.1,,35.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,6309.9,95,,89.776,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,5844.96,88,,75.888,Percent of Total Billed Charges,88% of Total Billed Charges,5977.8,90,,85.056,Percent of Total Billed charges,90% of Total Billed Charges,651.24,6309.9,
ARTHREX CALC PLT 5MM,2780002292,CDM,278,RC,C1716,HCPCS,Outpatient,,,5556.00,3611.40,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,4222.56,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4245.54,72,,5918.4,Percent of Total Billed Charges,72% of Total Billed Charges,4245.54,72,,5918.4,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,4245.54,72,,5918.4,Percent of Total Billed Charges,72% of Total Billed Charges,3456.21,60,,4932,Percent of Total Billed Charges,60% of Total Billed Charges,5000.4,90,,89.424,Percent of Total Billed Charges,90% of Total Billed Charges,2500.2,45,,38.808,Percent of Total Billed Charges,45% of Total Billed Charges,5000.4,90,,64.8,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,5348.06,65,,120.248,Percent of total Billed Charges,65% of Total Billed Charges,2450.2,44.1,,38.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,5278.2,95,,68.4,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,4889.28,88,,75.888,Percent of Total Billed Charges,88% of Total Billed Charges,5000.4,90,,64.8,Percent of Total Billed charges,90% of Total Billed Charges,651.24,5348.06,
ARTHREX LO-PRO SCW 3.5X18,2780002293,CDM,278,RC,C1716,HCPCS,Outpatient,,,305.00,198.25,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,231.8,76,,310.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,464.82,72,,5918.4,Percent of Total Billed Charges,72% of Total Billed Charges,464.82,72,,5918.4,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,464.82,72,,5918.4,Percent of Total Billed Charges,72% of Total Billed Charges,305.61,60,,4932,Percent of Total Billed Charges,60% of Total Billed Charges,274.5,90,,101.704,Percent of Total Billed Charges,90% of Total Billed Charges,137.25,45,,38.808,Percent of Total Billed Charges,45% of Total Billed Charges,274.5,90,,367.2,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1934.91,65,,120.248,Percent of total Billed Charges,65% of Total Billed Charges,134.51,44.1,,38.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,289.75,95,,387.6,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,268.4,88,,75.888,Percent of Total Billed Charges,88% of Total Billed Charges,274.5,90,,367.2,Percent of Total Billed charges,90% of Total Billed Charges,134.51,1934.91,
ARTHREX LCK SCW 3.5X18,2780002294,CDM,278,RC,C1716,HCPCS,Outpatient,,,763.00,495.95,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,579.88,76,,60.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,794.58,72,,6595.2,Percent of Total Billed Charges,72% of Total Billed Charges,794.58,72,,6595.2,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,794.58,72,,6595.2,Percent of Total Billed Charges,72% of Total Billed Charges,580.41,60,,5496,Percent of Total Billed Charges,60% of Total Billed Charges,686.7,90,,111.6,Percent of Total Billed Charges,90% of Total Billed Charges,343.35,45,,38.808,Percent of Total Billed Charges,45% of Total Billed Charges,686.7,90,,72,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2232.61,65,,120.248,Percent of total Billed Charges,65% of Total Billed Charges,336.48,44.1,,38.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,724.85,95,,76,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,671.44,88,,75.888,Percent of Total Billed Charges,88% of Total Billed Charges,686.7,90,,72,Percent of Total Billed charges,90% of Total Billed Charges,336.48,2232.61,
ARTHREX LO-PRO SCW 3.5X30,2780002295,CDM,278,RC,C1716,HCPCS,Outpatient,,,305.00,198.25,,1085.41,125,,,Fee Schedule,125% of CMS OPPS Rate,231.8,76,,65.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,464.82,72,,10840.32,Percent of Total Billed Charges,72% of Total Billed Charges,464.82,72,,10840.32,Percent of Total Billed charges,72% of Total Billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,464.82,72,,10840.32,Percent of Total Billed Charges,72% of Total Billed Charges,305.61,60,,9033.6,Percent of Total Billed Charges,60% of Total Billed Charges,274.5,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,137.25,45,,38.808,Percent of Total Billed Charges,45% of Total Billed Charges,274.5,90,,77.616,Percent of Total Billed Charges,90% of Total billed Charges,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1934.91,65,,98.152,Percent of total Billed Charges,65% of Total Billed Charges,134.51,44.1,,38.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,289.75,95,,81.928,Percent of Total Billed Charges,95% of Total Billed Charges,651.24,75,,,Fee Schedule,75% of CMS OPPS Rate,268.4,88,,109.12,Percent of Total Billed Charges,88% of Total Billed Charges,274.5,90,,77.616,Percent of Total Billed charges,90% of Total Billed Charges,134.51,1934.91,
Z4815-22-03 1.5MM CORT SCW 22,2780002296,CDM,278,RC,C1713,HCPCS,Outpatient,,,64.00,41.60,,64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,48.64,76,,65.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.08,72,,5410.08,Percent of Total Billed Charges,72% of Total Billed Charges,46.08,72,,5410.08,Percent of Total Billed charges,72% of Total Billed Charges,64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.08,72,,5410.08,Percent of Total Billed Charges,72% of Total Billed Charges,38.4,60,,4508.4,Percent of Total Billed Charges,60% of Total Billed Charges,57.6,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,28.8,45,,38.808,Percent of Total Billed Charges,45% of Total Billed Charges,57.6,90,,77.616,Percent of Total Billed Charges,90% of Total billed Charges,64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.6,65,,74.104,Percent of total Billed Charges,65% of Total Billed Charges,28.22,44.1,,38.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,60.8,95,,81.928,Percent of Total Billed Charges,95% of Total Billed Charges,64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.32,88,,108.68,Percent of Total Billed Charges,88% of Total Billed Charges,57.6,90,,77.616,Percent of Total Billed charges,90% of Total Billed Charges,28.22,64,
Z4827-06-01 2.7MM CORT SCW 6,2780002297,CDM,278,RC,C1713,HCPCS,Outpatient,,,64.00,41.60,,64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,48.64,76,,65.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.08,72,,5410.08,Percent of Total Billed Charges,72% of Total Billed Charges,46.08,72,,5410.08,Percent of Total Billed charges,72% of Total Billed Charges,64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.08,72,,5410.08,Percent of Total Billed Charges,72% of Total Billed Charges,38.4,60,,4508.4,Percent of Total Billed Charges,60% of Total Billed Charges,57.6,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,28.8,45,,55.8,Percent of Total Billed Charges,45% of Total Billed Charges,57.6,90,,77.616,Percent of Total Billed Charges,90% of Total billed Charges,64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.6,65,,74.104,Percent of total Billed Charges,65% of Total Billed Charges,28.22,44.1,,54.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,60.8,95,,81.928,Percent of Total Billed Charges,95% of Total Billed Charges,64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.32,88,,87.44,Percent of Total Billed Charges,88% of Total Billed Charges,57.6,90,,77.616,Percent of Total Billed charges,90% of Total Billed Charges,28.22,64,
Z4920-06 COMP PLATE 2.0X6 HOLE,2780002298,CDM,278,RC,C1713,HCPCS,Outpatient,,,476.00,309.40,,476,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,361.76,76,,65.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,342.72,72,,5918.4,Percent of Total Billed Charges,72% of Total Billed Charges,342.72,72,,5918.4,Percent of Total Billed charges,72% of Total Billed Charges,476,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.72,72,,5918.4,Percent of Total Billed Charges,72% of Total Billed Charges,285.6,60,,4932,Percent of Total Billed Charges,60% of Total Billed Charges,428.4,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,214.2,45,,55.576,Percent of Total Billed Charges,45% of Total Billed Charges,428.4,90,,77.616,Percent of Total Billed Charges,90% of Total billed Charges,476,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.4,65,,98.152,Percent of total Billed Charges,65% of Total Billed Charges,209.92,44.1,,54.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,452.2,95,,81.928,Percent of Total Billed Charges,95% of Total Billed Charges,476,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,418.88,88,,99.44,Percent of Total Billed Charges,88% of Total Billed Charges,428.4,90,,77.616,Percent of Total Billed charges,90% of Total Billed Charges,209.92,476,
Z4820-06-03 2.0 CORT SCW 16,2780002299,CDM,278,RC,C1713,HCPCS,Outpatient,,,67.00,43.55,,67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,50.92,76,,65.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,48.24,72,,5918.4,Percent of Total Billed Charges,72% of Total Billed Charges,48.24,72,,5918.4,Percent of Total Billed charges,72% of Total Billed Charges,67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.24,72,,5918.4,Percent of Total Billed Charges,72% of Total Billed Charges,40.2,60,,4932,Percent of Total Billed Charges,60% of Total Billed Charges,60.3,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,30.15,45,,44.712,Percent of Total Billed Charges,45% of Total Billed Charges,60.3,90,,77.616,Percent of Total Billed Charges,90% of Total billed Charges,67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.55,65,,74.104,Percent of total Billed Charges,65% of Total Billed Charges,29.55,44.1,,43.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,63.65,95,,81.928,Percent of Total Billed Charges,95% of Total Billed Charges,67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.96,88,,109.12,Percent of Total Billed Charges,88% of Total Billed Charges,60.3,90,,77.616,Percent of Total Billed charges,90% of Total Billed Charges,29.55,67,
ARTHREX IMP SYS CPR SCORPION,2780002300,CDM,278,RC,C1713,HCPCS,Outpatient,,,3887.00,2526.55,,3887,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2954.12,76,,94.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2798.64,72,,6595.2,Percent of Total Billed Charges,72% of Total Billed Charges,2798.64,72,,6595.2,Percent of Total Billed charges,72% of Total Billed Charges,3887,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2798.64,72,,6595.2,Percent of Total Billed Charges,72% of Total Billed Charges,2332.2,60,,5496,Percent of Total Billed Charges,60% of Total Billed Charges,3498.3,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,1749.15,45,,50.848,Percent of Total Billed Charges,45% of Total Billed Charges,3498.3,90,,111.6,Percent of Total Billed Charges,90% of Total billed Charges,3887,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3887,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3887,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2526.55,65,,74.104,Percent of total Billed Charges,65% of Total Billed Charges,1714.17,44.1,,49.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,3692.65,95,,117.8,Percent of Total Billed Charges,95% of Total Billed Charges,3887,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3420.56,88,,70.4,Percent of Total Billed Charges,88% of Total Billed Charges,3498.3,90,,111.6,Percent of Total Billed charges,90% of Total Billed Charges,1714.17,3887,
ARTHREX BIOACHILLES SPDB W/JS,2780002301,CDM,278,RC,C1713,HCPCS,Outpatient,,,7082.00,4603.30,,7082,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5382.32,76,,93.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5099.04,72,,10840.32,Percent of Total Billed Charges,72% of Total Billed Charges,5099.04,72,,10840.32,Percent of Total Billed charges,72% of Total Billed Charges,7082,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5099.04,72,,10840.32,Percent of Total Billed Charges,72% of Total Billed Charges,4249.2,60,,9033.6,Percent of Total Billed Charges,60% of Total Billed Charges,6373.8,90,,361.8,Percent of Total Billed Charges,90% of Total Billed Charges,3186.9,45,,55.8,Percent of Total Billed Charges,45% of Total Billed Charges,6373.8,90,,111.152,Percent of Total Billed Charges,90% of Total billed Charges,7082,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7082,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7082,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4603.3,65,,274.304,Percent of total Billed Charges,65% of Total Billed Charges,3123.16,44.1,,54.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,6727.9,95,,117.328,Percent of Total Billed Charges,95% of Total Billed Charges,7082,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6232.16,88,,70.4,Percent of Total Billed Charges,88% of Total Billed Charges,6373.8,90,,111.152,Percent of Total Billed charges,90% of Total Billed Charges,3123.16,7082,
STYKER 4.0X65MM TI CANN SCW,2780002302,CDM,278,RC,C1713,HCPCS,Outpatient,,,702.00,456.30,,702,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,533.52,76,,75.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,505.44,72,,5410.08,Percent of Total Billed Charges,72% of Total Billed Charges,505.44,72,,5410.08,Percent of Total Billed charges,72% of Total Billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,505.44,72,,5410.08,Percent of Total Billed Charges,72% of Total Billed Charges,421.2,60,,4508.4,Percent of Total Billed Charges,60% of Total Billed Charges,631.8,90,,433.8,Percent of Total Billed Charges,90% of Total Billed Charges,315.9,45,,36,Percent of Total Billed Charges,45% of Total Billed Charges,631.8,90,,89.424,Percent of Total Billed Charges,90% of Total billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.3,65,,747.504,Percent of total Billed Charges,65% of Total Billed Charges,309.58,44.1,,35.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,666.9,95,,94.392,Percent of Total Billed Charges,95% of Total Billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,617.76,88,,70.4,Percent of Total Billed Charges,88% of Total Billed Charges,631.8,90,,89.424,Percent of Total Billed charges,90% of Total Billed Charges,309.58,702,
STRYKER ASNIS III 1.4X150MM GD,2780002303,CDM,278,RC,C1713,HCPCS,Outpatient,,,307.00,199.55,,307,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,233.32,76,,85.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,221.04,72,,5410.08,Percent of Total Billed Charges,72% of Total Billed Charges,221.04,72,,5410.08,Percent of Total Billed charges,72% of Total Billed Charges,307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.04,72,,5410.08,Percent of Total Billed Charges,72% of Total Billed Charges,184.2,60,,4508.4,Percent of Total Billed Charges,60% of Total Billed Charges,276.3,90,,1071,Percent of Total Billed Charges,90% of Total Billed Charges,138.15,45,,36,Percent of Total Billed Charges,45% of Total Billed Charges,276.3,90,,101.704,Percent of Total Billed Charges,90% of Total billed Charges,307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.55,65,,1108.904,Percent of total Billed Charges,65% of Total Billed Charges,135.39,44.1,,35.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,291.65,95,,107.352,Percent of Total Billed Charges,95% of Total Billed Charges,307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.16,88,,70.4,Percent of Total Billed Charges,88% of Total Billed Charges,276.3,90,,101.704,Percent of Total Billed charges,90% of Total Billed Charges,135.39,307,
ARTHREX COMPR FT SCW 2.5 MI13M,2780002304,CDM,278,RC,C1713,HCPCS,Outpatient,,,1775.00,1153.75,,1775,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1349,76,,94.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1278,72,,5918.4,Percent of Total Billed Charges,72% of Total Billed Charges,1278,72,,5918.4,Percent of Total Billed charges,72% of Total Billed Charges,1775,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1278,72,,5918.4,Percent of Total Billed Charges,72% of Total Billed Charges,1065,60,,4932,Percent of Total Billed Charges,60% of Total Billed Charges,1597.5,90,,102.6,Percent of Total Billed Charges,90% of Total Billed Charges,798.75,45,,36,Percent of Total Billed Charges,45% of Total Billed Charges,1597.5,90,,111.6,Percent of Total Billed Charges,90% of Total billed Charges,1775,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1775,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1775,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1153.75,65,,19.112,Percent of total Billed Charges,65% of Total Billed Charges,782.78,44.1,,35.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,1686.25,95,,117.8,Percent of Total Billed Charges,95% of Total Billed Charges,1775,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1562,88,,70.4,Percent of Total Billed Charges,88% of Total Billed Charges,1597.5,90,,111.6,Percent of Total Billed charges,90% of Total Billed Charges,782.78,1775,
ARTHREX COMPR FT SCW 2.5 M 14M,2780002305,CDM,278,RC,C1713,HCPCS,Outpatient,,,1775.00,1153.75,,1775,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1349,76,,60.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1278,72,,5918.4,Percent of Total Billed Charges,72% of Total Billed Charges,1278,72,,5918.4,Percent of Total Billed charges,72% of Total Billed Charges,1775,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1278,72,,5918.4,Percent of Total Billed Charges,72% of Total Billed Charges,1065,60,,4932,Percent of Total Billed Charges,60% of Total Billed Charges,1597.5,90,,150.48,Percent of Total Billed Charges,90% of Total Billed Charges,798.75,45,,36,Percent of Total Billed Charges,45% of Total Billed Charges,1597.5,90,,72,Percent of Total Billed Charges,90% of Total billed Charges,1775,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1775,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1775,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1153.75,65,,1796.864,Percent of total Billed Charges,65% of Total Billed Charges,782.78,44.1,,35.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,1686.25,95,,76,Percent of Total Billed Charges,95% of Total Billed Charges,1775,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1562,88,,70.4,Percent of Total Billed Charges,88% of Total Billed Charges,1597.5,90,,72,Percent of Total Billed charges,90% of Total Billed Charges,782.78,1775,
ARTHREX COMPR FR SCW 2.5 M 30M,2780002306,CDM,278,RC,C1713,HCPCS,Outpatient,,,1775.00,1153.75,,1775,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1349,76,,60.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1278,72,,6595.2,Percent of Total Billed Charges,72% of Total Billed Charges,1278,72,,6595.2,Percent of Total Billed charges,72% of Total Billed Charges,1775,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1278,72,,6595.2,Percent of Total Billed Charges,72% of Total Billed Charges,1065,60,,5496,Percent of Total Billed Charges,60% of Total Billed Charges,1597.5,90,,150.48,Percent of Total Billed Charges,90% of Total Billed Charges,798.75,45,,36,Percent of Total Billed Charges,45% of Total Billed Charges,1597.5,90,,72,Percent of Total Billed Charges,90% of Total billed Charges,1775,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1775,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1775,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1153.75,65,,134.016,Percent of total Billed Charges,65% of Total Billed Charges,782.78,44.1,,35.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,1686.25,95,,76,Percent of Total Billed Charges,95% of Total Billed Charges,1775,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1562,88,,353.76,Percent of Total Billed Charges,88% of Total Billed Charges,1597.5,90,,72,Percent of Total Billed charges,90% of Total Billed Charges,782.78,1775,
ARTHREX QCKFIX SCW CANC 4X50MM,2780002307,CDM,278,RC,C1713,HCPCS,Outpatient,,,838.00,544.70,,838,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,636.88,76,,60.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,603.36,72,,10840.32,Percent of Total Billed Charges,72% of Total Billed Charges,603.36,72,,10840.32,Percent of Total Billed charges,72% of Total Billed Charges,838,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,603.36,72,,10840.32,Percent of Total Billed Charges,72% of Total Billed Charges,502.8,60,,9033.6,Percent of Total Billed Charges,60% of Total Billed Charges,754.2,90,,150.48,Percent of Total Billed Charges,90% of Total Billed Charges,377.1,45,,36,Percent of Total Billed Charges,45% of Total Billed Charges,754.2,90,,72,Percent of Total Billed Charges,90% of Total billed Charges,838,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,838,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,838,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,544.7,65,,258.704,Percent of total Billed Charges,65% of Total Billed Charges,369.56,44.1,,35.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,796.1,95,,76,Percent of Total Billed Charges,95% of Total Billed Charges,838,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.44,88,,424.16,Percent of Total Billed Charges,88% of Total Billed Charges,754.2,90,,72,Percent of Total Billed charges,90% of Total Billed Charges,369.56,838,
IRA TIP SILICONE,2780002308,CDM,278,RC,C1713,HCPCS,Outpatient,,,621.00,403.65,,621,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,471.96,76,,60.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,447.12,72,,2975.4,Percent of Total Billed Charges,72% of Total Billed Charges,447.12,72,,2975.4,Percent of Total Billed charges,72% of Total Billed Charges,621,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,447.12,72,,2975.4,Percent of Total Billed Charges,72% of Total Billed Charges,372.6,60,,2479.504,Percent of Total Billed Charges,60% of Total Billed Charges,558.9,90,,150.48,Percent of Total Billed Charges,90% of Total Billed Charges,279.45,45,,180.904,Percent of Total Billed Charges,45% of Total Billed Charges,558.9,90,,72,Percent of Total Billed Charges,90% of Total billed Charges,621,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,621,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,621,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,403.65,65,,92.304,Percent of total Billed Charges,65% of Total Billed Charges,273.86,44.1,,177.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,589.95,95,,76,Percent of Total Billed Charges,95% of Total Billed Charges,621,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.48,88,,1047.2,Percent of Total Billed Charges,88% of Total Billed Charges,558.9,90,,72,Percent of Total Billed charges,90% of Total Billed Charges,273.86,621,
Z1312-27-126 2.7 LCK SCW 26,2780002309,CDM,278,RC,C1713,HCPCS,Outpatient,,,323.00,209.95,,323,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,245.48,76,,60.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,232.56,72,,1166.968,Percent of Total Billed Charges,72% of Total Billed Charges,232.56,72,,1166.968,Percent of Total Billed charges,72% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.56,72,,1166.968,Percent of Total Billed Charges,72% of Total Billed Charges,193.8,60,,972.472,Percent of Total Billed Charges,60% of Total Billed Charges,290.7,90,,166.504,Percent of Total Billed Charges,90% of Total Billed Charges,145.35,45,,216.904,Percent of Total Billed Charges,45% of Total Billed Charges,290.7,90,,72,Percent of Total Billed Charges,90% of Total billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.95,65,,942.504,Percent of total Billed Charges,65% of Total Billed Charges,142.44,44.1,,212.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,306.85,95,,76,Percent of Total Billed Charges,95% of Total Billed Charges,323,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.24,88,,100.32,Percent of Total Billed Charges,88% of Total Billed Charges,290.7,90,,72,Percent of Total Billed charges,90% of Total Billed Charges,142.44,323,
Z131227210 2.7 MM NONLCK SCW10,2780002310,CDM,278,RC,C1713,HCPCS,Outpatient,,,170.00,110.50,,170,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.2,76,,60.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,122.4,72,,6566.4,Percent of Total Billed Charges,72% of Total Billed Charges,122.4,72,,6566.4,Percent of Total Billed charges,72% of Total Billed Charges,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.4,72,,6566.4,Percent of Total Billed Charges,72% of Total Billed Charges,102,60,,5472,Percent of Total Billed Charges,60% of Total Billed Charges,153,90,,166.504,Percent of Total Billed Charges,90% of Total Billed Charges,76.5,45,,535.504,Percent of Total Billed Charges,45% of Total Billed Charges,153,90,,72,Percent of Total Billed Charges,90% of Total billed Charges,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.5,65,,3900,Percent of total Billed Charges,65% of Total Billed Charges,74.97,44.1,,524.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,161.5,95,,76,Percent of Total Billed Charges,95% of Total Billed Charges,170,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.6,88,,147.136,Percent of Total Billed Charges,88% of Total Billed Charges,153,90,,72,Percent of Total Billed charges,90% of Total Billed Charges,74.97,170,
Z22533242 4.2 CORT SCW 32.5,2780002311,CDM,278,RC,C1713,HCPCS,Outpatient,,,477.00,310.05,,477,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,362.52,76,,305.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,343.44,72,,688.32,Percent of Total Billed Charges,72% of Total Billed Charges,343.44,72,,688.32,Percent of Total Billed charges,72% of Total Billed Charges,477,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.44,72,,688.32,Percent of Total Billed Charges,72% of Total Billed Charges,286.2,60,,573.6,Percent of Total Billed Charges,60% of Total Billed Charges,429.3,90,,166.504,Percent of Total Billed Charges,90% of Total Billed Charges,214.65,45,,51.304,Percent of Total Billed Charges,45% of Total Billed Charges,429.3,90,,361.8,Percent of Total Billed Charges,90% of Total billed Charges,477,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,477,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,477,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,310.05,65,,3900,Percent of total Billed Charges,65% of Total Billed Charges,210.36,44.1,,50.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,453.15,95,,381.904,Percent of Total Billed Charges,95% of Total Billed Charges,477,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.76,88,,147.136,Percent of Total Billed Charges,88% of Total Billed Charges,429.3,90,,361.8,Percent of Total Billed charges,90% of Total Billed Charges,210.36,477,
Z225334010 TIBIA NAIL 10Z34,2780002312,CDM,278,RC,C1713,HCPCS,Outpatient,,,2816.00,1830.40,,2816,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2140.16,76,,366.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2027.52,72,,688.32,Percent of Total Billed Charges,72% of Total Billed Charges,2027.52,72,,688.32,Percent of Total Billed charges,72% of Total Billed Charges,2816,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2027.52,72,,688.32,Percent of Total Billed Charges,72% of Total Billed Charges,1689.6,60,,573.6,Percent of Total Billed Charges,60% of Total Billed Charges,2534.4,90,,166.504,Percent of Total Billed Charges,90% of Total Billed Charges,1267.2,45,,75.24,Percent of Total Billed Charges,45% of Total Billed Charges,2534.4,90,,433.8,Percent of Total Billed Charges,90% of Total billed Charges,2816,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2816,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2816,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1830.4,65,,3900,Percent of total Billed Charges,65% of Total Billed Charges,1241.86,44.1,,73.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,2675.2,95,,457.904,Percent of Total Billed Charges,95% of Total Billed Charges,2816,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2478.08,88,,147.136,Percent of Total Billed Charges,88% of Total Billed Charges,2534.4,90,,433.8,Percent of Total Billed charges,90% of Total Billed Charges,1241.86,2816,
STRYKER VARIAX ST PL 12H,2780002313,CDM,278,RC,C1713,HCPCS,Outpatient,,,2726.00,1771.90,,2726,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2071.76,76,,904.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1962.72,72,,339.84,Percent of Total Billed Charges,72% of Total Billed Charges,1962.72,72,,339.84,Percent of Total Billed charges,72% of Total Billed Charges,2726,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1962.72,72,,339.84,Percent of Total Billed Charges,72% of Total Billed Charges,1635.6,60,,283.2,Percent of Total Billed Charges,60% of Total Billed Charges,2453.4,90,,166.504,Percent of Total Billed Charges,90% of Total Billed Charges,1226.7,45,,75.24,Percent of Total Billed Charges,45% of Total Billed Charges,2453.4,90,,1071,Percent of Total Billed Charges,90% of Total billed Charges,2726,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2726,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2726,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1771.9,65,,3900,Percent of total Billed Charges,65% of Total Billed Charges,1202.17,44.1,,73.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,2589.7,95,,1130.504,Percent of Total Billed Charges,95% of Total Billed Charges,2726,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2398.88,88,,147.136,Percent of Total Billed Charges,88% of Total Billed Charges,2453.4,90,,1071,Percent of Total Billed charges,90% of Total Billed Charges,1202.17,2726,
STRYKER BONE SCW T10 3.5X12MM,2780002314,CDM,278,RC,C1713,HCPCS,Outpatient,,,290.00,188.50,,290,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,220.4,76,,86.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,208.8,72,,227.52,Percent of Total Billed Charges,72% of Total Billed Charges,208.8,72,,227.52,Percent of Total Billed charges,72% of Total Billed Charges,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.8,72,,227.52,Percent of Total Billed Charges,72% of Total Billed Charges,174,60,,189.6,Percent of Total Billed Charges,60% of Total Billed Charges,261,90,,166.504,Percent of Total Billed Charges,90% of Total Billed Charges,130.5,45,,75.24,Percent of Total Billed Charges,45% of Total Billed Charges,261,90,,102.6,Percent of Total Billed Charges,90% of Total billed Charges,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.5,65,,176.8,Percent of total Billed Charges,65% of Total Billed Charges,127.89,44.1,,73.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,275.5,95,,108.304,Percent of Total Billed Charges,95% of Total Billed Charges,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.2,88,,162.8,Percent of Total Billed Charges,88% of Total Billed Charges,261,90,,102.6,Percent of Total Billed charges,90% of Total Billed Charges,127.89,290,
STRYKER BONE SCW T10 3.5X14MM,2780002315,CDM,278,RC,C1713,HCPCS,Outpatient,,,290.00,188.50,,290,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,220.4,76,,127.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,208.8,72,,227.52,Percent of Total Billed Charges,72% of Total Billed Charges,208.8,72,,227.52,Percent of Total Billed charges,72% of Total Billed Charges,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.8,72,,227.52,Percent of Total Billed Charges,72% of Total Billed Charges,174,60,,189.6,Percent of Total Billed Charges,60% of Total Billed Charges,261,90,,135.904,Percent of Total Billed Charges,90% of Total Billed Charges,130.5,45,,75.24,Percent of Total Billed Charges,45% of Total Billed Charges,261,90,,150.48,Percent of Total Billed Charges,90% of Total billed Charges,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.5,65,,118.304,Percent of total Billed Charges,65% of Total Billed Charges,127.89,44.1,,73.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,275.5,95,,158.84,Percent of Total Billed Charges,95% of Total Billed Charges,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.2,88,,162.8,Percent of Total Billed Charges,88% of Total Billed Charges,261,90,,150.48,Percent of Total Billed charges,90% of Total Billed Charges,127.89,290,
STRYKER LCK SCW T10 3.5X14MM,2780002316,CDM,278,RC,C1713,HCPCS,Outpatient,,,572.00,371.80,,572,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,434.72,76,,127.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,411.84,72,,607.68,Percent of Total Billed Charges,72% of Total Billed Charges,411.84,72,,607.68,Percent of Total Billed charges,72% of Total Billed Charges,572,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.84,72,,607.68,Percent of Total Billed Charges,72% of Total Billed Charges,343.2,60,,506.4,Percent of Total Billed Charges,60% of Total Billed Charges,514.8,90,,102.6,Percent of Total Billed Charges,90% of Total Billed Charges,257.4,45,,83.248,Percent of Total Billed Charges,45% of Total Billed Charges,514.8,90,,150.48,Percent of Total Billed Charges,90% of Total billed Charges,572,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,572,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,572,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.8,65,,6575.4,Percent of total Billed Charges,65% of Total Billed Charges,252.25,44.1,,81.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,543.4,95,,158.84,Percent of Total Billed Charges,95% of Total Billed Charges,572,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,503.36,88,,162.8,Percent of Total Billed Charges,88% of Total Billed Charges,514.8,90,,150.48,Percent of Total Billed charges,90% of Total Billed Charges,252.25,572,
STRYKER HOFFMANN3 RTR 5/8/11MM,2780002317,CDM,278,RC,C1713,HCPCS,Outpatient,,,3084.00,2004.60,,3084,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2343.84,76,,127.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2220.48,72,,123.84,Percent of Total Billed Charges,72% of Total Billed Charges,2220.48,72,,123.84,Percent of Total Billed charges,72% of Total Billed Charges,3084,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2220.48,72,,123.84,Percent of Total Billed Charges,72% of Total Billed Charges,1850.4,60,,103.2,Percent of Total Billed Charges,60% of Total Billed Charges,2775.6,90,,102.6,Percent of Total Billed Charges,90% of Total Billed Charges,1387.8,45,,83.248,Percent of Total Billed Charges,45% of Total Billed Charges,2775.6,90,,150.48,Percent of Total Billed Charges,90% of Total billed Charges,3084,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3084,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3084,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2004.6,65,,174.72,Percent of total Billed Charges,65% of Total Billed Charges,1360.04,44.1,,81.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,2929.8,95,,158.84,Percent of Total Billed Charges,95% of Total Billed Charges,3084,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2713.92,88,,162.8,Percent of Total Billed Charges,88% of Total Billed Charges,2775.6,90,,150.48,Percent of Total Billed charges,90% of Total Billed Charges,1360.04,3084,
STRYKER HOFFMANN3POST ST 11MM,2780002318,CDM,278,RC,C1713,HCPCS,Outpatient,,,678.00,440.70,,678,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,515.28,76,,127.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,488.16,72,,607.68,Percent of Total Billed Charges,72% of Total Billed Charges,488.16,72,,607.68,Percent of Total Billed charges,72% of Total Billed Charges,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.16,72,,607.68,Percent of Total Billed Charges,72% of Total Billed Charges,406.8,60,,506.4,Percent of Total Billed Charges,60% of Total Billed Charges,610.2,90,,135.904,Percent of Total Billed Charges,90% of Total Billed Charges,305.1,45,,83.248,Percent of Total Billed Charges,45% of Total Billed Charges,610.2,90,,150.48,Percent of Total Billed Charges,90% of Total billed Charges,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.7,65,,1363.704,Percent of total Billed Charges,65% of Total Billed Charges,299,44.1,,81.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,644.1,95,,158.84,Percent of Total Billed Charges,95% of Total Billed Charges,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,596.64,88,,162.8,Percent of Total Billed Charges,88% of Total Billed Charges,610.2,90,,150.48,Percent of Total Billed charges,90% of Total Billed Charges,299,678,
STRYKER HFFMANN3 5H PIN 4/5/6M,2780002319,CDM,278,RC,C1713,HCPCS,Outpatient,,,3178.00,2065.70,,3178,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2415.28,76,,140.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2288.16,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,2288.16,72,,122.4,Percent of Total Billed charges,72% of Total Billed Charges,3178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2288.16,72,,122.4,Percent of Total Billed Charges,72% of Total Billed Charges,1906.8,60,,102,Percent of Total Billed Charges,60% of Total Billed Charges,2860.2,90,,102.6,Percent of Total Billed Charges,90% of Total Billed Charges,1430.1,45,,83.248,Percent of Total Billed Charges,45% of Total Billed Charges,2860.2,90,,166.504,Percent of Total Billed Charges,90% of Total billed Charges,3178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2065.7,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,1401.5,44.1,,81.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,3019.1,95,,175.752,Percent of Total Billed Charges,95% of Total Billed Charges,3178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2796.64,88,,162.8,Percent of Total Billed Charges,88% of Total Billed Charges,2860.2,90,,166.504,Percent of Total Billed charges,90% of Total Billed Charges,1401.5,3178,
STRYKER HFFMANN3 5H PIN 4/5/6M,2780002320,CDM,278,RC,C1713,HCPCS,Outpatient,,,3519.00,2287.35,,3519,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2674.44,76,,140.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2533.68,72,,41.76,Percent of Total Billed Charges,72% of Total Billed Charges,2533.68,72,,41.76,Percent of Total Billed charges,72% of Total Billed Charges,3519,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2533.68,72,,41.76,Percent of Total Billed Charges,72% of Total Billed Charges,2111.4,60,,34.8,Percent of Total Billed Charges,60% of Total Billed Charges,3167.1,90,,102.6,Percent of Total Billed Charges,90% of Total Billed Charges,1583.55,45,,83.248,Percent of Total Billed Charges,45% of Total Billed Charges,3167.1,90,,166.504,Percent of Total Billed Charges,90% of Total billed Charges,3519,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3519,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3519,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2287.35,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,1551.88,44.1,,81.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,3343.05,95,,175.752,Percent of Total Billed Charges,95% of Total Billed Charges,3519,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3096.72,88,,132.88,Percent of Total Billed Charges,88% of Total Billed Charges,3167.1,90,,166.504,Percent of Total Billed charges,90% of Total Billed Charges,1551.88,3519,
STRYKER HFFMAN3 5H PN CL4/5/6M,2780002321,CDM,278,RC,C1713,HCPCS,Outpatient,,,3512.00,2282.80,,3512,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2669.12,76,,140.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2528.64,72,,1913.76,Percent of Total Billed Charges,72% of Total Billed Charges,2528.64,72,,1913.76,Percent of Total Billed charges,72% of Total Billed Charges,3512,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2528.64,72,,1913.76,Percent of Total Billed Charges,72% of Total Billed Charges,2107.2,60,,1594.8,Percent of Total Billed Charges,60% of Total Billed Charges,3160.8,90,,379.8,Percent of Total Billed Charges,90% of Total Billed Charges,1580.4,45,,83.248,Percent of Total Billed Charges,45% of Total Billed Charges,3160.8,90,,166.504,Percent of Total Billed Charges,90% of Total billed Charges,3512,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3512,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3512,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2282.8,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,1548.79,44.1,,81.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,3336.4,95,,175.752,Percent of Total Billed Charges,95% of Total Billed Charges,3512,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3090.56,88,,100.32,Percent of Total Billed Charges,88% of Total Billed Charges,3160.8,90,,166.504,Percent of Total Billed charges,90% of Total Billed Charges,1548.79,3512,
STRYKER SEMI CIRC CVD 11X220MM,2780002322,CDM,278,RC,C1713,HCPCS,Outpatient,,,2047.00,1330.55,,2047,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1555.72,76,,140.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1473.84,72,,688.32,Percent of Total Billed Charges,72% of Total Billed Charges,1473.84,72,,688.32,Percent of Total Billed charges,72% of Total Billed Charges,2047,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1473.84,72,,688.32,Percent of Total Billed Charges,72% of Total Billed Charges,1228.2,60,,573.6,Percent of Total Billed Charges,60% of Total Billed Charges,1842.3,90,,1035,Percent of Total Billed Charges,90% of Total Billed Charges,921.15,45,,67.952,Percent of Total Billed Charges,45% of Total Billed Charges,1842.3,90,,166.504,Percent of Total Billed Charges,90% of Total billed Charges,2047,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2047,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2047,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1330.55,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,902.73,44.1,,66.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,1944.65,95,,175.752,Percent of Total Billed Charges,95% of Total Billed Charges,2047,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1801.36,88,,100.32,Percent of Total Billed Charges,88% of Total Billed Charges,1842.3,90,,166.504,Percent of Total Billed charges,90% of Total Billed Charges,902.73,2047,
STRYKER HFFMANN3 CONN 11X150MM,2780002323,CDM,278,RC,C1713,HCPCS,Outpatient,,,1530.00,994.50,,1530,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1162.8,76,,140.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1101.6,72,,27.216,Percent of Total Billed Charges,72% of Total Billed Charges,1101.6,72,,27.216,Percent of Total Billed charges,72% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1101.6,72,,27.216,Percent of Total Billed Charges,72% of Total Billed Charges,918,60,,22.68,Percent of Total Billed Charges,60% of Total Billed Charges,1377,90,,1535.4,Percent of Total Billed Charges,90% of Total Billed Charges,688.5,45,,51.304,Percent of Total Billed Charges,45% of Total Billed Charges,1377,90,,166.504,Percent of Total Billed Charges,90% of Total billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.5,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,674.73,44.1,,50.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,1453.5,95,,175.752,Percent of Total Billed Charges,95% of Total Billed Charges,1530,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1346.4,88,,132.88,Percent of Total Billed Charges,88% of Total Billed Charges,1377,90,,166.504,Percent of Total Billed charges,90% of Total Billed Charges,674.73,1530,
STRYKER HFFMANN3 CONN 11X400MM,2780002324,CDM,278,RC,C1713,HCPCS,Outpatient,,,1842.00,1197.30,,1842,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1399.92,76,,140.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1326.24,72,,1046.88,Percent of Total Billed Charges,72% of Total Billed Charges,1326.24,72,,1046.88,Percent of Total Billed charges,72% of Total Billed Charges,1842,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1326.24,72,,1046.88,Percent of Total Billed Charges,72% of Total Billed Charges,1105.2,60,,872.4,Percent of Total Billed Charges,60% of Total Billed Charges,1657.8,90,,26.464,Percent of Total Billed Charges,90% of Total Billed Charges,828.9,45,,51.304,Percent of Total Billed Charges,45% of Total Billed Charges,1657.8,90,,166.504,Percent of Total Billed Charges,90% of Total billed Charges,1842,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1842,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1842,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1197.3,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,812.32,44.1,,50.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,1749.9,95,,175.752,Percent of Total Billed Charges,95% of Total Billed Charges,1842,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.96,88,,100.32,Percent of Total Billed Charges,88% of Total Billed Charges,1657.8,90,,166.504,Percent of Total Billed charges,90% of Total Billed Charges,812.32,1842,
STRYKER 5X150APEX S/D HLFPN50,2780002325,CDM,278,RC,C1713,HCPCS,Outpatient,,,586.00,380.90,,586,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,445.36,76,,114.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,421.92,72,,1046.88,Percent of Total Billed Charges,72% of Total Billed Charges,421.92,72,,1046.88,Percent of Total Billed charges,72% of Total Billed Charges,586,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,421.92,72,,1046.88,Percent of Total Billed Charges,72% of Total Billed Charges,351.6,60,,872.4,Percent of Total Billed Charges,60% of Total Billed Charges,527.4,90,,2487.96,Percent of Total Billed Charges,90% of Total Billed Charges,263.7,45,,67.952,Percent of Total Billed Charges,45% of Total Billed Charges,527.4,90,,135.904,Percent of Total Billed Charges,90% of Total billed Charges,586,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,586,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,586,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.9,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,258.43,44.1,,66.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,556.7,95,,143.448,Percent of Total Billed Charges,95% of Total Billed Charges,586,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,515.68,88,,100.32,Percent of Total Billed Charges,88% of Total Billed Charges,527.4,90,,135.904,Percent of Total Billed charges,90% of Total Billed Charges,258.43,586,
STRYKER TR PN APX5/6MM 40X300M,2780002326,CDM,278,RC,C1713,HCPCS,Outpatient,,,543.00,352.95,,543,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,412.68,76,,86.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,390.96,72,,1440,Percent of Total Billed Charges,72% of Total Billed Charges,390.96,72,,1440,Percent of Total Billed charges,72% of Total Billed Charges,543,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.96,72,,1440,Percent of Total Billed Charges,72% of Total Billed Charges,325.8,60,,1200,Percent of Total Billed Charges,60% of Total Billed Charges,488.7,90,,185.568,Percent of Total Billed Charges,90% of Total Billed Charges,244.35,45,,51.304,Percent of Total Billed Charges,45% of Total Billed Charges,488.7,90,,102.6,Percent of Total Billed Charges,90% of Total billed Charges,543,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,543,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,543,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.95,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,239.46,44.1,,50.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,515.85,95,,108.304,Percent of Total Billed Charges,95% of Total Billed Charges,543,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,477.84,88,,371.36,Percent of Total Billed Charges,88% of Total Billed Charges,488.7,90,,102.6,Percent of Total Billed charges,90% of Total Billed Charges,239.46,543,
Z11474640 4.0 CANN PT SCW 46,2780002327,CDM,278,RC,C1773,HCPCS,Outpatient,,,564.00,366.60,,564,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,428.64,76,,86.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,406.08,72,,688.32,Percent of Total Billed Charges,72% of Total Billed Charges,406.08,72,,688.32,Percent of Total Billed charges,72% of Total Billed Charges,564,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.08,72,,688.32,Percent of Total Billed Charges,72% of Total Billed Charges,338.4,60,,573.6,Percent of Total Billed Charges,60% of Total Billed Charges,507.6,90,,358.2,Percent of Total Billed Charges,90% of Total Billed Charges,253.8,45,,51.304,Percent of Total Billed Charges,45% of Total Billed Charges,507.6,90,,102.6,Percent of Total Billed Charges,90% of Total billed Charges,564,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,564,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,564,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.6,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,248.72,44.1,,50.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,535.8,95,,108.304,Percent of Total Billed Charges,95% of Total Billed Charges,564,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,496.32,88,,1012,Percent of Total Billed Charges,88% of Total Billed Charges,507.6,90,,102.6,Percent of Total Billed charges,90% of Total Billed Charges,248.72,564,
Z425120005-12 PERSONA SZ 12LFT,2780002328,CDM,278,RC,C1713,HCPCS,Outpatient,,,5902.00,3836.30,,5902,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4485.52,76,,114.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4249.44,72,,23.184,Percent of Total Billed Charges,72% of Total Billed Charges,4249.44,72,,23.184,Percent of Total Billed charges,72% of Total Billed Charges,5902,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4249.44,72,,23.184,Percent of Total Billed Charges,72% of Total Billed Charges,3541.2,60,,19.32,Percent of Total Billed Charges,60% of Total Billed Charges,5311.8,90,,127.8,Percent of Total Billed Charges,90% of Total Billed Charges,2655.9,45,,189.904,Percent of Total Billed Charges,45% of Total Billed Charges,5311.8,90,,135.904,Percent of Total Billed Charges,90% of Total billed Charges,5902,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5902,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5902,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3836.3,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,2602.78,44.1,,186.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,5606.9,95,,143.448,Percent of Total Billed Charges,95% of Total Billed Charges,5902,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5193.76,88,,1501.28,Percent of Total Billed Charges,88% of Total Billed Charges,5311.8,90,,135.904,Percent of Total Billed charges,90% of Total Billed Charges,2602.78,5902,
Z425026066-01 PERSONA FE SZ9LT,2780002329,CDM,278,RC,C1713,HCPCS,Outpatient,,,1353.00,879.45,,1353,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1028.28,76,,86.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,974.16,72,,217.728,Percent of Total Billed Charges,72% of Total Billed Charges,974.16,72,,217.728,Percent of Total Billed charges,72% of Total Billed Charges,1353,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,974.16,72,,217.728,Percent of Total Billed Charges,72% of Total Billed Charges,811.8,60,,181.44,Percent of Total Billed Charges,60% of Total Billed Charges,1217.7,90,,1305,Percent of Total Billed Charges,90% of Total Billed Charges,608.85,45,,517.504,Percent of Total Billed Charges,45% of Total Billed Charges,1217.7,90,,102.6,Percent of Total Billed Charges,90% of Total billed Charges,1353,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1353,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1353,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,879.45,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,596.67,44.1,,507.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,1285.35,95,,108.304,Percent of Total Billed Charges,95% of Total Billed Charges,1353,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1190.64,88,,25.872,Percent of Total Billed Charges,88% of Total Billed Charges,1217.7,90,,102.6,Percent of Total Billed charges,90% of Total Billed Charges,596.67,1353,
"ARTHREX 1B KIT,BC,W/CCFT&JS",2780002330,CDM,278,RC,C1713,HCPCS,Outpatient,,,5307.00,3449.55,,5307,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4033.32,76,,86.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3821.04,72,,217.728,Percent of Total Billed Charges,72% of Total Billed Charges,3821.04,72,,217.728,Percent of Total Billed charges,72% of Total Billed Charges,5307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3821.04,72,,217.728,Percent of Total Billed Charges,72% of Total Billed Charges,3184.2,60,,181.44,Percent of Total Billed Charges,60% of Total Billed Charges,4776.3,90,,5400,Percent of Total Billed Charges,90% of Total Billed Charges,2388.15,45,,767.704,Percent of Total Billed Charges,45% of Total Billed Charges,4776.3,90,,102.6,Percent of Total Billed Charges,90% of Total billed Charges,5307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3449.55,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,2340.39,44.1,,752.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,5041.65,95,,108.304,Percent of Total Billed Charges,95% of Total Billed Charges,5307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4670.16,88,,2432.672,Percent of Total Billed Charges,88% of Total Billed Charges,4776.3,90,,102.6,Percent of Total Billed charges,90% of Total Billed Charges,2340.39,5307,
Z4920-08 COMP PLTG 2.0/8H,2780002331,CDM,278,RC,C1713,HCPCS,Outpatient,,,500.00,325.00,,500,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,380,76,,320.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,360,72,,720,Percent of Total Billed Charges,72% of Total Billed Charges,360,72,,720,Percent of Total Billed charges,72% of Total Billed Charges,500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,72,,720,Percent of Total Billed Charges,72% of Total Billed Charges,300,60,,600,Percent of Total Billed Charges,60% of Total Billed Charges,450,90,,5400,Percent of Total Billed Charges,90% of Total Billed Charges,225,45,,13.232,Percent of Total Billed Charges,45% of Total Billed Charges,450,90,,379.8,Percent of Total Billed Charges,90% of Total billed Charges,500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,220.5,44.1,,12.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,475,95,,400.904,Percent of Total Billed Charges,95% of Total Billed Charges,500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440,88,,181.44,Percent of Total Billed Charges,88% of Total Billed Charges,450,90,,379.8,Percent of Total Billed charges,90% of Total Billed Charges,220.5,500,
EVERFLEX 5F 6X100X150 STNT,2780002332,CDM,278,RC,C1876,HCPCS,Outpatient,,,3607.00,2344.55,,3607,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2741.32,76,,874,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2597.04,72,,280.8,Percent of Total Billed Charges,72% of Total Billed Charges,2597.04,72,,292.504,Percent of Total Billed charges,72% of Total Billed Charges,3607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2597.04,72,,280.8,Percent of Total Billed Charges,72% of Total Billed Charges,2164.2,60,,234,Percent of Total Billed Charges,60% of Total Billed Charges,3246.3,90,,5400,Percent of Total Billed Charges,90% of Total Billed Charges,1623.15,45,,1243.984,Percent of Total Billed Charges,45% of Total Billed Charges,3246.3,90,,1035,Percent of Total Billed Charges,90% of Total billed Charges,3607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2344.55,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,1590.69,44.1,,1219.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,3426.65,95,,1092.504,Percent of Total Billed Charges,95% of Total Billed Charges,3607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3174.16,88,,350.24,Percent of Total Billed Charges,88% of Total Billed Charges,3246.3,90,,1035,Percent of Total Billed charges,90% of Total Billed Charges,1590.69,3607,
EVERFLEX 5F 6X80X120 STNT,2780002333,CDM,278,RC,C1876,HCPCS,Outpatient,,,3036.00,1973.40,,3036,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2307.36,76,,1296.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2185.92,72,,432,Percent of Total Billed Charges,72% of Total Billed Charges,2185.92,72,,432,Percent of Total Billed charges,72% of Total Billed Charges,3036,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2185.92,72,,432,Percent of Total Billed Charges,72% of Total Billed Charges,1821.6,60,,360,Percent of Total Billed Charges,60% of Total Billed Charges,2732.4,90,,5400,Percent of Total Billed Charges,90% of Total Billed Charges,1366.2,45,,92.784,Percent of Total Billed Charges,45% of Total Billed Charges,2732.4,90,,1535.4,Percent of Total Billed Charges,90% of Total billed Charges,3036,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3036,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3036,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1973.4,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,1338.88,44.1,,90.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,2884.2,95,,1620.704,Percent of Total Billed Charges,95% of Total Billed Charges,3036,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2671.68,88,,124.96,Percent of Total Billed Charges,88% of Total Billed Charges,2732.4,90,,1535.4,Percent of Total Billed charges,90% of Total Billed Charges,1338.88,3036,
EVERFLEX 5F 6X120X120 STNT,2780002334,CDM,278,RC,C1876,HCPCS,Outpatient,,,5529.00,3593.85,,5529,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4202.04,76,,22.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3980.88,72,,432,Percent of Total Billed Charges,72% of Total Billed Charges,3980.88,72,,432,Percent of Total Billed charges,72% of Total Billed Charges,5529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3980.88,72,,432,Percent of Total Billed Charges,72% of Total Billed Charges,3317.4,60,,360,Percent of Total Billed Charges,60% of Total Billed Charges,4976.1,90,,244.8,Percent of Total Billed Charges,90% of Total Billed Charges,2488.05,45,,179.104,Percent of Total Billed Charges,45% of Total Billed Charges,4976.1,90,,26.464,Percent of Total Billed Charges,90% of Total billed Charges,5529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3593.85,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,2438.29,44.1,,175.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,5252.55,95,,27.928,Percent of Total Billed Charges,95% of Total Billed Charges,5529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4865.52,88,,1276,Percent of Total Billed Charges,88% of Total Billed Charges,4976.1,90,,26.464,Percent of Total Billed charges,90% of Total Billed Charges,2438.29,5529,
Z5001-52 BIPOLAR SHELL 52MM,2780002335,CDM,278,RC,,,Outpatient,,,1857.00,1207.05,,1857,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1411.32,76,,2100.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1337.04,72,,339.84,Percent of Total Billed Charges,72% of Total Billed Charges,1337.04,72,,339.84,Percent of Total Billed charges,72% of Total Billed Charges,1857,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1337.04,72,,339.84,Percent of Total Billed Charges,72% of Total Billed Charges,1114.2,60,,283.2,Percent of Total Billed Charges,60% of Total Billed Charges,1671.3,90,,163.8,Percent of Total Billed Charges,90% of Total Billed Charges,835.65,45,,63.904,Percent of Total Billed Charges,45% of Total Billed Charges,1671.3,90,,2487.96,Percent of Total Billed Charges,90% of Total billed Charges,1857,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1857,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1857,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1207.05,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,818.94,44.1,,62.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,1764.15,95,,2626.184,Percent of Total Billed Charges,95% of Total Billed Charges,1857,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1634.16,88,,5280,Percent of Total Billed Charges,88% of Total Billed Charges,1671.3,90,,2487.96,Percent of Total Billed charges,90% of Total Billed Charges,818.94,1857,
AR-1676DS DISP INSTR KIT 278,2780002336,CDM,278,RC,,,Outpatient,,,990.00,643.50,,990,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,752.4,76,,156.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,712.8,72,,607.68,Percent of Total Billed Charges,72% of Total Billed Charges,712.8,72,,607.68,Percent of Total Billed charges,72% of Total Billed Charges,990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,712.8,72,,607.68,Percent of Total Billed Charges,72% of Total Billed Charges,594,60,,506.4,Percent of Total Billed Charges,60% of Total Billed Charges,891,90,,9104.4,Percent of Total Billed Charges,90% of Total Billed Charges,445.5,45,,652.504,Percent of Total Billed Charges,45% of Total Billed Charges,891,90,,185.568,Percent of Total Billed Charges,90% of Total billed Charges,990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,643.5,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,436.59,44.1,,639.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,940.5,95,,195.872,Percent of Total Billed Charges,95% of Total Billed Charges,990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,871.2,88,,5280,Percent of Total Billed Charges,88% of Total Billed Charges,891,90,,185.568,Percent of Total Billed charges,90% of Total Billed Charges,436.59,990,
Z2810-17-006 GDEWRE 2.0X70,2780002337,CDM,278,RC,,,Outpatient,,,602.00,391.30,,602,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,457.52,76,,302.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,433.44,72,,123.84,Percent of Total Billed Charges,72% of Total Billed Charges,433.44,72,,123.84,Percent of Total Billed charges,72% of Total Billed Charges,602,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,433.44,72,,123.84,Percent of Total Billed Charges,72% of Total Billed Charges,361.2,60,,103.2,Percent of Total Billed Charges,60% of Total Billed Charges,541.8,90,,241.92,Percent of Total Billed Charges,90% of Total Billed Charges,270.9,45,,2700,Percent of Total Billed Charges,45% of Total Billed Charges,541.8,90,,358.2,Percent of Total Billed Charges,90% of Total billed Charges,602,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,602,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,602,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,391.3,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,265.48,44.1,,2646,Percent of Total Billed Charges,44.1% of Total Billed Charges,571.9,95,,378.104,Percent of Total Billed Charges,95% of Total Billed Charges,602,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529.76,88,,5280,Percent of Total Billed Charges,88% of Total Billed Charges,541.8,90,,358.2,Percent of Total Billed charges,90% of Total Billed Charges,265.48,602,
Z2253-22-37 3.7 CORT SCW 22.5,2780002338,CDM,278,RC,,,Outpatient,,,477.00,310.05,,477,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,362.52,76,,107.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,343.44,72,,607.68,Percent of Total Billed Charges,72% of Total Billed Charges,343.44,72,,607.68,Percent of Total Billed charges,72% of Total Billed Charges,477,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.44,72,,607.68,Percent of Total Billed Charges,72% of Total Billed Charges,286.2,60,,506.4,Percent of Total Billed Charges,60% of Total Billed Charges,429.3,90,,1888.2,Percent of Total Billed Charges,90% of Total Billed Charges,214.65,45,,2700,Percent of Total Billed Charges,45% of Total Billed Charges,429.3,90,,127.8,Percent of Total Billed Charges,90% of Total billed Charges,477,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,477,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,477,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,310.05,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,210.36,44.1,,2646,Percent of Total Billed Charges,44.1% of Total Billed Charges,453.15,95,,134.904,Percent of Total Billed Charges,95% of Total Billed Charges,477,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.76,88,,5280,Percent of Total Billed Charges,88% of Total Billed Charges,429.3,90,,127.8,Percent of Total Billed charges,90% of Total Billed Charges,210.36,477,
Z2490-047-30 3.0 GDE PIN,2780002339,CDM,278,RC,C1713,HCPCS,Outpatient,,,444.00,288.60,,444,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,337.44,76,,1102,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,319.68,72,,1235.52,Percent of Total Billed Charges,72% of Total Billed Charges,319.68,72,,1235.52,Percent of Total Billed charges,72% of Total Billed Charges,444,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319.68,72,,1235.52,Percent of Total Billed Charges,72% of Total Billed Charges,266.4,60,,1029.6,Percent of Total Billed Charges,60% of Total Billed Charges,399.6,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,199.8,45,,2700,Percent of Total Billed Charges,45% of Total Billed Charges,399.6,90,,1305,Percent of Total Billed Charges,90% of Total billed Charges,444,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.6,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,195.8,44.1,,2646,Percent of Total Billed Charges,44.1% of Total Billed Charges,421.8,95,,1377.504,Percent of Total Billed Charges,95% of Total Billed Charges,444,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.72,88,,239.36,Percent of Total Billed Charges,88% of Total Billed Charges,399.6,90,,1305,Percent of Total Billed charges,90% of Total Billed Charges,195.8,444,
Z47-2484-070-60 CANCSCW,2780002340,CDM,278,RC,C1713,HCPCS,Outpatient,,,678.00,440.70,,678,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,515.28,76,,4560,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,488.16,72,,123.84,Percent of Total Billed Charges,72% of Total Billed Charges,488.16,72,,123.84,Percent of Total Billed charges,72% of Total Billed Charges,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.16,72,,123.84,Percent of Total Billed Charges,72% of Total Billed Charges,406.8,60,,103.2,Percent of Total Billed Charges,60% of Total Billed Charges,610.2,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,305.1,45,,2700,Percent of Total Billed Charges,45% of Total Billed Charges,610.2,90,,5400,Percent of Total Billed Charges,90% of Total billed Charges,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.7,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,299,44.1,,2646,Percent of Total Billed Charges,44.1% of Total Billed Charges,644.1,95,,5700,Percent of Total Billed Charges,95% of Total Billed Charges,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,596.64,88,,160.16,Percent of Total Billed Charges,88% of Total Billed Charges,610.2,90,,5400,Percent of Total Billed charges,90% of Total Billed Charges,299,678,
Z2490-034-50 5.0 CANN DB,2780002341,CDM,278,RC,C1713,HCPCS,Outpatient,,,1885.00,1225.25,,1885,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1432.6,76,,4560,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1357.2,72,,720,Percent of Total Billed Charges,72% of Total Billed Charges,1357.2,72,,720,Percent of Total Billed charges,72% of Total Billed Charges,1885,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1357.2,72,,720,Percent of Total Billed Charges,72% of Total Billed Charges,1131,60,,600,Percent of Total Billed Charges,60% of Total Billed Charges,1696.5,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,848.25,45,,122.4,Percent of Total Billed Charges,45% of Total Billed Charges,1696.5,90,,5400,Percent of Total Billed Charges,90% of Total billed Charges,1885,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1885,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1885,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1225.25,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,831.29,44.1,,119.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,1790.75,95,,5700,Percent of Total Billed Charges,95% of Total Billed Charges,1885,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1658.8,88,,8902.08,Percent of Total Billed Charges,88% of Total Billed Charges,1696.5,90,,5400,Percent of Total Billed charges,90% of Total Billed Charges,831.29,1885,
Z47-2484-045-60CANCSCW 6.0X45,2780002342,CDM,278,RC,C1713,HCPCS,Outpatient,,,678.00,440.70,,678,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,515.28,76,,4560,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,488.16,72,,6518.88,Percent of Total Billed Charges,72% of Total Billed Charges,488.16,72,,6518.88,Percent of Total Billed charges,72% of Total Billed Charges,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.16,72,,6518.88,Percent of Total Billed Charges,72% of Total Billed Charges,406.8,60,,5432.4,Percent of Total Billed Charges,60% of Total Billed Charges,610.2,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,305.1,45,,81.904,Percent of Total Billed Charges,45% of Total Billed Charges,610.2,90,,5400,Percent of Total Billed Charges,90% of Total billed Charges,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.7,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,299,44.1,,80.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,644.1,95,,5700,Percent of Total Billed Charges,95% of Total Billed Charges,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,596.64,88,,236.544,Percent of Total Billed Charges,88% of Total Billed Charges,610.2,90,,5400,Percent of Total Billed charges,90% of Total Billed Charges,299,678,
Z47-2494-200-11 RGFMNL ZZ 5X20,2780002343,CDM,278,RC,C1713,HCPCS,Outpatient,,,7229.00,4698.85,,7229,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5494.04,76,,4560,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5204.88,72,,286.56,Percent of Total Billed Charges,72% of Total Billed Charges,5204.88,72,,286.56,Percent of Total Billed charges,72% of Total Billed Charges,7229,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5204.88,72,,286.56,Percent of Total Billed Charges,72% of Total Billed Charges,4337.4,60,,238.8,Percent of Total Billed Charges,60% of Total Billed Charges,6506.1,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,3253.05,45,,4552.2,Percent of Total Billed Charges,45% of Total Billed Charges,6506.1,90,,5400,Percent of Total Billed Charges,90% of Total billed Charges,7229,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7229,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7229,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4698.85,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,3187.99,44.1,,4461.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,6867.55,95,,5700,Percent of Total Billed Charges,95% of Total Billed Charges,7229,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6361.52,88,,1846.24,Percent of Total Billed Charges,88% of Total Billed Charges,6506.1,90,,5400,Percent of Total Billed charges,90% of Total Billed Charges,3187.99,7229,
Z2490-034-49 4.9 CALIB DB,2780002344,CDM,278,RC,C1713,HCPCS,Outpatient,,,1463.00,950.95,,1463,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1111.88,76,,206.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1053.36,72,,5.76,Percent of Total Billed Charges,72% of Total Billed Charges,1053.36,72,,6,Percent of Total Billed charges,72% of Total Billed Charges,1463,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1053.36,72,,5.76,Percent of Total Billed Charges,72% of Total Billed Charges,877.8,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,1316.7,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,658.35,45,,120.96,Percent of Total Billed Charges,45% of Total Billed Charges,1316.7,90,,244.8,Percent of Total Billed Charges,90% of Total billed Charges,1463,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1463,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1463,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,950.95,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,645.18,44.1,,118.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,1389.85,95,,258.4,Percent of Total Billed Charges,95% of Total Billed Charges,1463,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1287.44,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,1316.7,90,,244.8,Percent of Total Billed charges,90% of Total Billed Charges,645.18,1463,
Z47-2484-065-60 CANCSCW 6.0X65,2780002345,CDM,278,RC,C1713,HCPCS,Outpatient,,,678.00,440.70,,678,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,515.28,76,,138.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,488.16,72,,648,Percent of Total Billed Charges,72% of Total Billed Charges,488.16,72,,648,Percent of Total Billed charges,72% of Total Billed Charges,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.16,72,,648,Percent of Total Billed Charges,72% of Total Billed Charges,406.8,60,,540,Percent of Total Billed Charges,60% of Total Billed Charges,610.2,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,305.1,45,,944.104,Percent of Total Billed Charges,45% of Total Billed Charges,610.2,90,,163.8,Percent of Total Billed Charges,90% of Total billed Charges,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.7,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,299,44.1,,925.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,644.1,95,,172.904,Percent of Total Billed Charges,95% of Total Billed Charges,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,596.64,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,610.2,90,,163.8,Percent of Total Billed charges,90% of Total Billed Charges,299,678,
REFOBACIN BONE CEMENT R 1X40,2780002346,CDM,278,RC,C1713,HCPCS,Outpatient,,,339.00,220.35,,339,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,257.64,76,,7688.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,244.08,72,,3075.84,Percent of Total Billed Charges,72% of Total Billed Charges,244.08,72,,3075.84,Percent of Total Billed charges,72% of Total Billed Charges,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.08,72,,3075.84,Percent of Total Billed Charges,72% of Total Billed Charges,203.4,60,,2563.2,Percent of Total Billed Charges,60% of Total Billed Charges,305.1,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,152.55,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,305.1,90,,9104.4,Percent of Total Billed Charges,90% of Total billed Charges,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.35,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,149.5,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,322.05,95,,9610.2,Percent of Total Billed Charges,95% of Total Billed Charges,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.32,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,305.1,90,,9104.4,Percent of Total Billed charges,90% of Total Billed Charges,149.5,339,
Z249003443 4.3 CALIB DB,2780002900,CDM,278,RC,,,Outpatient,,,678.00,440.70,,678,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,515.28,76,,204.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,488.16,72,,2030.4,Percent of Total Billed Charges,72% of Total Billed Charges,488.16,72,,2030.4,Percent of Total Billed charges,72% of Total Billed Charges,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.16,72,,2030.4,Percent of Total Billed Charges,72% of Total Billed Charges,406.8,60,,1692,Percent of Total Billed Charges,60% of Total Billed Charges,610.2,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,305.1,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,610.2,90,,241.92,Percent of Total Billed Charges,90% of Total billed Charges,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.7,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,299,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,644.1,95,,255.36,Percent of Total Billed Charges,95% of Total Billed Charges,678,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,596.64,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,610.2,90,,241.92,Percent of Total Billed charges,90% of Total Billed Charges,299,678,
ARTHREX CAN SCW FT SS 3X24,2780002901,CDM,278,RC,C1713,HCPCS,Outpatient,,,178.00,115.70,,178,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,135.28,76,,1594.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,128.16,72,,1142.064,Percent of Total Billed Charges,72% of Total Billed Charges,128.16,72,,1142.064,Percent of Total Billed charges,72% of Total Billed Charges,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.16,72,,1142.064,Percent of Total Billed Charges,72% of Total Billed Charges,106.8,60,,951.72,Percent of Total Billed Charges,60% of Total Billed Charges,160.2,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,80.1,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,160.2,90,,1888.2,Percent of Total Billed Charges,90% of Total billed Charges,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.7,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,78.5,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,169.1,95,,1993.104,Percent of Total Billed Charges,95% of Total Billed Charges,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.64,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,160.2,90,,1888.2,Percent of Total Billed charges,90% of Total Billed Charges,78.5,178,
ARTHREX 2.4X22 VAL SCW TI,2780002902,CDM,278,RC,C1713,HCPCS,Outpatient,,,710.00,461.50,,710,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,539.6,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,511.2,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,511.2,72,,1584,Percent of Total Billed charges,72% of Total Billed Charges,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511.2,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,426,60,,1320,Percent of Total Billed Charges,60% of Total Billed Charges,639,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,319.5,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,639,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,461.5,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,313.11,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,674.5,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,624.8,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,639,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,313.11,710,
ARTHREX 3.0S130 FIBNL LEFT,2780002903,CDM,278,RC,C1713,HCPCS,Outpatient,,,15190.00,9873.50,,15190,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11544.4,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10936.8,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,10936.8,72,,1584,Percent of Total Billed charges,72% of Total Billed Charges,15190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10936.8,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,9114,60,,1320,Percent of Total Billed Charges,60% of Total Billed Charges,13671,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,6835.5,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,13671,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,15190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9873.5,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,6698.79,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,14430.5,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,15190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13367.2,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,13671,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,6698.79,15190,
ARTHREX CANC SCW FT SS 3X14,2780002904,CDM,278,RC,C1713,HCPCS,Outpatient,,,178.00,115.70,,178,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,135.28,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,128.16,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,128.16,72,,1584,Percent of Total Billed charges,72% of Total Billed Charges,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.16,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,106.8,60,,1320,Percent of Total Billed Charges,60% of Total Billed Charges,160.2,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,80.1,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,160.2,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.7,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,78.5,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,169.1,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.64,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,160.2,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,78.5,178,
ARTHREX LO-PRO SCW TI 3.5X14,2780002905,CDM,278,RC,C1713,HCPCS,Outpatient,,,305.00,198.25,,305,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,231.8,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,219.6,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,219.6,72,,1584,Percent of Total Billed charges,72% of Total Billed Charges,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.6,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,183,60,,1320,Percent of Total Billed Charges,60% of Total Billed Charges,274.5,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,137.25,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,274.5,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.25,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,134.51,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,289.75,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.4,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,274.5,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,134.51,305,
ARTHREX CAN SCW FT SS 3X16,2780002906,CDM,278,RC,C1713,HCPCS,Outpatient,,,178.00,115.70,,178,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,135.28,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,128.16,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,128.16,72,,1584,Percent of Total Billed charges,72% of Total Billed Charges,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.16,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,106.8,60,,1320,Percent of Total Billed Charges,60% of Total Billed Charges,160.2,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,80.1,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,160.2,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.7,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,78.5,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,169.1,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.64,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,160.2,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,78.5,178,
ARTHREX 3.8X130 FIBNL RT,2780002907,CDM,278,RC,C1713,HCPCS,Outpatient,,,15190.00,9873.50,,15190,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11544.4,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10936.8,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,10936.8,72,,1584,Percent of Total Billed charges,72% of Total Billed Charges,15190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10936.8,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,9114,60,,1320,Percent of Total Billed Charges,60% of Total Billed Charges,13671,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,6835.5,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,13671,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,15190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9873.5,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,6698.79,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,14430.5,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,15190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13367.2,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,13671,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,6698.79,15190,
ARTHREX CANC SCW FT SS 3X26,2780002908,CDM,278,RC,C1713,HCPCS,Outpatient,,,178.00,115.70,,178,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,135.28,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,128.16,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,128.16,72,,1584,Percent of Total Billed charges,72% of Total Billed Charges,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.16,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,106.8,60,,1320,Percent of Total Billed Charges,60% of Total Billed Charges,160.2,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,80.1,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,160.2,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.7,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,78.5,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,169.1,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.64,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,160.2,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,78.5,178,
ARTHREX VLR DIST RD PLT RT 3H,2780002909,CDM,278,RC,C1713,HCPCS,Outpatient,,,4033.00,2621.45,,4033,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3065.08,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2903.76,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,2903.76,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,4033,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2903.76,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,2419.8,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,3629.7,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,1814.85,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,3629.7,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,4033,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4033,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4033,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2621.45,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,1778.55,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,3831.35,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,4033,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3549.04,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,3629.7,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,1778.55,4033,
ARTHREX CANC SCW FT SS 3X18,2780002910,CDM,278,RC,C1713,HCPCS,Outpatient,,,178.00,115.70,,178,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,135.28,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,128.16,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,128.16,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.16,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,106.8,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,160.2,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,80.1,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,160.2,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.7,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,78.5,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,169.1,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,178,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.64,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,160.2,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,78.5,178,
ARTHREX 2.4X18 VAL SCW TI,2780002911,CDM,278,RC,C1713,HCPCS,Outpatient,,,710.00,461.50,,710,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,539.6,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,511.2,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,511.2,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511.2,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,426,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,639,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,319.5,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,639,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,461.5,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,313.11,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,674.5,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,624.8,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,639,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,313.11,710,
ARTHREX 2.4X20 VAL SCW TI,2780002912,CDM,278,RC,C1713,HCPCS,Outpatient,,,710.00,461.50,,710,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,539.6,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,511.2,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,511.2,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511.2,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,426,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,639,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,319.5,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,639,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,461.5,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,313.11,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,674.5,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,624.8,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,639,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,313.11,710,
SN CURL KIT PD CATH 2C 62.5CM,2780002913,CDM,278,RC,C1750,HCPCS,Outpatient,,,209.76,136.34,,209.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,159.42,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,151.03,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,151.03,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,209.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.03,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,125.86,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,188.78,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,94.39,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,188.78,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,209.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.34,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,92.5,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,199.27,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,209.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.59,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,188.78,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,92.5,209.76,
CURLED PD 1C 62CM CATHETER,2780002914,CDM,278,RC,C1750,HCPCS,Outpatient,,,141.47,91.96,,141.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.52,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.86,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,101.86,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,141.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.86,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,84.88,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,127.32,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,63.66,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,127.32,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,141.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.96,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,62.39,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.4,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,141.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.49,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,127.32,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,62.39,141.47,
GASTRO 30F MIC MBO FEED TUBE,2780002915,CDM,278,RC,,,Outpatient,,,38.63,25.11,,38.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.36,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.81,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,27.81,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,38.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.81,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,23.18,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,34.77,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,17.38,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,34.77,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,38.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.11,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,17.04,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.7,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,38.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.99,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,34.77,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,17.04,38.63,
PRO SUBTALAR IMP 9X14MM,2780002916,CDM,278,RC,C1713,HCPCS,Outpatient,,,5307.00,3449.55,,5307,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4033.32,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3821.04,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,3821.04,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,5307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3821.04,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,3184.2,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,4776.3,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,2388.15,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,4776.3,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,5307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3449.55,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,2340.39,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,5041.65,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,5307,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4670.16,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,4776.3,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,2340.39,5307,
MICKEY 12F 1.5CM BUTTON G KIT,2780002917,CDM,278,RC,,,Outpatient,,,299.64,194.77,,299.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,227.73,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,215.74,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,215.74,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,299.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.74,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,179.78,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,269.68,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,134.84,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,269.68,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,299.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,299.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,299.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.77,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,132.14,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,284.66,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,299.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.68,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,269.68,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,132.14,299.64,
EVERFLEX 5F 6X60X120 STNT,2780002918,CDM,278,RC,C1876,HCPCS,Outpatient,,,3036.00,1973.40,,3036,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2307.36,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2185.92,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,2185.92,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,3036,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2185.92,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,1821.6,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,2732.4,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,1366.2,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,2732.4,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,3036,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3036,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3036,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1973.4,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,1338.88,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,2884.2,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,3036,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2671.68,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,2732.4,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,1338.88,3036,
CALCIGEN-S 25GR PASTE,2780002919,CDM,278,RC,C1713,HCPCS,Outpatient,,,9230.00,5999.50,,9230,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7014.8,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6645.6,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,6645.6,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,9230,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6645.6,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,5538,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,8307,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,4153.5,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,8307,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,9230,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9230,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9230,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5999.5,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,4070.43,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,8768.5,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,9230,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8122.4,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,8307,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,4070.43,9230,
EVERFLEX 6F 0.035 5X40X120,2780002920,CDM,278,RC,C1876,HCPCS,Outpatient,,,763.00,495.95,,763,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,579.88,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,549.36,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,549.36,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.36,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,457.8,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,686.7,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,343.35,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,686.7,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495.95,65,,23478,Percent of total Billed Charges,65% of Total Billed Charges,336.48,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,724.85,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,671.44,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,686.7,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,336.48,763,
IPG W1SR01 AZURE XT SR MRI,2780002921,CDM,275,RC,C1786,HCPCS,Outpatient,,,4835.00,3142.75,,4835,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3674.6,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3481.2,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,3481.2,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,4835,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3481.2,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,2901,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,4351.5,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,2175.75,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,4351.5,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,4835,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4835,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4835,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3142.75,65,,6702.8,Percent of total Billed Charges,65% of Total Billed Charges,2132.24,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,4593.25,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,4835,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4254.8,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,4351.5,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,2132.24,4835,
LEAD 5076-52 LEAD BS S FIX52,2780002922,CDM,278,RC,C1898,HCPCS,Outpatient,,,575.00,373.75,,575,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,437,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,414,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,414,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,345,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,517.5,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,258.75,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,517.5,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.75,65,,6702.8,Percent of total Billed Charges,65% of Total Billed Charges,253.58,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,546.25,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,517.5,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,253.58,575,
IPG W1DR01 AZURE XT DR MRI,2780002923,CDM,275,RC,C1785,HCPCS,Outpatient,,,5405.00,3513.25,,5405,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4107.8,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3891.6,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,3891.6,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,5405,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3891.6,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,3243,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,4864.5,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,2432.25,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,4864.5,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,5405,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5405,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5405,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3513.25,65,,5850,Percent of total Billed Charges,65% of Total Billed Charges,2383.61,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,5134.75,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,5405,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4756.4,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,4864.5,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,2383.61,5405,
LEAD 5076-45 LEAD B-S S SCREW,2780002924,CDM,278,RC,C1898,HCPCS,Outpatient,,,575.00,373.75,,575,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,437,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,414,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,414,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,345,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,517.5,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,258.75,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,517.5,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.75,65,,4884.104,Percent of total Billed Charges,65% of Total Billed Charges,253.58,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,546.25,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,517.5,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,253.58,575,
BIPOLAR SHELL 40MM,2780002925,CDM,278,RC,C1776,HCPCS,Outpatient,,,649.20,421.98,,649.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,493.39,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,467.42,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,467.42,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,649.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,467.42,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,389.52,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,584.28,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,292.14,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,584.28,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,649.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,421.98,65,,4884.104,Percent of total Billed Charges,65% of Total Billed Charges,286.3,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,616.74,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,649.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,571.3,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,584.28,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,286.3,649.2,
CATH PERITONEAL KT PLRX 9000-8,2780002926,CDM,278,RC,C1750,HCPCS,Outpatient,,,575.00,373.75,,575,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,437,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,414,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,414,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,345,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,517.5,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,258.75,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,517.5,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.75,65,,5343,Percent of total Billed Charges,65% of Total Billed Charges,253.58,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,546.25,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,517.5,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,253.58,575,
Z23570810 DIS/TIB PLT 10H LT,2780002927,CDM,278,RC,C1776,HCPCS,Outpatient,,,1236.20,803.53,,1236.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,939.51,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,890.06,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,890.06,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,1236.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,890.06,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,741.72,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,1112.58,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,556.29,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,1112.58,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,1236.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1236.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1236.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,803.53,65,,5343,Percent of total Billed Charges,65% of Total Billed Charges,545.16,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,1174.39,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,1236.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1087.86,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,1112.58,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,545.16,1236.2,
Z23594427 2.7 CORT SCW 44,2780002928,CDM,278,RC,C1776,HCPCS,Outpatient,,,74.20,48.23,,74.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.39,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.42,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,53.42,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,74.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.42,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,44.52,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,66.78,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,33.39,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,66.78,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,74.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.23,65,,5954,Percent of total Billed Charges,65% of Total Billed Charges,32.72,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,70.49,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,74.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.3,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,66.78,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,32.72,74.2,
PALINDROME 19 X 36 SPORT PACK,2780002929,CDM,278,RC,C1750,HCPCS,Outpatient,,,294.00,191.10,,294,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,223.44,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,211.68,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,211.68,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.68,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,176.4,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,264.6,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,132.3,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,264.6,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.1,65,,9786.4,Percent of total Billed Charges,65% of Total Billed Charges,129.65,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,279.3,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258.72,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,264.6,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,129.65,294,
GASTRO FEED TUBE W/Y PRT 28F,2780002930,CDM,278,RC,,,Outpatient,,,15.52,10.09,,15.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.8,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.17,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,11.17,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,15.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.17,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,9.31,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,13.97,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,6.98,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,13.97,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,15.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.09,65,,4884.104,Percent of total Billed Charges,65% of Total Billed Charges,6.84,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.74,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,15.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.66,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,13.97,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,6.84,15.52,
MICKEY 18FX1.7CM BUTTON KIT,2780002931,CDM,272,RC,B4088,HCPCS,Outpatient,,,151.36,98.38,,48.45,125,,,Fee Schedule,125% of CMS OPPS Rate,115.03,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.98,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,113.52,75,,1476,Percent of Total Billed charges,75% of Total Billed Charges,38.76,100,,,Fee Schedule,100% of CMS OPPS Rate,108.98,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,90.82,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,136.22,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,68.11,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,136.22,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,38.76,100,,,Fee Schedule,100% of CMS OPPS Rate,38.76,100,,,Fee Schedule,100% of CMS OPPS Rate,38.76,100,,,Fee Schedule,100% of CMS OPPS Rate,77.52,200,,4884.104,Fee Schedule,200% of CMS OPPS Rate,66.75,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,143.79,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,29.07,75,,,Fee Schedule,75% of CMS OPPS Rate,133.2,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,136.22,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,29.07,143.79,
MICKEY 24F X 1.7CM BUTTON KIT,2780002932,CDM,272,RC,B4088,HCPCS,Outpatient,,,151.36,98.38,,48.45,125,,,Fee Schedule,125% of CMS OPPS Rate,115.03,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.98,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,113.52,75,,1476,Percent of Total Billed charges,75% of Total Billed Charges,38.76,100,,,Fee Schedule,100% of CMS OPPS Rate,108.98,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,90.82,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,136.22,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,68.11,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,136.22,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,38.76,100,,,Fee Schedule,100% of CMS OPPS Rate,38.76,100,,,Fee Schedule,100% of CMS OPPS Rate,38.76,100,,,Fee Schedule,100% of CMS OPPS Rate,77.52,200,,5343,Fee Schedule,200% of CMS OPPS Rate,66.75,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,143.79,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,29.07,75,,,Fee Schedule,75% of CMS OPPS Rate,133.2,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,136.22,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,29.07,143.79,
MIC GASTRO ENTERIC TUBE 16FKIT,2780002933,CDM,272,RC,B4087,HCPCS,Outpatient,,,208.50,135.53,,41.26,125,,,Fee Schedule,125% of CMS OPPS Rate,158.46,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.12,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,156.38,75,,1476,Percent of Total Billed charges,75% of Total Billed Charges,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,150.12,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,125.1,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,187.65,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,93.83,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,187.65,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,66.02,200,,5343,Fee Schedule,200% of CMS OPPS Rate,91.95,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,198.08,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,24.76,75,,,Fee Schedule,75% of CMS OPPS Rate,183.48,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,187.65,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,24.76,198.08,
POWERWAND 3F X 6CM KIT,2780002934,CDM,278,RC,C1751,HCPCS,Outpatient,,,123.00,79.95,,123,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.48,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.56,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,88.56,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,123,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.56,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,73.8,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,110.7,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,55.35,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,110.7,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,123,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.95,65,,5954,Percent of total Billed Charges,65% of Total Billed Charges,54.24,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.85,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,123,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.24,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,110.7,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,54.24,123,
CATH PICC PROVENA SOLO 5F TL,2780002935,CDM,278,RC,C1751,HCPCS,Outpatient,,,92.73,60.27,,92.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,70.47,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,66.77,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,66.77,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,92.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.77,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,55.64,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,83.46,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,41.73,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,83.46,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,92.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.27,65,,9786.4,Percent of total Billed Charges,65% of Total Billed Charges,40.89,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,88.09,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,92.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.6,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,83.46,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,40.89,92.73,
1.5MM CORT SCW 20MM,2780002936,CDM,278,RC,C1713,HCPCS,Outpatient,,,18.20,11.83,,18.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.83,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.1,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,13.1,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,18.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.1,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,10.92,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,16.38,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,8.19,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,16.38,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,18.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.83,65,,4884.104,Percent of total Billed Charges,65% of Total Billed Charges,8.03,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.29,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,18.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.02,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,16.38,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,8.03,18.2,
FEMORAL ART LINE CATHETER KIT,2780002937,CDM,272,RC,,,Outpatient,,,37.50,24.38,,37.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.5,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,28.13,75,,1476,Percent of Total Billed charges,75% of Total Billed Charges,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,22.5,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,33.75,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,16.88,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,33.75,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.38,65,,4884.104,Percent of total Billed Charges,65% of Total Billed Charges,16.54,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.63,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,37.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,33.75,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,16.54,37.5,
Lead 6947M55 ADC Sprint 55CM,2780002938,CDM,278,RC,C1895,HCPCS,Outpatient,,,11400.00,7410.00,,11400,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8664,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8208,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,8208,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,11400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8208,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,6840,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,10260,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,5130,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,10260,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,11400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7410,65,,5343,Percent of total Billed Charges,65% of Total Billed Charges,5027.4,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,10830,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,11400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10032,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,10260,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,5027.4,11400,
Palindrome PHSI 28CM Kit,2780002939,CDM,278,RC,C1750,HCPCS,Outpatient,,,1187.50,771.88,,1187.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,902.5,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,855,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,855,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,1187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,855,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,712.5,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,1068.75,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,534.38,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,1068.75,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,1187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771.88,65,,5343,Percent of total Billed Charges,65% of Total Billed Charges,523.69,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,1128.13,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,1187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1045,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,1068.75,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,523.69,1187.5,
Palindrom 33CM 14F Sport Pack,2780002940,CDM,278,RC,C1750,HCPCS,Outpatient,,,1115.00,724.75,,1115,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,847.4,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,802.8,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,802.8,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,1115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,802.8,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,669,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,1003.5,90,,32508,Percent of Total Billed Charges,90% of Total Billed Charges,501.75,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,1003.5,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,1115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,724.75,65,,5954,Percent of total Billed Charges,65% of Total Billed Charges,491.72,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,1059.25,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,1115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,981.2,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,1003.5,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,491.72,1115,
Ingevity MRI IS-1 BSF 45cm,2780002941,CDM,278,RC,C1898,HCPCS,Outpatient,,,2020.00,1313.00,,2020,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1535.2,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1454.4,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,1454.4,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,2020,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1454.4,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,1212,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,1818,90,,9280.8,Percent of Total Billed Charges,90% of Total Billed Charges,909,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,1818,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,2020,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2020,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2020,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1313,65,,9786.4,Percent of total Billed Charges,65% of Total Billed Charges,890.82,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,1919,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,2020,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.6,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,1818,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,890.82,2020,
Ingevity MRI IS-1 BSF 52cm,2780002942,CDM,278,RC,C1898,HCPCS,Outpatient,,,2020.00,1313.00,,2020,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1535.2,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1454.4,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,1454.4,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,2020,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1454.4,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,1212,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,1818,90,,9280.8,Percent of Total Billed Charges,90% of Total Billed Charges,909,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,1818,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,2020,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2020,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2020,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1313,65,,4884.104,Percent of total Billed Charges,65% of Total Billed Charges,890.82,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,1919,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,2020,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.6,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,1818,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,890.82,2020,
ENDOBUTTON 25MM,2780002943,CDM,278,RC,,,Outpatient,,,590.20,383.63,,590.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,448.55,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,424.94,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,424.94,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,590.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.94,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,354.12,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,531.18,90,,8100,Percent of Total Billed Charges,90% of Total Billed Charges,265.59,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,531.18,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,590.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,590.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,590.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,383.63,65,,4884.104,Percent of total Billed Charges,65% of Total Billed Charges,260.28,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,560.69,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,590.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,519.38,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,531.18,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,260.28,590.2,
ENDOBUTTON 30MM,2780002944,CDM,278,RC,,,Outpatient,,,592.20,384.93,,592.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,450.07,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,426.38,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,426.38,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.38,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,355.32,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,532.98,90,,6762.6,Percent of Total Billed Charges,90% of Total Billed Charges,266.49,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,532.98,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.93,65,,5343,Percent of total Billed Charges,65% of Total Billed Charges,261.16,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,562.59,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,592.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521.14,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,532.98,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,261.16,592.2,
ENDOBUTTON 15MM,2780002945,CDM,278,RC,,,Outpatient,,,590.20,383.63,,590.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,448.55,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,424.94,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,424.94,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,590.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.94,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,354.12,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,531.18,90,,6762.6,Percent of Total Billed Charges,90% of Total Billed Charges,265.59,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,531.18,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,590.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,590.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,590.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,383.63,65,,5343,Percent of total Billed Charges,65% of Total Billed Charges,260.28,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,560.69,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,590.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,519.38,88,,31785.6,Percent of Total Billed Charges,88% of Total Billed Charges,531.18,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,260.28,590.2,
Acumed AT2-M18-S MINI SCW 18,2780002946,CDM,278,RC,,,Outpatient,,,1400.00,910.00,,1400,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1064,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1008,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,1008,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,1400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1008,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,840,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,1260,90,,7398,Percent of Total Billed Charges,90% of Total Billed Charges,630,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,1260,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,1400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,910,65,,5954,Percent of total Billed Charges,65% of Total Billed Charges,617.4,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,1330,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,1400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1232,88,,9074.56,Percent of Total Billed Charges,88% of Total Billed Charges,1260,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,617.4,1400,
Acumed AT2-M28-S MINI SCW 28,2780002947,CDM,278,RC,,,Outpatient,,,1372.50,892.13,,1372.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1043.1,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,988.2,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,988.2,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,1372.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,988.2,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,823.5,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,1235.25,90,,7398,Percent of Total Billed Charges,90% of Total Billed Charges,617.63,45,,16254,Percent of Total Billed Charges,45% of Total Billed Charges,1235.25,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,1372.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1372.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1372.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,892.13,65,,9786.4,Percent of total Billed Charges,65% of Total Billed Charges,605.27,44.1,,15928.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,1303.88,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,1372.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1207.8,88,,9074.56,Percent of Total Billed Charges,88% of Total Billed Charges,1235.25,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,605.27,1372.5,
Acumed AT2-C20-S 20 MICRO SCW,2780002948,CDM,278,RC,,,Outpatient,,,1372.50,892.13,,1372.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1043.1,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,988.2,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,988.2,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,1372.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,988.2,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,823.5,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,1235.25,90,,8244,Percent of Total Billed Charges,90% of Total Billed Charges,617.63,45,,4640.4,Percent of Total Billed Charges,45% of Total Billed Charges,1235.25,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,1372.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1372.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1372.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,892.13,65,,2686.128,Percent of total Billed Charges,65% of Total Billed Charges,605.27,44.1,,4547.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,1303.88,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,1372.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1207.8,88,,7920,Percent of Total Billed Charges,88% of Total Billed Charges,1235.25,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,605.27,1372.5,
Artegraft 6x36 Vascular,2780002949,CDM,278,RC,,,Outpatient,,,4247.50,2760.88,,4247.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3228.1,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3058.2,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,3058.2,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,4247.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3058.2,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,2548.5,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,3822.75,90,,13550.4,Percent of Total Billed Charges,90% of Total Billed Charges,1911.38,45,,4640.4,Percent of Total Billed Charges,45% of Total Billed Charges,3822.75,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,4247.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4247.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4247.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2760.88,65,,1053.512,Percent of total Billed Charges,65% of Total Billed Charges,1873.15,44.1,,4547.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,4035.13,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,4247.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3737.8,88,,6612.32,Percent of Total Billed Charges,88% of Total Billed Charges,3822.75,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,1873.15,4247.5,
Z1147-48-40 4.0 CANN PT SCW 48,2780002950,CDM,278,RC,,,Outpatient,,,397.25,258.21,,397.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,301.91,76,,27451.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,286.02,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,286.02,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,397.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.02,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,238.35,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,357.53,90,,6762.6,Percent of Total Billed Charges,90% of Total Billed Charges,178.76,45,,4050,Percent of Total Billed Charges,45% of Total Billed Charges,357.53,90,,32508,Percent of Total Billed Charges,90% of Total billed Charges,397.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258.21,65,,5928,Percent of total Billed Charges,65% of Total Billed Charges,175.19,44.1,,3969,Percent of Total Billed Charges,44.1% of Total Billed Charges,377.39,95,,34314,Percent of Total Billed Charges,95% of Total Billed Charges,397.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.58,88,,6612.32,Percent of Total Billed Charges,88% of Total Billed Charges,357.53,90,,32508,Percent of Total Billed charges,90% of Total Billed Charges,175.19,397.25,
Z1312-27-128 2.7MM LCK SCW 28,2780002951,CDM,278,RC,,,Outpatient,,,227.50,147.88,,227.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,172.9,76,,7837.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,163.8,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,163.8,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,227.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.8,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,136.5,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,204.75,90,,6762.6,Percent of Total Billed Charges,90% of Total Billed Charges,102.38,45,,3381.304,Percent of Total Billed Charges,45% of Total Billed Charges,204.75,90,,9280.8,Percent of Total Billed Charges,90% of Total billed Charges,227.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.88,65,,621.4,Percent of total Billed Charges,65% of Total Billed Charges,100.33,44.1,,3313.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,216.13,95,,9796.4,Percent of Total Billed Charges,95% of Total Billed Charges,227.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.2,88,,7233.6,Percent of Total Billed Charges,88% of Total Billed Charges,204.75,90,,9280.8,Percent of Total Billed charges,90% of Total Billed Charges,100.33,227.5,
Cancellous Bone Chips 4-10/10c,2780002952,CDM,278,RC,,,Outpatient,,,697.50,453.38,,697.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,530.1,76,,7837.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,502.2,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,502.2,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,697.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.2,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,418.5,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,627.75,90,,7398,Percent of Total Billed Charges,90% of Total Billed Charges,313.88,45,,3381.304,Percent of Total Billed Charges,45% of Total Billed Charges,627.75,90,,9280.8,Percent of Total Billed Charges,90% of Total billed Charges,697.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,697.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,697.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.38,65,,621.4,Percent of total Billed Charges,65% of Total Billed Charges,307.6,44.1,,3313.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,662.63,95,,9796.4,Percent of Total Billed Charges,95% of Total Billed Charges,697.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,613.8,88,,7233.6,Percent of Total Billed Charges,88% of Total Billed Charges,627.75,90,,9280.8,Percent of Total Billed charges,90% of Total Billed Charges,307.6,697.5,
ACUMED 3.5X20 LCK SCW,2780002953,CDM,278,RC,,,Outpatient,,,672.50,437.13,,672.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,511.1,76,,6840,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,484.2,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,484.2,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,672.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484.2,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,403.5,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,605.25,90,,7398,Percent of Total Billed Charges,90% of Total Billed Charges,302.63,45,,3699,Percent of Total Billed Charges,45% of Total Billed Charges,605.25,90,,8100,Percent of Total Billed Charges,90% of Total billed Charges,672.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.13,65,,306.8,Percent of total Billed Charges,65% of Total Billed Charges,296.57,44.1,,3625.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,638.88,95,,8550,Percent of Total Billed Charges,95% of Total Billed Charges,672.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,591.8,88,,8060.8,Percent of Total Billed Charges,88% of Total Billed Charges,605.25,90,,8100,Percent of Total Billed charges,90% of Total Billed Charges,296.57,672.5,
ACUMED 3.5X16 LCK SCW,2780002954,CDM,278,RC,,,Outpatient,,,672.50,437.13,,672.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,511.1,76,,5710.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,484.2,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,484.2,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,672.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484.2,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,403.5,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,605.25,90,,8244,Percent of Total Billed Charges,90% of Total Billed Charges,302.63,45,,3699,Percent of Total Billed Charges,45% of Total Billed Charges,605.25,90,,6762.6,Percent of Total Billed Charges,90% of Total billed Charges,672.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.13,65,,205.4,Percent of total Billed Charges,65% of Total Billed Charges,296.57,44.1,,3625.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,638.88,95,,7138.304,Percent of Total Billed Charges,95% of Total Billed Charges,672.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,591.8,88,,13249.28,Percent of Total Billed Charges,88% of Total Billed Charges,605.25,90,,6762.6,Percent of Total Billed charges,90% of Total Billed Charges,296.57,672.5,
Z2254-210-09 Hum Nail 9x21,2780002955,CDM,278,RC,,,Outpatient,,,2977.50,1935.38,,2977.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2262.9,76,,5710.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2143.8,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,2143.8,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,2977.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2143.8,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,1786.5,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,2679.75,90,,13550.4,Percent of Total Billed Charges,90% of Total Billed Charges,1339.88,45,,4122,Percent of Total Billed Charges,45% of Total Billed Charges,2679.75,90,,6762.6,Percent of Total Billed Charges,90% of Total billed Charges,2977.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2977.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2977.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1935.38,65,,205.4,Percent of total Billed Charges,65% of Total Billed Charges,1313.08,44.1,,4039.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,2828.63,95,,7138.304,Percent of Total Billed Charges,95% of Total Billed Charges,2977.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2620.2,88,,6612.32,Percent of Total Billed Charges,88% of Total Billed Charges,2679.75,90,,6762.6,Percent of Total Billed charges,90% of Total Billed Charges,1313.08,2977.5,
K-Wire 0.62 Smooth,2780002956,CDM,278,RC,,,Outpatient,,,15.18,9.87,,15.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.54,76,,6247.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.93,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,10.93,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,15.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.93,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,9.11,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,13.66,90,,6762.6,Percent of Total Billed Charges,90% of Total Billed Charges,6.83,45,,6775.2,Percent of Total Billed Charges,45% of Total Billed Charges,13.66,90,,7398,Percent of Total Billed Charges,90% of Total billed Charges,15.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.87,65,,548.6,Percent of total Billed Charges,65% of Total Billed Charges,6.69,44.1,,6639.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.42,95,,7809,Percent of Total Billed Charges,95% of Total Billed Charges,15.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.36,88,,6612.32,Percent of Total Billed Charges,88% of Total Billed Charges,13.66,90,,7398,Percent of Total Billed charges,90% of Total Billed Charges,6.69,15.18,
SM Stein Pins 5/64,2780002957,CDM,278,RC,,,Outpatient,,,17.20,11.18,,17.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.07,76,,6247.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.38,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,12.38,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,17.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.38,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,10.32,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,15.48,90,,6762.6,Percent of Total Billed Charges,90% of Total Billed Charges,7.74,45,,3381.304,Percent of Total Billed Charges,45% of Total Billed Charges,15.48,90,,7398,Percent of Total Billed Charges,90% of Total billed Charges,17.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.18,65,,111.8,Percent of total Billed Charges,65% of Total Billed Charges,7.59,44.1,,3313.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.34,95,,7809,Percent of Total Billed Charges,95% of Total Billed Charges,17.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.14,88,,7233.6,Percent of Total Billed Charges,88% of Total Billed Charges,15.48,90,,7398,Percent of Total Billed charges,90% of Total Billed Charges,7.59,17.2,
SM Stein Pins 3/32,2780002958,CDM,278,RC,,,Outpatient,,,17.20,11.18,,17.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.07,76,,6961.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.38,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,12.38,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,17.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.38,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,10.32,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,15.48,90,,7398,Percent of Total Billed Charges,90% of Total Billed Charges,7.74,45,,3381.304,Percent of Total Billed Charges,45% of Total Billed Charges,15.48,90,,8244,Percent of Total Billed Charges,90% of Total billed Charges,17.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.18,65,,548.6,Percent of total Billed Charges,65% of Total Billed Charges,7.59,44.1,,3313.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.34,95,,8702,Percent of Total Billed Charges,95% of Total Billed Charges,17.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.14,88,,7233.6,Percent of Total Billed Charges,88% of Total Billed Charges,15.48,90,,8244,Percent of Total Billed charges,90% of Total Billed Charges,7.59,17.2,
SM Stein Pins 7/64,2780002959,CDM,278,RC,,,Outpatient,,,17.20,11.18,,17.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.07,76,,11442.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.38,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,12.38,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,17.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.38,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,10.32,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,15.48,90,,7398,Percent of Total Billed Charges,90% of Total Billed Charges,7.74,45,,3699,Percent of Total Billed Charges,45% of Total Billed Charges,15.48,90,,13550.4,Percent of Total Billed Charges,90% of Total billed Charges,17.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.18,65,,110.504,Percent of total Billed Charges,65% of Total Billed Charges,7.59,44.1,,3625.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.34,95,,14303.2,Percent of Total Billed Charges,95% of Total Billed Charges,17.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.14,88,,8060.8,Percent of Total Billed Charges,88% of Total Billed Charges,15.48,90,,13550.4,Percent of Total Billed charges,90% of Total Billed Charges,7.59,17.2,
K-Wire .045 Smooth,2780002960,CDM,278,RC,,,Outpatient,,,15.18,9.87,,15.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.54,76,,5710.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.93,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,10.93,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,15.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.93,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,9.11,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,13.66,90,,8244,Percent of Total Billed Charges,90% of Total Billed Charges,6.83,45,,3699,Percent of Total Billed Charges,45% of Total Billed Charges,13.66,90,,6762.6,Percent of Total Billed Charges,90% of Total billed Charges,15.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.87,65,,37.704,Percent of total Billed Charges,65% of Total Billed Charges,6.69,44.1,,3625.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.42,95,,7138.304,Percent of Total Billed Charges,95% of Total Billed Charges,15.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.36,88,,13249.28,Percent of Total Billed Charges,88% of Total Billed Charges,13.66,90,,6762.6,Percent of Total Billed charges,90% of Total Billed Charges,6.69,15.18,
SM Stein Pins 5/32,2780002961,CDM,278,RC,,,Outpatient,,,6.95,4.52,,6.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.28,76,,5710.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,5,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,6.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,4.17,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,6.26,90,,13550.4,Percent of Total Billed Charges,90% of Total Billed Charges,3.13,45,,4122,Percent of Total Billed Charges,45% of Total Billed Charges,6.26,90,,6762.6,Percent of Total Billed Charges,90% of Total billed Charges,6.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.52,65,,1727.704,Percent of total Billed Charges,65% of Total Billed Charges,3.06,44.1,,4039.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.6,95,,7138.304,Percent of Total Billed Charges,95% of Total Billed Charges,6.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.12,88,,6612.32,Percent of Total Billed Charges,88% of Total Billed Charges,6.26,90,,6762.6,Percent of Total Billed charges,90% of Total Billed Charges,3.06,6.95,
SM Stein Pins 1/8,2780002962,CDM,278,RC,,,Outpatient,,,6.95,4.52,,6.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.28,76,,6247.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,5,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,6.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,4.17,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,6.26,90,,6762.6,Percent of Total Billed Charges,90% of Total Billed Charges,3.13,45,,6775.2,Percent of Total Billed Charges,45% of Total Billed Charges,6.26,90,,7398,Percent of Total Billed Charges,90% of Total billed Charges,6.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.52,65,,621.4,Percent of total Billed Charges,65% of Total Billed Charges,3.06,44.1,,6639.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.6,95,,7809,Percent of Total Billed Charges,95% of Total Billed Charges,6.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.12,88,,6612.32,Percent of Total Billed Charges,88% of Total Billed Charges,6.26,90,,7398,Percent of Total Billed charges,90% of Total Billed Charges,3.06,6.95,
SM Stein Pins 9/64,2780002963,CDM,278,RC,,,Outpatient,,,21.58,14.03,,21.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16.4,76,,6247.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.54,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,15.54,72,,1584,Percent of Total Billed charges,72% of Total Billed Charges,21.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.54,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,12.95,60,,1320,Percent of Total Billed Charges,60% of Total Billed Charges,19.42,90,,6762.6,Percent of Total Billed Charges,90% of Total Billed Charges,9.71,45,,3381.304,Percent of Total Billed Charges,45% of Total Billed Charges,19.42,90,,7398,Percent of Total Billed Charges,90% of Total billed Charges,21.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.03,65,,24.568,Percent of total Billed Charges,65% of Total Billed Charges,9.52,44.1,,3313.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,20.5,95,,7809,Percent of Total Billed Charges,95% of Total Billed Charges,21.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.99,88,,7233.6,Percent of Total Billed Charges,88% of Total Billed Charges,19.42,90,,7398,Percent of Total Billed charges,90% of Total Billed Charges,9.52,21.58,
SM Stein Pins 3/16,2780002964,CDM,278,RC,,,Outpatient,,,6.95,4.52,,6.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.28,76,,6961.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,5,72,,1584,Percent of Total Billed charges,72% of Total Billed Charges,6.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,4.17,60,,1320,Percent of Total Billed Charges,60% of Total Billed Charges,6.26,90,,7398,Percent of Total Billed Charges,90% of Total Billed Charges,3.13,45,,3381.304,Percent of Total Billed Charges,45% of Total Billed Charges,6.26,90,,8244,Percent of Total Billed Charges,90% of Total billed Charges,6.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.52,65,,945.104,Percent of total Billed Charges,65% of Total Billed Charges,3.06,44.1,,3313.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.6,95,,8702,Percent of Total Billed Charges,95% of Total Billed Charges,6.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.12,88,,7233.6,Percent of Total Billed Charges,88% of Total Billed Charges,6.26,90,,8244,Percent of Total Billed charges,90% of Total Billed Charges,3.06,6.95,
K-Wire Threaded .045,2780002965,CDM,278,RC,,,Outpatient,,,17.45,11.34,,17.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.26,76,,11442.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.56,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,12.56,72,,1584,Percent of Total Billed charges,72% of Total Billed Charges,17.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.56,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,10.47,60,,1320,Percent of Total Billed Charges,60% of Total Billed Charges,15.71,90,,7398,Percent of Total Billed Charges,90% of Total Billed Charges,7.85,45,,3699,Percent of Total Billed Charges,45% of Total Billed Charges,15.71,90,,13550.4,Percent of Total Billed Charges,90% of Total billed Charges,17.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.34,65,,945.104,Percent of total Billed Charges,65% of Total Billed Charges,7.7,44.1,,3625.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.58,95,,14303.2,Percent of Total Billed Charges,95% of Total Billed Charges,17.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.36,88,,8060.8,Percent of Total Billed Charges,88% of Total Billed Charges,15.71,90,,13550.4,Percent of Total Billed charges,90% of Total Billed Charges,7.7,17.45,
Threaded Stein Pins 5/32,2780002966,CDM,278,RC,,,Outpatient,,,20.68,13.44,,20.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.72,76,,5710.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.89,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,72,,1584,Percent of Total Billed charges,72% of Total Billed Charges,20.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.89,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,60,,1320,Percent of Total Billed Charges,60% of Total Billed Charges,18.61,90,,8244,Percent of Total Billed Charges,90% of Total Billed Charges,9.31,45,,3699,Percent of Total Billed Charges,45% of Total Billed Charges,18.61,90,,6762.6,Percent of Total Billed Charges,90% of Total billed Charges,20.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.44,65,,1300,Percent of total Billed Charges,65% of Total Billed Charges,9.12,44.1,,3625.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.65,95,,7138.304,Percent of Total Billed Charges,95% of Total Billed Charges,20.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.2,88,,13249.28,Percent of Total Billed Charges,88% of Total Billed Charges,18.61,90,,6762.6,Percent of Total Billed charges,90% of Total Billed Charges,9.12,20.68,
Threaded Stein Pins 7/64,2780002967,CDM,278,RC,,,Outpatient,,,17.48,11.36,,17.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.28,76,,5710.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.59,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,12.59,72,,1584,Percent of Total Billed charges,72% of Total Billed Charges,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.59,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,10.49,60,,1320,Percent of Total Billed Charges,60% of Total Billed Charges,15.73,90,,13550.4,Percent of Total Billed Charges,90% of Total Billed Charges,7.87,45,,4122,Percent of Total Billed Charges,45% of Total Billed Charges,15.73,90,,6762.6,Percent of Total Billed Charges,90% of Total billed Charges,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.36,65,,621.4,Percent of total Billed Charges,65% of Total Billed Charges,7.71,44.1,,4039.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.61,95,,7138.304,Percent of Total Billed Charges,95% of Total Billed Charges,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.38,88,,6612.32,Percent of Total Billed Charges,88% of Total Billed Charges,15.73,90,,6762.6,Percent of Total Billed charges,90% of Total Billed Charges,7.71,17.48,
Threaded Stein Pins 9/64,2780002968,CDM,278,RC,,,Outpatient,,,17.48,11.36,,17.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.28,76,,6247.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.59,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,12.59,72,,1584,Percent of Total Billed charges,72% of Total Billed Charges,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.59,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,10.49,60,,1320,Percent of Total Billed Charges,60% of Total Billed Charges,15.73,90,,3719.256,Percent of Total Billed Charges,90% of Total Billed Charges,7.87,45,,6775.2,Percent of Total Billed Charges,45% of Total Billed Charges,15.73,90,,7398,Percent of Total Billed Charges,90% of Total billed Charges,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.36,65,,20.928,Percent of total Billed Charges,65% of Total Billed Charges,7.71,44.1,,6639.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.61,95,,7809,Percent of Total Billed Charges,95% of Total Billed Charges,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.38,88,,6612.32,Percent of Total Billed Charges,88% of Total Billed Charges,15.73,90,,7398,Percent of Total Billed charges,90% of Total Billed Charges,7.71,17.48,
Threaded Stein Pins 1/8,2780002969,CDM,278,RC,,,Outpatient,,,17.48,11.36,,17.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.28,76,,6247.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.59,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,12.59,72,,1584,Percent of Total Billed charges,72% of Total Billed Charges,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.59,72,,1584,Percent of Total Billed Charges,72% of Total Billed Charges,10.49,60,,1320,Percent of Total Billed Charges,60% of Total Billed Charges,15.73,90,,1458.704,Percent of Total Billed Charges,90% of Total Billed Charges,7.87,45,,3381.304,Percent of Total Billed Charges,45% of Total Billed Charges,15.73,90,,7398,Percent of Total Billed Charges,90% of Total billed Charges,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.36,65,,196.56,Percent of total Billed Charges,65% of Total Billed Charges,7.71,44.1,,3313.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.61,95,,7809,Percent of Total Billed Charges,95% of Total Billed Charges,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.38,88,,7233.6,Percent of Total Billed Charges,88% of Total Billed Charges,15.73,90,,7398,Percent of Total Billed charges,90% of Total Billed Charges,7.71,17.48,
Threaded Stein Pins 3/32,2780002970,CDM,278,RC,,,Outpatient,,,17.48,11.36,,17.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.28,76,,6961.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.59,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,12.59,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.59,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,10.49,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,15.73,90,,8208,Percent of Total Billed Charges,90% of Total Billed Charges,7.87,45,,3381.304,Percent of Total Billed Charges,45% of Total Billed Charges,15.73,90,,8244,Percent of Total Billed Charges,90% of Total billed Charges,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.36,65,,196.56,Percent of total Billed Charges,65% of Total Billed Charges,7.71,44.1,,3313.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.61,95,,8702,Percent of Total Billed Charges,95% of Total Billed Charges,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.38,88,,7233.6,Percent of Total Billed Charges,88% of Total Billed Charges,15.73,90,,8244,Percent of Total Billed charges,90% of Total Billed Charges,7.71,17.48,
K-Wire Threaded .062,2780002971,CDM,278,RC,,,Outpatient,,,17.48,11.36,,17.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.28,76,,11442.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.59,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,12.59,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.59,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,10.49,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,15.73,90,,860.4,Percent of Total Billed Charges,90% of Total Billed Charges,7.87,45,,3699,Percent of Total Billed Charges,45% of Total Billed Charges,15.73,90,,13550.4,Percent of Total Billed Charges,90% of Total billed Charges,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.36,65,,650,Percent of total Billed Charges,65% of Total Billed Charges,7.71,44.1,,3625.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.61,95,,14303.2,Percent of Total Billed Charges,95% of Total Billed Charges,17.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.38,88,,8060.8,Percent of Total Billed Charges,88% of Total Billed Charges,15.73,90,,13550.4,Percent of Total Billed charges,90% of Total Billed Charges,7.71,17.48,
Threaded Stein Pins 5/64,2780002972,CDM,278,RC,,,Outpatient,,,20.68,13.44,,20.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.72,76,,5710.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.89,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,20.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.89,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,12.41,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,18.61,90,,860.4,Percent of Total Billed Charges,90% of Total Billed Charges,9.31,45,,3699,Percent of Total Billed Charges,45% of Total Billed Charges,18.61,90,,6762.6,Percent of Total Billed Charges,90% of Total billed Charges,20.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.44,65,,390,Percent of total Billed Charges,65% of Total Billed Charges,9.12,44.1,,3625.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.65,95,,7138.304,Percent of Total Billed Charges,95% of Total Billed Charges,20.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.2,88,,13249.28,Percent of Total Billed Charges,88% of Total Billed Charges,18.61,90,,6762.6,Percent of Total Billed charges,90% of Total Billed Charges,9.12,20.68,
Biorci Screw 9x25,2780002973,CDM,278,RC,,,Outpatient,,,511.43,332.43,,511.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,388.69,76,,5710.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,368.23,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,368.23,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,511.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.23,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,306.86,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,460.29,90,,424.8,Percent of Total Billed Charges,90% of Total Billed Charges,230.14,45,,4122,Percent of Total Billed Charges,45% of Total Billed Charges,460.29,90,,6762.6,Percent of Total Billed Charges,90% of Total billed Charges,511.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.43,65,,390,Percent of total Billed Charges,65% of Total Billed Charges,225.54,44.1,,4039.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,485.86,95,,7138.304,Percent of Total Billed Charges,95% of Total Billed Charges,511.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.06,88,,3636.6,Percent of Total Billed Charges,88% of Total Billed Charges,460.29,90,,6762.6,Percent of Total Billed charges,90% of Total Billed Charges,225.54,511.43,
RCI Screw 9x25,2780002974,CDM,278,RC,,,Outpatient,,,326.58,212.28,,326.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,248.2,76,,6247.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,235.14,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,235.14,72,,1476,Percent of Total Billed charges,72% of Total Billed Charges,326.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.14,72,,1476,Percent of Total Billed Charges,72% of Total Billed Charges,195.95,60,,1230,Percent of Total Billed Charges,60% of Total Billed Charges,293.92,90,,284.4,Percent of Total Billed Charges,90% of Total Billed Charges,146.96,45,,6775.2,Percent of Total Billed Charges,45% of Total Billed Charges,293.92,90,,7398,Percent of Total Billed Charges,90% of Total billed Charges,326.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.28,65,,306.8,Percent of total Billed Charges,65% of Total Billed Charges,144.02,44.1,,6639.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,310.25,95,,7809,Percent of Total Billed Charges,95% of Total Billed Charges,326.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,287.39,88,,1426.288,Percent of Total Billed Charges,88% of Total Billed Charges,293.92,90,,7398,Percent of Total Billed charges,90% of Total Billed Charges,144.02,326.58,
RCI Screw 10x25,2780002975,CDM,278,RC,,,Outpatient,,,277.68,180.49,,277.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,211.04,76,,6247.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,199.93,72,,1124.64,Percent of Total Billed Charges,72% of Total Billed Charges,199.93,72,,1124.64,Percent of Total Billed charges,72% of Total Billed Charges,277.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.93,72,,1124.64,Percent of Total Billed Charges,72% of Total Billed Charges,166.61,60,,937.2,Percent of Total Billed Charges,60% of Total Billed Charges,249.91,90,,284.4,Percent of Total Billed Charges,90% of Total Billed Charges,124.96,45,,1859.624,Percent of Total Billed Charges,45% of Total Billed Charges,249.91,90,,7398,Percent of Total Billed Charges,90% of Total billed Charges,277.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.49,65,,548.6,Percent of total Billed Charges,65% of Total Billed Charges,122.46,44.1,,1822.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,263.8,95,,7809,Percent of Total Billed Charges,95% of Total Billed Charges,277.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.36,88,,8025.6,Percent of Total Billed Charges,88% of Total Billed Charges,249.91,90,,7398,Percent of Total Billed charges,90% of Total Billed Charges,122.46,277.68,
1.0x7mm Cortex Screw,2780002976,CDM,278,RC,,,Outpatient,,,140.00,91.00,,140,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.4,76,,6961.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.8,72,,27.072,Percent of Total Billed Charges,72% of Total Billed Charges,100.8,72,,27.072,Percent of Total Billed charges,72% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.8,72,,27.072,Percent of Total Billed Charges,72% of Total Billed Charges,84,60,,22.56,Percent of Total Billed Charges,60% of Total Billed Charges,126,90,,759.6,Percent of Total Billed Charges,90% of Total Billed Charges,63,45,,729.352,Percent of Total Billed Charges,45% of Total Billed Charges,126,90,,8244,Percent of Total Billed Charges,90% of Total billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91,65,,111.8,Percent of total Billed Charges,65% of Total Billed Charges,61.74,44.1,,714.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,133,95,,8702,Percent of Total Billed Charges,95% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.2,88,,841.28,Percent of Total Billed Charges,88% of Total Billed Charges,126,90,,8244,Percent of Total Billed charges,90% of Total Billed Charges,61.74,140,
1.0x8MM Cortex Screw,2780002977,CDM,278,RC,,,Outpatient,,,140.00,91.00,,140,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.4,76,,11442.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.8,72,,2152.8,Percent of Total Billed Charges,72% of Total Billed Charges,100.8,72,,2152.8,Percent of Total Billed charges,72% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.8,72,,2152.8,Percent of Total Billed Charges,72% of Total Billed Charges,84,60,,1794,Percent of Total Billed Charges,60% of Total Billed Charges,126,90,,154.8,Percent of Total Billed Charges,90% of Total Billed Charges,63,45,,4104,Percent of Total Billed Charges,45% of Total Billed Charges,126,90,,13550.4,Percent of Total Billed Charges,90% of Total billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91,65,,548.6,Percent of total Billed Charges,65% of Total Billed Charges,61.74,44.1,,4021.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,133,95,,14303.2,Percent of Total Billed Charges,95% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.2,88,,841.28,Percent of Total Billed Charges,88% of Total Billed Charges,126,90,,13550.4,Percent of Total Billed charges,90% of Total Billed Charges,61.74,140,
1.0X9MM Cortex Screw,2780002978,CDM,278,RC,,,Outpatient,,,140.00,91.00,,140,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.4,76,,3140.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.8,72,,2152.8,Percent of Total Billed Charges,72% of Total Billed Charges,100.8,72,,2152.8,Percent of Total Billed charges,72% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.8,72,,2152.8,Percent of Total Billed Charges,72% of Total Billed Charges,84,60,,1794,Percent of Total Billed Charges,60% of Total Billed Charges,126,90,,759.6,Percent of Total Billed Charges,90% of Total Billed Charges,63,45,,430.2,Percent of Total Billed Charges,45% of Total Billed Charges,126,90,,3719.256,Percent of Total Billed Charges,90% of Total billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91,65,,1115.4,Percent of total Billed Charges,65% of Total Billed Charges,61.74,44.1,,421.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,133,95,,3925.88,Percent of Total Billed Charges,95% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.2,88,,415.36,Percent of Total Billed Charges,88% of Total Billed Charges,126,90,,3719.256,Percent of Total Billed charges,90% of Total Billed Charges,61.74,140,
1.0x10MM Cortex Screw,2780002979,CDM,278,RC,,,Outpatient,,,140.00,91.00,,140,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.4,76,,1231.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.8,72,,506.88,Percent of Total Billed Charges,72% of Total Billed Charges,100.8,72,,506.88,Percent of Total Billed charges,72% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.8,72,,506.88,Percent of Total Billed Charges,72% of Total Billed Charges,84,60,,422.4,Percent of Total Billed Charges,60% of Total Billed Charges,126,90,,153,Percent of Total Billed Charges,90% of Total Billed Charges,63,45,,430.2,Percent of Total Billed Charges,45% of Total Billed Charges,126,90,,1458.704,Percent of Total Billed Charges,90% of Total billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91,65,,111.8,Percent of total Billed Charges,65% of Total Billed Charges,61.74,44.1,,421.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,133,95,,1539.744,Percent of Total Billed Charges,95% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.2,88,,278.08,Percent of Total Billed Charges,88% of Total Billed Charges,126,90,,1458.704,Percent of Total Billed charges,90% of Total Billed Charges,61.74,140,
1.0x11MM Cortex Screw,2780002980,CDM,278,RC,,,Outpatient,,,140.00,91.00,,140,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.4,76,,6931.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.8,72,,889.2,Percent of Total Billed Charges,72% of Total Billed Charges,100.8,72,,889.2,Percent of Total Billed charges,72% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.8,72,,889.2,Percent of Total Billed Charges,72% of Total Billed Charges,84,60,,741,Percent of Total Billed Charges,60% of Total Billed Charges,126,90,,52.2,Percent of Total Billed Charges,90% of Total Billed Charges,63,45,,212.4,Percent of Total Billed Charges,45% of Total Billed Charges,126,90,,8208,Percent of Total Billed Charges,90% of Total billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91,65,,650,Percent of total Billed Charges,65% of Total Billed Charges,61.74,44.1,,208.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,133,95,,8664,Percent of Total Billed Charges,95% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.2,88,,278.08,Percent of Total Billed Charges,88% of Total Billed Charges,126,90,,8208,Percent of Total Billed charges,90% of Total Billed Charges,61.74,140,
1.0x12MM Cortex Screw,2780002981,CDM,278,RC,,,Outpatient,,,140.00,91.00,,140,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.4,76,,726.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.8,72,,1202.4,Percent of Total Billed Charges,72% of Total Billed Charges,100.8,72,,1202.4,Percent of Total Billed charges,72% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.8,72,,1202.4,Percent of Total Billed Charges,72% of Total Billed Charges,84,60,,1002,Percent of Total Billed Charges,60% of Total Billed Charges,126,90,,2392.2,Percent of Total Billed Charges,90% of Total Billed Charges,63,45,,142.2,Percent of Total Billed Charges,45% of Total Billed Charges,126,90,,860.4,Percent of Total Billed Charges,90% of Total billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91,65,,5885.104,Percent of total Billed Charges,65% of Total Billed Charges,61.74,44.1,,139.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,133,95,,908.2,Percent of Total Billed Charges,95% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.2,88,,742.72,Percent of Total Billed Charges,88% of Total Billed Charges,126,90,,860.4,Percent of Total Billed charges,90% of Total Billed Charges,61.74,140,
1.0X13MM Cortex Screw,2780002982,CDM,278,RC,,,Outpatient,,,140.00,91.00,,140,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.4,76,,726.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.8,72,,702.72,Percent of Total Billed Charges,72% of Total Billed Charges,100.8,72,,702.72,Percent of Total Billed charges,72% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.8,72,,702.72,Percent of Total Billed Charges,72% of Total Billed Charges,84,60,,585.6,Percent of Total Billed Charges,60% of Total Billed Charges,126,90,,860.4,Percent of Total Billed Charges,90% of Total Billed Charges,63,45,,142.2,Percent of Total Billed Charges,45% of Total Billed Charges,126,90,,860.4,Percent of Total Billed Charges,90% of Total billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91,65,,258.704,Percent of total Billed Charges,65% of Total Billed Charges,61.74,44.1,,139.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,133,95,,908.2,Percent of Total Billed Charges,95% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.2,88,,151.36,Percent of Total Billed Charges,88% of Total Billed Charges,126,90,,860.4,Percent of Total Billed charges,90% of Total Billed Charges,61.74,140,
1.0x14MM Cortex Screw,2780002983,CDM,278,RC,,,Outpatient,,,140.00,91.00,,140,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.4,76,,358.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.8,72,,1124.64,Percent of Total Billed Charges,72% of Total Billed Charges,100.8,72,,1124.64,Percent of Total Billed charges,72% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.8,72,,1124.64,Percent of Total Billed Charges,72% of Total Billed Charges,84,60,,937.2,Percent of Total Billed Charges,60% of Total Billed Charges,126,90,,34.024,Percent of Total Billed Charges,90% of Total Billed Charges,63,45,,379.8,Percent of Total Billed Charges,45% of Total Billed Charges,126,90,,424.8,Percent of Total Billed Charges,90% of Total billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91,65,,5.2,Percent of total Billed Charges,65% of Total Billed Charges,61.74,44.1,,372.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,133,95,,448.4,Percent of Total Billed Charges,95% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.2,88,,742.72,Percent of Total Billed Charges,88% of Total Billed Charges,126,90,,424.8,Percent of Total Billed charges,90% of Total Billed Charges,61.74,140,
1.3X7MM CORTEX SCREW,2780002984,CDM,278,RC,,,Outpatient,,,228.75,148.69,,228.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,173.85,76,,240.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,164.7,72,,1107.792,Percent of Total Billed Charges,72% of Total Billed Charges,164.7,72,,1107.792,Percent of Total Billed charges,72% of Total Billed Charges,228.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.7,72,,1107.792,Percent of Total Billed Charges,72% of Total Billed Charges,137.25,60,,923.16,Percent of Total Billed Charges,60% of Total Billed Charges,205.88,90,,1308.6,Percent of Total Billed Charges,90% of Total Billed Charges,102.94,45,,77.4,Percent of Total Billed Charges,45% of Total Billed Charges,205.88,90,,284.4,Percent of Total Billed Charges,90% of Total billed Charges,228.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.69,65,,585,Percent of total Billed Charges,65% of Total Billed Charges,100.88,44.1,,75.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,217.31,95,,300.2,Percent of Total Billed Charges,95% of Total Billed Charges,228.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.3,88,,149.6,Percent of Total Billed Charges,88% of Total Billed Charges,205.88,90,,284.4,Percent of Total Billed charges,90% of Total Billed Charges,100.88,228.75,
1.3X8MM CORTEX SCREW,2780002985,CDM,278,RC,,,Outpatient,,,219.13,142.43,,219.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,166.54,76,,240.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,157.77,72,,875.52,Percent of Total Billed Charges,72% of Total Billed Charges,157.77,72,,875.52,Percent of Total Billed charges,72% of Total Billed Charges,219.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.77,72,,875.52,Percent of Total Billed Charges,72% of Total Billed Charges,131.48,60,,729.6,Percent of Total Billed Charges,60% of Total Billed Charges,197.22,90,,1308.6,Percent of Total Billed Charges,90% of Total Billed Charges,98.61,45,,379.8,Percent of Total Billed Charges,45% of Total Billed Charges,197.22,90,,284.4,Percent of Total Billed Charges,90% of Total billed Charges,219.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.43,65,,2776.8,Percent of total Billed Charges,65% of Total Billed Charges,96.64,44.1,,372.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,208.17,95,,300.2,Percent of Total Billed Charges,95% of Total Billed Charges,219.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.83,88,,51.04,Percent of Total Billed Charges,88% of Total Billed Charges,197.22,90,,284.4,Percent of Total Billed charges,90% of Total Billed Charges,96.64,219.13,
1.3X9MM CORTEX SCREW,2780002986,CDM,278,RC,,,Outpatient,,,228.75,148.69,,228.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,173.85,76,,641.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,164.7,72,,1080,Percent of Total Billed Charges,72% of Total Billed Charges,164.7,72,,1080,Percent of Total Billed charges,72% of Total Billed Charges,228.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.7,72,,1080,Percent of Total Billed Charges,72% of Total Billed Charges,137.25,60,,900,Percent of Total Billed Charges,60% of Total Billed Charges,205.88,90,,1800,Percent of Total Billed Charges,90% of Total Billed Charges,102.94,45,,76.504,Percent of Total Billed Charges,45% of Total Billed Charges,205.88,90,,759.6,Percent of Total Billed Charges,90% of Total billed Charges,228.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.69,65,,1833,Percent of total Billed Charges,65% of Total Billed Charges,100.88,44.1,,74.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,217.31,95,,801.8,Percent of Total Billed Charges,95% of Total Billed Charges,228.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.3,88,,2339.04,Percent of Total Billed Charges,88% of Total Billed Charges,205.88,90,,759.6,Percent of Total Billed charges,90% of Total Billed Charges,100.88,228.75,
1.3X10MM CORTEX SCREW,2780002987,CDM,278,RC,,,Outpatient,,,132.50,86.13,,132.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.7,76,,130.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.4,72,,1584.576,Percent of Total Billed Charges,72% of Total Billed Charges,95.4,72,,1584.576,Percent of Total Billed charges,72% of Total Billed Charges,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.4,72,,1584.576,Percent of Total Billed Charges,72% of Total Billed Charges,79.5,60,,1320.48,Percent of Total Billed Charges,60% of Total Billed Charges,119.25,90,,860.4,Percent of Total Billed Charges,90% of Total Billed Charges,59.63,45,,26.104,Percent of Total Billed Charges,45% of Total Billed Charges,119.25,90,,154.8,Percent of Total Billed Charges,90% of Total billed Charges,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.13,65,,1031.032,Percent of total Billed Charges,65% of Total Billed Charges,58.43,44.1,,25.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.88,95,,163.4,Percent of Total Billed Charges,95% of Total Billed Charges,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.6,88,,841.28,Percent of Total Billed Charges,88% of Total Billed Charges,119.25,90,,154.8,Percent of Total Billed charges,90% of Total Billed Charges,58.43,132.5,
1.3X11MM CORTEX SCREW,2780002988,CDM,278,RC,,,Outpatient,,,132.50,86.13,,132.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.7,76,,641.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.4,72,,633.072,Percent of Total Billed Charges,72% of Total Billed Charges,95.4,72,,633.072,Percent of Total Billed charges,72% of Total Billed Charges,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.4,72,,633.072,Percent of Total Billed Charges,72% of Total Billed Charges,79.5,60,,527.56,Percent of Total Billed Charges,60% of Total Billed Charges,119.25,90,,28.984,Percent of Total Billed Charges,90% of Total Billed Charges,59.63,45,,1196.104,Percent of Total Billed Charges,45% of Total Billed Charges,119.25,90,,759.6,Percent of Total Billed Charges,90% of Total billed Charges,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.13,65,,1430,Percent of total Billed Charges,65% of Total Billed Charges,58.43,44.1,,1172.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.88,95,,801.8,Percent of Total Billed Charges,95% of Total Billed Charges,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.6,88,,33.264,Percent of Total Billed Charges,88% of Total Billed Charges,119.25,90,,759.6,Percent of Total Billed charges,90% of Total Billed Charges,58.43,132.5,
1.3X12MM CORTEX SCREW,2780002989,CDM,278,RC,,,Outpatient,,,132.50,86.13,,132.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.7,76,,129.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.4,72,,309.704,Percent of Total Billed Charges,72% of Total Billed Charges,95.4,72,,309.704,Percent of Total Billed charges,72% of Total Billed Charges,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.4,72,,309.704,Percent of Total Billed Charges,72% of Total Billed Charges,79.5,60,,258.088,Percent of Total Billed Charges,60% of Total Billed Charges,119.25,90,,272.16,Percent of Total Billed Charges,90% of Total Billed Charges,59.63,45,,430.2,Percent of Total Billed Charges,45% of Total Billed Charges,119.25,90,,153,Percent of Total Billed Charges,90% of Total billed Charges,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.13,65,,1430,Percent of total Billed Charges,65% of Total Billed Charges,58.43,44.1,,421.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.88,95,,161.504,Percent of Total Billed Charges,95% of Total Billed Charges,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.6,88,,1279.52,Percent of Total Billed Charges,88% of Total Billed Charges,119.25,90,,153,Percent of Total Billed charges,90% of Total Billed Charges,58.43,132.5,
1.3X13MM CORTEX SCREW,2780002990,CDM,278,RC,,,Outpatient,,,132.50,86.13,,132.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.7,76,,44.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.4,72,,299.016,Percent of Total Billed Charges,72% of Total Billed Charges,95.4,72,,299.016,Percent of Total Billed charges,72% of Total Billed Charges,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.4,72,,299.016,Percent of Total Billed Charges,72% of Total Billed Charges,79.5,60,,249.184,Percent of Total Billed Charges,60% of Total Billed Charges,119.25,90,,272.16,Percent of Total Billed Charges,90% of Total Billed Charges,59.63,45,,17.008,Percent of Total Billed Charges,45% of Total Billed Charges,119.25,90,,52.2,Percent of Total Billed Charges,90% of Total billed Charges,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.13,65,,1430,Percent of total Billed Charges,65% of Total Billed Charges,58.43,44.1,,16.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.88,95,,55.104,Percent of Total Billed Charges,95% of Total Billed Charges,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.6,88,,1279.52,Percent of Total Billed Charges,88% of Total Billed Charges,119.25,90,,52.2,Percent of Total Billed charges,90% of Total Billed Charges,58.43,132.5,
1.3X14MM CORTEX SCREW,2780002991,CDM,278,RC,,,Outpatient,,,132.50,86.13,,132.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.7,76,,2020.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.4,72,,2637.736,Percent of Total Billed Charges,72% of Total Billed Charges,95.4,72,,2637.736,Percent of Total Billed charges,72% of Total Billed Charges,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.4,72,,2637.736,Percent of Total Billed Charges,72% of Total Billed Charges,79.5,60,,2198.112,Percent of Total Billed Charges,60% of Total Billed Charges,119.25,90,,900,Percent of Total Billed Charges,90% of Total Billed Charges,59.63,45,,654.304,Percent of Total Billed Charges,45% of Total Billed Charges,119.25,90,,2392.2,Percent of Total Billed Charges,90% of Total billed Charges,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.13,65,,1430,Percent of total Billed Charges,65% of Total Billed Charges,58.43,44.1,,641.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.88,95,,2525.104,Percent of Total Billed Charges,95% of Total Billed Charges,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.6,88,,1760,Percent of Total Billed Charges,88% of Total Billed Charges,119.25,90,,2392.2,Percent of Total Billed charges,90% of Total Billed Charges,58.43,132.5,
1.3X16MM CORTEX SCREW,2780002992,CDM,278,RC,,,Outpatient,,,132.50,86.13,,132.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.7,76,,726.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.4,72,,309.704,Percent of Total Billed Charges,72% of Total Billed Charges,95.4,72,,309.704,Percent of Total Billed charges,72% of Total Billed Charges,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.4,72,,309.704,Percent of Total Billed Charges,72% of Total Billed Charges,79.5,60,,258.088,Percent of Total Billed Charges,60% of Total Billed Charges,119.25,90,,351,Percent of Total Billed Charges,90% of Total Billed Charges,59.63,45,,654.304,Percent of Total Billed Charges,45% of Total Billed Charges,119.25,90,,860.4,Percent of Total Billed Charges,90% of Total billed Charges,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.13,65,,1430,Percent of total Billed Charges,65% of Total Billed Charges,58.43,44.1,,641.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.88,95,,908.2,Percent of Total Billed Charges,95% of Total Billed Charges,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.6,88,,841.28,Percent of Total Billed Charges,88% of Total Billed Charges,119.25,90,,860.4,Percent of Total Billed charges,90% of Total Billed Charges,58.43,132.5,
1.3X18MM CORTEX SCREW,2780002993,CDM,278,RC,,,Outpatient,,,132.50,86.13,,132.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.7,76,,28.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.4,72,,309.704,Percent of Total Billed Charges,72% of Total Billed Charges,95.4,72,,309.704,Percent of Total Billed charges,72% of Total Billed Charges,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.4,72,,309.704,Percent of Total Billed Charges,72% of Total Billed Charges,79.5,60,,258.088,Percent of Total Billed Charges,60% of Total Billed Charges,119.25,90,,540,Percent of Total Billed Charges,90% of Total Billed Charges,59.63,45,,900,Percent of Total Billed Charges,45% of Total Billed Charges,119.25,90,,34.024,Percent of Total Billed Charges,90% of Total billed Charges,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.13,65,,1430,Percent of total Billed Charges,65% of Total Billed Charges,58.43,44.1,,882,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.88,95,,35.912,Percent of Total Billed Charges,95% of Total Billed Charges,132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.6,88,,28.336,Percent of Total Billed Charges,88% of Total Billed Charges,119.25,90,,34.024,Percent of Total Billed charges,90% of Total Billed Charges,58.43,132.5,
SYNTHES 1.3 EXT H-PLT L,2780002994,CDM,278,RC,,,Outpatient,,,400.00,260.00,,400,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,304,76,,1105.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,288,72,,4320,Percent of Total Billed Charges,72% of Total Billed Charges,288,72,,4320,Percent of Total Billed charges,72% of Total Billed Charges,400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288,72,,4320,Percent of Total Billed Charges,72% of Total Billed Charges,240,60,,3600,Percent of Total Billed Charges,60% of Total Billed Charges,360,90,,540,Percent of Total Billed Charges,90% of Total Billed Charges,180,45,,430.2,Percent of Total Billed Charges,45% of Total Billed Charges,360,90,,1308.6,Percent of Total Billed Charges,90% of Total billed Charges,400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260,65,,1430,Percent of total Billed Charges,65% of Total Billed Charges,176.4,44.1,,421.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,380,95,,1381.304,Percent of Total Billed Charges,95% of Total Billed Charges,400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352,88,,266.112,Percent of Total Billed Charges,88% of Total Billed Charges,360,90,,1308.6,Percent of Total Billed charges,90% of Total Billed Charges,176.4,400,
SYNTHES 1.3 S-PLT,2780002995,CDM,278,RC,,,Outpatient,,,382.50,248.63,,382.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,290.7,76,,1105.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,275.4,72,,4158,Percent of Total Billed Charges,72% of Total Billed Charges,275.4,72,,4158,Percent of Total Billed charges,72% of Total Billed Charges,382.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.4,72,,4158,Percent of Total Billed Charges,72% of Total Billed Charges,229.5,60,,3465,Percent of Total Billed Charges,60% of Total Billed Charges,344.25,90,,424.8,Percent of Total Billed Charges,90% of Total Billed Charges,172.13,45,,14.488,Percent of Total Billed Charges,45% of Total Billed Charges,344.25,90,,1308.6,Percent of Total Billed Charges,90% of Total billed Charges,382.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.63,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,168.68,44.1,,14.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,363.38,95,,1381.304,Percent of Total Billed Charges,95% of Total Billed Charges,382.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,336.6,88,,266.112,Percent of Total Billed Charges,88% of Total Billed Charges,344.25,90,,1308.6,Percent of Total Billed charges,90% of Total Billed Charges,168.68,382.5,
1.5X7MM CORTEX SCREW,2780002996,CDM,278,RC,,,Outpatient,,,90.00,58.50,,90,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.4,76,,1520,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.8,72,,207.888,Percent of Total Billed Charges,72% of Total Billed Charges,64.8,72,,207.888,Percent of Total Billed charges,72% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.8,72,,207.888,Percent of Total Billed Charges,72% of Total Billed Charges,54,60,,173.24,Percent of Total Billed Charges,60% of Total Billed Charges,81,90,,759.6,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,45,,136.08,Percent of Total Billed Charges,45% of Total Billed Charges,81,90,,1800,Percent of Total Billed Charges,90% of Total billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.5,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,39.69,44.1,,133.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.5,95,,1900,Percent of Total Billed Charges,95% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,88,,880,Percent of Total Billed Charges,88% of Total Billed Charges,81,90,,1800,Percent of Total Billed charges,90% of Total Billed Charges,39.69,90,
1.5X8MM CORTEX SCREW,2780002997,CDM,278,RC,,,Outpatient,,,141.30,91.85,,141.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.39,76,,726.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.74,72,,7624.8,Percent of Total Billed Charges,72% of Total Billed Charges,101.74,72,,7624.8,Percent of Total Billed charges,72% of Total Billed Charges,141.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.74,72,,7624.8,Percent of Total Billed Charges,72% of Total Billed Charges,84.78,60,,6354,Percent of Total Billed Charges,60% of Total Billed Charges,127.17,90,,154.8,Percent of Total Billed Charges,90% of Total Billed Charges,63.59,45,,136.08,Percent of Total Billed Charges,45% of Total Billed Charges,127.17,90,,860.4,Percent of Total Billed Charges,90% of Total billed Charges,141.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.85,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,62.31,44.1,,133.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.24,95,,908.2,Percent of Total Billed Charges,95% of Total Billed Charges,141.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.34,88,,343.2,Percent of Total Billed Charges,88% of Total Billed Charges,127.17,90,,860.4,Percent of Total Billed charges,90% of Total Billed Charges,62.31,141.3,
1.5X9MM CORTEX SCREW,2780002998,CDM,278,RC,,,Outpatient,,,128.75,83.69,,128.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,97.85,76,,24.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,92.7,72,,4158,Percent of Total Billed Charges,72% of Total Billed Charges,92.7,72,,4158,Percent of Total Billed charges,72% of Total Billed Charges,128.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.7,72,,4158,Percent of Total Billed Charges,72% of Total Billed Charges,77.25,60,,3465,Percent of Total Billed Charges,60% of Total Billed Charges,115.88,90,,759.6,Percent of Total Billed Charges,90% of Total Billed Charges,57.94,45,,450,Percent of Total Billed Charges,45% of Total Billed Charges,115.88,90,,28.984,Percent of Total Billed Charges,90% of Total billed Charges,128.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.69,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,56.78,44.1,,441,Percent of Total Billed Charges,44.1% of Total Billed Charges,122.31,95,,30.592,Percent of Total Billed Charges,95% of Total Billed Charges,128.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.3,88,,528,Percent of Total Billed Charges,88% of Total Billed Charges,115.88,90,,28.984,Percent of Total Billed charges,90% of Total Billed Charges,56.78,128.75,
1.5X10MM CORTEX SCREW,2780002999,CDM,278,RC,,,Outpatient,,,108.75,70.69,,108.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.65,76,,229.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,78.3,72,,4752,Percent of Total Billed Charges,72% of Total Billed Charges,78.3,72,,4752,Percent of Total Billed charges,72% of Total Billed Charges,108.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.3,72,,4752,Percent of Total Billed Charges,72% of Total Billed Charges,65.25,60,,3960,Percent of Total Billed Charges,60% of Total Billed Charges,97.88,90,,1544.4,Percent of Total Billed Charges,90% of Total Billed Charges,48.94,45,,175.504,Percent of Total Billed Charges,45% of Total Billed Charges,97.88,90,,272.16,Percent of Total Billed Charges,90% of Total billed Charges,108.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.69,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,47.96,44.1,,171.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,103.31,95,,287.28,Percent of Total Billed Charges,95% of Total Billed Charges,108.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.7,88,,528,Percent of Total Billed Charges,88% of Total Billed Charges,97.88,90,,272.16,Percent of Total Billed charges,90% of Total Billed Charges,47.96,108.75,
1.5X11MM CORTEX SCREW,2780003000,CDM,278,RC,,,Outpatient,,,90.00,58.50,,90,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.4,76,,229.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.8,72,,4752,Percent of Total Billed Charges,72% of Total Billed Charges,64.8,72,,4752,Percent of Total Billed charges,72% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.8,72,,4752,Percent of Total Billed Charges,72% of Total Billed Charges,54,60,,3960,Percent of Total Billed Charges,60% of Total Billed Charges,81,90,,154.8,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,45,,270,Percent of Total Billed Charges,45% of Total Billed Charges,81,90,,272.16,Percent of Total Billed Charges,90% of Total billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.5,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,39.69,44.1,,264.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.5,95,,287.28,Percent of Total Billed Charges,95% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,88,,415.36,Percent of Total Billed Charges,88% of Total Billed Charges,81,90,,272.16,Percent of Total Billed charges,90% of Total Billed Charges,39.69,90,
1.5X12MM CORTEX SCREW,2780003001,CDM,278,RC,,,Outpatient,,,108.75,70.69,,108.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.65,76,,760,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,78.3,72,,4752,Percent of Total Billed Charges,72% of Total Billed Charges,78.3,72,,4752,Percent of Total Billed charges,72% of Total Billed Charges,108.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.3,72,,4752,Percent of Total Billed Charges,72% of Total Billed Charges,65.25,60,,3960,Percent of Total Billed Charges,60% of Total Billed Charges,97.88,90,,900,Percent of Total Billed Charges,90% of Total Billed Charges,48.94,45,,270,Percent of Total Billed Charges,45% of Total Billed Charges,97.88,90,,900,Percent of Total Billed Charges,90% of Total billed Charges,108.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.69,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,47.96,44.1,,264.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,103.31,95,,950,Percent of Total Billed Charges,95% of Total Billed Charges,108.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.7,88,,742.72,Percent of Total Billed Charges,88% of Total Billed Charges,97.88,90,,900,Percent of Total Billed charges,90% of Total Billed Charges,47.96,108.75,
1.5X13MM CORTEX SCREW,2780003002,CDM,278,RC,,,Outpatient,,,90.00,58.50,,90,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.4,76,,296.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.8,72,,688.352,Percent of Total Billed Charges,72% of Total Billed Charges,64.8,72,,688.352,Percent of Total Billed charges,72% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.8,72,,688.352,Percent of Total Billed Charges,72% of Total Billed Charges,54,60,,573.624,Percent of Total Billed Charges,60% of Total Billed Charges,81,90,,8148.6,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,45,,212.4,Percent of Total Billed Charges,45% of Total Billed Charges,81,90,,351,Percent of Total Billed Charges,90% of Total billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.5,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,39.69,44.1,,208.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.5,95,,370.504,Percent of Total Billed Charges,95% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,88,,151.36,Percent of Total Billed Charges,88% of Total Billed Charges,81,90,,351,Percent of Total Billed charges,90% of Total Billed Charges,39.69,90,
1.5X14MM CORTEX SCREW,2780003003,CDM,278,RC,,,Outpatient,,,128.75,83.69,,128.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,97.85,76,,456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,92.7,72,,688.352,Percent of Total Billed Charges,72% of Total Billed Charges,92.7,72,,688.352,Percent of Total Billed charges,72% of Total Billed Charges,128.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.7,72,,688.352,Percent of Total Billed Charges,72% of Total Billed Charges,77.25,60,,573.624,Percent of Total Billed Charges,60% of Total Billed Charges,115.88,90,,358.2,Percent of Total Billed Charges,90% of Total Billed Charges,57.94,45,,379.8,Percent of Total Billed Charges,45% of Total Billed Charges,115.88,90,,540,Percent of Total Billed Charges,90% of Total billed Charges,128.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.69,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,56.78,44.1,,372.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,122.31,95,,570,Percent of Total Billed Charges,95% of Total Billed Charges,128.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.3,88,,742.72,Percent of Total Billed Charges,88% of Total Billed Charges,115.88,90,,540,Percent of Total Billed charges,90% of Total Billed Charges,56.78,128.75,
1.5X16MM CORTEX SCREW,2780003004,CDM,278,RC,,,Outpatient,,,141.30,91.85,,141.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.39,76,,456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.74,72,,267.808,Percent of Total Billed Charges,72% of Total Billed Charges,101.74,72,,267.808,Percent of Total Billed charges,72% of Total Billed Charges,141.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.74,72,,267.808,Percent of Total Billed Charges,72% of Total Billed Charges,84.78,60,,223.176,Percent of Total Billed Charges,60% of Total Billed Charges,127.17,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,63.59,45,,77.4,Percent of Total Billed Charges,45% of Total Billed Charges,127.17,90,,540,Percent of Total Billed Charges,90% of Total billed Charges,141.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.85,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,62.31,44.1,,75.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.24,95,,570,Percent of Total Billed Charges,95% of Total Billed Charges,141.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.34,88,,1510.08,Percent of Total Billed Charges,88% of Total Billed Charges,127.17,90,,540,Percent of Total Billed charges,90% of Total Billed Charges,62.31,141.3,
1.5X18MM CORTEX SCREW,2780003005,CDM,278,RC,,,Outpatient,,,141.25,91.81,,141.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.35,76,,358.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.7,72,,559.68,Percent of Total Billed Charges,72% of Total Billed Charges,101.7,72,,559.68,Percent of Total Billed charges,72% of Total Billed Charges,141.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.7,72,,559.68,Percent of Total Billed Charges,72% of Total Billed Charges,84.75,60,,466.4,Percent of Total Billed Charges,60% of Total Billed Charges,127.13,90,,810,Percent of Total Billed Charges,90% of Total Billed Charges,63.56,45,,379.8,Percent of Total Billed Charges,45% of Total Billed Charges,127.13,90,,424.8,Percent of Total Billed Charges,90% of Total billed Charges,141.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.81,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,62.29,44.1,,372.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.19,95,,448.4,Percent of Total Billed Charges,95% of Total Billed Charges,141.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.3,88,,151.36,Percent of Total Billed Charges,88% of Total Billed Charges,127.13,90,,424.8,Percent of Total Billed charges,90% of Total Billed Charges,62.29,141.25,
1.5X20MM CORTEX SCREW,2780003006,CDM,278,RC,,,Outpatient,,,141.25,91.81,,141.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.35,76,,641.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.7,72,,840.96,Percent of Total Billed Charges,72% of Total Billed Charges,101.7,72,,840.96,Percent of Total Billed charges,72% of Total Billed Charges,141.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.7,72,,840.96,Percent of Total Billed Charges,72% of Total Billed Charges,84.75,60,,700.8,Percent of Total Billed Charges,60% of Total Billed Charges,127.13,90,,3844.8,Percent of Total Billed Charges,90% of Total Billed Charges,63.56,45,,772.2,Percent of Total Billed Charges,45% of Total Billed Charges,127.13,90,,759.6,Percent of Total Billed Charges,90% of Total billed Charges,141.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.81,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,62.29,44.1,,756.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.19,95,,801.8,Percent of Total Billed Charges,95% of Total Billed Charges,141.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.3,88,,880,Percent of Total Billed Charges,88% of Total Billed Charges,127.13,90,,759.6,Percent of Total Billed charges,90% of Total Billed Charges,62.29,141.25,
1.5X22MM CORTEX SCREW,2780003007,CDM,278,RC,,,Outpatient,,,118.13,76.78,,118.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,89.78,76,,130.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,85.05,72,,310.608,Percent of Total Billed Charges,72% of Total Billed Charges,85.05,72,,310.608,Percent of Total Billed charges,72% of Total Billed Charges,118.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.05,72,,310.608,Percent of Total Billed Charges,72% of Total Billed Charges,70.88,60,,258.84,Percent of Total Billed Charges,60% of Total Billed Charges,106.32,90,,2538,Percent of Total Billed Charges,90% of Total Billed Charges,53.16,45,,77.4,Percent of Total Billed Charges,45% of Total Billed Charges,106.32,90,,154.8,Percent of Total Billed Charges,90% of Total billed Charges,118.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.78,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,52.1,44.1,,75.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,112.22,95,,163.4,Percent of Total Billed Charges,95% of Total Billed Charges,118.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.95,88,,7967.52,Percent of Total Billed Charges,88% of Total Billed Charges,106.32,90,,154.8,Percent of Total Billed charges,90% of Total Billed Charges,52.1,118.13,
1.5X24MM CORTEX SCREW,2780003008,CDM,278,RC,,,Outpatient,,,90.00,58.50,,90,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.4,76,,641.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.8,72,,331.2,Percent of Total Billed Charges,72% of Total Billed Charges,64.8,72,,331.2,Percent of Total Billed charges,72% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.8,72,,331.2,Percent of Total Billed Charges,72% of Total Billed Charges,54,60,,276,Percent of Total Billed Charges,60% of Total Billed Charges,81,90,,1427.584,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,45,,450,Percent of Total Billed Charges,45% of Total Billed Charges,81,90,,759.6,Percent of Total Billed Charges,90% of Total billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.5,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,39.69,44.1,,441,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.5,95,,801.8,Percent of Total Billed Charges,95% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,88,,350.24,Percent of Total Billed Charges,88% of Total Billed Charges,81,90,,759.6,Percent of Total Billed charges,90% of Total Billed Charges,39.69,90,
SYNTHES 1.5 EXT H-PLT L,2780003009,CDM,278,RC,,,Outpatient,,,510.00,331.50,,510,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,387.6,76,,1304.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,367.2,72,,331.2,Percent of Total Billed Charges,72% of Total Billed Charges,367.2,72,,331.2,Percent of Total Billed charges,72% of Total Billed Charges,510,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,367.2,72,,331.2,Percent of Total Billed Charges,72% of Total Billed Charges,306,60,,276,Percent of Total Billed Charges,60% of Total Billed Charges,459,90,,1980,Percent of Total Billed Charges,90% of Total Billed Charges,229.5,45,,4074.304,Percent of Total Billed Charges,45% of Total Billed Charges,459,90,,1544.4,Percent of Total Billed Charges,90% of Total billed Charges,510,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,510,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,510,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,331.5,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,224.91,44.1,,3992.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,484.5,95,,1630.2,Percent of Total Billed Charges,95% of Total Billed Charges,510,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,448.8,88,,7.04,Percent of Total Billed Charges,88% of Total Billed Charges,459,90,,1544.4,Percent of Total Billed charges,90% of Total Billed Charges,224.91,510,
2.0X7MM CORTEX SCREW,2780003010,CDM,278,RC,,,Outpatient,,,100.00,65.00,,100,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,76,76,,130.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,72,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,72,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,60,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,90,90,,1980,Percent of Total Billed Charges,90% of Total Billed Charges,45,45,,179.104,Percent of Total Billed Charges,45% of Total Billed Charges,90,90,,154.8,Percent of Total Billed Charges,90% of Total billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,44.1,44.1,,175.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,95,95,,163.4,Percent of Total Billed Charges,95% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88,88,,792,Percent of Total Billed Charges,88% of Total Billed Charges,90,90,,154.8,Percent of Total Billed charges,90% of Total Billed Charges,44.1,100,
2.0X8MM CORTEX SCREW,2780003011,CDM,278,RC,,,Outpatient,,,107.80,70.07,,107.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.93,76,,760,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.62,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,77.62,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,64.68,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,97.02,90,,1980,Percent of Total Billed Charges,90% of Total Billed Charges,48.51,45,,3.6,Percent of Total Billed Charges,45% of Total Billed Charges,97.02,90,,900,Percent of Total Billed Charges,90% of Total billed Charges,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.07,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,47.54,44.1,,3.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.41,95,,950,Percent of Total Billed Charges,95% of Total Billed Charges,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.86,88,,3759.36,Percent of Total Billed Charges,88% of Total Billed Charges,97.02,90,,900,Percent of Total Billed charges,90% of Total Billed Charges,47.54,107.8,
2.0X9MM CORTEX SCREW,2780003012,CDM,278,RC,,,Outpatient,,,107.80,70.07,,107.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.93,76,,6881.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.62,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,77.62,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,64.68,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,97.02,90,,1980,Percent of Total Billed Charges,90% of Total Billed Charges,48.51,45,,405,Percent of Total Billed Charges,45% of Total Billed Charges,97.02,90,,8148.6,Percent of Total Billed Charges,90% of Total billed Charges,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.07,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,47.54,44.1,,396.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.41,95,,8601.304,Percent of Total Billed Charges,95% of Total Billed Charges,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.86,88,,2481.6,Percent of Total Billed Charges,88% of Total Billed Charges,97.02,90,,8148.6,Percent of Total Billed charges,90% of Total Billed Charges,47.54,107.8,
2.0X10MM CORTEX SCREW,2780003013,CDM,278,RC,,,Outpatient,,,107.80,70.07,,107.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.93,76,,302.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.62,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,77.62,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,64.68,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,97.02,90,,1980,Percent of Total Billed Charges,90% of Total Billed Charges,48.51,45,,1922.4,Percent of Total Billed Charges,45% of Total Billed Charges,97.02,90,,358.2,Percent of Total Billed Charges,90% of Total billed Charges,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.07,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,47.54,44.1,,1883.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.41,95,,378.104,Percent of Total Billed Charges,95% of Total Billed Charges,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.86,88,,1395.856,Percent of Total Billed Charges,88% of Total Billed Charges,97.02,90,,358.2,Percent of Total Billed charges,90% of Total Billed Charges,47.54,107.8,
2.0X11MM CORTEX SCREW,2780003014,CDM,278,RC,,,Outpatient,,,107.80,70.07,,107.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.93,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.62,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,77.62,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,64.68,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,97.02,90,,1980,Percent of Total Billed Charges,90% of Total Billed Charges,48.51,45,,1269,Percent of Total Billed Charges,45% of Total Billed Charges,97.02,90,,7.2,Percent of Total Billed Charges,90% of Total billed Charges,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.07,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,47.54,44.1,,1243.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.41,95,,7.6,Percent of Total Billed Charges,95% of Total Billed Charges,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.86,88,,1936,Percent of Total Billed Charges,88% of Total Billed Charges,97.02,90,,7.2,Percent of Total Billed charges,90% of Total Billed Charges,47.54,107.8,
2.0X12MM CORTEX SCREW,2780003015,CDM,278,RC,,,Outpatient,,,107.80,70.07,,107.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.93,76,,684,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.62,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,77.62,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,64.68,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,97.02,90,,1980,Percent of Total Billed Charges,90% of Total Billed Charges,48.51,45,,713.792,Percent of Total Billed Charges,45% of Total Billed Charges,97.02,90,,810,Percent of Total Billed Charges,90% of Total billed Charges,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.07,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,47.54,44.1,,699.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.41,95,,855,Percent of Total Billed Charges,95% of Total Billed Charges,107.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.86,88,,1936,Percent of Total Billed Charges,88% of Total Billed Charges,97.02,90,,810,Percent of Total Billed charges,90% of Total Billed Charges,47.54,107.8,
2.0X13MM CORTEX SCREW,2780003016,CDM,278,RC,,,Outpatient,,,155.00,100.75,,155,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,117.8,76,,3246.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.6,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,111.6,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.6,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,93,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,139.5,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,69.75,45,,990,Percent of Total Billed Charges,45% of Total Billed Charges,139.5,90,,3844.8,Percent of Total Billed Charges,90% of Total billed Charges,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.75,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,68.36,44.1,,970.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,147.25,95,,4058.4,Percent of Total Billed Charges,95% of Total Billed Charges,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.4,88,,1936,Percent of Total Billed Charges,88% of Total Billed Charges,139.5,90,,3844.8,Percent of Total Billed charges,90% of Total Billed Charges,68.36,155,
2.0X14MM CORTEX SCREW,2780003017,CDM,278,RC,,,Outpatient,,,154.38,100.35,,154.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,117.33,76,,2143.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.15,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,111.15,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,154.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.15,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,92.63,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,138.94,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,69.47,45,,990,Percent of Total Billed Charges,45% of Total Billed Charges,138.94,90,,2538,Percent of Total Billed Charges,90% of Total billed Charges,154.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.35,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,68.08,44.1,,970.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,146.66,95,,2679,Percent of Total Billed Charges,95% of Total Billed Charges,154.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.85,88,,1936,Percent of Total Billed Charges,88% of Total Billed Charges,138.94,90,,2538,Percent of Total Billed charges,90% of Total Billed Charges,68.08,154.38,
2.0X16MM CORTEX SCREW,2780003018,CDM,278,RC,,,Outpatient,,,124.20,80.73,,124.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,94.39,76,,1205.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,89.42,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,89.42,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,124.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.42,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,74.52,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,111.78,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,55.89,45,,990,Percent of Total Billed Charges,45% of Total Billed Charges,111.78,90,,1427.584,Percent of Total Billed Charges,90% of Total billed Charges,124.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.73,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,54.77,44.1,,970.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,117.99,95,,1506.888,Percent of Total Billed Charges,95% of Total Billed Charges,124.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.3,88,,1936,Percent of Total Billed Charges,88% of Total Billed Charges,111.78,90,,1427.584,Percent of Total Billed charges,90% of Total Billed Charges,54.77,124.2,
2.0X18MM CORTEX SCREW,2780003019,CDM,278,RC,,,Outpatient,,,141.25,91.81,,141.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.35,76,,1672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.7,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,101.7,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,141.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.7,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,84.75,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,127.13,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,63.56,45,,990,Percent of Total Billed Charges,45% of Total Billed Charges,127.13,90,,1980,Percent of Total Billed Charges,90% of Total billed Charges,141.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.81,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,62.29,44.1,,970.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.19,95,,2090,Percent of Total Billed Charges,95% of Total Billed Charges,141.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.3,88,,1936,Percent of Total Billed Charges,88% of Total Billed Charges,127.13,90,,1980,Percent of Total Billed charges,90% of Total Billed Charges,62.29,141.25,
2.0X20MM CORTEX SCREW,2780003020,CDM,278,RC,,,Outpatient,,,155.00,100.75,,155,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,117.8,76,,1672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.6,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,111.6,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.6,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,93,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,139.5,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,69.75,45,,990,Percent of Total Billed Charges,45% of Total Billed Charges,139.5,90,,1980,Percent of Total Billed Charges,90% of Total billed Charges,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.75,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,68.36,44.1,,970.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,147.25,95,,2090,Percent of Total Billed Charges,95% of Total Billed Charges,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.4,88,,1936,Percent of Total Billed Charges,88% of Total Billed Charges,139.5,90,,1980,Percent of Total Billed charges,90% of Total Billed Charges,68.36,155,
2.0X22MM CORTEX SCREW,2780003021,CDM,278,RC,,,Outpatient,,,100.00,65.00,,100,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,76,76,,1672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,72,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,72,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,60,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,90,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,45,45,,990,Percent of Total Billed Charges,45% of Total Billed Charges,90,90,,1980,Percent of Total Billed Charges,90% of Total billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,44.1,44.1,,970.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,95,95,,2090,Percent of Total Billed Charges,95% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,90,90,,1980,Percent of Total Billed charges,90% of Total Billed Charges,44.1,100,
2.0X24MM CORTEX SCREW,2780003022,CDM,278,RC,,,Outpatient,,,100.00,65.00,,100,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,76,76,,1672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,72,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,72,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,60,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,90,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,45,45,,990,Percent of Total Billed Charges,45% of Total Billed Charges,90,90,,1980,Percent of Total Billed Charges,90% of Total billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,44.1,44.1,,970.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,95,95,,2090,Percent of Total Billed Charges,95% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,90,90,,1980,Percent of Total Billed charges,90% of Total Billed Charges,44.1,100,
2.0X26MM CORTEX SCREW,2780003023,CDM,278,RC,,,Outpatient,,,100.00,65.00,,100,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,76,76,,1672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,72,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,72,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,60,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,90,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,45,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,90,90,,1980,Percent of Total Billed Charges,90% of Total billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,44.1,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,95,95,,2090,Percent of Total Billed Charges,95% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,90,90,,1980,Percent of Total Billed charges,90% of Total Billed Charges,44.1,100,
2.0X28MM CORTEX SCREW,2780003024,CDM,278,RC,,,Outpatient,,,100.00,65.00,,100,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,76,76,,1672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,72,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,72,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,60,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,90,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,45,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,90,90,,1980,Percent of Total Billed Charges,90% of Total billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,44.1,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,95,95,,2090,Percent of Total Billed Charges,95% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,90,90,,1980,Percent of Total Billed charges,90% of Total Billed Charges,44.1,100,
2.0X30MM CORTEX SCREW,2780003025,CDM,278,RC,,,Outpatient,,,100.00,65.00,,100,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,76,76,,1672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,72,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,72,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,60,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,90,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,45,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,90,90,,1980,Percent of Total Billed Charges,90% of Total billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,44.1,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,95,95,,2090,Percent of Total Billed Charges,95% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,90,90,,1980,Percent of Total Billed charges,90% of Total Billed Charges,44.1,100,
2.0X32MM CORTEX SCREW,2780003026,CDM,278,RC,,,Outpatient,,,100.00,65.00,,100,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,76,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,72,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,72,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,60,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,90,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,45,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,90,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,44.1,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,95,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,90,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,44.1,100,
SYNTHES 2.0 CONDY PLT RT,2780003027,CDM,278,RC,,,Outpatient,,,502.50,326.63,,502.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,381.9,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,361.8,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,361.8,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,502.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.8,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,301.5,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,452.25,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,226.13,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,452.25,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,502.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.63,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,221.6,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,477.38,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,502.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,442.2,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,452.25,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,221.6,502.5,
SYNTHES 2.0 Y-PLT,2780003028,CDM,278,RC,,,Outpatient,,,602.50,391.63,,602.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,457.9,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,433.8,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,433.8,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,602.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,433.8,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,361.5,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,542.25,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,271.13,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,542.25,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,602.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,602.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,602.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,391.63,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,265.7,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,572.38,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,602.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.2,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,542.25,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,265.7,602.5,
Surgimesh SR Rectangle 14x15,2780003029,CDM,278,RC,,,Outpatient,,,1487.50,966.88,,1487.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1130.5,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1071,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,1071,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,1487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1071,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,892.5,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,1338.75,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,669.38,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,1338.75,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,1487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,966.88,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,655.99,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1413.13,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,1487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1309,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,1338.75,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,655.99,1487.5,
2.47 x 7MM Cortex Screw,2780003030,CDM,278,RC,,,Outpatient,,,142.50,92.63,,142.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,108.3,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,102.6,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,102.6,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.6,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,85.5,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,128.25,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,64.13,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,128.25,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.63,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,62.84,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,135.38,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.4,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,128.25,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,62.84,142.5,
2.4X8MM CORTEX SCREW,2780003031,CDM,278,RC,,,Outpatient,,,209.00,135.85,,209,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,158.84,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.48,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,150.48,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.48,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,125.4,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,188.1,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,94.05,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,188.1,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.85,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,92.17,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,198.55,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.92,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,188.1,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,92.17,209,
2.4X9MM CORTEX SCREW,2780003032,CDM,278,RC,,,Outpatient,,,209.00,135.85,,209,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,158.84,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.48,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,150.48,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.48,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,125.4,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,188.1,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,94.05,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,188.1,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.85,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,92.17,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,198.55,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.92,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,188.1,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,92.17,209,
2.4X10MM CORTEX SCREW,2780003033,CDM,278,RC,,,Outpatient,,,209.00,135.85,,209,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,158.84,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.48,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,150.48,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.48,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,125.4,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,188.1,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,94.05,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,188.1,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.85,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,92.17,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,198.55,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.92,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,188.1,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,92.17,209,
2.4X11MM CORTEX SCREW,2780003034,CDM,278,RC,,,Outpatient,,,209.00,135.85,,209,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,158.84,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.48,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,150.48,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.48,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,125.4,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,188.1,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,94.05,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,188.1,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.85,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,92.17,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,198.55,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.92,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,188.1,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,92.17,209,
2.4X12MM CORTEX SCREW,2780003035,CDM,278,RC,,,Outpatient,,,231.25,150.31,,231.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,175.75,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,166.5,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,166.5,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.5,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,138.75,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,208.13,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,104.06,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,208.13,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.31,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,101.98,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,219.69,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.5,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,208.13,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,101.98,231.25,
2.4X13MM CORTEX SCREW,2780003036,CDM,278,RC,,,Outpatient,,,231.25,150.31,,231.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,175.75,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,166.5,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,166.5,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.5,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,138.75,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,208.13,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,104.06,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,208.13,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.31,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,101.98,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,219.69,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.5,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,208.13,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,101.98,231.25,
2.4X14MM CORTEX SCREW,2780003037,CDM,278,RC,,,Outpatient,,,231.25,150.31,,231.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,175.75,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,166.5,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,166.5,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.5,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,138.75,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,208.13,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,104.06,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,208.13,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.31,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,101.98,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,219.69,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.5,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,208.13,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,101.98,231.25,
2.4X16MM CORTEX SCREW,2780003038,CDM,278,RC,,,Outpatient,,,231.25,150.31,,231.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,175.75,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,166.5,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,166.5,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.5,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,138.75,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,208.13,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,104.06,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,208.13,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.31,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,101.98,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,219.69,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.5,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,208.13,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,101.98,231.25,
2.4X18MM CORTEX SCREW,2780003039,CDM,278,RC,,,Outpatient,,,231.25,150.31,,231.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,175.75,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,166.5,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,166.5,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.5,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,138.75,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,208.13,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,104.06,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,208.13,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.31,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,101.98,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,219.69,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.5,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,208.13,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,101.98,231.25,
2.4X20MM CORTEX SCREW,2780003040,CDM,278,RC,,,Outpatient,,,231.25,150.31,,231.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,175.75,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,166.5,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,166.5,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.5,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,138.75,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,208.13,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,104.06,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,208.13,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.31,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,101.98,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,219.69,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,231.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.5,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,208.13,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,101.98,231.25,
2.4X22MM CORTEX SCREW,2780003041,CDM,278,RC,,,Outpatient,,,188.75,122.69,,188.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,143.45,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,135.9,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,135.9,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,188.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.9,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,113.25,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,169.88,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,84.94,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,169.88,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,188.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.69,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,83.24,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,179.31,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,188.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.1,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,169.88,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,83.24,188.75,
2.4X24MM CORTEX SCREW,2780003042,CDM,278,RC,,,Outpatient,,,142.50,92.63,,142.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,108.3,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,102.6,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,102.6,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.6,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,85.5,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,128.25,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,64.13,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,128.25,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.63,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,62.84,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,135.38,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.4,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,128.25,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,62.84,142.5,
2.4X26MM CORTEX SCREW,2780003043,CDM,278,RC,,,Outpatient,,,142.50,92.63,,142.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,108.3,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,102.6,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,102.6,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.6,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,85.5,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,128.25,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,64.13,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,128.25,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.63,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,62.84,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,135.38,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.4,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,128.25,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,62.84,142.5,
2.4X28MM CORTEX SCREW,2780003044,CDM,278,RC,,,Outpatient,,,188.75,122.69,,188.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,143.45,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,135.9,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,135.9,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,188.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.9,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,113.25,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,169.88,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,84.94,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,169.88,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,188.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.69,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,83.24,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,179.31,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,188.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.1,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,169.88,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,83.24,188.75,
2.4X30MM CORTEX SCREW,2780003045,CDM,278,RC,,,Outpatient,,,142.50,92.63,,142.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,108.3,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,102.6,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,102.6,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.6,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,85.5,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,128.25,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,64.13,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,128.25,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.63,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,62.84,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,135.38,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.4,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,128.25,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,62.84,142.5,
2.4X32MM CORTEX SCREW,2780003046,CDM,278,RC,,,Outpatient,,,142.50,92.63,,142.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,108.3,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,102.6,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,102.6,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.6,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,85.5,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,128.25,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,64.13,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,128.25,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.63,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,62.84,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,135.38,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.4,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,128.25,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,62.84,142.5,
SYNTHES 2.4 CONDY. PLT LT,2780003047,CDM,278,RC,,,Outpatient,,,527.50,342.88,,527.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,400.9,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,379.8,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,379.8,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,527.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.8,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,316.5,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,474.75,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,237.38,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,474.75,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,527.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,527.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,527.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.88,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,232.63,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,501.13,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,527.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,464.2,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,474.75,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,232.63,527.5,
ARTHRX AC TGHTROPE TT,2780003048,CDM,278,RC,,,Outpatient,,,1437.50,934.38,,1437.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1092.5,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1035,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,1035,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,1437.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1035,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,862.5,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,1293.75,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,646.88,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,1293.75,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,1437.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1437.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1437.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,934.38,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,633.94,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1365.63,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,1437.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1265,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,1293.75,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,633.94,1437.5,
INTERING 6X40 VASC GRFT,2780003049,CDM,278,RC,,,Outpatient,,,2132.50,1386.13,,2132.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1620.7,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1535.4,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,1535.4,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,2132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1535.4,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,1279.5,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,1919.25,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,959.63,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,1919.25,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1386.13,65,,1430,Percent of total Billed Charges,65% of Total Billed Charges,940.43,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,2025.88,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2132.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1876.6,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,1919.25,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,940.43,2132.5,
ECT SCW 40MM 4.5 CORT BN,2780003050,CDM,278,RC,,,Outpatient,,,36.75,23.89,,36.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.93,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.46,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,36.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,22.05,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,33.08,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,16.54,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,33.08,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,36.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.89,65,,1430,Percent of total Billed Charges,65% of Total Billed Charges,16.21,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.91,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,36.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.34,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,33.08,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,16.21,36.75,
VENTRLX HER PTCH 2.5X2.5,2780003051,CDM,278,RC,,,Outpatient,,,3455.50,2246.08,,3455.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2626.18,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2487.96,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,2487.96,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,3455.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2487.96,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,2073.3,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,3109.95,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,1554.98,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,3109.95,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,3455.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3455.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3455.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2246.08,65,,1430,Percent of total Billed Charges,65% of Total Billed Charges,1523.88,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,3282.73,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,3455.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3040.84,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,3109.95,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,1523.88,3455.5,
PERCUFLEX PLUS STENT 6X30,2780003052,CDM,278,RC,,,Outpatient,,,257.73,167.52,,257.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,195.87,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,185.57,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,185.57,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,257.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.57,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,154.64,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,231.96,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,115.98,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,231.96,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,257.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.52,65,,1430,Percent of total Billed Charges,65% of Total Billed Charges,113.66,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,244.84,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,257.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.8,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,231.96,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,113.66,257.73,
CAPSLR TNSION RNG 11MM,2780003053,CDM,278,RC,,,Outpatient,,,497.50,323.38,,497.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,378.1,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,358.2,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,358.2,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,497.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.2,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,298.5,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,447.75,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,223.88,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,447.75,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,497.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.38,65,,1430,Percent of total Billed Charges,65% of Total Billed Charges,219.4,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.63,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,497.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.8,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,447.75,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,219.4,497.5,
CAPSLR TNSION RNG 12MM,2780003054,CDM,278,RC,,,Outpatient,,,177.50,115.38,,177.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,134.9,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,127.8,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,127.8,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,177.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.8,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,106.5,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,159.75,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,79.88,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,159.75,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,177.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.38,65,,1430,Percent of total Billed Charges,65% of Total Billed Charges,78.28,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,168.63,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,177.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.2,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,159.75,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,78.28,177.5,
SURGIMESH WN T1415-8,2780003055,CDM,278,RC,,,Outpatient,,,1812.50,1178.13,,1812.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1377.5,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1305,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,1305,72,,187.504,Percent of Total Billed charges,72% of Total Billed Charges,1812.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1305,72,,180,Percent of Total Billed Charges,72% of Total Billed Charges,1087.5,60,,150,Percent of Total Billed Charges,60% of Total Billed Charges,1631.25,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,815.63,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,1631.25,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,1812.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1812.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1812.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.13,65,,1430,Percent of total Billed Charges,65% of Total Billed Charges,799.31,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1721.88,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,1812.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1595,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,1631.25,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,799.31,1812.5,
Papyrus Covered Stent 4 x 15,2780003056,CDM,278,RC,C1874,HCPCS,Outpatient,,,7500.00,4875.00,,7500,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5700,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5400,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,5400,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5400,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,4500,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,6750,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,3375,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,6750,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4875,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,3307.5,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,7125,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6600,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,6750,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,3307.5,7500,
Papyrus Covered Stent 3.5 x 15,2780003057,CDM,278,RC,C1874,HCPCS,Outpatient,,,7500.00,4875.00,,7500,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5700,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5400,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,5400,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5400,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,4500,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,6750,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,3375,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,6750,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4875,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,3307.5,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,7125,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6600,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,6750,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,3307.5,7500,
Papyrus Covered Stent 3 x 15,2780003058,CDM,278,RC,C1874,HCPCS,Outpatient,,,7500.00,4875.00,,7500,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5700,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5400,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,5400,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5400,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,4500,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,6750,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,3375,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,6750,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4875,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,3307.5,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,7125,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6600,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,6750,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,3307.5,7500,
Papyrus Covered Stent 2.5 x 15,2780003059,CDM,278,RC,C1874,HCPCS,Outpatient,,,7500.00,4875.00,,7500,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5700,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5400,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,5400,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5400,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,4500,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,6750,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,3375,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,6750,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4875,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,3307.5,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,7125,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6600,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,6750,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,3307.5,7500,
Acumed 3.5 x10 Nlck Scw,2780003060,CDM,278,RC,,,Outpatient,,,340.00,221.00,,340,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,258.4,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,244.8,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,244.8,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.8,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,204,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,306,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,153,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,306,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221,65,,1332.504,Percent of total Billed Charges,65% of Total Billed Charges,149.94,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,323,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,299.2,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,306,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,149.94,340,
Z1312-27-014 2.2 SM LCK PEG 14,2780003061,CDM,278,RC,,,Outpatient,,,227.50,147.88,,227.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,172.9,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,163.8,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,163.8,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,227.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.8,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,136.5,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,204.75,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,102.38,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,204.75,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,227.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.88,65,,1015.304,Percent of total Billed Charges,65% of Total Billed Charges,100.33,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,216.13,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,227.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.2,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,204.75,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,100.33,227.5,
Azure S Dr MRI,2780003062,CDM,275,RC,C1785,HCPCS,Outpatient,,,12645.00,8219.25,,12645,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9610.2,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9104.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,9104.4,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,12645,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9104.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,7587,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,11380.5,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,5690.25,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,11380.5,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,12645,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12645,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12645,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8219.25,65,,24.44,Percent of total Billed Charges,65% of Total Billed Charges,5576.45,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,12012.75,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,12645,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11127.6,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,11380.5,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,5576.45,12645,
Z2253-37-37 3.7 CORT SCW 37.5,2780003063,CDM,278,RC,,,Outpatient,,,336.00,218.40,,336,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,255.36,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,241.92,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,241.92,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.92,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,201.6,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,302.4,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,151.2,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,302.4,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.4,65,,1943.504,Percent of total Billed Charges,65% of Total Billed Charges,148.18,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,319.2,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.68,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,302.4,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,148.18,336,
Z2253-300-08 TIBIAL NAIL 8X30,2780003064,CDM,278,RC,,,Outpatient,,,2622.50,1704.63,,2622.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1993.1,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1888.2,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1888.2,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2622.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1888.2,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1573.5,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,2360.25,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,1180.13,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,2360.25,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2622.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2622.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2622.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1704.63,65,,1943.504,Percent of total Billed Charges,65% of Total Billed Charges,1156.52,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,2491.38,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2622.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2307.8,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,2360.25,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,1156.52,2622.5,
SKYPOINT RX DES 2.25MM X 8MM,2780003065,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,457.6,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.25MM X 12MM,2780003066,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,802.752,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.25MM X 15MM,2780003067,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,1085.504,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.25MM X 18MM,2780003068,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,634.4,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.25MM X 23MM,2780003069,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,1015.304,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.25MM X 28MM,2780003070,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1980,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,1000.088,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.25MM X 33MM,2780003071,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1980,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,790.4,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.25MM X 38MM,2780003072,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1980,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,975,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.5MM X 8MM,2780003073,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1980,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,1430.52,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.5MM X 12MM,2780003074,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1980,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,571.52,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.5MM X 15MM,2780003075,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1980,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,279.592,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1936,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.5MM X 18MM,2780003076,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1980,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,269.944,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1936,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.5MM X 23MM,2780003077,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,990,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,2381.288,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,970.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1936,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.5MM X 28MM,2780003078,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,990,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,279.592,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,970.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1936,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.5MM X 33MM,2780003079,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,990,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,279.592,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,970.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1936,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.5MM X 38MM,2780003080,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,990,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1980,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,3900,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,970.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,2090,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1936,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1980,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.75MM X 8MM,2780003081,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,990,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1980,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,3753.752,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,970.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,2090,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1936,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1980,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.75MM X 12MM,2780003082,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1405.8,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,990,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1980,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,187.68,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,970.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,2090,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1980,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.75MM X 15MM,2780003083,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,990,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1980,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,6883.504,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,970.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,2090,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1980,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.75MM X 18MM,2780003084,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,2691,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1980,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,3753.752,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,2090,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1980,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.75MM X 23MM,2780003085,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,2691,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1980,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,4290,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,2090,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1980,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.75MM X 28MM,2780003086,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,633.6,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1980,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,4290,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,2090,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1804,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1980,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.75MM X 33MM,2780003087,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1111.504,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,4290,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1374.56,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 2.75MM X 38MM,2780003088,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1503,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,922.504,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,621.424,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,904.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,33.088,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 3MM X 8MM,2780003089,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,878.4,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,702.904,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,621.424,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,688.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,2631.2,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 3MM X 12MM,2780003090,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1405.8,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,16.92,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,241.776,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,16.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,2631.2,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 3MM X 15MM,2780003091,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1558,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1384.744,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,1345.504,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1845,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,505.272,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,1318.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1947.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,619.52,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1845,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 3MM X 18MM,2780003092,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1187.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1094.4,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,1345.504,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1405.8,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,759.2,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,1318.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1483.904,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1086.8,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1405.8,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 3MM X 23MM,2780003093,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,28.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1350,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,316.8,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,33.84,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,280.408,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,310.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,35.72,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1469.6,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,33.84,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 3MM X 28MM,2780003094,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,2272.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1980.72,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,555.752,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,2691,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,299,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,544.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,2840.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,858.88,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,2691,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 3MM X 33MM,2780003095,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,2272.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,791.336,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,751.504,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,2691,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,299,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,736.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,2840.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1374.56,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,2691,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 3MM X 38MM,2780003096,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,535.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,387.128,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,439.2,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,633.6,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,430.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,668.8,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1353.968,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,633.6,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 3.5MM X 8MM,2780003097,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,938.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,373.776,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,702.904,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1111.504,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,688.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1173.248,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1070.08,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1111.504,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 3.5MM X 12MM,2780003098,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1269.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,3297.168,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,692.368,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1503,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,678.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1586.504,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1320,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1503,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 3.5MM X 15MM,2780003099,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,741.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,387.128,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,547.2,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,878.4,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,536.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,927.2,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1936.704,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,878.4,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 3.5MM X 18MM,2780003100,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1187.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,387.128,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,675,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1405.8,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,661.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1483.904,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,773.752,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1405.8,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 3.5MM X 23MM,2780003101,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1169.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,5400,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,990.36,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1384.744,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,970.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1461.672,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,378.528,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1384.744,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 3.5MM X 28MM,2780003102,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,924.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,5197.504,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,395.672,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1094.4,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,387.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1155.2,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,365.464,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1094.4,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 3.5MM X 33MM,2780003103,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1140,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,259.864,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,193.568,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1350,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,189.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1425,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,3223.896,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1350,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 3.5MM X 38MM,2780003104,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1672.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,9531,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,186.888,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1980.72,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,183.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,2090.76,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,378.528,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1980.72,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 4MM X 8MM,2780003105,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,668.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,889.2,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,889.2,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,889.2,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,741,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,5197.504,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,1648.584,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,791.336,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,1615.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,835.304,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,378.528,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,791.336,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 4MM X 12MM,2780003106,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,326.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,165.896,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,165.896,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,165.896,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,138.248,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,5940,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,193.568,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,387.128,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,189.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,408.64,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,5280,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,387.128,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 4MM X 15MM,2780003107,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,315.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,1560.96,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,1560.96,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,1560.96,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,1300.8,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,5940,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,193.568,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,373.776,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,189.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,394.536,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,5082,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,373.776,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 4MM X 18MM,2780003108,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,2784.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,432,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,432,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,432,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,360,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,5940,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,2700,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,3297.168,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,2646,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,3480.344,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,254.088,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,3297.168,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 4MM X 23MM,2780003109,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,326.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,432,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,432,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,432,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,360,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,860.44,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,2598.752,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,387.128,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,2546.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,408.64,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,9319.2,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,387.128,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 4MM X 28MM,2780003110,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,326.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,154.296,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,160.72,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,154.296,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,128.576,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,860.44,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,129.928,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,387.128,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,127.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,408.64,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,5082,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,387.128,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 4MM X 33MM,2780003111,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,4560,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,482.4,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,482.4,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,482.4,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,402,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,334.768,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,4765.504,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,5400,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,4670.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,5700,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,5808,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,5400,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SKYPOINT RX DES 4MM X 38MM,2780003112,CDM,278,RC,C1874,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,4389,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1440,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,699.6,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,2598.752,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,5197.504,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,2546.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,5486.248,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,5808,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,5197.504,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
RESONATE EL VR DF4 ICD,2780003113,CDM,278,RC,C1722,HCPCS,Outpatient,,,45150.00,29347.50,,45150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34314,76,,219.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32508,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,32508,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,45150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32508,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,27090,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,40635,90,,1051.2,Percent of Total Billed Charges,90% of Total Billed Charges,20317.5,45,,2970,Percent of Total Billed Charges,45% of Total Billed Charges,40635,90,,259.864,Percent of Total Billed Charges,90% of Total billed Charges,45150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29347.5,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,19911.15,44.1,,2910.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,42892.5,95,,274.296,Percent of Total Billed Charges,95% of Total Billed Charges,45150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39732,88,,5808,Percent of Total Billed Charges,88% of Total Billed Charges,40635,90,,259.864,Percent of Total Billed charges,90% of Total Billed Charges,19911.15,45150,
RELIANCE 4F SNG COIL LEAD 59CM,2780003114,CDM,278,RC,C1777,HCPCS,Outpatient,,,12890.00,8378.50,,12890,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9796.4,76,,8048.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9280.8,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,9280.8,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,12890,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9280.8,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,7734,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,11601,90,,388.264,Percent of Total Billed Charges,90% of Total Billed Charges,5800.5,45,,2970,Percent of Total Billed Charges,45% of Total Billed Charges,11601,90,,9531,Percent of Total Billed Charges,90% of Total billed Charges,12890,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12890,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12890,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8378.5,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,5684.49,44.1,,2910.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,12245.5,95,,10060.504,Percent of Total Billed Charges,95% of Total Billed Charges,12890,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11343.2,88,,841.312,Percent of Total Billed Charges,88% of Total Billed Charges,11601,90,,9531,Percent of Total Billed charges,90% of Total Billed Charges,5684.49,12890,
RELIANCE 4F SNG COIL LEAD 64CM,2780003115,CDM,278,RC,C1777,HCPCS,Outpatient,,,12890.00,8378.50,,12890,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9796.4,76,,4389,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9280.8,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,9280.8,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,12890,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9280.8,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,7734,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,11601,90,,414,Percent of Total Billed Charges,90% of Total Billed Charges,5800.5,45,,2970,Percent of Total Billed Charges,45% of Total Billed Charges,11601,90,,5197.504,Percent of Total Billed Charges,90% of Total billed Charges,12890,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12890,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12890,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8378.5,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,5684.49,44.1,,2910.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,12245.5,95,,5486.248,Percent of Total Billed Charges,95% of Total Billed Charges,12890,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11343.2,88,,841.312,Percent of Total Billed Charges,88% of Total Billed Charges,11601,90,,5197.504,Percent of Total Billed charges,90% of Total Billed Charges,5684.49,12890,
LUX-DX INSERT CARDIAC MONITOR,2780003116,CDM,278,RC,C1764,HCPCS,Outpatient,,,11250.00,7312.50,,11250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8550,76,,5016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8100,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,8100,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,11250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8100,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6750,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,10125,90,,414,Percent of Total Billed Charges,90% of Total Billed Charges,5062.5,45,,430.216,Percent of Total Billed Charges,45% of Total Billed Charges,10125,90,,5940,Percent of Total Billed Charges,90% of Total billed Charges,11250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7312.5,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,4961.25,44.1,,421.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,10687.5,95,,6270,Percent of Total Billed Charges,95% of Total Billed Charges,11250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9900,88,,327.328,Percent of Total Billed Charges,88% of Total Billed Charges,10125,90,,5940,Percent of Total Billed charges,90% of Total Billed Charges,4961.25,11250,
VIABN SX 6F 120CM 5MM X 2.5CM,2780003117,CDM,278,RC,C1874,HCPCS,Outpatient,,,9392.50,6105.13,,9392.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7138.3,76,,5016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6762.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6762.6,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6762.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,5635.5,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,8453.25,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,4226.63,45,,430.216,Percent of Total Billed Charges,45% of Total Billed Charges,8453.25,90,,5940,Percent of Total Billed Charges,90% of Total billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6105.13,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,4142.09,44.1,,421.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,8922.88,95,,6270,Percent of Total Billed Charges,95% of Total Billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8265.4,88,,684.056,Percent of Total Billed Charges,88% of Total Billed Charges,8453.25,90,,5940,Percent of Total Billed charges,90% of Total Billed Charges,4142.09,9392.5,
VIABN SX 6F 120CM 5MM X 5CM,2780003118,CDM,278,RC,C1874,HCPCS,Outpatient,,,9392.50,6105.13,,9392.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7138.3,76,,5016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6762.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6762.6,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6762.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,5635.5,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,8453.25,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,4226.63,45,,167.384,Percent of Total Billed Charges,45% of Total Billed Charges,8453.25,90,,5940,Percent of Total Billed Charges,90% of Total billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6105.13,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,4142.09,44.1,,164.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,8922.88,95,,6270,Percent of Total Billed Charges,95% of Total Billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8265.4,88,,1027.84,Percent of Total Billed Charges,88% of Total Billed Charges,8453.25,90,,5940,Percent of Total Billed charges,90% of Total Billed Charges,4142.09,9392.5,
VIABN SX 6F 120CM 5MM X 7.5CM,2780003119,CDM,278,RC,C1874,HCPCS,Outpatient,,,10275.00,6678.75,,10275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7809,76,,726.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7398,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,7398,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7398,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6165,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,9247.5,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,4623.75,45,,349.8,Percent of Total Billed Charges,45% of Total Billed Charges,9247.5,90,,860.44,Percent of Total Billed Charges,90% of Total billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6678.75,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,4531.28,44.1,,342.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,9761.25,95,,908.24,Percent of Total Billed Charges,95% of Total Billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9042,88,,379.632,Percent of Total Billed Charges,88% of Total Billed Charges,9247.5,90,,860.44,Percent of Total Billed charges,90% of Total Billed Charges,4531.28,10275,
VIABN SX 6F 120CM 5MM X 10CM,2780003120,CDM,278,RC,C1874,HCPCS,Outpatient,,,10275.00,6678.75,,10275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7809,76,,726.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7398,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,7398,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7398,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6165,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,9247.5,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,4623.75,45,,525.6,Percent of Total Billed Charges,45% of Total Billed Charges,9247.5,90,,860.44,Percent of Total Billed Charges,90% of Total billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6678.75,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,4531.28,44.1,,515.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,9761.25,95,,908.24,Percent of Total Billed Charges,95% of Total Billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9042,88,,404.8,Percent of Total Billed Charges,88% of Total Billed Charges,9247.5,90,,860.44,Percent of Total Billed charges,90% of Total Billed Charges,4531.28,10275,
VIABN SX 6F 120CM 5MM X 15CM,2780003121,CDM,278,RC,C1874,HCPCS,Outpatient,,,11450.00,7442.50,,11450,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8702,76,,282.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8244,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,8244,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,11450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8244,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6870,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,10305,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,5152.5,45,,194.128,Percent of Total Billed Charges,45% of Total Billed Charges,10305,90,,334.768,Percent of Total Billed Charges,90% of Total billed Charges,11450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7442.5,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,5049.45,44.1,,190.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,10877.5,95,,353.36,Percent of Total Billed Charges,95% of Total Billed Charges,11450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10076,88,,404.8,Percent of Total Billed Charges,88% of Total Billed Charges,10305,90,,334.768,Percent of Total Billed charges,90% of Total Billed Charges,5049.45,11450,
VIABN SX 6F 120CM 5MM X 25CM,2780003122,CDM,278,RC,C1874,HCPCS,Outpatient,,,18820.00,12233.00,,18820,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14303.2,76,,590.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13550.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,13550.4,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,18820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13550.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,11292,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,16938,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,8469,45,,207,Percent of Total Billed Charges,45% of Total Billed Charges,16938,90,,699.6,Percent of Total Billed Charges,90% of Total billed Charges,18820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12233,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,8299.62,44.1,,202.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,17879,95,,738.472,Percent of Total Billed Charges,95% of Total Billed Charges,18820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16561.6,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,16938,90,,699.6,Percent of Total Billed charges,90% of Total Billed Charges,8299.62,18820,
VIABN SX 6F 120CM 6MM X 2.5CM,2780003123,CDM,278,RC,C1874,HCPCS,Outpatient,,,9392.50,6105.13,,9392.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7138.3,76,,887.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6762.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6762.6,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6762.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,5635.5,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,8453.25,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,4226.63,45,,207,Percent of Total Billed Charges,45% of Total Billed Charges,8453.25,90,,1051.2,Percent of Total Billed Charges,90% of Total billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6105.13,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,4142.09,44.1,,202.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,8922.88,95,,1109.6,Percent of Total Billed Charges,95% of Total Billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8265.4,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,8453.25,90,,1051.2,Percent of Total Billed charges,90% of Total Billed Charges,4142.09,9392.5,
VIABN SX 6F 120CM 6MM X 5CM,2780003124,CDM,278,RC,C1874,HCPCS,Outpatient,,,9392.50,6105.13,,9392.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7138.3,76,,327.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6762.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6762.6,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6762.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,5635.5,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,8453.25,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,4226.63,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,8453.25,90,,388.264,Percent of Total Billed Charges,90% of Total billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6105.13,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,4142.09,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,8922.88,95,,409.832,Percent of Total Billed Charges,95% of Total Billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8265.4,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,8453.25,90,,388.264,Percent of Total Billed charges,90% of Total Billed Charges,4142.09,9392.5,
VIABN SX 6F 120CM 6MM X 7.5CM,2780003125,CDM,278,RC,C1874,HCPCS,Outpatient,,,10275.00,6678.75,,10275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7809,76,,349.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7398,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,7398,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7398,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6165,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,9247.5,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,4623.75,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,9247.5,90,,414,Percent of Total Billed Charges,90% of Total billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6678.75,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,4531.28,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,9761.25,95,,437,Percent of Total Billed Charges,95% of Total Billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9042,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,9247.5,90,,414,Percent of Total Billed charges,90% of Total Billed Charges,4531.28,10275,
VIABN SX 6F 120CM 6MM X 10CM,2780003126,CDM,278,RC,C1874,HCPCS,Outpatient,,,10275.00,6678.75,,10275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7809,76,,349.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7398,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,7398,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7398,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6165,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,9247.5,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,4623.75,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,9247.5,90,,414,Percent of Total Billed Charges,90% of Total billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6678.75,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,4531.28,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,9761.25,95,,437,Percent of Total Billed Charges,95% of Total Billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9042,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,9247.5,90,,414,Percent of Total Billed charges,90% of Total Billed Charges,4531.28,10275,
VIABN SX 6F 120CM 6MM X 15CM,2780003127,CDM,278,RC,C1874,HCPCS,Outpatient,,,11450.00,7442.50,,11450,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8702,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8244,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,8244,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,11450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8244,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6870,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,10305,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,5152.5,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,10305,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,11450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7442.5,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,5049.45,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,10877.5,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,11450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10076,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,10305,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,5049.45,11450,
VIABN SX 6F 120CM 6MM X 25CM,2780003128,CDM,278,RC,C1874,HCPCS,Outpatient,,,18820.00,12233.00,,18820,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14303.2,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13550.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,13550.4,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,18820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13550.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,11292,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,16938,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,8469,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,16938,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,18820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12233,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,8299.62,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,17879,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,18820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16561.6,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,16938,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,8299.62,18820,
VIABN SX 7F 120CM 7MM X 2.5CM,2780003129,CDM,278,RC,C1874,HCPCS,Outpatient,,,9392.50,6105.13,,9392.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7138.3,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6762.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6762.6,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6762.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,5635.5,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,8453.25,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,4226.63,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,8453.25,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6105.13,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,4142.09,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,8922.88,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8265.4,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,8453.25,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,4142.09,9392.5,
VIABN SX 7F 120CM 7MM X 5CM,2780003130,CDM,278,RC,C1874,HCPCS,Outpatient,,,9392.50,6105.13,,9392.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7138.3,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6762.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6762.6,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6762.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,5635.5,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,8453.25,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,4226.63,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,8453.25,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6105.13,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,4142.09,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,8922.88,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8265.4,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,8453.25,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,4142.09,9392.5,
VIABN SX 7F 120CM 7MM X 7.5CM,2780003131,CDM,278,RC,C1874,HCPCS,Outpatient,,,10275.00,6678.75,,10275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7809,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7398,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,7398,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7398,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6165,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,9247.5,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,4623.75,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,9247.5,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6678.75,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,4531.28,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,9761.25,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9042,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,9247.5,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,4531.28,10275,
VIABN SX 7F 120CM 7MM X 10CM,2780003132,CDM,278,RC,C1874,HCPCS,Outpatient,,,10275.00,6678.75,,10275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7809,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7398,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,7398,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7398,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6165,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,9247.5,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,4623.75,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,9247.5,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6678.75,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,4531.28,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,9761.25,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9042,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,9247.5,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,4531.28,10275,
VIABN SX 7F 120CM 7MM X 15CM,2780003133,CDM,278,RC,C1874,HCPCS,Outpatient,,,11450.00,7442.50,,11450,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8702,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8244,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,8244,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,11450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8244,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6870,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,10305,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,5152.5,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,10305,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,11450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7442.5,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,5049.45,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,10877.5,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,11450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10076,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,10305,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,5049.45,11450,
VIABN SX 7F 120CM 7MM X 25CM,2780003134,CDM,278,RC,C1874,HCPCS,Outpatient,,,18820.00,12233.00,,18820,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14303.2,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13550.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,13550.4,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,18820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13550.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,11292,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,16938,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,8469,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,16938,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,18820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12233,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,8299.62,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,17879,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,18820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16561.6,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,16938,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,8299.62,18820,
VIABN SX 7F 120CM 8MM X 2.5CM,2780003135,CDM,278,RC,C1874,HCPCS,Outpatient,,,9392.50,6105.13,,9392.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7138.3,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6762.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6762.6,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6762.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,5635.5,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,8453.25,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,4226.63,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,8453.25,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6105.13,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,4142.09,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,8922.88,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8265.4,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,8453.25,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,4142.09,9392.5,
VIABN SX 7F 120CM 8MM X 5CM,2780003136,CDM,278,RC,C1874,HCPCS,Outpatient,,,9392.50,6105.13,,9392.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7138.3,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6762.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6762.6,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6762.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,5635.5,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,8453.25,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,4226.63,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,8453.25,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6105.13,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,4142.09,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,8922.88,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,9392.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8265.4,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,8453.25,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,4142.09,9392.5,
VIABN SX 7F 120CM 8MM X 7.5CM,2780003137,CDM,278,RC,C1874,HCPCS,Outpatient,,,10275.00,6678.75,,10275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7809,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7398,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,7398,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7398,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6165,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,9247.5,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,4623.75,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,9247.5,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6678.75,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,4531.28,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,9761.25,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9042,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,9247.5,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,4531.28,10275,
VIABN SX 7F 120CM 8MM X 10CM,2780003138,CDM,278,RC,C1874,HCPCS,Outpatient,,,10275.00,6678.75,,10275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7809,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7398,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,7398,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7398,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6165,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,9247.5,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,4623.75,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,9247.5,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6678.75,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,4531.28,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,9761.25,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,10275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9042,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,9247.5,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,4531.28,10275,
VIABN SX 7F 120CM 8MM X 15CM,2780003139,CDM,278,RC,C1874,HCPCS,Outpatient,,,11450.00,7442.50,,11450,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8702,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8244,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,8244,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,11450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8244,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6870,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,10305,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,5152.5,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,10305,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,11450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7442.5,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,5049.45,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,10877.5,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,11450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10076,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,10305,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,5049.45,11450,
VIABN SX 7F 120CM 8MM X 25CM,2780003140,CDM,278,RC,C1874,HCPCS,Outpatient,,,18820.00,12233.00,,18820,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14303.2,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13550.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,13550.4,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,18820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13550.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,11292,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,16938,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,8469,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,16938,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,18820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12233,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,8299.62,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,17879,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,18820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16561.6,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,16938,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,8299.62,18820,
"LENEVA, ADIPOSE MATRIX 3CC",2780003141,CDM,278,RC,,,Outpatient,,,5165.63,3357.66,,5165.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3925.88,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3719.25,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,3719.25,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,5165.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3719.25,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,3099.38,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,4649.07,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,2324.53,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,4649.07,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,5165.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5165.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5165.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3357.66,65,,162.504,Percent of total Billed Charges,65% of Total Billed Charges,2278.04,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,4907.35,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,5165.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4545.75,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,4649.07,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,2278.04,5165.63,
Allopatch Allograft 4x4,2780003142,CDM,278,RC,,,Outpatient,,,2025.98,1316.89,,2025.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1539.74,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1458.71,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1458.71,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,2025.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1458.71,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1215.59,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1823.38,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,911.69,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,1823.38,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,2025.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2025.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2025.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1316.89,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,893.46,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,1924.68,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,2025.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782.86,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,1823.38,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,893.46,2025.98,
LAPIPLASTY SYS 2 BIPLNR IMPL,2780003143,CDM,278,RC,,,Outpatient,,,11400.00,7410.00,,11400,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8664,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8208,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,8208,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,11400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8208,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,6840,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,10260,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,5130,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,10260,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,11400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7410,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,5027.4,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,10830,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,11400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10032,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,10260,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,5027.4,11400,
FASTPITCH 2.7MM LCK SCW,2780003144,CDM,278,RC,,,Outpatient,,,1195.00,776.75,,1195,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,908.2,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,860.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,860.4,72,,225,Percent of Total Billed charges,72% of Total Billed Charges,1195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,860.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,717,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1075.5,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,537.75,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,1075.5,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,1195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,776.75,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,527,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,1135.25,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,1195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1051.6,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,1075.5,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,527,1195,
LAPIPLASTY 3.5MM TRNSVRS SCW,2780003145,CDM,278,RC,,,Outpatient,,,1195.00,776.75,,1195,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,908.2,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,860.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,860.4,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,1195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,860.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,717,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1075.5,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,537.75,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,1075.5,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,1195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,776.75,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,527,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,1135.25,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,1195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1051.6,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,1075.5,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,527,1195,
ARTHREX QCKFX CANN SCW 4.0X40,2780003146,CDM,278,RC,,,Outpatient,,,590.00,383.50,,590,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,448.4,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,424.8,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,424.8,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,590,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.8,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,354,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,531,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,265.5,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,531,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,590,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,590,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,590,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,383.5,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,260.19,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,560.5,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,590,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,519.2,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,531,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,260.19,590,
ARTHREX LO-PRO SCW 3.0X12,2780003147,CDM,278,RC,,,Outpatient,,,395.00,256.75,,395,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,300.2,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,284.4,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,395,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,237,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,355.5,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,177.75,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,355.5,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,395,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,395,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,395,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.75,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,174.2,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,375.25,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,395,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.6,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,355.5,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,174.2,395,
ARTHREX LO-PRO SCW 3.0X14,2780003148,CDM,278,RC,,,Outpatient,,,395.00,256.75,,395,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,300.2,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,284.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,284.4,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,395,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,237,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,355.5,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,177.75,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,355.5,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,395,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,395,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,395,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.75,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,174.2,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,375.25,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,395,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.6,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,355.5,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,174.2,395,
ARTHREX VAL KREULCK SCW 3.0X14,2780003149,CDM,278,RC,,,Outpatient,,,1055.00,685.75,,1055,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,801.8,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,759.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,759.6,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,633,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,949.5,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,474.75,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,949.5,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.75,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,465.26,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,1002.25,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,928.4,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,949.5,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,465.26,1055,
ARTHREX LO-PRO SCW 3.5X12,2780003150,CDM,278,RC,,,Outpatient,,,215.00,139.75,,215,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,163.4,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,154.8,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,154.8,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,215,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.8,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,129,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,193.5,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,96.75,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,193.5,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,215,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.75,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,94.82,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,204.25,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,215,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.2,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,193.5,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,94.82,215,
ARTHREX KREULCK SCW 3.5X16,2780003151,CDM,278,RC,,,Outpatient,,,1055.00,685.75,,1055,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,801.8,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,759.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,759.6,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,633,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,949.5,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,474.75,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,949.5,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.75,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,465.26,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,1002.25,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,928.4,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,949.5,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,465.26,1055,
ARTHREX 2.5 DRL BIT,2780003152,CDM,278,RC,,,Outpatient,,,212.50,138.13,,212.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.5,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,153,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,127.5,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,191.25,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,95.63,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,191.25,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.13,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,93.71,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,201.88,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,212.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,191.25,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,93.71,212.5,
ARTHREX THD G-WRE 1.35MM,2780003153,CDM,278,RC,,,Outpatient,,,72.50,47.13,,72.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.1,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.2,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,52.2,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,72.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.2,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,43.5,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,65.25,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,32.63,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,65.25,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,72.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.13,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,31.97,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.88,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,72.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.8,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,65.25,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,31.97,72.5,
ARTHREX LCK DSTL FIB PLT LT 10,2780003154,CDM,278,RC,,,Outpatient,,,3322.50,2159.63,,3322.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2525.1,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2392.2,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,2392.2,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,3322.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2392.2,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1993.5,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,2990.25,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,1495.13,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,2990.25,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,3322.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3322.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3322.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2159.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1465.22,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,3156.38,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,3322.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2923.8,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,2990.25,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,1465.22,3322.5,
Lapiplasty 2.0mm Snap-Off SCWS,2780003155,CDM,278,RC,,,Outpatient,,,1195.00,776.75,,1195,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,908.2,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,860.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,860.4,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,1195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,860.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,717,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1075.5,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,537.75,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,1075.5,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,1195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,776.75,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,527,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,1135.25,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,1195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1051.6,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,1075.5,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,527,1195,
Z4820-22-03 CORT SCW 22MM,2780003156,CDM,278,RC,,,Outpatient,,,47.25,30.71,,47.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.91,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.02,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,34.02,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,47.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.02,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,28.35,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,42.53,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,21.26,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,42.53,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,47.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.71,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,20.84,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.89,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,47.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.58,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,42.53,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,20.84,47.25,
INGEVITY+ IS-1BI POS FIX 45CM,2780003157,CDM,278,RC,C1898,HCPCS,Outpatient,,,1817.50,1181.38,,1817.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.3,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1308.6,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,1817.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1090.5,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1635.75,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,817.88,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,1635.75,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,1817.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1817.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1817.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.38,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,801.52,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,1726.63,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,1817.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.4,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,1635.75,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,801.52,1817.5,
INGEVITY+ IS-1BI POS FIX 52CM,2780003158,CDM,278,RC,C1898,HCPCS,Outpatient,,,1817.50,1181.38,,1817.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1381.3,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1308.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1308.6,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,1817.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.6,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1090.5,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1635.75,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,817.88,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,1635.75,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,1817.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1817.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1817.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.38,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,801.52,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,1726.63,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,1817.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.4,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,1635.75,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,801.52,1817.5,
Allosync Pure 5.0CC,2780003159,CDM,278,RC,,,Outpatient,,,2500.00,1625.00,,2500,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1900,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1800,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1800,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,2500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1800,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,1500,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,2250,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,1125,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,2250,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,2500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1625,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1102.5,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,2375,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,2500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2200,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,2250,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,1102.5,2500,
FASTPTCH 2.7 LCKSCW 16 SD21,2780003160,CDM,278,RC,,,Outpatient,,,1195.00,776.75,,1195,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,908.2,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,860.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,860.4,72,,216,Percent of Total Billed charges,72% of Total Billed Charges,1195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,860.4,72,,216,Percent of Total Billed Charges,72% of Total Billed Charges,717,60,,180,Percent of Total Billed Charges,60% of Total Billed Charges,1075.5,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,537.75,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,1075.5,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,1195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,776.75,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,527,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,1135.25,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,1195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1051.6,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,1075.5,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,527,1195,
Z4840-10-01 4.0 CANC SCW 10 PT,2780003161,CDM,278,RC,,,Outpatient,,,40.25,26.16,,40.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,30.59,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.98,72,,459.36,Percent of Total Billed Charges,72% of Total Billed Charges,28.98,72,,459.36,Percent of Total Billed charges,72% of Total Billed Charges,40.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.98,72,,459.36,Percent of Total Billed Charges,72% of Total Billed Charges,24.15,60,,382.8,Percent of Total Billed Charges,60% of Total Billed Charges,36.23,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,18.11,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,36.23,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,40.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.16,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,17.75,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.24,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,40.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.42,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,36.23,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,17.75,40.25,
Z1147-50-36 3.5 CANN SCW 50 FT,2780003162,CDM,278,RC,,,Outpatient,,,378.00,245.70,,378,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,287.28,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,272.16,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,272.16,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,378,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.16,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,226.8,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,340.2,90,,225,Percent of Total Billed Charges,90% of Total Billed Charges,170.1,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,340.2,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,378,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.7,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,166.7,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,359.1,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,378,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.64,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,340.2,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,166.7,378,
Z1147-40-36 3.5 CANN SCW 40 FT,2780003163,CDM,278,RC,,,Outpatient,,,378.00,245.70,,378,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,287.28,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,272.16,72,,4176,Percent of Total Billed Charges,72% of Total Billed Charges,272.16,72,,4176,Percent of Total Billed charges,72% of Total Billed Charges,378,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.16,72,,4176,Percent of Total Billed Charges,72% of Total Billed Charges,226.8,60,,3480,Percent of Total Billed Charges,60% of Total Billed Charges,340.2,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,170.1,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,340.2,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,378,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.7,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,166.7,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,359.1,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,378,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.64,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,340.2,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,166.7,378,
ARTHRX COMP FT SCW 2.5 MICRO16,2780003164,CDM,278,RC,,,Outpatient,,,1250.00,812.50,,1250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,950,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,900,72,,2333.632,Percent of Total Billed Charges,72% of Total Billed Charges,900,72,,2333.632,Percent of Total Billed charges,72% of Total Billed Charges,1250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,900,72,,2333.632,Percent of Total Billed Charges,72% of Total Billed Charges,750,60,,1944.696,Percent of Total Billed Charges,60% of Total Billed Charges,1125,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,562.5,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,1125,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,1250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,812.5,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,551.25,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,1187.5,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,1250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1100,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,1125,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,551.25,1250,
MIC GE FEEDING TUBE 24F 57.9CM,2780003165,CDM,272,RC,B4087,HCPCS,Outpatient,,,487.50,316.88,,41.26,125,,,Fee Schedule,125% of CMS OPPS Rate,370.5,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,351,72,,2808,Percent of Total Billed Charges,72% of Total Billed Charges,365.63,75,,2808,Percent of Total Billed charges,75% of Total Billed Charges,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,351,72,,2808,Percent of Total Billed Charges,72% of Total Billed Charges,292.5,60,,2340,Percent of Total Billed Charges,60% of Total Billed Charges,438.75,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,219.38,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,438.75,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,33.01,100,,,Fee Schedule,100% of CMS OPPS Rate,66.02,200,,195,Fee Schedule,200% of CMS OPPS Rate,214.99,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,463.13,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,24.76,75,,,Fee Schedule,75% of CMS OPPS Rate,429,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,438.75,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,24.76,463.13,
VECTORFLOW  15F 19CM ANTEGRADE,2780003166,CDM,278,RC,C1750,HCPCS,Outpatient,,,750.00,487.50,,750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,570,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,540,72,,106.848,Percent of Total Billed Charges,72% of Total Billed Charges,540,72,,106.848,Percent of Total Billed charges,72% of Total Billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540,72,,106.848,Percent of Total Billed Charges,72% of Total Billed Charges,450,60,,89.04,Percent of Total Billed Charges,60% of Total Billed Charges,675,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,337.5,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,675,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487.5,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,330.75,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,712.5,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,660,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,675,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,330.75,750,
VECTORFLOW 15F 23CM ANTEGRADE,2780003167,CDM,278,RC,C1750,HCPCS,Outpatient,,,750.00,487.50,,750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,570,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,540,72,,2152.8,Percent of Total Billed Charges,72% of Total Billed Charges,540,72,,2152.8,Percent of Total Billed charges,72% of Total Billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540,72,,2152.8,Percent of Total Billed Charges,72% of Total Billed Charges,450,60,,1794,Percent of Total Billed Charges,60% of Total Billed Charges,675,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,337.5,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,675,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487.5,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,330.75,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,712.5,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,660,88,,220,Percent of Total Billed Charges,88% of Total Billed Charges,675,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,330.75,750,
ARTHREX QCKFIX SCW CANC 4X46,2780003168,CDM,278,RC,,,Outpatient,,,590.00,383.50,,590,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,448.4,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,424.8,72,,2152.8,Percent of Total Billed Charges,72% of Total Billed Charges,424.8,72,,2152.8,Percent of Total Billed charges,72% of Total Billed Charges,590,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.8,72,,2152.8,Percent of Total Billed Charges,72% of Total Billed Charges,354,60,,1794,Percent of Total Billed Charges,60% of Total Billed Charges,531,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,265.5,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,531,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,590,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,590,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,590,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,383.5,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,260.19,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,560.5,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,590,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,519.2,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,531,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,260.19,590,
ARTHREX VAL KRLCK SCW 3X12,2780003169,CDM,278,RC,,,Outpatient,,,1055.00,685.75,,1055,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,801.8,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,759.6,72,,2152.8,Percent of Total Billed Charges,72% of Total Billed Charges,759.6,72,,2152.8,Percent of Total Billed charges,72% of Total Billed Charges,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759.6,72,,2152.8,Percent of Total Billed Charges,72% of Total Billed Charges,633,60,,1794,Percent of Total Billed Charges,60% of Total Billed Charges,949.5,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,474.75,45,,112.504,Percent of Total Billed Charges,45% of Total Billed Charges,949.5,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.75,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,465.26,44.1,,110.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,1002.25,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,928.4,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,949.5,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,465.26,1055,
ARTHREX LO-PRO SCW 3.5X24,2780003170,CDM,278,RC,,,Outpatient,,,215.00,139.75,,215,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,163.4,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,154.8,72,,2152.8,Percent of Total Billed Charges,72% of Total Billed Charges,154.8,72,,2152.8,Percent of Total Billed charges,72% of Total Billed Charges,215,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.8,72,,2152.8,Percent of Total Billed Charges,72% of Total Billed Charges,129,60,,1794,Percent of Total Billed Charges,60% of Total Billed Charges,193.5,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,96.75,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,193.5,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,215,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.75,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,94.82,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,204.25,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,215,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.2,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,193.5,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,94.82,215,
ARTHREX KRLCK SCW 3.5X12,2780003171,CDM,278,RC,,,Outpatient,,,1055.00,685.75,,1055,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,801.8,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,759.6,72,,2152.8,Percent of Total Billed Charges,72% of Total Billed Charges,759.6,72,,2152.8,Percent of Total Billed charges,72% of Total Billed Charges,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759.6,72,,2152.8,Percent of Total Billed Charges,72% of Total Billed Charges,633,60,,1794,Percent of Total Billed Charges,60% of Total Billed Charges,949.5,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,474.75,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,949.5,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.75,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,465.26,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,1002.25,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,1055,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,928.4,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,949.5,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,465.26,1055,
ARTHREX LCK DIS FIB PLT RT 4H,2780003172,CDM,278,RC,,,Outpatient,,,2145.00,1394.25,,2145,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1630.2,76,,190,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1544.4,72,,2296.8,Percent of Total Billed Charges,72% of Total Billed Charges,1544.4,72,,2296.8,Percent of Total Billed charges,72% of Total Billed Charges,2145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1544.4,72,,2296.8,Percent of Total Billed Charges,72% of Total Billed Charges,1287,60,,1914,Percent of Total Billed Charges,60% of Total Billed Charges,1930.5,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,965.25,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,1930.5,90,,225,Percent of Total Billed Charges,90% of Total billed Charges,2145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1394.25,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,945.95,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2037.75,95,,237.504,Percent of Total Billed Charges,95% of Total Billed Charges,2145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1887.6,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,1930.5,90,,225,Percent of Total Billed charges,90% of Total Billed Charges,945.95,2145,
ARTHREX LO-PRO SCW 3.5X20MM,2780003173,CDM,278,RC,,,Outpatient,,,215.00,139.75,,215,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,163.4,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,154.8,72,,2440.8,Percent of Total Billed Charges,72% of Total Billed Charges,154.8,72,,2440.8,Percent of Total Billed charges,72% of Total Billed Charges,215,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.8,72,,2440.8,Percent of Total Billed Charges,72% of Total Billed Charges,129,60,,2034,Percent of Total Billed Charges,60% of Total Billed Charges,193.5,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,96.75,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,193.5,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,215,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.75,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,94.82,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,204.25,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,215,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.2,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,193.5,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,94.82,215,
Arthrex Comp FT Scw 2.5 x 12MM,2780003174,CDM,278,RC,,,Outpatient,,,1250.00,812.50,,1250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,950,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,900,72,,2584.8,Percent of Total Billed Charges,72% of Total Billed Charges,900,72,,2584.8,Percent of Total Billed charges,72% of Total Billed Charges,1250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,900,72,,2584.8,Percent of Total Billed Charges,72% of Total Billed Charges,750,60,,2154,Percent of Total Billed Charges,60% of Total Billed Charges,1125,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,562.5,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,1125,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,1250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,812.5,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,551.25,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,1187.5,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,1250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1100,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,1125,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,551.25,1250,
IPG W3SRO1 AZURE S SR MRI,2780003175,CDM,278,RC,C1786,HCPCS,Outpatient,,,11317.50,7356.38,,11317.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8601.3,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8148.6,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,8148.6,72,,237.6,Percent of Total Billed charges,72% of Total Billed Charges,11317.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8148.6,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,6790.5,60,,198,Percent of Total Billed Charges,60% of Total Billed Charges,10185.75,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,5092.88,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,10185.75,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,11317.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11317.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11317.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7356.38,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,4991.02,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,10751.63,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,11317.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9959.4,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,10185.75,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,4991.02,11317.5,
Arthrex Dyn 1.1Cbl Tip G-Wire,2780003176,CDM,278,RC,,,Outpatient,,,497.50,323.38,,497.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,378.1,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,358.2,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,358.2,72,,237.6,Percent of Total Billed charges,72% of Total Billed Charges,497.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.2,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,298.5,60,,198,Percent of Total Billed Charges,60% of Total Billed Charges,447.75,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,223.88,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,447.75,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,497.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.38,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,219.4,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.63,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,497.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.8,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,447.75,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,219.4,497.5,
Faxitron Core Try,2780003177,CDM,272,RC,,,Outpatient,,,10.00,6.50,,10,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.6,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.2,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,7.5,75,,237.6,Percent of Total Billed charges,75% of Total Billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.2,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,6,60,,198,Percent of Total Billed Charges,60% of Total Billed Charges,9,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,9,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,4.41,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.5,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.8,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,9,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,4.41,10,
"ARTHREX PEEK TENO SCW, VENT",2780003178,CDM,278,RC,,,Outpatient,,,1125.00,731.25,,1125,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,855,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,810,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,810,72,,237.6,Percent of Total Billed charges,72% of Total Billed Charges,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,810,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,675,60,,198,Percent of Total Billed Charges,60% of Total Billed Charges,1012.5,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,506.25,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,1012.5,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,731.25,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,496.13,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,1068.75,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,990,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,1012.5,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,496.13,1125,
ARTHREX FDL IMPLT SYS 4.75MM,2780003179,CDM,278,RC,,,Outpatient,,,5340.00,3471.00,,5340,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4058.4,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3844.8,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,3844.8,72,,237.6,Percent of Total Billed charges,72% of Total Billed Charges,5340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3844.8,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,3204,60,,198,Percent of Total Billed Charges,60% of Total Billed Charges,4806,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,2403,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,4806,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,5340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3471,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,2354.94,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,5073,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,5340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4699.2,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,4806,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,2354.94,5340,
FLEXIGRAFT CONN PRESUTURD TEND,2780003180,CDM,278,RC,,,Outpatient,,,3525.00,2291.25,,3525,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2679,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2538,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,2538,72,,237.6,Percent of Total Billed charges,72% of Total Billed Charges,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2538,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,2115,60,,198,Percent of Total Billed Charges,60% of Total Billed Charges,3172.5,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1586.25,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,3172.5,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2291.25,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1554.53,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,3348.75,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,3525,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3102,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,3172.5,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1554.53,3525,
Z2253-300-10 TIBNAIL 10X30,2780003181,CDM,278,RC,,,Outpatient,,,1982.75,1288.79,,1982.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1506.89,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1427.58,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1427.58,72,,237.6,Percent of Total Billed charges,72% of Total Billed Charges,1982.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1427.58,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1189.65,60,,198,Percent of Total Billed Charges,60% of Total Billed Charges,1784.48,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,892.24,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,1784.48,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,1982.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1982.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1982.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1288.79,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,874.39,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,1883.61,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,1982.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1744.82,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,1784.48,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,874.39,1982.75,
ONYX FRONTIER 2MM X 8MM,2780003182,CDM,278,RC,C1874,HCPCS,Outpatient,,,2750.00,1787.50,,2750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2090,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1980,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1980,72,,237.6,Percent of Total Billed charges,72% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1980,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1650,60,,198,Percent of Total Billed Charges,60% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1237.5,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1787.5,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1212.75,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2612.5,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2420,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2475,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1212.75,2750,
ONYX FRONTIER 2MM X 12MM,2780003183,CDM,278,RC,C1874,HCPCS,Outpatient,,,2750.00,1787.50,,2750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2090,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1980,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1980,72,,237.6,Percent of Total Billed charges,72% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1980,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1650,60,,198,Percent of Total Billed Charges,60% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1237.5,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1787.5,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1212.75,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2612.5,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2420,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2475,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1212.75,2750,
ONYX FRONTIER 2MM X 15MM,2780003184,CDM,278,RC,C1874,HCPCS,Outpatient,,,2750.00,1787.50,,2750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2090,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1980,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1980,72,,237.6,Percent of Total Billed charges,72% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1980,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1650,60,,198,Percent of Total Billed Charges,60% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1237.5,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1787.5,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1212.75,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2612.5,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2420,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2475,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1212.75,2750,
ONYX FRONTIER 2MM X 18MM,2780003185,CDM,278,RC,C1874,HCPCS,Outpatient,,,2750.00,1787.50,,2750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2090,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1980,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1980,72,,237.6,Percent of Total Billed charges,72% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1980,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1650,60,,198,Percent of Total Billed Charges,60% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1237.5,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1787.5,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1212.75,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2612.5,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2420,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2475,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1212.75,2750,
ONYX FRONTIER 2MM X 22MM,2780003186,CDM,278,RC,C1874,HCPCS,Outpatient,,,2750.00,1787.50,,2750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2090,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1980,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1980,72,,237.6,Percent of Total Billed charges,72% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1980,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1650,60,,198,Percent of Total Billed Charges,60% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1237.5,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1787.5,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1212.75,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2612.5,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2420,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2475,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1212.75,2750,
ONYX FRONTIER 2MM X 26MM,2780003187,CDM,278,RC,C1874,HCPCS,Outpatient,,,2750.00,1787.50,,2750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2090,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1980,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1980,72,,237.6,Percent of Total Billed charges,72% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1980,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1650,60,,198,Percent of Total Billed Charges,60% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1237.5,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1787.5,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1212.75,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2612.5,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2420,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2475,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1212.75,2750,
ONYX FRONTIER 2MM X 30MM,2780003188,CDM,278,RC,C1874,HCPCS,Outpatient,,,2750.00,1787.50,,2750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2090,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1980,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1980,72,,237.6,Percent of Total Billed charges,72% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1980,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1650,60,,198,Percent of Total Billed Charges,60% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1237.5,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1787.5,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1212.75,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2612.5,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2420,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2475,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1212.75,2750,
ONYX FRONTIER 2.25MM X 8MM,2780003189,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,237.6,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,198,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.25MM X 12MM,2780003190,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,237.6,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,198,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.25MM X 15MM,2780003191,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,237.6,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,237.6,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,198,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,802.752,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.25MM X 18MM,2780003192,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,158.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,149.768,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.25MM X 22MM,2780003193,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,158.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,1409.2,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.25MM X 26MM,2780003194,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,158.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,390,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.25MM X 30MM,2780003195,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,158.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,390,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.25MM X 34MM,2780003196,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,158.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,435.504,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.25MM X 38MM,2780003197,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,158.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.5MM X 8MM,2780003198,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,158.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.5MM X 12MM,2780003199,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,158.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.5MM X 15MM,2780003200,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,158.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.5MM X 18MM,2780003201,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,158.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.5MM X 22MM,2780003202,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,158.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.5MM X 26MM,2780003203,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,158.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.5MM X 30MM,2780003204,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,158.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.5MM X 34MM,2780003205,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,158.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.5MM X 38MM,2780003206,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,158.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.75MM X 8MM,2780003207,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,158.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.75MM X 12MM,2780003208,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,158.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.75MM X 15MM,2780003209,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,158.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.75MM X 18MM,2780003210,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,158.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.75MM X 22MM,2780003211,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,158.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.75MM X 26MM,2780003212,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,158.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,1111.504,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.75MM X 30MM,2780003213,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,424.8,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,207.376,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.75MM X 34MM,2780003214,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,424.8,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,1951.2,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 2.75MM X 38MM,2780003215,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,424.8,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,540,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 3MM X 8MM,2780003216,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,424.8,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,540,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 3MM X 12MM,2780003217,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,424.8,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,192.864,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,1086.8,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 3MM X 15MM,2780003218,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,424.8,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,603,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,202.768,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 3MM x 18MM,2780003219,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,424.8,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,555.752,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,544.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,1907.84,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 3MM X 22MM,2780003220,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,424.8,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,103.688,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,101.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,528,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 3MM X 26MM,2780003221,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,424.8,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,975.6,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,956.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,528,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 3MM X 30MM,2780003222,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,938.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,270,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,1111.504,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,264.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,1173.248,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,188.584,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,1111.504,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 3MM X 34MM,2780003223,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,175.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,270,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,207.376,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,264.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,218.896,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,589.6,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,207.376,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 3MM X 38MM,2780003224,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,1647.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,96.432,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,1951.2,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,94.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,2059.6,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,1951.2,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 3.5MM X 8MM,2780003225,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,301.504,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,540,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,295.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,570,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,540,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 3.5MM X 12MM,2780003226,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,540,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,570,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,540,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 3.5MM X 15MM,2780003227,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,162.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,192.864,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,203.584,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,192.864,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 3.5MM X 18MM,2780003228,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,509.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,603,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,636.504,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,603,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 3.5MM X 22MM,2780003229,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 3.5MM X 26MM,2780003230,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 3.5MM X 30MM,2780003231,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 3.5MM X 34MM,2780003232,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 3.5MM X 38MM,2780003233,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 4MMX 8MM,2780003234,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 4MM X 12MM,2780003235,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 4MM X 15MM,2780003236,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 4MM X 18MM,2780003237,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 4MM X 22MM,2780003238,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 4MM X 26MM,2780003239,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 4MM X 30MM,2780003240,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 4MM X 34MM,2780003241,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 4MM X 38MM,2780003242,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 4.5MM X 12MM,2780003243,CDM,278,RC,C1874,HCPCS,Outpatient,,,2750.00,1787.50,,2750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2090,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1980,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1980,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1980,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1650,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1237.5,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1787.5,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1212.75,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2612.5,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2420,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2475,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1212.75,2750,
ONYX FRONTIER 4.5MM X 15MM,2780003244,CDM,278,RC,C1874,HCPCS,Outpatient,,,2750.00,1787.50,,2750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2090,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1980,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1980,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1980,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1650,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1237.5,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1787.5,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1212.75,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2612.5,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2420,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2475,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1212.75,2750,
ONYX FRONTIER 4.5MM X 18MM,2780003245,CDM,278,RC,C1874,HCPCS,Outpatient,,,2750.00,1787.50,,2750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2090,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1980,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1980,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1980,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1650,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1237.5,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1787.5,65,,195,Percent of total Billed Charges,65% of Total Billed Charges,1212.75,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2612.5,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2420,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2475,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1212.75,2750,
ONYX FRONTIER 4.5MM X 22MM,2780003246,CDM,278,RC,C1874,HCPCS,Outpatient,,,2750.00,1787.50,,2750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2090,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1980,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1980,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1980,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1650,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1237.5,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1787.5,65,,414.704,Percent of total Billed Charges,65% of Total Billed Charges,1212.75,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2612.5,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2420,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2475,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1212.75,2750,
ONYX FRONTIER 4.5MM X 26MM,2780003247,CDM,278,RC,C1874,HCPCS,Outpatient,,,2750.00,1787.50,,2750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2090,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1980,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1980,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1980,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1650,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1237.5,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1787.5,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,1212.75,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2612.5,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2420,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2475,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1212.75,2750,
ONYX FRONTIER 4.5MM X 30MM,2780003248,CDM,278,RC,C1874,HCPCS,Outpatient,,,2750.00,1787.50,,2750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2090,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1980,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1980,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1980,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1650,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1237.5,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1787.5,65,,3770,Percent of total Billed Charges,65% of Total Billed Charges,1212.75,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2612.5,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2420,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2475,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1212.75,2750,
ONYX FRONTIER 5MM X 12MM,2780003249,CDM,278,RC,C1874,HCPCS,Outpatient,,,2750.00,1787.50,,2750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2090,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1980,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1980,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1980,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1650,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1237.5,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2475,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1787.5,65,,2106.752,Percent of total Billed Charges,65% of Total Billed Charges,1212.75,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2612.5,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2420,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2475,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1212.75,2750,
ONYX FRONTIER 5MM X 15MM,2780003250,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,2535,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 5MM X 18MM,2780003251,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,96.464,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 5MM X 22MM,2780003252,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,1943.504,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 5MM X 26MM,2780003253,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,1943.504,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
ONYX FRONTIER 5MM X30MM,2780003254,CDM,278,RC,C1874,HCPCS,Outpatient,,,2562.50,1665.63,,2562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1947.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1845,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1845,72,,424.8,Percent of Total Billed charges,72% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1537.5,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1153.13,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.63,65,,1943.504,Percent of total Billed Charges,65% of Total Billed Charges,1130.06,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2434.38,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2306.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1130.06,2562.5,
TRUESPAN MENISCAL REP SYS 12,2780003255,CDM,278,RC,,,Outpatient,,,1952.50,1269.13,,1952.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1483.9,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1405.8,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1405.8,72,,424.8,Percent of Total Billed charges,72% of Total Billed Charges,1952.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1405.8,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,1171.5,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,1757.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,878.63,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,1757.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,1952.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1952.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1952.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1269.13,65,,1943.504,Percent of total Billed Charges,65% of Total Billed Charges,861.05,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,1854.88,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,1952.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1718.2,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,1757.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,861.05,1952.5,
Pencan Spinal Trays 10/CS,2780003256,CDM,278,RC,,,Outpatient,,,47.00,30.55,,47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.72,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.84,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,33.84,72,,424.8,Percent of Total Billed charges,72% of Total Billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.84,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,28.2,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,42.3,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,42.3,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.55,65,,1943.504,Percent of total Billed Charges,65% of Total Billed Charges,20.73,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.65,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.36,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,42.3,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,20.73,47,
SUBTALR ARTHREREIS IMP 11/16,2780003257,CDM,278,RC,,,Outpatient,,,3737.50,2429.38,,3737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2840.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2691,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,2691,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2691,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,2242.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,3363.75,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1681.88,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,3363.75,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2429.38,65,,2073.504,Percent of total Billed Charges,65% of Total Billed Charges,1648.24,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,3550.63,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3289,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,3363.75,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1648.24,3737.5,
SUBTALR ARTHREREIS IMP 12/16,2780003258,CDM,278,RC,,,Outpatient,,,3737.50,2429.38,,3737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2840.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2691,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,2691,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2691,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,2242.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,3363.75,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1681.88,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,3363.75,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2429.38,65,,2203.504,Percent of total Billed Charges,65% of Total Billed Charges,1648.24,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,3550.63,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3289,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,3363.75,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1648.24,3737.5,
VECTORFLOW KIT 15F 31CM ANTGRD,2780003259,CDM,278,RC,C1750,HCPCS,Outpatient,,,880.00,572.00,,880,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,668.8,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,633.6,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,633.6,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,880,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,633.6,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,528,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,792,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,396,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,792,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,880,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,880,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,880,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,572,65,,2333.504,Percent of total Billed Charges,65% of Total Billed Charges,388.08,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,836,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,880,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,774.4,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,792,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,388.08,880,
Z8022-28-04 FEM HEAD 28 + 7,2780003260,CDM,278,RC,,,Outpatient,,,1543.75,1003.44,,1543.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1173.25,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1111.5,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1111.5,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,1543.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1111.5,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,926.25,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,1389.38,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,694.69,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,1389.38,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,1543.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1543.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1543.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1003.44,65,,214.504,Percent of total Billed Charges,65% of Total Billed Charges,680.79,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,1466.56,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,1543.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1358.5,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,1389.38,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,680.79,1543.75,
SURGIMESH WN T1415,2780003261,CDM,278,RC,,,Outpatient,,,2087.50,1356.88,,2087.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1586.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1503,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1503,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,2087.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1503,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1252.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,1878.75,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,939.38,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,1878.75,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2087.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2087.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2087.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1356.88,65,,214.504,Percent of total Billed Charges,65% of Total Billed Charges,920.59,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,1983.13,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2087.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1837,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,1878.75,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,920.59,2087.5,
SURGIMESH WN T1015,2780003262,CDM,278,RC,,,Outpatient,,,1220.00,793.00,,1220,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,927.2,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,878.4,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,878.4,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,1220,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.4,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,732,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,1098,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,549,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,1098,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,1220,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1220,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1220,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,793,65,,214.504,Percent of total Billed Charges,65% of Total Billed Charges,538.02,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,1159,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,1220,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1073.6,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,1098,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,538.02,1220,
TRUESPAN MENISCAL REP SYS 24?,2780003263,CDM,278,RC,,,Outpatient,,,1952.50,1269.13,,1952.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1483.9,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1405.8,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1405.8,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,1952.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1405.8,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1171.5,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,1757.25,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,878.63,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,1757.25,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,1952.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1952.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1952.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1269.13,65,,214.504,Percent of total Billed Charges,65% of Total Billed Charges,861.05,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,1854.88,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,1952.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1718.2,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,1757.25,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,861.05,1952.5,
Z2252-380-10 FEMRECONAIL 10X38,2780003264,CDM,278,RC,,,Outpatient,,,1923.25,1250.11,,1923.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1461.67,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1384.74,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1384.74,72,,86.4,Percent of Total Billed charges,72% of Total Billed Charges,1923.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1384.74,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,1153.95,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,1730.93,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,865.46,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,1730.93,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,1923.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1923.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1923.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1250.11,65,,214.504,Percent of total Billed Charges,65% of Total Billed Charges,848.15,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,1827.09,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,1923.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1692.46,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,1730.93,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,848.15,1923.25,
ARTHREX DEX SWIVLCK SL 3.5X8,2780003265,CDM,278,RC,,,Outpatient,,,1520.00,988.00,,1520,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1155.2,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1094.4,72,,864,Percent of Total Billed Charges,72% of Total Billed Charges,1094.4,72,,864,Percent of Total Billed charges,72% of Total Billed Charges,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1094.4,72,,864,Percent of Total Billed Charges,72% of Total Billed Charges,912,60,,720,Percent of Total Billed Charges,60% of Total Billed Charges,1368,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,684,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,1368,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,988,65,,214.504,Percent of total Billed Charges,65% of Total Billed Charges,670.32,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,1444,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1337.6,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,1368,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,670.32,1520,
ARTHREX NANO SWIVLCK 2.5X7,2780003266,CDM,278,RC,,,Outpatient,,,1875.00,1218.75,,1875,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1425,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1350,72,,1008,Percent of Total Billed Charges,72% of Total Billed Charges,1350,72,,1008,Percent of Total Billed charges,72% of Total Billed Charges,1875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1350,72,,1008,Percent of Total Billed Charges,72% of Total Billed Charges,1125,60,,840,Percent of Total Billed Charges,60% of Total Billed Charges,1687.5,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,843.75,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,1687.5,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,1875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1218.75,65,,214.504,Percent of total Billed Charges,65% of Total Billed Charges,826.88,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,1781.25,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,1875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1650,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,1687.5,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,826.88,1875,
Z2254-225-09 HUM.NAIL 9X22.5,2780003267,CDM,278,RC,,,Outpatient,,,2751.00,1788.15,,2751,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2090.76,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1980.72,72,,1116,Percent of Total Billed Charges,72% of Total Billed Charges,1980.72,72,,1116,Percent of Total Billed charges,72% of Total Billed Charges,2751,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1980.72,72,,1116,Percent of Total Billed Charges,72% of Total Billed Charges,1650.6,60,,930,Percent of Total Billed Charges,60% of Total Billed Charges,2475.9,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,1237.95,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,2475.9,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,2751,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2751,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2751,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1788.15,65,,214.504,Percent of total Billed Charges,65% of Total Billed Charges,1213.19,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,2613.45,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,2751,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2420.88,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,2475.9,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,1213.19,2751,
Prolene Mesh,2780003268,CDM,278,RC,,,Outpatient,,,1099.08,714.40,,1099.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,835.3,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,791.34,72,,1216.8,Percent of Total Billed Charges,72% of Total Billed Charges,791.34,72,,1216.8,Percent of Total Billed charges,72% of Total Billed Charges,1099.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,791.34,72,,1216.8,Percent of Total Billed Charges,72% of Total Billed Charges,659.45,60,,1014,Percent of Total Billed Charges,60% of Total Billed Charges,989.17,90,,574.2,Percent of Total Billed Charges,90% of Total Billed Charges,494.59,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,989.17,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,1099.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1099.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1099.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,714.4,65,,214.504,Percent of total Billed Charges,65% of Total Billed Charges,484.69,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,1044.13,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,1099.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,967.19,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,989.17,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,484.69,1099.08,
6 x 65 Canc screw,2780003269,CDM,278,RC,,,Outpatient,,,537.68,349.49,,537.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,408.64,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,387.13,72,,1353.6,Percent of Total Billed Charges,72% of Total Billed Charges,387.13,72,,1353.6,Percent of Total Billed charges,72% of Total Billed Charges,537.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,387.13,72,,1353.6,Percent of Total Billed Charges,72% of Total Billed Charges,322.61,60,,1128,Percent of Total Billed Charges,60% of Total Billed Charges,483.91,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,241.96,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,483.91,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,537.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.49,65,,214.504,Percent of total Billed Charges,65% of Total Billed Charges,237.12,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,510.8,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,537.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.16,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,483.91,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,237.12,537.68,
5 x 42.5 Cort Screw,2780003270,CDM,278,RC,,,Outpatient,,,519.13,337.43,,519.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,394.54,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,373.77,72,,1368,Percent of Total Billed Charges,72% of Total Billed Charges,373.77,72,,1368,Percent of Total Billed charges,72% of Total Billed Charges,519.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.77,72,,1368,Percent of Total Billed Charges,72% of Total Billed Charges,311.48,60,,1140,Percent of Total Billed Charges,60% of Total Billed Charges,467.22,90,,5220,Percent of Total Billed Charges,90% of Total Billed Charges,233.61,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,467.22,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,519.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,519.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,519.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.43,65,,214.504,Percent of total Billed Charges,65% of Total Billed Charges,228.94,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,493.17,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,519.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.83,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,467.22,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,228.94,519.13,
10 x 36 Fem Nail,2780003271,CDM,278,RC,,,Outpatient,,,4579.40,2976.61,,4579.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3480.34,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3297.17,72,,1008,Percent of Total Billed Charges,72% of Total Billed Charges,3297.17,72,,1008,Percent of Total Billed charges,72% of Total Billed Charges,4579.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3297.17,72,,1008,Percent of Total Billed Charges,72% of Total Billed Charges,2747.64,60,,840,Percent of Total Billed Charges,60% of Total Billed Charges,4121.46,90,,2917.048,Percent of Total Billed Charges,90% of Total Billed Charges,2060.73,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,4121.46,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,4579.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4579.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4579.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2976.61,65,,214.504,Percent of total Billed Charges,65% of Total Billed Charges,2019.52,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,4350.43,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,4579.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4029.87,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,4121.46,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,2019.52,4579.4,
6.0 x 60 Canc Screw,2780003272,CDM,278,RC,,,Outpatient,,,537.68,349.49,,537.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,408.64,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,387.13,72,,1116,Percent of Total Billed Charges,72% of Total Billed Charges,387.13,72,,1116,Percent of Total Billed charges,72% of Total Billed Charges,537.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,387.13,72,,1116,Percent of Total Billed Charges,72% of Total Billed Charges,322.61,60,,930,Percent of Total Billed Charges,60% of Total Billed Charges,483.91,90,,3510,Percent of Total Billed Charges,90% of Total Billed Charges,241.96,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,483.91,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,537.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.49,65,,214.504,Percent of total Billed Charges,65% of Total Billed Charges,237.12,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,510.8,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,537.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.16,88,,264,Percent of Total Billed Charges,88% of Total Billed Charges,483.91,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,237.12,537.68,
6.0 x 45 Canc Screw,2780003273,CDM,278,RC,,,Outpatient,,,537.68,349.49,,537.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,408.64,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,387.13,72,,1216.8,Percent of Total Billed Charges,72% of Total Billed Charges,387.13,72,,1216.8,Percent of Total Billed charges,72% of Total Billed Charges,537.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,387.13,72,,1216.8,Percent of Total Billed Charges,72% of Total Billed Charges,322.61,60,,1014,Percent of Total Billed Charges,60% of Total Billed Charges,483.91,90,,133.56,Percent of Total Billed Charges,90% of Total Billed Charges,241.96,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,483.91,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,537.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.49,65,,214.504,Percent of total Billed Charges,65% of Total Billed Charges,237.12,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,510.8,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,537.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.16,88,,561.44,Percent of Total Billed Charges,88% of Total Billed Charges,483.91,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,237.12,537.68,
Papyrus Covered Stent 4 x 20,2780003274,CDM,278,RC,C1874,HCPCS,Outpatient,,,7500.00,4875.00,,7500,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5700,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5400,72,,1339.2,Percent of Total Billed Charges,72% of Total Billed Charges,5400,72,,1339.2,Percent of Total Billed charges,72% of Total Billed Charges,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5400,72,,1339.2,Percent of Total Billed Charges,72% of Total Billed Charges,4500,60,,1116,Percent of Total Billed Charges,60% of Total Billed Charges,6750,90,,2691,Percent of Total Billed Charges,90% of Total Billed Charges,3375,45,,135,Percent of Total Billed Charges,45% of Total Billed Charges,6750,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4875,65,,214.504,Percent of total Billed Charges,65% of Total Billed Charges,3307.5,44.1,,132.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,7125,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,7500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6600,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,6750,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,3307.5,7500,
Olymp Hanarostent Col 22DM 9cm,2780003275,CDM,278,RC,,,Outpatient,,,7218.75,4692.19,,7218.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5486.25,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5197.5,72,,1353.6,Percent of Total Billed Charges,72% of Total Billed Charges,5197.5,72,,1353.6,Percent of Total Billed charges,72% of Total Billed Charges,7218.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5197.5,72,,1353.6,Percent of Total Billed Charges,72% of Total Billed Charges,4331.25,60,,1128,Percent of Total Billed Charges,60% of Total Billed Charges,6496.88,90,,2691,Percent of Total Billed Charges,90% of Total Billed Charges,3248.44,45,,287.104,Percent of Total Billed Charges,45% of Total Billed Charges,6496.88,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,7218.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7218.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7218.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.19,65,,214.504,Percent of total Billed Charges,65% of Total Billed Charges,3183.47,44.1,,281.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,6857.81,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,7218.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6352.5,88,,5104,Percent of Total Billed Charges,88% of Total Billed Charges,6496.88,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,3183.47,7218.75,
"Olymp Revowave 0.035""x450CM ST",2780003276,CDM,278,RC,,,Outpatient,,,360.92,234.60,,360.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,274.3,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.86,72,,1368,Percent of Total Billed Charges,72% of Total Billed Charges,259.86,72,,1368,Percent of Total Billed charges,72% of Total Billed Charges,360.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.86,72,,1368,Percent of Total Billed Charges,72% of Total Billed Charges,216.55,60,,1140,Percent of Total Billed Charges,60% of Total Billed Charges,324.83,90,,2691,Percent of Total Billed Charges,90% of Total Billed Charges,162.41,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,324.83,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,360.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.6,65,,214.504,Percent of total Billed Charges,65% of Total Billed Charges,159.17,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,342.87,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,360.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,317.61,88,,2852.224,Percent of Total Billed Charges,88% of Total Billed Charges,324.83,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,159.17,360.92,
LINQ II (LNQ22) ICM,2780003277,CDM,278,RC,C1764,HCPCS,Outpatient,,,13237.50,8604.38,,13237.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10060.5,76,,228,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9531,72,,648,Percent of Total Billed Charges,72% of Total Billed Charges,9531,72,,648,Percent of Total Billed charges,72% of Total Billed Charges,13237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9531,72,,648,Percent of Total Billed Charges,72% of Total Billed Charges,7942.5,60,,540,Percent of Total Billed Charges,60% of Total Billed Charges,11913.75,90,,2691,Percent of Total Billed Charges,90% of Total Billed Charges,5956.88,45,,2610,Percent of Total Billed Charges,45% of Total Billed Charges,11913.75,90,,270,Percent of Total Billed Charges,90% of Total billed Charges,13237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8604.38,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,5837.74,44.1,,2557.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,12575.63,95,,285,Percent of Total Billed Charges,95% of Total Billed Charges,13237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11649,88,,3432,Percent of Total Billed Charges,88% of Total Billed Charges,11913.75,90,,270,Percent of Total Billed charges,90% of Total Billed Charges,5837.74,13237.5,
Olympus Hanarostent Col 60,2780003278,CDM,278,RC,,,Outpatient,,,7218.75,4692.19,,7218.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5486.25,76,,484.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5197.5,72,,756,Percent of Total Billed Charges,72% of Total Billed Charges,5197.5,72,,756,Percent of Total Billed charges,72% of Total Billed Charges,7218.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5197.5,72,,756,Percent of Total Billed Charges,72% of Total Billed Charges,4331.25,60,,630,Percent of Total Billed Charges,60% of Total Billed Charges,6496.88,90,,2691,Percent of Total Billed Charges,90% of Total Billed Charges,3248.44,45,,1458.52,Percent of Total Billed Charges,45% of Total Billed Charges,6496.88,90,,574.2,Percent of Total Billed Charges,90% of Total billed Charges,7218.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7218.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7218.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.19,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,3183.47,44.1,,1429.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,6857.81,95,,606.104,Percent of Total Billed Charges,95% of Total Billed Charges,7218.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6352.5,88,,130.592,Percent of Total Billed Charges,88% of Total Billed Charges,6496.88,90,,574.2,Percent of Total Billed charges,90% of Total Billed Charges,3183.47,7218.75,
PAPYRUS COVERED STENT 2.5 X 20,2780003279,CDM,278,RC,C1874,HCPCS,Outpatient,,,8250.00,5362.50,,8250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6270,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5940,72,,792,Percent of Total Billed Charges,72% of Total Billed Charges,5940,72,,792,Percent of Total Billed charges,72% of Total Billed Charges,8250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5940,72,,792,Percent of Total Billed Charges,72% of Total Billed Charges,4950,60,,660,Percent of Total Billed Charges,60% of Total Billed Charges,7425,90,,2871,Percent of Total Billed Charges,90% of Total Billed Charges,3712.5,45,,1755,Percent of Total Billed Charges,45% of Total Billed Charges,7425,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,8250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5362.5,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,3638.25,44.1,,1719.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,7837.5,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,8250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7260,88,,2631.2,Percent of Total Billed Charges,88% of Total Billed Charges,7425,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,3638.25,8250,
PAPYRUS COVERED STENT 3 X 20,2780003280,CDM,278,RC,C1874,HCPCS,Outpatient,,,8250.00,5362.50,,8250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6270,76,,4408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5940,72,,856.8,Percent of Total Billed Charges,72% of Total Billed Charges,5940,72,,856.8,Percent of Total Billed charges,72% of Total Billed Charges,8250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5940,72,,856.8,Percent of Total Billed Charges,72% of Total Billed Charges,4950,60,,714,Percent of Total Billed Charges,60% of Total Billed Charges,7425,90,,3051,Percent of Total Billed Charges,90% of Total Billed Charges,3712.5,45,,66.784,Percent of Total Billed Charges,45% of Total Billed Charges,7425,90,,5220,Percent of Total Billed Charges,90% of Total billed Charges,8250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5362.5,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,3638.25,44.1,,65.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,7837.5,95,,5510,Percent of Total Billed Charges,95% of Total Billed Charges,8250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7260,88,,2631.2,Percent of Total Billed Charges,88% of Total Billed Charges,7425,90,,5220,Percent of Total Billed charges,90% of Total Billed Charges,3638.25,8250,
PAPYRUS COVERED STENT 3.5 X 20,2780003281,CDM,278,RC,C1874,HCPCS,Outpatient,,,8250.00,5362.50,,8250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6270,76,,2463.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5940,72,,1000.8,Percent of Total Billed Charges,72% of Total Billed Charges,5940,72,,1000.8,Percent of Total Billed charges,72% of Total Billed Charges,8250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5940,72,,1000.8,Percent of Total Billed Charges,72% of Total Billed Charges,4950,60,,834,Percent of Total Billed Charges,60% of Total Billed Charges,7425,90,,3231,Percent of Total Billed Charges,90% of Total Billed Charges,3712.5,45,,1345.504,Percent of Total Billed Charges,45% of Total Billed Charges,7425,90,,2917.048,Percent of Total Billed Charges,90% of Total billed Charges,8250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5362.5,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,3638.25,44.1,,1318.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,7837.5,95,,3079.104,Percent of Total Billed Charges,95% of Total Billed Charges,8250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7260,88,,2631.2,Percent of Total Billed Charges,88% of Total Billed Charges,7425,90,,2917.048,Percent of Total Billed charges,90% of Total Billed Charges,3638.25,8250,
PHSL Hernia Mesh Large,2780003282,CDM,278,RC,,,Outpatient,,,1195.05,776.78,,1195.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,908.24,76,,2964,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,860.44,72,,1332,Percent of Total Billed Charges,72% of Total Billed Charges,860.44,72,,1332,Percent of Total Billed charges,72% of Total Billed Charges,1195.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,860.44,72,,1332,Percent of Total Billed Charges,72% of Total Billed Charges,717.03,60,,1110,Percent of Total Billed Charges,60% of Total Billed Charges,1075.55,90,,297,Percent of Total Billed Charges,90% of Total Billed Charges,537.77,45,,1345.504,Percent of Total Billed Charges,45% of Total Billed Charges,1075.55,90,,3510,Percent of Total Billed Charges,90% of Total billed Charges,1195.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1195.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1195.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,776.78,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,527.02,44.1,,1318.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,1135.3,95,,3705,Percent of Total Billed Charges,95% of Total Billed Charges,1195.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1051.64,88,,2631.2,Percent of Total Billed Charges,88% of Total Billed Charges,1075.55,90,,3510,Percent of Total Billed charges,90% of Total Billed Charges,527.02,1195.05,
PHSE Hernia Mesh Xlarge,2780003283,CDM,278,RC,,,Outpatient,,,1195.05,776.78,,1195.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,908.24,76,,112.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,860.44,72,,1382.4,Percent of Total Billed Charges,72% of Total Billed Charges,860.44,72,,1382.4,Percent of Total Billed charges,72% of Total Billed Charges,1195.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,860.44,72,,1382.4,Percent of Total Billed Charges,72% of Total Billed Charges,717.03,60,,1152,Percent of Total Billed Charges,60% of Total Billed Charges,1075.55,90,,297,Percent of Total Billed Charges,90% of Total Billed Charges,537.77,45,,1345.504,Percent of Total Billed Charges,45% of Total Billed Charges,1075.55,90,,133.56,Percent of Total Billed Charges,90% of Total billed Charges,1195.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1195.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1195.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,776.78,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,527.02,44.1,,1318.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,1135.3,95,,140.984,Percent of Total Billed Charges,95% of Total Billed Charges,1195.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1051.64,88,,2631.2,Percent of Total Billed Charges,88% of Total Billed Charges,1075.55,90,,133.56,Percent of Total Billed charges,90% of Total Billed Charges,527.02,1195.05,
Retromax Endopyelotomy Stent,2780003284,CDM,278,RC,,,Outpatient,,,464.95,302.22,,464.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,353.36,76,,2272.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,334.76,72,,1432.8,Percent of Total Billed Charges,72% of Total Billed Charges,334.76,72,,1432.8,Percent of Total Billed charges,72% of Total Billed Charges,464.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.76,72,,1432.8,Percent of Total Billed Charges,72% of Total Billed Charges,278.97,60,,1194,Percent of Total Billed Charges,60% of Total Billed Charges,418.46,90,,297,Percent of Total Billed Charges,90% of Total Billed Charges,209.23,45,,1345.504,Percent of Total Billed Charges,45% of Total Billed Charges,418.46,90,,2691,Percent of Total Billed Charges,90% of Total billed Charges,464.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,464.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,464.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.22,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,205.04,44.1,,1318.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,441.7,95,,2840.504,Percent of Total Billed Charges,95% of Total Billed Charges,464.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.16,88,,2807.2,Percent of Total Billed Charges,88% of Total Billed Charges,418.46,90,,2691,Percent of Total Billed charges,90% of Total Billed Charges,205.04,464.95,
Resolution Clip 235CM,2780003285,CDM,278,RC,,,Outpatient,,,971.67,631.59,,971.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,738.47,76,,2272.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,699.6,72,,1864.8,Percent of Total Billed Charges,72% of Total Billed Charges,699.6,72,,1864.8,Percent of Total Billed charges,72% of Total Billed Charges,971.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,699.6,72,,1864.8,Percent of Total Billed Charges,72% of Total Billed Charges,583,60,,1554,Percent of Total Billed Charges,60% of Total Billed Charges,874.5,90,,297,Percent of Total Billed Charges,90% of Total Billed Charges,437.25,45,,1345.504,Percent of Total Billed Charges,45% of Total Billed Charges,874.5,90,,2691,Percent of Total Billed Charges,90% of Total billed Charges,971.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,971.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,971.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,631.59,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,428.51,44.1,,1318.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,923.09,95,,2840.504,Percent of Total Billed Charges,95% of Total Billed Charges,971.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,855.07,88,,2983.2,Percent of Total Billed Charges,88% of Total Billed Charges,874.5,90,,2691,Percent of Total Billed charges,90% of Total Billed Charges,428.51,971.67,
ARTHREX COMPFT SCW 2.5X24,2780003286,CDM,278,RC,,,Outpatient,,,1460.00,949.00,,1460,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1109.6,76,,2272.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1051.2,72,,1936.8,Percent of Total Billed Charges,72% of Total Billed Charges,1051.2,72,,1936.8,Percent of Total Billed charges,72% of Total Billed Charges,1460,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1051.2,72,,1936.8,Percent of Total Billed Charges,72% of Total Billed Charges,876,60,,1614,Percent of Total Billed Charges,60% of Total Billed Charges,1314,90,,297,Percent of Total Billed Charges,90% of Total Billed Charges,657,45,,1435.504,Percent of Total Billed Charges,45% of Total Billed Charges,1314,90,,2691,Percent of Total Billed Charges,90% of Total billed Charges,1460,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1460,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1460,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,949,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,643.86,44.1,,1406.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,1387,95,,2840.504,Percent of Total Billed Charges,95% of Total Billed Charges,1460,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1284.8,88,,3159.2,Percent of Total Billed Charges,88% of Total Billed Charges,1314,90,,2691,Percent of Total Billed charges,90% of Total Billed Charges,643.86,1460,
Z47248405060 6.0X50 CANC SCW,2780003287,CDM,278,RC,,,Outpatient,,,539.25,350.51,,539.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,409.83,76,,2272.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,388.26,72,,2008.8,Percent of Total Billed Charges,72% of Total Billed Charges,388.26,72,,2008.8,Percent of Total Billed charges,72% of Total Billed Charges,539.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,388.26,72,,2008.8,Percent of Total Billed Charges,72% of Total Billed Charges,323.55,60,,1674,Percent of Total Billed Charges,60% of Total Billed Charges,485.33,90,,297,Percent of Total Billed Charges,90% of Total Billed Charges,242.66,45,,1525.504,Percent of Total Billed Charges,45% of Total Billed Charges,485.33,90,,2691,Percent of Total Billed Charges,90% of Total billed Charges,539.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,539.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,539.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.51,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,237.81,44.1,,1494.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,512.29,95,,2840.504,Percent of Total Billed Charges,95% of Total Billed Charges,539.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.54,88,,290.4,Percent of Total Billed Charges,88% of Total Billed Charges,485.33,90,,2691,Percent of Total Billed charges,90% of Total Billed Charges,237.81,539.25,
MYNX CONTROL DEVICE 5F,2780003288,CDM,278,RC,C1760,HCPCS,Outpatient,,,575.00,373.75,,575,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,437,76,,2272.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,414,72,,1864.8,Percent of Total Billed Charges,72% of Total Billed Charges,414,72,,1864.8,Percent of Total Billed charges,72% of Total Billed Charges,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414,72,,1864.8,Percent of Total Billed Charges,72% of Total Billed Charges,345,60,,1554,Percent of Total Billed Charges,60% of Total Billed Charges,517.5,90,,297,Percent of Total Billed Charges,90% of Total Billed Charges,258.75,45,,1615.504,Percent of Total Billed Charges,45% of Total Billed Charges,517.5,90,,2691,Percent of Total Billed Charges,90% of Total billed Charges,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.75,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,253.58,44.1,,1583.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,546.25,95,,2840.504,Percent of Total Billed Charges,95% of Total Billed Charges,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506,88,,290.4,Percent of Total Billed Charges,88% of Total Billed Charges,517.5,90,,2691,Percent of Total Billed charges,90% of Total Billed Charges,253.58,575,
MYNX CONTROL DEVICE 6/7F,2780003289,CDM,278,RC,C1760,HCPCS,Outpatient,,,575.00,373.75,,575,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,437,76,,2424.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,414,72,,1936.8,Percent of Total Billed Charges,72% of Total Billed Charges,414,72,,1936.8,Percent of Total Billed charges,72% of Total Billed Charges,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414,72,,1936.8,Percent of Total Billed Charges,72% of Total Billed Charges,345,60,,1614,Percent of Total Billed Charges,60% of Total Billed Charges,517.5,90,,297,Percent of Total Billed Charges,90% of Total Billed Charges,258.75,45,,148.504,Percent of Total Billed Charges,45% of Total Billed Charges,517.5,90,,2871,Percent of Total Billed Charges,90% of Total billed Charges,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.75,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,253.58,44.1,,145.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,546.25,95,,3030.504,Percent of Total Billed Charges,95% of Total Billed Charges,575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506,88,,290.4,Percent of Total Billed Charges,88% of Total Billed Charges,517.5,90,,2871,Percent of Total Billed charges,90% of Total Billed Charges,253.58,575,
B&L MXUE1500 12.5MM x 15,2780003290,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,2576.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,2008.8,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,2008.8,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,2008.8,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1674,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,148.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,3051,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,145.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,3220.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,290.4,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,3051,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE1550 12.5MM X 15.5,2780003291,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,2728.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,1864.8,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,1864.8,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,1864.8,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1554,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,148.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,3231,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,145.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,3410.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,290.4,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,3231,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE1600 12.5MM x16,2780003292,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,250.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,1936.8,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,1936.8,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,1936.8,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1614,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,148.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,145.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,313.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,290.4,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,297,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE1650 12.5MM x16.5,2780003293,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,250.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,2008.8,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,2008.8,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,2008.8,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1674,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,148.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,145.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,313.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,290.4,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,297,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L L161AOR1700 13.00MM x17,2780003294,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,250.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,1864.8,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,1864.8,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,1864.8,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1554,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,148.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,145.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,313.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,290.4,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,297,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L L161AOR1800 13.00MM x 18,2780003295,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,250.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,1936.8,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,1936.8,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,1936.8,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1614,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,148.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,145.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,313.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,290.4,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,297,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L L161AOR1800 13.00MM x18,2780003296,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,250.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,2008.8,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,2008.8,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,2008.8,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1674,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,148.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,145.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,313.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,290.4,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,297,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L L161AO1850 13.00MM x 18.5,2780003297,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,250.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,324,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,324,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,324,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,270,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,148.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,145.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,313.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,290.4,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,297,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L L161AOR1900 13.00MM x19,2780003298,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,250.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,338.4,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,338.4,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,338.4,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,282,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,148.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,145.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,313.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,290.4,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,297,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L L161AOR195013.00MM 19.5,2780003299,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,250.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,345.6,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,345.6,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,345.6,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,148.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,145.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,313.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,290.4,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,297,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L L161AOR2000 13.00MM x 20,2780003300,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,250.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,367.2,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,367.2,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,367.2,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,306,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,148.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,145.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,313.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,290.4,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,297,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L 61AOR2050 13.00MM X 20.5,2780003301,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,250.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,381.6,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,381.6,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,381.6,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,318,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,148.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,145.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,313.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,290.4,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,297,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L0L161AOR2100 13.00MM x 21,2780003302,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,250.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,403.2,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,403.2,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,403.2,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,336,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,148.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,145.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,313.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,290.4,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,297,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L L161AOR2150 13.00MM x 21.5,2780003303,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,250.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,432,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,432,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,432,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,360,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,148.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,145.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,313.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,290.4,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,297,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L L161AOR2200 13.00MM x 22,2780003304,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,250.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,1332,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,1332,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,1332,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1110,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,148.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,145.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,313.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,297,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L L161AOR2250 13.00MM x 22.5,2780003305,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,250.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,1382.4,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,1382.4,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,1382.4,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1152,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,148.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,145.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,313.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,297,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L L161AOR2300 13.00MM x23,2780003306,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,250.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,1432.8,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,1432.8,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,1432.8,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1194,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,313.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,297,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L L161AOR2350 13.00MM x 23.5,2780003307,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,250.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,1656,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,1656,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,1656,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1380,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,313.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,297,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L L161AOR2400 13.00MM x 24,2780003308,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,250.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,1728,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,1728,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,1728,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1440,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,297,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,313.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,297,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L K161AOR2450 13.00MM x 24.5,2780003309,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,1800,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,1800,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,1800,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1500,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L L161AOR2500 13.00MM x 25,2780003310,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,1872,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,1872,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,1872,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1560,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L L161AOR2550 13.00MM x 25.5,2780003311,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,1656,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,1656,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,1656,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1380,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L L161AOR2600 13.00MM x 26,2780003312,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,1728,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,1728,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,1728,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1440,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE1500 12.5MM X 15,2780003313,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,1800,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,1800,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,1800,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1500,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE1550 12.5MM X15.5,2780003314,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,1872,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,1872,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,1872,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1560,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE1600 12.5MM X 16,2780003315,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,1224,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,1224,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,1224,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1020,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE1650 12.5MM X 16.5,2780003316,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,1296,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,1296,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,1296,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1080,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE1700 12.5MM X 17,2780003317,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,1368,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,1368,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,1368,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1140,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE1750 12.5MM X 17.5,2780003318,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,1512,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,1512,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,1512,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,1260,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE1800 12.5MM X 18,2780003319,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,158.4,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE1850 12.5MM X18.5,2780003320,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,158.4,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE1900 12.5mm X 19,2780003321,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,158.4,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE1950 12.5MM X 19.5,2780003322,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,158.4,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE2000 12.5MM X 20,2780003323,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,158.4,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE2050 12.5MM X20.5,2780003324,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,158.4,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE2100 12.5MM X 21,2780003325,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,158.4,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE2150 12.5MM X 21.5,2780003326,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,158.4,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE2200 12.5MM X22,2780003327,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,158.4,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE2250 12.5MM X 22.5,2780003328,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,158.4,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE2300 12.5MM X23,2780003329,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,158.4,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE2350 12.5MM X 23.5,2780003330,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,158.4,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE2400 12.5MM X 24,2780003331,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,158.4,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE2450 12.5MM X 24.5,2780003332,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,158.4,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE2500 12.5MM X 25,2780003333,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,424.8,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE2550 12.5MM X 25.5,2780003334,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,424.8,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
B&L MXUE2600 12.5MM X 26,2780003335,CDM,276,RC,,,Outpatient,,,312.50,203.13,,312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.5,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,234.38,75,,424.8,Percent of Total Billed charges,75% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,281.25,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,140.63,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,281.25,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.13,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,137.81,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.88,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,281.25,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,137.81,312.5,
AMO DIB00 8.0,2780003336,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,424.8,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 8.5,2780003337,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,424.8,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 9.0,2780003338,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,424.8,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 9.5,2780003339,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,424.8,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 10.0,2780003340,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,424.8,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 10.5,2780003341,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,424.8,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 11.0,2780003342,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,424.8,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 11.5,2780003343,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,424.8,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 12.0,2780003344,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,424.8,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 12.5,2780003345,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,424.8,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 13.0,2780003346,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,201.6,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,168,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 13.5,2780003347,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,201.6,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,168,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 14.0,2780003348,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,201.6,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,168,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 14.5,2780003349,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,201.6,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,168,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 15.0,2780003350,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,201.6,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,168,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,780,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 15.5,2780003351,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,201.6,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,168,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,910,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 16.0,2780003352,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,201.6,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,168,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1007.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 16.5,2780003353,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,201.6,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,168,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1098.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 17.0,2780003354,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,201.6,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,168,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1222,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 17.5,2780003355,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,201.6,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,168,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1235,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 18.0,2780003356,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,201.6,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,168,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,910,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 18.5,2780003357,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,201.6,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,168,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1007.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 19.0,2780003358,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,201.6,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,168,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1098.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 19.5,2780003359,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,201.6,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,168,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1209,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 20.0,2780003360,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,1144.8,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,1144.8,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,1144.8,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,954,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1222,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 20.5,2780003361,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,1144.8,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,1144.8,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,1144.8,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,954,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1235,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 21.0,2780003362,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,1144.8,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,1144.8,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,1144.8,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,954,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,585,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 21.5,2780003363,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,421.92,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,421.92,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,421.92,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,351.6,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,682.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 22.0,2780003364,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,421.92,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,421.92,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,421.92,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,351.6,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,715,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 22.5,2780003365,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,421.92,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,421.92,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,421.92,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,351.6,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,773.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 23.0,2780003366,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,1206.72,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,1206.72,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,1206.72,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,1005.6,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,903.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 23.5,2780003367,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,5077.44,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,5077.44,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,5077.44,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,4231.2,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1202.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 24.0,2780003368,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,1154.952,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,1154.952,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,1154.952,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,962.464,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1248,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 24.5,2780003369,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,899.168,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,899.168,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,899.168,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,749.304,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1293.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 25.0,2780003370,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,750.344,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,750.344,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,750.344,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,625.288,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1683.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 25.5,2780003371,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,9436.32,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,9436.32,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,9436.32,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,7863.6,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1748.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 26.0,2780003372,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,9162.72,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,9162.72,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,9162.72,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,7635.6,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,1080,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1813.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 26.5,2780003373,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,424.8,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,424.8,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,354,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,1260,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1683.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 27.0,2780003374,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,1206.72,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,1206.72,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,1206.72,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,1005.6,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,1395,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1748.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 27.5,2780003375,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,5077.44,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,5077.44,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,5077.44,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,4231.2,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,1521,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1813.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 28.0,2780003376,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,767.048,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,767.048,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,767.048,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,639.208,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,1692,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1683.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 28.5,2780003377,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,1051.952,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,1051.952,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,1051.952,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,876.624,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,1710,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1748.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,1056,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 29.0,2780003378,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,956.304,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,956.304,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,956.304,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,796.92,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,1260,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1813.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,1232,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 29.5,2780003379,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,1534.064,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,1534.064,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,1534.064,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,1278.384,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,1395,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,540,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1683.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,529.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,1364,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 30.0,2780003380,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,473.76,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,473.76,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,473.76,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,394.8,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,1521,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,630,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1748.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,617.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,1487.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 30.5,2780003381,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,473.76,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,473.76,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,473.76,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,394.8,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,1674,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,697.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1813.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,683.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,1654.4,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 31.0,2780003382,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,473.76,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,473.76,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,473.76,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,394.8,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,1692,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,760.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,1080,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,292.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,745.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,1140,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,1672,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,1080,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 31.5,2780003383,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,1355.04,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,1355.04,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,1355.04,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,1129.2,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,1710,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,846,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,1260,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,305.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,829.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,1330,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,1232,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,1260,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
AMO DIB00 32.0,2780003384,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1178,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,5896.8,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,5896.8,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,5896.8,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,4914,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,810,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,855,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,1395,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,312,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,837.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,1472.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,1364,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,1395,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
Z8022-22-02 FEM HEAD 22.2 +0,2780003385,CDM,278,RC,,,Outpatient,,,1543.75,1003.44,,1543.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1173.25,76,,1284.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1111.5,72,,148.288,Percent of Total Billed Charges,72% of Total Billed Charges,1111.5,72,,148.288,Percent of Total Billed charges,72% of Total Billed Charges,1543.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1111.5,72,,148.288,Percent of Total Billed Charges,72% of Total Billed Charges,926.25,60,,123.576,Percent of Total Billed Charges,60% of Total Billed Charges,1389.38,90,,945,Percent of Total Billed Charges,90% of Total Billed Charges,694.69,45,,630,Percent of Total Billed Charges,45% of Total Billed Charges,1389.38,90,,1521,Percent of Total Billed Charges,90% of Total billed Charges,1543.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1543.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1543.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1003.44,65,,331.504,Percent of total Billed Charges,65% of Total Billed Charges,680.79,44.1,,617.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,1466.56,95,,1605.504,Percent of Total Billed Charges,95% of Total Billed Charges,1543.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1358.5,88,,1487.2,Percent of Total Billed Charges,88% of Total Billed Charges,1389.38,90,,1521,Percent of Total Billed charges,90% of Total Billed Charges,680.79,1543.75,
GI ANCHOR SET SAF T PEXY FAST,2780003386,CDM,278,RC,,,Outpatient,,,288.02,187.21,,288.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,218.9,76,,1428.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,207.37,72,,148.288,Percent of Total Billed Charges,72% of Total Billed Charges,207.37,72,,148.288,Percent of Total Billed charges,72% of Total Billed Charges,288.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.37,72,,148.288,Percent of Total Billed Charges,72% of Total Billed Charges,172.81,60,,123.576,Percent of Total Billed Charges,60% of Total Billed Charges,259.22,90,,990,Percent of Total Billed Charges,90% of Total Billed Charges,129.61,45,,697.504,Percent of Total Billed Charges,45% of Total Billed Charges,259.22,90,,1692,Percent of Total Billed Charges,90% of Total billed Charges,288.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.21,65,,344.504,Percent of total Billed Charges,65% of Total Billed Charges,127.02,44.1,,683.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,273.62,95,,1786,Percent of Total Billed Charges,95% of Total Billed Charges,288.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,253.46,88,,1636.8,Percent of Total Billed Charges,88% of Total Billed Charges,259.22,90,,1692,Percent of Total Billed charges,90% of Total Billed Charges,127.02,288.02,
TENOWRAP TENDON COLLAGEN WRAP,2780003387,CDM,278,RC,,,Outpatient,,,2710.00,1761.50,,2710,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2059.6,76,,1444,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1951.2,72,,624.384,Percent of Total Billed Charges,72% of Total Billed Charges,1951.2,72,,624.384,Percent of Total Billed charges,72% of Total Billed Charges,2710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1951.2,72,,624.384,Percent of Total Billed Charges,72% of Total Billed Charges,1626,60,,520.32,Percent of Total Billed Charges,60% of Total Billed Charges,2439,90,,1071,Percent of Total Billed Charges,90% of Total Billed Charges,1219.5,45,,760.504,Percent of Total Billed Charges,45% of Total Billed Charges,2439,90,,1710,Percent of Total Billed Charges,90% of Total billed Charges,2710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1761.5,65,,364,Percent of total Billed Charges,65% of Total Billed Charges,1195.11,44.1,,745.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,2574.5,95,,1805,Percent of Total Billed Charges,95% of Total Billed Charges,2710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2384.8,88,,1654.4,Percent of Total Billed Charges,88% of Total Billed Charges,2439,90,,1710,Percent of Total Billed charges,90% of Total Billed Charges,1195.11,2710,
VECTORFLOW KIT 15F 42CM,2780003388,CDM,278,RC,C1750,HCPCS,Outpatient,,,750.00,487.50,,750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,570,76,,1064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,540,72,,2653.632,Percent of Total Billed Charges,72% of Total Billed Charges,540,72,,2653.632,Percent of Total Billed charges,72% of Total Billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540,72,,2653.632,Percent of Total Billed Charges,72% of Total Billed Charges,450,60,,2211.36,Percent of Total Billed Charges,60% of Total Billed Charges,675,90,,1251,Percent of Total Billed Charges,90% of Total Billed Charges,337.5,45,,837,Percent of Total Billed Charges,45% of Total Billed Charges,675,90,,1260,Percent of Total Billed Charges,90% of Total billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487.5,65,,390,Percent of total Billed Charges,65% of Total Billed Charges,330.75,44.1,,820.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,712.5,95,,1330,Percent of Total Billed Charges,95% of Total Billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,660,88,,1672,Percent of Total Billed Charges,88% of Total Billed Charges,675,90,,1260,Percent of Total Billed charges,90% of Total Billed Charges,330.75,750,
VECTORFLOW KIT 15F 55CM,2780003389,CDM,278,RC,C1750,HCPCS,Outpatient,,,750.00,487.50,,750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,570,76,,1178,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,540,72,,6236.032,Percent of Total Billed Charges,72% of Total Billed Charges,540,72,,6236.032,Percent of Total Billed charges,72% of Total Billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540,72,,6236.032,Percent of Total Billed Charges,72% of Total Billed Charges,450,60,,5196.696,Percent of Total Billed Charges,60% of Total Billed Charges,675,90,,1665,Percent of Total Billed Charges,90% of Total Billed Charges,337.5,45,,846,Percent of Total Billed Charges,45% of Total Billed Charges,675,90,,1395,Percent of Total Billed Charges,90% of Total billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487.5,65,,1202.504,Percent of total Billed Charges,65% of Total Billed Charges,330.75,44.1,,829.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,712.5,95,,1472.504,Percent of Total Billed Charges,95% of Total Billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,660,88,,792,Percent of Total Billed Charges,88% of Total Billed Charges,675,90,,1395,Percent of Total Billed charges,90% of Total Billed Charges,330.75,750,
MICKEY 18F x 2.5CM BUTTON KIT,2780003390,CDM,272,RC,B4088,HCPCS,Outpatient,,,267.87,174.12,,48.45,125,,,Fee Schedule,125% of CMS OPPS Rate,203.58,76,,1284.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,192.87,72,,3051.68,Percent of Total Billed Charges,72% of Total Billed Charges,200.9,75,,3051.68,Percent of Total Billed charges,75% of Total Billed Charges,38.76,100,,,Fee Schedule,100% of CMS OPPS Rate,192.87,72,,3051.68,Percent of Total Billed Charges,72% of Total Billed Charges,160.72,60,,2543.064,Percent of Total Billed Charges,60% of Total Billed Charges,241.08,90,,1728,Percent of Total Billed Charges,90% of Total Billed Charges,120.54,45,,855,Percent of Total Billed Charges,45% of Total Billed Charges,241.08,90,,1521,Percent of Total Billed Charges,90% of Total billed Charges,38.76,100,,,Fee Schedule,100% of CMS OPPS Rate,38.76,100,,,Fee Schedule,100% of CMS OPPS Rate,38.76,100,,,Fee Schedule,100% of CMS OPPS Rate,77.52,200,,1248,Fee Schedule,200% of CMS OPPS Rate,118.13,44.1,,837.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,254.48,95,,1605.504,Percent of Total Billed Charges,95% of Total Billed Charges,29.07,75,,,Fee Schedule,75% of CMS OPPS Rate,235.73,88,,924,Percent of Total Billed Charges,88% of Total Billed Charges,241.08,90,,1521,Percent of Total Billed charges,90% of Total Billed Charges,29.07,254.48,
TEMP PACER CATH 7F W/BALLOON,2780003391,CDM,278,RC,C1751,HCPCS,Outpatient,,,837.50,544.38,,837.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,636.5,76,,1413.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,603,72,,1131.696,Percent of Total Billed Charges,72% of Total Billed Charges,603,72,,1131.696,Percent of Total Billed charges,72% of Total Billed Charges,837.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,603,72,,1131.696,Percent of Total Billed Charges,72% of Total Billed Charges,502.5,60,,943.08,Percent of Total Billed Charges,60% of Total Billed Charges,753.75,90,,1791,Percent of Total Billed Charges,90% of Total Billed Charges,376.88,45,,405,Percent of Total Billed Charges,45% of Total Billed Charges,753.75,90,,1674,Percent of Total Billed Charges,90% of Total billed Charges,837.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,837.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,837.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,544.38,65,,1293.504,Percent of total Billed Charges,65% of Total Billed Charges,369.34,44.1,,396.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,795.63,95,,1767,Percent of Total Billed Charges,95% of Total Billed Charges,837.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737,88,,968,Percent of Total Billed Charges,88% of Total Billed Charges,753.75,90,,1674,Percent of Total Billed charges,90% of Total Billed Charges,369.34,837.5,
B&L ASPIRE EA U +600,2780003392,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1428.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,858.528,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,858.528,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,858.528,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,715.44,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,2331,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,472.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,1692,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1495,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,463.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,1786,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,1047.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,1692,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +700,2780003393,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1444,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,858.528,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,858.528,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,858.528,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,715.44,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,2421,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,495,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,1710,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1560,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,485.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,1805,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,1223.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,1710,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +800,2780003394,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,684,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,858.528,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,858.528,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,858.528,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,715.44,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,2511,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,535.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,810,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1625,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,524.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,855,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,1628,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,810,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +900,2780003395,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,798,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,858.528,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,858.528,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,858.528,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,715.44,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,2331,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,625.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,945,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1690,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,612.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,997.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,1689.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,945,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +1000,2780003396,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,836,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,2767.248,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,2767.248,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,2767.248,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,2306.04,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,2421,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,832.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,990,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1495,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,815.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,1045,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,1751.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,990,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +1050,2780003397,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,904.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,283.536,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,283.536,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,283.536,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,236.28,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,2511,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,864,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,1071,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1560,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,846.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,1130.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,2279.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,1071,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +1100,2780003398,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1056.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,283.536,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,283.536,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,283.536,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,236.28,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,2331,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,895.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,1251,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1625,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,877.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,1320.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,2367.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,1251,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +1200,2780003399,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1406,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,199.584,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,199.584,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,199.584,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,166.32,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,2421,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,1165.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,1665,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1690,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,1142.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,1757.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,2455.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,1665,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +1250,2780003400,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1459.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,199.584,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,199.584,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,199.584,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,166.32,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,2511,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,1210.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,1728,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1105,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,1186.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,1824,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,2279.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,1728,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +1350,2780003401,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1512.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,393.12,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,393.12,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,393.12,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,327.6,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,2331,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,1255.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,1791,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1170,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,1230.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,1890.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,2367.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,1791,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +1400,2780003402,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1968.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,443.52,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,443.52,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,443.52,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,369.6,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,2421,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,1165.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,2331,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1235,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,1142.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,2460.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,2455.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,2331,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +1450,2780003403,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,2044.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,443.52,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,443.52,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,443.52,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,369.6,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,2511,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,1210.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,2421,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,1365,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,1186.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,2555.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,2279.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,2421,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +1500,2780003404,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,2120.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,551.232,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,551.232,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,551.232,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,459.36,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,405,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,1255.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,2511,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,1230.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,2650.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,2367.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,2511,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +1550,2780003405,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1968.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,60.48,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,60.48,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,60.48,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,50.4,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,423,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,1165.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,2331,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,1142.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,2460.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,2455.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,2331,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +1600,2780003406,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,2044.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,639.36,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,639.36,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,639.36,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,532.8,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,432,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,1210.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,2421,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,1186.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,2555.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,2279.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,2421,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +1650,2780003407,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,2120.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,82.08,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,82.08,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,82.08,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,68.4,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,459,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,1255.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,2511,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,1230.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,2650.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,2367.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,2511,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +1700,2780003408,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1968.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,340.528,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,340.528,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,340.528,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,283.776,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,477,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,1165.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,2331,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,1142.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,2460.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,2455.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,2331,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +1750,2780003409,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,2044.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,130.264,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,130.264,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,130.264,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,108.552,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,504,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,1210.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,2421,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,1186.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,2555.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,396,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,2421,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +1800,2780003410,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,2120.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,130.264,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,130.264,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,130.264,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,108.552,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,540,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,1255.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,2511,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,1230.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,2650.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,413.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,2511,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +1850,2780003411,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1968.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,130.264,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,130.264,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,130.264,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,108.552,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,1665,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,202.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,2331,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,198.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,2460.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,422.4,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,2331,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +1900,2780003412,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,2044.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,2981.432,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,2981.432,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,2981.432,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,2484.528,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,1728,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,211.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,2421,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,207.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,2555.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,448.8,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,2421,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +1950,2780003413,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,2120.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,3556.8,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,3556.8,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,3556.8,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,2964,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,1791,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,2511,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,211.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,2650.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,466.4,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,2511,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +2000,2780003414,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,342,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,21.24,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,21.24,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,21.24,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,17.704,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,2070,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,229.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,405,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,224.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,427.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,492.8,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,405,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +2050,2780003415,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,357.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,1355.04,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,1355.04,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,1355.04,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,1129.2,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,2160,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,238.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,423,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,233.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,446.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,528,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,423,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +2100,2780003416,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,364.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,560.16,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,560.16,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,560.16,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,466.8,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,2250,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,252,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,432,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,246.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,456,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,1628,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,432,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +2150,2780003417,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,387.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,473.76,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,473.76,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,473.76,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,394.8,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,2340,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,270,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,459,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,264.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,484.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,1689.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,459,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +2200,2780003418,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,402.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,2767.248,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,2767.248,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,2767.248,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,2306.04,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,2070,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,832.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,477,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,815.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,503.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,1751.2,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,477,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +2250,2780003419,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,425.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,283.536,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,283.536,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,283.536,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,236.28,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,2160,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,864,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,504,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,846.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,532,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,2024,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,504,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +2300,2780003420,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,199.584,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,199.584,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,199.584,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,166.32,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,2250,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,895.504,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,540,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,877.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,570,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,2112,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,540,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +2350,2780003421,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1406,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,199.584,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,199.584,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,199.584,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,166.32,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,2340,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,1035,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,1665,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,1014.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,1757.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,2200,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,1665,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +2400,2780003422,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1459.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,199.584,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,199.584,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,199.584,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,166.32,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,1530,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,1080,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,1728,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,1058.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,1824,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,2288,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,1728,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +2450,2780003423,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1512.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,217.44,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,217.44,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,217.44,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,181.2,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,1620,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,1125,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,1791,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,1102.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,1890.504,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,2024,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,1791,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +2500,2780003424,CDM,276,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1748,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,217.44,Percent of Total Billed Charges,72% of Total Billed Charges,281.25,75,,217.44,Percent of Total Billed charges,75% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,217.44,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,181.2,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,1710,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,1170,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,2070,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,1146.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,2185,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,2112,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,2070,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +2550,2780003425,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,217.44,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,217.44,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,217.44,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,181.2,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,1890,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,1035,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,2160,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,1014.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,2280,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,2200,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,2160,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +2600,2780003426,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1900,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,161.28,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,161.28,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,161.28,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,134.4,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,1080,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,2250,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,1058.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,2375,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,2288,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,2250,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +2650,2780003427,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,161.28,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,161.28,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,161.28,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,134.4,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,1125,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,2340,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,1102.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,2470,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,1496,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,2340,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +2700,2780003428,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1748,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,161.28,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,161.28,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,161.28,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,134.4,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,1170,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,2070,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,1146.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,2185,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,1584,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,2070,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +2750,2780003429,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,1717.056,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,1717.056,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,1717.056,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,1430.88,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,765,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,2160,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,749.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,2280,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,1672,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,2160,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +2800,2780003430,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1900,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,118.624,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,118.624,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,118.624,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,98.856,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,810,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,2250,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,793.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,2375,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,1848,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,2250,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +2850,2780003431,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,118.624,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,118.624,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,118.624,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,98.856,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,855,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,2340,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,182,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,837.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,2470,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,2340,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +2900,2780003432,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1292,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,811.696,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,811.696,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,811.696,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,676.416,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,945,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,1530,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,182,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,926.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,1615,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,1530,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +2950,2780003433,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,1942.2,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,1942.2,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,1942.2,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,1618.504,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,1620,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,182,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,1710,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,1620,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +3000,2780003434,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1444,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,429.264,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,429.264,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,429.264,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,357.72,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,1710,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,182,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,1805,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,1710,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +3100,2780003435,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,1596,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,632.192,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,632.192,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,632.192,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,526.824,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,1890,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,182,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,1995,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,1890,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +3200,2780003436,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,2981.432,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,2981.432,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,2981.432,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,2484.528,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,182,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +3300,2780003437,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,54.632,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,54.632,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,54.632,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,45.528,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,182,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +3400,2780003438,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,1092.672,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,1092.672,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,1092.672,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,910.56,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,182,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +1150,2780003439,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,148.288,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,148.288,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,148.288,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,123.576,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,182,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
B&L ASPIRE EA U +1300,2780003440,CDM,278,RC,,,Outpatient,,,375.00,243.75,,375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270,72,,443.52,Percent of Total Billed Charges,72% of Total Billed Charges,270,72,,443.52,Percent of Total Billed charges,72% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,72,,443.52,Percent of Total Billed Charges,72% of Total Billed Charges,225,60,,369.6,Percent of Total Billed Charges,60% of Total Billed Charges,337.5,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,168.75,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,337.5,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.75,65,,182,Percent of total Billed Charges,65% of Total Billed Charges,165.38,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,356.25,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,337.5,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,165.38,375,
TUTOPLAST 1.5 X 1.5,2780003441,CDM,278,RC,,,Outpatient,,,797.50,518.38,,797.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,606.1,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,574.2,72,,443.52,Percent of Total Billed Charges,72% of Total Billed Charges,574.2,72,,443.52,Percent of Total Billed charges,72% of Total Billed Charges,797.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,574.2,72,,443.52,Percent of Total Billed Charges,72% of Total Billed Charges,478.5,60,,369.6,Percent of Total Billed Charges,60% of Total Billed Charges,717.75,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,358.88,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,717.75,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,797.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,797.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,797.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,518.38,65,,182,Percent of total Billed Charges,65% of Total Billed Charges,351.7,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,757.63,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,797.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,701.8,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,717.75,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,351.7,797.5,
GONIOPRISMS(IPRISMS SGL5),2780003442,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,443.52,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,443.52,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,443.52,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,369.6,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,182,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
ISTENT INFINITES IS3,2780003443,CDM,278,RC,,,Outpatient,,,7250.00,4712.50,,7250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5510,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5220,72,,443.52,Percent of Total Billed Charges,72% of Total Billed Charges,5220,72,,443.52,Percent of Total Billed charges,72% of Total Billed Charges,7250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5220,72,,443.52,Percent of Total Billed Charges,72% of Total Billed Charges,4350,60,,369.6,Percent of Total Billed Charges,60% of Total Billed Charges,6525,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,3262.5,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,6525,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,7250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4712.5,65,,182,Percent of total Billed Charges,65% of Total Billed Charges,3197.25,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,6887.5,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,7250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6380,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,6525,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,3197.25,7250,
ARTHREX PROSTOP SUB ARTHROERES,2780003444,CDM,278,RC,,,Outpatient,,,4051.45,2633.44,,4051.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3079.1,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2917.04,72,,443.52,Percent of Total Billed Charges,72% of Total Billed Charges,2917.04,72,,443.52,Percent of Total Billed charges,72% of Total Billed Charges,4051.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2917.04,72,,443.52,Percent of Total Billed Charges,72% of Total Billed Charges,2430.87,60,,369.6,Percent of Total Billed Charges,60% of Total Billed Charges,3646.31,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,1823.15,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,3646.31,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,4051.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4051.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4051.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2633.44,65,,182,Percent of total Billed Charges,65% of Total Billed Charges,1786.69,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,3848.88,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,4051.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3565.28,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,3646.31,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,1786.69,4051.45,
SURGIMESH TINTRA R-1415,2780003445,CDM,278,RC,,,Outpatient,,,4875.00,3168.75,,4875,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3705,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3510,72,,443.52,Percent of Total Billed Charges,72% of Total Billed Charges,3510,72,,443.52,Percent of Total Billed charges,72% of Total Billed Charges,4875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3510,72,,443.52,Percent of Total Billed Charges,72% of Total Billed Charges,2925,60,,369.6,Percent of Total Billed Charges,60% of Total Billed Charges,4387.5,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,2193.75,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,4387.5,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,4875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3168.75,65,,1033.504,Percent of total Billed Charges,65% of Total Billed Charges,2149.88,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,4631.25,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,4875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4290,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,4387.5,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,2149.88,4875,
Z4927-03-04 T-PLATE 2.7,2780003446,CDM,278,RC,,,Outpatient,,,185.50,120.58,,185.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,140.98,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,133.56,72,,4298.4,Percent of Total Billed Charges,72% of Total Billed Charges,133.56,72,,4298.4,Percent of Total Billed charges,72% of Total Billed Charges,185.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.56,72,,4298.4,Percent of Total Billed Charges,72% of Total Billed Charges,111.3,60,,3582,Percent of Total Billed Charges,60% of Total Billed Charges,166.95,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,83.48,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,166.95,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,185.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.58,65,,1033.504,Percent of total Billed Charges,65% of Total Billed Charges,81.81,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,176.23,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,185.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.24,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,166.95,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,81.81,185.5,
"ARTHRX 3.5 LCK COMP PLT,TI,5H",2780003447,CDM,278,RC,,,Outpatient,,,3737.50,2429.38,,3737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2840.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2691,72,,473.76,Percent of Total Billed Charges,72% of Total Billed Charges,2691,72,,473.76,Percent of Total Billed charges,72% of Total Billed Charges,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2691,72,,473.76,Percent of Total Billed Charges,72% of Total Billed Charges,2242.5,60,,394.8,Percent of Total Billed Charges,60% of Total Billed Charges,3363.75,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,1681.88,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,3363.75,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2429.38,65,,1033.504,Percent of total Billed Charges,65% of Total Billed Charges,1648.24,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,3550.63,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3289,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,3363.75,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,1648.24,3737.5,
"ARTHRX 3.5 LCK COMP PLT,TI,6H",2780003448,CDM,278,RC,,,Outpatient,,,3737.50,2429.38,,3737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2840.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2691,72,,1355.04,Percent of Total Billed Charges,72% of Total Billed Charges,2691,72,,1355.04,Percent of Total Billed charges,72% of Total Billed Charges,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2691,72,,1355.04,Percent of Total Billed Charges,72% of Total Billed Charges,2242.5,60,,1129.2,Percent of Total Billed Charges,60% of Total Billed Charges,3363.75,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,1681.88,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,3363.75,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2429.38,65,,380.904,Percent of total Billed Charges,65% of Total Billed Charges,1648.24,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,3550.63,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3289,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,3363.75,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,1648.24,3737.5,
"ARTHRX 3.5 LCK COMP PLT,TI,7H",2780003449,CDM,278,RC,,,Outpatient,,,3737.50,2429.38,,3737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2840.5,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2691,72,,81.792,Percent of Total Billed Charges,72% of Total Billed Charges,2691,72,,85.2,Percent of Total Billed charges,72% of Total Billed Charges,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2691,72,,81.792,Percent of Total Billed Charges,72% of Total Billed Charges,2242.5,60,,68.16,Percent of Total Billed Charges,60% of Total Billed Charges,3363.75,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,1681.88,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,3363.75,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2429.38,65,,380.904,Percent of total Billed Charges,65% of Total Billed Charges,1648.24,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,3550.63,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3289,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,3363.75,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,1648.24,3737.5,
"ARTHRX 3.5 LCK COMP PLT,TI,8H",2780003450,CDM,278,RC,,,Outpatient,,,3737.50,2429.38,,3737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2840.5,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2691,72,,374.976,Percent of Total Billed Charges,72% of Total Billed Charges,2691,72,,390.6,Percent of Total Billed charges,72% of Total Billed Charges,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2691,72,,374.976,Percent of Total Billed Charges,72% of Total Billed Charges,2242.5,60,,312.48,Percent of Total Billed Charges,60% of Total Billed Charges,3363.75,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,1681.88,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,3363.75,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2429.38,65,,380.904,Percent of total Billed Charges,65% of Total Billed Charges,1648.24,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,3550.63,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3289,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,3363.75,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,1648.24,3737.5,
"ARTHRX 3.5 LCK COMP PLT,TI,9H",2780003451,CDM,278,RC,,,Outpatient,,,3737.50,2429.38,,3737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2840.5,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2691,72,,77.76,Percent of Total Billed Charges,72% of Total Billed Charges,2691,72,,81,Percent of Total Billed charges,72% of Total Billed Charges,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2691,72,,77.76,Percent of Total Billed Charges,72% of Total Billed Charges,2242.5,60,,64.8,Percent of Total Billed Charges,60% of Total Billed Charges,3363.75,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,1681.88,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,3363.75,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2429.38,65,,1089.4,Percent of total Billed Charges,65% of Total Billed Charges,1648.24,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,3550.63,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,3737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3289,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,3363.75,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,1648.24,3737.5,
"ARTHRX 3.5 LCK COMP PLT,TI,10H",2780003452,CDM,278,RC,,,Outpatient,,,3987.50,2591.88,,3987.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3030.5,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2871,72,,77.76,Percent of Total Billed Charges,72% of Total Billed Charges,2871,72,,81,Percent of Total Billed charges,72% of Total Billed Charges,3987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2871,72,,77.76,Percent of Total Billed Charges,72% of Total Billed Charges,2392.5,60,,64.8,Percent of Total Billed Charges,60% of Total Billed Charges,3588.75,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,1794.38,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,3588.75,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,3987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2591.88,65,,4583.8,Percent of total Billed Charges,65% of Total Billed Charges,1758.49,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,3788.13,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,3987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3509,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,3588.75,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,1758.49,3987.5,
"ARTHRX 3.5 LCK COMP PLT,TI,12H",2780003453,CDM,278,RC,,,Outpatient,,,4237.50,2754.38,,4237.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3220.5,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3051,72,,81.792,Percent of Total Billed Charges,72% of Total Billed Charges,3051,72,,85.2,Percent of Total Billed charges,72% of Total Billed Charges,4237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3051,72,,81.792,Percent of Total Billed Charges,72% of Total Billed Charges,2542.5,60,,68.16,Percent of Total Billed Charges,60% of Total Billed Charges,3813.75,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,1906.88,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,3813.75,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,4237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2754.38,65,,1042.664,Percent of total Billed Charges,65% of Total Billed Charges,1868.74,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,4025.63,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,4237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3729,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,3813.75,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,1868.74,4237.5,
"ARTHRX 3.5 LCK COMP PLT,TI,14H",2780003454,CDM,278,RC,,,Outpatient,,,4487.50,2916.88,,4487.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3410.5,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3231,72,,255.744,Percent of Total Billed Charges,72% of Total Billed Charges,3231,72,,266.4,Percent of Total Billed charges,72% of Total Billed Charges,4487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3231,72,,255.744,Percent of Total Billed Charges,72% of Total Billed Charges,2692.5,60,,213.12,Percent of Total Billed Charges,60% of Total Billed Charges,4038.75,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,2019.38,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,4038.75,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,4487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2916.88,65,,811.744,Percent of total Billed Charges,65% of Total Billed Charges,1978.99,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,4263.13,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,4487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3949,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,4038.75,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,1978.99,4487.5,
"ARTHRX QCKFIX SCW,CANN,ST 4X30",2780003455,CDM,278,RC,,,Outpatient,,,412.50,268.13,,412.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,313.5,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297,72,,81.792,Percent of Total Billed Charges,72% of Total Billed Charges,297,72,,85.2,Percent of Total Billed charges,72% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,72,,81.792,Percent of Total Billed Charges,72% of Total Billed Charges,247.5,60,,68.16,Percent of Total Billed Charges,60% of Total Billed Charges,371.25,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,185.63,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,371.25,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.13,65,,677.392,Percent of total Billed Charges,65% of Total Billed Charges,181.91,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,391.88,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,371.25,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,181.91,412.5,
"ARTHRX QCKFIX SCW,CANN,ST 4X32",2780003456,CDM,278,RC,,,Outpatient,,,412.50,268.13,,412.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,313.5,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297,72,,518.4,Percent of Total Billed Charges,72% of Total Billed Charges,297,72,,540,Percent of Total Billed charges,72% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,72,,518.4,Percent of Total Billed Charges,72% of Total Billed Charges,247.5,60,,432,Percent of Total Billed Charges,60% of Total Billed Charges,371.25,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,185.63,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,371.25,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.13,65,,8518.904,Percent of total Billed Charges,65% of Total Billed Charges,181.91,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,391.88,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,371.25,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,181.91,412.5,
"ARTHRX QCKFIX SCW,CANN,ST 4X34",2780003457,CDM,278,RC,,,Outpatient,,,412.50,268.13,,412.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,313.5,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297,72,,90.272,Percent of Total Billed Charges,72% of Total Billed Charges,297,72,,94.032,Percent of Total Billed charges,72% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,72,,90.272,Percent of Total Billed Charges,72% of Total Billed Charges,247.5,60,,75.224,Percent of Total Billed Charges,60% of Total Billed Charges,371.25,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,185.63,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,371.25,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.13,65,,8271.904,Percent of total Billed Charges,65% of Total Billed Charges,181.91,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,391.88,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,371.25,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,181.91,412.5,
"ARTHRX QCKFIX SCW,CANN,ST 4X34",2780003458,CDM,278,RC,,,Outpatient,,,412.50,268.13,,412.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,313.5,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297,72,,44.928,Percent of Total Billed Charges,72% of Total Billed Charges,297,72,,46.8,Percent of Total Billed charges,72% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,72,,44.928,Percent of Total Billed Charges,72% of Total Billed Charges,247.5,60,,37.44,Percent of Total Billed Charges,60% of Total Billed Charges,371.25,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,185.63,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,371.25,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.13,65,,383.504,Percent of total Billed Charges,65% of Total Billed Charges,181.91,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,391.88,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363,88,,246.4,Percent of Total Billed Charges,88% of Total Billed Charges,371.25,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,181.91,412.5,
"ARTHRX QCKFIX SCW,CANN,ST 4X38",2780003459,CDM,278,RC,,,Outpatient,,,412.50,268.13,,412.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,313.5,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297,72,,20.16,Percent of Total Billed Charges,72% of Total Billed Charges,297,72,,21,Percent of Total Billed charges,72% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,72,,20.16,Percent of Total Billed Charges,72% of Total Billed Charges,247.5,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,371.25,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,185.63,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,371.25,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.13,65,,1089.4,Percent of total Billed Charges,65% of Total Billed Charges,181.91,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,391.88,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363,88,,246.4,Percent of Total Billed Charges,88% of Total Billed Charges,371.25,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,181.91,412.5,
"ARTHRX QCKFIX SCW,CANN,ST 4X42",2780003460,CDM,278,RC,,,Outpatient,,,412.50,268.13,,412.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,313.5,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297,72,,164.16,Percent of Total Billed Charges,72% of Total Billed Charges,297,72,,171,Percent of Total Billed charges,72% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,72,,164.16,Percent of Total Billed Charges,72% of Total Billed Charges,247.5,60,,136.8,Percent of Total Billed Charges,60% of Total Billed Charges,371.25,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,185.63,45,,126,Percent of Total Billed Charges,45% of Total Billed Charges,371.25,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.13,65,,4583.8,Percent of total Billed Charges,65% of Total Billed Charges,181.91,44.1,,123.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,391.88,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363,88,,246.4,Percent of Total Billed Charges,88% of Total Billed Charges,371.25,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,181.91,412.5,
"ARTHRX QCKFIX SCW,CANN,ST 4X44",2780003461,CDM,278,RC,,,Outpatient,,,412.50,268.13,,412.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,313.5,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,297,72,,480,Percent of Total Billed charges,72% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,247.5,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,371.25,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,185.63,45,,126,Percent of Total Billed Charges,45% of Total Billed Charges,371.25,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.13,65,,692.472,Percent of total Billed Charges,65% of Total Billed Charges,181.91,44.1,,123.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,391.88,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363,88,,246.4,Percent of Total Billed Charges,88% of Total Billed Charges,371.25,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,181.91,412.5,
"ARTHRX QCKFIX SCW,CANN,ST 4X48",2780003462,CDM,278,RC,,,Outpatient,,,412.50,268.13,,412.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,313.5,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297,72,,140.984,Percent of Total Billed Charges,72% of Total Billed Charges,297,72,,146.856,Percent of Total Billed charges,72% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,72,,140.984,Percent of Total Billed Charges,72% of Total Billed Charges,247.5,60,,117.488,Percent of Total Billed Charges,60% of Total Billed Charges,371.25,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,185.63,45,,126,Percent of Total Billed Charges,45% of Total Billed Charges,371.25,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.13,65,,949.68,Percent of total Billed Charges,65% of Total Billed Charges,181.91,44.1,,123.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,391.88,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363,88,,246.4,Percent of Total Billed Charges,88% of Total Billed Charges,371.25,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,181.91,412.5,
"ARTHRX QCKFIX SCW,CANN,ST 4X52",2780003463,CDM,278,RC,,,Outpatient,,,412.50,268.13,,412.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,313.5,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297,72,,186.064,Percent of Total Billed Charges,72% of Total Billed Charges,297,72,,193.816,Percent of Total Billed charges,72% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,72,,186.064,Percent of Total Billed Charges,72% of Total Billed Charges,247.5,60,,155.056,Percent of Total Billed Charges,60% of Total Billed Charges,371.25,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,185.63,45,,126,Percent of Total Billed Charges,45% of Total Billed Charges,371.25,90,,252,Percent of Total Billed Charges,90% of Total billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.13,65,,863.328,Percent of total Billed Charges,65% of Total Billed Charges,181.91,44.1,,123.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,391.88,95,,266,Percent of Total Billed Charges,95% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363,88,,246.4,Percent of Total Billed Charges,88% of Total Billed Charges,371.25,90,,252,Percent of Total Billed charges,90% of Total Billed Charges,181.91,412.5,
"ARTHRX QCKFIX SCW,CANN,ST 4X54",2780003464,CDM,278,RC,,,Outpatient,,,412.50,268.13,,412.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,313.5,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297,72,,139.96,Percent of Total Billed Charges,72% of Total Billed Charges,297,72,,145.792,Percent of Total Billed charges,72% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,72,,139.96,Percent of Total Billed Charges,72% of Total Billed Charges,247.5,60,,116.632,Percent of Total Billed Charges,60% of Total Billed Charges,371.25,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,185.63,45,,126,Percent of Total Billed Charges,45% of Total Billed Charges,371.25,90,,252,Percent of Total Billed Charges,90% of Total billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.13,65,,1384.92,Percent of total Billed Charges,65% of Total Billed Charges,181.91,44.1,,123.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,391.88,95,,266,Percent of Total Billed Charges,95% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363,88,,246.4,Percent of Total Billed Charges,88% of Total Billed Charges,371.25,90,,252,Percent of Total Billed charges,90% of Total Billed Charges,181.91,412.5,
"ARTHRX QCKFIX SCW,CANN,ST 4X54",2780003465,CDM,278,RC,,,Outpatient,,,412.50,268.13,,412.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,313.5,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297,72,,63.936,Percent of Total Billed Charges,72% of Total Billed Charges,297,72,,66.6,Percent of Total Billed charges,72% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,72,,63.936,Percent of Total Billed Charges,72% of Total Billed Charges,247.5,60,,53.28,Percent of Total Billed Charges,60% of Total Billed Charges,371.25,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,185.63,45,,126,Percent of Total Billed Charges,45% of Total Billed Charges,371.25,90,,252,Percent of Total Billed Charges,90% of Total billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.13,65,,427.704,Percent of total Billed Charges,65% of Total Billed Charges,181.91,44.1,,123.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,391.88,95,,266,Percent of Total Billed Charges,95% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363,88,,246.4,Percent of Total Billed Charges,88% of Total Billed Charges,371.25,90,,252,Percent of Total Billed charges,90% of Total Billed Charges,181.91,412.5,
"ARTHRX QCKFIX SCW,CANN,ST 4X58",2780003466,CDM,278,RC,,,Outpatient,,,412.50,268.13,,412.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,313.5,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297,72,,88.128,Percent of Total Billed Charges,72% of Total Billed Charges,297,72,,91.8,Percent of Total Billed charges,72% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,72,,88.128,Percent of Total Billed Charges,72% of Total Billed Charges,247.5,60,,73.44,Percent of Total Billed Charges,60% of Total Billed Charges,371.25,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,185.63,45,,126,Percent of Total Billed Charges,45% of Total Billed Charges,371.25,90,,252,Percent of Total Billed Charges,90% of Total billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.13,65,,427.704,Percent of total Billed Charges,65% of Total Billed Charges,181.91,44.1,,123.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,391.88,95,,266,Percent of Total Billed Charges,95% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363,88,,246.4,Percent of Total Billed Charges,88% of Total Billed Charges,371.25,90,,252,Percent of Total Billed charges,90% of Total Billed Charges,181.91,412.5,
"ARTHRX QCKFIX SCW,CANN,ST 4X60",2780003467,CDM,278,RC,,,Outpatient,,,412.50,268.13,,412.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,313.5,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297,72,,194.328,Percent of Total Billed Charges,72% of Total Billed Charges,297,72,,202.424,Percent of Total Billed charges,72% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,72,,194.328,Percent of Total Billed Charges,72% of Total Billed Charges,247.5,60,,161.936,Percent of Total Billed Charges,60% of Total Billed Charges,371.25,90,,1431,Percent of Total Billed Charges,90% of Total Billed Charges,185.63,45,,126,Percent of Total Billed Charges,45% of Total Billed Charges,371.25,90,,252,Percent of Total Billed Charges,90% of Total billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.13,65,,427.704,Percent of total Billed Charges,65% of Total Billed Charges,181.91,44.1,,123.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,391.88,95,,266,Percent of Total Billed Charges,95% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363,88,,246.4,Percent of Total Billed Charges,88% of Total Billed Charges,371.25,90,,252,Percent of Total Billed charges,90% of Total Billed Charges,181.91,412.5,
"ARTHRX QCKFIX SCW,CANN,ST 4X65",2780003468,CDM,278,RC,,,Outpatient,,,412.50,268.13,,412.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,313.5,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,297,72,,69.456,Percent of Total Billed charges,72% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,247.5,60,,55.568,Percent of Total Billed Charges,60% of Total Billed Charges,371.25,90,,1431,Percent of Total Billed Charges,90% of Total Billed Charges,185.63,45,,126,Percent of Total Billed Charges,45% of Total Billed Charges,371.25,90,,252,Percent of Total Billed Charges,90% of Total billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.13,65,,1223.304,Percent of total Billed Charges,65% of Total Billed Charges,181.91,44.1,,123.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,391.88,95,,266,Percent of Total Billed Charges,95% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363,88,,246.4,Percent of Total Billed Charges,88% of Total Billed Charges,371.25,90,,252,Percent of Total Billed charges,90% of Total Billed Charges,181.91,412.5,
"ARTHRX QCKFIX SCW,CANN,ST 4X70",2780003469,CDM,278,RC,,,Outpatient,,,412.50,268.13,,412.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,313.5,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297,72,,294.336,Percent of Total Billed Charges,72% of Total Billed Charges,297,72,,306.6,Percent of Total Billed charges,72% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,72,,294.336,Percent of Total Billed Charges,72% of Total Billed Charges,247.5,60,,245.28,Percent of Total Billed Charges,60% of Total Billed Charges,371.25,90,,1431,Percent of Total Billed Charges,90% of Total Billed Charges,185.63,45,,126,Percent of Total Billed Charges,45% of Total Billed Charges,371.25,90,,252,Percent of Total Billed Charges,90% of Total billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.13,65,,5323.504,Percent of total Billed Charges,65% of Total Billed Charges,181.91,44.1,,123.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,391.88,95,,266,Percent of Total Billed Charges,95% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363,88,,246.4,Percent of Total Billed Charges,88% of Total Billed Charges,371.25,90,,252,Percent of Total Billed charges,90% of Total Billed Charges,181.91,412.5,
"ARTHRX QCKFIX SCW,CANN,ST 4X75",2780003470,CDM,278,RC,,,Outpatient,,,412.50,268.13,,412.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,313.5,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297,72,,26.496,Percent of Total Billed Charges,72% of Total Billed Charges,297,72,,27.6,Percent of Total Billed charges,72% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,72,,26.496,Percent of Total Billed Charges,72% of Total Billed Charges,247.5,60,,22.08,Percent of Total Billed Charges,60% of Total Billed Charges,371.25,90,,527.4,Percent of Total Billed Charges,90% of Total Billed Charges,185.63,45,,126,Percent of Total Billed Charges,45% of Total Billed Charges,371.25,90,,252,Percent of Total Billed Charges,90% of Total billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.13,65,,133.872,Percent of total Billed Charges,65% of Total Billed Charges,181.91,44.1,,123.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,391.88,95,,266,Percent of Total Billed Charges,95% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363,88,,246.4,Percent of Total Billed Charges,88% of Total Billed Charges,371.25,90,,252,Percent of Total Billed charges,90% of Total Billed Charges,181.91,412.5,
"ARTHRX QCKFIX SCW,CANN,ST 4X80",2780003471,CDM,278,RC,,,Outpatient,,,412.50,268.13,,412.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,313.5,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297,72,,132.088,Percent of Total Billed Charges,72% of Total Billed Charges,297,72,,137.592,Percent of Total Billed charges,72% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,72,,132.088,Percent of Total Billed Charges,72% of Total Billed Charges,247.5,60,,110.072,Percent of Total Billed Charges,60% of Total Billed Charges,371.25,90,,527.4,Percent of Total Billed Charges,90% of Total Billed Charges,185.63,45,,126,Percent of Total Billed Charges,45% of Total Billed Charges,371.25,90,,252,Percent of Total Billed Charges,90% of Total billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.13,65,,133.872,Percent of total Billed Charges,65% of Total Billed Charges,181.91,44.1,,123.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,391.88,95,,266,Percent of Total Billed Charges,95% of Total Billed Charges,412.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363,88,,246.4,Percent of Total Billed Charges,88% of Total Billed Charges,371.25,90,,252,Percent of Total Billed charges,90% of Total Billed Charges,181.91,412.5,
"ARTHREX LO-PRO SCW, 3X10 CORT",2780003472,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,15.88,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,12.704,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,527.4,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,126,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,252,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,563.68,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,123.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,266,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,1399.2,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,252,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
"ARTHREX LO-PRO SCW,3X16, CORT",2780003473,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,69.456,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,55.568,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,1508.4,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,126,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,252,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,2395.64,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,123.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,266,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,1399.2,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,252,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
"ARTHREX LO-PRO SCW 3X18,CORT",2780003474,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,64.136,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,66.808,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,64.136,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,53.448,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,6346.8,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,715.504,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,252,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,5629.752,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,701.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,266,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,1399.2,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,252,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
"ARTHREX LO-PRO SCW 3X20,CORT",2780003475,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,332.76,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,346.624,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,332.76,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,277.304,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,1443.696,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,715.504,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,252,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,2754.984,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,701.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,266,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,515.68,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,252,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
"ARTHREX LO-PRO SCW,3X22,CORT",2780003476,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,94.616,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,98.56,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,94.616,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,78.848,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,1123.96,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,715.504,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,252,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,1021.672,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,701.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,266,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,515.68,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,252,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
"ARTHREX LO-PRO SCW,3X24,CORT",2780003477,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,1208.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,181.44,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,189,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,181.44,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,151.2,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,937.928,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,263.704,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,1431,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,775.064,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,258.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,1510.504,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,515.68,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,1431,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
"ARTHREX LO-PRO SCW,3X26 CORT",2780003478,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,1208.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,22.464,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,23.4,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,22.464,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,18.72,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,11795.4,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,263.704,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,1431,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,775.064,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,258.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,1510.504,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,1474.88,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,1431,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
"ARTHREX LO-PRO 3X28 CORT, TI",2780003479,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,1208.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,94.6,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,98.536,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,94.6,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,78.832,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,11453.4,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,263.704,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,1431,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,775.064,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,258.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,1510.504,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,6205.76,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,1431,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
"ARTHREX LO-PRO 3X30,CORT,TI",2780003480,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,445.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,378.48,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,394.256,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,378.48,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,315.4,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,754.2,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,527.4,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,775.064,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,739.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,556.704,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,1411.608,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,527.4,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
"ARTHREX LO-PRO SCW 3X32,CORT",2780003481,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,445.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,15.88,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,15.24,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,12.704,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,1508.4,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,3173.4,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,527.4,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,2498.208,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,3109.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,556.704,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,1098.976,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,527.4,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
"ARTHREX LO-PRO SCW 3X34,CORT",2780003482,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,445.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,98.496,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,102.6,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,98.496,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,82.08,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,6346.8,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,721.848,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,527.4,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,255.968,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,707.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,556.704,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,917.088,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,527.4,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
ARTHREX LO-PRO SCW 3X36 CORT,2780003483,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,1273.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,274.336,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,285.768,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,274.336,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,228.616,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,958.808,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,561.976,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,1508.4,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,255.968,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,550.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,1592.2,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,11533.28,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,1508.4,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
"ARTHREX LO-PRO SCW 3X38,CORT",2780003484,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,5359.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,130.184,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,135.608,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,130.184,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,108.488,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,1314.936,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,468.968,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,6346.8,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,180.184,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,459.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,6699.4,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,11198.88,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,6346.8,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
"ARTHREX LO-PRO SCW 3X40,CORT",2780003485,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,1219.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,181.624,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,189.192,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,181.624,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,151.352,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,1195.384,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,5897.704,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,1443.696,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,180.184,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,5779.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,1523.896,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,519.2,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,1443.696,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
"ARTHREX LO-PRO SCW 3X42,CORT",2780003486,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,949.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,261,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,271.88,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,261,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,217.504,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,1917.576,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,5726.704,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,1123.96,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,354.904,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,5612.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,1186.4,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,1474.88,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,1123.96,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
"ARTHREX LO-PRO SCW 3X44,CORT",2780003487,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,792.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,21.832,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,20.952,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,17.464,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,592.2,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,265.504,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,937.928,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,400.4,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,260.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,990.04,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,6205.76,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,937.928,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
"ARTHREX LO-PRO SCW 3X46,CORT",2780003488,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,9960.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,19.848,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,15.88,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,592.2,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,754.2,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,11795.4,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,400.4,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,739.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,12450.704,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,937.504,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,11795.4,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
"ARTHREX LO-PRO SCW 3X48,CORT",2780003489,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,9671.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,33.984,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,35.4,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,33.984,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,28.32,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,592.2,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,3173.4,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,11453.4,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,497.64,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,3109.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,12089.704,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,1285.712,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,11453.4,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
"ARTHREX LO-PRO SCW 3X50, CORT",2780003490,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,448.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,33.984,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,35.4,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,33.984,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,28.32,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,1693.8,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,479.408,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,531,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,54.6,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,469.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,560.504,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,1168.816,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,531,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
"ARTHREX LO-PRO SCW 3X55,CORT",2780003491,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,1273.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,588.048,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,612.552,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,588.048,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,490.04,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,7371,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,657.472,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,1508.4,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,577.2,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,644.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,1592.2,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,1874.96,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,1508.4,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
"ARTHREX LO-PRO SCW 3X60,CORT",2780003492,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,5359.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,588.048,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,612.552,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,588.048,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,490.04,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,185.368,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,597.688,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,6346.8,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,74.104,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,585.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,6699.4,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,579.04,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,6346.8,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
ARTHREX VAL KRLCK SCW 3X10,2780003493,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,809.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,92.752,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,96.616,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,92.752,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,77.296,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,185.368,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,958.792,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,958.808,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,307.424,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,939.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,1012.08,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,579.04,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,958.808,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
ARTHREX VAL KRLCK SCW 3X16,2780003494,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,1110.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,33.984,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,35.4,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,33.984,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,28.32,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,780.48,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,296.104,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,1314.936,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,117.6,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,290.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,1387.992,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,579.04,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,1314.936,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
"ARTHREX VAL KRLCK SCW 3X18,TI",2780003495,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,1009.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,32.256,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,33.6,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,32.256,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,26.88,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,3317.04,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,296.104,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,1195.384,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,117.6,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,290.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,1261.792,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,1656.16,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,1195.384,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
"ARTHREX VAL KRLCK SCW 3X20,TI",2780003496,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,1619.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,5.76,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,6,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,5.76,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,7795.048,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,296.104,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,1917.576,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,117.6,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,290.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,2024.112,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,7207.2,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,1917.576,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
"ARTHREX VAL KRLCK SCW 3X22,TI",2780003497,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,500.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,449.28,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,468,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,449.28,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,374.4,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,3814.6,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,846.904,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,592.2,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,2691.576,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,829.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,625.104,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,181.248,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,592.2,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
"ARTHREX VAL KRLCK SCW 3X24,TI",2780003498,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,500.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,195.264,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,203.4,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,195.264,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,162.72,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,1414.624,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,3685.504,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,592.2,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,3211,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,3611.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,625.104,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,181.248,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,592.2,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
"ARTHREX VAL KRLCK SCW 3X26,TI",2780003499,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,500.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,42.624,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,44.4,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,42.624,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,35.52,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,1073.16,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,92.68,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,592.2,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,19.176,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,90.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,625.104,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,763.136,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,592.2,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
"ARTHREX VAL KRLCK SCW 3X28,TI",2780003500,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,1430.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,51.6,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,41.28,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,1073.16,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,92.68,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,1693.8,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,1223.304,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,90.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,1787.904,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,3243.328,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,1693.8,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
"ARTHREX VAL KRLCK SCW 3X30, TI",2780003501,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,6224.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,98.496,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,102.6,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,98.496,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,82.08,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,1073.16,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,390.24,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,7371,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,505.704,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,382.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,7780.504,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,7621.824,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,7371,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
"ARTHREX LO-PRO SCW 3.5X10,TI",2780003502,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,156.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,115.776,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,120.6,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,115.776,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,96.48,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,1073.16,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,1658.52,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,185.368,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,427.704,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,1625.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,195.664,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,3729.824,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,185.368,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X100,TI",2780003503,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,156.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,172.8,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,180,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,172.8,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,3459.064,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,3897.52,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,185.368,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,2498.208,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,3819.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,195.664,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,1383.184,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,185.368,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X105,TI",2780003504,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,659.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,151.488,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,157.8,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,151.488,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,126.24,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,354.424,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,1907.296,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,780.48,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,255.968,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,1869.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,823.84,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,1049.312,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,780.48,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X110,TI",2780003505,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,2801.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,150.912,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,157.2,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,150.912,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,125.76,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,354.424,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,707.312,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,3317.04,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,180.184,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,693.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,3501.32,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,1049.312,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,3317.04,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X16,TI",2780003506,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,6582.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,450.432,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,469.2,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,450.432,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,375.36,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,249.48,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,536.584,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,7795.048,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,180.184,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,525.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,8228.104,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,1049.312,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,7795.048,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X18,TI",2780003507,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,3221.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,235.008,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,244.8,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,235.008,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,195.84,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,249.48,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,536.584,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,3814.6,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,180.184,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,525.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,4026.52,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,1049.312,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,3814.6,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X22,TI",2780003508,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,1194.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,96.192,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,100.2,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,96.192,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,80.16,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,491.4,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,536.584,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,1414.624,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,196.304,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,525.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,1493.208,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,3382.192,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,1414.624,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X26,TI",2780003509,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,906.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,266.08,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,277.168,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,266.08,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,221.736,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,554.4,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,536.584,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,1073.16,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,196.304,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,525.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,1132.784,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,346.544,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,1073.16,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X28,TI",2780003510,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,906.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,56.448,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,58.8,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,56.448,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,47.04,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,554.4,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,1729.528,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,1073.16,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,196.304,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,1694.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,1132.784,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,346.544,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,1073.16,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X30,TI",2780003511,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,906.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,76.032,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,79.2,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,76.032,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,63.36,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,689.04,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,177.208,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,1073.16,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,145.6,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,173.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,1132.784,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,243.936,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,1073.16,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X32,TI",2780003512,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,906.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,287.568,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,299.552,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,287.568,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,239.64,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,75.6,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,177.208,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,1073.16,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,145.6,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,173.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,1132.784,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,243.936,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,1073.16,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X34,TI",2780003513,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,2920.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,61.056,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,63.6,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,61.056,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,50.88,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,799.2,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,124.744,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,3459.064,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,145.6,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,122.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,3651.232,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,480.48,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,3459.064,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X36,TI",2780003514,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,299.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,69.12,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,72,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,69.12,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,57.6,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,102.6,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,124.744,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,354.424,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,1550.12,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,122.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,374.112,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,542.08,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,354.424,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X38,TI",2780003515,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,299.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,59.4,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,47.52,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,425.664,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,245.704,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,354.424,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,107.096,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,240.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,374.112,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,542.08,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,354.424,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X40,TI",2780003516,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,210.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,62.784,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,65.4,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,62.784,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,52.32,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,162.832,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,277.2,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,249.48,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,107.096,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,271.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,263.344,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,673.728,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,249.48,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X42,TI",2780003517,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,210.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,194.328,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,202.424,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,194.328,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,161.936,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,162.832,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,277.2,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,249.48,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,732.784,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,271.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,263.344,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,73.92,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,249.48,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X44,TI",2780003518,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,414.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,63.504,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,66.152,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,63.504,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,52.92,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,162.832,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,344.52,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,491.4,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,1753.376,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,337.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,518.704,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,781.44,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,491.4,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X46,TI",2780003519,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,468.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,122.688,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,127.8,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,122.688,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,102.24,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,3726.792,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,37.8,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,554.4,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,387.528,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,37.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,585.2,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,100.32,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,554.4,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X48,TI",2780003520,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,468.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,140.984,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,146.856,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,140.984,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,117.488,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,4446,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,399.6,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,554.4,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,570.728,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,391.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,585.2,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,416.208,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,554.4,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X52,TI",2780003521,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,581.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,134.208,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,139.8,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,134.208,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,111.84,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,26.552,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,51.304,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,689.04,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,2691.576,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,50.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,727.32,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,159.208,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,689.04,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X52,TI",2780003522,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,63.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,134.208,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,139.8,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,134.208,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,111.84,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,1693.8,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,212.832,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,75.6,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,49.32,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,208.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,79.8,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,159.208,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,75.6,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X54,TI",2780003523,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,674.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,140.984,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,146.856,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,140.984,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,117.488,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,700.2,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,81.416,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,799.2,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,986.44,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,79.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,843.6,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,159.208,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,799.2,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X56,TI",2780003524,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,86.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,134.208,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,139.8,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,134.208,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,111.84,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,592.2,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,81.416,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,102.6,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,133.872,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,79.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,108.304,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,3643.976,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,102.6,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X58,TI",2780003525,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,359.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,195.264,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,203.4,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,195.264,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,162.72,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,3459.064,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,81.416,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,425.664,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,400.4,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,79.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,449.312,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,4347.2,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,425.664,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X60,TI",2780003526,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,137.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,195.264,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,203.4,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,195.264,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,162.72,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,354.424,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,1863.4,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,162.832,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,400.4,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,1826.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,171.872,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,25.96,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,162.832,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X65, TI",2780003527,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,137.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,186.064,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,193.816,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,186.064,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,155.056,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,249.48,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,2223,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,162.832,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,400.4,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,2178.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,171.872,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,1656.16,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,162.832,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X70, TI",2780003528,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,137.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,186.064,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,193.816,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,186.064,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,155.056,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,249.48,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,13.28,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,162.832,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,400.4,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,13.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,171.872,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,684.64,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,162.832,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X75, TI",2780003529,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,3147.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,186.064,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,193.816,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,186.064,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,155.056,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,249.48,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,846.904,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,3726.792,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,400.4,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,829.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,3933.84,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,579.04,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,3726.792,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X80, TI",2780003530,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,3754.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,95.616,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,99.6,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,95.616,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,79.68,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,271.8,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,350.104,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,4446,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,400.4,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,343.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,4693,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,3382.192,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,4446,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X85, TI",2780003531,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,22.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,94.6,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,75.68,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,271.8,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,296.104,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,26.552,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,3880.504,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,290.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,28.032,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,346.544,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,26.552,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X90, TI",2780003532,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,1430.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,94.6,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,75.68,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,271.8,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,1729.528,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,1693.8,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,427.704,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,1694.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,1787.904,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,243.936,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,1693.8,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 3.5X95, TI",2780003533,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,591.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,188.608,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,196.464,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,188.608,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,157.168,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,201.6,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,177.208,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,700.2,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,1223.304,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,173.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,739.104,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,243.936,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,700.2,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX KRLCK SCW 3.5X10, TI",2780003534,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,500.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,31.104,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,32.4,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,31.104,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,25.92,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,201.6,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,124.744,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,592.2,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,73.84,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,122.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,625.104,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,243.936,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,592.2,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
"ARTHREX KRLCK SCW 3.5X18, TI",2780003535,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,2920.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,34.296,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,35.728,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,34.296,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,28.576,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,201.6,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,124.744,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,3459.064,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,338.52,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,122.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,3651.232,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,265.76,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,3459.064,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
"ARTHREX KRLCK SCW 3.5X20, TI",2780003536,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,299.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,34.296,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,35.728,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,34.296,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,28.576,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,2146.32,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,124.744,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,354.424,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,70.2,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,122.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,374.112,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,265.76,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,354.424,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
"ARTHREX LO-PRO SCW 4.0X10, TI",2780003537,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,210.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,93.312,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,97.2,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,93.312,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,77.76,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,148.288,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,135.904,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,249.48,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,70.2,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,133.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,263.344,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,265.76,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,249.48,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 4.0X12, TI",2780003538,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,210.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,30.48,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,31.752,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,30.48,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,25.4,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,148.288,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,135.904,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,249.48,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,73.84,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,133.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,263.344,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,197.12,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,249.48,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 4.0X14, TI",2780003539,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,210.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,282.592,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,294.368,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,282.592,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,235.496,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,1014.624,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,135.904,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,249.48,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,230.88,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,133.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,263.344,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,197.12,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,249.48,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 4.0X16, TI",2780003540,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,229.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,107.136,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,111.6,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,107.136,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,89.28,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,2427.752,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,100.8,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,271.8,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,73.84,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,98.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,286.904,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,197.12,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,271.8,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 4.0X18, TI",2780003541,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,229.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,71.424,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,74.4,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,71.424,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,59.52,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,536.584,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,100.8,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,271.8,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,468,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,98.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,286.904,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,2098.624,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,271.8,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 4.0X20, TI",2780003542,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,229.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,134.784,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,140.4,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,134.784,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,112.32,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,790.24,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,100.8,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,271.8,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,81.496,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,98.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,286.904,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,144.992,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,271.8,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 4.0X22, TI",2780003543,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,170.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,129.656,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,103.72,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,3726.792,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,1073.16,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,201.6,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,40.56,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,1051.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,212.8,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,144.992,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,201.6,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
"ARTHREX LO-PRO SCW 4.0X24, TI",2780003544,CDM,278,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,170.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,134.784,Percent of Total Billed Charges,72% of Total Billed Charges,108,72,,140.4,Percent of Total Billed charges,72% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,134.784,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,112.32,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,68.296,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,74.144,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,201.6,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,18.2,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,72.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,212.8,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,992.08,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,201.6,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
ARTHREX LCK DIST FIB PLT LT 4H,2780003545,CDM,278,RC,,,Outpatient,,,1500.00,975.00,,1500,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1140,76,,170.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1080,72,,134.784,Percent of Total Billed Charges,72% of Total Billed Charges,1080,72,,140.4,Percent of Total Billed charges,72% of Total Billed Charges,1500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1080,72,,134.784,Percent of Total Billed Charges,72% of Total Billed Charges,900,60,,112.32,Percent of Total Billed Charges,60% of Total Billed Charges,1350,90,,1365.84,Percent of Total Billed Charges,90% of Total Billed Charges,675,45,,74.144,Percent of Total Billed Charges,45% of Total Billed Charges,1350,90,,201.6,Percent of Total Billed Charges,90% of Total billed Charges,1500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,975,65,,148.2,Percent of total Billed Charges,65% of Total Billed Charges,661.5,44.1,,72.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,1425,95,,212.8,Percent of Total Billed Charges,95% of Total Billed Charges,1500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1320,88,,2373.8,Percent of Total Billed Charges,88% of Total Billed Charges,1350,90,,201.6,Percent of Total Billed charges,90% of Total Billed Charges,661.5,1500,
ARTHREX LCK DIST FIB PLT LT 5H,2780003546,CDM,278,RC,,,Outpatient,,,1750.00,1137.50,,1750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1330,76,,1812.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1260,72,,133.992,Percent of Total Billed Charges,72% of Total Billed Charges,1260,72,,139.576,Percent of Total Billed charges,72% of Total Billed Charges,1750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1260,72,,133.992,Percent of Total Billed Charges,72% of Total Billed Charges,1050,60,,111.664,Percent of Total Billed Charges,60% of Total Billed Charges,1575,90,,185.368,Percent of Total Billed Charges,90% of Total Billed Charges,787.5,45,,507.312,Percent of Total Billed Charges,45% of Total Billed Charges,1575,90,,2146.32,Percent of Total Billed Charges,90% of Total billed Charges,1750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1137.5,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,771.75,44.1,,497.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,1662.5,95,,2265.56,Percent of Total Billed Charges,95% of Total Billed Charges,1750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1540,88,,524.656,Percent of Total Billed Charges,88% of Total Billed Charges,1575,90,,2146.32,Percent of Total Billed charges,90% of Total Billed Charges,771.75,1750,
ARTHREX LCK DIST FIB PLT LT 6H,2780003547,CDM,278,RC,,,Outpatient,,,1937.50,1259.38,,1937.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1472.5,76,,125.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1395,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,1395,72,,44.32,Percent of Total Billed charges,72% of Total Billed Charges,1937.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1395,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,1162.5,60,,35.456,Percent of Total Billed Charges,60% of Total Billed Charges,1743.75,90,,554.4,Percent of Total Billed Charges,90% of Total Billed Charges,871.88,45,,1213.88,Percent of Total Billed Charges,45% of Total Billed Charges,1743.75,90,,148.288,Percent of Total Billed Charges,90% of Total billed Charges,1937.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1937.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1937.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1259.38,65,,127.272,Percent of total Billed Charges,65% of Total Billed Charges,854.44,44.1,,1189.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,1840.63,95,,156.52,Percent of Total Billed Charges,95% of Total Billed Charges,1937.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1705,88,,772.672,Percent of Total Billed Charges,88% of Total Billed Charges,1743.75,90,,148.288,Percent of Total Billed charges,90% of Total Billed Charges,854.44,1937.5,
ARTHREX LCK DIST FIB PLT LT 8H,2780003548,CDM,278,RC,,,Outpatient,,,2112.50,1373.13,,2112.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1605.5,76,,125.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1521,72,,60.328,Percent of Total Billed Charges,72% of Total Billed Charges,1521,72,,62.848,Percent of Total Billed charges,72% of Total Billed Charges,2112.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1521,72,,60.328,Percent of Total Billed Charges,72% of Total Billed Charges,1267.5,60,,50.272,Percent of Total Billed Charges,60% of Total Billed Charges,1901.25,90,,554.4,Percent of Total Billed Charges,90% of Total Billed Charges,950.63,45,,268.288,Percent of Total Billed Charges,45% of Total Billed Charges,1901.25,90,,148.288,Percent of Total Billed Charges,90% of Total billed Charges,2112.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2112.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2112.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1373.13,65,,167.976,Percent of total Billed Charges,65% of Total Billed Charges,931.61,44.1,,262.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,2006.88,95,,156.52,Percent of Total Billed Charges,95% of Total Billed Charges,2112.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1859,88,,3643.976,Percent of Total Billed Charges,88% of Total Billed Charges,1901.25,90,,148.288,Percent of Total Billed charges,90% of Total Billed Charges,931.61,2112.5,
ARTHREX LCK DIST FIB PLT LT 12,2780003549,CDM,278,RC,,,Outpatient,,,2350.00,1527.50,,2350,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1786,76,,856.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1692,72,,69.216,Percent of Total Billed Charges,72% of Total Billed Charges,1692,72,,72.104,Percent of Total Billed charges,72% of Total Billed Charges,2350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1692,72,,69.216,Percent of Total Billed Charges,72% of Total Billed Charges,1410,60,,57.68,Percent of Total Billed Charges,60% of Total Billed Charges,2115,90,,554.4,Percent of Total Billed Charges,90% of Total Billed Charges,1057.5,45,,395.12,Percent of Total Billed Charges,45% of Total Billed Charges,2115,90,,1014.624,Percent of Total Billed Charges,90% of Total billed Charges,2350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1527.5,65,,126.352,Percent of total Billed Charges,65% of Total Billed Charges,1036.35,44.1,,387.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,2232.5,95,,1070.992,Percent of Total Billed Charges,95% of Total Billed Charges,2350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2068,88,,66.776,Percent of Total Billed Charges,88% of Total Billed Charges,2115,90,,1014.624,Percent of Total Billed charges,90% of Total Billed Charges,1036.35,2350,
2375,2780003550,CDM,278,RC,,,Outpatient,,,2375.00,1543.75,,2375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1805,76,,2050.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1710,72,,48.384,Percent of Total Billed Charges,72% of Total Billed Charges,1710,72,,50.4,Percent of Total Billed charges,72% of Total Billed Charges,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1710,72,,48.384,Percent of Total Billed Charges,72% of Total Billed Charges,1425,60,,40.32,Percent of Total Billed Charges,60% of Total Billed Charges,2137.5,90,,554.4,Percent of Total Billed Charges,90% of Total Billed Charges,1068.75,45,,1863.4,Percent of Total Billed Charges,45% of Total Billed Charges,2137.5,90,,2427.752,Percent of Total Billed Charges,90% of Total billed Charges,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1543.75,65,,57.72,Percent of total Billed Charges,65% of Total Billed Charges,1047.38,44.1,,1826.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,2256.25,95,,2562.632,Percent of Total Billed Charges,95% of Total Billed Charges,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2090,88,,1335.488,Percent of Total Billed Charges,88% of Total Billed Charges,2137.5,90,,2427.752,Percent of Total Billed charges,90% of Total Billed Charges,1047.38,2375,
ARTHREX LCK DIST FIB PLT RT 5H,2780003551,CDM,278,RC,,,Outpatient,,,1750.00,1137.50,,1750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1330,76,,453.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1260,72,,48.384,Percent of Total Billed Charges,72% of Total Billed Charges,1260,72,,50.4,Percent of Total Billed charges,72% of Total Billed Charges,1750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1260,72,,48.384,Percent of Total Billed Charges,72% of Total Billed Charges,1050,60,,40.32,Percent of Total Billed Charges,60% of Total Billed Charges,1575,90,,554.4,Percent of Total Billed Charges,90% of Total Billed Charges,787.5,45,,34.144,Percent of Total Billed Charges,45% of Total Billed Charges,1575,90,,536.584,Percent of Total Billed Charges,90% of Total billed Charges,1750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1137.5,65,,79.56,Percent of total Billed Charges,65% of Total Billed Charges,771.75,44.1,,33.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,1662.5,95,,566.392,Percent of Total Billed Charges,95% of Total Billed Charges,1750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1540,88,,181.248,Percent of Total Billed Charges,88% of Total Billed Charges,1575,90,,536.584,Percent of Total Billed charges,90% of Total Billed Charges,771.75,1750,
ARTHREX LCK DIST FIB PLT RT 6H,2780003552,CDM,278,RC,,,Outpatient,,,1937.50,1259.38,,1937.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1472.5,76,,667.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1395,72,,28.8,Percent of Total Billed Charges,72% of Total Billed Charges,1395,72,,30,Percent of Total Billed charges,72% of Total Billed Charges,1937.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1395,72,,28.8,Percent of Total Billed Charges,72% of Total Billed Charges,1162.5,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,1743.75,90,,554.4,Percent of Total Billed Charges,90% of Total Billed Charges,871.88,45,,682.92,Percent of Total Billed Charges,45% of Total Billed Charges,1743.75,90,,790.24,Percent of Total Billed Charges,90% of Total billed Charges,1937.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1937.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1937.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1259.38,65,,175.432,Percent of total Billed Charges,65% of Total Billed Charges,854.44,44.1,,669.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,1840.63,95,,834.136,Percent of Total Billed Charges,95% of Total Billed Charges,1937.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1705,88,,542.08,Percent of Total Billed Charges,88% of Total Billed Charges,1743.75,90,,790.24,Percent of Total Billed charges,90% of Total Billed Charges,854.44,1937.5,
ARTHREX LCK DIST FIB PLT RT 8H,2780003553,CDM,278,RC,,,Outpatient,,,2112.50,1373.13,,2112.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1605.5,76,,3147.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1521,72,,23.616,Percent of Total Billed Charges,72% of Total Billed Charges,1521,72,,24.6,Percent of Total Billed charges,72% of Total Billed Charges,2112.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1521,72,,23.616,Percent of Total Billed Charges,72% of Total Billed Charges,1267.5,60,,19.68,Percent of Total Billed Charges,60% of Total Billed Charges,1901.25,90,,5373,Percent of Total Billed Charges,90% of Total Billed Charges,950.63,45,,92.68,Percent of Total Billed Charges,45% of Total Billed Charges,1901.25,90,,3726.792,Percent of Total Billed Charges,90% of Total billed Charges,2112.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2112.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2112.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1373.13,65,,60.192,Percent of total Billed Charges,65% of Total Billed Charges,931.61,44.1,,90.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,2006.88,95,,3933.84,Percent of Total Billed Charges,95% of Total Billed Charges,2112.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1859,88,,542.08,Percent of Total Billed Charges,88% of Total Billed Charges,1901.25,90,,3726.792,Percent of Total Billed charges,90% of Total Billed Charges,931.61,2112.5,
ARTHREX LCK DIST FIB PLT RT 10,2780003554,CDM,278,RC,,,Outpatient,,,2325.00,1511.25,,2325,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1767,76,,57.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1674,72,,272.432,Percent of Total Billed Charges,72% of Total Billed Charges,1674,72,,283.784,Percent of Total Billed charges,72% of Total Billed Charges,2325,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1674,72,,272.432,Percent of Total Billed Charges,72% of Total Billed Charges,1395,60,,227.024,Percent of Total Billed Charges,60% of Total Billed Charges,2092.5,90,,592.2,Percent of Total Billed Charges,90% of Total Billed Charges,1046.25,45,,277.2,Percent of Total Billed Charges,45% of Total Billed Charges,2092.5,90,,68.296,Percent of Total Billed Charges,90% of Total billed Charges,2325,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2325,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2325,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1511.25,65,,265.72,Percent of total Billed Charges,65% of Total Billed Charges,1025.33,44.1,,271.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,2208.75,95,,72.088,Percent of Total Billed Charges,95% of Total Billed Charges,2325,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2046,88,,542.08,Percent of Total Billed Charges,88% of Total Billed Charges,2092.5,90,,68.296,Percent of Total Billed charges,90% of Total Billed Charges,1025.33,2325,
ARTHREX LCK DIST FIB PLT RT 12,2780003555,CDM,278,RC,,,Outpatient,,,2350.00,1527.50,,2350,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1786,76,,1153.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1692,72,,294.336,Percent of Total Billed Charges,72% of Total Billed Charges,1692,72,,306.6,Percent of Total Billed charges,72% of Total Billed Charges,2350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1692,72,,294.336,Percent of Total Billed Charges,72% of Total Billed Charges,1410,60,,245.28,Percent of Total Billed Charges,60% of Total Billed Charges,2115,90,,1693.8,Percent of Total Billed Charges,90% of Total Billed Charges,1057.5,45,,277.2,Percent of Total Billed Charges,45% of Total Billed Charges,2115,90,,1365.84,Percent of Total Billed Charges,90% of Total billed Charges,2350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1527.5,65,,23.92,Percent of total Billed Charges,65% of Total Billed Charges,1036.35,44.1,,271.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,2232.5,95,,1441.72,Percent of Total Billed Charges,95% of Total Billed Charges,2350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2068,88,,542.08,Percent of Total Billed Charges,88% of Total Billed Charges,2115,90,,1365.84,Percent of Total Billed charges,90% of Total Billed Charges,1036.35,2350,
ARTHREX LCK DIST FIB PLT RT 14,2780003556,CDM,278,RC,,,Outpatient,,,2375.00,1543.75,,2375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1805,76,,156.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1710,72,,272.432,Percent of Total Billed Charges,72% of Total Billed Charges,1710,72,,283.784,Percent of Total Billed charges,72% of Total Billed Charges,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1710,72,,272.432,Percent of Total Billed Charges,72% of Total Billed Charges,1425,60,,227.024,Percent of Total Billed Charges,60% of Total Billed Charges,2137.5,90,,102.24,Percent of Total Billed Charges,90% of Total Billed Charges,1068.75,45,,277.2,Percent of Total Billed Charges,45% of Total Billed Charges,2137.5,90,,185.368,Percent of Total Billed Charges,90% of Total billed Charges,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1543.75,65,,119.248,Percent of total Billed Charges,65% of Total Billed Charges,1047.38,44.1,,271.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,2256.25,95,,195.664,Percent of Total Billed Charges,95% of Total Billed Charges,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2090,88,,542.08,Percent of Total Billed Charges,88% of Total Billed Charges,2137.5,90,,185.368,Percent of Total Billed charges,90% of Total Billed Charges,1047.38,2375,
ARTHREX LCK STRAIGHT PLT 4H,2780003557,CDM,278,RC,,,Outpatient,,,1125.00,731.25,,1125,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,855,76,,468.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,810,72,,166.384,Percent of Total Billed Charges,72% of Total Billed Charges,810,72,,173.32,Percent of Total Billed charges,72% of Total Billed Charges,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,810,72,,166.384,Percent of Total Billed Charges,72% of Total Billed Charges,675,60,,138.656,Percent of Total Billed Charges,60% of Total Billed Charges,1012.5,90,,468.72,Percent of Total Billed Charges,90% of Total Billed Charges,506.25,45,,277.2,Percent of Total Billed Charges,45% of Total Billed Charges,1012.5,90,,554.4,Percent of Total Billed Charges,90% of Total billed Charges,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,731.25,65,,13.76,Percent of total Billed Charges,65% of Total Billed Charges,496.13,44.1,,271.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,1068.75,95,,585.2,Percent of Total Billed Charges,95% of Total Billed Charges,1125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,990,88,,542.08,Percent of Total Billed Charges,88% of Total Billed Charges,1012.5,90,,554.4,Percent of Total Billed charges,90% of Total Billed Charges,496.13,1125,
ARTHREX LCK STRAIGHT PLT 7H,2780003558,CDM,278,RC,,,Outpatient,,,1312.50,853.13,,1312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,997.5,76,,468.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,945,72,,139.968,Percent of Total Billed Charges,72% of Total Billed Charges,945,72,,145.8,Percent of Total Billed charges,72% of Total Billed Charges,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,945,72,,139.968,Percent of Total Billed Charges,72% of Total Billed Charges,787.5,60,,116.64,Percent of Total Billed Charges,60% of Total Billed Charges,1181.25,90,,97.2,Percent of Total Billed Charges,90% of Total Billed Charges,590.63,45,,277.2,Percent of Total Billed Charges,45% of Total Billed Charges,1181.25,90,,554.4,Percent of Total Billed Charges,90% of Total billed Charges,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,853.13,65,,60.192,Percent of total Billed Charges,65% of Total Billed Charges,578.81,44.1,,271.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,1246.88,95,,585.2,Percent of Total Billed Charges,95% of Total Billed Charges,1312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1155,88,,5253.6,Percent of Total Billed Charges,88% of Total Billed Charges,1181.25,90,,554.4,Percent of Total Billed charges,90% of Total Billed Charges,578.81,1312.5,
ARTHREX LCK STRAIGHT PLT 8H,2780003559,CDM,278,RC,,,Outpatient,,,1375.00,893.75,,1375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1045,76,,468.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,990,72,,147.328,Percent of Total Billed Charges,72% of Total Billed Charges,990,72,,153.472,Percent of Total Billed charges,72% of Total Billed Charges,1375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,990,72,,147.328,Percent of Total Billed Charges,72% of Total Billed Charges,825,60,,122.776,Percent of Total Billed Charges,60% of Total Billed Charges,1237.5,90,,97.2,Percent of Total Billed Charges,90% of Total Billed Charges,618.75,45,,277.2,Percent of Total Billed Charges,45% of Total Billed Charges,1237.5,90,,554.4,Percent of Total Billed Charges,90% of Total billed Charges,1375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,893.75,65,,57.904,Percent of total Billed Charges,65% of Total Billed Charges,606.38,44.1,,271.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,1306.25,95,,585.2,Percent of Total Billed Charges,95% of Total Billed Charges,1375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1210,88,,579.04,Percent of Total Billed Charges,88% of Total Billed Charges,1237.5,90,,554.4,Percent of Total Billed charges,90% of Total Billed Charges,606.38,1375,
ARTHREX LCK STRAIGHT PLT 10H,2780003560,CDM,278,RC,,,Outpatient,,,1487.50,966.88,,1487.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1130.5,76,,468.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1071,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,1071,72,,16.536,Percent of Total Billed charges,72% of Total Billed Charges,1487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1071,72,,15.872,Percent of Total Billed Charges,72% of Total Billed Charges,892.5,60,,13.232,Percent of Total Billed Charges,60% of Total Billed Charges,1338.75,90,,102.24,Percent of Total Billed Charges,90% of Total Billed Charges,669.38,45,,2686.504,Percent of Total Billed Charges,45% of Total Billed Charges,1338.75,90,,554.4,Percent of Total Billed Charges,90% of Total billed Charges,1487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,966.88,65,,300.408,Percent of total Billed Charges,65% of Total Billed Charges,655.99,44.1,,2632.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,1413.13,95,,585.2,Percent of Total Billed Charges,95% of Total Billed Charges,1487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1309,88,,1656.16,Percent of Total Billed Charges,88% of Total Billed Charges,1338.75,90,,554.4,Percent of Total Billed charges,90% of Total Billed Charges,655.99,1487.5,
ARTHREX LCK STRIAGHT PLT 12H,2780003561,CDM,278,RC,,,Outpatient,,,1737.50,1129.38,,1737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1320.5,76,,468.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1251,72,,17.856,Percent of Total Billed Charges,72% of Total Billed Charges,1251,72,,18.6,Percent of Total Billed charges,72% of Total Billed Charges,1737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1251,72,,17.856,Percent of Total Billed Charges,72% of Total Billed Charges,1042.5,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,1563.75,90,,319.68,Percent of Total Billed Charges,90% of Total Billed Charges,781.88,45,,296.104,Percent of Total Billed Charges,45% of Total Billed Charges,1563.75,90,,554.4,Percent of Total Billed Charges,90% of Total billed Charges,1737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1129.38,65,,85.424,Percent of total Billed Charges,65% of Total Billed Charges,766.24,44.1,,290.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,1650.63,95,,585.2,Percent of Total Billed Charges,95% of Total Billed Charges,1737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1529,88,,99.968,Percent of Total Billed Charges,88% of Total Billed Charges,1563.75,90,,554.4,Percent of Total Billed charges,90% of Total Billed Charges,766.24,1737.5,
ARTHREX LCK MED HOOK PLT 3H,2780003562,CDM,278,RC,,,Outpatient,,,2312.50,1503.13,,2312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1757.5,76,,468.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1665,72,,52.712,Percent of Total Billed Charges,72% of Total Billed Charges,1665,72,,54.904,Percent of Total Billed charges,72% of Total Billed Charges,2312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665,72,,52.712,Percent of Total Billed Charges,72% of Total Billed Charges,1387.5,60,,43.928,Percent of Total Billed Charges,60% of Total Billed Charges,2081.25,90,,102.24,Percent of Total Billed Charges,90% of Total Billed Charges,1040.63,45,,846.904,Percent of Total Billed Charges,45% of Total Billed Charges,2081.25,90,,554.4,Percent of Total Billed Charges,90% of Total billed Charges,2312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1503.13,65,,163.8,Percent of total Billed Charges,65% of Total Billed Charges,1019.81,44.1,,829.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,2196.88,95,,585.2,Percent of Total Billed Charges,95% of Total Billed Charges,2312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2035,88,,458.304,Percent of Total Billed Charges,88% of Total Billed Charges,2081.25,90,,554.4,Percent of Total Billed charges,90% of Total Billed Charges,1019.81,2312.5,
ARTHREX LCK MED HOOK PLT 5H,2780003563,CDM,278,RC,,,Outpatient,,,2400.00,1560.00,,2400,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1824,76,,4537.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1728,72,,148.6,Percent of Total Billed Charges,72% of Total Billed Charges,1728,72,,154.792,Percent of Total Billed charges,72% of Total Billed Charges,2400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1728,72,,148.6,Percent of Total Billed Charges,72% of Total Billed Charges,1440,60,,123.832,Percent of Total Billed Charges,60% of Total Billed Charges,2160,90,,648,Percent of Total Billed Charges,90% of Total Billed Charges,1080,45,,51.12,Percent of Total Billed Charges,45% of Total Billed Charges,2160,90,,5373,Percent of Total Billed Charges,90% of Total billed Charges,2400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1560,65,,20.28,Percent of total Billed Charges,65% of Total Billed Charges,1058.4,44.1,,50.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,2280,95,,5671.504,Percent of Total Billed Charges,95% of Total Billed Charges,2400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2112,88,,95.04,Percent of Total Billed Charges,88% of Total Billed Charges,2160,90,,5373,Percent of Total Billed charges,90% of Total Billed Charges,1058.4,2400,
ARTHREX LCK MED HOOK PLT 7H,2780003564,CDM,278,RC,,,Outpatient,,,2487.50,1616.88,,2487.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1890.5,76,,500.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1791,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,1791,72,,91.288,Percent of Total Billed charges,72% of Total Billed Charges,2487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1791,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,1492.5,60,,73.032,Percent of Total Billed Charges,60% of Total Billed Charges,2238.75,90,,112.84,Percent of Total Billed Charges,90% of Total Billed Charges,1119.38,45,,234.36,Percent of Total Billed Charges,45% of Total Billed Charges,2238.75,90,,592.2,Percent of Total Billed Charges,90% of Total billed Charges,2487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1616.88,65,,85.4,Percent of total Billed Charges,65% of Total Billed Charges,1096.99,44.1,,229.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,2363.13,95,,625.104,Percent of Total Billed Charges,95% of Total Billed Charges,2487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2189,88,,95.04,Percent of Total Billed Charges,88% of Total Billed Charges,2238.75,90,,592.2,Percent of Total Billed charges,90% of Total Billed Charges,1096.99,2487.5,
"ARTHRX PSTRO LAT DIS TIB 4H,LT",2780003565,CDM,278,RC,,,Outpatient,,,3237.50,2104.38,,3237.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2460.5,76,,1430.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2331,72,,40.008,Percent of Total Billed Charges,72% of Total Billed Charges,2331,72,,41.68,Percent of Total Billed charges,72% of Total Billed Charges,3237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2331,72,,40.008,Percent of Total Billed Charges,72% of Total Billed Charges,1942.5,60,,33.344,Percent of Total Billed Charges,60% of Total Billed Charges,2913.75,90,,56.16,Percent of Total Billed Charges,90% of Total Billed Charges,1456.88,45,,48.6,Percent of Total Billed Charges,45% of Total Billed Charges,2913.75,90,,1693.8,Percent of Total Billed Charges,90% of Total billed Charges,3237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2104.38,65,,341.688,Percent of total Billed Charges,65% of Total Billed Charges,1427.74,44.1,,47.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,3075.63,95,,1787.904,Percent of Total Billed Charges,95% of Total Billed Charges,3237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2849,88,,99.968,Percent of Total Billed Charges,88% of Total Billed Charges,2913.75,90,,1693.8,Percent of Total Billed charges,90% of Total Billed Charges,1427.74,3237.5,
"ARTHRX PSTRO LAT DIS TIB 6H,LT",2780003566,CDM,278,RC,,,Outpatient,,,3362.50,2185.63,,3362.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2555.5,76,,86.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2421,72,,48.384,Percent of Total Billed Charges,72% of Total Billed Charges,2421,72,,50.4,Percent of Total Billed charges,72% of Total Billed Charges,3362.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2421,72,,48.384,Percent of Total Billed Charges,72% of Total Billed Charges,2017.5,60,,40.32,Percent of Total Billed Charges,60% of Total Billed Charges,3026.25,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,1513.13,45,,48.6,Percent of Total Billed Charges,45% of Total Billed Charges,3026.25,90,,102.24,Percent of Total Billed Charges,90% of Total billed Charges,3362.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3362.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3362.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2185.63,65,,13.76,Percent of total Billed Charges,65% of Total Billed Charges,1482.86,44.1,,47.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,3194.38,95,,107.92,Percent of Total Billed Charges,95% of Total Billed Charges,3362.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2959,88,,312.576,Percent of Total Billed Charges,88% of Total Billed Charges,3026.25,90,,102.24,Percent of Total Billed charges,90% of Total Billed Charges,1482.86,3362.5,
"ARTHRX PSTRO LAT DIS TIB 8H,LT",2780003567,CDM,278,RC,,,Outpatient,,,3487.50,2266.88,,3487.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2650.5,76,,395.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2511,72,,228.616,Percent of Total Billed Charges,72% of Total Billed Charges,2511,72,,238.144,Percent of Total Billed charges,72% of Total Billed Charges,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2511,72,,228.616,Percent of Total Billed Charges,72% of Total Billed Charges,2092.5,60,,190.512,Percent of Total Billed Charges,60% of Total Billed Charges,3138.75,90,,205.2,Percent of Total Billed Charges,90% of Total Billed Charges,1569.38,45,,51.12,Percent of Total Billed Charges,45% of Total Billed Charges,3138.75,90,,468.72,Percent of Total Billed Charges,90% of Total billed Charges,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2266.88,65,,88.92,Percent of total Billed Charges,65% of Total Billed Charges,1537.99,44.1,,50.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,3313.13,95,,494.76,Percent of Total Billed Charges,95% of Total Billed Charges,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3069,88,,99.968,Percent of Total Billed Charges,88% of Total Billed Charges,3138.75,90,,468.72,Percent of Total Billed charges,90% of Total Billed Charges,1537.99,3487.5,
"ARTHRX PSTRO LAT DIS,TIB RT 4H",2780003568,CDM,278,RC,,,Outpatient,,,3237.50,2104.38,,3237.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2460.5,76,,82.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2331,72,,180.352,Percent of Total Billed Charges,72% of Total Billed Charges,2331,72,,187.864,Percent of Total Billed charges,72% of Total Billed Charges,3237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2331,72,,180.352,Percent of Total Billed Charges,72% of Total Billed Charges,1942.5,60,,150.296,Percent of Total Billed Charges,60% of Total Billed Charges,2913.75,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,1456.88,45,,159.84,Percent of Total Billed Charges,45% of Total Billed Charges,2913.75,90,,97.2,Percent of Total Billed Charges,90% of Total billed Charges,3237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2104.38,65,,247.664,Percent of total Billed Charges,65% of Total Billed Charges,1427.74,44.1,,156.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,3075.63,95,,102.6,Percent of Total Billed Charges,95% of Total Billed Charges,3237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2849,88,,633.6,Percent of Total Billed Charges,88% of Total Billed Charges,2913.75,90,,97.2,Percent of Total Billed charges,90% of Total Billed Charges,1427.74,3237.5,
ARTHRX PSTRO LAT DIS TIB 6H RT,2780003569,CDM,278,RC,,,Outpatient,,,3362.50,2185.63,,3362.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2555.5,76,,82.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2421,72,,180.352,Percent of Total Billed Charges,72% of Total Billed Charges,2421,72,,187.864,Percent of Total Billed charges,72% of Total Billed Charges,3362.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2421,72,,180.352,Percent of Total Billed Charges,72% of Total Billed Charges,2017.5,60,,150.296,Percent of Total Billed Charges,60% of Total Billed Charges,3026.25,90,,176.224,Percent of Total Billed Charges,90% of Total Billed Charges,1513.13,45,,51.12,Percent of Total Billed Charges,45% of Total Billed Charges,3026.25,90,,97.2,Percent of Total Billed Charges,90% of Total billed Charges,3362.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3362.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3362.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2185.63,65,,117.528,Percent of total Billed Charges,65% of Total Billed Charges,1482.86,44.1,,50.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,3194.38,95,,102.6,Percent of Total Billed Charges,95% of Total Billed Charges,3362.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2959,88,,110.328,Percent of Total Billed Charges,88% of Total Billed Charges,3026.25,90,,97.2,Percent of Total Billed charges,90% of Total Billed Charges,1482.86,3362.5,
ARTHRX PSTRO LAT DIS TIB RT 8H,2780003570,CDM,278,RC,,,Outpatient,,,3487.50,2266.88,,3487.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2650.5,76,,86.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2511,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,2511,72,,44.32,Percent of Total Billed charges,72% of Total Billed Charges,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2511,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,2092.5,60,,35.456,Percent of Total Billed Charges,60% of Total Billed Charges,3138.75,90,,232.584,Percent of Total Billed Charges,90% of Total Billed Charges,1569.38,45,,324,Percent of Total Billed Charges,45% of Total Billed Charges,3138.75,90,,102.24,Percent of Total Billed Charges,90% of Total billed Charges,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2266.88,65,,163.968,Percent of total Billed Charges,65% of Total Billed Charges,1537.99,44.1,,317.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,3313.13,95,,107.92,Percent of Total Billed Charges,95% of Total Billed Charges,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3069,88,,54.912,Percent of Total Billed Charges,88% of Total Billed Charges,3138.75,90,,102.24,Percent of Total Billed charges,90% of Total Billed Charges,1537.99,3487.5,
"ARTHRX PSTRO MED DIS TIB 4H,LT",2780003571,CDM,278,RC,,,Outpatient,,,3237.50,2104.38,,3237.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2460.5,76,,269.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2331,72,,168.768,Percent of Total Billed Charges,72% of Total Billed Charges,2331,72,,175.8,Percent of Total Billed charges,72% of Total Billed Charges,3237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2331,72,,168.768,Percent of Total Billed Charges,72% of Total Billed Charges,1942.5,60,,140.64,Percent of Total Billed Charges,60% of Total Billed Charges,2913.75,90,,174.944,Percent of Total Billed Charges,90% of Total Billed Charges,1456.88,45,,56.416,Percent of Total Billed Charges,45% of Total Billed Charges,2913.75,90,,319.68,Percent of Total Billed Charges,90% of Total billed Charges,3237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2104.38,65,,235.624,Percent of total Billed Charges,65% of Total Billed Charges,1427.74,44.1,,55.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,3075.63,95,,337.44,Percent of Total Billed Charges,95% of Total Billed Charges,3237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2849,88,,24.64,Percent of Total Billed Charges,88% of Total Billed Charges,2913.75,90,,319.68,Percent of Total Billed charges,90% of Total Billed Charges,1427.74,3237.5,
"ARTHRX PSTRO MED DIS TIB 6H,LT",2780003572,CDM,278,RC,,,Outpatient,,,3362.50,2185.63,,3362.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2555.5,76,,86.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2421,72,,132.088,Percent of Total Billed Charges,72% of Total Billed Charges,2421,72,,137.592,Percent of Total Billed charges,72% of Total Billed Charges,3362.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2421,72,,132.088,Percent of Total Billed Charges,72% of Total Billed Charges,2017.5,60,,110.072,Percent of Total Billed Charges,60% of Total Billed Charges,3026.25,90,,79.92,Percent of Total Billed Charges,90% of Total Billed Charges,1513.13,45,,28.08,Percent of Total Billed Charges,45% of Total Billed Charges,3026.25,90,,102.24,Percent of Total Billed Charges,90% of Total billed Charges,3362.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3362.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3362.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2185.63,65,,18.92,Percent of total Billed Charges,65% of Total Billed Charges,1482.86,44.1,,27.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,3194.38,95,,107.92,Percent of Total Billed Charges,95% of Total Billed Charges,3362.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2959,88,,200.64,Percent of Total Billed Charges,88% of Total Billed Charges,3026.25,90,,102.24,Percent of Total Billed charges,90% of Total Billed Charges,1482.86,3362.5,
"ARTHRX PSTRO MED DIS TIB 8H,LT",2780003573,CDM,278,RC,,,Outpatient,,,3487.50,2266.88,,3487.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2650.5,76,,547.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2511,72,,26.672,Percent of Total Billed Charges,72% of Total Billed Charges,2511,72,,27.784,Percent of Total Billed charges,72% of Total Billed Charges,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2511,72,,26.672,Percent of Total Billed Charges,72% of Total Billed Charges,2092.5,60,,22.232,Percent of Total Billed Charges,60% of Total Billed Charges,3138.75,90,,110.16,Percent of Total Billed Charges,90% of Total Billed Charges,1569.38,45,,12.6,Percent of Total Billed Charges,45% of Total Billed Charges,3138.75,90,,648,Percent of Total Billed Charges,90% of Total billed Charges,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2266.88,65,,17.2,Percent of total Billed Charges,65% of Total Billed Charges,1537.99,44.1,,12.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,3313.13,95,,684,Percent of Total Billed Charges,95% of Total Billed Charges,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3069,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,3138.75,90,,648,Percent of Total Billed charges,90% of Total Billed Charges,1537.99,3487.5,
"ARTHRX PSTRO MED DIS TIB 4H,RT",2780003574,CDM,278,RC,,,Outpatient,,,3237.50,2104.38,,3237.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2460.5,76,,95.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2331,72,,111.168,Percent of Total Billed Charges,72% of Total Billed Charges,2331,72,,115.8,Percent of Total Billed charges,72% of Total Billed Charges,3237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2331,72,,111.168,Percent of Total Billed Charges,72% of Total Billed Charges,1942.5,60,,92.64,Percent of Total Billed Charges,60% of Total Billed Charges,2913.75,90,,242.904,Percent of Total Billed Charges,90% of Total Billed Charges,1456.88,45,,102.6,Percent of Total Billed Charges,45% of Total Billed Charges,2913.75,90,,112.84,Percent of Total Billed Charges,90% of Total billed Charges,3237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2104.38,65,,30.68,Percent of total Billed Charges,65% of Total Billed Charges,1427.74,44.1,,100.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,3075.63,95,,119.104,Percent of Total Billed Charges,95% of Total Billed Charges,3237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2849,88,,172.312,Percent of Total Billed Charges,88% of Total Billed Charges,2913.75,90,,112.84,Percent of Total Billed charges,90% of Total Billed Charges,1427.74,3237.5,
"ARTHRX PSTRO MED DIS TIB 6H,RT",2780003575,CDM,278,RC,,,Outpatient,,,3362.50,2185.63,,3362.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2555.5,76,,47.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2421,72,,58.424,Percent of Total Billed Charges,72% of Total Billed Charges,2421,72,,60.856,Percent of Total Billed charges,72% of Total Billed Charges,3362.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2421,72,,58.424,Percent of Total Billed Charges,72% of Total Billed Charges,2017.5,60,,48.688,Percent of Total Billed Charges,60% of Total Billed Charges,3026.25,90,,83.344,Percent of Total Billed Charges,90% of Total Billed Charges,1513.13,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,3026.25,90,,56.16,Percent of Total Billed Charges,90% of Total billed Charges,3362.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3362.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3362.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2185.63,65,,30.68,Percent of total Billed Charges,65% of Total Billed Charges,1482.86,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,3194.38,95,,59.28,Percent of Total Billed Charges,95% of Total Billed Charges,3362.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2959,88,,227.416,Percent of Total Billed Charges,88% of Total Billed Charges,3026.25,90,,56.16,Percent of Total Billed charges,90% of Total Billed Charges,1482.86,3362.5,
"ARTHRX PSTRO MED DIS TIB 8H,RT",2780003576,CDM,278,RC,,,Outpatient,,,3487.50,2266.88,,3487.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2650.5,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2511,72,,154.368,Percent of Total Billed Charges,72% of Total Billed Charges,2511,72,,160.8,Percent of Total Billed charges,72% of Total Billed Charges,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2511,72,,154.368,Percent of Total Billed Charges,72% of Total Billed Charges,2092.5,60,,128.64,Percent of Total Billed Charges,60% of Total Billed Charges,3138.75,90,,367.92,Percent of Total Billed Charges,90% of Total Billed Charges,1569.38,45,,88.112,Percent of Total Billed Charges,45% of Total Billed Charges,3138.75,90,,25.2,Percent of Total Billed Charges,90% of Total billed Charges,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2266.88,65,,530.88,Percent of total Billed Charges,65% of Total Billed Charges,1537.99,44.1,,86.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,3313.13,95,,26.6,Percent of Total Billed Charges,95% of Total Billed Charges,3487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3069,88,,171.056,Percent of Total Billed Charges,88% of Total Billed Charges,3138.75,90,,25.2,Percent of Total Billed charges,90% of Total Billed Charges,1537.99,3487.5,
"ARTHREX LCK 3RD TUB PLT 4H,TI",2780003577,CDM,278,RC,,,Outpatient,,,562.50,365.63,,562.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,427.5,76,,173.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,405,72,,33.656,Percent of Total Billed Charges,72% of Total Billed Charges,405,72,,35.056,Percent of Total Billed charges,72% of Total Billed Charges,562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405,72,,33.656,Percent of Total Billed Charges,72% of Total Billed Charges,337.5,60,,28.048,Percent of Total Billed Charges,60% of Total Billed Charges,506.25,90,,33.12,Percent of Total Billed Charges,90% of Total Billed Charges,253.13,45,,116.288,Percent of Total Billed Charges,45% of Total Billed Charges,506.25,90,,205.2,Percent of Total Billed Charges,90% of Total billed Charges,562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365.63,65,,530.88,Percent of total Billed Charges,65% of Total Billed Charges,248.06,44.1,,113.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,534.38,95,,216.6,Percent of Total Billed Charges,95% of Total Billed Charges,562.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495,88,,78.144,Percent of Total Billed Charges,88% of Total Billed Charges,506.25,90,,205.2,Percent of Total Billed charges,90% of Total Billed Charges,248.06,562.5,
"ARTHREX LCK 3RD TUB PLT 5H,TI",2780003578,CDM,278,RC,,,Outpatient,,,587.50,381.88,,587.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,446.5,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,423,72,,96.768,Percent of Total Billed Charges,72% of Total Billed Charges,423,72,,100.8,Percent of Total Billed charges,72% of Total Billed Charges,587.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,423,72,,96.768,Percent of Total Billed Charges,72% of Total Billed Charges,352.5,60,,80.64,Percent of Total Billed Charges,60% of Total Billed Charges,528.75,90,,165.112,Percent of Total Billed Charges,90% of Total Billed Charges,264.38,45,,87.472,Percent of Total Billed Charges,45% of Total Billed Charges,528.75,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,587.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,587.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,587.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.88,65,,83.736,Percent of total Billed Charges,65% of Total Billed Charges,259.09,44.1,,85.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,558.13,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,587.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,517,88,,107.712,Percent of Total Billed Charges,88% of Total Billed Charges,528.75,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,259.09,587.5,
"ARTHREX LCK 3RD TUB PLT 6H,TI",2780003579,CDM,278,RC,,,Outpatient,,,600.00,390.00,,600,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,456,76,,148.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,432,72,,93.312,Percent of Total Billed Charges,72% of Total Billed Charges,432,72,,97.2,Percent of Total Billed charges,72% of Total Billed Charges,600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,432,72,,93.312,Percent of Total Billed Charges,72% of Total Billed Charges,360,60,,77.76,Percent of Total Billed Charges,60% of Total Billed Charges,540,90,,19.048,Percent of Total Billed Charges,90% of Total Billed Charges,270,45,,39.96,Percent of Total Billed Charges,45% of Total Billed Charges,540,90,,176.224,Percent of Total Billed Charges,90% of Total billed Charges,600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390,65,,30.68,Percent of total Billed Charges,65% of Total Billed Charges,264.6,44.1,,39.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,570,95,,186.016,Percent of Total Billed Charges,95% of Total Billed Charges,600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,528,88,,237.512,Percent of Total Billed Charges,88% of Total Billed Charges,540,90,,176.224,Percent of Total Billed charges,90% of Total Billed Charges,264.6,600,
"ARTHREX LCK 3RD TUB PLT 7H,TI",2780003580,CDM,278,RC,,,Outpatient,,,637.50,414.38,,637.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,484.5,76,,196.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,459,72,,142.848,Percent of Total Billed Charges,72% of Total Billed Charges,459,72,,148.8,Percent of Total Billed charges,72% of Total Billed Charges,637.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,459,72,,142.848,Percent of Total Billed Charges,72% of Total Billed Charges,382.5,60,,119.04,Percent of Total Billed Charges,60% of Total Billed Charges,573.75,90,,83.344,Percent of Total Billed Charges,90% of Total Billed Charges,286.88,45,,55.08,Percent of Total Billed Charges,45% of Total Billed Charges,573.75,90,,232.584,Percent of Total Billed Charges,90% of Total billed Charges,637.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,637.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,637.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.38,65,,29.12,Percent of total Billed Charges,65% of Total Billed Charges,281.14,44.1,,53.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,605.63,95,,245.504,Percent of Total Billed Charges,95% of Total Billed Charges,637.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,88,,81.496,Percent of Total Billed Charges,88% of Total Billed Charges,573.75,90,,232.584,Percent of Total Billed charges,90% of Total Billed Charges,281.14,637.5,
"ARTHREX LCK 3RD TUB PLT 8H,TI",2780003581,CDM,278,RC,,,Outpatient,,,662.50,430.63,,662.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,503.5,76,,147.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,477,72,,16.512,Percent of Total Billed Charges,72% of Total Billed Charges,477,72,,17.2,Percent of Total Billed charges,72% of Total Billed Charges,662.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,477,72,,16.512,Percent of Total Billed Charges,72% of Total Billed Charges,397.5,60,,13.76,Percent of Total Billed Charges,60% of Total Billed Charges,596.25,90,,80.176,Percent of Total Billed Charges,90% of Total Billed Charges,298.13,45,,121.456,Percent of Total Billed Charges,45% of Total Billed Charges,596.25,90,,174.944,Percent of Total Billed Charges,90% of Total billed Charges,662.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,662.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,662.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.63,65,,5.2,Percent of total Billed Charges,65% of Total Billed Charges,292.16,44.1,,119.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,629.38,95,,184.664,Percent of Total Billed Charges,95% of Total Billed Charges,662.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583,88,,359.744,Percent of Total Billed Charges,88% of Total Billed Charges,596.25,90,,174.944,Percent of Total Billed charges,90% of Total Billed Charges,292.16,662.5,
"ARTHREX LCK 3RD TUB PLT 10H,TI",2780003582,CDM,278,RC,,,Outpatient,,,700.00,455.00,,700,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,532,76,,67.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,504,72,,48.96,Percent of Total Billed Charges,72% of Total Billed Charges,504,72,,51,Percent of Total Billed charges,72% of Total Billed Charges,700,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,504,72,,48.96,Percent of Total Billed Charges,72% of Total Billed Charges,420,60,,40.8,Percent of Total Billed Charges,60% of Total Billed Charges,630,90,,415.952,Percent of Total Billed Charges,90% of Total Billed Charges,315,45,,41.672,Percent of Total Billed Charges,45% of Total Billed Charges,630,90,,79.92,Percent of Total Billed Charges,90% of Total billed Charges,700,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,700,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,700,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,455,65,,405.6,Percent of total Billed Charges,65% of Total Billed Charges,308.7,44.1,,40.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,665,95,,84.36,Percent of Total Billed Charges,95% of Total Billed Charges,700,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,616,88,,32.384,Percent of Total Billed Charges,88% of Total Billed Charges,630,90,,79.92,Percent of Total Billed charges,90% of Total Billed Charges,308.7,700,
"ARTHREX LCK 3RD TUB PLT 12H,TI",2780003583,CDM,278,RC,,,Outpatient,,,750.00,487.50,,750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,570,76,,93.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,540,72,,85.096,Percent of Total Billed Charges,72% of Total Billed Charges,540,72,,88.648,Percent of Total Billed charges,72% of Total Billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540,72,,85.096,Percent of Total Billed Charges,72% of Total Billed Charges,450,60,,70.912,Percent of Total Billed Charges,60% of Total Billed Charges,675,90,,118.272,Percent of Total Billed Charges,90% of Total Billed Charges,337.5,45,,183.96,Percent of Total Billed Charges,45% of Total Billed Charges,675,90,,110.16,Percent of Total Billed Charges,90% of Total billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487.5,65,,176.28,Percent of total Billed Charges,65% of Total Billed Charges,330.75,44.1,,180.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,712.5,95,,116.28,Percent of Total Billed Charges,95% of Total Billed Charges,750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,660,88,,161.44,Percent of Total Billed Charges,88% of Total Billed Charges,675,90,,110.16,Percent of Total Billed charges,90% of Total Billed Charges,330.75,750,
"ARTHREX LCK LAT HOOK PLT 3H,TI",2780003584,CDM,278,RC,,,Outpatient,,,2312.50,1503.13,,2312.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1757.5,76,,205.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1665,72,,88.904,Percent of Total Billed Charges,72% of Total Billed Charges,1665,72,,92.608,Percent of Total Billed charges,72% of Total Billed Charges,2312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665,72,,88.904,Percent of Total Billed Charges,72% of Total Billed Charges,1387.5,60,,74.088,Percent of Total Billed Charges,60% of Total Billed Charges,2081.25,90,,226.8,Percent of Total Billed Charges,90% of Total Billed Charges,1040.63,45,,16.56,Percent of Total Billed Charges,45% of Total Billed Charges,2081.25,90,,242.904,Percent of Total Billed Charges,90% of Total billed Charges,2312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1503.13,65,,38.48,Percent of total Billed Charges,65% of Total Billed Charges,1019.81,44.1,,16.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,2196.88,95,,256.4,Percent of Total Billed Charges,95% of Total Billed Charges,2312.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2035,88,,18.624,Percent of Total Billed Charges,88% of Total Billed Charges,2081.25,90,,242.904,Percent of Total Billed charges,90% of Total Billed Charges,1019.81,2312.5,
"ARTHREX LCK LAT HOOK PLT 5H,TI",2780003585,CDM,278,RC,,,Outpatient,,,2400.00,1560.00,,2400,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1824,76,,70.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1728,72,,324.504,Percent of Total Billed Charges,72% of Total Billed Charges,1728,72,,338.032,Percent of Total Billed charges,72% of Total Billed Charges,2400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1728,72,,324.504,Percent of Total Billed Charges,72% of Total Billed Charges,1440,60,,270.424,Percent of Total Billed Charges,60% of Total Billed Charges,2160,90,,28.08,Percent of Total Billed Charges,90% of Total Billed Charges,1080,45,,82.552,Percent of Total Billed Charges,45% of Total Billed Charges,2160,90,,83.344,Percent of Total Billed Charges,90% of Total billed Charges,2400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1560,65,,44.72,Percent of total Billed Charges,65% of Total Billed Charges,1058.4,44.1,,80.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,2280,95,,87.976,Percent of Total Billed Charges,95% of Total Billed Charges,2400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2112,88,,81.496,Percent of Total Billed Charges,88% of Total Billed Charges,2160,90,,83.344,Percent of Total Billed charges,90% of Total Billed Charges,1058.4,2400,
"ARTHREX LCK LAT HOOK PLT 7H,TI",2780003586,CDM,278,RC,,,Outpatient,,,2487.50,1616.88,,2487.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1890.5,76,,310.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1791,72,,120.024,Percent of Total Billed Charges,72% of Total Billed Charges,1791,72,,125.024,Percent of Total Billed charges,72% of Total Billed Charges,2487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1791,72,,120.024,Percent of Total Billed Charges,72% of Total Billed Charges,1492.5,60,,100.016,Percent of Total Billed Charges,60% of Total Billed Charges,2238.75,90,,118.248,Percent of Total Billed Charges,90% of Total Billed Charges,1119.38,45,,9.528,Percent of Total Billed Charges,45% of Total Billed Charges,2238.75,90,,367.92,Percent of Total Billed Charges,90% of Total billed Charges,2487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1616.88,65,,88.92,Percent of total Billed Charges,65% of Total Billed Charges,1096.99,44.1,,9.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,2363.13,95,,388.36,Percent of Total Billed Charges,95% of Total Billed Charges,2487.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2189,88,,78.392,Percent of Total Billed Charges,88% of Total Billed Charges,2238.75,90,,367.92,Percent of Total Billed charges,90% of Total Billed Charges,1096.99,2487.5,
ARTHREX POST ANT DIS FIB LT 4H,2780003587,CDM,278,RC,,,Outpatient,,,2875.00,1868.75,,2875,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2185,76,,27.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2070,72,,145.424,Percent of Total Billed Charges,72% of Total Billed Charges,2070,72,,151.48,Percent of Total Billed charges,72% of Total Billed Charges,2875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2070,72,,145.424,Percent of Total Billed Charges,72% of Total Billed Charges,1725,60,,121.184,Percent of Total Billed Charges,60% of Total Billed Charges,2587.5,90,,473.104,Percent of Total Billed Charges,90% of Total Billed Charges,1293.75,45,,41.672,Percent of Total Billed Charges,45% of Total Billed Charges,2587.5,90,,33.12,Percent of Total Billed Charges,90% of Total billed Charges,2875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1868.75,65,,104.52,Percent of total Billed Charges,65% of Total Billed Charges,1267.88,44.1,,40.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,2731.25,95,,34.96,Percent of Total Billed Charges,95% of Total Billed Charges,2875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2530,88,,406.704,Percent of Total Billed Charges,88% of Total Billed Charges,2587.5,90,,33.12,Percent of Total Billed charges,90% of Total Billed Charges,1267.88,2875,
ARTHREX POST ANT DIS FIB LT 6H,2780003588,CDM,278,RC,,,Outpatient,,,3000.00,1950.00,,3000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2280,76,,139.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2160,72,,127.008,Percent of Total Billed Charges,72% of Total Billed Charges,2160,72,,132.304,Percent of Total Billed charges,72% of Total Billed Charges,3000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2160,72,,127.008,Percent of Total Billed Charges,72% of Total Billed Charges,1800,60,,105.84,Percent of Total Billed Charges,60% of Total Billed Charges,2700,90,,19.048,Percent of Total Billed Charges,90% of Total Billed Charges,1350,45,,40.088,Percent of Total Billed Charges,45% of Total Billed Charges,2700,90,,165.112,Percent of Total Billed Charges,90% of Total billed Charges,3000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1950,65,,156,Percent of total Billed Charges,65% of Total Billed Charges,1323,44.1,,39.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,2850,95,,174.28,Percent of Total Billed Charges,95% of Total Billed Charges,3000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2640,88,,115.648,Percent of Total Billed Charges,88% of Total Billed Charges,2700,90,,165.112,Percent of Total Billed charges,90% of Total Billed Charges,1323,3000,
ARTHREX POST ANT DIS FIB LT 8H,2780003589,CDM,278,RC,,,Outpatient,,,3125.00,2031.25,,3125,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2375,76,,16.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2250,72,,153.216,Percent of Total Billed Charges,72% of Total Billed Charges,2250,72,,159.6,Percent of Total Billed charges,72% of Total Billed Charges,3125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2250,72,,153.216,Percent of Total Billed Charges,72% of Total Billed Charges,1875,60,,127.68,Percent of Total Billed Charges,60% of Total Billed Charges,2812.5,90,,123.12,Percent of Total Billed Charges,90% of Total Billed Charges,1406.25,45,,207.976,Percent of Total Billed Charges,45% of Total Billed Charges,2812.5,90,,19.048,Percent of Total Billed Charges,90% of Total billed Charges,3125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2031.25,65,,136.76,Percent of total Billed Charges,65% of Total Billed Charges,1378.13,44.1,,203.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,2968.75,95,,20.112,Percent of Total Billed Charges,95% of Total Billed Charges,3125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,88,,221.76,Percent of Total Billed Charges,88% of Total Billed Charges,2812.5,90,,19.048,Percent of Total Billed charges,90% of Total Billed Charges,1378.13,3125,
ARTHRX POST ANT DIS FIB LT 10,2780003590,CDM,278,RC,,,Outpatient,,,3250.00,2112.50,,3250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2470,76,,70.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2340,72,,176.256,Percent of Total Billed Charges,72% of Total Billed Charges,2340,72,,183.6,Percent of Total Billed charges,72% of Total Billed Charges,3250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2340,72,,176.256,Percent of Total Billed Charges,72% of Total Billed Charges,1950,60,,146.88,Percent of Total Billed Charges,60% of Total Billed Charges,2925,90,,342.92,Percent of Total Billed Charges,90% of Total Billed Charges,1462.5,45,,59.136,Percent of Total Billed Charges,45% of Total Billed Charges,2925,90,,83.344,Percent of Total Billed Charges,90% of Total billed Charges,3250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2112.5,65,,136.24,Percent of total Billed Charges,65% of Total Billed Charges,1433.25,44.1,,57.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,3087.5,95,,87.976,Percent of Total Billed Charges,95% of Total Billed Charges,3250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2860,88,,27.456,Percent of Total Billed Charges,88% of Total Billed Charges,2925,90,,83.344,Percent of Total Billed charges,90% of Total Billed Charges,1433.25,3250,
ARTHREX POST ANT DIS FIB RT 4H,2780003591,CDM,278,RC,,,Outpatient,,,2875.00,1868.75,,2875,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2185,76,,67.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2070,72,,47.808,Percent of Total Billed Charges,72% of Total Billed Charges,2070,72,,49.8,Percent of Total Billed charges,72% of Total Billed Charges,2875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2070,72,,47.808,Percent of Total Billed Charges,72% of Total Billed Charges,1725,60,,39.84,Percent of Total Billed Charges,60% of Total Billed Charges,2587.5,90,,162.728,Percent of Total Billed Charges,90% of Total Billed Charges,1293.75,45,,113.4,Percent of Total Billed Charges,45% of Total Billed Charges,2587.5,90,,80.176,Percent of Total Billed Charges,90% of Total billed Charges,2875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1868.75,65,,406.64,Percent of total Billed Charges,65% of Total Billed Charges,1267.88,44.1,,111.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,2731.25,95,,84.624,Percent of Total Billed Charges,95% of Total Billed Charges,2875,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2530,88,,115.616,Percent of Total Billed Charges,88% of Total Billed Charges,2587.5,90,,80.176,Percent of Total Billed charges,90% of Total Billed Charges,1267.88,2875,
ARTHREX POST ANT DIS FIB RT 6H,2780003592,CDM,278,RC,,,Outpatient,,,3000.00,1950.00,,3000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2280,76,,351.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2160,72,,61.6,Percent of Total Billed Charges,72% of Total Billed Charges,2160,72,,64.168,Percent of Total Billed charges,72% of Total Billed Charges,3000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2160,72,,61.6,Percent of Total Billed Charges,72% of Total Billed Charges,1800,60,,51.328,Percent of Total Billed Charges,60% of Total Billed Charges,2700,90,,227.032,Percent of Total Billed Charges,90% of Total Billed Charges,1350,45,,14.04,Percent of Total Billed Charges,45% of Total Billed Charges,2700,90,,415.952,Percent of Total Billed Charges,90% of Total billed Charges,3000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1950,65,,212.16,Percent of total Billed Charges,65% of Total Billed Charges,1323,44.1,,13.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,2850,95,,439.056,Percent of Total Billed Charges,95% of Total Billed Charges,3000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2640,88,,462.592,Percent of Total Billed Charges,88% of Total Billed Charges,2700,90,,415.952,Percent of Total Billed charges,90% of Total Billed Charges,1323,3000,
ARTHREX POST ANT DIS FIB RT 8H,2780003593,CDM,278,RC,,,Outpatient,,,3125.00,2031.25,,3125,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2375,76,,99.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2250,72,,67.32,Percent of Total Billed Charges,72% of Total Billed Charges,2250,72,,70.12,Percent of Total Billed charges,72% of Total Billed Charges,3125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2250,72,,67.32,Percent of Total Billed Charges,72% of Total Billed Charges,1875,60,,56.096,Percent of Total Billed Charges,60% of Total Billed Charges,2812.5,90,,326.256,Percent of Total Billed Charges,90% of Total Billed Charges,1406.25,45,,59.12,Percent of Total Billed Charges,45% of Total Billed Charges,2812.5,90,,118.272,Percent of Total Billed Charges,90% of Total billed Charges,3125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2031.25,65,,86.84,Percent of total Billed Charges,65% of Total Billed Charges,1378.13,44.1,,57.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,2968.75,95,,124.848,Percent of Total Billed Charges,95% of Total Billed Charges,3125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750,88,,18.624,Percent of Total Billed Charges,88% of Total Billed Charges,2812.5,90,,118.272,Percent of Total Billed charges,90% of Total Billed Charges,1378.13,3125,
ARTHREX POST ANT DIS FIB RT 10,2780003594,CDM,278,RC,,,Outpatient,,,3250.00,2112.50,,3250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2470,76,,191.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2340,72,,67.32,Percent of Total Billed Charges,72% of Total Billed Charges,2340,72,,70.12,Percent of Total Billed charges,72% of Total Billed Charges,3250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2340,72,,67.32,Percent of Total Billed Charges,72% of Total Billed Charges,1950,60,,56.096,Percent of Total Billed Charges,60% of Total Billed Charges,2925,90,,26.192,Percent of Total Billed Charges,90% of Total Billed Charges,1462.5,45,,236.552,Percent of Total Billed Charges,45% of Total Billed Charges,2925,90,,226.8,Percent of Total Billed Charges,90% of Total billed Charges,3250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2112.5,65,,240.216,Percent of total Billed Charges,65% of Total Billed Charges,1433.25,44.1,,231.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,3087.5,95,,239.4,Percent of Total Billed Charges,95% of Total Billed Charges,3250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2860,88,,120.384,Percent of Total Billed Charges,88% of Total Billed Charges,2925,90,,226.8,Percent of Total Billed charges,90% of Total Billed Charges,1433.25,3250,
ARTHREX POST DIST FIB 4H PLT,2780003595,CDM,278,RC,,,Outpatient,,,2125.00,1381.25,,2125,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1615,76,,23.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1530,72,,67.32,Percent of Total Billed Charges,72% of Total Billed Charges,1530,72,,70.12,Percent of Total Billed charges,72% of Total Billed Charges,2125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,72,,67.32,Percent of Total Billed Charges,72% of Total Billed Charges,1275,60,,56.096,Percent of Total Billed Charges,60% of Total Billed Charges,1912.5,90,,23.816,Percent of Total Billed Charges,90% of Total Billed Charges,956.25,45,,9.528,Percent of Total Billed Charges,45% of Total Billed Charges,1912.5,90,,28.08,Percent of Total Billed Charges,90% of Total billed Charges,2125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1381.25,65,,50.96,Percent of total Billed Charges,65% of Total Billed Charges,937.13,44.1,,9.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,2018.75,95,,29.64,Percent of Total Billed Charges,95% of Total Billed Charges,2125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1870,88,,335.304,Percent of Total Billed Charges,88% of Total Billed Charges,1912.5,90,,28.08,Percent of Total Billed charges,90% of Total Billed Charges,937.13,2125,
ARTHREX POST DIST FIB 5H PLT,2780003596,CDM,278,RC,,,Outpatient,,,2250.00,1462.50,,2250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1710,76,,99.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1620,72,,67.32,Percent of Total Billed Charges,72% of Total Billed Charges,1620,72,,70.12,Percent of Total Billed charges,72% of Total Billed Charges,2250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620,72,,67.32,Percent of Total Billed Charges,72% of Total Billed Charges,1350,60,,56.096,Percent of Total Billed Charges,60% of Total Billed Charges,2025,90,,42.48,Percent of Total Billed Charges,90% of Total Billed Charges,1012.5,45,,61.56,Percent of Total Billed Charges,45% of Total Billed Charges,2025,90,,118.248,Percent of Total Billed Charges,90% of Total billed Charges,2250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1462.5,65,,68.64,Percent of total Billed Charges,65% of Total Billed Charges,992.25,44.1,,60.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,2137.5,95,,124.816,Percent of Total Billed Charges,95% of Total Billed Charges,2250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1980,88,,159.112,Percent of Total Billed Charges,88% of Total Billed Charges,2025,90,,118.248,Percent of Total Billed charges,90% of Total Billed Charges,992.25,2250,
ARTHREX POST DIST FIB 6H PLT,2780003597,CDM,278,RC,,,Outpatient,,,2375.00,1543.75,,2375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1805,76,,399.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1710,72,,67.32,Percent of Total Billed Charges,72% of Total Billed Charges,1710,72,,70.12,Percent of Total Billed charges,72% of Total Billed Charges,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1710,72,,67.32,Percent of Total Billed Charges,72% of Total Billed Charges,1425,60,,56.096,Percent of Total Billed Charges,60% of Total Billed Charges,2137.5,90,,42.48,Percent of Total Billed Charges,90% of Total Billed Charges,1068.75,45,,171.464,Percent of Total Billed Charges,45% of Total Billed Charges,2137.5,90,,473.104,Percent of Total Billed Charges,90% of Total billed Charges,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1543.75,65,,259.608,Percent of total Billed Charges,65% of Total Billed Charges,1047.38,44.1,,168.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,2256.25,95,,499.392,Percent of Total Billed Charges,95% of Total Billed Charges,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2090,88,,221.984,Percent of Total Billed Charges,88% of Total Billed Charges,2137.5,90,,473.104,Percent of Total Billed charges,90% of Total Billed Charges,1047.38,2375,
ARTHREX POST DIST FIB 8H PLT,2780003598,CDM,278,RC,,,Outpatient,,,2625.00,1706.25,,2625,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1995,76,,16.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1890,72,,80.016,Percent of Total Billed Charges,72% of Total Billed Charges,1890,72,,83.352,Percent of Total Billed charges,72% of Total Billed Charges,2625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1890,72,,80.016,Percent of Total Billed Charges,72% of Total Billed Charges,1575,60,,66.68,Percent of Total Billed Charges,60% of Total Billed Charges,2362.5,90,,735.064,Percent of Total Billed Charges,90% of Total Billed Charges,1181.25,45,,81.36,Percent of Total Billed Charges,45% of Total Billed Charges,2362.5,90,,19.048,Percent of Total Billed Charges,90% of Total billed Charges,2625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1706.25,65,,55.12,Percent of total Billed Charges,65% of Total Billed Charges,1157.63,44.1,,79.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,2493.75,95,,20.112,Percent of Total Billed Charges,95% of Total Billed Charges,2625,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2310,88,,319,Percent of Total Billed Charges,88% of Total Billed Charges,2362.5,90,,19.048,Percent of Total Billed charges,90% of Total Billed Charges,1157.63,2625,
ARTHREX LO PRO SCW 2.4X8 CORTX,2780003599,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,103.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,19.848,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,19.056,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,15.88,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,735.064,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,113.512,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,123.12,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,62.4,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,111.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,129.96,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,25.608,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,123.12,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
ARTHREX LO PRO SCW 2.4X8 CORTX,2780003600,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,289.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,258.624,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,269.4,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,258.624,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,215.52,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,115.944,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,163.128,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,342.92,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,51.48,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,159.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,361.976,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,23.288,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,342.92,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
ARTHREX LO-PRO SCW 2.4X12 CORT,2780003601,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,137.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,80.016,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,83.352,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,80.016,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,66.68,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,42.48,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,13.096,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,162.728,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,56.68,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,12.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,171.768,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,41.536,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,162.728,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
ARTHREX LO-PRO SCW 2.4X14 CORT,2780003602,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,191.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,37.472,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,39.032,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,37.472,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,31.224,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,11.912,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,227.032,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,175.432,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,11.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,239.64,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,41.536,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,227.032,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
ARTHREX LO-PRO SCW 2.4X16 CORT,2780003603,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,275.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,36.288,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,37.8,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,36.288,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,30.24,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,21.24,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,326.256,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,57.328,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,20.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,344.376,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,718.728,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,326.256,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
ARTHREX LO-PRO SCW 2.4X18 CORT,2780003604,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,22.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,37.472,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,39.032,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,37.472,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,31.224,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,561.6,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,21.24,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,26.192,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,110.76,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,20.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,27.648,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,718.728,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,26.192,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
ARTHREX LO-PRO SCW 2.4X20 CORT,2780003605,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,20.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,36.288,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,37.8,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,36.288,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,30.24,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,244.08,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,367.528,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,23.816,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,127.272,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,360.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,25.144,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,113.368,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,23.816,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
ARTHREX LO-PRO SCW 2.4X22 CORT,2780003606,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,35.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,39.744,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,41.4,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,39.744,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,33.12,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,53.28,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,367.528,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,42.48,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,121.16,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,360.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,44.84,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,41.536,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,42.48,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
ARTHREX LO-PRO SCW 2.4X24 CORT,2780003607,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,35.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,70.272,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,73.2,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,70.272,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,58.56,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,57.968,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,42.48,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,121.16,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,56.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,44.84,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,39.424,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,42.48,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
ARTHREX LO-PRO SCW 2.4X26 CORT,2780003608,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,620.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,142.272,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,148.2,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,142.272,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,118.56,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,123.12,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,21.24,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,735.064,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,127.272,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,20.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,775.896,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,7.04,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,735.064,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
ARTHREX LO-PRO SCW 2.4X28 CORT,2780003609,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,620.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,61.632,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,64.2,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,61.632,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,51.36,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,144.72,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,20.16,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,735.064,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,121.16,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,19.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,775.896,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,549.12,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,735.064,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
ARTHREX LO-PRO SCW 2.4X30 CORT,2780003610,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,97.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,46.968,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,216,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,3.6,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,115.944,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,176.28,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,3.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,122.384,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,238.656,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,115.944,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
ARTHREX LO-PRO SCW 2.4X32 CORT,2780003611,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,35.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,34.296,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,35.728,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,34.296,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,28.576,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,189.36,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,280.8,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,42.48,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,176.28,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,275.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,44.84,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,52.096,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,42.48,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
ARTHREX LO-PRO SCW 2.4X34 CORT,2780003612,CDM,278,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,34.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,36.288,Percent of Total Billed Charges,72% of Total Billed Charges,198,72,,37.8,Percent of Total Billed charges,72% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,36.288,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,30.24,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,188.64,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,122.04,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,40.32,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,167.976,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,119.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,42.56,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,60.544,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,40.32,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
ARTHREX VAL KRLCK SCW 2.4X10,2780003613,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,57.6,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,46.08,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,563.04,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,30.96,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,7.2,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,167.976,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,30.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,7.6,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,120.384,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,7.2,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
ARTHREX VAL KRLCK SCW 2.4X12,2780003614,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,474.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,44.32,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,35.456,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,293.76,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,61.56,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,561.6,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,167.976,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,60.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,592.8,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,141.504,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,561.6,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
ARTHREX VAL KRLCK SCW 2.4X14,2780003615,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,206.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,69.456,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,66.68,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,55.568,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,120.24,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,72.36,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,244.08,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,86.32,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,70.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,257.64,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,211.2,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,244.08,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
ARTHREX VAL KRLCK SCW 2.4X16,2780003616,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,44.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,84.456,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,87.976,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,84.456,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,70.384,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,332.608,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,108,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,53.28,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,81.984,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,105.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,56.24,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,185.152,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,53.28,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
ARTHREX VAL KRLCK SCW 2.4X18,2780003617,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,52.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,81.92,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,85.336,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,81.92,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,68.264,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,70.56,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,94.68,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,61.92,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,81.984,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,92.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,65.36,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,184.448,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,61.92,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
ARTHREX VAL KRLCK SCW 2.4X20,2780003618,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,103.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,189.248,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,197.128,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,189.248,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,157.704,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,95.04,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,94.32,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,123.12,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,170.272,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,92.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,129.96,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,550.528,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,123.12,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
ARTHREX VAL KRLCK SCW 2.4X22,2780003619,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,122.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,189.248,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,197.128,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,189.248,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,157.704,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,359.464,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,281.52,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,144.72,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,28.08,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,275.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,152.76,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,287.232,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,144.72,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
ARTHREX VAL KRLCK SCW 2.4X24,2780003620,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,182.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,94.6,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,75.68,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,146.88,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,216,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,30.96,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,143.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,228,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,117.568,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,216,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
ARTHREX VAL KRLCK SCW 2.4X26,2780003621,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,159.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,116.352,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,121.2,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,116.352,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,96.96,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,86.4,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,60.12,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,189.36,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,30.96,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,58.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,199.88,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,325.216,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,189.36,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
ARTHREX VAL KRLCK SCW 2.4X28,2780003622,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,159.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,160.664,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,167.36,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,160.664,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,133.888,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,166.304,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,188.64,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,84.24,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,162.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,199.12,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,68.992,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,188.64,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
ARTHREX VAL KRLCK SCW 2.4X30,2780003623,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,475.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,69.216,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,72.104,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,69.216,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,57.68,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,78.48,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,35.28,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,563.04,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,27.52,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,34.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,594.32,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,92.928,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,563.04,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
ARTHREX VAL KRLCK SCW 2.4X32,2780003624,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,248.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,169.56,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,176.624,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,169.56,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,141.296,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,242.904,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,47.52,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,293.76,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,255.12,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,46.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,310.08,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,351.472,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,293.76,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
ARTHREX VAL KRLCK SCW 2.4X34,2780003625,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,101.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,169.56,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,176.624,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,169.56,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,141.296,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,79.384,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,179.728,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,120.24,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,96.72,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,176.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,126.92,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,74.624,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,120.24,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
ARTHREX VAL NR CORTX SCW 2.4X8,2780003626,CDM,278,RC,,,Outpatient,,,350.00,227.50,,350,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,266,76,,280.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,252,72,,169.56,Percent of Total Billed Charges,72% of Total Billed Charges,252,72,,176.624,Percent of Total Billed charges,72% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,72,,169.56,Percent of Total Billed Charges,72% of Total Billed Charges,210,60,,141.296,Percent of Total Billed Charges,60% of Total Billed Charges,315,90,,153.36,Percent of Total Billed Charges,90% of Total Billed Charges,157.5,45,,38.16,Percent of Total Billed Charges,45% of Total Billed Charges,315,90,,332.608,Percent of Total Billed Charges,90% of Total billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,65,,64.48,Percent of total Billed Charges,65% of Total Billed Charges,154.35,44.1,,37.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,332.5,95,,351.08,Percent of Total Billed Charges,95% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308,88,,84.48,Percent of Total Billed Charges,88% of Total Billed Charges,315,90,,332.608,Percent of Total Billed charges,90% of Total Billed Charges,154.35,350,
ARTHRX VAL NR CORTX SCW 2.4X10,2780003627,CDM,278,RC,,,Outpatient,,,350.00,227.50,,350,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,266,76,,59.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,252,72,,169.56,Percent of Total Billed Charges,72% of Total Billed Charges,252,72,,176.624,Percent of Total Billed charges,72% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,72,,169.56,Percent of Total Billed Charges,72% of Total Billed Charges,210,60,,141.296,Percent of Total Billed Charges,60% of Total Billed Charges,315,90,,176.224,Percent of Total Billed Charges,90% of Total Billed Charges,157.5,45,,43.2,Percent of Total Billed Charges,45% of Total Billed Charges,315,90,,70.56,Percent of Total Billed Charges,90% of Total billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,65,,121.68,Percent of total Billed Charges,65% of Total Billed Charges,154.35,44.1,,42.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,332.5,95,,74.48,Percent of Total Billed Charges,95% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308,88,,69.696,Percent of Total Billed Charges,88% of Total Billed Charges,315,90,,70.56,Percent of Total Billed charges,90% of Total Billed Charges,154.35,350,
ARTHRX VAL NR CORTX SCW 2.4X12,2780003628,CDM,278,RC,,,Outpatient,,,350.00,227.50,,350,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,266,76,,80.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,252,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,252,72,,367.792,Percent of Total Billed charges,72% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,210,60,,294.232,Percent of Total Billed Charges,60% of Total Billed Charges,315,90,,167.76,Percent of Total Billed Charges,90% of Total Billed Charges,157.5,45,,35.64,Percent of Total Billed Charges,45% of Total Billed Charges,315,90,,95.04,Percent of Total Billed Charges,90% of Total billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,65,,112.368,Percent of total Billed Charges,65% of Total Billed Charges,154.35,44.1,,34.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,332.5,95,,100.32,Percent of Total Billed Charges,95% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308,88,,76.736,Percent of Total Billed Charges,88% of Total Billed Charges,315,90,,95.04,Percent of Total Billed charges,90% of Total Billed Charges,154.35,350,
ARTHRX VAL NR CORTX SCW 2.4X14,2780003629,CDM,278,RC,,,Outpatient,,,350.00,227.50,,350,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,266,76,,303.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,252,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,252,72,,367.792,Percent of Total Billed charges,72% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,210,60,,294.232,Percent of Total Billed Charges,60% of Total Billed Charges,315,90,,167.76,Percent of Total Billed Charges,90% of Total Billed Charges,157.5,45,,39.24,Percent of Total Billed Charges,45% of Total Billed Charges,315,90,,359.464,Percent of Total Billed Charges,90% of Total billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,65,,121.68,Percent of total Billed Charges,65% of Total Billed Charges,154.35,44.1,,38.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,332.5,95,,379.432,Percent of Total Billed Charges,95% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308,88,,237.512,Percent of Total Billed Charges,88% of Total Billed Charges,315,90,,359.464,Percent of Total Billed charges,90% of Total Billed Charges,154.35,350,
ARTHRX VAL NR CORTX SCW 2.4X16,2780003630,CDM,278,RC,,,Outpatient,,,350.00,227.50,,350,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,266,76,,64.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,252,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,252,72,,367.792,Percent of Total Billed charges,72% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,210,60,,294.232,Percent of Total Billed Charges,60% of Total Billed Charges,315,90,,176.224,Percent of Total Billed Charges,90% of Total Billed Charges,157.5,45,,121.456,Percent of Total Billed Charges,45% of Total Billed Charges,315,90,,76.32,Percent of Total Billed Charges,90% of Total billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,65,,121.68,Percent of total Billed Charges,65% of Total Billed Charges,154.35,44.1,,119.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,332.5,95,,80.56,Percent of Total Billed Charges,95% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308,88,,77.616,Percent of Total Billed Charges,88% of Total Billed Charges,315,90,,76.32,Percent of Total Billed charges,90% of Total Billed Charges,154.35,350,
ARTHRX VAL NR CORTX SCW 2.4X18,2780003631,CDM,278,RC,,,Outpatient,,,350.00,227.50,,350,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,266,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,252,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,252,72,,367.792,Percent of Total Billed charges,72% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,210,60,,294.232,Percent of Total Billed Charges,60% of Total Billed Charges,315,90,,167.76,Percent of Total Billed Charges,90% of Total Billed Charges,157.5,45,,39.688,Percent of Total Billed Charges,45% of Total Billed Charges,315,90,,86.4,Percent of Total Billed Charges,90% of Total billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,65,,120.968,Percent of total Billed Charges,65% of Total Billed Charges,154.35,44.1,,38.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,332.5,95,,91.2,Percent of Total Billed Charges,95% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308,88,,149.952,Percent of Total Billed Charges,88% of Total Billed Charges,315,90,,86.4,Percent of Total Billed charges,90% of Total Billed Charges,154.35,350,
ARTHRX VAL NR CORTX SCW 2.4X20,2780003632,CDM,278,RC,,,Outpatient,,,350.00,227.50,,350,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,266,76,,60.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,252,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,252,72,,367.792,Percent of Total Billed charges,72% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,210,60,,294.232,Percent of Total Billed Charges,60% of Total Billed Charges,315,90,,244.08,Percent of Total Billed Charges,90% of Total Billed Charges,157.5,45,,76.68,Percent of Total Billed Charges,45% of Total Billed Charges,315,90,,71.28,Percent of Total Billed Charges,90% of Total billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,65,,38.416,Percent of total Billed Charges,65% of Total Billed Charges,154.35,44.1,,75.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,332.5,95,,75.24,Percent of Total Billed Charges,95% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308,88,,172.312,Percent of Total Billed Charges,88% of Total Billed Charges,315,90,,71.28,Percent of Total Billed charges,90% of Total Billed Charges,154.35,350,
ARTHRX VAL NR CORTX SCW 2.4X22,2780003633,CDM,278,RC,,,Outpatient,,,350.00,227.50,,350,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,266,76,,66.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,252,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,252,72,,367.792,Percent of Total Billed charges,72% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,210,60,,294.232,Percent of Total Billed Charges,60% of Total Billed Charges,315,90,,244.08,Percent of Total Billed Charges,90% of Total Billed Charges,157.5,45,,88.112,Percent of Total Billed Charges,45% of Total Billed Charges,315,90,,78.48,Percent of Total Billed Charges,90% of Total billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,65,,54.464,Percent of total Billed Charges,65% of Total Billed Charges,154.35,44.1,,86.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,332.5,95,,82.84,Percent of Total Billed Charges,95% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308,88,,164.032,Percent of Total Billed Charges,88% of Total Billed Charges,315,90,,78.48,Percent of Total Billed charges,90% of Total Billed Charges,154.35,350,
ARTHRX VAL NR CORTX SCW 2.4X24,2780003634,CDM,278,RC,,,Outpatient,,,350.00,227.50,,350,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,266,76,,205.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,252,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,252,72,,367.792,Percent of Total Billed charges,72% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,210,60,,294.232,Percent of Total Billed Charges,60% of Total Billed Charges,315,90,,232.584,Percent of Total Billed Charges,90% of Total Billed Charges,157.5,45,,83.88,Percent of Total Billed Charges,45% of Total Billed Charges,315,90,,242.904,Percent of Total Billed Charges,90% of Total billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,65,,62.488,Percent of total Billed Charges,65% of Total Billed Charges,154.35,44.1,,82.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,332.5,95,,256.4,Percent of Total Billed Charges,95% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308,88,,164.032,Percent of Total Billed Charges,88% of Total Billed Charges,315,90,,242.904,Percent of Total Billed charges,90% of Total Billed Charges,154.35,350,
ARTHRX VAL NR CORTX SCW 2.4X26,2780003635,CDM,278,RC,,,Outpatient,,,350.00,227.50,,350,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,266,76,,67.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,252,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,252,72,,367.792,Percent of Total Billed charges,72% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,210,60,,294.232,Percent of Total Billed Charges,60% of Total Billed Charges,315,90,,232.584,Percent of Total Billed Charges,90% of Total Billed Charges,157.5,45,,83.88,Percent of Total Billed Charges,45% of Total Billed Charges,315,90,,79.384,Percent of Total Billed Charges,90% of Total billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,65,,43.68,Percent of total Billed Charges,65% of Total Billed Charges,154.35,44.1,,82.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,332.5,95,,83.792,Percent of Total Billed Charges,95% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308,88,,172.312,Percent of Total Billed Charges,88% of Total Billed Charges,315,90,,79.384,Percent of Total Billed charges,90% of Total Billed Charges,154.35,350,
ARTHRX VAL NR CORTX SCW 2.4X28,2780003636,CDM,278,RC,,,Outpatient,,,350.00,227.50,,350,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,266,76,,129.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,252,72,,332.76,Percent of Total Billed Charges,72% of Total Billed Charges,252,72,,346.624,Percent of Total Billed charges,72% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,72,,332.76,Percent of Total Billed Charges,72% of Total Billed Charges,210,60,,277.304,Percent of Total Billed Charges,60% of Total Billed Charges,315,90,,232.584,Percent of Total Billed Charges,90% of Total Billed Charges,157.5,45,,88.112,Percent of Total Billed Charges,45% of Total Billed Charges,315,90,,153.36,Percent of Total Billed Charges,90% of Total billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,65,,43.68,Percent of total Billed Charges,65% of Total Billed Charges,154.35,44.1,,86.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,332.5,95,,161.88,Percent of Total Billed Charges,95% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308,88,,164.032,Percent of Total Billed Charges,88% of Total Billed Charges,315,90,,153.36,Percent of Total Billed charges,90% of Total Billed Charges,154.35,350,
ARTHRX VAL NR CORTX SCW 2.4X30,2780003637,CDM,278,RC,,,Outpatient,,,350.00,227.50,,350,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,266,76,,148.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,252,72,,100.336,Percent of Total Billed Charges,72% of Total Billed Charges,252,72,,104.52,Percent of Total Billed charges,72% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,72,,100.336,Percent of Total Billed Charges,72% of Total Billed Charges,210,60,,83.616,Percent of Total Billed Charges,60% of Total Billed Charges,315,90,,119.52,Percent of Total Billed Charges,90% of Total Billed Charges,157.5,45,,83.88,Percent of Total Billed Charges,45% of Total Billed Charges,315,90,,176.224,Percent of Total Billed Charges,90% of Total billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,65,,26,Percent of total Billed Charges,65% of Total Billed Charges,154.35,44.1,,82.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,332.5,95,,186.016,Percent of Total Billed Charges,95% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308,88,,238.656,Percent of Total Billed Charges,88% of Total Billed Charges,315,90,,176.224,Percent of Total Billed charges,90% of Total Billed Charges,154.35,350,
ARTHRX VAL NR CORTX SCW 2.4X32,2780003638,CDM,278,RC,,,Outpatient,,,350.00,227.50,,350,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,266,76,,141.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,252,72,,54.144,Percent of Total Billed Charges,72% of Total Billed Charges,252,72,,56.4,Percent of Total Billed charges,72% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,72,,54.144,Percent of Total Billed Charges,72% of Total Billed Charges,210,60,,45.12,Percent of Total Billed Charges,60% of Total Billed Charges,315,90,,197.28,Percent of Total Billed Charges,90% of Total Billed Charges,157.5,45,,122.04,Percent of Total Billed Charges,45% of Total Billed Charges,315,90,,167.76,Percent of Total Billed Charges,90% of Total billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,65,,21.32,Percent of total Billed Charges,65% of Total Billed Charges,154.35,44.1,,119.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,332.5,95,,177.08,Percent of Total Billed Charges,95% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308,88,,238.656,Percent of Total Billed Charges,88% of Total Billed Charges,315,90,,167.76,Percent of Total Billed charges,90% of Total Billed Charges,154.35,350,
ARTHRX VAL NR CORTX SCW 2.4X34,2780003639,CDM,278,RC,,,Outpatient,,,350.00,227.50,,350,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,266,76,,141.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,252,72,,175.68,Percent of Total Billed Charges,72% of Total Billed Charges,252,72,,183,Percent of Total Billed charges,72% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,72,,175.68,Percent of Total Billed Charges,72% of Total Billed Charges,210,60,,146.4,Percent of Total Billed Charges,60% of Total Billed Charges,315,90,,113.512,Percent of Total Billed Charges,90% of Total Billed Charges,157.5,45,,122.04,Percent of Total Billed Charges,45% of Total Billed Charges,315,90,,167.76,Percent of Total Billed Charges,90% of Total billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,65,,245.944,Percent of total Billed Charges,65% of Total Billed Charges,154.35,44.1,,119.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,332.5,95,,177.08,Percent of Total Billed Charges,95% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308,88,,227.416,Percent of Total Billed Charges,88% of Total Billed Charges,315,90,,167.76,Percent of Total Billed charges,90% of Total Billed Charges,154.35,350,
ARTHREX VOLR DIST RD PLT LT 3H,2780003640,CDM,278,RC,,,Outpatient,,,1987.50,1291.88,,1987.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1510.5,76,,148.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1431,72,,65.664,Percent of Total Billed Charges,72% of Total Billed Charges,1431,72,,68.4,Percent of Total Billed charges,72% of Total Billed Charges,1987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1431,72,,65.664,Percent of Total Billed Charges,72% of Total Billed Charges,1192.5,60,,54.72,Percent of Total Billed Charges,60% of Total Billed Charges,1788.75,90,,113.512,Percent of Total Billed Charges,90% of Total Billed Charges,894.38,45,,116.288,Percent of Total Billed Charges,45% of Total Billed Charges,1788.75,90,,176.224,Percent of Total Billed Charges,90% of Total billed Charges,1987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1291.88,65,,265.72,Percent of total Billed Charges,65% of Total Billed Charges,876.49,44.1,,113.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,1888.13,95,,186.016,Percent of Total Billed Charges,95% of Total Billed Charges,1987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1749,88,,227.416,Percent of Total Billed Charges,88% of Total Billed Charges,1788.75,90,,176.224,Percent of Total Billed charges,90% of Total Billed Charges,876.49,1987.5,
ARTHREX VOLR DIST RD PLT RT 3H,2780003641,CDM,278,RC,,,Outpatient,,,1987.50,1291.88,,1987.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1510.5,76,,141.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1431,72,,46.656,Percent of Total Billed Charges,72% of Total Billed Charges,1431,72,,48.6,Percent of Total Billed charges,72% of Total Billed Charges,1987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1431,72,,46.656,Percent of Total Billed Charges,72% of Total Billed Charges,1192.5,60,,38.88,Percent of Total Billed Charges,60% of Total Billed Charges,1788.75,90,,235.76,Percent of Total Billed Charges,90% of Total Billed Charges,894.38,45,,116.288,Percent of Total Billed Charges,45% of Total Billed Charges,1788.75,90,,167.76,Percent of Total Billed Charges,90% of Total billed Charges,1987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1291.88,65,,245.944,Percent of total Billed Charges,65% of Total Billed Charges,876.49,44.1,,113.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,1888.13,95,,177.08,Percent of Total Billed Charges,95% of Total Billed Charges,1987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1749,88,,227.416,Percent of Total Billed Charges,88% of Total Billed Charges,1788.75,90,,167.76,Percent of Total Billed charges,90% of Total Billed Charges,876.49,1987.5,
ARTHREX VOLR DIST RD STD LT 3H,2780003642,CDM,278,RC,,,Outpatient,,,1987.50,1291.88,,1987.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1510.5,76,,206.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1431,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,1431,72,,46.312,Percent of Total Billed charges,72% of Total Billed Charges,1987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1431,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,1192.5,60,,37.048,Percent of Total Billed Charges,60% of Total Billed Charges,1788.75,90,,38.88,Percent of Total Billed Charges,90% of Total Billed Charges,894.38,45,,116.288,Percent of Total Billed Charges,45% of Total Billed Charges,1788.75,90,,244.08,Percent of Total Billed Charges,90% of Total billed Charges,1987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1291.88,65,,150.208,Percent of total Billed Charges,65% of Total Billed Charges,876.49,44.1,,113.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,1888.13,95,,257.64,Percent of Total Billed Charges,95% of Total Billed Charges,1987.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1749,88,,116.864,Percent of Total Billed Charges,88% of Total Billed Charges,1788.75,90,,244.08,Percent of Total Billed charges,90% of Total Billed Charges,876.49,1987.5,
STRYKER 5X37.5MM LCK SCW,2780003643,CDM,278,RC,,,Outpatient,,,732.50,476.13,,732.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,556.7,76,,206.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,527.4,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,527.4,72,,46.312,Percent of Total Billed charges,72% of Total Billed Charges,732.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,527.4,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,439.5,60,,37.048,Percent of Total Billed Charges,60% of Total Billed Charges,659.25,90,,42.872,Percent of Total Billed Charges,90% of Total Billed Charges,329.63,45,,59.76,Percent of Total Billed Charges,45% of Total Billed Charges,659.25,90,,244.08,Percent of Total Billed Charges,90% of Total billed Charges,732.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,732.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,732.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.13,65,,126.36,Percent of total Billed Charges,65% of Total Billed Charges,323.03,44.1,,58.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,695.88,95,,257.64,Percent of Total Billed Charges,95% of Total Billed Charges,732.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,644.6,88,,192.896,Percent of Total Billed Charges,88% of Total Billed Charges,659.25,90,,244.08,Percent of Total Billed charges,90% of Total Billed Charges,323.03,732.5,
STRYKER 5X40MM LCK SCW,2780003644,CDM,278,RC,,,Outpatient,,,732.50,476.13,,732.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,556.7,76,,196.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,527.4,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,527.4,72,,46.312,Percent of Total Billed charges,72% of Total Billed Charges,732.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,527.4,72,,44.456,Percent of Total Billed Charges,72% of Total Billed Charges,439.5,60,,37.048,Percent of Total Billed Charges,60% of Total Billed Charges,659.25,90,,42.872,Percent of Total Billed Charges,90% of Total Billed Charges,329.63,45,,98.64,Percent of Total Billed Charges,45% of Total Billed Charges,659.25,90,,232.584,Percent of Total Billed Charges,90% of Total billed Charges,732.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,732.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,732.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.13,65,,133.008,Percent of total Billed Charges,65% of Total Billed Charges,323.03,44.1,,96.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,695.88,95,,245.504,Percent of Total Billed Charges,95% of Total Billed Charges,732.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,644.6,88,,110.992,Percent of Total Billed Charges,88% of Total Billed Charges,659.25,90,,232.584,Percent of Total Billed charges,90% of Total Billed Charges,323.03,732.5,
STRYKER 5X42.5MM LCK SCW,2780003645,CDM,278,RC,,,Outpatient,,,732.50,476.13,,732.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,556.7,76,,196.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,527.4,72,,40.32,Percent of Total Billed Charges,72% of Total Billed Charges,527.4,72,,42,Percent of Total Billed charges,72% of Total Billed Charges,732.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,527.4,72,,40.32,Percent of Total Billed Charges,72% of Total Billed Charges,439.5,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,659.25,90,,116.64,Percent of Total Billed Charges,90% of Total Billed Charges,329.63,45,,56.76,Percent of Total Billed Charges,45% of Total Billed Charges,659.25,90,,232.584,Percent of Total Billed Charges,90% of Total billed Charges,732.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,732.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,732.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.13,65,,14.328,Percent of total Billed Charges,65% of Total Billed Charges,323.03,44.1,,55.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,695.88,95,,245.504,Percent of Total Billed Charges,95% of Total Billed Charges,732.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,644.6,88,,110.992,Percent of Total Billed Charges,88% of Total Billed Charges,659.25,90,,232.584,Percent of Total Billed charges,90% of Total Billed Charges,323.03,732.5,
STRYKER 10.5X90MM LAG SCW,2780003646,CDM,278,RC,,,Outpatient,,,2095.00,1361.75,,2095,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1592.2,76,,196.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1508.4,72,,34.296,Percent of Total Billed Charges,72% of Total Billed Charges,1508.4,72,,35.728,Percent of Total Billed charges,72% of Total Billed Charges,2095,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1508.4,72,,34.296,Percent of Total Billed Charges,72% of Total Billed Charges,1257,60,,28.576,Percent of Total Billed Charges,60% of Total Billed Charges,1885.5,90,,38.104,Percent of Total Billed Charges,90% of Total Billed Charges,942.75,45,,56.76,Percent of Total Billed Charges,45% of Total Billed Charges,1885.5,90,,232.584,Percent of Total Billed Charges,90% of Total billed Charges,2095,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2095,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2095,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1361.75,65,,16.12,Percent of total Billed Charges,65% of Total Billed Charges,923.9,44.1,,55.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,1990.25,95,,245.504,Percent of Total Billed Charges,95% of Total Billed Charges,2095,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1843.6,88,,230.52,Percent of Total Billed Charges,88% of Total Billed Charges,1885.5,90,,232.584,Percent of Total Billed charges,90% of Total Billed Charges,923.9,2095,
STRYKR 11X320X125? LNG RT NAIL,2780003647,CDM,278,RC,,,Outpatient,,,8815.00,5729.75,,8815,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6699.4,76,,100.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6346.8,72,,142.848,Percent of Total Billed Charges,72% of Total Billed Charges,6346.8,72,,148.8,Percent of Total Billed charges,72% of Total Billed Charges,8815,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6346.8,72,,142.848,Percent of Total Billed Charges,72% of Total Billed Charges,5289,60,,119.04,Percent of Total Billed Charges,60% of Total Billed Charges,7933.5,90,,353.24,Percent of Total Billed Charges,90% of Total Billed Charges,3966.75,45,,117.88,Percent of Total Billed Charges,45% of Total Billed Charges,7933.5,90,,119.52,Percent of Total Billed Charges,90% of Total billed Charges,8815,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8815,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8815,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5729.75,65,,47.584,Percent of total Billed Charges,65% of Total Billed Charges,3887.42,44.1,,115.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,8374.25,95,,126.16,Percent of Total Billed Charges,95% of Total Billed Charges,8815,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7757.2,88,,38.016,Percent of Total Billed Charges,88% of Total Billed Charges,7933.5,90,,119.52,Percent of Total Billed charges,90% of Total Billed Charges,3887.42,8815,
PCO8VP VENTRAL PATCH 8CM,2780003648,CDM,278,RC,,,Outpatient,,,2005.13,1303.33,,2005.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1523.9,76,,166.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1443.69,72,,135.904,Percent of Total Billed Charges,72% of Total Billed Charges,1443.69,72,,141.568,Percent of Total Billed charges,72% of Total Billed Charges,2005.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1443.69,72,,135.904,Percent of Total Billed Charges,72% of Total Billed Charges,1203.08,60,,113.248,Percent of Total Billed Charges,60% of Total Billed Charges,1804.62,90,,133.92,Percent of Total Billed Charges,90% of Total Billed Charges,902.31,45,,19.44,Percent of Total Billed Charges,45% of Total Billed Charges,1804.62,90,,197.28,Percent of Total Billed Charges,90% of Total billed Charges,2005.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2005.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2005.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1303.33,65,,134.152,Percent of total Billed Charges,65% of Total Billed Charges,884.26,44.1,,19.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1904.87,95,,208.24,Percent of Total Billed Charges,95% of Total Billed Charges,2005.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1764.51,88,,41.92,Percent of Total Billed Charges,88% of Total Billed Charges,1804.62,90,,197.28,Percent of Total Billed charges,90% of Total Billed Charges,884.26,2005.13,
PCO6VP VENTRAL PATCH 6CM,2780003649,CDM,278,RC,,,Outpatient,,,1561.05,1014.68,,1561.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1186.4,76,,95.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1123.96,72,,135.904,Percent of Total Billed Charges,72% of Total Billed Charges,1123.96,72,,141.568,Percent of Total Billed charges,72% of Total Billed Charges,1561.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.96,72,,135.904,Percent of Total Billed Charges,72% of Total Billed Charges,936.63,60,,113.248,Percent of Total Billed Charges,60% of Total Billed Charges,1404.95,90,,89.28,Percent of Total Billed Charges,90% of Total Billed Charges,702.47,45,,21.432,Percent of Total Billed Charges,45% of Total Billed Charges,1404.95,90,,113.512,Percent of Total Billed Charges,90% of Total billed Charges,1561.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1561.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1561.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1014.68,65,,79.12,Percent of total Billed Charges,65% of Total Billed Charges,688.42,44.1,,21.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,1483,95,,119.824,Percent of Total Billed Charges,95% of Total Billed Charges,1561.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1373.72,88,,41.92,Percent of Total Billed Charges,88% of Total Billed Charges,1404.95,90,,113.512,Percent of Total Billed charges,90% of Total Billed Charges,688.42,1561.05,
PCO4VP VENTRAL PATCH 4CM,2780003650,CDM,278,RC,,,Outpatient,,,1302.68,846.74,,1302.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,990.04,76,,95.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,937.93,72,,75.568,Percent of Total Billed Charges,72% of Total Billed Charges,937.93,72,,78.72,Percent of Total Billed charges,72% of Total Billed Charges,1302.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,937.93,72,,75.568,Percent of Total Billed Charges,72% of Total Billed Charges,781.61,60,,62.976,Percent of Total Billed Charges,60% of Total Billed Charges,1172.41,90,,168.48,Percent of Total Billed Charges,90% of Total Billed Charges,586.21,45,,21.432,Percent of Total Billed Charges,45% of Total Billed Charges,1172.41,90,,113.512,Percent of Total Billed Charges,90% of Total billed Charges,1302.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1302.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1302.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,846.74,65,,36.12,Percent of total Billed Charges,65% of Total Billed Charges,574.48,44.1,,21.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,1237.55,95,,119.824,Percent of Total Billed Charges,95% of Total Billed Charges,1302.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1146.36,88,,114.048,Percent of Total Billed Charges,88% of Total Billed Charges,1172.41,90,,113.512,Percent of Total Billed charges,90% of Total Billed Charges,574.48,1302.68,
"STRATTICE MESH 10X16,PERFORATD",2780003651,CDM,278,RC,,,Outpatient,,,16382.50,10648.63,,16382.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12450.7,76,,199.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11795.4,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,11795.4,72,,44.32,Percent of Total Billed charges,72% of Total Billed Charges,16382.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11795.4,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,9829.5,60,,35.456,Percent of Total Billed Charges,60% of Total Billed Charges,14744.25,90,,155.584,Percent of Total Billed Charges,90% of Total Billed Charges,7372.13,45,,58.32,Percent of Total Billed Charges,45% of Total Billed Charges,14744.25,90,,235.76,Percent of Total Billed Charges,90% of Total billed Charges,16382.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16382.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16382.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10648.63,65,,43.68,Percent of total Billed Charges,65% of Total Billed Charges,7224.68,44.1,,57.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,15563.38,95,,248.856,Percent of Total Billed Charges,95% of Total Billed Charges,16382.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14416.6,88,,37.256,Percent of Total Billed Charges,88% of Total Billed Charges,14744.25,90,,235.76,Percent of Total Billed charges,90% of Total Billed Charges,7224.68,16382.5,
"STRATTICE MESH 10X16, NONPERF",2780003652,CDM,278,RC,,,Outpatient,,,15907.50,10339.88,,15907.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12089.7,76,,32.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11453.4,72,,38.736,Percent of Total Billed Charges,72% of Total Billed Charges,11453.4,72,,40.352,Percent of Total Billed charges,72% of Total Billed Charges,15907.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11453.4,72,,38.736,Percent of Total Billed Charges,72% of Total Billed Charges,9544.5,60,,32.28,Percent of Total Billed Charges,60% of Total Billed Charges,14316.75,90,,168.48,Percent of Total Billed Charges,90% of Total Billed Charges,7158.38,45,,19.048,Percent of Total Billed Charges,45% of Total Billed Charges,14316.75,90,,38.88,Percent of Total Billed Charges,90% of Total billed Charges,15907.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15907.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15907.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10339.88,65,,206.392,Percent of total Billed Charges,65% of Total Billed Charges,7015.21,44.1,,18.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,15112.13,95,,41.04,Percent of Total Billed Charges,95% of Total Billed Charges,15907.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13998.6,88,,345.392,Percent of Total Billed Charges,88% of Total Billed Charges,14316.75,90,,38.88,Percent of Total Billed charges,90% of Total Billed Charges,7015.21,15907.5,
STRYKER 4.2X180 DRILL,2780003653,CDM,278,RC,,,Outpatient,,,737.50,479.38,,737.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,560.5,76,,36.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531,72,,88.128,Percent of Total Billed Charges,72% of Total Billed Charges,531,72,,91.8,Percent of Total Billed charges,72% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531,72,,88.128,Percent of Total Billed Charges,72% of Total Billed Charges,442.5,60,,73.44,Percent of Total Billed Charges,60% of Total Billed Charges,663.75,90,,168.48,Percent of Total Billed Charges,90% of Total Billed Charges,331.88,45,,176.616,Percent of Total Billed Charges,45% of Total Billed Charges,663.75,90,,42.872,Percent of Total Billed Charges,90% of Total billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.38,65,,162.816,Percent of total Billed Charges,65% of Total Billed Charges,325.24,44.1,,173.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,700.63,95,,45.248,Percent of Total Billed Charges,95% of Total Billed Charges,737.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649,88,,130.944,Percent of Total Billed Charges,88% of Total Billed Charges,663.75,90,,42.872,Percent of Total Billed charges,90% of Total Billed Charges,325.24,737.5,
STRYKER 10.5X95 LAG SCW,2780003654,CDM,278,RC,,,Outpatient,,,2095.00,1361.75,,2095,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1592.2,76,,36.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1508.4,72,,243.224,Percent of Total Billed Charges,72% of Total Billed Charges,1508.4,72,,253.36,Percent of Total Billed charges,72% of Total Billed Charges,2095,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1508.4,72,,243.224,Percent of Total Billed Charges,72% of Total Billed Charges,1257,60,,202.688,Percent of Total Billed Charges,60% of Total Billed Charges,1885.5,90,,167.496,Percent of Total Billed Charges,90% of Total Billed Charges,942.75,45,,66.96,Percent of Total Billed Charges,45% of Total Billed Charges,1885.5,90,,42.872,Percent of Total Billed Charges,90% of Total billed Charges,2095,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2095,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2095,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1361.75,65,,162.816,Percent of total Billed Charges,65% of Total Billed Charges,923.9,44.1,,65.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,1990.25,95,,45.248,Percent of Total Billed Charges,95% of Total Billed Charges,2095,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1843.6,88,,87.296,Percent of Total Billed Charges,88% of Total Billed Charges,1885.5,90,,42.872,Percent of Total Billed charges,90% of Total Billed Charges,923.9,2095,
STRYKER 10X340X125 NAIL,2780003655,CDM,278,RC,,,Outpatient,,,8815.00,5729.75,,8815,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6699.4,76,,98.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6346.8,72,,243.224,Percent of Total Billed Charges,72% of Total Billed Charges,6346.8,72,,253.36,Percent of Total Billed charges,72% of Total Billed Charges,8815,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6346.8,72,,243.224,Percent of Total Billed Charges,72% of Total Billed Charges,5289,60,,202.688,Percent of Total Billed Charges,60% of Total Billed Charges,7933.5,90,,53.184,Percent of Total Billed Charges,90% of Total Billed Charges,3966.75,45,,44.64,Percent of Total Billed Charges,45% of Total Billed Charges,7933.5,90,,116.64,Percent of Total Billed Charges,90% of Total billed Charges,8815,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8815,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8815,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5729.75,65,,38.416,Percent of total Billed Charges,65% of Total Billed Charges,3887.42,44.1,,43.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,8374.25,95,,123.12,Percent of Total Billed Charges,95% of Total Billed Charges,8815,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7757.2,88,,164.736,Percent of Total Billed Charges,88% of Total Billed Charges,7933.5,90,,116.64,Percent of Total Billed charges,90% of Total Billed Charges,3887.42,8815,
SYM9 SYMBOTEX MESH 9CM,2780003656,CDM,278,RC,,,Outpatient,,,1331.68,865.59,,1331.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1012.08,76,,32.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,958.81,72,,163.008,Percent of Total Billed Charges,72% of Total Billed Charges,958.81,72,,169.8,Percent of Total Billed charges,72% of Total Billed Charges,1331.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,958.81,72,,163.008,Percent of Total Billed Charges,72% of Total Billed Charges,799.01,60,,135.84,Percent of Total Billed Charges,60% of Total Billed Charges,1198.51,90,,75.416,Percent of Total Billed Charges,90% of Total Billed Charges,599.26,45,,84.24,Percent of Total Billed Charges,45% of Total Billed Charges,1198.51,90,,38.104,Percent of Total Billed Charges,90% of Total billed Charges,1331.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1331.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1331.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,865.59,65,,152.36,Percent of total Billed Charges,65% of Total Billed Charges,587.27,44.1,,82.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,1265.1,95,,40.216,Percent of Total Billed Charges,95% of Total Billed Charges,1331.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1171.88,88,,152.128,Percent of Total Billed Charges,88% of Total Billed Charges,1198.51,90,,38.104,Percent of Total Billed charges,90% of Total Billed Charges,587.27,1331.68,
SYM12 SYMBOTEX MESH 12CM,2780003657,CDM,278,RC,,,Outpatient,,,1826.30,1187.10,,1826.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1387.99,76,,298.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1314.94,72,,170.192,Percent of Total Billed Charges,72% of Total Billed Charges,1314.94,72,,177.28,Percent of Total Billed charges,72% of Total Billed Charges,1826.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1314.94,72,,170.192,Percent of Total Billed Charges,72% of Total Billed Charges,1095.78,60,,141.824,Percent of Total Billed Charges,60% of Total Billed Charges,1643.67,90,,86.52,Percent of Total Billed Charges,90% of Total Billed Charges,821.84,45,,77.792,Percent of Total Billed Charges,45% of Total Billed Charges,1643.67,90,,353.24,Percent of Total Billed Charges,90% of Total billed Charges,1826.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1826.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1826.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1187.1,65,,119.248,Percent of total Billed Charges,65% of Total Billed Charges,805.4,44.1,,76.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,1734.99,95,,372.864,Percent of Total Billed Charges,95% of Total Billed Charges,1826.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1607.14,88,,164.736,Percent of Total Billed Charges,88% of Total Billed Charges,1643.67,90,,353.24,Percent of Total Billed charges,90% of Total Billed Charges,805.4,1826.3,
SYM1510 SYMBOTEX MESH 15X10,2780003658,CDM,278,RC,,,Outpatient,,,1660.25,1079.16,,1660.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1261.79,76,,113.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1195.38,72,,167.616,Percent of Total Billed Charges,72% of Total Billed Charges,1195.38,72,,174.6,Percent of Total Billed charges,72% of Total Billed Charges,1660.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1195.38,72,,167.616,Percent of Total Billed Charges,72% of Total Billed Charges,996.15,60,,139.68,Percent of Total Billed Charges,60% of Total Billed Charges,1494.23,90,,60.48,Percent of Total Billed Charges,90% of Total Billed Charges,747.11,45,,84.24,Percent of Total Billed Charges,45% of Total Billed Charges,1494.23,90,,133.92,Percent of Total Billed Charges,90% of Total billed Charges,1660.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1660.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1660.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1079.16,65,,24.08,Percent of total Billed Charges,65% of Total Billed Charges,732.17,44.1,,82.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,1577.24,95,,141.36,Percent of Total Billed Charges,95% of Total Billed Charges,1660.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1461.02,88,,164.736,Percent of Total Billed Charges,88% of Total Billed Charges,1494.23,90,,133.92,Percent of Total Billed charges,90% of Total Billed Charges,732.17,1660.25,
SYM2015 SYMBOTEX MESH 20X15,2780003659,CDM,278,RC,,,Outpatient,,,2663.30,1731.15,,2663.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2024.11,76,,75.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1917.58,72,,62.784,Percent of Total Billed Charges,72% of Total Billed Charges,1917.58,72,,65.4,Percent of Total Billed charges,72% of Total Billed Charges,2663.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1917.58,72,,62.784,Percent of Total Billed Charges,72% of Total Billed Charges,1597.98,60,,52.32,Percent of Total Billed Charges,60% of Total Billed Charges,2396.97,90,,60.48,Percent of Total Billed Charges,90% of Total Billed Charges,1198.49,45,,84.24,Percent of Total Billed Charges,45% of Total Billed Charges,2396.97,90,,89.28,Percent of Total Billed Charges,90% of Total billed Charges,2663.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2663.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2663.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1731.15,65,,100.36,Percent of total Billed Charges,65% of Total Billed Charges,1174.52,44.1,,82.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,2530.14,95,,94.24,Percent of Total Billed Charges,95% of Total Billed Charges,2663.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2343.7,88,,163.768,Percent of Total Billed Charges,88% of Total Billed Charges,2396.97,90,,89.28,Percent of Total Billed charges,90% of Total Billed Charges,1174.52,2663.3,
STRYKER 5X42.5 LCK SCW,2780003660,CDM,278,RC,,,Outpatient,,,822.50,534.63,,822.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,625.1,76,,142.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,592.2,72,,66.048,Percent of Total Billed Charges,72% of Total Billed Charges,592.2,72,,68.8,Percent of Total Billed charges,72% of Total Billed Charges,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.2,72,,66.048,Percent of Total Billed Charges,72% of Total Billed Charges,493.5,60,,55.04,Percent of Total Billed Charges,60% of Total Billed Charges,740.25,90,,36,Percent of Total Billed Charges,90% of Total Billed Charges,370.13,45,,83.744,Percent of Total Billed Charges,45% of Total Billed Charges,740.25,90,,168.48,Percent of Total Billed Charges,90% of Total billed Charges,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,534.63,65,,52.744,Percent of total Billed Charges,65% of Total Billed Charges,362.72,44.1,,82.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,781.38,95,,177.84,Percent of Total Billed Charges,95% of Total Billed Charges,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,723.8,88,,52.008,Percent of Total Billed Charges,88% of Total Billed Charges,740.25,90,,168.48,Percent of Total Billed charges,90% of Total Billed Charges,362.72,822.5,
STRYKER 5X45 LCK SCW,2780003661,CDM,278,RC,,,Outpatient,,,822.50,534.63,,822.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,625.1,76,,131.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,592.2,72,,92.08,Percent of Total Billed Charges,72% of Total Billed Charges,592.2,72,,95.92,Percent of Total Billed charges,72% of Total Billed Charges,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.2,72,,92.08,Percent of Total Billed Charges,72% of Total Billed Charges,493.5,60,,76.736,Percent of Total Billed Charges,60% of Total Billed Charges,740.25,90,,29.52,Percent of Total Billed Charges,90% of Total Billed Charges,370.13,45,,26.592,Percent of Total Billed Charges,45% of Total Billed Charges,740.25,90,,155.584,Percent of Total Billed Charges,90% of Total billed Charges,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,534.63,65,,139.36,Percent of total Billed Charges,65% of Total Billed Charges,362.72,44.1,,26.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,781.38,95,,164.232,Percent of Total Billed Charges,95% of Total Billed Charges,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,723.8,88,,73.736,Percent of Total Billed Charges,88% of Total Billed Charges,740.25,90,,155.584,Percent of Total Billed charges,90% of Total Billed Charges,362.72,822.5,
STRYKER 5X50 LCK SCW,2780003662,CDM,278,RC,,,Outpatient,,,822.50,534.63,,822.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,625.1,76,,142.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,592.2,72,,110.496,Percent of Total Billed Charges,72% of Total Billed Charges,592.2,72,,115.104,Percent of Total Billed charges,72% of Total Billed Charges,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.2,72,,110.496,Percent of Total Billed Charges,72% of Total Billed Charges,493.5,60,,92.08,Percent of Total Billed Charges,60% of Total Billed Charges,740.25,90,,340.536,Percent of Total Billed Charges,90% of Total Billed Charges,370.13,45,,37.704,Percent of Total Billed Charges,45% of Total Billed Charges,740.25,90,,168.48,Percent of Total Billed Charges,90% of Total billed Charges,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,534.63,65,,30.384,Percent of total Billed Charges,65% of Total Billed Charges,362.72,44.1,,36.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,781.38,95,,177.84,Percent of Total Billed Charges,95% of Total Billed Charges,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,723.8,88,,84.6,Percent of Total Billed Charges,88% of Total Billed Charges,740.25,90,,168.48,Percent of Total Billed charges,90% of Total Billed Charges,362.72,822.5,
STRYKER 10.5X95 LAG SCW,2780003663,CDM,278,RC,,,Outpatient,,,2352.50,1529.13,,2352.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1787.9,76,,142.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1693.8,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,1693.8,72,,21.168,Percent of Total Billed charges,72% of Total Billed Charges,2352.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1693.8,72,,20.32,Percent of Total Billed Charges,72% of Total Billed Charges,1411.5,60,,16.936,Percent of Total Billed Charges,60% of Total Billed Charges,2117.25,90,,367.92,Percent of Total Billed Charges,90% of Total Billed Charges,1058.63,45,,43.264,Percent of Total Billed Charges,45% of Total Billed Charges,2117.25,90,,168.48,Percent of Total Billed Charges,90% of Total billed Charges,2352.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2352.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2352.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1529.13,65,,87.36,Percent of total Billed Charges,65% of Total Billed Charges,1037.45,44.1,,42.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,2234.88,95,,177.84,Percent of Total Billed Charges,95% of Total Billed Charges,2352.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2070.2,88,,59.136,Percent of Total Billed Charges,88% of Total Billed Charges,2117.25,90,,168.48,Percent of Total Billed charges,90% of Total Billed Charges,1037.45,2352.5,
STRYKR 12X380X125? LNG NAIL LT,2780003664,CDM,278,RC,,,Outpatient,,,10237.50,6654.38,,10237.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7780.5,76,,141.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7371,72,,50.112,Percent of Total Billed Charges,72% of Total Billed Charges,7371,72,,52.2,Percent of Total Billed charges,72% of Total Billed Charges,10237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7371,72,,50.112,Percent of Total Billed Charges,72% of Total Billed Charges,6142.5,60,,41.76,Percent of Total Billed Charges,60% of Total Billed Charges,9213.75,90,,340.536,Percent of Total Billed Charges,90% of Total Billed Charges,4606.88,45,,30.24,Percent of Total Billed Charges,45% of Total Billed Charges,9213.75,90,,167.496,Percent of Total Billed Charges,90% of Total billed Charges,10237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6654.38,65,,84.24,Percent of total Billed Charges,65% of Total Billed Charges,4514.74,44.1,,29.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,9725.63,95,,176.8,Percent of Total Billed Charges,95% of Total Billed Charges,10237.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9009,88,,59.136,Percent of Total Billed Charges,88% of Total Billed Charges,9213.75,90,,167.496,Percent of Total Billed charges,90% of Total Billed Charges,4514.74,10237.5,
AR-7559 FIBERLINK SUTTAPE 0.9,2780003665,CDM,278,RC,,,Outpatient,,,257.45,167.34,,257.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,195.66,76,,44.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,185.36,72,,189.248,Percent of Total Billed Charges,72% of Total Billed Charges,185.36,72,,197.128,Percent of Total Billed charges,72% of Total Billed Charges,257.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.36,72,,189.248,Percent of Total Billed Charges,72% of Total Billed Charges,154.47,60,,157.704,Percent of Total Billed Charges,60% of Total Billed Charges,231.71,90,,207.976,Percent of Total Billed Charges,90% of Total Billed Charges,115.85,45,,30.24,Percent of Total Billed Charges,45% of Total Billed Charges,231.71,90,,53.184,Percent of Total Billed Charges,90% of Total billed Charges,257.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.34,65,,128.96,Percent of total Billed Charges,65% of Total Billed Charges,113.54,44.1,,29.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,244.58,95,,56.144,Percent of Total Billed Charges,95% of Total Billed Charges,257.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.56,88,,35.2,Percent of Total Billed Charges,88% of Total Billed Charges,231.71,90,,53.184,Percent of Total Billed charges,90% of Total Billed Charges,113.54,257.45,
AR-7559T TIGERLINK SUTTAPE 0.9,2780003666,CDM,278,RC,,,Outpatient,,,257.45,167.34,,257.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,195.66,76,,63.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,185.36,72,,7.936,Percent of Total Billed Charges,72% of Total Billed Charges,185.36,72,,8.272,Percent of Total Billed charges,72% of Total Billed Charges,257.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.36,72,,7.936,Percent of Total Billed Charges,72% of Total Billed Charges,154.47,60,,6.616,Percent of Total Billed Charges,60% of Total Billed Charges,231.71,90,,174.96,Percent of Total Billed Charges,90% of Total Billed Charges,115.85,45,,18,Percent of Total Billed Charges,45% of Total Billed Charges,231.71,90,,75.416,Percent of Total Billed Charges,90% of Total billed Charges,257.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.34,65,,14.912,Percent of total Billed Charges,65% of Total Billed Charges,113.54,44.1,,17.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,244.58,95,,79.6,Percent of Total Billed Charges,95% of Total Billed Charges,257.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.56,88,,28.864,Percent of Total Billed Charges,88% of Total Billed Charges,231.71,90,,75.416,Percent of Total Billed charges,90% of Total Billed Charges,113.54,257.45,
AR-1923BC BIO-COMP-SITE P-LCK,2780003667,CDM,278,RC,,,Outpatient,,,1084.00,704.60,,1084,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,823.84,76,,73.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,780.48,72,,177.808,Percent of Total Billed Charges,72% of Total Billed Charges,780.48,72,,185.224,Percent of Total Billed charges,72% of Total Billed Charges,1084,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.48,72,,177.808,Percent of Total Billed Charges,72% of Total Billed Charges,650.4,60,,148.176,Percent of Total Billed Charges,60% of Total Billed Charges,975.6,90,,184.16,Percent of Total Billed Charges,90% of Total Billed Charges,487.8,45,,14.76,Percent of Total Billed Charges,45% of Total Billed Charges,975.6,90,,86.52,Percent of Total Billed Charges,90% of Total billed Charges,1084,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1084,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1084,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704.6,65,,44.2,Percent of total Billed Charges,65% of Total Billed Charges,478.04,44.1,,14.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,1029.8,95,,91.328,Percent of Total Billed Charges,95% of Total Billed Charges,1084,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,953.92,88,,332.968,Percent of Total Billed Charges,88% of Total Billed Charges,975.6,90,,86.52,Percent of Total Billed charges,90% of Total Billed Charges,478.04,1084,
"AR-7209SN #2 FBRSNRE,#2 FBRWRE",2780003668,CDM,278,RC,,,Outpatient,,,4607.00,2994.55,,4607,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3501.32,76,,51.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3317.04,72,,44.352,Percent of Total Billed Charges,72% of Total Billed Charges,3317.04,72,,46.2,Percent of Total Billed charges,72% of Total Billed Charges,4607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3317.04,72,,44.352,Percent of Total Billed Charges,72% of Total Billed Charges,2764.2,60,,36.96,Percent of Total Billed Charges,60% of Total Billed Charges,4146.3,90,,19.84,Percent of Total Billed Charges,90% of Total Billed Charges,2073.15,45,,170.272,Percent of Total Billed Charges,45% of Total Billed Charges,4146.3,90,,60.48,Percent of Total Billed Charges,90% of Total billed Charges,4607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2994.55,65,,76.824,Percent of total Billed Charges,65% of Total Billed Charges,2031.69,44.1,,166.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,4376.65,95,,63.84,Percent of Total Billed Charges,95% of Total Billed Charges,4607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4054.16,88,,359.744,Percent of Total Billed Charges,88% of Total Billed Charges,4146.3,90,,60.48,Percent of Total Billed charges,90% of Total Billed Charges,2031.69,4607,
AR-8959TDS TIGHTROPE XP BTRSS,2780003669,CDM,278,RC,,,Outpatient,,,10826.45,7037.19,,10826.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8228.1,76,,51.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7795.04,72,,44.352,Percent of Total Billed Charges,72% of Total Billed Charges,7795.04,72,,46.2,Percent of Total Billed charges,72% of Total Billed Charges,10826.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7795.04,72,,44.352,Percent of Total Billed Charges,72% of Total Billed Charges,6495.87,60,,36.96,Percent of Total Billed Charges,60% of Total Billed Charges,9743.81,90,,22.32,Percent of Total Billed Charges,90% of Total Billed Charges,4871.9,45,,183.96,Percent of Total Billed Charges,45% of Total Billed Charges,9743.81,90,,60.48,Percent of Total Billed Charges,90% of Total billed Charges,10826.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10826.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10826.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7037.19,65,,80.264,Percent of total Billed Charges,65% of Total Billed Charges,4774.46,44.1,,180.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,10285.13,95,,63.84,Percent of Total Billed Charges,95% of Total Billed Charges,10826.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9527.28,88,,332.968,Percent of Total Billed Charges,88% of Total Billed Charges,9743.81,90,,60.48,Percent of Total Billed charges,90% of Total Billed Charges,4774.46,10826.45,
AR-1588AL-CP2 MPL SYS ALLOGRFT,2780003670,CDM,278,RC,,,Outpatient,,,5298.05,3443.73,,5298.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4026.52,76,,30.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3814.6,72,,43.816,Percent of Total Billed Charges,72% of Total Billed Charges,3814.6,72,,45.64,Percent of Total Billed charges,72% of Total Billed Charges,5298.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3814.6,72,,43.816,Percent of Total Billed Charges,72% of Total Billed Charges,3178.83,60,,36.512,Percent of Total Billed Charges,60% of Total Billed Charges,4768.25,90,,65.888,Percent of Total Billed Charges,90% of Total Billed Charges,2384.12,45,,170.272,Percent of Total Billed Charges,45% of Total Billed Charges,4768.25,90,,36,Percent of Total Billed Charges,90% of Total billed Charges,5298.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5298.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5298.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3443.73,65,,292.96,Percent of total Billed Charges,65% of Total Billed Charges,2336.44,44.1,,166.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,5033.15,95,,38,Percent of Total Billed Charges,95% of Total Billed Charges,5298.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4662.28,88,,203.36,Percent of Total Billed Charges,88% of Total Billed Charges,4768.25,90,,36,Percent of Total Billed charges,90% of Total Billed Charges,2336.44,5298.05,
AR-1593-BC 2NDRY FIXATION,2780003671,CDM,278,RC,,,Outpatient,,,1964.75,1277.09,,1964.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1493.21,76,,24.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1414.62,72,,40.32,Percent of Total Billed Charges,72% of Total Billed Charges,1414.62,72,,42,Percent of Total Billed charges,72% of Total Billed Charges,1964.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1414.62,72,,40.32,Percent of Total Billed Charges,72% of Total Billed Charges,1178.85,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,1768.28,90,,185.752,Percent of Total Billed Charges,90% of Total Billed Charges,884.14,45,,103.992,Percent of Total Billed Charges,45% of Total Billed Charges,1768.28,90,,29.52,Percent of Total Billed Charges,90% of Total billed Charges,1964.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1964.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1964.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1277.09,65,,108.352,Percent of total Billed Charges,65% of Total Billed Charges,866.45,44.1,,101.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,1866.51,95,,31.16,Percent of Total Billed Charges,95% of Total Billed Charges,1964.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1728.98,88,,171.072,Percent of Total Billed Charges,88% of Total Billed Charges,1768.28,90,,29.52,Percent of Total Billed charges,90% of Total Billed Charges,866.45,1964.75,
AR-4580 FIBERSTITCH 1.5 CVD,2780003672,CDM,278,RC,,,Outpatient,,,1490.50,968.83,,1490.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1132.78,76,,287.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1073.16,72,,61.6,Percent of Total Billed Charges,72% of Total Billed Charges,1073.16,72,,64.168,Percent of Total Billed charges,72% of Total Billed Charges,1490.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1073.16,72,,61.6,Percent of Total Billed Charges,72% of Total Billed Charges,894.3,60,,51.328,Percent of Total Billed Charges,60% of Total Billed Charges,1341.45,90,,109.552,Percent of Total Billed Charges,90% of Total Billed Charges,670.73,45,,87.48,Percent of Total Billed Charges,45% of Total Billed Charges,1341.45,90,,340.536,Percent of Total Billed Charges,90% of Total billed Charges,1490.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1490.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1490.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,968.83,65,,131.288,Percent of total Billed Charges,65% of Total Billed Charges,657.31,44.1,,85.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,1415.98,95,,359.456,Percent of Total Billed Charges,95% of Total Billed Charges,1490.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.64,88,,180.072,Percent of Total Billed Charges,88% of Total Billed Charges,1341.45,90,,340.536,Percent of Total Billed charges,90% of Total Billed Charges,657.31,1490.5,
AR-4580 FIBRSTCH 1.5 24? CVD,2780003673,CDM,278,RC,,,Outpatient,,,1490.50,968.83,,1490.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1132.78,76,,310.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1073.16,72,,36.288,Percent of Total Billed Charges,72% of Total Billed Charges,1073.16,72,,37.8,Percent of Total Billed charges,72% of Total Billed Charges,1490.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1073.16,72,,36.288,Percent of Total Billed Charges,72% of Total Billed Charges,894.3,60,,30.24,Percent of Total Billed Charges,60% of Total Billed Charges,1341.45,90,,50.008,Percent of Total Billed Charges,90% of Total Billed Charges,670.73,45,,92.08,Percent of Total Billed Charges,45% of Total Billed Charges,1341.45,90,,367.92,Percent of Total Billed Charges,90% of Total billed Charges,1490.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1490.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1490.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,968.83,65,,114.664,Percent of total Billed Charges,65% of Total Billed Charges,657.31,44.1,,90.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,1415.98,95,,388.36,Percent of Total Billed Charges,95% of Total Billed Charges,1490.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.64,88,,19.4,Percent of Total Billed Charges,88% of Total Billed Charges,1341.45,90,,367.92,Percent of Total Billed charges,90% of Total Billed Charges,657.31,1490.5,
AR-4580R FBRSTCH 1.5 RVRSE,2780003674,CDM,278,RC,,,Outpatient,,,1490.50,968.83,,1490.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1132.78,76,,287.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1073.16,72,,78.336,Percent of Total Billed Charges,72% of Total Billed Charges,1073.16,72,,81.6,Percent of Total Billed charges,72% of Total Billed Charges,1490.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1073.16,72,,78.336,Percent of Total Billed Charges,72% of Total Billed Charges,894.3,60,,65.28,Percent of Total Billed Charges,60% of Total Billed Charges,1341.45,90,,60.48,Percent of Total Billed Charges,90% of Total Billed Charges,670.73,45,,9.92,Percent of Total Billed Charges,45% of Total Billed Charges,1341.45,90,,340.536,Percent of Total Billed Charges,90% of Total billed Charges,1490.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1490.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1490.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,968.83,65,,138.32,Percent of total Billed Charges,65% of Total Billed Charges,657.31,44.1,,9.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,1415.98,95,,359.456,Percent of Total Billed Charges,95% of Total Billed Charges,1490.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.64,88,,21.824,Percent of Total Billed Charges,88% of Total Billed Charges,1341.45,90,,340.536,Percent of Total Billed charges,90% of Total Billed Charges,657.31,1490.5,
AR-4580S FIBERSTCH 1.5 ST,2780003675,CDM,278,RC,,,Outpatient,,,1490.50,968.83,,1490.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1132.78,76,,175.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1073.16,72,,70.848,Percent of Total Billed Charges,72% of Total Billed Charges,1073.16,72,,73.8,Percent of Total Billed charges,72% of Total Billed Charges,1490.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1073.16,72,,70.848,Percent of Total Billed Charges,72% of Total Billed Charges,894.3,60,,59.04,Percent of Total Billed Charges,60% of Total Billed Charges,1341.45,90,,285.768,Percent of Total Billed Charges,90% of Total Billed Charges,670.73,45,,11.16,Percent of Total Billed Charges,45% of Total Billed Charges,1341.45,90,,207.976,Percent of Total Billed Charges,90% of Total billed Charges,1490.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1490.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1490.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,968.83,65,,159.12,Percent of total Billed Charges,65% of Total Billed Charges,657.31,44.1,,10.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,1415.98,95,,219.536,Percent of Total Billed Charges,95% of Total Billed Charges,1490.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.64,88,,64.424,Percent of Total Billed Charges,88% of Total Billed Charges,1341.45,90,,207.976,Percent of Total Billed charges,90% of Total Billed Charges,657.31,1490.5,
PLP14341 MTP CP PLATE LEFT,2780003676,CDM,278,RC,,,Outpatient,,,4804.25,3122.76,,4804.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3651.23,76,,147.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3459.06,72,,65.664,Percent of Total Billed Charges,72% of Total Billed Charges,3459.06,72,,68.4,Percent of Total Billed charges,72% of Total Billed Charges,4804.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3459.06,72,,65.664,Percent of Total Billed Charges,72% of Total Billed Charges,2882.55,60,,54.72,Percent of Total Billed Charges,60% of Total Billed Charges,4323.83,90,,225.44,Percent of Total Billed Charges,90% of Total Billed Charges,2161.91,45,,32.944,Percent of Total Billed Charges,45% of Total Billed Charges,4323.83,90,,174.96,Percent of Total Billed Charges,90% of Total billed Charges,4804.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4804.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4804.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3122.76,65,,43.16,Percent of total Billed Charges,65% of Total Billed Charges,2118.67,44.1,,32.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,4564.04,95,,184.68,Percent of Total Billed Charges,95% of Total Billed Charges,4804.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4227.74,88,,181.624,Percent of Total Billed Charges,88% of Total Billed Charges,4323.83,90,,174.96,Percent of Total Billed charges,90% of Total Billed Charges,2118.67,4804.25,
"PLSL3010 LCK SCW,T8, 3.0X10",2780003677,CDM,278,RC,,,Outpatient,,,492.25,319.96,,492.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,374.11,76,,155.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,354.42,72,,88.128,Percent of Total Billed Charges,72% of Total Billed Charges,354.42,72,,91.8,Percent of Total Billed charges,72% of Total Billed Charges,492.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.42,72,,88.128,Percent of Total Billed Charges,72% of Total Billed Charges,295.35,60,,73.44,Percent of Total Billed Charges,60% of Total Billed Charges,443.03,90,,225.44,Percent of Total Billed Charges,90% of Total Billed Charges,221.51,45,,92.88,Percent of Total Billed Charges,45% of Total Billed Charges,443.03,90,,184.16,Percent of Total Billed Charges,90% of Total billed Charges,492.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319.96,65,,55.608,Percent of total Billed Charges,65% of Total Billed Charges,217.08,44.1,,91.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,467.64,95,,194.392,Percent of Total Billed Charges,95% of Total Billed Charges,492.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,433.18,88,,107.112,Percent of Total Billed Charges,88% of Total Billed Charges,443.03,90,,184.16,Percent of Total Billed charges,90% of Total Billed Charges,217.08,492.25,
"PLSL3016 LCK SCW,T8, 3.0X16",2780003678,CDM,278,RC,,,Outpatient,,,492.25,319.96,,492.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,374.11,76,,16.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,354.42,72,,160.704,Percent of Total Billed Charges,72% of Total Billed Charges,354.42,72,,167.4,Percent of Total Billed charges,72% of Total Billed Charges,492.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.42,72,,160.704,Percent of Total Billed Charges,72% of Total Billed Charges,295.35,60,,133.92,Percent of Total Billed Charges,60% of Total Billed Charges,443.03,90,,53.184,Percent of Total Billed Charges,90% of Total Billed Charges,221.51,45,,54.776,Percent of Total Billed Charges,45% of Total Billed Charges,443.03,90,,19.84,Percent of Total Billed Charges,90% of Total billed Charges,492.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319.96,65,,60.776,Percent of total Billed Charges,65% of Total Billed Charges,217.08,44.1,,53.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,467.64,95,,20.944,Percent of Total Billed Charges,95% of Total Billed Charges,492.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,433.18,88,,48.896,Percent of Total Billed Charges,88% of Total Billed Charges,443.03,90,,19.84,Percent of Total Billed charges,90% of Total Billed Charges,217.08,492.25,
"PLSS3012 NON-LCK SCW,T8,3.0X12",2780003679,CDM,278,RC,,,Outpatient,,,346.50,225.23,,346.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,263.34,76,,18.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,249.48,72,,175.68,Percent of Total Billed Charges,72% of Total Billed Charges,249.48,72,,183,Percent of Total Billed charges,72% of Total Billed Charges,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.48,72,,175.68,Percent of Total Billed Charges,72% of Total Billed Charges,207.9,60,,146.4,Percent of Total Billed Charges,60% of Total Billed Charges,311.85,90,,210.96,Percent of Total Billed Charges,90% of Total Billed Charges,155.93,45,,25.008,Percent of Total Billed Charges,45% of Total Billed Charges,311.85,90,,22.32,Percent of Total Billed Charges,90% of Total billed Charges,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.23,65,,60.776,Percent of total Billed Charges,65% of Total Billed Charges,152.81,44.1,,24.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,329.18,95,,23.56,Percent of Total Billed Charges,95% of Total Billed Charges,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.92,88,,59.136,Percent of Total Billed Charges,88% of Total Billed Charges,311.85,90,,22.32,Percent of Total Billed charges,90% of Total Billed Charges,152.81,346.5,
"PLSS3020 NON-LCK SCW,T8,3.0X20",2780003680,CDM,278,RC,,,Outpatient,,,346.50,225.23,,346.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,263.34,76,,55.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,249.48,72,,167.648,Percent of Total Billed Charges,72% of Total Billed Charges,249.48,72,,174.64,Percent of Total Billed charges,72% of Total Billed Charges,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.48,72,,167.648,Percent of Total Billed Charges,72% of Total Billed Charges,207.9,60,,139.712,Percent of Total Billed Charges,60% of Total Billed Charges,311.85,90,,165.112,Percent of Total Billed Charges,90% of Total Billed Charges,155.93,45,,30.24,Percent of Total Billed Charges,45% of Total Billed Charges,311.85,90,,65.888,Percent of Total Billed Charges,90% of Total billed Charges,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.23,65,,60.776,Percent of total Billed Charges,65% of Total Billed Charges,152.81,44.1,,29.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,329.18,95,,69.544,Percent of Total Billed Charges,95% of Total Billed Charges,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.92,88,,279.416,Percent of Total Billed Charges,88% of Total Billed Charges,311.85,90,,65.888,Percent of Total Billed charges,90% of Total Billed Charges,152.81,346.5,
XFO082001 STD DRILL BIT 2.0,2780003681,CDM,278,RC,,,Outpatient,,,682.50,443.63,,682.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,518.7,76,,156.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,491.4,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,491.4,72,,36.384,Percent of Total Billed charges,72% of Total Billed Charges,682.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.4,72,,34.928,Percent of Total Billed Charges,72% of Total Billed Charges,409.5,60,,29.104,Percent of Total Billed Charges,60% of Total Billed Charges,614.25,90,,33.344,Percent of Total Billed Charges,90% of Total Billed Charges,307.13,45,,142.888,Percent of Total Billed Charges,45% of Total Billed Charges,614.25,90,,185.752,Percent of Total Billed Charges,90% of Total billed Charges,682.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,682.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,682.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,443.63,65,,60.776,Percent of total Billed Charges,65% of Total Billed Charges,300.98,44.1,,140.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,648.38,95,,196.072,Percent of Total Billed Charges,95% of Total Billed Charges,682.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,600.6,88,,220.432,Percent of Total Billed Charges,88% of Total Billed Charges,614.25,90,,185.752,Percent of Total Billed charges,90% of Total Billed Charges,300.98,682.5,
STRYKER 40-20112 2.0 ASNIS SCW,2780003682,CDM,278,RC,,,Outpatient,,,770.00,500.50,,770,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,585.2,76,,92.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,554.4,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,554.4,72,,51.6,Percent of Total Billed charges,72% of Total Billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.4,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,462,60,,41.28,Percent of Total Billed Charges,60% of Total Billed Charges,693,90,,138.96,Percent of Total Billed Charges,90% of Total Billed Charges,346.5,45,,112.72,Percent of Total Billed Charges,45% of Total Billed Charges,693,90,,109.552,Percent of Total Billed Charges,90% of Total billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.5,65,,60.776,Percent of total Billed Charges,65% of Total Billed Charges,339.57,44.1,,110.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,731.5,95,,115.632,Percent of Total Billed Charges,95% of Total Billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.6,88,,220.432,Percent of Total Billed Charges,88% of Total Billed Charges,693,90,,109.552,Percent of Total Billed charges,90% of Total Billed Charges,339.57,770,
STRYKER 40-20114 2.0 ASNIS SCW,2780003683,CDM,278,RC,,,Outpatient,,,770.00,500.50,,770,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,585.2,76,,42.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,554.4,72,,47.232,Percent of Total Billed Charges,72% of Total Billed Charges,554.4,72,,49.2,Percent of Total Billed charges,72% of Total Billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.4,72,,47.232,Percent of Total Billed Charges,72% of Total Billed Charges,462,60,,39.36,Percent of Total Billed Charges,60% of Total Billed Charges,693,90,,73.032,Percent of Total Billed Charges,90% of Total Billed Charges,346.5,45,,112.72,Percent of Total Billed Charges,45% of Total Billed Charges,693,90,,50.008,Percent of Total Billed Charges,90% of Total billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.5,65,,72.24,Percent of total Billed Charges,65% of Total Billed Charges,339.57,44.1,,110.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,731.5,95,,52.792,Percent of Total Billed Charges,95% of Total Billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.6,88,,52.008,Percent of Total Billed Charges,88% of Total Billed Charges,693,90,,50.008,Percent of Total Billed charges,90% of Total Billed Charges,339.57,770,
STRYKER 45-20001S 2.0 SCWDRVR,2780003684,CDM,278,RC,,,Outpatient,,,957.00,622.05,,957,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,727.32,76,,51.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,689.04,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,689.04,72,,52.92,Percent of Total Billed charges,72% of Total Billed Charges,957,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,689.04,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,574.2,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,861.3,90,,192.96,Percent of Total Billed Charges,90% of Total Billed Charges,430.65,45,,26.592,Percent of Total Billed Charges,45% of Total Billed Charges,861.3,90,,60.48,Percent of Total Billed Charges,90% of Total billed Charges,957,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,957,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,957,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,622.05,65,,17.2,Percent of total Billed Charges,65% of Total Billed Charges,422.04,44.1,,26.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,909.15,95,,63.84,Percent of Total Billed Charges,95% of Total Billed Charges,957,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,842.16,88,,206.272,Percent of Total Billed Charges,88% of Total Billed Charges,861.3,90,,60.48,Percent of Total Billed charges,90% of Total Billed Charges,422.04,957,
STRYKER 45-20005S 2.0 DRILL CA,2780003685,CDM,278,RC,,,Outpatient,,,105.00,68.25,,105,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.8,76,,241.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75.6,72,,53.568,Percent of Total Billed Charges,72% of Total Billed Charges,75.6,72,,55.8,Percent of Total Billed charges,72% of Total Billed Charges,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.6,72,,53.568,Percent of Total Billed Charges,72% of Total Billed Charges,63,60,,44.64,Percent of Total Billed Charges,60% of Total Billed Charges,94.5,90,,42.072,Percent of Total Billed Charges,90% of Total Billed Charges,47.25,45,,105.48,Percent of Total Billed Charges,45% of Total Billed Charges,94.5,90,,285.768,Percent of Total Billed Charges,90% of Total billed Charges,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.25,65,,233.48,Percent of total Billed Charges,65% of Total Billed Charges,46.31,44.1,,103.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,99.75,95,,301.648,Percent of Total Billed Charges,95% of Total Billed Charges,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.4,88,,161.44,Percent of Total Billed Charges,88% of Total Billed Charges,94.5,90,,285.768,Percent of Total Billed charges,90% of Total Billed Charges,46.31,105,
STRYKER 45-20007S CNTRSINK CAN,2780003686,CDM,278,RC,,,Outpatient,,,1110.00,721.50,,1110,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,843.6,76,,190.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,799.2,72,,47.808,Percent of Total Billed Charges,72% of Total Billed Charges,799.2,72,,49.8,Percent of Total Billed charges,72% of Total Billed Charges,1110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,799.2,72,,47.808,Percent of Total Billed Charges,72% of Total Billed Charges,666,60,,39.84,Percent of Total Billed Charges,60% of Total Billed Charges,999,90,,120.96,Percent of Total Billed Charges,90% of Total Billed Charges,499.5,45,,82.552,Percent of Total Billed Charges,45% of Total Billed Charges,999,90,,225.44,Percent of Total Billed Charges,90% of Total billed Charges,1110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,721.5,65,,72.24,Percent of total Billed Charges,65% of Total Billed Charges,489.51,44.1,,80.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,1054.5,95,,237.96,Percent of Total Billed Charges,95% of Total Billed Charges,1110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,976.8,88,,32.6,Percent of Total Billed Charges,88% of Total Billed Charges,999,90,,225.44,Percent of Total Billed charges,90% of Total Billed Charges,489.51,1110,
TRYKER 45-20015S K-WIRE,2780003687,CDM,278,RC,,,Outpatient,,,142.50,92.63,,142.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,108.3,76,,190.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,102.6,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,102.6,72,,51.6,Percent of Total Billed charges,72% of Total Billed Charges,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.6,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,85.5,60,,41.28,Percent of Total Billed Charges,60% of Total Billed Charges,128.25,90,,116.64,Percent of Total Billed Charges,90% of Total Billed Charges,64.13,45,,16.672,Percent of Total Billed Charges,45% of Total Billed Charges,128.25,90,,225.44,Percent of Total Billed Charges,90% of Total billed Charges,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.63,65,,33.824,Percent of total Billed Charges,65% of Total Billed Charges,62.84,44.1,,16.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,135.38,95,,237.96,Percent of Total Billed Charges,95% of Total Billed Charges,142.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.4,88,,135.872,Percent of Total Billed Charges,88% of Total Billed Charges,128.25,90,,225.44,Percent of Total Billed charges,90% of Total Billed Charges,62.84,142.5,
M00509001 ENDOVIVE SFT PEG,2780003688,CDM,278,RC,,,Outpatient,,,591.20,384.28,,591.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,449.31,76,,44.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,425.66,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,425.66,72,,84.672,Percent of Total Billed charges,72% of Total Billed Charges,591.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,425.66,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,354.72,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,532.08,90,,178.56,Percent of Total Billed Charges,90% of Total Billed Charges,266.04,45,,69.48,Percent of Total Billed Charges,45% of Total Billed Charges,532.08,90,,53.184,Percent of Total Billed Charges,90% of Total billed Charges,591.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,591.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,591.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.28,65,,32.76,Percent of total Billed Charges,65% of Total Billed Charges,260.72,44.1,,68.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,561.64,95,,56.144,Percent of Total Billed Charges,95% of Total Billed Charges,591.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520.26,88,,71.408,Percent of Total Billed Charges,88% of Total Billed Charges,532.08,90,,53.184,Percent of Total Billed charges,90% of Total Billed Charges,260.72,591.2,
M00509911 18FR REPL G-TUBE ST,2780003689,CDM,278,RC,,,Outpatient,,,226.15,147.00,,226.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171.87,76,,178.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162.83,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,162.83,72,,84.672,Percent of Total Billed charges,72% of Total Billed Charges,226.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.83,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,135.69,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,203.54,90,,20.64,Percent of Total Billed Charges,90% of Total Billed Charges,101.77,45,,36.512,Percent of Total Billed Charges,45% of Total Billed Charges,203.54,90,,210.96,Percent of Total Billed Charges,90% of Total billed Charges,226.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147,65,,33.824,Percent of total Billed Charges,65% of Total Billed Charges,99.73,44.1,,35.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,214.84,95,,222.68,Percent of Total Billed Charges,95% of Total Billed Charges,226.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.01,88,,188.672,Percent of Total Billed Charges,88% of Total Billed Charges,203.54,90,,210.96,Percent of Total Billed charges,90% of Total Billed Charges,99.73,226.15,
M00509921 20FR REPL G-TUBE ST,2780003690,CDM,278,RC,,,Outpatient,,,226.15,147.00,,226.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171.87,76,,139.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162.83,72,,114.304,Percent of Total Billed Charges,72% of Total Billed Charges,162.83,72,,119.072,Percent of Total Billed charges,72% of Total Billed Charges,226.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.83,72,,114.304,Percent of Total Billed Charges,72% of Total Billed Charges,135.69,60,,95.256,Percent of Total Billed Charges,60% of Total Billed Charges,203.54,90,,61.2,Percent of Total Billed Charges,90% of Total Billed Charges,101.77,45,,96.48,Percent of Total Billed Charges,45% of Total Billed Charges,203.54,90,,165.112,Percent of Total Billed Charges,90% of Total billed Charges,226.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147,65,,32.76,Percent of total Billed Charges,65% of Total Billed Charges,99.73,44.1,,94.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,214.84,95,,174.28,Percent of Total Billed Charges,95% of Total Billed Charges,226.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.01,88,,41.136,Percent of Total Billed Charges,88% of Total Billed Charges,203.54,90,,165.112,Percent of Total Billed charges,90% of Total Billed Charges,99.73,226.15,
M00509931 22FR REPL G-TUBE ST,2780003691,CDM,278,RC,,,Outpatient,,,226.15,147.00,,226.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171.87,76,,28.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162.83,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,162.83,72,,28.448,Percent of Total Billed charges,72% of Total Billed Charges,226.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.83,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,135.69,60,,22.76,Percent of Total Billed Charges,60% of Total Billed Charges,203.54,90,,106.376,Percent of Total Billed Charges,90% of Total Billed Charges,101.77,45,,21.032,Percent of Total Billed Charges,45% of Total Billed Charges,203.54,90,,33.344,Percent of Total Billed Charges,90% of Total billed Charges,226.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147,65,,35.88,Percent of total Billed Charges,65% of Total Billed Charges,99.73,44.1,,20.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,214.84,95,,35.192,Percent of Total Billed Charges,95% of Total Billed Charges,226.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.01,88,,118.272,Percent of Total Billed Charges,88% of Total Billed Charges,203.54,90,,33.344,Percent of Total Billed charges,90% of Total Billed Charges,99.73,226.15,
AR-2600SBS-9 SPEEDBRG IMP SYS,2780003692,CDM,278,RC,,,Outpatient,,,5176.10,3364.47,,5176.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3933.84,76,,117.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3726.79,72,,365.784,Percent of Total Billed Charges,72% of Total Billed Charges,3726.79,72,,381.024,Percent of Total Billed charges,72% of Total Billed Charges,5176.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3726.79,72,,365.784,Percent of Total Billed Charges,72% of Total Billed Charges,3105.66,60,,304.816,Percent of Total Billed Charges,60% of Total Billed Charges,4658.49,90,,111.136,Percent of Total Billed Charges,90% of Total Billed Charges,2329.25,45,,60.48,Percent of Total Billed Charges,45% of Total Billed Charges,4658.49,90,,138.96,Percent of Total Billed Charges,90% of Total billed Charges,5176.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5176.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5176.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3364.47,65,,63.44,Percent of total Billed Charges,65% of Total Billed Charges,2282.66,44.1,,59.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,4917.3,95,,146.68,Percent of Total Billed Charges,95% of Total Billed Charges,5176.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4554.97,88,,114.048,Percent of Total Billed Charges,88% of Total Billed Charges,4658.49,90,,138.96,Percent of Total Billed charges,90% of Total Billed Charges,2282.66,5176.1,
FQL QUADLINK-ZORC FLEXIGRAFT,2780003693,CDM,278,RC,,,Outpatient,,,6175.00,4013.75,,6175,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4693,76,,61.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4446,72,,162.432,Percent of Total Billed Charges,72% of Total Billed Charges,4446,72,,169.2,Percent of Total Billed charges,72% of Total Billed Charges,6175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4446,72,,162.432,Percent of Total Billed Charges,72% of Total Billed Charges,3705,60,,135.36,Percent of Total Billed Charges,60% of Total Billed Charges,5557.5,90,,405.632,Percent of Total Billed Charges,90% of Total Billed Charges,2778.75,45,,58.32,Percent of Total Billed Charges,45% of Total Billed Charges,5557.5,90,,73.032,Percent of Total Billed Charges,90% of Total billed Charges,6175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4013.75,65,,128.44,Percent of total Billed Charges,65% of Total Billed Charges,2723.18,44.1,,57.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,5866.25,95,,77.088,Percent of Total Billed Charges,95% of Total Billed Charges,6175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5434,88,,174.592,Percent of Total Billed Charges,88% of Total Billed Charges,5557.5,90,,73.032,Percent of Total Billed charges,90% of Total Billed Charges,2723.18,6175,
SPINAL TRAY 25GX3.5(SUB),2780003694,CDM,278,RC,,,Outpatient,,,36.88,23.97,,36.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.03,76,,162.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.55,72,,137.8,Percent of Total Billed Charges,72% of Total Billed Charges,26.55,72,,143.544,Percent of Total Billed charges,72% of Total Billed Charges,36.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.55,72,,137.8,Percent of Total Billed Charges,72% of Total Billed Charges,22.13,60,,114.832,Percent of Total Billed Charges,60% of Total Billed Charges,33.19,90,,150.024,Percent of Total Billed Charges,90% of Total Billed Charges,16.6,45,,89.28,Percent of Total Billed Charges,45% of Total Billed Charges,33.19,90,,192.96,Percent of Total Billed Charges,90% of Total billed Charges,36.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.97,65,,55.64,Percent of total Billed Charges,65% of Total Billed Charges,16.26,44.1,,87.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.04,95,,203.68,Percent of Total Billed Charges,95% of Total Billed Charges,36.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.45,88,,20.184,Percent of Total Billed Charges,88% of Total Billed Charges,33.19,90,,192.96,Percent of Total Billed charges,90% of Total Billed Charges,16.26,36.88,
8160-0085S 10.5 X 85 LAG SCW,2780003695,CDM,278,RC,,,Outpatient,,,2352.50,1529.13,,2352.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1787.9,76,,35.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1693.8,72,,25.344,Percent of Total Billed Charges,72% of Total Billed Charges,1693.8,72,,26.4,Percent of Total Billed charges,72% of Total Billed Charges,2352.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1693.8,72,,25.344,Percent of Total Billed Charges,72% of Total Billed Charges,1411.5,60,,21.12,Percent of Total Billed Charges,60% of Total Billed Charges,2117.25,90,,181.776,Percent of Total Billed Charges,90% of Total Billed Charges,1058.63,45,,10.32,Percent of Total Billed Charges,45% of Total Billed Charges,2117.25,90,,42.072,Percent of Total Billed Charges,90% of Total billed Charges,2352.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2352.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2352.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1529.13,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,1037.45,44.1,,10.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,2234.88,95,,44.408,Percent of Total Billed Charges,95% of Total Billed Charges,2352.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2070.2,88,,59.84,Percent of Total Billed Charges,88% of Total Billed Charges,2117.25,90,,42.072,Percent of Total Billed charges,90% of Total Billed Charges,1037.45,2352.5,
2361-5032S 5X32.5 ADV LCK SCW,2780003696,CDM,278,RC,,,Outpatient,,,972.50,632.13,,972.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,739.1,76,,102.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,700.2,72,,26.496,Percent of Total Billed Charges,72% of Total Billed Charges,700.2,72,,27.6,Percent of Total Billed charges,72% of Total Billed Charges,972.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,700.2,72,,26.496,Percent of Total Billed Charges,72% of Total Billed Charges,583.5,60,,22.08,Percent of Total Billed Charges,60% of Total Billed Charges,875.25,90,,158.76,Percent of Total Billed Charges,90% of Total Billed Charges,437.63,45,,30.6,Percent of Total Billed Charges,45% of Total Billed Charges,875.25,90,,120.96,Percent of Total Billed Charges,90% of Total billed Charges,972.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,972.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,972.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,632.13,65,,30.96,Percent of total Billed Charges,65% of Total Billed Charges,428.87,44.1,,29.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,923.88,95,,127.68,Percent of Total Billed Charges,95% of Total Billed Charges,972.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,855.8,88,,104.008,Percent of Total Billed Charges,88% of Total Billed Charges,875.25,90,,120.96,Percent of Total Billed charges,90% of Total Billed Charges,428.87,972.5,
2360-5035S 5X35 LCK SCW,2780003697,CDM,278,RC,,,Outpatient,,,822.50,534.63,,822.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,625.1,76,,98.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,592.2,72,,33.408,Percent of Total Billed Charges,72% of Total Billed Charges,592.2,72,,34.8,Percent of Total Billed charges,72% of Total Billed Charges,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.2,72,,33.408,Percent of Total Billed Charges,72% of Total Billed Charges,493.5,60,,27.84,Percent of Total Billed Charges,60% of Total Billed Charges,740.25,90,,191.52,Percent of Total Billed Charges,90% of Total Billed Charges,370.13,45,,53.184,Percent of Total Billed Charges,45% of Total Billed Charges,740.25,90,,116.64,Percent of Total Billed Charges,90% of Total billed Charges,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,534.63,65,,32.76,Percent of total Billed Charges,65% of Total Billed Charges,362.72,44.1,,52.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,781.38,95,,123.12,Percent of Total Billed Charges,95% of Total Billed Charges,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,723.8,88,,108.664,Percent of Total Billed Charges,88% of Total Billed Charges,740.25,90,,116.64,Percent of Total Billed charges,90% of Total Billed Charges,362.72,822.5,
PLP14342 MTP PLATE RIGHT,2780003700,CDM,278,RC,,,Outpatient,,,4804.25,3122.76,,4804.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3651.23,76,,150.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3459.06,72,,55.248,Percent of Total Billed Charges,72% of Total Billed Charges,3459.06,72,,57.552,Percent of Total Billed charges,72% of Total Billed Charges,4804.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3459.06,72,,55.248,Percent of Total Billed Charges,72% of Total Billed Charges,2882.55,60,,46.04,Percent of Total Billed Charges,60% of Total Billed Charges,4323.83,90,,220.32,Percent of Total Billed Charges,90% of Total Billed Charges,2161.91,45,,55.568,Percent of Total Billed Charges,45% of Total Billed Charges,4323.83,90,,178.56,Percent of Total Billed Charges,90% of Total billed Charges,4804.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4804.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4804.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3122.76,65,,49.92,Percent of total Billed Charges,65% of Total Billed Charges,2118.67,44.1,,54.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,4564.04,95,,188.48,Percent of Total Billed Charges,95% of Total Billed Charges,4804.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4227.74,88,,396.616,Percent of Total Billed Charges,88% of Total Billed Charges,4323.83,90,,178.56,Percent of Total Billed charges,90% of Total Billed Charges,2118.67,4804.25,
PLSL3512 3.5 LCK SCW 12MM,2780003701,CDM,278,RC,,,Outpatient,,,492.25,319.96,,492.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,374.11,76,,17.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,354.42,72,,127.008,Percent of Total Billed Charges,72% of Total Billed Charges,354.42,72,,132.304,Percent of Total Billed charges,72% of Total Billed Charges,492.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.42,72,,127.008,Percent of Total Billed Charges,72% of Total Billed Charges,295.35,60,,105.84,Percent of Total Billed Charges,60% of Total Billed Charges,443.03,90,,59.76,Percent of Total Billed Charges,90% of Total Billed Charges,221.51,45,,202.816,Percent of Total Billed Charges,45% of Total Billed Charges,443.03,90,,20.64,Percent of Total Billed Charges,90% of Total billed Charges,492.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319.96,65,,38.416,Percent of total Billed Charges,65% of Total Billed Charges,217.08,44.1,,198.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,467.64,95,,21.792,Percent of Total Billed Charges,95% of Total Billed Charges,492.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,433.18,88,,146.696,Percent of Total Billed Charges,88% of Total Billed Charges,443.03,90,,20.64,Percent of Total Billed charges,90% of Total Billed Charges,217.08,492.25,
PLSS3512 3.5 NONLCK SCW 12MM,2780003702,CDM,278,RC,,,Outpatient,,,346.50,225.23,,346.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,263.34,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,249.48,72,,80.064,Percent of Total Billed Charges,72% of Total Billed Charges,249.48,72,,83.4,Percent of Total Billed charges,72% of Total Billed Charges,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.48,72,,80.064,Percent of Total Billed Charges,72% of Total Billed Charges,207.9,60,,66.72,Percent of Total Billed Charges,60% of Total Billed Charges,311.85,90,,77,Percent of Total Billed Charges,90% of Total Billed Charges,155.93,45,,75.016,Percent of Total Billed Charges,45% of Total Billed Charges,311.85,90,,61.2,Percent of Total Billed Charges,90% of Total billed Charges,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.23,65,,60.192,Percent of total Billed Charges,65% of Total Billed Charges,152.81,44.1,,73.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,329.18,95,,64.6,Percent of Total Billed Charges,95% of Total Billed Charges,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.92,88,,177.736,Percent of Total Billed Charges,88% of Total Billed Charges,311.85,90,,61.2,Percent of Total Billed charges,90% of Total Billed Charges,152.81,346.5,
PLSS3520 3.5 NONLCK SCW 20MM,2780003703,CDM,278,RC,,,Outpatient,,,346.50,225.23,,346.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,263.34,76,,89.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,249.48,72,,170.824,Percent of Total Billed Charges,72% of Total Billed Charges,249.48,72,,177.944,Percent of Total Billed charges,72% of Total Billed Charges,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.48,72,,170.824,Percent of Total Billed Charges,72% of Total Billed Charges,207.9,60,,142.352,Percent of Total Billed Charges,60% of Total Billed Charges,311.85,90,,84.144,Percent of Total Billed Charges,90% of Total Billed Charges,155.93,45,,90.888,Percent of Total Billed Charges,45% of Total Billed Charges,311.85,90,,106.376,Percent of Total Billed Charges,90% of Total billed Charges,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.23,65,,76.248,Percent of total Billed Charges,65% of Total Billed Charges,152.81,44.1,,89.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,329.18,95,,112.28,Percent of Total Billed Charges,95% of Total Billed Charges,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.92,88,,155.232,Percent of Total Billed Charges,88% of Total Billed Charges,311.85,90,,106.376,Percent of Total Billed charges,90% of Total Billed Charges,152.81,346.5,
PLSS3526 3.5 NONLCK SCW 26MM,2780003704,CDM,278,RC,,,Outpatient,,,346.50,225.23,,346.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,263.34,76,,93.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,249.48,72,,115.776,Percent of Total Billed Charges,72% of Total Billed Charges,249.48,72,,120.6,Percent of Total Billed charges,72% of Total Billed Charges,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.48,72,,115.776,Percent of Total Billed Charges,72% of Total Billed Charges,207.9,60,,96.48,Percent of Total Billed Charges,60% of Total Billed Charges,311.85,90,,84.144,Percent of Total Billed Charges,90% of Total Billed Charges,155.93,45,,79.384,Percent of Total Billed Charges,45% of Total Billed Charges,311.85,90,,111.136,Percent of Total Billed Charges,90% of Total billed Charges,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.23,65,,73.952,Percent of total Billed Charges,65% of Total Billed Charges,152.81,44.1,,77.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,329.18,95,,117.304,Percent of Total Billed Charges,95% of Total Billed Charges,346.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.92,88,,187.264,Percent of Total Billed Charges,88% of Total Billed Charges,311.85,90,,111.136,Percent of Total Billed charges,90% of Total Billed Charges,152.81,346.5,
663812 2.3X12 BONE SCW,2780003705,CDM,278,RC,,,Outpatient,,,377.50,245.38,,377.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,286.9,76,,342.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,271.8,72,,141.12,Percent of Total Billed Charges,72% of Total Billed Charges,271.8,72,,147,Percent of Total Billed charges,72% of Total Billed Charges,377.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.8,72,,141.12,Percent of Total Billed Charges,72% of Total Billed Charges,226.5,60,,117.6,Percent of Total Billed Charges,60% of Total Billed Charges,339.75,90,,84.144,Percent of Total Billed Charges,90% of Total Billed Charges,169.88,45,,95.76,Percent of Total Billed Charges,45% of Total Billed Charges,339.75,90,,405.632,Percent of Total Billed Charges,90% of Total billed Charges,377.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.38,65,,170.848,Percent of total Billed Charges,65% of Total Billed Charges,166.48,44.1,,93.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,358.63,95,,428.168,Percent of Total Billed Charges,95% of Total Billed Charges,377.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.2,88,,215.424,Percent of Total Billed Charges,88% of Total Billed Charges,339.75,90,,405.632,Percent of Total Billed charges,90% of Total Billed Charges,166.48,377.5,
663813 2.3X13 BONE SCW,2780003706,CDM,278,RC,,,Outpatient,,,377.50,245.38,,377.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,286.9,76,,126.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,271.8,72,,181.44,Percent of Total Billed Charges,72% of Total Billed Charges,271.8,72,,189,Percent of Total Billed charges,72% of Total Billed Charges,377.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.8,72,,181.44,Percent of Total Billed Charges,72% of Total Billed Charges,226.5,60,,151.2,Percent of Total Billed Charges,60% of Total Billed Charges,339.75,90,,84.144,Percent of Total Billed Charges,90% of Total Billed Charges,169.88,45,,110.16,Percent of Total Billed Charges,45% of Total Billed Charges,339.75,90,,150.024,Percent of Total Billed Charges,90% of Total billed Charges,377.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.38,65,,170.848,Percent of total Billed Charges,65% of Total Billed Charges,166.48,44.1,,107.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,358.63,95,,158.36,Percent of Total Billed Charges,95% of Total Billed Charges,377.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.2,88,,58.432,Percent of Total Billed Charges,88% of Total Billed Charges,339.75,90,,150.024,Percent of Total Billed charges,90% of Total Billed Charges,166.48,377.5,
663816 2.3X16 BONE SCW,2780003707,CDM,278,RC,,,Outpatient,,,377.50,245.38,,377.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,286.9,76,,153.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,271.8,72,,346.096,Percent of Total Billed Charges,72% of Total Billed Charges,271.8,72,,360.52,Percent of Total Billed charges,72% of Total Billed Charges,377.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.8,72,,346.096,Percent of Total Billed Charges,72% of Total Billed Charges,226.5,60,,288.416,Percent of Total Billed Charges,60% of Total Billed Charges,339.75,90,,84.144,Percent of Total Billed Charges,90% of Total Billed Charges,169.88,45,,29.88,Percent of Total Billed Charges,45% of Total Billed Charges,339.75,90,,181.776,Percent of Total Billed Charges,90% of Total billed Charges,377.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.38,65,,81.984,Percent of total Billed Charges,65% of Total Billed Charges,166.48,44.1,,29.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,358.63,95,,191.88,Percent of Total Billed Charges,95% of Total Billed Charges,377.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.2,88,,75.288,Percent of Total Billed Charges,88% of Total Billed Charges,339.75,90,,181.776,Percent of Total Billed charges,90% of Total Billed Charges,166.48,377.5,
657712 2.0X12MM BONE SCW T6,2780003708,CDM,278,RC,,,Outpatient,,,280.00,182.00,,280,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,212.8,76,,134.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,201.6,72,,61.056,Percent of Total Billed Charges,72% of Total Billed Charges,201.6,72,,63.6,Percent of Total Billed charges,72% of Total Billed Charges,280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.6,72,,61.056,Percent of Total Billed Charges,72% of Total Billed Charges,168,60,,50.88,Percent of Total Billed Charges,60% of Total Billed Charges,252,90,,100.024,Percent of Total Billed Charges,90% of Total Billed Charges,126,45,,38.496,Percent of Total Billed Charges,45% of Total Billed Charges,252,90,,158.76,Percent of Total Billed Charges,90% of Total billed Charges,280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182,65,,105.04,Percent of total Billed Charges,65% of Total Billed Charges,123.48,44.1,,37.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,266,95,,167.584,Percent of Total Billed Charges,95% of Total Billed Charges,280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.4,88,,82.28,Percent of Total Billed Charges,88% of Total Billed Charges,252,90,,158.76,Percent of Total Billed charges,90% of Total Billed Charges,123.48,280,
657713 2.0X13MM BONE SCW T6,2780003709,CDM,278,RC,,,Outpatient,,,280.00,182.00,,280,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,212.8,76,,161.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,201.6,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,201.6,72,,54,Percent of Total Billed charges,72% of Total Billed Charges,280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.6,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,168,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,252,90,,23.816,Percent of Total Billed Charges,90% of Total Billed Charges,126,45,,42.072,Percent of Total Billed Charges,45% of Total Billed Charges,252,90,,191.52,Percent of Total Billed Charges,90% of Total billed Charges,280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182,65,,145.04,Percent of total Billed Charges,65% of Total Billed Charges,123.48,44.1,,41.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,266,95,,202.16,Percent of Total Billed Charges,95% of Total Billed Charges,280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.4,88,,82.28,Percent of Total Billed Charges,88% of Total Billed Charges,252,90,,191.52,Percent of Total Billed charges,90% of Total Billed Charges,123.48,280,
657716 2.0X16MM BONE SCW T6,2780003710,CDM,278,RC,,,Outpatient,,,280.00,182.00,,280,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,212.8,76,,186.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,201.6,72,,62.784,Percent of Total Billed Charges,72% of Total Billed Charges,201.6,72,,65.4,Percent of Total Billed charges,72% of Total Billed Charges,280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.6,72,,62.784,Percent of Total Billed Charges,72% of Total Billed Charges,168,60,,52.32,Percent of Total Billed Charges,60% of Total Billed Charges,252,90,,323.28,Percent of Total Billed Charges,90% of Total Billed Charges,126,45,,42.072,Percent of Total Billed Charges,45% of Total Billed Charges,252,90,,220.32,Percent of Total Billed Charges,90% of Total billed Charges,280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182,65,,62.488,Percent of total Billed Charges,65% of Total Billed Charges,123.48,44.1,,41.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,266,95,,232.56,Percent of Total Billed Charges,95% of Total Billed Charges,280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.4,88,,82.28,Percent of Total Billed Charges,88% of Total Billed Charges,252,90,,220.32,Percent of Total Billed charges,90% of Total Billed Charges,123.48,280,
AR-2260BC IMPL DELIVERY SYS,2780003711,CDM,278,RC,,,Outpatient,,,2981.00,1937.65,,2981,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2265.56,76,,50.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2146.32,72,,98.496,Percent of Total Billed Charges,72% of Total Billed Charges,2146.32,72,,102.6,Percent of Total Billed charges,72% of Total Billed Charges,2981,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2146.32,72,,98.496,Percent of Total Billed Charges,72% of Total Billed Charges,1788.6,60,,82.08,Percent of Total Billed Charges,60% of Total Billed Charges,2682.9,90,,100.024,Percent of Total Billed Charges,90% of Total Billed Charges,1341.45,45,,42.072,Percent of Total Billed Charges,45% of Total Billed Charges,2682.9,90,,59.76,Percent of Total Billed Charges,90% of Total billed Charges,2981,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2981,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2981,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1937.65,65,,153.072,Percent of total Billed Charges,65% of Total Billed Charges,1314.62,44.1,,41.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,2831.95,95,,63.08,Percent of Total Billed Charges,95% of Total Billed Charges,2981,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2623.28,88,,82.28,Percent of Total Billed Charges,88% of Total Billed Charges,2682.9,90,,59.76,Percent of Total Billed charges,90% of Total Billed Charges,1314.62,2981,
"AR-7273-17N FBRTAPE 1.7X 34""",2780003712,CDM,278,RC,,,Outpatient,,,205.95,133.87,,205.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,156.52,76,,65.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,148.28,72,,112.32,Percent of Total Billed Charges,72% of Total Billed Charges,148.28,72,,117,Percent of Total Billed charges,72% of Total Billed Charges,205.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.28,72,,112.32,Percent of Total Billed Charges,72% of Total Billed Charges,123.57,60,,93.6,Percent of Total Billed Charges,60% of Total Billed Charges,185.36,90,,46.84,Percent of Total Billed Charges,90% of Total Billed Charges,92.68,45,,42.072,Percent of Total Billed Charges,45% of Total Billed Charges,185.36,90,,77,Percent of Total Billed Charges,90% of Total billed Charges,205.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.87,65,,153.072,Percent of total Billed Charges,65% of Total Billed Charges,90.82,44.1,,41.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,195.65,95,,81.272,Percent of Total Billed Charges,95% of Total Billed Charges,205.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.24,88,,82.28,Percent of Total Billed Charges,88% of Total Billed Charges,185.36,90,,77,Percent of Total Billed charges,90% of Total Billed Charges,90.82,205.95,
"AR-7273-17TN TGRTAPE 1.7X34""",2780003713,CDM,278,RC,,,Outpatient,,,205.95,133.87,,205.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,156.52,76,,71.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,148.28,72,,95.616,Percent of Total Billed Charges,72% of Total Billed Charges,148.28,72,,99.6,Percent of Total Billed charges,72% of Total Billed Charges,205.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.28,72,,95.616,Percent of Total Billed Charges,72% of Total Billed Charges,123.57,60,,79.68,Percent of Total Billed Charges,60% of Total Billed Charges,185.36,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,92.68,45,,42.072,Percent of Total Billed Charges,45% of Total Billed Charges,185.36,90,,84.144,Percent of Total Billed Charges,90% of Total billed Charges,205.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.87,65,,153.072,Percent of total Billed Charges,65% of Total Billed Charges,90.82,44.1,,41.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,195.65,95,,88.824,Percent of Total Billed Charges,95% of Total Billed Charges,205.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.24,88,,97.8,Percent of Total Billed Charges,88% of Total Billed Charges,185.36,90,,84.144,Percent of Total Billed charges,90% of Total Billed Charges,90.82,205.95,
AR-8980P DX KNOTLESS SWLCK4.75,2780003714,CDM,278,RC,,,Outpatient,,,1409.20,915.98,,1409.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1070.99,76,,71.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1014.62,72,,153.04,Percent of Total Billed Charges,72% of Total Billed Charges,1014.62,72,,159.424,Percent of Total Billed charges,72% of Total Billed Charges,1409.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1014.62,72,,153.04,Percent of Total Billed Charges,72% of Total Billed Charges,845.52,60,,127.536,Percent of Total Billed Charges,60% of Total Billed Charges,1268.28,90,,46.84,Percent of Total Billed Charges,90% of Total Billed Charges,634.14,45,,50.008,Percent of Total Billed Charges,45% of Total Billed Charges,1268.28,90,,84.144,Percent of Total Billed Charges,90% of Total billed Charges,1409.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1409.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1409.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,915.98,65,,153.072,Percent of total Billed Charges,65% of Total Billed Charges,621.46,44.1,,49.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,1338.74,95,,88.824,Percent of Total Billed Charges,95% of Total Billed Charges,1409.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1240.1,88,,23.288,Percent of Total Billed Charges,88% of Total Billed Charges,1268.28,90,,84.144,Percent of Total Billed charges,90% of Total Billed Charges,621.46,1409.2,
AR-1288RTT2-FC3 IMPLSYS FBRLNK,2780003715,CDM,278,RC,,,Outpatient,,,3371.88,2191.72,,3371.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2562.63,76,,71.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2427.75,72,,100.8,Percent of Total Billed Charges,72% of Total Billed Charges,2427.75,72,,105,Percent of Total Billed charges,72% of Total Billed Charges,3371.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2427.75,72,,100.8,Percent of Total Billed Charges,72% of Total Billed Charges,2023.13,60,,84,Percent of Total Billed Charges,60% of Total Billed Charges,3034.69,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,1517.35,45,,11.912,Percent of Total Billed Charges,45% of Total Billed Charges,3034.69,90,,84.144,Percent of Total Billed Charges,90% of Total billed Charges,3371.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3371.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3371.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2191.72,65,,318.752,Percent of total Billed Charges,65% of Total Billed Charges,1487,44.1,,11.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,3203.29,95,,88.824,Percent of Total Billed Charges,95% of Total Billed Charges,3371.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2967.25,88,,316.096,Percent of Total Billed Charges,88% of Total Billed Charges,3034.69,90,,84.144,Percent of Total Billed charges,90% of Total Billed Charges,1487,3371.88,
AR-1588TB-3IB TIGHTROPE 3H 11M,2780003716,CDM,278,RC,,,Outpatient,,,745.25,484.41,,745.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,566.39,76,,71.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,536.58,72,,59.328,Percent of Total Billed Charges,72% of Total Billed Charges,536.58,72,,61.8,Percent of Total Billed charges,72% of Total Billed Charges,745.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,536.58,72,,59.328,Percent of Total Billed Charges,72% of Total Billed Charges,447.15,60,,49.44,Percent of Total Billed Charges,60% of Total Billed Charges,670.73,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,335.36,45,,161.64,Percent of Total Billed Charges,45% of Total Billed Charges,670.73,90,,84.144,Percent of Total Billed Charges,90% of Total billed Charges,745.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,745.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,745.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484.41,65,,318.752,Percent of total Billed Charges,65% of Total Billed Charges,328.66,44.1,,158.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,707.99,95,,88.824,Percent of Total Billed Charges,95% of Total Billed Charges,745.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.82,88,,97.8,Percent of Total Billed Charges,88% of Total Billed Charges,670.73,90,,84.144,Percent of Total Billed charges,90% of Total Billed Charges,328.66,745.25,
AR-1588TNT2 FBRTAG TIGHTRP II,2780003717,CDM,278,RC,,,Outpatient,,,1097.55,713.41,,1097.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,834.14,76,,71.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,790.24,72,,44.928,Percent of Total Billed Charges,72% of Total Billed Charges,790.24,72,,46.8,Percent of Total Billed charges,72% of Total Billed Charges,1097.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,790.24,72,,44.928,Percent of Total Billed Charges,72% of Total Billed Charges,658.53,60,,37.44,Percent of Total Billed Charges,60% of Total Billed Charges,987.8,90,,87.84,Percent of Total Billed Charges,90% of Total Billed Charges,493.9,45,,50.008,Percent of Total Billed Charges,45% of Total Billed Charges,987.8,90,,84.144,Percent of Total Billed Charges,90% of Total billed Charges,1097.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1097.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1097.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,713.41,65,,318.752,Percent of total Billed Charges,65% of Total Billed Charges,484.02,44.1,,49.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,1042.67,95,,88.824,Percent of Total Billed Charges,95% of Total Billed Charges,1097.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,965.84,88,,45.792,Percent of Total Billed Charges,88% of Total Billed Charges,987.8,90,,84.144,Percent of Total Billed charges,90% of Total Billed Charges,484.02,1097.55,
AR-2600SBS-8 SPEEDBRG IMP SYS,2780003718,CDM,278,RC,,,Outpatient,,,5176.10,3364.47,,5176.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3933.84,76,,84.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3726.79,72,,57.792,Percent of Total Billed Charges,72% of Total Billed Charges,3726.79,72,,60.2,Percent of Total Billed charges,72% of Total Billed Charges,5176.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3726.79,72,,57.792,Percent of Total Billed Charges,72% of Total Billed Charges,3105.66,60,,48.16,Percent of Total Billed Charges,60% of Total Billed Charges,4658.49,90,,177.84,Percent of Total Billed Charges,90% of Total Billed Charges,2329.25,45,,23.416,Percent of Total Billed Charges,45% of Total Billed Charges,4658.49,90,,100.024,Percent of Total Billed Charges,90% of Total billed Charges,5176.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5176.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5176.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3364.47,65,,318.752,Percent of total Billed Charges,65% of Total Billed Charges,2282.66,44.1,,22.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,4917.3,95,,105.576,Percent of Total Billed Charges,95% of Total Billed Charges,5176.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4554.97,88,,44.352,Percent of Total Billed Charges,88% of Total Billed Charges,4658.49,90,,100.024,Percent of Total Billed charges,90% of Total Billed Charges,2282.66,5176.1,
"ARTHREX WASHER,7.0MM,TI",2780003719,CDM,278,RC,,,Outpatient,,,94.85,61.65,,94.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.09,76,,20.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,68.29,72,,153.68,Percent of Total Billed Charges,72% of Total Billed Charges,68.29,72,,160.088,Percent of Total Billed charges,72% of Total Billed Charges,94.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.29,72,,153.68,Percent of Total Billed Charges,72% of Total Billed Charges,56.91,60,,128.072,Percent of Total Billed Charges,60% of Total Billed Charges,85.37,90,,77.04,Percent of Total Billed Charges,90% of Total Billed Charges,42.68,45,,22.68,Percent of Total Billed Charges,45% of Total Billed Charges,85.37,90,,23.816,Percent of Total Billed Charges,90% of Total billed Charges,94.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.65,65,,318.752,Percent of total Billed Charges,65% of Total Billed Charges,41.83,44.1,,22.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,90.11,95,,25.144,Percent of Total Billed Charges,95% of Total Billed Charges,94.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.47,88,,45.792,Percent of Total Billed Charges,88% of Total Billed Charges,85.37,90,,23.816,Percent of Total Billed charges,90% of Total Billed Charges,41.83,94.85,
ARTHREX LCK DIST FIB PLT RT 5H,2780003720,CDM,278,RC,,,Outpatient,,,1897.00,1233.05,,1897,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1441.72,76,,272.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1365.84,72,,407.696,Percent of Total Billed Charges,72% of Total Billed Charges,1365.84,72,,424.688,Percent of Total Billed charges,72% of Total Billed Charges,1897,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1365.84,72,,407.696,Percent of Total Billed Charges,72% of Total Billed Charges,1138.2,60,,339.752,Percent of Total Billed Charges,60% of Total Billed Charges,1707.3,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,853.65,45,,23.416,Percent of Total Billed Charges,45% of Total Billed Charges,1707.3,90,,323.28,Percent of Total Billed Charges,90% of Total billed Charges,1897,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1897,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1897,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1233.05,65,,318.752,Percent of total Billed Charges,65% of Total Billed Charges,836.58,44.1,,22.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,1802.15,95,,341.24,Percent of Total Billed Charges,95% of Total Billed Charges,1897,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1669.36,88,,44.352,Percent of Total Billed Charges,88% of Total Billed Charges,1707.3,90,,323.28,Percent of Total Billed charges,90% of Total Billed Charges,836.58,1897,
"AR-8943-16 DRILL BIT,CALIB 2.0",2780003721,CDM,278,RC,,,Outpatient,,,257.45,167.34,,257.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,195.66,76,,84.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,185.36,72,,93.352,Percent of Total Billed Charges,72% of Total Billed Charges,185.36,72,,97.24,Percent of Total Billed charges,72% of Total Billed Charges,257.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.36,72,,93.352,Percent of Total Billed Charges,72% of Total Billed Charges,154.47,60,,77.792,Percent of Total Billed Charges,60% of Total Billed Charges,231.71,90,,42.872,Percent of Total Billed Charges,90% of Total Billed Charges,115.85,45,,22.68,Percent of Total Billed Charges,45% of Total Billed Charges,231.71,90,,100.024,Percent of Total Billed Charges,90% of Total billed Charges,257.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.34,65,,318.752,Percent of total Billed Charges,65% of Total Billed Charges,113.54,44.1,,22.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,244.58,95,,105.576,Percent of Total Billed Charges,95% of Total Billed Charges,257.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.56,88,,48.576,Percent of Total Billed Charges,88% of Total Billed Charges,231.71,90,,100.024,Percent of Total Billed charges,90% of Total Billed Charges,113.54,257.45,
STRYKER 40-30112 3.0 CANN SCW,2780003722,CDM,278,RC,,,Outpatient,,,770.00,500.50,,770,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,585.2,76,,39.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,554.4,72,,88.904,Percent of Total Billed Charges,72% of Total Billed Charges,554.4,72,,92.608,Percent of Total Billed charges,72% of Total Billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.4,72,,88.904,Percent of Total Billed Charges,72% of Total Billed Charges,462,60,,74.088,Percent of Total Billed Charges,60% of Total Billed Charges,693,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,346.5,45,,24.84,Percent of Total Billed Charges,45% of Total Billed Charges,693,90,,46.84,Percent of Total Billed Charges,90% of Total billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.5,65,,318.752,Percent of total Billed Charges,65% of Total Billed Charges,339.57,44.1,,24.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,731.5,95,,49.44,Percent of Total Billed Charges,95% of Total Billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.6,88,,85.888,Percent of Total Billed Charges,88% of Total Billed Charges,693,90,,46.84,Percent of Total Billed charges,90% of Total Billed Charges,339.57,770,
STRYKER 40-30118 3.0 CANN SCW,2780003723,CDM,278,RC,,,Outpatient,,,770.00,500.50,,770,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,585.2,76,,38.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,554.4,72,,128.448,Percent of Total Billed Charges,72% of Total Billed Charges,554.4,72,,133.8,Percent of Total Billed charges,72% of Total Billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.4,72,,128.448,Percent of Total Billed Charges,72% of Total Billed Charges,462,60,,107.04,Percent of Total Billed Charges,60% of Total Billed Charges,693,90,,69.12,Percent of Total Billed Charges,90% of Total Billed Charges,346.5,45,,43.92,Percent of Total Billed Charges,45% of Total Billed Charges,693,90,,45.36,Percent of Total Billed Charges,90% of Total billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.5,65,,300.408,Percent of total Billed Charges,65% of Total Billed Charges,339.57,44.1,,43.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,731.5,95,,47.88,Percent of Total Billed Charges,95% of Total Billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.6,88,,173.888,Percent of Total Billed Charges,88% of Total Billed Charges,693,90,,45.36,Percent of Total Billed charges,90% of Total Billed Charges,339.57,770,
STRYKER 40-30122 3.0 CANN SCW,2780003724,CDM,278,RC,,,Outpatient,,,770.00,500.50,,770,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,585.2,76,,39.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,554.4,72,,120.384,Percent of Total Billed Charges,72% of Total Billed Charges,554.4,72,,125.4,Percent of Total Billed charges,72% of Total Billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.4,72,,120.384,Percent of Total Billed Charges,72% of Total Billed Charges,462,60,,100.32,Percent of Total Billed Charges,60% of Total Billed Charges,693,90,,53.184,Percent of Total Billed Charges,90% of Total Billed Charges,346.5,45,,88.92,Percent of Total Billed Charges,45% of Total Billed Charges,693,90,,46.84,Percent of Total Billed Charges,90% of Total billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.5,65,,90.584,Percent of total Billed Charges,65% of Total Billed Charges,339.57,44.1,,87.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,731.5,95,,49.44,Percent of Total Billed Charges,95% of Total Billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.6,88,,75.328,Percent of Total Billed Charges,88% of Total Billed Charges,693,90,,46.84,Percent of Total Billed charges,90% of Total Billed Charges,339.57,770,
STRYKER 45110003 CHARLOTTE SCW,2780003725,CDM,278,RC,,,Outpatient,,,770.00,500.50,,770,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,585.2,76,,38.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,554.4,72,,33.656,Percent of Total Billed Charges,72% of Total Billed Charges,554.4,72,,35.056,Percent of Total Billed charges,72% of Total Billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.4,72,,33.656,Percent of Total Billed Charges,72% of Total Billed Charges,462,60,,28.048,Percent of Total Billed Charges,60% of Total Billed Charges,693,90,,83.344,Percent of Total Billed Charges,90% of Total Billed Charges,346.5,45,,38.52,Percent of Total Billed Charges,45% of Total Billed Charges,693,90,,45.36,Percent of Total Billed Charges,90% of Total billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.5,65,,48.88,Percent of total Billed Charges,65% of Total Billed Charges,339.57,44.1,,37.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,731.5,95,,47.88,Percent of Total Billed Charges,95% of Total Billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.6,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,693,90,,45.36,Percent of Total Billed charges,90% of Total Billed Charges,339.57,770,
STRYKER 40-20113 2.0 CANN SCW,2780003726,CDM,278,RC,,,Outpatient,,,770.00,500.50,,770,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,585.2,76,,41.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,554.4,72,,336.384,Percent of Total Billed Charges,72% of Total Billed Charges,554.4,72,,350.4,Percent of Total Billed charges,72% of Total Billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.4,72,,336.384,Percent of Total Billed Charges,72% of Total Billed Charges,462,60,,280.32,Percent of Total Billed Charges,60% of Total Billed Charges,693,90,,105.576,Percent of Total Billed Charges,90% of Total Billed Charges,346.5,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,693,90,,49.68,Percent of Total Billed Charges,90% of Total billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.5,65,,158.6,Percent of total Billed Charges,65% of Total Billed Charges,339.57,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,731.5,95,,52.44,Percent of Total Billed Charges,95% of Total Billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.6,88,,41.92,Percent of Total Billed Charges,88% of Total Billed Charges,693,90,,49.68,Percent of Total Billed charges,90% of Total Billed Charges,339.57,770,
STRYKER 40-20116 2.0 CANN SCW,2780003727,CDM,278,RC,,,Outpatient,,,770.00,500.50,,770,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,585.2,76,,74.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,554.4,72,,24.192,Percent of Total Billed Charges,72% of Total Billed Charges,554.4,72,,25.2,Percent of Total Billed charges,72% of Total Billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.4,72,,24.192,Percent of Total Billed Charges,72% of Total Billed Charges,462,60,,20.16,Percent of Total Billed Charges,60% of Total Billed Charges,693,90,,102.4,Percent of Total Billed Charges,90% of Total Billed Charges,346.5,45,,21.432,Percent of Total Billed Charges,45% of Total Billed Charges,693,90,,87.84,Percent of Total Billed Charges,90% of Total billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.5,65,,59.28,Percent of total Billed Charges,65% of Total Billed Charges,339.57,44.1,,21.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,731.5,95,,92.72,Percent of Total Billed Charges,95% of Total Billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.6,88,,44.352,Percent of Total Billed Charges,88% of Total Billed Charges,693,90,,87.84,Percent of Total Billed charges,90% of Total Billed Charges,339.57,770,
STRYKER 8125-3170S NAIL13X170,2780003728,CDM,278,RC,,,Outpatient,,,7462.50,4850.63,,7462.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5671.5,76,,150.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5373,72,,37.544,Percent of Total Billed Charges,72% of Total Billed Charges,5373,72,,39.112,Percent of Total Billed charges,72% of Total Billed Charges,7462.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5373,72,,37.544,Percent of Total Billed Charges,72% of Total Billed Charges,4477.5,60,,31.288,Percent of Total Billed Charges,60% of Total Billed Charges,6716.25,90,,236.56,Percent of Total Billed Charges,90% of Total Billed Charges,3358.13,45,,22.68,Percent of Total Billed Charges,45% of Total Billed Charges,6716.25,90,,177.84,Percent of Total Billed Charges,90% of Total billed Charges,7462.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7462.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7462.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4850.63,65,,42.12,Percent of total Billed Charges,65% of Total Billed Charges,3290.96,44.1,,22.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,7089.38,95,,187.72,Percent of Total Billed Charges,95% of Total Billed Charges,7462.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6567,88,,67.584,Percent of Total Billed Charges,88% of Total Billed Charges,6716.25,90,,177.84,Percent of Total Billed charges,90% of Total Billed Charges,3290.96,7462.5,
STRYKER 2360-5037S LCK SCW 5X3,2780003729,CDM,278,RC,,,Outpatient,,,822.50,534.63,,822.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,625.1,76,,65.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,592.2,72,,37.544,Percent of Total Billed Charges,72% of Total Billed Charges,592.2,72,,39.112,Percent of Total Billed charges,72% of Total Billed Charges,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.2,72,,37.544,Percent of Total Billed Charges,72% of Total Billed Charges,493.5,60,,31.288,Percent of Total Billed Charges,60% of Total Billed Charges,740.25,90,,236.56,Percent of Total Billed Charges,90% of Total Billed Charges,370.13,45,,34.56,Percent of Total Billed Charges,45% of Total Billed Charges,740.25,90,,77.04,Percent of Total Billed Charges,90% of Total billed Charges,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,534.63,65,,40.136,Percent of total Billed Charges,65% of Total Billed Charges,362.72,44.1,,33.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,781.38,95,,81.32,Percent of Total Billed Charges,95% of Total Billed Charges,822.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,723.8,88,,52.008,Percent of Total Billed Charges,88% of Total Billed Charges,740.25,90,,77.04,Percent of Total Billed charges,90% of Total Billed Charges,362.72,822.5,
STRYKER 8160-0110S LAG SCW 10.,2780003730,CDM,278,RC,,,Outpatient,,,2352.50,1529.13,,2352.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1787.9,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1693.8,72,,164.736,Percent of Total Billed Charges,72% of Total Billed Charges,1693.8,72,,171.6,Percent of Total Billed charges,72% of Total Billed Charges,2352.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1693.8,72,,164.736,Percent of Total Billed Charges,72% of Total Billed Charges,1411.5,60,,137.28,Percent of Total Billed Charges,60% of Total Billed Charges,2117.25,90,,113.512,Percent of Total Billed Charges,90% of Total Billed Charges,1058.63,45,,26.592,Percent of Total Billed Charges,45% of Total Billed Charges,2117.25,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,2352.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2352.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2352.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1529.13,65,,40.136,Percent of total Billed Charges,65% of Total Billed Charges,1037.45,44.1,,26.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,2234.88,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,2352.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2070.2,88,,81.496,Percent of Total Billed Charges,88% of Total Billed Charges,2117.25,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,1037.45,2352.5,
IV CHEMO INF DIFF 16-90MIN,2800000000,CDM,280,RC,,,Outpatient,,,142.00,92.30,,142,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.92,76,,36.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,102.24,72,,171.36,Percent of Total Billed Charges,72% of Total Billed Charges,106.5,75,,178.504,Percent of Total Billed charges,75% of Total Billed Charges,142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.24,72,,171.36,Percent of Total Billed Charges,72% of Total Billed Charges,85.2,60,,142.8,Percent of Total Billed Charges,60% of Total Billed Charges,127.8,90,,145.44,Percent of Total Billed Charges,90% of Total Billed Charges,63.9,45,,41.672,Percent of Total Billed Charges,45% of Total Billed Charges,127.8,90,,42.872,Percent of Total Billed Charges,90% of Total billed Charges,142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.3,65,,40.136,Percent of total Billed Charges,65% of Total Billed Charges,62.62,44.1,,40.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.9,95,,45.248,Percent of Total Billed Charges,95% of Total Billed Charges,142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.96,88,,103.224,Percent of Total Billed Charges,88% of Total Billed Charges,127.8,90,,42.872,Percent of Total Billed charges,90% of Total Billed Charges,62.62,142,
IV CHEMO INF INTL 16-90 MIN,2800000001,CDM,280,RC,,,Outpatient,,,651.00,423.15,,651,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,494.76,76,,38.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,468.72,72,,63.936,Percent of Total Billed Charges,72% of Total Billed Charges,488.25,75,,66.6,Percent of Total Billed charges,75% of Total Billed Charges,651,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,468.72,72,,63.936,Percent of Total Billed Charges,72% of Total Billed Charges,390.6,60,,53.28,Percent of Total Billed Charges,60% of Total Billed Charges,585.9,90,,200.832,Percent of Total Billed Charges,90% of Total Billed Charges,292.95,45,,52.784,Percent of Total Billed Charges,45% of Total Billed Charges,585.9,90,,45.36,Percent of Total Billed Charges,90% of Total billed Charges,651,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,651,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,651,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,423.15,65,,36.4,Percent of total Billed Charges,65% of Total Billed Charges,287.09,44.1,,51.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,618.45,95,,47.88,Percent of Total Billed Charges,95% of Total Billed Charges,651,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,572.88,88,,100.12,Percent of Total Billed Charges,88% of Total Billed Charges,585.9,90,,45.36,Percent of Total Billed charges,90% of Total Billed Charges,287.09,651,
IV CHEMO INF ADDL HR>30MIN,2800000002,CDM,280,RC,,,Outpatient,,,135.00,87.75,,135,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,102.6,76,,58.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,97.2,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,101.25,75,,9,Percent of Total Billed charges,75% of Total Billed Charges,135,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.2,72,,8.64,Percent of Total Billed Charges,72% of Total Billed Charges,81,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,121.5,90,,86.52,Percent of Total Billed Charges,90% of Total Billed Charges,60.75,45,,51.2,Percent of Total Billed Charges,45% of Total Billed Charges,121.5,90,,69.12,Percent of Total Billed Charges,90% of Total billed Charges,135,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.75,65,,30.96,Percent of total Billed Charges,65% of Total Billed Charges,59.54,44.1,,50.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,128.25,95,,72.96,Percent of Total Billed Charges,95% of Total Billed Charges,135,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.8,88,,231.296,Percent of Total Billed Charges,88% of Total Billed Charges,121.5,90,,69.12,Percent of Total Billed charges,90% of Total Billed Charges,59.54,135,
INJ IM/SQ HORMONAL ANTI-NEO,2800000003,CDM,280,RC,,,Outpatient,,,135.00,87.75,,135,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,102.6,76,,44.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,97.2,72,,335.808,Percent of Total Billed Charges,72% of Total Billed Charges,101.25,75,,349.8,Percent of Total Billed charges,75% of Total Billed Charges,135,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.2,72,,335.808,Percent of Total Billed Charges,72% of Total Billed Charges,81,60,,279.84,Percent of Total Billed Charges,60% of Total Billed Charges,121.5,90,,211.944,Percent of Total Billed Charges,90% of Total Billed Charges,60.75,45,,118.28,Percent of Total Billed Charges,45% of Total Billed Charges,121.5,90,,53.184,Percent of Total Billed Charges,90% of Total billed Charges,135,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.75,65,,128.96,Percent of total Billed Charges,65% of Total Billed Charges,59.54,44.1,,115.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,128.25,95,,56.144,Percent of Total Billed Charges,95% of Total Billed Charges,135,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.8,88,,231.296,Percent of Total Billed Charges,88% of Total Billed Charges,121.5,90,,53.184,Percent of Total Billed charges,90% of Total Billed Charges,59.54,135,
IV CHEMO PUSH ADDL (<16MIN),2800000004,CDM,280,RC,,,Outpatient,,,142.00,92.30,,142,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.92,76,,70.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,102.24,72,,329.472,Percent of Total Billed Charges,72% of Total Billed Charges,106.5,75,,343.2,Percent of Total Billed charges,75% of Total Billed Charges,142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.24,72,,329.472,Percent of Total Billed Charges,72% of Total Billed Charges,85.2,60,,274.56,Percent of Total Billed Charges,60% of Total Billed Charges,127.8,90,,211.944,Percent of Total Billed Charges,90% of Total Billed Charges,63.9,45,,118.28,Percent of Total Billed Charges,45% of Total Billed Charges,127.8,90,,83.344,Percent of Total Billed Charges,90% of Total billed Charges,142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.3,65,,122.688,Percent of total Billed Charges,65% of Total Billed Charges,62.62,44.1,,115.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.9,95,,87.976,Percent of Total Billed Charges,95% of Total Billed Charges,142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.96,88,,110.992,Percent of Total Billed Charges,88% of Total Billed Charges,127.8,90,,83.344,Percent of Total Billed charges,90% of Total Billed Charges,62.62,142,
IV CHEMO PUSH INTL (<16MIN),2800000005,CDM,280,RC,,,Outpatient,,,444.00,288.60,,444,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,337.44,76,,89.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,319.68,72,,378.48,Percent of Total Billed Charges,72% of Total Billed Charges,333,75,,394.256,Percent of Total Billed charges,75% of Total Billed Charges,444,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319.68,72,,378.48,Percent of Total Billed Charges,72% of Total Billed Charges,266.4,60,,315.4,Percent of Total Billed Charges,60% of Total Billed Charges,399.6,90,,211.944,Percent of Total Billed Charges,90% of Total Billed Charges,199.8,45,,56.76,Percent of Total Billed Charges,45% of Total Billed Charges,399.6,90,,105.576,Percent of Total Billed Charges,90% of Total billed Charges,444,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.6,65,,122.688,Percent of total Billed Charges,65% of Total Billed Charges,195.8,44.1,,55.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,421.8,95,,111.44,Percent of Total Billed Charges,95% of Total Billed Charges,444,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.72,88,,142.208,Percent of Total Billed Charges,88% of Total Billed Charges,399.6,90,,105.576,Percent of Total Billed charges,90% of Total Billed Charges,195.8,444,
INJ IM/SQ NON-HORM ANTI-NEO,2800000006,CDM,280,RC,,,Outpatient,,,142.00,92.30,,142,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.92,76,,86.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,102.24,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,106.5,75,,23.152,Percent of Total Billed charges,75% of Total Billed Charges,142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.24,72,,22.224,Percent of Total Billed Charges,72% of Total Billed Charges,85.2,60,,18.52,Percent of Total Billed Charges,60% of Total Billed Charges,127.8,90,,211.944,Percent of Total Billed Charges,90% of Total Billed Charges,63.9,45,,72.72,Percent of Total Billed Charges,45% of Total Billed Charges,127.8,90,,102.4,Percent of Total Billed Charges,90% of Total billed Charges,142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.3,65,,68.224,Percent of total Billed Charges,65% of Total Billed Charges,62.62,44.1,,71.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.9,95,,108.088,Percent of Total Billed Charges,95% of Total Billed Charges,142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.96,88,,196.368,Percent of Total Billed Charges,88% of Total Billed Charges,127.8,90,,102.4,Percent of Total Billed charges,90% of Total Billed Charges,62.62,142,
BCRABL1 KINASE DOM MUTATION,3000000001,CDM,300,RC,,,Outpatient,,,900.00,585.00,,900,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,684,76,,199.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,648,72,,116.216,Percent of Total Billed Charges,72% of Total Billed Charges,675,75,,121.056,Percent of Total Billed charges,75% of Total Billed Charges,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,648,72,,116.216,Percent of Total Billed Charges,72% of Total Billed Charges,540,60,,96.848,Percent of Total Billed Charges,60% of Total Billed Charges,810,90,,441.352,Percent of Total Billed Charges,90% of Total Billed Charges,405,45,,100.416,Percent of Total Billed Charges,45% of Total Billed Charges,810,90,,236.56,Percent of Total Billed Charges,90% of Total billed Charges,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,585,65,,38.416,Percent of total Billed Charges,65% of Total Billed Charges,396.9,44.1,,98.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,855,95,,249.696,Percent of Total Billed Charges,95% of Total Billed Charges,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,792,88,,84.6,Percent of Total Billed Charges,88% of Total Billed Charges,810,90,,236.56,Percent of Total Billed charges,90% of Total Billed Charges,396.9,900,
CLOSTRIDIUM DIF TOX B RT PCR,3000000002,CDM,300,RC,,,Outpatient,,,156.72,101.87,,156.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,119.11,76,,199.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,112.84,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,117.54,75,,367.792,Percent of Total Billed charges,75% of Total Billed Charges,156.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.84,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,94.03,60,,294.232,Percent of Total Billed Charges,60% of Total Billed Charges,141.05,90,,441.352,Percent of Total Billed Charges,90% of Total Billed Charges,70.52,45,,43.264,Percent of Total Billed Charges,45% of Total Billed Charges,141.05,90,,236.56,Percent of Total Billed Charges,90% of Total billed Charges,156.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.87,65,,34.968,Percent of total Billed Charges,65% of Total Billed Charges,69.11,44.1,,42.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,148.88,95,,249.696,Percent of Total Billed Charges,95% of Total Billed Charges,156.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.91,88,,207.24,Percent of Total Billed Charges,88% of Total Billed Charges,141.05,90,,236.56,Percent of Total Billed charges,90% of Total Billed Charges,69.11,156.72,
PHYSICIAN V/PUNCT,3000000003,CDM,360,RC,,,Outpatient,,,78.00,50.70,,78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.28,76,,95.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.16,72,,332.76,Percent of Total Billed Charges,72% of Total Billed Charges,58.5,75,,346.624,Percent of Total Billed charges,75% of Total Billed Charges,78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.16,72,,332.76,Percent of Total Billed Charges,72% of Total Billed Charges,46.8,60,,277.304,Percent of Total Billed Charges,60% of Total Billed Charges,70.2,90,,441.352,Percent of Total Billed Charges,90% of Total Billed Charges,35.1,45,,105.976,Percent of Total Billed Charges,45% of Total Billed Charges,70.2,90,,113.512,Percent of Total Billed Charges,90% of Total billed Charges,78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.7,65,,79.56,Percent of total Billed Charges,65% of Total Billed Charges,34.4,44.1,,103.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.1,95,,119.824,Percent of Total Billed Charges,95% of Total Billed Charges,78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.64,88,,207.24,Percent of Total Billed Charges,88% of Total Billed Charges,70.2,90,,113.512,Percent of Total Billed charges,90% of Total Billed Charges,34.4,78,
VENIPUNCTURE,3000000004,CDM,300,RC,,,Outpatient,,,35.00,22.75,,35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.6,76,,122.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.2,72,,149.872,Percent of Total Billed Charges,72% of Total Billed Charges,26.25,75,,156.112,Percent of Total Billed charges,75% of Total Billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.2,72,,149.872,Percent of Total Billed Charges,72% of Total Billed Charges,21,60,,124.888,Percent of Total Billed Charges,60% of Total Billed Charges,31.5,90,,441.352,Percent of Total Billed Charges,90% of Total Billed Charges,15.75,45,,105.976,Percent of Total Billed Charges,45% of Total Billed Charges,31.5,90,,145.44,Percent of Total Billed Charges,90% of Total billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.75,65,,219.576,Percent of total Billed Charges,65% of Total Billed Charges,15.44,44.1,,103.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.25,95,,153.52,Percent of Total Billed Charges,95% of Total Billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.8,88,,207.24,Percent of Total Billed Charges,88% of Total Billed Charges,31.5,90,,145.44,Percent of Total Billed charges,90% of Total Billed Charges,15.44,35,
ARTERIAL PUNCTURE BLD GAS DRA,3000000005,CDM,300,RC,,,Outpatient,,,285.00,185.25,,285,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,216.6,76,,169.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,205.2,72,,155.52,Percent of Total Billed Charges,72% of Total Billed Charges,213.75,75,,162,Percent of Total Billed charges,75% of Total Billed Charges,285,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.2,72,,155.52,Percent of Total Billed Charges,72% of Total Billed Charges,171,60,,129.6,Percent of Total Billed Charges,60% of Total Billed Charges,256.5,90,,441.352,Percent of Total Billed Charges,90% of Total Billed Charges,128.25,45,,105.976,Percent of Total Billed Charges,45% of Total Billed Charges,256.5,90,,200.832,Percent of Total Billed Charges,90% of Total billed Charges,285,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.25,65,,219.576,Percent of total Billed Charges,65% of Total Billed Charges,125.69,44.1,,103.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,270.75,95,,211.984,Percent of Total Billed Charges,95% of Total Billed Charges,285,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.8,88,,207.24,Percent of Total Billed Charges,88% of Total Billed Charges,256.5,90,,200.832,Percent of Total Billed charges,90% of Total Billed Charges,125.69,285,
GENERAL HEALTH PANEL,3000000006,CDM,300,RC,,,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,73.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,163.2,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,170.008,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,163.2,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,136,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,441.352,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,105.976,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,86.52,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,147.16,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,103.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,91.328,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,431.544,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,86.52,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
LACOSAMIDE,3000000007,CDM,300,RC,,,Outpatient,,,244.76,159.09,,244.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,186.02,76,,178.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,176.23,72,,15.552,Percent of Total Billed Charges,72% of Total Billed Charges,183.57,75,,16.2,Percent of Total Billed charges,75% of Total Billed Charges,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.23,72,,15.552,Percent of Total Billed Charges,72% of Total Billed Charges,146.86,60,,12.96,Percent of Total Billed Charges,60% of Total Billed Charges,220.28,90,,441.352,Percent of Total Billed Charges,90% of Total Billed Charges,110.14,45,,220.68,Percent of Total Billed Charges,45% of Total Billed Charges,220.28,90,,211.944,Percent of Total Billed Charges,90% of Total billed Charges,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.09,65,,153.648,Percent of total Billed Charges,65% of Total Billed Charges,107.94,44.1,,216.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,232.52,95,,223.72,Percent of Total Billed Charges,95% of Total Billed Charges,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.39,88,,431.544,Percent of Total Billed Charges,88% of Total Billed Charges,220.28,90,,211.944,Percent of Total Billed charges,90% of Total Billed Charges,107.94,244.76,
DRUG ABUSE PANEL 10,3000000008,CDM,300,RC,,,Outpatient,,,323.03,209.97,,323.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,245.5,76,,178.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,232.58,72,,212.736,Percent of Total Billed Charges,72% of Total Billed Charges,242.27,75,,221.608,Percent of Total Billed charges,75% of Total Billed Charges,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.58,72,,212.736,Percent of Total Billed Charges,72% of Total Billed Charges,193.82,60,,177.28,Percent of Total Billed Charges,60% of Total Billed Charges,290.73,90,,441.352,Percent of Total Billed Charges,90% of Total Billed Charges,145.36,45,,220.68,Percent of Total Billed Charges,45% of Total Billed Charges,290.73,90,,211.944,Percent of Total Billed Charges,90% of Total billed Charges,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.97,65,,151.32,Percent of total Billed Charges,65% of Total Billed Charges,142.46,44.1,,216.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,306.88,95,,223.72,Percent of Total Billed Charges,95% of Total Billed Charges,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.27,88,,431.544,Percent of Total Billed Charges,88% of Total Billed Charges,290.73,90,,211.944,Percent of Total Billed charges,90% of Total Billed Charges,142.46,323.03,
PREGABALIN SERUM,3000000009,CDM,300,RC,,,Outpatient,,,242.98,157.94,,242.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,184.66,76,,178.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,174.95,72,,238.776,Percent of Total Billed Charges,72% of Total Billed Charges,182.24,75,,248.728,Percent of Total Billed charges,75% of Total Billed Charges,242.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.95,72,,238.776,Percent of Total Billed Charges,72% of Total Billed Charges,145.79,60,,198.976,Percent of Total Billed Charges,60% of Total Billed Charges,218.68,90,,415.952,Percent of Total Billed Charges,90% of Total Billed Charges,109.34,45,,220.68,Percent of Total Billed Charges,45% of Total Billed Charges,218.68,90,,211.944,Percent of Total Billed Charges,90% of Total billed Charges,242.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.94,65,,56.68,Percent of total Billed Charges,65% of Total Billed Charges,107.15,44.1,,216.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,230.83,95,,223.72,Percent of Total Billed Charges,95% of Total Billed Charges,242.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.82,88,,431.544,Percent of Total Billed Charges,88% of Total Billed Charges,218.68,90,,211.944,Percent of Total Billed charges,90% of Total Billed Charges,107.15,242.98,
URINALYSIS WITH REFLEX CULTURE,3000000010,CDM,300,RC,,,Outpatient,,,111.00,72.15,,111,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,84.36,76,,178.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,79.92,72,,238.776,Percent of Total Billed Charges,72% of Total Billed Charges,83.25,75,,248.728,Percent of Total Billed charges,75% of Total Billed Charges,111,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.92,72,,238.776,Percent of Total Billed Charges,72% of Total Billed Charges,66.6,60,,198.976,Percent of Total Billed Charges,60% of Total Billed Charges,99.9,90,,125.424,Percent of Total Billed Charges,90% of Total Billed Charges,49.95,45,,220.68,Percent of Total Billed Charges,45% of Total Billed Charges,99.9,90,,211.944,Percent of Total Billed Charges,90% of Total billed Charges,111,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.15,65,,59.624,Percent of total Billed Charges,65% of Total Billed Charges,48.95,44.1,,216.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,105.45,95,,223.72,Percent of Total Billed Charges,95% of Total Billed Charges,111,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.68,88,,431.544,Percent of Total Billed Charges,88% of Total Billed Charges,99.9,90,,211.944,Percent of Total Billed charges,90% of Total Billed Charges,48.95,111,
BETAHYDROXYBUTYRATE QUANT,3000000011,CDM,300,RC,,,Outpatient,,,153.00,99.45,,153,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,116.28,76,,372.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,110.16,72,,180.984,Percent of Total Billed Charges,72% of Total Billed Charges,114.75,75,,188.528,Percent of Total Billed charges,75% of Total Billed Charges,153,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.16,72,,180.984,Percent of Total Billed Charges,72% of Total Billed Charges,91.8,60,,150.824,Percent of Total Billed Charges,60% of Total Billed Charges,137.7,90,,67.68,Percent of Total Billed Charges,90% of Total Billed Charges,68.85,45,,220.68,Percent of Total Billed Charges,45% of Total Billed Charges,137.7,90,,441.352,Percent of Total Billed Charges,90% of Total billed Charges,153,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.45,65,,83.128,Percent of total Billed Charges,65% of Total Billed Charges,67.47,44.1,,216.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,145.35,95,,465.872,Percent of Total Billed Charges,95% of Total Billed Charges,153,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.64,88,,431.544,Percent of Total Billed Charges,88% of Total Billed Charges,137.7,90,,441.352,Percent of Total Billed charges,90% of Total Billed Charges,67.47,153,
ACYLCARNITINE PROFIL SERUM,3000000012,CDM,300,RC,,,Outpatient,,,337.37,219.29,,337.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,256.4,76,,372.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,242.91,72,,180.984,Percent of Total Billed Charges,72% of Total Billed Charges,253.03,75,,188.528,Percent of Total Billed charges,75% of Total Billed Charges,337.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.91,72,,180.984,Percent of Total Billed Charges,72% of Total Billed Charges,202.42,60,,150.824,Percent of Total Billed Charges,60% of Total Billed Charges,303.63,90,,219.6,Percent of Total Billed Charges,90% of Total Billed Charges,151.82,45,,220.68,Percent of Total Billed Charges,45% of Total Billed Charges,303.63,90,,441.352,Percent of Total Billed Charges,90% of Total billed Charges,337.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.29,65,,99.76,Percent of total Billed Charges,65% of Total Billed Charges,148.78,44.1,,216.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,320.5,95,,465.872,Percent of Total Billed Charges,95% of Total Billed Charges,337.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.89,88,,431.544,Percent of Total Billed Charges,88% of Total Billed Charges,303.63,90,,441.352,Percent of Total Billed charges,90% of Total Billed Charges,148.78,337.37,
ALPHA FETOPROTEIN SERUM,3000000013,CDM,300,RC,,,Outpatient,,,115.76,75.24,,115.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.98,76,,372.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,83.35,72,,48.896,Percent of Total Billed Charges,72% of Total Billed Charges,86.82,75,,50.936,Percent of Total Billed charges,75% of Total Billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.35,72,,48.896,Percent of Total Billed Charges,72% of Total Billed Charges,69.46,60,,40.744,Percent of Total Billed Charges,60% of Total Billed Charges,104.18,90,,82.08,Percent of Total Billed Charges,90% of Total Billed Charges,52.09,45,,220.68,Percent of Total Billed Charges,45% of Total Billed Charges,104.18,90,,441.352,Percent of Total Billed Charges,90% of Total billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.24,65,,18.344,Percent of total Billed Charges,65% of Total Billed Charges,51.05,44.1,,216.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,109.97,95,,465.872,Percent of Total Billed Charges,95% of Total Billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.87,88,,431.544,Percent of Total Billed Charges,88% of Total Billed Charges,104.18,90,,441.352,Percent of Total Billed charges,90% of Total Billed Charges,51.05,115.76,
VITAMIN D 25OH (VVRMC),3000000014,CDM,300,RC,,,Outpatient,,,511.00,332.15,,511,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,388.36,76,,372.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,367.92,72,,8.064,Percent of Total Billed Charges,72% of Total Billed Charges,383.25,75,,8.4,Percent of Total Billed charges,75% of Total Billed Charges,511,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,367.92,72,,8.064,Percent of Total Billed Charges,72% of Total Billed Charges,306.6,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,459.9,90,,58.32,Percent of Total Billed Charges,90% of Total Billed Charges,229.95,45,,220.68,Percent of Total Billed Charges,45% of Total Billed Charges,459.9,90,,441.352,Percent of Total Billed Charges,90% of Total billed Charges,511,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.15,65,,45.24,Percent of total Billed Charges,65% of Total Billed Charges,225.35,44.1,,216.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,485.45,95,,465.872,Percent of Total Billed Charges,95% of Total Billed Charges,511,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,449.68,88,,406.704,Percent of Total Billed Charges,88% of Total Billed Charges,459.9,90,,441.352,Percent of Total Billed charges,90% of Total Billed Charges,225.35,511,
CHLORIDE OTHER SOURC,3000000015,CDM,300,RC,,,Outpatient,,,46.00,29.90,,46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.96,76,,372.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.12,72,,19.584,Percent of Total Billed Charges,72% of Total Billed Charges,34.5,75,,20.4,Percent of Total Billed charges,75% of Total Billed Charges,46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.12,72,,19.584,Percent of Total Billed Charges,72% of Total Billed Charges,27.6,60,,16.32,Percent of Total Billed Charges,60% of Total Billed Charges,41.4,90,,55.568,Percent of Total Billed Charges,90% of Total Billed Charges,20.7,45,,207.976,Percent of Total Billed Charges,45% of Total Billed Charges,41.4,90,,441.352,Percent of Total Billed Charges,90% of Total billed Charges,46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.9,65,,170.848,Percent of total Billed Charges,65% of Total Billed Charges,20.29,44.1,,203.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,43.7,95,,465.872,Percent of Total Billed Charges,95% of Total Billed Charges,46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.48,88,,122.64,Percent of Total Billed Charges,88% of Total Billed Charges,41.4,90,,441.352,Percent of Total Billed charges,90% of Total Billed Charges,20.29,46,
"CORTISOL, 3 SPECIMENS TOTAL",3000000016,CDM,300,RC,,,Outpatient,,,229.32,149.06,,229.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,174.28,76,,372.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,165.11,72,,77.48,Percent of Total Billed Charges,72% of Total Billed Charges,171.99,75,,80.704,Percent of Total Billed charges,75% of Total Billed Charges,229.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.11,72,,77.48,Percent of Total Billed Charges,72% of Total Billed Charges,137.59,60,,64.568,Percent of Total Billed Charges,60% of Total Billed Charges,206.39,90,,55.568,Percent of Total Billed Charges,90% of Total Billed Charges,103.19,45,,62.712,Percent of Total Billed Charges,45% of Total Billed Charges,206.39,90,,441.352,Percent of Total Billed Charges,90% of Total billed Charges,229.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.06,65,,7.168,Percent of total Billed Charges,65% of Total Billed Charges,101.13,44.1,,61.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,217.85,95,,465.872,Percent of Total Billed Charges,95% of Total Billed Charges,229.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.8,88,,66.176,Percent of Total Billed Charges,88% of Total Billed Charges,206.39,90,,441.352,Percent of Total Billed charges,90% of Total Billed Charges,101.13,229.32,
ESTRIOL,3000000017,CDM,300,RC,,,Outpatient,,,26.46,17.20,,26.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.11,76,,372.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.05,72,,77.48,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,75,,80.704,Percent of Total Billed charges,75% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.05,72,,77.48,Percent of Total Billed Charges,72% of Total Billed Charges,15.88,60,,64.568,Percent of Total Billed Charges,60% of Total Billed Charges,23.81,90,,55.568,Percent of Total Billed Charges,90% of Total Billed Charges,11.91,45,,33.84,Percent of Total Billed Charges,45% of Total Billed Charges,23.81,90,,441.352,Percent of Total Billed Charges,90% of Total billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,65,,160.528,Percent of total Billed Charges,65% of Total Billed Charges,11.67,44.1,,33.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.14,95,,465.872,Percent of Total Billed Charges,95% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.28,88,,214.72,Percent of Total Billed Charges,88% of Total Billed Charges,23.81,90,,441.352,Percent of Total Billed charges,90% of Total Billed Charges,11.67,26.46,
FSH,3000000018,CDM,300,RC,,,Outpatient,,,115.76,75.24,,115.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.98,76,,372.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,83.35,72,,77.48,Percent of Total Billed Charges,72% of Total Billed Charges,86.82,75,,80.704,Percent of Total Billed charges,75% of Total Billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.35,72,,77.48,Percent of Total Billed Charges,72% of Total Billed Charges,69.46,60,,64.568,Percent of Total Billed Charges,60% of Total Billed Charges,104.18,90,,50.4,Percent of Total Billed Charges,90% of Total Billed Charges,52.09,45,,109.8,Percent of Total Billed Charges,45% of Total Billed Charges,104.18,90,,441.352,Percent of Total Billed Charges,90% of Total billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.24,65,,40.04,Percent of total Billed Charges,65% of Total Billed Charges,51.05,44.1,,107.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,109.97,95,,465.872,Percent of Total Billed Charges,95% of Total Billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.87,88,,80.256,Percent of Total Billed Charges,88% of Total Billed Charges,104.18,90,,441.352,Percent of Total Billed charges,90% of Total Billed Charges,51.05,115.76,
LH,3000000019,CDM,300,RC,,,Outpatient,,,111.35,72.38,,111.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,84.63,76,,351.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,80.17,72,,409.6,Percent of Total Billed Charges,72% of Total Billed Charges,83.51,75,,426.664,Percent of Total Billed charges,75% of Total Billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.17,72,,409.6,Percent of Total Billed Charges,72% of Total Billed Charges,66.81,60,,341.336,Percent of Total Billed Charges,60% of Total Billed Charges,100.22,90,,42.872,Percent of Total Billed Charges,90% of Total Billed Charges,50.11,45,,41.04,Percent of Total Billed Charges,45% of Total Billed Charges,100.22,90,,415.952,Percent of Total Billed Charges,90% of Total billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.38,65,,40.04,Percent of total Billed Charges,65% of Total Billed Charges,49.11,44.1,,40.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,105.78,95,,439.056,Percent of Total Billed Charges,95% of Total Billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.99,88,,57.024,Percent of Total Billed Charges,88% of Total Billed Charges,100.22,90,,415.952,Percent of Total Billed charges,90% of Total Billed Charges,49.11,111.35,
MITOCHONDRIS M2 ANTI,3000000020,CDM,301,RC,,,Outpatient,,,577.71,375.51,,577.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,439.06,76,,105.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.95,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,433.28,75,,51.6,Percent of Total Billed charges,75% of Total Billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.95,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,346.63,60,,41.28,Percent of Total Billed Charges,60% of Total Billed Charges,519.94,90,,178.56,Percent of Total Billed Charges,90% of Total Billed Charges,259.97,45,,29.16,Percent of Total Billed Charges,45% of Total Billed Charges,519.94,90,,125.424,Percent of Total Billed Charges,90% of Total billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.51,65,,39.56,Percent of total Billed Charges,65% of Total Billed Charges,254.77,44.1,,28.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,548.82,95,,132.392,Percent of Total Billed Charges,95% of Total Billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.38,88,,54.336,Percent of Total Billed Charges,88% of Total Billed Charges,519.94,90,,125.424,Percent of Total Billed charges,90% of Total Billed Charges,254.77,577.71,
5 NUCLEOTIDASE,3000000021,CDM,300,RC,,,Outpatient,,,164.27,106.78,,164.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.85,76,,57.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,118.27,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,123.2,75,,18.52,Percent of Total Billed charges,75% of Total Billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.27,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,98.56,60,,14.816,Percent of Total Billed Charges,60% of Total Billed Charges,147.84,90,,169.88,Percent of Total Billed Charges,90% of Total Billed Charges,73.92,45,,27.784,Percent of Total Billed Charges,45% of Total Billed Charges,147.84,90,,67.68,Percent of Total Billed Charges,90% of Total billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.78,65,,36.4,Percent of total Billed Charges,65% of Total Billed Charges,72.44,44.1,,27.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,156.06,95,,71.44,Percent of Total Billed Charges,95% of Total Billed Charges,164.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.56,88,,54.336,Percent of Total Billed Charges,88% of Total Billed Charges,147.84,90,,67.68,Percent of Total Billed charges,90% of Total Billed Charges,72.44,164.27,
ROM TEST AMNISURE,3000000022,CDM,300,RC,,,Outpatient,,,315.00,204.75,,315,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,239.4,76,,185.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,226.8,72,,93.984,Percent of Total Billed Charges,72% of Total Billed Charges,236.25,75,,97.904,Percent of Total Billed charges,75% of Total Billed Charges,315,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.8,72,,93.984,Percent of Total Billed Charges,72% of Total Billed Charges,189,60,,78.32,Percent of Total Billed Charges,60% of Total Billed Charges,283.5,90,,169.88,Percent of Total Billed Charges,90% of Total Billed Charges,141.75,45,,27.784,Percent of Total Billed Charges,45% of Total Billed Charges,283.5,90,,219.6,Percent of Total Billed Charges,90% of Total billed Charges,315,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.75,65,,55.608,Percent of total Billed Charges,65% of Total Billed Charges,138.92,44.1,,27.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,299.25,95,,231.8,Percent of Total Billed Charges,95% of Total Billed Charges,315,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.2,88,,54.336,Percent of Total Billed Charges,88% of Total Billed Charges,283.5,90,,219.6,Percent of Total Billed charges,90% of Total Billed Charges,138.92,315,
THYROGLOBULIN,3000000023,CDM,300,RC,,,Outpatient,,,39.00,25.35,,39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.64,76,,69.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.08,72,,93.984,Percent of Total Billed Charges,72% of Total Billed Charges,29.25,75,,97.904,Percent of Total Billed charges,75% of Total Billed Charges,39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.08,72,,93.984,Percent of Total Billed Charges,72% of Total Billed Charges,23.4,60,,78.32,Percent of Total Billed Charges,60% of Total Billed Charges,35.1,90,,94.464,Percent of Total Billed Charges,90% of Total Billed Charges,17.55,45,,27.784,Percent of Total Billed Charges,45% of Total Billed Charges,35.1,90,,82.08,Percent of Total Billed Charges,90% of Total billed Charges,39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.35,65,,32.76,Percent of total Billed Charges,65% of Total Billed Charges,17.2,44.1,,27.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.05,95,,86.64,Percent of Total Billed Charges,95% of Total Billed Charges,39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.32,88,,49.28,Percent of Total Billed Charges,88% of Total Billed Charges,35.1,90,,82.08,Percent of Total Billed charges,90% of Total Billed Charges,17.2,39,
CHROMOGRANIN A,3000000025,CDM,300,RC,,,Outpatient,,,164.23,106.75,,164.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.81,76,,49.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,118.25,72,,68.584,Percent of Total Billed Charges,72% of Total Billed Charges,123.17,75,,71.44,Percent of Total Billed charges,75% of Total Billed Charges,164.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.25,72,,68.584,Percent of Total Billed Charges,72% of Total Billed Charges,98.54,60,,57.152,Percent of Total Billed Charges,60% of Total Billed Charges,147.81,90,,53.184,Percent of Total Billed Charges,90% of Total Billed Charges,73.9,45,,25.2,Percent of Total Billed Charges,45% of Total Billed Charges,147.81,90,,58.32,Percent of Total Billed Charges,90% of Total billed Charges,164.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.75,65,,70.72,Percent of total Billed Charges,65% of Total Billed Charges,72.43,44.1,,24.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,156.02,95,,61.56,Percent of Total Billed Charges,95% of Total Billed Charges,164.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.52,88,,41.92,Percent of Total Billed Charges,88% of Total Billed Charges,147.81,90,,58.32,Percent of Total Billed charges,90% of Total Billed Charges,72.43,164.23,
STREPTOCOCCUS PNEUMO,3000000026,CDM,300,RC,,,Outpatient,,,657.09,427.11,,657.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,499.39,76,,46.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,473.1,72,,199.296,Percent of Total Billed Charges,72% of Total Billed Charges,492.82,75,,207.6,Percent of Total Billed charges,75% of Total Billed Charges,657.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.1,72,,199.296,Percent of Total Billed Charges,72% of Total Billed Charges,394.25,60,,166.08,Percent of Total Billed Charges,60% of Total Billed Charges,591.38,90,,48.424,Percent of Total Billed Charges,90% of Total Billed Charges,295.69,45,,21.432,Percent of Total Billed Charges,45% of Total Billed Charges,591.38,90,,55.568,Percent of Total Billed Charges,90% of Total billed Charges,657.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,657.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,657.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.11,65,,63.96,Percent of total Billed Charges,65% of Total Billed Charges,289.78,44.1,,21.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,624.24,95,,58.656,Percent of Total Billed Charges,95% of Total Billed Charges,657.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,578.24,88,,174.592,Percent of Total Billed Charges,88% of Total Billed Charges,591.38,90,,55.568,Percent of Total Billed charges,90% of Total Billed Charges,289.78,657.09,
INHIBIN A,3000000027,CDM,300,RC,,,Outpatient,,,26.46,17.20,,26.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.11,76,,46.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.05,72,,100.8,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,75,,105,Percent of Total Billed charges,75% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.05,72,,100.8,Percent of Total Billed Charges,72% of Total Billed Charges,15.88,60,,84,Percent of Total Billed Charges,60% of Total Billed Charges,23.81,90,,110.16,Percent of Total Billed Charges,90% of Total Billed Charges,11.91,45,,89.28,Percent of Total Billed Charges,45% of Total Billed Charges,23.81,90,,55.568,Percent of Total Billed Charges,90% of Total billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,65,,59.28,Percent of total Billed Charges,65% of Total Billed Charges,11.67,44.1,,87.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.14,95,,58.656,Percent of Total Billed Charges,95% of Total Billed Charges,26.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.28,88,,166.104,Percent of Total Billed Charges,88% of Total Billed Charges,23.81,90,,55.568,Percent of Total Billed charges,90% of Total Billed Charges,11.67,26.46,
HEPATITIS B COREAB TOTAL,3000000028,CDM,300,RC,,,Outpatient,,,171.00,111.15,,171,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.96,76,,46.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.12,72,,76.84,Percent of Total Billed Charges,72% of Total Billed Charges,128.25,75,,80.04,Percent of Total Billed charges,75% of Total Billed Charges,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.12,72,,76.84,Percent of Total Billed Charges,72% of Total Billed Charges,102.6,60,,64.032,Percent of Total Billed Charges,60% of Total Billed Charges,153.9,90,,304.024,Percent of Total Billed Charges,90% of Total Billed Charges,76.95,45,,84.936,Percent of Total Billed Charges,45% of Total Billed Charges,153.9,90,,55.568,Percent of Total Billed Charges,90% of Total billed Charges,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.15,65,,79.56,Percent of total Billed Charges,65% of Total Billed Charges,75.41,44.1,,83.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,162.45,95,,58.656,Percent of Total Billed Charges,95% of Total Billed Charges,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.48,88,,166.104,Percent of Total Billed Charges,88% of Total Billed Charges,153.9,90,,55.568,Percent of Total Billed charges,90% of Total Billed Charges,75.41,171,
THYROGLOBULIN ANTIBODIES,3000000029,CDM,300,RC,,,Outpatient,,,476.28,309.58,,476.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,361.97,76,,42.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,342.92,72,,112.4,Percent of Total Billed Charges,72% of Total Billed Charges,357.21,75,,117.088,Percent of Total Billed charges,75% of Total Billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.92,72,,112.4,Percent of Total Billed Charges,72% of Total Billed Charges,285.77,60,,93.664,Percent of Total Billed Charges,60% of Total Billed Charges,428.65,90,,304.024,Percent of Total Billed Charges,90% of Total Billed Charges,214.33,45,,84.936,Percent of Total Billed Charges,45% of Total Billed Charges,428.65,90,,50.4,Percent of Total Billed Charges,90% of Total billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.58,65,,145.08,Percent of total Billed Charges,65% of Total Billed Charges,210.04,44.1,,83.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,452.47,95,,53.2,Percent of Total Billed Charges,95% of Total Billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.13,88,,92.368,Percent of Total Billed Charges,88% of Total Billed Charges,428.65,90,,50.4,Percent of Total Billed charges,90% of Total Billed Charges,210.04,476.28,
CMV  PCR,3000000030,CDM,300,RC,,,Outpatient,,,226.01,146.91,,226.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171.77,76,,36.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162.73,72,,112.4,Percent of Total Billed Charges,72% of Total Billed Charges,169.51,75,,117.088,Percent of Total Billed charges,75% of Total Billed Charges,226.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.73,72,,112.4,Percent of Total Billed Charges,72% of Total Billed Charges,135.61,60,,93.664,Percent of Total Billed Charges,60% of Total Billed Charges,203.41,90,,203.76,Percent of Total Billed Charges,90% of Total Billed Charges,101.7,45,,47.232,Percent of Total Billed Charges,45% of Total Billed Charges,203.41,90,,42.872,Percent of Total Billed Charges,90% of Total billed Charges,226.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.91,65,,158.6,Percent of total Billed Charges,65% of Total Billed Charges,99.67,44.1,,46.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,214.71,95,,45.248,Percent of Total Billed Charges,95% of Total Billed Charges,226.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.89,88,,52.008,Percent of Total Billed Charges,88% of Total Billed Charges,203.41,90,,42.872,Percent of Total Billed charges,90% of Total Billed Charges,99.67,226.01,
EBV DNA  QUALITATIVE RT PCR,3000000031,CDM,300,RC,,,Outpatient,,,315.32,204.96,,315.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,239.64,76,,150.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,227.03,72,,112.4,Percent of Total Billed Charges,72% of Total Billed Charges,236.49,75,,117.088,Percent of Total Billed charges,75% of Total Billed Charges,315.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.03,72,,112.4,Percent of Total Billed Charges,72% of Total Billed Charges,189.19,60,,93.664,Percent of Total Billed Charges,60% of Total Billed Charges,283.79,90,,212.736,Percent of Total Billed Charges,90% of Total Billed Charges,141.89,45,,26.592,Percent of Total Billed Charges,45% of Total Billed Charges,283.79,90,,178.56,Percent of Total Billed Charges,90% of Total billed Charges,315.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.96,65,,151.352,Percent of total Billed Charges,65% of Total Billed Charges,139.06,44.1,,26.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,299.55,95,,188.48,Percent of Total Billed Charges,95% of Total Billed Charges,315.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.48,88,,47.344,Percent of Total Billed Charges,88% of Total Billed Charges,283.79,90,,178.56,Percent of Total Billed charges,90% of Total Billed Charges,139.06,315.32,
915 MARKERS,3000000032,CDM,311,RC,,,Outpatient,,,453.13,294.53,,453.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,344.38,76,,143.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,326.25,72,,157.248,Percent of Total Billed Charges,72% of Total Billed Charges,339.85,75,,163.8,Percent of Total Billed charges,75% of Total Billed Charges,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.25,72,,157.248,Percent of Total Billed Charges,72% of Total Billed Charges,271.88,60,,131.04,Percent of Total Billed Charges,60% of Total Billed Charges,407.82,90,,209.52,Percent of Total Billed Charges,90% of Total Billed Charges,203.91,45,,24.208,Percent of Total Billed Charges,45% of Total Billed Charges,407.82,90,,169.88,Percent of Total Billed Charges,90% of Total billed Charges,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.53,65,,31.536,Percent of total Billed Charges,65% of Total Billed Charges,199.83,44.1,,23.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,430.47,95,,179.312,Percent of Total Billed Charges,95% of Total Billed Charges,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.75,88,,107.712,Percent of Total Billed Charges,88% of Total Billed Charges,407.82,90,,169.88,Percent of Total Billed charges,90% of Total Billed Charges,199.83,453.13,
SPERM ANTIBODIES(IGG,3000000033,CDM,300,RC,,,Outpatient,,,36.38,23.65,,36.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.65,76,,143.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.19,72,,165.12,Percent of Total Billed Charges,72% of Total Billed Charges,27.29,75,,172,Percent of Total Billed charges,75% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.19,72,,165.12,Percent of Total Billed Charges,72% of Total Billed Charges,21.83,60,,137.6,Percent of Total Billed Charges,60% of Total Billed Charges,32.74,90,,78.48,Percent of Total Billed Charges,90% of Total Billed Charges,16.37,45,,55.08,Percent of Total Billed Charges,45% of Total Billed Charges,32.74,90,,169.88,Percent of Total Billed Charges,90% of Total billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.65,65,,44.72,Percent of total Billed Charges,65% of Total Billed Charges,16.04,44.1,,53.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.56,95,,179.312,Percent of Total Billed Charges,95% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.01,88,,297.272,Percent of Total Billed Charges,88% of Total Billed Charges,32.74,90,,169.88,Percent of Total Billed charges,90% of Total Billed Charges,16.04,36.38,
PATH PACK FEE,3000000034,CDM,300,RC,,,Outpatient,,,33.08,21.50,,33.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.14,76,,79.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.82,72,,165.12,Percent of Total Billed Charges,72% of Total Billed Charges,24.81,75,,172,Percent of Total Billed charges,75% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.82,72,,165.12,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,60,,137.6,Percent of Total Billed Charges,60% of Total Billed Charges,29.77,90,,82.552,Percent of Total Billed Charges,90% of Total Billed Charges,14.89,45,,152.016,Percent of Total Billed Charges,45% of Total Billed Charges,29.77,90,,94.464,Percent of Total Billed Charges,90% of Total billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.5,65,,42.64,Percent of total Billed Charges,65% of Total Billed Charges,14.59,44.1,,148.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.43,95,,99.712,Percent of Total Billed Charges,95% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.11,88,,297.272,Percent of Total Billed Charges,88% of Total Billed Charges,29.77,90,,94.464,Percent of Total Billed charges,90% of Total Billed Charges,14.59,33.08,
PATERNITY TEST FEE,3000000035,CDM,300,RC,,,Outpatient,,,59.00,38.35,,59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,44.84,76,,44.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.48,72,,165.12,Percent of Total Billed Charges,72% of Total Billed Charges,44.25,75,,172,Percent of Total Billed charges,75% of Total Billed Charges,59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.48,72,,165.12,Percent of Total Billed Charges,72% of Total Billed Charges,35.4,60,,137.6,Percent of Total Billed Charges,60% of Total Billed Charges,53.1,90,,115.096,Percent of Total Billed Charges,90% of Total Billed Charges,26.55,45,,152.016,Percent of Total Billed Charges,45% of Total Billed Charges,53.1,90,,53.184,Percent of Total Billed Charges,90% of Total billed Charges,59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.35,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,26.02,44.1,,148.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,56.05,95,,56.144,Percent of Total Billed Charges,95% of Total Billed Charges,59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.92,88,,199.232,Percent of Total Billed Charges,88% of Total Billed Charges,53.1,90,,53.184,Percent of Total Billed charges,90% of Total Billed Charges,26.02,59,
BLOOD TRANSPORTATION FEE,3000000040,CDM,300,RC,,,Outpatient,,,59.00,38.35,,59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,44.84,76,,256.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.48,72,,156.224,Percent of Total Billed Charges,72% of Total Billed Charges,44.25,75,,162.736,Percent of Total Billed charges,75% of Total Billed Charges,59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.48,72,,156.224,Percent of Total Billed Charges,72% of Total Billed Charges,35.4,60,,130.184,Percent of Total Billed Charges,60% of Total Billed Charges,53.1,90,,236.56,Percent of Total Billed Charges,90% of Total Billed Charges,26.55,45,,39.24,Percent of Total Billed Charges,45% of Total Billed Charges,53.1,90,,304.024,Percent of Total Billed Charges,90% of Total billed Charges,59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.35,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,26.02,44.1,,38.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,56.05,95,,320.92,Percent of Total Billed Charges,95% of Total Billed Charges,59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.92,88,,80.72,Percent of Total Billed Charges,88% of Total Billed Charges,53.1,90,,304.024,Percent of Total Billed charges,90% of Total Billed Charges,26.02,59,
"HEPTIMAX HCV,RNA",3000000041,CDM,300,RC,,,Outpatient,,,1020.92,663.60,,1020.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,775.9,76,,172.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,735.06,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,765.69,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,1020.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,735.06,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,612.55,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,918.83,90,,9.92,Percent of Total Billed Charges,90% of Total Billed Charges,459.41,45,,41.28,Percent of Total Billed Charges,45% of Total Billed Charges,918.83,90,,203.76,Percent of Total Billed Charges,90% of Total billed Charges,1020.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1020.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1020.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,663.6,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,450.23,44.1,,40.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,969.87,95,,215.08,Percent of Total Billed Charges,95% of Total Billed Charges,1020.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.41,88,,112.544,Percent of Total Billed Charges,88% of Total Billed Charges,918.83,90,,203.76,Percent of Total Billed charges,90% of Total Billed Charges,450.23,1020.92,
"HEPTIMAX HCV,RNA",3000000042,CDM,300,RC,,,Outpatient,,,1020.92,663.60,,1020.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,775.9,76,,179.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,735.06,72,,114.304,Percent of Total Billed Charges,72% of Total Billed Charges,765.69,75,,119.072,Percent of Total Billed charges,75% of Total Billed Charges,1020.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,735.06,72,,114.304,Percent of Total Billed Charges,72% of Total Billed Charges,612.55,60,,95.256,Percent of Total Billed Charges,60% of Total Billed Charges,918.83,90,,222.264,Percent of Total Billed Charges,90% of Total Billed Charges,459.41,45,,57.552,Percent of Total Billed Charges,45% of Total Billed Charges,918.83,90,,212.736,Percent of Total Billed Charges,90% of Total billed Charges,1020.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1020.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1020.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,663.6,65,,103.192,Percent of total Billed Charges,65% of Total Billed Charges,450.23,44.1,,56.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,969.87,95,,224.56,Percent of Total Billed Charges,95% of Total Billed Charges,1020.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.41,88,,135.056,Percent of Total Billed Charges,88% of Total Billed Charges,918.83,90,,212.736,Percent of Total Billed charges,90% of Total Billed Charges,450.23,1020.92,
ALPHA-FETOPROTEIN L3,3000000044,CDM,300,RC,,,Outpatient,,,161.03,104.67,,161.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,122.38,76,,176.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,115.94,72,,91.008,Percent of Total Billed Charges,72% of Total Billed Charges,120.77,75,,94.8,Percent of Total Billed charges,75% of Total Billed Charges,161.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.94,72,,91.008,Percent of Total Billed Charges,72% of Total Billed Charges,96.62,60,,75.84,Percent of Total Billed Charges,60% of Total Billed Charges,144.93,90,,55.44,Percent of Total Billed Charges,90% of Total Billed Charges,72.46,45,,69.064,Percent of Total Billed Charges,45% of Total Billed Charges,144.93,90,,209.52,Percent of Total Billed Charges,90% of Total billed Charges,161.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.67,65,,24.656,Percent of total Billed Charges,65% of Total Billed Charges,71.01,44.1,,67.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,152.98,95,,221.16,Percent of Total Billed Charges,95% of Total Billed Charges,161.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.71,88,,24.84,Percent of Total Billed Charges,88% of Total Billed Charges,144.93,90,,209.52,Percent of Total Billed charges,90% of Total Billed Charges,71.01,161.03,
Send Out Test Handling Fee,3000000045,CDM,300,RC,,,Outpatient,,,59.00,38.35,,59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,44.84,76,,66.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.48,72,,66.048,Percent of Total Billed Charges,72% of Total Billed Charges,44.25,75,,68.8,Percent of Total Billed charges,75% of Total Billed Charges,59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.48,72,,66.048,Percent of Total Billed Charges,72% of Total Billed Charges,35.4,60,,55.04,Percent of Total Billed Charges,60% of Total Billed Charges,53.1,90,,55.44,Percent of Total Billed Charges,90% of Total Billed Charges,26.55,45,,12.704,Percent of Total Billed Charges,45% of Total Billed Charges,53.1,90,,78.48,Percent of Total Billed Charges,90% of Total billed Charges,59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.35,65,,330.224,Percent of total Billed Charges,65% of Total Billed Charges,26.02,44.1,,12.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,56.05,95,,82.84,Percent of Total Billed Charges,95% of Total Billed Charges,59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.92,88,,61.248,Percent of Total Billed Charges,88% of Total Billed Charges,53.1,90,,78.48,Percent of Total Billed charges,90% of Total Billed Charges,26.02,59,
SANE Venipuncture,3000000046,CDM,300,RC,,,Outpatient,,,56.00,36.40,,56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.56,76,,69.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.32,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,42,75,,91.288,Percent of Total Billed charges,75% of Total Billed Charges,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.32,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,33.6,60,,73.032,Percent of Total Billed Charges,60% of Total Billed Charges,50.4,90,,54.768,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,45,,31.32,Percent of Total Billed Charges,45% of Total Billed Charges,50.4,90,,82.552,Percent of Total Billed Charges,90% of Total billed Charges,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.4,65,,146.64,Percent of total Billed Charges,65% of Total Billed Charges,24.7,44.1,,30.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.2,95,,87.144,Percent of Total Billed Charges,95% of Total Billed Charges,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.28,88,,231.296,Percent of Total Billed Charges,88% of Total Billed Charges,50.4,90,,82.552,Percent of Total Billed charges,90% of Total Billed Charges,24.7,56,
SANE Lab Specimen Handling,3000000047,CDM,300,RC,,,Outpatient,,,10.00,6.50,,10,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.6,76,,97.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.2,72,,191.632,Percent of Total Billed Charges,72% of Total Billed Charges,7.5,75,,199.616,Percent of Total Billed charges,75% of Total Billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.2,72,,191.632,Percent of Total Billed Charges,72% of Total Billed Charges,6,60,,159.688,Percent of Total Billed Charges,60% of Total Billed Charges,9,90,,50.4,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,45,,118.28,Percent of Total Billed Charges,45% of Total Billed Charges,9,90,,115.096,Percent of Total Billed Charges,90% of Total billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,65,,124.408,Percent of total Billed Charges,65% of Total Billed Charges,4.41,44.1,,115.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.5,95,,121.496,Percent of Total Billed Charges,95% of Total Billed Charges,10,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.8,88,,9.704,Percent of Total Billed Charges,88% of Total Billed Charges,9,90,,115.096,Percent of Total Billed charges,90% of Total Billed Charges,4.41,10,
RBC Phenotyping,3000000048,CDM,300,RC,,,Outpatient,,,780.00,507.00,,780,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,592.8,76,,116.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,561.6,72,,62.24,Percent of Total Billed Charges,72% of Total Billed Charges,585,75,,64.832,Percent of Total Billed charges,75% of Total Billed Charges,780,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561.6,72,,62.24,Percent of Total Billed Charges,72% of Total Billed Charges,468,60,,51.864,Percent of Total Billed Charges,60% of Total Billed Charges,702,90,,77,Percent of Total Billed Charges,90% of Total Billed Charges,351,45,,4.96,Percent of Total Billed Charges,45% of Total Billed Charges,702,90,,138.128,Percent of Total Billed Charges,90% of Total billed Charges,780,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507,65,,22.88,Percent of total Billed Charges,65% of Total Billed Charges,343.98,44.1,,4.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,741,95,,145.8,Percent of Total Billed Charges,95% of Total Billed Charges,780,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,686.4,88,,217.328,Percent of Total Billed Charges,88% of Total Billed Charges,702,90,,138.128,Percent of Total Billed charges,90% of Total Billed Charges,343.98,780,
"Multiplex test(Covid,RSV,Flu)",3000000049,CDM,300,RC,,,Outpatient,,,339.00,220.35,,339,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,257.64,76,,21.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,244.08,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,254.25,75,,44.32,Percent of Total Billed charges,75% of Total Billed Charges,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.08,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,203.4,60,,35.456,Percent of Total Billed Charges,60% of Total Billed Charges,305.1,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,152.55,45,,111.136,Percent of Total Billed Charges,45% of Total Billed Charges,305.1,90,,25.4,Percent of Total Billed Charges,90% of Total billed Charges,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.35,65,,23.92,Percent of total Billed Charges,65% of Total Billed Charges,149.5,44.1,,108.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,322.05,95,,26.816,Percent of Total Billed Charges,95% of Total Billed Charges,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.32,88,,54.208,Percent of Total Billed Charges,88% of Total Billed Charges,305.1,90,,25.4,Percent of Total Billed charges,90% of Total Billed Charges,149.5,339,
Venipuncture <3 years,3000000050,CDM,510,RC,,,Outpatient,,,74.00,48.10,,74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.24,76,,52.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.28,72,,423.576,Percent of Total Billed Charges,72% of Total Billed Charges,55.5,75,,441.224,Percent of Total Billed charges,75% of Total Billed Charges,74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.28,72,,423.576,Percent of Total Billed Charges,72% of Total Billed Charges,44.4,60,,352.976,Percent of Total Billed Charges,60% of Total Billed Charges,66.6,90,,97.92,Percent of Total Billed Charges,90% of Total Billed Charges,74,100,,27.72,Case Rate,Pays based on per visit rate,66.6,90,,62.64,Percent of Total Billed Charges,90% of Total billed Charges,74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.1,65,,30.16,Percent of total Billed Charges,65% of Total Billed Charges,74,100,,27.168,Fee Schedule,Pays based on per visit rate,70.3,95,,66.12,Percent of Total Billed Charges,95% of Total Billed Charges,74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.12,88,,54.208,Percent of Total Billed Charges,88% of Total Billed Charges,66.6,90,,62.64,Percent of Total Billed charges,90% of Total Billed Charges,44.4,74,
PROTEIN TOTAL PERITONEAL FLD,3010000001,CDM,301,RC,,,Outpatient,,,86.00,55.90,,86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,65.36,76,,199.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.92,72,,144.792,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,75,,150.824,Percent of Total Billed charges,75% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.92,72,,144.792,Percent of Total Billed Charges,72% of Total Billed Charges,51.6,60,,120.656,Percent of Total Billed Charges,60% of Total Billed Charges,77.4,90,,88.56,Percent of Total Billed Charges,90% of Total Billed Charges,38.7,45,,27.72,Percent of Total Billed Charges,45% of Total Billed Charges,77.4,90,,236.56,Percent of Total Billed Charges,90% of Total billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.9,65,,49.88,Percent of total Billed Charges,65% of Total Billed Charges,37.93,44.1,,27.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,81.7,95,,249.696,Percent of Total Billed Charges,95% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.68,88,,53.552,Percent of Total Billed Charges,88% of Total Billed Charges,77.4,90,,236.56,Percent of Total Billed charges,90% of Total Billed Charges,37.93,86,
BASIC METABOLIC PANE,3010000002,CDM,301,RC,,,Outpatient,,,171.00,111.15,,171,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.96,76,,8.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.12,72,,144.792,Percent of Total Billed Charges,72% of Total Billed Charges,128.25,75,,150.824,Percent of Total Billed charges,75% of Total Billed Charges,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.12,72,,144.792,Percent of Total Billed Charges,72% of Total Billed Charges,102.6,60,,120.656,Percent of Total Billed Charges,60% of Total Billed Charges,153.9,90,,82.08,Percent of Total Billed Charges,90% of Total Billed Charges,76.95,45,,27.384,Percent of Total Billed Charges,45% of Total Billed Charges,153.9,90,,9.92,Percent of Total Billed Charges,90% of Total billed Charges,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.15,65,,114.664,Percent of total Billed Charges,65% of Total Billed Charges,75.41,44.1,,26.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,162.45,95,,10.472,Percent of Total Billed Charges,95% of Total Billed Charges,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.48,88,,49.28,Percent of Total Billed Charges,88% of Total Billed Charges,153.9,90,,9.92,Percent of Total Billed charges,90% of Total Billed Charges,75.41,171,
ELECTROLYTES PANEL,3010000003,CDM,301,RC,,,Outpatient,,,201.00,130.65,,201,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152.76,76,,187.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144.72,72,,552.488,Percent of Total Billed Charges,72% of Total Billed Charges,150.75,75,,575.512,Percent of Total Billed charges,75% of Total Billed Charges,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.72,72,,552.488,Percent of Total Billed Charges,72% of Total Billed Charges,120.6,60,,460.408,Percent of Total Billed Charges,60% of Total Billed Charges,180.9,90,,110.16,Percent of Total Billed Charges,90% of Total Billed Charges,90.45,45,,25.2,Percent of Total Billed Charges,45% of Total Billed Charges,180.9,90,,222.264,Percent of Total Billed Charges,90% of Total billed Charges,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.65,65,,72.28,Percent of total Billed Charges,65% of Total Billed Charges,88.64,44.1,,24.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,190.95,95,,234.616,Percent of Total Billed Charges,95% of Total Billed Charges,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.88,88,,75.288,Percent of Total Billed Charges,88% of Total Billed Charges,180.9,90,,222.264,Percent of Total Billed charges,90% of Total Billed Charges,88.64,201,
COMPREHENSIVE METABO,3010000004,CDM,301,RC,,,Outpatient,,,300.00,195.00,,300,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,228,76,,46.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,216,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,225,75,,91.288,Percent of Total Billed charges,75% of Total Billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216,72,,87.64,Percent of Total Billed Charges,72% of Total Billed Charges,180,60,,73.032,Percent of Total Billed Charges,60% of Total Billed Charges,270,90,,200.88,Percent of Total Billed Charges,90% of Total Billed Charges,135,45,,38.496,Percent of Total Billed Charges,45% of Total Billed Charges,270,90,,55.44,Percent of Total Billed Charges,90% of Total billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195,65,,154.216,Percent of total Billed Charges,65% of Total Billed Charges,132.3,44.1,,37.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,285,95,,58.52,Percent of Total Billed Charges,95% of Total Billed Charges,300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264,88,,44.352,Percent of Total Billed Charges,88% of Total Billed Charges,270,90,,55.44,Percent of Total Billed charges,90% of Total Billed Charges,132.3,300,
LIPID PROFILE,3010000005,CDM,301,RC,,,Outpatient,,,263.00,170.95,,263,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,199.88,76,,46.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,189.36,72,,89.248,Percent of Total Billed Charges,72% of Total Billed Charges,197.25,75,,92.968,Percent of Total Billed charges,75% of Total Billed Charges,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.36,72,,89.248,Percent of Total Billed Charges,72% of Total Billed Charges,157.8,60,,74.376,Percent of Total Billed Charges,60% of Total Billed Charges,236.7,90,,219.6,Percent of Total Billed Charges,90% of Total Billed Charges,118.35,45,,22.68,Percent of Total Billed Charges,45% of Total Billed Charges,236.7,90,,55.44,Percent of Total Billed Charges,90% of Total billed Charges,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.95,65,,104.52,Percent of total Billed Charges,65% of Total Billed Charges,115.98,44.1,,22.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,249.85,95,,58.52,Percent of Total Billed Charges,95% of Total Billed Charges,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.44,88,,95.744,Percent of Total Billed Charges,88% of Total Billed Charges,236.7,90,,55.44,Percent of Total Billed charges,90% of Total Billed Charges,115.98,263,
RENAL FUNCTION PANEL,3010000006,CDM,301,RC,,,Outpatient,,,262.00,170.30,,262,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,199.12,76,,46.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,188.64,72,,89.248,Percent of Total Billed Charges,72% of Total Billed Charges,196.5,75,,92.968,Percent of Total Billed charges,75% of Total Billed Charges,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.64,72,,89.248,Percent of Total Billed Charges,72% of Total Billed Charges,157.2,60,,74.376,Percent of Total Billed Charges,60% of Total Billed Charges,235.8,90,,209.56,Percent of Total Billed Charges,90% of Total Billed Charges,117.9,45,,48.96,Percent of Total Billed Charges,45% of Total Billed Charges,235.8,90,,54.768,Percent of Total Billed Charges,90% of Total billed Charges,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.3,65,,127.4,Percent of total Billed Charges,65% of Total Billed Charges,115.54,44.1,,47.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,248.9,95,,57.816,Percent of Total Billed Charges,95% of Total Billed Charges,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.56,88,,86.592,Percent of Total Billed Charges,88% of Total Billed Charges,235.8,90,,54.768,Percent of Total Billed charges,90% of Total Billed Charges,115.54,262,
HEP PANEL(A B NON A&,3010000007,CDM,301,RC,,,Outpatient,,,782.00,508.30,,782,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,594.32,76,,42.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,563.04,72,,375.944,Percent of Total Billed Charges,72% of Total Billed Charges,586.5,75,,391.608,Percent of Total Billed charges,75% of Total Billed Charges,782,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.04,72,,375.944,Percent of Total Billed Charges,72% of Total Billed Charges,469.2,60,,313.288,Percent of Total Billed Charges,60% of Total Billed Charges,703.8,90,,43.664,Percent of Total Billed Charges,90% of Total Billed Charges,351.9,45,,44.28,Percent of Total Billed Charges,45% of Total Billed Charges,703.8,90,,50.4,Percent of Total Billed Charges,90% of Total billed Charges,782,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,782,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,782,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.3,65,,163.8,Percent of total Billed Charges,65% of Total Billed Charges,344.86,44.1,,43.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,742.9,95,,53.2,Percent of Total Billed Charges,95% of Total Billed Charges,782,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,688.16,88,,80.256,Percent of Total Billed Charges,88% of Total Billed Charges,703.8,90,,50.4,Percent of Total Billed charges,90% of Total Billed Charges,344.86,782,
HEPATIC FUNCTION PAN,3010000008,CDM,301,RC,,,Outpatient,,,408.00,265.20,,408,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,310.08,76,,65.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,293.76,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,306,75,,34.2,Percent of Total Billed charges,75% of Total Billed Charges,408,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.76,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,244.8,60,,27.36,Percent of Total Billed Charges,60% of Total Billed Charges,367.2,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,183.6,45,,41.04,Percent of Total Billed Charges,45% of Total Billed Charges,367.2,90,,77,Percent of Total Billed Charges,90% of Total billed Charges,408,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,408,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,408,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.2,65,,312.448,Percent of total Billed Charges,65% of Total Billed Charges,179.93,44.1,,40.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,387.6,95,,81.272,Percent of Total Billed Charges,95% of Total Billed Charges,408,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.04,88,,107.712,Percent of Total Billed Charges,88% of Total Billed Charges,367.2,90,,77,Percent of Total Billed charges,90% of Total Billed Charges,179.93,408,
TEGRETOL TOTAL,3010000009,CDM,301,RC,,,Outpatient,,,167.00,108.55,,167,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,126.92,76,,38.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,120.24,72,,98.496,Percent of Total Billed Charges,72% of Total Billed Charges,125.25,75,,102.6,Percent of Total Billed charges,75% of Total Billed Charges,167,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.24,72,,98.496,Percent of Total Billed Charges,72% of Total Billed Charges,100.2,60,,82.08,Percent of Total Billed Charges,60% of Total Billed Charges,150.3,90,,59.04,Percent of Total Billed Charges,90% of Total Billed Charges,75.15,45,,55.08,Percent of Total Billed Charges,45% of Total Billed Charges,150.3,90,,45.36,Percent of Total Billed Charges,90% of Total billed Charges,167,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.55,65,,55.12,Percent of total Billed Charges,65% of Total Billed Charges,73.65,44.1,,53.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,158.65,95,,47.88,Percent of Total Billed Charges,95% of Total Billed Charges,167,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.96,88,,196.416,Percent of Total Billed Charges,88% of Total Billed Charges,150.3,90,,45.36,Percent of Total Billed charges,90% of Total Billed Charges,73.65,167,
CYCLOSPORINE (B),3010000010,CDM,301,RC,,,Outpatient,,,461.95,300.27,,461.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,351.08,76,,82.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,332.6,72,,73.664,Percent of Total Billed Charges,72% of Total Billed Charges,346.46,75,,76.736,Percent of Total Billed charges,75% of Total Billed Charges,461.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.6,72,,73.664,Percent of Total Billed Charges,72% of Total Billed Charges,277.17,60,,61.384,Percent of Total Billed Charges,60% of Total Billed Charges,415.76,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,207.88,45,,100.44,Percent of Total Billed Charges,45% of Total Billed Charges,415.76,90,,97.92,Percent of Total Billed Charges,90% of Total billed Charges,461.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,461.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,461.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.27,65,,46.8,Percent of total Billed Charges,65% of Total Billed Charges,203.72,44.1,,98.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,438.85,95,,103.36,Percent of Total Billed Charges,95% of Total Billed Charges,461.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.52,88,,214.72,Percent of Total Billed Charges,88% of Total Billed Charges,415.76,90,,97.92,Percent of Total Billed charges,90% of Total Billed Charges,203.72,461.95,
DIGOXIN TOTAL,3010000011,CDM,301,RC,,,Outpatient,,,98.00,63.70,,98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,74.48,76,,74.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,70.56,72,,73.664,Percent of Total Billed Charges,72% of Total Billed Charges,73.5,75,,76.736,Percent of Total Billed charges,75% of Total Billed Charges,98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,72,,73.664,Percent of Total Billed Charges,72% of Total Billed Charges,58.8,60,,61.384,Percent of Total Billed Charges,60% of Total Billed Charges,88.2,90,,66.96,Percent of Total Billed Charges,90% of Total Billed Charges,44.1,45,,109.8,Percent of Total Billed Charges,45% of Total Billed Charges,88.2,90,,88.56,Percent of Total Billed Charges,90% of Total billed Charges,98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.7,65,,56.68,Percent of total Billed Charges,65% of Total Billed Charges,43.22,44.1,,107.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,93.1,95,,93.48,Percent of Total Billed Charges,95% of Total Billed Charges,98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.24,88,,204.904,Percent of Total Billed Charges,88% of Total Billed Charges,88.2,90,,88.56,Percent of Total Billed charges,90% of Total Billed Charges,43.22,98,
DEPAKENE TOTAL,3010000012,CDM,301,RC,,,Outpatient,,,132.00,85.80,,132,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.32,76,,69.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.04,72,,73.664,Percent of Total Billed Charges,72% of Total Billed Charges,99,75,,76.736,Percent of Total Billed charges,75% of Total Billed Charges,132,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.04,72,,73.664,Percent of Total Billed Charges,72% of Total Billed Charges,79.2,60,,61.384,Percent of Total Billed Charges,60% of Total Billed Charges,118.8,90,,59.76,Percent of Total Billed Charges,90% of Total Billed Charges,59.4,45,,104.784,Percent of Total Billed Charges,45% of Total Billed Charges,118.8,90,,82.08,Percent of Total Billed Charges,90% of Total billed Charges,132,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.8,65,,88.92,Percent of total Billed Charges,65% of Total Billed Charges,58.21,44.1,,102.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.4,95,,86.64,Percent of Total Billed Charges,95% of Total Billed Charges,132,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.16,88,,42.688,Percent of Total Billed Charges,88% of Total Billed Charges,118.8,90,,82.08,Percent of Total Billed charges,90% of Total Billed Charges,58.21,132,
VALPORIC ACID FREE,3010000013,CDM,301,RC,,,Outpatient,,,499.25,324.51,,499.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,379.43,76,,93.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,359.46,72,,73.664,Percent of Total Billed Charges,72% of Total Billed Charges,374.44,75,,76.736,Percent of Total Billed charges,75% of Total Billed Charges,499.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.46,72,,73.664,Percent of Total Billed Charges,72% of Total Billed Charges,299.55,60,,61.384,Percent of Total Billed Charges,60% of Total Billed Charges,449.33,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,224.66,45,,21.832,Percent of Total Billed Charges,45% of Total Billed Charges,449.33,90,,110.16,Percent of Total Billed Charges,90% of Total billed Charges,499.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,499.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,499.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.51,65,,101.4,Percent of total Billed Charges,65% of Total Billed Charges,220.17,44.1,,21.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,474.29,95,,116.28,Percent of Total Billed Charges,95% of Total Billed Charges,499.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,439.34,88,,60.544,Percent of Total Billed Charges,88% of Total Billed Charges,449.33,90,,110.16,Percent of Total Billed charges,90% of Total Billed Charges,220.17,499.25,
GENTAMICIN,3010000014,CDM,301,RC,,,Outpatient,,,106.00,68.90,,106,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,80.56,76,,169.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,76.32,72,,73.664,Percent of Total Billed Charges,72% of Total Billed Charges,79.5,75,,76.736,Percent of Total Billed charges,75% of Total Billed Charges,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.32,72,,73.664,Percent of Total Billed Charges,72% of Total Billed Charges,63.6,60,,61.384,Percent of Total Billed Charges,60% of Total Billed Charges,95.4,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,47.7,45,,30.96,Percent of Total Billed Charges,45% of Total Billed Charges,95.4,90,,200.88,Percent of Total Billed Charges,90% of Total billed Charges,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.9,65,,86.32,Percent of total Billed Charges,65% of Total Billed Charges,46.75,44.1,,30.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,100.7,95,,212.04,Percent of Total Billed Charges,95% of Total Billed Charges,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.28,88,,57.728,Percent of Total Billed Charges,88% of Total Billed Charges,95.4,90,,200.88,Percent of Total Billed charges,90% of Total Billed Charges,46.75,106,
LITHIUM,3010000015,CDM,301,RC,,,Outpatient,,,120.00,78.00,,120,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,91.2,76,,185.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,86.4,72,,68.584,Percent of Total Billed Charges,72% of Total Billed Charges,90,75,,71.44,Percent of Total Billed charges,75% of Total Billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.4,72,,68.584,Percent of Total Billed Charges,72% of Total Billed Charges,72,60,,57.152,Percent of Total Billed Charges,60% of Total Billed Charges,108,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,54,45,,29.52,Percent of Total Billed Charges,45% of Total Billed Charges,108,90,,219.6,Percent of Total Billed Charges,90% of Total billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78,65,,138.168,Percent of total Billed Charges,65% of Total Billed Charges,52.92,44.1,,28.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,114,95,,231.8,Percent of Total Billed Charges,95% of Total Billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.6,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,108,90,,219.6,Percent of Total Billed charges,90% of Total Billed Charges,52.92,120,
PHENOBARBITAL LEVEL,3010000016,CDM,301,RC,,,Outpatient,,,99.00,64.35,,99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.24,76,,176.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71.28,72,,134.632,Percent of Total Billed Charges,72% of Total Billed Charges,74.25,75,,140.24,Percent of Total Billed charges,75% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.28,72,,134.632,Percent of Total Billed Charges,72% of Total Billed Charges,59.4,60,,112.192,Percent of Total Billed Charges,60% of Total Billed Charges,89.1,90,,142.888,Percent of Total Billed Charges,90% of Total Billed Charges,44.55,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,89.1,90,,209.56,Percent of Total Billed Charges,90% of Total billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.35,65,,91,Percent of total Billed Charges,65% of Total Billed Charges,43.66,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,94.05,95,,221.208,Percent of Total Billed Charges,95% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.12,88,,65.472,Percent of Total Billed Charges,88% of Total Billed Charges,89.1,90,,209.56,Percent of Total Billed charges,90% of Total Billed Charges,43.66,99,
DILANTIN TOTAL,3010000017,CDM,301,RC,,,Outpatient,,,109.00,70.85,,109,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.84,76,,36.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,78.48,72,,124.984,Percent of Total Billed Charges,72% of Total Billed Charges,81.75,75,,130.192,Percent of Total Billed charges,75% of Total Billed Charges,109,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.48,72,,124.984,Percent of Total Billed Charges,72% of Total Billed Charges,65.4,60,,104.152,Percent of Total Billed Charges,60% of Total Billed Charges,98.1,90,,34.136,Percent of Total Billed Charges,90% of Total Billed Charges,49.05,45,,33.48,Percent of Total Billed Charges,45% of Total Billed Charges,98.1,90,,43.664,Percent of Total Billed Charges,90% of Total billed Charges,109,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.85,65,,53.56,Percent of total Billed Charges,65% of Total Billed Charges,48.07,44.1,,32.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,103.55,95,,46.088,Percent of Total Billed Charges,95% of Total Billed Charges,109,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,88,,58.432,Percent of Total Billed Charges,88% of Total Billed Charges,98.1,90,,43.664,Percent of Total Billed charges,90% of Total Billed Charges,48.07,109,
TACROLIMUS,3010000018,CDM,301,RC,,,Outpatient,,,337.37,219.29,,337.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,256.4,76,,52.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,242.91,72,,93.312,Percent of Total Billed Charges,72% of Total Billed Charges,253.03,75,,97.2,Percent of Total Billed charges,75% of Total Billed Charges,337.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.91,72,,93.312,Percent of Total Billed Charges,72% of Total Billed Charges,202.42,60,,77.76,Percent of Total Billed Charges,60% of Total Billed Charges,303.63,90,,457.232,Percent of Total Billed Charges,90% of Total Billed Charges,151.82,45,,29.88,Percent of Total Billed Charges,45% of Total Billed Charges,303.63,90,,61.92,Percent of Total Billed Charges,90% of Total billed Charges,337.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.29,65,,40.56,Percent of total Billed Charges,65% of Total Billed Charges,148.78,44.1,,29.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,320.5,95,,65.36,Percent of Total Billed Charges,95% of Total Billed Charges,337.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.89,88,,60.544,Percent of Total Billed Charges,88% of Total Billed Charges,303.63,90,,61.92,Percent of Total Billed charges,90% of Total Billed Charges,148.78,337.37,
TOPIRAMATE,3010000019,CDM,301,RC,,,Outpatient,,,110.25,71.66,,110.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,83.79,76,,49.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,79.38,72,,95.256,Percent of Total Billed Charges,72% of Total Billed Charges,82.69,75,,99.232,Percent of Total Billed charges,75% of Total Billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.38,72,,95.256,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,60,,79.384,Percent of Total Billed Charges,60% of Total Billed Charges,99.23,90,,203.04,Percent of Total Billed Charges,90% of Total Billed Charges,49.61,45,,30.96,Percent of Total Billed Charges,45% of Total Billed Charges,99.23,90,,59.04,Percent of Total Billed Charges,90% of Total billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.66,65,,52.168,Percent of total Billed Charges,65% of Total Billed Charges,48.62,44.1,,30.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,104.74,95,,62.32,Percent of Total Billed Charges,95% of Total Billed Charges,110.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,99.23,90,,59.04,Percent of Total Billed charges,90% of Total Billed Charges,48.62,110.25,
VANCOMYCIN LEVEL,3010000020,CDM,301,RC,,,Outpatient,,,213.00,138.45,,213,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.88,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153.36,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,159.75,75,,44.984,Percent of Total Billed charges,75% of Total Billed Charges,213,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.36,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,127.8,60,,35.984,Percent of Total Billed Charges,60% of Total Billed Charges,191.7,90,,172.256,Percent of Total Billed Charges,90% of Total Billed Charges,95.85,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,191.7,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,213,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.45,65,,138.744,Percent of total Billed Charges,65% of Total Billed Charges,93.93,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,202.35,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,213,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.44,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,191.7,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,93.93,213,
NEUROTIN (GABAPENTIN,3010000021,CDM,301,RC,,,Outpatient,,,244.76,159.09,,244.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,186.02,76,,56.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,176.23,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,183.57,75,,44.984,Percent of Total Billed charges,75% of Total Billed Charges,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.23,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,146.86,60,,35.984,Percent of Total Billed Charges,60% of Total Billed Charges,220.28,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,110.14,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,220.28,90,,66.96,Percent of Total Billed Charges,90% of Total billed Charges,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.09,65,,368.064,Percent of total Billed Charges,65% of Total Billed Charges,107.94,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,232.52,95,,70.68,Percent of Total Billed Charges,95% of Total Billed Charges,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.39,88,,139.712,Percent of Total Billed Charges,88% of Total Billed Charges,220.28,90,,66.96,Percent of Total Billed charges,90% of Total Billed Charges,107.94,244.76,
LEVETIRACETAM,3010000022,CDM,301,RC,,,Outpatient,,,233.00,151.45,,233,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,177.08,76,,50.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,167.76,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,174.75,75,,44.984,Percent of Total Billed charges,75% of Total Billed Charges,233,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.76,72,,43.184,Percent of Total Billed Charges,72% of Total Billed Charges,139.8,60,,35.984,Percent of Total Billed Charges,60% of Total Billed Charges,209.7,90,,33.12,Percent of Total Billed Charges,90% of Total Billed Charges,104.85,45,,71.44,Percent of Total Billed Charges,45% of Total Billed Charges,209.7,90,,59.76,Percent of Total Billed Charges,90% of Total billed Charges,233,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.45,65,,84.28,Percent of total Billed Charges,65% of Total Billed Charges,102.75,44.1,,70.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,221.35,95,,63.08,Percent of Total Billed Charges,95% of Total Billed Charges,233,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.04,88,,33.376,Percent of Total Billed Charges,88% of Total Billed Charges,209.7,90,,59.76,Percent of Total Billed charges,90% of Total Billed Charges,102.75,233,
ZONISAMIDE ZONEGRAN(,3010000023,CDM,301,RC,,,Outpatient,,,233.00,151.45,,233,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,177.08,76,,52.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,167.76,72,,289.576,Percent of Total Billed Charges,72% of Total Billed Charges,174.75,75,,301.648,Percent of Total Billed charges,75% of Total Billed Charges,233,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.76,72,,289.576,Percent of Total Billed Charges,72% of Total Billed Charges,139.8,60,,241.312,Percent of Total Billed Charges,60% of Total Billed Charges,209.7,90,,41.76,Percent of Total Billed Charges,90% of Total Billed Charges,104.85,45,,17.064,Percent of Total Billed Charges,45% of Total Billed Charges,209.7,90,,61.92,Percent of Total Billed Charges,90% of Total billed Charges,233,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.45,65,,80.264,Percent of total Billed Charges,65% of Total Billed Charges,102.75,44.1,,16.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,221.35,95,,65.36,Percent of Total Billed Charges,95% of Total Billed Charges,233,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.04,88,,447.072,Percent of Total Billed Charges,88% of Total Billed Charges,209.7,90,,61.92,Percent of Total Billed charges,90% of Total Billed Charges,102.75,233,
LAMOTRIGINE,3010000024,CDM,301,RC,,,Outpatient,,,244.76,159.09,,244.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,186.02,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,176.23,72,,89.856,Percent of Total Billed Charges,72% of Total Billed Charges,183.57,75,,93.6,Percent of Total Billed charges,75% of Total Billed Charges,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.23,72,,89.856,Percent of Total Billed Charges,72% of Total Billed Charges,146.86,60,,74.88,Percent of Total Billed Charges,60% of Total Billed Charges,220.28,90,,69.064,Percent of Total Billed Charges,90% of Total Billed Charges,110.14,45,,228.616,Percent of Total Billed Charges,45% of Total Billed Charges,220.28,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.09,65,,115.96,Percent of total Billed Charges,65% of Total Billed Charges,107.94,44.1,,224.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,232.52,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.39,88,,198.528,Percent of Total Billed Charges,88% of Total Billed Charges,220.28,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,107.94,244.76,
TRILEPTAL,3010000025,CDM,301,RC,,,Outpatient,,,233.00,151.45,,233,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,177.08,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,167.76,72,,39.376,Percent of Total Billed Charges,72% of Total Billed Charges,174.75,75,,41.016,Percent of Total Billed charges,75% of Total Billed Charges,233,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.76,72,,39.376,Percent of Total Billed Charges,72% of Total Billed Charges,139.8,60,,32.816,Percent of Total Billed Charges,60% of Total Billed Charges,209.7,90,,158.76,Percent of Total Billed Charges,90% of Total Billed Charges,104.85,45,,101.52,Percent of Total Billed Charges,45% of Total Billed Charges,209.7,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,233,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.45,65,,108.68,Percent of total Billed Charges,65% of Total Billed Charges,102.75,44.1,,99.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,221.35,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,233,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.04,88,,168.424,Percent of Total Billed Charges,88% of Total Billed Charges,209.7,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,102.75,233,
NURSING STUDENT DRUG SCREEN,3010000026,CDM,301,RC,,,Outpatient,,,339.00,220.35,,339,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,257.64,76,,120.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,244.08,72,,197.496,Percent of Total Billed Charges,72% of Total Billed Charges,254.25,75,,205.728,Percent of Total Billed charges,75% of Total Billed Charges,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.08,72,,197.496,Percent of Total Billed Charges,72% of Total Billed Charges,203.4,60,,164.584,Percent of Total Billed Charges,60% of Total Billed Charges,305.1,90,,100.08,Percent of Total Billed Charges,90% of Total Billed Charges,152.55,45,,86.128,Percent of Total Billed Charges,45% of Total Billed Charges,305.1,90,,142.888,Percent of Total Billed Charges,90% of Total billed Charges,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.35,65,,30.384,Percent of total Billed Charges,65% of Total Billed Charges,149.5,44.1,,84.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,322.05,95,,150.824,Percent of Total Billed Charges,95% of Total Billed Charges,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.32,88,,30.976,Percent of Total Billed Charges,88% of Total Billed Charges,305.1,90,,142.888,Percent of Total Billed charges,90% of Total Billed Charges,149.5,339,
DIAG URINE DRUG SCRN,3010000027,CDM,301,RC,,,Outpatient,,,339.00,220.35,,339,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,257.64,76,,28.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,244.08,72,,116.352,Percent of Total Billed Charges,72% of Total Billed Charges,254.25,75,,121.2,Percent of Total Billed charges,75% of Total Billed Charges,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.08,72,,116.352,Percent of Total Billed Charges,72% of Total Billed Charges,203.4,60,,96.96,Percent of Total Billed Charges,60% of Total Billed Charges,305.1,90,,213.528,Percent of Total Billed Charges,90% of Total Billed Charges,152.55,45,,15.84,Percent of Total Billed Charges,45% of Total Billed Charges,305.1,90,,34.136,Percent of Total Billed Charges,90% of Total billed Charges,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.35,65,,303.68,Percent of total Billed Charges,65% of Total Billed Charges,149.5,44.1,,15.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,322.05,95,,36.032,Percent of Total Billed Charges,95% of Total Billed Charges,339,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.32,88,,32.384,Percent of Total Billed Charges,88% of Total Billed Charges,305.1,90,,34.136,Percent of Total Billed charges,90% of Total Billed Charges,149.5,339,
DRUG SCREENSERUM/TH,3010000028,CDM,301,RC,,,Outpatient,,,323.03,209.97,,323.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,245.5,76,,386.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,232.58,72,,82.368,Percent of Total Billed Charges,72% of Total Billed Charges,242.27,75,,85.8,Percent of Total Billed charges,75% of Total Billed Charges,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.58,72,,82.368,Percent of Total Billed Charges,72% of Total Billed Charges,193.82,60,,68.64,Percent of Total Billed Charges,60% of Total Billed Charges,290.73,90,,144.72,Percent of Total Billed Charges,90% of Total Billed Charges,145.36,45,,16.56,Percent of Total Billed Charges,45% of Total Billed Charges,290.73,90,,457.232,Percent of Total Billed Charges,90% of Total billed Charges,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.97,65,,21.84,Percent of total Billed Charges,65% of Total Billed Charges,142.46,44.1,,16.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,306.88,95,,482.632,Percent of Total Billed Charges,95% of Total Billed Charges,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.27,88,,40.832,Percent of Total Billed Charges,88% of Total Billed Charges,290.73,90,,457.232,Percent of Total Billed charges,90% of Total Billed Charges,142.46,323.03,
"DRUG ABUSE SCREEN 7, SERUM",3010000029,CDM,301,RC,,,Outpatient,,,323.03,209.97,,323.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,245.5,76,,171.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,232.58,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,242.27,75,,42.336,Percent of Total Billed charges,75% of Total Billed Charges,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.58,72,,40.64,Percent of Total Billed Charges,72% of Total Billed Charges,193.82,60,,33.872,Percent of Total Billed Charges,60% of Total Billed Charges,290.73,90,,176.4,Percent of Total Billed Charges,90% of Total Billed Charges,145.36,45,,20.88,Percent of Total Billed Charges,45% of Total Billed Charges,290.73,90,,203.04,Percent of Total Billed Charges,90% of Total billed Charges,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.97,65,,33.896,Percent of total Billed Charges,65% of Total Billed Charges,142.46,44.1,,20.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,306.88,95,,214.32,Percent of Total Billed Charges,95% of Total Billed Charges,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.27,88,,67.528,Percent of Total Billed Charges,88% of Total Billed Charges,290.73,90,,203.04,Percent of Total Billed charges,90% of Total Billed Charges,142.46,323.03,
MECONIUM DRUG SCREEN,3010000030,CDM,301,RC,,,Outpatient,,,323.03,209.97,,323.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,245.5,76,,145.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,232.58,72,,149.76,Percent of Total Billed Charges,72% of Total Billed Charges,242.27,75,,156,Percent of Total Billed charges,75% of Total Billed Charges,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.58,72,,149.76,Percent of Total Billed Charges,72% of Total Billed Charges,193.82,60,,124.8,Percent of Total Billed Charges,60% of Total Billed Charges,290.73,90,,226.8,Percent of Total Billed Charges,90% of Total Billed Charges,145.36,45,,34.528,Percent of Total Billed Charges,45% of Total Billed Charges,290.73,90,,172.256,Percent of Total Billed Charges,90% of Total billed Charges,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.97,65,,33.896,Percent of total Billed Charges,65% of Total Billed Charges,142.46,44.1,,33.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,306.88,95,,181.824,Percent of Total Billed Charges,95% of Total Billed Charges,323.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.27,88,,155.232,Percent of Total Billed Charges,88% of Total Billed Charges,290.73,90,,172.256,Percent of Total Billed charges,90% of Total Billed Charges,142.46,323.03,
ALCOHOL BLOOD,3010000031,CDM,301,RC,,,Outpatient,,,166.00,107.90,,166,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,126.16,76,,26.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,119.52,72,,48.384,Percent of Total Billed Charges,72% of Total Billed Charges,124.5,75,,50.4,Percent of Total Billed charges,75% of Total Billed Charges,166,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.52,72,,48.384,Percent of Total Billed Charges,72% of Total Billed Charges,99.6,60,,40.32,Percent of Total Billed Charges,60% of Total Billed Charges,149.4,90,,432.616,Percent of Total Billed Charges,90% of Total Billed Charges,74.7,45,,79.384,Percent of Total Billed Charges,45% of Total Billed Charges,149.4,90,,31.68,Percent of Total Billed Charges,90% of Total billed Charges,166,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.9,65,,148.72,Percent of total Billed Charges,65% of Total Billed Charges,73.21,44.1,,77.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,157.7,95,,33.44,Percent of Total Billed Charges,95% of Total Billed Charges,166,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.08,88,,97.856,Percent of Total Billed Charges,88% of Total Billed Charges,149.4,90,,31.68,Percent of Total Billed charges,90% of Total Billed Charges,73.21,166,
ACETAMINOPHEN,3010000032,CDM,301,RC,G0480,HCPCS,Outpatient,,,274.00,178.10,,143.03,125,,,Fee Schedule,125% of CMS OPPS Rate,208.24,76,,27.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,457.72,350,,142.248,Fee Schedule,350% of BCBS fee schedule,457.72,350,,148.176,Fee Schedule,350% of BCBS fee schedule,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,457.72,400,,142.248,Fee Schedule,400% of BCBS PPO fee schedule,114.43,100,,118.544,Fee Schedule,100% of Blue ADV HMO fee schedule,246.6,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,123.3,45,,50.04,Percent of Total Billed Charges,45% of Total Billed Charges,246.6,90,,33.12,Percent of Total Billed Charges,90% of Total billed Charges,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,228.86,200,,154.704,Fee Schedule,200% of CMS OPPS Rate,120.83,44.1,,49.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,260.3,95,,34.96,Percent of Total Billed Charges,95% of Total Billed Charges,85.82,75,,,Fee Schedule,75% of CMS OPPS Rate,241.12,88,,208.784,Percent of Total Billed Charges,88% of Total Billed Charges,246.6,90,,33.12,Percent of Total Billed charges,90% of Total Billed Charges,85.82,457.72,
BENZODAZEPINES,3010000034,CDM,301,RC,,,Outpatient,,,157.66,102.48,,157.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,119.82,76,,35.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,113.52,72,,54.616,Percent of Total Billed Charges,72% of Total Billed Charges,118.25,75,,56.896,Percent of Total Billed charges,75% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.52,72,,54.616,Percent of Total Billed Charges,72% of Total Billed Charges,94.6,60,,45.512,Percent of Total Billed Charges,60% of Total Billed Charges,141.89,90,,64.8,Percent of Total Billed Charges,90% of Total Billed Charges,70.95,45,,106.768,Percent of Total Billed Charges,45% of Total Billed Charges,141.89,90,,41.76,Percent of Total Billed Charges,90% of Total billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.48,65,,57.72,Percent of total Billed Charges,65% of Total Billed Charges,69.53,44.1,,104.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,149.78,95,,44.08,Percent of Total Billed Charges,95% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.74,88,,141.504,Percent of Total Billed Charges,88% of Total Billed Charges,141.89,90,,41.76,Percent of Total Billed charges,90% of Total Billed Charges,69.53,157.66,
CLONAZEPAN,3010000035,CDM,301,RC,,,Outpatient,,,157.66,102.48,,157.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,119.82,76,,58.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,113.52,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,118.25,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.52,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,94.6,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,141.89,90,,78.48,Percent of Total Billed Charges,90% of Total Billed Charges,70.95,45,,72.36,Percent of Total Billed Charges,45% of Total Billed Charges,141.89,90,,69.064,Percent of Total Billed Charges,90% of Total billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.48,65,,7.8,Percent of total Billed Charges,65% of Total Billed Charges,69.53,44.1,,70.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,149.78,95,,72.896,Percent of Total Billed Charges,95% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.74,88,,172.48,Percent of Total Billed Charges,88% of Total Billed Charges,141.89,90,,69.064,Percent of Total Billed charges,90% of Total Billed Charges,69.53,157.66,
ACTH,3010000036,CDM,301,RC,,,Outpatient,,,327.44,212.84,,327.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,248.85,76,,134.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,235.76,72,,159.552,Percent of Total Billed Charges,72% of Total Billed Charges,245.58,75,,166.2,Percent of Total Billed charges,75% of Total Billed Charges,327.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.76,72,,159.552,Percent of Total Billed Charges,72% of Total Billed Charges,196.46,60,,132.96,Percent of Total Billed Charges,60% of Total Billed Charges,294.7,90,,123.12,Percent of Total Billed Charges,90% of Total Billed Charges,147.35,45,,88.2,Percent of Total Billed Charges,45% of Total Billed Charges,294.7,90,,158.76,Percent of Total Billed Charges,90% of Total billed Charges,327.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.84,65,,303.16,Percent of total Billed Charges,65% of Total Billed Charges,144.4,44.1,,86.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,311.07,95,,167.584,Percent of Total Billed Charges,95% of Total Billed Charges,327.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.15,88,,221.76,Percent of Total Billed Charges,88% of Total Billed Charges,294.7,90,,158.76,Percent of Total Billed charges,90% of Total Billed Charges,144.4,327.44,
ALBUMIN SERUM,3010000037,CDM,301,RC,,,Outpatient,,,54.00,35.10,,54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.04,76,,84.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.88,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,40.5,75,,73.432,Percent of Total Billed charges,75% of Total Billed Charges,54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.88,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,32.4,60,,58.744,Percent of Total Billed Charges,60% of Total Billed Charges,48.6,90,,140.4,Percent of Total Billed Charges,90% of Total Billed Charges,24.3,45,,113.4,Percent of Total Billed Charges,45% of Total Billed Charges,48.6,90,,100.08,Percent of Total Billed Charges,90% of Total billed Charges,54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.1,65,,297.44,Percent of total Billed Charges,65% of Total Billed Charges,23.81,44.1,,111.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,51.3,95,,105.64,Percent of Total Billed Charges,95% of Total Billed Charges,54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.52,88,,423.008,Percent of Total Billed Charges,88% of Total Billed Charges,48.6,90,,100.08,Percent of Total Billed charges,90% of Total Billed Charges,23.81,54,
ALBUMIN PERITONEAL FLUID,3010000038,CDM,301,RC,,,Outpatient,,,59.54,38.70,,59.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.25,76,,180.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.87,72,,104.784,Percent of Total Billed Charges,72% of Total Billed Charges,44.66,75,,109.144,Percent of Total Billed charges,75% of Total Billed Charges,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.87,72,,104.784,Percent of Total Billed Charges,72% of Total Billed Charges,35.72,60,,87.32,Percent of Total Billed Charges,60% of Total Billed Charges,53.59,90,,119.52,Percent of Total Billed Charges,90% of Total Billed Charges,26.79,45,,216.312,Percent of Total Billed Charges,45% of Total Billed Charges,53.59,90,,213.528,Percent of Total Billed Charges,90% of Total billed Charges,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.7,65,,341.688,Percent of total Billed Charges,65% of Total Billed Charges,26.26,44.1,,211.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,56.56,95,,225.392,Percent of Total Billed Charges,95% of Total Billed Charges,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.4,88,,74.624,Percent of Total Billed Charges,88% of Total Billed Charges,53.59,90,,213.528,Percent of Total Billed charges,90% of Total Billed Charges,26.26,59.54,
ALBUMIN PLEURAL FLUID,3010000039,CDM,301,RC,,,Outpatient,,,59.54,38.70,,59.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.25,76,,122.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.87,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,44.66,75,,114.44,Percent of Total Billed charges,75% of Total Billed Charges,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.87,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,35.72,60,,91.552,Percent of Total Billed Charges,60% of Total Billed Charges,53.59,90,,191.304,Percent of Total Billed Charges,90% of Total Billed Charges,26.79,45,,38.16,Percent of Total Billed Charges,45% of Total Billed Charges,53.59,90,,144.72,Percent of Total Billed Charges,90% of Total billed Charges,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.7,65,,20.064,Percent of total Billed Charges,65% of Total Billed Charges,26.26,44.1,,37.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,56.56,95,,152.76,Percent of Total Billed Charges,95% of Total Billed Charges,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.4,88,,63.36,Percent of Total Billed Charges,88% of Total Billed Charges,53.59,90,,144.72,Percent of Total Billed charges,90% of Total Billed Charges,26.26,59.54,
MICROALBUMIN,3010000040,CDM,301,RC,,,Outpatient,,,162.00,105.30,,162,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,123.12,76,,148.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,116.64,72,,54.616,Percent of Total Billed Charges,72% of Total Billed Charges,121.5,75,,56.896,Percent of Total Billed charges,75% of Total Billed Charges,162,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.64,72,,54.616,Percent of Total Billed Charges,72% of Total Billed Charges,97.2,60,,45.512,Percent of Total Billed Charges,60% of Total Billed Charges,145.8,90,,126,Percent of Total Billed Charges,90% of Total Billed Charges,72.9,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,145.8,90,,176.4,Percent of Total Billed Charges,90% of Total billed Charges,162,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.3,65,,104.912,Percent of total Billed Charges,65% of Total Billed Charges,71.44,44.1,,31.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,153.9,95,,186.2,Percent of Total Billed Charges,95% of Total Billed Charges,162,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.56,88,,76.736,Percent of Total Billed Charges,88% of Total Billed Charges,145.8,90,,176.4,Percent of Total Billed charges,90% of Total Billed Charges,71.44,162,
ALDOLASE,3010000041,CDM,301,RC,,,Outpatient,,,52.92,34.40,,52.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.22,76,,191.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.1,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,39.69,75,,44.32,Percent of Total Billed charges,75% of Total Billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.1,72,,42.552,Percent of Total Billed Charges,72% of Total Billed Charges,31.75,60,,35.456,Percent of Total Billed Charges,60% of Total Billed Charges,47.63,90,,74.16,Percent of Total Billed Charges,90% of Total Billed Charges,23.81,45,,39.24,Percent of Total Billed Charges,45% of Total Billed Charges,47.63,90,,226.8,Percent of Total Billed Charges,90% of Total billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.4,65,,318.752,Percent of total Billed Charges,65% of Total Billed Charges,23.34,44.1,,38.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.27,95,,239.4,Percent of Total Billed Charges,95% of Total Billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.57,88,,120.384,Percent of Total Billed Charges,88% of Total Billed Charges,47.63,90,,226.8,Percent of Total Billed charges,90% of Total Billed Charges,23.34,52.92,
ALDOSTERONE,3010000042,CDM,301,RC,,,Outpatient,,,490.61,318.90,,490.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.86,76,,365.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,353.24,72,,274.336,Percent of Total Billed Charges,72% of Total Billed Charges,367.96,75,,285.768,Percent of Total Billed charges,75% of Total Billed Charges,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.24,72,,274.336,Percent of Total Billed Charges,72% of Total Billed Charges,294.37,60,,228.616,Percent of Total Billed Charges,60% of Total Billed Charges,441.55,90,,56.16,Percent of Total Billed Charges,90% of Total Billed Charges,220.77,45,,61.56,Percent of Total Billed Charges,45% of Total Billed Charges,441.55,90,,432.616,Percent of Total Billed Charges,90% of Total billed Charges,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.9,65,,300.408,Percent of total Billed Charges,65% of Total Billed Charges,216.36,44.1,,60.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,466.08,95,,456.656,Percent of Total Billed Charges,95% of Total Billed Charges,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,431.74,88,,137.28,Percent of Total Billed Charges,88% of Total Billed Charges,441.55,90,,432.616,Percent of Total Billed charges,90% of Total Billed Charges,216.36,490.61,
ALPHA1ANTITRYPSIN,3010000043,CDM,301,RC,,,Outpatient,,,186.00,120.90,,186,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,141.36,76,,64.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,133.92,72,,274.336,Percent of Total Billed Charges,72% of Total Billed Charges,139.5,75,,285.768,Percent of Total Billed charges,75% of Total Billed Charges,186,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.92,72,,274.336,Percent of Total Billed Charges,72% of Total Billed Charges,111.6,60,,228.616,Percent of Total Billed Charges,60% of Total Billed Charges,167.4,90,,72.24,Percent of Total Billed Charges,90% of Total Billed Charges,83.7,45,,70.2,Percent of Total Billed Charges,45% of Total Billed Charges,167.4,90,,76.32,Percent of Total Billed Charges,90% of Total billed Charges,186,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.9,65,,135.296,Percent of total Billed Charges,65% of Total Billed Charges,82.03,44.1,,68.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,176.7,95,,80.56,Percent of Total Billed Charges,95% of Total Billed Charges,186,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.68,88,,116.864,Percent of Total Billed Charges,88% of Total Billed Charges,167.4,90,,76.32,Percent of Total Billed charges,90% of Total Billed Charges,82.03,186,
AMMONIA,3010000044,CDM,301,RC,,,Outpatient,,,124.00,80.60,,124,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,94.24,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,89.28,72,,108.864,Percent of Total Billed Charges,72% of Total Billed Charges,93,75,,113.4,Percent of Total Billed charges,75% of Total Billed Charges,124,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.28,72,,108.864,Percent of Total Billed Charges,72% of Total Billed Charges,74.4,60,,90.72,Percent of Total Billed Charges,60% of Total Billed Charges,111.6,90,,192.104,Percent of Total Billed Charges,90% of Total Billed Charges,55.8,45,,59.76,Percent of Total Billed Charges,45% of Total Billed Charges,111.6,90,,64.8,Percent of Total Billed Charges,90% of Total billed Charges,124,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.6,65,,140.4,Percent of total Billed Charges,65% of Total Billed Charges,54.68,44.1,,58.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,117.8,95,,68.4,Percent of Total Billed Charges,95% of Total Billed Charges,124,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.12,88,,187.056,Percent of Total Billed Charges,88% of Total Billed Charges,111.6,90,,64.8,Percent of Total Billed charges,90% of Total Billed Charges,54.68,124,
AMYLASE BLOOD,3010000045,CDM,301,RC,,,Outpatient,,,234.00,152.10,,234,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,177.84,76,,66.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,168.48,72,,103.512,Percent of Total Billed Charges,72% of Total Billed Charges,175.5,75,,107.824,Percent of Total Billed charges,75% of Total Billed Charges,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.48,72,,103.512,Percent of Total Billed Charges,72% of Total Billed Charges,140.4,60,,86.264,Percent of Total Billed Charges,60% of Total Billed Charges,210.6,90,,509.624,Percent of Total Billed Charges,90% of Total Billed Charges,105.3,45,,95.656,Percent of Total Billed Charges,45% of Total Billed Charges,210.6,90,,78.48,Percent of Total Billed Charges,90% of Total billed Charges,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.1,65,,147.336,Percent of total Billed Charges,65% of Total Billed Charges,103.19,44.1,,93.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,222.3,95,,82.84,Percent of Total Billed Charges,95% of Total Billed Charges,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.92,88,,123.2,Percent of Total Billed Charges,88% of Total Billed Charges,210.6,90,,78.48,Percent of Total Billed charges,90% of Total Billed Charges,103.19,234,
AMYLASE URINE,3010000046,CDM,301,RC,,,Outpatient,,,216.09,140.46,,216.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,164.23,76,,103.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,155.58,72,,103.512,Percent of Total Billed Charges,72% of Total Billed Charges,162.07,75,,107.824,Percent of Total Billed charges,75% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.58,72,,103.512,Percent of Total Billed Charges,72% of Total Billed Charges,129.65,60,,86.264,Percent of Total Billed Charges,60% of Total Billed Charges,194.48,90,,116.688,Percent of Total Billed Charges,90% of Total Billed Charges,97.24,45,,63,Percent of Total Billed Charges,45% of Total Billed Charges,194.48,90,,123.12,Percent of Total Billed Charges,90% of Total billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.46,65,,14.04,Percent of total Billed Charges,65% of Total Billed Charges,95.3,44.1,,61.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,205.29,95,,129.96,Percent of Total Billed Charges,95% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.16,88,,72.512,Percent of Total Billed Charges,88% of Total Billed Charges,194.48,90,,123.12,Percent of Total Billed charges,90% of Total Billed Charges,95.3,216.09,
AMYLASE PLEURAL FLUID,3010000047,CDM,301,RC,,,Outpatient,,,234.00,152.10,,234,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,177.84,76,,118.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,168.48,72,,103.512,Percent of Total Billed Charges,72% of Total Billed Charges,175.5,75,,107.824,Percent of Total Billed charges,75% of Total Billed Charges,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.48,72,,103.512,Percent of Total Billed Charges,72% of Total Billed Charges,140.4,60,,86.264,Percent of Total Billed Charges,60% of Total Billed Charges,210.6,90,,111.136,Percent of Total Billed Charges,90% of Total Billed Charges,105.3,45,,37.08,Percent of Total Billed Charges,45% of Total Billed Charges,210.6,90,,140.4,Percent of Total Billed Charges,90% of Total billed Charges,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.1,65,,192.056,Percent of total Billed Charges,65% of Total Billed Charges,103.19,44.1,,36.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,222.3,95,,148.2,Percent of Total Billed Charges,95% of Total Billed Charges,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.92,88,,54.912,Percent of Total Billed Charges,88% of Total Billed Charges,210.6,90,,140.4,Percent of Total Billed charges,90% of Total Billed Charges,103.19,234,
AMYLASE PERITONEAL FLUID,3010000048,CDM,301,RC,,,Outpatient,,,234.00,152.10,,234,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,177.84,76,,100.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,168.48,72,,191.144,Percent of Total Billed Charges,72% of Total Billed Charges,175.5,75,,199.112,Percent of Total Billed charges,75% of Total Billed Charges,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.48,72,,191.144,Percent of Total Billed Charges,72% of Total Billed Charges,140.4,60,,159.288,Percent of Total Billed Charges,60% of Total Billed Charges,210.6,90,,160.56,Percent of Total Billed Charges,90% of Total Billed Charges,105.3,45,,28.08,Percent of Total Billed Charges,45% of Total Billed Charges,210.6,90,,119.52,Percent of Total Billed Charges,90% of Total billed Charges,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.1,65,,215.56,Percent of total Billed Charges,65% of Total Billed Charges,103.19,44.1,,27.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,222.3,95,,126.16,Percent of Total Billed Charges,95% of Total Billed Charges,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.92,88,,70.632,Percent of Total Billed Charges,88% of Total Billed Charges,210.6,90,,119.52,Percent of Total Billed charges,90% of Total Billed Charges,103.19,234,
ANDROSTENEDIONE,3010000049,CDM,301,RC,,,Outpatient,,,232.63,151.21,,232.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,176.8,76,,161.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,167.49,72,,85.096,Percent of Total Billed Charges,72% of Total Billed Charges,174.47,75,,88.648,Percent of Total Billed charges,75% of Total Billed Charges,232.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.49,72,,85.096,Percent of Total Billed Charges,72% of Total Billed Charges,139.58,60,,70.912,Percent of Total Billed Charges,60% of Total Billed Charges,209.37,90,,150.48,Percent of Total Billed Charges,90% of Total Billed Charges,104.68,45,,36.12,Percent of Total Billed Charges,45% of Total Billed Charges,209.37,90,,191.304,Percent of Total Billed Charges,90% of Total billed Charges,232.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.21,65,,215.56,Percent of total Billed Charges,65% of Total Billed Charges,102.59,44.1,,35.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,221,95,,201.936,Percent of Total Billed Charges,95% of Total Billed Charges,232.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.71,88,,187.832,Percent of Total Billed Charges,88% of Total Billed Charges,209.37,90,,191.304,Percent of Total Billed charges,90% of Total Billed Charges,102.59,232.63,
ANGIOTENSIN ENZYME,3010000050,CDM,301,RC,,,Outpatient,,,73.87,48.02,,73.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.14,76,,106.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.19,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,55.4,75,,73.432,Percent of Total Billed charges,75% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.19,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,44.32,60,,58.744,Percent of Total Billed Charges,60% of Total Billed Charges,66.48,90,,42.072,Percent of Total Billed Charges,90% of Total Billed Charges,33.24,45,,96.048,Percent of Total Billed Charges,45% of Total Billed Charges,66.48,90,,126,Percent of Total Billed Charges,90% of Total billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.02,65,,163.392,Percent of total Billed Charges,65% of Total Billed Charges,32.58,44.1,,94.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,70.18,95,,133,Percent of Total Billed Charges,95% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.01,88,,498.296,Percent of Total Billed Charges,88% of Total Billed Charges,66.48,90,,126,Percent of Total Billed charges,90% of Total Billed Charges,32.58,73.87,
APOLIPOPROTEIN A1,3010000051,CDM,301,RC,,,Outpatient,,,104.74,68.08,,104.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.6,76,,62.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75.41,72,,62.24,Percent of Total Billed Charges,72% of Total Billed Charges,78.56,75,,64.832,Percent of Total Billed charges,75% of Total Billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.41,72,,62.24,Percent of Total Billed Charges,72% of Total Billed Charges,62.84,60,,51.864,Percent of Total Billed Charges,60% of Total Billed Charges,94.27,90,,420.48,Percent of Total Billed Charges,90% of Total Billed Charges,47.13,45,,254.808,Percent of Total Billed Charges,45% of Total Billed Charges,94.27,90,,74.16,Percent of Total Billed Charges,90% of Total billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.08,65,,163.392,Percent of total Billed Charges,65% of Total Billed Charges,46.19,44.1,,249.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,99.5,95,,78.28,Percent of Total Billed Charges,95% of Total Billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.17,88,,114.096,Percent of Total Billed Charges,88% of Total Billed Charges,94.27,90,,74.16,Percent of Total Billed charges,90% of Total Billed Charges,46.19,104.74,
BETA2MICROGLOBULIN,3010000052,CDM,301,RC,,,Outpatient,,,120.17,78.11,,120.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,91.33,76,,47.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,86.52,72,,62.24,Percent of Total Billed Charges,72% of Total Billed Charges,90.13,75,,64.832,Percent of Total Billed charges,75% of Total Billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.52,72,,62.24,Percent of Total Billed Charges,72% of Total Billed Charges,72.1,60,,51.864,Percent of Total Billed Charges,60% of Total Billed Charges,108.15,90,,30.24,Percent of Total Billed Charges,90% of Total Billed Charges,54.08,45,,58.344,Percent of Total Billed Charges,45% of Total Billed Charges,108.15,90,,56.16,Percent of Total Billed Charges,90% of Total billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.11,65,,44.144,Percent of total Billed Charges,65% of Total Billed Charges,52.99,44.1,,57.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,114.16,95,,59.28,Percent of Total Billed Charges,95% of Total Billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.75,88,,108.664,Percent of Total Billed Charges,88% of Total Billed Charges,108.15,90,,56.16,Percent of Total Billed charges,90% of Total Billed Charges,52.99,120.17,
BILIRUBINTOTAL,3010000053,CDM,301,RC,,,Outpatient,,,84.00,54.60,,84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,63.84,76,,61,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,60.48,72,,18.544,Percent of Total Billed Charges,72% of Total Billed Charges,63,75,,19.32,Percent of Total Billed charges,75% of Total Billed Charges,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.48,72,,18.544,Percent of Total Billed Charges,72% of Total Billed Charges,50.4,60,,15.456,Percent of Total Billed Charges,60% of Total Billed Charges,75.6,90,,19.048,Percent of Total Billed Charges,90% of Total Billed Charges,37.8,45,,55.568,Percent of Total Billed Charges,45% of Total Billed Charges,75.6,90,,72.24,Percent of Total Billed Charges,90% of Total billed Charges,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.6,65,,7.28,Percent of total Billed Charges,65% of Total Billed Charges,37.04,44.1,,54.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,79.8,95,,76.248,Percent of Total Billed Charges,95% of Total Billed Charges,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.92,88,,156.992,Percent of Total Billed Charges,88% of Total Billed Charges,75.6,90,,72.24,Percent of Total Billed charges,90% of Total Billed Charges,37.04,84,
BILIRUBINDIRECT,3010000054,CDM,301,RC,,,Outpatient,,,84.00,54.60,,84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,63.84,76,,162.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,60.48,72,,64.112,Percent of Total Billed Charges,72% of Total Billed Charges,63,75,,66.784,Percent of Total Billed charges,75% of Total Billed Charges,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.48,72,,64.112,Percent of Total Billed Charges,72% of Total Billed Charges,50.4,60,,53.424,Percent of Total Billed Charges,60% of Total Billed Charges,75.6,90,,46.928,Percent of Total Billed Charges,90% of Total Billed Charges,37.8,45,,80.28,Percent of Total Billed Charges,45% of Total Billed Charges,75.6,90,,192.104,Percent of Total Billed Charges,90% of Total billed Charges,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.6,65,,17.68,Percent of total Billed Charges,65% of Total Billed Charges,37.04,44.1,,78.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,79.8,95,,202.776,Percent of Total Billed Charges,95% of Total Billed Charges,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.92,88,,147.136,Percent of Total Billed Charges,88% of Total Billed Charges,75.6,90,,192.104,Percent of Total Billed charges,90% of Total Billed Charges,37.04,84,
OCCULT BLOOD  OTHER,3010000055,CDM,301,RC,,,Outpatient,,,50.00,32.50,,50,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38,76,,430.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36,72,,24.768,Percent of Total Billed Charges,72% of Total Billed Charges,37.5,75,,25.8,Percent of Total Billed charges,75% of Total Billed Charges,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36,72,,24.768,Percent of Total Billed Charges,72% of Total Billed Charges,30,60,,20.64,Percent of Total Billed Charges,60% of Total Billed Charges,45,90,,46.928,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,45,,75.24,Percent of Total Billed Charges,45% of Total Billed Charges,45,90,,509.624,Percent of Total Billed Charges,90% of Total billed Charges,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.5,65,,69.944,Percent of total Billed Charges,65% of Total Billed Charges,22.05,44.1,,73.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,47.5,95,,537.936,Percent of Total Billed Charges,95% of Total Billed Charges,50,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44,88,,41.136,Percent of Total Billed Charges,88% of Total Billed Charges,45,90,,509.624,Percent of Total Billed charges,90% of Total Billed Charges,22.05,50,
OCCULT BLOOD  STOOL,3010000056,CDM,301,RC,,,Outpatient,,,41.00,26.65,,41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31.16,76,,98.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.52,72,,111.768,Percent of Total Billed Charges,72% of Total Billed Charges,30.75,75,,116.424,Percent of Total Billed charges,75% of Total Billed Charges,41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.52,72,,111.768,Percent of Total Billed Charges,72% of Total Billed Charges,24.6,60,,93.136,Percent of Total Billed Charges,60% of Total Billed Charges,36.9,90,,205.92,Percent of Total Billed Charges,90% of Total Billed Charges,18.45,45,,21.032,Percent of Total Billed Charges,45% of Total Billed Charges,36.9,90,,116.688,Percent of Total Billed Charges,90% of Total billed Charges,41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.65,65,,69.944,Percent of total Billed Charges,65% of Total Billed Charges,18.08,44.1,,20.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.95,95,,123.176,Percent of Total Billed Charges,95% of Total Billed Charges,41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.08,88,,411.136,Percent of Total Billed Charges,88% of Total Billed Charges,36.9,90,,116.688,Percent of Total Billed charges,90% of Total Billed Charges,18.08,41,
VITAMIN D2504,3010000057,CDM,301,RC,,,Outpatient,,,472.97,307.43,,472.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,359.46,76,,93.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,340.54,72,,153.216,Percent of Total Billed Charges,72% of Total Billed Charges,354.73,75,,159.6,Percent of Total Billed charges,75% of Total Billed Charges,472.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.54,72,,153.216,Percent of Total Billed Charges,72% of Total Billed Charges,283.78,60,,127.68,Percent of Total Billed Charges,60% of Total Billed Charges,425.67,90,,214.2,Percent of Total Billed Charges,90% of Total Billed Charges,212.84,45,,210.24,Percent of Total Billed Charges,45% of Total Billed Charges,425.67,90,,111.136,Percent of Total Billed Charges,90% of Total billed Charges,472.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.43,65,,69.944,Percent of total Billed Charges,65% of Total Billed Charges,208.58,44.1,,206.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,449.32,95,,117.304,Percent of Total Billed Charges,95% of Total Billed Charges,472.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,416.21,88,,29.568,Percent of Total Billed Charges,88% of Total Billed Charges,425.67,90,,111.136,Percent of Total Billed charges,90% of Total Billed Charges,208.58,472.97,
25HYDROXY VITAMIN D,3010000058,CDM,301,RC,,,Outpatient,,,511.00,332.15,,511,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,388.36,76,,135.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,367.92,72,,16.216,Percent of Total Billed Charges,72% of Total Billed Charges,383.25,75,,16.888,Percent of Total Billed charges,75% of Total Billed Charges,511,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,367.92,72,,16.216,Percent of Total Billed Charges,72% of Total Billed Charges,306.6,60,,13.512,Percent of Total Billed Charges,60% of Total Billed Charges,459.9,90,,79.92,Percent of Total Billed Charges,90% of Total Billed Charges,229.95,45,,15.12,Percent of Total Billed Charges,45% of Total Billed Charges,459.9,90,,160.56,Percent of Total Billed Charges,90% of Total billed Charges,511,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.15,65,,369.776,Percent of total Billed Charges,65% of Total Billed Charges,225.35,44.1,,14.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,485.45,95,,169.48,Percent of Total Billed Charges,95% of Total Billed Charges,511,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,449.68,88,,18.624,Percent of Total Billed Charges,88% of Total Billed Charges,459.9,90,,160.56,Percent of Total Billed charges,90% of Total Billed Charges,225.35,511,
VIT  D 25OH,3010000059,CDM,301,RC,,,Outpatient,,,472.97,307.43,,472.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,359.46,76,,127.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,340.54,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,354.73,75,,28.448,Percent of Total Billed charges,75% of Total Billed Charges,472.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.54,72,,27.312,Percent of Total Billed Charges,72% of Total Billed Charges,283.78,60,,22.76,Percent of Total Billed Charges,60% of Total Billed Charges,425.67,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,212.84,45,,9.528,Percent of Total Billed Charges,45% of Total Billed Charges,425.67,90,,150.48,Percent of Total Billed Charges,90% of Total billed Charges,472.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.43,65,,44.72,Percent of total Billed Charges,65% of Total Billed Charges,208.58,44.1,,9.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,449.32,95,,158.84,Percent of Total Billed Charges,95% of Total Billed Charges,472.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,416.21,88,,45.888,Percent of Total Billed Charges,88% of Total Billed Charges,425.67,90,,150.48,Percent of Total Billed charges,90% of Total Billed Charges,208.58,472.97,
CALCITONIN,3010000060,CDM,301,RC,,,Outpatient,,,288.86,187.76,,288.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,219.53,76,,35.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,207.98,72,,35.712,Percent of Total Billed Charges,72% of Total Billed Charges,216.65,75,,37.2,Percent of Total Billed charges,75% of Total Billed Charges,288.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.98,72,,35.712,Percent of Total Billed Charges,72% of Total Billed Charges,173.32,60,,29.76,Percent of Total Billed Charges,60% of Total Billed Charges,259.97,90,,419.76,Percent of Total Billed Charges,90% of Total Billed Charges,129.99,45,,23.464,Percent of Total Billed Charges,45% of Total Billed Charges,259.97,90,,42.072,Percent of Total Billed Charges,90% of Total billed Charges,288.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.76,65,,16.056,Percent of total Billed Charges,65% of Total Billed Charges,127.39,44.1,,22.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,274.42,95,,44.408,Percent of Total Billed Charges,95% of Total Billed Charges,288.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,254.2,88,,45.888,Percent of Total Billed Charges,88% of Total Billed Charges,259.97,90,,42.072,Percent of Total Billed charges,90% of Total Billed Charges,127.39,288.86,
CALCIUM TOTAL,3010000061,CDM,301,RC,,,Outpatient,,,243.00,157.95,,243,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,184.68,76,,355.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,174.96,72,,35.712,Percent of Total Billed Charges,72% of Total Billed Charges,182.25,75,,37.2,Percent of Total Billed charges,75% of Total Billed Charges,243,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.96,72,,35.712,Percent of Total Billed Charges,72% of Total Billed Charges,145.8,60,,29.76,Percent of Total Billed Charges,60% of Total Billed Charges,218.7,90,,411.84,Percent of Total Billed Charges,90% of Total Billed Charges,109.35,45,,23.464,Percent of Total Billed Charges,45% of Total Billed Charges,218.7,90,,420.48,Percent of Total Billed Charges,90% of Total billed Charges,243,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.95,65,,84.848,Percent of total Billed Charges,65% of Total Billed Charges,107.16,44.1,,22.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,230.85,95,,443.84,Percent of Total Billed Charges,95% of Total Billed Charges,243,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.84,88,,201.344,Percent of Total Billed Charges,88% of Total Billed Charges,218.7,90,,420.48,Percent of Total Billed charges,90% of Total Billed Charges,107.16,243,
PTH INTACT AND CALCI TOTAL,3010000062,CDM,301,RC,,,Outpatient,,,255.78,166.26,,255.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,194.39,76,,25.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,184.16,72,,99.648,Percent of Total Billed Charges,72% of Total Billed Charges,191.84,75,,103.8,Percent of Total Billed charges,75% of Total Billed Charges,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.16,72,,99.648,Percent of Total Billed Charges,72% of Total Billed Charges,153.47,60,,83.04,Percent of Total Billed Charges,60% of Total Billed Charges,230.2,90,,473.104,Percent of Total Billed Charges,90% of Total Billed Charges,115.1,45,,102.96,Percent of Total Billed Charges,45% of Total Billed Charges,230.2,90,,30.24,Percent of Total Billed Charges,90% of Total billed Charges,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.26,65,,84.848,Percent of total Billed Charges,65% of Total Billed Charges,112.8,44.1,,100.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,242.99,95,,31.92,Percent of Total Billed Charges,95% of Total Billed Charges,255.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.09,88,,209.44,Percent of Total Billed Charges,88% of Total Billed Charges,230.2,90,,30.24,Percent of Total Billed charges,90% of Total Billed Charges,112.8,255.78,
IONIZED CALCIUM,3010000063,CDM,301,RC,,,Outpatient,,,27.56,17.91,,27.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.95,76,,16.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.84,72,,53.344,Percent of Total Billed Charges,72% of Total Billed Charges,20.67,75,,55.568,Percent of Total Billed charges,75% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.84,72,,53.344,Percent of Total Billed Charges,72% of Total Billed Charges,16.54,60,,44.456,Percent of Total Billed Charges,60% of Total Billed Charges,24.8,90,,27.784,Percent of Total Billed Charges,90% of Total Billed Charges,12.4,45,,107.104,Percent of Total Billed Charges,45% of Total Billed Charges,24.8,90,,19.048,Percent of Total Billed Charges,90% of Total billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.91,65,,61.92,Percent of total Billed Charges,65% of Total Billed Charges,12.15,44.1,,104.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.18,95,,20.112,Percent of Total Billed Charges,95% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,88,,78.144,Percent of Total Billed Charges,88% of Total Billed Charges,24.8,90,,19.048,Percent of Total Billed charges,90% of Total Billed Charges,12.15,27.56,
CALCIUM QUAN URINE,3010000064,CDM,301,RC,,,Outpatient,,,31.00,20.15,,31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.56,76,,39.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.32,72,,50.688,Percent of Total Billed Charges,72% of Total Billed Charges,23.25,75,,52.8,Percent of Total Billed charges,75% of Total Billed Charges,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,72,,50.688,Percent of Total Billed Charges,72% of Total Billed Charges,18.6,60,,42.24,Percent of Total Billed Charges,60% of Total Billed Charges,27.9,90,,145.264,Percent of Total Billed Charges,90% of Total Billed Charges,13.95,45,,39.96,Percent of Total Billed Charges,45% of Total Billed Charges,27.9,90,,46.928,Percent of Total Billed Charges,90% of Total billed Charges,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.15,65,,179.92,Percent of total Billed Charges,65% of Total Billed Charges,13.67,44.1,,39.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.45,95,,49.536,Percent of Total Billed Charges,95% of Total Billed Charges,31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.28,88,,10.56,Percent of Total Billed Charges,88% of Total Billed Charges,27.9,90,,46.928,Percent of Total Billed charges,90% of Total Billed Charges,13.67,31,
STONE ANALYSIS,3010000065,CDM,301,RC,,,Outpatient,,,91.51,59.48,,91.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,69.55,76,,39.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.89,72,,25.344,Percent of Total Billed Charges,72% of Total Billed Charges,68.63,75,,26.4,Percent of Total Billed charges,75% of Total Billed Charges,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.89,72,,25.344,Percent of Total Billed Charges,72% of Total Billed Charges,54.91,60,,21.12,Percent of Total Billed Charges,60% of Total Billed Charges,82.36,90,,441.352,Percent of Total Billed Charges,90% of Total Billed Charges,41.18,45,,5.4,Percent of Total Billed Charges,45% of Total Billed Charges,82.36,90,,46.928,Percent of Total Billed Charges,90% of Total billed Charges,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.48,65,,91,Percent of total Billed Charges,65% of Total Billed Charges,40.36,44.1,,5.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,86.93,95,,49.536,Percent of Total Billed Charges,95% of Total Billed Charges,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.53,88,,410.432,Percent of Total Billed Charges,88% of Total Billed Charges,82.36,90,,46.928,Percent of Total Billed charges,90% of Total Billed Charges,40.36,91.51,
CARNITINE,3010000067,CDM,301,RC,,,Outpatient,,,257.99,167.69,,257.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,196.07,76,,173.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,185.75,72,,32.256,Percent of Total Billed Charges,72% of Total Billed Charges,193.49,75,,33.6,Percent of Total Billed charges,75% of Total Billed Charges,257.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.75,72,,32.256,Percent of Total Billed Charges,72% of Total Billed Charges,154.79,60,,26.88,Percent of Total Billed Charges,60% of Total Billed Charges,232.19,90,,415.952,Percent of Total Billed Charges,90% of Total Billed Charges,116.1,45,,209.88,Percent of Total Billed Charges,45% of Total Billed Charges,232.19,90,,205.92,Percent of Total Billed Charges,90% of Total billed Charges,257.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.69,65,,69.368,Percent of total Billed Charges,65% of Total Billed Charges,113.77,44.1,,205.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,245.09,95,,217.36,Percent of Total Billed Charges,95% of Total Billed Charges,257.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.03,88,,402.688,Percent of Total Billed Charges,88% of Total Billed Charges,232.19,90,,205.92,Percent of Total Billed charges,90% of Total Billed Charges,113.77,257.99,
CATECHOLAMINES URINE,3010000068,CDM,301,RC,,,Outpatient,,,152.15,98.90,,152.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,115.63,76,,180.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,109.55,72,,140.344,Percent of Total Billed Charges,72% of Total Billed Charges,114.11,75,,146.192,Percent of Total Billed charges,75% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.55,72,,140.344,Percent of Total Billed Charges,72% of Total Billed Charges,91.29,60,,116.952,Percent of Total Billed Charges,60% of Total Billed Charges,136.94,90,,187.336,Percent of Total Billed Charges,90% of Total Billed Charges,68.47,45,,205.92,Percent of Total Billed Charges,45% of Total Billed Charges,136.94,90,,214.2,Percent of Total Billed Charges,90% of Total billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.9,65,,101.472,Percent of total Billed Charges,65% of Total Billed Charges,67.1,44.1,,201.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,144.54,95,,226.104,Percent of Total Billed Charges,95% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.89,88,,462.592,Percent of Total Billed Charges,88% of Total Billed Charges,136.94,90,,214.2,Percent of Total Billed charges,90% of Total Billed Charges,67.1,152.15,
CERULOPLASMIN,3010000069,CDM,301,RC,,,Outpatient,,,69.46,45.15,,69.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.79,76,,67.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.01,72,,140.344,Percent of Total Billed Charges,72% of Total Billed Charges,52.1,75,,146.192,Percent of Total Billed charges,75% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.01,72,,140.344,Percent of Total Billed Charges,72% of Total Billed Charges,41.68,60,,116.952,Percent of Total Billed Charges,60% of Total Billed Charges,62.51,90,,194.4,Percent of Total Billed Charges,90% of Total Billed Charges,31.26,45,,236.552,Percent of Total Billed Charges,45% of Total Billed Charges,62.51,90,,79.92,Percent of Total Billed Charges,90% of Total billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.15,65,,101.472,Percent of total Billed Charges,65% of Total Billed Charges,30.63,44.1,,231.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.99,95,,84.36,Percent of Total Billed Charges,95% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,88,,27.168,Percent of Total Billed Charges,88% of Total Billed Charges,62.51,90,,79.92,Percent of Total Billed charges,90% of Total Billed Charges,30.63,69.46,
CHOLESTEROL (TOTAL),3010000070,CDM,301,RC,,,Outpatient,,,84.00,54.60,,84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,63.84,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,60.48,72,,140.344,Percent of Total Billed Charges,72% of Total Billed Charges,63,75,,146.192,Percent of Total Billed charges,75% of Total Billed Charges,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.48,72,,140.344,Percent of Total Billed Charges,72% of Total Billed Charges,50.4,60,,116.952,Percent of Total Billed Charges,60% of Total Billed Charges,75.6,90,,204.008,Percent of Total Billed Charges,90% of Total Billed Charges,37.8,45,,13.896,Percent of Total Billed Charges,45% of Total Billed Charges,75.6,90,,10.8,Percent of Total Billed Charges,90% of Total billed Charges,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.6,65,,101.472,Percent of total Billed Charges,65% of Total Billed Charges,37.04,44.1,,13.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,79.8,95,,11.4,Percent of Total Billed Charges,95% of Total Billed Charges,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.92,88,,142.04,Percent of Total Billed Charges,88% of Total Billed Charges,75.6,90,,10.8,Percent of Total Billed charges,90% of Total Billed Charges,37.04,84,
CITRIC ACID (U),3010000071,CDM,301,RC,,,Outpatient,,,396.90,257.99,,396.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,301.64,76,,354.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,285.77,72,,140.344,Percent of Total Billed Charges,72% of Total Billed Charges,297.68,75,,146.192,Percent of Total Billed charges,75% of Total Billed Charges,396.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.77,72,,140.344,Percent of Total Billed Charges,72% of Total Billed Charges,238.14,60,,116.952,Percent of Total Billed Charges,60% of Total Billed Charges,357.21,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,178.61,45,,72.632,Percent of Total Billed Charges,45% of Total Billed Charges,357.21,90,,419.76,Percent of Total Billed Charges,90% of Total billed Charges,396.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.99,65,,141.96,Percent of total Billed Charges,65% of Total Billed Charges,175.03,44.1,,71.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,377.06,95,,443.08,Percent of Total Billed Charges,95% of Total Billed Charges,396.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.27,88,,431.544,Percent of Total Billed Charges,88% of Total Billed Charges,357.21,90,,419.76,Percent of Total Billed charges,90% of Total Billed Charges,175.03,396.9,
COLL XLINKED NTELO,3010000072,CDM,301,RC,,,Outpatient,,,313.11,203.52,,313.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.96,76,,347.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225.44,72,,159.4,Percent of Total Billed Charges,72% of Total Billed Charges,234.83,75,,166.04,Percent of Total Billed charges,75% of Total Billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.44,72,,159.4,Percent of Total Billed Charges,72% of Total Billed Charges,187.87,60,,132.832,Percent of Total Billed Charges,60% of Total Billed Charges,281.8,90,,265.928,Percent of Total Billed Charges,90% of Total Billed Charges,140.9,45,,220.68,Percent of Total Billed Charges,45% of Total Billed Charges,281.8,90,,411.84,Percent of Total Billed Charges,90% of Total billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.52,65,,149.072,Percent of total Billed Charges,65% of Total Billed Charges,138.08,44.1,,216.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,297.45,95,,434.72,Percent of Total Billed Charges,95% of Total Billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.54,88,,406.704,Percent of Total Billed Charges,88% of Total Billed Charges,281.8,90,,411.84,Percent of Total Billed charges,90% of Total Billed Charges,138.08,313.11,
"NTELOPEPTIDE, SERUM",3010000073,CDM,301,RC,,,Outpatient,,,313.11,203.52,,313.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.96,76,,399.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225.44,72,,180.352,Percent of Total Billed Charges,72% of Total Billed Charges,234.83,75,,187.864,Percent of Total Billed charges,75% of Total Billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.44,72,,180.352,Percent of Total Billed Charges,72% of Total Billed Charges,187.87,60,,150.296,Percent of Total Billed Charges,60% of Total Billed Charges,281.8,90,,298.472,Percent of Total Billed Charges,90% of Total Billed Charges,140.9,45,,207.976,Percent of Total Billed Charges,45% of Total Billed Charges,281.8,90,,473.104,Percent of Total Billed Charges,90% of Total billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.52,65,,149.072,Percent of total Billed Charges,65% of Total Billed Charges,138.08,44.1,,203.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,297.45,95,,499.392,Percent of Total Billed Charges,95% of Total Billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.54,88,,183.176,Percent of Total Billed Charges,88% of Total Billed Charges,281.8,90,,473.104,Percent of Total Billed charges,90% of Total Billed Charges,138.08,313.11,
COPPER  SERUM,3010000074,CDM,301,RC,,,Outpatient,,,73.87,48.02,,73.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.14,76,,23.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.19,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,55.4,75,,243.432,Percent of Total Billed charges,75% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.19,72,,233.696,Percent of Total Billed Charges,72% of Total Billed Charges,44.32,60,,194.744,Percent of Total Billed Charges,60% of Total Billed Charges,66.48,90,,298.472,Percent of Total Billed Charges,90% of Total Billed Charges,33.24,45,,93.672,Percent of Total Billed Charges,45% of Total Billed Charges,66.48,90,,27.784,Percent of Total Billed Charges,90% of Total billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.02,65,,149.072,Percent of total Billed Charges,65% of Total Billed Charges,32.58,44.1,,91.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,70.18,95,,29.328,Percent of Total Billed Charges,95% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.01,88,,190.08,Percent of Total Billed Charges,88% of Total Billed Charges,66.48,90,,27.784,Percent of Total Billed charges,90% of Total Billed Charges,32.58,73.87,
CORTISOL FREE(24HR U,3010000075,CDM,301,RC,,,Outpatient,,,293.00,190.45,,293,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,222.68,76,,122.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,210.96,72,,166.384,Percent of Total Billed Charges,72% of Total Billed Charges,219.75,75,,173.32,Percent of Total Billed charges,75% of Total Billed Charges,293,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.96,72,,166.384,Percent of Total Billed Charges,72% of Total Billed Charges,175.8,60,,138.656,Percent of Total Billed Charges,60% of Total Billed Charges,263.7,90,,226.232,Percent of Total Billed Charges,90% of Total Billed Charges,131.85,45,,97.2,Percent of Total Billed Charges,45% of Total Billed Charges,263.7,90,,145.264,Percent of Total Billed Charges,90% of Total billed Charges,293,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.45,65,,147.336,Percent of total Billed Charges,65% of Total Billed Charges,129.21,44.1,,95.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,278.35,95,,153.336,Percent of Total Billed Charges,95% of Total Billed Charges,293,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.84,88,,199.472,Percent of Total Billed Charges,88% of Total Billed Charges,263.7,90,,145.264,Percent of Total Billed charges,90% of Total Billed Charges,129.21,293,
CORTISOL TOTAL,3010000076,CDM,301,RC,,,Outpatient,,,229.32,149.06,,229.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,174.28,76,,372.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,165.11,72,,66.816,Percent of Total Billed Charges,72% of Total Billed Charges,171.99,75,,69.6,Percent of Total Billed charges,75% of Total Billed Charges,229.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.11,72,,66.816,Percent of Total Billed Charges,72% of Total Billed Charges,137.59,60,,55.68,Percent of Total Billed Charges,60% of Total Billed Charges,206.39,90,,226.232,Percent of Total Billed Charges,90% of Total Billed Charges,103.19,45,,102,Percent of Total Billed Charges,45% of Total Billed Charges,206.39,90,,441.352,Percent of Total Billed Charges,90% of Total billed Charges,229.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.06,65,,147.336,Percent of total Billed Charges,65% of Total Billed Charges,101.13,44.1,,99.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,217.85,95,,465.872,Percent of Total Billed Charges,95% of Total Billed Charges,229.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.8,88,,19.008,Percent of Total Billed Charges,88% of Total Billed Charges,206.39,90,,441.352,Percent of Total Billed charges,90% of Total Billed Charges,101.13,229.32,
CREATINE,3010000077,CDM,301,RC,,,Outpatient,,,46.31,30.10,,46.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.2,76,,351.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.34,72,,70.272,Percent of Total Billed Charges,72% of Total Billed Charges,34.73,75,,73.2,Percent of Total Billed charges,75% of Total Billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.34,72,,70.272,Percent of Total Billed Charges,72% of Total Billed Charges,27.79,60,,58.56,Percent of Total Billed Charges,60% of Total Billed Charges,41.68,90,,61.12,Percent of Total Billed Charges,90% of Total Billed Charges,20.84,45,,9.72,Percent of Total Billed Charges,45% of Total Billed Charges,41.68,90,,415.952,Percent of Total Billed Charges,90% of Total billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.1,65,,141.032,Percent of total Billed Charges,65% of Total Billed Charges,20.42,44.1,,9.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,43.99,95,,439.056,Percent of Total Billed Charges,95% of Total Billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.75,88,,260.016,Percent of Total Billed Charges,88% of Total Billed Charges,41.68,90,,415.952,Percent of Total Billed charges,90% of Total Billed Charges,20.42,46.31,
CPK (BLOOD) TOTAL,3010000078,CDM,301,RC,,,Outpatient,,,193.00,125.45,,193,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,146.68,76,,158.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,138.96,72,,148.608,Percent of Total Billed Charges,72% of Total Billed Charges,144.75,75,,154.8,Percent of Total Billed charges,75% of Total Billed Charges,193,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.96,72,,148.608,Percent of Total Billed Charges,72% of Total Billed Charges,115.8,60,,123.84,Percent of Total Billed Charges,60% of Total Billed Charges,173.7,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,86.85,45,,132.96,Percent of Total Billed Charges,45% of Total Billed Charges,173.7,90,,187.336,Percent of Total Billed Charges,90% of Total billed Charges,193,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.45,65,,141.032,Percent of total Billed Charges,65% of Total Billed Charges,85.11,44.1,,130.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,183.35,95,,197.744,Percent of Total Billed Charges,95% of Total Billed Charges,193,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.84,88,,291.84,Percent of Total Billed Charges,88% of Total Billed Charges,173.7,90,,187.336,Percent of Total Billed charges,90% of Total Billed Charges,85.11,193,
CK  ISOENZYMES W/TOT,3010000079,CDM,301,RC,,,Outpatient,,,101.43,65.93,,101.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,77.09,76,,164.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,73.03,72,,50.112,Percent of Total Billed Charges,72% of Total Billed Charges,76.07,75,,52.2,Percent of Total Billed charges,75% of Total Billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.03,72,,50.112,Percent of Total Billed Charges,72% of Total Billed Charges,60.86,60,,41.76,Percent of Total Billed Charges,60% of Total Billed Charges,91.29,90,,24.48,Percent of Total Billed Charges,90% of Total Billed Charges,45.64,45,,149.232,Percent of Total Billed Charges,45% of Total Billed Charges,91.29,90,,194.4,Percent of Total Billed Charges,90% of Total billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.93,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,44.73,44.1,,146.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,96.36,95,,205.2,Percent of Total Billed Charges,95% of Total Billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.26,88,,291.84,Percent of Total Billed Charges,88% of Total Billed Charges,91.29,90,,194.4,Percent of Total Billed charges,90% of Total Billed Charges,44.73,101.43,
CKMB,3010000080,CDM,301,RC,,,Outpatient,,,268.00,174.20,,268,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,203.68,76,,172.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,192.96,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,201,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,268,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.96,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,160.8,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,241.2,90,,96.848,Percent of Total Billed Charges,90% of Total Billed Charges,120.6,45,,149.232,Percent of Total Billed Charges,45% of Total Billed Charges,241.2,90,,204.008,Percent of Total Billed Charges,90% of Total billed Charges,268,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.2,65,,103.192,Percent of total Billed Charges,65% of Total Billed Charges,118.19,44.1,,146.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,254.6,95,,215.336,Percent of Total Billed Charges,95% of Total Billed Charges,268,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.84,88,,221.2,Percent of Total Billed Charges,88% of Total Billed Charges,241.2,90,,204.008,Percent of Total Billed charges,90% of Total Billed Charges,118.19,268,
CPK MM FRACTIONS,3010000081,CDM,301,RC,,,Outpatient,,,58.43,37.98,,58.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,44.41,76,,16.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.07,72,,33.984,Percent of Total Billed Charges,72% of Total Billed Charges,43.82,75,,35.4,Percent of Total Billed charges,75% of Total Billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.07,72,,33.984,Percent of Total Billed Charges,72% of Total Billed Charges,35.06,60,,28.32,Percent of Total Billed Charges,60% of Total Billed Charges,52.59,90,,96.848,Percent of Total Billed Charges,90% of Total Billed Charges,26.29,45,,113.112,Percent of Total Billed Charges,45% of Total Billed Charges,52.59,90,,19.44,Percent of Total Billed Charges,90% of Total billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.98,65,,82.16,Percent of total Billed Charges,65% of Total Billed Charges,25.77,44.1,,110.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,55.51,95,,20.52,Percent of Total Billed Charges,95% of Total Billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.42,88,,221.2,Percent of Total Billed Charges,88% of Total Billed Charges,52.59,90,,19.44,Percent of Total Billed charges,90% of Total Billed Charges,25.77,58.43,
CREATININE BLOOD,3010000082,CDM,301,RC,,,Outpatient,,,168.00,109.20,,168,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,127.68,76,,224.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,120.96,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,126,75,,29.104,Percent of Total Billed charges,75% of Total Billed Charges,168,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.96,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,100.8,60,,23.288,Percent of Total Billed Charges,60% of Total Billed Charges,151.2,90,,96.848,Percent of Total Billed Charges,90% of Total Billed Charges,75.6,45,,113.112,Percent of Total Billed Charges,45% of Total Billed Charges,151.2,90,,265.928,Percent of Total Billed Charges,90% of Total billed Charges,168,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.2,65,,59.624,Percent of total Billed Charges,65% of Total Billed Charges,74.09,44.1,,110.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,159.6,95,,280.696,Percent of Total Billed Charges,95% of Total Billed Charges,168,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.84,88,,59.76,Percent of Total Billed Charges,88% of Total Billed Charges,151.2,90,,265.928,Percent of Total Billed charges,90% of Total Billed Charges,74.09,168,
CREATININE URINE,3010000083,CDM,301,RC,,,Outpatient,,,162.00,105.30,,162,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,123.12,76,,252.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,116.64,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,121.5,75,,29.104,Percent of Total Billed charges,75% of Total Billed Charges,162,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.64,72,,27.944,Percent of Total Billed Charges,72% of Total Billed Charges,97.2,60,,23.288,Percent of Total Billed Charges,60% of Total Billed Charges,145.8,90,,512,Percent of Total Billed Charges,90% of Total Billed Charges,72.9,45,,30.56,Percent of Total Billed Charges,45% of Total Billed Charges,145.8,90,,298.472,Percent of Total Billed Charges,90% of Total billed Charges,162,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.3,65,,79.12,Percent of total Billed Charges,65% of Total Billed Charges,71.44,44.1,,29.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,153.9,95,,315.048,Percent of Total Billed Charges,95% of Total Billed Charges,162,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.56,88,,9.856,Percent of Total Billed Charges,88% of Total Billed Charges,145.8,90,,298.472,Percent of Total Billed charges,90% of Total Billed Charges,71.44,162,
CREATININE CLEARANCE,3010000084,CDM,301,RC,,,Outpatient,,,248.00,161.20,,248,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,188.48,76,,252.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,178.56,72,,70.272,Percent of Total Billed Charges,72% of Total Billed Charges,186,75,,73.2,Percent of Total Billed charges,75% of Total Billed Charges,248,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.56,72,,70.272,Percent of Total Billed Charges,72% of Total Billed Charges,148.8,60,,58.56,Percent of Total Billed Charges,60% of Total Billed Charges,223.2,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,111.6,45,,5.04,Percent of Total Billed Charges,45% of Total Billed Charges,223.2,90,,298.472,Percent of Total Billed Charges,90% of Total billed Charges,248,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.2,65,,173,Percent of total Billed Charges,65% of Total Billed Charges,109.37,44.1,,4.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,235.6,95,,315.048,Percent of Total Billed Charges,95% of Total Billed Charges,248,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.24,88,,23.936,Percent of Total Billed Charges,88% of Total Billed Charges,223.2,90,,298.472,Percent of Total Billed charges,90% of Total Billed Charges,109.37,248,
CRYOGLOBULIN LEVEL,3010000085,CDM,301,RC,,,Outpatient,,,28.67,18.64,,28.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21.79,76,,191.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.64,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,21.5,75,,10.584,Percent of Total Billed charges,75% of Total Billed Charges,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.64,72,,10.16,Percent of Total Billed Charges,72% of Total Billed Charges,17.2,60,,8.464,Percent of Total Billed Charges,60% of Total Billed Charges,25.8,90,,22.224,Percent of Total Billed Charges,90% of Total Billed Charges,12.9,45,,12.24,Percent of Total Billed Charges,45% of Total Billed Charges,25.8,90,,226.232,Percent of Total Billed Charges,90% of Total billed Charges,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.64,65,,56.184,Percent of total Billed Charges,65% of Total Billed Charges,12.64,44.1,,11.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,27.24,95,,238.8,Percent of Total Billed Charges,95% of Total Billed Charges,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.23,88,,94.696,Percent of Total Billed Charges,88% of Total Billed Charges,25.8,90,,226.232,Percent of Total Billed charges,90% of Total Billed Charges,12.64,28.67,
VITAMIN B12,3010000086,CDM,301,RC,,,Outpatient,,,85.00,55.25,,85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,64.6,76,,191.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.2,72,,44.928,Percent of Total Billed Charges,72% of Total Billed Charges,63.75,75,,46.8,Percent of Total Billed charges,75% of Total Billed Charges,85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.2,72,,44.928,Percent of Total Billed Charges,72% of Total Billed Charges,51,60,,37.44,Percent of Total Billed Charges,60% of Total Billed Charges,76.5,90,,117.48,Percent of Total Billed Charges,90% of Total Billed Charges,38.25,45,,48.424,Percent of Total Billed Charges,45% of Total Billed Charges,76.5,90,,226.232,Percent of Total Billed Charges,90% of Total billed Charges,85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.25,65,,38.416,Percent of total Billed Charges,65% of Total Billed Charges,37.49,44.1,,47.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,80.75,95,,238.8,Percent of Total Billed Charges,95% of Total Billed Charges,85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.8,88,,94.696,Percent of Total Billed Charges,88% of Total Billed Charges,76.5,90,,226.232,Percent of Total Billed charges,90% of Total Billed Charges,37.49,85,
DHEA SULFATE,3010000087,CDM,301,RC,,,Outpatient,,,147.74,96.03,,147.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,112.28,76,,51.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,106.37,72,,176.544,Percent of Total Billed Charges,72% of Total Billed Charges,110.81,75,,183.904,Percent of Total Billed charges,75% of Total Billed Charges,147.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.37,72,,176.544,Percent of Total Billed Charges,72% of Total Billed Charges,88.64,60,,147.12,Percent of Total Billed Charges,60% of Total Billed Charges,132.97,90,,117.48,Percent of Total Billed Charges,90% of Total Billed Charges,66.48,45,,48.424,Percent of Total Billed Charges,45% of Total Billed Charges,132.97,90,,61.12,Percent of Total Billed Charges,90% of Total billed Charges,147.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.03,65,,382.392,Percent of total Billed Charges,65% of Total Billed Charges,65.15,44.1,,47.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,140.35,95,,64.52,Percent of Total Billed Charges,95% of Total Billed Charges,147.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.01,88,,94.696,Percent of Total Billed Charges,88% of Total Billed Charges,132.97,90,,61.12,Percent of Total Billed charges,90% of Total Billed Charges,65.15,147.74,
DIHYDROXYVITAMIN D,3010000088,CDM,301,RC,,,Outpatient,,,154.35,100.33,,154.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,117.31,76,,8.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.13,72,,123.832,Percent of Total Billed Charges,72% of Total Billed Charges,115.76,75,,128.992,Percent of Total Billed charges,75% of Total Billed Charges,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.13,72,,123.832,Percent of Total Billed Charges,72% of Total Billed Charges,92.61,60,,103.192,Percent of Total Billed Charges,60% of Total Billed Charges,138.92,90,,85.728,Percent of Total Billed Charges,90% of Total Billed Charges,69.46,45,,48.424,Percent of Total Billed Charges,45% of Total Billed Charges,138.92,90,,10.08,Percent of Total Billed Charges,90% of Total billed Charges,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.33,65,,130.712,Percent of total Billed Charges,65% of Total Billed Charges,68.07,44.1,,47.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,146.63,95,,10.64,Percent of Total Billed Charges,95% of Total Billed Charges,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.83,88,,500.624,Percent of Total Billed Charges,88% of Total Billed Charges,138.92,90,,10.08,Percent of Total Billed charges,90% of Total Billed Charges,68.07,154.35,
"ELASTASE EL1, STOOL",3010000089,CDM,301,RC,,,Outpatient,,,563.38,366.20,,563.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,428.17,76,,20.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,405.63,72,,140.984,Percent of Total Billed Charges,72% of Total Billed Charges,422.54,75,,146.856,Percent of Total Billed charges,75% of Total Billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.63,72,,140.984,Percent of Total Billed Charges,72% of Total Billed Charges,338.03,60,,117.488,Percent of Total Billed Charges,60% of Total Billed Charges,507.04,90,,249.12,Percent of Total Billed Charges,90% of Total Billed Charges,253.52,45,,256,Percent of Total Billed Charges,45% of Total Billed Charges,507.04,90,,24.48,Percent of Total Billed Charges,90% of Total billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.2,65,,130.712,Percent of total Billed Charges,65% of Total Billed Charges,248.45,44.1,,250.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,535.21,95,,25.84,Percent of Total Billed Charges,95% of Total Billed Charges,563.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495.77,88,,60.544,Percent of Total Billed Charges,88% of Total Billed Charges,507.04,90,,24.48,Percent of Total Billed charges,90% of Total Billed Charges,248.45,563.38,
ERYTHROPOIETIN,3010000090,CDM,301,RC,,,Outpatient,,,208.37,135.44,,208.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,158.36,76,,81.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.03,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,156.28,75,,34.2,Percent of Total Billed charges,75% of Total Billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.03,72,,32.832,Percent of Total Billed Charges,72% of Total Billed Charges,125.02,60,,27.36,Percent of Total Billed Charges,60% of Total Billed Charges,187.53,90,,126,Percent of Total Billed Charges,90% of Total Billed Charges,93.77,45,,30.96,Percent of Total Billed Charges,45% of Total Billed Charges,187.53,90,,96.848,Percent of Total Billed Charges,90% of Total billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.44,65,,498.776,Percent of total Billed Charges,65% of Total Billed Charges,91.89,44.1,,30.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,197.95,95,,102.224,Percent of Total Billed Charges,95% of Total Billed Charges,208.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.37,88,,21.736,Percent of Total Billed Charges,88% of Total Billed Charges,187.53,90,,96.848,Percent of Total Billed charges,90% of Total Billed Charges,91.89,208.37,
ESTROGENS TOT,3010000092,CDM,301,RC,,,Outpatient,,,252.47,164.11,,252.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,191.88,76,,81.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,181.78,72,,29.848,Percent of Total Billed Charges,72% of Total Billed Charges,189.35,75,,31.096,Percent of Total Billed charges,75% of Total Billed Charges,252.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.78,72,,29.848,Percent of Total Billed Charges,72% of Total Billed Charges,151.48,60,,24.872,Percent of Total Billed Charges,60% of Total Billed Charges,227.22,90,,96.048,Percent of Total Billed Charges,90% of Total Billed Charges,113.61,45,,11.112,Percent of Total Billed Charges,45% of Total Billed Charges,227.22,90,,96.848,Percent of Total Billed Charges,90% of Total billed Charges,252.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.11,65,,79.12,Percent of total Billed Charges,65% of Total Billed Charges,111.34,44.1,,10.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,239.85,95,,102.224,Percent of Total Billed Charges,95% of Total Billed Charges,252.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.17,88,,114.872,Percent of Total Billed Charges,88% of Total Billed Charges,227.22,90,,96.848,Percent of Total Billed charges,90% of Total Billed Charges,111.34,252.47,
FAT FECES QUAL,3010000093,CDM,301,RC,,,Outpatient,,,220.50,143.33,,220.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,167.58,76,,81.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,158.76,72,,29.848,Percent of Total Billed Charges,72% of Total Billed Charges,165.38,75,,31.096,Percent of Total Billed charges,75% of Total Billed Charges,220.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,72,,29.848,Percent of Total Billed Charges,72% of Total Billed Charges,132.3,60,,24.872,Percent of Total Billed Charges,60% of Total Billed Charges,198.45,90,,140.504,Percent of Total Billed Charges,90% of Total Billed Charges,99.23,45,,58.744,Percent of Total Billed Charges,45% of Total Billed Charges,198.45,90,,96.848,Percent of Total Billed Charges,90% of Total billed Charges,220.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.33,65,,80.576,Percent of total Billed Charges,65% of Total Billed Charges,97.24,44.1,,57.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,209.48,95,,102.224,Percent of Total Billed Charges,95% of Total Billed Charges,220.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.04,88,,114.872,Percent of Total Billed Charges,88% of Total Billed Charges,198.45,90,,96.848,Percent of Total Billed charges,90% of Total Billed Charges,97.24,220.5,
FERRITIN,3010000094,CDM,301,RC,,,Outpatient,,,266.00,172.90,,266,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,202.16,76,,432.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,191.52,72,,94.464,Percent of Total Billed Charges,72% of Total Billed Charges,199.5,75,,98.4,Percent of Total Billed charges,75% of Total Billed Charges,266,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.52,72,,94.464,Percent of Total Billed Charges,72% of Total Billed Charges,159.6,60,,78.72,Percent of Total Billed Charges,60% of Total Billed Charges,239.4,90,,140.504,Percent of Total Billed Charges,90% of Total Billed Charges,119.7,45,,58.744,Percent of Total Billed Charges,45% of Total Billed Charges,239.4,90,,512,Percent of Total Billed Charges,90% of Total billed Charges,266,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.9,65,,80.576,Percent of total Billed Charges,65% of Total Billed Charges,117.31,44.1,,57.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,252.7,95,,540.44,Percent of Total Billed Charges,95% of Total Billed Charges,266,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.08,88,,83.824,Percent of Total Billed Charges,88% of Total Billed Charges,239.4,90,,512,Percent of Total Billed charges,90% of Total Billed Charges,117.31,266,
FETAL FIBRONECTIN,3010000095,CDM,301,RC,,,Outpatient,,,306.00,198.90,,306,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,232.56,76,,52.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,220.32,72,,29.848,Percent of Total Billed Charges,72% of Total Billed Charges,229.5,75,,31.096,Percent of Total Billed charges,75% of Total Billed Charges,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.32,72,,29.848,Percent of Total Billed Charges,72% of Total Billed Charges,183.6,60,,24.872,Percent of Total Billed Charges,60% of Total Billed Charges,275.4,90,,140.504,Percent of Total Billed Charges,90% of Total Billed Charges,137.7,45,,42.864,Percent of Total Billed Charges,45% of Total Billed Charges,275.4,90,,61.92,Percent of Total Billed Charges,90% of Total billed Charges,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.9,65,,339.392,Percent of total Billed Charges,65% of Total Billed Charges,134.95,44.1,,42.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,290.7,95,,65.36,Percent of Total Billed Charges,95% of Total Billed Charges,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.28,88,,243.584,Percent of Total Billed Charges,88% of Total Billed Charges,275.4,90,,61.92,Percent of Total Billed charges,90% of Total Billed Charges,134.95,306,
FOLATE SERUM,3010000096,CDM,301,RC,,,Outpatient,,,83.00,53.95,,83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,63.08,76,,18.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.76,72,,135.36,Percent of Total Billed Charges,72% of Total Billed Charges,62.25,75,,141,Percent of Total Billed charges,75% of Total Billed Charges,83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.76,72,,135.36,Percent of Total Billed Charges,72% of Total Billed Charges,49.8,60,,112.8,Percent of Total Billed Charges,60% of Total Billed Charges,74.7,90,,196.56,Percent of Total Billed Charges,90% of Total Billed Charges,37.35,45,,124.56,Percent of Total Billed Charges,45% of Total Billed Charges,74.7,90,,22.224,Percent of Total Billed Charges,90% of Total billed Charges,83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.95,65,,29.64,Percent of total Billed Charges,65% of Total Billed Charges,36.6,44.1,,122.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,78.85,95,,23.464,Percent of Total Billed Charges,95% of Total Billed Charges,83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.04,88,,123.2,Percent of Total Billed Charges,88% of Total Billed Charges,74.7,90,,22.224,Percent of Total Billed charges,90% of Total Billed Charges,36.6,83,
FOLATE RBC,3010000097,CDM,301,RC,,,Outpatient,,,106.94,69.51,,106.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.27,76,,99.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77,72,,89.28,Percent of Total Billed Charges,72% of Total Billed Charges,80.21,75,,93,Percent of Total Billed charges,75% of Total Billed Charges,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77,72,,89.28,Percent of Total Billed Charges,72% of Total Billed Charges,64.16,60,,74.4,Percent of Total Billed Charges,60% of Total Billed Charges,96.25,90,,206.4,Percent of Total Billed Charges,90% of Total Billed Charges,48.12,45,,63,Percent of Total Billed Charges,45% of Total Billed Charges,96.25,90,,117.48,Percent of Total Billed Charges,90% of Total billed Charges,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.51,65,,88.92,Percent of total Billed Charges,65% of Total Billed Charges,47.16,44.1,,61.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,101.59,95,,124.008,Percent of Total Billed Charges,95% of Total Billed Charges,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.11,88,,93.912,Percent of Total Billed Charges,88% of Total Billed Charges,96.25,90,,117.48,Percent of Total Billed charges,90% of Total Billed Charges,47.16,106.94,
IMMUNOGLOBULINS PANE,3010000098,CDM,301,RC,,,Outpatient,,,116.87,75.97,,116.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,88.82,76,,99.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.15,72,,66.24,Percent of Total Billed Charges,72% of Total Billed Charges,87.65,75,,69,Percent of Total Billed charges,75% of Total Billed Charges,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.15,72,,66.24,Percent of Total Billed Charges,72% of Total Billed Charges,70.12,60,,55.2,Percent of Total Billed Charges,60% of Total Billed Charges,105.18,90,,206.4,Percent of Total Billed Charges,90% of Total Billed Charges,52.59,45,,48.024,Percent of Total Billed Charges,45% of Total Billed Charges,105.18,90,,117.48,Percent of Total Billed Charges,90% of Total billed Charges,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.97,65,,66.504,Percent of total Billed Charges,65% of Total Billed Charges,51.54,44.1,,47.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,111.03,95,,124.008,Percent of Total Billed Charges,95% of Total Billed Charges,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.85,88,,137.376,Percent of Total Billed Charges,88% of Total Billed Charges,105.18,90,,117.48,Percent of Total Billed charges,90% of Total Billed Charges,51.54,116.87,
IGA WITH REFLEXES,3010000099,CDM,301,RC,,,Outpatient,,,116.87,75.97,,116.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,88.82,76,,72.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.15,72,,66.24,Percent of Total Billed Charges,72% of Total Billed Charges,87.65,75,,69,Percent of Total Billed charges,75% of Total Billed Charges,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.15,72,,66.24,Percent of Total Billed Charges,72% of Total Billed Charges,70.12,60,,55.2,Percent of Total Billed Charges,60% of Total Billed Charges,105.18,90,,206.4,Percent of Total Billed Charges,90% of Total Billed Charges,52.59,45,,70.248,Percent of Total Billed Charges,45% of Total Billed Charges,105.18,90,,85.728,Percent of Total Billed Charges,90% of Total billed Charges,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.97,65,,66.504,Percent of total Billed Charges,65% of Total Billed Charges,51.54,44.1,,68.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,111.03,95,,90.496,Percent of Total Billed Charges,95% of Total Billed Charges,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.85,88,,137.376,Percent of Total Billed Charges,88% of Total Billed Charges,105.18,90,,85.728,Percent of Total Billed charges,90% of Total Billed Charges,51.54,116.87,
IMMUNOGLOBULIN M,3010000100,CDM,301,RC,,,Outpatient,,,116.87,75.97,,116.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,88.82,76,,210.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.15,72,,83.52,Percent of Total Billed Charges,72% of Total Billed Charges,87.65,75,,87,Percent of Total Billed charges,75% of Total Billed Charges,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.15,72,,83.52,Percent of Total Billed Charges,72% of Total Billed Charges,70.12,60,,69.6,Percent of Total Billed Charges,60% of Total Billed Charges,105.18,90,,204.008,Percent of Total Billed Charges,90% of Total Billed Charges,52.59,45,,70.248,Percent of Total Billed Charges,45% of Total Billed Charges,105.18,90,,249.12,Percent of Total Billed Charges,90% of Total billed Charges,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.97,65,,66.504,Percent of total Billed Charges,65% of Total Billed Charges,51.54,44.1,,68.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,111.03,95,,262.96,Percent of Total Billed Charges,95% of Total Billed Charges,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.85,88,,137.376,Percent of Total Billed Charges,88% of Total Billed Charges,105.18,90,,249.12,Percent of Total Billed charges,90% of Total Billed Charges,51.54,116.87,
IMMUNOGLOBULIN A,3010000101,CDM,301,RC,,,Outpatient,,,116.87,75.97,,116.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,88.82,76,,106.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.15,72,,67.392,Percent of Total Billed Charges,72% of Total Billed Charges,87.65,75,,70.2,Percent of Total Billed charges,75% of Total Billed Charges,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.15,72,,67.392,Percent of Total Billed Charges,72% of Total Billed Charges,70.12,60,,56.16,Percent of Total Billed Charges,60% of Total Billed Charges,105.18,90,,204.008,Percent of Total Billed Charges,90% of Total Billed Charges,52.59,45,,70.248,Percent of Total Billed Charges,45% of Total Billed Charges,105.18,90,,126,Percent of Total Billed Charges,90% of Total billed Charges,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.97,65,,66.504,Percent of total Billed Charges,65% of Total Billed Charges,51.54,44.1,,68.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,111.03,95,,133,Percent of Total Billed Charges,95% of Total Billed Charges,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.85,88,,192.192,Percent of Total Billed Charges,88% of Total Billed Charges,105.18,90,,126,Percent of Total Billed charges,90% of Total Billed Charges,51.54,116.87,
IMMUNOGLOBULIN G,3010000102,CDM,301,RC,,,Outpatient,,,116.87,75.97,,116.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,88.82,76,,81.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.15,72,,59.056,Percent of Total Billed Charges,72% of Total Billed Charges,87.65,75,,61.52,Percent of Total Billed charges,75% of Total Billed Charges,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.15,72,,59.056,Percent of Total Billed Charges,72% of Total Billed Charges,70.12,60,,49.216,Percent of Total Billed Charges,60% of Total Billed Charges,105.18,90,,195.28,Percent of Total Billed Charges,90% of Total Billed Charges,52.59,45,,98.28,Percent of Total Billed Charges,45% of Total Billed Charges,105.18,90,,96.048,Percent of Total Billed Charges,90% of Total billed Charges,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.97,65,,66.504,Percent of total Billed Charges,65% of Total Billed Charges,51.54,44.1,,96.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,111.03,95,,101.384,Percent of Total Billed Charges,95% of Total Billed Charges,116.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.85,88,,201.816,Percent of Total Billed Charges,88% of Total Billed Charges,105.18,90,,96.048,Percent of Total Billed charges,90% of Total Billed Charges,51.54,116.87,
IMMUNOGLOBULIN E,3010000103,CDM,301,RC,,,Outpatient,,,138.92,90.30,,138.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,105.58,76,,118.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.02,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,104.19,75,,46.968,Percent of Total Billed charges,75% of Total Billed Charges,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.02,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,83.35,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,125.03,90,,195.28,Percent of Total Billed Charges,90% of Total Billed Charges,62.51,45,,103.2,Percent of Total Billed Charges,45% of Total Billed Charges,125.03,90,,140.504,Percent of Total Billed Charges,90% of Total billed Charges,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.3,65,,61.92,Percent of total Billed Charges,65% of Total Billed Charges,61.26,44.1,,101.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,131.97,95,,148.304,Percent of Total Billed Charges,95% of Total Billed Charges,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.25,88,,201.816,Percent of Total Billed Charges,88% of Total Billed Charges,125.03,90,,140.504,Percent of Total Billed charges,90% of Total Billed Charges,61.26,138.92,
IMMUNOGLOBULIN SUBCL,3010000104,CDM,301,RC,,,Outpatient,,,33.08,21.50,,33.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.14,76,,118.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.82,72,,132.48,Percent of Total Billed Charges,72% of Total Billed Charges,24.81,75,,138,Percent of Total Billed charges,75% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.82,72,,132.48,Percent of Total Billed Charges,72% of Total Billed Charges,19.85,60,,110.4,Percent of Total Billed Charges,60% of Total Billed Charges,29.77,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,14.89,45,,103.2,Percent of Total Billed Charges,45% of Total Billed Charges,29.77,90,,140.504,Percent of Total Billed Charges,90% of Total billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.5,65,,121.536,Percent of total Billed Charges,65% of Total Billed Charges,14.59,44.1,,101.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,31.43,95,,148.304,Percent of Total Billed Charges,95% of Total Billed Charges,33.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.11,88,,201.816,Percent of Total Billed Charges,88% of Total Billed Charges,29.77,90,,140.504,Percent of Total Billed charges,90% of Total Billed Charges,14.59,33.08,
ARTER BLOODGAS STUDY,3010000105,CDM,301,RC,,,Outpatient,,,449.00,291.85,,449,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,341.24,76,,118.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,323.28,72,,27.072,Percent of Total Billed Charges,72% of Total Billed Charges,336.75,75,,28.2,Percent of Total Billed charges,75% of Total Billed Charges,449,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.28,72,,27.072,Percent of Total Billed Charges,72% of Total Billed Charges,269.4,60,,22.56,Percent of Total Billed Charges,60% of Total Billed Charges,404.1,90,,142.888,Percent of Total Billed Charges,90% of Total Billed Charges,202.05,45,,103.2,Percent of Total Billed Charges,45% of Total Billed Charges,404.1,90,,140.504,Percent of Total Billed Charges,90% of Total billed Charges,449,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,449,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,449,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291.85,65,,112.832,Percent of total Billed Charges,65% of Total Billed Charges,198.01,44.1,,101.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,426.55,95,,148.304,Percent of Total Billed Charges,95% of Total Billed Charges,449,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,395.12,88,,199.472,Percent of Total Billed Charges,88% of Total Billed Charges,404.1,90,,140.504,Percent of Total Billed charges,90% of Total Billed Charges,198.01,449,
GASTRIN SERUM,3010000106,CDM,301,RC,,,Outpatient,,,138.92,90.30,,138.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,105.58,76,,165.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.02,72,,69.216,Percent of Total Billed Charges,72% of Total Billed Charges,104.19,75,,72.104,Percent of Total Billed charges,75% of Total Billed Charges,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.02,72,,69.216,Percent of Total Billed Charges,72% of Total Billed Charges,83.35,60,,57.68,Percent of Total Billed Charges,60% of Total Billed Charges,125.03,90,,113.76,Percent of Total Billed Charges,90% of Total Billed Charges,62.51,45,,102,Percent of Total Billed Charges,45% of Total Billed Charges,125.03,90,,196.56,Percent of Total Billed Charges,90% of Total billed Charges,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.3,65,,84.24,Percent of total Billed Charges,65% of Total Billed Charges,61.26,44.1,,99.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,131.97,95,,207.48,Percent of Total Billed Charges,95% of Total Billed Charges,138.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.25,88,,199.472,Percent of Total Billed Charges,88% of Total Billed Charges,125.03,90,,196.56,Percent of Total Billed charges,90% of Total Billed Charges,61.26,138.92,
GLUCOSE BODY FLUID,3010000107,CDM,301,RC,,,Outpatient,,,65.05,42.28,,65.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.44,76,,174.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.84,72,,24.768,Percent of Total Billed Charges,72% of Total Billed Charges,48.79,75,,25.8,Percent of Total Billed charges,75% of Total Billed Charges,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.84,72,,24.768,Percent of Total Billed Charges,72% of Total Billed Charges,39.03,60,,20.64,Percent of Total Billed Charges,60% of Total Billed Charges,58.55,90,,82.552,Percent of Total Billed Charges,90% of Total Billed Charges,29.27,45,,102,Percent of Total Billed Charges,45% of Total Billed Charges,58.55,90,,206.4,Percent of Total Billed Charges,90% of Total billed Charges,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.28,65,,86,Percent of total Billed Charges,65% of Total Billed Charges,28.69,44.1,,99.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,61.8,95,,217.872,Percent of Total Billed Charges,95% of Total Billed Charges,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.24,88,,190.936,Percent of Total Billed Charges,88% of Total Billed Charges,58.55,90,,206.4,Percent of Total Billed charges,90% of Total Billed Charges,28.69,65.05,
GLUCOSE PERITONEAL FLUID,3010000108,CDM,301,RC,,,Outpatient,,,63.00,40.95,,63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.88,76,,174.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.36,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,47.25,75,,18.52,Percent of Total Billed charges,75% of Total Billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.36,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,37.8,60,,14.816,Percent of Total Billed Charges,60% of Total Billed Charges,56.7,90,,109.552,Percent of Total Billed Charges,90% of Total Billed Charges,28.35,45,,97.64,Percent of Total Billed Charges,45% of Total Billed Charges,56.7,90,,206.4,Percent of Total Billed Charges,90% of Total billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.95,65,,38.984,Percent of total Billed Charges,65% of Total Billed Charges,27.78,44.1,,95.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.85,95,,217.872,Percent of Total Billed Charges,95% of Total Billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.44,88,,190.936,Percent of Total Billed Charges,88% of Total Billed Charges,56.7,90,,206.4,Percent of Total Billed charges,90% of Total Billed Charges,27.78,63,
GLUCOSE PLEURAL FLUID,3010000109,CDM,301,RC,,,Outpatient,,,65.05,42.28,,65.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.44,76,,174.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.84,72,,60.48,Percent of Total Billed Charges,72% of Total Billed Charges,48.79,75,,63,Percent of Total Billed charges,75% of Total Billed Charges,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.84,72,,60.48,Percent of Total Billed Charges,72% of Total Billed Charges,39.03,60,,50.4,Percent of Total Billed Charges,60% of Total Billed Charges,58.55,90,,239.536,Percent of Total Billed Charges,90% of Total Billed Charges,29.27,45,,97.64,Percent of Total Billed Charges,45% of Total Billed Charges,58.55,90,,206.4,Percent of Total Billed Charges,90% of Total billed Charges,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.28,65,,38.984,Percent of total Billed Charges,65% of Total Billed Charges,28.69,44.1,,95.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,61.8,95,,217.872,Percent of Total Billed Charges,95% of Total Billed Charges,65.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.24,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,58.55,90,,206.4,Percent of Total Billed charges,90% of Total Billed Charges,28.69,65.05,
GLUCOSE SYNOVIAL FLUID,3010000110,CDM,301,RC,,,Outpatient,,,63.00,40.95,,63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.88,76,,172.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.36,72,,232.704,Percent of Total Billed Charges,72% of Total Billed Charges,47.25,75,,242.4,Percent of Total Billed charges,75% of Total Billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.36,72,,232.704,Percent of Total Billed Charges,72% of Total Billed Charges,37.8,60,,193.92,Percent of Total Billed Charges,60% of Total Billed Charges,56.7,90,,77.8,Percent of Total Billed Charges,90% of Total Billed Charges,28.35,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,56.7,90,,204.008,Percent of Total Billed Charges,90% of Total billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.95,65,,38.984,Percent of total Billed Charges,65% of Total Billed Charges,27.78,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.85,95,,215.336,Percent of Total Billed Charges,95% of Total Billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.44,88,,139.712,Percent of Total Billed Charges,88% of Total Billed Charges,56.7,90,,204.008,Percent of Total Billed charges,90% of Total Billed Charges,27.78,63,
GLUCOSE (VP),3010000111,CDM,301,RC,,,Outpatient,,,69.00,44.85,,69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.44,76,,172.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49.68,72,,67.968,Percent of Total Billed Charges,72% of Total Billed Charges,51.75,75,,70.8,Percent of Total Billed charges,75% of Total Billed Charges,69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.68,72,,67.968,Percent of Total Billed Charges,72% of Total Billed Charges,41.4,60,,56.64,Percent of Total Billed Charges,60% of Total Billed Charges,62.1,90,,53.184,Percent of Total Billed Charges,90% of Total Billed Charges,31.05,45,,71.44,Percent of Total Billed Charges,45% of Total Billed Charges,62.1,90,,204.008,Percent of Total Billed Charges,90% of Total billed Charges,69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.85,65,,261.424,Percent of total Billed Charges,65% of Total Billed Charges,30.43,44.1,,70.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.55,95,,215.336,Percent of Total Billed Charges,95% of Total Billed Charges,69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.72,88,,111.232,Percent of Total Billed Charges,88% of Total Billed Charges,62.1,90,,204.008,Percent of Total Billed charges,90% of Total Billed Charges,30.43,69,
GLUCOSE TOL 1HOUR,3010000112,CDM,301,RC,,,Outpatient,,,122.00,79.30,,122,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,92.72,76,,164.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,87.84,72,,111.136,Percent of Total Billed Charges,72% of Total Billed Charges,91.5,75,,115.768,Percent of Total Billed charges,75% of Total Billed Charges,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.84,72,,111.136,Percent of Total Billed Charges,72% of Total Billed Charges,73.2,60,,92.608,Percent of Total Billed Charges,60% of Total Billed Charges,109.8,90,,529.464,Percent of Total Billed Charges,90% of Total Billed Charges,54.9,45,,56.88,Percent of Total Billed Charges,45% of Total Billed Charges,109.8,90,,195.28,Percent of Total Billed Charges,90% of Total billed Charges,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.3,65,,81.12,Percent of total Billed Charges,65% of Total Billed Charges,53.8,44.1,,55.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,115.9,95,,206.128,Percent of Total Billed Charges,95% of Total Billed Charges,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.36,88,,80.72,Percent of Total Billed Charges,88% of Total Billed Charges,109.8,90,,195.28,Percent of Total Billed charges,90% of Total Billed Charges,53.8,122,
GLUCOSE TOL 3HOUR,3010000113,CDM,301,RC,,,Outpatient,,,247.00,160.55,,247,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,187.72,76,,164.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,177.84,72,,93.984,Percent of Total Billed Charges,72% of Total Billed Charges,185.25,75,,97.904,Percent of Total Billed charges,75% of Total Billed Charges,247,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.84,72,,93.984,Percent of Total Billed Charges,72% of Total Billed Charges,148.2,60,,78.32,Percent of Total Billed Charges,60% of Total Billed Charges,222.3,90,,180.984,Percent of Total Billed Charges,90% of Total Billed Charges,111.15,45,,41.28,Percent of Total Billed Charges,45% of Total Billed Charges,222.3,90,,195.28,Percent of Total Billed Charges,90% of Total billed Charges,247,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.55,65,,35.544,Percent of total Billed Charges,65% of Total Billed Charges,108.93,44.1,,40.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,234.65,95,,206.128,Percent of Total Billed Charges,95% of Total Billed Charges,247,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.36,88,,107.112,Percent of Total Billed Charges,88% of Total Billed Charges,222.3,90,,195.28,Percent of Total Billed charges,90% of Total Billed Charges,108.93,247,
GESTATIONAL DIABETES SCREEN,3010000114,CDM,301,RC,,,Outpatient,,,107.00,69.55,,107,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.32,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.04,72,,94.464,Percent of Total Billed Charges,72% of Total Billed Charges,80.25,75,,98.4,Percent of Total Billed charges,75% of Total Billed Charges,107,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.04,72,,94.464,Percent of Total Billed Charges,72% of Total Billed Charges,64.2,60,,78.72,Percent of Total Billed Charges,60% of Total Billed Charges,96.3,90,,180.984,Percent of Total Billed Charges,90% of Total Billed Charges,48.15,45,,54.776,Percent of Total Billed Charges,45% of Total Billed Charges,96.3,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,107,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.55,65,,178.296,Percent of total Billed Charges,65% of Total Billed Charges,47.19,44.1,,53.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,101.65,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,107,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.16,88,,234.216,Percent of Total Billed Charges,88% of Total Billed Charges,96.3,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,47.19,107,
G6PD QUANT BLOOD,3010000115,CDM,301,RC,,,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,120.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,809.04,Percent of Total Billed Charges,72% of Total Billed Charges,58.71,75,,842.752,Percent of Total Billed charges,75% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,809.04,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,674.2,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,690.608,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,119.768,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,142.888,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,105.04,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,117.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,150.824,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,76.064,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,142.888,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
FSBS GLUCOMETER CHEC,3010000116,CDM,301,RC,,,Outpatient,,,59.54,38.70,,59.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.25,76,,96.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.87,72,,297.832,Percent of Total Billed Charges,72% of Total Billed Charges,44.66,75,,310.24,Percent of Total Billed charges,75% of Total Billed Charges,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.87,72,,297.832,Percent of Total Billed Charges,72% of Total Billed Charges,35.72,60,,248.192,Percent of Total Billed Charges,60% of Total Billed Charges,53.59,90,,109.552,Percent of Total Billed Charges,90% of Total Billed Charges,26.79,45,,38.896,Percent of Total Billed Charges,45% of Total Billed Charges,53.59,90,,113.76,Percent of Total Billed Charges,90% of Total billed Charges,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.7,65,,74.36,Percent of total Billed Charges,65% of Total Billed Charges,26.26,44.1,,38.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,56.56,95,,120.08,Percent of Total Billed Charges,95% of Total Billed Charges,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.4,88,,52.008,Percent of Total Billed Charges,88% of Total Billed Charges,53.59,90,,113.76,Percent of Total Billed charges,90% of Total Billed Charges,26.26,59.54,
GLUCOSE (FS),3010000117,CDM,301,RC,,,Outpatient,,,63.00,40.95,,63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.88,76,,69.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.36,72,,410.872,Percent of Total Billed Charges,72% of Total Billed Charges,47.25,75,,427.992,Percent of Total Billed charges,75% of Total Billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.36,72,,410.872,Percent of Total Billed Charges,72% of Total Billed Charges,37.8,60,,342.392,Percent of Total Billed Charges,60% of Total Billed Charges,56.7,90,,111.568,Percent of Total Billed Charges,90% of Total Billed Charges,28.35,45,,26.592,Percent of Total Billed Charges,45% of Total Billed Charges,56.7,90,,82.552,Percent of Total Billed Charges,90% of Total billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.95,65,,36.688,Percent of total Billed Charges,65% of Total Billed Charges,27.78,44.1,,26.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.85,95,,87.144,Percent of Total Billed Charges,95% of Total Billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.44,88,,517.704,Percent of Total Billed Charges,88% of Total Billed Charges,56.7,90,,82.552,Percent of Total Billed charges,90% of Total Billed Charges,27.78,63,
GGT,3010000118,CDM,301,RC,,,Outpatient,,,96.00,62.40,,96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.96,76,,92.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.12,72,,241.92,Percent of Total Billed Charges,72% of Total Billed Charges,72,75,,252,Percent of Total Billed charges,75% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.12,72,,241.92,Percent of Total Billed Charges,72% of Total Billed Charges,57.6,60,,201.6,Percent of Total Billed Charges,60% of Total Billed Charges,86.4,90,,111.568,Percent of Total Billed Charges,90% of Total Billed Charges,43.2,45,,264.736,Percent of Total Billed Charges,45% of Total Billed Charges,86.4,90,,109.552,Percent of Total Billed Charges,90% of Total billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.4,65,,135.2,Percent of total Billed Charges,65% of Total Billed Charges,42.34,44.1,,259.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.2,95,,115.632,Percent of Total Billed Charges,95% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.48,88,,176.968,Percent of Total Billed Charges,88% of Total Billed Charges,86.4,90,,109.552,Percent of Total Billed charges,90% of Total Billed Charges,42.34,96,
FRUCTOSAMINE,3010000119,CDM,301,RC,,,Outpatient,,,73.87,48.02,,73.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.14,76,,202.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.19,72,,33.656,Percent of Total Billed Charges,72% of Total Billed Charges,55.4,75,,35.056,Percent of Total Billed charges,75% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.19,72,,33.656,Percent of Total Billed Charges,72% of Total Billed Charges,44.32,60,,28.048,Percent of Total Billed Charges,60% of Total Billed Charges,66.48,90,,469.928,Percent of Total Billed Charges,90% of Total Billed Charges,33.24,45,,90.496,Percent of Total Billed Charges,45% of Total Billed Charges,66.48,90,,239.536,Percent of Total Billed Charges,90% of Total billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.02,65,,43.68,Percent of total Billed Charges,65% of Total Billed Charges,32.58,44.1,,88.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,70.18,95,,252.848,Percent of Total Billed Charges,95% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.01,88,,176.968,Percent of Total Billed Charges,88% of Total Billed Charges,66.48,90,,239.536,Percent of Total Billed charges,90% of Total Billed Charges,32.58,73.87,
FSH,3010000120,CDM,301,RC,,,Outpatient,,,115.76,75.24,,115.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.98,76,,65.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,83.35,72,,312.656,Percent of Total Billed Charges,72% of Total Billed Charges,86.82,75,,325.68,Percent of Total Billed charges,75% of Total Billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.35,72,,312.656,Percent of Total Billed Charges,72% of Total Billed Charges,69.46,60,,260.544,Percent of Total Billed Charges,60% of Total Billed Charges,104.18,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,52.09,45,,90.496,Percent of Total Billed Charges,45% of Total Billed Charges,104.18,90,,77.8,Percent of Total Billed Charges,90% of Total billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.24,65,,128.416,Percent of total Billed Charges,65% of Total Billed Charges,51.05,44.1,,88.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,109.97,95,,82.12,Percent of Total Billed Charges,95% of Total Billed Charges,115.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.87,88,,675.264,Percent of Total Billed Charges,88% of Total Billed Charges,104.18,90,,77.8,Percent of Total Billed charges,90% of Total Billed Charges,51.05,115.76,
GROWTH HORMONE (GH),3010000122,CDM,301,RC,,,Outpatient,,,146.63,95.31,,146.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,111.44,76,,44.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,105.57,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,109.97,75,,59.4,Percent of Total Billed charges,75% of Total Billed Charges,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.57,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,87.98,60,,47.52,Percent of Total Billed Charges,60% of Total Billed Charges,131.97,90,,123.12,Percent of Total Billed Charges,90% of Total Billed Charges,65.98,45,,345.304,Percent of Total Billed Charges,45% of Total Billed Charges,131.97,90,,53.184,Percent of Total Billed Charges,90% of Total billed Charges,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.31,65,,49.304,Percent of total Billed Charges,65% of Total Billed Charges,64.66,44.1,,338.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,139.3,95,,56.144,Percent of Total Billed Charges,95% of Total Billed Charges,146.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.03,88,,107.112,Percent of Total Billed Charges,88% of Total Billed Charges,131.97,90,,53.184,Percent of Total Billed charges,90% of Total Billed Charges,64.66,146.63,
HAPTOGLOBIN QUANT,3010000123,CDM,301,RC,,,Outpatient,,,142.22,92.44,,142.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,108.09,76,,447.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,102.4,72,,103.104,Percent of Total Billed Charges,72% of Total Billed Charges,106.67,75,,107.4,Percent of Total Billed charges,75% of Total Billed Charges,142.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.4,72,,103.104,Percent of Total Billed Charges,72% of Total Billed Charges,85.33,60,,85.92,Percent of Total Billed Charges,60% of Total Billed Charges,128,90,,92.08,Percent of Total Billed Charges,90% of Total Billed Charges,64,45,,54.776,Percent of Total Billed Charges,45% of Total Billed Charges,128,90,,529.464,Percent of Total Billed Charges,90% of Total billed Charges,142.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.44,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,62.72,44.1,,53.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,135.11,95,,558.88,Percent of Total Billed Charges,95% of Total Billed Charges,142.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.15,88,,109.088,Percent of Total Billed Charges,88% of Total Billed Charges,128,90,,529.464,Percent of Total Billed charges,90% of Total Billed Charges,62.72,142.22,
METALS SCREENURINE,3010000124,CDM,301,RC,,,Outpatient,,,328.55,213.56,,328.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,249.7,76,,152.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,236.56,72,,386.736,Percent of Total Billed Charges,72% of Total Billed Charges,246.41,75,,402.856,Percent of Total Billed charges,75% of Total Billed Charges,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.56,72,,386.736,Percent of Total Billed Charges,72% of Total Billed Charges,197.13,60,,322.28,Percent of Total Billed Charges,60% of Total Billed Charges,295.7,90,,92.08,Percent of Total Billed Charges,90% of Total Billed Charges,147.85,45,,55.784,Percent of Total Billed Charges,45% of Total Billed Charges,295.7,90,,180.984,Percent of Total Billed Charges,90% of Total billed Charges,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.56,65,,144.04,Percent of total Billed Charges,65% of Total Billed Charges,144.89,44.1,,54.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,312.12,95,,191.04,Percent of Total Billed Charges,95% of Total Billed Charges,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.12,88,,109.088,Percent of Total Billed Charges,88% of Total Billed Charges,295.7,90,,180.984,Percent of Total Billed charges,90% of Total Billed Charges,144.89,328.55,
METAL SCREEN/HEAVYS,3010000125,CDM,301,RC,,,Outpatient,,,328.55,213.56,,328.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,249.7,76,,152.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,236.56,72,,141.56,Percent of Total Billed Charges,72% of Total Billed Charges,246.41,75,,147.464,Percent of Total Billed charges,75% of Total Billed Charges,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.56,72,,141.56,Percent of Total Billed Charges,72% of Total Billed Charges,197.13,60,,117.968,Percent of Total Billed Charges,60% of Total Billed Charges,295.7,90,,92.08,Percent of Total Billed Charges,90% of Total Billed Charges,147.85,45,,55.784,Percent of Total Billed Charges,45% of Total Billed Charges,295.7,90,,180.984,Percent of Total Billed Charges,90% of Total billed Charges,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.56,65,,63.64,Percent of total Billed Charges,65% of Total Billed Charges,144.89,44.1,,54.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,312.12,95,,191.04,Percent of Total Billed Charges,95% of Total Billed Charges,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.12,88,,459.488,Percent of Total Billed Charges,88% of Total Billed Charges,295.7,90,,180.984,Percent of Total Billed charges,90% of Total Billed Charges,144.89,328.55,
HGB ELECTROPHORESIS,3010000126,CDM,301,RC,,,Outpatient,,,157.66,102.48,,157.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,119.82,76,,583.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,113.52,72,,286.56,Percent of Total Billed Charges,72% of Total Billed Charges,118.25,75,,298.504,Percent of Total Billed charges,75% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.52,72,,286.56,Percent of Total Billed Charges,72% of Total Billed Charges,94.6,60,,238.8,Percent of Total Billed Charges,60% of Total Billed Charges,141.89,90,,92.08,Percent of Total Billed Charges,90% of Total Billed Charges,70.95,45,,234.968,Percent of Total Billed Charges,45% of Total Billed Charges,141.89,90,,690.608,Percent of Total Billed Charges,90% of Total billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.48,65,,94.592,Percent of total Billed Charges,65% of Total Billed Charges,69.53,44.1,,230.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,149.78,95,,728.976,Percent of Total Billed Charges,95% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.74,88,,40.128,Percent of Total Billed Charges,88% of Total Billed Charges,141.89,90,,690.608,Percent of Total Billed charges,90% of Total Billed Charges,69.53,157.66,
HAIC,3010000127,CDM,301,RC,,,Outpatient,,,202.00,131.30,,202,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,153.52,76,,92.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,145.44,72,,31.608,Percent of Total Billed Charges,72% of Total Billed Charges,151.5,75,,32.928,Percent of Total Billed charges,75% of Total Billed Charges,202,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.44,72,,31.608,Percent of Total Billed Charges,72% of Total Billed Charges,121.2,60,,26.344,Percent of Total Billed Charges,60% of Total Billed Charges,181.8,90,,92.08,Percent of Total Billed Charges,90% of Total Billed Charges,90.9,45,,20.52,Percent of Total Billed Charges,45% of Total Billed Charges,181.8,90,,109.552,Percent of Total Billed Charges,90% of Total billed Charges,202,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.3,65,,99.176,Percent of total Billed Charges,65% of Total Billed Charges,89.08,44.1,,20.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,191.9,95,,115.632,Percent of Total Billed Charges,95% of Total Billed Charges,202,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.76,88,,120.384,Percent of Total Billed Charges,88% of Total Billed Charges,181.8,90,,109.552,Percent of Total Billed charges,90% of Total Billed Charges,89.08,202,
HIAA,3010000129,CDM,301,RC,,,Outpatient,,,278.93,181.30,,278.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,211.99,76,,94.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,200.83,72,,15.712,Percent of Total Billed Charges,72% of Total Billed Charges,209.2,75,,16.368,Percent of Total Billed charges,75% of Total Billed Charges,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.83,72,,15.712,Percent of Total Billed Charges,72% of Total Billed Charges,167.36,60,,13.096,Percent of Total Billed Charges,60% of Total Billed Charges,251.04,90,,85.728,Percent of Total Billed Charges,90% of Total Billed Charges,125.52,45,,61.56,Percent of Total Billed Charges,45% of Total Billed Charges,251.04,90,,111.568,Percent of Total Billed Charges,90% of Total billed Charges,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.3,65,,49.304,Percent of total Billed Charges,65% of Total Billed Charges,123.01,44.1,,60.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,264.98,95,,117.76,Percent of Total Billed Charges,95% of Total Billed Charges,278.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.46,88,,90.032,Percent of Total Billed Charges,88% of Total Billed Charges,251.04,90,,111.568,Percent of Total Billed charges,90% of Total Billed Charges,123.01,278.93,
17HYDROXYPROGESTRON,3010000130,CDM,301,RC,,,Outpatient,,,120.17,78.11,,120.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,91.33,76,,94.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,86.52,72,,20.848,Percent of Total Billed Charges,72% of Total Billed Charges,90.13,75,,21.72,Percent of Total Billed charges,75% of Total Billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.52,72,,20.848,Percent of Total Billed Charges,72% of Total Billed Charges,72.1,60,,17.376,Percent of Total Billed Charges,60% of Total Billed Charges,108.15,90,,168.288,Percent of Total Billed Charges,90% of Total Billed Charges,54.08,45,,46.04,Percent of Total Billed Charges,45% of Total Billed Charges,108.15,90,,111.568,Percent of Total Billed Charges,90% of Total billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.11,65,,38.416,Percent of total Billed Charges,65% of Total Billed Charges,52.99,44.1,,45.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,114.16,95,,117.76,Percent of Total Billed Charges,95% of Total Billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.75,88,,90.032,Percent of Total Billed Charges,88% of Total Billed Charges,108.15,90,,111.568,Percent of Total Billed charges,90% of Total Billed Charges,52.99,120.17,
TISSUE TRANSGLUTAMIN,3010000131,CDM,301,RC,,,Outpatient,,,294.37,191.34,,294.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,223.72,76,,396.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,211.95,72,,66.72,Percent of Total Billed Charges,72% of Total Billed Charges,220.78,75,,69.504,Percent of Total Billed charges,75% of Total Billed Charges,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.95,72,,66.72,Percent of Total Billed Charges,72% of Total Billed Charges,176.62,60,,55.6,Percent of Total Billed Charges,60% of Total Billed Charges,264.93,90,,156.232,Percent of Total Billed Charges,90% of Total Billed Charges,132.47,45,,46.04,Percent of Total Billed Charges,45% of Total Billed Charges,264.93,90,,469.928,Percent of Total Billed Charges,90% of Total billed Charges,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.34,65,,247.664,Percent of total Billed Charges,65% of Total Billed Charges,129.82,44.1,,45.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,279.65,95,,496.04,Percent of Total Billed Charges,95% of Total Billed Charges,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.05,88,,90.032,Percent of Total Billed Charges,88% of Total Billed Charges,264.93,90,,469.928,Percent of Total Billed charges,90% of Total Billed Charges,129.82,294.37,
TTG IGA,3010000132,CDM,301,RC,,,Outpatient,,,294.37,191.34,,294.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,223.72,76,,34.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,211.95,72,,52.992,Percent of Total Billed Charges,72% of Total Billed Charges,220.78,75,,55.2,Percent of Total Billed charges,75% of Total Billed Charges,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.95,72,,52.992,Percent of Total Billed Charges,72% of Total Billed Charges,176.62,60,,44.16,Percent of Total Billed Charges,60% of Total Billed Charges,264.93,90,,116.64,Percent of Total Billed Charges,90% of Total Billed Charges,132.47,45,,46.04,Percent of Total Billed Charges,45% of Total Billed Charges,264.93,90,,41.04,Percent of Total Billed Charges,90% of Total billed Charges,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.34,65,,247.664,Percent of total Billed Charges,65% of Total Billed Charges,129.82,44.1,,45.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,279.65,95,,43.32,Percent of Total Billed Charges,95% of Total Billed Charges,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.05,88,,90.032,Percent of Total Billed Charges,88% of Total Billed Charges,264.93,90,,41.04,Percent of Total Billed charges,90% of Total Billed Charges,129.82,294.37,
TTG IGG IGA,3010000133,CDM,301,RC,,,Outpatient,,,294.37,191.34,,294.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,223.72,76,,103.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,211.95,72,,105.984,Percent of Total Billed Charges,72% of Total Billed Charges,220.78,75,,110.4,Percent of Total Billed charges,75% of Total Billed Charges,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.95,72,,105.984,Percent of Total Billed Charges,72% of Total Billed Charges,176.62,60,,88.32,Percent of Total Billed Charges,60% of Total Billed Charges,264.93,90,,119.072,Percent of Total Billed Charges,90% of Total Billed Charges,132.47,45,,46.04,Percent of Total Billed Charges,45% of Total Billed Charges,264.93,90,,123.12,Percent of Total Billed Charges,90% of Total billed Charges,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.34,65,,98.28,Percent of total Billed Charges,65% of Total Billed Charges,129.82,44.1,,45.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,279.65,95,,129.96,Percent of Total Billed Charges,95% of Total Billed Charges,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.05,88,,90.032,Percent of Total Billed Charges,88% of Total Billed Charges,264.93,90,,123.12,Percent of Total Billed charges,90% of Total Billed Charges,129.82,294.37,
ANTIPARIETAL AB,3010000134,CDM,301,RC,,,Outpatient,,,294.37,191.34,,294.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,223.72,76,,77.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,211.95,72,,63.936,Percent of Total Billed Charges,72% of Total Billed Charges,220.78,75,,66.6,Percent of Total Billed charges,75% of Total Billed Charges,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.95,72,,63.936,Percent of Total Billed Charges,72% of Total Billed Charges,176.62,60,,53.28,Percent of Total Billed Charges,60% of Total Billed Charges,264.93,90,,53.976,Percent of Total Billed Charges,90% of Total Billed Charges,132.47,45,,46.04,Percent of Total Billed Charges,45% of Total Billed Charges,264.93,90,,92.08,Percent of Total Billed Charges,90% of Total billed Charges,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.34,65,,93.448,Percent of total Billed Charges,65% of Total Billed Charges,129.82,44.1,,45.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,279.65,95,,97.2,Percent of Total Billed Charges,95% of Total Billed Charges,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.05,88,,83.824,Percent of Total Billed Charges,88% of Total Billed Charges,264.93,90,,92.08,Percent of Total Billed charges,90% of Total Billed Charges,129.82,294.37,
GROWTH HORMONE RELEA,3010000135,CDM,301,RC,,,Outpatient,,,612.99,398.44,,612.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.87,76,,77.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,441.35,72,,21.312,Percent of Total Billed Charges,72% of Total Billed Charges,459.74,75,,22.2,Percent of Total Billed charges,75% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,441.35,72,,21.312,Percent of Total Billed Charges,72% of Total Billed Charges,367.79,60,,17.76,Percent of Total Billed Charges,60% of Total Billed Charges,551.69,90,,53.976,Percent of Total Billed Charges,90% of Total Billed Charges,275.85,45,,42.864,Percent of Total Billed Charges,45% of Total Billed Charges,551.69,90,,92.08,Percent of Total Billed Charges,90% of Total billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.44,65,,93.448,Percent of total Billed Charges,65% of Total Billed Charges,270.33,44.1,,42.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,582.34,95,,97.2,Percent of Total Billed Charges,95% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,539.43,88,,164.544,Percent of Total Billed Charges,88% of Total Billed Charges,551.69,90,,92.08,Percent of Total Billed charges,90% of Total Billed Charges,270.33,612.99,
PTHRELATED PROTIEN,3010000136,CDM,301,RC,,,Outpatient,,,612.99,398.44,,612.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.87,76,,77.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,441.35,72,,59.056,Percent of Total Billed Charges,72% of Total Billed Charges,459.74,75,,61.52,Percent of Total Billed charges,75% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,441.35,72,,59.056,Percent of Total Billed Charges,72% of Total Billed Charges,367.79,60,,49.216,Percent of Total Billed Charges,60% of Total Billed Charges,551.69,90,,53.976,Percent of Total Billed Charges,90% of Total Billed Charges,275.85,45,,84.144,Percent of Total Billed Charges,45% of Total Billed Charges,551.69,90,,92.08,Percent of Total Billed Charges,90% of Total billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.44,65,,93.448,Percent of total Billed Charges,65% of Total Billed Charges,270.33,44.1,,82.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,582.34,95,,97.2,Percent of Total Billed Charges,95% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,539.43,88,,152.76,Percent of Total Billed Charges,88% of Total Billed Charges,551.69,90,,92.08,Percent of Total Billed charges,90% of Total Billed Charges,270.33,612.99,
ACETYL RECEPT BINDIN,3010000137,CDM,301,RC,,,Outpatient,,,612.99,398.44,,612.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.87,76,,77.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,441.35,72,,13.824,Percent of Total Billed Charges,72% of Total Billed Charges,459.74,75,,14.4,Percent of Total Billed charges,75% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,441.35,72,,13.824,Percent of Total Billed Charges,72% of Total Billed Charges,367.79,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,551.69,90,,361.976,Percent of Total Billed Charges,90% of Total Billed Charges,275.85,45,,78.12,Percent of Total Billed Charges,45% of Total Billed Charges,551.69,90,,92.08,Percent of Total Billed Charges,90% of Total billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.44,65,,172.56,Percent of total Billed Charges,65% of Total Billed Charges,270.33,44.1,,76.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,582.34,95,,97.2,Percent of Total Billed Charges,95% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,539.43,88,,114.048,Percent of Total Billed Charges,88% of Total Billed Charges,551.69,90,,92.08,Percent of Total Billed charges,90% of Total Billed Charges,270.33,612.99,
ACETYL RECEPT MODUL,3010000138,CDM,301,RC,,,Outpatient,,,612.99,398.44,,612.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.87,76,,77.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,441.35,72,,244.8,Percent of Total Billed Charges,72% of Total Billed Charges,459.74,75,,255,Percent of Total Billed charges,75% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,441.35,72,,244.8,Percent of Total Billed Charges,72% of Total Billed Charges,367.79,60,,204,Percent of Total Billed Charges,60% of Total Billed Charges,551.69,90,,112.32,Percent of Total Billed Charges,90% of Total Billed Charges,275.85,45,,58.32,Percent of Total Billed Charges,45% of Total Billed Charges,551.69,90,,92.08,Percent of Total Billed Charges,90% of Total billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.44,65,,76.824,Percent of total Billed Charges,65% of Total Billed Charges,270.33,44.1,,57.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,582.34,95,,97.2,Percent of Total Billed Charges,95% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,539.43,88,,116.424,Percent of Total Billed Charges,88% of Total Billed Charges,551.69,90,,92.08,Percent of Total Billed charges,90% of Total Billed Charges,270.33,612.99,
ACETYL RECEPT BLOCK,3010000139,CDM,301,RC,,,Outpatient,,,612.99,398.44,,612.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.87,76,,72.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,441.35,72,,148.032,Percent of Total Billed Charges,72% of Total Billed Charges,459.74,75,,154.2,Percent of Total Billed charges,75% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,441.35,72,,148.032,Percent of Total Billed Charges,72% of Total Billed Charges,367.79,60,,123.36,Percent of Total Billed Charges,60% of Total Billed Charges,551.69,90,,49.216,Percent of Total Billed Charges,90% of Total Billed Charges,275.85,45,,59.536,Percent of Total Billed Charges,45% of Total Billed Charges,551.69,90,,85.728,Percent of Total Billed Charges,90% of Total billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.44,65,,63.64,Percent of total Billed Charges,65% of Total Billed Charges,270.33,44.1,,58.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,582.34,95,,90.496,Percent of Total Billed Charges,95% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,539.43,88,,52.776,Percent of Total Billed Charges,88% of Total Billed Charges,551.69,90,,85.728,Percent of Total Billed charges,90% of Total Billed Charges,270.33,612.99,
IGF BINDING PROT1,3010000140,CDM,301,RC,,,Outpatient,,,612.99,398.44,,612.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.87,76,,142.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,441.35,72,,106.56,Percent of Total Billed Charges,72% of Total Billed Charges,459.74,75,,111,Percent of Total Billed charges,75% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,441.35,72,,106.56,Percent of Total Billed Charges,72% of Total Billed Charges,367.79,60,,88.8,Percent of Total Billed Charges,60% of Total Billed Charges,551.69,90,,246.872,Percent of Total Billed Charges,90% of Total Billed Charges,275.85,45,,26.992,Percent of Total Billed Charges,45% of Total Billed Charges,551.69,90,,168.288,Percent of Total Billed Charges,90% of Total billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.44,65,,56.184,Percent of total Billed Charges,65% of Total Billed Charges,270.33,44.1,,26.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,582.34,95,,177.632,Percent of Total Billed Charges,95% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,539.43,88,,52.776,Percent of Total Billed Charges,88% of Total Billed Charges,551.69,90,,168.288,Percent of Total Billed charges,90% of Total Billed Charges,270.33,612.99,
ANALYTE  IMMUNOASSAY,3010000141,CDM,301,RC,,,Outpatient,,,612.99,398.44,,612.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.87,76,,131.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,441.35,72,,69.12,Percent of Total Billed Charges,72% of Total Billed Charges,459.74,75,,72,Percent of Total Billed charges,75% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,441.35,72,,69.12,Percent of Total Billed Charges,72% of Total Billed Charges,367.79,60,,57.6,Percent of Total Billed Charges,60% of Total Billed Charges,551.69,90,,145.44,Percent of Total Billed Charges,90% of Total Billed Charges,275.85,45,,26.992,Percent of Total Billed Charges,45% of Total Billed Charges,551.69,90,,156.232,Percent of Total Billed Charges,90% of Total billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.44,65,,56.184,Percent of total Billed Charges,65% of Total Billed Charges,270.33,44.1,,26.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,582.34,95,,164.912,Percent of Total Billed Charges,95% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,539.43,88,,52.776,Percent of Total Billed Charges,88% of Total Billed Charges,551.69,90,,156.232,Percent of Total Billed charges,90% of Total Billed Charges,270.33,612.99,
THRROTROPIN BINDING,3010000142,CDM,301,RC,,,Outpatient,,,612.99,398.44,,612.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.87,76,,98.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,441.35,72,,518.4,Percent of Total Billed Charges,72% of Total Billed Charges,459.74,75,,540,Percent of Total Billed charges,75% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,441.35,72,,518.4,Percent of Total Billed Charges,72% of Total Billed Charges,367.79,60,,432,Percent of Total Billed Charges,60% of Total Billed Charges,551.69,90,,102.96,Percent of Total Billed Charges,90% of Total Billed Charges,275.85,45,,26.992,Percent of Total Billed Charges,45% of Total Billed Charges,551.69,90,,116.64,Percent of Total Billed Charges,90% of Total billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.44,65,,16.744,Percent of total Billed Charges,65% of Total Billed Charges,270.33,44.1,,26.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,582.34,95,,123.12,Percent of Total Billed Charges,95% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,539.43,88,,353.928,Percent of Total Billed Charges,88% of Total Billed Charges,551.69,90,,116.64,Percent of Total Billed charges,90% of Total Billed Charges,270.33,612.99,
ANTIMULLERIAN HORMO,3010000143,CDM,301,RC,,,Outpatient,,,577.71,375.51,,577.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,439.06,76,,100.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.95,72,,144.152,Percent of Total Billed Charges,72% of Total Billed Charges,433.28,75,,150.16,Percent of Total Billed charges,75% of Total Billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.95,72,,144.152,Percent of Total Billed Charges,72% of Total Billed Charges,346.63,60,,120.128,Percent of Total Billed Charges,60% of Total Billed Charges,519.94,90,,50.8,Percent of Total Billed Charges,90% of Total Billed Charges,259.97,45,,180.984,Percent of Total Billed Charges,45% of Total Billed Charges,519.94,90,,119.072,Percent of Total Billed Charges,90% of Total billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.51,65,,57.88,Percent of total Billed Charges,65% of Total Billed Charges,254.77,44.1,,177.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,548.82,95,,125.688,Percent of Total Billed Charges,95% of Total Billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.38,88,,109.824,Percent of Total Billed Charges,88% of Total Billed Charges,519.94,90,,119.072,Percent of Total Billed charges,90% of Total Billed Charges,254.77,577.71,
INSULIN TOTAL,3010000144,CDM,301,RC,,,Outpatient,,,174.20,113.23,,174.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,132.39,76,,45.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,125.42,72,,140.984,Percent of Total Billed Charges,72% of Total Billed Charges,130.65,75,,146.856,Percent of Total Billed charges,75% of Total Billed Charges,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.42,72,,140.984,Percent of Total Billed Charges,72% of Total Billed Charges,104.52,60,,117.488,Percent of Total Billed Charges,60% of Total Billed Charges,156.78,90,,187.2,Percent of Total Billed Charges,90% of Total Billed Charges,78.39,45,,56.16,Percent of Total Billed Charges,45% of Total Billed Charges,156.78,90,,53.976,Percent of Total Billed Charges,90% of Total billed Charges,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.23,65,,22.36,Percent of total Billed Charges,65% of Total Billed Charges,76.82,44.1,,55.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,165.49,95,,56.976,Percent of Total Billed Charges,95% of Total Billed Charges,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.3,88,,48.128,Percent of Total Billed Charges,88% of Total Billed Charges,156.78,90,,53.976,Percent of Total Billed charges,90% of Total Billed Charges,76.82,174.2,
IRON SERUM,3010000145,CDM,301,RC,,,Outpatient,,,94.00,61.10,,94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,71.44,76,,45.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,67.68,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,70.5,75,,54,Percent of Total Billed charges,75% of Total Billed Charges,94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.68,72,,51.84,Percent of Total Billed Charges,72% of Total Billed Charges,56.4,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,84.6,90,,60.48,Percent of Total Billed Charges,90% of Total Billed Charges,42.3,45,,24.608,Percent of Total Billed Charges,45% of Total Billed Charges,84.6,90,,53.976,Percent of Total Billed Charges,90% of Total billed Charges,94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.1,65,,100.904,Percent of total Billed Charges,65% of Total Billed Charges,41.45,44.1,,24.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,89.3,95,,56.976,Percent of Total Billed Charges,95% of Total Billed Charges,94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.72,88,,241.384,Percent of Total Billed Charges,88% of Total Billed Charges,84.6,90,,53.976,Percent of Total Billed charges,90% of Total Billed Charges,41.45,94,
TIBC,3010000146,CDM,301,RC,,,Outpatient,,,305.00,198.25,,305,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,231.8,76,,45.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,219.6,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,228.75,75,,94.6,Percent of Total Billed charges,75% of Total Billed Charges,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.6,72,,90.816,Percent of Total Billed Charges,72% of Total Billed Charges,183,60,,75.68,Percent of Total Billed Charges,60% of Total Billed Charges,274.5,90,,177.808,Percent of Total Billed Charges,90% of Total Billed Charges,137.25,45,,123.44,Percent of Total Billed Charges,45% of Total Billed Charges,274.5,90,,53.976,Percent of Total Billed Charges,90% of Total billed Charges,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.25,65,,138.32,Percent of total Billed Charges,65% of Total Billed Charges,134.51,44.1,,120.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,289.75,95,,56.976,Percent of Total Billed Charges,95% of Total Billed Charges,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.4,88,,142.208,Percent of Total Billed Charges,88% of Total Billed Charges,274.5,90,,53.976,Percent of Total Billed charges,90% of Total Billed Charges,134.51,305,
LACTATE ACID (LACTIC,3010000147,CDM,301,RC,,,Outpatient,,,114.00,74.10,,114,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,86.64,76,,305.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.08,72,,470.592,Percent of Total Billed Charges,72% of Total Billed Charges,85.5,75,,490.2,Percent of Total Billed charges,75% of Total Billed Charges,114,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.08,72,,470.592,Percent of Total Billed Charges,72% of Total Billed Charges,68.4,60,,392.16,Percent of Total Billed Charges,60% of Total Billed Charges,102.6,90,,68.272,Percent of Total Billed Charges,90% of Total Billed Charges,51.3,45,,72.72,Percent of Total Billed Charges,45% of Total Billed Charges,102.6,90,,361.976,Percent of Total Billed Charges,90% of Total billed Charges,114,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.1,65,,14.64,Percent of total Billed Charges,65% of Total Billed Charges,50.27,44.1,,71.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,108.3,95,,382.08,Percent of Total Billed Charges,95% of Total Billed Charges,114,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.32,88,,100.672,Percent of Total Billed Charges,88% of Total Billed Charges,102.6,90,,361.976,Percent of Total Billed charges,90% of Total Billed Charges,50.27,114,
LDH,3010000148,CDM,301,RC,,,Outpatient,,,81.00,52.65,,81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,61.56,76,,94.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,58.32,72,,434.88,Percent of Total Billed Charges,72% of Total Billed Charges,60.75,75,,453,Percent of Total Billed charges,75% of Total Billed Charges,81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.32,72,,434.88,Percent of Total Billed Charges,72% of Total Billed Charges,48.6,60,,362.4,Percent of Total Billed Charges,60% of Total Billed Charges,72.9,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,36.45,45,,51.48,Percent of Total Billed Charges,45% of Total Billed Charges,72.9,90,,112.32,Percent of Total Billed Charges,90% of Total billed Charges,81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.65,65,,24.656,Percent of total Billed Charges,65% of Total Billed Charges,35.72,44.1,,50.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,76.95,95,,118.56,Percent of Total Billed Charges,95% of Total Billed Charges,81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.28,88,,49.672,Percent of Total Billed Charges,88% of Total Billed Charges,72.9,90,,112.32,Percent of Total Billed charges,90% of Total Billed Charges,35.72,81,
LD  PERITONEAL FLUID,3010000150,CDM,301,RC,,,Outpatient,,,77.18,50.17,,77.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.66,76,,41.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.57,72,,440.64,Percent of Total Billed Charges,72% of Total Billed Charges,57.89,75,,459,Percent of Total Billed charges,75% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.57,72,,440.64,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,60,,367.2,Percent of Total Billed Charges,60% of Total Billed Charges,69.46,90,,199.44,Percent of Total Billed Charges,90% of Total Billed Charges,34.73,45,,25.4,Percent of Total Billed Charges,45% of Total Billed Charges,69.46,90,,49.216,Percent of Total Billed Charges,90% of Total billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.17,65,,32.24,Percent of total Billed Charges,65% of Total Billed Charges,34.04,44.1,,24.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.32,95,,51.952,Percent of Total Billed Charges,95% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.92,88,,183.04,Percent of Total Billed Charges,88% of Total Billed Charges,69.46,90,,49.216,Percent of Total Billed charges,90% of Total Billed Charges,34.04,77.18,
LD  SYNOVIAL FLUID,3010000151,CDM,301,RC,,,Outpatient,,,77.18,50.17,,77.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.66,76,,208.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.57,72,,120.384,Percent of Total Billed Charges,72% of Total Billed Charges,57.89,75,,125.4,Percent of Total Billed charges,75% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.57,72,,120.384,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,60,,100.32,Percent of Total Billed Charges,60% of Total Billed Charges,69.46,90,,88.112,Percent of Total Billed Charges,90% of Total Billed Charges,34.73,45,,93.6,Percent of Total Billed Charges,45% of Total Billed Charges,69.46,90,,246.872,Percent of Total Billed Charges,90% of Total billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.17,65,,32.24,Percent of total Billed Charges,65% of Total Billed Charges,34.04,44.1,,91.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.32,95,,260.592,Percent of Total Billed Charges,95% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.92,88,,59.136,Percent of Total Billed Charges,88% of Total Billed Charges,69.46,90,,246.872,Percent of Total Billed charges,90% of Total Billed Charges,34.04,77.18,
LD CSF FLUID,3010000152,CDM,301,RC,,,Outpatient,,,77.18,50.17,,77.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.66,76,,122.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.57,72,,107.136,Percent of Total Billed Charges,72% of Total Billed Charges,57.89,75,,111.6,Percent of Total Billed charges,75% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.57,72,,107.136,Percent of Total Billed Charges,72% of Total Billed Charges,46.31,60,,89.28,Percent of Total Billed Charges,60% of Total Billed Charges,69.46,90,,130.976,Percent of Total Billed Charges,90% of Total Billed Charges,34.73,45,,30.24,Percent of Total Billed Charges,45% of Total Billed Charges,69.46,90,,145.44,Percent of Total Billed Charges,90% of Total billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.17,65,,89.96,Percent of total Billed Charges,65% of Total Billed Charges,34.04,44.1,,29.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.32,95,,153.52,Percent of Total Billed Charges,95% of Total Billed Charges,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.92,88,,173.856,Percent of Total Billed Charges,88% of Total Billed Charges,69.46,90,,145.44,Percent of Total Billed charges,90% of Total Billed Charges,34.04,77.18,
LEUKO EZ VUE FECAL WBC QUAL,3010000153,CDM,301,RC,,,Outpatient,,,70.00,45.50,,70,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.2,76,,86.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.4,72,,60.328,Percent of Total Billed Charges,72% of Total Billed Charges,52.5,75,,62.848,Percent of Total Billed charges,75% of Total Billed Charges,70,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.4,72,,60.328,Percent of Total Billed Charges,72% of Total Billed Charges,42,60,,50.272,Percent of Total Billed Charges,60% of Total Billed Charges,63,90,,137.328,Percent of Total Billed Charges,90% of Total Billed Charges,31.5,45,,88.904,Percent of Total Billed Charges,45% of Total Billed Charges,63,90,,102.96,Percent of Total Billed Charges,90% of Total billed Charges,70,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.5,65,,48.16,Percent of total Billed Charges,65% of Total Billed Charges,30.87,44.1,,87.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,66.5,95,,108.68,Percent of Total Billed Charges,95% of Total Billed Charges,70,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.6,88,,66.752,Percent of Total Billed Charges,88% of Total Billed Charges,63,90,,102.96,Percent of Total Billed charges,90% of Total Billed Charges,30.87,70,
LEAD BLOOD,3010000154,CDM,301,RC,,,Outpatient,,,59.54,38.70,,59.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.25,76,,42.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.87,72,,76.032,Percent of Total Billed Charges,72% of Total Billed Charges,44.66,75,,79.2,Percent of Total Billed charges,75% of Total Billed Charges,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.87,72,,76.032,Percent of Total Billed Charges,72% of Total Billed Charges,35.72,60,,63.36,Percent of Total Billed Charges,60% of Total Billed Charges,53.59,90,,68.272,Percent of Total Billed Charges,90% of Total Billed Charges,26.79,45,,34.136,Percent of Total Billed Charges,45% of Total Billed Charges,53.59,90,,50.8,Percent of Total Billed Charges,90% of Total billed Charges,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.7,65,,45.76,Percent of total Billed Charges,65% of Total Billed Charges,26.26,44.1,,33.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,56.56,95,,53.624,Percent of Total Billed Charges,95% of Total Billed Charges,59.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.4,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,53.59,90,,50.8,Percent of Total Billed charges,90% of Total Billed Charges,26.26,59.54,
LIPASE,3010000155,CDM,301,RC,,,Outpatient,,,248.00,161.20,,248,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,188.48,76,,158.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,178.56,72,,24.192,Percent of Total Billed Charges,72% of Total Billed Charges,186,75,,25.2,Percent of Total Billed charges,75% of Total Billed Charges,248,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.56,72,,24.192,Percent of Total Billed Charges,72% of Total Billed Charges,148.8,60,,20.16,Percent of Total Billed Charges,60% of Total Billed Charges,223.2,90,,53.184,Percent of Total Billed Charges,90% of Total Billed Charges,111.6,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,223.2,90,,187.2,Percent of Total Billed Charges,90% of Total billed Charges,248,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.2,65,,22.88,Percent of total Billed Charges,65% of Total Billed Charges,109.37,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,235.6,95,,197.6,Percent of Total Billed Charges,95% of Total Billed Charges,248,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.24,88,,195.008,Percent of Total Billed Charges,88% of Total Billed Charges,223.2,90,,187.2,Percent of Total Billed charges,90% of Total Billed Charges,109.37,248,
LIPASE PLEURAL FLUID,3010000156,CDM,301,RC,,,Outpatient,,,235.94,153.36,,235.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,179.31,76,,51.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,169.88,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,176.96,75,,90,Percent of Total Billed charges,75% of Total Billed Charges,235.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.88,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,141.56,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,212.35,90,,342.92,Percent of Total Billed Charges,90% of Total Billed Charges,106.17,45,,99.72,Percent of Total Billed Charges,45% of Total Billed Charges,212.35,90,,60.48,Percent of Total Billed Charges,90% of Total billed Charges,235.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.36,65,,29.12,Percent of total Billed Charges,65% of Total Billed Charges,104.05,44.1,,97.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,224.14,95,,63.84,Percent of Total Billed Charges,95% of Total Billed Charges,235.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.63,88,,86.152,Percent of Total Billed Charges,88% of Total Billed Charges,212.35,90,,60.48,Percent of Total Billed charges,90% of Total Billed Charges,104.05,235.94,
LIPASE PERITONEAL FLUID,3010000157,CDM,301,RC,,,Outpatient,,,235.94,153.36,,235.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,179.31,76,,150.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,169.88,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,176.96,75,,150,Percent of Total Billed charges,75% of Total Billed Charges,235.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.88,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,141.56,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,212.35,90,,342.92,Percent of Total Billed Charges,90% of Total Billed Charges,106.17,45,,44.056,Percent of Total Billed Charges,45% of Total Billed Charges,212.35,90,,177.808,Percent of Total Billed Charges,90% of Total billed Charges,235.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.36,65,,126.696,Percent of total Billed Charges,65% of Total Billed Charges,104.05,44.1,,43.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,224.14,95,,187.688,Percent of Total Billed Charges,95% of Total Billed Charges,235.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.63,88,,128.064,Percent of Total Billed Charges,88% of Total Billed Charges,212.35,90,,177.808,Percent of Total Billed charges,90% of Total Billed Charges,104.05,235.94,
NMR FRACTIONATION OF,3010000158,CDM,301,RC,,,Outpatient,,,131.20,85.28,,131.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,99.71,76,,57.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,94.46,72,,56.736,Percent of Total Billed Charges,72% of Total Billed Charges,98.4,75,,59.104,Percent of Total Billed charges,75% of Total Billed Charges,131.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.46,72,,56.736,Percent of Total Billed Charges,72% of Total Billed Charges,78.72,60,,47.28,Percent of Total Billed Charges,60% of Total Billed Charges,118.08,90,,136.08,Percent of Total Billed Charges,90% of Total Billed Charges,59.04,45,,65.488,Percent of Total Billed Charges,45% of Total Billed Charges,118.08,90,,68.272,Percent of Total Billed Charges,90% of Total billed Charges,131.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.28,65,,126.696,Percent of total Billed Charges,65% of Total Billed Charges,57.86,44.1,,64.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,124.64,95,,72.064,Percent of Total Billed Charges,95% of Total Billed Charges,131.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.46,88,,134.272,Percent of Total Billed Charges,88% of Total Billed Charges,118.08,90,,68.272,Percent of Total Billed charges,90% of Total Billed Charges,57.86,131.2,
CHOLESTEROL HDL,3010000159,CDM,301,RC,,,Outpatient,,,73.87,48.02,,73.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.14,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.19,72,,107.32,Percent of Total Billed Charges,72% of Total Billed Charges,55.4,75,,111.792,Percent of Total Billed charges,75% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.19,72,,107.32,Percent of Total Billed Charges,72% of Total Billed Charges,44.32,60,,89.432,Percent of Total Billed Charges,60% of Total Billed Charges,66.48,90,,129.392,Percent of Total Billed Charges,90% of Total Billed Charges,33.24,45,,68.664,Percent of Total Billed Charges,45% of Total Billed Charges,66.48,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.02,65,,126.696,Percent of total Billed Charges,65% of Total Billed Charges,32.58,44.1,,67.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,70.18,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.01,88,,66.752,Percent of Total Billed Charges,88% of Total Billed Charges,66.48,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,32.58,73.87,
DIRECT LDL,3010000160,CDM,301,RC,,,Outpatient,,,67.25,43.71,,67.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.11,76,,168.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,48.42,72,,332.76,Percent of Total Billed Charges,72% of Total Billed Charges,50.44,75,,346.624,Percent of Total Billed charges,75% of Total Billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.42,72,,332.76,Percent of Total Billed Charges,72% of Total Billed Charges,40.35,60,,277.304,Percent of Total Billed Charges,60% of Total Billed Charges,60.53,90,,129.392,Percent of Total Billed Charges,90% of Total Billed Charges,30.26,45,,34.136,Percent of Total Billed Charges,45% of Total Billed Charges,60.53,90,,199.44,Percent of Total Billed Charges,90% of Total billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.71,65,,126.696,Percent of total Billed Charges,65% of Total Billed Charges,29.66,44.1,,33.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,63.89,95,,210.52,Percent of Total Billed Charges,95% of Total Billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.18,88,,52.008,Percent of Total Billed Charges,88% of Total Billed Charges,60.53,90,,199.44,Percent of Total Billed charges,90% of Total Billed Charges,29.66,67.25,
MAGNESIUM SERUM,3010000161,CDM,301,RC,,,Outpatient,,,153.00,99.45,,153,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,116.28,76,,74.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,110.16,72,,332.76,Percent of Total Billed Charges,72% of Total Billed Charges,114.75,75,,346.624,Percent of Total Billed charges,75% of Total Billed Charges,153,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.16,72,,332.76,Percent of Total Billed Charges,72% of Total Billed Charges,91.8,60,,277.304,Percent of Total Billed Charges,60% of Total Billed Charges,137.7,90,,129.392,Percent of Total Billed Charges,90% of Total Billed Charges,68.85,45,,26.592,Percent of Total Billed Charges,45% of Total Billed Charges,137.7,90,,88.112,Percent of Total Billed Charges,90% of Total billed Charges,153,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.45,65,,143.896,Percent of total Billed Charges,65% of Total Billed Charges,67.47,44.1,,26.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,145.35,95,,93.008,Percent of Total Billed Charges,95% of Total Billed Charges,153,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.64,88,,335.304,Percent of Total Billed Charges,88% of Total Billed Charges,137.7,90,,88.112,Percent of Total Billed charges,90% of Total Billed Charges,67.47,153,
METANEPHRINESURINE,3010000162,CDM,301,RC,,,Outpatient,,,422.26,274.47,,422.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,320.92,76,,110.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,304.03,72,,359.424,Percent of Total Billed Charges,72% of Total Billed Charges,316.7,75,,374.4,Percent of Total Billed charges,75% of Total Billed Charges,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.03,72,,359.424,Percent of Total Billed Charges,72% of Total Billed Charges,253.36,60,,299.52,Percent of Total Billed Charges,60% of Total Billed Charges,380.03,90,,238.936,Percent of Total Billed Charges,90% of Total Billed Charges,190.02,45,,171.464,Percent of Total Billed Charges,45% of Total Billed Charges,380.03,90,,130.976,Percent of Total Billed Charges,90% of Total billed Charges,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.47,65,,162.816,Percent of total Billed Charges,65% of Total Billed Charges,186.22,44.1,,168.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,401.15,95,,138.248,Percent of Total Billed Charges,95% of Total Billed Charges,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.59,88,,335.304,Percent of Total Billed Charges,88% of Total Billed Charges,380.03,90,,130.976,Percent of Total Billed charges,90% of Total Billed Charges,186.22,422.26,
METANEPHRINES FRACT,3010000163,CDM,301,RC,,,Outpatient,,,422.26,274.47,,422.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,320.92,76,,115.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,304.03,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,316.7,75,,150,Percent of Total Billed charges,75% of Total Billed Charges,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.03,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,253.36,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,380.03,90,,106.376,Percent of Total Billed Charges,90% of Total Billed Charges,190.02,45,,171.464,Percent of Total Billed Charges,45% of Total Billed Charges,380.03,90,,137.328,Percent of Total Billed Charges,90% of Total billed Charges,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.47,65,,210.976,Percent of total Billed Charges,65% of Total Billed Charges,186.22,44.1,,168.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,401.15,95,,144.952,Percent of Total Billed Charges,95% of Total Billed Charges,422.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.59,88,,133.056,Percent of Total Billed Charges,88% of Total Billed Charges,380.03,90,,137.328,Percent of Total Billed charges,90% of Total Billed Charges,186.22,422.26,
MYOGLOBIN,3010000164,CDM,301,RC,,,Outpatient,,,283.00,183.95,,283,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,215.08,76,,57.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,203.76,72,,75.568,Percent of Total Billed Charges,72% of Total Billed Charges,212.25,75,,78.72,Percent of Total Billed charges,75% of Total Billed Charges,283,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.76,72,,75.568,Percent of Total Billed Charges,72% of Total Billed Charges,169.8,60,,62.976,Percent of Total Billed Charges,60% of Total Billed Charges,254.7,90,,88.112,Percent of Total Billed Charges,90% of Total Billed Charges,127.35,45,,68.04,Percent of Total Billed Charges,45% of Total Billed Charges,254.7,90,,68.272,Percent of Total Billed Charges,90% of Total billed Charges,283,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.95,65,,150.208,Percent of total Billed Charges,65% of Total Billed Charges,124.8,44.1,,66.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,268.85,95,,72.064,Percent of Total Billed Charges,95% of Total Billed Charges,283,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.04,88,,126.512,Percent of Total Billed Charges,88% of Total Billed Charges,254.7,90,,68.272,Percent of Total Billed charges,90% of Total Billed Charges,124.8,283,
MYOGLOBIN URINE,3010000165,CDM,301,RC,,,Outpatient,,,295.47,192.06,,295.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,224.56,76,,44.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,212.74,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,221.6,75,,165,Percent of Total Billed charges,75% of Total Billed Charges,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.74,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,177.28,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,265.92,90,,77.8,Percent of Total Billed Charges,90% of Total Billed Charges,132.96,45,,64.696,Percent of Total Billed Charges,45% of Total Billed Charges,265.92,90,,53.184,Percent of Total Billed Charges,90% of Total billed Charges,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.06,65,,60.32,Percent of total Billed Charges,65% of Total Billed Charges,130.3,44.1,,63.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,280.7,95,,56.144,Percent of Total Billed Charges,95% of Total Billed Charges,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.01,88,,126.512,Percent of Total Billed Charges,88% of Total Billed Charges,265.92,90,,53.184,Percent of Total Billed charges,90% of Total Billed Charges,130.3,295.47,
TRIAGE BNP,3010000166,CDM,301,RC,,,Outpatient,,,291.00,189.15,,291,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,221.16,76,,289.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,209.52,72,,54.72,Percent of Total Billed Charges,72% of Total Billed Charges,218.25,75,,57,Percent of Total Billed charges,75% of Total Billed Charges,291,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.52,72,,54.72,Percent of Total Billed Charges,72% of Total Billed Charges,174.6,60,,45.6,Percent of Total Billed Charges,60% of Total Billed Charges,261.9,90,,77.8,Percent of Total Billed Charges,90% of Total Billed Charges,130.95,45,,64.696,Percent of Total Billed Charges,45% of Total Billed Charges,261.9,90,,342.92,Percent of Total Billed Charges,90% of Total billed Charges,291,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.15,65,,63.44,Percent of total Billed Charges,65% of Total Billed Charges,128.33,44.1,,63.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,276.45,95,,361.976,Percent of Total Billed Charges,95% of Total Billed Charges,291,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.08,88,,126.512,Percent of Total Billed Charges,88% of Total Billed Charges,261.9,90,,342.92,Percent of Total Billed charges,90% of Total Billed Charges,128.33,291,
KAPPA LIGHT CHAIN  F,3010000167,CDM,301,RC,,,Outpatient,,,109.00,70.85,,109,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.84,76,,289.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,78.48,72,,54.72,Percent of Total Billed Charges,72% of Total Billed Charges,81.75,75,,57,Percent of Total Billed charges,75% of Total Billed Charges,109,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.48,72,,54.72,Percent of Total Billed Charges,72% of Total Billed Charges,65.4,60,,45.6,Percent of Total Billed Charges,60% of Total Billed Charges,98.1,90,,23.184,Percent of Total Billed Charges,90% of Total Billed Charges,49.05,45,,64.696,Percent of Total Billed Charges,45% of Total Billed Charges,98.1,90,,342.92,Percent of Total Billed Charges,90% of Total billed Charges,109,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.85,65,,134.16,Percent of total Billed Charges,65% of Total Billed Charges,48.07,44.1,,63.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,103.55,95,,361.976,Percent of Total Billed Charges,95% of Total Billed Charges,109,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,88,,233.624,Percent of Total Billed Charges,88% of Total Billed Charges,98.1,90,,342.92,Percent of Total Billed charges,90% of Total Billed Charges,48.07,109,
LAMBDA LIGHT CHAIN,3010000168,CDM,301,RC,,,Outpatient,,,114.66,74.53,,114.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.14,76,,114.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.56,72,,98.496,Percent of Total Billed Charges,72% of Total Billed Charges,86,75,,102.6,Percent of Total Billed charges,75% of Total Billed Charges,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.56,72,,98.496,Percent of Total Billed Charges,72% of Total Billed Charges,68.8,60,,82.08,Percent of Total Billed Charges,60% of Total Billed Charges,103.19,90,,80.136,Percent of Total Billed Charges,90% of Total Billed Charges,51.6,45,,119.464,Percent of Total Billed Charges,45% of Total Billed Charges,103.19,90,,136.08,Percent of Total Billed Charges,90% of Total billed Charges,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.53,65,,45.24,Percent of total Billed Charges,65% of Total Billed Charges,50.57,44.1,,117.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,108.93,95,,143.64,Percent of Total Billed Charges,95% of Total Billed Charges,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.9,88,,104.008,Percent of Total Billed Charges,88% of Total Billed Charges,103.19,90,,136.08,Percent of Total Billed charges,90% of Total Billed Charges,50.57,114.66,
URINE ORGANIC ACID,3010000169,CDM,301,RC,,,Outpatient,,,159.86,103.91,,159.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,121.49,76,,109.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,115.1,72,,210.528,Percent of Total Billed Charges,72% of Total Billed Charges,119.9,75,,219.304,Percent of Total Billed charges,75% of Total Billed Charges,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.1,72,,210.528,Percent of Total Billed Charges,72% of Total Billed Charges,95.92,60,,175.44,Percent of Total Billed Charges,60% of Total Billed Charges,143.87,90,,30.96,Percent of Total Billed Charges,90% of Total Billed Charges,71.94,45,,53.184,Percent of Total Billed Charges,45% of Total Billed Charges,143.87,90,,129.392,Percent of Total Billed Charges,90% of Total billed Charges,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.91,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,70.5,44.1,,52.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,151.87,95,,136.576,Percent of Total Billed Charges,95% of Total Billed Charges,159.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.68,88,,86.152,Percent of Total Billed Charges,88% of Total Billed Charges,143.87,90,,129.392,Percent of Total Billed charges,90% of Total Billed Charges,70.5,159.86,
METHYLMALONIC ACID,3010000170,CDM,301,RC,,,Outpatient,,,191.84,124.70,,191.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,145.8,76,,109.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,138.12,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,143.88,75,,60,Percent of Total Billed charges,75% of Total Billed Charges,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.12,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,115.1,60,,48,Percent of Total Billed Charges,60% of Total Billed Charges,172.66,90,,139.712,Percent of Total Billed Charges,90% of Total Billed Charges,86.33,45,,44.056,Percent of Total Billed Charges,45% of Total Billed Charges,172.66,90,,129.392,Percent of Total Billed Charges,90% of Total billed Charges,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.7,65,,30.68,Percent of total Billed Charges,65% of Total Billed Charges,84.6,44.1,,43.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,182.25,95,,136.576,Percent of Total Billed Charges,95% of Total Billed Charges,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.82,88,,76.064,Percent of Total Billed Charges,88% of Total Billed Charges,172.66,90,,129.392,Percent of Total Billed charges,90% of Total Billed Charges,84.6,191.84,
OSMOLALITY SERUM,3010000171,CDM,301,RC,,,Outpatient,,,35.28,22.93,,35.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.81,76,,109.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.4,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,75,,60,Percent of Total Billed charges,75% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.4,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,21.17,60,,48,Percent of Total Billed Charges,60% of Total Billed Charges,31.75,90,,191.52,Percent of Total Billed Charges,90% of Total Billed Charges,15.88,45,,38.896,Percent of Total Billed Charges,45% of Total Billed Charges,31.75,90,,129.392,Percent of Total Billed Charges,90% of Total billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.93,65,,25.224,Percent of total Billed Charges,65% of Total Billed Charges,15.56,44.1,,38.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.52,95,,136.576,Percent of Total Billed Charges,95% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.05,88,,76.064,Percent of Total Billed Charges,88% of Total Billed Charges,31.75,90,,129.392,Percent of Total Billed charges,90% of Total Billed Charges,15.56,35.28,
OSMOLALITY URINE,3010000172,CDM,301,RC,,,Outpatient,,,87.00,56.55,,87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.12,76,,201.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.64,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,65.25,75,,84,Percent of Total Billed charges,75% of Total Billed Charges,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.64,72,,80.64,Percent of Total Billed Charges,72% of Total Billed Charges,52.2,60,,67.2,Percent of Total Billed Charges,60% of Total Billed Charges,78.3,90,,20.272,Percent of Total Billed Charges,90% of Total Billed Charges,39.15,45,,38.896,Percent of Total Billed Charges,45% of Total Billed Charges,78.3,90,,238.936,Percent of Total Billed Charges,90% of Total billed Charges,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.55,65,,25.224,Percent of total Billed Charges,65% of Total Billed Charges,38.37,44.1,,38.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.65,95,,252.208,Percent of Total Billed Charges,95% of Total Billed Charges,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.56,88,,22.672,Percent of Total Billed Charges,88% of Total Billed Charges,78.3,90,,238.936,Percent of Total Billed charges,90% of Total Billed Charges,38.37,87,
PTH INTACT,3010000173,CDM,301,RC,,,Outpatient,,,328.55,213.56,,328.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,249.7,76,,89.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,236.56,72,,93.984,Percent of Total Billed Charges,72% of Total Billed Charges,246.41,75,,97.904,Percent of Total Billed charges,75% of Total Billed Charges,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.56,72,,93.984,Percent of Total Billed Charges,72% of Total Billed Charges,197.13,60,,78.32,Percent of Total Billed Charges,60% of Total Billed Charges,295.7,90,,34.136,Percent of Total Billed Charges,90% of Total Billed Charges,147.85,45,,11.592,Percent of Total Billed Charges,45% of Total Billed Charges,295.7,90,,106.376,Percent of Total Billed Charges,90% of Total billed Charges,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.56,65,,63.44,Percent of total Billed Charges,65% of Total Billed Charges,144.89,44.1,,11.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,312.12,95,,112.28,Percent of Total Billed Charges,95% of Total Billed Charges,328.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.12,88,,78.352,Percent of Total Billed Charges,88% of Total Billed Charges,295.7,90,,106.376,Percent of Total Billed charges,90% of Total Billed Charges,144.89,328.55,
"PH, FECES",3010000174,CDM,301,RC,,,Outpatient,,,13.78,8.96,,13.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.47,76,,74.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.92,72,,83.808,Percent of Total Billed Charges,72% of Total Billed Charges,10.34,75,,87.304,Percent of Total Billed charges,75% of Total Billed Charges,13.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,72,,83.808,Percent of Total Billed Charges,72% of Total Billed Charges,8.27,60,,69.84,Percent of Total Billed Charges,60% of Total Billed Charges,12.4,90,,44.64,Percent of Total Billed Charges,90% of Total Billed Charges,6.2,45,,40.072,Percent of Total Billed Charges,45% of Total Billed Charges,12.4,90,,88.112,Percent of Total Billed Charges,90% of Total billed Charges,13.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.96,65,,9.176,Percent of total Billed Charges,65% of Total Billed Charges,6.08,44.1,,39.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.09,95,,93.008,Percent of Total Billed Charges,95% of Total Billed Charges,13.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,88,,30.272,Percent of Total Billed Charges,88% of Total Billed Charges,12.4,90,,88.112,Percent of Total Billed charges,90% of Total Billed Charges,6.08,13.78,
CALPROTECTIN,3010000175,CDM,301,RC,,,Outpatient,,,308.70,200.66,,308.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,234.61,76,,65.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,222.26,72,,124.984,Percent of Total Billed Charges,72% of Total Billed Charges,231.53,75,,130.192,Percent of Total Billed charges,75% of Total Billed Charges,308.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.26,72,,124.984,Percent of Total Billed Charges,72% of Total Billed Charges,185.22,60,,104.152,Percent of Total Billed Charges,60% of Total Billed Charges,277.83,90,,44.64,Percent of Total Billed Charges,90% of Total Billed Charges,138.92,45,,15.48,Percent of Total Billed Charges,45% of Total Billed Charges,277.83,90,,77.8,Percent of Total Billed Charges,90% of Total billed Charges,308.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.66,65,,40.56,Percent of total Billed Charges,65% of Total Billed Charges,136.14,44.1,,15.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,293.27,95,,82.12,Percent of Total Billed Charges,95% of Total Billed Charges,308.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.66,88,,136.608,Percent of Total Billed Charges,88% of Total Billed Charges,277.83,90,,77.8,Percent of Total Billed charges,90% of Total Billed Charges,136.14,308.7,
NEWBORN SCREENS,3010000176,CDM,301,RC,,,Outpatient,,,77.00,50.05,,77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.52,76,,65.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.44,72,,93.312,Percent of Total Billed Charges,72% of Total Billed Charges,57.75,75,,97.2,Percent of Total Billed charges,75% of Total Billed Charges,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.44,72,,93.312,Percent of Total Billed Charges,72% of Total Billed Charges,46.2,60,,77.76,Percent of Total Billed Charges,60% of Total Billed Charges,69.3,90,,124.56,Percent of Total Billed Charges,90% of Total Billed Charges,34.65,45,,69.856,Percent of Total Billed Charges,45% of Total Billed Charges,69.3,90,,77.8,Percent of Total Billed Charges,90% of Total billed Charges,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.05,65,,159.384,Percent of total Billed Charges,65% of Total Billed Charges,33.96,44.1,,68.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.15,95,,82.12,Percent of Total Billed Charges,95% of Total Billed Charges,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.76,88,,187.264,Percent of Total Billed Charges,88% of Total Billed Charges,69.3,90,,77.8,Percent of Total Billed charges,90% of Total Billed Charges,33.96,77,
NEWBORN SCREENS MEDICAID,3010000177,CDM,301,RC,,,Outpatient,,,77.00,50.05,,77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,58.52,76,,19.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,55.44,72,,88.704,Percent of Total Billed Charges,72% of Total Billed Charges,57.75,75,,92.4,Percent of Total Billed charges,75% of Total Billed Charges,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.44,72,,88.704,Percent of Total Billed Charges,72% of Total Billed Charges,46.2,60,,73.92,Percent of Total Billed Charges,60% of Total Billed Charges,69.3,90,,66.68,Percent of Total Billed Charges,90% of Total Billed Charges,34.65,45,,95.76,Percent of Total Billed Charges,45% of Total Billed Charges,69.3,90,,23.184,Percent of Total Billed Charges,90% of Total billed Charges,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.05,65,,111.792,Percent of total Billed Charges,65% of Total Billed Charges,33.96,44.1,,93.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,73.15,95,,24.472,Percent of Total Billed Charges,95% of Total Billed Charges,77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.76,88,,19.816,Percent of Total Billed Charges,88% of Total Billed Charges,69.3,90,,23.184,Percent of Total Billed charges,90% of Total Billed Charges,33.96,77,
PAP/PSA PROFILE,3010000178,CDM,301,RC,,,Outpatient,,,76.07,49.45,,76.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,57.81,76,,67.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,54.77,72,,111.168,Percent of Total Billed Charges,72% of Total Billed Charges,57.05,75,,115.8,Percent of Total Billed charges,75% of Total Billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.77,72,,111.168,Percent of Total Billed Charges,72% of Total Billed Charges,45.64,60,,92.64,Percent of Total Billed Charges,60% of Total Billed Charges,68.46,90,,63.36,Percent of Total Billed Charges,90% of Total Billed Charges,34.23,45,,10.136,Percent of Total Billed Charges,45% of Total Billed Charges,68.46,90,,80.136,Percent of Total Billed Charges,90% of Total billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.45,65,,127.272,Percent of total Billed Charges,65% of Total Billed Charges,33.55,44.1,,9.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,72.27,95,,84.592,Percent of Total Billed Charges,95% of Total Billed Charges,76.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.94,88,,33.376,Percent of Total Billed Charges,88% of Total Billed Charges,68.46,90,,80.136,Percent of Total Billed charges,90% of Total Billed Charges,33.55,76.07,
ALKALINE PHOSPHATE,3010000179,CDM,301,RC,,,Outpatient,,,70.00,45.50,,70,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.2,76,,26.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.4,72,,72,Percent of Total Billed Charges,72% of Total Billed Charges,52.5,75,,75,Percent of Total Billed charges,75% of Total Billed Charges,70,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.4,72,,72,Percent of Total Billed Charges,72% of Total Billed Charges,42,60,,60,Percent of Total Billed Charges,60% of Total Billed Charges,63,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,31.5,45,,17.064,Percent of Total Billed Charges,45% of Total Billed Charges,63,90,,30.96,Percent of Total Billed Charges,90% of Total billed Charges,70,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.5,65,,29.64,Percent of total Billed Charges,65% of Total Billed Charges,30.87,44.1,,16.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,66.5,95,,32.68,Percent of Total Billed Charges,95% of Total Billed Charges,70,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.6,88,,43.648,Percent of Total Billed Charges,88% of Total Billed Charges,63,90,,30.96,Percent of Total Billed charges,90% of Total Billed Charges,30.87,70,
ALKA PHOS ISOENZYMES,3010000180,CDM,301,RC,,,Outpatient,,,106.94,69.51,,106.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.27,76,,117.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77,72,,250.56,Percent of Total Billed Charges,72% of Total Billed Charges,80.21,75,,261,Percent of Total Billed charges,75% of Total Billed Charges,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77,72,,250.56,Percent of Total Billed Charges,72% of Total Billed Charges,64.16,60,,208.8,Percent of Total Billed Charges,60% of Total Billed Charges,96.25,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,48.12,45,,22.32,Percent of Total Billed Charges,45% of Total Billed Charges,96.25,90,,139.712,Percent of Total Billed Charges,90% of Total billed Charges,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.51,65,,26.944,Percent of total Billed Charges,65% of Total Billed Charges,47.16,44.1,,21.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,101.59,95,,147.472,Percent of Total Billed Charges,95% of Total Billed Charges,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.11,88,,43.648,Percent of Total Billed Charges,88% of Total Billed Charges,96.25,90,,139.712,Percent of Total Billed charges,90% of Total Billed Charges,47.16,106.94,
PHOSPHOROUS,3010000181,CDM,301,RC,,,Outpatient,,,63.00,40.95,,63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.88,76,,161.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.36,72,,31.104,Percent of Total Billed Charges,72% of Total Billed Charges,47.25,75,,32.4,Percent of Total Billed charges,75% of Total Billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.36,72,,31.104,Percent of Total Billed Charges,72% of Total Billed Charges,37.8,60,,25.92,Percent of Total Billed Charges,60% of Total Billed Charges,56.7,90,,175.432,Percent of Total Billed Charges,90% of Total Billed Charges,28.35,45,,22.32,Percent of Total Billed Charges,45% of Total Billed Charges,56.7,90,,191.52,Percent of Total Billed Charges,90% of Total billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.95,65,,26.944,Percent of total Billed Charges,65% of Total Billed Charges,27.78,44.1,,21.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.85,95,,202.16,Percent of Total Billed Charges,95% of Total Billed Charges,63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.44,88,,121.792,Percent of Total Billed Charges,88% of Total Billed Charges,56.7,90,,191.52,Percent of Total Billed charges,90% of Total Billed Charges,27.78,63,
POTASSIUMK,3010000182,CDM,301,RC,,,Outpatient,,,136.00,88.40,,136,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,103.36,76,,17.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,97.92,72,,38.104,Percent of Total Billed Charges,72% of Total Billed Charges,102,75,,39.688,Percent of Total Billed charges,75% of Total Billed Charges,136,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.92,72,,38.104,Percent of Total Billed Charges,72% of Total Billed Charges,81.6,60,,31.752,Percent of Total Billed Charges,60% of Total Billed Charges,122.4,90,,175.432,Percent of Total Billed Charges,90% of Total Billed Charges,61.2,45,,62.28,Percent of Total Billed Charges,45% of Total Billed Charges,122.4,90,,20.272,Percent of Total Billed Charges,90% of Total billed Charges,136,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.4,65,,85.28,Percent of total Billed Charges,65% of Total Billed Charges,59.98,44.1,,61.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,129.2,95,,21.392,Percent of Total Billed Charges,95% of Total Billed Charges,136,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.68,88,,65.2,Percent of Total Billed Charges,88% of Total Billed Charges,122.4,90,,20.272,Percent of Total Billed charges,90% of Total Billed Charges,59.98,136,
POTASSIUM URINE,3010000183,CDM,301,RC,,,Outpatient,,,123.00,79.95,,123,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.48,76,,28.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.56,72,,86.976,Percent of Total Billed Charges,72% of Total Billed Charges,92.25,75,,90.6,Percent of Total Billed charges,75% of Total Billed Charges,123,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.56,72,,86.976,Percent of Total Billed Charges,72% of Total Billed Charges,73.8,60,,72.48,Percent of Total Billed Charges,60% of Total Billed Charges,110.7,90,,175.432,Percent of Total Billed Charges,90% of Total Billed Charges,55.35,45,,33.336,Percent of Total Billed Charges,45% of Total Billed Charges,110.7,90,,34.136,Percent of Total Billed Charges,90% of Total billed Charges,123,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.95,65,,26.944,Percent of total Billed Charges,65% of Total Billed Charges,54.24,44.1,,32.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.85,95,,36.032,Percent of Total Billed Charges,95% of Total Billed Charges,123,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.24,88,,61.952,Percent of Total Billed Charges,88% of Total Billed Charges,110.7,90,,34.136,Percent of Total Billed charges,90% of Total Billed Charges,54.24,123,
PREALBUMIN,3010000184,CDM,301,RC,,,Outpatient,,,114.00,74.10,,114,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,86.64,76,,37.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.08,72,,26.672,Percent of Total Billed Charges,72% of Total Billed Charges,85.5,75,,27.784,Percent of Total Billed charges,75% of Total Billed Charges,114,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.08,72,,26.672,Percent of Total Billed Charges,72% of Total Billed Charges,68.4,60,,22.232,Percent of Total Billed Charges,60% of Total Billed Charges,102.6,90,,175.432,Percent of Total Billed Charges,90% of Total Billed Charges,51.3,45,,31.68,Percent of Total Billed Charges,45% of Total Billed Charges,102.6,90,,44.64,Percent of Total Billed Charges,90% of Total billed Charges,114,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.1,65,,122.2,Percent of total Billed Charges,65% of Total Billed Charges,50.27,44.1,,31.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,108.3,95,,47.12,Percent of Total Billed Charges,95% of Total Billed Charges,114,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.32,88,,30.976,Percent of Total Billed Charges,88% of Total Billed Charges,102.6,90,,44.64,Percent of Total Billed charges,90% of Total Billed Charges,50.27,114,
PROGESTERONE,3010000185,CDM,301,RC,,,Outpatient,,,153.00,99.45,,153,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,116.28,76,,37.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,110.16,72,,111.744,Percent of Total Billed Charges,72% of Total Billed Charges,114.75,75,,116.4,Percent of Total Billed charges,75% of Total Billed Charges,153,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.16,72,,111.744,Percent of Total Billed Charges,72% of Total Billed Charges,91.8,60,,93.12,Percent of Total Billed Charges,60% of Total Billed Charges,137.7,90,,199.248,Percent of Total Billed Charges,90% of Total Billed Charges,68.85,45,,15.84,Percent of Total Billed Charges,45% of Total Billed Charges,137.7,90,,44.64,Percent of Total Billed Charges,90% of Total billed Charges,153,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.45,65,,80.6,Percent of total Billed Charges,65% of Total Billed Charges,67.47,44.1,,15.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,145.35,95,,47.12,Percent of Total Billed Charges,95% of Total Billed Charges,153,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.64,88,,39.424,Percent of Total Billed Charges,88% of Total Billed Charges,137.7,90,,44.64,Percent of Total Billed charges,90% of Total Billed Charges,67.47,153,
PROLACTIN,3010000186,CDM,301,RC,,,Outpatient,,,279.00,181.35,,279,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,212.04,76,,105.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,200.88,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,209.25,75,,53.584,Percent of Total Billed charges,75% of Total Billed Charges,279,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.88,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,167.4,60,,42.864,Percent of Total Billed Charges,60% of Total Billed Charges,251.1,90,,225.44,Percent of Total Billed Charges,90% of Total Billed Charges,125.55,45,,20.16,Percent of Total Billed Charges,45% of Total Billed Charges,251.1,90,,124.56,Percent of Total Billed Charges,90% of Total billed Charges,279,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.35,65,,59.8,Percent of total Billed Charges,65% of Total Billed Charges,123.04,44.1,,19.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,265.05,95,,131.48,Percent of Total Billed Charges,95% of Total Billed Charges,279,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.52,88,,171.528,Percent of Total Billed Charges,88% of Total Billed Charges,251.1,90,,124.56,Percent of Total Billed charges,90% of Total Billed Charges,123.04,279,
PSA TOTAL,3010000187,CDM,301,RC,,,Outpatient,,,305.00,198.25,,305,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,231.8,76,,56.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,219.6,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,228.75,75,,53.584,Percent of Total Billed charges,75% of Total Billed Charges,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.6,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,183,60,,42.864,Percent of Total Billed Charges,60% of Total Billed Charges,274.5,90,,292.12,Percent of Total Billed Charges,90% of Total Billed Charges,137.25,45,,87.712,Percent of Total Billed Charges,45% of Total Billed Charges,274.5,90,,66.68,Percent of Total Billed Charges,90% of Total billed Charges,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.25,65,,59.8,Percent of total Billed Charges,65% of Total Billed Charges,134.51,44.1,,85.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,289.75,95,,70.384,Percent of Total Billed Charges,95% of Total Billed Charges,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.4,88,,171.528,Percent of Total Billed Charges,88% of Total Billed Charges,274.5,90,,66.68,Percent of Total Billed charges,90% of Total Billed Charges,134.51,305,
PSA TOTAL,3010000188,CDM,301,RC,,,Outpatient,,,291.06,189.19,,291.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,221.21,76,,53.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,209.56,72,,141.56,Percent of Total Billed Charges,72% of Total Billed Charges,218.3,75,,147.464,Percent of Total Billed charges,75% of Total Billed Charges,291.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.56,72,,141.56,Percent of Total Billed Charges,72% of Total Billed Charges,174.64,60,,117.968,Percent of Total Billed Charges,60% of Total Billed Charges,261.95,90,,207.976,Percent of Total Billed Charges,90% of Total Billed Charges,130.98,45,,87.712,Percent of Total Billed Charges,45% of Total Billed Charges,261.95,90,,63.36,Percent of Total Billed Charges,90% of Total billed Charges,291.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.19,65,,75.4,Percent of total Billed Charges,65% of Total Billed Charges,128.36,44.1,,85.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,276.51,95,,66.88,Percent of Total Billed Charges,95% of Total Billed Charges,291.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.13,88,,171.528,Percent of Total Billed Charges,88% of Total Billed Charges,261.95,90,,63.36,Percent of Total Billed charges,90% of Total Billed Charges,128.36,291.06,
PSA FREE,3010000189,CDM,301,RC,,,Outpatient,,,60.64,39.42,,60.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.09,76,,26.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.66,72,,169.56,Percent of Total Billed Charges,72% of Total Billed Charges,45.48,75,,176.624,Percent of Total Billed charges,75% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,72,,169.56,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,60,,141.296,Percent of Total Billed Charges,60% of Total Billed Charges,54.58,90,,83.52,Percent of Total Billed Charges,90% of Total Billed Charges,27.29,45,,87.712,Percent of Total Billed Charges,45% of Total Billed Charges,54.58,90,,31.68,Percent of Total Billed Charges,90% of Total billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.42,65,,60.84,Percent of total Billed Charges,65% of Total Billed Charges,26.74,44.1,,85.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.61,95,,33.44,Percent of Total Billed Charges,95% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.36,88,,171.528,Percent of Total Billed Charges,88% of Total Billed Charges,54.58,90,,31.68,Percent of Total Billed charges,90% of Total Billed Charges,26.74,60.64,
PROT TOTAL (SPINAL),3010000190,CDM,301,RC,,,Outpatient,,,86.00,55.90,,86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,65.36,76,,34.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.92,72,,112.32,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,75,,117,Percent of Total Billed charges,75% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.92,72,,112.32,Percent of Total Billed Charges,72% of Total Billed Charges,51.6,60,,93.6,Percent of Total Billed Charges,60% of Total Billed Charges,77.4,90,,87.84,Percent of Total Billed Charges,90% of Total Billed Charges,38.7,45,,87.712,Percent of Total Billed Charges,45% of Total Billed Charges,77.4,90,,40.32,Percent of Total Billed Charges,90% of Total billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.9,65,,53.312,Percent of total Billed Charges,65% of Total Billed Charges,37.93,44.1,,85.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,81.7,95,,42.56,Percent of Total Billed Charges,95% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.68,88,,194.816,Percent of Total Billed Charges,88% of Total Billed Charges,77.4,90,,40.32,Percent of Total Billed charges,90% of Total Billed Charges,37.93,86,
PROTEIN TOTAL,3010000191,CDM,301,RC,,,Outpatient,,,82.00,53.30,,82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.32,76,,148.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.04,72,,127.872,Percent of Total Billed Charges,72% of Total Billed Charges,61.5,75,,133.2,Percent of Total Billed charges,75% of Total Billed Charges,82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.04,72,,127.872,Percent of Total Billed Charges,72% of Total Billed Charges,49.2,60,,106.56,Percent of Total Billed Charges,60% of Total Billed Charges,73.8,90,,185.76,Percent of Total Billed Charges,90% of Total Billed Charges,36.9,45,,99.624,Percent of Total Billed Charges,45% of Total Billed Charges,73.8,90,,175.432,Percent of Total Billed Charges,90% of Total billed Charges,82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.3,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,36.16,44.1,,97.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,77.9,95,,185.176,Percent of Total Billed Charges,95% of Total Billed Charges,82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.16,88,,220.432,Percent of Total Billed Charges,88% of Total Billed Charges,73.8,90,,175.432,Percent of Total Billed charges,90% of Total Billed Charges,36.16,82,
PROT TOT 24 HR URINE,3010000192,CDM,301,RC,,,Outpatient,,,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,148.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,408.384,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,425.4,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,408.384,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,340.32,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,112.72,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,175.432,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,119.6,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,110.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,185.176,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,285.624,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,175.432,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
PROTEIN URINE,3010000193,CDM,301,RC,,,Outpatient,,,93.00,60.45,,93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,70.68,76,,148.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,66.96,72,,67.392,Percent of Total Billed Charges,72% of Total Billed Charges,69.75,75,,70.2,Percent of Total Billed charges,75% of Total Billed Charges,93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.96,72,,67.392,Percent of Total Billed Charges,72% of Total Billed Charges,55.8,60,,56.16,Percent of Total Billed Charges,60% of Total Billed Charges,83.7,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,41.85,45,,146.056,Percent of Total Billed Charges,45% of Total Billed Charges,83.7,90,,175.432,Percent of Total Billed Charges,90% of Total billed Charges,93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.45,65,,24.44,Percent of total Billed Charges,65% of Total Billed Charges,41.01,44.1,,143.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,88.35,95,,185.176,Percent of Total Billed Charges,95% of Total Billed Charges,93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.84,88,,203.36,Percent of Total Billed Charges,88% of Total Billed Charges,83.7,90,,175.432,Percent of Total Billed charges,90% of Total Billed Charges,41.01,93,
PROTEIN TOTAL PLEURAL FLUID,3010000194,CDM,301,RC,,,Outpatient,,,83.00,53.95,,83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,63.08,76,,148.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.76,72,,67.392,Percent of Total Billed Charges,72% of Total Billed Charges,62.25,75,,70.2,Percent of Total Billed charges,75% of Total Billed Charges,83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.76,72,,67.392,Percent of Total Billed Charges,72% of Total Billed Charges,49.8,60,,56.16,Percent of Total Billed Charges,60% of Total Billed Charges,74.7,90,,42.48,Percent of Total Billed Charges,90% of Total Billed Charges,37.35,45,,103.992,Percent of Total Billed Charges,45% of Total Billed Charges,74.7,90,,175.432,Percent of Total Billed Charges,90% of Total billed Charges,83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.95,65,,62.488,Percent of total Billed Charges,65% of Total Billed Charges,36.6,44.1,,101.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,78.85,95,,185.176,Percent of Total Billed Charges,95% of Total Billed Charges,83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.04,88,,81.664,Percent of Total Billed Charges,88% of Total Billed Charges,74.7,90,,175.432,Percent of Total Billed charges,90% of Total Billed Charges,36.6,83,
PROTEIN TOTAL SYNOVIAL FLUID,3010000195,CDM,301,RC,,,Outpatient,,,86.00,55.90,,86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,65.36,76,,168.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.92,72,,67.392,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,75,,70.2,Percent of Total Billed charges,75% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.92,72,,67.392,Percent of Total Billed Charges,72% of Total Billed Charges,51.6,60,,56.16,Percent of Total Billed Charges,60% of Total Billed Charges,77.4,90,,34.928,Percent of Total Billed Charges,90% of Total Billed Charges,38.7,45,,41.76,Percent of Total Billed Charges,45% of Total Billed Charges,77.4,90,,199.248,Percent of Total Billed Charges,90% of Total billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.9,65,,22.36,Percent of total Billed Charges,65% of Total Billed Charges,37.93,44.1,,40.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,81.7,95,,210.312,Percent of Total Billed Charges,95% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.68,88,,85.888,Percent of Total Billed Charges,88% of Total Billed Charges,77.4,90,,199.248,Percent of Total Billed charges,90% of Total Billed Charges,37.93,86,
PROTEIN ELECTROPHOR SERUM,3010000196,CDM,301,RC,,,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,190.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,800.064,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,833.4,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,800.064,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,666.72,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,34.928,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,43.92,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,225.44,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,16.056,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,43.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,237.96,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,181.632,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,225.44,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
ELETROPHORETIC FRACT SERUM,3010000197,CDM,301,RC,,,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,246.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,800.064,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,833.4,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,800.064,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,666.72,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,87.84,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,92.88,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,292.12,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,54.6,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,91.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,308.344,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,61.248,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,292.12,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
PROTEIN ELECTROPHORE OTH FLUID,3010000198,CDM,301,RC,,,Outpatient,,,198.45,128.99,,198.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,150.82,76,,175.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,142.88,72,,74.304,Percent of Total Billed Charges,72% of Total Billed Charges,148.84,75,,77.4,Percent of Total Billed charges,75% of Total Billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.88,72,,74.304,Percent of Total Billed Charges,72% of Total Billed Charges,119.07,60,,61.92,Percent of Total Billed Charges,60% of Total Billed Charges,178.61,90,,12.704,Percent of Total Billed Charges,90% of Total Billed Charges,89.3,45,,31.32,Percent of Total Billed Charges,45% of Total Billed Charges,178.61,90,,207.976,Percent of Total Billed Charges,90% of Total billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.99,65,,210.08,Percent of total Billed Charges,65% of Total Billed Charges,87.52,44.1,,30.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,188.53,95,,219.536,Percent of Total Billed Charges,95% of Total Billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.64,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,178.61,90,,207.976,Percent of Total Billed charges,90% of Total Billed Charges,87.52,198.45,
FREE RBC PROTO PORPH QUANT,3010000199,CDM,301,RC,,,Outpatient,,,47.41,30.82,,47.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.03,76,,70.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.14,72,,312.656,Percent of Total Billed Charges,72% of Total Billed Charges,35.56,75,,325.68,Percent of Total Billed charges,75% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.14,72,,312.656,Percent of Total Billed Charges,72% of Total Billed Charges,28.45,60,,260.544,Percent of Total Billed Charges,60% of Total Billed Charges,42.67,90,,56.16,Percent of Total Billed Charges,90% of Total Billed Charges,21.33,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,42.67,90,,83.52,Percent of Total Billed Charges,90% of Total billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.82,65,,61.36,Percent of total Billed Charges,65% of Total Billed Charges,20.91,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.04,95,,88.16,Percent of Total Billed Charges,95% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.72,88,,41.536,Percent of Total Billed Charges,88% of Total Billed Charges,42.67,90,,83.52,Percent of Total Billed charges,90% of Total Billed Charges,20.91,47.41,
EST & PROG RECPTA,3010000201,CDM,301,RC,,,Outpatient,,,635.04,412.78,,635.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,482.63,76,,74.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,457.23,72,,312.656,Percent of Total Billed Charges,72% of Total Billed Charges,476.28,75,,325.68,Percent of Total Billed charges,75% of Total Billed Charges,635.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,457.23,72,,312.656,Percent of Total Billed Charges,72% of Total Billed Charges,381.02,60,,260.544,Percent of Total Billed Charges,60% of Total Billed Charges,571.54,90,,220.68,Percent of Total Billed Charges,90% of Total Billed Charges,285.77,45,,21.24,Percent of Total Billed Charges,45% of Total Billed Charges,571.54,90,,87.84,Percent of Total Billed Charges,90% of Total billed Charges,635.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,635.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,635.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.78,65,,100.328,Percent of total Billed Charges,65% of Total Billed Charges,280.05,44.1,,20.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,603.29,95,,92.72,Percent of Total Billed Charges,95% of Total Billed Charges,635.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.84,88,,34.152,Percent of Total Billed Charges,88% of Total Billed Charges,571.54,90,,87.84,Percent of Total Billed charges,90% of Total Billed Charges,280.05,635.04,
SOLUBLE TRANSFERRIN,3010000202,CDM,301,RC,,,Outpatient,,,282.00,183.30,,282,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,214.32,76,,156.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,203.04,72,,184.896,Percent of Total Billed Charges,72% of Total Billed Charges,211.5,75,,192.6,Percent of Total Billed charges,75% of Total Billed Charges,282,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.04,72,,184.896,Percent of Total Billed Charges,72% of Total Billed Charges,169.2,60,,154.08,Percent of Total Billed Charges,60% of Total Billed Charges,253.8,90,,154.792,Percent of Total Billed Charges,90% of Total Billed Charges,126.9,45,,17.464,Percent of Total Billed Charges,45% of Total Billed Charges,253.8,90,,185.76,Percent of Total Billed Charges,90% of Total billed Charges,282,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.3,65,,84.848,Percent of total Billed Charges,65% of Total Billed Charges,124.36,44.1,,17.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,267.9,95,,196.08,Percent of Total Billed Charges,95% of Total Billed Charges,282,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.16,88,,34.152,Percent of Total Billed Charges,88% of Total Billed Charges,253.8,90,,185.76,Percent of Total Billed charges,90% of Total Billed Charges,124.36,282,
RENIN PLASMA,3010000203,CDM,301,RC,,,Outpatient,,,239.24,155.51,,239.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,181.82,76,,52.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,172.25,72,,40.32,Percent of Total Billed Charges,72% of Total Billed Charges,179.43,75,,42,Percent of Total Billed charges,75% of Total Billed Charges,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.25,72,,40.32,Percent of Total Billed Charges,72% of Total Billed Charges,143.54,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,215.32,90,,176.224,Percent of Total Billed Charges,90% of Total Billed Charges,107.66,45,,17.464,Percent of Total Billed Charges,45% of Total Billed Charges,215.32,90,,62.64,Percent of Total Billed Charges,90% of Total billed Charges,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.51,65,,85.28,Percent of total Billed Charges,65% of Total Billed Charges,105.5,44.1,,17.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,227.28,95,,66.12,Percent of Total Billed Charges,95% of Total Billed Charges,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.53,88,,85.888,Percent of Total Billed Charges,88% of Total Billed Charges,215.32,90,,62.64,Percent of Total Billed charges,90% of Total Billed Charges,105.5,239.24,
SELENIUM,3010000204,CDM,301,RC,,,Outpatient,,,44.00,28.60,,44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33.44,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,31.68,72,,40.32,Percent of Total Billed Charges,72% of Total Billed Charges,33,75,,42,Percent of Total Billed charges,75% of Total Billed Charges,44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.68,72,,40.32,Percent of Total Billed Charges,72% of Total Billed Charges,26.4,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,39.6,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,45,,43.92,Percent of Total Billed Charges,45% of Total Billed Charges,39.6,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.6,65,,730.384,Percent of total Billed Charges,65% of Total Billed Charges,19.4,44.1,,43.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.8,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.72,88,,12.416,Percent of Total Billed Charges,88% of Total Billed Charges,39.6,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,19.4,44,
SODIUM,3010000206,CDM,301,RC,,,Outpatient,,,46.00,29.90,,46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.96,76,,35.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.12,72,,48.384,Percent of Total Billed Charges,72% of Total Billed Charges,34.5,75,,50.4,Percent of Total Billed charges,75% of Total Billed Charges,46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.12,72,,48.384,Percent of Total Billed Charges,72% of Total Billed Charges,27.6,60,,40.32,Percent of Total Billed Charges,60% of Total Billed Charges,41.4,90,,37.312,Percent of Total Billed Charges,90% of Total Billed Charges,20.7,45,,6.352,Percent of Total Billed Charges,45% of Total Billed Charges,41.4,90,,42.48,Percent of Total Billed Charges,90% of Total billed Charges,46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.9,65,,268.88,Percent of total Billed Charges,65% of Total Billed Charges,20.29,44.1,,6.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,43.7,95,,44.84,Percent of Total Billed Charges,95% of Total Billed Charges,46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.48,88,,54.912,Percent of Total Billed Charges,88% of Total Billed Charges,41.4,90,,42.48,Percent of Total Billed charges,90% of Total Billed Charges,20.29,46,
SODIUM URINE,3010000207,CDM,301,RC,,,Outpatient,,,58.00,37.70,,58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,44.08,76,,29.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.76,72,,25.92,Percent of Total Billed Charges,72% of Total Billed Charges,43.5,75,,27,Percent of Total Billed charges,75% of Total Billed Charges,58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.76,72,,25.92,Percent of Total Billed Charges,72% of Total Billed Charges,34.8,60,,21.6,Percent of Total Billed Charges,60% of Total Billed Charges,52.2,90,,37.312,Percent of Total Billed Charges,90% of Total Billed Charges,26.1,45,,28.08,Percent of Total Billed Charges,45% of Total Billed Charges,52.2,90,,34.928,Percent of Total Billed Charges,90% of Total billed Charges,58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.7,65,,370.928,Percent of total Billed Charges,65% of Total Billed Charges,25.58,44.1,,27.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,55.1,95,,36.864,Percent of Total Billed Charges,95% of Total Billed Charges,58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.04,88,,215.776,Percent of Total Billed Charges,88% of Total Billed Charges,52.2,90,,34.928,Percent of Total Billed charges,90% of Total Billed Charges,25.58,58,
REDUCING SUBST FECES,3010000209,CDM,301,RC,,,Outpatient,,,95.92,62.35,,95.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.9,76,,29.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.06,72,,165.12,Percent of Total Billed Charges,72% of Total Billed Charges,71.94,75,,172,Percent of Total Billed charges,75% of Total Billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.06,72,,165.12,Percent of Total Billed Charges,72% of Total Billed Charges,57.55,60,,137.6,Percent of Total Billed Charges,60% of Total Billed Charges,86.33,90,,118.08,Percent of Total Billed Charges,90% of Total Billed Charges,43.16,45,,110.344,Percent of Total Billed Charges,45% of Total Billed Charges,86.33,90,,34.928,Percent of Total Billed Charges,90% of Total billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.35,65,,218.4,Percent of total Billed Charges,65% of Total Billed Charges,42.3,44.1,,108.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.12,95,,36.864,Percent of Total Billed Charges,95% of Total Billed Charges,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.41,88,,151.352,Percent of Total Billed Charges,88% of Total Billed Charges,86.33,90,,34.928,Percent of Total Billed charges,90% of Total Billed Charges,42.3,95.92,
RBC GALACTOSE1 PHOS,3010000210,CDM,301,RC,,,Outpatient,,,220.50,143.33,,220.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,167.58,76,,74.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,158.76,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,165.38,75,,150,Percent of Total Billed charges,75% of Total Billed Charges,220.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.76,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,132.3,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,198.45,90,,37.312,Percent of Total Billed Charges,90% of Total Billed Charges,99.23,45,,77.4,Percent of Total Billed Charges,45% of Total Billed Charges,198.45,90,,87.84,Percent of Total Billed Charges,90% of Total billed Charges,220.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.33,65,,30.384,Percent of total Billed Charges,65% of Total Billed Charges,97.24,44.1,,75.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,209.48,95,,92.72,Percent of Total Billed Charges,95% of Total Billed Charges,220.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.04,88,,172.312,Percent of Total Billed Charges,88% of Total Billed Charges,198.45,90,,87.84,Percent of Total Billed charges,90% of Total Billed Charges,97.24,220.5,
TESTOSTERONE  FREE,3010000211,CDM,301,RC,,,Outpatient,,,139.00,90.35,,139,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,105.64,76,,10.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.08,72,,302.912,Percent of Total Billed Charges,72% of Total Billed Charges,104.25,75,,315.536,Percent of Total Billed charges,75% of Total Billed Charges,139,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.08,72,,302.912,Percent of Total Billed Charges,72% of Total Billed Charges,83.4,60,,252.424,Percent of Total Billed Charges,60% of Total Billed Charges,125.1,90,,169.2,Percent of Total Billed Charges,90% of Total Billed Charges,62.55,45,,88.112,Percent of Total Billed Charges,45% of Total Billed Charges,125.1,90,,12.704,Percent of Total Billed Charges,90% of Total billed Charges,139,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.35,65,,282.256,Percent of total Billed Charges,65% of Total Billed Charges,61.3,44.1,,86.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,132.05,95,,13.408,Percent of Total Billed Charges,95% of Total Billed Charges,139,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.32,88,,40.128,Percent of Total Billed Charges,88% of Total Billed Charges,125.1,90,,12.704,Percent of Total Billed charges,90% of Total Billed Charges,61.3,139,
TESTOSTERONE TOTAL,3010000212,CDM,301,RC,,,Outpatient,,,296.57,192.77,,296.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,225.39,76,,47.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,213.53,72,,38.592,Percent of Total Billed Charges,72% of Total Billed Charges,222.43,75,,40.2,Percent of Total Billed charges,75% of Total Billed Charges,296.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.53,72,,38.592,Percent of Total Billed Charges,72% of Total Billed Charges,177.94,60,,32.16,Percent of Total Billed Charges,60% of Total Billed Charges,266.91,90,,111.6,Percent of Total Billed Charges,90% of Total Billed Charges,133.46,45,,20.52,Percent of Total Billed Charges,45% of Total Billed Charges,266.91,90,,56.16,Percent of Total Billed Charges,90% of Total billed Charges,296.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.77,65,,51.48,Percent of total Billed Charges,65% of Total Billed Charges,130.79,44.1,,20.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,281.74,95,,59.28,Percent of Total Billed Charges,95% of Total Billed Charges,296.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.98,88,,36.48,Percent of Total Billed Charges,88% of Total Billed Charges,266.91,90,,56.16,Percent of Total Billed charges,90% of Total Billed Charges,130.79,296.57,
TOTAL T4,3010000214,CDM,301,RC,,,Outpatient,,,201.00,130.65,,201,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152.76,76,,186.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144.72,72,,67.392,Percent of Total Billed Charges,72% of Total Billed Charges,150.75,75,,70.2,Percent of Total Billed charges,75% of Total Billed Charges,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.72,72,,67.392,Percent of Total Billed Charges,72% of Total Billed Charges,120.6,60,,56.16,Percent of Total Billed Charges,60% of Total Billed Charges,180.9,90,,82.8,Percent of Total Billed Charges,90% of Total Billed Charges,90.45,45,,18.656,Percent of Total Billed Charges,45% of Total Billed Charges,180.9,90,,220.68,Percent of Total Billed Charges,90% of Total billed Charges,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.65,65,,93.08,Percent of total Billed Charges,65% of Total Billed Charges,88.64,44.1,,18.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,190.95,95,,232.944,Percent of Total Billed Charges,95% of Total Billed Charges,201,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.88,88,,36.48,Percent of Total Billed Charges,88% of Total Billed Charges,180.9,90,,220.68,Percent of Total Billed charges,90% of Total Billed Charges,88.64,201,
FREE T4,3010000215,CDM,301,RC,,,Outpatient,,,245.00,159.25,,245,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,186.2,76,,130.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,176.4,72,,25.344,Percent of Total Billed Charges,72% of Total Billed Charges,183.75,75,,26.4,Percent of Total Billed charges,75% of Total Billed Charges,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.4,72,,25.344,Percent of Total Billed Charges,72% of Total Billed Charges,147,60,,21.12,Percent of Total Billed Charges,60% of Total Billed Charges,220.5,90,,82.8,Percent of Total Billed Charges,90% of Total Billed Charges,110.25,45,,18.656,Percent of Total Billed Charges,45% of Total Billed Charges,220.5,90,,154.792,Percent of Total Billed Charges,90% of Total billed Charges,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.25,65,,349.136,Percent of total Billed Charges,65% of Total Billed Charges,108.05,44.1,,18.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,232.75,95,,163.392,Percent of Total Billed Charges,95% of Total Billed Charges,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.6,88,,115.456,Percent of Total Billed Charges,88% of Total Billed Charges,220.5,90,,154.792,Percent of Total Billed charges,90% of Total Billed Charges,108.05,245,
THYROID STIM HORMONE,3010000216,CDM,301,RC,,,Outpatient,,,315.00,204.75,,315,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,239.4,76,,148.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,226.8,72,,22.6,Percent of Total Billed Charges,72% of Total Billed Charges,236.25,75,,23.536,Percent of Total Billed charges,75% of Total Billed Charges,315,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.8,72,,22.6,Percent of Total Billed Charges,72% of Total Billed Charges,189,60,,18.832,Percent of Total Billed Charges,60% of Total Billed Charges,283.5,90,,104.4,Percent of Total Billed Charges,90% of Total Billed Charges,141.75,45,,59.04,Percent of Total Billed Charges,45% of Total Billed Charges,283.5,90,,176.224,Percent of Total Billed Charges,90% of Total billed Charges,315,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.75,65,,127.8,Percent of total Billed Charges,65% of Total Billed Charges,138.92,44.1,,57.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,299.25,95,,186.016,Percent of Total Billed Charges,95% of Total Billed Charges,315,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.2,88,,36.48,Percent of Total Billed Charges,88% of Total Billed Charges,283.5,90,,176.224,Percent of Total Billed charges,90% of Total Billed Charges,138.92,315,
TSH RECEPTOR ANTIBOD,3010000217,CDM,301,RC,,,Outpatient,,,600.86,390.56,,600.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,456.65,76,,34.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,432.62,72,,62.24,Percent of Total Billed Charges,72% of Total Billed Charges,450.65,75,,64.832,Percent of Total Billed charges,75% of Total Billed Charges,600.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,432.62,72,,62.24,Percent of Total Billed Charges,72% of Total Billed Charges,360.52,60,,51.864,Percent of Total Billed Charges,60% of Total Billed Charges,540.77,90,,84.24,Percent of Total Billed Charges,90% of Total Billed Charges,270.39,45,,18.656,Percent of Total Billed Charges,45% of Total Billed Charges,540.77,90,,41.04,Percent of Total Billed Charges,90% of Total billed Charges,600.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,600.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,600.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.56,65,,258.704,Percent of total Billed Charges,65% of Total Billed Charges,264.98,44.1,,18.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,570.82,95,,43.32,Percent of Total Billed Charges,95% of Total Billed Charges,600.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,528.76,88,,165.44,Percent of Total Billed Charges,88% of Total Billed Charges,540.77,90,,41.04,Percent of Total Billed charges,90% of Total Billed Charges,264.98,600.86,
SGOT,3010000218,CDM,301,RC,,,Outpatient,,,106.00,68.90,,106,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,80.56,76,,31.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,76.32,72,,172.728,Percent of Total Billed Charges,72% of Total Billed Charges,79.5,75,,179.928,Percent of Total Billed charges,75% of Total Billed Charges,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.32,72,,172.728,Percent of Total Billed Charges,72% of Total Billed Charges,63.6,60,,143.944,Percent of Total Billed Charges,60% of Total Billed Charges,95.4,90,,73.824,Percent of Total Billed Charges,90% of Total Billed Charges,47.7,45,,84.6,Percent of Total Billed Charges,45% of Total Billed Charges,95.4,90,,37.312,Percent of Total Billed Charges,90% of Total billed Charges,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.9,65,,28.536,Percent of total Billed Charges,65% of Total Billed Charges,46.75,44.1,,82.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,100.7,95,,39.384,Percent of Total Billed Charges,95% of Total Billed Charges,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.28,88,,109.12,Percent of Total Billed Charges,88% of Total Billed Charges,95.4,90,,37.312,Percent of Total Billed charges,90% of Total Billed Charges,46.75,106,
SGPT,3010000219,CDM,301,RC,,,Outpatient,,,90.00,58.50,,90,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.4,76,,31.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.8,72,,115.168,Percent of Total Billed Charges,72% of Total Billed Charges,67.5,75,,119.968,Percent of Total Billed charges,75% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.8,72,,115.168,Percent of Total Billed Charges,72% of Total Billed Charges,54,60,,95.976,Percent of Total Billed Charges,60% of Total Billed Charges,81,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,45,,55.8,Percent of Total Billed Charges,45% of Total Billed Charges,81,90,,37.312,Percent of Total Billed Charges,90% of Total billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.5,65,,14.184,Percent of total Billed Charges,65% of Total Billed Charges,39.69,44.1,,54.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.5,95,,39.384,Percent of Total Billed Charges,95% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,88,,80.96,Percent of Total Billed Charges,88% of Total Billed Charges,81,90,,37.312,Percent of Total Billed charges,90% of Total Billed Charges,39.69,90,
TRANSFERRIN,3010000220,CDM,301,RC,,,Outpatient,,,109.00,70.85,,109,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.84,76,,99.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,78.48,72,,143.424,Percent of Total Billed Charges,72% of Total Billed Charges,81.75,75,,149.4,Percent of Total Billed charges,75% of Total Billed Charges,109,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.48,72,,143.424,Percent of Total Billed Charges,72% of Total Billed Charges,65.4,60,,119.52,Percent of Total Billed Charges,60% of Total Billed Charges,98.1,90,,165.6,Percent of Total Billed Charges,90% of Total Billed Charges,49.05,45,,41.4,Percent of Total Billed Charges,45% of Total Billed Charges,98.1,90,,118.08,Percent of Total Billed Charges,90% of Total billed Charges,109,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.85,65,,18.824,Percent of total Billed Charges,65% of Total Billed Charges,48.07,44.1,,40.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,103.55,95,,124.64,Percent of Total Billed Charges,95% of Total Billed Charges,109,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.92,88,,80.96,Percent of Total Billed Charges,88% of Total Billed Charges,98.1,90,,118.08,Percent of Total Billed charges,90% of Total Billed Charges,48.07,109,
TRIGLYCERIDES,3010000221,CDM,301,RC,,,Outpatient,,,171.00,111.15,,171,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.96,76,,31.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.12,72,,64.776,Percent of Total Billed Charges,72% of Total Billed Charges,128.25,75,,67.48,Percent of Total Billed charges,75% of Total Billed Charges,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.12,72,,64.776,Percent of Total Billed Charges,72% of Total Billed Charges,102.6,60,,53.984,Percent of Total Billed Charges,60% of Total Billed Charges,153.9,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,76.95,45,,41.4,Percent of Total Billed Charges,45% of Total Billed Charges,153.9,90,,37.312,Percent of Total Billed Charges,90% of Total billed Charges,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.15,65,,60.24,Percent of total Billed Charges,65% of Total Billed Charges,75.41,44.1,,40.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,162.45,95,,39.384,Percent of Total Billed Charges,95% of Total Billed Charges,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.48,88,,102.08,Percent of Total Billed Charges,88% of Total Billed Charges,153.9,90,,37.312,Percent of Total Billed charges,90% of Total Billed Charges,75.41,171,
T3 UPTAKE,3010000222,CDM,301,RC,,,Outpatient,,,195.00,126.75,,195,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,148.2,76,,142.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,140.4,72,,809.04,Percent of Total Billed Charges,72% of Total Billed Charges,146.25,75,,842.752,Percent of Total Billed charges,75% of Total Billed Charges,195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.4,72,,809.04,Percent of Total Billed Charges,72% of Total Billed Charges,117,60,,674.2,Percent of Total Billed Charges,60% of Total Billed Charges,175.5,90,,86.52,Percent of Total Billed Charges,90% of Total Billed Charges,87.75,45,,52.2,Percent of Total Billed Charges,45% of Total Billed Charges,175.5,90,,169.2,Percent of Total Billed Charges,90% of Total billed Charges,195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.75,65,,47.84,Percent of total Billed Charges,65% of Total Billed Charges,86,44.1,,51.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,185.25,95,,178.6,Percent of Total Billed Charges,95% of Total Billed Charges,195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.6,88,,82.368,Percent of Total Billed Charges,88% of Total Billed Charges,175.5,90,,169.2,Percent of Total Billed charges,90% of Total Billed Charges,86,195,
TOTAL T3,3010000223,CDM,301,RC,,,Outpatient,,,166.00,107.90,,166,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,126.16,76,,94.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,119.52,72,,332.76,Percent of Total Billed Charges,72% of Total Billed Charges,124.5,75,,346.624,Percent of Total Billed charges,75% of Total Billed Charges,166,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.52,72,,332.76,Percent of Total Billed Charges,72% of Total Billed Charges,99.6,60,,277.304,Percent of Total Billed Charges,60% of Total Billed Charges,149.4,90,,30.96,Percent of Total Billed Charges,90% of Total Billed Charges,74.7,45,,42.12,Percent of Total Billed Charges,45% of Total Billed Charges,149.4,90,,111.6,Percent of Total Billed Charges,90% of Total billed Charges,166,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.9,65,,95.68,Percent of total Billed Charges,65% of Total Billed Charges,73.21,44.1,,41.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,157.7,95,,117.8,Percent of Total Billed Charges,95% of Total Billed Charges,166,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.08,88,,72.184,Percent of Total Billed Charges,88% of Total Billed Charges,149.4,90,,111.6,Percent of Total Billed charges,90% of Total Billed Charges,73.21,166,
FREE T3,3010000224,CDM,301,RC,,,Outpatient,,,265.70,172.71,,265.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,201.93,76,,69.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,191.3,72,,140.984,Percent of Total Billed Charges,72% of Total Billed Charges,199.28,75,,146.856,Percent of Total Billed charges,75% of Total Billed Charges,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.3,72,,140.984,Percent of Total Billed Charges,72% of Total Billed Charges,159.42,60,,117.488,Percent of Total Billed Charges,60% of Total Billed Charges,239.13,90,,22.224,Percent of Total Billed Charges,90% of Total Billed Charges,119.57,45,,36.912,Percent of Total Billed Charges,45% of Total Billed Charges,239.13,90,,82.8,Percent of Total Billed Charges,90% of Total billed Charges,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.71,65,,57.72,Percent of total Billed Charges,65% of Total Billed Charges,117.17,44.1,,36.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,252.42,95,,87.4,Percent of Total Billed Charges,95% of Total Billed Charges,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.82,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,239.13,90,,82.8,Percent of Total Billed charges,90% of Total Billed Charges,117.17,265.7,
TROPONIN,3010000225,CDM,301,RC,,,Outpatient,,,175.00,113.75,,175,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,133,76,,69.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,126,72,,164.784,Percent of Total Billed Charges,72% of Total Billed Charges,131.25,75,,171.648,Percent of Total Billed charges,75% of Total Billed Charges,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126,72,,164.784,Percent of Total Billed Charges,72% of Total Billed Charges,105,60,,137.32,Percent of Total Billed Charges,60% of Total Billed Charges,157.5,90,,75.6,Percent of Total Billed Charges,90% of Total Billed Charges,78.75,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,157.5,90,,82.8,Percent of Total Billed Charges,90% of Total billed Charges,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.75,65,,19.24,Percent of total Billed Charges,65% of Total Billed Charges,77.18,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,166.25,95,,87.4,Percent of Total Billed Charges,95% of Total Billed Charges,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154,88,,161.92,Percent of Total Billed Charges,88% of Total Billed Charges,157.5,90,,82.8,Percent of Total Billed charges,90% of Total Billed Charges,77.18,175,
BUN,3010000226,CDM,301,RC,,,Outpatient,,,103.00,66.95,,103,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,78.28,76,,88.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,74.16,72,,11.264,Percent of Total Billed Charges,72% of Total Billed Charges,77.25,75,,11.728,Percent of Total Billed charges,75% of Total Billed Charges,103,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.16,72,,11.264,Percent of Total Billed Charges,72% of Total Billed Charges,61.8,60,,9.384,Percent of Total Billed Charges,60% of Total Billed Charges,92.7,90,,290.88,Percent of Total Billed Charges,90% of Total Billed Charges,46.35,45,,82.8,Percent of Total Billed Charges,45% of Total Billed Charges,92.7,90,,104.4,Percent of Total Billed Charges,90% of Total billed Charges,103,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.95,65,,53.312,Percent of total Billed Charges,65% of Total Billed Charges,45.42,44.1,,81.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,97.85,95,,110.2,Percent of Total Billed Charges,95% of Total Billed Charges,103,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.64,88,,33.088,Percent of Total Billed Charges,88% of Total Billed Charges,92.7,90,,104.4,Percent of Total Billed charges,90% of Total Billed Charges,45.42,103,
URIC ACID BLOOD,3010000227,CDM,301,RC,,,Outpatient,,,78.00,50.70,,78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.28,76,,71.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.16,72,,26.672,Percent of Total Billed Charges,72% of Total Billed Charges,58.5,75,,27.784,Percent of Total Billed charges,75% of Total Billed Charges,78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.16,72,,26.672,Percent of Total Billed Charges,72% of Total Billed Charges,46.8,60,,22.224,Percent of Total Billed Charges,60% of Total Billed Charges,70.2,90,,84.96,Percent of Total Billed Charges,90% of Total Billed Charges,35.1,45,,16.92,Percent of Total Billed Charges,45% of Total Billed Charges,70.2,90,,84.24,Percent of Total Billed Charges,90% of Total billed Charges,78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.7,65,,12.48,Percent of total Billed Charges,65% of Total Billed Charges,34.4,44.1,,16.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.1,95,,88.92,Percent of Total Billed Charges,95% of Total Billed Charges,78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.64,88,,84.6,Percent of Total Billed Charges,88% of Total Billed Charges,70.2,90,,84.24,Percent of Total Billed charges,90% of Total Billed Charges,34.4,78,
URIC ACID SYNOVIAL FLUID,3010000228,CDM,301,RC,,,Outpatient,,,100.33,65.21,,100.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,76.25,76,,62.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,72.24,72,,25.824,Percent of Total Billed Charges,72% of Total Billed Charges,75.25,75,,26.896,Percent of Total Billed charges,75% of Total Billed Charges,100.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.24,72,,25.824,Percent of Total Billed Charges,72% of Total Billed Charges,60.2,60,,21.52,Percent of Total Billed Charges,60% of Total Billed Charges,90.3,90,,138.92,Percent of Total Billed Charges,90% of Total Billed Charges,45.15,45,,43.264,Percent of Total Billed Charges,45% of Total Billed Charges,90.3,90,,73.824,Percent of Total Billed Charges,90% of Total billed Charges,100.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.21,65,,221,Percent of total Billed Charges,65% of Total Billed Charges,44.25,44.1,,42.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,95.31,95,,77.92,Percent of Total Billed Charges,95% of Total Billed Charges,100.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.29,88,,30.272,Percent of Total Billed Charges,88% of Total Billed Charges,90.3,90,,73.824,Percent of Total Billed charges,90% of Total Billed Charges,44.25,100.33,
VITAMIN A,3010000229,CDM,301,RC,,,Outpatient,,,266.81,173.43,,266.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,202.78,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,192.1,72,,309.888,Percent of Total Billed Charges,72% of Total Billed Charges,200.11,75,,322.8,Percent of Total Billed charges,75% of Total Billed Charges,266.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.1,72,,309.888,Percent of Total Billed Charges,72% of Total Billed Charges,160.09,60,,258.24,Percent of Total Billed Charges,60% of Total Billed Charges,240.13,90,,117.48,Percent of Total Billed Charges,90% of Total Billed Charges,120.06,45,,15.48,Percent of Total Billed Charges,45% of Total Billed Charges,240.13,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,266.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.43,65,,133.64,Percent of total Billed Charges,65% of Total Billed Charges,117.66,44.1,,15.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,253.47,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,266.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.79,88,,21.736,Percent of Total Billed Charges,88% of Total Billed Charges,240.13,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,117.66,266.81,
VITAMIN K,3010000230,CDM,301,RC,,,Outpatient,,,707.81,460.08,,707.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,537.94,76,,139.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,509.62,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,530.86,75,,367.792,Percent of Total Billed charges,75% of Total Billed Charges,707.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,509.62,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,424.69,60,,294.232,Percent of Total Billed Charges,60% of Total Billed Charges,637.03,90,,118.08,Percent of Total Billed Charges,90% of Total Billed Charges,318.51,45,,11.112,Percent of Total Billed Charges,45% of Total Billed Charges,637.03,90,,165.6,Percent of Total Billed Charges,90% of Total billed Charges,707.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,707.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,707.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,460.08,65,,96.2,Percent of total Billed Charges,65% of Total Billed Charges,312.14,44.1,,10.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,672.42,95,,174.8,Percent of Total Billed Charges,95% of Total Billed Charges,707.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,622.87,88,,73.92,Percent of Total Billed Charges,88% of Total Billed Charges,637.03,90,,165.6,Percent of Total Billed charges,90% of Total Billed Charges,312.14,707.81,
ZINC LEVEL,3010000231,CDM,301,RC,,,Outpatient,,,162.07,105.35,,162.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,123.17,76,,28.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,116.69,72,,18.736,Percent of Total Billed Charges,72% of Total Billed Charges,121.55,75,,19.52,Percent of Total Billed charges,75% of Total Billed Charges,162.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.69,72,,18.736,Percent of Total Billed Charges,72% of Total Billed Charges,97.24,60,,15.616,Percent of Total Billed Charges,60% of Total Billed Charges,145.86,90,,1011.304,Percent of Total Billed Charges,90% of Total Billed Charges,72.93,45,,37.8,Percent of Total Billed Charges,45% of Total Billed Charges,145.86,90,,33.84,Percent of Total Billed Charges,90% of Total billed Charges,162.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.35,65,,62.4,Percent of total Billed Charges,65% of Total Billed Charges,71.47,44.1,,37.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,153.97,95,,35.72,Percent of Total Billed Charges,95% of Total Billed Charges,162.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.62,88,,284.416,Percent of Total Billed Charges,88% of Total Billed Charges,145.86,90,,33.84,Percent of Total Billed charges,90% of Total Billed Charges,71.47,162.07,
CPEPTIDE,3010000232,CDM,301,RC,,,Outpatient,,,154.35,100.33,,154.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,117.31,76,,73.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.13,72,,42.16,Percent of Total Billed Charges,72% of Total Billed Charges,115.76,75,,43.92,Percent of Total Billed charges,75% of Total Billed Charges,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.13,72,,42.16,Percent of Total Billed Charges,72% of Total Billed Charges,92.61,60,,35.136,Percent of Total Billed Charges,60% of Total Billed Charges,138.92,90,,372.288,Percent of Total Billed Charges,90% of Total Billed Charges,69.46,45,,145.44,Percent of Total Billed Charges,45% of Total Billed Charges,138.92,90,,86.52,Percent of Total Billed Charges,90% of Total billed Charges,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.33,65,,468,Percent of total Billed Charges,65% of Total Billed Charges,68.07,44.1,,142.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,146.63,95,,91.328,Percent of Total Billed Charges,95% of Total Billed Charges,154.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.83,88,,83.072,Percent of Total Billed Charges,88% of Total Billed Charges,138.92,90,,86.52,Percent of Total Billed charges,90% of Total Billed Charges,68.07,154.35,
HCG QUANTITATIVE,3010000233,CDM,301,RC,,,Outpatient,,,223.00,144.95,,223,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,169.48,76,,26.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,160.56,72,,2627.712,Percent of Total Billed Charges,72% of Total Billed Charges,167.25,75,,2737.2,Percent of Total Billed charges,75% of Total Billed Charges,223,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.56,72,,2627.712,Percent of Total Billed Charges,72% of Total Billed Charges,133.8,60,,2189.76,Percent of Total Billed Charges,60% of Total Billed Charges,200.7,90,,513.592,Percent of Total Billed Charges,90% of Total Billed Charges,100.35,45,,42.48,Percent of Total Billed Charges,45% of Total Billed Charges,200.7,90,,30.96,Percent of Total Billed Charges,90% of Total billed Charges,223,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,223,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,223,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.95,65,,130.144,Percent of total Billed Charges,65% of Total Billed Charges,98.34,44.1,,41.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,211.85,95,,32.68,Percent of Total Billed Charges,95% of Total Billed Charges,223,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.24,88,,135.832,Percent of Total Billed Charges,88% of Total Billed Charges,200.7,90,,30.96,Percent of Total Billed charges,90% of Total Billed Charges,98.34,223,
HCGQUAL,3010000234,CDM,301,RC,,,Outpatient,,,209.00,135.85,,209,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,158.84,76,,18.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.48,72,,2627.712,Percent of Total Billed Charges,72% of Total Billed Charges,156.75,75,,2737.2,Percent of Total Billed charges,75% of Total Billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.48,72,,2627.712,Percent of Total Billed Charges,72% of Total Billed Charges,125.4,60,,2189.76,Percent of Total Billed Charges,60% of Total Billed Charges,188.1,90,,302.4,Percent of Total Billed Charges,90% of Total Billed Charges,94.05,45,,69.456,Percent of Total Billed Charges,45% of Total Billed Charges,188.1,90,,22.224,Percent of Total Billed Charges,90% of Total billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.85,65,,127.272,Percent of total Billed Charges,65% of Total Billed Charges,92.17,44.1,,68.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,198.55,95,,23.464,Percent of Total Billed Charges,95% of Total Billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.92,88,,114.872,Percent of Total Billed Charges,88% of Total Billed Charges,188.1,90,,22.224,Percent of Total Billed charges,90% of Total Billed Charges,92.17,209,
ISTAT HH,3010000235,CDM,305,RC,,,Outpatient,,,58.43,37.98,,58.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,44.41,76,,63.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.07,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,43.82,75,,367.792,Percent of Total Billed charges,75% of Total Billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.07,72,,353.08,Percent of Total Billed Charges,72% of Total Billed Charges,35.06,60,,294.232,Percent of Total Billed Charges,60% of Total Billed Charges,52.59,90,,42.072,Percent of Total Billed Charges,90% of Total Billed Charges,26.29,45,,58.744,Percent of Total Billed Charges,45% of Total Billed Charges,52.59,90,,75.6,Percent of Total Billed Charges,90% of Total billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.98,65,,46.8,Percent of total Billed Charges,65% of Total Billed Charges,25.77,44.1,,57.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,55.51,95,,79.8,Percent of Total Billed Charges,95% of Total Billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.42,88,,115.456,Percent of Total Billed Charges,88% of Total Billed Charges,52.59,90,,75.6,Percent of Total Billed charges,90% of Total Billed Charges,25.77,58.43,
FLOW CYTOMETRY 1ST MARKER,3010000237,CDM,311,RC,,,Outpatient,,,584.00,379.60,,584,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,443.84,76,,245.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,420.48,72,,164.192,Percent of Total Billed Charges,72% of Total Billed Charges,438,75,,171.032,Percent of Total Billed charges,75% of Total Billed Charges,584,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,420.48,72,,164.192,Percent of Total Billed Charges,72% of Total Billed Charges,350.4,60,,136.824,Percent of Total Billed Charges,60% of Total Billed Charges,525.6,90,,390.816,Percent of Total Billed Charges,90% of Total Billed Charges,262.8,45,,59.04,Percent of Total Billed Charges,45% of Total Billed Charges,525.6,90,,290.88,Percent of Total Billed Charges,90% of Total billed Charges,584,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,584,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,584,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.6,65,,81.984,Percent of total Billed Charges,65% of Total Billed Charges,257.54,44.1,,57.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,554.8,95,,307.04,Percent of Total Billed Charges,95% of Total Billed Charges,584,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.92,88,,988.832,Percent of Total Billed Charges,88% of Total Billed Charges,525.6,90,,290.88,Percent of Total Billed charges,90% of Total Billed Charges,257.54,584,
TRANSCUTANEOUS BITIR,3010000238,CDM,301,RC,,,Outpatient,,,42.00,27.30,,42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31.92,76,,71.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.24,72,,131.456,Percent of Total Billed Charges,72% of Total Billed Charges,31.5,75,,136.936,Percent of Total Billed charges,75% of Total Billed Charges,42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.24,72,,131.456,Percent of Total Billed Charges,72% of Total Billed Charges,25.2,60,,109.544,Percent of Total Billed Charges,60% of Total Billed Charges,37.8,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,18.9,45,,505.656,Percent of Total Billed Charges,45% of Total Billed Charges,37.8,90,,84.96,Percent of Total Billed Charges,90% of Total billed Charges,42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.3,65,,424.84,Percent of total Billed Charges,65% of Total Billed Charges,18.52,44.1,,495.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,39.9,95,,89.68,Percent of Total Billed Charges,95% of Total Billed Charges,42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.96,88,,364.016,Percent of Total Billed Charges,88% of Total Billed Charges,37.8,90,,84.96,Percent of Total Billed charges,90% of Total Billed Charges,18.52,42,
PSASCREENING TEST,3010000239,CDM,301,RC,G0103,HCPCS,Outpatient,,,26.46,17.20,,24.13,125,,,Fee Schedule,125% of CMS OPPS Rate,20.11,76,,117.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90.84,350,,132.72,Fee Schedule,350% of BCBS fee schedule,90.84,350,,138.256,Fee Schedule,350% of BCBS fee schedule,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,90.84,400,,132.72,Fee Schedule,400% of BCBS PPO fee schedule,22.71,100,,110.6,Fee Schedule,100% of Blue ADV HMO fee schedule,23.81,90,,128.88,Percent of Total Billed Charges,90% of Total Billed Charges,11.91,45,,186.144,Percent of Total Billed Charges,45% of Total Billed Charges,23.81,90,,138.92,Percent of Total Billed Charges,90% of Total billed Charges,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,38.61,200,,392.6,Fee Schedule,200% of CMS OPPS Rate,11.67,44.1,,182.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.14,95,,146.632,Percent of Total Billed Charges,95% of Total Billed Charges,14.48,75,,,Fee Schedule,75% of CMS OPPS Rate,23.28,88,,502.176,Percent of Total Billed Charges,88% of Total Billed Charges,23.81,90,,138.92,Percent of Total Billed charges,90% of Total Billed Charges,11.67,90.84,
VENOUS BLOOD GAS VBG,3010000246,CDM,301,RC,,,Outpatient,,,65.18,42.37,,65.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.54,76,,35.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.93,72,,86.368,Percent of Total Billed Charges,72% of Total Billed Charges,48.89,75,,89.968,Percent of Total Billed charges,75% of Total Billed Charges,65.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.93,72,,86.368,Percent of Total Billed Charges,72% of Total Billed Charges,39.11,60,,71.968,Percent of Total Billed Charges,60% of Total Billed Charges,58.66,90,,83.408,Percent of Total Billed Charges,90% of Total Billed Charges,29.33,45,,241.712,Percent of Total Billed Charges,45% of Total Billed Charges,58.66,90,,42.072,Percent of Total Billed Charges,90% of Total billed Charges,65.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.37,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,28.74,44.1,,236.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,61.92,95,,44.408,Percent of Total Billed Charges,95% of Total Billed Charges,65.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.36,88,,173.024,Percent of Total Billed Charges,88% of Total Billed Charges,58.66,90,,42.072,Percent of Total Billed charges,90% of Total Billed Charges,28.74,65.18,
CAPILLARY BLOOD GAS CBG,3010000247,CDM,301,RC,,,Outpatient,,,65.18,42.37,,65.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49.54,76,,330.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.93,72,,171.072,Percent of Total Billed Charges,72% of Total Billed Charges,48.89,75,,178.2,Percent of Total Billed charges,75% of Total Billed Charges,65.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.93,72,,171.072,Percent of Total Billed Charges,72% of Total Billed Charges,39.11,60,,142.56,Percent of Total Billed Charges,60% of Total Billed Charges,58.66,90,,66.24,Percent of Total Billed Charges,90% of Total Billed Charges,29.33,45,,88.48,Percent of Total Billed Charges,45% of Total Billed Charges,58.66,90,,390.816,Percent of Total Billed Charges,90% of Total billed Charges,65.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.37,65,,130,Percent of total Billed Charges,65% of Total Billed Charges,28.74,44.1,,86.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,61.92,95,,412.528,Percent of Total Billed Charges,95% of Total Billed Charges,65.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.36,88,,350.24,Percent of Total Billed Charges,88% of Total Billed Charges,58.66,90,,390.816,Percent of Total Billed charges,90% of Total Billed Charges,28.74,65.18,
IMIPRAMINE DESIPRAMINE AND TOT,3010000248,CDM,301,RC,,,Outpatient,,,286.00,185.90,,286,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,217.36,76,,60.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,205.92,72,,152.064,Percent of Total Billed Charges,72% of Total Billed Charges,214.5,75,,158.4,Percent of Total Billed charges,75% of Total Billed Charges,286,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.92,72,,152.064,Percent of Total Billed Charges,72% of Total Billed Charges,171.6,60,,126.72,Percent of Total Billed Charges,60% of Total Billed Charges,257.4,90,,132.48,Percent of Total Billed Charges,90% of Total Billed Charges,128.7,45,,179.104,Percent of Total Billed Charges,45% of Total Billed Charges,257.4,90,,71.28,Percent of Total Billed Charges,90% of Total billed Charges,286,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.9,65,,51.224,Percent of total Billed Charges,65% of Total Billed Charges,126.13,44.1,,175.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,271.7,95,,75.24,Percent of Total Billed Charges,95% of Total Billed Charges,286,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.68,88,,38.632,Percent of Total Billed Charges,88% of Total Billed Charges,257.4,90,,71.28,Percent of Total Billed charges,90% of Total Billed Charges,126.13,286,
COVID Antibody,3010000249,CDM,302,RC,,,Outpatient,,,297.50,193.38,,297.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,226.1,76,,108.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,214.2,72,,51.336,Percent of Total Billed Charges,72% of Total Billed Charges,223.13,75,,53.48,Percent of Total Billed charges,75% of Total Billed Charges,297.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.2,72,,51.336,Percent of Total Billed Charges,72% of Total Billed Charges,178.5,60,,42.784,Percent of Total Billed Charges,60% of Total Billed Charges,267.75,90,,79.92,Percent of Total Billed Charges,90% of Total Billed Charges,133.88,45,,19.76,Percent of Total Billed Charges,45% of Total Billed Charges,267.75,90,,128.88,Percent of Total Billed Charges,90% of Total billed Charges,297.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.38,65,,96.888,Percent of total Billed Charges,65% of Total Billed Charges,131.2,44.1,,19.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,282.63,95,,136.04,Percent of Total Billed Charges,95% of Total Billed Charges,297.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.8,88,,19.208,Percent of Total Billed Charges,88% of Total Billed Charges,267.75,90,,128.88,Percent of Total Billed charges,90% of Total Billed Charges,131.2,297.5,
Sars Cov 2 Rapid Antigen,3010000250,CDM,306,RC,,,Outpatient,,,111.00,72.15,,111,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,84.36,76,,408.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,79.92,72,,58.424,Percent of Total Billed Charges,72% of Total Billed Charges,83.25,75,,60.856,Percent of Total Billed charges,75% of Total Billed Charges,111,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.92,72,,58.424,Percent of Total Billed Charges,72% of Total Billed Charges,66.6,60,,48.688,Percent of Total Billed Charges,60% of Total Billed Charges,99.9,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,49.95,45,,9.824,Percent of Total Billed Charges,45% of Total Billed Charges,99.9,90,,483.424,Percent of Total Billed Charges,90% of Total billed Charges,111,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.15,65,,300.408,Percent of total Billed Charges,65% of Total Billed Charges,48.95,44.1,,9.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,105.45,95,,510.28,Percent of Total Billed Charges,95% of Total Billed Charges,111,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.68,88,,25.488,Percent of Total Billed Charges,88% of Total Billed Charges,99.9,90,,483.424,Percent of Total Billed charges,90% of Total Billed Charges,48.95,111,
Reagent Strip/Blood Glucose,3010000251,CDM,301,RC,,,Outpatient,,,15.00,9.75,,15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.4,76,,149.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.8,72,,198.144,Percent of Total Billed Charges,72% of Total Billed Charges,11.25,75,,206.4,Percent of Total Billed charges,75% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.8,72,,198.144,Percent of Total Billed Charges,72% of Total Billed Charges,9,60,,165.12,Percent of Total Billed Charges,60% of Total Billed Charges,13.5,90,,73.824,Percent of Total Billed Charges,90% of Total Billed Charges,6.75,45,,13.032,Percent of Total Billed Charges,45% of Total Billed Charges,13.5,90,,176.952,Percent of Total Billed Charges,90% of Total billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.75,65,,300.408,Percent of total Billed Charges,65% of Total Billed Charges,6.62,44.1,,12.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.25,95,,186.784,Percent of Total Billed Charges,95% of Total Billed Charges,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.2,88,,81.552,Percent of Total Billed Charges,88% of Total Billed Charges,13.5,90,,176.952,Percent of Total Billed charges,90% of Total Billed Charges,6.62,15,
SANE Alcohol Screen,3010000252,CDM,301,RC,,,Outpatient,,,583.00,378.95,,583,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,443.08,76,,302.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,419.76,72,,171.072,Percent of Total Billed Charges,72% of Total Billed Charges,437.25,75,,178.2,Percent of Total Billed charges,75% of Total Billed Charges,583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.76,72,,171.072,Percent of Total Billed Charges,72% of Total Billed Charges,349.8,60,,142.56,Percent of Total Billed Charges,60% of Total Billed Charges,524.7,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,262.35,45,,41.704,Percent of Total Billed Charges,45% of Total Billed Charges,524.7,90,,358.2,Percent of Total Billed Charges,90% of Total billed Charges,583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.95,65,,324.48,Percent of total Billed Charges,65% of Total Billed Charges,257.1,44.1,,40.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,553.85,95,,378.104,Percent of Total Billed Charges,95% of Total Billed Charges,583,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.04,88,,64.768,Percent of Total Billed Charges,88% of Total Billed Charges,524.7,90,,358.2,Percent of Total Billed charges,90% of Total Billed Charges,257.1,583,
SANE Urine Drug Screen,3010000253,CDM,301,RC,,,Outpatient,,,572.00,371.80,,572,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,434.72,76,,33.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,411.84,72,,171.072,Percent of Total Billed Charges,72% of Total Billed Charges,429,75,,178.2,Percent of Total Billed charges,75% of Total Billed Charges,572,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.84,72,,171.072,Percent of Total Billed Charges,72% of Total Billed Charges,343.2,60,,142.56,Percent of Total Billed Charges,60% of Total Billed Charges,514.8,90,,306,Percent of Total Billed Charges,90% of Total Billed Charges,257.4,45,,33.12,Percent of Total Billed Charges,45% of Total Billed Charges,514.8,90,,39.512,Percent of Total Billed Charges,90% of Total billed Charges,572,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,572,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,572,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.8,65,,130,Percent of total Billed Charges,65% of Total Billed Charges,252.25,44.1,,32.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,543.4,95,,41.712,Percent of Total Billed Charges,95% of Total Billed Charges,572,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,503.36,88,,129.536,Percent of Total Billed Charges,88% of Total Billed Charges,514.8,90,,39.512,Percent of Total Billed charges,90% of Total Billed Charges,252.25,572,
"HEP B SURF,AB, QUANTITATIVE",3020000001,CDM,302,RC,,,Outpatient,,,657.09,427.11,,657.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,499.39,76,,16.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,473.1,72,,179.712,Percent of Total Billed Charges,72% of Total Billed Charges,492.82,75,,187.2,Percent of Total Billed charges,75% of Total Billed Charges,657.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.1,72,,179.712,Percent of Total Billed Charges,72% of Total Billed Charges,394.25,60,,149.76,Percent of Total Billed Charges,60% of Total Billed Charges,591.38,90,,185.04,Percent of Total Billed Charges,90% of Total Billed Charges,295.69,45,,66.24,Percent of Total Billed Charges,45% of Total Billed Charges,591.38,90,,19.64,Percent of Total Billed Charges,90% of Total billed Charges,657.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,657.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,657.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.11,65,,68.224,Percent of total Billed Charges,65% of Total Billed Charges,289.78,44.1,,64.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,624.24,95,,20.736,Percent of Total Billed Charges,95% of Total Billed Charges,657.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,578.24,88,,78.144,Percent of Total Billed Charges,88% of Total Billed Charges,591.38,90,,19.64,Percent of Total Billed charges,90% of Total Billed Charges,289.78,657.09,
ISLET CELL  SCR W RFLX TO TITE,3020000002,CDM,302,RC,,,Outpatient,,,38.59,25.08,,38.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.33,76,,22.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,27.78,72,,296.064,Percent of Total Billed Charges,72% of Total Billed Charges,28.94,75,,308.4,Percent of Total Billed charges,75% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.78,72,,296.064,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,60,,246.72,Percent of Total Billed Charges,60% of Total Billed Charges,34.73,90,,133.2,Percent of Total Billed Charges,90% of Total Billed Charges,17.37,45,,39.96,Percent of Total Billed Charges,45% of Total Billed Charges,34.73,90,,26.064,Percent of Total Billed Charges,90% of Total billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.08,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,17.02,44.1,,39.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.66,95,,27.512,Percent of Total Billed Charges,95% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.96,88,,26.048,Percent of Total Billed Charges,88% of Total Billed Charges,34.73,90,,26.064,Percent of Total Billed charges,90% of Total Billed Charges,17.02,38.59,
H PYLORI UREA BREAT,3020000003,CDM,301,RC,,,Outpatient,,,201.76,131.14,,201.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,153.34,76,,70.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,145.27,72,,59.328,Percent of Total Billed Charges,72% of Total Billed Charges,151.32,75,,61.8,Percent of Total Billed charges,75% of Total Billed Charges,201.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.27,72,,59.328,Percent of Total Billed Charges,72% of Total Billed Charges,121.06,60,,49.44,Percent of Total Billed Charges,60% of Total Billed Charges,181.58,90,,86.4,Percent of Total Billed Charges,90% of Total Billed Charges,90.79,45,,13.32,Percent of Total Billed Charges,45% of Total Billed Charges,181.58,90,,83.408,Percent of Total Billed Charges,90% of Total billed Charges,201.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.14,65,,49.4,Percent of total Billed Charges,65% of Total Billed Charges,88.98,44.1,,13.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,191.67,95,,88.04,Percent of Total Billed Charges,95% of Total Billed Charges,201.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.55,88,,72.184,Percent of Total Billed Charges,88% of Total Billed Charges,181.58,90,,83.408,Percent of Total Billed charges,90% of Total Billed Charges,88.98,201.76,
IGF BINDING PROTEIN,3020000004,CDM,301,RC,,,Outpatient,,,612.99,398.44,,612.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.87,76,,55.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,441.35,72,,73.152,Percent of Total Billed Charges,72% of Total Billed Charges,459.74,75,,76.2,Percent of Total Billed charges,75% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,441.35,72,,73.152,Percent of Total Billed Charges,72% of Total Billed Charges,367.79,60,,60.96,Percent of Total Billed Charges,60% of Total Billed Charges,551.69,90,,648,Percent of Total Billed Charges,90% of Total Billed Charges,275.85,45,,36.912,Percent of Total Billed Charges,45% of Total Billed Charges,551.69,90,,66.24,Percent of Total Billed Charges,90% of Total billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.44,65,,49.4,Percent of total Billed Charges,65% of Total Billed Charges,270.33,44.1,,36.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,582.34,95,,69.92,Percent of Total Billed Charges,95% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,539.43,88,,16.896,Percent of Total Billed Charges,88% of Total Billed Charges,551.69,90,,66.24,Percent of Total Billed charges,90% of Total Billed Charges,270.33,612.99,
GLOMERULAR MEMBRANE,3020000005,CDM,301,RC,,,Outpatient,,,577.71,375.51,,577.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,439.06,76,,111.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.95,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,433.28,75,,165,Percent of Total Billed charges,75% of Total Billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.95,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,346.63,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,519.94,90,,180.192,Percent of Total Billed Charges,90% of Total Billed Charges,259.97,45,,8.64,Percent of Total Billed Charges,45% of Total Billed Charges,519.94,90,,132.48,Percent of Total Billed Charges,90% of Total billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.51,65,,88.92,Percent of total Billed Charges,65% of Total Billed Charges,254.77,44.1,,8.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,548.82,95,,139.84,Percent of Total Billed Charges,95% of Total Billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.38,88,,299.2,Percent of Total Billed Charges,88% of Total Billed Charges,519.94,90,,132.48,Percent of Total Billed charges,90% of Total Billed Charges,254.77,577.71,
MYCOPHENOLIC ACID,3020000006,CDM,301,RC,,,Outpatient,,,260.19,169.12,,260.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,197.74,76,,67.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,187.34,72,,164.16,Percent of Total Billed Charges,72% of Total Billed Charges,195.14,75,,171,Percent of Total Billed charges,75% of Total Billed Charges,260.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.34,72,,164.16,Percent of Total Billed Charges,72% of Total Billed Charges,156.11,60,,136.8,Percent of Total Billed Charges,60% of Total Billed Charges,234.17,90,,176.224,Percent of Total Billed Charges,90% of Total Billed Charges,117.09,45,,153,Percent of Total Billed Charges,45% of Total Billed Charges,234.17,90,,79.92,Percent of Total Billed Charges,90% of Total billed Charges,260.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.12,65,,190.064,Percent of total Billed Charges,65% of Total Billed Charges,114.74,44.1,,149.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,247.18,95,,84.36,Percent of Total Billed Charges,95% of Total Billed Charges,260.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.97,88,,180.928,Percent of Total Billed Charges,88% of Total Billed Charges,234.17,90,,79.92,Percent of Total Billed charges,90% of Total Billed Charges,114.74,260.19,
RESP ALLERGY PNL RE,3020000007,CDM,302,RC,,,Outpatient,,,270.00,175.50,,270,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,205.2,76,,22.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,194.4,72,,182.592,Percent of Total Billed Charges,72% of Total Billed Charges,202.5,75,,190.2,Percent of Total Billed charges,75% of Total Billed Charges,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.4,72,,182.592,Percent of Total Billed Charges,72% of Total Billed Charges,162,60,,152.16,Percent of Total Billed Charges,60% of Total Billed Charges,243,90,,64.8,Percent of Total Billed Charges,90% of Total Billed Charges,121.5,45,,92.52,Percent of Total Billed Charges,45% of Total Billed Charges,243,90,,26.64,Percent of Total Billed Charges,90% of Total billed Charges,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.5,65,,52,Percent of total Billed Charges,65% of Total Billed Charges,119.07,44.1,,90.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,256.5,95,,28.12,Percent of Total Billed Charges,95% of Total Billed Charges,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.6,88,,130.24,Percent of Total Billed Charges,88% of Total Billed Charges,243,90,,26.64,Percent of Total Billed charges,90% of Total Billed Charges,119.07,270,
FOOD ALLERGY PANEL,3020000008,CDM,302,RC,,,Outpatient,,,283.34,184.17,,283.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,215.34,76,,62.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,204,72,,452.736,Percent of Total Billed Charges,72% of Total Billed Charges,212.51,75,,471.6,Percent of Total Billed charges,75% of Total Billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204,72,,452.736,Percent of Total Billed Charges,72% of Total Billed Charges,170,60,,377.28,Percent of Total Billed Charges,60% of Total Billed Charges,255.01,90,,113.512,Percent of Total Billed Charges,90% of Total Billed Charges,127.5,45,,66.6,Percent of Total Billed Charges,45% of Total Billed Charges,255.01,90,,73.824,Percent of Total Billed Charges,90% of Total billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.17,65,,52,Percent of total Billed Charges,65% of Total Billed Charges,124.95,44.1,,65.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,269.17,95,,77.92,Percent of Total Billed Charges,95% of Total Billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.34,88,,84.48,Percent of Total Billed Charges,88% of Total Billed Charges,255.01,90,,73.824,Percent of Total Billed charges,90% of Total Billed Charges,124.95,283.34,
ALLG SPEC IGE CRUDE XTRC EA,3020000009,CDM,302,RC,,,Outpatient,,,27.00,17.55,,27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.52,76,,14.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.44,72,,48.264,Percent of Total Billed Charges,72% of Total Billed Charges,20.25,75,,50.272,Percent of Total Billed charges,75% of Total Billed Charges,27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.44,72,,48.264,Percent of Total Billed Charges,72% of Total Billed Charges,16.2,60,,40.216,Percent of Total Billed Charges,60% of Total Billed Charges,24.3,90,,588.24,Percent of Total Billed Charges,90% of Total Billed Charges,12.15,45,,43.2,Percent of Total Billed Charges,45% of Total Billed Charges,24.3,90,,17.28,Percent of Total Billed Charges,90% of Total billed Charges,27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.55,65,,72.8,Percent of total Billed Charges,65% of Total Billed Charges,11.91,44.1,,42.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.65,95,,18.24,Percent of Total Billed Charges,95% of Total Billed Charges,27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.76,88,,633.6,Percent of Total Billed Charges,88% of Total Billed Charges,24.3,90,,17.28,Percent of Total Billed charges,90% of Total Billed Charges,11.91,27,
LEUKOCYTE ANTIBODIES,3020000010,CDM,302,RC,,,Outpatient,,,369.34,240.07,,369.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,280.7,76,,258.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,265.92,72,,69.12,Percent of Total Billed Charges,72% of Total Billed Charges,277.01,75,,72,Percent of Total Billed charges,75% of Total Billed Charges,369.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.92,72,,69.12,Percent of Total Billed Charges,72% of Total Billed Charges,221.6,60,,57.6,Percent of Total Billed Charges,60% of Total Billed Charges,332.41,90,,543.6,Percent of Total Billed Charges,90% of Total Billed Charges,166.2,45,,324,Percent of Total Billed Charges,45% of Total Billed Charges,332.41,90,,306,Percent of Total Billed Charges,90% of Total billed Charges,369.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.07,65,,84.848,Percent of total Billed Charges,65% of Total Billed Charges,162.88,44.1,,317.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,350.87,95,,323,Percent of Total Billed Charges,95% of Total Billed Charges,369.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.02,88,,176.192,Percent of Total Billed Charges,88% of Total Billed Charges,332.41,90,,306,Percent of Total Billed charges,90% of Total Billed Charges,162.88,369.34,
ANCA VASCULIDITIES,3020000011,CDM,302,RC,,,Outpatient,,,414.54,269.45,,414.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,315.05,76,,156.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,298.47,72,,40.896,Percent of Total Billed Charges,72% of Total Billed Charges,310.91,75,,42.6,Percent of Total Billed charges,75% of Total Billed Charges,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.47,72,,40.896,Percent of Total Billed Charges,72% of Total Billed Charges,248.72,60,,34.08,Percent of Total Billed Charges,60% of Total Billed Charges,373.09,90,,550.8,Percent of Total Billed Charges,90% of Total Billed Charges,186.54,45,,90.096,Percent of Total Billed Charges,45% of Total Billed Charges,373.09,90,,185.04,Percent of Total Billed Charges,90% of Total billed Charges,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.45,65,,75.664,Percent of total Billed Charges,65% of Total Billed Charges,182.81,44.1,,88.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,393.81,95,,195.32,Percent of Total Billed Charges,95% of Total Billed Charges,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.8,88,,172.312,Percent of Total Billed Charges,88% of Total Billed Charges,373.09,90,,185.04,Percent of Total Billed charges,90% of Total Billed Charges,182.81,414.54,
ANCA SCREEN,3020000012,CDM,302,RC,,,Outpatient,,,414.54,269.45,,414.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,315.05,76,,112.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,298.47,72,,187.984,Percent of Total Billed Charges,72% of Total Billed Charges,310.91,75,,195.816,Percent of Total Billed charges,75% of Total Billed Charges,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.47,72,,187.984,Percent of Total Billed Charges,72% of Total Billed Charges,248.72,60,,156.656,Percent of Total Billed Charges,60% of Total Billed Charges,373.09,90,,150.48,Percent of Total Billed Charges,90% of Total Billed Charges,186.54,45,,88.112,Percent of Total Billed Charges,45% of Total Billed Charges,373.09,90,,133.2,Percent of Total Billed Charges,90% of Total billed Charges,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.45,65,,112.832,Percent of total Billed Charges,65% of Total Billed Charges,182.81,44.1,,86.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,393.81,95,,140.6,Percent of Total Billed Charges,95% of Total Billed Charges,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.8,88,,63.36,Percent of Total Billed Charges,88% of Total Billed Charges,373.09,90,,133.2,Percent of Total Billed charges,90% of Total Billed Charges,182.81,414.54,
CENTROMERE ANTIBODY,3020000013,CDM,302,RC,,,Outpatient,,,314.21,204.24,,314.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,238.8,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,226.23,72,,72,Percent of Total Billed Charges,72% of Total Billed Charges,235.66,75,,75,Percent of Total Billed charges,75% of Total Billed Charges,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.23,72,,72,Percent of Total Billed Charges,72% of Total Billed Charges,188.53,60,,60,Percent of Total Billed Charges,60% of Total Billed Charges,282.79,90,,133.92,Percent of Total Billed Charges,90% of Total Billed Charges,141.39,45,,32.4,Percent of Total Billed Charges,45% of Total Billed Charges,282.79,90,,86.4,Percent of Total Billed Charges,90% of Total billed Charges,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.24,65,,84.24,Percent of total Billed Charges,65% of Total Billed Charges,138.57,44.1,,31.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,298.5,95,,91.2,Percent of Total Billed Charges,95% of Total Billed Charges,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.5,88,,110.992,Percent of Total Billed Charges,88% of Total Billed Charges,282.79,90,,86.4,Percent of Total Billed charges,90% of Total Billed Charges,138.57,314.21,
ANA ANTIBODIES,3020000014,CDM,302,RC,,,Outpatient,,,314.21,204.24,,314.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,238.8,76,,547.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,226.23,72,,184.72,Percent of Total Billed Charges,72% of Total Billed Charges,235.66,75,,192.424,Percent of Total Billed charges,75% of Total Billed Charges,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.23,72,,184.72,Percent of Total Billed Charges,72% of Total Billed Charges,188.53,60,,153.936,Percent of Total Billed Charges,60% of Total Billed Charges,282.79,90,,75.416,Percent of Total Billed Charges,90% of Total Billed Charges,141.39,45,,56.76,Percent of Total Billed Charges,45% of Total Billed Charges,282.79,90,,648,Percent of Total Billed Charges,90% of Total billed Charges,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.24,65,,80.08,Percent of total Billed Charges,65% of Total Billed Charges,138.57,44.1,,55.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,298.5,95,,684,Percent of Total Billed Charges,95% of Total Billed Charges,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.5,88,,575.168,Percent of Total Billed Charges,88% of Total Billed Charges,282.79,90,,648,Percent of Total Billed charges,90% of Total Billed Charges,138.57,314.21,
ASO TITER,3020000015,CDM,302,RC,,,Outpatient,,,84.89,55.18,,84.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,64.52,76,,152.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.12,72,,48.896,Percent of Total Billed Charges,72% of Total Billed Charges,63.67,75,,50.936,Percent of Total Billed charges,75% of Total Billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,72,,48.896,Percent of Total Billed Charges,72% of Total Billed Charges,50.93,60,,40.744,Percent of Total Billed Charges,60% of Total Billed Charges,76.4,90,,95.04,Percent of Total Billed Charges,90% of Total Billed Charges,38.2,45,,294.12,Percent of Total Billed Charges,45% of Total Billed Charges,76.4,90,,180.192,Percent of Total Billed Charges,90% of Total billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.18,65,,100.36,Percent of total Billed Charges,65% of Total Billed Charges,37.44,44.1,,288.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,80.65,95,,190.208,Percent of Total Billed Charges,95% of Total Billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.7,88,,531.52,Percent of Total Billed Charges,88% of Total Billed Charges,76.4,90,,180.192,Percent of Total Billed charges,90% of Total Billed Charges,37.44,84.89,
CRP,3020000016,CDM,302,RC,,,Outpatient,,,14.00,9.10,,14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.64,76,,148.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.08,72,,169.92,Percent of Total Billed Charges,72% of Total Billed Charges,10.5,75,,177,Percent of Total Billed charges,75% of Total Billed Charges,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.08,72,,169.92,Percent of Total Billed Charges,72% of Total Billed Charges,8.4,60,,141.6,Percent of Total Billed Charges,60% of Total Billed Charges,12.6,90,,30.24,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,45,,271.8,Percent of Total Billed Charges,45% of Total Billed Charges,12.6,90,,176.224,Percent of Total Billed Charges,90% of Total billed Charges,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.1,65,,65,Percent of total Billed Charges,65% of Total Billed Charges,6.17,44.1,,266.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.3,95,,186.016,Percent of Total Billed Charges,95% of Total Billed Charges,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.32,88,,538.56,Percent of Total Billed Charges,88% of Total Billed Charges,12.6,90,,176.224,Percent of Total Billed charges,90% of Total Billed Charges,6.17,14,
CARDIO IQ HS CRP,3020000017,CDM,302,RC,,,Outpatient,,,34.00,22.10,,34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.84,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.48,72,,351.36,Percent of Total Billed Charges,72% of Total Billed Charges,25.5,75,,366,Percent of Total Billed charges,75% of Total Billed Charges,34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.48,72,,351.36,Percent of Total Billed Charges,72% of Total Billed Charges,20.4,60,,292.8,Percent of Total Billed Charges,60% of Total Billed Charges,30.6,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,45,,275.4,Percent of Total Billed Charges,45% of Total Billed Charges,30.6,90,,64.8,Percent of Total Billed Charges,90% of Total billed Charges,34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.1,65,,226.2,Percent of total Billed Charges,65% of Total Billed Charges,14.99,44.1,,269.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.3,95,,68.4,Percent of Total Billed Charges,95% of Total Billed Charges,34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.92,88,,147.136,Percent of Total Billed Charges,88% of Total Billed Charges,30.6,90,,64.8,Percent of Total Billed charges,90% of Total Billed Charges,14.99,34,
BETA2GLYCOPROTEIN I AB (IGA),3020000018,CDM,302,RC,,,Outpatient,,,134.51,87.43,,134.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,102.23,76,,95.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,96.85,72,,184.32,Percent of Total Billed Charges,72% of Total Billed Charges,100.88,75,,192,Percent of Total Billed charges,75% of Total Billed Charges,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.85,72,,184.32,Percent of Total Billed Charges,72% of Total Billed Charges,80.71,60,,153.6,Percent of Total Billed Charges,60% of Total Billed Charges,121.06,90,,180,Percent of Total Billed Charges,90% of Total Billed Charges,60.53,45,,75.24,Percent of Total Billed Charges,45% of Total Billed Charges,121.06,90,,113.512,Percent of Total Billed Charges,90% of Total billed Charges,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.43,65,,28.08,Percent of total Billed Charges,65% of Total Billed Charges,59.32,44.1,,73.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,127.78,95,,119.824,Percent of Total Billed Charges,95% of Total Billed Charges,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.37,88,,130.944,Percent of Total Billed Charges,88% of Total Billed Charges,121.06,90,,113.512,Percent of Total Billed charges,90% of Total Billed Charges,59.32,134.51,
BETA2GLYCOPROTEIN I AB (IGM),3020000019,CDM,302,RC,,,Outpatient,,,134.51,87.43,,134.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,102.23,76,,496.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,96.85,72,,211.68,Percent of Total Billed Charges,72% of Total Billed Charges,100.88,75,,220.504,Percent of Total Billed charges,75% of Total Billed Charges,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.85,72,,211.68,Percent of Total Billed Charges,72% of Total Billed Charges,80.71,60,,176.4,Percent of Total Billed Charges,60% of Total Billed Charges,121.06,90,,70.92,Percent of Total Billed Charges,90% of Total Billed Charges,60.53,45,,66.96,Percent of Total Billed Charges,45% of Total Billed Charges,121.06,90,,588.24,Percent of Total Billed Charges,90% of Total billed Charges,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.43,65,,34.4,Percent of total Billed Charges,65% of Total Billed Charges,59.32,44.1,,65.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,127.78,95,,620.92,Percent of Total Billed Charges,95% of Total Billed Charges,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.37,88,,73.736,Percent of Total Billed Charges,88% of Total Billed Charges,121.06,90,,588.24,Percent of Total Billed charges,90% of Total Billed Charges,59.32,134.51,
BETA2GLYCOPROTEIN AB (IGG),3020000020,CDM,302,RC,,,Outpatient,,,134.51,87.43,,134.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,102.23,76,,459.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,96.85,72,,103.68,Percent of Total Billed Charges,72% of Total Billed Charges,100.88,75,,108,Percent of Total Billed charges,75% of Total Billed Charges,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.85,72,,103.68,Percent of Total Billed Charges,72% of Total Billed Charges,80.71,60,,86.4,Percent of Total Billed Charges,60% of Total Billed Charges,121.06,90,,134.152,Percent of Total Billed Charges,90% of Total Billed Charges,60.53,45,,37.704,Percent of Total Billed Charges,45% of Total Billed Charges,121.06,90,,543.6,Percent of Total Billed Charges,90% of Total billed Charges,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.43,65,,78.52,Percent of total Billed Charges,65% of Total Billed Charges,59.32,44.1,,36.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,127.78,95,,573.8,Percent of Total Billed Charges,95% of Total Billed Charges,134.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.37,88,,92.928,Percent of Total Billed Charges,88% of Total Billed Charges,121.06,90,,543.6,Percent of Total Billed charges,90% of Total Billed Charges,59.32,134.51,
CARDIOLIPIN G/M/A,3020000021,CDM,302,RC,,,Outpatient,,,711.11,462.22,,711.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,540.44,76,,465.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,512,72,,262.656,Percent of Total Billed Charges,72% of Total Billed Charges,533.33,75,,273.6,Percent of Total Billed charges,75% of Total Billed Charges,711.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,512,72,,262.656,Percent of Total Billed Charges,72% of Total Billed Charges,426.67,60,,218.88,Percent of Total Billed Charges,60% of Total Billed Charges,640,90,,415.952,Percent of Total Billed Charges,90% of Total Billed Charges,320,45,,47.52,Percent of Total Billed Charges,45% of Total Billed Charges,640,90,,550.8,Percent of Total Billed Charges,90% of Total billed Charges,711.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,711.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,711.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.22,65,,24.08,Percent of total Billed Charges,65% of Total Billed Charges,313.6,44.1,,46.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,675.55,95,,581.4,Percent of Total Billed Charges,95% of Total Billed Charges,711.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.78,88,,29.568,Percent of Total Billed Charges,88% of Total Billed Charges,640,90,,550.8,Percent of Total Billed charges,90% of Total Billed Charges,313.6,711.11,
CARDIOLIPIN AB EACH,3020000022,CDM,302,RC,,,Outpatient,,,86.00,55.90,,86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,65.36,76,,127.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.92,72,,208.52,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,75,,217.208,Percent of Total Billed charges,75% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.92,72,,208.52,Percent of Total Billed Charges,72% of Total Billed Charges,51.6,60,,173.768,Percent of Total Billed Charges,60% of Total Billed Charges,77.4,90,,415.952,Percent of Total Billed Charges,90% of Total Billed Charges,38.7,45,,15.12,Percent of Total Billed Charges,45% of Total Billed Charges,77.4,90,,150.48,Percent of Total Billed Charges,90% of Total billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.9,65,,100.88,Percent of total Billed Charges,65% of Total Billed Charges,37.93,44.1,,14.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,81.7,95,,158.84,Percent of Total Billed Charges,95% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.68,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,77.4,90,,150.48,Percent of Total Billed charges,90% of Total Billed Charges,37.93,86,
ANTIPHOSPHATIDYLSERINE AB,3020000023,CDM,302,RC,,,Outpatient,,,30.87,20.07,,30.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.46,76,,113.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.23,72,,408.96,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,75,,426,Percent of Total Billed charges,75% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.23,72,,408.96,Percent of Total Billed Charges,72% of Total Billed Charges,18.52,60,,340.8,Percent of Total Billed Charges,60% of Total Billed Charges,27.78,90,,449.28,Percent of Total Billed Charges,90% of Total Billed Charges,13.89,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,27.78,90,,133.92,Percent of Total Billed Charges,90% of Total billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.07,65,,46.44,Percent of total Billed Charges,65% of Total Billed Charges,13.61,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.33,95,,141.36,Percent of Total Billed Charges,95% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.17,88,,176,Percent of Total Billed Charges,88% of Total Billed Charges,27.78,90,,133.92,Percent of Total Billed charges,90% of Total Billed Charges,13.61,30.87,
COMPLEMENT SERUM,3020000024,CDM,302,RC,,,Outpatient,,,163.17,106.06,,163.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.01,76,,63.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,117.48,72,,251.712,Percent of Total Billed Charges,72% of Total Billed Charges,122.38,75,,262.2,Percent of Total Billed charges,75% of Total Billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.48,72,,251.712,Percent of Total Billed Charges,72% of Total Billed Charges,97.9,60,,209.76,Percent of Total Billed Charges,60% of Total Billed Charges,146.85,90,,180,Percent of Total Billed Charges,90% of Total Billed Charges,73.43,45,,90,Percent of Total Billed Charges,45% of Total Billed Charges,146.85,90,,75.416,Percent of Total Billed Charges,90% of Total billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.06,65,,46.44,Percent of total Billed Charges,65% of Total Billed Charges,71.96,44.1,,88.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,155.01,95,,79.6,Percent of Total Billed Charges,95% of Total Billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.59,88,,69.344,Percent of Total Billed Charges,88% of Total Billed Charges,146.85,90,,75.416,Percent of Total Billed charges,90% of Total Billed Charges,71.96,163.17,
COMPLEMENT C4,3020000025,CDM,302,RC,,,Outpatient,,,163.17,106.06,,163.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.01,76,,80.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,117.48,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,122.38,75,,51.6,Percent of Total Billed charges,75% of Total Billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.48,72,,49.536,Percent of Total Billed Charges,72% of Total Billed Charges,97.9,60,,41.28,Percent of Total Billed Charges,60% of Total Billed Charges,146.85,90,,94.464,Percent of Total Billed Charges,90% of Total Billed Charges,73.43,45,,35.464,Percent of Total Billed Charges,45% of Total Billed Charges,146.85,90,,95.04,Percent of Total Billed Charges,90% of Total billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.06,65,,127.8,Percent of total Billed Charges,65% of Total Billed Charges,71.96,44.1,,34.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,155.01,95,,100.32,Percent of Total Billed Charges,95% of Total Billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.59,88,,131.168,Percent of Total Billed Charges,88% of Total Billed Charges,146.85,90,,95.04,Percent of Total Billed charges,90% of Total Billed Charges,71.96,163.17,
C3 (COMPLEMENT),3020000026,CDM,302,RC,,,Outpatient,,,119.07,77.40,,119.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,90.49,76,,25.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,85.73,72,,179.712,Percent of Total Billed Charges,72% of Total Billed Charges,89.3,75,,187.2,Percent of Total Billed charges,75% of Total Billed Charges,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.73,72,,179.712,Percent of Total Billed Charges,72% of Total Billed Charges,71.44,60,,149.76,Percent of Total Billed Charges,60% of Total Billed Charges,107.16,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,53.58,45,,67.072,Percent of Total Billed Charges,45% of Total Billed Charges,107.16,90,,30.24,Percent of Total Billed Charges,90% of Total billed Charges,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,65,,153.072,Percent of total Billed Charges,65% of Total Billed Charges,52.51,44.1,,65.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,113.12,95,,31.92,Percent of Total Billed Charges,95% of Total Billed Charges,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.78,88,,406.704,Percent of Total Billed Charges,88% of Total Billed Charges,107.16,90,,30.24,Percent of Total Billed charges,90% of Total Billed Charges,52.51,119.07,
CYCLIC CIT PEP CCP I,3020000027,CDM,302,RC,,,Outpatient,,,346.00,224.90,,346,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,262.96,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,249.12,72,,437.184,Percent of Total Billed Charges,72% of Total Billed Charges,259.5,75,,455.4,Percent of Total Billed charges,75% of Total Billed Charges,346,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.12,72,,437.184,Percent of Total Billed Charges,72% of Total Billed Charges,207.6,60,,364.32,Percent of Total Billed Charges,60% of Total Billed Charges,311.4,90,,68.4,Percent of Total Billed Charges,90% of Total Billed Charges,155.7,45,,207.976,Percent of Total Billed Charges,45% of Total Billed Charges,311.4,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,346,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.9,65,,101.4,Percent of total Billed Charges,65% of Total Billed Charges,152.59,44.1,,203.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,328.7,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,346,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.48,88,,406.704,Percent of Total Billed Charges,88% of Total Billed Charges,311.4,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,152.59,346,
ANTI DNA ANTIBODY,3020000028,CDM,302,RC,,,Outpatient,,,175.00,113.75,,175,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,133,76,,152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,126,72,,403.376,Percent of Total Billed Charges,72% of Total Billed Charges,131.25,75,,420.184,Percent of Total Billed charges,75% of Total Billed Charges,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126,72,,403.376,Percent of Total Billed Charges,72% of Total Billed Charges,105,60,,336.144,Percent of Total Billed Charges,60% of Total Billed Charges,157.5,90,,68.4,Percent of Total Billed Charges,90% of Total Billed Charges,78.75,45,,207.976,Percent of Total Billed Charges,45% of Total Billed Charges,157.5,90,,180,Percent of Total Billed Charges,90% of Total billed Charges,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.75,65,,115.44,Percent of total Billed Charges,65% of Total Billed Charges,77.18,44.1,,203.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,166.25,95,,190,Percent of Total Billed Charges,95% of Total Billed Charges,175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154,88,,439.296,Percent of Total Billed Charges,88% of Total Billed Charges,157.5,90,,180,Percent of Total Billed charges,90% of Total Billed Charges,77.18,175,
ANTIDNA X 2 STD NAT,3020000029,CDM,302,RC,,,Outpatient,,,133.40,86.71,,133.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,101.38,76,,59.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,96.05,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,100.05,75,,150,Percent of Total Billed charges,75% of Total Billed Charges,133.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.05,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,80.04,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,120.06,90,,123.12,Percent of Total Billed Charges,90% of Total Billed Charges,60.03,45,,224.64,Percent of Total Billed Charges,45% of Total Billed Charges,120.06,90,,70.92,Percent of Total Billed Charges,90% of Total billed Charges,133.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.71,65,,368.68,Percent of total Billed Charges,65% of Total Billed Charges,58.83,44.1,,220.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,126.73,95,,74.864,Percent of Total Billed Charges,95% of Total Billed Charges,133.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.39,88,,176,Percent of Total Billed Charges,88% of Total Billed Charges,120.06,90,,70.92,Percent of Total Billed charges,90% of Total Billed Charges,58.83,133.4,
SM AND SM/RNPANTI,3020000030,CDM,302,RC,,,Outpatient,,,195.14,126.84,,195.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,148.31,76,,113.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,140.5,72,,72.576,Percent of Total Billed Charges,72% of Total Billed Charges,146.36,75,,75.6,Percent of Total Billed charges,75% of Total Billed Charges,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.5,72,,72.576,Percent of Total Billed Charges,72% of Total Billed Charges,117.08,60,,60.48,Percent of Total Billed Charges,60% of Total Billed Charges,175.63,90,,263.16,Percent of Total Billed Charges,90% of Total Billed Charges,87.81,45,,90,Percent of Total Billed Charges,45% of Total Billed Charges,175.63,90,,134.152,Percent of Total Billed Charges,90% of Total billed Charges,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.84,65,,60.84,Percent of total Billed Charges,65% of Total Billed Charges,86.06,44.1,,88.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,185.38,95,,141.6,Percent of Total Billed Charges,95% of Total Billed Charges,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.72,88,,92.368,Percent of Total Billed Charges,88% of Total Billed Charges,175.63,90,,134.152,Percent of Total Billed charges,90% of Total Billed Charges,86.06,195.14,
SJORGENS AB (SSA SS,3020000031,CDM,302,RC,,,Outpatient,,,195.14,126.84,,195.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,148.31,76,,351.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,140.5,72,,873.208,Percent of Total Billed Charges,72% of Total Billed Charges,146.36,75,,909.592,Percent of Total Billed charges,75% of Total Billed Charges,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.5,72,,873.208,Percent of Total Billed Charges,72% of Total Billed Charges,117.08,60,,727.672,Percent of Total Billed Charges,60% of Total Billed Charges,175.63,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,87.81,45,,47.232,Percent of Total Billed Charges,45% of Total Billed Charges,175.63,90,,415.952,Percent of Total Billed Charges,90% of Total billed Charges,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.84,65,,60.84,Percent of total Billed Charges,65% of Total Billed Charges,86.06,44.1,,46.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,185.38,95,,439.056,Percent of Total Billed Charges,95% of Total Billed Charges,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.72,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,175.63,90,,415.952,Percent of Total Billed charges,90% of Total Billed Charges,86.06,195.14,
RNP ANTIBODY,3020000032,CDM,302,RC,,,Outpatient,,,195.14,126.84,,195.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,148.31,76,,351.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,140.5,72,,103.68,Percent of Total Billed Charges,72% of Total Billed Charges,146.36,75,,108,Percent of Total Billed charges,75% of Total Billed Charges,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.5,72,,103.68,Percent of Total Billed Charges,72% of Total Billed Charges,117.08,60,,86.4,Percent of Total Billed Charges,60% of Total Billed Charges,175.63,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,87.81,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,175.63,90,,415.952,Percent of Total Billed Charges,90% of Total billed Charges,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.84,65,,60.84,Percent of total Billed Charges,65% of Total Billed Charges,86.06,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,185.38,95,,439.056,Percent of Total Billed Charges,95% of Total Billed Charges,195.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.72,88,,66.88,Percent of Total Billed Charges,88% of Total Billed Charges,175.63,90,,415.952,Percent of Total Billed charges,90% of Total Billed Charges,86.06,195.14,
SMOOTH MUSC TFX/TIT,3020000033,CDM,302,RC,,,Outpatient,,,273.00,177.45,,273,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,207.48,76,,379.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,196.56,72,,288,Percent of Total Billed Charges,72% of Total Billed Charges,204.75,75,,300,Percent of Total Billed charges,75% of Total Billed Charges,273,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.56,72,,288,Percent of Total Billed Charges,72% of Total Billed Charges,163.8,60,,240,Percent of Total Billed Charges,60% of Total Billed Charges,245.7,90,,100.8,Percent of Total Billed Charges,90% of Total Billed Charges,122.85,45,,34.2,Percent of Total Billed Charges,45% of Total Billed Charges,245.7,90,,449.28,Percent of Total Billed Charges,90% of Total billed Charges,273,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.45,65,,722.28,Percent of total Billed Charges,65% of Total Billed Charges,120.39,44.1,,33.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,259.35,95,,474.24,Percent of Total Billed Charges,95% of Total Billed Charges,273,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.24,88,,66.88,Percent of Total Billed Charges,88% of Total Billed Charges,245.7,90,,449.28,Percent of Total Billed charges,90% of Total Billed Charges,120.39,273,
DSDNA,3020000034,CDM,302,RC,,,Outpatient,,,286.67,186.34,,286.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,217.87,76,,152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,206.4,72,,1186.256,Percent of Total Billed Charges,72% of Total Billed Charges,215,75,,1235.68,Percent of Total Billed charges,75% of Total Billed Charges,286.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.4,72,,1186.256,Percent of Total Billed Charges,72% of Total Billed Charges,172,60,,988.544,Percent of Total Billed Charges,60% of Total Billed Charges,258,90,,117.48,Percent of Total Billed Charges,90% of Total Billed Charges,129,45,,34.2,Percent of Total Billed Charges,45% of Total Billed Charges,258,90,,180,Percent of Total Billed Charges,90% of Total billed Charges,286.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.34,65,,722.28,Percent of total Billed Charges,65% of Total Billed Charges,126.42,44.1,,33.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,272.34,95,,190,Percent of Total Billed Charges,95% of Total Billed Charges,286.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.27,88,,120.384,Percent of Total Billed Charges,88% of Total Billed Charges,258,90,,180,Percent of Total Billed charges,90% of Total Billed Charges,126.42,286.67,
FLOR AGENT ANTIBODY,3020000035,CDM,302,RC,,,Outpatient,,,286.67,186.34,,286.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,217.87,76,,79.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,206.4,72,,4911.4,Percent of Total Billed Charges,72% of Total Billed Charges,215,75,,5116.048,Percent of Total Billed charges,75% of Total Billed Charges,286.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.4,72,,4911.4,Percent of Total Billed Charges,72% of Total Billed Charges,172,60,,4092.832,Percent of Total Billed Charges,60% of Total Billed Charges,258,90,,104.76,Percent of Total Billed Charges,90% of Total Billed Charges,129,45,,61.56,Percent of Total Billed Charges,45% of Total Billed Charges,258,90,,94.464,Percent of Total Billed Charges,90% of Total billed Charges,286.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.34,65,,67.08,Percent of total Billed Charges,65% of Total Billed Charges,126.42,44.1,,60.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,272.34,95,,99.712,Percent of Total Billed Charges,95% of Total Billed Charges,286.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.27,88,,257.312,Percent of Total Billed Charges,88% of Total Billed Charges,258,90,,94.464,Percent of Total Billed charges,90% of Total Billed Charges,126.42,286.67,
STRIATED MUSCLE AB SCREEN,3020000036,CDM,302,RC,,,Outpatient,,,286.67,186.34,,286.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,217.87,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,206.4,72,,252.112,Percent of Total Billed Charges,72% of Total Billed Charges,215,75,,262.616,Percent of Total Billed charges,75% of Total Billed Charges,286.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.4,72,,252.112,Percent of Total Billed Charges,72% of Total Billed Charges,172,60,,210.088,Percent of Total Billed Charges,60% of Total Billed Charges,258,90,,156.232,Percent of Total Billed Charges,90% of Total Billed Charges,129,45,,131.584,Percent of Total Billed Charges,45% of Total Billed Charges,258,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,286.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.34,65,,282.256,Percent of total Billed Charges,65% of Total Billed Charges,126.42,44.1,,128.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,272.34,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,286.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.27,88,,70.4,Percent of Total Billed Charges,88% of Total Billed Charges,258,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,126.42,286.67,
ENDOMYSIAL AB TITER,3020000037,CDM,302,RC,,,Outpatient,,,283.34,184.17,,283.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,215.34,76,,57.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,204,72,,374.4,Percent of Total Billed Charges,72% of Total Billed Charges,212.51,75,,390,Percent of Total Billed charges,75% of Total Billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204,72,,374.4,Percent of Total Billed Charges,72% of Total Billed Charges,170,60,,312,Percent of Total Billed Charges,60% of Total Billed Charges,255.01,90,,116.64,Percent of Total Billed Charges,90% of Total Billed Charges,127.5,45,,36,Percent of Total Billed Charges,45% of Total Billed Charges,255.01,90,,68.4,Percent of Total Billed Charges,90% of Total billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.17,65,,282.256,Percent of total Billed Charges,65% of Total Billed Charges,124.95,44.1,,35.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,269.17,95,,72.2,Percent of Total Billed Charges,95% of Total Billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.34,88,,70.4,Percent of Total Billed Charges,88% of Total Billed Charges,255.01,90,,68.4,Percent of Total Billed charges,90% of Total Billed Charges,124.95,283.34,
TITER  EA  ANTIBODY,3020000038,CDM,302,RC,,,Outpatient,,,283.34,184.17,,283.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,215.34,76,,57.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,204,72,,581.76,Percent of Total Billed Charges,72% of Total Billed Charges,212.51,75,,606,Percent of Total Billed charges,75% of Total Billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204,72,,581.76,Percent of Total Billed Charges,72% of Total Billed Charges,170,60,,484.8,Percent of Total Billed Charges,60% of Total Billed Charges,255.01,90,,110.88,Percent of Total Billed Charges,90% of Total Billed Charges,127.5,45,,36,Percent of Total Billed Charges,45% of Total Billed Charges,255.01,90,,68.4,Percent of Total Billed Charges,90% of Total billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.17,65,,166.92,Percent of total Billed Charges,65% of Total Billed Charges,124.95,44.1,,35.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,269.17,95,,72.2,Percent of Total Billed Charges,95% of Total Billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.34,88,,98.56,Percent of Total Billed Charges,88% of Total Billed Charges,255.01,90,,68.4,Percent of Total Billed charges,90% of Total Billed Charges,124.95,283.34,
CA 27.29 CHIRON/BAYE,3020000039,CDM,302,RC,,,Outpatient,,,271.22,176.29,,271.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,206.13,76,,103.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,195.28,72,,538.272,Percent of Total Billed Charges,72% of Total Billed Charges,203.42,75,,560.704,Percent of Total Billed charges,75% of Total Billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.28,72,,538.272,Percent of Total Billed Charges,72% of Total Billed Charges,162.73,60,,448.56,Percent of Total Billed Charges,60% of Total Billed Charges,244.1,90,,138.96,Percent of Total Billed Charges,90% of Total Billed Charges,122.05,45,,50.4,Percent of Total Billed Charges,45% of Total Billed Charges,244.1,90,,123.12,Percent of Total Billed Charges,90% of Total billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.29,65,,36.4,Percent of total Billed Charges,65% of Total Billed Charges,119.61,44.1,,49.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,257.66,95,,129.96,Percent of Total Billed Charges,95% of Total Billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.67,88,,114.872,Percent of Total Billed Charges,88% of Total Billed Charges,244.1,90,,123.12,Percent of Total Billed charges,90% of Total Billed Charges,119.61,271.22,
CA 153,3020000040,CDM,302,RC,,,Outpatient,,,271.22,176.29,,271.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,206.13,76,,222.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,195.28,72,,3340.8,Percent of Total Billed Charges,72% of Total Billed Charges,203.42,75,,3480,Percent of Total Billed charges,75% of Total Billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.28,72,,3340.8,Percent of Total Billed Charges,72% of Total Billed Charges,162.73,60,,2784,Percent of Total Billed Charges,60% of Total Billed Charges,244.1,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,122.05,45,,58.744,Percent of Total Billed Charges,45% of Total Billed Charges,244.1,90,,263.16,Percent of Total Billed Charges,90% of Total billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.29,65,,36.4,Percent of total Billed Charges,65% of Total Billed Charges,119.61,44.1,,57.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,257.66,95,,277.784,Percent of Total Billed Charges,95% of Total Billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.67,88,,102.432,Percent of Total Billed Charges,88% of Total Billed Charges,244.1,90,,263.16,Percent of Total Billed charges,90% of Total Billed Charges,119.61,271.22,
CA 199(CENTOCOR),3020000041,CDM,302,RC,,,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,60.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,435.64,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,453.792,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,435.64,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,363.032,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,313.2,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,52.384,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,72,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,43.68,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,51.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,76,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,152.76,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,72,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
CA125,3020000042,CDM,302,RC,,,Outpatient,,,198.45,128.99,,198.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,150.82,76,,60.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,142.88,72,,331.496,Percent of Total Billed Charges,72% of Total Billed Charges,148.84,75,,345.304,Percent of Total Billed charges,75% of Total Billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.88,72,,331.496,Percent of Total Billed Charges,72% of Total Billed Charges,119.07,60,,276.248,Percent of Total Billed Charges,60% of Total Billed Charges,178.61,90,,38.88,Percent of Total Billed Charges,90% of Total Billed Charges,89.3,45,,78.12,Percent of Total Billed Charges,45% of Total Billed Charges,178.61,90,,72,Percent of Total Billed Charges,90% of Total billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.99,65,,23.4,Percent of total Billed Charges,65% of Total Billed Charges,87.52,44.1,,76.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,188.53,95,,76,Percent of Total Billed Charges,95% of Total Billed Charges,198.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.64,88,,114.048,Percent of Total Billed Charges,88% of Total Billed Charges,178.61,90,,72,Percent of Total Billed charges,90% of Total Billed Charges,87.52,198.45,
MONOSPOT,3020000043,CDM,302,RC,,,Outpatient,,,158.00,102.70,,158,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.08,76,,85.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,113.76,72,,1156.496,Percent of Total Billed Charges,72% of Total Billed Charges,118.5,75,,1204.688,Percent of Total Billed charges,75% of Total Billed Charges,158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.76,72,,1156.496,Percent of Total Billed Charges,72% of Total Billed Charges,94.8,60,,963.752,Percent of Total Billed Charges,60% of Total Billed Charges,142.2,90,,47.632,Percent of Total Billed Charges,90% of Total Billed Charges,71.1,45,,58.32,Percent of Total Billed Charges,45% of Total Billed Charges,142.2,90,,100.8,Percent of Total Billed Charges,90% of Total billed Charges,158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.7,65,,149.072,Percent of total Billed Charges,65% of Total Billed Charges,69.68,44.1,,57.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,150.1,95,,106.4,Percent of Total Billed Charges,95% of Total Billed Charges,158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.04,88,,108.416,Percent of Total Billed Charges,88% of Total Billed Charges,142.2,90,,100.8,Percent of Total Billed charges,90% of Total Billed Charges,69.68,158,
IMMUNOELECTROPHORE SERUM,3020000044,CDM,302,RC,,,Outpatient,,,114.66,74.53,,114.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.14,76,,99.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.56,72,,1099.008,Percent of Total Billed Charges,72% of Total Billed Charges,86,75,,1144.8,Percent of Total Billed charges,75% of Total Billed Charges,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.56,72,,1099.008,Percent of Total Billed Charges,72% of Total Billed Charges,68.8,60,,915.84,Percent of Total Billed Charges,60% of Total Billed Charges,103.19,90,,108.72,Percent of Total Billed Charges,90% of Total Billed Charges,51.6,45,,55.44,Percent of Total Billed Charges,45% of Total Billed Charges,103.19,90,,117.48,Percent of Total Billed Charges,90% of Total billed Charges,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.53,65,,130,Percent of total Billed Charges,65% of Total Billed Charges,50.57,44.1,,54.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,108.93,95,,124.008,Percent of Total Billed Charges,95% of Total Billed Charges,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.9,88,,135.872,Percent of Total Billed Charges,88% of Total Billed Charges,103.19,90,,117.48,Percent of Total Billed charges,90% of Total Billed Charges,50.57,114.66,
IMMUNOELECTROPHORESI OTH FLUID,3020000045,CDM,302,RC,,,Outpatient,,,152.15,98.90,,152.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,115.63,76,,88.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,109.55,72,,945.792,Percent of Total Billed Charges,72% of Total Billed Charges,114.11,75,,985.2,Percent of Total Billed charges,75% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.55,72,,945.792,Percent of Total Billed Charges,72% of Total Billed Charges,91.29,60,,788.16,Percent of Total Billed Charges,60% of Total Billed Charges,136.94,90,,33.344,Percent of Total Billed Charges,90% of Total Billed Charges,68.47,45,,69.48,Percent of Total Billed Charges,45% of Total Billed Charges,136.94,90,,104.76,Percent of Total Billed Charges,90% of Total billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.9,65,,273.464,Percent of total Billed Charges,65% of Total Billed Charges,67.1,44.1,,68.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,144.54,95,,110.584,Percent of Total Billed Charges,95% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.89,88,,88,Percent of Total Billed Charges,88% of Total Billed Charges,136.94,90,,104.76,Percent of Total Billed charges,90% of Total Billed Charges,67.1,152.15,
IMMUNOFIXATION ELECT SERUM,3020000046,CDM,302,RC,,,Outpatient,,,332.69,216.25,,332.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,252.84,76,,131.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,239.54,72,,218.304,Percent of Total Billed Charges,72% of Total Billed Charges,249.52,75,,227.4,Percent of Total Billed charges,75% of Total Billed Charges,332.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.54,72,,218.304,Percent of Total Billed Charges,72% of Total Billed Charges,199.61,60,,181.92,Percent of Total Billed Charges,60% of Total Billed Charges,299.42,90,,139.68,Percent of Total Billed Charges,90% of Total Billed Charges,149.71,45,,45,Percent of Total Billed Charges,45% of Total Billed Charges,299.42,90,,156.232,Percent of Total Billed Charges,90% of Total billed Charges,332.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.25,65,,34.84,Percent of total Billed Charges,65% of Total Billed Charges,146.72,44.1,,44.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,316.06,95,,164.912,Percent of Total Billed Charges,95% of Total Billed Charges,332.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.77,88,,306.24,Percent of Total Billed Charges,88% of Total Billed Charges,299.42,90,,156.232,Percent of Total Billed charges,90% of Total Billed Charges,146.72,332.69,
IMMUNOFIXATION(IFE) OTH FLUID,3020000047,CDM,302,RC,,,Outpatient,,,108.05,70.23,,108.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.12,76,,98.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.8,72,,300.672,Percent of Total Billed Charges,72% of Total Billed Charges,81.04,75,,313.2,Percent of Total Billed charges,75% of Total Billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.8,72,,300.672,Percent of Total Billed Charges,72% of Total Billed Charges,64.83,60,,250.56,Percent of Total Billed Charges,60% of Total Billed Charges,97.25,90,,64.296,Percent of Total Billed Charges,90% of Total Billed Charges,48.62,45,,156.6,Percent of Total Billed Charges,45% of Total Billed Charges,97.25,90,,116.64,Percent of Total Billed Charges,90% of Total billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.23,65,,60.84,Percent of total Billed Charges,65% of Total Billed Charges,47.65,44.1,,153.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.65,95,,123.12,Percent of Total Billed Charges,95% of Total Billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.08,88,,38.016,Percent of Total Billed Charges,88% of Total Billed Charges,97.25,90,,116.64,Percent of Total Billed charges,90% of Total Billed Charges,47.65,108.05,
INTRINSIC FACTOR BLO,3020000048,CDM,302,RC,,,Outpatient,,,73.87,48.02,,73.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.14,76,,93.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.19,72,,645.2,Percent of Total Billed Charges,72% of Total Billed Charges,55.4,75,,672.088,Percent of Total Billed charges,75% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.19,72,,645.2,Percent of Total Billed Charges,72% of Total Billed Charges,44.32,60,,537.664,Percent of Total Billed Charges,60% of Total Billed Charges,66.48,90,,64.296,Percent of Total Billed Charges,90% of Total Billed Charges,33.24,45,,19.44,Percent of Total Billed Charges,45% of Total Billed Charges,66.48,90,,110.88,Percent of Total Billed Charges,90% of Total billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.02,65,,22.88,Percent of total Billed Charges,65% of Total Billed Charges,32.58,44.1,,19.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,70.18,95,,117.04,Percent of Total Billed Charges,95% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.01,88,,46.568,Percent of Total Billed Charges,88% of Total Billed Charges,66.48,90,,110.88,Percent of Total Billed charges,90% of Total Billed Charges,32.58,73.87,
LYMPHOCYTE SUBSET PA,3020000049,CDM,302,RC,,,Outpatient,,,735.37,477.99,,735.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,558.88,76,,117.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,529.47,72,,1096.488,Percent of Total Billed Charges,72% of Total Billed Charges,551.53,75,,1142.176,Percent of Total Billed charges,75% of Total Billed Charges,735.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529.47,72,,1096.488,Percent of Total Billed Charges,72% of Total Billed Charges,441.22,60,,913.736,Percent of Total Billed Charges,60% of Total Billed Charges,661.83,90,,176.952,Percent of Total Billed Charges,90% of Total Billed Charges,330.92,45,,23.816,Percent of Total Billed Charges,45% of Total Billed Charges,661.83,90,,138.96,Percent of Total Billed Charges,90% of Total billed Charges,735.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,735.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,735.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,477.99,65,,20.4,Percent of total Billed Charges,65% of Total Billed Charges,324.3,44.1,,23.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,698.6,95,,146.68,Percent of Total Billed Charges,95% of Total Billed Charges,735.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,647.13,88,,106.304,Percent of Total Billed Charges,88% of Total Billed Charges,661.83,90,,138.96,Percent of Total Billed charges,90% of Total Billed Charges,324.3,735.37,
ANTI MICROSOMAL ANTI,3020000050,CDM,302,RC,,,Outpatient,,,251.37,163.39,,251.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,191.04,76,,76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,180.99,72,,668.696,Percent of Total Billed Charges,72% of Total Billed Charges,188.53,75,,696.56,Percent of Total Billed charges,75% of Total Billed Charges,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.99,72,,668.696,Percent of Total Billed Charges,72% of Total Billed Charges,150.82,60,,557.248,Percent of Total Billed Charges,60% of Total Billed Charges,226.23,90,,211.944,Percent of Total Billed Charges,90% of Total Billed Charges,113.12,45,,54.36,Percent of Total Billed Charges,45% of Total Billed Charges,226.23,90,,90,Percent of Total Billed Charges,90% of Total billed Charges,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.39,65,,56.184,Percent of total Billed Charges,65% of Total Billed Charges,110.85,44.1,,53.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,238.8,95,,95,Percent of Total Billed Charges,95% of Total Billed Charges,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.21,88,,32.6,Percent of Total Billed Charges,88% of Total Billed Charges,226.23,90,,90,Percent of Total Billed charges,90% of Total Billed Charges,110.85,251.37,
ANTILKM1,3020000052,CDM,302,RC,,,Outpatient,,,251.37,163.39,,251.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,191.04,76,,264.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,180.99,72,,1587.6,Percent of Total Billed Charges,72% of Total Billed Charges,188.53,75,,1653.752,Percent of Total Billed charges,75% of Total Billed Charges,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.99,72,,1587.6,Percent of Total Billed Charges,72% of Total Billed Charges,150.82,60,,1323,Percent of Total Billed Charges,60% of Total Billed Charges,226.23,90,,140.4,Percent of Total Billed Charges,90% of Total Billed Charges,113.12,45,,16.672,Percent of Total Billed Charges,45% of Total Billed Charges,226.23,90,,313.2,Percent of Total Billed Charges,90% of Total billed Charges,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.39,65,,155.936,Percent of total Billed Charges,65% of Total Billed Charges,110.85,44.1,,16.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,238.8,95,,330.6,Percent of Total Billed Charges,95% of Total Billed Charges,251.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.21,88,,136.576,Percent of Total Billed Charges,88% of Total Billed Charges,226.23,90,,313.2,Percent of Total Billed charges,90% of Total Billed Charges,110.85,251.37,
BACTERIAL MENINGITIS,3020000053,CDM,302,RC,,,Outpatient,,,959.18,623.47,,959.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,728.98,76,,32.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,690.61,72,,5679.616,Percent of Total Billed Charges,72% of Total Billed Charges,719.39,75,,5916.272,Percent of Total Billed charges,75% of Total Billed Charges,959.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,690.61,72,,5679.616,Percent of Total Billed Charges,72% of Total Billed Charges,575.51,60,,4733.016,Percent of Total Billed Charges,60% of Total Billed Charges,863.26,90,,159.84,Percent of Total Billed Charges,90% of Total Billed Charges,431.63,45,,69.84,Percent of Total Billed Charges,45% of Total Billed Charges,863.26,90,,38.88,Percent of Total Billed Charges,90% of Total billed Charges,959.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,959.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,959.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,623.47,65,,103.976,Percent of total Billed Charges,65% of Total Billed Charges,423,44.1,,68.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,911.22,95,,41.04,Percent of Total Billed Charges,95% of Total Billed Charges,959.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,844.08,88,,62.864,Percent of Total Billed Charges,88% of Total Billed Charges,863.26,90,,38.88,Percent of Total Billed charges,90% of Total Billed Charges,423,959.18,
RA TEST,3020000054,CDM,302,RC,,,Outpatient,,,152.15,98.90,,152.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,115.63,76,,40.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,109.55,72,,3735.248,Percent of Total Billed Charges,72% of Total Billed Charges,114.11,75,,3890.88,Percent of Total Billed charges,75% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.55,72,,3735.248,Percent of Total Billed Charges,72% of Total Billed Charges,91.29,60,,3112.704,Percent of Total Billed Charges,60% of Total Billed Charges,136.94,90,,510.48,Percent of Total Billed Charges,90% of Total Billed Charges,68.47,45,,32.152,Percent of Total Billed Charges,45% of Total Billed Charges,136.94,90,,47.632,Percent of Total Billed Charges,90% of Total billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.9,65,,129.48,Percent of total Billed Charges,65% of Total Billed Charges,67.1,44.1,,31.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,144.54,95,,50.272,Percent of Total Billed Charges,95% of Total Billed Charges,152.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.89,88,,62.864,Percent of Total Billed Charges,88% of Total Billed Charges,136.94,90,,47.632,Percent of Total Billed charges,90% of Total Billed Charges,67.1,152.15,
QUANTIFERON TB GOLD,3020000055,CDM,302,RC,,,Outpatient,,,154.95,100.72,,154.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,117.76,76,,91.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.56,72,,4398.904,Percent of Total Billed Charges,72% of Total Billed Charges,116.21,75,,4582.192,Percent of Total Billed charges,75% of Total Billed Charges,154.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.56,72,,4398.904,Percent of Total Billed Charges,72% of Total Billed Charges,92.97,60,,3665.752,Percent of Total Billed Charges,60% of Total Billed Charges,139.46,90,,84.24,Percent of Total Billed Charges,90% of Total Billed Charges,69.73,45,,32.152,Percent of Total Billed Charges,45% of Total Billed Charges,139.46,90,,108.72,Percent of Total Billed Charges,90% of Total billed Charges,154.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.72,65,,58.48,Percent of total Billed Charges,65% of Total Billed Charges,68.33,44.1,,31.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,147.2,95,,114.76,Percent of Total Billed Charges,95% of Total Billed Charges,154.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.36,88,,173.024,Percent of Total Billed Charges,88% of Total Billed Charges,139.46,90,,108.72,Percent of Total Billed charges,90% of Total Billed Charges,68.33,154.95,
QUANTIFERON INCUBATE,3020000056,CDM,302,RC,,,Outpatient,,,154.95,100.72,,154.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,117.76,76,,28.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.56,72,,4398.904,Percent of Total Billed Charges,72% of Total Billed Charges,116.21,75,,4582.192,Percent of Total Billed charges,75% of Total Billed Charges,154.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.56,72,,4398.904,Percent of Total Billed Charges,72% of Total Billed Charges,92.97,60,,3665.752,Percent of Total Billed Charges,60% of Total Billed Charges,139.46,90,,84.24,Percent of Total Billed Charges,90% of Total Billed Charges,69.73,45,,88.48,Percent of Total Billed Charges,45% of Total Billed Charges,139.46,90,,33.344,Percent of Total Billed Charges,90% of Total billed Charges,154.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.72,65,,730.384,Percent of total Billed Charges,65% of Total Billed Charges,68.33,44.1,,86.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,147.2,95,,35.192,Percent of Total Billed Charges,95% of Total Billed Charges,154.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.36,88,,207.24,Percent of Total Billed Charges,88% of Total Billed Charges,139.46,90,,33.344,Percent of Total Billed charges,90% of Total Billed Charges,68.33,154.95,
CANDIN INJ,3020000057,CDM,302,RC,,,Outpatient,,,652.68,424.24,,652.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,496.04,76,,117.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,469.93,72,,813.888,Percent of Total Billed Charges,72% of Total Billed Charges,489.51,75,,847.8,Percent of Total Billed charges,75% of Total Billed Charges,652.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,469.93,72,,813.888,Percent of Total Billed Charges,72% of Total Billed Charges,391.61,60,,678.24,Percent of Total Billed Charges,60% of Total Billed Charges,587.41,90,,84.24,Percent of Total Billed Charges,90% of Total Billed Charges,293.71,45,,105.976,Percent of Total Billed Charges,45% of Total Billed Charges,587.41,90,,139.68,Percent of Total Billed Charges,90% of Total billed Charges,652.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,652.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,652.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.24,65,,300.408,Percent of total Billed Charges,65% of Total Billed Charges,287.83,44.1,,103.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,620.05,95,,147.44,Percent of Total Billed Charges,95% of Total Billed Charges,652.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,574.36,88,,137.28,Percent of Total Billed Charges,88% of Total Billed Charges,587.41,90,,139.68,Percent of Total Billed charges,90% of Total Billed Charges,287.83,652.68,
PPD SKIN TEST INJ,3020000058,CDM,302,RC,,,Outpatient,,,57.00,37.05,,57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.32,76,,54.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.04,72,,813.888,Percent of Total Billed Charges,72% of Total Billed Charges,42.75,75,,847.8,Percent of Total Billed charges,75% of Total Billed Charges,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.04,72,,813.888,Percent of Total Billed Charges,72% of Total Billed Charges,34.2,60,,678.24,Percent of Total Billed Charges,60% of Total Billed Charges,51.3,90,,1000.08,Percent of Total Billed Charges,90% of Total Billed Charges,25.65,45,,70.2,Percent of Total Billed Charges,45% of Total Billed Charges,51.3,90,,64.296,Percent of Total Billed Charges,90% of Total billed Charges,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.05,65,,127.272,Percent of total Billed Charges,65% of Total Billed Charges,25.14,44.1,,68.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.15,95,,67.872,Percent of Total Billed Charges,95% of Total Billed Charges,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.16,88,,156.288,Percent of Total Billed Charges,88% of Total Billed Charges,51.3,90,,64.296,Percent of Total Billed charges,90% of Total Billed Charges,25.14,57,
RPR,3020000059,CDM,302,RC,,,Outpatient,,,171.00,111.15,,171,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.96,76,,54.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.12,72,,3416.496,Percent of Total Billed Charges,72% of Total Billed Charges,128.25,75,,3558.856,Percent of Total Billed charges,75% of Total Billed Charges,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.12,72,,3416.496,Percent of Total Billed Charges,72% of Total Billed Charges,102.6,60,,2847.08,Percent of Total Billed Charges,60% of Total Billed Charges,153.9,90,,1000.08,Percent of Total Billed Charges,90% of Total Billed Charges,76.95,45,,79.92,Percent of Total Billed Charges,45% of Total Billed Charges,153.9,90,,64.296,Percent of Total Billed Charges,90% of Total billed Charges,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.15,65,,148.76,Percent of total Billed Charges,65% of Total Billed Charges,75.41,44.1,,78.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,162.45,95,,67.872,Percent of Total Billed Charges,95% of Total Billed Charges,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.48,88,,499.136,Percent of Total Billed Charges,88% of Total Billed Charges,153.9,90,,64.296,Percent of Total Billed charges,90% of Total Billed Charges,75.41,171,
B HENSELAE AB IGG IG,3020000060,CDM,302,RC,,,Outpatient,,,127.89,83.13,,127.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,97.2,76,,149.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,92.08,72,,4357.784,Percent of Total Billed Charges,72% of Total Billed Charges,95.92,75,,4539.36,Percent of Total Billed charges,75% of Total Billed Charges,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.08,72,,4357.784,Percent of Total Billed Charges,72% of Total Billed Charges,76.73,60,,3631.488,Percent of Total Billed Charges,60% of Total Billed Charges,115.1,90,,92.88,Percent of Total Billed Charges,90% of Total Billed Charges,57.55,45,,255.24,Percent of Total Billed Charges,45% of Total Billed Charges,115.1,90,,176.952,Percent of Total Billed Charges,90% of Total billed Charges,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.13,65,,10.168,Percent of total Billed Charges,65% of Total Billed Charges,56.4,44.1,,250.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,121.5,95,,186.784,Percent of Total Billed Charges,95% of Total Billed Charges,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.54,88,,82.368,Percent of Total Billed Charges,88% of Total Billed Charges,115.1,90,,176.952,Percent of Total Billed charges,90% of Total Billed Charges,56.4,127.89,
BARTONELLA ANTIBODIE,3020000061,CDM,302,RC,,,Outpatient,,,127.89,83.13,,127.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,97.2,76,,178.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,92.08,72,,2234.048,Percent of Total Billed Charges,72% of Total Billed Charges,95.92,75,,2327.136,Percent of Total Billed charges,75% of Total Billed Charges,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.08,72,,2234.048,Percent of Total Billed Charges,72% of Total Billed Charges,76.73,60,,1861.712,Percent of Total Billed Charges,60% of Total Billed Charges,115.1,90,,390.816,Percent of Total Billed Charges,90% of Total Billed Charges,57.55,45,,42.12,Percent of Total Billed Charges,45% of Total Billed Charges,115.1,90,,211.944,Percent of Total Billed Charges,90% of Total billed Charges,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.13,65,,24.08,Percent of total Billed Charges,65% of Total Billed Charges,56.4,44.1,,41.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,121.5,95,,223.72,Percent of Total Billed Charges,95% of Total Billed Charges,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.54,88,,82.368,Percent of Total Billed Charges,88% of Total Billed Charges,115.1,90,,211.944,Percent of Total Billed charges,90% of Total Billed Charges,56.4,127.89,
B HENSELAE AB IGM SCR,3020000062,CDM,302,RC,,,Outpatient,,,127.89,83.13,,127.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,97.2,76,,118.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,92.08,72,,1587.6,Percent of Total Billed Charges,72% of Total Billed Charges,95.92,75,,1653.752,Percent of Total Billed charges,75% of Total Billed Charges,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.08,72,,1587.6,Percent of Total Billed Charges,72% of Total Billed Charges,76.73,60,,1323,Percent of Total Billed Charges,60% of Total Billed Charges,115.1,90,,390.816,Percent of Total Billed Charges,90% of Total Billed Charges,57.55,45,,42.12,Percent of Total Billed Charges,45% of Total Billed Charges,115.1,90,,140.4,Percent of Total Billed Charges,90% of Total billed Charges,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.13,65,,23.312,Percent of total Billed Charges,65% of Total Billed Charges,56.4,44.1,,41.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,121.5,95,,148.2,Percent of Total Billed Charges,95% of Total Billed Charges,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.54,88,,82.368,Percent of Total Billed Charges,88% of Total Billed Charges,115.1,90,,140.4,Percent of Total Billed charges,90% of Total Billed Charges,56.4,127.89,
B HENSELAE QUINTANA IGM SCR,3020000063,CDM,302,RC,,,Outpatient,,,127.89,83.13,,127.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,97.2,76,,134.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,92.08,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,95.92,75,,960,Percent of Total Billed charges,75% of Total Billed Charges,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.08,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,76.73,60,,768,Percent of Total Billed Charges,60% of Total Billed Charges,115.1,90,,231.12,Percent of Total Billed Charges,90% of Total Billed Charges,57.55,45,,42.12,Percent of Total Billed Charges,45% of Total Billed Charges,115.1,90,,159.84,Percent of Total Billed Charges,90% of Total billed Charges,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.13,65,,279.76,Percent of total Billed Charges,65% of Total Billed Charges,56.4,44.1,,41.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,121.5,95,,168.72,Percent of Total Billed Charges,95% of Total Billed Charges,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.54,88,,977.856,Percent of Total Billed Charges,88% of Total Billed Charges,115.1,90,,159.84,Percent of Total Billed charges,90% of Total Billed Charges,56.4,127.89,
B HENSELAE QUINTANA IGG SCRN,3020000064,CDM,302,RC,,,Outpatient,,,127.89,83.13,,127.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,97.2,76,,431.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,92.08,72,,252.112,Percent of Total Billed Charges,72% of Total Billed Charges,95.92,75,,262.616,Percent of Total Billed charges,75% of Total Billed Charges,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.08,72,,252.112,Percent of Total Billed Charges,72% of Total Billed Charges,76.73,60,,210.088,Percent of Total Billed Charges,60% of Total Billed Charges,115.1,90,,50.4,Percent of Total Billed Charges,90% of Total Billed Charges,57.55,45,,500.04,Percent of Total Billed Charges,45% of Total Billed Charges,115.1,90,,510.48,Percent of Total Billed Charges,90% of Total billed Charges,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.13,65,,318.752,Percent of total Billed Charges,65% of Total Billed Charges,56.4,44.1,,490.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,121.5,95,,538.84,Percent of Total Billed Charges,95% of Total Billed Charges,127.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.54,88,,977.856,Percent of Total Billed Charges,88% of Total Billed Charges,115.1,90,,510.48,Percent of Total Billed charges,90% of Total Billed Charges,56.4,127.89,
LYME DIS IGG/IGM WBA,3020000065,CDM,302,RC,,,Outpatient,,,119.07,77.40,,119.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,90.49,76,,71.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,85.73,72,,4911.4,Percent of Total Billed Charges,72% of Total Billed Charges,89.3,75,,5116.048,Percent of Total Billed charges,75% of Total Billed Charges,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.73,72,,4911.4,Percent of Total Billed Charges,72% of Total Billed Charges,71.44,60,,4092.832,Percent of Total Billed Charges,60% of Total Billed Charges,107.16,90,,50.4,Percent of Total Billed Charges,90% of Total Billed Charges,53.58,45,,500.04,Percent of Total Billed Charges,45% of Total Billed Charges,107.16,90,,84.24,Percent of Total Billed Charges,90% of Total billed Charges,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,65,,16.912,Percent of total Billed Charges,65% of Total Billed Charges,52.51,44.1,,490.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,113.12,95,,88.92,Percent of Total Billed Charges,95% of Total Billed Charges,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.78,88,,90.816,Percent of Total Billed Charges,88% of Total Billed Charges,107.16,90,,84.24,Percent of Total Billed charges,90% of Total Billed Charges,52.51,119.07,
BRUCELLA IGG IGM,3020000066,CDM,302,RC,,,Outpatient,,,233.73,151.92,,233.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,177.63,76,,71.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,168.29,72,,345.6,Percent of Total Billed Charges,72% of Total Billed Charges,175.3,75,,360,Percent of Total Billed charges,75% of Total Billed Charges,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.29,72,,345.6,Percent of Total Billed Charges,72% of Total Billed Charges,140.24,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,210.36,90,,60.48,Percent of Total Billed Charges,90% of Total Billed Charges,105.18,45,,46.44,Percent of Total Billed Charges,45% of Total Billed Charges,210.36,90,,84.24,Percent of Total Billed Charges,90% of Total billed Charges,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.92,65,,38.064,Percent of total Billed Charges,65% of Total Billed Charges,103.07,44.1,,45.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,222.04,95,,88.92,Percent of Total Billed Charges,95% of Total Billed Charges,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.68,88,,382.128,Percent of Total Billed Charges,88% of Total Billed Charges,210.36,90,,84.24,Percent of Total Billed charges,90% of Total Billed Charges,103.07,233.73,
IGG,3020000067,CDM,302,RC,,,Outpatient,,,216.99,141.04,,216.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,164.91,76,,71.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,156.23,72,,1689.408,Percent of Total Billed Charges,72% of Total Billed Charges,162.74,75,,1759.8,Percent of Total Billed charges,75% of Total Billed Charges,216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.23,72,,1689.408,Percent of Total Billed Charges,72% of Total Billed Charges,130.19,60,,1407.84,Percent of Total Billed Charges,60% of Total Billed Charges,195.29,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,97.65,45,,195.408,Percent of Total Billed Charges,45% of Total Billed Charges,195.29,90,,84.24,Percent of Total Billed Charges,90% of Total billed Charges,216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.04,65,,2372.24,Percent of total Billed Charges,65% of Total Billed Charges,95.69,44.1,,191.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,206.14,95,,88.92,Percent of Total Billed Charges,95% of Total Billed Charges,216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.95,88,,382.128,Percent of Total Billed Charges,88% of Total Billed Charges,195.29,90,,84.24,Percent of Total Billed charges,90% of Total Billed Charges,95.69,216.99,
IGM,3020000068,CDM,302,RC,,,Outpatient,,,162.00,105.30,,162,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,123.12,76,,844.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,116.64,72,,1757.376,Percent of Total Billed Charges,72% of Total Billed Charges,121.5,75,,1830.6,Percent of Total Billed charges,75% of Total Billed Charges,162,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.64,72,,1757.376,Percent of Total Billed Charges,72% of Total Billed Charges,97.2,60,,1464.48,Percent of Total Billed Charges,60% of Total Billed Charges,145.8,90,,206.4,Percent of Total Billed Charges,90% of Total Billed Charges,72.9,45,,195.408,Percent of Total Billed Charges,45% of Total Billed Charges,145.8,90,,1000.08,Percent of Total Billed Charges,90% of Total billed Charges,162,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.3,65,,2372.24,Percent of total Billed Charges,65% of Total Billed Charges,71.44,44.1,,191.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,153.9,95,,1055.64,Percent of Total Billed Charges,95% of Total Billed Charges,162,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.56,88,,225.984,Percent of Total Billed Charges,88% of Total Billed Charges,145.8,90,,1000.08,Percent of Total Billed charges,90% of Total Billed Charges,71.44,162,
DIPHTHERIA ANTITOXID,3020000069,CDM,302,RC,,,Outpatient,,,165.38,107.50,,165.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,125.69,76,,844.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,119.07,72,,1587.6,Percent of Total Billed Charges,72% of Total Billed Charges,124.04,75,,1653.752,Percent of Total Billed charges,75% of Total Billed Charges,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.07,72,,1587.6,Percent of Total Billed Charges,72% of Total Billed Charges,99.23,60,,1323,Percent of Total Billed Charges,60% of Total Billed Charges,148.84,90,,180,Percent of Total Billed Charges,90% of Total Billed Charges,74.42,45,,115.56,Percent of Total Billed Charges,45% of Total Billed Charges,148.84,90,,1000.08,Percent of Total Billed Charges,90% of Total billed Charges,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.5,65,,318.752,Percent of total Billed Charges,65% of Total Billed Charges,72.93,44.1,,113.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,157.11,95,,1055.64,Percent of Total Billed Charges,95% of Total Billed Charges,165.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,88,,49.28,Percent of Total Billed Charges,88% of Total Billed Charges,148.84,90,,1000.08,Percent of Total Billed charges,90% of Total Billed Charges,72.93,165.38,
EBV NUCLEAR ANTIGEN AB IGG,3020000070,CDM,302,RC,,,Outpatient,,,74.97,48.73,,74.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.98,76,,78.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.98,72,,1587.6,Percent of Total Billed Charges,72% of Total Billed Charges,56.23,75,,1653.752,Percent of Total Billed charges,75% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.98,72,,1587.6,Percent of Total Billed Charges,72% of Total Billed Charges,44.98,60,,1323,Percent of Total Billed Charges,60% of Total Billed Charges,67.47,90,,378.64,Percent of Total Billed Charges,90% of Total Billed Charges,33.74,45,,25.2,Percent of Total Billed Charges,45% of Total Billed Charges,67.47,90,,92.88,Percent of Total Billed Charges,90% of Total billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.73,65,,148.224,Percent of total Billed Charges,65% of Total Billed Charges,33.06,44.1,,24.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,71.22,95,,98.04,Percent of Total Billed Charges,95% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.97,88,,49.28,Percent of Total Billed Charges,88% of Total Billed Charges,67.47,90,,92.88,Percent of Total Billed charges,90% of Total Billed Charges,33.06,74.97,
EBV VIRAL CAPSID AG AB IGM,3020000071,CDM,302,RC,,,Outpatient,,,74.97,48.73,,74.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.98,76,,330.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.98,72,,2576.992,Percent of Total Billed Charges,72% of Total Billed Charges,56.23,75,,2684.368,Percent of Total Billed charges,75% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.98,72,,2576.992,Percent of Total Billed Charges,72% of Total Billed Charges,44.98,60,,2147.496,Percent of Total Billed Charges,60% of Total Billed Charges,67.47,90,,48.24,Percent of Total Billed Charges,90% of Total Billed Charges,33.74,45,,25.2,Percent of Total Billed Charges,45% of Total Billed Charges,67.47,90,,390.816,Percent of Total Billed Charges,90% of Total billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.73,65,,118.672,Percent of total Billed Charges,65% of Total Billed Charges,33.06,44.1,,24.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,71.22,95,,412.528,Percent of Total Billed Charges,95% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.97,88,,59.136,Percent of Total Billed Charges,88% of Total Billed Charges,67.47,90,,390.816,Percent of Total Billed charges,90% of Total Billed Charges,33.06,74.97,
EBV VIRAL CAPSID AG AB IGG,3020000072,CDM,302,RC,,,Outpatient,,,74.97,48.73,,74.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.98,76,,330.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.98,72,,1587.6,Percent of Total Billed Charges,72% of Total Billed Charges,56.23,75,,1653.752,Percent of Total Billed charges,75% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.98,72,,1587.6,Percent of Total Billed Charges,72% of Total Billed Charges,44.98,60,,1323,Percent of Total Billed Charges,60% of Total Billed Charges,67.47,90,,84.24,Percent of Total Billed Charges,90% of Total Billed Charges,33.74,45,,30.24,Percent of Total Billed Charges,45% of Total Billed Charges,67.47,90,,390.816,Percent of Total Billed Charges,90% of Total billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.73,65,,119.816,Percent of total Billed Charges,65% of Total Billed Charges,33.06,44.1,,29.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,71.22,95,,412.528,Percent of Total Billed Charges,95% of Total Billed Charges,74.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.97,88,,31.68,Percent of Total Billed Charges,88% of Total Billed Charges,67.47,90,,390.816,Percent of Total Billed charges,90% of Total Billed Charges,33.06,74.97,
ASCA ANTIBODIES,3020000073,CDM,302,RC,,,Outpatient,,,502.74,326.78,,502.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,382.08,76,,195.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,361.97,72,,876.352,Percent of Total Billed Charges,72% of Total Billed Charges,377.06,75,,912.872,Percent of Total Billed charges,75% of Total Billed Charges,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.97,72,,876.352,Percent of Total Billed Charges,72% of Total Billed Charges,301.64,60,,730.296,Percent of Total Billed Charges,60% of Total Billed Charges,452.47,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,226.23,45,,16.2,Percent of Total Billed Charges,45% of Total Billed Charges,452.47,90,,231.12,Percent of Total Billed Charges,90% of Total billed Charges,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.78,65,,1605.24,Percent of total Billed Charges,65% of Total Billed Charges,221.71,44.1,,15.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,477.6,95,,243.96,Percent of Total Billed Charges,95% of Total Billed Charges,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,442.41,88,,201.816,Percent of Total Billed Charges,88% of Total Billed Charges,452.47,90,,231.12,Percent of Total Billed charges,90% of Total Billed Charges,221.71,502.74,
H PYLORI RAPID,3020000074,CDM,302,RC,,,Outpatient,,,156.00,101.40,,156,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,118.56,76,,42.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,112.32,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,117,75,,210,Percent of Total Billed charges,75% of Total Billed Charges,156,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.32,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,93.6,60,,168,Percent of Total Billed Charges,60% of Total Billed Charges,140.4,90,,28.248,Percent of Total Billed Charges,90% of Total Billed Charges,70.2,45,,103.2,Percent of Total Billed Charges,45% of Total Billed Charges,140.4,90,,50.4,Percent of Total Billed Charges,90% of Total billed Charges,156,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.4,65,,48.16,Percent of total Billed Charges,65% of Total Billed Charges,68.8,44.1,,101.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,148.2,95,,53.2,Percent of Total Billed Charges,95% of Total Billed Charges,156,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.28,88,,176,Percent of Total Billed Charges,88% of Total Billed Charges,140.4,90,,50.4,Percent of Total Billed charges,90% of Total Billed Charges,68.8,156,
HIV1 AB REFLE,3020000075,CDM,302,RC,,,Outpatient,,,68.36,44.43,,68.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.95,76,,42.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49.22,72,,164.736,Percent of Total Billed Charges,72% of Total Billed Charges,51.27,75,,171.6,Percent of Total Billed charges,75% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,72,,164.736,Percent of Total Billed Charges,72% of Total Billed Charges,41.02,60,,137.28,Percent of Total Billed Charges,60% of Total Billed Charges,61.52,90,,77.8,Percent of Total Billed Charges,90% of Total Billed Charges,30.76,45,,90,Percent of Total Billed Charges,45% of Total Billed Charges,61.52,90,,50.4,Percent of Total Billed Charges,90% of Total billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.43,65,,273.464,Percent of total Billed Charges,65% of Total Billed Charges,30.15,44.1,,88.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,64.94,95,,53.2,Percent of Total Billed Charges,95% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.16,88,,370.224,Percent of Total Billed Charges,88% of Total Billed Charges,61.52,90,,50.4,Percent of Total Billed charges,90% of Total Billed Charges,30.15,68.36,
HSVIGM,3020000076,CDM,302,RC,,,Outpatient,,,342.88,222.87,,342.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,260.59,76,,51.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,246.87,72,,148.608,Percent of Total Billed Charges,72% of Total Billed Charges,257.16,75,,154.8,Percent of Total Billed charges,75% of Total Billed Charges,342.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.87,72,,148.608,Percent of Total Billed Charges,72% of Total Billed Charges,205.73,60,,123.84,Percent of Total Billed Charges,60% of Total Billed Charges,308.59,90,,215.912,Percent of Total Billed Charges,90% of Total Billed Charges,154.3,45,,189.32,Percent of Total Billed Charges,45% of Total Billed Charges,308.59,90,,60.48,Percent of Total Billed Charges,90% of Total billed Charges,342.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.87,65,,107.488,Percent of total Billed Charges,65% of Total Billed Charges,151.21,44.1,,185.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,325.74,95,,63.84,Percent of Total Billed Charges,95% of Total Billed Charges,342.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.73,88,,47.168,Percent of Total Billed Charges,88% of Total Billed Charges,308.59,90,,60.48,Percent of Total Billed charges,90% of Total Billed Charges,151.21,342.88,
AB HSV TYPE 2,3020000077,CDM,302,RC,,,Outpatient,,,202.00,131.30,,202,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,153.52,76,,27.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,145.44,72,,184.8,Percent of Total Billed Charges,72% of Total Billed Charges,151.5,75,,192.496,Percent of Total Billed charges,75% of Total Billed Charges,202,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.44,72,,184.8,Percent of Total Billed Charges,72% of Total Billed Charges,121.2,60,,154,Percent of Total Billed Charges,60% of Total Billed Charges,181.8,90,,143.968,Percent of Total Billed Charges,90% of Total Billed Charges,90.9,45,,24.12,Percent of Total Billed Charges,45% of Total Billed Charges,181.8,90,,32.4,Percent of Total Billed Charges,90% of Total billed Charges,202,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.3,65,,107.488,Percent of total Billed Charges,65% of Total Billed Charges,89.08,44.1,,23.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,191.9,95,,34.2,Percent of Total Billed Charges,95% of Total Billed Charges,202,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.76,88,,82.368,Percent of Total Billed Charges,88% of Total Billed Charges,181.8,90,,32.4,Percent of Total Billed charges,90% of Total Billed Charges,89.08,202,
HIV1 AND HIV2 ANTI,3020000078,CDM,302,RC,,,Outpatient,,,143.00,92.95,,143,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,108.68,76,,174.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,102.96,72,,110.016,Percent of Total Billed Charges,72% of Total Billed Charges,107.25,75,,114.6,Percent of Total Billed charges,75% of Total Billed Charges,143,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.96,72,,110.016,Percent of Total Billed Charges,72% of Total Billed Charges,85.8,60,,91.68,Percent of Total Billed Charges,60% of Total Billed Charges,128.7,90,,179.28,Percent of Total Billed Charges,90% of Total Billed Charges,64.35,45,,42.12,Percent of Total Billed Charges,45% of Total Billed Charges,128.7,90,,206.4,Percent of Total Billed Charges,90% of Total billed Charges,143,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.95,65,,47.584,Percent of total Billed Charges,65% of Total Billed Charges,63.06,44.1,,41.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,135.85,95,,217.872,Percent of Total Billed Charges,95% of Total Billed Charges,143,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.84,88,,30.976,Percent of Total Billed Charges,88% of Total Billed Charges,128.7,90,,206.4,Percent of Total Billed charges,90% of Total Billed Charges,63.06,143,
HEPATITIS B COREB IGM,3020000080,CDM,302,RC,,,Outpatient,,,70.56,45.86,,70.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.63,76,,152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.8,72,,125.568,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,75,,130.8,Percent of Total Billed charges,75% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.8,72,,125.568,Percent of Total Billed Charges,72% of Total Billed Charges,42.34,60,,104.64,Percent of Total Billed Charges,60% of Total Billed Charges,63.5,90,,80.968,Percent of Total Billed Charges,90% of Total Billed Charges,31.75,45,,15.84,Percent of Total Billed Charges,45% of Total Billed Charges,63.5,90,,180,Percent of Total Billed Charges,90% of Total billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.86,65,,77.968,Percent of total Billed Charges,65% of Total Billed Charges,31.12,44.1,,15.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.03,95,,190,Percent of Total Billed Charges,95% of Total Billed Charges,70.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.09,88,,27.616,Percent of Total Billed Charges,88% of Total Billed Charges,63.5,90,,180,Percent of Total Billed charges,90% of Total Billed Charges,31.12,70.56,
HEPATITIS B SURF AB,3020000081,CDM,302,RC,,,Outpatient,,,260.00,169.00,,260,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,197.6,76,,319.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,187.2,72,,155.52,Percent of Total Billed Charges,72% of Total Billed Charges,195,75,,162,Percent of Total Billed charges,75% of Total Billed Charges,260,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.2,72,,155.52,Percent of Total Billed Charges,72% of Total Billed Charges,156,60,,129.6,Percent of Total Billed Charges,60% of Total Billed Charges,234,90,,1011.304,Percent of Total Billed Charges,90% of Total Billed Charges,117,45,,14.12,Percent of Total Billed Charges,45% of Total Billed Charges,234,90,,378.64,Percent of Total Billed Charges,90% of Total billed Charges,260,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169,65,,154.44,Percent of total Billed Charges,65% of Total Billed Charges,114.66,44.1,,13.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,247,95,,399.68,Percent of Total Billed Charges,95% of Total Billed Charges,260,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.8,88,,76.064,Percent of Total Billed Charges,88% of Total Billed Charges,234,90,,378.64,Percent of Total Billed charges,90% of Total Billed Charges,114.66,260,
HEPATITIS A ANTIBODY,3020000082,CDM,302,RC,,,Outpatient,,,84.00,54.60,,84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,63.84,76,,40.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,60.48,72,,110.496,Percent of Total Billed Charges,72% of Total Billed Charges,63,75,,115.104,Percent of Total Billed charges,75% of Total Billed Charges,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.48,72,,110.496,Percent of Total Billed Charges,72% of Total Billed Charges,50.4,60,,92.08,Percent of Total Billed Charges,60% of Total Billed Charges,75.6,90,,415.952,Percent of Total Billed Charges,90% of Total Billed Charges,37.8,45,,38.896,Percent of Total Billed Charges,45% of Total Billed Charges,75.6,90,,48.24,Percent of Total Billed Charges,90% of Total billed Charges,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.6,65,,137.28,Percent of total Billed Charges,65% of Total Billed Charges,37.04,44.1,,38.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,79.8,95,,50.92,Percent of Total Billed Charges,95% of Total Billed Charges,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.92,88,,211.112,Percent of Total Billed Charges,88% of Total Billed Charges,75.6,90,,48.24,Percent of Total Billed charges,90% of Total Billed Charges,37.04,84,
INFLUENZA A&B ANTIBO,3020000083,CDM,302,RC,,,Outpatient,,,246.96,160.52,,246.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,187.69,76,,71.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,177.81,72,,144.152,Percent of Total Billed Charges,72% of Total Billed Charges,185.22,75,,150.16,Percent of Total Billed charges,75% of Total Billed Charges,246.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.81,72,,144.152,Percent of Total Billed Charges,72% of Total Billed Charges,148.18,60,,120.128,Percent of Total Billed Charges,60% of Total Billed Charges,222.26,90,,176.224,Percent of Total Billed Charges,90% of Total Billed Charges,111.13,45,,107.96,Percent of Total Billed Charges,45% of Total Billed Charges,222.26,90,,84.24,Percent of Total Billed Charges,90% of Total billed Charges,246.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.52,65,,46.344,Percent of total Billed Charges,65% of Total Billed Charges,108.91,44.1,,105.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,234.61,95,,88.92,Percent of Total Billed Charges,95% of Total Billed Charges,246.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.32,88,,140.768,Percent of Total Billed Charges,88% of Total Billed Charges,222.26,90,,84.24,Percent of Total Billed charges,90% of Total Billed Charges,108.91,246.96,
MUMPS ANTIBODIES IGG,3020000084,CDM,302,RC,,,Outpatient,,,94.82,61.63,,94.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.06,76,,26.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,68.27,72,,225.216,Percent of Total Billed Charges,72% of Total Billed Charges,71.12,75,,234.6,Percent of Total Billed charges,75% of Total Billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.27,72,,225.216,Percent of Total Billed Charges,72% of Total Billed Charges,56.89,60,,187.68,Percent of Total Billed Charges,60% of Total Billed Charges,85.34,90,,205.976,Percent of Total Billed Charges,90% of Total Billed Charges,42.67,45,,71.984,Percent of Total Billed Charges,45% of Total Billed Charges,85.34,90,,31.68,Percent of Total Billed Charges,90% of Total billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.63,65,,52.744,Percent of total Billed Charges,65% of Total Billed Charges,41.82,44.1,,70.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,90.08,95,,33.44,Percent of Total Billed Charges,95% of Total Billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.44,88,,175.296,Percent of Total Billed Charges,88% of Total Billed Charges,85.34,90,,31.68,Percent of Total Billed charges,90% of Total Billed Charges,41.82,94.82,
MYCOPLASMA PNEUMONIA,3020000085,CDM,302,RC,,,Outpatient,,,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,23.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,282.816,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,294.6,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,282.816,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,235.68,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,14.08,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,89.64,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,28.248,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,178.88,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,87.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,29.816,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,79.168,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,28.248,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
ROTAVIRUS ANTIGEM,3020000086,CDM,302,RC,,,Outpatient,,,277.00,180.05,,277,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,210.52,76,,65.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,199.44,72,,102.88,Percent of Total Billed Charges,72% of Total Billed Charges,207.75,75,,107.168,Percent of Total Billed charges,75% of Total Billed Charges,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.44,72,,102.88,Percent of Total Billed Charges,72% of Total Billed Charges,166.2,60,,85.736,Percent of Total Billed Charges,60% of Total Billed Charges,249.3,90,,33.336,Percent of Total Billed Charges,90% of Total Billed Charges,124.65,45,,40.488,Percent of Total Billed Charges,45% of Total Billed Charges,249.3,90,,77.8,Percent of Total Billed Charges,90% of Total billed Charges,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.05,65,,154.44,Percent of total Billed Charges,65% of Total Billed Charges,122.16,44.1,,39.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,263.15,95,,82.12,Percent of Total Billed Charges,95% of Total Billed Charges,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.76,88,,988.832,Percent of Total Billed Charges,88% of Total Billed Charges,249.3,90,,77.8,Percent of Total Billed charges,90% of Total Billed Charges,122.16,277,
RUBELLA TITER,3020000087,CDM,302,RC,,,Outpatient,,,122.38,79.55,,122.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.01,76,,182.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.11,72,,199.872,Percent of Total Billed Charges,72% of Total Billed Charges,91.79,75,,208.2,Percent of Total Billed charges,75% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.11,72,,199.872,Percent of Total Billed Charges,72% of Total Billed Charges,73.43,60,,166.56,Percent of Total Billed Charges,60% of Total Billed Charges,110.14,90,,32.28,Percent of Total Billed Charges,90% of Total Billed Charges,55.07,45,,505.656,Percent of Total Billed Charges,45% of Total Billed Charges,110.14,90,,215.912,Percent of Total Billed Charges,90% of Total billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.55,65,,154.44,Percent of total Billed Charges,65% of Total Billed Charges,53.97,44.1,,495.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.26,95,,227.912,Percent of Total Billed Charges,95% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.69,88,,406.704,Percent of Total Billed Charges,88% of Total Billed Charges,110.14,90,,215.912,Percent of Total Billed charges,90% of Total Billed Charges,53.97,122.38,
RUBEOLA TITER,3020000088,CDM,302,RC,,,Outpatient,,,181.91,118.24,,181.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,138.25,76,,121.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,130.98,72,,317.376,Percent of Total Billed Charges,72% of Total Billed Charges,136.43,75,,330.6,Percent of Total Billed charges,75% of Total Billed Charges,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.98,72,,317.376,Percent of Total Billed Charges,72% of Total Billed Charges,109.15,60,,264.48,Percent of Total Billed Charges,60% of Total Billed Charges,163.72,90,,387.36,Percent of Total Billed Charges,90% of Total Billed Charges,81.86,45,,207.976,Percent of Total Billed Charges,45% of Total Billed Charges,163.72,90,,143.968,Percent of Total Billed Charges,90% of Total billed Charges,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.24,65,,162.24,Percent of total Billed Charges,65% of Total Billed Charges,80.22,44.1,,203.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,172.81,95,,151.96,Percent of Total Billed Charges,95% of Total Billed Charges,181.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.08,88,,172.312,Percent of Total Billed Charges,88% of Total Billed Charges,163.72,90,,143.968,Percent of Total Billed charges,90% of Total Billed Charges,80.22,181.91,
TETANUS ANTITOXOID A,3020000089,CDM,302,RC,,,Outpatient,,,190.73,123.97,,190.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.95,76,,151.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,137.33,72,,80.064,Percent of Total Billed Charges,72% of Total Billed Charges,143.05,75,,83.4,Percent of Total Billed charges,75% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.33,72,,80.064,Percent of Total Billed Charges,72% of Total Billed Charges,114.44,60,,66.72,Percent of Total Billed Charges,60% of Total Billed Charges,171.66,90,,441.352,Percent of Total Billed Charges,90% of Total Billed Charges,85.83,45,,88.112,Percent of Total Billed Charges,45% of Total Billed Charges,171.66,90,,179.28,Percent of Total Billed Charges,90% of Total billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.97,65,,267.28,Percent of total Billed Charges,65% of Total Billed Charges,84.11,44.1,,86.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,181.19,95,,189.24,Percent of Total Billed Charges,95% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.84,88,,201.4,Percent of Total Billed Charges,88% of Total Billed Charges,171.66,90,,179.28,Percent of Total Billed charges,90% of Total Billed Charges,84.11,190.73,
FTA ABSORPTION,3020000090,CDM,302,RC,,,Outpatient,,,94.82,61.63,,94.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.06,76,,68.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,68.27,72,,105.408,Percent of Total Billed Charges,72% of Total Billed Charges,71.12,75,,109.8,Percent of Total Billed charges,75% of Total Billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.27,72,,105.408,Percent of Total Billed Charges,72% of Total Billed Charges,56.89,60,,87.84,Percent of Total Billed Charges,60% of Total Billed Charges,85.34,90,,23.424,Percent of Total Billed Charges,90% of Total Billed Charges,42.67,45,,102.992,Percent of Total Billed Charges,45% of Total Billed Charges,85.34,90,,80.968,Percent of Total Billed Charges,90% of Total billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.63,65,,53.56,Percent of total Billed Charges,65% of Total Billed Charges,41.82,44.1,,100.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,90.08,95,,85.472,Percent of Total Billed Charges,95% of Total Billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.44,88,,13.76,Percent of Total Billed Charges,88% of Total Billed Charges,85.34,90,,80.968,Percent of Total Billed charges,90% of Total Billed Charges,41.82,94.82,
VARICELLAZOSTER VIR,3020000091,CDM,302,RC,,,Outpatient,,,73.87,48.02,,73.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.14,76,,853.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.19,72,,148.608,Percent of Total Billed Charges,72% of Total Billed Charges,55.4,75,,154.8,Percent of Total Billed charges,75% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.19,72,,148.608,Percent of Total Billed Charges,72% of Total Billed Charges,44.32,60,,123.84,Percent of Total Billed Charges,60% of Total Billed Charges,66.48,90,,52.704,Percent of Total Billed Charges,90% of Total Billed Charges,33.24,45,,7.04,Percent of Total Billed Charges,45% of Total Billed Charges,66.48,90,,1011.304,Percent of Total Billed Charges,90% of Total billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.02,65,,66.04,Percent of total Billed Charges,65% of Total Billed Charges,32.58,44.1,,6.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,70.18,95,,1067.488,Percent of Total Billed Charges,95% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.01,88,,32.592,Percent of Total Billed Charges,88% of Total Billed Charges,66.48,90,,1011.304,Percent of Total Billed charges,90% of Total Billed Charges,32.58,73.87,
THYROGLOBULIN AB,3020000092,CDM,302,RC,,,Outpatient,,,476.28,309.58,,476.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,361.97,76,,351.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,342.92,72,,143.424,Percent of Total Billed Charges,72% of Total Billed Charges,357.21,75,,149.4,Percent of Total Billed charges,75% of Total Billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.92,72,,143.424,Percent of Total Billed Charges,72% of Total Billed Charges,285.77,60,,119.52,Percent of Total Billed Charges,60% of Total Billed Charges,428.65,90,,3284.64,Percent of Total Billed Charges,90% of Total Billed Charges,214.33,45,,16.672,Percent of Total Billed Charges,45% of Total Billed Charges,428.65,90,,415.952,Percent of Total Billed Charges,90% of Total billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.58,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,210.04,44.1,,16.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,452.47,95,,439.056,Percent of Total Billed Charges,95% of Total Billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.13,88,,31.56,Percent of Total Billed Charges,88% of Total Billed Charges,428.65,90,,415.952,Percent of Total Billed charges,90% of Total Billed Charges,210.04,476.28,
THYROID CANCER MONITORING,3020000093,CDM,302,RC,,,Outpatient,,,476.28,309.58,,476.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,361.97,76,,148.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,342.92,72,,149.872,Percent of Total Billed Charges,72% of Total Billed Charges,357.21,75,,156.112,Percent of Total Billed charges,75% of Total Billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.92,72,,149.872,Percent of Total Billed Charges,72% of Total Billed Charges,285.77,60,,124.888,Percent of Total Billed Charges,60% of Total Billed Charges,428.65,90,,3284.64,Percent of Total Billed Charges,90% of Total Billed Charges,214.33,45,,16.136,Percent of Total Billed Charges,45% of Total Billed Charges,428.65,90,,176.224,Percent of Total Billed Charges,90% of Total billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.58,65,,148.2,Percent of total Billed Charges,65% of Total Billed Charges,210.04,44.1,,15.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,452.47,95,,186.016,Percent of Total Billed Charges,95% of Total Billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.13,88,,378.752,Percent of Total Billed Charges,88% of Total Billed Charges,428.65,90,,176.224,Percent of Total Billed charges,90% of Total Billed Charges,210.04,476.28,
HEPATITIS C AB,3020000094,CDM,302,RC,,,Outpatient,,,189.00,122.85,,189,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,143.64,76,,173.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,136.08,72,,251.712,Percent of Total Billed Charges,72% of Total Billed Charges,141.75,75,,262.2,Percent of Total Billed charges,75% of Total Billed Charges,189,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.08,72,,251.712,Percent of Total Billed Charges,72% of Total Billed Charges,113.4,60,,209.76,Percent of Total Billed Charges,60% of Total Billed Charges,170.1,90,,441.352,Percent of Total Billed Charges,90% of Total Billed Charges,85.05,45,,193.68,Percent of Total Billed Charges,45% of Total Billed Charges,170.1,90,,205.976,Percent of Total Billed Charges,90% of Total billed Charges,189,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.85,65,,164.84,Percent of total Billed Charges,65% of Total Billed Charges,83.35,44.1,,189.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,179.55,95,,217.424,Percent of Total Billed Charges,95% of Total Billed Charges,189,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.32,88,,431.544,Percent of Total Billed Charges,88% of Total Billed Charges,170.1,90,,205.976,Percent of Total Billed charges,90% of Total Billed Charges,83.35,189,
HCV AB/REFLEX TO RIB,3020000095,CDM,302,RC,,,Outpatient,,,179.71,116.81,,179.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,136.58,76,,11.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,129.39,72,,266.72,Percent of Total Billed Charges,72% of Total Billed Charges,134.78,75,,277.832,Percent of Total Billed charges,75% of Total Billed Charges,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.39,72,,266.72,Percent of Total Billed Charges,72% of Total Billed Charges,107.83,60,,222.264,Percent of Total Billed Charges,60% of Total Billed Charges,161.74,90,,205.24,Percent of Total Billed Charges,90% of Total Billed Charges,80.87,45,,220.68,Percent of Total Billed Charges,45% of Total Billed Charges,161.74,90,,14.08,Percent of Total Billed Charges,90% of Total billed Charges,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.81,65,,408.72,Percent of total Billed Charges,65% of Total Billed Charges,79.25,44.1,,216.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,170.72,95,,14.856,Percent of Total Billed Charges,95% of Total Billed Charges,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.14,88,,22.904,Percent of Total Billed Charges,88% of Total Billed Charges,161.74,90,,14.08,Percent of Total Billed charges,90% of Total Billed Charges,79.25,179.71,
DONOR HCV (ANTIHCV),3020000096,CDM,302,RC,,,Outpatient,,,179.71,116.81,,179.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,136.58,76,,28.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,129.39,72,,253.44,Percent of Total Billed Charges,72% of Total Billed Charges,134.78,75,,264,Percent of Total Billed charges,75% of Total Billed Charges,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.39,72,,253.44,Percent of Total Billed Charges,72% of Total Billed Charges,107.83,60,,211.2,Percent of Total Billed Charges,60% of Total Billed Charges,161.74,90,,164.32,Percent of Total Billed Charges,90% of Total Billed Charges,80.87,45,,11.712,Percent of Total Billed Charges,45% of Total Billed Charges,161.74,90,,33.336,Percent of Total Billed Charges,90% of Total billed Charges,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.81,65,,43.568,Percent of total Billed Charges,65% of Total Billed Charges,79.25,44.1,,11.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,170.72,95,,35.192,Percent of Total Billed Charges,95% of Total Billed Charges,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.14,88,,51.536,Percent of Total Billed Charges,88% of Total Billed Charges,161.74,90,,33.336,Percent of Total Billed charges,90% of Total Billed Charges,79.25,179.71,
HCV AB/REFLEX TO HCV,3020000097,CDM,302,RC,,,Outpatient,,,179.71,116.81,,179.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,136.58,76,,27.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,129.39,72,,289.576,Percent of Total Billed Charges,72% of Total Billed Charges,134.78,75,,301.648,Percent of Total Billed charges,75% of Total Billed Charges,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.39,72,,289.576,Percent of Total Billed Charges,72% of Total Billed Charges,107.83,60,,241.312,Percent of Total Billed Charges,60% of Total Billed Charges,161.74,90,,165.904,Percent of Total Billed Charges,90% of Total Billed Charges,80.87,45,,26.352,Percent of Total Billed Charges,45% of Total Billed Charges,161.74,90,,32.28,Percent of Total Billed Charges,90% of Total billed Charges,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.81,65,,62.4,Percent of total Billed Charges,65% of Total Billed Charges,79.25,44.1,,25.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,170.72,95,,34.072,Percent of Total Billed Charges,95% of Total Billed Charges,179.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.14,88,,3211.648,Percent of Total Billed Charges,88% of Total Billed Charges,161.74,90,,32.28,Percent of Total Billed charges,90% of Total Billed Charges,79.25,179.71,
HLAB27,3020000098,CDM,302,RC,,,Outpatient,,,331.85,215.70,,331.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,252.21,76,,327.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,238.93,72,,275.328,Percent of Total Billed Charges,72% of Total Billed Charges,248.89,75,,286.8,Percent of Total Billed charges,75% of Total Billed Charges,331.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.93,72,,275.328,Percent of Total Billed Charges,72% of Total Billed Charges,199.11,60,,229.44,Percent of Total Billed Charges,60% of Total Billed Charges,298.67,90,,2222.64,Percent of Total Billed Charges,90% of Total Billed Charges,149.33,45,,1642.32,Percent of Total Billed Charges,45% of Total Billed Charges,298.67,90,,387.36,Percent of Total Billed Charges,90% of Total billed Charges,331.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,331.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,331.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.7,65,,36.92,Percent of total Billed Charges,65% of Total Billed Charges,146.35,44.1,,1609.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,315.26,95,,408.88,Percent of Total Billed Charges,95% of Total Billed Charges,331.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.03,88,,3211.648,Percent of Total Billed Charges,88% of Total Billed Charges,298.67,90,,387.36,Percent of Total Billed charges,90% of Total Billed Charges,146.35,331.85,
E COLI 0157 CULTURE,3020000099,CDM,306,RC,,,Outpatient,,,147.74,96.03,,147.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,112.28,76,,372.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,106.37,72,,290.88,Percent of Total Billed Charges,72% of Total Billed Charges,110.81,75,,303,Percent of Total Billed charges,75% of Total Billed Charges,147.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.37,72,,290.88,Percent of Total Billed Charges,72% of Total Billed Charges,88.64,60,,242.4,Percent of Total Billed Charges,60% of Total Billed Charges,132.97,90,,66.68,Percent of Total Billed Charges,90% of Total Billed Charges,66.48,45,,1642.32,Percent of Total Billed Charges,45% of Total Billed Charges,132.97,90,,441.352,Percent of Total Billed Charges,90% of Total billed Charges,147.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.03,65,,169.704,Percent of total Billed Charges,65% of Total Billed Charges,65.15,44.1,,1609.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,140.35,95,,465.872,Percent of Total Billed Charges,95% of Total Billed Charges,147.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.01,88,,431.544,Percent of Total Billed Charges,88% of Total Billed Charges,132.97,90,,441.352,Percent of Total Billed charges,90% of Total Billed Charges,65.15,147.74,
COCCIDIODES AB COMP,3020000105,CDM,302,RC,,,Outpatient,,,122.38,79.55,,122.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.01,76,,372.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.11,72,,138.816,Percent of Total Billed Charges,72% of Total Billed Charges,91.79,75,,144.6,Percent of Total Billed charges,75% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.11,72,,138.816,Percent of Total Billed Charges,72% of Total Billed Charges,73.43,60,,115.68,Percent of Total Billed Charges,60% of Total Billed Charges,110.14,90,,107.96,Percent of Total Billed Charges,90% of Total Billed Charges,55.07,45,,1111.32,Percent of Total Billed Charges,45% of Total Billed Charges,110.14,90,,441.352,Percent of Total Billed Charges,90% of Total billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.55,65,,317.2,Percent of total Billed Charges,65% of Total Billed Charges,53.97,44.1,,1089.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.26,95,,465.872,Percent of Total Billed Charges,95% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.69,88,,65.2,Percent of Total Billed Charges,88% of Total Billed Charges,110.14,90,,441.352,Percent of Total Billed charges,90% of Total Billed Charges,53.97,122.38,
COCCIDIOIDES TOTAL A,3020000106,CDM,302,RC,,,Outpatient,,,108.05,70.23,,108.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.12,76,,173.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.8,72,,254.592,Percent of Total Billed Charges,72% of Total Billed Charges,81.04,75,,265.2,Percent of Total Billed charges,75% of Total Billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.8,72,,254.592,Percent of Total Billed Charges,72% of Total Billed Charges,64.83,60,,212.16,Percent of Total Billed Charges,60% of Total Billed Charges,97.25,90,,213.84,Percent of Total Billed Charges,90% of Total Billed Charges,48.62,45,,33.336,Percent of Total Billed Charges,45% of Total Billed Charges,97.25,90,,205.24,Percent of Total Billed Charges,90% of Total billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.23,65,,166.4,Percent of total Billed Charges,65% of Total Billed Charges,47.65,44.1,,32.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.65,95,,216.64,Percent of Total Billed Charges,95% of Total Billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.08,88,,370.224,Percent of Total Billed Charges,88% of Total Billed Charges,97.25,90,,205.24,Percent of Total Billed charges,90% of Total Billed Charges,47.65,108.05,
COCCIDIOIDES TOTAL A,3020000107,CDM,302,RC,,,Outpatient,,,108.05,70.23,,108.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.12,76,,138.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.8,72,,237.312,Percent of Total Billed Charges,72% of Total Billed Charges,81.04,75,,247.2,Percent of Total Billed charges,75% of Total Billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.8,72,,237.312,Percent of Total Billed Charges,72% of Total Billed Charges,64.83,60,,197.76,Percent of Total Billed Charges,60% of Total Billed Charges,97.25,90,,190.08,Percent of Total Billed Charges,90% of Total Billed Charges,48.62,45,,189.32,Percent of Total Billed Charges,45% of Total Billed Charges,97.25,90,,164.32,Percent of Total Billed Charges,90% of Total billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.23,65,,191.104,Percent of total Billed Charges,65% of Total Billed Charges,47.65,44.1,,185.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.65,95,,173.448,Percent of Total Billed Charges,95% of Total Billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.08,88,,145.52,Percent of Total Billed Charges,88% of Total Billed Charges,97.25,90,,164.32,Percent of Total Billed charges,90% of Total Billed Charges,47.65,108.05,
RPR Titer,3020000109,CDM,302,RC,,,Outpatient,,,32.20,20.93,,32.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.47,76,,140.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.18,72,,285.12,Percent of Total Billed Charges,72% of Total Billed Charges,24.15,75,,297,Percent of Total Billed charges,75% of Total Billed Charges,32.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.18,72,,285.12,Percent of Total Billed Charges,72% of Total Billed Charges,19.32,60,,237.6,Percent of Total Billed Charges,60% of Total Billed Charges,28.98,90,,64.176,Percent of Total Billed Charges,90% of Total Billed Charges,14.49,45,,74.416,Percent of Total Billed Charges,45% of Total Billed Charges,28.98,90,,165.904,Percent of Total Billed Charges,90% of Total billed Charges,32.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.93,65,,93.6,Percent of total Billed Charges,65% of Total Billed Charges,14.2,44.1,,72.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.59,95,,175.12,Percent of Total Billed Charges,95% of Total Billed Charges,32.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.34,88,,145.52,Percent of Total Billed Charges,88% of Total Billed Charges,28.98,90,,165.904,Percent of Total Billed charges,90% of Total Billed Charges,14.2,32.2,
RNA POLYMERASE III AB,3020000110,CDM,301,RC,,,Outpatient,,,111.30,72.35,,111.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,84.59,76,,1876.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,80.14,72,,266.112,Percent of Total Billed Charges,72% of Total Billed Charges,83.48,75,,277.2,Percent of Total Billed charges,75% of Total Billed Charges,111.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.14,72,,266.112,Percent of Total Billed Charges,72% of Total Billed Charges,66.78,60,,221.76,Percent of Total Billed Charges,60% of Total Billed Charges,100.17,90,,73.032,Percent of Total Billed Charges,90% of Total Billed Charges,50.09,45,,74.416,Percent of Total Billed Charges,45% of Total Billed Charges,100.17,90,,2222.64,Percent of Total Billed Charges,90% of Total billed Charges,111.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.35,65,,237.12,Percent of total Billed Charges,65% of Total Billed Charges,49.08,44.1,,72.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,105.74,95,,2346.12,Percent of Total Billed Charges,95% of Total Billed Charges,111.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.94,88,,64.424,Percent of Total Billed Charges,88% of Total Billed Charges,100.17,90,,2222.64,Percent of Total Billed charges,90% of Total Billed Charges,49.08,111.3,
Amoeba Antibody,3020000111,CDM,302,RC,,,Outpatient,,,43.00,27.95,,43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,32.68,76,,56.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.96,72,,242.496,Percent of Total Billed Charges,72% of Total Billed Charges,32.25,75,,252.6,Percent of Total Billed charges,75% of Total Billed Charges,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.96,72,,242.496,Percent of Total Billed Charges,72% of Total Billed Charges,25.8,60,,202.08,Percent of Total Billed Charges,60% of Total Billed Charges,38.7,90,,247.68,Percent of Total Billed Charges,90% of Total Billed Charges,19.35,45,,32.944,Percent of Total Billed Charges,45% of Total Billed Charges,38.7,90,,66.68,Percent of Total Billed Charges,90% of Total billed Charges,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.95,65,,188.248,Percent of total Billed Charges,65% of Total Billed Charges,18.96,44.1,,32.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,40.85,95,,70.384,Percent of Total Billed Charges,95% of Total Billed Charges,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.84,88,,105.56,Percent of Total Billed Charges,88% of Total Billed Charges,38.7,90,,66.68,Percent of Total Billed charges,90% of Total Billed Charges,18.96,43,
E. Histo AB,3020000112,CDM,302,RC,,,Outpatient,,,194.04,126.13,,194.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,147.47,76,,319.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,139.71,72,,244.224,Percent of Total Billed Charges,72% of Total Billed Charges,145.53,75,,254.4,Percent of Total Billed charges,75% of Total Billed Charges,194.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.71,72,,244.224,Percent of Total Billed Charges,72% of Total Billed Charges,116.42,60,,203.52,Percent of Total Billed Charges,60% of Total Billed Charges,174.64,90,,213.84,Percent of Total Billed Charges,90% of Total Billed Charges,87.32,45,,53.976,Percent of Total Billed Charges,45% of Total Billed Charges,174.64,90,,378.64,Percent of Total Billed Charges,90% of Total billed Charges,194.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.13,65,,369.2,Percent of total Billed Charges,65% of Total Billed Charges,85.57,44.1,,52.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,184.34,95,,399.68,Percent of Total Billed Charges,95% of Total Billed Charges,194.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.76,88,,209.088,Percent of Total Billed Charges,88% of Total Billed Charges,174.64,90,,378.64,Percent of Total Billed charges,90% of Total Billed Charges,85.57,194.04,
SANE Syphilis Test,3020000113,CDM,302,RC,,,Outpatient,,,266.00,172.90,,266,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,202.16,76,,125.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,191.52,72,,278.152,Percent of Total Billed Charges,72% of Total Billed Charges,199.5,75,,289.744,Percent of Total Billed charges,75% of Total Billed Charges,266,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.52,72,,278.152,Percent of Total Billed Charges,72% of Total Billed Charges,159.6,60,,231.792,Percent of Total Billed Charges,60% of Total Billed Charges,239.4,90,,213.84,Percent of Total Billed Charges,90% of Total Billed Charges,119.7,45,,106.92,Percent of Total Billed Charges,45% of Total Billed Charges,239.4,90,,148.832,Percent of Total Billed Charges,90% of Total billed Charges,266,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.9,65,,227.24,Percent of total Billed Charges,65% of Total Billed Charges,117.31,44.1,,104.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,252.7,95,,157.096,Percent of Total Billed Charges,95% of Total Billed Charges,266,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.08,88,,185.856,Percent of Total Billed Charges,88% of Total Billed Charges,239.4,90,,148.832,Percent of Total Billed charges,90% of Total Billed Charges,117.31,266,
"Hepatisis A, IgM",3020000114,CDM,302,RC,,,Outpatient,,,28.15,18.30,,28.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21.39,76,,125.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.27,72,,278.152,Percent of Total Billed Charges,72% of Total Billed Charges,21.11,75,,289.744,Percent of Total Billed charges,75% of Total Billed Charges,28.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.27,72,,278.152,Percent of Total Billed Charges,72% of Total Billed Charges,16.89,60,,231.792,Percent of Total Billed Charges,60% of Total Billed Charges,25.34,90,,224.64,Percent of Total Billed Charges,90% of Total Billed Charges,12.67,45,,95.04,Percent of Total Billed Charges,45% of Total Billed Charges,25.34,90,,148.832,Percent of Total Billed Charges,90% of Total billed Charges,28.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.3,65,,44.72,Percent of total Billed Charges,65% of Total Billed Charges,12.41,44.1,,93.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.74,95,,157.096,Percent of Total Billed Charges,95% of Total Billed Charges,28.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.77,88,,62.744,Percent of Total Billed Charges,88% of Total Billed Charges,25.34,90,,148.832,Percent of Total Billed charges,90% of Total Billed Charges,12.41,28.15,
DIFFERENTIAL WBC,3050000002,CDM,305,RC,,,Outpatient,,,47.41,30.82,,47.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.03,76,,55.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.14,72,,261,Percent of Total Billed Charges,72% of Total Billed Charges,35.56,75,,271.88,Percent of Total Billed charges,75% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.14,72,,261,Percent of Total Billed Charges,72% of Total Billed Charges,28.45,60,,217.504,Percent of Total Billed Charges,60% of Total Billed Charges,42.67,90,,370.08,Percent of Total Billed Charges,90% of Total Billed Charges,21.33,45,,32.088,Percent of Total Billed Charges,45% of Total Billed Charges,42.67,90,,65.888,Percent of Total Billed Charges,90% of Total billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.82,65,,162.24,Percent of total Billed Charges,65% of Total Billed Charges,20.91,44.1,,31.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.04,95,,69.544,Percent of Total Billed Charges,95% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.72,88,,71.408,Percent of Total Billed Charges,88% of Total Billed Charges,42.67,90,,65.888,Percent of Total Billed charges,90% of Total Billed Charges,20.91,47.41,
HEMATOCRIT,3050000003,CDM,305,RC,,,Outpatient,,,62.00,40.30,,62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.12,76,,91.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,44.64,72,,328.32,Percent of Total Billed Charges,72% of Total Billed Charges,46.5,75,,342,Percent of Total Billed charges,75% of Total Billed Charges,62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.64,72,,328.32,Percent of Total Billed Charges,72% of Total Billed Charges,37.2,60,,273.6,Percent of Total Billed Charges,60% of Total Billed Charges,55.8,90,,74.16,Percent of Total Billed Charges,90% of Total Billed Charges,27.9,45,,36.512,Percent of Total Billed Charges,45% of Total Billed Charges,55.8,90,,107.96,Percent of Total Billed Charges,90% of Total billed Charges,62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.3,65,,394.68,Percent of total Billed Charges,65% of Total Billed Charges,27.34,44.1,,35.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,58.9,95,,113.952,Percent of Total Billed Charges,95% of Total Billed Charges,62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.56,88,,242.176,Percent of Total Billed Charges,88% of Total Billed Charges,55.8,90,,107.96,Percent of Total Billed charges,90% of Total Billed Charges,27.34,62,
HEMOGLOBIN,3050000004,CDM,305,RC,,,Outpatient,,,62.00,40.30,,62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.12,76,,180.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,44.64,72,,313.92,Percent of Total Billed Charges,72% of Total Billed Charges,46.5,75,,327,Percent of Total Billed charges,75% of Total Billed Charges,62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.64,72,,313.92,Percent of Total Billed Charges,72% of Total Billed Charges,37.2,60,,261.6,Percent of Total Billed Charges,60% of Total Billed Charges,55.8,90,,91.44,Percent of Total Billed Charges,90% of Total Billed Charges,27.9,45,,123.84,Percent of Total Billed Charges,45% of Total Billed Charges,55.8,90,,213.84,Percent of Total Billed Charges,90% of Total billed Charges,62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.3,65,,364.16,Percent of total Billed Charges,65% of Total Billed Charges,27.34,44.1,,121.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,58.9,95,,225.72,Percent of Total Billed Charges,95% of Total Billed Charges,62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.56,88,,209.088,Percent of Total Billed Charges,88% of Total Billed Charges,55.8,90,,213.84,Percent of Total Billed charges,90% of Total Billed Charges,27.34,62,
CBC & AUTO DIFF,3050000005,CDM,305,RC,,,Outpatient,,,173.00,112.45,,173,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,131.48,76,,160.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,124.56,72,,153.68,Percent of Total Billed Charges,72% of Total Billed Charges,129.75,75,,160.088,Percent of Total Billed charges,75% of Total Billed Charges,173,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.56,72,,153.68,Percent of Total Billed Charges,72% of Total Billed Charges,103.8,60,,128.072,Percent of Total Billed Charges,60% of Total Billed Charges,155.7,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,77.85,45,,106.92,Percent of Total Billed Charges,45% of Total Billed Charges,155.7,90,,190.08,Percent of Total Billed Charges,90% of Total billed Charges,173,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.45,65,,130,Percent of total Billed Charges,65% of Total Billed Charges,76.29,44.1,,104.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,164.35,95,,200.64,Percent of Total Billed Charges,95% of Total Billed Charges,173,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.24,88,,209.088,Percent of Total Billed Charges,88% of Total Billed Charges,155.7,90,,190.08,Percent of Total Billed charges,90% of Total Billed Charges,76.29,173,
HEMOGRAM W/O PLATELE,3050000006,CDM,305,RC,,,Outpatient,,,92.61,60.20,,92.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,70.38,76,,54.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,66.68,72,,159.552,Percent of Total Billed Charges,72% of Total Billed Charges,69.46,75,,166.2,Percent of Total Billed charges,75% of Total Billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.68,72,,159.552,Percent of Total Billed Charges,72% of Total Billed Charges,55.57,60,,132.96,Percent of Total Billed Charges,60% of Total Billed Charges,83.35,90,,205.2,Percent of Total Billed Charges,90% of Total Billed Charges,41.67,45,,106.92,Percent of Total Billed Charges,45% of Total Billed Charges,83.35,90,,64.176,Percent of Total Billed Charges,90% of Total billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.2,65,,65.52,Percent of total Billed Charges,65% of Total Billed Charges,40.84,44.1,,104.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,87.98,95,,67.736,Percent of Total Billed Charges,95% of Total Billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.5,88,,219.648,Percent of Total Billed Charges,88% of Total Billed Charges,83.35,90,,64.176,Percent of Total Billed charges,90% of Total Billed Charges,40.84,92.61,
CBC,3050000007,CDM,305,RC,,,Outpatient,,,88.00,57.20,,88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.88,76,,61.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.36,72,,208.512,Percent of Total Billed Charges,72% of Total Billed Charges,66,75,,217.2,Percent of Total Billed charges,75% of Total Billed Charges,88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.36,72,,208.512,Percent of Total Billed Charges,72% of Total Billed Charges,52.8,60,,173.76,Percent of Total Billed Charges,60% of Total Billed Charges,79.2,90,,228.24,Percent of Total Billed Charges,90% of Total Billed Charges,39.6,45,,112.32,Percent of Total Billed Charges,45% of Total Billed Charges,79.2,90,,73.032,Percent of Total Billed Charges,90% of Total billed Charges,88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.2,65,,788.312,Percent of total Billed Charges,65% of Total Billed Charges,38.81,44.1,,110.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.6,95,,77.088,Percent of Total Billed Charges,95% of Total Billed Charges,88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.44,88,,361.856,Percent of Total Billed Charges,88% of Total Billed Charges,79.2,90,,73.032,Percent of Total Billed charges,90% of Total Billed Charges,38.81,88,
RETIC COUNT,3050000008,CDM,305,RC,,,Outpatient,,,44.00,28.60,,44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33.44,76,,209.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,31.68,72,,163.008,Percent of Total Billed Charges,72% of Total Billed Charges,33,75,,169.8,Percent of Total Billed charges,75% of Total Billed Charges,44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.68,72,,163.008,Percent of Total Billed Charges,72% of Total Billed Charges,26.4,60,,135.84,Percent of Total Billed Charges,60% of Total Billed Charges,39.6,90,,565.92,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,45,,185.04,Percent of Total Billed Charges,45% of Total Billed Charges,39.6,90,,247.68,Percent of Total Billed Charges,90% of Total billed Charges,44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.6,65,,93.6,Percent of total Billed Charges,65% of Total Billed Charges,19.4,44.1,,181.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.8,95,,261.44,Percent of Total Billed Charges,95% of Total Billed Charges,44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.72,88,,72.512,Percent of Total Billed Charges,88% of Total Billed Charges,39.6,90,,247.68,Percent of Total Billed charges,90% of Total Billed Charges,19.4,44,
PLATELET COUNT,3050000009,CDM,305,RC,,,Outpatient,,,56.00,36.40,,56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,42.56,76,,180.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40.32,72,,183.168,Percent of Total Billed Charges,72% of Total Billed Charges,42,75,,190.8,Percent of Total Billed charges,75% of Total Billed Charges,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.32,72,,183.168,Percent of Total Billed Charges,72% of Total Billed Charges,33.6,60,,152.64,Percent of Total Billed Charges,60% of Total Billed Charges,50.4,90,,60.328,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,45,,37.08,Percent of Total Billed Charges,45% of Total Billed Charges,50.4,90,,213.84,Percent of Total Billed Charges,90% of Total billed Charges,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.4,65,,260,Percent of total Billed Charges,65% of Total Billed Charges,24.7,44.1,,36.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,53.2,95,,225.72,Percent of Total Billed Charges,95% of Total Billed Charges,56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.28,88,,89.408,Percent of Total Billed Charges,88% of Total Billed Charges,50.4,90,,213.84,Percent of Total Billed charges,90% of Total Billed Charges,24.7,56,
FACTOR VIII  ONE STA,3050000010,CDM,305,RC,,,Outpatient,,,243.65,158.37,,243.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,185.17,76,,180.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,175.43,72,,160.704,Percent of Total Billed Charges,72% of Total Billed Charges,182.74,75,,167.4,Percent of Total Billed charges,75% of Total Billed Charges,243.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.43,72,,160.704,Percent of Total Billed Charges,72% of Total Billed Charges,146.19,60,,133.92,Percent of Total Billed Charges,60% of Total Billed Charges,219.29,90,,86.4,Percent of Total Billed Charges,90% of Total Billed Charges,109.64,45,,45.72,Percent of Total Billed Charges,45% of Total Billed Charges,219.29,90,,213.84,Percent of Total Billed Charges,90% of Total billed Charges,243.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.37,65,,1070.928,Percent of total Billed Charges,65% of Total Billed Charges,107.45,44.1,,44.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,231.47,95,,225.72,Percent of Total Billed Charges,95% of Total Billed Charges,243.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.41,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,219.29,90,,213.84,Percent of Total Billed charges,90% of Total Billed Charges,107.45,243.65,
FACTOR VIII  RISTOCE,3050000011,CDM,305,RC,,,Outpatient,,,243.65,158.37,,243.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,185.17,76,,189.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,175.43,72,,1195.376,Percent of Total Billed Charges,72% of Total Billed Charges,182.74,75,,1245.184,Percent of Total Billed charges,75% of Total Billed Charges,243.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.43,72,,1195.376,Percent of Total Billed Charges,72% of Total Billed Charges,146.19,60,,996.144,Percent of Total Billed Charges,60% of Total Billed Charges,219.29,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,109.64,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,219.29,90,,224.64,Percent of Total Billed Charges,90% of Total billed Charges,243.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.37,65,,4433.904,Percent of total Billed Charges,65% of Total Billed Charges,107.45,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,231.47,95,,237.12,Percent of Total Billed Charges,95% of Total Billed Charges,243.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.41,88,,200.64,Percent of Total Billed Charges,88% of Total Billed Charges,219.29,90,,224.64,Percent of Total Billed charges,90% of Total Billed Charges,107.45,243.65,
FACTOR VIII  VW FACT,3050000012,CDM,305,RC,,,Outpatient,,,243.65,158.37,,243.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,185.17,76,,312.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,175.43,72,,1195.376,Percent of Total Billed Charges,72% of Total Billed Charges,182.74,75,,1245.184,Percent of Total Billed charges,75% of Total Billed Charges,243.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.43,72,,1195.376,Percent of Total Billed Charges,72% of Total Billed Charges,146.19,60,,996.144,Percent of Total Billed Charges,60% of Total Billed Charges,219.29,90,,234.976,Percent of Total Billed Charges,90% of Total Billed Charges,109.64,45,,102.6,Percent of Total Billed Charges,45% of Total Billed Charges,219.29,90,,370.08,Percent of Total Billed Charges,90% of Total billed Charges,243.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.37,65,,227.6,Percent of total Billed Charges,65% of Total Billed Charges,107.45,44.1,,100.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,231.47,95,,390.64,Percent of Total Billed Charges,95% of Total Billed Charges,243.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.41,88,,223.168,Percent of Total Billed Charges,88% of Total Billed Charges,219.29,90,,370.08,Percent of Total Billed charges,90% of Total Billed Charges,107.45,243.65,
VON WILLIBRNAD FACTO,3050000013,CDM,305,RC,,,Outpatient,,,243.65,158.37,,243.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,185.17,76,,62.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,175.43,72,,654.736,Percent of Total Billed Charges,72% of Total Billed Charges,182.74,75,,682.024,Percent of Total Billed charges,75% of Total Billed Charges,243.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.43,72,,654.736,Percent of Total Billed Charges,72% of Total Billed Charges,146.19,60,,545.616,Percent of Total Billed Charges,60% of Total Billed Charges,219.29,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,109.64,45,,114.12,Percent of Total Billed Charges,45% of Total Billed Charges,219.29,90,,74.16,Percent of Total Billed Charges,90% of Total billed Charges,243.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.37,65,,338,Percent of total Billed Charges,65% of Total Billed Charges,107.45,44.1,,111.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,231.47,95,,78.28,Percent of Total Billed Charges,95% of Total Billed Charges,243.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.41,88,,553.344,Percent of Total Billed Charges,88% of Total Billed Charges,219.29,90,,74.16,Percent of Total Billed charges,90% of Total Billed Charges,107.45,243.65,
FACTOR X1 ACTIVITY,3050000014,CDM,305,RC,,,Outpatient,,,276.73,179.87,,276.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,210.31,76,,77.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,199.25,72,,654.736,Percent of Total Billed Charges,72% of Total Billed Charges,207.55,75,,682.024,Percent of Total Billed charges,75% of Total Billed Charges,276.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.25,72,,654.736,Percent of Total Billed Charges,72% of Total Billed Charges,166.04,60,,545.616,Percent of Total Billed Charges,60% of Total Billed Charges,249.06,90,,230.904,Percent of Total Billed Charges,90% of Total Billed Charges,124.53,45,,282.96,Percent of Total Billed Charges,45% of Total Billed Charges,249.06,90,,91.44,Percent of Total Billed Charges,90% of Total billed Charges,276.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.87,65,,525.2,Percent of total Billed Charges,65% of Total Billed Charges,122.04,44.1,,277.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,262.89,95,,96.52,Percent of Total Billed Charges,95% of Total Billed Charges,276.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.52,88,,58.992,Percent of Total Billed Charges,88% of Total Billed Charges,249.06,90,,91.44,Percent of Total Billed charges,90% of Total Billed Charges,122.04,276.73,
ANTITHROMBIN III ACT,3050000015,CDM,305,RC,,,Outpatient,,,313.11,203.52,,313.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.96,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,225.44,72,,54.144,Percent of Total Billed Charges,72% of Total Billed Charges,234.83,75,,56.4,Percent of Total Billed charges,75% of Total Billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.44,72,,54.144,Percent of Total Billed Charges,72% of Total Billed Charges,187.87,60,,45.12,Percent of Total Billed Charges,60% of Total Billed Charges,281.8,90,,61.12,Percent of Total Billed Charges,90% of Total Billed Charges,140.9,45,,30.168,Percent of Total Billed Charges,45% of Total Billed Charges,281.8,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.52,65,,485.944,Percent of total Billed Charges,65% of Total Billed Charges,138.08,44.1,,29.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,297.45,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,313.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.54,88,,84.48,Percent of Total Billed Charges,88% of Total Billed Charges,281.8,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,138.08,313.11,
ANTITHROMBIN III AG,3050000016,CDM,305,RC,,,Outpatient,,,405.72,263.72,,405.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,308.35,76,,173.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,292.12,72,,320.696,Percent of Total Billed Charges,72% of Total Billed Charges,304.29,75,,334.056,Percent of Total Billed charges,75% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.12,72,,320.696,Percent of Total Billed Charges,72% of Total Billed Charges,243.43,60,,267.248,Percent of Total Billed Charges,60% of Total Billed Charges,365.15,90,,212.4,Percent of Total Billed Charges,90% of Total Billed Charges,182.57,45,,43.2,Percent of Total Billed Charges,45% of Total Billed Charges,365.15,90,,205.2,Percent of Total Billed Charges,90% of Total billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.72,65,,3016,Percent of total Billed Charges,65% of Total Billed Charges,178.92,44.1,,42.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,385.43,95,,216.6,Percent of Total Billed Charges,95% of Total Billed Charges,405.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.03,88,,49.984,Percent of Total Billed Charges,88% of Total Billed Charges,365.15,90,,205.2,Percent of Total Billed charges,90% of Total Billed Charges,178.92,405.72,
PROTEIN S ACTIVITY,3050000017,CDM,305,RC,,,Outpatient,,,288.86,187.76,,288.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,219.53,76,,192.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,207.98,72,,188.928,Percent of Total Billed Charges,72% of Total Billed Charges,216.65,75,,196.8,Percent of Total Billed charges,75% of Total Billed Charges,288.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.98,72,,188.928,Percent of Total Billed Charges,72% of Total Billed Charges,173.32,60,,157.44,Percent of Total Billed Charges,60% of Total Billed Charges,259.97,90,,439.2,Percent of Total Billed Charges,90% of Total Billed Charges,129.99,45,,25.56,Percent of Total Billed Charges,45% of Total Billed Charges,259.97,90,,228.24,Percent of Total Billed Charges,90% of Total billed Charges,288.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.76,65,,393.288,Percent of total Billed Charges,65% of Total Billed Charges,127.39,44.1,,25.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,274.42,95,,240.92,Percent of Total Billed Charges,95% of Total Billed Charges,288.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,254.2,88,,229.76,Percent of Total Billed Charges,88% of Total Billed Charges,259.97,90,,228.24,Percent of Total Billed charges,90% of Total Billed Charges,127.39,288.86,
ISTAT KAOLIN ACT,3050000018,CDM,305,RC,,,Outpatient,,,116.00,75.40,,116,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,88.16,76,,477.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,83.52,72,,122.112,Percent of Total Billed Charges,72% of Total Billed Charges,87,75,,127.2,Percent of Total Billed charges,75% of Total Billed Charges,116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.52,72,,122.112,Percent of Total Billed Charges,72% of Total Billed Charges,69.6,60,,101.76,Percent of Total Billed Charges,60% of Total Billed Charges,104.4,90,,230.4,Percent of Total Billed Charges,90% of Total Billed Charges,52.2,45,,117.488,Percent of Total Billed Charges,45% of Total Billed Charges,104.4,90,,565.92,Percent of Total Billed Charges,90% of Total billed Charges,116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.4,65,,299.264,Percent of total Billed Charges,65% of Total Billed Charges,51.16,44.1,,115.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,110.2,95,,597.36,Percent of Total Billed Charges,95% of Total Billed Charges,116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.08,88,,88,Percent of Total Billed Charges,88% of Total Billed Charges,104.4,90,,565.92,Percent of Total Billed charges,90% of Total Billed Charges,51.16,116,
DDIMER (QUANT),3050000019,CDM,305,RC,,,Outpatient,,,122.00,79.30,,122,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,92.72,76,,50.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,87.84,72,,193.536,Percent of Total Billed Charges,72% of Total Billed Charges,91.5,75,,201.6,Percent of Total Billed charges,75% of Total Billed Charges,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.84,72,,193.536,Percent of Total Billed Charges,72% of Total Billed Charges,73.2,60,,161.28,Percent of Total Billed Charges,60% of Total Billed Charges,109.8,90,,264.6,Percent of Total Billed Charges,90% of Total Billed Charges,54.9,45,,45,Percent of Total Billed Charges,45% of Total Billed Charges,109.8,90,,60.328,Percent of Total Billed Charges,90% of Total billed Charges,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.3,65,,853.84,Percent of total Billed Charges,65% of Total Billed Charges,53.8,44.1,,44.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,115.9,95,,63.68,Percent of Total Billed Charges,95% of Total Billed Charges,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.36,88,,225.776,Percent of Total Billed Charges,88% of Total Billed Charges,109.8,90,,60.328,Percent of Total Billed charges,90% of Total Billed Charges,53.8,122,
FIBRINOGEN,3050000020,CDM,305,RC,,,Outpatient,,,258.00,167.70,,258,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,196.08,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,185.76,72,,246.528,Percent of Total Billed Charges,72% of Total Billed Charges,193.5,75,,256.8,Percent of Total Billed charges,75% of Total Billed Charges,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.76,72,,246.528,Percent of Total Billed Charges,72% of Total Billed Charges,154.8,60,,205.44,Percent of Total Billed Charges,60% of Total Billed Charges,232.2,90,,129.6,Percent of Total Billed Charges,90% of Total Billed Charges,116.1,45,,115.456,Percent of Total Billed Charges,45% of Total Billed Charges,232.2,90,,86.4,Percent of Total Billed Charges,90% of Total billed Charges,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.7,65,,197.08,Percent of total Billed Charges,65% of Total Billed Charges,113.78,44.1,,113.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,245.1,95,,91.2,Percent of Total Billed Charges,95% of Total Billed Charges,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.04,88,,59.76,Percent of Total Billed Charges,88% of Total Billed Charges,232.2,90,,86.4,Percent of Total Billed charges,90% of Total Billed Charges,113.78,258,
FETAL SCREEN,3050000021,CDM,305,RC,,,Outpatient,,,87.00,56.55,,87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.12,76,,43.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.64,72,,244.224,Percent of Total Billed Charges,72% of Total Billed Charges,65.25,75,,254.4,Percent of Total Billed charges,75% of Total Billed Charges,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.64,72,,244.224,Percent of Total Billed Charges,72% of Total Billed Charges,52.2,60,,203.52,Percent of Total Billed Charges,60% of Total Billed Charges,78.3,90,,328.32,Percent of Total Billed Charges,90% of Total Billed Charges,39.15,45,,30.56,Percent of Total Billed Charges,45% of Total Billed Charges,78.3,90,,51.12,Percent of Total Billed Charges,90% of Total billed Charges,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.55,65,,271.44,Percent of total Billed Charges,65% of Total Billed Charges,38.37,44.1,,29.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.65,95,,53.96,Percent of Total Billed Charges,95% of Total Billed Charges,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.56,88,,207.68,Percent of Total Billed Charges,88% of Total Billed Charges,78.3,90,,51.12,Percent of Total Billed charges,90% of Total Billed Charges,38.37,87,
LYSOZYME  SERUM,3050000022,CDM,305,RC,,,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,198.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,457.344,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,476.4,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,457.344,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,381.12,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,260.648,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,106.2,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,234.976,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,582.472,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,104.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,248.032,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,429.44,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,234.976,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
PROTHROMBIN TIME,3050000023,CDM,305,RC,,,Outpatient,,,59.00,38.35,,59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,44.84,76,,76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.48,72,,272.448,Percent of Total Billed Charges,72% of Total Billed Charges,44.25,75,,283.8,Percent of Total Billed charges,75% of Total Billed Charges,59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.48,72,,272.448,Percent of Total Billed Charges,72% of Total Billed Charges,35.4,60,,227.04,Percent of Total Billed Charges,60% of Total Billed Charges,53.1,90,,511.2,Percent of Total Billed Charges,90% of Total Billed Charges,26.55,45,,219.6,Percent of Total Billed Charges,45% of Total Billed Charges,53.1,90,,90,Percent of Total Billed Charges,90% of Total billed Charges,59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.35,65,,989.88,Percent of total Billed Charges,65% of Total Billed Charges,26.02,44.1,,215.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,56.05,95,,95,Percent of Total Billed Charges,95% of Total Billed Charges,59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.92,88,,225.28,Percent of Total Billed Charges,88% of Total Billed Charges,53.1,90,,90,Percent of Total Billed charges,90% of Total Billed Charges,26.02,59,
PTTLA,3050000024,CDM,305,RC,,,Outpatient,,,48.51,31.53,,48.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.87,76,,194.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.93,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,75,,210,Percent of Total Billed charges,75% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,29.11,60,,168,Percent of Total Billed Charges,60% of Total Billed Charges,43.66,90,,314.64,Percent of Total Billed Charges,90% of Total Billed Charges,21.83,45,,115.2,Percent of Total Billed Charges,45% of Total Billed Charges,43.66,90,,230.904,Percent of Total Billed Charges,90% of Total billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.53,65,,603.68,Percent of total Billed Charges,65% of Total Billed Charges,21.39,44.1,,112.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.08,95,,243.736,Percent of Total Billed Charges,95% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.69,88,,258.72,Percent of Total Billed Charges,88% of Total Billed Charges,43.66,90,,230.904,Percent of Total Billed charges,90% of Total Billed Charges,21.39,48.51,
DIL RUS VIP VEN TIME,3050000025,CDM,305,RC,,,Outpatient,,,48.51,31.53,,48.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.87,76,,51.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.93,72,,379.584,Percent of Total Billed Charges,72% of Total Billed Charges,36.38,75,,395.4,Percent of Total Billed charges,75% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.93,72,,379.584,Percent of Total Billed Charges,72% of Total Billed Charges,29.11,60,,316.32,Percent of Total Billed Charges,60% of Total Billed Charges,43.66,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,21.83,45,,132.304,Percent of Total Billed Charges,45% of Total Billed Charges,43.66,90,,61.12,Percent of Total Billed Charges,90% of Total billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.53,65,,1433.248,Percent of total Billed Charges,65% of Total Billed Charges,21.39,44.1,,129.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.08,95,,64.52,Percent of Total Billed Charges,95% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.69,88,,126.72,Percent of Total Billed Charges,88% of Total Billed Charges,43.66,90,,61.12,Percent of Total Billed charges,90% of Total Billed Charges,21.39,48.51,
SEDIMENTATION RATE,3050000026,CDM,305,RC,,,Outpatient,,,122.00,79.30,,122,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,92.72,76,,179.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,87.84,72,,607.104,Percent of Total Billed Charges,72% of Total Billed Charges,91.5,75,,632.4,Percent of Total Billed charges,75% of Total Billed Charges,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.84,72,,607.104,Percent of Total Billed Charges,72% of Total Billed Charges,73.2,60,,505.92,Percent of Total Billed Charges,60% of Total Billed Charges,109.8,90,,224.64,Percent of Total Billed Charges,90% of Total Billed Charges,54.9,45,,64.8,Percent of Total Billed Charges,45% of Total Billed Charges,109.8,90,,212.4,Percent of Total Billed Charges,90% of Total billed Charges,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.3,65,,5127.432,Percent of total Billed Charges,65% of Total Billed Charges,53.8,44.1,,63.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,115.9,95,,224.2,Percent of Total Billed Charges,95% of Total Billed Charges,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.36,88,,321.024,Percent of Total Billed Charges,88% of Total Billed Charges,109.8,90,,212.4,Percent of Total Billed charges,90% of Total Billed Charges,53.8,122,
SICKLE CELL STUDY,3050000027,CDM,305,RC,,,Outpatient,,,17.64,11.47,,17.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13.41,76,,370.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.7,72,,441.792,Percent of Total Billed Charges,72% of Total Billed Charges,13.23,75,,460.2,Percent of Total Billed charges,75% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.7,72,,441.792,Percent of Total Billed Charges,72% of Total Billed Charges,10.58,60,,368.16,Percent of Total Billed Charges,60% of Total Billed Charges,15.88,90,,546.48,Percent of Total Billed Charges,90% of Total Billed Charges,7.94,45,,164.16,Percent of Total Billed Charges,45% of Total Billed Charges,15.88,90,,439.2,Percent of Total Billed Charges,90% of Total billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.47,65,,3372.096,Percent of total Billed Charges,65% of Total Billed Charges,7.78,44.1,,160.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,16.76,95,,463.6,Percent of Total Billed Charges,95% of Total Billed Charges,17.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.52,88,,254.856,Percent of Total Billed Charges,88% of Total Billed Charges,15.88,90,,439.2,Percent of Total Billed charges,90% of Total Billed Charges,7.78,17.64,
PTT,3050000028,CDM,305,RC,,,Outpatient,,,78.00,50.70,,78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.28,76,,194.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.16,72,,441.792,Percent of Total Billed Charges,72% of Total Billed Charges,58.5,75,,460.2,Percent of Total Billed charges,75% of Total Billed Charges,78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.16,72,,441.792,Percent of Total Billed Charges,72% of Total Billed Charges,46.8,60,,368.16,Percent of Total Billed Charges,60% of Total Billed Charges,70.2,90,,504.216,Percent of Total Billed Charges,90% of Total Billed Charges,35.1,45,,130.32,Percent of Total Billed Charges,45% of Total Billed Charges,70.2,90,,230.4,Percent of Total Billed Charges,90% of Total billed Charges,78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.7,65,,3971.232,Percent of total Billed Charges,65% of Total Billed Charges,34.4,44.1,,127.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.1,95,,243.2,Percent of Total Billed Charges,95% of Total Billed Charges,78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.64,88,,499.84,Percent of Total Billed Charges,88% of Total Billed Charges,70.2,90,,230.4,Percent of Total Billed charges,90% of Total Billed Charges,34.4,78,
FACTOR VIII ACTIVITY,3050000031,CDM,305,RC,,,Outpatient,,,306.50,199.23,,306.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,232.94,76,,277.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,220.68,72,,559.472,Percent of Total Billed Charges,72% of Total Billed Charges,229.88,75,,582.784,Percent of Total Billed charges,75% of Total Billed Charges,306.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.68,72,,559.472,Percent of Total Billed Charges,72% of Total Billed Charges,183.9,60,,466.224,Percent of Total Billed Charges,60% of Total Billed Charges,275.85,90,,1091.512,Percent of Total Billed Charges,90% of Total Billed Charges,137.93,45,,30.96,Percent of Total Billed Charges,45% of Total Billed Charges,275.85,90,,328.32,Percent of Total Billed Charges,90% of Total billed Charges,306.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.23,65,,734.76,Percent of total Billed Charges,65% of Total Billed Charges,135.17,44.1,,30.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,291.18,95,,346.56,Percent of Total Billed Charges,95% of Total Billed Charges,306.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.72,88,,219.648,Percent of Total Billed Charges,88% of Total Billed Charges,275.85,90,,328.32,Percent of Total Billed charges,90% of Total Billed Charges,135.17,306.5,
Von Willibrand Factor,3050000032,CDM,305,RC,,,Outpatient,,,214.99,139.74,,214.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,163.39,76,,220.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,154.79,72,,326.416,Percent of Total Billed Charges,72% of Total Billed Charges,161.24,75,,340.016,Percent of Total Billed charges,75% of Total Billed Charges,214.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.79,72,,326.416,Percent of Total Billed Charges,72% of Total Billed Charges,128.99,60,,272.008,Percent of Total Billed Charges,60% of Total Billed Charges,193.49,90,,129.6,Percent of Total Billed Charges,90% of Total Billed Charges,96.75,45,,112.32,Percent of Total Billed Charges,45% of Total Billed Charges,193.49,90,,260.648,Percent of Total Billed Charges,90% of Total billed Charges,214.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.74,65,,3084.336,Percent of total Billed Charges,65% of Total Billed Charges,94.81,44.1,,110.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,204.24,95,,275.128,Percent of Total Billed Charges,95% of Total Billed Charges,214.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.19,88,,534.336,Percent of Total Billed Charges,88% of Total Billed Charges,193.49,90,,260.648,Percent of Total Billed charges,90% of Total Billed Charges,94.81,214.99,
Von Willibrand Antigen,3050000033,CDM,305,RC,,,Outpatient,,,244.76,159.09,,244.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,186.02,76,,431.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,176.23,72,,524.736,Percent of Total Billed Charges,72% of Total Billed Charges,183.57,75,,546.6,Percent of Total Billed charges,75% of Total Billed Charges,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.23,72,,524.736,Percent of Total Billed Charges,72% of Total Billed Charges,146.86,60,,437.28,Percent of Total Billed Charges,60% of Total Billed Charges,220.28,90,,360,Percent of Total Billed Charges,90% of Total Billed Charges,110.14,45,,273.24,Percent of Total Billed Charges,45% of Total Billed Charges,220.28,90,,511.2,Percent of Total Billed Charges,90% of Total billed Charges,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.09,65,,3934.112,Percent of total Billed Charges,65% of Total Billed Charges,107.94,44.1,,267.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,232.52,95,,539.6,Percent of Total Billed Charges,95% of Total Billed Charges,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.39,88,,493.008,Percent of Total Billed Charges,88% of Total Billed Charges,220.28,90,,511.2,Percent of Total Billed charges,90% of Total Billed Charges,107.94,244.76,
Blood Smear Peripheral,3050000034,CDM,305,RC,,,Outpatient,,,57.00,37.05,,57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.32,76,,265.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.04,72,,549.312,Percent of Total Billed Charges,72% of Total Billed Charges,42.75,75,,572.2,Percent of Total Billed charges,75% of Total Billed Charges,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.04,72,,549.312,Percent of Total Billed Charges,72% of Total Billed Charges,34.2,60,,457.76,Percent of Total Billed Charges,60% of Total Billed Charges,51.3,90,,1482.816,Percent of Total Billed Charges,90% of Total Billed Charges,25.65,45,,252.112,Percent of Total Billed Charges,45% of Total Billed Charges,51.3,90,,314.64,Percent of Total Billed Charges,90% of Total billed Charges,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.05,65,,2016.848,Percent of total Billed Charges,65% of Total Billed Charges,25.14,44.1,,247.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.15,95,,332.12,Percent of Total Billed Charges,95% of Total Billed Charges,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.16,88,,176,Percent of Total Billed Charges,88% of Total Billed Charges,51.3,90,,314.64,Percent of Total Billed charges,90% of Total Billed Charges,25.14,57,
CAND SPEC DIREC PROBE TECHN,3060000001,CDM,306,RC,,,Outpatient,,,51.82,33.68,,51.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,39.38,76,,52.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,37.31,72,,521.856,Percent of Total Billed Charges,72% of Total Billed Charges,38.87,75,,543.6,Percent of Total Billed charges,75% of Total Billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.31,72,,521.856,Percent of Total Billed Charges,72% of Total Billed Charges,31.09,60,,434.88,Percent of Total Billed Charges,60% of Total Billed Charges,46.64,90,,6139.256,Percent of Total Billed Charges,90% of Total Billed Charges,23.32,45,,90,Percent of Total Billed Charges,45% of Total Billed Charges,46.64,90,,61.92,Percent of Total Billed Charges,90% of Total billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.68,65,,1433.248,Percent of total Billed Charges,65% of Total Billed Charges,22.85,44.1,,88.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,49.23,95,,65.36,Percent of Total Billed Charges,95% of Total Billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.6,88,,88.704,Percent of Total Billed Charges,88% of Total Billed Charges,46.64,90,,61.92,Percent of Total Billed charges,90% of Total Billed Charges,22.85,51.82,
"GARDNERELLA VAG, DIR PROB TECH",3060000003,CDM,306,RC,,,Outpatient,,,51.82,33.68,,51.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,39.38,76,,189.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,37.31,72,,237.888,Percent of Total Billed Charges,72% of Total Billed Charges,38.87,75,,247.8,Percent of Total Billed charges,75% of Total Billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.31,72,,237.888,Percent of Total Billed Charges,72% of Total Billed Charges,31.09,60,,198.24,Percent of Total Billed Charges,60% of Total Billed Charges,46.64,90,,315.136,Percent of Total Billed Charges,90% of Total Billed Charges,23.32,45,,45.36,Percent of Total Billed Charges,45% of Total Billed Charges,46.64,90,,224.64,Percent of Total Billed Charges,90% of Total billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.68,65,,832,Percent of total Billed Charges,65% of Total Billed Charges,22.85,44.1,,44.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,49.23,95,,237.12,Percent of Total Billed Charges,95% of Total Billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.6,88,,1067.256,Percent of Total Billed Charges,88% of Total Billed Charges,46.64,90,,224.64,Percent of Total Billed charges,90% of Total Billed Charges,22.85,51.82,
STREP PNEUMONIAE ANTIGEN SCRN,3060000004,CDM,306,RC,,,Outpatient,,,164.00,106.60,,164,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.64,76,,461.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,118.08,72,,399.744,Percent of Total Billed Charges,72% of Total Billed Charges,123,75,,416.4,Percent of Total Billed charges,75% of Total Billed Charges,164,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.08,72,,399.744,Percent of Total Billed Charges,72% of Total Billed Charges,98.4,60,,333.12,Percent of Total Billed Charges,60% of Total Billed Charges,147.6,90,,468,Percent of Total Billed Charges,90% of Total Billed Charges,73.8,45,,545.76,Percent of Total Billed Charges,45% of Total Billed Charges,147.6,90,,546.48,Percent of Total Billed Charges,90% of Total billed Charges,164,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.6,65,,227.6,Percent of total Billed Charges,65% of Total Billed Charges,72.32,44.1,,534.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,155.8,95,,576.84,Percent of Total Billed Charges,95% of Total Billed Charges,164,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.32,88,,126.72,Percent of Total Billed Charges,88% of Total Billed Charges,147.6,90,,546.48,Percent of Total Billed charges,90% of Total Billed Charges,72.32,164,
TRICHOMONAS VAG DIR PROBE TECH,3060000005,CDM,306,RC,,,Outpatient,,,51.82,33.68,,51.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,39.38,76,,425.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,37.31,72,,474.048,Percent of Total Billed Charges,72% of Total Billed Charges,38.87,75,,493.8,Percent of Total Billed charges,75% of Total Billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.31,72,,474.048,Percent of Total Billed Charges,72% of Total Billed Charges,31.09,60,,395.04,Percent of Total Billed Charges,60% of Total Billed Charges,46.64,90,,727.2,Percent of Total Billed Charges,90% of Total Billed Charges,23.32,45,,64.8,Percent of Total Billed Charges,45% of Total Billed Charges,46.64,90,,504.216,Percent of Total Billed Charges,90% of Total billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.68,65,,4433.904,Percent of total Billed Charges,65% of Total Billed Charges,22.85,44.1,,63.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,49.23,95,,532.232,Percent of Total Billed Charges,95% of Total Billed Charges,51.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.6,88,,352,Percent of Total Billed Charges,88% of Total Billed Charges,46.64,90,,504.216,Percent of Total Billed charges,90% of Total Billed Charges,22.85,51.82,
BLOOD CULTURE,3060000006,CDM,306,RC,,,Outpatient,,,235.00,152.75,,235,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,178.6,76,,152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,169.2,72,,4666.176,Percent of Total Billed Charges,72% of Total Billed Charges,176.25,75,,4860.6,Percent of Total Billed charges,75% of Total Billed Charges,235,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.2,72,,4666.176,Percent of Total Billed Charges,72% of Total Billed Charges,141,60,,3888.48,Percent of Total Billed Charges,60% of Total Billed Charges,211.5,90,,672.84,Percent of Total Billed Charges,90% of Total Billed Charges,105.75,45,,180,Percent of Total Billed Charges,45% of Total Billed Charges,211.5,90,,180,Percent of Total Billed Charges,90% of Total billed Charges,235,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.75,65,,312,Percent of total Billed Charges,65% of Total Billed Charges,103.64,44.1,,176.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,223.25,95,,190,Percent of Total Billed Charges,95% of Total Billed Charges,235,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.8,88,,1449.864,Percent of Total Billed Charges,88% of Total Billed Charges,211.5,90,,180,Percent of Total Billed charges,90% of Total Billed Charges,103.64,235,
CULTURE STOOL,3060000007,CDM,306,RC,,,Outpatient,,,155.00,100.75,,155,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,117.8,76,,76.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.6,72,,4911.4,Percent of Total Billed Charges,72% of Total Billed Charges,116.25,75,,5116.048,Percent of Total Billed charges,75% of Total Billed Charges,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.6,72,,4911.4,Percent of Total Billed Charges,72% of Total Billed Charges,93,60,,4092.832,Percent of Total Billed Charges,60% of Total Billed Charges,139.5,90,,4176,Percent of Total Billed Charges,90% of Total Billed Charges,69.75,45,,741.408,Percent of Total Billed Charges,45% of Total Billed Charges,139.5,90,,90.72,Percent of Total Billed Charges,90% of Total billed Charges,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.75,65,,1525.16,Percent of total Billed Charges,65% of Total Billed Charges,68.36,44.1,,726.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,147.25,95,,95.76,Percent of Total Billed Charges,95% of Total Billed Charges,155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.4,88,,6002.824,Percent of Total Billed Charges,88% of Total Billed Charges,139.5,90,,90.72,Percent of Total Billed charges,90% of Total Billed Charges,68.36,155,
CULTURE AEROBIC,3060000008,CDM,306,RC,,,Outpatient,,,115.00,74.75,,115,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.4,76,,921.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.8,72,,4666.176,Percent of Total Billed Charges,72% of Total Billed Charges,86.25,75,,4860.6,Percent of Total Billed charges,75% of Total Billed Charges,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.8,72,,4666.176,Percent of Total Billed Charges,72% of Total Billed Charges,69,60,,3888.48,Percent of Total Billed Charges,60% of Total Billed Charges,103.5,90,,544.552,Percent of Total Billed Charges,90% of Total Billed Charges,51.75,45,,3069.624,Percent of Total Billed Charges,45% of Total Billed Charges,103.5,90,,1091.512,Percent of Total Billed Charges,90% of Total billed Charges,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.75,65,,1586.52,Percent of total Billed Charges,65% of Total Billed Charges,50.72,44.1,,3008.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,109.25,95,,1152.152,Percent of Total Billed Charges,95% of Total Billed Charges,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.2,88,,308.136,Percent of Total Billed Charges,88% of Total Billed Charges,103.5,90,,1091.512,Percent of Total Billed charges,90% of Total Billed Charges,50.72,115,
MRSA SCREEN,3060000009,CDM,306,RC,,,Outpatient,,,115.00,74.75,,115,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.4,76,,109.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.8,72,,4666.176,Percent of Total Billed Charges,72% of Total Billed Charges,86.25,75,,4860.6,Percent of Total Billed charges,75% of Total Billed Charges,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.8,72,,4666.176,Percent of Total Billed Charges,72% of Total Billed Charges,69,60,,3888.48,Percent of Total Billed Charges,60% of Total Billed Charges,103.5,90,,414.368,Percent of Total Billed Charges,90% of Total Billed Charges,51.75,45,,157.568,Percent of Total Billed Charges,45% of Total Billed Charges,103.5,90,,129.6,Percent of Total Billed Charges,90% of Total billed Charges,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.75,65,,1433.248,Percent of total Billed Charges,65% of Total Billed Charges,50.72,44.1,,154.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,109.25,95,,136.8,Percent of Total Billed Charges,95% of Total Billed Charges,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.2,88,,457.6,Percent of Total Billed Charges,88% of Total Billed Charges,103.5,90,,129.6,Percent of Total Billed charges,90% of Total Billed Charges,50.72,115,
CULTURE ANAROBIC W/,3060000010,CDM,306,RC,,,Outpatient,,,145.00,94.25,,145,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.2,76,,304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,104.4,72,,986.112,Percent of Total Billed Charges,72% of Total Billed Charges,108.75,75,,1027.2,Percent of Total Billed charges,75% of Total Billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.4,72,,986.112,Percent of Total Billed Charges,72% of Total Billed Charges,87,60,,821.76,Percent of Total Billed Charges,60% of Total Billed Charges,130.5,90,,1445.624,Percent of Total Billed Charges,90% of Total Billed Charges,65.25,45,,234,Percent of Total Billed Charges,45% of Total Billed Charges,130.5,90,,360,Percent of Total Billed Charges,90% of Total billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.25,65,,1433.248,Percent of total Billed Charges,65% of Total Billed Charges,63.95,44.1,,229.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,137.75,95,,380,Percent of Total Billed Charges,95% of Total Billed Charges,145,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.6,88,,711.04,Percent of Total Billed Charges,88% of Total Billed Charges,130.5,90,,360,Percent of Total Billed charges,90% of Total Billed Charges,63.95,145,
CULTURE URINE,3060000011,CDM,306,RC,,,Outpatient,,,117.00,76.05,,117,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,88.92,76,,1252.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.24,72,,436.272,Percent of Total Billed Charges,72% of Total Billed Charges,87.75,75,,454.456,Percent of Total Billed charges,75% of Total Billed Charges,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.24,72,,436.272,Percent of Total Billed Charges,72% of Total Billed Charges,70.2,60,,363.56,Percent of Total Billed Charges,60% of Total Billed Charges,105.3,90,,1373.76,Percent of Total Billed Charges,90% of Total Billed Charges,52.65,45,,363.6,Percent of Total Billed Charges,45% of Total Billed Charges,105.3,90,,1482.816,Percent of Total Billed Charges,90% of Total billed Charges,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.05,65,,2326.456,Percent of total Billed Charges,65% of Total Billed Charges,51.6,44.1,,356.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,111.15,95,,1565.2,Percent of Total Billed Charges,95% of Total Billed Charges,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.96,88,,657.888,Percent of Total Billed Charges,88% of Total Billed Charges,105.3,90,,1482.816,Percent of Total Billed charges,90% of Total Billed Charges,51.6,117,
FUNGUS CULTURE,3060000012,CDM,306,RC,,,Outpatient,,,102.53,66.64,,102.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,77.92,76,,5184.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,73.82,72,,1041.984,Percent of Total Billed Charges,72% of Total Billed Charges,76.9,75,,1085.4,Percent of Total Billed charges,75% of Total Billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.82,72,,1041.984,Percent of Total Billed Charges,72% of Total Billed Charges,61.52,60,,868.32,Percent of Total Billed Charges,60% of Total Billed Charges,92.28,90,,1182.24,Percent of Total Billed Charges,90% of Total Billed Charges,46.14,45,,336.424,Percent of Total Billed Charges,45% of Total Billed Charges,92.28,90,,6139.256,Percent of Total Billed Charges,90% of Total billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.64,65,,1433.248,Percent of total Billed Charges,65% of Total Billed Charges,45.22,44.1,,329.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,97.4,95,,6480.32,Percent of Total Billed Charges,95% of Total Billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.23,88,,4083.2,Percent of Total Billed Charges,88% of Total Billed Charges,92.28,90,,6139.256,Percent of Total Billed charges,90% of Total Billed Charges,45.22,102.53,
ACID FAST CULTURE,3060000013,CDM,306,RC,,,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,266.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,1624.32,Percent of Total Billed Charges,72% of Total Billed Charges,58.71,75,,1692,Percent of Total Billed charges,75% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,1624.32,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,1353.6,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,272.88,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,2088,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,315.136,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,791.152,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,2046.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,332.648,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,532.448,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,315.136,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
SENSITIVITY/ORGANISM,3060000015,CDM,306,RC,,,Outpatient,,,230.00,149.50,,230,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,174.8,76,,395.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,165.6,72,,1262.944,Percent of Total Billed Charges,72% of Total Billed Charges,172.5,75,,1315.568,Percent of Total Billed charges,75% of Total Billed Charges,230,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.6,72,,1262.944,Percent of Total Billed Charges,72% of Total Billed Charges,138,60,,1052.456,Percent of Total Billed Charges,60% of Total Billed Charges,207,90,,375.84,Percent of Total Billed Charges,90% of Total Billed Charges,103.5,45,,272.272,Percent of Total Billed Charges,45% of Total Billed Charges,207,90,,468,Percent of Total Billed Charges,90% of Total billed Charges,230,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.5,65,,182,Percent of total Billed Charges,65% of Total Billed Charges,101.43,44.1,,266.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,218.5,95,,494,Percent of Total Billed Charges,95% of Total Billed Charges,230,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.4,88,,405.16,Percent of Total Billed Charges,88% of Total Billed Charges,207,90,,468,Percent of Total Billed charges,90% of Total Billed Charges,101.43,230,
GRAM STAIN,3060000016,CDM,306,RC,,,Outpatient,,,47.00,30.55,,47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.72,76,,614.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.84,72,,3744,Percent of Total Billed Charges,72% of Total Billed Charges,35.25,75,,3900,Percent of Total Billed charges,75% of Total Billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.84,72,,3744,Percent of Total Billed Charges,72% of Total Billed Charges,28.2,60,,3120,Percent of Total Billed Charges,60% of Total Billed Charges,42.3,90,,806.504,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,45,,207.184,Percent of Total Billed Charges,45% of Total Billed Charges,42.3,90,,727.2,Percent of Total Billed Charges,90% of Total billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.55,65,,148.72,Percent of total Billed Charges,65% of Total Billed Charges,20.73,44.1,,203.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.65,95,,767.6,Percent of Total Billed Charges,95% of Total Billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.36,88,,1413.496,Percent of Total Billed Charges,88% of Total Billed Charges,42.3,90,,727.2,Percent of Total Billed charges,90% of Total Billed Charges,20.73,47,
ACID FAST SMEAR,3060000017,CDM,306,RC,,,Outpatient,,,120.17,78.11,,120.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,91.33,76,,568.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,86.52,72,,1437.696,Percent of Total Billed Charges,72% of Total Billed Charges,90.13,75,,1497.6,Percent of Total Billed charges,75% of Total Billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.52,72,,1437.696,Percent of Total Billed Charges,72% of Total Billed Charges,72.1,60,,1198.08,Percent of Total Billed Charges,60% of Total Billed Charges,108.15,90,,1370.608,Percent of Total Billed Charges,90% of Total Billed Charges,54.08,45,,722.808,Percent of Total Billed Charges,45% of Total Billed Charges,108.15,90,,672.84,Percent of Total Billed Charges,90% of Total billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.11,65,,134.16,Percent of total Billed Charges,65% of Total Billed Charges,52.99,44.1,,708.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,114.16,95,,710.224,Percent of Total Billed Charges,95% of Total Billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.75,88,,1343.232,Percent of Total Billed Charges,88% of Total Billed Charges,108.15,90,,672.84,Percent of Total Billed charges,90% of Total Billed Charges,52.99,120.17,
WET MOUNT SMEAR,3060000018,CDM,306,RC,,,Outpatient,,,43.00,27.95,,43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,32.68,76,,3526.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.96,72,,435.64,Percent of Total Billed Charges,72% of Total Billed Charges,32.25,75,,453.792,Percent of Total Billed charges,75% of Total Billed Charges,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.96,72,,435.64,Percent of Total Billed Charges,72% of Total Billed Charges,25.8,60,,363.032,Percent of Total Billed Charges,60% of Total Billed Charges,38.7,90,,835.872,Percent of Total Billed Charges,90% of Total Billed Charges,19.35,45,,686.88,Percent of Total Billed Charges,45% of Total Billed Charges,38.7,90,,4176,Percent of Total Billed Charges,90% of Total billed Charges,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.95,65,,166.832,Percent of total Billed Charges,65% of Total Billed Charges,18.96,44.1,,673.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,40.85,95,,4408,Percent of Total Billed Charges,95% of Total Billed Charges,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.84,88,,1155.968,Percent of Total Billed Charges,88% of Total Billed Charges,38.7,90,,4176,Percent of Total Billed charges,90% of Total Billed Charges,18.96,43,
KOH PREP,3060000019,CDM,306,RC,,,Outpatient,,,30.87,20.07,,30.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.46,76,,459.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.23,72,,1404.288,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,75,,1462.8,Percent of Total Billed charges,75% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.23,72,,1404.288,Percent of Total Billed Charges,72% of Total Billed Charges,18.52,60,,1170.24,Percent of Total Billed Charges,60% of Total Billed Charges,27.78,90,,1984.504,Percent of Total Billed Charges,90% of Total Billed Charges,13.89,45,,591.12,Percent of Total Billed Charges,45% of Total Billed Charges,27.78,90,,544.552,Percent of Total Billed Charges,90% of Total billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.07,65,,99.32,Percent of total Billed Charges,65% of Total Billed Charges,13.61,44.1,,579.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.33,95,,574.8,Percent of Total Billed Charges,95% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.17,88,,266.816,Percent of Total Billed Charges,88% of Total Billed Charges,27.78,90,,544.552,Percent of Total Billed charges,90% of Total Billed Charges,13.61,30.87,
CLOSTRIDIUM DIFTOX,3060000020,CDM,306,RC,,,Outpatient,,,105.00,68.25,,105,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.8,76,,349.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75.6,72,,1404.288,Percent of Total Billed Charges,72% of Total Billed Charges,78.75,75,,1462.8,Percent of Total Billed charges,75% of Total Billed Charges,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.6,72,,1404.288,Percent of Total Billed Charges,72% of Total Billed Charges,63,60,,1170.24,Percent of Total Billed Charges,60% of Total Billed Charges,94.5,90,,7099.528,Percent of Total Billed Charges,90% of Total Billed Charges,47.25,45,,136.44,Percent of Total Billed Charges,45% of Total Billed Charges,94.5,90,,414.368,Percent of Total Billed Charges,90% of Total billed Charges,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.25,65,,113.36,Percent of total Billed Charges,65% of Total Billed Charges,46.31,44.1,,133.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,99.75,95,,437.384,Percent of Total Billed Charges,95% of Total Billed Charges,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.4,88,,367.488,Percent of Total Billed Charges,88% of Total Billed Charges,94.5,90,,414.368,Percent of Total Billed charges,90% of Total Billed Charges,46.31,105,
HERPES CULTURE,3060000021,CDM,306,RC,,,Outpatient,,,404.00,262.60,,404,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,307.04,76,,1220.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,290.88,72,,182.592,Percent of Total Billed Charges,72% of Total Billed Charges,303,75,,190.2,Percent of Total Billed charges,75% of Total Billed Charges,404,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290.88,72,,182.592,Percent of Total Billed Charges,72% of Total Billed Charges,242.4,60,,152.16,Percent of Total Billed Charges,60% of Total Billed Charges,363.6,90,,4669.056,Percent of Total Billed Charges,90% of Total Billed Charges,181.8,45,,187.92,Percent of Total Billed Charges,45% of Total Billed Charges,363.6,90,,1445.624,Percent of Total Billed Charges,90% of Total billed Charges,404,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.6,65,,140.4,Percent of total Billed Charges,65% of Total Billed Charges,178.16,44.1,,184.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,383.8,95,,1525.936,Percent of Total Billed Charges,95% of Total Billed Charges,404,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.52,88,,788.576,Percent of Total Billed Charges,88% of Total Billed Charges,363.6,90,,1445.624,Percent of Total Billed charges,90% of Total Billed Charges,178.16,404,
RSV ANTIGEN TEST,3060000022,CDM,306,RC,,,Outpatient,,,118.00,76.70,,118,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,89.68,76,,1160.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.96,72,,191.672,Percent of Total Billed Charges,72% of Total Billed Charges,88.5,75,,199.656,Percent of Total Billed charges,75% of Total Billed Charges,118,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.96,72,,191.672,Percent of Total Billed Charges,72% of Total Billed Charges,70.8,60,,159.728,Percent of Total Billed Charges,60% of Total Billed Charges,106.2,90,,5498.624,Percent of Total Billed Charges,90% of Total Billed Charges,53.1,45,,403.248,Percent of Total Billed Charges,45% of Total Billed Charges,106.2,90,,1373.76,Percent of Total Billed Charges,90% of Total billed Charges,118,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.7,65,,99.76,Percent of total Billed Charges,65% of Total Billed Charges,52.04,44.1,,395.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,112.1,95,,1450.08,Percent of Total Billed Charges,95% of Total Billed Charges,118,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.84,88,,1340.152,Percent of Total Billed Charges,88% of Total Billed Charges,106.2,90,,1373.76,Percent of Total Billed charges,90% of Total Billed Charges,52.04,118,
GIARDIA ANTIGEN EIA STOOL,3060000023,CDM,306,RC,,,Outpatient,,,192.94,125.41,,192.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,146.63,76,,998.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,138.92,72,,280.512,Percent of Total Billed Charges,72% of Total Billed Charges,144.71,75,,292.2,Percent of Total Billed charges,75% of Total Billed Charges,192.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.92,72,,280.512,Percent of Total Billed Charges,72% of Total Billed Charges,115.76,60,,233.76,Percent of Total Billed Charges,60% of Total Billed Charges,173.65,90,,5498.624,Percent of Total Billed Charges,90% of Total Billed Charges,86.82,45,,685.304,Percent of Total Billed Charges,45% of Total Billed Charges,173.65,90,,1182.24,Percent of Total Billed Charges,90% of Total billed Charges,192.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.41,65,,130.144,Percent of total Billed Charges,65% of Total Billed Charges,85.09,44.1,,671.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,183.29,95,,1247.92,Percent of Total Billed Charges,95% of Total Billed Charges,192.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.79,88,,817.296,Percent of Total Billed Charges,88% of Total Billed Charges,173.65,90,,1182.24,Percent of Total Billed charges,90% of Total Billed Charges,85.09,192.94,
HEPATITIS B SURFACE,3060000025,CDM,306,RC,,,Outpatient,,,163.17,106.06,,163.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.01,76,,230.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,117.48,72,,349.272,Percent of Total Billed Charges,72% of Total Billed Charges,122.38,75,,363.832,Percent of Total Billed charges,75% of Total Billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.48,72,,349.272,Percent of Total Billed Charges,72% of Total Billed Charges,97.9,60,,291.064,Percent of Total Billed Charges,60% of Total Billed Charges,146.85,90,,1017.36,Percent of Total Billed Charges,90% of Total Billed Charges,73.43,45,,417.936,Percent of Total Billed Charges,45% of Total Billed Charges,146.85,90,,272.88,Percent of Total Billed Charges,90% of Total billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.06,65,,203.32,Percent of total Billed Charges,65% of Total Billed Charges,71.96,44.1,,409.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,155.01,95,,288.04,Percent of Total Billed Charges,95% of Total Billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.59,88,,1940.4,Percent of Total Billed Charges,88% of Total Billed Charges,146.85,90,,272.88,Percent of Total Billed charges,90% of Total Billed Charges,71.96,163.17,
LEGIONELLA ANTI  URI,3060000026,CDM,306,RC,,,Outpatient,,,164.00,106.60,,164,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.64,76,,317.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,118.08,72,,372.096,Percent of Total Billed Charges,72% of Total Billed Charges,123,75,,387.6,Percent of Total Billed charges,75% of Total Billed Charges,164,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.08,72,,372.096,Percent of Total Billed Charges,72% of Total Billed Charges,98.4,60,,310.08,Percent of Total Billed Charges,60% of Total Billed Charges,147.6,90,,1017.36,Percent of Total Billed Charges,90% of Total Billed Charges,73.8,45,,992.248,Percent of Total Billed Charges,45% of Total Billed Charges,147.6,90,,375.84,Percent of Total Billed Charges,90% of Total billed Charges,164,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.6,65,,255.32,Percent of total Billed Charges,65% of Total Billed Charges,72.32,44.1,,972.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,155.8,95,,396.72,Percent of Total Billed Charges,95% of Total Billed Charges,164,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.32,88,,6941.76,Percent of Total Billed Charges,88% of Total Billed Charges,147.6,90,,375.84,Percent of Total Billed charges,90% of Total Billed Charges,72.32,164,
HEP C VIRAL RNA QTY,3060000028,CDM,306,RC,,,Outpatient,,,1404.59,912.98,,1404.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1067.49,76,,681.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1011.3,72,,192.416,Percent of Total Billed Charges,72% of Total Billed Charges,1053.44,75,,200.44,Percent of Total Billed charges,75% of Total Billed Charges,1404.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1011.3,72,,192.416,Percent of Total Billed Charges,72% of Total Billed Charges,842.75,60,,160.352,Percent of Total Billed Charges,60% of Total Billed Charges,1264.13,90,,4270.624,Percent of Total Billed Charges,90% of Total Billed Charges,632.07,45,,3549.76,Percent of Total Billed Charges,45% of Total Billed Charges,1264.13,90,,806.504,Percent of Total Billed Charges,90% of Total billed Charges,1404.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1404.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1404.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,912.98,65,,92.88,Percent of total Billed Charges,65% of Total Billed Charges,619.42,44.1,,3478.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,1334.36,95,,851.304,Percent of Total Billed Charges,95% of Total Billed Charges,1404.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1236.04,88,,4565.296,Percent of Total Billed Charges,88% of Total Billed Charges,1264.13,90,,806.504,Percent of Total Billed charges,90% of Total Billed Charges,619.42,1404.59,
HSV TYPE 1&2 PCR,3060000029,CDM,306,RC,,,Outpatient,,,517.07,336.10,,517.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,392.97,76,,1157.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,372.29,72,,111.168,Percent of Total Billed Charges,72% of Total Billed Charges,387.8,75,,115.8,Percent of Total Billed charges,75% of Total Billed Charges,517.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,372.29,72,,111.168,Percent of Total Billed Charges,72% of Total Billed Charges,310.24,60,,92.64,Percent of Total Billed Charges,60% of Total Billed Charges,465.36,90,,5447.232,Percent of Total Billed Charges,90% of Total Billed Charges,232.68,45,,2334.528,Percent of Total Billed Charges,45% of Total Billed Charges,465.36,90,,1370.608,Percent of Total Billed Charges,90% of Total billed Charges,517.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,517.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,517.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,336.1,65,,180.44,Percent of total Billed Charges,65% of Total Billed Charges,228.03,44.1,,2287.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,491.22,95,,1446.752,Percent of Total Billed Charges,95% of Total Billed Charges,517.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,455.02,88,,5376.432,Percent of Total Billed Charges,88% of Total Billed Charges,465.36,90,,1370.608,Percent of Total Billed charges,90% of Total Billed Charges,228.03,517.07,
HIV1 RNA QUANTITATIVE PCR,3060000030,CDM,306,RC,,,Outpatient,,,713.32,463.66,,713.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,542.12,76,,705.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,513.59,72,,135.936,Percent of Total Billed Charges,72% of Total Billed Charges,534.99,75,,141.6,Percent of Total Billed charges,75% of Total Billed Charges,713.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.59,72,,135.936,Percent of Total Billed Charges,72% of Total Billed Charges,427.99,60,,113.28,Percent of Total Billed Charges,60% of Total Billed Charges,641.99,90,,2792.56,Percent of Total Billed Charges,90% of Total Billed Charges,320.99,45,,2749.312,Percent of Total Billed Charges,45% of Total Billed Charges,641.99,90,,835.872,Percent of Total Billed Charges,90% of Total billed Charges,713.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,713.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,713.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,463.66,65,,286.52,Percent of total Billed Charges,65% of Total Billed Charges,314.57,44.1,,2694.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,677.65,95,,882.304,Percent of Total Billed Charges,95% of Total Billed Charges,713.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,627.72,88,,5376.432,Percent of Total Billed Charges,88% of Total Billed Charges,641.99,90,,835.872,Percent of Total Billed charges,90% of Total Billed Charges,314.57,713.32,
MYCOBACTERIUM TB PCR,3060000031,CDM,306,RC,,,Outpatient,,,420.00,273.00,,420,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,319.2,76,,1675.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,302.4,72,,186.624,Percent of Total Billed Charges,72% of Total Billed Charges,315,75,,194.4,Percent of Total Billed charges,75% of Total Billed Charges,420,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.4,72,,186.624,Percent of Total Billed Charges,72% of Total Billed Charges,252,60,,155.52,Percent of Total Billed Charges,60% of Total Billed Charges,378,90,,1984.504,Percent of Total Billed Charges,90% of Total Billed Charges,189,45,,2749.312,Percent of Total Billed Charges,45% of Total Billed Charges,378,90,,1984.504,Percent of Total Billed Charges,90% of Total billed Charges,420,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,420,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,420,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273,65,,72.28,Percent of total Billed Charges,65% of Total Billed Charges,185.22,44.1,,2694.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,399,95,,2094.752,Percent of Total Billed Charges,95% of Total Billed Charges,420,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.6,88,,994.752,Percent of Total Billed Charges,88% of Total Billed Charges,378,90,,1984.504,Percent of Total Billed charges,90% of Total Billed Charges,185.22,420,
NEISSERIA GONORRHOEA,3060000032,CDM,306,RC,,,Outpatient,,,58.43,37.98,,58.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,44.41,76,,5995.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.07,72,,307.36,Percent of Total Billed Charges,72% of Total Billed Charges,43.82,75,,320.168,Percent of Total Billed charges,75% of Total Billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.07,72,,307.36,Percent of Total Billed Charges,72% of Total Billed Charges,35.06,60,,256.136,Percent of Total Billed Charges,60% of Total Billed Charges,52.59,90,,1152,Percent of Total Billed Charges,90% of Total Billed Charges,26.29,45,,508.68,Percent of Total Billed Charges,45% of Total Billed Charges,52.59,90,,7099.528,Percent of Total Billed Charges,90% of Total billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.98,65,,95.16,Percent of total Billed Charges,65% of Total Billed Charges,25.77,44.1,,498.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,55.51,95,,7493.944,Percent of Total Billed Charges,95% of Total Billed Charges,58.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.42,88,,994.752,Percent of Total Billed Charges,88% of Total Billed Charges,52.59,90,,7099.528,Percent of Total Billed charges,90% of Total Billed Charges,25.77,58.43,
BK VIRUS DNA QN URINE,3060000033,CDM,306,RC,,,Outpatient,,,542.80,352.82,,542.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,412.53,76,,3942.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,390.82,72,,502.272,Percent of Total Billed Charges,72% of Total Billed Charges,407.1,75,,523.2,Percent of Total Billed charges,75% of Total Billed Charges,542.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.82,72,,502.272,Percent of Total Billed Charges,72% of Total Billed Charges,325.68,60,,418.56,Percent of Total Billed Charges,60% of Total Billed Charges,488.52,90,,315.136,Percent of Total Billed Charges,90% of Total Billed Charges,244.26,45,,508.68,Percent of Total Billed Charges,45% of Total Billed Charges,488.52,90,,4669.056,Percent of Total Billed Charges,90% of Total billed Charges,542.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,542.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,542.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.82,65,,134.16,Percent of total Billed Charges,65% of Total Billed Charges,239.37,44.1,,498.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,515.66,95,,4928.448,Percent of Total Billed Charges,95% of Total Billed Charges,542.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,477.66,88,,4175.72,Percent of Total Billed Charges,88% of Total Billed Charges,488.52,90,,4669.056,Percent of Total Billed charges,90% of Total Billed Charges,239.37,542.8,
INFLUENZA A&B ANTIGE,3060000034,CDM,306,RC,,,Outpatient,,,99.00,64.35,,99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.24,76,,4643.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71.28,72,,354.816,Percent of Total Billed Charges,72% of Total Billed Charges,74.25,75,,369.6,Percent of Total Billed charges,75% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.28,72,,354.816,Percent of Total Billed Charges,72% of Total Billed Charges,59.4,60,,295.68,Percent of Total Billed Charges,60% of Total Billed Charges,89.1,90,,6139.256,Percent of Total Billed Charges,90% of Total Billed Charges,44.55,45,,2135.312,Percent of Total Billed Charges,45% of Total Billed Charges,89.1,90,,5498.624,Percent of Total Billed Charges,90% of Total billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.35,65,,129.48,Percent of total Billed Charges,65% of Total Billed Charges,43.66,44.1,,2092.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,94.05,95,,5804.104,Percent of Total Billed Charges,95% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.12,88,,5326.184,Percent of Total Billed Charges,88% of Total Billed Charges,89.1,90,,5498.624,Percent of Total Billed charges,90% of Total Billed Charges,43.66,99,
STREP SCREEN A SWAB,3060000035,CDM,306,RC,,,Outpatient,,,179.00,116.35,,179,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,136.04,76,,4643.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,128.88,72,,156.224,Percent of Total Billed Charges,72% of Total Billed Charges,134.25,75,,162.736,Percent of Total Billed charges,75% of Total Billed Charges,179,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.88,72,,156.224,Percent of Total Billed Charges,72% of Total Billed Charges,107.4,60,,130.184,Percent of Total Billed Charges,60% of Total Billed Charges,161.1,90,,432,Percent of Total Billed Charges,90% of Total Billed Charges,80.55,45,,2723.616,Percent of Total Billed Charges,45% of Total Billed Charges,161.1,90,,5498.624,Percent of Total Billed Charges,90% of Total billed Charges,179,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.35,65,,135.296,Percent of total Billed Charges,65% of Total Billed Charges,78.94,44.1,,2669.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,170.05,95,,5804.104,Percent of Total Billed Charges,95% of Total Billed Charges,179,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.52,88,,2730.504,Percent of Total Billed Charges,88% of Total Billed Charges,161.1,90,,5498.624,Percent of Total Billed charges,90% of Total Billed Charges,78.94,179,
HEP C VIRAL RNA GENO,3060000036,CDM,306,RC,,,Outpatient,,,671.42,436.42,,671.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,510.28,76,,859.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,483.42,72,,174,Percent of Total Billed Charges,72% of Total Billed Charges,503.57,75,,181.256,Percent of Total Billed charges,75% of Total Billed Charges,671.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,483.42,72,,174,Percent of Total Billed Charges,72% of Total Billed Charges,402.85,60,,145,Percent of Total Billed Charges,60% of Total Billed Charges,604.28,90,,2111.76,Percent of Total Billed Charges,90% of Total Billed Charges,302.14,45,,1396.28,Percent of Total Billed Charges,45% of Total Billed Charges,604.28,90,,1017.36,Percent of Total Billed Charges,90% of Total billed Charges,671.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,671.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,671.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,436.42,65,,227.24,Percent of total Billed Charges,65% of Total Billed Charges,296.1,44.1,,1368.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,637.85,95,,1073.88,Percent of Total Billed Charges,95% of Total Billed Charges,671.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,590.85,88,,1940.4,Percent of Total Billed Charges,88% of Total Billed Charges,604.28,90,,1017.36,Percent of Total Billed charges,90% of Total Billed Charges,296.1,671.42,
BLOOD CULTURE FLUID SET,3060000038,CDM,306,RC,,,Outpatient,,,245.77,159.75,,245.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,186.79,76,,3606.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,176.95,72,,153.04,Percent of Total Billed Charges,72% of Total Billed Charges,184.33,75,,159.424,Percent of Total Billed charges,75% of Total Billed Charges,245.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.95,72,,153.04,Percent of Total Billed Charges,72% of Total Billed Charges,147.46,60,,127.536,Percent of Total Billed Charges,60% of Total Billed Charges,221.19,90,,1984.504,Percent of Total Billed Charges,90% of Total Billed Charges,110.6,45,,576,Percent of Total Billed Charges,45% of Total Billed Charges,221.19,90,,4270.624,Percent of Total Billed Charges,90% of Total billed Charges,245.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.75,65,,228.8,Percent of total Billed Charges,65% of Total Billed Charges,108.38,44.1,,564.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,233.48,95,,4507.88,Percent of Total Billed Charges,95% of Total Billed Charges,245.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.28,88,,308.136,Percent of Total Billed Charges,88% of Total Billed Charges,221.19,90,,4270.624,Percent of Total Billed charges,90% of Total Billed Charges,108.38,245.77,
SARS-COV-2 COVID-19 AMP PRB,3060000039,CDM,309,RC,,,Outpatient,,,497.50,323.38,,497.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,378.1,76,,4599.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,358.2,72,,153.04,Percent of Total Billed Charges,72% of Total Billed Charges,373.13,75,,159.424,Percent of Total Billed charges,75% of Total Billed Charges,497.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.2,72,,153.04,Percent of Total Billed Charges,72% of Total Billed Charges,298.5,60,,127.536,Percent of Total Billed Charges,60% of Total Billed Charges,447.75,90,,1984.504,Percent of Total Billed Charges,90% of Total Billed Charges,223.88,45,,157.568,Percent of Total Billed Charges,45% of Total Billed Charges,447.75,90,,5447.232,Percent of Total Billed Charges,90% of Total billed Charges,497.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.38,65,,261.424,Percent of total Billed Charges,65% of Total Billed Charges,219.4,44.1,,154.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,472.63,95,,5749.856,Percent of Total Billed Charges,95% of Total Billed Charges,497.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.8,88,,6002.824,Percent of Total Billed Charges,88% of Total Billed Charges,447.75,90,,5447.232,Percent of Total Billed charges,90% of Total Billed Charges,219.4,497.5,
EHEC Shiga-like Toxin Assay,3060000040,CDM,306,RC,,,Outpatient,,,54.88,35.67,,54.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.71,76,,2358.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.51,72,,115.584,Percent of Total Billed Charges,72% of Total Billed Charges,41.16,75,,120.4,Percent of Total Billed charges,75% of Total Billed Charges,54.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.51,72,,115.584,Percent of Total Billed Charges,72% of Total Billed Charges,32.93,60,,96.32,Percent of Total Billed Charges,60% of Total Billed Charges,49.39,90,,3221.248,Percent of Total Billed Charges,90% of Total Billed Charges,24.7,45,,3069.624,Percent of Total Billed Charges,45% of Total Billed Charges,49.39,90,,2792.56,Percent of Total Billed Charges,90% of Total billed Charges,54.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.67,65,,248.56,Percent of total Billed Charges,65% of Total Billed Charges,24.2,44.1,,3008.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.14,95,,2947.704,Percent of Total Billed Charges,95% of Total Billed Charges,54.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.29,88,,422.4,Percent of Total Billed Charges,88% of Total Billed Charges,49.39,90,,2792.56,Percent of Total Billed charges,90% of Total Billed Charges,24.2,54.88,
MALDI ID,3060000041,CDM,306,RC,,,Outpatient,,,27.28,17.73,,27.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.73,76,,1675.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.64,72,,151.144,Percent of Total Billed Charges,72% of Total Billed Charges,20.46,75,,157.44,Percent of Total Billed charges,75% of Total Billed Charges,27.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.64,72,,151.144,Percent of Total Billed Charges,72% of Total Billed Charges,16.37,60,,125.952,Percent of Total Billed Charges,60% of Total Billed Charges,24.55,90,,1984.504,Percent of Total Billed Charges,90% of Total Billed Charges,12.28,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,24.55,90,,1984.504,Percent of Total Billed Charges,90% of Total billed Charges,27.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.73,65,,262.6,Percent of total Billed Charges,65% of Total Billed Charges,12.03,44.1,,211.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,25.92,95,,2094.752,Percent of Total Billed Charges,95% of Total Billed Charges,27.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.01,88,,2064.832,Percent of Total Billed Charges,88% of Total Billed Charges,24.55,90,,1984.504,Percent of Total Billed charges,90% of Total Billed Charges,12.03,27.28,
Acid Fast Bacilli (AFB) AGAR,3060000042,CDM,306,RC,,,Outpatient,,,36.20,23.53,,36.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.51,76,,972.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.06,72,,151.144,Percent of Total Billed Charges,72% of Total Billed Charges,27.15,75,,157.44,Percent of Total Billed charges,75% of Total Billed Charges,36.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.06,72,,151.144,Percent of Total Billed Charges,72% of Total Billed Charges,21.72,60,,125.952,Percent of Total Billed Charges,60% of Total Billed Charges,32.58,90,,1095.448,Percent of Total Billed Charges,90% of Total Billed Charges,16.29,45,,1055.88,Percent of Total Billed Charges,45% of Total Billed Charges,32.58,90,,1152,Percent of Total Billed Charges,90% of Total billed Charges,36.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.53,65,,187.2,Percent of total Billed Charges,65% of Total Billed Charges,15.96,44.1,,1034.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.39,95,,1216,Percent of Total Billed Charges,95% of Total Billed Charges,36.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.86,88,,2147.904,Percent of Total Billed Charges,88% of Total Billed Charges,32.58,90,,1152,Percent of Total Billed charges,90% of Total Billed Charges,15.96,36.2,
"Shiga Toxins, EIA Relex E Coli",3060000043,CDM,306,RC,,,Outpatient,,,115.84,75.30,,115.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,88.04,76,,266.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,83.4,72,,125.744,Percent of Total Billed Charges,72% of Total Billed Charges,86.88,75,,130.984,Percent of Total Billed charges,75% of Total Billed Charges,115.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.4,72,,125.744,Percent of Total Billed Charges,72% of Total Billed Charges,69.5,60,,104.784,Percent of Total Billed Charges,60% of Total Billed Charges,104.26,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,52.13,45,,1098.36,Percent of Total Billed Charges,45% of Total Billed Charges,104.26,90,,315.136,Percent of Total Billed Charges,90% of Total billed Charges,115.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.3,65,,180.96,Percent of total Billed Charges,65% of Total Billed Charges,51.09,44.1,,1076.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,110.05,95,,332.648,Percent of Total Billed Charges,95% of Total Billed Charges,115.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.94,88,,1940.4,Percent of Total Billed Charges,88% of Total Billed Charges,104.26,90,,315.136,Percent of Total Billed charges,90% of Total Billed Charges,51.09,115.84,
Group B Strep Direct NAAT,3060000044,CDM,306,RC,,,Outpatient,,,92.00,59.80,,92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,69.92,76,,5184.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,66.24,72,,125.744,Percent of Total Billed Charges,72% of Total Billed Charges,69,75,,130.984,Percent of Total Billed charges,75% of Total Billed Charges,92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.24,72,,125.744,Percent of Total Billed Charges,72% of Total Billed Charges,55.2,60,,104.784,Percent of Total Billed Charges,60% of Total Billed Charges,82.8,90,,205.92,Percent of Total Billed Charges,90% of Total Billed Charges,41.4,45,,992.248,Percent of Total Billed Charges,45% of Total Billed Charges,82.8,90,,6139.256,Percent of Total Billed Charges,90% of Total billed Charges,92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.8,65,,125.32,Percent of total Billed Charges,65% of Total Billed Charges,40.57,44.1,,972.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,87.4,95,,6480.32,Percent of Total Billed Charges,95% of Total Billed Charges,92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.96,88,,1940.4,Percent of Total Billed Charges,88% of Total Billed Charges,82.8,90,,6139.256,Percent of Total Billed charges,90% of Total Billed Charges,40.57,92,
DETECT AGNT MULT  DNA AMPL,3060000045,CDM,306,RC,,,Outpatient,,,184.00,119.60,,184,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,139.84,76,,364.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,132.48,72,,162.568,Percent of Total Billed Charges,72% of Total Billed Charges,138,75,,169.344,Percent of Total Billed charges,75% of Total Billed Charges,184,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.48,72,,162.568,Percent of Total Billed Charges,72% of Total Billed Charges,110.4,60,,135.472,Percent of Total Billed Charges,60% of Total Billed Charges,165.6,90,,185.76,Percent of Total Billed Charges,90% of Total Billed Charges,82.8,45,,992.248,Percent of Total Billed Charges,45% of Total Billed Charges,165.6,90,,432,Percent of Total Billed Charges,90% of Total billed Charges,184,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.6,65,,125.32,Percent of total Billed Charges,65% of Total Billed Charges,81.14,44.1,,972.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,174.8,95,,456,Percent of Total Billed Charges,95% of Total Billed Charges,184,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.92,88,,3149.664,Percent of Total Billed Charges,88% of Total Billed Charges,165.6,90,,432,Percent of Total Billed charges,90% of Total Billed Charges,81.14,184,
URINALYSIS,3070000001,CDM,307,RC,,,Outpatient,,,111.00,72.15,,111,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,84.36,76,,1783.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,79.92,72,,162.568,Percent of Total Billed Charges,72% of Total Billed Charges,83.25,75,,169.344,Percent of Total Billed charges,75% of Total Billed Charges,111,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.92,72,,162.568,Percent of Total Billed Charges,72% of Total Billed Charges,66.6,60,,135.472,Percent of Total Billed Charges,60% of Total Billed Charges,99.9,90,,231,Percent of Total Billed Charges,90% of Total Billed Charges,49.95,45,,1610.624,Percent of Total Billed Charges,45% of Total Billed Charges,99.9,90,,2111.76,Percent of Total Billed Charges,90% of Total billed Charges,111,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.15,65,,125.32,Percent of total Billed Charges,65% of Total Billed Charges,48.95,44.1,,1578.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,105.45,95,,2229.08,Percent of Total Billed Charges,95% of Total Billed Charges,111,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.68,88,,1940.4,Percent of Total Billed Charges,88% of Total Billed Charges,99.9,90,,2111.76,Percent of Total Billed charges,90% of Total Billed Charges,48.95,111,
SPEFC GRAVITY UA W/O,3070000002,CDM,307,RC,,,Outpatient,,,37.00,24.05,,37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28.12,76,,1855.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.64,72,,79.52,Percent of Total Billed Charges,72% of Total Billed Charges,27.75,75,,82.84,Percent of Total Billed charges,75% of Total Billed Charges,37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.64,72,,79.52,Percent of Total Billed Charges,72% of Total Billed Charges,22.2,60,,66.272,Percent of Total Billed Charges,60% of Total Billed Charges,33.3,90,,137.52,Percent of Total Billed Charges,90% of Total Billed Charges,16.65,45,,992.248,Percent of Total Billed Charges,45% of Total Billed Charges,33.3,90,,2196.72,Percent of Total Billed Charges,90% of Total billed Charges,37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.05,65,,229.84,Percent of total Billed Charges,65% of Total Billed Charges,16.32,44.1,,972.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,35.15,95,,2318.76,Percent of Total Billed Charges,95% of Total Billed Charges,37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.56,88,,1071.104,Percent of Total Billed Charges,88% of Total Billed Charges,33.3,90,,2196.72,Percent of Total Billed charges,90% of Total Billed Charges,16.32,37,
URINE  MICROSCOPIC O,3070000003,CDM,307,RC,,,Outpatient,,,102.53,66.64,,102.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,77.92,76,,1675.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,73.82,72,,79.52,Percent of Total Billed Charges,72% of Total Billed Charges,76.9,75,,82.84,Percent of Total Billed charges,75% of Total Billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.82,72,,79.52,Percent of Total Billed Charges,72% of Total Billed Charges,61.52,60,,66.272,Percent of Total Billed Charges,60% of Total Billed Charges,92.28,90,,156.96,Percent of Total Billed Charges,90% of Total Billed Charges,46.14,45,,547.72,Percent of Total Billed Charges,45% of Total Billed Charges,92.28,90,,1984.504,Percent of Total Billed Charges,90% of Total billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.64,65,,214.24,Percent of total Billed Charges,65% of Total Billed Charges,45.22,44.1,,536.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,97.4,95,,2094.752,Percent of Total Billed Charges,95% of Total Billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.23,88,,246.4,Percent of Total Billed Charges,88% of Total Billed Charges,92.28,90,,1984.504,Percent of Total Billed charges,90% of Total Billed Charges,45.22,102.53,
Urine Pregnancy test,3070000004,CDM,307,RC,,,Outpatient,,,24.00,15.60,,24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.24,76,,1675.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.28,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,18,75,,129.656,Percent of Total Billed charges,75% of Total Billed Charges,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.28,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,14.4,60,,103.72,Percent of Total Billed Charges,60% of Total Billed Charges,21.6,90,,194.4,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,45,,126,Percent of Total Billed Charges,45% of Total Billed Charges,21.6,90,,1984.504,Percent of Total Billed Charges,90% of Total billed Charges,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.6,65,,257.4,Percent of total Billed Charges,65% of Total Billed Charges,10.58,44.1,,123.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.8,95,,2094.752,Percent of Total Billed Charges,95% of Total Billed Charges,24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.12,88,,201.344,Percent of Total Billed Charges,88% of Total Billed Charges,21.6,90,,1984.504,Percent of Total Billed charges,90% of Total Billed Charges,10.58,24,
SANE pregnancy test,3070000005,CDM,307,RC,,,Outpatient,,,425.00,276.25,,425,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,323,76,,2720.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,306,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,318.75,75,,129.656,Percent of Total Billed charges,75% of Total Billed Charges,425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,255,60,,103.72,Percent of Total Billed Charges,60% of Total Billed Charges,382.5,90,,138.128,Percent of Total Billed Charges,90% of Total Billed Charges,191.25,45,,102.96,Percent of Total Billed Charges,45% of Total Billed Charges,382.5,90,,3221.248,Percent of Total Billed Charges,90% of Total billed Charges,425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.25,65,,240.24,Percent of total Billed Charges,65% of Total Billed Charges,187.43,44.1,,100.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,403.75,95,,3400.2,Percent of Total Billed Charges,95% of Total Billed Charges,425,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374,88,,181.632,Percent of Total Billed Charges,88% of Total Billed Charges,382.5,90,,3221.248,Percent of Total Billed charges,90% of Total Billed Charges,187.43,425,
SANE urinalysis,3070000006,CDM,307,RC,,,Outpatient,,,257.00,167.05,,257,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,195.32,76,,1675.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,185.04,72,,90.176,Percent of Total Billed Charges,72% of Total Billed Charges,192.75,75,,93.936,Percent of Total Billed charges,75% of Total Billed Charges,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.04,72,,90.176,Percent of Total Billed Charges,72% of Total Billed Charges,154.2,60,,75.152,Percent of Total Billed Charges,60% of Total Billed Charges,231.3,90,,180.192,Percent of Total Billed Charges,90% of Total Billed Charges,115.65,45,,92.88,Percent of Total Billed Charges,45% of Total Billed Charges,231.3,90,,1984.504,Percent of Total Billed Charges,90% of Total billed Charges,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.05,65,,218.92,Percent of total Billed Charges,65% of Total Billed Charges,113.34,44.1,,91.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,244.15,95,,2094.752,Percent of Total Billed Charges,95% of Total Billed Charges,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.16,88,,225.864,Percent of Total Billed Charges,88% of Total Billed Charges,231.3,90,,1984.504,Percent of Total Billed charges,90% of Total Billed Charges,113.34,257,
CARDIO IQ LIPOPROTEIN FRACTION,3090000001,CDM,309,RC,,,Outpatient,,,185.00,120.25,,185,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,140.6,76,,925.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,133.2,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,138.75,75,,129.656,Percent of Total Billed charges,75% of Total Billed Charges,185,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.2,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,111,60,,103.72,Percent of Total Billed Charges,60% of Total Billed Charges,166.5,90,,281.52,Percent of Total Billed Charges,90% of Total Billed Charges,83.25,45,,115.496,Percent of Total Billed Charges,45% of Total Billed Charges,166.5,90,,1095.448,Percent of Total Billed Charges,90% of Total billed Charges,185,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.25,65,,220.48,Percent of total Billed Charges,65% of Total Billed Charges,81.59,44.1,,113.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,175.75,95,,1156.304,Percent of Total Billed Charges,95% of Total Billed Charges,185,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.8,88,,134.464,Percent of Total Billed Charges,88% of Total Billed Charges,166.5,90,,1095.448,Percent of Total Billed charges,90% of Total Billed Charges,81.59,185,
"HPV GENOTYP 16, 18/45 ANAL REC",3090000002,CDM,309,RC,,,Outpatient,,,120.00,78.00,,120,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,91.2,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,86.4,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,90,75,,129.656,Percent of Total Billed charges,75% of Total Billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.4,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,72,60,,103.72,Percent of Total Billed Charges,60% of Total Billed Charges,108,90,,353.52,Percent of Total Billed Charges,90% of Total Billed Charges,54,45,,68.76,Percent of Total Billed Charges,45% of Total Billed Charges,108,90,,252,Percent of Total Billed Charges,90% of Total billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78,65,,251.112,Percent of total Billed Charges,65% of Total Billed Charges,52.92,44.1,,67.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,114,95,,266,Percent of Total Billed Charges,95% of Total Billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.6,88,,153.472,Percent of Total Billed Charges,88% of Total Billed Charges,108,90,,252,Percent of Total Billed charges,90% of Total Billed Charges,52.92,120,
OB PANEL,3090000003,CDM,309,RC,,,Outpatient,,,900.00,585.00,,900,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,684,76,,173.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,648,72,,214.272,Percent of Total Billed Charges,72% of Total Billed Charges,675,75,,223.2,Percent of Total Billed charges,75% of Total Billed Charges,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,648,72,,214.272,Percent of Total Billed Charges,72% of Total Billed Charges,540,60,,178.56,Percent of Total Billed Charges,60% of Total Billed Charges,810,90,,128.6,Percent of Total Billed Charges,90% of Total Billed Charges,405,45,,78.48,Percent of Total Billed Charges,45% of Total Billed Charges,810,90,,205.92,Percent of Total Billed Charges,90% of Total billed Charges,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,585,65,,251.112,Percent of total Billed Charges,65% of Total Billed Charges,396.9,44.1,,76.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,855,95,,217.36,Percent of Total Billed Charges,95% of Total Billed Charges,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,792,88,,190.08,Percent of Total Billed Charges,88% of Total Billed Charges,810,90,,205.92,Percent of Total Billed charges,90% of Total Billed Charges,396.9,900,
CARDIO IQ CHOLESTEROL,3090000004,CDM,309,RC,,,Outpatient,,,250.27,162.68,,250.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,190.21,76,,156.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,180.19,72,,214.272,Percent of Total Billed Charges,72% of Total Billed Charges,187.7,75,,223.2,Percent of Total Billed charges,75% of Total Billed Charges,250.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.19,72,,214.272,Percent of Total Billed Charges,72% of Total Billed Charges,150.16,60,,178.56,Percent of Total Billed Charges,60% of Total Billed Charges,225.24,90,,249.84,Percent of Total Billed Charges,90% of Total Billed Charges,112.62,45,,97.2,Percent of Total Billed Charges,45% of Total Billed Charges,225.24,90,,185.76,Percent of Total Billed Charges,90% of Total billed Charges,250.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.68,65,,235.624,Percent of total Billed Charges,65% of Total Billed Charges,110.37,44.1,,95.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,237.76,95,,196.08,Percent of Total Billed Charges,95% of Total Billed Charges,250.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.24,88,,135.056,Percent of Total Billed Charges,88% of Total Billed Charges,225.24,90,,185.76,Percent of Total Billed charges,90% of Total Billed Charges,110.37,250.27,
ITRACONAZOLE,3090000005,CDM,309,RC,,,Outpatient,,,244.76,159.09,,244.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,186.02,76,,195.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,176.23,72,,216.576,Percent of Total Billed Charges,72% of Total Billed Charges,183.57,75,,225.6,Percent of Total Billed charges,75% of Total Billed Charges,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.23,72,,216.576,Percent of Total Billed Charges,72% of Total Billed Charges,146.86,60,,180.48,Percent of Total Billed Charges,60% of Total Billed Charges,220.28,90,,396.72,Percent of Total Billed Charges,90% of Total Billed Charges,110.14,45,,69.064,Percent of Total Billed Charges,45% of Total Billed Charges,220.28,90,,231,Percent of Total Billed Charges,90% of Total billed Charges,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.09,65,,296.4,Percent of total Billed Charges,65% of Total Billed Charges,107.94,44.1,,67.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,232.52,95,,243.832,Percent of Total Billed Charges,95% of Total Billed Charges,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.39,88,,176.192,Percent of Total Billed Charges,88% of Total Billed Charges,220.28,90,,231,Percent of Total Billed charges,90% of Total Billed Charges,107.94,244.76,
PHOSPHATIDYLETHANOL BLOOD,3090000006,CDM,309,RC,,,Outpatient,,,90.00,58.50,,90,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,68.4,76,,116.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.8,72,,176.256,Percent of Total Billed Charges,72% of Total Billed Charges,67.5,75,,183.6,Percent of Total Billed charges,75% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.8,72,,176.256,Percent of Total Billed Charges,72% of Total Billed Charges,54,60,,146.88,Percent of Total Billed Charges,60% of Total Billed Charges,81,90,,100.08,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,45,,90.096,Percent of Total Billed Charges,45% of Total Billed Charges,81,90,,137.52,Percent of Total Billed Charges,90% of Total billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.5,65,,283.4,Percent of total Billed Charges,65% of Total Billed Charges,39.69,44.1,,88.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,85.5,95,,145.16,Percent of Total Billed Charges,95% of Total Billed Charges,90,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,88,,275.264,Percent of Total Billed Charges,88% of Total Billed Charges,81,90,,137.52,Percent of Total Billed charges,90% of Total Billed Charges,39.69,90,
CLOBAZAM,3090000007,CDM,309,RC,,,Outpatient,,,157.66,102.48,,157.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,119.82,76,,132.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,113.52,72,,176.256,Percent of Total Billed Charges,72% of Total Billed Charges,118.25,75,,183.6,Percent of Total Billed charges,75% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.52,72,,176.256,Percent of Total Billed Charges,72% of Total Billed Charges,94.6,60,,146.88,Percent of Total Billed Charges,60% of Total Billed Charges,141.89,90,,131.76,Percent of Total Billed Charges,90% of Total Billed Charges,70.95,45,,140.76,Percent of Total Billed Charges,45% of Total Billed Charges,141.89,90,,156.96,Percent of Total Billed Charges,90% of Total billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.48,65,,138.744,Percent of total Billed Charges,65% of Total Billed Charges,69.53,44.1,,137.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,149.78,95,,165.68,Percent of Total Billed Charges,95% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.74,88,,345.664,Percent of Total Billed Charges,88% of Total Billed Charges,141.89,90,,156.96,Percent of Total Billed charges,90% of Total Billed Charges,69.53,157.66,
JAK2 MUTATION QUANT,3090000008,CDM,309,RC,,,Outpatient,,,817.00,531.05,,817,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,620.92,76,,164.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,588.24,72,,155.52,Percent of Total Billed Charges,72% of Total Billed Charges,612.75,75,,162,Percent of Total Billed charges,75% of Total Billed Charges,817,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,588.24,72,,155.52,Percent of Total Billed Charges,72% of Total Billed Charges,490.2,60,,129.6,Percent of Total Billed Charges,60% of Total Billed Charges,735.3,90,,185.76,Percent of Total Billed Charges,90% of Total Billed Charges,367.65,45,,176.76,Percent of Total Billed Charges,45% of Total Billed Charges,735.3,90,,194.4,Percent of Total Billed Charges,90% of Total billed Charges,817,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,817,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,817,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531.05,65,,144.04,Percent of total Billed Charges,65% of Total Billed Charges,360.3,44.1,,173.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,776.15,95,,205.2,Percent of Total Billed Charges,95% of Total Billed Charges,817,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,718.96,88,,125.744,Percent of Total Billed Charges,88% of Total Billed Charges,735.3,90,,194.4,Percent of Total Billed charges,90% of Total Billed Charges,360.3,817,
MTHFR,3090000009,CDM,309,RC,,,Outpatient,,,755.00,490.75,,755,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,573.8,76,,116.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,543.6,72,,155.52,Percent of Total Billed Charges,72% of Total Billed Charges,566.25,75,,162,Percent of Total Billed charges,75% of Total Billed Charges,755,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,543.6,72,,155.52,Percent of Total Billed Charges,72% of Total Billed Charges,453,60,,129.6,Percent of Total Billed Charges,60% of Total Billed Charges,679.5,90,,179.28,Percent of Total Billed Charges,90% of Total Billed Charges,339.75,45,,64.296,Percent of Total Billed Charges,45% of Total Billed Charges,679.5,90,,138.128,Percent of Total Billed Charges,90% of Total billed Charges,755,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,755,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,755,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.75,65,,188.24,Percent of total Billed Charges,65% of Total Billed Charges,332.96,44.1,,63.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,717.25,95,,145.8,Percent of Total Billed Charges,95% of Total Billed Charges,755,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,664.4,88,,244.288,Percent of Total Billed Charges,88% of Total Billed Charges,679.5,90,,138.128,Percent of Total Billed charges,90% of Total Billed Charges,332.96,755,
SMA CARRIER SCREEN,3090000010,CDM,309,RC,,,Outpatient,,,765.00,497.25,,765,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,581.4,76,,152.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,550.8,72,,164.16,Percent of Total Billed Charges,72% of Total Billed Charges,573.75,75,,171,Percent of Total Billed charges,75% of Total Billed Charges,765,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.8,72,,164.16,Percent of Total Billed Charges,72% of Total Billed Charges,459,60,,136.8,Percent of Total Billed Charges,60% of Total Billed Charges,688.5,90,,187.336,Percent of Total Billed Charges,90% of Total Billed Charges,344.25,45,,124.92,Percent of Total Billed Charges,45% of Total Billed Charges,688.5,90,,180.192,Percent of Total Billed Charges,90% of Total billed Charges,765,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,765,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,765,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497.25,65,,147.16,Percent of total Billed Charges,65% of Total Billed Charges,337.37,44.1,,122.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,726.75,95,,190.208,Percent of Total Billed Charges,95% of Total Billed Charges,765,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,673.2,88,,387.904,Percent of Total Billed Charges,88% of Total Billed Charges,688.5,90,,180.192,Percent of Total Billed charges,90% of Total Billed Charges,337.37,765,
LIVERFIBROSIS,3090000011,CDM,309,RC,,,Outpatient,,,209.00,135.85,,209,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,158.84,76,,237.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.48,72,,164.16,Percent of Total Billed Charges,72% of Total Billed Charges,156.75,75,,171,Percent of Total Billed charges,75% of Total Billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.48,72,,164.16,Percent of Total Billed Charges,72% of Total Billed Charges,125.4,60,,136.8,Percent of Total Billed Charges,60% of Total Billed Charges,188.1,90,,314.64,Percent of Total Billed Charges,90% of Total Billed Charges,94.05,45,,198.36,Percent of Total Billed Charges,45% of Total Billed Charges,188.1,90,,281.52,Percent of Total Billed Charges,90% of Total billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.85,65,,165.36,Percent of total Billed Charges,65% of Total Billed Charges,92.17,44.1,,194.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,198.55,95,,297.16,Percent of Total Billed Charges,95% of Total Billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.92,88,,97.856,Percent of Total Billed Charges,88% of Total Billed Charges,188.1,90,,281.52,Percent of Total Billed charges,90% of Total Billed Charges,92.17,209,
ALPHA 1 ANTITRYPSIN STOOL,3090000012,CDM,309,RC,,,Outpatient,,,186.00,120.90,,186,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,141.36,76,,298.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,133.92,72,,198.72,Percent of Total Billed Charges,72% of Total Billed Charges,139.5,75,,207,Percent of Total Billed charges,75% of Total Billed Charges,186,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.92,72,,198.72,Percent of Total Billed Charges,72% of Total Billed Charges,111.6,60,,165.6,Percent of Total Billed Charges,60% of Total Billed Charges,167.4,90,,333.4,Percent of Total Billed Charges,90% of Total Billed Charges,83.7,45,,50.04,Percent of Total Billed Charges,45% of Total Billed Charges,167.4,90,,353.52,Percent of Total Billed Charges,90% of Total billed Charges,186,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.9,65,,145.08,Percent of total Billed Charges,65% of Total Billed Charges,82.03,44.1,,49.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,176.7,95,,373.16,Percent of Total Billed Charges,95% of Total Billed Charges,186,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.68,88,,128.832,Percent of Total Billed Charges,88% of Total Billed Charges,167.4,90,,353.52,Percent of Total Billed charges,90% of Total Billed Charges,82.03,186,
CARDIO IQ TRIGLYCERIDES,3090000013,CDM,309,RC,,,Outpatient,,,104.74,68.08,,104.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.6,76,,108.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75.41,72,,198.72,Percent of Total Billed Charges,72% of Total Billed Charges,78.56,75,,207,Percent of Total Billed charges,75% of Total Billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.41,72,,198.72,Percent of Total Billed Charges,72% of Total Billed Charges,62.84,60,,165.6,Percent of Total Billed Charges,60% of Total Billed Charges,94.27,90,,316.8,Percent of Total Billed Charges,90% of Total Billed Charges,47.13,45,,65.88,Percent of Total Billed Charges,45% of Total Billed Charges,94.27,90,,128.6,Percent of Total Billed Charges,90% of Total billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.08,65,,1079.16,Percent of total Billed Charges,65% of Total Billed Charges,46.19,44.1,,64.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,99.5,95,,135.744,Percent of Total Billed Charges,95% of Total Billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.17,88,,181.632,Percent of Total Billed Charges,88% of Total Billed Charges,94.27,90,,128.6,Percent of Total Billed charges,90% of Total Billed Charges,46.19,104.74,
FECAL GLOBIN INSURE QUEST,3090000014,CDM,309,RC,,,Outpatient,,,132.00,85.80,,132,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.32,76,,210.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.04,72,,137.8,Percent of Total Billed Charges,72% of Total Billed Charges,99,75,,143.544,Percent of Total Billed charges,75% of Total Billed Charges,132,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.04,72,,137.8,Percent of Total Billed Charges,72% of Total Billed Charges,79.2,60,,114.832,Percent of Total Billed Charges,60% of Total Billed Charges,118.8,90,,361.976,Percent of Total Billed Charges,90% of Total Billed Charges,59.4,45,,92.88,Percent of Total Billed Charges,45% of Total Billed Charges,118.8,90,,249.84,Percent of Total Billed Charges,90% of Total billed Charges,132,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.8,65,,1079.16,Percent of total Billed Charges,65% of Total Billed Charges,58.21,44.1,,91.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.4,95,,263.72,Percent of Total Billed Charges,95% of Total Billed Charges,132,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.16,88,,175.296,Percent of Total Billed Charges,88% of Total Billed Charges,118.8,90,,249.84,Percent of Total Billed charges,90% of Total Billed Charges,58.21,132,
CARBOXIDE HGB BLOOD QUANT,3090000015,CDM,309,RC,,,Outpatient,,,42.00,27.30,,42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31.92,76,,335.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30.24,72,,159.552,Percent of Total Billed Charges,72% of Total Billed Charges,31.5,75,,166.2,Percent of Total Billed charges,75% of Total Billed Charges,42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.24,72,,159.552,Percent of Total Billed Charges,72% of Total Billed Charges,25.2,60,,132.96,Percent of Total Billed Charges,60% of Total Billed Charges,37.8,90,,344.16,Percent of Total Billed Charges,90% of Total Billed Charges,18.9,45,,89.64,Percent of Total Billed Charges,45% of Total Billed Charges,37.8,90,,396.72,Percent of Total Billed Charges,90% of Total billed Charges,42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.3,65,,591.088,Percent of total Billed Charges,65% of Total Billed Charges,18.52,44.1,,87.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,39.9,95,,418.76,Percent of Total Billed Charges,95% of Total Billed Charges,42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.96,88,,183.176,Percent of Total Billed Charges,88% of Total Billed Charges,37.8,90,,396.72,Percent of Total Billed charges,90% of Total Billed Charges,18.52,42,
AMH FEMALE,3090000016,CDM,309,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,84.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,159.552,Percent of Total Billed Charges,72% of Total Billed Charges,112.5,75,,166.2,Percent of Total Billed charges,75% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,159.552,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,132.96,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,363.6,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,93.672,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,100.08,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,591.088,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,91.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,105.64,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,307.648,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,100.08,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
OMEGA 3 AND 6 FATTY ACIDS,3090000017,CDM,309,RC,,,Outpatient,,,250.00,162.50,,250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,190,76,,111.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,180,72,,181.44,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,75,,189,Percent of Total Billed charges,75% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180,72,,181.44,Percent of Total Billed Charges,72% of Total Billed Charges,150,60,,151.2,Percent of Total Billed Charges,60% of Total Billed Charges,225,90,,259.2,Percent of Total Billed Charges,90% of Total Billed Charges,112.5,45,,157.32,Percent of Total Billed Charges,45% of Total Billed Charges,225,90,,131.76,Percent of Total Billed Charges,90% of Total billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.5,65,,48.88,Percent of total Billed Charges,65% of Total Billed Charges,110.25,44.1,,154.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,237.5,95,,139.08,Percent of Total Billed Charges,95% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220,88,,325.984,Percent of Total Billed Charges,88% of Total Billed Charges,225,90,,131.76,Percent of Total Billed charges,90% of Total Billed Charges,110.25,250,
LACTOSE GTT EA ADDITIONAL,3090000019,CDM,309,RC,,,Outpatient,,,98.50,64.03,,98.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,74.86,76,,156.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,70.92,72,,181.44,Percent of Total Billed Charges,72% of Total Billed Charges,73.88,75,,189,Percent of Total Billed charges,75% of Total Billed Charges,98.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.92,72,,181.44,Percent of Total Billed Charges,72% of Total Billed Charges,59.1,60,,151.2,Percent of Total Billed Charges,60% of Total Billed Charges,88.65,90,,250.56,Percent of Total Billed Charges,90% of Total Billed Charges,44.33,45,,166.696,Percent of Total Billed Charges,45% of Total Billed Charges,88.65,90,,185.76,Percent of Total Billed Charges,90% of Total billed Charges,98.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.03,65,,289.512,Percent of total Billed Charges,65% of Total Billed Charges,43.44,44.1,,163.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,93.58,95,,196.08,Percent of Total Billed Charges,95% of Total Billed Charges,98.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.68,88,,309.76,Percent of Total Billed Charges,88% of Total Billed Charges,88.65,90,,185.76,Percent of Total Billed charges,90% of Total Billed Charges,43.44,98.5,
HAIC QUEST,3090000020,CDM,309,RC,,,Outpatient,,,186.32,121.11,,186.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,141.6,76,,151.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,134.15,72,,218.304,Percent of Total Billed Charges,72% of Total Billed Charges,139.74,75,,227.4,Percent of Total Billed charges,75% of Total Billed Charges,186.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.15,72,,218.304,Percent of Total Billed Charges,72% of Total Billed Charges,111.79,60,,181.92,Percent of Total Billed Charges,60% of Total Billed Charges,167.69,90,,173.52,Percent of Total Billed Charges,90% of Total Billed Charges,83.84,45,,158.4,Percent of Total Billed Charges,45% of Total Billed Charges,167.69,90,,179.28,Percent of Total Billed Charges,90% of Total billed Charges,186.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.11,65,,170.56,Percent of total Billed Charges,65% of Total Billed Charges,82.17,44.1,,155.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,177,95,,189.24,Percent of Total Billed Charges,95% of Total Billed Charges,186.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.96,88,,353.928,Percent of Total Billed Charges,88% of Total Billed Charges,167.69,90,,179.28,Percent of Total Billed charges,90% of Total Billed Charges,82.17,186.32,
TRYPTASE,3090000021,CDM,301,RC,,,Outpatient,,,577.71,375.51,,577.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,439.06,76,,158.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.95,72,,218.304,Percent of Total Billed Charges,72% of Total Billed Charges,433.28,75,,227.4,Percent of Total Billed charges,75% of Total Billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.95,72,,218.304,Percent of Total Billed Charges,72% of Total Billed Charges,346.63,60,,181.92,Percent of Total Billed Charges,60% of Total Billed Charges,519.94,90,,173.52,Percent of Total Billed Charges,90% of Total Billed Charges,259.97,45,,180.984,Percent of Total Billed Charges,45% of Total Billed Charges,519.94,90,,187.336,Percent of Total Billed Charges,90% of Total billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.51,65,,110.24,Percent of total Billed Charges,65% of Total Billed Charges,254.77,44.1,,177.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,548.82,95,,197.744,Percent of Total Billed Charges,95% of Total Billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.38,88,,336.512,Percent of Total Billed Charges,88% of Total Billed Charges,519.94,90,,187.336,Percent of Total Billed charges,90% of Total Billed Charges,254.77,577.71,
URTICARIA PANEL 3,3090000022,CDM,301,RC,,,Outpatient,,,577.71,375.51,,577.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,439.06,76,,265.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.95,72,,115.584,Percent of Total Billed Charges,72% of Total Billed Charges,433.28,75,,120.4,Percent of Total Billed charges,75% of Total Billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.95,72,,115.584,Percent of Total Billed Charges,72% of Total Billed Charges,346.63,60,,96.32,Percent of Total Billed Charges,60% of Total Billed Charges,519.94,90,,173.52,Percent of Total Billed Charges,90% of Total Billed Charges,259.97,45,,172.08,Percent of Total Billed Charges,45% of Total Billed Charges,519.94,90,,314.64,Percent of Total Billed Charges,90% of Total billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.51,65,,174.72,Percent of total Billed Charges,65% of Total Billed Charges,254.77,44.1,,168.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,548.82,95,,332.12,Percent of Total Billed Charges,95% of Total Billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.38,88,,355.52,Percent of Total Billed Charges,88% of Total Billed Charges,519.94,90,,314.64,Percent of Total Billed charges,90% of Total Billed Charges,254.77,577.71,
14 3.3 ETA PROTEIN,3090000023,CDM,301,RC,,,Outpatient,,,624.00,405.60,,624,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,474.24,76,,281.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,449.28,72,,168.768,Percent of Total Billed Charges,72% of Total Billed Charges,468,75,,175.8,Percent of Total Billed charges,75% of Total Billed Charges,624,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,449.28,72,,168.768,Percent of Total Billed Charges,72% of Total Billed Charges,374.4,60,,140.64,Percent of Total Billed Charges,60% of Total Billed Charges,561.6,90,,318.24,Percent of Total Billed Charges,90% of Total Billed Charges,280.8,45,,181.8,Percent of Total Billed Charges,45% of Total Billed Charges,561.6,90,,333.4,Percent of Total Billed Charges,90% of Total billed Charges,624,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,624,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,624,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.6,65,,222.56,Percent of total Billed Charges,65% of Total Billed Charges,275.18,44.1,,178.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,592.8,95,,351.92,Percent of Total Billed Charges,95% of Total Billed Charges,624,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.12,88,,253.44,Percent of Total Billed Charges,88% of Total Billed Charges,561.6,90,,333.4,Percent of Total Billed charges,90% of Total Billed Charges,275.18,624,
LPPLA2 ACTIVITY,3090000024,CDM,309,RC,,,Outpatient,,,250.00,162.50,,250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,190,76,,267.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,180,72,,168.768,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,75,,175.8,Percent of Total Billed charges,75% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180,72,,168.768,Percent of Total Billed Charges,72% of Total Billed Charges,150,60,,140.64,Percent of Total Billed Charges,60% of Total Billed Charges,225,90,,296.64,Percent of Total Billed Charges,90% of Total Billed Charges,112.5,45,,129.6,Percent of Total Billed Charges,45% of Total Billed Charges,225,90,,316.8,Percent of Total Billed Charges,90% of Total billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.5,65,,220.48,Percent of total Billed Charges,65% of Total Billed Charges,110.25,44.1,,127.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,237.5,95,,334.4,Percent of Total Billed Charges,95% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220,88,,244.992,Percent of Total Billed Charges,88% of Total Billed Charges,225,90,,316.8,Percent of Total Billed charges,90% of Total Billed Charges,110.25,250,
CARDIO IQ HDL CHOLESTEROL,3090000025,CDM,309,RC,,,Outpatient,,,131.20,85.28,,131.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,99.71,76,,305.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,94.46,72,,162.432,Percent of Total Billed Charges,72% of Total Billed Charges,98.4,75,,169.2,Percent of Total Billed charges,75% of Total Billed Charges,131.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.46,72,,162.432,Percent of Total Billed Charges,72% of Total Billed Charges,78.72,60,,135.36,Percent of Total Billed Charges,60% of Total Billed Charges,118.08,90,,356.4,Percent of Total Billed Charges,90% of Total Billed Charges,59.04,45,,125.28,Percent of Total Billed Charges,45% of Total Billed Charges,118.08,90,,361.976,Percent of Total Billed Charges,90% of Total billed Charges,131.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.28,65,,412.88,Percent of total Billed Charges,65% of Total Billed Charges,57.86,44.1,,122.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,124.64,95,,382.08,Percent of Total Billed Charges,95% of Total Billed Charges,131.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.46,88,,169.664,Percent of Total Billed Charges,88% of Total Billed Charges,118.08,90,,361.976,Percent of Total Billed charges,90% of Total Billed Charges,57.86,131.2,
MYELOPEROXIDASE,3090000026,CDM,309,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,290.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,162.432,Percent of Total Billed Charges,72% of Total Billed Charges,206.25,75,,169.2,Percent of Total Billed charges,75% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,162.432,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,135.36,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,332.64,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,86.76,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,344.16,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,245.96,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,85.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,363.28,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,169.664,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,344.16,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
AST QUEST,3090000027,CDM,309,RC,,,Outpatient,,,95.00,61.75,,95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.2,76,,307.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,68.4,72,,171.072,Percent of Total Billed Charges,72% of Total Billed Charges,71.25,75,,178.2,Percent of Total Billed charges,75% of Total Billed Charges,95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.4,72,,171.072,Percent of Total Billed Charges,72% of Total Billed Charges,57,60,,142.56,Percent of Total Billed Charges,60% of Total Billed Charges,85.5,90,,303.12,Percent of Total Billed Charges,90% of Total Billed Charges,42.75,45,,86.76,Percent of Total Billed Charges,45% of Total Billed Charges,85.5,90,,363.6,Percent of Total Billed Charges,90% of Total billed Charges,95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.75,65,,182,Percent of total Billed Charges,65% of Total Billed Charges,41.9,44.1,,85.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,90.25,95,,383.8,Percent of Total Billed Charges,95% of Total Billed Charges,95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.6,88,,169.664,Percent of Total Billed Charges,88% of Total Billed Charges,85.5,90,,363.6,Percent of Total Billed charges,90% of Total Billed Charges,41.9,95,
ALT QUEST,3090000028,CDM,309,RC,,,Outpatient,,,95.00,61.75,,95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.2,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,68.4,72,,171.072,Percent of Total Billed Charges,72% of Total Billed Charges,71.25,75,,178.2,Percent of Total Billed charges,75% of Total Billed Charges,95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.4,72,,171.072,Percent of Total Billed Charges,72% of Total Billed Charges,57,60,,142.56,Percent of Total Billed Charges,60% of Total Billed Charges,85.5,90,,305.28,Percent of Total Billed Charges,90% of Total Billed Charges,42.75,45,,86.76,Percent of Total Billed Charges,45% of Total Billed Charges,85.5,90,,259.2,Percent of Total Billed Charges,90% of Total billed Charges,95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.75,65,,342.68,Percent of total Billed Charges,65% of Total Billed Charges,41.9,44.1,,85.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,90.25,95,,273.6,Percent of Total Billed Charges,95% of Total Billed Charges,95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.6,88,,311.168,Percent of Total Billed Charges,88% of Total Billed Charges,85.5,90,,259.2,Percent of Total Billed charges,90% of Total Billed Charges,41.9,95,
TRIG PERITONEAL FLUID,3090000029,CDM,309,RC,,,Outpatient,,,171.00,111.15,,171,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,129.96,76,,211.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.12,72,,148.032,Percent of Total Billed Charges,72% of Total Billed Charges,128.25,75,,154.2,Percent of Total Billed charges,75% of Total Billed Charges,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.12,72,,148.032,Percent of Total Billed Charges,72% of Total Billed Charges,102.6,60,,123.36,Percent of Total Billed Charges,60% of Total Billed Charges,153.9,90,,347.688,Percent of Total Billed Charges,90% of Total Billed Charges,76.95,45,,159.12,Percent of Total Billed Charges,45% of Total Billed Charges,153.9,90,,250.56,Percent of Total Billed Charges,90% of Total billed Charges,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.15,65,,548.08,Percent of total Billed Charges,65% of Total Billed Charges,75.41,44.1,,155.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,162.45,95,,264.48,Percent of Total Billed Charges,95% of Total Billed Charges,171,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.48,88,,290.048,Percent of Total Billed Charges,88% of Total Billed Charges,153.9,90,,250.56,Percent of Total Billed charges,90% of Total Billed Charges,75.41,171,
URTICARIA IGE AB,3090000030,CDM,309,RC,,,Outpatient,,,365.50,237.58,,365.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,277.78,76,,146.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,263.16,72,,148.032,Percent of Total Billed Charges,72% of Total Billed Charges,274.13,75,,154.2,Percent of Total Billed charges,75% of Total Billed Charges,365.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.16,72,,148.032,Percent of Total Billed Charges,72% of Total Billed Charges,219.3,60,,123.36,Percent of Total Billed Charges,60% of Total Billed Charges,328.95,90,,347.688,Percent of Total Billed Charges,90% of Total Billed Charges,164.48,45,,148.32,Percent of Total Billed Charges,45% of Total Billed Charges,328.95,90,,173.52,Percent of Total Billed Charges,90% of Total billed Charges,365.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.58,65,,398.84,Percent of total Billed Charges,65% of Total Billed Charges,161.19,44.1,,145.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,347.23,95,,183.16,Percent of Total Billed Charges,95% of Total Billed Charges,365.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,321.64,88,,348.48,Percent of Total Billed Charges,88% of Total Billed Charges,328.95,90,,173.52,Percent of Total Billed charges,90% of Total Billed Charges,161.19,365.5,
CD3 FLOW,3090000031,CDM,309,RC,,,Outpatient,,,100.00,65.00,,100,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,76,76,,146.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,72,72,,175.68,Percent of Total Billed Charges,72% of Total Billed Charges,75,75,,183,Percent of Total Billed charges,75% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72,72,,175.68,Percent of Total Billed Charges,72% of Total Billed Charges,60,60,,146.4,Percent of Total Billed Charges,60% of Total Billed Charges,90,90,,326.256,Percent of Total Billed Charges,90% of Total Billed Charges,45,45,,178.2,Percent of Total Billed Charges,45% of Total Billed Charges,90,90,,173.52,Percent of Total Billed Charges,90% of Total billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,65,,398.84,Percent of total Billed Charges,65% of Total Billed Charges,44.1,44.1,,174.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,95,95,,183.16,Percent of Total Billed Charges,95% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88,88,,325.248,Percent of Total Billed Charges,88% of Total Billed Charges,90,90,,173.52,Percent of Total Billed charges,90% of Total Billed Charges,44.1,100,
CD8 FLOW,3090000032,CDM,309,RC,,,Outpatient,,,100.00,65.00,,100,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,76,76,,146.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,72,72,,175.68,Percent of Total Billed Charges,72% of Total Billed Charges,75,75,,183,Percent of Total Billed charges,75% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72,72,,175.68,Percent of Total Billed Charges,72% of Total Billed Charges,60,60,,146.4,Percent of Total Billed Charges,60% of Total Billed Charges,90,90,,410.4,Percent of Total Billed Charges,90% of Total Billed Charges,45,45,,166.32,Percent of Total Billed Charges,45% of Total Billed Charges,90,90,,173.52,Percent of Total Billed Charges,90% of Total billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,65,,573.56,Percent of total Billed Charges,65% of Total Billed Charges,44.1,44.1,,162.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,95,95,,183.16,Percent of Total Billed Charges,95% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88,88,,296.384,Percent of Total Billed Charges,88% of Total Billed Charges,90,90,,173.52,Percent of Total Billed charges,90% of Total Billed Charges,44.1,100,
CD 57 FLOW,3090000033,CDM,309,RC,,,Outpatient,,,140.00,91.00,,140,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,106.4,76,,268.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.8,72,,134.784,Percent of Total Billed Charges,72% of Total Billed Charges,105,75,,140.4,Percent of Total Billed charges,75% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.8,72,,134.784,Percent of Total Billed Charges,72% of Total Billed Charges,84,60,,112.32,Percent of Total Billed Charges,60% of Total Billed Charges,126,90,,392.4,Percent of Total Billed Charges,90% of Total Billed Charges,63,45,,151.56,Percent of Total Billed Charges,45% of Total Billed Charges,126,90,,318.24,Percent of Total Billed Charges,90% of Total billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91,65,,302.64,Percent of total Billed Charges,65% of Total Billed Charges,61.74,44.1,,148.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,133,95,,335.92,Percent of Total Billed Charges,95% of Total Billed Charges,140,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.2,88,,298.496,Percent of Total Billed Charges,88% of Total Billed Charges,126,90,,318.24,Percent of Total Billed charges,90% of Total Billed Charges,61.74,140,
RPR  REFL FTA QUEST,3090000034,CDM,309,RC,,,Outpatient,,,163.17,106.06,,163.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,124.01,76,,250.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,117.48,72,,134.784,Percent of Total Billed Charges,72% of Total Billed Charges,122.38,75,,140.4,Percent of Total Billed charges,75% of Total Billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.48,72,,134.784,Percent of Total Billed Charges,72% of Total Billed Charges,97.9,60,,112.32,Percent of Total Billed Charges,60% of Total Billed Charges,146.85,90,,192.104,Percent of Total Billed Charges,90% of Total Billed Charges,73.43,45,,152.64,Percent of Total Billed Charges,45% of Total Billed Charges,146.85,90,,296.64,Percent of Total Billed Charges,90% of Total billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.06,65,,505.08,Percent of total Billed Charges,65% of Total Billed Charges,71.96,44.1,,149.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,155.01,95,,313.12,Percent of Total Billed Charges,95% of Total Billed Charges,163.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.59,88,,339.96,Percent of Total Billed Charges,88% of Total Billed Charges,146.85,90,,296.64,Percent of Total Billed charges,90% of Total Billed Charges,71.96,163.17,
NEISSERIA GONORRHOEAE ANTIBODY,3090000035,CDM,309,RC,,,Outpatient,,,145.50,94.58,,145.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.58,76,,300.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,104.76,72,,173.952,Percent of Total Billed Charges,72% of Total Billed Charges,109.13,75,,181.2,Percent of Total Billed charges,75% of Total Billed Charges,145.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.76,72,,173.952,Percent of Total Billed Charges,72% of Total Billed Charges,87.3,60,,144.96,Percent of Total Billed Charges,60% of Total Billed Charges,130.95,90,,199.44,Percent of Total Billed Charges,90% of Total Billed Charges,65.48,45,,173.848,Percent of Total Billed Charges,45% of Total Billed Charges,130.95,90,,356.4,Percent of Total Billed Charges,90% of Total billed Charges,145.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.58,65,,294.68,Percent of total Billed Charges,65% of Total Billed Charges,64.17,44.1,,170.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,138.23,95,,376.2,Percent of Total Billed Charges,95% of Total Billed Charges,145.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.04,88,,339.96,Percent of Total Billed Charges,88% of Total Billed Charges,130.95,90,,356.4,Percent of Total Billed charges,90% of Total Billed Charges,64.17,145.5,
CMV IGG CSF,3090000036,CDM,309,RC,,,Outpatient,,,216.99,141.04,,216.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,164.91,76,,280.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,156.23,72,,173.952,Percent of Total Billed Charges,72% of Total Billed Charges,162.74,75,,181.2,Percent of Total Billed charges,75% of Total Billed Charges,216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.23,72,,173.952,Percent of Total Billed Charges,72% of Total Billed Charges,130.19,60,,144.96,Percent of Total Billed Charges,60% of Total Billed Charges,195.29,90,,260.64,Percent of Total Billed Charges,90% of Total Billed Charges,97.65,45,,173.848,Percent of Total Billed Charges,45% of Total Billed Charges,195.29,90,,332.64,Percent of Total Billed Charges,90% of Total billed Charges,216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.04,65,,473.72,Percent of total Billed Charges,65% of Total Billed Charges,95.69,44.1,,170.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,206.14,95,,351.12,Percent of Total Billed Charges,95% of Total Billed Charges,216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.95,88,,319,Percent of Total Billed Charges,88% of Total Billed Charges,195.29,90,,332.64,Percent of Total Billed charges,90% of Total Billed Charges,95.69,216.99,
CMV IGM CSF,3090000037,CDM,309,RC,,,Outpatient,,,162.00,105.30,,162,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,123.12,76,,255.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,116.64,72,,143.424,Percent of Total Billed Charges,72% of Total Billed Charges,121.5,75,,149.4,Percent of Total Billed charges,75% of Total Billed Charges,162,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.64,72,,143.424,Percent of Total Billed Charges,72% of Total Billed Charges,97.2,60,,119.52,Percent of Total Billed Charges,60% of Total Billed Charges,145.8,90,,203.76,Percent of Total Billed Charges,90% of Total Billed Charges,72.9,45,,163.128,Percent of Total Billed Charges,45% of Total Billed Charges,145.8,90,,303.12,Percent of Total Billed Charges,90% of Total billed Charges,162,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.3,65,,495.904,Percent of total Billed Charges,65% of Total Billed Charges,71.44,44.1,,159.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,153.9,95,,319.96,Percent of Total Billed Charges,95% of Total Billed Charges,162,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.56,88,,401.28,Percent of Total Billed Charges,88% of Total Billed Charges,145.8,90,,303.12,Percent of Total Billed charges,90% of Total Billed Charges,71.44,162,
MUMPS VIRUS AB IGM,3090000038,CDM,309,RC,,,Outpatient,,,154.00,100.10,,154,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,117.04,76,,257.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,110.88,72,,143.424,Percent of Total Billed Charges,72% of Total Billed Charges,115.5,75,,149.4,Percent of Total Billed charges,75% of Total Billed Charges,154,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.88,72,,143.424,Percent of Total Billed Charges,72% of Total Billed Charges,92.4,60,,119.52,Percent of Total Billed Charges,60% of Total Billed Charges,138.6,90,,228.96,Percent of Total Billed Charges,90% of Total Billed Charges,69.3,45,,205.2,Percent of Total Billed Charges,45% of Total Billed Charges,138.6,90,,305.28,Percent of Total Billed Charges,90% of Total billed Charges,154,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.1,65,,471.12,Percent of total Billed Charges,65% of Total Billed Charges,67.91,44.1,,201.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,146.3,95,,322.24,Percent of Total Billed Charges,95% of Total Billed Charges,154,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.52,88,,383.68,Percent of Total Billed Charges,88% of Total Billed Charges,138.6,90,,305.28,Percent of Total Billed charges,90% of Total Billed Charges,67.91,154,
PARAINFLUENZA,3090000039,CDM,309,RC,,,Outpatient,,,193.00,125.45,,193,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,146.68,76,,293.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,138.96,72,,83.824,Percent of Total Billed Charges,72% of Total Billed Charges,144.75,75,,87.32,Percent of Total Billed charges,75% of Total Billed Charges,193,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.96,72,,83.824,Percent of Total Billed Charges,72% of Total Billed Charges,115.8,60,,69.856,Percent of Total Billed Charges,60% of Total Billed Charges,173.7,90,,200.88,Percent of Total Billed Charges,90% of Total Billed Charges,86.85,45,,196.2,Percent of Total Billed Charges,45% of Total Billed Charges,173.7,90,,347.688,Percent of Total Billed Charges,90% of Total billed Charges,193,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.45,65,,214.76,Percent of total Billed Charges,65% of Total Billed Charges,85.11,44.1,,192.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,183.35,95,,367.008,Percent of Total Billed Charges,95% of Total Billed Charges,193,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.84,88,,187.832,Percent of Total Billed Charges,88% of Total Billed Charges,173.7,90,,347.688,Percent of Total Billed charges,90% of Total Billed Charges,85.11,193,
ANTIBODY SCREENING,3090000040,CDM,309,RC,,,Outpatient,,,125.00,81.25,,125,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95,76,,293.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90,72,,83.824,Percent of Total Billed Charges,72% of Total Billed Charges,93.75,75,,87.32,Percent of Total Billed charges,75% of Total Billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,72,,83.824,Percent of Total Billed Charges,72% of Total Billed Charges,75,60,,69.856,Percent of Total Billed Charges,60% of Total Billed Charges,112.5,90,,1494.216,Percent of Total Billed Charges,90% of Total Billed Charges,56.25,45,,96.048,Percent of Total Billed Charges,45% of Total Billed Charges,112.5,90,,347.688,Percent of Total Billed Charges,90% of Total billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.25,65,,360.88,Percent of total Billed Charges,65% of Total Billed Charges,55.13,44.1,,94.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,118.75,95,,367.008,Percent of Total Billed Charges,95% of Total Billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110,88,,195.008,Percent of Total Billed Charges,88% of Total Billed Charges,112.5,90,,347.688,Percent of Total Billed charges,90% of Total Billed Charges,55.13,125,
ANTIBODY ID,3090000041,CDM,309,RC,,,Outpatient,,,435.00,282.75,,435,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,330.6,76,,275.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,313.2,72,,87.552,Percent of Total Billed Charges,72% of Total Billed Charges,326.25,75,,91.2,Percent of Total Billed charges,75% of Total Billed Charges,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.2,72,,87.552,Percent of Total Billed Charges,72% of Total Billed Charges,261,60,,72.96,Percent of Total Billed Charges,60% of Total Billed Charges,391.5,90,,1494.216,Percent of Total Billed Charges,90% of Total Billed Charges,195.75,45,,99.72,Percent of Total Billed Charges,45% of Total Billed Charges,391.5,90,,326.256,Percent of Total Billed Charges,90% of Total billed Charges,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.75,65,,427.96,Percent of total Billed Charges,65% of Total Billed Charges,191.84,44.1,,97.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,413.25,95,,344.376,Percent of Total Billed Charges,95% of Total Billed Charges,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.8,88,,254.848,Percent of Total Billed Charges,88% of Total Billed Charges,391.5,90,,326.256,Percent of Total Billed charges,90% of Total Billed Charges,191.84,435,
COOMBS DIRECT,3090000042,CDM,309,RC,,,Outpatient,,,54.00,35.10,,54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.04,76,,346.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.88,72,,87.552,Percent of Total Billed Charges,72% of Total Billed Charges,40.5,75,,91.2,Percent of Total Billed charges,75% of Total Billed Charges,54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.88,72,,87.552,Percent of Total Billed Charges,72% of Total Billed Charges,32.4,60,,72.96,Percent of Total Billed Charges,60% of Total Billed Charges,48.6,90,,818.424,Percent of Total Billed Charges,90% of Total Billed Charges,24.3,45,,130.32,Percent of Total Billed Charges,45% of Total Billed Charges,48.6,90,,410.4,Percent of Total Billed Charges,90% of Total billed Charges,54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.1,65,,4212.52,Percent of total Billed Charges,65% of Total Billed Charges,23.81,44.1,,127.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,51.3,95,,433.2,Percent of Total Billed Charges,95% of Total Billed Charges,54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.52,88,,199.232,Percent of Total Billed Charges,88% of Total Billed Charges,48.6,90,,410.4,Percent of Total Billed charges,90% of Total Billed Charges,23.81,54,
COOMBS INDIRECT,3090000043,CDM,309,RC,,,Outpatient,,,66.15,43.00,,66.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,50.27,76,,331.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47.63,72,,145.152,Percent of Total Billed Charges,72% of Total Billed Charges,49.61,75,,151.2,Percent of Total Billed charges,75% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.63,72,,145.152,Percent of Total Billed Charges,72% of Total Billed Charges,39.69,60,,120.96,Percent of Total Billed Charges,60% of Total Billed Charges,59.54,90,,818.424,Percent of Total Billed Charges,90% of Total Billed Charges,29.77,45,,101.88,Percent of Total Billed Charges,45% of Total Billed Charges,59.54,90,,392.4,Percent of Total Billed Charges,90% of Total billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,65,,4433.904,Percent of total Billed Charges,65% of Total Billed Charges,29.17,44.1,,99.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.84,95,,414.2,Percent of Total Billed Charges,95% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.21,88,,223.872,Percent of Total Billed Charges,88% of Total Billed Charges,59.54,90,,392.4,Percent of Total Billed charges,90% of Total Billed Charges,29.17,66.15,
BLOOD TYPING ABO,3090000044,CDM,309,RC,,,Outpatient,,,151.00,98.15,,151,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114.76,76,,162.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.72,72,,145.152,Percent of Total Billed Charges,72% of Total Billed Charges,113.25,75,,151.2,Percent of Total Billed charges,75% of Total Billed Charges,151,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.72,72,,145.152,Percent of Total Billed Charges,72% of Total Billed Charges,90.6,60,,120.96,Percent of Total Billed Charges,60% of Total Billed Charges,135.9,90,,67.68,Percent of Total Billed Charges,90% of Total Billed Charges,67.95,45,,114.48,Percent of Total Billed Charges,45% of Total Billed Charges,135.9,90,,192.104,Percent of Total Billed Charges,90% of Total billed Charges,151,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.15,65,,4212.52,Percent of total Billed Charges,65% of Total Billed Charges,66.59,44.1,,112.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,143.45,95,,202.776,Percent of Total Billed Charges,95% of Total Billed Charges,151,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.88,88,,196.416,Percent of Total Billed Charges,88% of Total Billed Charges,135.9,90,,192.104,Percent of Total Billed charges,90% of Total Billed Charges,66.59,151,
RH(D),3090000045,CDM,309,RC,,,Outpatient,,,46.31,30.10,,46.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.2,76,,168.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.34,72,,174.528,Percent of Total Billed Charges,72% of Total Billed Charges,34.73,75,,181.8,Percent of Total Billed charges,75% of Total Billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.34,72,,174.528,Percent of Total Billed Charges,72% of Total Billed Charges,27.79,60,,145.44,Percent of Total Billed Charges,60% of Total Billed Charges,41.68,90,,400.864,Percent of Total Billed Charges,90% of Total Billed Charges,20.84,45,,100.44,Percent of Total Billed Charges,45% of Total Billed Charges,41.68,90,,199.44,Percent of Total Billed Charges,90% of Total billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.1,65,,4212.52,Percent of total Billed Charges,65% of Total Billed Charges,20.42,44.1,,98.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,43.99,95,,210.52,Percent of Total Billed Charges,95% of Total Billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.75,88,,1461.008,Percent of Total Billed Charges,88% of Total Billed Charges,41.68,90,,199.44,Percent of Total Billed charges,90% of Total Billed Charges,20.42,46.31,
COMPATIBILITY,3090000046,CDM,309,RC,,,Outpatient,,,194.00,126.10,,194,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,147.44,76,,220.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,139.68,72,,174.528,Percent of Total Billed Charges,72% of Total Billed Charges,145.5,75,,181.8,Percent of Total Billed charges,75% of Total Billed Charges,194,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.68,72,,174.528,Percent of Total Billed Charges,72% of Total Billed Charges,116.4,60,,145.44,Percent of Total Billed Charges,60% of Total Billed Charges,174.6,90,,236.16,Percent of Total Billed Charges,90% of Total Billed Charges,87.3,45,,747.112,Percent of Total Billed Charges,45% of Total Billed Charges,174.6,90,,260.64,Percent of Total Billed Charges,90% of Total billed Charges,194,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.1,65,,890.24,Percent of total Billed Charges,65% of Total Billed Charges,85.55,44.1,,732.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,184.3,95,,275.12,Percent of Total Billed Charges,95% of Total Billed Charges,194,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.72,88,,1461.008,Percent of Total Billed Charges,88% of Total Billed Charges,174.6,90,,260.64,Percent of Total Billed charges,90% of Total Billed Charges,85.55,194,
COLD AGGLUTININS,3090000047,CDM,309,RC,,,Outpatient,,,89.30,58.05,,89.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.87,76,,172.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.3,72,,228.096,Percent of Total Billed Charges,72% of Total Billed Charges,66.98,75,,237.6,Percent of Total Billed charges,75% of Total Billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.3,72,,228.096,Percent of Total Billed Charges,72% of Total Billed Charges,53.58,60,,190.08,Percent of Total Billed Charges,60% of Total Billed Charges,80.37,90,,152.64,Percent of Total Billed Charges,90% of Total Billed Charges,40.19,45,,747.112,Percent of Total Billed Charges,45% of Total Billed Charges,80.37,90,,203.76,Percent of Total Billed Charges,90% of Total billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.05,65,,393.856,Percent of total Billed Charges,65% of Total Billed Charges,39.38,44.1,,732.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,84.84,95,,215.08,Percent of Total Billed Charges,95% of Total Billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.58,88,,800.24,Percent of Total Billed Charges,88% of Total Billed Charges,80.37,90,,203.76,Percent of Total Billed charges,90% of Total Billed Charges,39.38,89.3,
SPLITTING BLOOD UNIT,3090000048,CDM,309,RC,,,Outpatient,,,89.30,58.05,,89.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.87,76,,193.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.3,72,,228.096,Percent of Total Billed Charges,72% of Total Billed Charges,66.98,75,,237.6,Percent of Total Billed charges,75% of Total Billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.3,72,,228.096,Percent of Total Billed Charges,72% of Total Billed Charges,53.58,60,,190.08,Percent of Total Billed Charges,60% of Total Billed Charges,80.37,90,,241.92,Percent of Total Billed Charges,90% of Total Billed Charges,40.19,45,,409.216,Percent of Total Billed Charges,45% of Total Billed Charges,80.37,90,,228.96,Percent of Total Billed Charges,90% of Total billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.05,65,,940.68,Percent of total Billed Charges,65% of Total Billed Charges,39.38,44.1,,401.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,84.84,95,,241.68,Percent of Total Billed Charges,95% of Total Billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.58,88,,800.24,Percent of Total Billed Charges,88% of Total Billed Charges,80.37,90,,228.96,Percent of Total Billed charges,90% of Total Billed Charges,39.38,89.3,
BLOOD CULTURE QUEST,3090000049,CDM,309,RC,,,Outpatient,,,245.77,159.75,,245.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,186.79,76,,169.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,176.95,72,,188.352,Percent of Total Billed Charges,72% of Total Billed Charges,184.33,75,,196.2,Percent of Total Billed charges,75% of Total Billed Charges,245.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.95,72,,188.352,Percent of Total Billed Charges,72% of Total Billed Charges,147.46,60,,156.96,Percent of Total Billed Charges,60% of Total Billed Charges,221.19,90,,308.16,Percent of Total Billed Charges,90% of Total Billed Charges,110.6,45,,409.216,Percent of Total Billed Charges,45% of Total Billed Charges,221.19,90,,200.88,Percent of Total Billed Charges,90% of Total billed Charges,245.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.75,65,,1466.4,Percent of total Billed Charges,65% of Total Billed Charges,108.38,44.1,,401.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,233.48,95,,212.04,Percent of Total Billed Charges,95% of Total Billed Charges,245.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.28,88,,66.176,Percent of Total Billed Charges,88% of Total Billed Charges,221.19,90,,200.88,Percent of Total Billed charges,90% of Total Billed Charges,108.38,245.77,
ANTHRACIS SCREEN,3090000050,CDM,309,RC,,,Outpatient,,,294.37,191.34,,294.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,223.72,76,,1261.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,211.95,72,,188.352,Percent of Total Billed Charges,72% of Total Billed Charges,220.78,75,,196.2,Percent of Total Billed charges,75% of Total Billed Charges,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.95,72,,188.352,Percent of Total Billed Charges,72% of Total Billed Charges,176.62,60,,156.96,Percent of Total Billed Charges,60% of Total Billed Charges,264.93,90,,305.28,Percent of Total Billed Charges,90% of Total Billed Charges,132.47,45,,33.84,Percent of Total Billed Charges,45% of Total Billed Charges,264.93,90,,1494.216,Percent of Total Billed Charges,90% of Total billed Charges,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.34,65,,1140.16,Percent of total Billed Charges,65% of Total Billed Charges,129.82,44.1,,33.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,279.65,95,,1577.232,Percent of Total Billed Charges,95% of Total Billed Charges,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.05,88,,391.96,Percent of Total Billed Charges,88% of Total Billed Charges,264.93,90,,1494.216,Percent of Total Billed charges,90% of Total Billed Charges,129.82,294.37,
CRYAGERA,3090000051,CDM,309,RC,,,Outpatient,,,195.00,126.75,,195,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,148.2,76,,1261.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,140.4,72,,141.12,Percent of Total Billed Charges,72% of Total Billed Charges,146.25,75,,147,Percent of Total Billed charges,75% of Total Billed Charges,195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.4,72,,141.12,Percent of Total Billed Charges,72% of Total Billed Charges,117,60,,117.6,Percent of Total Billed Charges,60% of Total Billed Charges,175.5,90,,571.68,Percent of Total Billed Charges,90% of Total Billed Charges,87.75,45,,200.432,Percent of Total Billed Charges,45% of Total Billed Charges,175.5,90,,1494.216,Percent of Total Billed Charges,90% of Total billed Charges,195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.75,65,,3380,Percent of total Billed Charges,65% of Total Billed Charges,86,44.1,,196.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,185.25,95,,1577.232,Percent of Total Billed Charges,95% of Total Billed Charges,195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.6,88,,230.912,Percent of Total Billed Charges,88% of Total Billed Charges,175.5,90,,1494.216,Percent of Total Billed charges,90% of Total Billed Charges,86,195,
CHLAMYDIA PNEUMONIE,3090000052,CDM,309,RC,,,Outpatient,,,222.00,144.30,,222,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,168.72,76,,691.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,159.84,72,,141.12,Percent of Total Billed Charges,72% of Total Billed Charges,166.5,75,,147,Percent of Total Billed charges,75% of Total Billed Charges,222,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.84,72,,141.12,Percent of Total Billed Charges,72% of Total Billed Charges,133.2,60,,117.6,Percent of Total Billed Charges,60% of Total Billed Charges,199.8,90,,340.56,Percent of Total Billed Charges,90% of Total Billed Charges,99.9,45,,118.08,Percent of Total Billed Charges,45% of Total Billed Charges,199.8,90,,818.424,Percent of Total Billed Charges,90% of Total billed Charges,222,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.3,65,,1297.92,Percent of total Billed Charges,65% of Total Billed Charges,97.9,44.1,,115.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,210.9,95,,863.896,Percent of Total Billed Charges,95% of Total Billed Charges,222,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.36,88,,149.248,Percent of Total Billed Charges,88% of Total Billed Charges,199.8,90,,818.424,Percent of Total Billed charges,90% of Total Billed Charges,97.9,222,
HHV 6 DNA QLPCR,3090000053,CDM,309,RC,,,Outpatient,,,709.00,460.85,,709,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,538.84,76,,691.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,510.48,72,,197.568,Percent of Total Billed Charges,72% of Total Billed Charges,531.75,75,,205.8,Percent of Total Billed charges,75% of Total Billed Charges,709,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,510.48,72,,197.568,Percent of Total Billed Charges,72% of Total Billed Charges,425.4,60,,164.64,Percent of Total Billed Charges,60% of Total Billed Charges,638.1,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,319.05,45,,76.32,Percent of Total Billed Charges,45% of Total Billed Charges,638.1,90,,818.424,Percent of Total Billed Charges,90% of Total billed Charges,709,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,709,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,709,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,460.85,65,,393.288,Percent of total Billed Charges,65% of Total Billed Charges,312.67,44.1,,74.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,673.55,95,,863.896,Percent of Total Billed Charges,95% of Total Billed Charges,709,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,623.92,88,,236.544,Percent of Total Billed Charges,88% of Total Billed Charges,638.1,90,,818.424,Percent of Total Billed charges,90% of Total Billed Charges,312.67,709,
MYCOPLASMA AMPLIFICATION,3090000054,CDM,309,RC,,,Outpatient,,,117.00,76.05,,117,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,88.92,76,,57.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.24,72,,197.568,Percent of Total Billed Charges,72% of Total Billed Charges,87.75,75,,205.8,Percent of Total Billed charges,75% of Total Billed Charges,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.24,72,,197.568,Percent of Total Billed Charges,72% of Total Billed Charges,70.2,60,,164.64,Percent of Total Billed Charges,60% of Total Billed Charges,105.3,90,,474.48,Percent of Total Billed Charges,90% of Total Billed Charges,52.65,45,,120.96,Percent of Total Billed Charges,45% of Total Billed Charges,105.3,90,,67.68,Percent of Total Billed Charges,90% of Total billed Charges,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.05,65,,1267.76,Percent of total Billed Charges,65% of Total Billed Charges,51.6,44.1,,118.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,111.15,95,,71.44,Percent of Total Billed Charges,95% of Total Billed Charges,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.96,88,,301.312,Percent of Total Billed Charges,88% of Total Billed Charges,105.3,90,,67.68,Percent of Total Billed charges,90% of Total Billed Charges,51.6,117,
ORARISK HPV,3090000055,CDM,309,RC,,,Outpatient,,,117.00,76.05,,117,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,88.92,76,,338.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.24,72,,148.608,Percent of Total Billed Charges,72% of Total Billed Charges,87.75,75,,154.8,Percent of Total Billed charges,75% of Total Billed Charges,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.24,72,,148.608,Percent of Total Billed Charges,72% of Total Billed Charges,70.2,60,,123.84,Percent of Total Billed Charges,60% of Total Billed Charges,105.3,90,,758.88,Percent of Total Billed Charges,90% of Total Billed Charges,52.65,45,,154.08,Percent of Total Billed Charges,45% of Total Billed Charges,105.3,90,,400.864,Percent of Total Billed Charges,90% of Total billed Charges,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.05,65,,1267.76,Percent of total Billed Charges,65% of Total Billed Charges,51.6,44.1,,151,Percent of Total Billed Charges,44.1% of Total Billed Charges,111.15,95,,423.136,Percent of Total Billed Charges,95% of Total Billed Charges,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.96,88,,298.496,Percent of Total Billed Charges,88% of Total Billed Charges,105.3,90,,400.864,Percent of Total Billed charges,90% of Total Billed Charges,51.6,117,
HPV MRNA E6/E7 RECTAL,3090000056,CDM,309,RC,,,Outpatient,,,117.00,76.05,,117,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,88.92,76,,199.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.24,72,,148.608,Percent of Total Billed Charges,72% of Total Billed Charges,87.75,75,,154.8,Percent of Total Billed charges,75% of Total Billed Charges,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.24,72,,148.608,Percent of Total Billed Charges,72% of Total Billed Charges,70.2,60,,123.84,Percent of Total Billed Charges,60% of Total Billed Charges,105.3,90,,552.24,Percent of Total Billed Charges,90% of Total Billed Charges,52.65,45,,152.64,Percent of Total Billed Charges,45% of Total Billed Charges,105.3,90,,236.16,Percent of Total Billed Charges,90% of Total billed Charges,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.05,65,,164.84,Percent of total Billed Charges,65% of Total Billed Charges,51.6,44.1,,149.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,111.15,95,,249.28,Percent of Total Billed Charges,95% of Total Billed Charges,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.96,88,,558.976,Percent of Total Billed Charges,88% of Total Billed Charges,105.3,90,,236.16,Percent of Total Billed charges,90% of Total Billed Charges,51.6,117,
RESPIRATORY VIRUS,3090000057,CDM,309,RC,,,Outpatient,,,1389.00,902.85,,1389,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1055.64,76,,128.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1000.08,72,,187.776,Percent of Total Billed Charges,72% of Total Billed Charges,1041.75,75,,195.6,Percent of Total Billed charges,75% of Total Billed Charges,1389,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1000.08,72,,187.776,Percent of Total Billed Charges,72% of Total Billed Charges,833.4,60,,156.48,Percent of Total Billed Charges,60% of Total Billed Charges,1250.1,90,,552.24,Percent of Total Billed Charges,90% of Total Billed Charges,625.05,45,,285.84,Percent of Total Billed Charges,45% of Total Billed Charges,1250.1,90,,152.64,Percent of Total Billed Charges,90% of Total billed Charges,1389,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1389,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1389,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,902.85,65,,173.032,Percent of total Billed Charges,65% of Total Billed Charges,612.55,44.1,,280.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,1319.55,95,,161.12,Percent of Total Billed Charges,95% of Total Billed Charges,1389,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1222.32,88,,332.992,Percent of Total Billed Charges,88% of Total Billed Charges,1250.1,90,,152.64,Percent of Total Billed charges,90% of Total Billed Charges,612.55,1389,
CORONA VIRUS,3090000058,CDM,309,RC,,,Outpatient,,,1389.00,902.85,,1389,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1055.64,76,,204.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1000.08,72,,196.224,Percent of Total Billed Charges,72% of Total Billed Charges,1041.75,75,,204.4,Percent of Total Billed charges,75% of Total Billed Charges,1389,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1000.08,72,,196.224,Percent of Total Billed Charges,72% of Total Billed Charges,833.4,60,,163.52,Percent of Total Billed Charges,60% of Total Billed Charges,1250.1,90,,794.16,Percent of Total Billed Charges,90% of Total Billed Charges,625.05,45,,170.28,Percent of Total Billed Charges,45% of Total Billed Charges,1250.1,90,,241.92,Percent of Total Billed Charges,90% of Total billed Charges,1389,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1389,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1389,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,902.85,65,,253.24,Percent of total Billed Charges,65% of Total Billed Charges,612.55,44.1,,166.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,1319.55,95,,255.36,Percent of Total Billed Charges,95% of Total Billed Charges,1389,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1222.32,88,,246.4,Percent of Total Billed Charges,88% of Total Billed Charges,1250.1,90,,241.92,Percent of Total Billed charges,90% of Total Billed Charges,612.55,1389,
"MUMPS VIRUS RNA, PCR",3090000059,CDM,309,RC,,,Outpatient,,,129.00,83.85,,129,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.04,76,,260.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,92.88,72,,157.824,Percent of Total Billed Charges,72% of Total Billed Charges,96.75,75,,164.4,Percent of Total Billed charges,75% of Total Billed Charges,129,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.88,72,,157.824,Percent of Total Billed Charges,72% of Total Billed Charges,77.4,60,,131.52,Percent of Total Billed Charges,60% of Total Billed Charges,116.1,90,,419.04,Percent of Total Billed Charges,90% of Total Billed Charges,58.05,45,,126,Percent of Total Billed Charges,45% of Total Billed Charges,116.1,90,,308.16,Percent of Total Billed Charges,90% of Total billed Charges,129,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.85,65,,315.32,Percent of total Billed Charges,65% of Total Billed Charges,56.89,44.1,,123.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,122.55,95,,325.28,Percent of Total Billed Charges,95% of Total Billed Charges,129,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.52,88,,463.936,Percent of Total Billed Charges,88% of Total Billed Charges,116.1,90,,308.16,Percent of Total Billed charges,90% of Total Billed Charges,56.89,129,
JCV ULTRA CSF,3090000060,CDM,309,RC,,,Outpatient,,,542.80,352.82,,542.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,412.53,76,,257.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,390.82,72,,163.008,Percent of Total Billed Charges,72% of Total Billed Charges,407.1,75,,169.8,Percent of Total Billed charges,75% of Total Billed Charges,542.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.82,72,,163.008,Percent of Total Billed Charges,72% of Total Billed Charges,325.68,60,,135.84,Percent of Total Billed Charges,60% of Total Billed Charges,488.52,90,,699.336,Percent of Total Billed Charges,90% of Total Billed Charges,244.26,45,,237.24,Percent of Total Billed Charges,45% of Total Billed Charges,488.52,90,,305.28,Percent of Total Billed Charges,90% of Total billed Charges,542.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,542.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,542.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.82,65,,335.92,Percent of total Billed Charges,65% of Total Billed Charges,239.37,44.1,,232.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,515.66,95,,322.24,Percent of Total Billed Charges,95% of Total Billed Charges,542.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,477.66,88,,742.016,Percent of Total Billed Charges,88% of Total Billed Charges,488.52,90,,305.28,Percent of Total Billed charges,90% of Total Billed Charges,239.37,542.8,
VZV DNA QN PCR,3090000061,CDM,309,RC,,,Outpatient,,,542.80,352.82,,542.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,412.53,76,,482.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,390.82,72,,163.008,Percent of Total Billed Charges,72% of Total Billed Charges,407.1,75,,169.8,Percent of Total Billed charges,75% of Total Billed Charges,542.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.82,72,,163.008,Percent of Total Billed Charges,72% of Total Billed Charges,325.68,60,,135.84,Percent of Total Billed Charges,60% of Total Billed Charges,488.52,90,,408.016,Percent of Total Billed Charges,90% of Total Billed Charges,244.26,45,,379.44,Percent of Total Billed Charges,45% of Total Billed Charges,488.52,90,,571.68,Percent of Total Billed Charges,90% of Total billed Charges,542.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,542.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,542.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.82,65,,173.712,Percent of total Billed Charges,65% of Total Billed Charges,239.37,44.1,,371.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,515.66,95,,603.44,Percent of Total Billed Charges,95% of Total Billed Charges,542.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,477.66,88,,539.968,Percent of Total Billed Charges,88% of Total Billed Charges,488.52,90,,571.68,Percent of Total Billed charges,90% of Total Billed Charges,239.37,542.8,
AFFIRM VAGINITIS PANEL,3090000062,CDM,309,RC,,,Outpatient,,,321.00,208.65,,321,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,243.96,76,,287.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,231.12,72,,786.608,Percent of Total Billed Charges,72% of Total Billed Charges,240.75,75,,819.384,Percent of Total Billed charges,75% of Total Billed Charges,321,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.12,72,,786.608,Percent of Total Billed Charges,72% of Total Billed Charges,192.6,60,,655.504,Percent of Total Billed Charges,60% of Total Billed Charges,288.9,90,,655.92,Percent of Total Billed Charges,90% of Total Billed Charges,144.45,45,,276.12,Percent of Total Billed Charges,45% of Total Billed Charges,288.9,90,,340.56,Percent of Total Billed Charges,90% of Total billed Charges,321,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,321,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,321,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.65,65,,100.36,Percent of total Billed Charges,65% of Total Billed Charges,141.56,44.1,,270.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,304.95,95,,359.48,Percent of Total Billed Charges,95% of Total Billed Charges,321,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.48,88,,539.968,Percent of Total Billed Charges,88% of Total Billed Charges,288.9,90,,340.56,Percent of Total Billed charges,90% of Total Billed Charges,141.56,321,
FLUID COUNT,3090000063,CDM,309,RC,,,Outpatient,,,70.00,45.50,,70,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.2,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.4,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,52.5,75,,114.44,Percent of Total Billed charges,75% of Total Billed Charges,70,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.4,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,42,60,,91.552,Percent of Total Billed Charges,60% of Total Billed Charges,63,90,,686.632,Percent of Total Billed Charges,90% of Total Billed Charges,31.5,45,,276.12,Percent of Total Billed Charges,45% of Total Billed Charges,63,90,,252,Percent of Total Billed Charges,90% of Total billed Charges,70,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.5,65,,122.72,Percent of total Billed Charges,65% of Total Billed Charges,30.87,44.1,,270.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,66.5,95,,266,Percent of Total Billed Charges,95% of Total Billed Charges,70,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.6,88,,776.512,Percent of Total Billed Charges,88% of Total Billed Charges,63,90,,252,Percent of Total Billed charges,90% of Total Billed Charges,30.87,70,
FLUID COUNT DIFF,3090000064,CDM,309,RC,,,Outpatient,,,70.00,45.50,,70,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.2,76,,400.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.4,72,,355.968,Percent of Total Billed Charges,72% of Total Billed Charges,52.5,75,,370.8,Percent of Total Billed charges,75% of Total Billed Charges,70,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.4,72,,355.968,Percent of Total Billed Charges,72% of Total Billed Charges,42,60,,296.64,Percent of Total Billed Charges,60% of Total Billed Charges,63,90,,652.32,Percent of Total Billed Charges,90% of Total Billed Charges,31.5,45,,397.08,Percent of Total Billed Charges,45% of Total Billed Charges,63,90,,474.48,Percent of Total Billed Charges,90% of Total billed Charges,70,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.5,65,,168.48,Percent of total Billed Charges,65% of Total Billed Charges,30.87,44.1,,389.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,66.5,95,,500.84,Percent of Total Billed Charges,95% of Total Billed Charges,70,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.6,88,,409.728,Percent of Total Billed Charges,88% of Total Billed Charges,63,90,,474.48,Percent of Total Billed charges,90% of Total Billed Charges,30.87,70,
SEMEN CT(POST VAS),3090000065,CDM,309,RC,,,Outpatient,,,84.00,54.60,,84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,63.84,76,,640.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,60.48,72,,122.08,Percent of Total Billed Charges,72% of Total Billed Charges,63,75,,127.168,Percent of Total Billed charges,75% of Total Billed Charges,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.48,72,,122.08,Percent of Total Billed Charges,72% of Total Billed Charges,50.4,60,,101.736,Percent of Total Billed Charges,60% of Total Billed Charges,75.6,90,,297.36,Percent of Total Billed Charges,90% of Total Billed Charges,37.8,45,,209.52,Percent of Total Billed Charges,45% of Total Billed Charges,75.6,90,,758.88,Percent of Total Billed Charges,90% of Total billed Charges,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.6,65,,277.48,Percent of total Billed Charges,65% of Total Billed Charges,37.04,44.1,,205.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,79.8,95,,801.04,Percent of Total Billed Charges,95% of Total Billed Charges,84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.92,88,,683.792,Percent of Total Billed Charges,88% of Total Billed Charges,75.6,90,,758.88,Percent of Total Billed charges,90% of Total Billed Charges,37.04,84,
JCV AB INHIBITION,3090000067,CDM,309,RC,,,Outpatient,,,45.00,29.25,,45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.2,76,,466.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.4,72,,2040.192,Percent of Total Billed Charges,72% of Total Billed Charges,33.75,75,,2125.2,Percent of Total Billed charges,75% of Total Billed Charges,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.4,72,,2040.192,Percent of Total Billed Charges,72% of Total Billed Charges,27,60,,1700.16,Percent of Total Billed Charges,60% of Total Billed Charges,40.5,90,,592.56,Percent of Total Billed Charges,90% of Total Billed Charges,20.25,45,,204.008,Percent of Total Billed Charges,45% of Total Billed Charges,40.5,90,,552.24,Percent of Total Billed Charges,90% of Total billed Charges,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.25,65,,320.32,Percent of total Billed Charges,65% of Total Billed Charges,19.85,44.1,,199.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.75,95,,582.92,Percent of Total Billed Charges,95% of Total Billed Charges,45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.6,88,,641.344,Percent of Total Billed Charges,88% of Total Billed Charges,40.5,90,,552.24,Percent of Total Billed charges,90% of Total Billed Charges,19.85,45,
BLOOD,3090000068,CDM,309,RC,,,Outpatient,,,286.67,186.34,,286.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,217.87,76,,670.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,206.4,72,,116.4,Percent of Total Billed Charges,72% of Total Billed Charges,215,75,,121.248,Percent of Total Billed charges,75% of Total Billed Charges,286.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.4,72,,116.4,Percent of Total Billed Charges,72% of Total Billed Charges,172,60,,97,Percent of Total Billed Charges,60% of Total Billed Charges,258,90,,5832.72,Percent of Total Billed Charges,90% of Total Billed Charges,129,45,,327.96,Percent of Total Billed Charges,45% of Total Billed Charges,258,90,,794.16,Percent of Total Billed Charges,90% of Total billed Charges,286.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.34,65,,141.032,Percent of total Billed Charges,65% of Total Billed Charges,126.42,44.1,,321.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,272.34,95,,838.28,Percent of Total Billed Charges,95% of Total Billed Charges,286.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.27,88,,671.376,Percent of Total Billed Charges,88% of Total Billed Charges,258,90,,794.16,Percent of Total Billed charges,90% of Total Billed Charges,126.42,286.67,
DEXAMETHASONE,3090000069,CDM,309,RC,,,Outpatient,,,250.00,162.50,,250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,190,76,,353.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,180,72,,182.592,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,75,,190.2,Percent of Total Billed charges,75% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180,72,,182.592,Percent of Total Billed Charges,72% of Total Billed Charges,150,60,,152.16,Percent of Total Billed Charges,60% of Total Billed Charges,225,90,,6139.256,Percent of Total Billed Charges,90% of Total Billed Charges,112.5,45,,343.32,Percent of Total Billed Charges,45% of Total Billed Charges,225,90,,419.04,Percent of Total Billed Charges,90% of Total billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.5,65,,157.088,Percent of total Billed Charges,65% of Total Billed Charges,110.25,44.1,,336.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,237.5,95,,442.32,Percent of Total Billed Charges,95% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220,88,,637.824,Percent of Total Billed Charges,88% of Total Billed Charges,225,90,,419.04,Percent of Total Billed charges,90% of Total Billed Charges,110.25,250,
HEMOCHROMATOSIS,3090000070,CDM,309,RC,,,Outpatient,,,525.89,341.83,,525.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,399.68,76,,590.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,378.64,72,,809.28,Percent of Total Billed Charges,72% of Total Billed Charges,394.42,75,,843,Percent of Total Billed charges,75% of Total Billed Charges,525.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.64,72,,809.28,Percent of Total Billed Charges,72% of Total Billed Charges,315.53,60,,674.4,Percent of Total Billed Charges,60% of Total Billed Charges,473.3,90,,5832.72,Percent of Total Billed Charges,90% of Total Billed Charges,236.65,45,,326.16,Percent of Total Billed Charges,45% of Total Billed Charges,473.3,90,,699.336,Percent of Total Billed Charges,90% of Total billed Charges,525.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,525.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,525.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.83,65,,124.408,Percent of total Billed Charges,65% of Total Billed Charges,231.92,44.1,,319.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,499.6,95,,738.192,Percent of Total Billed Charges,95% of Total Billed Charges,525.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.78,88,,290.752,Percent of Total Billed Charges,88% of Total Billed Charges,473.3,90,,699.336,Percent of Total Billed charges,90% of Total Billed Charges,231.92,525.89,
TPMT ACITVITY,3090000071,CDM,309,RC,,,Outpatient,,,67.00,43.55,,67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,50.92,76,,344.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,48.24,72,,809.28,Percent of Total Billed Charges,72% of Total Billed Charges,50.25,75,,843,Percent of Total Billed charges,75% of Total Billed Charges,67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.24,72,,809.28,Percent of Total Billed Charges,72% of Total Billed Charges,40.2,60,,674.4,Percent of Total Billed Charges,60% of Total Billed Charges,60.3,90,,5832.72,Percent of Total Billed Charges,90% of Total Billed Charges,30.15,45,,148.68,Percent of Total Billed Charges,45% of Total Billed Charges,60.3,90,,408.016,Percent of Total Billed Charges,90% of Total billed Charges,67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.55,65,,138.168,Percent of total Billed Charges,65% of Total Billed Charges,29.55,44.1,,145.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,63.65,95,,430.688,Percent of Total Billed Charges,95% of Total Billed Charges,67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.96,88,,488.576,Percent of Total Billed Charges,88% of Total Billed Charges,60.3,90,,408.016,Percent of Total Billed charges,90% of Total Billed Charges,29.55,67,
ENTEROVIRUS RNA,3090000072,CDM,309,RC,,,Outpatient,,,117.00,76.05,,117,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,88.92,76,,553.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.24,72,,714.416,Percent of Total Billed Charges,72% of Total Billed Charges,87.75,75,,744.184,Percent of Total Billed charges,75% of Total Billed Charges,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.24,72,,714.416,Percent of Total Billed Charges,72% of Total Billed Charges,70.2,60,,595.352,Percent of Total Billed Charges,60% of Total Billed Charges,105.3,90,,1232.64,Percent of Total Billed Charges,90% of Total Billed Charges,52.65,45,,249.84,Percent of Total Billed Charges,45% of Total Billed Charges,105.3,90,,655.92,Percent of Total Billed Charges,90% of Total billed Charges,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.05,65,,138.168,Percent of total Billed Charges,65% of Total Billed Charges,51.6,44.1,,244.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,111.15,95,,692.36,Percent of Total Billed Charges,95% of Total Billed Charges,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.96,88,,579.392,Percent of Total Billed Charges,88% of Total Billed Charges,105.3,90,,655.92,Percent of Total Billed charges,90% of Total Billed Charges,51.6,117,
HAEMOPHILUS INFLUENZA TYPE B,3090000073,CDM,309,RC,,,Outpatient,,,44.00,28.60,,44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33.44,76,,579.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,31.68,72,,679.104,Percent of Total Billed Charges,72% of Total Billed Charges,33,75,,707.4,Percent of Total Billed charges,75% of Total Billed Charges,44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.68,72,,679.104,Percent of Total Billed Charges,72% of Total Billed Charges,26.4,60,,565.92,Percent of Total Billed Charges,60% of Total Billed Charges,39.6,90,,545.344,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,45,,296.28,Percent of Total Billed Charges,45% of Total Billed Charges,39.6,90,,686.632,Percent of Total Billed Charges,90% of Total billed Charges,44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.6,65,,104.344,Percent of total Billed Charges,65% of Total Billed Charges,19.4,44.1,,290.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.8,95,,724.784,Percent of Total Billed Charges,95% of Total Billed Charges,44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.72,88,,5703.104,Percent of Total Billed Charges,88% of Total Billed Charges,39.6,90,,686.632,Percent of Total Billed charges,90% of Total Billed Charges,19.4,44,
ALPHA SUBUNIT,3090000074,CDM,309,RC,,,Outpatient,,,39.23,25.50,,39.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.81,76,,550.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.25,72,,714.416,Percent of Total Billed Charges,72% of Total Billed Charges,29.42,75,,744.184,Percent of Total Billed charges,75% of Total Billed Charges,39.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.25,72,,714.416,Percent of Total Billed Charges,72% of Total Billed Charges,23.54,60,,595.352,Percent of Total Billed Charges,60% of Total Billed Charges,35.31,90,,1302.48,Percent of Total Billed Charges,90% of Total Billed Charges,17.65,45,,2916.36,Percent of Total Billed Charges,45% of Total Billed Charges,35.31,90,,652.32,Percent of Total Billed Charges,90% of Total billed Charges,39.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.5,65,,136.448,Percent of total Billed Charges,65% of Total Billed Charges,17.3,44.1,,2858.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.27,95,,688.56,Percent of Total Billed Charges,95% of Total Billed Charges,39.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.52,88,,6002.824,Percent of Total Billed Charges,88% of Total Billed Charges,35.31,90,,652.32,Percent of Total Billed charges,90% of Total Billed Charges,17.3,39.23,
BETA 2 TRABSFERRIN,3090000077,CDM,309,RC,,,Outpatient,,,108.05,70.23,,108.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.12,76,,251.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.8,72,,679.104,Percent of Total Billed Charges,72% of Total Billed Charges,81.04,75,,707.4,Percent of Total Billed charges,75% of Total Billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.8,72,,679.104,Percent of Total Billed Charges,72% of Total Billed Charges,64.83,60,,565.92,Percent of Total Billed Charges,60% of Total Billed Charges,97.25,90,,2030.4,Percent of Total Billed Charges,90% of Total Billed Charges,48.62,45,,3069.624,Percent of Total Billed Charges,45% of Total Billed Charges,97.25,90,,297.36,Percent of Total Billed Charges,90% of Total billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.23,65,,136.448,Percent of total Billed Charges,65% of Total Billed Charges,47.65,44.1,,3008.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.65,95,,313.88,Percent of Total Billed Charges,95% of Total Billed Charges,108.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.08,88,,5703.104,Percent of Total Billed Charges,88% of Total Billed Charges,97.25,90,,297.36,Percent of Total Billed charges,90% of Total Billed Charges,47.65,108.05,
THYROID CASCADING REFLEX,3090000078,CDM,309,RC,,,Outpatient,,,299.88,194.92,,299.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,227.91,76,,421.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,215.91,72,,714.416,Percent of Total Billed Charges,72% of Total Billed Charges,224.91,75,,744.184,Percent of Total Billed charges,75% of Total Billed Charges,299.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.91,72,,714.416,Percent of Total Billed Charges,72% of Total Billed Charges,179.93,60,,595.352,Percent of Total Billed Charges,60% of Total Billed Charges,269.89,90,,1578.68,Percent of Total Billed Charges,90% of Total Billed Charges,134.95,45,,2916.36,Percent of Total Billed Charges,45% of Total Billed Charges,269.89,90,,499.68,Percent of Total Billed Charges,90% of Total billed Charges,299.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,299.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,299.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.92,65,,113.52,Percent of total Billed Charges,65% of Total Billed Charges,132.25,44.1,,2858.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,284.89,95,,527.44,Percent of Total Billed Charges,95% of Total Billed Charges,299.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.89,88,,5703.104,Percent of Total Billed Charges,88% of Total Billed Charges,269.89,90,,499.68,Percent of Total Billed charges,90% of Total Billed Charges,132.25,299.88,
ESTRONE,3090000079,CDM,309,RC,,,Outpatient,,,199.95,129.97,,199.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,151.96,76,,500.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,143.96,72,,714.416,Percent of Total Billed Charges,72% of Total Billed Charges,149.96,75,,744.184,Percent of Total Billed charges,75% of Total Billed Charges,199.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.96,72,,714.416,Percent of Total Billed Charges,72% of Total Billed Charges,119.97,60,,595.352,Percent of Total Billed Charges,60% of Total Billed Charges,179.96,90,,4680,Percent of Total Billed Charges,90% of Total Billed Charges,89.98,45,,2916.36,Percent of Total Billed Charges,45% of Total Billed Charges,179.96,90,,592.56,Percent of Total Billed Charges,90% of Total billed Charges,199.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.97,65,,113.52,Percent of total Billed Charges,65% of Total Billed Charges,88.18,44.1,,2858.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,189.95,95,,625.48,Percent of Total Billed Charges,95% of Total Billed Charges,199.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.96,88,,1205.248,Percent of Total Billed Charges,88% of Total Billed Charges,179.96,90,,592.56,Percent of Total Billed charges,90% of Total Billed Charges,88.18,199.95,
24 HR CATHECHOLAMINES WO CREAT,3090000080,CDM,309,RC,,,Outpatient,,,249.00,161.85,,249,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,189.24,76,,4925.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,179.28,72,,501.696,Percent of Total Billed Charges,72% of Total Billed Charges,186.75,75,,522.6,Percent of Total Billed charges,75% of Total Billed Charges,249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.28,72,,501.696,Percent of Total Billed Charges,72% of Total Billed Charges,149.4,60,,418.08,Percent of Total Billed Charges,60% of Total Billed Charges,224.1,90,,1797.12,Percent of Total Billed Charges,90% of Total Billed Charges,112.05,45,,616.32,Percent of Total Billed Charges,45% of Total Billed Charges,224.1,90,,5832.72,Percent of Total Billed Charges,90% of Total billed Charges,249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.85,65,,146.768,Percent of total Billed Charges,65% of Total Billed Charges,109.81,44.1,,603.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,236.55,95,,6156.76,Percent of Total Billed Charges,95% of Total Billed Charges,249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.12,88,,533.224,Percent of Total Billed Charges,88% of Total Billed Charges,224.1,90,,5832.72,Percent of Total Billed charges,90% of Total Billed Charges,109.81,249,
QUANTIEFERON TBGOLD PLUS 1 TUB,3090000081,CDM,309,RC,,,Outpatient,,,112.46,73.10,,112.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,85.47,76,,5184.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,80.97,72,,322.2,Percent of Total Billed Charges,72% of Total Billed Charges,84.35,75,,335.632,Percent of Total Billed charges,75% of Total Billed Charges,112.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.97,72,,322.2,Percent of Total Billed Charges,72% of Total Billed Charges,67.48,60,,268.504,Percent of Total Billed Charges,60% of Total Billed Charges,101.21,90,,544.552,Percent of Total Billed Charges,90% of Total Billed Charges,50.61,45,,272.672,Percent of Total Billed Charges,45% of Total Billed Charges,101.21,90,,6139.256,Percent of Total Billed Charges,90% of Total billed Charges,112.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.1,65,,146.768,Percent of total Billed Charges,65% of Total Billed Charges,49.59,44.1,,267.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,106.84,95,,6480.32,Percent of Total Billed Charges,95% of Total Billed Charges,112.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.96,88,,1273.536,Percent of Total Billed Charges,88% of Total Billed Charges,101.21,90,,6139.256,Percent of Total Billed charges,90% of Total Billed Charges,49.59,112.46,
HCV PCR,3090000082,CDM,309,RC,,,Outpatient,,,1404.59,912.98,,1404.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1067.49,76,,4925.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1011.3,72,,714.416,Percent of Total Billed Charges,72% of Total Billed Charges,1053.44,75,,744.184,Percent of Total Billed charges,75% of Total Billed Charges,1404.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1011.3,72,,714.416,Percent of Total Billed Charges,72% of Total Billed Charges,842.75,60,,595.352,Percent of Total Billed Charges,60% of Total Billed Charges,1264.13,90,,1755.36,Percent of Total Billed Charges,90% of Total Billed Charges,632.07,45,,651.24,Percent of Total Billed Charges,45% of Total Billed Charges,1264.13,90,,5832.72,Percent of Total Billed Charges,90% of Total billed Charges,1404.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1404.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1404.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,912.98,65,,71.792,Percent of total Billed Charges,65% of Total Billed Charges,619.42,44.1,,638.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,1334.36,95,,6156.76,Percent of Total Billed Charges,95% of Total Billed Charges,1404.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1236.04,88,,1985.28,Percent of Total Billed Charges,88% of Total Billed Charges,1264.13,90,,5832.72,Percent of Total Billed charges,90% of Total Billed Charges,619.42,1404.59,
SOLUBLE LIVER ANTIGEN SLA,3090000083,CDM,301,RC,,,Outpatient,,,577.71,375.51,,577.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,439.06,76,,4925.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.95,72,,527.896,Percent of Total Billed Charges,72% of Total Billed Charges,433.28,75,,549.888,Percent of Total Billed charges,75% of Total Billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.95,72,,527.896,Percent of Total Billed Charges,72% of Total Billed Charges,346.63,60,,439.912,Percent of Total Billed Charges,60% of Total Billed Charges,519.94,90,,1755.36,Percent of Total Billed Charges,90% of Total Billed Charges,259.97,45,,1015.2,Percent of Total Billed Charges,45% of Total Billed Charges,519.94,90,,5832.72,Percent of Total Billed Charges,90% of Total billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.51,65,,71.792,Percent of total Billed Charges,65% of Total Billed Charges,254.77,44.1,,994.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,548.82,95,,6156.76,Percent of Total Billed Charges,95% of Total Billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.38,88,,1543.6,Percent of Total Billed Charges,88% of Total Billed Charges,519.94,90,,5832.72,Percent of Total Billed charges,90% of Total Billed Charges,254.77,577.71,
THIOPURINE METABOLITES,3090000084,CDM,309,RC,,,Outpatient,,,244.76,159.09,,244.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,186.02,76,,1040.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,176.23,72,,527.896,Percent of Total Billed Charges,72% of Total Billed Charges,183.57,75,,549.888,Percent of Total Billed charges,75% of Total Billed Charges,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.23,72,,527.896,Percent of Total Billed Charges,72% of Total Billed Charges,146.86,60,,439.912,Percent of Total Billed Charges,60% of Total Billed Charges,220.28,90,,228.24,Percent of Total Billed Charges,90% of Total Billed Charges,110.14,45,,789.336,Percent of Total Billed Charges,45% of Total Billed Charges,220.28,90,,1232.64,Percent of Total Billed Charges,90% of Total billed Charges,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.09,65,,112.368,Percent of total Billed Charges,65% of Total Billed Charges,107.94,44.1,,773.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,232.52,95,,1301.12,Percent of Total Billed Charges,95% of Total Billed Charges,244.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.39,88,,4576,Percent of Total Billed Charges,88% of Total Billed Charges,220.28,90,,1232.64,Percent of Total Billed charges,90% of Total Billed Charges,107.94,244.76,
ALKALOIDS NOS,3090000085,CDM,309,RC,,,Outpatient,,,286.08,185.95,,286.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,217.42,76,,460.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,205.98,72,,2791.296,Percent of Total Billed Charges,72% of Total Billed Charges,214.56,75,,2907.6,Percent of Total Billed charges,75% of Total Billed Charges,286.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.98,72,,2791.296,Percent of Total Billed Charges,72% of Total Billed Charges,171.65,60,,2326.08,Percent of Total Billed Charges,60% of Total Billed Charges,257.47,90,,239.584,Percent of Total Billed Charges,90% of Total Billed Charges,128.74,45,,2340,Percent of Total Billed Charges,45% of Total Billed Charges,257.47,90,,545.344,Percent of Total Billed Charges,90% of Total billed Charges,286.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.95,65,,112.368,Percent of total Billed Charges,65% of Total Billed Charges,126.16,44.1,,2293.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,271.78,95,,575.64,Percent of Total Billed Charges,95% of Total Billed Charges,286.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.75,88,,1757.184,Percent of Total Billed Charges,88% of Total Billed Charges,257.47,90,,545.344,Percent of Total Billed charges,90% of Total Billed Charges,126.16,286.08,
ALLERG SP IGG QUAN OR SEMIQUAN,3090000086,CDM,309,RC,,,Outpatient,,,19.55,12.71,,19.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.86,76,,1099.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.08,72,,1605.744,Percent of Total Billed Charges,72% of Total Billed Charges,14.66,75,,1672.648,Percent of Total Billed charges,75% of Total Billed Charges,19.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.08,72,,1605.744,Percent of Total Billed Charges,72% of Total Billed Charges,11.73,60,,1338.12,Percent of Total Billed Charges,60% of Total Billed Charges,17.6,90,,350.64,Percent of Total Billed Charges,90% of Total Billed Charges,8.8,45,,898.56,Percent of Total Billed Charges,45% of Total Billed Charges,17.6,90,,1302.48,Percent of Total Billed Charges,90% of Total billed Charges,19.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.71,65,,81.408,Percent of total Billed Charges,65% of Total Billed Charges,8.62,44.1,,880.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.57,95,,1374.84,Percent of Total Billed Charges,95% of Total Billed Charges,19.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.2,88,,532.448,Percent of Total Billed Charges,88% of Total Billed Charges,17.6,90,,1302.48,Percent of Total Billed charges,90% of Total Billed Charges,8.62,19.55,
CYSTATIN C,3090000087,CDM,309,RC,,,Outpatient,,,46.30,30.10,,46.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.19,76,,1714.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.34,72,,251.712,Percent of Total Billed Charges,72% of Total Billed Charges,34.73,75,,262.2,Percent of Total Billed charges,75% of Total Billed Charges,46.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.34,72,,251.712,Percent of Total Billed Charges,72% of Total Billed Charges,27.78,60,,209.76,Percent of Total Billed Charges,60% of Total Billed Charges,41.67,90,,436.592,Percent of Total Billed Charges,90% of Total Billed Charges,20.84,45,,272.272,Percent of Total Billed Charges,45% of Total Billed Charges,41.67,90,,2030.4,Percent of Total Billed Charges,90% of Total billed Charges,46.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.1,65,,112.368,Percent of total Billed Charges,65% of Total Billed Charges,20.42,44.1,,266.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,43.99,95,,2143.2,Percent of Total Billed Charges,95% of Total Billed Charges,46.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.74,88,,1716.352,Percent of Total Billed Charges,88% of Total Billed Charges,41.67,90,,2030.4,Percent of Total Billed charges,90% of Total Billed Charges,20.42,46.3,
ALLG SPEC IGE RECOMB EA,3090000088,CDM,309,RC,,,Outpatient,,,44.83,29.14,,44.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.07,76,,1333.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.28,72,,607.728,Percent of Total Billed Charges,72% of Total Billed Charges,33.62,75,,633.056,Percent of Total Billed charges,75% of Total Billed Charges,44.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.28,72,,607.728,Percent of Total Billed Charges,72% of Total Billed Charges,26.9,60,,506.44,Percent of Total Billed Charges,60% of Total Billed Charges,40.35,90,,465.12,Percent of Total Billed Charges,90% of Total Billed Charges,20.17,45,,877.68,Percent of Total Billed Charges,45% of Total Billed Charges,40.35,90,,1578.68,Percent of Total Billed Charges,90% of Total billed Charges,44.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.14,65,,112.368,Percent of total Billed Charges,65% of Total Billed Charges,19.77,44.1,,860.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.59,95,,1666.384,Percent of Total Billed Charges,95% of Total Billed Charges,44.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.45,88,,1716.352,Percent of Total Billed Charges,88% of Total Billed Charges,40.35,90,,1578.68,Percent of Total Billed charges,90% of Total Billed Charges,19.77,44.83,
SARS-COV-2 COVID 19 LAB,3090000089,CDM,309,RC,,,Outpatient,,,538.00,349.70,,538,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,408.88,76,,3952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,387.36,72,,449.608,Percent of Total Billed Charges,72% of Total Billed Charges,403.5,75,,468.344,Percent of Total Billed charges,75% of Total Billed Charges,538,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,387.36,72,,449.608,Percent of Total Billed Charges,72% of Total Billed Charges,322.8,60,,374.672,Percent of Total Billed Charges,60% of Total Billed Charges,484.2,90,,240.52,Percent of Total Billed Charges,90% of Total Billed Charges,242.1,45,,877.68,Percent of Total Billed Charges,45% of Total Billed Charges,484.2,90,,4680,Percent of Total Billed Charges,90% of Total billed Charges,538,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.7,65,,193.44,Percent of total Billed Charges,65% of Total Billed Charges,237.26,44.1,,860.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,511.1,95,,4940,Percent of Total Billed Charges,95% of Total Billed Charges,538,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.44,88,,223.168,Percent of Total Billed Charges,88% of Total Billed Charges,484.2,90,,4680,Percent of Total Billed charges,90% of Total Billed Charges,237.26,538,
VGCG TYPE N AB,3090000091,CDM,309,RC,,,Outpatient,,,612.99,398.44,,612.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.87,76,,1517.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,441.35,72,,1073.088,Percent of Total Billed Charges,72% of Total Billed Charges,459.74,75,,1117.8,Percent of Total Billed charges,75% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,441.35,72,,1073.088,Percent of Total Billed Charges,72% of Total Billed Charges,367.79,60,,894.24,Percent of Total Billed Charges,60% of Total Billed Charges,551.69,90,,138.96,Percent of Total Billed Charges,90% of Total Billed Charges,275.85,45,,114.12,Percent of Total Billed Charges,45% of Total Billed Charges,551.69,90,,1797.12,Percent of Total Billed Charges,90% of Total billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.44,65,,193.44,Percent of total Billed Charges,65% of Total Billed Charges,270.33,44.1,,111.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,582.34,95,,1896.96,Percent of Total Billed Charges,95% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,539.43,88,,234.264,Percent of Total Billed Charges,88% of Total Billed Charges,551.69,90,,1797.12,Percent of Total Billed charges,90% of Total Billed Charges,270.33,612.99,
ECHINOCOCCUS AB,3090000092,CDM,309,RC,,,Outpatient,,,32.53,21.14,,32.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24.72,76,,459.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.42,72,,533.832,Percent of Total Billed Charges,72% of Total Billed Charges,24.4,75,,556.072,Percent of Total Billed charges,75% of Total Billed Charges,32.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.42,72,,533.832,Percent of Total Billed Charges,72% of Total Billed Charges,19.52,60,,444.856,Percent of Total Billed Charges,60% of Total Billed Charges,29.28,90,,169.92,Percent of Total Billed Charges,90% of Total Billed Charges,14.64,45,,119.792,Percent of Total Billed Charges,45% of Total Billed Charges,29.28,90,,544.552,Percent of Total Billed Charges,90% of Total billed Charges,32.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.14,65,,195.52,Percent of total Billed Charges,65% of Total Billed Charges,14.35,44.1,,117.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.9,95,,574.8,Percent of Total Billed Charges,95% of Total Billed Charges,32.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.63,88,,342.848,Percent of Total Billed Charges,88% of Total Billed Charges,29.28,90,,544.552,Percent of Total Billed charges,90% of Total Billed Charges,14.35,32.53,
DIHYDROTESTERONE,3090000093,CDM,309,RC,,,Outpatient,,,73.20,47.58,,73.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.63,76,,1482.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.7,72,,948.672,Percent of Total Billed Charges,72% of Total Billed Charges,54.9,75,,988.2,Percent of Total Billed charges,75% of Total Billed Charges,73.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.7,72,,948.672,Percent of Total Billed Charges,72% of Total Billed Charges,43.92,60,,790.56,Percent of Total Billed Charges,60% of Total Billed Charges,65.88,90,,233.28,Percent of Total Billed Charges,90% of Total Billed Charges,32.94,45,,175.32,Percent of Total Billed Charges,45% of Total Billed Charges,65.88,90,,1755.36,Percent of Total Billed Charges,90% of Total billed Charges,73.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.58,65,,159.12,Percent of total Billed Charges,65% of Total Billed Charges,32.28,44.1,,171.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,69.54,95,,1852.88,Percent of Total Billed Charges,95% of Total Billed Charges,73.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.42,88,,426.888,Percent of Total Billed Charges,88% of Total Billed Charges,65.88,90,,1755.36,Percent of Total Billed charges,90% of Total Billed Charges,32.28,73.2,
BRCA COMPREHENSIVE PANEL,3090000094,CDM,309,RC,,,Outpatient,,,4562.00,2965.30,,4562,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3467.12,76,,1482.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3284.64,72,,577.888,Percent of Total Billed Charges,72% of Total Billed Charges,3421.5,75,,601.968,Percent of Total Billed charges,75% of Total Billed Charges,4562,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3284.64,72,,577.888,Percent of Total Billed Charges,72% of Total Billed Charges,2737.2,60,,481.576,Percent of Total Billed Charges,60% of Total Billed Charges,4105.8,90,,384.2,Percent of Total Billed Charges,90% of Total Billed Charges,2052.9,45,,218.296,Percent of Total Billed Charges,45% of Total Billed Charges,4105.8,90,,1755.36,Percent of Total Billed Charges,90% of Total billed Charges,4562,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4562,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4562,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2965.3,65,,159.12,Percent of total Billed Charges,65% of Total Billed Charges,2011.84,44.1,,213.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,4333.9,95,,1852.88,Percent of Total Billed Charges,95% of Total Billed Charges,4562,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4014.56,88,,454.784,Percent of Total Billed Charges,88% of Total Billed Charges,4105.8,90,,1755.36,Percent of Total Billed charges,90% of Total Billed Charges,2011.84,4562,
BRCA COMPREHENSIVE PANEL,3090000095,CDM,309,RC,,,Outpatient,,,4562.00,2965.30,,4562,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3467.12,76,,192.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3284.64,72,,898.584,Percent of Total Billed Charges,72% of Total Billed Charges,3421.5,75,,936.024,Percent of Total Billed charges,75% of Total Billed Charges,4562,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3284.64,72,,898.584,Percent of Total Billed Charges,72% of Total Billed Charges,2737.2,60,,748.816,Percent of Total Billed Charges,60% of Total Billed Charges,4105.8,90,,627.84,Percent of Total Billed Charges,90% of Total Billed Charges,2052.9,45,,232.56,Percent of Total Billed Charges,45% of Total Billed Charges,4105.8,90,,228.24,Percent of Total Billed Charges,90% of Total billed Charges,4562,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4562,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4562,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2965.3,65,,140.4,Percent of total Billed Charges,65% of Total Billed Charges,2011.84,44.1,,227.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,4333.9,95,,240.92,Percent of Total Billed Charges,95% of Total Billed Charges,4562,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4014.56,88,,235.176,Percent of Total Billed Charges,88% of Total Billed Charges,4105.8,90,,228.24,Percent of Total Billed charges,90% of Total Billed Charges,2011.84,4562,
VGCC TYPE P/Q AB,3090000096,CDM,309,RC,,,Outpatient,,,612.99,398.44,,612.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,465.87,76,,202.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,441.35,72,,1137.6,Percent of Total Billed Charges,72% of Total Billed Charges,459.74,75,,1185,Percent of Total Billed charges,75% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,441.35,72,,1137.6,Percent of Total Billed Charges,72% of Total Billed Charges,367.79,60,,948,Percent of Total Billed Charges,60% of Total Billed Charges,551.69,90,,443.52,Percent of Total Billed Charges,90% of Total Billed Charges,275.85,45,,120.264,Percent of Total Billed Charges,45% of Total Billed Charges,551.69,90,,239.584,Percent of Total Billed Charges,90% of Total billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.44,65,,140.4,Percent of total Billed Charges,65% of Total Billed Charges,270.33,44.1,,117.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,582.34,95,,252.896,Percent of Total Billed Charges,95% of Total Billed Charges,612.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,539.43,88,,135.872,Percent of Total Billed Charges,88% of Total Billed Charges,551.69,90,,239.584,Percent of Total Billed charges,90% of Total Billed Charges,270.33,612.99,
PLASMINOGEN ACTIVATOR INHIB,3100000001,CDM,310,RC,,,Outpatient,,,285.05,185.28,,285.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,216.64,76,,296.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,205.24,72,,864,Percent of Total Billed Charges,72% of Total Billed Charges,213.79,75,,900,Percent of Total Billed charges,75% of Total Billed Charges,285.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.24,72,,864,Percent of Total Billed Charges,72% of Total Billed Charges,171.03,60,,720,Percent of Total Billed Charges,60% of Total Billed Charges,256.55,90,,195.28,Percent of Total Billed Charges,90% of Total Billed Charges,128.27,45,,69.48,Percent of Total Billed Charges,45% of Total Billed Charges,256.55,90,,350.64,Percent of Total Billed Charges,90% of Total billed Charges,285.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.28,65,,148.2,Percent of total Billed Charges,65% of Total Billed Charges,125.71,44.1,,68.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,270.8,95,,370.12,Percent of Total Billed Charges,95% of Total Billed Charges,285.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.84,88,,166.144,Percent of Total Billed Charges,88% of Total Billed Charges,256.55,90,,350.64,Percent of Total Billed charges,90% of Total Billed Charges,125.71,285.05,
PROTHROMBIN FAC II) MUTAT ANAL,3100000002,CDM,310,RC,,,Outpatient,,,228.22,148.34,,228.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,173.45,76,,368.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,164.32,72,,642.024,Percent of Total Billed Charges,72% of Total Billed Charges,171.17,75,,668.776,Percent of Total Billed charges,75% of Total Billed Charges,228.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.32,72,,642.024,Percent of Total Billed Charges,72% of Total Billed Charges,136.93,60,,535.024,Percent of Total Billed Charges,60% of Total Billed Charges,205.4,90,,217.504,Percent of Total Billed Charges,90% of Total Billed Charges,102.7,45,,84.96,Percent of Total Billed Charges,45% of Total Billed Charges,205.4,90,,436.592,Percent of Total Billed Charges,90% of Total billed Charges,228.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.34,65,,148.2,Percent of total Billed Charges,65% of Total Billed Charges,100.65,44.1,,83.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,216.81,95,,460.848,Percent of Total Billed Charges,95% of Total Billed Charges,228.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.83,88,,228.096,Percent of Total Billed Charges,88% of Total Billed Charges,205.4,90,,436.592,Percent of Total Billed charges,90% of Total Billed Charges,100.65,228.22,
BCR/ABL GENE QUANT PCR,3100000003,CDM,310,RC,,,Outpatient,,,230.42,149.77,,230.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,175.12,76,,392.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,165.9,72,,898.584,Percent of Total Billed Charges,72% of Total Billed Charges,172.82,75,,936.024,Percent of Total Billed charges,75% of Total Billed Charges,230.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.9,72,,898.584,Percent of Total Billed Charges,72% of Total Billed Charges,138.25,60,,748.816,Percent of Total Billed Charges,60% of Total Billed Charges,207.38,90,,172.256,Percent of Total Billed Charges,90% of Total Billed Charges,103.69,45,,116.64,Percent of Total Billed Charges,45% of Total Billed Charges,207.38,90,,465.12,Percent of Total Billed Charges,90% of Total billed Charges,230.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.77,65,,179.4,Percent of total Billed Charges,65% of Total Billed Charges,101.62,44.1,,114.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,218.9,95,,490.96,Percent of Total Billed Charges,95% of Total Billed Charges,230.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.77,88,,375.664,Percent of Total Billed Charges,88% of Total Billed Charges,207.38,90,,465.12,Percent of Total Billed charges,90% of Total Billed Charges,101.62,230.42,
CHROMOSOMAL MICROARRAY,3100000004,CDM,310,RC,,,Outpatient,,,3087.00,2006.55,,3087,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2346.12,76,,203.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2222.64,72,,830.016,Percent of Total Billed Charges,72% of Total Billed Charges,2315.25,75,,864.6,Percent of Total Billed charges,75% of Total Billed Charges,3087,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2222.64,72,,830.016,Percent of Total Billed Charges,72% of Total Billed Charges,1852.2,60,,691.68,Percent of Total Billed Charges,60% of Total Billed Charges,2778.3,90,,191.304,Percent of Total Billed Charges,90% of Total Billed Charges,1389.15,45,,192.096,Percent of Total Billed Charges,45% of Total Billed Charges,2778.3,90,,240.52,Percent of Total Billed Charges,90% of Total billed Charges,3087,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3087,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3087,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2006.55,65,,179.4,Percent of total Billed Charges,65% of Total Billed Charges,1361.37,44.1,,188.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,2932.65,95,,253.888,Percent of Total Billed Charges,95% of Total Billed Charges,3087,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2716.56,88,,613.888,Percent of Total Billed Charges,88% of Total Billed Charges,2778.3,90,,240.52,Percent of Total Billed charges,90% of Total Billed Charges,1361.37,3087,
FACTOR V MUTATION ANALYSIS,3100000005,CDM,310,RC,,,Outpatient,,,92.61,60.20,,92.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,70.38,76,,117.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,66.68,72,,1091,Percent of Total Billed Charges,72% of Total Billed Charges,69.46,75,,1136.464,Percent of Total Billed charges,75% of Total Billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.68,72,,1091,Percent of Total Billed Charges,72% of Total Billed Charges,55.57,60,,909.168,Percent of Total Billed Charges,60% of Total Billed Charges,83.35,90,,191.304,Percent of Total Billed Charges,90% of Total Billed Charges,41.67,45,,313.92,Percent of Total Billed Charges,45% of Total Billed Charges,83.35,90,,138.96,Percent of Total Billed Charges,90% of Total billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.2,65,,124.408,Percent of total Billed Charges,65% of Total Billed Charges,40.84,44.1,,307.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,87.98,95,,146.68,Percent of Total Billed Charges,95% of Total Billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.5,88,,433.664,Percent of Total Billed Charges,88% of Total Billed Charges,83.35,90,,138.96,Percent of Total Billed charges,90% of Total Billed Charges,40.84,92.61,
HEMOCHROMATOSIS GENE ANALYSIS,3100000006,CDM,310,RC,,,Outpatient,,,525.89,341.83,,525.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,399.68,76,,143.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,378.64,72,,1103.616,Percent of Total Billed Charges,72% of Total Billed Charges,394.42,75,,1149.6,Percent of Total Billed charges,75% of Total Billed Charges,525.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.64,72,,1103.616,Percent of Total Billed Charges,72% of Total Billed Charges,315.53,60,,919.68,Percent of Total Billed Charges,60% of Total Billed Charges,473.3,90,,144.472,Percent of Total Billed Charges,90% of Total Billed Charges,236.65,45,,221.76,Percent of Total Billed Charges,45% of Total Billed Charges,473.3,90,,169.92,Percent of Total Billed Charges,90% of Total billed Charges,525.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,525.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,525.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.83,65,,144.04,Percent of total Billed Charges,65% of Total Billed Charges,231.92,44.1,,217.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,499.6,95,,179.36,Percent of Total Billed Charges,95% of Total Billed Charges,525.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.78,88,,190.936,Percent of Total Billed Charges,88% of Total Billed Charges,473.3,90,,169.92,Percent of Total Billed charges,90% of Total Billed Charges,231.92,525.89,
HLA  DQ8,3100000007,CDM,310,RC,,,Outpatient,,,206.71,134.36,,206.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,157.1,76,,196.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,148.83,72,,1363.968,Percent of Total Billed Charges,72% of Total Billed Charges,155.03,75,,1420.8,Percent of Total Billed charges,75% of Total Billed Charges,206.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.83,72,,1363.968,Percent of Total Billed Charges,72% of Total Billed Charges,124.03,60,,1136.64,Percent of Total Billed Charges,60% of Total Billed Charges,186.04,90,,188.928,Percent of Total Billed Charges,90% of Total Billed Charges,93.02,45,,97.64,Percent of Total Billed Charges,45% of Total Billed Charges,186.04,90,,233.28,Percent of Total Billed Charges,90% of Total billed Charges,206.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.36,65,,144.04,Percent of total Billed Charges,65% of Total Billed Charges,91.16,44.1,,95.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,196.37,95,,246.24,Percent of Total Billed Charges,95% of Total Billed Charges,206.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.9,88,,212.672,Percent of Total Billed Charges,88% of Total Billed Charges,186.04,90,,233.28,Percent of Total Billed charges,90% of Total Billed Charges,91.16,206.71,
HLA  DQ2,3100000008,CDM,310,RC,,,Outpatient,,,206.71,134.36,,206.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,157.1,76,,324.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,148.83,72,,770.304,Percent of Total Billed Charges,72% of Total Billed Charges,155.03,75,,802.4,Percent of Total Billed charges,75% of Total Billed Charges,206.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.83,72,,770.304,Percent of Total Billed Charges,72% of Total Billed Charges,124.03,60,,641.92,Percent of Total Billed Charges,60% of Total Billed Charges,186.04,90,,188.928,Percent of Total Billed Charges,90% of Total Billed Charges,93.02,45,,108.752,Percent of Total Billed Charges,45% of Total Billed Charges,186.04,90,,384.2,Percent of Total Billed Charges,90% of Total billed Charges,206.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.36,65,,163.8,Percent of total Billed Charges,65% of Total Billed Charges,91.16,44.1,,106.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,196.37,95,,405.544,Percent of Total Billed Charges,95% of Total Billed Charges,206.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.9,88,,168.424,Percent of Total Billed Charges,88% of Total Billed Charges,186.04,90,,384.2,Percent of Total Billed charges,90% of Total Billed Charges,91.16,206.71,
CYTO SMEAR EXTRA GEN,3100000009,CDM,310,RC,,,Outpatient,,,91.51,59.48,,91.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,69.55,76,,530.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.89,72,,1026.856,Percent of Total Billed Charges,72% of Total Billed Charges,68.63,75,,1069.648,Percent of Total Billed charges,75% of Total Billed Charges,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.89,72,,1026.856,Percent of Total Billed Charges,72% of Total Billed Charges,54.91,60,,855.712,Percent of Total Billed Charges,60% of Total Billed Charges,82.36,90,,157.176,Percent of Total Billed Charges,90% of Total Billed Charges,41.18,45,,86.128,Percent of Total Billed Charges,45% of Total Billed Charges,82.36,90,,627.84,Percent of Total Billed Charges,90% of Total billed Charges,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.48,65,,163.8,Percent of total Billed Charges,65% of Total Billed Charges,40.36,44.1,,84.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,86.93,95,,662.72,Percent of Total Billed Charges,95% of Total Billed Charges,91.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.53,88,,187.056,Percent of Total Billed Charges,88% of Total Billed Charges,82.36,90,,627.84,Percent of Total Billed charges,90% of Total Billed Charges,40.36,91.51,
CYTOSPIN,3100000010,CDM,310,RC,,,Outpatient,,,149.94,97.46,,149.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,113.95,76,,374.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,107.96,72,,1091,Percent of Total Billed Charges,72% of Total Billed Charges,112.46,75,,1136.464,Percent of Total Billed charges,75% of Total Billed Charges,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.96,72,,1091,Percent of Total Billed Charges,72% of Total Billed Charges,89.96,60,,909.168,Percent of Total Billed Charges,60% of Total Billed Charges,134.95,90,,157.176,Percent of Total Billed Charges,90% of Total Billed Charges,67.47,45,,95.656,Percent of Total Billed Charges,45% of Total Billed Charges,134.95,90,,443.52,Percent of Total Billed Charges,90% of Total billed Charges,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.46,65,,197.08,Percent of total Billed Charges,65% of Total Billed Charges,66.12,44.1,,93.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.44,95,,468.16,Percent of Total Billed Charges,95% of Total Billed Charges,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.95,88,,187.056,Percent of Total Billed Charges,88% of Total Billed Charges,134.95,90,,443.52,Percent of Total Billed charges,90% of Total Billed Charges,66.12,149.94,
CYTO NONGYN THIN PREP,3100000011,CDM,310,RC,,,Outpatient,,,297.00,193.05,,297,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,225.72,76,,164.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,213.84,72,,1098.432,Percent of Total Billed Charges,72% of Total Billed Charges,222.75,75,,1144.2,Percent of Total Billed charges,75% of Total Billed Charges,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.84,72,,1098.432,Percent of Total Billed Charges,72% of Total Billed Charges,178.2,60,,915.36,Percent of Total Billed Charges,60% of Total Billed Charges,267.3,90,,203.216,Percent of Total Billed Charges,90% of Total Billed Charges,133.65,45,,95.656,Percent of Total Billed Charges,45% of Total Billed Charges,267.3,90,,195.28,Percent of Total Billed Charges,90% of Total billed Charges,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.05,65,,197.08,Percent of total Billed Charges,65% of Total Billed Charges,130.98,44.1,,93.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,282.15,95,,206.128,Percent of Total Billed Charges,95% of Total Billed Charges,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.36,88,,141.264,Percent of Total Billed Charges,88% of Total Billed Charges,267.3,90,,195.28,Percent of Total Billed charges,90% of Total Billed Charges,130.98,297,
CYTO PREP SCREEN & REPORT,3100000012,CDM,310,RC,,,Outpatient,,,264.00,171.60,,264,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,200.64,76,,183.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,190.08,72,,834.448,Percent of Total Billed Charges,72% of Total Billed Charges,198,75,,869.216,Percent of Total Billed charges,75% of Total Billed Charges,264,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.08,72,,834.448,Percent of Total Billed Charges,72% of Total Billed Charges,158.4,60,,695.368,Percent of Total Billed Charges,60% of Total Billed Charges,237.6,90,,203.216,Percent of Total Billed Charges,90% of Total Billed Charges,118.8,45,,72.24,Percent of Total Billed Charges,45% of Total Billed Charges,237.6,90,,217.504,Percent of Total Billed Charges,90% of Total billed Charges,264,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.6,65,,104.344,Percent of total Billed Charges,65% of Total Billed Charges,116.42,44.1,,70.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,250.8,95,,229.592,Percent of Total Billed Charges,95% of Total Billed Charges,264,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.32,88,,184.728,Percent of Total Billed Charges,88% of Total Billed Charges,237.6,90,,217.504,Percent of Total Billed charges,90% of Total Billed Charges,116.42,264,
CYTO NONGYN FILTER PREP,3100000013,CDM,310,RC,,,Outpatient,,,89.13,57.93,,89.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.74,76,,145.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.17,72,,1129.104,Percent of Total Billed Charges,72% of Total Billed Charges,66.85,75,,1176.152,Percent of Total Billed charges,75% of Total Billed Charges,89.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.17,72,,1129.104,Percent of Total Billed Charges,72% of Total Billed Charges,53.48,60,,940.92,Percent of Total Billed Charges,60% of Total Billed Charges,80.22,90,,99.4,Percent of Total Billed Charges,90% of Total Billed Charges,40.11,45,,94.464,Percent of Total Billed Charges,45% of Total Billed Charges,80.22,90,,172.256,Percent of Total Billed Charges,90% of Total billed Charges,89.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.93,65,,152.36,Percent of total Billed Charges,65% of Total Billed Charges,39.31,44.1,,92.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,84.67,95,,181.824,Percent of Total Billed Charges,95% of Total Billed Charges,89.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.43,88,,184.728,Percent of Total Billed Charges,88% of Total Billed Charges,80.22,90,,172.256,Percent of Total Billed charges,90% of Total Billed Charges,39.31,89.13,
CYTO SMEARMULTI,3100000014,CDM,310,RC,,,Outpatient,,,101.43,65.93,,101.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,77.09,76,,161.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,73.03,72,,521.368,Percent of Total Billed Charges,72% of Total Billed Charges,76.07,75,,543.088,Percent of Total Billed charges,75% of Total Billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.03,72,,521.368,Percent of Total Billed Charges,72% of Total Billed Charges,60.86,60,,434.472,Percent of Total Billed Charges,60% of Total Billed Charges,91.29,90,,99.4,Percent of Total Billed Charges,90% of Total Billed Charges,45.64,45,,94.464,Percent of Total Billed Charges,45% of Total Billed Charges,91.29,90,,191.304,Percent of Total Billed Charges,90% of Total billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.93,65,,152.36,Percent of total Billed Charges,65% of Total Billed Charges,44.73,44.1,,92.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,96.36,95,,201.936,Percent of Total Billed Charges,95% of Total Billed Charges,101.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.26,88,,153.68,Percent of Total Billed Charges,88% of Total Billed Charges,91.29,90,,191.304,Percent of Total Billed charges,90% of Total Billed Charges,44.73,101.43,
FINE NEEDLE ASP IMMED EVAL,3100000015,CDM,310,RC,,,Outpatient,,,344.00,223.60,,344,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,261.44,76,,161.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,247.68,72,,610.912,Percent of Total Billed Charges,72% of Total Billed Charges,258,75,,636.368,Percent of Total Billed charges,75% of Total Billed Charges,344,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.68,72,,610.912,Percent of Total Billed Charges,72% of Total Billed Charges,206.4,60,,509.096,Percent of Total Billed Charges,60% of Total Billed Charges,309.6,90,,155.584,Percent of Total Billed Charges,90% of Total Billed Charges,154.8,45,,78.592,Percent of Total Billed Charges,45% of Total Billed Charges,309.6,90,,191.304,Percent of Total Billed Charges,90% of Total billed Charges,344,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,344,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,344,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,223.6,65,,146.64,Percent of total Billed Charges,65% of Total Billed Charges,151.7,44.1,,77.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,326.8,95,,201.936,Percent of Total Billed Charges,95% of Total Billed Charges,344,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.72,88,,153.68,Percent of Total Billed Charges,88% of Total Billed Charges,309.6,90,,191.304,Percent of Total Billed charges,90% of Total Billed Charges,151.7,344,
FINE NEEDLE ASP INTERP REPORT,3100000016,CDM,310,RC,,,Outpatient,,,297.00,193.05,,297,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,225.72,76,,122,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,213.84,72,,1051.776,Percent of Total Billed Charges,72% of Total Billed Charges,222.75,75,,1095.6,Percent of Total Billed charges,75% of Total Billed Charges,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.84,72,,1051.776,Percent of Total Billed Charges,72% of Total Billed Charges,178.2,60,,876.48,Percent of Total Billed Charges,60% of Total Billed Charges,267.3,90,,155.584,Percent of Total Billed Charges,90% of Total Billed Charges,133.65,45,,78.592,Percent of Total Billed Charges,45% of Total Billed Charges,267.3,90,,144.472,Percent of Total Billed Charges,90% of Total billed Charges,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.05,65,,146.64,Percent of total Billed Charges,65% of Total Billed Charges,130.98,44.1,,77.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,282.15,95,,152.504,Percent of Total Billed Charges,95% of Total Billed Charges,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.36,88,,198.696,Percent of Total Billed Charges,88% of Total Billed Charges,267.3,90,,144.472,Percent of Total Billed charges,90% of Total Billed Charges,130.98,297,
FLOW CYTOMETRY CELL CYCLE,3100000017,CDM,310,RC,,,Outpatient,,,297.00,193.05,,297,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,225.72,76,,159.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,213.84,72,,1770.624,Percent of Total Billed Charges,72% of Total Billed Charges,222.75,75,,1844.4,Percent of Total Billed charges,75% of Total Billed Charges,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.84,72,,1770.624,Percent of Total Billed Charges,72% of Total Billed Charges,178.2,60,,1475.52,Percent of Total Billed Charges,60% of Total Billed Charges,267.3,90,,112.72,Percent of Total Billed Charges,90% of Total Billed Charges,133.65,45,,101.608,Percent of Total Billed Charges,45% of Total Billed Charges,267.3,90,,188.928,Percent of Total Billed Charges,90% of Total billed Charges,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.05,65,,154.44,Percent of total Billed Charges,65% of Total Billed Charges,130.98,44.1,,99.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,282.15,95,,199.424,Percent of Total Billed Charges,95% of Total Billed Charges,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.36,88,,198.696,Percent of Total Billed Charges,88% of Total Billed Charges,267.3,90,,188.928,Percent of Total Billed charges,90% of Total Billed Charges,130.98,297,
FLOW CYTOMETRY DNA QUEST,3100000018,CDM,310,RC,,,Outpatient,,,312.00,202.80,,312,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.12,76,,159.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,224.64,72,,2541.888,Percent of Total Billed Charges,72% of Total Billed Charges,234,75,,2647.8,Percent of Total Billed charges,75% of Total Billed Charges,312,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.64,72,,2541.888,Percent of Total Billed Charges,72% of Total Billed Charges,187.2,60,,2118.24,Percent of Total Billed Charges,60% of Total Billed Charges,280.8,90,,155.584,Percent of Total Billed Charges,90% of Total Billed Charges,140.4,45,,101.608,Percent of Total Billed Charges,45% of Total Billed Charges,280.8,90,,188.928,Percent of Total Billed Charges,90% of Total billed Charges,312,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.8,65,,154.44,Percent of total Billed Charges,65% of Total Billed Charges,137.59,44.1,,99.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.4,95,,199.424,Percent of Total Billed Charges,95% of Total Billed Charges,312,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.56,88,,97.192,Percent of Total Billed Charges,88% of Total Billed Charges,280.8,90,,188.928,Percent of Total Billed charges,90% of Total Billed Charges,137.59,312,
FLOW CYTOMETRY EA ADD MKR,3100000019,CDM,310,RC,,,Outpatient,,,514.00,334.10,,514,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,390.64,76,,132.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,370.08,72,,3122.496,Percent of Total Billed Charges,72% of Total Billed Charges,385.5,75,,3252.6,Percent of Total Billed charges,75% of Total Billed Charges,514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.08,72,,3122.496,Percent of Total Billed Charges,72% of Total Billed Charges,308.4,60,,2602.08,Percent of Total Billed Charges,60% of Total Billed Charges,462.6,90,,155.584,Percent of Total Billed Charges,90% of Total Billed Charges,231.3,45,,49.704,Percent of Total Billed Charges,45% of Total Billed Charges,462.6,90,,157.176,Percent of Total Billed Charges,90% of Total billed Charges,514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.1,65,,133.64,Percent of total Billed Charges,65% of Total Billed Charges,226.67,44.1,,48.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,488.3,95,,165.912,Percent of Total Billed Charges,95% of Total Billed Charges,514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,452.32,88,,97.192,Percent of Total Billed Charges,88% of Total Billed Charges,462.6,90,,157.176,Percent of Total Billed charges,90% of Total Billed Charges,226.67,514,
GROSS ONLY LEVEL I,3100000020,CDM,310,RC,,,Outpatient,,,103.00,66.95,,103,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,78.28,76,,132.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,74.16,72,,1001.456,Percent of Total Billed Charges,72% of Total Billed Charges,77.25,75,,1043.184,Percent of Total Billed charges,75% of Total Billed Charges,103,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.16,72,,1001.456,Percent of Total Billed Charges,72% of Total Billed Charges,61.8,60,,834.544,Percent of Total Billed Charges,60% of Total Billed Charges,92.7,90,,267.84,Percent of Total Billed Charges,90% of Total Billed Charges,46.35,45,,49.704,Percent of Total Billed Charges,45% of Total Billed Charges,92.7,90,,157.176,Percent of Total Billed Charges,90% of Total billed Charges,103,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.95,65,,133.64,Percent of total Billed Charges,65% of Total Billed Charges,45.42,44.1,,48.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,97.85,95,,165.912,Percent of Total Billed Charges,95% of Total Billed Charges,103,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.64,88,,152.128,Percent of Total Billed Charges,88% of Total Billed Charges,92.7,90,,157.176,Percent of Total Billed charges,90% of Total Billed Charges,45.42,103,
LEVEL II GROSS & MIC,3100000021,CDM,310,RC,,,Outpatient,,,127.00,82.55,,127,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,96.52,76,,171.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.44,72,,449.608,Percent of Total Billed Charges,72% of Total Billed Charges,95.25,75,,468.344,Percent of Total Billed charges,75% of Total Billed Charges,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.44,72,,449.608,Percent of Total Billed Charges,72% of Total Billed Charges,76.2,60,,374.672,Percent of Total Billed Charges,60% of Total Billed Charges,114.3,90,,267.84,Percent of Total Billed Charges,90% of Total Billed Charges,57.15,45,,77.792,Percent of Total Billed Charges,45% of Total Billed Charges,114.3,90,,203.216,Percent of Total Billed Charges,90% of Total billed Charges,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.55,65,,158.6,Percent of total Billed Charges,65% of Total Billed Charges,56.01,44.1,,76.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,120.65,95,,214.504,Percent of Total Billed Charges,95% of Total Billed Charges,127,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.76,88,,152.128,Percent of Total Billed Charges,88% of Total Billed Charges,114.3,90,,203.216,Percent of Total Billed charges,90% of Total Billed Charges,56.01,127,
LEVEL III GROSS & MI,3100000022,CDM,310,RC,,,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,171.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,642.024,Percent of Total Billed Charges,72% of Total Billed Charges,206.25,75,,668.776,Percent of Total Billed charges,75% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,642.024,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,535.024,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,270.72,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,77.792,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,203.216,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,158.6,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,76.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,214.504,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,110.216,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,203.216,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
LEVEL IV GROSS & MIC,3100000023,CDM,310,RC,,,Outpatient,,,285.00,185.25,,285,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,216.6,76,,83.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,205.2,72,,998.28,Percent of Total Billed Charges,72% of Total Billed Charges,213.75,75,,1039.88,Percent of Total Billed charges,75% of Total Billed Charges,285,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.2,72,,998.28,Percent of Total Billed Charges,72% of Total Billed Charges,171,60,,831.904,Percent of Total Billed Charges,60% of Total Billed Charges,256.5,90,,220.32,Percent of Total Billed Charges,90% of Total Billed Charges,128.25,45,,56.36,Percent of Total Billed Charges,45% of Total Billed Charges,256.5,90,,99.4,Percent of Total Billed Charges,90% of Total billed Charges,285,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.25,65,,121.68,Percent of total Billed Charges,65% of Total Billed Charges,125.69,44.1,,55.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,270.75,95,,104.928,Percent of Total Billed Charges,95% of Total Billed Charges,285,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.8,88,,152.128,Percent of Total Billed Charges,88% of Total Billed Charges,256.5,90,,99.4,Percent of Total Billed charges,90% of Total Billed Charges,125.69,285,
LEVEL V GROSS & MICR,3100000024,CDM,310,RC,,,Outpatient,,,317.00,206.05,,317,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,240.92,76,,83.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,228.24,72,,488.448,Percent of Total Billed Charges,72% of Total Billed Charges,237.75,75,,508.8,Percent of Total Billed charges,75% of Total Billed Charges,317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.24,72,,488.448,Percent of Total Billed Charges,72% of Total Billed Charges,190.2,60,,407.04,Percent of Total Billed Charges,60% of Total Billed Charges,285.3,90,,220.32,Percent of Total Billed Charges,90% of Total Billed Charges,142.65,45,,77.792,Percent of Total Billed Charges,45% of Total Billed Charges,285.3,90,,99.4,Percent of Total Billed Charges,90% of Total billed Charges,317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.05,65,,121.68,Percent of total Billed Charges,65% of Total Billed Charges,139.8,44.1,,76.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,301.15,95,,104.928,Percent of Total Billed Charges,95% of Total Billed Charges,317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.96,88,,152.128,Percent of Total Billed Charges,88% of Total Billed Charges,285.3,90,,99.4,Percent of Total Billed charges,90% of Total Billed Charges,139.8,317,
LEVEL VI GROSS & MIC,3100000025,CDM,310,RC,,,Outpatient,,,786.00,510.90,,786,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,597.36,76,,131.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,565.92,72,,834.448,Percent of Total Billed Charges,72% of Total Billed Charges,589.5,75,,869.216,Percent of Total Billed charges,75% of Total Billed Charges,786,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,565.92,72,,834.448,Percent of Total Billed Charges,72% of Total Billed Charges,471.6,60,,695.368,Percent of Total Billed Charges,60% of Total Billed Charges,707.4,90,,194.4,Percent of Total Billed Charges,90% of Total Billed Charges,353.7,45,,77.792,Percent of Total Billed Charges,45% of Total Billed Charges,707.4,90,,155.584,Percent of Total Billed Charges,90% of Total billed Charges,786,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,786,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,786,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,510.9,65,,157.04,Percent of total Billed Charges,65% of Total Billed Charges,346.63,44.1,,76.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,746.7,95,,164.232,Percent of Total Billed Charges,95% of Total Billed Charges,786,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,691.68,88,,261.888,Percent of Total Billed Charges,88% of Total Billed Charges,707.4,90,,155.584,Percent of Total Billed charges,90% of Total Billed Charges,346.63,786,
DECALCIFICATION,3100000026,CDM,310,RC,,,Outpatient,,,83.79,54.46,,83.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,63.68,76,,131.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,60.33,72,,385.472,Percent of Total Billed Charges,72% of Total Billed Charges,62.84,75,,401.536,Percent of Total Billed charges,75% of Total Billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.33,72,,385.472,Percent of Total Billed Charges,72% of Total Billed Charges,50.27,60,,321.224,Percent of Total Billed Charges,60% of Total Billed Charges,75.41,90,,194.4,Percent of Total Billed Charges,90% of Total Billed Charges,37.71,45,,133.92,Percent of Total Billed Charges,45% of Total Billed Charges,75.41,90,,155.584,Percent of Total Billed Charges,90% of Total billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.46,65,,157.04,Percent of total Billed Charges,65% of Total Billed Charges,36.95,44.1,,131.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,79.6,95,,164.232,Percent of Total Billed Charges,95% of Total Billed Charges,83.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.74,88,,261.888,Percent of Total Billed Charges,88% of Total Billed Charges,75.41,90,,155.584,Percent of Total Billed charges,90% of Total Billed Charges,36.95,83.79,
STAIN GROUP 1 MICROORGANISMS,3100000027,CDM,310,RC,,,Outpatient,,,120.00,78.00,,120,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,91.2,76,,95.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,86.4,72,,642.024,Percent of Total Billed Charges,72% of Total Billed Charges,90,75,,668.776,Percent of Total Billed charges,75% of Total Billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.4,72,,642.024,Percent of Total Billed Charges,72% of Total Billed Charges,72,60,,535.024,Percent of Total Billed Charges,60% of Total Billed Charges,108,90,,205.2,Percent of Total Billed Charges,90% of Total Billed Charges,54,45,,133.92,Percent of Total Billed Charges,45% of Total Billed Charges,108,90,,112.72,Percent of Total Billed Charges,90% of Total billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78,65,,129.48,Percent of total Billed Charges,65% of Total Billed Charges,52.92,44.1,,131.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,114,95,,118.984,Percent of Total Billed Charges,95% of Total Billed Charges,120,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.6,88,,264.704,Percent of Total Billed Charges,88% of Total Billed Charges,108,90,,112.72,Percent of Total Billed charges,90% of Total Billed Charges,52.92,120,
SPECIAL STAINII,3100000028,CDM,310,RC,,,Outpatient,,,71.00,46.15,,71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.96,76,,131.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.12,72,,834.448,Percent of Total Billed Charges,72% of Total Billed Charges,53.25,75,,869.216,Percent of Total Billed charges,75% of Total Billed Charges,71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.12,72,,834.448,Percent of Total Billed Charges,72% of Total Billed Charges,42.6,60,,695.368,Percent of Total Billed Charges,60% of Total Billed Charges,63.9,90,,205.2,Percent of Total Billed Charges,90% of Total Billed Charges,31.95,45,,135.36,Percent of Total Billed Charges,45% of Total Billed Charges,63.9,90,,155.584,Percent of Total Billed Charges,90% of Total billed Charges,71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.15,65,,129.48,Percent of total Billed Charges,65% of Total Billed Charges,31.31,44.1,,132.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.45,95,,164.232,Percent of Total Billed Charges,95% of Total Billed Charges,71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.48,88,,215.424,Percent of Total Billed Charges,88% of Total Billed Charges,63.9,90,,155.584,Percent of Total Billed charges,90% of Total Billed Charges,31.31,71,
HISTO CHEM STAIN ADD ON,3100000029,CDM,310,RC,,,Outpatient,,,326.36,212.13,,326.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,248.03,76,,131.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,234.98,72,,1026.856,Percent of Total Billed Charges,72% of Total Billed Charges,244.77,75,,1069.648,Percent of Total Billed charges,75% of Total Billed Charges,326.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.98,72,,1026.856,Percent of Total Billed Charges,72% of Total Billed Charges,195.82,60,,855.712,Percent of Total Billed Charges,60% of Total Billed Charges,293.72,90,,248.4,Percent of Total Billed Charges,90% of Total Billed Charges,146.86,45,,110.16,Percent of Total Billed Charges,45% of Total Billed Charges,293.72,90,,155.584,Percent of Total Billed Charges,90% of Total billed Charges,326.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.13,65,,75.672,Percent of total Billed Charges,65% of Total Billed Charges,143.92,44.1,,107.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,310.04,95,,164.232,Percent of Total Billed Charges,95% of Total Billed Charges,326.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,287.2,88,,215.424,Percent of Total Billed Charges,88% of Total Billed Charges,293.72,90,,155.584,Percent of Total Billed charges,90% of Total Billed Charges,143.92,326.36,
PERIPHERAL BLD SMEAR,3100000030,CDM,310,RC,,,Outpatient,,,125.00,81.25,,125,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95,76,,226.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90,72,,385.472,Percent of Total Billed Charges,72% of Total Billed Charges,93.75,75,,401.536,Percent of Total Billed charges,75% of Total Billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90,72,,385.472,Percent of Total Billed Charges,72% of Total Billed Charges,75,60,,321.224,Percent of Total Billed Charges,60% of Total Billed Charges,112.5,90,,248.4,Percent of Total Billed Charges,90% of Total Billed Charges,56.25,45,,110.16,Percent of Total Billed Charges,45% of Total Billed Charges,112.5,90,,267.84,Percent of Total Billed Charges,90% of Total billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.25,65,,75.672,Percent of total Billed Charges,65% of Total Billed Charges,55.13,44.1,,107.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,118.75,95,,282.72,Percent of Total Billed Charges,95% of Total Billed Charges,125,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110,88,,190.08,Percent of Total Billed Charges,88% of Total Billed Charges,112.5,90,,267.84,Percent of Total Billed charges,90% of Total Billed Charges,55.13,125,
ONE FROZEN SECTION,3100000031,CDM,310,RC,,,Outpatient,,,320.70,208.46,,320.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,243.73,76,,226.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,230.9,72,,385.472,Percent of Total Billed Charges,72% of Total Billed Charges,240.53,75,,401.536,Percent of Total Billed charges,75% of Total Billed Charges,320.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.9,72,,385.472,Percent of Total Billed Charges,72% of Total Billed Charges,192.42,60,,321.224,Percent of Total Billed Charges,60% of Total Billed Charges,288.63,90,,172.256,Percent of Total Billed Charges,90% of Total Billed Charges,144.32,45,,97.2,Percent of Total Billed Charges,45% of Total Billed Charges,288.63,90,,267.84,Percent of Total Billed Charges,90% of Total billed Charges,320.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.46,65,,79.04,Percent of total Billed Charges,65% of Total Billed Charges,141.43,44.1,,95.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,304.67,95,,282.72,Percent of Total Billed Charges,95% of Total Billed Charges,320.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.22,88,,190.08,Percent of Total Billed Charges,88% of Total Billed Charges,288.63,90,,267.84,Percent of Total Billed charges,90% of Total Billed Charges,141.43,320.7,
FROZEN SECT EA ADDL,3100000032,CDM,310,RC,,,Outpatient,,,84.89,55.18,,84.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,64.52,76,,228.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.12,72,,513.744,Percent of Total Billed Charges,72% of Total Billed Charges,63.67,75,,535.152,Percent of Total Billed charges,75% of Total Billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,72,,513.744,Percent of Total Billed Charges,72% of Total Billed Charges,50.93,60,,428.12,Percent of Total Billed Charges,60% of Total Billed Charges,76.4,90,,199.44,Percent of Total Billed Charges,90% of Total Billed Charges,38.2,45,,97.2,Percent of Total Billed Charges,45% of Total Billed Charges,76.4,90,,270.72,Percent of Total Billed Charges,90% of Total billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.18,65,,79.04,Percent of total Billed Charges,65% of Total Billed Charges,37.44,44.1,,95.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,80.65,95,,285.76,Percent of Total Billed Charges,95% of Total Billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.7,88,,200.64,Percent of Total Billed Charges,88% of Total Billed Charges,76.4,90,,270.72,Percent of Total Billed charges,90% of Total Billed Charges,37.44,84.89,
IMMUNOPEROXIDASE ADDITIONAL,3100000033,CDM,310,RC,,,Outpatient,,,295.00,191.75,,295,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,224.2,76,,186.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,212.4,72,,706.168,Percent of Total Billed Charges,72% of Total Billed Charges,221.25,75,,735.592,Percent of Total Billed charges,75% of Total Billed Charges,295,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.4,72,,706.168,Percent of Total Billed Charges,72% of Total Billed Charges,177,60,,588.472,Percent of Total Billed Charges,60% of Total Billed Charges,265.5,90,,199.44,Percent of Total Billed Charges,90% of Total Billed Charges,132.75,45,,102.6,Percent of Total Billed Charges,45% of Total Billed Charges,265.5,90,,220.32,Percent of Total Billed Charges,90% of Total billed Charges,295,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.75,65,,131.04,Percent of total Billed Charges,65% of Total Billed Charges,130.1,44.1,,100.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,280.25,95,,232.56,Percent of Total Billed Charges,95% of Total Billed Charges,295,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.6,88,,200.64,Percent of Total Billed Charges,88% of Total Billed Charges,265.5,90,,220.32,Percent of Total Billed charges,90% of Total Billed Charges,130.1,295,
IMMUNO STUDY,3100000034,CDM,310,RC,,,Outpatient,,,610.00,396.50,,610,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,463.6,76,,186.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,439.2,72,,990.144,Percent of Total Billed Charges,72% of Total Billed Charges,457.5,75,,1031.4,Percent of Total Billed charges,75% of Total Billed Charges,610,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,439.2,72,,990.144,Percent of Total Billed Charges,72% of Total Billed Charges,366,60,,825.12,Percent of Total Billed Charges,60% of Total Billed Charges,549,90,,226.8,Percent of Total Billed Charges,90% of Total Billed Charges,274.5,45,,102.6,Percent of Total Billed Charges,45% of Total Billed Charges,549,90,,220.32,Percent of Total Billed Charges,90% of Total billed Charges,610,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,610,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,610,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.5,65,,131.04,Percent of total Billed Charges,65% of Total Billed Charges,269.01,44.1,,100.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,579.5,95,,232.56,Percent of Total Billed Charges,95% of Total Billed Charges,610,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,536.8,88,,242.88,Percent of Total Billed Charges,88% of Total Billed Charges,549,90,,220.32,Percent of Total Billed charges,90% of Total Billed Charges,269.01,610,
IMMUNOHISTO ANTIBODY SLIDE,3100000035,CDM,310,RC,,,Outpatient,,,320.00,208.00,,320,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,243.2,76,,164.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,230.4,72,,898.584,Percent of Total Billed Charges,72% of Total Billed Charges,240,75,,936.024,Percent of Total Billed charges,75% of Total Billed Charges,320,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.4,72,,898.584,Percent of Total Billed Charges,72% of Total Billed Charges,192,60,,748.816,Percent of Total Billed Charges,60% of Total Billed Charges,288,90,,226.8,Percent of Total Billed Charges,90% of Total Billed Charges,144,45,,124.2,Percent of Total Billed Charges,45% of Total Billed Charges,288,90,,194.4,Percent of Total Billed Charges,90% of Total billed Charges,320,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208,65,,157.56,Percent of total Billed Charges,65% of Total Billed Charges,141.12,44.1,,121.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,304,95,,205.2,Percent of Total Billed Charges,95% of Total Billed Charges,320,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,281.6,88,,242.88,Percent of Total Billed Charges,88% of Total Billed Charges,288,90,,194.4,Percent of Total Billed charges,90% of Total Billed Charges,141.12,320,
IMMUNOFLORESCENT EA,3100000036,CDM,310,RC,,,Outpatient,,,367.50,238.88,,367.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,279.3,76,,164.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,264.6,72,,642.024,Percent of Total Billed Charges,72% of Total Billed Charges,275.63,75,,668.776,Percent of Total Billed charges,75% of Total Billed Charges,367.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.6,72,,642.024,Percent of Total Billed Charges,72% of Total Billed Charges,220.5,60,,535.024,Percent of Total Billed Charges,60% of Total Billed Charges,330.75,90,,272.88,Percent of Total Billed Charges,90% of Total Billed Charges,165.38,45,,124.2,Percent of Total Billed Charges,45% of Total Billed Charges,330.75,90,,194.4,Percent of Total Billed Charges,90% of Total billed Charges,367.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,367.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,367.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.88,65,,157.56,Percent of total Billed Charges,65% of Total Billed Charges,162.07,44.1,,121.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,349.13,95,,205.2,Percent of Total Billed Charges,95% of Total Billed Charges,367.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.4,88,,168.424,Percent of Total Billed Charges,88% of Total Billed Charges,330.75,90,,194.4,Percent of Total Billed charges,90% of Total Billed Charges,162.07,367.5,
IMMUNOFLUOR ANTB ADDL STAIN,3100000037,CDM,310,RC,,,Outpatient,,,180.00,117.00,,180,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,136.8,76,,173.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,129.6,72,,642.024,Percent of Total Billed Charges,72% of Total Billed Charges,135,75,,668.776,Percent of Total Billed charges,75% of Total Billed Charges,180,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.6,72,,642.024,Percent of Total Billed Charges,72% of Total Billed Charges,108,60,,535.024,Percent of Total Billed Charges,60% of Total Billed Charges,162,90,,272.88,Percent of Total Billed Charges,90% of Total Billed Charges,81,45,,86.128,Percent of Total Billed Charges,45% of Total Billed Charges,162,90,,205.2,Percent of Total Billed Charges,90% of Total billed Charges,180,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117,65,,205.92,Percent of total Billed Charges,65% of Total Billed Charges,79.38,44.1,,84.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,171,95,,216.6,Percent of Total Billed Charges,95% of Total Billed Charges,180,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.4,88,,195.008,Percent of Total Billed Charges,88% of Total Billed Charges,162,90,,205.2,Percent of Total Billed charges,90% of Total Billed Charges,79.38,180,
FISH MOP ANAL MANUAL,3100000038,CDM,310,RC,,,Outpatient,,,456.00,296.40,,456,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,346.56,76,,173.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,328.32,72,,577.888,Percent of Total Billed Charges,72% of Total Billed Charges,342,75,,601.968,Percent of Total Billed charges,75% of Total Billed Charges,456,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.32,72,,577.888,Percent of Total Billed Charges,72% of Total Billed Charges,273.6,60,,481.576,Percent of Total Billed Charges,60% of Total Billed Charges,410.4,90,,144.472,Percent of Total Billed Charges,90% of Total Billed Charges,205.2,45,,99.72,Percent of Total Billed Charges,45% of Total Billed Charges,410.4,90,,205.2,Percent of Total Billed Charges,90% of Total billed Charges,456,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.4,65,,205.92,Percent of total Billed Charges,65% of Total Billed Charges,201.1,44.1,,97.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,433.2,95,,216.6,Percent of Total Billed Charges,95% of Total Billed Charges,456,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.28,88,,195.008,Percent of Total Billed Charges,88% of Total Billed Charges,410.4,90,,205.2,Percent of Total Billed charges,90% of Total Billed Charges,201.1,456,
HPV TISSUE IN SITU,3100000039,CDM,310,RC,,,Outpatient,,,362.01,235.31,,362.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,275.13,76,,209.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,260.65,72,,1026.856,Percent of Total Billed Charges,72% of Total Billed Charges,271.51,75,,1069.648,Percent of Total Billed charges,75% of Total Billed Charges,362.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.65,72,,1026.856,Percent of Total Billed Charges,72% of Total Billed Charges,217.21,60,,855.712,Percent of Total Billed Charges,60% of Total Billed Charges,325.81,90,,210.96,Percent of Total Billed Charges,90% of Total Billed Charges,162.9,45,,99.72,Percent of Total Billed Charges,45% of Total Billed Charges,325.81,90,,248.4,Percent of Total Billed Charges,90% of Total billed Charges,362.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,362.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,362.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.31,65,,170.04,Percent of total Billed Charges,65% of Total Billed Charges,159.65,44.1,,97.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,343.91,95,,262.2,Percent of Total Billed Charges,95% of Total Billed Charges,362.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.57,88,,221.76,Percent of Total Billed Charges,88% of Total Billed Charges,325.81,90,,248.4,Percent of Total Billed charges,90% of Total Billed Charges,159.65,362.01,
PKU GENE SEQUENCING,3100000041,CDM,310,RC,,,Outpatient,,,710.00,461.50,,710,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,539.6,76,,145.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,511.2,72,,1758.76,Percent of Total Billed Charges,72% of Total Billed Charges,532.5,75,,1832.04,Percent of Total Billed charges,75% of Total Billed Charges,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511.2,72,,1758.76,Percent of Total Billed Charges,72% of Total Billed Charges,426,60,,1465.632,Percent of Total Billed Charges,60% of Total Billed Charges,639,90,,203.04,Percent of Total Billed Charges,90% of Total Billed Charges,319.5,45,,113.4,Percent of Total Billed Charges,45% of Total Billed Charges,639,90,,172.256,Percent of Total Billed Charges,90% of Total billed Charges,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,461.5,65,,127.4,Percent of total Billed Charges,65% of Total Billed Charges,313.11,44.1,,111.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,674.5,95,,181.824,Percent of Total Billed Charges,95% of Total Billed Charges,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,624.8,88,,266.816,Percent of Total Billed Charges,88% of Total Billed Charges,639,90,,172.256,Percent of Total Billed charges,90% of Total Billed Charges,313.11,710,
THIOPURINE S METHYLTRANSFERASE,3100000042,CDM,310,RC,,,Outpatient,,,437.00,284.05,,437,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,332.12,76,,168.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,314.64,72,,508.912,Percent of Total Billed Charges,72% of Total Billed Charges,327.75,75,,530.12,Percent of Total Billed charges,75% of Total Billed Charges,437,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.64,72,,508.912,Percent of Total Billed Charges,72% of Total Billed Charges,262.2,60,,424.096,Percent of Total Billed Charges,60% of Total Billed Charges,393.3,90,,203.04,Percent of Total Billed Charges,90% of Total Billed Charges,196.65,45,,136.44,Percent of Total Billed Charges,45% of Total Billed Charges,393.3,90,,199.44,Percent of Total Billed Charges,90% of Total billed Charges,437,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.05,65,,127.4,Percent of total Billed Charges,65% of Total Billed Charges,192.72,44.1,,133.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,415.15,95,,210.52,Percent of Total Billed Charges,95% of Total Billed Charges,437,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.56,88,,266.816,Percent of Total Billed Charges,88% of Total Billed Charges,393.3,90,,199.44,Percent of Total Billed charges,90% of Total Billed Charges,192.72,437,
CYTP FNA EVAL EA ADD,3110000001,CDM,311,RC,,,Outpatient,,,86.00,55.90,,86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,65.36,76,,168.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.92,72,,508.912,Percent of Total Billed Charges,72% of Total Billed Charges,64.5,75,,530.12,Percent of Total Billed charges,75% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.92,72,,508.912,Percent of Total Billed Charges,72% of Total Billed Charges,51.6,60,,424.096,Percent of Total Billed Charges,60% of Total Billed Charges,77.4,90,,213.84,Percent of Total Billed Charges,90% of Total Billed Charges,38.7,45,,136.44,Percent of Total Billed Charges,45% of Total Billed Charges,77.4,90,,199.44,Percent of Total Billed Charges,90% of Total billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.9,65,,178.36,Percent of total Billed Charges,65% of Total Billed Charges,37.93,44.1,,133.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,81.7,95,,210.52,Percent of Total Billed Charges,95% of Total Billed Charges,86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.68,88,,141.264,Percent of Total Billed Charges,88% of Total Billed Charges,77.4,90,,199.44,Percent of Total Billed charges,90% of Total Billed Charges,37.93,86,
FLOW CYTOMETRY DNA,3110000002,CDM,311,RC,,,Outpatient,,,312.00,202.80,,312,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,237.12,76,,191.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,224.64,72,,1808.632,Percent of Total Billed Charges,72% of Total Billed Charges,234,75,,1883.992,Percent of Total Billed charges,75% of Total Billed Charges,312,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.64,72,,1808.632,Percent of Total Billed Charges,72% of Total Billed Charges,187.2,60,,1507.192,Percent of Total Billed Charges,60% of Total Billed Charges,280.8,90,,213.84,Percent of Total Billed Charges,90% of Total Billed Charges,140.4,45,,72.24,Percent of Total Billed Charges,45% of Total Billed Charges,280.8,90,,226.8,Percent of Total Billed Charges,90% of Total billed Charges,312,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.8,65,,178.36,Percent of total Billed Charges,65% of Total Billed Charges,137.59,44.1,,70.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,296.4,95,,239.4,Percent of Total Billed Charges,95% of Total Billed Charges,312,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.56,88,,206.272,Percent of Total Billed Charges,88% of Total Billed Charges,280.8,90,,226.8,Percent of Total Billed charges,90% of Total Billed Charges,137.59,312,
CYTOLOGIC EXAMINATION CONSULT,3110000003,CDM,311,RC,,,Outpatient,,,759.00,493.35,,759,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,576.84,76,,191.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,546.48,72,,766.08,Percent of Total Billed Charges,72% of Total Billed Charges,569.25,75,,798,Percent of Total Billed charges,75% of Total Billed Charges,759,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.48,72,,766.08,Percent of Total Billed Charges,72% of Total Billed Charges,455.4,60,,638.4,Percent of Total Billed Charges,60% of Total Billed Charges,683.1,90,,185.04,Percent of Total Billed Charges,90% of Total Billed Charges,341.55,45,,105.48,Percent of Total Billed Charges,45% of Total Billed Charges,683.1,90,,226.8,Percent of Total Billed Charges,90% of Total billed Charges,759,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.35,65,,134.16,Percent of total Billed Charges,65% of Total Billed Charges,334.72,44.1,,103.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,721.05,95,,239.4,Percent of Total Billed Charges,95% of Total Billed Charges,759,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,667.92,88,,206.272,Percent of Total Billed Charges,88% of Total Billed Charges,683.1,90,,226.8,Percent of Total Billed charges,90% of Total Billed Charges,334.72,759,
FLOW CYTOMETRY TC 1ST MARKER,3110000004,CDM,311,RC,,,Outpatient,,,700.30,455.20,,700.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,532.23,76,,230.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,504.22,72,,1026.856,Percent of Total Billed Charges,72% of Total Billed Charges,525.23,75,,1069.648,Percent of Total Billed charges,75% of Total Billed Charges,700.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,504.22,72,,1026.856,Percent of Total Billed Charges,72% of Total Billed Charges,420.18,60,,855.712,Percent of Total Billed Charges,60% of Total Billed Charges,630.27,90,,185.04,Percent of Total Billed Charges,90% of Total Billed Charges,315.14,45,,105.48,Percent of Total Billed Charges,45% of Total Billed Charges,630.27,90,,272.88,Percent of Total Billed Charges,90% of Total billed Charges,700.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,700.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,700.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,455.2,65,,134.16,Percent of total Billed Charges,65% of Total Billed Charges,308.83,44.1,,103.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,665.29,95,,288.04,Percent of Total Billed Charges,95% of Total Billed Charges,700.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,616.26,88,,198.528,Percent of Total Billed Charges,88% of Total Billed Charges,630.27,90,,272.88,Percent of Total Billed charges,90% of Total Billed Charges,308.83,700.3,
CONSULT ON REF TO ANOTHER LAB,3120000001,CDM,312,RC,,,Outpatient,,,250.00,162.50,,250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,190,76,,230.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,180,72,,593.128,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,75,,617.848,Percent of Total Billed charges,75% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180,72,,593.128,Percent of Total Billed Charges,72% of Total Billed Charges,150,60,,494.272,Percent of Total Billed Charges,60% of Total Billed Charges,225,90,,219.6,Percent of Total Billed Charges,90% of Total Billed Charges,112.5,45,,101.52,Percent of Total Billed Charges,45% of Total Billed Charges,225,90,,272.88,Percent of Total Billed Charges,90% of Total billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.5,65,,169.52,Percent of total Billed Charges,65% of Total Billed Charges,110.25,44.1,,99.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,237.5,95,,288.04,Percent of Total Billed Charges,95% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220,88,,198.528,Percent of Total Billed Charges,88% of Total Billed Charges,225,90,,272.88,Percent of Total Billed charges,90% of Total Billed Charges,110.25,250,
PATH CONSULT DURING SURGERY,3120000002,CDM,312,RC,,,Outpatient,,,126.00,81.90,,126,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,95.76,76,,122,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,90.72,72,,252.112,Percent of Total Billed Charges,72% of Total Billed Charges,94.5,75,,262.616,Percent of Total Billed charges,75% of Total Billed Charges,126,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.72,72,,252.112,Percent of Total Billed Charges,72% of Total Billed Charges,75.6,60,,210.088,Percent of Total Billed Charges,60% of Total Billed Charges,113.4,90,,219.6,Percent of Total Billed Charges,90% of Total Billed Charges,56.7,45,,101.52,Percent of Total Billed Charges,45% of Total Billed Charges,113.4,90,,144.472,Percent of Total Billed Charges,90% of Total billed Charges,126,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.9,65,,177.152,Percent of total Billed Charges,65% of Total Billed Charges,55.57,44.1,,99.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,119.7,95,,152.504,Percent of Total Billed Charges,95% of Total Billed Charges,126,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.88,88,,209.088,Percent of Total Billed Charges,88% of Total Billed Charges,113.4,90,,144.472,Percent of Total Billed charges,90% of Total Billed Charges,55.57,126,
ELECTRON MICROSCOPY,3120000003,CDM,312,RC,,,Outpatient,,,1515.99,985.39,,1515.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1152.15,76,,178.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1091.51,72,,1508.544,Percent of Total Billed Charges,72% of Total Billed Charges,1136.99,75,,1571.4,Percent of Total Billed charges,75% of Total Billed Charges,1515.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1091.51,72,,1508.544,Percent of Total Billed Charges,72% of Total Billed Charges,909.59,60,,1257.12,Percent of Total Billed Charges,60% of Total Billed Charges,1364.39,90,,168.48,Percent of Total Billed Charges,90% of Total Billed Charges,682.2,45,,106.92,Percent of Total Billed Charges,45% of Total Billed Charges,1364.39,90,,210.96,Percent of Total Billed Charges,90% of Total billed Charges,1515.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1515.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1515.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,985.39,65,,142.48,Percent of total Billed Charges,65% of Total Billed Charges,668.55,44.1,,104.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,1440.19,95,,222.68,Percent of Total Billed Charges,95% of Total Billed Charges,1515.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1334.07,88,,209.088,Percent of Total Billed Charges,88% of Total Billed Charges,1364.39,90,,210.96,Percent of Total Billed charges,90% of Total Billed Charges,668.55,1515.99,
SPECIAL STAIN PATHOLOGY,3120000004,CDM,312,RC,,,Outpatient,,,180.00,117.00,,180,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,136.8,76,,178.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,129.6,72,,2122.56,Percent of Total Billed Charges,72% of Total Billed Charges,135,75,,2211,Percent of Total Billed charges,75% of Total Billed Charges,180,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.6,72,,2122.56,Percent of Total Billed Charges,72% of Total Billed Charges,108,60,,1768.8,Percent of Total Billed Charges,60% of Total Billed Charges,162,90,,168.48,Percent of Total Billed Charges,90% of Total Billed Charges,81,45,,106.92,Percent of Total Billed Charges,45% of Total Billed Charges,162,90,,210.96,Percent of Total Billed Charges,90% of Total billed Charges,180,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117,65,,147.16,Percent of total Billed Charges,65% of Total Billed Charges,79.38,44.1,,104.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,171,95,,222.68,Percent of Total Billed Charges,95% of Total Billed Charges,180,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.4,88,,180.928,Percent of Total Billed Charges,88% of Total Billed Charges,162,90,,210.96,Percent of Total Billed charges,90% of Total Billed Charges,79.38,180,
INSITU HYBRID FISH,3120000005,CDM,312,RC,,,Outpatient,,,500.00,325.00,,500,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,380,76,,171.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,360,72,,345.6,Percent of Total Billed Charges,72% of Total Billed Charges,375,75,,360,Percent of Total Billed charges,75% of Total Billed Charges,500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,72,,345.6,Percent of Total Billed Charges,72% of Total Billed Charges,300,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,450,90,,217.44,Percent of Total Billed Charges,90% of Total Billed Charges,225,45,,92.52,Percent of Total Billed Charges,45% of Total Billed Charges,450,90,,203.04,Percent of Total Billed Charges,90% of Total billed Charges,500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325,65,,147.16,Percent of total Billed Charges,65% of Total Billed Charges,220.5,44.1,,90.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,475,95,,214.32,Percent of Total Billed Charges,95% of Total Billed Charges,500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440,88,,180.928,Percent of Total Billed Charges,88% of Total Billed Charges,450,90,,203.04,Percent of Total Billed charges,90% of Total Billed Charges,220.5,500,
PERCU DRAIN PERITON/ VISCERAL,3200000001,CDM,320,RC,,,Outpatient,,,2059.47,1338.66,,2059.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1565.2,76,,171.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1482.82,72,,1099.008,Percent of Total Billed Charges,72% of Total Billed Charges,1544.6,75,,1144.8,Percent of Total Billed charges,75% of Total Billed Charges,2059.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1482.82,72,,1099.008,Percent of Total Billed Charges,72% of Total Billed Charges,1235.68,60,,915.84,Percent of Total Billed Charges,60% of Total Billed Charges,1853.52,90,,217.44,Percent of Total Billed Charges,90% of Total Billed Charges,926.76,45,,92.52,Percent of Total Billed Charges,45% of Total Billed Charges,1853.52,90,,203.04,Percent of Total Billed Charges,90% of Total billed Charges,2059.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2059.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2059.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1338.66,65,,710.136,Percent of total Billed Charges,65% of Total Billed Charges,908.23,44.1,,90.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,1956.5,95,,214.32,Percent of Total Billed Charges,95% of Total Billed Charges,2059.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1812.33,88,,214.72,Percent of Total Billed Charges,88% of Total Billed Charges,1853.52,90,,203.04,Percent of Total Billed charges,90% of Total Billed Charges,908.23,2059.47,
ANGIOGRAPHY EXTREMITY UNILAT,3200000002,CDM,320,RC,,,Outpatient,,,8526.74,5542.38,,8526.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6480.32,76,,180.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6139.25,72,,922.712,Percent of Total Billed Charges,72% of Total Billed Charges,6395.06,75,,961.16,Percent of Total Billed charges,75% of Total Billed Charges,8526.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6139.25,72,,922.712,Percent of Total Billed Charges,72% of Total Billed Charges,5116.04,60,,768.928,Percent of Total Billed Charges,60% of Total Billed Charges,7674.07,90,,179.28,Percent of Total Billed Charges,90% of Total Billed Charges,3837.03,45,,109.8,Percent of Total Billed Charges,45% of Total Billed Charges,7674.07,90,,213.84,Percent of Total Billed Charges,90% of Total billed Charges,8526.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8526.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8526.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5542.38,65,,446.032,Percent of total Billed Charges,65% of Total Billed Charges,3760.29,44.1,,107.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,8100.4,95,,225.72,Percent of Total Billed Charges,95% of Total Billed Charges,8526.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7503.53,88,,214.72,Percent of Total Billed Charges,88% of Total Billed Charges,7674.07,90,,213.84,Percent of Total Billed charges,90% of Total Billed Charges,3760.29,8526.74,
ARTHROGRAM HIP INJE W/OUT ANES,3200000003,CDM,320,RC,,,Outpatient,,,437.69,284.50,,437.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,332.64,76,,180.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,315.14,72,,1127.232,Percent of Total Billed Charges,72% of Total Billed Charges,328.27,75,,1174.2,Percent of Total Billed charges,75% of Total Billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.14,72,,1127.232,Percent of Total Billed Charges,72% of Total Billed Charges,262.61,60,,939.36,Percent of Total Billed Charges,60% of Total Billed Charges,393.92,90,,179.28,Percent of Total Billed Charges,90% of Total Billed Charges,196.96,45,,109.8,Percent of Total Billed Charges,45% of Total Billed Charges,393.92,90,,213.84,Percent of Total Billed Charges,90% of Total billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.5,65,,446.032,Percent of total Billed Charges,65% of Total Billed Charges,193.02,44.1,,107.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,415.81,95,,225.72,Percent of Total Billed Charges,95% of Total Billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.17,88,,164.736,Percent of Total Billed Charges,88% of Total Billed Charges,393.92,90,,213.84,Percent of Total Billed charges,90% of Total Billed Charges,193.02,437.69,
FISTULA ABCES/SINUS TRACT STDY,3200000004,CDM,320,RC,,,Outpatient,,,650.00,422.50,,650,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,494,76,,156.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,468,72,,772.208,Percent of Total Billed Charges,72% of Total Billed Charges,487.5,75,,804.384,Percent of Total Billed charges,75% of Total Billed Charges,650,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,468,72,,772.208,Percent of Total Billed Charges,72% of Total Billed Charges,390,60,,643.504,Percent of Total Billed Charges,60% of Total Billed Charges,585,90,,104.784,Percent of Total Billed Charges,90% of Total Billed Charges,292.5,45,,84.24,Percent of Total Billed Charges,45% of Total Billed Charges,585,90,,185.04,Percent of Total Billed Charges,90% of Total billed Charges,650,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,650,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,650,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.5,65,,812.84,Percent of total Billed Charges,65% of Total Billed Charges,286.65,44.1,,82.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,617.5,95,,195.32,Percent of Total Billed Charges,95% of Total Billed Charges,650,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,572,88,,164.736,Percent of Total Billed Charges,88% of Total Billed Charges,585,90,,185.04,Percent of Total Billed charges,90% of Total Billed Charges,286.65,650,
FLUORO GDE CVC PLCE OR REP/REM,3200000005,CDM,320,RC,,,Outpatient,,,1010.00,656.50,,1010,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,767.6,76,,156.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,727.2,72,,4468.8,Percent of Total Billed Charges,72% of Total Billed Charges,757.5,75,,4655.008,Percent of Total Billed charges,75% of Total Billed Charges,1010,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,727.2,72,,4468.8,Percent of Total Billed Charges,72% of Total Billed Charges,606,60,,3724,Percent of Total Billed Charges,60% of Total Billed Charges,909,90,,104.784,Percent of Total Billed Charges,90% of Total Billed Charges,454.5,45,,84.24,Percent of Total Billed Charges,45% of Total Billed Charges,909,90,,185.04,Percent of Total Billed Charges,90% of Total billed Charges,1010,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1010,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1010,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,656.5,65,,99.176,Percent of total Billed Charges,65% of Total Billed Charges,445.41,44.1,,82.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,959.5,95,,195.32,Percent of Total Billed Charges,95% of Total Billed Charges,1010,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,888.8,88,,212.608,Percent of Total Billed Charges,88% of Total Billed Charges,909,90,,185.04,Percent of Total Billed charges,90% of Total Billed Charges,445.41,1010,
FLUORO GDE CVC PLCE OR REP/REM,3200000006,CDM,320,RC,,,Outpatient,,,934.50,607.43,,934.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,710.22,76,,185.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,672.84,72,,4459.968,Percent of Total Billed Charges,72% of Total Billed Charges,700.88,75,,4645.8,Percent of Total Billed charges,75% of Total Billed Charges,934.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.84,72,,4459.968,Percent of Total Billed Charges,72% of Total Billed Charges,560.7,60,,3716.64,Percent of Total Billed Charges,60% of Total Billed Charges,841.05,90,,109.44,Percent of Total Billed Charges,90% of Total Billed Charges,420.53,45,,108.72,Percent of Total Billed Charges,45% of Total Billed Charges,841.05,90,,219.6,Percent of Total Billed Charges,90% of Total billed Charges,934.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,934.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,934.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.43,65,,321.36,Percent of total Billed Charges,65% of Total Billed Charges,412.11,44.1,,106.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,887.78,95,,231.8,Percent of Total Billed Charges,95% of Total Billed Charges,934.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,822.36,88,,212.608,Percent of Total Billed Charges,88% of Total Billed Charges,841.05,90,,219.6,Percent of Total Billed charges,90% of Total Billed Charges,412.11,934.5,
HEPATIC VENOGRAPHY W/O HEMO EV,3200000007,CDM,320,RC,,,Outpatient,,,5800.00,3770.00,,5800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4408,76,,185.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4176,72,,2448.576,Percent of Total Billed Charges,72% of Total Billed Charges,4350,75,,2550.6,Percent of Total Billed charges,75% of Total Billed Charges,5800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4176,72,,2448.576,Percent of Total Billed Charges,72% of Total Billed Charges,3480,60,,2040.48,Percent of Total Billed Charges,60% of Total Billed Charges,5220,90,,109.44,Percent of Total Billed Charges,90% of Total Billed Charges,2610,45,,108.72,Percent of Total Billed Charges,45% of Total Billed Charges,5220,90,,219.6,Percent of Total Billed Charges,90% of Total billed Charges,5800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3770,65,,110.216,Percent of total Billed Charges,65% of Total Billed Charges,2557.8,44.1,,106.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,5510,95,,231.8,Percent of Total Billed Charges,95% of Total Billed Charges,5800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5104,88,,175.296,Percent of Total Billed Charges,88% of Total Billed Charges,5220,90,,219.6,Percent of Total Billed charges,90% of Total Billed Charges,2557.8,5800,
PERC DRAIN CATH TUBE CHANGE,3200000008,CDM,320,RC,,,Outpatient,,,756.32,491.61,,756.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,574.8,76,,142.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,544.55,72,,875.52,Percent of Total Billed Charges,72% of Total Billed Charges,567.24,75,,912,Percent of Total Billed charges,75% of Total Billed Charges,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,544.55,72,,875.52,Percent of Total Billed Charges,72% of Total Billed Charges,453.79,60,,729.6,Percent of Total Billed Charges,60% of Total Billed Charges,680.69,90,,181.44,Percent of Total Billed Charges,90% of Total Billed Charges,340.34,45,,89.64,Percent of Total Billed Charges,45% of Total Billed Charges,680.69,90,,168.48,Percent of Total Billed Charges,90% of Total billed Charges,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.61,65,,287.24,Percent of total Billed Charges,65% of Total Billed Charges,333.54,44.1,,87.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,718.5,95,,177.84,Percent of Total Billed Charges,95% of Total Billed Charges,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,665.56,88,,175.296,Percent of Total Billed Charges,88% of Total Billed Charges,680.69,90,,168.48,Percent of Total Billed charges,90% of Total Billed Charges,333.54,756.32,
PERCU CONTR INJ EX TBE W/IMAG,3200000009,CDM,320,RC,,,Outpatient,,,575.51,374.08,,575.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,437.39,76,,142.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,414.37,72,,484.536,Percent of Total Billed Charges,72% of Total Billed Charges,431.63,75,,504.728,Percent of Total Billed charges,75% of Total Billed Charges,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.37,72,,484.536,Percent of Total Billed Charges,72% of Total Billed Charges,345.31,60,,403.784,Percent of Total Billed Charges,60% of Total Billed Charges,517.96,90,,181.44,Percent of Total Billed Charges,90% of Total Billed Charges,258.98,45,,89.64,Percent of Total Billed Charges,45% of Total Billed Charges,517.96,90,,168.48,Percent of Total Billed Charges,90% of Total billed Charges,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.08,65,,1841.84,Percent of total Billed Charges,65% of Total Billed Charges,253.8,44.1,,87.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,546.73,95,,177.84,Percent of Total Billed Charges,95% of Total Billed Charges,575.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.45,88,,102.456,Percent of Total Billed Charges,88% of Total Billed Charges,517.96,90,,168.48,Percent of Total Billed charges,90% of Total Billed Charges,253.8,575.51,
RAD INJ SACROILIAC JNT W/ IMAG,3200000010,CDM,320,RC,G0260,HCPCS,Outpatient,,,2007.81,1305.08,,870.53,125,,,Fee Schedule,125% of CMS OPPS Rate,1525.94,76,,183.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1445.62,72,,1067.904,Percent of Total Billed Charges,72% of Total Billed Charges,1505.86,75,,1112.4,Percent of Total Billed charges,75% of Total Billed Charges,696.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1445.62,72,,1067.904,Percent of Total Billed Charges,72% of Total Billed Charges,1204.69,60,,889.92,Percent of Total Billed Charges,60% of Total Billed Charges,1807.03,90,,218.16,Percent of Total Billed Charges,90% of Total Billed Charges,903.51,45,,52.392,Percent of Total Billed Charges,45% of Total Billed Charges,1807.03,90,,217.44,Percent of Total Billed Charges,90% of Total billed Charges,696.42,100,,,Fee Schedule,100% of CMS OPPS Rate,696.42,100,,,Fee Schedule,100% of CMS OPPS Rate,696.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1300.52,200,,105.08,Fee Schedule,200% of CMS OPPS Rate,885.44,44.1,,51.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,1907.42,95,,229.52,Percent of Total Billed Charges,95% of Total Billed Charges,522.3,75,,,Fee Schedule,75% of CMS OPPS Rate,1766.87,88,,102.456,Percent of Total Billed Charges,88% of Total Billed Charges,1807.03,90,,217.44,Percent of Total Billed charges,90% of Total Billed Charges,522.3,1907.42,
RAD INJ SACROILIAC JNT W/ IMAG,3200000011,CDM,320,RC,G0260,HCPCS,Outpatient,,,1908.00,1240.20,,870.53,125,,,Fee Schedule,125% of CMS OPPS Rate,1450.08,76,,183.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1373.76,72,,1689.408,Percent of Total Billed Charges,72% of Total Billed Charges,1431,75,,1759.8,Percent of Total Billed charges,75% of Total Billed Charges,696.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1373.76,72,,1689.408,Percent of Total Billed Charges,72% of Total Billed Charges,1144.8,60,,1407.84,Percent of Total Billed Charges,60% of Total Billed Charges,1717.2,90,,218.16,Percent of Total Billed Charges,90% of Total Billed Charges,858.6,45,,52.392,Percent of Total Billed Charges,45% of Total Billed Charges,1717.2,90,,217.44,Percent of Total Billed Charges,90% of Total billed Charges,696.42,100,,,Fee Schedule,100% of CMS OPPS Rate,696.42,100,,,Fee Schedule,100% of CMS OPPS Rate,696.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1300.52,200,,164.84,Fee Schedule,200% of CMS OPPS Rate,841.43,44.1,,51.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,1812.6,95,,229.52,Percent of Total Billed Charges,95% of Total Billed Charges,522.3,75,,,Fee Schedule,75% of CMS OPPS Rate,1679.04,88,,107.008,Percent of Total Billed Charges,88% of Total Billed Charges,1717.2,90,,217.44,Percent of Total Billed charges,90% of Total Billed Charges,522.3,1812.6,
SCLEROTHERAPY OF FLUID COLLEC,3200000012,CDM,320,RC,,,Outpatient,,,1642.00,1067.30,,1642,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1247.92,76,,151.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1182.24,72,,1587.6,Percent of Total Billed Charges,72% of Total Billed Charges,1231.5,75,,1653.752,Percent of Total Billed charges,75% of Total Billed Charges,1642,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1182.24,72,,1587.6,Percent of Total Billed Charges,72% of Total Billed Charges,985.2,60,,1323,Percent of Total Billed Charges,60% of Total Billed Charges,1477.8,90,,285.12,Percent of Total Billed Charges,90% of Total Billed Charges,738.9,45,,54.72,Percent of Total Billed Charges,45% of Total Billed Charges,1477.8,90,,179.28,Percent of Total Billed Charges,90% of Total billed Charges,1642,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1642,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1642,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1067.3,65,,730.6,Percent of total Billed Charges,65% of Total Billed Charges,724.12,44.1,,53.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,1559.9,95,,189.24,Percent of Total Billed Charges,95% of Total Billed Charges,1642,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1444.96,88,,107.008,Percent of Total Billed Charges,88% of Total Billed Charges,1477.8,90,,179.28,Percent of Total Billed charges,90% of Total Billed Charges,724.12,1642,
SCOLIOSIS EVAL 2 OR 3 VIEWS,3200000013,CDM,320,RC,,,Outpatient,,,379.00,246.35,,379,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,288.04,76,,151.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,272.88,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,284.25,75,,1200,Percent of Total Billed charges,75% of Total Billed Charges,379,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.88,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,227.4,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,341.1,90,,285.12,Percent of Total Billed Charges,90% of Total Billed Charges,170.55,45,,54.72,Percent of Total Billed Charges,45% of Total Billed Charges,341.1,90,,179.28,Percent of Total Billed Charges,90% of Total billed Charges,379,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.35,65,,730.6,Percent of total Billed Charges,65% of Total Billed Charges,167.14,44.1,,53.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,360.05,95,,189.24,Percent of Total Billed Charges,95% of Total Billed Charges,379,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.52,88,,177.408,Percent of Total Billed Charges,88% of Total Billed Charges,341.1,90,,179.28,Percent of Total Billed charges,90% of Total Billed Charges,167.14,379,
SCOLIOSIS EVAL ONE VIEW ONLY,3200000014,CDM,320,RC,,,Outpatient,,,522.00,339.30,,522,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,396.72,76,,88.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,375.84,72,,1668.096,Percent of Total Billed Charges,72% of Total Billed Charges,391.5,75,,1737.6,Percent of Total Billed charges,75% of Total Billed Charges,522,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.84,72,,1668.096,Percent of Total Billed Charges,72% of Total Billed Charges,313.2,60,,1390.08,Percent of Total Billed Charges,60% of Total Billed Charges,469.8,90,,235.44,Percent of Total Billed Charges,90% of Total Billed Charges,234.9,45,,90.72,Percent of Total Billed Charges,45% of Total Billed Charges,469.8,90,,104.784,Percent of Total Billed Charges,90% of Total billed Charges,522,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,522,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,522,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,339.3,65,,644.96,Percent of total Billed Charges,65% of Total Billed Charges,230.2,44.1,,88.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,495.9,95,,110.6,Percent of Total Billed Charges,95% of Total Billed Charges,522,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,459.36,88,,177.408,Percent of Total Billed Charges,88% of Total Billed Charges,469.8,90,,104.784,Percent of Total Billed charges,90% of Total Billed Charges,230.2,522,
"SPINAL PUNCTURE  LUMBAR, DIAG",3200000015,CDM,320,RC,,,Outpatient,,,1120.14,728.09,,1120.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,851.31,76,,88.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,806.5,72,,1412.352,Percent of Total Billed Charges,72% of Total Billed Charges,840.11,75,,1471.2,Percent of Total Billed charges,75% of Total Billed Charges,1120.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,806.5,72,,1412.352,Percent of Total Billed Charges,72% of Total Billed Charges,672.08,60,,1176.96,Percent of Total Billed Charges,60% of Total Billed Charges,1008.13,90,,235.44,Percent of Total Billed Charges,90% of Total Billed Charges,504.06,45,,90.72,Percent of Total Billed Charges,45% of Total Billed Charges,1008.13,90,,104.784,Percent of Total Billed Charges,90% of Total billed Charges,1120.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1120.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1120.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,728.09,65,,613.08,Percent of total Billed Charges,65% of Total Billed Charges,493.98,44.1,,88.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,1064.13,95,,110.6,Percent of Total Billed Charges,95% of Total Billed Charges,1120.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,985.72,88,,213.312,Percent of Total Billed Charges,88% of Total Billed Charges,1008.13,90,,104.784,Percent of Total Billed charges,90% of Total Billed Charges,493.98,1120.14,
SUPERIOR SAGITTAL SIN VENOGRAM,3200000016,CDM,320,RC,,,Outpatient,,,1903.62,1237.35,,1903.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1446.75,76,,92.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1370.61,72,,2183.616,Percent of Total Billed Charges,72% of Total Billed Charges,1427.72,75,,2274.6,Percent of Total Billed charges,75% of Total Billed Charges,1903.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1370.61,72,,2183.616,Percent of Total Billed Charges,72% of Total Billed Charges,1142.17,60,,1819.68,Percent of Total Billed Charges,60% of Total Billed Charges,1713.26,90,,176.4,Percent of Total Billed Charges,90% of Total Billed Charges,856.63,45,,109.08,Percent of Total Billed Charges,45% of Total Billed Charges,1713.26,90,,109.44,Percent of Total Billed Charges,90% of Total billed Charges,1903.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1903.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1903.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1237.35,65,,644.96,Percent of total Billed Charges,65% of Total Billed Charges,839.5,44.1,,106.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,1808.44,95,,115.52,Percent of Total Billed Charges,95% of Total Billed Charges,1903.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1675.19,88,,213.312,Percent of Total Billed Charges,88% of Total Billed Charges,1713.26,90,,109.44,Percent of Total Billed charges,90% of Total Billed Charges,839.5,1903.62,
UROGRAPHY W NEPHROTOMOGRAPHY,3200000020,CDM,320,RC,,,Outpatient,,,1160.93,754.60,,1160.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,882.31,76,,92.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,835.87,72,,1585.728,Percent of Total Billed Charges,72% of Total Billed Charges,870.7,75,,1651.8,Percent of Total Billed charges,75% of Total Billed Charges,1160.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,835.87,72,,1585.728,Percent of Total Billed Charges,72% of Total Billed Charges,696.56,60,,1321.44,Percent of Total Billed Charges,60% of Total Billed Charges,1044.84,90,,176.4,Percent of Total Billed Charges,90% of Total Billed Charges,522.42,45,,109.08,Percent of Total Billed Charges,45% of Total Billed Charges,1044.84,90,,109.44,Percent of Total Billed Charges,90% of Total billed Charges,1160.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1160.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1160.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,754.6,65,,613.08,Percent of total Billed Charges,65% of Total Billed Charges,511.97,44.1,,106.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,1102.88,95,,115.52,Percent of Total Billed Charges,95% of Total Billed Charges,1160.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1021.62,88,,278.784,Percent of Total Billed Charges,88% of Total Billed Charges,1044.84,90,,109.44,Percent of Total Billed charges,90% of Total Billed Charges,511.97,1160.93,
US ABDOM/RETROPERIT MAS BIOPSY,3200000021,CDM,320,RC,,,Outpatient,,,2756.25,1791.56,,2756.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2094.75,76,,153.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1984.5,72,,1287.936,Percent of Total Billed Charges,72% of Total Billed Charges,2067.19,75,,1341.6,Percent of Total Billed charges,75% of Total Billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1984.5,72,,1287.936,Percent of Total Billed Charges,72% of Total Billed Charges,1653.75,60,,1073.28,Percent of Total Billed Charges,60% of Total Billed Charges,2480.63,90,,246.96,Percent of Total Billed Charges,90% of Total Billed Charges,1240.31,45,,142.56,Percent of Total Billed Charges,45% of Total Billed Charges,2480.63,90,,181.44,Percent of Total Billed Charges,90% of Total billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1791.56,65,,644.96,Percent of total Billed Charges,65% of Total Billed Charges,1215.51,44.1,,139.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,2618.44,95,,191.52,Percent of Total Billed Charges,95% of Total Billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2425.5,88,,278.784,Percent of Total Billed Charges,88% of Total Billed Charges,2480.63,90,,181.44,Percent of Total Billed charges,90% of Total Billed Charges,1215.51,2756.25,
VENOGRAPHY ADRENAL BILAT SELEC,3200000022,CDM,320,RC,,,Outpatient,,,9860.45,6409.29,,9860.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7493.94,76,,153.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7099.52,72,,1463.616,Percent of Total Billed Charges,72% of Total Billed Charges,7395.34,75,,1524.6,Percent of Total Billed charges,75% of Total Billed Charges,9860.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7099.52,72,,1463.616,Percent of Total Billed Charges,72% of Total Billed Charges,5916.27,60,,1219.68,Percent of Total Billed Charges,60% of Total Billed Charges,8874.41,90,,246.96,Percent of Total Billed Charges,90% of Total Billed Charges,4437.2,45,,142.56,Percent of Total Billed Charges,45% of Total Billed Charges,8874.41,90,,181.44,Percent of Total Billed Charges,90% of Total billed Charges,9860.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9860.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9860.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6409.29,65,,644.96,Percent of total Billed Charges,65% of Total Billed Charges,4348.46,44.1,,139.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,9367.43,95,,191.52,Percent of Total Billed Charges,95% of Total Billed Charges,9860.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8677.2,88,,230.208,Percent of Total Billed Charges,88% of Total Billed Charges,8874.41,90,,181.44,Percent of Total Billed charges,90% of Total Billed Charges,4348.46,9860.45,
"VENOGRAPHY ADRENAL, UNILA SEL",3200000023,CDM,320,RC,,,Outpatient,,,6484.80,4215.12,,6484.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4928.45,76,,184.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4669.06,72,,1585.728,Percent of Total Billed Charges,72% of Total Billed Charges,4863.6,75,,1651.8,Percent of Total Billed charges,75% of Total Billed Charges,6484.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4669.06,72,,1585.728,Percent of Total Billed Charges,72% of Total Billed Charges,3890.88,60,,1321.44,Percent of Total Billed Charges,60% of Total Billed Charges,5836.32,90,,185.76,Percent of Total Billed Charges,90% of Total Billed Charges,2918.16,45,,117.72,Percent of Total Billed Charges,45% of Total Billed Charges,5836.32,90,,218.16,Percent of Total Billed Charges,90% of Total billed Charges,6484.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6484.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6484.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4215.12,65,,452.92,Percent of total Billed Charges,65% of Total Billed Charges,2859.8,44.1,,115.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,6160.56,95,,230.28,Percent of Total Billed Charges,95% of Total Billed Charges,6484.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5706.62,88,,230.208,Percent of Total Billed Charges,88% of Total Billed Charges,5836.32,90,,218.16,Percent of Total Billed charges,90% of Total Billed Charges,2859.8,6484.8,
VENOGRAPHY CAVAL INFER (IVC),3200000024,CDM,320,RC,,,Outpatient,,,7636.98,4964.04,,7636.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5804.1,76,,184.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5498.63,72,,1510.848,Percent of Total Billed Charges,72% of Total Billed Charges,5727.74,75,,1573.8,Percent of Total Billed charges,75% of Total Billed Charges,7636.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5498.63,72,,1510.848,Percent of Total Billed Charges,72% of Total Billed Charges,4582.19,60,,1259.04,Percent of Total Billed Charges,60% of Total Billed Charges,6873.28,90,,185.76,Percent of Total Billed Charges,90% of Total Billed Charges,3436.64,45,,117.72,Percent of Total Billed Charges,45% of Total Billed Charges,6873.28,90,,218.16,Percent of Total Billed Charges,90% of Total billed Charges,7636.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7636.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7636.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4964.04,65,,290.88,Percent of total Billed Charges,65% of Total Billed Charges,3367.91,44.1,,115.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,7255.13,95,,230.28,Percent of Total Billed Charges,95% of Total Billed Charges,7636.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6720.54,88,,172.48,Percent of Total Billed Charges,88% of Total Billed Charges,6873.28,90,,218.16,Percent of Total Billed charges,90% of Total Billed Charges,3367.91,7636.98,
VENOGRAPHY CAVAL INFER (IVC),3200000025,CDM,320,RC,,,Outpatient,,,7636.98,4964.04,,7636.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5804.1,76,,240.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5498.63,72,,120.384,Percent of Total Billed Charges,72% of Total Billed Charges,5727.74,75,,125.4,Percent of Total Billed charges,75% of Total Billed Charges,7636.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5498.63,72,,120.384,Percent of Total Billed Charges,72% of Total Billed Charges,4582.19,60,,100.32,Percent of Total Billed Charges,60% of Total Billed Charges,6873.28,90,,234.72,Percent of Total Billed Charges,90% of Total Billed Charges,3436.64,45,,88.2,Percent of Total Billed Charges,45% of Total Billed Charges,6873.28,90,,285.12,Percent of Total Billed Charges,90% of Total billed Charges,7636.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7636.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7636.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4964.04,65,,644.96,Percent of total Billed Charges,65% of Total Billed Charges,3367.91,44.1,,86.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,7255.13,95,,300.96,Percent of Total Billed Charges,95% of Total Billed Charges,7636.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6720.54,88,,172.48,Percent of Total Billed Charges,88% of Total Billed Charges,6873.28,90,,285.12,Percent of Total Billed charges,90% of Total Billed Charges,3367.91,7636.98,
VENOGRAPHY EXT BILATERAL,3200000026,CDM,320,RC,,,Outpatient,,,1413.00,918.45,,1413,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1073.88,76,,240.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1017.36,72,,1527.552,Percent of Total Billed Charges,72% of Total Billed Charges,1059.75,75,,1591.2,Percent of Total Billed charges,75% of Total Billed Charges,1413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1017.36,72,,1527.552,Percent of Total Billed Charges,72% of Total Billed Charges,847.8,60,,1272.96,Percent of Total Billed Charges,60% of Total Billed Charges,1271.7,90,,245.28,Percent of Total Billed Charges,90% of Total Billed Charges,635.85,45,,88.2,Percent of Total Billed Charges,45% of Total Billed Charges,1271.7,90,,285.12,Percent of Total Billed Charges,90% of Total billed Charges,1413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,918.45,65,,476.568,Percent of total Billed Charges,65% of Total Billed Charges,623.13,44.1,,86.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,1342.35,95,,300.96,Percent of Total Billed Charges,95% of Total Billed Charges,1413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1243.44,88,,241.472,Percent of Total Billed Charges,88% of Total Billed Charges,1271.7,90,,285.12,Percent of Total Billed charges,90% of Total Billed Charges,623.13,1413,
VENOGRAPHY EXTREM UNILATERAL,3200000027,CDM,320,RC,,,Outpatient,,,1413.00,918.45,,1413,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1073.88,76,,198.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1017.36,72,,1767.744,Percent of Total Billed Charges,72% of Total Billed Charges,1059.75,75,,1841.4,Percent of Total Billed charges,75% of Total Billed Charges,1413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1017.36,72,,1767.744,Percent of Total Billed Charges,72% of Total Billed Charges,847.8,60,,1473.12,Percent of Total Billed Charges,60% of Total Billed Charges,1271.7,90,,197.28,Percent of Total Billed Charges,90% of Total Billed Charges,635.85,45,,123.48,Percent of Total Billed Charges,45% of Total Billed Charges,1271.7,90,,235.44,Percent of Total Billed Charges,90% of Total billed Charges,1413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,918.45,65,,476.568,Percent of total Billed Charges,65% of Total Billed Charges,623.13,44.1,,121.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,1342.35,95,,248.52,Percent of Total Billed Charges,95% of Total Billed Charges,1413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1243.44,88,,241.472,Percent of Total Billed Charges,88% of Total Billed Charges,1271.7,90,,235.44,Percent of Total Billed charges,90% of Total Billed Charges,623.13,1413,
"VENOGRAPHY REN, UNILAT, SELE",3200000028,CDM,320,RC,,,Outpatient,,,5931.42,3855.42,,5931.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4507.88,76,,198.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4270.62,72,,635.672,Percent of Total Billed Charges,72% of Total Billed Charges,4448.57,75,,662.16,Percent of Total Billed charges,75% of Total Billed Charges,5931.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4270.62,72,,635.672,Percent of Total Billed Charges,72% of Total Billed Charges,3558.85,60,,529.728,Percent of Total Billed Charges,60% of Total Billed Charges,5338.28,90,,203.76,Percent of Total Billed Charges,90% of Total Billed Charges,2669.14,45,,123.48,Percent of Total Billed Charges,45% of Total Billed Charges,5338.28,90,,235.44,Percent of Total Billed Charges,90% of Total billed Charges,5931.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5931.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5931.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3855.42,65,,2519.92,Percent of total Billed Charges,65% of Total Billed Charges,2615.76,44.1,,121.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,5634.85,95,,248.52,Percent of Total Billed Charges,95% of Total Billed Charges,5931.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5219.65,88,,181.632,Percent of Total Billed Charges,88% of Total Billed Charges,5338.28,90,,235.44,Percent of Total Billed charges,90% of Total Billed Charges,2615.76,5931.42,
VENOGRAPHY RENAL BILAT SELCTV,3200000029,CDM,320,RC,,,Outpatient,,,7565.60,4917.64,,7565.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5749.86,76,,148.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5447.23,72,,1619.136,Percent of Total Billed Charges,72% of Total Billed Charges,5674.2,75,,1686.6,Percent of Total Billed charges,75% of Total Billed Charges,7565.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5447.23,72,,1619.136,Percent of Total Billed Charges,72% of Total Billed Charges,4539.36,60,,1349.28,Percent of Total Billed Charges,60% of Total Billed Charges,6809.04,90,,203.76,Percent of Total Billed Charges,90% of Total Billed Charges,3404.52,45,,92.88,Percent of Total Billed Charges,45% of Total Billed Charges,6809.04,90,,176.4,Percent of Total Billed Charges,90% of Total billed Charges,7565.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7565.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7565.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4917.64,65,,1449.632,Percent of total Billed Charges,65% of Total Billed Charges,3336.43,44.1,,91.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,7187.32,95,,186.2,Percent of Total Billed Charges,95% of Total Billed Charges,7565.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6657.73,88,,181.632,Percent of Total Billed Charges,88% of Total Billed Charges,6809.04,90,,176.4,Percent of Total Billed charges,90% of Total Billed Charges,3336.43,7565.6,
XR  EXC DRAIN CATH W/ GUID,3200000030,CDM,320,RC,,,Outpatient,,,3878.56,2521.06,,3878.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2947.71,76,,148.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2792.56,72,,691.2,Percent of Total Billed Charges,72% of Total Billed Charges,2908.92,75,,720,Percent of Total Billed charges,75% of Total Billed Charges,3878.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2792.56,72,,691.2,Percent of Total Billed Charges,72% of Total Billed Charges,2327.14,60,,576,Percent of Total Billed Charges,60% of Total Billed Charges,3490.7,90,,983.264,Percent of Total Billed Charges,90% of Total Billed Charges,1745.35,45,,92.88,Percent of Total Billed Charges,45% of Total Billed Charges,3490.7,90,,176.4,Percent of Total Billed Charges,90% of Total billed Charges,3878.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3878.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3878.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.06,65,,227.24,Percent of total Billed Charges,65% of Total Billed Charges,1710.44,44.1,,91.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,3684.63,95,,186.2,Percent of Total Billed Charges,95% of Total Billed Charges,3878.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3413.13,88,,229.504,Percent of Total Billed Charges,88% of Total Billed Charges,3490.7,90,,176.4,Percent of Total Billed charges,90% of Total Billed Charges,1710.44,3878.56,
XR ABDOM/RETROPERIT MAS BIOPSY,3200000031,CDM,320,RC,,,Outpatient,,,2756.25,1791.56,,2756.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2094.75,76,,208.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1984.5,72,,956.808,Percent of Total Billed Charges,72% of Total Billed Charges,2067.19,75,,996.68,Percent of Total Billed charges,75% of Total Billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1984.5,72,,956.808,Percent of Total Billed Charges,72% of Total Billed Charges,1653.75,60,,797.344,Percent of Total Billed Charges,60% of Total Billed Charges,2480.63,90,,617.584,Percent of Total Billed Charges,90% of Total Billed Charges,1240.31,45,,117.36,Percent of Total Billed Charges,45% of Total Billed Charges,2480.63,90,,246.96,Percent of Total Billed Charges,90% of Total billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1791.56,65,,548.648,Percent of total Billed Charges,65% of Total Billed Charges,1215.51,44.1,,115.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,2618.44,95,,260.68,Percent of Total Billed Charges,95% of Total Billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2425.5,88,,239.832,Percent of Total Billed Charges,88% of Total Billed Charges,2480.63,90,,246.96,Percent of Total Billed charges,90% of Total Billed Charges,1215.51,2756.25,
XR FNA WFLUORO GUID 1ST LESION,3200000032,CDM,320,RC,,,Outpatient,,,1600.00,1040.00,,1600,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1216,76,,208.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1152,72,,1684.032,Percent of Total Billed Charges,72% of Total Billed Charges,1200,75,,1754.2,Percent of Total Billed charges,75% of Total Billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1152,72,,1684.032,Percent of Total Billed Charges,72% of Total Billed Charges,960,60,,1403.36,Percent of Total Billed Charges,60% of Total Billed Charges,1440,90,,617.584,Percent of Total Billed Charges,90% of Total Billed Charges,720,45,,122.64,Percent of Total Billed Charges,45% of Total Billed Charges,1440,90,,246.96,Percent of Total Billed Charges,90% of Total billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1040,65,,405.896,Percent of total Billed Charges,65% of Total Billed Charges,705.6,44.1,,120.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,1520,95,,260.68,Percent of Total Billed Charges,95% of Total Billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1408,88,,192.896,Percent of Total Billed Charges,88% of Total Billed Charges,1440,90,,246.96,Percent of Total Billed charges,90% of Total Billed Charges,705.6,1600,
XR INJ OF CONTR KNEE ARTHROG,3200000033,CDM,320,RC,,,Outpatient,,,437.69,284.50,,437.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,332.64,76,,156.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,315.14,72,,1608.768,Percent of Total Billed Charges,72% of Total Billed Charges,328.27,75,,1675.8,Percent of Total Billed charges,75% of Total Billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.14,72,,1608.768,Percent of Total Billed Charges,72% of Total Billed Charges,262.61,60,,1340.64,Percent of Total Billed Charges,60% of Total Billed Charges,393.92,90,,1125.472,Percent of Total Billed Charges,90% of Total Billed Charges,196.96,45,,98.64,Percent of Total Billed Charges,45% of Total Billed Charges,393.92,90,,185.76,Percent of Total Billed Charges,90% of Total billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.5,65,,968.76,Percent of total Billed Charges,65% of Total Billed Charges,193.02,44.1,,96.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,415.81,95,,196.08,Percent of Total Billed Charges,95% of Total Billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.17,88,,199.232,Percent of Total Billed Charges,88% of Total Billed Charges,393.92,90,,185.76,Percent of Total Billed charges,90% of Total Billed Charges,193.02,437.69,
XR S AND I BILAT EXT UE OR LE,3200000034,CDM,320,RC,,,Outpatient,,,8526.74,5542.38,,8526.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6480.32,76,,156.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6139.25,72,,865.728,Percent of Total Billed Charges,72% of Total Billed Charges,6395.06,75,,901.8,Percent of Total Billed charges,75% of Total Billed Charges,8526.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6139.25,72,,865.728,Percent of Total Billed Charges,72% of Total Billed Charges,5116.04,60,,721.44,Percent of Total Billed Charges,60% of Total Billed Charges,7674.07,90,,137.328,Percent of Total Billed Charges,90% of Total Billed Charges,3837.03,45,,101.88,Percent of Total Billed Charges,45% of Total Billed Charges,7674.07,90,,185.76,Percent of Total Billed Charges,90% of Total billed Charges,8526.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8526.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8526.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5542.38,65,,481.928,Percent of total Billed Charges,65% of Total Billed Charges,3760.29,44.1,,99.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,8100.4,95,,196.08,Percent of Total Billed Charges,95% of Total Billed Charges,8526.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7503.53,88,,199.232,Percent of Total Billed Charges,88% of Total Billed Charges,7674.07,90,,185.76,Percent of Total Billed charges,90% of Total Billed Charges,3760.29,8526.74,
XR FNA FLUORO GUID EA ADDL LES,3200000035,CDM,320,RC,,,Outpatient,,,600.00,390.00,,600,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,456,76,,198.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,432,72,,1415.232,Percent of Total Billed Charges,72% of Total Billed Charges,450,75,,1474.2,Percent of Total Billed charges,75% of Total Billed Charges,600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,432,72,,1415.232,Percent of Total Billed Charges,72% of Total Billed Charges,360,60,,1179.36,Percent of Total Billed Charges,60% of Total Billed Charges,540,90,,444.96,Percent of Total Billed Charges,90% of Total Billed Charges,270,45,,101.88,Percent of Total Billed Charges,45% of Total Billed Charges,540,90,,234.72,Percent of Total Billed Charges,90% of Total billed Charges,600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390,65,,856.44,Percent of total Billed Charges,65% of Total Billed Charges,264.6,44.1,,99.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,570,95,,247.76,Percent of Total Billed Charges,95% of Total Billed Charges,600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,528,88,,961.408,Percent of Total Billed Charges,88% of Total Billed Charges,540,90,,234.72,Percent of Total Billed charges,90% of Total Billed Charges,264.6,600,
LIVER BIOPSY WITH ULTRASOUND,3200000037,CDM,320,RC,,,Outpatient,,,2933.00,1906.45,,2933,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2229.08,76,,207.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2111.76,72,,1910.592,Percent of Total Billed Charges,72% of Total Billed Charges,2199.75,75,,1990.2,Percent of Total Billed charges,75% of Total Billed Charges,2933,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2111.76,72,,1910.592,Percent of Total Billed Charges,72% of Total Billed Charges,1759.8,60,,1592.16,Percent of Total Billed Charges,60% of Total Billed Charges,2639.7,90,,152.608,Percent of Total Billed Charges,90% of Total Billed Charges,1319.85,45,,491.632,Percent of Total Billed Charges,45% of Total Billed Charges,2639.7,90,,245.28,Percent of Total Billed Charges,90% of Total billed Charges,2933,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2933,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2933,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1906.45,65,,521.704,Percent of total Billed Charges,65% of Total Billed Charges,1293.45,44.1,,481.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,2786.35,95,,258.912,Percent of Total Billed Charges,95% of Total Billed Charges,2933,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2581.04,88,,603.856,Percent of Total Billed Charges,88% of Total Billed Charges,2639.7,90,,245.28,Percent of Total Billed charges,90% of Total Billed Charges,1293.45,2933,
CHOLANGIOGRAM T TUBE,3200000038,CDM,320,RC,,,Outpatient,,,3051.00,1983.15,,3051,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2318.76,76,,166.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2196.72,72,,1980.288,Percent of Total Billed Charges,72% of Total Billed Charges,2288.25,75,,2062.8,Percent of Total Billed charges,75% of Total Billed Charges,3051,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2196.72,72,,1980.288,Percent of Total Billed Charges,72% of Total Billed Charges,1830.6,60,,1650.24,Percent of Total Billed Charges,60% of Total Billed Charges,2745.9,90,,397.712,Percent of Total Billed Charges,90% of Total Billed Charges,1372.95,45,,308.792,Percent of Total Billed Charges,45% of Total Billed Charges,2745.9,90,,197.28,Percent of Total Billed Charges,90% of Total billed Charges,3051,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3051,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3051,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1983.15,65,,811.224,Percent of total Billed Charges,65% of Total Billed Charges,1345.49,44.1,,302.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,2898.45,95,,208.24,Percent of Total Billed Charges,95% of Total Billed Charges,3051,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2684.88,88,,603.856,Percent of Total Billed Charges,88% of Total Billed Charges,2745.9,90,,197.28,Percent of Total Billed charges,90% of Total Billed Charges,1345.49,3051,
XR PANCREAS BIOPSY,3200000039,CDM,320,RC,,,Outpatient,,,2756.25,1791.56,,2756.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2094.75,76,,172.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1984.5,72,,1585.728,Percent of Total Billed Charges,72% of Total Billed Charges,2067.19,75,,1651.8,Percent of Total Billed charges,75% of Total Billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1984.5,72,,1585.728,Percent of Total Billed Charges,72% of Total Billed Charges,1653.75,60,,1321.44,Percent of Total Billed Charges,60% of Total Billed Charges,2480.63,90,,2550.24,Percent of Total Billed Charges,90% of Total Billed Charges,1240.31,45,,308.792,Percent of Total Billed Charges,45% of Total Billed Charges,2480.63,90,,203.76,Percent of Total Billed Charges,90% of Total billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1791.56,65,,1027,Percent of total Billed Charges,65% of Total Billed Charges,1215.51,44.1,,302.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,2618.44,95,,215.08,Percent of Total Billed Charges,95% of Total Billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2425.5,88,,1100.456,Percent of Total Billed Charges,88% of Total Billed Charges,2480.63,90,,203.76,Percent of Total Billed charges,90% of Total Billed Charges,1215.51,2756.25,
US PANCREAS BIOPSY,3200000040,CDM,320,RC,,,Outpatient,,,2756.25,1791.56,,2756.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2094.75,76,,172.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1984.5,72,,1695.744,Percent of Total Billed Charges,72% of Total Billed Charges,2067.19,75,,1766.4,Percent of Total Billed charges,75% of Total Billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1984.5,72,,1695.744,Percent of Total Billed Charges,72% of Total Billed Charges,1653.75,60,,1413.12,Percent of Total Billed Charges,60% of Total Billed Charges,2480.63,90,,145.496,Percent of Total Billed Charges,90% of Total Billed Charges,1240.31,45,,562.736,Percent of Total Billed Charges,45% of Total Billed Charges,2480.63,90,,203.76,Percent of Total Billed Charges,90% of Total billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1791.56,65,,780,Percent of total Billed Charges,65% of Total Billed Charges,1215.51,44.1,,551.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,2618.44,95,,215.08,Percent of Total Billed Charges,95% of Total Billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2425.5,88,,134.272,Percent of Total Billed Charges,88% of Total Billed Charges,2480.63,90,,203.76,Percent of Total Billed charges,90% of Total Billed Charges,1215.51,2756.25,
RETROPERL ABCESS PE,3200000041,CDM,320,RC,,,Outpatient,,,4473.95,2908.07,,4473.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3400.2,76,,830.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3221.24,72,,1775.568,Percent of Total Billed Charges,72% of Total Billed Charges,3355.46,75,,1849.552,Percent of Total Billed charges,75% of Total Billed Charges,4473.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3221.24,72,,1775.568,Percent of Total Billed Charges,72% of Total Billed Charges,2684.37,60,,1479.64,Percent of Total Billed Charges,60% of Total Billed Charges,4026.56,90,,228.24,Percent of Total Billed Charges,90% of Total Billed Charges,2013.28,45,,68.664,Percent of Total Billed Charges,45% of Total Billed Charges,4026.56,90,,983.264,Percent of Total Billed Charges,90% of Total billed Charges,4473.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4473.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4473.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2908.07,65,,579.608,Percent of total Billed Charges,65% of Total Billed Charges,1973.01,44.1,,67.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,4250.25,95,,1037.888,Percent of Total Billed Charges,95% of Total Billed Charges,4473.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3937.08,88,,435.072,Percent of Total Billed Charges,88% of Total Billed Charges,4026.56,90,,983.264,Percent of Total Billed charges,90% of Total Billed Charges,1973.01,4473.95,
US KIDNEY BIOPSY,3200000042,CDM,320,RC,,,Outpatient,,,2756.25,1791.56,,2756.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2094.75,76,,521.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1984.5,72,,2041.344,Percent of Total Billed Charges,72% of Total Billed Charges,2067.19,75,,2126.4,Percent of Total Billed charges,75% of Total Billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1984.5,72,,2041.344,Percent of Total Billed Charges,72% of Total Billed Charges,1653.75,60,,1701.12,Percent of Total Billed Charges,60% of Total Billed Charges,2480.63,90,,1011.6,Percent of Total Billed Charges,90% of Total Billed Charges,1240.31,45,,222.48,Percent of Total Billed Charges,45% of Total Billed Charges,2480.63,90,,617.584,Percent of Total Billed Charges,90% of Total billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1791.56,65,,811.224,Percent of total Billed Charges,65% of Total Billed Charges,1215.51,44.1,,218.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,2618.44,95,,651.888,Percent of Total Billed Charges,95% of Total Billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2425.5,88,,149.216,Percent of Total Billed Charges,88% of Total Billed Charges,2480.63,90,,617.584,Percent of Total Billed charges,90% of Total Billed Charges,1215.51,2756.25,
RAD  CISTERNOGRAPHY,3200000043,CDM,320,RC,,,Outpatient,,,1521.45,988.94,,1521.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1156.3,76,,521.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1095.44,72,,1948.304,Percent of Total Billed Charges,72% of Total Billed Charges,1141.09,75,,2029.48,Percent of Total Billed charges,75% of Total Billed Charges,1521.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1095.44,72,,1948.304,Percent of Total Billed Charges,72% of Total Billed Charges,912.87,60,,1623.584,Percent of Total Billed Charges,60% of Total Billed Charges,1369.31,90,,1011.6,Percent of Total Billed Charges,90% of Total Billed Charges,684.65,45,,76.304,Percent of Total Billed Charges,45% of Total Billed Charges,1369.31,90,,617.584,Percent of Total Billed Charges,90% of Total billed Charges,1521.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1521.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1521.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,988.94,65,,749.32,Percent of total Billed Charges,65% of Total Billed Charges,670.96,44.1,,74.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,1445.38,95,,651.888,Percent of Total Billed Charges,95% of Total Billed Charges,1521.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1338.88,88,,388.872,Percent of Total Billed Charges,88% of Total Billed Charges,1369.31,90,,617.584,Percent of Total Billed charges,90% of Total Billed Charges,670.96,1521.45,
MANDIBLE PRT LESS TH,3200000044,CDM,320,RC,,,Outpatient,,,350.00,227.50,,350,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,266,76,,950.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,252,72,,2227.968,Percent of Total Billed Charges,72% of Total Billed Charges,262.5,75,,2320.8,Percent of Total Billed charges,75% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,72,,2227.968,Percent of Total Billed Charges,72% of Total Billed Charges,210,60,,1856.64,Percent of Total Billed Charges,60% of Total Billed Charges,315,90,,893.024,Percent of Total Billed Charges,90% of Total Billed Charges,157.5,45,,198.856,Percent of Total Billed Charges,45% of Total Billed Charges,315,90,,1125.472,Percent of Total Billed Charges,90% of Total billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,65,,984.936,Percent of total Billed Charges,65% of Total Billed Charges,154.35,44.1,,194.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,332.5,95,,1187.992,Percent of Total Billed Charges,95% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308,88,,2493.568,Percent of Total Billed Charges,88% of Total Billed Charges,315,90,,1125.472,Percent of Total Billed charges,90% of Total Billed Charges,154.35,350,
MANDIBLE COMP MIN 4,3200000045,CDM,320,RC,,,Outpatient,,,286.00,185.90,,286,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,217.36,76,,115.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,205.92,72,,2345.2,Percent of Total Billed Charges,72% of Total Billed Charges,214.5,75,,2442.92,Percent of Total Billed charges,75% of Total Billed Charges,286,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.92,72,,2345.2,Percent of Total Billed Charges,72% of Total Billed Charges,171.6,60,,1954.336,Percent of Total Billed Charges,60% of Total Billed Charges,257.4,90,,848.88,Percent of Total Billed Charges,90% of Total Billed Charges,128.7,45,,1275.12,Percent of Total Billed Charges,45% of Total Billed Charges,257.4,90,,137.328,Percent of Total Billed Charges,90% of Total billed Charges,286,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.9,65,,996.32,Percent of total Billed Charges,65% of Total Billed Charges,126.13,44.1,,1249.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,271.7,95,,144.952,Percent of Total Billed Charges,95% of Total Billed Charges,286,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.68,88,,142.264,Percent of Total Billed Charges,88% of Total Billed Charges,257.4,90,,137.328,Percent of Total Billed charges,90% of Total Billed Charges,126.13,286,
MASTOIDS <3 VIEWS,3200000046,CDM,320,RC,,,Outpatient,,,258.00,167.70,,258,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,196.08,76,,375.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,185.76,72,,1120.32,Percent of Total Billed Charges,72% of Total Billed Charges,193.5,75,,1167,Percent of Total Billed charges,75% of Total Billed Charges,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.76,72,,1120.32,Percent of Total Billed Charges,72% of Total Billed Charges,154.8,60,,933.6,Percent of Total Billed Charges,60% of Total Billed Charges,232.2,90,,893.024,Percent of Total Billed Charges,90% of Total Billed Charges,116.1,45,,72.752,Percent of Total Billed Charges,45% of Total Billed Charges,232.2,90,,444.96,Percent of Total Billed Charges,90% of Total billed Charges,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.7,65,,1231.36,Percent of total Billed Charges,65% of Total Billed Charges,113.78,44.1,,71.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,245.1,95,,469.68,Percent of Total Billed Charges,95% of Total Billed Charges,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.04,88,,223.168,Percent of Total Billed Charges,88% of Total Billed Charges,232.2,90,,444.96,Percent of Total Billed charges,90% of Total Billed Charges,113.78,258,
MASTOIDS COMP MIN 3,3200000047,CDM,320,RC,,,Outpatient,,,320.83,208.54,,320.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,243.83,76,,128.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,231,72,,1687.68,Percent of Total Billed Charges,72% of Total Billed Charges,240.62,75,,1758,Percent of Total Billed charges,75% of Total Billed Charges,320.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231,72,,1687.68,Percent of Total Billed Charges,72% of Total Billed Charges,192.5,60,,1406.4,Percent of Total Billed Charges,60% of Total Billed Charges,288.75,90,,848.88,Percent of Total Billed Charges,90% of Total Billed Charges,144.37,45,,114.12,Percent of Total Billed Charges,45% of Total Billed Charges,288.75,90,,152.608,Percent of Total Billed Charges,90% of Total billed Charges,320.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.54,65,,695.408,Percent of total Billed Charges,65% of Total Billed Charges,141.49,44.1,,111.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,304.79,95,,161.08,Percent of Total Billed Charges,95% of Total Billed Charges,320.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.33,88,,989.12,Percent of Total Billed Charges,88% of Total Billed Charges,288.75,90,,152.608,Percent of Total Billed charges,90% of Total Billed Charges,141.49,320.83,
FACIAL BONE <3 VWS,3200000048,CDM,320,RC,,,Outpatient,,,191.00,124.15,,191,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,145.16,76,,335.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,137.52,72,,2167.488,Percent of Total Billed Charges,72% of Total Billed Charges,143.25,75,,2257.8,Percent of Total Billed charges,75% of Total Billed Charges,191,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.52,72,,2167.488,Percent of Total Billed Charges,72% of Total Billed Charges,114.6,60,,1806.24,Percent of Total Billed Charges,60% of Total Billed Charges,171.9,90,,893.024,Percent of Total Billed Charges,90% of Total Billed Charges,85.95,45,,505.8,Percent of Total Billed Charges,45% of Total Billed Charges,171.9,90,,397.712,Percent of Total Billed Charges,90% of Total billed Charges,191,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.15,65,,927.024,Percent of total Billed Charges,65% of Total Billed Charges,84.23,44.1,,495.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,181.45,95,,419.808,Percent of Total Billed Charges,95% of Total Billed Charges,191,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.08,88,,989.12,Percent of Total Billed Charges,88% of Total Billed Charges,171.9,90,,397.712,Percent of Total Billed charges,90% of Total Billed Charges,84.23,191,
FACIAL BONE MIN 3 VI,3200000049,CDM,320,RC,,,Outpatient,,,218.00,141.70,,218,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,165.68,76,,2153.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,156.96,72,,1518.912,Percent of Total Billed Charges,72% of Total Billed Charges,163.5,75,,1582.2,Percent of Total Billed charges,75% of Total Billed Charges,218,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.96,72,,1518.912,Percent of Total Billed Charges,72% of Total Billed Charges,130.8,60,,1265.76,Percent of Total Billed Charges,60% of Total Billed Charges,196.2,90,,893.024,Percent of Total Billed Charges,90% of Total Billed Charges,98.1,45,,505.8,Percent of Total Billed Charges,45% of Total Billed Charges,196.2,90,,2550.24,Percent of Total Billed Charges,90% of Total billed Charges,218,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.7,65,,984.936,Percent of total Billed Charges,65% of Total Billed Charges,96.14,44.1,,495.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,207.1,95,,2691.92,Percent of Total Billed Charges,95% of Total Billed Charges,218,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.84,88,,873.176,Percent of Total Billed Charges,88% of Total Billed Charges,196.2,90,,2550.24,Percent of Total Billed charges,90% of Total Billed Charges,96.14,218,
NASAL BONES MIN 3 VI,3200000050,CDM,320,RC,,,Outpatient,,,270.00,175.50,,270,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,205.2,76,,122.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,194.4,72,,3037.248,Percent of Total Billed Charges,72% of Total Billed Charges,202.5,75,,3163.8,Percent of Total Billed charges,75% of Total Billed Charges,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.4,72,,3037.248,Percent of Total Billed Charges,72% of Total Billed Charges,162,60,,2531.04,Percent of Total Billed Charges,60% of Total Billed Charges,243,90,,627.12,Percent of Total Billed Charges,90% of Total Billed Charges,121.5,45,,446.512,Percent of Total Billed Charges,45% of Total Billed Charges,243,90,,145.496,Percent of Total Billed Charges,90% of Total billed Charges,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.5,65,,991.64,Percent of total Billed Charges,65% of Total Billed Charges,119.07,44.1,,437.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,256.5,95,,153.584,Percent of Total Billed Charges,95% of Total Billed Charges,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.6,88,,830.016,Percent of Total Billed Charges,88% of Total Billed Charges,243,90,,145.496,Percent of Total Billed charges,90% of Total Billed Charges,119.07,270,
OPTIC FORAMINA,3200000051,CDM,320,RC,,,Outpatient,,,191.84,124.70,,191.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,145.8,76,,192.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,138.12,72,,1518.912,Percent of Total Billed Charges,72% of Total Billed Charges,143.88,75,,1582.2,Percent of Total Billed charges,75% of Total Billed Charges,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.12,72,,1518.912,Percent of Total Billed Charges,72% of Total Billed Charges,115.1,60,,1265.76,Percent of Total Billed Charges,60% of Total Billed Charges,172.66,90,,402.752,Percent of Total Billed Charges,90% of Total Billed Charges,86.33,45,,424.44,Percent of Total Billed Charges,45% of Total Billed Charges,172.66,90,,228.24,Percent of Total Billed Charges,90% of Total billed Charges,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.7,65,,753.32,Percent of total Billed Charges,65% of Total Billed Charges,84.6,44.1,,415.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,182.25,95,,240.92,Percent of Total Billed Charges,95% of Total Billed Charges,191.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.82,88,,873.176,Percent of Total Billed Charges,88% of Total Billed Charges,172.66,90,,228.24,Percent of Total Billed charges,90% of Total Billed Charges,84.6,191.84,
ORBITS COMP MIN 4VW,3200000052,CDM,320,RC,,,Outpatient,,,250.27,162.68,,250.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,190.21,76,,854.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,180.19,72,,1308.672,Percent of Total Billed Charges,72% of Total Billed Charges,187.7,75,,1363.2,Percent of Total Billed charges,75% of Total Billed Charges,250.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.19,72,,1308.672,Percent of Total Billed Charges,72% of Total Billed Charges,150.16,60,,1090.56,Percent of Total Billed Charges,60% of Total Billed Charges,225.24,90,,893.024,Percent of Total Billed Charges,90% of Total Billed Charges,112.62,45,,446.512,Percent of Total Billed Charges,45% of Total Billed Charges,225.24,90,,1011.6,Percent of Total Billed Charges,90% of Total billed Charges,250.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.68,65,,1019.328,Percent of total Billed Charges,65% of Total Billed Charges,110.37,44.1,,437.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,237.76,95,,1067.8,Percent of Total Billed Charges,95% of Total Billed Charges,250.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.24,88,,830.016,Percent of Total Billed Charges,88% of Total Billed Charges,225.24,90,,1011.6,Percent of Total Billed charges,90% of Total Billed Charges,110.37,250.27,
SINUS LESS THN 3 VWS,3200000053,CDM,320,RC,,,Outpatient,,,391.00,254.15,,391,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,297.16,76,,854.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,281.52,72,,1455.552,Percent of Total Billed Charges,72% of Total Billed Charges,293.25,75,,1516.2,Percent of Total Billed charges,75% of Total Billed Charges,391,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,281.52,72,,1455.552,Percent of Total Billed Charges,72% of Total Billed Charges,234.6,60,,1212.96,Percent of Total Billed Charges,60% of Total Billed Charges,351.9,90,,659.864,Percent of Total Billed Charges,90% of Total Billed Charges,175.95,45,,424.44,Percent of Total Billed Charges,45% of Total Billed Charges,351.9,90,,1011.6,Percent of Total Billed Charges,90% of Total billed Charges,391,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,391,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,391,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,254.15,65,,470.68,Percent of total Billed Charges,65% of Total Billed Charges,172.43,44.1,,415.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,371.45,95,,1067.8,Percent of Total Billed Charges,95% of Total Billed Charges,391,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,344.08,88,,873.176,Percent of Total Billed Charges,88% of Total Billed Charges,351.9,90,,1011.6,Percent of Total Billed charges,90% of Total Billed Charges,172.43,391,
SINUS COMP MIN 3 VW,3200000054,CDM,320,RC,,,Outpatient,,,491.00,319.15,,491,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,373.16,76,,754.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,353.52,72,,2058.048,Percent of Total Billed Charges,72% of Total Billed Charges,368.25,75,,2143.8,Percent of Total Billed charges,75% of Total Billed Charges,491,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.52,72,,2058.048,Percent of Total Billed Charges,72% of Total Billed Charges,294.6,60,,1715.04,Percent of Total Billed Charges,60% of Total Billed Charges,441.9,90,,659.864,Percent of Total Billed Charges,90% of Total Billed Charges,220.95,45,,446.512,Percent of Total Billed Charges,45% of Total Billed Charges,441.9,90,,893.024,Percent of Total Billed Charges,90% of Total billed Charges,491,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319.15,65,,551.52,Percent of total Billed Charges,65% of Total Billed Charges,216.53,44.1,,437.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,466.45,95,,942.632,Percent of Total Billed Charges,95% of Total Billed Charges,491,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,432.08,88,,873.176,Percent of Total Billed Charges,88% of Total Billed Charges,441.9,90,,893.024,Percent of Total Billed charges,90% of Total Billed Charges,216.53,491,
SELLA TURCICA 1 OR 2,3200000055,CDM,320,RC,,,Outpatient,,,178.61,116.10,,178.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,135.74,76,,716.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,128.6,72,,1518.912,Percent of Total Billed Charges,72% of Total Billed Charges,133.96,75,,1582.2,Percent of Total Billed charges,75% of Total Billed Charges,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.6,72,,1518.912,Percent of Total Billed Charges,72% of Total Billed Charges,107.17,60,,1265.76,Percent of Total Billed Charges,60% of Total Billed Charges,160.75,90,,3489.12,Percent of Total Billed Charges,90% of Total Billed Charges,80.37,45,,446.512,Percent of Total Billed Charges,45% of Total Billed Charges,160.75,90,,848.88,Percent of Total Billed Charges,90% of Total billed Charges,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.1,65,,949.52,Percent of total Billed Charges,65% of Total Billed Charges,78.77,44.1,,437.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,169.68,95,,896.04,Percent of Total Billed Charges,95% of Total Billed Charges,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.18,88,,613.184,Percent of Total Billed Charges,88% of Total Billed Charges,160.75,90,,848.88,Percent of Total Billed charges,90% of Total Billed Charges,78.77,178.61,
SKULL LESS THN 4 VWS,3200000056,CDM,320,RC,,,Outpatient,,,347.00,225.55,,347,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,263.72,76,,754.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,249.84,72,,1844.928,Percent of Total Billed Charges,72% of Total Billed Charges,260.25,75,,1921.8,Percent of Total Billed charges,75% of Total Billed Charges,347,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.84,72,,1844.928,Percent of Total Billed Charges,72% of Total Billed Charges,208.2,60,,1537.44,Percent of Total Billed Charges,60% of Total Billed Charges,312.3,90,,2007.184,Percent of Total Billed Charges,90% of Total Billed Charges,156.15,45,,313.56,Percent of Total Billed Charges,45% of Total Billed Charges,312.3,90,,893.024,Percent of Total Billed Charges,90% of Total billed Charges,347,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.55,65,,1598.48,Percent of total Billed Charges,65% of Total Billed Charges,153.03,44.1,,307.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,329.65,95,,942.632,Percent of Total Billed Charges,95% of Total Billed Charges,347,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305.36,88,,393.8,Percent of Total Billed Charges,88% of Total Billed Charges,312.3,90,,893.024,Percent of Total Billed charges,90% of Total Billed Charges,153.03,347,
SKULL COMP MIN 4 VW,3200000057,CDM,320,RC,,,Outpatient,,,551.00,358.15,,551,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,418.76,76,,716.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,396.72,72,,1247.04,Percent of Total Billed Charges,72% of Total Billed Charges,413.25,75,,1299,Percent of Total Billed charges,75% of Total Billed Charges,551,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.72,72,,1247.04,Percent of Total Billed Charges,72% of Total Billed Charges,330.6,60,,1039.2,Percent of Total Billed Charges,60% of Total Billed Charges,495.9,90,,314.64,Percent of Total Billed Charges,90% of Total Billed Charges,247.95,45,,201.376,Percent of Total Billed Charges,45% of Total Billed Charges,495.9,90,,848.88,Percent of Total Billed Charges,90% of Total billed Charges,551,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,551,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,551,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.15,65,,2294.76,Percent of total Billed Charges,65% of Total Billed Charges,242.99,44.1,,197.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,523.45,95,,896.04,Percent of Total Billed Charges,95% of Total Billed Charges,551,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484.88,88,,873.176,Percent of Total Billed Charges,88% of Total Billed Charges,495.9,90,,848.88,Percent of Total Billed charges,90% of Total Billed Charges,242.99,551,
TMJ JNT UNILT OPN/CL,3200000058,CDM,320,RC,,,Outpatient,,,139.00,90.35,,139,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,105.64,76,,754.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,100.08,72,,1404.288,Percent of Total Billed Charges,72% of Total Billed Charges,104.25,75,,1462.8,Percent of Total Billed charges,75% of Total Billed Charges,139,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.08,72,,1404.288,Percent of Total Billed Charges,72% of Total Billed Charges,83.4,60,,1170.24,Percent of Total Billed Charges,60% of Total Billed Charges,125.1,90,,759.664,Percent of Total Billed Charges,90% of Total Billed Charges,62.55,45,,446.512,Percent of Total Billed Charges,45% of Total Billed Charges,125.1,90,,893.024,Percent of Total Billed Charges,90% of Total billed Charges,139,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.35,65,,2818.92,Percent of total Billed Charges,65% of Total Billed Charges,61.3,44.1,,437.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,132.05,95,,942.632,Percent of Total Billed Charges,95% of Total Billed Charges,139,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.32,88,,645.2,Percent of Total Billed Charges,88% of Total Billed Charges,125.1,90,,893.024,Percent of Total Billed charges,90% of Total Billed Charges,61.3,139,
TMJ JNT BILAT OPN/CL,3200000059,CDM,320,RC,,,Outpatient,,,183.00,118.95,,183,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,139.08,76,,754.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,131.76,72,,1247.04,Percent of Total Billed Charges,72% of Total Billed Charges,137.25,75,,1299,Percent of Total Billed charges,75% of Total Billed Charges,183,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.76,72,,1247.04,Percent of Total Billed Charges,72% of Total Billed Charges,109.8,60,,1039.2,Percent of Total Billed Charges,60% of Total Billed Charges,164.7,90,,562.008,Percent of Total Billed Charges,90% of Total Billed Charges,82.35,45,,329.936,Percent of Total Billed Charges,45% of Total Billed Charges,164.7,90,,893.024,Percent of Total Billed Charges,90% of Total billed Charges,183,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.95,65,,904.096,Percent of total Billed Charges,65% of Total Billed Charges,80.7,44.1,,323.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,173.85,95,,942.632,Percent of Total Billed Charges,95% of Total Billed Charges,183,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.04,88,,645.2,Percent of Total Billed Charges,88% of Total Billed Charges,164.7,90,,893.024,Percent of Total Billed charges,90% of Total Billed Charges,80.7,183,
NECK SOFT TISSUE,3200000060,CDM,320,RC,,,Outpatient,,,258.00,167.70,,258,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,196.08,76,,529.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,185.76,72,,1404.288,Percent of Total Billed Charges,72% of Total Billed Charges,193.5,75,,1462.8,Percent of Total Billed charges,75% of Total Billed Charges,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.76,72,,1404.288,Percent of Total Billed Charges,72% of Total Billed Charges,154.8,60,,1170.24,Percent of Total Billed Charges,60% of Total Billed Charges,232.2,90,,1341.36,Percent of Total Billed Charges,90% of Total Billed Charges,116.1,45,,329.936,Percent of Total Billed Charges,45% of Total Billed Charges,232.2,90,,627.12,Percent of Total Billed Charges,90% of Total billed Charges,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.7,65,,405.896,Percent of total Billed Charges,65% of Total Billed Charges,113.78,44.1,,323.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,245.1,95,,661.96,Percent of Total Billed Charges,95% of Total Billed Charges,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.04,88,,3411.584,Percent of Total Billed Charges,88% of Total Billed Charges,232.2,90,,627.12,Percent of Total Billed charges,90% of Total Billed Charges,113.78,258,
CHEST 1 VIEW,3200000061,CDM,320,RC,,,Outpatient,,,249.00,161.85,,249,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,189.24,76,,340.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,179.28,72,,1516.608,Percent of Total Billed Charges,72% of Total Billed Charges,186.75,75,,1579.8,Percent of Total Billed charges,75% of Total Billed Charges,249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.28,72,,1516.608,Percent of Total Billed Charges,72% of Total Billed Charges,149.4,60,,1263.84,Percent of Total Billed Charges,60% of Total Billed Charges,224.1,90,,667.288,Percent of Total Billed Charges,90% of Total Billed Charges,112.05,45,,1744.56,Percent of Total Billed Charges,45% of Total Billed Charges,224.1,90,,402.752,Percent of Total Billed Charges,90% of Total billed Charges,249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.85,65,,579.608,Percent of total Billed Charges,65% of Total Billed Charges,109.81,44.1,,1709.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,236.55,95,,425.128,Percent of Total Billed Charges,95% of Total Billed Charges,249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.12,88,,1962.576,Percent of Total Billed Charges,88% of Total Billed Charges,224.1,90,,402.752,Percent of Total Billed charges,90% of Total Billed Charges,109.81,249,
1 VW CXR TDH,3200000062,CDM,320,RC,,,Outpatient,,,260.19,169.12,,260.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,197.74,76,,754.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,187.34,72,,1120.32,Percent of Total Billed Charges,72% of Total Billed Charges,195.14,75,,1167,Percent of Total Billed charges,75% of Total Billed Charges,260.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.34,72,,1120.32,Percent of Total Billed Charges,72% of Total Billed Charges,156.11,60,,933.6,Percent of Total Billed Charges,60% of Total Billed Charges,234.17,90,,1185.84,Percent of Total Billed Charges,90% of Total Billed Charges,117.09,45,,1003.592,Percent of Total Billed Charges,45% of Total Billed Charges,234.17,90,,893.024,Percent of Total Billed Charges,90% of Total billed Charges,260.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.12,65,,901.224,Percent of total Billed Charges,65% of Total Billed Charges,114.74,44.1,,983.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,247.18,95,,942.632,Percent of Total Billed Charges,95% of Total Billed Charges,260.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.97,88,,307.648,Percent of Total Billed Charges,88% of Total Billed Charges,234.17,90,,893.024,Percent of Total Billed charges,90% of Total Billed Charges,114.74,260.19,
CHEST 2 VIEWS,3200000063,CDM,320,RC,,,Outpatient,,,437.00,284.05,,437,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,332.12,76,,557.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,314.64,72,,1247.04,Percent of Total Billed Charges,72% of Total Billed Charges,327.75,75,,1299,Percent of Total Billed charges,75% of Total Billed Charges,437,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.64,72,,1247.04,Percent of Total Billed Charges,72% of Total Billed Charges,262.2,60,,1039.2,Percent of Total Billed Charges,60% of Total Billed Charges,393.3,90,,722.36,Percent of Total Billed Charges,90% of Total Billed Charges,196.65,45,,157.32,Percent of Total Billed Charges,45% of Total Billed Charges,393.3,90,,659.864,Percent of Total Billed Charges,90% of Total billed Charges,437,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.05,65,,440.96,Percent of total Billed Charges,65% of Total Billed Charges,192.72,44.1,,154.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,415.15,95,,696.528,Percent of Total Billed Charges,95% of Total Billed Charges,437,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.56,88,,742.784,Percent of Total Billed Charges,88% of Total Billed Charges,393.3,90,,659.864,Percent of Total Billed charges,90% of Total Billed Charges,192.72,437,
CHST 3VW PA LAT LORD,3200000064,CDM,320,RC,,,Outpatient,,,463.05,300.98,,463.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,351.92,76,,557.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,333.4,72,,1900.224,Percent of Total Billed Charges,72% of Total Billed Charges,347.29,75,,1979.4,Percent of Total Billed charges,75% of Total Billed Charges,463.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.4,72,,1900.224,Percent of Total Billed Charges,72% of Total Billed Charges,277.83,60,,1583.52,Percent of Total Billed Charges,60% of Total Billed Charges,416.75,90,,1123.232,Percent of Total Billed Charges,90% of Total Billed Charges,208.37,45,,379.832,Percent of Total Billed Charges,45% of Total Billed Charges,416.75,90,,659.864,Percent of Total Billed Charges,90% of Total billed Charges,463.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,463.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,463.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.98,65,,753.32,Percent of total Billed Charges,65% of Total Billed Charges,204.21,44.1,,372.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,439.9,95,,696.528,Percent of Total Billed Charges,95% of Total Billed Charges,463.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.48,88,,549.52,Percent of Total Billed Charges,88% of Total Billed Charges,416.75,90,,659.864,Percent of Total Billed charges,90% of Total Billed Charges,204.21,463.05,
CHST 3VW PA LAT OBLI,3200000065,CDM,320,RC,,,Outpatient,,,440.00,286.00,,440,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,334.4,76,,2946.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,316.8,72,,1590.144,Percent of Total Billed Charges,72% of Total Billed Charges,330,75,,1656.4,Percent of Total Billed charges,75% of Total Billed Charges,440,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,72,,1590.144,Percent of Total Billed Charges,72% of Total Billed Charges,264,60,,1325.12,Percent of Total Billed Charges,60% of Total Billed Charges,396,90,,1422,Percent of Total Billed Charges,90% of Total Billed Charges,198,45,,281.008,Percent of Total Billed Charges,45% of Total Billed Charges,396,90,,3489.12,Percent of Total Billed Charges,90% of Total billed Charges,440,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286,65,,347.992,Percent of total Billed Charges,65% of Total Billed Charges,194.04,44.1,,275.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,418,95,,3682.96,Percent of Total Billed Charges,95% of Total Billed Charges,440,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,387.2,88,,1311.552,Percent of Total Billed Charges,88% of Total Billed Charges,396,90,,3489.12,Percent of Total Billed charges,90% of Total Billed Charges,194.04,440,
CHEST MIN 4V,3200000066,CDM,320,RC,,,Outpatient,,,502.74,326.78,,502.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,382.08,76,,1694.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,361.97,72,,1675.584,Percent of Total Billed Charges,72% of Total Billed Charges,377.06,75,,1745.4,Percent of Total Billed charges,75% of Total Billed Charges,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.97,72,,1675.584,Percent of Total Billed Charges,72% of Total Billed Charges,301.64,60,,1396.32,Percent of Total Billed Charges,60% of Total Billed Charges,452.47,90,,1080,Percent of Total Billed Charges,90% of Total Billed Charges,226.23,45,,670.68,Percent of Total Billed Charges,45% of Total Billed Charges,452.47,90,,2007.184,Percent of Total Billed Charges,90% of Total billed Charges,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.78,65,,579.608,Percent of total Billed Charges,65% of Total Billed Charges,221.71,44.1,,657.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,477.6,95,,2118.688,Percent of Total Billed Charges,95% of Total Billed Charges,502.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,442.41,88,,652.464,Percent of Total Billed Charges,88% of Total Billed Charges,452.47,90,,2007.184,Percent of Total Billed charges,90% of Total Billed Charges,221.71,502.74,
CHST COMPLETE MIN 4,3200000067,CDM,320,RC,,,Outpatient,,,478.00,310.70,,478,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,363.28,76,,265.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,344.16,72,,2119.104,Percent of Total Billed Charges,72% of Total Billed Charges,358.5,75,,2207.4,Percent of Total Billed charges,75% of Total Billed Charges,478,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,344.16,72,,2119.104,Percent of Total Billed Charges,72% of Total Billed Charges,286.8,60,,1765.92,Percent of Total Billed Charges,60% of Total Billed Charges,430.2,90,,802.536,Percent of Total Billed Charges,90% of Total Billed Charges,215.1,45,,333.648,Percent of Total Billed Charges,45% of Total Billed Charges,430.2,90,,314.64,Percent of Total Billed Charges,90% of Total billed Charges,478,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,478,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,478,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,310.7,65,,753.32,Percent of total Billed Charges,65% of Total Billed Charges,210.8,44.1,,326.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,454.1,95,,332.12,Percent of Total Billed Charges,95% of Total Billed Charges,478,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,420.64,88,,1159.488,Percent of Total Billed Charges,88% of Total Billed Charges,430.2,90,,314.64,Percent of Total Billed charges,90% of Total Billed Charges,210.8,478,
RIBS BILT MIN 4VW/PA,3200000068,CDM,320,RC,,,Outpatient,,,505.00,328.25,,505,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,383.8,76,,641.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,363.6,72,,2163.456,Percent of Total Billed Charges,72% of Total Billed Charges,378.75,75,,2253.6,Percent of Total Billed charges,75% of Total Billed Charges,505,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.6,72,,2163.456,Percent of Total Billed Charges,72% of Total Billed Charges,303,60,,1802.88,Percent of Total Billed Charges,60% of Total Billed Charges,454.5,90,,1123.232,Percent of Total Billed Charges,90% of Total Billed Charges,227.25,45,,592.92,Percent of Total Billed Charges,45% of Total Billed Charges,454.5,90,,759.664,Percent of Total Billed Charges,90% of Total billed Charges,505,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,505,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,505,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.25,65,,927.024,Percent of total Billed Charges,65% of Total Billed Charges,222.71,44.1,,581.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,479.75,95,,801.872,Percent of Total Billed Charges,95% of Total Billed Charges,505,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.4,88,,706.312,Percent of Total Billed Charges,88% of Total Billed Charges,454.5,90,,759.664,Percent of Total Billed charges,90% of Total Billed Charges,222.71,505,
STERNUM 2 VIEWS,3200000069,CDM,320,RC,,,Outpatient,,,360.00,234.00,,360,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,273.6,76,,474.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,259.2,72,,1510.848,Percent of Total Billed Charges,72% of Total Billed Charges,270,75,,1573.8,Percent of Total Billed charges,75% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.2,72,,1510.848,Percent of Total Billed Charges,72% of Total Billed Charges,216,60,,1259.04,Percent of Total Billed Charges,60% of Total Billed Charges,324,90,,1037.52,Percent of Total Billed Charges,90% of Total Billed Charges,162,45,,361.184,Percent of Total Billed Charges,45% of Total Billed Charges,324,90,,562.008,Percent of Total Billed Charges,90% of Total billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,65,,347.992,Percent of total Billed Charges,65% of Total Billed Charges,158.76,44.1,,353.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,342,95,,593.232,Percent of Total Billed Charges,95% of Total Billed Charges,360,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.8,88,,1098.272,Percent of Total Billed Charges,88% of Total Billed Charges,324,90,,562.008,Percent of Total Billed charges,90% of Total Billed Charges,158.76,360,
STNO CLAVCULR JNT MI,3200000070,CDM,320,RC,,,Outpatient,,,348.00,226.20,,348,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,264.48,76,,1132.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,250.56,72,,1345.536,Percent of Total Billed Charges,72% of Total Billed Charges,261,75,,1401.6,Percent of Total Billed charges,75% of Total Billed Charges,348,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.56,72,,1345.536,Percent of Total Billed Charges,72% of Total Billed Charges,208.8,60,,1121.28,Percent of Total Billed Charges,60% of Total Billed Charges,313.2,90,,1363.752,Percent of Total Billed Charges,90% of Total Billed Charges,156.6,45,,561.616,Percent of Total Billed Charges,45% of Total Billed Charges,313.2,90,,1341.36,Percent of Total Billed Charges,90% of Total billed Charges,348,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.2,65,,347.992,Percent of total Billed Charges,65% of Total Billed Charges,153.47,44.1,,550.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,330.6,95,,1415.88,Percent of Total Billed Charges,95% of Total Billed Charges,348,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.24,88,,1390.4,Percent of Total Billed Charges,88% of Total Billed Charges,313.2,90,,1341.36,Percent of Total Billed charges,90% of Total Billed Charges,153.47,348,
SPINE CERVICAL 1 VW,3200000071,CDM,320,RC,,,Outpatient,,,241.00,156.65,,241,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,183.16,76,,563.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,173.52,72,,1920.96,Percent of Total Billed Charges,72% of Total Billed Charges,180.75,75,,2001,Percent of Total Billed charges,75% of Total Billed Charges,241,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.52,72,,1920.96,Percent of Total Billed Charges,72% of Total Billed Charges,144.6,60,,1600.8,Percent of Total Billed Charges,60% of Total Billed Charges,216.9,90,,1379.52,Percent of Total Billed Charges,90% of Total Billed Charges,108.45,45,,711,Percent of Total Billed Charges,45% of Total Billed Charges,216.9,90,,667.288,Percent of Total Billed Charges,90% of Total billed Charges,241,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.65,65,,463.8,Percent of total Billed Charges,65% of Total Billed Charges,106.28,44.1,,696.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,228.95,95,,704.36,Percent of Total Billed Charges,95% of Total Billed Charges,241,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.08,88,,1056,Percent of Total Billed Charges,88% of Total Billed Charges,216.9,90,,667.288,Percent of Total Billed charges,90% of Total Billed Charges,106.28,241,
SPINE DORSAL 1 VW,3200000072,CDM,320,RC,,,Outpatient,,,241.00,156.65,,241,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,183.16,76,,1001.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,173.52,72,,2385.792,Percent of Total Billed Charges,72% of Total Billed Charges,180.75,75,,2485.2,Percent of Total Billed charges,75% of Total Billed Charges,241,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.52,72,,2385.792,Percent of Total Billed Charges,72% of Total Billed Charges,144.6,60,,1988.16,Percent of Total Billed Charges,60% of Total Billed Charges,216.9,90,,1704.96,Percent of Total Billed Charges,90% of Total Billed Charges,108.45,45,,540,Percent of Total Billed Charges,45% of Total Billed Charges,216.9,90,,1185.84,Percent of Total Billed Charges,90% of Total billed Charges,241,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.65,65,,637.512,Percent of total Billed Charges,65% of Total Billed Charges,106.28,44.1,,529.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,228.95,95,,1251.72,Percent of Total Billed Charges,95% of Total Billed Charges,241,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.08,88,,784.696,Percent of Total Billed Charges,88% of Total Billed Charges,216.9,90,,1185.84,Percent of Total Billed charges,90% of Total Billed Charges,106.28,241,
SPINE LUMBAR 1 VW,3200000073,CDM,320,RC,,,Outpatient,,,241.00,156.65,,241,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,183.16,76,,609.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,173.52,72,,1510.848,Percent of Total Billed Charges,72% of Total Billed Charges,180.75,75,,1573.8,Percent of Total Billed charges,75% of Total Billed Charges,241,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.52,72,,1510.848,Percent of Total Billed Charges,72% of Total Billed Charges,144.6,60,,1259.04,Percent of Total Billed Charges,60% of Total Billed Charges,216.9,90,,962.88,Percent of Total Billed Charges,90% of Total Billed Charges,108.45,45,,401.264,Percent of Total Billed Charges,45% of Total Billed Charges,216.9,90,,722.36,Percent of Total Billed Charges,90% of Total billed Charges,241,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.65,65,,893.88,Percent of total Billed Charges,65% of Total Billed Charges,106.28,44.1,,393.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,228.95,95,,762.496,Percent of Total Billed Charges,95% of Total Billed Charges,241,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.08,88,,1098.272,Percent of Total Billed Charges,88% of Total Billed Charges,216.9,90,,722.36,Percent of Total Billed charges,90% of Total Billed Charges,106.28,241,
SPINE CERVICAL 2OR3,3200000074,CDM,320,RC,,,Outpatient,,,442.00,287.30,,442,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,335.92,76,,948.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,318.24,72,,3119.616,Percent of Total Billed Charges,72% of Total Billed Charges,331.5,75,,3249.6,Percent of Total Billed charges,75% of Total Billed Charges,442,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.24,72,,3119.616,Percent of Total Billed Charges,72% of Total Billed Charges,265.2,60,,2599.68,Percent of Total Billed Charges,60% of Total Billed Charges,397.8,90,,1283.576,Percent of Total Billed Charges,90% of Total Billed Charges,198.9,45,,561.616,Percent of Total Billed Charges,45% of Total Billed Charges,397.8,90,,1123.232,Percent of Total Billed Charges,90% of Total billed Charges,442,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,442,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,442,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,287.3,65,,811.224,Percent of total Billed Charges,65% of Total Billed Charges,194.92,44.1,,550.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,419.9,95,,1185.632,Percent of Total Billed Charges,95% of Total Billed Charges,442,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,388.96,88,,1014.464,Percent of Total Billed Charges,88% of Total Billed Charges,397.8,90,,1123.232,Percent of Total Billed charges,90% of Total Billed Charges,194.92,442,
SPINE CERVICAL MIN 4,3200000075,CDM,320,RC,,,Outpatient,,,412.00,267.80,,412,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,313.12,76,,1200.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,296.64,72,,4439.232,Percent of Total Billed Charges,72% of Total Billed Charges,309,75,,4624.2,Percent of Total Billed charges,75% of Total Billed Charges,412,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.64,72,,4439.232,Percent of Total Billed Charges,72% of Total Billed Charges,247.2,60,,3699.36,Percent of Total Billed Charges,60% of Total Billed Charges,370.8,90,,1363.752,Percent of Total Billed Charges,90% of Total Billed Charges,185.4,45,,518.76,Percent of Total Billed Charges,45% of Total Billed Charges,370.8,90,,1422,Percent of Total Billed Charges,90% of Total billed Charges,412,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.8,65,,579.608,Percent of total Billed Charges,65% of Total Billed Charges,181.69,44.1,,508.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,391.4,95,,1501,Percent of Total Billed Charges,95% of Total Billed Charges,412,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,362.56,88,,1333.448,Percent of Total Billed Charges,88% of Total Billed Charges,370.8,90,,1422,Percent of Total Billed charges,90% of Total Billed Charges,181.69,412,
SPINE CERVICAL COMP,3200000076,CDM,320,RC,,,Outpatient,,,495.00,321.75,,495,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,376.2,76,,912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,356.4,72,,4662.144,Percent of Total Billed Charges,72% of Total Billed Charges,371.25,75,,4856.4,Percent of Total Billed charges,75% of Total Billed Charges,495,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.4,72,,4662.144,Percent of Total Billed Charges,72% of Total Billed Charges,297,60,,3885.12,Percent of Total Billed Charges,60% of Total Billed Charges,445.5,90,,1373.04,Percent of Total Billed Charges,90% of Total Billed Charges,222.75,45,,681.88,Percent of Total Billed Charges,45% of Total Billed Charges,445.5,90,,1080,Percent of Total Billed Charges,90% of Total billed Charges,495,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,321.75,65,,579.608,Percent of total Billed Charges,65% of Total Billed Charges,218.3,44.1,,668.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,470.25,95,,1140,Percent of Total Billed Charges,95% of Total Billed Charges,495,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.6,88,,1348.864,Percent of Total Billed Charges,88% of Total Billed Charges,445.5,90,,1080,Percent of Total Billed charges,90% of Total Billed Charges,218.3,495,
SPINE DORSAL 2 VWS,3200000077,CDM,320,RC,,,Outpatient,,,462.00,300.30,,462,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,351.12,76,,677.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,332.64,72,,1510.848,Percent of Total Billed Charges,72% of Total Billed Charges,346.5,75,,1573.8,Percent of Total Billed charges,75% of Total Billed Charges,462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.64,72,,1510.848,Percent of Total Billed Charges,72% of Total Billed Charges,277.2,60,,1259.04,Percent of Total Billed Charges,60% of Total Billed Charges,415.8,90,,1043.056,Percent of Total Billed Charges,90% of Total Billed Charges,207.9,45,,689.76,Percent of Total Billed Charges,45% of Total Billed Charges,415.8,90,,802.536,Percent of Total Billed Charges,90% of Total billed Charges,462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.3,65,,521.704,Percent of total Billed Charges,65% of Total Billed Charges,203.74,44.1,,675.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,438.9,95,,847.12,Percent of Total Billed Charges,95% of Total Billed Charges,462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.56,88,,1667.072,Percent of Total Billed Charges,88% of Total Billed Charges,415.8,90,,802.536,Percent of Total Billed charges,90% of Total Billed Charges,203.74,462,
SPINE DORSAL 3 VWS,3200000078,CDM,320,RC,,,Outpatient,,,421.00,273.65,,421,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,319.96,76,,948.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,303.12,72,,264.808,Percent of Total Billed Charges,72% of Total Billed Charges,315.75,75,,275.848,Percent of Total Billed charges,75% of Total Billed Charges,421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.12,72,,264.808,Percent of Total Billed Charges,72% of Total Billed Charges,252.6,60,,220.672,Percent of Total Billed Charges,60% of Total Billed Charges,378.9,90,,1411.384,Percent of Total Billed Charges,90% of Total Billed Charges,189.45,45,,852.48,Percent of Total Billed Charges,45% of Total Billed Charges,378.9,90,,1123.232,Percent of Total Billed Charges,90% of Total billed Charges,421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.65,65,,927.024,Percent of total Billed Charges,65% of Total Billed Charges,185.66,44.1,,835.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,399.95,95,,1185.632,Percent of Total Billed Charges,95% of Total Billed Charges,421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.48,88,,941.48,Percent of Total Billed Charges,88% of Total Billed Charges,378.9,90,,1123.232,Percent of Total Billed charges,90% of Total Billed Charges,185.66,421,
SPINE DORSAL MIN 4VW,3200000079,CDM,320,RC,,,Outpatient,,,424.00,275.60,,424,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,322.24,76,,876.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,305.28,72,,1333.584,Percent of Total Billed Charges,72% of Total Billed Charges,318,75,,1389.152,Percent of Total Billed charges,75% of Total Billed Charges,424,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305.28,72,,1333.584,Percent of Total Billed Charges,72% of Total Billed Charges,254.4,60,,1111.32,Percent of Total Billed Charges,60% of Total Billed Charges,381.6,90,,651.712,Percent of Total Billed Charges,90% of Total Billed Charges,190.8,45,,481.44,Percent of Total Billed Charges,45% of Total Billed Charges,381.6,90,,1037.52,Percent of Total Billed Charges,90% of Total billed Charges,424,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.6,65,,927.024,Percent of total Billed Charges,65% of Total Billed Charges,186.98,44.1,,471.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,402.8,95,,1095.16,Percent of Total Billed Charges,95% of Total Billed Charges,424,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.12,88,,1255.048,Percent of Total Billed Charges,88% of Total Billed Charges,381.6,90,,1037.52,Percent of Total Billed charges,90% of Total Billed Charges,186.98,424,
SPINE THORCOLUMBAR 2,3200000080,CDM,320,RC,,,Outpatient,,,482.90,313.89,,482.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,367,76,,1151.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,347.69,72,,2594.304,Percent of Total Billed Charges,72% of Total Billed Charges,362.18,75,,2702.4,Percent of Total Billed charges,75% of Total Billed Charges,482.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.69,72,,2594.304,Percent of Total Billed Charges,72% of Total Billed Charges,289.74,60,,2161.92,Percent of Total Billed Charges,60% of Total Billed Charges,434.61,90,,763.64,Percent of Total Billed Charges,90% of Total Billed Charges,217.31,45,,641.784,Percent of Total Billed Charges,45% of Total Billed Charges,434.61,90,,1363.752,Percent of Total Billed Charges,90% of Total billed Charges,482.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.89,65,,1587.768,Percent of total Billed Charges,65% of Total Billed Charges,212.96,44.1,,628.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,458.76,95,,1439.52,Percent of Total Billed Charges,95% of Total Billed Charges,482.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.95,88,,1333.448,Percent of Total Billed Charges,88% of Total Billed Charges,434.61,90,,1363.752,Percent of Total Billed charges,90% of Total Billed Charges,212.96,482.9,
SPINE SCOLIOSIS STAN 1 VIEW,3200000081,CDM,320,RC,,,Outpatient,,,482.90,313.89,,482.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,367,76,,1164.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,347.69,72,,3299.896,Percent of Total Billed Charges,72% of Total Billed Charges,362.18,75,,3437.392,Percent of Total Billed charges,75% of Total Billed Charges,482.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.69,72,,3299.896,Percent of Total Billed Charges,72% of Total Billed Charges,289.74,60,,2749.912,Percent of Total Billed Charges,60% of Total Billed Charges,434.61,90,,1314.72,Percent of Total Billed Charges,90% of Total Billed Charges,217.31,45,,681.88,Percent of Total Billed Charges,45% of Total Billed Charges,434.61,90,,1379.52,Percent of Total Billed Charges,90% of Total billed Charges,482.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.89,65,,459.432,Percent of total Billed Charges,65% of Total Billed Charges,212.96,44.1,,668.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,458.76,95,,1456.16,Percent of Total Billed Charges,95% of Total Billed Charges,482.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.95,88,,1342.528,Percent of Total Billed Charges,88% of Total Billed Charges,434.61,90,,1379.52,Percent of Total Billed charges,90% of Total Billed Charges,212.96,482.9,
SPINE LUMBAR 2OR3 VW,3200000082,CDM,320,RC,,,Outpatient,,,453.13,294.53,,453.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,344.38,76,,1439.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,326.25,72,,1501.872,Percent of Total Billed Charges,72% of Total Billed Charges,339.85,75,,1564.448,Percent of Total Billed charges,75% of Total Billed Charges,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.25,72,,1501.872,Percent of Total Billed Charges,72% of Total Billed Charges,271.88,60,,1251.56,Percent of Total Billed Charges,60% of Total Billed Charges,407.82,90,,2213.28,Percent of Total Billed Charges,90% of Total Billed Charges,203.91,45,,686.52,Percent of Total Billed Charges,45% of Total Billed Charges,407.82,90,,1704.96,Percent of Total Billed Charges,90% of Total billed Charges,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.53,65,,459.432,Percent of total Billed Charges,65% of Total Billed Charges,199.83,44.1,,672.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,430.47,95,,1799.68,Percent of Total Billed Charges,95% of Total Billed Charges,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.75,88,,1019.88,Percent of Total Billed Charges,88% of Total Billed Charges,407.82,90,,1704.96,Percent of Total Billed charges,90% of Total Billed Charges,199.83,453.13,
SPINE LUMBAR MIN 4 V,3200000083,CDM,320,RC,,,Outpatient,,,570.00,370.50,,570,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,433.2,76,,813.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,410.4,72,,3299.896,Percent of Total Billed Charges,72% of Total Billed Charges,427.5,75,,3437.392,Percent of Total Billed charges,75% of Total Billed Charges,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,410.4,72,,3299.896,Percent of Total Billed Charges,72% of Total Billed Charges,342,60,,2749.912,Percent of Total Billed Charges,60% of Total Billed Charges,513,90,,3177.36,Percent of Total Billed Charges,90% of Total Billed Charges,256.5,45,,521.528,Percent of Total Billed Charges,45% of Total Billed Charges,513,90,,962.88,Percent of Total Billed Charges,90% of Total billed Charges,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.5,65,,1632.792,Percent of total Billed Charges,65% of Total Billed Charges,251.37,44.1,,511.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,541.5,95,,1016.368,Percent of Total Billed Charges,95% of Total Billed Charges,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.6,88,,1380.016,Percent of Total Billed Charges,88% of Total Billed Charges,513,90,,962.88,Percent of Total Billed charges,90% of Total Billed Charges,251.37,570,
SPN LUMR COMP W/BNDI,3200000084,CDM,320,RC,,,Outpatient,,,545.00,354.25,,545,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.2,76,,1083.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,392.4,72,,556.16,Percent of Total Billed Charges,72% of Total Billed Charges,408.75,75,,579.328,Percent of Total Billed charges,75% of Total Billed Charges,545,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.4,72,,556.16,Percent of Total Billed Charges,72% of Total Billed Charges,327,60,,463.464,Percent of Total Billed Charges,60% of Total Billed Charges,490.5,90,,3903.12,Percent of Total Billed Charges,90% of Total Billed Charges,245.25,45,,705.688,Percent of Total Billed Charges,45% of Total Billed Charges,490.5,90,,1283.576,Percent of Total Billed Charges,90% of Total billed Charges,545,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,545,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,545,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.25,65,,691.6,Percent of total Billed Charges,65% of Total Billed Charges,240.35,44.1,,691.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,517.75,95,,1354.88,Percent of Total Billed Charges,95% of Total Billed Charges,545,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.6,88,,637.224,Percent of Total Billed Charges,88% of Total Billed Charges,490.5,90,,1283.576,Percent of Total Billed charges,90% of Total Billed Charges,240.35,545,
SPN LUMBR BND 5VW MI,3200000085,CDM,320,RC,,,Outpatient,,,266.81,173.43,,266.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,202.78,76,,1151.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,192.1,72,,858.816,Percent of Total Billed Charges,72% of Total Billed Charges,200.11,75,,894.6,Percent of Total Billed charges,75% of Total Billed Charges,266.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.1,72,,858.816,Percent of Total Billed Charges,72% of Total Billed Charges,160.09,60,,715.68,Percent of Total Billed Charges,60% of Total Billed Charges,240.13,90,,1251.824,Percent of Total Billed Charges,90% of Total Billed Charges,120.06,45,,325.856,Percent of Total Billed Charges,45% of Total Billed Charges,240.13,90,,1363.752,Percent of Total Billed Charges,90% of Total billed Charges,266.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.43,65,,310.84,Percent of total Billed Charges,65% of Total Billed Charges,117.66,44.1,,319.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,253.47,95,,1439.52,Percent of Total Billed Charges,95% of Total Billed Charges,266.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.79,88,,746.672,Percent of Total Billed Charges,88% of Total Billed Charges,240.13,90,,1363.752,Percent of Total Billed charges,90% of Total Billed Charges,117.66,266.81,
PELVIS 1 OR 2 VIEWS,3200000086,CDM,320,RC,,,Outpatient,,,277.00,180.05,,277,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,210.52,76,,1159.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,199.44,72,,575.424,Percent of Total Billed Charges,72% of Total Billed Charges,207.75,75,,599.4,Percent of Total Billed charges,75% of Total Billed Charges,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.44,72,,575.424,Percent of Total Billed Charges,72% of Total Billed Charges,166.2,60,,479.52,Percent of Total Billed Charges,60% of Total Billed Charges,249.3,90,,562.008,Percent of Total Billed Charges,90% of Total Billed Charges,124.65,45,,381.816,Percent of Total Billed Charges,45% of Total Billed Charges,249.3,90,,1373.04,Percent of Total Billed Charges,90% of Total billed Charges,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.05,65,,171.704,Percent of total Billed Charges,65% of Total Billed Charges,122.16,44.1,,374.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,263.15,95,,1449.32,Percent of Total Billed Charges,95% of Total Billed Charges,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.76,88,,1285.504,Percent of Total Billed Charges,88% of Total Billed Charges,249.3,90,,1373.04,Percent of Total Billed charges,90% of Total Billed Charges,122.16,277,
PELVIC COMP MIN 3VW,3200000087,CDM,320,RC,,,Outpatient,,,362.00,235.30,,362,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,275.12,76,,880.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,260.64,72,,8079.696,Percent of Total Billed Charges,72% of Total Billed Charges,271.5,75,,8416.352,Percent of Total Billed charges,75% of Total Billed Charges,362,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.64,72,,8079.696,Percent of Total Billed Charges,72% of Total Billed Charges,217.2,60,,6733.08,Percent of Total Billed Charges,60% of Total Billed Charges,325.8,90,,802.536,Percent of Total Billed Charges,90% of Total Billed Charges,162.9,45,,657.36,Percent of Total Billed Charges,45% of Total Billed Charges,325.8,90,,1043.056,Percent of Total Billed Charges,90% of Total billed Charges,362,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,362,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,362,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.3,65,,927.024,Percent of total Billed Charges,65% of Total Billed Charges,159.64,44.1,,644.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,343.9,95,,1101.008,Percent of Total Billed Charges,95% of Total Billed Charges,362,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.56,88,,2164.096,Percent of Total Billed Charges,88% of Total Billed Charges,325.8,90,,1043.056,Percent of Total Billed charges,90% of Total Billed Charges,159.64,362,
SI JNTS LESS THN 3 V,3200000088,CDM,320,RC,,,Outpatient,,,283.00,183.95,,283,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,215.08,76,,1191.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,203.76,72,,5367.232,Percent of Total Billed Charges,72% of Total Billed Charges,212.25,75,,5590.864,Percent of Total Billed charges,75% of Total Billed Charges,283,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.76,72,,5367.232,Percent of Total Billed Charges,72% of Total Billed Charges,169.8,60,,4472.696,Percent of Total Billed Charges,60% of Total Billed Charges,254.7,90,,1247.856,Percent of Total Billed Charges,90% of Total Billed Charges,127.35,45,,1106.64,Percent of Total Billed Charges,45% of Total Billed Charges,254.7,90,,1411.384,Percent of Total Billed Charges,90% of Total billed Charges,283,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.95,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,124.8,44.1,,1084.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,268.85,95,,1489.792,Percent of Total Billed Charges,95% of Total Billed Charges,283,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.04,88,,3106.752,Percent of Total Billed Charges,88% of Total Billed Charges,254.7,90,,1411.384,Percent of Total Billed charges,90% of Total Billed Charges,124.8,283,
SI JNTS 3 OR MORE VW,3200000089,CDM,320,RC,,,Outpatient,,,318.00,206.70,,318,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,241.68,76,,550.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,228.96,72,,39505.2,Percent of Total Billed Charges,72% of Total Billed Charges,238.5,75,,41151.256,Percent of Total Billed charges,75% of Total Billed Charges,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.96,72,,39505.2,Percent of Total Billed Charges,72% of Total Billed Charges,190.8,60,,32921,Percent of Total Billed Charges,60% of Total Billed Charges,286.2,90,,610.56,Percent of Total Billed Charges,90% of Total Billed Charges,143.1,45,,1588.68,Percent of Total Billed Charges,45% of Total Billed Charges,286.2,90,,651.712,Percent of Total Billed Charges,90% of Total billed Charges,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.7,65,,23.504,Percent of total Billed Charges,65% of Total Billed Charges,140.24,44.1,,1556.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,302.1,95,,687.912,Percent of Total Billed Charges,95% of Total Billed Charges,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279.84,88,,3816.384,Percent of Total Billed Charges,88% of Total Billed Charges,286.2,90,,651.712,Percent of Total Billed charges,90% of Total Billed Charges,140.24,318,
SACRUM COCCYX MIN 2,3200000090,CDM,320,RC,,,Outpatient,,,279.00,181.35,,279,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,212.04,76,,644.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,200.88,72,,38553.912,Percent of Total Billed Charges,72% of Total Billed Charges,209.25,75,,40160.328,Percent of Total Billed charges,75% of Total Billed Charges,279,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.88,72,,38553.912,Percent of Total Billed Charges,72% of Total Billed Charges,167.4,60,,32128.264,Percent of Total Billed Charges,60% of Total Billed Charges,251.1,90,,1043.056,Percent of Total Billed Charges,90% of Total Billed Charges,125.55,45,,1951.56,Percent of Total Billed Charges,45% of Total Billed Charges,251.1,90,,763.64,Percent of Total Billed Charges,90% of Total billed Charges,279,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.35,65,,157.088,Percent of total Billed Charges,65% of Total Billed Charges,123.04,44.1,,1912.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,265.05,95,,806.064,Percent of Total Billed Charges,95% of Total Billed Charges,279,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.52,88,,1224,Percent of Total Billed Charges,88% of Total Billed Charges,251.1,90,,763.64,Percent of Total Billed charges,90% of Total Billed Charges,123.04,279,
MYELOGRAM CERVICAL RS & I,3200000091,CDM,320,RC,,,Outpatient,,,2075.30,1348.95,,2075.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1577.23,76,,1110.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1494.22,72,,37782.336,Percent of Total Billed Charges,72% of Total Billed Charges,1556.48,75,,39356.608,Percent of Total Billed charges,75% of Total Billed Charges,2075.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1494.22,72,,37782.336,Percent of Total Billed Charges,72% of Total Billed Charges,1245.18,60,,31485.28,Percent of Total Billed Charges,60% of Total Billed Charges,1867.77,90,,481.84,Percent of Total Billed Charges,90% of Total Billed Charges,933.89,45,,625.912,Percent of Total Billed Charges,45% of Total Billed Charges,1867.77,90,,1314.72,Percent of Total Billed Charges,90% of Total billed Charges,2075.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2075.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2075.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1348.95,65,,468,Percent of total Billed Charges,65% of Total Billed Charges,915.21,44.1,,613.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1971.54,95,,1387.76,Percent of Total Billed Charges,95% of Total Billed Charges,2075.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1826.26,88,,549.52,Percent of Total Billed Charges,88% of Total Billed Charges,1867.77,90,,1314.72,Percent of Total Billed charges,90% of Total Billed Charges,915.21,2075.3,
MYELOGRAM THORACIC RS & I,3200000092,CDM,320,RC,,,Outpatient,,,2075.30,1348.95,,2075.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1577.23,76,,1868.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1494.22,72,,5825.856,Percent of Total Billed Charges,72% of Total Billed Charges,1556.48,75,,6068.608,Percent of Total Billed charges,75% of Total Billed Charges,2075.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1494.22,72,,5825.856,Percent of Total Billed Charges,72% of Total Billed Charges,1245.18,60,,4854.88,Percent of Total Billed Charges,60% of Total Billed Charges,1867.77,90,,802.536,Percent of Total Billed Charges,90% of Total Billed Charges,933.89,45,,281.008,Percent of Total Billed Charges,45% of Total Billed Charges,1867.77,90,,2213.28,Percent of Total Billed Charges,90% of Total billed Charges,2075.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2075.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2075.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1348.95,65,,349.128,Percent of total Billed Charges,65% of Total Billed Charges,915.21,44.1,,275.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,1971.54,95,,2336.24,Percent of Total Billed Charges,95% of Total Billed Charges,2075.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1826.26,88,,784.696,Percent of Total Billed Charges,88% of Total Billed Charges,1867.77,90,,2213.28,Percent of Total Billed charges,90% of Total Billed Charges,915.21,2075.3,
MYELOGRAM LUMBOSACRAL RS & I,3200000093,CDM,320,RC,,,Outpatient,,,1136.70,738.86,,1136.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,863.89,76,,2683.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,818.42,72,,12045.44,Percent of Total Billed Charges,72% of Total Billed Charges,852.53,75,,12547.336,Percent of Total Billed charges,75% of Total Billed Charges,1136.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,818.42,72,,12045.44,Percent of Total Billed Charges,72% of Total Billed Charges,682.02,60,,10037.864,Percent of Total Billed Charges,60% of Total Billed Charges,1023.03,90,,1043.056,Percent of Total Billed Charges,90% of Total Billed Charges,511.52,45,,401.264,Percent of Total Billed Charges,45% of Total Billed Charges,1023.03,90,,3177.36,Percent of Total Billed Charges,90% of Total billed Charges,1136.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1136.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1136.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,738.86,65,,587.608,Percent of total Billed Charges,65% of Total Billed Charges,501.28,44.1,,393.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,1079.87,95,,3353.88,Percent of Total Billed Charges,95% of Total Billed Charges,1136.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1000.3,88,,1220.12,Percent of Total Billed Charges,88% of Total Billed Charges,1023.03,90,,3177.36,Percent of Total Billed charges,90% of Total Billed Charges,501.28,1136.7,
SPINE MYELOGRAM,3200000094,CDM,320,RC,,,Outpatient,,,1136.70,738.86,,1136.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,863.89,76,,3295.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,818.42,72,,3189.808,Percent of Total Billed Charges,72% of Total Billed Charges,852.53,75,,3322.72,Percent of Total Billed charges,75% of Total Billed Charges,1136.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,818.42,72,,3189.808,Percent of Total Billed Charges,72% of Total Billed Charges,682.02,60,,2658.176,Percent of Total Billed Charges,60% of Total Billed Charges,1023.03,90,,1283.576,Percent of Total Billed Charges,90% of Total Billed Charges,511.52,45,,623.928,Percent of Total Billed Charges,45% of Total Billed Charges,1023.03,90,,3903.12,Percent of Total Billed Charges,90% of Total billed Charges,1136.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1136.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1136.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,738.86,65,,587.608,Percent of total Billed Charges,65% of Total Billed Charges,501.28,44.1,,611.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,1079.87,95,,4119.96,Percent of Total Billed Charges,95% of Total Billed Charges,1136.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1000.3,88,,596.992,Percent of Total Billed Charges,88% of Total Billed Charges,1023.03,90,,3903.12,Percent of Total Billed charges,90% of Total Billed Charges,501.28,1136.7,
AC JOINTS,3200000095,CDM,320,RC,,,Outpatient,,,94.00,61.10,,94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,71.44,76,,1057.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,67.68,72,,1333.584,Percent of Total Billed Charges,72% of Total Billed Charges,70.5,75,,1389.152,Percent of Total Billed charges,75% of Total Billed Charges,94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.68,72,,1333.584,Percent of Total Billed Charges,72% of Total Billed Charges,56.4,60,,1111.32,Percent of Total Billed Charges,60% of Total Billed Charges,84.6,90,,481.84,Percent of Total Billed Charges,90% of Total Billed Charges,42.3,45,,305.28,Percent of Total Billed Charges,45% of Total Billed Charges,84.6,90,,1251.824,Percent of Total Billed Charges,90% of Total billed Charges,94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.1,65,,69.368,Percent of total Billed Charges,65% of Total Billed Charges,41.45,44.1,,299.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,89.3,95,,1321.368,Percent of Total Billed Charges,95% of Total Billed Charges,94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.72,88,,1019.88,Percent of Total Billed Charges,88% of Total Billed Charges,84.6,90,,1251.824,Percent of Total Billed charges,90% of Total Billed Charges,41.45,94,
PEL&HIP INFT CHLD MI,3200000096,CDM,320,RC,,,Outpatient,,,556.76,361.89,,556.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,423.14,76,,474.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,400.87,72,,2730.672,Percent of Total Billed Charges,72% of Total Billed Charges,417.57,75,,2844.448,Percent of Total Billed charges,75% of Total Billed Charges,556.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.87,72,,2730.672,Percent of Total Billed Charges,72% of Total Billed Charges,334.06,60,,2275.56,Percent of Total Billed Charges,60% of Total Billed Charges,501.08,90,,481.84,Percent of Total Billed Charges,90% of Total Billed Charges,250.54,45,,521.528,Percent of Total Billed Charges,45% of Total Billed Charges,501.08,90,,562.008,Percent of Total Billed Charges,90% of Total billed Charges,556.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,556.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,556.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.89,65,,340.048,Percent of total Billed Charges,65% of Total Billed Charges,245.53,44.1,,511.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,528.92,95,,593.232,Percent of Total Billed Charges,95% of Total Billed Charges,556.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.95,88,,471.128,Percent of Total Billed Charges,88% of Total Billed Charges,501.08,90,,562.008,Percent of Total Billed charges,90% of Total Billed Charges,245.53,556.76,
BILAT HIP/AP PELVIC,3200000097,CDM,320,RC,,,Outpatient,,,328.00,213.20,,328,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,249.28,76,,677.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,236.16,72,,7694.952,Percent of Total Billed Charges,72% of Total Billed Charges,246,75,,8015.576,Percent of Total Billed charges,75% of Total Billed Charges,328,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.16,72,,7694.952,Percent of Total Billed Charges,72% of Total Billed Charges,196.8,60,,6412.456,Percent of Total Billed Charges,60% of Total Billed Charges,295.2,90,,642.184,Percent of Total Billed Charges,90% of Total Billed Charges,147.6,45,,240.92,Percent of Total Billed Charges,45% of Total Billed Charges,295.2,90,,802.536,Percent of Total Billed Charges,90% of Total billed Charges,328,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.2,65,,242.528,Percent of total Billed Charges,65% of Total Billed Charges,144.65,44.1,,236.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,311.6,95,,847.12,Percent of Total Billed Charges,95% of Total Billed Charges,328,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.64,88,,784.696,Percent of Total Billed Charges,88% of Total Billed Charges,295.2,90,,802.536,Percent of Total Billed charges,90% of Total Billed Charges,144.65,328,
KNEE BILAT AP STNDIN,3200000098,CDM,320,RC,,,Outpatient,,,212.00,137.80,,212,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.12,76,,1053.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,152.64,72,,1333.584,Percent of Total Billed Charges,72% of Total Billed Charges,159,75,,1389.152,Percent of Total Billed charges,75% of Total Billed Charges,212,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.64,72,,1333.584,Percent of Total Billed Charges,72% of Total Billed Charges,127.2,60,,1111.32,Percent of Total Billed Charges,60% of Total Billed Charges,190.8,90,,882.704,Percent of Total Billed Charges,90% of Total Billed Charges,95.4,45,,401.264,Percent of Total Billed Charges,45% of Total Billed Charges,190.8,90,,1247.856,Percent of Total Billed Charges,90% of Total billed Charges,212,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.8,65,,34.4,Percent of total Billed Charges,65% of Total Billed Charges,93.49,44.1,,393.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,201.4,95,,1317.176,Percent of Total Billed Charges,95% of Total Billed Charges,212,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.56,88,,1019.88,Percent of Total Billed Charges,88% of Total Billed Charges,190.8,90,,1247.856,Percent of Total Billed charges,90% of Total Billed Charges,93.49,212,
ABDOMEN 1 VIEW,3200000099,CDM,320,RC,,,Outpatient,,,336.00,218.40,,336,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,255.36,76,,515.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,241.92,72,,2730.672,Percent of Total Billed Charges,72% of Total Billed Charges,252,75,,2844.448,Percent of Total Billed charges,75% of Total Billed Charges,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.92,72,,2730.672,Percent of Total Billed Charges,72% of Total Billed Charges,201.6,60,,2275.56,Percent of Total Billed Charges,60% of Total Billed Charges,302.4,90,,1237.68,Percent of Total Billed Charges,90% of Total Billed Charges,151.2,45,,521.528,Percent of Total Billed Charges,45% of Total Billed Charges,302.4,90,,610.56,Percent of Total Billed Charges,90% of Total billed Charges,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.4,65,,208.68,Percent of total Billed Charges,65% of Total Billed Charges,148.18,44.1,,511.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,319.2,95,,644.48,Percent of Total Billed Charges,95% of Total Billed Charges,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.68,88,,1255.048,Percent of Total Billed Charges,88% of Total Billed Charges,302.4,90,,610.56,Percent of Total Billed charges,90% of Total Billed Charges,148.18,336,
ABDOMEN UP TO 5V DECUB/UPRIGHT,3200000100,CDM,320,RC,,,Outpatient,,,428.00,278.20,,428,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,325.28,76,,880.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,308.16,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,321,75,,3009.832,Percent of Total Billed charges,75% of Total Billed Charges,428,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.16,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,256.8,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,385.2,90,,1123.232,Percent of Total Billed Charges,90% of Total Billed Charges,192.6,45,,641.784,Percent of Total Billed Charges,45% of Total Billed Charges,385.2,90,,1043.056,Percent of Total Billed Charges,90% of Total billed Charges,428,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,428,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,428,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.2,65,,490.744,Percent of total Billed Charges,65% of Total Billed Charges,188.75,44.1,,628.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,406.6,95,,1101.008,Percent of Total Billed Charges,95% of Total Billed Charges,428,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.64,88,,471.128,Percent of Total Billed Charges,88% of Total Billed Charges,385.2,90,,1043.056,Percent of Total Billed charges,90% of Total Billed Charges,188.75,428,
ABD AP OBLIQUE UP TO 4V,3200000101,CDM,320,RC,,,Outpatient,,,424.00,275.60,,424,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,322.24,76,,406.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,305.28,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,318,75,,3009.832,Percent of Total Billed charges,75% of Total Billed Charges,424,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305.28,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,254.4,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,381.6,90,,802.536,Percent of Total Billed Charges,90% of Total Billed Charges,190.8,45,,240.92,Percent of Total Billed Charges,45% of Total Billed Charges,381.6,90,,481.84,Percent of Total Billed Charges,90% of Total billed Charges,424,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.6,65,,535.464,Percent of total Billed Charges,65% of Total Billed Charges,186.98,44.1,,236.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,402.8,95,,508.608,Percent of Total Billed Charges,95% of Total Billed Charges,424,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.12,88,,471.128,Percent of Total Billed Charges,88% of Total Billed Charges,381.6,90,,481.84,Percent of Total Billed charges,90% of Total Billed Charges,186.98,424,
ABD ACUT COMP AP ECT,3200000102,CDM,320,RC,,,Outpatient,,,794.00,516.10,,794,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,603.44,76,,677.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,571.68,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,595.5,75,,3009.832,Percent of Total Billed charges,75% of Total Billed Charges,794,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,571.68,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,476.4,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,714.6,90,,802.536,Percent of Total Billed Charges,90% of Total Billed Charges,357.3,45,,240.92,Percent of Total Billed Charges,45% of Total Billed Charges,714.6,90,,802.536,Percent of Total Billed Charges,90% of Total billed Charges,794,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,794,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,794,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,516.1,65,,227.6,Percent of total Billed Charges,65% of Total Billed Charges,350.15,44.1,,236.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,754.3,95,,847.12,Percent of Total Billed Charges,95% of Total Billed Charges,794,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,698.72,88,,627.912,Percent of Total Billed Charges,88% of Total Billed Charges,714.6,90,,802.536,Percent of Total Billed charges,90% of Total Billed Charges,350.15,794,
ESOPHAGRAM W/SPOTS,3200000103,CDM,320,RC,,,Outpatient,,,473.00,307.45,,473,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,359.48,76,,880.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,340.56,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,354.75,75,,3009.832,Percent of Total Billed charges,75% of Total Billed Charges,473,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.56,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,283.8,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,425.7,90,,722.36,Percent of Total Billed Charges,90% of Total Billed Charges,212.85,45,,321.088,Percent of Total Billed Charges,45% of Total Billed Charges,425.7,90,,1043.056,Percent of Total Billed Charges,90% of Total billed Charges,473,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.45,65,,1361.88,Percent of total Billed Charges,65% of Total Billed Charges,208.59,44.1,,314.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,449.35,95,,1101.008,Percent of Total Billed Charges,95% of Total Billed Charges,473,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,416.24,88,,863.088,Percent of Total Billed Charges,88% of Total Billed Charges,425.7,90,,1043.056,Percent of Total Billed charges,90% of Total Billed Charges,208.59,473,
MODIFIED BA SWALLOW,3200000104,CDM,320,RC,,,Outpatient,,,350.00,227.50,,350,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,266,76,,1083.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,252,72,,549.944,Percent of Total Billed Charges,72% of Total Billed Charges,262.5,75,,572.864,Percent of Total Billed charges,75% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,72,,549.944,Percent of Total Billed Charges,72% of Total Billed Charges,210,60,,458.288,Percent of Total Billed Charges,60% of Total Billed Charges,315,90,,1283.576,Percent of Total Billed Charges,90% of Total Billed Charges,157.5,45,,441.352,Percent of Total Billed Charges,45% of Total Billed Charges,315,90,,1283.576,Percent of Total Billed Charges,90% of Total billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,65,,1916.2,Percent of total Billed Charges,65% of Total Billed Charges,154.35,44.1,,432.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,332.5,95,,1354.88,Percent of Total Billed Charges,95% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308,88,,1210.176,Percent of Total Billed Charges,88% of Total Billed Charges,315,90,,1283.576,Percent of Total Billed charges,90% of Total Billed Charges,154.35,350,
UPPER GI SGL WO KUB,3200000105,CDM,320,RC,,,Outpatient,,,659.00,428.35,,659,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,500.84,76,,406.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,474.48,72,,549.944,Percent of Total Billed Charges,72% of Total Billed Charges,494.25,75,,572.864,Percent of Total Billed charges,75% of Total Billed Charges,659,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.48,72,,549.944,Percent of Total Billed Charges,72% of Total Billed Charges,395.4,60,,458.288,Percent of Total Billed Charges,60% of Total Billed Charges,593.1,90,,1283.576,Percent of Total Billed Charges,90% of Total Billed Charges,296.55,45,,618.84,Percent of Total Billed Charges,45% of Total Billed Charges,593.1,90,,481.84,Percent of Total Billed Charges,90% of Total billed Charges,659,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,659,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,659,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,428.35,65,,312,Percent of total Billed Charges,65% of Total Billed Charges,290.62,44.1,,606.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,626.05,95,,508.608,Percent of Total Billed Charges,95% of Total Billed Charges,659,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.92,88,,1098.272,Percent of Total Billed Charges,88% of Total Billed Charges,593.1,90,,481.84,Percent of Total Billed charges,90% of Total Billed Charges,290.62,659,
UPPER GI SERIES DBL,3200000108,CDM,320,RC,,,Outpatient,,,1054.00,685.10,,1054,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,801.04,76,,406.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,758.88,72,,1387.584,Percent of Total Billed Charges,72% of Total Billed Charges,790.5,75,,1445.4,Percent of Total Billed charges,75% of Total Billed Charges,1054,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,758.88,72,,1387.584,Percent of Total Billed Charges,72% of Total Billed Charges,632.4,60,,1156.32,Percent of Total Billed Charges,60% of Total Billed Charges,948.6,90,,2198.448,Percent of Total Billed Charges,90% of Total Billed Charges,474.3,45,,561.616,Percent of Total Billed Charges,45% of Total Billed Charges,948.6,90,,481.84,Percent of Total Billed Charges,90% of Total billed Charges,1054,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1054,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1054,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.1,65,,833,Percent of total Billed Charges,65% of Total Billed Charges,464.81,44.1,,550.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,1001.3,95,,508.608,Percent of Total Billed Charges,95% of Total Billed Charges,1054,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,927.52,88,,784.696,Percent of Total Billed Charges,88% of Total Billed Charges,948.6,90,,481.84,Percent of Total Billed charges,90% of Total Billed Charges,464.81,1054,
SMALL BOWEL SERIES,3200000109,CDM,320,RC,,,Outpatient,,,767.00,498.55,,767,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,582.92,76,,542.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,552.24,72,,1460.592,Percent of Total Billed Charges,72% of Total Billed Charges,575.25,75,,1521.448,Percent of Total Billed charges,75% of Total Billed Charges,767,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.24,72,,1460.592,Percent of Total Billed Charges,72% of Total Billed Charges,460.2,60,,1217.16,Percent of Total Billed Charges,60% of Total Billed Charges,690.3,90,,636.144,Percent of Total Billed Charges,90% of Total Billed Charges,345.15,45,,401.264,Percent of Total Billed Charges,45% of Total Billed Charges,690.3,90,,642.184,Percent of Total Billed Charges,90% of Total billed Charges,767,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,767,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,767,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.55,65,,1017.64,Percent of total Billed Charges,65% of Total Billed Charges,338.25,44.1,,393.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,728.65,95,,677.856,Percent of Total Billed Charges,95% of Total Billed Charges,767,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,674.96,88,,784.696,Percent of Total Billed Charges,88% of Total Billed Charges,690.3,90,,642.184,Percent of Total Billed charges,90% of Total Billed Charges,338.25,767,
BE SINGLE,3200000110,CDM,320,RC,,,Outpatient,,,767.00,498.55,,767,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,582.92,76,,745.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,552.24,72,,1387.584,Percent of Total Billed Charges,72% of Total Billed Charges,575.25,75,,1445.4,Percent of Total Billed charges,75% of Total Billed Charges,767,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.24,72,,1387.584,Percent of Total Billed Charges,72% of Total Billed Charges,460.2,60,,1156.32,Percent of Total Billed Charges,60% of Total Billed Charges,690.3,90,,636.144,Percent of Total Billed Charges,90% of Total Billed Charges,345.15,45,,401.264,Percent of Total Billed Charges,45% of Total Billed Charges,690.3,90,,882.704,Percent of Total Billed Charges,90% of Total billed Charges,767,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,767,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,767,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.55,65,,697.136,Percent of total Billed Charges,65% of Total Billed Charges,338.25,44.1,,393.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,728.65,95,,931.744,Percent of Total Billed Charges,95% of Total Billed Charges,767,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,674.96,88,,706.312,Percent of Total Billed Charges,88% of Total Billed Charges,690.3,90,,882.704,Percent of Total Billed charges,90% of Total Billed Charges,338.25,767,
BA ENEMA W/AIR CONT,3200000111,CDM,320,RC,,,Outpatient,,,1103.00,716.95,,1103,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,838.28,76,,1045.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,794.16,72,,481.36,Percent of Total Billed Charges,72% of Total Billed Charges,827.25,75,,501.424,Percent of Total Billed charges,75% of Total Billed Charges,1103,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,794.16,72,,481.36,Percent of Total Billed Charges,72% of Total Billed Charges,661.8,60,,401.136,Percent of Total Billed Charges,60% of Total Billed Charges,992.7,90,,2260.784,Percent of Total Billed Charges,90% of Total Billed Charges,496.35,45,,361.184,Percent of Total Billed Charges,45% of Total Billed Charges,992.7,90,,1237.68,Percent of Total Billed Charges,90% of Total billed Charges,1103,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1103,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1103,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,716.95,65,,4034.336,Percent of total Billed Charges,65% of Total Billed Charges,486.42,44.1,,353.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,1047.85,95,,1306.44,Percent of Total Billed Charges,95% of Total Billed Charges,1103,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,970.64,88,,1255.048,Percent of Total Billed Charges,88% of Total Billed Charges,992.7,90,,1237.68,Percent of Total Billed charges,90% of Total Billed Charges,486.42,1103,
CHOLANG OPERATIVE,3200000112,CDM,320,RC,,,Outpatient,,,582.00,378.30,,582,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,442.32,76,,948.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,419.04,72,,295.928,Percent of Total Billed Charges,72% of Total Billed Charges,436.5,75,,308.264,Percent of Total Billed charges,75% of Total Billed Charges,582,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.04,72,,295.928,Percent of Total Billed Charges,72% of Total Billed Charges,349.2,60,,246.608,Percent of Total Billed Charges,60% of Total Billed Charges,523.8,90,,957.6,Percent of Total Billed Charges,90% of Total Billed Charges,261.9,45,,641.784,Percent of Total Billed Charges,45% of Total Billed Charges,523.8,90,,1123.232,Percent of Total Billed Charges,90% of Total billed Charges,582,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,582,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,582,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.3,65,,4026.36,Percent of total Billed Charges,65% of Total Billed Charges,256.66,44.1,,628.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,552.9,95,,1185.632,Percent of Total Billed Charges,95% of Total Billed Charges,582,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,512.16,88,,1255.048,Percent of Total Billed Charges,88% of Total Billed Charges,523.8,90,,1123.232,Percent of Total Billed charges,90% of Total Billed Charges,256.66,582,
PYELOGRAM IV W/WO TO,3200000113,CDM,320,RC,,,Outpatient,,,971.30,631.35,,971.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,738.19,76,,677.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,699.34,72,,1587.6,Percent of Total Billed Charges,72% of Total Billed Charges,728.48,75,,1653.752,Percent of Total Billed charges,75% of Total Billed Charges,971.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,699.34,72,,1587.6,Percent of Total Billed Charges,72% of Total Billed Charges,582.78,60,,1323,Percent of Total Billed Charges,60% of Total Billed Charges,874.17,90,,430.392,Percent of Total Billed Charges,90% of Total Billed Charges,437.09,45,,641.784,Percent of Total Billed Charges,45% of Total Billed Charges,874.17,90,,802.536,Percent of Total Billed Charges,90% of Total billed Charges,971.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,971.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,971.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,631.35,65,,2210.52,Percent of total Billed Charges,65% of Total Billed Charges,428.34,44.1,,628.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,922.74,95,,847.12,Percent of Total Billed Charges,95% of Total Billed Charges,971.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,854.74,88,,2149.592,Percent of Total Billed Charges,88% of Total Billed Charges,874.17,90,,802.536,Percent of Total Billed charges,90% of Total Billed Charges,428.34,971.3,
PYELOGRAM DRP IV OR,3200000114,CDM,320,RC,,,Outpatient,,,566.69,368.35,,566.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.68,76,,677.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,408.02,72,,1587.6,Percent of Total Billed Charges,72% of Total Billed Charges,425.02,75,,1653.752,Percent of Total Billed charges,75% of Total Billed Charges,566.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,408.02,72,,1587.6,Percent of Total Billed Charges,72% of Total Billed Charges,340.01,60,,1323,Percent of Total Billed Charges,60% of Total Billed Charges,510.02,90,,237.744,Percent of Total Billed Charges,90% of Total Billed Charges,255.01,45,,1099.224,Percent of Total Billed Charges,45% of Total Billed Charges,510.02,90,,802.536,Percent of Total Billed Charges,90% of Total billed Charges,566.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.35,65,,790.4,Percent of total Billed Charges,65% of Total Billed Charges,249.91,44.1,,1077.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.36,95,,847.12,Percent of Total Billed Charges,95% of Total Billed Charges,566.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.69,88,,622.008,Percent of Total Billed Charges,88% of Total Billed Charges,510.02,90,,802.536,Percent of Total Billed charges,90% of Total Billed Charges,249.91,566.69,
PYELOGRAM RETROGRADE,3200000115,CDM,320,RC,,,Outpatient,,,911.00,592.15,,911,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,692.36,76,,609.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,655.92,72,,1587.6,Percent of Total Billed Charges,72% of Total Billed Charges,683.25,75,,1653.752,Percent of Total Billed charges,75% of Total Billed Charges,911,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.92,72,,1587.6,Percent of Total Billed Charges,72% of Total Billed Charges,546.6,60,,1323,Percent of Total Billed Charges,60% of Total Billed Charges,819.9,90,,1283.576,Percent of Total Billed Charges,90% of Total Billed Charges,409.95,45,,318.072,Percent of Total Billed Charges,45% of Total Billed Charges,819.9,90,,722.36,Percent of Total Billed Charges,90% of Total billed Charges,911,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,911,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,911,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.15,65,,437.432,Percent of total Billed Charges,65% of Total Billed Charges,401.75,44.1,,311.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,865.45,95,,762.496,Percent of Total Billed Charges,95% of Total Billed Charges,911,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,801.68,88,,622.008,Percent of Total Billed Charges,88% of Total Billed Charges,819.9,90,,722.36,Percent of Total Billed charges,90% of Total Billed Charges,401.75,911,
URETHROGRAM,3200000116,CDM,320,RC,,,Outpatient,,,953.66,619.88,,953.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,724.78,76,,1083.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,686.64,72,,1540.608,Percent of Total Billed Charges,72% of Total Billed Charges,715.25,75,,1604.8,Percent of Total Billed charges,75% of Total Billed Charges,953.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,686.64,72,,1540.608,Percent of Total Billed Charges,72% of Total Billed Charges,572.2,60,,1283.84,Percent of Total Billed Charges,60% of Total Billed Charges,858.29,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,429.15,45,,318.072,Percent of Total Billed Charges,45% of Total Billed Charges,858.29,90,,1283.576,Percent of Total Billed Charges,90% of Total billed Charges,953.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,953.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,953.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,619.88,65,,964.08,Percent of total Billed Charges,65% of Total Billed Charges,420.56,44.1,,311.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,905.98,95,,1354.88,Percent of Total Billed Charges,95% of Total Billed Charges,953.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,839.22,88,,2210.544,Percent of Total Billed Charges,88% of Total Billed Charges,858.29,90,,1283.576,Percent of Total Billed charges,90% of Total Billed Charges,420.56,953.66,
UROGRAPHY ANTEGRADE RS & I,3200000117,CDM,320,RC,,,Outpatient,,,906.00,588.90,,906,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,688.56,76,,1083.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,652.32,72,,3820.032,Percent of Total Billed Charges,72% of Total Billed Charges,679.5,75,,3979.2,Percent of Total Billed charges,75% of Total Billed Charges,906,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,652.32,72,,3820.032,Percent of Total Billed Charges,72% of Total Billed Charges,543.6,60,,3183.36,Percent of Total Billed Charges,60% of Total Billed Charges,815.4,90,,32.544,Percent of Total Billed Charges,90% of Total Billed Charges,407.7,45,,1130.392,Percent of Total Billed Charges,45% of Total Billed Charges,815.4,90,,1283.576,Percent of Total Billed Charges,90% of Total billed Charges,906,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,906,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,906,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,588.9,65,,1525.16,Percent of total Billed Charges,65% of Total Billed Charges,399.55,44.1,,1107.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,860.7,95,,1354.88,Percent of Total Billed Charges,95% of Total Billed Charges,906,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,797.28,88,,936.32,Percent of Total Billed Charges,88% of Total Billed Charges,815.4,90,,1283.576,Percent of Total Billed charges,90% of Total Billed Charges,399.55,906,
CYSTOGRAM,3200000118,CDM,320,RC,,,Outpatient,,,413.00,268.45,,413,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,313.88,76,,1856.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,297.36,72,,1619.136,Percent of Total Billed Charges,72% of Total Billed Charges,309.75,75,,1686.6,Percent of Total Billed charges,75% of Total Billed Charges,413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.36,72,,1619.136,Percent of Total Billed Charges,72% of Total Billed Charges,247.8,60,,1349.28,Percent of Total Billed Charges,60% of Total Billed Charges,371.7,90,,217.504,Percent of Total Billed Charges,90% of Total Billed Charges,185.85,45,,478.8,Percent of Total Billed Charges,45% of Total Billed Charges,371.7,90,,2198.448,Percent of Total Billed Charges,90% of Total billed Charges,413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.45,65,,1433.248,Percent of total Billed Charges,65% of Total Billed Charges,182.13,44.1,,469.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,392.35,95,,2320.584,Percent of Total Billed Charges,95% of Total Billed Charges,413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.44,88,,420.832,Percent of Total Billed Charges,88% of Total Billed Charges,371.7,90,,2198.448,Percent of Total Billed charges,90% of Total Billed Charges,182.13,413,
CYSTOGRAM VOIDING,3200000119,CDM,320,RC,,,Outpatient,,,694.00,451.10,,694,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,527.44,76,,537.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,499.68,72,,13021.496,Percent of Total Billed Charges,72% of Total Billed Charges,520.5,75,,13564.056,Percent of Total Billed charges,75% of Total Billed Charges,694,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,499.68,72,,13021.496,Percent of Total Billed Charges,72% of Total Billed Charges,416.4,60,,10851.248,Percent of Total Billed Charges,60% of Total Billed Charges,624.6,90,,648,Percent of Total Billed Charges,90% of Total Billed Charges,312.3,45,,215.2,Percent of Total Billed Charges,45% of Total Billed Charges,624.6,90,,636.144,Percent of Total Billed Charges,90% of Total billed Charges,694,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,694,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,694,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,451.1,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,306.05,44.1,,210.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,659.3,95,,671.48,Percent of Total Billed Charges,95% of Total Billed Charges,694,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,610.72,88,,232.464,Percent of Total Billed Charges,88% of Total Billed Charges,624.6,90,,636.144,Percent of Total Billed charges,90% of Total Billed Charges,306.05,694,
HYSTEROSALPINGOGRAM,3200000120,CDM,320,RC,,,Outpatient,,,823.00,534.95,,823,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,625.48,76,,537.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,592.56,72,,11931.128,Percent of Total Billed Charges,72% of Total Billed Charges,617.25,75,,12428.264,Percent of Total Billed charges,75% of Total Billed Charges,823,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.56,72,,11931.128,Percent of Total Billed Charges,72% of Total Billed Charges,493.8,60,,9942.608,Percent of Total Billed Charges,60% of Total Billed Charges,740.7,90,,483.408,Percent of Total Billed Charges,90% of Total Billed Charges,370.35,45,,118.872,Percent of Total Billed Charges,45% of Total Billed Charges,740.7,90,,636.144,Percent of Total Billed Charges,90% of Total billed Charges,823,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,823,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,823,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,534.95,65,,1505.92,Percent of total Billed Charges,65% of Total Billed Charges,362.94,44.1,,116.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,781.85,95,,671.48,Percent of Total Billed Charges,95% of Total Billed Charges,823,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,724.24,88,,1255.048,Percent of Total Billed Charges,88% of Total Billed Charges,740.7,90,,636.144,Percent of Total Billed charges,90% of Total Billed Charges,362.94,823,
AORTOGRAM OF ABDOMEN,3200000121,CDM,323,RC,,,Outpatient,,,8101.00,5265.65,,8101,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6156.76,76,,1909.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5832.72,72,,12045.44,Percent of Total Billed Charges,72% of Total Billed Charges,6075.75,75,,12547.336,Percent of Total Billed charges,75% of Total Billed Charges,8101,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5832.72,72,,12045.44,Percent of Total Billed Charges,72% of Total Billed Charges,4860.6,60,,10037.864,Percent of Total Billed Charges,60% of Total Billed Charges,7290.9,90,,813.608,Percent of Total Billed Charges,90% of Total Billed Charges,3645.45,45,,641.784,Percent of Total Billed Charges,45% of Total Billed Charges,7290.9,90,,2260.784,Percent of Total Billed Charges,90% of Total billed Charges,8101,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8101,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8101,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5265.65,65,,1275.04,Percent of total Billed Charges,65% of Total Billed Charges,3572.54,44.1,,628.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,7695.95,95,,2386.384,Percent of Total Billed Charges,95% of Total Billed Charges,8101,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7128.88,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,7290.9,90,,2260.784,Percent of Total Billed charges,90% of Total Billed Charges,3572.54,8101,
ABD AORTA W/RUNOFFS,3200000122,CDM,323,RC,,,Outpatient,,,8526.74,5542.38,,8526.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6480.32,76,,808.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6139.25,72,,7733.624,Percent of Total Billed Charges,72% of Total Billed Charges,6395.06,75,,8055.856,Percent of Total Billed charges,75% of Total Billed Charges,8526.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6139.25,72,,7733.624,Percent of Total Billed Charges,72% of Total Billed Charges,5116.04,60,,6444.688,Percent of Total Billed Charges,60% of Total Billed Charges,7674.07,90,,813.608,Percent of Total Billed Charges,90% of Total Billed Charges,3837.03,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,7674.07,90,,957.6,Percent of Total Billed Charges,90% of Total billed Charges,8526.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8526.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8526.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5542.38,65,,1971.32,Percent of total Billed Charges,65% of Total Billed Charges,3760.29,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,8100.4,95,,1010.8,Percent of Total Billed Charges,95% of Total Billed Charges,8526.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7503.53,88,,31.824,Percent of Total Billed Charges,88% of Total Billed Charges,7674.07,90,,957.6,Percent of Total Billed charges,90% of Total Billed Charges,3760.29,8526.74,
UNILATERAL EXTREMITY,3200000123,CDM,323,RC,,,Outpatient,,,8101.00,5265.65,,8101,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6156.76,76,,363.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5832.72,72,,5155.672,Percent of Total Billed Charges,72% of Total Billed Charges,6075.75,75,,5370.496,Percent of Total Billed charges,75% of Total Billed Charges,8101,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5832.72,72,,5155.672,Percent of Total Billed Charges,72% of Total Billed Charges,4860.6,60,,4296.392,Percent of Total Billed Charges,60% of Total Billed Charges,7290.9,90,,96.048,Percent of Total Billed Charges,90% of Total Billed Charges,3645.45,45,,16.272,Percent of Total Billed Charges,45% of Total Billed Charges,7290.9,90,,430.392,Percent of Total Billed Charges,90% of Total billed Charges,8101,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8101,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8101,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5265.65,65,,1431.56,Percent of total Billed Charges,65% of Total Billed Charges,3572.54,44.1,,15.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,7695.95,95,,454.304,Percent of Total Billed Charges,95% of Total Billed Charges,8101,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7128.88,88,,212.672,Percent of Total Billed Charges,88% of Total Billed Charges,7290.9,90,,430.392,Percent of Total Billed charges,90% of Total Billed Charges,3572.54,8101,
ANGIO BILATERAL EXTR,3200000124,CDM,323,RC,,,Outpatient,,,8101.00,5265.65,,8101,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6156.76,76,,200.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5832.72,72,,5133.312,Percent of Total Billed Charges,72% of Total Billed Charges,6075.75,75,,5347.2,Percent of Total Billed charges,75% of Total Billed Charges,8101,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5832.72,72,,5133.312,Percent of Total Billed Charges,72% of Total Billed Charges,4860.6,60,,4277.76,Percent of Total Billed Charges,60% of Total Billed Charges,7290.9,90,,470.84,Percent of Total Billed Charges,90% of Total Billed Charges,3645.45,45,,108.752,Percent of Total Billed Charges,45% of Total Billed Charges,7290.9,90,,237.744,Percent of Total Billed Charges,90% of Total billed Charges,8101,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8101,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8101,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5265.65,65,,1162.72,Percent of total Billed Charges,65% of Total Billed Charges,3572.54,44.1,,106.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,7695.95,95,,250.952,Percent of Total Billed Charges,95% of Total Billed Charges,8101,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7128.88,88,,633.6,Percent of Total Billed Charges,88% of Total Billed Charges,7290.9,90,,237.744,Percent of Total Billed charges,90% of Total Billed Charges,3572.54,8101,
ANGIO SELECTIVE EA A,3200000125,CDM,323,RC,,,Outpatient,,,1712.00,1112.80,,1712,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1301.12,76,,1083.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1232.64,72,,1440,Percent of Total Billed Charges,72% of Total Billed Charges,1284,75,,1500,Percent of Total Billed charges,75% of Total Billed Charges,1712,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1232.64,72,,1440,Percent of Total Billed Charges,72% of Total Billed Charges,1027.2,60,,1200,Percent of Total Billed Charges,60% of Total Billed Charges,1540.8,90,,335.808,Percent of Total Billed Charges,90% of Total Billed Charges,770.4,45,,324,Percent of Total Billed Charges,45% of Total Billed Charges,1540.8,90,,1283.576,Percent of Total Billed Charges,90% of Total billed Charges,1712,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1712,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1712,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1112.8,65,,1321.32,Percent of total Billed Charges,65% of Total Billed Charges,754.99,44.1,,317.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,1626.4,95,,1354.88,Percent of Total Billed Charges,95% of Total Billed Charges,1712,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1506.56,88,,472.664,Percent of Total Billed Charges,88% of Total Billed Charges,1540.8,90,,1283.576,Percent of Total Billed charges,90% of Total Billed Charges,754.99,1712,
VENOGRAM EXT BILAT,3200000126,CDM,320,RC,,,Outpatient,,,757.42,492.32,,757.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,575.64,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,545.34,72,,669.336,Percent of Total Billed Charges,72% of Total Billed Charges,568.07,75,,697.224,Percent of Total Billed charges,75% of Total Billed Charges,757.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,545.34,72,,669.336,Percent of Total Billed Charges,72% of Total Billed Charges,454.45,60,,557.776,Percent of Total Billed Charges,60% of Total Billed Charges,681.68,90,,47.632,Percent of Total Billed Charges,90% of Total Billed Charges,340.84,45,,241.704,Percent of Total Billed Charges,45% of Total Billed Charges,681.68,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,757.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,757.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,757.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.32,65,,1431.56,Percent of total Billed Charges,65% of Total Billed Charges,334.02,44.1,,236.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,719.55,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,757.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,666.53,88,,795.528,Percent of Total Billed Charges,88% of Total Billed Charges,681.68,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,334.02,757.42,
VENOGRAM SVC W SERIALOGRAPHY,3200000127,CDM,320,RC,,,Outpatient,,,1809.00,1175.85,,1809,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1374.84,76,,27.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1302.48,72,,588.68,Percent of Total Billed Charges,72% of Total Billed Charges,1356.75,75,,613.216,Percent of Total Billed charges,75% of Total Billed Charges,1809,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1302.48,72,,588.68,Percent of Total Billed Charges,72% of Total Billed Charges,1085.4,60,,490.568,Percent of Total Billed Charges,60% of Total Billed Charges,1628.1,90,,288.944,Percent of Total Billed Charges,90% of Total Billed Charges,814.05,45,,406.8,Percent of Total Billed Charges,45% of Total Billed Charges,1628.1,90,,32.544,Percent of Total Billed Charges,90% of Total billed Charges,1809,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1809,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1809,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1175.85,65,,1363.96,Percent of total Billed Charges,65% of Total Billed Charges,797.77,44.1,,398.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,1718.55,95,,34.352,Percent of Total Billed Charges,95% of Total Billed Charges,1809,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1591.92,88,,795.528,Percent of Total Billed Charges,88% of Total Billed Charges,1628.1,90,,32.544,Percent of Total Billed charges,90% of Total Billed Charges,797.77,1809,
SINUS OR JUGL CATH VENOGRAM,3200000128,CDM,320,RC,,,Outpatient,,,2820.00,1833.00,,2820,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2143.2,76,,183.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2030.4,72,,1885.432,Percent of Total Billed Charges,72% of Total Billed Charges,2115,75,,1963.992,Percent of Total Billed charges,75% of Total Billed Charges,2820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2030.4,72,,1885.432,Percent of Total Billed Charges,72% of Total Billed Charges,1692,60,,1571.192,Percent of Total Billed Charges,60% of Total Billed Charges,2538,90,,679.496,Percent of Total Billed Charges,90% of Total Billed Charges,1269,45,,406.8,Percent of Total Billed Charges,45% of Total Billed Charges,2538,90,,217.504,Percent of Total Billed Charges,90% of Total billed Charges,2820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1833,65,,108.68,Percent of total Billed Charges,65% of Total Billed Charges,1243.62,44.1,,398.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,2679,95,,229.592,Percent of Total Billed Charges,95% of Total Billed Charges,2820,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2481.6,88,,93.912,Percent of Total Billed Charges,88% of Total Billed Charges,2538,90,,217.504,Percent of Total Billed charges,90% of Total Billed Charges,1243.62,2820,
"VENOGRAPHY, EPIDURAL",3200000129,CDM,320,RC,,,Outpatient,,,2192.61,1425.20,,2192.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1666.38,76,,547.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1578.68,72,,1888.608,Percent of Total Billed Charges,72% of Total Billed Charges,1644.46,75,,1967.304,Percent of Total Billed charges,75% of Total Billed Charges,2192.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1578.68,72,,1888.608,Percent of Total Billed Charges,72% of Total Billed Charges,1315.57,60,,1573.84,Percent of Total Billed Charges,60% of Total Billed Charges,1973.35,90,,29.304,Percent of Total Billed Charges,90% of Total Billed Charges,986.67,45,,48.024,Percent of Total Billed Charges,45% of Total Billed Charges,1973.35,90,,648,Percent of Total Billed Charges,90% of Total billed Charges,2192.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2192.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2192.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1425.2,65,,1379.04,Percent of total Billed Charges,65% of Total Billed Charges,966.94,44.1,,47.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,2082.98,95,,684,Percent of Total Billed Charges,95% of Total Billed Charges,2192.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1929.5,88,,460.376,Percent of Total Billed Charges,88% of Total Billed Charges,1973.35,90,,648,Percent of Total Billed charges,90% of Total Billed Charges,966.94,2192.61,
HEPATIC VENOGRAPHY W/HEMO EVAL,3200000130,CDM,320,RC,,,Outpatient,,,6500.00,4225.00,,6500,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4940,76,,408.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4680,72,,2392.2,Percent of Total Billed Charges,72% of Total Billed Charges,4875,75,,2491.872,Percent of Total Billed charges,75% of Total Billed Charges,6500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4680,72,,2392.2,Percent of Total Billed Charges,72% of Total Billed Charges,3900,60,,1993.496,Percent of Total Billed Charges,60% of Total Billed Charges,5850,90,,741.416,Percent of Total Billed Charges,90% of Total Billed Charges,2925,45,,235.416,Percent of Total Billed Charges,45% of Total Billed Charges,5850,90,,483.408,Percent of Total Billed Charges,90% of Total billed Charges,6500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4225,65,,1595.88,Percent of total Billed Charges,65% of Total Billed Charges,2866.5,44.1,,230.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,6175,95,,510.264,Percent of Total Billed Charges,95% of Total Billed Charges,6500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5720,88,,328.344,Percent of Total Billed Charges,88% of Total Billed Charges,5850,90,,483.408,Percent of Total Billed charges,90% of Total Billed Charges,2866.5,6500,
TRANSCATH BX RAD S & I,3200000131,CDM,320,RC,,,Outpatient,,,2496.00,1622.40,,2496,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1896.96,76,,687.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1797.12,72,,906.84,Percent of Total Billed Charges,72% of Total Billed Charges,1872,75,,944.624,Percent of Total Billed charges,75% of Total Billed Charges,2496,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1797.12,72,,906.84,Percent of Total Billed Charges,72% of Total Billed Charges,1497.6,60,,755.696,Percent of Total Billed Charges,60% of Total Billed Charges,2246.4,90,,315.136,Percent of Total Billed Charges,90% of Total Billed Charges,1123.2,45,,167.904,Percent of Total Billed Charges,45% of Total Billed Charges,2246.4,90,,813.608,Percent of Total Billed Charges,90% of Total billed Charges,2496,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2496,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2496,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1622.4,65,,573.872,Percent of total Billed Charges,65% of Total Billed Charges,1100.74,44.1,,164.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,2371.2,95,,858.808,Percent of Total Billed Charges,95% of Total Billed Charges,2496,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2196.48,88,,46.568,Percent of Total Billed Charges,88% of Total Billed Charges,2246.4,90,,813.608,Percent of Total Billed charges,90% of Total Billed Charges,1100.74,2496,
XRAY CONTROL CATH CHANGE,3200000132,CDM,320,RC,,,Outpatient,,,756.32,491.61,,756.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,574.8,76,,687.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,544.55,72,,593.76,Percent of Total Billed Charges,72% of Total Billed Charges,567.24,75,,618.504,Percent of Total Billed charges,75% of Total Billed Charges,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,544.55,72,,593.76,Percent of Total Billed Charges,72% of Total Billed Charges,453.79,60,,494.8,Percent of Total Billed Charges,60% of Total Billed Charges,680.69,90,,1885.68,Percent of Total Billed Charges,90% of Total Billed Charges,340.34,45,,23.816,Percent of Total Billed Charges,45% of Total Billed Charges,680.69,90,,813.608,Percent of Total Billed Charges,90% of Total billed Charges,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.61,65,,1461.72,Percent of total Billed Charges,65% of Total Billed Charges,333.54,44.1,,23.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,718.5,95,,858.808,Percent of Total Billed Charges,95% of Total Billed Charges,756.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,665.56,88,,282.52,Percent of Total Billed Charges,88% of Total Billed Charges,680.69,90,,813.608,Percent of Total Billed charges,90% of Total Billed Charges,333.54,756.32,
DRAINAGE CATH UNDER XR,3200000133,CDM,320,RC,,,Outpatient,,,2438.00,1584.70,,2438,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1852.88,76,,81.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1755.36,72,,645.832,Percent of Total Billed Charges,72% of Total Billed Charges,1828.5,75,,672.744,Percent of Total Billed charges,75% of Total Billed Charges,2438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1755.36,72,,645.832,Percent of Total Billed Charges,72% of Total Billed Charges,1462.8,60,,538.192,Percent of Total Billed Charges,60% of Total Billed Charges,2194.2,90,,2653.2,Percent of Total Billed Charges,90% of Total Billed Charges,1097.1,45,,144.472,Percent of Total Billed Charges,45% of Total Billed Charges,2194.2,90,,96.048,Percent of Total Billed Charges,90% of Total billed Charges,2438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1584.7,65,,624,Percent of total Billed Charges,65% of Total Billed Charges,1075.16,44.1,,141.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,2316.1,95,,101.384,Percent of Total Billed Charges,95% of Total Billed Charges,2438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2145.44,88,,664.392,Percent of Total Billed Charges,88% of Total Billed Charges,2194.2,90,,96.048,Percent of Total Billed charges,90% of Total Billed Charges,1075.16,2438,
US DRAINAGE CATH GUIDANCE,3200000134,CDM,320,RC,,,Outpatient,,,2438.00,1584.70,,2438,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1852.88,76,,397.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1755.36,72,,645.2,Percent of Total Billed Charges,72% of Total Billed Charges,1828.5,75,,672.088,Percent of Total Billed charges,75% of Total Billed Charges,2438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1755.36,72,,645.2,Percent of Total Billed Charges,72% of Total Billed Charges,1462.8,60,,537.664,Percent of Total Billed Charges,60% of Total Billed Charges,2194.2,90,,432,Percent of Total Billed Charges,90% of Total Billed Charges,1097.1,45,,339.744,Percent of Total Billed Charges,45% of Total Billed Charges,2194.2,90,,470.84,Percent of Total Billed Charges,90% of Total billed Charges,2438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1584.7,65,,863.784,Percent of total Billed Charges,65% of Total Billed Charges,1075.16,44.1,,332.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,2316.1,95,,496.992,Percent of Total Billed Charges,95% of Total Billed Charges,2438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2145.44,88,,28.656,Percent of Total Billed Charges,88% of Total Billed Charges,2194.2,90,,470.84,Percent of Total Billed charges,90% of Total Billed Charges,1075.16,2438,
FLUOROSCOPY<1HR PHYS,3200000135,CDM,320,RC,,,Outpatient,,,317.00,206.05,,317,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,240.92,76,,283.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,228.24,72,,1253.376,Percent of Total Billed Charges,72% of Total Billed Charges,237.75,75,,1305.6,Percent of Total Billed charges,75% of Total Billed Charges,317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.24,72,,1253.376,Percent of Total Billed Charges,72% of Total Billed Charges,190.2,60,,1044.48,Percent of Total Billed Charges,60% of Total Billed Charges,285.3,90,,1373.76,Percent of Total Billed Charges,90% of Total Billed Charges,142.65,45,,14.656,Percent of Total Billed Charges,45% of Total Billed Charges,285.3,90,,335.808,Percent of Total Billed Charges,90% of Total billed Charges,317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.05,65,,1520.312,Percent of total Billed Charges,65% of Total Billed Charges,139.8,44.1,,14.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,301.15,95,,354.464,Percent of Total Billed Charges,95% of Total Billed Charges,317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.96,88,,724.936,Percent of Total Billed Charges,88% of Total Billed Charges,285.3,90,,335.808,Percent of Total Billed charges,90% of Total Billed Charges,139.8,317,
FLUOROSCOPY,3200000136,CDM,320,RC,,,Outpatient,,,332.76,216.29,,332.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,252.9,76,,40.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,239.59,72,,514.368,Percent of Total Billed Charges,72% of Total Billed Charges,249.57,75,,535.8,Percent of Total Billed charges,75% of Total Billed Charges,332.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.59,72,,514.368,Percent of Total Billed Charges,72% of Total Billed Charges,199.66,60,,428.64,Percent of Total Billed Charges,60% of Total Billed Charges,299.48,90,,1153.392,Percent of Total Billed Charges,90% of Total Billed Charges,149.74,45,,370.704,Percent of Total Billed Charges,45% of Total Billed Charges,299.48,90,,47.632,Percent of Total Billed Charges,90% of Total billed Charges,332.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.29,65,,1452.36,Percent of total Billed Charges,65% of Total Billed Charges,146.75,44.1,,363.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,316.12,95,,50.272,Percent of Total Billed Charges,95% of Total Billed Charges,332.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.83,88,,308.136,Percent of Total Billed Charges,88% of Total Billed Charges,299.48,90,,47.632,Percent of Total Billed charges,90% of Total Billed Charges,146.75,332.76,
MAMMO SURG SPECIMEN,3200000137,CDM,320,RC,,,Outpatient,,,487.00,316.55,,487,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,370.12,76,,244,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,350.64,72,,616.624,Percent of Total Billed Charges,72% of Total Billed Charges,365.25,75,,642.32,Percent of Total Billed charges,75% of Total Billed Charges,487,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.64,72,,616.624,Percent of Total Billed Charges,72% of Total Billed Charges,292.2,60,,513.856,Percent of Total Billed Charges,60% of Total Billed Charges,438.3,90,,1409.04,Percent of Total Billed Charges,90% of Total Billed Charges,219.15,45,,157.568,Percent of Total Billed Charges,45% of Total Billed Charges,438.3,90,,288.944,Percent of Total Billed Charges,90% of Total billed Charges,487,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.55,65,,781.56,Percent of total Billed Charges,65% of Total Billed Charges,214.77,44.1,,154.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,462.65,95,,304.992,Percent of Total Billed Charges,95% of Total Billed Charges,487,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,428.56,88,,1843.776,Percent of Total Billed Charges,88% of Total Billed Charges,438.3,90,,288.944,Percent of Total Billed charges,90% of Total Billed Charges,214.77,487,
TOMOGRAPHY,3200000138,CDM,320,RC,,,Outpatient,,,606.38,394.15,,606.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,460.85,76,,573.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,436.59,72,,1160.216,Percent of Total Billed Charges,72% of Total Billed Charges,454.79,75,,1208.56,Percent of Total Billed charges,75% of Total Billed Charges,606.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,436.59,72,,1160.216,Percent of Total Billed Charges,72% of Total Billed Charges,363.83,60,,966.848,Percent of Total Billed Charges,60% of Total Billed Charges,545.74,90,,965.264,Percent of Total Billed Charges,90% of Total Billed Charges,272.87,45,,942.84,Percent of Total Billed Charges,45% of Total Billed Charges,545.74,90,,679.496,Percent of Total Billed Charges,90% of Total billed Charges,606.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,606.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,606.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.15,65,,1277.64,Percent of total Billed Charges,65% of Total Billed Charges,267.41,44.1,,923.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,576.06,95,,717.24,Percent of Total Billed Charges,95% of Total Billed Charges,606.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,533.61,88,,2594.24,Percent of Total Billed Charges,88% of Total Billed Charges,545.74,90,,679.496,Percent of Total Billed charges,90% of Total Billed Charges,267.41,606.38,
FLUORO OR NEEDLE GUIDANCE,3200000139,CDM,320,RC,,,Outpatient,,,646.00,419.90,,646,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,490.96,76,,24.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,465.12,72,,616.624,Percent of Total Billed Charges,72% of Total Billed Charges,484.5,75,,642.32,Percent of Total Billed charges,75% of Total Billed Charges,646,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.12,72,,616.624,Percent of Total Billed Charges,72% of Total Billed Charges,387.6,60,,513.856,Percent of Total Billed Charges,60% of Total Billed Charges,581.4,90,,5586.008,Percent of Total Billed Charges,90% of Total Billed Charges,290.7,45,,1326.6,Percent of Total Billed Charges,45% of Total Billed Charges,581.4,90,,29.304,Percent of Total Billed Charges,90% of Total billed Charges,646,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,646,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,646,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.9,65,,1724.84,Percent of total Billed Charges,65% of Total Billed Charges,284.89,44.1,,1300.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,613.7,95,,30.936,Percent of Total Billed Charges,95% of Total Billed Charges,646,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.48,88,,422.4,Percent of Total Billed Charges,88% of Total Billed Charges,581.4,90,,29.304,Percent of Total Billed charges,90% of Total Billed Charges,284.89,646,
FLUORO GUIDED SPINE INJECTION,3200000140,CDM,320,RC,,,Outpatient,,,334.06,217.14,,334.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,253.89,76,,626.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,240.52,72,,575.424,Percent of Total Billed Charges,72% of Total Billed Charges,250.55,75,,599.4,Percent of Total Billed charges,75% of Total Billed Charges,334.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.52,72,,575.424,Percent of Total Billed Charges,72% of Total Billed Charges,200.44,60,,479.52,Percent of Total Billed Charges,60% of Total Billed Charges,300.65,90,,5574.96,Percent of Total Billed Charges,90% of Total Billed Charges,150.33,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,300.65,90,,741.416,Percent of Total Billed Charges,90% of Total billed Charges,334.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.14,65,,1787.76,Percent of total Billed Charges,65% of Total Billed Charges,147.32,44.1,,211.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,317.36,95,,782.6,Percent of Total Billed Charges,95% of Total Billed Charges,334.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.97,88,,1343.232,Percent of Total Billed Charges,88% of Total Billed Charges,300.65,90,,741.416,Percent of Total Billed charges,90% of Total Billed Charges,147.32,334.06,
XR  STRESS VIEWS,3200000141,CDM,320,RC,,,Outpatient,,,193.00,125.45,,193,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,146.68,76,,266.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,138.96,72,,1182.448,Percent of Total Billed Charges,72% of Total Billed Charges,144.75,75,,1231.72,Percent of Total Billed charges,75% of Total Billed Charges,193,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.96,72,,1182.448,Percent of Total Billed Charges,72% of Total Billed Charges,115.8,60,,985.376,Percent of Total Billed Charges,60% of Total Billed Charges,173.7,90,,3060.72,Percent of Total Billed Charges,90% of Total Billed Charges,86.85,45,,686.88,Percent of Total Billed Charges,45% of Total Billed Charges,173.7,90,,315.136,Percent of Total Billed Charges,90% of Total billed Charges,193,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.45,65,,1431.56,Percent of total Billed Charges,65% of Total Billed Charges,85.11,44.1,,673.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,183.35,95,,332.648,Percent of Total Billed Charges,95% of Total Billed Charges,193,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.84,88,,1127.76,Percent of Total Billed Charges,88% of Total Billed Charges,173.7,90,,315.136,Percent of Total Billed charges,90% of Total Billed Charges,85.11,193,
BONE AGE,3200000142,CDM,320,RC,,,Outpatient,,,236.00,153.40,,236,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,179.36,76,,1592.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,169.92,72,,1160.216,Percent of Total Billed Charges,72% of Total Billed Charges,177,75,,1208.56,Percent of Total Billed charges,75% of Total Billed Charges,236,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.92,72,,1160.216,Percent of Total Billed Charges,72% of Total Billed Charges,141.6,60,,966.848,Percent of Total Billed Charges,60% of Total Billed Charges,212.4,90,,1094.4,Percent of Total Billed Charges,90% of Total Billed Charges,106.2,45,,576.696,Percent of Total Billed Charges,45% of Total Billed Charges,212.4,90,,1885.68,Percent of Total Billed Charges,90% of Total billed Charges,236,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.4,65,,1530.88,Percent of total Billed Charges,65% of Total Billed Charges,104.08,44.1,,565.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,224.2,95,,1990.44,Percent of Total Billed Charges,95% of Total Billed Charges,236,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.68,88,,1377.728,Percent of Total Billed Charges,88% of Total Billed Charges,212.4,90,,1885.68,Percent of Total Billed charges,90% of Total Billed Charges,104.08,236,
LONG BONES,3200000143,CDM,320,RC,,,Outpatient,,,324.00,210.60,,324,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,246.24,76,,2240.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,233.28,72,,616.624,Percent of Total Billed Charges,72% of Total Billed Charges,243,75,,642.32,Percent of Total Billed charges,75% of Total Billed Charges,324,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.28,72,,616.624,Percent of Total Billed Charges,72% of Total Billed Charges,194.4,60,,513.856,Percent of Total Billed Charges,60% of Total Billed Charges,291.6,90,,605.672,Percent of Total Billed Charges,90% of Total Billed Charges,145.8,45,,704.52,Percent of Total Billed Charges,45% of Total Billed Charges,291.6,90,,2653.2,Percent of Total Billed Charges,90% of Total billed Charges,324,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.6,65,,1602.944,Percent of total Billed Charges,65% of Total Billed Charges,142.88,44.1,,690.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,307.8,95,,2800.6,Percent of Total Billed Charges,95% of Total Billed Charges,324,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.12,88,,943.808,Percent of Total Billed Charges,88% of Total Billed Charges,291.6,90,,2653.2,Percent of Total Billed charges,90% of Total Billed Charges,142.88,324,
BONE SURVEY LIMITED,3200000144,CDM,320,RC,,,Outpatient,,,533.61,346.85,,533.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,405.54,76,,364.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,384.2,72,,1160.216,Percent of Total Billed Charges,72% of Total Billed Charges,400.21,75,,1208.56,Percent of Total Billed charges,75% of Total Billed Charges,533.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.2,72,,1160.216,Percent of Total Billed Charges,72% of Total Billed Charges,320.17,60,,966.848,Percent of Total Billed Charges,60% of Total Billed Charges,480.25,90,,1334.88,Percent of Total Billed Charges,90% of Total Billed Charges,240.12,45,,482.632,Percent of Total Billed Charges,45% of Total Billed Charges,480.25,90,,432,Percent of Total Billed Charges,90% of Total billed Charges,533.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,533.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,533.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.85,65,,1842.88,Percent of total Billed Charges,65% of Total Billed Charges,235.32,44.1,,472.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,506.93,95,,456,Percent of Total Billed Charges,95% of Total Billed Charges,533.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,469.58,88,,5461.872,Percent of Total Billed Charges,88% of Total Billed Charges,480.25,90,,432,Percent of Total Billed charges,90% of Total Billed Charges,235.32,533.61,
BONE SURVEY COMPLETE,3200000145,CDM,320,RC,,,Outpatient,,,872.00,566.80,,872,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,662.72,76,,1160.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,627.84,72,,605.192,Percent of Total Billed Charges,72% of Total Billed Charges,654,75,,630.408,Percent of Total Billed charges,75% of Total Billed Charges,872,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,627.84,72,,605.192,Percent of Total Billed Charges,72% of Total Billed Charges,523.2,60,,504.328,Percent of Total Billed Charges,60% of Total Billed Charges,784.8,90,,2111.76,Percent of Total Billed Charges,90% of Total Billed Charges,392.4,45,,2793,Percent of Total Billed Charges,45% of Total Billed Charges,784.8,90,,1373.76,Percent of Total Billed Charges,90% of Total billed Charges,872,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,872,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,872,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.8,65,,1758.888,Percent of total Billed Charges,65% of Total Billed Charges,384.55,44.1,,2737.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,828.4,95,,1450.08,Percent of Total Billed Charges,95% of Total Billed Charges,872,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,767.36,88,,5451.072,Percent of Total Billed Charges,88% of Total Billed Charges,784.8,90,,1373.76,Percent of Total Billed charges,90% of Total Billed Charges,384.55,872,
DEXA ONE OR MORE AXI,3200000146,CDM,320,RC,,,Outpatient,,,616.00,400.40,,616,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,468.16,76,,973.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,443.52,72,,1182.448,Percent of Total Billed Charges,72% of Total Billed Charges,462,75,,1231.72,Percent of Total Billed charges,75% of Total Billed Charges,616,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,443.52,72,,1182.448,Percent of Total Billed Charges,72% of Total Billed Charges,369.6,60,,985.376,Percent of Total Billed Charges,60% of Total Billed Charges,554.4,90,,1984.504,Percent of Total Billed Charges,90% of Total Billed Charges,277.2,45,,2787.48,Percent of Total Billed Charges,45% of Total Billed Charges,554.4,90,,1153.392,Percent of Total Billed Charges,90% of Total billed Charges,616,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,616,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,616,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.4,65,,2011.36,Percent of total Billed Charges,65% of Total Billed Charges,271.66,44.1,,2731.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,585.2,95,,1217.464,Percent of Total Billed Charges,95% of Total Billed Charges,616,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,542.08,88,,2992.704,Percent of Total Billed Charges,88% of Total Billed Charges,554.4,90,,1153.392,Percent of Total Billed charges,90% of Total Billed Charges,271.66,616,
STERNUM 1 VW,3200000147,CDM,320,RC,,,Outpatient,,,271.22,176.29,,271.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,206.13,76,,1189.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,195.28,72,,1182.448,Percent of Total Billed Charges,72% of Total Billed Charges,203.42,75,,1231.72,Percent of Total Billed charges,75% of Total Billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.28,72,,1182.448,Percent of Total Billed Charges,72% of Total Billed Charges,162.73,60,,985.376,Percent of Total Billed Charges,60% of Total Billed Charges,244.1,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,122.05,45,,1530.36,Percent of Total Billed Charges,45% of Total Billed Charges,244.1,90,,1409.04,Percent of Total Billed Charges,90% of Total billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.29,65,,2117.192,Percent of total Billed Charges,65% of Total Billed Charges,119.61,44.1,,1499.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,257.66,95,,1487.32,Percent of Total Billed Charges,95% of Total Billed Charges,271.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.67,88,,1070.08,Percent of Total Billed Charges,88% of Total Billed Charges,244.1,90,,1409.04,Percent of Total Billed charges,90% of Total Billed Charges,119.61,271.22,
SACRUM/COCCYX 1 VW,3200000148,CDM,320,RC,,,Outpatient,,,302.09,196.36,,302.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,229.59,76,,815.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,217.5,72,,71.128,Percent of Total Billed Charges,72% of Total Billed Charges,226.57,75,,74.088,Percent of Total Billed charges,75% of Total Billed Charges,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.5,72,,71.128,Percent of Total Billed Charges,72% of Total Billed Charges,181.25,60,,59.272,Percent of Total Billed Charges,60% of Total Billed Charges,271.88,90,,2085.12,Percent of Total Billed Charges,90% of Total Billed Charges,135.94,45,,547.2,Percent of Total Billed Charges,45% of Total Billed Charges,271.88,90,,965.264,Percent of Total Billed Charges,90% of Total billed Charges,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.36,65,,1011.4,Percent of total Billed Charges,65% of Total Billed Charges,133.22,44.1,,536.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,286.99,95,,1018.888,Percent of Total Billed Charges,95% of Total Billed Charges,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.84,88,,592.208,Percent of Total Billed Charges,88% of Total Billed Charges,271.88,90,,965.264,Percent of Total Billed charges,90% of Total Billed Charges,133.22,302.09,
HUMERUS 1 VW RT,3200000149,CDM,320,RC,,,Outpatient,,,239.24,155.51,,239.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,181.82,76,,4717.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,172.25,72,,11605.992,Percent of Total Billed Charges,72% of Total Billed Charges,179.43,75,,12089.576,Percent of Total Billed charges,75% of Total Billed Charges,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.25,72,,11605.992,Percent of Total Billed Charges,72% of Total Billed Charges,143.54,60,,9671.656,Percent of Total Billed Charges,60% of Total Billed Charges,215.32,90,,1765.44,Percent of Total Billed Charges,90% of Total Billed Charges,107.66,45,,302.832,Percent of Total Billed Charges,45% of Total Billed Charges,215.32,90,,5586.008,Percent of Total Billed Charges,90% of Total billed Charges,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.51,65,,1523.6,Percent of total Billed Charges,65% of Total Billed Charges,105.5,44.1,,296.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,227.28,95,,5896.336,Percent of Total Billed Charges,95% of Total Billed Charges,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.53,88,,1305.216,Percent of Total Billed Charges,88% of Total Billed Charges,215.32,90,,5586.008,Percent of Total Billed charges,90% of Total Billed Charges,105.5,239.24,
ELBOW 1VW RT,3200000150,CDM,320,RC,,,Outpatient,,,265.70,172.71,,265.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,201.93,76,,4707.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,191.3,72,,1927.344,Percent of Total Billed Charges,72% of Total Billed Charges,199.28,75,,2007.656,Percent of Total Billed charges,75% of Total Billed Charges,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.3,72,,1927.344,Percent of Total Billed Charges,72% of Total Billed Charges,159.42,60,,1606.12,Percent of Total Billed Charges,60% of Total Billed Charges,239.13,90,,2729.52,Percent of Total Billed Charges,90% of Total Billed Charges,119.57,45,,667.44,Percent of Total Billed Charges,45% of Total Billed Charges,239.13,90,,5574.96,Percent of Total Billed Charges,90% of Total billed Charges,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.71,65,,1956.76,Percent of total Billed Charges,65% of Total Billed Charges,117.17,44.1,,654.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,252.42,95,,5884.68,Percent of Total Billed Charges,95% of Total Billed Charges,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.82,88,,2064.832,Percent of Total Billed Charges,88% of Total Billed Charges,239.13,90,,5574.96,Percent of Total Billed charges,90% of Total Billed Charges,117.17,265.7,
ELBOW 1VW LT,3200000151,CDM,320,RC,,,Outpatient,,,265.70,172.71,,265.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,201.93,76,,2584.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,191.3,72,,2085.696,Percent of Total Billed Charges,72% of Total Billed Charges,199.28,75,,2172.6,Percent of Total Billed charges,75% of Total Billed Charges,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.3,72,,2085.696,Percent of Total Billed Charges,72% of Total Billed Charges,159.42,60,,1738.08,Percent of Total Billed Charges,60% of Total Billed Charges,239.13,90,,1982.16,Percent of Total Billed Charges,90% of Total Billed Charges,119.57,45,,1055.88,Percent of Total Billed Charges,45% of Total Billed Charges,239.13,90,,3060.72,Percent of Total Billed Charges,90% of Total billed Charges,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.71,65,,1371.24,Percent of total Billed Charges,65% of Total Billed Charges,117.17,44.1,,1034.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,252.42,95,,3230.76,Percent of Total Billed Charges,95% of Total Billed Charges,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.82,88,,1940.4,Percent of Total Billed Charges,88% of Total Billed Charges,239.13,90,,3060.72,Percent of Total Billed charges,90% of Total Billed Charges,117.17,265.7,
FOREARM 1VW RT,3200000152,CDM,320,RC,,,Outpatient,,,200.66,130.43,,200.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152.5,76,,924.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144.48,72,,2315.992,Percent of Total Billed Charges,72% of Total Billed Charges,150.5,75,,2412.496,Percent of Total Billed charges,75% of Total Billed Charges,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.48,72,,2315.992,Percent of Total Billed Charges,72% of Total Billed Charges,120.4,60,,1929.992,Percent of Total Billed Charges,60% of Total Billed Charges,180.59,90,,1609.92,Percent of Total Billed Charges,90% of Total Billed Charges,90.3,45,,992.248,Percent of Total Billed Charges,45% of Total Billed Charges,180.59,90,,1094.4,Percent of Total Billed Charges,90% of Total billed Charges,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.43,65,,2741.96,Percent of total Billed Charges,65% of Total Billed Charges,88.49,44.1,,972.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,190.63,95,,1155.2,Percent of Total Billed Charges,95% of Total Billed Charges,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.58,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,180.59,90,,1094.4,Percent of Total Billed charges,90% of Total Billed Charges,88.49,200.66,
WRIST 1 VW RT,3200000153,CDM,320,RC,,,Outpatient,,,262.40,170.56,,262.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,199.42,76,,511.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,188.93,72,,3382.848,Percent of Total Billed Charges,72% of Total Billed Charges,196.8,75,,3523.8,Percent of Total Billed charges,75% of Total Billed Charges,262.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.93,72,,3382.848,Percent of Total Billed Charges,72% of Total Billed Charges,157.44,60,,2819.04,Percent of Total Billed Charges,60% of Total Billed Charges,236.16,90,,1829.52,Percent of Total Billed Charges,90% of Total Billed Charges,118.08,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,236.16,90,,605.672,Percent of Total Billed Charges,90% of Total billed Charges,262.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.56,65,,1371.24,Percent of total Billed Charges,65% of Total Billed Charges,115.72,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,249.28,95,,639.32,Percent of Total Billed Charges,95% of Total Billed Charges,262.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.91,88,,2038.784,Percent of Total Billed Charges,88% of Total Billed Charges,236.16,90,,605.672,Percent of Total Billed charges,90% of Total Billed Charges,115.72,262.4,
WRIST 1 VW LT,3200000154,CDM,320,RC,,,Outpatient,,,262.40,170.56,,262.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,199.42,76,,1127.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,188.93,72,,3384.768,Percent of Total Billed Charges,72% of Total Billed Charges,196.8,75,,3525.8,Percent of Total Billed charges,75% of Total Billed Charges,262.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.93,72,,3384.768,Percent of Total Billed Charges,72% of Total Billed Charges,157.44,60,,2820.64,Percent of Total Billed Charges,60% of Total Billed Charges,236.16,90,,1982.16,Percent of Total Billed Charges,90% of Total Billed Charges,118.08,45,,1042.56,Percent of Total Billed Charges,45% of Total Billed Charges,236.16,90,,1334.88,Percent of Total Billed Charges,90% of Total billed Charges,262.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.56,65,,1181.44,Percent of total Billed Charges,65% of Total Billed Charges,115.72,44.1,,1021.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,249.28,95,,1409.04,Percent of Total Billed Charges,95% of Total Billed Charges,262.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.91,88,,1726.208,Percent of Total Billed Charges,88% of Total Billed Charges,236.16,90,,1334.88,Percent of Total Billed charges,90% of Total Billed Charges,115.72,262.4,
HAND 1 VW RT,3200000155,CDM,320,RC,,,Outpatient,,,218.30,141.90,,218.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,165.91,76,,1783.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,157.18,72,,3389.184,Percent of Total Billed Charges,72% of Total Billed Charges,163.73,75,,3530.4,Percent of Total Billed charges,75% of Total Billed Charges,218.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.18,72,,3389.184,Percent of Total Billed Charges,72% of Total Billed Charges,130.98,60,,2824.32,Percent of Total Billed Charges,60% of Total Billed Charges,196.47,90,,1888.56,Percent of Total Billed Charges,90% of Total Billed Charges,98.24,45,,882.72,Percent of Total Billed Charges,45% of Total Billed Charges,196.47,90,,2111.76,Percent of Total Billed Charges,90% of Total billed Charges,218.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.9,65,,1314.04,Percent of total Billed Charges,65% of Total Billed Charges,96.27,44.1,,865.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,207.39,95,,2229.08,Percent of Total Billed Charges,95% of Total Billed Charges,218.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.1,88,,2668.864,Percent of Total Billed Charges,88% of Total Billed Charges,196.47,90,,2111.76,Percent of Total Billed charges,90% of Total Billed Charges,96.27,218.3,
HAND 1 VW LT,3200000156,CDM,320,RC,,,Outpatient,,,218.30,141.90,,218.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,165.91,76,,1675.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,157.18,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,163.73,75,,43.664,Percent of Total Billed charges,75% of Total Billed Charges,218.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.18,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,130.98,60,,34.928,Percent of Total Billed Charges,60% of Total Billed Charges,196.47,90,,150.48,Percent of Total Billed Charges,90% of Total Billed Charges,98.24,45,,1364.76,Percent of Total Billed Charges,45% of Total Billed Charges,196.47,90,,1984.504,Percent of Total Billed Charges,90% of Total billed Charges,218.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.9,65,,1857.96,Percent of total Billed Charges,65% of Total Billed Charges,96.27,44.1,,1337.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,207.39,95,,2094.752,Percent of Total Billed Charges,95% of Total Billed Charges,218.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.1,88,,1938.112,Percent of Total Billed Charges,88% of Total Billed Charges,196.47,90,,1984.504,Percent of Total Billed charges,90% of Total Billed Charges,96.27,218.3,
LOWERLEG 1 VW RT,3200000157,CDM,320,RC,,,Outpatient,,,282.24,183.46,,282.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,214.5,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,203.21,72,,9.216,Percent of Total Billed Charges,72% of Total Billed Charges,211.68,75,,9.6,Percent of Total Billed charges,75% of Total Billed Charges,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.21,72,,9.216,Percent of Total Billed Charges,72% of Total Billed Charges,169.34,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,254.02,90,,1909.44,Percent of Total Billed Charges,90% of Total Billed Charges,127.01,45,,991.08,Percent of Total Billed Charges,45% of Total Billed Charges,254.02,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.46,65,,1371.24,Percent of total Billed Charges,65% of Total Billed Charges,124.47,44.1,,971.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,268.13,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.37,88,,1574.144,Percent of Total Billed Charges,88% of Total Billed Charges,254.02,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,124.47,282.24,
LOWER LEG 1 VW LT,3200000158,CDM,320,RC,,,Outpatient,,,282.24,183.46,,282.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,214.5,76,,1760.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,203.21,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,211.68,75,,57.6,Percent of Total Billed charges,75% of Total Billed Charges,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.21,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,169.34,60,,46.08,Percent of Total Billed Charges,60% of Total Billed Charges,254.02,90,,2209.68,Percent of Total Billed Charges,90% of Total Billed Charges,127.01,45,,804.96,Percent of Total Billed Charges,45% of Total Billed Charges,254.02,90,,2085.12,Percent of Total Billed Charges,90% of Total billed Charges,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.46,65,,1665.56,Percent of total Billed Charges,65% of Total Billed Charges,124.47,44.1,,788.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,268.13,95,,2200.96,Percent of Total Billed Charges,95% of Total Billed Charges,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.37,88,,1788.864,Percent of Total Billed Charges,88% of Total Billed Charges,254.02,90,,2085.12,Percent of Total Billed charges,90% of Total Billed Charges,124.47,282.24,
ANKLE 1VW RT,3200000159,CDM,320,RC,,,Outpatient,,,138.06,89.74,,138.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,104.93,76,,1490.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,99.4,72,,2719.296,Percent of Total Billed Charges,72% of Total Billed Charges,103.55,75,,2832.6,Percent of Total Billed charges,75% of Total Billed Charges,138.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.4,72,,2719.296,Percent of Total Billed Charges,72% of Total Billed Charges,82.84,60,,2266.08,Percent of Total Billed Charges,60% of Total Billed Charges,124.25,90,,794.592,Percent of Total Billed Charges,90% of Total Billed Charges,62.13,45,,914.76,Percent of Total Billed Charges,45% of Total Billed Charges,124.25,90,,1765.44,Percent of Total Billed Charges,90% of Total billed Charges,138.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.74,65,,1125.8,Percent of total Billed Charges,65% of Total Billed Charges,60.88,44.1,,896.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,131.16,95,,1863.52,Percent of Total Billed Charges,95% of Total Billed Charges,138.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.49,88,,1938.112,Percent of Total Billed Charges,88% of Total Billed Charges,124.25,90,,1765.44,Percent of Total Billed charges,90% of Total Billed Charges,60.88,138.06,
ANKLE 1VW LT,3200000160,CDM,320,RC,,,Outpatient,,,138.06,89.74,,138.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,104.93,76,,2304.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,99.4,72,,4660.992,Percent of Total Billed Charges,72% of Total Billed Charges,103.55,75,,4855.2,Percent of Total Billed charges,75% of Total Billed Charges,138.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.4,72,,4660.992,Percent of Total Billed Charges,72% of Total Billed Charges,82.84,60,,3884.16,Percent of Total Billed Charges,60% of Total Billed Charges,124.25,90,,2023.92,Percent of Total Billed Charges,90% of Total Billed Charges,62.13,45,,991.08,Percent of Total Billed Charges,45% of Total Billed Charges,124.25,90,,2729.52,Percent of Total Billed Charges,90% of Total billed Charges,138.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.74,65,,1267.76,Percent of total Billed Charges,65% of Total Billed Charges,60.88,44.1,,971.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,131.16,95,,2881.16,Percent of Total Billed Charges,95% of Total Billed Charges,138.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.49,88,,1846.592,Percent of Total Billed Charges,88% of Total Billed Charges,124.25,90,,2729.52,Percent of Total Billed charges,90% of Total Billed Charges,60.88,138.06,
FOOT 1 VW RT,3200000161,CDM,320,RC,,,Outpatient,,,216.09,140.46,,216.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,164.23,76,,1673.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,155.58,72,,5701.824,Percent of Total Billed Charges,72% of Total Billed Charges,162.07,75,,5939.4,Percent of Total Billed charges,75% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.58,72,,5701.824,Percent of Total Billed Charges,72% of Total Billed Charges,129.65,60,,4751.52,Percent of Total Billed Charges,60% of Total Billed Charges,194.48,90,,864,Percent of Total Billed Charges,90% of Total Billed Charges,97.24,45,,944.28,Percent of Total Billed Charges,45% of Total Billed Charges,194.48,90,,1982.16,Percent of Total Billed Charges,90% of Total billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.46,65,,1125.8,Percent of total Billed Charges,65% of Total Billed Charges,95.3,44.1,,925.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,205.29,95,,2092.28,Percent of Total Billed Charges,95% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.16,88,,147.136,Percent of Total Billed Charges,88% of Total Billed Charges,194.48,90,,1982.16,Percent of Total Billed charges,90% of Total Billed Charges,95.3,216.09,
FOOT 1VW LT,3200000162,CDM,320,RC,,,Outpatient,,,216.09,140.46,,216.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,164.23,76,,1359.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,155.58,72,,2476.8,Percent of Total Billed Charges,72% of Total Billed Charges,162.07,75,,2580,Percent of Total Billed charges,75% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.58,72,,2476.8,Percent of Total Billed Charges,72% of Total Billed Charges,129.65,60,,2064,Percent of Total Billed Charges,60% of Total Billed Charges,194.48,90,,1196.016,Percent of Total Billed Charges,90% of Total Billed Charges,97.24,45,,75.24,Percent of Total Billed Charges,45% of Total Billed Charges,194.48,90,,1609.92,Percent of Total Billed Charges,90% of Total billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.46,65,,1267.76,Percent of total Billed Charges,65% of Total Billed Charges,95.3,44.1,,73.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,205.29,95,,1699.36,Percent of Total Billed Charges,95% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.16,88,,1867.008,Percent of Total Billed Charges,88% of Total Billed Charges,194.48,90,,1609.92,Percent of Total Billed charges,90% of Total Billed Charges,95.3,216.09,
CALCANEUS (HEEL) 1 V,3200000163,CDM,320,RC,,,Outpatient,,,156.56,101.76,,156.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,118.99,76,,1544.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,112.72,72,,5068.8,Percent of Total Billed Charges,72% of Total Billed Charges,117.42,75,,5280,Percent of Total Billed charges,75% of Total Billed Charges,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.72,72,,5068.8,Percent of Total Billed Charges,72% of Total Billed Charges,93.94,60,,4224,Percent of Total Billed Charges,60% of Total Billed Charges,140.9,90,,2105.04,Percent of Total Billed Charges,90% of Total Billed Charges,70.45,45,,954.72,Percent of Total Billed Charges,45% of Total Billed Charges,140.9,90,,1829.52,Percent of Total Billed Charges,90% of Total billed Charges,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.76,65,,1369.16,Percent of total Billed Charges,65% of Total Billed Charges,69.04,44.1,,935.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,148.73,95,,1931.16,Percent of Total Billed Charges,95% of Total Billed Charges,156.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.77,88,,2160.576,Percent of Total Billed Charges,88% of Total Billed Charges,140.9,90,,1829.52,Percent of Total Billed charges,90% of Total Billed Charges,69.04,156.56,
EYE FB LT,3200000164,CDM,320,RC,,,Outpatient,,,216.09,140.46,,216.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,164.23,76,,1673.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,155.58,72,,11980.8,Percent of Total Billed Charges,72% of Total Billed Charges,162.07,75,,12480,Percent of Total Billed charges,75% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.58,72,,11980.8,Percent of Total Billed Charges,72% of Total Billed Charges,129.65,60,,9984,Percent of Total Billed Charges,60% of Total Billed Charges,194.48,90,,2010.96,Percent of Total Billed Charges,90% of Total Billed Charges,97.24,45,,1104.84,Percent of Total Billed Charges,45% of Total Billed Charges,194.48,90,,1982.16,Percent of Total Billed Charges,90% of Total billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.46,65,,1011.4,Percent of total Billed Charges,65% of Total Billed Charges,95.3,44.1,,1082.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,205.29,95,,2092.28,Percent of Total Billed Charges,95% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.16,88,,776.936,Percent of Total Billed Charges,88% of Total Billed Charges,194.48,90,,1982.16,Percent of Total Billed charges,90% of Total Billed Charges,95.3,216.09,
EYE FB RT,3200000165,CDM,320,RC,,,Outpatient,,,216.09,140.46,,216.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,164.23,76,,1594.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,155.58,72,,3299.896,Percent of Total Billed Charges,72% of Total Billed Charges,162.07,75,,3437.392,Percent of Total Billed charges,75% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.58,72,,3299.896,Percent of Total Billed Charges,72% of Total Billed Charges,129.65,60,,2749.912,Percent of Total Billed Charges,60% of Total Billed Charges,194.48,90,,1082.16,Percent of Total Billed Charges,90% of Total Billed Charges,97.24,45,,397.296,Percent of Total Billed Charges,45% of Total Billed Charges,194.48,90,,1888.56,Percent of Total Billed Charges,90% of Total billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.46,65,,1125.8,Percent of total Billed Charges,65% of Total Billed Charges,95.3,44.1,,389.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,205.29,95,,1993.48,Percent of Total Billed Charges,95% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.16,88,,1978.944,Percent of Total Billed Charges,88% of Total Billed Charges,194.48,90,,1888.56,Percent of Total Billed charges,90% of Total Billed Charges,95.3,216.09,
RIBS UNILAT 2 VWS LT,3200000166,CDM,320,RC,,,Outpatient,,,372.00,241.80,,372,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,282.72,76,,127.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,267.84,72,,1071.36,Percent of Total Billed Charges,72% of Total Billed Charges,279,75,,1116,Percent of Total Billed charges,75% of Total Billed Charges,372,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.84,72,,1071.36,Percent of Total Billed Charges,72% of Total Billed Charges,223.2,60,,892.8,Percent of Total Billed Charges,60% of Total Billed Charges,334.8,90,,1769.04,Percent of Total Billed Charges,90% of Total Billed Charges,167.4,45,,1011.96,Percent of Total Billed Charges,45% of Total Billed Charges,334.8,90,,150.48,Percent of Total Billed Charges,90% of Total billed Charges,372,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,372,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,372,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.8,65,,1715.48,Percent of total Billed Charges,65% of Total Billed Charges,164.05,44.1,,991.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,353.4,95,,158.84,Percent of Total Billed Charges,95% of Total Billed Charges,372,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.36,88,,844.8,Percent of Total Billed Charges,88% of Total Billed Charges,334.8,90,,150.48,Percent of Total Billed charges,90% of Total Billed Charges,164.05,372,
RIBS UNILAT 2 VWS RT,3200000167,CDM,320,RC,,,Outpatient,,,372.00,241.80,,372,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,282.72,76,,1612.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,267.84,72,,1071.36,Percent of Total Billed Charges,72% of Total Billed Charges,279,75,,1116,Percent of Total Billed charges,75% of Total Billed Charges,372,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.84,72,,1071.36,Percent of Total Billed Charges,72% of Total Billed Charges,223.2,60,,892.8,Percent of Total Billed Charges,60% of Total Billed Charges,334.8,90,,2388.24,Percent of Total Billed Charges,90% of Total Billed Charges,167.4,45,,432,Percent of Total Billed Charges,45% of Total Billed Charges,334.8,90,,1909.44,Percent of Total Billed Charges,90% of Total billed Charges,372,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,372,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,372,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.8,65,,1435.544,Percent of total Billed Charges,65% of Total Billed Charges,164.05,44.1,,423.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,353.4,95,,2015.52,Percent of Total Billed Charges,95% of Total Billed Charges,372,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.36,88,,1169.432,Percent of Total Billed Charges,88% of Total Billed Charges,334.8,90,,1909.44,Percent of Total Billed charges,90% of Total Billed Charges,164.05,372,
RIBS UNL/PA CHSTMIN,3200000168,CDM,320,RC,,,Outpatient,,,376.00,244.40,,376,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,285.76,76,,1865.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,270.72,72,,1071.36,Percent of Total Billed Charges,72% of Total Billed Charges,282,75,,1116,Percent of Total Billed charges,75% of Total Billed Charges,376,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.72,72,,1071.36,Percent of Total Billed Charges,72% of Total Billed Charges,225.6,60,,892.8,Percent of Total Billed Charges,60% of Total Billed Charges,338.4,90,,2475.36,Percent of Total Billed Charges,90% of Total Billed Charges,169.2,45,,598.008,Percent of Total Billed Charges,45% of Total Billed Charges,338.4,90,,2209.68,Percent of Total Billed Charges,90% of Total billed Charges,376,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.4,65,,1512.68,Percent of total Billed Charges,65% of Total Billed Charges,165.82,44.1,,586.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,357.2,95,,2332.44,Percent of Total Billed Charges,95% of Total Billed Charges,376,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330.88,88,,2058.264,Percent of Total Billed Charges,88% of Total Billed Charges,338.4,90,,2209.68,Percent of Total Billed charges,90% of Total Billed Charges,165.82,376,
CLAVICLE COMPLETE LT,3200000169,CDM,320,RC,,,Outpatient,,,306.00,198.90,,306,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,232.56,76,,670.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,220.32,72,,795.568,Percent of Total Billed Charges,72% of Total Billed Charges,229.5,75,,828.72,Percent of Total Billed charges,75% of Total Billed Charges,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.32,72,,795.568,Percent of Total Billed Charges,72% of Total Billed Charges,183.6,60,,662.976,Percent of Total Billed Charges,60% of Total Billed Charges,275.4,90,,1982.16,Percent of Total Billed Charges,90% of Total Billed Charges,137.7,45,,1052.52,Percent of Total Billed Charges,45% of Total Billed Charges,275.4,90,,794.592,Percent of Total Billed Charges,90% of Total billed Charges,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.9,65,,1913.08,Percent of total Billed Charges,65% of Total Billed Charges,134.95,44.1,,1031.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,290.7,95,,838.736,Percent of Total Billed Charges,95% of Total Billed Charges,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.28,88,,1966.272,Percent of Total Billed Charges,88% of Total Billed Charges,275.4,90,,794.592,Percent of Total Billed charges,90% of Total Billed Charges,134.95,306,
CLAVICLE COMPLETE RT,3200000170,CDM,320,RC,,,Outpatient,,,306.00,198.90,,306,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,232.56,76,,1709.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,220.32,72,,397.784,Percent of Total Billed Charges,72% of Total Billed Charges,229.5,75,,414.36,Percent of Total Billed charges,75% of Total Billed Charges,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.32,72,,397.784,Percent of Total Billed Charges,72% of Total Billed Charges,183.6,60,,331.488,Percent of Total Billed Charges,60% of Total Billed Charges,275.4,90,,2119.68,Percent of Total Billed Charges,90% of Total Billed Charges,137.7,45,,1005.48,Percent of Total Billed Charges,45% of Total Billed Charges,275.4,90,,2023.92,Percent of Total Billed Charges,90% of Total billed Charges,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.9,65,,1953.12,Percent of total Billed Charges,65% of Total Billed Charges,134.95,44.1,,985.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,290.7,95,,2136.36,Percent of Total Billed Charges,95% of Total Billed Charges,306,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.28,88,,1058.112,Percent of Total Billed Charges,88% of Total Billed Charges,275.4,90,,2023.92,Percent of Total Billed charges,90% of Total Billed Charges,134.95,306,
SCAPULA COMPLETE LT,3200000171,CDM,320,RC,,,Outpatient,,,270.00,175.50,,270,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,205.2,76,,729.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,194.4,72,,384.192,Percent of Total Billed Charges,72% of Total Billed Charges,202.5,75,,400.2,Percent of Total Billed charges,75% of Total Billed Charges,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.4,72,,384.192,Percent of Total Billed Charges,72% of Total Billed Charges,162,60,,320.16,Percent of Total Billed Charges,60% of Total Billed Charges,243,90,,2219.464,Percent of Total Billed Charges,90% of Total Billed Charges,121.5,45,,541.08,Percent of Total Billed Charges,45% of Total Billed Charges,243,90,,864,Percent of Total Billed Charges,90% of Total billed Charges,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.5,65,,1363.96,Percent of total Billed Charges,65% of Total Billed Charges,119.07,44.1,,530.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,256.5,95,,912,Percent of Total Billed Charges,95% of Total Billed Charges,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.6,88,,1729.728,Percent of Total Billed Charges,88% of Total Billed Charges,243,90,,864,Percent of Total Billed charges,90% of Total Billed Charges,119.07,270,
SCAPULA COMPLETE RT,3200000172,CDM,320,RC,,,Outpatient,,,270.00,175.50,,270,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,205.2,76,,1009.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,194.4,72,,459.648,Percent of Total Billed Charges,72% of Total Billed Charges,202.5,75,,478.8,Percent of Total Billed charges,75% of Total Billed Charges,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.4,72,,459.648,Percent of Total Billed Charges,72% of Total Billed Charges,162,60,,383.04,Percent of Total Billed Charges,60% of Total Billed Charges,243,90,,2551.68,Percent of Total Billed Charges,90% of Total Billed Charges,121.5,45,,884.52,Percent of Total Billed Charges,45% of Total Billed Charges,243,90,,1196.016,Percent of Total Billed Charges,90% of Total billed Charges,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.5,65,,1214.72,Percent of total Billed Charges,65% of Total Billed Charges,119.07,44.1,,866.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,256.5,95,,1262.456,Percent of Total Billed Charges,95% of Total Billed Charges,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.6,88,,2335.168,Percent of Total Billed Charges,88% of Total Billed Charges,243,90,,1196.016,Percent of Total Billed charges,90% of Total Billed Charges,119.07,270,
SHLDR 1 VW LT,3200000173,CDM,320,RC,,,Outpatient,,,285.00,185.25,,285,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,216.6,76,,1777.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,205.2,72,,459.648,Percent of Total Billed Charges,72% of Total Billed Charges,213.75,75,,478.8,Percent of Total Billed charges,75% of Total Billed Charges,285,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.2,72,,459.648,Percent of Total Billed Charges,72% of Total Billed Charges,171,60,,383.04,Percent of Total Billed Charges,60% of Total Billed Charges,256.5,90,,2435.376,Percent of Total Billed Charges,90% of Total Billed Charges,128.25,45,,1194.12,Percent of Total Billed Charges,45% of Total Billed Charges,256.5,90,,2105.04,Percent of Total Billed Charges,90% of Total billed Charges,285,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.25,65,,1734.2,Percent of total Billed Charges,65% of Total Billed Charges,125.69,44.1,,1170.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,270.75,95,,2221.992,Percent of Total Billed Charges,95% of Total Billed Charges,285,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.8,88,,2420.352,Percent of Total Billed Charges,88% of Total Billed Charges,256.5,90,,2105.04,Percent of Total Billed charges,90% of Total Billed Charges,125.69,285,
SHLDR 1 VW RT,3200000174,CDM,320,RC,,,Outpatient,,,285.00,185.25,,285,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,216.6,76,,1698.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,205.2,72,,404.352,Percent of Total Billed Charges,72% of Total Billed Charges,213.75,75,,421.2,Percent of Total Billed charges,75% of Total Billed Charges,285,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.2,72,,404.352,Percent of Total Billed Charges,72% of Total Billed Charges,171,60,,336.96,Percent of Total Billed Charges,60% of Total Billed Charges,256.5,90,,2784.96,Percent of Total Billed Charges,90% of Total Billed Charges,128.25,45,,1237.68,Percent of Total Billed Charges,45% of Total Billed Charges,256.5,90,,2010.96,Percent of Total Billed Charges,90% of Total billed Charges,285,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.25,65,,2153.84,Percent of total Billed Charges,65% of Total Billed Charges,125.69,44.1,,1212.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,270.75,95,,2122.68,Percent of Total Billed Charges,95% of Total Billed Charges,285,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.8,88,,1938.112,Percent of Total Billed Charges,88% of Total Billed Charges,256.5,90,,2010.96,Percent of Total Billed charges,90% of Total Billed Charges,125.69,285,
SHLDR COMP MIN 2 VW,3200000175,CDM,320,RC,,,Outpatient,,,345.00,224.25,,345,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,262.2,76,,913.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,248.4,72,,296.064,Percent of Total Billed Charges,72% of Total Billed Charges,258.75,75,,308.4,Percent of Total Billed charges,75% of Total Billed Charges,345,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.4,72,,296.064,Percent of Total Billed Charges,72% of Total Billed Charges,207,60,,246.72,Percent of Total Billed Charges,60% of Total Billed Charges,310.5,90,,2931.504,Percent of Total Billed Charges,90% of Total Billed Charges,155.25,45,,991.08,Percent of Total Billed Charges,45% of Total Billed Charges,310.5,90,,1082.16,Percent of Total Billed Charges,90% of Total billed Charges,345,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.25,65,,1363.96,Percent of total Billed Charges,65% of Total Billed Charges,152.15,44.1,,971.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,327.75,95,,1142.28,Percent of Total Billed Charges,95% of Total Billed Charges,345,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.6,88,,2072.576,Percent of Total Billed Charges,88% of Total Billed Charges,310.5,90,,1082.16,Percent of Total Billed charges,90% of Total Billed Charges,152.15,345,
SHLDR COMP MIN 2 VW,3200000176,CDM,320,RC,,,Outpatient,,,345.00,224.25,,345,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,262.2,76,,1493.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,248.4,72,,312.248,Percent of Total Billed Charges,72% of Total Billed Charges,258.75,75,,325.264,Percent of Total Billed charges,75% of Total Billed Charges,345,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.4,72,,312.248,Percent of Total Billed Charges,72% of Total Billed Charges,207,60,,260.208,Percent of Total Billed Charges,60% of Total Billed Charges,310.5,90,,1400.4,Percent of Total Billed Charges,90% of Total Billed Charges,155.25,45,,1059.84,Percent of Total Billed Charges,45% of Total Billed Charges,310.5,90,,1769.04,Percent of Total Billed Charges,90% of Total billed Charges,345,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.25,65,,2816.32,Percent of total Billed Charges,65% of Total Billed Charges,152.15,44.1,,1038.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,327.75,95,,1867.32,Percent of Total Billed Charges,95% of Total Billed Charges,345,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.6,88,,2170.144,Percent of Total Billed Charges,88% of Total Billed Charges,310.5,90,,1769.04,Percent of Total Billed charges,90% of Total Billed Charges,152.15,345,
HUMERUS 1 VW LT,3200000177,CDM,320,RC,,,Outpatient,,,239.24,155.51,,239.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,181.82,76,,2016.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,172.25,72,,2493.024,Percent of Total Billed Charges,72% of Total Billed Charges,179.43,75,,2596.904,Percent of Total Billed charges,75% of Total Billed Charges,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.25,72,,2493.024,Percent of Total Billed Charges,72% of Total Billed Charges,143.54,60,,2077.52,Percent of Total Billed Charges,60% of Total Billed Charges,215.32,90,,2109.6,Percent of Total Billed Charges,90% of Total Billed Charges,107.66,45,,1109.736,Percent of Total Billed Charges,45% of Total Billed Charges,215.32,90,,2388.24,Percent of Total Billed Charges,90% of Total billed Charges,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.51,65,,4007.64,Percent of total Billed Charges,65% of Total Billed Charges,105.5,44.1,,1087.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,227.28,95,,2520.92,Percent of Total Billed Charges,95% of Total Billed Charges,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.53,88,,2494.976,Percent of Total Billed Charges,88% of Total Billed Charges,215.32,90,,2388.24,Percent of Total Billed charges,90% of Total Billed Charges,105.5,239.24,
HUMERUS 2VW LT,3200000178,CDM,320,RC,,,Outpatient,,,277.00,180.05,,277,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,210.52,76,,2090.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,199.44,72,,860.544,Percent of Total Billed Charges,72% of Total Billed Charges,207.75,75,,896.4,Percent of Total Billed charges,75% of Total Billed Charges,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.44,72,,860.544,Percent of Total Billed Charges,72% of Total Billed Charges,166.2,60,,717.12,Percent of Total Billed Charges,60% of Total Billed Charges,249.3,90,,2709.36,Percent of Total Billed Charges,90% of Total Billed Charges,124.65,45,,1275.84,Percent of Total Billed Charges,45% of Total Billed Charges,249.3,90,,2475.36,Percent of Total Billed Charges,90% of Total billed Charges,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.05,65,,4208.88,Percent of total Billed Charges,65% of Total Billed Charges,122.16,44.1,,1250.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,263.15,95,,2612.88,Percent of Total Billed Charges,95% of Total Billed Charges,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.76,88,,2381.256,Percent of Total Billed Charges,88% of Total Billed Charges,249.3,90,,2475.36,Percent of Total Billed charges,90% of Total Billed Charges,122.16,277,
HUMERUS 2 VW RT,3200000179,CDM,320,RC,,,Outpatient,,,277.00,180.05,,277,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,210.52,76,,1673.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,199.44,72,,248.936,Percent of Total Billed Charges,72% of Total Billed Charges,207.75,75,,259.312,Percent of Total Billed charges,75% of Total Billed Charges,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.44,72,,248.936,Percent of Total Billed Charges,72% of Total Billed Charges,166.2,60,,207.448,Percent of Total Billed Charges,60% of Total Billed Charges,249.3,90,,1898.64,Percent of Total Billed Charges,90% of Total Billed Charges,124.65,45,,1217.688,Percent of Total Billed Charges,45% of Total Billed Charges,249.3,90,,1982.16,Percent of Total Billed Charges,90% of Total billed Charges,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.05,65,,1363.96,Percent of total Billed Charges,65% of Total Billed Charges,122.16,44.1,,1193.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,263.15,95,,2092.28,Percent of Total Billed Charges,95% of Total Billed Charges,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.76,88,,2723.072,Percent of Total Billed Charges,88% of Total Billed Charges,249.3,90,,1982.16,Percent of Total Billed charges,90% of Total Billed Charges,122.16,277,
ELBOW 2VW LT,3200000180,CDM,320,RC,,,Outpatient,,,315.00,204.75,,315,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,239.4,76,,1789.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,226.8,72,,2364.48,Percent of Total Billed Charges,72% of Total Billed Charges,236.25,75,,2463,Percent of Total Billed charges,75% of Total Billed Charges,315,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.8,72,,2364.48,Percent of Total Billed Charges,72% of Total Billed Charges,189,60,,1970.4,Percent of Total Billed Charges,60% of Total Billed Charges,283.5,90,,3796.56,Percent of Total Billed Charges,90% of Total Billed Charges,141.75,45,,1392.48,Percent of Total Billed Charges,45% of Total Billed Charges,283.5,90,,2119.68,Percent of Total Billed Charges,90% of Total billed Charges,315,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.75,65,,239.064,Percent of total Billed Charges,65% of Total Billed Charges,138.92,44.1,,1364.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,299.25,95,,2237.44,Percent of Total Billed Charges,95% of Total Billed Charges,315,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.2,88,,2866.36,Percent of Total Billed Charges,88% of Total Billed Charges,283.5,90,,2119.68,Percent of Total Billed charges,90% of Total Billed Charges,138.92,315,
ELBOW 2VW RT,3200000181,CDM,320,RC,,,Outpatient,,,315.00,204.75,,315,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,239.4,76,,1874.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,226.8,72,,3835.184,Percent of Total Billed Charges,72% of Total Billed Charges,236.25,75,,3994.984,Percent of Total Billed charges,75% of Total Billed Charges,315,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.8,72,,3835.184,Percent of Total Billed Charges,72% of Total Billed Charges,189,60,,3195.992,Percent of Total Billed Charges,60% of Total Billed Charges,283.5,90,,1898.64,Percent of Total Billed Charges,90% of Total Billed Charges,141.75,45,,1465.752,Percent of Total Billed Charges,45% of Total Billed Charges,283.5,90,,2219.464,Percent of Total Billed Charges,90% of Total billed Charges,315,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.75,65,,1203.928,Percent of total Billed Charges,65% of Total Billed Charges,138.92,44.1,,1436.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,299.25,95,,2342.768,Percent of Total Billed Charges,95% of Total Billed Charges,315,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.2,88,,1369.28,Percent of Total Billed Charges,88% of Total Billed Charges,283.5,90,,2219.464,Percent of Total Billed charges,90% of Total Billed Charges,138.92,315,
ELBOW 3 VW LT,3200000182,CDM,320,RC,,,Outpatient,,,379.00,246.35,,379,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,288.04,76,,2154.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,272.88,72,,941.608,Percent of Total Billed Charges,72% of Total Billed Charges,284.25,75,,980.848,Percent of Total Billed charges,75% of Total Billed Charges,379,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.88,72,,941.608,Percent of Total Billed Charges,72% of Total Billed Charges,227.4,60,,784.672,Percent of Total Billed Charges,60% of Total Billed Charges,341.1,90,,1635.84,Percent of Total Billed Charges,90% of Total Billed Charges,170.55,45,,700.2,Percent of Total Billed Charges,45% of Total Billed Charges,341.1,90,,2551.68,Percent of Total Billed Charges,90% of Total billed Charges,379,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.35,65,,2342.08,Percent of total Billed Charges,65% of Total Billed Charges,167.14,44.1,,686.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,360.05,95,,2693.44,Percent of Total Billed Charges,95% of Total Billed Charges,379,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.52,88,,2062.72,Percent of Total Billed Charges,88% of Total Billed Charges,341.1,90,,2551.68,Percent of Total Billed charges,90% of Total Billed Charges,167.14,379,
ELBOW 3 VW RT,3200000183,CDM,320,RC,,,Outpatient,,,379.00,246.35,,379,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,288.04,76,,2056.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,272.88,72,,11734.848,Percent of Total Billed Charges,72% of Total Billed Charges,284.25,75,,12223.8,Percent of Total Billed charges,75% of Total Billed Charges,379,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.88,72,,11734.848,Percent of Total Billed Charges,72% of Total Billed Charges,227.4,60,,9779.04,Percent of Total Billed Charges,60% of Total Billed Charges,341.1,90,,1819.44,Percent of Total Billed Charges,90% of Total Billed Charges,170.55,45,,1054.8,Percent of Total Billed Charges,45% of Total Billed Charges,341.1,90,,2435.376,Percent of Total Billed Charges,90% of Total billed Charges,379,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.35,65,,2979.072,Percent of total Billed Charges,65% of Total Billed Charges,167.14,44.1,,1033.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,360.05,95,,2570.68,Percent of Total Billed Charges,95% of Total Billed Charges,379,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.52,88,,2649.152,Percent of Total Billed Charges,88% of Total Billed Charges,341.1,90,,2435.376,Percent of Total Billed charges,90% of Total Billed Charges,167.14,379,
FOREARM 1VW LT,3200000184,CDM,320,RC,,,Outpatient,,,200.66,130.43,,200.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152.5,76,,2351.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144.48,72,,620.928,Percent of Total Billed Charges,72% of Total Billed Charges,150.5,75,,646.8,Percent of Total Billed charges,75% of Total Billed Charges,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.48,72,,620.928,Percent of Total Billed Charges,72% of Total Billed Charges,120.4,60,,517.44,Percent of Total Billed Charges,60% of Total Billed Charges,180.59,90,,2572.56,Percent of Total Billed Charges,90% of Total Billed Charges,90.3,45,,1354.68,Percent of Total Billed Charges,45% of Total Billed Charges,180.59,90,,2784.96,Percent of Total Billed Charges,90% of Total billed Charges,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.43,65,,1355.856,Percent of total Billed Charges,65% of Total Billed Charges,88.49,44.1,,1327.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,190.63,95,,2939.68,Percent of Total Billed Charges,95% of Total Billed Charges,200.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.58,88,,1856.448,Percent of Total Billed Charges,88% of Total Billed Charges,180.59,90,,2784.96,Percent of Total Billed charges,90% of Total Billed Charges,88.49,200.66,
FOREARM 2 VW LT,3200000185,CDM,320,RC,,,Outpatient,,,293.00,190.45,,293,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,222.68,76,,2475.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,210.96,72,,2965.64,Percent of Total Billed Charges,72% of Total Billed Charges,219.75,75,,3089.208,Percent of Total Billed charges,75% of Total Billed Charges,293,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.96,72,,2965.64,Percent of Total Billed Charges,72% of Total Billed Charges,175.8,60,,2471.368,Percent of Total Billed Charges,60% of Total Billed Charges,263.7,90,,1898.64,Percent of Total Billed Charges,90% of Total Billed Charges,131.85,45,,949.32,Percent of Total Billed Charges,45% of Total Billed Charges,263.7,90,,2931.504,Percent of Total Billed Charges,90% of Total billed Charges,293,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.45,65,,2979.072,Percent of total Billed Charges,65% of Total Billed Charges,129.21,44.1,,930.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,278.35,95,,3094.36,Percent of Total Billed Charges,95% of Total Billed Charges,293,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.84,88,,3712.192,Percent of Total Billed Charges,88% of Total Billed Charges,263.7,90,,2931.504,Percent of Total Billed charges,90% of Total Billed Charges,129.21,293,
FOREARM 2 VW RT,3200000186,CDM,320,RC,,,Outpatient,,,293.00,190.45,,293,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,222.68,76,,1182.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,210.96,72,,280.512,Percent of Total Billed Charges,72% of Total Billed Charges,219.75,75,,292.2,Percent of Total Billed charges,75% of Total Billed Charges,293,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.96,72,,280.512,Percent of Total Billed Charges,72% of Total Billed Charges,175.8,60,,233.76,Percent of Total Billed Charges,60% of Total Billed Charges,263.7,90,,2306.16,Percent of Total Billed Charges,90% of Total Billed Charges,131.85,45,,1898.28,Percent of Total Billed Charges,45% of Total Billed Charges,263.7,90,,1400.4,Percent of Total Billed Charges,90% of Total billed Charges,293,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.45,65,,502.088,Percent of total Billed Charges,65% of Total Billed Charges,129.21,44.1,,1860.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,278.35,95,,1478.2,Percent of Total Billed Charges,95% of Total Billed Charges,293,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.84,88,,1856.448,Percent of Total Billed Charges,88% of Total Billed Charges,263.7,90,,1400.4,Percent of Total Billed charges,90% of Total Billed Charges,129.21,293,
WRIST 2VWS LT,3200000187,CDM,320,RC,,,Outpatient,,,282.00,183.30,,282,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,214.32,76,,1781.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,203.04,72,,2594.136,Percent of Total Billed Charges,72% of Total Billed Charges,211.5,75,,2702.224,Percent of Total Billed charges,75% of Total Billed Charges,282,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.04,72,,2594.136,Percent of Total Billed Charges,72% of Total Billed Charges,169.2,60,,2161.784,Percent of Total Billed Charges,60% of Total Billed Charges,253.8,90,,1558.8,Percent of Total Billed Charges,90% of Total Billed Charges,126.9,45,,949.32,Percent of Total Billed Charges,45% of Total Billed Charges,253.8,90,,2109.6,Percent of Total Billed Charges,90% of Total billed Charges,282,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.3,65,,775.32,Percent of total Billed Charges,65% of Total Billed Charges,124.36,44.1,,930.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,267.9,95,,2226.8,Percent of Total Billed Charges,95% of Total Billed Charges,282,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.16,88,,1599.488,Percent of Total Billed Charges,88% of Total Billed Charges,253.8,90,,2109.6,Percent of Total Billed charges,90% of Total Billed Charges,124.36,282,
WRIST 2VWS RT,3200000188,CDM,320,RC,,,Outpatient,,,282.00,183.30,,282,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,214.32,76,,2287.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,203.04,72,,6289.576,Percent of Total Billed Charges,72% of Total Billed Charges,211.5,75,,6551.64,Percent of Total Billed charges,75% of Total Billed Charges,282,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.04,72,,6289.576,Percent of Total Billed Charges,72% of Total Billed Charges,169.2,60,,5241.312,Percent of Total Billed Charges,60% of Total Billed Charges,253.8,90,,1755.36,Percent of Total Billed Charges,90% of Total Billed Charges,126.9,45,,817.92,Percent of Total Billed Charges,45% of Total Billed Charges,253.8,90,,2709.36,Percent of Total Billed Charges,90% of Total billed Charges,282,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.3,65,,519.48,Percent of total Billed Charges,65% of Total Billed Charges,124.36,44.1,,801.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,267.9,95,,2859.88,Percent of Total Billed Charges,95% of Total Billed Charges,282,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.16,88,,1779.008,Percent of Total Billed Charges,88% of Total Billed Charges,253.8,90,,2709.36,Percent of Total Billed charges,90% of Total Billed Charges,124.36,282,
WRIST COMP MIN 3VW L,3200000189,CDM,320,RC,,,Outpatient,,,297.00,193.05,,297,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,225.72,76,,1603.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,213.84,72,,6947.352,Percent of Total Billed Charges,72% of Total Billed Charges,222.75,75,,7236.832,Percent of Total Billed charges,75% of Total Billed Charges,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.84,72,,6947.352,Percent of Total Billed Charges,72% of Total Billed Charges,178.2,60,,5789.464,Percent of Total Billed Charges,60% of Total Billed Charges,267.3,90,,1558.8,Percent of Total Billed Charges,90% of Total Billed Charges,133.65,45,,909.72,Percent of Total Billed Charges,45% of Total Billed Charges,267.3,90,,1898.64,Percent of Total Billed Charges,90% of Total billed Charges,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.05,65,,7294.168,Percent of total Billed Charges,65% of Total Billed Charges,130.98,44.1,,891.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,282.15,95,,2004.12,Percent of Total Billed Charges,95% of Total Billed Charges,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.36,88,,2515.392,Percent of Total Billed Charges,88% of Total Billed Charges,267.3,90,,1898.64,Percent of Total Billed charges,90% of Total Billed Charges,130.98,297,
WRIST COMP MIN 3VW R,3200000190,CDM,320,RC,,,Outpatient,,,297.00,193.05,,297,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,225.72,76,,3205.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,213.84,72,,1697.464,Percent of Total Billed Charges,72% of Total Billed Charges,222.75,75,,1768.192,Percent of Total Billed charges,75% of Total Billed Charges,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.84,72,,1697.464,Percent of Total Billed Charges,72% of Total Billed Charges,178.2,60,,1414.552,Percent of Total Billed Charges,60% of Total Billed Charges,267.3,90,,1755.36,Percent of Total Billed Charges,90% of Total Billed Charges,133.65,45,,1286.28,Percent of Total Billed Charges,45% of Total Billed Charges,267.3,90,,3796.56,Percent of Total Billed Charges,90% of Total billed Charges,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.05,65,,4845.416,Percent of total Billed Charges,65% of Total Billed Charges,130.98,44.1,,1260.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,282.15,95,,4007.48,Percent of Total Billed Charges,95% of Total Billed Charges,297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.36,88,,1856.448,Percent of Total Billed Charges,88% of Total Billed Charges,267.3,90,,3796.56,Percent of Total Billed charges,90% of Total Billed Charges,130.98,297,
HAND 2 VW LT,3200000191,CDM,320,RC,,,Outpatient,,,257.00,167.05,,257,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,195.32,76,,1603.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,185.04,72,,1254.176,Percent of Total Billed Charges,72% of Total Billed Charges,192.75,75,,1306.432,Percent of Total Billed charges,75% of Total Billed Charges,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.04,72,,1254.176,Percent of Total Billed Charges,72% of Total Billed Charges,154.2,60,,1045.144,Percent of Total Billed Charges,60% of Total Billed Charges,231.3,90,,1895.76,Percent of Total Billed Charges,90% of Total Billed Charges,115.65,45,,949.32,Percent of Total Billed Charges,45% of Total Billed Charges,231.3,90,,1898.64,Percent of Total Billed Charges,90% of Total billed Charges,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.05,65,,35664.416,Percent of total Billed Charges,65% of Total Billed Charges,113.34,44.1,,930.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,244.15,95,,2004.12,Percent of Total Billed Charges,95% of Total Billed Charges,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.16,88,,2254.912,Percent of Total Billed Charges,88% of Total Billed Charges,231.3,90,,1898.64,Percent of Total Billed charges,90% of Total Billed Charges,113.34,257,
HAND 2 VW RT,3200000192,CDM,320,RC,,,Outpatient,,,257.00,167.05,,257,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,195.32,76,,1381.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,185.04,72,,835.344,Percent of Total Billed Charges,72% of Total Billed Charges,192.75,75,,870.152,Percent of Total Billed charges,75% of Total Billed Charges,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.04,72,,835.344,Percent of Total Billed Charges,72% of Total Billed Charges,154.2,60,,696.12,Percent of Total Billed Charges,60% of Total Billed Charges,231.3,90,,1400.4,Percent of Total Billed Charges,90% of Total Billed Charges,115.65,45,,1153.08,Percent of Total Billed Charges,45% of Total Billed Charges,231.3,90,,1635.84,Percent of Total Billed Charges,90% of Total billed Charges,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.05,65,,34805.616,Percent of total Billed Charges,65% of Total Billed Charges,113.34,44.1,,1130.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,244.15,95,,1726.72,Percent of Total Billed Charges,95% of Total Billed Charges,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.16,88,,1524.16,Percent of Total Billed Charges,88% of Total Billed Charges,231.3,90,,1635.84,Percent of Total Billed charges,90% of Total Billed Charges,113.34,257,
HAND 3 VW LT,3200000193,CDM,320,RC,,,Outpatient,,,305.00,198.25,,305,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,231.8,76,,1536.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,219.6,72,,1397.408,Percent of Total Billed Charges,72% of Total Billed Charges,228.75,75,,1455.632,Percent of Total Billed charges,75% of Total Billed Charges,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.6,72,,1397.408,Percent of Total Billed Charges,72% of Total Billed Charges,183,60,,1164.504,Percent of Total Billed Charges,60% of Total Billed Charges,274.5,90,,1558.8,Percent of Total Billed Charges,90% of Total Billed Charges,137.25,45,,779.4,Percent of Total Billed Charges,45% of Total Billed Charges,274.5,90,,1819.44,Percent of Total Billed Charges,90% of Total billed Charges,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.25,65,,34109.056,Percent of total Billed Charges,65% of Total Billed Charges,134.51,44.1,,763.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,289.75,95,,1920.52,Percent of Total Billed Charges,95% of Total Billed Charges,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.4,88,,1716.352,Percent of Total Billed Charges,88% of Total Billed Charges,274.5,90,,1819.44,Percent of Total Billed charges,90% of Total Billed Charges,134.51,305,
HAND 3 VW RT,3200000194,CDM,320,RC,,,Outpatient,,,305.00,198.25,,305,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,231.8,76,,2172.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,219.6,72,,1303.736,Percent of Total Billed Charges,72% of Total Billed Charges,228.75,75,,1358.056,Percent of Total Billed charges,75% of Total Billed Charges,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.6,72,,1303.736,Percent of Total Billed Charges,72% of Total Billed Charges,183,60,,1086.448,Percent of Total Billed Charges,60% of Total Billed Charges,274.5,90,,2375.28,Percent of Total Billed Charges,90% of Total Billed Charges,137.25,45,,877.68,Percent of Total Billed Charges,45% of Total Billed Charges,274.5,90,,2572.56,Percent of Total Billed Charges,90% of Total billed Charges,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.25,65,,5259.456,Percent of total Billed Charges,65% of Total Billed Charges,134.51,44.1,,860.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,289.75,95,,2715.48,Percent of Total Billed Charges,95% of Total Billed Charges,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.4,88,,1524.16,Percent of Total Billed Charges,88% of Total Billed Charges,274.5,90,,2572.56,Percent of Total Billed charges,90% of Total Billed Charges,134.51,305,
FINGERS MIN 2 VW LT,3200000195,CDM,320,RC,,,Outpatient,,,234.00,152.10,,234,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,177.84,76,,1603.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,168.48,72,,1254.176,Percent of Total Billed Charges,72% of Total Billed Charges,175.5,75,,1306.432,Percent of Total Billed charges,75% of Total Billed Charges,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.48,72,,1254.176,Percent of Total Billed Charges,72% of Total Billed Charges,140.4,60,,1045.144,Percent of Total Billed Charges,60% of Total Billed Charges,210.6,90,,1987.672,Percent of Total Billed Charges,90% of Total Billed Charges,105.3,45,,779.4,Percent of Total Billed Charges,45% of Total Billed Charges,210.6,90,,1898.64,Percent of Total Billed Charges,90% of Total billed Charges,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.1,65,,10874.352,Percent of total Billed Charges,65% of Total Billed Charges,103.19,44.1,,763.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,222.3,95,,2004.12,Percent of Total Billed Charges,95% of Total Billed Charges,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.92,88,,1716.352,Percent of Total Billed Charges,88% of Total Billed Charges,210.6,90,,1898.64,Percent of Total Billed charges,90% of Total Billed Charges,103.19,234,
FINGERS MIN 2 VW RT,3200000196,CDM,320,RC,,,Outpatient,,,234.00,152.10,,234,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,177.84,76,,1947.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,168.48,72,,1949.576,Percent of Total Billed Charges,72% of Total Billed Charges,175.5,75,,2030.808,Percent of Total Billed charges,75% of Total Billed Charges,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.48,72,,1949.576,Percent of Total Billed Charges,72% of Total Billed Charges,140.4,60,,1624.648,Percent of Total Billed Charges,60% of Total Billed Charges,210.6,90,,2094.48,Percent of Total Billed Charges,90% of Total Billed Charges,105.3,45,,877.68,Percent of Total Billed Charges,45% of Total Billed Charges,210.6,90,,2306.16,Percent of Total Billed Charges,90% of Total billed Charges,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.1,65,,2879.688,Percent of total Billed Charges,65% of Total Billed Charges,103.19,44.1,,860.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,222.3,95,,2434.28,Percent of Total Billed Charges,95% of Total Billed Charges,234,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.92,88,,1853.632,Percent of Total Billed Charges,88% of Total Billed Charges,210.6,90,,2306.16,Percent of Total Billed charges,90% of Total Billed Charges,103.19,234,
HIP 1 VW LT,3200000197,CDM,320,RC,,,Outpatient,,,302.00,196.30,,302,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,229.52,76,,1316.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,217.44,72,,2965,Percent of Total Billed Charges,72% of Total Billed Charges,226.5,75,,3088.544,Percent of Total Billed charges,75% of Total Billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.44,72,,2965,Percent of Total Billed Charges,72% of Total Billed Charges,181.2,60,,2470.832,Percent of Total Billed Charges,60% of Total Billed Charges,271.8,90,,2648.88,Percent of Total Billed Charges,90% of Total Billed Charges,135.9,45,,947.88,Percent of Total Billed Charges,45% of Total Billed Charges,271.8,90,,1558.8,Percent of Total Billed Charges,90% of Total billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.3,65,,1203.928,Percent of total Billed Charges,65% of Total Billed Charges,133.18,44.1,,928.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,286.9,95,,1645.4,Percent of Total Billed Charges,95% of Total Billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.76,88,,1369.28,Percent of Total Billed Charges,88% of Total Billed Charges,271.8,90,,1558.8,Percent of Total Billed charges,90% of Total Billed Charges,133.18,302,
HIP 1 VW RT,3200000198,CDM,320,RC,,,Outpatient,,,302.00,196.30,,302,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,229.52,76,,1482.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,217.44,72,,1944.144,Percent of Total Billed Charges,72% of Total Billed Charges,226.5,75,,2025.152,Percent of Total Billed charges,75% of Total Billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.44,72,,1944.144,Percent of Total Billed Charges,72% of Total Billed Charges,181.2,60,,1620.12,Percent of Total Billed Charges,60% of Total Billed Charges,271.8,90,,2704.32,Percent of Total Billed Charges,90% of Total Billed Charges,135.9,45,,700.2,Percent of Total Billed Charges,45% of Total Billed Charges,271.8,90,,1755.36,Percent of Total Billed Charges,90% of Total billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.3,65,,2465.192,Percent of total Billed Charges,65% of Total Billed Charges,133.18,44.1,,686.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,286.9,95,,1852.88,Percent of Total Billed Charges,95% of Total Billed Charges,302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.76,88,,1524.16,Percent of Total Billed Charges,88% of Total Billed Charges,271.8,90,,1755.36,Percent of Total Billed charges,90% of Total Billed Charges,133.18,302,
HIP 2 V W PELVIS LT,3200000199,CDM,320,RC,,,Outpatient,,,249.00,161.85,,249,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,189.24,76,,1316.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,179.28,72,,3024.696,Percent of Total Billed Charges,72% of Total Billed Charges,186.75,75,,3150.728,Percent of Total Billed charges,75% of Total Billed Charges,249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.28,72,,3024.696,Percent of Total Billed Charges,72% of Total Billed Charges,149.4,60,,2520.584,Percent of Total Billed Charges,60% of Total Billed Charges,224.1,90,,1888.56,Percent of Total Billed Charges,90% of Total Billed Charges,112.05,45,,779.4,Percent of Total Billed Charges,45% of Total Billed Charges,224.1,90,,1558.8,Percent of Total Billed Charges,90% of Total billed Charges,249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.85,65,,6946.832,Percent of total Billed Charges,65% of Total Billed Charges,109.81,44.1,,763.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,236.55,95,,1645.4,Percent of Total Billed Charges,95% of Total Billed Charges,249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.12,88,,2322.496,Percent of Total Billed Charges,88% of Total Billed Charges,224.1,90,,1558.8,Percent of Total Billed charges,90% of Total Billed Charges,109.81,249,
HIP 2 V  W PELVIS  RT,3200000200,CDM,320,RC,,,Outpatient,,,249.00,161.85,,249,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,189.24,76,,1482.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,179.28,72,,1232.064,Percent of Total Billed Charges,72% of Total Billed Charges,186.75,75,,1283.4,Percent of Total Billed charges,75% of Total Billed Charges,249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.28,72,,1232.064,Percent of Total Billed Charges,72% of Total Billed Charges,149.4,60,,1026.72,Percent of Total Billed Charges,60% of Total Billed Charges,224.1,90,,1681.92,Percent of Total Billed Charges,90% of Total Billed Charges,112.05,45,,1187.64,Percent of Total Billed Charges,45% of Total Billed Charges,224.1,90,,1755.36,Percent of Total Billed Charges,90% of Total billed Charges,249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.85,65,,1203.928,Percent of total Billed Charges,65% of Total Billed Charges,109.81,44.1,,1163.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,236.55,95,,1852.88,Percent of Total Billed Charges,95% of Total Billed Charges,249,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.12,88,,1943.504,Percent of Total Billed Charges,88% of Total Billed Charges,224.1,90,,1755.36,Percent of Total Billed charges,90% of Total Billed Charges,109.81,249,
FEMUR 1 VW LT,3200000201,CDM,320,RC,,,Outpatient,,,145.53,94.59,,145.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.6,76,,1600.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,104.78,72,,3024.696,Percent of Total Billed Charges,72% of Total Billed Charges,109.15,75,,3150.728,Percent of Total Billed charges,75% of Total Billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.78,72,,3024.696,Percent of Total Billed Charges,72% of Total Billed Charges,87.32,60,,2520.584,Percent of Total Billed Charges,60% of Total Billed Charges,130.98,90,,2401.2,Percent of Total Billed Charges,90% of Total Billed Charges,65.49,45,,993.84,Percent of Total Billed Charges,45% of Total Billed Charges,130.98,90,,1895.76,Percent of Total Billed Charges,90% of Total billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.59,65,,2465.192,Percent of total Billed Charges,65% of Total Billed Charges,64.18,44.1,,973.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,138.25,95,,2001.08,Percent of Total Billed Charges,95% of Total Billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.07,88,,2047.936,Percent of Total Billed Charges,88% of Total Billed Charges,130.98,90,,1895.76,Percent of Total Billed charges,90% of Total Billed Charges,64.18,145.53,
FEMUR 1VW RT,3200000202,CDM,320,RC,,,Outpatient,,,145.53,94.59,,145.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.6,76,,1182.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,104.78,72,,3106.944,Percent of Total Billed Charges,72% of Total Billed Charges,109.15,75,,3236.4,Percent of Total Billed charges,75% of Total Billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.78,72,,3106.944,Percent of Total Billed Charges,72% of Total Billed Charges,87.32,60,,2589.12,Percent of Total Billed Charges,60% of Total Billed Charges,130.98,90,,2982.24,Percent of Total Billed Charges,90% of Total Billed Charges,65.49,45,,1047.24,Percent of Total Billed Charges,45% of Total Billed Charges,130.98,90,,1400.4,Percent of Total Billed Charges,90% of Total billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.59,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,64.18,44.1,,1026.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,138.25,95,,1478.2,Percent of Total Billed Charges,95% of Total Billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.07,88,,2590.016,Percent of Total Billed Charges,88% of Total Billed Charges,130.98,90,,1400.4,Percent of Total Billed charges,90% of Total Billed Charges,64.18,145.53,
FEMUR 2 VW LT,3200000203,CDM,320,RC,,,Outpatient,,,152.00,98.80,,152,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,115.52,76,,1316.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,109.44,72,,3615.92,Percent of Total Billed Charges,72% of Total Billed Charges,114,75,,3766.584,Percent of Total Billed charges,75% of Total Billed Charges,152,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.44,72,,3615.92,Percent of Total Billed Charges,72% of Total Billed Charges,91.2,60,,3013.264,Percent of Total Billed Charges,60% of Total Billed Charges,136.8,90,,1888.56,Percent of Total Billed Charges,90% of Total Billed Charges,68.4,45,,1324.44,Percent of Total Billed Charges,45% of Total Billed Charges,136.8,90,,1558.8,Percent of Total Billed Charges,90% of Total billed Charges,152,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.8,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,67.03,44.1,,1297.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,144.4,95,,1645.4,Percent of Total Billed Charges,95% of Total Billed Charges,152,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.76,88,,2644.224,Percent of Total Billed Charges,88% of Total Billed Charges,136.8,90,,1558.8,Percent of Total Billed charges,90% of Total Billed Charges,67.03,152,
FEMUR 2 VW RT,3200000204,CDM,320,RC,,,Outpatient,,,152.00,98.80,,152,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,115.52,76,,2005.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,109.44,72,,2965.64,Percent of Total Billed Charges,72% of Total Billed Charges,114,75,,3089.208,Percent of Total Billed charges,75% of Total Billed Charges,152,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.44,72,,2965.64,Percent of Total Billed Charges,72% of Total Billed Charges,91.2,60,,2471.368,Percent of Total Billed Charges,60% of Total Billed Charges,136.8,90,,3899.52,Percent of Total Billed Charges,90% of Total Billed Charges,68.4,45,,1352.16,Percent of Total Billed Charges,45% of Total Billed Charges,136.8,90,,2375.28,Percent of Total Billed Charges,90% of Total billed Charges,152,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.8,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,67.03,44.1,,1325.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,144.4,95,,2507.24,Percent of Total Billed Charges,95% of Total Billed Charges,152,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.76,88,,1846.592,Percent of Total Billed Charges,88% of Total Billed Charges,136.8,90,,2375.28,Percent of Total Billed charges,90% of Total Billed Charges,67.03,152,
KNEE 1 OR 2 VW LT,3200000205,CDM,320,RC,,,Outpatient,,,252.00,163.80,,252,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,191.52,76,,1678.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,181.44,72,,843.264,Percent of Total Billed Charges,72% of Total Billed Charges,189,75,,878.4,Percent of Total Billed charges,75% of Total Billed Charges,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.44,72,,843.264,Percent of Total Billed Charges,72% of Total Billed Charges,151.2,60,,702.72,Percent of Total Billed Charges,60% of Total Billed Charges,226.8,90,,5549.04,Percent of Total Billed Charges,90% of Total Billed Charges,113.4,45,,944.28,Percent of Total Billed Charges,45% of Total Billed Charges,226.8,90,,1987.672,Percent of Total Billed Charges,90% of Total billed Charges,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.8,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,111.13,44.1,,925.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,239.4,95,,2098.104,Percent of Total Billed Charges,95% of Total Billed Charges,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.76,88,,1644.544,Percent of Total Billed Charges,88% of Total Billed Charges,226.8,90,,1987.672,Percent of Total Billed charges,90% of Total Billed Charges,111.13,252,
KNEE 1 OR 2 VW RT,3200000206,CDM,320,RC,,,Outpatient,,,252.00,163.80,,252,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,191.52,76,,1768.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,181.44,72,,1520.64,Percent of Total Billed Charges,72% of Total Billed Charges,189,75,,1584,Percent of Total Billed charges,75% of Total Billed Charges,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.44,72,,1520.64,Percent of Total Billed Charges,72% of Total Billed Charges,151.2,60,,1267.2,Percent of Total Billed Charges,60% of Total Billed Charges,226.8,90,,5827.68,Percent of Total Billed Charges,90% of Total Billed Charges,113.4,45,,840.96,Percent of Total Billed Charges,45% of Total Billed Charges,226.8,90,,2094.48,Percent of Total Billed Charges,90% of Total billed Charges,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.8,65,,496.48,Percent of total Billed Charges,65% of Total Billed Charges,111.13,44.1,,824.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,239.4,95,,2210.84,Percent of Total Billed Charges,95% of Total Billed Charges,252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.76,88,,2347.84,Percent of Total Billed Charges,88% of Total Billed Charges,226.8,90,,2094.48,Percent of Total Billed charges,90% of Total Billed Charges,111.13,252,
KNEE 3 VW LT,3200000207,CDM,320,RC,,,Outpatient,,,303.00,196.95,,303,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,230.28,76,,2236.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,218.16,72,,733.472,Percent of Total Billed Charges,72% of Total Billed Charges,227.25,75,,764.032,Percent of Total Billed charges,75% of Total Billed Charges,303,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.16,72,,733.472,Percent of Total Billed Charges,72% of Total Billed Charges,181.8,60,,611.224,Percent of Total Billed Charges,60% of Total Billed Charges,272.7,90,,1888.56,Percent of Total Billed Charges,90% of Total Billed Charges,136.35,45,,1200.6,Percent of Total Billed Charges,45% of Total Billed Charges,272.7,90,,2648.88,Percent of Total Billed Charges,90% of Total billed Charges,303,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.95,65,,496.48,Percent of total Billed Charges,65% of Total Billed Charges,133.62,44.1,,1176.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,287.85,95,,2796.04,Percent of Total Billed Charges,95% of Total Billed Charges,303,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.64,88,,2915.968,Percent of Total Billed Charges,88% of Total Billed Charges,272.7,90,,2648.88,Percent of Total Billed charges,90% of Total Billed Charges,133.62,303,
KNEE 3 VW RT,3200000208,CDM,320,RC,,,Outpatient,,,303.00,196.95,,303,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,230.28,76,,2283.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,218.16,72,,761.416,Percent of Total Billed Charges,72% of Total Billed Charges,227.25,75,,793.144,Percent of Total Billed charges,75% of Total Billed Charges,303,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.16,72,,761.416,Percent of Total Billed Charges,72% of Total Billed Charges,181.8,60,,634.512,Percent of Total Billed Charges,60% of Total Billed Charges,272.7,90,,331.016,Percent of Total Billed Charges,90% of Total Billed Charges,136.35,45,,1491.12,Percent of Total Billed Charges,45% of Total Billed Charges,272.7,90,,2704.32,Percent of Total Billed Charges,90% of Total billed Charges,303,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.95,65,,1252.68,Percent of total Billed Charges,65% of Total Billed Charges,133.62,44.1,,1461.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,287.85,95,,2854.56,Percent of Total Billed Charges,95% of Total Billed Charges,303,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.64,88,,1846.592,Percent of Total Billed Charges,88% of Total Billed Charges,272.7,90,,2704.32,Percent of Total Billed charges,90% of Total Billed Charges,133.62,303,
KNEE 4 OR MORE VW LT,3200000209,CDM,320,RC,,,Outpatient,,,396.00,257.40,,396,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,300.96,76,,1594.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,285.12,72,,849.688,Percent of Total Billed Charges,72% of Total Billed Charges,297,75,,885.088,Percent of Total Billed charges,75% of Total Billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.12,72,,849.688,Percent of Total Billed Charges,72% of Total Billed Charges,237.6,60,,708.072,Percent of Total Billed Charges,60% of Total Billed Charges,356.4,90,,1666.984,Percent of Total Billed Charges,90% of Total Billed Charges,178.2,45,,944.28,Percent of Total Billed Charges,45% of Total Billed Charges,356.4,90,,1888.56,Percent of Total Billed Charges,90% of Total billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.4,65,,1252.68,Percent of total Billed Charges,65% of Total Billed Charges,174.64,44.1,,925.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,376.2,95,,1993.48,Percent of Total Billed Charges,95% of Total Billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.48,88,,3812.864,Percent of Total Billed Charges,88% of Total Billed Charges,356.4,90,,1888.56,Percent of Total Billed charges,90% of Total Billed Charges,174.64,396,
KNEE 4 OR MORE VW RT,3200000210,CDM,320,RC,,,Outpatient,,,396.00,257.40,,396,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,300.96,76,,1420.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,285.12,72,,2006.416,Percent of Total Billed Charges,72% of Total Billed Charges,297,75,,2090.016,Percent of Total Billed charges,75% of Total Billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.12,72,,2006.416,Percent of Total Billed Charges,72% of Total Billed Charges,237.6,60,,1672.016,Percent of Total Billed Charges,60% of Total Billed Charges,356.4,90,,3242.88,Percent of Total Billed Charges,90% of Total Billed Charges,178.2,45,,1949.76,Percent of Total Billed Charges,45% of Total Billed Charges,356.4,90,,1681.92,Percent of Total Billed Charges,90% of Total billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.4,65,,1318.592,Percent of total Billed Charges,65% of Total Billed Charges,174.64,44.1,,1910.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,376.2,95,,1775.36,Percent of Total Billed Charges,95% of Total Billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.48,88,,5425.728,Percent of Total Billed Charges,88% of Total Billed Charges,356.4,90,,1681.92,Percent of Total Billed charges,90% of Total Billed Charges,174.64,396,
LOWER LEG 2 VW LT,3200000211,CDM,320,RC,,,Outpatient,,,327.00,212.55,,327,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,248.52,76,,2027.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,235.44,72,,1035.072,Percent of Total Billed Charges,72% of Total Billed Charges,245.25,75,,1078.2,Percent of Total Billed charges,75% of Total Billed Charges,327,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.44,72,,1035.072,Percent of Total Billed Charges,72% of Total Billed Charges,196.2,60,,862.56,Percent of Total Billed Charges,60% of Total Billed Charges,294.3,90,,4124.864,Percent of Total Billed Charges,90% of Total Billed Charges,147.15,45,,2774.52,Percent of Total Billed Charges,45% of Total Billed Charges,294.3,90,,2401.2,Percent of Total Billed Charges,90% of Total billed Charges,327,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.55,65,,1252.68,Percent of total Billed Charges,65% of Total Billed Charges,144.21,44.1,,2719.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,310.65,95,,2534.6,Percent of Total Billed Charges,95% of Total Billed Charges,327,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,287.76,88,,5698.176,Percent of Total Billed Charges,88% of Total Billed Charges,294.3,90,,2401.2,Percent of Total Billed charges,90% of Total Billed Charges,144.21,327,
LOWER LEG 2 VW RT,3200000212,CDM,320,RC,,,Outpatient,,,327.00,212.55,,327,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,248.52,76,,2518.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,235.44,72,,2764.8,Percent of Total Billed Charges,72% of Total Billed Charges,245.25,75,,2880,Percent of Total Billed charges,75% of Total Billed Charges,327,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.44,72,,2764.8,Percent of Total Billed Charges,72% of Total Billed Charges,196.2,60,,2304,Percent of Total Billed Charges,60% of Total Billed Charges,294.3,90,,1877.336,Percent of Total Billed Charges,90% of Total Billed Charges,147.15,45,,2913.84,Percent of Total Billed Charges,45% of Total Billed Charges,294.3,90,,2982.24,Percent of Total Billed Charges,90% of Total billed Charges,327,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.55,65,,434.568,Percent of total Billed Charges,65% of Total Billed Charges,144.21,44.1,,2855.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,310.65,95,,3147.92,Percent of Total Billed Charges,95% of Total Billed Charges,327,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,287.76,88,,1846.592,Percent of Total Billed Charges,88% of Total Billed Charges,294.3,90,,2982.24,Percent of Total Billed charges,90% of Total Billed Charges,144.21,327,
ANKLE 2VWS LT,3200000213,CDM,320,RC,,,Outpatient,,,245.00,159.25,,245,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,186.2,76,,1594.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,176.4,72,,1899.616,Percent of Total Billed Charges,72% of Total Billed Charges,183.75,75,,1978.768,Percent of Total Billed charges,75% of Total Billed Charges,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.4,72,,1899.616,Percent of Total Billed Charges,72% of Total Billed Charges,147,60,,1583.016,Percent of Total Billed Charges,60% of Total Billed Charges,220.5,90,,4124.864,Percent of Total Billed Charges,90% of Total Billed Charges,110.25,45,,944.28,Percent of Total Billed Charges,45% of Total Billed Charges,220.5,90,,1888.56,Percent of Total Billed Charges,90% of Total billed Charges,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.25,65,,267.16,Percent of total Billed Charges,65% of Total Billed Charges,108.05,44.1,,925.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,232.75,95,,1993.48,Percent of Total Billed Charges,95% of Total Billed Charges,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.6,88,,323.656,Percent of Total Billed Charges,88% of Total Billed Charges,220.5,90,,1888.56,Percent of Total Billed charges,90% of Total Billed Charges,108.05,245,
ANKLE 2VW RT,3200000214,CDM,320,RC,,,Outpatient,,,245.00,159.25,,245,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,186.2,76,,3292.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,176.4,72,,4468.8,Percent of Total Billed Charges,72% of Total Billed Charges,183.75,75,,4655.008,Percent of Total Billed charges,75% of Total Billed Charges,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.4,72,,4468.8,Percent of Total Billed Charges,72% of Total Billed Charges,147,60,,3724,Percent of Total Billed Charges,60% of Total Billed Charges,220.5,90,,695.2,Percent of Total Billed Charges,90% of Total Billed Charges,110.25,45,,165.504,Percent of Total Billed Charges,45% of Total Billed Charges,220.5,90,,3899.52,Percent of Total Billed Charges,90% of Total billed Charges,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.25,65,,1433.248,Percent of total Billed Charges,65% of Total Billed Charges,108.05,44.1,,162.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,232.75,95,,4116.16,Percent of Total Billed Charges,95% of Total Billed Charges,245,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.6,88,,1629.936,Percent of Total Billed Charges,88% of Total Billed Charges,220.5,90,,3899.52,Percent of Total Billed charges,90% of Total Billed Charges,108.05,245,
ANKLE 3 VW LT,3200000215,CDM,320,RC,,,Outpatient,,,343.00,222.95,,343,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,260.68,76,,4685.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,246.96,72,,864.048,Percent of Total Billed Charges,72% of Total Billed Charges,257.25,75,,900.056,Percent of Total Billed charges,75% of Total Billed Charges,343,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.96,72,,864.048,Percent of Total Billed Charges,72% of Total Billed Charges,205.8,60,,720.04,Percent of Total Billed Charges,60% of Total Billed Charges,308.7,90,,1073.52,Percent of Total Billed Charges,90% of Total Billed Charges,154.35,45,,833.488,Percent of Total Billed Charges,45% of Total Billed Charges,308.7,90,,5549.04,Percent of Total Billed Charges,90% of Total billed Charges,343,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.95,65,,1433.248,Percent of total Billed Charges,65% of Total Billed Charges,151.26,44.1,,816.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,325.85,95,,5857.32,Percent of Total Billed Charges,95% of Total Billed Charges,343,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.84,88,,3170.816,Percent of Total Billed Charges,88% of Total Billed Charges,308.7,90,,5549.04,Percent of Total Billed charges,90% of Total Billed Charges,151.26,343,
ANKLE 3VW RT,3200000216,CDM,320,RC,,,Outpatient,,,343.00,222.95,,343,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,260.68,76,,4921.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,246.96,72,,864.048,Percent of Total Billed Charges,72% of Total Billed Charges,257.25,75,,900.056,Percent of Total Billed charges,75% of Total Billed Charges,343,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.96,72,,864.048,Percent of Total Billed Charges,72% of Total Billed Charges,205.8,60,,720.04,Percent of Total Billed Charges,60% of Total Billed Charges,308.7,90,,719.28,Percent of Total Billed Charges,90% of Total Billed Charges,154.35,45,,1621.44,Percent of Total Billed Charges,45% of Total Billed Charges,308.7,90,,5827.68,Percent of Total Billed Charges,90% of Total billed Charges,343,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.95,65,,1433.248,Percent of total Billed Charges,65% of Total Billed Charges,151.26,44.1,,1589.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,325.85,95,,6151.44,Percent of Total Billed Charges,95% of Total Billed Charges,343,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.84,88,,4033.2,Percent of Total Billed Charges,88% of Total Billed Charges,308.7,90,,5827.68,Percent of Total Billed charges,90% of Total Billed Charges,151.26,343,
FOOT 2 VW LT,3200000217,CDM,320,RC,,,Outpatient,,,258.00,167.70,,258,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,196.08,76,,1594.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,185.76,72,,864.048,Percent of Total Billed Charges,72% of Total Billed Charges,193.5,75,,900.056,Percent of Total Billed charges,75% of Total Billed Charges,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.76,72,,864.048,Percent of Total Billed Charges,72% of Total Billed Charges,154.8,60,,720.04,Percent of Total Billed Charges,60% of Total Billed Charges,232.2,90,,10099.624,Percent of Total Billed Charges,90% of Total Billed Charges,116.1,45,,2062.432,Percent of Total Billed Charges,45% of Total Billed Charges,232.2,90,,1888.56,Percent of Total Billed Charges,90% of Total billed Charges,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.7,65,,1390.832,Percent of total Billed Charges,65% of Total Billed Charges,113.78,44.1,,2021.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,245.1,95,,1993.48,Percent of Total Billed Charges,95% of Total Billed Charges,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.04,88,,1835.616,Percent of Total Billed Charges,88% of Total Billed Charges,232.2,90,,1888.56,Percent of Total Billed charges,90% of Total Billed Charges,113.78,258,
FOOT 2 VW RT,3200000218,CDM,320,RC,,,Outpatient,,,258.00,167.70,,258,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,196.08,76,,279.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,185.76,72,,2477.952,Percent of Total Billed Charges,72% of Total Billed Charges,193.5,75,,2581.2,Percent of Total Billed charges,75% of Total Billed Charges,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.76,72,,2477.952,Percent of Total Billed Charges,72% of Total Billed Charges,154.8,60,,2064.96,Percent of Total Billed Charges,60% of Total Billed Charges,232.2,90,,6709.04,Percent of Total Billed Charges,90% of Total Billed Charges,116.1,45,,938.664,Percent of Total Billed Charges,45% of Total Billed Charges,232.2,90,,331.016,Percent of Total Billed Charges,90% of Total billed Charges,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.7,65,,3448.64,Percent of total Billed Charges,65% of Total Billed Charges,113.78,44.1,,919.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,245.1,95,,349.4,Percent of Total Billed Charges,95% of Total Billed Charges,258,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.04,88,,4033.2,Percent of Total Billed Charges,88% of Total Billed Charges,232.2,90,,331.016,Percent of Total Billed charges,90% of Total Billed Charges,113.78,258,
FOOT 3 VW LT,3200000219,CDM,320,RC,,,Outpatient,,,326.00,211.90,,326,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,247.76,76,,1407.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,234.72,72,,11734.848,Percent of Total Billed Charges,72% of Total Billed Charges,244.5,75,,12223.8,Percent of Total Billed charges,75% of Total Billed Charges,326,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.72,72,,11734.848,Percent of Total Billed Charges,72% of Total Billed Charges,195.6,60,,9779.04,Percent of Total Billed Charges,60% of Total Billed Charges,293.4,90,,49381.504,Percent of Total Billed Charges,90% of Total Billed Charges,146.7,45,,2062.432,Percent of Total Billed Charges,45% of Total Billed Charges,293.4,90,,1666.984,Percent of Total Billed Charges,90% of Total billed Charges,326,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.9,65,,1461.72,Percent of total Billed Charges,65% of Total Billed Charges,143.77,44.1,,2021.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,309.7,95,,1759.592,Percent of Total Billed Charges,95% of Total Billed Charges,326,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.88,88,,679.744,Percent of Total Billed Charges,88% of Total Billed Charges,293.4,90,,1666.984,Percent of Total Billed charges,90% of Total Billed Charges,143.77,326,
FOOT 3 VW RT,3200000220,CDM,320,RC,,,Outpatient,,,340.67,221.44,,340.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,258.91,76,,2738.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,245.28,72,,11734.848,Percent of Total Billed Charges,72% of Total Billed Charges,255.5,75,,12223.8,Percent of Total Billed charges,75% of Total Billed Charges,340.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.28,72,,11734.848,Percent of Total Billed Charges,72% of Total Billed Charges,204.4,60,,9779.04,Percent of Total Billed Charges,60% of Total Billed Charges,306.6,90,,48192.392,Percent of Total Billed Charges,90% of Total Billed Charges,153.3,45,,347.6,Percent of Total Billed Charges,45% of Total Billed Charges,306.6,90,,3242.88,Percent of Total Billed Charges,90% of Total billed Charges,340.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.44,65,,11755.512,Percent of total Billed Charges,65% of Total Billed Charges,150.24,44.1,,340.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,323.64,95,,3423.04,Percent of Total Billed Charges,95% of Total Billed Charges,340.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,299.79,88,,1049.664,Percent of Total Billed Charges,88% of Total Billed Charges,306.6,90,,3242.88,Percent of Total Billed charges,90% of Total Billed Charges,150.24,340.67,
CALCANEUS (HEEL) MIN 2,3200000221,CDM,320,RC,,,Outpatient,,,274.00,178.10,,274,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,208.24,76,,3483.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,197.28,72,,11734.848,Percent of Total Billed Charges,72% of Total Billed Charges,205.5,75,,12223.8,Percent of Total Billed charges,75% of Total Billed Charges,274,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.28,72,,11734.848,Percent of Total Billed Charges,72% of Total Billed Charges,164.4,60,,9779.04,Percent of Total Billed Charges,60% of Total Billed Charges,246.6,90,,47227.928,Percent of Total Billed Charges,90% of Total Billed Charges,123.3,45,,536.76,Percent of Total Billed Charges,45% of Total Billed Charges,246.6,90,,4124.864,Percent of Total Billed Charges,90% of Total billed Charges,274,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.1,65,,10771.16,Percent of total Billed Charges,65% of Total Billed Charges,120.83,44.1,,526.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,260.3,95,,4354.024,Percent of Total Billed Charges,95% of Total Billed Charges,274,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.12,88,,703.296,Percent of Total Billed Charges,88% of Total Billed Charges,246.6,90,,4124.864,Percent of Total Billed charges,90% of Total Billed Charges,120.83,274,
TOE(S) MIN 2 VWS LT,3200000222,CDM,320,RC,,,Outpatient,,,283.00,183.95,,283,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,215.08,76,,1585.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,203.76,72,,295.928,Percent of Total Billed Charges,72% of Total Billed Charges,212.25,75,,308.264,Percent of Total Billed charges,75% of Total Billed Charges,283,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.76,72,,295.928,Percent of Total Billed Charges,72% of Total Billed Charges,169.8,60,,246.608,Percent of Total Billed Charges,60% of Total Billed Charges,254.7,90,,7282.328,Percent of Total Billed Charges,90% of Total Billed Charges,127.35,45,,359.64,Percent of Total Billed Charges,45% of Total Billed Charges,254.7,90,,1877.336,Percent of Total Billed Charges,90% of Total billed Charges,283,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.95,65,,10874.352,Percent of total Billed Charges,65% of Total Billed Charges,124.8,44.1,,352.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,268.85,95,,1981.632,Percent of Total Billed Charges,95% of Total Billed Charges,283,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.04,88,,9875.184,Percent of Total Billed Charges,88% of Total Billed Charges,254.7,90,,1877.336,Percent of Total Billed charges,90% of Total Billed Charges,124.8,283,
TOE(S) MIN 2 VWS RT,3200000223,CDM,320,RC,,,Outpatient,,,283.00,183.95,,283,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,215.08,76,,3483.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,203.76,72,,887.528,Percent of Total Billed Charges,72% of Total Billed Charges,212.25,75,,924.512,Percent of Total Billed charges,75% of Total Billed Charges,283,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.76,72,,887.528,Percent of Total Billed Charges,72% of Total Billed Charges,169.8,60,,739.608,Percent of Total Billed Charges,60% of Total Billed Charges,254.7,90,,15056.8,Percent of Total Billed Charges,90% of Total Billed Charges,127.35,45,,5049.808,Percent of Total Billed Charges,45% of Total Billed Charges,254.7,90,,4124.864,Percent of Total Billed Charges,90% of Total billed Charges,283,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.95,65,,6981.744,Percent of total Billed Charges,65% of Total Billed Charges,124.8,44.1,,4948.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,268.85,95,,4354.024,Percent of Total Billed Charges,95% of Total Billed Charges,283,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.04,88,,6559.952,Percent of Total Billed Charges,88% of Total Billed Charges,254.7,90,,4124.864,Percent of Total Billed charges,90% of Total Billed Charges,124.8,283,
VENOGRAM EXT UNILAT,3200000224,CDM,320,RC,,,Outpatient,,,1365.64,887.67,,1365.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1037.89,76,,587.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,983.26,72,,887.528,Percent of Total Billed Charges,72% of Total Billed Charges,1024.23,75,,924.512,Percent of Total Billed charges,75% of Total Billed Charges,1365.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,983.26,72,,887.528,Percent of Total Billed Charges,72% of Total Billed Charges,819.38,60,,739.608,Percent of Total Billed Charges,60% of Total Billed Charges,1229.08,90,,3987.256,Percent of Total Billed Charges,90% of Total Billed Charges,614.54,45,,3354.52,Percent of Total Billed Charges,45% of Total Billed Charges,1229.08,90,,695.2,Percent of Total Billed Charges,90% of Total billed Charges,1365.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1365.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1365.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,887.67,65,,4654.424,Percent of total Billed Charges,65% of Total Billed Charges,602.25,44.1,,3287.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,1297.36,95,,733.816,Percent of Total Billed Charges,95% of Total Billed Charges,1365.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1201.76,88,,48284.136,Percent of Total Billed Charges,88% of Total Billed Charges,1229.08,90,,695.2,Percent of Total Billed charges,90% of Total Billed Charges,602.25,1365.64,
SCRNG BE MEDI NOT HI,3200000225,CDM,320,RC,G0106,HCPCS,Outpatient,,,857.75,557.54,,857.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,651.89,76,,906.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,928.17,350,,911.92,Fee Schedule,350% of BCBS fee schedule,928.17,350,,949.912,Fee Schedule,350% of BCBS fee schedule,857.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,928.17,561,,911.92,Fee Schedule,561% of BCBS PPO fee schedule,165.45,100,,759.928,Fee Schedule,100% of Blue ADV HMO fee schedule,771.98,90,,1666.984,Percent of Total Billed Charges,90% of Total Billed Charges,385.99,45,,24690.752,Percent of Total Billed Charges,45% of Total Billed Charges,771.98,90,,1073.52,Percent of Total Billed Charges,90% of Total billed Charges,857.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,857.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,857.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,557.54,65,,4634.24,Percent of total Billed Charges,65% of Total Billed Charges,378.27,44.1,,24196.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,814.86,95,,1133.16,Percent of Total Billed Charges,95% of Total Billed Charges,857.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,754.82,88,,47121.448,Percent of Total Billed Charges,88% of Total Billed Charges,771.98,90,,1073.52,Percent of Total Billed charges,90% of Total Billed Charges,165.45,928.17,
SCREENING BE MEDI HI,3200000226,CDM,320,RC,G0120,HCPCS,Outpatient,,,857.75,557.54,,857.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,651.89,76,,607.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,928.17,350,,988.776,Fee Schedule,350% of BCBS fee schedule,928.17,350,,1029.976,Fee Schedule,350% of BCBS fee schedule,857.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,928.17,561,,988.776,Fee Schedule,561% of BCBS PPO fee schedule,165.45,100,,823.984,Fee Schedule,100% of Blue ADV HMO fee schedule,771.98,90,,3413.344,Percent of Total Billed Charges,90% of Total Billed Charges,385.99,45,,24096.2,Percent of Total Billed Charges,45% of Total Billed Charges,771.98,90,,719.28,Percent of Total Billed Charges,90% of Total billed Charges,857.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,857.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,857.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,557.54,65,,1300,Percent of total Billed Charges,65% of Total Billed Charges,378.27,44.1,,23614.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,814.86,95,,759.24,Percent of Total Billed Charges,95% of Total Billed Charges,857.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,754.82,88,,46178.416,Percent of Total Billed Charges,88% of Total Billed Charges,771.98,90,,719.28,Percent of Total Billed charges,90% of Total Billed Charges,165.45,928.17,
XR LE ANGIO NON SELECTIVE,3200000227,CDM,320,RC,G0278,HCPCS,Outpatient,,,1563.15,1016.05,,1563.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1187.99,76,,8528.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1563.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1406.84,90,,9618.688,Percent of Total Billed Charges,90% of Total Billed Charges,703.42,45,,23613.96,Percent of Total Billed Charges,45% of Total Billed Charges,1406.84,90,,10099.624,Percent of Total Billed Charges,90% of Total billed Charges,1563.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1563.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1563.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1016.05,65,,604.264,Percent of total Billed Charges,65% of Total Billed Charges,689.35,44.1,,23141.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,1484.99,95,,10660.712,Percent of Total Billed Charges,95% of Total Billed Charges,1563.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1375.57,88,,7120.496,Percent of Total Billed Charges,88% of Total Billed Charges,1406.84,90,,10099.624,Percent of Total Billed charges,90% of Total Billed Charges,689.35,1563.15,
CHOLANGIOGRAM INJECT W/IMAGING,3200000229,CDM,320,RC,,,Outpatient,,,190.73,123.97,,190.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.95,76,,41699.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,137.33,72,,677.592,Percent of Total Billed Charges,72% of Total Billed Charges,143.05,75,,705.824,Percent of Total Billed charges,75% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.33,72,,677.592,Percent of Total Billed Charges,72% of Total Billed Charges,114.44,60,,564.656,Percent of Total Billed Charges,60% of Total Billed Charges,171.66,90,,3413.344,Percent of Total Billed Charges,90% of Total Billed Charges,85.83,45,,7528.4,Percent of Total Billed Charges,45% of Total Billed Charges,171.66,90,,49381.504,Percent of Total Billed Charges,90% of Total billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.97,65,,1702.128,Percent of total Billed Charges,65% of Total Billed Charges,84.11,44.1,,7377.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,181.19,95,,52124.92,Percent of Total Billed Charges,95% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.84,88,,3898.656,Percent of Total Billed Charges,88% of Total Billed Charges,171.66,90,,49381.504,Percent of Total Billed charges,90% of Total Billed Charges,84.11,190.73,
ABCESS FISTULA/SINUS RS&I,3200000230,CDM,320,RC,,,Outpatient,,,618.00,401.70,,618,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,469.68,76,,40695.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,444.96,72,,757.6,Percent of Total Billed Charges,72% of Total Billed Charges,463.5,75,,789.168,Percent of Total Billed charges,75% of Total Billed Charges,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.96,72,,757.6,Percent of Total Billed Charges,72% of Total Billed Charges,370.8,60,,631.336,Percent of Total Billed Charges,60% of Total Billed Charges,556.2,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,278.1,45,,1993.632,Percent of Total Billed Charges,45% of Total Billed Charges,556.2,90,,48192.392,Percent of Total Billed Charges,90% of Total billed Charges,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.7,65,,1705,Percent of total Billed Charges,65% of Total Billed Charges,272.54,44.1,,1953.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,587.1,95,,50869.752,Percent of Total Billed Charges,95% of Total Billed Charges,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,543.84,88,,1629.936,Percent of Total Billed Charges,88% of Total Billed Charges,556.2,90,,48192.392,Percent of Total Billed charges,90% of Total Billed Charges,272.54,618,
MECH RMVL LUMEN OBSTRUCT RS&I,3200000234,CDM,320,RC,,,Outpatient,,,211.95,137.77,,211.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.08,76,,12714.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,152.6,72,,9210.24,Percent of Total Billed Charges,72% of Total Billed Charges,158.96,75,,9594,Percent of Total Billed charges,75% of Total Billed Charges,211.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.6,72,,9210.24,Percent of Total Billed Charges,72% of Total Billed Charges,127.17,60,,7675.2,Percent of Total Billed Charges,60% of Total Billed Charges,190.76,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,95.38,45,,4809.344,Percent of Total Billed Charges,45% of Total Billed Charges,190.76,90,,15056.8,Percent of Total Billed Charges,90% of Total billed Charges,211.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.77,65,,536.04,Percent of total Billed Charges,65% of Total Billed Charges,93.47,44.1,,4713.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,201.35,95,,15893.288,Percent of Total Billed Charges,95% of Total Billed Charges,211.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.52,88,,1629.936,Percent of Total Billed Charges,88% of Total Billed Charges,190.76,90,,15056.8,Percent of Total Billed charges,90% of Total Billed Charges,93.47,211.95,
REM OBSTRUCTION FROM CVD RS&I,3200000235,CDM,320,RC,,,Outpatient,,,552.38,359.05,,552.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,419.81,76,,3367.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,397.71,72,,4968.712,Percent of Total Billed Charges,72% of Total Billed Charges,414.29,75,,5175.744,Percent of Total Billed charges,75% of Total Billed Charges,552.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.71,72,,4968.712,Percent of Total Billed Charges,72% of Total Billed Charges,331.43,60,,4140.592,Percent of Total Billed Charges,60% of Total Billed Charges,497.14,90,,687.432,Percent of Total Billed Charges,90% of Total Billed Charges,248.57,45,,833.488,Percent of Total Billed Charges,45% of Total Billed Charges,497.14,90,,3987.256,Percent of Total Billed Charges,90% of Total billed Charges,552.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.05,65,,583.048,Percent of total Billed Charges,65% of Total Billed Charges,243.6,44.1,,816.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,524.76,95,,4208.776,Percent of Total Billed Charges,95% of Total Billed Charges,552.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,486.09,88,,3337.488,Percent of Total Billed Charges,88% of Total Billed Charges,497.14,90,,3987.256,Percent of Total Billed charges,90% of Total Billed Charges,243.6,552.38,
MM Stereotactic loc BI,3200000236,CDM,320,RC,,,Outpatient,,,3542.00,2302.30,,3542,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2691.92,76,,1407.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2550.24,72,,696.96,Percent of Total Billed Charges,72% of Total Billed Charges,2656.5,75,,726,Percent of Total Billed charges,75% of Total Billed Charges,3542,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2550.24,72,,696.96,Percent of Total Billed Charges,72% of Total Billed Charges,2125.2,60,,580.8,Percent of Total Billed Charges,60% of Total Billed Charges,3187.8,90,,687.432,Percent of Total Billed Charges,90% of Total Billed Charges,1593.9,45,,1706.672,Percent of Total Billed Charges,45% of Total Billed Charges,3187.8,90,,1666.984,Percent of Total Billed Charges,90% of Total billed Charges,3542,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3542,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3542,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2302.3,65,,582.472,Percent of total Billed Charges,65% of Total Billed Charges,1562.02,44.1,,1672.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,3364.9,95,,1759.592,Percent of Total Billed Charges,95% of Total Billed Charges,3542,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3116.96,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,3187.8,90,,1666.984,Percent of Total Billed charges,90% of Total Billed Charges,1562.02,3542,
MM Stereotactic Loc Each Addtl,3200000237,CDM,320,RC,,,Outpatient,,,202.08,131.35,,202.08,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,153.58,76,,2882.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,145.5,72,,761.416,Percent of Total Billed Charges,72% of Total Billed Charges,151.56,75,,793.144,Percent of Total Billed charges,75% of Total Billed Charges,202.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.5,72,,761.416,Percent of Total Billed Charges,72% of Total Billed Charges,121.25,60,,634.512,Percent of Total Billed Charges,60% of Total Billed Charges,181.87,90,,1734.48,Percent of Total Billed Charges,90% of Total Billed Charges,90.94,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,181.87,90,,3413.344,Percent of Total Billed Charges,90% of Total billed Charges,202.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.35,65,,1131.52,Percent of total Billed Charges,65% of Total Billed Charges,89.12,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,191.98,95,,3602.968,Percent of Total Billed Charges,95% of Total Billed Charges,202.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.83,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,181.87,90,,3413.344,Percent of Total Billed charges,90% of Total Billed Charges,89.12,202.08,
Fluoroscopy up to 1hr phys tim,3200000238,CDM,320,RC,,,Outpatient,,,317.00,206.05,,317,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,240.92,76,,8122.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,228.24,72,,807.552,Percent of Total Billed Charges,72% of Total Billed Charges,237.75,75,,841.2,Percent of Total Billed charges,75% of Total Billed Charges,317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.24,72,,807.552,Percent of Total Billed Charges,72% of Total Billed Charges,190.2,60,,672.96,Percent of Total Billed Charges,60% of Total Billed Charges,285.3,90,,1734.48,Percent of Total Billed Charges,90% of Total Billed Charges,142.65,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,285.3,90,,9618.688,Percent of Total Billed Charges,90% of Total billed Charges,317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.05,65,,464.36,Percent of total Billed Charges,65% of Total Billed Charges,139.8,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,301.15,95,,10153.064,Percent of Total Billed Charges,95% of Total Billed Charges,317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.96,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,285.3,90,,9618.688,Percent of Total Billed charges,90% of Total Billed Charges,139.8,317,
IR Genicular Nerve Block,3200000240,CDM,320,RC,,,Outpatient,,,1405.00,913.25,,1405,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1067.8,76,,2882.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1011.6,72,,4132.8,Percent of Total Billed Charges,72% of Total Billed Charges,1053.75,75,,4305,Percent of Total Billed charges,75% of Total Billed Charges,1405,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1011.6,72,,4132.8,Percent of Total Billed Charges,72% of Total Billed Charges,843,60,,3444,Percent of Total Billed Charges,60% of Total Billed Charges,1264.5,90,,1734.48,Percent of Total Billed Charges,90% of Total Billed Charges,632.25,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,1264.5,90,,3413.344,Percent of Total Billed Charges,90% of Total billed Charges,1405,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1405,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1405,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.25,65,,1047.424,Percent of total Billed Charges,65% of Total Billed Charges,619.61,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,1334.75,95,,3602.968,Percent of Total Billed Charges,95% of Total Billed Charges,1405,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1236.4,88,,672.16,Percent of Total Billed Charges,88% of Total Billed Charges,1264.5,90,,3413.344,Percent of Total Billed charges,90% of Total Billed Charges,619.61,1405,
NJX AA&/STRD PLTR COM DG NRV,3200000241,CDM,320,RC,,,Outpatient,,,1405.00,913.25,,1405,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1067.8,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1011.6,72,,3783.424,Percent of Total Billed Charges,72% of Total Billed Charges,1053.75,75,,3941.064,Percent of Total Billed charges,75% of Total Billed Charges,1405,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1011.6,72,,3783.424,Percent of Total Billed Charges,72% of Total Billed Charges,843,60,,3152.848,Percent of Total Billed Charges,60% of Total Billed Charges,1264.5,90,,601.704,Percent of Total Billed Charges,90% of Total Billed Charges,632.25,45,,343.72,Percent of Total Billed Charges,45% of Total Billed Charges,1264.5,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,1405,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1405,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1405,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.25,65,,556.672,Percent of total Billed Charges,65% of Total Billed Charges,619.61,44.1,,336.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,1334.75,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,1405,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1236.4,88,,672.16,Percent of Total Billed Charges,88% of Total Billed Charges,1264.5,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,619.61,1405,
ARTHOGRAM SHOULDER LT,3220000001,CDM,322,RC,,,Outpatient,,,1240.31,806.20,,1240.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,942.64,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,893.02,72,,6692.056,Percent of Total Billed Charges,72% of Total Billed Charges,930.23,75,,6970.888,Percent of Total Billed charges,75% of Total Billed Charges,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,893.02,72,,6692.056,Percent of Total Billed Charges,72% of Total Billed Charges,744.19,60,,5576.712,Percent of Total Billed Charges,60% of Total Billed Charges,1116.28,90,,369.912,Percent of Total Billed Charges,90% of Total Billed Charges,558.14,45,,343.72,Percent of Total Billed Charges,45% of Total Billed Charges,1116.28,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,806.2,65,,519.48,Percent of total Billed Charges,65% of Total Billed Charges,546.98,44.1,,336.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,1178.29,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1091.47,88,,1695.936,Percent of Total Billed Charges,88% of Total Billed Charges,1116.28,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,546.98,1240.31,
ARTHROGRAM SHLDR RT,3220000002,CDM,322,RC,,,Outpatient,,,1179.00,766.35,,1179,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,896.04,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,848.88,72,,3615.92,Percent of Total Billed Charges,72% of Total Billed Charges,884.25,75,,3766.584,Percent of Total Billed charges,75% of Total Billed Charges,1179,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,848.88,72,,3615.92,Percent of Total Billed Charges,72% of Total Billed Charges,707.4,60,,3013.264,Percent of Total Billed Charges,60% of Total Billed Charges,1061.1,90,,1984.504,Percent of Total Billed Charges,90% of Total Billed Charges,530.55,45,,867.24,Percent of Total Billed Charges,45% of Total Billed Charges,1061.1,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,1179,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1179,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1179,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,766.35,65,,1067.488,Percent of total Billed Charges,65% of Total Billed Charges,519.94,44.1,,849.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,1120.05,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,1179,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1037.52,88,,1695.936,Percent of Total Billed Charges,88% of Total Billed Charges,1061.1,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,519.94,1179,
ARTHROGRAM OF THE HIP  LT,3220000003,CDM,322,RC,,,Outpatient,,,1240.31,806.20,,1240.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,942.64,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,893.02,72,,3615.92,Percent of Total Billed Charges,72% of Total Billed Charges,930.23,75,,3766.584,Percent of Total Billed charges,75% of Total Billed Charges,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,893.02,72,,3615.92,Percent of Total Billed Charges,72% of Total Billed Charges,744.19,60,,3013.264,Percent of Total Billed Charges,60% of Total Billed Charges,1116.28,90,,1984.504,Percent of Total Billed Charges,90% of Total Billed Charges,558.14,45,,867.24,Percent of Total Billed Charges,45% of Total Billed Charges,1116.28,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,806.2,65,,1047.424,Percent of total Billed Charges,65% of Total Billed Charges,546.98,44.1,,849.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,1178.29,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1091.47,88,,1785.168,Percent of Total Billed Charges,88% of Total Billed Charges,1116.28,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,546.98,1240.31,
ARTHROGRAM OF THE HIP  RT,3220000004,CDM,322,RC,,,Outpatient,,,1179.00,766.35,,1179,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,896.04,76,,580.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,848.88,72,,2937.056,Percent of Total Billed Charges,72% of Total Billed Charges,884.25,75,,3059.44,Percent of Total Billed charges,75% of Total Billed Charges,1179,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,848.88,72,,2937.056,Percent of Total Billed Charges,72% of Total Billed Charges,707.4,60,,2447.552,Percent of Total Billed Charges,60% of Total Billed Charges,1061.1,90,,1984.504,Percent of Total Billed Charges,90% of Total Billed Charges,530.55,45,,912.872,Percent of Total Billed Charges,45% of Total Billed Charges,1061.1,90,,687.432,Percent of Total Billed Charges,90% of Total billed Charges,1179,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1179,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1179,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,766.35,65,,556.672,Percent of total Billed Charges,65% of Total Billed Charges,519.94,44.1,,894.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,1120.05,95,,725.624,Percent of Total Billed Charges,95% of Total Billed Charges,1179,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1037.52,88,,1695.936,Percent of Total Billed Charges,88% of Total Billed Charges,1061.1,90,,687.432,Percent of Total Billed charges,90% of Total Billed Charges,519.94,1179,
ARTHOGRAM KNEE LT,3220000005,CDM,322,RC,,,Outpatient,,,1240.31,806.20,,1240.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,942.64,76,,580.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,893.02,72,,911.92,Percent of Total Billed Charges,72% of Total Billed Charges,930.23,75,,949.912,Percent of Total Billed charges,75% of Total Billed Charges,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,893.02,72,,911.92,Percent of Total Billed Charges,72% of Total Billed Charges,744.19,60,,759.928,Percent of Total Billed Charges,60% of Total Billed Charges,1116.28,90,,1925.76,Percent of Total Billed Charges,90% of Total Billed Charges,558.14,45,,867.24,Percent of Total Billed Charges,45% of Total Billed Charges,1116.28,90,,687.432,Percent of Total Billed Charges,90% of Total billed Charges,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,806.2,65,,1047.424,Percent of total Billed Charges,65% of Total Billed Charges,546.98,44.1,,849.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,1178.29,95,,725.624,Percent of Total Billed Charges,95% of Total Billed Charges,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1091.47,88,,588.336,Percent of Total Billed Charges,88% of Total Billed Charges,1116.28,90,,687.432,Percent of Total Billed charges,90% of Total Billed Charges,546.98,1240.31,
ARTHROGRAM KNEE RT,3220000006,CDM,322,RC,,,Outpatient,,,1240.31,806.20,,1240.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,942.64,76,,1464.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,893.02,72,,911.92,Percent of Total Billed Charges,72% of Total Billed Charges,930.23,75,,949.912,Percent of Total Billed charges,75% of Total Billed Charges,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,893.02,72,,911.92,Percent of Total Billed Charges,72% of Total Billed Charges,744.19,60,,759.928,Percent of Total Billed Charges,60% of Total Billed Charges,1116.28,90,,4775.04,Percent of Total Billed Charges,90% of Total Billed Charges,558.14,45,,300.856,Percent of Total Billed Charges,45% of Total Billed Charges,1116.28,90,,1734.48,Percent of Total Billed Charges,90% of Total billed Charges,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,806.2,65,,546.352,Percent of total Billed Charges,65% of Total Billed Charges,546.98,44.1,,294.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,1178.29,95,,1830.84,Percent of Total Billed Charges,95% of Total Billed Charges,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1091.47,88,,361.696,Percent of Total Billed Charges,88% of Total Billed Charges,1116.28,90,,1734.48,Percent of Total Billed charges,90% of Total Billed Charges,546.98,1240.31,
ANKLE ARTHROGRAM RS & I,3220000007,CDM,322,RC,,,Outpatient,,,871.00,566.15,,871,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,661.96,76,,1464.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,627.12,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,653.25,75,,1200,Percent of Total Billed charges,75% of Total Billed Charges,871,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,627.12,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,522.6,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,783.9,90,,2023.92,Percent of Total Billed Charges,90% of Total Billed Charges,391.95,45,,184.96,Percent of Total Billed Charges,45% of Total Billed Charges,783.9,90,,1734.48,Percent of Total Billed Charges,90% of Total billed Charges,871,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,871,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,871,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.15,65,,1067.488,Percent of total Billed Charges,65% of Total Billed Charges,384.11,44.1,,181.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,827.45,95,,1830.84,Percent of Total Billed Charges,95% of Total Billed Charges,871,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,766.48,88,,1940.4,Percent of Total Billed Charges,88% of Total Billed Charges,783.9,90,,1734.48,Percent of Total Billed charges,90% of Total Billed Charges,384.11,871,
TMJ JT ARTHROGRAM RS & I,3220000008,CDM,322,RC,,,Outpatient,,,559.38,363.60,,559.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,425.13,76,,1541.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,402.75,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,419.54,75,,1200,Percent of Total Billed charges,75% of Total Billed Charges,559.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,402.75,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,335.63,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,503.44,90,,16276.864,Percent of Total Billed Charges,90% of Total Billed Charges,251.72,45,,992.248,Percent of Total Billed Charges,45% of Total Billed Charges,503.44,90,,1825.744,Percent of Total Billed Charges,90% of Total billed Charges,559.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.6,65,,1067.488,Percent of total Billed Charges,65% of Total Billed Charges,246.69,44.1,,972.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,531.41,95,,1927.168,Percent of Total Billed Charges,95% of Total Billed Charges,559.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.25,88,,1940.4,Percent of Total Billed Charges,88% of Total Billed Charges,503.44,90,,1825.744,Percent of Total Billed charges,90% of Total Billed Charges,246.69,559.38,
SHOULDER ARTHROGRAM RS & I,3220000009,CDM,322,RC,,,Outpatient,,,1240.31,806.20,,1240.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,942.64,76,,1464.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,893.02,72,,248.936,Percent of Total Billed Charges,72% of Total Billed Charges,930.23,75,,259.312,Percent of Total Billed charges,75% of Total Billed Charges,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,893.02,72,,248.936,Percent of Total Billed Charges,72% of Total Billed Charges,744.19,60,,207.448,Percent of Total Billed Charges,60% of Total Billed Charges,1116.28,90,,14913.912,Percent of Total Billed Charges,90% of Total Billed Charges,558.14,45,,992.248,Percent of Total Billed Charges,45% of Total Billed Charges,1116.28,90,,1734.48,Percent of Total Billed Charges,90% of Total billed Charges,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,806.2,65,,64.208,Percent of total Billed Charges,65% of Total Billed Charges,546.98,44.1,,972.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,1178.29,95,,1830.84,Percent of Total Billed Charges,95% of Total Billed Charges,1240.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1091.47,88,,1940.4,Percent of Total Billed Charges,88% of Total Billed Charges,1116.28,90,,1734.48,Percent of Total Billed charges,90% of Total Billed Charges,546.98,1240.31,
ELBOW ARTHROGRAM RS & I,3220000010,CDM,322,RC,,,Outpatient,,,916.48,595.71,,916.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,696.52,76,,508.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,659.87,72,,726.912,Percent of Total Billed Charges,72% of Total Billed Charges,687.36,75,,757.2,Percent of Total Billed charges,75% of Total Billed Charges,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,659.87,72,,726.912,Percent of Total Billed Charges,72% of Total Billed Charges,549.89,60,,605.76,Percent of Total Billed Charges,60% of Total Billed Charges,824.83,90,,15056.8,Percent of Total Billed Charges,90% of Total Billed Charges,412.42,45,,992.248,Percent of Total Billed Charges,45% of Total Billed Charges,824.83,90,,601.704,Percent of Total Billed Charges,90% of Total billed Charges,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,595.71,65,,10477.632,Percent of total Billed Charges,65% of Total Billed Charges,404.17,44.1,,972.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,870.66,95,,635.136,Percent of Total Billed Charges,95% of Total Billed Charges,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,806.5,88,,1882.968,Percent of Total Billed Charges,88% of Total Billed Charges,824.83,90,,601.704,Percent of Total Billed charges,90% of Total Billed Charges,404.17,916.48,
WRIST ARTHROGRAM RS & I,3220000011,CDM,322,RC,,,Outpatient,,,916.48,595.71,,916.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,696.52,76,,312.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,659.87,72,,1981.328,Percent of Total Billed Charges,72% of Total Billed Charges,687.36,75,,2063.88,Percent of Total Billed charges,75% of Total Billed Charges,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,659.87,72,,1981.328,Percent of Total Billed Charges,72% of Total Billed Charges,549.89,60,,1651.104,Percent of Total Billed Charges,60% of Total Billed Charges,824.83,90,,9667.032,Percent of Total Billed Charges,90% of Total Billed Charges,412.42,45,,962.88,Percent of Total Billed Charges,45% of Total Billed Charges,824.83,90,,369.912,Percent of Total Billed Charges,90% of Total billed Charges,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,595.71,65,,1739.968,Percent of total Billed Charges,65% of Total Billed Charges,404.17,44.1,,943.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,870.66,95,,390.464,Percent of Total Billed Charges,95% of Total Billed Charges,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,806.5,88,,4668.928,Percent of Total Billed Charges,88% of Total Billed Charges,824.83,90,,369.912,Percent of Total Billed charges,90% of Total Billed Charges,404.17,916.48,
VISCERAL ANGIOGRAM SEL/SUP SEL,3230000002,CDM,323,RC,,,Outpatient,,,4846.00,3149.90,,4846,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3682.96,76,,1675.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3489.12,72,,456.192,Percent of Total Billed Charges,72% of Total Billed Charges,3634.5,75,,475.2,Percent of Total Billed charges,75% of Total Billed Charges,4846,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3489.12,72,,456.192,Percent of Total Billed Charges,72% of Total Billed Charges,2907.6,60,,380.16,Percent of Total Billed Charges,60% of Total Billed Charges,4361.4,90,,6444.592,Percent of Total Billed Charges,90% of Total Billed Charges,2180.7,45,,2387.52,Percent of Total Billed Charges,45% of Total Billed Charges,4361.4,90,,1984.504,Percent of Total Billed Charges,90% of Total billed Charges,4846,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4846,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4846,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3149.9,65,,1882.92,Percent of total Billed Charges,65% of Total Billed Charges,2137.09,44.1,,2339.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,4603.7,95,,2094.752,Percent of Total Billed Charges,95% of Total Billed Charges,4846,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4264.48,88,,1978.944,Percent of Total Billed Charges,88% of Total Billed Charges,4361.4,90,,1984.504,Percent of Total Billed charges,90% of Total Billed Charges,2137.09,4846,
DESCENDING THORACIC AORTOGRAM,3230000005,CDM,323,RC,,,Outpatient,,,2787.75,1812.04,,2787.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2118.69,76,,1675.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2007.18,72,,1024.048,Percent of Total Billed Charges,72% of Total Billed Charges,2090.81,75,,1066.72,Percent of Total Billed charges,75% of Total Billed Charges,2787.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2007.18,72,,1024.048,Percent of Total Billed Charges,72% of Total Billed Charges,1672.65,60,,853.376,Percent of Total Billed Charges,60% of Total Billed Charges,2508.98,90,,6416.64,Percent of Total Billed Charges,90% of Total Billed Charges,1254.49,45,,1011.96,Percent of Total Billed Charges,45% of Total Billed Charges,2508.98,90,,1984.504,Percent of Total Billed Charges,90% of Total billed Charges,2787.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2787.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2787.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1812.04,65,,2090.824,Percent of total Billed Charges,65% of Total Billed Charges,1229.4,44.1,,991.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,2648.36,95,,2094.752,Percent of Total Billed Charges,95% of Total Billed Charges,2787.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2453.22,88,,15915.16,Percent of Total Billed Charges,88% of Total Billed Charges,2508.98,90,,1984.504,Percent of Total Billed charges,90% of Total Billed Charges,1229.4,2787.75,
2 VW CXR TDH,3240000001,CDM,324,RC,,,Outpatient,,,437.00,284.05,,437,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,332.12,76,,1675.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,314.64,72,,1600.584,Percent of Total Billed Charges,72% of Total Billed Charges,327.75,75,,1667.272,Percent of Total Billed charges,75% of Total Billed Charges,437,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.64,72,,1600.584,Percent of Total Billed Charges,72% of Total Billed Charges,262.2,60,,1333.816,Percent of Total Billed Charges,60% of Total Billed Charges,393.3,90,,1800,Percent of Total Billed Charges,90% of Total Billed Charges,196.65,45,,8138.432,Percent of Total Billed Charges,45% of Total Billed Charges,393.3,90,,1984.504,Percent of Total Billed Charges,90% of Total billed Charges,437,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.05,65,,3053.96,Percent of total Billed Charges,65% of Total Billed Charges,192.72,44.1,,7975.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,415.15,95,,2094.752,Percent of Total Billed Charges,95% of Total Billed Charges,437,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.56,88,,14582.496,Percent of Total Billed Charges,88% of Total Billed Charges,393.3,90,,1984.504,Percent of Total Billed charges,90% of Total Billed Charges,192.72,437,
THYROID UPTAKES,3400000001,CDM,340,RC,,,Outpatient,,,1055.09,685.81,,1055.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,801.87,76,,1626.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,759.66,72,,167.016,Percent of Total Billed Charges,72% of Total Billed Charges,791.32,75,,173.976,Percent of Total Billed charges,75% of Total Billed Charges,1055.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759.66,72,,167.016,Percent of Total Billed Charges,72% of Total Billed Charges,633.05,60,,139.184,Percent of Total Billed Charges,60% of Total Billed Charges,949.58,90,,836.672,Percent of Total Billed Charges,90% of Total Billed Charges,474.79,45,,7456.96,Percent of Total Billed Charges,45% of Total Billed Charges,949.58,90,,1925.76,Percent of Total Billed Charges,90% of Total billed Charges,1055.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.81,65,,3055.688,Percent of total Billed Charges,65% of Total Billed Charges,465.29,44.1,,7307.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,1002.34,95,,2032.752,Percent of Total Billed Charges,95% of Total Billed Charges,1055.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,928.48,88,,14722.2,Percent of Total Billed Charges,88% of Total Billed Charges,949.58,90,,1925.76,Percent of Total Billed charges,90% of Total Billed Charges,465.29,1055.09,
THYROID SCAN,3400000002,CDM,340,RC,,,Outpatient,,,780.57,507.37,,780.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,593.23,76,,4032.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,562.01,72,,522.64,Percent of Total Billed Charges,72% of Total Billed Charges,585.43,75,,544.416,Percent of Total Billed charges,75% of Total Billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.01,72,,522.64,Percent of Total Billed Charges,72% of Total Billed Charges,468.34,60,,435.536,Percent of Total Billed Charges,60% of Total Billed Charges,702.51,90,,735.856,Percent of Total Billed Charges,90% of Total Billed Charges,351.26,45,,7528.4,Percent of Total Billed Charges,45% of Total Billed Charges,702.51,90,,4775.04,Percent of Total Billed Charges,90% of Total billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.37,65,,3059.68,Percent of total Billed Charges,65% of Total Billed Charges,344.23,44.1,,7377.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,741.54,95,,5040.32,Percent of Total Billed Charges,95% of Total Billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,686.9,88,,9452.208,Percent of Total Billed Charges,88% of Total Billed Charges,702.51,90,,4775.04,Percent of Total Billed charges,90% of Total Billed Charges,344.23,780.57,
THYROID SCAN & UPTAKES,3400000003,CDM,340,RC,,,Outpatient,,,1863.00,1210.95,,1863,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1415.88,76,,1709.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1341.36,72,,313.712,Percent of Total Billed Charges,72% of Total Billed Charges,1397.25,75,,326.784,Percent of Total Billed charges,75% of Total Billed Charges,1863,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1341.36,72,,313.712,Percent of Total Billed Charges,72% of Total Billed Charges,1117.8,60,,261.424,Percent of Total Billed Charges,60% of Total Billed Charges,1676.7,90,,2356.792,Percent of Total Billed Charges,90% of Total Billed Charges,838.35,45,,4833.512,Percent of Total Billed Charges,45% of Total Billed Charges,1676.7,90,,2023.92,Percent of Total Billed Charges,90% of Total billed Charges,1863,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1863,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1863,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1210.95,65,,37.84,Percent of total Billed Charges,65% of Total Billed Charges,821.58,44.1,,4736.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,1769.85,95,,2136.36,Percent of Total Billed Charges,95% of Total Billed Charges,1863,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1639.44,88,,6301.376,Percent of Total Billed Charges,88% of Total Billed Charges,1676.7,90,,2023.92,Percent of Total Billed charges,90% of Total Billed Charges,821.58,1863,
NM PARATHYROID W SPECT,3400000004,CDM,340,RC,,,Outpatient,,,926.79,602.41,,926.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,704.36,76,,13744.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,667.29,72,,1736.832,Percent of Total Billed Charges,72% of Total Billed Charges,695.09,75,,1809.208,Percent of Total Billed charges,75% of Total Billed Charges,926.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,667.29,72,,1736.832,Percent of Total Billed Charges,72% of Total Billed Charges,556.07,60,,1447.36,Percent of Total Billed Charges,60% of Total Billed Charges,834.11,90,,2360.768,Percent of Total Billed Charges,90% of Total Billed Charges,417.06,45,,3222.296,Percent of Total Billed Charges,45% of Total Billed Charges,834.11,90,,16276.864,Percent of Total Billed Charges,90% of Total billed Charges,926.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,926.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,926.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,602.41,65,,8.32,Percent of total Billed Charges,65% of Total Billed Charges,408.71,44.1,,3157.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,880.45,95,,17181.136,Percent of Total Billed Charges,95% of Total Billed Charges,926.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,815.58,88,,6274.048,Percent of Total Billed Charges,88% of Total Billed Charges,834.11,90,,16276.864,Percent of Total Billed charges,90% of Total Billed Charges,408.71,926.79,
NM RESTING MUGA BY CARDIO,3410000001,CDM,341,RC,,,Outpatient,,,1647.00,1070.55,,1647,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1251.72,76,,12593.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1185.84,72,,1540.608,Percent of Total Billed Charges,72% of Total Billed Charges,1235.25,75,,1604.8,Percent of Total Billed charges,75% of Total Billed Charges,1647,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1185.84,72,,1540.608,Percent of Total Billed Charges,72% of Total Billed Charges,988.2,60,,1283.84,Percent of Total Billed Charges,60% of Total Billed Charges,1482.3,90,,2990.248,Percent of Total Billed Charges,90% of Total Billed Charges,741.15,45,,3208.32,Percent of Total Billed Charges,45% of Total Billed Charges,1482.3,90,,14913.912,Percent of Total Billed Charges,90% of Total billed Charges,1647,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1647,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1647,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1070.55,65,,49.92,Percent of total Billed Charges,65% of Total Billed Charges,726.33,44.1,,3144.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,1564.65,95,,15742.464,Percent of Total Billed Charges,95% of Total Billed Charges,1647,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1449.36,88,,1760,Percent of Total Billed Charges,88% of Total Billed Charges,1482.3,90,,14913.912,Percent of Total Billed charges,90% of Total Billed Charges,726.33,1647,
NM THYD CARA LMTD TH,3410000002,CDM,341,RC,,,Outpatient,,,1003.28,652.13,,1003.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,762.49,76,,12714.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,722.36,72,,3831.192,Percent of Total Billed Charges,72% of Total Billed Charges,752.46,75,,3990.832,Percent of Total Billed charges,75% of Total Billed Charges,1003.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,722.36,72,,3831.192,Percent of Total Billed Charges,72% of Total Billed Charges,601.97,60,,3192.664,Percent of Total Billed Charges,60% of Total Billed Charges,902.95,90,,1133.544,Percent of Total Billed Charges,90% of Total Billed Charges,451.48,45,,900,Percent of Total Billed Charges,45% of Total Billed Charges,902.95,90,,15056.8,Percent of Total Billed Charges,90% of Total billed Charges,1003.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1003.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1003.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,652.13,65,,2454.92,Percent of total Billed Charges,65% of Total Billed Charges,442.45,44.1,,882,Percent of Total Billed Charges,44.1% of Total Billed Charges,953.12,95,,15893.288,Percent of Total Billed Charges,95% of Total Billed Charges,1003.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,882.89,88,,818.08,Percent of Total Billed Charges,88% of Total Billed Charges,902.95,90,,15056.8,Percent of Total Billed charges,90% of Total Billed Charges,442.45,1003.28,
NM THYRD CA WB THY W,3410000003,CDM,341,RC,,,Outpatient,,,1560.04,1014.03,,1560.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1185.63,76,,8163.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1123.23,72,,6682.432,Percent of Total Billed Charges,72% of Total Billed Charges,1170.03,75,,6960.872,Percent of Total Billed charges,75% of Total Billed Charges,1560.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.23,72,,6682.432,Percent of Total Billed Charges,72% of Total Billed Charges,936.02,60,,5568.696,Percent of Total Billed Charges,60% of Total Billed Charges,1404.04,90,,742.208,Percent of Total Billed Charges,90% of Total Billed Charges,702.02,45,,418.336,Percent of Total Billed Charges,45% of Total Billed Charges,1404.04,90,,9667.032,Percent of Total Billed Charges,90% of Total billed Charges,1560.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1560.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1560.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1014.03,65,,4207.84,Percent of total Billed Charges,65% of Total Billed Charges,687.98,44.1,,409.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,1482.04,95,,10204.088,Percent of Total Billed Charges,95% of Total Billed Charges,1560.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1372.84,88,,719.504,Percent of Total Billed Charges,88% of Total Billed Charges,1404.04,90,,9667.032,Percent of Total Billed charges,90% of Total Billed Charges,687.98,1560.04,
NM PARATHYROID SCAN,3410000004,CDM,341,RC,,,Outpatient,,,1975.00,1283.75,,1975,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1501,76,,5442.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1422,72,,6682.432,Percent of Total Billed Charges,72% of Total Billed Charges,1481.25,75,,6960.872,Percent of Total Billed charges,75% of Total Billed Charges,1975,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1422,72,,6682.432,Percent of Total Billed Charges,72% of Total Billed Charges,1185,60,,5568.696,Percent of Total Billed Charges,60% of Total Billed Charges,1777.5,90,,807.296,Percent of Total Billed Charges,90% of Total Billed Charges,888.75,45,,367.928,Percent of Total Billed Charges,45% of Total Billed Charges,1777.5,90,,6444.592,Percent of Total Billed Charges,90% of Total billed Charges,1975,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1975,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1975,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1283.75,65,,5147.48,Percent of total Billed Charges,65% of Total Billed Charges,870.98,44.1,,360.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,1876.25,95,,6802.624,Percent of Total Billed Charges,95% of Total Billed Charges,1975,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1738,88,,2304.416,Percent of Total Billed Charges,88% of Total Billed Charges,1777.5,90,,6444.592,Percent of Total Billed charges,90% of Total Billed Charges,870.98,1975,
NM LYMPH NODE SCAN,3410000005,CDM,341,RC,,,Outpatient,,,1500.00,975.00,,1500,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1140,76,,5418.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1080,72,,1387.584,Percent of Total Billed Charges,72% of Total Billed Charges,1125,75,,1445.4,Percent of Total Billed charges,75% of Total Billed Charges,1500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1080,72,,1387.584,Percent of Total Billed Charges,72% of Total Billed Charges,900,60,,1156.32,Percent of Total Billed Charges,60% of Total Billed Charges,1350,90,,806.504,Percent of Total Billed Charges,90% of Total Billed Charges,675,45,,1178.392,Percent of Total Billed Charges,45% of Total Billed Charges,1350,90,,6416.64,Percent of Total Billed Charges,90% of Total billed Charges,1500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,975,65,,2236,Percent of total Billed Charges,65% of Total Billed Charges,661.5,44.1,,1154.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,1425,95,,6773.12,Percent of Total Billed Charges,95% of Total Billed Charges,1500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1320,88,,2308.304,Percent of Total Billed Charges,88% of Total Billed Charges,1350,90,,6416.64,Percent of Total Billed charges,90% of Total Billed Charges,661.5,1500,
NM LIVER IMGE STAT L,3410000006,CDM,341,RC,,,Outpatient,,,1114.63,724.51,,1114.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,847.12,76,,1520,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,802.53,72,,875.52,Percent of Total Billed Charges,72% of Total Billed Charges,835.97,75,,912,Percent of Total Billed charges,75% of Total Billed Charges,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,802.53,72,,875.52,Percent of Total Billed Charges,72% of Total Billed Charges,668.78,60,,729.6,Percent of Total Billed Charges,60% of Total Billed Charges,1003.17,90,,1566.72,Percent of Total Billed Charges,90% of Total Billed Charges,501.58,45,,1180.384,Percent of Total Billed Charges,45% of Total Billed Charges,1003.17,90,,1800,Percent of Total Billed Charges,90% of Total billed Charges,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,724.51,65,,4576,Percent of total Billed Charges,65% of Total Billed Charges,491.55,44.1,,1156.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,1058.9,95,,1900,Percent of Total Billed Charges,95% of Total Billed Charges,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,980.87,88,,2923.8,Percent of Total Billed Charges,88% of Total Billed Charges,1003.17,90,,1800,Percent of Total Billed charges,90% of Total Billed Charges,491.55,1114.63,
NM LIVER FLOW,3410000007,CDM,341,RC,,,Outpatient,,,1560.04,1014.03,,1560.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1185.63,76,,706.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1123.23,72,,328.32,Percent of Total Billed Charges,72% of Total Billed Charges,1170.03,75,,342,Percent of Total Billed charges,75% of Total Billed Charges,1560.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.23,72,,328.32,Percent of Total Billed Charges,72% of Total Billed Charges,936.02,60,,273.6,Percent of Total Billed Charges,60% of Total Billed Charges,1404.04,90,,642.96,Percent of Total Billed Charges,90% of Total Billed Charges,702.02,45,,1495.12,Percent of Total Billed Charges,45% of Total Billed Charges,1404.04,90,,836.672,Percent of Total Billed Charges,90% of Total billed Charges,1560.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1560.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1560.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1014.03,65,,10816,Percent of total Billed Charges,65% of Total Billed Charges,687.98,44.1,,1465.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,1482.04,95,,883.152,Percent of Total Billed Charges,95% of Total Billed Charges,1560.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1372.84,88,,1108.36,Percent of Total Billed Charges,88% of Total Billed Charges,1404.04,90,,836.672,Percent of Total Billed charges,90% of Total Billed Charges,687.98,1560.04,
NM LIVER SPLEEN STAT,3410000009,CDM,341,RC,,,Outpatient,,,1441.00,936.65,,1441,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1095.16,76,,621.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1037.52,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,1080.75,75,,960,Percent of Total Billed charges,75% of Total Billed Charges,1441,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1037.52,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,864.6,60,,768,Percent of Total Billed Charges,60% of Total Billed Charges,1296.9,90,,770.784,Percent of Total Billed Charges,90% of Total Billed Charges,648.45,45,,566.776,Percent of Total Billed Charges,45% of Total Billed Charges,1296.9,90,,735.856,Percent of Total Billed Charges,90% of Total billed Charges,1441,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1441,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1441,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,936.65,65,,2979.072,Percent of total Billed Charges,65% of Total Billed Charges,635.48,44.1,,555.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,1368.95,95,,776.736,Percent of Total Billed Charges,95% of Total Billed Charges,1441,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1268.08,88,,725.712,Percent of Total Billed Charges,88% of Total Billed Charges,1296.9,90,,735.856,Percent of Total Billed charges,90% of Total Billed Charges,635.48,1441,
NM LIVER SPLEEN FLOW,3410000010,CDM,341,RC,,,Outpatient,,,1894.10,1231.17,,1894.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1439.52,76,,1990.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1363.75,72,,345.6,Percent of Total Billed Charges,72% of Total Billed Charges,1420.58,75,,360,Percent of Total Billed charges,75% of Total Billed Charges,1894.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1363.75,72,,345.6,Percent of Total Billed Charges,72% of Total Billed Charges,1136.46,60,,288,Percent of Total Billed Charges,60% of Total Billed Charges,1704.69,90,,1450.272,Percent of Total Billed Charges,90% of Total Billed Charges,852.35,45,,371.104,Percent of Total Billed Charges,45% of Total Billed Charges,1704.69,90,,2356.792,Percent of Total Billed Charges,90% of Total billed Charges,1894.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1894.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1894.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1231.17,65,,967.2,Percent of total Billed Charges,65% of Total Billed Charges,835.3,44.1,,363.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,1799.4,95,,2487.72,Percent of Total Billed Charges,95% of Total Billed Charges,1894.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1666.81,88,,789.352,Percent of Total Billed Charges,88% of Total Billed Charges,1704.69,90,,2356.792,Percent of Total Billed charges,90% of Total Billed Charges,835.3,1894.1,
HIDA SCAN,3410000011,CDM,341,RC,,,Outpatient,,,1916.00,1245.40,,1916,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1456.16,76,,1993.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1379.52,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,1437,75,,960,Percent of Total Billed charges,75% of Total Billed Charges,1916,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1379.52,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,1149.6,60,,768,Percent of Total Billed Charges,60% of Total Billed Charges,1724.4,90,,770.784,Percent of Total Billed Charges,90% of Total Billed Charges,862.2,45,,403.648,Percent of Total Billed Charges,45% of Total Billed Charges,1724.4,90,,2360.768,Percent of Total Billed Charges,90% of Total billed Charges,1916,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1916,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1916,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1245.4,65,,967.2,Percent of total Billed Charges,65% of Total Billed Charges,844.96,44.1,,395.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,1820.2,95,,2491.92,Percent of Total Billed Charges,95% of Total Billed Charges,1916,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1686.08,88,,788.576,Percent of Total Billed Charges,88% of Total Billed Charges,1724.4,90,,2360.768,Percent of Total Billed charges,90% of Total Billed Charges,844.96,1916,
HIDA SCAN WITH EF,3410000012,CDM,341,RC,,,Outpatient,,,2368.00,1539.20,,2368,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1799.68,76,,2525.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1704.96,72,,230.52,Percent of Total Billed Charges,72% of Total Billed Charges,1776,75,,240.128,Percent of Total Billed charges,75% of Total Billed Charges,2368,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1704.96,72,,230.52,Percent of Total Billed Charges,72% of Total Billed Charges,1420.8,60,,192.104,Percent of Total Billed Charges,60% of Total Billed Charges,2131.2,90,,719.28,Percent of Total Billed Charges,90% of Total Billed Charges,1065.6,45,,403.248,Percent of Total Billed Charges,45% of Total Billed Charges,2131.2,90,,2990.248,Percent of Total Billed Charges,90% of Total billed Charges,2368,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2368,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2368,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1539.2,65,,967.2,Percent of total Billed Charges,65% of Total Billed Charges,1044.29,44.1,,395.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,2249.6,95,,3156.368,Percent of Total Billed Charges,95% of Total Billed Charges,2368,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2083.84,88,,1531.904,Percent of Total Billed Charges,88% of Total Billed Charges,2131.2,90,,2990.248,Percent of Total Billed charges,90% of Total Billed Charges,1044.29,2368,
NM SALIVARY GLAND IM,3410000013,CDM,341,RC,,,Outpatient,,,1337.33,869.26,,1337.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1016.37,76,,957.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,962.88,72,,501.12,Percent of Total Billed Charges,72% of Total Billed Charges,1003,75,,522,Percent of Total Billed charges,75% of Total Billed Charges,1337.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,962.88,72,,501.12,Percent of Total Billed Charges,72% of Total Billed Charges,802.4,60,,417.6,Percent of Total Billed Charges,60% of Total Billed Charges,1203.6,90,,1478.056,Percent of Total Billed Charges,90% of Total Billed Charges,601.8,45,,783.36,Percent of Total Billed Charges,45% of Total Billed Charges,1203.6,90,,1133.544,Percent of Total Billed Charges,90% of Total billed Charges,1337.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1337.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1337.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,869.26,65,,718.224,Percent of total Billed Charges,65% of Total Billed Charges,589.76,44.1,,767.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,1270.46,95,,1196.52,Percent of Total Billed Charges,95% of Total Billed Charges,1337.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1176.85,88,,628.672,Percent of Total Billed Charges,88% of Total Billed Charges,1203.6,90,,1133.544,Percent of Total Billed charges,90% of Total Billed Charges,589.76,1337.33,
NM SAL SERIAL IMGN,3410000014,CDM,341,RC,,,Outpatient,,,1782.74,1158.78,,1782.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1354.88,76,,626.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1283.57,72,,279.936,Percent of Total Billed Charges,72% of Total Billed Charges,1337.06,75,,291.6,Percent of Total Billed charges,75% of Total Billed Charges,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1283.57,72,,279.936,Percent of Total Billed Charges,72% of Total Billed Charges,1069.64,60,,233.28,Percent of Total Billed Charges,60% of Total Billed Charges,1604.47,90,,1450.272,Percent of Total Billed Charges,90% of Total Billed Charges,802.23,45,,321.48,Percent of Total Billed Charges,45% of Total Billed Charges,1604.47,90,,742.208,Percent of Total Billed Charges,90% of Total billed Charges,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1158.78,65,,359.112,Percent of total Billed Charges,65% of Total Billed Charges,786.19,44.1,,315.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1693.6,95,,783.44,Percent of Total Billed Charges,95% of Total Billed Charges,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1568.81,88,,753.656,Percent of Total Billed Charges,88% of Total Billed Charges,1604.47,90,,742.208,Percent of Total Billed charges,90% of Total Billed Charges,786.19,1782.74,
NM GASTROESOPHAGEAL,3410000015,CDM,341,RC,,,Outpatient,,,1894.10,1231.17,,1894.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1439.52,76,,681.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1363.75,72,,1013.76,Percent of Total Billed Charges,72% of Total Billed Charges,1420.58,75,,1056,Percent of Total Billed charges,75% of Total Billed Charges,1894.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1363.75,72,,1013.76,Percent of Total Billed Charges,72% of Total Billed Charges,1136.46,60,,844.8,Percent of Total Billed Charges,60% of Total Billed Charges,1704.69,90,,770.784,Percent of Total Billed Charges,90% of Total Billed Charges,852.35,45,,385.392,Percent of Total Billed Charges,45% of Total Billed Charges,1704.69,90,,807.296,Percent of Total Billed Charges,90% of Total billed Charges,1894.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1894.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1894.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1231.17,65,,346.84,Percent of total Billed Charges,65% of Total Billed Charges,835.3,44.1,,377.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,1799.4,95,,852.144,Percent of Total Billed Charges,95% of Total Billed Charges,1894.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1666.81,88,,1418.048,Percent of Total Billed Charges,88% of Total Billed Charges,1704.69,90,,807.296,Percent of Total Billed charges,90% of Total Billed Charges,835.3,1894.1,
NM GASTRIC EMPTYING,3410000016,CDM,341,RC,,,Outpatient,,,1907.00,1239.55,,1907,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1449.32,76,,681.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1373.04,72,,347.904,Percent of Total Billed Charges,72% of Total Billed Charges,1430.25,75,,362.4,Percent of Total Billed charges,75% of Total Billed Charges,1907,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1373.04,72,,347.904,Percent of Total Billed Charges,72% of Total Billed Charges,1144.2,60,,289.92,Percent of Total Billed Charges,60% of Total Billed Charges,1716.3,90,,1450.272,Percent of Total Billed Charges,90% of Total Billed Charges,858.15,45,,725.136,Percent of Total Billed Charges,45% of Total Billed Charges,1716.3,90,,806.504,Percent of Total Billed Charges,90% of Total billed Charges,1907,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1907,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1907,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1239.55,65,,414.96,Percent of total Billed Charges,65% of Total Billed Charges,840.99,44.1,,710.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,1811.65,95,,851.304,Percent of Total Billed Charges,95% of Total Billed Charges,1907,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1678.16,88,,753.656,Percent of Total Billed Charges,88% of Total Billed Charges,1716.3,90,,806.504,Percent of Total Billed charges,90% of Total Billed Charges,840.99,1907,
NM BLEEDING SCAN RBC,3410000017,CDM,341,RC,,,Outpatient,,,1448.69,941.65,,1448.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1101,76,,1323.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1043.06,72,,349.632,Percent of Total Billed Charges,72% of Total Billed Charges,1086.52,75,,364.2,Percent of Total Billed charges,75% of Total Billed Charges,1448.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1043.06,72,,349.632,Percent of Total Billed Charges,72% of Total Billed Charges,869.21,60,,291.36,Percent of Total Billed Charges,60% of Total Billed Charges,1303.82,90,,756.488,Percent of Total Billed Charges,90% of Total Billed Charges,651.91,45,,385.392,Percent of Total Billed Charges,45% of Total Billed Charges,1303.82,90,,1566.72,Percent of Total Billed Charges,90% of Total billed Charges,1448.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1448.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1448.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,941.65,65,,414.96,Percent of total Billed Charges,65% of Total Billed Charges,638.87,44.1,,377.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,1376.26,95,,1653.76,Percent of Total Billed Charges,95% of Total Billed Charges,1448.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1274.85,88,,703.296,Percent of Total Billed Charges,88% of Total Billed Charges,1303.82,90,,1566.72,Percent of Total Billed charges,90% of Total Billed Charges,638.87,1448.69,
NM BOWEL IMAGING MEC,3410000018,CDM,341,RC,,,Outpatient,,,1960.25,1274.16,,1960.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1489.79,76,,542.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1411.38,72,,320.016,Percent of Total Billed Charges,72% of Total Billed Charges,1470.19,75,,333.352,Percent of Total Billed charges,75% of Total Billed Charges,1960.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1411.38,72,,320.016,Percent of Total Billed Charges,72% of Total Billed Charges,1176.15,60,,266.68,Percent of Total Billed Charges,60% of Total Billed Charges,1764.23,90,,1478.056,Percent of Total Billed Charges,90% of Total Billed Charges,882.11,45,,359.64,Percent of Total Billed Charges,45% of Total Billed Charges,1764.23,90,,642.96,Percent of Total Billed Charges,90% of Total billed Charges,1960.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1960.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1960.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1274.16,65,,365.04,Percent of total Billed Charges,65% of Total Billed Charges,864.47,44.1,,352.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,1862.24,95,,678.68,Percent of Total Billed Charges,95% of Total Billed Charges,1960.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1725.02,88,,1445.216,Percent of Total Billed Charges,88% of Total Billed Charges,1764.23,90,,642.96,Percent of Total Billed charges,90% of Total Billed Charges,864.47,1960.25,
NM BONE LIMITED BONE,3410000019,CDM,341,RC,,,Outpatient,,,905.15,588.35,,905.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,687.91,76,,650.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,651.71,72,,388.12,Percent of Total Billed Charges,72% of Total Billed Charges,678.86,75,,404.296,Percent of Total Billed charges,75% of Total Billed Charges,905.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,651.71,72,,388.12,Percent of Total Billed Charges,72% of Total Billed Charges,543.09,60,,323.432,Percent of Total Billed Charges,60% of Total Billed Charges,814.64,90,,1478.056,Percent of Total Billed Charges,90% of Total Billed Charges,407.32,45,,739.032,Percent of Total Billed Charges,45% of Total Billed Charges,814.64,90,,770.784,Percent of Total Billed Charges,90% of Total billed Charges,905.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,905.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,905.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,588.35,65,,267.28,Percent of total Billed Charges,65% of Total Billed Charges,399.17,44.1,,724.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,859.89,95,,813.6,Percent of Total Billed Charges,95% of Total Billed Charges,905.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.53,88,,1418.048,Percent of Total Billed Charges,88% of Total Billed Charges,814.64,90,,770.784,Percent of Total Billed charges,90% of Total Billed Charges,399.17,905.15,
NB BN SCAN 58 VIEWS,3410000020,CDM,341,RC,,,Outpatient,,,1060.61,689.40,,1060.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,806.06,76,,1224.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,763.64,72,,404.352,Percent of Total Billed Charges,72% of Total Billed Charges,795.46,75,,421.2,Percent of Total Billed charges,75% of Total Billed Charges,1060.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,763.64,72,,404.352,Percent of Total Billed Charges,72% of Total Billed Charges,636.37,60,,336.96,Percent of Total Billed Charges,60% of Total Billed Charges,954.55,90,,88.904,Percent of Total Billed Charges,90% of Total Billed Charges,477.27,45,,725.136,Percent of Total Billed Charges,45% of Total Billed Charges,954.55,90,,1450.272,Percent of Total Billed Charges,90% of Total billed Charges,1060.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1060.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1060.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,689.4,65,,281.896,Percent of total Billed Charges,65% of Total Billed Charges,467.73,44.1,,710.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,1007.58,95,,1530.848,Percent of Total Billed Charges,95% of Total Billed Charges,1060.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,933.34,88,,753.656,Percent of Total Billed Charges,88% of Total Billed Charges,954.55,90,,1450.272,Percent of Total Billed charges,90% of Total Billed Charges,467.73,1060.61,
NM TOTAL BONE SCAN,3410000021,CDM,341,RC,,,Outpatient,,,1826.00,1186.90,,1826,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1387.76,76,,650.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1314.72,72,,425.48,Percent of Total Billed Charges,72% of Total Billed Charges,1369.5,75,,443.208,Percent of Total Billed charges,75% of Total Billed Charges,1826,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1314.72,72,,425.48,Percent of Total Billed Charges,72% of Total Billed Charges,1095.6,60,,354.568,Percent of Total Billed Charges,60% of Total Billed Charges,1643.4,90,,14507.488,Percent of Total Billed Charges,90% of Total Billed Charges,821.7,45,,385.392,Percent of Total Billed Charges,45% of Total Billed Charges,1643.4,90,,770.784,Percent of Total Billed Charges,90% of Total billed Charges,1826,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1826,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1826,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1186.9,65,,2250.648,Percent of total Billed Charges,65% of Total Billed Charges,805.27,44.1,,377.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,1734.7,95,,813.6,Percent of Total Billed Charges,95% of Total Billed Charges,1826,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1606.88,88,,1418.048,Percent of Total Billed Charges,88% of Total Billed Charges,1643.4,90,,770.784,Percent of Total Billed charges,90% of Total Billed Charges,805.27,1826,
NM TRIPHASIC BONE,3410000022,CDM,341,RC,,,Outpatient,,,3074.00,1998.10,,3074,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2336.24,76,,607.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2213.28,72,,1209.6,Percent of Total Billed Charges,72% of Total Billed Charges,2305.5,75,,1260,Percent of Total Billed charges,75% of Total Billed Charges,3074,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2213.28,72,,1209.6,Percent of Total Billed Charges,72% of Total Billed Charges,1844.4,60,,1008,Percent of Total Billed Charges,60% of Total Billed Charges,2766.6,90,,2409.184,Percent of Total Billed Charges,90% of Total Billed Charges,1383.3,45,,725.136,Percent of Total Billed Charges,45% of Total Billed Charges,2766.6,90,,719.28,Percent of Total Billed Charges,90% of Total billed Charges,3074,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3074,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3074,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1998.1,65,,776.88,Percent of total Billed Charges,65% of Total Billed Charges,1355.63,44.1,,710.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,2920.3,95,,759.24,Percent of Total Billed Charges,95% of Total Billed Charges,3074,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2705.12,88,,739.68,Percent of Total Billed Charges,88% of Total Billed Charges,2766.6,90,,719.28,Percent of Total Billed charges,90% of Total Billed Charges,1355.63,3074,
REST OR STRESS CARDI,3410000024,CDM,341,RC,,,Outpatient,,,4413.00,2868.45,,4413,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3353.88,76,,1248.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3177.36,72,,388.512,Percent of Total Billed Charges,72% of Total Billed Charges,3309.75,75,,404.704,Percent of Total Billed charges,75% of Total Billed Charges,4413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.36,72,,388.512,Percent of Total Billed Charges,72% of Total Billed Charges,2647.8,60,,323.76,Percent of Total Billed Charges,60% of Total Billed Charges,3971.7,90,,2607.12,Percent of Total Billed Charges,90% of Total Billed Charges,1985.85,45,,378.248,Percent of Total Billed Charges,45% of Total Billed Charges,3971.7,90,,1478.056,Percent of Total Billed Charges,90% of Total billed Charges,4413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2868.45,65,,224.736,Percent of total Billed Charges,65% of Total Billed Charges,1946.13,44.1,,370.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,4192.35,95,,1560.176,Percent of Total Billed Charges,95% of Total Billed Charges,4413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3883.44,88,,1445.216,Percent of Total Billed Charges,88% of Total Billed Charges,3971.7,90,,1478.056,Percent of Total Billed charges,90% of Total Billed Charges,1946.13,4413,
REST & STRESS CARDIO,3410000025,CDM,341,RC,,,Outpatient,,,5421.00,3523.65,,5421,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4119.96,76,,1224.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3903.12,72,,252.112,Percent of Total Billed Charges,72% of Total Billed Charges,4065.75,75,,262.616,Percent of Total Billed charges,75% of Total Billed Charges,5421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3903.12,72,,252.112,Percent of Total Billed Charges,72% of Total Billed Charges,3252.6,60,,210.088,Percent of Total Billed Charges,60% of Total Billed Charges,4878.9,90,,2894.992,Percent of Total Billed Charges,90% of Total Billed Charges,2439.45,45,,739.032,Percent of Total Billed Charges,45% of Total Billed Charges,4878.9,90,,1450.272,Percent of Total Billed Charges,90% of Total billed Charges,5421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3523.65,65,,2134.6,Percent of total Billed Charges,65% of Total Billed Charges,2390.66,44.1,,724.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,5149.95,95,,1530.848,Percent of Total Billed Charges,95% of Total Billed Charges,5421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4770.48,88,,1445.216,Percent of Total Billed Charges,88% of Total Billed Charges,4878.9,90,,1450.272,Percent of Total Billed charges,90% of Total Billed Charges,2390.66,5421,
ACUTEVENOUS THROMB A,3410000026,CDM,341,RC,,,Outpatient,,,1738.64,1130.12,,1738.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1321.37,76,,650.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1251.82,72,,1303.736,Percent of Total Billed Charges,72% of Total Billed Charges,1303.98,75,,1358.056,Percent of Total Billed charges,75% of Total Billed Charges,1738.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1251.82,72,,1303.736,Percent of Total Billed Charges,72% of Total Billed Charges,1043.18,60,,1086.448,Percent of Total Billed Charges,60% of Total Billed Charges,1564.78,90,,4228.56,Percent of Total Billed Charges,90% of Total Billed Charges,782.39,45,,739.032,Percent of Total Billed Charges,45% of Total Billed Charges,1564.78,90,,770.784,Percent of Total Billed Charges,90% of Total billed Charges,1738.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1738.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1738.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1130.12,65,,3462.32,Percent of total Billed Charges,65% of Total Billed Charges,766.74,44.1,,724.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,1651.71,95,,813.6,Percent of Total Billed Charges,95% of Total Billed Charges,1738.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530,88,,86.928,Percent of Total Billed Charges,88% of Total Billed Charges,1564.78,90,,770.784,Percent of Total Billed charges,90% of Total Billed Charges,766.74,1738.64,
NM VENOGM THROMB UNI,3410000027,CDM,341,RC,,,Outpatient,,,780.57,507.37,,780.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,593.23,76,,1224.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,562.01,72,,1949.576,Percent of Total Billed Charges,72% of Total Billed Charges,585.43,75,,2030.808,Percent of Total Billed charges,75% of Total Billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.01,72,,1949.576,Percent of Total Billed Charges,72% of Total Billed Charges,468.34,60,,1624.648,Percent of Total Billed Charges,60% of Total Billed Charges,702.51,90,,4230.96,Percent of Total Billed Charges,90% of Total Billed Charges,351.26,45,,44.456,Percent of Total Billed Charges,45% of Total Billed Charges,702.51,90,,1450.272,Percent of Total Billed Charges,90% of Total billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.37,65,,850.064,Percent of total Billed Charges,65% of Total Billed Charges,344.23,44.1,,43.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,741.54,95,,1530.848,Percent of Total Billed Charges,95% of Total Billed Charges,780.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,686.9,88,,14185.104,Percent of Total Billed Charges,88% of Total Billed Charges,702.51,90,,1450.272,Percent of Total Billed charges,90% of Total Billed Charges,344.23,780.57,
NM VENOGRAM THROM BI,3410000028,CDM,341,RC,,,Outpatient,,,1114.63,724.51,,1114.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,847.12,76,,638.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,802.53,72,,1397.408,Percent of Total Billed Charges,72% of Total Billed Charges,835.97,75,,1455.632,Percent of Total Billed charges,75% of Total Billed Charges,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,802.53,72,,1397.408,Percent of Total Billed Charges,72% of Total Billed Charges,668.78,60,,1164.504,Percent of Total Billed Charges,60% of Total Billed Charges,1003.17,90,,4236.48,Percent of Total Billed Charges,90% of Total Billed Charges,501.58,45,,7253.744,Percent of Total Billed Charges,45% of Total Billed Charges,1003.17,90,,756.488,Percent of Total Billed Charges,90% of Total billed Charges,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,724.51,65,,1721.2,Percent of total Billed Charges,65% of Total Billed Charges,491.55,44.1,,7108.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,1058.9,95,,798.52,Percent of Total Billed Charges,95% of Total Billed Charges,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,980.87,88,,2355.648,Percent of Total Billed Charges,88% of Total Billed Charges,1003.17,90,,756.488,Percent of Total Billed charges,90% of Total Billed Charges,491.55,1114.63,
MUGA AT REST,3410000029,CDM,341,RC,,,Outpatient,,,1733.13,1126.53,,1733.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1317.18,76,,1248.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1247.85,72,,2971.584,Percent of Total Billed Charges,72% of Total Billed Charges,1299.85,75,,3095.4,Percent of Total Billed charges,75% of Total Billed Charges,1733.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1247.85,72,,2971.584,Percent of Total Billed Charges,72% of Total Billed Charges,1039.88,60,,2476.32,Percent of Total Billed Charges,60% of Total Billed Charges,1559.82,90,,52.392,Percent of Total Billed Charges,90% of Total Billed Charges,779.91,45,,1204.592,Percent of Total Billed Charges,45% of Total Billed Charges,1559.82,90,,1478.056,Percent of Total Billed Charges,90% of Total billed Charges,1733.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1733.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1733.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1126.53,65,,3625.96,Percent of total Billed Charges,65% of Total Billed Charges,764.31,44.1,,1180.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,1646.47,95,,1560.176,Percent of Total Billed Charges,95% of Total Billed Charges,1733.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1525.15,88,,2549.184,Percent of Total Billed Charges,88% of Total Billed Charges,1559.82,90,,1478.056,Percent of Total Billed charges,90% of Total Billed Charges,764.31,1733.13,
NM LUNG PERFUSION,3410000030,CDM,341,RC,,,Outpatient,,,848.00,551.20,,848,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,644.48,76,,1248.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,610.56,72,,747.44,Percent of Total Billed Charges,72% of Total Billed Charges,636,75,,778.584,Percent of Total Billed charges,75% of Total Billed Charges,848,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,610.56,72,,747.44,Percent of Total Billed Charges,72% of Total Billed Charges,508.8,60,,622.864,Percent of Total Billed Charges,60% of Total Billed Charges,763.2,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,381.6,45,,1303.56,Percent of Total Billed Charges,45% of Total Billed Charges,763.2,90,,1478.056,Percent of Total Billed Charges,90% of Total billed Charges,848,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,848,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,848,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,551.2,65,,3415.592,Percent of total Billed Charges,65% of Total Billed Charges,373.97,44.1,,1277.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,805.6,95,,1560.176,Percent of Total Billed Charges,95% of Total Billed Charges,848,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,746.24,88,,2830.656,Percent of Total Billed Charges,88% of Total Billed Charges,763.2,90,,1478.056,Percent of Total Billed charges,90% of Total Billed Charges,373.97,848,
PERF/VENT LUNG SCAN,3410000031,CDM,341,RC,,,Outpatient,,,1448.69,941.65,,1448.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1101,76,,75.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1043.06,72,,1379.208,Percent of Total Billed Charges,72% of Total Billed Charges,1086.52,75,,1436.68,Percent of Total Billed charges,75% of Total Billed Charges,1448.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1043.06,72,,1379.208,Percent of Total Billed Charges,72% of Total Billed Charges,869.21,60,,1149.344,Percent of Total Billed Charges,60% of Total Billed Charges,1303.82,90,,69.12,Percent of Total Billed Charges,90% of Total Billed Charges,651.91,45,,1447.496,Percent of Total Billed Charges,45% of Total Billed Charges,1303.82,90,,88.904,Percent of Total Billed Charges,90% of Total billed Charges,1448.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1448.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1448.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,941.65,65,,10593.96,Percent of total Billed Charges,65% of Total Billed Charges,638.87,44.1,,1418.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,1376.26,95,,93.848,Percent of Total Billed Charges,95% of Total Billed Charges,1448.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1274.85,88,,4134.592,Percent of Total Billed Charges,88% of Total Billed Charges,1303.82,90,,88.904,Percent of Total Billed charges,90% of Total Billed Charges,638.87,1448.69,
NM BRAIN LIMITED BRA,3410000032,CDM,341,RC,,,Outpatient,,,669.22,434.99,,669.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,508.61,76,,12250.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,481.84,72,,866.88,Percent of Total Billed Charges,72% of Total Billed Charges,501.92,75,,903,Percent of Total Billed charges,75% of Total Billed Charges,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,481.84,72,,866.88,Percent of Total Billed Charges,72% of Total Billed Charges,401.53,60,,722.4,Percent of Total Billed Charges,60% of Total Billed Charges,602.3,90,,3399.12,Percent of Total Billed Charges,90% of Total Billed Charges,301.15,45,,2114.28,Percent of Total Billed Charges,45% of Total Billed Charges,602.3,90,,14507.488,Percent of Total Billed Charges,90% of Total billed Charges,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,434.99,65,,560.56,Percent of total Billed Charges,65% of Total Billed Charges,295.13,44.1,,2071.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,635.76,95,,15313.464,Percent of Total Billed Charges,95% of Total Billed Charges,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,588.91,88,,4136.936,Percent of Total Billed Charges,88% of Total Billed Charges,602.3,90,,14507.488,Percent of Total Billed charges,90% of Total Billed Charges,295.13,669.22,
NM BRAIN LIM FLOW,3410000033,CDM,341,RC,,,Outpatient,,,1114.63,724.51,,1114.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,847.12,76,,2034.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,802.53,72,,1067.904,Percent of Total Billed Charges,72% of Total Billed Charges,835.97,75,,1112.4,Percent of Total Billed charges,75% of Total Billed Charges,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,802.53,72,,1067.904,Percent of Total Billed Charges,72% of Total Billed Charges,668.78,60,,889.92,Percent of Total Billed Charges,60% of Total Billed Charges,1003.17,90,,5826.24,Percent of Total Billed Charges,90% of Total Billed Charges,501.58,45,,2115.48,Percent of Total Billed Charges,45% of Total Billed Charges,1003.17,90,,2409.184,Percent of Total Billed Charges,90% of Total billed Charges,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,724.51,65,,2677.312,Percent of total Billed Charges,65% of Total Billed Charges,491.55,44.1,,2073.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,1058.9,95,,2543.032,Percent of Total Billed Charges,95% of Total Billed Charges,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,980.87,88,,4142.336,Percent of Total Billed Charges,88% of Total Billed Charges,1003.17,90,,2409.184,Percent of Total Billed charges,90% of Total Billed Charges,491.55,1114.63,
NM BRAINCOMP,3410000034,CDM,341,RC,,,Outpatient,,,1448.69,941.65,,1448.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1101,76,,2201.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1043.06,72,,813.888,Percent of Total Billed Charges,72% of Total Billed Charges,1086.52,75,,847.8,Percent of Total Billed charges,75% of Total Billed Charges,1448.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1043.06,72,,813.888,Percent of Total Billed Charges,72% of Total Billed Charges,869.21,60,,678.24,Percent of Total Billed Charges,60% of Total Billed Charges,1303.82,90,,7127.28,Percent of Total Billed Charges,90% of Total Billed Charges,651.91,45,,2118.24,Percent of Total Billed Charges,45% of Total Billed Charges,1303.82,90,,2607.12,Percent of Total Billed Charges,90% of Total billed Charges,1448.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1448.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1448.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,941.65,65,,253.24,Percent of total Billed Charges,65% of Total Billed Charges,638.87,44.1,,2075.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,1376.26,95,,2751.96,Percent of Total Billed Charges,95% of Total Billed Charges,1448.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1274.85,88,,51.232,Percent of Total Billed Charges,88% of Total Billed Charges,1303.82,90,,2607.12,Percent of Total Billed charges,90% of Total Billed Charges,638.87,1448.69,
NM BRAIN FLOW,3410000035,CDM,341,RC,,,Outpatient,,,1782.74,1158.78,,1782.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1354.88,76,,2444.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1283.57,72,,2499.84,Percent of Total Billed Charges,72% of Total Billed Charges,1337.06,75,,2604,Percent of Total Billed charges,75% of Total Billed Charges,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1283.57,72,,2499.84,Percent of Total Billed Charges,72% of Total Billed Charges,1069.64,60,,2083.2,Percent of Total Billed Charges,60% of Total Billed Charges,1604.47,90,,3096,Percent of Total Billed Charges,90% of Total Billed Charges,802.23,45,,26.2,Percent of Total Billed Charges,45% of Total Billed Charges,1604.47,90,,2894.992,Percent of Total Billed Charges,90% of Total billed Charges,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1158.78,65,,1456,Percent of total Billed Charges,65% of Total Billed Charges,786.19,44.1,,25.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,1693.6,95,,3055.824,Percent of Total Billed Charges,95% of Total Billed Charges,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1568.81,88,,11.264,Percent of Total Billed Charges,88% of Total Billed Charges,1604.47,90,,2894.992,Percent of Total Billed charges,90% of Total Billed Charges,786.19,1782.74,
NM BRAIN FLOW ONLY,3410000036,CDM,341,RC,,,Outpatient,,,669.22,434.99,,669.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,508.61,76,,3570.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,481.84,72,,1208.48,Percent of Total Billed Charges,72% of Total Billed Charges,501.92,75,,1258.84,Percent of Total Billed charges,75% of Total Billed Charges,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,481.84,72,,1208.48,Percent of Total Billed Charges,72% of Total Billed Charges,401.53,60,,1007.072,Percent of Total Billed Charges,60% of Total Billed Charges,602.3,90,,6336,Percent of Total Billed Charges,90% of Total Billed Charges,301.15,45,,5.76,Percent of Total Billed Charges,45% of Total Billed Charges,602.3,90,,4228.56,Percent of Total Billed Charges,90% of Total billed Charges,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,434.99,65,,2341.928,Percent of total Billed Charges,65% of Total Billed Charges,295.13,44.1,,5.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,635.76,95,,4463.48,Percent of Total Billed Charges,95% of Total Billed Charges,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,588.91,88,,67.584,Percent of Total Billed Charges,88% of Total Billed Charges,602.3,90,,4228.56,Percent of Total Billed charges,90% of Total Billed Charges,295.13,669.22,
NM KIDNY IMGE STAT K,3410000037,CDM,341,RC,,,Outpatient,,,669.22,434.99,,669.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,508.61,76,,3572.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,481.84,72,,9227.96,Percent of Total Billed Charges,72% of Total Billed Charges,501.92,75,,9612.464,Percent of Total Billed charges,75% of Total Billed Charges,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,481.84,72,,9227.96,Percent of Total Billed Charges,72% of Total Billed Charges,401.53,60,,7689.968,Percent of Total Billed Charges,60% of Total Billed Charges,602.3,90,,14976,Percent of Total Billed Charges,90% of Total Billed Charges,301.15,45,,34.56,Percent of Total Billed Charges,45% of Total Billed Charges,602.3,90,,4230.96,Percent of Total Billed Charges,90% of Total billed Charges,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,434.99,65,,2341.928,Percent of total Billed Charges,65% of Total Billed Charges,295.13,44.1,,33.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,635.76,95,,4466.008,Percent of Total Billed Charges,95% of Total Billed Charges,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,588.91,88,,3323.584,Percent of Total Billed Charges,88% of Total Billed Charges,602.3,90,,4230.96,Percent of Total Billed charges,90% of Total Billed Charges,295.13,669.22,
NM KIDNEY VASC FLOW,3410000038,CDM,341,RC,,,Outpatient,,,891.92,579.75,,891.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,677.86,76,,3577.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,642.18,72,,1327.24,Percent of Total Billed Charges,72% of Total Billed Charges,668.94,75,,1382.536,Percent of Total Billed charges,75% of Total Billed Charges,891.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,642.18,72,,1327.24,Percent of Total Billed Charges,72% of Total Billed Charges,535.15,60,,1106.032,Percent of Total Billed Charges,60% of Total Billed Charges,802.73,90,,4124.864,Percent of Total Billed Charges,90% of Total Billed Charges,401.36,45,,1699.56,Percent of Total Billed Charges,45% of Total Billed Charges,802.73,90,,4236.48,Percent of Total Billed Charges,90% of Total billed Charges,891.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,891.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,891.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.75,65,,5678.088,Percent of total Billed Charges,65% of Total Billed Charges,393.34,44.1,,1665.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,847.32,95,,4471.84,Percent of Total Billed Charges,95% of Total Billed Charges,891.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,784.89,88,,5696.768,Percent of Total Billed Charges,88% of Total Billed Charges,802.73,90,,4236.48,Percent of Total Billed charges,90% of Total Billed Charges,393.34,891.92,
NM KIDNEY FLOW WO,3410000039,CDM,341,RC,,,Outpatient,,,1225.98,796.89,,1225.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,931.74,76,,44.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,882.71,72,,1750.168,Percent of Total Billed Charges,72% of Total Billed Charges,919.49,75,,1823.096,Percent of Total Billed charges,75% of Total Billed Charges,1225.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,882.71,72,,1750.168,Percent of Total Billed Charges,72% of Total Billed Charges,735.59,60,,1458.472,Percent of Total Billed Charges,60% of Total Billed Charges,1103.38,90,,1339.2,Percent of Total Billed Charges,90% of Total Billed Charges,551.69,45,,2913.12,Percent of Total Billed Charges,45% of Total Billed Charges,1103.38,90,,52.392,Percent of Total Billed Charges,90% of Total billed Charges,1225.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1225.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1225.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.89,65,,6271.92,Percent of total Billed Charges,65% of Total Billed Charges,540.66,44.1,,2854.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,1164.68,95,,55.304,Percent of Total Billed Charges,95% of Total Billed Charges,1225.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1078.86,88,,6968.896,Percent of Total Billed Charges,88% of Total Billed Charges,1103.38,90,,52.392,Percent of Total Billed charges,90% of Total Billed Charges,540.66,1225.98,
NM SNGL STDY LASX KI,3410000040,CDM,341,RC,,,Outpatient,,,1719.00,1117.35,,1719,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1306.44,76,,9.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1237.68,72,,1954.528,Percent of Total Billed Charges,72% of Total Billed Charges,1289.25,75,,2035.968,Percent of Total Billed charges,75% of Total Billed Charges,1719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1237.68,72,,1954.528,Percent of Total Billed Charges,72% of Total Billed Charges,1031.4,60,,1628.776,Percent of Total Billed Charges,60% of Total Billed Charges,1547.1,90,,1339.2,Percent of Total Billed Charges,90% of Total Billed Charges,773.55,45,,3563.64,Percent of Total Billed Charges,45% of Total Billed Charges,1547.1,90,,11.52,Percent of Total Billed Charges,90% of Total billed Charges,1719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1117.35,65,,478.92,Percent of total Billed Charges,65% of Total Billed Charges,758.08,44.1,,3492.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,1633.05,95,,12.16,Percent of Total Billed Charges,95% of Total Billed Charges,1719,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1512.72,88,,3027.2,Percent of Total Billed Charges,88% of Total Billed Charges,1547.1,90,,11.52,Percent of Total Billed charges,90% of Total Billed Charges,758.08,1719,
NM MULT ANAS INH KID,3410000041,CDM,341,RC,,,Outpatient,,,1560.04,1014.03,,1560.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1185.63,76,,58.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1123.23,72,,1857.024,Percent of Total Billed Charges,72% of Total Billed Charges,1170.03,75,,1934.4,Percent of Total Billed charges,75% of Total Billed Charges,1560.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.23,72,,1857.024,Percent of Total Billed Charges,72% of Total Billed Charges,936.02,60,,1547.52,Percent of Total Billed Charges,60% of Total Billed Charges,1404.04,90,,1339.2,Percent of Total Billed Charges,90% of Total Billed Charges,702.02,45,,1548,Percent of Total Billed Charges,45% of Total Billed Charges,1404.04,90,,69.12,Percent of Total Billed Charges,90% of Total billed Charges,1560.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1560.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1560.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1014.03,65,,212.12,Percent of total Billed Charges,65% of Total Billed Charges,687.98,44.1,,1517.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,1482.04,95,,72.96,Percent of Total Billed Charges,95% of Total Billed Charges,1560.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1372.84,88,,6195.2,Percent of Total Billed Charges,88% of Total Billed Charges,1404.04,90,,69.12,Percent of Total Billed charges,90% of Total Billed Charges,687.98,1560.04,
NM TESTICULAR IMGN T,3410000042,CDM,341,RC,,,Outpatient,,,1114.63,724.51,,1114.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,847.12,76,,2870.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,802.53,72,,1507.392,Percent of Total Billed Charges,72% of Total Billed Charges,835.97,75,,1570.2,Percent of Total Billed charges,75% of Total Billed Charges,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,802.53,72,,1507.392,Percent of Total Billed Charges,72% of Total Billed Charges,668.78,60,,1256.16,Percent of Total Billed Charges,60% of Total Billed Charges,1003.17,90,,994.464,Percent of Total Billed Charges,90% of Total Billed Charges,501.58,45,,3168,Percent of Total Billed Charges,45% of Total Billed Charges,1003.17,90,,3399.12,Percent of Total Billed Charges,90% of Total billed Charges,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,724.51,65,,1532.432,Percent of total Billed Charges,65% of Total Billed Charges,491.55,44.1,,3104.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,1058.9,95,,3587.96,Percent of Total Billed Charges,95% of Total Billed Charges,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,980.87,88,,14643.2,Percent of Total Billed Charges,88% of Total Billed Charges,1003.17,90,,3399.12,Percent of Total Billed charges,90% of Total Billed Charges,491.55,1114.63,
NM TESTICULAR FLOW,3410000043,CDM,341,RC,,,Outpatient,,,1114.63,724.51,,1114.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,847.12,76,,4919.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,802.53,72,,425.664,Percent of Total Billed Charges,72% of Total Billed Charges,835.97,75,,443.4,Percent of Total Billed charges,75% of Total Billed Charges,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,802.53,72,,425.664,Percent of Total Billed Charges,72% of Total Billed Charges,668.78,60,,354.72,Percent of Total Billed Charges,60% of Total Billed Charges,1003.17,90,,497.232,Percent of Total Billed Charges,90% of Total Billed Charges,501.58,45,,7488,Percent of Total Billed Charges,45% of Total Billed Charges,1003.17,90,,5826.24,Percent of Total Billed Charges,90% of Total billed Charges,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,724.51,65,,255.12,Percent of total Billed Charges,65% of Total Billed Charges,491.55,44.1,,7338.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,1058.9,95,,6149.92,Percent of Total Billed Charges,95% of Total Billed Charges,1114.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,980.87,88,,4033.2,Percent of Total Billed Charges,88% of Total Billed Charges,1003.17,90,,5826.24,Percent of Total Billed charges,90% of Total Billed Charges,491.55,1114.63,
NM LOCAL TUMOR GALL,3410000044,CDM,341,RC,,,Outpatient,,,1003.28,652.13,,1003.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,762.49,76,,6018.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,722.36,72,,1218.816,Percent of Total Billed Charges,72% of Total Billed Charges,752.46,75,,1269.6,Percent of Total Billed charges,75% of Total Billed Charges,1003.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,722.36,72,,1218.816,Percent of Total Billed Charges,72% of Total Billed Charges,601.97,60,,1015.68,Percent of Total Billed Charges,60% of Total Billed Charges,902.95,90,,480.24,Percent of Total Billed Charges,90% of Total Billed Charges,451.48,45,,2062.432,Percent of Total Billed Charges,45% of Total Billed Charges,902.95,90,,7127.28,Percent of Total Billed Charges,90% of Total billed Charges,1003.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1003.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1003.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,652.13,65,,1132.24,Percent of total Billed Charges,65% of Total Billed Charges,442.45,44.1,,2021.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,953.12,95,,7523.24,Percent of Total Billed Charges,95% of Total Billed Charges,1003.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,882.89,88,,1309.44,Percent of Total Billed Charges,88% of Total Billed Charges,902.95,90,,7127.28,Percent of Total Billed charges,90% of Total Billed Charges,442.45,1003.28,
NM LOCAL TUMR W B G,3410000045,CDM,341,RC,,,Outpatient,,,1782.74,1158.78,,1782.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1354.88,76,,2614.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1283.57,72,,8594.496,Percent of Total Billed Charges,72% of Total Billed Charges,1337.06,75,,8952.6,Percent of Total Billed charges,75% of Total Billed Charges,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1283.57,72,,8594.496,Percent of Total Billed Charges,72% of Total Billed Charges,1069.64,60,,7162.08,Percent of Total Billed Charges,60% of Total Billed Charges,1604.47,90,,574.56,Percent of Total Billed Charges,90% of Total Billed Charges,802.23,45,,669.6,Percent of Total Billed Charges,45% of Total Billed Charges,1604.47,90,,3096,Percent of Total Billed Charges,90% of Total billed Charges,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1158.78,65,,754.128,Percent of total Billed Charges,65% of Total Billed Charges,786.19,44.1,,656.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,1693.6,95,,3268,Percent of Total Billed Charges,95% of Total Billed Charges,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1568.81,88,,1309.44,Percent of Total Billed Charges,88% of Total Billed Charges,1604.47,90,,3096,Percent of Total Billed charges,90% of Total Billed Charges,786.19,1782.74,
NM SPECT FOR ABASS,3410000046,CDM,341,RC,,,Outpatient,,,1782.74,1158.78,,1782.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1354.88,76,,5350.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1283.57,72,,16623.856,Percent of Total Billed Charges,72% of Total Billed Charges,1337.06,75,,17316.52,Percent of Total Billed charges,75% of Total Billed Charges,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1283.57,72,,16623.856,Percent of Total Billed Charges,72% of Total Billed Charges,1069.64,60,,13853.216,Percent of Total Billed Charges,60% of Total Billed Charges,1604.47,90,,574.56,Percent of Total Billed Charges,90% of Total Billed Charges,802.23,45,,669.6,Percent of Total Billed Charges,45% of Total Billed Charges,1604.47,90,,6336,Percent of Total Billed Charges,90% of Total billed Charges,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1158.78,65,,1261.544,Percent of total Billed Charges,65% of Total Billed Charges,786.19,44.1,,656.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,1693.6,95,,6688,Percent of Total Billed Charges,95% of Total Billed Charges,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1568.81,88,,1309.44,Percent of Total Billed Charges,88% of Total Billed Charges,1604.47,90,,6336,Percent of Total Billed charges,90% of Total Billed Charges,786.19,1782.74,
ADRENAL IMAGING,3410000049,CDM,341,RC,,,Outpatient,,,3053.40,1984.71,,3053.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2320.58,76,,12646.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2198.45,72,,7733.512,Percent of Total Billed Charges,72% of Total Billed Charges,2290.05,75,,8055.736,Percent of Total Billed charges,75% of Total Billed Charges,3053.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2198.45,72,,7733.512,Percent of Total Billed Charges,72% of Total Billed Charges,1832.04,60,,6444.592,Percent of Total Billed Charges,60% of Total Billed Charges,2748.06,90,,505.44,Percent of Total Billed Charges,90% of Total Billed Charges,1374.03,45,,669.6,Percent of Total Billed Charges,45% of Total Billed Charges,2748.06,90,,14976,Percent of Total Billed Charges,90% of Total billed Charges,3053.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3053.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3053.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1984.71,65,,1176.984,Percent of total Billed Charges,65% of Total Billed Charges,1346.55,44.1,,656.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,2900.73,95,,15808,Percent of Total Billed Charges,95% of Total Billed Charges,3053.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2686.99,88,,972.368,Percent of Total Billed Charges,88% of Total Billed Charges,2748.06,90,,14976,Percent of Total Billed charges,90% of Total Billed Charges,1346.55,3053.4,
SENTINEL WO IMG INJ ONLY,3410000050,CDM,341,RC,,,Outpatient,,,883.53,574.29,,883.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,671.48,76,,3483.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,636.14,72,,7864.36,Percent of Total Billed Charges,72% of Total Billed Charges,662.65,75,,8192.04,Percent of Total Billed charges,75% of Total Billed Charges,883.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,636.14,72,,7864.36,Percent of Total Billed Charges,72% of Total Billed Charges,530.12,60,,6553.632,Percent of Total Billed Charges,60% of Total Billed Charges,795.18,90,,370.08,Percent of Total Billed Charges,90% of Total Billed Charges,397.59,45,,497.232,Percent of Total Billed Charges,45% of Total Billed Charges,795.18,90,,4124.864,Percent of Total Billed Charges,90% of Total billed Charges,883.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,883.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,883.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,574.29,65,,928.2,Percent of total Billed Charges,65% of Total Billed Charges,389.64,44.1,,487.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,839.35,95,,4354.024,Percent of Total Billed Charges,95% of Total Billed Charges,883.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,777.51,88,,486.184,Percent of Total Billed Charges,88% of Total Billed Charges,795.18,90,,4124.864,Percent of Total Billed charges,90% of Total Billed Charges,389.64,883.53,
VASCULAR FLOW NON CARDIAC,3410000051,CDM,341,RC,,,Outpatient,,,883.53,574.29,,883.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,671.48,76,,1130.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,636.14,72,,23691.832,Percent of Total Billed Charges,72% of Total Billed Charges,662.65,75,,24678.992,Percent of Total Billed charges,75% of Total Billed Charges,883.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,636.14,72,,23691.832,Percent of Total Billed Charges,72% of Total Billed Charges,530.12,60,,19743.192,Percent of Total Billed Charges,60% of Total Billed Charges,795.18,90,,390.312,Percent of Total Billed Charges,90% of Total Billed Charges,397.59,45,,248.616,Percent of Total Billed Charges,45% of Total Billed Charges,795.18,90,,1339.2,Percent of Total Billed Charges,90% of Total billed Charges,883.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,883.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,883.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,574.29,65,,1132.24,Percent of total Billed Charges,65% of Total Billed Charges,389.64,44.1,,243.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,839.35,95,,1413.6,Percent of Total Billed Charges,95% of Total Billed Charges,883.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,777.51,88,,469.568,Percent of Total Billed Charges,88% of Total Billed Charges,795.18,90,,1339.2,Percent of Total Billed charges,90% of Total Billed Charges,389.64,883.53,
NM Mandible SPECT,3410000052,CDM,341,RC,,,Outpatient,,,3139.98,2040.99,,3139.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2386.38,76,,1130.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2260.79,72,,5188.608,Percent of Total Billed Charges,72% of Total Billed Charges,2354.99,75,,5404.8,Percent of Total Billed charges,75% of Total Billed Charges,3139.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2260.79,72,,5188.608,Percent of Total Billed Charges,72% of Total Billed Charges,1883.99,60,,4323.84,Percent of Total Billed Charges,60% of Total Billed Charges,2825.98,90,,3116.28,Percent of Total Billed Charges,90% of Total Billed Charges,1412.99,45,,240.12,Percent of Total Billed Charges,45% of Total Billed Charges,2825.98,90,,1339.2,Percent of Total Billed Charges,90% of Total billed Charges,3139.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3139.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3139.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2040.99,65,,1760.032,Percent of total Billed Charges,65% of Total Billed Charges,1384.73,44.1,,235.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,2982.98,95,,1413.6,Percent of Total Billed Charges,95% of Total Billed Charges,3139.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2763.18,88,,561.792,Percent of Total Billed Charges,88% of Total Billed Charges,2825.98,90,,1339.2,Percent of Total Billed charges,90% of Total Billed Charges,1384.73,3139.98,
NM THYROID THPY ORAL,3420000001,CDM,342,RC,,,Outpatient,,,1330.00,864.50,,1330,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1010.8,76,,1130.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,957.6,72,,8311.928,Percent of Total Billed Charges,72% of Total Billed Charges,997.5,75,,8658.256,Percent of Total Billed charges,75% of Total Billed Charges,1330,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,957.6,72,,8311.928,Percent of Total Billed Charges,72% of Total Billed Charges,798,60,,6926.608,Percent of Total Billed Charges,60% of Total Billed Charges,1197,90,,1075.68,Percent of Total Billed Charges,90% of Total Billed Charges,598.5,45,,287.28,Percent of Total Billed Charges,45% of Total Billed Charges,1197,90,,1339.2,Percent of Total Billed Charges,90% of Total billed Charges,1330,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1330,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1330,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,864.5,65,,2677.312,Percent of total Billed Charges,65% of Total Billed Charges,586.53,44.1,,281.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,1263.5,95,,1413.6,Percent of Total Billed Charges,95% of Total Billed Charges,1330,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170.4,88,,561.792,Percent of Total Billed Charges,88% of Total Billed Charges,1197,90,,1339.2,Percent of Total Billed charges,90% of Total Billed Charges,586.53,1330,
SESTAMIBI 40MCI,3430000001,CDM,343,RC,A9500,HCPCS,Outpatient,,,597.77,388.55,,597.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,454.31,76,,839.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,476.46,350,,1218.816,Fee Schedule,350% of BCBS fee schedule,476.46,350,,1269.6,Fee Schedule,350% of BCBS fee schedule,597.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.46,350,,1218.816,Fee Schedule,350% of BCBS PPO fee schedule,136.13,100,,1015.68,Fee Schedule,100% of Blue ADV HMO fee schedule,537.99,90,,311.168,Percent of Total Billed Charges,90% of Total Billed Charges,269,45,,287.28,Percent of Total Billed Charges,45% of Total Billed Charges,537.99,90,,994.464,Percent of Total Billed Charges,90% of Total billed Charges,597.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,597.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,597.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,388.55,65,,1123.2,Percent of total Billed Charges,65% of Total Billed Charges,263.62,44.1,,281.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,567.88,95,,1049.712,Percent of Total Billed Charges,95% of Total Billed Charges,597.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,526.04,88,,494.208,Percent of Total Billed Charges,88% of Total Billed Charges,537.99,90,,994.464,Percent of Total Billed charges,90% of Total Billed Charges,136.13,597.77,
TC99M MDP 30 MCI,3430000002,CDM,343,RC,A9503,HCPCS,Outpatient,,,330.20,214.63,,330.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,250.95,76,,419.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.33,350,,3189.808,Fee Schedule,350% of BCBS fee schedule,45.33,350,,3322.72,Fee Schedule,350% of BCBS fee schedule,330.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.33,350,,3189.808,Fee Schedule,350% of BCBS PPO fee schedule,12.95,100,,2658.176,Fee Schedule,100% of Blue ADV HMO fee schedule,297.18,90,,2955.6,Percent of Total Billed Charges,90% of Total Billed Charges,148.59,45,,252.72,Percent of Total Billed Charges,45% of Total Billed Charges,297.18,90,,497.232,Percent of Total Billed Charges,90% of Total billed Charges,330.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.63,65,,2676.736,Percent of total Billed Charges,65% of Total Billed Charges,145.62,44.1,,247.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,313.69,95,,524.856,Percent of Total Billed Charges,95% of Total Billed Charges,330.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290.58,88,,361.856,Percent of Total Billed Charges,88% of Total Billed Charges,297.18,90,,497.232,Percent of Total Billed charges,90% of Total Billed Charges,12.95,330.2,
ACUTECT 20MCI,3430000003,CDM,343,RC,A9504,HCPCS,Outpatient,,,1782.74,1158.78,,1782.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1354.88,76,,405.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1283.57,72,,3189.808,Percent of Total Billed Charges,72% of Total Billed Charges,1337.06,75,,3322.72,Percent of Total Billed charges,75% of Total Billed Charges,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1283.57,72,,3189.808,Percent of Total Billed Charges,72% of Total Billed Charges,1069.64,60,,2658.176,Percent of Total Billed Charges,60% of Total Billed Charges,1604.47,90,,4793.984,Percent of Total Billed Charges,90% of Total Billed Charges,802.23,45,,185.04,Percent of Total Billed Charges,45% of Total Billed Charges,1604.47,90,,480.24,Percent of Total Billed Charges,90% of Total billed Charges,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1158.78,65,,1755.128,Percent of total Billed Charges,65% of Total Billed Charges,786.19,44.1,,181.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,1693.6,95,,506.92,Percent of Total Billed Charges,95% of Total Billed Charges,1782.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1568.81,88,,381.64,Percent of Total Billed Charges,88% of Total Billed Charges,1604.47,90,,480.24,Percent of Total Billed charges,90% of Total Billed Charges,786.19,1782.74,
TL201 PER MCI,3430000004,CDM,343,RC,A9505,HCPCS,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,485.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,350,,8477.784,Fee Schedule,350% of BCBS fee schedule,101.61,350,,8831.032,Fee Schedule,350% of BCBS fee schedule,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,350,,8477.784,Fee Schedule,350% of BCBS PPO fee schedule,29.03,100,,7064.824,Fee Schedule,100% of Blue ADV HMO fee schedule,49.62,90,,1177.016,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,195.16,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,574.56,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,2730.632,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,191.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,606.48,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,3047.032,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,574.56,Percent of Total Billed charges,90% of Total Billed Charges,24.31,101.61,
TC99M PERTEC PER MCI,3430000005,CDM,343,RC,A9512,HCPCS,Outpatient,,,45.20,29.38,,45.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.35,76,,485.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.76,350,,13021.496,Fee Schedule,350% of BCBS fee schedule,13.76,350,,13564.056,Fee Schedule,350% of BCBS fee schedule,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.76,350,,13021.496,Fee Schedule,350% of BCBS PPO fee schedule,3.93,100,,10851.248,Fee Schedule,100% of Blue ADV HMO fee schedule,40.68,90,,2383.2,Percent of Total Billed Charges,90% of Total Billed Charges,20.34,45,,1558.144,Percent of Total Billed Charges,45% of Total Billed Charges,40.68,90,,574.56,Percent of Total Billed Charges,90% of Total billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.38,65,,1182.144,Percent of total Billed Charges,65% of Total Billed Charges,19.93,44.1,,1526.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.94,95,,606.48,Percent of Total Billed Charges,95% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.78,88,,1051.776,Percent of Total Billed Charges,88% of Total Billed Charges,40.68,90,,574.56,Percent of Total Billed charges,90% of Total Billed Charges,3.93,45.2,
I123 CAP PER 100 UCI,3430000006,CDM,343,RC,A9516,HCPCS,Outpatient,,,302.09,196.36,,302.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,229.59,76,,426.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,630.46,350,,21439.872,Fee Schedule,350% of BCBS fee schedule,630.46,350,,22333.2,Fee Schedule,350% of BCBS fee schedule,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,630.46,350,,21439.872,Fee Schedule,350% of BCBS PPO fee schedule,180.13,100,,17866.56,Fee Schedule,100% of Blue ADV HMO fee schedule,271.88,90,,5020.56,Percent of Total Billed Charges,90% of Total Billed Charges,135.94,45,,537.84,Percent of Total Billed Charges,45% of Total Billed Charges,271.88,90,,505.44,Percent of Total Billed Charges,90% of Total billed Charges,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.36,65,,1112.28,Percent of total Billed Charges,65% of Total Billed Charges,133.22,44.1,,527.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,286.99,95,,533.52,Percent of Total Billed Charges,95% of Total Billed Charges,302.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.84,88,,304.256,Percent of Total Billed Charges,88% of Total Billed Charges,271.88,90,,505.44,Percent of Total Billed charges,90% of Total Billed Charges,133.22,630.46,
TC99 NM LYMPHOSEEK 0.5MCI,3430000007,CDM,343,RC,A9520,HCPCS,Outpatient,,,900.00,585.00,,900,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,684,76,,312.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1634.47,350,,8477.784,Fee Schedule,350% of BCBS fee schedule,1634.47,350,,8831.032,Fee Schedule,350% of BCBS fee schedule,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1634.47,350,,8477.784,Fee Schedule,350% of BCBS PPO fee schedule,466.99,100,,7064.824,Fee Schedule,100% of Blue ADV HMO fee schedule,810,90,,4729.28,Percent of Total Billed Charges,90% of Total Billed Charges,405,45,,155.584,Percent of Total Billed Charges,45% of Total Billed Charges,810,90,,370.08,Percent of Total Billed Charges,90% of Total billed Charges,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,585,65,,1112.28,Percent of total Billed Charges,65% of Total Billed Charges,396.9,44.1,,152.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,855,95,,390.64,Percent of Total Billed Charges,95% of Total Billed Charges,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,792,88,,2889.92,Percent of Total Billed Charges,88% of Total Billed Charges,810,90,,370.08,Percent of Total Billed charges,90% of Total Billed Charges,396.9,1634.47,
TC99 CHOLETEC 15MCI,3430000008,CDM,343,RC,A9537,HCPCS,Outpatient,,,671.40,436.41,,671.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,510.26,76,,329.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,192.85,350,,8054.208,Fee Schedule,350% of BCBS fee schedule,192.85,350,,8389.8,Fee Schedule,350% of BCBS fee schedule,671.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.85,350,,8054.208,Fee Schedule,350% of BCBS PPO fee schedule,55.1,100,,6711.84,Fee Schedule,100% of Blue ADV HMO fee schedule,604.26,90,,14668.56,Percent of Total Billed Charges,90% of Total Billed Charges,302.13,45,,1477.8,Percent of Total Billed Charges,45% of Total Billed Charges,604.26,90,,390.312,Percent of Total Billed Charges,90% of Total billed Charges,671.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,671.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,671.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,436.41,65,,2730.632,Percent of total Billed Charges,65% of Total Billed Charges,296.09,44.1,,1448.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,637.83,95,,412,Percent of Total Billed Charges,95% of Total Billed Charges,671.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,590.83,88,,4687.448,Percent of Total Billed Charges,88% of Total Billed Charges,604.26,90,,390.312,Percent of Total Billed charges,90% of Total Billed Charges,55.1,671.4,
NM PYP KIT,3430000009,CDM,343,RC,A9538,HCPCS,Outpatient,,,1130.01,734.51,,1130.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,858.81,76,,2631.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,139.44,350,,14298.048,Fee Schedule,350% of BCBS fee schedule,139.44,350,,14893.8,Fee Schedule,350% of BCBS fee schedule,1130.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.44,350,,14298.048,Fee Schedule,350% of BCBS PPO fee schedule,39.84,100,,11915.04,Fee Schedule,100% of Blue ADV HMO fee schedule,1017.01,90,,776.16,Percent of Total Billed Charges,90% of Total Billed Charges,508.5,45,,2396.992,Percent of Total Billed Charges,45% of Total Billed Charges,1017.01,90,,3116.28,Percent of Total Billed Charges,90% of Total billed Charges,1130.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1130.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1130.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,734.51,65,,2676.736,Percent of total Billed Charges,65% of Total Billed Charges,498.33,44.1,,2349.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1073.51,95,,3289.408,Percent of Total Billed Charges,95% of Total Billed Charges,1130.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.41,88,,1150.856,Percent of Total Billed Charges,88% of Total Billed Charges,1017.01,90,,3116.28,Percent of Total Billed charges,90% of Total Billed Charges,39.84,1130.01,
NM PYP KIT / TC99M PERTEC MCI,3430000010,CDM,343,RC,A9538,HCPCS,Outpatient,,,1130.01,734.51,,1130.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,858.81,76,,908.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,139.44,350,,11335.104,Fee Schedule,350% of BCBS fee schedule,139.44,350,,11807.4,Fee Schedule,350% of BCBS fee schedule,1130.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.44,350,,11335.104,Fee Schedule,350% of BCBS PPO fee schedule,39.84,100,,9445.92,Fee Schedule,100% of Blue ADV HMO fee schedule,1017.01,90,,3707.048,Percent of Total Billed Charges,90% of Total Billed Charges,508.5,45,,588.504,Percent of Total Billed Charges,45% of Total Billed Charges,1017.01,90,,1075.68,Percent of Total Billed Charges,90% of Total billed Charges,1130.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1130.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1130.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,734.51,65,,2804.88,Percent of total Billed Charges,65% of Total Billed Charges,498.33,44.1,,576.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,1073.51,95,,1135.44,Percent of Total Billed Charges,95% of Total Billed Charges,1130.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.41,88,,2330.24,Percent of Total Billed Charges,88% of Total Billed Charges,1017.01,90,,1075.68,Percent of Total Billed charges,90% of Total Billed Charges,39.84,1130.01,
TC99M DTPA 25MCI,3430000011,CDM,343,RC,A9539,HCPCS,Outpatient,,,133.40,86.71,,133.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,101.38,76,,262.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,109.24,350,,16592.352,Fee Schedule,350% of BCBS fee schedule,109.24,350,,17283.696,Fee Schedule,350% of BCBS fee schedule,133.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.24,350,,16592.352,Fee Schedule,350% of BCBS PPO fee schedule,31.21,100,,13826.96,Fee Schedule,100% of Blue ADV HMO fee schedule,120.06,90,,350.64,Percent of Total Billed Charges,90% of Total Billed Charges,60.03,45,,1191.6,Percent of Total Billed Charges,45% of Total Billed Charges,120.06,90,,311.168,Percent of Total Billed Charges,90% of Total billed Charges,133.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.71,65,,3264.376,Percent of total Billed Charges,65% of Total Billed Charges,58.83,44.1,,1167.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,126.73,95,,328.456,Percent of Total Billed Charges,95% of Total Billed Charges,133.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.39,88,,4908.992,Percent of Total Billed Charges,88% of Total Billed Charges,120.06,90,,311.168,Percent of Total Billed charges,90% of Total Billed Charges,31.21,133.4,
TC99M MAA 10MCI,3430000012,CDM,343,RC,A9540,HCPCS,Outpatient,,,653.94,425.06,,653.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,496.99,76,,2495.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.55,350,,12427.776,Fee Schedule,350% of BCBS fee schedule,69.55,350,,12945.6,Fee Schedule,350% of BCBS fee schedule,653.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.55,350,,12427.776,Fee Schedule,350% of BCBS PPO fee schedule,19.87,100,,10356.48,Fee Schedule,100% of Blue ADV HMO fee schedule,588.55,90,,2016,Percent of Total Billed Charges,90% of Total Billed Charges,294.27,45,,2510.28,Percent of Total Billed Charges,45% of Total Billed Charges,588.55,90,,2955.6,Percent of Total Billed Charges,90% of Total billed Charges,653.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,653.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,653.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,425.06,65,,2677.312,Percent of total Billed Charges,65% of Total Billed Charges,288.39,44.1,,2460.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,621.24,95,,3119.8,Percent of Total Billed Charges,95% of Total Billed Charges,653.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.47,88,,4624.184,Percent of Total Billed Charges,88% of Total Billed Charges,588.55,90,,2955.6,Percent of Total Billed charges,90% of Total Billed Charges,19.87,653.94,
TC99 SULFUR COLL 20MCI,3430000013,CDM,343,RC,A9541,HCPCS,Outpatient,,,466.40,303.16,,466.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,354.46,76,,4048.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,186.41,350,,15050.448,Fee Schedule,350% of BCBS fee schedule,186.41,350,,15677.552,Fee Schedule,350% of BCBS fee schedule,466.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.41,350,,15050.448,Fee Schedule,350% of BCBS PPO fee schedule,53.26,100,,12542.04,Fee Schedule,100% of Blue ADV HMO fee schedule,419.76,90,,3242.672,Percent of Total Billed Charges,90% of Total Billed Charges,209.88,45,,2364.64,Percent of Total Billed Charges,45% of Total Billed Charges,419.76,90,,4793.984,Percent of Total Billed Charges,90% of Total billed Charges,466.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,466.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,466.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.16,65,,3101.28,Percent of total Billed Charges,65% of Total Billed Charges,205.68,44.1,,2317.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,443.08,95,,5060.312,Percent of Total Billed Charges,95% of Total Billed Charges,466.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,410.43,88,,14342.592,Percent of Total Billed Charges,88% of Total Billed Charges,419.76,90,,4793.984,Percent of Total Billed charges,90% of Total Billed Charges,53.26,466.4,
GALLIUM GA67 PER MCI,3430000014,CDM,343,RC,A9556,HCPCS,Outpatient,,,66.15,43.00,,66.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,50.27,76,,993.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,346.19,350,,11311.928,Fee Schedule,350% of BCBS fee schedule,346.19,350,,11783.264,Fee Schedule,350% of BCBS fee schedule,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.19,350,,11311.928,Fee Schedule,350% of BCBS PPO fee schedule,98.91,100,,9426.608,Fee Schedule,100% of Blue ADV HMO fee schedule,59.54,90,,3242.672,Percent of Total Billed Charges,90% of Total Billed Charges,29.77,45,,7334.28,Percent of Total Billed Charges,45% of Total Billed Charges,59.54,90,,1177.016,Percent of Total Billed Charges,90% of Total billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,65,,1123.2,Percent of total Billed Charges,65% of Total Billed Charges,29.17,44.1,,7187.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.84,95,,1242.4,Percent of Total Billed Charges,95% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.21,88,,758.912,Percent of Total Billed Charges,88% of Total Billed Charges,59.54,90,,1177.016,Percent of Total Billed charges,90% of Total Billed Charges,29.17,346.19,
TC99M ULTRATAG 30MCI,3430000015,CDM,343,RC,A9560,HCPCS,Outpatient,,,401.31,260.85,,401.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,305,76,,2012.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,325.61,350,,12957.984,Fee Schedule,350% of BCBS fee schedule,325.61,350,,13497.904,Fee Schedule,350% of BCBS fee schedule,401.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.61,350,,12957.984,Fee Schedule,350% of BCBS PPO fee schedule,93.03,100,,10798.32,Fee Schedule,100% of Blue ADV HMO fee schedule,361.18,90,,7861.968,Percent of Total Billed Charges,90% of Total Billed Charges,180.59,45,,388.08,Percent of Total Billed Charges,45% of Total Billed Charges,361.18,90,,2383.2,Percent of Total Billed Charges,90% of Total billed Charges,401.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.85,65,,761.28,Percent of total Billed Charges,65% of Total Billed Charges,176.98,44.1,,380.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,381.24,95,,2515.6,Percent of Total Billed Charges,95% of Total Billed Charges,401.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.15,88,,3624.672,Percent of Total Billed Charges,88% of Total Billed Charges,361.18,90,,2383.2,Percent of Total Billed charges,90% of Total Billed Charges,93.03,401.31,
TC99M MAG3 15 MCI,3430000016,CDM,343,RC,A9562,HCPCS,Outpatient,,,943.74,613.43,,943.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,717.24,76,,4239.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2700.88,350,,5588.152,Fee Schedule,350% of BCBS fee schedule,2700.88,350,,5820.992,Fee Schedule,350% of BCBS fee schedule,943.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2700.88,350,,5588.152,Fee Schedule,350% of BCBS PPO fee schedule,771.68,100,,4656.792,Fee Schedule,100% of Blue ADV HMO fee schedule,849.37,90,,8684.192,Percent of Total Billed Charges,90% of Total Billed Charges,424.68,45,,1853.528,Percent of Total Billed Charges,45% of Total Billed Charges,849.37,90,,5020.56,Percent of Total Billed Charges,90% of Total billed Charges,943.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,943.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,943.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,613.43,65,,1372.8,Percent of total Billed Charges,65% of Total Billed Charges,416.19,44.1,,1816.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,896.55,95,,5299.48,Percent of Total Billed Charges,95% of Total Billed Charges,943.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,830.49,88,,342.848,Percent of Total Billed Charges,88% of Total Billed Charges,849.37,90,,5020.56,Percent of Total Billed charges,90% of Total Billed Charges,416.19,2700.88,
I131 IODIDE CAP RX PER 1MCI,3440000001,CDM,344,RC,A9517,HCPCS,Outpatient,,,40.70,26.46,,28.91,125,,,Fee Schedule,125% of CMS OPPS Rate,30.93,76,,3993.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,124.46,350,,12547.76,Fee Schedule,350% of BCBS fee schedule,124.46,350,,13070.584,Fee Schedule,350% of BCBS fee schedule,23.13,100,,,Fee Schedule,100% of CMS OPPS Rate,124.46,350,,12547.76,Fee Schedule,350% of BCBS PPO fee schedule,35.56,100,,10456.464,Fee Schedule,100% of Blue ADV HMO fee schedule,36.63,90,,663.12,Percent of Total Billed Charges,90% of Total Billed Charges,18.32,45,,175.32,Percent of Total Billed Charges,45% of Total Billed Charges,36.63,90,,4729.28,Percent of Total Billed Charges,90% of Total billed Charges,23.13,100,,,Fee Schedule,100% of CMS OPPS Rate,23.13,100,,,Fee Schedule,100% of CMS OPPS Rate,23.13,100,,,Fee Schedule,100% of CMS OPPS Rate,46.26,200,,662.16,Fee Schedule,200% of CMS OPPS Rate,17.95,44.1,,171.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,38.67,95,,4992.016,Percent of Total Billed Charges,95% of Total Billed Charges,17.34,75,,,Fee Schedule,75% of CMS OPPS Rate,35.82,88,,1971.2,Percent of Total Billed Charges,88% of Total Billed Charges,36.63,90,,4729.28,Percent of Total Billed charges,90% of Total Billed Charges,17.34,124.46,
INJ CYSTOGRPH/URETHROCYSTO,3500000001,CDM,320,RC,,,Outpatient,,,1029.74,669.33,,1029.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,782.6,76,,12386.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,741.41,72,,6478.992,Percent of Total Billed Charges,72% of Total Billed Charges,772.31,75,,6748.952,Percent of Total Billed charges,75% of Total Billed Charges,1029.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,741.41,72,,6478.992,Percent of Total Billed Charges,72% of Total Billed Charges,617.84,60,,5399.16,Percent of Total Billed Charges,60% of Total Billed Charges,926.77,90,,293.712,Percent of Total Billed Charges,90% of Total Billed Charges,463.38,45,,1008,Percent of Total Billed Charges,45% of Total Billed Charges,926.77,90,,14668.56,Percent of Total Billed Charges,90% of Total billed Charges,1029.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1029.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1029.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,669.33,65,,687.392,Percent of total Billed Charges,65% of Total Billed Charges,454.12,44.1,,987.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,978.25,95,,15483.48,Percent of Total Billed Charges,95% of Total Billed Charges,1029.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,906.17,88,,3170.608,Percent of Total Billed Charges,88% of Total Billed Charges,926.77,90,,14668.56,Percent of Total Billed charges,90% of Total Billed Charges,454.12,1029.74,
CT  INJ OF CONTR KNEE ARTHROGR,3500000002,CDM,350,RC,,,Outpatient,,,437.69,284.50,,437.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,332.64,76,,655.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,315.14,72,,5655.952,Percent of Total Billed Charges,72% of Total Billed Charges,328.27,75,,5891.616,Percent of Total Billed charges,75% of Total Billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.14,72,,5655.952,Percent of Total Billed Charges,72% of Total Billed Charges,262.61,60,,4713.296,Percent of Total Billed Charges,60% of Total Billed Charges,393.92,90,,2121.824,Percent of Total Billed Charges,90% of Total Billed Charges,196.96,45,,1621.336,Percent of Total Billed Charges,45% of Total Billed Charges,393.92,90,,776.16,Percent of Total Billed Charges,90% of Total billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.5,65,,767.08,Percent of total Billed Charges,65% of Total Billed Charges,193.02,44.1,,1588.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,415.81,95,,819.28,Percent of Total Billed Charges,95% of Total Billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.17,88,,3170.608,Percent of Total Billed Charges,88% of Total Billed Charges,393.92,90,,776.16,Percent of Total Billed charges,90% of Total Billed Charges,193.02,437.69,
CT ABD/RETROPERITONEL MAS BIOP,3500000003,CDM,350,RC,,,Outpatient,,,2619.00,1702.35,,2619,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1990.44,76,,3130.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1885.68,72,,8079.696,Percent of Total Billed Charges,72% of Total Billed Charges,1964.25,75,,8416.352,Percent of Total Billed charges,75% of Total Billed Charges,2619,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1885.68,72,,8079.696,Percent of Total Billed Charges,72% of Total Billed Charges,1571.4,60,,6733.08,Percent of Total Billed Charges,60% of Total Billed Charges,2357.1,90,,353.24,Percent of Total Billed Charges,90% of Total Billed Charges,1178.55,45,,1621.336,Percent of Total Billed Charges,45% of Total Billed Charges,2357.1,90,,3707.048,Percent of Total Billed Charges,90% of Total billed Charges,2619,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2619,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2619,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1702.35,65,,1811.344,Percent of total Billed Charges,65% of Total Billed Charges,1154.98,44.1,,1588.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,2488.05,95,,3913,Percent of Total Billed Charges,95% of Total Billed Charges,2619,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2304.72,88,,7687.256,Percent of Total Billed Charges,88% of Total Billed Charges,2357.1,90,,3707.048,Percent of Total Billed charges,90% of Total Billed Charges,1154.98,2619,
CT EXC DRAINAGE CATH W/ GUID,3500000004,CDM,350,RC,,,Outpatient,,,3685.00,2395.25,,3685,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2800.6,76,,296.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2653.2,72,,5367.232,Percent of Total Billed Charges,72% of Total Billed Charges,2763.75,75,,5590.864,Percent of Total Billed charges,75% of Total Billed Charges,3685,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2653.2,72,,5367.232,Percent of Total Billed Charges,72% of Total Billed Charges,2211,60,,4472.696,Percent of Total Billed Charges,60% of Total Billed Charges,3316.5,90,,1567.72,Percent of Total Billed Charges,90% of Total Billed Charges,1658.25,45,,3930.984,Percent of Total Billed Charges,45% of Total Billed Charges,3316.5,90,,350.64,Percent of Total Billed Charges,90% of Total billed Charges,3685,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3685,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3685,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2395.25,65,,934.44,Percent of total Billed Charges,65% of Total Billed Charges,1625.09,44.1,,3852.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,3500.75,95,,370.12,Percent of Total Billed Charges,95% of Total Billed Charges,3685,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3242.8,88,,8491.208,Percent of Total Billed Charges,88% of Total Billed Charges,3316.5,90,,350.64,Percent of Total Billed charges,90% of Total Billed Charges,1625.09,3685,
CT FNA BIOPSY GDN  EA ADDL LES,3500000005,CDM,350,RC,,,Outpatient,,,600.00,390.00,,600,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,456,76,,1702.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,432,72,,12045.44,Percent of Total Billed Charges,72% of Total Billed Charges,450,75,,12547.336,Percent of Total Billed charges,75% of Total Billed Charges,600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,432,72,,12045.44,Percent of Total Billed Charges,72% of Total Billed Charges,360,60,,10037.864,Percent of Total Billed Charges,60% of Total Billed Charges,540,90,,1044.184,Percent of Total Billed Charges,90% of Total Billed Charges,270,45,,4342.096,Percent of Total Billed Charges,45% of Total Billed Charges,540,90,,2016,Percent of Total Billed Charges,90% of Total billed Charges,600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390,65,,2496,Percent of total Billed Charges,65% of Total Billed Charges,264.6,44.1,,4255.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,570,95,,2128,Percent of Total Billed Charges,95% of Total Billed Charges,600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,528,88,,648.384,Percent of Total Billed Charges,88% of Total Billed Charges,540,90,,2016,Percent of Total Billed charges,90% of Total Billed Charges,264.6,600,
CT INJ  SACROILIAC JNT W/ IMAG,3500000006,CDM,350,RC,G0260,HCPCS,Outpatient,,,1908.00,1240.20,,870.53,125,,,Fee Schedule,125% of CMS OPPS Rate,1450.08,76,,2738.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1373.76,72,,5825.856,Percent of Total Billed Charges,72% of Total Billed Charges,1431,75,,6068.608,Percent of Total Billed charges,75% of Total Billed Charges,696.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1373.76,72,,5825.856,Percent of Total Billed Charges,72% of Total Billed Charges,1144.8,60,,4854.88,Percent of Total Billed Charges,60% of Total Billed Charges,1717.2,90,,1746.76,Percent of Total Billed Charges,90% of Total Billed Charges,858.6,45,,331.56,Percent of Total Billed Charges,45% of Total Billed Charges,1717.2,90,,3242.672,Percent of Total Billed Charges,90% of Total billed Charges,696.42,100,,,Fee Schedule,100% of CMS OPPS Rate,696.42,100,,,Fee Schedule,100% of CMS OPPS Rate,696.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1300.52,200,,1714.936,Fee Schedule,200% of CMS OPPS Rate,841.43,44.1,,324.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,1812.6,95,,3422.816,Percent of Total Billed Charges,95% of Total Billed Charges,522.3,75,,,Fee Schedule,75% of CMS OPPS Rate,1679.04,88,,287.184,Percent of Total Billed Charges,88% of Total Billed Charges,1717.2,90,,3242.672,Percent of Total Billed charges,90% of Total Billed Charges,522.3,1812.6,
CT INJ SINUS TRACT THERAPEUTIC,3500000007,CDM,350,RC,,,Outpatient,,,1601.93,1041.25,,1601.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1217.47,76,,2738.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1153.39,72,,13263.552,Percent of Total Billed Charges,72% of Total Billed Charges,1201.45,75,,13816.2,Percent of Total Billed charges,75% of Total Billed Charges,1601.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1153.39,72,,13263.552,Percent of Total Billed Charges,72% of Total Billed Charges,961.16,60,,11052.96,Percent of Total Billed Charges,60% of Total Billed Charges,1441.74,90,,1629.672,Percent of Total Billed Charges,90% of Total Billed Charges,720.87,45,,146.856,Percent of Total Billed Charges,45% of Total Billed Charges,1441.74,90,,3242.672,Percent of Total Billed Charges,90% of Total billed Charges,1601.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1601.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1601.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1041.25,65,,4034.336,Percent of total Billed Charges,65% of Total Billed Charges,706.45,44.1,,143.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,1521.83,95,,3422.816,Percent of Total Billed Charges,95% of Total Billed Charges,1601.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1409.7,88,,2074.672,Percent of Total Billed Charges,88% of Total Billed Charges,1441.74,90,,3242.672,Percent of Total Billed charges,90% of Total Billed Charges,706.45,1601.93,
CT PERCU DRNGE PERITON/VISCER,3500000008,CDM,350,RC,,,Outpatient,,,1957.00,1272.05,,1957,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1487.32,76,,6638.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1409.04,72,,7347.456,Percent of Total Billed Charges,72% of Total Billed Charges,1467.75,75,,7653.6,Percent of Total Billed charges,75% of Total Billed Charges,1957,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1409.04,72,,7347.456,Percent of Total Billed Charges,72% of Total Billed Charges,1174.2,60,,6122.88,Percent of Total Billed Charges,60% of Total Billed Charges,1761.3,90,,1285.2,Percent of Total Billed Charges,90% of Total Billed Charges,880.65,45,,1060.912,Percent of Total Billed Charges,45% of Total Billed Charges,1761.3,90,,7861.968,Percent of Total Billed Charges,90% of Total billed Charges,1957,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1957,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1957,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1272.05,65,,780.048,Percent of total Billed Charges,65% of Total Billed Charges,863.04,44.1,,1039.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,1859.15,95,,8298.744,Percent of Total Billed Charges,95% of Total Billed Charges,1957,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1722.16,88,,345.392,Percent of Total Billed Charges,88% of Total Billed Charges,1761.3,90,,7861.968,Percent of Total Billed charges,90% of Total Billed Charges,863.04,1957,
CT PLEURAL DRNGE PERC W/ IMAG,3500000009,CDM,350,RC,,,Outpatient,,,1340.64,871.42,,1340.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1018.89,76,,7333.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,965.26,72,,5155.672,Percent of Total Billed Charges,72% of Total Billed Charges,1005.48,75,,5370.496,Percent of Total Billed charges,75% of Total Billed Charges,1340.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,965.26,72,,5155.672,Percent of Total Billed Charges,72% of Total Billed Charges,804.38,60,,4296.392,Percent of Total Billed Charges,60% of Total Billed Charges,1206.58,90,,1567.72,Percent of Total Billed Charges,90% of Total Billed Charges,603.29,45,,176.616,Percent of Total Billed Charges,45% of Total Billed Charges,1206.58,90,,8684.192,Percent of Total Billed Charges,90% of Total billed Charges,1340.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1340.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1340.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,871.42,65,,780.048,Percent of total Billed Charges,65% of Total Billed Charges,591.22,44.1,,173.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,1273.61,95,,9166.648,Percent of Total Billed Charges,95% of Total Billed Charges,1340.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1179.76,88,,1532.88,Percent of Total Billed Charges,88% of Total Billed Charges,1206.58,90,,8684.192,Percent of Total Billed charges,90% of Total Billed Charges,591.22,1340.64,
CT PLMT BILIARY DRGE CATH,3500000010,CDM,320,RC,,,Outpatient,,,7758.34,5042.92,,7758.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5896.34,76,,559.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5586,72,,5403.024,Percent of Total Billed Charges,72% of Total Billed Charges,5818.76,75,,5628.152,Percent of Total Billed charges,75% of Total Billed Charges,7758.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5586,72,,5403.024,Percent of Total Billed Charges,72% of Total Billed Charges,4655,60,,4502.52,Percent of Total Billed Charges,60% of Total Billed Charges,6982.51,90,,2436.968,Percent of Total Billed Charges,90% of Total Billed Charges,3491.25,45,,783.864,Percent of Total Billed Charges,45% of Total Billed Charges,6982.51,90,,663.12,Percent of Total Billed Charges,90% of Total billed Charges,7758.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7758.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7758.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5042.92,65,,780.048,Percent of total Billed Charges,65% of Total Billed Charges,3421.43,44.1,,768.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,7370.42,95,,699.96,Percent of Total Billed Charges,95% of Total Billed Charges,7758.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6827.34,88,,1020.976,Percent of Total Billed Charges,88% of Total Billed Charges,6982.51,90,,663.12,Percent of Total Billed charges,90% of Total Billed Charges,3421.43,7758.34,
CT PLMT BILIARY DRNGE CATH EXT,3500000011,CDM,320,RC,,,Outpatient,,,7743.00,5032.95,,7743,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5884.68,76,,248.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5574.96,72,,605.192,Percent of Total Billed Charges,72% of Total Billed Charges,5807.25,75,,630.408,Percent of Total Billed charges,75% of Total Billed Charges,7743,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5574.96,72,,605.192,Percent of Total Billed Charges,72% of Total Billed Charges,4645.8,60,,504.328,Percent of Total Billed Charges,60% of Total Billed Charges,6968.7,90,,3707.048,Percent of Total Billed Charges,90% of Total Billed Charges,3484.35,45,,522.088,Percent of Total Billed Charges,45% of Total Billed Charges,6968.7,90,,293.712,Percent of Total Billed Charges,90% of Total billed Charges,7743,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7743,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7743,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5032.95,65,,2237.04,Percent of total Billed Charges,65% of Total Billed Charges,3414.66,44.1,,511.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,7355.85,95,,310.024,Percent of Total Billed Charges,95% of Total Billed Charges,7743,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6813.84,88,,1707.936,Percent of Total Billed Charges,88% of Total Billed Charges,6968.7,90,,293.712,Percent of Total Billed charges,90% of Total Billed Charges,3414.66,7743,
CTPERCU DRGE TROPERITONEL ABCS,3500000012,CDM,350,RC,,,Outpatient,,,4251.00,2763.15,,4251,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3230.76,76,,1791.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3060.72,72,,386.496,Percent of Total Billed Charges,72% of Total Billed Charges,3188.25,75,,402.6,Percent of Total Billed charges,75% of Total Billed Charges,4251,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3060.72,72,,386.496,Percent of Total Billed Charges,72% of Total Billed Charges,2550.6,60,,322.08,Percent of Total Billed Charges,60% of Total Billed Charges,3825.9,90,,1555.2,Percent of Total Billed Charges,90% of Total Billed Charges,1912.95,45,,873.376,Percent of Total Billed Charges,45% of Total Billed Charges,3825.9,90,,2121.824,Percent of Total Billed Charges,90% of Total billed Charges,4251,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4251,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4251,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2763.15,65,,10593.96,Percent of total Billed Charges,65% of Total Billed Charges,1874.69,44.1,,855.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,4038.45,95,,2239.704,Percent of Total Billed Charges,95% of Total Billed Charges,4251,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3740.88,88,,1593.456,Percent of Total Billed Charges,88% of Total Billed Charges,3825.9,90,,2121.824,Percent of Total Billed charges,90% of Total Billed Charges,1874.69,4251,
CT FNA BIOPSY  INCDL GUIDANCE,3500000013,CDM,350,RC,,,Outpatient,,,1520.00,988.00,,1520,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1155.2,76,,298.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1094.4,72,,658.944,Percent of Total Billed Charges,72% of Total Billed Charges,1140,75,,686.4,Percent of Total Billed charges,75% of Total Billed Charges,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1094.4,72,,658.944,Percent of Total Billed Charges,72% of Total Billed Charges,912,60,,549.12,Percent of Total Billed Charges,60% of Total Billed Charges,1368,90,,3706.248,Percent of Total Billed Charges,90% of Total Billed Charges,684,45,,814.832,Percent of Total Billed Charges,45% of Total Billed Charges,1368,90,,353.24,Percent of Total Billed Charges,90% of Total billed Charges,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,988,65,,10593.96,Percent of total Billed Charges,65% of Total Billed Charges,670.32,44.1,,798.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,1444,95,,372.864,Percent of Total Billed Charges,95% of Total Billed Charges,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1337.6,88,,1256.64,Percent of Total Billed Charges,88% of Total Billed Charges,1368,90,,353.24,Percent of Total Billed charges,90% of Total Billed Charges,670.32,1520,
CT SINOGRAM DIAGNOSTIC,3500000014,CDM,350,RC,,,Outpatient,,,841.21,546.79,,841.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,639.32,76,,1323.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,605.67,72,,2526.336,Percent of Total Billed Charges,72% of Total Billed Charges,630.91,75,,2631.6,Percent of Total Billed charges,75% of Total Billed Charges,841.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,605.67,72,,2526.336,Percent of Total Billed Charges,72% of Total Billed Charges,504.73,60,,2105.28,Percent of Total Billed Charges,60% of Total Billed Charges,757.09,90,,2430.184,Percent of Total Billed Charges,90% of Total Billed Charges,378.54,45,,642.6,Percent of Total Billed Charges,45% of Total Billed Charges,757.09,90,,1567.72,Percent of Total Billed Charges,90% of Total billed Charges,841.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,841.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,841.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.79,65,,10593.96,Percent of total Billed Charges,65% of Total Billed Charges,370.97,44.1,,629.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,799.15,95,,1654.816,Percent of Total Billed Charges,95% of Total Billed Charges,841.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,740.26,88,,1532.88,Percent of Total Billed Charges,88% of Total Billed Charges,757.09,90,,1567.72,Percent of Total Billed charges,90% of Total Billed Charges,370.97,841.21,
CT THORACENTESIS W IMAGING,3500000015,CDM,350,RC,,,Outpatient,,,1854.00,1205.10,,1854,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1409.04,76,,881.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1334.88,72,,1064.448,Percent of Total Billed Charges,72% of Total Billed Charges,1390.5,75,,1108.8,Percent of Total Billed charges,75% of Total Billed Charges,1854,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1334.88,72,,1064.448,Percent of Total Billed Charges,72% of Total Billed Charges,1112.4,60,,887.04,Percent of Total Billed Charges,60% of Total Billed Charges,1668.6,90,,3780.872,Percent of Total Billed Charges,90% of Total Billed Charges,834.3,45,,783.864,Percent of Total Billed Charges,45% of Total Billed Charges,1668.6,90,,1044.184,Percent of Total Billed Charges,90% of Total billed Charges,1854,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1854,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1854,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1205.1,65,,267.16,Percent of total Billed Charges,65% of Total Billed Charges,817.61,44.1,,768.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,1761.3,95,,1102.192,Percent of Total Billed Charges,95% of Total Billed Charges,1854,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1631.52,88,,2382.816,Percent of Total Billed Charges,88% of Total Billed Charges,1668.6,90,,1044.184,Percent of Total Billed charges,90% of Total Billed Charges,817.61,1854,
CT BIOPSY LIVER,3500000016,CDM,350,RC,,,Outpatient,,,2933.00,1906.45,,2933,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2229.08,76,,1475.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2111.76,72,,1857.024,Percent of Total Billed Charges,72% of Total Billed Charges,2199.75,75,,1934.4,Percent of Total Billed charges,75% of Total Billed Charges,2933,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2111.76,72,,1857.024,Percent of Total Billed Charges,72% of Total Billed Charges,1759.8,60,,1547.52,Percent of Total Billed Charges,60% of Total Billed Charges,2639.7,90,,1636.816,Percent of Total Billed Charges,90% of Total Billed Charges,1319.85,45,,1218.488,Percent of Total Billed Charges,45% of Total Billed Charges,2639.7,90,,1746.76,Percent of Total Billed Charges,90% of Total billed Charges,2933,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2933,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2933,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1906.45,65,,801.24,Percent of total Billed Charges,65% of Total Billed Charges,1293.45,44.1,,1194.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,2786.35,95,,1843.8,Percent of Total Billed Charges,95% of Total Billed Charges,2933,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2581.04,88,,3624.672,Percent of Total Billed Charges,88% of Total Billed Charges,2639.7,90,,1746.76,Percent of Total Billed charges,90% of Total Billed Charges,1293.45,2933,
CT PANCREAS BIOPSY,3500000017,CDM,350,RC,,,Outpatient,,,2756.25,1791.56,,2756.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2094.75,76,,1376.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1984.5,72,,872.064,Percent of Total Billed Charges,72% of Total Billed Charges,2067.19,75,,908.4,Percent of Total Billed charges,75% of Total Billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1984.5,72,,872.064,Percent of Total Billed Charges,72% of Total Billed Charges,1653.75,60,,726.72,Percent of Total Billed Charges,60% of Total Billed Charges,2480.63,90,,1540.08,Percent of Total Billed Charges,90% of Total Billed Charges,1240.31,45,,1853.528,Percent of Total Billed Charges,45% of Total Billed Charges,2480.63,90,,1629.672,Percent of Total Billed Charges,90% of Total billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1791.56,65,,801.24,Percent of total Billed Charges,65% of Total Billed Charges,1215.51,44.1,,1816.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,2618.44,95,,1720.208,Percent of Total Billed Charges,95% of Total Billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2425.5,88,,1520.64,Percent of Total Billed Charges,88% of Total Billed Charges,2480.63,90,,1629.672,Percent of Total Billed charges,90% of Total Billed Charges,1215.51,2756.25,
PARACENTESIS WITH CT,3500000018,CDM,350,RC,,,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1085.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,872.064,Percent of Total Billed Charges,72% of Total Billed Charges,1500,75,,908.4,Percent of Total Billed charges,75% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,872.064,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,726.72,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,1540.08,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,777.6,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1285.2,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,823.256,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,762.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1356.6,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,3623.888,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1285.2,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
CT KIDNEY BIOPSY,3500000019,CDM,350,RC,,,Outpatient,,,2896.00,1882.40,,2896,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2200.96,76,,1323.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2085.12,72,,872.064,Percent of Total Billed Charges,72% of Total Billed Charges,2172,75,,908.4,Percent of Total Billed charges,75% of Total Billed Charges,2896,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2085.12,72,,872.064,Percent of Total Billed Charges,72% of Total Billed Charges,1737.6,60,,726.72,Percent of Total Billed Charges,60% of Total Billed Charges,2606.4,90,,3780.872,Percent of Total Billed Charges,90% of Total Billed Charges,1303.2,45,,1853.128,Percent of Total Billed Charges,45% of Total Billed Charges,2606.4,90,,1567.72,Percent of Total Billed Charges,90% of Total billed Charges,2896,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2896,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2896,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1882.4,65,,892.648,Percent of total Billed Charges,65% of Total Billed Charges,1277.14,44.1,,1816.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,2751.2,95,,1654.816,Percent of Total Billed Charges,95% of Total Billed Charges,2896,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2548.48,88,,2376.176,Percent of Total Billed Charges,88% of Total Billed Charges,2606.4,90,,1567.72,Percent of Total Billed charges,90% of Total Billed Charges,1277.14,2896,
CT UPPER EXT WO CONT,3500000020,CDM,350,RC,,,Outpatient,,,2452.00,1593.80,,2452,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1863.52,76,,2057.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1765.44,72,,3640.32,Percent of Total Billed Charges,72% of Total Billed Charges,1839,75,,3792,Percent of Total Billed charges,75% of Total Billed Charges,2452,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1765.44,72,,3640.32,Percent of Total Billed Charges,72% of Total Billed Charges,1471.2,60,,3033.6,Percent of Total Billed Charges,60% of Total Billed Charges,2206.8,90,,3706.248,Percent of Total Billed Charges,90% of Total Billed Charges,1103.4,45,,1215.088,Percent of Total Billed Charges,45% of Total Billed Charges,2206.8,90,,2436.968,Percent of Total Billed Charges,90% of Total billed Charges,2452,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2452,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2452,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1593.8,65,,761.28,Percent of total Billed Charges,65% of Total Billed Charges,1081.33,44.1,,1190.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,2329.4,95,,2572.36,Percent of Total Billed Charges,95% of Total Billed Charges,2452,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2157.76,88,,3696.848,Percent of Total Billed Charges,88% of Total Billed Charges,2206.8,90,,2436.968,Percent of Total Billed charges,90% of Total Billed Charges,1081.33,2452,
CT UPPER EXT W CONT,3500000021,CDM,350,RC,,,Outpatient,,,3791.00,2464.15,,3791,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2881.16,76,,3130.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2729.52,72,,3831.624,Percent of Total Billed Charges,72% of Total Billed Charges,2843.25,75,,3991.28,Percent of Total Billed charges,75% of Total Billed Charges,3791,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2729.52,72,,3831.624,Percent of Total Billed Charges,72% of Total Billed Charges,2274.6,60,,3193.024,Percent of Total Billed Charges,60% of Total Billed Charges,3411.9,90,,3883.68,Percent of Total Billed Charges,90% of Total Billed Charges,1705.95,45,,1890.432,Percent of Total Billed Charges,45% of Total Billed Charges,3411.9,90,,3707.048,Percent of Total Billed Charges,90% of Total billed Charges,3791,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3791,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3791,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2464.15,65,,1024.488,Percent of total Billed Charges,65% of Total Billed Charges,1671.83,44.1,,1852.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,3601.45,95,,3913,Percent of Total Billed Charges,95% of Total Billed Charges,3791,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3336.08,88,,1600.448,Percent of Total Billed Charges,88% of Total Billed Charges,3411.9,90,,3707.048,Percent of Total Billed charges,90% of Total Billed Charges,1671.83,3791,
CT UPPER EXT WWO CON,3500000022,CDM,350,RC,,,Outpatient,,,2753.00,1789.45,,2753,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2092.28,76,,1313.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1982.16,72,,751.296,Percent of Total Billed Charges,72% of Total Billed Charges,2064.75,75,,782.6,Percent of Total Billed charges,75% of Total Billed Charges,2753,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1982.16,72,,751.296,Percent of Total Billed Charges,72% of Total Billed Charges,1651.8,60,,626.08,Percent of Total Billed Charges,60% of Total Billed Charges,2477.7,90,,4519.904,Percent of Total Billed Charges,90% of Total Billed Charges,1238.85,45,,818.408,Percent of Total Billed Charges,45% of Total Billed Charges,2477.7,90,,1555.2,Percent of Total Billed Charges,90% of Total billed Charges,2753,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2753,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2753,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1789.45,65,,611.712,Percent of total Billed Charges,65% of Total Billed Charges,1214.07,44.1,,802.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,2615.35,95,,1641.6,Percent of Total Billed Charges,95% of Total Billed Charges,2753,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2422.64,88,,1505.856,Percent of Total Billed Charges,88% of Total Billed Charges,2477.7,90,,1555.2,Percent of Total Billed charges,90% of Total Billed Charges,1214.07,2753,
CT LOWER EXTRE W/O,3500000023,CDM,350,RC,,,Outpatient,,,2236.00,1453.40,,2236,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1699.36,76,,3129.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1609.92,72,,2104.704,Percent of Total Billed Charges,72% of Total Billed Charges,1677,75,,2192.4,Percent of Total Billed charges,75% of Total Billed Charges,2236,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1609.92,72,,2104.704,Percent of Total Billed Charges,72% of Total Billed Charges,1341.6,60,,1753.92,Percent of Total Billed Charges,60% of Total Billed Charges,2012.4,90,,3707.048,Percent of Total Billed Charges,90% of Total Billed Charges,1006.2,45,,770.04,Percent of Total Billed Charges,45% of Total Billed Charges,2012.4,90,,3706.248,Percent of Total Billed Charges,90% of Total billed Charges,2236,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2236,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2236,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1453.4,65,,683.944,Percent of total Billed Charges,65% of Total Billed Charges,986.08,44.1,,754.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,2124.2,95,,3912.152,Percent of Total Billed Charges,95% of Total Billed Charges,2236,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.68,88,,1505.856,Percent of Total Billed Charges,88% of Total Billed Charges,2012.4,90,,3706.248,Percent of Total Billed charges,90% of Total Billed Charges,986.08,2236,
CT LOWER EXTRE W/C,3500000024,CDM,350,RC,,,Outpatient,,,2541.00,1651.65,,2541,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1931.16,76,,2052.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1829.52,72,,4201.344,Percent of Total Billed Charges,72% of Total Billed Charges,1905.75,75,,4376.4,Percent of Total Billed charges,75% of Total Billed Charges,2541,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1829.52,72,,4201.344,Percent of Total Billed Charges,72% of Total Billed Charges,1524.6,60,,3501.12,Percent of Total Billed Charges,60% of Total Billed Charges,2286.9,90,,4294.08,Percent of Total Billed Charges,90% of Total Billed Charges,1143.45,45,,770.04,Percent of Total Billed Charges,45% of Total Billed Charges,2286.9,90,,2430.184,Percent of Total Billed Charges,90% of Total billed Charges,2541,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2541,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2541,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1651.65,65,,764.208,Percent of total Billed Charges,65% of Total Billed Charges,1120.58,44.1,,754.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,2413.95,95,,2565.192,Percent of Total Billed Charges,95% of Total Billed Charges,2541,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2236.08,88,,3696.848,Percent of Total Billed Charges,88% of Total Billed Charges,2286.9,90,,2430.184,Percent of Total Billed charges,90% of Total Billed Charges,1120.58,2541,
CT LOWER EXTR W/WO,3500000025,CDM,350,RC,,,Outpatient,,,2753.00,1789.45,,2753,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2092.28,76,,3192.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1982.16,72,,1858.176,Percent of Total Billed Charges,72% of Total Billed Charges,2064.75,75,,1935.6,Percent of Total Billed charges,75% of Total Billed Charges,2753,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1982.16,72,,1858.176,Percent of Total Billed Charges,72% of Total Billed Charges,1651.8,60,,1548.48,Percent of Total Billed Charges,60% of Total Billed Charges,2477.7,90,,1555.2,Percent of Total Billed Charges,90% of Total Billed Charges,1238.85,45,,1890.432,Percent of Total Billed Charges,45% of Total Billed Charges,2477.7,90,,3780.872,Percent of Total Billed Charges,90% of Total billed Charges,2753,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2753,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2753,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1789.45,65,,720.64,Percent of total Billed Charges,65% of Total Billed Charges,1214.07,44.1,,1852.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,2615.35,95,,3990.92,Percent of Total Billed Charges,95% of Total Billed Charges,2753,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2422.64,88,,3623.888,Percent of Total Billed Charges,88% of Total Billed Charges,2477.7,90,,3780.872,Percent of Total Billed charges,90% of Total Billed Charges,1214.07,2753,
CTA LOWER EXTREM,3500000026,CDM,350,RC,,,Outpatient,,,2623.00,1704.95,,2623,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1993.48,76,,1382.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1888.56,72,,1981.984,Percent of Total Billed Charges,72% of Total Billed Charges,1967.25,75,,2064.568,Percent of Total Billed charges,75% of Total Billed Charges,2623,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1888.56,72,,1981.984,Percent of Total Billed Charges,72% of Total Billed Charges,1573.8,60,,1651.656,Percent of Total Billed Charges,60% of Total Billed Charges,2360.7,90,,4692.152,Percent of Total Billed Charges,90% of Total Billed Charges,1180.35,45,,1853.128,Percent of Total Billed Charges,45% of Total Billed Charges,2360.7,90,,1636.816,Percent of Total Billed Charges,90% of Total billed Charges,2623,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2623,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2623,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1704.95,65,,6396,Percent of total Billed Charges,65% of Total Billed Charges,1156.74,44.1,,1816.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,2491.85,95,,1727.752,Percent of Total Billed Charges,95% of Total Billed Charges,2623,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2308.24,88,,3797.376,Percent of Total Billed Charges,88% of Total Billed Charges,2360.7,90,,1636.816,Percent of Total Billed charges,90% of Total Billed Charges,1156.74,2623,
CT CALCIUM SCORING,3500000027,CDM,350,RC,,,Outpatient,,,209.00,135.85,,209,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,158.84,76,,1300.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,150.48,72,,66.24,Percent of Total Billed Charges,72% of Total Billed Charges,156.75,75,,69,Percent of Total Billed charges,75% of Total Billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.48,72,,66.24,Percent of Total Billed Charges,72% of Total Billed Charges,125.4,60,,55.2,Percent of Total Billed Charges,60% of Total Billed Charges,188.1,90,,4399.24,Percent of Total Billed Charges,90% of Total Billed Charges,94.05,45,,1941.84,Percent of Total Billed Charges,45% of Total Billed Charges,188.1,90,,1540.08,Percent of Total Billed Charges,90% of Total billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.85,65,,8314.8,Percent of total Billed Charges,65% of Total Billed Charges,92.17,44.1,,1903,Percent of Total Billed Charges,44.1% of Total Billed Charges,198.55,95,,1625.64,Percent of Total Billed Charges,95% of Total Billed Charges,209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.92,88,,4419.456,Percent of Total Billed Charges,88% of Total Billed Charges,188.1,90,,1540.08,Percent of Total Billed charges,90% of Total Billed Charges,92.17,209,
CT HEART WCON STR MORPH,3500000028,CDM,350,RC,,,Outpatient,,,2652.00,1723.80,,2652,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2015.52,76,,1300.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1909.44,72,,468.864,Percent of Total Billed Charges,72% of Total Billed Charges,1989,75,,488.4,Percent of Total Billed charges,75% of Total Billed Charges,2652,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1909.44,72,,468.864,Percent of Total Billed Charges,72% of Total Billed Charges,1591.2,60,,390.72,Percent of Total Billed Charges,60% of Total Billed Charges,2386.8,90,,1054.08,Percent of Total Billed Charges,90% of Total Billed Charges,1193.4,45,,2259.952,Percent of Total Billed Charges,45% of Total Billed Charges,2386.8,90,,1540.08,Percent of Total Billed Charges,90% of Total billed Charges,2652,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2652,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2652,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1723.8,65,,4485.648,Percent of total Billed Charges,65% of Total Billed Charges,1169.53,44.1,,2214.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,2519.4,95,,1625.64,Percent of Total Billed Charges,95% of Total Billed Charges,2652,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2333.76,88,,3624.672,Percent of Total Billed Charges,88% of Total Billed Charges,2386.8,90,,1540.08,Percent of Total Billed charges,90% of Total Billed Charges,1169.53,2652,
CTA HEART  W 3D IMAGE,3500000030,CDM,350,RC,,,Outpatient,,,3069.00,1994.85,,3069,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2332.44,76,,3192.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2209.68,72,,8.064,Percent of Total Billed Charges,72% of Total Billed Charges,2301.75,75,,8.4,Percent of Total Billed charges,75% of Total Billed Charges,3069,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2209.68,72,,8.064,Percent of Total Billed Charges,72% of Total Billed Charges,1841.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2762.1,90,,1900.8,Percent of Total Billed Charges,90% of Total Billed Charges,1381.05,45,,1853.528,Percent of Total Billed Charges,45% of Total Billed Charges,2762.1,90,,3780.872,Percent of Total Billed Charges,90% of Total billed Charges,3069,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3069,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3069,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1994.85,65,,629.2,Percent of total Billed Charges,65% of Total Billed Charges,1353.43,44.1,,1816.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,2915.55,95,,3990.92,Percent of Total Billed Charges,95% of Total Billed Charges,3069,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2700.72,88,,4198.656,Percent of Total Billed Charges,88% of Total Billed Charges,2762.1,90,,3780.872,Percent of Total Billed charges,90% of Total Billed Charges,1353.43,3069,
CT LTD OR FOLLOWUP,3500000031,CDM,350,RC,,,Outpatient,,,1103.60,717.34,,1103.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,838.74,76,,3129.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,794.59,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,827.7,75,,480,Percent of Total Billed charges,75% of Total Billed Charges,1103.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,794.59,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,662.16,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,993.24,90,,916.84,Percent of Total Billed Charges,90% of Total Billed Charges,496.62,45,,2147.04,Percent of Total Billed Charges,45% of Total Billed Charges,993.24,90,,3706.248,Percent of Total Billed Charges,90% of Total billed Charges,1103.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1103.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1103.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,717.34,65,,687.392,Percent of total Billed Charges,65% of Total Billed Charges,486.69,44.1,,2104.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,1048.42,95,,3912.152,Percent of Total Billed Charges,95% of Total Billed Charges,1103.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,971.17,88,,1520.64,Percent of Total Billed Charges,88% of Total Billed Charges,993.24,90,,3706.248,Percent of Total Billed charges,90% of Total Billed Charges,486.69,1103.6,
CT GUIDE NEEDLE LOC,3500000033,CDM,350,RC,,,Outpatient,,,2811.00,1827.15,,2811,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2136.36,76,,3279.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2023.92,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,2108.25,75,,480,Percent of Total Billed charges,75% of Total Billed Charges,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2023.92,72,,460.8,Percent of Total Billed Charges,72% of Total Billed Charges,1686.6,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,2529.9,90,,951.768,Percent of Total Billed Charges,90% of Total Billed Charges,1264.95,45,,777.6,Percent of Total Billed Charges,45% of Total Billed Charges,2529.9,90,,3883.68,Percent of Total Billed Charges,90% of Total billed Charges,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1827.15,65,,729.04,Percent of total Billed Charges,65% of Total Billed Charges,1239.65,44.1,,762.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,2670.45,95,,4099.44,Percent of Total Billed Charges,95% of Total Billed Charges,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2473.68,88,,4587.88,Percent of Total Billed Charges,88% of Total Billed Charges,2529.9,90,,3883.68,Percent of Total Billed charges,90% of Total Billed Charges,1239.65,2811,
CT Monitor PRCHL Tissue Ablate,3500000034,CDM,350,RC,,,Outpatient,,,1200.00,780.00,,1200,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,912,76,,3816.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,864,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,900,75,,135,Percent of Total Billed charges,75% of Total Billed Charges,1200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,864,72,,129.6,Percent of Total Billed Charges,72% of Total Billed Charges,720,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,1080,90,,1062.112,Percent of Total Billed Charges,90% of Total Billed Charges,540,45,,2346.08,Percent of Total Billed Charges,45% of Total Billed Charges,1080,90,,4519.904,Percent of Total Billed Charges,90% of Total billed Charges,1200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780,65,,885.744,Percent of total Billed Charges,65% of Total Billed Charges,529.2,44.1,,2299.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,1140,95,,4771.008,Percent of Total Billed Charges,95% of Total Billed Charges,1200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1056,88,,4301.48,Percent of Total Billed Charges,88% of Total Billed Charges,1080,90,,4519.904,Percent of Total Billed charges,90% of Total Billed Charges,529.2,1200,
IMG GID FLU COLL DRG SFT TIS,3500000035,CDM,350,RC,,,Outpatient,,,1661.13,1079.73,,1661.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1262.46,76,,3130.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1196.01,72,,347.328,Percent of Total Billed Charges,72% of Total Billed Charges,1245.85,75,,361.8,Percent of Total Billed charges,75% of Total Billed Charges,1661.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1196.01,72,,347.328,Percent of Total Billed Charges,72% of Total Billed Charges,996.68,60,,289.44,Percent of Total Billed Charges,60% of Total Billed Charges,1495.02,90,,2508.016,Percent of Total Billed Charges,90% of Total Billed Charges,747.51,45,,2199.624,Percent of Total Billed Charges,45% of Total Billed Charges,1495.02,90,,3707.048,Percent of Total Billed Charges,90% of Total billed Charges,1661.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1661.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1661.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1079.73,65,,3731,Percent of total Billed Charges,65% of Total Billed Charges,732.56,44.1,,2155.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,1578.07,95,,3913,Percent of Total Billed Charges,95% of Total Billed Charges,1661.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1461.79,88,,1030.656,Percent of Total Billed Charges,88% of Total Billed Charges,1495.02,90,,3707.048,Percent of Total Billed charges,90% of Total Billed Charges,732.56,1661.13,
CT HEAD/BRAIN W/O STKE ALERT,3510000001,CDM,351,RC,,,Outpatient,,,2923.67,1900.39,,2923.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2221.99,76,,3626.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2105.04,72,,47.232,Percent of Total Billed Charges,72% of Total Billed Charges,2192.75,75,,49.2,Percent of Total Billed charges,75% of Total Billed Charges,2923.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2105.04,72,,47.232,Percent of Total Billed Charges,72% of Total Billed Charges,1754.2,60,,39.36,Percent of Total Billed Charges,60% of Total Billed Charges,2631.3,90,,1293.84,Percent of Total Billed Charges,90% of Total Billed Charges,1315.65,45,,527.04,Percent of Total Billed Charges,45% of Total Billed Charges,2631.3,90,,4294.08,Percent of Total Billed Charges,90% of Total billed Charges,2923.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2923.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2923.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1900.39,65,,3415.592,Percent of total Billed Charges,65% of Total Billed Charges,1289.34,44.1,,516.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,2777.49,95,,4532.64,Percent of Total Billed Charges,95% of Total Billed Charges,2923.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2572.83,88,,1858.56,Percent of Total Billed Charges,88% of Total Billed Charges,2631.3,90,,4294.08,Percent of Total Billed charges,90% of Total Billed Charges,1289.34,2923.67,
CT HEAD/BRAIN W/O,3510000002,CDM,351,RC,,,Outpatient,,,2793.00,1815.45,,2793,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2122.68,76,,1313.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2010.96,72,,288,Percent of Total Billed Charges,72% of Total Billed Charges,2094.75,75,,300,Percent of Total Billed charges,75% of Total Billed Charges,2793,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2010.96,72,,288,Percent of Total Billed Charges,72% of Total Billed Charges,1675.8,60,,240,Percent of Total Billed Charges,60% of Total Billed Charges,2513.7,90,,3456,Percent of Total Billed Charges,90% of Total Billed Charges,1256.85,45,,950.4,Percent of Total Billed Charges,45% of Total Billed Charges,2513.7,90,,1555.2,Percent of Total Billed Charges,90% of Total billed Charges,2793,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2793,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2793,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1815.45,65,,616.72,Percent of total Billed Charges,65% of Total Billed Charges,1231.71,44.1,,931.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,2653.35,95,,1641.6,Percent of Total Billed Charges,95% of Total Billed Charges,2793,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2457.84,88,,896.464,Percent of Total Billed Charges,88% of Total Billed Charges,2513.7,90,,1555.2,Percent of Total Billed charges,90% of Total Billed Charges,1231.71,2793,
CT HEAD/BRAIN W/CO,3510000003,CDM,351,RC,,,Outpatient,,,1503.00,976.95,,1503,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1142.28,76,,3962.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1082.16,72,,389.952,Percent of Total Billed Charges,72% of Total Billed Charges,1127.25,75,,406.2,Percent of Total Billed charges,75% of Total Billed Charges,1503,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1082.16,72,,389.952,Percent of Total Billed Charges,72% of Total Billed Charges,901.8,60,,324.96,Percent of Total Billed Charges,60% of Total Billed Charges,1352.7,90,,2374.528,Percent of Total Billed Charges,90% of Total Billed Charges,676.35,45,,458.424,Percent of Total Billed Charges,45% of Total Billed Charges,1352.7,90,,4692.152,Percent of Total Billed Charges,90% of Total billed Charges,1503,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1503,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1503,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,976.95,65,,1755.128,Percent of total Billed Charges,65% of Total Billed Charges,662.82,44.1,,449.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,1427.85,95,,4952.832,Percent of Total Billed Charges,95% of Total Billed Charges,1503,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1322.64,88,,930.616,Percent of Total Billed Charges,88% of Total Billed Charges,1352.7,90,,4692.152,Percent of Total Billed charges,90% of Total Billed Charges,662.82,1503,
CT HEAD/BRAIN W/WO,3510000004,CDM,351,RC,,,Outpatient,,,2457.00,1597.05,,2457,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1867.32,76,,3714.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1769.04,72,,88.904,Percent of Total Billed Charges,72% of Total Billed Charges,1842.75,75,,92.608,Percent of Total Billed charges,75% of Total Billed Charges,2457,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1769.04,72,,88.904,Percent of Total Billed Charges,72% of Total Billed Charges,1474.2,60,,74.088,Percent of Total Billed Charges,60% of Total Billed Charges,2211.3,90,,5586.008,Percent of Total Billed Charges,90% of Total Billed Charges,1105.65,45,,475.888,Percent of Total Billed Charges,45% of Total Billed Charges,2211.3,90,,4399.24,Percent of Total Billed Charges,90% of Total billed Charges,2457,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2457,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2457,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1597.05,65,,6041.44,Percent of total Billed Charges,65% of Total Billed Charges,1083.54,44.1,,466.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,2334.15,95,,4643.648,Percent of Total Billed Charges,95% of Total Billed Charges,2457,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2162.16,88,,1038.504,Percent of Total Billed Charges,88% of Total Billed Charges,2211.3,90,,4399.24,Percent of Total Billed charges,90% of Total Billed Charges,1083.54,2457,
CT ORBITS W/O CONT,3510000005,CDM,351,RC,,,Outpatient,,,3317.00,2156.05,,3317,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2520.92,76,,890.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2388.24,72,,389.952,Percent of Total Billed Charges,72% of Total Billed Charges,2487.75,75,,406.2,Percent of Total Billed charges,75% of Total Billed Charges,3317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2388.24,72,,389.952,Percent of Total Billed Charges,72% of Total Billed Charges,1990.2,60,,324.96,Percent of Total Billed Charges,60% of Total Billed Charges,2985.3,90,,1080.064,Percent of Total Billed Charges,90% of Total Billed Charges,1492.65,45,,531.056,Percent of Total Billed Charges,45% of Total Billed Charges,2985.3,90,,1054.08,Percent of Total Billed Charges,90% of Total billed Charges,3317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2156.05,65,,3264.376,Percent of total Billed Charges,65% of Total Billed Charges,1462.8,44.1,,520.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,3151.15,95,,1112.64,Percent of Total Billed Charges,95% of Total Billed Charges,3317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2918.96,88,,2452.288,Percent of Total Billed Charges,88% of Total Billed Charges,2985.3,90,,1054.08,Percent of Total Billed charges,90% of Total Billed Charges,1462.8,3317,
CT ORBITS W/CONT,3510000006,CDM,351,RC,,,Outpatient,,,3438.00,2234.70,,3438,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2612.88,76,,1605.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2475.36,72,,131.904,Percent of Total Billed Charges,72% of Total Billed Charges,2578.5,75,,137.4,Percent of Total Billed charges,75% of Total Billed Charges,3438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2475.36,72,,131.904,Percent of Total Billed Charges,72% of Total Billed Charges,2062.8,60,,109.92,Percent of Total Billed Charges,60% of Total Billed Charges,3094.2,90,,1080.064,Percent of Total Billed Charges,90% of Total Billed Charges,1547.1,45,,1254.008,Percent of Total Billed Charges,45% of Total Billed Charges,3094.2,90,,1900.8,Percent of Total Billed Charges,90% of Total billed Charges,3438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2234.7,65,,3264.376,Percent of total Billed Charges,65% of Total Billed Charges,1516.16,44.1,,1228.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,3266.1,95,,2006.4,Percent of Total Billed Charges,95% of Total Billed Charges,3438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3025.44,88,,1265.088,Percent of Total Billed Charges,88% of Total Billed Charges,3094.2,90,,1900.8,Percent of Total Billed charges,90% of Total Billed Charges,1516.16,3438,
CT ORBITS W/WO CON,3510000007,CDM,351,RC,,,Outpatient,,,2753.00,1789.45,,2753,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2092.28,76,,774.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1982.16,72,,1035.648,Percent of Total Billed Charges,72% of Total Billed Charges,2064.75,75,,1078.8,Percent of Total Billed charges,75% of Total Billed Charges,2753,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1982.16,72,,1035.648,Percent of Total Billed Charges,72% of Total Billed Charges,1651.8,60,,863.04,Percent of Total Billed Charges,60% of Total Billed Charges,2477.7,90,,1080.064,Percent of Total Billed Charges,90% of Total Billed Charges,1238.85,45,,646.92,Percent of Total Billed Charges,45% of Total Billed Charges,2477.7,90,,916.84,Percent of Total Billed Charges,90% of Total billed Charges,2753,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2753,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2753,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1789.45,65,,2651.512,Percent of total Billed Charges,65% of Total Billed Charges,1214.07,44.1,,633.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,2615.35,95,,967.776,Percent of Total Billed Charges,95% of Total Billed Charges,2753,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2422.64,88,,3379.2,Percent of Total Billed Charges,88% of Total Billed Charges,2477.7,90,,916.84,Percent of Total Billed charges,90% of Total Billed Charges,1214.07,2753,
CT FACIAL BONE W/O,3510000008,CDM,351,RC,,,Outpatient,,,2944.00,1913.60,,2944,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2237.44,76,,803.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2119.68,72,,328.32,Percent of Total Billed Charges,72% of Total Billed Charges,2208,75,,342,Percent of Total Billed charges,75% of Total Billed Charges,2944,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2119.68,72,,328.32,Percent of Total Billed Charges,72% of Total Billed Charges,1766.4,60,,273.6,Percent of Total Billed Charges,60% of Total Billed Charges,2649.6,90,,3097.44,Percent of Total Billed Charges,90% of Total Billed Charges,1324.8,45,,1728,Percent of Total Billed Charges,45% of Total Billed Charges,2649.6,90,,951.768,Percent of Total Billed Charges,90% of Total billed Charges,2944,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2944,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2944,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1913.6,65,,823.256,Percent of total Billed Charges,65% of Total Billed Charges,1298.3,44.1,,1693.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,2796.8,95,,1004.648,Percent of Total Billed Charges,95% of Total Billed Charges,2944,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2590.72,88,,2321.76,Percent of Total Billed Charges,88% of Total Billed Charges,2649.6,90,,951.768,Percent of Total Billed charges,90% of Total Billed Charges,1298.3,2944,
CT SINUS W/O CONT,3510000009,CDM,351,RC,,,Outpatient,,,3082.59,2003.68,,3082.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2342.77,76,,896.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2219.46,72,,725.76,Percent of Total Billed Charges,72% of Total Billed Charges,2311.94,75,,756,Percent of Total Billed charges,75% of Total Billed Charges,3082.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2219.46,72,,725.76,Percent of Total Billed Charges,72% of Total Billed Charges,1849.55,60,,604.8,Percent of Total Billed Charges,60% of Total Billed Charges,2774.33,90,,14668.56,Percent of Total Billed Charges,90% of Total Billed Charges,1387.17,45,,1187.264,Percent of Total Billed Charges,45% of Total Billed Charges,2774.33,90,,1062.112,Percent of Total Billed Charges,90% of Total billed Charges,3082.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3082.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3082.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2003.68,65,,823.256,Percent of total Billed Charges,65% of Total Billed Charges,1359.42,44.1,,1163.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,2928.46,95,,1121.112,Percent of Total Billed Charges,95% of Total Billed Charges,3082.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2712.68,88,,5461.872,Percent of Total Billed Charges,88% of Total Billed Charges,2774.33,90,,1062.112,Percent of Total Billed charges,90% of Total Billed Charges,1359.42,3082.59,
CT FACIAL BONE W/C,3510000010,CDM,351,RC,,,Outpatient,,,3544.00,2303.60,,3544,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2693.44,76,,2117.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2551.68,72,,568.512,Percent of Total Billed Charges,72% of Total Billed Charges,2658,75,,592.2,Percent of Total Billed charges,75% of Total Billed Charges,3544,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2551.68,72,,568.512,Percent of Total Billed Charges,72% of Total Billed Charges,2126.4,60,,473.76,Percent of Total Billed Charges,60% of Total Billed Charges,3189.6,90,,14668.56,Percent of Total Billed Charges,90% of Total Billed Charges,1594.8,45,,2793,Percent of Total Billed Charges,45% of Total Billed Charges,3189.6,90,,2508.016,Percent of Total Billed Charges,90% of Total billed Charges,3544,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3544,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3544,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2303.6,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,1562.9,44.1,,2737.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,3366.8,95,,2647.352,Percent of Total Billed Charges,95% of Total Billed Charges,3544,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3118.72,88,,1056.064,Percent of Total Billed Charges,88% of Total Billed Charges,3189.6,90,,2508.016,Percent of Total Billed charges,90% of Total Billed Charges,1562.9,3544,
CT SINUS W/CONT,3510000011,CDM,351,RC,,,Outpatient,,,3382.47,2198.61,,3382.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2570.68,76,,1092.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2435.38,72,,568.512,Percent of Total Billed Charges,72% of Total Billed Charges,2536.85,75,,592.2,Percent of Total Billed charges,75% of Total Billed Charges,3382.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2435.38,72,,568.512,Percent of Total Billed Charges,72% of Total Billed Charges,2029.48,60,,473.76,Percent of Total Billed Charges,60% of Total Billed Charges,3044.22,90,,14668.56,Percent of Total Billed Charges,90% of Total Billed Charges,1522.11,45,,540.032,Percent of Total Billed Charges,45% of Total Billed Charges,3044.22,90,,1293.84,Percent of Total Billed Charges,90% of Total billed Charges,3382.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3382.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3382.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2198.61,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,1491.67,44.1,,529.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,3213.35,95,,1365.72,Percent of Total Billed Charges,95% of Total Billed Charges,3382.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2976.57,88,,1056.064,Percent of Total Billed Charges,88% of Total Billed Charges,3044.22,90,,1293.84,Percent of Total Billed charges,90% of Total Billed Charges,1491.67,3382.47,
CT FACIAL BONE W/WO,3510000012,CDM,351,RC,,,Outpatient,,,3868.00,2514.20,,3868,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2939.68,76,,2918.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2784.96,72,,180.984,Percent of Total Billed Charges,72% of Total Billed Charges,2901,75,,188.528,Percent of Total Billed charges,75% of Total Billed Charges,3868,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2784.96,72,,180.984,Percent of Total Billed Charges,72% of Total Billed Charges,2320.8,60,,150.824,Percent of Total Billed Charges,60% of Total Billed Charges,3481.2,90,,369.912,Percent of Total Billed Charges,90% of Total Billed Charges,1740.6,45,,540.032,Percent of Total Billed Charges,45% of Total Billed Charges,3481.2,90,,3456,Percent of Total Billed Charges,90% of Total billed Charges,3868,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3868,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3868,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2514.2,65,,934.44,Percent of total Billed Charges,65% of Total Billed Charges,1705.79,44.1,,529.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,3674.6,95,,3648,Percent of Total Billed Charges,95% of Total Billed Charges,3868,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3403.84,88,,1056.064,Percent of Total Billed Charges,88% of Total Billed Charges,3481.2,90,,3456,Percent of Total Billed charges,90% of Total Billed Charges,1705.79,3868,
CT SINUS W/WO CONT,3510000013,CDM,351,RC,,,Outpatient,,,4071.53,2646.49,,4071.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3094.36,76,,2005.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2931.5,72,,279.36,Percent of Total Billed Charges,72% of Total Billed Charges,3053.65,75,,291,Percent of Total Billed charges,75% of Total Billed Charges,4071.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2931.5,72,,279.36,Percent of Total Billed Charges,72% of Total Billed Charges,2442.92,60,,232.8,Percent of Total Billed Charges,60% of Total Billed Charges,3664.38,90,,1109.416,Percent of Total Billed Charges,90% of Total Billed Charges,1832.19,45,,540.032,Percent of Total Billed Charges,45% of Total Billed Charges,3664.38,90,,2374.528,Percent of Total Billed Charges,90% of Total billed Charges,4071.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4071.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4071.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2646.49,65,,1205.648,Percent of total Billed Charges,65% of Total Billed Charges,1795.54,44.1,,529.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,3867.95,95,,2506.44,Percent of Total Billed Charges,95% of Total Billed Charges,4071.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3582.95,88,,3028.608,Percent of Total Billed Charges,88% of Total Billed Charges,3664.38,90,,2374.528,Percent of Total Billed charges,90% of Total Billed Charges,1795.54,4071.53,
CT NECKSFT TIS W/O,3510000014,CDM,351,RC,,,Outpatient,,,1945.00,1264.25,,1945,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1478.2,76,,4717.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1400.4,72,,341.568,Percent of Total Billed Charges,72% of Total Billed Charges,1458.75,75,,355.8,Percent of Total Billed charges,75% of Total Billed Charges,1945,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1400.4,72,,341.568,Percent of Total Billed Charges,72% of Total Billed Charges,1167,60,,284.64,Percent of Total Billed Charges,60% of Total Billed Charges,1750.5,90,,1109.416,Percent of Total Billed Charges,90% of Total Billed Charges,875.25,45,,1548.72,Percent of Total Billed Charges,45% of Total Billed Charges,1750.5,90,,5586.008,Percent of Total Billed Charges,90% of Total billed Charges,1945,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1945,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1945,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1264.25,65,,224.736,Percent of total Billed Charges,65% of Total Billed Charges,857.75,44.1,,1517.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,1847.75,95,,5896.336,Percent of Total Billed Charges,95% of Total Billed Charges,1945,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1711.6,88,,14342.592,Percent of Total Billed Charges,88% of Total Billed Charges,1750.5,90,,5586.008,Percent of Total Billed charges,90% of Total Billed Charges,857.75,1945,
CT NECKSFT TIS W/,3510000015,CDM,351,RC,,,Outpatient,,,2930.00,1904.50,,2930,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2226.8,76,,912.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2109.6,72,,751.104,Percent of Total Billed Charges,72% of Total Billed Charges,2197.5,75,,782.4,Percent of Total Billed charges,75% of Total Billed Charges,2930,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2109.6,72,,751.104,Percent of Total Billed Charges,72% of Total Billed Charges,1758,60,,625.92,Percent of Total Billed Charges,60% of Total Billed Charges,2637,90,,1139.896,Percent of Total Billed Charges,90% of Total Billed Charges,1318.5,45,,7334.28,Percent of Total Billed Charges,45% of Total Billed Charges,2637,90,,1080.064,Percent of Total Billed Charges,90% of Total billed Charges,2930,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2930,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2930,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1904.5,65,,656.24,Percent of total Billed Charges,65% of Total Billed Charges,1292.13,44.1,,7187.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,2783.5,95,,1140.072,Percent of Total Billed Charges,95% of Total Billed Charges,2930,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2578.4,88,,14342.592,Percent of Total Billed Charges,88% of Total Billed Charges,2637,90,,1080.064,Percent of Total Billed charges,90% of Total Billed Charges,1292.13,2930,
CT NECK SFT TIS W/WO,3510000016,CDM,351,RC,,,Outpatient,,,3763.00,2445.95,,3763,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2859.88,76,,912.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2709.36,72,,635.04,Percent of Total Billed Charges,72% of Total Billed Charges,2822.25,75,,661.504,Percent of Total Billed charges,75% of Total Billed Charges,3763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2709.36,72,,635.04,Percent of Total Billed Charges,72% of Total Billed Charges,2257.8,60,,529.2,Percent of Total Billed Charges,60% of Total Billed Charges,3386.7,90,,1235.976,Percent of Total Billed Charges,90% of Total Billed Charges,1693.35,45,,7334.28,Percent of Total Billed Charges,45% of Total Billed Charges,3386.7,90,,1080.064,Percent of Total Billed Charges,90% of Total billed Charges,3763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2445.95,65,,1788.696,Percent of total Billed Charges,65% of Total Billed Charges,1659.48,44.1,,7187.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,3574.85,95,,1140.072,Percent of Total Billed Charges,95% of Total Billed Charges,3763,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3311.44,88,,14342.592,Percent of Total Billed Charges,88% of Total Billed Charges,3386.7,90,,1080.064,Percent of Total Billed charges,90% of Total Billed Charges,1659.48,3763,
CTA HEAD,3510000017,CDM,351,RC,,,Outpatient,,,2637.00,1714.05,,2637,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2004.12,76,,912.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1898.64,72,,36.864,Percent of Total Billed Charges,72% of Total Billed Charges,1977.75,75,,38.4,Percent of Total Billed charges,75% of Total Billed Charges,2637,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1898.64,72,,36.864,Percent of Total Billed Charges,72% of Total Billed Charges,1582.2,60,,30.72,Percent of Total Billed Charges,60% of Total Billed Charges,2373.3,90,,1054.08,Percent of Total Billed Charges,90% of Total Billed Charges,1186.65,45,,7334.28,Percent of Total Billed Charges,45% of Total Billed Charges,2373.3,90,,1080.064,Percent of Total Billed Charges,90% of Total billed Charges,2637,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2637,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2637,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1714.05,65,,411.84,Percent of total Billed Charges,65% of Total Billed Charges,1162.92,44.1,,7187.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,2505.15,95,,1140.072,Percent of Total Billed Charges,95% of Total Billed Charges,2637,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2320.56,88,,361.696,Percent of Total Billed Charges,88% of Total Billed Charges,2373.3,90,,1080.064,Percent of Total Billed charges,90% of Total Billed Charges,1162.92,2637,
CTA ABD AND PELVIS,3510000018,CDM,352,RC,,,Outpatient,,,5273.00,3427.45,,5273,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4007.48,76,,2615.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3796.56,72,,326.016,Percent of Total Billed Charges,72% of Total Billed Charges,3954.75,75,,339.6,Percent of Total Billed charges,75% of Total Billed Charges,5273,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3796.56,72,,326.016,Percent of Total Billed Charges,72% of Total Billed Charges,3163.8,60,,271.68,Percent of Total Billed Charges,60% of Total Billed Charges,4745.7,90,,1418.52,Percent of Total Billed Charges,90% of Total Billed Charges,2372.85,45,,184.96,Percent of Total Billed Charges,45% of Total Billed Charges,4745.7,90,,3097.44,Percent of Total Billed Charges,90% of Total billed Charges,5273,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5273,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5273,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3427.45,65,,924.488,Percent of total Billed Charges,65% of Total Billed Charges,2325.39,44.1,,181.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,5009.35,95,,3269.52,Percent of Total Billed Charges,95% of Total Billed Charges,5273,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4640.24,88,,1084.76,Percent of Total Billed Charges,88% of Total Billed Charges,4745.7,90,,3097.44,Percent of Total Billed charges,90% of Total Billed Charges,2325.39,5273,
CTA NECK,3520000001,CDM,352,RC,,,Outpatient,,,2637.00,1714.05,,2637,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2004.12,76,,12386.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1898.64,72,,1186.256,Percent of Total Billed Charges,72% of Total Billed Charges,1977.75,75,,1235.68,Percent of Total Billed charges,75% of Total Billed Charges,2637,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1898.64,72,,1186.256,Percent of Total Billed Charges,72% of Total Billed Charges,1582.2,60,,988.544,Percent of Total Billed Charges,60% of Total Billed Charges,2373.3,90,,947,Percent of Total Billed Charges,90% of Total Billed Charges,1186.65,45,,554.704,Percent of Total Billed Charges,45% of Total Billed Charges,2373.3,90,,14668.56,Percent of Total Billed Charges,90% of Total billed Charges,2637,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2637,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2637,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1714.05,65,,150.776,Percent of total Billed Charges,65% of Total Billed Charges,1162.92,44.1,,543.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,2505.15,95,,15483.48,Percent of Total Billed Charges,95% of Total Billed Charges,2637,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2320.56,88,,1114.568,Percent of Total Billed Charges,88% of Total Billed Charges,2373.3,90,,14668.56,Percent of Total Billed charges,90% of Total Billed Charges,1162.92,2637,
CT CHEST W/O CONT,3520000002,CDM,352,RC,,,Outpatient,,,2272.00,1476.80,,2272,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1726.72,76,,12386.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1635.84,72,,449.28,Percent of Total Billed Charges,72% of Total Billed Charges,1704,75,,468,Percent of Total Billed charges,75% of Total Billed Charges,2272,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1635.84,72,,449.28,Percent of Total Billed Charges,72% of Total Billed Charges,1363.2,60,,374.4,Percent of Total Billed Charges,60% of Total Billed Charges,2044.8,90,,1058.136,Percent of Total Billed Charges,90% of Total Billed Charges,1022.4,45,,569.952,Percent of Total Billed Charges,45% of Total Billed Charges,2044.8,90,,14668.56,Percent of Total Billed Charges,90% of Total billed Charges,2272,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2272,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2272,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1476.8,65,,471.824,Percent of total Billed Charges,65% of Total Billed Charges,1001.95,44.1,,558.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,2158.4,95,,15483.48,Percent of Total Billed Charges,95% of Total Billed Charges,2272,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1999.36,88,,1208.504,Percent of Total Billed Charges,88% of Total Billed Charges,2044.8,90,,14668.56,Percent of Total Billed charges,90% of Total Billed Charges,1001.95,2272,
CT CHEST W/CONT,3520000003,CDM,352,RC,,,Outpatient,,,2527.00,1642.55,,2527,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1920.52,76,,312.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1819.44,72,,472.896,Percent of Total Billed Charges,72% of Total Billed Charges,1895.25,75,,492.6,Percent of Total Billed charges,75% of Total Billed Charges,2527,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1819.44,72,,472.896,Percent of Total Billed Charges,72% of Total Billed Charges,1516.2,60,,394.08,Percent of Total Billed Charges,60% of Total Billed Charges,2274.3,90,,997.808,Percent of Total Billed Charges,90% of Total Billed Charges,1137.15,45,,617.984,Percent of Total Billed Charges,45% of Total Billed Charges,2274.3,90,,369.912,Percent of Total Billed Charges,90% of Total billed Charges,2527,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2527,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2527,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1642.55,65,,283.216,Percent of total Billed Charges,65% of Total Billed Charges,1114.41,44.1,,605.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,2400.65,95,,390.464,Percent of Total Billed Charges,95% of Total Billed Charges,2527,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2223.76,88,,1030.656,Percent of Total Billed Charges,88% of Total Billed Charges,2274.3,90,,369.912,Percent of Total Billed charges,90% of Total Billed Charges,1114.41,2527,
CT CHEST W/WO CONT,3520000004,CDM,352,RC,,,Outpatient,,,3573.00,2322.45,,3573,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2715.48,76,,936.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2572.56,72,,472.896,Percent of Total Billed Charges,72% of Total Billed Charges,2679.75,75,,492.6,Percent of Total Billed charges,75% of Total Billed Charges,3573,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2572.56,72,,472.896,Percent of Total Billed Charges,72% of Total Billed Charges,2143.8,60,,394.08,Percent of Total Billed Charges,60% of Total Billed Charges,3215.7,90,,8856,Percent of Total Billed Charges,90% of Total Billed Charges,1607.85,45,,527.04,Percent of Total Billed Charges,45% of Total Billed Charges,3215.7,90,,1109.416,Percent of Total Billed Charges,90% of Total billed Charges,3573,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3573,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3573,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322.45,65,,1567.976,Percent of total Billed Charges,65% of Total Billed Charges,1575.69,44.1,,516.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,3394.35,95,,1171.048,Percent of Total Billed Charges,95% of Total Billed Charges,3573,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3144.24,88,,1387,Percent of Total Billed Charges,88% of Total Billed Charges,3215.7,90,,1109.416,Percent of Total Billed charges,90% of Total Billed Charges,1575.69,3573,
CTA CHEST,3520000005,CDM,352,RC,,,Outpatient,,,2637.00,1714.05,,2637,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2004.12,76,,936.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1898.64,72,,2104.704,Percent of Total Billed Charges,72% of Total Billed Charges,1977.75,75,,2192.4,Percent of Total Billed charges,75% of Total Billed Charges,2637,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1898.64,72,,2104.704,Percent of Total Billed Charges,72% of Total Billed Charges,1582.2,60,,1753.92,Percent of Total Billed Charges,60% of Total Billed Charges,2373.3,90,,11512.8,Percent of Total Billed Charges,90% of Total Billed Charges,1186.65,45,,709.264,Percent of Total Billed Charges,45% of Total Billed Charges,2373.3,90,,1109.416,Percent of Total Billed Charges,90% of Total billed Charges,2637,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2637,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2637,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1714.05,65,,1390.832,Percent of total Billed Charges,65% of Total Billed Charges,1162.92,44.1,,695.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,2505.15,95,,1171.048,Percent of Total Billed Charges,95% of Total Billed Charges,2637,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2320.56,88,,828.168,Percent of Total Billed Charges,88% of Total Billed Charges,2373.3,90,,1109.416,Percent of Total Billed charges,90% of Total Billed Charges,1162.92,2637,
CT CSPINE W/O CON,3520000006,CDM,352,RC,,,Outpatient,,,3203.00,2081.95,,3203,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2434.28,76,,962.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2306.16,72,,2576.992,Percent of Total Billed Charges,72% of Total Billed Charges,2402.25,75,,2684.368,Percent of Total Billed charges,75% of Total Billed Charges,3203,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2306.16,72,,2576.992,Percent of Total Billed Charges,72% of Total Billed Charges,1921.8,60,,2147.496,Percent of Total Billed Charges,60% of Total Billed Charges,2882.7,90,,6210.896,Percent of Total Billed Charges,90% of Total Billed Charges,1441.35,45,,423.496,Percent of Total Billed Charges,45% of Total Billed Charges,2882.7,90,,1139.896,Percent of Total Billed Charges,90% of Total billed Charges,3203,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3203,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3203,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2081.95,65,,3458.72,Percent of total Billed Charges,65% of Total Billed Charges,1412.52,44.1,,415.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,3042.85,95,,1203.224,Percent of Total Billed Charges,95% of Total Billed Charges,3203,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2818.64,88,,925.96,Percent of Total Billed Charges,88% of Total Billed Charges,2882.7,90,,1139.896,Percent of Total Billed charges,90% of Total Billed Charges,1412.52,3203,
CT CSPINE W/CONT,3520000007,CDM,352,RC,,,Outpatient,,,2165.00,1407.25,,2165,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1645.4,76,,1043.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1558.8,72,,875.52,Percent of Total Billed Charges,72% of Total Billed Charges,1623.75,75,,912,Percent of Total Billed charges,75% of Total Billed Charges,2165,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1558.8,72,,875.52,Percent of Total Billed Charges,72% of Total Billed Charges,1299,60,,729.6,Percent of Total Billed Charges,60% of Total Billed Charges,1948.5,90,,871.2,Percent of Total Billed Charges,90% of Total Billed Charges,974.25,45,,473.504,Percent of Total Billed Charges,45% of Total Billed Charges,1948.5,90,,1235.976,Percent of Total Billed Charges,90% of Total billed Charges,2165,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2165,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2165,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1407.25,65,,6032.752,Percent of total Billed Charges,65% of Total Billed Charges,954.77,44.1,,464.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,2056.75,95,,1304.64,Percent of Total Billed Charges,95% of Total Billed Charges,2165,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1905.2,88,,1034.616,Percent of Total Billed Charges,88% of Total Billed Charges,1948.5,90,,1235.976,Percent of Total Billed charges,90% of Total Billed Charges,954.77,2165,
CT CSPINE W/WO CO,3520000008,CDM,352,RC,,,Outpatient,,,2438.00,1584.70,,2438,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1852.88,76,,890.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1755.36,72,,328.32,Percent of Total Billed Charges,72% of Total Billed Charges,1828.5,75,,342,Percent of Total Billed charges,75% of Total Billed Charges,2438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1755.36,72,,328.32,Percent of Total Billed Charges,72% of Total Billed Charges,1462.8,60,,273.6,Percent of Total Billed Charges,60% of Total Billed Charges,2194.2,90,,951.768,Percent of Total Billed Charges,90% of Total Billed Charges,1097.1,45,,529.064,Percent of Total Billed Charges,45% of Total Billed Charges,2194.2,90,,1054.08,Percent of Total Billed Charges,90% of Total billed Charges,2438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1584.7,65,,6032.752,Percent of total Billed Charges,65% of Total Billed Charges,1075.16,44.1,,518.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,2316.1,95,,1112.64,Percent of Total Billed Charges,95% of Total Billed Charges,2438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2145.44,88,,975.632,Percent of Total Billed Charges,88% of Total Billed Charges,2194.2,90,,1054.08,Percent of Total Billed charges,90% of Total Billed Charges,1075.16,2438,
CT TSPINE W/O CON,3520000009,CDM,352,RC,,,Outpatient,,,2165.00,1407.25,,2165,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1645.4,76,,1197.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1558.8,72,,1244.16,Percent of Total Billed Charges,72% of Total Billed Charges,1623.75,75,,1296,Percent of Total Billed charges,75% of Total Billed Charges,2165,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1558.8,72,,1244.16,Percent of Total Billed Charges,72% of Total Billed Charges,1299,60,,1036.8,Percent of Total Billed Charges,60% of Total Billed Charges,1948.5,90,,1009.44,Percent of Total Billed Charges,90% of Total Billed Charges,974.25,45,,498.904,Percent of Total Billed Charges,45% of Total Billed Charges,1948.5,90,,1418.52,Percent of Total Billed Charges,90% of Total billed Charges,2165,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2165,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2165,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1407.25,65,,1252.68,Percent of total Billed Charges,65% of Total Billed Charges,954.77,44.1,,488.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,2056.75,95,,1497.328,Percent of Total Billed Charges,95% of Total Billed Charges,2165,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1905.2,88,,8659.2,Percent of Total Billed Charges,88% of Total Billed Charges,1948.5,90,,1418.52,Percent of Total Billed charges,90% of Total Billed Charges,954.77,2165,
CT TSPINE W/CONT,3520000010,CDM,352,RC,,,Outpatient,,,2438.00,1584.70,,2438,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1852.88,76,,715.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1755.36,72,,2671.024,Percent of Total Billed Charges,72% of Total Billed Charges,1828.5,75,,2782.32,Percent of Total Billed charges,75% of Total Billed Charges,2438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1755.36,72,,2671.024,Percent of Total Billed Charges,72% of Total Billed Charges,1462.8,60,,2225.856,Percent of Total Billed Charges,60% of Total Billed Charges,2194.2,90,,1226.416,Percent of Total Billed Charges,90% of Total Billed Charges,1097.1,45,,4428,Percent of Total Billed Charges,45% of Total Billed Charges,2194.2,90,,846.984,Percent of Total Billed Charges,90% of Total billed Charges,2438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1584.7,65,,790.4,Percent of total Billed Charges,65% of Total Billed Charges,1075.16,44.1,,4339.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,2316.1,95,,894.04,Percent of Total Billed Charges,95% of Total Billed Charges,2438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2145.44,88,,11256.96,Percent of Total Billed Charges,88% of Total Billed Charges,2194.2,90,,846.984,Percent of Total Billed charges,90% of Total Billed Charges,1075.16,2438,
CT TSPINE W/WO CO,3520000011,CDM,352,RC,,,Outpatient,,,2633.00,1711.45,,2633,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2001.08,76,,799.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1895.76,72,,443.52,Percent of Total Billed Charges,72% of Total Billed Charges,1974.75,75,,462,Percent of Total Billed charges,75% of Total Billed Charges,2633,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1895.76,72,,443.52,Percent of Total Billed Charges,72% of Total Billed Charges,1579.8,60,,369.6,Percent of Total Billed Charges,60% of Total Billed Charges,2369.7,90,,5166,Percent of Total Billed Charges,90% of Total Billed Charges,1184.85,45,,5756.4,Percent of Total Billed Charges,45% of Total Billed Charges,2369.7,90,,947,Percent of Total Billed Charges,90% of Total billed Charges,2633,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2633,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2633,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1711.45,65,,296.4,Percent of total Billed Charges,65% of Total Billed Charges,1161.15,44.1,,5641.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,2501.35,95,,999.616,Percent of Total Billed Charges,95% of Total Billed Charges,2633,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2317.04,88,,6072.872,Percent of Total Billed Charges,88% of Total Billed Charges,2369.7,90,,947,Percent of Total Billed charges,90% of Total Billed Charges,1161.15,2633,
CT LSPINE W/O CON,3520000012,CDM,352,RC,,,Outpatient,,,1945.00,1264.25,,1945,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1478.2,76,,893.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1400.4,72,,531.072,Percent of Total Billed Charges,72% of Total Billed Charges,1458.75,75,,553.2,Percent of Total Billed charges,75% of Total Billed Charges,1945,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1400.4,72,,531.072,Percent of Total Billed Charges,72% of Total Billed Charges,1167,60,,442.56,Percent of Total Billed Charges,60% of Total Billed Charges,1750.5,90,,4729.28,Percent of Total Billed Charges,90% of Total Billed Charges,875.25,45,,3105.448,Percent of Total Billed Charges,45% of Total Billed Charges,1750.5,90,,1058.136,Percent of Total Billed Charges,90% of Total billed Charges,1945,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1945,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1945,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1264.25,65,,832,Percent of total Billed Charges,65% of Total Billed Charges,857.75,44.1,,3043.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,1847.75,95,,1116.92,Percent of Total Billed Charges,95% of Total Billed Charges,1945,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1711.6,88,,851.84,Percent of Total Billed Charges,88% of Total Billed Charges,1750.5,90,,1058.136,Percent of Total Billed charges,90% of Total Billed Charges,857.75,1945,
CT LSPINE W/CONT,3520000013,CDM,352,RC,,,Outpatient,,,2165.00,1407.25,,2165,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1645.4,76,,842.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1558.8,72,,531.072,Percent of Total Billed Charges,72% of Total Billed Charges,1623.75,75,,553.2,Percent of Total Billed charges,75% of Total Billed Charges,2165,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1558.8,72,,531.072,Percent of Total Billed Charges,72% of Total Billed Charges,1299,60,,442.56,Percent of Total Billed Charges,60% of Total Billed Charges,1948.5,90,,853.92,Percent of Total Billed Charges,90% of Total Billed Charges,974.25,45,,435.6,Percent of Total Billed Charges,45% of Total Billed Charges,1948.5,90,,997.808,Percent of Total Billed Charges,90% of Total billed Charges,2165,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2165,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2165,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1407.25,65,,312,Percent of total Billed Charges,65% of Total Billed Charges,954.77,44.1,,426.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,2056.75,95,,1053.24,Percent of Total Billed Charges,95% of Total Billed Charges,2165,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1905.2,88,,930.616,Percent of Total Billed Charges,88% of Total Billed Charges,1948.5,90,,997.808,Percent of Total Billed charges,90% of Total Billed Charges,954.77,2165,
CT LSPINE W/WO CO,3520000014,CDM,352,RC,,,Outpatient,,,3299.00,2144.35,,3299,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2507.24,76,,7478.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2375.28,72,,210.24,Percent of Total Billed Charges,72% of Total Billed Charges,2474.25,75,,219,Percent of Total Billed charges,75% of Total Billed Charges,3299,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2375.28,72,,210.24,Percent of Total Billed Charges,72% of Total Billed Charges,1979.4,60,,175.2,Percent of Total Billed Charges,60% of Total Billed Charges,2969.1,90,,2430.184,Percent of Total Billed Charges,90% of Total Billed Charges,1484.55,45,,475.888,Percent of Total Billed Charges,45% of Total Billed Charges,2969.1,90,,8856,Percent of Total Billed Charges,90% of Total billed Charges,3299,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3299,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3299,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2144.35,65,,832,Percent of total Billed Charges,65% of Total Billed Charges,1454.86,44.1,,466.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,3134.05,95,,9348,Percent of Total Billed Charges,95% of Total Billed Charges,3299,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2903.12,88,,987.008,Percent of Total Billed Charges,88% of Total Billed Charges,2969.1,90,,8856,Percent of Total Billed charges,90% of Total Billed Charges,1454.86,3299,
CTA PELVIS,3520000015,CDM,352,RC,,,Outpatient,,,2760.66,1794.43,,2760.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2098.1,76,,9721.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1987.68,72,,766.656,Percent of Total Billed Charges,72% of Total Billed Charges,2070.5,75,,798.6,Percent of Total Billed charges,75% of Total Billed Charges,2760.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1987.68,72,,766.656,Percent of Total Billed Charges,72% of Total Billed Charges,1656.4,60,,638.88,Percent of Total Billed Charges,60% of Total Billed Charges,2484.59,90,,8365.072,Percent of Total Billed Charges,90% of Total Billed Charges,1242.3,45,,504.72,Percent of Total Billed Charges,45% of Total Billed Charges,2484.59,90,,11512.8,Percent of Total Billed Charges,90% of Total billed Charges,2760.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2760.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2760.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1794.43,65,,208.112,Percent of total Billed Charges,65% of Total Billed Charges,1217.45,44.1,,494.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,2622.63,95,,12152.4,Percent of Total Billed Charges,95% of Total Billed Charges,2760.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2429.38,88,,1199.168,Percent of Total Billed Charges,88% of Total Billed Charges,2484.59,90,,11512.8,Percent of Total Billed charges,90% of Total Billed Charges,1217.45,2760.66,
CT PELVIC W/O CONT,3520000016,CDM,352,RC,,,Outpatient,,,2909.00,1890.85,,2909,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2210.84,76,,5244.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2094.48,72,,569.088,Percent of Total Billed Charges,72% of Total Billed Charges,2181.75,75,,592.8,Percent of Total Billed charges,75% of Total Billed Charges,2909,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2094.48,72,,569.088,Percent of Total Billed Charges,72% of Total Billed Charges,1745.4,60,,474.24,Percent of Total Billed Charges,60% of Total Billed Charges,2618.1,90,,4519.904,Percent of Total Billed Charges,90% of Total Billed Charges,1309.05,45,,613.208,Percent of Total Billed Charges,45% of Total Billed Charges,2618.1,90,,6210.896,Percent of Total Billed Charges,90% of Total billed Charges,2909,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2909,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2909,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1890.85,65,,452.4,Percent of total Billed Charges,65% of Total Billed Charges,1282.87,44.1,,600.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,2763.55,95,,6555.944,Percent of Total Billed Charges,95% of Total Billed Charges,2909,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2559.92,88,,5051.2,Percent of Total Billed Charges,88% of Total Billed Charges,2618.1,90,,6210.896,Percent of Total Billed charges,90% of Total Billed Charges,1282.87,2909,
CT PELVIC W/CONT,3520000017,CDM,352,RC,,,Outpatient,,,3679.00,2391.35,,3679,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2796.04,76,,735.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2648.88,72,,569.088,Percent of Total Billed Charges,72% of Total Billed Charges,2759.25,75,,592.8,Percent of Total Billed charges,75% of Total Billed Charges,3679,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2648.88,72,,569.088,Percent of Total Billed Charges,72% of Total Billed Charges,2207.4,60,,474.24,Percent of Total Billed Charges,60% of Total Billed Charges,3311.1,90,,4519.904,Percent of Total Billed Charges,90% of Total Billed Charges,1655.55,45,,2583,Percent of Total Billed Charges,45% of Total Billed Charges,3311.1,90,,871.2,Percent of Total Billed Charges,90% of Total billed Charges,3679,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3679,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3679,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2391.35,65,,252.72,Percent of total Billed Charges,65% of Total Billed Charges,1622.44,44.1,,2531.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,3495.05,95,,919.6,Percent of Total Billed Charges,95% of Total Billed Charges,3679,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3237.52,88,,4624.184,Percent of Total Billed Charges,88% of Total Billed Charges,3311.1,90,,871.2,Percent of Total Billed charges,90% of Total Billed Charges,1622.44,3679,
CT PELVIC W/WO CON,3520000018,CDM,352,RC,,,Outpatient,,,3756.00,2441.40,,3756,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2854.56,76,,803.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2704.32,72,,569.088,Percent of Total Billed Charges,72% of Total Billed Charges,2817,75,,592.8,Percent of Total Billed charges,75% of Total Billed Charges,3756,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2704.32,72,,569.088,Percent of Total Billed Charges,72% of Total Billed Charges,2253.6,60,,474.24,Percent of Total Billed Charges,60% of Total Billed Charges,3380.4,90,,3671.32,Percent of Total Billed Charges,90% of Total Billed Charges,1690.2,45,,2364.64,Percent of Total Billed Charges,45% of Total Billed Charges,3380.4,90,,951.768,Percent of Total Billed Charges,90% of Total billed Charges,3756,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3756,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3756,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2441.4,65,,915.2,Percent of total Billed Charges,65% of Total Billed Charges,1656.4,44.1,,2317.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,3568.2,95,,1004.648,Percent of Total Billed Charges,95% of Total Billed Charges,3756,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3305.28,88,,834.944,Percent of Total Billed Charges,88% of Total Billed Charges,3380.4,90,,951.768,Percent of Total Billed charges,90% of Total Billed Charges,1656.4,3756,
CTA UPPER EXTREM,3520000019,CDM,352,RC,,,Outpatient,,,2623.00,1704.95,,2623,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1993.48,76,,852.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1888.56,72,,542.96,Percent of Total Billed Charges,72% of Total Billed Charges,1967.25,75,,565.584,Percent of Total Billed charges,75% of Total Billed Charges,2623,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1888.56,72,,542.96,Percent of Total Billed Charges,72% of Total Billed Charges,1573.8,60,,452.464,Percent of Total Billed Charges,60% of Total Billed Charges,2360.7,90,,1139.896,Percent of Total Billed Charges,90% of Total Billed Charges,1180.35,45,,426.96,Percent of Total Billed Charges,45% of Total Billed Charges,2360.7,90,,1009.44,Percent of Total Billed Charges,90% of Total billed Charges,2623,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2623,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2623,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1704.95,65,,314.08,Percent of total Billed Charges,65% of Total Billed Charges,1156.74,44.1,,418.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,2491.85,95,,1065.52,Percent of Total Billed Charges,95% of Total Billed Charges,2623,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2308.24,88,,2376.176,Percent of Total Billed Charges,88% of Total Billed Charges,2360.7,90,,1009.44,Percent of Total Billed charges,90% of Total Billed Charges,1156.74,2623,
CT ABD W/O CONT,3520000020,CDM,352,RC,,,Outpatient,,,2336.00,1518.40,,2336,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1775.36,76,,1035.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1681.92,72,,569.088,Percent of Total Billed Charges,72% of Total Billed Charges,1752,75,,592.8,Percent of Total Billed charges,75% of Total Billed Charges,2336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1681.92,72,,569.088,Percent of Total Billed Charges,72% of Total Billed Charges,1401.6,60,,474.24,Percent of Total Billed Charges,60% of Total Billed Charges,2102.4,90,,1139.896,Percent of Total Billed Charges,90% of Total Billed Charges,1051.2,45,,1215.088,Percent of Total Billed Charges,45% of Total Billed Charges,2102.4,90,,1226.416,Percent of Total Billed Charges,90% of Total billed Charges,2336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1518.4,65,,315.64,Percent of total Billed Charges,65% of Total Billed Charges,1030.18,44.1,,1190.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,2219.2,95,,1294.552,Percent of Total Billed Charges,95% of Total Billed Charges,2336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2055.68,88,,8179.176,Percent of Total Billed Charges,88% of Total Billed Charges,2102.4,90,,1226.416,Percent of Total Billed charges,90% of Total Billed Charges,1030.18,2336,
CT ABD W/CONT,3520000021,CDM,352,RC,,,Outpatient,,,3335.00,2167.75,,3335,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2534.6,76,,4362.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2401.2,72,,457.344,Percent of Total Billed Charges,72% of Total Billed Charges,2501.25,75,,476.4,Percent of Total Billed charges,75% of Total Billed Charges,3335,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2401.2,72,,457.344,Percent of Total Billed Charges,72% of Total Billed Charges,2001,60,,381.12,Percent of Total Billed Charges,60% of Total Billed Charges,3001.5,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,1500.75,45,,4182.536,Percent of Total Billed Charges,45% of Total Billed Charges,3001.5,90,,5166,Percent of Total Billed Charges,90% of Total billed Charges,3335,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3335,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3335,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2167.75,65,,288.904,Percent of total Billed Charges,65% of Total Billed Charges,1470.74,44.1,,4098.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,3168.25,95,,5453,Percent of Total Billed Charges,95% of Total Billed Charges,3335,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2934.8,88,,4419.456,Percent of Total Billed Charges,88% of Total Billed Charges,3001.5,90,,5166,Percent of Total Billed charges,90% of Total Billed Charges,1470.74,3335,
CT ABD W/WO CONT,3520000022,CDM,352,RC,,,Outpatient,,,4142.00,2692.30,,4142,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3147.92,76,,3993.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2982.24,72,,420.48,Percent of Total Billed Charges,72% of Total Billed Charges,3106.5,75,,438,Percent of Total Billed charges,75% of Total Billed Charges,4142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2982.24,72,,420.48,Percent of Total Billed Charges,72% of Total Billed Charges,2485.2,60,,350.4,Percent of Total Billed Charges,60% of Total Billed Charges,3727.8,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,1863.9,45,,2259.952,Percent of Total Billed Charges,45% of Total Billed Charges,3727.8,90,,4729.28,Percent of Total Billed Charges,90% of Total billed Charges,4142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2692.3,65,,350.384,Percent of total Billed Charges,65% of Total Billed Charges,1826.62,44.1,,2214.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,3934.9,95,,4992.016,Percent of Total Billed Charges,95% of Total Billed Charges,4142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3644.96,88,,4419.456,Percent of Total Billed Charges,88% of Total Billed Charges,3727.8,90,,4729.28,Percent of Total Billed charges,90% of Total Billed Charges,1826.62,4142,
CTA ABD,3520000023,CDM,352,RC,,,Outpatient,,,2623.00,1704.95,,2623,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1993.48,76,,721.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1888.56,72,,457.344,Percent of Total Billed Charges,72% of Total Billed Charges,1967.25,75,,476.4,Percent of Total Billed charges,75% of Total Billed Charges,2623,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1888.56,72,,457.344,Percent of Total Billed Charges,72% of Total Billed Charges,1573.8,60,,381.12,Percent of Total Billed Charges,60% of Total Billed Charges,2360.7,90,,1293.84,Percent of Total Billed Charges,90% of Total Billed Charges,1180.35,45,,2259.952,Percent of Total Billed Charges,45% of Total Billed Charges,2360.7,90,,853.92,Percent of Total Billed Charges,90% of Total billed Charges,2623,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2623,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2623,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1704.95,65,,365.04,Percent of total Billed Charges,65% of Total Billed Charges,1156.74,44.1,,2214.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,2491.85,95,,901.36,Percent of Total Billed Charges,95% of Total Billed Charges,2623,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2308.24,88,,3589.736,Percent of Total Billed Charges,88% of Total Billed Charges,2360.7,90,,853.92,Percent of Total Billed charges,90% of Total Billed Charges,1156.74,2623,
CT ABD & PEL W/O CON,3520000024,CDM,352,RC,,,Outpatient,,,5416.00,3520.40,,5416,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4116.16,76,,2052.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3899.52,72,,481.36,Percent of Total Billed Charges,72% of Total Billed Charges,4062,75,,501.424,Percent of Total Billed charges,75% of Total Billed Charges,5416,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3899.52,72,,481.36,Percent of Total Billed Charges,72% of Total Billed Charges,3249.6,60,,401.136,Percent of Total Billed Charges,60% of Total Billed Charges,4874.4,90,,1669.36,Percent of Total Billed Charges,90% of Total Billed Charges,2437.2,45,,1835.664,Percent of Total Billed Charges,45% of Total Billed Charges,4874.4,90,,2430.184,Percent of Total Billed Charges,90% of Total billed Charges,5416,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5416,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5416,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3520.4,65,,384.112,Percent of total Billed Charges,65% of Total Billed Charges,2388.46,44.1,,1798.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,5145.2,95,,2565.192,Percent of Total Billed Charges,95% of Total Billed Charges,5416,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4766.08,88,,1114.568,Percent of Total Billed Charges,88% of Total Billed Charges,4874.4,90,,2430.184,Percent of Total Billed charges,90% of Total Billed Charges,2388.46,5416,
CT ABD & PEL W/ CONT,3520000025,CDM,352,RC,,,Outpatient,,,7707.00,5009.55,,7707,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5857.32,76,,7063.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5549.04,72,,475.776,Percent of Total Billed Charges,72% of Total Billed Charges,5780.25,75,,495.6,Percent of Total Billed charges,75% of Total Billed Charges,7707,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5549.04,72,,475.776,Percent of Total Billed Charges,72% of Total Billed Charges,4624.2,60,,396.48,Percent of Total Billed Charges,60% of Total Billed Charges,6936.3,90,,311.168,Percent of Total Billed Charges,90% of Total Billed Charges,3468.15,45,,569.952,Percent of Total Billed Charges,45% of Total Billed Charges,6936.3,90,,8365.072,Percent of Total Billed Charges,90% of Total billed Charges,7707,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7707,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7707,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5009.55,65,,1092,Percent of total Billed Charges,65% of Total Billed Charges,3398.79,44.1,,558.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,7321.65,95,,8829.792,Percent of Total Billed Charges,95% of Total Billed Charges,7707,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6782.16,88,,1114.568,Percent of Total Billed Charges,88% of Total Billed Charges,6936.3,90,,8365.072,Percent of Total Billed charges,90% of Total Billed Charges,3398.79,7707,
CT ABD & PEL W/WO CO,3520000026,CDM,352,RC,,,Outpatient,,,8094.00,5261.10,,8094,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6151.44,76,,3816.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5827.68,72,,230.4,Percent of Total Billed Charges,72% of Total Billed Charges,6070.5,75,,240,Percent of Total Billed charges,75% of Total Billed Charges,8094,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5827.68,72,,230.4,Percent of Total Billed Charges,72% of Total Billed Charges,4856.4,60,,192,Percent of Total Billed Charges,60% of Total Billed Charges,7284.6,90,,908.64,Percent of Total Billed Charges,90% of Total Billed Charges,3642.3,45,,569.952,Percent of Total Billed Charges,45% of Total Billed Charges,7284.6,90,,4519.904,Percent of Total Billed Charges,90% of Total billed Charges,8094,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8094,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8094,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5261.1,65,,350.744,Percent of total Billed Charges,65% of Total Billed Charges,3569.45,44.1,,558.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,7689.3,95,,4771.008,Percent of Total Billed Charges,95% of Total Billed Charges,8094,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7122.72,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,7284.6,90,,4519.904,Percent of Total Billed charges,90% of Total Billed Charges,3569.45,8094,
CTA ABD AND ILIACS,3520000027,CDM,352,RC,,,Outpatient,,,2623.00,1704.95,,2623,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1993.48,76,,3816.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1888.56,72,,410.112,Percent of Total Billed Charges,72% of Total Billed Charges,1967.25,75,,427.2,Percent of Total Billed charges,75% of Total Billed Charges,2623,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1888.56,72,,410.112,Percent of Total Billed Charges,72% of Total Billed Charges,1573.8,60,,341.76,Percent of Total Billed Charges,60% of Total Billed Charges,2360.7,90,,2476.656,Percent of Total Billed Charges,90% of Total Billed Charges,1180.35,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,2360.7,90,,4519.904,Percent of Total Billed Charges,90% of Total billed Charges,2623,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2623,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2623,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1704.95,65,,227.6,Percent of total Billed Charges,65% of Total Billed Charges,1156.74,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,2491.85,95,,4771.008,Percent of Total Billed Charges,95% of Total Billed Charges,2623,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2308.24,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,2360.7,90,,4519.904,Percent of Total Billed charges,90% of Total Billed Charges,1156.74,2623,
CT CORNL SAG OBL 3D,3590000001,CDM,359,RC,,,Outpatient,,,459.74,298.83,,459.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,349.4,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,331.01,72,,347.368,Percent of Total Billed Charges,72% of Total Billed Charges,344.81,75,,361.84,Percent of Total Billed charges,75% of Total Billed Charges,459.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,331.01,72,,347.368,Percent of Total Billed Charges,72% of Total Billed Charges,275.84,60,,289.472,Percent of Total Billed Charges,60% of Total Billed Charges,413.77,90,,653.296,Percent of Total Billed Charges,90% of Total Billed Charges,206.88,45,,454.32,Percent of Total Billed Charges,45% of Total Billed Charges,413.77,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,459.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,459.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,459.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.83,65,,674.776,Percent of total Billed Charges,65% of Total Billed Charges,202.75,44.1,,445.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,436.75,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,459.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404.57,88,,2421.616,Percent of Total Billed Charges,88% of Total Billed Charges,413.77,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,202.75,459.74,
CT BONE NEEDLE BX/SUPERFICIAL,3600000004,CDM,360,RC,,,Outpatient,,,2315.25,1504.91,,2315.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1759.59,76,,1092.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1666.98,72,,364.032,Percent of Total Billed Charges,72% of Total Billed Charges,1736.44,75,,379.2,Percent of Total Billed charges,75% of Total Billed Charges,2315.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1666.98,72,,364.032,Percent of Total Billed Charges,72% of Total Billed Charges,1389.15,60,,303.36,Percent of Total Billed Charges,60% of Total Billed Charges,2083.73,90,,392.144,Percent of Total Billed Charges,90% of Total Billed Charges,1041.86,45,,1238.328,Percent of Total Billed Charges,45% of Total Billed Charges,2083.73,90,,1293.84,Percent of Total Billed Charges,90% of Total billed Charges,2315.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2315.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2315.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1504.91,65,,1245.12,Percent of total Billed Charges,65% of Total Billed Charges,1021.03,44.1,,1213.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,2199.49,95,,1365.72,Percent of Total Billed Charges,95% of Total Billed Charges,2315.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2037.42,88,,557.568,Percent of Total Billed Charges,88% of Total Billed Charges,2083.73,90,,1293.84,Percent of Total Billed charges,90% of Total Billed Charges,1021.03,2315.25,
CT BONE  VERTEBRAL  FEMUR DEEP,3600000005,CDM,360,RC,,,Outpatient,,,4504.00,2927.60,,4504,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3423.04,76,,1409.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3242.88,72,,330.048,Percent of Total Billed Charges,72% of Total Billed Charges,3378,75,,343.8,Percent of Total Billed charges,75% of Total Billed Charges,4504,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3242.88,72,,330.048,Percent of Total Billed Charges,72% of Total Billed Charges,2702.4,60,,275.04,Percent of Total Billed Charges,60% of Total Billed Charges,4053.6,90,,2171.048,Percent of Total Billed Charges,90% of Total Billed Charges,2026.8,45,,285.12,Percent of Total Billed Charges,45% of Total Billed Charges,4053.6,90,,1669.36,Percent of Total Billed Charges,90% of Total billed Charges,4504,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4504,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4504,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2927.6,65,,782.6,Percent of total Billed Charges,65% of Total Billed Charges,1986.26,44.1,,279.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,4278.8,95,,1762.104,Percent of Total Billed Charges,95% of Total Billed Charges,4504,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3963.52,88,,1251.616,Percent of Total Billed Charges,88% of Total Billed Charges,4053.6,90,,1669.36,Percent of Total Billed charges,90% of Total Billed Charges,1986.26,4504,
CT DRGE OVAR CYS UNI/BILAT ABD,3600000006,CDM,360,RC,,,Outpatient,,,5728.98,3723.84,,5728.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4354.02,76,,262.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4124.87,72,,607.104,Percent of Total Billed Charges,72% of Total Billed Charges,4296.74,75,,632.4,Percent of Total Billed charges,75% of Total Billed Charges,5728.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4124.87,72,,607.104,Percent of Total Billed Charges,72% of Total Billed Charges,3437.39,60,,505.92,Percent of Total Billed Charges,60% of Total Billed Charges,5156.08,90,,1925.76,Percent of Total Billed Charges,90% of Total Billed Charges,2578.04,45,,640.032,Percent of Total Billed Charges,45% of Total Billed Charges,5156.08,90,,311.168,Percent of Total Billed Charges,90% of Total billed Charges,5728.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5728.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5728.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3723.84,65,,964.08,Percent of total Billed Charges,65% of Total Billed Charges,2526.48,44.1,,627.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,5442.53,95,,328.456,Percent of Total Billed Charges,95% of Total Billed Charges,5728.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5041.5,88,,1956.272,Percent of Total Billed Charges,88% of Total Billed Charges,5156.08,90,,311.168,Percent of Total Billed charges,90% of Total Billed Charges,2526.48,5728.98,
CT PERC ASP INJ RENA PELV CYST,3600000007,CDM,360,RC,,,Outpatient,,,2607.41,1694.82,,2607.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1981.63,76,,767.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1877.34,72,,715.392,Percent of Total Billed Charges,72% of Total Billed Charges,1955.56,75,,745.2,Percent of Total Billed charges,75% of Total Billed Charges,2607.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1877.34,72,,715.392,Percent of Total Billed Charges,72% of Total Billed Charges,1564.45,60,,596.16,Percent of Total Billed Charges,60% of Total Billed Charges,2346.67,90,,4788.992,Percent of Total Billed Charges,90% of Total Billed Charges,1173.33,45,,1000.368,Percent of Total Billed Charges,45% of Total Billed Charges,2346.67,90,,908.64,Percent of Total Billed Charges,90% of Total billed Charges,2607.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2607.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2607.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1694.82,65,,734.76,Percent of total Billed Charges,65% of Total Billed Charges,1149.87,44.1,,980.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,2477.04,95,,959.12,Percent of Total Billed Charges,95% of Total Billed Charges,2607.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2294.52,88,,204.128,Percent of Total Billed Charges,88% of Total Billed Charges,2346.67,90,,908.64,Percent of Total Billed charges,90% of Total Billed Charges,1149.87,2607.41,
DRGE OVAR CYS UNI  BILAT ABD,3600000008,CDM,360,RC,,,Outpatient,,,5728.98,3723.84,,5728.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4354.02,76,,2091.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4124.87,72,,699.264,Percent of Total Billed Charges,72% of Total Billed Charges,4296.74,75,,728.4,Percent of Total Billed charges,75% of Total Billed Charges,5728.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4124.87,72,,699.264,Percent of Total Billed Charges,72% of Total Billed Charges,3437.39,60,,582.72,Percent of Total Billed Charges,60% of Total Billed Charges,5156.08,90,,8353.048,Percent of Total Billed Charges,90% of Total Billed Charges,2578.04,45,,104.384,Percent of Total Billed Charges,45% of Total Billed Charges,5156.08,90,,2476.656,Percent of Total Billed Charges,90% of Total billed Charges,5728.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5728.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5728.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3723.84,65,,2256.8,Percent of total Billed Charges,65% of Total Billed Charges,2526.48,44.1,,102.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,5442.53,95,,2614.248,Percent of Total Billed Charges,95% of Total Billed Charges,5728.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5041.5,88,,638.784,Percent of Total Billed Charges,88% of Total Billed Charges,5156.08,90,,2476.656,Percent of Total Billed charges,90% of Total Billed Charges,2526.48,5728.98,
LIGATE FALOP TBE ABD/VAG POSTP,3600000009,CDM,360,RC,,,Outpatient,,,965.55,627.61,,965.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,733.82,76,,481.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,695.2,72,,432.312,Percent of Total Billed Charges,72% of Total Billed Charges,724.16,75,,450.328,Percent of Total Billed charges,75% of Total Billed Charges,965.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.2,72,,432.312,Percent of Total Billed Charges,72% of Total Billed Charges,579.33,60,,360.256,Percent of Total Billed Charges,60% of Total Billed Charges,869,90,,8353.048,Percent of Total Billed Charges,90% of Total Billed Charges,434.5,45,,326.648,Percent of Total Billed Charges,45% of Total Billed Charges,869,90,,570.24,Percent of Total Billed Charges,90% of Total billed Charges,965.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,965.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,965.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,627.61,65,,1090.992,Percent of total Billed Charges,65% of Total Billed Charges,425.81,44.1,,320.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,917.27,95,,601.92,Percent of Total Billed Charges,95% of Total Billed Charges,965.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,849.68,88,,383.424,Percent of Total Billed Charges,88% of Total Billed Charges,869,90,,570.24,Percent of Total Billed charges,90% of Total Billed Charges,425.81,965.55,
MEDTRONIC EXTERNAL NEUROSTIM,3600000010,CDM,360,RC,,,Outpatient,,,1491.00,969.15,,1491,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1133.16,76,,1080.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1073.52,72,,652.608,Percent of Total Billed Charges,72% of Total Billed Charges,1118.25,75,,679.8,Percent of Total Billed charges,75% of Total Billed Charges,1491,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1073.52,72,,652.608,Percent of Total Billed Charges,72% of Total Billed Charges,894.6,60,,543.84,Percent of Total Billed Charges,60% of Total Billed Charges,1341.9,90,,1734.48,Percent of Total Billed Charges,90% of Total Billed Charges,670.95,45,,196.072,Percent of Total Billed Charges,45% of Total Billed Charges,1341.9,90,,1280.056,Percent of Total Billed Charges,90% of Total billed Charges,1491,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1491,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1491,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,969.15,65,,8330.8,Percent of total Billed Charges,65% of Total Billed Charges,657.53,44.1,,192.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,1416.45,95,,1351.176,Percent of Total Billed Charges,95% of Total Billed Charges,1491,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.08,88,,2122.8,Percent of Total Billed Charges,88% of Total Billed Charges,1341.9,90,,1280.056,Percent of Total Billed charges,90% of Total Billed Charges,657.53,1491,
NRVE BLK ILIOING ILIOHYPOGAST,3600000011,CDM,360,RC,,,Outpatient,,,999.00,649.35,,999,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,759.24,76,,1689.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,719.28,72,,385.472,Percent of Total Billed Charges,72% of Total Billed Charges,749.25,75,,401.536,Percent of Total Billed charges,75% of Total Billed Charges,999,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,719.28,72,,385.472,Percent of Total Billed Charges,72% of Total Billed Charges,599.4,60,,321.224,Percent of Total Billed Charges,60% of Total Billed Charges,899.1,90,,1094.4,Percent of Total Billed Charges,90% of Total Billed Charges,449.55,45,,1085.52,Percent of Total Billed Charges,45% of Total Billed Charges,899.1,90,,2000.728,Percent of Total Billed Charges,90% of Total billed Charges,999,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,999,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,999,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649.35,65,,1198.2,Percent of total Billed Charges,65% of Total Billed Charges,440.56,44.1,,1063.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,949.05,95,,2111.88,Percent of Total Billed Charges,95% of Total Billed Charges,999,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,879.12,88,,1882.968,Percent of Total Billed Charges,88% of Total Billed Charges,899.1,90,,2000.728,Percent of Total Billed charges,90% of Total Billed Charges,440.56,999,
PERIPHERAL ARTERY STENT INIT,3600000012,CDM,360,RC,,,Outpatient,,,14027.25,9117.71,,14027.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10660.71,76,,176.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10099.62,72,,404.352,Percent of Total Billed Charges,72% of Total Billed Charges,10520.44,75,,421.2,Percent of Total Billed charges,75% of Total Billed Charges,14027.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10099.62,72,,404.352,Percent of Total Billed Charges,72% of Total Billed Charges,8416.35,60,,336.96,Percent of Total Billed Charges,60% of Total Billed Charges,12624.53,90,,410.4,Percent of Total Billed Charges,90% of Total Billed Charges,6312.26,45,,962.88,Percent of Total Billed Charges,45% of Total Billed Charges,12624.53,90,,208.768,Percent of Total Billed Charges,90% of Total billed Charges,14027.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14027.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14027.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9117.71,65,,1580.016,Percent of total Billed Charges,65% of Total Billed Charges,6186.02,44.1,,943.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,13325.89,95,,220.368,Percent of Total Billed Charges,95% of Total Billed Charges,14027.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12343.98,88,,4682.568,Percent of Total Billed Charges,88% of Total Billed Charges,12624.53,90,,208.768,Percent of Total Billed charges,90% of Total Billed Charges,6186.02,14027.25,
PERIPHERAL ARTERY STNT EA ADD,3600000013,CDM,360,RC,,,Outpatient,,,9318.11,6056.77,,9318.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7081.76,76,,551.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6709.04,72,,715.392,Percent of Total Billed Charges,72% of Total Billed Charges,6988.58,75,,745.2,Percent of Total Billed charges,75% of Total Billed Charges,9318.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6709.04,72,,715.392,Percent of Total Billed Charges,72% of Total Billed Charges,5590.87,60,,596.16,Percent of Total Billed Charges,60% of Total Billed Charges,8386.3,90,,1152,Percent of Total Billed Charges,90% of Total Billed Charges,4193.15,45,,2394.496,Percent of Total Billed Charges,45% of Total Billed Charges,8386.3,90,,653.296,Percent of Total Billed Charges,90% of Total billed Charges,9318.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9318.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9318.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6056.77,65,,1764.504,Percent of total Billed Charges,65% of Total Billed Charges,4109.29,44.1,,2346.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,8852.2,95,,689.592,Percent of Total Billed Charges,95% of Total Billed Charges,9318.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8199.94,88,,8167.424,Percent of Total Billed Charges,88% of Total Billed Charges,8386.3,90,,653.296,Percent of Total Billed charges,90% of Total Billed Charges,4109.29,9318.11,
REM AICD GEN W/REP AICD DUAL,3600000015,CDM,360,RC,,,Outpatient,,,68585.42,44580.52,,68585.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52124.92,76,,331.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,49381.5,72,,353.664,Percent of Total Billed Charges,72% of Total Billed Charges,51439.07,75,,368.4,Percent of Total Billed charges,75% of Total Billed Charges,68585.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49381.5,72,,353.664,Percent of Total Billed Charges,72% of Total Billed Charges,41151.25,60,,294.72,Percent of Total Billed Charges,60% of Total Billed Charges,61726.88,90,,432,Percent of Total Billed Charges,90% of Total Billed Charges,30863.44,45,,4176.52,Percent of Total Billed Charges,45% of Total Billed Charges,61726.88,90,,392.144,Percent of Total Billed Charges,90% of Total billed Charges,68585.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68585.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68585.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44580.52,65,,1676.48,Percent of total Billed Charges,65% of Total Billed Charges,30246.17,44.1,,4092.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,65156.15,95,,413.928,Percent of Total Billed Charges,95% of Total Billed Charges,68585.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60355.17,88,,8167.424,Percent of Total Billed Charges,88% of Total Billed Charges,61726.88,90,,392.144,Percent of Total Billed charges,90% of Total Billed Charges,30246.17,68585.42,
REM AICD GEN W/REP AICD SINGLE,3600000016,CDM,360,RC,,,Outpatient,,,66933.88,43507.02,,66933.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,50869.75,76,,1833.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,48192.39,72,,456.192,Percent of Total Billed Charges,72% of Total Billed Charges,50200.41,75,,475.2,Percent of Total Billed charges,75% of Total Billed Charges,66933.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48192.39,72,,456.192,Percent of Total Billed Charges,72% of Total Billed Charges,40160.33,60,,380.16,Percent of Total Billed Charges,60% of Total Billed Charges,60240.49,90,,1152,Percent of Total Billed Charges,90% of Total Billed Charges,30120.25,45,,4176.52,Percent of Total Billed Charges,45% of Total Billed Charges,60240.49,90,,2171.048,Percent of Total Billed Charges,90% of Total billed Charges,66933.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66933.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66933.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43507.02,65,,1360.84,Percent of total Billed Charges,65% of Total Billed Charges,29517.84,44.1,,4092.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,63587.19,95,,2291.656,Percent of Total Billed Charges,95% of Total Billed Charges,66933.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58901.81,88,,1695.936,Percent of Total Billed Charges,88% of Total Billed Charges,60240.49,90,,2171.048,Percent of Total Billed charges,90% of Total Billed Charges,29517.84,66933.88,
REM ICD/BIV GEN W/REP GEN MUL,3600000017,CDM,360,RC,,,Outpatient,,,65594.34,42636.32,,65594.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,49851.7,76,,1626.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47227.92,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,49195.76,75,,317.4,Percent of Total Billed charges,75% of Total Billed Charges,65594.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47227.92,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,39356.6,60,,253.92,Percent of Total Billed Charges,60% of Total Billed Charges,59034.91,90,,288.152,Percent of Total Billed Charges,90% of Total Billed Charges,29517.45,45,,867.24,Percent of Total Billed Charges,45% of Total Billed Charges,59034.91,90,,1925.76,Percent of Total Billed Charges,90% of Total billed Charges,65594.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65594.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65594.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42636.32,65,,384.28,Percent of total Billed Charges,65% of Total Billed Charges,28927.1,44.1,,849.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,62314.62,95,,2032.752,Percent of Total Billed Charges,95% of Total Billed Charges,65594.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57723.02,88,,1070.08,Percent of Total Billed Charges,88% of Total Billed Charges,59034.91,90,,1925.76,Percent of Total Billed charges,90% of Total Billed Charges,28927.1,65594.34,
TRANS INTRVS STNT PLC EA AD VN,3600000028,CDM,481,RC,,,Outpatient,,,10114.34,6574.32,,10114.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7686.9,76,,4044.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7282.32,72,,404.352,Percent of Total Billed Charges,72% of Total Billed Charges,7585.76,75,,421.2,Percent of Total Billed charges,75% of Total Billed Charges,10114.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7282.32,72,,404.352,Percent of Total Billed Charges,72% of Total Billed Charges,6068.6,60,,336.96,Percent of Total Billed Charges,60% of Total Billed Charges,9102.91,90,,626.4,Percent of Total Billed Charges,90% of Total Billed Charges,4551.45,45,,547.2,Percent of Total Billed Charges,45% of Total Billed Charges,9102.91,90,,4788.992,Percent of Total Billed Charges,90% of Total billed Charges,10114.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10114.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10114.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6574.32,65,,1100.32,Percent of total Billed Charges,65% of Total Billed Charges,4460.42,44.1,,536.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,9608.62,95,,5055.048,Percent of Total Billed Charges,95% of Total Billed Charges,10114.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8900.62,88,,401.28,Percent of Total Billed Charges,88% of Total Billed Charges,9102.91,90,,4788.992,Percent of Total Billed charges,90% of Total Billed Charges,4460.42,10114.34,
TRANS INTRVS STNT PLC INIT VN,3600000029,CDM,481,RC,,,Outpatient,,,20912.22,13592.94,,20912.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15893.29,76,,7053.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15056.8,72,,335.304,Percent of Total Billed Charges,72% of Total Billed Charges,15684.17,75,,349.272,Percent of Total Billed charges,75% of Total Billed Charges,20912.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15056.8,72,,335.304,Percent of Total Billed Charges,72% of Total Billed Charges,12547.33,60,,279.416,Percent of Total Billed Charges,60% of Total Billed Charges,18821,90,,349.92,Percent of Total Billed Charges,90% of Total Billed Charges,9410.5,45,,205.2,Percent of Total Billed Charges,45% of Total Billed Charges,18821,90,,8353.048,Percent of Total Billed Charges,90% of Total billed Charges,20912.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20912.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20912.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13592.94,65,,7758.92,Percent of total Billed Charges,65% of Total Billed Charges,9222.29,44.1,,201.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,19866.61,95,,8817.104,Percent of Total Billed Charges,95% of Total Billed Charges,20912.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18402.75,88,,1126.4,Percent of Total Billed Charges,88% of Total Billed Charges,18821,90,,8353.048,Percent of Total Billed charges,90% of Total Billed Charges,9222.29,20912.22,
TRANSC ART/VEN THROM TX SUB DY,3600000030,CDM,360,RC,,,Outpatient,,,5537.86,3599.61,,5537.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4208.77,76,,7053.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3987.26,72,,437.184,Percent of Total Billed Charges,72% of Total Billed Charges,4153.4,75,,455.4,Percent of Total Billed charges,75% of Total Billed Charges,5537.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3987.26,72,,437.184,Percent of Total Billed Charges,72% of Total Billed Charges,3322.72,60,,364.32,Percent of Total Billed Charges,60% of Total Billed Charges,4984.07,90,,1267.2,Percent of Total Billed Charges,90% of Total Billed Charges,2492.04,45,,576,Percent of Total Billed Charges,45% of Total Billed Charges,4984.07,90,,8353.048,Percent of Total Billed Charges,90% of Total billed Charges,5537.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5537.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5537.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3599.61,65,,15007.648,Percent of total Billed Charges,65% of Total Billed Charges,2442.2,44.1,,564.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,5260.97,95,,8817.104,Percent of Total Billed Charges,95% of Total Billed Charges,5537.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4873.32,88,,422.4,Percent of Total Billed Charges,88% of Total Billed Charges,4984.07,90,,8353.048,Percent of Total Billed charges,90% of Total Billed Charges,2442.2,5537.86,
US BONE NEEDLE BX/ SUPERFICIAL,3600000031,CDM,360,RC,,,Outpatient,,,2315.25,1504.91,,2315.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1759.59,76,,1464.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1666.98,72,,258.464,Percent of Total Billed Charges,72% of Total Billed Charges,1736.44,75,,269.232,Percent of Total Billed charges,75% of Total Billed Charges,2315.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1666.98,72,,258.464,Percent of Total Billed Charges,72% of Total Billed Charges,1389.15,60,,215.384,Percent of Total Billed Charges,60% of Total Billed Charges,2083.73,90,,434.88,Percent of Total Billed Charges,90% of Total Billed Charges,1041.86,45,,216,Percent of Total Billed Charges,45% of Total Billed Charges,2083.73,90,,1734.48,Percent of Total Billed Charges,90% of Total billed Charges,2315.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2315.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2315.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1504.91,65,,6981.64,Percent of total Billed Charges,65% of Total Billed Charges,1021.03,44.1,,211.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,2199.49,95,,1830.84,Percent of Total Billed Charges,95% of Total Billed Charges,2315.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2037.42,88,,1126.4,Percent of Total Billed Charges,88% of Total Billed Charges,2083.73,90,,1734.48,Percent of Total Billed charges,90% of Total Billed Charges,1021.03,2315.25,
US BONE  VERTEBRAL  FEM DEEP,3600000032,CDM,360,RC,,,Outpatient,,,4740.75,3081.49,,4740.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3602.97,76,,924.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3413.34,72,,357.696,Percent of Total Billed Charges,72% of Total Billed Charges,3555.56,75,,372.6,Percent of Total Billed charges,75% of Total Billed Charges,4740.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3413.34,72,,357.696,Percent of Total Billed Charges,72% of Total Billed Charges,2844.45,60,,298.08,Percent of Total Billed Charges,60% of Total Billed Charges,4266.68,90,,437.04,Percent of Total Billed Charges,90% of Total Billed Charges,2133.34,45,,576,Percent of Total Billed Charges,45% of Total Billed Charges,4266.68,90,,1094.4,Percent of Total Billed Charges,90% of Total billed Charges,4740.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4740.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4740.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3081.49,65,,7099.768,Percent of total Billed Charges,65% of Total Billed Charges,2090.67,44.1,,564.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,4503.71,95,,1155.2,Percent of Total Billed Charges,95% of Total Billed Charges,4740.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4171.86,88,,281.744,Percent of Total Billed Charges,88% of Total Billed Charges,4266.68,90,,1094.4,Percent of Total Billed charges,90% of Total Billed Charges,2090.67,4740.75,
VAS EMBOLIZATION VEN W/O HEMMO,3600000033,CDM,360,RC,,,Outpatient,,,13359.29,8683.54,,13359.29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10153.06,76,,346.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9618.69,72,,193.536,Percent of Total Billed Charges,72% of Total Billed Charges,10019.47,75,,201.6,Percent of Total Billed charges,75% of Total Billed Charges,13359.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9618.69,72,,193.536,Percent of Total Billed Charges,72% of Total Billed Charges,8015.57,60,,161.28,Percent of Total Billed Charges,60% of Total Billed Charges,12023.36,90,,400.024,Percent of Total Billed Charges,90% of Total Billed Charges,6011.68,45,,144.072,Percent of Total Billed Charges,45% of Total Billed Charges,12023.36,90,,410.4,Percent of Total Billed Charges,90% of Total billed Charges,13359.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13359.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13359.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8683.54,65,,21388.456,Percent of total Billed Charges,65% of Total Billed Charges,5891.45,44.1,,141.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,12691.33,95,,433.2,Percent of Total Billed Charges,95% of Total Billed Charges,13359.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11756.18,88,,612.48,Percent of Total Billed Charges,88% of Total Billed Charges,12023.36,90,,410.4,Percent of Total Billed charges,90% of Total Billed Charges,5891.45,13359.29,
XR BONE NEEDLE BX/ SUPERFICIAL,3600000034,CDM,360,RC,,,Outpatient,,,2315.25,1504.91,,2315.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1759.59,76,,972.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1666.98,72,,147.456,Percent of Total Billed Charges,72% of Total Billed Charges,1736.44,75,,153.6,Percent of Total Billed charges,75% of Total Billed Charges,2315.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1666.98,72,,147.456,Percent of Total Billed Charges,72% of Total Billed Charges,1389.15,60,,122.88,Percent of Total Billed Charges,60% of Total Billed Charges,2083.73,90,,485.152,Percent of Total Billed Charges,90% of Total Billed Charges,1041.86,45,,313.2,Percent of Total Billed Charges,45% of Total Billed Charges,2083.73,90,,1152,Percent of Total Billed Charges,90% of Total billed Charges,2315.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2315.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2315.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1504.91,65,,4684.16,Percent of total Billed Charges,65% of Total Billed Charges,1021.03,44.1,,306.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,2199.49,95,,1216,Percent of Total Billed Charges,95% of Total Billed Charges,2315.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2037.42,88,,342.144,Percent of Total Billed Charges,88% of Total Billed Charges,2083.73,90,,1152,Percent of Total Billed charges,90% of Total Billed Charges,1021.03,2315.25,
XR BONE  VERTEBRAL  FEM DEEP,3600000035,CDM,360,RC,,,Outpatient,,,4740.75,3081.49,,4740.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3602.97,76,,364.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3413.34,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,3555.56,75,,317.4,Percent of Total Billed charges,75% of Total Billed Charges,4740.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3413.34,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,2844.45,60,,253.92,Percent of Total Billed Charges,60% of Total Billed Charges,4266.68,90,,505.44,Percent of Total Billed Charges,90% of Total Billed Charges,2133.34,45,,174.96,Percent of Total Billed Charges,45% of Total Billed Charges,4266.68,90,,432,Percent of Total Billed Charges,90% of Total billed Charges,4740.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4740.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4740.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3081.49,65,,7503.824,Percent of total Billed Charges,65% of Total Billed Charges,2090.67,44.1,,171.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,4503.71,95,,456,Percent of Total Billed Charges,95% of Total Billed Charges,4740.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4171.86,88,,1239.04,Percent of Total Billed Charges,88% of Total Billed Charges,4266.68,90,,432,Percent of Total Billed charges,90% of Total Billed Charges,2090.67,4740.75,
Apligraf ALT Application,3600000036,CDM,360,RC,,,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,972.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,3762.29,75,,317.4,Percent of Total Billed charges,75% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,304.704,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,253.92,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,531.848,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,633.6,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,1152,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,1100.32,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,620.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,1216,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,425.216,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,1152,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
SHIRE APPLICATION,3600000037,CDM,360,RC,,,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,243.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,288,Percent of Total Billed Charges,72% of Total Billed Charges,3762.29,75,,300,Percent of Total Billed charges,75% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,288,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,240,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,1512,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,217.44,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,288.152,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,2879.688,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,213.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,304.16,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,427.328,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,288.152,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
APLIGRAFT APPLICATION FGFH,3600000038,CDM,360,RC,,,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,528.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,400.016,Percent of Total Billed Charges,72% of Total Billed Charges,3762.29,75,,416.68,Percent of Total Billed charges,75% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,400.016,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,333.344,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,485.64,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,218.52,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,626.4,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,2879.688,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,214.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,661.2,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,391.136,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,626.4,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
THERASKIN APPLICATION,3600000039,CDM,360,RC,,,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,295.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,400.016,Percent of Total Billed Charges,72% of Total Billed Charges,3762.29,75,,416.68,Percent of Total Billed charges,75% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,400.016,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,333.344,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,315.136,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,200.016,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,349.92,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,7653.56,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,196.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,369.36,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,474.368,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,349.92,Percent of Total Billed charges,90% of Total Billed Charges,2212.22,5016.38,
EA ADDTL 25 SQ CM,3600000040,CDM,360,RC,,,Outpatient,,,954.77,620.60,,954.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,725.63,76,,1070.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,687.43,72,,400.016,Percent of Total Billed Charges,72% of Total Billed Charges,716.08,75,,416.68,Percent of Total Billed charges,75% of Total Billed Charges,954.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,687.43,72,,400.016,Percent of Total Billed Charges,72% of Total Billed Charges,572.86,60,,333.344,Percent of Total Billed Charges,60% of Total Billed Charges,859.29,90,,1629.672,Percent of Total Billed Charges,90% of Total Billed Charges,429.65,45,,242.576,Percent of Total Billed Charges,45% of Total Billed Charges,859.29,90,,1267.2,Percent of Total Billed Charges,90% of Total billed Charges,954.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,954.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,954.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,620.6,65,,11755.512,Percent of total Billed Charges,65% of Total Billed Charges,421.05,44.1,,237.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,907.03,95,,1337.6,Percent of Total Billed Charges,95% of Total Billed Charges,954.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,840.2,88,,494.208,Percent of Total Billed Charges,88% of Total Billed Charges,859.29,90,,1267.2,Percent of Total Billed charges,90% of Total Billed Charges,421.05,954.77,
APLIGRAFT APPLICATION EA,3600000041,CDM,360,RC,,,Outpatient,,,954.77,620.60,,954.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,725.63,76,,367.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,687.43,72,,252.288,Percent of Total Billed Charges,72% of Total Billed Charges,716.08,75,,262.8,Percent of Total Billed charges,75% of Total Billed Charges,954.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,687.43,72,,252.288,Percent of Total Billed Charges,72% of Total Billed Charges,572.86,60,,210.24,Percent of Total Billed Charges,60% of Total Billed Charges,859.29,90,,2436.968,Percent of Total Billed Charges,90% of Total Billed Charges,429.65,45,,252.72,Percent of Total Billed Charges,45% of Total Billed Charges,859.29,90,,434.88,Percent of Total Billed Charges,90% of Total billed Charges,954.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,954.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,954.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,620.6,65,,19355.44,Percent of total Billed Charges,65% of Total Billed Charges,421.05,44.1,,247.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,907.03,95,,459.04,Percent of Total Billed Charges,95% of Total Billed Charges,954.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,840.2,88,,520.032,Percent of Total Billed Charges,88% of Total Billed Charges,859.29,90,,434.88,Percent of Total Billed charges,90% of Total Billed Charges,421.05,954.77,
CT MUSCLE BIOPSY,3600000042,CDM,360,RC,,,Outpatient,,,2409.00,1565.85,,2409,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1830.84,76,,369.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1734.48,72,,86.536,Percent of Total Billed Charges,72% of Total Billed Charges,1806.75,75,,90.136,Percent of Total Billed charges,75% of Total Billed Charges,2409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1734.48,72,,86.536,Percent of Total Billed Charges,72% of Total Billed Charges,1445.4,60,,72.112,Percent of Total Billed Charges,60% of Total Billed Charges,2168.1,90,,1746.76,Percent of Total Billed Charges,90% of Total Billed Charges,1084.05,45,,265.928,Percent of Total Billed Charges,45% of Total Billed Charges,2168.1,90,,437.04,Percent of Total Billed Charges,90% of Total billed Charges,2409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1565.85,65,,7653.56,Percent of total Billed Charges,65% of Total Billed Charges,1062.37,44.1,,260.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,2288.55,95,,461.32,Percent of Total Billed Charges,95% of Total Billed Charges,2409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2119.92,88,,1478.4,Percent of Total Billed Charges,88% of Total Billed Charges,2168.1,90,,437.04,Percent of Total Billed charges,90% of Total Billed Charges,1062.37,2409,
SP MUSCLE BIOPSY,3600000043,CDM,761,RC,,,Outpatient,,,2409.00,1565.85,,2409,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1830.84,76,,337.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,586.944,Case Rate,Pays Based on per visit rate,50,100,,611.4,Case Rate,Pays based on per visit rate,2409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,586.944,Case Rate,Pays based on per visit rate,50,100,,489.12,Case Rate,Pays based on per visit rate,2168.1,90,,3714.48,Percent of Total Billed Charges,90% of Total Billed Charges,1084.05,45,,756,Percent of Total Billed Charges,45% of Total Billed Charges,2168.1,90,,400.024,Percent of Total Billed Charges,90% of Total billed Charges,2409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1565.85,65,,7271.16,Percent of total Billed Charges,65% of Total Billed Charges,1062.37,44.1,,740.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,2288.55,95,,422.248,Percent of Total Billed Charges,95% of Total Billed Charges,2409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2119.92,88,,474.848,Percent of Total Billed Charges,88% of Total Billed Charges,2168.1,90,,400.024,Percent of Total Billed charges,90% of Total Billed Charges,50,2409,
XR MUSCLE BIOPSY,3600000044,CDM,360,RC,,,Outpatient,,,2535.75,1648.24,,2535.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1927.17,76,,409.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1825.74,72,,318.528,Percent of Total Billed Charges,72% of Total Billed Charges,1901.81,75,,331.8,Percent of Total Billed charges,75% of Total Billed Charges,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1825.74,72,,318.528,Percent of Total Billed Charges,72% of Total Billed Charges,1521.45,60,,265.44,Percent of Total Billed Charges,60% of Total Billed Charges,2282.18,90,,934.304,Percent of Total Billed Charges,90% of Total Billed Charges,1141.09,45,,242.824,Percent of Total Billed Charges,45% of Total Billed Charges,2282.18,90,,485.152,Percent of Total Billed Charges,90% of Total billed Charges,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1648.24,65,,12907.96,Percent of total Billed Charges,65% of Total Billed Charges,1118.27,44.1,,237.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,2408.96,95,,512.104,Percent of Total Billed Charges,95% of Total Billed Charges,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2231.46,88,,308.136,Percent of Total Billed Charges,88% of Total Billed Charges,2282.18,90,,485.152,Percent of Total Billed charges,90% of Total Billed Charges,1118.27,2535.75,
US MUSCLE BIOPSY,3600000045,CDM,360,RC,,,Outpatient,,,2409.00,1565.85,,2409,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1830.84,76,,426.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1734.48,72,,191.808,Percent of Total Billed Charges,72% of Total Billed Charges,1806.75,75,,199.8,Percent of Total Billed charges,75% of Total Billed Charges,2409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1734.48,72,,191.808,Percent of Total Billed Charges,72% of Total Billed Charges,1445.4,60,,159.84,Percent of Total Billed Charges,60% of Total Billed Charges,2168.1,90,,1724.008,Percent of Total Billed Charges,90% of Total Billed Charges,1084.05,45,,157.568,Percent of Total Billed Charges,45% of Total Billed Charges,2168.1,90,,505.44,Percent of Total Billed Charges,90% of Total billed Charges,2409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1565.85,65,,10233.08,Percent of total Billed Charges,65% of Total Billed Charges,1062.37,44.1,,154.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,2288.55,95,,533.52,Percent of Total Billed Charges,95% of Total Billed Charges,2409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2119.92,88,,1593.456,Percent of Total Billed Charges,88% of Total Billed Charges,2168.1,90,,505.44,Percent of Total Billed charges,90% of Total Billed Charges,1062.37,2409,
TX1 TISSUE REMOVAL SYS,3600000046,CDM,360,RC,,,Outpatient,,,835.70,543.21,,835.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,635.13,76,,449.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,601.7,72,,76.608,Percent of Total Billed Charges,72% of Total Billed Charges,626.78,75,,79.8,Percent of Total Billed charges,75% of Total Billed Charges,835.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,601.7,72,,76.608,Percent of Total Billed Charges,72% of Total Billed Charges,501.42,60,,63.84,Percent of Total Billed Charges,60% of Total Billed Charges,752.13,90,,1083.6,Percent of Total Billed Charges,90% of Total Billed Charges,376.07,45,,814.832,Percent of Total Billed Charges,45% of Total Billed Charges,752.13,90,,531.848,Percent of Total Billed Charges,90% of Total billed Charges,835.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,835.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,835.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,543.21,65,,14979.2,Percent of total Billed Charges,65% of Total Billed Charges,368.54,44.1,,798.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,793.92,95,,561.4,Percent of Total Billed Charges,95% of Total Billed Charges,835.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,735.42,88,,2382.816,Percent of Total Billed Charges,88% of Total Billed Charges,752.13,90,,531.848,Percent of Total Billed charges,90% of Total Billed Charges,368.54,835.7,
INTUBATION (EMERGENC,3600000047,CDM,360,RC,,,Outpatient,,,513.77,333.95,,513.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,390.47,76,,1276.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,369.91,72,,38.016,Percent of Total Billed Charges,72% of Total Billed Charges,385.33,75,,39.6,Percent of Total Billed charges,75% of Total Billed Charges,513.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.91,72,,38.016,Percent of Total Billed Charges,72% of Total Billed Charges,308.26,60,,31.68,Percent of Total Billed Charges,60% of Total Billed Charges,462.39,90,,1334.88,Percent of Total Billed Charges,90% of Total Billed Charges,231.2,45,,1218.488,Percent of Total Billed Charges,45% of Total Billed Charges,462.39,90,,1512,Percent of Total Billed Charges,90% of Total billed Charges,513.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.95,65,,11219.52,Percent of total Billed Charges,65% of Total Billed Charges,226.57,44.1,,1194.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,488.08,95,,1596,Percent of Total Billed Charges,95% of Total Billed Charges,513.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,452.12,88,,1707.936,Percent of Total Billed Charges,88% of Total Billed Charges,462.39,90,,1512,Percent of Total Billed charges,90% of Total Billed Charges,226.57,513.77,
CT PLEURA BIOPSY,3600000048,CDM,360,RC,,,Outpatient,,,2756.25,1791.56,,2756.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2094.75,76,,410.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1984.5,72,,132.48,Percent of Total Billed Charges,72% of Total Billed Charges,2067.19,75,,138,Percent of Total Billed charges,75% of Total Billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1984.5,72,,132.48,Percent of Total Billed Charges,72% of Total Billed Charges,1653.75,60,,110.4,Percent of Total Billed Charges,60% of Total Billed Charges,2480.63,90,,1017.36,Percent of Total Billed Charges,90% of Total Billed Charges,1240.31,45,,873.376,Percent of Total Billed Charges,45% of Total Billed Charges,2480.63,90,,485.64,Percent of Total Billed Charges,90% of Total billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1791.56,65,,13587.208,Percent of total Billed Charges,65% of Total Billed Charges,1215.51,44.1,,855.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,2618.44,95,,512.624,Percent of Total Billed Charges,95% of Total Billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2425.5,88,,3631.936,Percent of Total Billed Charges,88% of Total Billed Charges,2480.63,90,,485.64,Percent of Total Billed charges,90% of Total Billed Charges,1215.51,2756.25,
XR PLEURA BIOPSY,3600000049,CDM,360,RC,,,Outpatient,,,2756.25,1791.56,,2756.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2094.75,76,,266.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1984.5,72,,110.592,Percent of Total Billed Charges,72% of Total Billed Charges,2067.19,75,,115.2,Percent of Total Billed charges,75% of Total Billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1984.5,72,,110.592,Percent of Total Billed Charges,72% of Total Billed Charges,1653.75,60,,92.16,Percent of Total Billed Charges,60% of Total Billed Charges,2480.63,90,,3124.8,Percent of Total Billed Charges,90% of Total Billed Charges,1240.31,45,,1857.24,Percent of Total Billed Charges,45% of Total Billed Charges,2480.63,90,,315.136,Percent of Total Billed Charges,90% of Total billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1791.56,65,,10212.16,Percent of total Billed Charges,65% of Total Billed Charges,1215.51,44.1,,1820.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,2618.44,95,,332.648,Percent of Total Billed Charges,95% of Total Billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2425.5,88,,913.536,Percent of Total Billed Charges,88% of Total Billed Charges,2480.63,90,,315.136,Percent of Total Billed charges,90% of Total Billed Charges,1215.51,2756.25,
US PLEURA BIOPSY,3600000050,CDM,360,RC,,,Outpatient,,,2756.25,1791.56,,2756.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2094.75,76,,1376.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1984.5,72,,167.04,Percent of Total Billed Charges,72% of Total Billed Charges,2067.19,75,,174,Percent of Total Billed charges,75% of Total Billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1984.5,72,,167.04,Percent of Total Billed Charges,72% of Total Billed Charges,1653.75,60,,139.2,Percent of Total Billed Charges,60% of Total Billed Charges,2480.63,90,,1510.6,Percent of Total Billed Charges,90% of Total Billed Charges,1240.31,45,,467.152,Percent of Total Billed Charges,45% of Total Billed Charges,2480.63,90,,1629.672,Percent of Total Billed Charges,90% of Total billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1791.56,65,,11698.184,Percent of total Billed Charges,65% of Total Billed Charges,1215.51,44.1,,457.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,2618.44,95,,1720.208,Percent of Total Billed Charges,95% of Total Billed Charges,2756.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2425.5,88,,1685.696,Percent of Total Billed Charges,88% of Total Billed Charges,2480.63,90,,1629.672,Percent of Total Billed charges,90% of Total Billed Charges,1215.51,2756.25,
PACEMAKR INSRT FLRO,3600000057,CDM,360,RC,,,Outpatient,,,2674.67,1738.54,,2674.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2032.75,76,,2057.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1925.76,72,,65.088,Percent of Total Billed Charges,72% of Total Billed Charges,2006,75,,67.8,Percent of Total Billed charges,75% of Total Billed Charges,2674.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1925.76,72,,65.088,Percent of Total Billed Charges,72% of Total Billed Charges,1604.8,60,,54.24,Percent of Total Billed Charges,60% of Total Billed Charges,2407.2,90,,11534.952,Percent of Total Billed Charges,90% of Total Billed Charges,1203.6,45,,862.008,Percent of Total Billed Charges,45% of Total Billed Charges,2407.2,90,,2436.968,Percent of Total Billed Charges,90% of Total billed Charges,2674.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2674.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2674.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1738.54,65,,5044.856,Percent of total Billed Charges,65% of Total Billed Charges,1179.53,44.1,,844.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,2540.94,95,,2572.36,Percent of Total Billed Charges,95% of Total Billed Charges,2674.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2353.71,88,,1059.52,Percent of Total Billed Charges,88% of Total Billed Charges,2407.2,90,,2436.968,Percent of Total Billed charges,90% of Total Billed Charges,1179.53,2674.67,
INS IA PERC BALLOON,3600000058,CDM,360,RC,,,Outpatient,,,6632.00,4310.80,,6632,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5040.32,76,,1475.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4775.04,72,,167.04,Percent of Total Billed Charges,72% of Total Billed Charges,4974,75,,174,Percent of Total Billed charges,75% of Total Billed Charges,6632,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4775.04,72,,167.04,Percent of Total Billed Charges,72% of Total Billed Charges,3979.2,60,,139.2,Percent of Total Billed Charges,60% of Total Billed Charges,5968.8,90,,1659.048,Percent of Total Billed Charges,90% of Total Billed Charges,2984.4,45,,541.8,Percent of Total Billed Charges,45% of Total Billed Charges,5968.8,90,,1746.76,Percent of Total Billed Charges,90% of Total billed Charges,6632,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6632,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6632,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4310.8,65,,11327.84,Percent of total Billed Charges,65% of Total Billed Charges,2924.71,44.1,,530.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,6300.4,95,,1843.8,Percent of Total Billed Charges,95% of Total Billed Charges,6632,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5836.16,88,,1305.216,Percent of Total Billed Charges,88% of Total Billed Charges,5968.8,90,,1746.76,Percent of Total Billed charges,90% of Total Billed Charges,2924.71,6632,
CENTRAL LINE,3600000059,CDM,360,RC,,,Outpatient,,,2811.00,1827.15,,2811,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2136.36,76,,3136.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2023.92,72,,191.808,Percent of Total Billed Charges,72% of Total Billed Charges,2108.25,75,,199.8,Percent of Total Billed charges,75% of Total Billed Charges,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2023.92,72,,191.808,Percent of Total Billed Charges,72% of Total Billed Charges,1686.6,60,,159.84,Percent of Total Billed Charges,60% of Total Billed Charges,2529.9,90,,2187.712,Percent of Total Billed Charges,90% of Total Billed Charges,1264.95,45,,667.44,Percent of Total Billed Charges,45% of Total Billed Charges,2529.9,90,,3714.48,Percent of Total Billed Charges,90% of Total billed Charges,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1827.15,65,,5849.088,Percent of total Billed Charges,65% of Total Billed Charges,1239.65,44.1,,654.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,2670.45,95,,3920.84,Percent of Total Billed Charges,95% of Total Billed Charges,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2473.68,88,,994.752,Percent of Total Billed Charges,88% of Total Billed Charges,2529.9,90,,3714.48,Percent of Total Billed charges,90% of Total Billed Charges,1239.65,2811,
XR STENT ILIAC ARTERY INITIAL,3600000061,CDM,360,RC,,,Outpatient,,,22606.76,14694.39,,22606.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17181.14,76,,1455.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16276.87,72,,183.168,Percent of Total Billed Charges,72% of Total Billed Charges,16955.07,75,,190.8,Percent of Total Billed charges,75% of Total Billed Charges,22606.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16276.87,72,,183.168,Percent of Total Billed Charges,72% of Total Billed Charges,13564.06,60,,152.64,Percent of Total Billed Charges,60% of Total Billed Charges,20346.08,90,,2321.28,Percent of Total Billed Charges,90% of Total Billed Charges,10173.04,45,,1562.4,Percent of Total Billed Charges,45% of Total Billed Charges,20346.08,90,,1724.008,Percent of Total Billed Charges,90% of Total billed Charges,22606.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22606.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22606.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14694.39,65,,7294.168,Percent of total Billed Charges,65% of Total Billed Charges,9969.58,44.1,,1531.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,21476.42,95,,1819.792,Percent of Total Billed Charges,95% of Total Billed Charges,22606.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19893.95,88,,1477.032,Percent of Total Billed Charges,88% of Total Billed Charges,20346.08,90,,1724.008,Percent of Total Billed charges,90% of Total Billed Charges,9969.58,22606.76,
XR STENT FEM OR POP ARTERY,3600000063,CDM,360,RC,,,Outpatient,,,20713.77,13463.95,,20713.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15742.47,76,,915.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14913.91,72,,192.656,Percent of Total Billed Charges,72% of Total Billed Charges,15535.33,75,,200.68,Percent of Total Billed charges,75% of Total Billed Charges,20713.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14913.91,72,,192.656,Percent of Total Billed Charges,72% of Total Billed Charges,12428.26,60,,160.544,Percent of Total Billed Charges,60% of Total Billed Charges,18642.39,90,,1884.24,Percent of Total Billed Charges,90% of Total Billed Charges,9321.2,45,,755.304,Percent of Total Billed Charges,45% of Total Billed Charges,18642.39,90,,1083.6,Percent of Total Billed Charges,90% of Total billed Charges,20713.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20713.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20713.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13463.95,65,,4845.416,Percent of total Billed Charges,65% of Total Billed Charges,9134.77,44.1,,740.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,19678.08,95,,1143.8,Percent of Total Billed Charges,95% of Total Billed Charges,20713.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18228.12,88,,11278.624,Percent of Total Billed Charges,88% of Total Billed Charges,18642.39,90,,1083.6,Percent of Total Billed charges,90% of Total Billed Charges,9134.77,20713.77,
XR STENT PERIPH VEIN UE,3600000065,CDM,360,RC,,,Outpatient,,,20912.22,13592.94,,20912.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15893.29,76,,1127.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15056.8,72,,183.168,Percent of Total Billed Charges,72% of Total Billed Charges,15684.17,75,,190.8,Percent of Total Billed charges,75% of Total Billed Charges,20912.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15056.8,72,,183.168,Percent of Total Billed Charges,72% of Total Billed Charges,12547.33,60,,152.64,Percent of Total Billed Charges,60% of Total Billed Charges,18821,90,,532.08,Percent of Total Billed Charges,90% of Total Billed Charges,9410.5,45,,5767.48,Percent of Total Billed Charges,45% of Total Billed Charges,18821,90,,1334.88,Percent of Total Billed Charges,90% of Total billed Charges,20912.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20912.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20912.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13592.94,65,,10874.352,Percent of total Billed Charges,65% of Total Billed Charges,9222.29,44.1,,5652.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,19866.61,95,,1409.04,Percent of Total Billed Charges,95% of Total Billed Charges,20912.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18402.75,88,,1622.176,Percent of Total Billed Charges,88% of Total Billed Charges,18821,90,,1334.88,Percent of Total Billed charges,90% of Total Billed Charges,9222.29,20912.22,
TRLUML BALO ANGIOP 1ST VEIN,3600000067,CDM,481,RC,,,Outpatient,,,13426.43,8727.18,,13426.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10204.09,76,,859.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9667.03,72,,192.656,Percent of Total Billed Charges,72% of Total Billed Charges,10069.82,75,,200.68,Percent of Total Billed charges,75% of Total Billed Charges,13426.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9667.03,72,,192.656,Percent of Total Billed Charges,72% of Total Billed Charges,8055.86,60,,160.544,Percent of Total Billed Charges,60% of Total Billed Charges,12083.79,90,,1523.52,Percent of Total Billed Charges,90% of Total Billed Charges,6041.89,45,,829.52,Percent of Total Billed Charges,45% of Total Billed Charges,12083.79,90,,1017.36,Percent of Total Billed Charges,90% of Total billed Charges,13426.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13426.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13426.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8727.18,65,,5259.456,Percent of total Billed Charges,65% of Total Billed Charges,5921.06,44.1,,812.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,12755.11,95,,1073.88,Percent of Total Billed Charges,95% of Total Billed Charges,13426.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11815.26,88,,2139.096,Percent of Total Billed Charges,88% of Total Billed Charges,12083.79,90,,1017.36,Percent of Total Billed charges,90% of Total Billed Charges,5921.06,13426.43,
TRLUML BALO ANGIOP ADDL VEIN,3600000068,CDM,481,RC,,,Outpatient,,,8950.82,5818.03,,8950.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6802.62,76,,2638.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6444.59,72,,245.392,Percent of Total Billed Charges,72% of Total Billed Charges,6713.12,75,,255.616,Percent of Total Billed charges,75% of Total Billed Charges,8950.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6444.59,72,,245.392,Percent of Total Billed Charges,72% of Total Billed Charges,5370.49,60,,204.496,Percent of Total Billed Charges,60% of Total Billed Charges,8055.74,90,,10743.12,Percent of Total Billed Charges,90% of Total Billed Charges,4027.87,45,,1093.856,Percent of Total Billed Charges,45% of Total Billed Charges,8055.74,90,,3124.8,Percent of Total Billed Charges,90% of Total billed Charges,8950.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8950.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8950.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5818.03,65,,11974.04,Percent of total Billed Charges,65% of Total Billed Charges,3947.31,44.1,,1071.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,8503.28,95,,3298.4,Percent of Total Billed Charges,95% of Total Billed Charges,8950.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7876.72,88,,2388.872,Percent of Total Billed Charges,88% of Total Billed Charges,8055.74,90,,3124.8,Percent of Total Billed charges,90% of Total Billed Charges,3947.31,8950.82,
UNLISTED VASC PROCEDURE,3600000069,CDM,360,RC,,,Outpatient,,,8912.00,5792.80,,8912,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6773.12,76,,1275.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6416.64,72,,133.056,Percent of Total Billed Charges,72% of Total Billed Charges,6684,75,,138.6,Percent of Total Billed charges,75% of Total Billed Charges,8912,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6416.64,72,,133.056,Percent of Total Billed Charges,72% of Total Billed Charges,5347.2,60,,110.88,Percent of Total Billed Charges,60% of Total Billed Charges,8020.8,90,,20779.816,Percent of Total Billed Charges,90% of Total Billed Charges,4010.4,45,,1221.584,Percent of Total Billed Charges,45% of Total Billed Charges,8020.8,90,,1510.6,Percent of Total Billed Charges,90% of Total billed Charges,8912,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8912,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8912,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5792.8,65,,6633.12,Percent of total Billed Charges,65% of Total Billed Charges,3930.19,44.1,,1197.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,8466.4,95,,1594.528,Percent of Total Billed Charges,95% of Total Billed Charges,8912,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7842.56,88,,2269.696,Percent of Total Billed Charges,88% of Total Billed Charges,8020.8,90,,1510.6,Percent of Total Billed charges,90% of Total Billed Charges,3930.19,8912,
DIAGNOSTIC SIGMOIDOSCOPY,3600000070,CDM,360,RC,,,Outpatient,,,2500.00,1625.00,,2500,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1900,76,,9740.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1800,72,,99.072,Percent of Total Billed Charges,72% of Total Billed Charges,1875,75,,103.2,Percent of Total Billed charges,75% of Total Billed Charges,2500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1800,72,,99.072,Percent of Total Billed Charges,72% of Total Billed Charges,1500,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,2250,90,,9666.888,Percent of Total Billed Charges,90% of Total Billed Charges,1125,45,,1160.64,Percent of Total Billed Charges,45% of Total Billed Charges,2250,90,,11534.952,Percent of Total Billed Charges,90% of Total billed Charges,2500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1625,65,,4654.424,Percent of total Billed Charges,65% of Total Billed Charges,1102.5,44.1,,1137.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,2375,95,,12175.784,Percent of Total Billed Charges,95% of Total Billed Charges,2500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2200,88,,1842.368,Percent of Total Billed Charges,88% of Total Billed Charges,2250,90,,11534.952,Percent of Total Billed charges,90% of Total Billed Charges,1102.5,2500,
COAPTITE INJECTABLE IMPLANT,3600000071,CDM,360,RC,,,Outpatient,,,1162.04,755.33,,1162.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,883.15,76,,1400.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,836.67,72,,134.632,Percent of Total Billed Charges,72% of Total Billed Charges,871.53,75,,140.24,Percent of Total Billed charges,75% of Total Billed Charges,1162.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,836.67,72,,134.632,Percent of Total Billed Charges,72% of Total Billed Charges,697.22,60,,112.192,Percent of Total Billed Charges,60% of Total Billed Charges,1045.84,90,,9830.448,Percent of Total Billed Charges,90% of Total Billed Charges,522.92,45,,942.12,Percent of Total Billed Charges,45% of Total Billed Charges,1045.84,90,,1659.048,Percent of Total Billed Charges,90% of Total billed Charges,1162.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1162.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1162.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,755.33,65,,4877.728,Percent of total Billed Charges,65% of Total Billed Charges,512.46,44.1,,923.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,1103.94,95,,1751.216,Percent of Total Billed Charges,95% of Total Billed Charges,1162.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1022.6,88,,520.256,Percent of Total Billed Charges,88% of Total Billed Charges,1045.84,90,,1659.048,Percent of Total Billed charges,90% of Total Billed Charges,512.46,1162.04,
COMPLEX CYSTOMETROGR,3600000072,CDM,360,RC,,,Outpatient,,,1022.02,664.31,,1022.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,776.74,76,,1847.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,735.85,72,,256.896,Percent of Total Billed Charges,72% of Total Billed Charges,766.52,75,,267.6,Percent of Total Billed charges,75% of Total Billed Charges,1022.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,735.85,72,,256.896,Percent of Total Billed Charges,72% of Total Billed Charges,613.21,60,,214.08,Percent of Total Billed Charges,60% of Total Billed Charges,919.82,90,,29614.792,Percent of Total Billed Charges,90% of Total Billed Charges,459.91,45,,266.04,Percent of Total Billed Charges,45% of Total Billed Charges,919.82,90,,2187.712,Percent of Total Billed Charges,90% of Total billed Charges,1022.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1022.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1022.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,664.31,65,,546.352,Percent of total Billed Charges,65% of Total Billed Charges,450.71,44.1,,260.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,970.92,95,,2309.256,Percent of Total Billed Charges,95% of Total Billed Charges,1022.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,899.38,88,,1489.664,Percent of Total Billed Charges,88% of Total Billed Charges,919.82,90,,2187.712,Percent of Total Billed charges,90% of Total Billed Charges,450.71,1022.02,
GREEN LIGHT LASER PV,3600000073,CDM,360,RC,,,Outpatient,,,3273.32,2127.66,,3273.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2487.72,76,,2063.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2356.79,72,,183.168,Percent of Total Billed Charges,72% of Total Billed Charges,2454.99,75,,190.8,Percent of Total Billed charges,75% of Total Billed Charges,3273.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2356.79,72,,183.168,Percent of Total Billed Charges,72% of Total Billed Charges,1963.99,60,,152.64,Percent of Total Billed Charges,60% of Total Billed Charges,2945.99,90,,6485.76,Percent of Total Billed Charges,90% of Total Billed Charges,1472.99,45,,761.76,Percent of Total Billed Charges,45% of Total Billed Charges,2945.99,90,,2443.16,Percent of Total Billed Charges,90% of Total billed Charges,3273.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3273.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3273.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2127.66,65,,348.92,Percent of total Billed Charges,65% of Total Billed Charges,1443.53,44.1,,746.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,3109.65,95,,2578.896,Percent of Total Billed Charges,95% of Total Billed Charges,3273.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2880.52,88,,10504.384,Percent of Total Billed Charges,88% of Total Billed Charges,2945.99,90,,2443.16,Percent of Total Billed charges,90% of Total Billed Charges,1443.53,3273.32,
HOLMIUM LASER INT UR,3600000074,CDM,360,RC,,,Outpatient,,,3278.84,2131.25,,3278.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2491.92,76,,1960.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2360.76,72,,183.168,Percent of Total Billed Charges,72% of Total Billed Charges,2459.13,75,,190.8,Percent of Total Billed charges,75% of Total Billed Charges,3278.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2360.76,72,,183.168,Percent of Total Billed Charges,72% of Total Billed Charges,1967.3,60,,152.64,Percent of Total Billed Charges,60% of Total Billed Charges,2950.96,90,,10389.912,Percent of Total Billed Charges,90% of Total Billed Charges,1475.48,45,,5371.56,Percent of Total Billed Charges,45% of Total Billed Charges,2950.96,90,,2321.28,Percent of Total Billed Charges,90% of Total billed Charges,3278.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3278.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3278.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2131.25,65,,594.88,Percent of total Billed Charges,65% of Total Billed Charges,1445.97,44.1,,5264.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,3114.9,95,,2450.24,Percent of Total Billed Charges,95% of Total Billed Charges,3278.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2885.38,88,,20318.048,Percent of Total Billed Charges,88% of Total Billed Charges,2950.96,90,,2321.28,Percent of Total Billed charges,90% of Total Billed Charges,1445.97,3278.84,
HOLAP,3600000075,CDM,360,RC,,,Outpatient,,,4153.12,2699.53,,4153.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3156.37,76,,1591.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2990.25,72,,192.656,Percent of Total Billed Charges,72% of Total Billed Charges,3114.84,75,,200.68,Percent of Total Billed charges,75% of Total Billed Charges,4153.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2990.25,72,,192.656,Percent of Total Billed Charges,72% of Total Billed Charges,2491.87,60,,160.544,Percent of Total Billed Charges,60% of Total Billed Charges,3737.81,90,,1523.52,Percent of Total Billed Charges,90% of Total Billed Charges,1868.9,45,,10389.912,Percent of Total Billed Charges,45% of Total Billed Charges,3737.81,90,,1884.24,Percent of Total Billed Charges,90% of Total billed Charges,4153.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4153.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4153.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2699.53,65,,2280.72,Percent of total Billed Charges,65% of Total Billed Charges,1831.53,44.1,,10182.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,3945.46,95,,1988.92,Percent of Total Billed Charges,95% of Total Billed Charges,4153.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3654.75,88,,9452.064,Percent of Total Billed Charges,88% of Total Billed Charges,3737.81,90,,1884.24,Percent of Total Billed charges,90% of Total Billed Charges,1831.53,4153.12,
SO14X SIS SYSTEM,3600000076,CDM,360,RC,,,Outpatient,,,1574.37,1023.34,,1574.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1196.52,76,,449.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1133.55,72,,192.656,Percent of Total Billed Charges,72% of Total Billed Charges,1180.78,75,,200.68,Percent of Total Billed charges,75% of Total Billed Charges,1574.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1133.55,72,,192.656,Percent of Total Billed Charges,72% of Total Billed Charges,944.62,60,,160.544,Percent of Total Billed Charges,60% of Total Billed Charges,1416.93,90,,3987.256,Percent of Total Billed Charges,90% of Total Billed Charges,708.47,45,,4833.44,Percent of Total Billed Charges,45% of Total Billed Charges,1416.93,90,,532.08,Percent of Total Billed Charges,90% of Total billed Charges,1574.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1574.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1574.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1023.34,65,,960.96,Percent of total Billed Charges,65% of Total Billed Charges,694.3,44.1,,4736.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,1495.65,95,,561.64,Percent of Total Billed Charges,95% of Total Billed Charges,1574.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1385.45,88,,9611.992,Percent of Total Billed Charges,88% of Total Billed Charges,1416.93,90,,532.08,Percent of Total Billed charges,90% of Total Billed Charges,694.3,1574.37,
MYOSURE,3600000077,CDM,360,RC,,,Outpatient,,,1030.84,670.05,,1030.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,783.44,76,,1286.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,742.2,72,,245.392,Percent of Total Billed Charges,72% of Total Billed Charges,773.13,75,,255.616,Percent of Total Billed charges,75% of Total Billed Charges,1030.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,742.2,72,,245.392,Percent of Total Billed Charges,72% of Total Billed Charges,618.5,60,,204.496,Percent of Total Billed Charges,60% of Total Billed Charges,927.76,90,,3987.256,Percent of Total Billed Charges,90% of Total Billed Charges,463.88,45,,4915.224,Percent of Total Billed Charges,45% of Total Billed Charges,927.76,90,,1523.52,Percent of Total Billed Charges,90% of Total billed Charges,1030.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1030.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1030.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,670.05,65,,1676.48,Percent of total Billed Charges,65% of Total Billed Charges,454.6,44.1,,4816.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,979.3,95,,1608.16,Percent of Total Billed Charges,95% of Total Billed Charges,1030.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,907.14,88,,28956.68,Percent of Total Billed Charges,88% of Total Billed Charges,927.76,90,,1523.52,Percent of Total Billed charges,90% of Total Billed Charges,454.6,1030.84,
SPINAL TAP,3600000078,CDM,360,RC,,,Outpatient,,,1121.24,728.81,,1121.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,852.14,76,,9071.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,807.29,72,,133.056,Percent of Total Billed Charges,72% of Total Billed Charges,840.93,75,,138.6,Percent of Total Billed charges,75% of Total Billed Charges,1121.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,807.29,72,,133.056,Percent of Total Billed Charges,72% of Total Billed Charges,672.74,60,,110.88,Percent of Total Billed Charges,60% of Total Billed Charges,1009.12,90,,10597.232,Percent of Total Billed Charges,90% of Total Billed Charges,504.56,45,,14807.392,Percent of Total Billed Charges,45% of Total Billed Charges,1009.12,90,,10743.12,Percent of Total Billed Charges,90% of Total billed Charges,1121.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1121.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1121.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,728.81,65,,787.28,Percent of total Billed Charges,65% of Total Billed Charges,494.47,44.1,,14511.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,1065.18,95,,11339.96,Percent of Total Billed Charges,95% of Total Billed Charges,1121.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,986.69,88,,6341.632,Percent of Total Billed Charges,88% of Total Billed Charges,1009.12,90,,10743.12,Percent of Total Billed charges,90% of Total Billed Charges,494.47,1121.24,
LUMBAR PUNCTURE,3600000079,CDM,360,RC,,,Outpatient,,,1120.14,728.09,,1120.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,851.31,76,,17547.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,806.5,72,,99.072,Percent of Total Billed Charges,72% of Total Billed Charges,840.11,75,,103.2,Percent of Total Billed charges,75% of Total Billed Charges,1120.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,806.5,72,,99.072,Percent of Total Billed Charges,72% of Total Billed Charges,672.08,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,1008.13,90,,16276.864,Percent of Total Billed Charges,90% of Total Billed Charges,504.06,45,,3242.88,Percent of Total Billed Charges,45% of Total Billed Charges,1008.13,90,,20779.816,Percent of Total Billed Charges,90% of Total billed Charges,1120.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1120.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1120.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,728.09,65,,787.28,Percent of total Billed Charges,65% of Total Billed Charges,493.98,44.1,,3178.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,1064.13,95,,21934.256,Percent of Total Billed Charges,95% of Total Billed Charges,1120.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,985.72,88,,10159.024,Percent of Total Billed Charges,88% of Total Billed Charges,1008.13,90,,20779.816,Percent of Total Billed charges,90% of Total Billed Charges,493.98,1120.14,
EPIDURAL BLOOD PATCH,3600000080,CDM,360,RC,,,Outpatient,,,2176.00,1414.40,,2176,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1653.76,76,,8163.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1566.72,72,,134.632,Percent of Total Billed Charges,72% of Total Billed Charges,1632,75,,140.24,Percent of Total Billed charges,75% of Total Billed Charges,2176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1566.72,72,,134.632,Percent of Total Billed Charges,72% of Total Billed Charges,1305.6,60,,112.192,Percent of Total Billed Charges,60% of Total Billed Charges,1958.4,90,,26799.84,Percent of Total Billed Charges,90% of Total Billed Charges,979.2,45,,5194.952,Percent of Total Billed Charges,45% of Total Billed Charges,1958.4,90,,9666.888,Percent of Total Billed Charges,90% of Total billed Charges,2176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1414.4,65,,787.28,Percent of total Billed Charges,65% of Total Billed Charges,959.62,44.1,,5091.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,2067.2,95,,10203.936,Percent of Total Billed Charges,95% of Total Billed Charges,2176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1914.88,88,,1489.664,Percent of Total Billed Charges,88% of Total Billed Charges,1958.4,90,,9666.888,Percent of Total Billed charges,90% of Total Billed Charges,959.62,2176,
OB EPIDURAL,3600000081,CDM,360,RC,,,Outpatient,,,893.00,580.45,,893,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,678.68,76,,8301.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,642.96,72,,269.888,Percent of Total Billed Charges,72% of Total Billed Charges,669.75,75,,281.136,Percent of Total Billed charges,75% of Total Billed Charges,893,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,642.96,72,,269.888,Percent of Total Billed Charges,72% of Total Billed Charges,535.8,60,,224.912,Percent of Total Billed Charges,60% of Total Billed Charges,803.7,90,,10597.232,Percent of Total Billed Charges,90% of Total Billed Charges,401.85,45,,761.76,Percent of Total Billed Charges,45% of Total Billed Charges,803.7,90,,9830.448,Percent of Total Billed Charges,90% of Total billed Charges,893,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,893,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,893,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,580.45,65,,3286.4,Percent of total Billed Charges,65% of Total Billed Charges,393.81,44.1,,746.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,848.35,95,,10376.584,Percent of Total Billed Charges,95% of Total Billed Charges,893,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,785.84,88,,3898.656,Percent of Total Billed Charges,88% of Total Billed Charges,803.7,90,,9830.448,Percent of Total Billed charges,90% of Total Billed Charges,393.81,893,
BRACHIAL PLEXUS NERV W/IMAGING,3600000083,CDM,360,RC,,,Outpatient,,,1070.53,695.84,,1070.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,813.6,76,,25008.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,770.78,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,802.9,75,,126,Percent of Total Billed charges,75% of Total Billed Charges,1070.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770.78,72,,120.96,Percent of Total Billed Charges,72% of Total Billed Charges,642.32,60,,100.8,Percent of Total Billed Charges,60% of Total Billed Charges,963.48,90,,10067.76,Percent of Total Billed Charges,90% of Total Billed Charges,481.74,45,,1993.632,Percent of Total Billed Charges,45% of Total Billed Charges,963.48,90,,29614.792,Percent of Total Billed Charges,90% of Total billed Charges,1070.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1070.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1070.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.84,65,,3459.104,Percent of total Billed Charges,65% of Total Billed Charges,472.1,44.1,,1953.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,1017,95,,31260.056,Percent of Total Billed Charges,95% of Total Billed Charges,1070.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,942.07,88,,3898.656,Percent of Total Billed Charges,88% of Total Billed Charges,963.48,90,,29614.792,Percent of Total Billed charges,90% of Total Billed Charges,472.1,1070.53,
BRACHIAL PLEXUS CATH W/IMAGING,3600000084,CDM,360,RC,,,Outpatient,,,2014.27,1309.28,,2014.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1530.85,76,,5476.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1450.27,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,1510.7,75,,59.4,Percent of Total Billed charges,75% of Total Billed Charges,2014.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1450.27,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,1208.56,60,,47.52,Percent of Total Billed Charges,60% of Total Billed Charges,1812.84,90,,17872.56,Percent of Total Billed Charges,90% of Total Billed Charges,906.42,45,,1993.632,Percent of Total Billed Charges,45% of Total Billed Charges,1812.84,90,,6485.76,Percent of Total Billed Charges,90% of Total billed Charges,2014.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2014.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2014.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1309.28,65,,678.248,Percent of total Billed Charges,65% of Total Billed Charges,888.29,44.1,,1953.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,1913.56,95,,6846.08,Percent of Total Billed Charges,95% of Total Billed Charges,2014.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1772.56,88,,10361.736,Percent of Total Billed Charges,88% of Total Billed Charges,1812.84,90,,6485.76,Percent of Total Billed charges,90% of Total Billed Charges,888.29,2014.27,
AXILLARY NERVE BLOCK W/ IMAGIN,3600000085,CDM,360,RC,,,Outpatient,,,1070.53,695.84,,1070.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,813.6,76,,8773.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,770.78,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,802.9,75,,59.4,Percent of Total Billed charges,75% of Total Billed Charges,1070.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770.78,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,642.32,60,,47.52,Percent of Total Billed Charges,60% of Total Billed Charges,963.48,90,,14168.88,Percent of Total Billed Charges,90% of Total Billed Charges,481.74,45,,5298.616,Percent of Total Billed Charges,45% of Total Billed Charges,963.48,90,,10389.912,Percent of Total Billed Charges,90% of Total billed Charges,1070.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1070.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1070.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.84,65,,1900.08,Percent of total Billed Charges,65% of Total Billed Charges,472.1,44.1,,5192.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,1017,95,,10967.128,Percent of Total Billed Charges,95% of Total Billed Charges,1070.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,942.07,88,,15915.16,Percent of Total Billed Charges,88% of Total Billed Charges,963.48,90,,10389.912,Percent of Total Billed charges,90% of Total Billed Charges,472.1,1070.53,
ILIOINGUINAL ILIOHY,3600000086,CDM,360,RC,,,Outpatient,,,999.00,649.35,,999,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,759.24,76,,1286.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,719.28,72,,99.072,Percent of Total Billed Charges,72% of Total Billed Charges,749.25,75,,103.2,Percent of Total Billed charges,75% of Total Billed Charges,999,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,719.28,72,,99.072,Percent of Total Billed Charges,72% of Total Billed Charges,599.4,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,899.1,90,,20740.432,Percent of Total Billed Charges,90% of Total Billed Charges,449.55,45,,8138.432,Percent of Total Billed Charges,45% of Total Billed Charges,899.1,90,,1523.52,Percent of Total Billed Charges,90% of Total billed Charges,999,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,999,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,999,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649.35,65,,3792.88,Percent of total Billed Charges,65% of Total Billed Charges,440.56,44.1,,7975.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,949.05,95,,1608.16,Percent of Total Billed Charges,95% of Total Billed Charges,999,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,879.12,88,,26204.288,Percent of Total Billed Charges,88% of Total Billed Charges,899.1,90,,1523.52,Percent of Total Billed charges,90% of Total Billed Charges,440.56,999,
SCIATIC NERVE BLOCK W/IMAGING,3600000087,CDM,360,RC,,,Outpatient,,,2052.86,1334.36,,2052.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1560.17,76,,3367.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1478.06,72,,104.144,Percent of Total Billed Charges,72% of Total Billed Charges,1539.65,75,,108.488,Percent of Total Billed charges,75% of Total Billed Charges,2052.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1478.06,72,,104.144,Percent of Total Billed Charges,72% of Total Billed Charges,1231.72,60,,86.792,Percent of Total Billed Charges,60% of Total Billed Charges,1847.57,90,,15534.72,Percent of Total Billed Charges,90% of Total Billed Charges,923.79,45,,13399.92,Percent of Total Billed Charges,45% of Total Billed Charges,1847.57,90,,3987.256,Percent of Total Billed Charges,90% of Total billed Charges,2052.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2052.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2052.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1334.36,65,,1677.52,Percent of total Billed Charges,65% of Total Billed Charges,905.31,44.1,,13131.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,1950.22,95,,4208.776,Percent of Total Billed Charges,95% of Total Billed Charges,2052.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1806.52,88,,10361.736,Percent of Total Billed Charges,88% of Total Billed Charges,1847.57,90,,3987.256,Percent of Total Billed charges,90% of Total Billed Charges,905.31,2052.86,
SCIATIC CATHETER W IMAGING,3600000088,CDM,360,RC,,,Outpatient,,,2014.27,1309.28,,2014.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1530.85,76,,3367.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1450.27,72,,70.272,Percent of Total Billed Charges,72% of Total Billed Charges,1510.7,75,,73.2,Percent of Total Billed charges,75% of Total Billed Charges,2014.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1450.27,72,,70.272,Percent of Total Billed Charges,72% of Total Billed Charges,1208.56,60,,58.56,Percent of Total Billed Charges,60% of Total Billed Charges,1812.84,90,,18813.064,Percent of Total Billed Charges,90% of Total Billed Charges,906.42,45,,5298.616,Percent of Total Billed Charges,45% of Total Billed Charges,1812.84,90,,3987.256,Percent of Total Billed Charges,90% of Total billed Charges,2014.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2014.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2014.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1309.28,65,,1789.296,Percent of total Billed Charges,65% of Total Billed Charges,888.29,44.1,,5192.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,1913.56,95,,4208.776,Percent of Total Billed Charges,95% of Total Billed Charges,2014.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1772.56,88,,9844.032,Percent of Total Billed Charges,88% of Total Billed Charges,1812.84,90,,3987.256,Percent of Total Billed charges,90% of Total Billed Charges,888.29,2014.27,
FEMORAL NERVE BLOCK W/IMAGING,3600000089,CDM,360,RC,,,Outpatient,,,1070.53,695.84,,1070.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,813.6,76,,8948.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,770.78,72,,70.272,Percent of Total Billed Charges,72% of Total Billed Charges,802.9,75,,73.2,Percent of Total Billed charges,75% of Total Billed Charges,1070.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770.78,72,,70.272,Percent of Total Billed Charges,72% of Total Billed Charges,642.32,60,,58.56,Percent of Total Billed Charges,60% of Total Billed Charges,963.48,90,,14139.912,Percent of Total Billed Charges,90% of Total Billed Charges,481.74,45,,5033.88,Percent of Total Billed Charges,45% of Total Billed Charges,963.48,90,,10597.232,Percent of Total Billed Charges,90% of Total billed Charges,1070.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1070.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1070.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.84,65,,59.8,Percent of total Billed Charges,65% of Total Billed Charges,472.1,44.1,,4933.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,1017,95,,11185.968,Percent of Total Billed Charges,95% of Total Billed Charges,1070.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,942.07,88,,17475.392,Percent of Total Billed Charges,88% of Total Billed Charges,963.48,90,,10597.232,Percent of Total Billed charges,90% of Total Billed Charges,472.1,1070.53,
FEMORAL CATHETER W/IMAGING,3600000090,CDM,360,RC,,,Outpatient,,,2014.27,1309.28,,2014.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1530.85,76,,13744.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1450.27,72,,118.656,Percent of Total Billed Charges,72% of Total Billed Charges,1510.7,75,,123.6,Percent of Total Billed charges,75% of Total Billed Charges,2014.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1450.27,72,,118.656,Percent of Total Billed Charges,72% of Total Billed Charges,1208.56,60,,98.88,Percent of Total Billed Charges,60% of Total Billed Charges,1812.84,90,,16197.48,Percent of Total Billed Charges,90% of Total Billed Charges,906.42,45,,8936.28,Percent of Total Billed Charges,45% of Total Billed Charges,1812.84,90,,16276.864,Percent of Total Billed Charges,90% of Total billed Charges,2014.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2014.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2014.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1309.28,65,,423.28,Percent of total Billed Charges,65% of Total Billed Charges,888.29,44.1,,8757.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,1913.56,95,,17181.136,Percent of Total Billed Charges,95% of Total Billed Charges,2014.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1772.56,88,,13854.016,Percent of Total Billed Charges,88% of Total Billed Charges,1812.84,90,,16276.864,Percent of Total Billed charges,90% of Total Billed Charges,888.29,2014.27,
SINGLE NERVE BLOCK (OTHER),3600000091,CDM,360,RC,,,Outpatient,,,1050.68,682.94,,1050.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,798.52,76,,22630.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,756.49,72,,118.656,Percent of Total Billed Charges,72% of Total Billed Charges,788.01,75,,123.6,Percent of Total Billed charges,75% of Total Billed Charges,1050.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.49,72,,118.656,Percent of Total Billed Charges,72% of Total Billed Charges,630.41,60,,98.88,Percent of Total Billed Charges,60% of Total Billed Charges,945.61,90,,6985.192,Percent of Total Billed Charges,90% of Total Billed Charges,472.81,45,,7084.44,Percent of Total Billed Charges,45% of Total Billed Charges,945.61,90,,26799.84,Percent of Total Billed Charges,90% of Total billed Charges,1050.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,682.94,65,,7.28,Percent of total Billed Charges,65% of Total Billed Charges,463.35,44.1,,6942.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,998.15,95,,28288.72,Percent of Total Billed Charges,95% of Total Billed Charges,1050.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,924.6,88,,20279.536,Percent of Total Billed Charges,88% of Total Billed Charges,945.61,90,,26799.84,Percent of Total Billed charges,90% of Total Billed Charges,463.35,1050.68,
CAUDAL NERVE BLOCK,3600000092,CDM,360,RC,,,Outpatient,,,2052.86,1334.36,,2052.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1560.17,76,,8948.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1478.06,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,1539.65,75,,129.656,Percent of Total Billed charges,75% of Total Billed Charges,2052.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1478.06,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,1231.72,60,,103.72,Percent of Total Billed Charges,60% of Total Billed Charges,1847.57,90,,15684.696,Percent of Total Billed Charges,90% of Total Billed Charges,923.79,45,,10370.216,Percent of Total Billed Charges,45% of Total Billed Charges,1847.57,90,,10597.232,Percent of Total Billed Charges,90% of Total billed Charges,2052.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2052.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2052.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1334.36,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,905.31,44.1,,10162.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,1950.22,95,,11185.968,Percent of Total Billed Charges,95% of Total Billed Charges,2052.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1806.52,88,,15189.504,Percent of Total Billed Charges,88% of Total Billed Charges,1847.57,90,,10597.232,Percent of Total Billed charges,90% of Total Billed Charges,905.31,2052.86,
EPIDURAL STERIOD INJ,3600000093,CDM,360,RC,,,Outpatient,,,2052.86,1334.36,,2052.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1560.17,76,,8501.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1478.06,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,1539.65,75,,129.656,Percent of Total Billed charges,75% of Total Billed Charges,2052.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1478.06,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,1231.72,60,,103.72,Percent of Total Billed Charges,60% of Total Billed Charges,1847.57,90,,8098.744,Percent of Total Billed Charges,90% of Total Billed Charges,923.79,45,,7767.36,Percent of Total Billed Charges,45% of Total Billed Charges,1847.57,90,,10067.76,Percent of Total Billed Charges,90% of Total billed Charges,2052.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2052.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2052.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1334.36,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,905.31,44.1,,7612.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,1950.22,95,,10627.08,Percent of Total Billed Charges,95% of Total Billed Charges,2052.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1806.52,88,,18394.992,Percent of Total Billed Charges,88% of Total Billed Charges,1847.57,90,,10067.76,Percent of Total Billed charges,90% of Total Billed Charges,905.31,2052.86,
IRA TIP SILICONE,3600000094,CDM,360,RC,,,Outpatient,,,123.48,80.26,,123.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.84,76,,15092.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.91,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,92.61,75,,129.656,Percent of Total Billed charges,75% of Total Billed Charges,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.91,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,74.09,60,,103.72,Percent of Total Billed Charges,60% of Total Billed Charges,111.13,90,,7069.936,Percent of Total Billed Charges,90% of Total Billed Charges,55.57,45,,9406.528,Percent of Total Billed Charges,45% of Total Billed Charges,111.13,90,,17872.56,Percent of Total Billed Charges,90% of Total billed Charges,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.26,65,,117,Percent of total Billed Charges,65% of Total Billed Charges,54.45,44.1,,9218.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,117.31,95,,18865.48,Percent of Total Billed Charges,95% of Total Billed Charges,123.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.66,88,,13825.696,Percent of Total Billed Charges,88% of Total Billed Charges,111.13,90,,17872.56,Percent of Total Billed charges,90% of Total Billed Charges,54.45,123.48,
Probe/Needle Cryo,3600000096,CDM,270,RC,C2618,HCPCS,Outpatient,,,20149.29,13097.04,,20149.29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15313.46,76,,11964.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14507.49,72,,118.656,Percent of Total Billed Charges,72% of Total Billed Charges,15111.97,75,,123.6,Percent of Total Billed charges,75% of Total Billed Charges,20149.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14507.49,72,,118.656,Percent of Total Billed Charges,72% of Total Billed Charges,12089.57,60,,98.88,Percent of Total Billed Charges,60% of Total Billed Charges,18134.36,90,,10099.624,Percent of Total Billed Charges,90% of Total Billed Charges,9067.18,45,,7069.96,Percent of Total Billed Charges,45% of Total Billed Charges,18134.36,90,,14168.88,Percent of Total Billed Charges,90% of Total billed Charges,20149.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20149.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20149.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13097.04,65,,313.56,Percent of total Billed Charges,65% of Total Billed Charges,8885.84,44.1,,6928.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,19141.83,95,,14956.04,Percent of Total Billed Charges,95% of Total Billed Charges,20149.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17731.38,88,,15837.536,Percent of Total Billed Charges,88% of Total Billed Charges,18134.36,90,,14168.88,Percent of Total Billed charges,90% of Total Billed Charges,8885.84,20149.29,
OR ROOM 30 MIN,3600000097,CDM,360,RC,,,Outpatient,,,3346.09,2174.96,,3346.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2543.03,76,,17514.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2409.18,72,,130.176,Percent of Total Billed Charges,72% of Total Billed Charges,2509.57,75,,135.6,Percent of Total Billed charges,75% of Total Billed Charges,3346.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2409.18,72,,130.176,Percent of Total Billed Charges,72% of Total Billed Charges,2007.65,60,,108.48,Percent of Total Billed Charges,60% of Total Billed Charges,3011.48,90,,6709.04,Percent of Total Billed Charges,90% of Total Billed Charges,1505.74,45,,8098.744,Percent of Total Billed Charges,45% of Total Billed Charges,3011.48,90,,20740.432,Percent of Total Billed Charges,90% of Total billed Charges,3346.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3346.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3346.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2174.96,65,,42.64,Percent of total Billed Charges,65% of Total Billed Charges,1475.63,44.1,,7936.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,3178.79,95,,21892.68,Percent of Total Billed Charges,95% of Total Billed Charges,3346.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2944.56,88,,6829.96,Percent of Total Billed Charges,88% of Total Billed Charges,3011.48,90,,20740.432,Percent of Total Billed charges,90% of Total Billed Charges,1475.63,3346.09,
GASTROSCOPY,3600000098,CDM,360,RC,,,Outpatient,,,3621.00,2353.65,,3621,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2751.96,76,,13118.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2607.12,72,,130.176,Percent of Total Billed Charges,72% of Total Billed Charges,2715.75,75,,135.6,Percent of Total Billed charges,75% of Total Billed Charges,3621,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2607.12,72,,130.176,Percent of Total Billed Charges,72% of Total Billed Charges,2172.6,60,,108.48,Percent of Total Billed Charges,60% of Total Billed Charges,3258.9,90,,15056.8,Percent of Total Billed Charges,90% of Total Billed Charges,1629.45,45,,3492.592,Percent of Total Billed Charges,45% of Total Billed Charges,3258.9,90,,15534.72,Percent of Total Billed Charges,90% of Total billed Charges,3621,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3621,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3621,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2353.65,65,,260,Percent of total Billed Charges,65% of Total Billed Charges,1596.86,44.1,,3422.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,3439.95,95,,16397.76,Percent of Total Billed Charges,95% of Total Billed Charges,3621,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3186.48,88,,15336.144,Percent of Total Billed Charges,88% of Total Billed Charges,3258.9,90,,15534.72,Percent of Total Billed charges,90% of Total Billed Charges,1596.86,3621,
GASTROSCOPY/PEG,3600000099,CDM,360,RC,,,Outpatient,,,4020.82,2613.53,,4020.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3055.82,76,,15886.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2894.99,72,,68.584,Percent of Total Billed Charges,72% of Total Billed Charges,3015.62,75,,71.44,Percent of Total Billed charges,75% of Total Billed Charges,4020.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2894.99,72,,68.584,Percent of Total Billed Charges,72% of Total Billed Charges,2412.49,60,,57.152,Percent of Total Billed Charges,60% of Total Billed Charges,3618.74,90,,7282.328,Percent of Total Billed Charges,90% of Total Billed Charges,1809.37,45,,7842.352,Percent of Total Billed Charges,45% of Total Billed Charges,3618.74,90,,18813.064,Percent of Total Billed Charges,90% of Total billed Charges,4020.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4020.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4020.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2613.53,65,,352.04,Percent of total Billed Charges,65% of Total Billed Charges,1773.18,44.1,,7685.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,3819.78,95,,19858.232,Percent of Total Billed Charges,95% of Total Billed Charges,4020.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3538.32,88,,7918.768,Percent of Total Billed Charges,88% of Total Billed Charges,3618.74,90,,18813.064,Percent of Total Billed charges,90% of Total Billed Charges,1773.18,4020.82,
COLONOSCOPY,3600000100,CDM,360,RC,,,Outpatient,,,5873.00,3817.45,,5873,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4463.48,76,,11940.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4228.56,72,,68.584,Percent of Total Billed Charges,72% of Total Billed Charges,4404.75,75,,71.44,Percent of Total Billed charges,75% of Total Billed Charges,5873,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4228.56,72,,68.584,Percent of Total Billed Charges,72% of Total Billed Charges,3523.8,60,,57.152,Percent of Total Billed Charges,60% of Total Billed Charges,5285.7,90,,16579.44,Percent of Total Billed Charges,90% of Total Billed Charges,2642.85,45,,4049.368,Percent of Total Billed Charges,45% of Total Billed Charges,5285.7,90,,14139.912,Percent of Total Billed Charges,90% of Total billed Charges,5873,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5873,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5873,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3817.45,65,,296.4,Percent of total Billed Charges,65% of Total Billed Charges,2589.99,44.1,,3968.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,5579.35,95,,14925.464,Percent of Total Billed Charges,95% of Total Billed Charges,5873,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.24,88,,6912.832,Percent of Total Billed Charges,88% of Total Billed Charges,5285.7,90,,14139.912,Percent of Total Billed charges,90% of Total Billed Charges,2589.99,5873,
COLONOSCOPY POLYPECT,3600000101,CDM,360,RC,,,Outpatient,,,5876.33,3819.61,,5876.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4466.01,76,,13677.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4230.96,72,,62.208,Percent of Total Billed Charges,72% of Total Billed Charges,4407.25,75,,64.8,Percent of Total Billed charges,75% of Total Billed Charges,5876.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4230.96,72,,62.208,Percent of Total Billed Charges,72% of Total Billed Charges,3525.8,60,,51.84,Percent of Total Billed Charges,60% of Total Billed Charges,5288.7,90,,9184.32,Percent of Total Billed Charges,90% of Total Billed Charges,2644.35,45,,3534.968,Percent of Total Billed Charges,45% of Total Billed Charges,5288.7,90,,16197.48,Percent of Total Billed Charges,90% of Total billed Charges,5876.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5876.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5876.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3819.61,65,,513.24,Percent of total Billed Charges,65% of Total Billed Charges,2591.46,44.1,,3464.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,5582.51,95,,17097.344,Percent of Total Billed Charges,95% of Total Billed Charges,5876.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5171.17,88,,9875.184,Percent of Total Billed Charges,88% of Total Billed Charges,5288.7,90,,16197.48,Percent of Total Billed charges,90% of Total Billed Charges,2591.46,5876.33,
GASTROSCOPY COLONOSC,3600000102,CDM,360,RC,,,Outpatient,,,5884.00,3824.60,,5884,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4471.84,76,,5898.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4236.48,72,,62.208,Percent of Total Billed Charges,72% of Total Billed Charges,4413,75,,64.8,Percent of Total Billed charges,75% of Total Billed Charges,5884,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4236.48,72,,62.208,Percent of Total Billed Charges,72% of Total Billed Charges,3530.4,60,,51.84,Percent of Total Billed Charges,60% of Total Billed Charges,5295.6,90,,6444.592,Percent of Total Billed Charges,90% of Total Billed Charges,2647.8,45,,5049.808,Percent of Total Billed Charges,45% of Total Billed Charges,5295.6,90,,6985.192,Percent of Total Billed Charges,90% of Total billed Charges,5884,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5884,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5884,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3824.6,65,,513.24,Percent of total Billed Charges,65% of Total Billed Charges,2594.84,44.1,,4948.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,5589.8,95,,7373.256,Percent of Total Billed Charges,95% of Total Billed Charges,5884,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5177.92,88,,6559.952,Percent of Total Billed Charges,88% of Total Billed Charges,5295.6,90,,6985.192,Percent of Total Billed charges,90% of Total Billed Charges,2594.84,5884,
OR ROOM EA ADDL 1 M,3600000103,CDM,360,RC,,,Outpatient,,,72.77,47.30,,72.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.31,76,,13244.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.39,72,,91.584,Percent of Total Billed Charges,72% of Total Billed Charges,54.58,75,,95.4,Percent of Total Billed charges,75% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.39,72,,91.584,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,60,,76.32,Percent of Total Billed Charges,60% of Total Billed Charges,65.49,90,,6753.784,Percent of Total Billed Charges,90% of Total Billed Charges,32.75,45,,3354.52,Percent of Total Billed Charges,45% of Total Billed Charges,65.49,90,,15684.696,Percent of Total Billed Charges,90% of Total billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.3,65,,163.392,Percent of total Billed Charges,65% of Total Billed Charges,32.09,44.1,,3287.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,69.13,95,,16556.072,Percent of Total Billed Charges,95% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.04,88,,14722.2,Percent of Total Billed Charges,88% of Total Billed Charges,65.49,90,,15684.696,Percent of Total Billed charges,90% of Total Billed Charges,32.09,72.77,
POLYP TRAP,3600000104,CDM,272,RC,,,Outpatient,,,16.00,10.40,,16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.16,76,,6838.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.52,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,12,75,,90.624,Percent of Total Billed charges,75% of Total Billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.52,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,9.6,60,,72.496,Percent of Total Billed Charges,60% of Total Billed Charges,14.4,90,,756.488,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,45,,7528.4,Percent of Total Billed Charges,45% of Total Billed Charges,14.4,90,,8098.744,Percent of Total Billed Charges,90% of Total billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.4,65,,252.2,Percent of total Billed Charges,65% of Total Billed Charges,7.06,44.1,,7377.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.2,95,,8548.672,Percent of Total Billed Charges,95% of Total Billed Charges,16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.08,88,,7120.496,Percent of Total Billed Charges,88% of Total Billed Charges,14.4,90,,8098.744,Percent of Total Billed charges,90% of Total Billed Charges,7.06,16,
URETERAL BRUSH BX SET,3600000105,CDM,360,RC,,,Outpatient,,,96.00,62.40,,96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.96,76,,5970.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.12,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,72,75,,90.624,Percent of Total Billed charges,75% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.12,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,57.6,60,,72.496,Percent of Total Billed Charges,60% of Total Billed Charges,86.4,90,,483.12,Percent of Total Billed Charges,90% of Total Billed Charges,43.2,45,,3641.16,Percent of Total Billed Charges,45% of Total Billed Charges,86.4,90,,7069.936,Percent of Total Billed Charges,90% of Total billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.4,65,,308.36,Percent of total Billed Charges,65% of Total Billed Charges,42.34,44.1,,3568.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.2,95,,7462.712,Percent of Total Billed Charges,95% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.48,88,,16211.008,Percent of Total Billed Charges,88% of Total Billed Charges,86.4,90,,7069.936,Percent of Total Billed charges,90% of Total Billed Charges,42.34,96,
OPERATING ROOM LEVEL 1 MINOR,3600000106,CDM,360,RC,,,Outpatient,,,4721.00,3068.65,,4721,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3587.96,76,,8528.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3399.12,72,,91.584,Percent of Total Billed Charges,72% of Total Billed Charges,3540.75,75,,95.4,Percent of Total Billed charges,75% of Total Billed Charges,4721,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3399.12,72,,91.584,Percent of Total Billed Charges,72% of Total Billed Charges,2832.6,60,,76.32,Percent of Total Billed Charges,60% of Total Billed Charges,4248.9,90,,823.68,Percent of Total Billed Charges,90% of Total Billed Charges,2124.45,45,,8289.72,Percent of Total Billed Charges,45% of Total Billed Charges,4248.9,90,,10099.624,Percent of Total Billed Charges,90% of Total billed Charges,4721,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4721,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4721,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3068.65,65,,678.08,Percent of total Billed Charges,65% of Total Billed Charges,2081.96,44.1,,8123.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,4484.95,95,,10660.712,Percent of Total Billed Charges,95% of Total Billed Charges,4721,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4154.48,88,,8980.224,Percent of Total Billed Charges,88% of Total Billed Charges,4248.9,90,,10099.624,Percent of Total Billed charges,90% of Total Billed Charges,2081.96,4721,
OPERATING ROOM LEVEL 2 INTERM,3600000107,CDM,360,RC,,,Outpatient,,,8092.00,5259.80,,8092,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6149.92,76,,5665.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5826.24,72,,93.888,Percent of Total Billed Charges,72% of Total Billed Charges,6069,75,,97.8,Percent of Total Billed charges,75% of Total Billed Charges,8092,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5826.24,72,,93.888,Percent of Total Billed Charges,72% of Total Billed Charges,4855.2,60,,78.24,Percent of Total Billed Charges,60% of Total Billed Charges,7282.8,90,,3157.92,Percent of Total Billed Charges,90% of Total Billed Charges,3641.4,45,,4592.16,Percent of Total Billed Charges,45% of Total Billed Charges,7282.8,90,,6709.04,Percent of Total Billed Charges,90% of Total billed Charges,8092,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8092,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8092,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5259.8,65,,573.304,Percent of total Billed Charges,65% of Total Billed Charges,3568.57,44.1,,4500.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,7687.4,95,,7081.76,Percent of Total Billed Charges,95% of Total Billed Charges,8092,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7120.96,88,,6301.376,Percent of Total Billed Charges,88% of Total Billed Charges,7282.8,90,,6709.04,Percent of Total Billed charges,90% of Total Billed Charges,3568.57,8092,
OPERATING RM LEVEL3 MAJOR PROC,3600000108,CDM,360,RC,,,Outpatient,,,9899.00,6434.35,,9899,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7523.24,76,,12714.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7127.28,72,,93.888,Percent of Total Billed Charges,72% of Total Billed Charges,7424.25,75,,97.8,Percent of Total Billed charges,75% of Total Billed Charges,9899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7127.28,72,,93.888,Percent of Total Billed Charges,72% of Total Billed Charges,5939.4,60,,78.24,Percent of Total Billed Charges,60% of Total Billed Charges,8909.1,90,,1330.56,Percent of Total Billed Charges,90% of Total Billed Charges,4454.55,45,,3222.296,Percent of Total Billed Charges,45% of Total Billed Charges,8909.1,90,,15056.8,Percent of Total Billed Charges,90% of Total billed Charges,9899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6434.35,65,,33.28,Percent of total Billed Charges,65% of Total Billed Charges,4365.46,44.1,,3157.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,9404.05,95,,15893.288,Percent of Total Billed Charges,95% of Total Billed Charges,9899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8711.12,88,,6603.696,Percent of Total Billed Charges,88% of Total Billed Charges,8909.1,90,,15056.8,Percent of Total Billed charges,90% of Total Billed Charges,4365.46,9899,
CATH LAB OPER RM LEVEL 1 MINOR,3600000109,CDM,360,RC,,,Outpatient,,,4300.00,2795.00,,4300,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3268,76,,6149.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3096,72,,101.376,Percent of Total Billed Charges,72% of Total Billed Charges,3225,75,,105.6,Percent of Total Billed charges,75% of Total Billed Charges,4300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3096,72,,101.376,Percent of Total Billed Charges,72% of Total Billed Charges,2580,60,,84.48,Percent of Total Billed Charges,60% of Total Billed Charges,3870,90,,2321.28,Percent of Total Billed Charges,90% of Total Billed Charges,1935,45,,3376.888,Percent of Total Billed Charges,45% of Total Billed Charges,3870,90,,7282.328,Percent of Total Billed Charges,90% of Total billed Charges,4300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2795,65,,964.08,Percent of total Billed Charges,65% of Total Billed Charges,1896.3,44.1,,3309.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,4085,95,,7686.896,Percent of Total Billed Charges,95% of Total Billed Charges,4300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3784,88,,739.68,Percent of Total Billed Charges,88% of Total Billed Charges,3870,90,,7282.328,Percent of Total Billed charges,90% of Total Billed Charges,1896.3,4300,
CATH LAB OPER RM LEVEL 2 INTER,3600000110,CDM,360,RC,,,Outpatient,,,8800.00,5720.00,,8800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6688,76,,14000.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6336,72,,101.376,Percent of Total Billed Charges,72% of Total Billed Charges,6600,75,,105.6,Percent of Total Billed charges,75% of Total Billed Charges,8800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6336,72,,101.376,Percent of Total Billed Charges,72% of Total Billed Charges,5280,60,,84.48,Percent of Total Billed Charges,60% of Total Billed Charges,7920,90,,1090.08,Percent of Total Billed Charges,90% of Total Billed Charges,3960,45,,378.248,Percent of Total Billed Charges,45% of Total Billed Charges,7920,90,,16579.44,Percent of Total Billed Charges,90% of Total billed Charges,8800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5720,65,,294.32,Percent of total Billed Charges,65% of Total Billed Charges,3880.8,44.1,,370.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,8360,95,,17500.52,Percent of Total Billed Charges,95% of Total Billed Charges,8800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7744,88,,472.384,Percent of Total Billed Charges,88% of Total Billed Charges,7920,90,,16579.44,Percent of Total Billed charges,90% of Total Billed Charges,3880.8,8800,
CATH LAB OPER RM LEVEL 3 MAJOR,3600000111,CDM,360,RC,,,Outpatient,,,20800.00,13520.00,,20800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15808,76,,7755.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14976,72,,60.328,Percent of Total Billed Charges,72% of Total Billed Charges,15600,75,,62.848,Percent of Total Billed charges,75% of Total Billed Charges,20800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14976,72,,60.328,Percent of Total Billed Charges,72% of Total Billed Charges,12480,60,,50.272,Percent of Total Billed Charges,60% of Total Billed Charges,18720,90,,1090.08,Percent of Total Billed Charges,90% of Total Billed Charges,9360,45,,241.56,Percent of Total Billed Charges,45% of Total Billed Charges,18720,90,,9184.32,Percent of Total Billed Charges,90% of Total billed Charges,20800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13520,65,,322.92,Percent of total Billed Charges,65% of Total Billed Charges,9172.8,44.1,,236.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,19760,95,,9694.56,Percent of Total Billed Charges,95% of Total Billed Charges,20800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18304,88,,805.376,Percent of Total Billed Charges,88% of Total Billed Charges,18720,90,,9184.32,Percent of Total Billed charges,90% of Total Billed Charges,9172.8,20800,
DRAINAGE OVARIAN CYST ABD,3600000114,CDM,360,RC,,,Outpatient,,,5728.98,3723.84,,5728.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4354.02,76,,5442.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4124.87,72,,60.328,Percent of Total Billed Charges,72% of Total Billed Charges,4296.74,75,,62.848,Percent of Total Billed charges,75% of Total Billed Charges,5728.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4124.87,72,,60.328,Percent of Total Billed Charges,72% of Total Billed Charges,3437.39,60,,50.272,Percent of Total Billed Charges,60% of Total Billed Charges,5156.08,90,,1090.08,Percent of Total Billed Charges,90% of Total Billed Charges,2578.04,45,,411.84,Percent of Total Billed Charges,45% of Total Billed Charges,5156.08,90,,6444.592,Percent of Total Billed Charges,90% of Total billed Charges,5728.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5728.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5728.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3723.84,65,,1070.928,Percent of total Billed Charges,65% of Total Billed Charges,2526.48,44.1,,403.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,5442.53,95,,6802.624,Percent of Total Billed Charges,95% of Total Billed Charges,5728.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5041.5,88,,3087.744,Percent of Total Billed Charges,88% of Total Billed Charges,5156.08,90,,6444.592,Percent of Total Billed charges,90% of Total Billed Charges,2526.48,5728.98,
UMC tubal ligation,3600000116,CDM,360,RC,,,Outpatient,,,1860.00,1209.00,,1860,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1413.6,76,,5703.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1339.2,72,,61.056,Percent of Total Billed Charges,72% of Total Billed Charges,1395,75,,63.6,Percent of Total Billed charges,75% of Total Billed Charges,1860,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1339.2,72,,61.056,Percent of Total Billed Charges,72% of Total Billed Charges,1116,60,,50.88,Percent of Total Billed Charges,60% of Total Billed Charges,1674,90,,4550.4,Percent of Total Billed Charges,90% of Total Billed Charges,837,45,,1578.96,Percent of Total Billed Charges,45% of Total Billed Charges,1674,90,,6753.784,Percent of Total Billed Charges,90% of Total billed Charges,1860,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1209,65,,405.6,Percent of total Billed Charges,65% of Total Billed Charges,820.26,44.1,,1547.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,1767,95,,7128.992,Percent of Total Billed Charges,95% of Total Billed Charges,1860,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1636.8,88,,1300.992,Percent of Total Billed Charges,88% of Total Billed Charges,1674,90,,6753.784,Percent of Total Billed charges,90% of Total Billed Charges,820.26,1860,
UMC tubal Lig Astudillo,3600000117,CDM,360,RC,,,Outpatient,,,1860.00,1209.00,,1860,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1413.6,76,,638.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1339.2,72,,61.056,Percent of Total Billed Charges,72% of Total Billed Charges,1395,75,,63.6,Percent of Total Billed charges,75% of Total Billed Charges,1860,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1339.2,72,,61.056,Percent of Total Billed Charges,72% of Total Billed Charges,1116,60,,50.88,Percent of Total Billed Charges,60% of Total Billed Charges,1674,90,,4789.536,Percent of Total Billed Charges,90% of Total Billed Charges,837,45,,665.28,Percent of Total Billed Charges,45% of Total Billed Charges,1674,90,,756.488,Percent of Total Billed Charges,90% of Total billed Charges,1860,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1209,65,,426.92,Percent of total Billed Charges,65% of Total Billed Charges,820.26,44.1,,651.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,1767,95,,798.52,Percent of Total Billed Charges,95% of Total Billed Charges,1860,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1636.8,88,,2269.696,Percent of Total Billed Charges,88% of Total Billed Charges,1674,90,,756.488,Percent of Total Billed charges,90% of Total Billed Charges,820.26,1860,
UMC Tubal lig Salama,3600000118,CDM,360,RC,,,Outpatient,,,1860.00,1209.00,,1860,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1413.6,76,,407.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1339.2,72,,131.328,Percent of Total Billed Charges,72% of Total Billed Charges,1395,75,,136.8,Percent of Total Billed charges,75% of Total Billed Charges,1860,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1339.2,72,,131.328,Percent of Total Billed Charges,72% of Total Billed Charges,1116,60,,109.44,Percent of Total Billed Charges,60% of Total Billed Charges,1674,90,,939.12,Percent of Total Billed Charges,90% of Total Billed Charges,837,45,,1160.64,Percent of Total Billed Charges,45% of Total Billed Charges,1674,90,,483.12,Percent of Total Billed Charges,90% of Total billed Charges,1860,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1209,65,,426.92,Percent of total Billed Charges,65% of Total Billed Charges,820.26,44.1,,1137.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,1767,95,,509.96,Percent of Total Billed Charges,95% of Total Billed Charges,1860,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1636.8,88,,1065.856,Percent of Total Billed Charges,88% of Total Billed Charges,1674,90,,483.12,Percent of Total Billed charges,90% of Total Billed Charges,820.26,1860,
OR Time Initial 30 Minutes,3600000119,CDM,360,RC,,,Outpatient,,,1381.20,897.78,,1381.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1049.71,76,,695.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,994.46,72,,125.104,Percent of Total Billed Charges,72% of Total Billed Charges,1035.9,75,,130.312,Percent of Total Billed charges,75% of Total Billed Charges,1381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.46,72,,125.104,Percent of Total Billed Charges,72% of Total Billed Charges,828.72,60,,104.248,Percent of Total Billed Charges,60% of Total Billed Charges,1243.08,90,,2630.88,Percent of Total Billed Charges,90% of Total Billed Charges,621.54,45,,545.04,Percent of Total Billed Charges,45% of Total Billed Charges,1243.08,90,,823.68,Percent of Total Billed Charges,90% of Total billed Charges,1381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,897.78,65,,1759.16,Percent of total Billed Charges,65% of Total Billed Charges,609.11,44.1,,534.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,1312.14,95,,869.44,Percent of Total Billed Charges,95% of Total Billed Charges,1381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1215.46,88,,1065.856,Percent of Total Billed Charges,88% of Total Billed Charges,1243.08,90,,823.68,Percent of Total Billed charges,90% of Total Billed Charges,609.11,1381.2,
OR Time Each Additl 15 Minutes,3600000120,CDM,360,RC,,,Outpatient,,,690.60,448.89,,690.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,524.86,76,,2666.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,497.23,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,517.95,75,,120,Percent of Total Billed charges,75% of Total Billed Charges,690.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497.23,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,414.36,60,,96,Percent of Total Billed Charges,60% of Total Billed Charges,621.54,90,,5251.68,Percent of Total Billed Charges,90% of Total Billed Charges,310.77,45,,545.04,Percent of Total Billed Charges,45% of Total Billed Charges,621.54,90,,3157.92,Percent of Total Billed Charges,90% of Total billed Charges,690.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,690.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,690.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,448.89,65,,1900.08,Percent of total Billed Charges,65% of Total Billed Charges,304.55,44.1,,534.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,656.07,95,,3333.36,Percent of Total Billed Charges,95% of Total Billed Charges,690.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.73,88,,1065.856,Percent of Total Billed Charges,88% of Total Billed Charges,621.54,90,,3157.92,Percent of Total Billed charges,90% of Total Billed Charges,304.55,690.6,
ARTHRO ASP/INJ INTER JNT W/US,3610000001,CDM,361,RC,,,Outpatient,,,667.00,433.55,,667,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,506.92,76,,1123.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,480.24,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,500.25,75,,120,Percent of Total Billed charges,75% of Total Billed Charges,667,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.24,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,400.2,60,,96,Percent of Total Billed Charges,60% of Total Billed Charges,600.3,90,,2322.72,Percent of Total Billed Charges,90% of Total Billed Charges,300.15,45,,545.04,Percent of Total Billed Charges,45% of Total Billed Charges,600.3,90,,1330.56,Percent of Total Billed Charges,90% of Total billed Charges,667,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,667,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,667,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,433.55,65,,627.768,Percent of total Billed Charges,65% of Total Billed Charges,294.15,44.1,,534.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,633.65,95,,1404.48,Percent of Total Billed Charges,95% of Total Billed Charges,667,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,586.96,88,,4449.28,Percent of Total Billed Charges,88% of Total Billed Charges,600.3,90,,1330.56,Percent of Total Billed charges,90% of Total Billed Charges,294.15,667,
ARTHROCENTESIS INTER JNT WRIST,3610000002,CDM,361,RC,,,Outpatient,,,798.00,518.70,,798,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,606.48,76,,1960.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,574.56,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,598.5,75,,120,Percent of Total Billed charges,75% of Total Billed Charges,798,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,574.56,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,478.8,60,,96,Percent of Total Billed Charges,60% of Total Billed Charges,718.2,90,,2477.488,Percent of Total Billed Charges,90% of Total Billed Charges,359.1,45,,2275.2,Percent of Total Billed Charges,45% of Total Billed Charges,718.2,90,,2321.28,Percent of Total Billed Charges,90% of Total billed Charges,798,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,798,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,798,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,518.7,65,,2326.456,Percent of total Billed Charges,65% of Total Billed Charges,351.92,44.1,,2229.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,758.1,95,,2450.24,Percent of Total Billed Charges,95% of Total Billed Charges,798,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702.24,88,,4683.096,Percent of Total Billed Charges,88% of Total Billed Charges,718.2,90,,2321.28,Percent of Total Billed charges,90% of Total Billed Charges,351.92,798,
ARTHROCENTESIS MAJ JNT SHDR/HP,3610000003,CDM,361,RC,,,Outpatient,,,798.00,518.70,,798,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,606.48,76,,920.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,574.56,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,598.5,75,,114.44,Percent of Total Billed charges,75% of Total Billed Charges,798,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,574.56,72,,109.864,Percent of Total Billed Charges,72% of Total Billed Charges,478.8,60,,91.552,Percent of Total Billed Charges,60% of Total Billed Charges,718.2,90,,4399.24,Percent of Total Billed Charges,90% of Total Billed Charges,359.1,45,,2394.768,Percent of Total Billed Charges,45% of Total Billed Charges,718.2,90,,1090.08,Percent of Total Billed Charges,90% of Total billed Charges,798,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,798,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,798,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,518.7,65,,790.4,Percent of total Billed Charges,65% of Total Billed Charges,351.92,44.1,,2346.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,758.1,95,,1150.64,Percent of Total Billed Charges,95% of Total Billed Charges,798,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702.24,88,,918.248,Percent of Total Billed Charges,88% of Total Billed Charges,718.2,90,,1090.08,Percent of Total Billed charges,90% of Total Billed Charges,351.92,798,
ARTHROCENTESIS SM JNT FING/TOE,3610000004,CDM,361,RC,,,Outpatient,,,702.00,456.30,,702,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,533.52,76,,920.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,505.44,72,,63.36,Percent of Total Billed Charges,72% of Total Billed Charges,526.5,75,,66,Percent of Total Billed charges,75% of Total Billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,505.44,72,,63.36,Percent of Total Billed Charges,72% of Total Billed Charges,421.2,60,,52.8,Percent of Total Billed Charges,60% of Total Billed Charges,631.8,90,,4692.152,Percent of Total Billed Charges,90% of Total Billed Charges,315.9,45,,469.56,Percent of Total Billed Charges,45% of Total Billed Charges,631.8,90,,1090.08,Percent of Total Billed Charges,90% of Total billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.3,65,,296.4,Percent of total Billed Charges,65% of Total Billed Charges,309.58,44.1,,460.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,666.9,95,,1150.64,Percent of Total Billed Charges,95% of Total Billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,617.76,88,,2572.416,Percent of Total Billed Charges,88% of Total Billed Charges,631.8,90,,1090.08,Percent of Total Billed charges,90% of Total Billed Charges,309.58,702,
ASPIR INJ GANGLION CYST(S),3610000005,CDM,361,RC,,,Outpatient,,,514.00,334.10,,514,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,390.64,76,,920.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,370.08,72,,63.36,Percent of Total Billed Charges,72% of Total Billed Charges,385.5,75,,66,Percent of Total Billed charges,75% of Total Billed Charges,514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.08,72,,63.36,Percent of Total Billed Charges,72% of Total Billed Charges,308.4,60,,52.8,Percent of Total Billed Charges,60% of Total Billed Charges,462.6,90,,82.8,Percent of Total Billed Charges,90% of Total Billed Charges,231.3,45,,1315.44,Percent of Total Billed Charges,45% of Total Billed Charges,462.6,90,,1090.08,Percent of Total Billed Charges,90% of Total billed Charges,514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.1,65,,1123.2,Percent of total Billed Charges,65% of Total Billed Charges,226.67,44.1,,1289.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,488.3,95,,1150.64,Percent of Total Billed Charges,95% of Total Billed Charges,514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,452.32,88,,5134.976,Percent of Total Billed Charges,88% of Total Billed Charges,462.6,90,,1090.08,Percent of Total Billed charges,90% of Total Billed Charges,226.67,514,
BIOPSY ENDO URTR/RNL/PLVS W/IM,3610000006,CDM,361,RC,,,Outpatient,,,542.10,352.37,,542.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,412,76,,3842.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,390.31,72,,64.136,Percent of Total Billed Charges,72% of Total Billed Charges,406.58,75,,66.808,Percent of Total Billed charges,75% of Total Billed Charges,542.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,72,,64.136,Percent of Total Billed Charges,72% of Total Billed Charges,325.26,60,,53.448,Percent of Total Billed Charges,60% of Total Billed Charges,487.89,90,,586.08,Percent of Total Billed Charges,90% of Total Billed Charges,243.95,45,,2625.84,Percent of Total Billed Charges,45% of Total Billed Charges,487.89,90,,4550.4,Percent of Total Billed Charges,90% of Total billed Charges,542.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,542.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,542.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.37,65,,2411.344,Percent of total Billed Charges,65% of Total Billed Charges,239.07,44.1,,2573.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,515,95,,4803.2,Percent of Total Billed Charges,95% of Total Billed Charges,542.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,477.05,88,,2271.104,Percent of Total Billed Charges,88% of Total Billed Charges,487.89,90,,4550.4,Percent of Total Billed charges,90% of Total Billed Charges,239.07,542.1,
BX SOFT TISS THIGH/KNEE SUPERF,3610000007,CDM,361,RC,,,Outpatient,,,4328.17,2813.31,,4328.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3289.41,76,,4044.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3116.28,72,,64.136,Percent of Total Billed Charges,72% of Total Billed Charges,3246.13,75,,66.808,Percent of Total Billed charges,75% of Total Billed Charges,4328.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3116.28,72,,64.136,Percent of Total Billed Charges,72% of Total Billed Charges,2596.9,60,,53.448,Percent of Total Billed Charges,60% of Total Billed Charges,3895.35,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,1947.68,45,,1161.36,Percent of Total Billed Charges,45% of Total Billed Charges,3895.35,90,,4789.536,Percent of Total Billed Charges,90% of Total billed Charges,4328.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4328.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4328.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2813.31,65,,400.4,Percent of total Billed Charges,65% of Total Billed Charges,1908.72,44.1,,1138.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,4111.76,95,,5055.616,Percent of Total Billed Charges,95% of Total Billed Charges,4328.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3808.79,88,,2422.432,Percent of Total Billed Charges,88% of Total Billed Charges,3895.35,90,,4789.536,Percent of Total Billed charges,90% of Total Billed Charges,1908.72,4328.17,
C1C2 PUN W MD/SB INJ DX OR TX,3610000008,CDM,361,RC,,,Outpatient,,,1494.00,971.10,,1494,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1135.44,76,,793.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1075.68,72,,64.136,Percent of Total Billed Charges,72% of Total Billed Charges,1120.5,75,,66.808,Percent of Total Billed charges,75% of Total Billed Charges,1494,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1075.68,72,,64.136,Percent of Total Billed Charges,72% of Total Billed Charges,896.4,60,,53.448,Percent of Total Billed Charges,60% of Total Billed Charges,1344.6,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,672.3,45,,1238.744,Percent of Total Billed Charges,45% of Total Billed Charges,1344.6,90,,939.12,Percent of Total Billed Charges,90% of Total billed Charges,1494,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1494,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1494,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,971.1,65,,479.44,Percent of total Billed Charges,65% of Total Billed Charges,658.85,44.1,,1213.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,1419.3,95,,991.288,Percent of Total Billed Charges,95% of Total Billed Charges,1494,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1314.72,88,,4301.48,Percent of Total Billed Charges,88% of Total Billed Charges,1344.6,90,,939.12,Percent of Total Billed charges,90% of Total Billed Charges,658.85,1494,
CATH FOR HYSTEROSALPINOGRAPHY,3610000009,CDM,361,RC,,,Outpatient,,,432.18,280.92,,432.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,328.46,76,,2221.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,311.17,72,,64.136,Percent of Total Billed Charges,72% of Total Billed Charges,324.14,75,,66.808,Percent of Total Billed charges,75% of Total Billed Charges,432.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,311.17,72,,64.136,Percent of Total Billed Charges,72% of Total Billed Charges,259.31,60,,53.448,Percent of Total Billed Charges,60% of Total Billed Charges,388.96,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,194.48,45,,2199.624,Percent of Total Billed Charges,45% of Total Billed Charges,388.96,90,,2630.88,Percent of Total Billed Charges,90% of Total billed Charges,432.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,432.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,432.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280.92,65,,479.44,Percent of total Billed Charges,65% of Total Billed Charges,190.59,44.1,,2155.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,410.57,95,,2777.04,Percent of Total Billed Charges,95% of Total Billed Charges,432.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.32,88,,4587.88,Percent of Total Billed Charges,88% of Total Billed Charges,388.96,90,,2630.88,Percent of Total Billed charges,90% of Total Billed Charges,190.59,432.18,
CIRCUMCISION CLAMP OR RING BLk,3610000010,CDM,361,RC,,,Outpatient,,,4105.00,2668.25,,4105,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3119.8,76,,4434.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2955.6,72,,61.6,Percent of Total Billed Charges,72% of Total Billed Charges,3078.75,75,,64.168,Percent of Total Billed charges,75% of Total Billed Charges,4105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2955.6,72,,61.6,Percent of Total Billed Charges,72% of Total Billed Charges,2463,60,,51.328,Percent of Total Billed Charges,60% of Total Billed Charges,3694.5,90,,162,Percent of Total Billed Charges,90% of Total Billed Charges,1847.25,45,,2346.08,Percent of Total Billed Charges,45% of Total Billed Charges,3694.5,90,,5251.68,Percent of Total Billed Charges,90% of Total billed Charges,4105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2668.25,65,,189.8,Percent of total Billed Charges,65% of Total Billed Charges,1810.31,44.1,,2299.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,3899.75,95,,5543.44,Percent of Total Billed Charges,95% of Total Billed Charges,4105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3612.4,88,,80.96,Percent of Total Billed Charges,88% of Total Billed Charges,3694.5,90,,5251.68,Percent of Total Billed charges,90% of Total Billed Charges,1810.31,4105,
CONV EXT BIL DRG CATH INT-EXT,3610000011,CDM,361,RC,,,Outpatient,,,6658.31,4327.90,,6658.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5060.32,76,,1961.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4793.98,72,,61.6,Percent of Total Billed Charges,72% of Total Billed Charges,4993.73,75,,64.168,Percent of Total Billed charges,75% of Total Billed Charges,6658.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4793.98,72,,61.6,Percent of Total Billed Charges,72% of Total Billed Charges,3994.99,60,,51.328,Percent of Total Billed Charges,60% of Total Billed Charges,5992.48,90,,434.16,Percent of Total Billed Charges,90% of Total Billed Charges,2996.24,45,,41.4,Percent of Total Billed Charges,45% of Total Billed Charges,5992.48,90,,2322.72,Percent of Total Billed Charges,90% of Total billed Charges,6658.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6658.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6658.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4327.9,65,,692.12,Percent of total Billed Charges,65% of Total Billed Charges,2936.31,44.1,,40.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,6325.39,95,,2451.76,Percent of Total Billed Charges,95% of Total Billed Charges,6658.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5859.31,88,,573.056,Percent of Total Billed Charges,88% of Total Billed Charges,5992.48,90,,2322.72,Percent of Total Billed charges,90% of Total Billed Charges,2936.31,6658.31,
DRAIN/INJ SMALL JNT/BURSA W/US,3610000012,CDM,361,RC,,,Outpatient,,,1634.74,1062.58,,1634.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1242.4,76,,2092.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1177.01,72,,250.56,Percent of Total Billed Charges,72% of Total Billed Charges,1226.06,75,,261,Percent of Total Billed charges,75% of Total Billed Charges,1634.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1177.01,72,,250.56,Percent of Total Billed Charges,72% of Total Billed Charges,980.84,60,,208.8,Percent of Total Billed Charges,60% of Total Billed Charges,1471.27,90,,59.04,Percent of Total Billed Charges,90% of Total Billed Charges,735.63,45,,293.04,Percent of Total Billed Charges,45% of Total Billed Charges,1471.27,90,,2477.488,Percent of Total Billed Charges,90% of Total billed Charges,1634.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1634.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1634.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1062.58,65,,513.76,Percent of total Billed Charges,65% of Total Billed Charges,720.92,44.1,,287.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,1553,95,,2615.12,Percent of Total Billed Charges,95% of Total Billed Charges,1634.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1438.57,88,,9.856,Percent of Total Billed Charges,88% of Total Billed Charges,1471.27,90,,2477.488,Percent of Total Billed charges,90% of Total Billed Charges,720.92,1634.74,
EXCH BILIARY DRAIN CATH PERC,3610000013,CDM,761,RC,,,Outpatient,,,3310.00,2151.50,,3310,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2515.6,76,,3714.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,250.56,Case Rate,Pays Based on per visit rate,50,100,,261,Case Rate,Pays based on per visit rate,3310,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,250.56,Case Rate,Pays based on per visit rate,50,100,,208.8,Case Rate,Pays based on per visit rate,2979,90,,360,Percent of Total Billed Charges,90% of Total Billed Charges,1489.5,45,,5.04,Percent of Total Billed Charges,45% of Total Billed Charges,2979,90,,4399.24,Percent of Total Billed Charges,90% of Total billed Charges,3310,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3310,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3310,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2151.5,65,,513.76,Percent of total Billed Charges,65% of Total Billed Charges,1459.71,44.1,,4.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,3144.5,95,,4643.648,Percent of Total Billed Charges,95% of Total Billed Charges,3310,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2912.8,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,2979,90,,4399.24,Percent of Total Billed charges,90% of Total Billed Charges,50,3310,
INSER TUNLED CVC W/ SUB Q PORT,3610000014,CDM,761,RC,,,Outpatient,,,6973.00,4532.45,,6973,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5299.48,76,,3962.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,355.968,Case Rate,Pays Based on per visit rate,50,100,,370.8,Case Rate,Pays based on per visit rate,6973,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,355.968,Case Rate,Pays based on per visit rate,50,100,,296.64,Case Rate,Pays based on per visit rate,6275.7,90,,487.44,Percent of Total Billed Charges,90% of Total Billed Charges,3137.85,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,6275.7,90,,4692.152,Percent of Total Billed Charges,90% of Total billed Charges,6973,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6973,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6973,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4532.45,65,,513.76,Percent of total Billed Charges,65% of Total Billed Charges,3075.09,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,6624.35,95,,4952.832,Percent of Total Billed Charges,95% of Total Billed Charges,6973,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6136.24,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,6275.7,90,,4692.152,Percent of Total Billed charges,90% of Total Billed Charges,50,6973,
INSER TUNN CV2X CATH WO SQ PRT,3610000015,CDM,761,RC,,,Outpatient,,,6568.44,4269.49,,6568.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4992.01,76,,69.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,355.968,Case Rate,Pays Based on per visit rate,50,100,,370.8,Case Rate,Pays based on per visit rate,6568.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,355.968,Case Rate,Pays based on per visit rate,50,100,,296.64,Case Rate,Pays based on per visit rate,5911.6,90,,111.136,Percent of Total Billed Charges,90% of Total Billed Charges,2955.8,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,5911.6,90,,82.8,Percent of Total Billed Charges,90% of Total billed Charges,6568.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6568.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6568.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4269.49,65,,490.176,Percent of total Billed Charges,65% of Total Billed Charges,2896.68,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,6240.02,95,,87.4,Percent of Total Billed Charges,95% of Total Billed Charges,6568.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5780.23,88,,158.4,Percent of Total Billed Charges,88% of Total Billed Charges,5911.6,90,,82.8,Percent of Total Billed charges,90% of Total Billed Charges,50,6568.44,
KYPHOPLASTY EACH ADDL BODY,3610000016,CDM,361,RC,,,Outpatient,,,20373.00,13242.45,,20373,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15483.48,76,,494.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14668.56,72,,228.096,Percent of Total Billed Charges,72% of Total Billed Charges,15279.75,75,,237.6,Percent of Total Billed charges,75% of Total Billed Charges,20373,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14668.56,72,,228.096,Percent of Total Billed Charges,72% of Total Billed Charges,12223.8,60,,190.08,Percent of Total Billed Charges,60% of Total Billed Charges,18335.7,90,,487.44,Percent of Total Billed Charges,90% of Total Billed Charges,9167.85,45,,81,Percent of Total Billed Charges,45% of Total Billed Charges,18335.7,90,,586.08,Percent of Total Billed Charges,90% of Total billed Charges,20373,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20373,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20373,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13242.45,65,,513.76,Percent of total Billed Charges,65% of Total Billed Charges,8984.49,44.1,,79.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,19354.35,95,,618.64,Percent of Total Billed Charges,95% of Total Billed Charges,20373,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17928.24,88,,424.512,Percent of Total Billed Charges,88% of Total Billed Charges,18335.7,90,,586.08,Percent of Total Billed charges,90% of Total Billed Charges,8984.49,20373,
LUMBAR PUNCT  NSY DIAGNOSTIC,3610000017,CDM,361,RC,,,Outpatient,,,1078.00,700.70,,1078,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,819.28,76,,8.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,776.16,72,,228.096,Percent of Total Billed Charges,72% of Total Billed Charges,808.5,75,,237.6,Percent of Total Billed charges,75% of Total Billed Charges,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,776.16,72,,228.096,Percent of Total Billed Charges,72% of Total Billed Charges,646.8,60,,190.08,Percent of Total Billed Charges,60% of Total Billed Charges,970.2,90,,164.88,Percent of Total Billed Charges,90% of Total Billed Charges,485.1,45,,217.08,Percent of Total Billed Charges,45% of Total Billed Charges,970.2,90,,10.08,Percent of Total Billed Charges,90% of Total billed Charges,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,700.7,65,,412.88,Percent of total Billed Charges,65% of Total Billed Charges,475.4,44.1,,212.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,1024.1,95,,10.64,Percent of Total Billed Charges,95% of Total Billed Charges,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,948.64,88,,57.728,Percent of Total Billed Charges,88% of Total Billed Charges,970.2,90,,10.08,Percent of Total Billed charges,90% of Total Billed Charges,475.4,1078,
MECHAN REM OBSTRUC FROM CVC,3610000018,CDM,361,RC,,,Outpatient,,,5148.68,3346.64,,5148.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3913,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3707.05,72,,239.04,Percent of Total Billed Charges,72% of Total Billed Charges,3861.51,75,,249,Percent of Total Billed charges,75% of Total Billed Charges,5148.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3707.05,72,,239.04,Percent of Total Billed Charges,72% of Total Billed Charges,3089.21,60,,199.2,Percent of Total Billed Charges,60% of Total Billed Charges,4633.81,90,,1294.56,Percent of Total Billed Charges,90% of Total Billed Charges,2316.91,45,,29.52,Percent of Total Billed Charges,45% of Total Billed Charges,4633.81,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,5148.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5148.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5148.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3346.64,65,,379.6,Percent of total Billed Charges,65% of Total Billed Charges,2270.57,44.1,,28.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,4891.25,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,5148.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4530.84,88,,352,Percent of Total Billed Charges,88% of Total Billed Charges,4633.81,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,2270.57,5148.68,
NASO  ORO GAST TUBE PLACEMNT,3610000019,CDM,361,RC,,,Outpatient,,,487.00,316.55,,487,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,370.12,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,350.64,72,,239.04,Percent of Total Billed Charges,72% of Total Billed Charges,365.25,75,,249,Percent of Total Billed charges,75% of Total Billed Charges,487,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.64,72,,239.04,Percent of Total Billed Charges,72% of Total Billed Charges,292.2,60,,199.2,Percent of Total Billed Charges,60% of Total Billed Charges,438.3,90,,410.4,Percent of Total Billed Charges,90% of Total Billed Charges,219.15,45,,180,Percent of Total Billed Charges,45% of Total Billed Charges,438.3,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,487,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.55,65,,412.88,Percent of total Billed Charges,65% of Total Billed Charges,214.77,44.1,,176.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,462.65,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,487,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,428.56,88,,476.608,Percent of Total Billed Charges,88% of Total Billed Charges,438.3,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,214.77,487,
NEPHROSTOMY TUB PLCEMNT INSERT,3610000020,CDM,761,RC,,,Outpatient,,,2800.00,1820.00,,2800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2128,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,328.32,Case Rate,Pays Based on per visit rate,50,100,,342,Case Rate,Pays based on per visit rate,2800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,328.32,Case Rate,Pays based on per visit rate,50,100,,273.6,Case Rate,Pays based on per visit rate,2520,90,,907.2,Percent of Total Billed Charges,90% of Total Billed Charges,1260,45,,243.72,Percent of Total Billed Charges,45% of Total Billed Charges,2520,90,,162,Percent of Total Billed Charges,90% of Total billed Charges,2800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1820,65,,434.568,Percent of total Billed Charges,65% of Total Billed Charges,1234.8,44.1,,238.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,2660,95,,171,Percent of Total Billed Charges,95% of Total Billed Charges,2800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2464,88,,108.664,Percent of Total Billed Charges,88% of Total Billed Charges,2520,90,,162,Percent of Total Billed charges,90% of Total Billed Charges,50,2800,
PERCU URETER STNT PL DRN O INJ,3610000021,CDM,761,RC,,,Outpatient,,,4503.71,2927.41,,4503.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3422.82,76,,366.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,328.32,Case Rate,Pays Based on per visit rate,50,100,,342,Case Rate,Pays based on per visit rate,4503.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,328.32,Case Rate,Pays based on per visit rate,50,100,,273.6,Case Rate,Pays based on per visit rate,4053.34,90,,710.64,Percent of Total Billed Charges,90% of Total Billed Charges,2026.67,45,,55.568,Percent of Total Billed Charges,45% of Total Billed Charges,4053.34,90,,434.16,Percent of Total Billed Charges,90% of Total billed Charges,4503.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4503.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4503.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2927.41,65,,429.52,Percent of total Billed Charges,65% of Total Billed Charges,1986.14,44.1,,54.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,4278.52,95,,458.28,Percent of Total Billed Charges,95% of Total Billed Charges,4503.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3963.26,88,,476.608,Percent of Total Billed Charges,88% of Total Billed Charges,4053.34,90,,434.16,Percent of Total Billed charges,90% of Total Billed Charges,50,4503.71,
PERCU URETER STNT PL DRN O INJ,3610000029,CDM,361,RC,,,Outpatient,,,4503.71,2927.41,,4503.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3422.82,76,,49.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3242.67,72,,91.584,Percent of Total Billed Charges,72% of Total Billed Charges,3377.78,75,,95.4,Percent of Total Billed charges,75% of Total Billed Charges,4503.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3242.67,72,,91.584,Percent of Total Billed Charges,72% of Total Billed Charges,2702.23,60,,76.32,Percent of Total Billed Charges,60% of Total Billed Charges,4053.34,90,,710.64,Percent of Total Billed Charges,90% of Total Billed Charges,2026.67,45,,243.72,Percent of Total Billed Charges,45% of Total Billed Charges,4053.34,90,,59.04,Percent of Total Billed Charges,90% of Total billed Charges,4503.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4503.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4503.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2927.41,65,,208,Percent of total Billed Charges,65% of Total Billed Charges,1986.14,44.1,,238.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,4278.52,95,,62.32,Percent of Total Billed Charges,95% of Total Billed Charges,4503.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3963.26,88,,161.216,Percent of Total Billed Charges,88% of Total Billed Charges,4053.34,90,,59.04,Percent of Total Billed charges,90% of Total Billed Charges,1986.14,4503.71,
PLCE CATH CAROT/INOM ART INTRA,3610000030,CDM,481,RC,,,Outpatient,,,10919.40,7097.61,,10919.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8298.74,76,,304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7861.97,72,,91.584,Percent of Total Billed Charges,72% of Total Billed Charges,8189.55,75,,95.4,Percent of Total Billed charges,75% of Total Billed Charges,10919.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7861.97,72,,91.584,Percent of Total Billed Charges,72% of Total Billed Charges,6551.64,60,,76.32,Percent of Total Billed Charges,60% of Total Billed Charges,9827.46,90,,226.232,Percent of Total Billed Charges,90% of Total Billed Charges,4913.73,45,,82.44,Percent of Total Billed Charges,45% of Total Billed Charges,9827.46,90,,360,Percent of Total Billed Charges,90% of Total billed Charges,10919.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10919.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10919.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7097.61,65,,370.24,Percent of total Billed Charges,65% of Total Billed Charges,4815.46,44.1,,80.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,10373.43,95,,380,Percent of Total Billed Charges,95% of Total Billed Charges,10919.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9609.07,88,,1265.792,Percent of Total Billed Charges,88% of Total Billed Charges,9827.46,90,,360,Percent of Total Billed charges,90% of Total Billed Charges,4815.46,10919.4,
PLCE CATH INTERN CAROTD UNILAT,3610000031,CDM,481,RC,,,Outpatient,,,12061.38,7839.90,,12061.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9166.65,76,,411.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8684.19,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,9046.04,75,,33.08,Percent of Total Billed charges,75% of Total Billed Charges,12061.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8684.19,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,7236.83,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,10855.24,90,,349.2,Percent of Total Billed Charges,90% of Total Billed Charges,5427.62,45,,647.28,Percent of Total Billed Charges,45% of Total Billed Charges,10855.24,90,,487.44,Percent of Total Billed Charges,90% of Total billed Charges,12061.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12061.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12061.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7839.9,65,,201.24,Percent of total Billed Charges,65% of Total Billed Charges,5319.07,44.1,,634.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,11458.31,95,,514.52,Percent of Total Billed Charges,95% of Total Billed Charges,12061.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10614.01,88,,401.28,Percent of Total Billed Charges,88% of Total Billed Charges,10855.24,90,,487.44,Percent of Total Billed charges,90% of Total Billed Charges,5319.07,12061.38,
PUNC ASPIRATION OF BREAST CYST,3610000032,CDM,761,RC,,,Outpatient,,,921.00,598.65,,921,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,699.96,76,,93.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,31.752,Case Rate,Pays Based on per visit rate,50,100,,33.08,Case Rate,Pays based on per visit rate,921,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,31.752,Case Rate,Pays based on per visit rate,50,100,,26.464,Case Rate,Pays based on per visit rate,828.9,90,,426.96,Percent of Total Billed Charges,90% of Total Billed Charges,414.45,45,,205.2,Percent of Total Billed Charges,45% of Total Billed Charges,828.9,90,,111.136,Percent of Total Billed Charges,90% of Total billed Charges,921,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,921,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,921,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,598.65,65,,448.76,Percent of total Billed Charges,65% of Total Billed Charges,406.16,44.1,,201.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,874.95,95,,117.304,Percent of Total Billed Charges,95% of Total Billed Charges,921,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,810.48,88,,887.04,Percent of Total Billed Charges,88% of Total Billed Charges,828.9,90,,111.136,Percent of Total Billed charges,90% of Total Billed Charges,50,921,
PUNCT ASPIR BREAST CYST EA ADD,3610000033,CDM,761,RC,,,Outpatient,,,407.93,265.15,,407.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,310.03,76,,411.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,70.488,Case Rate,Pays Based on per visit rate,50,100,,73.432,Case Rate,Pays based on per visit rate,407.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,70.488,Case Rate,Pays based on per visit rate,50,100,,58.744,Case Rate,Pays based on per visit rate,367.14,90,,938.88,Percent of Total Billed Charges,90% of Total Billed Charges,183.57,45,,453.6,Percent of Total Billed Charges,45% of Total Billed Charges,367.14,90,,487.44,Percent of Total Billed Charges,90% of Total billed Charges,407.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.15,65,,247.52,Percent of total Billed Charges,65% of Total Billed Charges,179.9,44.1,,444.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,387.53,95,,514.52,Percent of Total Billed Charges,95% of Total Billed Charges,407.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.98,88,,694.848,Percent of Total Billed Charges,88% of Total Billed Charges,367.14,90,,487.44,Percent of Total Billed charges,90% of Total Billed Charges,50,407.93,
RAD  PERCU INTR INTRACATH REN,3610000034,CDM,361,RC,,,Outpatient,,,2946.98,1915.54,,2946.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2239.7,76,,139.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2121.83,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,2210.24,75,,73.432,Percent of Total Billed charges,75% of Total Billed Charges,2946.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2121.83,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,1768.19,60,,58.744,Percent of Total Billed Charges,60% of Total Billed Charges,2652.28,90,,793.8,Percent of Total Billed Charges,90% of Total Billed Charges,1326.14,45,,355.32,Percent of Total Billed Charges,45% of Total Billed Charges,2652.28,90,,164.88,Percent of Total Billed Charges,90% of Total billed Charges,2946.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2946.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2946.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1915.54,65,,313.6,Percent of total Billed Charges,65% of Total Billed Charges,1299.62,44.1,,348.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,2799.63,95,,174.04,Percent of Total Billed Charges,95% of Total Billed Charges,2946.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2593.34,88,,694.848,Percent of Total Billed Charges,88% of Total Billed Charges,2652.28,90,,164.88,Percent of Total Billed charges,90% of Total Billed Charges,1299.62,2946.98,
RAD EVAL OF CENT VEN ACC DEV,3610000035,CDM,761,RC,,,Outpatient,,,490.61,318.90,,490.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.86,76,,1093.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,70.488,Case Rate,Pays Based on per visit rate,50,100,,73.432,Case Rate,Pays based on per visit rate,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,70.488,Case Rate,Pays based on per visit rate,50,100,,58.744,Case Rate,Pays based on per visit rate,441.55,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,220.77,45,,355.32,Percent of Total Billed Charges,45% of Total Billed Charges,441.55,90,,1294.56,Percent of Total Billed Charges,90% of Total billed Charges,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.9,65,,313.6,Percent of total Billed Charges,65% of Total Billed Charges,216.36,44.1,,348.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,466.08,95,,1366.48,Percent of Total Billed Charges,95% of Total Billed Charges,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,431.74,88,,221.2,Percent of Total Billed Charges,88% of Total Billed Charges,441.55,90,,1294.56,Percent of Total Billed charges,90% of Total Billed Charges,50,490.61,
REM FB DEEP THIGH / KNEE AREA,3610000036,CDM,361,RC,,,Outpatient,,,2177.39,1415.30,,2177.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1654.82,76,,346.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1567.72,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,1633.04,75,,73.432,Percent of Total Billed charges,75% of Total Billed Charges,2177.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1567.72,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,1306.43,60,,58.744,Percent of Total Billed Charges,60% of Total Billed Charges,1959.65,90,,47.52,Percent of Total Billed Charges,90% of Total Billed Charges,979.83,45,,113.112,Percent of Total Billed Charges,45% of Total Billed Charges,1959.65,90,,410.4,Percent of Total Billed Charges,90% of Total billed Charges,2177.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2177.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2177.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1415.3,65,,328.64,Percent of total Billed Charges,65% of Total Billed Charges,960.23,44.1,,110.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,2068.52,95,,433.2,Percent of Total Billed Charges,95% of Total Billed Charges,2177.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1916.1,88,,341.44,Percent of Total Billed Charges,88% of Total Billed Charges,1959.65,90,,410.4,Percent of Total Billed charges,90% of Total Billed Charges,960.23,2177.39,
REM FB MUSCLE TENDON SIMPLE,3610000037,CDM,361,RC,,,Outpatient,,,1450.25,942.66,,1450.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1102.19,76,,766.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1044.18,72,,250.56,Percent of Total Billed Charges,72% of Total Billed Charges,1087.69,75,,261,Percent of Total Billed charges,75% of Total Billed Charges,1450.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1044.18,72,,250.56,Percent of Total Billed Charges,72% of Total Billed Charges,870.15,60,,208.8,Percent of Total Billed Charges,60% of Total Billed Charges,1305.23,90,,1334.88,Percent of Total Billed Charges,90% of Total Billed Charges,652.61,45,,174.6,Percent of Total Billed Charges,45% of Total Billed Charges,1305.23,90,,907.2,Percent of Total Billed Charges,90% of Total billed Charges,1450.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1450.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1450.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,942.66,65,,297.96,Percent of total Billed Charges,65% of Total Billed Charges,639.56,44.1,,171.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,1377.74,95,,957.6,Percent of Total Billed Charges,95% of Total Billed Charges,1450.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1276.22,88,,417.472,Percent of Total Billed Charges,88% of Total Billed Charges,1305.23,90,,907.2,Percent of Total Billed charges,90% of Total Billed Charges,639.56,1450.25,
REM FOREIGN BODY FOOT COMPL,3610000038,CDM,361,RC,,,Outpatient,,,2426.05,1576.93,,2426.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1843.8,76,,600.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1746.76,72,,250.56,Percent of Total Billed Charges,72% of Total Billed Charges,1819.54,75,,261,Percent of Total Billed charges,75% of Total Billed Charges,2426.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1746.76,72,,250.56,Percent of Total Billed Charges,72% of Total Billed Charges,1455.63,60,,208.8,Percent of Total Billed Charges,60% of Total Billed Charges,2183.45,90,,407.52,Percent of Total Billed Charges,90% of Total Billed Charges,1091.72,45,,213.48,Percent of Total Billed Charges,45% of Total Billed Charges,2183.45,90,,710.64,Percent of Total Billed Charges,90% of Total billed Charges,2426.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2426.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2426.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1576.93,65,,548.08,Percent of total Billed Charges,65% of Total Billed Charges,1069.89,44.1,,209.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,2304.75,95,,750.12,Percent of Total Billed Charges,95% of Total Billed Charges,2426.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2134.92,88,,918.016,Percent of Total Billed Charges,88% of Total Billed Charges,2183.45,90,,710.64,Percent of Total Billed charges,90% of Total Billed Charges,1069.89,2426.05,
REM FORGN BDY FT SUBCUTANOUS,3610000039,CDM,361,RC,,,Outpatient,,,2263.43,1471.23,,2263.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1720.21,76,,600.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1629.67,72,,355.968,Percent of Total Billed Charges,72% of Total Billed Charges,1697.57,75,,370.8,Percent of Total Billed charges,75% of Total Billed Charges,2263.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1629.67,72,,355.968,Percent of Total Billed Charges,72% of Total Billed Charges,1358.06,60,,296.64,Percent of Total Billed Charges,60% of Total Billed Charges,2037.09,90,,447.12,Percent of Total Billed Charges,90% of Total Billed Charges,1018.54,45,,469.44,Percent of Total Billed Charges,45% of Total Billed Charges,2037.09,90,,710.64,Percent of Total Billed Charges,90% of Total billed Charges,2263.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2263.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2263.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1471.23,65,,645.84,Percent of total Billed Charges,65% of Total Billed Charges,998.17,44.1,,460.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,2150.26,95,,750.12,Percent of Total Billed Charges,95% of Total Billed Charges,2263.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1991.82,88,,776.16,Percent of Total Billed Charges,88% of Total Billed Charges,2037.09,90,,710.64,Percent of Total Billed charges,90% of Total Billed Charges,998.17,2263.43,
REM OF TUNLED CENTR VENOUS CAT,3610000040,CDM,761,RC,,,Outpatient,,,1785.00,1160.25,,1785,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1356.6,76,,191.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,355.968,Case Rate,Pays Based on per visit rate,50,100,,370.8,Case Rate,Pays based on per visit rate,1785,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,355.968,Case Rate,Pays based on per visit rate,50,100,,296.64,Case Rate,Pays based on per visit rate,1606.5,90,,1482.816,Percent of Total Billed Charges,90% of Total Billed Charges,803.25,45,,396.904,Percent of Total Billed Charges,45% of Total Billed Charges,1606.5,90,,226.232,Percent of Total Billed Charges,90% of Total billed Charges,1785,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1785,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1785,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1160.25,65,,631.28,Percent of total Billed Charges,65% of Total Billed Charges,787.19,44.1,,388.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,1695.75,95,,238.8,Percent of Total Billed Charges,95% of Total Billed Charges,1785,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1570.8,88,,45.056,Percent of Total Billed Charges,88% of Total Billed Charges,1606.5,90,,226.232,Percent of Total Billed charges,90% of Total Billed Charges,50,1785,
REMOVAL FB MUSCLE/TENDON DEEP,3610000041,CDM,361,RC,,,Outpatient,,,2177.39,1415.30,,2177.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1654.82,76,,294.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1567.72,72,,228.096,Percent of Total Billed Charges,72% of Total Billed Charges,1633.04,75,,237.6,Percent of Total Billed charges,75% of Total Billed Charges,2177.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1567.72,72,,228.096,Percent of Total Billed Charges,72% of Total Billed Charges,1306.43,60,,190.08,Percent of Total Billed Charges,60% of Total Billed Charges,1959.65,90,,561.6,Percent of Total Billed Charges,90% of Total Billed Charges,979.83,45,,23.04,Percent of Total Billed Charges,45% of Total Billed Charges,1959.65,90,,349.2,Percent of Total Billed Charges,90% of Total billed Charges,2177.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2177.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2177.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1415.3,65,,390.28,Percent of total Billed Charges,65% of Total Billed Charges,960.23,44.1,,22.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,2068.52,95,,368.6,Percent of Total Billed Charges,95% of Total Billed Charges,2177.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1916.1,88,,46.464,Percent of Total Billed Charges,88% of Total Billed Charges,1959.65,90,,349.2,Percent of Total Billed charges,90% of Total Billed Charges,960.23,2177.39,
REMOVAL FOREIGN BODY FOOT DEEP,3610000042,CDM,361,RC,,,Outpatient,,,3384.68,2200.04,,3384.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2572.36,76,,360.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2436.97,72,,228.096,Percent of Total Billed Charges,72% of Total Billed Charges,2538.51,75,,237.6,Percent of Total Billed charges,75% of Total Billed Charges,3384.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2436.97,72,,228.096,Percent of Total Billed Charges,72% of Total Billed Charges,2030.81,60,,190.08,Percent of Total Billed Charges,60% of Total Billed Charges,3046.21,90,,591.12,Percent of Total Billed Charges,90% of Total Billed Charges,1523.11,45,,23.76,Percent of Total Billed Charges,45% of Total Billed Charges,3046.21,90,,426.96,Percent of Total Billed Charges,90% of Total billed Charges,3384.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3384.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3384.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2200.04,65,,589.16,Percent of total Billed Charges,65% of Total Billed Charges,1492.64,44.1,,23.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,3215.45,95,,450.68,Percent of Total Billed Charges,95% of Total Billed Charges,3384.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2978.52,88,,1305.216,Percent of Total Billed Charges,88% of Total Billed Charges,3046.21,90,,426.96,Percent of Total Billed charges,90% of Total Billed Charges,1492.64,3384.68,
REMOVAL OF OBSTRUCT FRM CVC,3610000043,CDM,761,RC,,,Outpatient,,,5148.68,3346.64,,5148.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3913,76,,792.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,250.56,Case Rate,Pays Based on per visit rate,50,100,,261,Case Rate,Pays based on per visit rate,5148.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,250.56,Case Rate,Pays based on per visit rate,50,100,,208.8,Case Rate,Pays based on per visit rate,4633.81,90,,591.12,Percent of Total Billed Charges,90% of Total Billed Charges,2316.91,45,,667.44,Percent of Total Billed Charges,45% of Total Billed Charges,4633.81,90,,938.88,Percent of Total Billed Charges,90% of Total billed Charges,5148.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5148.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5148.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3346.64,65,,347.992,Percent of total Billed Charges,65% of Total Billed Charges,2270.57,44.1,,654.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,4891.25,95,,991.04,Percent of Total Billed Charges,95% of Total Billed Charges,5148.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4530.84,88,,398.464,Percent of Total Billed Charges,88% of Total Billed Charges,4633.81,90,,938.88,Percent of Total Billed charges,90% of Total Billed Charges,50,5148.68,
REMOVAL OF TUNNELED CVC W PORT,3610000044,CDM,761,RC,,,Outpatient,,,2160.00,1404.00,,2160,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1641.6,76,,670.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,250.56,Case Rate,Pays Based on per visit rate,50,100,,261,Case Rate,Pays based on per visit rate,2160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,250.56,Case Rate,Pays based on per visit rate,50,100,,208.8,Case Rate,Pays based on per visit rate,1944,90,,2435.76,Percent of Total Billed Charges,90% of Total Billed Charges,972,45,,203.76,Percent of Total Billed Charges,45% of Total Billed Charges,1944,90,,793.8,Percent of Total Billed Charges,90% of Total billed Charges,2160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1404,65,,365.04,Percent of total Billed Charges,65% of Total Billed Charges,952.56,44.1,,199.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,2052,95,,837.904,Percent of Total Billed Charges,95% of Total Billed Charges,2160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1900.8,88,,437.184,Percent of Total Billed Charges,88% of Total Billed Charges,1944,90,,793.8,Percent of Total Billed charges,90% of Total Billed Charges,50,2160,
REP CVC W/PORT CATHETER ONLY,3610000045,CDM,361,RC,,,Outpatient,,,5147.57,3345.92,,5147.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3912.15,76,,38.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3706.25,72,,355.968,Percent of Total Billed Charges,72% of Total Billed Charges,3860.68,75,,370.8,Percent of Total Billed charges,75% of Total Billed Charges,5147.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3706.25,72,,355.968,Percent of Total Billed Charges,72% of Total Billed Charges,3088.54,60,,296.64,Percent of Total Billed Charges,60% of Total Billed Charges,4632.81,90,,2630.88,Percent of Total Billed Charges,90% of Total Billed Charges,2316.41,45,,223.56,Percent of Total Billed Charges,45% of Total Billed Charges,4632.81,90,,46.08,Percent of Total Billed Charges,90% of Total billed Charges,5147.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5147.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5147.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3345.92,65,,645.84,Percent of total Billed Charges,65% of Total Billed Charges,2270.08,44.1,,219.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,4890.19,95,,48.64,Percent of Total Billed Charges,95% of Total Billed Charges,5147.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4529.86,88,,1449.864,Percent of Total Billed Charges,88% of Total Billed Charges,4632.81,90,,46.08,Percent of Total Billed charges,90% of Total Billed Charges,2270.08,5147.57,
REP NONTUN CVC W/O PRT SAME AC,3610000046,CDM,361,RC,,,Outpatient,,,3375.25,2193.91,,3375.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2565.19,76,,40.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2430.18,72,,355.968,Percent of Total Billed Charges,72% of Total Billed Charges,2531.44,75,,370.8,Percent of Total Billed charges,75% of Total Billed Charges,3375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2430.18,72,,355.968,Percent of Total Billed Charges,72% of Total Billed Charges,2025.15,60,,296.64,Percent of Total Billed Charges,60% of Total Billed Charges,3037.73,90,,869.216,Percent of Total Billed Charges,90% of Total Billed Charges,1518.86,45,,741.408,Percent of Total Billed Charges,45% of Total Billed Charges,3037.73,90,,47.52,Percent of Total Billed Charges,90% of Total billed Charges,3375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2193.91,65,,319.28,Percent of total Billed Charges,65% of Total Billed Charges,1488.49,44.1,,726.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,3206.49,95,,50.16,Percent of Total Billed Charges,95% of Total Billed Charges,3375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2970.22,88,,549.12,Percent of Total Billed Charges,88% of Total Billed Charges,3037.73,90,,47.52,Percent of Total Billed charges,90% of Total Billed Charges,1488.49,3375.25,
REP OF PICC W/PORT SAME ACCESS,3610000047,CDM,361,RC,,,Outpatient,,,5251.21,3413.29,,5251.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3990.92,76,,1127.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3780.87,72,,228.096,Percent of Total Billed Charges,72% of Total Billed Charges,3938.41,75,,237.6,Percent of Total Billed charges,75% of Total Billed Charges,5251.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3780.87,72,,228.096,Percent of Total Billed Charges,72% of Total Billed Charges,3150.73,60,,190.08,Percent of Total Billed Charges,60% of Total Billed Charges,4726.09,90,,3221.248,Percent of Total Billed Charges,90% of Total Billed Charges,2363.04,45,,280.8,Percent of Total Billed Charges,45% of Total Billed Charges,4726.09,90,,1334.88,Percent of Total Billed Charges,90% of Total billed Charges,5251.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5251.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5251.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3413.29,65,,411.84,Percent of total Billed Charges,65% of Total Billed Charges,2315.78,44.1,,275.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,4988.65,95,,1409.04,Percent of Total Billed Charges,95% of Total Billed Charges,5251.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4621.06,88,,577.984,Percent of Total Billed Charges,88% of Total Billed Charges,4726.09,90,,1334.88,Percent of Total Billed charges,90% of Total Billed Charges,2315.78,5251.21,
REP OF TUNN CVC W/SUB Q PRT,3610000048,CDM,761,RC,,,Outpatient,,,2273.36,1477.68,,2273.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1727.75,76,,344.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,228.096,Case Rate,Pays Based on per visit rate,50,100,,237.6,Case Rate,Pays based on per visit rate,2273.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,228.096,Case Rate,Pays based on per visit rate,50,100,,190.08,Case Rate,Pays based on per visit rate,2046.02,90,,1094.4,Percent of Total Billed Charges,90% of Total Billed Charges,1023.01,45,,295.56,Percent of Total Billed Charges,45% of Total Billed Charges,2046.02,90,,407.52,Percent of Total Billed Charges,90% of Total billed Charges,2273.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2273.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2273.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1477.68,65,,275.08,Percent of total Billed Charges,65% of Total Billed Charges,1002.55,44.1,,289.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,2159.69,95,,430.16,Percent of Total Billed Charges,95% of Total Billed Charges,2273.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000.56,88,,577.984,Percent of Total Billed Charges,88% of Total Billed Charges,2046.02,90,,407.52,Percent of Total Billed charges,90% of Total Billed Charges,50,2273.36,
REP PIC W/OUT PORT SAME ACCESS,3610000049,CDM,361,RC,,,Outpatient,,,2139.00,1390.35,,2139,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1625.64,76,,377.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1540.08,72,,59.056,Percent of Total Billed Charges,72% of Total Billed Charges,1604.25,75,,61.52,Percent of Total Billed charges,75% of Total Billed Charges,2139,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1540.08,72,,59.056,Percent of Total Billed Charges,72% of Total Billed Charges,1283.4,60,,49.216,Percent of Total Billed Charges,60% of Total Billed Charges,1925.1,90,,410.4,Percent of Total Billed Charges,90% of Total Billed Charges,962.55,45,,295.56,Percent of Total Billed Charges,45% of Total Billed Charges,1925.1,90,,447.12,Percent of Total Billed Charges,90% of Total billed Charges,2139,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2139,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2139,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1390.35,65,,365.04,Percent of total Billed Charges,65% of Total Billed Charges,943.3,44.1,,289.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,2032.05,95,,471.96,Percent of Total Billed Charges,95% of Total Billed Charges,2139,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1882.32,88,,2381.632,Percent of Total Billed Charges,88% of Total Billed Charges,1925.1,90,,447.12,Percent of Total Billed charges,90% of Total Billed Charges,943.3,2139,
REP PIC W/OUT PRT SAME ACCESS,3610000050,CDM,761,RC,,,Outpatient,,,2139.00,1390.35,,2139,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1625.64,76,,1252.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,59.056,Case Rate,Pays Based on per visit rate,50,100,,61.52,Case Rate,Pays based on per visit rate,2139,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,59.056,Case Rate,Pays based on per visit rate,50,100,,49.216,Case Rate,Pays based on per visit rate,1925.1,90,,1555.2,Percent of Total Billed Charges,90% of Total Billed Charges,962.55,45,,1217.88,Percent of Total Billed Charges,45% of Total Billed Charges,1925.1,90,,1482.816,Percent of Total Billed Charges,90% of Total billed Charges,2139,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2139,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2139,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1390.35,65,,302.704,Percent of total Billed Charges,65% of Total Billed Charges,943.3,44.1,,1193.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,2032.05,95,,1565.2,Percent of Total Billed Charges,95% of Total Billed Charges,2139,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1882.32,88,,2572.416,Percent of Total Billed Charges,88% of Total Billed Charges,1925.1,90,,1482.816,Percent of Total Billed charges,90% of Total Billed Charges,50,2139,
REP TUN CVC W/PRT SAME ACCESS,3610000051,CDM,361,RC,,,Outpatient,,,5251.21,3413.29,,5251.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3990.92,76,,474.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3780.87,72,,151.488,Percent of Total Billed Charges,72% of Total Billed Charges,3938.41,75,,157.8,Percent of Total Billed charges,75% of Total Billed Charges,5251.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3780.87,72,,151.488,Percent of Total Billed Charges,72% of Total Billed Charges,3150.73,60,,126.24,Percent of Total Billed Charges,60% of Total Billed Charges,4726.09,90,,3338.784,Percent of Total Billed Charges,90% of Total Billed Charges,2363.04,45,,1315.44,Percent of Total Billed Charges,45% of Total Billed Charges,4726.09,90,,561.6,Percent of Total Billed Charges,90% of Total billed Charges,5251.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5251.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5251.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3413.29,65,,394.68,Percent of total Billed Charges,65% of Total Billed Charges,2315.78,44.1,,1289.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,4988.65,95,,592.8,Percent of Total Billed Charges,95% of Total Billed Charges,5251.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4621.06,88,,849.896,Percent of Total Billed Charges,88% of Total Billed Charges,4726.09,90,,561.6,Percent of Total Billed charges,90% of Total Billed Charges,2315.78,5251.21,
REPL CVC W/ PORT CATHETER ONLY,3610000052,CDM,761,RC,,,Outpatient,,,5147.57,3345.92,,5147.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3912.15,76,,499.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,167.04,Case Rate,Pays Based on per visit rate,50,100,,174,Case Rate,Pays based on per visit rate,5147.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,167.04,Case Rate,Pays based on per visit rate,50,100,,139.2,Case Rate,Pays based on per visit rate,4632.81,90,,554.4,Percent of Total Billed Charges,90% of Total Billed Charges,2316.41,45,,434.608,Percent of Total Billed Charges,45% of Total Billed Charges,4632.81,90,,591.12,Percent of Total Billed Charges,90% of Total billed Charges,5147.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5147.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5147.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3345.92,65,,233.336,Percent of total Billed Charges,65% of Total Billed Charges,2270.08,44.1,,425.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,4890.19,95,,623.96,Percent of Total Billed Charges,95% of Total Billed Charges,5147.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4529.86,88,,3149.664,Percent of Total Billed Charges,88% of Total Billed Charges,4632.81,90,,591.12,Percent of Total Billed charges,90% of Total Billed Charges,50,5147.57,
REPL OF TUNNELED CVC W/OUT PRT,3610000053,CDM,361,RC,,,Outpatient,,,5394.00,3506.10,,5394,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4099.44,76,,499.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3883.68,72,,182.592,Percent of Total Billed Charges,72% of Total Billed Charges,4045.5,75,,190.2,Percent of Total Billed charges,75% of Total Billed Charges,5394,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3883.68,72,,182.592,Percent of Total Billed Charges,72% of Total Billed Charges,3236.4,60,,152.16,Percent of Total Billed Charges,60% of Total Billed Charges,4854.6,90,,663.84,Percent of Total Billed Charges,90% of Total Billed Charges,2427.3,45,,1610.624,Percent of Total Billed Charges,45% of Total Billed Charges,4854.6,90,,591.12,Percent of Total Billed Charges,90% of Total billed Charges,5394,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5394,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5394,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3506.1,65,,322.92,Percent of total Billed Charges,65% of Total Billed Charges,2378.75,44.1,,1578.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,5124.3,95,,623.96,Percent of Total Billed Charges,95% of Total Billed Charges,5394,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4746.72,88,,1070.08,Percent of Total Billed Charges,88% of Total Billed Charges,4854.6,90,,591.12,Percent of Total Billed charges,90% of Total Billed Charges,2378.75,5394,
REPLACEMENT OF CVC W/PORT COMP,3610000054,CDM,361,RC,,,Outpatient,,,6277.64,4080.47,,6277.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4771.01,76,,2056.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4519.9,72,,61.056,Percent of Total Billed Charges,72% of Total Billed Charges,4708.23,75,,63.6,Percent of Total Billed charges,75% of Total Billed Charges,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4519.9,72,,61.056,Percent of Total Billed Charges,72% of Total Billed Charges,3766.58,60,,50.88,Percent of Total Billed Charges,60% of Total Billed Charges,5649.88,90,,663.84,Percent of Total Billed Charges,90% of Total Billed Charges,2824.94,45,,547.2,Percent of Total Billed Charges,45% of Total Billed Charges,5649.88,90,,2435.76,Percent of Total Billed Charges,90% of Total billed Charges,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4080.47,65,,174.72,Percent of total Billed Charges,65% of Total Billed Charges,2768.44,44.1,,536.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,5963.76,95,,2571.08,Percent of Total Billed Charges,95% of Total Billed Charges,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5524.32,88,,401.28,Percent of Total Billed Charges,88% of Total Billed Charges,5649.88,90,,2435.76,Percent of Total Billed charges,90% of Total Billed Charges,2768.44,6277.64,
REPLACEMENT TUNN CVC W/OUT PRT,3610000055,CDM,361,RC,,,Outpatient,,,5148.68,3346.64,,5148.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3913,76,,2221.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3707.05,72,,134.632,Percent of Total Billed Charges,72% of Total Billed Charges,3861.51,75,,140.24,Percent of Total Billed charges,75% of Total Billed Charges,5148.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3707.05,72,,134.632,Percent of Total Billed Charges,72% of Total Billed Charges,3089.21,60,,112.192,Percent of Total Billed Charges,60% of Total Billed Charges,4633.81,90,,262.8,Percent of Total Billed Charges,90% of Total Billed Charges,2316.91,45,,205.2,Percent of Total Billed Charges,45% of Total Billed Charges,4633.81,90,,2630.88,Percent of Total Billed Charges,90% of Total billed Charges,5148.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5148.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5148.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3346.64,65,,133.12,Percent of total Billed Charges,65% of Total Billed Charges,2270.57,44.1,,201.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,4891.25,95,,2777.04,Percent of Total Billed Charges,95% of Total Billed Charges,5148.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4530.84,88,,1520.64,Percent of Total Billed Charges,88% of Total Billed Charges,4633.81,90,,2630.88,Percent of Total Billed charges,90% of Total Billed Charges,2270.57,5148.68,
REPLACMNT OF CVC W/ PORT COMP,3610000056,CDM,761,RC,,,Outpatient,,,5964.00,3876.60,,5964,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4532.64,76,,734,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,269.888,Case Rate,Pays Based on per visit rate,50,100,,281.136,Case Rate,Pays based on per visit rate,5964,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,269.888,Case Rate,Pays based on per visit rate,50,100,,224.912,Case Rate,Pays based on per visit rate,5367.6,90,,958.32,Percent of Total Billed Charges,90% of Total Billed Charges,2683.8,45,,777.6,Percent of Total Billed Charges,45% of Total Billed Charges,5367.6,90,,869.216,Percent of Total Billed Charges,90% of Total billed Charges,5964,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5964,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5964,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3876.6,65,,275.08,Percent of total Billed Charges,65% of Total Billed Charges,2630.12,44.1,,762.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,5665.8,95,,917.504,Percent of Total Billed Charges,95% of Total Billed Charges,5964,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5248.32,88,,3264.592,Percent of Total Billed Charges,88% of Total Billed Charges,5367.6,90,,869.216,Percent of Total Billed charges,90% of Total Billed Charges,50,5964,
REPOSCVC UNDER FLUORO GUIDE,3610000057,CDM,761,RC,,,Outpatient,,,2160.00,1404.00,,2160,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1641.6,76,,2720.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,134.632,Case Rate,Pays Based on per visit rate,50,100,,140.24,Case Rate,Pays based on per visit rate,2160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,134.632,Case Rate,Pays based on per visit rate,50,100,,112.192,Case Rate,Pays based on per visit rate,1944,90,,711.36,Percent of Total Billed Charges,90% of Total Billed Charges,972,45,,1669.392,Percent of Total Billed Charges,45% of Total Billed Charges,1944,90,,3221.248,Percent of Total Billed Charges,90% of Total billed Charges,2160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1404,65,,275.08,Percent of total Billed Charges,65% of Total Billed Charges,952.56,44.1,,1636.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,2052,95,,3400.2,Percent of Total Billed Charges,95% of Total Billed Charges,2160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1900.8,88,,542.08,Percent of Total Billed Charges,88% of Total Billed Charges,1944,90,,3221.248,Percent of Total Billed charges,90% of Total Billed Charges,50,2160,
SACROPLASTY BILAT W/ IMAG GUDE,3610000058,CDM,361,RC,0201T,HCPCS,Outpatient,,,6516.88,4235.97,,8980.08,125,,,Fee Schedule,125% of CMS OPPS Rate,4952.83,76,,924.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11212.84,200,,269.888,Fee Schedule,200% of ASC Tier Groupings,11212.84,200,,281.136,Fee Schedule,200% of ASC Tier Groupings,7184.07,100,,,Fee Schedule,100% of CMS OPPS Rate,11212.84,200,,269.888,Fee Schedule,200% of ASC Tier Groupings,11212.84,200,,224.912,Fee Schedule,200% of ASC Tier Groupings,5865.19,90,,711.36,Percent of Total Billed Charges,90% of Total Billed Charges,2932.6,45,,277.2,Percent of Total Billed Charges,45% of Total Billed Charges,5865.19,90,,1094.4,Percent of Total Billed Charges,90% of Total billed Charges,7184.07,100,,,Fee Schedule,100% of CMS OPPS Rate,7184.07,100,,,Fee Schedule,100% of CMS OPPS Rate,7184.07,100,,,Fee Schedule,100% of CMS OPPS Rate,13415.63,200,,260,Fee Schedule,200% of CMS OPPS Rate,2873.94,44.1,,271.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,6191.04,95,,1155.2,Percent of Total Billed Charges,95% of Total Billed Charges,5388.04,75,,,Fee Schedule,75% of CMS OPPS Rate,5734.85,88,,649.088,Percent of Total Billed Charges,88% of Total Billed Charges,5865.19,90,,1094.4,Percent of Total Billed charges,90% of Total Billed Charges,2873.94,13415.63,
SACROPLASTY UNILAT W/ IMAG GDE,3610000059,CDM,361,RC,0200T,HCPCS,Outpatient,,,6110.06,3971.54,,8980.08,125,,,Fee Schedule,125% of CMS OPPS Rate,4643.65,76,,346.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11212.84,200,,95.896,Fee Schedule,200% of ASC Tier Groupings,11212.84,200,,99.888,Fee Schedule,200% of ASC Tier Groupings,7184.07,100,,,Fee Schedule,100% of CMS OPPS Rate,11212.84,200,,95.896,Fee Schedule,200% of ASC Tier Groupings,11212.84,200,,79.912,Fee Schedule,200% of ASC Tier Groupings,5499.05,90,,711.36,Percent of Total Billed Charges,90% of Total Billed Charges,2749.53,45,,331.92,Percent of Total Billed Charges,45% of Total Billed Charges,5499.05,90,,410.4,Percent of Total Billed Charges,90% of Total billed Charges,7184.07,100,,,Fee Schedule,100% of CMS OPPS Rate,7184.07,100,,,Fee Schedule,100% of CMS OPPS Rate,7184.07,100,,,Fee Schedule,100% of CMS OPPS Rate,13415.63,200,,361.128,Fee Schedule,200% of CMS OPPS Rate,2694.54,44.1,,325.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,5804.56,95,,433.2,Percent of Total Billed Charges,95% of Total Billed Charges,5388.04,75,,,Fee Schedule,75% of CMS OPPS Rate,5376.85,88,,649.088,Percent of Total Billed Charges,88% of Total Billed Charges,5499.05,90,,410.4,Percent of Total Billed charges,90% of Total Billed Charges,2694.54,13415.63,
SELEC CATH PLACMNT 2ND ORD,3610000060,CDM,481,RC,,,Outpatient,,,1464.00,951.60,,1464,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1112.64,76,,1313.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1054.08,72,,95.896,Percent of Total Billed Charges,72% of Total Billed Charges,1098,75,,99.888,Percent of Total Billed charges,75% of Total Billed Charges,1464,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1054.08,72,,95.896,Percent of Total Billed Charges,72% of Total Billed Charges,878.4,60,,79.912,Percent of Total Billed Charges,60% of Total Billed Charges,1317.6,90,,678.704,Percent of Total Billed Charges,90% of Total Billed Charges,658.8,45,,331.92,Percent of Total Billed Charges,45% of Total Billed Charges,1317.6,90,,1555.2,Percent of Total Billed Charges,90% of Total billed Charges,1464,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1464,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1464,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,951.6,65,,361.128,Percent of total Billed Charges,65% of Total Billed Charges,645.62,44.1,,325.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,1390.8,95,,1641.6,Percent of Total Billed Charges,95% of Total Billed Charges,1464,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1288.32,88,,256.96,Percent of Total Billed Charges,88% of Total Billed Charges,1317.6,90,,1555.2,Percent of Total Billed charges,90% of Total Billed Charges,645.62,1464,
TRANSFORA CERV/THORACIC EA ADD,3610000061,CDM,361,RC,,,Outpatient,,,2640.00,1716.00,,2640,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2006.4,76,,2819.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1900.8,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,1980,75,,59.4,Percent of Total Billed charges,75% of Total Billed Charges,2640,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1900.8,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,1584,60,,47.52,Percent of Total Billed Charges,60% of Total Billed Charges,2376,90,,711.36,Percent of Total Billed Charges,90% of Total Billed Charges,1188,45,,131.4,Percent of Total Billed Charges,45% of Total Billed Charges,2376,90,,3338.784,Percent of Total Billed Charges,90% of Total billed Charges,2640,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2640,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2640,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1716,65,,361.128,Percent of total Billed Charges,65% of Total Billed Charges,1164.24,44.1,,128.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,2508,95,,3524.272,Percent of Total Billed Charges,95% of Total Billed Charges,2640,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2323.2,88,,937.024,Percent of Total Billed Charges,88% of Total Billed Charges,2376,90,,3338.784,Percent of Total Billed charges,90% of Total Billed Charges,1164.24,2640,
XR CATH 1ST ORDER BELOW DIAPH,3610000062,CDM,361,RC,,,Outpatient,,,1273.39,827.70,,1273.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,967.78,76,,468.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,916.84,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,955.04,75,,59.4,Percent of Total Billed charges,75% of Total Billed Charges,1273.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.84,72,,57.024,Percent of Total Billed Charges,72% of Total Billed Charges,764.03,60,,47.52,Percent of Total Billed Charges,60% of Total Billed Charges,1146.05,90,,571.68,Percent of Total Billed Charges,90% of Total Billed Charges,573.03,45,,479.16,Percent of Total Billed Charges,45% of Total Billed Charges,1146.05,90,,554.4,Percent of Total Billed Charges,90% of Total billed Charges,1273.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1273.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1273.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,827.7,65,,227.76,Percent of total Billed Charges,65% of Total Billed Charges,561.56,44.1,,469.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,1209.72,95,,585.2,Percent of Total Billed Charges,95% of Total Billed Charges,1273.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1120.58,88,,695.552,Percent of Total Billed Charges,88% of Total Billed Charges,1146.05,90,,554.4,Percent of Total Billed charges,90% of Total Billed Charges,561.56,1273.39,
XR CATH 2ND ORDER BELOW DIAPH,3610000063,CDM,361,RC,,,Outpatient,,,1321.90,859.24,,1321.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1004.64,76,,560.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,951.77,72,,70.272,Percent of Total Billed Charges,72% of Total Billed Charges,991.43,75,,73.2,Percent of Total Billed charges,75% of Total Billed Charges,1321.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,951.77,72,,70.272,Percent of Total Billed Charges,72% of Total Billed Charges,793.14,60,,58.56,Percent of Total Billed Charges,60% of Total Billed Charges,1189.71,90,,525.6,Percent of Total Billed Charges,90% of Total Billed Charges,594.86,45,,355.68,Percent of Total Billed Charges,45% of Total Billed Charges,1189.71,90,,663.84,Percent of Total Billed Charges,90% of Total billed Charges,1321.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,859.24,65,,78.12,Percent of total Billed Charges,65% of Total Billed Charges,582.96,44.1,,348.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,1255.81,95,,700.72,Percent of Total Billed Charges,95% of Total Billed Charges,1321.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1163.27,88,,695.552,Percent of Total Billed Charges,88% of Total Billed Charges,1189.71,90,,663.84,Percent of Total Billed charges,90% of Total Billed Charges,582.96,1321.9,
XR CATH 3RD ORDER BELOW DIAPH,3610000064,CDM,361,RC,,,Outpatient,,,1475.15,958.85,,1475.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1121.11,76,,560.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1062.11,72,,70.272,Percent of Total Billed Charges,72% of Total Billed Charges,1106.36,75,,73.2,Percent of Total Billed charges,75% of Total Billed Charges,1475.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1062.11,72,,70.272,Percent of Total Billed Charges,72% of Total Billed Charges,885.09,60,,58.56,Percent of Total Billed Charges,60% of Total Billed Charges,1327.64,90,,571.68,Percent of Total Billed Charges,90% of Total Billed Charges,663.82,45,,355.68,Percent of Total Billed Charges,45% of Total Billed Charges,1327.64,90,,663.84,Percent of Total Billed Charges,90% of Total billed Charges,1475.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1475.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1475.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,958.85,65,,529.88,Percent of total Billed Charges,65% of Total Billed Charges,650.54,44.1,,348.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,1401.39,95,,700.72,Percent of Total Billed Charges,95% of Total Billed Charges,1475.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1298.13,88,,695.552,Percent of Total Billed Charges,88% of Total Billed Charges,1327.64,90,,663.84,Percent of Total Billed charges,90% of Total Billed Charges,650.54,1475.15,
XR EXC BILIARY DRAIN CATH PERC,3610000065,CDM,361,RC,,,Outpatient,,,3483.36,2264.18,,3483.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2647.35,76,,221.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2508.02,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,2612.52,75,,129.656,Percent of Total Billed charges,75% of Total Billed Charges,3483.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2508.02,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,2090.02,60,,103.72,Percent of Total Billed Charges,60% of Total Billed Charges,3135.02,90,,601.704,Percent of Total Billed Charges,90% of Total Billed Charges,1567.51,45,,355.68,Percent of Total Billed Charges,45% of Total Billed Charges,3135.02,90,,262.8,Percent of Total Billed Charges,90% of Total billed Charges,3483.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3483.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3483.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2264.18,65,,287.56,Percent of total Billed Charges,65% of Total Billed Charges,1536.16,44.1,,348.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,3309.19,95,,277.4,Percent of Total Billed Charges,95% of Total Billed Charges,3483.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3065.36,88,,663.616,Percent of Total Billed Charges,88% of Total Billed Charges,3135.02,90,,262.8,Percent of Total Billed charges,90% of Total Billed Charges,1536.16,3483.36,
XR PERC NEPHROST/PYELOS TBE EX,3610000066,CDM,361,RC,,,Outpatient,,,1797.00,1168.05,,1797,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1365.72,76,,809.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1293.84,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,1347.75,75,,129.656,Percent of Total Billed charges,75% of Total Billed Charges,1797,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1293.84,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,1078.2,60,,103.72,Percent of Total Billed Charges,60% of Total Billed Charges,1617.3,90,,594.72,Percent of Total Billed Charges,90% of Total Billed Charges,808.65,45,,339.352,Percent of Total Billed Charges,45% of Total Billed Charges,1617.3,90,,958.32,Percent of Total Billed Charges,90% of Total billed Charges,1797,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1797,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1797,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1168.05,65,,173.16,Percent of total Billed Charges,65% of Total Billed Charges,792.48,44.1,,332.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,1707.15,95,,1011.56,Percent of Total Billed Charges,95% of Total Billed Charges,1797,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1581.36,88,,695.552,Percent of Total Billed Charges,88% of Total Billed Charges,1617.3,90,,958.32,Percent of Total Billed charges,90% of Total Billed Charges,792.48,1797,
XR PERC REMOVAL URETERAL STNT,3610000067,CDM,361,RC,,,Outpatient,,,4800.00,3120.00,,4800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3648,76,,600.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3456,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,3600,75,,129.656,Percent of Total Billed charges,75% of Total Billed Charges,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3456,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,2880,60,,103.72,Percent of Total Billed Charges,60% of Total Billed Charges,4320,90,,288,Percent of Total Billed Charges,90% of Total Billed Charges,2160,45,,355.68,Percent of Total Billed Charges,45% of Total Billed Charges,4320,90,,711.36,Percent of Total Billed Charges,90% of Total billed Charges,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3120,65,,69.16,Percent of total Billed Charges,65% of Total Billed Charges,2116.8,44.1,,348.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,4560,95,,750.88,Percent of Total Billed Charges,95% of Total Billed Charges,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4224,88,,558.976,Percent of Total Billed Charges,88% of Total Billed Charges,4320,90,,711.36,Percent of Total Billed charges,90% of Total Billed Charges,2116.8,4800,
XR PERCUTAN URET STENT PLCMNT,3610000068,CDM,361,RC,,,Outpatient,,,3297.95,2143.67,,3297.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2506.44,76,,600.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2374.52,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,2473.46,75,,129.656,Percent of Total Billed charges,75% of Total Billed Charges,3297.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2374.52,72,,124.464,Percent of Total Billed Charges,72% of Total Billed Charges,1978.77,60,,103.72,Percent of Total Billed Charges,60% of Total Billed Charges,2968.16,90,,512.64,Percent of Total Billed Charges,90% of Total Billed Charges,1484.08,45,,285.84,Percent of Total Billed Charges,45% of Total Billed Charges,2968.16,90,,711.36,Percent of Total Billed Charges,90% of Total billed Charges,3297.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3297.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3297.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2143.67,65,,34.32,Percent of total Billed Charges,65% of Total Billed Charges,1454.4,44.1,,280.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,3133.05,95,,750.88,Percent of Total Billed Charges,95% of Total Billed Charges,3297.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2902.2,88,,513.92,Percent of Total Billed Charges,88% of Total Billed Charges,2968.16,90,,711.36,Percent of Total Billed charges,90% of Total Billed Charges,1454.4,3297.95,
BILIARY DRG CATH INS R INT-EXT,3610000069,CDM,361,RC,,,Outpatient,,,7758.34,5042.92,,7758.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5896.34,76,,600.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5586,72,,130.176,Percent of Total Billed Charges,72% of Total Billed Charges,5818.76,75,,135.6,Percent of Total Billed charges,75% of Total Billed Charges,7758.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5586,72,,130.176,Percent of Total Billed Charges,72% of Total Billed Charges,4655,60,,108.48,Percent of Total Billed Charges,60% of Total Billed Charges,6982.51,90,,278.64,Percent of Total Billed Charges,90% of Total Billed Charges,3491.25,45,,262.8,Percent of Total Billed Charges,45% of Total Billed Charges,6982.51,90,,711.36,Percent of Total Billed Charges,90% of Total billed Charges,7758.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7758.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7758.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5042.92,65,,119.6,Percent of total Billed Charges,65% of Total Billed Charges,3421.43,44.1,,257.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,7370.42,95,,750.88,Percent of Total Billed Charges,95% of Total Billed Charges,7758.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6827.34,88,,558.976,Percent of Total Billed Charges,88% of Total Billed Charges,6982.51,90,,711.36,Percent of Total Billed charges,90% of Total Billed Charges,3421.43,7758.34,
PERQ DEVICE BREAST EA IMAG,3610000070,CDM,361,RC,,,Outpatient,,,1500.09,975.06,,1500.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1140.07,76,,573.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1080.06,72,,130.176,Percent of Total Billed Charges,72% of Total Billed Charges,1125.07,75,,135.6,Percent of Total Billed charges,75% of Total Billed Charges,1500.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1080.06,72,,130.176,Percent of Total Billed Charges,72% of Total Billed Charges,900.05,60,,108.48,Percent of Total Billed Charges,60% of Total Billed Charges,1350.08,90,,621.36,Percent of Total Billed Charges,90% of Total Billed Charges,675.04,45,,285.84,Percent of Total Billed Charges,45% of Total Billed Charges,1350.08,90,,678.704,Percent of Total Billed Charges,90% of Total billed Charges,1500.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1500.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1500.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,975.06,65,,99.84,Percent of total Billed Charges,65% of Total Billed Charges,661.54,44.1,,280.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,1425.09,95,,716.408,Percent of Total Billed Charges,95% of Total Billed Charges,1500.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1320.08,88,,588.336,Percent of Total Billed Charges,88% of Total Billed Charges,1350.08,90,,678.704,Percent of Total Billed charges,90% of Total Billed Charges,661.54,1500.09,
PERQ DEV BREAST 1ST US IMAG,3610000071,CDM,361,RC,,,Outpatient,,,1500.09,975.06,,1500.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1140.07,76,,600.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1080.06,72,,68.584,Percent of Total Billed Charges,72% of Total Billed Charges,1125.07,75,,71.44,Percent of Total Billed charges,75% of Total Billed Charges,1500.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1080.06,72,,68.584,Percent of Total Billed Charges,72% of Total Billed Charges,900.05,60,,57.152,Percent of Total Billed Charges,60% of Total Billed Charges,1350.08,90,,342.72,Percent of Total Billed Charges,90% of Total Billed Charges,675.04,45,,300.856,Percent of Total Billed Charges,45% of Total Billed Charges,1350.08,90,,711.36,Percent of Total Billed Charges,90% of Total billed Charges,1500.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1500.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1500.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,975.06,65,,150.8,Percent of total Billed Charges,65% of Total Billed Charges,661.54,44.1,,294.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,1425.09,95,,750.88,Percent of Total Billed Charges,95% of Total Billed Charges,1500.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1320.08,88,,581.504,Percent of Total Billed Charges,88% of Total Billed Charges,1350.08,90,,711.36,Percent of Total Billed charges,90% of Total Billed Charges,661.54,1500.09,
PERQ DEV BREAST ADD US IMAG,3610000072,CDM,361,RC,,,Outpatient,,,1500.09,975.06,,1500.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1140.07,76,,482.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1080.06,72,,62.208,Percent of Total Billed Charges,72% of Total Billed Charges,1125.07,75,,64.8,Percent of Total Billed charges,75% of Total Billed Charges,1500.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1080.06,72,,62.208,Percent of Total Billed Charges,72% of Total Billed Charges,900.05,60,,51.84,Percent of Total Billed Charges,60% of Total Billed Charges,1350.08,90,,434.208,Percent of Total Billed Charges,90% of Total Billed Charges,675.04,45,,297.36,Percent of Total Billed Charges,45% of Total Billed Charges,1350.08,90,,571.68,Percent of Total Billed Charges,90% of Total billed Charges,1500.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1500.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1500.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,975.06,65,,58.76,Percent of total Billed Charges,65% of Total Billed Charges,661.54,44.1,,291.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,1425.09,95,,603.44,Percent of Total Billed Charges,95% of Total Billed Charges,1500.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1320.08,88,,281.6,Percent of Total Billed Charges,88% of Total Billed Charges,1350.08,90,,571.68,Percent of Total Billed charges,90% of Total Billed Charges,661.54,1500.09,
BX SOFT TISSUE NECK OR THORAX,3610000073,CDM,361,RC,,,Outpatient,,,4302.00,2796.30,,4302,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3269.52,76,,443.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3097.44,72,,65.408,Percent of Total Billed Charges,72% of Total Billed Charges,3226.5,75,,68.136,Percent of Total Billed charges,75% of Total Billed Charges,4302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3097.44,72,,65.408,Percent of Total Billed Charges,72% of Total Billed Charges,2581.2,60,,54.512,Percent of Total Billed Charges,60% of Total Billed Charges,3871.8,90,,434.208,Percent of Total Billed Charges,90% of Total Billed Charges,1935.9,45,,144,Percent of Total Billed Charges,45% of Total Billed Charges,3871.8,90,,525.6,Percent of Total Billed Charges,90% of Total billed Charges,4302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2796.3,65,,150.8,Percent of total Billed Charges,65% of Total Billed Charges,1897.18,44.1,,141.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,4086.9,95,,554.8,Percent of Total Billed Charges,95% of Total Billed Charges,4302,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3785.76,88,,501.248,Percent of Total Billed Charges,88% of Total Billed Charges,3871.8,90,,525.6,Percent of Total Billed charges,90% of Total Billed Charges,1897.18,4302,
KYPHOPLASTY THORACIC,3610000074,CDM,361,RC,,,Outpatient,,,20373.00,13242.45,,20373,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15483.48,76,,482.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14668.56,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,15279.75,75,,90.624,Percent of Total Billed charges,75% of Total Billed Charges,20373,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14668.56,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,12223.8,60,,72.496,Percent of Total Billed Charges,60% of Total Billed Charges,18335.7,90,,455.04,Percent of Total Billed Charges,90% of Total Billed Charges,9167.85,45,,256.32,Percent of Total Billed Charges,45% of Total Billed Charges,18335.7,90,,571.68,Percent of Total Billed Charges,90% of Total billed Charges,20373,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20373,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20373,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13242.45,65,,173.16,Percent of total Billed Charges,65% of Total Billed Charges,8984.49,44.1,,251.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,19354.35,95,,603.44,Percent of Total Billed Charges,95% of Total Billed Charges,20373,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17928.24,88,,272.448,Percent of Total Billed Charges,88% of Total Billed Charges,18335.7,90,,571.68,Percent of Total Billed charges,90% of Total Billed Charges,8984.49,20373,
KYPHOPLASTY LUMBAR,3610000075,CDM,361,RC,,,Outpatient,,,20373.00,13242.45,,20373,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15483.48,76,,508.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14668.56,72,,91.584,Percent of Total Billed Charges,72% of Total Billed Charges,15279.75,75,,95.4,Percent of Total Billed charges,75% of Total Billed Charges,20373,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14668.56,72,,91.584,Percent of Total Billed Charges,72% of Total Billed Charges,12223.8,60,,76.32,Percent of Total Billed Charges,60% of Total Billed Charges,18335.7,90,,412.56,Percent of Total Billed Charges,90% of Total Billed Charges,9167.85,45,,139.32,Percent of Total Billed Charges,45% of Total Billed Charges,18335.7,90,,601.704,Percent of Total Billed Charges,90% of Total billed Charges,20373,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20373,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20373,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13242.45,65,,83.2,Percent of total Billed Charges,65% of Total Billed Charges,8984.49,44.1,,136.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,19354.35,95,,635.136,Percent of Total Billed Charges,95% of Total Billed Charges,20373,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17928.24,88,,607.552,Percent of Total Billed Charges,88% of Total Billed Charges,18335.7,90,,601.704,Percent of Total Billed charges,90% of Total Billed Charges,8984.49,20373,
KYPHOPLASTY EACH ADDITIONAL,3610000076,CDM,361,RC,,,Outpatient,,,20373.00,13242.45,,20373,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15483.48,76,,502.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14668.56,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,15279.75,75,,90.624,Percent of Total Billed charges,75% of Total Billed Charges,20373,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14668.56,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,12223.8,60,,72.496,Percent of Total Billed Charges,60% of Total Billed Charges,18335.7,90,,758.88,Percent of Total Billed Charges,90% of Total Billed Charges,9167.85,45,,310.68,Percent of Total Billed Charges,45% of Total Billed Charges,18335.7,90,,594.72,Percent of Total Billed Charges,90% of Total billed Charges,20373,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20373,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20373,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13242.45,65,,165.36,Percent of total Billed Charges,65% of Total Billed Charges,8984.49,44.1,,304.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,19354.35,95,,627.76,Percent of Total Billed Charges,95% of Total Billed Charges,20373,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17928.24,88,,335.104,Percent of Total Billed Charges,88% of Total Billed Charges,18335.7,90,,594.72,Percent of Total Billed charges,90% of Total Billed Charges,8984.49,20373,
INTUBATION,3610000077,CDM,361,RC,,,Outpatient,,,513.77,333.95,,513.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,390.47,76,,243.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,369.91,72,,91.584,Percent of Total Billed Charges,72% of Total Billed Charges,385.33,75,,95.4,Percent of Total Billed charges,75% of Total Billed Charges,513.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.91,72,,91.584,Percent of Total Billed Charges,72% of Total Billed Charges,308.26,60,,76.32,Percent of Total Billed Charges,60% of Total Billed Charges,462.39,90,,894.24,Percent of Total Billed Charges,90% of Total Billed Charges,231.2,45,,171.36,Percent of Total Billed Charges,45% of Total Billed Charges,462.39,90,,288,Percent of Total Billed Charges,90% of Total billed Charges,513.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.95,65,,173.928,Percent of total Billed Charges,65% of Total Billed Charges,226.57,44.1,,167.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,488.08,95,,304,Percent of Total Billed Charges,95% of Total Billed Charges,513.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,452.12,88,,424.56,Percent of Total Billed Charges,88% of Total Billed Charges,462.39,90,,288,Percent of Total Billed charges,90% of Total Billed Charges,226.57,513.77,
CHEST TUBE INSERTION,3610000078,CDM,361,RC,,,Outpatient,,,1540.85,1001.55,,1540.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1171.05,76,,432.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1109.41,72,,93.888,Percent of Total Billed Charges,72% of Total Billed Charges,1155.64,75,,97.8,Percent of Total Billed charges,75% of Total Billed Charges,1540.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1109.41,72,,93.888,Percent of Total Billed Charges,72% of Total Billed Charges,924.51,60,,78.24,Percent of Total Billed Charges,60% of Total Billed Charges,1386.77,90,,874.08,Percent of Total Billed Charges,90% of Total Billed Charges,693.38,45,,217.104,Percent of Total Billed Charges,45% of Total Billed Charges,1386.77,90,,512.64,Percent of Total Billed Charges,90% of Total billed Charges,1540.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1540.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1540.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1001.55,65,,165.36,Percent of total Billed Charges,65% of Total Billed Charges,679.51,44.1,,212.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,1463.81,95,,541.12,Percent of Total Billed Charges,95% of Total Billed Charges,1540.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1355.95,88,,424.56,Percent of Total Billed Charges,88% of Total Billed Charges,1386.77,90,,512.64,Percent of Total Billed charges,90% of Total Billed Charges,679.51,1540.85,
THORACENTESIS,3610000079,CDM,361,RC,,,Outpatient,,,1540.85,1001.55,,1540.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1171.05,76,,235.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1109.41,72,,93.888,Percent of Total Billed Charges,72% of Total Billed Charges,1155.64,75,,97.8,Percent of Total Billed charges,75% of Total Billed Charges,1540.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1109.41,72,,93.888,Percent of Total Billed Charges,72% of Total Billed Charges,924.51,60,,78.24,Percent of Total Billed Charges,60% of Total Billed Charges,1386.77,90,,540.392,Percent of Total Billed Charges,90% of Total Billed Charges,693.38,45,,217.104,Percent of Total Billed Charges,45% of Total Billed Charges,1386.77,90,,278.64,Percent of Total Billed Charges,90% of Total billed Charges,1540.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1540.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1540.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1001.55,65,,173.928,Percent of total Billed Charges,65% of Total Billed Charges,679.51,44.1,,212.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,1463.81,95,,294.12,Percent of Total Billed Charges,95% of Total Billed Charges,1540.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1355.95,88,,444.928,Percent of Total Billed Charges,88% of Total Billed Charges,1386.77,90,,278.64,Percent of Total Billed charges,90% of Total Billed Charges,679.51,1540.85,
THORA/WITHOUT IMAGIN,3610000080,CDM,361,RC,,,Outpatient,,,1583.19,1029.07,,1583.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1203.22,76,,524.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1139.9,72,,101.376,Percent of Total Billed Charges,72% of Total Billed Charges,1187.39,75,,105.6,Percent of Total Billed charges,75% of Total Billed Charges,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1139.9,72,,101.376,Percent of Total Billed Charges,72% of Total Billed Charges,949.91,60,,84.48,Percent of Total Billed Charges,60% of Total Billed Charges,1424.87,90,,815.76,Percent of Total Billed Charges,90% of Total Billed Charges,712.44,45,,227.52,Percent of Total Billed Charges,45% of Total Billed Charges,1424.87,90,,621.36,Percent of Total Billed Charges,90% of Total billed Charges,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1029.07,65,,221.536,Percent of total Billed Charges,65% of Total Billed Charges,698.19,44.1,,222.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,1504.03,95,,655.88,Percent of Total Billed Charges,95% of Total Billed Charges,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1393.21,88,,403.392,Percent of Total Billed Charges,88% of Total Billed Charges,1424.87,90,,621.36,Percent of Total Billed charges,90% of Total Billed Charges,698.19,1583.19,
THORA/WITH IMAGING,3610000081,CDM,361,RC,,,Outpatient,,,1716.63,1115.81,,1716.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1304.64,76,,289.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1235.97,72,,101.376,Percent of Total Billed Charges,72% of Total Billed Charges,1287.47,75,,105.6,Percent of Total Billed charges,75% of Total Billed Charges,1716.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1235.97,72,,101.376,Percent of Total Billed Charges,72% of Total Billed Charges,1029.98,60,,84.48,Percent of Total Billed Charges,60% of Total Billed Charges,1544.97,90,,481.84,Percent of Total Billed Charges,90% of Total Billed Charges,772.48,45,,206.28,Percent of Total Billed Charges,45% of Total Billed Charges,1544.97,90,,342.72,Percent of Total Billed Charges,90% of Total billed Charges,1716.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1716.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1716.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1115.81,65,,120.12,Percent of total Billed Charges,65% of Total Billed Charges,757.03,44.1,,202.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,1630.8,95,,361.76,Percent of Total Billed Charges,95% of Total Billed Charges,1716.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1510.63,88,,742.016,Percent of Total Billed Charges,88% of Total Billed Charges,1544.97,90,,342.72,Percent of Total Billed charges,90% of Total Billed Charges,757.03,1716.63,
INTRO CATH VENA CAVA,3610000083,CDM,481,RC,,,Outpatient,,,1464.00,951.60,,1464,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1112.64,76,,366.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1054.08,72,,131.328,Percent of Total Billed Charges,72% of Total Billed Charges,1098,75,,136.8,Percent of Total Billed charges,75% of Total Billed Charges,1464,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1054.08,72,,131.328,Percent of Total Billed Charges,72% of Total Billed Charges,878.4,60,,109.44,Percent of Total Billed Charges,60% of Total Billed Charges,1317.6,90,,505.44,Percent of Total Billed Charges,90% of Total Billed Charges,658.8,45,,379.44,Percent of Total Billed Charges,45% of Total Billed Charges,1317.6,90,,434.208,Percent of Total Billed Charges,90% of Total billed Charges,1464,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1464,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1464,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,951.6,65,,89.44,Percent of total Billed Charges,65% of Total Billed Charges,645.62,44.1,,371.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,1390.8,95,,458.336,Percent of Total Billed Charges,95% of Total Billed Charges,1464,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1288.32,88,,874.368,Percent of Total Billed Charges,88% of Total Billed Charges,1317.6,90,,434.208,Percent of Total Billed charges,90% of Total Billed Charges,645.62,1464,
ILIAC ENTRY NEEDL OR,3610000084,CDM,361,RC,,,Outpatient,,,1970.17,1280.61,,1970.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1497.33,76,,366.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1418.52,72,,131.328,Percent of Total Billed Charges,72% of Total Billed Charges,1477.63,75,,136.8,Percent of Total Billed charges,75% of Total Billed Charges,1970.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1418.52,72,,131.328,Percent of Total Billed Charges,72% of Total Billed Charges,1182.1,60,,109.44,Percent of Total Billed Charges,60% of Total Billed Charges,1773.15,90,,894.24,Percent of Total Billed Charges,90% of Total Billed Charges,886.58,45,,447.12,Percent of Total Billed Charges,45% of Total Billed Charges,1773.15,90,,434.208,Percent of Total Billed Charges,90% of Total billed Charges,1970.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1970.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1970.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1280.61,65,,121.536,Percent of total Billed Charges,65% of Total Billed Charges,868.84,44.1,,438.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,1871.66,95,,458.336,Percent of Total Billed Charges,95% of Total Billed Charges,1970.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1733.75,88,,854.656,Percent of Total Billed Charges,88% of Total Billed Charges,1773.15,90,,434.208,Percent of Total Billed charges,90% of Total Billed Charges,868.84,1970.17,
AORTA NONSELECTIVE,3610000085,CDM,481,RC,,,Outpatient,,,1176.37,764.64,,1176.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,894.04,76,,384.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,846.99,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,882.28,75,,120,Percent of Total Billed charges,75% of Total Billed Charges,1176.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,846.99,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,705.82,60,,96,Percent of Total Billed Charges,60% of Total Billed Charges,1058.73,90,,442.08,Percent of Total Billed Charges,90% of Total Billed Charges,529.37,45,,437.04,Percent of Total Billed Charges,45% of Total Billed Charges,1058.73,90,,455.04,Percent of Total Billed Charges,90% of Total billed Charges,1176.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1176.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1176.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,764.64,65,,231.92,Percent of total Billed Charges,65% of Total Billed Charges,518.78,44.1,,428.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,1117.55,95,,480.32,Percent of Total Billed Charges,95% of Total Billed Charges,1176.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1035.21,88,,528.384,Percent of Total Billed Charges,88% of Total Billed Charges,1058.73,90,,455.04,Percent of Total Billed charges,90% of Total Billed Charges,518.78,1176.37,
SEL CATH 2ND ORD CAR,3610000086,CDM,481,RC,,,Outpatient,,,1315.28,854.93,,1315.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,999.61,76,,348.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,947,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,986.46,75,,120,Percent of Total Billed charges,75% of Total Billed Charges,1315.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,947,72,,115.2,Percent of Total Billed Charges,72% of Total Billed Charges,789.17,60,,96,Percent of Total Billed Charges,60% of Total Billed Charges,1183.75,90,,570.24,Percent of Total Billed Charges,90% of Total Billed Charges,591.88,45,,270.192,Percent of Total Billed Charges,45% of Total Billed Charges,1183.75,90,,412.56,Percent of Total Billed Charges,90% of Total billed Charges,1315.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1315.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1315.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,854.93,65,,165.36,Percent of total Billed Charges,65% of Total Billed Charges,580.04,44.1,,264.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,1249.52,95,,435.48,Percent of Total Billed Charges,95% of Total Billed Charges,1315.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1157.45,88,,797.632,Percent of Total Billed Charges,88% of Total Billed Charges,1183.75,90,,412.56,Percent of Total Billed charges,90% of Total Billed Charges,580.04,1315.28,
SEL CATH 3RD ORD CAR,3610000087,CDM,481,RC,,,Outpatient,,,1469.63,955.26,,1469.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1116.92,76,,640.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1058.13,72,,63.36,Percent of Total Billed Charges,72% of Total Billed Charges,1102.22,75,,66,Percent of Total Billed charges,75% of Total Billed Charges,1469.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1058.13,72,,63.36,Percent of Total Billed Charges,72% of Total Billed Charges,881.78,60,,52.8,Percent of Total Billed Charges,60% of Total Billed Charges,1322.67,90,,380.88,Percent of Total Billed Charges,90% of Total Billed Charges,661.33,45,,407.88,Percent of Total Billed Charges,45% of Total Billed Charges,1322.67,90,,758.88,Percent of Total Billed Charges,90% of Total billed Charges,1469.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1469.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1469.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,955.26,65,,165.36,Percent of total Billed Charges,65% of Total Billed Charges,648.11,44.1,,399.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,1396.15,95,,801.04,Percent of Total Billed Charges,95% of Total Billed Charges,1469.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1293.27,88,,471.128,Percent of Total Billed Charges,88% of Total Billed Charges,1322.67,90,,758.88,Percent of Total Billed charges,90% of Total Billed Charges,648.11,1469.63,
SELEC CATH ADD 2ND I,3610000088,CDM,761,RC,,,Outpatient,,,1385.84,900.80,,1385.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1053.24,76,,755.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,63.36,Case Rate,Pays Based on per visit rate,50,100,,66,Case Rate,Pays based on per visit rate,1385.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,63.36,Case Rate,Pays based on per visit rate,50,100,,52.8,Case Rate,Pays based on per visit rate,1247.26,90,,505.44,Percent of Total Billed Charges,90% of Total Billed Charges,623.63,45,,240.92,Percent of Total Billed Charges,45% of Total Billed Charges,1247.26,90,,894.24,Percent of Total Billed Charges,90% of Total billed Charges,1385.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1385.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1385.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,900.8,65,,173.928,Percent of total Billed Charges,65% of Total Billed Charges,611.16,44.1,,236.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,1316.55,95,,943.92,Percent of Total Billed Charges,95% of Total Billed Charges,1385.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1219.54,88,,494.208,Percent of Total Billed Charges,88% of Total Billed Charges,1247.26,90,,894.24,Percent of Total Billed charges,90% of Total Billed Charges,50,1385.84,
PLACE CATH THORACIC AORTA,3610000089,CDM,481,RC,,,Outpatient,,,12300.00,7995.00,,12300,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9348,76,,738.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8856,72,,69.216,Percent of Total Billed Charges,72% of Total Billed Charges,9225,75,,72.104,Percent of Total Billed charges,75% of Total Billed Charges,12300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8856,72,,69.216,Percent of Total Billed Charges,72% of Total Billed Charges,7380,60,,57.68,Percent of Total Billed Charges,60% of Total Billed Charges,11070,90,,419.128,Percent of Total Billed Charges,90% of Total Billed Charges,5535,45,,252.72,Percent of Total Billed Charges,45% of Total Billed Charges,11070,90,,874.08,Percent of Total Billed Charges,90% of Total billed Charges,12300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7995,65,,173.928,Percent of total Billed Charges,65% of Total Billed Charges,5424.3,44.1,,247.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,11685,95,,922.64,Percent of Total Billed Charges,95% of Total Billed Charges,12300,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10824,88,,874.368,Percent of Total Billed Charges,88% of Total Billed Charges,11070,90,,874.08,Percent of Total Billed charges,90% of Total Billed Charges,5424.3,12300,
PLACE CATH CAROTID/INOM ART,3610000090,CDM,481,RC,,,Outpatient,,,15990.00,10393.50,,15990,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12152.4,76,,456.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11512.8,72,,69.216,Percent of Total Billed Charges,72% of Total Billed Charges,11992.5,75,,72.104,Percent of Total Billed charges,75% of Total Billed Charges,15990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11512.8,72,,69.216,Percent of Total Billed Charges,72% of Total Billed Charges,9594,60,,57.68,Percent of Total Billed Charges,60% of Total Billed Charges,14391,90,,546.48,Percent of Total Billed Charges,90% of Total Billed Charges,7195.5,45,,447.12,Percent of Total Billed Charges,45% of Total Billed Charges,14391,90,,540.392,Percent of Total Billed Charges,90% of Total billed Charges,15990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10393.5,65,,221.536,Percent of total Billed Charges,65% of Total Billed Charges,7051.59,44.1,,438.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,15190.5,95,,570.408,Percent of Total Billed Charges,95% of Total Billed Charges,15990,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14071.2,88,,432.256,Percent of Total Billed Charges,88% of Total Billed Charges,14391,90,,540.392,Percent of Total Billed charges,90% of Total Billed Charges,7051.59,15990,
PLACE CATH SUBCLAVIAN ART,3610000091,CDM,481,RC,,,Outpatient,,,8626.24,5607.06,,8626.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6555.94,76,,688.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6210.89,72,,69.696,Percent of Total Billed Charges,72% of Total Billed Charges,6469.68,75,,72.6,Percent of Total Billed charges,75% of Total Billed Charges,8626.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6210.89,72,,69.696,Percent of Total Billed Charges,72% of Total Billed Charges,5175.74,60,,58.08,Percent of Total Billed Charges,60% of Total Billed Charges,7763.62,90,,323.08,Percent of Total Billed Charges,90% of Total Billed Charges,3881.81,45,,221.04,Percent of Total Billed Charges,45% of Total Billed Charges,7763.62,90,,815.76,Percent of Total Billed Charges,90% of Total billed Charges,8626.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8626.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8626.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5607.06,65,,120.12,Percent of total Billed Charges,65% of Total Billed Charges,3804.17,44.1,,216.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,8194.93,95,,861.08,Percent of Total Billed Charges,95% of Total Billed Charges,8626.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7591.09,88,,557.568,Percent of Total Billed Charges,88% of Total Billed Charges,7763.62,90,,815.76,Percent of Total Billed charges,90% of Total Billed Charges,3804.17,8626.24,
1ST ORDER EXTREMITY,3610000092,CDM,481,RC,,,Outpatient,,,1210.00,786.50,,1210,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,919.6,76,,406.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,871.2,72,,69.696,Percent of Total Billed Charges,72% of Total Billed Charges,907.5,75,,72.6,Percent of Total Billed charges,75% of Total Billed Charges,1210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,871.2,72,,69.696,Percent of Total Billed Charges,72% of Total Billed Charges,726,60,,58.08,Percent of Total Billed Charges,60% of Total Billed Charges,1089,90,,447.12,Percent of Total Billed Charges,90% of Total Billed Charges,544.5,45,,285.12,Percent of Total Billed Charges,45% of Total Billed Charges,1089,90,,481.84,Percent of Total Billed Charges,90% of Total billed Charges,1210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,786.5,65,,89.44,Percent of total Billed Charges,65% of Total Billed Charges,533.61,44.1,,279.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,1149.5,95,,508.608,Percent of Total Billed Charges,95% of Total Billed Charges,1210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1064.8,88,,372.416,Percent of Total Billed Charges,88% of Total Billed Charges,1089,90,,481.84,Percent of Total Billed charges,90% of Total Billed Charges,533.61,1210,
2ND ORDER EXTREMITY,3610000093,CDM,481,RC,,,Outpatient,,,1321.90,859.24,,1321.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1004.64,76,,426.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,951.77,72,,64.136,Percent of Total Billed Charges,72% of Total Billed Charges,991.43,75,,66.808,Percent of Total Billed charges,75% of Total Billed Charges,1321.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,951.77,72,,64.136,Percent of Total Billed Charges,72% of Total Billed Charges,793.14,60,,53.448,Percent of Total Billed Charges,60% of Total Billed Charges,1189.71,90,,241.92,Percent of Total Billed Charges,90% of Total Billed Charges,594.86,45,,190.44,Percent of Total Billed Charges,45% of Total Billed Charges,1189.71,90,,505.44,Percent of Total Billed Charges,90% of Total billed Charges,1321.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,859.24,65,,121.536,Percent of total Billed Charges,65% of Total Billed Charges,582.96,44.1,,186.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,1255.81,95,,533.52,Percent of Total Billed Charges,95% of Total Billed Charges,1321.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1163.27,88,,494.208,Percent of Total Billed Charges,88% of Total Billed Charges,1189.71,90,,505.44,Percent of Total Billed charges,90% of Total Billed Charges,582.96,1321.9,
3RD ORDER EXTREMITY,3610000094,CDM,481,RC,,,Outpatient,,,1402.00,911.30,,1402,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1065.52,76,,755.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1009.44,72,,64.136,Percent of Total Billed Charges,72% of Total Billed Charges,1051.5,75,,66.808,Percent of Total Billed charges,75% of Total Billed Charges,1402,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1009.44,72,,64.136,Percent of Total Billed Charges,72% of Total Billed Charges,841.2,60,,53.448,Percent of Total Billed Charges,60% of Total Billed Charges,1261.8,90,,184.32,Percent of Total Billed Charges,90% of Total Billed Charges,630.9,45,,252.72,Percent of Total Billed Charges,45% of Total Billed Charges,1261.8,90,,894.24,Percent of Total Billed Charges,90% of Total billed Charges,1402,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1402,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1402,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,911.3,65,,243.648,Percent of total Billed Charges,65% of Total Billed Charges,618.28,44.1,,247.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,1331.9,95,,943.92,Percent of Total Billed Charges,95% of Total Billed Charges,1402,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1233.76,88,,409.816,Percent of Total Billed Charges,88% of Total Billed Charges,1261.8,90,,894.24,Percent of Total Billed charges,90% of Total Billed Charges,618.28,1402,
SEL CTH ADD 2D3D ABD,3610000095,CDM,481,RC,,,Outpatient,,,1703.36,1107.18,,1703.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1294.55,76,,373.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1226.42,72,,374.696,Percent of Total Billed Charges,72% of Total Billed Charges,1277.52,75,,390.312,Percent of Total Billed charges,75% of Total Billed Charges,1703.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1226.42,72,,374.696,Percent of Total Billed Charges,72% of Total Billed Charges,1022.02,60,,312.248,Percent of Total Billed Charges,60% of Total Billed Charges,1533.02,90,,380.88,Percent of Total Billed Charges,90% of Total Billed Charges,766.51,45,,209.56,Percent of Total Billed Charges,45% of Total Billed Charges,1533.02,90,,442.08,Percent of Total Billed Charges,90% of Total billed Charges,1703.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1703.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1703.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1107.18,65,,109.2,Percent of total Billed Charges,65% of Total Billed Charges,751.18,44.1,,205.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,1618.19,95,,466.64,Percent of Total Billed Charges,95% of Total Billed Charges,1703.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1498.96,88,,534.336,Percent of Total Billed Charges,88% of Total Billed Charges,1533.02,90,,442.08,Percent of Total Billed charges,90% of Total Billed Charges,751.18,1703.36,
INS CATH REN ART 2ND+ UNILAT,3610000096,CDM,481,RC,,,Outpatient,,,7175.00,4663.75,,7175,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5453,76,,481.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5166,72,,374.696,Percent of Total Billed Charges,72% of Total Billed Charges,5381.25,75,,390.312,Percent of Total Billed charges,75% of Total Billed Charges,7175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5166,72,,374.696,Percent of Total Billed Charges,72% of Total Billed Charges,4305,60,,312.248,Percent of Total Billed Charges,60% of Total Billed Charges,6457.5,90,,380.88,Percent of Total Billed Charges,90% of Total Billed Charges,3228.75,45,,273.24,Percent of Total Billed Charges,45% of Total Billed Charges,6457.5,90,,570.24,Percent of Total Billed Charges,90% of Total billed Charges,7175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4663.75,65,,51.48,Percent of total Billed Charges,65% of Total Billed Charges,3164.18,44.1,,267.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,6816.25,95,,601.92,Percent of Total Billed Charges,95% of Total Billed Charges,7175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6314,88,,315.896,Percent of Total Billed Charges,88% of Total Billed Charges,6457.5,90,,570.24,Percent of Total Billed charges,90% of Total Billed Charges,3164.18,7175,
INS CATH REN ART 2ND+ BILAT,3610000097,CDM,481,RC,,,Outpatient,,,6568.44,4269.49,,6568.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4992.01,76,,321.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4729.28,72,,133.992,Percent of Total Billed Charges,72% of Total Billed Charges,4926.33,75,,139.576,Percent of Total Billed charges,75% of Total Billed Charges,6568.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4729.28,72,,133.992,Percent of Total Billed Charges,72% of Total Billed Charges,3941.06,60,,111.664,Percent of Total Billed Charges,60% of Total Billed Charges,5911.6,90,,360,Percent of Total Billed Charges,90% of Total Billed Charges,2955.8,45,,161.536,Percent of Total Billed Charges,45% of Total Billed Charges,5911.6,90,,380.88,Percent of Total Billed Charges,90% of Total billed Charges,6568.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6568.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6568.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4269.49,65,,51.48,Percent of total Billed Charges,65% of Total Billed Charges,2896.68,44.1,,158.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,6240.02,95,,402.04,Percent of Total Billed Charges,95% of Total Billed Charges,6568.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5780.23,88,,437.184,Percent of Total Billed Charges,88% of Total Billed Charges,5911.6,90,,380.88,Percent of Total Billed charges,90% of Total Billed Charges,2896.68,6568.44,
REPAIR OF CVC W/OUT SUB Q PORT,3610000098,CDM,761,RC,,,Outpatient,,,1186.00,770.90,,1186,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,901.36,76,,426.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,133.992,Case Rate,Pays Based on per visit rate,50,100,,139.576,Case Rate,Pays based on per visit rate,1186,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,133.992,Case Rate,Pays based on per visit rate,50,100,,111.664,Case Rate,Pays based on per visit rate,1067.4,90,,500.016,Percent of Total Billed Charges,90% of Total Billed Charges,533.7,45,,223.56,Percent of Total Billed Charges,45% of Total Billed Charges,1067.4,90,,505.44,Percent of Total Billed Charges,90% of Total billed Charges,1186,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1186,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1186,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770.9,65,,89.44,Percent of total Billed Charges,65% of Total Billed Charges,523.03,44.1,,219.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,1126.7,95,,533.52,Percent of Total Billed Charges,95% of Total Billed Charges,1186,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1043.68,88,,236.544,Percent of Total Billed Charges,88% of Total Billed Charges,1067.4,90,,505.44,Percent of Total Billed charges,90% of Total Billed Charges,50,1186,
REPLACE NONTUNNELED CV CATH,3610000099,CDM,761,RC,,,Outpatient,,,3375.25,2193.91,,3375.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2565.19,76,,353.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,30.528,Case Rate,Pays Based on per visit rate,50,100,,31.8,Case Rate,Pays based on per visit rate,3375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,30.528,Case Rate,Pays based on per visit rate,50,100,,25.44,Case Rate,Pays based on per visit rate,3037.73,90,,500.016,Percent of Total Billed Charges,90% of Total Billed Charges,1518.86,45,,120.96,Percent of Total Billed Charges,45% of Total Billed Charges,3037.73,90,,419.128,Percent of Total Billed Charges,90% of Total billed Charges,3375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2193.91,65,,94.024,Percent of total Billed Charges,65% of Total Billed Charges,1488.49,44.1,,118.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,3206.49,95,,442.408,Percent of Total Billed Charges,95% of Total Billed Charges,3375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2970.22,88,,180.224,Percent of Total Billed Charges,88% of Total Billed Charges,3037.73,90,,419.128,Percent of Total Billed charges,90% of Total Billed Charges,50,3375.25,
INSERTION VENA CAVA,3610000100,CDM,481,RC,,,Outpatient,,,11618.15,7551.80,,11618.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8829.79,76,,461.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8365.07,72,,30.528,Percent of Total Billed Charges,72% of Total Billed Charges,8713.61,75,,31.8,Percent of Total Billed charges,75% of Total Billed Charges,11618.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8365.07,72,,30.528,Percent of Total Billed Charges,72% of Total Billed Charges,6970.89,60,,25.44,Percent of Total Billed Charges,60% of Total Billed Charges,10456.34,90,,500.016,Percent of Total Billed Charges,90% of Total Billed Charges,5228.17,45,,92.16,Percent of Total Billed Charges,45% of Total Billed Charges,10456.34,90,,546.48,Percent of Total Billed Charges,90% of Total billed Charges,11618.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11618.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11618.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7551.8,65,,63.44,Percent of total Billed Charges,65% of Total Billed Charges,5123.6,44.1,,90.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,11037.24,95,,576.84,Percent of Total Billed Charges,95% of Total Billed Charges,11618.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10223.97,88,,372.416,Percent of Total Billed Charges,88% of Total Billed Charges,10456.34,90,,546.48,Percent of Total Billed charges,90% of Total Billed Charges,5123.6,11618.15,
REPOSITIONING OF IVC FILTER,3610000101,CDM,481,RC,,,Outpatient,,,6277.64,4080.47,,6277.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4771.01,76,,272.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4519.9,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,4708.23,75,,73.432,Percent of Total Billed charges,75% of Total Billed Charges,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4519.9,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,3766.58,60,,58.744,Percent of Total Billed Charges,60% of Total Billed Charges,5649.88,90,,315.36,Percent of Total Billed Charges,90% of Total Billed Charges,2824.94,45,,190.44,Percent of Total Billed Charges,45% of Total Billed Charges,5649.88,90,,323.08,Percent of Total Billed Charges,90% of Total billed Charges,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4080.47,65,,63.44,Percent of total Billed Charges,65% of Total Billed Charges,2768.44,44.1,,186.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,5963.76,95,,341.024,Percent of Total Billed Charges,95% of Total Billed Charges,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5524.32,88,,372.416,Percent of Total Billed Charges,88% of Total Billed Charges,5649.88,90,,323.08,Percent of Total Billed charges,90% of Total Billed Charges,2768.44,6277.64,
REMOVAL OF IVC FILTER,3610000102,CDM,320,RC,,,Outpatient,,,6277.64,4080.47,,6277.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4771.01,76,,377.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4519.9,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,4708.23,75,,73.432,Percent of Total Billed charges,75% of Total Billed Charges,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4519.9,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,3766.58,60,,58.744,Percent of Total Billed Charges,60% of Total Billed Charges,5649.88,90,,108.168,Percent of Total Billed Charges,90% of Total Billed Charges,2824.94,45,,190.44,Percent of Total Billed Charges,45% of Total Billed Charges,5649.88,90,,447.12,Percent of Total Billed Charges,90% of Total billed Charges,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4080.47,65,,107.12,Percent of total Billed Charges,65% of Total Billed Charges,2768.44,44.1,,186.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,5963.76,95,,471.96,Percent of Total Billed Charges,95% of Total Billed Charges,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5524.32,88,,352,Percent of Total Billed Charges,88% of Total Billed Charges,5649.88,90,,447.12,Percent of Total Billed charges,90% of Total Billed Charges,2768.44,6277.64,
LIGATION OF AV FISTULA,3610000103,CDM,361,RC,,,Outpatient,,,5099.06,3314.39,,5099.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3875.29,76,,204.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3671.32,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,3824.3,75,,73.432,Percent of Total Billed charges,75% of Total Billed Charges,5099.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3671.32,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,3059.44,60,,58.744,Percent of Total Billed Charges,60% of Total Billed Charges,4589.15,90,,733.68,Percent of Total Billed Charges,90% of Total Billed Charges,2294.58,45,,180,Percent of Total Billed Charges,45% of Total Billed Charges,4589.15,90,,241.92,Percent of Total Billed Charges,90% of Total billed Charges,5099.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5099.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5099.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3314.39,65,,107.12,Percent of total Billed Charges,65% of Total Billed Charges,2248.69,44.1,,176.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,4844.11,95,,255.36,Percent of Total Billed Charges,95% of Total Billed Charges,5099.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4487.17,88,,488.904,Percent of Total Billed Charges,88% of Total Billed Charges,4589.15,90,,241.92,Percent of Total Billed charges,90% of Total Billed Charges,2248.69,5099.06,
PARACENT/WITHOUT IMA,3610000104,CDM,361,RC,,,Outpatient,,,1583.19,1029.07,,1583.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1203.22,76,,155.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1139.9,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,1187.39,75,,73.432,Percent of Total Billed charges,75% of Total Billed Charges,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1139.9,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,949.91,60,,58.744,Percent of Total Billed Charges,60% of Total Billed Charges,1424.87,90,,398.16,Percent of Total Billed Charges,90% of Total Billed Charges,712.44,45,,250.008,Percent of Total Billed Charges,45% of Total Billed Charges,1424.87,90,,184.32,Percent of Total Billed Charges,90% of Total billed Charges,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1029.07,65,,112.368,Percent of total Billed Charges,65% of Total Billed Charges,698.19,44.1,,245.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,1504.03,95,,194.56,Percent of Total Billed Charges,95% of Total Billed Charges,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1393.21,88,,488.904,Percent of Total Billed Charges,88% of Total Billed Charges,1424.87,90,,184.32,Percent of Total Billed charges,90% of Total Billed Charges,698.19,1583.19,
PARACENTESIS W/OUT IMAGING,3610000105,CDM,361,RC,,,Outpatient,,,1583.19,1029.07,,1583.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1203.22,76,,321.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1139.9,72,,95.896,Percent of Total Billed Charges,72% of Total Billed Charges,1187.39,75,,99.888,Percent of Total Billed charges,75% of Total Billed Charges,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1139.9,72,,95.896,Percent of Total Billed Charges,72% of Total Billed Charges,949.91,60,,79.912,Percent of Total Billed Charges,60% of Total Billed Charges,1424.87,90,,239.76,Percent of Total Billed Charges,90% of Total Billed Charges,712.44,45,,250.008,Percent of Total Billed Charges,45% of Total Billed Charges,1424.87,90,,380.88,Percent of Total Billed Charges,90% of Total billed Charges,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1029.07,65,,112.368,Percent of total Billed Charges,65% of Total Billed Charges,698.19,44.1,,245.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,1504.03,95,,402.04,Percent of Total Billed Charges,95% of Total Billed Charges,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1393.21,88,,488.904,Percent of Total Billed Charges,88% of Total Billed Charges,1424.87,90,,380.88,Percent of Total Billed charges,90% of Total Billed Charges,698.19,1583.19,
PARCENT/WITH IMAGING,3610000106,CDM,361,RC,,,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,321.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,150.76,Percent of Total Billed Charges,72% of Total Billed Charges,1500,75,,157.04,Percent of Total Billed charges,75% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,150.76,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,125.632,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,95.76,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,250.008,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,380.88,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,112.368,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,245.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,402.04,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,308.352,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,380.88,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
PARACENTESIS W/ IMAGING  RAD,3610000107,CDM,361,RC,,,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,150.76,Percent of Total Billed Charges,72% of Total Billed Charges,1500,75,,157.04,Percent of Total Billed charges,75% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,150.76,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,125.632,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,47.52,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,157.68,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,360,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,107.12,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,154.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,380,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,105.76,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,360,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
NEPHROSTOMY TUBE EXCHANGE,3610000108,CDM,761,RC,,,Outpatient,,,1797.00,1168.05,,1797,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1365.72,76,,422.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,76.064,Case Rate,Pays Based on per visit rate,50,100,,79.232,Case Rate,Pays based on per visit rate,1797,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,76.064,Case Rate,Pays based on per visit rate,50,100,,63.384,Case Rate,Pays based on per visit rate,1617.3,90,,165.6,Percent of Total Billed Charges,90% of Total Billed Charges,808.65,45,,54.08,Percent of Total Billed Charges,45% of Total Billed Charges,1617.3,90,,500.016,Percent of Total Billed Charges,90% of Total billed Charges,1797,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1797,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1797,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1168.05,65,,117.52,Percent of total Billed Charges,65% of Total Billed Charges,792.48,44.1,,53,Percent of Total Billed Charges,44.1% of Total Billed Charges,1707.15,95,,527.8,Percent of Total Billed Charges,95% of Total Billed Charges,1797,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1581.36,88,,717.376,Percent of Total Billed Charges,88% of Total Billed Charges,1617.3,90,,500.016,Percent of Total Billed charges,90% of Total Billed Charges,50,1797,
BALLOON DILATION URTRL STRIX,3610000109,CDM,761,RC,,,Outpatient,,,2318.56,1507.06,,2318.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1762.11,76,,422.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,76.064,Case Rate,Pays Based on per visit rate,50,100,,79.232,Case Rate,Pays based on per visit rate,2318.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,76.064,Case Rate,Pays based on per visit rate,50,100,,63.384,Case Rate,Pays based on per visit rate,2086.7,90,,138.24,Percent of Total Billed Charges,90% of Total Billed Charges,1043.35,45,,366.84,Percent of Total Billed Charges,45% of Total Billed Charges,2086.7,90,,500.016,Percent of Total Billed Charges,90% of Total billed Charges,2318.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2318.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2318.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1507.06,65,,117.52,Percent of total Billed Charges,65% of Total Billed Charges,1022.48,44.1,,359.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,2202.63,95,,527.8,Percent of Total Billed Charges,95% of Total Billed Charges,2318.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2040.33,88,,389.312,Percent of Total Billed Charges,88% of Total Billed Charges,2086.7,90,,500.016,Percent of Total Billed charges,90% of Total Billed Charges,50,2318.56,
CATHETERIZAT HYSTEROSALPINOGRA,3610000110,CDM,361,RC,,,Outpatient,,,432.18,280.92,,432.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,328.46,76,,422.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,311.17,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,324.14,75,,90.624,Percent of Total Billed charges,75% of Total Billed Charges,432.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,311.17,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,259.31,60,,72.496,Percent of Total Billed Charges,60% of Total Billed Charges,388.96,90,,208.8,Percent of Total Billed Charges,90% of Total Billed Charges,194.48,45,,199.08,Percent of Total Billed Charges,45% of Total Billed Charges,388.96,90,,500.016,Percent of Total Billed Charges,90% of Total billed Charges,432.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,432.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,432.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280.92,65,,61.92,Percent of total Billed Charges,65% of Total Billed Charges,190.59,44.1,,195.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,410.57,95,,527.8,Percent of Total Billed Charges,95% of Total Billed Charges,432.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.32,88,,234.432,Percent of Total Billed Charges,88% of Total Billed Charges,388.96,90,,500.016,Percent of Total Billed charges,90% of Total Billed Charges,190.59,432.18,
BIOPSY OF THYROID,3610000111,CDM,361,RC,,,Outpatient,,,1262.00,820.30,,1262,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,959.12,76,,266.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,908.64,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,946.5,75,,90.624,Percent of Total Billed charges,75% of Total Billed Charges,1262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,908.64,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,757.2,60,,72.496,Percent of Total Billed Charges,60% of Total Billed Charges,1135.8,90,,81.36,Percent of Total Billed Charges,90% of Total Billed Charges,567.9,45,,119.88,Percent of Total Billed Charges,45% of Total Billed Charges,1135.8,90,,315.36,Percent of Total Billed Charges,90% of Total billed Charges,1262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,820.3,65,,61.92,Percent of total Billed Charges,65% of Total Billed Charges,556.54,44.1,,117.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,1198.9,95,,332.88,Percent of Total Billed Charges,95% of Total Billed Charges,1262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1110.56,88,,93.632,Percent of Total Billed Charges,88% of Total Billed Charges,1135.8,90,,315.36,Percent of Total Billed charges,90% of Total Billed Charges,556.54,1262,
C1C2 PUNCTURE W/OUT INJECTION,3610000112,CDM,361,RC,,,Outpatient,,,3439.80,2235.87,,3439.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2614.25,76,,91.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2476.66,72,,59.056,Percent of Total Billed Charges,72% of Total Billed Charges,2579.85,75,,61.52,Percent of Total Billed charges,75% of Total Billed Charges,3439.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2476.66,72,,59.056,Percent of Total Billed Charges,72% of Total Billed Charges,2063.88,60,,49.216,Percent of Total Billed Charges,60% of Total Billed Charges,3095.82,90,,208.8,Percent of Total Billed Charges,90% of Total Billed Charges,1547.91,45,,47.88,Percent of Total Billed Charges,45% of Total Billed Charges,3095.82,90,,108.168,Percent of Total Billed Charges,90% of Total billed Charges,3439.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3439.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3439.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.87,65,,56.16,Percent of total Billed Charges,65% of Total Billed Charges,1516.95,44.1,,46.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,3267.81,95,,114.176,Percent of Total Billed Charges,95% of Total Billed Charges,3439.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3027.02,88,,46.464,Percent of Total Billed Charges,88% of Total Billed Charges,3095.82,90,,108.168,Percent of Total Billed charges,90% of Total Billed Charges,1516.95,3439.8,
MYELO SPINE INJECT,3610000113,CDM,361,RC,,,Outpatient,,,792.00,514.80,,792,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,601.92,76,,619.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,570.24,72,,59.056,Percent of Total Billed Charges,72% of Total Billed Charges,594,75,,61.52,Percent of Total Billed charges,75% of Total Billed Charges,792,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,570.24,72,,59.056,Percent of Total Billed Charges,72% of Total Billed Charges,475.2,60,,49.216,Percent of Total Billed Charges,60% of Total Billed Charges,712.8,90,,239.76,Percent of Total Billed Charges,90% of Total Billed Charges,356.4,45,,23.76,Percent of Total Billed Charges,45% of Total Billed Charges,712.8,90,,733.68,Percent of Total Billed Charges,90% of Total billed Charges,792,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,792,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,792,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,514.8,65,,56.16,Percent of total Billed Charges,65% of Total Billed Charges,349.27,44.1,,23.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,752.4,95,,774.44,Percent of Total Billed Charges,95% of Total Billed Charges,792,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,696.96,88,,161.92,Percent of Total Billed Charges,88% of Total Billed Charges,712.8,90,,733.68,Percent of Total Billed charges,90% of Total Billed Charges,349.27,792,
XR INJ ANESTH PUDENDAL NERVE,3610000114,CDM,361,RC,,,Outpatient,,,1777.86,1155.61,,1777.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1351.17,76,,336.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1280.06,72,,177.408,Percent of Total Billed Charges,72% of Total Billed Charges,1333.4,75,,184.8,Percent of Total Billed charges,75% of Total Billed Charges,1777.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1280.06,72,,177.408,Percent of Total Billed Charges,72% of Total Billed Charges,1066.72,60,,147.84,Percent of Total Billed Charges,60% of Total Billed Charges,1600.07,90,,56.872,Percent of Total Billed Charges,90% of Total Billed Charges,800.04,45,,82.8,Percent of Total Billed Charges,45% of Total Billed Charges,1600.07,90,,398.16,Percent of Total Billed Charges,90% of Total billed Charges,1777.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1777.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1155.61,65,,82.68,Percent of total Billed Charges,65% of Total Billed Charges,784.04,44.1,,81.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,1688.97,95,,420.28,Percent of Total Billed Charges,95% of Total Billed Charges,1777.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1564.52,88,,135.168,Percent of Total Billed Charges,88% of Total Billed Charges,1600.07,90,,398.16,Percent of Total Billed charges,90% of Total Billed Charges,784.04,1777.86,
IJ CV/TH EA AD LV BL,3610000115,CDM,361,RC,,,Outpatient,,,2778.79,1806.21,,2778.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2111.88,76,,202.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2000.73,72,,161.28,Percent of Total Billed Charges,72% of Total Billed Charges,2084.09,75,,168,Percent of Total Billed charges,75% of Total Billed Charges,2778.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000.73,72,,161.28,Percent of Total Billed Charges,72% of Total Billed Charges,1667.27,60,,134.4,Percent of Total Billed Charges,60% of Total Billed Charges,2500.91,90,,56.872,Percent of Total Billed Charges,90% of Total Billed Charges,1250.46,45,,69.12,Percent of Total Billed Charges,45% of Total Billed Charges,2500.91,90,,239.76,Percent of Total Billed Charges,90% of Total billed Charges,2778.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2778.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2778.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1806.21,65,,78.544,Percent of total Billed Charges,65% of Total Billed Charges,1225.45,44.1,,67.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,2639.85,95,,253.08,Percent of Total Billed Charges,95% of Total Billed Charges,2778.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2445.34,88,,204.16,Percent of Total Billed Charges,88% of Total Billed Charges,2500.91,90,,239.76,Percent of Total Billed charges,90% of Total Billed Charges,1225.45,2778.79,
SIMPLE PROCEDURE,3610000116,CDM,361,RC,,,Outpatient,,,289.96,188.47,,289.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,220.37,76,,80.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,208.77,72,,161.856,Percent of Total Billed Charges,72% of Total Billed Charges,217.47,75,,168.6,Percent of Total Billed charges,75% of Total Billed Charges,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.77,72,,161.856,Percent of Total Billed Charges,72% of Total Billed Charges,173.98,60,,134.88,Percent of Total Billed Charges,60% of Total Billed Charges,260.96,90,,56.872,Percent of Total Billed Charges,90% of Total Billed Charges,130.48,45,,104.4,Percent of Total Billed Charges,45% of Total Billed Charges,260.96,90,,95.76,Percent of Total Billed Charges,90% of Total billed Charges,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.47,65,,78.544,Percent of total Billed Charges,65% of Total Billed Charges,127.87,44.1,,102.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,275.46,95,,101.08,Percent of Total Billed Charges,95% of Total Billed Charges,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.16,88,,79.552,Percent of Total Billed Charges,88% of Total Billed Charges,260.96,90,,95.76,Percent of Total Billed charges,90% of Total Billed Charges,127.87,289.96,
COMPLEX PROCEDURE,3610000117,CDM,361,RC,,,Outpatient,,,907.36,589.78,,907.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,689.59,76,,40.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,653.3,72,,67.392,Percent of Total Billed Charges,72% of Total Billed Charges,680.52,75,,70.2,Percent of Total Billed charges,75% of Total Billed Charges,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,653.3,72,,67.392,Percent of Total Billed Charges,72% of Total Billed Charges,544.42,60,,56.16,Percent of Total Billed Charges,60% of Total Billed Charges,816.62,90,,115.2,Percent of Total Billed Charges,90% of Total Billed Charges,408.31,45,,40.68,Percent of Total Billed Charges,45% of Total Billed Charges,816.62,90,,47.52,Percent of Total Billed Charges,90% of Total billed Charges,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,589.78,65,,82.68,Percent of total Billed Charges,65% of Total Billed Charges,400.15,44.1,,39.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,861.99,95,,50.16,Percent of Total Billed Charges,95% of Total Billed Charges,907.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,798.48,88,,204.16,Percent of Total Billed Charges,88% of Total Billed Charges,816.62,90,,47.52,Percent of Total Billed charges,90% of Total Billed Charges,400.15,907.36,
INTERMEDIATE PROCEDURE,3610000118,CDM,361,RC,,,Outpatient,,,544.64,354.02,,544.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,413.93,76,,139.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,392.14,72,,38.104,Percent of Total Billed Charges,72% of Total Billed Charges,408.48,75,,39.688,Percent of Total Billed charges,75% of Total Billed Charges,544.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.14,72,,38.104,Percent of Total Billed Charges,72% of Total Billed Charges,326.78,60,,31.752,Percent of Total Billed Charges,60% of Total Billed Charges,490.18,90,,228.96,Percent of Total Billed Charges,90% of Total Billed Charges,245.09,45,,104.4,Percent of Total Billed Charges,45% of Total Billed Charges,490.18,90,,165.6,Percent of Total Billed Charges,90% of Total billed Charges,544.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,544.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,544.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.02,65,,84.76,Percent of total Billed Charges,65% of Total Billed Charges,240.19,44.1,,102.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,517.41,95,,174.8,Percent of Total Billed Charges,95% of Total Billed Charges,544.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.28,88,,234.432,Percent of Total Billed Charges,88% of Total Billed Charges,490.18,90,,165.6,Percent of Total Billed charges,90% of Total Billed Charges,240.19,544.64,
PRE OP BREAST NEEDLE,3610000120,CDM,361,RC,,,Outpatient,,,3015.34,1959.97,,3015.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2291.66,76,,116.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2171.04,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,2261.51,75,,46.968,Percent of Total Billed charges,75% of Total Billed Charges,3015.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2171.04,72,,45.088,Percent of Total Billed Charges,72% of Total Billed Charges,1809.2,60,,37.576,Percent of Total Billed Charges,60% of Total Billed Charges,2713.81,90,,240.816,Percent of Total Billed Charges,90% of Total Billed Charges,1356.9,45,,119.88,Percent of Total Billed Charges,45% of Total Billed Charges,2713.81,90,,138.24,Percent of Total Billed Charges,90% of Total billed Charges,3015.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3015.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3015.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1959.97,65,,84.76,Percent of total Billed Charges,65% of Total Billed Charges,1329.76,44.1,,117.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,2864.57,95,,145.92,Percent of Total Billed Charges,95% of Total Billed Charges,3015.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2653.5,88,,55.608,Percent of Total Billed Charges,88% of Total Billed Charges,2713.81,90,,138.24,Percent of Total Billed charges,90% of Total Billed Charges,1329.76,3015.34,
PREOP BREAST LOC >1L,3610000121,CDM,361,RC,,,Outpatient,,,2674.67,1738.54,,2674.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2032.75,76,,176.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1925.76,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,2006,75,,27.12,Percent of Total Billed charges,75% of Total Billed Charges,2674.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1925.76,72,,26.032,Percent of Total Billed Charges,72% of Total Billed Charges,1604.8,60,,21.696,Percent of Total Billed Charges,60% of Total Billed Charges,2407.2,90,,228.96,Percent of Total Billed Charges,90% of Total Billed Charges,1203.6,45,,28.44,Percent of Total Billed Charges,45% of Total Billed Charges,2407.2,90,,208.8,Percent of Total Billed Charges,90% of Total billed Charges,2674.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2674.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2674.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1738.54,65,,91.52,Percent of total Billed Charges,65% of Total Billed Charges,1179.53,44.1,,27.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,2540.94,95,,220.4,Percent of Total Billed Charges,95% of Total Billed Charges,2674.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2353.71,88,,55.608,Percent of Total Billed Charges,88% of Total Billed Charges,2407.2,90,,208.8,Percent of Total Billed charges,90% of Total Billed Charges,1179.53,2674.67,
ANGIO FOREIGN BODY RETRIEV,3610000122,CDM,361,RC,,,Outpatient,,,6651.38,4323.40,,6651.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5055.05,76,,68.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4788.99,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,4988.54,75,,33.08,Percent of Total Billed charges,75% of Total Billed Charges,6651.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4788.99,72,,31.752,Percent of Total Billed Charges,72% of Total Billed Charges,3990.83,60,,26.464,Percent of Total Billed Charges,60% of Total Billed Charges,5986.24,90,,240.816,Percent of Total Billed Charges,90% of Total Billed Charges,2993.12,45,,28.44,Percent of Total Billed Charges,45% of Total Billed Charges,5986.24,90,,81.36,Percent of Total Billed Charges,90% of Total billed Charges,6651.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6651.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6651.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4323.4,65,,91.52,Percent of total Billed Charges,65% of Total Billed Charges,2933.26,44.1,,27.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,6318.81,95,,85.88,Percent of Total Billed Charges,95% of Total Billed Charges,6651.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5853.21,88,,55.608,Percent of Total Billed Charges,88% of Total Billed Charges,5986.24,90,,81.36,Percent of Total Billed charges,90% of Total Billed Charges,2933.26,6651.38,
BILIARY DRAIN PERC STENT,3610000123,CDM,361,RC,,,Outpatient,,,11601.45,7540.94,,11601.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8817.1,76,,176.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8353.04,72,,235.008,Percent of Total Billed Charges,72% of Total Billed Charges,8701.09,75,,244.8,Percent of Total Billed charges,75% of Total Billed Charges,11601.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8353.04,72,,235.008,Percent of Total Billed Charges,72% of Total Billed Charges,6960.87,60,,195.84,Percent of Total Billed Charges,60% of Total Billed Charges,10441.31,90,,306.744,Percent of Total Billed Charges,90% of Total Billed Charges,5220.65,45,,28.44,Percent of Total Billed Charges,45% of Total Billed Charges,10441.31,90,,208.8,Percent of Total Billed Charges,90% of Total billed Charges,11601.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11601.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11601.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7540.94,65,,54.464,Percent of total Billed Charges,65% of Total Billed Charges,5116.24,44.1,,27.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,11021.38,95,,220.4,Percent of Total Billed Charges,95% of Total Billed Charges,11601.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10209.28,88,,112.64,Percent of Total Billed Charges,88% of Total Billed Charges,10441.31,90,,208.8,Percent of Total Billed charges,90% of Total Billed Charges,5116.24,11601.45,
BILIARY TUBE REVISE/REINSRT,3610000124,CDM,361,RC,,,Outpatient,,,11601.45,7540.94,,11601.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8817.1,76,,202.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8353.04,72,,186.624,Percent of Total Billed Charges,72% of Total Billed Charges,8701.09,75,,194.4,Percent of Total Billed charges,75% of Total Billed Charges,11601.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8353.04,72,,186.624,Percent of Total Billed Charges,72% of Total Billed Charges,6960.87,60,,155.52,Percent of Total Billed Charges,60% of Total Billed Charges,10441.31,90,,166.32,Percent of Total Billed Charges,90% of Total Billed Charges,5220.65,45,,57.6,Percent of Total Billed Charges,45% of Total Billed Charges,10441.31,90,,239.76,Percent of Total Billed Charges,90% of Total billed Charges,11601.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11601.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11601.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7540.94,65,,54.464,Percent of total Billed Charges,65% of Total Billed Charges,5116.24,44.1,,56.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,11021.38,95,,253.08,Percent of Total Billed Charges,95% of Total Billed Charges,11601.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10209.28,88,,223.872,Percent of Total Billed Charges,88% of Total Billed Charges,10441.31,90,,239.76,Percent of Total Billed charges,90% of Total Billed Charges,5116.24,11601.45,
SP MUSCLE BIOPSY,3610000125,CDM,361,RC,,,Outpatient,,,2409.00,1565.85,,2409,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1830.84,76,,48.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1734.48,72,,50.688,Percent of Total Billed Charges,72% of Total Billed Charges,1806.75,75,,52.8,Percent of Total Billed charges,75% of Total Billed Charges,2409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1734.48,72,,50.688,Percent of Total Billed Charges,72% of Total Billed Charges,1445.4,60,,42.24,Percent of Total Billed Charges,60% of Total Billed Charges,2168.1,90,,123.84,Percent of Total Billed Charges,90% of Total Billed Charges,1084.05,45,,114.48,Percent of Total Billed Charges,45% of Total Billed Charges,2168.1,90,,56.872,Percent of Total Billed Charges,90% of Total billed Charges,2409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1565.85,65,,55.12,Percent of total Billed Charges,65% of Total Billed Charges,1062.37,44.1,,112.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,2288.55,95,,60.032,Percent of Total Billed Charges,95% of Total Billed Charges,2409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2119.92,88,,235.464,Percent of Total Billed Charges,88% of Total Billed Charges,2168.1,90,,56.872,Percent of Total Billed charges,90% of Total Billed Charges,1062.37,2409,
FNA BX W US GDN 1ST LESION,3610000126,CDM,361,RC,,,Outpatient,,,1520.00,988.00,,1520,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1155.2,76,,48.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1094.4,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,1140,75,,57.6,Percent of Total Billed charges,75% of Total Billed Charges,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1094.4,72,,55.296,Percent of Total Billed Charges,72% of Total Billed Charges,912,60,,46.08,Percent of Total Billed Charges,60% of Total Billed Charges,1368,90,,168.288,Percent of Total Billed Charges,90% of Total Billed Charges,684,45,,120.408,Percent of Total Billed Charges,45% of Total Billed Charges,1368,90,,56.872,Percent of Total Billed Charges,90% of Total billed Charges,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,988,65,,55.12,Percent of total Billed Charges,65% of Total Billed Charges,670.32,44.1,,118,Percent of Total Billed Charges,44.1% of Total Billed Charges,1444,95,,60.032,Percent of Total Billed Charges,95% of Total Billed Charges,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1337.6,88,,223.872,Percent of Total Billed Charges,88% of Total Billed Charges,1368,90,,56.872,Percent of Total Billed charges,90% of Total Billed Charges,670.32,1520,
FMA BX W US GDN EA ADD LESION,3610000127,CDM,361,RC,,,Outpatient,,,570.00,370.50,,570,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,433.2,76,,48.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,410.4,72,,242.496,Percent of Total Billed Charges,72% of Total Billed Charges,427.5,75,,252.6,Percent of Total Billed charges,75% of Total Billed Charges,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,410.4,72,,242.496,Percent of Total Billed Charges,72% of Total Billed Charges,342,60,,202.08,Percent of Total Billed Charges,60% of Total Billed Charges,513,90,,321.12,Percent of Total Billed Charges,90% of Total Billed Charges,256.5,45,,114.48,Percent of Total Billed Charges,45% of Total Billed Charges,513,90,,56.872,Percent of Total Billed Charges,90% of Total billed Charges,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.5,65,,118.56,Percent of total Billed Charges,65% of Total Billed Charges,251.37,44.1,,112.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,541.5,95,,60.032,Percent of Total Billed Charges,95% of Total Billed Charges,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.6,88,,235.464,Percent of Total Billed Charges,88% of Total Billed Charges,513,90,,56.872,Percent of Total Billed charges,90% of Total Billed Charges,251.37,570,
FNA BX W FL GDN 1ST LESION,3610000128,CDM,361,RC,,,Outpatient,,,1600.00,1040.00,,1600,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1216,76,,97.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1152,72,,242.496,Percent of Total Billed Charges,72% of Total Billed Charges,1200,75,,252.6,Percent of Total Billed charges,75% of Total Billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1152,72,,242.496,Percent of Total Billed Charges,72% of Total Billed Charges,960,60,,202.08,Percent of Total Billed Charges,60% of Total Billed Charges,1440,90,,228.96,Percent of Total Billed Charges,90% of Total Billed Charges,720,45,,120.408,Percent of Total Billed Charges,45% of Total Billed Charges,1440,90,,115.2,Percent of Total Billed Charges,90% of Total billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1040,65,,112.936,Percent of total Billed Charges,65% of Total Billed Charges,705.6,44.1,,118,Percent of Total Billed Charges,44.1% of Total Billed Charges,1520,95,,121.6,Percent of Total Billed Charges,95% of Total Billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1408,88,,299.928,Percent of Total Billed Charges,88% of Total Billed Charges,1440,90,,115.2,Percent of Total Billed charges,90% of Total Billed Charges,705.6,1600,
FNA BX W FL GDN EA ADD LESION,3610000129,CDM,361,RC,,,Outpatient,,,600.00,390.00,,600,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,456,76,,193.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,432,72,,82.368,Percent of Total Billed Charges,72% of Total Billed Charges,450,75,,85.8,Percent of Total Billed charges,75% of Total Billed Charges,600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,432,72,,82.368,Percent of Total Billed Charges,72% of Total Billed Charges,360,60,,68.64,Percent of Total Billed Charges,60% of Total Billed Charges,540,90,,228.96,Percent of Total Billed Charges,90% of Total Billed Charges,270,45,,153.368,Percent of Total Billed Charges,45% of Total Billed Charges,540,90,,228.96,Percent of Total Billed Charges,90% of Total billed Charges,600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390,65,,104,Percent of total Billed Charges,65% of Total Billed Charges,264.6,44.1,,150.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,570,95,,241.68,Percent of Total Billed Charges,95% of Total Billed Charges,600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,528,88,,162.624,Percent of Total Billed Charges,88% of Total Billed Charges,540,90,,228.96,Percent of Total Billed charges,90% of Total Billed Charges,264.6,600,
IMAGE GUIDED DRAINAGE BY CATHE,3610000130,CDM,361,RC,,,Outpatient,,,1600.00,1040.00,,1600,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1216,76,,203.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1152,72,,86.368,Percent of Total Billed Charges,72% of Total Billed Charges,1200,75,,89.968,Percent of Total Billed charges,75% of Total Billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1152,72,,86.368,Percent of Total Billed Charges,72% of Total Billed Charges,960,60,,71.968,Percent of Total Billed Charges,60% of Total Billed Charges,1440,90,,240.816,Percent of Total Billed Charges,90% of Total Billed Charges,720,45,,83.16,Percent of Total Billed Charges,45% of Total Billed Charges,1440,90,,240.816,Percent of Total Billed Charges,90% of Total billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1040,65,,104,Percent of total Billed Charges,65% of Total Billed Charges,705.6,44.1,,81.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,1520,95,,254.2,Percent of Total Billed Charges,95% of Total Billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1408,88,,121.088,Percent of Total Billed Charges,88% of Total Billed Charges,1440,90,,240.816,Percent of Total Billed charges,90% of Total Billed Charges,705.6,1600,
INCIS & DRAIN OF ABSCES SNGLE,3610000131,CDM,361,RC,,,Outpatient,,,400.21,260.14,,400.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,304.16,76,,193.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,288.15,72,,253.384,Percent of Total Billed Charges,72% of Total Billed Charges,300.16,75,,263.944,Percent of Total Billed charges,75% of Total Billed Charges,400.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.15,72,,253.384,Percent of Total Billed Charges,72% of Total Billed Charges,240.13,60,,211.152,Percent of Total Billed Charges,60% of Total Billed Charges,360.19,90,,240.816,Percent of Total Billed Charges,90% of Total Billed Charges,180.09,45,,61.92,Percent of Total Billed Charges,45% of Total Billed Charges,360.19,90,,228.96,Percent of Total Billed Charges,90% of Total billed Charges,400.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.14,65,,104,Percent of total Billed Charges,65% of Total Billed Charges,176.49,44.1,,60.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,380.2,95,,241.68,Percent of Total Billed Charges,95% of Total Billed Charges,400.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.18,88,,164.544,Percent of Total Billed Charges,88% of Total Billed Charges,360.19,90,,228.96,Percent of Total Billed charges,90% of Total Billed Charges,176.49,400.21,
INCISION/REMOVAL FB SQ SIMPLE,3610000132,CDM,361,RC,,,Outpatient,,,870.00,565.50,,870,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,661.2,76,,203.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,626.4,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,652.5,75,,53.584,Percent of Total Billed charges,75% of Total Billed Charges,870,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,626.4,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,522,60,,42.864,Percent of Total Billed Charges,60% of Total Billed Charges,783,90,,306.744,Percent of Total Billed Charges,90% of Total Billed Charges,391.5,45,,84.144,Percent of Total Billed Charges,45% of Total Billed Charges,783,90,,240.816,Percent of Total Billed Charges,90% of Total billed Charges,870,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,870,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,870,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,565.5,65,,99.176,Percent of total Billed Charges,65% of Total Billed Charges,383.67,44.1,,82.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,826.5,95,,254.2,Percent of Total Billed Charges,95% of Total Billed Charges,870,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,765.6,88,,313.984,Percent of Total Billed Charges,88% of Total Billed Charges,783,90,,240.816,Percent of Total Billed charges,90% of Total Billed Charges,383.67,870,
CYST ABSCESS ASPIRATION,3610000133,CDM,361,RC,,,Outpatient,,,486.00,315.90,,486,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,369.36,76,,259.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,349.92,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,364.5,75,,53.584,Percent of Total Billed charges,75% of Total Billed Charges,486,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.92,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,291.6,60,,42.864,Percent of Total Billed Charges,60% of Total Billed Charges,437.4,90,,166.32,Percent of Total Billed Charges,90% of Total Billed Charges,218.7,45,,160.56,Percent of Total Billed Charges,45% of Total Billed Charges,437.4,90,,306.744,Percent of Total Billed Charges,90% of Total billed Charges,486,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,486,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,486,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.9,65,,57.2,Percent of total Billed Charges,65% of Total Billed Charges,214.33,44.1,,157.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,461.7,95,,323.784,Percent of Total Billed Charges,95% of Total Billed Charges,486,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.68,88,,223.872,Percent of Total Billed Charges,88% of Total Billed Charges,437.4,90,,306.744,Percent of Total Billed charges,90% of Total Billed Charges,214.33,486,
SP EXC F/E/E/N/L MAL+MRG 0.61,3610000134,CDM,361,RC,,,Outpatient,,,1760.00,1144.00,,1760,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1337.6,76,,140.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1267.2,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,1320,75,,53.584,Percent of Total Billed charges,75% of Total Billed Charges,1760,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1267.2,72,,51.44,Percent of Total Billed Charges,72% of Total Billed Charges,1056,60,,42.864,Percent of Total Billed Charges,60% of Total Billed Charges,1584,90,,123.84,Percent of Total Billed Charges,90% of Total Billed Charges,792,45,,114.48,Percent of Total Billed Charges,45% of Total Billed Charges,1584,90,,166.32,Percent of Total Billed Charges,90% of Total billed Charges,1760,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1144,65,,57.2,Percent of total Billed Charges,65% of Total Billed Charges,776.16,44.1,,112.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,1672,95,,175.56,Percent of Total Billed Charges,95% of Total Billed Charges,1760,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1548.8,88,,223.872,Percent of Total Billed Charges,88% of Total Billed Charges,1584,90,,166.32,Percent of Total Billed charges,90% of Total Billed Charges,776.16,1760,
INJEC(S) SINGLE TENDON SHEATH,3610000135,CDM,361,RC,,,Outpatient,,,604.00,392.60,,604,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,459.04,76,,104.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,434.88,72,,203.904,Percent of Total Billed Charges,72% of Total Billed Charges,453,75,,212.4,Percent of Total Billed charges,75% of Total Billed Charges,604,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,434.88,72,,203.904,Percent of Total Billed Charges,72% of Total Billed Charges,362.4,60,,169.92,Percent of Total Billed Charges,60% of Total Billed Charges,543.6,90,,168.288,Percent of Total Billed Charges,90% of Total Billed Charges,271.8,45,,114.48,Percent of Total Billed Charges,45% of Total Billed Charges,543.6,90,,123.84,Percent of Total Billed Charges,90% of Total billed Charges,604,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,604,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,604,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.6,65,,57.904,Percent of total Billed Charges,65% of Total Billed Charges,266.36,44.1,,112.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,573.8,95,,130.72,Percent of Total Billed Charges,95% of Total Billed Charges,604,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531.52,88,,235.464,Percent of Total Billed Charges,88% of Total Billed Charges,543.6,90,,123.84,Percent of Total Billed charges,90% of Total Billed Charges,266.36,604,
INJECTION(S) SINGLE TENDON,3610000136,CDM,361,RC,,,Outpatient,,,607.00,394.55,,607,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,461.32,76,,142.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,437.04,72,,175.68,Percent of Total Billed Charges,72% of Total Billed Charges,455.25,75,,183,Percent of Total Billed charges,75% of Total Billed Charges,607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.04,72,,175.68,Percent of Total Billed Charges,72% of Total Billed Charges,364.2,60,,146.4,Percent of Total Billed Charges,60% of Total Billed Charges,546.3,90,,337.36,Percent of Total Billed Charges,90% of Total Billed Charges,273.15,45,,120.408,Percent of Total Billed Charges,45% of Total Billed Charges,546.3,90,,168.288,Percent of Total Billed Charges,90% of Total billed Charges,607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.55,65,,57.904,Percent of total Billed Charges,65% of Total Billed Charges,267.69,44.1,,118,Percent of Total Billed Charges,44.1% of Total Billed Charges,576.65,95,,177.632,Percent of Total Billed Charges,95% of Total Billed Charges,607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,534.16,88,,235.464,Percent of Total Billed Charges,88% of Total Billed Charges,546.3,90,,168.288,Percent of Total Billed charges,90% of Total Billed Charges,267.69,607,
XR INJ TRIGGER POINT 12 MUSC,3610000137,CDM,361,RC,,,Outpatient,,,555.59,361.13,,555.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,422.25,76,,271.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,400.02,72,,175.272,Percent of Total Billed Charges,72% of Total Billed Charges,416.69,75,,182.576,Percent of Total Billed charges,75% of Total Billed Charges,555.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.02,72,,175.272,Percent of Total Billed Charges,72% of Total Billed Charges,333.35,60,,146.056,Percent of Total Billed Charges,60% of Total Billed Charges,500.03,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,250.02,45,,120.408,Percent of Total Billed Charges,45% of Total Billed Charges,500.03,90,,321.12,Percent of Total Billed Charges,90% of Total billed Charges,555.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.13,65,,57.904,Percent of total Billed Charges,65% of Total Billed Charges,245.02,44.1,,118,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.81,95,,338.96,Percent of Total Billed Charges,95% of Total Billed Charges,555.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.92,88,,299.928,Percent of Total Billed Charges,88% of Total Billed Charges,500.03,90,,321.12,Percent of Total Billed charges,90% of Total Billed Charges,245.02,555.59,
XR INJ TRIGGER POINT >3 MUSC,3610000138,CDM,361,RC,,,Outpatient,,,673.82,437.98,,673.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,512.1,76,,193.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,485.15,72,,215.424,Percent of Total Billed Charges,72% of Total Billed Charges,505.37,75,,224.4,Percent of Total Billed charges,75% of Total Billed Charges,673.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.15,72,,215.424,Percent of Total Billed Charges,72% of Total Billed Charges,404.29,60,,179.52,Percent of Total Billed Charges,60% of Total Billed Charges,606.44,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,303.22,45,,153.368,Percent of Total Billed Charges,45% of Total Billed Charges,606.44,90,,228.96,Percent of Total Billed Charges,90% of Total billed Charges,673.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,673.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,673.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.98,65,,57.904,Percent of total Billed Charges,65% of Total Billed Charges,297.15,44.1,,150.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,640.13,95,,241.68,Percent of Total Billed Charges,95% of Total Billed Charges,673.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.96,88,,162.624,Percent of Total Billed Charges,88% of Total Billed Charges,606.44,90,,228.96,Percent of Total Billed charges,90% of Total Billed Charges,297.15,673.82,
"ARTHROC ASP/INJ,MAJ JNT W/US",3610000139,CDM,361,RC,,,Outpatient,,,702.00,456.30,,702,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,533.52,76,,193.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,505.44,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,526.5,75,,73.432,Percent of Total Billed charges,75% of Total Billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,505.44,72,,70.488,Percent of Total Billed Charges,72% of Total Billed Charges,421.2,60,,58.744,Percent of Total Billed Charges,60% of Total Billed Charges,631.8,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,315.9,45,,83.16,Percent of Total Billed Charges,45% of Total Billed Charges,631.8,90,,228.96,Percent of Total Billed Charges,90% of Total billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.3,65,,55.608,Percent of total Billed Charges,65% of Total Billed Charges,309.58,44.1,,81.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,666.9,95,,241.68,Percent of Total Billed Charges,95% of Total Billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,617.76,88,,121.088,Percent of Total Billed Charges,88% of Total Billed Charges,631.8,90,,228.96,Percent of Total Billed charges,90% of Total Billed Charges,309.58,702,
"ARTHROC ASP/INJ,MAJ JNT W/US",3610000140,CDM,361,RC,,,Outpatient,,,738.68,480.14,,738.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,561.4,76,,203.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,531.85,72,,368.32,Percent of Total Billed Charges,72% of Total Billed Charges,554.01,75,,383.672,Percent of Total Billed charges,75% of Total Billed Charges,738.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531.85,72,,368.32,Percent of Total Billed Charges,72% of Total Billed Charges,443.21,60,,306.936,Percent of Total Billed Charges,60% of Total Billed Charges,664.81,90,,123.84,Percent of Total Billed Charges,90% of Total Billed Charges,332.41,45,,61.92,Percent of Total Billed Charges,45% of Total Billed Charges,664.81,90,,240.816,Percent of Total Billed Charges,90% of Total billed Charges,738.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,738.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,738.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.14,65,,55.608,Percent of total Billed Charges,65% of Total Billed Charges,325.76,44.1,,60.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,701.75,95,,254.2,Percent of Total Billed Charges,95% of Total Billed Charges,738.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,650.04,88,,164.544,Percent of Total Billed Charges,88% of Total Billed Charges,664.81,90,,240.816,Percent of Total Billed charges,90% of Total Billed Charges,325.76,738.68,
REPLGJ TUBE PERC UNDER FLUORO,3610000141,CDM,361,RC,,,Outpatient,,,2100.00,1365.00,,2100,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1596,76,,203.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1512,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,1575,75,,37.704,Percent of Total Billed charges,75% of Total Billed Charges,2100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1512,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,1260,60,,30.16,Percent of Total Billed Charges,60% of Total Billed Charges,1890,90,,130.184,Percent of Total Billed Charges,90% of Total Billed Charges,945,45,,84.144,Percent of Total Billed Charges,45% of Total Billed Charges,1890,90,,240.816,Percent of Total Billed Charges,90% of Total billed Charges,2100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1365,65,,226.2,Percent of total Billed Charges,65% of Total Billed Charges,926.1,44.1,,82.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,1995,95,,254.2,Percent of Total Billed Charges,95% of Total Billed Charges,2100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1848,88,,329.864,Percent of Total Billed Charges,88% of Total Billed Charges,1890,90,,240.816,Percent of Total Billed charges,90% of Total Billed Charges,926.1,2100,
TMJ ARTHROGRAPHY INJECTION,3610000142,CDM,361,RC,,,Outpatient,,,674.50,438.43,,674.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,512.62,76,,259.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,485.64,72,,241.952,Percent of Total Billed Charges,72% of Total Billed Charges,505.88,75,,252.032,Percent of Total Billed charges,75% of Total Billed Charges,674.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.64,72,,241.952,Percent of Total Billed Charges,72% of Total Billed Charges,404.7,60,,201.624,Percent of Total Billed Charges,60% of Total Billed Charges,607.05,90,,87.84,Percent of Total Billed Charges,90% of Total Billed Charges,303.53,45,,168.68,Percent of Total Billed Charges,45% of Total Billed Charges,607.05,90,,306.744,Percent of Total Billed Charges,90% of Total billed Charges,674.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,674.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,674.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,438.43,65,,226.2,Percent of total Billed Charges,65% of Total Billed Charges,297.45,44.1,,165.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,640.78,95,,323.784,Percent of Total Billed Charges,95% of Total Billed Charges,674.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,593.56,88,,147.84,Percent of Total Billed Charges,88% of Total Billed Charges,607.05,90,,306.744,Percent of Total Billed charges,90% of Total Billed Charges,297.45,674.5,
INJEC FOR SHOULDER ARTHROGRAM,3610000143,CDM,361,RC,,,Outpatient,,,437.69,284.50,,437.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,332.64,76,,140.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,315.14,72,,241.952,Percent of Total Billed Charges,72% of Total Billed Charges,328.27,75,,252.032,Percent of Total Billed charges,75% of Total Billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.14,72,,241.952,Percent of Total Billed Charges,72% of Total Billed Charges,262.61,60,,201.624,Percent of Total Billed Charges,60% of Total Billed Charges,393.92,90,,87.84,Percent of Total Billed Charges,90% of Total Billed Charges,196.96,45,,75.6,Percent of Total Billed Charges,45% of Total Billed Charges,393.92,90,,166.32,Percent of Total Billed Charges,90% of Total billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.5,65,,321.36,Percent of total Billed Charges,65% of Total Billed Charges,193.02,44.1,,74.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,415.81,95,,175.56,Percent of Total Billed Charges,95% of Total Billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.17,88,,69.696,Percent of Total Billed Charges,88% of Total Billed Charges,393.92,90,,166.32,Percent of Total Billed charges,90% of Total Billed Charges,193.02,437.69,
REM FOREIGN BODY FOOT SUBCUT,3610000144,CDM,361,RC,,,Outpatient,,,2263.43,1471.23,,2263.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1720.21,76,,104.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1629.67,72,,195.84,Percent of Total Billed Charges,72% of Total Billed Charges,1697.57,75,,204,Percent of Total Billed charges,75% of Total Billed Charges,2263.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1629.67,72,,195.84,Percent of Total Billed Charges,72% of Total Billed Charges,1358.06,60,,163.2,Percent of Total Billed Charges,60% of Total Billed Charges,2037.09,90,,148.32,Percent of Total Billed Charges,90% of Total Billed Charges,1018.54,45,,35.64,Percent of Total Billed Charges,45% of Total Billed Charges,2037.09,90,,123.84,Percent of Total Billed Charges,90% of Total billed Charges,2263.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2263.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2263.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1471.23,65,,321.36,Percent of total Billed Charges,65% of Total Billed Charges,998.17,44.1,,34.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,2150.26,95,,130.72,Percent of Total Billed Charges,95% of Total Billed Charges,2263.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1991.82,88,,69.696,Percent of Total Billed Charges,88% of Total Billed Charges,2037.09,90,,123.84,Percent of Total Billed charges,90% of Total Billed Charges,998.17,2263.43,
REMOVAL FOREIGN BODY FOOT DEEP,3610000145,CDM,361,RC,,,Outpatient,,,3384.68,2200.04,,3384.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2572.36,76,,142.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2436.97,72,,211.968,Percent of Total Billed Charges,72% of Total Billed Charges,2538.51,75,,220.8,Percent of Total Billed charges,75% of Total Billed Charges,3384.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2436.97,72,,211.968,Percent of Total Billed Charges,72% of Total Billed Charges,2030.81,60,,176.64,Percent of Total Billed Charges,60% of Total Billed Charges,3046.21,90,,148.32,Percent of Total Billed Charges,90% of Total Billed Charges,1523.11,45,,35.64,Percent of Total Billed Charges,45% of Total Billed Charges,3046.21,90,,168.288,Percent of Total Billed Charges,90% of Total billed Charges,3384.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3384.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3384.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2200.04,65,,205.92,Percent of total Billed Charges,65% of Total Billed Charges,1492.64,44.1,,34.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,3215.45,95,,177.632,Percent of Total Billed Charges,95% of Total Billed Charges,3384.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2978.52,88,,121.088,Percent of Total Billed Charges,88% of Total Billed Charges,3046.21,90,,168.288,Percent of Total Billed charges,90% of Total Billed Charges,1492.64,3384.68,
REMOVAL FOREIGN BDY FOOT COMP,3610000146,CDM,361,RC,,,Outpatient,,,2426.05,1576.93,,2426.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1843.8,76,,284.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1746.76,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1819.54,75,,165,Percent of Total Billed charges,75% of Total Billed Charges,2426.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1746.76,72,,158.4,Percent of Total Billed Charges,72% of Total Billed Charges,1455.63,60,,132,Percent of Total Billed Charges,60% of Total Billed Charges,2183.45,90,,155.584,Percent of Total Billed Charges,90% of Total Billed Charges,1091.72,45,,61.92,Percent of Total Billed Charges,45% of Total Billed Charges,2183.45,90,,337.36,Percent of Total Billed Charges,90% of Total billed Charges,2426.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2426.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2426.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1576.93,65,,205.92,Percent of total Billed Charges,65% of Total Billed Charges,1069.89,44.1,,60.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,2304.75,95,,356.104,Percent of Total Billed Charges,95% of Total Billed Charges,2426.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2134.92,88,,127.288,Percent of Total Billed Charges,88% of Total Billed Charges,2183.45,90,,337.36,Percent of Total Billed charges,90% of Total Billed Charges,1069.89,2426.05,
PLEURAL CATH INS TUNNL/INDWELL,3610000147,CDM,361,RC,,,Outpatient,,,5159.00,3353.35,,5159,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3920.84,76,,127.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3714.48,72,,190.512,Percent of Total Billed Charges,72% of Total Billed Charges,3869.25,75,,198.448,Percent of Total Billed charges,75% of Total Billed Charges,5159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3714.48,72,,190.512,Percent of Total Billed Charges,72% of Total Billed Charges,3095.4,60,,158.76,Percent of Total Billed Charges,60% of Total Billed Charges,4643.1,90,,155.584,Percent of Total Billed Charges,90% of Total Billed Charges,2321.55,45,,65.088,Percent of Total Billed Charges,45% of Total Billed Charges,4643.1,90,,151.2,Percent of Total Billed Charges,90% of Total billed Charges,5159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3353.35,65,,215.8,Percent of total Billed Charges,65% of Total Billed Charges,2275.12,44.1,,63.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,4901.05,95,,159.6,Percent of Total Billed Charges,95% of Total Billed Charges,5159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4539.92,88,,85.888,Percent of Total Billed Charges,88% of Total Billed Charges,4643.1,90,,151.2,Percent of Total Billed charges,90% of Total Billed Charges,2275.12,5159,
INSERTION OF CHEST TUBE,3610000148,CDM,361,RC,,,Outpatient,,,1297.64,843.47,,1297.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,986.21,76,,60.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,934.3,72,,22.464,Percent of Total Billed Charges,72% of Total Billed Charges,973.23,75,,23.4,Percent of Total Billed charges,75% of Total Billed Charges,1297.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,934.3,72,,22.464,Percent of Total Billed Charges,72% of Total Billed Charges,778.58,60,,18.72,Percent of Total Billed Charges,60% of Total Billed Charges,1167.88,90,,155.584,Percent of Total Billed Charges,90% of Total Billed Charges,583.94,45,,43.92,Percent of Total Billed Charges,45% of Total Billed Charges,1167.88,90,,71.28,Percent of Total Billed Charges,90% of Total billed Charges,1297.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1297.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1297.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,843.47,65,,215.8,Percent of total Billed Charges,65% of Total Billed Charges,572.26,44.1,,43.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,1232.76,95,,75.24,Percent of Total Billed Charges,95% of Total Billed Charges,1297.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1141.92,88,,85.888,Percent of Total Billed Charges,88% of Total Billed Charges,1167.88,90,,71.28,Percent of Total Billed charges,90% of Total Billed Charges,572.26,1297.64,
REMOV TUNN PLEURAL CATH W/CUFF,3610000149,CDM,361,RC,,,Outpatient,,,2394.46,1556.40,,2394.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1819.79,76,,60.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1724.01,72,,168.192,Percent of Total Billed Charges,72% of Total Billed Charges,1795.85,75,,175.2,Percent of Total Billed charges,75% of Total Billed Charges,2394.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1724.01,72,,168.192,Percent of Total Billed Charges,72% of Total Billed Charges,1436.68,60,,140.16,Percent of Total Billed Charges,60% of Total Billed Charges,2155.01,90,,148.32,Percent of Total Billed Charges,90% of Total Billed Charges,1077.51,45,,43.92,Percent of Total Billed Charges,45% of Total Billed Charges,2155.01,90,,71.28,Percent of Total Billed Charges,90% of Total billed Charges,2394.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2394.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2394.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1556.4,65,,296.4,Percent of total Billed Charges,65% of Total Billed Charges,1055.96,44.1,,43.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,2274.74,95,,75.24,Percent of Total Billed Charges,95% of Total Billed Charges,2394.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2107.12,88,,145.024,Percent of Total Billed Charges,88% of Total Billed Charges,2155.01,90,,71.28,Percent of Total Billed charges,90% of Total Billed Charges,1055.96,2394.46,
THORACENTESIS W/OUT IMAGING,3610000150,CDM,361,RC,,,Outpatient,,,1505.00,978.25,,1505,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1143.8,76,,104.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1083.6,72,,168.192,Percent of Total Billed Charges,72% of Total Billed Charges,1128.75,75,,175.2,Percent of Total Billed charges,75% of Total Billed Charges,1505,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1083.6,72,,168.192,Percent of Total Billed Charges,72% of Total Billed Charges,903,60,,140.16,Percent of Total Billed Charges,60% of Total Billed Charges,1354.5,90,,162.72,Percent of Total Billed Charges,90% of Total Billed Charges,677.25,45,,74.16,Percent of Total Billed Charges,45% of Total Billed Charges,1354.5,90,,123.84,Percent of Total Billed Charges,90% of Total billed Charges,1505,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1505,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1505,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,978.25,65,,296.4,Percent of total Billed Charges,65% of Total Billed Charges,663.71,44.1,,72.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,1429.75,95,,130.72,Percent of Total Billed Charges,95% of Total Billed Charges,1505,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1324.4,88,,145.024,Percent of Total Billed Charges,88% of Total Billed Charges,1354.5,90,,123.84,Percent of Total Billed charges,90% of Total Billed Charges,663.71,1505,
THORACENTESIS W/ IMAGING,3610000151,CDM,361,RC,,,Outpatient,,,1854.00,1205.10,,1854,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1409.04,76,,109.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1334.88,72,,62.208,Percent of Total Billed Charges,72% of Total Billed Charges,1390.5,75,,64.8,Percent of Total Billed charges,75% of Total Billed Charges,1854,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1334.88,72,,62.208,Percent of Total Billed Charges,72% of Total Billed Charges,1112.4,60,,51.84,Percent of Total Billed Charges,60% of Total Billed Charges,1668.6,90,,162.72,Percent of Total Billed Charges,90% of Total Billed Charges,834.3,45,,74.16,Percent of Total Billed Charges,45% of Total Billed Charges,1668.6,90,,130.184,Percent of Total Billed Charges,90% of Total billed Charges,1854,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1854,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1854,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1205.1,65,,82.68,Percent of total Billed Charges,65% of Total Billed Charges,817.61,44.1,,72.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,1761.3,95,,137.416,Percent of Total Billed Charges,95% of Total Billed Charges,1854,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1631.52,88,,152.128,Percent of Total Billed Charges,88% of Total Billed Charges,1668.6,90,,130.184,Percent of Total Billed charges,90% of Total Billed Charges,817.61,1854,
PLEURAL DRAINGE PERC W IMAGING,3610000152,CDM,361,RC,,,Outpatient,,,1413.00,918.45,,1413,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1073.88,76,,74.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1017.36,72,,399.168,Percent of Total Billed Charges,72% of Total Billed Charges,1059.75,75,,415.8,Percent of Total Billed charges,75% of Total Billed Charges,1413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1017.36,72,,399.168,Percent of Total Billed Charges,72% of Total Billed Charges,847.8,60,,332.64,Percent of Total Billed Charges,60% of Total Billed Charges,1271.7,90,,85.728,Percent of Total Billed Charges,90% of Total Billed Charges,635.85,45,,77.792,Percent of Total Billed Charges,45% of Total Billed Charges,1271.7,90,,87.84,Percent of Total Billed Charges,90% of Total billed Charges,1413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,918.45,65,,82.68,Percent of total Billed Charges,65% of Total Billed Charges,623.13,44.1,,76.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,1342.35,95,,92.72,Percent of Total Billed Charges,95% of Total Billed Charges,1413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1243.44,88,,152.128,Percent of Total Billed Charges,88% of Total Billed Charges,1271.7,90,,87.84,Percent of Total Billed charges,90% of Total Billed Charges,623.13,1413,
HIP ARTHROGRAPHY INJ W ANESTH,3610000153,CDM,361,RC,,,Outpatient,,,4340.00,2821.00,,4340,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3298.4,76,,74.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3124.8,72,,1619.136,Percent of Total Billed Charges,72% of Total Billed Charges,3255,75,,1686.6,Percent of Total Billed charges,75% of Total Billed Charges,4340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3124.8,72,,1619.136,Percent of Total Billed Charges,72% of Total Billed Charges,2604,60,,1349.28,Percent of Total Billed Charges,60% of Total Billed Charges,3906,90,,85.728,Percent of Total Billed Charges,90% of Total Billed Charges,1953,45,,77.792,Percent of Total Billed Charges,45% of Total Billed Charges,3906,90,,87.84,Percent of Total Billed Charges,90% of Total billed Charges,4340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2821,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,1913.94,44.1,,76.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,4123,95,,92.72,Percent of Total Billed Charges,95% of Total Billed Charges,4340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3819.2,88,,152.128,Percent of Total Billed Charges,88% of Total Billed Charges,3906,90,,87.84,Percent of Total Billed charges,90% of Total Billed Charges,1913.94,4340,
SEL CATH 1ST ORD CAR,3610000154,CDM,361,RC,,,Outpatient,,,2098.06,1363.74,,2098.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1594.53,76,,125.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1510.6,72,,1124.928,Percent of Total Billed Charges,72% of Total Billed Charges,1573.55,75,,1171.8,Percent of Total Billed charges,75% of Total Billed Charges,2098.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1510.6,72,,1124.928,Percent of Total Billed Charges,72% of Total Billed Charges,1258.84,60,,937.44,Percent of Total Billed Charges,60% of Total Billed Charges,1888.25,90,,77.76,Percent of Total Billed Charges,90% of Total Billed Charges,944.13,45,,77.792,Percent of Total Billed Charges,45% of Total Billed Charges,1888.25,90,,148.32,Percent of Total Billed Charges,90% of Total billed Charges,2098.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2098.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2098.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1363.74,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,925.24,44.1,,76.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,1993.16,95,,156.56,Percent of Total Billed Charges,95% of Total Billed Charges,2098.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1846.29,88,,145.024,Percent of Total Billed Charges,88% of Total Billed Charges,1888.25,90,,148.32,Percent of Total Billed charges,90% of Total Billed Charges,925.24,2098.06,
SEL CATH PLACEVERTEBL ARTY UNI,3610000155,CDM,361,RC,,,Outpatient,,,16020.77,10413.50,,16020.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12175.79,76,,125.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11534.95,72,,280.512,Percent of Total Billed Charges,72% of Total Billed Charges,12015.58,75,,292.2,Percent of Total Billed charges,75% of Total Billed Charges,16020.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11534.95,72,,280.512,Percent of Total Billed Charges,72% of Total Billed Charges,9612.46,60,,233.76,Percent of Total Billed Charges,60% of Total Billed Charges,14418.69,90,,77.76,Percent of Total Billed Charges,90% of Total Billed Charges,7209.35,45,,74.16,Percent of Total Billed Charges,45% of Total Billed Charges,14418.69,90,,148.32,Percent of Total Billed Charges,90% of Total billed Charges,16020.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16020.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16020.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10413.5,65,,63.64,Percent of total Billed Charges,65% of Total Billed Charges,7065.16,44.1,,72.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,15219.73,95,,156.56,Percent of Total Billed Charges,95% of Total Billed Charges,16020.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14098.28,88,,159.104,Percent of Total Billed Charges,88% of Total Billed Charges,14418.69,90,,148.32,Percent of Total Billed charges,90% of Total Billed Charges,7065.16,16020.77,
ANGIO RENAL UNILAT S,3610000156,CDM,361,RC,,,Outpatient,,,2304.23,1497.75,,2304.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1751.21,76,,131.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1659.05,72,,1051.2,Percent of Total Billed Charges,72% of Total Billed Charges,1728.17,75,,1095,Percent of Total Billed charges,75% of Total Billed Charges,2304.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1659.05,72,,1051.2,Percent of Total Billed Charges,72% of Total Billed Charges,1382.54,60,,876,Percent of Total Billed Charges,60% of Total Billed Charges,2073.81,90,,114.48,Percent of Total Billed Charges,90% of Total Billed Charges,1036.9,45,,81.36,Percent of Total Billed Charges,45% of Total Billed Charges,2073.81,90,,155.584,Percent of Total Billed Charges,90% of Total billed Charges,2304.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2304.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2304.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1497.75,65,,63.64,Percent of total Billed Charges,65% of Total Billed Charges,1016.17,44.1,,79.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,2189.02,95,,164.232,Percent of Total Billed Charges,95% of Total Billed Charges,2304.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2027.72,88,,159.104,Percent of Total Billed Charges,88% of Total Billed Charges,2073.81,90,,155.584,Percent of Total Billed charges,90% of Total Billed Charges,1016.17,2304.23,
ANGIO RENAL BILAT SE,3610000157,CDM,361,RC,,,Outpatient,,,3038.49,1975.02,,3038.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2309.25,76,,131.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2187.71,72,,139.712,Percent of Total Billed Charges,72% of Total Billed Charges,2278.87,75,,145.528,Percent of Total Billed charges,75% of Total Billed Charges,3038.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.71,72,,139.712,Percent of Total Billed Charges,72% of Total Billed Charges,1823.09,60,,116.424,Percent of Total Billed Charges,60% of Total Billed Charges,2734.64,90,,108.752,Percent of Total Billed Charges,90% of Total Billed Charges,1367.32,45,,81.36,Percent of Total Billed Charges,45% of Total Billed Charges,2734.64,90,,155.584,Percent of Total Billed Charges,90% of Total billed Charges,3038.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3038.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3038.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1975.02,65,,63.64,Percent of total Billed Charges,65% of Total Billed Charges,1339.97,44.1,,79.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,2886.57,95,,164.232,Percent of Total Billed Charges,95% of Total Billed Charges,3038.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2673.87,88,,83.824,Percent of Total Billed Charges,88% of Total Billed Charges,2734.64,90,,155.584,Percent of Total Billed charges,90% of Total Billed Charges,1339.97,3038.49,
MIDLINE CATHETER INSERTION,3610000158,CDM,361,RC,,,Outpatient,,,3393.28,2205.63,,3393.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2578.89,76,,131.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2443.16,72,,301.248,Percent of Total Billed Charges,72% of Total Billed Charges,2544.96,75,,313.8,Percent of Total Billed charges,75% of Total Billed Charges,3393.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2443.16,72,,301.248,Percent of Total Billed Charges,72% of Total Billed Charges,2035.97,60,,251.04,Percent of Total Billed Charges,60% of Total Billed Charges,3053.95,90,,108.752,Percent of Total Billed Charges,90% of Total Billed Charges,1526.98,45,,42.864,Percent of Total Billed Charges,45% of Total Billed Charges,3053.95,90,,155.584,Percent of Total Billed Charges,90% of Total billed Charges,3393.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3393.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3393.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2205.63,65,,63.64,Percent of total Billed Charges,65% of Total Billed Charges,1496.44,44.1,,42.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,3223.62,95,,164.232,Percent of Total Billed Charges,95% of Total Billed Charges,3393.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2986.09,88,,83.824,Percent of Total Billed Charges,88% of Total Billed Charges,3053.95,90,,155.584,Percent of Total Billed charges,90% of Total Billed Charges,1496.44,3393.28,
INS PICC W/ U S IMG 5YR+,3610000160,CDM,361,RC,,,Outpatient,,,3224.00,2095.60,,3224,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2450.24,76,,125.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2321.28,72,,1019.88,Percent of Total Billed Charges,72% of Total Billed Charges,2418,75,,1062.376,Percent of Total Billed charges,75% of Total Billed Charges,3224,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2321.28,72,,1019.88,Percent of Total Billed Charges,72% of Total Billed Charges,1934.4,60,,849.896,Percent of Total Billed Charges,60% of Total Billed Charges,2901.6,90,,114.48,Percent of Total Billed Charges,90% of Total Billed Charges,1450.8,45,,42.864,Percent of Total Billed Charges,45% of Total Billed Charges,2901.6,90,,148.32,Percent of Total Billed Charges,90% of Total billed Charges,3224,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3224,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3224,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2095.6,65,,12.192,Percent of total Billed Charges,65% of Total Billed Charges,1421.78,44.1,,42.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,3062.8,95,,156.56,Percent of Total Billed Charges,95% of Total Billed Charges,3224,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2837.12,88,,76.032,Percent of Total Billed Charges,88% of Total Billed Charges,2901.6,90,,148.32,Percent of Total Billed charges,90% of Total Billed Charges,1421.78,3224,
MIDLINE CATHETER REPLACEMENT,3610000161,CDM,361,RC,,,Outpatient,,,2617.00,1701.05,,2617,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1988.92,76,,137.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1884.24,72,,988.776,Percent of Total Billed Charges,72% of Total Billed Charges,1962.75,75,,1029.976,Percent of Total Billed charges,75% of Total Billed Charges,2617,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1884.24,72,,988.776,Percent of Total Billed Charges,72% of Total Billed Charges,1570.2,60,,823.984,Percent of Total Billed Charges,60% of Total Billed Charges,2355.3,90,,117.36,Percent of Total Billed Charges,90% of Total Billed Charges,1177.65,45,,38.88,Percent of Total Billed Charges,45% of Total Billed Charges,2355.3,90,,162.72,Percent of Total Billed Charges,90% of Total billed Charges,2617,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2617,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2617,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1701.05,65,,226.2,Percent of total Billed Charges,65% of Total Billed Charges,1154.1,44.1,,38.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,2486.15,95,,171.76,Percent of Total Billed Charges,95% of Total Billed Charges,2617,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2302.96,88,,76.032,Percent of Total Billed Charges,88% of Total Billed Charges,2355.3,90,,162.72,Percent of Total Billed charges,90% of Total Billed Charges,1154.1,2617,
DECLOT IMPLANTED VASCULAR DEV,3610000162,CDM,361,RC,,,Outpatient,,,739.00,480.35,,739,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,561.64,76,,137.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,532.08,72,,850.752,Percent of Total Billed Charges,72% of Total Billed Charges,554.25,75,,886.2,Percent of Total Billed charges,75% of Total Billed Charges,739,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,532.08,72,,850.752,Percent of Total Billed Charges,72% of Total Billed Charges,443.4,60,,708.96,Percent of Total Billed Charges,60% of Total Billed Charges,665.1,90,,117.36,Percent of Total Billed Charges,90% of Total Billed Charges,332.55,45,,38.88,Percent of Total Billed Charges,45% of Total Billed Charges,665.1,90,,162.72,Percent of Total Billed Charges,90% of Total billed Charges,739,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,739,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,739,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.35,65,,226.2,Percent of total Billed Charges,65% of Total Billed Charges,325.9,44.1,,38.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,702.05,95,,171.76,Percent of Total Billed Charges,95% of Total Billed Charges,739,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,650.32,88,,111.936,Percent of Total Billed Charges,88% of Total Billed Charges,665.1,90,,162.72,Percent of Total Billed charges,90% of Total Billed Charges,325.9,739,
FISTULA DIAGNOSTIC ANGIOGRAPHY,3610000163,CDM,361,RC,,,Outpatient,,,2116.00,1375.40,,2116,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1608.16,76,,72.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1523.52,72,,426.24,Percent of Total Billed Charges,72% of Total Billed Charges,1587,75,,444,Percent of Total Billed charges,75% of Total Billed Charges,2116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1523.52,72,,426.24,Percent of Total Billed Charges,72% of Total Billed Charges,1269.6,60,,355.2,Percent of Total Billed Charges,60% of Total Billed Charges,1904.4,90,,126.72,Percent of Total Billed Charges,90% of Total Billed Charges,952.2,45,,57.24,Percent of Total Billed Charges,45% of Total Billed Charges,1904.4,90,,85.728,Percent of Total Billed Charges,90% of Total billed Charges,2116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1375.4,65,,321.36,Percent of total Billed Charges,65% of Total Billed Charges,933.16,44.1,,56.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,2010.2,95,,90.496,Percent of Total Billed Charges,95% of Total Billed Charges,2116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1862.08,88,,106.336,Percent of Total Billed Charges,88% of Total Billed Charges,1904.4,90,,85.728,Percent of Total Billed charges,90% of Total Billed Charges,933.16,2116,
FISTULA PTA  ANGIOPLASTY,3610000164,CDM,361,RC,,,Outpatient,,,14921.00,9698.65,,14921,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11339.96,76,,72.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10743.12,72,,911.92,Percent of Total Billed Charges,72% of Total Billed Charges,11190.75,75,,949.912,Percent of Total Billed charges,75% of Total Billed Charges,14921,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10743.12,72,,911.92,Percent of Total Billed Charges,72% of Total Billed Charges,8952.6,60,,759.928,Percent of Total Billed Charges,60% of Total Billed Charges,13428.9,90,,126.72,Percent of Total Billed Charges,90% of Total Billed Charges,6714.45,45,,54.376,Percent of Total Billed Charges,45% of Total Billed Charges,13428.9,90,,85.728,Percent of Total Billed Charges,90% of Total billed Charges,14921,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14921,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14921,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9698.65,65,,321.36,Percent of total Billed Charges,65% of Total Billed Charges,6580.16,44.1,,53.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,14174.95,95,,90.496,Percent of Total Billed Charges,95% of Total Billed Charges,14921,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13130.48,88,,106.336,Percent of Total Billed Charges,88% of Total Billed Charges,13428.9,90,,85.728,Percent of Total Billed charges,90% of Total Billed Charges,6580.16,14921,
FISTULA PTA  ANGIOPLAST A STNT,3610000165,CDM,361,RC,,,Outpatient,,,28860.86,18759.56,,28860.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21934.25,76,,65.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20779.82,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,21645.65,75,,1200,Percent of Total Billed charges,75% of Total Billed Charges,28860.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20779.82,72,,1152,Percent of Total Billed Charges,72% of Total Billed Charges,17316.52,60,,960,Percent of Total Billed Charges,60% of Total Billed Charges,25974.77,90,,75.416,Percent of Total Billed Charges,90% of Total Billed Charges,12987.39,45,,54.376,Percent of Total Billed Charges,45% of Total Billed Charges,25974.77,90,,77.76,Percent of Total Billed Charges,90% of Total billed Charges,28860.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28860.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28860.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18759.56,65,,205.92,Percent of total Billed Charges,65% of Total Billed Charges,12727.64,44.1,,53.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,27417.82,95,,82.08,Percent of Total Billed Charges,95% of Total Billed Charges,28860.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25397.56,88,,111.936,Percent of Total Billed Charges,88% of Total Billed Charges,25974.77,90,,77.76,Percent of Total Billed charges,90% of Total Billed Charges,12727.64,28860.86,
FRST PERC TRANSL MECH THROMBEC,3610000166,CDM,361,RC,,,Outpatient,,,13426.23,8727.05,,13426.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10203.93,76,,65.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9666.89,72,,337.84,Percent of Total Billed Charges,72% of Total Billed Charges,10069.67,75,,351.92,Percent of Total Billed charges,75% of Total Billed Charges,13426.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9666.89,72,,337.84,Percent of Total Billed Charges,72% of Total Billed Charges,8055.74,60,,281.536,Percent of Total Billed Charges,60% of Total Billed Charges,12083.61,90,,75.416,Percent of Total Billed Charges,90% of Total Billed Charges,6041.8,45,,57.24,Percent of Total Billed Charges,45% of Total Billed Charges,12083.61,90,,77.76,Percent of Total Billed Charges,90% of Total billed Charges,13426.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13426.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13426.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8727.05,65,,205.92,Percent of total Billed Charges,65% of Total Billed Charges,5920.97,44.1,,56.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,12754.92,95,,82.08,Percent of Total Billed Charges,95% of Total Billed Charges,13426.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11815.08,88,,114.752,Percent of Total Billed Charges,88% of Total Billed Charges,12083.61,90,,77.76,Percent of Total Billed charges,90% of Total Billed Charges,5920.97,13426.23,
FIST PT MECH THROMBECTMY & PTA,3610000167,CDM,361,RC,,,Outpatient,,,13653.40,8874.71,,13653.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10376.58,76,,96.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9830.45,72,,620.928,Percent of Total Billed Charges,72% of Total Billed Charges,10240.05,75,,646.8,Percent of Total Billed charges,75% of Total Billed Charges,13653.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9830.45,72,,620.928,Percent of Total Billed Charges,72% of Total Billed Charges,8192.04,60,,517.44,Percent of Total Billed Charges,60% of Total Billed Charges,12288.06,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,6144.03,45,,58.68,Percent of Total Billed Charges,45% of Total Billed Charges,12288.06,90,,114.48,Percent of Total Billed Charges,90% of Total billed Charges,13653.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13653.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13653.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8874.71,65,,226.2,Percent of total Billed Charges,65% of Total Billed Charges,6021.15,44.1,,57.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,12970.73,95,,120.84,Percent of Total Billed Charges,95% of Total Billed Charges,13653.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12014.99,88,,114.752,Percent of Total Billed Charges,88% of Total Billed Charges,12288.06,90,,114.48,Percent of Total Billed charges,90% of Total Billed Charges,6021.15,13653.4,
FRST PT MECH THROMB PTA STNT,3610000168,CDM,361,RC,,,Outpatient,,,41131.65,26735.57,,41131.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31260.05,76,,91.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29614.79,72,,403.888,Percent of Total Billed Charges,72% of Total Billed Charges,30848.74,75,,420.712,Percent of Total Billed charges,75% of Total Billed Charges,41131.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29614.79,72,,403.888,Percent of Total Billed Charges,72% of Total Billed Charges,24678.99,60,,336.568,Percent of Total Billed Charges,60% of Total Billed Charges,37018.49,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,18509.24,45,,58.68,Percent of Total Billed Charges,45% of Total Billed Charges,37018.49,90,,108.752,Percent of Total Billed Charges,90% of Total billed Charges,41131.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41131.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41131.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26735.57,65,,226.2,Percent of total Billed Charges,65% of Total Billed Charges,18139.06,44.1,,57.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,39075.07,95,,114.792,Percent of Total Billed Charges,95% of Total Billed Charges,41131.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36195.85,88,,123.904,Percent of Total Billed Charges,88% of Total Billed Charges,37018.49,90,,108.752,Percent of Total Billed charges,90% of Total Billed Charges,18139.06,41131.65,
Trans Ball Angiopl cent Dialy,3610000169,CDM,361,RC,,,Outpatient,,,9008.00,5855.20,,9008,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6846.08,76,,91.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6485.76,72,,1923.84,Percent of Total Billed Charges,72% of Total Billed Charges,6756,75,,2004,Percent of Total Billed charges,75% of Total Billed Charges,9008,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6485.76,72,,1923.84,Percent of Total Billed Charges,72% of Total Billed Charges,5404.8,60,,1603.2,Percent of Total Billed Charges,60% of Total Billed Charges,8107.2,90,,164.16,Percent of Total Billed Charges,90% of Total Billed Charges,4053.6,45,,63.36,Percent of Total Billed Charges,45% of Total Billed Charges,8107.2,90,,108.752,Percent of Total Billed Charges,90% of Total billed Charges,9008,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9008,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9008,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5855.2,65,,321.36,Percent of total Billed Charges,65% of Total Billed Charges,3972.53,44.1,,62.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,8557.6,95,,114.792,Percent of Total Billed Charges,95% of Total Billed Charges,9008,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7927.04,88,,123.904,Percent of Total Billed Charges,88% of Total Billed Charges,8107.2,90,,108.752,Percent of Total Billed charges,90% of Total Billed Charges,3972.53,9008,
STENT PLMT CTR DIALYSIS SEG,3610000170,CDM,361,RC,,,Outpatient,,,14430.43,9379.78,,14430.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10967.13,76,,96.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10389.91,72,,398.168,Percent of Total Billed Charges,72% of Total Billed Charges,10822.82,75,,414.76,Percent of Total Billed charges,75% of Total Billed Charges,14430.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10389.91,72,,398.168,Percent of Total Billed Charges,72% of Total Billed Charges,8658.26,60,,331.808,Percent of Total Billed Charges,60% of Total Billed Charges,12987.39,90,,156.376,Percent of Total Billed Charges,90% of Total Billed Charges,6493.69,45,,63.36,Percent of Total Billed Charges,45% of Total Billed Charges,12987.39,90,,114.48,Percent of Total Billed Charges,90% of Total billed Charges,14430.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14430.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14430.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9379.78,65,,321.36,Percent of total Billed Charges,65% of Total Billed Charges,6363.82,44.1,,62.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,13708.91,95,,120.84,Percent of Total Billed Charges,95% of Total Billed Charges,14430.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12698.78,88,,73.736,Percent of Total Billed Charges,88% of Total Billed Charges,12987.39,90,,114.48,Percent of Total Billed charges,90% of Total Billed Charges,6363.82,14430.43,
DIALYSIS CIRCUIT EMBOLIZATION,3610000171,CDM,361,RC,,,Outpatient,,,2116.00,1375.40,,2116,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1608.16,76,,99.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1523.52,72,,724.576,Percent of Total Billed Charges,72% of Total Billed Charges,1587,75,,754.768,Percent of Total Billed charges,75% of Total Billed Charges,2116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1523.52,72,,724.576,Percent of Total Billed Charges,72% of Total Billed Charges,1269.6,60,,603.816,Percent of Total Billed Charges,60% of Total Billed Charges,1904.4,90,,144,Percent of Total Billed Charges,90% of Total Billed Charges,952.2,45,,37.704,Percent of Total Billed Charges,45% of Total Billed Charges,1904.4,90,,117.36,Percent of Total Billed Charges,90% of Total billed Charges,2116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1375.4,65,,205.92,Percent of total Billed Charges,65% of Total Billed Charges,933.16,44.1,,36.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,2010.2,95,,123.88,Percent of Total Billed Charges,95% of Total Billed Charges,2116,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1862.08,88,,73.736,Percent of Total Billed Charges,88% of Total Billed Charges,1904.4,90,,117.36,Percent of Total Billed charges,90% of Total Billed Charges,933.16,2116,
TRANSC ART/VEN THROM TX SUB DY,3610000172,CDM,361,RC,,,Outpatient,,,5537.86,3599.61,,5537.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4208.77,76,,99.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3987.26,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,4153.4,75,,43.664,Percent of Total Billed charges,75% of Total Billed Charges,5537.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3987.26,72,,41.912,Percent of Total Billed Charges,72% of Total Billed Charges,3322.72,60,,34.928,Percent of Total Billed Charges,60% of Total Billed Charges,4984.07,90,,144,Percent of Total Billed Charges,90% of Total Billed Charges,2492.04,45,,37.704,Percent of Total Billed Charges,45% of Total Billed Charges,4984.07,90,,117.36,Percent of Total Billed Charges,90% of Total billed Charges,5537.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5537.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5537.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3599.61,65,,205.92,Percent of total Billed Charges,65% of Total Billed Charges,2442.2,44.1,,36.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,5260.97,95,,123.88,Percent of Total Billed Charges,95% of Total Billed Charges,5537.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4873.32,88,,74.624,Percent of Total Billed Charges,88% of Total Billed Charges,4984.07,90,,117.36,Percent of Total Billed charges,90% of Total Billed Charges,2442.2,5537.86,
THROMBLYTIC ART/VEN THRPY REM,3610000173,CDM,361,RC,,,Outpatient,,,5537.86,3599.61,,5537.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4208.77,76,,107.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3987.26,72,,159.552,Percent of Total Billed Charges,72% of Total Billed Charges,4153.4,75,,166.2,Percent of Total Billed charges,75% of Total Billed Charges,5537.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3987.26,72,,159.552,Percent of Total Billed Charges,72% of Total Billed Charges,3322.72,60,,132.96,Percent of Total Billed Charges,60% of Total Billed Charges,4984.07,90,,144,Percent of Total Billed Charges,90% of Total Billed Charges,2492.04,45,,38.16,Percent of Total Billed Charges,45% of Total Billed Charges,4984.07,90,,126.72,Percent of Total Billed Charges,90% of Total billed Charges,5537.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5537.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5537.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3599.61,65,,53.312,Percent of total Billed Charges,65% of Total Billed Charges,2442.2,44.1,,37.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,5260.97,95,,133.76,Percent of Total Billed Charges,95% of Total Billed Charges,5537.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4873.32,88,,74.624,Percent of Total Billed Charges,88% of Total Billed Charges,4984.07,90,,126.72,Percent of Total Billed charges,90% of Total Billed Charges,2442.2,5537.86,
REVASC ILIAC ART INITIAL VES,3610000174,CDM,361,RC,,,Outpatient,,,14718.38,9566.95,,14718.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11185.97,76,,107.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10597.23,72,,272.448,Percent of Total Billed Charges,72% of Total Billed Charges,11038.79,75,,283.8,Percent of Total Billed charges,75% of Total Billed Charges,14718.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10597.23,72,,272.448,Percent of Total Billed Charges,72% of Total Billed Charges,8831.03,60,,227.04,Percent of Total Billed Charges,60% of Total Billed Charges,13246.54,90,,137.328,Percent of Total Billed Charges,90% of Total Billed Charges,6623.27,45,,38.16,Percent of Total Billed Charges,45% of Total Billed Charges,13246.54,90,,126.72,Percent of Total Billed Charges,90% of Total billed Charges,14718.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14718.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14718.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9566.95,65,,53.312,Percent of total Billed Charges,65% of Total Billed Charges,6490.81,44.1,,37.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,13982.46,95,,133.76,Percent of Total Billed Charges,95% of Total Billed Charges,14718.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12952.17,88,,160.512,Percent of Total Billed Charges,88% of Total Billed Charges,13246.54,90,,126.72,Percent of Total Billed charges,90% of Total Billed Charges,6490.81,14718.38,
REV ILIAC ART W/STNT INIT VSSL,3610000175,CDM,361,RC,,,Outpatient,,,22606.76,14694.39,,22606.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17181.14,76,,63.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16276.87,72,,440.64,Percent of Total Billed Charges,72% of Total Billed Charges,16955.07,75,,459,Percent of Total Billed charges,75% of Total Billed Charges,22606.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16276.87,72,,440.64,Percent of Total Billed Charges,72% of Total Billed Charges,13564.06,60,,367.2,Percent of Total Billed Charges,60% of Total Billed Charges,20346.08,90,,79.2,Percent of Total Billed Charges,90% of Total Billed Charges,10173.04,45,,82.08,Percent of Total Billed Charges,45% of Total Billed Charges,20346.08,90,,75.416,Percent of Total Billed Charges,90% of Total billed Charges,22606.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22606.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22606.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14694.39,65,,136.76,Percent of total Billed Charges,65% of Total Billed Charges,9969.58,44.1,,80.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,21476.42,95,,79.6,Percent of Total Billed Charges,95% of Total Billed Charges,22606.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19893.95,88,,152.904,Percent of Total Billed Charges,88% of Total Billed Charges,20346.08,90,,75.416,Percent of Total Billed charges,90% of Total Billed Charges,9969.58,22606.76,
REVASC ILIAC ARTERY EA ADD VES,3610000176,CDM,361,RC,,,Outpatient,,,37222.00,24194.30,,37222,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,28288.72,76,,63.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26799.84,72,,440.64,Percent of Total Billed Charges,72% of Total Billed Charges,27916.5,75,,459,Percent of Total Billed charges,75% of Total Billed Charges,37222,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26799.84,72,,440.64,Percent of Total Billed Charges,72% of Total Billed Charges,22333.2,60,,367.2,Percent of Total Billed Charges,60% of Total Billed Charges,33499.8,90,,79.2,Percent of Total Billed Charges,90% of Total Billed Charges,16749.9,45,,78.192,Percent of Total Billed Charges,45% of Total Billed Charges,33499.8,90,,75.416,Percent of Total Billed Charges,90% of Total billed Charges,37222,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37222,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37222,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24194.3,65,,150.8,Percent of total Billed Charges,65% of Total Billed Charges,16414.9,44.1,,76.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,35360.9,95,,79.6,Percent of Total Billed Charges,95% of Total Billed Charges,37222,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32755.36,88,,140.8,Percent of Total Billed Charges,88% of Total Billed Charges,33499.8,90,,75.416,Percent of Total Billed charges,90% of Total Billed Charges,16414.9,37222,
RE ILIAC ART EA ADD VES W/STNT,3610000177,CDM,361,RC,,,Outpatient,,,14718.38,9566.95,,14718.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11185.97,76,,64.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10597.23,72,,722.88,Percent of Total Billed Charges,72% of Total Billed Charges,11038.79,75,,753,Percent of Total Billed charges,75% of Total Billed Charges,14718.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10597.23,72,,722.88,Percent of Total Billed Charges,72% of Total Billed Charges,8831.03,60,,602.4,Percent of Total Billed Charges,60% of Total Billed Charges,13246.54,90,,80.176,Percent of Total Billed Charges,90% of Total Billed Charges,6623.27,45,,72,Percent of Total Billed Charges,45% of Total Billed Charges,13246.54,90,,76.32,Percent of Total Billed Charges,90% of Total billed Charges,14718.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14718.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14718.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9566.95,65,,164.84,Percent of total Billed Charges,65% of Total Billed Charges,6490.81,44.1,,70.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,13982.46,95,,80.56,Percent of Total Billed Charges,95% of Total Billed Charges,14718.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12952.17,88,,140.8,Percent of Total Billed Charges,88% of Total Billed Charges,13246.54,90,,76.32,Percent of Total Billed charges,90% of Total Billed Charges,6490.81,14718.38,
REVA FEM/POP ART UNILAT W/ANGI,3610000178,CDM,361,RC,,,Outpatient,,,13983.00,9088.95,,13983,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10627.08,76,,64.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10067.76,72,,1070.784,Percent of Total Billed Charges,72% of Total Billed Charges,10487.25,75,,1115.4,Percent of Total Billed charges,75% of Total Billed Charges,13983,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10067.76,72,,1070.784,Percent of Total Billed Charges,72% of Total Billed Charges,8389.8,60,,892.32,Percent of Total Billed Charges,60% of Total Billed Charges,12584.7,90,,80.176,Percent of Total Billed Charges,90% of Total Billed Charges,6292.35,45,,72,Percent of Total Billed Charges,45% of Total Billed Charges,12584.7,90,,76.32,Percent of Total Billed Charges,90% of Total billed Charges,13983,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13983,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13983,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9088.95,65,,55.12,Percent of total Billed Charges,65% of Total Billed Charges,6166.5,44.1,,70.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,13283.85,95,,80.56,Percent of Total Billed Charges,95% of Total Billed Charges,13983,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12305.04,88,,140.8,Percent of Total Billed Charges,88% of Total Billed Charges,12584.7,90,,76.32,Percent of Total Billed charges,90% of Total Billed Charges,6166.5,13983,
ATHERECTOMY FEM POP ART UNILA,3610000179,CDM,361,RC,,,Outpatient,,,24823.00,16134.95,,24823,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18865.48,76,,138.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17872.56,72,,1929.024,Percent of Total Billed Charges,72% of Total Billed Charges,18617.25,75,,2009.4,Percent of Total Billed charges,75% of Total Billed Charges,24823,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17872.56,72,,1929.024,Percent of Total Billed Charges,72% of Total Billed Charges,14893.8,60,,1607.52,Percent of Total Billed Charges,60% of Total Billed Charges,22340.7,90,,80.176,Percent of Total Billed Charges,90% of Total Billed Charges,11170.35,45,,72,Percent of Total Billed Charges,45% of Total Billed Charges,22340.7,90,,164.16,Percent of Total Billed Charges,90% of Total billed Charges,24823,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24823,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24823,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16134.95,65,,121.536,Percent of total Billed Charges,65% of Total Billed Charges,10946.94,44.1,,70.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,23581.85,95,,173.28,Percent of Total Billed Charges,95% of Total Billed Charges,24823,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21844.24,88,,134.272,Percent of Total Billed Charges,88% of Total Billed Charges,22340.7,90,,164.16,Percent of Total Billed charges,90% of Total Billed Charges,10946.94,24823,
PIOPLITEAL ARTERY AN,3610000180,CDM,361,RC,,,Outpatient,,,19679.00,12791.35,,19679,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14956.04,76,,132.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14168.88,72,,470.016,Percent of Total Billed Charges,72% of Total Billed Charges,14759.25,75,,489.6,Percent of Total Billed charges,75% of Total Billed Charges,19679,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14168.88,72,,470.016,Percent of Total Billed Charges,72% of Total Billed Charges,11807.4,60,,391.68,Percent of Total Billed Charges,60% of Total Billed Charges,17711.1,90,,80.176,Percent of Total Billed Charges,90% of Total Billed Charges,8855.55,45,,68.664,Percent of Total Billed Charges,45% of Total Billed Charges,17711.1,90,,156.376,Percent of Total Billed Charges,90% of Total billed Charges,19679,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19679,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19679,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12791.35,65,,243.648,Percent of total Billed Charges,65% of Total Billed Charges,8678.44,44.1,,67.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,18695.05,95,,165.064,Percent of Total Billed Charges,95% of Total Billed Charges,19679,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17317.52,88,,77.44,Percent of Total Billed Charges,88% of Total Billed Charges,17711.1,90,,156.376,Percent of Total Billed charges,90% of Total Billed Charges,8678.44,19679,
REVA FEM/POP ART STNT ARTHEREC,3610000181,CDM,361,RC,,,Outpatient,,,28806.16,18724.00,,28806.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21892.68,76,,121.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20740.44,72,,180.864,Percent of Total Billed Charges,72% of Total Billed Charges,21604.62,75,,188.4,Percent of Total Billed charges,75% of Total Billed Charges,28806.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20740.44,72,,180.864,Percent of Total Billed Charges,72% of Total Billed Charges,17283.7,60,,150.72,Percent of Total Billed Charges,60% of Total Billed Charges,25925.54,90,,77,Percent of Total Billed Charges,90% of Total Billed Charges,12962.77,45,,39.6,Percent of Total Billed Charges,45% of Total Billed Charges,25925.54,90,,144,Percent of Total Billed Charges,90% of Total billed Charges,28806.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28806.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28806.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18724,65,,121.536,Percent of total Billed Charges,65% of Total Billed Charges,12703.52,44.1,,38.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,27365.85,95,,152,Percent of Total Billed Charges,95% of Total Billed Charges,28806.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25349.42,88,,77.44,Percent of Total Billed Charges,88% of Total Billed Charges,25925.54,90,,144,Percent of Total Billed charges,90% of Total Billed Charges,12703.52,28806.16,
ANTERIOR TIBIAL ANGI,3610000182,CDM,361,RC,,,Outpatient,,,21576.00,14024.40,,21576,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16397.76,76,,121.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15534.72,72,,564.48,Percent of Total Billed Charges,72% of Total Billed Charges,16182,75,,588,Percent of Total Billed charges,75% of Total Billed Charges,21576,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15534.72,72,,564.48,Percent of Total Billed Charges,72% of Total Billed Charges,12945.6,60,,470.4,Percent of Total Billed Charges,60% of Total Billed Charges,19418.4,90,,77,Percent of Total Billed Charges,90% of Total Billed Charges,9709.2,45,,39.6,Percent of Total Billed Charges,45% of Total Billed Charges,19418.4,90,,144,Percent of Total Billed Charges,90% of Total billed Charges,21576,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21576,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21576,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14024.4,65,,243.648,Percent of total Billed Charges,65% of Total Billed Charges,9515.02,44.1,,38.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,20497.2,95,,152,Percent of Total Billed Charges,95% of Total Billed Charges,21576,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18986.88,88,,78.392,Percent of Total Billed Charges,88% of Total Billed Charges,19418.4,90,,144,Percent of Total Billed charges,90% of Total Billed Charges,9515.02,21576,
ATHERECTOMY TIBIOPERO ART INIT,3610000183,CDM,361,RC,,,Outpatient,,,26129.25,16984.01,,26129.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19858.23,76,,121.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18813.06,72,,393.088,Percent of Total Billed Charges,72% of Total Billed Charges,19596.94,75,,409.472,Percent of Total Billed charges,75% of Total Billed Charges,26129.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18813.06,72,,393.088,Percent of Total Billed Charges,72% of Total Billed Charges,15677.55,60,,327.576,Percent of Total Billed Charges,60% of Total Billed Charges,23516.33,90,,313.2,Percent of Total Billed Charges,90% of Total Billed Charges,11758.16,45,,40.088,Percent of Total Billed Charges,45% of Total Billed Charges,23516.33,90,,144,Percent of Total Billed Charges,90% of Total billed Charges,26129.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26129.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26129.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16984.01,65,,86.568,Percent of total Billed Charges,65% of Total Billed Charges,11523,44.1,,39.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,24822.79,95,,152,Percent of Total Billed Charges,95% of Total Billed Charges,26129.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22993.74,88,,78.392,Percent of Total Billed Charges,88% of Total Billed Charges,23516.33,90,,144,Percent of Total Billed charges,90% of Total Billed Charges,11523,26129.25,
TIBIOPERONEAL ART STNT  INIT,3610000184,CDM,361,RC,,,Outpatient,,,19638.77,12765.20,,19638.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14925.47,76,,115.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14139.91,72,,339.264,Percent of Total Billed Charges,72% of Total Billed Charges,14729.08,75,,353.4,Percent of Total Billed charges,75% of Total Billed Charges,19638.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14139.91,72,,339.264,Percent of Total Billed Charges,72% of Total Billed Charges,11783.26,60,,282.72,Percent of Total Billed Charges,60% of Total Billed Charges,17674.89,90,,313.2,Percent of Total Billed Charges,90% of Total Billed Charges,8837.45,45,,40.088,Percent of Total Billed Charges,45% of Total Billed Charges,17674.89,90,,137.328,Percent of Total Billed Charges,90% of Total billed Charges,19638.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19638.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19638.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12765.2,65,,86.568,Percent of total Billed Charges,65% of Total Billed Charges,8660.7,44.1,,39.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,18656.83,95,,144.952,Percent of Total Billed Charges,95% of Total Billed Charges,19638.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17282.12,88,,78.392,Percent of Total Billed Charges,88% of Total Billed Charges,17674.89,90,,137.328,Percent of Total Billed charges,90% of Total Billed Charges,8660.7,19638.77,
TIBIOPERO ART STNT & ARTH  INI,3610000185,CDM,361,RC,,,Outpatient,,,22496.50,14622.73,,22496.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17097.34,76,,66.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16197.48,72,,376.704,Percent of Total Billed Charges,72% of Total Billed Charges,16872.38,75,,392.4,Percent of Total Billed charges,75% of Total Billed Charges,22496.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16197.48,72,,376.704,Percent of Total Billed Charges,72% of Total Billed Charges,13497.9,60,,313.92,Percent of Total Billed Charges,60% of Total Billed Charges,20246.85,90,,444.96,Percent of Total Billed Charges,90% of Total Billed Charges,10123.43,45,,40.088,Percent of Total Billed Charges,45% of Total Billed Charges,20246.85,90,,79.2,Percent of Total Billed Charges,90% of Total billed Charges,22496.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22496.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22496.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14622.73,65,,51.48,Percent of total Billed Charges,65% of Total Billed Charges,9920.96,44.1,,39.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,21371.68,95,,83.6,Percent of Total Billed Charges,95% of Total Billed Charges,22496.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19796.92,88,,78.392,Percent of Total Billed Charges,88% of Total Billed Charges,20246.85,90,,79.2,Percent of Total Billed charges,90% of Total Billed Charges,9920.96,22496.5,
TIBIOPERONEAL ART ADD ANGIO,3610000186,CDM,361,RC,,,Outpatient,,,9701.65,6306.07,,9701.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7373.25,76,,66.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6985.19,72,,602.496,Percent of Total Billed Charges,72% of Total Billed Charges,7276.24,75,,627.6,Percent of Total Billed charges,75% of Total Billed Charges,9701.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6985.19,72,,602.496,Percent of Total Billed Charges,72% of Total Billed Charges,5820.99,60,,502.08,Percent of Total Billed Charges,60% of Total Billed Charges,8731.49,90,,444.96,Percent of Total Billed Charges,90% of Total Billed Charges,4365.74,45,,40.088,Percent of Total Billed Charges,45% of Total Billed Charges,8731.49,90,,79.2,Percent of Total Billed Charges,90% of Total billed Charges,9701.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9701.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9701.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6306.07,65,,51.48,Percent of total Billed Charges,65% of Total Billed Charges,4278.43,44.1,,39.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,9216.57,95,,83.6,Percent of Total Billed Charges,95% of Total Billed Charges,9701.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8537.45,88,,75.288,Percent of Total Billed Charges,88% of Total Billed Charges,8731.49,90,,79.2,Percent of Total Billed charges,90% of Total Billed Charges,4278.43,9701.65,
ATHER TIBPER ARTERY EA ADD,3610000187,CDM,361,RC,,,Outpatient,,,21784.30,14159.80,,21784.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16556.07,76,,67.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15684.7,72,,225.792,Percent of Total Billed Charges,72% of Total Billed Charges,16338.23,75,,235.2,Percent of Total Billed charges,75% of Total Billed Charges,21784.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15684.7,72,,225.792,Percent of Total Billed Charges,72% of Total Billed Charges,13070.58,60,,188.16,Percent of Total Billed Charges,60% of Total Billed Charges,19605.87,90,,285.12,Percent of Total Billed Charges,90% of Total Billed Charges,9802.94,45,,38.496,Percent of Total Billed Charges,45% of Total Billed Charges,19605.87,90,,80.176,Percent of Total Billed Charges,90% of Total billed Charges,21784.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21784.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21784.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14159.8,65,,63.44,Percent of total Billed Charges,65% of Total Billed Charges,9606.88,44.1,,37.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,20695.09,95,,84.624,Percent of Total Billed Charges,95% of Total Billed Charges,21784.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19170.18,88,,75.288,Percent of Total Billed Charges,88% of Total Billed Charges,19605.87,90,,80.176,Percent of Total Billed charges,90% of Total Billed Charges,9606.88,21784.3,
TIBIOPERONEAL ARTRY STNT EA AD,3610000188,CDM,361,RC,,,Outpatient,,,11248.25,7311.36,,11248.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8548.67,76,,67.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8098.74,72,,451.584,Percent of Total Billed Charges,72% of Total Billed Charges,8436.19,75,,470.4,Percent of Total Billed charges,75% of Total Billed Charges,11248.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8098.74,72,,451.584,Percent of Total Billed Charges,72% of Total Billed Charges,6748.95,60,,376.32,Percent of Total Billed Charges,60% of Total Billed Charges,10123.43,90,,285.12,Percent of Total Billed Charges,90% of Total Billed Charges,5061.71,45,,38.496,Percent of Total Billed Charges,45% of Total Billed Charges,10123.43,90,,80.176,Percent of Total Billed Charges,90% of Total billed Charges,11248.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11248.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11248.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7311.36,65,,63.44,Percent of total Billed Charges,65% of Total Billed Charges,4960.48,44.1,,37.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,10685.84,95,,84.624,Percent of Total Billed Charges,95% of Total Billed Charges,11248.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9898.46,88,,306.24,Percent of Total Billed Charges,88% of Total Billed Charges,10123.43,90,,80.176,Percent of Total Billed charges,90% of Total Billed Charges,4960.48,11248.25,
TIBIOPERO ART STNT&ARTH EA ADD,3610000189,CDM,361,RC,,,Outpatient,,,9819.36,6382.58,,9819.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7462.71,76,,67.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7069.94,72,,828.288,Percent of Total Billed Charges,72% of Total Billed Charges,7364.52,75,,862.8,Percent of Total Billed charges,75% of Total Billed Charges,9819.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7069.94,72,,828.288,Percent of Total Billed Charges,72% of Total Billed Charges,5891.62,60,,690.24,Percent of Total Billed Charges,60% of Total Billed Charges,8837.42,90,,298.8,Percent of Total Billed Charges,90% of Total Billed Charges,4418.71,45,,156.6,Percent of Total Billed Charges,45% of Total Billed Charges,8837.42,90,,80.176,Percent of Total Billed Charges,90% of Total billed Charges,9819.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9819.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9819.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6382.58,65,,112.368,Percent of total Billed Charges,65% of Total Billed Charges,4330.34,44.1,,153.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,9328.39,95,,84.624,Percent of Total Billed Charges,95% of Total Billed Charges,9819.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8641.04,88,,306.24,Percent of Total Billed Charges,88% of Total Billed Charges,8837.42,90,,80.176,Percent of Total Billed charges,90% of Total Billed Charges,4330.34,9819.36,
PERIPHERAL ARTERY STENT INIT,3610000190,CDM,361,RC,,,Outpatient,,,14027.25,9117.71,,14027.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10660.71,76,,67.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10099.62,72,,459.648,Percent of Total Billed Charges,72% of Total Billed Charges,10520.44,75,,478.8,Percent of Total Billed charges,75% of Total Billed Charges,14027.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10099.62,72,,459.648,Percent of Total Billed Charges,72% of Total Billed Charges,8416.35,60,,383.04,Percent of Total Billed Charges,60% of Total Billed Charges,12624.53,90,,298.8,Percent of Total Billed Charges,90% of Total Billed Charges,6312.26,45,,156.6,Percent of Total Billed Charges,45% of Total Billed Charges,12624.53,90,,80.176,Percent of Total Billed Charges,90% of Total billed Charges,14027.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14027.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14027.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9117.71,65,,112.368,Percent of total Billed Charges,65% of Total Billed Charges,6186.02,44.1,,153.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,13325.89,95,,84.624,Percent of Total Billed Charges,95% of Total Billed Charges,14027.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12343.98,88,,435.072,Percent of Total Billed Charges,88% of Total Billed Charges,12624.53,90,,80.176,Percent of Total Billed charges,90% of Total Billed Charges,6186.02,14027.25,
PERIPHERAL ARTERY STNT EA ADD,3610000191,CDM,361,RC,,,Outpatient,,,9318.11,6056.77,,9318.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7081.76,76,,65.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6709.04,72,,82.368,Percent of Total Billed Charges,72% of Total Billed Charges,6988.58,75,,85.8,Percent of Total Billed charges,75% of Total Billed Charges,9318.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6709.04,72,,82.368,Percent of Total Billed Charges,72% of Total Billed Charges,5590.87,60,,68.64,Percent of Total Billed Charges,60% of Total Billed Charges,8386.3,90,,410.4,Percent of Total Billed Charges,90% of Total Billed Charges,4193.15,45,,222.48,Percent of Total Billed Charges,45% of Total Billed Charges,8386.3,90,,77,Percent of Total Billed Charges,90% of Total billed Charges,9318.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9318.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9318.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6056.77,65,,112.368,Percent of total Billed Charges,65% of Total Billed Charges,4109.29,44.1,,218.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,8852.2,95,,81.272,Percent of Total Billed Charges,95% of Total Billed Charges,9318.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8199.94,88,,435.072,Percent of Total Billed Charges,88% of Total Billed Charges,8386.3,90,,77,Percent of Total Billed charges,90% of Total Billed Charges,4109.29,9318.11,
TRANS INTRVS STNT PLC INIT VN,3610000192,CDM,361,RC,,,Outpatient,,,20912.22,13592.94,,20912.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15893.29,76,,65.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15056.8,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,15684.17,75,,150,Percent of Total Billed charges,75% of Total Billed Charges,20912.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15056.8,72,,144,Percent of Total Billed Charges,72% of Total Billed Charges,12547.33,60,,120,Percent of Total Billed Charges,60% of Total Billed Charges,18821,90,,410.4,Percent of Total Billed Charges,90% of Total Billed Charges,9410.5,45,,222.48,Percent of Total Billed Charges,45% of Total Billed Charges,18821,90,,77,Percent of Total Billed Charges,90% of Total billed Charges,20912.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20912.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20912.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13592.94,65,,112.368,Percent of total Billed Charges,65% of Total Billed Charges,9222.29,44.1,,218.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,19866.61,95,,81.272,Percent of Total Billed Charges,95% of Total Billed Charges,20912.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18402.75,88,,278.784,Percent of Total Billed Charges,88% of Total Billed Charges,18821,90,,77,Percent of Total Billed charges,90% of Total Billed Charges,9222.29,20912.22,
TRANS INTRVS STNT PLC EA AD VN,3610000193,CDM,361,RC,,,Outpatient,,,10114.34,6574.32,,10114.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7686.9,76,,264.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7282.32,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,7585.76,75,,90,Percent of Total Billed charges,75% of Total Billed Charges,10114.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7282.32,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,6068.6,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,9102.91,90,,114.48,Percent of Total Billed Charges,90% of Total Billed Charges,4551.45,45,,142.56,Percent of Total Billed Charges,45% of Total Billed Charges,9102.91,90,,313.2,Percent of Total Billed Charges,90% of Total billed Charges,10114.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10114.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10114.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6574.32,65,,117.52,Percent of total Billed Charges,65% of Total Billed Charges,4460.42,44.1,,139.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,9608.62,95,,330.6,Percent of Total Billed Charges,95% of Total Billed Charges,10114.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8900.62,88,,278.784,Percent of Total Billed Charges,88% of Total Billed Charges,9102.91,90,,313.2,Percent of Total Billed charges,90% of Total Billed Charges,4460.42,10114.34,
EMBOLIZATION OF UTERINE ARTERY,3610000194,CDM,361,RC,,,Outpatient,,,23027.00,14967.55,,23027,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17500.52,76,,264.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16579.44,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,17270.25,75,,90,Percent of Total Billed charges,75% of Total Billed Charges,23027,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16579.44,72,,86.4,Percent of Total Billed Charges,72% of Total Billed Charges,13816.2,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,20724.3,90,,114.48,Percent of Total Billed Charges,90% of Total Billed Charges,10362.15,45,,142.56,Percent of Total Billed Charges,45% of Total Billed Charges,20724.3,90,,313.2,Percent of Total Billed Charges,90% of Total billed Charges,23027,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23027,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23027,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14967.55,65,,117.52,Percent of total Billed Charges,65% of Total Billed Charges,10154.91,44.1,,139.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,21875.65,95,,330.6,Percent of Total Billed Charges,95% of Total Billed Charges,23027,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20263.76,88,,292.16,Percent of Total Billed Charges,88% of Total Billed Charges,20724.3,90,,313.2,Percent of Total Billed charges,90% of Total Billed Charges,10154.91,23027,
TRLUML BALO ANGIOP 1ST VEIN,3610000195,CDM,361,RC,,,Outpatient,,,12756.00,8291.40,,12756,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9694.56,76,,375.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9184.32,72,,40.896,Percent of Total Billed Charges,72% of Total Billed Charges,9567,75,,42.6,Percent of Total Billed charges,75% of Total Billed Charges,12756,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9184.32,72,,40.896,Percent of Total Billed Charges,72% of Total Billed Charges,7653.6,60,,34.08,Percent of Total Billed Charges,60% of Total Billed Charges,11480.4,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,5740.2,45,,149.4,Percent of Total Billed Charges,45% of Total Billed Charges,11480.4,90,,444.96,Percent of Total Billed Charges,90% of Total billed Charges,12756,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12756,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12756,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8291.4,65,,61.92,Percent of total Billed Charges,65% of Total Billed Charges,5625.4,44.1,,146.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,12118.2,95,,469.68,Percent of Total Billed Charges,95% of Total Billed Charges,12756,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11225.28,88,,292.16,Percent of Total Billed Charges,88% of Total Billed Charges,11480.4,90,,444.96,Percent of Total Billed charges,90% of Total Billed Charges,5625.4,12756,
TRLUML BALO ANGIOP ADDL VEIN,3610000196,CDM,361,RC,,,Outpatient,,,8950.82,5818.03,,8950.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6802.62,76,,375.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6444.59,72,,61.056,Percent of Total Billed Charges,72% of Total Billed Charges,6713.12,75,,63.6,Percent of Total Billed charges,75% of Total Billed Charges,8950.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6444.59,72,,61.056,Percent of Total Billed Charges,72% of Total Billed Charges,5370.49,60,,50.88,Percent of Total Billed Charges,60% of Total Billed Charges,8055.74,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,4027.87,45,,149.4,Percent of Total Billed Charges,45% of Total Billed Charges,8055.74,90,,444.96,Percent of Total Billed Charges,90% of Total billed Charges,8950.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8950.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8950.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5818.03,65,,56.16,Percent of total Billed Charges,65% of Total Billed Charges,3947.31,44.1,,146.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,8503.28,95,,469.68,Percent of Total Billed Charges,95% of Total Billed Charges,8950.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7876.72,88,,401.28,Percent of Total Billed Charges,88% of Total Billed Charges,8055.74,90,,444.96,Percent of Total Billed charges,90% of Total Billed Charges,3947.31,8950.82,
UNLISTED VASC PROCEDURE,3610000197,CDM,361,RC,,,Outpatient,,,9380.25,6097.16,,9380.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7128.99,76,,240.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6753.78,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,7035.19,75,,210,Percent of Total Billed charges,75% of Total Billed Charges,9380.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6753.78,72,,201.6,Percent of Total Billed Charges,72% of Total Billed Charges,5628.15,60,,168,Percent of Total Billed Charges,60% of Total Billed Charges,8442.23,90,,88.112,Percent of Total Billed Charges,90% of Total Billed Charges,4221.11,45,,205.2,Percent of Total Billed Charges,45% of Total Billed Charges,8442.23,90,,285.12,Percent of Total Billed Charges,90% of Total billed Charges,9380.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9380.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9380.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6097.16,65,,59.048,Percent of total Billed Charges,65% of Total Billed Charges,4136.69,44.1,,201.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,8911.24,95,,300.96,Percent of Total Billed Charges,95% of Total Billed Charges,9380.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8254.62,88,,401.28,Percent of Total Billed Charges,88% of Total Billed Charges,8442.23,90,,285.12,Percent of Total Billed charges,90% of Total Billed Charges,4136.69,9380.25,
NRVE BLK ILIOING ILIOHYPOGAST,3610000198,CDM,361,RC,,,Outpatient,,,1050.68,682.94,,1050.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,798.52,76,,240.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,756.49,72,,182.016,Percent of Total Billed Charges,72% of Total Billed Charges,788.01,75,,189.6,Percent of Total Billed charges,75% of Total Billed Charges,1050.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.49,72,,182.016,Percent of Total Billed Charges,72% of Total Billed Charges,630.41,60,,151.68,Percent of Total Billed Charges,60% of Total Billed Charges,945.61,90,,88.112,Percent of Total Billed Charges,90% of Total Billed Charges,472.81,45,,205.2,Percent of Total Billed Charges,45% of Total Billed Charges,945.61,90,,285.12,Percent of Total Billed Charges,90% of Total billed Charges,1050.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,682.94,65,,78.544,Percent of total Billed Charges,65% of Total Billed Charges,463.35,44.1,,201.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,998.15,95,,300.96,Percent of Total Billed Charges,95% of Total Billed Charges,1050.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,924.6,88,,111.936,Percent of Total Billed Charges,88% of Total Billed Charges,945.61,90,,285.12,Percent of Total Billed charges,90% of Total Billed Charges,463.35,1050.68,
INJ FACET LUMB SAC SEC LEV,3610000199,CDM,361,RC,,,Outpatient,,,671.00,436.15,,671,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,509.96,76,,252.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,483.12,72,,349.936,Percent of Total Billed Charges,72% of Total Billed Charges,503.25,75,,364.52,Percent of Total Billed charges,75% of Total Billed Charges,671,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,483.12,72,,349.936,Percent of Total Billed Charges,72% of Total Billed Charges,402.6,60,,291.616,Percent of Total Billed Charges,60% of Total Billed Charges,603.9,90,,88.112,Percent of Total Billed Charges,90% of Total Billed Charges,301.95,45,,57.24,Percent of Total Billed Charges,45% of Total Billed Charges,603.9,90,,298.8,Percent of Total Billed Charges,90% of Total billed Charges,671,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,671,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,671,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,436.15,65,,82.68,Percent of total Billed Charges,65% of Total Billed Charges,295.91,44.1,,56.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,637.45,95,,315.4,Percent of Total Billed Charges,95% of Total Billed Charges,671,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,590.48,88,,111.936,Percent of Total Billed Charges,88% of Total Billed Charges,603.9,90,,298.8,Percent of Total Billed charges,90% of Total Billed Charges,295.91,671,
INJ FACET LUMB SACRAL SING LEV,3610000200,CDM,361,RC,,,Outpatient,,,1144.00,743.60,,1144,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,869.44,76,,252.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,823.68,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,858,75,,90.624,Percent of Total Billed charges,75% of Total Billed Charges,1144,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,823.68,72,,87,Percent of Total Billed Charges,72% of Total Billed Charges,686.4,60,,72.496,Percent of Total Billed Charges,60% of Total Billed Charges,1029.6,90,,88.112,Percent of Total Billed Charges,90% of Total Billed Charges,514.8,45,,57.24,Percent of Total Billed Charges,45% of Total Billed Charges,1029.6,90,,298.8,Percent of Total Billed Charges,90% of Total billed Charges,1144,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1144,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1144,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,743.6,65,,78.544,Percent of total Billed Charges,65% of Total Billed Charges,504.5,44.1,,56.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,1086.8,95,,315.4,Percent of Total Billed Charges,95% of Total Billed Charges,1144,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1006.72,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,1029.6,90,,298.8,Percent of Total Billed charges,90% of Total Billed Charges,504.5,1144,
ARTHROGRAM ANKLE INJECTION,3610000201,CDM,361,RC,,,Outpatient,,,4386.00,2850.90,,4386,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3333.36,76,,346.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3157.92,72,,265.136,Percent of Total Billed Charges,72% of Total Billed Charges,3289.5,75,,276.184,Percent of Total Billed charges,75% of Total Billed Charges,4386,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3157.92,72,,265.136,Percent of Total Billed Charges,72% of Total Billed Charges,2631.6,60,,220.944,Percent of Total Billed Charges,60% of Total Billed Charges,3947.4,90,,191.304,Percent of Total Billed Charges,90% of Total Billed Charges,1973.7,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,3947.4,90,,410.4,Percent of Total Billed Charges,90% of Total billed Charges,4386,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4386,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4386,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2850.9,65,,82.68,Percent of total Billed Charges,65% of Total Billed Charges,1934.23,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,4166.7,95,,433.2,Percent of Total Billed Charges,95% of Total Billed Charges,4386,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3859.68,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,3947.4,90,,410.4,Percent of Total Billed charges,90% of Total Billed Charges,1934.23,4386,
ARTHROGRAM WRIST INJECTION,3610000202,CDM,361,RC,,,Outpatient,,,1848.00,1201.20,,1848,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1404.48,76,,346.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1330.56,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,1386,75,,60,Percent of Total Billed charges,75% of Total Billed Charges,1848,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1330.56,72,,57.6,Percent of Total Billed Charges,72% of Total Billed Charges,1108.8,60,,48,Percent of Total Billed Charges,60% of Total Billed Charges,1663.2,90,,191.304,Percent of Total Billed Charges,90% of Total Billed Charges,831.6,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,1663.2,90,,410.4,Percent of Total Billed Charges,90% of Total billed Charges,1848,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1848,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1848,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1201.2,65,,84.76,Percent of total Billed Charges,65% of Total Billed Charges,814.97,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,1755.6,95,,433.2,Percent of Total Billed Charges,95% of Total Billed Charges,1848,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1626.24,88,,86.152,Percent of Total Billed Charges,88% of Total Billed Charges,1663.2,90,,410.4,Percent of Total Billed charges,90% of Total Billed Charges,814.97,1848,
MIDLINE CATH INSERT RS&I 5+YR,3610000203,CDM,361,RC,,,Outpatient,,,3224.00,2095.60,,3224,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2450.24,76,,96.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2321.28,72,,274.336,Percent of Total Billed Charges,72% of Total Billed Charges,2418,75,,285.768,Percent of Total Billed charges,75% of Total Billed Charges,3224,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2321.28,72,,274.336,Percent of Total Billed Charges,72% of Total Billed Charges,1934.4,60,,228.616,Percent of Total Billed Charges,60% of Total Billed Charges,2901.6,90,,214.56,Percent of Total Billed Charges,90% of Total Billed Charges,1450.8,45,,44.056,Percent of Total Billed Charges,45% of Total Billed Charges,2901.6,90,,114.48,Percent of Total Billed Charges,90% of Total billed Charges,3224,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3224,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3224,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2095.6,65,,84.76,Percent of total Billed Charges,65% of Total Billed Charges,1421.78,44.1,,43.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,3062.8,95,,120.84,Percent of Total Billed Charges,95% of Total Billed Charges,3224,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2837.12,88,,86.152,Percent of Total Billed Charges,88% of Total Billed Charges,2901.6,90,,114.48,Percent of Total Billed charges,90% of Total Billed Charges,1421.78,3224,
TREAT PLEURODESIS W/AGENT,3610000204,CDM,361,RC,,,Outpatient,,,1514.00,984.10,,1514,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1150.64,76,,96.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1090.08,72,,79.488,Percent of Total Billed Charges,72% of Total Billed Charges,1135.5,75,,82.8,Percent of Total Billed charges,75% of Total Billed Charges,1514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1090.08,72,,79.488,Percent of Total Billed Charges,72% of Total Billed Charges,908.4,60,,66.24,Percent of Total Billed Charges,60% of Total Billed Charges,1362.6,90,,214.56,Percent of Total Billed Charges,90% of Total Billed Charges,681.3,45,,44.056,Percent of Total Billed Charges,45% of Total Billed Charges,1362.6,90,,114.48,Percent of Total Billed Charges,90% of Total billed Charges,1514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,984.1,65,,91.52,Percent of total Billed Charges,65% of Total Billed Charges,667.67,44.1,,43.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,1438.3,95,,120.84,Percent of Total Billed Charges,95% of Total Billed Charges,1514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1332.32,88,,86.152,Percent of Total Billed Charges,88% of Total Billed Charges,1362.6,90,,114.48,Percent of Total Billed charges,90% of Total Billed Charges,667.67,1514,
LYSE CHEST FIBRIN SUBQ DAY,3610000205,CDM,361,RC,,,Outpatient,,,1514.00,984.10,,1514,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1150.64,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1090.08,72,,153.456,Percent of Total Billed Charges,72% of Total Billed Charges,1135.5,75,,159.856,Percent of Total Billed charges,75% of Total Billed Charges,1514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1090.08,72,,153.456,Percent of Total Billed Charges,72% of Total Billed Charges,908.4,60,,127.88,Percent of Total Billed Charges,60% of Total Billed Charges,1362.6,90,,16.888,Percent of Total Billed Charges,90% of Total Billed Charges,681.3,45,,44.056,Percent of Total Billed Charges,45% of Total Billed Charges,1362.6,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,1514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,984.1,65,,91.52,Percent of total Billed Charges,65% of Total Billed Charges,667.67,44.1,,43.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,1438.3,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,1514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1332.32,88,,86.152,Percent of Total Billed Charges,88% of Total Billed Charges,1362.6,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,667.67,1514,
LYSE CHEST FIBRIN INIT DAY,3610000206,CDM,361,RC,,,Outpatient,,,1514.00,984.10,,1514,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1150.64,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1090.08,72,,194.688,Percent of Total Billed Charges,72% of Total Billed Charges,1135.5,75,,202.8,Percent of Total Billed charges,75% of Total Billed Charges,1514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1090.08,72,,194.688,Percent of Total Billed Charges,72% of Total Billed Charges,908.4,60,,162.24,Percent of Total Billed Charges,60% of Total Billed Charges,1362.6,90,,313.2,Percent of Total Billed Charges,90% of Total Billed Charges,681.3,45,,44.056,Percent of Total Billed Charges,45% of Total Billed Charges,1362.6,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,1514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,984.1,65,,118.56,Percent of total Billed Charges,65% of Total Billed Charges,667.67,44.1,,43.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,1438.3,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,1514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1332.32,88,,187.056,Percent of Total Billed Charges,88% of Total Billed Charges,1362.6,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,667.67,1514,
REMOVE TUNNEL PERITONEAL CATH,3610000209,CDM,361,RC,,,Outpatient,,,6320.00,4108.00,,6320,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4803.2,76,,74.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4550.4,72,,366.248,Percent of Total Billed Charges,72% of Total Billed Charges,4740,75,,381.512,Percent of Total Billed charges,75% of Total Billed Charges,6320,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4550.4,72,,366.248,Percent of Total Billed Charges,72% of Total Billed Charges,3792,60,,305.208,Percent of Total Billed Charges,60% of Total Billed Charges,5688,90,,313.2,Percent of Total Billed Charges,90% of Total Billed Charges,2844,45,,95.656,Percent of Total Billed Charges,45% of Total Billed Charges,5688,90,,88.112,Percent of Total Billed Charges,90% of Total billed Charges,6320,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6320,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6320,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4108,65,,118.56,Percent of total Billed Charges,65% of Total Billed Charges,2787.12,44.1,,93.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,6004,95,,93.008,Percent of Total Billed Charges,95% of Total Billed Charges,6320,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5561.6,88,,187.056,Percent of Total Billed Charges,88% of Total Billed Charges,5688,90,,88.112,Percent of Total Billed charges,90% of Total Billed Charges,2787.12,6320,
REMOVE TUNNEL PERITONEAL CATH,3610000210,CDM,361,RC,,,Outpatient,,,6652.13,4323.88,,6652.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5055.62,76,,74.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4789.53,72,,405.504,Percent of Total Billed Charges,72% of Total Billed Charges,4989.1,75,,422.4,Percent of Total Billed charges,75% of Total Billed Charges,6652.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4789.53,72,,405.504,Percent of Total Billed Charges,72% of Total Billed Charges,3991.28,60,,337.92,Percent of Total Billed Charges,60% of Total Billed Charges,5986.92,90,,444.96,Percent of Total Billed Charges,90% of Total Billed Charges,2993.46,45,,95.656,Percent of Total Billed Charges,45% of Total Billed Charges,5986.92,90,,88.112,Percent of Total Billed Charges,90% of Total billed Charges,6652.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6652.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6652.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4323.88,65,,104,Percent of total Billed Charges,65% of Total Billed Charges,2933.59,44.1,,93.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,6319.52,95,,93.008,Percent of Total Billed Charges,95% of Total Billed Charges,6652.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5853.87,88,,209.792,Percent of Total Billed Charges,88% of Total Billed Charges,5986.92,90,,88.112,Percent of Total Billed charges,90% of Total Billed Charges,2933.59,6652.13,
Insertion PICC w US imag < 5yr,3610000211,CDM,361,RC,,,Outpatient,,,1304.33,847.81,,1304.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,991.29,76,,74.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,939.12,72,,17348.568,Percent of Total Billed Charges,72% of Total Billed Charges,978.25,75,,18071.424,Percent of Total Billed charges,75% of Total Billed Charges,1304.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,939.12,72,,17348.568,Percent of Total Billed Charges,72% of Total Billed Charges,782.6,60,,14457.136,Percent of Total Billed Charges,60% of Total Billed Charges,1173.9,90,,444.96,Percent of Total Billed Charges,90% of Total Billed Charges,586.95,45,,107.28,Percent of Total Billed Charges,45% of Total Billed Charges,1173.9,90,,88.112,Percent of Total Billed Charges,90% of Total billed Charges,1304.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1304.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1304.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,847.81,65,,104,Percent of total Billed Charges,65% of Total Billed Charges,575.21,44.1,,105.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,1239.11,95,,93.008,Percent of Total Billed Charges,95% of Total Billed Charges,1304.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1147.81,88,,209.792,Percent of Total Billed Charges,88% of Total Billed Charges,1173.9,90,,88.112,Percent of Total Billed charges,90% of Total Billed Charges,575.21,1304.33,
Lung Biopsy percutaneous,3610000212,CDM,361,RC,,,Outpatient,,,3654.00,2375.10,,3654,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2777.04,76,,74.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2630.88,72,,27787.624,Percent of Total Billed Charges,72% of Total Billed Charges,2740.5,75,,28945.44,Percent of Total Billed charges,75% of Total Billed Charges,3654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2630.88,72,,27787.624,Percent of Total Billed Charges,72% of Total Billed Charges,2192.4,60,,23156.352,Percent of Total Billed Charges,60% of Total Billed Charges,3288.6,90,,285.12,Percent of Total Billed Charges,90% of Total Billed Charges,1644.3,45,,107.28,Percent of Total Billed Charges,45% of Total Billed Charges,3288.6,90,,88.112,Percent of Total Billed Charges,90% of Total billed Charges,3654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2375.1,65,,57.2,Percent of total Billed Charges,65% of Total Billed Charges,1611.41,44.1,,105.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,3471.3,95,,93.008,Percent of Total Billed Charges,95% of Total Billed Charges,3654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3215.52,88,,16.512,Percent of Total Billed Charges,88% of Total Billed Charges,3288.6,90,,88.112,Percent of Total Billed charges,90% of Total Billed Charges,1611.41,3654,
CHOLECYSTOSTOMY PRQ W DRAIN,3610000213,CDM,361,RC,,,Outpatient,,,7294.00,4741.10,,7294,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5543.44,76,,161.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5251.68,72,,17067.968,Percent of Total Billed Charges,72% of Total Billed Charges,5470.5,75,,17779.136,Percent of Total Billed charges,75% of Total Billed Charges,7294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5251.68,72,,17067.968,Percent of Total Billed Charges,72% of Total Billed Charges,4376.4,60,,14223.304,Percent of Total Billed Charges,60% of Total Billed Charges,6564.6,90,,285.12,Percent of Total Billed Charges,90% of Total Billed Charges,3282.3,45,,8.44,Percent of Total Billed Charges,45% of Total Billed Charges,6564.6,90,,191.304,Percent of Total Billed Charges,90% of Total billed Charges,7294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4741.1,65,,57.2,Percent of total Billed Charges,65% of Total Billed Charges,3216.65,44.1,,8.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,6929.3,95,,201.936,Percent of Total Billed Charges,95% of Total Billed Charges,7294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6418.72,88,,306.24,Percent of Total Billed Charges,88% of Total Billed Charges,6564.6,90,,191.304,Percent of Total Billed charges,90% of Total Billed Charges,3216.65,7294,
BIOPSY SOFT TISSUE OF BACK,3610000214,CDM,361,RC,,,Outpatient,,,3226.00,2096.90,,3226,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2451.76,76,,161.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2322.72,72,,16214.976,Percent of Total Billed Charges,72% of Total Billed Charges,2419.5,75,,16890.6,Percent of Total Billed charges,75% of Total Billed Charges,3226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322.72,72,,16214.976,Percent of Total Billed Charges,72% of Total Billed Charges,1935.6,60,,13512.48,Percent of Total Billed Charges,60% of Total Billed Charges,2903.4,90,,313.2,Percent of Total Billed Charges,90% of Total Billed Charges,1451.7,45,,156.6,Percent of Total Billed Charges,45% of Total Billed Charges,2903.4,90,,191.304,Percent of Total Billed Charges,90% of Total billed Charges,3226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2096.9,65,,62.488,Percent of total Billed Charges,65% of Total Billed Charges,1422.67,44.1,,153.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,3064.7,95,,201.936,Percent of Total Billed Charges,95% of Total Billed Charges,3226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2838.88,88,,306.24,Percent of Total Billed Charges,88% of Total Billed Charges,2903.4,90,,191.304,Percent of Total Billed charges,90% of Total Billed Charges,1422.67,3226,
BIOPSY SOFT TISSUE PELVIS&HIP,3610000215,CDM,361,RC,,,Outpatient,,,3440.95,2236.62,,3440.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2615.12,76,,181.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2477.48,72,,14629.416,Percent of Total Billed Charges,72% of Total Billed Charges,2580.71,75,,15238.976,Percent of Total Billed charges,75% of Total Billed Charges,3440.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2477.48,72,,14629.416,Percent of Total Billed Charges,72% of Total Billed Charges,2064.57,60,,12191.176,Percent of Total Billed Charges,60% of Total Billed Charges,3096.86,90,,313.2,Percent of Total Billed Charges,90% of Total Billed Charges,1548.43,45,,156.6,Percent of Total Billed Charges,45% of Total Billed Charges,3096.86,90,,214.56,Percent of Total Billed Charges,90% of Total billed Charges,3440.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3440.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3440.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2236.62,65,,62.488,Percent of total Billed Charges,65% of Total Billed Charges,1517.46,44.1,,153.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,3268.9,95,,226.48,Percent of Total Billed Charges,95% of Total Billed Charges,3440.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3028.04,88,,435.072,Percent of Total Billed Charges,88% of Total Billed Charges,3096.86,90,,214.56,Percent of Total Billed charges,90% of Total Billed Charges,1517.46,3440.95,
SACRALPLASTY UNILATERAL,3690000001,CDM,369,RC,0200T,HCPCS,Outpatient,,,6110.06,3971.54,,8980.08,125,,,Fee Schedule,125% of CMS OPPS Rate,4643.65,76,,181.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11212.84,200,,18208.504,Fee Schedule,200% of ASC Tier Groupings,11212.84,200,,18967.192,Fee Schedule,200% of ASC Tier Groupings,7184.07,100,,,Fee Schedule,100% of CMS OPPS Rate,11212.84,200,,18208.504,Fee Schedule,200% of ASC Tier Groupings,11212.84,200,,15173.752,Fee Schedule,200% of ASC Tier Groupings,5499.05,90,,444.96,Percent of Total Billed Charges,90% of Total Billed Charges,2749.53,45,,222.48,Percent of Total Billed Charges,45% of Total Billed Charges,5499.05,90,,214.56,Percent of Total Billed Charges,90% of Total billed Charges,7184.07,100,,,Fee Schedule,100% of CMS OPPS Rate,7184.07,100,,,Fee Schedule,100% of CMS OPPS Rate,7184.07,100,,,Fee Schedule,100% of CMS OPPS Rate,13415.63,200,,62.92,Fee Schedule,200% of CMS OPPS Rate,2694.54,44.1,,218.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,5804.56,95,,226.48,Percent of Total Billed Charges,95% of Total Billed Charges,5388.04,75,,,Fee Schedule,75% of CMS OPPS Rate,5376.85,88,,435.072,Percent of Total Billed Charges,88% of Total Billed Charges,5499.05,90,,214.56,Percent of Total Billed charges,90% of Total Billed Charges,2694.54,13415.63,
SACRALPLASTY BILATERAL,3690000002,CDM,369,RC,0201T,HCPCS,Outpatient,,,6516.88,4235.97,,8980.08,125,,,Fee Schedule,125% of CMS OPPS Rate,4952.83,76,,14.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11212.84,200,,22536.936,Fee Schedule,200% of ASC Tier Groupings,11212.84,200,,23475.976,Fee Schedule,200% of ASC Tier Groupings,7184.07,100,,,Fee Schedule,100% of CMS OPPS Rate,11212.84,200,,22536.936,Fee Schedule,200% of ASC Tier Groupings,11212.84,200,,18780.776,Fee Schedule,200% of ASC Tier Groupings,5865.19,90,,444.96,Percent of Total Billed Charges,90% of Total Billed Charges,2932.6,45,,222.48,Percent of Total Billed Charges,45% of Total Billed Charges,5865.19,90,,16.888,Percent of Total Billed Charges,90% of Total billed Charges,7184.07,100,,,Fee Schedule,100% of CMS OPPS Rate,7184.07,100,,,Fee Schedule,100% of CMS OPPS Rate,7184.07,100,,,Fee Schedule,100% of CMS OPPS Rate,13415.63,200,,62.92,Fee Schedule,200% of CMS OPPS Rate,2873.94,44.1,,218.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,6191.04,95,,17.824,Percent of Total Billed Charges,95% of Total Billed Charges,5388.04,75,,,Fee Schedule,75% of CMS OPPS Rate,5734.85,88,,278.784,Percent of Total Billed Charges,88% of Total Billed Charges,5865.19,90,,16.888,Percent of Total Billed charges,90% of Total Billed Charges,2873.94,13415.63,
OB LOCAL ANESTHESIA,3700000001,CDM,370,RC,,,Outpatient,,,115.00,74.75,,115,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.4,76,,264.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.8,72,,2965,Percent of Total Billed Charges,72% of Total Billed Charges,86.25,75,,3088.544,Percent of Total Billed charges,75% of Total Billed Charges,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.8,72,,2965,Percent of Total Billed Charges,72% of Total Billed Charges,69,60,,2470.832,Percent of Total Billed Charges,60% of Total Billed Charges,103.5,90,,285.12,Percent of Total Billed Charges,90% of Total Billed Charges,51.75,45,,142.56,Percent of Total Billed Charges,45% of Total Billed Charges,103.5,90,,313.2,Percent of Total Billed Charges,90% of Total billed Charges,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.75,65,,57.904,Percent of total Billed Charges,65% of Total Billed Charges,50.72,44.1,,139.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,109.25,95,,330.6,Percent of Total Billed Charges,95% of Total Billed Charges,115,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.2,88,,278.784,Percent of Total Billed Charges,88% of Total Billed Charges,103.5,90,,313.2,Percent of Total Billed charges,90% of Total Billed Charges,50.72,115,
ANES. MATERIALS 30MI,3700000002,CDM,370,RC,,,Outpatient,,,814.00,529.10,,814,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,618.64,76,,264.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,586.08,72,,2965,Percent of Total Billed Charges,72% of Total Billed Charges,610.5,75,,3088.544,Percent of Total Billed charges,75% of Total Billed Charges,814,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,586.08,72,,2965,Percent of Total Billed Charges,72% of Total Billed Charges,488.4,60,,2470.832,Percent of Total Billed Charges,60% of Total Billed Charges,732.6,90,,285.12,Percent of Total Billed Charges,90% of Total Billed Charges,366.3,45,,142.56,Percent of Total Billed Charges,45% of Total Billed Charges,732.6,90,,313.2,Percent of Total Billed Charges,90% of Total billed Charges,814,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,814,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,814,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529.1,65,,57.904,Percent of total Billed Charges,65% of Total Billed Charges,358.97,44.1,,139.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,773.3,95,,330.6,Percent of Total Billed Charges,95% of Total Billed Charges,814,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,716.32,88,,306.24,Percent of Total Billed Charges,88% of Total Billed Charges,732.6,90,,313.2,Percent of Total Billed charges,90% of Total Billed Charges,358.97,814,
ANES ADDL 1 M,3700000003,CDM,370,RC,,,Outpatient,,,14.00,9.10,,14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.64,76,,375.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.08,72,,1923.84,Percent of Total Billed Charges,72% of Total Billed Charges,10.5,75,,2004,Percent of Total Billed charges,75% of Total Billed Charges,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.08,72,,1923.84,Percent of Total Billed Charges,72% of Total Billed Charges,8.4,60,,1603.2,Percent of Total Billed Charges,60% of Total Billed Charges,12.6,90,,73.824,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,45,,156.6,Percent of Total Billed Charges,45% of Total Billed Charges,12.6,90,,444.96,Percent of Total Billed Charges,90% of Total billed Charges,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.1,65,,338.272,Percent of total Billed Charges,65% of Total Billed Charges,6.17,44.1,,153.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.3,95,,469.68,Percent of Total Billed Charges,95% of Total Billed Charges,14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.32,88,,306.24,Percent of Total Billed Charges,88% of Total Billed Charges,12.6,90,,444.96,Percent of Total Billed charges,90% of Total Billed Charges,6.17,14,
OR GENERAL ANESTHESIA,3700000004,CDM,370,RC,,,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,375.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,1300.184,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,1354.36,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,1300.184,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,1083.488,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,73.824,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,156.6,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,444.96,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,338.272,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,153.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,469.68,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,435.072,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,444.96,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
CATH LAB GENERAL ANESTHESIA,3700000005,CDM,370,RC,,,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,240.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,576,72,,1362.24,Percent of Total Billed Charges,72% of Total Billed Charges,600,75,,1419,Percent of Total Billed charges,75% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576,72,,1362.24,Percent of Total Billed Charges,72% of Total Billed Charges,480,60,,1135.2,Percent of Total Billed Charges,60% of Total Billed Charges,720,90,,189.36,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,222.48,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,285.12,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,120.968,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,218.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,300.96,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,435.072,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,285.12,Percent of Total Billed charges,90% of Total Billed Charges,352.8,800,
SC EUPHORA RX 3MM X 10MM,3720002308,CDM,272,RC,C1725,HCPCS,Outpatient,,,225.00,146.25,,225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171,76,,240.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162,72,,535.344,Percent of Total Billed Charges,72% of Total Billed Charges,168.75,75,,557.648,Percent of Total Billed charges,75% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162,72,,535.344,Percent of Total Billed Charges,72% of Total Billed Charges,135,60,,446.12,Percent of Total Billed Charges,60% of Total Billed Charges,202.5,90,,208.8,Percent of Total Billed Charges,90% of Total Billed Charges,101.25,45,,222.48,Percent of Total Billed Charges,45% of Total Billed Charges,202.5,90,,285.12,Percent of Total Billed Charges,90% of Total billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.25,65,,120.968,Percent of total Billed Charges,65% of Total Billed Charges,99.23,44.1,,218.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,213.75,95,,300.96,Percent of Total Billed Charges,95% of Total Billed Charges,225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,88,,278.784,Percent of Total Billed Charges,88% of Total Billed Charges,202.5,90,,285.12,Percent of Total Billed charges,90% of Total Billed Charges,99.23,225,
MOD SEDATION 15 MIN INITIAL,3790000001,CDM,379,RC,,,Outpatient,,,603.00,391.95,,603,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,458.28,76,,264.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,434.16,72,,366.336,Percent of Total Billed Charges,72% of Total Billed Charges,452.25,75,,381.6,Percent of Total Billed charges,75% of Total Billed Charges,603,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,434.16,72,,366.336,Percent of Total Billed Charges,72% of Total Billed Charges,361.8,60,,305.28,Percent of Total Billed Charges,60% of Total Billed Charges,542.7,90,,228.24,Percent of Total Billed Charges,90% of Total Billed Charges,271.35,45,,142.56,Percent of Total Billed Charges,45% of Total Billed Charges,542.7,90,,313.2,Percent of Total Billed Charges,90% of Total billed Charges,603,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,603,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,603,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,391.95,65,,27.56,Percent of total Billed Charges,65% of Total Billed Charges,265.92,44.1,,139.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,572.85,95,,330.6,Percent of Total Billed Charges,95% of Total Billed Charges,603,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.64,88,,278.784,Percent of Total Billed Charges,88% of Total Billed Charges,542.7,90,,313.2,Percent of Total Billed charges,90% of Total Billed Charges,265.92,603,
MODERATE SEDATION ADD 15 MIN,3790000002,CDM,379,RC,,,Outpatient,,,82.00,53.30,,82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.32,76,,264.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,59.04,72,,1563.472,Percent of Total Billed Charges,72% of Total Billed Charges,61.5,75,,1628.616,Percent of Total Billed charges,75% of Total Billed Charges,82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.04,72,,1563.472,Percent of Total Billed Charges,72% of Total Billed Charges,49.2,60,,1302.896,Percent of Total Billed Charges,60% of Total Billed Charges,73.8,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,36.9,45,,142.56,Percent of Total Billed Charges,45% of Total Billed Charges,73.8,90,,313.2,Percent of Total Billed Charges,90% of Total billed Charges,82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.3,65,,27.56,Percent of total Billed Charges,65% of Total Billed Charges,36.16,44.1,,139.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,77.9,95,,330.6,Percent of Total Billed Charges,95% of Total Billed Charges,82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.16,88,,72.184,Percent of Total Billed Charges,88% of Total Billed Charges,73.8,90,,313.2,Percent of Total Billed charges,90% of Total Billed Charges,36.16,82,
LEUKOCYTE APHERISIS RBC,3810000000,CDM,390,RC,,,Outpatient,,,500.00,325.00,,500,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,380,76,,375.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,360,72,,678.472,Percent of Total Billed Charges,72% of Total Billed Charges,375,75,,706.744,Percent of Total Billed charges,75% of Total Billed Charges,500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,72,,678.472,Percent of Total Billed Charges,72% of Total Billed Charges,300,60,,565.392,Percent of Total Billed Charges,60% of Total Billed Charges,450,90,,337.36,Percent of Total Billed Charges,90% of Total Billed Charges,225,45,,36.912,Percent of Total Billed Charges,45% of Total Billed Charges,450,90,,444.96,Percent of Total Billed Charges,90% of Total billed Charges,500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325,65,,63.64,Percent of total Billed Charges,65% of Total Billed Charges,220.5,44.1,,36.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,475,95,,469.68,Percent of Total Billed Charges,95% of Total Billed Charges,500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440,88,,185.152,Percent of Total Billed Charges,88% of Total Billed Charges,450,90,,444.96,Percent of Total Billed charges,90% of Total Billed Charges,220.5,500,
Blood (whole) for transfusion,3810000001,CDM,390,RC,,,Outpatient,,,677.00,440.05,,677,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,514.52,76,,240.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,487.44,72,,68.544,Percent of Total Billed Charges,72% of Total Billed Charges,507.75,75,,71.4,Percent of Total Billed charges,75% of Total Billed Charges,677,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487.44,72,,68.544,Percent of Total Billed Charges,72% of Total Billed Charges,406.2,60,,57.12,Percent of Total Billed Charges,60% of Total Billed Charges,609.3,90,,168.288,Percent of Total Billed Charges,90% of Total Billed Charges,304.65,45,,94.68,Percent of Total Billed Charges,45% of Total Billed Charges,609.3,90,,285.12,Percent of Total Billed Charges,90% of Total billed Charges,677,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.05,65,,63.64,Percent of total Billed Charges,65% of Total Billed Charges,298.56,44.1,,92.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,643.15,95,,300.96,Percent of Total Billed Charges,95% of Total Billed Charges,677,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,595.76,88,,204.16,Percent of Total Billed Charges,88% of Total Billed Charges,609.3,90,,285.12,Percent of Total Billed charges,90% of Total Billed Charges,298.56,677,
CRYOPRECIPITATE,3900000001,CDM,390,RC,P9012,HCPCS,Outpatient,,,154.35,100.33,,79.45,125,,,Fee Schedule,125% of CMS OPPS Rate,117.31,76,,240.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.13,72,,1368,Percent of Total Billed Charges,72% of Total Billed Charges,115.76,75,,1425,Percent of Total Billed charges,75% of Total Billed Charges,63.57,100,,,Fee Schedule,100% of CMS OPPS Rate,111.13,72,,1368,Percent of Total Billed Charges,72% of Total Billed Charges,92.61,60,,1140,Percent of Total Billed Charges,60% of Total Billed Charges,138.92,90,,337.36,Percent of Total Billed Charges,90% of Total Billed Charges,69.46,45,,104.4,Percent of Total Billed Charges,45% of Total Billed Charges,138.92,90,,285.12,Percent of Total Billed Charges,90% of Total billed Charges,63.57,100,,,Fee Schedule,100% of CMS OPPS Rate,63.57,100,,,Fee Schedule,100% of CMS OPPS Rate,63.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.14,200,,63.64,Fee Schedule,200% of CMS OPPS Rate,68.07,44.1,,102.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,146.63,95,,300.96,Percent of Total Billed Charges,95% of Total Billed Charges,47.67,75,,,Fee Schedule,75% of CMS OPPS Rate,135.83,88,,223.168,Percent of Total Billed Charges,88% of Total Billed Charges,138.92,90,,285.12,Percent of Total Billed charges,90% of Total Billed Charges,47.67,146.63,
PACKED RBC  LEUCYT R,3900000002,CDM,390,RC,P9016,HCPCS,Outpatient,,,677.00,440.05,,227.5,125,,,Fee Schedule,125% of CMS OPPS Rate,514.52,76,,62.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,487.44,72,,10849.536,Percent of Total Billed Charges,72% of Total Billed Charges,507.75,75,,11301.6,Percent of Total Billed charges,75% of Total Billed Charges,182,100,,,Fee Schedule,100% of CMS OPPS Rate,487.44,72,,10849.536,Percent of Total Billed Charges,72% of Total Billed Charges,406.2,60,,9041.28,Percent of Total Billed Charges,60% of Total Billed Charges,609.3,90,,119.864,Percent of Total Billed Charges,90% of Total Billed Charges,304.65,45,,114.12,Percent of Total Billed Charges,45% of Total Billed Charges,609.3,90,,73.824,Percent of Total Billed Charges,90% of Total billed Charges,182,100,,,Fee Schedule,100% of CMS OPPS Rate,182,100,,,Fee Schedule,100% of CMS OPPS Rate,182,100,,,Fee Schedule,100% of CMS OPPS Rate,364,200,,86.568,Fee Schedule,200% of CMS OPPS Rate,298.56,44.1,,111.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,643.15,95,,77.92,Percent of Total Billed Charges,95% of Total Billed Charges,136.5,75,,,Fee Schedule,75% of CMS OPPS Rate,595.76,88,,74.624,Percent of Total Billed Charges,88% of Total Billed Charges,609.3,90,,73.824,Percent of Total Billed charges,90% of Total Billed Charges,136.5,643.15,
FRESH FROZEN PLASMA,3900000003,CDM,390,RC,P9017,HCPCS,Outpatient,,,229.00,148.85,,105.36,125,,,Fee Schedule,125% of CMS OPPS Rate,174.04,76,,62.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,164.88,72,,12704.616,Percent of Total Billed Charges,72% of Total Billed Charges,171.75,75,,13233.976,Percent of Total Billed charges,75% of Total Billed Charges,84.29,100,,,Fee Schedule,100% of CMS OPPS Rate,164.88,72,,12704.616,Percent of Total Billed Charges,72% of Total Billed Charges,137.4,60,,10587.176,Percent of Total Billed Charges,60% of Total Billed Charges,206.1,90,,119.864,Percent of Total Billed Charges,90% of Total Billed Charges,103.05,45,,38.16,Percent of Total Billed Charges,45% of Total Billed Charges,206.1,90,,73.824,Percent of Total Billed Charges,90% of Total billed Charges,84.29,100,,,Fee Schedule,100% of CMS OPPS Rate,84.29,100,,,Fee Schedule,100% of CMS OPPS Rate,84.29,100,,,Fee Schedule,100% of CMS OPPS Rate,168.58,200,,136.096,Fee Schedule,200% of CMS OPPS Rate,100.99,44.1,,37.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,217.55,95,,77.92,Percent of Total Billed Charges,95% of Total Billed Charges,63.21,75,,,Fee Schedule,75% of CMS OPPS Rate,201.52,88,,164.544,Percent of Total Billed Charges,88% of Total Billed Charges,206.1,90,,73.824,Percent of Total Billed charges,90% of Total Billed Charges,63.21,217.55,
PLATELETAPHERESIS,3900000004,CDM,390,RC,P9035,HCPCS,Outpatient,,,1798.00,1168.70,,608.87,125,,,Fee Schedule,125% of CMS OPPS Rate,1366.48,76,,159.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1294.56,72,,12704.616,Percent of Total Billed Charges,72% of Total Billed Charges,1348.5,75,,13233.976,Percent of Total Billed charges,75% of Total Billed Charges,487.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1294.56,72,,12704.616,Percent of Total Billed Charges,72% of Total Billed Charges,1078.8,60,,10587.176,Percent of Total Billed Charges,60% of Total Billed Charges,1618.2,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,809.1,45,,84.144,Percent of Total Billed Charges,45% of Total Billed Charges,1618.2,90,,189.36,Percent of Total Billed Charges,90% of Total billed Charges,487.1,100,,,Fee Schedule,100% of CMS OPPS Rate,487.1,100,,,Fee Schedule,100% of CMS OPPS Rate,487.1,100,,,Fee Schedule,100% of CMS OPPS Rate,974.2,200,,136.096,Fee Schedule,200% of CMS OPPS Rate,792.92,44.1,,82.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,1708.1,95,,199.88,Percent of Total Billed Charges,95% of Total Billed Charges,365.32,75,,,Fee Schedule,75% of CMS OPPS Rate,1582.24,88,,329.864,Percent of Total Billed Charges,88% of Total Billed Charges,1618.2,90,,189.36,Percent of Total Billed charges,90% of Total Billed Charges,365.32,1708.1,
IRRADIATED BLOOD CHARGE,3900000005,CDM,390,RC,,,Outpatient,,,570.00,370.50,,570,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,433.2,76,,176.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,410.4,72,,9949.808,Percent of Total Billed Charges,72% of Total Billed Charges,427.5,75,,10364.384,Percent of Total Billed charges,75% of Total Billed Charges,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,410.4,72,,9949.808,Percent of Total Billed Charges,72% of Total Billed Charges,342,60,,8291.504,Percent of Total Billed Charges,60% of Total Billed Charges,513,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,256.5,45,,168.68,Percent of Total Billed Charges,45% of Total Billed Charges,513,90,,208.8,Percent of Total Billed Charges,90% of Total billed Charges,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.5,65,,68.664,Percent of total Billed Charges,65% of Total Billed Charges,251.37,44.1,,165.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,541.5,95,,220.4,Percent of Total Billed Charges,95% of Total Billed Charges,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.6,88,,164.544,Percent of Total Billed Charges,88% of Total Billed Charges,513,90,,208.8,Percent of Total Billed charges,90% of Total Billed Charges,251.37,570,
PR PLASMA EA UNIT,3900000006,CDM,390,RC,P9020,HCPCS,Outpatient,,,1260.00,819.00,,696.65,125,,,Fee Schedule,125% of CMS OPPS Rate,957.6,76,,192.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,907.2,72,,12704.616,Percent of Total Billed Charges,72% of Total Billed Charges,945,75,,13233.976,Percent of Total Billed charges,75% of Total Billed Charges,557.32,100,,,Fee Schedule,100% of CMS OPPS Rate,907.2,72,,12704.616,Percent of Total Billed Charges,72% of Total Billed Charges,756,60,,10587.176,Percent of Total Billed Charges,60% of Total Billed Charges,1134,90,,87.84,Percent of Total Billed Charges,90% of Total Billed Charges,567,45,,84.144,Percent of Total Billed Charges,45% of Total Billed Charges,1134,90,,228.24,Percent of Total Billed Charges,90% of Total billed Charges,557.32,100,,,Fee Schedule,100% of CMS OPPS Rate,557.32,100,,,Fee Schedule,100% of CMS OPPS Rate,557.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1114.64,200,,68.664,Fee Schedule,200% of CMS OPPS Rate,555.66,44.1,,82.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,1197,95,,240.92,Percent of Total Billed Charges,95% of Total Billed Charges,417.99,75,,,Fee Schedule,75% of CMS OPPS Rate,1108.8,88,,329.864,Percent of Total Billed Charges,88% of Total Billed Charges,1134,90,,228.24,Percent of Total Billed charges,90% of Total Billed Charges,417.99,1197,
BLOOD TRANSFUSION,3910000001,CDM,391,RC,,,Outpatient,,,987.00,641.55,,987,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,750.12,76,,64.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,710.64,72,,1278.712,Percent of Total Billed Charges,72% of Total Billed Charges,740.25,75,,1331.992,Percent of Total Billed charges,75% of Total Billed Charges,987,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,710.64,72,,1278.712,Percent of Total Billed Charges,72% of Total Billed Charges,592.2,60,,1065.592,Percent of Total Billed Charges,60% of Total Billed Charges,888.3,90,,87.84,Percent of Total Billed Charges,90% of Total Billed Charges,444.15,45,,168.68,Percent of Total Billed Charges,45% of Total Billed Charges,888.3,90,,76.32,Percent of Total Billed Charges,90% of Total billed Charges,987,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,987,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,987,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,641.55,65,,78.544,Percent of total Billed Charges,65% of Total Billed Charges,435.27,44.1,,165.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,937.65,95,,80.56,Percent of Total Billed Charges,95% of Total Billed Charges,987,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,868.56,88,,117.2,Percent of Total Billed Charges,88% of Total Billed Charges,888.3,90,,76.32,Percent of Total Billed charges,90% of Total Billed Charges,435.27,987,
BLOOD ADMINISTRATION,3910000002,CDM,391,RC,,,Outpatient,,,987.00,641.55,,987,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,750.12,76,,142.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,710.64,72,,7733.512,Percent of Total Billed Charges,72% of Total Billed Charges,740.25,75,,8055.736,Percent of Total Billed charges,75% of Total Billed Charges,987,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,710.64,72,,7733.512,Percent of Total Billed Charges,72% of Total Billed Charges,592.2,60,,6444.592,Percent of Total Billed Charges,60% of Total Billed Charges,888.3,90,,155.584,Percent of Total Billed Charges,90% of Total Billed Charges,444.15,45,,59.936,Percent of Total Billed Charges,45% of Total Billed Charges,888.3,90,,168.288,Percent of Total Billed Charges,90% of Total billed Charges,987,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,987,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,987,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,641.55,65,,78.544,Percent of total Billed Charges,65% of Total Billed Charges,435.27,44.1,,58.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,937.65,95,,177.632,Percent of Total Billed Charges,95% of Total Billed Charges,987,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,868.56,88,,117.2,Percent of Total Billed Charges,88% of Total Billed Charges,888.3,90,,168.288,Percent of Total Billed charges,90% of Total Billed Charges,435.27,987,
BLOOD EXCHANG TRANSF,3910000003,CDM,391,RC,,,Outpatient,,,314.21,204.24,,314.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,238.8,76,,284.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,226.23,72,,7694.952,Percent of Total Billed Charges,72% of Total Billed Charges,235.66,75,,8015.576,Percent of Total Billed charges,75% of Total Billed Charges,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.23,72,,7694.952,Percent of Total Billed Charges,72% of Total Billed Charges,188.53,60,,6412.456,Percent of Total Billed Charges,60% of Total Billed Charges,282.79,90,,155.584,Percent of Total Billed Charges,90% of Total Billed Charges,141.39,45,,59.936,Percent of Total Billed Charges,45% of Total Billed Charges,282.79,90,,337.36,Percent of Total Billed Charges,90% of Total billed Charges,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.24,65,,12.192,Percent of total Billed Charges,65% of Total Billed Charges,138.57,44.1,,58.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,298.5,95,,356.104,Percent of Total Billed Charges,95% of Total Billed Charges,314.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.5,88,,69.696,Percent of Total Billed Charges,88% of Total Billed Charges,282.79,90,,337.36,Percent of Total Billed charges,90% of Total Billed Charges,138.57,314.21,
DIG DIAGN MAMMO W/CAD  UNILAT,4010000001,CDM,401,RC,,,Outpatient,,,485.00,315.25,,485,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,368.6,76,,142.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,349.2,72,,15630.536,Percent of Total Billed Charges,72% of Total Billed Charges,363.75,75,,16281.808,Percent of Total Billed charges,75% of Total Billed Charges,485,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.2,72,,15630.536,Percent of Total Billed Charges,72% of Total Billed Charges,291,60,,13025.448,Percent of Total Billed Charges,60% of Total Billed Charges,436.5,90,,155.584,Percent of Total Billed Charges,90% of Total Billed Charges,218.25,45,,35.64,Percent of Total Billed Charges,45% of Total Billed Charges,436.5,90,,168.288,Percent of Total Billed Charges,90% of Total billed Charges,485,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.25,65,,53.312,Percent of total Billed Charges,65% of Total Billed Charges,213.89,44.1,,34.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,460.75,95,,177.632,Percent of Total Billed Charges,95% of Total Billed Charges,485,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.8,88,,69.696,Percent of Total Billed Charges,88% of Total Billed Charges,436.5,90,,168.288,Percent of Total Billed charges,90% of Total Billed Charges,213.89,485,
DIG DIAGN MAMMO W/CAD BILAT,4010000002,CDM,401,RC,,,Outpatient,,,593.00,385.45,,593,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,450.68,76,,284.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,426.96,72,,4315.392,Percent of Total Billed Charges,72% of Total Billed Charges,444.75,75,,4495.2,Percent of Total Billed charges,75% of Total Billed Charges,593,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.96,72,,4315.392,Percent of Total Billed Charges,72% of Total Billed Charges,355.8,60,,3596.16,Percent of Total Billed Charges,60% of Total Billed Charges,533.7,90,,155.584,Percent of Total Billed Charges,90% of Total Billed Charges,266.85,45,,35.64,Percent of Total Billed Charges,45% of Total Billed Charges,533.7,90,,337.36,Percent of Total Billed Charges,90% of Total billed Charges,593,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,593,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,593,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.45,65,,53.312,Percent of total Billed Charges,65% of Total Billed Charges,261.51,44.1,,34.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,563.35,95,,356.104,Percent of Total Billed Charges,95% of Total Billed Charges,593,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521.84,88,,85.888,Percent of Total Billed Charges,88% of Total Billed Charges,533.7,90,,337.36,Percent of Total Billed charges,90% of Total Billed Charges,261.51,593,
US BRST BIOP W/PLC LOC ADD LES,4010000003,CDM,402,RC,,,Outpatient,,,1304.00,847.60,,1304,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,991.04,76,,101.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,938.88,72,,12432.176,Percent of Total Billed Charges,72% of Total Billed Charges,978,75,,12950.184,Percent of Total Billed charges,75% of Total Billed Charges,1304,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,938.88,72,,12432.176,Percent of Total Billed Charges,72% of Total Billed Charges,782.4,60,,10360.144,Percent of Total Billed Charges,60% of Total Billed Charges,1173.6,90,,162.72,Percent of Total Billed Charges,90% of Total Billed Charges,586.8,45,,43.92,Percent of Total Billed Charges,45% of Total Billed Charges,1173.6,90,,119.864,Percent of Total Billed Charges,90% of Total billed Charges,1304,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1304,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1304,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,847.6,65,,160.16,Percent of total Billed Charges,65% of Total Billed Charges,575.06,44.1,,43.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,1238.8,95,,126.528,Percent of Total Billed Charges,95% of Total Billed Charges,1304,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1147.52,88,,85.888,Percent of Total Billed Charges,88% of Total Billed Charges,1173.6,90,,119.864,Percent of Total Billed charges,90% of Total Billed Charges,575.06,1304,
MAMMO LOCAL,4010000004,CDM,401,RC,,,Outpatient,,,1102.50,716.63,,1102.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,837.9,76,,101.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,793.8,72,,13969.616,Percent of Total Billed Charges,72% of Total Billed Charges,826.88,75,,14551.68,Percent of Total Billed charges,75% of Total Billed Charges,1102.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,793.8,72,,13969.616,Percent of Total Billed Charges,72% of Total Billed Charges,661.5,60,,11641.344,Percent of Total Billed Charges,60% of Total Billed Charges,992.25,90,,162.72,Percent of Total Billed Charges,90% of Total Billed Charges,496.13,45,,43.92,Percent of Total Billed Charges,45% of Total Billed Charges,992.25,90,,119.864,Percent of Total Billed Charges,90% of Total billed Charges,1102.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1102.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1102.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,716.63,65,,145.6,Percent of total Billed Charges,65% of Total Billed Charges,486.2,44.1,,43.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,1047.38,95,,126.528,Percent of Total Billed Charges,95% of Total Billed Charges,1102.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,970.2,88,,152.128,Percent of Total Billed Charges,88% of Total Billed Charges,992.25,90,,119.864,Percent of Total Billed charges,90% of Total Billed Charges,486.2,1102.5,
Scrn Diag Brst Tomosyntesis Bi,4010000007,CDM,403,RC,,,Outpatient,,,64.00,41.60,,64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,48.64,76,,60.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,46.08,72,,13969.616,Percent of Total Billed Charges,72% of Total Billed Charges,48,75,,14551.68,Percent of Total Billed charges,75% of Total Billed Charges,64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.08,72,,13969.616,Percent of Total Billed Charges,72% of Total Billed Charges,38.4,60,,11641.344,Percent of Total Billed Charges,60% of Total Billed Charges,57.6,90,,85.728,Percent of Total Billed Charges,90% of Total Billed Charges,28.8,45,,77.792,Percent of Total Billed Charges,45% of Total Billed Charges,57.6,90,,71.28,Percent of Total Billed Charges,90% of Total billed Charges,64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.6,65,,146.12,Percent of total Billed Charges,65% of Total Billed Charges,28.22,44.1,,76.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,60.8,95,,75.24,Percent of Total Billed Charges,95% of Total Billed Charges,64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.32,88,,152.128,Percent of Total Billed Charges,88% of Total Billed Charges,57.6,90,,71.28,Percent of Total Billed charges,90% of Total Billed Charges,28.22,64,
Diag dig Brst Tomosynthesis,4010000008,CDM,401,RC,G0279,HCPCS,Outpatient,,,66.00,42.90,,17.95,125,,,Fee Schedule,125% of CMS OPPS Rate,50.16,76,,60.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,142.94,350,,19811.984,Fee Schedule,350% of BCBS fee schedule,142.94,350,,20637.48,Fee Schedule,350% of BCBS fee schedule,14.36,100,,,Fee Schedule,100% of CMS OPPS Rate,142.94,561,,19811.984,Fee Schedule,561% of BCBS PPO fee schedule,25.48,100,,16509.984,Fee Schedule,100% of Blue ADV HMO fee schedule,59.4,90,,77.76,Percent of Total Billed Charges,90% of Total Billed Charges,29.7,45,,77.792,Percent of Total Billed Charges,45% of Total Billed Charges,59.4,90,,71.28,Percent of Total Billed Charges,90% of Total billed Charges,14.36,100,,,Fee Schedule,100% of CMS OPPS Rate,14.36,100,,,Fee Schedule,100% of CMS OPPS Rate,14.36,100,,,Fee Schedule,100% of CMS OPPS Rate,28.72,200,,60.84,Fee Schedule,200% of CMS OPPS Rate,29.11,44.1,,76.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.7,95,,75.24,Percent of Total Billed Charges,95% of Total Billed Charges,10.77,75,,,Fee Schedule,75% of CMS OPPS Rate,58.08,88,,152.128,Percent of Total Billed Charges,88% of Total Billed Charges,59.4,90,,71.28,Percent of Total Billed charges,90% of Total Billed Charges,10.77,142.94,
THORACENTESIS W/ IMAGING GUID,4020000001,CDM,761,RC,,,Outpatient,,,1854.00,1205.10,,1854,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1409.04,76,,131.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,3396.824,Case Rate,Pays Based on per visit rate,50,100,,3538.36,Case Rate,Pays based on per visit rate,1854,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,3396.824,Case Rate,Pays based on per visit rate,50,100,,2830.688,Case Rate,Pays based on per visit rate,1668.6,90,,108.752,Percent of Total Billed Charges,90% of Total Billed Charges,834.3,45,,81.36,Percent of Total Billed Charges,45% of Total Billed Charges,1668.6,90,,155.584,Percent of Total Billed Charges,90% of Total billed Charges,1854,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1854,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1854,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1205.1,65,,28.664,Percent of total Billed Charges,65% of Total Billed Charges,817.61,44.1,,79.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,1761.3,95,,164.232,Percent of Total Billed Charges,95% of Total Billed Charges,1854,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1631.52,88,,83.824,Percent of Total Billed Charges,88% of Total Billed Charges,1668.6,90,,155.584,Percent of Total Billed charges,90% of Total Billed Charges,50,1854,
US  BREAST UNILATERAL LIMITED,4020000002,CDM,402,RC,,,Outpatient,,,566.00,367.90,,566,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.16,76,,131.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,407.52,72,,3396.824,Percent of Total Billed Charges,72% of Total Billed Charges,424.5,75,,3538.36,Percent of Total Billed charges,75% of Total Billed Charges,566,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.52,72,,3396.824,Percent of Total Billed Charges,72% of Total Billed Charges,339.6,60,,2830.688,Percent of Total Billed Charges,60% of Total Billed Charges,509.4,90,,114.48,Percent of Total Billed Charges,90% of Total Billed Charges,254.7,45,,42.864,Percent of Total Billed Charges,45% of Total Billed Charges,509.4,90,,155.584,Percent of Total Billed Charges,90% of Total billed Charges,566,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,367.9,65,,212.16,Percent of total Billed Charges,65% of Total Billed Charges,249.61,44.1,,42.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,537.7,95,,164.232,Percent of Total Billed Charges,95% of Total Billed Charges,566,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.08,88,,76.032,Percent of Total Billed Charges,88% of Total Billed Charges,509.4,90,,155.584,Percent of Total Billed charges,90% of Total Billed Charges,249.61,566,
US  BREAST UNILATERAL COMP,4020000003,CDM,402,RC,,,Outpatient,,,621.00,403.65,,621,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,471.96,76,,131.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,447.12,72,,29173.736,Percent of Total Billed Charges,72% of Total Billed Charges,465.75,75,,30389.312,Percent of Total Billed charges,75% of Total Billed Charges,621,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,447.12,72,,29173.736,Percent of Total Billed Charges,72% of Total Billed Charges,372.6,60,,24311.448,Percent of Total Billed Charges,60% of Total Billed Charges,558.9,90,,117.36,Percent of Total Billed Charges,90% of Total Billed Charges,279.45,45,,38.88,Percent of Total Billed Charges,45% of Total Billed Charges,558.9,90,,155.584,Percent of Total Billed Charges,90% of Total billed Charges,621,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,621,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,621,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,403.65,65,,168.48,Percent of total Billed Charges,65% of Total Billed Charges,273.86,44.1,,38.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,589.95,95,,164.232,Percent of Total Billed Charges,95% of Total Billed Charges,621,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.48,88,,79.944,Percent of Total Billed Charges,88% of Total Billed Charges,558.9,90,,155.584,Percent of Total Billed charges,90% of Total Billed Charges,273.86,621,
US  PERCU DRNGE PERITON/VISCE,4020000004,CDM,402,RC,,,Outpatient,,,2059.47,1338.66,,2059.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1565.2,76,,137.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1482.82,72,,29173.736,Percent of Total Billed Charges,72% of Total Billed Charges,1544.6,75,,30389.312,Percent of Total Billed charges,75% of Total Billed Charges,2059.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1482.82,72,,29173.736,Percent of Total Billed Charges,72% of Total Billed Charges,1235.68,60,,24311.448,Percent of Total Billed Charges,60% of Total Billed Charges,1853.52,90,,117.36,Percent of Total Billed Charges,90% of Total Billed Charges,926.76,45,,40.88,Percent of Total Billed Charges,45% of Total Billed Charges,1853.52,90,,162.72,Percent of Total Billed Charges,90% of Total billed Charges,2059.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2059.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2059.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1338.66,65,,45.76,Percent of total Billed Charges,65% of Total Billed Charges,908.23,44.1,,40.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,1956.5,95,,171.76,Percent of Total Billed Charges,95% of Total Billed Charges,2059.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1812.33,88,,106.336,Percent of Total Billed Charges,88% of Total Billed Charges,1853.52,90,,162.72,Percent of Total Billed charges,90% of Total Billed Charges,908.23,2059.47,
US  VASC GUID FOR SITE ACCESS,4020000005,CDM,402,RC,,,Outpatient,,,780.00,507.00,,780,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,592.8,76,,137.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,561.6,72,,60149.72,Percent of Total Billed Charges,72% of Total Billed Charges,585,75,,62655.96,Percent of Total Billed charges,75% of Total Billed Charges,780,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561.6,72,,60149.72,Percent of Total Billed Charges,72% of Total Billed Charges,468,60,,50124.768,Percent of Total Billed Charges,60% of Total Billed Charges,702,90,,126.72,Percent of Total Billed Charges,90% of Total Billed Charges,351,45,,54.376,Percent of Total Billed Charges,45% of Total Billed Charges,702,90,,162.72,Percent of Total Billed Charges,90% of Total billed Charges,780,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507,65,,49.92,Percent of total Billed Charges,65% of Total Billed Charges,343.98,44.1,,53.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,741,95,,171.76,Percent of Total Billed Charges,95% of Total Billed Charges,780,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,686.4,88,,111.936,Percent of Total Billed Charges,88% of Total Billed Charges,702,90,,162.72,Percent of Total Billed charges,90% of Total Billed Charges,343.98,780,
US  VASC GUID FOR SITE ACCESS,4020000006,CDM,402,RC,,,Outpatient,,,821.00,533.65,,821,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,623.96,76,,72.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,591.12,72,,60149.72,Percent of Total Billed Charges,72% of Total Billed Charges,615.75,75,,62655.96,Percent of Total Billed charges,75% of Total Billed Charges,821,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,591.12,72,,60149.72,Percent of Total Billed Charges,72% of Total Billed Charges,492.6,60,,50124.768,Percent of Total Billed Charges,60% of Total Billed Charges,738.9,90,,126.72,Percent of Total Billed Charges,90% of Total Billed Charges,369.45,45,,57.24,Percent of Total Billed Charges,45% of Total Billed Charges,738.9,90,,85.728,Percent of Total Billed Charges,90% of Total billed Charges,821,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,821,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,821,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,533.65,65,,12.192,Percent of total Billed Charges,65% of Total Billed Charges,362.06,44.1,,56.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,779.95,95,,90.496,Percent of Total Billed Charges,95% of Total Billed Charges,821,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,722.48,88,,106.336,Percent of Total Billed Charges,88% of Total Billed Charges,738.9,90,,85.728,Percent of Total Billed charges,90% of Total Billed Charges,362.06,821,
US  VASC GUID FOR SITE ACCESS,4020000007,CDM,402,RC,,,Outpatient,,,821.00,533.65,,821,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,623.96,76,,65.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,591.12,72,,60149.72,Percent of Total Billed Charges,72% of Total Billed Charges,615.75,75,,62655.96,Percent of Total Billed charges,75% of Total Billed Charges,821,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,591.12,72,,60149.72,Percent of Total Billed Charges,72% of Total Billed Charges,492.6,60,,50124.768,Percent of Total Billed Charges,60% of Total Billed Charges,738.9,90,,164.16,Percent of Total Billed Charges,90% of Total Billed Charges,369.45,45,,54.376,Percent of Total Billed Charges,45% of Total Billed Charges,738.9,90,,77.76,Percent of Total Billed Charges,90% of Total billed Charges,821,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,821,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,821,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,533.65,65,,218.92,Percent of total Billed Charges,65% of Total Billed Charges,362.06,44.1,,53.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,779.95,95,,82.08,Percent of Total Billed Charges,95% of Total Billed Charges,821,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,722.48,88,,111.936,Percent of Total Billed Charges,88% of Total Billed Charges,738.9,90,,77.76,Percent of Total Billed charges,90% of Total Billed Charges,362.06,821,
US BRST BIOP W PLC LOC 1ST LES,4020000008,CDM,761,RC,,,Outpatient,,,3383.00,2198.95,,3383,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2571.08,76,,69.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,293.392,Case Rate,Pays Based on per visit rate,50,100,,305.616,Case Rate,Pays based on per visit rate,3383,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,293.392,Case Rate,Pays based on per visit rate,50,100,,244.496,Case Rate,Pays based on per visit rate,3044.7,90,,164.16,Percent of Total Billed Charges,90% of Total Billed Charges,1522.35,45,,57.24,Percent of Total Billed Charges,45% of Total Billed Charges,3044.7,90,,81.76,Percent of Total Billed Charges,90% of Total billed Charges,3383,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3383,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3383,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2198.95,65,,218.92,Percent of total Billed Charges,65% of Total Billed Charges,1491.9,44.1,,56.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,3213.85,95,,86.304,Percent of Total Billed Charges,95% of Total Billed Charges,3383,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2977.04,88,,114.752,Percent of Total Billed Charges,88% of Total Billed Charges,3044.7,90,,81.76,Percent of Total Billed charges,90% of Total Billed Charges,50,3383,
US BRST BIOP W/PLC LOC 1ST LES,4020000009,CDM,402,RC,,,Outpatient,,,3654.00,2375.10,,3654,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2777.04,76,,91.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2630.88,72,,7833.6,Percent of Total Billed Charges,72% of Total Billed Charges,2740.5,75,,8160,Percent of Total Billed charges,75% of Total Billed Charges,3654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2630.88,72,,7833.6,Percent of Total Billed Charges,72% of Total Billed Charges,2192.4,60,,6528,Percent of Total Billed Charges,60% of Total Billed Charges,3288.6,90,,144,Percent of Total Billed Charges,90% of Total Billed Charges,1644.3,45,,58.68,Percent of Total Billed Charges,45% of Total Billed Charges,3288.6,90,,108.752,Percent of Total Billed Charges,90% of Total billed Charges,3654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2375.1,65,,74.36,Percent of total Billed Charges,65% of Total Billed Charges,1611.41,44.1,,57.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,3471.3,95,,114.792,Percent of Total Billed Charges,95% of Total Billed Charges,3654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3215.52,88,,114.752,Percent of Total Billed Charges,88% of Total Billed Charges,3288.6,90,,108.752,Percent of Total Billed charges,90% of Total Billed Charges,1611.41,3654,
US BRST BIOP W/PLC LOC ADD LES,4020000010,CDM,761,RC,,,Outpatient,,,1207.24,784.71,,1207.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,917.5,76,,96.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,3144.784,Case Rate,Pays Based on per visit rate,50,100,,3275.816,Case Rate,Pays based on per visit rate,1207.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,3144.784,Case Rate,Pays based on per visit rate,50,100,,2620.648,Case Rate,Pays based on per visit rate,1086.52,90,,144,Percent of Total Billed Charges,90% of Total Billed Charges,543.26,45,,58.68,Percent of Total Billed Charges,45% of Total Billed Charges,1086.52,90,,114.48,Percent of Total Billed Charges,90% of Total billed Charges,1207.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1207.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1207.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,784.71,65,,77.968,Percent of total Billed Charges,65% of Total Billed Charges,532.39,44.1,,57.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,1146.88,95,,120.84,Percent of Total Billed Charges,95% of Total Billed Charges,1207.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1062.37,88,,123.904,Percent of Total Billed Charges,88% of Total Billed Charges,1086.52,90,,114.48,Percent of Total Billed charges,90% of Total Billed Charges,50,1207.24,
USPERCU DRNGE RETROPERITO ABC,4020000011,CDM,402,RC,,,Outpatient,,,4473.95,2908.07,,4473.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3400.2,76,,91.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3221.24,72,,15630.536,Percent of Total Billed Charges,72% of Total Billed Charges,3355.46,75,,16281.808,Percent of Total Billed charges,75% of Total Billed Charges,4473.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3221.24,72,,15630.536,Percent of Total Billed Charges,72% of Total Billed Charges,2684.37,60,,13025.448,Percent of Total Billed Charges,60% of Total Billed Charges,4026.56,90,,79.2,Percent of Total Billed Charges,90% of Total Billed Charges,2013.28,45,,63.36,Percent of Total Billed Charges,45% of Total Billed Charges,4026.56,90,,108.752,Percent of Total Billed Charges,90% of Total billed Charges,4473.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4473.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4473.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2908.07,65,,228.752,Percent of total Billed Charges,65% of Total Billed Charges,1973.01,44.1,,62.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,4250.25,95,,114.792,Percent of Total Billed Charges,95% of Total Billed Charges,4473.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3937.08,88,,123.904,Percent of Total Billed Charges,88% of Total Billed Charges,4026.56,90,,108.752,Percent of Total Billed charges,90% of Total Billed Charges,1973.01,4473.95,
US FNA BIOPSY  INCDL GUIDANCE,4020000012,CDM,402,RC,,,Outpatient,,,1520.00,988.00,,1520,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1155.2,76,,96.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1094.4,72,,5155.672,Percent of Total Billed Charges,72% of Total Billed Charges,1140,75,,5370.496,Percent of Total Billed charges,75% of Total Billed Charges,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1094.4,72,,5155.672,Percent of Total Billed Charges,72% of Total Billed Charges,912,60,,4296.392,Percent of Total Billed Charges,60% of Total Billed Charges,1368,90,,79.2,Percent of Total Billed Charges,90% of Total Billed Charges,684,45,,63.36,Percent of Total Billed Charges,45% of Total Billed Charges,1368,90,,114.48,Percent of Total Billed Charges,90% of Total billed Charges,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,988,65,,46.44,Percent of total Billed Charges,65% of Total Billed Charges,670.32,44.1,,62.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,1444,95,,120.84,Percent of Total Billed Charges,95% of Total Billed Charges,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1337.6,88,,160.512,Percent of Total Billed Charges,88% of Total Billed Charges,1368,90,,114.48,Percent of Total Billed charges,90% of Total Billed Charges,670.32,1520,
US FNA  ADDL LESION,4020000013,CDM,402,RC,,,Outpatient,,,570.00,370.50,,570,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,433.2,76,,99.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,410.4,72,,981.136,Percent of Total Billed Charges,72% of Total Billed Charges,427.5,75,,1022.016,Percent of Total Billed charges,75% of Total Billed Charges,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,410.4,72,,981.136,Percent of Total Billed Charges,72% of Total Billed Charges,342,60,,817.616,Percent of Total Billed Charges,60% of Total Billed Charges,513,90,,86.52,Percent of Total Billed Charges,90% of Total Billed Charges,256.5,45,,82.08,Percent of Total Billed Charges,45% of Total Billed Charges,513,90,,117.36,Percent of Total Billed Charges,90% of Total billed Charges,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.5,65,,46.44,Percent of total Billed Charges,65% of Total Billed Charges,251.37,44.1,,80.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,541.5,95,,123.88,Percent of Total Billed Charges,95% of Total Billed Charges,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.6,88,,160.512,Percent of Total Billed Charges,88% of Total Billed Charges,513,90,,117.36,Percent of Total Billed charges,90% of Total Billed Charges,251.37,570,
PARACENTESIS WITH ULTRASOUND,4020000014,CDM,402,RC,,,Outpatient,,,2160.00,1404.00,,2160,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1641.6,76,,99.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1555.2,72,,16972.08,Percent of Total Billed Charges,72% of Total Billed Charges,1620,75,,17679.256,Percent of Total Billed charges,75% of Total Billed Charges,2160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1555.2,72,,16972.08,Percent of Total Billed Charges,72% of Total Billed Charges,1296,60,,14143.4,Percent of Total Billed Charges,60% of Total Billed Charges,1944,90,,86.52,Percent of Total Billed Charges,90% of Total Billed Charges,972,45,,82.08,Percent of Total Billed Charges,45% of Total Billed Charges,1944,90,,117.36,Percent of Total Billed Charges,90% of Total billed Charges,2160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1404,65,,46.44,Percent of total Billed Charges,65% of Total Billed Charges,952.56,44.1,,80.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,2052,95,,123.88,Percent of Total Billed Charges,95% of Total Billed Charges,2160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1900.8,88,,140.8,Percent of Total Billed Charges,88% of Total Billed Charges,1944,90,,117.36,Percent of Total Billed charges,90% of Total Billed Charges,952.56,2160,
US PROSTATE BIOPSY,4020000015,CDM,402,RC,,,Outpatient,,,4637.20,3014.18,,4637.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3524.27,76,,107.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3338.78,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,3477.9,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,4637.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3338.78,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,2782.32,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,4173.48,90,,87.12,Percent of Total Billed Charges,90% of Total Billed Charges,2086.74,45,,72,Percent of Total Billed Charges,45% of Total Billed Charges,4173.48,90,,126.72,Percent of Total Billed Charges,90% of Total billed Charges,4637.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4637.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4637.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3014.18,65,,184.08,Percent of total Billed Charges,65% of Total Billed Charges,2045.01,44.1,,70.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,4405.34,95,,133.76,Percent of Total Billed Charges,95% of Total Billed Charges,4637.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4080.74,88,,140.8,Percent of Total Billed Charges,88% of Total Billed Charges,4173.48,90,,126.72,Percent of Total Billed charges,90% of Total Billed Charges,2045.01,4637.2,
BRAIN NEONATAL(HEAD),4020000016,CDM,402,RC,,,Outpatient,,,770.00,500.50,,770,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,585.2,76,,107.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,554.4,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,577.5,75,,14082.016,Percent of Total Billed charges,75% of Total Billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.4,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,462,60,,11265.608,Percent of Total Billed Charges,60% of Total Billed Charges,693,90,,87.12,Percent of Total Billed Charges,90% of Total Billed Charges,346.5,45,,72,Percent of Total Billed Charges,45% of Total Billed Charges,693,90,,126.72,Percent of Total Billed Charges,90% of Total billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.5,65,,158.6,Percent of total Billed Charges,65% of Total Billed Charges,339.57,44.1,,70.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,731.5,95,,133.76,Percent of Total Billed Charges,95% of Total Billed Charges,770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.6,88,,77.44,Percent of Total Billed Charges,88% of Total Billed Charges,693,90,,126.72,Percent of Total Billed charges,90% of Total Billed Charges,339.57,770,
THYROID ECHO B MODE,4020000017,CDM,402,RC,,,Outpatient,,,922.00,599.30,,922,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,700.72,76,,138.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,663.84,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,691.5,75,,14082.016,Percent of Total Billed charges,75% of Total Billed Charges,922,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,663.84,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,553.2,60,,11265.608,Percent of Total Billed Charges,60% of Total Billed Charges,829.8,90,,80.176,Percent of Total Billed Charges,90% of Total Billed Charges,414.9,45,,39.6,Percent of Total Billed Charges,45% of Total Billed Charges,829.8,90,,164.16,Percent of Total Billed Charges,90% of Total billed Charges,922,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,922,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,922,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,599.3,65,,158.232,Percent of total Billed Charges,65% of Total Billed Charges,406.6,44.1,,38.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,875.9,95,,173.28,Percent of Total Billed Charges,95% of Total Billed Charges,922,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,811.36,88,,77.44,Percent of Total Billed Charges,88% of Total Billed Charges,829.8,90,,164.16,Percent of Total Billed charges,90% of Total Billed Charges,406.6,922,
US HEAD/NECK SOFT TI,4020000018,CDM,402,RC,,,Outpatient,,,922.00,599.30,,922,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,700.72,76,,138.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,663.84,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,691.5,75,,14082.016,Percent of Total Billed charges,75% of Total Billed Charges,922,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,663.84,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,553.2,60,,11265.608,Percent of Total Billed Charges,60% of Total Billed Charges,829.8,90,,80.176,Percent of Total Billed Charges,90% of Total Billed Charges,414.9,45,,39.6,Percent of Total Billed Charges,45% of Total Billed Charges,829.8,90,,164.16,Percent of Total Billed Charges,90% of Total billed Charges,922,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,922,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,922,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,599.3,65,,194.48,Percent of total Billed Charges,65% of Total Billed Charges,406.6,44.1,,38.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,875.9,95,,173.28,Percent of Total Billed Charges,95% of Total Billed Charges,922,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,811.36,88,,84.6,Percent of Total Billed Charges,88% of Total Billed Charges,829.8,90,,164.16,Percent of Total Billed charges,90% of Total Billed Charges,406.6,922,
US CHEST,4020000019,CDM,402,RC,,,Outpatient,,,365.00,237.25,,365,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,277.4,76,,121.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,262.8,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,273.75,75,,14082.016,Percent of Total Billed charges,75% of Total Billed Charges,365,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.8,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,219,60,,11265.608,Percent of Total Billed Charges,60% of Total Billed Charges,328.5,90,,468.376,Percent of Total Billed Charges,90% of Total Billed Charges,164.25,45,,43.264,Percent of Total Billed Charges,45% of Total Billed Charges,328.5,90,,144,Percent of Total Billed Charges,90% of Total billed Charges,365,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.25,65,,63.64,Percent of total Billed Charges,65% of Total Billed Charges,160.97,44.1,,42.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,346.75,95,,152,Percent of Total Billed Charges,95% of Total Billed Charges,365,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,321.2,88,,84.6,Percent of Total Billed Charges,88% of Total Billed Charges,328.5,90,,144,Percent of Total Billed charges,90% of Total Billed Charges,160.97,365,
ABDOMEN COMPLETE,4020000020,CDM,402,RC,,,Outpatient,,,1331.00,865.15,,1331,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1011.56,76,,121.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,958.32,72,,959.04,Percent of Total Billed Charges,72% of Total Billed Charges,998.25,75,,999,Percent of Total Billed charges,75% of Total Billed Charges,1331,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,958.32,72,,959.04,Percent of Total Billed Charges,72% of Total Billed Charges,798.6,60,,799.2,Percent of Total Billed Charges,60% of Total Billed Charges,1197.9,90,,468.376,Percent of Total Billed Charges,90% of Total Billed Charges,598.95,45,,43.264,Percent of Total Billed Charges,45% of Total Billed Charges,1197.9,90,,144,Percent of Total Billed Charges,90% of Total billed Charges,1331,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1331,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1331,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,865.15,65,,332.512,Percent of total Billed Charges,65% of Total Billed Charges,586.97,44.1,,42.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1264.45,95,,152,Percent of Total Billed Charges,95% of Total Billed Charges,1331,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1171.28,88,,85.184,Percent of Total Billed Charges,88% of Total Billed Charges,1197.9,90,,144,Percent of Total Billed charges,90% of Total Billed Charges,586.97,1331,
HEPATIC/LIVER ECHO,4020000021,CDM,402,RC,,,Outpatient,,,988.00,642.20,,988,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,750.88,76,,66.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,711.36,72,,2098.704,Percent of Total Billed Charges,72% of Total Billed Charges,741,75,,2186.152,Percent of Total Billed charges,75% of Total Billed Charges,988,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,711.36,72,,2098.704,Percent of Total Billed Charges,72% of Total Billed Charges,592.8,60,,1748.92,Percent of Total Billed Charges,60% of Total Billed Charges,889.2,90,,167.496,Percent of Total Billed Charges,90% of Total Billed Charges,444.6,45,,43.56,Percent of Total Billed Charges,45% of Total Billed Charges,889.2,90,,79.2,Percent of Total Billed Charges,90% of Total billed Charges,988,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,988,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,988,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,642.2,65,,32.68,Percent of total Billed Charges,65% of Total Billed Charges,435.71,44.1,,42.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,938.6,95,,83.6,Percent of Total Billed Charges,95% of Total Billed Charges,988,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,869.44,88,,85.184,Percent of Total Billed Charges,88% of Total Billed Charges,889.2,90,,79.2,Percent of Total Billed charges,90% of Total Billed Charges,435.71,988,
GALL BLADDER ECHO,4020000022,CDM,402,RC,,,Outpatient,,,988.00,642.20,,988,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,750.88,76,,66.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,711.36,72,,1049.36,Percent of Total Billed Charges,72% of Total Billed Charges,741,75,,1093.08,Percent of Total Billed charges,75% of Total Billed Charges,988,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,711.36,72,,1049.36,Percent of Total Billed Charges,72% of Total Billed Charges,592.8,60,,874.464,Percent of Total Billed Charges,60% of Total Billed Charges,889.2,90,,167.496,Percent of Total Billed Charges,90% of Total Billed Charges,444.6,45,,43.56,Percent of Total Billed Charges,45% of Total Billed Charges,889.2,90,,79.2,Percent of Total Billed Charges,90% of Total billed Charges,988,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,988,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,988,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,642.2,65,,218.424,Percent of total Billed Charges,65% of Total Billed Charges,435.71,44.1,,42.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,938.6,95,,83.6,Percent of Total Billed Charges,95% of Total Billed Charges,988,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,869.44,88,,78.392,Percent of Total Billed Charges,88% of Total Billed Charges,889.2,90,,79.2,Percent of Total Billed charges,90% of Total Billed Charges,435.71,988,
SPLEEN ECHO B MODE,4020000023,CDM,402,RC,,,Outpatient,,,988.00,642.20,,988,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,750.88,76,,73.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,711.36,72,,1485.504,Percent of Total Billed Charges,72% of Total Billed Charges,741,75,,1547.4,Percent of Total Billed charges,75% of Total Billed Charges,988,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,711.36,72,,1485.504,Percent of Total Billed Charges,72% of Total Billed Charges,592.8,60,,1237.92,Percent of Total Billed Charges,60% of Total Billed Charges,889.2,90,,38.16,Percent of Total Billed Charges,90% of Total Billed Charges,444.6,45,,40.088,Percent of Total Billed Charges,45% of Total Billed Charges,889.2,90,,86.52,Percent of Total Billed Charges,90% of Total billed Charges,988,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,988,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,988,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,642.2,65,,218.424,Percent of total Billed Charges,65% of Total Billed Charges,435.71,44.1,,39.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,938.6,95,,91.328,Percent of Total Billed Charges,95% of Total Billed Charges,988,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,869.44,88,,78.392,Percent of Total Billed Charges,88% of Total Billed Charges,889.2,90,,86.52,Percent of Total Billed charges,90% of Total Billed Charges,435.71,988,
PANCREAS ECHO B MODE,4020000024,CDM,402,RC,,,Outpatient,,,942.64,612.72,,942.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,716.41,76,,73.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,678.7,72,,4849.344,Percent of Total Billed Charges,72% of Total Billed Charges,706.98,75,,5051.4,Percent of Total Billed charges,75% of Total Billed Charges,942.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678.7,72,,4849.344,Percent of Total Billed Charges,72% of Total Billed Charges,565.58,60,,4041.12,Percent of Total Billed Charges,60% of Total Billed Charges,848.38,90,,38.16,Percent of Total Billed Charges,90% of Total Billed Charges,424.19,45,,40.088,Percent of Total Billed Charges,45% of Total Billed Charges,848.38,90,,86.52,Percent of Total Billed Charges,90% of Total billed Charges,942.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,942.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,942.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.72,65,,176.8,Percent of total Billed Charges,65% of Total Billed Charges,415.7,44.1,,39.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,895.51,95,,91.328,Percent of Total Billed Charges,95% of Total Billed Charges,942.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,829.52,88,,457.968,Percent of Total Billed Charges,88% of Total Billed Charges,848.38,90,,86.52,Percent of Total Billed charges,90% of Total Billed Charges,415.7,942.64,
US LIMITED ABDOMEN,4020000025,CDM,402,RC,,,Outpatient,,,988.00,642.20,,988,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,750.88,76,,73.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,711.36,72,,7825.6,Percent of Total Billed Charges,72% of Total Billed Charges,741,75,,8151.664,Percent of Total Billed charges,75% of Total Billed Charges,988,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,711.36,72,,7825.6,Percent of Total Billed Charges,72% of Total Billed Charges,592.8,60,,6521.336,Percent of Total Billed Charges,60% of Total Billed Charges,889.2,90,,88.112,Percent of Total Billed Charges,90% of Total Billed Charges,444.6,45,,234.184,Percent of Total Billed Charges,45% of Total Billed Charges,889.2,90,,87.12,Percent of Total Billed Charges,90% of Total billed Charges,988,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,988,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,988,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,642.2,65,,191.36,Percent of total Billed Charges,65% of Total Billed Charges,435.71,44.1,,229.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,938.6,95,,91.96,Percent of Total Billed Charges,95% of Total Billed Charges,988,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,869.44,88,,457.968,Percent of Total Billed Charges,88% of Total Billed Charges,889.2,90,,87.12,Percent of Total Billed charges,90% of Total Billed Charges,435.71,988,
SCREENING AAA,4020000026,CDM,402,RC,,,Outpatient,,,794.00,516.10,,794,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,603.44,76,,73.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,571.68,72,,3743.424,Percent of Total Billed Charges,72% of Total Billed Charges,595.5,75,,3899.4,Percent of Total Billed charges,75% of Total Billed Charges,794,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,571.68,72,,3743.424,Percent of Total Billed Charges,72% of Total Billed Charges,476.4,60,,3119.52,Percent of Total Billed Charges,60% of Total Billed Charges,714.6,90,,88.112,Percent of Total Billed Charges,90% of Total Billed Charges,357.3,45,,234.184,Percent of Total Billed Charges,45% of Total Billed Charges,714.6,90,,87.12,Percent of Total Billed Charges,90% of Total billed Charges,794,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,794,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,794,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,516.1,65,,143,Percent of total Billed Charges,65% of Total Billed Charges,350.15,44.1,,229.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,754.3,95,,91.96,Percent of Total Billed Charges,95% of Total Billed Charges,794,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,698.72,88,,163.768,Percent of Total Billed Charges,88% of Total Billed Charges,714.6,90,,87.12,Percent of Total Billed charges,90% of Total Billed Charges,350.15,794,
US COMPLE RTROTONL C,4020000027,CDM,402,RC,,,Outpatient,,,730.00,474.50,,730,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,554.8,76,,67.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,525.6,72,,10033.632,Percent of Total Billed Charges,72% of Total Billed Charges,547.5,75,,10451.704,Percent of Total Billed charges,75% of Total Billed Charges,730,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,525.6,72,,10033.632,Percent of Total Billed Charges,72% of Total Billed Charges,438,60,,8361.36,Percent of Total Billed Charges,60% of Total Billed Charges,657,90,,88.112,Percent of Total Billed Charges,90% of Total Billed Charges,328.5,45,,83.744,Percent of Total Billed Charges,45% of Total Billed Charges,657,90,,80.176,Percent of Total Billed Charges,90% of Total billed Charges,730,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,730,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,730,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.5,65,,171.992,Percent of total Billed Charges,65% of Total Billed Charges,321.93,44.1,,82.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,693.5,95,,84.624,Percent of Total Billed Charges,95% of Total Billed Charges,730,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,642.4,88,,163.768,Percent of Total Billed Charges,88% of Total Billed Charges,657,90,,80.176,Percent of Total Billed charges,90% of Total Billed Charges,321.93,730,
US AORTA/ORGAN,4020000028,CDM,402,RC,,,Outpatient,,,794.00,516.10,,794,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,603.44,76,,67.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,571.68,72,,10033.632,Percent of Total Billed Charges,72% of Total Billed Charges,595.5,75,,10451.704,Percent of Total Billed charges,75% of Total Billed Charges,794,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,571.68,72,,10033.632,Percent of Total Billed Charges,72% of Total Billed Charges,476.4,60,,8361.36,Percent of Total Billed Charges,60% of Total Billed Charges,714.6,90,,88.112,Percent of Total Billed Charges,90% of Total Billed Charges,357.3,45,,83.744,Percent of Total Billed Charges,45% of Total Billed Charges,714.6,90,,80.176,Percent of Total Billed Charges,90% of Total billed Charges,794,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,794,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,794,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,516.1,65,,20.28,Percent of total Billed Charges,65% of Total Billed Charges,350.15,44.1,,82.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,754.3,95,,84.624,Percent of Total Billed Charges,95% of Total Billed Charges,794,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,698.72,88,,37.312,Percent of Total Billed Charges,88% of Total Billed Charges,714.6,90,,80.176,Percent of Total Billed charges,90% of Total Billed Charges,350.15,794,
US LIMITED RETROPERITONEAL,4020000029,CDM,402,RC,,,Outpatient,,,835.70,543.21,,835.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,635.13,76,,395.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,601.7,72,,9532.224,Percent of Total Billed Charges,72% of Total Billed Charges,626.78,75,,9929.4,Percent of Total Billed charges,75% of Total Billed Charges,835.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,601.7,72,,9532.224,Percent of Total Billed Charges,72% of Total Billed Charges,501.42,60,,7943.52,Percent of Total Billed Charges,60% of Total Billed Charges,752.13,90,,214.56,Percent of Total Billed Charges,90% of Total Billed Charges,376.07,45,,19.08,Percent of Total Billed Charges,45% of Total Billed Charges,752.13,90,,468.376,Percent of Total Billed Charges,90% of Total billed Charges,835.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,835.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,835.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,543.21,65,,151.84,Percent of total Billed Charges,65% of Total Billed Charges,368.54,44.1,,18.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,793.92,95,,494.392,Percent of Total Billed Charges,95% of Total Billed Charges,835.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,735.42,88,,37.312,Percent of Total Billed Charges,88% of Total Billed Charges,752.13,90,,468.376,Percent of Total Billed charges,90% of Total Billed Charges,368.54,835.7,
US KIDNEY TRANSPLANT,4020000030,CDM,402,RC,,,Outpatient,,,826.00,536.90,,826,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,627.76,76,,395.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,594.72,72,,6568.856,Percent of Total Billed Charges,72% of Total Billed Charges,619.5,75,,6842.56,Percent of Total Billed charges,75% of Total Billed Charges,826,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,594.72,72,,6568.856,Percent of Total Billed Charges,72% of Total Billed Charges,495.6,60,,5474.048,Percent of Total Billed Charges,60% of Total Billed Charges,743.4,90,,214.56,Percent of Total Billed Charges,90% of Total Billed Charges,371.7,45,,19.08,Percent of Total Billed Charges,45% of Total Billed Charges,743.4,90,,468.376,Percent of Total Billed Charges,90% of Total billed Charges,826,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,536.9,65,,151.84,Percent of total Billed Charges,65% of Total Billed Charges,364.27,44.1,,18.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,784.7,95,,494.392,Percent of Total Billed Charges,95% of Total Billed Charges,826,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,726.88,88,,86.152,Percent of Total Billed Charges,88% of Total Billed Charges,743.4,90,,468.376,Percent of Total Billed charges,90% of Total Billed Charges,364.27,826,
US SPINAL CANAL,4020000031,CDM,402,RC,,,Outpatient,,,400.00,260.00,,400,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,304,76,,141.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,288,72,,4992.688,Percent of Total Billed Charges,72% of Total Billed Charges,300,75,,5200.72,Percent of Total Billed charges,75% of Total Billed Charges,400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288,72,,4992.688,Percent of Total Billed Charges,72% of Total Billed Charges,240,60,,4160.576,Percent of Total Billed Charges,60% of Total Billed Charges,360,90,,119.864,Percent of Total Billed Charges,90% of Total Billed Charges,180,45,,44.056,Percent of Total Billed Charges,45% of Total Billed Charges,360,90,,167.496,Percent of Total Billed Charges,90% of Total billed Charges,400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260,65,,56.16,Percent of total Billed Charges,65% of Total Billed Charges,176.4,44.1,,43.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,380,95,,176.8,Percent of Total Billed Charges,95% of Total Billed Charges,400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352,88,,86.152,Percent of Total Billed Charges,88% of Total Billed Charges,360,90,,167.496,Percent of Total Billed charges,90% of Total Billed Charges,176.4,400,
TRANS ABD PREG < 14 WKS,4020000032,CDM,402,RC,,,Outpatient,,,712.00,462.80,,712,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,541.12,76,,141.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,512.64,72,,9447.552,Percent of Total Billed Charges,72% of Total Billed Charges,534,75,,9841.2,Percent of Total Billed charges,75% of Total Billed Charges,712,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,512.64,72,,9447.552,Percent of Total Billed Charges,72% of Total Billed Charges,427.2,60,,7872.96,Percent of Total Billed Charges,60% of Total Billed Charges,640.8,90,,188.448,Percent of Total Billed Charges,90% of Total Billed Charges,320.4,45,,44.056,Percent of Total Billed Charges,45% of Total Billed Charges,640.8,90,,167.496,Percent of Total Billed Charges,90% of Total billed Charges,712,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,712,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,712,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.8,65,,360.36,Percent of total Billed Charges,65% of Total Billed Charges,313.99,44.1,,43.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,676.4,95,,176.8,Percent of Total Billed Charges,95% of Total Billed Charges,712,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,626.56,88,,86.152,Percent of Total Billed Charges,88% of Total Billed Charges,640.8,90,,167.496,Percent of Total Billed charges,90% of Total Billed Charges,313.99,712,
TWIN PREG < 14 WKS,4020000033,CDM,402,RC,,,Outpatient,,,387.00,251.55,,387,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,294.12,76,,32.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,278.64,72,,10081.728,Percent of Total Billed Charges,72% of Total Billed Charges,290.25,75,,10501.8,Percent of Total Billed charges,75% of Total Billed Charges,387,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.64,72,,10081.728,Percent of Total Billed Charges,72% of Total Billed Charges,232.2,60,,8401.44,Percent of Total Billed Charges,60% of Total Billed Charges,348.3,90,,188.448,Percent of Total Billed Charges,90% of Total Billed Charges,174.15,45,,44.056,Percent of Total Billed Charges,45% of Total Billed Charges,348.3,90,,38.16,Percent of Total Billed Charges,90% of Total billed Charges,387,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,387,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,387,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.55,65,,1461.72,Percent of total Billed Charges,65% of Total Billed Charges,170.67,44.1,,43.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,367.65,95,,40.28,Percent of Total Billed Charges,95% of Total Billed Charges,387,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.56,88,,86.152,Percent of Total Billed Charges,88% of Total Billed Charges,348.3,90,,38.16,Percent of Total Billed charges,90% of Total Billed Charges,170.67,387,
TRANS ABD PREG > 14 WKS,4020000034,CDM,402,RC,,,Outpatient,,,863.00,560.95,,863,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,655.88,76,,32.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,621.36,72,,10612.152,Percent of Total Billed Charges,72% of Total Billed Charges,647.25,75,,11054.328,Percent of Total Billed charges,75% of Total Billed Charges,863,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,621.36,72,,10612.152,Percent of Total Billed Charges,72% of Total Billed Charges,517.8,60,,8843.464,Percent of Total Billed Charges,60% of Total Billed Charges,776.7,90,,95.08,Percent of Total Billed Charges,90% of Total Billed Charges,388.35,45,,44.056,Percent of Total Billed Charges,45% of Total Billed Charges,776.7,90,,38.16,Percent of Total Billed Charges,90% of Total billed Charges,863,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,863,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,863,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,560.95,65,,1015.56,Percent of total Billed Charges,65% of Total Billed Charges,380.58,44.1,,43.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,819.85,95,,40.28,Percent of Total Billed Charges,95% of Total Billed Charges,863,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759.44,88,,209.792,Percent of Total Billed Charges,88% of Total Billed Charges,776.7,90,,38.16,Percent of Total Billed charges,90% of Total Billed Charges,380.58,863,
TWIN PREG > 14 WKS,4020000035,CDM,402,RC,,,Outpatient,,,476.00,309.40,,476,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,361.76,76,,74.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,342.72,72,,887.792,Percent of Total Billed Charges,72% of Total Billed Charges,357,75,,924.784,Percent of Total Billed charges,75% of Total Billed Charges,476,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.72,72,,887.792,Percent of Total Billed Charges,72% of Total Billed Charges,285.6,60,,739.824,Percent of Total Billed Charges,60% of Total Billed Charges,428.4,90,,95.08,Percent of Total Billed Charges,90% of Total Billed Charges,214.2,45,,107.28,Percent of Total Billed Charges,45% of Total Billed Charges,428.4,90,,88.112,Percent of Total Billed Charges,90% of Total billed Charges,476,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.4,65,,253.24,Percent of total Billed Charges,65% of Total Billed Charges,209.92,44.1,,105.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,452.2,95,,93.008,Percent of Total Billed Charges,95% of Total Billed Charges,476,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,418.88,88,,209.792,Percent of Total Billed Charges,88% of Total Billed Charges,428.4,90,,88.112,Percent of Total Billed charges,90% of Total Billed Charges,209.92,476,
PLACENTA LOCAL,4020000036,CDM,402,RC,,,Outpatient,,,603.07,392.00,,603.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,458.33,76,,74.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,434.21,72,,1870.984,Percent of Total Billed Charges,72% of Total Billed Charges,452.3,75,,1948.936,Percent of Total Billed charges,75% of Total Billed Charges,603.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,434.21,72,,1870.984,Percent of Total Billed Charges,72% of Total Billed Charges,361.84,60,,1559.152,Percent of Total Billed Charges,60% of Total Billed Charges,542.76,90,,108.752,Percent of Total Billed Charges,90% of Total Billed Charges,271.38,45,,107.28,Percent of Total Billed Charges,45% of Total Billed Charges,542.76,90,,88.112,Percent of Total Billed Charges,90% of Total billed Charges,603.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,603.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,603.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392,65,,949,Percent of total Billed Charges,65% of Total Billed Charges,265.95,44.1,,105.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,572.92,95,,93.008,Percent of Total Billed Charges,95% of Total Billed Charges,603.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.7,88,,117.2,Percent of Total Billed Charges,88% of Total Billed Charges,542.76,90,,88.112,Percent of Total Billed charges,90% of Total Billed Charges,265.95,603.07,
FETAL GROWTH RATE,4020000037,CDM,402,RC,,,Outpatient,,,603.07,392.00,,603.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,458.33,76,,74.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,434.21,72,,1179.512,Percent of Total Billed Charges,72% of Total Billed Charges,452.3,75,,1228.656,Percent of Total Billed charges,75% of Total Billed Charges,603.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,434.21,72,,1179.512,Percent of Total Billed Charges,72% of Total Billed Charges,361.84,60,,982.928,Percent of Total Billed Charges,60% of Total Billed Charges,542.76,90,,108.752,Percent of Total Billed Charges,90% of Total Billed Charges,271.38,45,,59.936,Percent of Total Billed Charges,45% of Total Billed Charges,542.76,90,,88.112,Percent of Total Billed Charges,90% of Total billed Charges,603.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,603.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,603.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392,65,,126.128,Percent of total Billed Charges,65% of Total Billed Charges,265.95,44.1,,58.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,572.92,95,,93.008,Percent of Total Billed Charges,95% of Total Billed Charges,603.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.7,88,,184.256,Percent of Total Billed Charges,88% of Total Billed Charges,542.76,90,,88.112,Percent of Total Billed charges,90% of Total Billed Charges,265.95,603.07,
US LIMITED OB,4020000038,CDM,402,RC,,,Outpatient,,,632.00,410.80,,632,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,480.32,76,,74.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,455.04,72,,17175.296,Percent of Total Billed Charges,72% of Total Billed Charges,474,75,,17890.936,Percent of Total Billed charges,75% of Total Billed Charges,632,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,455.04,72,,17175.296,Percent of Total Billed Charges,72% of Total Billed Charges,379.2,60,,14312.744,Percent of Total Billed Charges,60% of Total Billed Charges,568.8,90,,16.888,Percent of Total Billed Charges,90% of Total Billed Charges,284.4,45,,94.224,Percent of Total Billed Charges,45% of Total Billed Charges,568.8,90,,88.112,Percent of Total Billed Charges,90% of Total billed Charges,632,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,632,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,632,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,410.8,65,,271.96,Percent of total Billed Charges,65% of Total Billed Charges,278.71,44.1,,92.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,600.4,95,,93.008,Percent of Total Billed Charges,95% of Total Billed Charges,632,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,556.16,88,,184.256,Percent of Total Billed Charges,88% of Total Billed Charges,568.8,90,,88.112,Percent of Total Billed charges,90% of Total Billed Charges,278.71,632,
US OB FLU OR REPET F,4020000039,CDM,402,RC,,,Outpatient,,,573.00,372.45,,573,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,435.48,76,,181.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,412.56,72,,17175.296,Percent of Total Billed Charges,72% of Total Billed Charges,429.75,75,,17890.936,Percent of Total Billed charges,75% of Total Billed Charges,573,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.56,72,,17175.296,Percent of Total Billed Charges,72% of Total Billed Charges,343.8,60,,14312.744,Percent of Total Billed Charges,60% of Total Billed Charges,515.7,90,,73.824,Percent of Total Billed Charges,90% of Total Billed Charges,257.85,45,,94.224,Percent of Total Billed Charges,45% of Total Billed Charges,515.7,90,,214.56,Percent of Total Billed Charges,90% of Total billed Charges,573,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,573,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,573,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,372.45,65,,920.72,Percent of total Billed Charges,65% of Total Billed Charges,252.69,44.1,,92.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,544.35,95,,226.48,Percent of Total Billed Charges,95% of Total Billed Charges,573,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,504.24,88,,92.96,Percent of Total Billed Charges,88% of Total Billed Charges,515.7,90,,214.56,Percent of Total Billed charges,90% of Total Billed Charges,252.69,573,
PREG UTERUS TRANS VA,4020000040,CDM,402,RC,,,Outpatient,,,1054.00,685.10,,1054,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,801.04,76,,181.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,758.88,72,,8136.768,Percent of Total Billed Charges,72% of Total Billed Charges,790.5,75,,8475.8,Percent of Total Billed charges,75% of Total Billed Charges,1054,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,758.88,72,,8136.768,Percent of Total Billed Charges,72% of Total Billed Charges,632.4,60,,6780.64,Percent of Total Billed Charges,60% of Total Billed Charges,948.6,90,,73.824,Percent of Total Billed Charges,90% of Total Billed Charges,474.3,45,,47.536,Percent of Total Billed Charges,45% of Total Billed Charges,948.6,90,,214.56,Percent of Total Billed Charges,90% of Total billed Charges,1054,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1054,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1054,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.1,65,,892.648,Percent of total Billed Charges,65% of Total Billed Charges,464.81,44.1,,46.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,1001.3,95,,226.48,Percent of Total Billed Charges,95% of Total Billed Charges,1054,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,927.52,88,,92.96,Percent of Total Billed Charges,88% of Total Billed Charges,948.6,90,,214.56,Percent of Total Billed charges,90% of Total Billed Charges,464.81,1054,
BIOPHYSICAL PROFILE,4020000041,CDM,402,RC,,,Outpatient,,,1242.00,807.30,,1242,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,943.92,76,,101.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,894.24,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,931.5,75,,11.912,Percent of Total Billed charges,75% of Total Billed Charges,1242,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,894.24,72,,11.432,Percent of Total Billed Charges,72% of Total Billed Charges,745.2,60,,9.528,Percent of Total Billed Charges,60% of Total Billed Charges,1117.8,90,,221.76,Percent of Total Billed Charges,90% of Total Billed Charges,558.9,45,,47.536,Percent of Total Billed Charges,45% of Total Billed Charges,1117.8,90,,119.864,Percent of Total Billed Charges,90% of Total billed Charges,1242,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1242,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1242,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,807.3,65,,768.04,Percent of total Billed Charges,65% of Total Billed Charges,547.72,44.1,,46.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,1179.9,95,,126.528,Percent of Total Billed Charges,95% of Total Billed Charges,1242,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1092.96,88,,106.336,Percent of Total Billed Charges,88% of Total Billed Charges,1117.8,90,,119.864,Percent of Total Billed charges,90% of Total Billed Charges,547.72,1242,
TRANSVAGINAL,4020000042,CDM,402,RC,,,Outpatient,,,1214.00,789.10,,1214,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,922.64,76,,159.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,874.08,72,,3836.272,Percent of Total Billed Charges,72% of Total Billed Charges,910.5,75,,3996.12,Percent of Total Billed charges,75% of Total Billed Charges,1214,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,874.08,72,,3836.272,Percent of Total Billed Charges,72% of Total Billed Charges,728.4,60,,3196.896,Percent of Total Billed Charges,60% of Total Billed Charges,1092.6,90,,201.6,Percent of Total Billed Charges,90% of Total Billed Charges,546.3,45,,54.376,Percent of Total Billed Charges,45% of Total Billed Charges,1092.6,90,,188.448,Percent of Total Billed Charges,90% of Total billed Charges,1214,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1214,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1214,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,789.1,65,,384.8,Percent of total Billed Charges,65% of Total Billed Charges,535.37,44.1,,53.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,1153.3,95,,198.912,Percent of Total Billed Charges,95% of Total Billed Charges,1214,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1068.32,88,,106.336,Percent of Total Billed Charges,88% of Total Billed Charges,1092.6,90,,188.448,Percent of Total Billed charges,90% of Total Billed Charges,535.37,1214,
US  SIS,4020000043,CDM,402,RC,,,Outpatient,,,750.54,487.85,,750.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,570.41,76,,159.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,540.39,72,,32749.016,Percent of Total Billed Charges,72% of Total Billed Charges,562.91,75,,34113.56,Percent of Total Billed charges,75% of Total Billed Charges,750.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540.39,72,,32749.016,Percent of Total Billed Charges,72% of Total Billed Charges,450.32,60,,27290.848,Percent of Total Billed Charges,60% of Total Billed Charges,675.49,90,,202.32,Percent of Total Billed Charges,90% of Total Billed Charges,337.74,45,,54.376,Percent of Total Billed Charges,45% of Total Billed Charges,675.49,90,,188.448,Percent of Total Billed Charges,90% of Total billed Charges,750.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,750.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,750.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487.85,65,,823.256,Percent of total Billed Charges,65% of Total Billed Charges,330.99,44.1,,53.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,713.01,95,,198.912,Percent of Total Billed Charges,95% of Total Billed Charges,750.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,660.48,88,,16.512,Percent of Total Billed Charges,88% of Total Billed Charges,675.49,90,,188.448,Percent of Total Billed charges,90% of Total Billed Charges,330.99,750.54,
PELVIC MASS EVAL,4020000044,CDM,402,RC,,,Outpatient,,,1133.00,736.45,,1133,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,861.08,76,,80.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,815.76,72,,29173.736,Percent of Total Billed Charges,72% of Total Billed Charges,849.75,75,,30389.312,Percent of Total Billed charges,75% of Total Billed Charges,1133,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,815.76,72,,29173.736,Percent of Total Billed Charges,72% of Total Billed Charges,679.8,60,,24311.448,Percent of Total Billed Charges,60% of Total Billed Charges,1019.7,90,,84.24,Percent of Total Billed Charges,90% of Total Billed Charges,509.85,45,,8.44,Percent of Total Billed Charges,45% of Total Billed Charges,1019.7,90,,95.08,Percent of Total Billed Charges,90% of Total billed Charges,1133,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1133,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1133,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,736.45,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,499.65,44.1,,8.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,1076.35,95,,100.36,Percent of Total Billed Charges,95% of Total Billed Charges,1133,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,997.04,88,,72.184,Percent of Total Billed Charges,88% of Total Billed Charges,1019.7,90,,95.08,Percent of Total Billed charges,90% of Total Billed Charges,499.65,1133,
US PELVC (NON OB) US,4020000045,CDM,402,RC,,,Outpatient,,,669.22,434.99,,669.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,508.61,76,,80.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,481.84,72,,60149.72,Percent of Total Billed Charges,72% of Total Billed Charges,501.92,75,,62655.96,Percent of Total Billed charges,75% of Total Billed Charges,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,481.84,72,,60149.72,Percent of Total Billed Charges,72% of Total Billed Charges,401.53,60,,50124.768,Percent of Total Billed Charges,60% of Total Billed Charges,602.3,90,,47.632,Percent of Total Billed Charges,90% of Total Billed Charges,301.15,45,,36.912,Percent of Total Billed Charges,45% of Total Billed Charges,602.3,90,,95.08,Percent of Total Billed Charges,90% of Total billed Charges,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,434.99,65,,304.992,Percent of total Billed Charges,65% of Total Billed Charges,295.13,44.1,,36.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,635.76,95,,100.36,Percent of Total Billed Charges,95% of Total Billed Charges,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,588.91,88,,72.184,Percent of Total Billed Charges,88% of Total Billed Charges,602.3,90,,95.08,Percent of Total Billed charges,90% of Total Billed Charges,295.13,669.22,
US  LIMITED PELVIS,4020000046,CDM,402,RC,,,Outpatient,,,702.00,456.30,,702,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,533.52,76,,91.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,505.44,72,,17175.296,Percent of Total Billed Charges,72% of Total Billed Charges,526.5,75,,17890.936,Percent of Total Billed charges,75% of Total Billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,505.44,72,,17175.296,Percent of Total Billed Charges,72% of Total Billed Charges,421.2,60,,14312.744,Percent of Total Billed Charges,60% of Total Billed Charges,631.8,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,315.9,45,,36.912,Percent of Total Billed Charges,45% of Total Billed Charges,631.8,90,,108.752,Percent of Total Billed Charges,90% of Total billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.3,65,,560.56,Percent of total Billed Charges,65% of Total Billed Charges,309.58,44.1,,36.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,666.9,95,,114.792,Percent of Total Billed Charges,95% of Total Billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,617.76,88,,216.832,Percent of Total Billed Charges,88% of Total Billed Charges,631.8,90,,108.752,Percent of Total Billed charges,90% of Total Billed Charges,309.58,702,
TESTICULAR SONOGRAM,4020000047,CDM,402,RC,,,Outpatient,,,1242.00,807.30,,1242,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,943.92,76,,91.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,894.24,72,,17175.296,Percent of Total Billed Charges,72% of Total Billed Charges,931.5,75,,17890.936,Percent of Total Billed charges,75% of Total Billed Charges,1242,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,894.24,72,,17175.296,Percent of Total Billed Charges,72% of Total Billed Charges,745.2,60,,14312.744,Percent of Total Billed Charges,60% of Total Billed Charges,1117.8,90,,32.544,Percent of Total Billed Charges,90% of Total Billed Charges,558.9,45,,110.88,Percent of Total Billed Charges,45% of Total Billed Charges,1117.8,90,,108.752,Percent of Total Billed Charges,90% of Total billed Charges,1242,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1242,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1242,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,807.3,65,,364.616,Percent of total Billed Charges,65% of Total Billed Charges,547.72,44.1,,108.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,1179.9,95,,114.792,Percent of Total Billed Charges,95% of Total Billed Charges,1242,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1092.96,88,,197.12,Percent of Total Billed Charges,88% of Total Billed Charges,1117.8,90,,108.752,Percent of Total Billed charges,90% of Total Billed Charges,547.72,1242,
US PROSTATE TRANSREC,4020000048,CDM,402,RC,,,Outpatient,,,614.00,399.10,,614,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,466.64,76,,14.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,442.08,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,460.5,75,,6677.76,Percent of Total Billed charges,75% of Total Billed Charges,614,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,442.08,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,368.4,60,,5342.208,Percent of Total Billed Charges,60% of Total Billed Charges,552.6,90,,39.696,Percent of Total Billed Charges,90% of Total Billed Charges,276.3,45,,100.8,Percent of Total Billed Charges,45% of Total Billed Charges,552.6,90,,16.888,Percent of Total Billed Charges,90% of Total billed Charges,614,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,614,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,614,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.1,65,,1736.8,Percent of total Billed Charges,65% of Total Billed Charges,270.77,44.1,,98.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,583.3,95,,17.824,Percent of Total Billed Charges,95% of Total Billed Charges,614,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540.32,88,,197.824,Percent of Total Billed Charges,88% of Total Billed Charges,552.6,90,,16.888,Percent of Total Billed charges,90% of Total Billed Charges,270.77,614,
US SOFT TISSUE COMPLETE,4020000049,CDM,402,RC,,,Outpatient,,,792.00,514.80,,792,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,601.92,76,,62.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,570.24,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,594,75,,6677.76,Percent of Total Billed charges,75% of Total Billed Charges,792,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,570.24,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,475.2,60,,5342.208,Percent of Total Billed Charges,60% of Total Billed Charges,712.8,90,,293.76,Percent of Total Billed Charges,90% of Total Billed Charges,356.4,45,,101.16,Percent of Total Billed Charges,45% of Total Billed Charges,712.8,90,,73.824,Percent of Total Billed Charges,90% of Total billed Charges,792,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,792,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,792,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,514.8,65,,359.464,Percent of total Billed Charges,65% of Total Billed Charges,349.27,44.1,,99.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,752.4,95,,77.92,Percent of Total Billed Charges,95% of Total Billed Charges,792,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,696.96,88,,82.368,Percent of Total Billed Charges,88% of Total Billed Charges,712.8,90,,73.824,Percent of Total Billed charges,90% of Total Billed Charges,349.27,792,
US SOFT TISSUE LIMITED,4020000050,CDM,402,RC,,,Outpatient,,,529.00,343.85,,529,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,402.04,76,,62.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,380.88,72,,16972.08,Percent of Total Billed Charges,72% of Total Billed Charges,396.75,75,,17679.256,Percent of Total Billed charges,75% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.88,72,,16972.08,Percent of Total Billed Charges,72% of Total Billed Charges,317.4,60,,14143.4,Percent of Total Billed Charges,60% of Total Billed Charges,476.1,90,,233.28,Percent of Total Billed Charges,90% of Total Billed Charges,238.05,45,,42.12,Percent of Total Billed Charges,45% of Total Billed Charges,476.1,90,,73.824,Percent of Total Billed Charges,90% of Total billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.85,65,,654.136,Percent of total Billed Charges,65% of Total Billed Charges,233.29,44.1,,41.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,502.55,95,,77.92,Percent of Total Billed Charges,95% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.52,88,,46.568,Percent of Total Billed Charges,88% of Total Billed Charges,476.1,90,,73.824,Percent of Total Billed charges,90% of Total Billed Charges,233.29,529,
US INFANT HIP MANIBU,4020000051,CDM,402,RC,,,Outpatient,,,702.00,456.30,,702,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,533.52,76,,187.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,505.44,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,526.5,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,505.44,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,421.2,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,631.8,90,,63.36,Percent of Total Billed Charges,90% of Total Billed Charges,315.9,45,,23.816,Percent of Total Billed Charges,45% of Total Billed Charges,631.8,90,,221.76,Percent of Total Billed Charges,90% of Total billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.3,65,,37.84,Percent of total Billed Charges,65% of Total Billed Charges,309.58,44.1,,23.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,666.9,95,,234.08,Percent of Total Billed Charges,95% of Total Billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,617.76,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,631.8,90,,221.76,Percent of Total Billed charges,90% of Total Billed Charges,309.58,702,
US GUIDED COMP REPR,4020000052,CDM,402,RC,,,Outpatient,,,582.12,378.38,,582.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,442.41,76,,170.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,419.13,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,436.59,75,,14082.016,Percent of Total Billed charges,75% of Total Billed Charges,582.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.13,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,349.27,60,,11265.608,Percent of Total Billed Charges,60% of Total Billed Charges,523.91,90,,69.12,Percent of Total Billed Charges,90% of Total Billed Charges,261.95,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,523.91,90,,201.6,Percent of Total Billed Charges,90% of Total billed Charges,582.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,582.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,582.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.38,65,,144.04,Percent of total Billed Charges,65% of Total Billed Charges,256.71,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,553.01,95,,212.8,Percent of Total Billed Charges,95% of Total Billed Charges,582.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,512.27,88,,31.824,Percent of Total Billed Charges,88% of Total Billed Charges,523.91,90,,201.6,Percent of Total Billed charges,90% of Total Billed Charges,256.71,582.12,
US GUIDED NEEDLE PLACEMENT,4020000053,CDM,402,RC,,,Outpatient,,,759.00,493.35,,759,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,576.84,76,,170.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,546.48,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,569.25,75,,14082.016,Percent of Total Billed charges,75% of Total Billed Charges,759,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.48,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,455.4,60,,11265.608,Percent of Total Billed Charges,60% of Total Billed Charges,683.1,90,,16.888,Percent of Total Billed Charges,90% of Total Billed Charges,341.55,45,,16.272,Percent of Total Billed Charges,45% of Total Billed Charges,683.1,90,,202.32,Percent of Total Billed Charges,90% of Total billed Charges,759,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.35,65,,245.96,Percent of total Billed Charges,65% of Total Billed Charges,334.72,44.1,,15.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,721.05,95,,213.56,Percent of Total Billed Charges,95% of Total Billed Charges,759,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,667.92,88,,38.808,Percent of Total Billed Charges,88% of Total Billed Charges,683.1,90,,202.32,Percent of Total Billed charges,90% of Total Billed Charges,334.72,759,
AMNIOCENTESIS ECHO,4020000054,CDM,402,RC,,,Outpatient,,,448.72,291.67,,448.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,341.03,76,,71.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,323.08,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,336.54,75,,14082.016,Percent of Total Billed charges,75% of Total Billed Charges,448.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.08,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,269.23,60,,11265.608,Percent of Total Billed Charges,60% of Total Billed Charges,403.85,90,,303.12,Percent of Total Billed Charges,90% of Total Billed Charges,201.92,45,,19.848,Percent of Total Billed Charges,45% of Total Billed Charges,403.85,90,,84.24,Percent of Total Billed Charges,90% of Total billed Charges,448.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,448.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,448.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291.67,65,,397.8,Percent of total Billed Charges,65% of Total Billed Charges,197.89,44.1,,19.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,426.28,95,,88.92,Percent of Total Billed Charges,95% of Total Billed Charges,448.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.87,88,,287.232,Percent of Total Billed Charges,88% of Total Billed Charges,403.85,90,,84.24,Percent of Total Billed charges,90% of Total Billed Charges,197.89,448.72,
US BREAST UNILATERAL COMPLETE,4020000055,CDM,402,RC,,,Outpatient,,,621.00,403.65,,621,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,471.96,76,,40.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,447.12,72,,1944.144,Percent of Total Billed Charges,72% of Total Billed Charges,465.75,75,,2025.152,Percent of Total Billed charges,75% of Total Billed Charges,621,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,447.12,72,,1944.144,Percent of Total Billed Charges,72% of Total Billed Charges,372.6,60,,1620.12,Percent of Total Billed Charges,60% of Total Billed Charges,558.9,90,,303.12,Percent of Total Billed Charges,90% of Total Billed Charges,279.45,45,,146.88,Percent of Total Billed Charges,45% of Total Billed Charges,558.9,90,,47.632,Percent of Total Billed Charges,90% of Total billed Charges,621,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,621,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,621,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,403.65,65,,397.8,Percent of total Billed Charges,65% of Total Billed Charges,273.86,44.1,,143.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,589.95,95,,50.272,Percent of Total Billed Charges,95% of Total Billed Charges,621,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.48,88,,228.096,Percent of Total Billed Charges,88% of Total Billed Charges,558.9,90,,47.632,Percent of Total Billed charges,90% of Total Billed Charges,273.86,621,
US VESSEL MAP FOR HEMODIALYSIS,4020000058,CDM,402,RC,,,Outpatient,,,336.00,218.40,,336,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,255.36,76,,33.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,241.92,72,,6090.624,Percent of Total Billed Charges,72% of Total Billed Charges,252,75,,6344.4,Percent of Total Billed charges,75% of Total Billed Charges,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.92,72,,6090.624,Percent of Total Billed Charges,72% of Total Billed Charges,201.6,60,,5075.52,Percent of Total Billed Charges,60% of Total Billed Charges,302.4,90,,316.728,Percent of Total Billed Charges,90% of Total Billed Charges,151.2,45,,34.56,Percent of Total Billed Charges,45% of Total Billed Charges,302.4,90,,39.696,Percent of Total Billed Charges,90% of Total billed Charges,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.4,65,,1741.48,Percent of total Billed Charges,65% of Total Billed Charges,148.18,44.1,,33.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,319.2,95,,41.896,Percent of Total Billed Charges,95% of Total Billed Charges,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.68,88,,16.512,Percent of Total Billed Charges,88% of Total Billed Charges,302.4,90,,39.696,Percent of Total Billed charges,90% of Total Billed Charges,148.18,336,
US VEIN MAP UNILAT DIALYSIS,4020000059,CDM,402,RC,,,Outpatient,,,256.00,166.40,,256,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,194.56,76,,248.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,184.32,72,,6090.624,Percent of Total Billed Charges,72% of Total Billed Charges,192,75,,6344.4,Percent of Total Billed charges,75% of Total Billed Charges,256,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.32,72,,6090.624,Percent of Total Billed Charges,72% of Total Billed Charges,153.6,60,,5075.52,Percent of Total Billed Charges,60% of Total Billed Charges,230.4,90,,64.296,Percent of Total Billed Charges,90% of Total Billed Charges,115.2,45,,8.44,Percent of Total Billed Charges,45% of Total Billed Charges,230.4,90,,293.76,Percent of Total Billed Charges,90% of Total billed Charges,256,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.4,65,,424.32,Percent of total Billed Charges,65% of Total Billed Charges,112.9,44.1,,8.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,243.2,95,,310.08,Percent of Total Billed Charges,95% of Total Billed Charges,256,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.28,88,,296.384,Percent of Total Billed Charges,88% of Total Billed Charges,230.4,90,,293.76,Percent of Total Billed charges,90% of Total Billed Charges,112.9,256,
US AXILLA LEFT,4020000060,CDM,402,RC,,,Outpatient,,,529.00,343.85,,529,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,402.04,76,,196.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,380.88,72,,6090.624,Percent of Total Billed Charges,72% of Total Billed Charges,396.75,75,,6344.4,Percent of Total Billed charges,75% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.88,72,,6090.624,Percent of Total Billed Charges,72% of Total Billed Charges,317.4,60,,5075.52,Percent of Total Billed Charges,60% of Total Billed Charges,476.1,90,,64.296,Percent of Total Billed Charges,90% of Total Billed Charges,238.05,45,,151.56,Percent of Total Billed Charges,45% of Total Billed Charges,476.1,90,,233.28,Percent of Total Billed Charges,90% of Total billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.85,65,,163.28,Percent of total Billed Charges,65% of Total Billed Charges,233.29,44.1,,148.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,502.55,95,,246.24,Percent of Total Billed Charges,95% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.52,88,,296.384,Percent of Total Billed Charges,88% of Total Billed Charges,476.1,90,,233.28,Percent of Total Billed charges,90% of Total Billed Charges,233.29,529,
US AXILLA RIGHT,4020000061,CDM,402,RC,,,Outpatient,,,529.00,343.85,,529,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,402.04,76,,53.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,380.88,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,396.75,75,,6677.76,Percent of Total Billed charges,75% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.88,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,317.4,60,,5342.208,Percent of Total Billed Charges,60% of Total Billed Charges,476.1,90,,64.296,Percent of Total Billed Charges,90% of Total Billed Charges,238.05,45,,151.56,Percent of Total Billed Charges,45% of Total Billed Charges,476.1,90,,63.36,Percent of Total Billed Charges,90% of Total billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.85,65,,509.6,Percent of total Billed Charges,65% of Total Billed Charges,233.29,44.1,,148.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,502.55,95,,66.88,Percent of Total Billed Charges,95% of Total Billed Charges,529,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.52,88,,100.672,Percent of Total Billed Charges,88% of Total Billed Charges,476.1,90,,63.36,Percent of Total Billed charges,90% of Total Billed Charges,233.29,529,
US GUIDE TISSUE ABLATION,4020000063,CDM,402,RC,,,Outpatient,,,500.00,325.00,,500,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,380,76,,58.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,360,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,375,75,,6677.76,Percent of Total Billed charges,75% of Total Billed Charges,500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,300,60,,5342.208,Percent of Total Billed Charges,60% of Total Billed Charges,450,90,,254.88,Percent of Total Billed Charges,90% of Total Billed Charges,225,45,,51.48,Percent of Total Billed Charges,45% of Total Billed Charges,450,90,,69.12,Percent of Total Billed Charges,90% of Total billed Charges,500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325,65,,354.872,Percent of total Billed Charges,65% of Total Billed Charges,220.5,44.1,,50.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,475,95,,72.96,Percent of Total Billed Charges,95% of Total Billed Charges,500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440,88,,105.56,Percent of Total Billed Charges,88% of Total Billed Charges,450,90,,69.12,Percent of Total Billed charges,90% of Total Billed Charges,220.5,500,
"US, elastography; parenchyma",4020000064,CDM,402,RC,,,Outpatient,,,694.47,451.41,,694.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,527.8,76,,14.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,500.02,72,,3045.312,Percent of Total Billed Charges,72% of Total Billed Charges,520.85,75,,3172.2,Percent of Total Billed charges,75% of Total Billed Charges,694.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.02,72,,3045.312,Percent of Total Billed Charges,72% of Total Billed Charges,416.68,60,,2537.76,Percent of Total Billed Charges,60% of Total Billed Charges,625.02,90,,219.6,Percent of Total Billed Charges,90% of Total Billed Charges,312.51,45,,53.976,Percent of Total Billed Charges,45% of Total Billed Charges,625.02,90,,16.888,Percent of Total Billed Charges,90% of Total billed Charges,694.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,694.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,694.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,451.41,65,,306.28,Percent of total Billed Charges,65% of Total Billed Charges,306.26,44.1,,52.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,659.75,95,,17.824,Percent of Total Billed Charges,95% of Total Billed Charges,694.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.13,88,,309.688,Percent of Total Billed Charges,88% of Total Billed Charges,625.02,90,,16.888,Percent of Total Billed charges,90% of Total Billed Charges,306.26,694.47,
US elastography; first target,4020000065,CDM,402,RC,,,Outpatient,,,694.47,451.41,,694.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,527.8,76,,255.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,500.02,72,,3045.312,Percent of Total Billed Charges,72% of Total Billed Charges,520.85,75,,3172.2,Percent of Total Billed charges,75% of Total Billed Charges,694.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.02,72,,3045.312,Percent of Total Billed Charges,72% of Total Billed Charges,416.68,60,,2537.76,Percent of Total Billed Charges,60% of Total Billed Charges,625.02,90,,219.088,Percent of Total Billed Charges,90% of Total Billed Charges,312.51,45,,158.368,Percent of Total Billed Charges,45% of Total Billed Charges,625.02,90,,303.12,Percent of Total Billed Charges,90% of Total billed Charges,694.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,694.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,694.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,451.41,65,,340.08,Percent of total Billed Charges,65% of Total Billed Charges,306.26,44.1,,155.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,659.75,95,,319.96,Percent of Total Billed Charges,95% of Total Billed Charges,694.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.13,88,,62.864,Percent of Total Billed Charges,88% of Total Billed Charges,625.02,90,,303.12,Percent of Total Billed charges,90% of Total Billed Charges,306.26,694.47,
US elastography; ea addt targt,4020000066,CDM,402,RC,,,Outpatient,,,694.47,451.41,,694.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,527.8,76,,255.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,500.02,72,,3205.328,Percent of Total Billed Charges,72% of Total Billed Charges,520.85,75,,3338.88,Percent of Total Billed charges,75% of Total Billed Charges,694.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.02,72,,3205.328,Percent of Total Billed Charges,72% of Total Billed Charges,416.68,60,,2671.104,Percent of Total Billed Charges,60% of Total Billed Charges,625.02,90,,269.28,Percent of Total Billed Charges,90% of Total Billed Charges,312.51,45,,32.152,Percent of Total Billed Charges,45% of Total Billed Charges,625.02,90,,303.12,Percent of Total Billed Charges,90% of Total billed Charges,694.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,694.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,694.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,451.41,65,,543.92,Percent of total Billed Charges,65% of Total Billed Charges,306.26,44.1,,31.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,659.75,95,,319.96,Percent of Total Billed Charges,95% of Total Billed Charges,694.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.13,88,,62.864,Percent of Total Billed Charges,88% of Total Billed Charges,625.02,90,,303.12,Percent of Total Billed charges,90% of Total Billed Charges,306.26,694.47,
DIG SCREENING MAMMO W/CAD,4030000001,CDM,403,RC,,,Outpatient,,,438.00,284.70,,438,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,332.88,76,,86.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,315.36,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,328.5,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.36,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,262.8,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,394.2,90,,88.112,Percent of Total Billed Charges,90% of Total Billed Charges,197.1,45,,32.152,Percent of Total Billed Charges,45% of Total Billed Charges,394.2,90,,102.96,Percent of Total Billed Charges,90% of Total billed Charges,438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.7,65,,203.84,Percent of total Billed Charges,65% of Total Billed Charges,193.16,44.1,,31.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,416.1,95,,108.68,Percent of Total Billed Charges,95% of Total Billed Charges,438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.44,88,,62.864,Percent of Total Billed Charges,88% of Total Billed Charges,394.2,90,,102.96,Percent of Total Billed charges,90% of Total Billed Charges,193.16,438,
RT SPUTUM SPEC  AEROS INDUCED,4100000001,CDM,300,RC,,,Outpatient,,,150.23,97.65,,150.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114.17,76,,91.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.17,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,112.67,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,150.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.17,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,90.14,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,135.21,90,,460.408,Percent of Total Billed Charges,90% of Total Billed Charges,67.6,45,,32.152,Percent of Total Billed Charges,45% of Total Billed Charges,135.21,90,,107.96,Percent of Total Billed Charges,90% of Total billed Charges,150.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.65,65,,407.68,Percent of total Billed Charges,65% of Total Billed Charges,66.25,44.1,,31.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.72,95,,113.952,Percent of Total Billed Charges,95% of Total Billed Charges,150.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.2,88,,249.216,Percent of Total Billed Charges,88% of Total Billed Charges,135.21,90,,107.96,Percent of Total Billed charges,90% of Total Billed Charges,66.25,150.23,
VENTILATION 1ST DAY,4100000002,CDM,410,RC,,,Outpatient,,,1019.00,662.35,,1019,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,774.44,76,,267.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,733.68,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,764.25,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,1019,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,733.68,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,611.4,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,917.1,90,,45.248,Percent of Total Billed Charges,90% of Total Billed Charges,458.55,45,,127.44,Percent of Total Billed Charges,45% of Total Billed Charges,917.1,90,,316.728,Percent of Total Billed Charges,90% of Total billed Charges,1019,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1019,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1019,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,662.35,65,,747.76,Percent of total Billed Charges,65% of Total Billed Charges,449.38,44.1,,124.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,968.05,95,,334.328,Percent of Total Billed Charges,95% of Total Billed Charges,1019,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,896.72,88,,214.72,Percent of Total Billed Charges,88% of Total Billed Charges,917.1,90,,316.728,Percent of Total Billed charges,90% of Total Billed Charges,449.38,1019,
VENTILATION SUBSEQ,4100000003,CDM,410,RC,,,Outpatient,,,553.00,359.45,,553,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,420.28,76,,54.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,398.16,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,414.75,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,553,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.16,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,331.8,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,497.7,90,,302.44,Percent of Total Billed Charges,90% of Total Billed Charges,248.85,45,,109.8,Percent of Total Billed Charges,45% of Total Billed Charges,497.7,90,,64.296,Percent of Total Billed Charges,90% of Total billed Charges,553,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,553,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,553,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.45,65,,414.96,Percent of total Billed Charges,65% of Total Billed Charges,243.87,44.1,,107.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,525.35,95,,67.872,Percent of Total Billed Charges,95% of Total Billed Charges,553,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,486.64,88,,214.224,Percent of Total Billed Charges,88% of Total Billed Charges,497.7,90,,64.296,Percent of Total Billed charges,90% of Total Billed Charges,243.87,553,
INHALATION TX,4100000004,CDM,410,RC,,,Outpatient,,,333.00,216.45,,333,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,253.08,76,,54.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,239.76,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,249.75,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,333,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.76,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,199.8,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,299.7,90,,302.44,Percent of Total Billed Charges,90% of Total Billed Charges,149.85,45,,109.544,Percent of Total Billed Charges,45% of Total Billed Charges,299.7,90,,64.296,Percent of Total Billed Charges,90% of Total billed Charges,333,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.45,65,,74.36,Percent of total Billed Charges,65% of Total Billed Charges,146.85,44.1,,107.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,316.35,95,,67.872,Percent of Total Billed Charges,95% of Total Billed Charges,333,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.04,88,,263.296,Percent of Total Billed Charges,88% of Total Billed Charges,299.7,90,,64.296,Percent of Total Billed charges,90% of Total Billed Charges,146.85,333,
CONT NEB 1ST HR,4100000005,CDM,410,RC,,,Outpatient,,,133.00,86.45,,133,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,101.08,76,,54.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.76,72,,6494.24,Percent of Total Billed Charges,72% of Total Billed Charges,99.75,75,,6764.832,Percent of Total Billed charges,75% of Total Billed Charges,133,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.76,72,,6494.24,Percent of Total Billed Charges,72% of Total Billed Charges,79.8,60,,5411.864,Percent of Total Billed Charges,60% of Total Billed Charges,119.7,90,,244.8,Percent of Total Billed Charges,90% of Total Billed Charges,59.85,45,,134.64,Percent of Total Billed Charges,45% of Total Billed Charges,119.7,90,,64.296,Percent of Total Billed Charges,90% of Total billed Charges,133,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.45,65,,130,Percent of total Billed Charges,65% of Total Billed Charges,58.65,44.1,,131.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,126.35,95,,67.872,Percent of Total Billed Charges,95% of Total Billed Charges,133,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.04,88,,86.152,Percent of Total Billed Charges,88% of Total Billed Charges,119.7,90,,64.296,Percent of Total Billed charges,90% of Total Billed Charges,58.65,133,
CONT NEB ADDL HR,4100000006,CDM,410,RC,,,Outpatient,,,66.00,42.90,,66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,50.16,76,,215.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47.52,72,,6494.24,Percent of Total Billed Charges,72% of Total Billed Charges,49.5,75,,6764.832,Percent of Total Billed charges,75% of Total Billed Charges,66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.52,72,,6494.24,Percent of Total Billed Charges,72% of Total Billed Charges,39.6,60,,5411.864,Percent of Total Billed Charges,60% of Total Billed Charges,59.4,90,,264.96,Percent of Total Billed Charges,90% of Total Billed Charges,29.7,45,,44.056,Percent of Total Billed Charges,45% of Total Billed Charges,59.4,90,,254.88,Percent of Total Billed Charges,90% of Total billed Charges,66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.9,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,29.11,44.1,,43.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.7,95,,269.04,Percent of Total Billed Charges,95% of Total Billed Charges,66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.08,88,,450.176,Percent of Total Billed Charges,88% of Total Billed Charges,59.4,90,,254.88,Percent of Total Billed charges,90% of Total Billed Charges,29.11,66,
CPAP I & M,4100000007,CDM,410,RC,,,Outpatient,,,230.00,149.50,,230,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,174.8,76,,185.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,165.6,72,,6494.24,Percent of Total Billed Charges,72% of Total Billed Charges,172.5,75,,6764.832,Percent of Total Billed charges,75% of Total Billed Charges,230,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.6,72,,6494.24,Percent of Total Billed Charges,72% of Total Billed Charges,138,60,,5411.864,Percent of Total Billed Charges,60% of Total Billed Charges,207,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,103.5,45,,230.2,Percent of Total Billed Charges,45% of Total Billed Charges,207,90,,219.6,Percent of Total Billed Charges,90% of Total billed Charges,230,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.5,65,,78,Percent of total Billed Charges,65% of Total Billed Charges,101.43,44.1,,225.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,218.5,95,,231.8,Percent of Total Billed Charges,95% of Total Billed Charges,230,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.4,88,,44.24,Percent of Total Billed Charges,88% of Total Billed Charges,207,90,,219.6,Percent of Total Billed charges,90% of Total Billed Charges,101.43,230,
PERCUSSION/POSTURAL,4100000008,CDM,410,RC,,,Outpatient,,,192.00,124.80,,192,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,145.92,76,,185.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,138.24,72,,12843.072,Percent of Total Billed Charges,72% of Total Billed Charges,144,75,,13378.2,Percent of Total Billed charges,75% of Total Billed Charges,192,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.24,72,,12843.072,Percent of Total Billed Charges,72% of Total Billed Charges,115.2,60,,10702.56,Percent of Total Billed Charges,60% of Total Billed Charges,172.8,90,,238.144,Percent of Total Billed Charges,90% of Total Billed Charges,86.4,45,,22.624,Percent of Total Billed Charges,45% of Total Billed Charges,172.8,90,,219.088,Percent of Total Billed Charges,90% of Total billed Charges,192,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.8,65,,36.92,Percent of total Billed Charges,65% of Total Billed Charges,84.67,44.1,,22.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,182.4,95,,231.264,Percent of Total Billed Charges,95% of Total Billed Charges,192,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.96,88,,295.712,Percent of Total Billed Charges,88% of Total Billed Charges,172.8,90,,219.088,Percent of Total Billed charges,90% of Total Billed Charges,84.67,192,
CHEST PT INIT OR EVAL,4100000009,CDM,410,RC,,,Outpatient,,,290.00,188.50,,290,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,220.4,76,,227.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,208.8,72,,12843.072,Percent of Total Billed Charges,72% of Total Billed Charges,217.5,75,,13378.2,Percent of Total Billed charges,75% of Total Billed Charges,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.8,72,,12843.072,Percent of Total Billed Charges,72% of Total Billed Charges,174,60,,10702.56,Percent of Total Billed Charges,60% of Total Billed Charges,261,90,,28.08,Percent of Total Billed Charges,90% of Total Billed Charges,130.5,45,,151.216,Percent of Total Billed Charges,45% of Total Billed Charges,261,90,,269.28,Percent of Total Billed Charges,90% of Total billed Charges,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.5,65,,55.12,Percent of total Billed Charges,65% of Total Billed Charges,127.89,44.1,,148.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,275.5,95,,284.24,Percent of Total Billed Charges,95% of Total Billed Charges,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.2,88,,295.712,Percent of Total Billed Charges,88% of Total Billed Charges,261,90,,269.28,Percent of Total Billed charges,90% of Total Billed Charges,127.89,290,
MAN CHEST WALL SUB,4100000010,CDM,410,RC,,,Outpatient,,,113.00,73.45,,113,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,85.88,76,,74.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,81.36,72,,12843.072,Percent of Total Billed Charges,72% of Total Billed Charges,84.75,75,,13378.2,Percent of Total Billed charges,75% of Total Billed Charges,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.36,72,,12843.072,Percent of Total Billed Charges,72% of Total Billed Charges,67.8,60,,10702.56,Percent of Total Billed Charges,60% of Total Billed Charges,101.7,90,,210.24,Percent of Total Billed Charges,90% of Total Billed Charges,50.85,45,,151.216,Percent of Total Billed Charges,45% of Total Billed Charges,101.7,90,,88.112,Percent of Total Billed Charges,90% of Total billed Charges,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.45,65,,182,Percent of total Billed Charges,65% of Total Billed Charges,49.83,44.1,,148.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,107.35,95,,93.008,Percent of Total Billed Charges,95% of Total Billed Charges,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.44,88,,239.36,Percent of Total Billed Charges,88% of Total Billed Charges,101.7,90,,88.112,Percent of Total Billed charges,90% of Total Billed Charges,49.83,113,
CHEST PT SUBSEQUENT,4100000011,CDM,410,RC,,,Outpatient,,,290.00,188.50,,290,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,220.4,76,,388.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,208.8,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,217.5,75,,14082.016,Percent of Total Billed charges,75% of Total Billed Charges,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.8,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,174,60,,11265.608,Percent of Total Billed Charges,60% of Total Billed Charges,261,90,,210.24,Percent of Total Billed Charges,90% of Total Billed Charges,130.5,45,,122.4,Percent of Total Billed Charges,45% of Total Billed Charges,261,90,,460.408,Percent of Total Billed Charges,90% of Total billed Charges,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.5,65,,164.32,Percent of total Billed Charges,65% of Total Billed Charges,127.89,44.1,,119.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,275.5,95,,485.984,Percent of Total Billed Charges,95% of Total Billed Charges,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.2,88,,259.072,Percent of Total Billed Charges,88% of Total Billed Charges,261,90,,460.408,Percent of Total Billed charges,90% of Total Billed Charges,127.89,290,
INHALATION TX EA ADD,4100000012,CDM,410,RC,,,Outpatient,,,333.00,216.45,,333,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,253.08,76,,38.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,239.76,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,249.75,75,,14082.016,Percent of Total Billed charges,75% of Total Billed Charges,333,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.76,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,199.8,60,,11265.608,Percent of Total Billed Charges,60% of Total Billed Charges,299.7,90,,77.76,Percent of Total Billed Charges,90% of Total Billed Charges,149.85,45,,132.48,Percent of Total Billed Charges,45% of Total Billed Charges,299.7,90,,45.248,Percent of Total Billed Charges,90% of Total billed Charges,333,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.45,65,,315.912,Percent of total Billed Charges,65% of Total Billed Charges,146.85,44.1,,129.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,316.35,95,,47.76,Percent of Total Billed Charges,95% of Total Billed Charges,333,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.04,88,,193.6,Percent of Total Billed Charges,88% of Total Billed Charges,299.7,90,,45.248,Percent of Total Billed charges,90% of Total Billed Charges,146.85,333,
THERAPEUTIC PROCD STRG ENDUR,4100000013,CDM,410,RC,G0237,HCPCS,Outpatient,,,78.99,51.34,,30.78,125,,,Fee Schedule,125% of CMS OPPS Rate,60.03,76,,255.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.74,350,,20775.456,Fee Schedule,350% of BCBS fee schedule,28.74,350,,21641.104,Fee Schedule,350% of BCBS fee schedule,24.62,100,,,Fee Schedule,100% of CMS OPPS Rate,28.74,286,,20775.456,Fee Schedule,286% of BCBS PPO fee schedule,10.05,100,,17312.88,Fee Schedule,100% of Blue ADV HMO fee schedule,71.09,90,,498.96,Percent of Total Billed Charges,90% of Total Billed Charges,35.55,45,,99,Percent of Total Billed Charges,45% of Total Billed Charges,71.09,90,,302.44,Percent of Total Billed Charges,90% of Total billed Charges,24.62,100,,,Fee Schedule,100% of CMS OPPS Rate,24.62,100,,,Fee Schedule,100% of CMS OPPS Rate,24.62,100,,,Fee Schedule,100% of CMS OPPS Rate,45.99,200,,78.544,Fee Schedule,200% of CMS OPPS Rate,34.83,44.1,,97.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,75.04,95,,319.24,Percent of Total Billed Charges,95% of Total Billed Charges,18.46,75,,,Fee Schedule,75% of CMS OPPS Rate,69.51,88,,232.848,Percent of Total Billed Charges,88% of Total Billed Charges,71.09,90,,302.44,Percent of Total Billed charges,90% of Total Billed Charges,10.05,75.04,
OTH RESP PROC INDIV,4100000014,CDM,410,RC,G0238,HCPCS,Outpatient,,,78.99,51.34,,30.78,125,,,Fee Schedule,125% of CMS OPPS Rate,60.03,76,,255.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.77,350,,20775.456,Fee Schedule,350% of BCBS fee schedule,29.77,350,,21641.104,Fee Schedule,350% of BCBS fee schedule,24.62,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,286,,20775.456,Fee Schedule,286% of BCBS PPO fee schedule,10.41,100,,17312.88,Fee Schedule,100% of Blue ADV HMO fee schedule,71.09,90,,2023.92,Percent of Total Billed Charges,90% of Total Billed Charges,35.55,45,,119.072,Percent of Total Billed Charges,45% of Total Billed Charges,71.09,90,,302.44,Percent of Total Billed Charges,90% of Total billed Charges,24.62,100,,,Fee Schedule,100% of CMS OPPS Rate,24.62,100,,,Fee Schedule,100% of CMS OPPS Rate,24.62,100,,,Fee Schedule,100% of CMS OPPS Rate,45.99,200,,239.36,Fee Schedule,200% of CMS OPPS Rate,34.83,44.1,,116.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,75.04,95,,319.24,Percent of Total Billed Charges,95% of Total Billed Charges,18.46,75,,,Fee Schedule,75% of CMS OPPS Rate,69.51,88,,27.456,Percent of Total Billed Charges,88% of Total Billed Charges,71.09,90,,302.44,Percent of Total Billed charges,90% of Total Billed Charges,10.41,75.04,
OTH RESP PROC GROUP,4100000015,CDM,410,RC,G0239,HCPCS,Outpatient,,,78.99,51.34,,49.33,125,,,Fee Schedule,125% of CMS OPPS Rate,60.03,76,,206.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,37.98,350,,19737.216,Fee Schedule,350% of BCBS fee schedule,37.98,350,,20559.6,Fee Schedule,350% of BCBS fee schedule,39.46,100,,,Fee Schedule,100% of CMS OPPS Rate,37.98,286,,19737.216,Fee Schedule,286% of BCBS PPO fee schedule,13.28,100,,16447.68,Fee Schedule,100% of Blue ADV HMO fee schedule,71.09,90,,1406.16,Percent of Total Billed Charges,90% of Total Billed Charges,35.55,45,,14.04,Percent of Total Billed Charges,45% of Total Billed Charges,71.09,90,,244.8,Percent of Total Billed Charges,90% of Total billed Charges,39.46,100,,,Fee Schedule,100% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of CMS OPPS Rate,39.46,100,,,Fee Schedule,100% of CMS OPPS Rate,73.7,200,,52,Fee Schedule,200% of CMS OPPS Rate,34.83,44.1,,13.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,75.04,95,,258.4,Percent of Total Billed Charges,95% of Total Billed Charges,29.59,75,,,Fee Schedule,75% of CMS OPPS Rate,69.51,88,,205.568,Percent of Total Billed Charges,88% of Total Billed Charges,71.09,90,,244.8,Percent of Total Billed charges,90% of Total Billed Charges,13.28,75.04,
PT CANALITH REPO PROCED PR DAY,4200000001,CDM,420,RC,,,Outpatient,,,160.00,104.00,,160,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,121.6,76,,223.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,115.2,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,120,75,,21641.104,Percent of Total Billed charges,75% of Total Billed Charges,160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.2,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,96,60,,17312.88,Percent of Total Billed Charges,60% of Total Billed Charges,144,90,,350.64,Percent of Total Billed Charges,90% of Total Billed Charges,72,45,,105.12,Percent of Total Billed Charges,45% of Total Billed Charges,144,90,,264.96,Percent of Total Billed Charges,90% of Total billed Charges,160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104,65,,247.664,Percent of total Billed Charges,65% of Total Billed Charges,70.56,44.1,,103.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,152,95,,279.68,Percent of Total Billed Charges,95% of Total Billed Charges,160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.8,88,,205.568,Percent of Total Billed Charges,88% of Total Billed Charges,144,90,,264.96,Percent of Total Billed charges,90% of Total Billed Charges,70.56,160,
PT COMP WRAP LEG BEL KNEE RT,4200000002,CDM,420,RC,,,Outpatient,,,318.00,206.70,,318,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,241.68,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,228.96,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,238.5,75,,21641.104,Percent of Total Billed charges,75% of Total Billed Charges,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.96,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,190.8,60,,17312.88,Percent of Total Billed Charges,60% of Total Billed Charges,286.2,90,,1314,Percent of Total Billed Charges,90% of Total Billed Charges,143.1,45,,105.12,Percent of Total Billed Charges,45% of Total Billed Charges,286.2,90,,198,Percent of Total Billed Charges,90% of Total billed Charges,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.7,65,,71.76,Percent of total Billed Charges,65% of Total Billed Charges,140.24,44.1,,103.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,302.1,95,,209,Percent of Total Billed Charges,95% of Total Billed Charges,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279.84,88,,76.032,Percent of Total Billed Charges,88% of Total Billed Charges,286.2,90,,198,Percent of Total Billed charges,90% of Total Billed Charges,140.24,318,
PT COMP WRP  UPP ARM/HND  LEFT,4200000003,CDM,420,RC,,,Outpatient,,,334.47,217.41,,334.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,254.2,76,,201.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,240.82,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,250.85,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,334.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.82,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,200.68,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,301.02,90,,174.64,Percent of Total Billed Charges,90% of Total Billed Charges,150.51,45,,38.88,Percent of Total Billed Charges,45% of Total Billed Charges,301.02,90,,238.144,Percent of Total Billed Charges,90% of Total billed Charges,334.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.41,65,,138.536,Percent of total Billed Charges,65% of Total Billed Charges,147.5,44.1,,38.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,317.75,95,,251.368,Percent of Total Billed Charges,95% of Total Billed Charges,334.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.33,88,,487.872,Percent of Total Billed Charges,88% of Total Billed Charges,301.02,90,,238.144,Percent of Total Billed charges,90% of Total Billed Charges,147.5,334.47,
PT COMP WRP LEG LEFT,4200000004,CDM,420,RC,,,Outpatient,,,318.00,206.70,,318,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,241.68,76,,23.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,228.96,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,238.5,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.96,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,190.8,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,286.2,90,,376.56,Percent of Total Billed Charges,90% of Total Billed Charges,143.1,45,,249.48,Percent of Total Billed Charges,45% of Total Billed Charges,286.2,90,,28.08,Percent of Total Billed Charges,90% of Total billed Charges,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.7,65,,175.76,Percent of total Billed Charges,65% of Total Billed Charges,140.24,44.1,,244.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,302.1,95,,29.64,Percent of Total Billed Charges,95% of Total Billed Charges,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279.84,88,,1978.944,Percent of Total Billed Charges,88% of Total Billed Charges,286.2,90,,28.08,Percent of Total Billed charges,90% of Total Billed Charges,140.24,318,
PT COMPWRP  UPPARM/HND RIGHT,4200000005,CDM,420,RC,,,Outpatient,,,334.47,217.41,,334.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,254.2,76,,177.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,240.82,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,250.85,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,334.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.82,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,200.68,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,301.02,90,,1274.848,Percent of Total Billed Charges,90% of Total Billed Charges,150.51,45,,1011.96,Percent of Total Billed Charges,45% of Total Billed Charges,301.02,90,,210.24,Percent of Total Billed Charges,90% of Total billed Charges,334.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.41,65,,330.64,Percent of total Billed Charges,65% of Total Billed Charges,147.5,44.1,,991.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,317.75,95,,221.92,Percent of Total Billed Charges,95% of Total Billed Charges,334.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.33,88,,1374.912,Percent of Total Billed Charges,88% of Total Billed Charges,301.02,90,,210.24,Percent of Total Billed charges,90% of Total Billed Charges,147.5,334.47,
PT ULTRASLOWFRQ NONTHER PR DAY,4200000006,CDM,420,RC,,,Outpatient,,,426.03,276.92,,426.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,323.78,76,,177.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,306.74,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,319.52,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,426.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.74,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,255.62,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,383.43,90,,1235.976,Percent of Total Billed Charges,90% of Total Billed Charges,191.71,45,,703.08,Percent of Total Billed Charges,45% of Total Billed Charges,383.43,90,,210.24,Percent of Total Billed Charges,90% of Total billed Charges,426.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.92,65,,366.08,Percent of total Billed Charges,65% of Total Billed Charges,187.88,44.1,,689.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,404.73,95,,221.92,Percent of Total Billed Charges,95% of Total Billed Charges,426.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.91,88,,342.848,Percent of Total Billed Charges,88% of Total Billed Charges,383.43,90,,210.24,Percent of Total Billed charges,90% of Total Billed Charges,187.88,426.03,
PT UNNA BOOT APPLIC  BILAT,4200000007,CDM,420,RC,,,Outpatient,,,231.00,150.15,,231,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,175.56,76,,65.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,166.32,72,,1777.536,Percent of Total Billed Charges,72% of Total Billed Charges,173.25,75,,1851.6,Percent of Total Billed charges,75% of Total Billed Charges,231,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.32,72,,1777.536,Percent of Total Billed Charges,72% of Total Billed Charges,138.6,60,,1481.28,Percent of Total Billed Charges,60% of Total Billed Charges,207.9,90,,1063.44,Percent of Total Billed Charges,90% of Total Billed Charges,103.95,45,,175.32,Percent of Total Billed Charges,45% of Total Billed Charges,207.9,90,,77.76,Percent of Total Billed Charges,90% of Total billed Charges,231,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.15,65,,15661.904,Percent of total Billed Charges,65% of Total Billed Charges,101.87,44.1,,171.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,219.45,95,,82.08,Percent of Total Billed Charges,95% of Total Billed Charges,231,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.28,88,,1284.8,Percent of Total Billed Charges,88% of Total Billed Charges,207.9,90,,77.76,Percent of Total Billed charges,90% of Total Billed Charges,101.87,231,
PT UNNA BOOT APPLIC UNILAT,4200000008,CDM,420,RC,,,Outpatient,,,172.00,111.80,,172,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.72,76,,421.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.84,72,,1777.536,Percent of Total Billed Charges,72% of Total Billed Charges,129,75,,1851.6,Percent of Total Billed charges,75% of Total Billed Charges,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.84,72,,1777.536,Percent of Total Billed Charges,72% of Total Billed Charges,103.2,60,,1481.28,Percent of Total Billed Charges,60% of Total Billed Charges,154.8,90,,532.8,Percent of Total Billed Charges,90% of Total Billed Charges,77.4,45,,657,Percent of Total Billed Charges,45% of Total Billed Charges,154.8,90,,498.96,Percent of Total Billed Charges,90% of Total billed Charges,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.8,65,,25086.048,Percent of total Billed Charges,65% of Total Billed Charges,75.85,44.1,,643.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.4,95,,526.68,Percent of Total Billed Charges,95% of Total Billed Charges,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.36,88,,170.752,Percent of Total Billed Charges,88% of Total Billed Charges,154.8,90,,498.96,Percent of Total Billed charges,90% of Total Billed Charges,75.85,172,
PT WORK HARDEN COND ADDL 1HR,4200000009,CDM,420,RC,,,Outpatient,,,233.73,151.92,,233.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,177.63,76,,1709.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,168.29,72,,1777.536,Percent of Total Billed Charges,72% of Total Billed Charges,175.3,75,,1851.6,Percent of Total Billed charges,75% of Total Billed Charges,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.29,72,,1777.536,Percent of Total Billed Charges,72% of Total Billed Charges,140.24,60,,1481.28,Percent of Total Billed Charges,60% of Total Billed Charges,210.36,90,,1139.896,Percent of Total Billed Charges,90% of Total Billed Charges,105.18,45,,87.32,Percent of Total Billed Charges,45% of Total Billed Charges,210.36,90,,2023.92,Percent of Total Billed Charges,90% of Total billed Charges,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.92,65,,15408.584,Percent of total Billed Charges,65% of Total Billed Charges,103.07,44.1,,85.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,222.04,95,,2136.36,Percent of Total Billed Charges,95% of Total Billed Charges,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.68,88,,368.192,Percent of Total Billed Charges,88% of Total Billed Charges,210.36,90,,2023.92,Percent of Total Billed charges,90% of Total Billed Charges,103.07,233.73,
PT WRK HARDEN COND INIT 2HRS,4200000010,CDM,420,RC,,,Outpatient,,,446.00,289.90,,446,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,338.96,76,,1187.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,321.12,72,,1777.536,Percent of Total Billed Charges,72% of Total Billed Charges,334.5,75,,1851.6,Percent of Total Billed charges,75% of Total Billed Charges,446,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,321.12,72,,1777.536,Percent of Total Billed Charges,72% of Total Billed Charges,267.6,60,,1481.28,Percent of Total Billed Charges,60% of Total Billed Charges,401.4,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,200.7,45,,188.28,Percent of Total Billed Charges,45% of Total Billed Charges,401.4,90,,1406.16,Percent of Total Billed Charges,90% of Total billed Charges,446,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.9,65,,14638.52,Percent of total Billed Charges,65% of Total Billed Charges,196.69,44.1,,184.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,423.7,95,,1484.28,Percent of Total Billed Charges,95% of Total Billed Charges,446,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.48,88,,1246.52,Percent of Total Billed Charges,88% of Total Billed Charges,401.4,90,,1406.16,Percent of Total Billed charges,90% of Total Billed Charges,196.69,446,
PTA COMP WRAP LEG BELKNE RIGHT,4200000011,CDM,420,RC,,,Outpatient,,,318.00,206.70,,318,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,241.68,76,,296.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,228.96,72,,1777.536,Percent of Total Billed Charges,72% of Total Billed Charges,238.5,75,,1851.6,Percent of Total Billed charges,75% of Total Billed Charges,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.96,72,,1777.536,Percent of Total Billed Charges,72% of Total Billed Charges,190.8,60,,1481.28,Percent of Total Billed Charges,60% of Total Billed Charges,286.2,90,,422.304,Percent of Total Billed Charges,90% of Total Billed Charges,143.1,45,,637.424,Percent of Total Billed Charges,45% of Total Billed Charges,286.2,90,,350.64,Percent of Total Billed Charges,90% of Total billed Charges,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.7,65,,13207.112,Percent of total Billed Charges,65% of Total Billed Charges,140.24,44.1,,624.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,302.1,95,,370.12,Percent of Total Billed Charges,95% of Total Billed Charges,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279.84,88,,1208.504,Percent of Total Billed Charges,88% of Total Billed Charges,286.2,90,,350.64,Percent of Total Billed charges,90% of Total Billed Charges,140.24,318,
PTA COMP WRP LEG LEFT,4200000012,CDM,420,RC,,,Outpatient,,,318.00,206.70,,318,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,241.68,76,,1109.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,228.96,72,,1120.896,Percent of Total Billed Charges,72% of Total Billed Charges,238.5,75,,1167.6,Percent of Total Billed charges,75% of Total Billed Charges,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.96,72,,1120.896,Percent of Total Billed Charges,72% of Total Billed Charges,190.8,60,,934.08,Percent of Total Billed Charges,60% of Total Billed Charges,286.2,90,,776.16,Percent of Total Billed Charges,90% of Total Billed Charges,143.1,45,,617.984,Percent of Total Billed Charges,45% of Total Billed Charges,286.2,90,,1314,Percent of Total Billed Charges,90% of Total billed Charges,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.7,65,,16438.232,Percent of total Billed Charges,65% of Total Billed Charges,140.24,44.1,,605.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,302.1,95,,1387,Percent of Total Billed Charges,95% of Total Billed Charges,318,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279.84,88,,1039.808,Percent of Total Billed Charges,88% of Total Billed Charges,286.2,90,,1314,Percent of Total Billed charges,90% of Total Billed Charges,140.24,318,
PTA COMPWRAP UPP ARM/HND LEFT,4200000013,CDM,420,RC,,,Outpatient,,,334.47,217.41,,334.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,254.2,76,,147.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,240.82,72,,1120.896,Percent of Total Billed Charges,72% of Total Billed Charges,250.85,75,,1167.6,Percent of Total Billed charges,75% of Total Billed Charges,334.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.82,72,,1120.896,Percent of Total Billed Charges,72% of Total Billed Charges,200.68,60,,934.08,Percent of Total Billed Charges,60% of Total Billed Charges,301.02,90,,504.856,Percent of Total Billed Charges,90% of Total Billed Charges,150.51,45,,531.72,Percent of Total Billed Charges,45% of Total Billed Charges,301.02,90,,174.64,Percent of Total Billed Charges,90% of Total billed Charges,334.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.41,65,,20345.84,Percent of total Billed Charges,65% of Total Billed Charges,147.5,44.1,,521.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,317.75,95,,184.336,Percent of Total Billed Charges,95% of Total Billed Charges,334.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.33,88,,520.96,Percent of Total Billed Charges,88% of Total Billed Charges,301.02,90,,174.64,Percent of Total Billed charges,90% of Total Billed Charges,147.5,334.47,
PTA COMPWRP UPP ARM/HND RIGHT,4200000014,CDM,420,RC,,,Outpatient,,,334.47,217.41,,334.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,254.2,76,,317.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,240.82,72,,1120.896,Percent of Total Billed Charges,72% of Total Billed Charges,250.85,75,,1167.6,Percent of Total Billed charges,75% of Total Billed Charges,334.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.82,72,,1120.896,Percent of Total Billed Charges,72% of Total Billed Charges,200.68,60,,934.08,Percent of Total Billed Charges,60% of Total Billed Charges,301.02,90,,2404.8,Percent of Total Billed Charges,90% of Total Billed Charges,150.51,45,,266.4,Percent of Total Billed Charges,45% of Total Billed Charges,301.02,90,,376.56,Percent of Total Billed Charges,90% of Total billed Charges,334.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.41,65,,2676.736,Percent of total Billed Charges,65% of Total Billed Charges,147.5,44.1,,261.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,317.75,95,,397.48,Percent of Total Billed Charges,95% of Total Billed Charges,334.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.33,88,,1114.568,Percent of Total Billed Charges,88% of Total Billed Charges,301.02,90,,376.56,Percent of Total Billed charges,90% of Total Billed Charges,147.5,334.47,
PTA ULTRASLWFRQ NONTHER PR DAY,4200000015,CDM,420,RC,,,Outpatient,,,426.03,276.92,,426.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,323.78,76,,1076.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,306.74,72,,1179.512,Percent of Total Billed Charges,72% of Total Billed Charges,319.52,75,,1228.656,Percent of Total Billed charges,75% of Total Billed Charges,426.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.74,72,,1179.512,Percent of Total Billed Charges,72% of Total Billed Charges,255.62,60,,982.928,Percent of Total Billed Charges,60% of Total Billed Charges,383.43,90,,497.712,Percent of Total Billed Charges,90% of Total Billed Charges,191.71,45,,569.952,Percent of Total Billed Charges,45% of Total Billed Charges,383.43,90,,1274.848,Percent of Total Billed Charges,90% of Total billed Charges,426.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.92,65,,2676.736,Percent of total Billed Charges,65% of Total Billed Charges,187.88,44.1,,558.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,404.73,95,,1345.672,Percent of Total Billed Charges,95% of Total Billed Charges,426.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.91,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,383.43,90,,1274.848,Percent of Total Billed charges,90% of Total Billed Charges,187.88,426.03,
PTA UNNA BOOT APPLIC BILAT,4200000016,CDM,420,RC,,,Outpatient,,,231.00,150.15,,231,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,175.56,76,,1043.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,166.32,72,,1179.512,Percent of Total Billed Charges,72% of Total Billed Charges,173.25,75,,1228.656,Percent of Total Billed charges,75% of Total Billed Charges,231,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.32,72,,1179.512,Percent of Total Billed Charges,72% of Total Billed Charges,138.6,60,,982.928,Percent of Total Billed Charges,60% of Total Billed Charges,207.9,90,,905.728,Percent of Total Billed Charges,90% of Total Billed Charges,103.95,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,207.9,90,,1235.976,Percent of Total Billed Charges,90% of Total billed Charges,231,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.15,65,,1736.8,Percent of total Billed Charges,65% of Total Billed Charges,101.87,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,219.45,95,,1304.64,Percent of Total Billed Charges,95% of Total Billed Charges,231,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.28,88,,412.92,Percent of Total Billed Charges,88% of Total Billed Charges,207.9,90,,1235.976,Percent of Total Billed charges,90% of Total Billed Charges,101.87,231,
PTA UNNA BOOT APPLIC UNILAT,4200000017,CDM,420,RC,,,Outpatient,,,172.00,111.80,,172,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.72,76,,898.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.84,72,,1994.112,Percent of Total Billed Charges,72% of Total Billed Charges,129,75,,2077.2,Percent of Total Billed charges,75% of Total Billed Charges,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.84,72,,1994.112,Percent of Total Billed Charges,72% of Total Billed Charges,103.2,60,,1661.76,Percent of Total Billed Charges,60% of Total Billed Charges,154.8,90,,52.392,Percent of Total Billed Charges,90% of Total Billed Charges,77.4,45,,211.152,Percent of Total Billed Charges,45% of Total Billed Charges,154.8,90,,1063.44,Percent of Total Billed Charges,90% of Total billed Charges,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.8,65,,1173.776,Percent of total Billed Charges,65% of Total Billed Charges,75.85,44.1,,206.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.4,95,,1122.52,Percent of Total Billed Charges,95% of Total Billed Charges,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.36,88,,758.912,Percent of Total Billed Charges,88% of Total Billed Charges,154.8,90,,1063.44,Percent of Total Billed charges,90% of Total Billed Charges,75.85,172,
PTA WORK HARDEN COND ADDL 1HR,4200000018,CDM,420,RC,,,Outpatient,,,233.73,151.92,,233.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,177.63,76,,449.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,168.29,72,,1994.112,Percent of Total Billed Charges,72% of Total Billed Charges,175.3,75,,2077.2,Percent of Total Billed charges,75% of Total Billed Charges,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.29,72,,1994.112,Percent of Total Billed Charges,72% of Total Billed Charges,140.24,60,,1661.76,Percent of Total Billed Charges,60% of Total Billed Charges,210.36,90,,199.44,Percent of Total Billed Charges,90% of Total Billed Charges,105.18,45,,388.08,Percent of Total Billed Charges,45% of Total Billed Charges,210.36,90,,532.8,Percent of Total Billed Charges,90% of Total billed Charges,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.92,65,,1229.8,Percent of total Billed Charges,65% of Total Billed Charges,103.07,44.1,,380.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,222.04,95,,562.4,Percent of Total Billed Charges,95% of Total Billed Charges,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.68,88,,493.64,Percent of Total Billed Charges,88% of Total Billed Charges,210.36,90,,532.8,Percent of Total Billed charges,90% of Total Billed Charges,103.07,233.73,
PTA WRK HARDEN COND INIT 2HRS,4200000019,CDM,420,RC,,,Outpatient,,,468.56,304.56,,468.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,356.11,76,,962.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,337.36,72,,1994.112,Percent of Total Billed Charges,72% of Total Billed Charges,351.42,75,,2077.2,Percent of Total Billed charges,75% of Total Billed Charges,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.36,72,,1994.112,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,60,,1661.76,Percent of Total Billed Charges,60% of Total Billed Charges,421.7,90,,340.56,Percent of Total Billed Charges,90% of Total Billed Charges,210.85,45,,252.432,Percent of Total Billed Charges,45% of Total Billed Charges,421.7,90,,1139.896,Percent of Total Billed Charges,90% of Total billed Charges,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.56,65,,483.296,Percent of total Billed Charges,65% of Total Billed Charges,206.63,44.1,,247.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,445.13,95,,1203.224,Percent of Total Billed Charges,95% of Total Billed Charges,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.33,88,,2351.36,Percent of Total Billed Charges,88% of Total Billed Charges,421.7,90,,1139.896,Percent of Total Billed charges,90% of Total Billed Charges,206.63,468.56,
BILILITE THERAPY,4200000020,CDM,420,RC,,,Outpatient,,,210.00,136.50,,210,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,159.6,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,151.2,72,,2098.704,Percent of Total Billed Charges,72% of Total Billed Charges,157.5,75,,2186.152,Percent of Total Billed charges,75% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.2,72,,2098.704,Percent of Total Billed Charges,72% of Total Billed Charges,126,60,,1748.92,Percent of Total Billed Charges,60% of Total Billed Charges,189,90,,550.8,Percent of Total Billed Charges,90% of Total Billed Charges,94.5,45,,1202.4,Percent of Total Billed Charges,45% of Total Billed Charges,189,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.5,65,,330.72,Percent of total Billed Charges,65% of Total Billed Charges,92.61,44.1,,1178.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,199.5,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,210,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.8,88,,486.656,Percent of Total Billed Charges,88% of Total Billed Charges,189,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,92.61,210,
PT COLD OR HOT PACK,4200000021,CDM,420,RC,,,Outpatient,,,99.00,64.35,,99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.24,76,,356.608,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71.28,72,,1994.112,Percent of Total Billed Charges,72% of Total Billed Charges,74.25,75,,2077.2,Percent of Total Billed charges,75% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.28,72,,1994.112,Percent of Total Billed Charges,72% of Total Billed Charges,59.4,60,,1661.76,Percent of Total Billed Charges,60% of Total Billed Charges,89.1,90,,550.8,Percent of Total Billed Charges,90% of Total Billed Charges,44.55,45,,248.856,Percent of Total Billed Charges,45% of Total Billed Charges,89.1,90,,422.304,Percent of Total Billed Charges,90% of Total billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.35,65,,1411.464,Percent of total Billed Charges,65% of Total Billed Charges,43.66,44.1,,243.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,94.05,95,,445.76,Percent of Total Billed Charges,95% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.12,88,,885.6,Percent of Total Billed Charges,88% of Total Billed Charges,89.1,90,,422.304,Percent of Total Billed charges,90% of Total Billed Charges,43.66,99,
PTA COLD OR HOT PACK,4200000022,CDM,420,RC,,,Outpatient,,,99.00,64.35,,99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.24,76,,655.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71.28,72,,997.056,Percent of Total Billed Charges,72% of Total Billed Charges,74.25,75,,1038.6,Percent of Total Billed charges,75% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.28,72,,997.056,Percent of Total Billed Charges,72% of Total Billed Charges,59.4,60,,830.88,Percent of Total Billed Charges,60% of Total Billed Charges,89.1,90,,903.6,Percent of Total Billed Charges,90% of Total Billed Charges,44.55,45,,452.864,Percent of Total Billed Charges,45% of Total Billed Charges,89.1,90,,776.16,Percent of Total Billed Charges,90% of Total billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.35,65,,1043.408,Percent of total Billed Charges,65% of Total Billed Charges,43.66,44.1,,443.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,94.05,95,,819.28,Percent of Total Billed Charges,95% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.12,88,,51.232,Percent of Total Billed Charges,88% of Total Billed Charges,89.1,90,,776.16,Percent of Total Billed charges,90% of Total Billed Charges,43.66,99,
PT MECHANICAL TRACTION,4200000023,CDM,420,RC,,,Outpatient,,,172.00,111.80,,172,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.72,76,,426.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,123.84,72,,997.056,Percent of Total Billed Charges,72% of Total Billed Charges,129,75,,1038.6,Percent of Total Billed charges,75% of Total Billed Charges,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.84,72,,997.056,Percent of Total Billed Charges,72% of Total Billed Charges,103.2,60,,830.88,Percent of Total Billed Charges,60% of Total Billed Charges,154.8,90,,1338.48,Percent of Total Billed Charges,90% of Total Billed Charges,77.4,45,,26.2,Percent of Total Billed Charges,45% of Total Billed Charges,154.8,90,,504.856,Percent of Total Billed Charges,90% of Total billed Charges,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.8,65,,612.512,Percent of total Billed Charges,65% of Total Billed Charges,75.85,44.1,,25.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.4,95,,532.904,Percent of Total Billed Charges,95% of Total Billed Charges,172,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.36,88,,195.008,Percent of Total Billed Charges,88% of Total Billed Charges,154.8,90,,504.856,Percent of Total Billed charges,90% of Total Billed Charges,75.85,172,
PTA MECHANICAL TRACTION,4200000024,CDM,420,RC,,,Outpatient,,,180.81,117.53,,180.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,137.42,76,,2030.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,130.18,72,,997.056,Percent of Total Billed Charges,72% of Total Billed Charges,135.61,75,,1038.6,Percent of Total Billed charges,75% of Total Billed Charges,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.18,72,,997.056,Percent of Total Billed Charges,72% of Total Billed Charges,108.49,60,,830.88,Percent of Total Billed Charges,60% of Total Billed Charges,162.73,90,,2411.28,Percent of Total Billed Charges,90% of Total Billed Charges,81.36,45,,99.72,Percent of Total Billed Charges,45% of Total Billed Charges,162.73,90,,2404.8,Percent of Total Billed Charges,90% of Total billed Charges,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.53,65,,61.88,Percent of total Billed Charges,65% of Total Billed Charges,79.74,44.1,,97.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,171.77,95,,2538.4,Percent of Total Billed Charges,95% of Total Billed Charges,180.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.11,88,,332.992,Percent of Total Billed Charges,88% of Total Billed Charges,162.73,90,,2404.8,Percent of Total Billed charges,90% of Total Billed Charges,79.74,180.81,
PT PARAFFINMODALITY,4200000025,CDM,420,RC,,,Outpatient,,,122.00,79.30,,122,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,92.72,76,,420.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,87.84,72,,1049.36,Percent of Total Billed Charges,72% of Total Billed Charges,91.5,75,,1093.08,Percent of Total Billed charges,75% of Total Billed Charges,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.84,72,,1049.36,Percent of Total Billed Charges,72% of Total Billed Charges,73.2,60,,874.464,Percent of Total Billed Charges,60% of Total Billed Charges,109.8,90,,587.52,Percent of Total Billed Charges,90% of Total Billed Charges,54.9,45,,170.28,Percent of Total Billed Charges,45% of Total Billed Charges,109.8,90,,497.712,Percent of Total Billed Charges,90% of Total billed Charges,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.3,65,,812.84,Percent of total Billed Charges,65% of Total Billed Charges,53.8,44.1,,166.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,115.9,95,,525.368,Percent of Total Billed Charges,95% of Total Billed Charges,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.36,88,,538.56,Percent of Total Billed Charges,88% of Total Billed Charges,109.8,90,,497.712,Percent of Total Billed charges,90% of Total Billed Charges,53.8,122,
PTA PARAFFINMODALITY,4200000026,CDM,420,RC,,,Outpatient,,,122.00,79.30,,122,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,92.72,76,,764.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,87.84,72,,1049.36,Percent of Total Billed Charges,72% of Total Billed Charges,91.5,75,,1093.08,Percent of Total Billed charges,75% of Total Billed Charges,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.84,72,,1049.36,Percent of Total Billed Charges,72% of Total Billed Charges,73.2,60,,874.464,Percent of Total Billed Charges,60% of Total Billed Charges,109.8,90,,226.08,Percent of Total Billed Charges,90% of Total Billed Charges,54.9,45,,275.4,Percent of Total Billed Charges,45% of Total Billed Charges,109.8,90,,905.728,Percent of Total Billed Charges,90% of Total billed Charges,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.3,65,,1235,Percent of total Billed Charges,65% of Total Billed Charges,53.8,44.1,,269.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,115.9,95,,956.04,Percent of Total Billed Charges,95% of Total Billed Charges,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.36,88,,538.56,Percent of Total Billed Charges,88% of Total Billed Charges,109.8,90,,905.728,Percent of Total Billed charges,90% of Total Billed Charges,53.8,122,
PT WHIRLPOOL SMALL,4200000027,CDM,420,RC,,,Outpatient,,,206.00,133.90,,206,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,156.56,76,,44.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,148.32,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,154.5,75,,12853.2,Percent of Total Billed charges,75% of Total Billed Charges,206,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.32,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,123.6,60,,10282.56,Percent of Total Billed Charges,60% of Total Billed Charges,185.4,90,,705.6,Percent of Total Billed Charges,90% of Total Billed Charges,92.7,45,,275.4,Percent of Total Billed Charges,45% of Total Billed Charges,185.4,90,,52.392,Percent of Total Billed Charges,90% of Total billed Charges,206,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.9,65,,9794.72,Percent of total Billed Charges,65% of Total Billed Charges,90.85,44.1,,269.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,195.7,95,,55.304,Percent of Total Billed Charges,95% of Total Billed Charges,206,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.28,88,,883.52,Percent of Total Billed Charges,88% of Total Billed Charges,185.4,90,,52.392,Percent of Total Billed charges,90% of Total Billed Charges,90.85,206,
PT WHIRLPOOLLARGE,4200000028,CDM,420,RC,,,Outpatient,,,206.00,133.90,,206,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,156.56,76,,168.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,148.32,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,154.5,75,,12853.2,Percent of Total Billed charges,75% of Total Billed Charges,206,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.32,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,123.6,60,,10282.56,Percent of Total Billed Charges,60% of Total Billed Charges,185.4,90,,491.368,Percent of Total Billed Charges,90% of Total Billed Charges,92.7,45,,451.8,Percent of Total Billed Charges,45% of Total Billed Charges,185.4,90,,199.44,Percent of Total Billed Charges,90% of Total billed Charges,206,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.9,65,,11469.44,Percent of total Billed Charges,65% of Total Billed Charges,90.85,44.1,,442.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,195.7,95,,210.52,Percent of Total Billed Charges,95% of Total Billed Charges,206,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.28,88,,1308.736,Percent of Total Billed Charges,88% of Total Billed Charges,185.4,90,,199.44,Percent of Total Billed charges,90% of Total Billed Charges,90.85,206,
PT FLUIDO THERAPY,4200000029,CDM,420,RC,,,Outpatient,,,216.09,140.46,,216.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,164.23,76,,287.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,155.58,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,162.07,75,,12853.2,Percent of Total Billed charges,75% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.58,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,129.65,60,,10282.56,Percent of Total Billed Charges,60% of Total Billed Charges,194.48,90,,424.08,Percent of Total Billed Charges,90% of Total Billed Charges,97.24,45,,669.24,Percent of Total Billed Charges,45% of Total Billed Charges,194.48,90,,340.56,Percent of Total Billed Charges,90% of Total billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.46,65,,11469.44,Percent of total Billed Charges,65% of Total Billed Charges,95.3,44.1,,655.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,205.29,95,,359.48,Percent of Total Billed Charges,95% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.16,88,,2357.696,Percent of Total Billed Charges,88% of Total Billed Charges,194.48,90,,340.56,Percent of Total Billed charges,90% of Total Billed Charges,95.3,216.09,
PTA FLUIDO THERAPY,4200000030,CDM,420,RC,,,Outpatient,,,216.09,140.46,,216.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,164.23,76,,465.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,155.58,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,162.07,75,,12853.2,Percent of Total Billed charges,75% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.58,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,129.65,60,,10282.56,Percent of Total Billed Charges,60% of Total Billed Charges,194.48,90,,470.88,Percent of Total Billed Charges,90% of Total Billed Charges,97.24,45,,1205.64,Percent of Total Billed Charges,45% of Total Billed Charges,194.48,90,,550.8,Percent of Total Billed Charges,90% of Total billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.46,65,,8982.464,Percent of total Billed Charges,65% of Total Billed Charges,95.3,44.1,,1181.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,205.29,95,,581.4,Percent of Total Billed Charges,95% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.16,88,,574.464,Percent of Total Billed Charges,88% of Total Billed Charges,194.48,90,,550.8,Percent of Total Billed charges,90% of Total Billed Charges,95.3,216.09,
PTA WHIRLPOOLLARGE,4200000031,CDM,420,RC,,,Outpatient,,,216.09,140.46,,216.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,164.23,76,,465.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,155.58,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,162.07,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.58,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,129.65,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,194.48,90,,753.12,Percent of Total Billed Charges,90% of Total Billed Charges,97.24,45,,293.76,Percent of Total Billed Charges,45% of Total Billed Charges,194.48,90,,550.8,Percent of Total Billed Charges,90% of Total billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.46,65,,11469.44,Percent of total Billed Charges,65% of Total Billed Charges,95.3,44.1,,287.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,205.29,95,,581.4,Percent of Total Billed Charges,95% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.16,88,,221.056,Percent of Total Billed Charges,88% of Total Billed Charges,194.48,90,,550.8,Percent of Total Billed charges,90% of Total Billed Charges,95.3,216.09,
PTA WHIRLPOOL SMALL,4200000032,CDM,420,RC,,,Outpatient,,,206.00,133.90,,206,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,156.56,76,,763.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,148.32,72,,11387.52,Percent of Total Billed Charges,72% of Total Billed Charges,154.5,75,,11862,Percent of Total Billed charges,75% of Total Billed Charges,206,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.32,72,,11387.52,Percent of Total Billed Charges,72% of Total Billed Charges,123.6,60,,9489.6,Percent of Total Billed Charges,60% of Total Billed Charges,185.4,90,,282.24,Percent of Total Billed Charges,90% of Total Billed Charges,92.7,45,,113.04,Percent of Total Billed Charges,45% of Total Billed Charges,185.4,90,,903.6,Percent of Total Billed Charges,90% of Total billed Charges,206,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.9,65,,1154.392,Percent of total Billed Charges,65% of Total Billed Charges,90.85,44.1,,110.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,195.7,95,,953.8,Percent of Total Billed Charges,95% of Total Billed Charges,206,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.28,88,,689.92,Percent of Total Billed Charges,88% of Total Billed Charges,185.4,90,,903.6,Percent of Total Billed charges,90% of Total Billed Charges,90.85,206,
PT ELEC STIM MAN 15 MIN,4200000033,CDM,420,RC,,,Outpatient,,,226.00,146.90,,226,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171.76,76,,1130.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162.72,72,,804.384,Percent of Total Billed Charges,72% of Total Billed Charges,169.5,75,,837.904,Percent of Total Billed charges,75% of Total Billed Charges,226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.72,72,,804.384,Percent of Total Billed Charges,72% of Total Billed Charges,135.6,60,,670.32,Percent of Total Billed Charges,60% of Total Billed Charges,203.4,90,,564.48,Percent of Total Billed Charges,90% of Total Billed Charges,101.7,45,,352.8,Percent of Total Billed Charges,45% of Total Billed Charges,203.4,90,,1338.48,Percent of Total Billed Charges,90% of Total billed Charges,226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.9,65,,6981.64,Percent of total Billed Charges,65% of Total Billed Charges,99.67,44.1,,345.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,214.7,95,,1412.84,Percent of Total Billed Charges,95% of Total Billed Charges,226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.88,88,,480.448,Percent of Total Billed Charges,88% of Total Billed Charges,203.4,90,,1338.48,Percent of Total Billed charges,90% of Total Billed Charges,99.67,226,
PTA ELEC STIM MAN 15 MIN,4200000034,CDM,420,RC,,,Outpatient,,,226.00,146.90,,226,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171.76,76,,2036.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162.72,72,,228.096,Percent of Total Billed Charges,72% of Total Billed Charges,169.5,75,,237.6,Percent of Total Billed charges,75% of Total Billed Charges,226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.72,72,,228.096,Percent of Total Billed Charges,72% of Total Billed Charges,135.6,60,,190.08,Percent of Total Billed Charges,60% of Total Billed Charges,203.4,90,,1035.36,Percent of Total Billed Charges,90% of Total Billed Charges,101.7,45,,245.68,Percent of Total Billed Charges,45% of Total Billed Charges,203.4,90,,2411.28,Percent of Total Billed Charges,90% of Total billed Charges,226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.9,65,,6946.832,Percent of total Billed Charges,65% of Total Billed Charges,99.67,44.1,,240.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,214.7,95,,2545.24,Percent of Total Billed Charges,95% of Total Billed Charges,226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.88,88,,414.656,Percent of Total Billed Charges,88% of Total Billed Charges,203.4,90,,2411.28,Percent of Total Billed charges,90% of Total Billed Charges,99.67,226,
PT IONTOPHRSISATTND/15,4200000035,CDM,420,RC,,,Outpatient,,,119.07,77.40,,119.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,90.49,76,,496.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,85.73,72,,46.336,Percent of Total Billed Charges,72% of Total Billed Charges,89.3,75,,48.272,Percent of Total Billed charges,75% of Total Billed Charges,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.73,72,,46.336,Percent of Total Billed Charges,72% of Total Billed Charges,71.44,60,,38.616,Percent of Total Billed Charges,60% of Total Billed Charges,107.16,90,,574.56,Percent of Total Billed Charges,90% of Total Billed Charges,53.58,45,,212.04,Percent of Total Billed Charges,45% of Total Billed Charges,107.16,90,,587.52,Percent of Total Billed Charges,90% of Total billed Charges,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,65,,14110.904,Percent of total Billed Charges,65% of Total Billed Charges,52.51,44.1,,207.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,113.12,95,,620.16,Percent of Total Billed Charges,95% of Total Billed Charges,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.78,88,,460.416,Percent of Total Billed Charges,88% of Total Billed Charges,107.16,90,,587.52,Percent of Total Billed charges,90% of Total Billed Charges,52.51,119.07,
PTA IONTOPHRSISATTND/15,4200000036,CDM,420,RC,,,Outpatient,,,119.07,77.40,,119.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,90.49,76,,190.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,85.73,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,89.3,75,,6677.76,Percent of Total Billed charges,75% of Total Billed Charges,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.73,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,71.44,60,,5342.208,Percent of Total Billed Charges,60% of Total Billed Charges,107.16,90,,102.96,Percent of Total Billed Charges,90% of Total Billed Charges,53.58,45,,235.44,Percent of Total Billed Charges,45% of Total Billed Charges,107.16,90,,226.08,Percent of Total Billed Charges,90% of Total billed Charges,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,65,,3895.84,Percent of total Billed Charges,65% of Total Billed Charges,52.51,44.1,,230.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,113.12,95,,238.64,Percent of Total Billed Charges,95% of Total Billed Charges,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.78,88,,736.384,Percent of Total Billed Charges,88% of Total Billed Charges,107.16,90,,226.08,Percent of Total Billed charges,90% of Total Billed Charges,52.51,119.07,
PT CONTRAST BATH/15 MIN,4200000037,CDM,420,RC,,,Outpatient,,,108.00,70.20,,108,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.08,76,,595.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.76,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,81,75,,6677.76,Percent of Total Billed charges,75% of Total Billed Charges,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.76,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,64.8,60,,5342.208,Percent of Total Billed Charges,60% of Total Billed Charges,97.2,90,,180,Percent of Total Billed Charges,90% of Total Billed Charges,48.6,45,,376.56,Percent of Total Billed Charges,45% of Total Billed Charges,97.2,90,,705.6,Percent of Total Billed Charges,90% of Total billed Charges,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.2,65,,11223.496,Percent of total Billed Charges,65% of Total Billed Charges,47.63,44.1,,369.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.6,95,,744.8,Percent of Total Billed Charges,95% of Total Billed Charges,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.04,88,,275.968,Percent of Total Billed Charges,88% of Total Billed Charges,97.2,90,,705.6,Percent of Total Billed charges,90% of Total Billed Charges,47.63,108,
PTA CONTRAST BATH/15 MIN,4200000038,CDM,420,RC,,,Outpatient,,,108.00,70.20,,108,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.08,76,,414.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.76,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,81,75,,6677.76,Percent of Total Billed charges,75% of Total Billed Charges,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.76,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,64.8,60,,5342.208,Percent of Total Billed Charges,60% of Total Billed Charges,97.2,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,48.6,45,,141.12,Percent of Total Billed Charges,45% of Total Billed Charges,97.2,90,,491.368,Percent of Total Billed Charges,90% of Total billed Charges,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.2,65,,12611.456,Percent of total Billed Charges,65% of Total Billed Charges,47.63,44.1,,138.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.6,95,,518.664,Percent of Total Billed Charges,95% of Total Billed Charges,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.04,88,,551.936,Percent of Total Billed Charges,88% of Total Billed Charges,97.2,90,,491.368,Percent of Total Billed charges,90% of Total Billed Charges,47.63,108,
PT ULTRASOUND/15 MIN,4200000039,CDM,420,RC,,,Outpatient,,,159.00,103.35,,159,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.84,76,,358.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.48,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,119.25,75,,6677.76,Percent of Total Billed charges,75% of Total Billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.48,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,95.4,60,,5342.208,Percent of Total Billed Charges,60% of Total Billed Charges,143.1,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,71.55,45,,282.24,Percent of Total Billed Charges,45% of Total Billed Charges,143.1,90,,424.08,Percent of Total Billed Charges,90% of Total billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.35,65,,12611.456,Percent of total Billed Charges,65% of Total Billed Charges,70.12,44.1,,276.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,151.05,95,,447.64,Percent of Total Billed Charges,95% of Total Billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.92,88,,1012.352,Percent of Total Billed Charges,88% of Total Billed Charges,143.1,90,,424.08,Percent of Total Billed charges,90% of Total Billed Charges,70.12,159,
PT PHONOPHORESIS 15 MIN,4200000040,CDM,420,RC,,,Outpatient,,,151.04,98.18,,151.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114.79,76,,397.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.75,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,113.28,75,,6677.76,Percent of Total Billed charges,75% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.75,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,90.62,60,,5342.208,Percent of Total Billed Charges,60% of Total Billed Charges,135.94,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,67.97,45,,517.68,Percent of Total Billed Charges,45% of Total Billed Charges,135.94,90,,470.88,Percent of Total Billed Charges,90% of Total billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.18,65,,17885.816,Percent of total Billed Charges,65% of Total Billed Charges,66.61,44.1,,507.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,143.49,95,,497.04,Percent of Total Billed Charges,95% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.92,88,,561.792,Percent of Total Billed Charges,88% of Total Billed Charges,135.94,90,,470.88,Percent of Total Billed charges,90% of Total Billed Charges,66.61,151.04,
PTA PHONOPHORESIS 15 MIN,4200000041,CDM,420,RC,,,Outpatient,,,151.04,98.18,,151.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114.79,76,,635.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.75,72,,3205.328,Percent of Total Billed Charges,72% of Total Billed Charges,113.28,75,,3338.88,Percent of Total Billed charges,75% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.75,72,,3205.328,Percent of Total Billed Charges,72% of Total Billed Charges,90.62,60,,2671.104,Percent of Total Billed Charges,60% of Total Billed Charges,135.94,90,,1229.04,Percent of Total Billed Charges,90% of Total Billed Charges,67.97,45,,287.28,Percent of Total Billed Charges,45% of Total Billed Charges,135.94,90,,753.12,Percent of Total Billed Charges,90% of Total billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.18,65,,3023.584,Percent of total Billed Charges,65% of Total Billed Charges,66.61,44.1,,281.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,143.49,95,,794.96,Percent of Total Billed Charges,95% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.92,88,,100.672,Percent of Total Billed Charges,88% of Total Billed Charges,135.94,90,,753.12,Percent of Total Billed charges,90% of Total Billed Charges,66.61,151.04,
PTA ULTRASOUND/15 MIN,4200000042,CDM,420,RC,,,Outpatient,,,159.00,103.35,,159,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.84,76,,238.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.48,72,,3205.328,Percent of Total Billed Charges,72% of Total Billed Charges,119.25,75,,3338.88,Percent of Total Billed charges,75% of Total Billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.48,72,,3205.328,Percent of Total Billed Charges,72% of Total Billed Charges,95.4,60,,2671.104,Percent of Total Billed Charges,60% of Total Billed Charges,143.1,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,71.55,45,,51.48,Percent of Total Billed Charges,45% of Total Billed Charges,143.1,90,,282.24,Percent of Total Billed Charges,90% of Total billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.35,65,,3066.584,Percent of total Billed Charges,65% of Total Billed Charges,70.12,44.1,,50.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,151.05,95,,297.92,Percent of Total Billed Charges,95% of Total Billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.92,88,,176,Percent of Total Billed Charges,88% of Total Billed Charges,143.1,90,,282.24,Percent of Total Billed charges,90% of Total Billed Charges,70.12,159,
PT THER EXER 15MIN,4200000043,CDM,420,RC,,,Outpatient,,,163.00,105.95,,163,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,123.88,76,,476.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,117.36,72,,3205.328,Percent of Total Billed Charges,72% of Total Billed Charges,122.25,75,,3338.88,Percent of Total Billed charges,75% of Total Billed Charges,163,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.36,72,,3205.328,Percent of Total Billed Charges,72% of Total Billed Charges,97.8,60,,2671.104,Percent of Total Billed Charges,60% of Total Billed Charges,146.7,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,73.35,45,,90,Percent of Total Billed Charges,45% of Total Billed Charges,146.7,90,,564.48,Percent of Total Billed Charges,90% of Total billed Charges,163,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.95,65,,3066.584,Percent of total Billed Charges,65% of Total Billed Charges,71.88,44.1,,88.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,154.85,95,,595.84,Percent of Total Billed Charges,95% of Total Billed Charges,163,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.44,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,146.7,90,,564.48,Percent of Total Billed charges,90% of Total Billed Charges,71.88,163,
PTA THER EXER 15MIN,4200000044,CDM,420,RC,,,Outpatient,,,163.00,105.95,,163,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,123.88,76,,874.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,117.36,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,122.25,75,,12853.2,Percent of Total Billed charges,75% of Total Billed Charges,163,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.36,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,97.8,60,,10282.56,Percent of Total Billed Charges,60% of Total Billed Charges,146.7,90,,223.92,Percent of Total Billed Charges,90% of Total Billed Charges,73.35,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,146.7,90,,1035.36,Percent of Total Billed Charges,90% of Total billed Charges,163,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.95,65,,3066.584,Percent of total Billed Charges,65% of Total Billed Charges,71.88,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,154.85,95,,1092.88,Percent of Total Billed Charges,95% of Total Billed Charges,163,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.44,88,,105.6,Percent of Total Billed Charges,88% of Total Billed Charges,146.7,90,,1035.36,Percent of Total Billed charges,90% of Total Billed Charges,71.88,163,
PT NM REED BAL PST CRD,4200000045,CDM,420,RC,,,Outpatient,,,176.00,114.40,,176,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,133.76,76,,485.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,126.72,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,132,75,,12853.2,Percent of Total Billed charges,75% of Total Billed Charges,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.72,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,105.6,60,,10282.56,Percent of Total Billed Charges,60% of Total Billed Charges,158.4,90,,367.92,Percent of Total Billed Charges,90% of Total Billed Charges,79.2,45,,54,Percent of Total Billed Charges,45% of Total Billed Charges,158.4,90,,574.56,Percent of Total Billed Charges,90% of Total billed Charges,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.4,65,,3066.584,Percent of total Billed Charges,65% of Total Billed Charges,77.62,44.1,,52.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,167.2,95,,606.48,Percent of Total Billed Charges,95% of Total Billed Charges,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.88,88,,49.984,Percent of Total Billed Charges,88% of Total Billed Charges,158.4,90,,574.56,Percent of Total Billed charges,90% of Total Billed Charges,77.62,176,
PTA NM REED BAL PST CRD,4200000046,CDM,420,RC,,,Outpatient,,,176.00,114.40,,176,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,133.76,76,,86.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,126.72,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,132,75,,12853.2,Percent of Total Billed charges,75% of Total Billed Charges,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.72,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,105.6,60,,10282.56,Percent of Total Billed Charges,60% of Total Billed Charges,158.4,90,,541.44,Percent of Total Billed Charges,90% of Total Billed Charges,79.2,45,,25.56,Percent of Total Billed Charges,45% of Total Billed Charges,158.4,90,,102.96,Percent of Total Billed Charges,90% of Total billed Charges,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.4,65,,26337.4,Percent of total Billed Charges,65% of Total Billed Charges,77.62,44.1,,25.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,167.2,95,,108.68,Percent of Total Billed Charges,95% of Total Billed Charges,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.88,88,,1201.728,Percent of Total Billed Charges,88% of Total Billed Charges,158.4,90,,102.96,Percent of Total Billed charges,90% of Total Billed Charges,77.62,176,
PT AQUATICS/15 MIN,4200000047,CDM,420,RC,,,Outpatient,,,104.74,68.08,,104.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.6,76,,152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75.41,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,78.56,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.41,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,62.84,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,94.27,90,,699.84,Percent of Total Billed Charges,90% of Total Billed Charges,47.13,45,,614.52,Percent of Total Billed Charges,45% of Total Billed Charges,94.27,90,,180,Percent of Total Billed Charges,90% of Total billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.08,65,,26337.4,Percent of total Billed Charges,65% of Total Billed Charges,46.19,44.1,,602.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,99.5,95,,190,Percent of Total Billed Charges,95% of Total Billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.17,88,,74.624,Percent of Total Billed Charges,88% of Total Billed Charges,94.27,90,,180,Percent of Total Billed charges,90% of Total Billed Charges,46.19,104.74,
PTA AQUATICS/15 MIN,4200000048,CDM,420,RC,,,Outpatient,,,104.74,68.08,,104.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.6,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75.41,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,78.56,75,,12853.2,Percent of Total Billed charges,75% of Total Billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.41,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,62.84,60,,10282.56,Percent of Total Billed Charges,60% of Total Billed Charges,94.27,90,,138.24,Percent of Total Billed Charges,90% of Total Billed Charges,47.13,45,,38.16,Percent of Total Billed Charges,45% of Total Billed Charges,94.27,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.08,65,,54301.832,Percent of total Billed Charges,65% of Total Billed Charges,46.19,44.1,,37.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,99.5,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.17,88,,246.4,Percent of Total Billed Charges,88% of Total Billed Charges,94.27,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,46.19,104.74,
PT GAIT TRAINING 15 MIN,4200000049,CDM,420,RC,,,Outpatient,,,106.00,68.90,,106,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,80.56,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,76.32,72,,12843.072,Percent of Total Billed Charges,72% of Total Billed Charges,79.5,75,,13378.2,Percent of Total Billed charges,75% of Total Billed Charges,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.32,72,,12843.072,Percent of Total Billed Charges,72% of Total Billed Charges,63.6,60,,10702.56,Percent of Total Billed Charges,60% of Total Billed Charges,95.4,90,,227.52,Percent of Total Billed Charges,90% of Total Billed Charges,47.7,45,,126,Percent of Total Billed Charges,45% of Total Billed Charges,95.4,90,,108,Percent of Total Billed Charges,90% of Total billed Charges,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.9,65,,54301.832,Percent of total Billed Charges,65% of Total Billed Charges,46.75,44.1,,123.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,100.7,95,,114,Percent of Total Billed Charges,95% of Total Billed Charges,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.28,88,,218.944,Percent of Total Billed Charges,88% of Total Billed Charges,95.4,90,,108,Percent of Total Billed charges,90% of Total Billed Charges,46.75,106,
PTA GAIT TRAINING 15 MIN,4200000050,CDM,420,RC,,,Outpatient,,,106.00,68.90,,106,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,80.56,76,,43.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,76.32,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,79.5,75,,14082.016,Percent of Total Billed charges,75% of Total Billed Charges,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.32,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,63.6,60,,11265.608,Percent of Total Billed Charges,60% of Total Billed Charges,95.4,90,,437.424,Percent of Total Billed Charges,90% of Total Billed Charges,47.7,45,,111.96,Percent of Total Billed Charges,45% of Total Billed Charges,95.4,90,,51.12,Percent of Total Billed Charges,90% of Total billed Charges,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.9,65,,54301.832,Percent of total Billed Charges,65% of Total Billed Charges,46.75,44.1,,109.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,100.7,95,,53.96,Percent of Total Billed Charges,95% of Total Billed Charges,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.28,88,,359.744,Percent of Total Billed Charges,88% of Total Billed Charges,95.4,90,,51.12,Percent of Total Billed charges,90% of Total Billed Charges,46.75,106,
PT MASSAGE 15 MIN,4200000051,CDM,420,RC,,,Outpatient,,,228.00,148.20,,228,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,173.28,76,,1037.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,164.16,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,171,75,,14082.016,Percent of Total Billed charges,75% of Total Billed Charges,228,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.16,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,136.8,60,,11265.608,Percent of Total Billed Charges,60% of Total Billed Charges,205.2,90,,108.752,Percent of Total Billed Charges,90% of Total Billed Charges,102.6,45,,183.96,Percent of Total Billed Charges,45% of Total Billed Charges,205.2,90,,1229.04,Percent of Total Billed Charges,90% of Total billed Charges,228,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.2,65,,264.864,Percent of total Billed Charges,65% of Total Billed Charges,100.55,44.1,,180.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,216.6,95,,1297.32,Percent of Total Billed Charges,95% of Total Billed Charges,228,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.64,88,,529.408,Percent of Total Billed Charges,88% of Total Billed Charges,205.2,90,,1229.04,Percent of Total Billed charges,90% of Total Billed Charges,100.55,228,
PTA MASSAGE 15 MIN,4200000052,CDM,420,RC,,,Outpatient,,,217.19,141.17,,217.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,165.06,76,,64.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,156.38,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,162.89,75,,14082.016,Percent of Total Billed charges,75% of Total Billed Charges,217.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.38,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,130.31,60,,11265.608,Percent of Total Billed Charges,60% of Total Billed Charges,195.47,90,,331.416,Percent of Total Billed Charges,90% of Total Billed Charges,97.74,45,,270.72,Percent of Total Billed Charges,45% of Total Billed Charges,195.47,90,,76.32,Percent of Total Billed Charges,90% of Total billed Charges,217.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.17,65,,7072,Percent of total Billed Charges,65% of Total Billed Charges,95.78,44.1,,265.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,206.33,95,,80.56,Percent of Total Billed Charges,95% of Total Billed Charges,217.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.13,88,,684.288,Percent of Total Billed Charges,88% of Total Billed Charges,195.47,90,,76.32,Percent of Total Billed charges,90% of Total Billed Charges,95.78,217.19,
PT MANUAL TRACTION,4200000053,CDM,420,RC,,,Outpatient,,,200.00,130.00,,200,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,150,75,,14082.016,Percent of Total Billed charges,75% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,120,60,,11265.608,Percent of Total Billed Charges,60% of Total Billed Charges,180,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,90,45,,349.92,Percent of Total Billed Charges,45% of Total Billed Charges,180,90,,252,Percent of Total Billed Charges,90% of Total billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130,65,,2839.04,Percent of total Billed Charges,65% of Total Billed Charges,88.2,44.1,,342.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,190,95,,266,Percent of Total Billed Charges,95% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,88,,135.168,Percent of Total Billed Charges,88% of Total Billed Charges,180,90,,252,Percent of Total Billed charges,90% of Total Billed Charges,88.2,200,
PT MOBILZTNJNTS SFT TI,4200000054,CDM,420,RC,,,Outpatient,,,200.00,130.00,,200,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152,76,,189.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,150,75,,21641.104,Percent of Total Billed charges,75% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,120,60,,17312.88,Percent of Total Billed Charges,60% of Total Billed Charges,180,90,,342.92,Percent of Total Billed Charges,90% of Total Billed Charges,90,45,,69.12,Percent of Total Billed Charges,45% of Total Billed Charges,180,90,,223.92,Percent of Total Billed Charges,90% of Total billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130,65,,14110.904,Percent of total Billed Charges,65% of Total Billed Charges,88.2,44.1,,67.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,190,95,,236.36,Percent of Total Billed Charges,95% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,88,,222.464,Percent of Total Billed Charges,88% of Total Billed Charges,180,90,,223.92,Percent of Total Billed charges,90% of Total Billed Charges,88.2,200,
PTA MOBILZTNJNTS SFT TI 15MIN,4200000055,CDM,420,RC,,,Outpatient,,,200.00,130.00,,200,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152,76,,310.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,150,75,,21641.104,Percent of Total Billed charges,75% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,120,60,,17312.88,Percent of Total Billed Charges,60% of Total Billed Charges,180,90,,99.36,Percent of Total Billed Charges,90% of Total Billed Charges,90,45,,113.76,Percent of Total Billed Charges,45% of Total Billed Charges,180,90,,367.92,Percent of Total Billed Charges,90% of Total billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130,65,,4654.424,Percent of total Billed Charges,65% of Total Billed Charges,88.2,44.1,,111.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,190,95,,388.36,Percent of Total Billed Charges,95% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,88,,427.704,Percent of Total Billed Charges,88% of Total Billed Charges,180,90,,367.92,Percent of Total Billed charges,90% of Total Billed Charges,88.2,200,
PTA MANUAL TRACTION 15MIN,4200000056,CDM,420,RC,,,Outpatient,,,190.73,123.97,,190.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.95,76,,457.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,137.33,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,143.05,75,,21641.104,Percent of Total Billed charges,75% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.33,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,114.44,60,,17312.88,Percent of Total Billed Charges,60% of Total Billed Charges,171.66,90,,191.824,Percent of Total Billed Charges,90% of Total Billed Charges,85.83,45,,218.712,Percent of Total Billed Charges,45% of Total Billed Charges,171.66,90,,541.44,Percent of Total Billed Charges,90% of Total billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.97,65,,885.744,Percent of total Billed Charges,65% of Total Billed Charges,84.11,44.1,,214.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,181.19,95,,571.52,Percent of Total Billed Charges,95% of Total Billed Charges,190.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.84,88,,106.336,Percent of Total Billed Charges,88% of Total Billed Charges,171.66,90,,541.44,Percent of Total Billed charges,90% of Total Billed Charges,84.11,190.73,
PT THERAPEUTIC ACTIVITS 15MIN,4200000057,CDM,420,RC,,,Outpatient,,,110.00,71.50,,110,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,83.6,76,,590.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,79.2,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,82.5,75,,21641.104,Percent of Total Billed charges,75% of Total Billed Charges,110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,66,60,,17312.88,Percent of Total Billed Charges,60% of Total Billed Charges,99,90,,243.36,Percent of Total Billed Charges,90% of Total Billed Charges,49.5,45,,54.376,Percent of Total Billed Charges,45% of Total Billed Charges,99,90,,699.84,Percent of Total Billed Charges,90% of Total billed Charges,110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.5,65,,15322.016,Percent of total Billed Charges,65% of Total Billed Charges,48.51,44.1,,53.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,104.5,95,,738.72,Percent of Total Billed Charges,95% of Total Billed Charges,110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.8,88,,324.048,Percent of Total Billed Charges,88% of Total Billed Charges,99,90,,699.84,Percent of Total Billed charges,90% of Total Billed Charges,48.51,110,
PTA THERAPEUTIC ACTIVITS 15MIN,4200000058,CDM,420,RC,,,Outpatient,,,110.00,71.50,,110,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,83.6,76,,116.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,79.2,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,82.5,75,,21641.104,Percent of Total Billed charges,75% of Total Billed Charges,110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,66,60,,17312.88,Percent of Total Billed Charges,60% of Total Billed Charges,99,90,,457.816,Percent of Total Billed Charges,90% of Total Billed Charges,49.5,45,,165.712,Percent of Total Billed Charges,45% of Total Billed Charges,99,90,,138.24,Percent of Total Billed Charges,90% of Total billed Charges,110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.5,65,,11725.704,Percent of total Billed Charges,65% of Total Billed Charges,48.51,44.1,,162.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,104.5,95,,145.92,Percent of Total Billed Charges,95% of Total Billed Charges,110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.8,88,,70.4,Percent of Total Billed Charges,88% of Total Billed Charges,99,90,,138.24,Percent of Total Billed charges,90% of Total Billed Charges,48.51,110,
PT SELF CARE HM MGMT AD 15MIN,4200000059,CDM,420,RC,,,Outpatient,,,111.35,72.38,,111.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,84.63,76,,192.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,80.17,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,83.51,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.17,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,66.81,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,100.22,90,,506.88,Percent of Total Billed Charges,90% of Total Billed Charges,50.11,45,,36,Percent of Total Billed Charges,45% of Total Billed Charges,100.22,90,,227.52,Percent of Total Billed Charges,90% of Total billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.38,65,,12204.408,Percent of total Billed Charges,65% of Total Billed Charges,49.11,44.1,,35.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,105.78,95,,240.16,Percent of Total Billed Charges,95% of Total Billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.99,88,,335.304,Percent of Total Billed Charges,88% of Total Billed Charges,100.22,90,,227.52,Percent of Total Billed charges,90% of Total Billed Charges,49.11,111.35,
PTA SELF CARE HM MGMT AD 15MIN,4200000060,CDM,420,RC,,,Outpatient,,,111.35,72.38,,111.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,84.63,76,,369.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,80.17,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,83.51,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.17,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,66.81,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,100.22,90,,21685.712,Percent of Total Billed Charges,90% of Total Billed Charges,50.11,45,,171.464,Percent of Total Billed Charges,45% of Total Billed Charges,100.22,90,,437.424,Percent of Total Billed Charges,90% of Total billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.38,65,,12204.408,Percent of total Billed Charges,65% of Total Billed Charges,49.11,44.1,,168.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,105.78,95,,461.72,Percent of Total Billed Charges,95% of Total Billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.99,88,,97.152,Percent of Total Billed Charges,88% of Total Billed Charges,100.22,90,,437.424,Percent of Total Billed charges,90% of Total Billed Charges,49.11,111.35,
PT COMNTY WK REINTRGRAT 15M,4200000061,CDM,420,RC,,,Outpatient,,,111.35,72.38,,111.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,84.63,76,,91.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,80.17,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,83.51,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.17,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,66.81,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,100.22,90,,34734.528,Percent of Total Billed Charges,90% of Total Billed Charges,50.11,45,,49.68,Percent of Total Billed Charges,45% of Total Billed Charges,100.22,90,,108.752,Percent of Total Billed Charges,90% of Total billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.38,65,,12204.408,Percent of total Billed Charges,65% of Total Billed Charges,49.11,44.1,,48.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,105.78,95,,114.792,Percent of Total Billed Charges,95% of Total Billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.99,88,,187.56,Percent of Total Billed Charges,88% of Total Billed Charges,100.22,90,,108.752,Percent of Total Billed charges,90% of Total Billed Charges,49.11,111.35,
PTA COMNTY WK REINTRGRAT 15M,4200000062,CDM,420,RC,,,Outpatient,,,111.35,72.38,,111.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,84.63,76,,279.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,80.17,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,83.51,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.17,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,66.81,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,100.22,90,,21334.96,Percent of Total Billed Charges,90% of Total Billed Charges,50.11,45,,95.912,Percent of Total Billed Charges,45% of Total Billed Charges,100.22,90,,331.416,Percent of Total Billed Charges,90% of Total billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.38,65,,12204.408,Percent of total Billed Charges,65% of Total Billed Charges,49.11,44.1,,93.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,105.78,95,,349.832,Percent of Total Billed Charges,95% of Total Billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.99,88,,237.952,Percent of Total Billed Charges,88% of Total Billed Charges,100.22,90,,331.416,Percent of Total Billed charges,90% of Total Billed Charges,49.11,111.35,
PT PROPLUSION MANAGE 15M,4200000063,CDM,420,RC,,,Outpatient,,,106.94,69.51,,106.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.27,76,,60.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77,72,,1440,Percent of Total Billed Charges,72% of Total Billed Charges,80.21,75,,1500,Percent of Total Billed charges,75% of Total Billed Charges,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77,72,,1440,Percent of Total Billed Charges,72% of Total Billed Charges,64.16,60,,1200,Percent of Total Billed Charges,60% of Total Billed Charges,96.25,90,,20268.72,Percent of Total Billed Charges,90% of Total Billed Charges,48.12,45,,121.68,Percent of Total Billed Charges,45% of Total Billed Charges,96.25,90,,72,Percent of Total Billed Charges,90% of Total billed Charges,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.51,65,,865.8,Percent of total Billed Charges,65% of Total Billed Charges,47.16,44.1,,119.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,101.59,95,,76,Percent of Total Billed Charges,95% of Total Billed Charges,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.11,88,,447.64,Percent of Total Billed Charges,88% of Total Billed Charges,96.25,90,,72,Percent of Total Billed charges,90% of Total Billed Charges,47.16,106.94,
PTA PROPLUSION MANAGEMEN 15M,4200000064,CDM,420,RC,,,Outpatient,,,106.94,69.51,,106.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,81.27,76,,289.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77,72,,3978.896,Percent of Total Billed Charges,72% of Total Billed Charges,80.21,75,,4144.68,Percent of Total Billed charges,75% of Total Billed Charges,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77,72,,3978.896,Percent of Total Billed Charges,72% of Total Billed Charges,64.16,60,,3315.744,Percent of Total Billed Charges,60% of Total Billed Charges,96.25,90,,18286.768,Percent of Total Billed Charges,90% of Total Billed Charges,48.12,45,,228.904,Percent of Total Billed Charges,45% of Total Billed Charges,96.25,90,,342.92,Percent of Total Billed Charges,90% of Total billed Charges,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.51,65,,1894.664,Percent of total Billed Charges,65% of Total Billed Charges,47.16,44.1,,224.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,101.59,95,,361.976,Percent of Total Billed Charges,95% of Total Billed Charges,106.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.11,88,,495.616,Percent of Total Billed Charges,88% of Total Billed Charges,96.25,90,,342.92,Percent of Total Billed charges,90% of Total Billed Charges,47.16,106.94,
PT SELECT DEBRIDEMEN<20 RIGHT,4200000065,CDM,420,RC,,,Outpatient,,,435.00,282.75,,435,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,330.6,76,,83.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,313.2,72,,984.96,Percent of Total Billed Charges,72% of Total Billed Charges,326.25,75,,1026,Percent of Total Billed charges,75% of Total Billed Charges,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.2,72,,984.96,Percent of Total Billed Charges,72% of Total Billed Charges,261,60,,820.8,Percent of Total Billed Charges,60% of Total Billed Charges,391.5,90,,22760.624,Percent of Total Billed Charges,90% of Total Billed Charges,195.75,45,,253.44,Percent of Total Billed Charges,45% of Total Billed Charges,391.5,90,,99.36,Percent of Total Billed Charges,90% of Total billed Charges,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.75,65,,947.336,Percent of total Billed Charges,65% of Total Billed Charges,191.84,44.1,,248.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,413.25,95,,104.88,Percent of Total Billed Charges,95% of Total Billed Charges,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.8,88,,21203.808,Percent of Total Billed Charges,88% of Total Billed Charges,391.5,90,,99.36,Percent of Total Billed charges,90% of Total Billed Charges,191.84,435,
PTA SELECT DEBRIDEMEN<20 RIGHT,4200000066,CDM,420,RC,,,Outpatient,,,435.00,282.75,,435,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,330.6,76,,161.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,313.2,72,,984.96,Percent of Total Billed Charges,72% of Total Billed Charges,326.25,75,,1026,Percent of Total Billed charges,75% of Total Billed Charges,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.2,72,,984.96,Percent of Total Billed Charges,72% of Total Billed Charges,261,60,,820.8,Percent of Total Billed Charges,60% of Total Billed Charges,391.5,90,,28171.168,Percent of Total Billed Charges,90% of Total Billed Charges,195.75,45,,10842.856,Percent of Total Billed Charges,45% of Total Billed Charges,391.5,90,,191.824,Percent of Total Billed Charges,90% of Total billed Charges,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.75,65,,1341.08,Percent of total Billed Charges,65% of Total Billed Charges,191.84,44.1,,10626,Percent of Total Billed Charges,44.1% of Total Billed Charges,413.25,95,,202.48,Percent of Total Billed Charges,95% of Total Billed Charges,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.8,88,,33962.648,Percent of Total Billed Charges,88% of Total Billed Charges,391.5,90,,191.824,Percent of Total Billed charges,90% of Total Billed Charges,191.84,435,
PT SELECT DEBRIDEMEN>20 RIGHT,4200000067,CDM,420,RC,,,Outpatient,,,618.00,401.70,,618,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,469.68,76,,205.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,444.96,72,,984.96,Percent of Total Billed Charges,72% of Total Billed Charges,463.5,75,,1026,Percent of Total Billed charges,75% of Total Billed Charges,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.96,72,,984.96,Percent of Total Billed Charges,72% of Total Billed Charges,370.8,60,,820.8,Percent of Total Billed Charges,60% of Total Billed Charges,556.2,90,,3706.248,Percent of Total Billed Charges,90% of Total Billed Charges,278.1,45,,17367.264,Percent of Total Billed Charges,45% of Total Billed Charges,556.2,90,,243.36,Percent of Total Billed Charges,90% of Total billed Charges,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.7,65,,4377.88,Percent of total Billed Charges,65% of Total Billed Charges,272.54,44.1,,17019.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,587.1,95,,256.88,Percent of Total Billed Charges,95% of Total Billed Charges,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,543.84,88,,20860.848,Percent of Total Billed Charges,88% of Total Billed Charges,556.2,90,,243.36,Percent of Total Billed charges,90% of Total Billed Charges,272.54,618,
PTA SELECT DEBRIDEMEN>20 RIGHT,4200000068,CDM,420,RC,,,Outpatient,,,618.00,401.70,,618,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,469.68,76,,386.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,444.96,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,463.5,75,,1080,Percent of Total Billed charges,75% of Total Billed Charges,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.96,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,370.8,60,,864,Percent of Total Billed Charges,60% of Total Billed Charges,556.2,90,,3706.248,Percent of Total Billed Charges,90% of Total Billed Charges,278.1,45,,10667.48,Percent of Total Billed Charges,45% of Total Billed Charges,556.2,90,,457.816,Percent of Total Billed Charges,90% of Total billed Charges,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.7,65,,7064.776,Percent of total Billed Charges,65% of Total Billed Charges,272.54,44.1,,10454.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,587.1,95,,483.248,Percent of Total Billed Charges,95% of Total Billed Charges,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,543.84,88,,19818.304,Percent of Total Billed Charges,88% of Total Billed Charges,556.2,90,,457.816,Percent of Total Billed charges,90% of Total Billed Charges,272.54,618,
PT NONSEL DEBRIDE RIGHT,4200000069,CDM,420,RC,,,Outpatient,,,396.00,257.40,,396,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,300.96,76,,428.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,285.12,72,,984.96,Percent of Total Billed Charges,72% of Total Billed Charges,297,75,,1026,Percent of Total Billed charges,75% of Total Billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.12,72,,984.96,Percent of Total Billed Charges,72% of Total Billed Charges,237.6,60,,820.8,Percent of Total Billed Charges,60% of Total Billed Charges,356.4,90,,2404.8,Percent of Total Billed Charges,90% of Total Billed Charges,178.2,45,,10134.36,Percent of Total Billed Charges,45% of Total Billed Charges,356.4,90,,506.88,Percent of Total Billed Charges,90% of Total billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.4,65,,3379.48,Percent of total Billed Charges,65% of Total Billed Charges,174.64,44.1,,9931.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,376.2,95,,535.04,Percent of Total Billed Charges,95% of Total Billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.48,88,,17880.4,Percent of Total Billed Charges,88% of Total Billed Charges,356.4,90,,506.88,Percent of Total Billed charges,90% of Total Billed Charges,174.64,396,
PTA NONSEL DEBRIDE RIGHT,4200000070,CDM,420,RC,,,Outpatient,,,396.00,257.40,,396,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,300.96,76,,18312.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,285.12,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,297,75,,1080,Percent of Total Billed charges,75% of Total Billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.12,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,237.6,60,,864,Percent of Total Billed Charges,60% of Total Billed Charges,356.4,90,,1625.224,Percent of Total Billed Charges,90% of Total Billed Charges,178.2,45,,9143.384,Percent of Total Billed Charges,45% of Total Billed Charges,356.4,90,,21685.712,Percent of Total Billed Charges,90% of Total billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.4,65,,9058.144,Percent of total Billed Charges,65% of Total Billed Charges,174.64,44.1,,8960.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,376.2,95,,22890.472,Percent of Total Billed Charges,95% of Total Billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.48,88,,22254.832,Percent of Total Billed Charges,88% of Total Billed Charges,356.4,90,,21685.712,Percent of Total Billed charges,90% of Total Billed Charges,174.64,396,
PT NEG PRESS<50 SQ CM,4200000071,CDM,420,RC,,,Outpatient,,,415.00,269.75,,415,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,315.4,76,,29331.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,298.8,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,311.25,75,,1080,Percent of Total Billed charges,75% of Total Billed Charges,415,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.8,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,249,60,,864,Percent of Total Billed Charges,60% of Total Billed Charges,373.5,90,,1702.8,Percent of Total Billed Charges,90% of Total Billed Charges,186.75,45,,11380.312,Percent of Total Billed Charges,45% of Total Billed Charges,373.5,90,,34734.528,Percent of Total Billed Charges,90% of Total billed Charges,415,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.75,65,,9058.144,Percent of total Billed Charges,65% of Total Billed Charges,183.02,44.1,,11152.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,394.25,95,,36664.224,Percent of Total Billed Charges,95% of Total Billed Charges,415,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365.2,88,,27545.144,Percent of Total Billed Charges,88% of Total Billed Charges,373.5,90,,34734.528,Percent of Total Billed charges,90% of Total Billed Charges,183.02,415,
PTA NEG PRESS<50 SQ CM,4200000072,CDM,420,RC,,,Outpatient,,,415.00,269.75,,415,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,315.4,76,,18016.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,298.8,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,311.25,75,,1080,Percent of Total Billed charges,75% of Total Billed Charges,415,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.8,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,249,60,,864,Percent of Total Billed Charges,60% of Total Billed Charges,373.5,90,,669.176,Percent of Total Billed Charges,90% of Total Billed Charges,186.75,45,,14085.584,Percent of Total Billed Charges,45% of Total Billed Charges,373.5,90,,21334.96,Percent of Total Billed Charges,90% of Total billed Charges,415,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.75,65,,8605.48,Percent of total Billed Charges,65% of Total Billed Charges,183.02,44.1,,13803.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,394.25,95,,22520.24,Percent of Total Billed Charges,95% of Total Billed Charges,415,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365.2,88,,3623.888,Percent of Total Billed Charges,88% of Total Billed Charges,373.5,90,,21334.96,Percent of Total Billed charges,90% of Total Billed Charges,183.02,415,
PT NEG PRESS>50 SQ CM,4200000073,CDM,420,RC,,,Outpatient,,,570.00,370.50,,570,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,433.2,76,,17115.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,410.4,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,427.5,75,,1080,Percent of Total Billed charges,75% of Total Billed Charges,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,410.4,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,342,60,,864,Percent of Total Billed Charges,60% of Total Billed Charges,513,90,,457.92,Percent of Total Billed Charges,90% of Total Billed Charges,256.5,45,,1853.128,Percent of Total Billed Charges,45% of Total Billed Charges,513,90,,20268.72,Percent of Total Billed Charges,90% of Total billed Charges,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.5,65,,5930.216,Percent of total Billed Charges,65% of Total Billed Charges,251.37,44.1,,1816.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,541.5,95,,21394.76,Percent of Total Billed Charges,95% of Total Billed Charges,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.6,88,,3623.888,Percent of Total Billed Charges,88% of Total Billed Charges,513,90,,20268.72,Percent of Total Billed charges,90% of Total Billed Charges,251.37,570,
PTA NEG PRESS>50 SQ CM,4200000074,CDM,420,RC,,,Outpatient,,,570.00,370.50,,570,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,433.2,76,,15442.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,410.4,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,427.5,75,,1080,Percent of Total Billed charges,75% of Total Billed Charges,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,410.4,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,342,60,,864,Percent of Total Billed Charges,60% of Total Billed Charges,513,90,,1954.336,Percent of Total Billed Charges,90% of Total Billed Charges,256.5,45,,1853.128,Percent of Total Billed Charges,45% of Total Billed Charges,513,90,,18286.768,Percent of Total Billed Charges,90% of Total billed Charges,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.5,65,,4507.288,Percent of total Billed Charges,65% of Total Billed Charges,251.37,44.1,,1816.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,541.5,95,,19302.704,Percent of Total Billed Charges,95% of Total Billed Charges,570,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.6,88,,2351.36,Percent of Total Billed Charges,88% of Total Billed Charges,513,90,,18286.768,Percent of Total Billed charges,90% of Total Billed Charges,251.37,570,
FCE/15 MIN,4200000075,CDM,420,RC,,,Outpatient,,,159.00,103.35,,159,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.84,76,,19220.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.48,72,,15094.08,Percent of Total Billed Charges,72% of Total Billed Charges,119.25,75,,15723,Percent of Total Billed charges,75% of Total Billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.48,72,,15094.08,Percent of Total Billed Charges,72% of Total Billed Charges,95.4,60,,12578.4,Percent of Total Billed Charges,60% of Total Billed Charges,143.1,90,,1444.72,Percent of Total Billed Charges,90% of Total Billed Charges,71.55,45,,1202.4,Percent of Total Billed Charges,45% of Total Billed Charges,143.1,90,,22760.624,Percent of Total Billed Charges,90% of Total billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.35,65,,8529.04,Percent of total Billed Charges,65% of Total Billed Charges,70.12,44.1,,1178.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,151.05,95,,24025.104,Percent of Total Billed Charges,95% of Total Billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.92,88,,1589.112,Percent of Total Billed Charges,88% of Total Billed Charges,143.1,90,,22760.624,Percent of Total Billed charges,90% of Total Billed Charges,70.12,159,
WHEELCHAIR EVAL 15 M,4200000076,CDM,420,RC,,,Outpatient,,,159.00,103.35,,159,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.84,76,,23788.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.48,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,119.25,75,,25060.504,Percent of Total Billed charges,75% of Total Billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.48,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,95.4,60,,20048.4,Percent of Total Billed Charges,60% of Total Billed Charges,143.1,90,,848.088,Percent of Total Billed Charges,90% of Total Billed Charges,71.55,45,,812.616,Percent of Total Billed Charges,45% of Total Billed Charges,143.1,90,,28171.168,Percent of Total Billed Charges,90% of Total billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.35,65,,9101.56,Percent of total Billed Charges,65% of Total Billed Charges,70.12,44.1,,796.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,151.05,95,,29736.232,Percent of Total Billed Charges,95% of Total Billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.92,88,,1664.96,Percent of Total Billed Charges,88% of Total Billed Charges,143.1,90,,28171.168,Percent of Total Billed charges,90% of Total Billed Charges,70.12,159,
PT ORTHOTIC FITTING/INITIAL,4200000077,CDM,420,RC,,,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,3129.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,25060.504,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,20048.4,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,85.68,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,851.4,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,3706.248,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,9580.416,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,834.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,3912.152,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,654.304,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,3706.248,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
PTA ORTHOTIC FITTING/INITIAL,4200000078,CDM,420,RC,,,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,3129.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,25060.504,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,20048.4,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,1125.472,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,334.584,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,3706.248,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,801.48,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,327.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,3912.152,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,447.744,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,3706.248,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
PT PROSTHETIC TRAIN INITI 15MI,4200000079,CDM,420,RC,,,Outpatient,,,122.38,79.55,,122.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.01,76,,2030.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.11,72,,15094.08,Percent of Total Billed Charges,72% of Total Billed Charges,91.79,75,,15723,Percent of Total Billed charges,75% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.11,72,,15094.08,Percent of Total Billed Charges,72% of Total Billed Charges,73.43,60,,12578.4,Percent of Total Billed Charges,60% of Total Billed Charges,110.14,90,,1710,Percent of Total Billed Charges,90% of Total Billed Charges,55.07,45,,228.96,Percent of Total Billed Charges,45% of Total Billed Charges,110.14,90,,2404.8,Percent of Total Billed Charges,90% of Total billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.55,65,,1689.08,Percent of total Billed Charges,65% of Total Billed Charges,53.97,44.1,,224.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.26,95,,2538.4,Percent of Total Billed Charges,95% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.69,88,,1910.912,Percent of Total Billed Charges,88% of Total Billed Charges,110.14,90,,2404.8,Percent of Total Billed charges,90% of Total Billed Charges,53.97,122.38,
PTA PROSTHETIC TRAIN INITIAL,4200000080,CDM,420,RC,,,Outpatient,,,122.38,79.55,,122.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.01,76,,1372.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.11,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,91.79,75,,25060.504,Percent of Total Billed charges,75% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.11,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,73.43,60,,20048.4,Percent of Total Billed Charges,60% of Total Billed Charges,110.14,90,,13561.92,Percent of Total Billed Charges,90% of Total Billed Charges,55.07,45,,977.168,Percent of Total Billed Charges,45% of Total Billed Charges,110.14,90,,1625.224,Percent of Total Billed Charges,90% of Total billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.55,65,,1064.832,Percent of total Billed Charges,65% of Total Billed Charges,53.97,44.1,,957.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.26,95,,1715.52,Percent of Total Billed Charges,95% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.69,88,,1412.608,Percent of Total Billed Charges,88% of Total Billed Charges,110.14,90,,1625.224,Percent of Total Billed charges,90% of Total Billed Charges,53.97,122.38,
PT ORTHOTICPROS ADJ.15,4200000081,CDM,420,RC,,,Outpatient,,,122.38,79.55,,122.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.01,76,,1437.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.11,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,91.79,75,,25060.504,Percent of Total Billed charges,75% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.11,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,73.43,60,,20048.4,Percent of Total Billed Charges,60% of Total Billed Charges,110.14,90,,15880.768,Percent of Total Billed Charges,90% of Total Billed Charges,55.07,45,,722.36,Percent of Total Billed Charges,45% of Total Billed Charges,110.14,90,,1702.8,Percent of Total Billed Charges,90% of Total billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.55,65,,15505.472,Percent of total Billed Charges,65% of Total Billed Charges,53.97,44.1,,707.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.26,95,,1797.4,Percent of Total Billed Charges,95% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.69,88,,829.24,Percent of Total Billed Charges,88% of Total Billed Charges,110.14,90,,1702.8,Percent of Total Billed charges,90% of Total Billed Charges,53.97,122.38,
PTA ORTHOTIC PROS ADJ 15,4200000082,CDM,420,RC,,,Outpatient,,,122.38,79.55,,122.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.01,76,,565.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.11,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,91.79,75,,25060.504,Percent of Total Billed charges,75% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.11,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,73.43,60,,20048.4,Percent of Total Billed Charges,60% of Total Billed Charges,110.14,90,,15880.768,Percent of Total Billed Charges,90% of Total Billed Charges,55.07,45,,424.048,Percent of Total Billed Charges,45% of Total Billed Charges,110.14,90,,669.176,Percent of Total Billed Charges,90% of Total billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.55,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,53.97,44.1,,415.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.26,95,,706.352,Percent of Total Billed Charges,95% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.69,88,,83.776,Percent of Total Billed Charges,88% of Total Billed Charges,110.14,90,,669.176,Percent of Total Billed charges,90% of Total Billed Charges,53.97,122.38,
PT ESTIM W/WOUNDCARE,4200000083,CDM,420,RC,G0281,HCPCS,Outpatient,,,265.70,172.71,,13.76,125,,,Fee Schedule,125% of CMS OPPS Rate,201.93,76,,386.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.1,350,,612.864,Fee Schedule,350% of BCBS fee schedule,43.1,350,,638.4,Fee Schedule,350% of BCBS fee schedule,11.01,100,,,Fee Schedule,100% of CMS OPPS Rate,43.1,286,,612.864,Fee Schedule,286% of BCBS PPO fee schedule,15.07,100,,510.72,Fee Schedule,100% of Blue ADV HMO fee schedule,239.13,90,,12437.256,Percent of Total Billed Charges,90% of Total Billed Charges,119.57,45,,42.84,Percent of Total Billed Charges,45% of Total Billed Charges,239.13,90,,457.92,Percent of Total Billed Charges,90% of Total billed Charges,11.01,100,,,Fee Schedule,100% of CMS OPPS Rate,11.01,100,,,Fee Schedule,100% of CMS OPPS Rate,11.01,100,,,Fee Schedule,100% of CMS OPPS Rate,22.02,200,,3463.304,Fee Schedule,200% of CMS OPPS Rate,117.17,44.1,,41.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,252.42,95,,483.36,Percent of Total Billed Charges,95% of Total Billed Charges,8.26,75,,,Fee Schedule,75% of CMS OPPS Rate,233.82,88,,1100.456,Percent of Total Billed Charges,88% of Total Billed Charges,239.13,90,,457.92,Percent of Total Billed charges,90% of Total Billed Charges,8.26,252.42,
PTA ESTIM W/WOUNDCARE,4200000084,CDM,420,RC,G0281,HCPCS,Outpatient,,,265.70,172.71,,13.76,125,,,Fee Schedule,125% of CMS OPPS Rate,201.93,76,,1650.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.1,350,,787.448,Fee Schedule,350% of BCBS fee schedule,43.1,350,,820.264,Fee Schedule,350% of BCBS fee schedule,11.01,100,,,Fee Schedule,100% of CMS OPPS Rate,43.1,286,,787.448,Fee Schedule,286% of BCBS PPO fee schedule,15.07,100,,656.208,Fee Schedule,100% of Blue ADV HMO fee schedule,239.13,90,,15880.768,Percent of Total Billed Charges,90% of Total Billed Charges,119.57,45,,562.736,Percent of Total Billed Charges,45% of Total Billed Charges,239.13,90,,1954.336,Percent of Total Billed Charges,90% of Total billed Charges,11.01,100,,,Fee Schedule,100% of CMS OPPS Rate,11.01,100,,,Fee Schedule,100% of CMS OPPS Rate,11.01,100,,,Fee Schedule,100% of CMS OPPS Rate,22.02,200,,29565.08,Fee Schedule,200% of CMS OPPS Rate,117.17,44.1,,551.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,252.42,95,,2062.912,Percent of Total Billed Charges,95% of Total Billed Charges,8.26,75,,,Fee Schedule,75% of CMS OPPS Rate,233.82,88,,1672,Percent of Total Billed Charges,88% of Total Billed Charges,239.13,90,,1954.336,Percent of Total Billed charges,90% of Total Billed Charges,8.26,252.42,
PT ELEC STIM UNATTEND,4200000085,CDM,420,RC,G0283,HCPCS,Outpatient,,,298.00,193.70,,14.91,125,,,Fee Schedule,125% of CMS OPPS Rate,226.48,76,,1219.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.1,350,,994.408,Fee Schedule,350% of BCBS fee schedule,43.1,350,,1035.84,Fee Schedule,350% of BCBS fee schedule,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate,43.1,286,,994.408,Fee Schedule,286% of BCBS PPO fee schedule,15.07,100,,828.672,Fee Schedule,100% of Blue ADV HMO fee schedule,268.2,90,,1598.392,Percent of Total Billed Charges,90% of Total Billed Charges,134.1,45,,855,Percent of Total Billed Charges,45% of Total Billed Charges,268.2,90,,1444.72,Percent of Total Billed Charges,90% of Total billed Charges,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate,23.86,200,,26337.4,Fee Schedule,200% of CMS OPPS Rate,131.42,44.1,,837.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,283.1,95,,1524.976,Percent of Total Billed Charges,95% of Total Billed Charges,8.95,75,,,Fee Schedule,75% of CMS OPPS Rate,262.24,88,,13260.544,Percent of Total Billed Charges,88% of Total Billed Charges,268.2,90,,1444.72,Percent of Total Billed charges,90% of Total Billed Charges,8.95,283.1,
PTA ELEC STIM UNATTEND,4200000086,CDM,420,RC,G0283,HCPCS,Outpatient,,,298.00,193.70,,14.91,125,,,Fee Schedule,125% of CMS OPPS Rate,226.48,76,,716.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.1,350,,511.832,Fee Schedule,350% of BCBS fee schedule,43.1,350,,533.16,Fee Schedule,350% of BCBS fee schedule,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate,43.1,286,,511.832,Fee Schedule,286% of BCBS PPO fee schedule,15.07,100,,426.528,Fee Schedule,100% of Blue ADV HMO fee schedule,268.2,90,,9666.888,Percent of Total Billed Charges,90% of Total Billed Charges,134.1,45,,6780.96,Percent of Total Billed Charges,45% of Total Billed Charges,268.2,90,,848.088,Percent of Total Billed Charges,90% of Total billed Charges,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate,23.86,200,,54301.832,Fee Schedule,200% of CMS OPPS Rate,131.42,44.1,,6645.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,283.1,95,,895.208,Percent of Total Billed Charges,95% of Total Billed Charges,8.95,75,,,Fee Schedule,75% of CMS OPPS Rate,262.24,88,,15527.864,Percent of Total Billed Charges,88% of Total Billed Charges,268.2,90,,848.088,Percent of Total Billed charges,90% of Total Billed Charges,8.95,283.1,
REMOT IMAGE SUBMIT BY PT,4200000090,CDM,420,RC,G2010,HCPCS,Outpatient,,,23.45,15.24,,23.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.82,76,,72.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.68,350,,1202.768,Fee Schedule,350% of BCBS fee schedule,26.68,350,,1252.888,Fee Schedule,350% of BCBS fee schedule,23.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.68,286,,1202.768,Fee Schedule,286% of BCBS PPO fee schedule,9.33,100,,1002.304,Fee Schedule,100% of Blue ADV HMO fee schedule,21.11,90,,9618.688,Percent of Total Billed Charges,90% of Total Billed Charges,10.55,45,,7940.384,Percent of Total Billed Charges,45% of Total Billed Charges,21.11,90,,85.68,Percent of Total Billed Charges,90% of Total billed Charges,23.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.24,65,,15505.472,Percent of total Billed Charges,65% of Total Billed Charges,10.34,44.1,,7781.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.28,95,,90.44,Percent of Total Billed Charges,95% of Total Billed Charges,23.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.64,88,,15527.864,Percent of Total Billed Charges,88% of Total Billed Charges,21.11,90,,85.68,Percent of Total Billed charges,90% of Total Billed Charges,9.33,26.68,
PT Select Debridement <20 LEFT,4200000092,CDM,420,RC,,,Outpatient,,,435.00,282.75,,435,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,330.6,76,,950.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,313.2,72,,1202.768,Percent of Total Billed Charges,72% of Total Billed Charges,326.25,75,,1252.888,Percent of Total Billed charges,75% of Total Billed Charges,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.2,72,,1202.768,Percent of Total Billed Charges,72% of Total Billed Charges,261,60,,1002.304,Percent of Total Billed Charges,60% of Total Billed Charges,391.5,90,,19538.176,Percent of Total Billed Charges,90% of Total Billed Charges,195.75,45,,7940.384,Percent of Total Billed Charges,45% of Total Billed Charges,391.5,90,,1125.472,Percent of Total Billed Charges,90% of Total billed Charges,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.75,65,,5862.856,Percent of total Billed Charges,65% of Total Billed Charges,191.84,44.1,,7781.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,413.25,95,,1187.992,Percent of Total Billed Charges,95% of Total Billed Charges,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.8,88,,12160.872,Percent of Total Billed Charges,88% of Total Billed Charges,391.5,90,,1125.472,Percent of Total Billed charges,90% of Total Billed Charges,191.84,435,
PTA Select Debridement <20 LFT,4200000093,CDM,420,RC,,,Outpatient,,,435.00,282.75,,435,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,330.6,76,,1444,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,313.2,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,326.25,75,,9.264,Percent of Total Billed charges,75% of Total Billed Charges,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.2,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,261,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,391.5,90,,5394.24,Percent of Total Billed Charges,90% of Total Billed Charges,195.75,45,,6218.632,Percent of Total Billed Charges,45% of Total Billed Charges,391.5,90,,1710,Percent of Total Billed Charges,90% of Total billed Charges,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.75,65,,15505.472,Percent of total Billed Charges,65% of Total Billed Charges,191.84,44.1,,6094.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,413.25,95,,1805,Percent of Total Billed Charges,95% of Total Billed Charges,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.8,88,,15527.864,Percent of Total Billed Charges,88% of Total Billed Charges,391.5,90,,1710,Percent of Total Billed charges,90% of Total Billed Charges,191.84,435,
PT Select Debridement>20 LEFT,4200000094,CDM,420,RC,,,Outpatient,,,618.00,401.70,,618,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,469.68,76,,11452.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,444.96,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,463.5,75,,18.52,Percent of Total Billed charges,75% of Total Billed Charges,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.96,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,370.8,60,,14.816,Percent of Total Billed Charges,60% of Total Billed Charges,556.2,90,,15540.224,Percent of Total Billed Charges,90% of Total Billed Charges,278.1,45,,7940.384,Percent of Total Billed Charges,45% of Total Billed Charges,556.2,90,,13561.92,Percent of Total Billed Charges,90% of Total billed Charges,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.7,65,,5787.392,Percent of total Billed Charges,65% of Total Billed Charges,272.54,44.1,,7781.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,587.1,95,,14315.36,Percent of Total Billed Charges,95% of Total Billed Charges,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,543.84,88,,1562.872,Percent of Total Billed Charges,88% of Total Billed Charges,556.2,90,,13561.92,Percent of Total Billed charges,90% of Total Billed Charges,272.54,618,
PTA Select Debridement >20 LFT,4200000095,CDM,420,RC,,,Outpatient,,,618.00,401.70,,618,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,469.68,76,,13410.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,444.96,72,,2576.992,Percent of Total Billed Charges,72% of Total Billed Charges,463.5,75,,2684.368,Percent of Total Billed charges,75% of Total Billed Charges,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.96,72,,2576.992,Percent of Total Billed Charges,72% of Total Billed Charges,370.8,60,,2147.496,Percent of Total Billed Charges,60% of Total Billed Charges,556.2,90,,17462.016,Percent of Total Billed Charges,90% of Total Billed Charges,278.1,45,,799.2,Percent of Total Billed Charges,45% of Total Billed Charges,556.2,90,,15880.768,Percent of Total Billed Charges,90% of Total billed Charges,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.7,65,,5787.392,Percent of total Billed Charges,65% of Total Billed Charges,272.54,44.1,,783.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,587.1,95,,16763.032,Percent of Total Billed Charges,95% of Total Billed Charges,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,543.84,88,,9452.064,Percent of Total Billed Charges,88% of Total Billed Charges,556.2,90,,15880.768,Percent of Total Billed charges,90% of Total Billed Charges,272.54,618,
PT Non Select Debride Left,4200000096,CDM,420,RC,,,Outpatient,,,396.00,257.40,,396,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,300.96,76,,13410.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,285.12,72,,783.936,Percent of Total Billed Charges,72% of Total Billed Charges,297,75,,816.6,Percent of Total Billed charges,75% of Total Billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.12,72,,783.936,Percent of Total Billed Charges,72% of Total Billed Charges,237.6,60,,653.28,Percent of Total Billed Charges,60% of Total Billed Charges,356.4,90,,17462.016,Percent of Total Billed Charges,90% of Total Billed Charges,178.2,45,,4833.44,Percent of Total Billed Charges,45% of Total Billed Charges,356.4,90,,15880.768,Percent of Total Billed Charges,90% of Total billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.4,65,,15322.016,Percent of total Billed Charges,65% of Total Billed Charges,174.64,44.1,,4736.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,376.2,95,,16763.032,Percent of Total Billed Charges,95% of Total Billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.48,88,,9404.944,Percent of Total Billed Charges,88% of Total Billed Charges,356.4,90,,15880.768,Percent of Total Billed charges,90% of Total Billed Charges,174.64,396,
PTA Non Select Debride Left,4200000097,CDM,420,RC,,,Outpatient,,,396.00,257.40,,396,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,300.96,76,,10502.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,285.12,72,,1987.2,Percent of Total Billed Charges,72% of Total Billed Charges,297,75,,2070,Percent of Total Billed charges,75% of Total Billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.12,72,,1987.2,Percent of Total Billed Charges,72% of Total Billed Charges,237.6,60,,1656,Percent of Total Billed Charges,60% of Total Billed Charges,356.4,90,,24764.976,Percent of Total Billed Charges,90% of Total Billed Charges,178.2,45,,4809.344,Percent of Total Billed Charges,45% of Total Billed Charges,356.4,90,,12437.256,Percent of Total Billed Charges,90% of Total billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.4,65,,11725.704,Percent of total Billed Charges,65% of Total Billed Charges,174.64,44.1,,4713.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,376.2,95,,13128.216,Percent of Total Billed Charges,95% of Total Billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.48,88,,19103.992,Percent of Total Billed Charges,88% of Total Billed Charges,356.4,90,,12437.256,Percent of Total Billed charges,90% of Total Billed Charges,174.64,396,
PT Sel Debride<20 Hd/Trnk/Sacr,4200000098,CDM,420,RC,,,Outpatient,,,435.00,282.75,,435,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,330.6,76,,13410.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,313.2,72,,2239.488,Percent of Total Billed Charges,72% of Total Billed Charges,326.25,75,,2332.8,Percent of Total Billed charges,75% of Total Billed Charges,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.2,72,,2239.488,Percent of Total Billed Charges,72% of Total Billed Charges,261,60,,1866.24,Percent of Total Billed Charges,60% of Total Billed Charges,391.5,90,,4186.504,Percent of Total Billed Charges,90% of Total Billed Charges,195.75,45,,9769.088,Percent of Total Billed Charges,45% of Total Billed Charges,391.5,90,,15880.768,Percent of Total Billed Charges,90% of Total billed Charges,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.75,65,,12204.408,Percent of total Billed Charges,65% of Total Billed Charges,191.84,44.1,,9573.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,413.25,95,,16763.032,Percent of Total Billed Charges,95% of Total Billed Charges,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.8,88,,5274.368,Percent of Total Billed Charges,88% of Total Billed Charges,391.5,90,,15880.768,Percent of Total Billed charges,90% of Total Billed Charges,191.84,435,
PTA Select Deb<20 Hd/trnk/sacr,4200000099,CDM,420,RC,,,Outpatient,,,435.00,282.75,,435,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,330.6,76,,1349.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,313.2,72,,3136.32,Percent of Total Billed Charges,72% of Total Billed Charges,326.25,75,,3267,Percent of Total Billed charges,75% of Total Billed Charges,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.2,72,,3136.32,Percent of Total Billed Charges,72% of Total Billed Charges,261,60,,2613.6,Percent of Total Billed Charges,60% of Total Billed Charges,391.5,90,,4246.032,Percent of Total Billed Charges,90% of Total Billed Charges,195.75,45,,2697.12,Percent of Total Billed Charges,45% of Total Billed Charges,391.5,90,,1598.392,Percent of Total Billed Charges,90% of Total billed Charges,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.75,65,,12204.408,Percent of total Billed Charges,65% of Total Billed Charges,191.84,44.1,,2643.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,413.25,95,,1687.192,Percent of Total Billed Charges,95% of Total Billed Charges,435,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.8,88,,15194.88,Percent of Total Billed Charges,88% of Total Billed Charges,391.5,90,,1598.392,Percent of Total Billed charges,90% of Total Billed Charges,191.84,435,
"PT Sel Debrd>20 Head,trnk/sacr",4200000100,CDM,420,RC,,,Outpatient,,,618.00,401.70,,618,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,469.68,76,,8163.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,444.96,72,,2903.4,Percent of Total Billed Charges,72% of Total Billed Charges,463.5,75,,3024.376,Percent of Total Billed charges,75% of Total Billed Charges,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.96,72,,2903.4,Percent of Total Billed Charges,72% of Total Billed Charges,370.8,60,,2419.504,Percent of Total Billed Charges,60% of Total Billed Charges,556.2,90,,4246.032,Percent of Total Billed Charges,90% of Total Billed Charges,278.1,45,,7770.112,Percent of Total Billed Charges,45% of Total Billed Charges,556.2,90,,9666.888,Percent of Total Billed Charges,90% of Total billed Charges,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.7,65,,12204.408,Percent of total Billed Charges,65% of Total Billed Charges,272.54,44.1,,7614.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,587.1,95,,10203.936,Percent of Total Billed Charges,95% of Total Billed Charges,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,543.84,88,,17073.968,Percent of Total Billed Charges,88% of Total Billed Charges,556.2,90,,9666.888,Percent of Total Billed charges,90% of Total Billed Charges,272.54,618,
PTA Sel Debr >20 head/trnk/sac,4200000101,CDM,420,RC,,,Outpatient,,,618.00,401.70,,618,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,469.68,76,,8122.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,444.96,72,,3224.736,Percent of Total Billed Charges,72% of Total Billed Charges,463.5,75,,3359.104,Percent of Total Billed charges,75% of Total Billed Charges,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.96,72,,3224.736,Percent of Total Billed Charges,72% of Total Billed Charges,370.8,60,,2687.28,Percent of Total Billed Charges,60% of Total Billed Charges,556.2,90,,4246.032,Percent of Total Billed Charges,90% of Total Billed Charges,278.1,45,,8731.008,Percent of Total Billed Charges,45% of Total Billed Charges,556.2,90,,9618.688,Percent of Total Billed Charges,90% of Total billed Charges,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.7,65,,1755.128,Percent of total Billed Charges,65% of Total Billed Charges,272.54,44.1,,8556.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,587.1,95,,10153.064,Percent of Total Billed Charges,95% of Total Billed Charges,618,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,543.84,88,,17073.968,Percent of Total Billed Charges,88% of Total Billed Charges,556.2,90,,9618.688,Percent of Total Billed charges,90% of Total Billed Charges,272.54,618,
PT NonSel Debrid Head/Trnk/Sac,4200000102,CDM,420,RC,,,Outpatient,,,396.00,257.40,,396,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,300.96,76,,16498.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,285.12,72,,3537.792,Percent of Total Billed Charges,72% of Total Billed Charges,297,75,,3685.2,Percent of Total Billed charges,75% of Total Billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.12,72,,3537.792,Percent of Total Billed Charges,72% of Total Billed Charges,237.6,60,,2948.16,Percent of Total Billed Charges,60% of Total Billed Charges,356.4,90,,4246.032,Percent of Total Billed Charges,90% of Total Billed Charges,178.2,45,,8731.008,Percent of Total Billed Charges,45% of Total Billed Charges,356.4,90,,19538.176,Percent of Total Billed Charges,90% of Total billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.4,65,,794.976,Percent of total Billed Charges,65% of Total Billed Charges,174.64,44.1,,8556.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,376.2,95,,20623.624,Percent of Total Billed Charges,95% of Total Billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.48,88,,24214.64,Percent of Total Billed Charges,88% of Total Billed Charges,356.4,90,,19538.176,Percent of Total Billed charges,90% of Total Billed Charges,174.64,396,
PTA NonSel Debr Head/Trnk/Sacr,4200000103,CDM,420,RC,,,Outpatient,,,396.00,257.40,,396,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,300.96,76,,4555.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,285.12,72,,2058.048,Percent of Total Billed Charges,72% of Total Billed Charges,297,75,,2143.8,Percent of Total Billed charges,75% of Total Billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.12,72,,2058.048,Percent of Total Billed Charges,72% of Total Billed Charges,237.6,60,,1715.04,Percent of Total Billed Charges,60% of Total Billed Charges,356.4,90,,36467.176,Percent of Total Billed Charges,90% of Total Billed Charges,178.2,45,,12382.488,Percent of Total Billed Charges,45% of Total Billed Charges,356.4,90,,5394.24,Percent of Total Billed Charges,90% of Total billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.4,65,,794.976,Percent of total Billed Charges,65% of Total Billed Charges,174.64,44.1,,12134.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,376.2,95,,5693.92,Percent of Total Billed Charges,95% of Total Billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.48,88,,4093.472,Percent of Total Billed Charges,88% of Total Billed Charges,356.4,90,,5394.24,Percent of Total Billed charges,90% of Total Billed Charges,174.64,396,
PT GROUP THERAPY,4230000001,CDM,423,RC,,,Outpatient,,,102.53,66.64,,102.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,77.92,76,,13122.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,73.82,72,,2362.352,Percent of Total Billed Charges,72% of Total Billed Charges,76.9,75,,2460.784,Percent of Total Billed charges,75% of Total Billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.82,72,,2362.352,Percent of Total Billed Charges,72% of Total Billed Charges,61.52,60,,1968.624,Percent of Total Billed Charges,60% of Total Billed Charges,92.28,90,,36467.176,Percent of Total Billed Charges,90% of Total Billed Charges,46.14,45,,2093.256,Percent of Total Billed Charges,45% of Total Billed Charges,92.28,90,,15540.224,Percent of Total Billed Charges,90% of Total billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.64,65,,5498.48,Percent of total Billed Charges,65% of Total Billed Charges,45.22,44.1,,2051.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,97.4,95,,16403.568,Percent of Total Billed Charges,95% of Total Billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.23,88,,4151.68,Percent of Total Billed Charges,88% of Total Billed Charges,92.28,90,,15540.224,Percent of Total Billed charges,90% of Total Billed Charges,45.22,102.53,
PTA GROUP THERAPY 15 MIN,4230000002,CDM,423,RC,,,Outpatient,,,102.53,66.64,,102.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,77.92,76,,14745.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,73.82,72,,3466.368,Percent of Total Billed Charges,72% of Total Billed Charges,76.9,75,,3610.8,Percent of Total Billed charges,75% of Total Billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.82,72,,3466.368,Percent of Total Billed Charges,72% of Total Billed Charges,61.52,60,,2888.64,Percent of Total Billed Charges,60% of Total Billed Charges,92.28,90,,75187.152,Percent of Total Billed Charges,90% of Total Billed Charges,46.14,45,,2123.016,Percent of Total Billed Charges,45% of Total Billed Charges,92.28,90,,17462.016,Percent of Total Billed Charges,90% of Total billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.64,65,,5498.48,Percent of total Billed Charges,65% of Total Billed Charges,45.22,44.1,,2080.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,97.4,95,,18432.128,Percent of Total Billed Charges,95% of Total Billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.23,88,,4151.68,Percent of Total Billed Charges,88% of Total Billed Charges,92.28,90,,17462.016,Percent of Total Billed charges,90% of Total Billed Charges,45.22,102.53,
PT  THERAPY EVAL 20 MIN,4240000001,CDM,424,RC,,,Outpatient,,,263.00,170.95,,263,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,199.88,76,,14745.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,189.36,72,,3031.68,Percent of Total Billed Charges,72% of Total Billed Charges,197.25,75,,3158.008,Percent of Total Billed charges,75% of Total Billed Charges,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.36,72,,3031.68,Percent of Total Billed Charges,72% of Total Billed Charges,157.8,60,,2526.4,Percent of Total Billed Charges,60% of Total Billed Charges,236.7,90,,75187.152,Percent of Total Billed Charges,90% of Total Billed Charges,118.35,45,,2123.016,Percent of Total Billed Charges,45% of Total Billed Charges,236.7,90,,17462.016,Percent of Total Billed Charges,90% of Total billed Charges,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.95,65,,5498.48,Percent of total Billed Charges,65% of Total Billed Charges,115.98,44.1,,2080.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,249.85,95,,18432.128,Percent of Total Billed Charges,95% of Total Billed Charges,263,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.44,88,,4151.68,Percent of Total Billed Charges,88% of Total Billed Charges,236.7,90,,17462.016,Percent of Total Billed charges,90% of Total Billed Charges,115.98,263,
PT  THERAPY EVAL 30 MIN,4240000002,CDM,424,RC,,,Outpatient,,,290.00,188.50,,290,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,220.4,76,,20912.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,208.8,72,,3176.064,Percent of Total Billed Charges,72% of Total Billed Charges,217.5,75,,3308.4,Percent of Total Billed charges,75% of Total Billed Charges,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.8,72,,3176.064,Percent of Total Billed Charges,72% of Total Billed Charges,174,60,,2646.72,Percent of Total Billed Charges,60% of Total Billed Charges,261,90,,75187.152,Percent of Total Billed Charges,90% of Total Billed Charges,130.5,45,,2123.016,Percent of Total Billed Charges,45% of Total Billed Charges,261,90,,24764.976,Percent of Total Billed Charges,90% of Total billed Charges,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.5,65,,5787.392,Percent of total Billed Charges,65% of Total Billed Charges,127.89,44.1,,2080.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,275.5,95,,26140.808,Percent of Total Billed Charges,95% of Total Billed Charges,290,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.2,88,,4151.68,Percent of Total Billed Charges,88% of Total Billed Charges,261,90,,24764.976,Percent of Total Billed charges,90% of Total Billed Charges,127.89,290,
PT  THERAPY EVAL 45 MIN,4240000003,CDM,424,RC,,,Outpatient,,,317.00,206.05,,317,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,240.92,76,,3535.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,228.24,72,,3224.736,Percent of Total Billed Charges,72% of Total Billed Charges,237.75,75,,3359.104,Percent of Total Billed charges,75% of Total Billed Charges,317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.24,72,,3224.736,Percent of Total Billed Charges,72% of Total Billed Charges,190.2,60,,2687.28,Percent of Total Billed Charges,60% of Total Billed Charges,285.3,90,,366.736,Percent of Total Billed Charges,90% of Total Billed Charges,142.65,45,,2123.016,Percent of Total Billed Charges,45% of Total Billed Charges,285.3,90,,4186.504,Percent of Total Billed Charges,90% of Total billed Charges,317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.05,65,,5787.392,Percent of total Billed Charges,65% of Total Billed Charges,139.8,44.1,,2080.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,301.15,95,,4419.088,Percent of Total Billed Charges,95% of Total Billed Charges,317,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.96,88,,35656.792,Percent of Total Billed Charges,88% of Total Billed Charges,285.3,90,,4186.504,Percent of Total Billed charges,90% of Total Billed Charges,139.8,317,
PT  THERAPY REEVAL 20 MIN,4240000004,CDM,424,RC,,,Outpatient,,,106.00,68.90,,106,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,80.56,76,,3585.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,76.32,72,,247.032,Percent of Total Billed Charges,72% of Total Billed Charges,79.5,75,,257.32,Percent of Total Billed charges,75% of Total Billed Charges,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.32,72,,247.032,Percent of Total Billed Charges,72% of Total Billed Charges,63.6,60,,205.856,Percent of Total Billed Charges,60% of Total Billed Charges,95.4,90,,9792,Percent of Total Billed Charges,90% of Total Billed Charges,47.7,45,,18233.584,Percent of Total Billed Charges,45% of Total Billed Charges,95.4,90,,4246.032,Percent of Total Billed Charges,90% of Total billed Charges,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.9,65,,2749.24,Percent of total Billed Charges,65% of Total Billed Charges,46.75,44.1,,17868.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,100.7,95,,4481.928,Percent of Total Billed Charges,95% of Total Billed Charges,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.28,88,,35656.792,Percent of Total Billed Charges,88% of Total Billed Charges,95.4,90,,4246.032,Percent of Total Billed charges,90% of Total Billed Charges,46.75,106,
OT WK HARDEN COND EA ADDL 1HR,4300000001,CDM,430,RC,,,Outpatient,,,233.73,151.92,,233.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,177.63,76,,3585.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,168.29,72,,2090.304,Percent of Total Billed Charges,72% of Total Billed Charges,175.3,75,,2177.4,Percent of Total Billed charges,75% of Total Billed Charges,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.29,72,,2090.304,Percent of Total Billed Charges,72% of Total Billed Charges,140.24,60,,1741.92,Percent of Total Billed Charges,60% of Total Billed Charges,210.36,90,,3930.976,Percent of Total Billed Charges,90% of Total Billed Charges,105.18,45,,18233.584,Percent of Total Billed Charges,45% of Total Billed Charges,210.36,90,,4246.032,Percent of Total Billed Charges,90% of Total billed Charges,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.92,65,,2749.24,Percent of total Billed Charges,65% of Total Billed Charges,103.07,44.1,,17868.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,222.04,95,,4481.928,Percent of Total Billed Charges,95% of Total Billed Charges,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.68,88,,73516.328,Percent of Total Billed Charges,88% of Total Billed Charges,210.36,90,,4246.032,Percent of Total Billed charges,90% of Total Billed Charges,103.07,233.73,
OT WRK HARDEN COND INT 2HRS,4300000002,CDM,430,RC,,,Outpatient,,,468.56,304.56,,468.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,356.11,76,,3585.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,337.36,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,351.42,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.36,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,421.7,90,,19538.176,Percent of Total Billed Charges,90% of Total Billed Charges,210.85,45,,37593.576,Percent of Total Billed Charges,45% of Total Billed Charges,421.7,90,,4246.032,Percent of Total Billed Charges,90% of Total billed Charges,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.56,65,,2893.696,Percent of total Billed Charges,65% of Total Billed Charges,206.63,44.1,,36841.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,445.13,95,,4481.928,Percent of Total Billed Charges,95% of Total Billed Charges,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.33,88,,73516.328,Percent of Total Billed Charges,88% of Total Billed Charges,421.7,90,,4246.032,Percent of Total Billed charges,90% of Total Billed Charges,206.63,468.56,
OTA WK HARDEN COND EA ADDL 1HR,4300000003,CDM,430,RC,,,Outpatient,,,233.73,151.92,,233.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,177.63,76,,3585.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,168.29,72,,2689.92,Percent of Total Billed Charges,72% of Total Billed Charges,175.3,75,,2802,Percent of Total Billed charges,75% of Total Billed Charges,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.29,72,,2689.92,Percent of Total Billed Charges,72% of Total Billed Charges,140.24,60,,2241.6,Percent of Total Billed Charges,60% of Total Billed Charges,210.36,90,,6444.592,Percent of Total Billed Charges,90% of Total Billed Charges,105.18,45,,37593.576,Percent of Total Billed Charges,45% of Total Billed Charges,210.36,90,,4246.032,Percent of Total Billed Charges,90% of Total billed Charges,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.92,65,,11725.704,Percent of total Billed Charges,65% of Total Billed Charges,103.07,44.1,,36841.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,222.04,95,,4481.928,Percent of Total Billed Charges,95% of Total Billed Charges,233.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.68,88,,73516.328,Percent of Total Billed Charges,88% of Total Billed Charges,210.36,90,,4246.032,Percent of Total Billed charges,90% of Total Billed Charges,103.07,233.73,
OTA WK HARDEN COND INT 2HRS,4300000004,CDM,430,RC,,,Outpatient,,,468.56,304.56,,468.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,356.11,76,,30794.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,337.36,72,,1952.064,Percent of Total Billed Charges,72% of Total Billed Charges,351.42,75,,2033.4,Percent of Total Billed charges,75% of Total Billed Charges,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.36,72,,1952.064,Percent of Total Billed Charges,72% of Total Billed Charges,281.14,60,,1626.72,Percent of Total Billed Charges,60% of Total Billed Charges,421.7,90,,1226.416,Percent of Total Billed Charges,90% of Total Billed Charges,210.85,45,,37593.576,Percent of Total Billed Charges,45% of Total Billed Charges,421.7,90,,36467.176,Percent of Total Billed Charges,90% of Total billed Charges,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.56,65,,11725.704,Percent of total Billed Charges,65% of Total Billed Charges,206.63,44.1,,36841.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,445.13,95,,38493.128,Percent of Total Billed Charges,95% of Total Billed Charges,468.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.33,88,,358.592,Percent of Total Billed Charges,88% of Total Billed Charges,421.7,90,,36467.176,Percent of Total Billed charges,90% of Total Billed Charges,206.63,468.56,
OT BIOFEEDBACK,4300000005,CDM,430,RC,,,Outpatient,,,166.48,108.21,,166.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,126.52,76,,30794.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,119.87,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,124.86,75,,2307.312,Percent of Total Billed charges,75% of Total Billed Charges,166.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.87,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,99.89,60,,1845.848,Percent of Total Billed Charges,60% of Total Billed Charges,149.83,90,,21215.104,Percent of Total Billed Charges,90% of Total Billed Charges,74.92,45,,183.368,Percent of Total Billed Charges,45% of Total Billed Charges,149.83,90,,36467.176,Percent of Total Billed Charges,90% of Total billed Charges,166.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.21,65,,11725.704,Percent of total Billed Charges,65% of Total Billed Charges,73.42,44.1,,179.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,158.16,95,,38493.128,Percent of Total Billed Charges,95% of Total Billed Charges,166.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.5,88,,9574.4,Percent of Total Billed Charges,88% of Total Billed Charges,149.83,90,,36467.176,Percent of Total Billed charges,90% of Total Billed Charges,73.42,166.48,
OTA BIOFEEDBACK,4300000006,CDM,430,RC,,,Outpatient,,,166.48,108.21,,166.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,126.52,76,,63491.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,119.87,72,,2366.208,Percent of Total Billed Charges,72% of Total Billed Charges,124.86,75,,2464.8,Percent of Total Billed charges,75% of Total Billed Charges,166.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.87,72,,2366.208,Percent of Total Billed Charges,72% of Total Billed Charges,99.89,60,,1971.84,Percent of Total Billed Charges,60% of Total Billed Charges,149.83,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,74.92,45,,4896,Percent of Total Billed Charges,45% of Total Billed Charges,149.83,90,,75187.152,Percent of Total Billed Charges,90% of Total billed Charges,166.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.21,65,,11725.704,Percent of total Billed Charges,65% of Total Billed Charges,73.42,44.1,,4798.08,Percent of Total Billed Charges,44.1% of Total Billed Charges,158.16,95,,79364.216,Percent of Total Billed Charges,95% of Total Billed Charges,166.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.5,88,,3843.624,Percent of Total Billed Charges,88% of Total Billed Charges,149.83,90,,75187.152,Percent of Total Billed charges,90% of Total Billed Charges,73.42,166.48,
OT COLD OR HOT PACK,4300000007,CDM,430,RC,,,Outpatient,,,99.00,64.35,,99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.24,76,,63491.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71.28,72,,2052.288,Percent of Total Billed Charges,72% of Total Billed Charges,74.25,75,,2137.8,Percent of Total Billed charges,75% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.28,72,,2052.288,Percent of Total Billed Charges,72% of Total Billed Charges,59.4,60,,1710.24,Percent of Total Billed Charges,60% of Total Billed Charges,89.1,90,,16898.416,Percent of Total Billed Charges,90% of Total Billed Charges,44.55,45,,1965.488,Percent of Total Billed Charges,45% of Total Billed Charges,89.1,90,,75187.152,Percent of Total Billed Charges,90% of Total billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.35,65,,11725.704,Percent of total Billed Charges,65% of Total Billed Charges,43.66,44.1,,1926.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,94.05,95,,79364.216,Percent of Total Billed Charges,95% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.12,88,,19103.992,Percent of Total Billed Charges,88% of Total Billed Charges,89.1,90,,75187.152,Percent of Total Billed charges,90% of Total Billed Charges,43.66,99,
OTA COLD OR HOT PACK,4300000008,CDM,430,RC,,,Outpatient,,,99.00,64.35,,99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.24,76,,63491.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,71.28,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,74.25,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.28,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,59.4,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,89.1,90,,16898.416,Percent of Total Billed Charges,90% of Total Billed Charges,44.55,45,,9769.088,Percent of Total Billed Charges,45% of Total Billed Charges,89.1,90,,75187.152,Percent of Total Billed Charges,90% of Total billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.35,65,,5862.856,Percent of total Billed Charges,65% of Total Billed Charges,43.66,44.1,,9573.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,94.05,95,,79364.216,Percent of Total Billed Charges,95% of Total Billed Charges,99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.12,88,,6301.376,Percent of Total Billed Charges,88% of Total Billed Charges,89.1,90,,75187.152,Percent of Total Billed charges,90% of Total Billed Charges,43.66,99,
OT PARAFFIN MODALITY,4300000009,CDM,430,RC,,,Outpatient,,,122.00,79.30,,122,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,92.72,76,,309.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,87.84,72,,2366.208,Percent of Total Billed Charges,72% of Total Billed Charges,91.5,75,,2464.8,Percent of Total Billed charges,75% of Total Billed Charges,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.84,72,,2366.208,Percent of Total Billed Charges,72% of Total Billed Charges,73.2,60,,1971.84,Percent of Total Billed Charges,60% of Total Billed Charges,109.8,90,,16898.416,Percent of Total Billed Charges,90% of Total Billed Charges,54.9,45,,3222.296,Percent of Total Billed Charges,45% of Total Billed Charges,109.8,90,,366.736,Percent of Total Billed Charges,90% of Total billed Charges,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.3,65,,5862.856,Percent of total Billed Charges,65% of Total Billed Charges,53.8,44.1,,3157.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,115.9,95,,387.112,Percent of Total Billed Charges,95% of Total Billed Charges,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.36,88,,1199.168,Percent of Total Billed Charges,88% of Total Billed Charges,109.8,90,,366.736,Percent of Total Billed charges,90% of Total Billed Charges,53.8,122,
OTA PARAFFIN MODALITY,4300000010,CDM,430,RC,,,Outpatient,,,122.00,79.30,,122,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,92.72,76,,8268.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,87.84,72,,2180.16,Percent of Total Billed Charges,72% of Total Billed Charges,91.5,75,,2271,Percent of Total Billed charges,75% of Total Billed Charges,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.84,72,,2180.16,Percent of Total Billed Charges,72% of Total Billed Charges,73.2,60,,1816.8,Percent of Total Billed Charges,60% of Total Billed Charges,109.8,90,,16898.416,Percent of Total Billed Charges,90% of Total Billed Charges,54.9,45,,613.208,Percent of Total Billed Charges,45% of Total Billed Charges,109.8,90,,9792,Percent of Total Billed Charges,90% of Total billed Charges,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.3,65,,5862.856,Percent of total Billed Charges,65% of Total Billed Charges,53.8,44.1,,600.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,115.9,95,,10336,Percent of Total Billed Charges,95% of Total Billed Charges,122,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.36,88,,20743.656,Percent of Total Billed Charges,88% of Total Billed Charges,109.8,90,,9792,Percent of Total Billed charges,90% of Total Billed Charges,53.8,122,
OT WHIRLPOOL SMALL,4300000011,CDM,430,RC,,,Outpatient,,,216.09,140.46,,216.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,164.23,76,,3319.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,155.58,72,,1703.232,Percent of Total Billed Charges,72% of Total Billed Charges,162.07,75,,1774.2,Percent of Total Billed charges,75% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.58,72,,1703.232,Percent of Total Billed Charges,72% of Total Billed Charges,129.65,60,,1419.36,Percent of Total Billed Charges,60% of Total Billed Charges,194.48,90,,1198.8,Percent of Total Billed Charges,90% of Total Billed Charges,97.24,45,,10607.552,Percent of Total Billed Charges,45% of Total Billed Charges,194.48,90,,3930.976,Percent of Total Billed Charges,90% of Total billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.46,65,,9377.808,Percent of total Billed Charges,65% of Total Billed Charges,95.3,44.1,,10395.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,205.29,95,,4149.368,Percent of Total Billed Charges,95% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.16,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,194.48,90,,3930.976,Percent of Total Billed charges,90% of Total Billed Charges,95.3,216.09,
OT FLUIDO THERAPY,4300000012,CDM,430,RC,,,Outpatient,,,216.09,140.46,,216.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,164.23,76,,16498.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,155.58,72,,3201.408,Percent of Total Billed Charges,72% of Total Billed Charges,162.07,75,,3334.8,Percent of Total Billed charges,75% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.58,72,,3201.408,Percent of Total Billed Charges,72% of Total Billed Charges,129.65,60,,2667.84,Percent of Total Billed Charges,60% of Total Billed Charges,194.48,90,,2623.384,Percent of Total Billed Charges,90% of Total Billed Charges,97.24,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,194.48,90,,19538.176,Percent of Total Billed Charges,90% of Total billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.46,65,,9377.808,Percent of total Billed Charges,65% of Total Billed Charges,95.3,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,205.29,95,,20623.624,Percent of Total Billed Charges,95% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.16,88,,16522.896,Percent of Total Billed Charges,88% of Total Billed Charges,194.48,90,,19538.176,Percent of Total Billed charges,90% of Total Billed Charges,95.3,216.09,
OTA WHIRLPOOL SMALL,4300000013,CDM,430,RC,,,Outpatient,,,216.09,140.46,,216.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,164.23,76,,5442.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,155.58,72,,315.072,Percent of Total Billed Charges,72% of Total Billed Charges,162.07,75,,328.2,Percent of Total Billed charges,75% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.58,72,,315.072,Percent of Total Billed Charges,72% of Total Billed Charges,129.65,60,,262.56,Percent of Total Billed Charges,60% of Total Billed Charges,194.48,90,,1311.696,Percent of Total Billed Charges,90% of Total Billed Charges,97.24,45,,8449.208,Percent of Total Billed Charges,45% of Total Billed Charges,194.48,90,,6444.592,Percent of Total Billed Charges,90% of Total billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.46,65,,9377.808,Percent of total Billed Charges,65% of Total Billed Charges,95.3,44.1,,8280.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,205.29,95,,6802.624,Percent of Total Billed Charges,95% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.16,88,,16522.896,Percent of Total Billed Charges,88% of Total Billed Charges,194.48,90,,6444.592,Percent of Total Billed charges,90% of Total Billed Charges,95.3,216.09,
OTA FLUIDO THERAPY,4300000014,CDM,430,RC,,,Outpatient,,,216.09,140.46,,216.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,164.23,76,,1035.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,155.58,72,,299.52,Percent of Total Billed Charges,72% of Total Billed Charges,162.07,75,,312,Percent of Total Billed charges,75% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.58,72,,299.52,Percent of Total Billed Charges,72% of Total Billed Charges,129.65,60,,249.6,Percent of Total Billed Charges,60% of Total Billed Charges,194.48,90,,1856.88,Percent of Total Billed Charges,90% of Total Billed Charges,97.24,45,,8449.208,Percent of Total Billed Charges,45% of Total Billed Charges,194.48,90,,1226.416,Percent of Total Billed Charges,90% of Total billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.46,65,,11725.704,Percent of total Billed Charges,65% of Total Billed Charges,95.3,44.1,,8280.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,205.29,95,,1294.552,Percent of Total Billed Charges,95% of Total Billed Charges,216.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.16,88,,16522.896,Percent of Total Billed Charges,88% of Total Billed Charges,194.48,90,,1226.416,Percent of Total Billed charges,90% of Total Billed Charges,95.3,216.09,
OT ESTIM MAN 15 MIN,4300000015,CDM,430,RC,,,Outpatient,,,226.00,146.90,,226,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171.76,76,,17914.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162.72,72,,315.072,Percent of Total Billed Charges,72% of Total Billed Charges,169.5,75,,328.2,Percent of Total Billed charges,75% of Total Billed Charges,226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.72,72,,315.072,Percent of Total Billed Charges,72% of Total Billed Charges,135.6,60,,262.56,Percent of Total Billed Charges,60% of Total Billed Charges,203.4,90,,6061.68,Percent of Total Billed Charges,90% of Total Billed Charges,101.7,45,,8449.208,Percent of Total Billed Charges,45% of Total Billed Charges,203.4,90,,21215.104,Percent of Total Billed Charges,90% of Total billed Charges,226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.9,65,,11725.704,Percent of total Billed Charges,65% of Total Billed Charges,99.67,44.1,,8280.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,214.7,95,,22393.72,Percent of Total Billed Charges,95% of Total Billed Charges,226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.88,88,,16522.896,Percent of Total Billed Charges,88% of Total Billed Charges,203.4,90,,21215.104,Percent of Total Billed charges,90% of Total Billed Charges,99.67,226,
OTA ESTIM MAN 15 MIN,4300000016,CDM,430,RC,,,Outpatient,,,226.00,146.90,,226,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,171.76,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,162.72,72,,2736,Percent of Total Billed Charges,72% of Total Billed Charges,169.5,75,,2850,Percent of Total Billed charges,75% of Total Billed Charges,226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.72,72,,2736,Percent of Total Billed Charges,72% of Total Billed Charges,135.6,60,,2280,Percent of Total Billed Charges,60% of Total Billed Charges,203.4,90,,9782,Percent of Total Billed Charges,90% of Total Billed Charges,101.7,45,,8449.208,Percent of Total Billed Charges,45% of Total Billed Charges,203.4,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.9,65,,11725.704,Percent of total Billed Charges,65% of Total Billed Charges,99.67,44.1,,8280.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,214.7,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,226,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.88,88,,1172.16,Percent of Total Billed Charges,88% of Total Billed Charges,203.4,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,99.67,226,
OT IONTOPHRSIS 15MN,4300000017,CDM,430,RC,,,Outpatient,,,119.07,77.40,,119.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,90.49,76,,14269.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,85.73,72,,2880,Percent of Total Billed Charges,72% of Total Billed Charges,89.3,75,,3000,Percent of Total Billed charges,75% of Total Billed Charges,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.73,72,,2880,Percent of Total Billed Charges,72% of Total Billed Charges,71.44,60,,2400,Percent of Total Billed Charges,60% of Total Billed Charges,107.16,90,,4679.28,Percent of Total Billed Charges,90% of Total Billed Charges,53.58,45,,599.4,Percent of Total Billed Charges,45% of Total Billed Charges,107.16,90,,16898.416,Percent of Total Billed Charges,90% of Total billed Charges,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.4,65,,11725.704,Percent of total Billed Charges,65% of Total Billed Charges,52.51,44.1,,587.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,113.12,95,,17837.216,Percent of Total Billed Charges,95% of Total Billed Charges,119.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.78,88,,2565.088,Percent of Total Billed Charges,88% of Total Billed Charges,107.16,90,,16898.416,Percent of Total Billed charges,90% of Total Billed Charges,52.51,119.07,
OT CONTRST BATH 15MN,4300000018,CDM,430,RC,,,Outpatient,,,108.00,70.20,,108,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.08,76,,14269.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.76,72,,2043.56,Percent of Total Billed Charges,72% of Total Billed Charges,81,75,,2128.712,Percent of Total Billed charges,75% of Total Billed Charges,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.76,72,,2043.56,Percent of Total Billed Charges,72% of Total Billed Charges,64.8,60,,1702.968,Percent of Total Billed Charges,60% of Total Billed Charges,97.2,90,,12542.04,Percent of Total Billed Charges,90% of Total Billed Charges,48.6,45,,1311.696,Percent of Total Billed Charges,45% of Total Billed Charges,97.2,90,,16898.416,Percent of Total Billed Charges,90% of Total billed Charges,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.2,65,,1604.72,Percent of total Billed Charges,65% of Total Billed Charges,47.63,44.1,,1285.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.6,95,,17837.216,Percent of Total Billed Charges,95% of Total Billed Charges,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.04,88,,1282.544,Percent of Total Billed Charges,88% of Total Billed Charges,97.2,90,,16898.416,Percent of Total Billed charges,90% of Total Billed Charges,47.63,108,
OTA CONTRST BATH 15MN,4300000019,CDM,430,RC,,,Outpatient,,,113.56,73.81,,113.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,86.31,76,,14269.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,81.76,72,,2043.56,Percent of Total Billed Charges,72% of Total Billed Charges,85.17,75,,2128.712,Percent of Total Billed charges,75% of Total Billed Charges,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.76,72,,2043.56,Percent of Total Billed Charges,72% of Total Billed Charges,68.14,60,,1702.968,Percent of Total Billed Charges,60% of Total Billed Charges,102.2,90,,12542.04,Percent of Total Billed Charges,90% of Total Billed Charges,51.1,45,,655.848,Percent of Total Billed Charges,45% of Total Billed Charges,102.2,90,,16898.416,Percent of Total Billed Charges,90% of Total billed Charges,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.81,65,,1604.72,Percent of total Billed Charges,65% of Total Billed Charges,50.08,44.1,,642.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,107.88,95,,17837.216,Percent of Total Billed Charges,95% of Total Billed Charges,113.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.93,88,,1815.616,Percent of Total Billed Charges,88% of Total Billed Charges,102.2,90,,16898.416,Percent of Total Billed charges,90% of Total Billed Charges,50.08,113.56,
OT PHONOPHORESIS 15M,4300000020,CDM,430,RC,,,Outpatient,,,151.04,98.18,,151.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114.79,76,,14269.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.75,72,,2043.56,Percent of Total Billed Charges,72% of Total Billed Charges,113.28,75,,2128.712,Percent of Total Billed charges,75% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.75,72,,2043.56,Percent of Total Billed Charges,72% of Total Billed Charges,90.62,60,,1702.968,Percent of Total Billed Charges,60% of Total Billed Charges,135.94,90,,11915.28,Percent of Total Billed Charges,90% of Total Billed Charges,67.97,45,,928.44,Percent of Total Billed Charges,45% of Total Billed Charges,135.94,90,,16898.416,Percent of Total Billed Charges,90% of Total billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.18,65,,1604.72,Percent of total Billed Charges,65% of Total Billed Charges,66.61,44.1,,909.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,143.49,95,,17837.216,Percent of Total Billed Charges,95% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.92,88,,5926.976,Percent of Total Billed Charges,88% of Total Billed Charges,135.94,90,,16898.416,Percent of Total Billed charges,90% of Total Billed Charges,66.61,151.04,
OT ULTRASOUND 15 MIN,4300000021,CDM,430,RC,,,Outpatient,,,159.00,103.35,,159,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.84,76,,1012.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.48,72,,2043.56,Percent of Total Billed Charges,72% of Total Billed Charges,119.25,75,,2128.712,Percent of Total Billed charges,75% of Total Billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.48,72,,2043.56,Percent of Total Billed Charges,72% of Total Billed Charges,95.4,60,,1702.968,Percent of Total Billed Charges,60% of Total Billed Charges,143.1,90,,8211.064,Percent of Total Billed Charges,90% of Total Billed Charges,71.55,45,,3030.84,Percent of Total Billed Charges,45% of Total Billed Charges,143.1,90,,1198.8,Percent of Total Billed Charges,90% of Total billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.35,65,,1604.72,Percent of total Billed Charges,65% of Total Billed Charges,70.12,44.1,,2970.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,151.05,95,,1265.4,Percent of Total Billed Charges,95% of Total Billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.92,88,,9564.624,Percent of Total Billed Charges,88% of Total Billed Charges,143.1,90,,1198.8,Percent of Total Billed charges,90% of Total Billed Charges,70.12,159,
OTA PHONOPHORESIS 15M,4300000022,CDM,430,RC,,,Outpatient,,,151.04,98.18,,151.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114.79,76,,2215.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.75,72,,2043.56,Percent of Total Billed Charges,72% of Total Billed Charges,113.28,75,,2128.712,Percent of Total Billed charges,75% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.75,72,,2043.56,Percent of Total Billed Charges,72% of Total Billed Charges,90.62,60,,1702.968,Percent of Total Billed Charges,60% of Total Billed Charges,135.94,90,,6240.856,Percent of Total Billed Charges,90% of Total Billed Charges,67.97,45,,4891,Percent of Total Billed Charges,45% of Total Billed Charges,135.94,90,,2623.384,Percent of Total Billed Charges,90% of Total billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.18,65,,1604.72,Percent of total Billed Charges,65% of Total Billed Charges,66.61,44.1,,4793.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,143.49,95,,2769.128,Percent of Total Billed Charges,95% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.92,88,,4575.296,Percent of Total Billed Charges,88% of Total Billed Charges,135.94,90,,2623.384,Percent of Total Billed charges,90% of Total Billed Charges,66.61,151.04,
OTA ULTRASOUND 15 MIN,4300000023,CDM,430,RC,,,Outpatient,,,159.00,103.35,,159,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.84,76,,1107.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.48,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,119.25,75,,2307.312,Percent of Total Billed charges,75% of Total Billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.48,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,95.4,60,,1845.848,Percent of Total Billed Charges,60% of Total Billed Charges,143.1,90,,11809.44,Percent of Total Billed Charges,90% of Total Billed Charges,71.55,45,,2339.64,Percent of Total Billed Charges,45% of Total Billed Charges,143.1,90,,1311.696,Percent of Total Billed Charges,90% of Total billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.35,65,,1011.92,Percent of total Billed Charges,65% of Total Billed Charges,70.12,44.1,,2292.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,151.05,95,,1384.568,Percent of Total Billed Charges,95% of Total Billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.92,88,,12263.328,Percent of Total Billed Charges,88% of Total Billed Charges,143.1,90,,1311.696,Percent of Total Billed charges,90% of Total Billed Charges,70.12,159,
OT THER EXER 15 MIN,4300000024,CDM,430,RC,,,Outpatient,,,163.00,105.95,,163,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,123.88,76,,1568.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,117.36,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,122.25,75,,2307.312,Percent of Total Billed charges,75% of Total Billed Charges,163,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.36,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,97.8,60,,1845.848,Percent of Total Billed Charges,60% of Total Billed Charges,146.7,90,,12602.16,Percent of Total Billed Charges,90% of Total Billed Charges,73.35,45,,6271.024,Percent of Total Billed Charges,45% of Total Billed Charges,146.7,90,,1856.88,Percent of Total Billed Charges,90% of Total billed Charges,163,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.95,65,,1011.92,Percent of total Billed Charges,65% of Total Billed Charges,71.88,44.1,,6145.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,154.85,95,,1960.04,Percent of Total Billed Charges,95% of Total Billed Charges,163,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.44,88,,12263.328,Percent of Total Billed Charges,88% of Total Billed Charges,146.7,90,,1856.88,Percent of Total Billed charges,90% of Total Billed Charges,71.88,163,
OTA THER EXER 15 MIN,4300000025,CDM,430,RC,,,Outpatient,,,163.00,105.95,,163,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,123.88,76,,5118.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,117.36,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,122.25,75,,2307.312,Percent of Total Billed charges,75% of Total Billed Charges,163,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.36,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,97.8,60,,1845.848,Percent of Total Billed Charges,60% of Total Billed Charges,146.7,90,,13265.192,Percent of Total Billed Charges,90% of Total Billed Charges,73.35,45,,6271.024,Percent of Total Billed Charges,45% of Total Billed Charges,146.7,90,,6061.68,Percent of Total Billed Charges,90% of Total billed Charges,163,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.95,65,,1011.92,Percent of total Billed Charges,65% of Total Billed Charges,71.88,44.1,,6145.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,154.85,95,,6398.44,Percent of Total Billed Charges,95% of Total Billed Charges,163,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.44,88,,11650.496,Percent of Total Billed Charges,88% of Total Billed Charges,146.7,90,,6061.68,Percent of Total Billed charges,90% of Total Billed Charges,71.88,163,
OT NM REEDUCT 15MIN,4300000026,CDM,430,RC,,,Outpatient,,,176.00,114.40,,176,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,133.76,76,,8260.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,126.72,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,132,75,,2307.312,Percent of Total Billed charges,75% of Total Billed Charges,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.72,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,105.6,60,,1845.848,Percent of Total Billed Charges,60% of Total Billed Charges,158.4,90,,1109.736,Percent of Total Billed Charges,90% of Total Billed Charges,79.2,45,,5957.64,Percent of Total Billed Charges,45% of Total Billed Charges,158.4,90,,9782,Percent of Total Billed Charges,90% of Total billed Charges,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.4,65,,1064.832,Percent of total Billed Charges,65% of Total Billed Charges,77.62,44.1,,5838.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,167.2,95,,10325.44,Percent of Total Billed Charges,95% of Total Billed Charges,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.88,88,,8028.6,Percent of Total Billed Charges,88% of Total Billed Charges,158.4,90,,9782,Percent of Total Billed charges,90% of Total Billed Charges,77.62,176,
OTA NM REEDUCT 15MIN,4300000027,CDM,430,RC,,,Outpatient,,,176.00,114.40,,176,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,133.76,76,,3951.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,126.72,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,132,75,,2307.312,Percent of Total Billed charges,75% of Total Billed Charges,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.72,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,105.6,60,,1845.848,Percent of Total Billed Charges,60% of Total Billed Charges,158.4,90,,2338.728,Percent of Total Billed Charges,90% of Total Billed Charges,79.2,45,,4105.536,Percent of Total Billed Charges,45% of Total Billed Charges,158.4,90,,4679.28,Percent of Total Billed Charges,90% of Total billed Charges,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.4,65,,1064.832,Percent of total Billed Charges,65% of Total Billed Charges,77.62,44.1,,4023.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,167.2,95,,4939.24,Percent of Total Billed Charges,95% of Total Billed Charges,176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.88,88,,6102.176,Percent of Total Billed Charges,88% of Total Billed Charges,158.4,90,,4679.28,Percent of Total Billed charges,90% of Total Billed Charges,77.62,176,
OT MASSAGE 15 MIN,4300000028,CDM,430,RC,,,Outpatient,,,228.00,148.20,,228,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,173.28,76,,10591.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,164.16,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,171,75,,2307.312,Percent of Total Billed charges,75% of Total Billed Charges,228,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.16,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,136.8,60,,1845.848,Percent of Total Billed Charges,60% of Total Billed Charges,205.2,90,,1474.384,Percent of Total Billed Charges,90% of Total Billed Charges,102.6,45,,3120.432,Percent of Total Billed Charges,45% of Total Billed Charges,205.2,90,,12542.04,Percent of Total Billed Charges,90% of Total billed Charges,228,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.2,65,,1800.24,Percent of total Billed Charges,65% of Total Billed Charges,100.55,44.1,,3058.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,216.6,95,,13238.824,Percent of Total Billed Charges,95% of Total Billed Charges,228,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.64,88,,11547.008,Percent of Total Billed Charges,88% of Total Billed Charges,205.2,90,,12542.04,Percent of Total Billed charges,90% of Total Billed Charges,100.55,228,
OTA MASSAGE 15 MIN,4300000029,CDM,430,RC,,,Outpatient,,,228.00,148.20,,228,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,173.28,76,,10591.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,164.16,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,171,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,228,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.16,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,136.8,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,205.2,90,,21469.12,Percent of Total Billed Charges,90% of Total Billed Charges,102.6,45,,5904.72,Percent of Total Billed Charges,45% of Total Billed Charges,205.2,90,,12542.04,Percent of Total Billed Charges,90% of Total billed Charges,228,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.2,65,,1800.24,Percent of total Billed Charges,65% of Total Billed Charges,100.55,44.1,,5786.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,216.6,95,,13238.824,Percent of Total Billed Charges,95% of Total Billed Charges,228,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.64,88,,12322.112,Percent of Total Billed Charges,88% of Total Billed Charges,205.2,90,,12542.04,Percent of Total Billed charges,90% of Total Billed Charges,100.55,228,
OT MBL JT ST TI 15MN,4300000032,CDM,430,RC,,,Outpatient,,,200.00,130.00,,200,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152,76,,10061.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,150,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,120,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,180,90,,21469.12,Percent of Total Billed Charges,90% of Total Billed Charges,90,45,,6301.08,Percent of Total Billed Charges,45% of Total Billed Charges,180,90,,11915.28,Percent of Total Billed Charges,90% of Total billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130,65,,1800.24,Percent of total Billed Charges,65% of Total Billed Charges,88.2,44.1,,6175.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,190,95,,12577.24,Percent of Total Billed Charges,95% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,88,,12970.408,Percent of Total Billed Charges,88% of Total Billed Charges,180,90,,11915.28,Percent of Total Billed charges,90% of Total Billed Charges,88.2,200,
OTA MBL JT ST TI 15MN,4300000033,CDM,430,RC,,,Outpatient,,,200.00,130.00,,200,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,152,76,,6933.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,144,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,150,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,120,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,180,90,,10170.96,Percent of Total Billed Charges,90% of Total Billed Charges,90,45,,6632.6,Percent of Total Billed Charges,45% of Total Billed Charges,180,90,,8211.064,Percent of Total Billed Charges,90% of Total billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130,65,,1894.664,Percent of total Billed Charges,65% of Total Billed Charges,88.2,44.1,,6499.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,190,95,,8667.24,Percent of Total Billed Charges,95% of Total Billed Charges,200,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176,88,,1085.072,Percent of Total Billed Charges,88% of Total Billed Charges,180,90,,8211.064,Percent of Total Billed charges,90% of Total Billed Charges,88.2,200,
OT THERAPEU ACT 15MN,4300000034,CDM,430,RC,,,Outpatient,,,110.00,71.50,,110,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,83.6,76,,5270.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,79.2,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,82.5,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,66,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,99,90,,21469.12,Percent of Total Billed Charges,90% of Total Billed Charges,49.5,45,,554.872,Percent of Total Billed Charges,45% of Total Billed Charges,99,90,,6240.856,Percent of Total Billed Charges,90% of Total billed Charges,110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.5,65,,1800.24,Percent of total Billed Charges,65% of Total Billed Charges,48.51,44.1,,543.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,104.5,95,,6587.576,Percent of Total Billed Charges,95% of Total Billed Charges,110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.8,88,,2286.752,Percent of Total Billed Charges,88% of Total Billed Charges,99,90,,6240.856,Percent of Total Billed charges,90% of Total Billed Charges,48.51,110,
OTA THERAPEU ACT 15MN,4300000035,CDM,430,RC,,,Outpatient,,,110.00,71.50,,110,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,83.6,76,,9972.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,79.2,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,82.5,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.2,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,66,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,99,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,49.5,45,,1169.36,Percent of Total Billed Charges,45% of Total Billed Charges,99,90,,11809.44,Percent of Total Billed Charges,90% of Total billed Charges,110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.5,65,,900.12,Percent of total Billed Charges,65% of Total Billed Charges,48.51,44.1,,1145.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,104.5,95,,12465.52,Percent of Total Billed Charges,95% of Total Billed Charges,110,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.8,88,,1441.624,Percent of Total Billed Charges,88% of Total Billed Charges,99,90,,11809.44,Percent of Total Billed charges,90% of Total Billed Charges,48.51,110,
OT SENSORY INT 15MN,4300000036,CDM,430,RC,,,Outpatient,,,120.17,78.11,,120.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,91.33,76,,10641.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,86.52,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,90.13,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.52,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,72.1,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,108.15,90,,4795.344,Percent of Total Billed Charges,90% of Total Billed Charges,54.08,45,,737.192,Percent of Total Billed Charges,45% of Total Billed Charges,108.15,90,,12602.16,Percent of Total Billed Charges,90% of Total billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.11,65,,900.12,Percent of total Billed Charges,65% of Total Billed Charges,52.99,44.1,,722.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,114.16,95,,13302.28,Percent of Total Billed Charges,95% of Total Billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.75,88,,20992.024,Percent of Total Billed Charges,88% of Total Billed Charges,108.15,90,,12602.16,Percent of Total Billed charges,90% of Total Billed Charges,52.99,120.17,
OTA SENSORY INT 15MN,4300000037,CDM,430,RC,,,Outpatient,,,120.17,78.11,,120.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,91.33,76,,11201.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,86.52,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,90.13,75,,2249.76,Percent of Total Billed charges,75% of Total Billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.52,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,72.1,60,,1799.808,Percent of Total Billed Charges,60% of Total Billed Charges,108.15,90,,40936.272,Percent of Total Billed Charges,90% of Total Billed Charges,54.08,45,,10734.56,Percent of Total Billed Charges,45% of Total Billed Charges,108.15,90,,13265.192,Percent of Total Billed Charges,90% of Total billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.11,65,,900.12,Percent of total Billed Charges,65% of Total Billed Charges,52.99,44.1,,10519.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,114.16,95,,14002.152,Percent of Total Billed Charges,95% of Total Billed Charges,120.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.75,88,,20992.024,Percent of Total Billed Charges,88% of Total Billed Charges,108.15,90,,13265.192,Percent of Total Billed charges,90% of Total Billed Charges,52.99,120.17,
OT SELFCARE ADL 15MN,4300000038,CDM,430,RC,,,Outpatient,,,121.00,78.65,,121,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,91.96,76,,937.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,87.12,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,90.75,75,,2249.76,Percent of Total Billed charges,75% of Total Billed Charges,121,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.12,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,72.6,60,,1799.808,Percent of Total Billed Charges,60% of Total Billed Charges,108.9,90,,36467.176,Percent of Total Billed Charges,90% of Total Billed Charges,54.45,45,,10734.56,Percent of Total Billed Charges,45% of Total Billed Charges,108.9,90,,1109.736,Percent of Total Billed Charges,90% of Total billed Charges,121,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.65,65,,947.336,Percent of total Billed Charges,65% of Total Billed Charges,53.36,44.1,,10519.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,114.95,95,,1171.392,Percent of Total Billed Charges,95% of Total Billed Charges,121,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.48,88,,9944.936,Percent of Total Billed Charges,88% of Total Billed Charges,108.9,90,,1109.736,Percent of Total Billed charges,90% of Total Billed Charges,53.36,121,
OTA SELFCARE ADL 15MN,4300000039,CDM,430,RC,,,Outpatient,,,121.00,78.65,,121,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,91.96,76,,1974.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,87.12,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,90.75,75,,2249.76,Percent of Total Billed charges,75% of Total Billed Charges,121,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.12,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,72.6,60,,1799.808,Percent of Total Billed Charges,60% of Total Billed Charges,108.9,90,,75187.152,Percent of Total Billed Charges,90% of Total Billed Charges,54.45,45,,5085.48,Percent of Total Billed Charges,45% of Total Billed Charges,108.9,90,,2338.728,Percent of Total Billed Charges,90% of Total billed Charges,121,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.65,65,,947.336,Percent of total Billed Charges,65% of Total Billed Charges,53.36,44.1,,4983.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,114.95,95,,2468.656,Percent of Total Billed Charges,95% of Total Billed Charges,121,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.48,88,,20992.024,Percent of Total Billed Charges,88% of Total Billed Charges,108.9,90,,2338.728,Percent of Total Billed charges,90% of Total Billed Charges,53.36,121,
OT COMM WK REIN 15MN,4300000040,CDM,430,RC,,,Outpatient,,,111.35,72.38,,111.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,84.63,76,,1245.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,80.17,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,83.51,75,,2249.76,Percent of Total Billed charges,75% of Total Billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.17,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,66.81,60,,1799.808,Percent of Total Billed Charges,60% of Total Billed Charges,100.22,90,,21469.12,Percent of Total Billed Charges,90% of Total Billed Charges,50.11,45,,10734.56,Percent of Total Billed Charges,45% of Total Billed Charges,100.22,90,,1474.384,Percent of Total Billed Charges,90% of Total billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.38,65,,5569.72,Percent of total Billed Charges,65% of Total Billed Charges,49.11,44.1,,10519.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,105.78,95,,1556.296,Percent of Total Billed Charges,95% of Total Billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.99,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,100.22,90,,1474.384,Percent of Total Billed charges,90% of Total Billed Charges,49.11,111.35,
OTA COMM WK REIN 15MN,4300000041,CDM,430,RC,,,Outpatient,,,111.35,72.38,,111.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,84.63,76,,18129.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,80.17,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,83.51,75,,2249.76,Percent of Total Billed charges,75% of Total Billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.17,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,66.81,60,,1799.808,Percent of Total Billed Charges,60% of Total Billed Charges,100.22,90,,21469.12,Percent of Total Billed Charges,90% of Total Billed Charges,50.11,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,100.22,90,,21469.12,Percent of Total Billed Charges,90% of Total billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.38,65,,5569.72,Percent of total Billed Charges,65% of Total Billed Charges,49.11,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,105.78,95,,22661.848,Percent of Total Billed Charges,95% of Total Billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.99,88,,4688.784,Percent of Total Billed Charges,88% of Total Billed Charges,100.22,90,,21469.12,Percent of Total Billed charges,90% of Total Billed Charges,49.11,111.35,
OT SEL DEBRIDE >20CM,4300000042,CDM,430,RC,,,Outpatient,,,650.52,422.84,,650.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,494.4,76,,18129.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,468.37,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,487.89,75,,2249.76,Percent of Total Billed charges,75% of Total Billed Charges,650.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,468.37,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,390.31,60,,1799.808,Percent of Total Billed Charges,60% of Total Billed Charges,585.47,90,,8117.8,Percent of Total Billed Charges,90% of Total Billed Charges,292.73,45,,2397.672,Percent of Total Billed Charges,45% of Total Billed Charges,585.47,90,,21469.12,Percent of Total Billed Charges,90% of Total billed Charges,650.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,650.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,650.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.84,65,,5569.72,Percent of total Billed Charges,65% of Total Billed Charges,286.88,44.1,,2349.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,617.99,95,,22661.848,Percent of Total Billed Charges,95% of Total Billed Charges,650.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,572.46,88,,40026.576,Percent of Total Billed Charges,88% of Total Billed Charges,585.47,90,,21469.12,Percent of Total Billed charges,90% of Total Billed Charges,286.88,650.52,
OTA SEL DEBRIDE >20CM,4300000043,CDM,430,RC,,,Outpatient,,,650.52,422.84,,650.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,494.4,76,,8588.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,468.37,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,487.89,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,650.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,468.37,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,390.31,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,585.47,90,,21469.12,Percent of Total Billed Charges,90% of Total Billed Charges,292.73,45,,20468.136,Percent of Total Billed Charges,45% of Total Billed Charges,585.47,90,,10170.96,Percent of Total Billed Charges,90% of Total billed Charges,650.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,650.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,650.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.84,65,,10280.4,Percent of total Billed Charges,65% of Total Billed Charges,286.88,44.1,,20058.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,617.99,95,,10736.008,Percent of Total Billed Charges,95% of Total Billed Charges,650.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,572.46,88,,35656.792,Percent of Total Billed Charges,88% of Total Billed Charges,585.47,90,,10170.96,Percent of Total Billed charges,90% of Total Billed Charges,286.88,650.52,
OT NONSEL DEBRIDE,4300000044,CDM,430,RC,,,Outpatient,,,232.63,151.21,,232.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,176.8,76,,18129.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,167.49,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,174.47,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,232.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.49,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,139.58,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,209.37,90,,21469.12,Percent of Total Billed Charges,90% of Total Billed Charges,104.68,45,,18233.584,Percent of Total Billed Charges,45% of Total Billed Charges,209.37,90,,21469.12,Percent of Total Billed Charges,90% of Total billed Charges,232.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.21,65,,726.184,Percent of total Billed Charges,65% of Total Billed Charges,102.59,44.1,,17868.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,221,95,,22661.848,Percent of Total Billed Charges,95% of Total Billed Charges,232.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.71,88,,73516.328,Percent of Total Billed Charges,88% of Total Billed Charges,209.37,90,,21469.12,Percent of Total Billed charges,90% of Total Billed Charges,102.59,232.63,
OTA NONSEL DEBRIDE,4300000045,CDM,430,RC,,,Outpatient,,,232.63,151.21,,232.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,176.8,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,167.49,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,174.47,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,232.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.49,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,139.58,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,209.37,90,,8013.312,Percent of Total Billed Charges,90% of Total Billed Charges,104.68,45,,37593.576,Percent of Total Billed Charges,45% of Total Billed Charges,209.37,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,232.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.21,65,,205.92,Percent of total Billed Charges,65% of Total Billed Charges,102.59,44.1,,36841.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,221,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,232.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.71,88,,20992.024,Percent of Total Billed Charges,88% of Total Billed Charges,209.37,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,102.59,232.63,
OT ORTHO FITTING 15M INITIAL,4300000046,CDM,430,RC,,,Outpatient,,,53.00,34.45,,53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.28,76,,4049.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.16,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,39.75,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.16,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,31.8,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,47.7,90,,8013.312,Percent of Total Billed Charges,90% of Total Billed Charges,23.85,45,,10734.56,Percent of Total Billed Charges,45% of Total Billed Charges,47.7,90,,4795.344,Percent of Total Billed Charges,90% of Total billed Charges,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.45,65,,41.832,Percent of total Billed Charges,65% of Total Billed Charges,23.37,44.1,,10519.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.35,95,,5061.752,Percent of Total Billed Charges,95% of Total Billed Charges,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.64,88,,20992.024,Percent of Total Billed Charges,88% of Total Billed Charges,47.7,90,,4795.344,Percent of Total Billed charges,90% of Total Billed Charges,23.37,53,
OTA ORTHO FITTING 15M INITIAL,4300000047,CDM,430,RC,,,Outpatient,,,53.00,34.45,,53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.28,76,,34568.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,38.16,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,39.75,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.16,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,31.8,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,47.7,90,,21215.104,Percent of Total Billed Charges,90% of Total Billed Charges,23.85,45,,10734.56,Percent of Total Billed Charges,45% of Total Billed Charges,47.7,90,,40936.272,Percent of Total Billed Charges,90% of Total billed Charges,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.45,65,,5787.392,Percent of total Billed Charges,65% of Total Billed Charges,23.37,44.1,,10519.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.35,95,,43210.504,Percent of Total Billed Charges,95% of Total Billed Charges,53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.64,88,,7937.4,Percent of Total Billed Charges,88% of Total Billed Charges,47.7,90,,40936.272,Percent of Total Billed charges,90% of Total Billed Charges,23.37,53,
OT PROSTH TRAIN 15MN INITIAL,4300000048,CDM,430,RC,,,Outpatient,,,122.38,79.55,,122.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.01,76,,30794.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.11,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,91.79,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.11,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,73.43,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,110.14,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,55.07,45,,4058.896,Percent of Total Billed Charges,45% of Total Billed Charges,110.14,90,,36467.176,Percent of Total Billed Charges,90% of Total billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.55,65,,5787.392,Percent of total Billed Charges,65% of Total Billed Charges,53.97,44.1,,3977.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.26,95,,38493.128,Percent of Total Billed Charges,95% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.69,88,,20992.024,Percent of Total Billed Charges,88% of Total Billed Charges,110.14,90,,36467.176,Percent of Total Billed charges,90% of Total Billed Charges,53.97,122.38,
OTA PROSTH TRAIN 15MN INITIAL,4300000049,CDM,430,RC,,,Outpatient,,,122.38,79.55,,122.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.01,76,,63491.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.11,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,91.79,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.11,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,73.43,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,110.14,90,,16898.416,Percent of Total Billed Charges,90% of Total Billed Charges,55.07,45,,10734.56,Percent of Total Billed Charges,45% of Total Billed Charges,110.14,90,,75187.152,Percent of Total Billed Charges,90% of Total billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.55,65,,5787.392,Percent of total Billed Charges,65% of Total Billed Charges,53.97,44.1,,10519.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.26,95,,79364.216,Percent of Total Billed Charges,95% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.69,88,,20992.024,Percent of Total Billed Charges,88% of Total Billed Charges,110.14,90,,75187.152,Percent of Total Billed charges,90% of Total Billed Charges,53.97,122.38,
OT ORTHOTIC PROS ADJMT 15MN,4300000050,CDM,430,RC,,,Outpatient,,,122.38,79.55,,122.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.01,76,,18129.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.11,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,91.79,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.11,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,73.43,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,110.14,90,,16898.416,Percent of Total Billed Charges,90% of Total Billed Charges,55.07,45,,10734.56,Percent of Total Billed Charges,45% of Total Billed Charges,110.14,90,,21469.12,Percent of Total Billed Charges,90% of Total billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.55,65,,5787.392,Percent of total Billed Charges,65% of Total Billed Charges,53.97,44.1,,10519.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.26,95,,22661.848,Percent of Total Billed Charges,95% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.69,88,,7835.24,Percent of Total Billed Charges,88% of Total Billed Charges,110.14,90,,21469.12,Percent of Total Billed charges,90% of Total Billed Charges,53.97,122.38,
OTA ORTHOTIC PROS ADJMT 15MN,4300000051,CDM,430,RC,,,Outpatient,,,122.38,79.55,,122.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.01,76,,18129.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.11,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,91.79,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.11,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,73.43,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,110.14,90,,16898.416,Percent of Total Billed Charges,90% of Total Billed Charges,55.07,45,,4006.656,Percent of Total Billed Charges,45% of Total Billed Charges,110.14,90,,21469.12,Percent of Total Billed Charges,90% of Total billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.55,65,,5787.392,Percent of total Billed Charges,65% of Total Billed Charges,53.97,44.1,,3926.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.26,95,,22661.848,Percent of Total Billed Charges,95% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.69,88,,7835.24,Percent of Total Billed Charges,88% of Total Billed Charges,110.14,90,,21469.12,Percent of Total Billed charges,90% of Total Billed Charges,53.97,122.38,
OT ESTIM UNATTENDED,4300000052,CDM,430,RC,G0283,HCPCS,Outpatient,,,298.00,193.70,,14.91,125,,,Fee Schedule,125% of CMS OPPS Rate,226.48,76,,6855.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.1,350,,2490.632,Fee Schedule,350% of BCBS fee schedule,43.1,350,,2594.408,Fee Schedule,350% of BCBS fee schedule,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate,43.1,286,,2490.632,Fee Schedule,286% of BCBS PPO fee schedule,15.07,100,,2075.528,Fee Schedule,100% of Blue ADV HMO fee schedule,268.2,90,,2430.184,Percent of Total Billed Charges,90% of Total Billed Charges,134.1,45,,4006.656,Percent of Total Billed Charges,45% of Total Billed Charges,268.2,90,,8117.8,Percent of Total Billed Charges,90% of Total billed Charges,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate,23.86,200,,2893.696,Fee Schedule,200% of CMS OPPS Rate,131.42,44.1,,3926.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,283.1,95,,8568.784,Percent of Total Billed Charges,95% of Total Billed Charges,8.95,75,,,Fee Schedule,75% of CMS OPPS Rate,262.24,88,,20743.656,Percent of Total Billed Charges,88% of Total Billed Charges,268.2,90,,8117.8,Percent of Total Billed charges,90% of Total Billed Charges,8.95,283.1,
OTA ESTIM UNATTENDED,4300000053,CDM,430,RC,G0283,HCPCS,Outpatient,,,298.00,193.70,,14.91,125,,,Fee Schedule,125% of CMS OPPS Rate,226.48,76,,18129.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.1,350,,2282.336,Fee Schedule,350% of BCBS fee schedule,43.1,350,,2377.432,Fee Schedule,350% of BCBS fee schedule,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate,43.1,286,,2282.336,Fee Schedule,286% of BCBS PPO fee schedule,15.07,100,,1901.944,Fee Schedule,100% of Blue ADV HMO fee schedule,268.2,90,,1100.736,Percent of Total Billed Charges,90% of Total Billed Charges,134.1,45,,10607.552,Percent of Total Billed Charges,45% of Total Billed Charges,268.2,90,,21469.12,Percent of Total Billed Charges,90% of Total billed Charges,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate,23.86,200,,2893.696,Fee Schedule,200% of CMS OPPS Rate,131.42,44.1,,10395.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,283.1,95,,22661.848,Percent of Total Billed Charges,95% of Total Billed Charges,8.95,75,,,Fee Schedule,75% of CMS OPPS Rate,262.24,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,268.2,90,,21469.12,Percent of Total Billed charges,90% of Total Billed Charges,8.95,283.1,
FCE/15MIN,4300000055,CDM,430,RC,,,Outpatient,,,166.48,108.21,,166.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,126.52,76,,18129.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,119.87,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,124.86,75,,2377.432,Percent of Total Billed charges,75% of Total Billed Charges,166.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.87,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,99.89,60,,1901.944,Percent of Total Billed Charges,60% of Total Billed Charges,149.83,90,,1100.736,Percent of Total Billed Charges,90% of Total Billed Charges,74.92,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,149.83,90,,21469.12,Percent of Total Billed Charges,90% of Total billed Charges,166.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.21,65,,2893.696,Percent of total Billed Charges,65% of Total Billed Charges,73.42,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,158.16,95,,22661.848,Percent of Total Billed Charges,95% of Total Billed Charges,166.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.5,88,,16522.896,Percent of Total Billed Charges,88% of Total Billed Charges,149.83,90,,21469.12,Percent of Total Billed charges,90% of Total Billed Charges,73.42,166.48,
APPLY SHORT ARM SPLINT STATIC,4300000056,CDM,430,RC,,,Outpatient,,,261.73,170.12,,261.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,198.91,76,,6766.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,188.45,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,196.3,75,,2377.432,Percent of Total Billed charges,75% of Total Billed Charges,261.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.45,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,157.04,60,,1901.944,Percent of Total Billed Charges,60% of Total Billed Charges,235.56,90,,7613.28,Percent of Total Billed Charges,90% of Total Billed Charges,117.78,45,,8449.208,Percent of Total Billed Charges,45% of Total Billed Charges,235.56,90,,8013.312,Percent of Total Billed Charges,90% of Total billed Charges,261.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.12,65,,5862.856,Percent of total Billed Charges,65% of Total Billed Charges,115.42,44.1,,8280.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,248.64,95,,8458.496,Percent of Total Billed Charges,95% of Total Billed Charges,261.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.32,88,,16522.896,Percent of Total Billed Charges,88% of Total Billed Charges,235.56,90,,8013.312,Percent of Total Billed charges,90% of Total Billed Charges,115.42,261.73,
APPLY SHORT ARM SPLINT DYNAMIC,4300000057,CDM,430,RC,,,Outpatient,,,261.73,170.12,,261.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,198.91,76,,6766.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,188.45,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,196.3,75,,2377.432,Percent of Total Billed charges,75% of Total Billed Charges,261.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.45,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,157.04,60,,1901.944,Percent of Total Billed Charges,60% of Total Billed Charges,235.56,90,,7613.28,Percent of Total Billed Charges,90% of Total Billed Charges,117.78,45,,8449.208,Percent of Total Billed Charges,45% of Total Billed Charges,235.56,90,,8013.312,Percent of Total Billed Charges,90% of Total billed Charges,261.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.12,65,,5862.856,Percent of total Billed Charges,65% of Total Billed Charges,115.42,44.1,,8280.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,248.64,95,,8458.496,Percent of Total Billed Charges,95% of Total Billed Charges,261.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.32,88,,16522.896,Percent of Total Billed Charges,88% of Total Billed Charges,235.56,90,,8013.312,Percent of Total Billed charges,90% of Total Billed Charges,115.42,261.73,
APPLY FINGER SPLINT STATIC,4300000058,CDM,430,RC,,,Outpatient,,,132.05,85.83,,132.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.36,76,,17914.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.08,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,99.04,75,,2377.432,Percent of Total Billed charges,75% of Total Billed Charges,132.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.08,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,79.23,60,,1901.944,Percent of Total Billed Charges,60% of Total Billed Charges,118.85,90,,7613.28,Percent of Total Billed Charges,90% of Total Billed Charges,59.42,45,,8449.208,Percent of Total Billed Charges,45% of Total Billed Charges,118.85,90,,21215.104,Percent of Total Billed Charges,90% of Total billed Charges,132.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.83,65,,5569.72,Percent of total Billed Charges,65% of Total Billed Charges,58.23,44.1,,8280.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.45,95,,22393.72,Percent of Total Billed Charges,95% of Total Billed Charges,132.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.2,88,,2376.176,Percent of Total Billed Charges,88% of Total Billed Charges,118.85,90,,21215.104,Percent of Total Billed charges,90% of Total Billed Charges,58.23,132.05,
APPLY FINGER SPLINT DYNAMIC,4300000059,CDM,430,RC,,,Outpatient,,,132.05,85.83,,132.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.36,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,95.08,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,99.04,75,,2377.432,Percent of Total Billed charges,75% of Total Billed Charges,132.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.08,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,79.23,60,,1901.944,Percent of Total Billed Charges,60% of Total Billed Charges,118.85,90,,8013.312,Percent of Total Billed Charges,90% of Total Billed Charges,59.42,45,,1215.088,Percent of Total Billed Charges,45% of Total Billed Charges,118.85,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,132.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.83,65,,9377.808,Percent of total Billed Charges,65% of Total Billed Charges,58.23,44.1,,1190.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.45,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,132.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.2,88,,1076.272,Percent of Total Billed Charges,88% of Total Billed Charges,118.85,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,58.23,132.05,
OTA COGNIT EA ADDL 15MIN,4300000060,CDM,430,RC,,,Outpatient,,,151.04,98.18,,151.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114.79,76,,14269.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.75,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,113.28,75,,2377.432,Percent of Total Billed charges,75% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.75,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,90.62,60,,1901.944,Percent of Total Billed Charges,60% of Total Billed Charges,135.94,90,,8013.312,Percent of Total Billed Charges,90% of Total Billed Charges,67.97,45,,550.368,Percent of Total Billed Charges,45% of Total Billed Charges,135.94,90,,16898.416,Percent of Total Billed Charges,90% of Total billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.18,65,,9377.808,Percent of total Billed Charges,65% of Total Billed Charges,66.61,44.1,,539.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,143.49,95,,17837.216,Percent of Total Billed Charges,95% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.92,88,,1076.272,Percent of Total Billed Charges,88% of Total Billed Charges,135.94,90,,16898.416,Percent of Total Billed charges,90% of Total Billed Charges,66.61,151.04,
OT COGNIT EA ADDL 15MIN,4300000061,CDM,430,RC,,,Outpatient,,,151.04,98.18,,151.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114.79,76,,14269.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.75,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,113.28,75,,2377.432,Percent of Total Billed charges,75% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.75,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,90.62,60,,1901.944,Percent of Total Billed Charges,60% of Total Billed Charges,135.94,90,,3806.64,Percent of Total Billed Charges,90% of Total Billed Charges,67.97,45,,550.368,Percent of Total Billed Charges,45% of Total Billed Charges,135.94,90,,16898.416,Percent of Total Billed Charges,90% of Total billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.18,65,,9377.808,Percent of total Billed Charges,65% of Total Billed Charges,66.61,44.1,,539.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,143.49,95,,17837.216,Percent of Total Billed Charges,95% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.92,88,,7444.096,Percent of Total Billed Charges,88% of Total Billed Charges,135.94,90,,16898.416,Percent of Total Billed charges,90% of Total Billed Charges,66.61,151.04,
REMOT IMAGE SUBMIT BY PT,4300000065,CDM,430,RC,G2010,HCPCS,Outpatient,,,23.45,15.24,,23.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.82,76,,14269.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.68,350,,1792.72,Fee Schedule,350% of BCBS fee schedule,26.68,350,,1867.416,Fee Schedule,350% of BCBS fee schedule,23.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.68,286,,1792.72,Fee Schedule,286% of BCBS PPO fee schedule,9.33,100,,1493.936,Fee Schedule,100% of Blue ADV HMO fee schedule,21.11,90,,3806.64,Percent of Total Billed Charges,90% of Total Billed Charges,10.55,45,,3806.64,Percent of Total Billed Charges,45% of Total Billed Charges,21.11,90,,16898.416,Percent of Total Billed Charges,90% of Total billed Charges,23.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.24,65,,11725.704,Percent of total Billed Charges,65% of Total Billed Charges,10.34,44.1,,3730.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.28,95,,17837.216,Percent of Total Billed Charges,95% of Total Billed Charges,23.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.64,88,,7444.096,Percent of Total Billed Charges,88% of Total Billed Charges,21.11,90,,16898.416,Percent of Total Billed charges,90% of Total Billed Charges,9.33,26.68,
OT GROUP THERAPY 15 MIN,4330000001,CDM,433,RC,,,Outpatient,,,102.53,66.64,,102.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,77.92,76,,2052.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,73.82,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,76.9,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.82,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,61.52,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,92.28,90,,4006.656,Percent of Total Billed Charges,90% of Total Billed Charges,46.14,45,,3806.64,Percent of Total Billed Charges,45% of Total Billed Charges,92.28,90,,2430.184,Percent of Total Billed Charges,90% of Total billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.64,65,,11725.704,Percent of total Billed Charges,65% of Total Billed Charges,45.22,44.1,,3730.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,97.4,95,,2565.192,Percent of Total Billed Charges,95% of Total Billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.23,88,,7444.096,Percent of Total Billed Charges,88% of Total Billed Charges,92.28,90,,2430.184,Percent of Total Billed charges,90% of Total Billed Charges,45.22,102.53,
OTA GROUP THERAPY 15 MIN,4330000002,CDM,433,RC,,,Outpatient,,,102.53,66.64,,102.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,77.92,76,,929.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,73.82,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,76.9,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.82,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,61.52,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,92.28,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,46.14,45,,3806.64,Percent of Total Billed Charges,45% of Total Billed Charges,92.28,90,,1100.736,Percent of Total Billed Charges,90% of Total billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.64,65,,11725.704,Percent of total Billed Charges,65% of Total Billed Charges,45.22,44.1,,3730.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,97.4,95,,1161.888,Percent of Total Billed Charges,95% of Total Billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.23,88,,7835.24,Percent of Total Billed Charges,88% of Total Billed Charges,92.28,90,,1100.736,Percent of Total Billed charges,90% of Total Billed Charges,45.22,102.53,
OT  THERAPY EVAL   60 MIN,4340000001,CDM,434,RC,,,Outpatient,,,308.00,200.20,,308,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,234.08,76,,929.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,221.76,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,231,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,308,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.76,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,184.8,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,277.2,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,138.6,45,,4006.656,Percent of Total Billed Charges,45% of Total Billed Charges,277.2,90,,1100.736,Percent of Total Billed Charges,90% of Total billed Charges,308,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.2,65,,11725.704,Percent of total Billed Charges,65% of Total Billed Charges,135.83,44.1,,3926.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,292.6,95,,1161.888,Percent of Total Billed Charges,95% of Total Billed Charges,308,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.04,88,,7835.24,Percent of Total Billed Charges,88% of Total Billed Charges,277.2,90,,1100.736,Percent of Total Billed charges,90% of Total Billed Charges,135.83,308,
OT  THERAPY EVAL 30 MIN,4340000002,CDM,434,RC,,,Outpatient,,,280.00,182.00,,280,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,212.8,76,,6428.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,201.6,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,210,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.6,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,168,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,252,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,126,45,,4006.656,Percent of Total Billed Charges,45% of Total Billed Charges,252,90,,7613.28,Percent of Total Billed Charges,90% of Total billed Charges,280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182,65,,1300,Percent of total Billed Charges,65% of Total Billed Charges,123.48,44.1,,3926.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,266,95,,8036.24,Percent of Total Billed Charges,95% of Total Billed Charges,280,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.4,88,,3722.048,Percent of Total Billed Charges,88% of Total Billed Charges,252,90,,7613.28,Percent of Total Billed charges,90% of Total Billed Charges,123.48,280,
OT  THERAPY EVAL 45 MIN,4340000003,CDM,434,RC,,,Outpatient,,,281.00,182.65,,281,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,213.56,76,,6428.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,202.32,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,210.75,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,281,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.32,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,168.6,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,252.9,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,126.45,45,,1903.32,Percent of Total Billed Charges,45% of Total Billed Charges,252.9,90,,7613.28,Percent of Total Billed Charges,90% of Total billed Charges,281,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,281,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,281,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182.65,65,,3592.056,Percent of total Billed Charges,65% of Total Billed Charges,123.92,44.1,,1865.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,266.95,95,,8036.24,Percent of Total Billed Charges,95% of Total Billed Charges,281,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.28,88,,3722.048,Percent of Total Billed Charges,88% of Total Billed Charges,252.9,90,,7613.28,Percent of Total Billed charges,90% of Total Billed Charges,123.92,281,
OT THER REEVAL 30 MINUTES,4340000004,CDM,434,RC,,,Outpatient,,,117.00,76.05,,117,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,88.92,76,,6428.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.24,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,87.75,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.24,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,70.2,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,105.3,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,52.65,45,,1903.32,Percent of Total Billed Charges,45% of Total Billed Charges,105.3,90,,7613.28,Percent of Total Billed Charges,90% of Total billed Charges,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.05,65,,889.2,Percent of total Billed Charges,65% of Total Billed Charges,51.6,44.1,,1865.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,111.15,95,,8036.24,Percent of Total Billed Charges,95% of Total Billed Charges,117,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.96,88,,3917.616,Percent of Total Billed Charges,88% of Total Billed Charges,105.3,90,,7613.28,Percent of Total Billed charges,90% of Total Billed Charges,51.6,117,
ST AUDIO SCRN 2 EARS,4400000001,CDM,471,RC,,,Outpatient,,,66.15,43.00,,66.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,50.27,76,,6766.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47.63,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,49.61,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.63,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,39.69,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,59.54,90,,8117.8,Percent of Total Billed Charges,90% of Total Billed Charges,29.77,45,,2003.328,Percent of Total Billed Charges,45% of Total Billed Charges,59.54,90,,8013.312,Percent of Total Billed Charges,90% of Total billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,65,,889.2,Percent of total Billed Charges,65% of Total Billed Charges,29.17,44.1,,1963.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.84,95,,8458.496,Percent of Total Billed Charges,95% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.21,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,59.54,90,,8013.312,Percent of Total Billed charges,90% of Total Billed Charges,29.17,66.15,
ST PURE TONE AUDIO 2,4400000002,CDM,471,RC,,,Outpatient,,,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,6766.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.36,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,58.71,75,,3509.92,Percent of Total Billed charges,75% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.36,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,46.97,60,,2807.936,Percent of Total Billed Charges,60% of Total Billed Charges,70.45,90,,8117.8,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,8013.312,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,889.2,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,8458.496,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,8013.312,Percent of Total Billed charges,90% of Total Billed Charges,34.52,78.28,
ST AUDIO SCRN 1 EAR,4400000003,CDM,471,RC,,,Outpatient,,,45.20,29.38,,45.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.35,76,,3214.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.54,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,33.9,75,,3509.92,Percent of Total Billed charges,75% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.54,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,27.12,60,,2807.936,Percent of Total Billed Charges,60% of Total Billed Charges,40.68,90,,8117.8,Percent of Total Billed Charges,90% of Total Billed Charges,20.34,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,40.68,90,,3806.64,Percent of Total Billed Charges,90% of Total billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.38,65,,936,Percent of total Billed Charges,65% of Total Billed Charges,19.93,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.94,95,,4018.12,Percent of Total Billed Charges,95% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.78,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,40.68,90,,3806.64,Percent of Total Billed charges,90% of Total Billed Charges,19.93,45.2,
ST PURE TONE AUDIO 1,4400000004,CDM,471,RC,,,Outpatient,,,55.13,35.83,,55.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.9,76,,3214.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.69,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,41.35,75,,3509.92,Percent of Total Billed charges,75% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.69,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,60,,2807.936,Percent of Total Billed Charges,60% of Total Billed Charges,49.62,90,,16053.84,Percent of Total Billed Charges,90% of Total Billed Charges,24.81,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,49.62,90,,3806.64,Percent of Total Billed Charges,90% of Total billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.83,65,,889.2,Percent of total Billed Charges,65% of Total Billed Charges,24.31,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,52.37,95,,4018.12,Percent of Total Billed Charges,95% of Total Billed Charges,55.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,49.62,90,,3806.64,Percent of Total Billed charges,90% of Total Billed Charges,24.31,55.13,
ST FLUOROSCOPIC SWL,4400000005,CDM,440,RC,,,Outpatient,,,408.00,265.20,,408,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,310.08,76,,3383.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,293.76,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,306,75,,3509.92,Percent of Total Billed charges,75% of Total Billed Charges,408,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.76,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,244.8,60,,2807.936,Percent of Total Billed Charges,60% of Total Billed Charges,367.2,90,,16053.84,Percent of Total Billed Charges,90% of Total Billed Charges,183.6,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,367.2,90,,4006.656,Percent of Total Billed Charges,90% of Total billed Charges,408,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,408,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,408,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.2,65,,936,Percent of total Billed Charges,65% of Total Billed Charges,179.93,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,387.6,95,,4229.248,Percent of Total Billed Charges,95% of Total Billed Charges,408,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.04,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,367.2,90,,4006.656,Percent of Total Billed charges,90% of Total Billed Charges,179.93,408,
COGNITIVE EVAL HR,4400000006,CDM,440,RC,,,Outpatient,,,324.00,210.60,,324,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,246.24,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,233.28,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,243,75,,3509.92,Percent of Total Billed charges,75% of Total Billed Charges,324,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.28,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,194.4,60,,2807.936,Percent of Total Billed Charges,60% of Total Billed Charges,291.6,90,,16053.84,Percent of Total Billed Charges,90% of Total Billed Charges,145.8,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,291.6,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,324,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.6,65,,936,Percent of total Billed Charges,65% of Total Billed Charges,142.88,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,307.8,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,324,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.12,88,,7937.4,Percent of Total Billed Charges,88% of Total Billed Charges,291.6,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,142.88,324,
ST COGNITIVE TX INI 15MIN,4400000007,CDM,440,RC,,,Outpatient,,,88.00,57.20,,88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.88,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.36,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,66,75,,3509.92,Percent of Total Billed charges,75% of Total Billed Charges,88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.36,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,52.8,60,,2807.936,Percent of Total Billed Charges,60% of Total Billed Charges,79.2,90,,16898.416,Percent of Total Billed Charges,90% of Total Billed Charges,39.6,45,,4058.896,Percent of Total Billed Charges,45% of Total Billed Charges,79.2,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.2,65,,936,Percent of total Billed Charges,65% of Total Billed Charges,38.81,44.1,,3977.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.6,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.44,88,,7937.4,Percent of Total Billed Charges,88% of Total Billed Charges,79.2,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,38.81,88,
ST COGNITIVE TX EA ADDL 15MIN,4400000031,CDM,440,RC,,,Outpatient,,,96.00,62.40,,96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.96,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.12,72,,2824.704,Percent of Total Billed Charges,72% of Total Billed Charges,72,75,,2942.4,Percent of Total Billed charges,75% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.12,72,,2824.704,Percent of Total Billed Charges,72% of Total Billed Charges,57.6,60,,2353.92,Percent of Total Billed Charges,60% of Total Billed Charges,86.4,90,,16898.416,Percent of Total Billed Charges,90% of Total Billed Charges,43.2,45,,4058.896,Percent of Total Billed Charges,45% of Total Billed Charges,86.4,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.4,65,,936,Percent of total Billed Charges,65% of Total Billed Charges,42.34,44.1,,3977.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.2,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.48,88,,7937.4,Percent of Total Billed Charges,88% of Total Billed Charges,86.4,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,42.34,96,
REMOT IMAGE SUBMIT BY PT,4400000035,CDM,440,RC,G2010,HCPCS,Outpatient,,,23.45,15.24,,23.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.82,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.68,350,,2469.312,Fee Schedule,350% of BCBS fee schedule,26.68,350,,2572.2,Fee Schedule,350% of BCBS fee schedule,23.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.68,286,,2469.312,Fee Schedule,286% of BCBS PPO fee schedule,9.33,100,,2057.76,Fee Schedule,100% of Blue ADV HMO fee schedule,21.11,90,,25969.32,Percent of Total Billed Charges,90% of Total Billed Charges,10.55,45,,4058.896,Percent of Total Billed Charges,45% of Total Billed Charges,21.11,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,23.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.24,65,,936,Percent of total Billed Charges,65% of Total Billed Charges,10.34,44.1,,3977.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.28,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,23.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.64,88,,15697.088,Percent of Total Billed Charges,88% of Total Billed Charges,21.11,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,9.33,26.68,
ST SPEECH TX INDIVID,4410000001,CDM,441,RC,,,Outpatient,,,421.00,273.65,,421,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,319.96,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,303.12,72,,2469.312,Percent of Total Billed Charges,72% of Total Billed Charges,315.75,75,,2572.2,Percent of Total Billed charges,75% of Total Billed Charges,421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.12,72,,2469.312,Percent of Total Billed Charges,72% of Total Billed Charges,252.6,60,,2057.76,Percent of Total Billed Charges,60% of Total Billed Charges,378.9,90,,25969.32,Percent of Total Billed Charges,90% of Total Billed Charges,189.45,45,,8026.92,Percent of Total Billed Charges,45% of Total Billed Charges,378.9,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.65,65,,13626.6,Percent of total Billed Charges,65% of Total Billed Charges,185.66,44.1,,7866.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,399.95,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.48,88,,15697.088,Percent of Total Billed Charges,88% of Total Billed Charges,378.9,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,185.66,421,
STA SPEECH TX INDIVID,4410000002,CDM,441,RC,,,Outpatient,,,421.00,273.65,,421,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,319.96,76,,6855.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,303.12,72,,2357.272,Percent of Total Billed Charges,72% of Total Billed Charges,315.75,75,,2455.488,Percent of Total Billed charges,75% of Total Billed Charges,421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.12,72,,2357.272,Percent of Total Billed Charges,72% of Total Billed Charges,252.6,60,,1964.392,Percent of Total Billed Charges,60% of Total Billed Charges,378.9,90,,24671.52,Percent of Total Billed Charges,90% of Total Billed Charges,189.45,45,,8026.92,Percent of Total Billed Charges,45% of Total Billed Charges,378.9,90,,8117.8,Percent of Total Billed Charges,90% of Total billed Charges,421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.65,65,,21719.104,Percent of total Billed Charges,65% of Total Billed Charges,185.66,44.1,,7866.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,399.95,95,,8568.784,Percent of Total Billed Charges,95% of Total Billed Charges,421,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.48,88,,15697.088,Percent of Total Billed Charges,88% of Total Billed Charges,378.9,90,,8117.8,Percent of Total Billed charges,90% of Total Billed Charges,185.66,421,
ST SWALLW OR FEED TX,4410000003,CDM,441,RC,,,Outpatient,,,143.00,92.95,,143,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,108.68,76,,6855.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,102.96,72,,2357.272,Percent of Total Billed Charges,72% of Total Billed Charges,107.25,75,,2455.488,Percent of Total Billed charges,75% of Total Billed Charges,143,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.96,72,,2357.272,Percent of Total Billed Charges,72% of Total Billed Charges,85.8,60,,1964.392,Percent of Total Billed Charges,60% of Total Billed Charges,128.7,90,,25969.32,Percent of Total Billed Charges,90% of Total Billed Charges,64.35,45,,8026.92,Percent of Total Billed Charges,45% of Total Billed Charges,128.7,90,,8117.8,Percent of Total Billed Charges,90% of Total billed Charges,143,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.95,65,,21719.104,Percent of total Billed Charges,65% of Total Billed Charges,63.06,44.1,,7866.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,135.85,95,,8568.784,Percent of Total Billed Charges,95% of Total Billed Charges,143,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.84,88,,16522.896,Percent of Total Billed Charges,88% of Total Billed Charges,128.7,90,,8117.8,Percent of Total Billed charges,90% of Total Billed Charges,63.06,143,
STA SWALLOW OR FEED TX,4410000004,CDM,441,RC,,,Outpatient,,,149.94,97.46,,149.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,113.95,76,,6855.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,107.96,72,,2824.704,Percent of Total Billed Charges,72% of Total Billed Charges,112.46,75,,2942.4,Percent of Total Billed charges,75% of Total Billed Charges,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.96,72,,2824.704,Percent of Total Billed Charges,72% of Total Billed Charges,89.96,60,,2353.92,Percent of Total Billed Charges,60% of Total Billed Charges,134.95,90,,25969.32,Percent of Total Billed Charges,90% of Total Billed Charges,67.47,45,,8449.208,Percent of Total Billed Charges,45% of Total Billed Charges,134.95,90,,8117.8,Percent of Total Billed Charges,90% of Total billed Charges,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.46,65,,21719.104,Percent of total Billed Charges,65% of Total Billed Charges,66.12,44.1,,8280.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.44,95,,8568.784,Percent of Total Billed Charges,95% of Total Billed Charges,149.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.95,88,,16522.896,Percent of Total Billed Charges,88% of Total Billed Charges,134.95,90,,8117.8,Percent of Total Billed charges,90% of Total Billed Charges,66.12,149.94,
ST TELEHEALTH SPEECH TX IND,4410000005,CDM,441,RC,,,Outpatient,,,439.90,285.94,,439.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,334.32,76,,13556.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,316.73,72,,2459.52,Percent of Total Billed Charges,72% of Total Billed Charges,329.93,75,,2562,Percent of Total Billed charges,75% of Total Billed Charges,439.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.73,72,,2459.52,Percent of Total Billed Charges,72% of Total Billed Charges,263.94,60,,2049.6,Percent of Total Billed Charges,60% of Total Billed Charges,395.91,90,,12984.664,Percent of Total Billed Charges,90% of Total Billed Charges,197.96,45,,8449.208,Percent of Total Billed Charges,45% of Total Billed Charges,395.91,90,,16053.84,Percent of Total Billed Charges,90% of Total billed Charges,439.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,439.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,439.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.94,65,,13626.6,Percent of total Billed Charges,65% of Total Billed Charges,194,44.1,,8280.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,417.91,95,,16945.72,Percent of Total Billed Charges,95% of Total Billed Charges,439.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,387.11,88,,25392.224,Percent of Total Billed Charges,88% of Total Billed Charges,395.91,90,,16053.84,Percent of Total Billed charges,90% of Total Billed Charges,194,439.9,
ST GROUP TREATMENT,4430000001,CDM,443,RC,,,Outpatient,,,89.30,58.05,,89.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.87,76,,13556.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.3,72,,1799.704,Percent of Total Billed Charges,72% of Total Billed Charges,66.98,75,,1874.696,Percent of Total Billed charges,75% of Total Billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.3,72,,1799.704,Percent of Total Billed Charges,72% of Total Billed Charges,53.58,60,,1499.752,Percent of Total Billed Charges,60% of Total Billed Charges,80.37,90,,12984.664,Percent of Total Billed Charges,90% of Total Billed Charges,40.19,45,,12984.664,Percent of Total Billed Charges,45% of Total Billed Charges,80.37,90,,16053.84,Percent of Total Billed Charges,90% of Total billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.05,65,,21719.104,Percent of total Billed Charges,65% of Total Billed Charges,39.38,44.1,,12724.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,84.84,95,,16945.72,Percent of Total Billed Charges,95% of Total Billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.58,88,,25392.224,Percent of Total Billed Charges,88% of Total Billed Charges,80.37,90,,16053.84,Percent of Total Billed charges,90% of Total Billed Charges,39.38,89.3,
STA GROUP TREATMENT,4430000002,CDM,443,RC,,,Outpatient,,,89.30,58.05,,89.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.87,76,,13556.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.3,72,,1695.744,Percent of Total Billed Charges,72% of Total Billed Charges,66.98,75,,1766.4,Percent of Total Billed charges,75% of Total Billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.3,72,,1695.744,Percent of Total Billed Charges,72% of Total Billed Charges,53.58,60,,1413.12,Percent of Total Billed Charges,60% of Total Billed Charges,80.37,90,,12984.664,Percent of Total Billed Charges,90% of Total Billed Charges,40.19,45,,12984.664,Percent of Total Billed Charges,45% of Total Billed Charges,80.37,90,,16053.84,Percent of Total Billed Charges,90% of Total billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.05,65,,21719.104,Percent of total Billed Charges,65% of Total Billed Charges,39.38,44.1,,12724.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,84.84,95,,16945.72,Percent of Total Billed Charges,95% of Total Billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.58,88,,24123.264,Percent of Total Billed Charges,88% of Total Billed Charges,80.37,90,,16053.84,Percent of Total Billed charges,90% of Total Billed Charges,39.38,89.3,
STA GROUP TREATMENT,4430000003,CDM,443,RC,,,Outpatient,,,89.30,58.05,,89.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.87,76,,14269.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.3,72,,1799.704,Percent of Total Billed Charges,72% of Total Billed Charges,66.98,75,,1874.696,Percent of Total Billed charges,75% of Total Billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.3,72,,1799.704,Percent of Total Billed Charges,72% of Total Billed Charges,53.58,60,,1499.752,Percent of Total Billed Charges,60% of Total Billed Charges,80.37,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,40.19,45,,12335.76,Percent of Total Billed Charges,45% of Total Billed Charges,80.37,90,,16898.416,Percent of Total Billed Charges,90% of Total billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.05,65,,21719.104,Percent of total Billed Charges,65% of Total Billed Charges,39.38,44.1,,12089.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,84.84,95,,17837.216,Percent of Total Billed Charges,95% of Total Billed Charges,89.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.58,88,,25392.224,Percent of Total Billed Charges,88% of Total Billed Charges,80.37,90,,16898.416,Percent of Total Billed charges,90% of Total Billed Charges,39.38,89.3,
SPEECH PROD W/ LANG EVAL,4440000001,CDM,444,RC,,,Outpatient,,,354.00,230.10,,354,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,269.04,76,,14269.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,254.88,72,,2242.368,Percent of Total Billed Charges,72% of Total Billed Charges,265.5,75,,2335.8,Percent of Total Billed charges,75% of Total Billed Charges,354,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,254.88,72,,2242.368,Percent of Total Billed Charges,72% of Total Billed Charges,212.4,60,,1868.64,Percent of Total Billed Charges,60% of Total Billed Charges,318.6,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,159.3,45,,12984.664,Percent of Total Billed Charges,45% of Total Billed Charges,318.6,90,,16898.416,Percent of Total Billed Charges,90% of Total billed Charges,354,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.1,65,,553.28,Percent of total Billed Charges,65% of Total Billed Charges,156.11,44.1,,12724.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,336.3,95,,17837.216,Percent of Total Billed Charges,95% of Total Billed Charges,354,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,311.52,88,,25392.224,Percent of Total Billed Charges,88% of Total Billed Charges,318.6,90,,16898.416,Percent of Total Billed charges,90% of Total Billed Charges,156.11,354,
SPEECH SOUND PRODUCTION EVAL,4440000002,CDM,444,RC,,,Outpatient,,,305.00,198.25,,305,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,231.8,76,,21929.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,219.6,72,,1710.144,Percent of Total Billed Charges,72% of Total Billed Charges,228.75,75,,1781.4,Percent of Total Billed charges,75% of Total Billed Charges,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.6,72,,1710.144,Percent of Total Billed Charges,72% of Total Billed Charges,183,60,,1425.12,Percent of Total Billed Charges,60% of Total Billed Charges,274.5,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,137.25,45,,12984.664,Percent of Total Billed Charges,45% of Total Billed Charges,274.5,90,,25969.32,Percent of Total Billed Charges,90% of Total billed Charges,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.25,65,,710.896,Percent of total Billed Charges,65% of Total Billed Charges,134.51,44.1,,12724.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,289.75,95,,27412.064,Percent of Total Billed Charges,95% of Total Billed Charges,305,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.4,88,,12696.112,Percent of Total Billed Charges,88% of Total Billed Charges,274.5,90,,25969.32,Percent of Total Billed charges,90% of Total Billed Charges,134.51,305,
ST EVAL AUDITORY,4440000003,CDM,444,RC,,,Outpatient,,,304.29,197.79,,304.29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,231.26,76,,21929.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,219.09,72,,2531.52,Percent of Total Billed Charges,72% of Total Billed Charges,228.22,75,,2637,Percent of Total Billed charges,75% of Total Billed Charges,304.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.09,72,,2531.52,Percent of Total Billed Charges,72% of Total Billed Charges,182.57,60,,2109.6,Percent of Total Billed Charges,60% of Total Billed Charges,273.86,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,136.93,45,,6492.328,Percent of Total Billed Charges,45% of Total Billed Charges,273.86,90,,25969.32,Percent of Total Billed Charges,90% of Total billed Charges,304.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.79,65,,897.728,Percent of total Billed Charges,65% of Total Billed Charges,134.19,44.1,,6362.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,289.08,95,,27412.064,Percent of Total Billed Charges,95% of Total Billed Charges,304.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.78,88,,12696.112,Percent of Total Billed Charges,88% of Total Billed Charges,273.86,90,,25969.32,Percent of Total Billed charges,90% of Total Billed Charges,134.19,304.29,
SPEECH FLUENCY EVALUATION,4440000004,CDM,444,RC,,,Outpatient,,,374.00,243.10,,374,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,284.24,76,,20833.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,269.28,72,,2393.28,Percent of Total Billed Charges,72% of Total Billed Charges,280.5,75,,2493,Percent of Total Billed charges,75% of Total Billed Charges,374,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.28,72,,2393.28,Percent of Total Billed Charges,72% of Total Billed Charges,224.4,60,,1994.4,Percent of Total Billed Charges,60% of Total Billed Charges,336.6,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,168.3,45,,6492.328,Percent of Total Billed Charges,45% of Total Billed Charges,336.6,90,,24671.52,Percent of Total Billed Charges,90% of Total billed Charges,374,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.1,65,,462.072,Percent of total Billed Charges,65% of Total Billed Charges,164.93,44.1,,6362.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,355.3,95,,26042.16,Percent of Total Billed Charges,95% of Total Billed Charges,374,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.12,88,,12696.112,Percent of Total Billed Charges,88% of Total Billed Charges,336.6,90,,24671.52,Percent of Total Billed charges,90% of Total Billed Charges,164.93,374,
ST AUGMENT EVAL,4440000005,CDM,444,RC,,,Outpatient,,,122.38,79.55,,122.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.01,76,,21929.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,88.11,72,,2639.232,Percent of Total Billed Charges,72% of Total Billed Charges,91.79,75,,2749.2,Percent of Total Billed charges,75% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.11,72,,2639.232,Percent of Total Billed Charges,72% of Total Billed Charges,73.43,60,,2199.36,Percent of Total Billed Charges,60% of Total Billed Charges,110.14,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,55.07,45,,6492.328,Percent of Total Billed Charges,45% of Total Billed Charges,110.14,90,,25969.32,Percent of Total Billed Charges,90% of Total billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.55,65,,1085.832,Percent of total Billed Charges,65% of Total Billed Charges,53.97,44.1,,6362.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.26,95,,27412.064,Percent of Total Billed Charges,95% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.69,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,110.14,90,,25969.32,Percent of Total Billed charges,90% of Total Billed Charges,53.97,122.38,
ST EVAL SP GEN DEV,4440000006,CDM,444,RC,,,Outpatient,,,639.45,415.64,,639.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,485.98,76,,21929.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,460.4,72,,3556.8,Percent of Total Billed Charges,72% of Total Billed Charges,479.59,75,,3705,Percent of Total Billed charges,75% of Total Billed Charges,639.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,460.4,72,,3556.8,Percent of Total Billed Charges,72% of Total Billed Charges,383.67,60,,2964,Percent of Total Billed Charges,60% of Total Billed Charges,575.51,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,287.75,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,575.51,90,,25969.32,Percent of Total Billed Charges,90% of Total billed Charges,639.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,639.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,639.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.64,65,,1085.832,Percent of total Billed Charges,65% of Total Billed Charges,282,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,607.48,95,,27412.064,Percent of Total Billed Charges,95% of Total Billed Charges,639.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.72,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,575.51,90,,25969.32,Percent of Total Billed charges,90% of Total Billed Charges,282,639.45,
ST EVAL SP DEV AD 30,4440000007,CDM,444,RC,,,Outpatient,,,62.84,40.85,,62.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.76,76,,10964.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.24,72,,1619.136,Percent of Total Billed Charges,72% of Total Billed Charges,47.13,75,,1686.6,Percent of Total Billed charges,75% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.24,72,,1619.136,Percent of Total Billed Charges,72% of Total Billed Charges,37.7,60,,1349.28,Percent of Total Billed Charges,60% of Total Billed Charges,56.56,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,28.28,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,56.56,90,,12984.664,Percent of Total Billed Charges,90% of Total billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.85,65,,50.448,Percent of total Billed Charges,65% of Total Billed Charges,27.71,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.7,95,,13706.032,Percent of Total Billed Charges,95% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.3,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,56.56,90,,12984.664,Percent of Total Billed charges,90% of Total Billed Charges,27.71,62.84,
ST SP GEN DEV TREAT,4440000008,CDM,441,RC,,,Outpatient,,,420.05,273.03,,420.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,319.24,76,,10964.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,302.44,72,,1742.552,Percent of Total Billed Charges,72% of Total Billed Charges,315.04,75,,1815.16,Percent of Total Billed charges,75% of Total Billed Charges,420.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.44,72,,1742.552,Percent of Total Billed Charges,72% of Total Billed Charges,252.03,60,,1452.128,Percent of Total Billed Charges,60% of Total Billed Charges,378.05,90,,2221.92,Percent of Total Billed Charges,90% of Total Billed Charges,189.02,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,378.05,90,,12984.664,Percent of Total Billed Charges,90% of Total billed Charges,420.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,420.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,420.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.03,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,185.24,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,399.05,95,,13706.032,Percent of Total Billed Charges,95% of Total Billed Charges,420.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.64,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,378.05,90,,12984.664,Percent of Total Billed charges,90% of Total Billed Charges,185.24,420.05,
STA SP GEN DEV TREAT,4440000009,CDM,441,RC,,,Outpatient,,,420.05,273.03,,420.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,319.24,76,,10964.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,302.44,72,,2439.824,Percent of Total Billed Charges,72% of Total Billed Charges,315.04,75,,2541.488,Percent of Total Billed charges,75% of Total Billed Charges,420.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.44,72,,2439.824,Percent of Total Billed Charges,72% of Total Billed Charges,252.03,60,,2033.192,Percent of Total Billed Charges,60% of Total Billed Charges,378.05,90,,2221.92,Percent of Total Billed Charges,90% of Total Billed Charges,189.02,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,378.05,90,,12984.664,Percent of Total Billed Charges,90% of Total billed Charges,420.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,420.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,420.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.03,65,,16.056,Percent of total Billed Charges,65% of Total Billed Charges,185.24,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,399.05,95,,13706.032,Percent of Total Billed Charges,95% of Total Billed Charges,420.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.64,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,378.05,90,,12984.664,Percent of Total Billed charges,90% of Total Billed Charges,185.24,420.05,
ST BEDSIDE SWL STUDY,4440000010,CDM,444,RC,,,Outpatient,,,340.00,221.00,,340,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,258.4,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,244.8,72,,1669.824,Percent of Total Billed Charges,72% of Total Billed Charges,255,75,,1739.4,Percent of Total Billed charges,75% of Total Billed Charges,340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.8,72,,1669.824,Percent of Total Billed Charges,72% of Total Billed Charges,204,60,,1391.52,Percent of Total Billed Charges,60% of Total Billed Charges,306,90,,2221.92,Percent of Total Billed Charges,90% of Total Billed Charges,153,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,306,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221,65,,2326.456,Percent of total Billed Charges,65% of Total Billed Charges,149.94,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,323,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,299.2,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,306,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,149.94,340,
ASPHASIA EVAL HR,4440000011,CDM,444,RC,,,Outpatient,,,368.00,239.20,,368,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,279.68,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,264.96,72,,1742.552,Percent of Total Billed Charges,72% of Total Billed Charges,276,75,,1815.16,Percent of Total Billed charges,75% of Total Billed Charges,368,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.96,72,,1742.552,Percent of Total Billed Charges,72% of Total Billed Charges,220.8,60,,1452.128,Percent of Total Billed Charges,60% of Total Billed Charges,331.2,90,,2221.92,Percent of Total Billed Charges,90% of Total Billed Charges,165.6,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,331.2,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,368,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.2,65,,707.72,Percent of total Billed Charges,65% of Total Billed Charges,162.29,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,349.6,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,368,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.84,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,331.2,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,162.29,368,
SPEECH THERAPY REEVALUATION,4440000012,CDM,444,RC,S9152,HCPCS,Outpatient,,,275.00,178.75,,275,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,209,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,198,72,,2635.2,Percent of Total Billed Charges,72% of Total Billed Charges,206.25,75,,2745,Percent of Total Billed charges,75% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198,72,,2635.2,Percent of Total Billed Charges,72% of Total Billed Charges,165,60,,2196,Percent of Total Billed Charges,60% of Total Billed Charges,247.5,90,,2221.92,Percent of Total Billed Charges,90% of Total Billed Charges,123.75,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,247.5,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.75,65,,1794,Percent of total Billed Charges,65% of Total Billed Charges,121.28,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,261.25,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,275,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,247.5,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,121.28,275,
VOICE AND RESONANCE EVALUATION,4440000013,CDM,444,RC,,,Outpatient,,,330.75,214.99,,330.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,251.37,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,238.14,72,,2658.28,Percent of Total Billed Charges,72% of Total Billed Charges,248.06,75,,2769.04,Percent of Total Billed charges,75% of Total Billed Charges,330.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.14,72,,2658.28,Percent of Total Billed Charges,72% of Total Billed Charges,198.45,60,,2215.232,Percent of Total Billed Charges,60% of Total Billed Charges,297.68,90,,1401.12,Percent of Total Billed Charges,90% of Total Billed Charges,148.84,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,297.68,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,330.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.99,65,,2021.76,Percent of total Billed Charges,65% of Total Billed Charges,145.86,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,314.21,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,330.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291.06,88,,2172.544,Percent of Total Billed Charges,88% of Total Billed Charges,297.68,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,145.86,330.75,
SANE AFTER HRS INCLUDES WKENDS,4500000001,CDM,450,RC,,,Outpatient,,,39.00,25.35,,39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.64,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.08,72,,3049.344,Percent of Total Billed Charges,72% of Total Billed Charges,29.25,75,,3176.4,Percent of Total Billed charges,75% of Total Billed Charges,39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.08,72,,3049.344,Percent of Total Billed Charges,72% of Total Billed Charges,23.4,60,,2541.12,Percent of Total Billed Charges,60% of Total Billed Charges,35.1,90,,1401.12,Percent of Total Billed Charges,90% of Total Billed Charges,17.55,45,,1110.96,Percent of Total Billed Charges,45% of Total Billed Charges,35.1,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.35,65,,2831.4,Percent of total Billed Charges,65% of Total Billed Charges,17.2,44.1,,1088.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,37.05,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.32,88,,2172.544,Percent of Total Billed Charges,88% of Total Billed Charges,35.1,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,17.2,39,
COLL OF BLOOD FROM SUBQ PORT,4500000002,CDM,450,RC,,,Outpatient,,,292.00,189.80,,292,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,221.92,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,210.24,72,,4.752,Percent of Total Billed Charges,72% of Total Billed Charges,219,75,,4.952,Percent of Total Billed charges,75% of Total Billed Charges,292,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.24,72,,4.752,Percent of Total Billed Charges,72% of Total Billed Charges,175.2,60,,3.96,Percent of Total Billed Charges,60% of Total Billed Charges,262.8,90,,1401.12,Percent of Total Billed Charges,90% of Total Billed Charges,131.4,45,,1110.96,Percent of Total Billed Charges,45% of Total Billed Charges,262.8,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,292,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.8,65,,2621.128,Percent of total Billed Charges,65% of Total Billed Charges,128.77,44.1,,1088.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,277.4,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,292,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.96,88,,2172.544,Percent of Total Billed Charges,88% of Total Billed Charges,262.8,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,128.77,292,
COLLEC OF BLOOD FR CVC OR PICC,4500000003,CDM,450,RC,,,Outpatient,,,292.00,189.80,,292,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,221.92,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,210.24,72,,39.168,Percent of Total Billed Charges,72% of Total Billed Charges,219,75,,40.8,Percent of Total Billed charges,75% of Total Billed Charges,292,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.24,72,,39.168,Percent of Total Billed Charges,72% of Total Billed Charges,175.2,60,,32.64,Percent of Total Billed Charges,60% of Total Billed Charges,262.8,90,,1474.384,Percent of Total Billed Charges,90% of Total Billed Charges,131.4,45,,1110.96,Percent of Total Billed Charges,45% of Total Billed Charges,262.8,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,292,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.8,65,,2911.224,Percent of total Billed Charges,65% of Total Billed Charges,128.77,44.1,,1088.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,277.4,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,292,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.96,88,,2172.544,Percent of Total Billed Charges,88% of Total Billed Charges,262.8,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,128.77,292,
DIG PHOTOGRAPHY HIGH RESOL,4500000004,CDM,450,RC,,,Outpatient,,,108.00,70.20,,108,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,82.08,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,77.76,72,,174.56,Percent of Total Billed Charges,72% of Total Billed Charges,81,75,,181.84,Percent of Total Billed charges,75% of Total Billed Charges,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.76,72,,174.56,Percent of Total Billed Charges,72% of Total Billed Charges,64.8,60,,145.472,Percent of Total Billed Charges,60% of Total Billed Charges,97.2,90,,1474.384,Percent of Total Billed Charges,90% of Total Billed Charges,48.6,45,,1110.96,Percent of Total Billed Charges,45% of Total Billed Charges,97.2,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.2,65,,3193.84,Percent of total Billed Charges,65% of Total Billed Charges,47.63,44.1,,1088.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,102.6,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.04,88,,2172.544,Percent of Total Billed Charges,88% of Total Billed Charges,97.2,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,47.63,108,
EXCISION OF NAIL PART OR COMP,4500000005,CDM,450,RC,,,Outpatient,,,693.00,450.45,,693,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,526.68,76,,1876.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,498.96,72,,26.696,Percent of Total Billed Charges,72% of Total Billed Charges,519.75,75,,27.808,Percent of Total Billed charges,75% of Total Billed Charges,693,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.96,72,,26.696,Percent of Total Billed Charges,72% of Total Billed Charges,415.8,60,,22.248,Percent of Total Billed Charges,60% of Total Billed Charges,623.7,90,,2492.64,Percent of Total Billed Charges,90% of Total Billed Charges,311.85,45,,1110.96,Percent of Total Billed Charges,45% of Total Billed Charges,623.7,90,,2221.92,Percent of Total Billed Charges,90% of Total billed Charges,693,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,693,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,693,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.45,65,,1857.96,Percent of total Billed Charges,65% of Total Billed Charges,305.61,44.1,,1088.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,658.35,95,,2345.36,Percent of Total Billed Charges,95% of Total Billed Charges,693,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,609.84,88,,1369.984,Percent of Total Billed Charges,88% of Total Billed Charges,623.7,90,,2221.92,Percent of Total Billed charges,90% of Total Billed Charges,305.61,693,
INSER OF CENTRAL VENOUS CATH,4500000006,CDM,450,RC,,,Outpatient,,,2811.00,1827.15,,2811,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2136.36,76,,1876.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2023.92,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,2108.25,75,,7.2,Percent of Total Billed charges,75% of Total Billed Charges,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2023.92,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,1686.6,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,2529.9,90,,2492.64,Percent of Total Billed Charges,90% of Total Billed Charges,1264.95,45,,700.56,Percent of Total Billed Charges,45% of Total Billed Charges,2529.9,90,,2221.92,Percent of Total Billed Charges,90% of Total billed Charges,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1827.15,65,,2132.68,Percent of total Billed Charges,65% of Total Billed Charges,1239.65,44.1,,686.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,2670.45,95,,2345.36,Percent of Total Billed Charges,95% of Total Billed Charges,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2473.68,88,,1369.984,Percent of Total Billed Charges,88% of Total Billed Charges,2529.9,90,,2221.92,Percent of Total Billed charges,90% of Total Billed Charges,1239.65,2811,
INSR OF PIC LN W/OUT SUB Q PRT,4500000007,CDM,361,RC,,,Outpatient,,,1953.00,1269.45,,1953,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1484.28,76,,1876.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1406.16,72,,30.032,Percent of Total Billed Charges,72% of Total Billed Charges,1464.75,75,,31.288,Percent of Total Billed charges,75% of Total Billed Charges,1953,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1406.16,72,,30.032,Percent of Total Billed Charges,72% of Total Billed Charges,1171.8,60,,25.024,Percent of Total Billed Charges,60% of Total Billed Charges,1757.7,90,,2492.64,Percent of Total Billed Charges,90% of Total Billed Charges,878.85,45,,700.56,Percent of Total Billed Charges,45% of Total Billed Charges,1757.7,90,,2221.92,Percent of Total Billed Charges,90% of Total billed Charges,1953,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1953,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1953,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1269.45,65,,3129.36,Percent of total Billed Charges,65% of Total Billed Charges,861.27,44.1,,686.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,1855.35,95,,2345.36,Percent of Total Billed Charges,95% of Total Billed Charges,1953,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1718.64,88,,1369.984,Percent of Total Billed Charges,88% of Total Billed Charges,1757.7,90,,2221.92,Percent of Total Billed charges,90% of Total Billed Charges,861.27,1953,
NASO/ORO GASTRIC TUBE PLCEMNT,4500000008,CDM,450,RC,,,Outpatient,,,487.00,316.55,,487,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,370.12,76,,1876.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,350.64,72,,223.848,Percent of Total Billed Charges,72% of Total Billed Charges,365.25,75,,233.176,Percent of Total Billed charges,75% of Total Billed Charges,487,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.64,72,,223.848,Percent of Total Billed Charges,72% of Total Billed Charges,292.2,60,,186.544,Percent of Total Billed Charges,60% of Total Billed Charges,438.3,90,,2623.384,Percent of Total Billed Charges,90% of Total Billed Charges,219.15,45,,700.56,Percent of Total Billed Charges,45% of Total Billed Charges,438.3,90,,2221.92,Percent of Total Billed Charges,90% of Total billed Charges,487,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.55,65,,2736.936,Percent of total Billed Charges,65% of Total Billed Charges,214.77,44.1,,686.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,462.65,95,,2345.36,Percent of Total Billed Charges,95% of Total Billed Charges,487,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,428.56,88,,1441.624,Percent of Total Billed Charges,88% of Total Billed Charges,438.3,90,,2221.92,Percent of Total Billed charges,90% of Total Billed Charges,214.77,487,
REP OF GASTROSTOMY TBE W IMAG,4500000009,CDM,450,RC,,,Outpatient,,,1825.00,1186.25,,1825,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1387,76,,1876.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1314,72,,894.768,Percent of Total Billed Charges,72% of Total Billed Charges,1368.75,75,,932.056,Percent of Total Billed charges,75% of Total Billed Charges,1825,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1314,72,,894.768,Percent of Total Billed Charges,72% of Total Billed Charges,1095,60,,745.64,Percent of Total Billed Charges,60% of Total Billed Charges,1642.5,90,,2492.64,Percent of Total Billed Charges,90% of Total Billed Charges,821.25,45,,737.192,Percent of Total Billed Charges,45% of Total Billed Charges,1642.5,90,,2221.92,Percent of Total Billed Charges,90% of Total billed Charges,1825,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1825,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1825,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1186.25,65,,2867.28,Percent of total Billed Charges,65% of Total Billed Charges,804.83,44.1,,722.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,1733.75,95,,2345.36,Percent of Total Billed Charges,95% of Total Billed Charges,1825,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1606,88,,1441.624,Percent of Total Billed Charges,88% of Total Billed Charges,1642.5,90,,2221.92,Percent of Total Billed charges,90% of Total Billed Charges,804.83,1825,
BRN DRSNG &/OR DBRDM,4500000010,CDM,450,RC,,,Outpatient,,,242.55,157.66,,242.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,184.34,76,,1183.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,174.64,72,,17.496,Percent of Total Billed Charges,72% of Total Billed Charges,181.91,75,,18.224,Percent of Total Billed charges,75% of Total Billed Charges,242.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.64,72,,17.496,Percent of Total Billed Charges,72% of Total Billed Charges,145.53,60,,14.576,Percent of Total Billed Charges,60% of Total Billed Charges,218.3,90,,1246.32,Percent of Total Billed Charges,90% of Total Billed Charges,109.15,45,,737.192,Percent of Total Billed Charges,45% of Total Billed Charges,218.3,90,,1401.12,Percent of Total Billed Charges,90% of Total billed Charges,242.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,65,,2911.224,Percent of total Billed Charges,65% of Total Billed Charges,106.96,44.1,,722.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,230.42,95,,1478.96,Percent of Total Billed Charges,95% of Total Billed Charges,242.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.44,88,,2437.248,Percent of Total Billed Charges,88% of Total Billed Charges,218.3,90,,1401.12,Percent of Total Billed charges,90% of Total Billed Charges,106.96,242.55,
INTUBATION ET,4500000011,CDM,450,RC,,,Outpatient,,,523.00,339.95,,523,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,397.48,76,,1183.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,376.56,72,,681.4,Percent of Total Billed Charges,72% of Total Billed Charges,392.25,75,,709.792,Percent of Total Billed charges,75% of Total Billed Charges,523,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.56,72,,681.4,Percent of Total Billed Charges,72% of Total Billed Charges,313.8,60,,567.832,Percent of Total Billed Charges,60% of Total Billed Charges,470.7,90,,1246.32,Percent of Total Billed Charges,90% of Total Billed Charges,235.35,45,,1246.32,Percent of Total Billed Charges,45% of Total Billed Charges,470.7,90,,1401.12,Percent of Total Billed Charges,90% of Total billed Charges,523,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,523,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,523,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,339.95,65,,223.016,Percent of total Billed Charges,65% of Total Billed Charges,230.64,44.1,,1221.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,496.85,95,,1478.96,Percent of Total Billed Charges,95% of Total Billed Charges,523,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,460.24,88,,2437.248,Percent of Total Billed Charges,88% of Total Billed Charges,470.7,90,,1401.12,Percent of Total Billed charges,90% of Total Billed Charges,230.64,523,
TRACHEOSTOMY CRICOTHYROID,4500000012,CDM,450,RC,,,Outpatient,,,1770.62,1150.90,,1770.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1345.67,76,,1183.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1274.85,72,,4569.112,Percent of Total Billed Charges,72% of Total Billed Charges,1327.97,75,,4759.488,Percent of Total Billed charges,75% of Total Billed Charges,1770.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1274.85,72,,4569.112,Percent of Total Billed Charges,72% of Total Billed Charges,1062.37,60,,3807.592,Percent of Total Billed Charges,60% of Total Billed Charges,1593.56,90,,1246.32,Percent of Total Billed Charges,90% of Total Billed Charges,796.78,45,,1246.32,Percent of Total Billed Charges,45% of Total Billed Charges,1593.56,90,,1401.12,Percent of Total Billed Charges,90% of Total billed Charges,1770.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1770.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1770.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1150.9,65,,1887.08,Percent of total Billed Charges,65% of Total Billed Charges,780.84,44.1,,1221.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1682.09,95,,1478.96,Percent of Total Billed Charges,95% of Total Billed Charges,1770.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1558.15,88,,2437.248,Percent of Total Billed Charges,88% of Total Billed Charges,1593.56,90,,1401.12,Percent of Total Billed charges,90% of Total Billed Charges,780.84,1770.62,
THORACENTESIS WITH IMAGING,4500000013,CDM,450,RC,,,Outpatient,,,1716.63,1115.81,,1716.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1304.64,76,,1245.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1235.97,72,,222.904,Percent of Total Billed Charges,72% of Total Billed Charges,1287.47,75,,232.192,Percent of Total Billed charges,75% of Total Billed Charges,1716.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1235.97,72,,222.904,Percent of Total Billed Charges,72% of Total Billed Charges,1029.98,60,,185.752,Percent of Total Billed Charges,60% of Total Billed Charges,1544.97,90,,1311.696,Percent of Total Billed Charges,90% of Total Billed Charges,772.48,45,,1246.32,Percent of Total Billed Charges,45% of Total Billed Charges,1544.97,90,,1474.384,Percent of Total Billed Charges,90% of Total billed Charges,1716.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1716.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1716.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1115.81,65,,1618.424,Percent of total Billed Charges,65% of Total Billed Charges,757.03,44.1,,1221.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1630.8,95,,1556.296,Percent of Total Billed Charges,95% of Total Billed Charges,1716.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1510.63,88,,2565.088,Percent of Total Billed Charges,88% of Total Billed Charges,1544.97,90,,1474.384,Percent of Total Billed charges,90% of Total Billed Charges,757.03,1716.63,
ALTEPLA CEREBAL,4500000014,CDM,450,RC,,,Outpatient,,,1477.00,960.05,,1477,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1122.52,76,,1245.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1063.44,72,,357.408,Percent of Total Billed Charges,72% of Total Billed Charges,1107.75,75,,372.304,Percent of Total Billed charges,75% of Total Billed Charges,1477,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1063.44,72,,357.408,Percent of Total Billed Charges,72% of Total Billed Charges,886.2,60,,297.84,Percent of Total Billed Charges,60% of Total Billed Charges,1329.3,90,,1311.696,Percent of Total Billed Charges,90% of Total Billed Charges,664.65,45,,1311.696,Percent of Total Billed Charges,45% of Total Billed Charges,1329.3,90,,1474.384,Percent of Total Billed Charges,90% of Total billed Charges,1477,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1477,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1477,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,960.05,65,,2428.4,Percent of total Billed Charges,65% of Total Billed Charges,651.36,44.1,,1285.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,1403.15,95,,1556.296,Percent of Total Billed Charges,95% of Total Billed Charges,1477,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1299.76,88,,2437.248,Percent of Total Billed Charges,88% of Total Billed Charges,1329.3,90,,1474.384,Percent of Total Billed charges,90% of Total Billed Charges,651.36,1477,
CHG OF GASTROSTOMY T,4500000015,CDM,450,RC,,,Outpatient,,,740.00,481.00,,740,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,562.4,76,,2104.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,532.8,72,,554.832,Percent of Total Billed Charges,72% of Total Billed Charges,555,75,,577.952,Percent of Total Billed charges,75% of Total Billed Charges,740,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,532.8,72,,554.832,Percent of Total Billed Charges,72% of Total Billed Charges,444,60,,462.36,Percent of Total Billed Charges,60% of Total Billed Charges,666,90,,15423.84,Percent of Total Billed Charges,90% of Total Billed Charges,333,45,,1246.32,Percent of Total Billed Charges,45% of Total Billed Charges,666,90,,2492.64,Percent of Total Billed Charges,90% of Total billed Charges,740,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,740,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,740,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,481,65,,1762.28,Percent of total Billed Charges,65% of Total Billed Charges,326.34,44.1,,1221.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,703,95,,2631.12,Percent of Total Billed Charges,95% of Total Billed Charges,740,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,651.2,88,,1218.624,Percent of Total Billed Charges,88% of Total Billed Charges,666,90,,2492.64,Percent of Total Billed charges,90% of Total Billed Charges,326.34,740,
PARACENTESIS W/OUT IMAGING,4500000016,CDM,450,RC,,,Outpatient,,,1583.19,1029.07,,1583.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1203.22,76,,2104.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1139.9,72,,36.552,Percent of Total Billed Charges,72% of Total Billed Charges,1187.39,75,,38.08,Percent of Total Billed charges,75% of Total Billed Charges,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1139.9,72,,36.552,Percent of Total Billed Charges,72% of Total Billed Charges,949.91,60,,30.464,Percent of Total Billed Charges,60% of Total Billed Charges,1424.87,90,,15423.84,Percent of Total Billed Charges,90% of Total Billed Charges,712.44,45,,623.16,Percent of Total Billed Charges,45% of Total Billed Charges,1424.87,90,,2492.64,Percent of Total Billed Charges,90% of Total billed Charges,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1029.07,65,,1999.672,Percent of total Billed Charges,65% of Total Billed Charges,698.19,44.1,,610.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,1504.03,95,,2631.12,Percent of Total Billed Charges,95% of Total Billed Charges,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1393.21,88,,1218.624,Percent of Total Billed Charges,88% of Total Billed Charges,1424.87,90,,2492.64,Percent of Total Billed charges,90% of Total Billed Charges,698.19,1583.19,
PARACENTESIS WITH IMAGING,4500000017,CDM,450,RC,,,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,2104.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1440,72,,14.112,Percent of Total Billed Charges,72% of Total Billed Charges,1500,75,,14.704,Percent of Total Billed charges,75% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440,72,,14.112,Percent of Total Billed Charges,72% of Total Billed Charges,1200,60,,11.76,Percent of Total Billed Charges,60% of Total Billed Charges,1800,90,,15423.84,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,623.16,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,2492.64,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,2136.16,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,610.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,2631.12,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1218.624,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,2492.64,Percent of Total Billed charges,90% of Total Billed Charges,882,2000,
SA EXAM W/ COLPOSCOP,4500000018,CDM,450,RC,,,Outpatient,,,586.53,381.24,,586.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,445.76,76,,2215.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,422.3,72,,111.096,Percent of Total Billed Charges,72% of Total Billed Charges,439.9,75,,115.728,Percent of Total Billed charges,75% of Total Billed Charges,586.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.3,72,,111.096,Percent of Total Billed Charges,72% of Total Billed Charges,351.92,60,,92.584,Percent of Total Billed Charges,60% of Total Billed Charges,527.88,90,,15423.84,Percent of Total Billed Charges,90% of Total Billed Charges,263.94,45,,623.16,Percent of Total Billed Charges,45% of Total Billed Charges,527.88,90,,2623.384,Percent of Total Billed Charges,90% of Total billed Charges,586.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,586.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,586.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.24,65,,1852.76,Percent of total Billed Charges,65% of Total Billed Charges,258.66,44.1,,610.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,557.2,95,,2769.128,Percent of Total Billed Charges,95% of Total Billed Charges,586.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,516.15,88,,1282.544,Percent of Total Billed Charges,88% of Total Billed Charges,527.88,90,,2623.384,Percent of Total Billed charges,90% of Total Billed Charges,258.66,586.53,
SPINAL PUNCTURE LUMB,4500000019,CDM,450,RC,,,Outpatient,,,1078.00,700.70,,1078,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,819.28,76,,2104.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,776.16,72,,96.976,Percent of Total Billed Charges,72% of Total Billed Charges,808.5,75,,101.016,Percent of Total Billed charges,75% of Total Billed Charges,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,776.16,72,,96.976,Percent of Total Billed Charges,72% of Total Billed Charges,646.8,60,,80.816,Percent of Total Billed Charges,60% of Total Billed Charges,970.2,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,485.1,45,,655.848,Percent of Total Billed Charges,45% of Total Billed Charges,970.2,90,,2492.64,Percent of Total Billed Charges,90% of Total billed Charges,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,700.7,65,,1618.424,Percent of total Billed Charges,65% of Total Billed Charges,475.4,44.1,,642.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,1024.1,95,,2631.12,Percent of Total Billed Charges,95% of Total Billed Charges,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,948.64,88,,1282.544,Percent of Total Billed Charges,88% of Total Billed Charges,970.2,90,,2492.64,Percent of Total Billed charges,90% of Total Billed Charges,475.4,1078,
DENTAL NERVE BLOCK INJECTION,4500000020,CDM,450,RC,,,Outpatient,,,701.19,455.77,,701.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,532.9,76,,1052.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,504.86,72,,513.352,Percent of Total Billed Charges,72% of Total Billed Charges,525.89,75,,534.736,Percent of Total Billed charges,75% of Total Billed Charges,701.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,504.86,72,,513.352,Percent of Total Billed Charges,72% of Total Billed Charges,420.71,60,,427.792,Percent of Total Billed Charges,60% of Total Billed Charges,631.07,90,,7711.92,Percent of Total Billed Charges,90% of Total Billed Charges,315.54,45,,655.848,Percent of Total Billed Charges,45% of Total Billed Charges,631.07,90,,1246.32,Percent of Total Billed Charges,90% of Total billed Charges,701.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,701.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,701.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,455.77,65,,2136.16,Percent of total Billed Charges,65% of Total Billed Charges,309.22,44.1,,642.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,666.13,95,,1315.56,Percent of Total Billed Charges,95% of Total Billed Charges,701.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,617.05,88,,15081.088,Percent of Total Billed Charges,88% of Total Billed Charges,631.07,90,,1246.32,Percent of Total Billed charges,90% of Total Billed Charges,309.22,701.19,
CARDIO PUL RESIS,4500000021,CDM,450,RC,,,Outpatient,,,3340.00,2171.00,,3340,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2538.4,76,,1052.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2404.8,72,,65.92,Percent of Total Billed Charges,72% of Total Billed Charges,2505,75,,68.672,Percent of Total Billed charges,75% of Total Billed Charges,3340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2404.8,72,,65.92,Percent of Total Billed Charges,72% of Total Billed Charges,2004,60,,54.936,Percent of Total Billed Charges,60% of Total Billed Charges,3006,90,,7711.92,Percent of Total Billed Charges,90% of Total Billed Charges,1503,45,,7711.92,Percent of Total Billed Charges,45% of Total Billed Charges,3006,90,,1246.32,Percent of Total Billed Charges,90% of Total billed Charges,3340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2171,65,,1968.2,Percent of total Billed Charges,65% of Total Billed Charges,1472.94,44.1,,7557.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,3173,95,,1315.56,Percent of Total Billed Charges,95% of Total Billed Charges,3340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2939.2,88,,15081.088,Percent of Total Billed Charges,88% of Total Billed Charges,3006,90,,1246.32,Percent of Total Billed charges,90% of Total Billed Charges,1472.94,3340,
EXTERNAL PACING,4500000022,CDM,450,RC,,,Outpatient,,,691.27,449.33,,691.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,525.37,76,,1052.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,497.71,72,,162.568,Percent of Total Billed Charges,72% of Total Billed Charges,518.45,75,,169.344,Percent of Total Billed charges,75% of Total Billed Charges,691.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497.71,72,,162.568,Percent of Total Billed Charges,72% of Total Billed Charges,414.76,60,,135.472,Percent of Total Billed Charges,60% of Total Billed Charges,622.14,90,,7711.92,Percent of Total Billed Charges,90% of Total Billed Charges,311.07,45,,7711.92,Percent of Total Billed Charges,45% of Total Billed Charges,622.14,90,,1246.32,Percent of Total Billed Charges,90% of Total billed Charges,691.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,691.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,691.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,449.33,65,,1537.64,Percent of total Billed Charges,65% of Total Billed Charges,304.85,44.1,,7557.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,656.71,95,,1315.56,Percent of Total Billed Charges,95% of Total Billed Charges,691.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,608.32,88,,15081.088,Percent of Total Billed Charges,88% of Total Billed Charges,622.14,90,,1246.32,Percent of Total Billed charges,90% of Total Billed Charges,304.85,691.27,
TNKASE CORONARY,4500000023,CDM,450,RC,,,Outpatient,,,1257.95,817.67,,1257.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,956.04,76,,1107.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,905.72,72,,49.68,Percent of Total Billed Charges,72% of Total Billed Charges,943.46,75,,51.752,Percent of Total Billed charges,75% of Total Billed Charges,1257.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,905.72,72,,49.68,Percent of Total Billed Charges,72% of Total Billed Charges,754.77,60,,41.4,Percent of Total Billed Charges,60% of Total Billed Charges,1132.16,90,,14234.4,Percent of Total Billed Charges,90% of Total Billed Charges,566.08,45,,7711.92,Percent of Total Billed Charges,45% of Total Billed Charges,1132.16,90,,1311.696,Percent of Total Billed Charges,90% of Total billed Charges,1257.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1257.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1257.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,817.67,65,,2890.16,Percent of total Billed Charges,65% of Total Billed Charges,554.76,44.1,,7557.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,1195.05,95,,1384.568,Percent of Total Billed Charges,95% of Total Billed Charges,1257.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1107,88,,15081.088,Percent of Total Billed Charges,88% of Total Billed Charges,1132.16,90,,1311.696,Percent of Total Billed charges,90% of Total Billed Charges,554.76,1257.95,
MED INF SEQUENTIAL,4500000024,CDM,260,RC,,,Outpatient,,,72.77,47.30,,72.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,55.31,76,,1107.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,52.39,72,,27.744,Percent of Total Billed Charges,72% of Total Billed Charges,54.58,75,,28.896,Percent of Total Billed charges,75% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.39,72,,27.744,Percent of Total Billed Charges,72% of Total Billed Charges,43.66,60,,23.12,Percent of Total Billed Charges,60% of Total Billed Charges,65.49,90,,1005.48,Percent of Total Billed Charges,90% of Total Billed Charges,32.75,45,,7711.92,Percent of Total Billed Charges,45% of Total Billed Charges,65.49,90,,1311.696,Percent of Total Billed Charges,90% of Total billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.3,65,,284.44,Percent of total Billed Charges,65% of Total Billed Charges,32.09,44.1,,7557.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,69.13,95,,1384.568,Percent of Total Billed Charges,95% of Total Billed Charges,72.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.04,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,65.49,90,,1311.696,Percent of Total Billed charges,90% of Total Billed Charges,32.09,72.77,
ED LEVEL1,4500000025,CDM,450,RC,,,Outpatient,,,277.00,180.05,,277,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,210.52,76,,13024.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,199.44,72,,163.2,Percent of Total Billed Charges,72% of Total Billed Charges,207.75,75,,170.008,Percent of Total Billed charges,75% of Total Billed Charges,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.44,72,,163.2,Percent of Total Billed Charges,72% of Total Billed Charges,166.2,60,,136,Percent of Total Billed Charges,60% of Total Billed Charges,249.3,90,,285.12,Percent of Total Billed Charges,90% of Total Billed Charges,124.65,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,249.3,90,,15423.84,Percent of Total Billed Charges,90% of Total billed Charges,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.05,65,,270.4,Percent of total Billed Charges,65% of Total Billed Charges,122.16,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,263.15,95,,16280.72,Percent of Total Billed Charges,95% of Total Billed Charges,277,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.76,88,,7540.544,Percent of Total Billed Charges,88% of Total Billed Charges,249.3,90,,15423.84,Percent of Total Billed charges,90% of Total Billed Charges,122.16,277,
ED LEVEL2,4500000027,CDM,450,RC,,,Outpatient,,,473.00,307.45,,473,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,359.48,76,,13024.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,340.56,72,,108.36,Percent of Total Billed Charges,72% of Total Billed Charges,354.75,75,,112.872,Percent of Total Billed charges,75% of Total Billed Charges,473,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.56,72,,108.36,Percent of Total Billed Charges,72% of Total Billed Charges,283.8,60,,90.296,Percent of Total Billed Charges,60% of Total Billed Charges,425.7,90,,57.928,Percent of Total Billed Charges,90% of Total Billed Charges,212.85,45,,3855.96,Percent of Total Billed Charges,45% of Total Billed Charges,425.7,90,,15423.84,Percent of Total Billed Charges,90% of Total billed Charges,473,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.45,65,,284.44,Percent of total Billed Charges,65% of Total Billed Charges,208.59,44.1,,3778.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,449.35,95,,16280.72,Percent of Total Billed Charges,95% of Total Billed Charges,473,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,416.24,88,,7540.544,Percent of Total Billed Charges,88% of Total Billed Charges,425.7,90,,15423.84,Percent of Total Billed charges,90% of Total Billed Charges,208.59,473,
ED LEVEL3,4500000028,CDM,450,RC,,,Outpatient,,,765.00,497.25,,765,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,581.4,76,,13024.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,550.8,72,,66.048,Percent of Total Billed Charges,72% of Total Billed Charges,573.75,75,,68.8,Percent of Total Billed charges,75% of Total Billed Charges,765,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.8,72,,66.048,Percent of Total Billed Charges,72% of Total Billed Charges,459,60,,55.04,Percent of Total Billed Charges,60% of Total Billed Charges,688.5,90,,8013.312,Percent of Total Billed Charges,90% of Total Billed Charges,344.25,45,,3855.96,Percent of Total Billed Charges,45% of Total Billed Charges,688.5,90,,15423.84,Percent of Total Billed Charges,90% of Total billed Charges,765,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,765,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,765,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497.25,65,,2470,Percent of total Billed Charges,65% of Total Billed Charges,337.37,44.1,,3778.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,726.75,95,,16280.72,Percent of Total Billed Charges,95% of Total Billed Charges,765,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,673.2,88,,7540.544,Percent of Total Billed Charges,88% of Total Billed Charges,688.5,90,,15423.84,Percent of Total Billed charges,90% of Total Billed Charges,337.37,765,
SA EXAM W/O COLPOSCO,4500000029,CDM,450,RC,,,Outpatient,,,765.00,497.25,,765,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,581.4,76,,13024.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,550.8,72,,23.712,Percent of Total Billed Charges,72% of Total Billed Charges,573.75,75,,24.704,Percent of Total Billed charges,75% of Total Billed Charges,765,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.8,72,,23.712,Percent of Total Billed Charges,72% of Total Billed Charges,459,60,,19.76,Percent of Total Billed Charges,60% of Total Billed Charges,688.5,90,,8013.312,Percent of Total Billed Charges,90% of Total Billed Charges,344.25,45,,3855.96,Percent of Total Billed Charges,45% of Total Billed Charges,688.5,90,,15423.84,Percent of Total Billed Charges,90% of Total billed Charges,765,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,765,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,765,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497.25,65,,2600,Percent of total Billed Charges,65% of Total Billed Charges,337.37,44.1,,3778.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,726.75,95,,16280.72,Percent of Total Billed Charges,95% of Total Billed Charges,765,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,673.2,88,,13918.08,Percent of Total Billed Charges,88% of Total Billed Charges,688.5,90,,15423.84,Percent of Total Billed charges,90% of Total Billed Charges,337.37,765,
ED LEVEL4,4500000030,CDM,450,RC,,,Outpatient,,,1255.00,815.75,,1255,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,953.8,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,903.6,72,,65.904,Percent of Total Billed Charges,72% of Total Billed Charges,941.25,75,,68.648,Percent of Total Billed charges,75% of Total Billed Charges,1255,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,903.6,72,,65.904,Percent of Total Billed Charges,72% of Total Billed Charges,753,60,,54.92,Percent of Total Billed Charges,60% of Total Billed Charges,1129.5,90,,8013.312,Percent of Total Billed Charges,90% of Total Billed Charges,564.75,45,,7117.2,Percent of Total Billed Charges,45% of Total Billed Charges,1129.5,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,1255,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1255,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1255,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,815.75,65,,1844.88,Percent of total Billed Charges,65% of Total Billed Charges,553.46,44.1,,6974.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,1192.25,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,1255,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1104.4,88,,983.136,Percent of Total Billed Charges,88% of Total Billed Charges,1129.5,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,553.46,1255,
ED LEVEL5,4500000031,CDM,450,RC,,,Outpatient,,,1859.00,1208.35,,1859,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1412.84,76,,6512.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1338.48,72,,40.928,Percent of Total Billed Charges,72% of Total Billed Charges,1394.25,75,,42.632,Percent of Total Billed charges,75% of Total Billed Charges,1859,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1338.48,72,,40.928,Percent of Total Billed Charges,72% of Total Billed Charges,1115.4,60,,34.104,Percent of Total Billed Charges,60% of Total Billed Charges,1673.1,90,,8013.312,Percent of Total Billed Charges,90% of Total Billed Charges,836.55,45,,502.744,Percent of Total Billed Charges,45% of Total Billed Charges,1673.1,90,,7711.92,Percent of Total Billed Charges,90% of Total billed Charges,1859,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1859,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1859,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1208.35,65,,1844.88,Percent of total Billed Charges,65% of Total Billed Charges,819.82,44.1,,492.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,1766.05,95,,8140.36,Percent of Total Billed Charges,95% of Total Billed Charges,1859,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1635.92,88,,278.784,Percent of Total Billed Charges,88% of Total Billed Charges,1673.1,90,,7711.92,Percent of Total Billed charges,90% of Total Billed Charges,819.82,1859,
CRITICAL CARE 3074M,4500000032,CDM,450,RC,,,Outpatient,,,3349.00,2176.85,,3349,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2545.24,76,,6512.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2411.28,72,,195.592,Percent of Total Billed Charges,72% of Total Billed Charges,2511.75,75,,203.744,Percent of Total Billed charges,75% of Total Billed Charges,3349,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2411.28,72,,195.592,Percent of Total Billed Charges,72% of Total Billed Charges,2009.4,60,,162.992,Percent of Total Billed Charges,60% of Total Billed Charges,3014.1,90,,8013.312,Percent of Total Billed Charges,90% of Total Billed Charges,1507.05,45,,142.56,Percent of Total Billed Charges,45% of Total Billed Charges,3014.1,90,,7711.92,Percent of Total Billed Charges,90% of Total billed Charges,3349,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3349,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3349,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2176.85,65,,1844.88,Percent of total Billed Charges,65% of Total Billed Charges,1476.91,44.1,,139.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,3181.55,95,,8140.36,Percent of Total Billed Charges,95% of Total Billed Charges,3349,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2947.12,88,,56.64,Percent of Total Billed Charges,88% of Total Billed Charges,3014.1,90,,7711.92,Percent of Total Billed charges,90% of Total Billed Charges,1476.91,3349,
CRIT CARE EA ADD 30M,4500000033,CDM,450,RC,,,Outpatient,,,816.00,530.40,,816,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,620.16,76,,6512.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,587.52,72,,64.616,Percent of Total Billed Charges,72% of Total Billed Charges,612,75,,67.312,Percent of Total Billed charges,75% of Total Billed Charges,816,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,587.52,72,,64.616,Percent of Total Billed Charges,72% of Total Billed Charges,489.6,60,,53.848,Percent of Total Billed Charges,60% of Total Billed Charges,734.4,90,,4006.656,Percent of Total Billed Charges,90% of Total Billed Charges,367.2,45,,28.96,Percent of Total Billed Charges,45% of Total Billed Charges,734.4,90,,7711.92,Percent of Total Billed Charges,90% of Total billed Charges,816,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,816,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,816,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.4,65,,1844.88,Percent of total Billed Charges,65% of Total Billed Charges,359.86,44.1,,28.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,775.2,95,,8140.36,Percent of Total Billed Charges,95% of Total Billed Charges,816,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,718.08,88,,7835.24,Percent of Total Billed Charges,88% of Total Billed Charges,734.4,90,,7711.92,Percent of Total Billed charges,90% of Total Billed Charges,359.86,816,
OTHER PROCEDURE SIMP,4500000035,CDM,450,RC,,,Outpatient,,,314.00,204.10,,314,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,238.64,76,,12020.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,226.08,72,,122.496,Percent of Total Billed Charges,72% of Total Billed Charges,235.5,75,,127.6,Percent of Total Billed charges,75% of Total Billed Charges,314,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.08,72,,122.496,Percent of Total Billed Charges,72% of Total Billed Charges,188.4,60,,102.08,Percent of Total Billed Charges,60% of Total Billed Charges,282.6,90,,4006.656,Percent of Total Billed Charges,90% of Total Billed Charges,141.3,45,,4006.656,Percent of Total Billed Charges,45% of Total Billed Charges,282.6,90,,14234.4,Percent of Total Billed Charges,90% of Total billed Charges,314,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.1,65,,1844.88,Percent of total Billed Charges,65% of Total Billed Charges,138.47,44.1,,3926.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,298.3,95,,15025.2,Percent of Total Billed Charges,95% of Total Billed Charges,314,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.32,88,,7835.24,Percent of Total Billed Charges,88% of Total Billed Charges,282.6,90,,14234.4,Percent of Total Billed charges,90% of Total Billed Charges,138.47,314,
OTHER PROCEDURE COMP,4500000036,CDM,450,RC,,,Outpatient,,,980.00,637.00,,980,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,744.8,76,,849.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,705.6,72,,168.92,Percent of Total Billed Charges,72% of Total Billed Charges,735,75,,175.96,Percent of Total Billed charges,75% of Total Billed Charges,980,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,705.6,72,,168.92,Percent of Total Billed Charges,72% of Total Billed Charges,588,60,,140.768,Percent of Total Billed Charges,60% of Total Billed Charges,882,90,,4006.656,Percent of Total Billed Charges,90% of Total Billed Charges,441,45,,4006.656,Percent of Total Billed Charges,45% of Total Billed Charges,882,90,,1005.48,Percent of Total Billed Charges,90% of Total billed Charges,980,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,980,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,980,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,637,65,,1999.672,Percent of total Billed Charges,65% of Total Billed Charges,432.18,44.1,,3926.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,931,95,,1061.344,Percent of Total Billed Charges,95% of Total Billed Charges,980,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,862.4,88,,7835.24,Percent of Total Billed Charges,88% of Total Billed Charges,882,90,,1005.48,Percent of Total Billed charges,90% of Total Billed Charges,432.18,980,
SANE EXAM ROOM,4500000037,CDM,450,RC,,,Outpatient,,,682.45,443.59,,682.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,518.66,76,,240.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,491.36,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,511.84,75,,17.864,Percent of Total Billed charges,75% of Total Billed Charges,682.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.36,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,409.47,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,614.21,90,,15423.84,Percent of Total Billed Charges,90% of Total Billed Charges,307.1,45,,4006.656,Percent of Total Billed Charges,45% of Total Billed Charges,614.21,90,,285.12,Percent of Total Billed Charges,90% of Total billed Charges,682.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,682.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,682.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,443.59,65,,1999.672,Percent of total Billed Charges,65% of Total Billed Charges,300.96,44.1,,3926.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,648.33,95,,300.96,Percent of Total Billed Charges,95% of Total Billed Charges,682.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,600.56,88,,7835.24,Percent of Total Billed Charges,88% of Total Billed Charges,614.21,90,,285.12,Percent of Total Billed charges,90% of Total Billed Charges,300.96,682.45,
OTHER PROCEDURE INTE,4500000038,CDM,450,RC,,,Outpatient,,,589.00,382.85,,589,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,447.64,76,,48.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,424.08,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,441.75,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,589,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.08,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,353.4,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,530.1,90,,15423.84,Percent of Total Billed Charges,90% of Total Billed Charges,265.05,45,,4006.656,Percent of Total Billed Charges,45% of Total Billed Charges,530.1,90,,57.928,Percent of Total Billed Charges,90% of Total billed Charges,589,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,589,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,589,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.85,65,,1999.672,Percent of total Billed Charges,65% of Total Billed Charges,259.75,44.1,,3926.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,559.55,95,,61.144,Percent of Total Billed Charges,95% of Total Billed Charges,589,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,518.32,88,,7835.24,Percent of Total Billed Charges,88% of Total Billed Charges,530.1,90,,57.928,Percent of Total Billed charges,90% of Total Billed Charges,259.75,589,
FX TX NO MANIPULATIO,4500000039,CDM,450,RC,,,Outpatient,,,654.00,425.10,,654,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,497.04,76,,6766.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,470.88,72,,149.232,Percent of Total Billed Charges,72% of Total Billed Charges,490.5,75,,155.456,Percent of Total Billed charges,75% of Total Billed Charges,654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,470.88,72,,149.232,Percent of Total Billed Charges,72% of Total Billed Charges,392.4,60,,124.36,Percent of Total Billed Charges,60% of Total Billed Charges,588.6,90,,15423.84,Percent of Total Billed Charges,90% of Total Billed Charges,294.3,45,,4006.656,Percent of Total Billed Charges,45% of Total Billed Charges,588.6,90,,8013.312,Percent of Total Billed Charges,90% of Total billed Charges,654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,425.1,65,,1999.672,Percent of total Billed Charges,65% of Total Billed Charges,288.41,44.1,,3926.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,621.3,95,,8458.496,Percent of Total Billed Charges,95% of Total Billed Charges,654,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.52,88,,3917.616,Percent of Total Billed Charges,88% of Total Billed Charges,588.6,90,,8013.312,Percent of Total Billed charges,90% of Total Billed Charges,288.41,654,
FX TX WITH MANIPULAT,4500000040,CDM,450,RC,,,Outpatient,,,1046.00,679.90,,1046,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,794.96,76,,6766.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,753.12,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,784.5,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,1046,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,753.12,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,627.6,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,941.4,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,470.7,45,,2003.328,Percent of Total Billed Charges,45% of Total Billed Charges,941.4,90,,8013.312,Percent of Total Billed Charges,90% of Total billed Charges,1046,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,679.9,65,,1999.672,Percent of total Billed Charges,65% of Total Billed Charges,461.29,44.1,,1963.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,993.7,95,,8458.496,Percent of Total Billed Charges,95% of Total Billed Charges,1046,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,920.48,88,,3917.616,Percent of Total Billed Charges,88% of Total Billed Charges,941.4,90,,8013.312,Percent of Total Billed charges,90% of Total Billed Charges,461.29,1046,
WOUND REPAIR SIMPLE,4500000041,CDM,450,RC,,,Outpatient,,,392.00,254.80,,392,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,297.92,76,,6766.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,282.24,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,294,75,,7.936,Percent of Total Billed charges,75% of Total Billed Charges,392,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.24,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,235.2,60,,6.352,Percent of Total Billed Charges,60% of Total Billed Charges,352.8,90,,15423.84,Percent of Total Billed Charges,90% of Total Billed Charges,176.4,45,,2003.328,Percent of Total Billed Charges,45% of Total Billed Charges,352.8,90,,8013.312,Percent of Total Billed Charges,90% of Total billed Charges,392,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,254.8,65,,1999.672,Percent of total Billed Charges,65% of Total Billed Charges,172.87,44.1,,1963.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,372.4,95,,8458.496,Percent of Total Billed Charges,95% of Total Billed Charges,392,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,344.96,88,,3917.616,Percent of Total Billed Charges,88% of Total Billed Charges,352.8,90,,8013.312,Percent of Total Billed charges,90% of Total Billed Charges,172.87,392,
WOUND REPAIR INTERMI,4500000042,CDM,450,RC,,,Outpatient,,,784.00,509.60,,784,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,595.84,76,,6766.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,564.48,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,588,75,,37.704,Percent of Total Billed charges,75% of Total Billed Charges,784,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,564.48,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,470.4,60,,30.16,Percent of Total Billed Charges,60% of Total Billed Charges,705.6,90,,8117.8,Percent of Total Billed Charges,90% of Total Billed Charges,352.8,45,,2003.328,Percent of Total Billed Charges,45% of Total Billed Charges,705.6,90,,8013.312,Percent of Total Billed Charges,90% of Total billed Charges,784,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,784,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,784,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,509.6,65,,2248.488,Percent of total Billed Charges,65% of Total Billed Charges,345.74,44.1,,1963.264,Percent of Total Billed Charges,44.1% of Total Billed Charges,744.8,95,,8458.496,Percent of Total Billed Charges,95% of Total Billed Charges,784,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,689.92,88,,15081.088,Percent of Total Billed Charges,88% of Total Billed Charges,705.6,90,,8013.312,Percent of Total Billed charges,90% of Total Billed Charges,345.74,784,
WOUND REPAIR COMPLEX,4500000043,CDM,450,RC,,,Outpatient,,,1438.00,934.70,,1438,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1092.88,76,,6766.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1035.36,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,1078.5,75,,26.464,Percent of Total Billed charges,75% of Total Billed Charges,1438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1035.36,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,862.8,60,,21.168,Percent of Total Billed Charges,60% of Total Billed Charges,1294.2,90,,8117.8,Percent of Total Billed Charges,90% of Total Billed Charges,647.1,45,,7711.92,Percent of Total Billed Charges,45% of Total Billed Charges,1294.2,90,,8013.312,Percent of Total Billed Charges,90% of Total billed Charges,1438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,934.7,65,,2248.488,Percent of total Billed Charges,65% of Total Billed Charges,634.16,44.1,,7557.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,1366.1,95,,8458.496,Percent of Total Billed Charges,95% of Total Billed Charges,1438,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1265.44,88,,15081.088,Percent of Total Billed Charges,88% of Total Billed Charges,1294.2,90,,8013.312,Percent of Total Billed charges,90% of Total Billed Charges,634.16,1438,
MAJOR JOINT/BURSA ASPIRATION,4500000044,CDM,450,RC,,,Outpatient,,,798.00,518.70,,798,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,606.48,76,,3383.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,574.56,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,598.5,75,,43,Percent of Total Billed charges,75% of Total Billed Charges,798,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,574.56,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,478.8,60,,34.4,Percent of Total Billed Charges,60% of Total Billed Charges,718.2,90,,7711.92,Percent of Total Billed Charges,90% of Total Billed Charges,359.1,45,,7711.92,Percent of Total Billed Charges,45% of Total Billed Charges,718.2,90,,4006.656,Percent of Total Billed Charges,90% of Total billed Charges,798,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,798,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,798,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,518.7,65,,2248.488,Percent of total Billed Charges,65% of Total Billed Charges,351.92,44.1,,7557.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,758.1,95,,4229.248,Percent of Total Billed Charges,95% of Total Billed Charges,798,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702.24,88,,15081.088,Percent of Total Billed Charges,88% of Total Billed Charges,718.2,90,,4006.656,Percent of Total Billed charges,90% of Total Billed Charges,351.92,798,
US PV RESIDUAL URINE,4500000045,CDM,450,RC,,,Outpatient,,,143.00,92.95,,143,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,108.68,76,,3383.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,102.96,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,107.25,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,143,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.96,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,85.8,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,128.7,90,,16053.84,Percent of Total Billed Charges,90% of Total Billed Charges,64.35,45,,7711.92,Percent of Total Billed Charges,45% of Total Billed Charges,128.7,90,,4006.656,Percent of Total Billed Charges,90% of Total billed Charges,143,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.95,65,,2248.488,Percent of total Billed Charges,65% of Total Billed Charges,63.06,44.1,,7557.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,135.85,95,,4229.248,Percent of Total Billed Charges,95% of Total Billed Charges,143,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.84,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,128.7,90,,4006.656,Percent of Total Billed charges,90% of Total Billed Charges,63.06,143,
SA EXAM W VAG COLPOSCOPY,4500000046,CDM,450,RC,,,Outpatient,,,250.00,162.50,,250,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,190,76,,3383.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,180,72,,1.168,Percent of Total Billed Charges,72% of Total Billed Charges,187.5,75,,1.216,Percent of Total Billed charges,75% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180,72,,1.168,Percent of Total Billed Charges,72% of Total Billed Charges,150,60,,0.976,Percent of Total Billed Charges,60% of Total Billed Charges,225,90,,16898.416,Percent of Total Billed Charges,90% of Total Billed Charges,112.5,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,225,90,,4006.656,Percent of Total Billed Charges,90% of Total billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.5,65,,2248.488,Percent of total Billed Charges,65% of Total Billed Charges,110.25,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,237.5,95,,4229.248,Percent of Total Billed Charges,95% of Total Billed Charges,250,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220,88,,15081.088,Percent of Total Billed Charges,88% of Total Billed Charges,225,90,,4006.656,Percent of Total Billed charges,90% of Total Billed Charges,110.25,250,
SA Anogenital Exam Adult,4500000047,CDM,450,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,13024.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,8.928,Percent of Total Billed Charges,72% of Total Billed Charges,112.5,75,,9.304,Percent of Total Billed charges,75% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,8.928,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,7.44,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,16898.416,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,7711.92,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,15423.84,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,2248.488,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,7557.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,16280.72,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,7937.4,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,15423.84,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
SA Exam  vulva w magnification,4500000048,CDM,450,RC,,,Outpatient,,,150.00,97.50,,150,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114,76,,13024.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,112.5,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,90,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,135,90,,16898.416,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,45,,4058.896,Percent of Total Billed Charges,45% of Total Billed Charges,135,90,,15423.84,Percent of Total Billed Charges,90% of Total billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,65,,1949.792,Percent of total Billed Charges,65% of Total Billed Charges,66.15,44.1,,3977.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,142.5,95,,16280.72,Percent of Total Billed Charges,95% of Total Billed Charges,150,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,88,,7937.4,Percent of Total Billed Charges,88% of Total Billed Charges,135,90,,15423.84,Percent of Total Billed charges,90% of Total Billed Charges,66.15,150,
SA Anoscopy,4500000049,CDM,450,RC,,,Outpatient,,,71.00,46.15,,71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,53.96,76,,13024.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.12,72,,3.016,Percent of Total Billed Charges,72% of Total Billed Charges,53.25,75,,3.136,Percent of Total Billed charges,75% of Total Billed Charges,71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.12,72,,3.016,Percent of Total Billed Charges,72% of Total Billed Charges,42.6,60,,2.512,Percent of Total Billed Charges,60% of Total Billed Charges,63.9,90,,16898.416,Percent of Total Billed Charges,90% of Total Billed Charges,31.95,45,,4058.896,Percent of Total Billed Charges,45% of Total Billed Charges,63.9,90,,15423.84,Percent of Total Billed Charges,90% of Total billed Charges,71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.15,65,,1949.792,Percent of total Billed Charges,65% of Total Billed Charges,31.31,44.1,,3977.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.45,95,,16280.72,Percent of Total Billed Charges,95% of Total Billed Charges,71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.48,88,,7540.544,Percent of Total Billed Charges,88% of Total Billed Charges,63.9,90,,15423.84,Percent of Total Billed charges,90% of Total Billed Charges,31.31,71,
Dialysis ESRD unscheduled,4500000051,CDM,450,RC,G0257,HCPCS,Outpatient,,,1707.00,1109.55,,879.58,125,,,Fee Schedule,125% of CMS OPPS Rate,1297.32,76,,13024.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1710.37,350,,10.792,Fee Schedule,350% of BCBS fee schedule,1710.37,350,,11.248,Fee Schedule,350% of BCBS fee schedule,703.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1710.37,286,,10.792,Fee Schedule,286% of BCBS PPO fee schedule,598.03,100,,8.992,Fee Schedule,100% of Blue ADV HMO fee schedule,1536.3,90,,25969.32,Percent of Total Billed Charges,90% of Total Billed Charges,768.15,45,,8026.92,Percent of Total Billed Charges,45% of Total Billed Charges,1536.3,90,,15423.84,Percent of Total Billed Charges,90% of Total billed Charges,703.66,100,,,Fee Schedule,100% of CMS OPPS Rate,703.66,100,,,Fee Schedule,100% of CMS OPPS Rate,703.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1314.04,200,,1949.792,Fee Schedule,200% of CMS OPPS Rate,752.79,44.1,,7866.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,1621.65,95,,16280.72,Percent of Total Billed Charges,95% of Total Billed Charges,527.74,75,,,Fee Schedule,75% of CMS OPPS Rate,1502.16,88,,16522.896,Percent of Total Billed Charges,88% of Total Billed Charges,1536.3,90,,15423.84,Percent of Total Billed charges,90% of Total Billed Charges,527.74,1710.37,
SA Addtnl E/M,4500000052,CDM,450,RC,,,Outpatient,,,106.00,68.90,,106,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,80.56,76,,6855.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,76.32,72,,23.848,Percent of Total Billed Charges,72% of Total Billed Charges,79.5,75,,24.84,Percent of Total Billed charges,75% of Total Billed Charges,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.32,72,,23.848,Percent of Total Billed Charges,72% of Total Billed Charges,63.6,60,,19.872,Percent of Total Billed Charges,60% of Total Billed Charges,95.4,90,,25969.32,Percent of Total Billed Charges,90% of Total Billed Charges,47.7,45,,8449.208,Percent of Total Billed Charges,45% of Total Billed Charges,95.4,90,,8117.8,Percent of Total Billed Charges,90% of Total billed Charges,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.9,65,,1949.792,Percent of total Billed Charges,65% of Total Billed Charges,46.75,44.1,,8280.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,100.7,95,,8568.784,Percent of Total Billed Charges,95% of Total Billed Charges,106,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.28,88,,16522.896,Percent of Total Billed Charges,88% of Total Billed Charges,95.4,90,,8117.8,Percent of Total Billed charges,90% of Total Billed Charges,46.75,106,
SA POS fee for exam in Hosp,4500000053,CDM,450,RC,,,Outpatient,,,350.00,227.50,,350,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,266,76,,6855.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,252,72,,57.792,Percent of Total Billed Charges,72% of Total Billed Charges,262.5,75,,60.2,Percent of Total Billed charges,75% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252,72,,57.792,Percent of Total Billed Charges,72% of Total Billed Charges,210,60,,48.16,Percent of Total Billed Charges,60% of Total Billed Charges,315,90,,25969.32,Percent of Total Billed Charges,90% of Total Billed Charges,157.5,45,,8449.208,Percent of Total Billed Charges,45% of Total Billed Charges,315,90,,8117.8,Percent of Total Billed Charges,90% of Total billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.5,65,,1949.792,Percent of total Billed Charges,65% of Total Billed Charges,154.35,44.1,,8280.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,332.5,95,,8568.784,Percent of Total Billed Charges,95% of Total Billed Charges,350,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308,88,,16522.896,Percent of Total Billed Charges,88% of Total Billed Charges,315,90,,8117.8,Percent of Total Billed charges,90% of Total Billed Charges,154.35,350,
ED VISIT TYPE B LEV 2,4500000054,CDM,450,RC,G0381,HCPCS,Outpatient,,,311.00,202.15,,139.09,125,,,Fee Schedule,125% of CMS OPPS Rate,236.36,76,,6512.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,286.37,350,,18.32,Fee Schedule,350% of BCBS fee schedule,286.37,350,,19.08,Fee Schedule,350% of BCBS fee schedule,111.27,100,,,Fee Schedule,100% of CMS OPPS Rate,286.37,286,,18.32,Fee Schedule,286% of BCBS PPO fee schedule,100.13,100,,15.264,Fee Schedule,100% of Blue ADV HMO fee schedule,279.9,90,,25969.32,Percent of Total Billed Charges,90% of Total Billed Charges,139.95,45,,8449.208,Percent of Total Billed Charges,45% of Total Billed Charges,279.9,90,,7711.92,Percent of Total Billed Charges,90% of Total billed Charges,111.27,100,,,Fee Schedule,100% of CMS OPPS Rate,111.27,100,,,Fee Schedule,100% of CMS OPPS Rate,111.27,100,,,Fee Schedule,100% of CMS OPPS Rate,207.81,200,,1618.424,Fee Schedule,200% of CMS OPPS Rate,137.15,44.1,,8280.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,295.45,95,,8140.36,Percent of Total Billed Charges,95% of Total Billed Charges,83.45,75,,,Fee Schedule,75% of CMS OPPS Rate,273.68,88,,16522.896,Percent of Total Billed Charges,88% of Total Billed Charges,279.9,90,,7711.92,Percent of Total Billed charges,90% of Total Billed Charges,83.45,295.45,
ED VISIT TYPE B LEV 3,4500000055,CDM,450,RC,G0382,HCPCS,Outpatient,,,511.00,332.15,,234.53,125,,,Fee Schedule,125% of CMS OPPS Rate,388.36,76,,13556.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,473.19,350,,17.136,Fee Schedule,350% of BCBS fee schedule,473.19,350,,17.848,Fee Schedule,350% of BCBS fee schedule,187.63,100,,,Fee Schedule,100% of CMS OPPS Rate,473.19,286,,17.136,Fee Schedule,286% of BCBS PPO fee schedule,165.45,100,,14.28,Fee Schedule,100% of Blue ADV HMO fee schedule,459.9,90,,12984.664,Percent of Total Billed Charges,90% of Total Billed Charges,229.95,45,,8449.208,Percent of Total Billed Charges,45% of Total Billed Charges,459.9,90,,16053.84,Percent of Total Billed Charges,90% of Total billed Charges,187.63,100,,,Fee Schedule,100% of CMS OPPS Rate,187.63,100,,,Fee Schedule,100% of CMS OPPS Rate,187.63,100,,,Fee Schedule,100% of CMS OPPS Rate,350.4,200,,1618.424,Fee Schedule,200% of CMS OPPS Rate,225.35,44.1,,8280.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,485.45,95,,16945.72,Percent of Total Billed Charges,95% of Total Billed Charges,140.72,75,,,Fee Schedule,75% of CMS OPPS Rate,449.68,88,,25392.224,Percent of Total Billed Charges,88% of Total Billed Charges,459.9,90,,16053.84,Percent of Total Billed charges,90% of Total Billed Charges,140.72,485.45,
ED VISIT TYPE B LEV 4,4500000056,CDM,450,RC,G0383,HCPCS,Outpatient,,,752.00,488.80,,358.94,125,,,Fee Schedule,125% of CMS OPPS Rate,571.52,76,,14269.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,716.43,350,,6.912,Fee Schedule,350% of BCBS fee schedule,716.43,350,,7.2,Fee Schedule,350% of BCBS fee schedule,287.14,100,,,Fee Schedule,100% of CMS OPPS Rate,716.43,286,,6.912,Fee Schedule,286% of BCBS PPO fee schedule,250.5,100,,5.76,Fee Schedule,100% of Blue ADV HMO fee schedule,676.8,90,,12984.664,Percent of Total Billed Charges,90% of Total Billed Charges,338.4,45,,12984.664,Percent of Total Billed Charges,45% of Total Billed Charges,676.8,90,,16898.416,Percent of Total Billed Charges,90% of Total billed Charges,287.14,100,,,Fee Schedule,100% of CMS OPPS Rate,287.14,100,,,Fee Schedule,100% of CMS OPPS Rate,287.14,100,,,Fee Schedule,100% of CMS OPPS Rate,536.25,200,,1618.424,Fee Schedule,200% of CMS OPPS Rate,331.63,44.1,,12724.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,714.4,95,,17837.216,Percent of Total Billed Charges,95% of Total Billed Charges,215.36,75,,,Fee Schedule,75% of CMS OPPS Rate,661.76,88,,25392.224,Percent of Total Billed Charges,88% of Total Billed Charges,676.8,90,,16898.416,Percent of Total Billed charges,90% of Total Billed Charges,215.36,716.43,
ED VISIT TYPE B LEV 5,4500000057,CDM,450,RC,G0384,HCPCS,Outpatient,,,972.00,631.80,,507.7,125,,,Fee Schedule,125% of CMS OPPS Rate,738.72,76,,14269.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1060.29,350,,6.912,Fee Schedule,350% of BCBS fee schedule,1060.29,350,,7.2,Fee Schedule,350% of BCBS fee schedule,406.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1060.29,286,,6.912,Fee Schedule,286% of BCBS PPO fee schedule,370.73,100,,5.76,Fee Schedule,100% of Blue ADV HMO fee schedule,874.8,90,,12984.664,Percent of Total Billed Charges,90% of Total Billed Charges,437.4,45,,12984.664,Percent of Total Billed Charges,45% of Total Billed Charges,874.8,90,,16898.416,Percent of Total Billed Charges,90% of Total billed Charges,406.16,100,,,Fee Schedule,100% of CMS OPPS Rate,406.16,100,,,Fee Schedule,100% of CMS OPPS Rate,406.16,100,,,Fee Schedule,100% of CMS OPPS Rate,758.49,200,,1618.424,Fee Schedule,200% of CMS OPPS Rate,428.65,44.1,,12724.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,923.4,95,,17837.216,Percent of Total Billed Charges,95% of Total Billed Charges,304.61,75,,,Fee Schedule,75% of CMS OPPS Rate,855.36,88,,25392.224,Percent of Total Billed Charges,88% of Total Billed Charges,874.8,90,,16898.416,Percent of Total Billed charges,90% of Total Billed Charges,304.61,1060.29,
ED VISIT TYPE B LEV 1,4500000058,CDM,450,RC,G0380,HCPCS,Outpatient,,,192.00,124.80,,105.66,125,,,Fee Schedule,125% of CMS OPPS Rate,145.92,76,,14269.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,177.58,350,,274.336,Fee Schedule,350% of BCBS fee schedule,177.58,350,,285.768,Fee Schedule,350% of BCBS fee schedule,84.54,100,,,Fee Schedule,100% of CMS OPPS Rate,177.58,286,,274.336,Fee Schedule,286% of BCBS PPO fee schedule,62.09,100,,228.616,Fee Schedule,100% of Blue ADV HMO fee schedule,172.8,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,86.4,45,,12984.664,Percent of Total Billed Charges,45% of Total Billed Charges,172.8,90,,16898.416,Percent of Total Billed Charges,90% of Total billed Charges,84.54,100,,,Fee Schedule,100% of CMS OPPS Rate,84.54,100,,,Fee Schedule,100% of CMS OPPS Rate,84.54,100,,,Fee Schedule,100% of CMS OPPS Rate,157.88,200,,2248.488,Fee Schedule,200% of CMS OPPS Rate,84.67,44.1,,12724.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,182.4,95,,17837.216,Percent of Total Billed Charges,95% of Total Billed Charges,63.4,75,,,Fee Schedule,75% of CMS OPPS Rate,168.96,88,,25392.224,Percent of Total Billed Charges,88% of Total Billed Charges,172.8,90,,16898.416,Percent of Total Billed charges,90% of Total Billed Charges,62.09,182.4,
PFUNC BASIC SCREEN,4600000001,CDM,460,RC,,,Outpatient,,,316.00,205.40,,316,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,240.16,76,,14269.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,227.52,72,,126.376,Percent of Total Billed Charges,72% of Total Billed Charges,237,75,,131.64,Percent of Total Billed charges,75% of Total Billed Charges,316,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.52,72,,126.376,Percent of Total Billed Charges,72% of Total Billed Charges,189.6,60,,105.312,Percent of Total Billed Charges,60% of Total Billed Charges,284.4,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,142.2,45,,12984.664,Percent of Total Billed Charges,45% of Total Billed Charges,284.4,90,,16898.416,Percent of Total Billed Charges,90% of Total billed Charges,316,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.4,65,,2248.488,Percent of total Billed Charges,65% of Total Billed Charges,139.36,44.1,,12724.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,300.2,95,,17837.216,Percent of Total Billed Charges,95% of Total Billed Charges,316,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.08,88,,25392.224,Percent of Total Billed Charges,88% of Total Billed Charges,284.4,90,,16898.416,Percent of Total Billed charges,90% of Total Billed Charges,139.36,316,
PUL FUNC PRE/PST BRD,4600000002,CDM,460,RC,,,Outpatient,,,607.53,394.89,,607.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,461.72,76,,21929.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,437.42,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,455.65,75,,11.248,Percent of Total Billed charges,75% of Total Billed Charges,607.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.42,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,364.52,60,,8.992,Percent of Total Billed Charges,60% of Total Billed Charges,546.78,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,273.39,45,,12984.664,Percent of Total Billed Charges,45% of Total Billed Charges,546.78,90,,25969.32,Percent of Total Billed Charges,90% of Total billed Charges,607.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.89,65,,2248.488,Percent of total Billed Charges,65% of Total Billed Charges,267.92,44.1,,12724.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,577.15,95,,27412.064,Percent of Total Billed Charges,95% of Total Billed Charges,607.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,534.63,88,,12696.112,Percent of Total Billed Charges,88% of Total Billed Charges,546.78,90,,25969.32,Percent of Total Billed charges,90% of Total Billed Charges,267.92,607.53,
VITAL CAPACITY SCREE,4600000003,CDM,460,RC,,,Outpatient,,,151.04,98.18,,151.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,114.79,76,,21929.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,108.75,72,,738.552,Percent of Total Billed Charges,72% of Total Billed Charges,113.28,75,,769.328,Percent of Total Billed charges,75% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.75,72,,738.552,Percent of Total Billed Charges,72% of Total Billed Charges,90.62,60,,615.464,Percent of Total Billed Charges,60% of Total Billed Charges,135.94,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,67.97,45,,6492.328,Percent of Total Billed Charges,45% of Total Billed Charges,135.94,90,,25969.32,Percent of Total Billed Charges,90% of Total billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.18,65,,2248.488,Percent of total Billed Charges,65% of Total Billed Charges,66.61,44.1,,6362.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,143.49,95,,27412.064,Percent of Total Billed Charges,95% of Total Billed Charges,151.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.92,88,,12696.112,Percent of Total Billed Charges,88% of Total Billed Charges,135.94,90,,25969.32,Percent of Total Billed charges,90% of Total Billed Charges,66.61,151.04,
FLOW VOLUME LOOP,4600000004,CDM,460,RC,,,Outpatient,,,460.30,299.20,,460.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,349.83,76,,21929.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,331.42,72,,48.896,Percent of Total Billed Charges,72% of Total Billed Charges,345.23,75,,50.936,Percent of Total Billed charges,75% of Total Billed Charges,460.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,331.42,72,,48.896,Percent of Total Billed Charges,72% of Total Billed Charges,276.18,60,,40.744,Percent of Total Billed Charges,60% of Total Billed Charges,414.27,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,207.14,45,,6492.328,Percent of Total Billed Charges,45% of Total Billed Charges,414.27,90,,25969.32,Percent of Total Billed Charges,90% of Total billed Charges,460.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,460.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,460.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,299.2,65,,2248.488,Percent of total Billed Charges,65% of Total Billed Charges,202.99,44.1,,6362.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,437.29,95,,27412.064,Percent of Total Billed Charges,95% of Total Billed Charges,460.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.06,88,,12696.112,Percent of Total Billed Charges,88% of Total Billed Charges,414.27,90,,25969.32,Percent of Total Billed charges,90% of Total Billed Charges,202.99,460.3,
PULSE OXIMETRY SINGL,4600000005,CDM,460,RC,,,Outpatient,,,100.00,65.00,,100,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,76,76,,21929.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,72,72,,83.824,Percent of Total Billed Charges,72% of Total Billed Charges,75,75,,87.32,Percent of Total Billed charges,75% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72,72,,83.824,Percent of Total Billed Charges,72% of Total Billed Charges,60,60,,69.856,Percent of Total Billed Charges,60% of Total Billed Charges,90,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,45,45,,6492.328,Percent of Total Billed Charges,45% of Total Billed Charges,90,90,,25969.32,Percent of Total Billed Charges,90% of Total billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65,65,,2248.488,Percent of total Billed Charges,65% of Total Billed Charges,44.1,44.1,,6362.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,95,95,,27412.064,Percent of Total Billed Charges,95% of Total Billed Charges,100,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,90,90,,25969.32,Percent of Total Billed charges,90% of Total Billed Charges,44.1,100,
PULSE OXIMETRY MULTI,4600000006,CDM,460,RC,,,Outpatient,,,476.28,309.58,,476.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,361.97,76,,21929.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,342.92,72,,13.536,Percent of Total Billed Charges,72% of Total Billed Charges,357.21,75,,14.104,Percent of Total Billed charges,75% of Total Billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.92,72,,13.536,Percent of Total Billed Charges,72% of Total Billed Charges,285.77,60,,11.28,Percent of Total Billed Charges,60% of Total Billed Charges,428.65,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,214.33,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,428.65,90,,25969.32,Percent of Total Billed Charges,90% of Total billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.58,65,,2060.44,Percent of total Billed Charges,65% of Total Billed Charges,210.04,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,452.47,95,,27412.064,Percent of Total Billed Charges,95% of Total Billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.13,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,428.65,90,,25969.32,Percent of Total Billed charges,90% of Total Billed Charges,210.04,476.28,
PULSE OX CONT,4600000007,CDM,460,RC,,,Outpatient,,,138.00,89.70,,138,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,104.88,76,,10964.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,99.36,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,103.5,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,138,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.36,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,82.8,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,124.2,90,,16235.592,Percent of Total Billed Charges,90% of Total Billed Charges,62.1,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,124.2,90,,12984.664,Percent of Total Billed Charges,90% of Total billed Charges,138,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.7,65,,2060.44,Percent of total Billed Charges,65% of Total Billed Charges,60.86,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,131.1,95,,13706.032,Percent of Total Billed Charges,95% of Total Billed Charges,138,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.44,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,124.2,90,,12984.664,Percent of Total Billed charges,90% of Total Billed Charges,60.86,138,
Pulmonary Stress Test,4600000008,CDM,460,RC,,,Outpatient,,,266.42,173.17,,266.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,202.48,76,,10964.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,191.82,72,,247.208,Percent of Total Billed Charges,72% of Total Billed Charges,199.82,75,,257.512,Percent of Total Billed charges,75% of Total Billed Charges,266.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.82,72,,247.208,Percent of Total Billed Charges,72% of Total Billed Charges,159.85,60,,206.008,Percent of Total Billed Charges,60% of Total Billed Charges,239.78,90,,1800,Percent of Total Billed Charges,90% of Total Billed Charges,119.89,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,239.78,90,,12984.664,Percent of Total Billed Charges,90% of Total billed Charges,266.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.17,65,,2060.44,Percent of total Billed Charges,65% of Total Billed Charges,117.49,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,253.1,95,,13706.032,Percent of Total Billed Charges,95% of Total Billed Charges,266.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.45,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,239.78,90,,12984.664,Percent of Total Billed charges,90% of Total Billed Charges,117.49,266.42,
Auditory EP Limited (Newborn),4710000003,CDM,471,RC,,,Outpatient,,,338.00,219.70,,338,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,256.88,76,,10964.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,243.36,72,,247.208,Percent of Total Billed Charges,72% of Total Billed Charges,253.5,75,,257.512,Percent of Total Billed charges,75% of Total Billed Charges,338,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.36,72,,247.208,Percent of Total Billed Charges,72% of Total Billed Charges,202.8,60,,206.008,Percent of Total Billed Charges,60% of Total Billed Charges,304.2,90,,4973.616,Percent of Total Billed Charges,90% of Total Billed Charges,152.1,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,304.2,90,,12984.664,Percent of Total Billed Charges,90% of Total billed Charges,338,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,338,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,338,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.7,65,,2060.44,Percent of total Billed Charges,65% of Total Billed Charges,149.06,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,321.1,95,,13706.032,Percent of Total Billed Charges,95% of Total Billed Charges,338,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.44,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,304.2,90,,12984.664,Percent of Total Billed charges,90% of Total Billed Charges,149.06,338,
Auditory testing mult freq,4710000004,CDM,471,RC,,,Outpatient,,,635.85,413.30,,635.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,483.25,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,457.81,72,,50.168,Percent of Total Billed Charges,72% of Total Billed Charges,476.89,75,,52.264,Percent of Total Billed charges,75% of Total Billed Charges,635.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,457.81,72,,50.168,Percent of Total Billed Charges,72% of Total Billed Charges,381.51,60,,41.808,Percent of Total Billed Charges,60% of Total Billed Charges,572.27,90,,1231.2,Percent of Total Billed Charges,90% of Total Billed Charges,286.13,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,572.27,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,635.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,635.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,635.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.3,65,,2060.44,Percent of total Billed Charges,65% of Total Billed Charges,280.41,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,604.06,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,635.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.55,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,572.27,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,280.41,635.85,
Auditory repeat screening,4710000005,CDM,471,RC,,,Outpatient,,,704.00,457.60,,704,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,535.04,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,506.88,72,,247.208,Percent of Total Billed Charges,72% of Total Billed Charges,528,75,,257.512,Percent of Total Billed charges,75% of Total Billed Charges,704,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.88,72,,247.208,Percent of Total Billed Charges,72% of Total Billed Charges,422.4,60,,206.008,Percent of Total Billed Charges,60% of Total Billed Charges,633.6,90,,1231.2,Percent of Total Billed Charges,90% of Total Billed Charges,316.8,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,633.6,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,704,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,457.6,65,,2060.44,Percent of total Billed Charges,65% of Total Billed Charges,310.46,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,668.8,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,704,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,619.52,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,633.6,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,310.46,704,
INS ICD GEN ONLY W/ EX MULTI,4800000001,CDM,480,RC,,,Outpatient,,,30119.04,19577.38,,30119.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22890.47,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21685.71,72,,247.208,Percent of Total Billed Charges,72% of Total Billed Charges,22589.28,75,,257.512,Percent of Total Billed charges,75% of Total Billed Charges,30119.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21685.71,72,,247.208,Percent of Total Billed Charges,72% of Total Billed Charges,18071.42,60,,206.008,Percent of Total Billed Charges,60% of Total Billed Charges,27107.14,90,,1231.2,Percent of Total Billed Charges,90% of Total Billed Charges,13553.57,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,27107.14,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,30119.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30119.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30119.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19577.38,65,,2060.44,Percent of total Billed Charges,65% of Total Billed Charges,13282.5,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,28613.09,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,30119.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26504.76,88,,15874.8,Percent of Total Billed Charges,88% of Total Billed Charges,27107.14,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,13282.5,30119.04,
INSERT OR REPL DEFIB W/LEAD(S),4800000002,CDM,480,RC,,,Outpatient,,,48242.40,31357.56,,48242.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36664.22,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34734.53,72,,1094.168,Percent of Total Billed Charges,72% of Total Billed Charges,36181.8,75,,1139.76,Percent of Total Billed charges,75% of Total Billed Charges,48242.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34734.53,72,,1094.168,Percent of Total Billed Charges,72% of Total Billed Charges,28945.44,60,,911.808,Percent of Total Billed Charges,60% of Total Billed Charges,43418.16,90,,1296,Percent of Total Billed Charges,90% of Total Billed Charges,21709.08,45,,8117.792,Percent of Total Billed Charges,45% of Total Billed Charges,43418.16,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,48242.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48242.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48242.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31357.56,65,,2060.44,Percent of total Billed Charges,65% of Total Billed Charges,21274.9,44.1,,7955.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,45830.28,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,48242.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42453.31,88,,1760,Percent of Total Billed Charges,88% of Total Billed Charges,43418.16,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,21274.9,48242.4,
REM & REP PPM GEN MULTI LEAD,4800000003,CDM,480,RC,,,Outpatient,,,29631.89,19260.73,,29631.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22520.24,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21334.96,72,,547.088,Percent of Total Billed Charges,72% of Total Billed Charges,22223.92,75,,569.88,Percent of Total Billed charges,75% of Total Billed Charges,29631.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21334.96,72,,547.088,Percent of Total Billed Charges,72% of Total Billed Charges,17779.13,60,,455.904,Percent of Total Billed Charges,60% of Total Billed Charges,26668.7,90,,1231.2,Percent of Total Billed Charges,90% of Total Billed Charges,13334.35,45,,900,Percent of Total Billed Charges,45% of Total Billed Charges,26668.7,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,29631.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29631.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29631.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19260.73,65,,1618.424,Percent of total Billed Charges,65% of Total Billed Charges,13067.66,44.1,,882,Percent of Total Billed Charges,44.1% of Total Billed Charges,28150.3,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,29631.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26076.06,88,,4863.088,Percent of Total Billed Charges,88% of Total Billed Charges,26668.7,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,13067.66,29631.89,
REM & REPLAC PPM GEN DUAL LEAD,4800000004,CDM,480,RC,,,Outpatient,,,28151.00,18298.15,,28151,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21394.76,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20268.72,72,,273.544,Percent of Total Billed Charges,72% of Total Billed Charges,21113.25,75,,284.944,Percent of Total Billed charges,75% of Total Billed Charges,28151,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20268.72,72,,273.544,Percent of Total Billed Charges,72% of Total Billed Charges,16890.6,60,,227.952,Percent of Total Billed Charges,60% of Total Billed Charges,25335.9,90,,1296,Percent of Total Billed Charges,90% of Total Billed Charges,12667.95,45,,2486.808,Percent of Total Billed Charges,45% of Total Billed Charges,25335.9,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,28151,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28151,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28151,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18298.15,65,,1618.424,Percent of total Billed Charges,65% of Total Billed Charges,12414.59,44.1,,2437.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,26743.45,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,28151,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24772.88,88,,1203.84,Percent of Total Billed Charges,88% of Total Billed Charges,25335.9,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,12414.59,28151,
REM& REP PPM GEN SINGLE LEAD,4800000005,CDM,480,RC,,,Outpatient,,,25398.29,16508.89,,25398.29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19302.7,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18286.77,72,,218.832,Percent of Total Billed Charges,72% of Total Billed Charges,19048.72,75,,227.952,Percent of Total Billed charges,75% of Total Billed Charges,25398.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18286.77,72,,218.832,Percent of Total Billed Charges,72% of Total Billed Charges,15238.97,60,,182.36,Percent of Total Billed Charges,60% of Total Billed Charges,22858.46,90,,1296,Percent of Total Billed Charges,90% of Total Billed Charges,11429.23,45,,615.6,Percent of Total Billed Charges,45% of Total Billed Charges,22858.46,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,25398.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25398.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25398.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16508.89,65,,1618.424,Percent of total Billed Charges,65% of Total Billed Charges,11200.65,44.1,,603.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,24128.38,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,25398.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22350.5,88,,1203.84,Percent of Total Billed Charges,88% of Total Billed Charges,22858.46,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,11200.65,25398.29,
PPM SC INITIAL INS,4800000006,CDM,480,RC,,,Outpatient,,,31611.98,20547.79,,31611.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,24025.1,76,,13710.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22760.63,72,,364.608,Percent of Total Billed Charges,72% of Total Billed Charges,23708.99,75,,379.8,Percent of Total Billed charges,75% of Total Billed Charges,31611.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22760.63,72,,364.608,Percent of Total Billed Charges,72% of Total Billed Charges,18967.19,60,,303.84,Percent of Total Billed Charges,60% of Total Billed Charges,28450.78,90,,1296,Percent of Total Billed Charges,90% of Total Billed Charges,14225.39,45,,615.6,Percent of Total Billed Charges,45% of Total Billed Charges,28450.78,90,,16235.592,Percent of Total Billed Charges,90% of Total billed Charges,31611.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31611.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31611.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20547.79,65,,1618.424,Percent of total Billed Charges,65% of Total Billed Charges,13940.88,44.1,,603.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,30031.38,95,,17137.568,Percent of Total Billed Charges,95% of Total Billed Charges,31611.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27818.54,88,,1203.84,Percent of Total Billed Charges,88% of Total Billed Charges,28450.78,90,,16235.592,Percent of Total Billed charges,90% of Total Billed Charges,13940.88,31611.98,
PPM DC INITIAL INSERTION,4800000007,CDM,480,RC,,,Outpatient,,,39126.62,25432.30,,39126.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29736.23,76,,1520,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28171.17,72,,364.72,Percent of Total Billed Charges,72% of Total Billed Charges,29344.97,75,,379.92,Percent of Total Billed charges,75% of Total Billed Charges,39126.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28171.17,72,,364.72,Percent of Total Billed Charges,72% of Total Billed Charges,23475.97,60,,303.936,Percent of Total Billed Charges,60% of Total Billed Charges,35213.96,90,,1296,Percent of Total Billed Charges,90% of Total Billed Charges,17606.98,45,,615.6,Percent of Total Billed Charges,45% of Total Billed Charges,35213.96,90,,1800,Percent of Total Billed Charges,90% of Total billed Charges,39126.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39126.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39126.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25432.3,65,,1618.424,Percent of total Billed Charges,65% of Total Billed Charges,17254.84,44.1,,603.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,37170.29,95,,1900,Percent of Total Billed Charges,95% of Total Billed Charges,39126.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34431.43,88,,1267.2,Percent of Total Billed Charges,88% of Total Billed Charges,35213.96,90,,1800,Percent of Total Billed charges,90% of Total Billed Charges,17254.84,39126.62,
REVISE PPM POCKET,4800000008,CDM,480,RC,,,Outpatient,,,5147.57,3345.92,,5147.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3912.15,76,,4199.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3706.25,72,,273.544,Percent of Total Billed Charges,72% of Total Billed Charges,3860.68,75,,284.944,Percent of Total Billed charges,75% of Total Billed Charges,5147.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3706.25,72,,273.544,Percent of Total Billed Charges,72% of Total Billed Charges,3088.54,60,,227.952,Percent of Total Billed Charges,60% of Total Billed Charges,4632.81,90,,1296,Percent of Total Billed Charges,90% of Total Billed Charges,2316.41,45,,648,Percent of Total Billed Charges,45% of Total Billed Charges,4632.81,90,,4973.616,Percent of Total Billed Charges,90% of Total billed Charges,5147.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5147.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5147.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3345.92,65,,1618.424,Percent of total Billed Charges,65% of Total Billed Charges,2270.08,44.1,,635.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,4890.19,95,,5249.928,Percent of Total Billed Charges,95% of Total Billed Charges,5147.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4529.86,88,,1203.84,Percent of Total Billed Charges,88% of Total Billed Charges,4632.81,90,,4973.616,Percent of Total Billed charges,90% of Total Billed Charges,2270.08,5147.57,
REVISE ICD POCKET,4800000009,CDM,480,RC,,,Outpatient,,,5147.57,3345.92,,5147.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3912.15,76,,1039.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3706.25,72,,1094.168,Percent of Total Billed Charges,72% of Total Billed Charges,3860.68,75,,1139.76,Percent of Total Billed charges,75% of Total Billed Charges,5147.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3706.25,72,,1094.168,Percent of Total Billed Charges,72% of Total Billed Charges,3088.54,60,,911.808,Percent of Total Billed Charges,60% of Total Billed Charges,4632.81,90,,18867.6,Percent of Total Billed Charges,90% of Total Billed Charges,2316.41,45,,615.6,Percent of Total Billed Charges,45% of Total Billed Charges,4632.81,90,,1231.2,Percent of Total Billed Charges,90% of Total billed Charges,5147.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5147.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5147.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3345.92,65,,1618.424,Percent of total Billed Charges,65% of Total Billed Charges,2270.08,44.1,,603.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,4890.19,95,,1299.6,Percent of Total Billed Charges,95% of Total Billed Charges,5147.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4529.86,88,,1267.2,Percent of Total Billed Charges,88% of Total Billed Charges,4632.81,90,,1231.2,Percent of Total Billed charges,90% of Total Billed Charges,2270.08,5147.57,
CPR,4800000012,CDM,480,RC,,,Outpatient,,,3340.00,2171.00,,3340,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2538.4,76,,1039.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2404.8,72,,547.088,Percent of Total Billed Charges,72% of Total Billed Charges,2505,75,,569.88,Percent of Total Billed charges,75% of Total Billed Charges,3340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2404.8,72,,547.088,Percent of Total Billed Charges,72% of Total Billed Charges,2004,60,,455.904,Percent of Total Billed Charges,60% of Total Billed Charges,3006,90,,30072.6,Percent of Total Billed Charges,90% of Total Billed Charges,1503,45,,648,Percent of Total Billed Charges,45% of Total Billed Charges,3006,90,,1231.2,Percent of Total Billed Charges,90% of Total billed Charges,3340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2171,65,,1618.424,Percent of total Billed Charges,65% of Total Billed Charges,1472.94,44.1,,635.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,3173,95,,1299.6,Percent of Total Billed Charges,95% of Total Billed Charges,3340,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2939.2,88,,1267.2,Percent of Total Billed Charges,88% of Total Billed Charges,3006,90,,1231.2,Percent of Total Billed charges,90% of Total Billed Charges,1472.94,3340,
2D ECHO COMPLETE,4800000013,CDM,480,RC,,,Outpatient,,,2257.26,1467.22,,2257.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1715.52,76,,1039.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1625.23,72,,218.832,Percent of Total Billed Charges,72% of Total Billed Charges,1692.95,75,,227.952,Percent of Total Billed charges,75% of Total Billed Charges,2257.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1625.23,72,,218.832,Percent of Total Billed Charges,72% of Total Billed Charges,1354.36,60,,182.36,Percent of Total Billed Charges,60% of Total Billed Charges,2031.53,90,,30072.6,Percent of Total Billed Charges,90% of Total Billed Charges,1015.77,45,,648,Percent of Total Billed Charges,45% of Total Billed Charges,2031.53,90,,1231.2,Percent of Total Billed Charges,90% of Total billed Charges,2257.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2257.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1467.22,65,,3041.936,Percent of total Billed Charges,65% of Total Billed Charges,995.45,44.1,,635.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,2144.4,95,,1299.6,Percent of Total Billed Charges,95% of Total Billed Charges,2257.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1986.39,88,,1267.2,Percent of Total Billed Charges,88% of Total Billed Charges,2031.53,90,,1231.2,Percent of Total Billed charges,90% of Total Billed Charges,995.45,2257.26,
ECHO COMPLETE,4800000014,CDM,480,RC,,,Outpatient,,,2365.00,1537.25,,2365,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1797.4,76,,1094.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1702.8,72,,164.448,Percent of Total Billed Charges,72% of Total Billed Charges,1773.75,75,,171.304,Percent of Total Billed charges,75% of Total Billed Charges,2365,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1702.8,72,,164.448,Percent of Total Billed Charges,72% of Total Billed Charges,1419,60,,137.04,Percent of Total Billed Charges,60% of Total Billed Charges,2128.5,90,,30072.6,Percent of Total Billed Charges,90% of Total Billed Charges,1064.25,45,,648,Percent of Total Billed Charges,45% of Total Billed Charges,2128.5,90,,1296,Percent of Total Billed Charges,90% of Total billed Charges,2365,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2365,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2365,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1537.25,65,,3041.936,Percent of total Billed Charges,65% of Total Billed Charges,1042.97,44.1,,635.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,2246.75,95,,1368,Percent of Total Billed Charges,95% of Total Billed Charges,2365,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2081.2,88,,1267.2,Percent of Total Billed Charges,88% of Total Billed Charges,2128.5,90,,1296,Percent of Total Billed charges,90% of Total Billed Charges,1042.97,2365,
ECHO 2D MMODE S COLOR,4800000015,CDM,480,RC,,,Outpatient,,,929.41,604.12,,929.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,706.35,76,,1039.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,669.18,72,,50.832,Percent of Total Billed Charges,72% of Total Billed Charges,697.06,75,,52.952,Percent of Total Billed charges,75% of Total Billed Charges,929.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,669.18,72,,50.832,Percent of Total Billed Charges,72% of Total Billed Charges,557.65,60,,42.36,Percent of Total Billed Charges,60% of Total Billed Charges,836.47,90,,18867.6,Percent of Total Billed Charges,90% of Total Billed Charges,418.23,45,,648,Percent of Total Billed Charges,45% of Total Billed Charges,836.47,90,,1231.2,Percent of Total Billed Charges,90% of Total billed Charges,929.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,929.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,929.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,604.12,65,,3041.936,Percent of total Billed Charges,65% of Total Billed Charges,409.87,44.1,,635.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,882.94,95,,1299.6,Percent of Total Billed Charges,95% of Total Billed Charges,929.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,817.88,88,,1267.2,Percent of Total Billed Charges,88% of Total Billed Charges,836.47,90,,1231.2,Percent of Total Billed charges,90% of Total Billed Charges,409.87,929.41,
ECHO LIMITED,4800000016,CDM,480,RC,,,Outpatient,,,636.00,413.40,,636,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,483.36,76,,1094.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,457.92,72,,27.072,Percent of Total Billed Charges,72% of Total Billed Charges,477,75,,28.2,Percent of Total Billed charges,75% of Total Billed Charges,636,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,457.92,72,,27.072,Percent of Total Billed Charges,72% of Total Billed Charges,381.6,60,,22.56,Percent of Total Billed Charges,60% of Total Billed Charges,572.4,90,,30072.6,Percent of Total Billed Charges,90% of Total Billed Charges,286.2,45,,648,Percent of Total Billed Charges,45% of Total Billed Charges,572.4,90,,1296,Percent of Total Billed Charges,90% of Total billed Charges,636,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,636,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,636,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.4,65,,3041.936,Percent of total Billed Charges,65% of Total Billed Charges,280.48,44.1,,635.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,604.2,95,,1368,Percent of Total Billed Charges,95% of Total Billed Charges,636,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.68,88,,18448.32,Percent of Total Billed Charges,88% of Total Billed Charges,572.4,90,,1296,Percent of Total Billed charges,90% of Total Billed Charges,280.48,636,
TRANSESOPHAGEAL ECH,4800000017,CDM,480,RC,,,Outpatient,,,2714.36,1764.33,,2714.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2062.91,76,,1094.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1954.34,72,,101.056,Percent of Total Billed Charges,72% of Total Billed Charges,2035.77,75,,105.272,Percent of Total Billed charges,75% of Total Billed Charges,2714.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1954.34,72,,101.056,Percent of Total Billed Charges,72% of Total Billed Charges,1628.62,60,,84.216,Percent of Total Billed Charges,60% of Total Billed Charges,2442.92,90,,30072.6,Percent of Total Billed Charges,90% of Total Billed Charges,1221.46,45,,9433.8,Percent of Total Billed Charges,45% of Total Billed Charges,2442.92,90,,1296,Percent of Total Billed Charges,90% of Total billed Charges,2714.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2714.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2714.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1764.33,65,,3041.936,Percent of total Billed Charges,65% of Total Billed Charges,1197.03,44.1,,9245.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,2578.64,95,,1368,Percent of Total Billed Charges,95% of Total Billed Charges,2714.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2388.64,88,,29404.32,Percent of Total Billed Charges,88% of Total Billed Charges,2442.92,90,,1296,Percent of Total Billed charges,90% of Total Billed Charges,1197.03,2714.36,
STRESS ECHO,4800000018,CDM,480,RC,,,Outpatient,,,2006.55,1304.26,,2006.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1524.98,76,,1094.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1444.72,72,,102.784,Percent of Total Billed Charges,72% of Total Billed Charges,1504.91,75,,107.072,Percent of Total Billed charges,75% of Total Billed Charges,2006.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1444.72,72,,102.784,Percent of Total Billed Charges,72% of Total Billed Charges,1203.93,60,,85.656,Percent of Total Billed Charges,60% of Total Billed Charges,1805.9,90,,30072.6,Percent of Total Billed Charges,90% of Total Billed Charges,902.95,45,,15036.304,Percent of Total Billed Charges,45% of Total Billed Charges,1805.9,90,,1296,Percent of Total Billed Charges,90% of Total billed Charges,2006.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2006.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2006.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1304.26,65,,3041.936,Percent of total Billed Charges,65% of Total Billed Charges,884.89,44.1,,14735.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,1906.22,95,,1368,Percent of Total Billed Charges,95% of Total Billed Charges,2006.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1765.76,88,,29404.32,Percent of Total Billed Charges,88% of Total Billed Charges,1805.9,90,,1296,Percent of Total Billed charges,90% of Total Billed Charges,884.89,2006.55,
TILT TABLE TEST,4800000019,CDM,480,RC,,,Outpatient,,,1177.90,765.64,,1177.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,895.2,76,,1094.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,848.09,72,,102.784,Percent of Total Billed Charges,72% of Total Billed Charges,883.43,75,,107.072,Percent of Total Billed charges,75% of Total Billed Charges,1177.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,848.09,72,,102.784,Percent of Total Billed Charges,72% of Total Billed Charges,706.74,60,,85.656,Percent of Total Billed Charges,60% of Total Billed Charges,1060.11,90,,766.08,Percent of Total Billed Charges,90% of Total Billed Charges,530.06,45,,15036.304,Percent of Total Billed Charges,45% of Total Billed Charges,1060.11,90,,1296,Percent of Total Billed Charges,90% of Total billed Charges,1177.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1177.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1177.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,765.64,65,,2550.08,Percent of total Billed Charges,65% of Total Billed Charges,519.45,44.1,,14735.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,1119.01,95,,1368,Percent of Total Billed Charges,95% of Total Billed Charges,1177.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1036.55,88,,29404.32,Percent of Total Billed Charges,88% of Total Billed Charges,1060.11,90,,1296,Percent of Total Billed charges,90% of Total Billed Charges,519.45,1177.9,
PERPHERAL VASCULAR REHAB,4800000020,CDM,480,RC,,,Outpatient,,,119.00,77.35,,119,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,90.44,76,,1094.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,85.68,72,,381.304,Percent of Total Billed Charges,72% of Total Billed Charges,89.25,75,,397.192,Percent of Total Billed charges,75% of Total Billed Charges,119,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.68,72,,381.304,Percent of Total Billed Charges,72% of Total Billed Charges,71.4,60,,317.752,Percent of Total Billed Charges,60% of Total Billed Charges,107.1,90,,984.312,Percent of Total Billed Charges,90% of Total Billed Charges,53.55,45,,15036.304,Percent of Total Billed Charges,45% of Total Billed Charges,107.1,90,,1296,Percent of Total Billed Charges,90% of Total billed Charges,119,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.35,65,,2229.24,Percent of total Billed Charges,65% of Total Billed Charges,52.48,44.1,,14735.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,113.05,95,,1368,Percent of Total Billed Charges,95% of Total Billed Charges,119,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.72,88,,18448.32,Percent of Total Billed Charges,88% of Total Billed Charges,107.1,90,,1296,Percent of Total Billed charges,90% of Total Billed Charges,52.48,119,
ILIAC/FEMORAL ART ANG NNSEL CC,4810000001,CDM,481,RC,G0278,HCPCS,Outpatient,,,1563.15,1016.05,,1563.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1187.99,76,,15932.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1563.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1406.84,90,,1243.008,Percent of Total Billed Charges,90% of Total Billed Charges,703.42,45,,9433.8,Percent of Total Billed Charges,45% of Total Billed Charges,1406.84,90,,18867.6,Percent of Total Billed Charges,90% of Total billed Charges,1563.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1563.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1563.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1016.05,65,,2229.24,Percent of total Billed Charges,65% of Total Billed Charges,689.35,44.1,,9245.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,1484.99,95,,19915.8,Percent of Total Billed Charges,95% of Total Billed Charges,1563.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1375.57,88,,29404.32,Percent of Total Billed Charges,88% of Total Billed Charges,1406.84,90,,18867.6,Percent of Total Billed charges,90% of Total Billed Charges,689.35,1563.15,
INJ SUPRAVALVULAR AORTAGRAPHY,4810000002,CDM,481,RC,,,Outpatient,,,2375.00,1543.75,,2375,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1805,76,,25394.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1710,72,,12513.6,Percent of Total Billed Charges,72% of Total Billed Charges,1781.25,75,,13035,Percent of Total Billed charges,75% of Total Billed Charges,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1710,72,,12513.6,Percent of Total Billed Charges,72% of Total Billed Charges,1425,60,,10428,Percent of Total Billed Charges,60% of Total Billed Charges,2137.5,90,,639.792,Percent of Total Billed Charges,90% of Total Billed Charges,1068.75,45,,15036.304,Percent of Total Billed Charges,45% of Total Billed Charges,2137.5,90,,30072.6,Percent of Total Billed Charges,90% of Total billed Charges,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1543.75,65,,2128.088,Percent of total Billed Charges,65% of Total Billed Charges,1047.38,44.1,,14735.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,2256.25,95,,31743.304,Percent of Total Billed Charges,95% of Total Billed Charges,2375,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2090,88,,29404.32,Percent of Total Billed Charges,88% of Total Billed Charges,2137.5,90,,30072.6,Percent of Total Billed charges,90% of Total Billed Charges,1047.38,2375,
RIGHT & LEFT HEART CATH LV COR,4810000003,CDM,481,RC,,,Outpatient,,,18836.00,12243.40,,18836,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14315.36,76,,25394.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13561.92,72,,83.664,Percent of Total Billed Charges,72% of Total Billed Charges,14127,75,,87.152,Percent of Total Billed charges,75% of Total Billed Charges,18836,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13561.92,72,,83.664,Percent of Total Billed Charges,72% of Total Billed Charges,11301.6,60,,69.72,Percent of Total Billed Charges,60% of Total Billed Charges,16952.4,90,,1503.464,Percent of Total Billed Charges,90% of Total Billed Charges,8476.2,45,,15036.304,Percent of Total Billed Charges,45% of Total Billed Charges,16952.4,90,,30072.6,Percent of Total Billed Charges,90% of Total billed Charges,18836,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18836,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18836,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12243.4,65,,2128.088,Percent of total Billed Charges,65% of Total Billed Charges,8306.68,44.1,,14735.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,17894.2,95,,31743.304,Percent of Total Billed Charges,95% of Total Billed Charges,18836,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16575.68,88,,29404.32,Percent of Total Billed Charges,88% of Total Billed Charges,16952.4,90,,30072.6,Percent of Total Billed charges,90% of Total Billed Charges,8306.68,18836,
RIGHT & LEFT HEART CATH LV IMA,4810000004,CDM,481,RC,,,Outpatient,,,22056.62,14336.80,,22056.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16763.03,76,,25394.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15880.77,72,,108,Percent of Total Billed Charges,72% of Total Billed Charges,16542.47,75,,112.504,Percent of Total Billed charges,75% of Total Billed Charges,22056.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15880.77,72,,108,Percent of Total Billed Charges,72% of Total Billed Charges,13233.97,60,,90,Percent of Total Billed Charges,60% of Total Billed Charges,19850.96,90,,1503.464,Percent of Total Billed Charges,90% of Total Billed Charges,9925.48,45,,15036.304,Percent of Total Billed Charges,45% of Total Billed Charges,19850.96,90,,30072.6,Percent of Total Billed Charges,90% of Total billed Charges,22056.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22056.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22056.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14336.8,65,,2550.08,Percent of total Billed Charges,65% of Total Billed Charges,9726.97,44.1,,14735.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,20953.79,95,,31743.304,Percent of Total Billed Charges,95% of Total Billed Charges,22056.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19409.83,88,,749.056,Percent of Total Billed Charges,88% of Total Billed Charges,19850.96,90,,30072.6,Percent of Total Billed charges,90% of Total Billed Charges,9726.97,22056.62,
RIGHT & LEFT HEART CATH LV SVG,4810000005,CDM,481,RC,,,Outpatient,,,22056.62,14336.80,,22056.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16763.03,76,,15932.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15880.77,72,,112.32,Percent of Total Billed Charges,72% of Total Billed Charges,16542.47,75,,117,Percent of Total Billed charges,75% of Total Billed Charges,22056.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15880.77,72,,112.32,Percent of Total Billed Charges,72% of Total Billed Charges,13233.97,60,,93.6,Percent of Total Billed Charges,60% of Total Billed Charges,19850.96,90,,69.856,Percent of Total Billed Charges,90% of Total Billed Charges,9925.48,45,,383.04,Percent of Total Billed Charges,45% of Total Billed Charges,19850.96,90,,18867.6,Percent of Total Billed Charges,90% of Total billed Charges,22056.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22056.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22056.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14336.8,65,,2220.4,Percent of total Billed Charges,65% of Total Billed Charges,9726.97,44.1,,375.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,20953.79,95,,19915.8,Percent of Total Billed Charges,95% of Total Billed Charges,22056.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19409.83,88,,962.44,Percent of Total Billed Charges,88% of Total Billed Charges,19850.96,90,,18867.6,Percent of Total Billed charges,90% of Total Billed Charges,9726.97,22056.62,
"RIGHT & LFT HRT CATH, LV ONLY",4810000006,CDM,481,RC,,,Outpatient,,,17273.97,11228.08,,17273.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13128.22,76,,25394.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12437.26,72,,9.36,Percent of Total Billed Charges,72% of Total Billed Charges,12955.48,75,,9.752,Percent of Total Billed charges,75% of Total Billed Charges,17273.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12437.26,72,,9.36,Percent of Total Billed Charges,72% of Total Billed Charges,10364.38,60,,7.8,Percent of Total Billed Charges,60% of Total Billed Charges,15546.57,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,7773.29,45,,492.16,Percent of Total Billed Charges,45% of Total Billed Charges,15546.57,90,,30072.6,Percent of Total Billed Charges,90% of Total billed Charges,17273.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17273.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17273.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11228.08,65,,1624.736,Percent of total Billed Charges,65% of Total Billed Charges,7617.82,44.1,,482.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,16410.27,95,,31743.304,Percent of Total Billed Charges,95% of Total Billed Charges,17273.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15201.09,88,,1215.384,Percent of Total Billed Charges,88% of Total Billed Charges,15546.57,90,,30072.6,Percent of Total Billed charges,90% of Total Billed Charges,7617.82,17273.97,
RT&LT HRT CATH LV COR SVG IMA,4810000007,CDM,481,RC,,,Outpatient,,,22056.62,14336.80,,22056.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16763.03,76,,25394.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15880.77,72,,268.056,Percent of Total Billed Charges,72% of Total Billed Charges,16542.47,75,,279.232,Percent of Total Billed charges,75% of Total Billed Charges,22056.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15880.77,72,,268.056,Percent of Total Billed Charges,72% of Total Billed Charges,13233.97,60,,223.384,Percent of Total Billed Charges,60% of Total Billed Charges,19850.96,90,,22.224,Percent of Total Billed Charges,90% of Total Billed Charges,9925.48,45,,621.504,Percent of Total Billed Charges,45% of Total Billed Charges,19850.96,90,,30072.6,Percent of Total Billed Charges,90% of Total billed Charges,22056.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22056.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22056.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14336.8,65,,1530.88,Percent of total Billed Charges,65% of Total Billed Charges,9726.97,44.1,,609.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,20953.79,95,,31743.304,Percent of Total Billed Charges,95% of Total Billed Charges,22056.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19409.83,88,,625.576,Percent of Total Billed Charges,88% of Total Billed Charges,19850.96,90,,30072.6,Percent of Total Billed charges,90% of Total Billed Charges,9726.97,22056.62,
TRANS RTRV PERC TRAV FB W/IMA,4810000008,CDM,481,RC,,,Outpatient,,,2219.99,1442.99,,2219.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1687.19,76,,25394.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1598.39,72,,1117.352,Percent of Total Billed Charges,72% of Total Billed Charges,1664.99,75,,1163.912,Percent of Total Billed charges,75% of Total Billed Charges,2219.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1598.39,72,,1117.352,Percent of Total Billed Charges,72% of Total Billed Charges,1331.99,60,,931.128,Percent of Total Billed Charges,60% of Total Billed Charges,1997.99,90,,3221.248,Percent of Total Billed Charges,90% of Total Billed Charges,999,45,,319.896,Percent of Total Billed Charges,45% of Total Billed Charges,1997.99,90,,30072.6,Percent of Total Billed Charges,90% of Total billed Charges,2219.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2219.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2219.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1442.99,65,,1624.736,Percent of total Billed Charges,65% of Total Billed Charges,979.02,44.1,,313.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,2108.99,95,,31743.304,Percent of Total Billed Charges,95% of Total Billed Charges,2219.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1953.59,88,,1470.048,Percent of Total Billed Charges,88% of Total Billed Charges,1997.99,90,,30072.6,Percent of Total Billed charges,90% of Total Billed Charges,979.02,2219.99,
Translumin Ba Angiopla 1st Art,4810000009,CDM,481,RC,,,Outpatient,,,13426.23,8727.05,,13426.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10203.93,76,,646.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9666.89,72,,205.24,Percent of Total Billed Charges,72% of Total Billed Charges,10069.67,75,,213.792,Percent of Total Billed charges,75% of Total Billed Charges,13426.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9666.89,72,,205.24,Percent of Total Billed Charges,72% of Total Billed Charges,8055.74,60,,171.032,Percent of Total Billed Charges,60% of Total Billed Charges,12083.61,90,,979.92,Percent of Total Billed Charges,90% of Total Billed Charges,6041.8,45,,751.728,Percent of Total Billed Charges,45% of Total Billed Charges,12083.61,90,,766.08,Percent of Total Billed Charges,90% of Total billed Charges,13426.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13426.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13426.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8727.05,65,,2024.36,Percent of total Billed Charges,65% of Total Billed Charges,5920.97,44.1,,736.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,12754.92,95,,808.64,Percent of Total Billed Charges,95% of Total Billed Charges,13426.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11815.08,88,,1470.048,Percent of Total Billed Charges,88% of Total Billed Charges,12083.61,90,,766.08,Percent of Total Billed charges,90% of Total Billed Charges,5920.97,13426.23,
VAS EMBOLIZATION VEN W/O HEMMO,4810000010,CDM,481,RC,,,Outpatient,,,13359.29,8683.54,,13359.29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10153.06,76,,831.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9618.69,72,,3548.552,Percent of Total Billed Charges,72% of Total Billed Charges,10019.47,75,,3696.408,Percent of Total Billed charges,75% of Total Billed Charges,13359.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9618.69,72,,3548.552,Percent of Total Billed Charges,72% of Total Billed Charges,8015.57,60,,2957.128,Percent of Total Billed Charges,60% of Total Billed Charges,12023.36,90,,2484,Percent of Total Billed Charges,90% of Total Billed Charges,6011.68,45,,751.728,Percent of Total Billed Charges,45% of Total Billed Charges,12023.36,90,,984.312,Percent of Total Billed Charges,90% of Total billed Charges,13359.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13359.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13359.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8683.54,65,,1543.88,Percent of total Billed Charges,65% of Total Billed Charges,5891.45,44.1,,736.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,12691.33,95,,1039,Percent of Total Billed Charges,95% of Total Billed Charges,13359.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11756.18,88,,68.304,Percent of Total Billed Charges,88% of Total Billed Charges,12023.36,90,,984.312,Percent of Total Billed charges,90% of Total Billed Charges,5891.45,13359.29,
VASC EMBO/OCCLUDE BLEED ART VN,4810000011,CDM,320,RC,,,Outpatient,,,27136.35,17638.63,,27136.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20623.63,76,,1049.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19538.17,72,,0.272,Percent of Total Billed Charges,72% of Total Billed Charges,20352.26,75,,0.28,Percent of Total Billed charges,75% of Total Billed Charges,27136.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19538.17,72,,0.272,Percent of Total Billed Charges,72% of Total Billed Charges,16281.81,60,,0.224,Percent of Total Billed Charges,60% of Total Billed Charges,24422.72,90,,2799.36,Percent of Total Billed Charges,90% of Total Billed Charges,12211.36,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,24422.72,90,,1243.008,Percent of Total Billed Charges,90% of Total billed Charges,27136.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27136.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27136.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17638.63,65,,2285.4,Percent of total Billed Charges,65% of Total Billed Charges,11967.13,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,25779.53,95,,1312.064,Percent of Total Billed Charges,95% of Total Billed Charges,27136.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23879.99,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,24422.72,90,,1243.008,Percent of Total Billed charges,90% of Total Billed Charges,11967.13,27136.35,
TEMPORARY PACER,4810000012,CDM,481,RC,,,Outpatient,,,7492.00,4869.80,,7492,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5693.92,76,,540.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5394.24,72,,16.984,Percent of Total Billed Charges,72% of Total Billed Charges,5619,75,,17.688,Percent of Total Billed charges,75% of Total Billed Charges,7492,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5394.24,72,,16.984,Percent of Total Billed Charges,72% of Total Billed Charges,4495.2,60,,14.152,Percent of Total Billed Charges,60% of Total Billed Charges,6742.8,90,,3920.4,Percent of Total Billed Charges,90% of Total Billed Charges,3371.4,45,,11.112,Percent of Total Billed Charges,45% of Total Billed Charges,6742.8,90,,639.792,Percent of Total Billed Charges,90% of Total billed Charges,7492,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7492,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7492,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4869.8,65,,2160.6,Percent of total Billed Charges,65% of Total Billed Charges,3303.97,44.1,,10.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,7117.4,95,,675.336,Percent of Total Billed Charges,95% of Total Billed Charges,7492,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6592.96,88,,21.736,Percent of Total Billed Charges,88% of Total Billed Charges,6742.8,90,,639.792,Percent of Total Billed charges,90% of Total Billed Charges,3303.97,7492,
PACEMKR SINGLE CHAM,4810000013,CDM,481,RC,,,Outpatient,,,21583.64,14029.37,,21583.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16403.57,76,,1269.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15540.22,72,,339.352,Percent of Total Billed Charges,72% of Total Billed Charges,16187.73,75,,353.488,Percent of Total Billed charges,75% of Total Billed Charges,21583.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15540.22,72,,339.352,Percent of Total Billed Charges,72% of Total Billed Charges,12950.18,60,,282.792,Percent of Total Billed Charges,60% of Total Billed Charges,19425.28,90,,3629.256,Percent of Total Billed Charges,90% of Total Billed Charges,9712.64,45,,1610.624,Percent of Total Billed Charges,45% of Total Billed Charges,19425.28,90,,1503.464,Percent of Total Billed Charges,90% of Total billed Charges,21583.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21583.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21583.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14029.37,65,,2382.64,Percent of total Billed Charges,65% of Total Billed Charges,9518.39,44.1,,1578.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,20504.46,95,,1586.984,Percent of Total Billed Charges,95% of Total Billed Charges,21583.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18993.6,88,,3149.664,Percent of Total Billed Charges,88% of Total Billed Charges,19425.28,90,,1503.464,Percent of Total Billed charges,90% of Total Billed Charges,9518.39,21583.64,
INS REPL PACE DUAL C,4810000014,CDM,481,RC,,,Outpatient,,,24252.80,15764.32,,24252.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18432.13,76,,1269.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17462.02,72,,3963.992,Percent of Total Billed Charges,72% of Total Billed Charges,18189.6,75,,4129.16,Percent of Total Billed charges,75% of Total Billed Charges,24252.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17462.02,72,,3963.992,Percent of Total Billed Charges,72% of Total Billed Charges,14551.68,60,,3303.328,Percent of Total Billed Charges,60% of Total Billed Charges,21827.52,90,,4030.92,Percent of Total Billed Charges,90% of Total Billed Charges,10913.76,45,,489.96,Percent of Total Billed Charges,45% of Total Billed Charges,21827.52,90,,1503.464,Percent of Total Billed Charges,90% of Total billed Charges,24252.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24252.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24252.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15764.32,65,,3211,Percent of total Billed Charges,65% of Total Billed Charges,10695.48,44.1,,480.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,23040.16,95,,1586.984,Percent of Total Billed Charges,95% of Total Billed Charges,24252.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21342.46,88,,958.144,Percent of Total Billed Charges,88% of Total Billed Charges,21827.52,90,,1503.464,Percent of Total Billed charges,90% of Total Billed Charges,10695.48,24252.8,
BIVENT PACEMKR INSE,4810000015,CDM,481,RC,,,Outpatient,,,24252.80,15764.32,,24252.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18432.13,76,,58.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17462.02,72,,3742.568,Percent of Total Billed Charges,72% of Total Billed Charges,18189.6,75,,3898.512,Percent of Total Billed charges,75% of Total Billed Charges,24252.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17462.02,72,,3742.568,Percent of Total Billed Charges,72% of Total Billed Charges,14551.68,60,,3118.808,Percent of Total Billed Charges,60% of Total Billed Charges,21827.52,90,,4422.24,Percent of Total Billed Charges,90% of Total Billed Charges,10913.76,45,,1242,Percent of Total Billed Charges,45% of Total Billed Charges,21827.52,90,,69.856,Percent of Total Billed Charges,90% of Total billed Charges,24252.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24252.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24252.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15764.32,65,,1461.72,Percent of total Billed Charges,65% of Total Billed Charges,10695.48,44.1,,1217.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,23040.16,95,,73.736,Percent of Total Billed Charges,95% of Total Billed Charges,24252.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21342.46,88,,2428.8,Percent of Total Billed Charges,88% of Total Billed Charges,21827.52,90,,69.856,Percent of Total Billed charges,90% of Total Billed Charges,10695.48,24252.8,
UPGRD SINGLE PM TO D,4810000016,CDM,481,RC,,,Outpatient,,,34395.80,22357.27,,34395.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26140.81,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24764.98,72,,331.52,Percent of Total Billed Charges,72% of Total Billed Charges,25796.85,75,,345.328,Percent of Total Billed charges,75% of Total Billed Charges,34395.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24764.98,72,,331.52,Percent of Total Billed Charges,72% of Total Billed Charges,20637.48,60,,276.264,Percent of Total Billed Charges,60% of Total Billed Charges,30956.22,90,,2572.56,Percent of Total Billed Charges,90% of Total Billed Charges,15478.11,45,,1399.68,Percent of Total Billed Charges,45% of Total Billed Charges,30956.22,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,34395.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34395.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34395.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22357.27,65,,1573.136,Percent of total Billed Charges,65% of Total Billed Charges,15168.55,44.1,,1371.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,32676.01,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,34395.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30268.3,88,,2737.152,Percent of Total Billed Charges,88% of Total Billed Charges,30956.22,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,15168.55,34395.8,
REPOS OF LEAD PM/AIC,4810000017,CDM,481,RC,,,Outpatient,,,5814.59,3779.48,,5814.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4419.09,76,,18.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4186.5,72,,10867.256,Percent of Total Billed Charges,72% of Total Billed Charges,4360.94,75,,11320.064,Percent of Total Billed charges,75% of Total Billed Charges,5814.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4186.5,72,,10867.256,Percent of Total Billed Charges,72% of Total Billed Charges,3488.75,60,,9056.048,Percent of Total Billed Charges,60% of Total Billed Charges,5233.13,90,,2952.936,Percent of Total Billed Charges,90% of Total Billed Charges,2616.57,45,,1960.2,Percent of Total Billed Charges,45% of Total Billed Charges,5233.13,90,,22.224,Percent of Total Billed Charges,90% of Total billed Charges,5814.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5814.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5814.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3779.48,65,,2202.624,Percent of total Billed Charges,65% of Total Billed Charges,2564.23,44.1,,1921,Percent of Total Billed Charges,44.1% of Total Billed Charges,5523.86,95,,23.464,Percent of Total Billed Charges,95% of Total Billed Charges,5814.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5116.84,88,,3833.28,Percent of Total Billed Charges,88% of Total Billed Charges,5233.13,90,,22.224,Percent of Total Billed charges,90% of Total Billed Charges,2564.23,5814.59,
REMOVAL PERM PACEMA,4810000018,CDM,481,RC,,,Outpatient,,,5897.27,3833.23,,5897.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4481.93,76,,2720.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4246.03,72,,10054.84,Percent of Total Billed Charges,72% of Total Billed Charges,4422.95,75,,10473.792,Percent of Total Billed charges,75% of Total Billed Charges,5897.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4246.03,72,,10054.84,Percent of Total Billed Charges,72% of Total Billed Charges,3538.36,60,,8379.032,Percent of Total Billed Charges,60% of Total Billed Charges,5307.54,90,,4332.96,Percent of Total Billed Charges,90% of Total Billed Charges,2653.77,45,,1814.624,Percent of Total Billed Charges,45% of Total Billed Charges,5307.54,90,,3221.248,Percent of Total Billed Charges,90% of Total billed Charges,5897.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5897.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5897.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3833.23,65,,1507.48,Percent of total Billed Charges,65% of Total Billed Charges,2600.7,44.1,,1778.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,5602.41,95,,3400.2,Percent of Total Billed Charges,95% of Total Billed Charges,5897.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5189.6,88,,3548.6,Percent of Total Billed Charges,88% of Total Billed Charges,5307.54,90,,3221.248,Percent of Total Billed charges,90% of Total Billed Charges,2600.7,5897.27,
BIVENT PACEMKR REMO,4810000019,CDM,481,RC,,,Outpatient,,,5897.27,3833.23,,5897.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4481.93,76,,827.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4246.03,72,,36256.968,Percent of Total Billed Charges,72% of Total Billed Charges,4422.95,75,,37767.672,Percent of Total Billed charges,75% of Total Billed Charges,5897.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4246.03,72,,36256.968,Percent of Total Billed Charges,72% of Total Billed Charges,3538.36,60,,30214.136,Percent of Total Billed Charges,60% of Total Billed Charges,5307.54,90,,3789.608,Percent of Total Billed Charges,90% of Total Billed Charges,2653.77,45,,2015.464,Percent of Total Billed Charges,45% of Total Billed Charges,5307.54,90,,979.92,Percent of Total Billed Charges,90% of Total billed Charges,5897.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5897.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5897.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3833.23,65,,1573.136,Percent of total Billed Charges,65% of Total Billed Charges,2600.7,44.1,,1975.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,5602.41,95,,1034.36,Percent of Total Billed Charges,95% of Total Billed Charges,5897.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5189.6,88,,3941.344,Percent of Total Billed Charges,88% of Total Billed Charges,5307.54,90,,979.92,Percent of Total Billed charges,90% of Total Billed Charges,2600.7,5897.27,
PACEMKR SINGL CHAM R,4810000020,CDM,481,RC,,,Outpatient,,,5897.27,3833.23,,5897.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4481.93,76,,2097.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4246.03,72,,24588.376,Percent of Total Billed Charges,72% of Total Billed Charges,4422.95,75,,25612.888,Percent of Total Billed charges,75% of Total Billed Charges,5897.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4246.03,72,,24588.376,Percent of Total Billed Charges,72% of Total Billed Charges,3538.36,60,,20490.312,Percent of Total Billed Charges,60% of Total Billed Charges,5307.54,90,,3970.08,Percent of Total Billed Charges,90% of Total Billed Charges,2653.77,45,,2211.12,Percent of Total Billed Charges,45% of Total Billed Charges,5307.54,90,,2484,Percent of Total Billed Charges,90% of Total billed Charges,5897.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5897.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5897.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3833.23,65,,2379,Percent of total Billed Charges,65% of Total Billed Charges,2600.7,44.1,,2166.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,5602.41,95,,2622,Percent of Total Billed Charges,95% of Total Billed Charges,5897.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5189.6,88,,4323.968,Percent of Total Billed Charges,88% of Total Billed Charges,5307.54,90,,2484,Percent of Total Billed charges,90% of Total Billed Charges,2600.7,5897.27,
PACEMKR DUAL CHAM RE,4810000021,CDM,481,RC,,,Outpatient,,,5897.27,3833.23,,5897.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4481.93,76,,2363.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4246.03,72,,2120.544,Percent of Total Billed Charges,72% of Total Billed Charges,4422.95,75,,2208.904,Percent of Total Billed charges,75% of Total Billed Charges,5897.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4246.03,72,,2120.544,Percent of Total Billed Charges,72% of Total Billed Charges,3538.36,60,,1767.12,Percent of Total Billed Charges,60% of Total Billed Charges,5307.54,90,,4030.92,Percent of Total Billed Charges,90% of Total Billed Charges,2653.77,45,,1286.28,Percent of Total Billed Charges,45% of Total Billed Charges,5307.54,90,,2799.36,Percent of Total Billed Charges,90% of Total billed Charges,5897.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5897.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5897.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3833.23,65,,2399.84,Percent of total Billed Charges,65% of Total Billed Charges,2600.7,44.1,,1260.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,5602.41,95,,2954.88,Percent of Total Billed Charges,95% of Total Billed Charges,5897.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5189.6,88,,2515.392,Percent of Total Billed Charges,88% of Total Billed Charges,5307.54,90,,2799.36,Percent of Total Billed charges,90% of Total Billed Charges,2600.7,5897.27,
AICD SINGLE CHAM INS,4810000022,CDM,481,RC,,,Outpatient,,,50648.85,32921.75,,50648.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38493.13,76,,3310.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36467.17,72,,1883.968,Percent of Total Billed Charges,72% of Total Billed Charges,37986.64,75,,1962.472,Percent of Total Billed charges,75% of Total Billed Charges,50648.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36467.17,72,,1883.968,Percent of Total Billed Charges,72% of Total Billed Charges,30389.31,60,,1569.976,Percent of Total Billed Charges,60% of Total Billed Charges,45583.97,90,,308.784,Percent of Total Billed Charges,90% of Total Billed Charges,22791.98,45,,1476.472,Percent of Total Billed Charges,45% of Total Billed Charges,45583.97,90,,3920.4,Percent of Total Billed Charges,90% of Total billed Charges,50648.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50648.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50648.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32921.75,65,,2752.88,Percent of total Billed Charges,65% of Total Billed Charges,22336.14,44.1,,1446.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,48116.41,95,,4138.2,Percent of Total Billed Charges,95% of Total Billed Charges,50648.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44570.99,88,,2887.312,Percent of Total Billed Charges,88% of Total Billed Charges,45583.97,90,,3920.4,Percent of Total Billed charges,90% of Total Billed Charges,22336.14,50648.85,
ICD DUAL CHMBER INSERT INITIAL,4810000023,CDM,481,RC,,,Outpatient,,,50648.85,32921.75,,50648.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38493.13,76,,3064.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36467.17,72,,4608.36,Percent of Total Billed Charges,72% of Total Billed Charges,37986.64,75,,4800.376,Percent of Total Billed charges,75% of Total Billed Charges,50648.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36467.17,72,,4608.36,Percent of Total Billed Charges,72% of Total Billed Charges,30389.31,60,,3840.304,Percent of Total Billed Charges,60% of Total Billed Charges,45583.97,90,,2612.88,Percent of Total Billed Charges,90% of Total Billed Charges,22791.98,45,,2166.48,Percent of Total Billed Charges,45% of Total Billed Charges,45583.97,90,,3629.256,Percent of Total Billed Charges,90% of Total billed Charges,50648.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50648.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50648.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32921.75,65,,100.328,Percent of total Billed Charges,65% of Total Billed Charges,22336.14,44.1,,2123.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,48116.41,95,,3830.88,Percent of Total Billed Charges,95% of Total Billed Charges,50648.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44570.99,88,,4236.672,Percent of Total Billed Charges,88% of Total Billed Charges,45583.97,90,,3629.256,Percent of Total Billed charges,90% of Total Billed Charges,22336.14,50648.85,
REMOVAL OF AICD,4810000024,CDM,481,RC,,,Outpatient,,,104426.60,67877.29,,104426.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79364.22,76,,3403.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75187.15,72,,67.68,Percent of Total Billed Charges,72% of Total Billed Charges,78319.95,75,,70.504,Percent of Total Billed charges,75% of Total Billed Charges,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75187.15,72,,67.68,Percent of Total Billed Charges,72% of Total Billed Charges,62655.96,60,,56.4,Percent of Total Billed Charges,60% of Total Billed Charges,93983.94,90,,2240.896,Percent of Total Billed Charges,90% of Total Billed Charges,46991.97,45,,1894.8,Percent of Total Billed Charges,45% of Total Billed Charges,93983.94,90,,4030.92,Percent of Total Billed Charges,90% of Total billed Charges,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67877.29,65,,150.208,Percent of total Billed Charges,65% of Total Billed Charges,46052.13,44.1,,1856.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,99205.27,95,,4254.864,Percent of Total Billed Charges,95% of Total Billed Charges,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91895.41,88,,3705.392,Percent of Total Billed Charges,88% of Total Billed Charges,93983.94,90,,4030.92,Percent of Total Billed charges,90% of Total Billed Charges,46052.13,104426.6,
AICD SINGLE CHAM REM,4810000025,CDM,481,RC,,,Outpatient,,,104426.60,67877.29,,104426.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79364.22,76,,3734.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75187.15,72,,9.496,Percent of Total Billed Charges,72% of Total Billed Charges,78319.95,75,,9.888,Percent of Total Billed charges,75% of Total Billed Charges,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75187.15,72,,9.496,Percent of Total Billed Charges,72% of Total Billed Charges,62655.96,60,,7.912,Percent of Total Billed Charges,60% of Total Billed Charges,93983.94,90,,3362.4,Percent of Total Billed Charges,90% of Total Billed Charges,46991.97,45,,1985.04,Percent of Total Billed Charges,45% of Total Billed Charges,93983.94,90,,4422.24,Percent of Total Billed Charges,90% of Total billed Charges,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67877.29,65,,553.232,Percent of total Billed Charges,65% of Total Billed Charges,46052.13,44.1,,1945.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,99205.27,95,,4667.92,Percent of Total Billed Charges,95% of Total Billed Charges,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91895.41,88,,3881.856,Percent of Total Billed Charges,88% of Total Billed Charges,93983.94,90,,4422.24,Percent of Total Billed charges,90% of Total Billed Charges,46052.13,104426.6,
AICD DUAL CHAM REMOV,4810000026,CDM,481,RC,,,Outpatient,,,104426.60,67877.29,,104426.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79364.22,76,,2172.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75187.15,72,,176.776,Percent of Total Billed Charges,72% of Total Billed Charges,78319.95,75,,184.144,Percent of Total Billed charges,75% of Total Billed Charges,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75187.15,72,,176.776,Percent of Total Billed Charges,72% of Total Billed Charges,62655.96,60,,147.312,Percent of Total Billed Charges,60% of Total Billed Charges,93983.94,90,,2440.08,Percent of Total Billed Charges,90% of Total Billed Charges,46991.97,45,,2015.464,Percent of Total Billed Charges,45% of Total Billed Charges,93983.94,90,,2572.56,Percent of Total Billed Charges,90% of Total billed Charges,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67877.29,65,,924.728,Percent of total Billed Charges,65% of Total Billed Charges,46052.13,44.1,,1975.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,99205.27,95,,2715.48,Percent of Total Billed Charges,95% of Total Billed Charges,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91895.41,88,,3941.344,Percent of Total Billed Charges,88% of Total Billed Charges,93983.94,90,,2572.56,Percent of Total Billed charges,90% of Total Billed Charges,46052.13,104426.6,
INJECTION VENOGRAM,4810000027,CDM,481,RC,,,Outpatient,,,509.36,331.08,,509.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,387.11,76,,2493.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,366.74,72,,19.864,Percent of Total Billed Charges,72% of Total Billed Charges,382.02,75,,20.688,Percent of Total Billed charges,75% of Total Billed Charges,509.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.74,72,,19.864,Percent of Total Billed Charges,72% of Total Billed Charges,305.62,60,,16.552,Percent of Total Billed Charges,60% of Total Billed Charges,458.42,90,,2768.776,Percent of Total Billed Charges,90% of Total Billed Charges,229.21,45,,154.392,Percent of Total Billed Charges,45% of Total Billed Charges,458.42,90,,2952.936,Percent of Total Billed Charges,90% of Total billed Charges,509.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,509.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,509.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,331.08,65,,4.288,Percent of total Billed Charges,65% of Total Billed Charges,224.63,44.1,,151.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,483.89,95,,3116.992,Percent of Total Billed Charges,95% of Total Billed Charges,509.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,448.24,88,,301.928,Percent of Total Billed Charges,88% of Total Billed Charges,458.42,90,,2952.936,Percent of Total Billed charges,90% of Total Billed Charges,224.63,509.36,
REM REV HEPATIC SHUNT (TIPS),4810000028,CDM,481,RC,,,Outpatient,,,13600.00,8840.00,,13600,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10336,76,,3658.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9792,72,,357.352,Percent of Total Billed Charges,72% of Total Billed Charges,10200,75,,372.24,Percent of Total Billed charges,75% of Total Billed Charges,13600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9792,72,,357.352,Percent of Total Billed Charges,72% of Total Billed Charges,8160,60,,297.792,Percent of Total Billed Charges,60% of Total Billed Charges,12240,90,,2957.76,Percent of Total Billed Charges,90% of Total Billed Charges,6120,45,,1306.44,Percent of Total Billed Charges,45% of Total Billed Charges,12240,90,,4332.96,Percent of Total Billed Charges,90% of Total billed Charges,13600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8840,65,,235.624,Percent of total Billed Charges,65% of Total Billed Charges,5997.6,44.1,,1280.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,12920,95,,4573.68,Percent of Total Billed Charges,95% of Total Billed Charges,13600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11968,88,,2554.816,Percent of Total Billed Charges,88% of Total Billed Charges,12240,90,,4332.96,Percent of Total Billed charges,90% of Total Billed Charges,5997.6,13600,
SEC ART THROMBECTOMY ADDON,4810000029,CDM,481,RC,,,Outpatient,,,5459.69,3548.80,,5459.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4149.36,76,,3200.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3930.98,72,,112.336,Percent of Total Billed Charges,72% of Total Billed Charges,4094.77,75,,117.016,Percent of Total Billed charges,75% of Total Billed Charges,5459.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3930.98,72,,112.336,Percent of Total Billed Charges,72% of Total Billed Charges,3275.81,60,,93.616,Percent of Total Billed Charges,60% of Total Billed Charges,4913.72,90,,2565.36,Percent of Total Billed Charges,90% of Total Billed Charges,2456.86,45,,1120.448,Percent of Total Billed Charges,45% of Total Billed Charges,4913.72,90,,3789.608,Percent of Total Billed Charges,90% of Total billed Charges,5459.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5459.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5459.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3548.8,65,,235.624,Percent of total Billed Charges,65% of Total Billed Charges,2407.72,44.1,,1098.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,5186.71,95,,4000.136,Percent of Total Billed Charges,95% of Total Billed Charges,5459.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4804.53,88,,2191.104,Percent of Total Billed Charges,88% of Total Billed Charges,4913.72,90,,3789.608,Percent of Total Billed charges,90% of Total Billed Charges,2407.72,5459.69,
VASC EMBOLIZE/OCCLUDE VENOUS,4810000030,CDM,481,RC,,,Outpatient,,,27136.35,17638.63,,27136.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20623.63,76,,3352.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19538.17,72,,448.2,Percent of Total Billed Charges,72% of Total Billed Charges,20352.26,75,,466.88,Percent of Total Billed charges,75% of Total Billed Charges,27136.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19538.17,72,,448.2,Percent of Total Billed Charges,72% of Total Billed Charges,16281.81,60,,373.504,Percent of Total Billed Charges,60% of Total Billed Charges,24422.72,90,,2240.896,Percent of Total Billed Charges,90% of Total Billed Charges,12211.36,45,,1681.2,Percent of Total Billed Charges,45% of Total Billed Charges,24422.72,90,,3970.08,Percent of Total Billed Charges,90% of Total billed Charges,27136.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27136.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27136.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17638.63,65,,35.36,Percent of total Billed Charges,65% of Total Billed Charges,11967.13,44.1,,1647.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,25779.53,95,,4190.64,Percent of Total Billed Charges,95% of Total Billed Charges,27136.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23879.99,88,,3287.68,Percent of Total Billed Charges,88% of Total Billed Charges,24422.72,90,,3970.08,Percent of Total Billed charges,90% of Total Billed Charges,11967.13,27136.35,
TRLUML BALO ANGIOP ADDL ART,4810000031,CDM,481,RC,,,Outpatient,,,8950.82,5818.03,,8950.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6802.62,76,,3403.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6444.59,72,,67.68,Percent of Total Billed Charges,72% of Total Billed Charges,6713.12,75,,70.504,Percent of Total Billed charges,75% of Total Billed Charges,8950.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6444.59,72,,67.68,Percent of Total Billed Charges,72% of Total Billed Charges,5370.49,60,,56.4,Percent of Total Billed Charges,60% of Total Billed Charges,8055.74,90,,2957.76,Percent of Total Billed Charges,90% of Total Billed Charges,4027.87,45,,1220.04,Percent of Total Billed Charges,45% of Total Billed Charges,8055.74,90,,4030.92,Percent of Total Billed Charges,90% of Total billed Charges,8950.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8950.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8950.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5818.03,65,,157.592,Percent of total Billed Charges,65% of Total Billed Charges,3947.31,44.1,,1195.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,8503.28,95,,4254.864,Percent of Total Billed Charges,95% of Total Billed Charges,8950.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7876.72,88,,2385.856,Percent of Total Billed Charges,88% of Total Billed Charges,8055.74,90,,4030.92,Percent of Total Billed charges,90% of Total Billed Charges,3947.31,8950.82,
AVF FU ANGIOGRAM,4810000032,CDM,320,RC,,,Outpatient,,,1703.36,1107.18,,1703.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1294.55,76,,260.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1226.42,72,,67.68,Percent of Total Billed Charges,72% of Total Billed Charges,1277.52,75,,70.504,Percent of Total Billed charges,75% of Total Billed Charges,1703.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1226.42,72,,67.68,Percent of Total Billed Charges,72% of Total Billed Charges,1022.02,60,,56.4,Percent of Total Billed Charges,60% of Total Billed Charges,1533.02,90,,2725.2,Percent of Total Billed Charges,90% of Total Billed Charges,766.51,45,,1384.384,Percent of Total Billed Charges,45% of Total Billed Charges,1533.02,90,,308.784,Percent of Total Billed Charges,90% of Total billed Charges,1703.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1703.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1703.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1107.18,65,,24.104,Percent of total Billed Charges,65% of Total Billed Charges,751.18,44.1,,1356.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,1618.19,95,,325.944,Percent of Total Billed Charges,95% of Total Billed Charges,1703.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1498.96,88,,2707.248,Percent of Total Billed Charges,88% of Total Billed Charges,1533.02,90,,308.784,Percent of Total Billed charges,90% of Total Billed Charges,751.18,1703.36,
PRQ TRANSLUMINAL COR,4810000033,CDM,481,RC,,,Outpatient,,,29465.42,19152.52,,29465.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22393.72,76,,2206.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21215.1,72,,1632.456,Percent of Total Billed Charges,72% of Total Billed Charges,22099.07,75,,1700.48,Percent of Total Billed charges,75% of Total Billed Charges,29465.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21215.1,72,,1632.456,Percent of Total Billed Charges,72% of Total Billed Charges,17679.25,60,,1360.384,Percent of Total Billed Charges,60% of Total Billed Charges,26518.88,90,,2129.04,Percent of Total Billed Charges,90% of Total Billed Charges,13259.44,45,,1478.88,Percent of Total Billed Charges,45% of Total Billed Charges,26518.88,90,,2612.88,Percent of Total Billed Charges,90% of Total billed Charges,29465.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29465.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29465.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19152.52,65,,6.24,Percent of total Billed Charges,65% of Total Billed Charges,12994.25,44.1,,1449.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,27992.15,95,,2758.04,Percent of Total Billed Charges,95% of Total Billed Charges,29465.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25929.57,88,,2892.032,Percent of Total Billed Charges,88% of Total Billed Charges,26518.88,90,,2612.88,Percent of Total Billed charges,90% of Total Billed Charges,12994.25,29465.42,
PRQ CARDIO STENT W/A,4810000034,CDM,481,RC,,,Outpatient,,,22549.43,14657.13,,22549.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17137.57,76,,1892.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16235.59,72,,122.312,Percent of Total Billed Charges,72% of Total Billed Charges,16912.07,75,,127.408,Percent of Total Billed charges,75% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16235.59,72,,122.312,Percent of Total Billed Charges,72% of Total Billed Charges,13529.66,60,,101.928,Percent of Total Billed Charges,60% of Total Billed Charges,20294.49,90,,4001.76,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,1282.68,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,2240.896,Percent of Total Billed Charges,90% of Total billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14657.13,65,,24.44,Percent of total Billed Charges,65% of Total Billed Charges,9944.3,44.1,,1257.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,2365.392,Percent of Total Billed Charges,95% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19843.5,88,,2508.352,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,2240.896,Percent of Total Billed charges,90% of Total Billed Charges,9944.3,22549.43,
PRQ CARDIO ATHERECTO,4810000035,CDM,481,RC,,,Outpatient,,,23470.02,15255.51,,23470.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17837.22,76,,2839.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16898.41,72,,503.104,Percent of Total Billed Charges,72% of Total Billed Charges,17602.52,75,,524.072,Percent of Total Billed charges,75% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16898.41,72,,503.104,Percent of Total Billed Charges,72% of Total Billed Charges,14082.01,60,,419.256,Percent of Total Billed Charges,60% of Total Billed Charges,21123.02,90,,3894.384,Percent of Total Billed Charges,90% of Total Billed Charges,10561.51,45,,1120.448,Percent of Total Billed Charges,45% of Total Billed Charges,21123.02,90,,3362.4,Percent of Total Billed Charges,90% of Total billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15255.51,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,10350.28,44.1,,1098.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,22296.52,95,,3549.2,Percent of Total Billed Charges,95% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20653.62,88,,2191.104,Percent of Total Billed Charges,88% of Total Billed Charges,21123.02,90,,3362.4,Percent of Total Billed charges,90% of Total Billed Charges,10350.28,23470.02,
PRQ REVASC BYP GRAF,4810000036,CDM,481,RC,,,Outpatient,,,23470.02,15255.51,,23470.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17837.22,76,,2060.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16898.41,72,,59.24,Percent of Total Billed Charges,72% of Total Billed Charges,17602.52,75,,61.712,Percent of Total Billed charges,75% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16898.41,72,,59.24,Percent of Total Billed Charges,72% of Total Billed Charges,14082.01,60,,49.368,Percent of Total Billed Charges,60% of Total Billed Charges,21123.02,90,,5217.648,Percent of Total Billed Charges,90% of Total Billed Charges,10561.51,45,,1478.88,Percent of Total Billed Charges,45% of Total Billed Charges,21123.02,90,,2440.08,Percent of Total Billed Charges,90% of Total billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15255.51,65,,27.112,Percent of total Billed Charges,65% of Total Billed Charges,10350.28,44.1,,1449.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,22296.52,95,,2575.64,Percent of Total Billed Charges,95% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20653.62,88,,2892.032,Percent of Total Billed Charges,88% of Total Billed Charges,21123.02,90,,2440.08,Percent of Total Billed charges,90% of Total Billed Charges,10350.28,23470.02,
PRQ CARDIO REVASC M,4810000037,CDM,481,RC,,,Outpatient,,,23470.02,15255.51,,23470.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17837.22,76,,2338.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16898.41,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,17602.52,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16898.41,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,14082.01,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,21123.02,90,,5156.64,Percent of Total Billed Charges,90% of Total Billed Charges,10561.51,45,,1362.6,Percent of Total Billed Charges,45% of Total Billed Charges,21123.02,90,,2768.776,Percent of Total Billed Charges,90% of Total billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15255.51,65,,202.088,Percent of total Billed Charges,65% of Total Billed Charges,10350.28,44.1,,1335.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,22296.52,95,,2922.592,Percent of Total Billed Charges,95% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20653.62,88,,2664.64,Percent of Total Billed Charges,88% of Total Billed Charges,21123.02,90,,2768.776,Percent of Total Billed charges,90% of Total Billed Charges,10350.28,23470.02,
PRQ CARDIO REVASC C,4810000038,CDM,481,RC,,,Outpatient,,,23470.02,15255.51,,23470.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17837.22,76,,2497.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16898.41,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,17602.52,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16898.41,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,14082.01,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,21123.02,90,,3894.384,Percent of Total Billed Charges,90% of Total Billed Charges,10561.51,45,,1064.52,Percent of Total Billed Charges,45% of Total Billed Charges,21123.02,90,,2957.76,Percent of Total Billed Charges,90% of Total billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15255.51,65,,807.776,Percent of total Billed Charges,65% of Total Billed Charges,10350.28,44.1,,1043.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,22296.52,95,,3122.08,Percent of Total Billed Charges,95% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20653.62,88,,2081.728,Percent of Total Billed Charges,88% of Total Billed Charges,21123.02,90,,2957.76,Percent of Total Billed charges,90% of Total Billed Charges,10350.28,23470.02,
CARDIO ELEC ELECCONV,4810000039,CDM,481,RC,,,Outpatient,,,1665.00,1082.25,,1665,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1265.4,76,,2166.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1198.8,72,,54.616,Percent of Total Billed Charges,72% of Total Billed Charges,1248.75,75,,56.896,Percent of Total Billed charges,75% of Total Billed Charges,1665,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1198.8,72,,54.616,Percent of Total Billed Charges,72% of Total Billed Charges,999,60,,45.512,Percent of Total Billed Charges,60% of Total Billed Charges,1498.5,90,,3857.08,Percent of Total Billed Charges,90% of Total Billed Charges,749.25,45,,2000.88,Percent of Total Billed Charges,45% of Total Billed Charges,1498.5,90,,2565.36,Percent of Total Billed Charges,90% of Total billed Charges,1665,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1082.25,65,,15.792,Percent of total Billed Charges,65% of Total Billed Charges,734.27,44.1,,1960.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,1581.75,95,,2707.88,Percent of Total Billed Charges,95% of Total Billed Charges,1665,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1465.2,88,,3912.832,Percent of Total Billed Charges,88% of Total Billed Charges,1498.5,90,,2565.36,Percent of Total Billed charges,90% of Total Billed Charges,734.27,1665,
CORONARY IVUS INITIAL,4810000040,CDM,481,RC,,,Outpatient,,,3643.59,2368.33,,3643.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2769.13,76,,1892.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2623.38,72,,901.12,Percent of Total Billed Charges,72% of Total Billed Charges,2732.69,75,,938.672,Percent of Total Billed charges,75% of Total Billed Charges,3643.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2623.38,72,,901.12,Percent of Total Billed Charges,72% of Total Billed Charges,2186.15,60,,750.936,Percent of Total Billed Charges,60% of Total Billed Charges,3279.23,90,,4011.872,Percent of Total Billed Charges,90% of Total Billed Charges,1639.62,45,,1947.192,Percent of Total Billed Charges,45% of Total Billed Charges,3279.23,90,,2240.896,Percent of Total Billed Charges,90% of Total billed Charges,3643.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3643.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3643.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2368.33,65,,670.952,Percent of total Billed Charges,65% of Total Billed Charges,1606.82,44.1,,1908.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,3461.41,95,,2365.392,Percent of Total Billed Charges,95% of Total Billed Charges,3643.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3206.36,88,,3807.848,Percent of Total Billed Charges,88% of Total Billed Charges,3279.23,90,,2240.896,Percent of Total Billed charges,90% of Total Billed Charges,1606.82,3643.59,
CORONARY IVUS EACH ADDITIONAL,4810000041,CDM,481,RC,,,Outpatient,,,1821.80,1184.17,,1821.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1384.57,76,,2497.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1311.7,72,,11.568,Percent of Total Billed Charges,72% of Total Billed Charges,1366.35,75,,12.056,Percent of Total Billed charges,75% of Total Billed Charges,1821.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.7,72,,11.568,Percent of Total Billed Charges,72% of Total Billed Charges,1093.08,60,,9.64,Percent of Total Billed Charges,60% of Total Billed Charges,1639.62,90,,3894.384,Percent of Total Billed Charges,90% of Total Billed Charges,819.81,45,,2608.824,Percent of Total Billed Charges,45% of Total Billed Charges,1639.62,90,,2957.76,Percent of Total Billed Charges,90% of Total billed Charges,1821.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1821.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1821.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1184.17,65,,615.152,Percent of total Billed Charges,65% of Total Billed Charges,803.41,44.1,,2556.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,1730.71,95,,3122.08,Percent of Total Billed Charges,95% of Total Billed Charges,1821.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1603.18,88,,5101.696,Percent of Total Billed Charges,88% of Total Billed Charges,1639.62,90,,2957.76,Percent of Total Billed charges,90% of Total Billed Charges,803.41,1821.8,
TRANS ESOPHAGEAL ECHO,4810000042,CDM,481,RC,,,Outpatient,,,2579.00,1676.35,,2579,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1960.04,76,,2301.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1856.88,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,1934.25,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,2579,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1856.88,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,1547.4,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,2321.1,90,,3856.288,Percent of Total Billed Charges,90% of Total Billed Charges,1160.55,45,,2578.32,Percent of Total Billed Charges,45% of Total Billed Charges,2321.1,90,,2725.2,Percent of Total Billed Charges,90% of Total billed Charges,2579,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2579,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2579,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1676.35,65,,4124.888,Percent of total Billed Charges,65% of Total Billed Charges,1137.34,44.1,,2526.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,2450.05,95,,2876.6,Percent of Total Billed Charges,95% of Total Billed Charges,2579,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2269.52,88,,5042.048,Percent of Total Billed Charges,88% of Total Billed Charges,2321.1,90,,2725.2,Percent of Total Billed charges,90% of Total Billed Charges,1137.34,2579,
RHC ONLY,4810000043,CDM,481,RC,,,Outpatient,,,8419.00,5472.35,,8419,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6398.44,76,,1797.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6061.68,72,,963.352,Percent of Total Billed Charges,72% of Total Billed Charges,6314.25,75,,1003.496,Percent of Total Billed charges,75% of Total Billed Charges,8419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6061.68,72,,963.352,Percent of Total Billed Charges,72% of Total Billed Charges,5051.4,60,,802.792,Percent of Total Billed Charges,60% of Total Billed Charges,7577.1,90,,4011.872,Percent of Total Billed Charges,90% of Total Billed Charges,3788.55,45,,1947.192,Percent of Total Billed Charges,45% of Total Billed Charges,7577.1,90,,2129.04,Percent of Total Billed Charges,90% of Total billed Charges,8419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5472.35,65,,201.232,Percent of total Billed Charges,65% of Total Billed Charges,3712.78,44.1,,1908.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,7998.05,95,,2247.32,Percent of Total Billed Charges,95% of Total Billed Charges,8419,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7408.72,88,,3807.848,Percent of Total Billed Charges,88% of Total Billed Charges,7577.1,90,,2129.04,Percent of Total Billed charges,90% of Total Billed Charges,3712.78,8419,
LHC LV ONLY,4810000044,CDM,481,RC,,,Outpatient,,,13586.11,8830.97,,13586.11,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10325.44,76,,3379.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9782,72,,1460.16,Percent of Total Billed Charges,72% of Total Billed Charges,10189.58,75,,1521,Percent of Total Billed charges,75% of Total Billed Charges,13586.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9782,72,,1460.16,Percent of Total Billed Charges,72% of Total Billed Charges,8151.67,60,,1216.8,Percent of Total Billed Charges,60% of Total Billed Charges,12227.5,90,,3894.384,Percent of Total Billed Charges,90% of Total Billed Charges,6113.75,45,,1928.536,Percent of Total Billed Charges,45% of Total Billed Charges,12227.5,90,,4001.76,Percent of Total Billed Charges,90% of Total billed Charges,13586.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13586.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13586.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8830.97,65,,322.664,Percent of total Billed Charges,65% of Total Billed Charges,5991.47,44.1,,1889.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,12906.8,95,,4224.08,Percent of Total Billed Charges,95% of Total Billed Charges,13586.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11955.78,88,,3771.36,Percent of Total Billed Charges,88% of Total Billed Charges,12227.5,90,,4001.76,Percent of Total Billed charges,90% of Total Billed Charges,5991.47,13586.11,
COR ONLY,4810000045,CDM,481,RC,,,Outpatient,,,6499.00,4224.35,,6499,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4939.24,76,,3288.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4679.28,72,,973.44,Percent of Total Billed Charges,72% of Total Billed Charges,4874.25,75,,1014,Percent of Total Billed charges,75% of Total Billed Charges,6499,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4679.28,72,,973.44,Percent of Total Billed Charges,72% of Total Billed Charges,3899.4,60,,811.2,Percent of Total Billed Charges,60% of Total Billed Charges,5849.1,90,,5217.648,Percent of Total Billed Charges,90% of Total Billed Charges,2924.55,45,,2005.936,Percent of Total Billed Charges,45% of Total Billed Charges,5849.1,90,,3894.384,Percent of Total Billed Charges,90% of Total billed Charges,6499,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6499,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6499,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4224.35,65,,500.888,Percent of total Billed Charges,65% of Total Billed Charges,2866.06,44.1,,1965.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,6174.05,95,,4110.744,Percent of Total Billed Charges,95% of Total Billed Charges,6499,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5719.12,88,,3922.72,Percent of Total Billed Charges,88% of Total Billed Charges,5849.1,90,,3894.384,Percent of Total Billed charges,90% of Total Billed Charges,2866.06,6499,
COR ONLY SVG,4810000046,CDM,481,RC,,,Outpatient,,,17419.50,11322.68,,17419.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13238.82,76,,4406.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12542.04,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,13064.63,75,,960,Percent of Total Billed charges,75% of Total Billed Charges,17419.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12542.04,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,10451.7,60,,768,Percent of Total Billed Charges,60% of Total Billed Charges,15677.55,90,,4011.872,Percent of Total Billed Charges,90% of Total Billed Charges,7838.78,45,,1947.192,Percent of Total Billed Charges,45% of Total Billed Charges,15677.55,90,,5217.648,Percent of Total Billed Charges,90% of Total billed Charges,17419.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17419.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17419.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11322.68,65,,33,Percent of total Billed Charges,65% of Total Billed Charges,7682,44.1,,1908.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,16548.53,95,,5507.512,Percent of Total Billed Charges,95% of Total Billed Charges,17419.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15329.16,88,,3807.848,Percent of Total Billed Charges,88% of Total Billed Charges,15677.55,90,,5217.648,Percent of Total Billed charges,90% of Total Billed Charges,7682,17419.5,
COR ONLY  IMA,4810000047,CDM,481,RC,,,Outpatient,,,17419.50,11322.68,,17419.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13238.82,76,,4354.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12542.04,72,,864,Percent of Total Billed Charges,72% of Total Billed Charges,13064.63,75,,900,Percent of Total Billed charges,75% of Total Billed Charges,17419.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12542.04,72,,864,Percent of Total Billed Charges,72% of Total Billed Charges,10451.7,60,,720,Percent of Total Billed Charges,60% of Total Billed Charges,15677.55,90,,393.84,Percent of Total Billed Charges,90% of Total Billed Charges,7838.78,45,,1928.144,Percent of Total Billed Charges,45% of Total Billed Charges,15677.55,90,,5156.64,Percent of Total Billed Charges,90% of Total billed Charges,17419.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17419.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17419.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11322.68,65,,12.744,Percent of total Billed Charges,65% of Total Billed Charges,7682,44.1,,1889.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,16548.53,95,,5443.12,Percent of Total Billed Charges,95% of Total Billed Charges,17419.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15329.16,88,,3770.592,Percent of Total Billed Charges,88% of Total Billed Charges,15677.55,90,,5156.64,Percent of Total Billed charges,90% of Total Billed Charges,7682,17419.5,
COR ONLY SVG IMA,4810000048,CDM,481,RC,,,Outpatient,,,16549.00,10756.85,,16549,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12577.24,76,,3288.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11915.28,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,12411.75,75,,960,Percent of Total Billed charges,75% of Total Billed Charges,16549,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11915.28,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,9929.4,60,,768,Percent of Total Billed Charges,60% of Total Billed Charges,14894.1,90,,374.4,Percent of Total Billed Charges,90% of Total Billed Charges,7447.05,45,,2005.936,Percent of Total Billed Charges,45% of Total Billed Charges,14894.1,90,,3894.384,Percent of Total Billed Charges,90% of Total billed Charges,16549,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16549,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16549,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10756.85,65,,100.296,Percent of total Billed Charges,65% of Total Billed Charges,7298.11,44.1,,1965.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,15721.55,95,,4110.744,Percent of Total Billed Charges,95% of Total Billed Charges,16549,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14563.12,88,,3922.72,Percent of Total Billed Charges,88% of Total Billed Charges,14894.1,90,,3894.384,Percent of Total Billed charges,90% of Total Billed Charges,7298.11,16549,
RHC COR ONLY,4810000049,CDM,481,RC,,,Outpatient,,,11404.26,7412.77,,11404.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8667.24,76,,3257.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8211.07,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,8553.2,75,,960,Percent of Total Billed charges,75% of Total Billed Charges,11404.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8211.07,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,6842.56,60,,768,Percent of Total Billed Charges,60% of Total Billed Charges,10263.83,90,,4446,Percent of Total Billed Charges,90% of Total Billed Charges,5131.92,45,,1947.192,Percent of Total Billed Charges,45% of Total Billed Charges,10263.83,90,,3857.08,Percent of Total Billed Charges,90% of Total billed Charges,11404.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11404.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11404.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7412.77,65,,87.544,Percent of total Billed Charges,65% of Total Billed Charges,5029.28,44.1,,1908.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,10834.05,95,,4071.36,Percent of Total Billed Charges,95% of Total Billed Charges,11404.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10035.75,88,,3807.848,Percent of Total Billed Charges,88% of Total Billed Charges,10263.83,90,,3857.08,Percent of Total Billed charges,90% of Total Billed Charges,5029.28,11404.26,
RHC COR ONLY SVG IMA,4810000050,CDM,481,RC,,,Outpatient,,,8667.86,5634.11,,8667.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6587.57,76,,3387.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6240.86,72,,875.52,Percent of Total Billed Charges,72% of Total Billed Charges,6500.9,75,,912,Percent of Total Billed charges,75% of Total Billed Charges,8667.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6240.86,72,,875.52,Percent of Total Billed Charges,72% of Total Billed Charges,5200.72,60,,729.6,Percent of Total Billed Charges,60% of Total Billed Charges,7801.07,90,,3600,Percent of Total Billed Charges,90% of Total Billed Charges,3900.54,45,,2608.824,Percent of Total Billed Charges,45% of Total Billed Charges,7801.07,90,,4011.872,Percent of Total Billed Charges,90% of Total billed Charges,8667.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8667.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8667.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5634.11,65,,463.44,Percent of total Billed Charges,65% of Total Billed Charges,3822.53,44.1,,2556.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,8234.47,95,,4234.752,Percent of Total Billed Charges,95% of Total Billed Charges,8667.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7627.72,88,,5101.696,Percent of Total Billed Charges,88% of Total Billed Charges,7801.07,90,,4011.872,Percent of Total Billed charges,90% of Total Billed Charges,3822.53,8667.86,
LHC LV COR,4810000051,CDM,481,RC,,,Outpatient,,,16402.00,10661.30,,16402,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12465.52,76,,3288.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11809.44,72,,995.328,Percent of Total Billed Charges,72% of Total Billed Charges,12301.5,75,,1036.8,Percent of Total Billed charges,75% of Total Billed Charges,16402,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11809.44,72,,995.328,Percent of Total Billed Charges,72% of Total Billed Charges,9841.2,60,,829.44,Percent of Total Billed Charges,60% of Total Billed Charges,14761.8,90,,393.84,Percent of Total Billed Charges,90% of Total Billed Charges,7380.9,45,,2005.936,Percent of Total Billed Charges,45% of Total Billed Charges,14761.8,90,,3894.384,Percent of Total Billed Charges,90% of Total billed Charges,16402,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16402,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16402,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10661.3,65,,59.512,Percent of total Billed Charges,65% of Total Billed Charges,7233.28,44.1,,1965.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,15581.9,95,,4110.744,Percent of Total Billed Charges,95% of Total Billed Charges,16402,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14433.76,88,,3922.72,Percent of Total Billed Charges,88% of Total Billed Charges,14761.8,90,,3894.384,Percent of Total Billed charges,90% of Total Billed Charges,7233.28,16402,
LHC LV COR SVG IMA,4810000054,CDM,481,RC,,,Outpatient,,,17503.00,11376.95,,17503,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13302.28,76,,3256.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12602.16,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,13127.25,75,,960,Percent of Total Billed charges,75% of Total Billed Charges,17503,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12602.16,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,10501.8,60,,768,Percent of Total Billed Charges,60% of Total Billed Charges,15752.7,90,,3420,Percent of Total Billed Charges,90% of Total Billed Charges,7876.35,45,,196.92,Percent of Total Billed Charges,45% of Total Billed Charges,15752.7,90,,3856.288,Percent of Total Billed Charges,90% of Total billed Charges,17503,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17503,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17503,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11376.95,65,,146.768,Percent of total Billed Charges,65% of Total Billed Charges,7718.82,44.1,,192.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,16627.85,95,,4070.52,Percent of Total Billed Charges,95% of Total Billed Charges,17503,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15402.64,88,,385.088,Percent of Total Billed Charges,88% of Total Billed Charges,15752.7,90,,3856.288,Percent of Total Billed charges,90% of Total Billed Charges,7718.82,17503,
LHC LV COR SVG,4810000055,CDM,481,RC,,,Outpatient,,,18423.88,11975.52,,18423.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14002.15,76,,3387.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13265.19,72,,995.328,Percent of Total Billed Charges,72% of Total Billed Charges,13817.91,75,,1036.8,Percent of Total Billed charges,75% of Total Billed Charges,18423.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13265.19,72,,995.328,Percent of Total Billed Charges,72% of Total Billed Charges,11054.33,60,,829.44,Percent of Total Billed Charges,60% of Total Billed Charges,16581.49,90,,3600,Percent of Total Billed Charges,90% of Total Billed Charges,8290.75,45,,187.2,Percent of Total Billed Charges,45% of Total Billed Charges,16581.49,90,,4011.872,Percent of Total Billed Charges,90% of Total billed Charges,18423.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18423.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18423.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11975.52,65,,44.848,Percent of total Billed Charges,65% of Total Billed Charges,8124.93,44.1,,183.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,17502.69,95,,4234.752,Percent of Total Billed Charges,95% of Total Billed Charges,18423.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16213.01,88,,366.08,Percent of Total Billed Charges,88% of Total Billed Charges,16581.49,90,,4011.872,Percent of Total Billed charges,90% of Total Billed Charges,8124.93,18423.88,
INS PLCMT FLW DIR CA,4810000056,CDM,481,RC,,,Outpatient,,,1541.30,1001.85,,1541.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1171.39,76,,3288.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1109.74,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,1155.98,75,,960,Percent of Total Billed charges,75% of Total Billed Charges,1541.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1109.74,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,924.78,60,,768,Percent of Total Billed Charges,60% of Total Billed Charges,1387.17,90,,2554.456,Percent of Total Billed Charges,90% of Total Billed Charges,693.59,45,,2223,Percent of Total Billed Charges,45% of Total Billed Charges,1387.17,90,,3894.384,Percent of Total Billed Charges,90% of Total billed Charges,1541.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1541.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1541.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1001.85,65,,25.04,Percent of total Billed Charges,65% of Total Billed Charges,679.71,44.1,,2178.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,1464.24,95,,4110.744,Percent of Total Billed Charges,95% of Total Billed Charges,1541.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1356.34,88,,4347.2,Percent of Total Billed Charges,88% of Total Billed Charges,1387.17,90,,3894.384,Percent of Total Billed charges,90% of Total Billed Charges,679.71,1541.3,
FFR INITIAL VESSEL,4810000057,CDM,481,RC,,,Outpatient,,,3248.23,2111.35,,3248.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2468.65,76,,4406.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2338.73,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,2436.17,75,,960,Percent of Total Billed charges,75% of Total Billed Charges,3248.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2338.73,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,1948.94,60,,768,Percent of Total Billed Charges,60% of Total Billed Charges,2923.41,90,,2554.456,Percent of Total Billed Charges,90% of Total Billed Charges,1461.7,45,,1800,Percent of Total Billed Charges,45% of Total Billed Charges,2923.41,90,,5217.648,Percent of Total Billed Charges,90% of Total billed Charges,3248.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3248.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3248.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2111.35,65,,147.336,Percent of total Billed Charges,65% of Total Billed Charges,1432.47,44.1,,1764,Percent of Total Billed Charges,44.1% of Total Billed Charges,3085.82,95,,5507.512,Percent of Total Billed Charges,95% of Total Billed Charges,3248.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2858.44,88,,3520,Percent of Total Billed Charges,88% of Total Billed Charges,2923.41,90,,5217.648,Percent of Total Billed charges,90% of Total Billed Charges,1432.47,3248.23,
FFR EACH ADDITIONAL VESSEL,4810000058,CDM,481,RC,,,Outpatient,,,2047.76,1331.04,,2047.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1556.3,76,,3387.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1474.39,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,1535.82,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,2047.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1474.39,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,1228.66,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,1842.98,90,,2554.456,Percent of Total Billed Charges,90% of Total Billed Charges,921.49,45,,196.92,Percent of Total Billed Charges,45% of Total Billed Charges,1842.98,90,,4011.872,Percent of Total Billed Charges,90% of Total billed Charges,2047.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2047.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2047.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1331.04,65,,97.824,Percent of total Billed Charges,65% of Total Billed Charges,903.06,44.1,,192.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,1945.37,95,,4234.752,Percent of Total Billed Charges,95% of Total Billed Charges,2047.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1802.03,88,,385.088,Percent of Total Billed Charges,88% of Total Billed Charges,1842.98,90,,4011.872,Percent of Total Billed charges,90% of Total Billed Charges,903.06,2047.76,
PERC DRGELU COR STE,4810000059,CDM,481,RC,C9600,HCPCS,Outpatient,,,29818.22,19381.84,,14255.75,125,,,Fee Schedule,125% of CMS OPPS Rate,22661.85,76,,332.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21469.12,72,,1802.248,Percent of Total Billed Charges,72% of Total Billed Charges,22363.67,75,,1877.344,Percent of Total Billed charges,75% of Total Billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21469.12,72,,1802.248,Percent of Total Billed Charges,72% of Total Billed Charges,17890.93,60,,1501.872,Percent of Total Billed Charges,60% of Total Billed Charges,26836.4,90,,2554.456,Percent of Total Billed Charges,90% of Total Billed Charges,13418.2,45,,1710,Percent of Total Billed Charges,45% of Total Billed Charges,26836.4,90,,393.84,Percent of Total Billed Charges,90% of Total billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21297.13,200,,59.624,Fee Schedule,200% of CMS OPPS Rate,13149.84,44.1,,1675.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,28327.31,95,,415.72,Percent of Total Billed Charges,95% of Total Billed Charges,8553.44,75,,,Fee Schedule,75% of CMS OPPS Rate,26240.03,88,,3344,Percent of Total Billed Charges,88% of Total Billed Charges,26836.4,90,,393.84,Percent of Total Billed charges,90% of Total Billed Charges,8553.44,28327.31,
PERC DRGELU COR RE,4810000060,CDM,481,RC,C9606,HCPCS,Outpatient,,,29818.22,19381.84,,29818.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22661.85,76,,316.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21469.12,72,,246.528,Percent of Total Billed Charges,72% of Total Billed Charges,22363.67,75,,256.8,Percent of Total Billed charges,75% of Total Billed Charges,29818.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21469.12,72,,246.528,Percent of Total Billed Charges,72% of Total Billed Charges,17890.93,60,,205.44,Percent of Total Billed Charges,60% of Total Billed Charges,26836.4,90,,2554.456,Percent of Total Billed Charges,90% of Total Billed Charges,13418.2,45,,1800,Percent of Total Billed Charges,45% of Total Billed Charges,26836.4,90,,374.4,Percent of Total Billed Charges,90% of Total billed Charges,29818.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,29818.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,29818.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,29818.22,100,,21.408,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,13149.84,44.1,,1764,Percent of Total Billed Charges,44.1% of Total Billed Charges,28327.31,95,,395.2,Percent of Total Billed Charges,95% of Total Billed Charges,29818.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,26240.03,88,,3520,Percent of Total Billed Charges,88% of Total Billed Charges,26836.4,90,,374.4,Percent of Total Billed charges,90% of Total Billed Charges,13149.84,29818.22,
EVERFLEX 6X200X120CM STENT,4810000061,CDM,481,RC,C9607,HCPCS,Outpatient,,,14126.33,9182.11,,22572.66,125,,,Fee Schedule,125% of CMS OPPS Rate,10736.01,76,,3754.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10170.96,72,,3348.424,Percent of Total Billed Charges,72% of Total Billed Charges,10594.75,75,,3487.936,Percent of Total Billed charges,75% of Total Billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,10170.96,72,,3348.424,Percent of Total Billed Charges,72% of Total Billed Charges,8475.8,60,,2790.352,Percent of Total Billed Charges,60% of Total Billed Charges,12713.7,90,,2768.776,Percent of Total Billed Charges,90% of Total Billed Charges,6356.85,45,,1277.224,Percent of Total Billed Charges,45% of Total Billed Charges,12713.7,90,,4446,Percent of Total Billed Charges,90% of Total billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,33722,200,,59.496,Fee Schedule,200% of CMS OPPS Rate,6229.71,44.1,,1251.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,13420.01,95,,4693,Percent of Total Billed Charges,95% of Total Billed Charges,13543.59,75,,,Fee Schedule,75% of CMS OPPS Rate,12431.17,88,,2497.688,Percent of Total Billed Charges,88% of Total Billed Charges,12713.7,90,,4446,Percent of Total Billed charges,90% of Total Billed Charges,6229.71,33722,
PERC DRGELU COR RE,4810000062,CDM,481,RC,C9608,HCPCS,Outpatient,,,29818.22,19381.84,,29818.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22661.85,76,,3040,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29818.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26836.4,90,,2768.776,Percent of Total Billed Charges,90% of Total Billed Charges,13418.2,45,,1277.224,Percent of Total Billed Charges,45% of Total Billed Charges,26836.4,90,,3600,Percent of Total Billed Charges,90% of Total billed Charges,29818.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29818.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29818.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19381.84,65,,36.944,Percent of total Billed Charges,65% of Total Billed Charges,13149.84,44.1,,1251.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,28327.31,95,,3800,Percent of Total Billed Charges,95% of Total Billed Charges,29818.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26240.03,88,,2497.688,Percent of Total Billed Charges,88% of Total Billed Charges,26836.4,90,,3600,Percent of Total Billed charges,90% of Total Billed Charges,13149.84,29818.22,
DISPOSABLE ECG LEADS,4810000065,CDM,272,RC,,,Outpatient,,,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,332.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.29,72,,5500.8,Percent of Total Billed Charges,72% of Total Billed Charges,14.89,75,,5730,Percent of Total Billed charges,75% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.29,72,,5500.8,Percent of Total Billed Charges,72% of Total Billed Charges,11.91,60,,4584,Percent of Total Billed Charges,60% of Total Billed Charges,17.87,90,,2768.776,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,1277.224,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,393.84,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,176.576,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,1251.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,415.72,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,2497.688,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,393.84,Percent of Total Billed charges,90% of Total Billed Charges,8.75,19.85,
LINEAR 34CC BALLOON,4810000066,CDM,270,RC,C1729,HCPCS,Outpatient,,,6660.20,4329.13,,6660.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5061.75,76,,2888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4795.34,72,,163.84,Percent of Total Billed Charges,72% of Total Billed Charges,4995.15,75,,170.672,Percent of Total Billed charges,75% of Total Billed Charges,6660.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4795.34,72,,163.84,Percent of Total Billed Charges,72% of Total Billed Charges,3996.12,60,,136.536,Percent of Total Billed Charges,60% of Total Billed Charges,5994.18,90,,2768.776,Percent of Total Billed Charges,90% of Total Billed Charges,2997.09,45,,1277.224,Percent of Total Billed Charges,45% of Total Billed Charges,5994.18,90,,3420,Percent of Total Billed Charges,90% of Total billed Charges,6660.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6660.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6660.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4329.13,65,,58.336,Percent of total Billed Charges,65% of Total Billed Charges,2937.15,44.1,,1251.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,6327.19,95,,3610,Percent of Total Billed Charges,95% of Total Billed Charges,6660.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5860.98,88,,2497.688,Percent of Total Billed Charges,88% of Total Billed Charges,5994.18,90,,3420,Percent of Total Billed charges,90% of Total Billed Charges,2937.15,6660.2,
INS DEFIB/PACE DUAL,4810000068,CDM,481,RC,,,Outpatient,,,56855.93,36956.35,,56855.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43210.51,76,,3040,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,40936.27,72,,150.76,Percent of Total Billed Charges,72% of Total Billed Charges,42641.95,75,,157.04,Percent of Total Billed charges,75% of Total Billed Charges,56855.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40936.27,72,,150.76,Percent of Total Billed Charges,72% of Total Billed Charges,34113.56,60,,125.632,Percent of Total Billed Charges,60% of Total Billed Charges,51170.34,90,,2768.776,Percent of Total Billed Charges,90% of Total Billed Charges,25585.17,45,,1277.224,Percent of Total Billed Charges,45% of Total Billed Charges,51170.34,90,,3600,Percent of Total Billed Charges,90% of Total billed Charges,56855.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56855.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56855.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36956.35,65,,110.592,Percent of total Billed Charges,65% of Total Billed Charges,25073.47,44.1,,1251.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,54013.13,95,,3800,Percent of Total Billed Charges,95% of Total Billed Charges,56855.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50033.22,88,,2497.688,Percent of Total Billed Charges,88% of Total Billed Charges,51170.34,90,,3600,Percent of Total Billed charges,90% of Total Billed Charges,25073.47,56855.93,
BI V AICD INSERTION,4810000069,CDM,481,RC,,,Outpatient,,,50648.85,32921.75,,50648.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,38493.13,76,,2157.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36467.17,72,,541.688,Percent of Total Billed Charges,72% of Total Billed Charges,37986.64,75,,564.256,Percent of Total Billed charges,75% of Total Billed Charges,50648.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36467.17,72,,541.688,Percent of Total Billed Charges,72% of Total Billed Charges,30389.31,60,,451.408,Percent of Total Billed Charges,60% of Total Billed Charges,45583.97,90,,2768.776,Percent of Total Billed Charges,90% of Total Billed Charges,22791.98,45,,1384.384,Percent of Total Billed Charges,45% of Total Billed Charges,45583.97,90,,2554.456,Percent of Total Billed Charges,90% of Total billed Charges,50648.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50648.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50648.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32921.75,65,,152.504,Percent of total Billed Charges,65% of Total Billed Charges,22336.14,44.1,,1356.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,48116.41,95,,2696.368,Percent of Total Billed Charges,95% of Total Billed Charges,50648.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44570.99,88,,2707.248,Percent of Total Billed Charges,88% of Total Billed Charges,45583.97,90,,2554.456,Percent of Total Billed charges,90% of Total Billed Charges,22336.14,50648.85,
BI VENT AICD BATT CH,4810000070,CDM,481,RC,,,Outpatient,,,104426.60,67877.29,,104426.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79364.22,76,,2157.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75187.15,72,,150.76,Percent of Total Billed Charges,72% of Total Billed Charges,78319.95,75,,157.04,Percent of Total Billed charges,75% of Total Billed Charges,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75187.15,72,,150.76,Percent of Total Billed Charges,72% of Total Billed Charges,62655.96,60,,125.632,Percent of Total Billed Charges,60% of Total Billed Charges,93983.94,90,,3113.288,Percent of Total Billed Charges,90% of Total Billed Charges,46991.97,45,,1384.384,Percent of Total Billed Charges,45% of Total Billed Charges,93983.94,90,,2554.456,Percent of Total Billed Charges,90% of Total billed Charges,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67877.29,65,,15.48,Percent of total Billed Charges,65% of Total Billed Charges,46052.13,44.1,,1356.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,99205.27,95,,2696.368,Percent of Total Billed Charges,95% of Total Billed Charges,104426.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91895.41,88,,2707.248,Percent of Total Billed Charges,88% of Total Billed Charges,93983.94,90,,2554.456,Percent of Total Billed charges,90% of Total Billed Charges,46052.13,104426.6,
PERC DRG-ELU COR RE,4810000071,CDM,481,RC,C9604,HCPCS,Outpatient,,,29818.22,19381.84,,14255.75,125,,,Fee Schedule,125% of CMS OPPS Rate,22661.85,76,,2157.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21469.12,72,,370.864,Percent of Total Billed Charges,72% of Total Billed Charges,22363.67,75,,386.32,Percent of Total Billed charges,75% of Total Billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21469.12,72,,370.864,Percent of Total Billed Charges,72% of Total Billed Charges,17890.93,60,,309.056,Percent of Total Billed Charges,60% of Total Billed Charges,26836.4,90,,3113.288,Percent of Total Billed Charges,90% of Total Billed Charges,13418.2,45,,1384.384,Percent of Total Billed Charges,45% of Total Billed Charges,26836.4,90,,2554.456,Percent of Total Billed Charges,90% of Total billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21297.13,200,,2.296,Fee Schedule,200% of CMS OPPS Rate,13149.84,44.1,,1356.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,28327.31,95,,2696.368,Percent of Total Billed Charges,95% of Total Billed Charges,8553.44,75,,,Fee Schedule,75% of CMS OPPS Rate,26240.03,88,,2707.248,Percent of Total Billed Charges,88% of Total Billed Charges,26836.4,90,,2554.456,Percent of Total Billed charges,90% of Total Billed Charges,8553.44,28327.31,
PERC DRG-ELU COR RE,4810000072,CDM,481,RC,C9605,HCPCS,Outpatient,,,29818.22,19381.84,,29818.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22661.85,76,,2157.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29818.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26836.4,90,,3113.288,Percent of Total Billed Charges,90% of Total Billed Charges,13418.2,45,,1384.384,Percent of Total Billed Charges,45% of Total Billed Charges,26836.4,90,,2554.456,Percent of Total Billed Charges,90% of Total billed Charges,29818.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29818.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29818.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19381.84,65,,43,Percent of total Billed Charges,65% of Total Billed Charges,13149.84,44.1,,1356.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,28327.31,95,,2696.368,Percent of Total Billed Charges,95% of Total Billed Charges,29818.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26240.03,88,,2707.248,Percent of Total Billed Charges,88% of Total Billed Charges,26836.4,90,,2554.456,Percent of Total Billed charges,90% of Total Billed Charges,13149.84,29818.22,
PERC DRG-ELU COR STE,4810000073,CDM,481,RC,C9601,HCPCS,Outpatient,,,11274.72,7328.57,,11274.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8568.79,76,,2157.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10147.25,90,,3113.288,Percent of Total Billed Charges,90% of Total Billed Charges,5073.62,45,,1384.384,Percent of Total Billed Charges,45% of Total Billed Charges,10147.25,90,,2554.456,Percent of Total Billed Charges,90% of Total billed Charges,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7328.57,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,4972.15,44.1,,1356.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,10710.98,95,,2696.368,Percent of Total Billed Charges,95% of Total Billed Charges,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9921.75,88,,2707.248,Percent of Total Billed Charges,88% of Total Billed Charges,10147.25,90,,2554.456,Percent of Total Billed charges,90% of Total Billed Charges,4972.15,11274.72,
PERC DRG-ELU COR STE,4810000074,CDM,481,RC,C9602,HCPCS,Outpatient,,,29818.22,19381.84,,22572.66,125,,,Fee Schedule,125% of CMS OPPS Rate,22661.85,76,,2338.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21469.12,72,,1162.944,Percent of Total Billed Charges,72% of Total Billed Charges,22363.67,75,,1211.4,Percent of Total Billed charges,75% of Total Billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,21469.12,72,,1162.944,Percent of Total Billed Charges,72% of Total Billed Charges,17890.93,60,,969.12,Percent of Total Billed Charges,60% of Total Billed Charges,26836.4,90,,3113.288,Percent of Total Billed Charges,90% of Total Billed Charges,13418.2,45,,1384.384,Percent of Total Billed Charges,45% of Total Billed Charges,26836.4,90,,2768.776,Percent of Total Billed Charges,90% of Total billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,33722,200,,14.328,Fee Schedule,200% of CMS OPPS Rate,13149.84,44.1,,1356.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,28327.31,95,,2922.592,Percent of Total Billed Charges,95% of Total Billed Charges,13543.59,75,,,Fee Schedule,75% of CMS OPPS Rate,26240.03,88,,2707.248,Percent of Total Billed Charges,88% of Total Billed Charges,26836.4,90,,2768.776,Percent of Total Billed charges,90% of Total Billed Charges,13149.84,33722,
PERC DRG-ELU COR STE,4810000075,CDM,481,RC,C9603,HCPCS,Outpatient,,,29818.22,19381.84,,29818.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22661.85,76,,2338.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29818.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26836.4,90,,3113.288,Percent of Total Billed Charges,90% of Total Billed Charges,13418.2,45,,1556.64,Percent of Total Billed Charges,45% of Total Billed Charges,26836.4,90,,2768.776,Percent of Total Billed Charges,90% of Total billed Charges,29818.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29818.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29818.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19381.84,65,,134.728,Percent of total Billed Charges,65% of Total Billed Charges,13149.84,44.1,,1525.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,28327.31,95,,2922.592,Percent of Total Billed Charges,95% of Total Billed Charges,29818.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26240.03,88,,3044.104,Percent of Total Billed Charges,88% of Total Billed Charges,26836.4,90,,2768.776,Percent of Total Billed charges,90% of Total Billed Charges,13149.84,29818.22,
PRQ TRANSLUMINAL COR,4810000076,CDM,481,RC,,,Outpatient,,,11129.60,7234.24,,11129.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8458.5,76,,2338.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8013.31,72,,918.152,Percent of Total Billed Charges,72% of Total Billed Charges,8347.2,75,,956.416,Percent of Total Billed charges,75% of Total Billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8013.31,72,,918.152,Percent of Total Billed Charges,72% of Total Billed Charges,6677.76,60,,765.128,Percent of Total Billed Charges,60% of Total Billed Charges,10016.64,90,,2699.712,Percent of Total Billed Charges,90% of Total Billed Charges,5008.32,45,,1556.64,Percent of Total Billed Charges,45% of Total Billed Charges,10016.64,90,,2768.776,Percent of Total Billed Charges,90% of Total billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7234.24,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,4908.15,44.1,,1525.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,10573.12,95,,2922.592,Percent of Total Billed Charges,95% of Total Billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9794.05,88,,3044.104,Percent of Total Billed Charges,88% of Total Billed Charges,10016.64,90,,2768.776,Percent of Total Billed charges,90% of Total Billed Charges,4908.15,11129.6,
PRQ TRANSLUMINAL COR,4810000077,CDM,481,RC,,,Outpatient,,,11129.60,7234.24,,11129.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8458.5,76,,2338.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8013.31,72,,1202.768,Percent of Total Billed Charges,72% of Total Billed Charges,8347.2,75,,1252.888,Percent of Total Billed charges,75% of Total Billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8013.31,72,,1202.768,Percent of Total Billed Charges,72% of Total Billed Charges,6677.76,60,,1002.304,Percent of Total Billed Charges,60% of Total Billed Charges,10016.64,90,,2699.712,Percent of Total Billed Charges,90% of Total Billed Charges,5008.32,45,,1556.64,Percent of Total Billed Charges,45% of Total Billed Charges,10016.64,90,,2768.776,Percent of Total Billed Charges,90% of Total billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7234.24,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,4908.15,44.1,,1525.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,10573.12,95,,2922.592,Percent of Total Billed Charges,95% of Total Billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9794.05,88,,3044.104,Percent of Total Billed Charges,88% of Total Billed Charges,10016.64,90,,2768.776,Percent of Total Billed charges,90% of Total Billed Charges,4908.15,11129.6,
PRQ TRASLUMINAL COR,4810000078,CDM,481,RC,,,Outpatient,,,29465.42,19152.52,,29465.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22393.72,76,,2338.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21215.1,72,,1202.768,Percent of Total Billed Charges,72% of Total Billed Charges,22099.07,75,,1252.888,Percent of Total Billed charges,75% of Total Billed Charges,29465.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21215.1,72,,1202.768,Percent of Total Billed Charges,72% of Total Billed Charges,17679.25,60,,1002.304,Percent of Total Billed Charges,60% of Total Billed Charges,26518.88,90,,2699.712,Percent of Total Billed Charges,90% of Total Billed Charges,13259.44,45,,1556.64,Percent of Total Billed Charges,45% of Total Billed Charges,26518.88,90,,2768.776,Percent of Total Billed Charges,90% of Total billed Charges,29465.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29465.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29465.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19152.52,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,12994.25,44.1,,1525.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,27992.15,95,,2922.592,Percent of Total Billed Charges,95% of Total Billed Charges,29465.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25929.57,88,,3044.104,Percent of Total Billed Charges,88% of Total Billed Charges,26518.88,90,,2768.776,Percent of Total Billed charges,90% of Total Billed Charges,12994.25,29465.42,
PRQ CARDIO STENT W/A,4810000079,CDM,481,RC,,,Outpatient,,,22549.43,14657.13,,22549.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17137.57,76,,2338.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16235.59,72,,1230.448,Percent of Total Billed Charges,72% of Total Billed Charges,16912.07,75,,1281.712,Percent of Total Billed charges,75% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16235.59,72,,1230.448,Percent of Total Billed Charges,72% of Total Billed Charges,13529.66,60,,1025.368,Percent of Total Billed Charges,60% of Total Billed Charges,20294.49,90,,2699.712,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,1556.64,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,2768.776,Percent of Total Billed Charges,90% of Total billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14657.13,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,9944.3,44.1,,1525.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,2922.592,Percent of Total Billed Charges,95% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19843.5,88,,3044.104,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,2768.776,Percent of Total Billed charges,90% of Total Billed Charges,9944.3,22549.43,
PRQ CARDIO ATHERECTO,4810000080,CDM,481,RC,,,Outpatient,,,23470.02,15255.51,,23470.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17837.22,76,,2629,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16898.41,72,,349.632,Percent of Total Billed Charges,72% of Total Billed Charges,17602.52,75,,364.2,Percent of Total Billed charges,75% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16898.41,72,,349.632,Percent of Total Billed Charges,72% of Total Billed Charges,14082.01,60,,291.36,Percent of Total Billed Charges,60% of Total Billed Charges,21123.02,90,,2699.712,Percent of Total Billed Charges,90% of Total Billed Charges,10561.51,45,,1556.64,Percent of Total Billed Charges,45% of Total Billed Charges,21123.02,90,,3113.288,Percent of Total Billed Charges,90% of Total billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15255.51,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,10350.28,44.1,,1525.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,22296.52,95,,3286.248,Percent of Total Billed Charges,95% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20653.62,88,,3044.104,Percent of Total Billed Charges,88% of Total Billed Charges,21123.02,90,,3113.288,Percent of Total Billed charges,90% of Total Billed Charges,10350.28,23470.02,
PRQ RE-VASC BYP GRAF,4810000081,CDM,481,RC,,,Outpatient,,,23470.02,15255.51,,23470.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17837.22,76,,2629,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16898.41,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,17602.52,75,,3009.832,Percent of Total Billed charges,75% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16898.41,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,14082.01,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,21123.02,90,,2699.712,Percent of Total Billed Charges,90% of Total Billed Charges,10561.51,45,,1349.856,Percent of Total Billed Charges,45% of Total Billed Charges,21123.02,90,,3113.288,Percent of Total Billed Charges,90% of Total billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15255.51,65,,466.672,Percent of total Billed Charges,65% of Total Billed Charges,10350.28,44.1,,1322.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,22296.52,95,,3286.248,Percent of Total Billed Charges,95% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20653.62,88,,2639.72,Percent of Total Billed Charges,88% of Total Billed Charges,21123.02,90,,3113.288,Percent of Total Billed charges,90% of Total Billed Charges,10350.28,23470.02,
PRQ CARDIO-RE VASC C,4810000082,CDM,481,RC,,,Outpatient,,,23470.02,15255.51,,23470.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17837.22,76,,2629,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16898.41,72,,408.96,Percent of Total Billed Charges,72% of Total Billed Charges,17602.52,75,,426,Percent of Total Billed charges,75% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16898.41,72,,408.96,Percent of Total Billed Charges,72% of Total Billed Charges,14082.01,60,,340.8,Percent of Total Billed Charges,60% of Total Billed Charges,21123.02,90,,2240.896,Percent of Total Billed Charges,90% of Total Billed Charges,10561.51,45,,1349.856,Percent of Total Billed Charges,45% of Total Billed Charges,21123.02,90,,3113.288,Percent of Total Billed Charges,90% of Total billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15255.51,65,,24.656,Percent of total Billed Charges,65% of Total Billed Charges,10350.28,44.1,,1322.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,22296.52,95,,3286.248,Percent of Total Billed Charges,95% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20653.62,88,,2639.72,Percent of Total Billed Charges,88% of Total Billed Charges,21123.02,90,,3113.288,Percent of Total Billed charges,90% of Total Billed Charges,10350.28,23470.02,
Pericardiocentesis w/imaging,4810000083,CDM,481,RC,,,Outpatient,,,3375.25,2193.91,,3375.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2565.19,76,,2629,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2430.18,72,,1217.368,Percent of Total Billed Charges,72% of Total Billed Charges,2531.44,75,,1268.096,Percent of Total Billed charges,75% of Total Billed Charges,3375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2430.18,72,,1217.368,Percent of Total Billed Charges,72% of Total Billed Charges,2025.15,60,,1014.472,Percent of Total Billed Charges,60% of Total Billed Charges,3037.73,90,,2240.896,Percent of Total Billed Charges,90% of Total Billed Charges,1518.86,45,,1349.856,Percent of Total Billed Charges,45% of Total Billed Charges,3037.73,90,,3113.288,Percent of Total Billed Charges,90% of Total billed Charges,3375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2193.91,65,,13.184,Percent of total Billed Charges,65% of Total Billed Charges,1488.49,44.1,,1322.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,3206.49,95,,3286.248,Percent of Total Billed Charges,95% of Total Billed Charges,3375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2970.22,88,,2639.72,Percent of Total Billed Charges,88% of Total Billed Charges,3037.73,90,,3113.288,Percent of Total Billed charges,90% of Total Billed Charges,1488.49,3375.25,
Pedicardial Cath insert/drain,4810000084,CDM,481,RC,,,Outpatient,,,1528.80,993.72,,1528.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1161.89,76,,2629,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1100.74,72,,46.656,Percent of Total Billed Charges,72% of Total Billed Charges,1146.6,75,,48.6,Percent of Total Billed charges,75% of Total Billed Charges,1528.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1100.74,72,,46.656,Percent of Total Billed Charges,72% of Total Billed Charges,917.28,60,,38.88,Percent of Total Billed Charges,60% of Total Billed Charges,1375.92,90,,2240.896,Percent of Total Billed Charges,90% of Total Billed Charges,687.96,45,,1349.856,Percent of Total Billed Charges,45% of Total Billed Charges,1375.92,90,,3113.288,Percent of Total Billed Charges,90% of Total billed Charges,1528.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,993.72,65,,7.448,Percent of total Billed Charges,65% of Total Billed Charges,674.2,44.1,,1322.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,1452.36,95,,3286.248,Percent of Total Billed Charges,95% of Total Billed Charges,1528.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1345.34,88,,2639.72,Percent of Total Billed Charges,88% of Total Billed Charges,1375.92,90,,3113.288,Percent of Total Billed charges,90% of Total Billed Charges,674.2,1528.8,
Pedicardial Drainage  CT Guide,4810000085,CDM,481,RC,,,Outpatient,,,1528.80,993.72,,1528.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1161.89,76,,2629,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1100.74,72,,46.656,Percent of Total Billed Charges,72% of Total Billed Charges,1146.6,75,,48.6,Percent of Total Billed charges,75% of Total Billed Charges,1528.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1100.74,72,,46.656,Percent of Total Billed Charges,72% of Total Billed Charges,917.28,60,,38.88,Percent of Total Billed Charges,60% of Total Billed Charges,1375.92,90,,2240.896,Percent of Total Billed Charges,90% of Total Billed Charges,687.96,45,,1349.856,Percent of Total Billed Charges,45% of Total Billed Charges,1375.92,90,,3113.288,Percent of Total Billed Charges,90% of Total billed Charges,1528.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,993.72,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,674.2,44.1,,1322.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,1452.36,95,,3286.248,Percent of Total Billed Charges,95% of Total Billed Charges,1528.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1345.34,88,,2639.72,Percent of Total Billed Charges,88% of Total Billed Charges,1375.92,90,,3113.288,Percent of Total Billed charges,90% of Total Billed Charges,674.2,1528.8,
PTCA Major LD,4810000086,CDM,481,RC,,,Outpatient,,,10574.00,6873.10,,10574,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8036.24,76,,2279.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7613.28,72,,20.16,Percent of Total Billed Charges,72% of Total Billed Charges,7930.5,75,,21,Percent of Total Billed charges,75% of Total Billed Charges,10574,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7613.28,72,,20.16,Percent of Total Billed Charges,72% of Total Billed Charges,6344.4,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,9516.6,90,,3113.288,Percent of Total Billed Charges,90% of Total Billed Charges,4758.3,45,,1349.856,Percent of Total Billed Charges,45% of Total Billed Charges,9516.6,90,,2699.712,Percent of Total Billed Charges,90% of Total billed Charges,10574,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10574,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10574,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6873.1,65,,18.344,Percent of total Billed Charges,65% of Total Billed Charges,4663.13,44.1,,1322.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,10045.3,95,,2849.696,Percent of Total Billed Charges,95% of Total Billed Charges,10574,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9305.12,88,,2639.72,Percent of Total Billed Charges,88% of Total Billed Charges,9516.6,90,,2699.712,Percent of Total Billed charges,90% of Total Billed Charges,4663.13,10574,
PTCA Major LC,4810000087,CDM,481,RC,,,Outpatient,,,10574.00,6873.10,,10574,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8036.24,76,,2279.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7613.28,72,,869.368,Percent of Total Billed Charges,72% of Total Billed Charges,7930.5,75,,905.592,Percent of Total Billed charges,75% of Total Billed Charges,10574,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7613.28,72,,869.368,Percent of Total Billed Charges,72% of Total Billed Charges,6344.4,60,,724.472,Percent of Total Billed Charges,60% of Total Billed Charges,9516.6,90,,3113.288,Percent of Total Billed Charges,90% of Total Billed Charges,4758.3,45,,1120.448,Percent of Total Billed Charges,45% of Total Billed Charges,9516.6,90,,2699.712,Percent of Total Billed Charges,90% of Total billed Charges,10574,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10574,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10574,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6873.1,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,4663.13,44.1,,1098.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,10045.3,95,,2849.696,Percent of Total Billed Charges,95% of Total Billed Charges,10574,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9305.12,88,,2191.104,Percent of Total Billed Charges,88% of Total Billed Charges,9516.6,90,,2699.712,Percent of Total Billed charges,90% of Total Billed Charges,4663.13,10574,
PTCA Major RC,4810000088,CDM,481,RC,,,Outpatient,,,10574.00,6873.10,,10574,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8036.24,76,,2279.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7613.28,72,,911.232,Percent of Total Billed Charges,72% of Total Billed Charges,7930.5,75,,949.2,Percent of Total Billed charges,75% of Total Billed Charges,10574,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7613.28,72,,911.232,Percent of Total Billed Charges,72% of Total Billed Charges,6344.4,60,,759.36,Percent of Total Billed Charges,60% of Total Billed Charges,9516.6,90,,3113.288,Percent of Total Billed Charges,90% of Total Billed Charges,4758.3,45,,1120.448,Percent of Total Billed Charges,45% of Total Billed Charges,9516.6,90,,2699.712,Percent of Total Billed Charges,90% of Total billed Charges,10574,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10574,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10574,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6873.1,65,,23.504,Percent of total Billed Charges,65% of Total Billed Charges,4663.13,44.1,,1098.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,10045.3,95,,2849.696,Percent of Total Billed Charges,95% of Total Billed Charges,10574,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9305.12,88,,2191.104,Percent of Total Billed Charges,88% of Total Billed Charges,9516.6,90,,2699.712,Percent of Total Billed charges,90% of Total Billed Charges,4663.13,10574,
PTCA Major RI,4810000089,CDM,481,RC,,,Outpatient,,,11129.60,7234.24,,11129.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8458.5,76,,2279.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8013.31,72,,865.152,Percent of Total Billed Charges,72% of Total Billed Charges,8347.2,75,,901.2,Percent of Total Billed charges,75% of Total Billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8013.31,72,,865.152,Percent of Total Billed Charges,72% of Total Billed Charges,6677.76,60,,720.96,Percent of Total Billed Charges,60% of Total Billed Charges,10016.64,90,,3113.288,Percent of Total Billed Charges,90% of Total Billed Charges,5008.32,45,,1120.448,Percent of Total Billed Charges,45% of Total Billed Charges,10016.64,90,,2699.712,Percent of Total Billed Charges,90% of Total billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7234.24,65,,20.152,Percent of total Billed Charges,65% of Total Billed Charges,4908.15,44.1,,1098.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,10573.12,95,,2849.696,Percent of Total Billed Charges,95% of Total Billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9794.05,88,,2191.104,Percent of Total Billed Charges,88% of Total Billed Charges,10016.64,90,,2699.712,Percent of Total Billed charges,90% of Total Billed Charges,4908.15,11129.6,
PTCA Major LM,4810000090,CDM,481,RC,,,Outpatient,,,11129.60,7234.24,,11129.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8458.5,76,,2279.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8013.31,72,,503.76,Percent of Total Billed Charges,72% of Total Billed Charges,8347.2,75,,524.752,Percent of Total Billed charges,75% of Total Billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8013.31,72,,503.76,Percent of Total Billed Charges,72% of Total Billed Charges,6677.76,60,,419.8,Percent of Total Billed Charges,60% of Total Billed Charges,10016.64,90,,3113.288,Percent of Total Billed Charges,90% of Total Billed Charges,5008.32,45,,1120.448,Percent of Total Billed Charges,45% of Total Billed Charges,10016.64,90,,2699.712,Percent of Total Billed Charges,90% of Total billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7234.24,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,4908.15,44.1,,1098.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,10573.12,95,,2849.696,Percent of Total Billed Charges,95% of Total Billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9794.05,88,,2191.104,Percent of Total Billed Charges,88% of Total Billed Charges,10016.64,90,,2699.712,Percent of Total Billed charges,90% of Total Billed Charges,4908.15,11129.6,
PTCA Ea Addtl LD,4810000091,CDM,481,RC,,,Outpatient,,,5287.00,3436.55,,5287,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4018.12,76,,2279.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3806.64,72,,167.016,Percent of Total Billed Charges,72% of Total Billed Charges,3965.25,75,,173.976,Percent of Total Billed charges,75% of Total Billed Charges,5287,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3806.64,72,,167.016,Percent of Total Billed Charges,72% of Total Billed Charges,3172.2,60,,139.184,Percent of Total Billed Charges,60% of Total Billed Charges,4758.3,90,,3113.288,Percent of Total Billed Charges,90% of Total Billed Charges,2379.15,45,,1556.64,Percent of Total Billed Charges,45% of Total Billed Charges,4758.3,90,,2699.712,Percent of Total Billed Charges,90% of Total billed Charges,5287,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5287,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5287,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3436.55,65,,35.544,Percent of total Billed Charges,65% of Total Billed Charges,2331.57,44.1,,1525.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,5022.65,95,,2849.696,Percent of Total Billed Charges,95% of Total Billed Charges,5287,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4652.56,88,,3044.104,Percent of Total Billed Charges,88% of Total Billed Charges,4758.3,90,,2699.712,Percent of Total Billed charges,90% of Total Billed Charges,2331.57,5287,
PTCA Each Addtl LC,4810000092,CDM,481,RC,,,Outpatient,,,5287.00,3436.55,,5287,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4018.12,76,,1892.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3806.64,72,,170.192,Percent of Total Billed Charges,72% of Total Billed Charges,3965.25,75,,177.28,Percent of Total Billed charges,75% of Total Billed Charges,5287,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3806.64,72,,170.192,Percent of Total Billed Charges,72% of Total Billed Charges,3172.2,60,,141.824,Percent of Total Billed Charges,60% of Total Billed Charges,4758.3,90,,2852.92,Percent of Total Billed Charges,90% of Total Billed Charges,2379.15,45,,1556.64,Percent of Total Billed Charges,45% of Total Billed Charges,4758.3,90,,2240.896,Percent of Total Billed Charges,90% of Total billed Charges,5287,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5287,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5287,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3436.55,65,,22.936,Percent of total Billed Charges,65% of Total Billed Charges,2331.57,44.1,,1525.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,5022.65,95,,2365.392,Percent of Total Billed Charges,95% of Total Billed Charges,5287,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4652.56,88,,3044.104,Percent of Total Billed Charges,88% of Total Billed Charges,4758.3,90,,2240.896,Percent of Total Billed charges,90% of Total Billed Charges,2331.57,5287,
PTCA Ea Addtl RC,4810000093,CDM,481,RC,,,Outpatient,,,5564.80,3617.12,,5564.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4229.25,76,,1892.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4006.66,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,4173.6,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,5564.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4006.66,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,3338.88,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,5008.32,90,,2852.92,Percent of Total Billed Charges,90% of Total Billed Charges,2504.16,45,,1556.64,Percent of Total Billed Charges,45% of Total Billed Charges,5008.32,90,,2240.896,Percent of Total Billed Charges,90% of Total billed Charges,5564.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5564.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5564.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3617.12,65,,12.616,Percent of total Billed Charges,65% of Total Billed Charges,2454.08,44.1,,1525.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,5286.56,95,,2365.392,Percent of Total Billed Charges,95% of Total Billed Charges,5564.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4897.02,88,,3044.104,Percent of Total Billed Charges,88% of Total Billed Charges,5008.32,90,,2240.896,Percent of Total Billed charges,90% of Total Billed Charges,2454.08,5564.8,
BM Stent Major LD,4810000094,CDM,481,RC,,,Outpatient,,,22549.43,14657.13,,22549.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17137.57,76,,1892.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16235.59,72,,320.696,Percent of Total Billed Charges,72% of Total Billed Charges,16912.07,75,,334.056,Percent of Total Billed charges,75% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16235.59,72,,320.696,Percent of Total Billed Charges,72% of Total Billed Charges,13529.66,60,,267.248,Percent of Total Billed Charges,60% of Total Billed Charges,20294.49,90,,2852.92,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,1556.64,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,2240.896,Percent of Total Billed Charges,90% of Total billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14657.13,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,9944.3,44.1,,1525.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,2365.392,Percent of Total Billed Charges,95% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19843.5,88,,3044.104,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,2240.896,Percent of Total Billed charges,90% of Total Billed Charges,9944.3,22549.43,
BM Stent Major LC,4810000095,CDM,481,RC,,,Outpatient,,,22549.43,14657.13,,22549.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17137.57,76,,1892.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16235.59,72,,55360.512,Percent of Total Billed Charges,72% of Total Billed Charges,16912.07,75,,57667.2,Percent of Total Billed charges,75% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16235.59,72,,55360.512,Percent of Total Billed Charges,72% of Total Billed Charges,13529.66,60,,46133.76,Percent of Total Billed Charges,60% of Total Billed Charges,20294.49,90,,2852.92,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,1556.64,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,2240.896,Percent of Total Billed Charges,90% of Total billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14657.13,65,,83.704,Percent of total Billed Charges,65% of Total Billed Charges,9944.3,44.1,,1525.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,2365.392,Percent of Total Billed Charges,95% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19843.5,88,,3044.104,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,2240.896,Percent of Total Billed charges,90% of Total Billed Charges,9944.3,22549.43,
BM Stent Major Vssl  RC,4810000096,CDM,481,RC,,,Outpatient,,,22549.43,14657.13,,22549.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17137.57,76,,2629,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16235.59,72,,226.704,Percent of Total Billed Charges,72% of Total Billed Charges,16912.07,75,,236.152,Percent of Total Billed charges,75% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16235.59,72,,226.704,Percent of Total Billed Charges,72% of Total Billed Charges,13529.66,60,,188.92,Percent of Total Billed Charges,60% of Total Billed Charges,20294.49,90,,2852.92,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,1556.64,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,3113.288,Percent of Total Billed Charges,90% of Total billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14657.13,65,,81.984,Percent of total Billed Charges,65% of Total Billed Charges,9944.3,44.1,,1525.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,3286.248,Percent of Total Billed Charges,95% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19843.5,88,,3044.104,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,3113.288,Percent of Total Billed charges,90% of Total Billed Charges,9944.3,22549.43,
BM Stent Major Vssl RI,4810000097,CDM,481,RC,,,Outpatient,,,22549.43,14657.13,,22549.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17137.57,76,,2629,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16235.59,72,,196.224,Percent of Total Billed Charges,72% of Total Billed Charges,16912.07,75,,204.4,Percent of Total Billed charges,75% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16235.59,72,,196.224,Percent of Total Billed Charges,72% of Total Billed Charges,13529.66,60,,163.52,Percent of Total Billed Charges,60% of Total Billed Charges,20294.49,90,,2852.92,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,1426.464,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,3113.288,Percent of Total Billed Charges,90% of Total billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14657.13,65,,116.08,Percent of total Billed Charges,65% of Total Billed Charges,9944.3,44.1,,1397.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,3286.248,Percent of Total Billed Charges,95% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19843.5,88,,2789.52,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,3113.288,Percent of Total Billed charges,90% of Total Billed Charges,9944.3,22549.43,
BM Stent Major LM,4810000098,CDM,481,RC,,,Outpatient,,,22549.43,14657.13,,22549.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17137.57,76,,2629,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16235.59,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,16912.07,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16235.59,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,13529.66,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,20294.49,90,,2852.92,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,1426.464,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,3113.288,Percent of Total Billed Charges,90% of Total billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14657.13,65,,88.568,Percent of total Billed Charges,65% of Total Billed Charges,9944.3,44.1,,1397.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,3286.248,Percent of Total Billed Charges,95% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19843.5,88,,2789.52,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,3113.288,Percent of Total Billed charges,90% of Total Billed Charges,9944.3,22549.43,
BM Stent Ea Addt LD,4810000099,CDM,481,RC,,,Outpatient,,,11274.72,7328.57,,11274.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8568.79,76,,2629,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8117.8,72,,650.88,Percent of Total Billed Charges,72% of Total Billed Charges,8456.04,75,,678,Percent of Total Billed charges,75% of Total Billed Charges,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8117.8,72,,650.88,Percent of Total Billed Charges,72% of Total Billed Charges,6764.83,60,,542.4,Percent of Total Billed Charges,60% of Total Billed Charges,10147.25,90,,2852.92,Percent of Total Billed Charges,90% of Total Billed Charges,5073.62,45,,1426.464,Percent of Total Billed Charges,45% of Total Billed Charges,10147.25,90,,3113.288,Percent of Total Billed Charges,90% of Total billed Charges,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7328.57,65,,200.568,Percent of total Billed Charges,65% of Total Billed Charges,4972.15,44.1,,1397.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,10710.98,95,,3286.248,Percent of Total Billed Charges,95% of Total Billed Charges,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9921.75,88,,2789.52,Percent of Total Billed Charges,88% of Total Billed Charges,10147.25,90,,3113.288,Percent of Total Billed charges,90% of Total Billed Charges,4972.15,11274.72,
BM Stent Ea Addt LC,4810000100,CDM,481,RC,,,Outpatient,,,11274.72,7328.57,,11274.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8568.79,76,,2629,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8117.8,72,,510.576,Percent of Total Billed Charges,72% of Total Billed Charges,8456.04,75,,531.848,Percent of Total Billed charges,75% of Total Billed Charges,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8117.8,72,,510.576,Percent of Total Billed Charges,72% of Total Billed Charges,6764.83,60,,425.48,Percent of Total Billed Charges,60% of Total Billed Charges,10147.25,90,,2240.896,Percent of Total Billed Charges,90% of Total Billed Charges,5073.62,45,,1426.464,Percent of Total Billed Charges,45% of Total Billed Charges,10147.25,90,,3113.288,Percent of Total Billed Charges,90% of Total billed Charges,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7328.57,65,,9.744,Percent of total Billed Charges,65% of Total Billed Charges,4972.15,44.1,,1397.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,10710.98,95,,3286.248,Percent of Total Billed Charges,95% of Total Billed Charges,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9921.75,88,,2789.52,Percent of Total Billed Charges,88% of Total Billed Charges,10147.25,90,,3113.288,Percent of Total Billed charges,90% of Total Billed Charges,4972.15,11274.72,
BM Stent Ea Addt RC,4810000101,CDM,481,RC,,,Outpatient,,,11274.72,7328.57,,11274.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8568.79,76,,2629,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8117.8,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,8456.04,75,,341.336,Percent of Total Billed charges,75% of Total Billed Charges,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8117.8,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,6764.83,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,10147.25,90,,2240.896,Percent of Total Billed Charges,90% of Total Billed Charges,5073.62,45,,1426.464,Percent of Total Billed Charges,45% of Total Billed Charges,10147.25,90,,3113.288,Percent of Total Billed Charges,90% of Total billed Charges,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7328.57,65,,13.184,Percent of total Billed Charges,65% of Total Billed Charges,4972.15,44.1,,1397.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,10710.98,95,,3286.248,Percent of Total Billed Charges,95% of Total Billed Charges,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9921.75,88,,2789.52,Percent of Total Billed Charges,88% of Total Billed Charges,10147.25,90,,3113.288,Percent of Total Billed charges,90% of Total Billed Charges,4972.15,11274.72,
PCI AMI Any LD,4810000102,CDM,481,RC,C9606,HCPCS,Outpatient,,,22297.00,14493.05,,22297,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16945.72,76,,2409.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16053.84,72,,732.84,Percent of Total Billed Charges,72% of Total Billed Charges,16722.75,75,,763.376,Percent of Total Billed charges,75% of Total Billed Charges,22297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16053.84,72,,732.84,Percent of Total Billed Charges,72% of Total Billed Charges,13378.2,60,,610.696,Percent of Total Billed Charges,60% of Total Billed Charges,20067.3,90,,2240.896,Percent of Total Billed Charges,90% of Total Billed Charges,10033.65,45,,1426.464,Percent of Total Billed Charges,45% of Total Billed Charges,20067.3,90,,2852.92,Percent of Total Billed Charges,90% of Total billed Charges,22297,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,22297,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,22297,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,22297,100,,46.152,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,9832.98,44.1,,1397.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,21182.15,95,,3011.416,Percent of Total Billed Charges,95% of Total Billed Charges,22297,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,19621.36,88,,2789.52,Percent of Total Billed Charges,88% of Total Billed Charges,20067.3,90,,2852.92,Percent of Total Billed charges,90% of Total Billed Charges,9832.98,22297,
PCI AMI any LC,4810000103,CDM,481,RC,C9606,HCPCS,Outpatient,,,22297.00,14493.05,,22297,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16945.72,76,,2409.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16053.84,72,,326.416,Percent of Total Billed Charges,72% of Total Billed Charges,16722.75,75,,340.016,Percent of Total Billed charges,75% of Total Billed Charges,22297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16053.84,72,,326.416,Percent of Total Billed Charges,72% of Total Billed Charges,13378.2,60,,272.008,Percent of Total Billed Charges,60% of Total Billed Charges,20067.3,90,,2240.896,Percent of Total Billed Charges,90% of Total Billed Charges,10033.65,45,,1426.464,Percent of Total Billed Charges,45% of Total Billed Charges,20067.3,90,,2852.92,Percent of Total Billed Charges,90% of Total billed Charges,22297,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,22297,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,22297,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,22297,100,,6.88,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,9832.98,44.1,,1397.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,21182.15,95,,3011.416,Percent of Total Billed Charges,95% of Total Billed Charges,22297,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,19621.36,88,,2789.52,Percent of Total Billed Charges,88% of Total Billed Charges,20067.3,90,,2852.92,Percent of Total Billed charges,90% of Total Billed Charges,9832.98,22297,
PCI AMI Any RC,4810000104,CDM,481,RC,C9606,HCPCS,Outpatient,,,22297.00,14493.05,,22297,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16945.72,76,,2409.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16053.84,72,,747.072,Percent of Total Billed Charges,72% of Total Billed Charges,16722.75,75,,778.2,Percent of Total Billed charges,75% of Total Billed Charges,22297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16053.84,72,,747.072,Percent of Total Billed Charges,72% of Total Billed Charges,13378.2,60,,622.56,Percent of Total Billed Charges,60% of Total Billed Charges,20067.3,90,,2240.896,Percent of Total Billed Charges,90% of Total Billed Charges,10033.65,45,,1426.464,Percent of Total Billed Charges,45% of Total Billed Charges,20067.3,90,,2852.92,Percent of Total Billed Charges,90% of Total billed Charges,22297,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,22297,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,22297,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,22297,100,,1000.984,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,9832.98,44.1,,1397.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,21182.15,95,,3011.416,Percent of Total Billed Charges,95% of Total Billed Charges,22297,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,19621.36,88,,2789.52,Percent of Total Billed Charges,88% of Total Billed Charges,20067.3,90,,2852.92,Percent of Total Billed charges,90% of Total Billed Charges,9832.98,22297,
PCI AMI Any RI,4810000105,CDM,481,RC,C9606,HCPCS,Outpatient,,,23470.02,15255.51,,23470.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17837.22,76,,2409.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16898.41,72,,1155.776,Percent of Total Billed Charges,72% of Total Billed Charges,17602.52,75,,1203.928,Percent of Total Billed charges,75% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16898.41,72,,1155.776,Percent of Total Billed Charges,72% of Total Billed Charges,14082.01,60,,963.144,Percent of Total Billed Charges,60% of Total Billed Charges,21123.02,90,,2240.896,Percent of Total Billed Charges,90% of Total Billed Charges,10561.51,45,,1120.448,Percent of Total Billed Charges,45% of Total Billed Charges,21123.02,90,,2852.92,Percent of Total Billed Charges,90% of Total billed Charges,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23470.02,100,,8.6,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,10350.28,44.1,,1098.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,22296.52,95,,3011.416,Percent of Total Billed Charges,95% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,20653.62,88,,2191.104,Percent of Total Billed Charges,88% of Total Billed Charges,21123.02,90,,2852.92,Percent of Total Billed charges,90% of Total Billed Charges,10350.28,23470.02,
PCI AMI Any LM,4810000106,CDM,481,RC,C9606,HCPCS,Outpatient,,,23470.02,15255.51,,23470.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17837.22,76,,2409.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16898.41,72,,552.384,Percent of Total Billed Charges,72% of Total Billed Charges,17602.52,75,,575.4,Percent of Total Billed charges,75% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16898.41,72,,552.384,Percent of Total Billed Charges,72% of Total Billed Charges,14082.01,60,,460.32,Percent of Total Billed Charges,60% of Total Billed Charges,21123.02,90,,2240.896,Percent of Total Billed Charges,90% of Total Billed Charges,10561.51,45,,1120.448,Percent of Total Billed Charges,45% of Total Billed Charges,21123.02,90,,2852.92,Percent of Total Billed Charges,90% of Total billed Charges,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23470.02,100,,2.864,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,10350.28,44.1,,1098.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,22296.52,95,,3011.416,Percent of Total Billed Charges,95% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,20653.62,88,,2191.104,Percent of Total Billed Charges,88% of Total Billed Charges,21123.02,90,,2852.92,Percent of Total Billed charges,90% of Total Billed Charges,10350.28,23470.02,
PCI CTO Any LD,4810000107,CDM,481,RC,C9607,HCPCS,Outpatient,,,36068.50,23444.53,,22572.66,125,,,Fee Schedule,125% of CMS OPPS Rate,27412.06,76,,2409.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25969.32,72,,404.352,Percent of Total Billed Charges,72% of Total Billed Charges,27051.38,75,,421.2,Percent of Total Billed charges,75% of Total Billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,25969.32,72,,404.352,Percent of Total Billed Charges,72% of Total Billed Charges,21641.1,60,,336.96,Percent of Total Billed Charges,60% of Total Billed Charges,32461.65,90,,2240.896,Percent of Total Billed Charges,90% of Total Billed Charges,16230.83,45,,1120.448,Percent of Total Billed Charges,45% of Total Billed Charges,32461.65,90,,2852.92,Percent of Total Billed Charges,90% of Total billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,33722,200,,6.24,Fee Schedule,200% of CMS OPPS Rate,15906.21,44.1,,1098.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,34265.08,95,,3011.416,Percent of Total Billed Charges,95% of Total Billed Charges,13543.59,75,,,Fee Schedule,75% of CMS OPPS Rate,31740.28,88,,2191.104,Percent of Total Billed Charges,88% of Total Billed Charges,32461.65,90,,2852.92,Percent of Total Billed charges,90% of Total Billed Charges,13543.59,34265.08,
PCI CTO Any LC,4810000108,CDM,481,RC,C9607,HCPCS,Outpatient,,,36068.50,23444.53,,22572.66,125,,,Fee Schedule,125% of CMS OPPS Rate,27412.06,76,,2409.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25969.32,72,,404.352,Percent of Total Billed Charges,72% of Total Billed Charges,27051.38,75,,421.2,Percent of Total Billed charges,75% of Total Billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,25969.32,72,,404.352,Percent of Total Billed Charges,72% of Total Billed Charges,21641.1,60,,336.96,Percent of Total Billed Charges,60% of Total Billed Charges,32461.65,90,,4211.904,Percent of Total Billed Charges,90% of Total Billed Charges,16230.83,45,,1120.448,Percent of Total Billed Charges,45% of Total Billed Charges,32461.65,90,,2852.92,Percent of Total Billed Charges,90% of Total billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,33722,200,,54.6,Fee Schedule,200% of CMS OPPS Rate,15906.21,44.1,,1098.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,34265.08,95,,3011.416,Percent of Total Billed Charges,95% of Total Billed Charges,13543.59,75,,,Fee Schedule,75% of CMS OPPS Rate,31740.28,88,,2191.104,Percent of Total Billed Charges,88% of Total Billed Charges,32461.65,90,,2852.92,Percent of Total Billed charges,90% of Total Billed Charges,13543.59,34265.08,
PCI CTO Any RC,4810000109,CDM,481,RC,C9607,HCPCS,Outpatient,,,34266.00,22272.90,,22572.66,125,,,Fee Schedule,125% of CMS OPPS Rate,26042.16,76,,2409.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24671.52,72,,549.504,Percent of Total Billed Charges,72% of Total Billed Charges,25699.5,75,,572.4,Percent of Total Billed charges,75% of Total Billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,24671.52,72,,549.504,Percent of Total Billed Charges,72% of Total Billed Charges,20559.6,60,,457.92,Percent of Total Billed Charges,60% of Total Billed Charges,30839.4,90,,4211.904,Percent of Total Billed Charges,90% of Total Billed Charges,15419.7,45,,1120.448,Percent of Total Billed Charges,45% of Total Billed Charges,30839.4,90,,2852.92,Percent of Total Billed Charges,90% of Total billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,33722,200,,17.776,Fee Schedule,200% of CMS OPPS Rate,15111.31,44.1,,1098.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,32552.7,95,,3011.416,Percent of Total Billed Charges,95% of Total Billed Charges,13543.59,75,,,Fee Schedule,75% of CMS OPPS Rate,30154.08,88,,2191.104,Percent of Total Billed Charges,88% of Total Billed Charges,30839.4,90,,2852.92,Percent of Total Billed charges,90% of Total Billed Charges,13543.59,33722,
PCI CTO Any RI,4810000110,CDM,481,RC,C9607,HCPCS,Outpatient,,,36068.50,23444.53,,22572.66,125,,,Fee Schedule,125% of CMS OPPS Rate,27412.06,76,,1892.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25969.32,72,,368.64,Percent of Total Billed Charges,72% of Total Billed Charges,27051.38,75,,384,Percent of Total Billed charges,75% of Total Billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,25969.32,72,,368.64,Percent of Total Billed Charges,72% of Total Billed Charges,21641.1,60,,307.2,Percent of Total Billed Charges,60% of Total Billed Charges,32461.65,90,,4211.904,Percent of Total Billed Charges,90% of Total Billed Charges,16230.83,45,,1120.448,Percent of Total Billed Charges,45% of Total Billed Charges,32461.65,90,,2240.896,Percent of Total Billed Charges,90% of Total billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,33722,200,,29.64,Fee Schedule,200% of CMS OPPS Rate,15906.21,44.1,,1098.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,34265.08,95,,2365.392,Percent of Total Billed Charges,95% of Total Billed Charges,13543.59,75,,,Fee Schedule,75% of CMS OPPS Rate,31740.28,88,,2191.104,Percent of Total Billed Charges,88% of Total Billed Charges,32461.65,90,,2240.896,Percent of Total Billed charges,90% of Total Billed Charges,13543.59,34265.08,
PCI CTO Any LM,4810000111,CDM,481,RC,C9607,HCPCS,Outpatient,,,36068.50,23444.53,,22572.66,125,,,Fee Schedule,125% of CMS OPPS Rate,27412.06,76,,1892.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25969.32,72,,203.328,Percent of Total Billed Charges,72% of Total Billed Charges,27051.38,75,,211.8,Percent of Total Billed charges,75% of Total Billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,25969.32,72,,203.328,Percent of Total Billed Charges,72% of Total Billed Charges,21641.1,60,,169.44,Percent of Total Billed Charges,60% of Total Billed Charges,32461.65,90,,4211.904,Percent of Total Billed Charges,90% of Total Billed Charges,16230.83,45,,1120.448,Percent of Total Billed Charges,45% of Total Billed Charges,32461.65,90,,2240.896,Percent of Total Billed Charges,90% of Total billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,33722,200,,6.88,Fee Schedule,200% of CMS OPPS Rate,15906.21,44.1,,1098.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,34265.08,95,,2365.392,Percent of Total Billed Charges,95% of Total Billed Charges,13543.59,75,,,Fee Schedule,75% of CMS OPPS Rate,31740.28,88,,2191.104,Percent of Total Billed Charges,88% of Total Billed Charges,32461.65,90,,2240.896,Percent of Total Billed charges,90% of Total Billed Charges,13543.59,34265.08,
PCI CTO Ea Add LD,4810000112,CDM,481,RC,C9608,HCPCS,Outpatient,,,18034.25,11722.26,,18034.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13706.03,76,,1892.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16230.83,90,,4211.904,Percent of Total Billed Charges,90% of Total Billed Charges,8115.41,45,,1120.448,Percent of Total Billed Charges,45% of Total Billed Charges,16230.83,90,,2240.896,Percent of Total Billed Charges,90% of Total billed Charges,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11722.26,65,,18.344,Percent of total Billed Charges,65% of Total Billed Charges,7953.1,44.1,,1098.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,17132.54,95,,2365.392,Percent of Total Billed Charges,95% of Total Billed Charges,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15870.14,88,,2191.104,Percent of Total Billed Charges,88% of Total Billed Charges,16230.83,90,,2240.896,Percent of Total Billed charges,90% of Total Billed Charges,7953.1,18034.25,
PCI CTO Ea Add LC,4810000113,CDM,481,RC,C9608,HCPCS,Outpatient,,,18034.25,11722.26,,18034.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13706.03,76,,1892.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16230.83,90,,4211.904,Percent of Total Billed Charges,90% of Total Billed Charges,8115.41,45,,2105.952,Percent of Total Billed Charges,45% of Total Billed Charges,16230.83,90,,2240.896,Percent of Total Billed Charges,90% of Total billed Charges,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11722.26,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,7953.1,44.1,,2063.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,17132.54,95,,2365.392,Percent of Total Billed Charges,95% of Total Billed Charges,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15870.14,88,,4118.312,Percent of Total Billed Charges,88% of Total Billed Charges,16230.83,90,,2240.896,Percent of Total Billed charges,90% of Total Billed Charges,7953.1,18034.25,
PCI CTO Ea Add RC,4810000114,CDM,481,RC,C9608,HCPCS,Outpatient,,,18034.25,11722.26,,18034.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13706.03,76,,1892.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16230.83,90,,3530.88,Percent of Total Billed Charges,90% of Total Billed Charges,8115.41,45,,2105.952,Percent of Total Billed Charges,45% of Total Billed Charges,16230.83,90,,2240.896,Percent of Total Billed Charges,90% of Total billed Charges,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11722.26,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,7953.1,44.1,,2063.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,17132.54,95,,2365.392,Percent of Total Billed Charges,95% of Total Billed Charges,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15870.14,88,,4118.312,Percent of Total Billed Charges,88% of Total Billed Charges,16230.83,90,,2240.896,Percent of Total Billed charges,90% of Total Billed Charges,7953.1,18034.25,
PCI Any Of/Thru LD,4810000115,CDM,481,RC,C9604,HCPCS,Outpatient,,,22549.43,14657.13,,14255.75,125,,,Fee Schedule,125% of CMS OPPS Rate,17137.57,76,,1892.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16235.59,72,,552.384,Percent of Total Billed Charges,72% of Total Billed Charges,16912.07,75,,575.4,Percent of Total Billed charges,75% of Total Billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16235.59,72,,552.384,Percent of Total Billed Charges,72% of Total Billed Charges,13529.66,60,,460.32,Percent of Total Billed Charges,60% of Total Billed Charges,20294.49,90,,3086.64,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,2105.952,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,2240.896,Percent of Total Billed Charges,90% of Total billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21297.13,200,,10.32,Fee Schedule,200% of CMS OPPS Rate,9944.3,44.1,,2063.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,2365.392,Percent of Total Billed Charges,95% of Total Billed Charges,8553.44,75,,,Fee Schedule,75% of CMS OPPS Rate,19843.5,88,,4118.312,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,2240.896,Percent of Total Billed charges,90% of Total Billed Charges,8553.44,21421.96,
PCI Any Of/Thru LC,4810000116,CDM,481,RC,C9604,HCPCS,Outpatient,,,22549.43,14657.13,,14255.75,125,,,Fee Schedule,125% of CMS OPPS Rate,17137.57,76,,1892.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16235.59,72,,313.344,Percent of Total Billed Charges,72% of Total Billed Charges,16912.07,75,,326.4,Percent of Total Billed charges,75% of Total Billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16235.59,72,,313.344,Percent of Total Billed Charges,72% of Total Billed Charges,13529.66,60,,261.12,Percent of Total Billed Charges,60% of Total Billed Charges,20294.49,90,,3086.64,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,2105.952,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,2240.896,Percent of Total Billed Charges,90% of Total billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21297.13,200,,95.168,Fee Schedule,200% of CMS OPPS Rate,9944.3,44.1,,2063.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,2365.392,Percent of Total Billed Charges,95% of Total Billed Charges,8553.44,75,,,Fee Schedule,75% of CMS OPPS Rate,19843.5,88,,4118.312,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,2240.896,Percent of Total Billed charges,90% of Total Billed Charges,8553.44,21421.96,
PCI Any Of/Thru RC,4810000117,CDM,481,RC,C9604,HCPCS,Outpatient,,,22549.43,14657.13,,14255.75,125,,,Fee Schedule,125% of CMS OPPS Rate,17137.57,76,,1892.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16235.59,72,,696.384,Percent of Total Billed Charges,72% of Total Billed Charges,16912.07,75,,725.4,Percent of Total Billed charges,75% of Total Billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16235.59,72,,696.384,Percent of Total Billed Charges,72% of Total Billed Charges,13529.66,60,,580.32,Percent of Total Billed Charges,60% of Total Billed Charges,20294.49,90,,2946.584,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,2105.952,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,2240.896,Percent of Total Billed Charges,90% of Total billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21297.13,200,,32.68,Fee Schedule,200% of CMS OPPS Rate,9944.3,44.1,,2063.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,2365.392,Percent of Total Billed Charges,95% of Total Billed Charges,8553.44,75,,,Fee Schedule,75% of CMS OPPS Rate,19843.5,88,,4118.312,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,2240.896,Percent of Total Billed charges,90% of Total Billed Charges,8553.44,21421.96,
PCI Any Of/Thru RI,4810000118,CDM,481,RC,C9604,HCPCS,Outpatient,,,22549.43,14657.13,,14255.75,125,,,Fee Schedule,125% of CMS OPPS Rate,17137.57,76,,3556.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16235.59,72,,326.416,Percent of Total Billed Charges,72% of Total Billed Charges,16912.07,75,,340.016,Percent of Total Billed charges,75% of Total Billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16235.59,72,,326.416,Percent of Total Billed Charges,72% of Total Billed Charges,13529.66,60,,272.008,Percent of Total Billed Charges,60% of Total Billed Charges,20294.49,90,,2946.584,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,2105.952,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,4211.904,Percent of Total Billed Charges,90% of Total billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21297.13,200,,67.656,Fee Schedule,200% of CMS OPPS Rate,9944.3,44.1,,2063.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,4445.904,Percent of Total Billed Charges,95% of Total Billed Charges,8553.44,75,,,Fee Schedule,75% of CMS OPPS Rate,19843.5,88,,4118.312,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,4211.904,Percent of Total Billed charges,90% of Total Billed Charges,8553.44,21421.96,
PCI Any Addtl LD,4810000119,CDM,481,RC,C9605,HCPCS,Outpatient,,,22549.43,14657.13,,22549.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17137.57,76,,3556.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20294.49,90,,3530.88,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,1765.44,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,4211.904,Percent of Total Billed Charges,90% of Total billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14657.13,65,,34.4,Percent of total Billed Charges,65% of Total Billed Charges,9944.3,44.1,,1730.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,4445.904,Percent of Total Billed Charges,95% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19843.5,88,,3452.416,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,4211.904,Percent of Total Billed charges,90% of Total Billed Charges,9944.3,22549.43,
PCI Add Of/Thru LC,4810000120,CDM,481,RC,C9605,HCPCS,Outpatient,,,22549.43,14657.13,,22549.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17137.57,76,,3556.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20294.49,90,,3074.4,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,1543.32,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,4211.904,Percent of Total Billed Charges,90% of Total billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14657.13,65,,137.664,Percent of total Billed Charges,65% of Total Billed Charges,9944.3,44.1,,1512.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,4445.904,Percent of Total Billed Charges,95% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19843.5,88,,3018.048,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,4211.904,Percent of Total Billed charges,90% of Total Billed Charges,9944.3,22549.43,
PCI Add Of/Thru RC,4810000121,CDM,481,RC,C9605,HCPCS,Outpatient,,,22549.43,14657.13,,22549.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17137.57,76,,3556.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20294.49,90,,2249.632,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,1543.32,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,4211.904,Percent of Total Billed Charges,90% of Total billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14657.13,65,,49.304,Percent of total Billed Charges,65% of Total Billed Charges,9944.3,44.1,,1512.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,4445.904,Percent of Total Billed Charges,95% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19843.5,88,,3018.048,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,4211.904,Percent of Total Billed charges,90% of Total Billed Charges,9944.3,22549.43,
PCI Add Of/Thru RI,4810000122,CDM,481,RC,C9605,HCPCS,Outpatient,,,22549.43,14657.13,,22549.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17137.57,76,,3556.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20294.49,90,,2119.68,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,1473.296,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,4211.904,Percent of Total Billed Charges,90% of Total billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14657.13,65,,92.88,Percent of total Billed Charges,65% of Total Billed Charges,9944.3,44.1,,1443.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,4445.904,Percent of Total Billed Charges,95% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19843.5,88,,2881.104,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,4211.904,Percent of Total Billed charges,90% of Total Billed Charges,9944.3,22549.43,
Coro Flow LD,4810000123,CDM,481,RC,,,Outpatient,,,3086.00,2005.90,,3086,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2345.36,76,,3556.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2221.92,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,2314.5,75,,341.336,Percent of Total Billed charges,75% of Total Billed Charges,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2221.92,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,1851.6,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,2777.4,90,,2249.632,Percent of Total Billed Charges,90% of Total Billed Charges,1388.7,45,,1473.296,Percent of Total Billed Charges,45% of Total Billed Charges,2777.4,90,,4211.904,Percent of Total Billed Charges,90% of Total billed Charges,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2005.9,65,,547.504,Percent of total Billed Charges,65% of Total Billed Charges,1360.93,44.1,,1443.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,2931.7,95,,4445.904,Percent of Total Billed Charges,95% of Total Billed Charges,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2715.68,88,,2881.104,Percent of Total Billed Charges,88% of Total Billed Charges,2777.4,90,,4211.904,Percent of Total Billed charges,90% of Total Billed Charges,1360.93,3086,
Coro Flow LC,4810000124,CDM,481,RC,,,Outpatient,,,3086.00,2005.90,,3086,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2345.36,76,,2981.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2221.92,72,,148.032,Percent of Total Billed Charges,72% of Total Billed Charges,2314.5,75,,154.2,Percent of Total Billed charges,75% of Total Billed Charges,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2221.92,72,,148.032,Percent of Total Billed Charges,72% of Total Billed Charges,1851.6,60,,123.36,Percent of Total Billed Charges,60% of Total Billed Charges,2777.4,90,,2802.96,Percent of Total Billed Charges,90% of Total Billed Charges,1388.7,45,,1765.44,Percent of Total Billed Charges,45% of Total Billed Charges,2777.4,90,,3530.88,Percent of Total Billed Charges,90% of Total billed Charges,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2005.9,65,,8646.928,Percent of total Billed Charges,65% of Total Billed Charges,1360.93,44.1,,1730.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,2931.7,95,,3727.04,Percent of Total Billed Charges,95% of Total Billed Charges,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2715.68,88,,3452.416,Percent of Total Billed Charges,88% of Total Billed Charges,2777.4,90,,3530.88,Percent of Total Billed charges,90% of Total Billed Charges,1360.93,3086,
Coro Flow RC,4810000125,CDM,481,RC,,,Outpatient,,,3086.00,2005.90,,3086,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2345.36,76,,2606.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2221.92,72,,217.824,Percent of Total Billed Charges,72% of Total Billed Charges,2314.5,75,,226.896,Percent of Total Billed charges,75% of Total Billed Charges,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2221.92,72,,217.824,Percent of Total Billed Charges,72% of Total Billed Charges,1851.6,60,,181.52,Percent of Total Billed Charges,60% of Total Billed Charges,2777.4,90,,2137.68,Percent of Total Billed Charges,90% of Total Billed Charges,1388.7,45,,1537.2,Percent of Total Billed Charges,45% of Total Billed Charges,2777.4,90,,3086.64,Percent of Total Billed Charges,90% of Total billed Charges,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2005.9,65,,90.768,Percent of total Billed Charges,65% of Total Billed Charges,1360.93,44.1,,1506.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,2931.7,95,,3258.12,Percent of Total Billed Charges,95% of Total Billed Charges,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2715.68,88,,3006.08,Percent of Total Billed Charges,88% of Total Billed Charges,2777.4,90,,3086.64,Percent of Total Billed charges,90% of Total Billed Charges,1360.93,3086,
Cor Flow Measure RI,4810000126,CDM,481,RC,,,Outpatient,,,3086.00,2005.90,,3086,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2345.36,76,,2606.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2221.92,72,,91.584,Percent of Total Billed Charges,72% of Total Billed Charges,2314.5,75,,95.4,Percent of Total Billed charges,75% of Total Billed Charges,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2221.92,72,,91.584,Percent of Total Billed Charges,72% of Total Billed Charges,1851.6,60,,76.32,Percent of Total Billed Charges,60% of Total Billed Charges,2777.4,90,,3164.4,Percent of Total Billed Charges,90% of Total Billed Charges,1388.7,45,,1124.816,Percent of Total Billed Charges,45% of Total Billed Charges,2777.4,90,,3086.64,Percent of Total Billed Charges,90% of Total billed Charges,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2005.9,65,,23.128,Percent of total Billed Charges,65% of Total Billed Charges,1360.93,44.1,,1102.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,2931.7,95,,3258.12,Percent of Total Billed Charges,95% of Total Billed Charges,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2715.68,88,,2199.64,Percent of Total Billed Charges,88% of Total Billed Charges,2777.4,90,,3086.64,Percent of Total Billed charges,90% of Total Billed Charges,1360.93,3086,
Coro Flow LM,4810000127,CDM,481,RC,,,Outpatient,,,3086.00,2005.90,,3086,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2345.36,76,,2488.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2221.92,72,,128.448,Percent of Total Billed Charges,72% of Total Billed Charges,2314.5,75,,133.8,Percent of Total Billed charges,75% of Total Billed Charges,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2221.92,72,,128.448,Percent of Total Billed Charges,72% of Total Billed Charges,1851.6,60,,107.04,Percent of Total Billed Charges,60% of Total Billed Charges,2777.4,90,,2991.6,Percent of Total Billed Charges,90% of Total Billed Charges,1388.7,45,,1059.84,Percent of Total Billed Charges,45% of Total Billed Charges,2777.4,90,,2946.584,Percent of Total Billed Charges,90% of Total billed Charges,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2005.9,65,,37.456,Percent of total Billed Charges,65% of Total Billed Charges,1360.93,44.1,,1038.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,2931.7,95,,3110.288,Percent of Total Billed Charges,95% of Total Billed Charges,3086,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2715.68,88,,2072.576,Percent of Total Billed Charges,88% of Total Billed Charges,2777.4,90,,2946.584,Percent of Total Billed charges,90% of Total Billed Charges,1360.93,3086,
Cor Flow Meas FFR LD,4810000128,CDM,481,RC,,,Outpatient,,,1946.00,1264.90,,1946,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1478.96,76,,2488.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1401.12,72,,217.824,Percent of Total Billed Charges,72% of Total Billed Charges,1459.5,75,,226.896,Percent of Total Billed charges,75% of Total Billed Charges,1946,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1401.12,72,,217.824,Percent of Total Billed Charges,72% of Total Billed Charges,1167.6,60,,181.52,Percent of Total Billed Charges,60% of Total Billed Charges,1751.4,90,,3299.04,Percent of Total Billed Charges,90% of Total Billed Charges,875.7,45,,1124.816,Percent of Total Billed Charges,45% of Total Billed Charges,1751.4,90,,2946.584,Percent of Total Billed Charges,90% of Total billed Charges,1946,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1946,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1946,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1264.9,65,,94.928,Percent of total Billed Charges,65% of Total Billed Charges,858.19,44.1,,1102.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,1848.7,95,,3110.288,Percent of Total Billed Charges,95% of Total Billed Charges,1946,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1712.48,88,,2199.64,Percent of Total Billed Charges,88% of Total Billed Charges,1751.4,90,,2946.584,Percent of Total Billed charges,90% of Total Billed Charges,858.19,1946,
Cor Flow Meas FFR LC,4810000129,CDM,481,RC,,,Outpatient,,,1946.00,1264.90,,1946,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1478.96,76,,2981.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1401.12,72,,217.824,Percent of Total Billed Charges,72% of Total Billed Charges,1459.5,75,,226.896,Percent of Total Billed charges,75% of Total Billed Charges,1946,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1401.12,72,,217.824,Percent of Total Billed Charges,72% of Total Billed Charges,1167.6,60,,181.52,Percent of Total Billed Charges,60% of Total Billed Charges,1751.4,90,,4446,Percent of Total Billed Charges,90% of Total Billed Charges,875.7,45,,1401.48,Percent of Total Billed Charges,45% of Total Billed Charges,1751.4,90,,3530.88,Percent of Total Billed Charges,90% of Total billed Charges,1946,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1946,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1946,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1264.9,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,858.19,44.1,,1373.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,1848.7,95,,3727.04,Percent of Total Billed Charges,95% of Total Billed Charges,1946,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1712.48,88,,2740.672,Percent of Total Billed Charges,88% of Total Billed Charges,1751.4,90,,3530.88,Percent of Total Billed charges,90% of Total Billed Charges,858.19,1946,
Cor Flow Meas FFR RC,4810000130,CDM,481,RC,,,Outpatient,,,1946.00,1264.90,,1946,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1478.96,76,,2596.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1401.12,72,,25.8,Percent of Total Billed Charges,72% of Total Billed Charges,1459.5,75,,26.872,Percent of Total Billed charges,75% of Total Billed Charges,1946,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1401.12,72,,25.8,Percent of Total Billed Charges,72% of Total Billed Charges,1167.6,60,,21.496,Percent of Total Billed Charges,60% of Total Billed Charges,1751.4,90,,2023.92,Percent of Total Billed Charges,90% of Total Billed Charges,875.7,45,,1068.84,Percent of Total Billed Charges,45% of Total Billed Charges,1751.4,90,,3074.4,Percent of Total Billed Charges,90% of Total billed Charges,1946,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1946,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1946,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1264.9,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,858.19,44.1,,1047.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,1848.7,95,,3245.2,Percent of Total Billed Charges,95% of Total Billed Charges,1946,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1712.48,88,,2090.176,Percent of Total Billed Charges,88% of Total Billed Charges,1751.4,90,,3074.4,Percent of Total Billed charges,90% of Total Billed Charges,858.19,1946,
Cor Flow Meas FFR RI,4810000131,CDM,481,RC,,,Outpatient,,,2047.76,1331.04,,2047.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1556.3,76,,1899.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1474.39,72,,46.776,Percent of Total Billed Charges,72% of Total Billed Charges,1535.82,75,,48.728,Percent of Total Billed charges,75% of Total Billed Charges,2047.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1474.39,72,,46.776,Percent of Total Billed Charges,72% of Total Billed Charges,1228.66,60,,38.984,Percent of Total Billed Charges,60% of Total Billed Charges,1842.98,90,,2178.184,Percent of Total Billed Charges,90% of Total Billed Charges,921.49,45,,1582.2,Percent of Total Billed Charges,45% of Total Billed Charges,1842.98,90,,2249.632,Percent of Total Billed Charges,90% of Total billed Charges,2047.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2047.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2047.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1331.04,65,,118.672,Percent of total Billed Charges,65% of Total Billed Charges,903.06,44.1,,1550.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,1945.37,95,,2374.616,Percent of Total Billed Charges,95% of Total Billed Charges,2047.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1802.03,88,,3094.08,Percent of Total Billed Charges,88% of Total Billed Charges,1842.98,90,,2249.632,Percent of Total Billed charges,90% of Total Billed Charges,903.06,2047.76,
Cor Flow Meas FFR LM,4810000132,CDM,481,RC,,,Outpatient,,,2047.76,1331.04,,2047.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1556.3,76,,1789.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1474.39,72,,55.208,Percent of Total Billed Charges,72% of Total Billed Charges,1535.82,75,,57.512,Percent of Total Billed charges,75% of Total Billed Charges,2047.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1474.39,72,,55.208,Percent of Total Billed Charges,72% of Total Billed Charges,1228.66,60,,46.008,Percent of Total Billed Charges,60% of Total Billed Charges,1842.98,90,,3049.784,Percent of Total Billed Charges,90% of Total Billed Charges,921.49,45,,1495.8,Percent of Total Billed Charges,45% of Total Billed Charges,1842.98,90,,2119.68,Percent of Total Billed Charges,90% of Total billed Charges,2047.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2047.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2047.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1331.04,65,,7.448,Percent of total Billed Charges,65% of Total Billed Charges,903.06,44.1,,1465.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,1945.37,95,,2237.44,Percent of Total Billed Charges,95% of Total Billed Charges,2047.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1802.03,88,,2925.12,Percent of Total Billed Charges,88% of Total Billed Charges,1842.98,90,,2119.68,Percent of Total Billed charges,90% of Total Billed Charges,903.06,2047.76,
Ivus Coro Initial LD,4810000133,CDM,481,RC,,,Outpatient,,,3462.00,2250.30,,3462,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2631.12,76,,1899.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2492.64,72,,176.656,Percent of Total Billed Charges,72% of Total Billed Charges,2596.5,75,,184.016,Percent of Total Billed charges,75% of Total Billed Charges,3462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2492.64,72,,176.656,Percent of Total Billed Charges,72% of Total Billed Charges,2077.2,60,,147.208,Percent of Total Billed Charges,60% of Total Billed Charges,3115.8,90,,2087.28,Percent of Total Billed Charges,90% of Total Billed Charges,1557.9,45,,1649.52,Percent of Total Billed Charges,45% of Total Billed Charges,3115.8,90,,2249.632,Percent of Total Billed Charges,90% of Total billed Charges,3462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2250.3,65,,10582.888,Percent of total Billed Charges,65% of Total Billed Charges,1526.74,44.1,,1616.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,3288.9,95,,2374.616,Percent of Total Billed Charges,95% of Total Billed Charges,3462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3046.56,88,,3225.728,Percent of Total Billed Charges,88% of Total Billed Charges,3115.8,90,,2249.632,Percent of Total Billed charges,90% of Total Billed Charges,1526.74,3462,
Ivus Coro Initial LC,4810000134,CDM,481,RC,,,Outpatient,,,3462.00,2250.30,,3462,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2631.12,76,,2366.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2492.64,72,,168.192,Percent of Total Billed Charges,72% of Total Billed Charges,2596.5,75,,175.2,Percent of Total Billed charges,75% of Total Billed Charges,3462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2492.64,72,,168.192,Percent of Total Billed Charges,72% of Total Billed Charges,2077.2,60,,140.16,Percent of Total Billed Charges,60% of Total Billed Charges,3115.8,90,,2178.184,Percent of Total Billed Charges,90% of Total Billed Charges,1557.9,45,,2223,Percent of Total Billed Charges,45% of Total Billed Charges,3115.8,90,,2802.96,Percent of Total Billed Charges,90% of Total billed Charges,3462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2250.3,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,1526.74,44.1,,2178.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,3288.9,95,,2958.68,Percent of Total Billed Charges,95% of Total Billed Charges,3462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3046.56,88,,4347.2,Percent of Total Billed Charges,88% of Total Billed Charges,3115.8,90,,2802.96,Percent of Total Billed charges,90% of Total Billed Charges,1526.74,3462,
IVUS Coro Initial RC,4810000135,CDM,481,RC,,,Outpatient,,,3462.00,2250.30,,3462,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2631.12,76,,1805.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2492.64,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,2596.5,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,3462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2492.64,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,2077.2,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,3115.8,90,,3294,Percent of Total Billed Charges,90% of Total Billed Charges,1557.9,45,,1011.96,Percent of Total Billed Charges,45% of Total Billed Charges,3115.8,90,,2137.68,Percent of Total Billed Charges,90% of Total billed Charges,3462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2250.3,65,,5.736,Percent of total Billed Charges,65% of Total Billed Charges,1526.74,44.1,,991.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,3288.9,95,,2256.44,Percent of Total Billed Charges,95% of Total Billed Charges,3462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3046.56,88,,1978.944,Percent of Total Billed Charges,88% of Total Billed Charges,3115.8,90,,2137.68,Percent of Total Billed charges,90% of Total Billed Charges,1526.74,3462,
IVUS Coro Initial RI,4810000136,CDM,481,RC,,,Outpatient,,,3643.59,2368.33,,3643.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2769.13,76,,2672.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2623.38,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,2732.69,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,3643.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2623.38,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,2186.15,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,3279.23,90,,3322.848,Percent of Total Billed Charges,90% of Total Billed Charges,1639.62,45,,1089.096,Percent of Total Billed Charges,45% of Total Billed Charges,3279.23,90,,3164.4,Percent of Total Billed Charges,90% of Total billed Charges,3643.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3643.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3643.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2368.33,65,,4.16,Percent of total Billed Charges,65% of Total Billed Charges,1606.82,44.1,,1067.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,3461.41,95,,3340.2,Percent of Total Billed Charges,95% of Total Billed Charges,3643.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3206.36,88,,2129.784,Percent of Total Billed Charges,88% of Total Billed Charges,3279.23,90,,3164.4,Percent of Total Billed charges,90% of Total Billed Charges,1606.82,3643.59,
IVUS Coro Initial LM,4810000137,CDM,481,RC,,,Outpatient,,,3462.00,2250.30,,3462,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2631.12,76,,2526.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2492.64,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,2596.5,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,3462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2492.64,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,2077.2,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,3115.8,90,,3811.68,Percent of Total Billed Charges,90% of Total Billed Charges,1557.9,45,,1524.888,Percent of Total Billed Charges,45% of Total Billed Charges,3115.8,90,,2991.6,Percent of Total Billed Charges,90% of Total billed Charges,3462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2250.3,65,,1414.08,Percent of total Billed Charges,65% of Total Billed Charges,1526.74,44.1,,1494.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,3288.9,95,,3157.8,Percent of Total Billed Charges,95% of Total Billed Charges,3462,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3046.56,88,,2982.008,Percent of Total Billed Charges,88% of Total Billed Charges,3115.8,90,,2991.6,Percent of Total Billed charges,90% of Total Billed Charges,1526.74,3462,
IVUS Coro Ea Add LD,4810000138,CDM,481,RC,,,Outpatient,,,1731.00,1125.15,,1731,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1315.56,76,,2785.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1246.32,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,1298.25,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,1731,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1246.32,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,1038.6,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,1557.9,90,,4011.872,Percent of Total Billed Charges,90% of Total Billed Charges,778.95,45,,1043.64,Percent of Total Billed Charges,45% of Total Billed Charges,1557.9,90,,3299.04,Percent of Total Billed Charges,90% of Total billed Charges,1731,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1731,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1731,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1125.15,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,763.37,44.1,,1022.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,1644.45,95,,3482.32,Percent of Total Billed Charges,95% of Total Billed Charges,1731,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1523.28,88,,2040.896,Percent of Total Billed Charges,88% of Total Billed Charges,1557.9,90,,3299.04,Percent of Total Billed charges,90% of Total Billed Charges,763.37,1731,
IVUS Coro Ea Add LC,4810000139,CDM,481,RC,,,Outpatient,,,1731.00,1125.15,,1731,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1315.56,76,,3754.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1246.32,72,,52.696,Percent of Total Billed Charges,72% of Total Billed Charges,1298.25,75,,54.888,Percent of Total Billed charges,75% of Total Billed Charges,1731,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1246.32,72,,52.696,Percent of Total Billed Charges,72% of Total Billed Charges,1038.6,60,,43.912,Percent of Total Billed Charges,60% of Total Billed Charges,1557.9,90,,4011.872,Percent of Total Billed Charges,90% of Total Billed Charges,778.95,45,,1089.096,Percent of Total Billed Charges,45% of Total Billed Charges,1557.9,90,,4446,Percent of Total Billed Charges,90% of Total billed Charges,1731,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1731,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1731,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1125.15,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,763.37,44.1,,1067.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,1644.45,95,,4693,Percent of Total Billed Charges,95% of Total Billed Charges,1731,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1523.28,88,,2129.784,Percent of Total Billed Charges,88% of Total Billed Charges,1557.9,90,,4446,Percent of Total Billed charges,90% of Total Billed Charges,763.37,1731,
IVUS Coro Ea Add RC,4810000140,CDM,481,RC,,,Outpatient,,,1731.00,1125.15,,1731,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1315.56,76,,1709.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1246.32,72,,2479.032,Percent of Total Billed Charges,72% of Total Billed Charges,1298.25,75,,2582.328,Percent of Total Billed charges,75% of Total Billed Charges,1731,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1246.32,72,,2479.032,Percent of Total Billed Charges,72% of Total Billed Charges,1038.6,60,,2065.864,Percent of Total Billed Charges,60% of Total Billed Charges,1557.9,90,,138.92,Percent of Total Billed Charges,90% of Total Billed Charges,778.95,45,,1647,Percent of Total Billed Charges,45% of Total Billed Charges,1557.9,90,,2023.92,Percent of Total Billed Charges,90% of Total billed Charges,1731,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1731,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1731,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1125.15,65,,6.24,Percent of total Billed Charges,65% of Total Billed Charges,763.37,44.1,,1614.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,1644.45,95,,2136.36,Percent of Total Billed Charges,95% of Total Billed Charges,1731,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1523.28,88,,3220.8,Percent of Total Billed Charges,88% of Total Billed Charges,1557.9,90,,2023.92,Percent of Total Billed charges,90% of Total Billed Charges,763.37,1731,
IVUS Coro Ea Add RI,4810000141,CDM,481,RC,,,Outpatient,,,1821.80,1184.17,,1821.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1384.57,76,,1839.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1311.7,72,,52.696,Percent of Total Billed Charges,72% of Total Billed Charges,1366.35,75,,54.888,Percent of Total Billed charges,75% of Total Billed Charges,1821.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.7,72,,52.696,Percent of Total Billed Charges,72% of Total Billed Charges,1093.08,60,,43.912,Percent of Total Billed Charges,60% of Total Billed Charges,1639.62,90,,207.976,Percent of Total Billed Charges,90% of Total Billed Charges,819.81,45,,1661.424,Percent of Total Billed Charges,45% of Total Billed Charges,1639.62,90,,2178.184,Percent of Total Billed Charges,90% of Total billed Charges,1821.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1821.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1821.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1184.17,65,,124.408,Percent of total Billed Charges,65% of Total Billed Charges,803.41,44.1,,1628.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,1730.71,95,,2299.2,Percent of Total Billed Charges,95% of Total Billed Charges,1821.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1603.18,88,,3249.008,Percent of Total Billed Charges,88% of Total Billed Charges,1639.62,90,,2178.184,Percent of Total Billed charges,90% of Total Billed Charges,803.41,1821.8,
IVUS Coro Ea Add LM,4810000142,CDM,481,RC,,,Outpatient,,,1821.80,1184.17,,1821.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1384.57,76,,2575.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1311.7,72,,52.696,Percent of Total Billed Charges,72% of Total Billed Charges,1366.35,75,,54.888,Percent of Total Billed charges,75% of Total Billed Charges,1821.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.7,72,,52.696,Percent of Total Billed Charges,72% of Total Billed Charges,1093.08,60,,43.912,Percent of Total Billed Charges,60% of Total Billed Charges,1639.62,90,,49.088,Percent of Total Billed Charges,90% of Total Billed Charges,819.81,45,,1905.84,Percent of Total Billed Charges,45% of Total Billed Charges,1639.62,90,,3049.784,Percent of Total Billed Charges,90% of Total billed Charges,1821.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1821.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1821.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1184.17,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,803.41,44.1,,1867.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,1730.71,95,,3219.216,Percent of Total Billed Charges,95% of Total Billed Charges,1821.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1603.18,88,,3726.976,Percent of Total Billed Charges,88% of Total Billed Charges,1639.62,90,,3049.784,Percent of Total Billed charges,90% of Total Billed Charges,803.41,1821.8,
DE Stent Major LD,4810000143,CDM,481,RC,C9600,HCPCS,Outpatient,,,21422.00,13924.30,,14255.75,125,,,Fee Schedule,125% of CMS OPPS Rate,16280.72,76,,1762.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15423.84,72,,52.696,Percent of Total Billed Charges,72% of Total Billed Charges,16066.5,75,,54.888,Percent of Total Billed charges,75% of Total Billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15423.84,72,,52.696,Percent of Total Billed Charges,72% of Total Billed Charges,12853.2,60,,43.912,Percent of Total Billed Charges,60% of Total Billed Charges,19279.8,90,,14.632,Percent of Total Billed Charges,90% of Total Billed Charges,9639.9,45,,2005.936,Percent of Total Billed Charges,45% of Total Billed Charges,19279.8,90,,2087.28,Percent of Total Billed Charges,90% of Total billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21297.13,200,,3011.544,Fee Schedule,200% of CMS OPPS Rate,9447.1,44.1,,1965.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,20350.9,95,,2203.24,Percent of Total Billed Charges,95% of Total Billed Charges,8553.44,75,,,Fee Schedule,75% of CMS OPPS Rate,18851.36,88,,3922.72,Percent of Total Billed Charges,88% of Total Billed Charges,19279.8,90,,2087.28,Percent of Total Billed charges,90% of Total Billed Charges,8553.44,21297.13,
DE Stent major LC,4810000144,CDM,481,RC,C9600,HCPCS,Outpatient,,,21422.00,13924.30,,14255.75,125,,,Fee Schedule,125% of CMS OPPS Rate,16280.72,76,,1839.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15423.84,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,16066.5,75,,12853.2,Percent of Total Billed charges,75% of Total Billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15423.84,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,12853.2,60,,10282.56,Percent of Total Billed Charges,60% of Total Billed Charges,19279.8,90,,14.632,Percent of Total Billed Charges,90% of Total Billed Charges,9639.9,45,,2005.936,Percent of Total Billed Charges,45% of Total Billed Charges,19279.8,90,,2178.184,Percent of Total Billed Charges,90% of Total billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21297.13,200,,63.64,Fee Schedule,200% of CMS OPPS Rate,9447.1,44.1,,1965.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,20350.9,95,,2299.2,Percent of Total Billed Charges,95% of Total Billed Charges,8553.44,75,,,Fee Schedule,75% of CMS OPPS Rate,18851.36,88,,3922.72,Percent of Total Billed Charges,88% of Total Billed Charges,19279.8,90,,2178.184,Percent of Total Billed charges,90% of Total Billed Charges,8553.44,21297.13,
DE Stent Major RC,4810000145,CDM,481,RC,C9600,HCPCS,Outpatient,,,21422.00,13924.30,,14255.75,125,,,Fee Schedule,125% of CMS OPPS Rate,16280.72,76,,2781.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15423.84,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,16066.5,75,,12853.2,Percent of Total Billed charges,75% of Total Billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15423.84,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,12853.2,60,,10282.56,Percent of Total Billed Charges,60% of Total Billed Charges,19279.8,90,,14.632,Percent of Total Billed Charges,90% of Total Billed Charges,9639.9,45,,69.456,Percent of Total Billed Charges,45% of Total Billed Charges,19279.8,90,,3294,Percent of Total Billed Charges,90% of Total billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21297.13,200,,5.288,Fee Schedule,200% of CMS OPPS Rate,9447.1,44.1,,68.072,Percent of Total Billed Charges,44.1% of Total Billed Charges,20350.9,95,,3477,Percent of Total Billed Charges,95% of Total Billed Charges,8553.44,75,,,Fee Schedule,75% of CMS OPPS Rate,18851.36,88,,135.832,Percent of Total Billed Charges,88% of Total Billed Charges,19279.8,90,,3294,Percent of Total Billed charges,90% of Total Billed Charges,8553.44,21297.13,
DE Stent Major RI,4810000146,CDM,481,RC,C9600,HCPCS,Outpatient,,,21422.00,13924.30,,14255.75,125,,,Fee Schedule,125% of CMS OPPS Rate,16280.72,76,,2805.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15423.84,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,16066.5,75,,12853.2,Percent of Total Billed charges,75% of Total Billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15423.84,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,12853.2,60,,10282.56,Percent of Total Billed Charges,60% of Total Billed Charges,19279.8,90,,766.016,Percent of Total Billed Charges,90% of Total Billed Charges,9639.9,45,,103.992,Percent of Total Billed Charges,45% of Total Billed Charges,19279.8,90,,3322.848,Percent of Total Billed Charges,90% of Total billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21297.13,200,,1168.808,Fee Schedule,200% of CMS OPPS Rate,9447.1,44.1,,101.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,20350.9,95,,3507.456,Percent of Total Billed Charges,95% of Total Billed Charges,8553.44,75,,,Fee Schedule,75% of CMS OPPS Rate,18851.36,88,,203.36,Percent of Total Billed Charges,88% of Total Billed Charges,19279.8,90,,3322.848,Percent of Total Billed charges,90% of Total Billed Charges,8553.44,21297.13,
DE Stent Major LM,4810000147,CDM,481,RC,C9600,HCPCS,Outpatient,,,22549.43,14657.13,,14255.75,125,,,Fee Schedule,125% of CMS OPPS Rate,17137.57,76,,3218.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16235.59,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,16912.07,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16235.59,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,13529.66,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,20294.49,90,,1280.4,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,24.544,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,3811.68,Percent of Total Billed Charges,90% of Total billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21297.13,200,,734.824,Fee Schedule,200% of CMS OPPS Rate,9944.3,44.1,,24.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,4023.44,Percent of Total Billed Charges,95% of Total Billed Charges,8553.44,75,,,Fee Schedule,75% of CMS OPPS Rate,19843.5,88,,48,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,3811.68,Percent of Total Billed charges,90% of Total Billed Charges,8553.44,21421.96,
DE Stent Ea Add LD,4810000148,CDM,481,RC,C9601,HCPCS,Outpatient,,,10711.00,6962.15,,10711,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8140.36,76,,3387.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10711,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9639.9,90,,5.944,Percent of Total Billed Charges,90% of Total Billed Charges,4819.95,45,,7.312,Percent of Total Billed Charges,45% of Total Billed Charges,9639.9,90,,4011.872,Percent of Total Billed Charges,90% of Total billed Charges,10711,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10711,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10711,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6962.15,65,,65.928,Percent of total Billed Charges,65% of Total Billed Charges,4723.55,44.1,,7.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,10175.45,95,,4234.752,Percent of Total Billed Charges,95% of Total Billed Charges,10711,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9425.68,88,,14.304,Percent of Total Billed Charges,88% of Total Billed Charges,9639.9,90,,4011.872,Percent of Total Billed charges,90% of Total Billed Charges,4723.55,10711,
DE Stent Ea Add LC,4810000149,CDM,481,RC,C9601,HCPCS,Outpatient,,,10711.00,6962.15,,10711,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8140.36,76,,3387.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10711,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9639.9,90,,326.256,Percent of Total Billed Charges,90% of Total Billed Charges,4819.95,45,,7.312,Percent of Total Billed Charges,45% of Total Billed Charges,9639.9,90,,4011.872,Percent of Total Billed Charges,90% of Total billed Charges,10711,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10711,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10711,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6962.15,65,,1261.288,Percent of total Billed Charges,65% of Total Billed Charges,4723.55,44.1,,7.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,10175.45,95,,4234.752,Percent of Total Billed Charges,95% of Total Billed Charges,10711,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9425.68,88,,14.304,Percent of Total Billed Charges,88% of Total Billed Charges,9639.9,90,,4011.872,Percent of Total Billed charges,90% of Total Billed Charges,4723.55,10711,
DE Stent Ea Add Br RC,4810000150,CDM,481,RC,C9601,HCPCS,Outpatient,,,10711.00,6962.15,,10711,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8140.36,76,,117.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10711,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9639.9,90,,326.256,Percent of Total Billed Charges,90% of Total Billed Charges,4819.95,45,,7.312,Percent of Total Billed Charges,45% of Total Billed Charges,9639.9,90,,138.92,Percent of Total Billed Charges,90% of Total billed Charges,10711,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10711,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10711,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6962.15,65,,6730.352,Percent of total Billed Charges,65% of Total Billed Charges,4723.55,44.1,,7.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,10175.45,95,,146.632,Percent of Total Billed Charges,95% of Total Billed Charges,10711,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9425.68,88,,14.304,Percent of Total Billed Charges,88% of Total Billed Charges,9639.9,90,,138.92,Percent of Total Billed charges,90% of Total Billed Charges,4723.55,10711,
Insert Cardiac Rhythm Monitor,4810000151,CDM,481,RC,,,Outpatient,,,19770.00,12850.50,,19770,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15025.2,76,,175.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14234.4,72,,11387.52,Percent of Total Billed Charges,72% of Total Billed Charges,14827.5,75,,11862,Percent of Total Billed charges,75% of Total Billed Charges,19770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14234.4,72,,11387.52,Percent of Total Billed Charges,72% of Total Billed Charges,11862,60,,9489.6,Percent of Total Billed Charges,60% of Total Billed Charges,17793,90,,48.96,Percent of Total Billed Charges,90% of Total Billed Charges,8896.5,45,,383.008,Percent of Total Billed Charges,45% of Total Billed Charges,17793,90,,207.976,Percent of Total Billed Charges,90% of Total billed Charges,19770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12850.5,65,,240.592,Percent of total Billed Charges,65% of Total Billed Charges,8718.57,44.1,,375.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,18781.5,95,,219.536,Percent of Total Billed Charges,95% of Total Billed Charges,19770,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17397.6,88,,748.992,Percent of Total Billed Charges,88% of Total Billed Charges,17793,90,,207.976,Percent of Total Billed charges,90% of Total Billed Charges,8718.57,19770,
Remove Cardiac Rhythm Monitor,4810000152,CDM,481,RC,,,Outpatient,,,1396.50,907.73,,1396.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1061.34,76,,41.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1005.48,72,,804.384,Percent of Total Billed Charges,72% of Total Billed Charges,1047.38,75,,837.904,Percent of Total Billed charges,75% of Total Billed Charges,1396.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1005.48,72,,804.384,Percent of Total Billed Charges,72% of Total Billed Charges,837.9,60,,670.32,Percent of Total Billed Charges,60% of Total Billed Charges,1256.85,90,,218.2,Percent of Total Billed Charges,90% of Total Billed Charges,628.43,45,,640.2,Percent of Total Billed Charges,45% of Total Billed Charges,1256.85,90,,49.088,Percent of Total Billed Charges,90% of Total billed Charges,1396.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1396.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1396.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,907.73,65,,28.088,Percent of total Billed Charges,65% of Total Billed Charges,615.86,44.1,,627.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1326.68,95,,51.816,Percent of Total Billed Charges,95% of Total Billed Charges,1396.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1228.92,88,,1251.944,Percent of Total Billed Charges,88% of Total Billed Charges,1256.85,90,,49.088,Percent of Total Billed charges,90% of Total Billed Charges,615.86,1396.5,
CORO THROMBECTOMY MECHANICAL,4810000153,CDM,481,RC,,,Outpatient,,,396.00,257.40,,396,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,300.96,76,,12.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,285.12,72,,228.096,Percent of Total Billed Charges,72% of Total Billed Charges,297,75,,237.6,Percent of Total Billed charges,75% of Total Billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.12,72,,228.096,Percent of Total Billed Charges,72% of Total Billed Charges,237.6,60,,190.08,Percent of Total Billed Charges,60% of Total Billed Charges,356.4,90,,33.376,Percent of Total Billed Charges,90% of Total Billed Charges,178.2,45,,2.968,Percent of Total Billed Charges,45% of Total Billed Charges,356.4,90,,14.632,Percent of Total Billed Charges,90% of Total billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.4,65,,6.88,Percent of total Billed Charges,65% of Total Billed Charges,174.64,44.1,,2.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,376.2,95,,15.44,Percent of Total Billed Charges,95% of Total Billed Charges,396,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.48,88,,5.808,Percent of Total Billed Charges,88% of Total Billed Charges,356.4,90,,14.632,Percent of Total Billed charges,90% of Total Billed Charges,174.64,396,
Removal of Percutaneous IABP,4810000154,CDM,481,RC,,,Outpatient,,,80.45,52.29,,80.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,61.14,76,,12.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.92,72,,46.336,Percent of Total Billed Charges,72% of Total Billed Charges,60.34,75,,48.272,Percent of Total Billed charges,75% of Total Billed Charges,80.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.92,72,,46.336,Percent of Total Billed Charges,72% of Total Billed Charges,48.27,60,,38.616,Percent of Total Billed Charges,60% of Total Billed Charges,72.41,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,36.2,45,,163.128,Percent of Total Billed Charges,45% of Total Billed Charges,72.41,90,,14.632,Percent of Total Billed Charges,90% of Total billed Charges,80.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.29,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,35.48,44.1,,159.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,76.43,95,,15.44,Percent of Total Billed Charges,95% of Total Billed Charges,80.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.8,88,,319,Percent of Total Billed Charges,88% of Total Billed Charges,72.41,90,,14.632,Percent of Total Billed charges,90% of Total Billed Charges,35.48,80.45,
IVL PTCA Major Vessl/Brnch LAD,4810000156,CDM,481,RC,,,Outpatient,,,11129.60,7234.24,,11129.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8458.5,76,,12.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8013.31,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,8347.2,75,,6677.76,Percent of Total Billed charges,75% of Total Billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8013.31,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,6677.76,60,,5342.208,Percent of Total Billed Charges,60% of Total Billed Charges,10016.64,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,5008.32,45,,163.128,Percent of Total Billed Charges,45% of Total Billed Charges,10016.64,90,,14.632,Percent of Total Billed Charges,90% of Total billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7234.24,65,,580.192,Percent of total Billed Charges,65% of Total Billed Charges,4908.15,44.1,,159.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,10573.12,95,,15.44,Percent of Total Billed Charges,95% of Total Billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9794.05,88,,319,Percent of Total Billed Charges,88% of Total Billed Charges,10016.64,90,,14.632,Percent of Total Billed charges,90% of Total Billed Charges,4908.15,11129.6,
IVL PTCA Majr Vssl/Brnch Lt Cx,4810000157,CDM,481,RC,,,Outpatient,,,11129.60,7234.24,,11129.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8458.5,76,,646.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8013.31,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,8347.2,75,,6677.76,Percent of Total Billed charges,75% of Total Billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8013.31,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,6677.76,60,,5342.208,Percent of Total Billed Charges,60% of Total Billed Charges,10016.64,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,5008.32,45,,24.48,Percent of Total Billed Charges,45% of Total Billed Charges,10016.64,90,,766.016,Percent of Total Billed Charges,90% of Total billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7234.24,65,,38.416,Percent of total Billed Charges,65% of Total Billed Charges,4908.15,44.1,,23.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,10573.12,95,,808.568,Percent of Total Billed Charges,95% of Total Billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9794.05,88,,47.872,Percent of Total Billed Charges,88% of Total Billed Charges,10016.64,90,,766.016,Percent of Total Billed charges,90% of Total Billed Charges,4908.15,11129.6,
IVL PTCA Mjr Vssl/Brnch Rt Cor,4810000158,CDM,481,RC,,,Outpatient,,,11129.60,7234.24,,11129.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8458.5,76,,1081.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8013.31,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,8347.2,75,,6677.76,Percent of Total Billed charges,75% of Total Billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8013.31,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,6677.76,60,,5342.208,Percent of Total Billed Charges,60% of Total Billed Charges,10016.64,90,,37.544,Percent of Total Billed Charges,90% of Total Billed Charges,5008.32,45,,109.104,Percent of Total Billed Charges,45% of Total Billed Charges,10016.64,90,,1280.4,Percent of Total Billed Charges,90% of Total billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7234.24,65,,283.784,Percent of total Billed Charges,65% of Total Billed Charges,4908.15,44.1,,106.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,10573.12,95,,1351.528,Percent of Total Billed Charges,95% of Total Billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9794.05,88,,213.352,Percent of Total Billed Charges,88% of Total Billed Charges,10016.64,90,,1280.4,Percent of Total Billed charges,90% of Total Billed Charges,4908.15,11129.6,
IVL PTCA Majr Vssl/Brnch Ramus,4810000159,CDM,481,RC,,,Outpatient,,,11129.60,7234.24,,11129.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8458.5,76,,5.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8013.31,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,8347.2,75,,6677.76,Percent of Total Billed charges,75% of Total Billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8013.31,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,6677.76,60,,5342.208,Percent of Total Billed Charges,60% of Total Billed Charges,10016.64,90,,279.816,Percent of Total Billed Charges,90% of Total Billed Charges,5008.32,45,,16.688,Percent of Total Billed Charges,45% of Total Billed Charges,10016.64,90,,5.944,Percent of Total Billed Charges,90% of Total billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7234.24,65,,354.304,Percent of total Billed Charges,65% of Total Billed Charges,4908.15,44.1,,16.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,10573.12,95,,6.272,Percent of Total Billed Charges,95% of Total Billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9794.05,88,,32.632,Percent of Total Billed Charges,88% of Total Billed Charges,10016.64,90,,5.944,Percent of Total Billed charges,90% of Total Billed Charges,4908.15,11129.6,
IVL PTCA Mjr Vssl/Brch Lt Main,4810000160,CDM,481,RC,,,Outpatient,,,11129.60,7234.24,,11129.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8458.5,76,,275.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8013.31,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,8347.2,75,,6677.76,Percent of Total Billed charges,75% of Total Billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8013.31,72,,6410.648,Percent of Total Billed Charges,72% of Total Billed Charges,6677.76,60,,5342.208,Percent of Total Billed Charges,60% of Total Billed Charges,10016.64,90,,1118.464,Percent of Total Billed Charges,90% of Total Billed Charges,5008.32,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,10016.64,90,,326.256,Percent of Total Billed Charges,90% of Total billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7234.24,65,,57.904,Percent of total Billed Charges,65% of Total Billed Charges,4908.15,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,10573.12,95,,344.376,Percent of Total Billed Charges,95% of Total Billed Charges,11129.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9794.05,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,10016.64,90,,326.256,Percent of Total Billed charges,90% of Total Billed Charges,4908.15,11129.6,
IVL PTCA Each add Branch LAD,4810000161,CDM,481,RC,,,Outpatient,,,5564.80,3617.12,,5564.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4229.25,76,,275.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4006.66,72,,3205.328,Percent of Total Billed Charges,72% of Total Billed Charges,4173.6,75,,3338.88,Percent of Total Billed charges,75% of Total Billed Charges,5564.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4006.66,72,,3205.328,Percent of Total Billed Charges,72% of Total Billed Charges,3338.88,60,,2671.104,Percent of Total Billed Charges,60% of Total Billed Charges,5008.32,90,,21.864,Percent of Total Billed Charges,90% of Total Billed Charges,2504.16,45,,16.92,Percent of Total Billed Charges,45% of Total Billed Charges,5008.32,90,,326.256,Percent of Total Billed Charges,90% of Total billed Charges,5564.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5564.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5564.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3617.12,65,,77.4,Percent of total Billed Charges,65% of Total Billed Charges,2454.08,44.1,,16.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,5286.56,95,,344.376,Percent of Total Billed Charges,95% of Total Billed Charges,5564.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4897.02,88,,33.088,Percent of Total Billed Charges,88% of Total Billed Charges,5008.32,90,,326.256,Percent of Total Billed charges,90% of Total Billed Charges,2454.08,5564.8,
IVL PTCA Ea Add Brnch Lt Circ,4810000162,CDM,481,RC,,,Outpatient,,,5564.80,3617.12,,5564.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4229.25,76,,41.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4006.66,72,,3205.328,Percent of Total Billed Charges,72% of Total Billed Charges,4173.6,75,,3338.88,Percent of Total Billed charges,75% of Total Billed Charges,5564.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4006.66,72,,3205.328,Percent of Total Billed Charges,72% of Total Billed Charges,3338.88,60,,2671.104,Percent of Total Billed Charges,60% of Total Billed Charges,5008.32,90,,604.88,Percent of Total Billed Charges,90% of Total Billed Charges,2504.16,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,5008.32,90,,48.96,Percent of Total Billed Charges,90% of Total billed Charges,5564.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5564.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5564.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3617.12,65,,115.808,Percent of total Billed Charges,65% of Total Billed Charges,2454.08,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,5286.56,95,,51.68,Percent of Total Billed Charges,95% of Total Billed Charges,5564.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4897.02,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,5008.32,90,,48.96,Percent of Total Billed charges,90% of Total Billed Charges,2454.08,5564.8,
IVL PTCA Ea Add Brnch Rt Coro,4810000163,CDM,481,RC,,,Outpatient,,,5564.80,3617.12,,5564.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4229.25,76,,184.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4006.66,72,,3205.328,Percent of Total Billed Charges,72% of Total Billed Charges,4173.6,75,,3338.88,Percent of Total Billed charges,75% of Total Billed Charges,5564.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4006.66,72,,3205.328,Percent of Total Billed Charges,72% of Total Billed Charges,3338.88,60,,2671.104,Percent of Total Billed Charges,60% of Total Billed Charges,5008.32,90,,851.744,Percent of Total Billed Charges,90% of Total Billed Charges,2504.16,45,,18.768,Percent of Total Billed Charges,45% of Total Billed Charges,5008.32,90,,218.2,Percent of Total Billed Charges,90% of Total billed Charges,5564.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5564.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5564.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3617.12,65,,154.792,Percent of total Billed Charges,65% of Total Billed Charges,2454.08,44.1,,18.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,5286.56,95,,230.328,Percent of Total Billed Charges,95% of Total Billed Charges,5564.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4897.02,88,,36.704,Percent of Total Billed Charges,88% of Total Billed Charges,5008.32,90,,218.2,Percent of Total Billed charges,90% of Total Billed Charges,2454.08,5564.8,
IVL DES Major Vssl/Brnch LAD,4810000164,CDM,481,RC,C9600,HCPCS,Outpatient,,,21422.00,13924.30,,14255.75,125,,,Fee Schedule,125% of CMS OPPS Rate,16280.72,76,,28.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15423.84,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,16066.5,75,,12853.2,Percent of Total Billed charges,75% of Total Billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15423.84,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,12853.2,60,,10282.56,Percent of Total Billed Charges,60% of Total Billed Charges,19279.8,90,,5711.384,Percent of Total Billed Charges,90% of Total Billed Charges,9639.9,45,,139.904,Percent of Total Billed Charges,45% of Total Billed Charges,19279.8,90,,33.376,Percent of Total Billed Charges,90% of Total billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21297.13,200,,1938.28,Fee Schedule,200% of CMS OPPS Rate,9447.1,44.1,,137.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,20350.9,95,,35.224,Percent of Total Billed Charges,95% of Total Billed Charges,8553.44,75,,,Fee Schedule,75% of CMS OPPS Rate,18851.36,88,,273.592,Percent of Total Billed Charges,88% of Total Billed Charges,19279.8,90,,33.376,Percent of Total Billed charges,90% of Total Billed Charges,8553.44,21297.13,
IVL DES Mjr Vssl/Brnch Lt Circ,4810000165,CDM,481,RC,C9600,HCPCS,Outpatient,,,21422.00,13924.30,,14255.75,125,,,Fee Schedule,125% of CMS OPPS Rate,16280.72,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15423.84,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,16066.5,75,,12853.2,Percent of Total Billed charges,75% of Total Billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15423.84,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,12853.2,60,,10282.56,Percent of Total Billed Charges,60% of Total Billed Charges,19279.8,90,,278.624,Percent of Total Billed Charges,90% of Total Billed Charges,9639.9,45,,559.232,Percent of Total Billed Charges,45% of Total Billed Charges,19279.8,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21297.13,200,,13.184,Fee Schedule,200% of CMS OPPS Rate,9447.1,44.1,,548.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,20350.9,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,8553.44,75,,,Fee Schedule,75% of CMS OPPS Rate,18851.36,88,,1093.608,Percent of Total Billed Charges,88% of Total Billed Charges,19279.8,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,8553.44,21297.13,
IVL DES Mjr Vssl/Brnch Rt Coro,4810000166,CDM,481,RC,C9600,HCPCS,Outpatient,,,21422.00,13924.30,,14255.75,125,,,Fee Schedule,125% of CMS OPPS Rate,16280.72,76,,28.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15423.84,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,16066.5,75,,12853.2,Percent of Total Billed charges,75% of Total Billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15423.84,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,12853.2,60,,10282.56,Percent of Total Billed Charges,60% of Total Billed Charges,19279.8,90,,446.76,Percent of Total Billed Charges,90% of Total Billed Charges,9639.9,45,,10.936,Percent of Total Billed Charges,45% of Total Billed Charges,19279.8,90,,33.84,Percent of Total Billed Charges,90% of Total billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21297.13,200,,24.656,Fee Schedule,200% of CMS OPPS Rate,9447.1,44.1,,10.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,20350.9,95,,35.72,Percent of Total Billed Charges,95% of Total Billed Charges,8553.44,75,,,Fee Schedule,75% of CMS OPPS Rate,18851.36,88,,21.384,Percent of Total Billed Charges,88% of Total Billed Charges,19279.8,90,,33.84,Percent of Total Billed charges,90% of Total Billed Charges,8553.44,21297.13,
IVL DES Mjr Vssl/Brnch Ramus,4810000167,CDM,481,RC,C9600,HCPCS,Outpatient,,,22549.43,14657.13,,14255.75,125,,,Fee Schedule,125% of CMS OPPS Rate,17137.57,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16235.59,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,16912.07,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16235.59,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,13529.66,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,20294.49,90,,693.544,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,302.44,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21297.13,200,,53.896,Fee Schedule,200% of CMS OPPS Rate,9944.3,44.1,,296.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,8553.44,75,,,Fee Schedule,75% of CMS OPPS Rate,19843.5,88,,591.44,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,8553.44,21421.96,
IVL DES Mjr Vssl/Brnch Lt Main,4810000168,CDM,481,RC,C9600,HCPCS,Outpatient,,,21422.00,13924.30,,14255.75,125,,,Fee Schedule,125% of CMS OPPS Rate,16280.72,76,,31.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15423.84,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,16066.5,75,,12853.2,Percent of Total Billed charges,75% of Total Billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15423.84,72,,12339.072,Percent of Total Billed Charges,72% of Total Billed Charges,12853.2,60,,10282.56,Percent of Total Billed Charges,60% of Total Billed Charges,19279.8,90,,45.688,Percent of Total Billed Charges,90% of Total Billed Charges,9639.9,45,,425.872,Percent of Total Billed Charges,45% of Total Billed Charges,19279.8,90,,37.544,Percent of Total Billed Charges,90% of Total billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21297.13,200,,100.904,Fee Schedule,200% of CMS OPPS Rate,9447.1,44.1,,417.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,20350.9,95,,39.624,Percent of Total Billed Charges,95% of Total Billed Charges,8553.44,75,,,Fee Schedule,75% of CMS OPPS Rate,18851.36,88,,832.816,Percent of Total Billed Charges,88% of Total Billed Charges,19279.8,90,,37.544,Percent of Total Billed charges,90% of Total Billed Charges,8553.44,21297.13,
IVL DES Ea Add Branch LAD,4810000169,CDM,481,RC,C9601,HCPCS,Outpatient,,,11274.72,7328.57,,11274.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8568.79,76,,236.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10147.25,90,,17.64,Percent of Total Billed Charges,90% of Total Billed Charges,5073.62,45,,2855.696,Percent of Total Billed Charges,45% of Total Billed Charges,10147.25,90,,279.816,Percent of Total Billed Charges,90% of Total billed Charges,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7328.57,65,,1.184,Percent of total Billed Charges,65% of Total Billed Charges,4972.15,44.1,,2798.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,10710.98,95,,295.36,Percent of Total Billed Charges,95% of Total Billed Charges,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9921.75,88,,5584.464,Percent of Total Billed Charges,88% of Total Billed Charges,10147.25,90,,279.816,Percent of Total Billed charges,90% of Total Billed Charges,4972.15,11274.72,
IVL DES Ea Add Brnch Lt Circ,4810000170,CDM,481,RC,C9601,HCPCS,Outpatient,,,11274.72,7328.57,,11274.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8568.79,76,,944.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10147.25,90,,138.872,Percent of Total Billed Charges,90% of Total Billed Charges,5073.62,45,,139.312,Percent of Total Billed Charges,45% of Total Billed Charges,10147.25,90,,1118.464,Percent of Total Billed Charges,90% of Total billed Charges,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7328.57,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,4972.15,44.1,,136.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,10710.98,95,,1180.6,Percent of Total Billed Charges,95% of Total Billed Charges,11274.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9921.75,88,,272.432,Percent of Total Billed Charges,88% of Total Billed Charges,10147.25,90,,1118.464,Percent of Total Billed charges,90% of Total Billed Charges,4972.15,11274.72,
IVL DES Ea Add Branch Rt Coro,4810000171,CDM,481,RC,C9601,HCPCS,Outpatient,,,10711.00,6962.15,,10711,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8140.36,76,,18.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10711,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9639.9,90,,121.216,Percent of Total Billed Charges,90% of Total Billed Charges,4819.95,45,,223.384,Percent of Total Billed Charges,45% of Total Billed Charges,9639.9,90,,21.864,Percent of Total Billed Charges,90% of Total billed Charges,10711,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10711,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10711,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6962.15,65,,18.92,Percent of total Billed Charges,65% of Total Billed Charges,4723.55,44.1,,218.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,10175.45,95,,23.08,Percent of Total Billed Charges,95% of Total Billed Charges,10711,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9425.68,88,,436.832,Percent of Total Billed Charges,88% of Total Billed Charges,9639.9,90,,21.864,Percent of Total Billed charges,90% of Total Billed Charges,4723.55,10711,
IVL AMI Art/Brnch/Grft LAD,4810000172,CDM,481,RC,C9606,HCPCS,Outpatient,,,22297.00,14493.05,,22297,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16945.72,76,,510.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16053.84,72,,12843.072,Percent of Total Billed Charges,72% of Total Billed Charges,16722.75,75,,13378.2,Percent of Total Billed charges,75% of Total Billed Charges,22297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16053.84,72,,12843.072,Percent of Total Billed Charges,72% of Total Billed Charges,13378.2,60,,10702.56,Percent of Total Billed Charges,60% of Total Billed Charges,20067.3,90,,641.688,Percent of Total Billed Charges,90% of Total Billed Charges,10033.65,45,,346.768,Percent of Total Billed Charges,45% of Total Billed Charges,20067.3,90,,604.88,Percent of Total Billed Charges,90% of Total billed Charges,22297,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,22297,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,22297,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,22297,100,,3.984,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,9832.98,44.1,,339.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,21182.15,95,,638.48,Percent of Total Billed Charges,95% of Total Billed Charges,22297,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,19621.36,88,,678.128,Percent of Total Billed Charges,88% of Total Billed Charges,20067.3,90,,604.88,Percent of Total Billed charges,90% of Total Billed Charges,9832.98,22297,
IVL AMI Art/Br/Grft Lt Circ,4810000173,CDM,481,RC,C9606,HCPCS,Outpatient,,,23470.02,15255.51,,23470.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17837.22,76,,719.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16898.41,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,17602.52,75,,14082.016,Percent of Total Billed charges,75% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16898.41,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,14082.01,60,,11265.608,Percent of Total Billed Charges,60% of Total Billed Charges,21123.02,90,,82.408,Percent of Total Billed Charges,90% of Total Billed Charges,10561.51,45,,22.848,Percent of Total Billed Charges,45% of Total Billed Charges,21123.02,90,,851.744,Percent of Total Billed Charges,90% of Total billed Charges,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23470.02,100,,3.984,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,10350.28,44.1,,22.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,22296.52,95,,899.064,Percent of Total Billed Charges,95% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,20653.62,88,,44.672,Percent of Total Billed Charges,88% of Total Billed Charges,21123.02,90,,851.744,Percent of Total Billed charges,90% of Total Billed Charges,10350.28,23470.02,
IVL AMI Art/Br/Grft Rt Coro,4810000174,CDM,481,RC,C9606,HCPCS,Outpatient,,,23470.02,15255.51,,23470.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17837.22,76,,4822.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16898.41,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,17602.52,75,,14082.016,Percent of Total Billed charges,75% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16898.41,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,14082.01,60,,11265.608,Percent of Total Billed Charges,60% of Total Billed Charges,21123.02,90,,203.216,Percent of Total Billed Charges,90% of Total Billed Charges,10561.51,45,,8.824,Percent of Total Billed Charges,45% of Total Billed Charges,21123.02,90,,5711.384,Percent of Total Billed Charges,90% of Total billed Charges,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23470.02,100,,5.16,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,10350.28,44.1,,8.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,22296.52,95,,6028.688,Percent of Total Billed Charges,95% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,20653.62,88,,17.248,Percent of Total Billed Charges,88% of Total Billed Charges,21123.02,90,,5711.384,Percent of Total Billed charges,90% of Total Billed Charges,10350.28,23470.02,
IVL AMI Art/Br/Grft Ramus,4810000175,CDM,481,RC,C9606,HCPCS,Outpatient,,,23470.02,15255.51,,23470.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17837.22,76,,235.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16898.41,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,17602.52,75,,14082.016,Percent of Total Billed charges,75% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16898.41,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,14082.01,60,,11265.608,Percent of Total Billed Charges,60% of Total Billed Charges,21123.02,90,,62.104,Percent of Total Billed Charges,90% of Total Billed Charges,10561.51,45,,69.44,Percent of Total Billed Charges,45% of Total Billed Charges,21123.02,90,,278.624,Percent of Total Billed Charges,90% of Total billed Charges,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23470.02,100,,2.864,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,10350.28,44.1,,68.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,22296.52,95,,294.104,Percent of Total Billed Charges,95% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,20653.62,88,,135.784,Percent of Total Billed Charges,88% of Total Billed Charges,21123.02,90,,278.624,Percent of Total Billed charges,90% of Total Billed Charges,10350.28,23470.02,
IVL AMI Art/Br/Grft Lt Main,4810000176,CDM,481,RC,C9606,HCPCS,Outpatient,,,23470.02,15255.51,,23470.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17837.22,76,,377.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16898.41,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,17602.52,75,,14082.016,Percent of Total Billed charges,75% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16898.41,72,,13518.728,Percent of Total Billed Charges,72% of Total Billed Charges,14082.01,60,,11265.608,Percent of Total Billed Charges,60% of Total Billed Charges,21123.02,90,,34.672,Percent of Total Billed Charges,90% of Total Billed Charges,10561.51,45,,60.608,Percent of Total Billed Charges,45% of Total Billed Charges,21123.02,90,,446.76,Percent of Total Billed Charges,90% of Total billed Charges,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,23470.02,100,,3.44,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,10350.28,44.1,,59.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,22296.52,95,,471.584,Percent of Total Billed Charges,95% of Total Billed Charges,23470.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,20653.62,88,,118.528,Percent of Total Billed Charges,88% of Total Billed Charges,21123.02,90,,446.76,Percent of Total Billed charges,90% of Total Billed Charges,10350.28,23470.02,
IVL CTO Art/Br/Grft LAD,4810000177,CDM,481,RC,C9607,HCPCS,Outpatient,,,36068.50,23444.53,,22572.66,125,,,Fee Schedule,125% of CMS OPPS Rate,27412.06,76,,585.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25969.32,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,27051.38,75,,21641.104,Percent of Total Billed charges,75% of Total Billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,25969.32,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,21641.1,60,,17312.88,Percent of Total Billed Charges,60% of Total Billed Charges,32461.65,90,,204.008,Percent of Total Billed Charges,90% of Total Billed Charges,16230.83,45,,320.84,Percent of Total Billed Charges,45% of Total Billed Charges,32461.65,90,,693.544,Percent of Total Billed Charges,90% of Total billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,33722,200,,7730.696,Fee Schedule,200% of CMS OPPS Rate,15906.21,44.1,,314.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,34265.08,95,,732.072,Percent of Total Billed Charges,95% of Total Billed Charges,13543.59,75,,,Fee Schedule,75% of CMS OPPS Rate,31740.28,88,,627.424,Percent of Total Billed Charges,88% of Total Billed Charges,32461.65,90,,693.544,Percent of Total Billed charges,90% of Total Billed Charges,13543.59,34265.08,
IVL CTO Art/Br/Grft Lt Circ,4810000178,CDM,481,RC,C9607,HCPCS,Outpatient,,,36068.50,23444.53,,22572.66,125,,,Fee Schedule,125% of CMS OPPS Rate,27412.06,76,,38.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25969.32,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,27051.38,75,,21641.104,Percent of Total Billed charges,75% of Total Billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,25969.32,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,21641.1,60,,17312.88,Percent of Total Billed Charges,60% of Total Billed Charges,32461.65,90,,135.448,Percent of Total Billed Charges,90% of Total Billed Charges,16230.83,45,,41.2,Percent of Total Billed Charges,45% of Total Billed Charges,32461.65,90,,45.688,Percent of Total Billed Charges,90% of Total billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,33722,200,,24.44,Fee Schedule,200% of CMS OPPS Rate,15906.21,44.1,,40.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,34265.08,95,,48.232,Percent of Total Billed Charges,95% of Total Billed Charges,13543.59,75,,,Fee Schedule,75% of CMS OPPS Rate,31740.28,88,,80.576,Percent of Total Billed Charges,88% of Total Billed Charges,32461.65,90,,45.688,Percent of Total Billed charges,90% of Total Billed Charges,13543.59,34265.08,
IVL CTO Art/Br/Grft Rt Coro,4810000179,CDM,481,RC,C9607,HCPCS,Outpatient,,,36068.50,23444.53,,22572.66,125,,,Fee Schedule,125% of CMS OPPS Rate,27412.06,76,,14.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25969.32,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,27051.38,75,,21641.104,Percent of Total Billed charges,75% of Total Billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,25969.32,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,21641.1,60,,17312.88,Percent of Total Billed Charges,60% of Total Billed Charges,32461.65,90,,82.552,Percent of Total Billed Charges,90% of Total Billed Charges,16230.83,45,,101.608,Percent of Total Billed Charges,45% of Total Billed Charges,32461.65,90,,17.64,Percent of Total Billed Charges,90% of Total billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,33722,200,,65.928,Fee Schedule,200% of CMS OPPS Rate,15906.21,44.1,,99.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,34265.08,95,,18.624,Percent of Total Billed Charges,95% of Total Billed Charges,13543.59,75,,,Fee Schedule,75% of CMS OPPS Rate,31740.28,88,,198.696,Percent of Total Billed Charges,88% of Total Billed Charges,32461.65,90,,17.64,Percent of Total Billed charges,90% of Total Billed Charges,13543.59,34265.08,
IVL CTO Art/Br/Grft Ramus,4810000180,CDM,481,RC,C9607,HCPCS,Outpatient,,,36068.50,23444.53,,22572.66,125,,,Fee Schedule,125% of CMS OPPS Rate,27412.06,76,,117.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25969.32,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,27051.38,75,,21641.104,Percent of Total Billed charges,75% of Total Billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,25969.32,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,21641.1,60,,17312.88,Percent of Total Billed Charges,60% of Total Billed Charges,32461.65,90,,29.64,Percent of Total Billed Charges,90% of Total Billed Charges,16230.83,45,,31.048,Percent of Total Billed Charges,45% of Total Billed Charges,32461.65,90,,138.872,Percent of Total Billed Charges,90% of Total billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,33722,200,,175.432,Fee Schedule,200% of CMS OPPS Rate,15906.21,44.1,,30.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,34265.08,95,,146.592,Percent of Total Billed Charges,95% of Total Billed Charges,13543.59,75,,,Fee Schedule,75% of CMS OPPS Rate,31740.28,88,,60.72,Percent of Total Billed Charges,88% of Total Billed Charges,32461.65,90,,138.872,Percent of Total Billed charges,90% of Total Billed Charges,13543.59,34265.08,
IVL CTO Art/Br/Grft Left Main,4810000181,CDM,481,RC,C9607,HCPCS,Outpatient,,,36068.50,23444.53,,22572.66,125,,,Fee Schedule,125% of CMS OPPS Rate,27412.06,76,,102.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25969.32,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,27051.38,75,,21641.104,Percent of Total Billed charges,75% of Total Billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,25969.32,72,,20775.456,Percent of Total Billed Charges,72% of Total Billed Charges,21641.1,60,,17312.88,Percent of Total Billed Charges,60% of Total Billed Charges,32461.65,90,,82.376,Percent of Total Billed Charges,90% of Total Billed Charges,16230.83,45,,17.336,Percent of Total Billed Charges,45% of Total Billed Charges,32461.65,90,,121.216,Percent of Total Billed Charges,90% of Total billed Charges,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,18058.13,100,,,Fee Schedule,100% of CMS OPPS Rate,33722,200,,1.056,Fee Schedule,200% of CMS OPPS Rate,15906.21,44.1,,16.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,34265.08,95,,127.952,Percent of Total Billed Charges,95% of Total Billed Charges,13543.59,75,,,Fee Schedule,75% of CMS OPPS Rate,31740.28,88,,33.904,Percent of Total Billed Charges,88% of Total Billed Charges,32461.65,90,,121.216,Percent of Total Billed charges,90% of Total Billed Charges,13543.59,34265.08,
IVL CTO Ea Add Art/Br/Grft LAD,4810000182,CDM,481,RC,C9608,HCPCS,Outpatient,,,18034.25,11722.26,,18034.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13706.03,76,,541.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16230.83,90,,51.16,Percent of Total Billed Charges,90% of Total Billed Charges,8115.41,45,,102,Percent of Total Billed Charges,45% of Total Billed Charges,16230.83,90,,641.688,Percent of Total Billed Charges,90% of Total billed Charges,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11722.26,65,,8.064,Percent of total Billed Charges,65% of Total Billed Charges,7953.1,44.1,,99.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,17132.54,95,,677.336,Percent of Total Billed Charges,95% of Total Billed Charges,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15870.14,88,,199.472,Percent of Total Billed Charges,88% of Total Billed Charges,16230.83,90,,641.688,Percent of Total Billed charges,90% of Total Billed Charges,7953.1,18034.25,
IVL CTO Ea Ad Art/Br/Gr Lt Cx,4810000183,CDM,481,RC,C9608,HCPCS,Outpatient,,,18034.25,11722.26,,18034.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13706.03,76,,69.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16230.83,90,,244.488,Percent of Total Billed Charges,90% of Total Billed Charges,8115.41,45,,67.72,Percent of Total Billed Charges,45% of Total Billed Charges,16230.83,90,,82.408,Percent of Total Billed Charges,90% of Total billed Charges,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11722.26,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,7953.1,44.1,,66.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,17132.54,95,,86.984,Percent of Total Billed Charges,95% of Total Billed Charges,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15870.14,88,,132.44,Percent of Total Billed Charges,88% of Total Billed Charges,16230.83,90,,82.408,Percent of Total Billed charges,90% of Total Billed Charges,7953.1,18034.25,
IVL CTO Ea Ad Art/Br/Gr Rt Cor,4810000184,CDM,481,RC,C9608,HCPCS,Outpatient,,,18034.25,11722.26,,18034.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,13706.03,76,,171.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16230.83,90,,80.768,Percent of Total Billed Charges,90% of Total Billed Charges,8115.41,45,,41.28,Percent of Total Billed Charges,45% of Total Billed Charges,16230.83,90,,203.216,Percent of Total Billed Charges,90% of Total billed Charges,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11722.26,65,,2.72,Percent of total Billed Charges,65% of Total Billed Charges,7953.1,44.1,,40.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,17132.54,95,,214.504,Percent of Total Billed Charges,95% of Total Billed Charges,18034.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15870.14,88,,80.72,Percent of Total Billed Charges,88% of Total Billed Charges,16230.83,90,,203.216,Percent of Total Billed charges,90% of Total Billed Charges,7953.1,18034.25,
IVL PCI Any/Thru Grft LAD,4810000185,CDM,481,RC,C9604,HCPCS,Outpatient,,,22549.43,14657.13,,14255.75,125,,,Fee Schedule,125% of CMS OPPS Rate,17137.57,76,,52.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16235.59,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,16912.07,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16235.59,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,13529.66,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,20294.49,90,,153.12,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,14.824,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,62.104,Percent of Total Billed Charges,90% of Total billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21297.13,200,,343.408,Fee Schedule,200% of CMS OPPS Rate,9944.3,44.1,,14.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,65.552,Percent of Total Billed Charges,95% of Total Billed Charges,8553.44,75,,,Fee Schedule,75% of CMS OPPS Rate,19843.5,88,,28.984,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,62.104,Percent of Total Billed charges,90% of Total Billed Charges,8553.44,21421.96,
IVL PCI Any/Thru Grft Lt Circ,4810000186,CDM,481,RC,C9604,HCPCS,Outpatient,,,22549.43,14657.13,,14255.75,125,,,Fee Schedule,125% of CMS OPPS Rate,17137.57,76,,29.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16235.59,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,16912.07,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16235.59,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,13529.66,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,20294.49,90,,211.152,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,41.184,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,34.672,Percent of Total Billed Charges,90% of Total billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21297.13,200,,4.584,Fee Schedule,200% of CMS OPPS Rate,9944.3,44.1,,40.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,36.6,Percent of Total Billed Charges,95% of Total Billed Charges,8553.44,75,,,Fee Schedule,75% of CMS OPPS Rate,19843.5,88,,80.544,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,34.672,Percent of Total Billed charges,90% of Total Billed Charges,8553.44,21421.96,
IVL PCI Any/Thru Grft Rt Coro,4810000187,CDM,481,RC,C9604,HCPCS,Outpatient,,,22549.43,14657.13,,14255.75,125,,,Fee Schedule,125% of CMS OPPS Rate,17137.57,76,,172.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16235.59,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,16912.07,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16235.59,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,13529.66,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,20294.49,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,25.576,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,204.008,Percent of Total Billed Charges,90% of Total billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21297.13,200,,5.736,Fee Schedule,200% of CMS OPPS Rate,9944.3,44.1,,25.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,215.336,Percent of Total Billed Charges,95% of Total Billed Charges,8553.44,75,,,Fee Schedule,75% of CMS OPPS Rate,19843.5,88,,50.016,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,204.008,Percent of Total Billed charges,90% of Total Billed Charges,8553.44,21421.96,
IVL PCI Any/Thru Grft Ramus,4810000188,CDM,481,RC,C9604,HCPCS,Outpatient,,,22549.43,14657.13,,14255.75,125,,,Fee Schedule,125% of CMS OPPS Rate,17137.57,76,,114.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16235.59,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,16912.07,75,,13529.656,Percent of Total Billed charges,75% of Total Billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16235.59,72,,12988.472,Percent of Total Billed Charges,72% of Total Billed Charges,13529.66,60,,10823.728,Percent of Total Billed Charges,60% of Total Billed Charges,20294.49,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,122.248,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,135.448,Percent of Total Billed Charges,90% of Total billed Charges,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11404.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21297.13,200,,22.936,Fee Schedule,200% of CMS OPPS Rate,9944.3,44.1,,119.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,142.968,Percent of Total Billed Charges,95% of Total Billed Charges,8553.44,75,,,Fee Schedule,75% of CMS OPPS Rate,19843.5,88,,239.056,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,135.448,Percent of Total Billed charges,90% of Total Billed Charges,8553.44,21421.96,
IVL PCI Any Add/Thru Grft LAD,4810000189,CDM,481,RC,C9605,HCPCS,Outpatient,,,22549.43,14657.13,,22549.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17137.57,76,,69.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20294.49,90,,59.536,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,40.384,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,82.552,Percent of Total Billed Charges,90% of Total billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14657.13,65,,13.128,Percent of total Billed Charges,65% of Total Billed Charges,9944.3,44.1,,39.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,87.144,Percent of Total Billed Charges,95% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19843.5,88,,78.976,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,82.552,Percent of Total Billed charges,90% of Total Billed Charges,9944.3,22549.43,
IVL PCI Any Ad/Thru Gr Lt Circ,4810000190,CDM,481,RC,C9605,HCPCS,Outpatient,,,22549.43,14657.13,,22549.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17137.57,76,,25.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20294.49,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,76.56,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,29.64,Percent of Total Billed Charges,90% of Total billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14657.13,65,,45.24,Percent of total Billed Charges,65% of Total Billed Charges,9944.3,44.1,,75.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,31.288,Percent of Total Billed Charges,95% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19843.5,88,,149.72,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,29.64,Percent of Total Billed charges,90% of Total Billed Charges,9944.3,22549.43,
IVL PCI Any Ad/Thru Gr Rt Coro,4810000191,CDM,481,RC,C9605,HCPCS,Outpatient,,,22549.43,14657.13,,22549.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17137.57,76,,69.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20294.49,90,,19.84,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,105.576,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,82.376,Percent of Total Billed Charges,90% of Total billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14657.13,65,,24.08,Percent of total Billed Charges,65% of Total Billed Charges,9944.3,44.1,,103.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,86.952,Percent of Total Billed Charges,95% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19843.5,88,,206.464,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,82.376,Percent of Total Billed charges,90% of Total Billed Charges,9944.3,22549.43,
IVL PCI Any Ad/Thru Grft Ramus,4810000192,CDM,481,RC,C9605,HCPCS,Outpatient,,,22549.43,14657.13,,22549.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17137.57,76,,43.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20294.49,90,,186.544,Percent of Total Billed Charges,90% of Total Billed Charges,10147.24,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,20294.49,90,,51.16,Percent of Total Billed Charges,90% of Total billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14657.13,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,9944.3,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,21421.96,95,,54,Percent of Total Billed Charges,95% of Total Billed Charges,22549.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19843.5,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,20294.49,90,,51.16,Percent of Total Billed charges,90% of Total Billed Charges,9944.3,22549.43,
Pulmonary Angiography,4810000193,CDM,481,RC,,,Outpatient,,,2500.00,1625.00,,2500,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1900,76,,206.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1800,72,,1440,Percent of Total Billed Charges,72% of Total Billed Charges,1875,75,,1500,Percent of Total Billed charges,75% of Total Billed Charges,2500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1800,72,,1440,Percent of Total Billed Charges,72% of Total Billed Charges,1500,60,,1200,Percent of Total Billed Charges,60% of Total Billed Charges,2250,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,1125,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,2250,90,,244.488,Percent of Total Billed Charges,90% of Total billed Charges,2500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1625,65,,96.888,Percent of total Billed Charges,65% of Total Billed Charges,1102.5,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,2375,95,,258.072,Percent of Total Billed Charges,95% of Total Billed Charges,2500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2200,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,2250,90,,244.488,Percent of Total Billed charges,90% of Total Billed Charges,1102.5,2500,
Right/Left IMA Angiography,4810000194,CDM,481,RC,,,Outpatient,,,6907.80,4490.07,,6907.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5249.93,76,,68.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4973.62,72,,3978.896,Percent of Total Billed Charges,72% of Total Billed Charges,5180.85,75,,4144.68,Percent of Total Billed charges,75% of Total Billed Charges,6907.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4973.62,72,,3978.896,Percent of Total Billed Charges,72% of Total Billed Charges,4144.68,60,,3315.744,Percent of Total Billed Charges,60% of Total Billed Charges,6217.02,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,3108.51,45,,29.768,Percent of Total Billed Charges,45% of Total Billed Charges,6217.02,90,,80.768,Percent of Total Billed Charges,90% of Total billed Charges,6907.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6907.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6907.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4490.07,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,3046.34,44.1,,29.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,6562.41,95,,85.256,Percent of Total Billed Charges,95% of Total Billed Charges,6907.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6078.86,88,,58.216,Percent of Total Billed Charges,88% of Total Billed Charges,6217.02,90,,80.768,Percent of Total Billed charges,90% of Total Billed Charges,3046.34,6907.8,
PTCL Major Vessel/Branch LAD,4810000195,CDM,481,RC,,,Outpatient,,,1710.00,1111.50,,1710,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1299.6,76,,129.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1231.2,72,,984.96,Percent of Total Billed Charges,72% of Total Billed Charges,1282.5,75,,1026,Percent of Total Billed charges,75% of Total Billed Charges,1710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1231.2,72,,984.96,Percent of Total Billed Charges,72% of Total Billed Charges,1026,60,,820.8,Percent of Total Billed Charges,60% of Total Billed Charges,1539,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,769.5,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,1539,90,,153.12,Percent of Total Billed Charges,90% of Total billed Charges,1710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1111.5,65,,481.576,Percent of total Billed Charges,65% of Total Billed Charges,754.11,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,1624.5,95,,161.632,Percent of Total Billed Charges,95% of Total Billed Charges,1710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1504.8,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,1539,90,,153.12,Percent of Total Billed charges,90% of Total Billed Charges,754.11,1710,
PTCL Major Vessel/Branch Lt Cx,4810000196,CDM,481,RC,,,Outpatient,,,1710.00,1111.50,,1710,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1299.6,76,,178.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1231.2,72,,984.96,Percent of Total Billed Charges,72% of Total Billed Charges,1282.5,75,,1026,Percent of Total Billed charges,75% of Total Billed Charges,1710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1231.2,72,,984.96,Percent of Total Billed Charges,72% of Total Billed Charges,1026,60,,820.8,Percent of Total Billed Charges,60% of Total Billed Charges,1539,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,769.5,45,,9.92,Percent of Total Billed Charges,45% of Total Billed Charges,1539,90,,211.152,Percent of Total Billed Charges,90% of Total billed Charges,1710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1111.5,65,,24.08,Percent of total Billed Charges,65% of Total Billed Charges,754.11,44.1,,9.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,1624.5,95,,222.888,Percent of Total Billed Charges,95% of Total Billed Charges,1710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1504.8,88,,19.4,Percent of Total Billed Charges,88% of Total Billed Charges,1539,90,,211.152,Percent of Total Billed charges,90% of Total Billed Charges,754.11,1710,
PTCL Major Vssl/Branch Rt Coro,4810000197,CDM,481,RC,,,Outpatient,,,1710.00,1111.50,,1710,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1299.6,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1231.2,72,,984.96,Percent of Total Billed Charges,72% of Total Billed Charges,1282.5,75,,1026,Percent of Total Billed charges,75% of Total Billed Charges,1710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1231.2,72,,984.96,Percent of Total Billed Charges,72% of Total Billed Charges,1026,60,,820.8,Percent of Total Billed Charges,60% of Total Billed Charges,1539,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,769.5,45,,93.272,Percent of Total Billed Charges,45% of Total Billed Charges,1539,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,1710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1111.5,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,754.11,44.1,,91.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,1624.5,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,1710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1504.8,88,,182.4,Percent of Total Billed Charges,88% of Total Billed Charges,1539,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,754.11,1710,
PTCL Major Vessel/Branch Ramus,4810000198,CDM,481,RC,,,Outpatient,,,1800.00,1170.00,,1800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1368,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1296,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,1350,75,,1080,Percent of Total Billed charges,75% of Total Billed Charges,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1296,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,1080,60,,864,Percent of Total Billed Charges,60% of Total Billed Charges,1620,90,,646.16,Percent of Total Billed Charges,90% of Total Billed Charges,810,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,1620,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,793.8,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,1710,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1584,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,1620,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,793.8,1800,
PTCL Major Vssl/Branch Lt Main,4810000199,CDM,481,RC,,,Outpatient,,,1710.00,1111.50,,1710,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1299.6,76,,50.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1231.2,72,,984.96,Percent of Total Billed Charges,72% of Total Billed Charges,1282.5,75,,1026,Percent of Total Billed charges,75% of Total Billed Charges,1710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1231.2,72,,984.96,Percent of Total Billed Charges,72% of Total Billed Charges,1026,60,,820.8,Percent of Total Billed Charges,60% of Total Billed Charges,1539,90,,34.136,Percent of Total Billed Charges,90% of Total Billed Charges,769.5,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,1539,90,,59.536,Percent of Total Billed Charges,90% of Total billed Charges,1710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1111.5,65,,5.16,Percent of total Billed Charges,65% of Total Billed Charges,754.11,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,1624.5,95,,62.848,Percent of Total Billed Charges,95% of Total Billed Charges,1710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1504.8,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,1539,90,,59.536,Percent of Total Billed charges,90% of Total Billed Charges,754.11,1710,
Coro Mech Thrombectomy LAD,4810000200,CDM,481,RC,,,Outpatient,,,1800.00,1170.00,,1800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1368,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1296,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,1350,75,,1080,Percent of Total Billed charges,75% of Total Billed Charges,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1296,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,1080,60,,864,Percent of Total Billed Charges,60% of Total Billed Charges,1620,90,,18.256,Percent of Total Billed Charges,90% of Total Billed Charges,810,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,1620,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170,65,,14.912,Percent of total Billed Charges,65% of Total Billed Charges,793.8,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,1710,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1584,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,1620,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,793.8,1800,
Coro Mech Thrombectomy Lt Circ,4810000201,CDM,481,RC,,,Outpatient,,,1800.00,1170.00,,1800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1368,76,,16.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1296,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,1350,75,,1080,Percent of Total Billed charges,75% of Total Billed Charges,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1296,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,1080,60,,864,Percent of Total Billed Charges,60% of Total Billed Charges,1620,90,,10.32,Percent of Total Billed Charges,90% of Total Billed Charges,810,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,1620,90,,19.84,Percent of Total Billed Charges,90% of Total billed Charges,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,793.8,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,1710,95,,20.944,Percent of Total Billed Charges,95% of Total Billed Charges,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1584,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,1620,90,,19.84,Percent of Total Billed charges,90% of Total Billed Charges,793.8,1800,
Coro Mech Thrombectomy Rt Coro,4810000202,CDM,481,RC,,,Outpatient,,,1800.00,1170.00,,1800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1368,76,,157.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1296,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,1350,75,,1080,Percent of Total Billed charges,75% of Total Billed Charges,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1296,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,1080,60,,864,Percent of Total Billed Charges,60% of Total Billed Charges,1620,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,810,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,1620,90,,186.544,Percent of Total Billed Charges,90% of Total billed Charges,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170,65,,25.224,Percent of total Billed Charges,65% of Total Billed Charges,793.8,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,1710,95,,196.912,Percent of Total Billed Charges,95% of Total Billed Charges,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1584,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,1620,90,,186.544,Percent of Total Billed charges,90% of Total Billed Charges,793.8,1800,
Coro Mech Thrombectomy Ramus,4810000203,CDM,481,RC,,,Outpatient,,,1800.00,1170.00,,1800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1368,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1296,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,1350,75,,1080,Percent of Total Billed charges,75% of Total Billed Charges,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1296,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,1080,60,,864,Percent of Total Billed Charges,60% of Total Billed Charges,1620,90,,25.4,Percent of Total Billed Charges,90% of Total Billed Charges,810,45,,323.08,Percent of Total Billed Charges,45% of Total Billed Charges,1620,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170,65,,48.16,Percent of total Billed Charges,65% of Total Billed Charges,793.8,44.1,,316.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,1710,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1584,88,,631.8,Percent of Total Billed Charges,88% of Total Billed Charges,1620,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,793.8,1800,
Coro Mech Thrombectomy Lt Main,4810000204,CDM,481,RC,,,Outpatient,,,1800.00,1170.00,,1800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1368,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1296,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,1350,75,,1080,Percent of Total Billed charges,75% of Total Billed Charges,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1296,72,,1036.8,Percent of Total Billed Charges,72% of Total Billed Charges,1080,60,,864,Percent of Total Billed Charges,60% of Total Billed Charges,1620,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,810,45,,17.064,Percent of Total Billed Charges,45% of Total Billed Charges,1620,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170,65,,404.432,Percent of total Billed Charges,65% of Total Billed Charges,793.8,44.1,,16.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,1710,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,1800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1584,88,,33.376,Percent of Total Billed Charges,88% of Total Billed Charges,1620,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,793.8,1800,
IVL Peripheral ATK PTA,4810000205,CDM,481,RC,,,Outpatient,,,26205.00,17033.25,,26205,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19915.8,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18867.6,72,,15094.08,Percent of Total Billed Charges,72% of Total Billed Charges,19653.75,75,,15723,Percent of Total Billed charges,75% of Total Billed Charges,26205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18867.6,72,,15094.08,Percent of Total Billed Charges,72% of Total Billed Charges,15723,60,,12578.4,Percent of Total Billed Charges,60% of Total Billed Charges,23584.5,90,,32.544,Percent of Total Billed Charges,90% of Total Billed Charges,11792.25,45,,9.128,Percent of Total Billed Charges,45% of Total Billed Charges,23584.5,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,26205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17033.25,65,,522.848,Percent of total Billed Charges,65% of Total Billed Charges,11556.41,44.1,,8.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,24894.75,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,26205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23060.4,88,,17.856,Percent of Total Billed Charges,88% of Total Billed Charges,23584.5,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,11556.41,26205,
IVL Peripheral ATK PTA/Stent,4810000206,CDM,481,RC,,,Outpatient,,,41767.50,27148.88,,41767.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31743.3,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30072.6,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,31325.63,75,,25060.504,Percent of Total Billed charges,75% of Total Billed Charges,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30072.6,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,25060.5,60,,20048.4,Percent of Total Billed Charges,60% of Total Billed Charges,37590.75,90,,27.904,Percent of Total Billed Charges,90% of Total Billed Charges,18795.38,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,37590.75,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27148.88,65,,53.312,Percent of total Billed Charges,65% of Total Billed Charges,18419.47,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,39679.13,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36755.4,88,,10.088,Percent of Total Billed Charges,88% of Total Billed Charges,37590.75,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,18419.47,41767.5,
IVL Periph ATK PTA/Atherectomy,4810000207,CDM,481,RC,,,Outpatient,,,41767.50,27148.88,,41767.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31743.3,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30072.6,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,31325.63,75,,25060.504,Percent of Total Billed charges,75% of Total Billed Charges,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30072.6,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,25060.5,60,,20048.4,Percent of Total Billed Charges,60% of Total Billed Charges,37590.75,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,18795.38,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,37590.75,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27148.88,65,,342.256,Percent of total Billed Charges,65% of Total Billed Charges,18419.47,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,39679.13,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36755.4,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,37590.75,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,18419.47,41767.5,
IVL Peri ATK PTA/Stent/Atherec,4810000208,CDM,481,RC,,,Outpatient,,,41767.50,27148.88,,41767.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31743.3,76,,545.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30072.6,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,31325.63,75,,25060.504,Percent of Total Billed charges,75% of Total Billed Charges,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30072.6,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,25060.5,60,,20048.4,Percent of Total Billed Charges,60% of Total Billed Charges,37590.75,90,,49.216,Percent of Total Billed Charges,90% of Total Billed Charges,18795.38,45,,12.704,Percent of Total Billed Charges,45% of Total Billed Charges,37590.75,90,,646.16,Percent of Total Billed Charges,90% of Total billed Charges,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27148.88,65,,22.36,Percent of total Billed Charges,65% of Total Billed Charges,18419.47,44.1,,12.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,39679.13,95,,682.056,Percent of Total Billed Charges,95% of Total Billed Charges,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36755.4,88,,24.84,Percent of Total Billed Charges,88% of Total Billed Charges,37590.75,90,,646.16,Percent of Total Billed charges,90% of Total Billed Charges,18419.47,41767.5,
IVL Peripheral BTK PTA,4810000209,CDM,481,RC,,,Outpatient,,,26205.00,17033.25,,26205,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19915.8,76,,28.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18867.6,72,,15094.08,Percent of Total Billed Charges,72% of Total Billed Charges,19653.75,75,,15723,Percent of Total Billed charges,75% of Total Billed Charges,26205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18867.6,72,,15094.08,Percent of Total Billed Charges,72% of Total Billed Charges,15723,60,,12578.4,Percent of Total Billed Charges,60% of Total Billed Charges,23584.5,90,,31.752,Percent of Total Billed Charges,90% of Total Billed Charges,11792.25,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,23584.5,90,,34.136,Percent of Total Billed Charges,90% of Total billed Charges,26205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17033.25,65,,31.464,Percent of total Billed Charges,65% of Total Billed Charges,11556.41,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,24894.75,95,,36.032,Percent of Total Billed Charges,95% of Total Billed Charges,26205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23060.4,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,23584.5,90,,34.136,Percent of Total Billed charges,90% of Total Billed Charges,11556.41,26205,
IVL Peripheral BTK PTA/Stent,4810000210,CDM,481,RC,,,Outpatient,,,41767.50,27148.88,,41767.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31743.3,76,,15.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30072.6,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,31325.63,75,,25060.504,Percent of Total Billed charges,75% of Total Billed Charges,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30072.6,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,25060.5,60,,20048.4,Percent of Total Billed Charges,60% of Total Billed Charges,37590.75,90,,17.464,Percent of Total Billed Charges,90% of Total Billed Charges,18795.38,45,,16.272,Percent of Total Billed Charges,45% of Total Billed Charges,37590.75,90,,18.256,Percent of Total Billed Charges,90% of Total billed Charges,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27148.88,65,,24.44,Percent of total Billed Charges,65% of Total Billed Charges,18419.47,44.1,,15.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,39679.13,95,,19.272,Percent of Total Billed Charges,95% of Total Billed Charges,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36755.4,88,,31.824,Percent of Total Billed Charges,88% of Total Billed Charges,37590.75,90,,18.256,Percent of Total Billed charges,90% of Total Billed Charges,18419.47,41767.5,
IVL Periph BTK PTA/Atherectomy,4810000211,CDM,481,RC,,,Outpatient,,,41767.50,27148.88,,41767.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31743.3,76,,8.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30072.6,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,31325.63,75,,25060.504,Percent of Total Billed charges,75% of Total Billed Charges,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30072.6,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,25060.5,60,,20048.4,Percent of Total Billed Charges,60% of Total Billed Charges,37590.75,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,18795.38,45,,13.952,Percent of Total Billed Charges,45% of Total Billed Charges,37590.75,90,,10.32,Percent of Total Billed Charges,90% of Total billed Charges,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27148.88,65,,54.464,Percent of total Billed Charges,65% of Total Billed Charges,18419.47,44.1,,13.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,39679.13,95,,10.888,Percent of Total Billed Charges,95% of Total Billed Charges,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36755.4,88,,27.28,Percent of Total Billed Charges,88% of Total Billed Charges,37590.75,90,,10.32,Percent of Total Billed charges,90% of Total Billed Charges,18419.47,41767.5,
IVL Peri BTK PTA/Stent/Atherec,4810000212,CDM,481,RC,,,Outpatient,,,41767.50,27148.88,,41767.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31743.3,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30072.6,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,31325.63,75,,25060.504,Percent of Total Billed charges,75% of Total Billed Charges,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30072.6,72,,24058.08,Percent of Total Billed Charges,72% of Total Billed Charges,25060.5,60,,20048.4,Percent of Total Billed Charges,60% of Total Billed Charges,37590.75,90,,115.896,Percent of Total Billed Charges,90% of Total Billed Charges,18795.38,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,37590.75,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27148.88,65,,36.12,Percent of total Billed Charges,65% of Total Billed Charges,18419.47,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,39679.13,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,41767.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36755.4,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,37590.75,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,18419.47,41767.5,
EXERCISE STRESS TEST,4820000001,CDM,482,RC,,,Outpatient,,,1064.00,691.60,,1064,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,808.64,76,,21.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,766.08,72,,612.864,Percent of Total Billed Charges,72% of Total Billed Charges,798,75,,638.4,Percent of Total Billed charges,75% of Total Billed Charges,1064,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,766.08,72,,612.864,Percent of Total Billed Charges,72% of Total Billed Charges,638.4,60,,510.72,Percent of Total Billed Charges,60% of Total Billed Charges,957.6,90,,113.512,Percent of Total Billed Charges,90% of Total Billed Charges,478.8,45,,24.608,Percent of Total Billed Charges,45% of Total Billed Charges,957.6,90,,25.4,Percent of Total Billed Charges,90% of Total billed Charges,1064,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1064,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1064,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,691.6,65,,6.304,Percent of total Billed Charges,65% of Total Billed Charges,469.22,44.1,,24.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,1010.8,95,,26.816,Percent of Total Billed Charges,95% of Total Billed Charges,1064,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,936.32,88,,48.128,Percent of Total Billed Charges,88% of Total Billed Charges,957.6,90,,25.4,Percent of Total Billed charges,90% of Total Billed Charges,469.22,1064,
US  ECHO CONGENITAL,4830000001,CDM,483,RC,,,Outpatient,,,1367.10,888.62,,1367.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1039,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,984.31,72,,787.448,Percent of Total Billed Charges,72% of Total Billed Charges,1025.33,75,,820.264,Percent of Total Billed charges,75% of Total Billed Charges,1367.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,984.31,72,,787.448,Percent of Total Billed Charges,72% of Total Billed Charges,820.26,60,,656.208,Percent of Total Billed Charges,60% of Total Billed Charges,1230.39,90,,122.248,Percent of Total Billed Charges,90% of Total Billed Charges,615.2,45,,15.88,Percent of Total Billed Charges,45% of Total Billed Charges,1230.39,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,1367.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1367.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1367.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,888.62,65,,81.984,Percent of total Billed Charges,65% of Total Billed Charges,602.89,44.1,,15.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,1298.75,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,1367.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1203.05,88,,31.048,Percent of Total Billed Charges,88% of Total Billed Charges,1230.39,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,602.89,1367.1,
2D TTE w or w/o Complete,4830000002,CDM,483,RC,,,Outpatient,,,1726.40,1122.16,,1726.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1312.06,76,,27.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1243.01,72,,994.408,Percent of Total Billed Charges,72% of Total Billed Charges,1294.8,75,,1035.84,Percent of Total Billed charges,75% of Total Billed Charges,1726.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1243.01,72,,994.408,Percent of Total Billed Charges,72% of Total Billed Charges,1035.84,60,,828.672,Percent of Total Billed Charges,60% of Total Billed Charges,1553.76,90,,84.144,Percent of Total Billed Charges,90% of Total Billed Charges,776.88,45,,8.736,Percent of Total Billed Charges,45% of Total Billed Charges,1553.76,90,,32.544,Percent of Total Billed Charges,90% of Total billed Charges,1726.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1726.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1726.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1122.16,65,,31.536,Percent of total Billed Charges,65% of Total Billed Charges,761.34,44.1,,8.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,1640.08,95,,34.352,Percent of Total Billed Charges,95% of Total Billed Charges,1726.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1519.23,88,,17.08,Percent of Total Billed Charges,88% of Total Billed Charges,1553.76,90,,32.544,Percent of Total Billed charges,90% of Total Billed Charges,761.34,1726.4,
2D TTE W OR W/O Limited study,4830000003,CDM,483,RC,,,Outpatient,,,888.60,577.59,,888.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,675.34,76,,23.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,639.79,72,,511.832,Percent of Total Billed Charges,72% of Total Billed Charges,666.45,75,,533.16,Percent of Total Billed charges,75% of Total Billed Charges,888.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,639.79,72,,511.832,Percent of Total Billed Charges,72% of Total Billed Charges,533.16,60,,426.528,Percent of Total Billed Charges,60% of Total Billed Charges,799.74,90,,218.296,Percent of Total Billed Charges,90% of Total Billed Charges,399.87,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,799.74,90,,27.904,Percent of Total Billed Charges,90% of Total billed Charges,888.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,888.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,888.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.59,65,,107.208,Percent of total Billed Charges,65% of Total Billed Charges,391.87,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,844.17,95,,29.448,Percent of Total Billed Charges,95% of Total Billed Charges,888.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,781.97,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,799.74,90,,27.904,Percent of Total Billed charges,90% of Total Billed Charges,391.87,888.6,
TRANSCATH ARTER HROMB INIT,4900000001,CDM,490,RC,,,Outpatient,,,2088.14,1357.29,,2088.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1586.99,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1503.46,72,,1202.768,Percent of Total Billed Charges,72% of Total Billed Charges,1566.11,75,,1252.888,Percent of Total Billed charges,75% of Total Billed Charges,2088.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1503.46,72,,1202.768,Percent of Total Billed Charges,72% of Total Billed Charges,1252.88,60,,1002.304,Percent of Total Billed Charges,60% of Total Billed Charges,1879.33,90,,13.496,Percent of Total Billed Charges,90% of Total Billed Charges,939.66,45,,57.952,Percent of Total Billed Charges,45% of Total Billed Charges,1879.33,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,2088.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2088.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2088.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1357.29,65,,12.04,Percent of total Billed Charges,65% of Total Billed Charges,920.87,44.1,,56.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,1983.73,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,2088.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1837.56,88,,113.32,Percent of Total Billed Charges,88% of Total Billed Charges,1879.33,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,920.87,2088.14,
TRANSCATH VENOUS THROMB INIT,4900000002,CDM,490,RC,,,Outpatient,,,2088.14,1357.29,,2088.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1586.99,76,,41.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1503.46,72,,1202.768,Percent of Total Billed Charges,72% of Total Billed Charges,1566.11,75,,1252.888,Percent of Total Billed charges,75% of Total Billed Charges,2088.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1503.46,72,,1202.768,Percent of Total Billed Charges,72% of Total Billed Charges,1252.88,60,,1002.304,Percent of Total Billed Charges,60% of Total Billed Charges,1879.33,90,,18.256,Percent of Total Billed Charges,90% of Total Billed Charges,939.66,45,,56.76,Percent of Total Billed Charges,45% of Total Billed Charges,1879.33,90,,49.216,Percent of Total Billed Charges,90% of Total billed Charges,2088.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2088.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2088.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1357.29,65,,130.032,Percent of total Billed Charges,65% of Total Billed Charges,920.87,44.1,,55.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,1983.73,95,,51.952,Percent of Total Billed Charges,95% of Total Billed Charges,2088.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1837.56,88,,110.992,Percent of Total Billed Charges,88% of Total Billed Charges,1879.33,90,,49.216,Percent of Total Billed charges,90% of Total Billed Charges,920.87,2088.14,
TELEHEALTH FACILITY,5100000001,CDM,510,RC,Q3014,HCPCS,Outpatient,,,97.02,63.06,,97.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73.74,76,,26.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,455.74,350,,,Fee Schedule,350% of BCBS fee schedule,455.74,350,,,Fee Schedule,350% of BCBS fee schedule,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,455.74,286,,,Fee Schedule,286% of BCBS PPO fee schedule,159.35,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,87.32,90,,63.904,Percent of Total Billed Charges,90% of Total Billed Charges,97.02,100,,61.128,Case Rate,Pays based on per visit rate,87.32,90,,31.752,Percent of Total Billed Charges,90% of Total billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.06,65,,342.728,Percent of total Billed Charges,65% of Total Billed Charges,97.02,100,,59.904,Fee Schedule,Pays based on per visit rate,92.17,95,,33.52,Percent of Total Billed Charges,95% of Total Billed Charges,97.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.38,88,,119.536,Percent of Total Billed Charges,88% of Total Billed Charges,87.32,90,,31.752,Percent of Total Billed charges,90% of Total Billed Charges,63.06,455.74,
SOC WKR FU 15 MINS,5610000001,CDM,561,RC,G0155,HCPCS,Outpatient,,,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,14.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.12,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,11.58,75,,9.264,Percent of Total Billed charges,75% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,72,,8.896,Percent of Total Billed Charges,72% of Total Billed Charges,9.26,60,,7.408,Percent of Total Billed Charges,60% of Total Billed Charges,13.9,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,42.072,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,17.464,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,67.072,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,41.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,18.44,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,82.28,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,17.464,Percent of Total Billed charges,90% of Total Billed Charges,6.81,15.44,
HOME HLTH AID 15 MIN,5710000001,CDM,571,RC,G0156,HCPCS,Outpatient,,,30.87,20.07,,30.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.46,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.23,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,23.15,75,,18.52,Percent of Total Billed charges,75% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.23,72,,17.784,Percent of Total Billed Charges,72% of Total Billed Charges,18.52,60,,14.816,Percent of Total Billed Charges,60% of Total Billed Charges,27.78,90,,1385.976,Percent of Total Billed Charges,90% of Total Billed Charges,13.89,45,,109.152,Percent of Total Billed Charges,45% of Total Billed Charges,27.78,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.07,65,,34.968,Percent of total Billed Charges,65% of Total Billed Charges,13.61,44.1,,106.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,29.33,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,30.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.17,88,,213.448,Percent of Total Billed Charges,88% of Total Billed Charges,27.78,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,13.61,30.87,
MRI PERCU DRNGE RETROPERITIONA,6100000001,CDM,610,RC,,,Outpatient,,,4473.95,2908.07,,4473.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3400.2,76,,97.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3221.24,72,,2576.992,Percent of Total Billed Charges,72% of Total Billed Charges,3355.46,75,,2684.368,Percent of Total Billed charges,75% of Total Billed Charges,4473.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3221.24,72,,2576.992,Percent of Total Billed Charges,72% of Total Billed Charges,2684.37,60,,2147.496,Percent of Total Billed Charges,60% of Total Billed Charges,4026.56,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,2013.28,45,,6.744,Percent of Total Billed Charges,45% of Total Billed Charges,4026.56,90,,115.896,Percent of Total Billed Charges,90% of Total billed Charges,4473.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4473.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4473.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2908.07,65,,6.24,Percent of total Billed Charges,65% of Total Billed Charges,1973.01,44.1,,6.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,4250.25,95,,122.336,Percent of Total Billed Charges,95% of Total Billed Charges,4473.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3937.08,88,,13.192,Percent of Total Billed Charges,88% of Total Billed Charges,4026.56,90,,115.896,Percent of Total Billed charges,90% of Total Billed Charges,1973.01,4473.95,
MRI TMJ,6100000002,CDM,610,RC,,,Outpatient,,,1361.00,884.65,,1361,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1034.36,76,,95.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,979.92,72,,783.936,Percent of Total Billed Charges,72% of Total Billed Charges,1020.75,75,,816.6,Percent of Total Billed charges,75% of Total Billed Charges,1361,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,979.92,72,,783.936,Percent of Total Billed Charges,72% of Total Billed Charges,816.6,60,,653.28,Percent of Total Billed Charges,60% of Total Billed Charges,1224.9,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,612.45,45,,9.128,Percent of Total Billed Charges,45% of Total Billed Charges,1224.9,90,,113.512,Percent of Total Billed Charges,90% of Total billed Charges,1361,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1361,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1361,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,884.65,65,,6.24,Percent of total Billed Charges,65% of Total Billed Charges,600.2,44.1,,8.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,1292.95,95,,119.824,Percent of Total Billed Charges,95% of Total Billed Charges,1361,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1197.68,88,,17.856,Percent of Total Billed Charges,88% of Total Billed Charges,1224.9,90,,113.512,Percent of Total Billed charges,90% of Total Billed Charges,600.2,1361,
MRI ORBIT FACE NK WO,6100000003,CDM,610,RC,,,Outpatient,,,3450.00,2242.50,,3450,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2622,76,,103.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2484,72,,1987.2,Percent of Total Billed Charges,72% of Total Billed Charges,2587.5,75,,2070,Percent of Total Billed charges,75% of Total Billed Charges,3450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2484,72,,1987.2,Percent of Total Billed Charges,72% of Total Billed Charges,2070,60,,1656,Percent of Total Billed Charges,60% of Total Billed Charges,3105,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,1552.5,45,,31.952,Percent of Total Billed Charges,45% of Total Billed Charges,3105,90,,122.248,Percent of Total Billed Charges,90% of Total billed Charges,3450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2242.5,65,,22.936,Percent of total Billed Charges,65% of Total Billed Charges,1521.45,44.1,,31.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,3277.5,95,,129.04,Percent of Total Billed Charges,95% of Total Billed Charges,3450,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3036,88,,62.48,Percent of Total Billed Charges,88% of Total Billed Charges,3105,90,,122.248,Percent of Total Billed charges,90% of Total Billed Charges,1521.45,3450,
MRI ORBT FACE NECK W,6100000004,CDM,610,RC,,,Outpatient,,,3888.00,2527.20,,3888,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2954.88,76,,71.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2799.36,72,,2239.488,Percent of Total Billed Charges,72% of Total Billed Charges,2916,75,,2332.8,Percent of Total Billed charges,75% of Total Billed Charges,3888,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2799.36,72,,2239.488,Percent of Total Billed Charges,72% of Total Billed Charges,2332.8,60,,1866.24,Percent of Total Billed Charges,60% of Total Billed Charges,3499.2,90,,75.6,Percent of Total Billed Charges,90% of Total Billed Charges,1749.6,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,3499.2,90,,84.144,Percent of Total Billed Charges,90% of Total billed Charges,3888,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3888,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3888,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2527.2,65,,930.096,Percent of total Billed Charges,65% of Total Billed Charges,1714.61,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,3693.6,95,,88.824,Percent of Total Billed Charges,95% of Total Billed Charges,3888,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3421.44,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,3499.2,90,,84.144,Percent of Total Billed charges,90% of Total Billed Charges,1714.61,3888,
MRI ORBT FAC NK W/W0,6100000005,CDM,610,RC,,,Outpatient,,,5445.00,3539.25,,5445,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4138.2,76,,184.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3920.4,72,,3136.32,Percent of Total Billed Charges,72% of Total Billed Charges,4083.75,75,,3267,Percent of Total Billed charges,75% of Total Billed Charges,5445,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3920.4,72,,3136.32,Percent of Total Billed Charges,72% of Total Billed Charges,3267,60,,2613.6,Percent of Total Billed Charges,60% of Total Billed Charges,4900.5,90,,24.608,Percent of Total Billed Charges,90% of Total Billed Charges,2450.25,45,,692.992,Percent of Total Billed Charges,45% of Total Billed Charges,4900.5,90,,218.296,Percent of Total Billed Charges,90% of Total billed Charges,5445,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5445,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5445,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3539.25,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,2401.25,44.1,,679.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,5172.75,95,,230.424,Percent of Total Billed Charges,95% of Total Billed Charges,5445,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4791.6,88,,1355.176,Percent of Total Billed Charges,88% of Total Billed Charges,4900.5,90,,218.296,Percent of Total Billed charges,90% of Total Billed Charges,2401.25,5445,
MRI CHEST WO/ CONT,6100000006,CDM,610,RC,,,Outpatient,,,5040.63,3276.41,,5040.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3830.88,76,,11.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3629.25,72,,2903.4,Percent of Total Billed Charges,72% of Total Billed Charges,3780.47,75,,3024.376,Percent of Total Billed charges,75% of Total Billed Charges,5040.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3629.25,72,,2903.4,Percent of Total Billed Charges,72% of Total Billed Charges,3024.38,60,,2419.504,Percent of Total Billed Charges,60% of Total Billed Charges,4536.57,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,2268.28,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,4536.57,90,,13.496,Percent of Total Billed Charges,90% of Total billed Charges,5040.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5040.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5040.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3276.41,65,,10.896,Percent of total Billed Charges,65% of Total Billed Charges,2222.92,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,4788.6,95,,14.24,Percent of Total Billed Charges,95% of Total Billed Charges,5040.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4435.75,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,4536.57,90,,13.496,Percent of Total Billed charges,90% of Total Billed Charges,2222.92,5040.63,
MRI CHEST W/ CONT,6100000007,CDM,610,RC,,,Outpatient,,,5598.50,3639.03,,5598.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4254.86,76,,15.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4030.92,72,,3224.736,Percent of Total Billed Charges,72% of Total Billed Charges,4198.88,75,,3359.104,Percent of Total Billed charges,75% of Total Billed Charges,5598.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4030.92,72,,3224.736,Percent of Total Billed Charges,72% of Total Billed Charges,3359.1,60,,2687.28,Percent of Total Billed Charges,60% of Total Billed Charges,5038.65,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,2519.33,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,5038.65,90,,18.256,Percent of Total Billed Charges,90% of Total billed Charges,5598.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5598.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5598.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3639.03,65,,624.896,Percent of total Billed Charges,65% of Total Billed Charges,2468.94,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,5318.58,95,,19.272,Percent of Total Billed Charges,95% of Total Billed Charges,5598.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4926.68,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,5038.65,90,,18.256,Percent of Total Billed charges,90% of Total Billed Charges,2468.94,5598.5,
MRI CHEST W/WO,6100000008,CDM,610,RC,,,Outpatient,,,6142.00,3992.30,,6142,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4667.92,76,,53.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4422.24,72,,3537.792,Percent of Total Billed Charges,72% of Total Billed Charges,4606.5,75,,3685.2,Percent of Total Billed charges,75% of Total Billed Charges,6142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4422.24,72,,3537.792,Percent of Total Billed Charges,72% of Total Billed Charges,3685.2,60,,2948.16,Percent of Total Billed Charges,60% of Total Billed Charges,5527.8,90,,25.4,Percent of Total Billed Charges,90% of Total Billed Charges,2763.9,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,5527.8,90,,63.904,Percent of Total Billed Charges,90% of Total billed Charges,6142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3992.3,65,,61.36,Percent of total Billed Charges,65% of Total Billed Charges,2708.62,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,5834.9,95,,67.448,Percent of Total Billed Charges,95% of Total Billed Charges,6142,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5404.96,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,5527.8,90,,63.904,Percent of Total Billed charges,90% of Total Billed Charges,2708.62,6142,
MRI PELVIS WO/CONT,6100000009,CDM,610,RC,,,Outpatient,,,3573.00,2322.45,,3573,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2715.48,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2572.56,72,,2058.048,Percent of Total Billed Charges,72% of Total Billed Charges,2679.75,75,,2143.8,Percent of Total Billed charges,75% of Total Billed Charges,3573,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2572.56,72,,2058.048,Percent of Total Billed Charges,72% of Total Billed Charges,2143.8,60,,1715.04,Percent of Total Billed Charges,60% of Total Billed Charges,3215.7,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,1607.85,45,,37.8,Percent of Total Billed Charges,45% of Total Billed Charges,3215.7,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,3573,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3573,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3573,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2322.45,65,,38.872,Percent of total Billed Charges,65% of Total Billed Charges,1575.69,44.1,,37.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,3394.35,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,3573,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3144.24,88,,73.92,Percent of Total Billed Charges,88% of Total Billed Charges,3215.7,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,1575.69,3573,
MRI PELVIS W/CONT,6100000010,CDM,610,RC,,,Outpatient,,,4101.30,2665.85,,4101.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3116.99,76,,1170.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2952.94,72,,2362.352,Percent of Total Billed Charges,72% of Total Billed Charges,3075.98,75,,2460.784,Percent of Total Billed charges,75% of Total Billed Charges,4101.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2952.94,72,,2362.352,Percent of Total Billed Charges,72% of Total Billed Charges,2460.78,60,,1968.624,Percent of Total Billed Charges,60% of Total Billed Charges,3691.17,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,1845.59,45,,12.304,Percent of Total Billed Charges,45% of Total Billed Charges,3691.17,90,,1385.976,Percent of Total Billed Charges,90% of Total billed Charges,4101.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4101.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4101.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2665.85,65,,32.104,Percent of total Billed Charges,65% of Total Billed Charges,1808.67,44.1,,12.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,3896.24,95,,1462.976,Percent of Total Billed Charges,95% of Total Billed Charges,4101.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3609.14,88,,24.064,Percent of Total Billed Charges,88% of Total Billed Charges,3691.17,90,,1385.976,Percent of Total Billed charges,90% of Total Billed Charges,1808.67,4101.3,
MRI PELVIS W/WO CONT,6100000011,CDM,610,RC,,,Outpatient,,,6018.00,3911.70,,6018,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4573.68,76,,10.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4332.96,72,,3466.368,Percent of Total Billed Charges,72% of Total Billed Charges,4513.5,75,,3610.8,Percent of Total Billed charges,75% of Total Billed Charges,6018,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4332.96,72,,3466.368,Percent of Total Billed Charges,72% of Total Billed Charges,3610.8,60,,2888.64,Percent of Total Billed Charges,60% of Total Billed Charges,5416.2,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,2708.1,45,,20.52,Percent of Total Billed Charges,45% of Total Billed Charges,5416.2,90,,11.912,Percent of Total Billed Charges,90% of Total billed Charges,6018,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6018,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6018,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3911.7,65,,49.304,Percent of total Billed Charges,65% of Total Billed Charges,2653.94,44.1,,20.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,5717.1,95,,12.568,Percent of Total Billed Charges,95% of Total Billed Charges,6018,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5295.84,88,,40.128,Percent of Total Billed Charges,88% of Total Billed Charges,5416.2,90,,11.912,Percent of Total Billed charges,90% of Total Billed Charges,2653.94,6018,
MRI ABD WO/ CONT,6100000012,CDM,610,RC,,,Outpatient,,,5263.34,3421.17,,5263.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4000.14,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3789.6,72,,3031.68,Percent of Total Billed Charges,72% of Total Billed Charges,3947.51,75,,3158.008,Percent of Total Billed charges,75% of Total Billed Charges,5263.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3789.6,72,,3031.68,Percent of Total Billed Charges,72% of Total Billed Charges,3158,60,,2526.4,Percent of Total Billed Charges,60% of Total Billed Charges,4737.01,90,,131.776,Percent of Total Billed Charges,90% of Total Billed Charges,2368.5,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,4737.01,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,5263.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5263.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5263.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3421.17,65,,19.888,Percent of total Billed Charges,65% of Total Billed Charges,2321.13,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,5000.17,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,5263.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4631.74,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,4737.01,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,2321.13,5263.34,
MRCP MRI ABD WO/ CONT,6100000013,CDM,610,RC,,,Outpatient,,,5514.00,3584.10,,5514,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4190.64,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3970.08,72,,3176.064,Percent of Total Billed Charges,72% of Total Billed Charges,4135.5,75,,3308.4,Percent of Total Billed charges,75% of Total Billed Charges,5514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3970.08,72,,3176.064,Percent of Total Billed Charges,72% of Total Billed Charges,3308.4,60,,2646.72,Percent of Total Billed Charges,60% of Total Billed Charges,4962.6,90,,45.248,Percent of Total Billed Charges,90% of Total Billed Charges,2481.3,45,,12.704,Percent of Total Billed Charges,45% of Total Billed Charges,4962.6,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,5514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3584.1,65,,215.56,Percent of total Billed Charges,65% of Total Billed Charges,2431.67,44.1,,12.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,5238.3,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,5514,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4852.32,88,,24.84,Percent of Total Billed Charges,88% of Total Billed Charges,4962.6,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,2431.67,5514,
MRI ABD W/ CONT,6100000014,CDM,610,RC,,,Outpatient,,,5598.50,3639.03,,5598.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4254.86,76,,63.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4030.92,72,,3224.736,Percent of Total Billed Charges,72% of Total Billed Charges,4198.88,75,,3359.104,Percent of Total Billed charges,75% of Total Billed Charges,5598.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4030.92,72,,3224.736,Percent of Total Billed Charges,72% of Total Billed Charges,3359.1,60,,2687.28,Percent of Total Billed Charges,60% of Total Billed Charges,5038.65,90,,93.672,Percent of Total Billed Charges,90% of Total Billed Charges,2519.33,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,5038.65,90,,75.6,Percent of Total Billed Charges,90% of Total billed Charges,5598.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5598.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5598.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3639.03,65,,31.536,Percent of total Billed Charges,65% of Total Billed Charges,2468.94,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,5318.58,95,,79.8,Percent of Total Billed Charges,95% of Total Billed Charges,5598.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4926.68,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,5038.65,90,,75.6,Percent of Total Billed charges,90% of Total Billed Charges,2468.94,5598.5,
MRI CORNL SAGAL MULT,6100000015,CDM,610,RC,,,Outpatient,,,428.87,278.77,,428.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,325.94,76,,20.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,308.79,72,,247.032,Percent of Total Billed Charges,72% of Total Billed Charges,321.65,75,,257.32,Percent of Total Billed charges,75% of Total Billed Charges,428.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.79,72,,247.032,Percent of Total Billed Charges,72% of Total Billed Charges,257.32,60,,205.856,Percent of Total Billed Charges,60% of Total Billed Charges,385.98,90,,47.632,Percent of Total Billed Charges,90% of Total Billed Charges,192.99,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,385.98,90,,24.608,Percent of Total Billed Charges,90% of Total billed Charges,428.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,428.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,428.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.77,65,,90.584,Percent of total Billed Charges,65% of Total Billed Charges,189.13,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,407.43,95,,25.976,Percent of Total Billed Charges,95% of Total Billed Charges,428.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.41,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,385.98,90,,24.608,Percent of Total Billed charges,90% of Total Billed Charges,189.13,428.87,
MRI EXT UP O/T JT WO,6100000016,CDM,610,RC,,,Outpatient,,,3629.00,2358.85,,3629,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2758.04,76,,34.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2612.88,72,,2090.304,Percent of Total Billed Charges,72% of Total Billed Charges,2721.75,75,,2177.4,Percent of Total Billed charges,75% of Total Billed Charges,3629,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.88,72,,2090.304,Percent of Total Billed Charges,72% of Total Billed Charges,2177.4,60,,1741.92,Percent of Total Billed Charges,60% of Total Billed Charges,3266.1,90,,190.616,Percent of Total Billed Charges,90% of Total Billed Charges,1633.05,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,3266.1,90,,41.04,Percent of Total Billed Charges,90% of Total billed Charges,3629,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3629,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3629,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2358.85,65,,10.176,Percent of total Billed Charges,65% of Total Billed Charges,1600.39,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,3447.55,95,,43.32,Percent of Total Billed Charges,95% of Total Billed Charges,3629,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3193.52,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,3266.1,90,,41.04,Percent of Total Billed charges,90% of Total Billed Charges,1600.39,3629,
MRI EXT UP OT JT W/C,6100000017,CDM,610,RC,,,Outpatient,,,3112.36,2023.03,,3112.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2365.39,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,2334.27,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,1867.42,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,2801.12,90,,68.272,Percent of Total Billed Charges,90% of Total Billed Charges,1400.56,45,,65.888,Percent of Total Billed Charges,45% of Total Billed Charges,2801.12,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2023.03,65,,21.96,Percent of total Billed Charges,65% of Total Billed Charges,1372.55,44.1,,64.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,2956.74,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2738.88,88,,128.848,Percent of Total Billed Charges,88% of Total Billed Charges,2801.12,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,1372.55,3112.36,
MRI EX UP OT JT W/WO,6100000018,CDM,610,RC,,,Outpatient,,,4670.00,3035.50,,4670,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3549.2,76,,21.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3362.4,72,,2689.92,Percent of Total Billed Charges,72% of Total Billed Charges,3502.5,75,,2802,Percent of Total Billed charges,75% of Total Billed Charges,4670,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3362.4,72,,2689.92,Percent of Total Billed Charges,72% of Total Billed Charges,2802,60,,2241.6,Percent of Total Billed Charges,60% of Total Billed Charges,4203,90,,128.6,Percent of Total Billed Charges,90% of Total Billed Charges,2101.5,45,,22.624,Percent of Total Billed Charges,45% of Total Billed Charges,4203,90,,25.4,Percent of Total Billed Charges,90% of Total billed Charges,4670,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4670,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4670,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3035.5,65,,52.6,Percent of total Billed Charges,65% of Total Billed Charges,2059.47,44.1,,22.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,4436.5,95,,26.816,Percent of Total Billed Charges,95% of Total Billed Charges,4670,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4109.6,88,,44.24,Percent of Total Billed Charges,88% of Total Billed Charges,4203,90,,25.4,Percent of Total Billed charges,90% of Total Billed Charges,2059.47,4670,
MRI Uppr Extrmty w/o contrast,6100000019,CDM,610,RC,,,Outpatient,,,3389.00,2202.85,,3389,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2575.64,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2440.08,72,,1952.064,Percent of Total Billed Charges,72% of Total Billed Charges,2541.75,75,,2033.4,Percent of Total Billed charges,75% of Total Billed Charges,3389,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2440.08,72,,1952.064,Percent of Total Billed Charges,72% of Total Billed Charges,2033.4,60,,1626.72,Percent of Total Billed Charges,60% of Total Billed Charges,3050.1,90,,758.08,Percent of Total Billed Charges,90% of Total Billed Charges,1525.05,45,,46.84,Percent of Total Billed Charges,45% of Total Billed Charges,3050.1,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,3389,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3389,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3389,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2202.85,65,,16.968,Percent of total Billed Charges,65% of Total Billed Charges,1494.55,44.1,,45.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,3219.55,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,3389,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2982.32,88,,91.592,Percent of Total Billed Charges,88% of Total Billed Charges,3050.1,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,1494.55,3389,
MRI EX UP NE JT W/CO,6100000020,CDM,610,RC,,,Outpatient,,,3845.52,2499.59,,3845.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2922.6,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2768.77,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,2884.14,75,,2307.312,Percent of Total Billed charges,75% of Total Billed Charges,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2768.77,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,2307.31,60,,1845.848,Percent of Total Billed Charges,60% of Total Billed Charges,3460.97,90,,8030.08,Percent of Total Billed Charges,90% of Total Billed Charges,1730.48,45,,23.816,Percent of Total Billed Charges,45% of Total Billed Charges,3460.97,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2499.59,65,,14088.456,Percent of total Billed Charges,65% of Total Billed Charges,1695.87,44.1,,23.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,3653.24,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3384.06,88,,46.568,Percent of Total Billed Charges,88% of Total Billed Charges,3460.97,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,1695.87,3845.52,
MRI EX UP NE JT W/WO,6100000021,CDM,610,RC,,,Outpatient,,,4108.00,2670.20,,4108,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3122.08,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2957.76,72,,2366.208,Percent of Total Billed Charges,72% of Total Billed Charges,3081,75,,2464.8,Percent of Total Billed charges,75% of Total Billed Charges,4108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2957.76,72,,2366.208,Percent of Total Billed Charges,72% of Total Billed Charges,2464.8,60,,1971.84,Percent of Total Billed Charges,60% of Total Billed Charges,3697.2,90,,64.4,Percent of Total Billed Charges,90% of Total Billed Charges,1848.6,45,,95.304,Percent of Total Billed Charges,45% of Total Billed Charges,3697.2,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,4108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2670.2,65,,441.616,Percent of total Billed Charges,65% of Total Billed Charges,1811.63,44.1,,93.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,3902.6,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,4108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3615.04,88,,186.376,Percent of Total Billed Charges,88% of Total Billed Charges,3697.2,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,1811.63,4108,
MRI EXT LR O/T JT WO,6100000022,CDM,610,RC,,,Outpatient,,,3563.00,2315.95,,3563,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2707.88,76,,111.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2565.36,72,,2052.288,Percent of Total Billed Charges,72% of Total Billed Charges,2672.25,75,,2137.8,Percent of Total Billed charges,75% of Total Billed Charges,3563,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2565.36,72,,2052.288,Percent of Total Billed Charges,72% of Total Billed Charges,2137.8,60,,1710.24,Percent of Total Billed Charges,60% of Total Billed Charges,3206.7,90,,31.752,Percent of Total Billed Charges,90% of Total Billed Charges,1603.35,45,,34.136,Percent of Total Billed Charges,45% of Total Billed Charges,3206.7,90,,131.776,Percent of Total Billed Charges,90% of Total billed Charges,3563,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3563,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3563,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2315.95,65,,7117.128,Percent of total Billed Charges,65% of Total Billed Charges,1571.28,44.1,,33.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,3384.85,95,,139.096,Percent of Total Billed Charges,95% of Total Billed Charges,3563,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.44,88,,66.752,Percent of Total Billed Charges,88% of Total Billed Charges,3206.7,90,,131.776,Percent of Total Billed charges,90% of Total Billed Charges,1571.28,3563,
MRI EXT LR O/T JT W/,6100000023,CDM,610,RC,,,Outpatient,,,3112.36,2023.03,,3112.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2365.39,76,,38.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,2334.27,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,1867.42,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,2801.12,90,,51.592,Percent of Total Billed Charges,90% of Total Billed Charges,1400.56,45,,64.296,Percent of Total Billed Charges,45% of Total Billed Charges,2801.12,90,,45.248,Percent of Total Billed Charges,90% of Total billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2023.03,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,1372.55,44.1,,63.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,2956.74,95,,47.76,Percent of Total Billed Charges,95% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2738.88,88,,125.744,Percent of Total Billed Charges,88% of Total Billed Charges,2801.12,90,,45.248,Percent of Total Billed charges,90% of Total Billed Charges,1372.55,3112.36,
MRI LE NOT JT W/WO,6100000024,CDM,610,RC,,,Outpatient,,,4108.00,2670.20,,4108,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3122.08,76,,79.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2957.76,72,,2366.208,Percent of Total Billed Charges,72% of Total Billed Charges,3081,75,,2464.8,Percent of Total Billed charges,75% of Total Billed Charges,4108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2957.76,72,,2366.208,Percent of Total Billed Charges,72% of Total Billed Charges,2464.8,60,,1971.84,Percent of Total Billed Charges,60% of Total Billed Charges,3697.2,90,,131.44,Percent of Total Billed Charges,90% of Total Billed Charges,1848.6,45,,379.04,Percent of Total Billed Charges,45% of Total Billed Charges,3697.2,90,,93.672,Percent of Total Billed Charges,90% of Total billed Charges,4108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2670.2,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,1811.63,44.1,,371.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,3902.6,95,,98.88,Percent of Total Billed Charges,95% of Total Billed Charges,4108,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3615.04,88,,741.232,Percent of Total Billed Charges,88% of Total Billed Charges,3697.2,90,,93.672,Percent of Total Billed charges,90% of Total Billed Charges,1811.63,4108,
MRI EX LW JT WO CONT,6100000025,CDM,610,RC,,,Outpatient,,,3785.00,2460.25,,3785,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2876.6,76,,40.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2725.2,72,,2180.16,Percent of Total Billed Charges,72% of Total Billed Charges,2838.75,75,,2271,Percent of Total Billed charges,75% of Total Billed Charges,3785,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2725.2,72,,2180.16,Percent of Total Billed Charges,72% of Total Billed Charges,2271,60,,1816.8,Percent of Total Billed Charges,60% of Total Billed Charges,3406.5,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,1703.25,45,,4015.04,Percent of Total Billed Charges,45% of Total Billed Charges,3406.5,90,,47.632,Percent of Total Billed Charges,90% of Total billed Charges,3785,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3785,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3785,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2460.25,65,,9409.184,Percent of total Billed Charges,65% of Total Billed Charges,1669.19,44.1,,3934.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,3595.75,95,,50.272,Percent of Total Billed Charges,95% of Total Billed Charges,3785,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3330.8,88,,7851.632,Percent of Total Billed Charges,88% of Total Billed Charges,3406.5,90,,47.632,Percent of Total Billed charges,90% of Total Billed Charges,1669.19,3785,
MRI EXT LWR JNT W/CO,6100000026,CDM,610,RC,,,Outpatient,,,2957.00,1922.05,,2957,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2247.32,76,,160.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2129.04,72,,1703.232,Percent of Total Billed Charges,72% of Total Billed Charges,2217.75,75,,1774.2,Percent of Total Billed charges,75% of Total Billed Charges,2957,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2129.04,72,,1703.232,Percent of Total Billed Charges,72% of Total Billed Charges,1774.2,60,,1419.36,Percent of Total Billed Charges,60% of Total Billed Charges,2661.3,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,1330.65,45,,32.2,Percent of Total Billed Charges,45% of Total Billed Charges,2661.3,90,,190.616,Percent of Total Billed Charges,90% of Total billed Charges,2957,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2957,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2957,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1922.05,65,,51.6,Percent of total Billed Charges,65% of Total Billed Charges,1304.04,44.1,,31.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,2809.15,95,,201.2,Percent of Total Billed Charges,95% of Total Billed Charges,2957,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2602.16,88,,62.968,Percent of Total Billed Charges,88% of Total Billed Charges,2661.3,90,,190.616,Percent of Total Billed charges,90% of Total Billed Charges,1304.04,2957,
MRI EXT LWR JT W/WO,6100000027,CDM,610,RC,,,Outpatient,,,5558.00,3612.70,,5558,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4224.08,76,,57.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4001.76,72,,3201.408,Percent of Total Billed Charges,72% of Total Billed Charges,4168.5,75,,3334.8,Percent of Total Billed charges,75% of Total Billed Charges,5558,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4001.76,72,,3201.408,Percent of Total Billed Charges,72% of Total Billed Charges,3334.8,60,,2667.84,Percent of Total Billed Charges,60% of Total Billed Charges,5002.2,90,,164.32,Percent of Total Billed Charges,90% of Total Billed Charges,2501.1,45,,15.88,Percent of Total Billed Charges,45% of Total Billed Charges,5002.2,90,,68.272,Percent of Total Billed Charges,90% of Total billed Charges,5558,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5558,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5558,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3612.7,65,,1477.392,Percent of total Billed Charges,65% of Total Billed Charges,2451.08,44.1,,15.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,5280.1,95,,72.064,Percent of Total Billed Charges,95% of Total Billed Charges,5558,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4891.04,88,,31.048,Percent of Total Billed Charges,88% of Total Billed Charges,5002.2,90,,68.272,Percent of Total Billed charges,90% of Total Billed Charges,2451.08,5558,
MRA ABD W/ CONT (MC),6100000028,CDM,610,RC,C8900,HCPCS,Outpatient,,,5408.87,3515.77,,448.93,125,,,Fee Schedule,125% of CMS OPPS Rate,4110.74,76,,108.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1417.87,350,,,Fee Schedule,350% of BCBS fee schedule,1417.87,350,,,Fee Schedule,350% of BCBS fee schedule,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,1417.87,561,,,Fee Schedule,561% of BCBS PPO fee schedule,252.74,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,4867.98,90,,10.32,Percent of Total Billed Charges,90% of Total Billed Charges,2433.99,45,,25.8,Percent of Total Billed Charges,45% of Total Billed Charges,4867.98,90,,128.6,Percent of Total Billed Charges,90% of Total billed Charges,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,670.67,200,,10.896,Fee Schedule,200% of CMS OPPS Rate,2385.31,44.1,,25.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,5138.43,95,,135.744,Percent of Total Billed Charges,95% of Total Billed Charges,269.33,75,,,Fee Schedule,75% of CMS OPPS Rate,4759.81,88,,50.448,Percent of Total Billed Charges,88% of Total Billed Charges,4867.98,90,,128.6,Percent of Total Billed charges,90% of Total Billed Charges,252.74,5138.43,
MRA ABD W/O CONT (MC,6100000029,CDM,610,RC,C8901,HCPCS,Outpatient,,,7246.73,4710.37,,303.85,125,,,Fee Schedule,125% of CMS OPPS Rate,5507.51,76,,640.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1303.26,350,,,Fee Schedule,350% of BCBS fee schedule,1303.26,350,,,Fee Schedule,350% of BCBS fee schedule,243.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1303.26,561,,,Fee Schedule,561% of BCBS PPO fee schedule,232.31,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,6522.06,90,,3421.28,Percent of Total Billed Charges,90% of Total Billed Charges,3261.03,45,,65.72,Percent of Total Billed Charges,45% of Total Billed Charges,6522.06,90,,758.08,Percent of Total Billed Charges,90% of Total billed Charges,243.08,100,,,Fee Schedule,100% of CMS OPPS Rate,243.08,100,,,Fee Schedule,100% of CMS OPPS Rate,243.08,100,,,Fee Schedule,100% of CMS OPPS Rate,453.94,200,,18.92,Fee Schedule,200% of CMS OPPS Rate,3195.81,44.1,,64.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,6884.39,95,,800.2,Percent of Total Billed Charges,95% of Total Billed Charges,182.3,75,,,Fee Schedule,75% of CMS OPPS Rate,6377.12,88,,128.512,Percent of Total Billed Charges,88% of Total Billed Charges,6522.06,90,,758.08,Percent of Total Billed charges,90% of Total Billed Charges,182.3,6884.39,
MRA ABD W/WO CONT (M,6100000030,CDM,610,RC,C8902,HCPCS,Outpatient,,,7162.00,4655.30,,448.93,125,,,Fee Schedule,125% of CMS OPPS Rate,5443.12,76,,6780.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2560.24,350,,,Fee Schedule,350% of BCBS fee schedule,2560.24,350,,,Fee Schedule,350% of BCBS fee schedule,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,2560.24,561,,,Fee Schedule,561% of BCBS PPO fee schedule,456.37,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,6445.8,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,3222.9,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,6445.8,90,,8030.08,Percent of Total Billed Charges,90% of Total billed Charges,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,670.67,200,,25.224,Fee Schedule,200% of CMS OPPS Rate,3158.44,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,6803.9,95,,8476.2,Percent of Total Billed Charges,95% of Total Billed Charges,269.33,75,,,Fee Schedule,75% of CMS OPPS Rate,6302.56,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,6445.8,90,,8030.08,Percent of Total Billed charges,90% of Total Billed Charges,269.33,6803.9,
MRA CHEST W/ CONT (M,6100000031,CDM,610,RC,C8909,HCPCS,Outpatient,,,5408.87,3515.77,,448.93,125,,,Fee Schedule,125% of CMS OPPS Rate,4110.74,76,,54.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1417.87,350,,,Fee Schedule,350% of BCBS fee schedule,1417.87,350,,,Fee Schedule,350% of BCBS fee schedule,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,1417.87,561,,,Fee Schedule,561% of BCBS PPO fee schedule,252.74,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,4867.98,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,2433.99,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,4867.98,90,,64.4,Percent of Total Billed Charges,90% of Total billed Charges,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,670.67,200,,24.656,Fee Schedule,200% of CMS OPPS Rate,2385.31,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,5138.43,95,,67.976,Percent of Total Billed Charges,95% of Total Billed Charges,269.33,75,,,Fee Schedule,75% of CMS OPPS Rate,4759.81,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,4867.98,90,,64.4,Percent of Total Billed charges,90% of Total Billed Charges,252.74,5138.43,
MRA CHEST W/O CONT (,6100000032,CDM,610,RC,C8910,HCPCS,Outpatient,,,5357.05,3482.08,,303.85,125,,,Fee Schedule,125% of CMS OPPS Rate,4071.36,76,,26.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1303.26,350,,,Fee Schedule,350% of BCBS fee schedule,1303.26,350,,,Fee Schedule,350% of BCBS fee schedule,243.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1303.26,561,,,Fee Schedule,561% of BCBS PPO fee schedule,232.31,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,4821.35,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,2410.67,45,,82.16,Percent of Total Billed Charges,45% of Total Billed Charges,4821.35,90,,31.752,Percent of Total Billed Charges,90% of Total billed Charges,243.08,100,,,Fee Schedule,100% of CMS OPPS Rate,243.08,100,,,Fee Schedule,100% of CMS OPPS Rate,243.08,100,,,Fee Schedule,100% of CMS OPPS Rate,453.94,200,,68.512,Fee Schedule,200% of CMS OPPS Rate,2362.46,44.1,,80.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,5089.2,95,,33.52,Percent of Total Billed Charges,95% of Total Billed Charges,182.3,75,,,Fee Schedule,75% of CMS OPPS Rate,4714.2,88,,160.664,Percent of Total Billed Charges,88% of Total Billed Charges,4821.35,90,,31.752,Percent of Total Billed charges,90% of Total Billed Charges,182.3,5089.2,
MRA CHEST W/WO CONT,6100000033,CDM,610,RC,C8911,HCPCS,Outpatient,,,5572.04,3621.83,,448.93,125,,,Fee Schedule,125% of CMS OPPS Rate,4234.75,76,,43.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2560.24,350,,,Fee Schedule,350% of BCBS fee schedule,2560.24,350,,,Fee Schedule,350% of BCBS fee schedule,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,2560.24,561,,,Fee Schedule,561% of BCBS PPO fee schedule,456.37,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5014.84,90,,373.088,Percent of Total Billed Charges,90% of Total Billed Charges,2507.42,45,,5.16,Percent of Total Billed Charges,45% of Total Billed Charges,5014.84,90,,51.592,Percent of Total Billed Charges,90% of Total billed Charges,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,670.67,200,,26.784,Fee Schedule,200% of CMS OPPS Rate,2457.27,44.1,,5.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,5293.44,95,,54.464,Percent of Total Billed Charges,95% of Total Billed Charges,269.33,75,,,Fee Schedule,75% of CMS OPPS Rate,4903.4,88,,10.088,Percent of Total Billed Charges,88% of Total Billed Charges,5014.84,90,,51.592,Percent of Total Billed charges,90% of Total Billed Charges,269.33,5293.44,
MRA LWR EXT W/ CONT,6100000034,CDM,610,RC,C8912,HCPCS,Outpatient,,,5408.87,3515.77,,448.93,125,,,Fee Schedule,125% of CMS OPPS Rate,4110.74,76,,110.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2560.24,350,,,Fee Schedule,350% of BCBS fee schedule,2560.24,350,,,Fee Schedule,350% of BCBS fee schedule,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,2560.24,561,,,Fee Schedule,561% of BCBS PPO fee schedule,456.37,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,4867.98,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,2433.99,45,,1710.64,Percent of Total Billed Charges,45% of Total Billed Charges,4867.98,90,,131.44,Percent of Total Billed Charges,90% of Total billed Charges,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,670.67,200,,26.784,Fee Schedule,200% of CMS OPPS Rate,2385.31,44.1,,1676.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,5138.43,95,,138.736,Percent of Total Billed Charges,95% of Total Billed Charges,269.33,75,,,Fee Schedule,75% of CMS OPPS Rate,4759.81,88,,3345.256,Percent of Total Billed Charges,88% of Total Billed Charges,4867.98,90,,131.44,Percent of Total Billed charges,90% of Total Billed Charges,269.33,5138.43,
MRA LWR EXT W/O CONT,6100000035,CDM,610,RC,C8913,HCPCS,Outpatient,,,5355.95,3481.37,,303.85,125,,,Fee Schedule,125% of CMS OPPS Rate,4070.52,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1303.26,350,,,Fee Schedule,350% of BCBS fee schedule,1303.26,350,,,Fee Schedule,350% of BCBS fee schedule,243.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1303.26,561,,,Fee Schedule,561% of BCBS PPO fee schedule,232.31,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,4820.36,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,2410.18,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,4820.36,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,243.08,100,,,Fee Schedule,100% of CMS OPPS Rate,243.08,100,,,Fee Schedule,100% of CMS OPPS Rate,243.08,100,,,Fee Schedule,100% of CMS OPPS Rate,453.94,200,,17.776,Fee Schedule,200% of CMS OPPS Rate,2361.97,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,5088.15,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,182.3,75,,,Fee Schedule,75% of CMS OPPS Rate,4713.24,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,4820.36,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,182.3,5088.15,
MRA LWR EXT W/WO CON,6100000036,CDM,610,RC,C8914,HCPCS,Outpatient,,,5572.04,3621.83,,448.93,125,,,Fee Schedule,125% of CMS OPPS Rate,4234.75,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2560.24,350,,,Fee Schedule,350% of BCBS fee schedule,2560.24,350,,,Fee Schedule,350% of BCBS fee schedule,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,2560.24,561,,,Fee Schedule,561% of BCBS PPO fee schedule,456.37,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5014.84,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,2507.42,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,5014.84,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,670.67,200,,15.48,Fee Schedule,200% of CMS OPPS Rate,2457.27,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,5293.44,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,269.33,75,,,Fee Schedule,75% of CMS OPPS Rate,4903.4,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,5014.84,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,269.33,5293.44,
MRA PELVIS W/ CONTRA,6100000037,CDM,610,RC,C8918,HCPCS,Outpatient,,,5408.87,3515.77,,448.93,125,,,Fee Schedule,125% of CMS OPPS Rate,4110.74,76,,138.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1417.87,350,,,Fee Schedule,350% of BCBS fee schedule,1417.87,350,,,Fee Schedule,350% of BCBS fee schedule,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,1417.87,561,,,Fee Schedule,561% of BCBS PPO fee schedule,252.74,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,4867.98,90,,172.256,Percent of Total Billed Charges,90% of Total Billed Charges,2433.99,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,4867.98,90,,164.32,Percent of Total Billed Charges,90% of Total billed Charges,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,670.67,200,,9.744,Fee Schedule,200% of CMS OPPS Rate,2385.31,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,5138.43,95,,173.448,Percent of Total Billed Charges,95% of Total Billed Charges,269.33,75,,,Fee Schedule,75% of CMS OPPS Rate,4759.81,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,4867.98,90,,164.32,Percent of Total Billed charges,90% of Total Billed Charges,252.74,5138.43,
MRA PELVIS W/O CONTR,6100000038,CDM,610,RC,C8919,HCPCS,Outpatient,,,7246.73,4710.37,,303.85,125,,,Fee Schedule,125% of CMS OPPS Rate,5507.51,76,,8.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1303.26,350,,,Fee Schedule,350% of BCBS fee schedule,1303.26,350,,,Fee Schedule,350% of BCBS fee schedule,243.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1303.26,561,,,Fee Schedule,561% of BCBS PPO fee schedule,232.31,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,6522.06,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,3261.03,45,,186.544,Percent of Total Billed Charges,45% of Total Billed Charges,6522.06,90,,10.32,Percent of Total Billed Charges,90% of Total billed Charges,243.08,100,,,Fee Schedule,100% of CMS OPPS Rate,243.08,100,,,Fee Schedule,100% of CMS OPPS Rate,243.08,100,,,Fee Schedule,100% of CMS OPPS Rate,453.94,200,,10.896,Fee Schedule,200% of CMS OPPS Rate,3195.81,44.1,,182.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,6884.39,95,,10.888,Percent of Total Billed Charges,95% of Total Billed Charges,182.3,75,,,Fee Schedule,75% of CMS OPPS Rate,6377.12,88,,364.8,Percent of Total Billed Charges,88% of Total Billed Charges,6522.06,90,,10.32,Percent of Total Billed charges,90% of Total Billed Charges,182.3,6884.39,
MRA PELVIS W/WO CONT,6100000039,CDM,610,RC,C8920,HCPCS,Outpatient,,,5572.04,3621.83,,448.93,125,,,Fee Schedule,125% of CMS OPPS Rate,4234.75,76,,2889.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2560.24,350,,,Fee Schedule,350% of BCBS fee schedule,2560.24,350,,,Fee Schedule,350% of BCBS fee schedule,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,2560.24,561,,,Fee Schedule,561% of BCBS PPO fee schedule,456.37,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5014.84,90,,4169.832,Percent of Total Billed Charges,90% of Total Billed Charges,2507.42,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,5014.84,90,,3421.28,Percent of Total Billed Charges,90% of Total billed Charges,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,670.67,200,,10.896,Fee Schedule,200% of CMS OPPS Rate,2457.27,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,5293.44,95,,3611.352,Percent of Total Billed Charges,95% of Total Billed Charges,269.33,75,,,Fee Schedule,75% of CMS OPPS Rate,4903.4,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,5014.84,90,,3421.28,Percent of Total Billed charges,90% of Total Billed Charges,269.33,5293.44,
MR BREAST LT WO CON,6100000040,CDM,610,RC,,,Outpatient,,,547.00,355.55,,547,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,415.72,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.84,72,,315.072,Percent of Total Billed Charges,72% of Total Billed Charges,410.25,75,,328.2,Percent of Total Billed charges,75% of Total Billed Charges,547,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.84,72,,315.072,Percent of Total Billed Charges,72% of Total Billed Charges,328.2,60,,262.56,Percent of Total Billed Charges,60% of Total Billed Charges,492.3,90,,88.112,Percent of Total Billed Charges,90% of Total Billed Charges,246.15,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,492.3,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,547,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.55,65,,10.32,Percent of total Billed Charges,65% of Total Billed Charges,241.23,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,519.65,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,547,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,481.36,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,492.3,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,241.23,547,
MR BREAST BL WO CON,6100000041,CDM,610,RC,,,Outpatient,,,520.00,338.00,,520,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,395.2,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,374.4,72,,299.52,Percent of Total Billed Charges,72% of Total Billed Charges,390,75,,312,Percent of Total Billed charges,75% of Total Billed Charges,520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.4,72,,299.52,Percent of Total Billed Charges,72% of Total Billed Charges,312,60,,249.6,Percent of Total Billed Charges,60% of Total Billed Charges,468,90,,4.864,Percent of Total Billed Charges,90% of Total Billed Charges,234,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,468,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,338,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,229.32,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,494,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,457.6,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,468,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,229.32,520,
MR BREAST BL WO/ W CON,6100000042,CDM,610,RC,C8905,HCPCS,Outpatient,,,6175.00,4013.75,,448.93,125,,,Fee Schedule,125% of CMS OPPS Rate,4693,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2560.24,350,,,Fee Schedule,350% of BCBS fee schedule,2560.24,350,,,Fee Schedule,350% of BCBS fee schedule,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,2560.24,561,,,Fee Schedule,561% of BCBS PPO fee schedule,456.37,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5557.5,90,,1616.176,Percent of Total Billed Charges,90% of Total Billed Charges,2778.75,45,,86.128,Percent of Total Billed Charges,45% of Total Billed Charges,5557.5,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,670.67,200,,17.776,Fee Schedule,200% of CMS OPPS Rate,2723.18,44.1,,84.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,5866.25,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,269.33,75,,,Fee Schedule,75% of CMS OPPS Rate,5434,88,,168.424,Percent of Total Billed Charges,88% of Total Billed Charges,5557.5,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,269.33,5866.25,
MR BREAST LT WO/W CON,6100000043,CDM,610,RC,C8905,HCPCS,Outpatient,,,5000.00,3250.00,,448.93,125,,,Fee Schedule,125% of CMS OPPS Rate,3800,76,,315.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2560.24,350,,,Fee Schedule,350% of BCBS fee schedule,2560.24,350,,,Fee Schedule,350% of BCBS fee schedule,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,2560.24,561,,,Fee Schedule,561% of BCBS PPO fee schedule,456.37,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,4500,90,,1015.272,Percent of Total Billed Charges,90% of Total Billed Charges,2250,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,4500,90,,373.088,Percent of Total Billed Charges,90% of Total billed Charges,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,670.67,200,,38.416,Fee Schedule,200% of CMS OPPS Rate,2205,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,4750,95,,393.816,Percent of Total Billed Charges,95% of Total Billed Charges,269.33,75,,,Fee Schedule,75% of CMS OPPS Rate,4400,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,4500,90,,373.088,Percent of Total Billed charges,90% of Total Billed Charges,269.33,4750,
MR BREAST RT WO CON,6100000044,CDM,610,RC,,,Outpatient,,,547.00,355.55,,547,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,415.72,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,393.84,72,,315.072,Percent of Total Billed Charges,72% of Total Billed Charges,410.25,75,,328.2,Percent of Total Billed charges,75% of Total Billed Charges,547,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.84,72,,315.072,Percent of Total Billed Charges,72% of Total Billed Charges,328.2,60,,262.56,Percent of Total Billed Charges,60% of Total Billed Charges,492.3,90,,91.288,Percent of Total Billed Charges,90% of Total Billed Charges,246.15,45,,2084.912,Percent of Total Billed Charges,45% of Total Billed Charges,492.3,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,547,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.55,65,,27.52,Percent of total Billed Charges,65% of Total Billed Charges,241.23,44.1,,2043.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,519.65,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,547,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,481.36,88,,4077.168,Percent of Total Billed Charges,88% of Total Billed Charges,492.3,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,241.23,547,
MR BREAST RT WO/ W CON,6100000045,CDM,610,RC,,,Outpatient,,,4750.00,3087.50,,4750,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3610,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3420,72,,2736,Percent of Total Billed Charges,72% of Total Billed Charges,3562.5,75,,2850,Percent of Total Billed charges,75% of Total Billed Charges,4750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3420,72,,2736,Percent of Total Billed Charges,72% of Total Billed Charges,2850,60,,2280,Percent of Total Billed Charges,60% of Total Billed Charges,4275,90,,1637.824,Percent of Total Billed Charges,90% of Total Billed Charges,2137.5,45,,44.056,Percent of Total Billed Charges,45% of Total Billed Charges,4275,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,4750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3087.5,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,2094.75,44.1,,43.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,4512.5,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,4750,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4180,88,,86.152,Percent of Total Billed Charges,88% of Total Billed Charges,4275,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,2094.75,4750,
MRI Breast W/O Cont Unilateral,6100000047,CDM,610,RC,,,Outpatient,,,5000.00,3250.00,,5000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3800,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3600,72,,2880,Percent of Total Billed Charges,72% of Total Billed Charges,3750,75,,3000,Percent of Total Billed charges,75% of Total Billed Charges,5000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3600,72,,2880,Percent of Total Billed Charges,72% of Total Billed Charges,3000,60,,2400,Percent of Total Billed Charges,60% of Total Billed Charges,4500,90,,9216.024,Percent of Total Billed Charges,90% of Total Billed Charges,2250,45,,2.432,Percent of Total Billed Charges,45% of Total Billed Charges,4500,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,5000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3250,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,2205,44.1,,2.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,4750,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,5000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4400,88,,4.76,Percent of Total Billed Charges,88% of Total Billed Charges,4500,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,2205,5000,
MRI shoulder LT WO Contrast,6100000048,CDM,610,RC,,,Outpatient,,,3547.85,2306.10,,3547.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2696.37,76,,145.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2554.45,72,,2043.56,Percent of Total Billed Charges,72% of Total Billed Charges,2660.89,75,,2128.712,Percent of Total Billed charges,75% of Total Billed Charges,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2554.45,72,,2043.56,Percent of Total Billed Charges,72% of Total Billed Charges,2128.71,60,,1702.968,Percent of Total Billed Charges,60% of Total Billed Charges,3193.07,90,,230.208,Percent of Total Billed Charges,90% of Total Billed Charges,1596.53,45,,808.088,Percent of Total Billed Charges,45% of Total Billed Charges,3193.07,90,,172.256,Percent of Total Billed Charges,90% of Total billed Charges,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2306.1,65,,21.792,Percent of total Billed Charges,65% of Total Billed Charges,1564.6,44.1,,791.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,3370.46,95,,181.824,Percent of Total Billed Charges,95% of Total Billed Charges,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3122.11,88,,1580.264,Percent of Total Billed Charges,88% of Total Billed Charges,3193.07,90,,172.256,Percent of Total Billed charges,90% of Total Billed Charges,1564.6,3547.85,
MRI Wrist RT WO Constrast,6100000049,CDM,610,RC,,,Outpatient,,,3547.85,2306.10,,3547.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2696.37,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2554.45,72,,2043.56,Percent of Total Billed Charges,72% of Total Billed Charges,2660.89,75,,2128.712,Percent of Total Billed charges,75% of Total Billed Charges,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2554.45,72,,2043.56,Percent of Total Billed Charges,72% of Total Billed Charges,2128.71,60,,1702.968,Percent of Total Billed Charges,60% of Total Billed Charges,3193.07,90,,38.896,Percent of Total Billed Charges,90% of Total Billed Charges,1596.53,45,,507.64,Percent of Total Billed Charges,45% of Total Billed Charges,3193.07,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2306.1,65,,20.064,Percent of total Billed Charges,65% of Total Billed Charges,1564.6,44.1,,497.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,3370.46,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3122.11,88,,992.712,Percent of Total Billed Charges,88% of Total Billed Charges,3193.07,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,1564.6,3547.85,
MRI Wrist LT WO Contrast,6100000050,CDM,610,RC,,,Outpatient,,,3547.85,2306.10,,3547.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2696.37,76,,3521.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2554.45,72,,2043.56,Percent of Total Billed Charges,72% of Total Billed Charges,2660.89,75,,2128.712,Percent of Total Billed charges,75% of Total Billed Charges,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2554.45,72,,2043.56,Percent of Total Billed Charges,72% of Total Billed Charges,2128.71,60,,1702.968,Percent of Total Billed Charges,60% of Total Billed Charges,3193.07,90,,9.528,Percent of Total Billed Charges,90% of Total Billed Charges,1596.53,45,,45.648,Percent of Total Billed Charges,45% of Total Billed Charges,3193.07,90,,4169.832,Percent of Total Billed Charges,90% of Total billed Charges,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2306.1,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,1564.6,44.1,,44.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,3370.46,95,,4401.488,Percent of Total Billed Charges,95% of Total Billed Charges,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3122.11,88,,89.264,Percent of Total Billed Charges,88% of Total Billed Charges,3193.07,90,,4169.832,Percent of Total Billed charges,90% of Total Billed Charges,1564.6,3547.85,
MRI Elbow RT WO contrast,6100000051,CDM,610,RC,,,Outpatient,,,3547.85,2306.10,,3547.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2696.37,76,,74.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2554.45,72,,2043.56,Percent of Total Billed Charges,72% of Total Billed Charges,2660.89,75,,2128.712,Percent of Total Billed charges,75% of Total Billed Charges,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2554.45,72,,2043.56,Percent of Total Billed Charges,72% of Total Billed Charges,2128.71,60,,1702.968,Percent of Total Billed Charges,60% of Total Billed Charges,3193.07,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,1596.53,45,,818.912,Percent of Total Billed Charges,45% of Total Billed Charges,3193.07,90,,88.112,Percent of Total Billed Charges,90% of Total billed Charges,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2306.1,65,,3.44,Percent of total Billed Charges,65% of Total Billed Charges,1564.6,44.1,,802.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,3370.46,95,,93.008,Percent of Total Billed Charges,95% of Total Billed Charges,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3122.11,88,,1601.424,Percent of Total Billed Charges,88% of Total Billed Charges,3193.07,90,,88.112,Percent of Total Billed charges,90% of Total Billed Charges,1564.6,3547.85,
MRI Elbow LT WO contrast,6100000052,CDM,610,RC,,,Outpatient,,,3547.85,2306.10,,3547.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2696.37,76,,4.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2554.45,72,,2043.56,Percent of Total Billed Charges,72% of Total Billed Charges,2660.89,75,,2128.712,Percent of Total Billed charges,75% of Total Billed Charges,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2554.45,72,,2043.56,Percent of Total Billed Charges,72% of Total Billed Charges,2128.71,60,,1702.968,Percent of Total Billed Charges,60% of Total Billed Charges,3193.07,90,,395.32,Percent of Total Billed Charges,90% of Total Billed Charges,1596.53,45,,4608.008,Percent of Total Billed Charges,45% of Total Billed Charges,3193.07,90,,4.864,Percent of Total Billed Charges,90% of Total billed Charges,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2306.1,65,,24.44,Percent of total Billed Charges,65% of Total Billed Charges,1564.6,44.1,,4515.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,3370.46,95,,5.136,Percent of Total Billed Charges,95% of Total Billed Charges,3547.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3122.11,88,,9011.224,Percent of Total Billed Charges,88% of Total Billed Charges,3193.07,90,,4.864,Percent of Total Billed charges,90% of Total Billed Charges,1564.6,3547.85,
MRI Shoulder RT W Contrast,6100000053,CDM,610,RC,,,Outpatient,,,3845.52,2499.59,,3845.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2922.6,76,,1364.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2768.77,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,2884.14,75,,2307.312,Percent of Total Billed charges,75% of Total Billed Charges,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2768.77,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,2307.31,60,,1845.848,Percent of Total Billed Charges,60% of Total Billed Charges,3460.97,90,,53.184,Percent of Total Billed Charges,90% of Total Billed Charges,1730.48,45,,115.104,Percent of Total Billed Charges,45% of Total Billed Charges,3460.97,90,,1616.176,Percent of Total Billed Charges,90% of Total billed Charges,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2499.59,65,,40.704,Percent of total Billed Charges,65% of Total Billed Charges,1695.87,44.1,,112.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,3653.24,95,,1705.968,Percent of Total Billed Charges,95% of Total Billed Charges,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3384.06,88,,225.088,Percent of Total Billed Charges,88% of Total Billed Charges,3460.97,90,,1616.176,Percent of Total Billed charges,90% of Total Billed Charges,1695.87,3845.52,
MRI Shoulder LT W Contrast,6100000054,CDM,610,RC,,,Outpatient,,,3845.52,2499.59,,3845.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2922.6,76,,857.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2768.77,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,2884.14,75,,2307.312,Percent of Total Billed charges,75% of Total Billed Charges,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2768.77,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,2307.31,60,,1845.848,Percent of Total Billed Charges,60% of Total Billed Charges,3460.97,90,,392.936,Percent of Total Billed Charges,90% of Total Billed Charges,1730.48,45,,19.448,Percent of Total Billed Charges,45% of Total Billed Charges,3460.97,90,,1015.272,Percent of Total Billed Charges,90% of Total billed Charges,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2499.59,65,,8.6,Percent of total Billed Charges,65% of Total Billed Charges,1695.87,44.1,,19.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,3653.24,95,,1071.68,Percent of Total Billed Charges,95% of Total Billed Charges,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3384.06,88,,38.032,Percent of Total Billed Charges,88% of Total Billed Charges,3460.97,90,,1015.272,Percent of Total Billed charges,90% of Total Billed Charges,1695.87,3845.52,
MRI Wrist RT W Contrast,6100000055,CDM,610,RC,,,Outpatient,,,3845.52,2499.59,,3845.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2922.6,76,,77.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2768.77,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,2884.14,75,,2307.312,Percent of Total Billed charges,75% of Total Billed Charges,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2768.77,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,2307.31,60,,1845.848,Percent of Total Billed Charges,60% of Total Billed Charges,3460.97,90,,490.576,Percent of Total Billed Charges,90% of Total Billed Charges,1730.48,45,,4.76,Percent of Total Billed Charges,45% of Total Billed Charges,3460.97,90,,91.288,Percent of Total Billed Charges,90% of Total billed Charges,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2499.59,65,,15.472,Percent of total Billed Charges,65% of Total Billed Charges,1695.87,44.1,,4.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,3653.24,95,,96.36,Percent of Total Billed Charges,95% of Total Billed Charges,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3384.06,88,,9.312,Percent of Total Billed Charges,88% of Total Billed Charges,3460.97,90,,91.288,Percent of Total Billed charges,90% of Total Billed Charges,1695.87,3845.52,
MRI Wrist LT W Contrast,6100000056,CDM,610,RC,,,Outpatient,,,3845.52,2499.59,,3845.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2922.6,76,,1383.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2768.77,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,2884.14,75,,2307.312,Percent of Total Billed charges,75% of Total Billed Charges,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2768.77,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,2307.31,60,,1845.848,Percent of Total Billed Charges,60% of Total Billed Charges,3460.97,90,,80.176,Percent of Total Billed Charges,90% of Total Billed Charges,1730.48,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,3460.97,90,,1637.824,Percent of Total Billed Charges,90% of Total billed Charges,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2499.59,65,,6.24,Percent of total Billed Charges,65% of Total Billed Charges,1695.87,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,3653.24,95,,1728.808,Percent of Total Billed Charges,95% of Total Billed Charges,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3384.06,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,3460.97,90,,1637.824,Percent of Total Billed charges,90% of Total Billed Charges,1695.87,3845.52,
MRI Elbow RT W Contrast,6100000057,CDM,610,RC,,,Outpatient,,,3845.52,2499.59,,3845.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2922.6,76,,7782.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2768.77,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,2884.14,75,,2307.312,Percent of Total Billed charges,75% of Total Billed Charges,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2768.77,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,2307.31,60,,1845.848,Percent of Total Billed Charges,60% of Total Billed Charges,3460.97,90,,107.168,Percent of Total Billed Charges,90% of Total Billed Charges,1730.48,45,,197.656,Percent of Total Billed Charges,45% of Total Billed Charges,3460.97,90,,9216.024,Percent of Total Billed Charges,90% of Total billed Charges,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2499.59,65,,6.24,Percent of total Billed Charges,65% of Total Billed Charges,1695.87,44.1,,193.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,3653.24,95,,9728.024,Percent of Total Billed Charges,95% of Total Billed Charges,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3384.06,88,,386.528,Percent of Total Billed Charges,88% of Total Billed Charges,3460.97,90,,9216.024,Percent of Total Billed charges,90% of Total Billed Charges,1695.87,3845.52,
MRI Elbow LT W Contrast,6100000058,CDM,610,RC,,,Outpatient,,,3845.52,2499.59,,3845.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2922.6,76,,194.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2768.77,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,2884.14,75,,2307.312,Percent of Total Billed charges,75% of Total Billed Charges,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2768.77,72,,2215.016,Percent of Total Billed Charges,72% of Total Billed Charges,2307.31,60,,1845.848,Percent of Total Billed Charges,60% of Total Billed Charges,3460.97,90,,160.352,Percent of Total Billed Charges,90% of Total Billed Charges,1730.48,45,,26.592,Percent of Total Billed Charges,45% of Total Billed Charges,3460.97,90,,230.208,Percent of Total Billed Charges,90% of Total billed Charges,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2499.59,65,,247.664,Percent of total Billed Charges,65% of Total Billed Charges,1695.87,44.1,,26.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,3653.24,95,,242.992,Percent of Total Billed Charges,95% of Total Billed Charges,3845.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3384.06,88,,52.008,Percent of Total Billed Charges,88% of Total Billed Charges,3460.97,90,,230.208,Percent of Total Billed charges,90% of Total Billed Charges,1695.87,3845.52,
MRI Shoulder RT WO W contrast,6100000059,CDM,610,RC,,,Outpatient,,,4324.01,2810.61,,4324.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3286.25,76,,32.848,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,3243.01,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,2594.41,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,3891.61,90,,214.328,Percent of Total Billed Charges,90% of Total Billed Charges,1945.8,45,,196.464,Percent of Total Billed Charges,45% of Total Billed Charges,3891.61,90,,38.896,Percent of Total Billed Charges,90% of Total billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2810.61,65,,114.088,Percent of total Billed Charges,65% of Total Billed Charges,1906.89,44.1,,192.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,4107.81,95,,41.056,Percent of Total Billed Charges,95% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3805.13,88,,384.2,Percent of Total Billed Charges,88% of Total Billed Charges,3891.61,90,,38.896,Percent of Total Billed charges,90% of Total Billed Charges,1906.89,4324.01,
MRI Shoulder LT WO W contrast,6100000060,CDM,610,RC,,,Outpatient,,,4324.01,2810.61,,4324.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3286.25,76,,8.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,3243.01,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,2594.41,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,3891.61,90,,1416.424,Percent of Total Billed Charges,90% of Total Billed Charges,1945.8,45,,245.288,Percent of Total Billed Charges,45% of Total Billed Charges,3891.61,90,,9.528,Percent of Total Billed Charges,90% of Total billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2810.61,65,,9.744,Percent of total Billed Charges,65% of Total Billed Charges,1906.89,44.1,,240.384,Percent of Total Billed Charges,44.1% of Total Billed Charges,4107.81,95,,10.056,Percent of Total Billed Charges,95% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3805.13,88,,479.672,Percent of Total Billed Charges,88% of Total Billed Charges,3891.61,90,,9.528,Percent of Total Billed charges,90% of Total Billed Charges,1906.89,4324.01,
MRI Wrist RT WO W Contrast,6100000061,CDM,610,RC,,,Outpatient,,,4324.01,2810.61,,4324.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3286.25,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,3243.01,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,2594.41,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,3891.61,90,,18.256,Percent of Total Billed Charges,90% of Total Billed Charges,1945.8,45,,40.088,Percent of Total Billed Charges,45% of Total Billed Charges,3891.61,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2810.61,65,,666.752,Percent of total Billed Charges,65% of Total Billed Charges,1906.89,44.1,,39.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,4107.81,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3805.13,88,,78.392,Percent of Total Billed Charges,88% of Total Billed Charges,3891.61,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,1906.89,4324.01,
MRI Wrist LT WO W Contrast,6100000062,CDM,610,RC,,,Outpatient,,,4324.01,2810.61,,4324.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3286.25,76,,333.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,3243.01,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,2594.41,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,3891.61,90,,34.136,Percent of Total Billed Charges,90% of Total Billed Charges,1945.8,45,,53.584,Percent of Total Billed Charges,45% of Total Billed Charges,3891.61,90,,395.32,Percent of Total Billed Charges,90% of Total billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2810.61,65,,44.144,Percent of total Billed Charges,65% of Total Billed Charges,1906.89,44.1,,52.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,4107.81,95,,417.28,Percent of Total Billed Charges,95% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3805.13,88,,104.784,Percent of Total Billed Charges,88% of Total Billed Charges,3891.61,90,,395.32,Percent of Total Billed charges,90% of Total Billed Charges,1906.89,4324.01,
MRI Elbow RT WO W Contrast,6100000063,CDM,610,RC,,,Outpatient,,,4324.01,2810.61,,4324.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3286.25,76,,44.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,3243.01,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,2594.41,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,3891.61,90,,74.624,Percent of Total Billed Charges,90% of Total Billed Charges,1945.8,45,,80.176,Percent of Total Billed Charges,45% of Total Billed Charges,3891.61,90,,53.184,Percent of Total Billed Charges,90% of Total billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2810.61,65,,75.672,Percent of total Billed Charges,65% of Total Billed Charges,1906.89,44.1,,78.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,4107.81,95,,56.144,Percent of Total Billed Charges,95% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3805.13,88,,156.784,Percent of Total Billed Charges,88% of Total Billed Charges,3891.61,90,,53.184,Percent of Total Billed charges,90% of Total Billed Charges,1906.89,4324.01,
MRI Elbow LT WO W Contrast,6100000064,CDM,610,RC,,,Outpatient,,,4324.01,2810.61,,4324.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3286.25,76,,331.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,3243.01,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,2594.41,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,3891.61,90,,139.712,Percent of Total Billed Charges,90% of Total Billed Charges,1945.8,45,,107.168,Percent of Total Billed Charges,45% of Total Billed Charges,3891.61,90,,392.936,Percent of Total Billed Charges,90% of Total billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2810.61,65,,12.224,Percent of total Billed Charges,65% of Total Billed Charges,1906.89,44.1,,105.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,4107.81,95,,414.76,Percent of Total Billed Charges,95% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3805.13,88,,209.568,Percent of Total Billed Charges,88% of Total Billed Charges,3891.61,90,,392.936,Percent of Total Billed charges,90% of Total Billed Charges,1906.89,4324.01,
MRI Foot RT WO Contrast,6100000065,CDM,610,RC,,,Outpatient,,,3749.60,2437.24,,3749.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2849.7,76,,414.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2699.71,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,2812.2,75,,2249.76,Percent of Total Billed charges,75% of Total Billed Charges,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2699.71,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,2249.76,60,,1799.808,Percent of Total Billed Charges,60% of Total Billed Charges,3374.64,90,,1.64,Percent of Total Billed Charges,90% of Total Billed Charges,1687.32,45,,708.208,Percent of Total Billed Charges,45% of Total Billed Charges,3374.64,90,,490.576,Percent of Total Billed Charges,90% of Total billed Charges,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2437.24,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,1653.57,44.1,,694.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,3562.12,95,,517.824,Percent of Total Billed Charges,95% of Total Billed Charges,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3299.65,88,,1384.944,Percent of Total Billed Charges,88% of Total Billed Charges,3374.64,90,,490.576,Percent of Total Billed charges,90% of Total Billed Charges,1653.57,3749.6,
MRI Foot LT WO Contrast,6100000066,CDM,610,RC,,,Outpatient,,,3749.60,2437.24,,3749.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2849.7,76,,67.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2699.71,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,2812.2,75,,2249.76,Percent of Total Billed charges,75% of Total Billed Charges,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2699.71,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,2249.76,60,,1799.808,Percent of Total Billed Charges,60% of Total Billed Charges,3374.64,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,1687.32,45,,9.128,Percent of Total Billed Charges,45% of Total Billed Charges,3374.64,90,,80.176,Percent of Total Billed Charges,90% of Total billed Charges,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2437.24,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,1653.57,44.1,,8.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,3562.12,95,,84.624,Percent of Total Billed Charges,95% of Total Billed Charges,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3299.65,88,,17.856,Percent of Total Billed Charges,88% of Total Billed Charges,3374.64,90,,80.176,Percent of Total Billed charges,90% of Total Billed Charges,1653.57,3749.6,
MRI Femur RT WO Contrast,6100000067,CDM,610,RC,,,Outpatient,,,3749.60,2437.24,,3749.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2849.7,76,,90.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2699.71,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,2812.2,75,,2249.76,Percent of Total Billed charges,75% of Total Billed Charges,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2699.71,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,2249.76,60,,1799.808,Percent of Total Billed Charges,60% of Total Billed Charges,3374.64,90,,26.192,Percent of Total Billed Charges,90% of Total Billed Charges,1687.32,45,,17.064,Percent of Total Billed Charges,45% of Total Billed Charges,3374.64,90,,107.168,Percent of Total Billed Charges,90% of Total billed Charges,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2437.24,65,,25.8,Percent of total Billed Charges,65% of Total Billed Charges,1653.57,44.1,,16.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,3562.12,95,,113.12,Percent of Total Billed Charges,95% of Total Billed Charges,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3299.65,88,,33.376,Percent of Total Billed Charges,88% of Total Billed Charges,3374.64,90,,107.168,Percent of Total Billed charges,90% of Total Billed Charges,1653.57,3749.6,
MRI Femur LT WO Contrast,6100000068,CDM,610,RC,,,Outpatient,,,3749.60,2437.24,,3749.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2849.7,76,,135.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2699.71,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,2812.2,75,,2249.76,Percent of Total Billed charges,75% of Total Billed Charges,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2699.71,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,2249.76,60,,1799.808,Percent of Total Billed Charges,60% of Total Billed Charges,3374.64,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,1687.32,45,,37.312,Percent of Total Billed Charges,45% of Total Billed Charges,3374.64,90,,160.352,Percent of Total Billed Charges,90% of Total billed Charges,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2437.24,65,,384.28,Percent of total Billed Charges,65% of Total Billed Charges,1653.57,44.1,,36.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,3562.12,95,,169.256,Percent of Total Billed Charges,95% of Total Billed Charges,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3299.65,88,,72.96,Percent of Total Billed Charges,88% of Total Billed Charges,3374.64,90,,160.352,Percent of Total Billed charges,90% of Total Billed Charges,1653.57,3749.6,
MRI  Lower Leg RT WO Contrast,6100000069,CDM,610,RC,,,Outpatient,,,3749.60,2437.24,,3749.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2849.7,76,,180.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2699.71,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,2812.2,75,,2249.76,Percent of Total Billed charges,75% of Total Billed Charges,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2699.71,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,2249.76,60,,1799.808,Percent of Total Billed Charges,60% of Total Billed Charges,3374.64,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,1687.32,45,,69.856,Percent of Total Billed Charges,45% of Total Billed Charges,3374.64,90,,214.328,Percent of Total Billed Charges,90% of Total billed Charges,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2437.24,65,,440.912,Percent of total Billed Charges,65% of Total Billed Charges,1653.57,44.1,,68.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,3562.12,95,,226.24,Percent of Total Billed Charges,95% of Total Billed Charges,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3299.65,88,,136.608,Percent of Total Billed Charges,88% of Total Billed Charges,3374.64,90,,214.328,Percent of Total Billed charges,90% of Total Billed Charges,1653.57,3749.6,
MRI Lower Leg LT WO Contrast,6100000070,CDM,610,RC,,,Outpatient,,,3749.60,2437.24,,3749.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2849.7,76,,1196.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2699.71,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,2812.2,75,,2249.76,Percent of Total Billed charges,75% of Total Billed Charges,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2699.71,72,,2159.768,Percent of Total Billed Charges,72% of Total Billed Charges,2249.76,60,,1799.808,Percent of Total Billed Charges,60% of Total Billed Charges,3374.64,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,1687.32,45,,0.824,Percent of Total Billed Charges,45% of Total Billed Charges,3374.64,90,,1416.424,Percent of Total Billed Charges,90% of Total billed Charges,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2437.24,65,,29.216,Percent of total Billed Charges,65% of Total Billed Charges,1653.57,44.1,,0.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,3562.12,95,,1495.112,Percent of Total Billed Charges,95% of Total Billed Charges,3749.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3299.65,88,,1.608,Percent of Total Billed Charges,88% of Total Billed Charges,3374.64,90,,1416.424,Percent of Total Billed charges,90% of Total Billed Charges,1653.57,3749.6,
MRI Femur RT  W Contrast,6100000071,CDM,610,RC,,,Outpatient,,,3112.36,2023.03,,3112.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2365.39,76,,15.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,2334.27,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,1867.42,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,2801.12,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,1400.56,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,2801.12,90,,18.256,Percent of Total Billed Charges,90% of Total billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2023.03,65,,3049.984,Percent of total Billed Charges,65% of Total Billed Charges,1372.55,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,2956.74,95,,19.272,Percent of Total Billed Charges,95% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2738.88,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,2801.12,90,,18.256,Percent of Total Billed charges,90% of Total Billed Charges,1372.55,3112.36,
MRI Femur LT W Contrast,6100000072,CDM,610,RC,,,Outpatient,,,3112.36,2023.03,,3112.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2365.39,76,,28.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,2334.27,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,1867.42,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,2801.12,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,1400.56,45,,13.096,Percent of Total Billed Charges,45% of Total Billed Charges,2801.12,90,,34.136,Percent of Total Billed Charges,90% of Total billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2023.03,65,,9.744,Percent of total Billed Charges,65% of Total Billed Charges,1372.55,44.1,,12.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,2956.74,95,,36.032,Percent of Total Billed Charges,95% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2738.88,88,,25.608,Percent of Total Billed Charges,88% of Total Billed Charges,2801.12,90,,34.136,Percent of Total Billed charges,90% of Total Billed Charges,1372.55,3112.36,
MRI Lower Leg RT W Contrast,6100000073,CDM,610,RC,,,Outpatient,,,3112.36,2023.03,,3112.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2365.39,76,,63.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,2334.27,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,1867.42,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,2801.12,90,,10303.528,Percent of Total Billed Charges,90% of Total Billed Charges,1400.56,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,2801.12,90,,74.624,Percent of Total Billed Charges,90% of Total billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2023.03,65,,4.016,Percent of total Billed Charges,65% of Total Billed Charges,1372.55,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,2956.74,95,,78.768,Percent of Total Billed Charges,95% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2738.88,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,2801.12,90,,74.624,Percent of Total Billed charges,90% of Total Billed Charges,1372.55,3112.36,
MRI Lower Leg LT W Contrast,6100000074,CDM,610,RC,,,Outpatient,,,3112.36,2023.03,,3112.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2365.39,76,,117.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,2334.27,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,1867.42,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,2801.12,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,1400.56,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,2801.12,90,,139.712,Percent of Total Billed Charges,90% of Total billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2023.03,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,1372.55,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,2956.74,95,,147.472,Percent of Total Billed Charges,95% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2738.88,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,2801.12,90,,139.712,Percent of Total Billed charges,90% of Total Billed Charges,1372.55,3112.36,
MRI Femur Rt WO W Contrast,6100000075,CDM,610,RC,,,Outpatient,,,4324.01,2810.61,,4324.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3286.25,76,,1.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,3243.01,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,2594.41,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,3891.61,90,,91.288,Percent of Total Billed Charges,90% of Total Billed Charges,1945.8,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,3891.61,90,,1.64,Percent of Total Billed Charges,90% of Total billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2810.61,65,,4.584,Percent of total Billed Charges,65% of Total Billed Charges,1906.89,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,4107.81,95,,1.736,Percent of Total Billed Charges,95% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3805.13,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,3891.61,90,,1.64,Percent of Total Billed charges,90% of Total Billed Charges,1906.89,4324.01,
MRI Femur LT WO W Contrast,6100000076,CDM,610,RC,,,Outpatient,,,4324.01,2810.61,,4324.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3286.25,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,3243.01,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,2594.41,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,3891.61,90,,242.904,Percent of Total Billed Charges,90% of Total Billed Charges,1945.8,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,3891.61,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2810.61,65,,64.784,Percent of total Billed Charges,65% of Total Billed Charges,1906.89,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,4107.81,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3805.13,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,3891.61,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,1906.89,4324.01,
MRI Foot RT WO W Contrast,6100000077,CDM,610,RC,,,Outpatient,,,4324.01,2810.61,,4324.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3286.25,76,,22.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,3243.01,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,2594.41,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,3891.61,90,,1.464,Percent of Total Billed Charges,90% of Total Billed Charges,1945.8,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,3891.61,90,,26.192,Percent of Total Billed Charges,90% of Total billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2810.61,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,1906.89,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,4107.81,95,,27.648,Percent of Total Billed Charges,95% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3805.13,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,3891.61,90,,26.192,Percent of Total Billed charges,90% of Total Billed Charges,1906.89,4324.01,
MRI Foot LT WO W Contrast,6100000078,CDM,610,RC,,,Outpatient,,,4324.01,2810.61,,4324.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3286.25,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,3243.01,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,2594.41,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,3891.61,90,,11.16,Percent of Total Billed Charges,90% of Total Billed Charges,1945.8,45,,5151.76,Percent of Total Billed Charges,45% of Total Billed Charges,3891.61,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2810.61,65,,1.72,Percent of total Billed Charges,65% of Total Billed Charges,1906.89,44.1,,5048.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,4107.81,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3805.13,88,,10074.56,Percent of Total Billed Charges,88% of Total Billed Charges,3891.61,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,1906.89,4324.01,
MRI Lower Leg RT WO W contrast,6100000079,CDM,610,RC,,,Outpatient,,,4324.01,2810.61,,4324.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3286.25,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,3243.01,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,2594.41,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,3891.61,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,1945.8,45,,16.92,Percent of Total Billed Charges,45% of Total Billed Charges,3891.61,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2810.61,65,,8.032,Percent of total Billed Charges,65% of Total Billed Charges,1906.89,44.1,,16.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,4107.81,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3805.13,88,,33.088,Percent of Total Billed Charges,88% of Total Billed Charges,3891.61,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,1906.89,4324.01,
MRI Lower Leg LT WO W Contrast,6100000080,CDM,610,RC,,,Outpatient,,,4324.01,2810.61,,4324.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3286.25,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,3243.01,75,,2594.408,Percent of Total Billed charges,75% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3113.29,72,,2490.632,Percent of Total Billed Charges,72% of Total Billed Charges,2594.41,60,,2075.528,Percent of Total Billed Charges,60% of Total Billed Charges,3891.61,90,,3.768,Percent of Total Billed Charges,90% of Total Billed Charges,1945.8,45,,45.648,Percent of Total Billed Charges,45% of Total Billed Charges,3891.61,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2810.61,65,,89.432,Percent of total Billed Charges,65% of Total Billed Charges,1906.89,44.1,,44.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,4107.81,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,4324.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3805.13,88,,89.264,Percent of Total Billed Charges,88% of Total Billed Charges,3891.61,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,1906.89,4324.01,
MRI Hip RT WO Contrast,6100000081,CDM,610,RC,,,Outpatient,,,3962.39,2575.55,,3962.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3011.42,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2852.92,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,2971.79,75,,2377.432,Percent of Total Billed charges,75% of Total Billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2852.92,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,2377.43,60,,1901.944,Percent of Total Billed Charges,60% of Total Billed Charges,3566.15,90,,475.488,Percent of Total Billed Charges,90% of Total Billed Charges,1783.08,45,,121.456,Percent of Total Billed Charges,45% of Total Billed Charges,3566.15,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2575.55,65,,13.184,Percent of total Billed Charges,65% of Total Billed Charges,1747.41,44.1,,119.024,Percent of Total Billed Charges,44.1% of Total Billed Charges,3764.27,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3486.9,88,,237.512,Percent of Total Billed Charges,88% of Total Billed Charges,3566.15,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,1747.41,3962.39,
MRI Hip LT WO Contrast,6100000082,CDM,610,RC,,,Outpatient,,,3962.39,2575.55,,3962.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3011.42,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2852.92,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,2971.79,75,,2377.432,Percent of Total Billed charges,75% of Total Billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2852.92,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,2377.43,60,,1901.944,Percent of Total Billed Charges,60% of Total Billed Charges,3566.15,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,1783.08,45,,0.728,Percent of Total Billed Charges,45% of Total Billed Charges,3566.15,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2575.55,65,,234.112,Percent of total Billed Charges,65% of Total Billed Charges,1747.41,44.1,,0.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,3764.27,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3486.9,88,,1.432,Percent of Total Billed Charges,88% of Total Billed Charges,3566.15,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,1747.41,3962.39,
MRI Knee RT WO Contrast,6100000083,CDM,610,RC,,,Outpatient,,,3962.39,2575.55,,3962.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3011.42,76,,8700.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2852.92,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,2971.79,75,,2377.432,Percent of Total Billed charges,75% of Total Billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2852.92,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,2377.43,60,,1901.944,Percent of Total Billed Charges,60% of Total Billed Charges,3566.15,90,,7.944,Percent of Total Billed Charges,90% of Total Billed Charges,1783.08,45,,5.584,Percent of Total Billed Charges,45% of Total Billed Charges,3566.15,90,,10303.528,Percent of Total Billed Charges,90% of Total billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2575.55,65,,290.664,Percent of total Billed Charges,65% of Total Billed Charges,1747.41,44.1,,5.472,Percent of Total Billed Charges,44.1% of Total Billed Charges,3764.27,95,,10875.944,Percent of Total Billed Charges,95% of Total Billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3486.9,88,,10.912,Percent of Total Billed Charges,88% of Total Billed Charges,3566.15,90,,10303.528,Percent of Total Billed charges,90% of Total Billed Charges,1747.41,3962.39,
MRI Knee LT WO Contrast,6100000084,CDM,610,RC,,,Outpatient,,,3962.39,2575.55,,3962.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3011.42,76,,28.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2852.92,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,2971.79,75,,2377.432,Percent of Total Billed charges,75% of Total Billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2852.92,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,2377.43,60,,1901.944,Percent of Total Billed Charges,60% of Total Billed Charges,3566.15,90,,31.752,Percent of Total Billed Charges,90% of Total Billed Charges,1783.08,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,3566.15,90,,33.84,Percent of Total Billed Charges,90% of Total billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2575.55,65,,68.224,Percent of total Billed Charges,65% of Total Billed Charges,1747.41,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,3764.27,95,,35.72,Percent of Total Billed Charges,95% of Total Billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3486.9,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,3566.15,90,,33.84,Percent of Total Billed charges,90% of Total Billed Charges,1747.41,3962.39,
MRI Ankle RT WO Contrast,6100000085,CDM,610,RC,,,Outpatient,,,3962.39,2575.55,,3962.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3011.42,76,,77.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2852.92,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,2971.79,75,,2377.432,Percent of Total Billed charges,75% of Total Billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2852.92,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,2377.43,60,,1901.944,Percent of Total Billed Charges,60% of Total Billed Charges,3566.15,90,,18.184,Percent of Total Billed Charges,90% of Total Billed Charges,1783.08,45,,1.88,Percent of Total Billed Charges,45% of Total Billed Charges,3566.15,90,,91.288,Percent of Total Billed Charges,90% of Total billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2575.55,65,,205.248,Percent of total Billed Charges,65% of Total Billed Charges,1747.41,44.1,,1.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,3764.27,95,,96.36,Percent of Total Billed Charges,95% of Total Billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3486.9,88,,3.68,Percent of Total Billed Charges,88% of Total Billed Charges,3566.15,90,,91.288,Percent of Total Billed charges,90% of Total Billed Charges,1747.41,3962.39,
MRI Ankle LT WO Contrast,6100000086,CDM,610,RC,,,Outpatient,,,3962.39,2575.55,,3962.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3011.42,76,,205.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2852.92,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,2971.79,75,,2377.432,Percent of Total Billed charges,75% of Total Billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2852.92,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,2377.43,60,,1901.944,Percent of Total Billed Charges,60% of Total Billed Charges,3566.15,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,1783.08,45,,237.744,Percent of Total Billed Charges,45% of Total Billed Charges,3566.15,90,,242.904,Percent of Total Billed Charges,90% of Total billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2575.55,65,,45.296,Percent of total Billed Charges,65% of Total Billed Charges,1747.41,44.1,,232.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,3764.27,95,,256.4,Percent of Total Billed Charges,95% of Total Billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3486.9,88,,464.92,Percent of Total Billed Charges,88% of Total Billed Charges,3566.15,90,,242.904,Percent of Total Billed charges,90% of Total Billed Charges,1747.41,3962.39,
MRI Zimmer Knee RT,6100000087,CDM,610,RC,,,Outpatient,,,3962.39,2575.55,,3962.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3011.42,76,,1.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2852.92,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,2971.79,75,,2377.432,Percent of Total Billed charges,75% of Total Billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2852.92,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,2377.43,60,,1901.944,Percent of Total Billed Charges,60% of Total Billed Charges,3566.15,90,,33.344,Percent of Total Billed Charges,90% of Total Billed Charges,1783.08,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,3566.15,90,,1.464,Percent of Total Billed Charges,90% of Total billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2575.55,65,,45.296,Percent of total Billed Charges,65% of Total Billed Charges,1747.41,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,3764.27,95,,1.544,Percent of Total Billed Charges,95% of Total Billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3486.9,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,3566.15,90,,1.464,Percent of Total Billed charges,90% of Total Billed Charges,1747.41,3962.39,
MRI Zimmer Knee LT,6100000088,CDM,610,RC,,,Outpatient,,,3962.39,2575.55,,3962.39,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3011.42,76,,9.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2852.92,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,2971.79,75,,2377.432,Percent of Total Billed charges,75% of Total Billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2852.92,72,,2282.336,Percent of Total Billed Charges,72% of Total Billed Charges,2377.43,60,,1901.944,Percent of Total Billed Charges,60% of Total Billed Charges,3566.15,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,1783.08,45,,3.968,Percent of Total Billed Charges,45% of Total Billed Charges,3566.15,90,,11.16,Percent of Total Billed Charges,90% of Total billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2575.55,65,,45.296,Percent of total Billed Charges,65% of Total Billed Charges,1747.41,44.1,,3.888,Percent of Total Billed Charges,44.1% of Total Billed Charges,3764.27,95,,11.784,Percent of Total Billed Charges,95% of Total Billed Charges,3962.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3486.9,88,,7.768,Percent of Total Billed Charges,88% of Total Billed Charges,3566.15,90,,11.16,Percent of Total Billed charges,90% of Total Billed Charges,1747.41,3962.39,
MRI Knee RT W Contrast,6100000089,CDM,610,RC,,,Outpatient,,,3112.36,2023.03,,3112.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2365.39,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,2334.27,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,1867.42,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,2801.12,90,,134.152,Percent of Total Billed Charges,90% of Total Billed Charges,1400.56,45,,15.88,Percent of Total Billed Charges,45% of Total Billed Charges,2801.12,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2023.03,65,,45.296,Percent of total Billed Charges,65% of Total Billed Charges,1372.55,44.1,,15.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,2956.74,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2738.88,88,,31.048,Percent of Total Billed Charges,88% of Total Billed Charges,2801.12,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,1372.55,3112.36,
MRI Knee LT W Contrast,6100000090,CDM,610,RC,,,Outpatient,,,3112.36,2023.03,,3112.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2365.39,76,,3.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,2334.27,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,1867.42,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,2801.12,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,1400.56,45,,9.088,Percent of Total Billed Charges,45% of Total Billed Charges,2801.12,90,,3.768,Percent of Total Billed Charges,90% of Total billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2023.03,65,,45.296,Percent of total Billed Charges,65% of Total Billed Charges,1372.55,44.1,,8.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,2956.74,95,,3.976,Percent of Total Billed Charges,95% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2738.88,88,,17.776,Percent of Total Billed Charges,88% of Total Billed Charges,2801.12,90,,3.768,Percent of Total Billed charges,90% of Total Billed Charges,1372.55,3112.36,
MRI Foot RT W Contrast,6100000091,CDM,610,RC,,,Outpatient,,,3112.36,2023.03,,3112.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2365.39,76,,401.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,2334.27,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,1867.42,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,2801.12,90,,666.792,Percent of Total Billed Charges,90% of Total Billed Charges,1400.56,45,,31.32,Percent of Total Billed Charges,45% of Total Billed Charges,2801.12,90,,475.488,Percent of Total Billed Charges,90% of Total billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2023.03,65,,3381.328,Percent of total Billed Charges,65% of Total Billed Charges,1372.55,44.1,,30.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,2956.74,95,,501.904,Percent of Total Billed Charges,95% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2738.88,88,,61.248,Percent of Total Billed Charges,88% of Total Billed Charges,2801.12,90,,475.488,Percent of Total Billed charges,90% of Total Billed Charges,1372.55,3112.36,
MRI Foot LT W Contrast,6100000092,CDM,610,RC,,,Outpatient,,,3112.36,2023.03,,3112.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2365.39,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,2334.27,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,1867.42,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,2801.12,90,,33.344,Percent of Total Billed Charges,90% of Total Billed Charges,1400.56,45,,16.672,Percent of Total Billed Charges,45% of Total Billed Charges,2801.12,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2023.03,65,,223.176,Percent of total Billed Charges,65% of Total Billed Charges,1372.55,44.1,,16.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,2956.74,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2738.88,88,,32.6,Percent of Total Billed Charges,88% of Total Billed Charges,2801.12,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,1372.55,3112.36,
MRI Ankle RT W Contrast,6100000093,CDM,610,RC,,,Outpatient,,,3112.36,2023.03,,3112.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2365.39,76,,6.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,2334.27,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,1867.42,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,2801.12,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,1400.56,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,2801.12,90,,7.944,Percent of Total Billed Charges,90% of Total billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2023.03,65,,223.176,Percent of total Billed Charges,65% of Total Billed Charges,1372.55,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,2956.74,95,,8.384,Percent of Total Billed Charges,95% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2738.88,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,2801.12,90,,7.944,Percent of Total Billed charges,90% of Total Billed Charges,1372.55,3112.36,
MRI Ankle LT W Contrast,6100000094,CDM,610,RC,,,Outpatient,,,3112.36,2023.03,,3112.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2365.39,76,,26.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,2334.27,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,1867.42,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,2801.12,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,1400.56,45,,67.072,Percent of Total Billed Charges,45% of Total Billed Charges,2801.12,90,,31.752,Percent of Total Billed Charges,90% of Total billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2023.03,65,,45.296,Percent of total Billed Charges,65% of Total Billed Charges,1372.55,44.1,,65.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,2956.74,95,,33.52,Percent of Total Billed Charges,95% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2738.88,88,,131.168,Percent of Total Billed Charges,88% of Total Billed Charges,2801.12,90,,31.752,Percent of Total Billed charges,90% of Total Billed Charges,1372.55,3112.36,
MRI Hip RT W Contrast,6100000095,CDM,610,RC,,,Outpatient,,,3112.36,2023.03,,3112.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2365.39,76,,15.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,2334.27,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,1867.42,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,2801.12,90,,7.144,Percent of Total Billed Charges,90% of Total Billed Charges,1400.56,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,2801.12,90,,18.184,Percent of Total Billed Charges,90% of Total billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2023.03,65,,223.176,Percent of total Billed Charges,65% of Total Billed Charges,1372.55,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,2956.74,95,,19.192,Percent of Total Billed Charges,95% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2738.88,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,2801.12,90,,18.184,Percent of Total Billed charges,90% of Total Billed Charges,1372.55,3112.36,
MRI Hip LT W Contrast,6100000096,CDM,610,RC,,,Outpatient,,,3112.36,2023.03,,3112.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2365.39,76,,52.896,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,2334.27,75,,1867.416,Percent of Total Billed charges,75% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2240.9,72,,1792.72,Percent of Total Billed Charges,72% of Total Billed Charges,1867.42,60,,1493.936,Percent of Total Billed Charges,60% of Total Billed Charges,2801.12,90,,20.64,Percent of Total Billed Charges,90% of Total Billed Charges,1400.56,45,,333.4,Percent of Total Billed Charges,45% of Total Billed Charges,2801.12,90,,62.64,Percent of Total Billed Charges,90% of Total billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2023.03,65,,223.176,Percent of total Billed Charges,65% of Total Billed Charges,1372.55,44.1,,326.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,2956.74,95,,66.12,Percent of Total Billed Charges,95% of Total Billed Charges,3112.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2738.88,88,,651.976,Percent of Total Billed Charges,88% of Total Billed Charges,2801.12,90,,62.64,Percent of Total Billed charges,90% of Total Billed Charges,1372.55,3112.36,
MRI Hip RT WO W Contrast,6100000097,CDM,610,RC,,,Outpatient,,,5849.87,3802.42,,5849.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4445.9,76,,28.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4211.91,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,4387.4,75,,3509.92,Percent of Total Billed charges,75% of Total Billed Charges,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4211.91,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,3509.92,60,,2807.936,Percent of Total Billed Charges,60% of Total Billed Charges,5264.88,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,2632.44,45,,16.672,Percent of Total Billed Charges,45% of Total Billed Charges,5264.88,90,,33.344,Percent of Total Billed Charges,90% of Total billed Charges,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3802.42,65,,987.792,Percent of total Billed Charges,65% of Total Billed Charges,2579.79,44.1,,16.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,5557.38,95,,35.192,Percent of Total Billed Charges,95% of Total Billed Charges,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5147.89,88,,32.6,Percent of Total Billed Charges,88% of Total Billed Charges,5264.88,90,,33.344,Percent of Total Billed charges,90% of Total Billed Charges,2579.79,5849.87,
MRI Hip LT WO W Contrast,6100000098,CDM,610,RC,,,Outpatient,,,5849.87,3802.42,,5849.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4445.9,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4211.91,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,4387.4,75,,3509.92,Percent of Total Billed charges,75% of Total Billed Charges,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4211.91,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,3509.92,60,,2807.936,Percent of Total Billed Charges,60% of Total Billed Charges,5264.88,90,,34.928,Percent of Total Billed Charges,90% of Total Billed Charges,2632.44,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,5264.88,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3802.42,65,,493.896,Percent of total Billed Charges,65% of Total Billed Charges,2579.79,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,5557.38,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5147.89,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,5264.88,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,2579.79,5849.87,
MRI Knee RT WO W Contrast,6100000099,CDM,610,RC,,,Outpatient,,,5849.87,3802.42,,5849.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4445.9,76,,113.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4211.91,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,4387.4,75,,3509.92,Percent of Total Billed charges,75% of Total Billed Charges,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4211.91,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,3509.92,60,,2807.936,Percent of Total Billed Charges,60% of Total Billed Charges,5264.88,90,,66.68,Percent of Total Billed Charges,90% of Total Billed Charges,2632.44,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,5264.88,90,,134.152,Percent of Total Billed Charges,90% of Total billed Charges,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3802.42,65,,246.952,Percent of total Billed Charges,65% of Total Billed Charges,2579.79,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,5557.38,95,,141.6,Percent of Total Billed Charges,95% of Total Billed Charges,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5147.89,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,5264.88,90,,134.152,Percent of Total Billed charges,90% of Total Billed Charges,2579.79,5849.87,
MRI Knee LT WO W Contrast,6100000100,CDM,610,RC,,,Outpatient,,,5849.87,3802.42,,5849.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4445.9,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4211.91,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,4387.4,75,,3509.92,Percent of Total Billed charges,75% of Total Billed Charges,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4211.91,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,3509.92,60,,2807.936,Percent of Total Billed Charges,60% of Total Billed Charges,5264.88,90,,76.208,Percent of Total Billed Charges,90% of Total Billed Charges,2632.44,45,,3.568,Percent of Total Billed Charges,45% of Total Billed Charges,5264.88,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3802.42,65,,197.56,Percent of total Billed Charges,65% of Total Billed Charges,2579.79,44.1,,3.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,5557.38,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5147.89,88,,6.984,Percent of Total Billed Charges,88% of Total Billed Charges,5264.88,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,2579.79,5849.87,
MRI Ankle RT WO W Contrast,6100000101,CDM,610,RC,,,Outpatient,,,5849.87,3802.42,,5849.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4445.9,76,,563.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4211.91,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,4387.4,75,,3509.92,Percent of Total Billed charges,75% of Total Billed Charges,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4211.91,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,3509.92,60,,2807.936,Percent of Total Billed Charges,60% of Total Billed Charges,5264.88,90,,723.944,Percent of Total Billed Charges,90% of Total Billed Charges,2632.44,45,,10.32,Percent of Total Billed Charges,45% of Total Billed Charges,5264.88,90,,666.792,Percent of Total Billed Charges,90% of Total billed Charges,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3802.42,65,,329.16,Percent of total Billed Charges,65% of Total Billed Charges,2579.79,44.1,,10.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,5557.38,95,,703.84,Percent of Total Billed Charges,95% of Total Billed Charges,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5147.89,88,,20.184,Percent of Total Billed Charges,88% of Total Billed Charges,5264.88,90,,666.792,Percent of Total Billed charges,90% of Total Billed Charges,2579.79,5849.87,
MRI Ankle LT WO W Contrast,6100000102,CDM,610,RC,,,Outpatient,,,5849.87,3802.42,,5849.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4445.9,76,,28.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4211.91,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,4387.4,75,,3509.92,Percent of Total Billed charges,75% of Total Billed Charges,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4211.91,72,,3369.528,Percent of Total Billed Charges,72% of Total Billed Charges,3509.92,60,,2807.936,Percent of Total Billed Charges,60% of Total Billed Charges,5264.88,90,,73.824,Percent of Total Billed Charges,90% of Total Billed Charges,2632.44,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,5264.88,90,,33.344,Percent of Total Billed Charges,90% of Total billed Charges,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3802.42,65,,329.264,Percent of total Billed Charges,65% of Total Billed Charges,2579.79,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,5557.38,95,,35.192,Percent of Total Billed Charges,95% of Total Billed Charges,5849.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5147.89,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,5264.88,90,,33.344,Percent of Total Billed charges,90% of Total Billed Charges,2579.79,5849.87,
MRI PITUITARY W  W/O CONTRAST,6110000001,CDM,611,RC,,,Outpatient,,,4904.00,3187.60,,4904,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3727.04,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3530.88,72,,2824.704,Percent of Total Billed Charges,72% of Total Billed Charges,3678,75,,2942.4,Percent of Total Billed charges,75% of Total Billed Charges,4904,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3530.88,72,,2824.704,Percent of Total Billed Charges,72% of Total Billed Charges,2942.4,60,,2353.92,Percent of Total Billed Charges,60% of Total Billed Charges,4413.6,90,,473.896,Percent of Total Billed Charges,90% of Total Billed Charges,2206.8,45,,17.464,Percent of Total Billed Charges,45% of Total Billed Charges,4413.6,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,4904,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4904,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4904,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3187.6,65,,246.952,Percent of total Billed Charges,65% of Total Billed Charges,2162.66,44.1,,17.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,4658.8,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,4904,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4315.52,88,,34.152,Percent of Total Billed Charges,88% of Total Billed Charges,4413.6,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,2162.66,4904,
MRI BRAIN W/O CONT,6110000002,CDM,611,RC,,,Outpatient,,,4287.00,2786.55,,4287,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3258.12,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3086.64,72,,2469.312,Percent of Total Billed Charges,72% of Total Billed Charges,3215.25,75,,2572.2,Percent of Total Billed charges,75% of Total Billed Charges,4287,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3086.64,72,,2469.312,Percent of Total Billed Charges,72% of Total Billed Charges,2572.2,60,,2057.76,Percent of Total Billed Charges,60% of Total Billed Charges,3858.3,90,,30.96,Percent of Total Billed Charges,90% of Total Billed Charges,1929.15,45,,33.336,Percent of Total Billed Charges,45% of Total Billed Charges,3858.3,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,4287,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4287,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4287,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2786.55,65,,987.792,Percent of total Billed Charges,65% of Total Billed Charges,1890.57,44.1,,32.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,4072.65,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,4287,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3772.56,88,,65.2,Percent of Total Billed Charges,88% of Total Billed Charges,3858.3,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,1890.57,4287,
MRI PITUITARY WITHOUT CONTRAST,6110000003,CDM,611,RC,,,Outpatient,,,4287.00,2786.55,,4287,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3258.12,76,,6.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3086.64,72,,2469.312,Percent of Total Billed Charges,72% of Total Billed Charges,3215.25,75,,2572.2,Percent of Total Billed charges,75% of Total Billed Charges,4287,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3086.64,72,,2469.312,Percent of Total Billed Charges,72% of Total Billed Charges,2572.2,60,,2057.76,Percent of Total Billed Charges,60% of Total Billed Charges,3858.3,90,,43.56,Percent of Total Billed Charges,90% of Total Billed Charges,1929.15,45,,38.104,Percent of Total Billed Charges,45% of Total Billed Charges,3858.3,90,,7.144,Percent of Total Billed Charges,90% of Total billed Charges,4287,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4287,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4287,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2786.55,65,,493.896,Percent of total Billed Charges,65% of Total Billed Charges,1890.57,44.1,,37.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,4072.65,95,,7.536,Percent of Total Billed Charges,95% of Total Billed Charges,4287,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3772.56,88,,74.512,Percent of Total Billed Charges,88% of Total Billed Charges,3858.3,90,,7.144,Percent of Total Billed charges,90% of Total Billed Charges,1890.57,4287,
MRI BRAIN W/CONT,6110000004,CDM,611,RC,,,Outpatient,,,4092.48,2660.11,,4092.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3110.28,76,,17.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2946.59,72,,2357.272,Percent of Total Billed Charges,72% of Total Billed Charges,3069.36,75,,2455.488,Percent of Total Billed charges,75% of Total Billed Charges,4092.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2946.59,72,,2357.272,Percent of Total Billed Charges,72% of Total Billed Charges,2455.49,60,,1964.392,Percent of Total Billed Charges,60% of Total Billed Charges,3683.23,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,1841.62,45,,361.976,Percent of Total Billed Charges,45% of Total Billed Charges,3683.23,90,,20.64,Percent of Total Billed Charges,90% of Total billed Charges,4092.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4092.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4092.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2660.11,65,,197.56,Percent of total Billed Charges,65% of Total Billed Charges,1804.78,44.1,,354.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,3887.86,95,,21.792,Percent of Total Billed Charges,95% of Total Billed Charges,4092.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3601.38,88,,707.856,Percent of Total Billed Charges,88% of Total Billed Charges,3683.23,90,,20.64,Percent of Total Billed charges,90% of Total Billed Charges,1804.78,4092.48,
MRI PITUITARY WITH CONTRAST,6110000005,CDM,611,RC,,,Outpatient,,,4092.48,2660.11,,4092.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3110.28,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2946.59,72,,2357.272,Percent of Total Billed Charges,72% of Total Billed Charges,3069.36,75,,2455.488,Percent of Total Billed charges,75% of Total Billed Charges,4092.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2946.59,72,,2357.272,Percent of Total Billed Charges,72% of Total Billed Charges,2455.49,60,,1964.392,Percent of Total Billed Charges,60% of Total Billed Charges,3683.23,90,,75.416,Percent of Total Billed Charges,90% of Total Billed Charges,1841.62,45,,36.912,Percent of Total Billed Charges,45% of Total Billed Charges,3683.23,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,4092.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4092.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4092.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2660.11,65,,59.624,Percent of total Billed Charges,65% of Total Billed Charges,1804.78,44.1,,36.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,3887.86,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,4092.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3601.38,88,,72.184,Percent of Total Billed Charges,88% of Total Billed Charges,3683.23,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,1804.78,4092.48,
MRI BRAIN W/WO CONT,6110000006,CDM,611,RC,,,Outpatient,,,4904.00,3187.60,,4904,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3727.04,76,,29.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3530.88,72,,2824.704,Percent of Total Billed Charges,72% of Total Billed Charges,3678,75,,2942.4,Percent of Total Billed charges,75% of Total Billed Charges,4904,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3530.88,72,,2824.704,Percent of Total Billed Charges,72% of Total Billed Charges,2942.4,60,,2353.92,Percent of Total Billed Charges,60% of Total Billed Charges,4413.6,90,,50.008,Percent of Total Billed Charges,90% of Total Billed Charges,2206.8,45,,236.952,Percent of Total Billed Charges,45% of Total Billed Charges,4413.6,90,,34.928,Percent of Total Billed Charges,90% of Total billed Charges,4904,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4904,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4904,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3187.6,65,,2.296,Percent of total Billed Charges,65% of Total Billed Charges,2162.66,44.1,,232.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,4658.8,95,,36.864,Percent of Total Billed Charges,95% of Total Billed Charges,4904,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4315.52,88,,463.368,Percent of Total Billed Charges,88% of Total Billed Charges,4413.6,90,,34.928,Percent of Total Billed charges,90% of Total Billed Charges,2162.66,4904,
MRI SPINL CERVICL WO,6120000001,CDM,612,RC,,,Outpatient,,,4270.00,2775.50,,4270,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3245.2,76,,56.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3074.4,72,,2459.52,Percent of Total Billed Charges,72% of Total Billed Charges,3202.5,75,,2562,Percent of Total Billed charges,75% of Total Billed Charges,4270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3074.4,72,,2459.52,Percent of Total Billed Charges,72% of Total Billed Charges,2562,60,,2049.6,Percent of Total Billed Charges,60% of Total Billed Charges,3843,90,,8.736,Percent of Total Billed Charges,90% of Total Billed Charges,1921.5,45,,15.48,Percent of Total Billed Charges,45% of Total Billed Charges,3843,90,,66.68,Percent of Total Billed Charges,90% of Total billed Charges,4270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2775.5,65,,17.68,Percent of total Billed Charges,65% of Total Billed Charges,1883.07,44.1,,15.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,4056.5,95,,70.384,Percent of Total Billed Charges,95% of Total Billed Charges,4270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3757.6,88,,30.272,Percent of Total Billed Charges,88% of Total Billed Charges,3843,90,,66.68,Percent of Total Billed charges,90% of Total Billed Charges,1883.07,4270,
MRI SPINE CERVICAL W,6120000002,CDM,612,RC,,,Outpatient,,,3124.49,2030.92,,3124.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2374.61,76,,64.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2249.63,72,,1799.704,Percent of Total Billed Charges,72% of Total Billed Charges,2343.37,75,,1874.696,Percent of Total Billed charges,75% of Total Billed Charges,3124.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2249.63,72,,1799.704,Percent of Total Billed Charges,72% of Total Billed Charges,1874.69,60,,1499.752,Percent of Total Billed Charges,60% of Total Billed Charges,2812.04,90,,113.512,Percent of Total Billed Charges,90% of Total Billed Charges,1406.02,45,,21.784,Percent of Total Billed Charges,45% of Total Billed Charges,2812.04,90,,76.208,Percent of Total Billed Charges,90% of Total billed Charges,3124.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3124.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3124.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2030.92,65,,148.464,Percent of total Billed Charges,65% of Total Billed Charges,1377.9,44.1,,21.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,2968.27,95,,80.44,Percent of Total Billed Charges,95% of Total Billed Charges,3124.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2749.55,88,,42.592,Percent of Total Billed Charges,88% of Total Billed Charges,2812.04,90,,76.208,Percent of Total Billed charges,90% of Total Billed Charges,1377.9,3124.49,
MRI SPINE THORAC W/O,6120000003,CDM,612,RC,,,Outpatient,,,2944.00,1913.60,,2944,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2237.44,76,,611.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2119.68,72,,1695.744,Percent of Total Billed Charges,72% of Total Billed Charges,2208,75,,1766.4,Percent of Total Billed charges,75% of Total Billed Charges,2944,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2119.68,72,,1695.744,Percent of Total Billed Charges,72% of Total Billed Charges,1766.4,60,,1413.12,Percent of Total Billed Charges,60% of Total Billed Charges,2649.6,90,,43.664,Percent of Total Billed Charges,90% of Total Billed Charges,1324.8,45,,16.92,Percent of Total Billed Charges,45% of Total Billed Charges,2649.6,90,,723.944,Percent of Total Billed Charges,90% of Total billed Charges,2944,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2944,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2944,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1913.6,65,,45.888,Percent of total Billed Charges,65% of Total Billed Charges,1298.3,44.1,,16.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,2796.8,95,,764.168,Percent of Total Billed Charges,95% of Total Billed Charges,2944,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2590.72,88,,33.088,Percent of Total Billed Charges,88% of Total Billed Charges,2649.6,90,,723.944,Percent of Total Billed charges,90% of Total Billed Charges,1298.3,2944,
MRI SPINE THORAC W/,6120000004,CDM,612,RC,,,Outpatient,,,3124.49,2030.92,,3124.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2374.61,76,,62.336,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2249.63,72,,1799.704,Percent of Total Billed Charges,72% of Total Billed Charges,2343.37,75,,1874.696,Percent of Total Billed charges,75% of Total Billed Charges,3124.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2249.63,72,,1799.704,Percent of Total Billed Charges,72% of Total Billed Charges,1874.69,60,,1499.752,Percent of Total Billed Charges,60% of Total Billed Charges,2812.04,90,,148.44,Percent of Total Billed Charges,90% of Total Billed Charges,1406.02,45,,37.704,Percent of Total Billed Charges,45% of Total Billed Charges,2812.04,90,,73.824,Percent of Total Billed Charges,90% of Total billed Charges,3124.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3124.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3124.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2030.92,65,,24.44,Percent of total Billed Charges,65% of Total Billed Charges,1377.9,44.1,,36.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,2968.27,95,,77.92,Percent of Total Billed Charges,95% of Total Billed Charges,3124.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2749.55,88,,73.736,Percent of Total Billed Charges,88% of Total Billed Charges,2812.04,90,,73.824,Percent of Total Billed charges,90% of Total Billed Charges,1377.9,3124.49,
MRI SPINE LUMBAR W/O,6120000005,CDM,612,RC,,,Outpatient,,,3893.00,2530.45,,3893,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2958.68,76,,400.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2802.96,72,,2242.368,Percent of Total Billed Charges,72% of Total Billed Charges,2919.75,75,,2335.8,Percent of Total Billed charges,75% of Total Billed Charges,3893,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2802.96,72,,2242.368,Percent of Total Billed Charges,72% of Total Billed Charges,2335.8,60,,1868.64,Percent of Total Billed Charges,60% of Total Billed Charges,3503.7,90,,16.672,Percent of Total Billed Charges,90% of Total Billed Charges,1751.85,45,,25.008,Percent of Total Billed Charges,45% of Total Billed Charges,3503.7,90,,473.896,Percent of Total Billed Charges,90% of Total billed Charges,3893,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3893,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3893,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2530.45,65,,91.232,Percent of total Billed Charges,65% of Total Billed Charges,1716.81,44.1,,24.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,3698.35,95,,500.224,Percent of Total Billed Charges,95% of Total Billed Charges,3893,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3425.84,88,,48.896,Percent of Total Billed Charges,88% of Total Billed Charges,3503.7,90,,473.896,Percent of Total Billed charges,90% of Total Billed Charges,1716.81,3893,
MRI SPINE LUMBAR W/C,6120000006,CDM,612,RC,,,Outpatient,,,2969.00,1929.85,,2969,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2256.44,76,,26.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2137.68,72,,1710.144,Percent of Total Billed Charges,72% of Total Billed Charges,2226.75,75,,1781.4,Percent of Total Billed charges,75% of Total Billed Charges,2969,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2137.68,72,,1710.144,Percent of Total Billed Charges,72% of Total Billed Charges,1781.4,60,,1425.12,Percent of Total Billed Charges,60% of Total Billed Charges,2672.1,90,,169.08,Percent of Total Billed Charges,90% of Total Billed Charges,1336.05,45,,4.368,Percent of Total Billed Charges,45% of Total Billed Charges,2672.1,90,,30.96,Percent of Total Billed Charges,90% of Total billed Charges,2969,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2969,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2969,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1929.85,65,,2226.248,Percent of total Billed Charges,65% of Total Billed Charges,1309.33,44.1,,4.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,2820.55,95,,32.68,Percent of Total Billed Charges,95% of Total Billed Charges,2969,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2612.72,88,,8.536,Percent of Total Billed Charges,88% of Total Billed Charges,2672.1,90,,30.96,Percent of Total Billed charges,90% of Total Billed Charges,1309.33,2969,
MRI SPINE CERV W/WO,6120000007,CDM,612,RC,,,Outpatient,,,4395.00,2856.75,,4395,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3340.2,76,,36.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3164.4,72,,2531.52,Percent of Total Billed Charges,72% of Total Billed Charges,3296.25,75,,2637,Percent of Total Billed charges,75% of Total Billed Charges,4395,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3164.4,72,,2531.52,Percent of Total Billed Charges,72% of Total Billed Charges,2637,60,,2109.6,Percent of Total Billed Charges,60% of Total Billed Charges,3955.5,90,,69.064,Percent of Total Billed Charges,90% of Total Billed Charges,1977.75,45,,56.76,Percent of Total Billed Charges,45% of Total Billed Charges,3955.5,90,,43.56,Percent of Total Billed Charges,90% of Total billed Charges,4395,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4395,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4395,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2856.75,65,,2447.608,Percent of total Billed Charges,65% of Total Billed Charges,1938.2,44.1,,55.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,4175.25,95,,45.984,Percent of Total Billed Charges,95% of Total Billed Charges,4395,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3867.6,88,,110.992,Percent of Total Billed Charges,88% of Total Billed Charges,3955.5,90,,43.56,Percent of Total Billed charges,90% of Total Billed Charges,1938.2,4395,
MRI SPNE THORAC W/WO,6120000008,CDM,612,RC,,,Outpatient,,,4155.00,2700.75,,4155,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3157.8,76,,28.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2991.6,72,,2393.28,Percent of Total Billed Charges,72% of Total Billed Charges,3116.25,75,,2493,Percent of Total Billed charges,75% of Total Billed Charges,4155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2991.6,72,,2393.28,Percent of Total Billed Charges,72% of Total Billed Charges,2493,60,,1994.4,Percent of Total Billed Charges,60% of Total Billed Charges,3739.5,90,,92.872,Percent of Total Billed Charges,90% of Total Billed Charges,1869.75,45,,21.832,Percent of Total Billed Charges,45% of Total Billed Charges,3739.5,90,,33.84,Percent of Total Billed Charges,90% of Total billed Charges,4155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2700.75,65,,94.824,Percent of total Billed Charges,65% of Total Billed Charges,1832.36,44.1,,21.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,3947.25,95,,35.72,Percent of Total Billed Charges,95% of Total Billed Charges,4155,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3656.4,88,,42.688,Percent of Total Billed Charges,88% of Total Billed Charges,3739.5,90,,33.84,Percent of Total Billed charges,90% of Total Billed Charges,1832.36,4155,
MRI SPINE LUMBR W/WO,6120000009,CDM,612,RC,,,Outpatient,,,4582.00,2978.30,,4582,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3482.32,76,,63.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3299.04,72,,2639.232,Percent of Total Billed Charges,72% of Total Billed Charges,3436.5,75,,2749.2,Percent of Total Billed charges,75% of Total Billed Charges,4582,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3299.04,72,,2639.232,Percent of Total Billed Charges,72% of Total Billed Charges,2749.2,60,,2199.36,Percent of Total Billed Charges,60% of Total Billed Charges,4123.8,90,,48.424,Percent of Total Billed Charges,90% of Total Billed Charges,2061.9,45,,74.224,Percent of Total Billed Charges,45% of Total Billed Charges,4123.8,90,,75.416,Percent of Total Billed Charges,90% of Total billed Charges,4582,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4582,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4582,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2978.3,65,,365.968,Percent of total Billed Charges,65% of Total Billed Charges,2020.66,44.1,,72.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,4352.9,95,,79.6,Percent of Total Billed Charges,95% of Total Billed Charges,4582,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4032.16,88,,145.144,Percent of Total Billed Charges,88% of Total Billed Charges,4123.8,90,,75.416,Percent of Total Billed charges,90% of Total Billed Charges,2020.66,4582,
MRI ABD W/WO CONT,6140000001,CDM,614,RC,,,Outpatient,,,6175.00,4013.75,,6175,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4693,76,,42.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4446,72,,3556.8,Percent of Total Billed Charges,72% of Total Billed Charges,4631.25,75,,3705,Percent of Total Billed charges,75% of Total Billed Charges,6175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4446,72,,3556.8,Percent of Total Billed Charges,72% of Total Billed Charges,3705,60,,2964,Percent of Total Billed Charges,60% of Total Billed Charges,5557.5,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,2778.75,45,,8.336,Percent of Total Billed Charges,45% of Total Billed Charges,5557.5,90,,50.008,Percent of Total Billed Charges,90% of Total billed Charges,6175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4013.75,65,,891.32,Percent of total Billed Charges,65% of Total Billed Charges,2723.18,44.1,,8.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,5866.25,95,,52.792,Percent of Total Billed Charges,95% of Total Billed Charges,6175,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5434,88,,16.296,Percent of Total Billed Charges,88% of Total Billed Charges,5557.5,90,,50.008,Percent of Total Billed charges,90% of Total Billed Charges,2723.18,6175,
MRA HEAD WO CONT,6150000001,CDM,615,RC,,,Outpatient,,,2811.00,1827.15,,2811,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2136.36,76,,7.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2023.92,72,,1619.136,Percent of Total Billed Charges,72% of Total Billed Charges,2108.25,75,,1686.6,Percent of Total Billed charges,75% of Total Billed Charges,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2023.92,72,,1619.136,Percent of Total Billed Charges,72% of Total Billed Charges,1686.6,60,,1349.28,Percent of Total Billed Charges,60% of Total Billed Charges,2529.9,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,1264.95,45,,84.536,Percent of Total Billed Charges,45% of Total Billed Charges,2529.9,90,,8.736,Percent of Total Billed Charges,90% of Total billed Charges,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1827.15,65,,4495.592,Percent of total Billed Charges,65% of Total Billed Charges,1239.65,44.1,,82.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,2670.45,95,,9.216,Percent of Total Billed Charges,95% of Total Billed Charges,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2473.68,88,,165.32,Percent of Total Billed Charges,88% of Total Billed Charges,2529.9,90,,8.736,Percent of Total Billed charges,90% of Total Billed Charges,1239.65,2811,
MRA HEAD W/ CONT,6150000002,CDM,615,RC,,,Outpatient,,,3025.26,1966.42,,3025.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2299.2,76,,95.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2178.19,72,,1742.552,Percent of Total Billed Charges,72% of Total Billed Charges,2268.95,75,,1815.16,Percent of Total Billed charges,75% of Total Billed Charges,3025.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178.19,72,,1742.552,Percent of Total Billed Charges,72% of Total Billed Charges,1815.16,60,,1452.128,Percent of Total Billed Charges,60% of Total Billed Charges,2722.73,90,,31.752,Percent of Total Billed Charges,90% of Total Billed Charges,1361.37,45,,34.528,Percent of Total Billed Charges,45% of Total Billed Charges,2722.73,90,,113.512,Percent of Total Billed Charges,90% of Total billed Charges,3025.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3025.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3025.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1966.42,65,,87.48,Percent of total Billed Charges,65% of Total Billed Charges,1334.14,44.1,,33.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,2874,95,,119.824,Percent of Total Billed Charges,95% of Total Billed Charges,3025.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2662.23,88,,67.528,Percent of Total Billed Charges,88% of Total Billed Charges,2722.73,90,,113.512,Percent of Total Billed charges,90% of Total Billed Charges,1334.14,3025.26,
MRA HEAD W/WO CONT,6150000003,CDM,615,RC,,,Outpatient,,,4235.81,2753.28,,4235.81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3219.22,76,,36.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3049.78,72,,2439.824,Percent of Total Billed Charges,72% of Total Billed Charges,3176.86,75,,2541.488,Percent of Total Billed charges,75% of Total Billed Charges,4235.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3049.78,72,,2439.824,Percent of Total Billed Charges,72% of Total Billed Charges,2541.49,60,,2033.192,Percent of Total Billed Charges,60% of Total Billed Charges,3812.23,90,,413.568,Percent of Total Billed Charges,90% of Total Billed Charges,1906.11,45,,46.44,Percent of Total Billed Charges,45% of Total Billed Charges,3812.23,90,,43.664,Percent of Total Billed Charges,90% of Total billed Charges,4235.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4235.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4235.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2753.28,65,,92.792,Percent of total Billed Charges,65% of Total Billed Charges,1867.99,44.1,,45.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,4024.02,95,,46.088,Percent of Total Billed Charges,95% of Total Billed Charges,4235.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3727.51,88,,90.808,Percent of Total Billed Charges,88% of Total Billed Charges,3812.23,90,,43.664,Percent of Total Billed charges,90% of Total Billed Charges,1867.99,4235.81,
MRA NECK W/O CONT,6150000004,CDM,615,RC,,,Outpatient,,,2899.00,1884.35,,2899,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2203.24,76,,125.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2087.28,72,,1669.824,Percent of Total Billed Charges,72% of Total Billed Charges,2174.25,75,,1739.4,Percent of Total Billed charges,75% of Total Billed Charges,2899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2087.28,72,,1669.824,Percent of Total Billed Charges,72% of Total Billed Charges,1739.4,60,,1391.52,Percent of Total Billed Charges,60% of Total Billed Charges,2609.1,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,1304.55,45,,24.208,Percent of Total Billed Charges,45% of Total Billed Charges,2609.1,90,,148.44,Percent of Total Billed Charges,90% of Total billed Charges,2899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1884.35,65,,92.792,Percent of total Billed Charges,65% of Total Billed Charges,1278.46,44.1,,23.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,2754.05,95,,156.688,Percent of Total Billed Charges,95% of Total Billed Charges,2899,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2551.12,88,,47.344,Percent of Total Billed Charges,88% of Total Billed Charges,2609.1,90,,148.44,Percent of Total Billed charges,90% of Total Billed Charges,1278.46,2899,
MRA NECK W/ CONT,6150000005,CDM,615,RC,,,Outpatient,,,3025.26,1966.42,,3025.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2299.2,76,,14.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2178.19,72,,1742.552,Percent of Total Billed Charges,72% of Total Billed Charges,2268.95,75,,1815.16,Percent of Total Billed charges,75% of Total Billed Charges,3025.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2178.19,72,,1742.552,Percent of Total Billed Charges,72% of Total Billed Charges,1815.16,60,,1452.128,Percent of Total Billed Charges,60% of Total Billed Charges,2722.73,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,1361.37,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,2722.73,90,,16.672,Percent of Total Billed Charges,90% of Total billed Charges,3025.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3025.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3025.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1966.42,65,,4774.144,Percent of total Billed Charges,65% of Total Billed Charges,1334.14,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,2874,95,,17.592,Percent of Total Billed Charges,95% of Total Billed Charges,3025.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2662.23,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,2722.73,90,,16.672,Percent of Total Billed charges,90% of Total Billed Charges,1334.14,3025.26,
MRA NECK W/WO CONT,6150000006,CDM,615,RC,,,Outpatient,,,4575.00,2973.75,,4575,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3477,76,,142.776,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3294,72,,2635.2,Percent of Total Billed Charges,72% of Total Billed Charges,3431.25,75,,2745,Percent of Total Billed charges,75% of Total Billed Charges,4575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3294,72,,2635.2,Percent of Total Billed Charges,72% of Total Billed Charges,2745,60,,2196,Percent of Total Billed Charges,60% of Total Billed Charges,4117.5,90,,865.248,Percent of Total Billed Charges,90% of Total Billed Charges,2058.75,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,4117.5,90,,169.08,Percent of Total Billed Charges,90% of Total billed Charges,4575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2973.75,65,,215.88,Percent of total Billed Charges,65% of Total Billed Charges,2017.58,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,4346.25,95,,178.472,Percent of Total Billed Charges,95% of Total Billed Charges,4575,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4026,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,4117.5,90,,169.08,Percent of Total Billed charges,90% of Total Billed Charges,2017.58,4575,
MRA SPINAL CANL W OR WO,6180000001,CDM,618,RC,,,Outpatient,,,4615.07,2999.80,,4615.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3507.45,76,,58.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3322.85,72,,2658.28,Percent of Total Billed Charges,72% of Total Billed Charges,3461.3,75,,2769.04,Percent of Total Billed charges,75% of Total Billed Charges,4615.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3322.85,72,,2658.28,Percent of Total Billed Charges,72% of Total Billed Charges,2769.04,60,,2215.232,Percent of Total Billed Charges,60% of Total Billed Charges,4153.56,90,,84.96,Percent of Total Billed Charges,90% of Total Billed Charges,2076.78,45,,15.88,Percent of Total Billed Charges,45% of Total Billed Charges,4153.56,90,,69.064,Percent of Total Billed Charges,90% of Total billed Charges,4615.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4615.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4615.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2999.8,65,,6.24,Percent of total Billed Charges,65% of Total Billed Charges,2035.25,44.1,,15.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,4384.32,95,,72.896,Percent of Total Billed Charges,95% of Total Billed Charges,4615.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4061.26,88,,31.048,Percent of Total Billed Charges,88% of Total Billed Charges,4153.56,90,,69.064,Percent of Total Billed charges,90% of Total Billed Charges,2035.25,4615.07,
MRA EXT UPR W OR WO,6180000002,CDM,618,RC,,,Outpatient,,,5294.00,3441.10,,5294,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4023.44,76,,78.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3811.68,72,,3049.344,Percent of Total Billed Charges,72% of Total Billed Charges,3970.5,75,,3176.4,Percent of Total Billed charges,75% of Total Billed Charges,5294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3811.68,72,,3049.344,Percent of Total Billed Charges,72% of Total Billed Charges,3176.4,60,,2541.12,Percent of Total Billed Charges,60% of Total Billed Charges,4764.6,90,,53.824,Percent of Total Billed Charges,90% of Total Billed Charges,2382.3,45,,206.784,Percent of Total Billed Charges,45% of Total Billed Charges,4764.6,90,,92.872,Percent of Total Billed Charges,90% of Total billed Charges,5294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3441.1,65,,3.384,Percent of total Billed Charges,65% of Total Billed Charges,2334.65,44.1,,202.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,5029.3,95,,98.032,Percent of Total Billed Charges,95% of Total Billed Charges,5294,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4658.72,88,,404.376,Percent of Total Billed Charges,88% of Total Billed Charges,4764.6,90,,92.872,Percent of Total Billed charges,90% of Total Billed Charges,2334.65,5294,
MRA CHEST W OR WO CO,6180000004,CDM,618,RC,C8911,HCPCS,Outpatient,,,5572.04,3621.83,,448.93,125,,,Fee Schedule,125% of CMS OPPS Rate,4234.75,76,,40.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2560.24,350,,,Fee Schedule,350% of BCBS fee schedule,2560.24,350,,,Fee Schedule,350% of BCBS fee schedule,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,2560.24,561,,,Fee Schedule,561% of BCBS PPO fee schedule,456.37,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5014.84,90,,44.456,Percent of Total Billed Charges,90% of Total Billed Charges,2507.42,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,5014.84,90,,48.424,Percent of Total Billed Charges,90% of Total billed Charges,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,670.67,200,,344.232,Fee Schedule,200% of CMS OPPS Rate,2457.27,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,5293.44,95,,51.112,Percent of Total Billed Charges,95% of Total Billed Charges,269.33,75,,,Fee Schedule,75% of CMS OPPS Rate,4903.4,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,5014.84,90,,48.424,Percent of Total Billed charges,90% of Total Billed Charges,269.33,5293.44,
MRA PELVIS W OR WO C,6180000005,CDM,618,RC,C8920,HCPCS,Outpatient,,,5572.04,3621.83,,448.93,125,,,Fee Schedule,125% of CMS OPPS Rate,4234.75,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2560.24,350,,,Fee Schedule,350% of BCBS fee schedule,2560.24,350,,,Fee Schedule,350% of BCBS fee schedule,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,2560.24,561,,,Fee Schedule,561% of BCBS PPO fee schedule,456.37,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5014.84,90,,68.272,Percent of Total Billed Charges,90% of Total Billed Charges,2507.42,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,5014.84,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,359.13,100,,,Fee Schedule,100% of CMS OPPS Rate,670.67,200,,460.944,Fee Schedule,200% of CMS OPPS Rate,2457.27,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,5293.44,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,269.33,75,,,Fee Schedule,75% of CMS OPPS Rate,4903.4,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,5014.84,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,269.33,5293.44,
PROCRIT 2000U INJ,6340000001,CDM,634,RC,Q4081,HCPCS,Outpatient,,,192.94,125.41,,192.94,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,146.63,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.64,350,,,Fee Schedule,350% of BCBS fee schedule,5.64,350,,,Fee Schedule,350% of BCBS fee schedule,192.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.64,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.61,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,173.65,90,,27.544,Percent of Total Billed Charges,90% of Total Billed Charges,86.82,45,,432.624,Percent of Total Billed Charges,45% of Total Billed Charges,173.65,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,192.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.41,65,,3.384,Percent of total Billed Charges,65% of Total Billed Charges,85.09,44.1,,423.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,183.29,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,192.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.79,88,,846.016,Percent of Total Billed Charges,88% of Total Billed Charges,173.65,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,1.61,192.94,
PROCRIT 3000 INJ,6340000002,CDM,634,RC,Q4081,HCPCS,Outpatient,,,288.86,187.76,,288.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,219.53,76,,26.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.64,350,,,Fee Schedule,350% of BCBS fee schedule,5.64,350,,,Fee Schedule,350% of BCBS fee schedule,288.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.64,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.61,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,259.97,90,,298.472,Percent of Total Billed Charges,90% of Total Billed Charges,129.99,45,,42.48,Percent of Total Billed Charges,45% of Total Billed Charges,259.97,90,,31.752,Percent of Total Billed Charges,90% of Total billed Charges,288.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.76,65,,3.384,Percent of total Billed Charges,65% of Total Billed Charges,127.39,44.1,,41.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,274.42,95,,33.52,Percent of Total Billed Charges,95% of Total Billed Charges,288.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,254.2,88,,83.072,Percent of Total Billed Charges,88% of Total Billed Charges,259.97,90,,31.752,Percent of Total Billed charges,90% of Total Billed Charges,1.61,288.86,
Retacrit 3000u/ml inj ESRD,6340000003,CDM,634,RC,Q5105,HCPCS,Outpatient,,,68.18,44.32,,0.93,125,,,Fee Schedule,125% of CMS OPPS Rate,51.82,76,,349.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.55,350,,,Fee Schedule,350% of BCBS fee schedule,4.55,350,,,Fee Schedule,350% of BCBS fee schedule,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.55,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.3,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,61.36,90,,43.664,Percent of Total Billed Charges,90% of Total Billed Charges,30.68,45,,26.912,Percent of Total Billed Charges,45% of Total Billed Charges,61.36,90,,413.568,Percent of Total Billed Charges,90% of Total billed Charges,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,1.5,200,,3.384,Fee Schedule,200% of CMS OPPS Rate,30.07,44.1,,26.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,64.77,95,,436.544,Percent of Total Billed Charges,95% of Total Billed Charges,0.56,75,,,Fee Schedule,75% of CMS OPPS Rate,60,88,,52.624,Percent of Total Billed Charges,88% of Total Billed Charges,61.36,90,,413.568,Percent of Total Billed charges,90% of Total Billed Charges,0.56,64.77,
Retacrit 2000u/mlESRD,6340000004,CDM,634,RC,Q5105,HCPCS,Outpatient,,,20.32,13.21,,0.93,125,,,Fee Schedule,125% of CMS OPPS Rate,15.44,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.55,350,,,Fee Schedule,350% of BCBS fee schedule,4.55,350,,,Fee Schedule,350% of BCBS fee schedule,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.55,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.3,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,18.29,90,,125.424,Percent of Total Billed Charges,90% of Total Billed Charges,9.14,45,,22.224,Percent of Total Billed Charges,45% of Total Billed Charges,18.29,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,1.5,200,,5223.352,Fee Schedule,200% of CMS OPPS Rate,8.96,44.1,,21.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.3,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,0.56,75,,,Fee Schedule,75% of CMS OPPS Rate,17.88,88,,43.464,Percent of Total Billed Charges,88% of Total Billed Charges,18.29,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,0.56,19.3,
Retacrit 4000u/mlESRD,6340000005,CDM,634,RC,Q5105,HCPCS,Outpatient,,,20.32,13.21,,0.93,125,,,Fee Schedule,125% of CMS OPPS Rate,15.44,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.55,350,,,Fee Schedule,350% of BCBS fee schedule,4.55,350,,,Fee Schedule,350% of BCBS fee schedule,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.55,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.3,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,18.29,90,,13.496,Percent of Total Billed Charges,90% of Total Billed Charges,9.14,45,,34.136,Percent of Total Billed Charges,45% of Total Billed Charges,18.29,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,1.5,200,,23.168,Fee Schedule,200% of CMS OPPS Rate,8.96,44.1,,33.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.3,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,0.56,75,,,Fee Schedule,75% of CMS OPPS Rate,17.88,88,,66.752,Percent of Total Billed Charges,88% of Total Billed Charges,18.29,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,0.56,19.3,
Retacrit 20000u/mlESRD,6340000006,CDM,634,RC,Q5105,HCPCS,Outpatient,,,20.32,13.21,,0.93,125,,,Fee Schedule,125% of CMS OPPS Rate,15.44,76,,730.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.55,350,,,Fee Schedule,350% of BCBS fee schedule,4.55,350,,,Fee Schedule,350% of BCBS fee schedule,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.55,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.3,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,18.29,90,,29.808,Percent of Total Billed Charges,90% of Total Billed Charges,9.14,45,,13.768,Percent of Total Billed Charges,45% of Total Billed Charges,18.29,90,,865.248,Percent of Total Billed Charges,90% of Total billed Charges,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,1.5,200,,11297,Fee Schedule,200% of CMS OPPS Rate,8.96,44.1,,13.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.3,95,,913.312,Percent of Total Billed Charges,95% of Total Billed Charges,0.56,75,,,Fee Schedule,75% of CMS OPPS Rate,17.88,88,,26.928,Percent of Total Billed Charges,88% of Total Billed Charges,18.29,90,,865.248,Percent of Total Billed charges,90% of Total Billed Charges,0.56,19.3,
PROCRIT 10000U INJ,6350000001,CDM,635,RC,Q4081,HCPCS,Outpatient,,,1063.91,691.54,,1063.91,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,808.57,76,,71.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.64,350,,,Fee Schedule,350% of BCBS fee schedule,5.64,350,,,Fee Schedule,350% of BCBS fee schedule,1063.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.64,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.61,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,957.52,90,,72.24,Percent of Total Billed Charges,90% of Total Billed Charges,478.76,45,,149.232,Percent of Total Billed Charges,45% of Total Billed Charges,957.52,90,,84.96,Percent of Total Billed Charges,90% of Total billed Charges,1063.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1063.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1063.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,691.54,65,,2090.76,Percent of total Billed Charges,65% of Total Billed Charges,469.18,44.1,,146.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,1010.71,95,,89.68,Percent of Total Billed Charges,95% of Total Billed Charges,1063.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,936.24,88,,291.84,Percent of Total Billed Charges,88% of Total Billed Charges,957.52,90,,84.96,Percent of Total Billed charges,90% of Total Billed Charges,1.61,1063.91,
PROCRIT 20000U INJ,6350000002,CDM,635,RC,Q4081,HCPCS,Outpatient,,,1778.33,1155.91,,1778.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1351.53,76,,45.448,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.64,350,,,Fee Schedule,350% of BCBS fee schedule,5.64,350,,,Fee Schedule,350% of BCBS fee schedule,1778.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.64,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.61,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,1600.5,90,,22.896,Percent of Total Billed Charges,90% of Total Billed Charges,800.25,45,,21.832,Percent of Total Billed Charges,45% of Total Billed Charges,1600.5,90,,53.824,Percent of Total Billed Charges,90% of Total billed Charges,1778.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1778.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1778.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1155.91,65,,75.528,Percent of total Billed Charges,65% of Total Billed Charges,784.24,44.1,,21.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1689.41,95,,56.808,Percent of Total Billed Charges,95% of Total Billed Charges,1778.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1564.93,88,,42.688,Percent of Total Billed Charges,88% of Total Billed Charges,1600.5,90,,53.824,Percent of Total Billed charges,90% of Total Billed Charges,1.61,1778.33,
CALCIUM CARB 500MG/5ML SUSP,6360000002,CDM,250,RC,,,Outpatient,500,GM,8.25,5.36,,8.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.27,76,,37.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.94,72,,4.752,Percent of Total Billed Charges,72% of Total Billed Charges,6.19,75,,4.952,Percent of Total Billed charges,75% of Total Billed Charges,8.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.94,72,,4.752,Percent of Total Billed Charges,72% of Total Billed Charges,4.95,60,,3.96,Percent of Total Billed Charges,60% of Total Billed Charges,7.43,90,,19304.424,Percent of Total Billed Charges,90% of Total Billed Charges,3.71,45,,62.712,Percent of Total Billed Charges,45% of Total Billed Charges,7.43,90,,44.456,Percent of Total Billed Charges,90% of Total billed Charges,8.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.36,65,,7300.712,Percent of total Billed Charges,65% of Total Billed Charges,3.64,44.1,,61.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.84,95,,46.92,Percent of Total Billed Charges,95% of Total Billed Charges,8.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.26,88,,122.64,Percent of Total Billed Charges,88% of Total Billed Charges,7.43,90,,44.456,Percent of Total Billed charges,90% of Total Billed Charges,3.64,8.25,
EPINEP INJ PEN JR 0.15MG/0.3ML,6360000005,CDM,636,RC,J0171,HCPCS,Outpatient,0.15,GM,453.13,294.53,,453.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,344.38,76,,23.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.49,350,,,Fee Schedule,350% of BCBS fee schedule,0.49,350,,,Fee Schedule,350% of BCBS fee schedule,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.49,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.14,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,407.82,90,,9651.816,Percent of Total Billed Charges,90% of Total Billed Charges,203.91,45,,14.904,Percent of Total Billed Charges,45% of Total Billed Charges,407.82,90,,27.544,Percent of Total Billed Charges,90% of Total billed Charges,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.53,65,,6747.456,Percent of total Billed Charges,65% of Total Billed Charges,199.83,44.1,,14.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,430.47,95,,29.072,Percent of Total Billed Charges,95% of Total Billed Charges,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.75,88,,29.144,Percent of Total Billed Charges,88% of Total Billed Charges,407.82,90,,27.544,Percent of Total Billed charges,90% of Total Billed Charges,0.14,453.13,
EPINEPH  INJ PEN 0.3MG/0.3ML,6360000006,CDM,636,RC,J0171,HCPCS,Outpatient,0.3,GM,453.13,294.53,,453.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,344.38,76,,252.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.49,350,,,Fee Schedule,350% of BCBS fee schedule,0.49,350,,,Fee Schedule,350% of BCBS fee schedule,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.49,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.14,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,407.82,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,203.91,45,,36.12,Percent of Total Billed Charges,45% of Total Billed Charges,407.82,90,,298.472,Percent of Total Billed Charges,90% of Total billed Charges,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.53,65,,177.048,Percent of total Billed Charges,65% of Total Billed Charges,199.83,44.1,,35.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,430.47,95,,315.048,Percent of Total Billed Charges,95% of Total Billed Charges,453.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.75,88,,70.632,Percent of Total Billed Charges,88% of Total Billed Charges,407.82,90,,298.472,Percent of Total Billed charges,90% of Total Billed Charges,0.14,453.13,
INFLUEN QUADRIVALENT 0.5ML INJ,6360000008,CDM,636,RC,,,Outpatient,0.5,ML,68.00,44.20,,68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.68,76,,36.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,48.96,72,,39.168,Percent of Total Billed Charges,72% of Total Billed Charges,51,75,,40.8,Percent of Total Billed charges,75% of Total Billed Charges,68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.96,72,,39.168,Percent of Total Billed Charges,72% of Total Billed Charges,40.8,60,,32.64,Percent of Total Billed Charges,60% of Total Billed Charges,61.2,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,30.6,45,,11.448,Percent of Total Billed Charges,45% of Total Billed Charges,61.2,90,,43.664,Percent of Total Billed Charges,90% of Total billed Charges,68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.2,65,,101.4,Percent of total Billed Charges,65% of Total Billed Charges,29.99,44.1,,11.216,Percent of Total Billed Charges,44.1% of Total Billed Charges,64.6,95,,46.088,Percent of Total Billed Charges,95% of Total Billed Charges,68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.84,88,,22.384,Percent of Total Billed Charges,88% of Total Billed Charges,61.2,90,,43.664,Percent of Total Billed charges,90% of Total Billed Charges,29.99,68,
IPV POLIOVIRUS 5ML INJ,6360000009,CDM,636,RC,,,Outpatient,5,ML,303.06,196.99,,303.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,230.33,76,,105.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,218.2,72,,174.56,Percent of Total Billed Charges,72% of Total Billed Charges,227.3,75,,181.84,Percent of Total Billed charges,75% of Total Billed Charges,303.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.2,72,,174.56,Percent of Total Billed Charges,72% of Total Billed Charges,181.84,60,,145.472,Percent of Total Billed Charges,60% of Total Billed Charges,272.75,90,,12668.256,Percent of Total Billed Charges,90% of Total Billed Charges,136.38,45,,9652.216,Percent of Total Billed Charges,45% of Total Billed Charges,272.75,90,,125.424,Percent of Total Billed Charges,90% of Total billed Charges,303.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.99,65,,8.448,Percent of total Billed Charges,65% of Total Billed Charges,133.65,44.1,,9459.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,287.91,95,,132.392,Percent of Total Billed Charges,95% of Total Billed Charges,303.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.69,88,,18875.44,Percent of Total Billed Charges,88% of Total Billed Charges,272.75,90,,125.424,Percent of Total Billed charges,90% of Total Billed Charges,133.65,303.06,
KINRIX 0.5ML INJ (46 YR ONLY),6360000010,CDM,636,RC,,,Outpatient,0.5,ML,46.35,30.13,,46.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.23,76,,11.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.37,72,,26.696,Percent of Total Billed Charges,72% of Total Billed Charges,34.76,75,,27.808,Percent of Total Billed charges,75% of Total Billed Charges,46.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.37,72,,26.696,Percent of Total Billed Charges,72% of Total Billed Charges,27.81,60,,22.248,Percent of Total Billed Charges,60% of Total Billed Charges,41.72,90,,71.448,Percent of Total Billed Charges,90% of Total Billed Charges,20.86,45,,204.408,Percent of Total Billed Charges,45% of Total Billed Charges,41.72,90,,13.496,Percent of Total Billed Charges,90% of Total billed Charges,46.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.13,65,,242,Percent of total Billed Charges,65% of Total Billed Charges,20.44,44.1,,200.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.03,95,,14.24,Percent of Total Billed Charges,95% of Total Billed Charges,46.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.79,88,,399.728,Percent of Total Billed Charges,88% of Total Billed Charges,41.72,90,,13.496,Percent of Total Billed charges,90% of Total Billed Charges,20.44,46.35,
LIDOCAINE W/EPINEPHRINE 5MLAMP,6360000011,CDM,636,RC,J3490,HCPCS,Outpatient,,,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,25.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.64,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,9,75,,7.2,Percent of Total Billed charges,75% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.64,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,7.2,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,10.8,90,,2045.624,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,4825.912,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,29.808,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,3689.6,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,4729.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,31.464,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,9437.328,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,29.808,Percent of Total Billed charges,90% of Total Billed Charges,5.29,12,
POTAS CHLOR 20 MEQ/ 50ML INJ,6360000018,CDM,636,RC,J3480,HCPCS,Outpatient,50,ML,47.00,30.55,,47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.72,76,,8150.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.14,350,,,Fee Schedule,350% of BCBS fee schedule,0.14,350,,,Fee Schedule,350% of BCBS fee schedule,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.14,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.04,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,42.3,90,,94.864,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,45,,1022.808,Percent of Total Billed Charges,45% of Total Billed Charges,42.3,90,,9651.816,Percent of Total Billed Charges,90% of Total billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.55,65,,5951.304,Percent of total Billed Charges,65% of Total Billed Charges,20.73,44.1,,1002.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.65,95,,10188.032,Percent of Total Billed Charges,95% of Total Billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.36,88,,2000.16,Percent of Total Billed Charges,88% of Total Billed Charges,42.3,90,,9651.816,Percent of Total Billed charges,90% of Total Billed Charges,0.04,47,
POTASS CHLORIDE 10MEQ/5ML INJ,6360000019,CDM,636,RC,J3480,HCPCS,Outpatient,5,ML,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.14,350,,,Fee Schedule,350% of BCBS fee schedule,0.14,350,,,Fee Schedule,350% of BCBS fee schedule,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.14,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.04,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,7.94,90,,37.08,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,60.912,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,0.04,8.82,
SODIUM POLYSTYRENE SULF 15GM,6360000021,CDM,250,RC,,,Outpatient,15,gm,52.14,33.89,,52.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,39.63,76,,10697.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,37.54,72,,30.032,Percent of Total Billed Charges,72% of Total Billed Charges,39.11,75,,31.288,Percent of Total Billed charges,75% of Total Billed Charges,52.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.54,72,,30.032,Percent of Total Billed Charges,72% of Total Billed Charges,31.28,60,,25.024,Percent of Total Billed Charges,60% of Total Billed Charges,46.93,90,,24.608,Percent of Total Billed Charges,90% of Total Billed Charges,23.46,45,,17.464,Percent of Total Billed Charges,45% of Total Billed Charges,46.93,90,,12668.256,Percent of Total Billed Charges,90% of Total billed Charges,52.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.89,65,,1038.832,Percent of total Billed Charges,65% of Total Billed Charges,22.99,44.1,,17.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,49.53,95,,13372.048,Percent of Total Billed Charges,95% of Total Billed Charges,52.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.88,88,,34.152,Percent of Total Billed Charges,88% of Total Billed Charges,46.93,90,,12668.256,Percent of Total Billed charges,90% of Total Billed Charges,22.99,52.14,
TDAP VAC  BOOSTRIX 0.5ML INJ,6360000022,CDM,636,RC,,,Outpatient,0.5,ML,388.63,252.61,,388.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,295.36,76,,60.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,279.81,72,,223.848,Percent of Total Billed Charges,72% of Total Billed Charges,291.47,75,,233.176,Percent of Total Billed charges,75% of Total Billed Charges,388.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279.81,72,,223.848,Percent of Total Billed Charges,72% of Total Billed Charges,233.18,60,,186.544,Percent of Total Billed Charges,60% of Total Billed Charges,349.77,90,,21.432,Percent of Total Billed Charges,90% of Total Billed Charges,174.88,45,,17.064,Percent of Total Billed Charges,45% of Total Billed Charges,349.77,90,,71.448,Percent of Total Billed Charges,90% of Total billed Charges,388.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,388.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,388.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.61,65,,185.288,Percent of total Billed Charges,65% of Total Billed Charges,171.39,44.1,,16.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,369.2,95,,75.416,Percent of Total Billed Charges,95% of Total Billed Charges,388.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.99,88,,33.376,Percent of Total Billed Charges,88% of Total Billed Charges,349.77,90,,71.448,Percent of Total Billed charges,90% of Total Billed Charges,171.39,388.63,
"THROMB BOVINE 20,000 UN INJEC",6360000023,CDM,636,RC,J3490,HCPCS,Outpatient,,,1553.42,1009.72,,1553.42,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1180.6,76,,1727.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1118.46,72,,894.768,Percent of Total Billed Charges,72% of Total Billed Charges,1165.07,75,,932.056,Percent of Total Billed charges,75% of Total Billed Charges,1553.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1118.46,72,,894.768,Percent of Total Billed Charges,72% of Total Billed Charges,932.05,60,,745.64,Percent of Total Billed Charges,60% of Total Billed Charges,1398.08,90,,13.496,Percent of Total Billed Charges,90% of Total Billed Charges,699.04,45,,47.432,Percent of Total Billed Charges,45% of Total Billed Charges,1398.08,90,,2045.624,Percent of Total Billed Charges,90% of Total billed Charges,1553.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1553.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1553.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1009.72,65,,3236.784,Percent of total Billed Charges,65% of Total Billed Charges,685.06,44.1,,46.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,1475.75,95,,2159.264,Percent of Total Billed Charges,95% of Total Billed Charges,1553.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1367.01,88,,92.752,Percent of Total Billed Charges,88% of Total Billed Charges,1398.08,90,,2045.624,Percent of Total Billed charges,90% of Total Billed Charges,685.06,1553.42,
VAQTA HEP A 25 UNTS/0.5ML INJ,6360000024,CDM,636,RC,,,Outpatient,0.5,ML,30.37,19.74,,30.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,23.08,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.87,72,,17.496,Percent of Total Billed Charges,72% of Total Billed Charges,22.78,75,,18.224,Percent of Total Billed charges,75% of Total Billed Charges,30.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.87,72,,17.496,Percent of Total Billed Charges,72% of Total Billed Charges,18.22,60,,14.576,Percent of Total Billed Charges,60% of Total Billed Charges,27.33,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,13.67,45,,18.544,Percent of Total Billed Charges,45% of Total Billed Charges,27.33,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,30.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.74,65,,3.392,Percent of total Billed Charges,65% of Total Billed Charges,13.39,44.1,,18.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.85,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,30.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.73,88,,36.256,Percent of Total Billed Charges,88% of Total Billed Charges,27.33,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,13.39,30.37,
NABIHB 1ML VIAL,6360000025,CDM,636,RC,90371,HCPCS,Outpatient,1,ML,840.11,546.07,,182.88,125,,,Fee Schedule,125% of CMS OPPS Rate,638.48,76,,22.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,450.49,350,,,Fee Schedule,350% of BCBS fee schedule,450.49,350,,,Fee Schedule,350% of BCBS fee schedule,146.31,100,,,Fee Schedule,100% of CMS OPPS Rate,450.49,350,,,Fee Schedule,350% of BCBS PPO fee schedule,128.71,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,756.1,90,,15.088,Percent of Total Billed Charges,90% of Total Billed Charges,378.05,45,,18.544,Percent of Total Billed Charges,45% of Total Billed Charges,756.1,90,,26.192,Percent of Total Billed Charges,90% of Total billed Charges,146.31,100,,,Fee Schedule,100% of CMS OPPS Rate,146.31,100,,,Fee Schedule,100% of CMS OPPS Rate,146.31,100,,,Fee Schedule,100% of CMS OPPS Rate,838.69,65,,187.272,Percent of total Billed Charges,65% of Total Billed Charges,370.49,44.1,,18.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,798.1,95,,27.648,Percent of Total Billed Charges,95% of Total Billed Charges,109.73,75,,,Fee Schedule,75% of CMS OPPS Rate,739.3,88,,36.256,Percent of Total Billed Charges,88% of Total Billed Charges,756.1,90,,26.192,Percent of Total Billed charges,90% of Total Billed Charges,109.73,838.69,
RABIES IMM GLOB 150U INJ,6360000026,CDM,636,RC,,,Outpatient,,,1182.98,768.94,,1182.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,899.06,76,,29.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,851.75,72,,681.4,Percent of Total Billed Charges,72% of Total Billed Charges,887.24,75,,709.792,Percent of Total Billed charges,75% of Total Billed Charges,1182.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,851.75,72,,681.4,Percent of Total Billed Charges,72% of Total Billed Charges,709.79,60,,567.832,Percent of Total Billed Charges,60% of Total Billed Charges,1064.68,90,,14.296,Percent of Total Billed Charges,90% of Total Billed Charges,532.34,45,,12.304,Percent of Total Billed Charges,45% of Total Billed Charges,1064.68,90,,34.928,Percent of Total Billed Charges,90% of Total billed Charges,1182.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1182.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1182.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,768.94,65,,69.048,Percent of total Billed Charges,65% of Total Billed Charges,521.69,44.1,,12.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,1123.83,95,,36.864,Percent of Total Billed Charges,95% of Total Billed Charges,1182.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1041.02,88,,24.064,Percent of Total Billed Charges,88% of Total Billed Charges,1064.68,90,,34.928,Percent of Total Billed charges,90% of Total Billed Charges,521.69,1182.98,
RABIES IMM GLOB  300U INJ,6360000027,CDM,636,RC,,,Outpatient,,,7932.48,5156.11,,7932.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6028.68,76,,28.824,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5711.39,72,,4569.112,Percent of Total Billed Charges,72% of Total Billed Charges,5949.36,75,,4759.488,Percent of Total Billed charges,75% of Total Billed Charges,7932.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5711.39,72,,4569.112,Percent of Total Billed Charges,72% of Total Billed Charges,4759.49,60,,3807.592,Percent of Total Billed Charges,60% of Total Billed Charges,7139.23,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,3569.62,45,,10.72,Percent of Total Billed Charges,45% of Total Billed Charges,7139.23,90,,34.136,Percent of Total Billed Charges,90% of Total billed Charges,7932.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7932.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7932.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5156.11,65,,0.248,Percent of total Billed Charges,65% of Total Billed Charges,3498.22,44.1,,10.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,7535.86,95,,36.032,Percent of Total Billed Charges,95% of Total Billed Charges,7932.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6980.58,88,,20.96,Percent of Total Billed Charges,88% of Total Billed Charges,7139.23,90,,34.136,Percent of Total Billed charges,90% of Total Billed Charges,3498.22,7932.48,
RHOGAM DOSE,6360000028,CDM,636,RC,,,Outpatient,,,386.98,251.54,,386.98,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,294.1,76,,80.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,278.63,72,,222.904,Percent of Total Billed Charges,72% of Total Billed Charges,290.24,75,,232.192,Percent of Total Billed charges,75% of Total Billed Charges,386.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.63,72,,222.904,Percent of Total Billed Charges,72% of Total Billed Charges,232.19,60,,185.752,Percent of Total Billed Charges,60% of Total Billed Charges,348.28,90,,24.608,Percent of Total Billed Charges,90% of Total Billed Charges,174.14,45,,6.744,Percent of Total Billed Charges,45% of Total Billed Charges,348.28,90,,94.864,Percent of Total Billed Charges,90% of Total billed Charges,386.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.54,65,,34.608,Percent of total Billed Charges,65% of Total Billed Charges,170.66,44.1,,6.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,367.63,95,,100.128,Percent of Total Billed Charges,95% of Total Billed Charges,386.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.54,88,,13.192,Percent of Total Billed Charges,88% of Total Billed Charges,348.28,90,,94.864,Percent of Total Billed charges,90% of Total Billed Charges,170.66,386.98,
BCG LIVE 50MG,6360000029,CDM,636,RC,,,Outpatient,50,GM,620.50,403.33,,620.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,471.58,76,,31.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,446.76,72,,357.408,Percent of Total Billed Charges,72% of Total Billed Charges,465.38,75,,372.304,Percent of Total Billed charges,75% of Total Billed Charges,620.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.76,72,,357.408,Percent of Total Billed Charges,72% of Total Billed Charges,372.3,60,,297.84,Percent of Total Billed Charges,60% of Total Billed Charges,558.45,90,,53.184,Percent of Total Billed Charges,90% of Total Billed Charges,279.23,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,558.45,90,,37.08,Percent of Total Billed Charges,90% of Total billed Charges,620.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,620.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,620.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,403.33,65,,705.184,Percent of total Billed Charges,65% of Total Billed Charges,273.64,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,589.48,95,,39.144,Percent of Total Billed Charges,95% of Total Billed Charges,620.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.04,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,558.45,90,,37.08,Percent of Total Billed charges,90% of Total Billed Charges,273.64,620.5,
TRUMENBA 0.5ML INJ,6360000030,CDM,636,RC,,,Outpatient,0.5,ML,963.25,626.11,,963.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,732.07,76,,31.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,693.54,72,,554.832,Percent of Total Billed Charges,72% of Total Billed Charges,722.44,75,,577.952,Percent of Total Billed charges,75% of Total Billed Charges,963.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,693.54,72,,554.832,Percent of Total Billed Charges,72% of Total Billed Charges,577.95,60,,462.36,Percent of Total Billed Charges,60% of Total Billed Charges,866.93,90,,38.104,Percent of Total Billed Charges,90% of Total Billed Charges,433.46,45,,7.544,Percent of Total Billed Charges,45% of Total Billed Charges,866.93,90,,37.08,Percent of Total Billed Charges,90% of Total billed Charges,963.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,963.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,963.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,626.11,65,,357.76,Percent of total Billed Charges,65% of Total Billed Charges,424.79,44.1,,7.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,915.09,95,,39.144,Percent of Total Billed Charges,95% of Total Billed Charges,963.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,847.66,88,,14.752,Percent of Total Billed Charges,88% of Total Billed Charges,866.93,90,,37.08,Percent of Total Billed charges,90% of Total Billed Charges,424.79,963.25,
VAQTA (HEP A) 50 UNITS/1ML INJ,6360000031,CDM,636,RC,,,Outpatient,1,ML,63.46,41.25,,63.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,48.23,76,,20.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.69,72,,36.552,Percent of Total Billed Charges,72% of Total Billed Charges,47.6,75,,38.08,Percent of Total Billed charges,75% of Total Billed Charges,63.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.69,72,,36.552,Percent of Total Billed Charges,72% of Total Billed Charges,38.08,60,,30.464,Percent of Total Billed Charges,60% of Total Billed Charges,57.11,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,28.56,45,,7.144,Percent of Total Billed Charges,45% of Total Billed Charges,57.11,90,,24.608,Percent of Total Billed Charges,90% of Total billed Charges,63.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.25,65,,79.832,Percent of total Billed Charges,65% of Total Billed Charges,27.99,44.1,,7,Percent of Total Billed Charges,44.1% of Total Billed Charges,60.29,95,,25.976,Percent of Total Billed Charges,95% of Total Billed Charges,63.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.84,88,,13.976,Percent of Total Billed Charges,88% of Total Billed Charges,57.11,90,,24.608,Percent of Total Billed charges,90% of Total Billed Charges,27.99,63.46,
PEDVAXHIB 0.5ML INJ,6360000032,CDM,636,RC,,,Outpatient,0.5,ML,24.50,15.93,,24.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.62,76,,18.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.64,72,,14.112,Percent of Total Billed Charges,72% of Total Billed Charges,18.38,75,,14.704,Percent of Total Billed charges,75% of Total Billed Charges,24.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.64,72,,14.112,Percent of Total Billed Charges,72% of Total Billed Charges,14.7,60,,11.76,Percent of Total Billed Charges,60% of Total Billed Charges,22.05,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,11.03,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,22.05,90,,21.432,Percent of Total Billed Charges,90% of Total billed Charges,24.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.93,65,,114.568,Percent of total Billed Charges,65% of Total Billed Charges,10.8,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.28,95,,22.624,Percent of Total Billed Charges,95% of Total Billed Charges,24.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.56,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,22.05,90,,21.432,Percent of Total Billed charges,90% of Total Billed Charges,10.8,24.5,
HPV (GARDASIL 9) 0.5ML INJ,6360000033,CDM,636,RC,,,Outpatient,0.5,ML,192.88,125.37,,192.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,146.59,76,,11.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,138.87,72,,111.096,Percent of Total Billed Charges,72% of Total Billed Charges,144.66,75,,115.728,Percent of Total Billed charges,75% of Total Billed Charges,192.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.87,72,,111.096,Percent of Total Billed Charges,72% of Total Billed Charges,115.73,60,,92.584,Percent of Total Billed Charges,60% of Total Billed Charges,173.59,90,,30.168,Percent of Total Billed Charges,90% of Total Billed Charges,86.8,45,,12.304,Percent of Total Billed Charges,45% of Total Billed Charges,173.59,90,,13.496,Percent of Total Billed Charges,90% of Total billed Charges,192.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.37,65,,34.976,Percent of total Billed Charges,65% of Total Billed Charges,85.06,44.1,,12.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,183.24,95,,14.24,Percent of Total Billed Charges,95% of Total Billed Charges,192.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.73,88,,24.064,Percent of Total Billed Charges,88% of Total Billed Charges,173.59,90,,13.496,Percent of Total Billed charges,90% of Total Billed Charges,85.06,192.88,
PREVNAR13 0.5ML INJ,6360000034,CDM,636,RC,,,Outpatient,0.5,ML,168.36,109.43,,168.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,127.95,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,121.22,72,,96.976,Percent of Total Billed Charges,72% of Total Billed Charges,126.27,75,,101.016,Percent of Total Billed charges,75% of Total Billed Charges,168.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.22,72,,96.976,Percent of Total Billed Charges,72% of Total Billed Charges,101.02,60,,80.816,Percent of Total Billed Charges,60% of Total Billed Charges,151.52,90,,27.784,Percent of Total Billed Charges,90% of Total Billed Charges,75.76,45,,26.592,Percent of Total Billed Charges,45% of Total Billed Charges,151.52,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,168.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.43,65,,631.776,Percent of total Billed Charges,65% of Total Billed Charges,74.25,44.1,,26.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,159.94,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,168.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.16,88,,52.008,Percent of Total Billed Charges,88% of Total Billed Charges,151.52,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,74.25,168.36,
RABIES VACCINE 1 DOS INJ,6360000035,CDM,636,RC,,,Outpatient,,,891.23,579.30,,891.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,677.33,76,,12.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,641.69,72,,513.352,Percent of Total Billed Charges,72% of Total Billed Charges,668.42,75,,534.736,Percent of Total Billed charges,75% of Total Billed Charges,891.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,641.69,72,,513.352,Percent of Total Billed Charges,72% of Total Billed Charges,534.74,60,,427.792,Percent of Total Billed Charges,60% of Total Billed Charges,802.11,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,401.05,45,,19.048,Percent of Total Billed Charges,45% of Total Billed Charges,802.11,90,,15.088,Percent of Total Billed Charges,90% of Total billed Charges,891.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,891.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,891.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.3,65,,34.608,Percent of total Billed Charges,65% of Total Billed Charges,393.03,44.1,,18.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,846.67,95,,15.92,Percent of Total Billed Charges,95% of Total Billed Charges,891.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,784.28,88,,37.256,Percent of Total Billed Charges,88% of Total Billed Charges,802.11,90,,15.088,Percent of Total Billed charges,90% of Total Billed Charges,393.03,891.23,
ROTARIX 1ML INJ,6360000036,CDM,636,RC,,,Outpatient,1,ML,114.45,74.39,,114.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,86.98,76,,12.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.4,72,,65.92,Percent of Total Billed Charges,72% of Total Billed Charges,85.84,75,,68.672,Percent of Total Billed charges,75% of Total Billed Charges,114.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.4,72,,65.92,Percent of Total Billed Charges,72% of Total Billed Charges,68.67,60,,54.936,Percent of Total Billed Charges,60% of Total Billed Charges,103.01,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,51.5,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,103.01,90,,14.296,Percent of Total Billed Charges,90% of Total billed Charges,114.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.39,65,,34.608,Percent of total Billed Charges,65% of Total Billed Charges,50.47,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,108.73,95,,15.088,Percent of Total Billed Charges,95% of Total Billed Charges,114.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.72,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,103.01,90,,14.296,Percent of Total Billed charges,90% of Total Billed Charges,50.47,114.45,
FLUZONE HIGH DOSE 0.,6360000037,CDM,636,RC,,,Outpatient,,,282.24,183.46,,282.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,214.5,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,203.21,72,,162.568,Percent of Total Billed Charges,72% of Total Billed Charges,211.68,75,,169.344,Percent of Total Billed charges,75% of Total Billed Charges,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.21,72,,162.568,Percent of Total Billed Charges,72% of Total Billed Charges,169.34,60,,135.472,Percent of Total Billed Charges,60% of Total Billed Charges,254.02,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,127.01,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,254.02,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.46,65,,707.192,Percent of total Billed Charges,65% of Total Billed Charges,124.47,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,268.13,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,282.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.37,88,,3.88,Percent of Total Billed Charges,88% of Total Billed Charges,254.02,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,124.47,282.24,
PENTACEL 0.5ML INJ,6360000038,CDM,636,RC,,,Outpatient,0.5,ML,86.25,56.06,,86.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,65.55,76,,20.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.1,72,,49.68,Percent of Total Billed Charges,72% of Total Billed Charges,64.69,75,,51.752,Percent of Total Billed charges,75% of Total Billed Charges,86.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.1,72,,49.68,Percent of Total Billed Charges,72% of Total Billed Charges,51.75,60,,41.4,Percent of Total Billed Charges,60% of Total Billed Charges,77.63,90,,56.36,Percent of Total Billed Charges,90% of Total Billed Charges,38.81,45,,15.088,Percent of Total Billed Charges,45% of Total Billed Charges,77.63,90,,24.608,Percent of Total Billed Charges,90% of Total billed Charges,86.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.06,65,,1.536,Percent of total Billed Charges,65% of Total Billed Charges,38.04,44.1,,14.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,81.94,95,,25.976,Percent of Total Billed Charges,95% of Total Billed Charges,86.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.9,88,,29.496,Percent of Total Billed Charges,88% of Total Billed Charges,77.63,90,,24.608,Percent of Total Billed charges,90% of Total Billed Charges,38.04,86.25,
DT (DIPHTH/TET/TOX PEDI) INJ,6360000039,CDM,636,RC,,,Outpatient,,,48.16,31.30,,48.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.6,76,,44.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.68,72,,27.744,Percent of Total Billed Charges,72% of Total Billed Charges,36.12,75,,28.896,Percent of Total Billed charges,75% of Total Billed Charges,48.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.68,72,,27.744,Percent of Total Billed Charges,72% of Total Billed Charges,28.9,60,,23.12,Percent of Total Billed Charges,60% of Total Billed Charges,43.34,90,,11.912,Percent of Total Billed Charges,90% of Total Billed Charges,21.67,45,,13.896,Percent of Total Billed Charges,45% of Total Billed Charges,43.34,90,,53.184,Percent of Total Billed Charges,90% of Total billed Charges,48.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.3,65,,59.624,Percent of total Billed Charges,65% of Total Billed Charges,21.24,44.1,,13.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.75,95,,56.144,Percent of Total Billed Charges,95% of Total Billed Charges,48.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.38,88,,27.168,Percent of Total Billed Charges,88% of Total Billed Charges,43.34,90,,53.184,Percent of Total Billed charges,90% of Total Billed Charges,21.24,48.16,
MMR II VAC 1EA INJ,6360000040,CDM,636,RC,,,Outpatient,,,283.34,184.17,,283.34,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,215.34,76,,32.176,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,204,72,,163.2,Percent of Total Billed Charges,72% of Total Billed Charges,212.51,75,,170.008,Percent of Total Billed charges,75% of Total Billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204,72,,163.2,Percent of Total Billed Charges,72% of Total Billed Charges,170,60,,136,Percent of Total Billed Charges,60% of Total Billed Charges,255.01,90,,21.424,Percent of Total Billed Charges,90% of Total Billed Charges,127.5,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,255.01,90,,38.104,Percent of Total Billed Charges,90% of Total billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.17,65,,22.768,Percent of total Billed Charges,65% of Total Billed Charges,124.95,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,269.17,95,,40.216,Percent of Total Billed Charges,95% of Total Billed Charges,283.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.34,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,255.01,90,,38.104,Percent of Total Billed charges,90% of Total Billed Charges,124.95,283.34,
PROQUAD 0.5ML INJ,6360000041,CDM,636,RC,,,Outpatient,0.5,ML,188.12,122.28,,188.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,142.97,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,135.45,72,,108.36,Percent of Total Billed Charges,72% of Total Billed Charges,141.09,75,,112.872,Percent of Total Billed charges,75% of Total Billed Charges,188.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.45,72,,108.36,Percent of Total Billed Charges,72% of Total Billed Charges,112.87,60,,90.296,Percent of Total Billed Charges,60% of Total Billed Charges,169.31,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,84.65,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,169.31,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,188.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.28,65,,363.24,Percent of total Billed Charges,65% of Total Billed Charges,82.96,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,178.71,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,188.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.55,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,169.31,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,82.96,188.12,
TETANUS/DIPTHERIA INJ,6360000042,CDM,636,RC,,,Outpatient,,,114.66,74.53,,114.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.14,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.56,72,,66.048,Percent of Total Billed Charges,72% of Total Billed Charges,86,75,,68.8,Percent of Total Billed charges,75% of Total Billed Charges,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.56,72,,66.048,Percent of Total Billed Charges,72% of Total Billed Charges,68.8,60,,55.04,Percent of Total Billed Charges,60% of Total Billed Charges,103.19,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,51.6,45,,16.92,Percent of Total Billed Charges,45% of Total Billed Charges,103.19,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.53,65,,377,Percent of total Billed Charges,65% of Total Billed Charges,50.57,44.1,,16.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,108.93,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.9,88,,33.088,Percent of Total Billed Charges,88% of Total Billed Charges,103.19,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,50.57,114.66,
ADACEL (TDAP) 0.5ML INJ,6360000043,CDM,636,RC,,,Outpatient,0.5,ML,41.17,26.76,,41.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31.29,76,,25.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.64,72,,23.712,Percent of Total Billed Charges,72% of Total Billed Charges,30.88,75,,24.704,Percent of Total Billed charges,75% of Total Billed Charges,41.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.64,72,,23.712,Percent of Total Billed Charges,72% of Total Billed Charges,24.7,60,,19.76,Percent of Total Billed Charges,60% of Total Billed Charges,37.05,90,,342.92,Percent of Total Billed Charges,90% of Total Billed Charges,18.53,45,,28.184,Percent of Total Billed Charges,45% of Total Billed Charges,37.05,90,,30.168,Percent of Total Billed Charges,90% of Total billed Charges,41.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.76,65,,3578.6,Percent of total Billed Charges,65% of Total Billed Charges,18.16,44.1,,27.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,39.11,95,,31.848,Percent of Total Billed Charges,95% of Total Billed Charges,41.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.23,88,,55.112,Percent of Total Billed Charges,88% of Total Billed Charges,37.05,90,,30.168,Percent of Total Billed charges,90% of Total Billed Charges,18.16,41.17,
VARICELLA (VARIVAX 0.5ML INJ,6360000044,CDM,636,RC,,,Outpatient,0.5,ML,114.41,74.37,,114.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,86.95,76,,23.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,82.38,72,,65.904,Percent of Total Billed Charges,72% of Total Billed Charges,85.81,75,,68.648,Percent of Total Billed charges,75% of Total Billed Charges,114.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.38,72,,65.904,Percent of Total Billed Charges,72% of Total Billed Charges,68.65,60,,54.92,Percent of Total Billed Charges,60% of Total Billed Charges,102.97,90,,157.968,Percent of Total Billed Charges,90% of Total Billed Charges,51.48,45,,5.952,Percent of Total Billed Charges,45% of Total Billed Charges,102.97,90,,27.784,Percent of Total Billed Charges,90% of Total billed Charges,114.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.37,65,,3378.712,Percent of total Billed Charges,65% of Total Billed Charges,50.45,44.1,,5.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,108.69,95,,29.328,Percent of Total Billed Charges,95% of Total Billed Charges,114.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.68,88,,11.648,Percent of Total Billed Charges,88% of Total Billed Charges,102.97,90,,27.784,Percent of Total Billed charges,90% of Total Billed Charges,50.45,114.41,
PEDIARIX 0.5ML INJ,6360000045,CDM,636,RC,,,Outpatient,0.5,ML,71.05,46.18,,71.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,54,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.16,72,,40.928,Percent of Total Billed Charges,72% of Total Billed Charges,53.29,75,,42.632,Percent of Total Billed charges,75% of Total Billed Charges,71.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.16,72,,40.928,Percent of Total Billed Charges,72% of Total Billed Charges,42.63,60,,34.104,Percent of Total Billed Charges,60% of Total Billed Charges,63.95,90,,13.496,Percent of Total Billed Charges,90% of Total Billed Charges,31.97,45,,10.712,Percent of Total Billed Charges,45% of Total Billed Charges,63.95,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,71.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.18,65,,22.52,Percent of total Billed Charges,65% of Total Billed Charges,31.33,44.1,,10.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,67.5,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,71.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.52,88,,20.944,Percent of Total Billed Charges,88% of Total Billed Charges,63.95,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,31.33,71.05,
PNUIMUNE23 INJ,6360000046,CDM,636,RC,,,Outpatient,,,339.57,220.72,,339.57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,258.07,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,244.49,72,,195.592,Percent of Total Billed Charges,72% of Total Billed Charges,254.68,75,,203.744,Percent of Total Billed charges,75% of Total Billed Charges,339.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.49,72,,195.592,Percent of Total Billed Charges,72% of Total Billed Charges,203.74,60,,162.992,Percent of Total Billed Charges,60% of Total Billed Charges,305.61,90,,923.192,Percent of Total Billed Charges,90% of Total Billed Charges,152.81,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,305.61,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,339.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,339.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,339.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.72,65,,22.52,Percent of total Billed Charges,65% of Total Billed Charges,149.75,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,322.59,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,339.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.82,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,305.61,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,149.75,339.57,
MCV4 (MENACTRA) INJ,6360000047,CDM,636,RC,,,Outpatient,,,112.18,72.92,,112.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,85.26,76,,28.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,80.77,72,,64.616,Percent of Total Billed Charges,72% of Total Billed Charges,84.14,75,,67.312,Percent of Total Billed charges,75% of Total Billed Charges,112.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.77,72,,64.616,Percent of Total Billed Charges,72% of Total Billed Charges,67.31,60,,53.848,Percent of Total Billed Charges,60% of Total Billed Charges,100.96,90,,61.12,Percent of Total Billed Charges,90% of Total Billed Charges,50.48,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,100.96,90,,33.84,Percent of Total Billed Charges,90% of Total billed Charges,112.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.92,65,,34.608,Percent of total Billed Charges,65% of Total Billed Charges,49.47,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,106.57,95,,35.72,Percent of Total Billed Charges,95% of Total Billed Charges,112.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.72,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,100.96,90,,33.84,Percent of Total Billed charges,90% of Total Billed Charges,49.47,112.18,
ZOSTER (ZOSTAVAX) SDV INJ,6360000048,CDM,636,RC,,,Outpatient,,,212.67,138.24,,212.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.63,76,,47.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153.12,72,,122.496,Percent of Total Billed Charges,72% of Total Billed Charges,159.5,75,,127.6,Percent of Total Billed charges,75% of Total Billed Charges,212.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.12,72,,122.496,Percent of Total Billed Charges,72% of Total Billed Charges,127.6,60,,102.08,Percent of Total Billed Charges,60% of Total Billed Charges,191.4,90,,104.784,Percent of Total Billed Charges,90% of Total Billed Charges,95.7,45,,171.464,Percent of Total Billed Charges,45% of Total Billed Charges,191.4,90,,56.36,Percent of Total Billed Charges,90% of Total billed Charges,212.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.24,65,,299.288,Percent of total Billed Charges,65% of Total Billed Charges,93.79,44.1,,168.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,202.04,95,,59.496,Percent of Total Billed Charges,95% of Total Billed Charges,212.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.15,88,,335.304,Percent of Total Billed Charges,88% of Total Billed Charges,191.4,90,,56.36,Percent of Total Billed charges,90% of Total Billed Charges,93.79,212.67,
HEPATITIS B ADLT VAC INJ,6360000050,CDM,636,RC,,,Outpatient,,,293.27,190.63,,293.27,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,222.89,76,,18.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,211.15,72,,168.92,Percent of Total Billed Charges,72% of Total Billed Charges,219.95,75,,175.96,Percent of Total Billed charges,75% of Total Billed Charges,293.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.15,72,,168.92,Percent of Total Billed Charges,72% of Total Billed Charges,175.96,60,,140.768,Percent of Total Billed Charges,60% of Total Billed Charges,263.94,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,131.97,45,,6.744,Percent of Total Billed Charges,45% of Total Billed Charges,263.94,90,,21.424,Percent of Total Billed Charges,90% of Total billed Charges,293.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.63,65,,9921.168,Percent of total Billed Charges,65% of Total Billed Charges,129.33,44.1,,6.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,278.61,95,,22.608,Percent of Total Billed Charges,95% of Total Billed Charges,293.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258.08,88,,13.192,Percent of Total Billed Charges,88% of Total Billed Charges,263.94,90,,21.424,Percent of Total Billed charges,90% of Total Billed Charges,129.33,293.27,
PROTONIX 40MG INJ,6360000051,CDM,636,RC,J2471,HCPCS,Outpatient,40,GM,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.43,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,22.33,75,,17.864,Percent of Total Billed charges,75% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.43,72,,17.144,Percent of Total Billed Charges,72% of Total Billed Charges,17.86,60,,14.288,Percent of Total Billed Charges,60% of Total Billed Charges,26.79,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,461.592,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,829.648,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,452.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,902.672,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,13.13,29.77,
ACETYLCYSTCINE 20% 10ML VIAL,6360000053,CDM,250,RC,,,Outpatient,10,ML,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,532.08,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,30.56,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,288.656,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,29.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,59.76,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
ZOVIRAX 500MG INJ,6360000055,CDM,636,RC,J0133,HCPCS,Outpatient,500,GM,82.69,53.75,,82.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,62.84,76,,133.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.18,350,,,Fee Schedule,350% of BCBS fee schedule,0.18,350,,,Fee Schedule,350% of BCBS fee schedule,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.18,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.05,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,74.42,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,37.21,45,,8.464,Percent of Total Billed Charges,45% of Total Billed Charges,74.42,90,,157.968,Percent of Total Billed Charges,90% of Total billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.75,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,36.47,44.1,,8.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,78.56,95,,166.744,Percent of Total Billed Charges,95% of Total Billed Charges,82.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,88,,16.544,Percent of Total Billed Charges,88% of Total Billed Charges,74.42,90,,157.968,Percent of Total Billed charges,90% of Total Billed Charges,0.05,82.69,
ADENOSCAN 6MG/2ML VIAL,6360000056,CDM,636,RC,J0153,HCPCS,Outpatient,6,GM,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,11.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.41,350,,,Fee Schedule,350% of BCBS fee schedule,4.41,350,,,Fee Schedule,350% of BCBS fee schedule,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.26,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,79.38,90,,3056.928,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,13.496,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,14.24,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,13.496,Percent of Total Billed charges,90% of Total Billed Charges,1.26,88.2,
EPINEPHRINE 1:10000 INJ,6360000059,CDM,636,RC,J0171,HCPCS,Outpatient,,,27.56,17.91,,27.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,20.95,76,,51.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.49,350,,,Fee Schedule,350% of BCBS fee schedule,0.49,350,,,Fee Schedule,350% of BCBS fee schedule,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.49,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.14,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,24.8,90,,5.56,Percent of Total Billed Charges,90% of Total Billed Charges,12.4,45,,17.856,Percent of Total Billed Charges,45% of Total Billed Charges,24.8,90,,61.12,Percent of Total Billed Charges,90% of Total billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.91,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,12.15,44.1,,17.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.18,95,,64.52,Percent of Total Billed Charges,95% of Total Billed Charges,27.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.25,88,,34.928,Percent of Total Billed Charges,88% of Total Billed Charges,24.8,90,,61.12,Percent of Total Billed charges,90% of Total Billed Charges,0.14,27.56,
EPI SHUGARCANIE MIX INJ,6360000060,CDM,250,RC,,,Outpatient,,,259.09,168.41,,259.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,196.91,76,,88.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,186.54,72,,149.232,Percent of Total Billed Charges,72% of Total Billed Charges,194.32,75,,155.456,Percent of Total Billed charges,75% of Total Billed Charges,259.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.54,72,,149.232,Percent of Total Billed Charges,72% of Total Billed Charges,155.45,60,,124.36,Percent of Total Billed Charges,60% of Total Billed Charges,233.18,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,116.59,45,,266.04,Percent of Total Billed Charges,45% of Total Billed Charges,233.18,90,,104.784,Percent of Total Billed Charges,90% of Total billed Charges,259.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.41,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,114.26,44.1,,260.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,246.14,95,,110.6,Percent of Total Billed Charges,95% of Total Billed Charges,259.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228,88,,520.256,Percent of Total Billed Charges,88% of Total Billed Charges,233.18,90,,104.784,Percent of Total Billed charges,90% of Total Billed Charges,114.26,259.09,
ADRENALIN 1CC INJ,6360000061,CDM,250,RC,,,Outpatient,,,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,14.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.35,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,6.62,75,,5.296,Percent of Total Billed charges,75% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.35,72,,5.08,Percent of Total Billed Charges,72% of Total Billed Charges,5.29,60,,4.232,Percent of Total Billed Charges,60% of Total Billed Charges,7.94,90,,6.352,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,305.248,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,16.92,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,299.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,17.864,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,596.92,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,16.92,Percent of Total Billed charges,90% of Total Billed Charges,3.89,8.82,
ADRENALIN 30ML INJ,6360000062,CDM,636,RC,J0171,HCPCS,Outpatient,30,ML,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.49,350,,,Fee Schedule,350% of BCBS fee schedule,0.49,350,,,Fee Schedule,350% of BCBS fee schedule,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.49,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.14,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,3.97,90,,89.696,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,10.08,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,69.424,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,9.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,19.712,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,0.14,4.41,
AMINOPHYLLINE 250MG INJ,6360000063,CDM,636,RC,J0280,HCPCS,Outpatient,250,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.43,350,,,Fee Schedule,350% of BCBS fee schedule,17.43,350,,,Fee Schedule,350% of BCBS fee schedule,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.43,350,,,Fee Schedule,350% of BCBS PPO fee schedule,4.98,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,7.94,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,1528.464,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,122.128,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,1497.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,2988.992,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,3.89,17.43,
AMINOPHYLLIN 500 IV INJ,6360000064,CDM,636,RC,J0280,HCPCS,Outpatient,,,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,30.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.43,350,,,Fee Schedule,350% of BCBS fee schedule,17.43,350,,,Fee Schedule,350% of BCBS fee schedule,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.43,350,,,Fee Schedule,350% of BCBS PPO fee schedule,4.98,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,9.93,90,,2.384,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,6.744,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,35.72,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,175.92,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,6.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,37.704,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,13.192,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,35.72,Percent of Total Billed charges,90% of Total Billed Charges,4.86,17.43,
AMIODARONE 150MG/3ML INJ,6360000065,CDM,636,RC,J0282,HCPCS,Outpatient,150,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,449.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.7,350,,,Fee Schedule,350% of BCBS fee schedule,0.7,350,,,Fee Schedule,350% of BCBS fee schedule,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.7,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.2,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,7.94,90,,11.12,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,2.776,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,532.08,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,5.304,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,2.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,561.64,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,5.432,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,532.08,Percent of Total Billed charges,90% of Total Billed Charges,0.2,8.82,
AMPHOTERICIN B 50MG INJ,6360000068,CDM,636,RC,J0285,HCPCS,Outpatient,50,GM,897.44,583.34,,897.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,682.05,76,,515.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,91.95,350,,,Fee Schedule,350% of BCBS fee schedule,91.95,350,,,Fee Schedule,350% of BCBS fee schedule,897.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.95,350,,,Fee Schedule,350% of BCBS PPO fee schedule,26.27,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,807.7,90,,123.832,Percent of Total Billed Charges,90% of Total Billed Charges,403.85,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,807.7,90,,610.488,Percent of Total Billed Charges,90% of Total billed Charges,897.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,897.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,897.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.34,65,,250.328,Percent of total Billed Charges,65% of Total Billed Charges,395.77,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,852.57,95,,644.408,Percent of Total Billed Charges,95% of Total Billed Charges,897.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,789.75,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,807.7,90,,610.488,Percent of Total Billed charges,90% of Total Billed Charges,26.27,897.44,
AMPICILLIN 2GM VL INJ,6360000069,CDM,636,RC,J0290,HCPCS,Outpatient,2,gm,47.41,30.82,,47.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.03,76,,17.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,350,,,Fee Schedule,350% of BCBS fee schedule,7.14,350,,,Fee Schedule,350% of BCBS fee schedule,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.04,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,42.67,90,,18.256,Percent of Total Billed Charges,90% of Total Billed Charges,21.33,45,,3.176,Percent of Total Billed Charges,45% of Total Billed Charges,42.67,90,,20.16,Percent of Total Billed Charges,90% of Total billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.82,65,,7.84,Percent of total Billed Charges,65% of Total Billed Charges,20.91,44.1,,3.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.04,95,,21.28,Percent of Total Billed Charges,95% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.72,88,,6.208,Percent of Total Billed Charges,88% of Total Billed Charges,42.67,90,,20.16,Percent of Total Billed charges,90% of Total Billed Charges,2.04,47.41,
AMPICILN 125MG INJ,6360000070,CDM,636,RC,J0290,HCPCS,Outpatient,125,GM,25.36,16.48,,25.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.27,76,,2581.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,350,,,Fee Schedule,350% of BCBS fee schedule,7.14,350,,,Fee Schedule,350% of BCBS fee schedule,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.04,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,22.82,90,,221.472,Percent of Total Billed Charges,90% of Total Billed Charges,11.41,45,,44.848,Percent of Total Billed Charges,45% of Total Billed Charges,22.82,90,,3056.928,Percent of Total Billed Charges,90% of Total billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,65,,4.424,Percent of total Billed Charges,65% of Total Billed Charges,11.18,44.1,,43.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.09,95,,3226.752,Percent of Total Billed Charges,95% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,88,,87.704,Percent of Total Billed Charges,88% of Total Billed Charges,22.82,90,,3056.928,Percent of Total Billed charges,90% of Total Billed Charges,2.04,25.36,
AMPICILN 250MG INJ,6360000071,CDM,636,RC,J0290,HCPCS,Outpatient,250,GM,14.33,9.31,,14.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.89,76,,11.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,350,,,Fee Schedule,350% of BCBS fee schedule,7.14,350,,,Fee Schedule,350% of BCBS fee schedule,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.04,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,12.9,90,,402.456,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,12.9,90,,13.496,Percent of Total Billed Charges,90% of Total billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.31,65,,52.224,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.61,95,,14.24,Percent of Total Billed Charges,95% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.61,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,12.9,90,,13.496,Percent of Total Billed charges,90% of Total Billed Charges,2.04,14.33,
AMPICILN 500MG INJ,6360000072,CDM,636,RC,J0290,HCPCS,Outpatient,500,GM,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,4.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,350,,,Fee Schedule,350% of BCBS fee schedule,7.14,350,,,Fee Schedule,350% of BCBS fee schedule,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.04,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,13.9,90,,94.464,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,1.192,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,5.56,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,10.376,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,1.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,5.864,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,2.328,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,5.56,Percent of Total Billed charges,90% of Total Billed Charges,2.04,15.44,
AMPICILN 1GM INJ,6360000073,CDM,636,RC,J0290,HCPCS,Outpatient,1,gm,35.28,22.93,,35.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.81,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.14,350,,,Fee Schedule,350% of BCBS fee schedule,7.14,350,,,Fee Schedule,350% of BCBS fee schedule,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.14,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.04,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,31.75,90,,284.184,Percent of Total Billed Charges,90% of Total Billed Charges,15.88,45,,5.56,Percent of Total Billed Charges,45% of Total Billed Charges,31.75,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.93,65,,1594.552,Percent of total Billed Charges,65% of Total Billed Charges,15.56,44.1,,5.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.52,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.05,88,,10.872,Percent of Total Billed Charges,88% of Total Billed Charges,31.75,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,2.04,35.28,
UNASYN 1.5GM INJ,6360000074,CDM,636,RC,J0295,HCPCS,Outpatient,1.5,gm,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,5.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.42,350,,,Fee Schedule,350% of BCBS fee schedule,9.42,350,,,Fee Schedule,350% of BCBS fee schedule,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.42,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.69,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,21.83,90,,62.712,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,61.92,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,6.352,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,1594.552,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,60.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,6.704,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,121.08,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,6.352,Percent of Total Billed charges,90% of Total Billed Charges,2.69,24.26,
UNASYN 3.0GM INJ,6360000075,CDM,636,RC,J0295,HCPCS,Outpatient,3,gm,45.20,29.38,,45.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.35,76,,75.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.42,350,,,Fee Schedule,350% of BCBS fee schedule,9.42,350,,,Fee Schedule,350% of BCBS fee schedule,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.42,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.69,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,40.68,90,,62.712,Percent of Total Billed Charges,90% of Total Billed Charges,20.34,45,,9.128,Percent of Total Billed Charges,45% of Total Billed Charges,40.68,90,,89.696,Percent of Total Billed Charges,90% of Total billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.38,65,,10581.584,Percent of total Billed Charges,65% of Total Billed Charges,19.93,44.1,,8.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.94,95,,94.68,Percent of Total Billed Charges,95% of Total Billed Charges,45.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.78,88,,17.856,Percent of Total Billed Charges,88% of Total Billed Charges,40.68,90,,89.696,Percent of Total Billed charges,90% of Total Billed Charges,2.69,45.2,
UNASYN 3.0GM ADV,6360000076,CDM,636,RC,J0295,HCPCS,Outpatient,3,gm,38.75,25.19,,38.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.45,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.42,350,,,Fee Schedule,350% of BCBS fee schedule,9.42,350,,,Fee Schedule,350% of BCBS fee schedule,38.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.42,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.69,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,34.88,90,,62.712,Percent of Total Billed Charges,90% of Total Billed Charges,17.44,45,,110.736,Percent of Total Billed Charges,45% of Total Billed Charges,34.88,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,38.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.19,65,,460.624,Percent of total Billed Charges,65% of Total Billed Charges,17.09,44.1,,108.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.81,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,38.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.1,88,,216.552,Percent of Total Billed Charges,88% of Total Billed Charges,34.88,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,2.69,38.75,
ANECTINE INJ 20MG INJ,6360000077,CDM,636,RC,J0330,HCPCS,Outpatient,20,GM,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,2.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.6,350,,,Fee Schedule,350% of BCBS fee schedule,0.6,350,,,Fee Schedule,350% of BCBS fee schedule,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.6,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.17,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,17.87,90,,62.712,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,201.232,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,2.384,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,9108.2,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,197.208,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,2.512,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,393.512,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,2.384,Percent of Total Billed charges,90% of Total Billed Charges,0.17,19.85,
APRESOLINE 20MG INJ,6360000078,CDM,636,RC,J0360,HCPCS,Outpatient,20,GM,68.36,44.43,,68.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.95,76,,9.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.23,350,,,Fee Schedule,350% of BCBS fee schedule,22.23,350,,,Fee Schedule,350% of BCBS fee schedule,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.23,350,,,Fee Schedule,350% of BCBS PPO fee schedule,6.35,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,61.52,90,,62.712,Percent of Total Billed Charges,90% of Total Billed Charges,30.76,45,,47.232,Percent of Total Billed Charges,45% of Total Billed Charges,61.52,90,,11.12,Percent of Total Billed Charges,90% of Total billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.43,65,,36235.344,Percent of total Billed Charges,65% of Total Billed Charges,30.15,44.1,,46.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,64.94,95,,11.736,Percent of Total Billed Charges,95% of Total Billed Charges,68.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.16,88,,92.368,Percent of Total Billed Charges,88% of Total Billed Charges,61.52,90,,11.12,Percent of Total Billed charges,90% of Total Billed Charges,6.35,68.36,
ZITHROMAX 500MG INJ,6360000079,CDM,636,RC,J0456,HCPCS,Outpatient,500,GM,44.10,28.67,,44.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33.52,76,,104.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.53,350,,,Fee Schedule,350% of BCBS fee schedule,14.53,350,,,Fee Schedule,350% of BCBS fee schedule,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.53,350,,,Fee Schedule,350% of BCBS PPO fee schedule,4.15,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,39.69,90,,4681.84,Percent of Total Billed Charges,90% of Total Billed Charges,19.85,45,,142.096,Percent of Total Billed Charges,45% of Total Billed Charges,39.69,90,,123.832,Percent of Total Billed Charges,90% of Total billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,65,,24574.936,Percent of total Billed Charges,65% of Total Billed Charges,19.45,44.1,,139.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.9,95,,130.712,Percent of Total Billed Charges,95% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.81,88,,277.872,Percent of Total Billed Charges,88% of Total Billed Charges,39.69,90,,123.832,Percent of Total Billed charges,90% of Total Billed Charges,4.15,44.1,
ATROPINE 1MG SYRINGE,6360000080,CDM,636,RC,J0461,HCPCS,Outpatient,1,GM,24.26,15.77,,24.26,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,18.44,76,,15.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.04,350,,,Fee Schedule,350% of BCBS fee schedule,0.04,350,,,Fee Schedule,350% of BCBS fee schedule,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.04,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.01,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,21.83,90,,309.008,Percent of Total Billed Charges,90% of Total Billed Charges,10.92,45,,31.36,Percent of Total Billed Charges,45% of Total Billed Charges,21.83,90,,18.256,Percent of Total Billed Charges,90% of Total billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.77,65,,2315.216,Percent of total Billed Charges,65% of Total Billed Charges,10.7,44.1,,30.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.05,95,,19.272,Percent of Total Billed Charges,95% of Total Billed Charges,24.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.35,88,,61.32,Percent of Total Billed Charges,88% of Total Billed Charges,21.83,90,,18.256,Percent of Total Billed charges,90% of Total Billed Charges,0.01,24.26,
ATROPINE 0.4MG/1ML INJ,6360000081,CDM,636,RC,J0461,HCPCS,Outpatient,0.4,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,187.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.04,350,,,Fee Schedule,350% of BCBS fee schedule,0.04,350,,,Fee Schedule,350% of BCBS fee schedule,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.04,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.01,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,9.93,90,,309.008,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,31.36,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,221.472,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,998.384,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,30.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,233.776,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,61.32,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,221.472,Percent of Total Billed charges,90% of Total Billed Charges,0.01,11.03,
ATROPINE 8MG/20ML INJ,6360000082,CDM,636,RC,J0461,HCPCS,Outpatient,8,GM,160.97,104.63,,160.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,122.34,76,,339.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.04,350,,,Fee Schedule,350% of BCBS fee schedule,0.04,350,,,Fee Schedule,350% of BCBS fee schedule,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.04,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.01,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,144.87,90,,62.712,Percent of Total Billed Charges,90% of Total Billed Charges,72.44,45,,31.36,Percent of Total Billed Charges,45% of Total Billed Charges,144.87,90,,402.456,Percent of Total Billed Charges,90% of Total billed Charges,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.63,65,,998.384,Percent of total Billed Charges,65% of Total Billed Charges,70.99,44.1,,30.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,152.92,95,,424.816,Percent of Total Billed Charges,95% of Total Billed Charges,160.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.65,88,,61.32,Percent of Total Billed Charges,88% of Total Billed Charges,144.87,90,,402.456,Percent of Total Billed charges,90% of Total Billed Charges,0.01,160.97,
BENTYL 10MG 1ML/CC INJ,6360000083,CDM,636,RC,J0500,HCPCS,Outpatient,10,GM,157.66,102.48,,157.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,119.82,76,,79.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,149.52,350,,,Fee Schedule,350% of BCBS fee schedule,149.52,350,,,Fee Schedule,350% of BCBS fee schedule,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.52,350,,,Fee Schedule,350% of BCBS PPO fee schedule,42.72,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,141.89,90,,309.008,Percent of Total Billed Charges,90% of Total Billed Charges,70.95,45,,31.36,Percent of Total Billed Charges,45% of Total Billed Charges,141.89,90,,94.464,Percent of Total Billed Charges,90% of Total billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.48,65,,1702.936,Percent of total Billed Charges,65% of Total Billed Charges,69.53,44.1,,30.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,149.78,95,,99.712,Percent of Total Billed Charges,95% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.74,88,,61.32,Percent of Total Billed Charges,88% of Total Billed Charges,141.89,90,,94.464,Percent of Total Billed charges,90% of Total Billed Charges,42.72,157.66,
BICILLIN CR 1200000 INJ,6360000084,CDM,636,RC,J0558,HCPCS,Outpatient,,,169.79,110.36,,21.71,125,,,Fee Schedule,125% of CMS OPPS Rate,129.04,76,,239.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.1,350,,,Fee Schedule,350% of BCBS fee schedule,16.1,350,,,Fee Schedule,350% of BCBS fee schedule,17.37,100,,,Fee Schedule,100% of CMS OPPS Rate,16.1,350,,,Fee Schedule,350% of BCBS PPO fee schedule,4.6,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,152.81,90,,309.008,Percent of Total Billed Charges,90% of Total Billed Charges,76.41,45,,31.36,Percent of Total Billed Charges,45% of Total Billed Charges,152.81,90,,284.184,Percent of Total Billed Charges,90% of Total billed Charges,17.37,100,,,Fee Schedule,100% of CMS OPPS Rate,17.37,100,,,Fee Schedule,100% of CMS OPPS Rate,17.37,100,,,Fee Schedule,100% of CMS OPPS Rate,145.1,65,,4162.456,Percent of total Billed Charges,65% of Total Billed Charges,74.88,44.1,,30.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,161.3,95,,299.976,Percent of Total Billed Charges,95% of Total Billed Charges,13.02,75,,,Fee Schedule,75% of CMS OPPS Rate,149.42,88,,61.32,Percent of Total Billed Charges,88% of Total Billed Charges,152.81,90,,284.184,Percent of Total Billed charges,90% of Total Billed Charges,4.6,161.3,
BICILLIN CR 900/300 INJ,6360000085,CDM,636,RC,J0558,HCPCS,Outpatient,,,116.87,75.97,,21.71,125,,,Fee Schedule,125% of CMS OPPS Rate,88.82,76,,52.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.1,350,,,Fee Schedule,350% of BCBS fee schedule,16.1,350,,,Fee Schedule,350% of BCBS fee schedule,17.37,100,,,Fee Schedule,100% of CMS OPPS Rate,16.1,350,,,Fee Schedule,350% of BCBS PPO fee schedule,4.6,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,105.18,90,,1367.712,Percent of Total Billed Charges,90% of Total Billed Charges,52.59,45,,2340.92,Percent of Total Billed Charges,45% of Total Billed Charges,105.18,90,,62.712,Percent of Total Billed Charges,90% of Total billed Charges,17.37,100,,,Fee Schedule,100% of CMS OPPS Rate,17.37,100,,,Fee Schedule,100% of CMS OPPS Rate,17.37,100,,,Fee Schedule,100% of CMS OPPS Rate,110.71,65,,15.6,Percent of total Billed Charges,65% of Total Billed Charges,51.54,44.1,,2294.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,111.03,95,,66.2,Percent of Total Billed Charges,95% of Total Billed Charges,13.02,75,,,Fee Schedule,75% of CMS OPPS Rate,102.85,88,,4577.792,Percent of Total Billed Charges,88% of Total Billed Charges,105.18,90,,62.712,Percent of Total Billed charges,90% of Total Billed Charges,4.6,111.03,
BICILLIN LA 1200000 INJ,6360000086,CDM,636,RC,J0561,HCPCS,Outpatient,,,303.19,197.07,,33.52,125,,,Fee Schedule,125% of CMS OPPS Rate,230.42,76,,52.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.79,350,,,Fee Schedule,350% of BCBS fee schedule,41.79,350,,,Fee Schedule,350% of BCBS fee schedule,26.82,100,,,Fee Schedule,100% of CMS OPPS Rate,41.79,350,,,Fee Schedule,350% of BCBS PPO fee schedule,11.94,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,272.87,90,,683.856,Percent of Total Billed Charges,90% of Total Billed Charges,136.44,45,,154.504,Percent of Total Billed Charges,45% of Total Billed Charges,272.87,90,,62.712,Percent of Total Billed Charges,90% of Total billed Charges,26.82,100,,,Fee Schedule,100% of CMS OPPS Rate,26.82,100,,,Fee Schedule,100% of CMS OPPS Rate,26.82,100,,,Fee Schedule,100% of CMS OPPS Rate,250.71,65,,184.864,Percent of total Billed Charges,65% of Total Billed Charges,133.71,44.1,,151.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,288.03,95,,66.2,Percent of Total Billed Charges,95% of Total Billed Charges,20.11,75,,,Fee Schedule,75% of CMS OPPS Rate,266.81,88,,302.144,Percent of Total Billed Charges,88% of Total Billed Charges,272.87,90,,62.712,Percent of Total Billed charges,90% of Total Billed Charges,11.94,288.03,
STADOL 1MG INJ,6360000087,CDM,636,RC,J0595,HCPCS,Outpatient,1,GM,18.74,12.18,,18.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.24,76,,52.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.64,350,,,Fee Schedule,350% of BCBS fee schedule,3.64,350,,,Fee Schedule,350% of BCBS fee schedule,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.64,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.04,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,16.87,90,,341.928,Percent of Total Billed Charges,90% of Total Billed Charges,8.43,45,,154.504,Percent of Total Billed Charges,45% of Total Billed Charges,16.87,90,,62.712,Percent of Total Billed Charges,90% of Total billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.18,65,,697.336,Percent of total Billed Charges,65% of Total Billed Charges,8.26,44.1,,151.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.8,95,,66.2,Percent of Total Billed Charges,95% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,88,,302.144,Percent of Total Billed Charges,88% of Total Billed Charges,16.87,90,,62.712,Percent of Total Billed charges,90% of Total Billed Charges,1.04,18.74,
STADOL 2MG INJ,6360000088,CDM,636,RC,J0595,HCPCS,Outpatient,2,GM,25.36,16.48,,25.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.27,76,,52.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.64,350,,,Fee Schedule,350% of BCBS fee schedule,3.64,350,,,Fee Schedule,350% of BCBS fee schedule,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.64,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.04,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,22.82,90,,273.544,Percent of Total Billed Charges,90% of Total Billed Charges,11.41,45,,31.36,Percent of Total Billed Charges,45% of Total Billed Charges,22.82,90,,62.712,Percent of Total Billed Charges,90% of Total billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,65,,61.104,Percent of total Billed Charges,65% of Total Billed Charges,11.18,44.1,,30.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.09,95,,66.2,Percent of Total Billed Charges,95% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,88,,61.32,Percent of Total Billed Charges,88% of Total Billed Charges,22.82,90,,62.712,Percent of Total Billed charges,90% of Total Billed Charges,1.04,25.36,
SENSIPAR 30MG,6360000089,CDM,636,RC,J0604,HCPCS,Outpatient,30,GM,88.75,57.69,,88.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.45,76,,52.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.15,350,,,Fee Schedule,350% of BCBS fee schedule,3.15,350,,,Fee Schedule,350% of BCBS fee schedule,88.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.15,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.9,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,79.88,90,,455.76,Percent of Total Billed Charges,90% of Total Billed Charges,39.94,45,,154.504,Percent of Total Billed Charges,45% of Total Billed Charges,79.88,90,,62.712,Percent of Total Billed Charges,90% of Total billed Charges,88.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.69,65,,152.232,Percent of total Billed Charges,65% of Total Billed Charges,39.14,44.1,,151.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,84.31,95,,66.2,Percent of Total Billed Charges,95% of Total Billed Charges,88.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.1,88,,302.144,Percent of Total Billed Charges,88% of Total Billed Charges,79.88,90,,62.712,Percent of Total Billed charges,90% of Total Billed Charges,0.9,88.75,
CALCIUM GLUCONATE 10ML INJ,6360000090,CDM,636,RC,J0612,HCPCS,Outpatient,10,ML,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,3953.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.53,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,9.92,75,,7.936,Percent of Total Billed charges,75% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.53,72,,7.624,Percent of Total Billed Charges,72% of Total Billed Charges,7.94,60,,6.352,Percent of Total Billed Charges,60% of Total Billed Charges,11.91,90,,455.904,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,154.504,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,4681.84,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,67422.344,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,151.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,4941.936,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,302.144,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,4681.84,Percent of Total Billed charges,90% of Total Billed Charges,5.83,13.23,
CANCIDAS 70MG INJ,6360000092,CDM,636,RC,J0637,HCPCS,Outpatient,70,GM,1924.97,1251.23,,1924.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1462.98,76,,260.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,87.47,350,,,Fee Schedule,350% of BCBS fee schedule,87.47,350,,,Fee Schedule,350% of BCBS fee schedule,1924.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.47,350,,,Fee Schedule,350% of BCBS PPO fee schedule,24.99,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,1732.47,90,,341.928,Percent of Total Billed Charges,90% of Total Billed Charges,866.24,45,,683.856,Percent of Total Billed Charges,45% of Total Billed Charges,1732.47,90,,309.008,Percent of Total Billed Charges,90% of Total billed Charges,1924.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1924.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1924.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1251.23,65,,4596.896,Percent of total Billed Charges,65% of Total Billed Charges,848.91,44.1,,670.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,1828.72,95,,326.176,Percent of Total Billed Charges,95% of Total Billed Charges,1924.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1693.97,88,,1337.32,Percent of Total Billed Charges,88% of Total Billed Charges,1732.47,90,,309.008,Percent of Total Billed charges,90% of Total Billed Charges,24.99,1924.97,
ANCEF 500MG VIAL INJ,6360000093,CDM,636,RC,J0690,HCPCS,Outpatient,500,GM,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,260.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.56,350,,,Fee Schedule,350% of BCBS fee schedule,0.56,350,,,Fee Schedule,350% of BCBS fee schedule,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.56,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.16,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,14.89,90,,1367.712,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,341.928,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,309.008,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,18066.384,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,335.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,326.176,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,668.656,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,309.008,Percent of Total Billed charges,90% of Total Billed Charges,0.16,16.54,
ANCEF 1GM VIAL INJ,6360000094,CDM,636,RC,J0690,HCPCS,Outpatient,1,gm,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,52.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.56,350,,,Fee Schedule,350% of BCBS fee schedule,0.56,350,,,Fee Schedule,350% of BCBS fee schedule,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.56,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.16,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,4.96,90,,683.856,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,170.968,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,62.712,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,73.112,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,167.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,66.2,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,334.328,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,62.712,Percent of Total Billed charges,90% of Total Billed Charges,0.16,5.51,
CEFAZOLIN 1GM VIAL ADV,6360000097,CDM,636,RC,J0690,HCPCS,Outpatient,1,gm,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,1154.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.56,350,,,Fee Schedule,350% of BCBS fee schedule,0.56,350,,,Fee Schedule,350% of BCBS fee schedule,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.56,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.16,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,10.8,90,,3.176,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,227.952,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,1367.712,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,17.928,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,223.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,1443.696,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,445.776,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,1367.712,Percent of Total Billed charges,90% of Total Billed Charges,0.16,12,
CEFEPIME/DEXTROSE 1GM/50ML,6360000098,CDM,636,RC,J0692,HCPCS,Outpatient,1,gm,105.00,68.25,,105,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.8,76,,577.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.58,350,,,Fee Schedule,350% of BCBS fee schedule,8.58,350,,,Fee Schedule,350% of BCBS fee schedule,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.58,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.45,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,94.5,90,,4.768,Percent of Total Billed Charges,90% of Total Billed Charges,47.25,45,,170.968,Percent of Total Billed Charges,45% of Total Billed Charges,94.5,90,,683.856,Percent of Total Billed Charges,90% of Total billed Charges,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.25,65,,322.608,Percent of total Billed Charges,65% of Total Billed Charges,46.31,44.1,,167.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,99.75,95,,721.848,Percent of Total Billed Charges,95% of Total Billed Charges,105,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.4,88,,334.328,Percent of Total Billed Charges,88% of Total Billed Charges,94.5,90,,683.856,Percent of Total Billed charges,90% of Total Billed Charges,2.45,105,
MAXIPIME 1GM VIAL INJ,6360000099,CDM,636,RC,J0692,HCPCS,Outpatient,1,gm,34.18,22.22,,34.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.98,76,,288.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.58,350,,,Fee Schedule,350% of BCBS fee schedule,8.58,350,,,Fee Schedule,350% of BCBS fee schedule,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.58,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.45,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,30.76,90,,205.56,Percent of Total Billed Charges,90% of Total Billed Charges,15.38,45,,683.856,Percent of Total Billed Charges,45% of Total Billed Charges,30.76,90,,341.928,Percent of Total Billed Charges,90% of Total billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.22,65,,101.416,Percent of total Billed Charges,65% of Total Billed Charges,15.07,44.1,,670.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.47,95,,360.928,Percent of Total Billed Charges,95% of Total Billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.08,88,,1337.32,Percent of Total Billed Charges,88% of Total Billed Charges,30.76,90,,341.928,Percent of Total Billed charges,90% of Total Billed Charges,2.45,34.18,
CEFTRIAXONE/DEXTROSE 1GM/50ML,6360000100,CDM,636,RC,J0696,HCPCS,Outpatient,1,gm,57.00,37.05,,57,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,43.32,76,,230.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.86,350,,,Fee Schedule,350% of BCBS fee schedule,8.86,350,,,Fee Schedule,350% of BCBS fee schedule,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.86,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.53,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,51.3,90,,63.544,Percent of Total Billed Charges,90% of Total Billed Charges,25.65,45,,341.928,Percent of Total Billed Charges,45% of Total Billed Charges,51.3,90,,273.544,Percent of Total Billed Charges,90% of Total billed Charges,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.05,65,,410.432,Percent of total Billed Charges,65% of Total Billed Charges,25.14,44.1,,335.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,54.15,95,,288.736,Percent of Total Billed Charges,95% of Total Billed Charges,57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.16,88,,668.656,Percent of Total Billed Charges,88% of Total Billed Charges,51.3,90,,273.544,Percent of Total Billed charges,90% of Total Billed Charges,2.53,57,
ROCEPHIN 1GRAM VIAL INJ,6360000101,CDM,636,RC,J0696,HCPCS,Outpatient,,,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,384.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.86,350,,,Fee Schedule,350% of BCBS fee schedule,8.86,350,,,Fee Schedule,350% of BCBS fee schedule,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.86,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.53,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,11.91,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,136.768,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,455.76,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,61.104,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,134.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,481.08,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,267.464,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,455.76,Percent of Total Billed charges,90% of Total Billed Charges,2.53,13.23,
ROCEPHIN 2GRAM VIAL INJ,6360000102,CDM,636,RC,J0696,HCPCS,Outpatient,,,35.28,22.93,,35.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.81,76,,384.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.86,350,,,Fee Schedule,350% of BCBS fee schedule,8.86,350,,,Fee Schedule,350% of BCBS fee schedule,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.86,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.53,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,31.75,90,,126.328,Percent of Total Billed Charges,90% of Total Billed Charges,15.88,45,,41.28,Percent of Total Billed Charges,45% of Total Billed Charges,31.75,90,,455.904,Percent of Total Billed Charges,90% of Total billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.93,65,,61.104,Percent of total Billed Charges,65% of Total Billed Charges,15.56,44.1,,40.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.52,95,,481.232,Percent of Total Billed Charges,95% of Total Billed Charges,35.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.05,88,,80.72,Percent of Total Billed Charges,88% of Total Billed Charges,31.75,90,,455.904,Percent of Total Billed charges,90% of Total Billed Charges,2.53,35.28,
ROCEPHIN 500MG VIAL,6360000103,CDM,636,RC,J0696,HCPCS,Outpatient,500,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,288.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.86,350,,,Fee Schedule,350% of BCBS fee schedule,8.86,350,,,Fee Schedule,350% of BCBS fee schedule,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.86,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.53,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,7.94,90,,3082.504,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,1.584,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,341.928,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,1473.744,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,1.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,360.928,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,3.104,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,341.928,Percent of Total Billed charges,90% of Total Billed Charges,2.53,8.86,
ROCEPHIN 250MG VIAL,6360000104,CDM,636,RC,J0696,HCPCS,Outpatient,250,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,1154.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.86,350,,,Fee Schedule,350% of BCBS fee schedule,8.86,350,,,Fee Schedule,350% of BCBS fee schedule,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.86,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.53,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,6.95,90,,3321.36,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,2.384,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,1367.712,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,110.424,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,2.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,1443.696,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,4.664,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,1367.712,Percent of Total Billed charges,90% of Total Billed Charges,2.53,8.86,
ZINACEF 1.5GM IV INJ,6360000105,CDM,636,RC,J0697,HCPCS,Outpatient,1.5,gm,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,577.48,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.83,350,,,Fee Schedule,350% of BCBS fee schedule,4.83,350,,,Fee Schedule,350% of BCBS fee schedule,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.83,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.38,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,17.87,90,,70.024,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,102.784,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,683.856,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,454.192,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,100.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,721.848,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,200.992,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,683.856,Percent of Total Billed charges,90% of Total Billed Charges,1.38,19.85,
CELESTONE SOLUSP 6MG/ML INJ,6360000108,CDM,636,RC,J0702,HCPCS,Outpatient,6,GM,183.02,118.96,,183.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,139.1,76,,230.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.92,350,,,Fee Schedule,350% of BCBS fee schedule,24.92,350,,,Fee Schedule,350% of BCBS fee schedule,183.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.92,350,,,Fee Schedule,350% of BCBS PPO fee schedule,7.12,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,164.72,90,,487.008,Percent of Total Billed Charges,90% of Total Billed Charges,82.36,45,,31.768,Percent of Total Billed Charges,45% of Total Billed Charges,164.72,90,,273.544,Percent of Total Billed Charges,90% of Total billed Charges,183.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.96,65,,53.48,Percent of total Billed Charges,65% of Total Billed Charges,80.71,44.1,,31.136,Percent of Total Billed Charges,44.1% of Total Billed Charges,173.87,95,,288.736,Percent of Total Billed Charges,95% of Total Billed Charges,183.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.06,88,,62.128,Percent of Total Billed Charges,88% of Total Billed Charges,164.72,90,,273.544,Percent of Total Billed charges,90% of Total Billed Charges,7.12,183.02,
CAFFEINE CITRATE(Oral)60mg/3ml,6360000110,CDM,250,RC,,,Outpatient,60,GM,62.84,40.85,,62.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,47.76,76,,2.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.24,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,47.13,75,,37.704,Percent of Total Billed charges,75% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.24,72,,36.192,Percent of Total Billed Charges,72% of Total Billed Charges,37.7,60,,30.16,Percent of Total Billed Charges,60% of Total Billed Charges,56.56,90,,6211.44,Percent of Total Billed Charges,90% of Total Billed Charges,28.28,45,,63.16,Percent of Total Billed Charges,45% of Total Billed Charges,56.56,90,,3.176,Percent of Total Billed Charges,90% of Total billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.85,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,27.71,44.1,,61.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,59.7,95,,3.352,Percent of Total Billed Charges,95% of Total Billed Charges,62.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.3,88,,123.52,Percent of Total Billed Charges,88% of Total Billed Charges,56.56,90,,3.176,Percent of Total Billed charges,90% of Total Billed Charges,27.71,62.84,
FORTAZ 2GM INJ,6360000111,CDM,636,RC,J0713,HCPCS,Outpatient,2,gm,130.10,84.57,,130.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.88,76,,4.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.88,350,,,Fee Schedule,350% of BCBS fee schedule,5.88,350,,,Fee Schedule,350% of BCBS fee schedule,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.88,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.68,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,117.09,90,,73.12,Percent of Total Billed Charges,90% of Total Billed Charges,58.55,45,,1541.248,Percent of Total Billed Charges,45% of Total Billed Charges,117.09,90,,4.768,Percent of Total Billed Charges,90% of Total billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.57,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,57.37,44.1,,1510.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,123.6,95,,5.032,Percent of Total Billed Charges,95% of Total Billed Charges,130.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.49,88,,3014,Percent of Total Billed Charges,88% of Total Billed Charges,117.09,90,,4.768,Percent of Total Billed charges,90% of Total Billed Charges,1.68,130.1,
FORTAZ 1GM INJ 500MG INJ,6360000112,CDM,636,RC,J0713,HCPCS,Outpatient,1,GM,66.15,43.00,,66.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,50.27,76,,173.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.88,350,,,Fee Schedule,350% of BCBS fee schedule,5.88,350,,,Fee Schedule,350% of BCBS fee schedule,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.88,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.68,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,59.54,90,,128.488,Percent of Total Billed Charges,90% of Total Billed Charges,29.77,45,,1660.68,Percent of Total Billed Charges,45% of Total Billed Charges,59.54,90,,205.56,Percent of Total Billed Charges,90% of Total billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,65,,49.304,Percent of total Billed Charges,65% of Total Billed Charges,29.17,44.1,,1627.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,62.84,95,,216.984,Percent of Total Billed Charges,95% of Total Billed Charges,66.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.21,88,,3247.552,Percent of Total Billed Charges,88% of Total Billed Charges,59.54,90,,205.56,Percent of Total Billed charges,90% of Total Billed Charges,1.68,66.15,
"NOVAREL 10,000 UNITS 10ML INJ",6360000114,CDM,636,RC,J0725,HCPCS,Outpatient,10,ML,264.74,172.08,,264.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,201.2,76,,28.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.62,350,,,Fee Schedule,350% of BCBS fee schedule,34.62,350,,,Fee Schedule,350% of BCBS fee schedule,264.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.62,350,,,Fee Schedule,350% of BCBS PPO fee schedule,9.89,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,238.27,90,,6603.768,Percent of Total Billed Charges,90% of Total Billed Charges,119.13,45,,243.504,Percent of Total Billed Charges,45% of Total Billed Charges,238.27,90,,33.84,Percent of Total Billed Charges,90% of Total billed Charges,264.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.08,65,,10.448,Percent of total Billed Charges,65% of Total Billed Charges,116.75,44.1,,238.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,251.5,95,,35.72,Percent of Total Billed Charges,95% of Total Billed Charges,264.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.97,88,,476.184,Percent of Total Billed Charges,88% of Total Billed Charges,238.27,90,,33.84,Percent of Total Billed charges,90% of Total Billed Charges,9.89,264.74,
PRIMAXIN 250 MG VIAL,6360000115,CDM,636,RC,J0743,HCPCS,Outpatient,250,GM,94.82,61.63,,94.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.06,76,,106.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.72,350,,,Fee Schedule,350% of BCBS fee schedule,15.72,350,,,Fee Schedule,350% of BCBS fee schedule,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.72,350,,,Fee Schedule,350% of BCBS PPO fee schedule,4.49,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,85.34,90,,168.712,Percent of Total Billed Charges,90% of Total Billed Charges,42.67,45,,483.392,Percent of Total Billed Charges,45% of Total Billed Charges,85.34,90,,126.328,Percent of Total Billed Charges,90% of Total billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.63,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,41.82,44.1,,473.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,90.08,95,,133.344,Percent of Total Billed Charges,95% of Total Billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.44,88,,945.296,Percent of Total Billed Charges,88% of Total Billed Charges,85.34,90,,126.328,Percent of Total Billed charges,90% of Total Billed Charges,4.49,94.82,
PRIMAXIN 500MG (ADV) INJ,6360000116,CDM,636,RC,J0743,HCPCS,Outpatient,500,GM,178.61,116.10,,178.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,135.74,76,,2603,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.72,350,,,Fee Schedule,350% of BCBS fee schedule,15.72,350,,,Fee Schedule,350% of BCBS fee schedule,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.72,350,,,Fee Schedule,350% of BCBS PPO fee schedule,4.49,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,160.75,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,80.37,45,,3105.72,Percent of Total Billed Charges,45% of Total Billed Charges,160.75,90,,3082.504,Percent of Total Billed Charges,90% of Total billed Charges,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.1,65,,869.696,Percent of total Billed Charges,65% of Total Billed Charges,78.77,44.1,,3043.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,169.68,95,,3253.752,Percent of Total Billed Charges,95% of Total Billed Charges,178.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.18,88,,6073.408,Percent of Total Billed Charges,88% of Total Billed Charges,160.75,90,,3082.504,Percent of Total Billed charges,90% of Total Billed Charges,4.49,178.61,
CORTROSYN 0.25MG/ML INJ,6360000117,CDM,250,RC,J0834,HCPCS,Outpatient,0.25,GM,1052.89,684.38,,1052.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,800.2,76,,2804.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,194.01,350,,,Fee Schedule,350% of BCBS fee schedule,194.01,350,,,Fee Schedule,350% of BCBS fee schedule,1052.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.01,350,,,Fee Schedule,350% of BCBS PPO fee schedule,55.43,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,947.6,90,,4.68,Percent of Total Billed Charges,90% of Total Billed Charges,473.8,45,,36.56,Percent of Total Billed Charges,45% of Total Billed Charges,947.6,90,,3321.36,Percent of Total Billed Charges,90% of Total billed Charges,1052.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1052.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1052.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,684.38,65,,1318.2,Percent of total Billed Charges,65% of Total Billed Charges,464.32,44.1,,35.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,1000.25,95,,3505.88,Percent of Total Billed Charges,95% of Total Billed Charges,1052.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,926.54,88,,71.496,Percent of Total Billed Charges,88% of Total Billed Charges,947.6,90,,3321.36,Percent of Total Billed charges,90% of Total Billed Charges,55.43,1052.89,
CROFAB 1GM INJ,6360000118,CDM,636,RC,J0840,HCPCS,Outpatient,1,gm,11152.89,7249.38,,2224.55,125,,,Fee Schedule,125% of CMS OPPS Rate,8476.2,76,,59.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10398.5,350,,,Fee Schedule,350% of BCBS fee schedule,10398.5,350,,,Fee Schedule,350% of BCBS fee schedule,1779.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10398.5,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2971,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,10037.6,90,,476.632,Percent of Total Billed Charges,90% of Total Billed Charges,5018.8,45,,64.24,Percent of Total Billed Charges,45% of Total Billed Charges,10037.6,90,,70.024,Percent of Total Billed Charges,90% of Total billed Charges,1779.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1779.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1779.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10808.66,65,,878.8,Percent of total Billed Charges,65% of Total Billed Charges,4918.42,44.1,,62.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,10595.25,95,,73.912,Percent of Total Billed Charges,95% of Total Billed Charges,1334.73,75,,,Fee Schedule,75% of CMS OPPS Rate,9814.54,88,,125.632,Percent of Total Billed Charges,88% of Total Billed Charges,10037.6,90,,70.024,Percent of Total Billed charges,90% of Total Billed Charges,1334.73,10808.66,
XGEVA 120MG/ 1.7ML,6360000119,CDM,636,RC,J0897,HCPCS,Outpatient,120,GM,89.44,58.14,,34.57,125,,,Fee Schedule,125% of CMS OPPS Rate,67.97,76,,411.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.13,350,,,Fee Schedule,350% of BCBS fee schedule,62.13,350,,,Fee Schedule,350% of BCBS fee schedule,27.66,100,,,Fee Schedule,100% of CMS OPPS Rate,62.13,350,,,Fee Schedule,350% of BCBS PPO fee schedule,17.75,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,80.5,90,,638.232,Percent of Total Billed Charges,90% of Total Billed Charges,40.25,45,,64.24,Percent of Total Billed Charges,45% of Total Billed Charges,80.5,90,,487.008,Percent of Total Billed Charges,90% of Total billed Charges,27.66,100,,,Fee Schedule,100% of CMS OPPS Rate,27.66,100,,,Fee Schedule,100% of CMS OPPS Rate,27.66,100,,,Fee Schedule,100% of CMS OPPS Rate,113.46,65,,832,Percent of total Billed Charges,65% of Total Billed Charges,39.44,44.1,,62.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,84.97,95,,514.064,Percent of Total Billed Charges,95% of Total Billed Charges,20.74,75,,,Fee Schedule,75% of CMS OPPS Rate,78.71,88,,125.632,Percent of Total Billed Charges,88% of Total Billed Charges,80.5,90,,487.008,Percent of Total Billed charges,90% of Total Billed Charges,17.75,113.46,
DEPOMEDROL 40MG 1CC INJ,6360000120,CDM,636,RC,J1010,HCPCS,Outpatient,40,GM,44.10,28.67,,0.15,125,,,Fee Schedule,125% of CMS OPPS Rate,33.52,76,,816.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,31.75,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,33.08,75,,26.464,Percent of Total Billed charges,75% of Total Billed Charges,0.12,100,,,Fee Schedule,100% of CMS OPPS Rate,31.75,72,,25.4,Percent of Total Billed Charges,72% of Total Billed Charges,26.46,60,,21.168,Percent of Total Billed Charges,60% of Total Billed Charges,39.69,90,,4.68,Percent of Total Billed Charges,90% of Total Billed Charges,19.85,45,,3301.888,Percent of Total Billed Charges,45% of Total Billed Charges,39.69,90,,966.784,Percent of Total Billed Charges,90% of Total billed Charges,0.12,100,,,Fee Schedule,100% of CMS OPPS Rate,0.12,100,,,Fee Schedule,100% of CMS OPPS Rate,0.12,100,,,Fee Schedule,100% of CMS OPPS Rate,28.91,65,,780,Percent of total Billed Charges,65% of Total Billed Charges,19.45,44.1,,3235.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.9,95,,1020.488,Percent of Total Billed Charges,95% of Total Billed Charges,0.09,75,,,Fee Schedule,75% of CMS OPPS Rate,38.81,88,,6457.016,Percent of Total Billed Charges,88% of Total Billed Charges,39.69,90,,966.784,Percent of Total Billed charges,90% of Total Billed Charges,0.09,41.9,
DEPOMEDROL 80MG INJ,6360000121,CDM,636,RC,J1010,HCPCS,Outpatient,80,GM,71.66,46.58,,0.15,125,,,Fee Schedule,125% of CMS OPPS Rate,54.46,76,,5245.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,51.6,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,53.75,75,,43,Percent of Total Billed charges,75% of Total Billed Charges,0.12,100,,,Fee Schedule,100% of CMS OPPS Rate,51.6,72,,41.28,Percent of Total Billed Charges,72% of Total Billed Charges,43,60,,34.4,Percent of Total Billed Charges,60% of Total Billed Charges,64.49,90,,4.68,Percent of Total Billed Charges,90% of Total Billed Charges,32.25,45,,84.352,Percent of Total Billed Charges,45% of Total Billed Charges,64.49,90,,6211.44,Percent of Total Billed Charges,90% of Total billed Charges,0.12,100,,,Fee Schedule,100% of CMS OPPS Rate,0.12,100,,,Fee Schedule,100% of CMS OPPS Rate,0.12,100,,,Fee Schedule,100% of CMS OPPS Rate,46.82,65,,832,Percent of total Billed Charges,65% of Total Billed Charges,31.6,44.1,,82.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,68.08,95,,6556.52,Percent of Total Billed Charges,95% of Total Billed Charges,0.09,75,,,Fee Schedule,75% of CMS OPPS Rate,63.06,88,,164.96,Percent of Total Billed Charges,88% of Total Billed Charges,64.49,90,,6211.44,Percent of Total Billed charges,90% of Total Billed Charges,0.09,68.08,
DEPO PROVERA 150MG/ML SYRINGE,6360000122,CDM,636,RC,J1050,HCPCS,Outpatient,150,GM,182.55,118.66,,182.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,138.74,76,,61.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.79,350,,,Fee Schedule,350% of BCBS fee schedule,1.79,350,,,Fee Schedule,350% of BCBS fee schedule,182.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.79,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.51,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,164.3,90,,4.68,Percent of Total Billed Charges,90% of Total Billed Charges,82.15,45,,4.32,Percent of Total Billed Charges,45% of Total Billed Charges,164.3,90,,73.12,Percent of Total Billed Charges,90% of Total billed Charges,182.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.66,65,,832,Percent of total Billed Charges,65% of Total Billed Charges,80.5,44.1,,4.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,173.42,95,,77.184,Percent of Total Billed Charges,95% of Total Billed Charges,182.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.64,88,,8.448,Percent of Total Billed Charges,88% of Total Billed Charges,164.3,90,,73.12,Percent of Total Billed charges,90% of Total Billed Charges,0.51,182.55,
DECADRON 4MG 1CC INJ,6360000124,CDM,636,RC,J1100,HCPCS,Outpatient,4,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,108.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.11,350,,,Fee Schedule,350% of BCBS fee schedule,0.11,350,,,Fee Schedule,350% of BCBS fee schedule,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.11,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.03,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,6.95,90,,32.08,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,238.32,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,128.488,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,898.56,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,233.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,135.624,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,466.04,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,128.488,Percent of Total Billed charges,90% of Total Billed Charges,0.03,7.72,
DEXAMETHASONE 10MG/1ML INJ,6360000125,CDM,636,RC,J1100,HCPCS,Outpatient,10,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,5576.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.11,350,,,Fee Schedule,350% of BCBS fee schedule,0.11,350,,,Fee Schedule,350% of BCBS fee schedule,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.11,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.03,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,7.94,90,,15642,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,319.112,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,6603.768,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,832,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,312.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,6970.648,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,624.048,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,6603.768,Percent of Total Billed charges,90% of Total Billed Charges,0.03,8.82,
DIAMOX 500MG IV INJ,6360000126,CDM,636,RC,J1120,HCPCS,Outpatient,500,GM,228.22,148.34,,228.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,173.45,76,,142.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,98.6,350,,,Fee Schedule,350% of BCBS fee schedule,98.6,350,,,Fee Schedule,350% of BCBS fee schedule,228.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.6,350,,,Fee Schedule,350% of BCBS PPO fee schedule,28.17,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,205.4,90,,2831.688,Percent of Total Billed Charges,90% of Total Billed Charges,102.7,45,,2.344,Percent of Total Billed Charges,45% of Total Billed Charges,205.4,90,,168.712,Percent of Total Billed Charges,90% of Total billed Charges,228.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.34,65,,898.56,Percent of total Billed Charges,65% of Total Billed Charges,100.65,44.1,,2.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,216.81,95,,178.08,Percent of Total Billed Charges,95% of Total Billed Charges,228.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.83,88,,4.576,Percent of Total Billed Charges,88% of Total Billed Charges,205.4,90,,168.712,Percent of Total Billed charges,90% of Total Billed Charges,28.17,228.22,
LANOXIN 0.5MG/2ML INJ,6360000127,CDM,636,RC,J1160,HCPCS,Outpatient,0.5,GM,14.33,9.31,,14.33,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.89,76,,7.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.3,350,,,Fee Schedule,350% of BCBS fee schedule,13.3,350,,,Fee Schedule,350% of BCBS fee schedule,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.3,350,,,Fee Schedule,350% of BCBS PPO fee schedule,3.8,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,12.9,90,,104.584,Percent of Total Billed Charges,90% of Total Billed Charges,6.45,45,,2.344,Percent of Total Billed Charges,45% of Total Billed Charges,12.9,90,,8.64,Percent of Total Billed Charges,90% of Total billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.31,65,,832,Percent of total Billed Charges,65% of Total Billed Charges,6.32,44.1,,2.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,13.61,95,,9.12,Percent of Total Billed Charges,95% of Total Billed Charges,14.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.61,88,,4.576,Percent of Total Billed Charges,88% of Total Billed Charges,12.9,90,,8.64,Percent of Total Billed charges,90% of Total Billed Charges,3.8,14.33,
DIGIBIND 38MG INJ,6360000128,CDM,636,RC,J1162,HCPCS,Outpatient,38,GM,4751.78,3088.66,,6337.47,125,,,Fee Schedule,125% of CMS OPPS Rate,3611.35,76,,3.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11833.5,350,,,Fee Schedule,350% of BCBS fee schedule,11833.5,350,,,Fee Schedule,350% of BCBS fee schedule,5069.97,100,,,Fee Schedule,100% of CMS OPPS Rate,11833.5,350,,,Fee Schedule,350% of BCBS PPO fee schedule,3381,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,4276.6,90,,9999.504,Percent of Total Billed Charges,90% of Total Billed Charges,2138.3,45,,2.344,Percent of Total Billed Charges,45% of Total Billed Charges,4276.6,90,,4.68,Percent of Total Billed Charges,90% of Total billed Charges,5069.97,100,,,Fee Schedule,100% of CMS OPPS Rate,5069.97,100,,,Fee Schedule,100% of CMS OPPS Rate,5069.97,100,,,Fee Schedule,100% of CMS OPPS Rate,13228.61,65,,832,Percent of total Billed Charges,65% of Total Billed Charges,2095.53,44.1,,2.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,4514.19,95,,4.944,Percent of Total Billed Charges,95% of Total Billed Charges,3802.48,75,,,Fee Schedule,75% of CMS OPPS Rate,4181.57,88,,4.576,Percent of Total Billed Charges,88% of Total Billed Charges,4276.6,90,,4.68,Percent of Total Billed charges,90% of Total Billed Charges,2095.53,13228.61,
DILANTIN 100MG/2ML INJ,6360000130,CDM,636,RC,J1165,HCPCS,Outpatient,100,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,402.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.4,350,,,Fee Schedule,350% of BCBS fee schedule,1.4,350,,,Fee Schedule,350% of BCBS fee schedule,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.4,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.4,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,6.95,90,,135,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,3561.88,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,476.632,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,3490.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,503.112,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,6965.448,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,476.632,Percent of Total Billed charges,90% of Total Billed Charges,0.4,7.72,
DILANTIN 250MG/5ML INJ,6360000131,CDM,636,RC,J1165,HCPCS,Outpatient,250,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,538.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.4,350,,,Fee Schedule,350% of BCBS fee schedule,1.4,350,,,Fee Schedule,350% of BCBS fee schedule,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.4,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.4,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,9.93,90,,8176.504,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,16.04,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,638.232,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,1627.032,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,15.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,673.688,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,31.368,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,638.232,Percent of Total Billed charges,90% of Total Billed Charges,0.4,11.03,
DILAUDID 1/16 1CC INJ,6360000132,CDM,636,RC,J1171,HCPCS,Outpatient,,,7.72,5.02,,0.11,125,,,Fee Schedule,125% of CMS OPPS Rate,5.87,76,,3.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.56,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,5.79,75,,4.632,Percent of Total Billed charges,75% of Total Billed Charges,0.09,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,72,,4.448,Percent of Total Billed Charges,72% of Total Billed Charges,4.63,60,,3.704,Percent of Total Billed Charges,60% of Total Billed Charges,6.95,90,,148.112,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,7821,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,4.68,Percent of Total Billed Charges,90% of Total billed Charges,0.09,100,,,Fee Schedule,100% of CMS OPPS Rate,0.09,100,,,Fee Schedule,100% of CMS OPPS Rate,0.09,100,,,Fee Schedule,100% of CMS OPPS Rate,5.2,65,,222.56,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,7664.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,4.944,Percent of Total Billed Charges,95% of Total Billed Charges,0.06,75,,,Fee Schedule,75% of CMS OPPS Rate,6.79,88,,15294.4,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,4.68,Percent of Total Billed charges,90% of Total Billed Charges,0.06,7.33,
RIMSO50 SOL INJ,6360000133,CDM,636,RC,J1212,HCPCS,Outpatient,,,518.18,336.82,,894.23,125,,,Fee Schedule,125% of CMS OPPS Rate,393.82,76,,3.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1989.96,350,,,Fee Schedule,350% of BCBS fee schedule,1989.96,350,,,Fee Schedule,350% of BCBS fee schedule,715.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1989.96,350,,,Fee Schedule,350% of BCBS PPO fee schedule,568.56,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,466.36,90,,140.4,Percent of Total Billed Charges,90% of Total Billed Charges,233.18,45,,1415.848,Percent of Total Billed Charges,45% of Total Billed Charges,466.36,90,,4.68,Percent of Total Billed Charges,90% of Total billed Charges,715.39,100,,,Fee Schedule,100% of CMS OPPS Rate,715.39,100,,,Fee Schedule,100% of CMS OPPS Rate,715.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1767.6,65,,3022.88,Percent of total Billed Charges,65% of Total Billed Charges,228.52,44.1,,1387.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,492.27,95,,4.944,Percent of Total Billed Charges,95% of Total Billed Charges,536.54,75,,,Fee Schedule,75% of CMS OPPS Rate,456,88,,2768.76,Percent of Total Billed Charges,88% of Total Billed Charges,466.36,90,,4.68,Percent of Total Billed charges,90% of Total Billed Charges,228.52,1989.96,
DOBUTREX 250MG INJ,6360000134,CDM,636,RC,J1250,HCPCS,Outpatient,250,GM,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,3.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.98,350,,,Fee Schedule,350% of BCBS fee schedule,9.98,350,,,Fee Schedule,350% of BCBS fee schedule,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.98,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.85,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,18.86,90,,11.704,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,52.288,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,4.68,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,770.384,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,51.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,4.944,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,102.256,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,4.68,Percent of Total Billed charges,90% of Total Billed Charges,2.85,20.95,
DOBUTAMINE 500MG/250ML INJ,6360000135,CDM,636,RC,J1250,HCPCS,Outpatient,500,GM,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,6015.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.98,350,,,Fee Schedule,350% of BCBS fee schedule,9.98,350,,,Fee Schedule,350% of BCBS fee schedule,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.98,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.85,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,79.38,90,,335.072,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,4999.752,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,7123.752,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,4966,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,4899.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,7519.52,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,9777.296,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,7123.752,Percent of Total Billed charges,90% of Total Billed Charges,2.85,88.2,
DOPAMINE 40MG ML 5ML,6360000136,CDM,636,RC,J1265,HCPCS,Outpatient,40,GM,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,27.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.42,350,,,Fee Schedule,350% of BCBS fee schedule,0.42,350,,,Fee Schedule,350% of BCBS fee schedule,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.42,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.12,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,10.8,90,,5068.8,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,67.504,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,32.08,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,147.912,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,66.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,33.864,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,132,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,32.08,Percent of Total Billed charges,90% of Total Billed Charges,0.12,12,
DOPAMINE 800MG/500ML INJ,6360000137,CDM,636,RC,J1265,HCPCS,Outpatient,800,GM,239.24,155.51,,239.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,181.82,76,,13208.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.42,350,,,Fee Schedule,350% of BCBS fee schedule,0.42,350,,,Fee Schedule,350% of BCBS fee schedule,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.42,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.12,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,215.32,90,,9154.696,Percent of Total Billed Charges,90% of Total Billed Charges,107.66,45,,4088.248,Percent of Total Billed Charges,45% of Total Billed Charges,215.32,90,,15642,Percent of Total Billed Charges,90% of Total billed Charges,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.51,65,,136.096,Percent of total Billed Charges,65% of Total Billed Charges,105.5,44.1,,4006.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,227.28,95,,16511,Percent of Total Billed Charges,95% of Total Billed Charges,239.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.53,88,,7994.8,Percent of Total Billed Charges,88% of Total Billed Charges,215.32,90,,15642,Percent of Total Billed charges,90% of Total Billed Charges,0.12,239.24,
DOPAMINE 40MG/10ML,6360000138,CDM,636,RC,J1265,HCPCS,Outpatient,40,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,2391.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.42,350,,,Fee Schedule,350% of BCBS fee schedule,0.42,350,,,Fee Schedule,350% of BCBS fee schedule,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.42,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.12,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5.96,90,,8176.504,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,74.056,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,2831.688,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,489.024,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,72.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,2989.008,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,144.816,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,2831.688,Percent of Total Billed charges,90% of Total Billed Charges,0.12,6.62,
INTEGRILIN 200MG/100ML INJ,6360000141,CDM,636,RC,J1327,HCPCS,Outpatient,200,GM,5791.43,3764.43,,5791.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4401.49,76,,114,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,75.81,350,,,Fee Schedule,350% of BCBS fee schedule,75.81,350,,,Fee Schedule,350% of BCBS fee schedule,5791.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.81,350,,,Fee Schedule,350% of BCBS PPO fee schedule,21.66,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5212.29,90,,8239.432,Percent of Total Billed Charges,90% of Total Billed Charges,2606.14,45,,167.536,Percent of Total Billed Charges,45% of Total Billed Charges,5212.29,90,,135,Percent of Total Billed Charges,90% of Total billed Charges,5791.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5791.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5791.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3764.43,65,,669.616,Percent of total Billed Charges,65% of Total Billed Charges,2554.02,44.1,,164.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,5501.86,95,,142.504,Percent of Total Billed Charges,95% of Total Billed Charges,5791.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5096.46,88,,327.624,Percent of Total Billed Charges,88% of Total Billed Charges,5212.29,90,,135,Percent of Total Billed charges,90% of Total Billed Charges,21.66,5791.43,
ERYTHRO LAC 500MG VL INJ,6360000143,CDM,636,RC,J1364,HCPCS,Outpatient,500,GM,122.38,79.55,,122.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.01,76,,125.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.73,350,,,Fee Schedule,350% of BCBS fee schedule,65.73,350,,,Fee Schedule,350% of BCBS fee schedule,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.73,350,,,Fee Schedule,350% of BCBS PPO fee schedule,18.78,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,110.14,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,55.07,45,,4577.344,Percent of Total Billed Charges,45% of Total Billed Charges,110.14,90,,148.112,Percent of Total Billed Charges,90% of Total billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.55,65,,365.04,Percent of total Billed Charges,65% of Total Billed Charges,53.97,44.1,,4485.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.26,95,,156.336,Percent of Total Billed Charges,95% of Total Billed Charges,122.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.69,88,,8951.256,Percent of Total Billed Charges,88% of Total Billed Charges,110.14,90,,148.112,Percent of Total Billed charges,90% of Total Billed Charges,18.78,122.38,
INJECTAFER 750MG/15ML VIAL,6360000145,CDM,636,RC,J1439,HCPCS,Outpatient,750,GM,6.76,4.39,,1.38,125,,,Fee Schedule,125% of CMS OPPS Rate,5.14,76,,9.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.38,350,,,Fee Schedule,350% of BCBS fee schedule,4.38,350,,,Fee Schedule,350% of BCBS fee schedule,1.11,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.25,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,6.08,90,,256.552,Percent of Total Billed Charges,90% of Total Billed Charges,3.04,45,,4088.248,Percent of Total Billed Charges,45% of Total Billed Charges,6.08,90,,11.704,Percent of Total Billed Charges,90% of Total billed Charges,1.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1.11,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,65,,1059.392,Percent of total Billed Charges,65% of Total Billed Charges,2.98,44.1,,4006.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.42,95,,12.352,Percent of Total Billed Charges,95% of Total Billed Charges,0.83,75,,,Fee Schedule,75% of CMS OPPS Rate,5.95,88,,7994.8,Percent of Total Billed Charges,88% of Total Billed Charges,6.08,90,,11.704,Percent of Total Billed charges,90% of Total Billed Charges,0.83,6.61,
NEUPOGEN 480MCG INJ,6360000146,CDM,636,RC,J1442,HCPCS,Outpatient,480,GM,2244.69,1459.05,,1.22,125,,,Fee Schedule,125% of CMS OPPS Rate,1705.96,76,,282.952,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.43,350,,,Fee Schedule,350% of BCBS fee schedule,3.43,350,,,Fee Schedule,350% of BCBS fee schedule,0.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3.43,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.98,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,2020.22,90,,4435.688,Percent of Total Billed Charges,90% of Total Billed Charges,1010.11,45,,3.232,Percent of Total Billed Charges,45% of Total Billed Charges,2020.22,90,,335.072,Percent of Total Billed Charges,90% of Total billed Charges,0.98,100,,,Fee Schedule,100% of CMS OPPS Rate,0.98,100,,,Fee Schedule,100% of CMS OPPS Rate,0.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.01,65,,1318.592,Percent of total Billed Charges,65% of Total Billed Charges,989.91,44.1,,3.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,2132.46,95,,353.688,Percent of Total Billed Charges,95% of Total Billed Charges,0.73,75,,,Fee Schedule,75% of CMS OPPS Rate,1975.33,88,,6.32,Percent of Total Billed Charges,88% of Total Billed Charges,2020.22,90,,335.072,Percent of Total Billed charges,90% of Total Billed Charges,0.73,2132.46,
NEUPOGEN 300MCG VIAL,6360000147,CDM,636,RC,J1442,HCPCS,Outpatient,300,GM,1410.10,916.57,,1.22,125,,,Fee Schedule,125% of CMS OPPS Rate,1071.68,76,,4280.32,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.43,350,,,Fee Schedule,350% of BCBS fee schedule,3.43,350,,,Fee Schedule,350% of BCBS fee schedule,0.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3.43,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.98,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,1269.09,90,,4.704,Percent of Total Billed Charges,90% of Total Billed Charges,634.55,45,,4119.712,Percent of Total Billed Charges,45% of Total Billed Charges,1269.09,90,,5068.8,Percent of Total Billed Charges,90% of Total billed Charges,0.98,100,,,Fee Schedule,100% of CMS OPPS Rate,0.98,100,,,Fee Schedule,100% of CMS OPPS Rate,0.98,100,,,Fee Schedule,100% of CMS OPPS Rate,918.53,65,,1043.768,Percent of total Billed Charges,65% of Total Billed Charges,621.85,44.1,,4037.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,1339.6,95,,5350.4,Percent of Total Billed Charges,95% of Total Billed Charges,0.73,75,,,Fee Schedule,75% of CMS OPPS Rate,1240.89,88,,8056.328,Percent of Total Billed Charges,88% of Total Billed Charges,1269.09,90,,5068.8,Percent of Total Billed charges,90% of Total Billed Charges,0.73,1339.6,
DIFLUCAN 200MG IVPB,6360000148,CDM,636,RC,J1450,HCPCS,Outpatient,200,GM,126.79,82.41,,126.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,96.36,76,,7730.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.26,350,,,Fee Schedule,350% of BCBS fee schedule,15.26,350,,,Fee Schedule,350% of BCBS fee schedule,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.26,350,,,Fee Schedule,350% of BCBS PPO fee schedule,4.36,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,114.11,90,,137.648,Percent of Total Billed Charges,90% of Total Billed Charges,57.06,45,,22.904,Percent of Total Billed Charges,45% of Total Billed Charges,114.11,90,,9154.696,Percent of Total Billed Charges,90% of Total billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.41,65,,236.456,Percent of total Billed Charges,65% of Total Billed Charges,55.91,44.1,,22.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,120.45,95,,9663.288,Percent of Total Billed Charges,95% of Total Billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.58,88,,44.792,Percent of Total Billed Charges,88% of Total Billed Charges,114.11,90,,9154.696,Percent of Total Billed charges,90% of Total Billed Charges,4.36,126.79,
GAMUNEXC 10% IVIG 50ML,6360000150,CDM,636,RC,J1561,HCPCS,Outpatient,50,ML,2274.75,1478.59,,61.26,125,,,Fee Schedule,125% of CMS OPPS Rate,1728.81,76,,6904.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,146.41,350,,,Fee Schedule,350% of BCBS fee schedule,146.41,350,,,Fee Schedule,350% of BCBS fee schedule,49.01,100,,,Fee Schedule,100% of CMS OPPS Rate,146.41,350,,,Fee Schedule,350% of BCBS PPO fee schedule,41.83,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,2047.28,90,,0.336,Percent of Total Billed Charges,90% of Total Billed Charges,1023.64,45,,698.344,Percent of Total Billed Charges,45% of Total Billed Charges,2047.28,90,,8176.504,Percent of Total Billed Charges,90% of Total billed Charges,49.01,100,,,Fee Schedule,100% of CMS OPPS Rate,49.01,100,,,Fee Schedule,100% of CMS OPPS Rate,49.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1576.61,65,,333.088,Percent of total Billed Charges,65% of Total Billed Charges,1003.16,44.1,,684.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,2161.01,95,,8630.752,Percent of Total Billed Charges,95% of Total Billed Charges,36.75,75,,,Fee Schedule,75% of CMS OPPS Rate,2001.78,88,,1365.656,Percent of Total Billed Charges,88% of Total Billed Charges,2047.28,90,,8176.504,Percent of Total Billed charges,90% of Total Billed Charges,36.75,2161.01,
GAMMAGARD 10% IVIG 2,6360000151,CDM,636,RC,J1569,HCPCS,Outpatient,,,12800.03,8320.02,,58.07,125,,,Fee Schedule,125% of CMS OPPS Rate,9728.02,76,,5.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153.62,350,,,Fee Schedule,350% of BCBS fee schedule,153.62,350,,,Fee Schedule,350% of BCBS fee schedule,46.46,100,,,Fee Schedule,100% of CMS OPPS Rate,153.62,350,,,Fee Schedule,350% of BCBS PPO fee schedule,43.89,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,11520.03,90,,31.368,Percent of Total Billed Charges,90% of Total Billed Charges,5760.01,45,,128.272,Percent of Total Billed Charges,45% of Total Billed Charges,11520.03,90,,6.464,Percent of Total Billed Charges,90% of Total billed Charges,46.46,100,,,Fee Schedule,100% of CMS OPPS Rate,46.46,100,,,Fee Schedule,100% of CMS OPPS Rate,46.46,100,,,Fee Schedule,100% of CMS OPPS Rate,8412.94,65,,1383.2,Percent of total Billed Charges,65% of Total Billed Charges,5644.81,44.1,,125.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,12160.03,95,,6.824,Percent of Total Billed Charges,95% of Total Billed Charges,34.84,75,,,Fee Schedule,75% of CMS OPPS Rate,11264.03,88,,250.848,Percent of Total Billed Charges,88% of Total Billed Charges,11520.03,90,,6.464,Percent of Total Billed charges,90% of Total Billed Charges,34.84,12160.03,
GAMMAGARD 500MG/5ML,6360000152,CDM,636,RC,J1569,HCPCS,Outpatient,500,GM,319.73,207.82,,58.07,125,,,Fee Schedule,125% of CMS OPPS Rate,242.99,76,,6957.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,153.62,350,,,Fee Schedule,350% of BCBS fee schedule,153.62,350,,,Fee Schedule,350% of BCBS fee schedule,46.46,100,,,Fee Schedule,100% of CMS OPPS Rate,153.62,350,,,Fee Schedule,350% of BCBS PPO fee schedule,43.89,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,287.76,90,,962.104,Percent of Total Billed Charges,90% of Total Billed Charges,143.88,45,,2217.848,Percent of Total Billed Charges,45% of Total Billed Charges,287.76,90,,8239.432,Percent of Total Billed Charges,90% of Total billed Charges,46.46,100,,,Fee Schedule,100% of CMS OPPS Rate,46.46,100,,,Fee Schedule,100% of CMS OPPS Rate,46.46,100,,,Fee Schedule,100% of CMS OPPS Rate,300.74,65,,1049.88,Percent of total Billed Charges,65% of Total Billed Charges,141,44.1,,2173.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,303.74,95,,8697.176,Percent of Total Billed Charges,95% of Total Billed Charges,34.84,75,,,Fee Schedule,75% of CMS OPPS Rate,281.36,88,,4337.12,Percent of Total Billed Charges,88% of Total Billed Charges,287.76,90,,8239.432,Percent of Total Billed charges,90% of Total Billed Charges,34.84,303.74,
GENTAMICIN 80MG/100M INJ,6360000153,CDM,636,RC,J1580,HCPCS,Outpatient,80,GM,54.02,35.11,,54.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,41.06,76,,38.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.87,350,,,Fee Schedule,350% of BCBS fee schedule,2.87,350,,,Fee Schedule,350% of BCBS fee schedule,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.82,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,48.62,90,,481.056,Percent of Total Billed Charges,90% of Total Billed Charges,24.31,45,,2.352,Percent of Total Billed Charges,45% of Total Billed Charges,48.62,90,,45.808,Percent of Total Billed Charges,90% of Total billed Charges,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.11,65,,1099.016,Percent of total Billed Charges,65% of Total Billed Charges,23.82,44.1,,2.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,51.32,95,,48.352,Percent of Total Billed Charges,95% of Total Billed Charges,54.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.54,88,,4.6,Percent of Total Billed Charges,88% of Total Billed Charges,48.62,90,,45.808,Percent of Total Billed charges,90% of Total Billed Charges,0.82,54.02,
GARAMYCIN 80MG/2ML INJ,6360000154,CDM,636,RC,J1580,HCPCS,Outpatient,80,GM,13.23,8.60,,13.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,10.05,76,,18.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.87,350,,,Fee Schedule,350% of BCBS fee schedule,2.87,350,,,Fee Schedule,350% of BCBS fee schedule,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.82,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,11.91,90,,96.232,Percent of Total Billed Charges,90% of Total Billed Charges,5.95,45,,68.824,Percent of Total Billed Charges,45% of Total Billed Charges,11.91,90,,21.6,Percent of Total Billed Charges,90% of Total billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.6,65,,1231.36,Percent of total Billed Charges,65% of Total Billed Charges,5.83,44.1,,67.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,12.57,95,,22.8,Percent of Total Billed Charges,95% of Total Billed Charges,13.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,88,,134.592,Percent of Total Billed Charges,88% of Total Billed Charges,11.91,90,,21.6,Percent of Total Billed charges,90% of Total Billed Charges,0.82,13.23,
GARAMYCIN 20MG/2ML INJ,6360000156,CDM,636,RC,J1580,HCPCS,Outpatient,20,GM,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,1179.432,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.87,350,,,Fee Schedule,350% of BCBS fee schedule,2.87,350,,,Fee Schedule,350% of BCBS fee schedule,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.82,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,17.87,90,,144.328,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,28.504,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,1396.696,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,1175.264,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,27.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,1474.288,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,55.744,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,1396.696,Percent of Total Billed charges,90% of Total Billed Charges,0.82,19.85,
GLUCAGON 1ML VIAL,6360000158,CDM,636,RC,J1610,HCPCS,Outpatient,1,ML,549.05,356.88,,230.22,125,,,Fee Schedule,125% of CMS OPPS Rate,417.28,76,,216.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,402.19,350,,,Fee Schedule,350% of BCBS fee schedule,402.19,350,,,Fee Schedule,350% of BCBS fee schedule,184.18,100,,,Fee Schedule,100% of CMS OPPS Rate,402.19,350,,,Fee Schedule,350% of BCBS PPO fee schedule,114.91,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,494.15,90,,21.224,Percent of Total Billed Charges,90% of Total Billed Charges,247.07,45,,15.688,Percent of Total Billed Charges,45% of Total Billed Charges,494.15,90,,256.552,Percent of Total Billed Charges,90% of Total billed Charges,184.18,100,,,Fee Schedule,100% of CMS OPPS Rate,184.18,100,,,Fee Schedule,100% of CMS OPPS Rate,184.18,100,,,Fee Schedule,100% of CMS OPPS Rate,725.24,65,,762.84,Percent of total Billed Charges,65% of Total Billed Charges,242.13,44.1,,15.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,521.6,95,,270.8,Percent of Total Billed Charges,95% of Total Billed Charges,138.13,75,,,Fee Schedule,75% of CMS OPPS Rate,483.16,88,,0.328,Percent of Total Billed Charges,88% of Total Billed Charges,494.15,90,,256.552,Percent of Total Billed charges,90% of Total Billed Charges,114.91,725.24,
HALDOL 5MG/1ML INJ,6360000159,CDM,636,RC,J1630,HCPCS,Outpatient,5,GM,73.87,48.02,,73.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.14,76,,3745.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.21,350,,,Fee Schedule,350% of BCBS fee schedule,14.21,350,,,Fee Schedule,350% of BCBS fee schedule,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.21,350,,,Fee Schedule,350% of BCBS PPO fee schedule,4.06,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,66.48,90,,507.264,Percent of Total Billed Charges,90% of Total Billed Charges,33.24,45,,481.048,Percent of Total Billed Charges,45% of Total Billed Charges,66.48,90,,4435.688,Percent of Total Billed Charges,90% of Total billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.02,65,,1014.52,Percent of total Billed Charges,65% of Total Billed Charges,32.58,44.1,,471.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,70.18,95,,4682.12,Percent of Total Billed Charges,95% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.01,88,,30.672,Percent of Total Billed Charges,88% of Total Billed Charges,66.48,90,,4435.688,Percent of Total Billed charges,90% of Total Billed Charges,4.06,73.87,
LOVENOX 120MG INJ,6360000160,CDM,250,RC,J1650,HCPCS,Outpatient,120,GM,545.74,354.73,,545.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,414.76,76,,3.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.95,350,,,Fee Schedule,350% of BCBS fee schedule,0.95,350,,,Fee Schedule,350% of BCBS fee schedule,545.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.95,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.27,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,491.17,90,,31.368,Percent of Total Billed Charges,90% of Total Billed Charges,245.58,45,,240.528,Percent of Total Billed Charges,45% of Total Billed Charges,491.17,90,,4.704,Percent of Total Billed Charges,90% of Total billed Charges,545.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,545.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,545.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.73,65,,940.488,Percent of total Billed Charges,65% of Total Billed Charges,240.67,44.1,,235.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,518.45,95,,4.96,Percent of Total Billed Charges,95% of Total Billed Charges,545.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.25,88,,940.72,Percent of Total Billed Charges,88% of Total Billed Charges,491.17,90,,4.704,Percent of Total Billed charges,90% of Total Billed Charges,0.27,545.74,
LOVENOX 150MG INJ,6360000161,CDM,636,RC,J1650,HCPCS,Outpatient,150,GM,681.35,442.88,,681.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,517.83,76,,116.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.95,350,,,Fee Schedule,350% of BCBS fee schedule,0.95,350,,,Fee Schedule,350% of BCBS fee schedule,681.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.95,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.27,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,613.22,90,,14.64,Percent of Total Billed Charges,90% of Total Billed Charges,306.61,45,,48.112,Percent of Total Billed Charges,45% of Total Billed Charges,613.22,90,,137.648,Percent of Total Billed Charges,90% of Total billed Charges,681.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,681.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,681.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,442.88,65,,940.488,Percent of total Billed Charges,65% of Total Billed Charges,300.48,44.1,,47.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,647.28,95,,145.296,Percent of Total Billed Charges,95% of Total Billed Charges,681.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,599.59,88,,470.36,Percent of Total Billed Charges,88% of Total Billed Charges,613.22,90,,137.648,Percent of Total Billed charges,90% of Total Billed Charges,0.27,681.35,
LOVENOX 30MG INJ,6360000162,CDM,636,RC,J1650,HCPCS,Outpatient,30,GM,111.35,72.38,,111.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,84.63,76,,48.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.95,350,,,Fee Schedule,350% of BCBS fee schedule,0.95,350,,,Fee Schedule,350% of BCBS fee schedule,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.95,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.27,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,100.22,90,,31.368,Percent of Total Billed Charges,90% of Total Billed Charges,50.11,45,,72.16,Percent of Total Billed Charges,45% of Total Billed Charges,100.22,90,,57.008,Percent of Total Billed Charges,90% of Total billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.38,65,,1110.528,Percent of total Billed Charges,65% of Total Billed Charges,49.11,44.1,,70.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,105.78,95,,60.176,Percent of Total Billed Charges,95% of Total Billed Charges,111.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.99,88,,94.088,Percent of Total Billed Charges,88% of Total Billed Charges,100.22,90,,57.008,Percent of Total Billed charges,90% of Total Billed Charges,0.27,111.35,
LOVENOX 40MG INJ,6360000163,CDM,636,RC,J1650,HCPCS,Outpatient,40,GM,148.84,96.75,,148.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,113.12,76,,0.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.95,350,,,Fee Schedule,350% of BCBS fee schedule,0.95,350,,,Fee Schedule,350% of BCBS fee schedule,148.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.95,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.27,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,133.96,90,,14.64,Percent of Total Billed Charges,90% of Total Billed Charges,66.98,45,,10.616,Percent of Total Billed Charges,45% of Total Billed Charges,133.96,90,,0.336,Percent of Total Billed Charges,90% of Total billed Charges,148.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.75,65,,1110.528,Percent of total Billed Charges,65% of Total Billed Charges,65.64,44.1,,10.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,141.4,95,,0.36,Percent of Total Billed Charges,95% of Total Billed Charges,148.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.98,88,,141.12,Percent of Total Billed Charges,88% of Total Billed Charges,133.96,90,,0.336,Percent of Total Billed charges,90% of Total Billed Charges,0.27,148.84,
LOVENOX 60MG INJ,6360000164,CDM,636,RC,J1650,HCPCS,Outpatient,60,GM,222.71,144.76,,222.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,169.26,76,,26.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.95,350,,,Fee Schedule,350% of BCBS fee schedule,0.95,350,,,Fee Schedule,350% of BCBS fee schedule,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.95,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.27,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,200.44,90,,424.192,Percent of Total Billed Charges,90% of Total Billed Charges,100.22,45,,253.632,Percent of Total Billed Charges,45% of Total Billed Charges,200.44,90,,31.368,Percent of Total Billed Charges,90% of Total billed Charges,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.76,65,,1354.872,Percent of total Billed Charges,65% of Total Billed Charges,98.22,44.1,,248.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,211.57,95,,33.112,Percent of Total Billed Charges,95% of Total Billed Charges,222.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.98,88,,20.752,Percent of Total Billed Charges,88% of Total Billed Charges,200.44,90,,31.368,Percent of Total Billed charges,90% of Total Billed Charges,0.27,222.71,
LOVENOX 80MG INJ,6360000165,CDM,636,RC,J1650,HCPCS,Outpatient,80,GM,297.68,193.49,,297.68,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,226.24,76,,812.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.95,350,,,Fee Schedule,350% of BCBS fee schedule,0.95,350,,,Fee Schedule,350% of BCBS fee schedule,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.95,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.27,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,267.91,90,,2.128,Percent of Total Billed Charges,90% of Total Billed Charges,133.96,45,,15.688,Percent of Total Billed Charges,45% of Total Billed Charges,267.91,90,,962.104,Percent of Total Billed Charges,90% of Total billed Charges,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.49,65,,208.112,Percent of total Billed Charges,65% of Total Billed Charges,131.28,44.1,,15.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,282.8,95,,1015.552,Percent of Total Billed Charges,95% of Total Billed Charges,297.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.96,88,,495.992,Percent of Total Billed Charges,88% of Total Billed Charges,267.91,90,,962.104,Percent of Total Billed charges,90% of Total Billed Charges,0.27,297.68,
TETANUS IMM GLOB  250U INJ,6360000166,CDM,636,RC,J1670,HCPCS,Outpatient,,,1967.25,1278.71,,715.08,125,,,Fee Schedule,125% of CMS OPPS Rate,1495.11,76,,406.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1743.11,350,,,Fee Schedule,350% of BCBS fee schedule,1743.11,350,,,Fee Schedule,350% of BCBS fee schedule,572.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1743.11,350,,,Fee Schedule,350% of BCBS PPO fee schedule,498.03,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,1770.53,90,,57.104,Percent of Total Billed Charges,90% of Total Billed Charges,885.26,45,,7.32,Percent of Total Billed Charges,45% of Total Billed Charges,1770.53,90,,481.056,Percent of Total Billed Charges,90% of Total billed Charges,572.07,100,,,Fee Schedule,100% of CMS OPPS Rate,572.07,100,,,Fee Schedule,100% of CMS OPPS Rate,572.07,100,,,Fee Schedule,100% of CMS OPPS Rate,2422.85,65,,1014.52,Percent of total Billed Charges,65% of Total Billed Charges,867.56,44.1,,7.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,1868.89,95,,507.776,Percent of Total Billed Charges,95% of Total Billed Charges,429.05,75,,,Fee Schedule,75% of CMS OPPS Rate,1731.18,88,,30.672,Percent of Total Billed Charges,88% of Total Billed Charges,1770.53,90,,481.056,Percent of Total Billed charges,90% of Total Billed Charges,429.05,2422.85,
SOLUCORT 100MG 1CC INJ,6360000167,CDM,636,RC,J1720,HCPCS,Outpatient,100,GM,25.36,16.48,,25.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.27,76,,81.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7,350,,,Fee Schedule,350% of BCBS fee schedule,7,350,,,Fee Schedule,350% of BCBS fee schedule,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,22.82,90,,16.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.41,45,,15.688,Percent of Total Billed Charges,45% of Total Billed Charges,22.82,90,,96.232,Percent of Total Billed Charges,90% of Total billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,65,,413.688,Percent of total Billed Charges,65% of Total Billed Charges,11.18,44.1,,15.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.09,95,,101.576,Percent of Total Billed Charges,95% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,88,,14.312,Percent of Total Billed Charges,88% of Total Billed Charges,22.82,90,,96.232,Percent of Total Billed charges,90% of Total Billed Charges,2,25.36,
SOLUCORT 250MG 1CC INJ,6360000168,CDM,636,RC,J1720,HCPCS,Outpatient,250,GM,47.41,30.82,,47.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.03,76,,121.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7,350,,,Fee Schedule,350% of BCBS fee schedule,7,350,,,Fee Schedule,350% of BCBS fee schedule,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,42.67,90,,235.6,Percent of Total Billed Charges,90% of Total Billed Charges,21.33,45,,7.32,Percent of Total Billed Charges,45% of Total Billed Charges,42.67,90,,144.328,Percent of Total Billed Charges,90% of Total billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.82,65,,292.584,Percent of total Billed Charges,65% of Total Billed Charges,20.91,44.1,,7.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.04,95,,152.344,Percent of Total Billed Charges,95% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.72,88,,30.672,Percent of Total Billed Charges,88% of Total Billed Charges,42.67,90,,144.328,Percent of Total Billed charges,90% of Total Billed Charges,2,47.41,
SOLUCORT 500MG 1CC INJ,6360000169,CDM,636,RC,J1720,HCPCS,Outpatient,500,GM,103.64,67.37,,103.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,78.77,76,,17.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7,350,,,Fee Schedule,350% of BCBS fee schedule,7,350,,,Fee Schedule,350% of BCBS fee schedule,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,93.28,90,,522,Percent of Total Billed Charges,90% of Total Billed Charges,46.64,45,,212.096,Percent of Total Billed Charges,45% of Total Billed Charges,93.28,90,,21.224,Percent of Total Billed Charges,90% of Total billed Charges,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.37,65,,535.464,Percent of total Billed Charges,65% of Total Billed Charges,45.71,44.1,,207.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,98.46,95,,22.408,Percent of Total Billed Charges,95% of Total Billed Charges,103.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.2,88,,14.312,Percent of Total Billed Charges,88% of Total Billed Charges,93.28,90,,21.224,Percent of Total Billed charges,90% of Total Billed Charges,2,103.64,
SOLUCORTEF 1GM INJ,6360000170,CDM,636,RC,J1720,HCPCS,Outpatient,1,gm,194.04,126.13,,194.04,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,147.47,76,,428.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7,350,,,Fee Schedule,350% of BCBS fee schedule,7,350,,,Fee Schedule,350% of BCBS fee schedule,194.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,174.64,90,,4954.992,Percent of Total Billed Charges,90% of Total Billed Charges,87.32,45,,1.064,Percent of Total Billed Charges,45% of Total Billed Charges,174.64,90,,507.264,Percent of Total Billed Charges,90% of Total billed Charges,194.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.13,65,,1918.28,Percent of total Billed Charges,65% of Total Billed Charges,85.57,44.1,,1.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,184.34,95,,535.44,Percent of Total Billed Charges,95% of Total Billed Charges,194.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.76,88,,414.76,Percent of Total Billed Charges,88% of Total Billed Charges,174.64,90,,507.264,Percent of Total Billed charges,90% of Total Billed Charges,2,194.04,
VENOFER 20MG/5ML,6360000171,CDM,636,RC,J1756,HCPCS,Outpatient,20,GM,2.28,1.48,,2.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.73,76,,26.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.26,350,,,Fee Schedule,350% of BCBS fee schedule,1.26,350,,,Fee Schedule,350% of BCBS fee schedule,2.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.26,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.36,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,2.05,90,,4678.216,Percent of Total Billed Charges,90% of Total Billed Charges,1.03,45,,28.552,Percent of Total Billed Charges,45% of Total Billed Charges,2.05,90,,31.368,Percent of Total Billed Charges,90% of Total billed Charges,2.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.48,65,,348.92,Percent of total Billed Charges,65% of Total Billed Charges,1.01,44.1,,27.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.17,95,,33.112,Percent of Total Billed Charges,95% of Total Billed Charges,2.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.01,88,,2.08,Percent of Total Billed Charges,88% of Total Billed Charges,2.05,90,,31.368,Percent of Total Billed charges,90% of Total Billed Charges,0.36,2.28,
DROPERIDOL 2.5MG/ML INJ,6360000172,CDM,636,RC,J1790,HCPCS,Outpatient,2.5,GM,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,12.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.85,350,,,Fee Schedule,350% of BCBS fee schedule,5.85,350,,,Fee Schedule,350% of BCBS fee schedule,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.85,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.67,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,18.86,90,,14.632,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,8.344,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,14.64,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,594.88,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,8.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,15.448,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,55.832,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,14.64,Percent of Total Billed charges,90% of Total Billed Charges,1.67,20.95,
INDERAL 1MG INJ,6360000173,CDM,636,RC,J1800,HCPCS,Outpatient,1,GM,36.38,23.65,,36.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.65,76,,26.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,20.16,350,,,Fee Schedule,350% of BCBS fee schedule,20.16,350,,,Fee Schedule,350% of BCBS fee schedule,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.16,350,,,Fee Schedule,350% of BCBS PPO fee schedule,5.76,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,32.74,90,,14.632,Percent of Total Billed Charges,90% of Total Billed Charges,16.37,45,,117.8,Percent of Total Billed Charges,45% of Total Billed Charges,32.74,90,,31.368,Percent of Total Billed Charges,90% of Total billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.65,65,,1272.256,Percent of total Billed Charges,65% of Total Billed Charges,16.04,44.1,,115.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.56,95,,33.112,Percent of Total Billed Charges,95% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.01,88,,16.312,Percent of Total Billed Charges,88% of Total Billed Charges,32.74,90,,31.368,Percent of Total Billed charges,90% of Total Billed Charges,5.76,36.38,
TORADOL 30MG/ML INJ,6360000183,CDM,636,RC,J1885,HCPCS,Outpatient,30,GM,5.51,3.58,,0.93,125,,,Fee Schedule,125% of CMS OPPS Rate,4.19,76,,3950.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.77,350,,,Fee Schedule,350% of BCBS fee schedule,0.77,350,,,Fee Schedule,350% of BCBS fee schedule,0.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.77,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.22,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,4.96,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,6792.04,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,4678.216,Percent of Total Billed Charges,90% of Total billed Charges,0.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.98,65,,847.488,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,6656.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,4938.112,Percent of Total Billed Charges,95% of Total Billed Charges,0.55,75,,,Fee Schedule,75% of CMS OPPS Rate,4.85,88,,261.256,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,4678.216,Percent of Total Billed charges,90% of Total Billed Charges,0.22,5.23,
TORADOL 60MG/ML INJ,6360000184,CDM,636,RC,J1885,HCPCS,Outpatient,60,GM,5.51,3.58,,0.93,125,,,Fee Schedule,125% of CMS OPPS Rate,4.19,76,,12.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.77,350,,,Fee Schedule,350% of BCBS fee schedule,0.77,350,,,Fee Schedule,350% of BCBS fee schedule,0.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.77,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.22,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,4.96,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,550.36,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,14.632,Percent of Total Billed Charges,90% of Total billed Charges,0.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.98,65,,227.6,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,539.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,15.44,Percent of Total Billed Charges,95% of Total Billed Charges,0.55,75,,,Fee Schedule,75% of CMS OPPS Rate,4.85,88,,13282.208,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,14.632,Percent of Total Billed charges,90% of Total Billed Charges,0.22,5.23,
LASIX 2ML AMP INJ,6360000185,CDM,636,RC,J1940,HCPCS,Outpatient,2,ML,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,12.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.78,350,,,Fee Schedule,350% of BCBS fee schedule,5.78,350,,,Fee Schedule,350% of BCBS fee schedule,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.78,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.65,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,8.93,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,199.84,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,14.632,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,1319.72,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,195.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,15.44,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,1076.256,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,14.632,Percent of Total Billed charges,90% of Total Billed Charges,1.65,9.92,
LASIX 10MG/4ML,6360000186,CDM,636,RC,J1940,HCPCS,Outpatient,10,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,26.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.78,350,,,Fee Schedule,350% of BCBS fee schedule,5.78,350,,,Fee Schedule,350% of BCBS fee schedule,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.78,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.65,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,4.96,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,7205.88,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,31.368,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,2682.16,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,7061.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,33.112,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,390.792,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,31.368,Percent of Total Billed charges,90% of Total Billed Charges,1.65,5.78,
LASIX 100MG INJ,6360000187,CDM,636,RC,J1940,HCPCS,Outpatient,100,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,349.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.78,350,,,Fee Schedule,350% of BCBS fee schedule,5.78,350,,,Fee Schedule,350% of BCBS fee schedule,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.78,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.65,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5.96,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,414.4,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,1461.72,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,437.416,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,14091.496,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,414.4,Percent of Total Billed charges,90% of Total Billed Charges,1.65,6.62,
LUPRON 22.5MG INJ,6360000188,CDM,636,RC,J9217,HCPCS,Outpatient,22.5,GM,14310.45,9301.79,,225.98,125,,,Fee Schedule,125% of CMS OPPS Rate,10875.94,76,,225.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1559.25,350,,,Fee Schedule,350% of BCBS fee schedule,1559.25,350,,,Fee Schedule,350% of BCBS fee schedule,180.79,100,,,Fee Schedule,100% of CMS OPPS Rate,1559.25,350,,,Fee Schedule,350% of BCBS PPO fee schedule,445.5,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,12879.41,90,,61.56,Percent of Total Billed Charges,90% of Total Billed Charges,6439.7,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,12879.41,90,,267.192,Percent of Total Billed Charges,90% of Total billed Charges,180.79,100,,,Fee Schedule,100% of CMS OPPS Rate,180.79,100,,,Fee Schedule,100% of CMS OPPS Rate,180.79,100,,,Fee Schedule,100% of CMS OPPS Rate,9663.37,65,,1181.568,Percent of total Billed Charges,65% of Total Billed Charges,6310.91,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,13594.93,95,,282.04,Percent of Total Billed Charges,95% of Total Billed Charges,135.59,75,,,Fee Schedule,75% of CMS OPPS Rate,12593.2,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,12879.41,90,,267.192,Percent of Total Billed charges,90% of Total Billed Charges,135.59,13594.93,
KEPPRA 500 MG INJ,6360000189,CDM,636,RC,J1953,HCPCS,Outpatient,500,GM,47.00,30.55,,47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.72,76,,11471,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.84,350,,,Fee Schedule,350% of BCBS fee schedule,0.84,350,,,Fee Schedule,350% of BCBS fee schedule,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.84,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.24,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,42.3,90,,59.88,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,42.3,90,,13584.072,Percent of Total Billed Charges,90% of Total billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.55,65,,2682.16,Percent of total Billed Charges,65% of Total Billed Charges,20.73,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.65,95,,14338.744,Percent of Total Billed Charges,95% of Total Billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.36,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,42.3,90,,13584.072,Percent of Total Billed charges,90% of Total Billed Charges,0.24,47,
Levofloxacin 250mg/50ml primix,6360000190,CDM,250,RC,J1956,HCPCS,Outpatient,250,GM,126.79,82.41,,126.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,96.36,76,,929.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.02,350,,,Fee Schedule,350% of BCBS fee schedule,6.02,350,,,Fee Schedule,350% of BCBS fee schedule,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.02,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.72,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,114.11,90,,134.368,Percent of Total Billed Charges,90% of Total Billed Charges,57.06,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,114.11,90,,1100.712,Percent of Total Billed Charges,90% of Total billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.41,65,,2682.16,Percent of total Billed Charges,65% of Total Billed Charges,55.91,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,120.45,95,,1161.864,Percent of Total Billed Charges,95% of Total Billed Charges,126.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.58,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,114.11,90,,1100.712,Percent of Total Billed charges,90% of Total Billed Charges,1.72,126.79,
LEVAQUIN 750MG IVPB INJ,6360000191,CDM,636,RC,J1956,HCPCS,Outpatient,750,GM,337.37,219.29,,337.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,256.4,76,,337.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.02,350,,,Fee Schedule,350% of BCBS fee schedule,6.02,350,,,Fee Schedule,350% of BCBS fee schedule,337.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.02,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.72,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,303.63,90,,7.344,Percent of Total Billed Charges,90% of Total Billed Charges,151.82,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,303.63,90,,399.672,Percent of Total Billed Charges,90% of Total billed Charges,337.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.29,65,,6041.44,Percent of total Billed Charges,65% of Total Billed Charges,148.78,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,320.5,95,,421.88,Percent of Total Billed Charges,95% of Total Billed Charges,337.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.89,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,303.63,90,,399.672,Percent of Total Billed charges,90% of Total Billed Charges,1.72,337.37,
LIDOCAINE 1% MDV 10ML,6360000192,CDM,636,RC,J2003,HCPCS,Outpatient,10,ML,2.03,1.32,,2.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1.54,76,,12169.928,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.46,72,,1.168,Percent of Total Billed Charges,72% of Total Billed Charges,1.52,75,,1.216,Percent of Total Billed charges,75% of Total Billed Charges,2.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.46,72,,1.168,Percent of Total Billed Charges,72% of Total Billed Charges,1.22,60,,0.976,Percent of Total Billed Charges,60% of Total Billed Charges,1.83,90,,346.608,Percent of Total Billed Charges,90% of Total Billed Charges,0.91,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,1.83,90,,14411.76,Percent of Total Billed Charges,90% of Total billed Charges,2.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.32,65,,3357.248,Percent of total Billed Charges,65% of Total Billed Charges,0.9,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.93,95,,15212.408,Percent of Total Billed Charges,95% of Total Billed Charges,2.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.79,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,1.83,90,,14411.76,Percent of Total Billed charges,90% of Total Billed Charges,0.9,2.03,
XYLOCAINE MPF 1% 5ML,6360000193,CDM,636,RC,J2003,HCPCS,Outpatient,5,ML,15.50,10.08,,15.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.78,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.16,72,,8.928,Percent of Total Billed Charges,72% of Total Billed Charges,11.63,75,,9.304,Percent of Total Billed charges,75% of Total Billed Charges,15.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.16,72,,8.928,Percent of Total Billed Charges,72% of Total Billed Charges,9.3,60,,7.44,Percent of Total Billed Charges,60% of Total Billed Charges,13.95,90,,10.848,Percent of Total Billed Charges,90% of Total Billed Charges,6.98,45,,30.784,Percent of Total Billed Charges,45% of Total Billed Charges,13.95,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,15.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.08,65,,1015.56,Percent of total Billed Charges,65% of Total Billed Charges,6.84,44.1,,30.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.73,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,15.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.64,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,13.95,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,6.84,15.5,
LIDOCAINE 2% PF 5ML,6360000194,CDM,636,RC,J2003,HCPCS,Outpatient,5,ML,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,6.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,29.944,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,3357.248,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,29.344,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,60.192,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
XYLOCAINE MPF 2% 5ML,6360000195,CDM,636,RC,J2003,HCPCS,Outpatient,5,ML,5.23,3.40,,5.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.97,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.77,72,,3.016,Percent of Total Billed Charges,72% of Total Billed Charges,3.92,75,,3.136,Percent of Total Billed charges,75% of Total Billed Charges,5.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.77,72,,3.016,Percent of Total Billed Charges,72% of Total Billed Charges,3.14,60,,2.512,Percent of Total Billed Charges,60% of Total Billed Charges,4.71,90,,20.056,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,45,,67.184,Percent of Total Billed Charges,45% of Total Billed Charges,4.71,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,5.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.4,65,,1087.32,Percent of total Billed Charges,65% of Total Billed Charges,2.31,44.1,,65.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.97,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,5.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.6,88,,58.552,Percent of Total Billed Charges,88% of Total Billed Charges,4.71,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,2.31,5.23,
ZYVOX 600MG PREMIX INJ,6360000196,CDM,636,RC,J2020,HCPCS,Outpatient,600,GM,660.40,429.26,,660.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,501.9,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.4,350,,,Fee Schedule,350% of BCBS fee schedule,50.4,350,,,Fee Schedule,350% of BCBS fee schedule,660.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.4,350,,,Fee Schedule,350% of BCBS PPO fee schedule,14.4,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,594.36,90,,14.368,Percent of Total Billed Charges,90% of Total Billed Charges,297.18,45,,3.672,Percent of Total Billed Charges,45% of Total Billed Charges,594.36,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,660.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,660.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,660.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,429.26,65,,1380.712,Percent of total Billed Charges,65% of Total Billed Charges,291.24,44.1,,3.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,627.38,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,660.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,581.15,88,,131.384,Percent of Total Billed Charges,88% of Total Billed Charges,594.36,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,14.4,660.4,
MANNITOL 25% 12.5GM/50ML INJ,6360000197,CDM,636,RC,J2150,HCPCS,Outpatient,50,gm,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.22,350,,,Fee Schedule,350% of BCBS fee schedule,5.22,350,,,Fee Schedule,350% of BCBS fee schedule,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.22,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.49,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,7.94,90,,2201.256,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,173.304,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,2197,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,169.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,7.184,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,1.49,8.82,
DEMEROL 75MG INJ SLI INJ,6360000198,CDM,636,RC,J2175,HCPCS,Outpatient,75,GM,11.03,7.17,,11.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8.38,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.29,350,,,Fee Schedule,350% of BCBS fee schedule,3.29,350,,,Fee Schedule,350% of BCBS fee schedule,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.29,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.94,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,9.93,90,,2201.256,Percent of Total Billed Charges,90% of Total Billed Charges,4.96,45,,5.424,Percent of Total Billed Charges,45% of Total Billed Charges,9.93,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.17,65,,3919.08,Percent of total Billed Charges,65% of Total Billed Charges,4.86,44.1,,5.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,10.48,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,11.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.71,88,,338.904,Percent of Total Billed Charges,88% of Total Billed Charges,9.93,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,0.94,11.03,
MEPERIDINE *PCA* 300MG INJ,6360000199,CDM,636,RC,J2175,HCPCS,Outpatient,300,GM,44.10,28.67,,44.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33.52,76,,51.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.29,350,,,Fee Schedule,350% of BCBS fee schedule,3.29,350,,,Fee Schedule,350% of BCBS fee schedule,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.29,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.94,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,39.69,90,,14529.784,Percent of Total Billed Charges,90% of Total Billed Charges,19.85,45,,3.064,Percent of Total Billed Charges,45% of Total Billed Charges,39.69,90,,61.56,Percent of Total Billed Charges,90% of Total billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,65,,5678.072,Percent of total Billed Charges,65% of Total Billed Charges,19.45,44.1,,3,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.9,95,,64.984,Percent of Total Billed Charges,95% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.81,88,,10.608,Percent of Total Billed Charges,88% of Total Billed Charges,39.69,90,,61.56,Percent of Total Billed charges,90% of Total Billed Charges,0.94,44.1,
MEROPENEM 500MG VIAL,6360000201,CDM,636,RC,J2185,HCPCS,Outpatient,500,GM,25.25,16.41,,25.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.19,76,,113.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.66,350,,,Fee Schedule,350% of BCBS fee schedule,9.66,350,,,Fee Schedule,350% of BCBS fee schedule,25.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.66,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.76,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,22.73,90,,12568.552,Percent of Total Billed Charges,90% of Total Billed Charges,11.36,45,,7.184,Percent of Total Billed Charges,45% of Total Billed Charges,22.73,90,,134.368,Percent of Total Billed Charges,90% of Total billed Charges,25.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.41,65,,3919.08,Percent of total Billed Charges,65% of Total Billed Charges,11.14,44.1,,7.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.99,95,,141.832,Percent of Total Billed Charges,95% of Total Billed Charges,25.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.22,88,,19.608,Percent of Total Billed Charges,88% of Total Billed Charges,22.73,90,,134.368,Percent of Total Billed charges,90% of Total Billed Charges,2.76,25.25,
MEROPENEM/0.9% NACL 1G/50ML,6360000202,CDM,636,RC,J2185,HCPCS,Outpatient,50,ML,87.00,56.55,,87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.12,76,,6.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.66,350,,,Fee Schedule,350% of BCBS fee schedule,9.66,350,,,Fee Schedule,350% of BCBS fee schedule,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.66,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.76,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,78.3,90,,45321.208,Percent of Total Billed Charges,90% of Total Billed Charges,39.15,45,,1100.632,Percent of Total Billed Charges,45% of Total Billed Charges,78.3,90,,7.344,Percent of Total Billed Charges,90% of Total billed Charges,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.55,65,,4180.504,Percent of total Billed Charges,65% of Total Billed Charges,38.37,44.1,,1078.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.65,95,,7.752,Percent of Total Billed Charges,95% of Total Billed Charges,87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.56,88,,14.048,Percent of Total Billed Charges,88% of Total Billed Charges,78.3,90,,7.344,Percent of Total Billed charges,90% of Total Billed Charges,2.76,87,
METHERGINE 0.2MG/1ML INJ,6360000203,CDM,250,RC,,,Outpatient,0.2,GM,46.31,30.10,,46.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.2,76,,292.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.34,72,,26.672,Percent of Total Billed Charges,72% of Total Billed Charges,34.73,75,,27.784,Percent of Total Billed charges,75% of Total Billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.34,72,,26.672,Percent of Total Billed Charges,72% of Total Billed Charges,27.79,60,,22.232,Percent of Total Billed Charges,60% of Total Billed Charges,41.68,90,,30735.472,Percent of Total Billed Charges,90% of Total Billed Charges,20.84,45,,1100.632,Percent of Total Billed Charges,45% of Total Billed Charges,41.68,90,,346.608,Percent of Total Billed Charges,90% of Total billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.1,65,,4180.504,Percent of total Billed Charges,65% of Total Billed Charges,20.42,44.1,,1078.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,43.99,95,,365.864,Percent of Total Billed Charges,95% of Total Billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.75,88,,2152.336,Percent of Total Billed Charges,88% of Total Billed Charges,41.68,90,,346.608,Percent of Total Billed charges,90% of Total Billed Charges,20.42,46.31,
VERSED 5MG/ML,6360000204,CDM,636,RC,J2250,HCPCS,Outpatient,5,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,9.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.39,350,,,Fee Schedule,350% of BCBS fee schedule,0.39,350,,,Fee Schedule,350% of BCBS fee schedule,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.39,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.11,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5.96,90,,2650.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,7264.888,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,10.848,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,1318.592,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,7119.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,11.456,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,2152.336,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,10.848,Percent of Total Billed charges,90% of Total Billed Charges,0.11,6.62,
VERSED 10MG AMP INJ,6360000205,CDM,636,RC,J2250,HCPCS,Outpatient,10,GM,186.32,121.11,,186.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,141.6,76,,5.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.39,350,,,Fee Schedule,350% of BCBS fee schedule,0.39,350,,,Fee Schedule,350% of BCBS fee schedule,186.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.39,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.11,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,167.69,90,,1375.8,Percent of Total Billed Charges,90% of Total Billed Charges,83.84,45,,318.896,Percent of Total Billed Charges,45% of Total Billed Charges,167.69,90,,6.12,Percent of Total Billed Charges,90% of Total billed Charges,186.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.11,65,,2138.92,Percent of total Billed Charges,65% of Total Billed Charges,82.17,44.1,,312.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,177,95,,6.464,Percent of Total Billed Charges,95% of Total Billed Charges,186.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.96,88,,14206.896,Percent of Total Billed Charges,88% of Total Billed Charges,167.69,90,,6.12,Percent of Total Billed charges,90% of Total Billed Charges,0.11,186.32,
VERSED 2MG/2ML INJ,6360000206,CDM,636,RC,J2250,HCPCS,Outpatient,2,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,16.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.39,350,,,Fee Schedule,350% of BCBS fee schedule,0.39,350,,,Fee Schedule,350% of BCBS fee schedule,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.39,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.11,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,4.96,90,,1375.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,6284.272,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,20.056,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,2138.92,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,6158.592,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,21.168,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,623.616,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,20.056,Percent of Total Billed charges,90% of Total Billed Charges,0.11,5.51,
PRIMACOR PREMIX PB INJ,6360000208,CDM,636,RC,J2260,HCPCS,Outpatient,,,926.10,601.97,,926.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,703.84,76,,12.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.76,350,,,Fee Schedule,350% of BCBS fee schedule,6.76,350,,,Fee Schedule,350% of BCBS fee schedule,926.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.76,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.93,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,833.49,90,,2354.96,Percent of Total Billed Charges,90% of Total Billed Charges,416.75,45,,22660.6,Percent of Total Billed Charges,45% of Total Billed Charges,833.49,90,,14.368,Percent of Total Billed Charges,90% of Total billed Charges,926.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,926.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,926.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,601.97,65,,1778.4,Percent of total Billed Charges,65% of Total Billed Charges,408.41,44.1,,22207.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,879.8,95,,15.16,Percent of Total Billed Charges,95% of Total Billed Charges,926.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,814.97,88,,12289.248,Percent of Total Billed Charges,88% of Total Billed Charges,833.49,90,,14.368,Percent of Total Billed charges,90% of Total Billed Charges,1.93,926.1,
MORPHINE *PCA* 30MG/30ML,6360000209,CDM,636,RC,J2270,HCPCS,Outpatient,30,GM,46.31,30.10,,46.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.2,76,,1858.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.25,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.07,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,41.68,90,,5760.456,Percent of Total Billed Charges,90% of Total Billed Charges,20.84,45,,15367.736,Percent of Total Billed Charges,45% of Total Billed Charges,41.68,90,,2201.256,Percent of Total Billed Charges,90% of Total billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.1,65,,1524.12,Percent of total Billed Charges,65% of Total Billed Charges,20.42,44.1,,15060.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,43.99,95,,2323.552,Percent of Total Billed Charges,95% of Total Billed Charges,46.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.75,88,,44314.072,Percent of Total Billed Charges,88% of Total Billed Charges,41.68,90,,2201.256,Percent of Total Billed charges,90% of Total Billed Charges,0.07,46.31,
MORPHINE 4MG INJ SLI INJ,6360000210,CDM,636,RC,J2270,HCPCS,Outpatient,4,GM,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,1858.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.25,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.07,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,8.93,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,1325.344,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,2201.256,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,1079.16,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,1298.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,2323.552,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,30052.456,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,2201.256,Percent of Total Billed charges,90% of Total Billed Charges,0.07,9.92,
DURAMORPH 5MG/CC 10CC INJ,6360000211,CDM,636,RC,J2270,HCPCS,Outpatient,5,GM,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,12269.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.25,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.07,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,10.92,90,,255.96,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,687.896,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,14529.784,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,1604.2,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,674.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,15336.992,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,2591.776,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,14529.784,Percent of Total Billed charges,90% of Total Billed Charges,0.07,12.13,
MORPHINE C/J 10MG INJ,6360000212,CDM,636,RC,J2270,HCPCS,Outpatient,10,GM,9.92,6.45,,9.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.54,76,,538.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.25,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.07,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,8.93,90,,965.544,Percent of Total Billed Charges,90% of Total Billed Charges,4.46,45,,687.896,Percent of Total Billed Charges,45% of Total Billed Charges,8.93,90,,637.792,Percent of Total Billed Charges,90% of Total billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.45,65,,116.376,Percent of total Billed Charges,65% of Total Billed Charges,4.37,44.1,,674.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.42,95,,673.224,Percent of Total Billed Charges,95% of Total Billed Charges,9.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.73,88,,1345.224,Percent of Total Billed Charges,88% of Total Billed Charges,8.93,90,,637.792,Percent of Total Billed charges,90% of Total Billed Charges,0.07,9.92,
MORPHINE PF 10MG/10ML INJ,6360000214,CDM,636,RC,J2270,HCPCS,Outpatient,10,GM,28.67,18.64,,28.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,21.79,76,,10613.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.25,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.07,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,25.8,90,,84.6,Percent of Total Billed Charges,90% of Total Billed Charges,12.9,45,,1177.48,Percent of Total Billed Charges,45% of Total Billed Charges,25.8,90,,12568.552,Percent of Total Billed Charges,90% of Total billed Charges,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.64,65,,284.44,Percent of total Billed Charges,65% of Total Billed Charges,12.64,44.1,,1153.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,27.24,95,,13266.8,Percent of Total Billed Charges,95% of Total Billed Charges,28.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.23,88,,1345.224,Percent of Total Billed Charges,88% of Total Billed Charges,25.8,90,,12568.552,Percent of Total Billed charges,90% of Total Billed Charges,0.07,28.67,
NUBAIN 10ML/1ML AMP INJ,6360000215,CDM,636,RC,J2300,HCPCS,Outpatient,10,ML,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,38271.24,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.78,350,,,Fee Schedule,350% of BCBS fee schedule,5.78,350,,,Fee Schedule,350% of BCBS fee schedule,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.78,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.65,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5.96,90,,210.784,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,2880.224,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,45321.208,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,2576.392,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,2822.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,47839.048,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,2302.632,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,45321.208,Percent of Total Billed charges,90% of Total Billed Charges,1.65,6.62,
NARCAN .4MG AMP INJ,6360000216,CDM,636,RC,J2310,HCPCS,Outpatient,0.4,GM,48.51,31.53,,48.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.87,76,,25954.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.9,350,,,Fee Schedule,350% of BCBS fee schedule,39.9,350,,,Fee Schedule,350% of BCBS fee schedule,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.9,350,,,Fee Schedule,350% of BCBS PPO fee schedule,11.4,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,43.66,90,,84326.168,Percent of Total Billed Charges,90% of Total Billed Charges,21.83,45,,10.8,Percent of Total Billed Charges,45% of Total Billed Charges,43.66,90,,30735.472,Percent of Total Billed Charges,90% of Total billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.53,65,,2016.872,Percent of total Billed Charges,65% of Total Billed Charges,21.39,44.1,,10.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.08,95,,32442.992,Percent of Total Billed Charges,95% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.69,88,,5632.44,Percent of Total Billed Charges,88% of Total Billed Charges,43.66,90,,30735.472,Percent of Total Billed charges,90% of Total Billed Charges,11.4,48.51,
NARCAN 1MG/ML (ML) INJ,6360000217,CDM,636,RC,J2310,HCPCS,Outpatient,1,GM,92.61,60.20,,92.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,70.38,76,,2238.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,39.9,350,,,Fee Schedule,350% of BCBS fee schedule,39.9,350,,,Fee Schedule,350% of BCBS fee schedule,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.9,350,,,Fee Schedule,350% of BCBS PPO fee schedule,11.4,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,83.35,90,,6301.28,Percent of Total Billed Charges,90% of Total Billed Charges,41.67,45,,127.984,Percent of Total Billed Charges,45% of Total Billed Charges,83.35,90,,2650.68,Percent of Total Billed Charges,90% of Total billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.2,65,,252.72,Percent of total Billed Charges,65% of Total Billed Charges,40.84,44.1,,125.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,87.98,95,,2797.944,Percent of Total Billed Charges,95% of Total Billed Charges,92.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.5,88,,21.12,Percent of Total Billed Charges,88% of Total Billed Charges,83.35,90,,2650.68,Percent of Total Billed charges,90% of Total Billed Charges,11.4,92.61,
SANDOSTATIN LAR 1MG INJ,6360000219,CDM,636,RC,J2353,HCPCS,Outpatient,1,GM,105.84,68.80,,272.95,125,,,Fee Schedule,125% of CMS OPPS Rate,80.44,76,,1161.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,614.57,350,,,Fee Schedule,350% of BCBS fee schedule,614.57,350,,,Fee Schedule,350% of BCBS fee schedule,218.37,100,,,Fee Schedule,100% of CMS OPPS Rate,614.57,350,,,Fee Schedule,350% of BCBS PPO fee schedule,175.59,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,95.26,90,,24951.352,Percent of Total Billed Charges,90% of Total Billed Charges,47.63,45,,482.768,Percent of Total Billed Charges,45% of Total Billed Charges,95.26,90,,1375.8,Percent of Total Billed Charges,90% of Total billed Charges,218.37,100,,,Fee Schedule,100% of CMS OPPS Rate,218.37,100,,,Fee Schedule,100% of CMS OPPS Rate,218.37,100,,,Fee Schedule,100% of CMS OPPS Rate,505.54,65,,333.088,Percent of total Billed Charges,65% of Total Billed Charges,46.68,44.1,,473.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,100.55,95,,1452.232,Percent of Total Billed Charges,95% of Total Billed Charges,163.77,75,,,Fee Schedule,75% of CMS OPPS Rate,93.14,88,,250.272,Percent of Total Billed Charges,88% of Total Billed Charges,95.26,90,,1375.8,Percent of Total Billed charges,90% of Total Billed Charges,46.68,614.57,
SANDOSTATIN 1MG/ML I,6360000220,CDM,636,RC,J2354,HCPCS,Outpatient,1,GM,1005.48,653.56,,1005.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,764.16,76,,1161.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.09,350,,,Fee Schedule,350% of BCBS fee schedule,1.09,350,,,Fee Schedule,350% of BCBS fee schedule,1005.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.09,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.31,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,904.93,90,,37.584,Percent of Total Billed Charges,90% of Total Billed Charges,452.47,45,,42.304,Percent of Total Billed Charges,45% of Total Billed Charges,904.93,90,,1375.8,Percent of Total Billed Charges,90% of Total billed Charges,1005.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1005.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1005.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,653.56,65,,697.136,Percent of total Billed Charges,65% of Total Billed Charges,443.42,44.1,,41.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,955.21,95,,1452.232,Percent of Total Billed Charges,95% of Total Billed Charges,1005.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,884.82,88,,944.088,Percent of Total Billed Charges,88% of Total Billed Charges,904.93,90,,1375.8,Percent of Total Billed charges,90% of Total Billed Charges,0.31,1005.48,
NORFLEX 60MG/2ML INJ,6360000222,CDM,636,RC,J2360,HCPCS,Outpatient,60,GM,102.53,66.64,,102.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,77.92,76,,1988.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.81,350,,,Fee Schedule,350% of BCBS fee schedule,33.81,350,,,Fee Schedule,350% of BCBS fee schedule,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.81,350,,,Fee Schedule,350% of BCBS PPO fee schedule,9.66,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,92.28,90,,11.864,Percent of Total Billed Charges,90% of Total Billed Charges,46.14,45,,105.392,Percent of Total Billed Charges,45% of Total Billed Charges,92.28,90,,2354.96,Percent of Total Billed Charges,90% of Total billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.64,65,,1318.592,Percent of total Billed Charges,65% of Total Billed Charges,45.22,44.1,,103.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,97.4,95,,2485.792,Percent of Total Billed Charges,95% of Total Billed Charges,102.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.23,88,,82.72,Percent of Total Billed Charges,88% of Total Billed Charges,92.28,90,,2354.96,Percent of Total Billed charges,90% of Total Billed Charges,9.66,102.53,
AREDIA 90MG INJ,6360000224,CDM,636,RC,J2430,HCPCS,Outpatient,90,GM,658.19,427.82,,658.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,500.22,76,,4864.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.92,350,,,Fee Schedule,350% of BCBS fee schedule,33.92,350,,,Fee Schedule,350% of BCBS fee schedule,658.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.92,350,,,Fee Schedule,350% of BCBS PPO fee schedule,9.69,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,592.37,90,,220.968,Percent of Total Billed Charges,90% of Total Billed Charges,296.19,45,,42163.088,Percent of Total Billed Charges,45% of Total Billed Charges,592.37,90,,5760.456,Percent of Total Billed Charges,90% of Total billed Charges,658.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,658.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.82,65,,255.12,Percent of total Billed Charges,65% of Total Billed Charges,290.26,44.1,,41319.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,625.28,95,,6080.48,Percent of Total Billed Charges,95% of Total Billed Charges,658.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.21,88,,206.096,Percent of Total Billed Charges,88% of Total Billed Charges,592.37,90,,5760.456,Percent of Total Billed charges,90% of Total Billed Charges,9.69,658.19,
PFIZERPEN 5MU INJ,6360000228,CDM,636,RC,J2540,HCPCS,Outpatient,,,43.00,27.95,,43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,32.68,76,,216.144,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.41,350,,,Fee Schedule,350% of BCBS fee schedule,4.41,350,,,Fee Schedule,350% of BCBS fee schedule,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.26,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,38.7,90,,446.688,Percent of Total Billed Charges,90% of Total Billed Charges,19.35,45,,12475.672,Percent of Total Billed Charges,45% of Total Billed Charges,38.7,90,,255.96,Percent of Total Billed Charges,90% of Total billed Charges,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.95,65,,1182.144,Percent of total Billed Charges,65% of Total Billed Charges,18.96,44.1,,12226.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,40.85,95,,270.184,Percent of Total Billed Charges,95% of Total Billed Charges,43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.84,88,,6161.256,Percent of Total Billed Charges,88% of Total Billed Charges,38.7,90,,255.96,Percent of Total Billed charges,90% of Total Billed Charges,1.26,43,
ZOSYN 2.25G IVPB,6360000230,CDM,636,RC,J2543,HCPCS,Outpatient,,,60.50,39.33,,60.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,45.98,76,,815.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.96,350,,,Fee Schedule,350% of BCBS fee schedule,8.96,350,,,Fee Schedule,350% of BCBS fee schedule,60.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.96,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.56,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,54.45,90,,140.424,Percent of Total Billed Charges,90% of Total Billed Charges,27.23,45,,18.792,Percent of Total Billed Charges,45% of Total Billed Charges,54.45,90,,965.544,Percent of Total Billed Charges,90% of Total billed Charges,60.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.33,65,,3264.376,Percent of total Billed Charges,65% of Total Billed Charges,26.68,44.1,,18.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.48,95,,1019.184,Percent of Total Billed Charges,95% of Total Billed Charges,60.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.24,88,,24396.872,Percent of Total Billed Charges,88% of Total Billed Charges,54.45,90,,965.544,Percent of Total Billed charges,90% of Total Billed Charges,2.56,60.5,
ZOSYN 3.375G IVPB,6360000231,CDM,636,RC,J2543,HCPCS,Outpatient,,,47.00,30.55,,47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.72,76,,71.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.96,350,,,Fee Schedule,350% of BCBS fee schedule,8.96,350,,,Fee Schedule,350% of BCBS fee schedule,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.96,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.56,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,42.3,90,,560.256,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,45,,5.936,Percent of Total Billed Charges,45% of Total Billed Charges,42.3,90,,84.6,Percent of Total Billed Charges,90% of Total billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.55,65,,1717.848,Percent of total Billed Charges,65% of Total Billed Charges,20.73,44.1,,5.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.65,95,,89.304,Percent of Total Billed Charges,95% of Total Billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.36,88,,36.752,Percent of Total Billed Charges,88% of Total Billed Charges,42.3,90,,84.6,Percent of Total Billed charges,90% of Total Billed Charges,2.56,47,
ZOSYN 3.375INJ,6360000232,CDM,636,RC,J2543,HCPCS,Outpatient,,,104.74,68.08,,104.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,79.6,76,,177.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.96,350,,,Fee Schedule,350% of BCBS fee schedule,8.96,350,,,Fee Schedule,350% of BCBS fee schedule,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.96,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.56,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,94.27,90,,84.6,Percent of Total Billed Charges,90% of Total Billed Charges,47.13,45,,110.488,Percent of Total Billed Charges,45% of Total Billed Charges,94.27,90,,210.784,Percent of Total Billed Charges,90% of Total billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.08,65,,885.744,Percent of total Billed Charges,65% of Total Billed Charges,46.19,44.1,,108.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,99.5,95,,222.488,Percent of Total Billed Charges,95% of Total Billed Charges,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.17,88,,11.6,Percent of Total Billed Charges,88% of Total Billed Charges,94.27,90,,210.784,Percent of Total Billed charges,90% of Total Billed Charges,2.56,104.74,
ZOSYN 2.25 GM VIAL INJ,6360000233,CDM,250,RC,J2543,HCPCS,Outpatient,2.25,gm,69.46,45.15,,69.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,52.79,76,,71208.768,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.96,350,,,Fee Schedule,350% of BCBS fee schedule,8.96,350,,,Fee Schedule,350% of BCBS fee schedule,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.96,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.56,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,62.51,90,,84.6,Percent of Total Billed Charges,90% of Total Billed Charges,31.26,45,,12.416,Percent of Total Billed Charges,45% of Total Billed Charges,62.51,90,,84326.168,Percent of Total Billed Charges,90% of Total billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.15,65,,462.08,Percent of total Billed Charges,65% of Total Billed Charges,30.63,44.1,,12.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,65.99,95,,89010.96,Percent of Total Billed Charges,95% of Total Billed Charges,69.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,88,,216.056,Percent of Total Billed Charges,88% of Total Billed Charges,62.51,90,,84326.168,Percent of Total Billed charges,90% of Total Billed Charges,2.56,69.46,
PHENERGAN 50MG INJ,6360000234,CDM,636,RC,J2550,HCPCS,Outpatient,50,GM,12.13,7.88,,12.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.22,76,,5321.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.48,350,,,Fee Schedule,350% of BCBS fee schedule,4.48,350,,,Fee Schedule,350% of BCBS fee schedule,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.48,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.28,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,10.92,90,,2040.576,Percent of Total Billed Charges,90% of Total Billed Charges,5.46,45,,223.344,Percent of Total Billed Charges,45% of Total Billed Charges,10.92,90,,6301.28,Percent of Total Billed Charges,90% of Total billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.88,65,,949,Percent of total Billed Charges,65% of Total Billed Charges,5.35,44.1,,218.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.52,95,,6651.352,Percent of Total Billed Charges,95% of Total Billed Charges,12.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.67,88,,24.272,Percent of Total Billed Charges,88% of Total Billed Charges,10.92,90,,6301.28,Percent of Total Billed charges,90% of Total Billed Charges,1.28,12.13,
PHENOBARBITAL INJ 130MG,6360000235,CDM,636,RC,J2560,HCPCS,Outpatient,130,GM,157.66,102.48,,157.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,119.82,76,,21070.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,93.17,350,,,Fee Schedule,350% of BCBS fee schedule,93.17,350,,,Fee Schedule,350% of BCBS fee schedule,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.17,350,,,Fee Schedule,350% of BCBS PPO fee schedule,26.62,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,141.89,90,,152.896,Percent of Total Billed Charges,90% of Total Billed Charges,70.95,45,,70.208,Percent of Total Billed Charges,45% of Total Billed Charges,141.89,90,,24951.352,Percent of Total Billed Charges,90% of Total billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.48,65,,673.632,Percent of total Billed Charges,65% of Total Billed Charges,69.53,44.1,,68.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,149.78,95,,26337.536,Percent of Total Billed Charges,95% of Total Billed Charges,157.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.74,88,,436.76,Percent of Total Billed Charges,88% of Total Billed Charges,141.89,90,,24951.352,Percent of Total Billed charges,90% of Total Billed Charges,26.62,157.66,
PHENOBARBITAL INJ 65MG,6360000236,CDM,636,RC,J2560,HCPCS,Outpatient,65,GM,60.64,39.42,,60.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.09,76,,31.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,93.17,350,,,Fee Schedule,350% of BCBS fee schedule,93.17,350,,,Fee Schedule,350% of BCBS fee schedule,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.17,350,,,Fee Schedule,350% of BCBS PPO fee schedule,26.62,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,54.58,90,,628.888,Percent of Total Billed Charges,90% of Total Billed Charges,27.29,45,,280.128,Percent of Total Billed Charges,45% of Total Billed Charges,54.58,90,,37.584,Percent of Total Billed Charges,90% of Total billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.42,65,,673.632,Percent of total Billed Charges,65% of Total Billed Charges,26.74,44.1,,274.528,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.61,95,,39.672,Percent of Total Billed Charges,95% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.36,88,,137.304,Percent of Total Billed Charges,88% of Total Billed Charges,54.58,90,,37.584,Percent of Total Billed charges,90% of Total Billed Charges,26.62,93.17,
OXYTOCIN 10U/ML 10ML INJ,6360000237,CDM,636,RC,J2590,HCPCS,Outpatient,10,ML,206.17,134.01,,206.17,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,156.69,76,,10.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.28,350,,,Fee Schedule,350% of BCBS fee schedule,2.28,350,,,Fee Schedule,350% of BCBS fee schedule,206.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.28,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.65,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,185.55,90,,74.056,Percent of Total Billed Charges,90% of Total Billed Charges,92.78,45,,42.304,Percent of Total Billed Charges,45% of Total Billed Charges,185.55,90,,11.864,Percent of Total Billed Charges,90% of Total billed Charges,206.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.01,65,,1182.144,Percent of total Billed Charges,65% of Total Billed Charges,90.92,44.1,,41.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,195.86,95,,12.528,Percent of Total Billed Charges,95% of Total Billed Charges,206.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.43,88,,547.8,Percent of Total Billed Charges,88% of Total Billed Charges,185.55,90,,11.864,Percent of Total Billed charges,90% of Total Billed Charges,0.65,206.17,
SYNTOCINON 1OU'S INJ,6360000238,CDM,250,RC,J2590,HCPCS,Outpatient,,,23.15,15.05,,23.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.59,76,,186.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.28,350,,,Fee Schedule,350% of BCBS fee schedule,2.28,350,,,Fee Schedule,350% of BCBS fee schedule,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.28,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.65,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,20.84,90,,17897.384,Percent of Total Billed Charges,90% of Total Billed Charges,10.42,45,,42.304,Percent of Total Billed Charges,45% of Total Billed Charges,20.84,90,,220.968,Percent of Total Billed Charges,90% of Total billed Charges,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.05,65,,3264.376,Percent of total Billed Charges,65% of Total Billed Charges,10.21,44.1,,41.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,21.99,95,,233.248,Percent of Total Billed Charges,95% of Total Billed Charges,23.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.37,88,,82.72,Percent of Total Billed Charges,88% of Total Billed Charges,20.84,90,,220.968,Percent of Total Billed charges,90% of Total Billed Charges,0.65,23.15,
DDAVP 4MCG/ML INJ,6360000239,CDM,636,RC,J2597,HCPCS,Outpatient,4,GM,234.83,152.64,,6.18,125,,,Fee Schedule,125% of CMS OPPS Rate,178.47,76,,20.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.52,350,,,Fee Schedule,350% of BCBS fee schedule,4.52,350,,,Fee Schedule,350% of BCBS fee schedule,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.52,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.29,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,211.35,90,,4545.36,Percent of Total Billed Charges,90% of Total Billed Charges,105.67,45,,1020.288,Percent of Total Billed Charges,45% of Total Billed Charges,211.35,90,,24.824,Percent of Total Billed Charges,90% of Total billed Charges,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,162.54,65,,2496,Percent of total Billed Charges,65% of Total Billed Charges,103.56,44.1,,999.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,223.09,95,,26.208,Percent of Total Billed Charges,95% of Total Billed Charges,3.71,75,,,Fee Schedule,75% of CMS OPPS Rate,206.65,88,,82.72,Percent of Total Billed Charges,88% of Total Billed Charges,211.35,90,,24.824,Percent of Total Billed charges,90% of Total Billed Charges,1.29,223.09,
PRONESTYL 1000MG INJ,6360000240,CDM,636,RC,J2690,HCPCS,Outpatient,1000,GM,95.92,62.35,,228.78,125,,,Fee Schedule,125% of CMS OPPS Rate,72.9,76,,377.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,190.96,350,,,Fee Schedule,350% of BCBS fee schedule,190.96,350,,,Fee Schedule,350% of BCBS fee schedule,183.03,100,,,Fee Schedule,100% of CMS OPPS Rate,190.96,350,,,Fee Schedule,350% of BCBS PPO fee schedule,54.56,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,86.33,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,43.16,45,,76.448,Percent of Total Billed Charges,45% of Total Billed Charges,86.33,90,,446.688,Percent of Total Billed Charges,90% of Total billed Charges,183.03,100,,,Fee Schedule,100% of CMS OPPS Rate,183.03,100,,,Fee Schedule,100% of CMS OPPS Rate,183.03,100,,,Fee Schedule,100% of CMS OPPS Rate,428.41,65,,720.64,Percent of total Billed Charges,65% of Total Billed Charges,42.3,44.1,,74.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.12,95,,471.504,Percent of Total Billed Charges,95% of Total Billed Charges,137.27,75,,,Fee Schedule,75% of CMS OPPS Rate,84.41,88,,1995.224,Percent of Total Billed Charges,88% of Total Billed Charges,86.33,90,,446.688,Percent of Total Billed charges,90% of Total Billed Charges,42.3,428.41,
OXACILLIN 2GM IV INJ,6360000241,CDM,636,RC,J2700,HCPCS,Outpatient,2,gm,128.99,83.84,,128.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,98.03,76,,118.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.97,350,,,Fee Schedule,350% of BCBS fee schedule,6.97,350,,,Fee Schedule,350% of BCBS fee schedule,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.97,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.99,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,116.09,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,58.05,45,,314.44,Percent of Total Billed Charges,45% of Total Billed Charges,116.09,90,,140.424,Percent of Total Billed Charges,90% of Total billed Charges,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.84,65,,1090.992,Percent of total Billed Charges,65% of Total Billed Charges,56.88,44.1,,308.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,122.54,95,,148.224,Percent of Total Billed Charges,95% of Total Billed Charges,128.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.51,88,,149.496,Percent of Total Billed Charges,88% of Total Billed Charges,116.09,90,,140.424,Percent of Total Billed charges,90% of Total Billed Charges,1.99,128.99,
OXACILLIN 1GM IV INJ,6360000242,CDM,636,RC,J2700,HCPCS,Outpatient,1,gm,67.25,43.71,,67.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,51.11,76,,473.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.97,350,,,Fee Schedule,350% of BCBS fee schedule,6.97,350,,,Fee Schedule,350% of BCBS fee schedule,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.97,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.99,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,60.53,90,,68.272,Percent of Total Billed Charges,90% of Total Billed Charges,30.26,45,,37.024,Percent of Total Billed Charges,45% of Total Billed Charges,60.53,90,,560.256,Percent of Total Billed Charges,90% of Total billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.71,65,,683.944,Percent of total Billed Charges,65% of Total Billed Charges,29.66,44.1,,36.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,63.89,95,,591.376,Percent of Total Billed Charges,95% of Total Billed Charges,67.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.18,88,,614.912,Percent of Total Billed Charges,88% of Total Billed Charges,60.53,90,,560.256,Percent of Total Billed charges,90% of Total Billed Charges,1.99,67.25,
DIPRIVAN 200MG/20ML VIAL,6360000243,CDM,636,RC,J2704,HCPCS,Outpatient,200,GM,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,71.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.25,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.07,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,10.8,90,,1126.408,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,8948.696,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,84.6,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,764.208,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,8769.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,89.304,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,72.408,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,84.6,Percent of Total Billed charges,90% of Total Billed Charges,0.07,12,
DIPRIVAN 100MG/10ML VIAL,6360000244,CDM,636,RC,J2704,HCPCS,Outpatient,100,GM,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,71.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.25,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.07,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,10.8,90,,14.464,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,2272.68,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,84.6,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,582.472,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,2227.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,89.304,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,17499.664,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,84.6,Percent of Total Billed charges,90% of Total Billed Charges,0.07,12,
PROTAMINE 10MG/ML INJ,6360000248,CDM,636,RC,J2720,HCPCS,Outpatient,10,GM,44.10,28.67,,44.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33.52,76,,531.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.71,350,,,Fee Schedule,350% of BCBS fee schedule,3.71,350,,,Fee Schedule,350% of BCBS fee schedule,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.71,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.06,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,39.69,90,,1825.2,Percent of Total Billed Charges,90% of Total Billed Charges,19.85,45,,34.136,Percent of Total Billed Charges,45% of Total Billed Charges,39.69,90,,628.888,Percent of Total Billed Charges,90% of Total billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.67,65,,2879.688,Percent of total Billed Charges,65% of Total Billed Charges,19.45,44.1,,33.456,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.9,95,,663.824,Percent of Total Billed Charges,95% of Total Billed Charges,44.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.81,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,39.69,90,,628.888,Percent of Total Billed charges,90% of Total Billed Charges,1.06,44.1,
PHENTOLAMINE 5MG INJ,6360000249,CDM,636,RC,J2760,HCPCS,Outpatient,5,GM,574.40,373.36,,493.28,125,,,Fee Schedule,125% of CMS OPPS Rate,436.54,76,,62.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,366.63,350,,,Fee Schedule,350% of BCBS fee schedule,366.63,350,,,Fee Schedule,350% of BCBS fee schedule,394.63,100,,,Fee Schedule,100% of CMS OPPS Rate,366.63,350,,,Fee Schedule,350% of BCBS PPO fee schedule,104.75,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,516.96,90,,1216.8,Percent of Total Billed Charges,90% of Total Billed Charges,258.48,45,,563.2,Percent of Total Billed Charges,45% of Total Billed Charges,516.96,90,,74.056,Percent of Total Billed Charges,90% of Total billed Charges,394.63,100,,,Fee Schedule,100% of CMS OPPS Rate,394.63,100,,,Fee Schedule,100% of CMS OPPS Rate,394.63,100,,,Fee Schedule,100% of CMS OPPS Rate,1162.62,65,,1085.832,Percent of total Billed Charges,65% of Total Billed Charges,253.31,44.1,,551.936,Percent of Total Billed Charges,44.1% of Total Billed Charges,545.68,95,,78.168,Percent of Total Billed Charges,95% of Total Billed Charges,295.97,75,,,Fee Schedule,75% of CMS OPPS Rate,505.47,88,,66.752,Percent of Total Billed Charges,88% of Total Billed Charges,516.96,90,,74.056,Percent of Total Billed charges,90% of Total Billed Charges,104.75,1162.62,
REGLAN 5 MG / ML INJ,6360000250,CDM,636,RC,J2765,HCPCS,Outpatient,5,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,15113.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.17,350,,,Fee Schedule,350% of BCBS fee schedule,2.17,350,,,Fee Schedule,350% of BCBS fee schedule,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.17,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.62,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,4.96,90,,1152,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,7.232,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,17897.384,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,1085.832,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,7.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,18891.688,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,1101.376,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,17897.384,Percent of Total Billed charges,90% of Total Billed Charges,0.62,5.51,
ZANTAC INJ 50MG INJ,6360000252,CDM,636,RC,J2780,HCPCS,Outpatient,50,GM,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,3838.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.61,350,,,Fee Schedule,350% of BCBS fee schedule,15.61,350,,,Fee Schedule,350% of BCBS fee schedule,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.61,350,,,Fee Schedule,350% of BCBS PPO fee schedule,4.46,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,18.86,90,,1080,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,4545.36,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,2018.96,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,4797.88,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,14.144,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,4545.36,Percent of Total Billed charges,90% of Total Billed Charges,4.46,20.95,
LEXISCAN 0.4MG/5ML INJ,6360000253,CDM,636,RC,J2785,HCPCS,Outpatient,0.4,GM,1201.73,781.12,,1201.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,913.31,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,207.41,350,,,Fee Schedule,350% of BCBS fee schedule,207.41,350,,,Fee Schedule,350% of BCBS fee schedule,1201.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.41,350,,,Fee Schedule,350% of BCBS PPO fee schedule,59.26,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,1081.56,90,,1152,Percent of Total Billed Charges,90% of Total Billed Charges,540.78,45,,602.096,Percent of Total Billed Charges,45% of Total Billed Charges,1081.56,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,1201.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1201.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1201.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,781.12,65,,762.84,Percent of total Billed Charges,65% of Total Billed Charges,529.96,44.1,,590.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,1141.64,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,1201.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1057.52,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,1081.56,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,59.26,1201.73,
RHOGAM UF 300MCG SYG,6360000254,CDM,636,RC,J2790,HCPCS,Outpatient,300,GM,118.00,76.70,,118,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,89.68,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,264.32,350,,,Fee Schedule,350% of BCBS fee schedule,264.32,350,,,Fee Schedule,350% of BCBS fee schedule,118,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.32,350,,,Fee Schedule,350% of BCBS PPO fee schedule,75.52,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,106.2,90,,1152,Percent of Total Billed Charges,90% of Total Billed Charges,53.1,45,,912.6,Percent of Total Billed Charges,45% of Total Billed Charges,106.2,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,118,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.7,65,,1014.52,Percent of total Billed Charges,65% of Total Billed Charges,52.04,44.1,,894.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,112.1,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,118,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.84,88,,1177.432,Percent of Total Billed Charges,88% of Total Billed Charges,106.2,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,52.04,264.32,
NAROPIN 7.5MG/ML,6360000255,CDM,636,RC,J2795,HCPCS,Outpatient,7.5,GM,74.75,48.59,,74.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.81,76,,57.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.18,350,,,Fee Schedule,350% of BCBS fee schedule,0.18,350,,,Fee Schedule,350% of BCBS fee schedule,74.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.18,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.05,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,67.28,90,,1094.4,Percent of Total Billed Charges,90% of Total Billed Charges,33.64,45,,608.4,Percent of Total Billed Charges,45% of Total Billed Charges,67.28,90,,68.272,Percent of Total Billed Charges,90% of Total billed Charges,74.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.59,65,,3648.32,Percent of total Billed Charges,65% of Total Billed Charges,32.96,44.1,,596.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,71.01,95,,72.064,Percent of Total Billed Charges,95% of Total Billed Charges,74.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.78,88,,1784.64,Percent of Total Billed Charges,88% of Total Billed Charges,67.28,90,,68.272,Percent of Total Billed charges,90% of Total Billed Charges,0.05,74.75,
NAROPIN 5MG/ML INJ 3,6360000256,CDM,636,RC,J2795,HCPCS,Outpatient,5,GM,61.74,40.13,,61.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.92,76,,951.184,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.18,350,,,Fee Schedule,350% of BCBS fee schedule,0.18,350,,,Fee Schedule,350% of BCBS fee schedule,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.18,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.05,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,55.57,90,,1244.16,Percent of Total Billed Charges,90% of Total Billed Charges,27.78,45,,576,Percent of Total Billed Charges,45% of Total Billed Charges,55.57,90,,1126.408,Percent of Total Billed Charges,90% of Total billed Charges,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.13,65,,2496,Percent of total Billed Charges,65% of Total Billed Charges,27.23,44.1,,564.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,58.65,95,,1188.984,Percent of Total Billed Charges,95% of Total Billed Charges,61.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.33,88,,1189.76,Percent of Total Billed Charges,88% of Total Billed Charges,55.57,90,,1126.408,Percent of Total Billed charges,90% of Total Billed Charges,0.05,61.74,
NAROPIN 100ML VIAL INJ,6360000257,CDM,636,RC,J2795,HCPCS,Outpatient,100,ML,94.82,61.63,,94.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.06,76,,12.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.18,350,,,Fee Schedule,350% of BCBS fee schedule,0.18,350,,,Fee Schedule,350% of BCBS fee schedule,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.18,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.05,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,85.34,90,,1152,Percent of Total Billed Charges,90% of Total Billed Charges,42.67,45,,540,Percent of Total Billed Charges,45% of Total Billed Charges,85.34,90,,14.464,Percent of Total Billed Charges,90% of Total billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.63,65,,2496,Percent of total Billed Charges,65% of Total Billed Charges,41.82,44.1,,529.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,90.08,95,,15.272,Percent of Total Billed Charges,95% of Total Billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.44,88,,1126.4,Percent of Total Billed Charges,88% of Total Billed Charges,85.34,90,,14.464,Percent of Total Billed charges,90% of Total Billed Charges,0.05,94.82,
NAROPIN 20ML VIAL INJ,6360000258,CDM,636,RC,J2795,HCPCS,Outpatient,20,ML,38.25,24.86,,38.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.07,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.18,350,,,Fee Schedule,350% of BCBS fee schedule,0.18,350,,,Fee Schedule,350% of BCBS fee schedule,38.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.18,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.05,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,34.43,90,,1244.16,Percent of Total Billed Charges,90% of Total Billed Charges,17.21,45,,576,Percent of Total Billed Charges,45% of Total Billed Charges,34.43,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,38.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.86,65,,2496,Percent of total Billed Charges,65% of Total Billed Charges,16.87,44.1,,564.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.34,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,38.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.66,88,,1056,Percent of Total Billed Charges,88% of Total Billed Charges,34.43,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,0.05,38.25,
KINEVACDIAGNOSTIC 5MCG INJ,6360000259,CDM,636,RC,J2805,HCPCS,Outpatient,5,GM,414.54,269.45,,414.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,315.05,76,,1016.872,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,354.1,350,,,Fee Schedule,350% of BCBS fee schedule,354.1,350,,,Fee Schedule,350% of BCBS fee schedule,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.1,350,,,Fee Schedule,350% of BCBS PPO fee schedule,101.17,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,373.09,90,,1152,Percent of Total Billed Charges,90% of Total Billed Charges,186.54,45,,576,Percent of Total Billed Charges,45% of Total Billed Charges,373.09,90,,1204.192,Percent of Total Billed Charges,90% of Total billed Charges,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.45,65,,2496,Percent of total Billed Charges,65% of Total Billed Charges,182.81,44.1,,564.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,393.81,95,,1271.096,Percent of Total Billed Charges,95% of Total Billed Charges,414.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.8,88,,1126.4,Percent of Total Billed Charges,88% of Total Billed Charges,373.09,90,,1204.192,Percent of Total Billed charges,90% of Total Billed Charges,101.17,414.54,
KINEVAC 5MCG,6360000260,CDM,636,RC,J2805,HCPCS,Outpatient,5,GM,60.64,39.42,,60.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,46.09,76,,1541.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,354.1,350,,,Fee Schedule,350% of BCBS fee schedule,354.1,350,,,Fee Schedule,350% of BCBS fee schedule,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.1,350,,,Fee Schedule,350% of BCBS PPO fee schedule,101.17,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,54.58,90,,1152,Percent of Total Billed Charges,90% of Total Billed Charges,27.29,45,,547.2,Percent of Total Billed Charges,45% of Total Billed Charges,54.58,90,,1825.2,Percent of Total Billed Charges,90% of Total billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.42,65,,1015.56,Percent of total Billed Charges,65% of Total Billed Charges,26.74,44.1,,536.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,57.61,95,,1926.6,Percent of Total Billed Charges,95% of Total Billed Charges,60.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.36,88,,1126.4,Percent of Total Billed Charges,88% of Total Billed Charges,54.58,90,,1825.2,Percent of Total Billed charges,90% of Total Billed Charges,26.74,354.1,
FERRLECIT 62.5MG/5ML INJ,6360000261,CDM,636,RC,J2916,HCPCS,Outpatient,62.5,GM,174.20,113.23,,174.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,132.39,76,,1027.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.4,350,,,Fee Schedule,350% of BCBS fee schedule,15.4,350,,,Fee Schedule,350% of BCBS fee schedule,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.4,350,,,Fee Schedule,350% of BCBS PPO fee schedule,4.4,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,156.78,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,78.39,45,,622.08,Percent of Total Billed Charges,45% of Total Billed Charges,156.78,90,,1216.8,Percent of Total Billed Charges,90% of Total billed Charges,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.23,65,,1381.64,Percent of total Billed Charges,65% of Total Billed Charges,76.82,44.1,,609.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,165.49,95,,1284.4,Percent of Total Billed Charges,95% of Total Billed Charges,174.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.3,88,,1070.08,Percent of Total Billed Charges,88% of Total Billed Charges,156.78,90,,1216.8,Percent of Total Billed charges,90% of Total Billed Charges,4.4,174.2,
SOLUMEDROL 40MG 1CC INJ,6360000262,CDM,636,RC,J2919,HCPCS,Outpatient,40,GM,18.74,12.18,,0.33,125,,,Fee Schedule,125% of CMS OPPS Rate,14.24,76,,972.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.49,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,14.06,75,,11.248,Percent of Total Billed charges,75% of Total Billed Charges,0.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.49,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,11.24,60,,8.992,Percent of Total Billed Charges,60% of Total Billed Charges,16.87,90,,2252.808,Percent of Total Billed Charges,90% of Total Billed Charges,8.43,45,,576,Percent of Total Billed Charges,45% of Total Billed Charges,16.87,90,,1152,Percent of Total Billed Charges,90% of Total billed Charges,0.27,100,,,Fee Schedule,100% of CMS OPPS Rate,0.27,100,,,Fee Schedule,100% of CMS OPPS Rate,0.27,100,,,Fee Schedule,100% of CMS OPPS Rate,12.72,65,,246.48,Percent of total Billed Charges,65% of Total Billed Charges,8.26,44.1,,564.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.8,95,,1216,Percent of Total Billed Charges,95% of Total Billed Charges,0.2,75,,,Fee Schedule,75% of CMS OPPS Rate,16.49,88,,1216.512,Percent of Total Billed Charges,88% of Total Billed Charges,16.87,90,,1152,Percent of Total Billed charges,90% of Total Billed Charges,0.2,17.8,
SOLUMEDROL 125MG 1CC INJ,6360000263,CDM,636,RC,J2919,HCPCS,Outpatient,125,GM,41.40,26.91,,0.33,125,,,Fee Schedule,125% of CMS OPPS Rate,31.46,76,,912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.81,72,,23.848,Percent of Total Billed Charges,72% of Total Billed Charges,31.05,75,,24.84,Percent of Total Billed charges,75% of Total Billed Charges,0.27,100,,,Fee Schedule,100% of CMS OPPS Rate,29.81,72,,23.848,Percent of Total Billed Charges,72% of Total Billed Charges,24.84,60,,19.872,Percent of Total Billed Charges,60% of Total Billed Charges,37.26,90,,308.16,Percent of Total Billed Charges,90% of Total Billed Charges,18.63,45,,622.08,Percent of Total Billed Charges,45% of Total Billed Charges,37.26,90,,1080,Percent of Total Billed Charges,90% of Total billed Charges,0.27,100,,,Fee Schedule,100% of CMS OPPS Rate,0.27,100,,,Fee Schedule,100% of CMS OPPS Rate,0.27,100,,,Fee Schedule,100% of CMS OPPS Rate,27.45,65,,333.088,Percent of total Billed Charges,65% of Total Billed Charges,18.26,44.1,,609.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,39.33,95,,1140,Percent of Total Billed Charges,95% of Total Billed Charges,0.2,75,,,Fee Schedule,75% of CMS OPPS Rate,36.43,88,,1126.4,Percent of Total Billed Charges,88% of Total Billed Charges,37.26,90,,1080,Percent of Total Billed charges,90% of Total Billed Charges,0.2,39.33,
SOLUMEDROL 500MG 1CC INJ,6360000264,CDM,636,RC,J2919,HCPCS,Outpatient,500,GM,100.33,65.21,,0.33,125,,,Fee Schedule,125% of CMS OPPS Rate,76.25,76,,972.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,72.24,72,,57.792,Percent of Total Billed Charges,72% of Total Billed Charges,75.25,75,,60.2,Percent of Total Billed charges,75% of Total Billed Charges,0.27,100,,,Fee Schedule,100% of CMS OPPS Rate,72.24,72,,57.792,Percent of Total Billed Charges,72% of Total Billed Charges,60.2,60,,48.16,Percent of Total Billed Charges,60% of Total Billed Charges,90.3,90,,4185.528,Percent of Total Billed Charges,90% of Total Billed Charges,45.15,45,,576,Percent of Total Billed Charges,45% of Total Billed Charges,90.3,90,,1152,Percent of Total Billed Charges,90% of Total billed Charges,0.27,100,,,Fee Schedule,100% of CMS OPPS Rate,0.27,100,,,Fee Schedule,100% of CMS OPPS Rate,0.27,100,,,Fee Schedule,100% of CMS OPPS Rate,65.75,65,,2823.6,Percent of total Billed Charges,65% of Total Billed Charges,44.25,44.1,,564.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,95.31,95,,1216,Percent of Total Billed Charges,95% of Total Billed Charges,0.2,75,,,Fee Schedule,75% of CMS OPPS Rate,88.29,88,,1216.512,Percent of Total Billed Charges,88% of Total Billed Charges,90.3,90,,1152,Percent of Total Billed charges,90% of Total Billed Charges,0.2,95.31,
SOLUMEDROL 1000MG 1CC INJ,6360000265,CDM,636,RC,J2919,HCPCS,Outpatient,1000,GM,31.80,20.67,,0.33,125,,,Fee Schedule,125% of CMS OPPS Rate,24.17,76,,972.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.9,72,,18.32,Percent of Total Billed Charges,72% of Total Billed Charges,23.85,75,,19.08,Percent of Total Billed charges,75% of Total Billed Charges,0.27,100,,,Fee Schedule,100% of CMS OPPS Rate,22.9,72,,18.32,Percent of Total Billed Charges,72% of Total Billed Charges,19.08,60,,15.264,Percent of Total Billed Charges,60% of Total Billed Charges,28.62,90,,1066.688,Percent of Total Billed Charges,90% of Total Billed Charges,14.31,45,,576,Percent of Total Billed Charges,45% of Total Billed Charges,28.62,90,,1152,Percent of Total Billed Charges,90% of Total billed Charges,0.27,100,,,Fee Schedule,100% of CMS OPPS Rate,0.27,100,,,Fee Schedule,100% of CMS OPPS Rate,0.27,100,,,Fee Schedule,100% of CMS OPPS Rate,21.21,65,,1355.856,Percent of total Billed Charges,65% of Total Billed Charges,14.02,44.1,,564.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,30.21,95,,1216,Percent of Total Billed Charges,95% of Total Billed Charges,0.2,75,,,Fee Schedule,75% of CMS OPPS Rate,27.98,88,,1126.4,Percent of Total Billed Charges,88% of Total Billed Charges,28.62,90,,1152,Percent of Total Billed charges,90% of Total Billed Charges,0.2,30.21,
ACTIVASE 100MG INJ,6360000267,CDM,636,RC,J2997,HCPCS,Outpatient,100,GM,26811.70,17427.61,,114.35,125,,,Fee Schedule,125% of CMS OPPS Rate,20376.89,76,,924.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,126.7,350,,,Fee Schedule,350% of BCBS fee schedule,126.7,350,,,Fee Schedule,350% of BCBS fee schedule,91.48,100,,,Fee Schedule,100% of CMS OPPS Rate,126.7,350,,,Fee Schedule,350% of BCBS PPO fee schedule,36.2,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,24130.53,90,,6876,Percent of Total Billed Charges,90% of Total Billed Charges,12065.27,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,24130.53,90,,1094.4,Percent of Total Billed Charges,90% of Total billed Charges,91.48,100,,,Fee Schedule,100% of CMS OPPS Rate,91.48,100,,,Fee Schedule,100% of CMS OPPS Rate,91.48,100,,,Fee Schedule,100% of CMS OPPS Rate,17610.57,65,,2016.152,Percent of total Billed Charges,65% of Total Billed Charges,11823.96,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,25471.12,95,,1155.2,Percent of Total Billed Charges,95% of Total Billed Charges,68.61,75,,,Fee Schedule,75% of CMS OPPS Rate,23594.3,88,,1126.4,Percent of Total Billed Charges,88% of Total Billed Charges,24130.53,90,,1094.4,Percent of Total Billed charges,90% of Total Billed Charges,36.2,25471.12,
CATHFLO ACTIVASE 1MG,6360000268,CDM,636,RC,J2997,HCPCS,Outpatient,1,GM,567.79,369.06,,114.35,125,,,Fee Schedule,125% of CMS OPPS Rate,431.52,76,,1050.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,126.7,350,,,Fee Schedule,350% of BCBS fee schedule,126.7,350,,,Fee Schedule,350% of BCBS fee schedule,91.48,100,,,Fee Schedule,100% of CMS OPPS Rate,126.7,350,,,Fee Schedule,350% of BCBS PPO fee schedule,36.2,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,511.01,90,,204.808,Percent of Total Billed Charges,90% of Total Billed Charges,255.51,45,,1126.408,Percent of Total Billed Charges,45% of Total Billed Charges,511.01,90,,1244.16,Percent of Total Billed Charges,90% of Total billed Charges,91.48,100,,,Fee Schedule,100% of CMS OPPS Rate,91.48,100,,,Fee Schedule,100% of CMS OPPS Rate,91.48,100,,,Fee Schedule,100% of CMS OPPS Rate,552.02,65,,728,Percent of total Billed Charges,65% of Total Billed Charges,250.4,44.1,,1103.872,Percent of Total Billed Charges,44.1% of Total Billed Charges,539.4,95,,1313.28,Percent of Total Billed Charges,95% of Total Billed Charges,68.61,75,,,Fee Schedule,75% of CMS OPPS Rate,499.66,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,511.01,90,,1244.16,Percent of Total Billed charges,90% of Total Billed Charges,36.2,552.02,
ACTIVASE 50MG INJ,6360000269,CDM,636,RC,J2997,HCPCS,Outpatient,50,GM,13405.30,8713.45,,114.35,125,,,Fee Schedule,125% of CMS OPPS Rate,10188.03,76,,972.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,126.7,350,,,Fee Schedule,350% of BCBS fee schedule,126.7,350,,,Fee Schedule,350% of BCBS fee schedule,91.48,100,,,Fee Schedule,100% of CMS OPPS Rate,126.7,350,,,Fee Schedule,350% of BCBS PPO fee schedule,36.2,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,12064.77,90,,188.448,Percent of Total Billed Charges,90% of Total Billed Charges,6032.39,45,,154.08,Percent of Total Billed Charges,45% of Total Billed Charges,12064.77,90,,1152,Percent of Total Billed Charges,90% of Total billed Charges,91.48,100,,,Fee Schedule,100% of CMS OPPS Rate,91.48,100,,,Fee Schedule,100% of CMS OPPS Rate,91.48,100,,,Fee Schedule,100% of CMS OPPS Rate,8896.41,65,,333.32,Percent of total Billed Charges,65% of Total Billed Charges,5911.74,44.1,,151,Percent of Total Billed Charges,44.1% of Total Billed Charges,12735.04,95,,1216,Percent of Total Billed Charges,95% of Total Billed Charges,68.61,75,,,Fee Schedule,75% of CMS OPPS Rate,11796.66,88,,2202.744,Percent of Total Billed Charges,88% of Total Billed Charges,12064.77,90,,1152,Percent of Total Billed charges,90% of Total Billed Charges,36.2,12735.04,
SUBLIMAZE 2ML INJ,6360000270,CDM,636,RC,J3010,HCPCS,Outpatient,2,ML,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,1050.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.37,350,,,Fee Schedule,350% of BCBS fee schedule,1.37,350,,,Fee Schedule,350% of BCBS fee schedule,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.37,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.39,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5.96,90,,677.112,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,2092.76,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,1244.16,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,274.56,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,2050.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,1313.28,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,301.312,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,1244.16,Percent of Total Billed charges,90% of Total Billed Charges,0.39,6.62,
FENTANYL 250MCG/5ML INJ,6360000271,CDM,636,RC,J3010,HCPCS,Outpatient,250,GM,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,972.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.37,350,,,Fee Schedule,350% of BCBS fee schedule,1.37,350,,,Fee Schedule,350% of BCBS fee schedule,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.37,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.39,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,4.96,90,,188.448,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,533.344,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,1152,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,934.44,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,522.68,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,1216,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,4092.512,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,1152,Percent of Total Billed charges,90% of Total Billed Charges,0.39,5.51,
TNKASE 50MG KIT,6360000272,CDM,636,RC,J3101,HCPCS,Outpatient,50,GM,17594.80,11436.62,,203.03,125,,,Fee Schedule,125% of CMS OPPS Rate,13372.05,76,,972.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,376.46,350,,,Fee Schedule,350% of BCBS fee schedule,376.46,350,,,Fee Schedule,350% of BCBS fee schedule,162.43,100,,,Fee Schedule,100% of CMS OPPS Rate,376.46,350,,,Fee Schedule,350% of BCBS PPO fee schedule,107.56,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,15835.32,90,,463.576,Percent of Total Billed Charges,90% of Total Billed Charges,7917.66,45,,3438,Percent of Total Billed Charges,45% of Total Billed Charges,15835.32,90,,1152,Percent of Total Billed Charges,90% of Total billed Charges,162.43,100,,,Fee Schedule,100% of CMS OPPS Rate,162.43,100,,,Fee Schedule,100% of CMS OPPS Rate,162.43,100,,,Fee Schedule,100% of CMS OPPS Rate,11761.48,65,,1245.12,Percent of total Billed Charges,65% of Total Billed Charges,7759.31,44.1,,3369.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,16715.06,95,,1216,Percent of Total Billed Charges,95% of Total Billed Charges,121.82,75,,,Fee Schedule,75% of CMS OPPS Rate,15483.42,88,,1042.984,Percent of Total Billed Charges,88% of Total Billed Charges,15835.32,90,,1152,Percent of Total Billed charges,90% of Total Billed Charges,107.56,16715.06,
BRETHINE 1MG INJ,6360000273,CDM,636,RC,J3105,HCPCS,Outpatient,1,GM,99.23,64.50,,99.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,75.41,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,9.66,350,,,Fee Schedule,350% of BCBS fee schedule,9.66,350,,,Fee Schedule,350% of BCBS fee schedule,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.66,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.76,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,89.31,90,,927.16,Percent of Total Billed Charges,90% of Total Billed Charges,44.65,45,,102.4,Percent of Total Billed Charges,45% of Total Billed Charges,89.31,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.5,65,,1110.816,Percent of total Billed Charges,65% of Total Billed Charges,43.76,44.1,,100.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,94.27,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,99.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.32,88,,6723.2,Percent of Total Billed Charges,88% of Total Billed Charges,89.31,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,2.76,99.23,
AGGRASTAT 12.5MG/50M INJ,6360000274,CDM,636,RC,J3246,HCPCS,Outpatient,12.5,GM,2841.14,1846.74,,2841.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2159.27,76,,1902.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36.26,350,,,Fee Schedule,350% of BCBS fee schedule,36.26,350,,,Fee Schedule,350% of BCBS fee schedule,2841.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.26,350,,,Fee Schedule,350% of BCBS PPO fee schedule,10.36,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,2557.03,90,,558.832,Percent of Total Billed Charges,90% of Total Billed Charges,1278.51,45,,94.224,Percent of Total Billed Charges,45% of Total Billed Charges,2557.03,90,,2252.808,Percent of Total Billed Charges,90% of Total billed Charges,2841.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2841.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2841.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1846.74,65,,1110.816,Percent of total Billed Charges,65% of Total Billed Charges,1252.94,44.1,,92.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,2699.08,95,,2377.968,Percent of Total Billed Charges,95% of Total Billed Charges,2841.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2500.2,88,,200.256,Percent of Total Billed Charges,88% of Total Billed Charges,2557.03,90,,2252.808,Percent of Total Billed charges,90% of Total Billed Charges,10.36,2841.14,
NEBCIN 80MG INJ,6360000276,CDM,636,RC,J3260,HCPCS,Outpatient,80,GM,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,260.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.03,350,,,Fee Schedule,350% of BCBS fee schedule,4.03,350,,,Fee Schedule,350% of BCBS fee schedule,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.03,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.15,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,18.86,90,,505.44,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,338.552,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,308.16,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,401.04,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,331.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,325.28,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,184.256,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,308.16,Percent of Total Billed charges,90% of Total Billed Charges,1.15,20.95,
KENALOG 40MG/10ML INJ,6360000277,CDM,636,RC,J3301,HCPCS,Outpatient,40,GM,36.38,23.65,,36.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,27.65,76,,3534.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.99,350,,,Fee Schedule,350% of BCBS fee schedule,5.99,350,,,Fee Schedule,350% of BCBS fee schedule,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.99,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.71,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,32.74,90,,505.44,Percent of Total Billed Charges,90% of Total Billed Charges,16.37,45,,94.224,Percent of Total Billed Charges,45% of Total Billed Charges,32.74,90,,4185.528,Percent of Total Billed Charges,90% of Total billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.65,65,,401.04,Percent of total Billed Charges,65% of Total Billed Charges,16.04,44.1,,92.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,34.56,95,,4418.056,Percent of Total Billed Charges,95% of Total Billed Charges,36.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.01,88,,662.064,Percent of Total Billed Charges,88% of Total Billed Charges,32.74,90,,4185.528,Percent of Total Billed charges,90% of Total Billed Charges,1.71,36.38,
KENALOG40 40MG/ML INJ,6360000278,CDM,636,RC,J3301,HCPCS,Outpatient,40,GM,48.51,31.53,,48.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.87,76,,900.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.99,350,,,Fee Schedule,350% of BCBS fee schedule,5.99,350,,,Fee Schedule,350% of BCBS fee schedule,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.99,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.71,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,43.66,90,,1466.848,Percent of Total Billed Charges,90% of Total Billed Charges,21.83,45,,231.792,Percent of Total Billed Charges,45% of Total Billed Charges,43.66,90,,1066.688,Percent of Total Billed Charges,90% of Total billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.53,65,,832,Percent of total Billed Charges,65% of Total Billed Charges,21.39,44.1,,227.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.08,95,,1125.944,Percent of Total Billed Charges,95% of Total Billed Charges,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.69,88,,184.256,Percent of Total Billed Charges,88% of Total Billed Charges,43.66,90,,1066.688,Percent of Total Billed charges,90% of Total Billed Charges,1.71,48.51,
VALIUM 10MG/2ML INJ,6360000279,CDM,636,RC,J3360,HCPCS,Outpatient,10,GM,47.41,30.82,,47.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,36.03,76,,5806.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.95,350,,,Fee Schedule,350% of BCBS fee schedule,7.95,350,,,Fee Schedule,350% of BCBS fee schedule,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.95,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.27,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,42.67,90,,1825.744,Percent of Total Billed Charges,90% of Total Billed Charges,21.33,45,,463.576,Percent of Total Billed Charges,45% of Total Billed Charges,42.67,90,,6876,Percent of Total Billed Charges,90% of Total billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.82,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,20.91,44.1,,454.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,45.04,95,,7258,Percent of Total Billed Charges,95% of Total Billed Charges,47.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.72,88,,453.28,Percent of Total Billed Charges,88% of Total Billed Charges,42.67,90,,6876,Percent of Total Billed charges,90% of Total Billed Charges,2.27,47.41,
VALIUM 5MG/ML,6360000280,CDM,636,RC,J3360,HCPCS,Outpatient,5,GM,131.75,85.64,,131.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,100.13,76,,172.944,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.95,350,,,Fee Schedule,350% of BCBS fee schedule,7.95,350,,,Fee Schedule,350% of BCBS fee schedule,131.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.95,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.27,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,118.58,90,,1445.224,Percent of Total Billed Charges,90% of Total Billed Charges,59.29,45,,279.416,Percent of Total Billed Charges,45% of Total Billed Charges,118.58,90,,204.808,Percent of Total Billed Charges,90% of Total billed Charges,131.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.64,65,,315.64,Percent of total Billed Charges,65% of Total Billed Charges,58.1,44.1,,273.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,125.16,95,,216.184,Percent of Total Billed Charges,95% of Total Billed Charges,131.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.94,88,,906.552,Percent of Total Billed Charges,88% of Total Billed Charges,118.58,90,,204.808,Percent of Total Billed charges,90% of Total Billed Charges,2.27,131.75,
VANCOMYCIN IN NS 750MG,6360000281,CDM,636,RC,J3370,HCPCS,Outpatient,750,GM,51.50,33.48,,51.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,39.14,76,,159.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.65,350,,,Fee Schedule,350% of BCBS fee schedule,15.65,350,,,Fee Schedule,350% of BCBS fee schedule,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.65,350,,,Fee Schedule,350% of BCBS PPO fee schedule,4.47,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,46.35,90,,327.4,Percent of Total Billed Charges,90% of Total Billed Charges,23.18,45,,252.72,Percent of Total Billed Charges,45% of Total Billed Charges,46.35,90,,188.448,Percent of Total Billed Charges,90% of Total billed Charges,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.48,65,,182.312,Percent of total Billed Charges,65% of Total Billed Charges,22.71,44.1,,247.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.93,95,,198.912,Percent of Total Billed Charges,95% of Total Billed Charges,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.32,88,,546.416,Percent of Total Billed Charges,88% of Total Billed Charges,46.35,90,,188.448,Percent of Total Billed charges,90% of Total Billed Charges,4.47,51.5,
VANCOMYCIN IN NS 1G,6360000282,CDM,636,RC,J3370,HCPCS,Outpatient,,,51.50,33.48,,51.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,39.14,76,,571.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.65,350,,,Fee Schedule,350% of BCBS fee schedule,15.65,350,,,Fee Schedule,350% of BCBS fee schedule,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.65,350,,,Fee Schedule,350% of BCBS PPO fee schedule,4.47,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,46.35,90,,1825.744,Percent of Total Billed Charges,90% of Total Billed Charges,23.18,45,,252.72,Percent of Total Billed Charges,45% of Total Billed Charges,46.35,90,,677.112,Percent of Total Billed Charges,90% of Total billed Charges,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.48,65,,182.312,Percent of total Billed Charges,65% of Total Billed Charges,22.71,44.1,,247.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,48.93,95,,714.728,Percent of Total Billed Charges,95% of Total Billed Charges,51.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.32,88,,494.208,Percent of Total Billed Charges,88% of Total Billed Charges,46.35,90,,677.112,Percent of Total Billed charges,90% of Total Billed Charges,4.47,51.5,
VANCOMYCIN 1G INJ,6360000283,CDM,636,RC,J3370,HCPCS,Outpatient,,,34.18,22.22,,34.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.98,76,,159.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.65,350,,,Fee Schedule,350% of BCBS fee schedule,15.65,350,,,Fee Schedule,350% of BCBS fee schedule,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.65,350,,,Fee Schedule,350% of BCBS PPO fee schedule,4.47,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,30.76,90,,461.2,Percent of Total Billed Charges,90% of Total Billed Charges,15.38,45,,733.424,Percent of Total Billed Charges,45% of Total Billed Charges,30.76,90,,188.448,Percent of Total Billed Charges,90% of Total billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.22,65,,734.76,Percent of total Billed Charges,65% of Total Billed Charges,15.07,44.1,,718.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.47,95,,198.912,Percent of Total Billed Charges,95% of Total Billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.08,88,,494.208,Percent of Total Billed Charges,88% of Total Billed Charges,30.76,90,,188.448,Percent of Total Billed charges,90% of Total Billed Charges,4.47,34.18,
VANCOMYCIN 1GRAM INJ,6360000284,CDM,636,RC,J3370,HCPCS,Outpatient,,,29.77,19.35,,29.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.63,76,,391.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.65,350,,,Fee Schedule,350% of BCBS fee schedule,15.65,350,,,Fee Schedule,350% of BCBS fee schedule,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.65,350,,,Fee Schedule,350% of BCBS PPO fee schedule,4.47,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,26.79,90,,1915.2,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,45,,912.872,Percent of Total Billed Charges,45% of Total Billed Charges,26.79,90,,463.576,Percent of Total Billed Charges,90% of Total billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.35,65,,892.648,Percent of total Billed Charges,65% of Total Billed Charges,13.13,44.1,,894.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.28,95,,489.336,Percent of Total Billed Charges,95% of Total Billed Charges,29.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,88,,1434.256,Percent of Total Billed Charges,88% of Total Billed Charges,26.79,90,,463.576,Percent of Total Billed charges,90% of Total Billed Charges,4.47,29.77,
VANCOMYCIN 500MG VIAL,6360000285,CDM,636,RC,J3370,HCPCS,Outpatient,500,GM,18.74,12.18,,18.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.24,76,,782.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.65,350,,,Fee Schedule,350% of BCBS fee schedule,15.65,350,,,Fee Schedule,350% of BCBS fee schedule,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.65,350,,,Fee Schedule,350% of BCBS PPO fee schedule,4.47,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,16.87,90,,1453.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.43,45,,722.608,Percent of Total Billed Charges,45% of Total Billed Charges,16.87,90,,927.16,Percent of Total Billed Charges,90% of Total billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.18,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,8.26,44.1,,708.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.8,95,,978.664,Percent of Total Billed Charges,95% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,88,,1785.168,Percent of Total Billed Charges,88% of Total Billed Charges,16.87,90,,927.16,Percent of Total Billed charges,90% of Total Billed Charges,4.47,18.74,
VISTARIL 100MG/2CC INJ,6360000286,CDM,636,RC,J3410,HCPCS,Outpatient,100,GM,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,471.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.72,350,,,Fee Schedule,350% of BCBS fee schedule,1.72,350,,,Fee Schedule,350% of BCBS fee schedule,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.72,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.49,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,18.86,90,,1521.712,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,163.696,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,558.832,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,1381.112,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,160.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,589.88,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,1413.104,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,558.832,Percent of Total Billed charges,90% of Total Billed Charges,0.49,20.95,
VISTARIL 50MG/1CC INJ,6360000287,CDM,636,RC,J3410,HCPCS,Outpatient,50,GM,20.95,13.62,,20.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.92,76,,426.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.72,350,,,Fee Schedule,350% of BCBS fee schedule,1.72,350,,,Fee Schedule,350% of BCBS fee schedule,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.72,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.49,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,18.86,90,,1704.96,Percent of Total Billed Charges,90% of Total Billed Charges,9.43,45,,912.872,Percent of Total Billed Charges,45% of Total Billed Charges,18.86,90,,505.44,Percent of Total Billed Charges,90% of Total billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.62,65,,1381.112,Percent of total Billed Charges,65% of Total Billed Charges,9.24,44.1,,894.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.9,95,,533.52,Percent of Total Billed Charges,95% of Total Billed Charges,20.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.44,88,,320.12,Percent of Total Billed Charges,88% of Total Billed Charges,18.86,90,,505.44,Percent of Total Billed charges,90% of Total Billed Charges,0.49,20.95,
THIAMINE 100MG INJ,6360000288,CDM,636,RC,J3411,HCPCS,Outpatient,100,GM,19.85,12.90,,19.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.09,76,,426.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.75,350,,,Fee Schedule,350% of BCBS fee schedule,10.75,350,,,Fee Schedule,350% of BCBS fee schedule,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,350,,,Fee Schedule,350% of BCBS PPO fee schedule,3.07,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,17.87,90,,1627.296,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,45,,230.6,Percent of Total Billed Charges,45% of Total Billed Charges,17.87,90,,505.44,Percent of Total Billed Charges,90% of Total billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.9,65,,1181.568,Percent of total Billed Charges,65% of Total Billed Charges,8.75,44.1,,225.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.86,95,,533.52,Percent of Total Billed Charges,95% of Total Billed Charges,19.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.47,88,,1785.168,Percent of Total Billed Charges,88% of Total Billed Charges,17.87,90,,505.44,Percent of Total Billed charges,90% of Total Billed Charges,3.07,19.85,
B12 1000MG/ML INJ,6360000289,CDM,636,RC,J3420,HCPCS,Outpatient,1000,GM,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,1238.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15.51,350,,,Fee Schedule,350% of BCBS fee schedule,15.51,350,,,Fee Schedule,350% of BCBS fee schedule,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.51,350,,,Fee Schedule,350% of BCBS PPO fee schedule,4.43,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5.96,90,,1056.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,957.6,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,1466.848,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,1461.72,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,938.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,1548.344,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,450.944,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,1466.848,Percent of Total Billed charges,90% of Total Billed Charges,2.92,15.51,
AQUA MEPHYTON 1MG 1CC INJ,6360000290,CDM,636,RC,J3430,HCPCS,Outpatient,1,GM,34.18,22.22,,34.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,25.98,76,,1541.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.51,350,,,Fee Schedule,350% of BCBS fee schedule,13.51,350,,,Fee Schedule,350% of BCBS fee schedule,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.51,350,,,Fee Schedule,350% of BCBS PPO fee schedule,3.86,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,30.76,90,,1404.72,Percent of Total Billed Charges,90% of Total Billed Charges,15.38,45,,726.84,Percent of Total Billed Charges,45% of Total Billed Charges,30.76,90,,1825.744,Percent of Total Billed Charges,90% of Total billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.22,65,,181.736,Percent of total Billed Charges,65% of Total Billed Charges,15.07,44.1,,712.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.47,95,,1927.168,Percent of Total Billed Charges,95% of Total Billed Charges,34.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.08,88,,1872.64,Percent of Total Billed Charges,88% of Total Billed Charges,30.76,90,,1825.744,Percent of Total Billed charges,90% of Total Billed Charges,3.86,34.18,
AQUA MEPHY 10MG 1CC INJ,6360000291,CDM,636,RC,J3430,HCPCS,Outpatient,10,GM,73.87,48.02,,73.87,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,56.14,76,,1220.408,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.51,350,,,Fee Schedule,350% of BCBS fee schedule,13.51,350,,,Fee Schedule,350% of BCBS fee schedule,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.51,350,,,Fee Schedule,350% of BCBS PPO fee schedule,3.86,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,66.48,90,,1302.216,Percent of Total Billed Charges,90% of Total Billed Charges,33.24,45,,760.856,Percent of Total Billed Charges,45% of Total Billed Charges,66.48,90,,1445.224,Percent of Total Billed Charges,90% of Total billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.02,65,,300.408,Percent of total Billed Charges,65% of Total Billed Charges,32.58,44.1,,745.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,70.18,95,,1525.512,Percent of Total Billed Charges,95% of Total Billed Charges,73.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.01,88,,1421.376,Percent of Total Billed Charges,88% of Total Billed Charges,66.48,90,,1445.224,Percent of Total Billed charges,90% of Total Billed Charges,3.86,73.87,
MAG. SULFATE 40G/1000 INJ,6360000292,CDM,636,RC,J3475,HCPCS,Outpatient,,,52.92,34.40,,52.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,40.22,76,,276.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.25,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.07,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,47.63,90,,1302.216,Percent of Total Billed Charges,90% of Total Billed Charges,23.81,45,,852.48,Percent of Total Billed Charges,45% of Total Billed Charges,47.63,90,,327.4,Percent of Total Billed Charges,90% of Total billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.4,65,,3264.376,Percent of total Billed Charges,65% of Total Billed Charges,23.34,44.1,,835.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,50.27,95,,345.584,Percent of Total Billed Charges,95% of Total Billed Charges,52.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.57,88,,1487.896,Percent of Total Billed Charges,88% of Total Billed Charges,47.63,90,,327.4,Percent of Total Billed charges,90% of Total Billed Charges,0.07,52.92,
MAG SULFATE 5GM/10ML INJ,6360000293,CDM,636,RC,J3475,HCPCS,Outpatient,5,gm,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,1541.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.25,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.07,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,6.95,90,,1537.656,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,813.648,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,1825.744,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,144.376,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,797.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,1927.168,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,1667.072,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,1825.744,Percent of Total Billed charges,90% of Total Billed Charges,0.07,7.72,
MAG SULFATE 4.06M/ML INJ,6360000294,CDM,636,RC,J3475,HCPCS,Outpatient,1,ML,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,389.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.25,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.07,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,4.96,90,,1537.656,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,528.12,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,461.2,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,236.456,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,517.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,486.816,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.85,88,,1591.128,Percent of Total Billed Charges,88% of Total Billed Charges,4.96,90,,461.2,Percent of Total Billed charges,90% of Total Billed Charges,0.07,5.51,
MAG SULF IN D5W 1GM/100ML,6360000295,CDM,636,RC,J3475,HCPCS,Outpatient,1,gm,41.90,27.24,,41.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,31.84,76,,1617.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.25,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.07,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,37.71,90,,1875.976,Percent of Total Billed Charges,90% of Total Billed Charges,18.86,45,,702.36,Percent of Total Billed Charges,45% of Total Billed Charges,37.71,90,,1915.2,Percent of Total Billed Charges,90% of Total billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.24,65,,836.68,Percent of total Billed Charges,65% of Total Billed Charges,18.48,44.1,,688.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,39.81,95,,2021.6,Percent of Total Billed Charges,95% of Total Billed Charges,41.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.87,88,,1032.768,Percent of Total Billed Charges,88% of Total Billed Charges,37.71,90,,1915.2,Percent of Total Billed charges,90% of Total Billed Charges,0.07,41.9,
MAGNESIUM 2G/50ML INJ,6360000296,CDM,636,RC,J3475,HCPCS,Outpatient,50,ML,38.59,25.08,,38.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,29.33,76,,1227.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.25,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.07,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,34.73,90,,288.152,Percent of Total Billed Charges,90% of Total Billed Charges,17.37,45,,651.104,Percent of Total Billed Charges,45% of Total Billed Charges,34.73,90,,1453.68,Percent of Total Billed Charges,90% of Total billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.08,65,,801.24,Percent of total Billed Charges,65% of Total Billed Charges,17.02,44.1,,638.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,36.66,95,,1534.44,Percent of Total Billed Charges,95% of Total Billed Charges,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.96,88,,1373.504,Percent of Total Billed Charges,88% of Total Billed Charges,34.73,90,,1453.68,Percent of Total Billed charges,90% of Total Billed Charges,0.07,38.59,
KCL 40MEQ/20ML INJ,6360000297,CDM,636,RC,J3480,HCPCS,Outpatient,20,ML,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,1285,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.14,350,,,Fee Schedule,350% of BCBS fee schedule,0.14,350,,,Fee Schedule,350% of BCBS fee schedule,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.14,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.04,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5.96,90,,1404.72,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,651.104,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,1521.712,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,782.6,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,638.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,1606.256,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,1273.272,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,1521.712,Percent of Total Billed charges,90% of Total Billed Charges,0.04,6.62,
KCL 20MEQ/10ML VIAL INJ,6360000298,CDM,636,RC,J3480,HCPCS,Outpatient,10,ML,6.62,4.30,,6.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.03,76,,1439.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.14,350,,,Fee Schedule,350% of BCBS fee schedule,0.14,350,,,Fee Schedule,350% of BCBS fee schedule,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.14,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.04,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5.96,90,,572.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,768.824,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,1704.96,Percent of Total Billed Charges,90% of Total billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.3,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,753.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,1799.68,Percent of Total Billed Charges,95% of Total Billed Charges,6.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.83,88,,1273.272,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,1704.96,Percent of Total Billed charges,90% of Total Billed Charges,0.04,6.62,
D5NS W/KCL 20MEQ 1000ML,6360000299,CDM,636,RC,J3480,HCPCS,Outpatient,1000,ML,47.00,30.55,,47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.72,76,,1374.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.14,350,,,Fee Schedule,350% of BCBS fee schedule,0.14,350,,,Fee Schedule,350% of BCBS fee schedule,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.14,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.04,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,42.3,90,,405.112,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,45,,768.824,Percent of Total Billed Charges,45% of Total Billed Charges,42.3,90,,1627.296,Percent of Total Billed Charges,90% of Total billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.55,65,,1123.2,Percent of total Billed Charges,65% of Total Billed Charges,20.73,44.1,,753.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.65,95,,1717.696,Percent of Total Billed Charges,95% of Total Billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.36,88,,1503.48,Percent of Total Billed Charges,88% of Total Billed Charges,42.3,90,,1627.296,Percent of Total Billed charges,90% of Total Billed Charges,0.04,47,
KCL 10MEQ/100ML PREM,6360000300,CDM,636,RC,J3480,HCPCS,Outpatient,100,ML,78.28,50.88,,78.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,59.49,76,,891.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.14,350,,,Fee Schedule,350% of BCBS fee schedule,0.14,350,,,Fee Schedule,350% of BCBS fee schedule,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.14,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.04,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,70.45,90,,741.416,Percent of Total Billed Charges,90% of Total Billed Charges,35.23,45,,937.984,Percent of Total Billed Charges,45% of Total Billed Charges,70.45,90,,1056.24,Percent of Total Billed Charges,90% of Total billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.88,65,,1087.32,Percent of total Billed Charges,65% of Total Billed Charges,34.52,44.1,,919.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,74.37,95,,1114.92,Percent of Total Billed Charges,95% of Total Billed Charges,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.89,88,,1503.48,Percent of Total Billed Charges,88% of Total Billed Charges,70.45,90,,1056.24,Percent of Total Billed charges,90% of Total Billed Charges,0.04,78.28,
KCL 20MEQ/100ML PREM,6360000301,CDM,636,RC,J3480,HCPCS,Outpatient,100,ML,16.54,10.75,,16.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.57,76,,1186.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.14,350,,,Fee Schedule,350% of BCBS fee schedule,0.14,350,,,Fee Schedule,350% of BCBS fee schedule,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.14,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.04,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,14.89,90,,2656.08,Percent of Total Billed Charges,90% of Total Billed Charges,7.44,45,,144.072,Percent of Total Billed Charges,45% of Total Billed Charges,14.89,90,,1404.72,Percent of Total Billed Charges,90% of Total billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.75,65,,2016.152,Percent of total Billed Charges,65% of Total Billed Charges,7.29,44.1,,141.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.71,95,,1482.76,Percent of Total Billed Charges,95% of Total Billed Charges,16.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.56,88,,1834.288,Percent of Total Billed Charges,88% of Total Billed Charges,14.89,90,,1404.72,Percent of Total Billed charges,90% of Total Billed Charges,0.04,16.54,
AZITHROMYCIN 100MG/5ML SUSP,6360000303,CDM,636,RC,J3490,HCPCS,Outpatient,100,GM,29.75,19.34,,29.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.61,76,,1099.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.42,72,,17.136,Percent of Total Billed Charges,72% of Total Billed Charges,22.31,75,,17.848,Percent of Total Billed charges,75% of Total Billed Charges,29.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.42,72,,17.136,Percent of Total Billed Charges,72% of Total Billed Charges,17.85,60,,14.28,Percent of Total Billed Charges,60% of Total Billed Charges,26.78,90,,823.68,Percent of Total Billed Charges,90% of Total Billed Charges,13.39,45,,286.4,Percent of Total Billed Charges,45% of Total Billed Charges,26.78,90,,1302.216,Percent of Total Billed Charges,90% of Total billed Charges,29.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.34,65,,876.72,Percent of total Billed Charges,65% of Total Billed Charges,13.12,44.1,,280.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.26,95,,1374.56,Percent of Total Billed Charges,95% of Total Billed Charges,29.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.18,88,,1373.504,Percent of Total Billed Charges,88% of Total Billed Charges,26.78,90,,1302.216,Percent of Total Billed charges,90% of Total Billed Charges,13.12,29.75,
BUPIVACAINE 0.25% 10ML,6360000308,CDM,636,RC,J3490,HCPCS,Outpatient,10,ML,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,1298.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.64,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,9,75,,7.2,Percent of Total Billed charges,75% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.64,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,7.2,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,10.8,90,,1761.592,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,202.56,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,1537.656,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,289.64,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,198.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,1623.08,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,560.064,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,1537.656,Percent of Total Billed charges,90% of Total Billed Charges,5.29,12,
BUPIVACAINE 0.5% 10ML,6360000309,CDM,636,RC,J0665,HCPCS,Outpatient,10,ML,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,1298.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,8.64,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,9,75,,7.2,Percent of Total Billed charges,75% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.64,72,,6.912,Percent of Total Billed Charges,72% of Total Billed Charges,7.2,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,10.8,90,,1225.44,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,370.704,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,1537.656,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,289.64,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,363.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,1623.08,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,396.112,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,1537.656,Percent of Total Billed charges,90% of Total Billed Charges,5.29,12,
CARDENE 25MG/10ML INJECTION,6360000311,CDM,636,RC,J3490,HCPCS,Outpatient,25,GM,476.28,309.58,,476.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,361.97,76,,1584.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,342.92,72,,274.336,Percent of Total Billed Charges,72% of Total Billed Charges,357.21,75,,285.768,Percent of Total Billed charges,75% of Total Billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.92,72,,274.336,Percent of Total Billed Charges,72% of Total Billed Charges,285.77,60,,228.616,Percent of Total Billed Charges,60% of Total Billed Charges,428.65,90,,1289.92,Percent of Total Billed Charges,90% of Total Billed Charges,214.33,45,,1328.04,Percent of Total Billed Charges,45% of Total Billed Charges,428.65,90,,1875.976,Percent of Total Billed Charges,90% of Total billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.58,65,,98.8,Percent of total Billed Charges,65% of Total Billed Charges,210.04,44.1,,1301.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,452.47,95,,1980.192,Percent of Total Billed Charges,95% of Total Billed Charges,476.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.13,88,,724.936,Percent of Total Billed Charges,88% of Total Billed Charges,428.65,90,,1875.976,Percent of Total Billed charges,90% of Total Billed Charges,210.04,476.28,
ANTIBIOTIC OPHTH MIX INJ,6360000312,CDM,636,RC,J3490,HCPCS,Outpatient,,,219.40,142.61,,219.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,166.74,76,,243.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,157.97,72,,126.376,Percent of Total Billed Charges,72% of Total Billed Charges,164.55,75,,131.64,Percent of Total Billed charges,75% of Total Billed Charges,219.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.97,72,,126.376,Percent of Total Billed Charges,72% of Total Billed Charges,131.64,60,,105.312,Percent of Total Billed Charges,60% of Total Billed Charges,197.46,90,,648,Percent of Total Billed Charges,90% of Total Billed Charges,98.73,45,,241.56,Percent of Total Billed Charges,45% of Total Billed Charges,197.46,90,,288.152,Percent of Total Billed Charges,90% of Total billed Charges,219.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.61,65,,58.76,Percent of total Billed Charges,65% of Total Billed Charges,96.76,44.1,,236.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,208.43,95,,304.16,Percent of Total Billed Charges,95% of Total Billed Charges,219.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.07,88,,2597.056,Percent of Total Billed Charges,88% of Total Billed Charges,197.46,90,,288.152,Percent of Total Billed charges,90% of Total Billed Charges,96.76,219.4,
VASOTEC 1.25MG/ML INJ,6360000313,CDM,636,RC,J3490,HCPCS,Outpatient,1.25,GM,18.74,12.18,,18.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.24,76,,1186.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.49,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,14.06,75,,11.248,Percent of Total Billed charges,75% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.49,72,,10.792,Percent of Total Billed Charges,72% of Total Billed Charges,11.24,60,,8.992,Percent of Total Billed Charges,60% of Total Billed Charges,16.87,90,,681.88,Percent of Total Billed Charges,90% of Total Billed Charges,8.43,45,,411.84,Percent of Total Billed Charges,45% of Total Billed Charges,16.87,90,,1404.72,Percent of Total Billed Charges,90% of Total billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.18,65,,71.76,Percent of total Billed Charges,65% of Total Billed Charges,8.26,44.1,,403.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.8,95,,1482.76,Percent of Total Billed Charges,95% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,88,,472.384,Percent of Total Billed Charges,88% of Total Billed Charges,16.87,90,,1404.72,Percent of Total Billed charges,90% of Total Billed Charges,8.26,18.74,
CARDENE 40MG/200ML PREMIX,6360000315,CDM,636,RC,J3490,HCPCS,Outpatient,40,GM,1282.21,833.44,,1282.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,974.48,76,,483.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,923.19,72,,738.552,Percent of Total Billed Charges,72% of Total Billed Charges,961.66,75,,769.328,Percent of Total Billed charges,75% of Total Billed Charges,1282.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.19,72,,738.552,Percent of Total Billed Charges,72% of Total Billed Charges,769.33,60,,615.464,Percent of Total Billed Charges,60% of Total Billed Charges,1153.99,90,,353.752,Percent of Total Billed Charges,90% of Total Billed Charges,576.99,45,,880.792,Percent of Total Billed Charges,45% of Total Billed Charges,1153.99,90,,572.8,Percent of Total Billed Charges,90% of Total billed Charges,1282.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1282.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1282.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,833.44,65,,691.6,Percent of total Billed Charges,65% of Total Billed Charges,565.45,44.1,,863.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,1218.1,95,,604.616,Percent of Total Billed Charges,95% of Total Billed Charges,1282.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1128.34,88,,805.376,Percent of Total Billed Charges,88% of Total Billed Charges,1153.99,90,,572.8,Percent of Total Billed charges,90% of Total Billed Charges,565.45,1282.21,
VIBRAMYCIN 100MG INJ,6360000316,CDM,636,RC,J3490,HCPCS,Outpatient,100,GM,84.89,55.18,,84.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,64.52,76,,342.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.12,72,,48.896,Percent of Total Billed Charges,72% of Total Billed Charges,63.67,75,,50.936,Percent of Total Billed charges,75% of Total Billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.12,72,,48.896,Percent of Total Billed Charges,72% of Total Billed Charges,50.93,60,,40.744,Percent of Total Billed Charges,60% of Total Billed Charges,76.4,90,,556.192,Percent of Total Billed Charges,90% of Total Billed Charges,38.2,45,,612.72,Percent of Total Billed Charges,45% of Total Billed Charges,76.4,90,,405.112,Percent of Total Billed Charges,90% of Total billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.18,65,,456.344,Percent of total Billed Charges,65% of Total Billed Charges,37.44,44.1,,600.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,80.65,95,,427.624,Percent of Total Billed Charges,95% of Total Billed Charges,84.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.7,88,,1722.44,Percent of Total Billed Charges,88% of Total Billed Charges,76.4,90,,405.112,Percent of Total Billed charges,90% of Total Billed Charges,37.44,84.89,
AZACTAM 1GM INJ,6360000317,CDM,636,RC,J3490,HCPCS,Outpatient,1,gm,145.53,94.59,,145.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.6,76,,626.08,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,104.78,72,,83.824,Percent of Total Billed Charges,72% of Total Billed Charges,109.15,75,,87.32,Percent of Total Billed charges,75% of Total Billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.78,72,,83.824,Percent of Total Billed Charges,72% of Total Billed Charges,87.32,60,,69.856,Percent of Total Billed Charges,60% of Total Billed Charges,130.98,90,,556.192,Percent of Total Billed Charges,90% of Total Billed Charges,65.49,45,,644.96,Percent of Total Billed Charges,45% of Total Billed Charges,130.98,90,,741.416,Percent of Total Billed Charges,90% of Total billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.59,65,,138.168,Percent of total Billed Charges,65% of Total Billed Charges,64.18,44.1,,632.064,Percent of Total Billed Charges,44.1% of Total Billed Charges,138.25,95,,782.6,Percent of Total Billed Charges,95% of Total Billed Charges,145.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.07,88,,1198.208,Percent of Total Billed Charges,88% of Total Billed Charges,130.98,90,,741.416,Percent of Total Billed charges,90% of Total Billed Charges,64.18,145.53,
VASOTEC 1.25MG/ML 2ML INJ,6360000320,CDM,636,RC,J3490,HCPCS,Outpatient,1.25,GM,23.50,15.28,,23.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,17.86,76,,407.968,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.92,72,,13.536,Percent of Total Billed Charges,72% of Total Billed Charges,17.63,75,,14.104,Percent of Total Billed charges,75% of Total Billed Charges,23.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.92,72,,13.536,Percent of Total Billed Charges,72% of Total Billed Charges,14.1,60,,11.28,Percent of Total Billed Charges,60% of Total Billed Charges,21.15,90,,1173.448,Percent of Total Billed Charges,90% of Total Billed Charges,10.58,45,,340.936,Percent of Total Billed Charges,45% of Total Billed Charges,21.15,90,,483.12,Percent of Total Billed Charges,90% of Total billed Charges,23.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.28,65,,912.496,Percent of total Billed Charges,65% of Total Billed Charges,10.36,44.1,,334.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.33,95,,509.96,Percent of Total Billed Charges,95% of Total Billed Charges,23.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.68,88,,633.6,Percent of Total Billed Charges,88% of Total Billed Charges,21.15,90,,483.12,Percent of Total Billed charges,90% of Total Billed Charges,10.36,23.5,
NITRO INJ 100MCG/ML 10ML,6360000321,CDM,636,RC,J3590,HCPCS,Outpatient,100,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,695.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.18,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,75,,2.648,Percent of Total Billed charges,75% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.18,72,,2.544,Percent of Total Billed Charges,72% of Total Billed Charges,2.65,60,,2.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.97,90,,315.136,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,176.872,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,823.68,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,912.496,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,173.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,869.44,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,666.72,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,823.68,Percent of Total Billed charges,90% of Total Billed Charges,1.94,4.41,
SODIUM CHLORIDE 1GM,6360000322,CDM,250,RC,J7030,HCPCS,Outpatient,10,gm,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,1487.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,57.86,350,,,Fee Schedule,350% of BCBS fee schedule,57.86,350,,,Fee Schedule,350% of BCBS fee schedule,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.86,350,,,Fee Schedule,350% of BCBS PPO fee schedule,16.53,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,0.99,90,,1827.304,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,278.096,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,1761.592,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,1417.888,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,272.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,1859.456,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.97,88,,345.888,Percent of Total Billed Charges,88% of Total Billed Charges,0.99,90,,1761.592,Percent of Total Billed charges,90% of Total Billed Charges,0.49,57.86,
NS 150ML IV SOL,6360000323,CDM,636,RC,J7050,HCPCS,Outpatient,150,ML,49.61,32.25,,49.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,37.7,76,,1034.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.46,350,,,Fee Schedule,350% of BCBS fee schedule,14.46,350,,,Fee Schedule,350% of BCBS fee schedule,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.46,350,,,Fee Schedule,350% of BCBS PPO fee schedule,4.13,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,,,,,Other,Not Separately Reimbursable,22.32,45,,278.096,Percent of Total Billed Charges,45% of Total Billed Charges,44.65,90,,1225.44,Percent of Total Billed Charges,90% of Total billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.25,65,,3022.88,Percent of total Billed Charges,65% of Total Billed Charges,21.88,44.1,,272.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,47.13,95,,1293.52,Percent of Total Billed Charges,95% of Total Billed Charges,49.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.66,88,,543.832,Percent of Total Billed Charges,88% of Total Billed Charges,44.65,90,,1225.44,Percent of Total Billed charges,90% of Total Billed Charges,4.13,49.61,
PARAGARD T 380A IUD,6360000324,CDM,636,RC,J7300,HCPCS,Outpatient,,,739.00,480.35,,739,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,561.64,76,,1089.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2586.5,350,,,Fee Schedule,350% of BCBS fee schedule,2586.5,350,,,Fee Schedule,350% of BCBS fee schedule,739,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2586.5,350,,,Fee Schedule,350% of BCBS PPO fee schedule,739,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,665.1,90,,2023.92,Percent of Total Billed Charges,90% of Total Billed Charges,332.55,45,,586.728,Percent of Total Billed Charges,45% of Total Billed Charges,665.1,90,,1289.92,Percent of Total Billed Charges,90% of Total billed Charges,739,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,739,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,739,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.35,65,,864.76,Percent of total Billed Charges,65% of Total Billed Charges,325.9,44.1,,574.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,702.05,95,,1361.584,Percent of Total Billed Charges,95% of Total Billed Charges,739,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,650.32,88,,543.832,Percent of Total Billed Charges,88% of Total Billed Charges,665.1,90,,1289.92,Percent of Total Billed charges,90% of Total Billed Charges,325.9,2586.5,
NEXPLANON 68MG IMPLANT,6360000325,CDM,636,RC,J7307,HCPCS,Outpatient,68,GM,847.90,551.14,,847.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,644.4,76,,547.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2967.65,350,,,Fee Schedule,350% of BCBS fee schedule,2967.65,350,,,Fee Schedule,350% of BCBS fee schedule,847.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2967.65,350,,,Fee Schedule,350% of BCBS PPO fee schedule,847.9,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,763.11,90,,1636.024,Percent of Total Billed Charges,90% of Total Billed Charges,381.56,45,,586.728,Percent of Total Billed Charges,45% of Total Billed Charges,763.11,90,,648,Percent of Total Billed Charges,90% of Total billed Charges,847.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,847.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,847.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,551.14,65,,560.56,Percent of total Billed Charges,65% of Total Billed Charges,373.92,44.1,,574.992,Percent of Total Billed Charges,44.1% of Total Billed Charges,805.51,95,,684,Percent of Total Billed Charges,95% of Total Billed Charges,847.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,746.15,88,,1147.376,Percent of Total Billed Charges,88% of Total Billed Charges,763.11,90,,648,Percent of Total Billed charges,90% of Total Billed Charges,373.92,2967.65,
SYNVISCONE 48 MG / 6 ML,6360000326,CDM,636,RC,J7325,HCPCS,Outpatient,48,GM,28.00,18.20,,11.45,125,,,Fee Schedule,125% of CMS OPPS Rate,21.28,76,,575.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,44.59,350,,,Fee Schedule,350% of BCBS fee schedule,44.59,350,,,Fee Schedule,350% of BCBS fee schedule,9.16,100,,,Fee Schedule,100% of CMS OPPS Rate,44.59,350,,,Fee Schedule,350% of BCBS PPO fee schedule,12.74,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,25.2,90,,3713.76,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,45,,157.568,Percent of Total Billed Charges,45% of Total Billed Charges,25.2,90,,681.88,Percent of Total Billed Charges,90% of Total billed Charges,9.16,100,,,Fee Schedule,100% of CMS OPPS Rate,9.16,100,,,Fee Schedule,100% of CMS OPPS Rate,9.16,100,,,Fee Schedule,100% of CMS OPPS Rate,36.52,65,,594.8,Percent of total Billed Charges,65% of Total Billed Charges,12.35,44.1,,154.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.6,95,,719.76,Percent of Total Billed Charges,95% of Total Billed Charges,6.87,75,,,Fee Schedule,75% of CMS OPPS Rate,24.64,88,,1147.376,Percent of Total Billed Charges,88% of Total Billed Charges,25.2,90,,681.88,Percent of Total Billed charges,90% of Total Billed Charges,6.87,44.59,
GEL ONE HYALURONATE (ZIMMER),6360000327,CDM,636,RC,J7326,HCPCS,Outpatient,,,4245.73,2759.72,,657.97,125,,,Fee Schedule,125% of CMS OPPS Rate,3226.75,76,,298.72,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1854.41,350,,,Fee Schedule,350% of BCBS fee schedule,1854.41,350,,,Fee Schedule,350% of BCBS fee schedule,526.38,100,,,Fee Schedule,100% of CMS OPPS Rate,1854.41,350,,,Fee Schedule,350% of BCBS PPO fee schedule,529.83,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,3821.16,90,,3713.76,Percent of Total Billed Charges,90% of Total Billed Charges,1910.58,45,,913.648,Percent of Total Billed Charges,45% of Total Billed Charges,3821.16,90,,353.752,Percent of Total Billed Charges,90% of Total billed Charges,526.38,100,,,Fee Schedule,100% of CMS OPPS Rate,526.38,100,,,Fee Schedule,100% of CMS OPPS Rate,526.38,100,,,Fee Schedule,100% of CMS OPPS Rate,3812.48,65,,560.56,Percent of total Billed Charges,65% of Total Billed Charges,1872.37,44.1,,895.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,4033.44,95,,373.4,Percent of Total Billed Charges,95% of Total Billed Charges,394.78,75,,,Fee Schedule,75% of CMS OPPS Rate,3736.24,88,,308.136,Percent of Total Billed Charges,88% of Total Billed Charges,3821.16,90,,353.752,Percent of Total Billed charges,90% of Total Billed Charges,394.78,4033.44,
PROGRAF 1MG CAPSULE,6360000329,CDM,636,RC,J7507,HCPCS,Outpatient,1,GM,18.74,12.18,,18.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,14.24,76,,469.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.95,350,,,Fee Schedule,350% of BCBS fee schedule,0.95,350,,,Fee Schedule,350% of BCBS fee schedule,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.95,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.27,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,16.87,90,,4648.496,Percent of Total Billed Charges,90% of Total Billed Charges,8.43,45,,1011.96,Percent of Total Billed Charges,45% of Total Billed Charges,16.87,90,,556.192,Percent of Total Billed Charges,90% of Total billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.18,65,,1871.56,Percent of total Billed Charges,65% of Total Billed Charges,8.26,44.1,,991.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,17.8,95,,587.096,Percent of Total Billed Charges,95% of Total Billed Charges,18.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,88,,3631.232,Percent of Total Billed Charges,88% of Total Billed Charges,16.87,90,,556.192,Percent of Total Billed charges,90% of Total Billed Charges,0.27,18.74,
MEDROL 4MG TAB,6360000330,CDM,636,RC,J7509,HCPCS,Outpatient,4,GM,7.72,5.02,,7.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5.87,76,,990.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.16,350,,,Fee Schedule,350% of BCBS fee schedule,1.16,350,,,Fee Schedule,350% of BCBS fee schedule,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.16,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.33,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,6.95,90,,1406.16,Percent of Total Billed Charges,90% of Total Billed Charges,3.47,45,,818.008,Percent of Total Billed Charges,45% of Total Billed Charges,6.95,90,,1173.448,Percent of Total Billed Charges,90% of Total billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.02,65,,364,Percent of total Billed Charges,65% of Total Billed Charges,3.4,44.1,,801.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,7.33,95,,1238.64,Percent of Total Billed Charges,95% of Total Billed Charges,7.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.79,88,,1978.944,Percent of Total Billed Charges,88% of Total Billed Charges,6.95,90,,1173.448,Percent of Total Billed charges,90% of Total Billed Charges,0.33,7.72,
PRELONE 15MG/5ML SOLN,6360000331,CDM,636,RC,J7510,HCPCS,Outpatient,15,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,990.912,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.35,350,,,Fee Schedule,350% of BCBS fee schedule,0.35,350,,,Fee Schedule,350% of BCBS fee schedule,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.35,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.1,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,7.94,90,,4648.496,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,1856.88,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,1173.448,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,519.48,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,1819.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,1238.64,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,1599.664,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,1173.448,Percent of Total Billed charges,90% of Total Billed Charges,0.1,8.82,
ORAPRED 15MG/5ML UD,6360000332,CDM,636,RC,J7510,HCPCS,Outpatient,15,GM,8.82,5.73,,8.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.7,76,,266.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.35,350,,,Fee Schedule,350% of BCBS fee schedule,0.35,350,,,Fee Schedule,350% of BCBS fee schedule,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.35,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.1,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,7.94,90,,1505.52,Percent of Total Billed Charges,90% of Total Billed Charges,3.97,45,,1856.88,Percent of Total Billed Charges,45% of Total Billed Charges,7.94,90,,315.136,Percent of Total Billed Charges,90% of Total billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.73,65,,1444.968,Percent of total Billed Charges,65% of Total Billed Charges,3.89,44.1,,1819.744,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.38,95,,332.648,Percent of Total Billed Charges,95% of Total Billed Charges,8.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.76,88,,3631.232,Percent of Total Billed Charges,88% of Total Billed Charges,7.94,90,,315.136,Percent of Total Billed charges,90% of Total Billed Charges,0.1,8.82,
XELODA 500MG TAB,6360000334,CDM,636,RC,J8520,HCPCS,Outpatient,500,GM,124.58,80.98,,124.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,94.68,76,,3136.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12.39,350,,,Fee Schedule,350% of BCBS fee schedule,12.39,350,,,Fee Schedule,350% of BCBS fee schedule,124.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.39,350,,,Fee Schedule,350% of BCBS PPO fee schedule,3.54,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,112.12,90,,3042,Percent of Total Billed Charges,90% of Total Billed Charges,56.06,45,,2324.248,Percent of Total Billed Charges,45% of Total Billed Charges,112.12,90,,3713.76,Percent of Total Billed Charges,90% of Total billed Charges,124.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.98,65,,802.84,Percent of total Billed Charges,65% of Total Billed Charges,54.94,44.1,,2277.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,118.35,95,,3920.08,Percent of Total Billed Charges,95% of Total Billed Charges,124.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.63,88,,8179.176,Percent of Total Billed Charges,88% of Total Billed Charges,112.12,90,,3713.76,Percent of Total Billed charges,90% of Total Billed Charges,3.54,124.58,
DECADRON 1MG/ML ORAL SOLN,6360000335,CDM,636,RC,J8540,HCPCS,Outpatient,1,GM,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,1709.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.04,350,,,Fee Schedule,350% of BCBS fee schedule,0.04,350,,,Fee Schedule,350% of BCBS fee schedule,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.04,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.01,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,3.97,90,,5426.416,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,703.08,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,2023.92,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,697.136,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,689.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,2136.36,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,4545.192,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,2023.92,Percent of Total Billed charges,90% of Total Billed Charges,0.01,4.41,
DECADRON 4MG TAB,6360000337,CDM,636,RC,J8540,HCPCS,Outpatient,4,GM,3.31,2.15,,3.31,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.52,76,,1381.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.04,350,,,Fee Schedule,350% of BCBS fee schedule,0.04,350,,,Fee Schedule,350% of BCBS fee schedule,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.04,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.01,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,2.98,90,,7861.944,Percent of Total Billed Charges,90% of Total Billed Charges,1.49,45,,2324.248,Percent of Total Billed Charges,45% of Total Billed Charges,2.98,90,,1636.024,Percent of Total Billed Charges,90% of Total billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.15,65,,153.072,Percent of total Billed Charges,65% of Total Billed Charges,1.46,44.1,,2277.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,3.14,95,,1726.912,Percent of Total Billed Charges,95% of Total Billed Charges,3.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.91,88,,1374.912,Percent of Total Billed Charges,88% of Total Billed Charges,2.98,90,,1636.024,Percent of Total Billed charges,90% of Total Billed Charges,0.01,3.31,
METHOTREXAT 2.5MG TAB,6360000339,CDM,636,RC,J8610,HCPCS,Outpatient,2.5,GM,15.44,10.04,,15.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.73,76,,3136.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.18,350,,,Fee Schedule,350% of BCBS fee schedule,7.18,350,,,Fee Schedule,350% of BCBS fee schedule,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.18,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.05,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,13.9,90,,1147.696,Percent of Total Billed Charges,90% of Total Billed Charges,6.95,45,,752.76,Percent of Total Billed Charges,45% of Total Billed Charges,13.9,90,,3713.76,Percent of Total Billed Charges,90% of Total billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.04,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,6.81,44.1,,737.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.67,95,,3920.08,Percent of Total Billed Charges,95% of Total Billed Charges,15.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.59,88,,4545.192,Percent of Total Billed Charges,88% of Total Billed Charges,13.9,90,,3713.76,Percent of Total Billed charges,90% of Total Billed Charges,2.05,15.44,
BLENOXANE 15 UNIT IN,6360000340,CDM,636,RC,J9040,HCPCS,Outpatient,,,171.99,111.79,,171.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,130.71,76,,3136.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,111.58,350,,,Fee Schedule,350% of BCBS fee schedule,111.58,350,,,Fee Schedule,350% of BCBS fee schedule,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.58,350,,,Fee Schedule,350% of BCBS PPO fee schedule,31.88,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,154.79,90,,5426.416,Percent of Total Billed Charges,90% of Total Billed Charges,77.4,45,,955.872,Percent of Total Billed Charges,45% of Total Billed Charges,154.79,90,,3713.76,Percent of Total Billed Charges,90% of Total billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.79,65,,356.696,Percent of total Billed Charges,65% of Total Billed Charges,75.85,44.1,,936.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,163.39,95,,3920.08,Percent of Total Billed Charges,95% of Total Billed Charges,171.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.35,88,,1472.064,Percent of Total Billed Charges,88% of Total Billed Charges,154.79,90,,3713.76,Percent of Total Billed charges,90% of Total Billed Charges,31.88,171.99,
METHOTREXATE 25MG/2ML INJ,6360000342,CDM,636,RC,J9250,HCPCS,Outpatient,25,GM,25.36,16.48,,25.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19.27,76,,7063.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.42,350,,,Fee Schedule,350% of BCBS fee schedule,0.42,350,,,Fee Schedule,350% of BCBS fee schedule,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.42,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.12,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,22.82,90,,5788.392,Percent of Total Billed Charges,90% of Total Billed Charges,11.41,45,,1521,Percent of Total Billed Charges,45% of Total Billed Charges,22.82,90,,8365.072,Percent of Total Billed Charges,90% of Total billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,11.18,44.1,,1490.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,24.09,95,,8829.792,Percent of Total Billed Charges,95% of Total Billed Charges,25.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.32,88,,1869.264,Percent of Total Billed Charges,88% of Total Billed Charges,22.82,90,,8365.072,Percent of Total Billed charges,90% of Total Billed Charges,0.12,25.36,
MITOMYCIN 5MG INJ,6360000343,CDM,636,RC,J9280,HCPCS,Outpatient,5,GM,307.60,199.94,,57.93,125,,,Fee Schedule,125% of CMS OPPS Rate,233.78,76,,3925.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,356.76,350,,,Fee Schedule,350% of BCBS fee schedule,356.76,350,,,Fee Schedule,350% of BCBS fee schedule,46.35,100,,,Fee Schedule,100% of CMS OPPS Rate,356.76,350,,,Fee Schedule,350% of BCBS PPO fee schedule,101.93,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,276.84,90,,5788.392,Percent of Total Billed Charges,90% of Total Billed Charges,138.42,45,,2713.208,Percent of Total Billed Charges,45% of Total Billed Charges,276.84,90,,4648.496,Percent of Total Billed Charges,90% of Total billed Charges,46.35,100,,,Fee Schedule,100% of CMS OPPS Rate,46.35,100,,,Fee Schedule,100% of CMS OPPS Rate,46.35,100,,,Fee Schedule,100% of CMS OPPS Rate,292.64,65,,496.48,Percent of total Billed Charges,65% of Total Billed Charges,135.65,44.1,,2658.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,292.22,95,,4906.744,Percent of Total Billed Charges,95% of Total Billed Charges,34.76,75,,,Fee Schedule,75% of CMS OPPS Rate,270.69,88,,2974.4,Percent of Total Billed Charges,88% of Total Billed Charges,276.84,90,,4648.496,Percent of Total Billed charges,90% of Total Billed Charges,34.76,356.76,
ALBUMIN 25% 50ML,6360000346,CDM,636,RC,P9047,HCPCS,Outpatient,50,ML,558.97,363.33,,558.97,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,424.82,76,,1187.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,217.74,350,,,Fee Schedule,350% of BCBS fee schedule,217.74,350,,,Fee Schedule,350% of BCBS fee schedule,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.74,350,,,Fee Schedule,350% of BCBS PPO fee schedule,62.21,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,503.07,90,,1825.744,Percent of Total Billed Charges,90% of Total Billed Charges,251.54,45,,3930.976,Percent of Total Billed Charges,45% of Total Billed Charges,503.07,90,,1406.16,Percent of Total Billed Charges,90% of Total billed Charges,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.33,65,,729.872,Percent of total Billed Charges,65% of Total Billed Charges,246.51,44.1,,3852.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,531.02,95,,1484.28,Percent of Total Billed Charges,95% of Total Billed Charges,558.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.89,88,,5305.832,Percent of Total Billed Charges,88% of Total Billed Charges,503.07,90,,1406.16,Percent of Total Billed charges,90% of Total Billed Charges,62.21,558.97,
CEREBYX 100MG INJ,6360000347,CDM,636,RC,Q2009,HCPCS,Outpatient,100,GM,131.20,85.28,,131.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,99.71,76,,3925.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.62,350,,,Fee Schedule,350% of BCBS fee schedule,11.62,350,,,Fee Schedule,350% of BCBS fee schedule,131.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.62,350,,,Fee Schedule,350% of BCBS PPO fee schedule,3.32,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,118.08,90,,2961.576,Percent of Total Billed Charges,90% of Total Billed Charges,59.04,45,,573.848,Percent of Total Billed Charges,45% of Total Billed Charges,118.08,90,,4648.496,Percent of Total Billed Charges,90% of Total billed Charges,131.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.28,65,,444.88,Percent of total Billed Charges,65% of Total Billed Charges,57.86,44.1,,562.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,124.64,95,,4906.744,Percent of Total Billed Charges,95% of Total Billed Charges,131.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.46,88,,7687.24,Percent of Total Billed Charges,88% of Total Billed Charges,118.08,90,,4648.496,Percent of Total Billed charges,90% of Total Billed Charges,3.32,131.2,
CEREBYX 500MG/10ML INJ,6360000348,CDM,636,RC,Q2009,HCPCS,Outpatient,500,GM,394.70,256.56,,394.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.97,76,,1271.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.62,350,,,Fee Schedule,350% of BCBS fee schedule,11.62,350,,,Fee Schedule,350% of BCBS fee schedule,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.62,350,,,Fee Schedule,350% of BCBS PPO fee schedule,3.32,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,355.23,90,,2961.576,Percent of Total Billed Charges,90% of Total Billed Charges,177.62,45,,2713.208,Percent of Total Billed Charges,45% of Total Billed Charges,355.23,90,,1505.52,Percent of Total Billed Charges,90% of Total billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.56,65,,1354.872,Percent of total Billed Charges,65% of Total Billed Charges,174.06,44.1,,2658.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,374.97,95,,1589.16,Percent of Total Billed Charges,95% of Total Billed Charges,394.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.34,88,,1122.192,Percent of Total Billed Charges,88% of Total Billed Charges,355.23,90,,1505.52,Percent of Total Billed charges,90% of Total Billed Charges,3.32,394.7,
APLIGRAF (PER SQ CM),6360000349,CDM,636,RC,Q4101,HCPCS,Outpatient,,,87.10,56.62,,87.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.2,76,,1614.368,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,120.4,350,,,Fee Schedule,350% of BCBS fee schedule,120.4,350,,,Fee Schedule,350% of BCBS fee schedule,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.4,350,,,Fee Schedule,350% of BCBS PPO fee schedule,34.4,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,78.39,90,,2462.4,Percent of Total Billed Charges,90% of Total Billed Charges,39.2,45,,2894.192,Percent of Total Billed Charges,45% of Total Billed Charges,78.39,90,,1911.752,Percent of Total Billed Charges,90% of Total billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.62,65,,384.28,Percent of total Billed Charges,65% of Total Billed Charges,38.41,44.1,,2836.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.75,95,,2017.96,Percent of Total Billed Charges,95% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.65,88,,5305.832,Percent of Total Billed Charges,88% of Total Billed Charges,78.39,90,,1911.752,Percent of Total Billed charges,90% of Total Billed Charges,34.4,120.4,
APLIGRAF 1 CM,6360000350,CDM,636,RC,Q4101,HCPCS,Outpatient,,,87.10,56.62,,87.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.2,76,,2568.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,120.4,350,,,Fee Schedule,350% of BCBS fee schedule,120.4,350,,,Fee Schedule,350% of BCBS fee schedule,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.4,350,,,Fee Schedule,350% of BCBS PPO fee schedule,34.4,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,78.39,90,,2110.32,Percent of Total Billed Charges,90% of Total Billed Charges,39.2,45,,2894.192,Percent of Total Billed Charges,45% of Total Billed Charges,78.39,90,,3042,Percent of Total Billed Charges,90% of Total billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.62,65,,140.4,Percent of total Billed Charges,65% of Total Billed Charges,38.41,44.1,,2836.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.75,95,,3211,Percent of Total Billed Charges,95% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.65,88,,5659.76,Percent of Total Billed Charges,88% of Total Billed Charges,78.39,90,,3042,Percent of Total Billed charges,90% of Total Billed Charges,34.4,120.4,
APLIGRAF NOT USED 1,6360000351,CDM,636,RC,Q4101,HCPCS,Outpatient,,,87.10,56.62,,87.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.2,76,,4582.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,120.4,350,,,Fee Schedule,350% of BCBS fee schedule,120.4,350,,,Fee Schedule,350% of BCBS fee schedule,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.4,350,,,Fee Schedule,350% of BCBS PPO fee schedule,34.4,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,78.39,90,,1494.216,Percent of Total Billed Charges,90% of Total Billed Charges,39.2,45,,912.872,Percent of Total Billed Charges,45% of Total Billed Charges,78.39,90,,5426.416,Percent of Total Billed Charges,90% of Total billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.62,65,,227.6,Percent of total Billed Charges,65% of Total Billed Charges,38.41,44.1,,894.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.75,95,,5727.888,Percent of Total Billed Charges,95% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.65,88,,5659.76,Percent of Total Billed Charges,88% of Total Billed Charges,78.39,90,,5426.416,Percent of Total Billed charges,90% of Total Billed Charges,34.4,120.4,
DERMASKIN PER CM APP,6360000352,CDM,636,RC,Q4106,HCPCS,Outpatient,,,87.10,56.62,,87.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.2,76,,6638.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,129.47,350,,,Fee Schedule,350% of BCBS fee schedule,129.47,350,,,Fee Schedule,350% of BCBS fee schedule,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.47,350,,,Fee Schedule,350% of BCBS PPO fee schedule,36.99,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,78.39,90,,2221.2,Percent of Total Billed Charges,90% of Total Billed Charges,39.2,45,,1480.792,Percent of Total Billed Charges,45% of Total Billed Charges,78.39,90,,7861.944,Percent of Total Billed Charges,90% of Total billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.62,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,38.41,44.1,,1451.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.75,95,,8298.72,Percent of Total Billed Charges,95% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.65,88,,1785.168,Percent of Total Billed Charges,88% of Total Billed Charges,78.39,90,,7861.944,Percent of Total Billed charges,90% of Total Billed Charges,36.99,129.47,
DERMASKIN PER CM WAS,6360000353,CDM,636,RC,Q4106,HCPCS,Outpatient,,,87.10,56.62,,87.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.2,76,,969.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,129.47,350,,,Fee Schedule,350% of BCBS fee schedule,129.47,350,,,Fee Schedule,350% of BCBS fee schedule,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.47,350,,,Fee Schedule,350% of BCBS PPO fee schedule,36.99,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,78.39,90,,161.136,Percent of Total Billed Charges,90% of Total Billed Charges,39.2,45,,1480.792,Percent of Total Billed Charges,45% of Total Billed Charges,78.39,90,,1147.696,Percent of Total Billed Charges,90% of Total billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.62,65,,476.568,Percent of total Billed Charges,65% of Total Billed Charges,38.41,44.1,,1451.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.75,95,,1211.456,Percent of Total Billed Charges,95% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.65,88,,2895.76,Percent of Total Billed Charges,88% of Total Billed Charges,78.39,90,,1147.696,Percent of Total Billed charges,90% of Total Billed Charges,36.99,129.47,
SHIRE DERMAGRAFT,6360000354,CDM,636,RC,Q4106,HCPCS,Outpatient,,,6502.55,4226.66,,6502.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4941.94,76,,4582.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,129.47,350,,,Fee Schedule,350% of BCBS fee schedule,129.47,350,,,Fee Schedule,350% of BCBS fee schedule,6502.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.47,350,,,Fee Schedule,350% of BCBS PPO fee schedule,36.99,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5852.3,90,,393.84,Percent of Total Billed Charges,90% of Total Billed Charges,2926.15,45,,1231.2,Percent of Total Billed Charges,45% of Total Billed Charges,5852.3,90,,5426.416,Percent of Total Billed Charges,90% of Total billed Charges,6502.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6502.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6502.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4226.66,65,,476.568,Percent of total Billed Charges,65% of Total Billed Charges,2867.62,44.1,,1206.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,6177.42,95,,5727.888,Percent of Total Billed Charges,95% of Total Billed Charges,6502.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5722.24,88,,2895.76,Percent of Total Billed Charges,88% of Total Billed Charges,5852.3,90,,5426.416,Percent of Total Billed charges,90% of Total Billed Charges,36.99,6502.55,
OR GRAFIX CORE PER CM,6360000360,CDM,636,RC,Q4132,HCPCS,Outpatient,,,429.18,278.97,,429.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,326.18,76,,4887.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,309.01,72,,247.208,Percent of Total Billed Charges,72% of Total Billed Charges,321.89,75,,257.512,Percent of Total Billed charges,75% of Total Billed Charges,429.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.01,72,,247.208,Percent of Total Billed Charges,72% of Total Billed Charges,257.51,60,,206.008,Percent of Total Billed Charges,60% of Total Billed Charges,386.26,90,,3567.312,Percent of Total Billed Charges,90% of Total Billed Charges,193.13,45,,1055.16,Percent of Total Billed Charges,45% of Total Billed Charges,386.26,90,,5788.392,Percent of Total Billed Charges,90% of Total billed Charges,429.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,429.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,429.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.97,65,,476.568,Percent of total Billed Charges,65% of Total Billed Charges,189.27,44.1,,1034.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,407.72,95,,6109.968,Percent of Total Billed Charges,95% of Total Billed Charges,429.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.68,88,,2407.68,Percent of Total Billed Charges,88% of Total Billed Charges,386.26,90,,5788.392,Percent of Total Billed charges,90% of Total Billed Charges,189.27,429.18,
PT GRAFIX CORE PER CM,6360000361,CDM,636,RC,Q4132,HCPCS,Outpatient,,,429.18,278.97,,429.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,326.18,76,,4887.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,309.01,72,,247.208,Percent of Total Billed Charges,72% of Total Billed Charges,321.89,75,,257.512,Percent of Total Billed charges,75% of Total Billed Charges,429.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.01,72,,247.208,Percent of Total Billed Charges,72% of Total Billed Charges,257.51,60,,206.008,Percent of Total Billed Charges,60% of Total Billed Charges,386.26,90,,2792.592,Percent of Total Billed Charges,90% of Total Billed Charges,193.13,45,,747.112,Percent of Total Billed Charges,45% of Total Billed Charges,386.26,90,,5788.392,Percent of Total Billed Charges,90% of Total billed Charges,429.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,429.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,429.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.97,65,,476.568,Percent of total Billed Charges,65% of Total Billed Charges,189.27,44.1,,732.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,407.72,95,,6109.968,Percent of Total Billed Charges,95% of Total Billed Charges,429.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.68,88,,2063.424,Percent of Total Billed Charges,88% of Total Billed Charges,386.26,90,,5788.392,Percent of Total Billed charges,90% of Total Billed Charges,189.27,429.18,
GRAFIX PRIME  PER SQUARE CM,6360000362,CDM,636,RC,Q4133,HCPCS,Outpatient,,,87.10,56.62,,87.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,66.2,76,,1541.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.71,72,,50.168,Percent of Total Billed Charges,72% of Total Billed Charges,65.33,75,,52.264,Percent of Total Billed charges,75% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.71,72,,50.168,Percent of Total Billed Charges,72% of Total Billed Charges,52.26,60,,41.808,Percent of Total Billed Charges,60% of Total Billed Charges,78.39,90,,349.92,Percent of Total Billed Charges,90% of Total Billed Charges,39.2,45,,1110.6,Percent of Total Billed Charges,45% of Total Billed Charges,78.39,90,,1825.744,Percent of Total Billed Charges,90% of Total billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.62,65,,476.568,Percent of total Billed Charges,65% of Total Billed Charges,38.41,44.1,,1088.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,82.75,95,,1927.168,Percent of Total Billed Charges,95% of Total Billed Charges,87.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.65,88,,1461.008,Percent of Total Billed Charges,88% of Total Billed Charges,78.39,90,,1825.744,Percent of Total Billed charges,90% of Total Billed Charges,38.41,87.1,
OR GRAFIX PRIME PER CM,6360000363,CDM,636,RC,Q4133,HCPCS,Outpatient,,,429.18,278.97,,429.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,326.18,76,,2500.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,309.01,72,,247.208,Percent of Total Billed Charges,72% of Total Billed Charges,321.89,75,,257.512,Percent of Total Billed charges,75% of Total Billed Charges,429.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.01,72,,247.208,Percent of Total Billed Charges,72% of Total Billed Charges,257.51,60,,206.008,Percent of Total Billed Charges,60% of Total Billed Charges,386.26,90,,461.2,Percent of Total Billed Charges,90% of Total Billed Charges,193.13,45,,80.568,Percent of Total Billed Charges,45% of Total Billed Charges,386.26,90,,2961.576,Percent of Total Billed Charges,90% of Total billed Charges,429.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,429.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,429.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.97,65,,476.568,Percent of total Billed Charges,65% of Total Billed Charges,189.27,44.1,,78.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,407.72,95,,3126.112,Percent of Total Billed Charges,95% of Total Billed Charges,429.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.68,88,,2171.84,Percent of Total Billed Charges,88% of Total Billed Charges,386.26,90,,2961.576,Percent of Total Billed charges,90% of Total Billed Charges,189.27,429.18,
PT GRAFIX PRIME PER CM,6360000364,CDM,636,RC,Q4133,HCPCS,Outpatient,,,429.18,278.97,,429.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,326.18,76,,2500.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,309.01,72,,247.208,Percent of Total Billed Charges,72% of Total Billed Charges,321.89,75,,257.512,Percent of Total Billed charges,75% of Total Billed Charges,429.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.01,72,,247.208,Percent of Total Billed Charges,72% of Total Billed Charges,257.51,60,,206.008,Percent of Total Billed Charges,60% of Total Billed Charges,386.26,90,,965.264,Percent of Total Billed Charges,90% of Total Billed Charges,193.13,45,,196.92,Percent of Total Billed Charges,45% of Total Billed Charges,386.26,90,,2961.576,Percent of Total Billed Charges,90% of Total billed Charges,429.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,429.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,429.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.97,65,,849.696,Percent of total Billed Charges,65% of Total Billed Charges,189.27,44.1,,192.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,407.72,95,,3126.112,Percent of Total Billed Charges,95% of Total Billed Charges,429.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.68,88,,157.552,Percent of Total Billed Charges,88% of Total Billed Charges,386.26,90,,2961.576,Percent of Total Billed charges,90% of Total Billed Charges,189.27,429.18,
BIOVANCE 2 SQ CM APP,6360000365,CDM,636,RC,Q4154,HCPCS,Outpatient,,,1899.60,1234.74,,1899.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1443.7,76,,2079.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1367.71,72,,1094.168,Percent of Total Billed Charges,72% of Total Billed Charges,1424.7,75,,1139.76,Percent of Total Billed charges,75% of Total Billed Charges,1899.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1367.71,72,,1094.168,Percent of Total Billed Charges,72% of Total Billed Charges,1139.76,60,,911.808,Percent of Total Billed Charges,60% of Total Billed Charges,1709.64,90,,1825.744,Percent of Total Billed Charges,90% of Total Billed Charges,854.82,45,,1783.656,Percent of Total Billed Charges,45% of Total Billed Charges,1709.64,90,,2462.4,Percent of Total Billed Charges,90% of Total billed Charges,1899.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1899.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1899.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1234.74,65,,3767.312,Percent of total Billed Charges,65% of Total Billed Charges,837.72,44.1,,1747.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,1804.62,95,,2599.2,Percent of Total Billed Charges,95% of Total Billed Charges,1899.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1671.65,88,,385.088,Percent of Total Billed Charges,88% of Total Billed Charges,1709.64,90,,2462.4,Percent of Total Billed charges,90% of Total Billed Charges,837.72,1899.6,
BIOVANCE 4 SQ CM APP,6360000366,CDM,636,RC,Q4154,HCPCS,Outpatient,,,949.80,617.37,,949.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,721.85,76,,1782.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,683.86,72,,547.088,Percent of Total Billed Charges,72% of Total Billed Charges,712.35,75,,569.88,Percent of Total Billed charges,75% of Total Billed Charges,949.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,683.86,72,,547.088,Percent of Total Billed Charges,72% of Total Billed Charges,569.88,60,,455.904,Percent of Total Billed Charges,60% of Total Billed Charges,854.82,90,,353.24,Percent of Total Billed Charges,90% of Total Billed Charges,427.41,45,,1396.296,Percent of Total Billed Charges,45% of Total Billed Charges,854.82,90,,2110.32,Percent of Total Billed Charges,90% of Total billed Charges,949.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,949.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,949.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,617.37,65,,694.592,Percent of total Billed Charges,65% of Total Billed Charges,418.86,44.1,,1368.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,902.31,95,,2227.56,Percent of Total Billed Charges,95% of Total Billed Charges,949.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,835.82,88,,3488.04,Percent of Total Billed Charges,88% of Total Billed Charges,854.82,90,,2110.32,Percent of Total Billed charges,90% of Total Billed Charges,418.86,949.8,
BIOVANCE 8 SQ CM APP,6360000367,CDM,636,RC,Q4154,HCPCS,Outpatient,,,474.90,308.69,,474.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,360.92,76,,1261.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,341.93,72,,273.544,Percent of Total Billed Charges,72% of Total Billed Charges,356.18,75,,284.944,Percent of Total Billed charges,75% of Total Billed Charges,474.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.93,72,,273.544,Percent of Total Billed Charges,72% of Total Billed Charges,284.94,60,,227.952,Percent of Total Billed Charges,60% of Total Billed Charges,427.41,90,,1153.392,Percent of Total Billed Charges,90% of Total Billed Charges,213.71,45,,174.96,Percent of Total Billed Charges,45% of Total Billed Charges,427.41,90,,1494.216,Percent of Total Billed Charges,90% of Total billed Charges,474.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.69,65,,1253.32,Percent of total Billed Charges,65% of Total Billed Charges,209.43,44.1,,171.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,451.16,95,,1577.232,Percent of Total Billed Charges,95% of Total Billed Charges,474.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.91,88,,2730.536,Percent of Total Billed Charges,88% of Total Billed Charges,427.41,90,,1494.216,Percent of Total Billed charges,90% of Total Billed Charges,209.43,474.9,
BIOVANCE 10 SQ CM APP,6360000368,CDM,636,RC,Q4154,HCPCS,Outpatient,,,379.92,246.95,,379.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,288.74,76,,1875.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,273.54,72,,218.832,Percent of Total Billed Charges,72% of Total Billed Charges,284.94,75,,227.952,Percent of Total Billed charges,75% of Total Billed Charges,379.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.54,72,,218.832,Percent of Total Billed Charges,72% of Total Billed Charges,227.95,60,,182.36,Percent of Total Billed Charges,60% of Total Billed Charges,341.93,90,,1636.816,Percent of Total Billed Charges,90% of Total Billed Charges,170.96,45,,230.6,Percent of Total Billed Charges,45% of Total Billed Charges,341.93,90,,2221.2,Percent of Total Billed Charges,90% of Total billed Charges,379.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.95,65,,413.688,Percent of total Billed Charges,65% of Total Billed Charges,167.54,44.1,,225.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,360.92,95,,2344.6,Percent of Total Billed Charges,95% of Total Billed Charges,379.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.33,88,,342.144,Percent of Total Billed Charges,88% of Total Billed Charges,341.93,90,,2221.2,Percent of Total Billed charges,90% of Total Billed Charges,167.54,379.92,
BIOVANCE 6 SQ CM APP,6360000369,CDM,636,RC,,,Outpatient,,,633.00,411.45,,633,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,481.08,76,,136.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,455.76,72,,364.608,Percent of Total Billed Charges,72% of Total Billed Charges,474.75,75,,379.8,Percent of Total Billed charges,75% of Total Billed Charges,633,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,455.76,72,,364.608,Percent of Total Billed Charges,72% of Total Billed Charges,379.8,60,,303.84,Percent of Total Billed Charges,60% of Total Billed Charges,569.7,90,,4519.904,Percent of Total Billed Charges,90% of Total Billed Charges,284.85,45,,482.632,Percent of Total Billed Charges,45% of Total Billed Charges,569.7,90,,161.136,Percent of Total Billed Charges,90% of Total billed Charges,633,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,633,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,633,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.45,65,,1944.904,Percent of total Billed Charges,65% of Total Billed Charges,279.15,44.1,,472.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,601.35,95,,170.088,Percent of Total Billed Charges,95% of Total Billed Charges,633,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,557.04,88,,450.944,Percent of Total Billed Charges,88% of Total Billed Charges,569.7,90,,161.136,Percent of Total Billed charges,90% of Total Billed Charges,279.15,633,
BIOVANCE 6 SQ CM WAS,6360000370,CDM,636,RC,Q4154,HCPCS,Outpatient,,,633.20,411.58,,633.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,481.23,76,,332.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,455.9,72,,364.72,Percent of Total Billed Charges,72% of Total Billed Charges,474.9,75,,379.92,Percent of Total Billed charges,75% of Total Billed Charges,633.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,455.9,72,,364.72,Percent of Total Billed Charges,72% of Total Billed Charges,379.92,60,,303.936,Percent of Total Billed Charges,60% of Total Billed Charges,569.88,90,,2378.56,Percent of Total Billed Charges,90% of Total Billed Charges,284.94,45,,912.872,Percent of Total Billed Charges,45% of Total Billed Charges,569.88,90,,393.84,Percent of Total Billed Charges,90% of Total billed Charges,633.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,633.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,633.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.58,65,,369.2,Percent of total Billed Charges,65% of Total Billed Charges,279.24,44.1,,894.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,601.54,95,,415.72,Percent of Total Billed Charges,95% of Total Billed Charges,633.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,557.22,88,,943.808,Percent of Total Billed Charges,88% of Total Billed Charges,569.88,90,,393.84,Percent of Total Billed charges,90% of Total Billed Charges,279.24,633.2,
BIOVANCE 8 SQ CM WAS,6360000371,CDM,636,RC,Q4154,HCPCS,Outpatient,,,474.90,308.69,,474.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,360.92,76,,3012.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,341.93,72,,273.544,Percent of Total Billed Charges,72% of Total Billed Charges,356.18,75,,284.944,Percent of Total Billed charges,75% of Total Billed Charges,474.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.93,72,,273.544,Percent of Total Billed Charges,72% of Total Billed Charges,284.94,60,,227.952,Percent of Total Billed Charges,60% of Total Billed Charges,427.41,90,,1226.416,Percent of Total Billed Charges,90% of Total Billed Charges,213.71,45,,176.616,Percent of Total Billed Charges,45% of Total Billed Charges,427.41,90,,3567.312,Percent of Total Billed Charges,90% of Total billed Charges,474.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.69,65,,1175.264,Percent of total Billed Charges,65% of Total Billed Charges,209.43,44.1,,173.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,451.16,95,,3765.496,Percent of Total Billed Charges,95% of Total Billed Charges,474.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.91,88,,1785.168,Percent of Total Billed Charges,88% of Total Billed Charges,427.41,90,,3567.312,Percent of Total Billed charges,90% of Total Billed Charges,209.43,474.9,
BIOVANCE 2 SQ CM WAS,6360000372,CDM,636,RC,Q4154,HCPCS,Outpatient,,,1899.60,1234.74,,1899.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1443.7,76,,2358.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1367.71,72,,1094.168,Percent of Total Billed Charges,72% of Total Billed Charges,1424.7,75,,1139.76,Percent of Total Billed charges,75% of Total Billed Charges,1899.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1367.71,72,,1094.168,Percent of Total Billed Charges,72% of Total Billed Charges,1139.76,60,,911.808,Percent of Total Billed Charges,60% of Total Billed Charges,1709.64,90,,639.808,Percent of Total Billed Charges,90% of Total Billed Charges,854.82,45,,576.696,Percent of Total Billed Charges,45% of Total Billed Charges,1709.64,90,,2792.592,Percent of Total Billed Charges,90% of Total billed Charges,1899.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1899.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1899.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1234.74,65,,1099.016,Percent of total Billed Charges,65% of Total Billed Charges,837.72,44.1,,565.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,1804.62,95,,2947.736,Percent of Total Billed Charges,95% of Total Billed Charges,1899.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1671.65,88,,345.392,Percent of Total Billed Charges,88% of Total Billed Charges,1709.64,90,,2792.592,Percent of Total Billed charges,90% of Total Billed Charges,837.72,1899.6,
BIOVANCE 4 SQ CM WAS,6360000373,CDM,636,RC,Q4154,HCPCS,Outpatient,,,949.80,617.37,,949.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,721.85,76,,295.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,683.86,72,,547.088,Percent of Total Billed Charges,72% of Total Billed Charges,712.35,75,,569.88,Percent of Total Billed charges,75% of Total Billed Charges,949.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,683.86,72,,547.088,Percent of Total Billed Charges,72% of Total Billed Charges,569.88,60,,455.904,Percent of Total Billed Charges,60% of Total Billed Charges,854.82,90,,1314,Percent of Total Billed Charges,90% of Total Billed Charges,427.41,45,,818.408,Percent of Total Billed Charges,45% of Total Billed Charges,854.82,90,,349.92,Percent of Total Billed Charges,90% of Total billed Charges,949.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,949.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,949.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,617.37,65,,1586.52,Percent of total Billed Charges,65% of Total Billed Charges,418.86,44.1,,802.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,902.31,95,,369.36,Percent of Total Billed Charges,95% of Total Billed Charges,949.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,835.82,88,,1127.76,Percent of Total Billed Charges,88% of Total Billed Charges,854.82,90,,349.92,Percent of Total Billed charges,90% of Total Billed Charges,418.86,949.8,
BIOVANCE 10 SQ CM WAS,6360000374,CDM,636,RC,Q4154,HCPCS,Outpatient,,,379.92,246.95,,379.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,288.74,76,,389.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,273.54,72,,218.832,Percent of Total Billed Charges,72% of Total Billed Charges,284.94,75,,227.952,Percent of Total Billed charges,75% of Total Billed Charges,379.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.54,72,,218.832,Percent of Total Billed Charges,72% of Total Billed Charges,227.95,60,,182.36,Percent of Total Billed Charges,60% of Total Billed Charges,341.93,90,,932.72,Percent of Total Billed Charges,90% of Total Billed Charges,170.96,45,,2259.952,Percent of Total Billed Charges,45% of Total Billed Charges,341.93,90,,461.2,Percent of Total Billed Charges,90% of Total billed Charges,379.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.95,65,,980.984,Percent of total Billed Charges,65% of Total Billed Charges,167.54,44.1,,2214.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,360.92,95,,486.816,Percent of Total Billed Charges,95% of Total Billed Charges,379.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.33,88,,1600.448,Percent of Total Billed Charges,88% of Total Billed Charges,341.93,90,,461.2,Percent of Total Billed charges,90% of Total Billed Charges,167.54,379.92,
OMNIPAQUE 180 PER ML,6360000375,CDM,250,RC,Q9965,HCPCS,Outpatient,1,ML,114.66,74.53,,114.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,87.14,76,,815.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.16,350,,,Fee Schedule,350% of BCBS fee schedule,1.16,350,,,Fee Schedule,350% of BCBS fee schedule,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.16,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.33,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,103.19,90,,932.72,Percent of Total Billed Charges,90% of Total Billed Charges,51.6,45,,1189.28,Percent of Total Billed Charges,45% of Total Billed Charges,103.19,90,,965.264,Percent of Total Billed Charges,90% of Total billed Charges,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.53,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,50.57,44.1,,1165.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,108.93,95,,1018.888,Percent of Total Billed Charges,95% of Total Billed Charges,114.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.9,88,,4419.456,Percent of Total Billed Charges,88% of Total Billed Charges,103.19,90,,965.264,Percent of Total Billed charges,90% of Total Billed Charges,0.33,114.66,
LOCM300,6360000376,CDM,255,RC,Q9967,HCPCS,Outpatient,,,4.41,2.87,,4.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3.35,76,,1541.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.37,350,,,Fee Schedule,350% of BCBS fee schedule,1.37,350,,,Fee Schedule,350% of BCBS fee schedule,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.37,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.39,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,3.97,90,,1636.816,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,45,,613.208,Percent of Total Billed Charges,45% of Total Billed Charges,3.97,90,,1825.744,Percent of Total Billed Charges,90% of Total billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,65,,173.16,Percent of total Billed Charges,65% of Total Billed Charges,1.94,44.1,,600.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,4.19,95,,1927.168,Percent of Total Billed Charges,95% of Total Billed Charges,4.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.88,88,,2325.704,Percent of Total Billed Charges,88% of Total Billed Charges,3.97,90,,1825.744,Percent of Total Billed charges,90% of Total Billed Charges,0.39,4.41,
METHYLEN BL 1% INJ,6360000377,CDM,636,RC,Q9968,HCPCS,Outpatient,,,6.62,4.30,,11.12,125,,,Fee Schedule,125% of CMS OPPS Rate,5.03,76,,298.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.06,350,,,Fee Schedule,350% of BCBS fee schedule,4.06,350,,,Fee Schedule,350% of BCBS fee schedule,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,4.06,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.16,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5.96,90,,4519.904,Percent of Total Billed Charges,90% of Total Billed Charges,2.98,45,,319.904,Percent of Total Billed Charges,45% of Total Billed Charges,5.96,90,,353.24,Percent of Total Billed Charges,90% of Total billed Charges,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,22.1,65,,660.4,Percent of total Billed Charges,65% of Total Billed Charges,2.92,44.1,,313.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.29,95,,372.864,Percent of Total Billed Charges,95% of Total Billed Charges,6.67,75,,,Fee Schedule,75% of CMS OPPS Rate,5.83,88,,1199.168,Percent of Total Billed Charges,88% of Total Billed Charges,5.96,90,,353.24,Percent of Total Billed charges,90% of Total Billed Charges,1.16,22.1,
ALINIA 500MG TAB,6360000378,CDM,250,RC,,,Outpatient,500,GM,285.50,185.58,,285.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,216.98,76,,973.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,205.56,72,,164.448,Percent of Total Billed Charges,72% of Total Billed Charges,214.13,75,,171.304,Percent of Total Billed charges,75% of Total Billed Charges,285.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.56,72,,164.448,Percent of Total Billed Charges,72% of Total Billed Charges,171.3,60,,137.04,Percent of Total Billed Charges,60% of Total Billed Charges,256.95,90,,3456,Percent of Total Billed Charges,90% of Total Billed Charges,128.48,45,,657,Percent of Total Billed Charges,45% of Total Billed Charges,256.95,90,,1153.392,Percent of Total Billed Charges,90% of Total billed Charges,285.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.58,65,,1713.288,Percent of total Billed Charges,65% of Total Billed Charges,125.91,44.1,,643.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,271.23,95,,1217.464,Percent of Total Billed Charges,95% of Total Billed Charges,285.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.24,88,,625.592,Percent of Total Billed Charges,88% of Total Billed Charges,256.95,90,,1153.392,Percent of Total Billed charges,90% of Total Billed Charges,125.91,285.5,
ENGERIXB PRIVATE,6360000379,CDM,636,RC,,,Outpatient,,,88.25,57.36,,88.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.07,76,,1382.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.54,72,,50.832,Percent of Total Billed Charges,72% of Total Billed Charges,66.19,75,,52.952,Percent of Total Billed charges,75% of Total Billed Charges,88.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.54,72,,50.832,Percent of Total Billed Charges,72% of Total Billed Charges,52.95,60,,42.36,Percent of Total Billed Charges,60% of Total Billed Charges,79.43,90,,997.808,Percent of Total Billed Charges,90% of Total Billed Charges,39.71,45,,466.36,Percent of Total Billed Charges,45% of Total Billed Charges,79.43,90,,1636.816,Percent of Total Billed Charges,90% of Total billed Charges,88.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.36,65,,1755.128,Percent of total Billed Charges,65% of Total Billed Charges,38.92,44.1,,457.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.84,95,,1727.752,Percent of Total Billed Charges,95% of Total Billed Charges,88.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.66,88,,1284.8,Percent of Total Billed Charges,88% of Total Billed Charges,79.43,90,,1636.816,Percent of Total Billed charges,90% of Total Billed Charges,38.92,88.25,
ACETIC ACID 0.25% IRRG 500ML,6360000380,CDM,250,RC,,,Outpatient,500,ML,47.00,30.55,,47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,35.72,76,,3816.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.84,72,,27.072,Percent of Total Billed Charges,72% of Total Billed Charges,35.25,75,,28.2,Percent of Total Billed charges,75% of Total Billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.84,72,,27.072,Percent of Total Billed Charges,72% of Total Billed Charges,28.2,60,,22.56,Percent of Total Billed Charges,60% of Total Billed Charges,42.3,90,,1510.6,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,45,,466.36,Percent of Total Billed Charges,45% of Total Billed Charges,42.3,90,,4519.904,Percent of Total Billed Charges,90% of Total billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.55,65,,149.76,Percent of total Billed Charges,65% of Total Billed Charges,20.73,44.1,,457.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,44.65,95,,4771.008,Percent of Total Billed Charges,95% of Total Billed Charges,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.36,88,,911.992,Percent of Total Billed Charges,88% of Total Billed Charges,42.3,90,,4519.904,Percent of Total Billed charges,90% of Total Billed Charges,20.73,47,
ACETIC ACID 0.25% IRRG 500ML,6360000381,CDM,636,RC,,,Outpatient,500,ML,175.45,114.04,,175.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,133.34,76,,2008.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,126.32,72,,101.056,Percent of Total Billed Charges,72% of Total Billed Charges,131.59,75,,105.272,Percent of Total Billed charges,75% of Total Billed Charges,175.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.32,72,,101.056,Percent of Total Billed Charges,72% of Total Billed Charges,105.27,60,,84.216,Percent of Total Billed Charges,60% of Total Billed Charges,157.91,90,,947,Percent of Total Billed Charges,90% of Total Billed Charges,78.95,45,,818.408,Percent of Total Billed Charges,45% of Total Billed Charges,157.91,90,,2378.56,Percent of Total Billed Charges,90% of Total billed Charges,175.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.04,65,,1010.544,Percent of total Billed Charges,65% of Total Billed Charges,77.37,44.1,,802.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,166.68,95,,2510.704,Percent of Total Billed Charges,95% of Total Billed Charges,175.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.4,88,,911.992,Percent of Total Billed Charges,88% of Total Billed Charges,157.91,90,,2378.56,Percent of Total Billed charges,90% of Total Billed Charges,77.37,175.45,
RECLAST 5MG/100ML,6360000383,CDM,636,RC,J3489,HCPCS,Outpatient,5,GM,4281.25,2782.81,,4281.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3253.75,76,,1035.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.35,350,,,Fee Schedule,350% of BCBS fee schedule,28.35,350,,,Fee Schedule,350% of BCBS fee schedule,4281.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.35,350,,,Fee Schedule,350% of BCBS PPO fee schedule,8.1,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,3853.13,90,,1058.136,Percent of Total Billed Charges,90% of Total Billed Charges,1926.56,45,,2259.952,Percent of Total Billed Charges,45% of Total Billed Charges,3853.13,90,,1226.416,Percent of Total Billed Charges,90% of Total billed Charges,4281.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4281.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4281.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2782.81,65,,6316.416,Percent of total Billed Charges,65% of Total Billed Charges,1888.03,44.1,,2214.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,4067.19,95,,1294.552,Percent of Total Billed Charges,95% of Total Billed Charges,4281.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3767.5,88,,1600.448,Percent of Total Billed Charges,88% of Total Billed Charges,3853.13,90,,1226.416,Percent of Total Billed charges,90% of Total Billed Charges,8.1,4281.25,
REMICADE 100MG,6360000385,CDM,636,RC,J1745,HCPCS,Outpatient,100,GM,4613.00,2998.45,,38.15,125,,,Fee Schedule,125% of CMS OPPS Rate,3505.88,76,,540.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,380.14,350,,,Fee Schedule,350% of BCBS fee schedule,380.14,350,,,Fee Schedule,350% of BCBS fee schedule,30.53,100,,,Fee Schedule,100% of CMS OPPS Rate,380.14,350,,,Fee Schedule,350% of BCBS PPO fee schedule,108.61,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,4151.7,90,,806.504,Percent of Total Billed Charges,90% of Total Billed Charges,2075.85,45,,1728,Percent of Total Billed Charges,45% of Total Billed Charges,4151.7,90,,639.808,Percent of Total Billed Charges,90% of Total billed Charges,30.53,100,,,Fee Schedule,100% of CMS OPPS Rate,30.53,100,,,Fee Schedule,100% of CMS OPPS Rate,30.53,100,,,Fee Schedule,100% of CMS OPPS Rate,3059.51,65,,4026.36,Percent of total Billed Charges,65% of Total Billed Charges,2034.33,44.1,,1693.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,4382.35,95,,675.352,Percent of Total Billed Charges,95% of Total Billed Charges,22.89,75,,,Fee Schedule,75% of CMS OPPS Rate,4059.44,88,,4419.456,Percent of Total Billed Charges,88% of Total Billed Charges,4151.7,90,,639.808,Percent of Total Billed charges,90% of Total Billed Charges,22.89,4382.35,
PROLIA 60MG/1ML,6360000386,CDM,636,RC,J0897,HCPCS,Outpatient,60,GM,97.25,63.21,,34.57,125,,,Fee Schedule,125% of CMS OPPS Rate,73.91,76,,1109.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.13,350,,,Fee Schedule,350% of BCBS fee schedule,62.13,350,,,Fee Schedule,350% of BCBS fee schedule,27.66,100,,,Fee Schedule,100% of CMS OPPS Rate,62.13,350,,,Fee Schedule,350% of BCBS PPO fee schedule,17.75,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,87.53,90,,776.16,Percent of Total Billed Charges,90% of Total Billed Charges,43.76,45,,498.904,Percent of Total Billed Charges,45% of Total Billed Charges,87.53,90,,1314,Percent of Total Billed Charges,90% of Total billed Charges,27.66,100,,,Fee Schedule,100% of CMS OPPS Rate,27.66,100,,,Fee Schedule,100% of CMS OPPS Rate,27.66,100,,,Fee Schedule,100% of CMS OPPS Rate,118.53,65,,6316.416,Percent of total Billed Charges,65% of Total Billed Charges,42.89,44.1,,488.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,92.39,95,,1387,Percent of Total Billed Charges,95% of Total Billed Charges,20.74,75,,,Fee Schedule,75% of CMS OPPS Rate,85.58,88,,3379.2,Percent of Total Billed Charges,88% of Total Billed Charges,87.53,90,,1314,Percent of Total Billed charges,90% of Total Billed Charges,17.75,118.53,
PROVAYBLUE 0.5% UBH,6360000387,CDM,636,RC,Q9968,HCPCS,Outpatient,,,676.40,439.66,,11.12,125,,,Fee Schedule,125% of CMS OPPS Rate,514.06,76,,787.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.06,350,,,Fee Schedule,350% of BCBS fee schedule,4.06,350,,,Fee Schedule,350% of BCBS fee schedule,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,4.06,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.16,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,608.76,90,,1139.896,Percent of Total Billed Charges,90% of Total Billed Charges,304.38,45,,755.304,Percent of Total Billed Charges,45% of Total Billed Charges,608.76,90,,932.72,Percent of Total Billed Charges,90% of Total billed Charges,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,457.46,65,,752.96,Percent of total Billed Charges,65% of Total Billed Charges,298.29,44.1,,740.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,642.58,95,,984.536,Percent of Total Billed Charges,95% of Total Billed Charges,6.67,75,,,Fee Schedule,75% of CMS OPPS Rate,595.23,88,,975.632,Percent of Total Billed Charges,88% of Total Billed Charges,608.76,90,,932.72,Percent of Total Billed charges,90% of Total Billed Charges,1.16,642.58,
EUFLEXXA 20MG/2ML,6360000389,CDM,636,RC,J7323,HCPCS,Outpatient,20,GM,1342.75,872.79,,150.85,125,,,Fee Schedule,125% of CMS OPPS Rate,1020.49,76,,787.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,640.68,350,,,Fee Schedule,350% of BCBS fee schedule,640.68,350,,,Fee Schedule,350% of BCBS fee schedule,120.68,100,,,Fee Schedule,100% of CMS OPPS Rate,640.68,350,,,Fee Schedule,350% of BCBS PPO fee schedule,183.05,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,1208.48,90,,3987.256,Percent of Total Billed Charges,90% of Total Billed Charges,604.24,45,,473.504,Percent of Total Billed Charges,45% of Total Billed Charges,1208.48,90,,932.72,Percent of Total Billed Charges,90% of Total billed Charges,120.68,100,,,Fee Schedule,100% of CMS OPPS Rate,120.68,100,,,Fee Schedule,100% of CMS OPPS Rate,120.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1114.15,65,,3399.24,Percent of total Billed Charges,65% of Total Billed Charges,592.15,44.1,,464.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,1275.61,95,,984.536,Percent of Total Billed Charges,95% of Total Billed Charges,90.51,75,,,Fee Schedule,75% of CMS OPPS Rate,1181.62,88,,1477.032,Percent of Total Billed Charges,88% of Total Billed Charges,1208.48,90,,932.72,Percent of Total Billed charges,90% of Total Billed Charges,90.51,1275.61,
ACTEMRA 400MG/20ML,6360000390,CDM,636,RC,J3262,HCPCS,Outpatient,400,GM,8627.00,5607.55,,7.46,125,,,Fee Schedule,125% of CMS OPPS Rate,6556.52,76,,1382.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,17.15,350,,,Fee Schedule,350% of BCBS fee schedule,17.15,350,,,Fee Schedule,350% of BCBS fee schedule,5.97,100,,,Fee Schedule,100% of CMS OPPS Rate,17.15,350,,,Fee Schedule,350% of BCBS PPO fee schedule,4.9,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,7764.3,90,,1503.464,Percent of Total Billed Charges,90% of Total Billed Charges,3882.15,45,,529.064,Percent of Total Billed Charges,45% of Total Billed Charges,7764.3,90,,1636.816,Percent of Total Billed Charges,90% of Total billed Charges,5.97,100,,,Fee Schedule,100% of CMS OPPS Rate,5.97,100,,,Fee Schedule,100% of CMS OPPS Rate,5.97,100,,,Fee Schedule,100% of CMS OPPS Rate,5619.49,65,,655.36,Percent of total Billed Charges,65% of Total Billed Charges,3804.51,44.1,,518.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,8195.65,95,,1727.752,Percent of Total Billed Charges,95% of Total Billed Charges,4.47,75,,,Fee Schedule,75% of CMS OPPS Rate,7591.76,88,,925.96,Percent of Total Billed Charges,88% of Total Billed Charges,7764.3,90,,1636.816,Percent of Total Billed charges,90% of Total Billed Charges,4.47,8195.65,
ENTYVIO 300MG INJ,6360000391,CDM,636,RC,J3380,HCPCS,Outpatient,300,GM,101.56,66.01,,27.08,125,,,Fee Schedule,125% of CMS OPPS Rate,77.19,76,,3816.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,62.62,350,,,Fee Schedule,350% of BCBS fee schedule,62.62,350,,,Fee Schedule,350% of BCBS fee schedule,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,62.62,350,,,Fee Schedule,350% of BCBS PPO fee schedule,17.89,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,91.4,90,,1503.464,Percent of Total Billed Charges,90% of Total Billed Charges,45.7,45,,403.248,Percent of Total Billed Charges,45% of Total Billed Charges,91.4,90,,4519.904,Percent of Total Billed Charges,90% of Total billed Charges,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,109.35,65,,655.36,Percent of total Billed Charges,65% of Total Billed Charges,44.79,44.1,,395.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,96.48,95,,4771.008,Percent of Total Billed Charges,95% of Total Billed Charges,16.25,75,,,Fee Schedule,75% of CMS OPPS Rate,89.37,88,,1034.616,Percent of Total Billed Charges,88% of Total Billed Charges,91.4,90,,4519.904,Percent of Total Billed charges,90% of Total Billed Charges,16.25,109.35,
DEXMEDETOMIDINE 200MCG/2ML,6360000392,CDM,250,RC,,,Outpatient,200,GM,178.45,115.99,,178.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,135.62,76,,2918.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,128.48,72,,102.784,Percent of Total Billed Charges,72% of Total Billed Charges,133.84,75,,107.072,Percent of Total Billed charges,75% of Total Billed Charges,178.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.48,72,,102.784,Percent of Total Billed Charges,72% of Total Billed Charges,107.07,60,,85.656,Percent of Total Billed Charges,60% of Total Billed Charges,160.61,90,,2795.488,Percent of Total Billed Charges,90% of Total Billed Charges,80.3,45,,388.08,Percent of Total Billed Charges,45% of Total Billed Charges,160.61,90,,3456,Percent of Total Billed Charges,90% of Total billed Charges,178.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.99,65,,973.256,Percent of total Billed Charges,65% of Total Billed Charges,78.7,44.1,,380.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,169.53,95,,3648,Percent of Total Billed Charges,95% of Total Billed Charges,178.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.04,88,,788.576,Percent of Total Billed Charges,88% of Total Billed Charges,160.61,90,,3456,Percent of Total Billed charges,90% of Total Billed Charges,78.7,178.45,
DEXMEDTOMIDINE/NS 200MCG/50ML,6360000393,CDM,250,RC,,,Outpatient,200,GM,178.45,115.99,,178.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,135.62,76,,842.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,128.48,72,,102.784,Percent of Total Billed Charges,72% of Total Billed Charges,133.84,75,,107.072,Percent of Total Billed charges,75% of Total Billed Charges,178.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.48,72,,102.784,Percent of Total Billed Charges,72% of Total Billed Charges,107.07,60,,85.656,Percent of Total Billed Charges,60% of Total Billed Charges,160.61,90,,1056.24,Percent of Total Billed Charges,90% of Total Billed Charges,80.3,45,,569.952,Percent of Total Billed Charges,45% of Total Billed Charges,160.61,90,,997.808,Percent of Total Billed Charges,90% of Total billed Charges,178.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.99,65,,1759.16,Percent of total Billed Charges,65% of Total Billed Charges,78.7,44.1,,558.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,169.53,95,,1053.24,Percent of Total Billed Charges,95% of Total Billed Charges,178.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.04,88,,758.912,Percent of Total Billed Charges,88% of Total Billed Charges,160.61,90,,997.808,Percent of Total Billed charges,90% of Total Billed Charges,78.7,178.45,
ARANESP 300MCG/0.6ML INJ,6360000394,CDM,636,RC,J0882,HCPCS,Outpatient,300,GM,9171.90,5961.74,,3.71,125,,,Fee Schedule,125% of CMS OPPS Rate,6970.64,76,,1275.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.08,350,,,Fee Schedule,350% of BCBS fee schedule,26.08,350,,,Fee Schedule,350% of BCBS fee schedule,2.97,100,,,Fee Schedule,100% of CMS OPPS Rate,26.08,350,,,Fee Schedule,350% of BCBS PPO fee schedule,7.45,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,8254.71,90,,1404.72,Percent of Total Billed Charges,90% of Total Billed Charges,4127.36,45,,1993.632,Percent of Total Billed Charges,45% of Total Billed Charges,8254.71,90,,1510.6,Percent of Total Billed Charges,90% of Total billed Charges,2.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2.97,100,,,Fee Schedule,100% of CMS OPPS Rate,5967.68,65,,3980.176,Percent of total Billed Charges,65% of Total Billed Charges,4044.81,44.1,,1953.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,8713.31,95,,1594.528,Percent of Total Billed Charges,95% of Total Billed Charges,2.22,75,,,Fee Schedule,75% of CMS OPPS Rate,8071.27,88,,1114.568,Percent of Total Billed Charges,88% of Total Billed Charges,8254.71,90,,1510.6,Percent of Total Billed charges,90% of Total Billed Charges,2.22,8713.31,
OCREVUS 300MG/10ML INJ,6360000395,CDM,636,RC,J2350,HCPCS,Outpatient,300,GM,234.32,152.31,,73.45,125,,,Fee Schedule,125% of CMS OPPS Rate,178.08,76,,799.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,222.39,350,,,Fee Schedule,350% of BCBS fee schedule,222.39,350,,,Fee Schedule,350% of BCBS fee schedule,58.77,100,,,Fee Schedule,100% of CMS OPPS Rate,222.39,350,,,Fee Schedule,350% of BCBS PPO fee schedule,63.54,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,210.89,90,,5051.52,Percent of Total Billed Charges,90% of Total Billed Charges,105.44,45,,751.728,Percent of Total Billed Charges,45% of Total Billed Charges,210.89,90,,947,Percent of Total Billed Charges,90% of Total billed Charges,58.77,100,,,Fee Schedule,100% of CMS OPPS Rate,58.77,100,,,Fee Schedule,100% of CMS OPPS Rate,58.77,100,,,Fee Schedule,100% of CMS OPPS Rate,269.85,65,,1829.104,Percent of total Billed Charges,65% of Total Billed Charges,103.34,44.1,,736.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,222.6,95,,999.616,Percent of Total Billed Charges,95% of Total Billed Charges,44.07,75,,,Fee Schedule,75% of CMS OPPS Rate,206.2,88,,3898.656,Percent of Total Billed Charges,88% of Total Billed Charges,210.89,90,,947,Percent of Total Billed charges,90% of Total Billed Charges,44.07,269.85,
DEXAMETHASONE 20MG/5ML INJ,6360000396,CDM,636,RC,J1100,HCPCS,Outpatient,20,GM,12.00,7.80,,12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9.12,76,,893.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.11,350,,,Fee Schedule,350% of BCBS fee schedule,0.11,350,,,Fee Schedule,350% of BCBS fee schedule,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.11,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.03,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,10.8,90,,3456,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,45,,751.728,Percent of Total Billed Charges,45% of Total Billed Charges,10.8,90,,1058.136,Percent of Total Billed Charges,90% of Total billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.8,65,,795.496,Percent of total Billed Charges,65% of Total Billed Charges,5.29,44.1,,736.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,11.4,95,,1116.92,Percent of Total Billed Charges,95% of Total Billed Charges,12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,88,,1470.048,Percent of Total Billed Charges,88% of Total Billed Charges,10.8,90,,1058.136,Percent of Total Billed charges,90% of Total Billed Charges,0.03,12,
DECADRON 2MG TAB,6360000397,CDM,636,RC,J8540,HCPCS,Outpatient,2,GM,6.50,4.23,,6.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.94,76,,681.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.04,350,,,Fee Schedule,350% of BCBS fee schedule,0.04,350,,,Fee Schedule,350% of BCBS fee schedule,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.04,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.01,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5.85,90,,3456,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,1397.744,Percent of Total Billed Charges,45% of Total Billed Charges,5.85,90,,806.504,Percent of Total Billed Charges,90% of Total billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,65,,795.496,Percent of total Billed Charges,65% of Total Billed Charges,2.87,44.1,,1369.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.18,95,,851.304,Percent of Total Billed Charges,95% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,88,,1470.048,Percent of Total Billed Charges,88% of Total Billed Charges,5.85,90,,806.504,Percent of Total Billed charges,90% of Total Billed Charges,0.01,6.5,
PULMICORT 90MCG INH,6360000398,CDM,636,RC,J3535,HCPCS,Outpatient,90,GM,661.99,430.29,,661.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,503.11,76,,655.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,476.63,72,,381.304,Percent of Total Billed Charges,72% of Total Billed Charges,496.49,75,,397.192,Percent of Total Billed charges,75% of Total Billed Charges,661.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.63,72,,381.304,Percent of Total Billed Charges,72% of Total Billed Charges,397.19,60,,317.752,Percent of Total Billed Charges,60% of Total Billed Charges,595.79,90,,3456,Percent of Total Billed Charges,90% of Total Billed Charges,297.9,45,,528.12,Percent of Total Billed Charges,45% of Total Billed Charges,595.79,90,,776.16,Percent of Total Billed Charges,90% of Total billed Charges,661.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,661.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,661.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.29,65,,6349.176,Percent of total Billed Charges,65% of Total Billed Charges,291.94,44.1,,517.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,628.89,95,,819.28,Percent of Total Billed Charges,95% of Total Billed Charges,661.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,582.55,88,,2733.368,Percent of Total Billed Charges,88% of Total Billed Charges,595.79,90,,776.16,Percent of Total Billed charges,90% of Total Billed Charges,291.94,661.99,
PULMICORT 180MCG INH,6360000399,CDM,636,RC,J3535,HCPCS,Outpatient,180,GM,886.43,576.18,,886.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,673.69,76,,962.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,638.23,72,,510.584,Percent of Total Billed Charges,72% of Total Billed Charges,664.82,75,,531.856,Percent of Total Billed charges,75% of Total Billed Charges,886.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,638.23,72,,510.584,Percent of Total Billed Charges,72% of Total Billed Charges,531.86,60,,425.488,Percent of Total Billed Charges,60% of Total Billed Charges,797.79,90,,3456,Percent of Total Billed Charges,90% of Total Billed Charges,398.89,45,,702.36,Percent of Total Billed Charges,45% of Total Billed Charges,797.79,90,,1139.896,Percent of Total Billed Charges,90% of Total billed Charges,886.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,886.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,886.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.18,65,,324.432,Percent of total Billed Charges,65% of Total Billed Charges,390.92,44.1,,688.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,842.11,95,,1203.224,Percent of Total Billed Charges,95% of Total Billed Charges,886.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.06,88,,1032.768,Percent of Total Billed Charges,88% of Total Billed Charges,797.79,90,,1139.896,Percent of Total Billed charges,90% of Total Billed Charges,390.92,886.43,
DECADRON 1MG TAB,6360000400,CDM,636,RC,J8540,HCPCS,Outpatient,1,GM,6.50,4.23,,6.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.94,76,,3367.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.04,350,,,Fee Schedule,350% of BCBS fee schedule,0.04,350,,,Fee Schedule,350% of BCBS fee schedule,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.04,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.01,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5.85,90,,1406.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,2525.76,Percent of Total Billed Charges,45% of Total Billed Charges,5.85,90,,3987.256,Percent of Total Billed Charges,90% of Total billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,65,,1789.296,Percent of total Billed Charges,65% of Total Billed Charges,2.87,44.1,,2475.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.18,95,,4208.776,Percent of Total Billed Charges,95% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,88,,1373.504,Percent of Total Billed Charges,88% of Total Billed Charges,5.85,90,,3987.256,Percent of Total Billed charges,90% of Total Billed Charges,0.01,6.5,
DECADRON 1.5MG TAB,6360000401,CDM,636,RC,J8540,HCPCS,Outpatient,1.5,GM,6.50,4.23,,6.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.94,76,,1269.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.04,350,,,Fee Schedule,350% of BCBS fee schedule,0.04,350,,,Fee Schedule,350% of BCBS fee schedule,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.04,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.01,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5.85,90,,1913.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,1728,Percent of Total Billed Charges,45% of Total Billed Charges,5.85,90,,1503.464,Percent of Total Billed Charges,90% of Total billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,65,,3488.552,Percent of total Billed Charges,65% of Total Billed Charges,2.87,44.1,,1693.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.18,95,,1586.984,Percent of Total Billed Charges,95% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,88,,4939.264,Percent of Total Billed Charges,88% of Total Billed Charges,5.85,90,,1503.464,Percent of Total Billed charges,90% of Total Billed Charges,0.01,6.5,
DECADRON 6MG TAB,6360000402,CDM,636,RC,J8540,HCPCS,Outpatient,6,GM,6.50,4.23,,6.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.94,76,,1269.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.04,350,,,Fee Schedule,350% of BCBS fee schedule,0.04,350,,,Fee Schedule,350% of BCBS fee schedule,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.04,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.01,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5.85,90,,341.28,Percent of Total Billed Charges,90% of Total Billed Charges,2.93,45,,1728,Percent of Total Billed Charges,45% of Total Billed Charges,5.85,90,,1503.464,Percent of Total Billed Charges,90% of Total billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.23,65,,63.96,Percent of total Billed Charges,65% of Total Billed Charges,2.87,44.1,,1693.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.18,95,,1586.984,Percent of Total Billed Charges,95% of Total Billed Charges,6.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.72,88,,3379.2,Percent of Total Billed Charges,88% of Total Billed Charges,5.85,90,,1503.464,Percent of Total Billed charges,90% of Total Billed Charges,0.01,6.5,
GAMUNEX-C 20Gram/200ml vial,6360000403,CDM,636,RC,J1561,HCPCS,Outpatient,200,ML,9894.10,6431.17,,61.26,125,,,Fee Schedule,125% of CMS OPPS Rate,7519.52,76,,2360.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,146.41,350,,,Fee Schedule,350% of BCBS fee schedule,146.41,350,,,Fee Schedule,350% of BCBS fee schedule,49.01,100,,,Fee Schedule,100% of CMS OPPS Rate,146.41,350,,,Fee Schedule,350% of BCBS PPO fee schedule,41.83,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,8904.69,90,,461.2,Percent of Total Billed Charges,90% of Total Billed Charges,4452.35,45,,1728,Percent of Total Billed Charges,45% of Total Billed Charges,8904.69,90,,2795.488,Percent of Total Billed Charges,90% of Total billed Charges,49.01,100,,,Fee Schedule,100% of CMS OPPS Rate,49.01,100,,,Fee Schedule,100% of CMS OPPS Rate,49.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6529.19,65,,63.96,Percent of total Billed Charges,65% of Total Billed Charges,4363.3,44.1,,1693.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,9399.4,95,,2950.792,Percent of Total Billed Charges,95% of Total Billed Charges,36.75,75,,,Fee Schedule,75% of CMS OPPS Rate,8706.81,88,,3379.2,Percent of Total Billed Charges,88% of Total Billed Charges,8904.69,90,,2795.488,Percent of Total Billed charges,90% of Total Billed Charges,36.75,9399.4,
CANCIDAS 50MG INJ,6360000404,CDM,636,RC,J0637,HCPCS,Outpatient,50,GM,44.56,28.96,,44.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,33.87,76,,891.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,87.47,350,,,Fee Schedule,350% of BCBS fee schedule,87.47,350,,,Fee Schedule,350% of BCBS fee schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.47,350,,,Fee Schedule,350% of BCBS PPO fee schedule,24.99,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,40.1,90,,3909.6,Percent of Total Billed Charges,90% of Total Billed Charges,20.05,45,,1728,Percent of Total Billed Charges,45% of Total Billed Charges,40.1,90,,1056.24,Percent of Total Billed Charges,90% of Total billed Charges,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.96,65,,42.12,Percent of total Billed Charges,65% of Total Billed Charges,19.65,44.1,,1693.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.33,95,,1114.92,Percent of Total Billed Charges,95% of Total Billed Charges,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.21,88,,3379.2,Percent of Total Billed Charges,88% of Total Billed Charges,40.1,90,,1056.24,Percent of Total Billed charges,90% of Total Billed Charges,19.65,87.47,
ANDEXXA 200MG INJ,6360000405,CDM,636,RC,,,Outpatient,200,GM,21725.00,14121.25,,21725,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,16511,76,,1186.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,15642,72,,12513.6,Percent of Total Billed Charges,72% of Total Billed Charges,16293.75,75,,13035,Percent of Total Billed charges,75% of Total Billed Charges,21725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15642,72,,12513.6,Percent of Total Billed Charges,72% of Total Billed Charges,13035,60,,10428,Percent of Total Billed Charges,60% of Total Billed Charges,19552.5,90,,1877.336,Percent of Total Billed Charges,90% of Total Billed Charges,9776.25,45,,703.08,Percent of Total Billed Charges,45% of Total Billed Charges,19552.5,90,,1404.72,Percent of Total Billed Charges,90% of Total billed Charges,21725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14121.25,65,,42.12,Percent of total Billed Charges,65% of Total Billed Charges,9580.73,44.1,,689.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,20638.75,95,,1482.76,Percent of Total Billed Charges,95% of Total Billed Charges,21725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19118,88,,3379.2,Percent of Total Billed Charges,88% of Total Billed Charges,19552.5,90,,1404.72,Percent of Total Billed charges,90% of Total Billed Charges,9580.73,21725,
Orbactive 400mg inj,6360000406,CDM,636,RC,J2407,HCPCS,Outpatient,400,GM,3932.90,2556.39,,35.65,125,,,Fee Schedule,125% of CMS OPPS Rate,2989,76,,4265.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.6,350,,,Fee Schedule,350% of BCBS fee schedule,84.6,350,,,Fee Schedule,350% of BCBS fee schedule,28.53,100,,,Fee Schedule,100% of CMS OPPS Rate,84.6,350,,,Fee Schedule,350% of BCBS PPO fee schedule,24.17,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,3539.61,90,,2791.592,Percent of Total Billed Charges,90% of Total Billed Charges,1769.81,45,,956.52,Percent of Total Billed Charges,45% of Total Billed Charges,3539.61,90,,5051.52,Percent of Total Billed Charges,90% of Total billed Charges,28.53,100,,,Fee Schedule,100% of CMS OPPS Rate,28.53,100,,,Fee Schedule,100% of CMS OPPS Rate,28.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2613.45,65,,18.2,Percent of total Billed Charges,65% of Total Billed Charges,1734.41,44.1,,937.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,3736.26,95,,5332.16,Percent of Total Billed Charges,95% of Total Billed Charges,21.39,75,,,Fee Schedule,75% of CMS OPPS Rate,3460.95,88,,1374.912,Percent of Total Billed Charges,88% of Total Billed Charges,3539.61,90,,5051.52,Percent of Total Billed charges,90% of Total Billed Charges,21.39,3736.26,
MYXREDLIN 100UNIT/100ML BAG,6360000407,CDM,250,RC,,,Outpatient,100,ML,145.25,94.41,,145.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,110.39,76,,2918.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,104.58,72,,83.664,Percent of Total Billed Charges,72% of Total Billed Charges,108.94,75,,87.152,Percent of Total Billed charges,75% of Total Billed Charges,145.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.58,72,,83.664,Percent of Total Billed Charges,72% of Total Billed Charges,87.15,60,,69.72,Percent of Total Billed Charges,60% of Total Billed Charges,130.73,90,,1008,Percent of Total Billed Charges,90% of Total Billed Charges,65.36,45,,170.64,Percent of Total Billed Charges,45% of Total Billed Charges,130.73,90,,3456,Percent of Total Billed Charges,90% of Total billed Charges,145.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.41,65,,784.848,Percent of total Billed Charges,65% of Total Billed Charges,64.06,44.1,,167.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,137.99,95,,3648,Percent of Total Billed Charges,95% of Total Billed Charges,145.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.82,88,,1870.528,Percent of Total Billed Charges,88% of Total Billed Charges,130.73,90,,3456,Percent of Total Billed charges,90% of Total Billed Charges,64.06,145.25,
Privigen 40gm 400ml vial,6360000409,CDM,636,RC,J1459,HCPCS,Outpatient,40,gm,13888.20,9027.33,,61.6,125,,,Fee Schedule,125% of CMS OPPS Rate,10555.03,76,,2918.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,159.95,350,,,Fee Schedule,350% of BCBS fee schedule,159.95,350,,,Fee Schedule,350% of BCBS fee schedule,49.28,100,,,Fee Schedule,100% of CMS OPPS Rate,159.95,350,,,Fee Schedule,350% of BCBS PPO fee schedule,45.7,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,12499.38,90,,461.52,Percent of Total Billed Charges,90% of Total Billed Charges,6249.69,45,,230.6,Percent of Total Billed Charges,45% of Total Billed Charges,12499.38,90,,3456,Percent of Total Billed Charges,90% of Total billed Charges,49.28,100,,,Fee Schedule,100% of CMS OPPS Rate,49.28,100,,,Fee Schedule,100% of CMS OPPS Rate,49.28,100,,,Fee Schedule,100% of CMS OPPS Rate,9125.89,65,,822.64,Percent of total Billed Charges,65% of Total Billed Charges,6124.7,44.1,,225.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,13193.79,95,,3648,Percent of Total Billed Charges,95% of Total Billed Charges,36.96,75,,,Fee Schedule,75% of CMS OPPS Rate,12221.62,88,,333.696,Percent of Total Billed Charges,88% of Total Billed Charges,12499.38,90,,3456,Percent of Total Billed charges,90% of Total Billed Charges,36.96,13193.79,
WATER FOR INHALATION 2000ML,6360000412,CDM,250,RC,,,Outpatient,2000,ML,187.50,121.88,,187.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,142.5,76,,2918.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,135,72,,108,Percent of Total Billed Charges,72% of Total Billed Charges,140.63,75,,112.504,Percent of Total Billed charges,75% of Total Billed Charges,187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135,72,,108,Percent of Total Billed Charges,72% of Total Billed Charges,112.5,60,,90,Percent of Total Billed Charges,60% of Total Billed Charges,168.75,90,,380.16,Percent of Total Billed Charges,90% of Total Billed Charges,84.38,45,,1954.8,Percent of Total Billed Charges,45% of Total Billed Charges,168.75,90,,3456,Percent of Total Billed Charges,90% of Total billed Charges,187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.88,65,,781.04,Percent of total Billed Charges,65% of Total Billed Charges,82.69,44.1,,1915.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,178.13,95,,3648,Percent of Total Billed Charges,95% of Total Billed Charges,187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165,88,,450.944,Percent of Total Billed Charges,88% of Total Billed Charges,168.75,90,,3456,Percent of Total Billed charges,90% of Total Billed Charges,82.69,187.5,
Gel One  30mg/3ml inj,6360000415,CDM,636,RC,J7326,HCPCS,Outpatient,30,GM,11356.25,7381.56,,657.97,125,,,Fee Schedule,125% of CMS OPPS Rate,8630.75,76,,1187.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1854.41,350,,,Fee Schedule,350% of BCBS fee schedule,1854.41,350,,,Fee Schedule,350% of BCBS fee schedule,526.38,100,,,Fee Schedule,100% of CMS OPPS Rate,1854.41,350,,,Fee Schedule,350% of BCBS PPO fee schedule,529.83,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,10220.63,90,,1724.008,Percent of Total Billed Charges,90% of Total Billed Charges,5110.31,45,,1395.792,Percent of Total Billed Charges,45% of Total Billed Charges,10220.63,90,,1406.16,Percent of Total Billed Charges,90% of Total billed Charges,526.38,100,,,Fee Schedule,100% of CMS OPPS Rate,526.38,100,,,Fee Schedule,100% of CMS OPPS Rate,526.38,100,,,Fee Schedule,100% of CMS OPPS Rate,8434.32,65,,150.776,Percent of total Billed Charges,65% of Total Billed Charges,5008.11,44.1,,1367.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,10788.44,95,,1484.28,Percent of Total Billed Charges,95% of Total Billed Charges,394.78,75,,,Fee Schedule,75% of CMS OPPS Rate,9993.5,88,,1835.616,Percent of Total Billed Charges,88% of Total Billed Charges,10220.63,90,,1406.16,Percent of Total Billed charges,90% of Total Billed Charges,394.78,10788.44,
Orencia 250mg Vial,6360000416,CDM,636,RC,J0129,HCPCS,Outpatient,250,GM,205.71,133.71,,54.75,125,,,Fee Schedule,125% of CMS OPPS Rate,156.34,76,,1615.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,136.29,350,,,Fee Schedule,350% of BCBS fee schedule,136.29,350,,,Fee Schedule,350% of BCBS fee schedule,43.8,100,,,Fee Schedule,100% of CMS OPPS Rate,136.29,350,,,Fee Schedule,350% of BCBS PPO fee schedule,38.94,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,185.14,90,,1538.056,Percent of Total Billed Charges,90% of Total Billed Charges,92.57,45,,504,Percent of Total Billed Charges,45% of Total Billed Charges,185.14,90,,1913.04,Percent of Total Billed Charges,90% of Total billed Charges,43.8,100,,,Fee Schedule,100% of CMS OPPS Rate,43.8,100,,,Fee Schedule,100% of CMS OPPS Rate,43.8,100,,,Fee Schedule,100% of CMS OPPS Rate,221.31,65,,153.648,Percent of total Billed Charges,65% of Total Billed Charges,90.72,44.1,,493.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,195.42,95,,2019.32,Percent of Total Billed Charges,95% of Total Billed Charges,32.85,75,,,Fee Schedule,75% of CMS OPPS Rate,181.02,88,,2729.552,Percent of Total Billed Charges,88% of Total Billed Charges,185.14,90,,1913.04,Percent of Total Billed charges,90% of Total Billed Charges,32.85,221.31,
LOKELMA 5gm packet,6360000417,CDM,250,RC,,,Outpatient,,,195.00,126.75,,195,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,148.2,76,,288.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,140.4,72,,112.32,Percent of Total Billed Charges,72% of Total Billed Charges,146.25,75,,117,Percent of Total Billed charges,75% of Total Billed Charges,195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.4,72,,112.32,Percent of Total Billed Charges,72% of Total Billed Charges,117,60,,93.6,Percent of Total Billed Charges,60% of Total Billed Charges,175.5,90,,1538.056,Percent of Total Billed Charges,90% of Total Billed Charges,87.75,45,,230.76,Percent of Total Billed Charges,45% of Total Billed Charges,175.5,90,,341.28,Percent of Total Billed Charges,90% of Total billed Charges,195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.75,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,86,44.1,,226.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,185.25,95,,360.24,Percent of Total Billed Charges,95% of Total Billed Charges,195,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.6,88,,985.6,Percent of Total Billed Charges,88% of Total Billed Charges,175.5,90,,341.28,Percent of Total Billed charges,90% of Total Billed Charges,86,195,
Metronidazole 50mg/1ml,6360000418,CDM,250,RC,,,Outpatient,50,GM,16.25,10.56,,16.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.35,76,,389.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.7,72,,9.36,Percent of Total Billed Charges,72% of Total Billed Charges,12.19,75,,9.752,Percent of Total Billed charges,75% of Total Billed Charges,16.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.7,72,,9.36,Percent of Total Billed Charges,72% of Total Billed Charges,9.75,60,,7.8,Percent of Total Billed Charges,60% of Total Billed Charges,14.63,90,,555.288,Percent of Total Billed Charges,90% of Total Billed Charges,7.31,45,,190.08,Percent of Total Billed Charges,45% of Total Billed Charges,14.63,90,,461.2,Percent of Total Billed Charges,90% of Total billed Charges,16.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.56,65,,289.512,Percent of total Billed Charges,65% of Total Billed Charges,7.17,44.1,,186.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.44,95,,486.816,Percent of Total Billed Charges,95% of Total Billed Charges,16.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.3,88,,451.264,Percent of Total Billed Charges,88% of Total Billed Charges,14.63,90,,461.2,Percent of Total Billed charges,90% of Total Billed Charges,7.17,16.25,
Metronidazole 7500mg/150ml bot,6360000419,CDM,250,RC,,,Outpatient,7500,GM,465.38,302.50,,465.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,353.69,76,,3301.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,335.07,72,,268.056,Percent of Total Billed Charges,72% of Total Billed Charges,349.04,75,,279.232,Percent of Total Billed charges,75% of Total Billed Charges,465.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,335.07,72,,268.056,Percent of Total Billed Charges,72% of Total Billed Charges,279.23,60,,223.384,Percent of Total Billed Charges,60% of Total Billed Charges,418.84,90,,555.288,Percent of Total Billed Charges,90% of Total Billed Charges,209.42,45,,646.92,Percent of Total Billed Charges,45% of Total Billed Charges,418.84,90,,3909.6,Percent of Total Billed Charges,90% of Total billed Charges,465.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.5,65,,49978.24,Percent of total Billed Charges,65% of Total Billed Charges,205.23,44.1,,633.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,442.11,95,,4126.8,Percent of Total Billed Charges,95% of Total Billed Charges,465.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.53,88,,371.712,Percent of Total Billed Charges,88% of Total Billed Charges,418.84,90,,3909.6,Percent of Total Billed charges,90% of Total Billed Charges,205.23,465.38,
Zilretta 32mg,6360000420,CDM,636,RC,J3304,HCPCS,Outpatient,32,GM,7040.00,4576.00,,22.5,125,,,Fee Schedule,125% of CMS OPPS Rate,5350.4,76,,1585.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,73.57,350,,,Fee Schedule,350% of BCBS fee schedule,73.57,350,,,Fee Schedule,350% of BCBS fee schedule,18,100,,,Fee Schedule,100% of CMS OPPS Rate,73.57,350,,,Fee Schedule,350% of BCBS PPO fee schedule,21.02,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,6336,90,,1152,Percent of Total Billed Charges,90% of Total Billed Charges,3168,45,,862.008,Percent of Total Billed Charges,45% of Total Billed Charges,6336,90,,1877.336,Percent of Total Billed Charges,90% of Total billed Charges,18,100,,,Fee Schedule,100% of CMS OPPS Rate,18,100,,,Fee Schedule,100% of CMS OPPS Rate,18,100,,,Fee Schedule,100% of CMS OPPS Rate,4612,65,,204.664,Percent of total Billed Charges,65% of Total Billed Charges,3104.64,44.1,,844.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,6688,95,,1981.632,Percent of Total Billed Charges,95% of Total Billed Charges,13.5,75,,,Fee Schedule,75% of CMS OPPS Rate,6195.2,88,,1265.088,Percent of Total Billed Charges,88% of Total Billed Charges,6336,90,,1877.336,Percent of Total Billed charges,90% of Total Billed Charges,13.5,6688,
Synvisc 48mg/6ml syrg,6360000421,CDM,636,RC,J7325,HCPCS,Outpatient,48,GM,12714.85,8264.65,,11.45,125,,,Fee Schedule,125% of CMS OPPS Rate,9663.29,76,,2357.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,44.59,350,,,Fee Schedule,350% of BCBS fee schedule,44.59,350,,,Fee Schedule,350% of BCBS fee schedule,9.16,100,,,Fee Schedule,100% of CMS OPPS Rate,44.59,350,,,Fee Schedule,350% of BCBS PPO fee schedule,12.74,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,11443.37,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,5721.68,45,,769.032,Percent of Total Billed Charges,45% of Total Billed Charges,11443.37,90,,2791.592,Percent of Total Billed Charges,90% of Total billed Charges,9.16,100,,,Fee Schedule,100% of CMS OPPS Rate,9.16,100,,,Fee Schedule,100% of CMS OPPS Rate,9.16,100,,,Fee Schedule,100% of CMS OPPS Rate,8282.97,65,,177.152,Percent of total Billed Charges,65% of Total Billed Charges,5607.25,44.1,,753.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,12079.11,95,,2946.68,Percent of Total Billed Charges,95% of Total Billed Charges,6.87,75,,,Fee Schedule,75% of CMS OPPS Rate,11189.07,88,,1685.696,Percent of Total Billed Charges,88% of Total Billed Charges,11443.37,90,,2791.592,Percent of Total Billed charges,90% of Total Billed Charges,6.87,12079.11,
Orthovisc 30mg/2ml,6360000422,CDM,636,RC,J7326,HCPCS,Outpatient,30,GM,11356.25,7381.56,,657.97,125,,,Fee Schedule,125% of CMS OPPS Rate,8630.75,76,,851.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1854.41,350,,,Fee Schedule,350% of BCBS fee schedule,1854.41,350,,,Fee Schedule,350% of BCBS fee schedule,526.38,100,,,Fee Schedule,100% of CMS OPPS Rate,1854.41,350,,,Fee Schedule,350% of BCBS PPO fee schedule,529.83,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,10220.63,90,,437.04,Percent of Total Billed Charges,90% of Total Billed Charges,5110.31,45,,769.032,Percent of Total Billed Charges,45% of Total Billed Charges,10220.63,90,,1008,Percent of Total Billed Charges,90% of Total billed Charges,526.38,100,,,Fee Schedule,100% of CMS OPPS Rate,526.38,100,,,Fee Schedule,100% of CMS OPPS Rate,526.38,100,,,Fee Schedule,100% of CMS OPPS Rate,8434.32,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,5008.11,44.1,,753.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,10788.44,95,,1064,Percent of Total Billed Charges,95% of Total Billed Charges,394.78,75,,,Fee Schedule,75% of CMS OPPS Rate,9993.5,88,,1503.88,Percent of Total Billed Charges,88% of Total Billed Charges,10220.63,90,,1008,Percent of Total Billed charges,90% of Total Billed Charges,394.78,10788.44,
Monovisc 88mg/4ml,6360000423,CDM,636,RC,J7326,HCPCS,Outpatient,88,GM,11356.25,7381.56,,657.97,125,,,Fee Schedule,125% of CMS OPPS Rate,8630.75,76,,389.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1854.41,350,,,Fee Schedule,350% of BCBS fee schedule,1854.41,350,,,Fee Schedule,350% of BCBS fee schedule,526.38,100,,,Fee Schedule,100% of CMS OPPS Rate,1854.41,350,,,Fee Schedule,350% of BCBS PPO fee schedule,529.83,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,10220.63,90,,252.432,Percent of Total Billed Charges,90% of Total Billed Charges,5110.31,45,,277.64,Percent of Total Billed Charges,45% of Total Billed Charges,10220.63,90,,461.52,Percent of Total Billed Charges,90% of Total billed Charges,526.38,100,,,Fee Schedule,100% of CMS OPPS Rate,526.38,100,,,Fee Schedule,100% of CMS OPPS Rate,526.38,100,,,Fee Schedule,100% of CMS OPPS Rate,8434.32,65,,587.6,Percent of total Billed Charges,65% of Total Billed Charges,5008.11,44.1,,272.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,10788.44,95,,487.16,Percent of Total Billed Charges,95% of Total Billed Charges,394.78,75,,,Fee Schedule,75% of CMS OPPS Rate,9993.5,88,,1503.88,Percent of Total Billed Charges,88% of Total Billed Charges,10220.63,90,,461.52,Percent of Total Billed charges,90% of Total Billed Charges,394.78,10788.44,
FERAHEME 510MG INJ NON ESRD,6360000424,CDM,636,RC,Q0138,HCPCS,Outpatient,510,GM,8.98,5.84,,0.47,125,,,Fee Schedule,125% of CMS OPPS Rate,6.82,76,,321.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.18,350,,,Fee Schedule,350% of BCBS fee schedule,5.18,350,,,Fee Schedule,350% of BCBS fee schedule,0.38,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.48,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,8.08,90,,252.432,Percent of Total Billed Charges,90% of Total Billed Charges,4.04,45,,277.64,Percent of Total Billed Charges,45% of Total Billed Charges,8.08,90,,380.16,Percent of Total Billed Charges,90% of Total billed Charges,0.38,100,,,Fee Schedule,100% of CMS OPPS Rate,0.38,100,,,Fee Schedule,100% of CMS OPPS Rate,0.38,100,,,Fee Schedule,100% of CMS OPPS Rate,6.6,65,,460.936,Percent of total Billed Charges,65% of Total Billed Charges,3.96,44.1,,272.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.53,95,,401.28,Percent of Total Billed Charges,95% of Total Billed Charges,0.28,75,,,Fee Schedule,75% of CMS OPPS Rate,7.9,88,,542.944,Percent of Total Billed Charges,88% of Total Billed Charges,8.08,90,,380.16,Percent of Total Billed charges,90% of Total Billed Charges,0.28,8.53,
FERAHEME 510MG/17ML INJ ESRD,6360000425,CDM,636,RC,Q0139,HCPCS,Outpatient,510,GM,11443.65,7438.37,,0.47,125,,,Fee Schedule,125% of CMS OPPS Rate,8697.17,76,,1092.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.18,350,,,Fee Schedule,350% of BCBS fee schedule,5.18,350,,,Fee Schedule,350% of BCBS fee schedule,0.38,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.48,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,10299.29,90,,1017.36,Percent of Total Billed Charges,90% of Total Billed Charges,5149.64,45,,576,Percent of Total Billed Charges,45% of Total Billed Charges,10299.29,90,,1293.84,Percent of Total Billed Charges,90% of Total billed Charges,0.38,100,,,Fee Schedule,100% of CMS OPPS Rate,0.38,100,,,Fee Schedule,100% of CMS OPPS Rate,0.38,100,,,Fee Schedule,100% of CMS OPPS Rate,7439.13,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,5046.65,44.1,,564.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,10871.47,95,,1365.72,Percent of Total Billed Charges,95% of Total Billed Charges,0.28,75,,,Fee Schedule,75% of CMS OPPS Rate,10070.41,88,,542.944,Percent of Total Billed Charges,88% of Total Billed Charges,10299.29,90,,1293.84,Percent of Total Billed charges,90% of Total Billed Charges,0.28,10871.47,
Infed 100mg/2ml Inj,6360000427,CDM,636,RC,J1750,HCPCS,Outpatient,100,GM,63.62,41.35,,21.75,125,,,Fee Schedule,125% of CMS OPPS Rate,48.35,76,,1298.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,43.23,350,,,Fee Schedule,350% of BCBS fee schedule,43.23,350,,,Fee Schedule,350% of BCBS fee schedule,17.39,100,,,Fee Schedule,100% of CMS OPPS Rate,43.23,350,,,Fee Schedule,350% of BCBS PPO fee schedule,12.35,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,57.26,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,28.63,45,,218.52,Percent of Total Billed Charges,45% of Total Billed Charges,57.26,90,,1538.056,Percent of Total Billed Charges,90% of Total billed Charges,17.39,100,,,Fee Schedule,100% of CMS OPPS Rate,17.39,100,,,Fee Schedule,100% of CMS OPPS Rate,17.39,100,,,Fee Schedule,100% of CMS OPPS Rate,76.14,65,,294.68,Percent of total Billed Charges,65% of Total Billed Charges,28.06,44.1,,214.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,60.44,95,,1623.504,Percent of Total Billed Charges,95% of Total Billed Charges,13.05,75,,,Fee Schedule,75% of CMS OPPS Rate,55.99,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,57.26,90,,1538.056,Percent of Total Billed charges,90% of Total Billed Charges,12.35,76.14,
"HEPARIN 10,000 UNITS/10 ML INJ",6360000428,CDM,636,RC,J1644,HCPCS,Outpatient,10,ML,30.00,19.50,,30,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.8,76,,1298.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.67,350,,,Fee Schedule,350% of BCBS fee schedule,0.67,350,,,Fee Schedule,350% of BCBS fee schedule,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.67,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.19,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,27,90,,1912.312,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,45,,126.216,Percent of Total Billed Charges,45% of Total Billed Charges,27,90,,1538.056,Percent of Total Billed Charges,90% of Total billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.5,65,,674.44,Percent of total Billed Charges,65% of Total Billed Charges,13.23,44.1,,123.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.5,95,,1623.504,Percent of Total Billed Charges,95% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.4,88,,427.328,Percent of Total Billed Charges,88% of Total Billed Charges,27,90,,1538.056,Percent of Total Billed charges,90% of Total Billed Charges,0.19,30,
CANGRELOR 50MG INJ,6360000429,CDM,636,RC,C9460,HCPCS,Outpatient,50,GM,1939.85,1260.90,,23.52,125,,,Fee Schedule,125% of CMS OPPS Rate,1474.29,76,,468.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1396.69,72,,1117.352,Percent of Total Billed Charges,72% of Total Billed Charges,1454.89,75,,1163.912,Percent of Total Billed charges,75% of Total Billed Charges,18.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.69,72,,1117.352,Percent of Total Billed Charges,72% of Total Billed Charges,1163.91,60,,931.128,Percent of Total Billed Charges,60% of Total Billed Charges,1745.87,90,,1912.312,Percent of Total Billed Charges,90% of Total Billed Charges,872.93,45,,126.216,Percent of Total Billed Charges,45% of Total Billed Charges,1745.87,90,,555.288,Percent of Total Billed Charges,90% of Total billed Charges,18.82,100,,,Fee Schedule,100% of CMS OPPS Rate,18.82,100,,,Fee Schedule,100% of CMS OPPS Rate,18.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1298.54,65,,1043.408,Percent of total Billed Charges,65% of Total Billed Charges,855.47,44.1,,123.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,1842.86,95,,586.136,Percent of Total Billed Charges,95% of Total Billed Charges,14.11,75,,,Fee Schedule,75% of CMS OPPS Rate,1707.07,88,,246.824,Percent of Total Billed Charges,88% of Total Billed Charges,1745.87,90,,555.288,Percent of Total Billed charges,90% of Total Billed Charges,14.11,1842.86,
MicRhogam uf 50MCG SYG,6360000430,CDM,636,RC,,,Outpatient,50,GM,356.32,231.61,,356.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,270.8,76,,468.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,256.55,72,,205.24,Percent of Total Billed Charges,72% of Total Billed Charges,267.24,75,,213.792,Percent of Total Billed charges,75% of Total Billed Charges,356.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.55,72,,205.24,Percent of Total Billed Charges,72% of Total Billed Charges,213.79,60,,171.032,Percent of Total Billed Charges,60% of Total Billed Charges,320.69,90,,1636.024,Percent of Total Billed Charges,90% of Total Billed Charges,160.34,45,,508.68,Percent of Total Billed Charges,45% of Total Billed Charges,320.69,90,,555.288,Percent of Total Billed Charges,90% of Total billed Charges,356.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.61,65,,498.68,Percent of total Billed Charges,65% of Total Billed Charges,157.14,44.1,,498.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,338.5,95,,586.136,Percent of Total Billed Charges,95% of Total Billed Charges,356.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.56,88,,246.824,Percent of Total Billed Charges,88% of Total Billed Charges,320.69,90,,555.288,Percent of Total Billed charges,90% of Total Billed Charges,157.14,356.32,
MONOFERRIC 1000MG/10ML INJ,6360000431,CDM,636,RC,J1437,HCPCS,Outpatient,1000,GM,6160.68,4004.44,,25.96,125,,,Fee Schedule,125% of CMS OPPS Rate,4682.12,76,,972.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4435.69,72,,3548.552,Percent of Total Billed Charges,72% of Total Billed Charges,4620.51,75,,3696.408,Percent of Total Billed charges,75% of Total Billed Charges,20.77,100,,,Fee Schedule,100% of CMS OPPS Rate,4435.69,72,,3548.552,Percent of Total Billed Charges,72% of Total Billed Charges,3696.41,60,,2957.128,Percent of Total Billed Charges,60% of Total Billed Charges,5544.61,90,,2023.92,Percent of Total Billed Charges,90% of Total Billed Charges,2772.31,45,,617.984,Percent of Total Billed Charges,45% of Total Billed Charges,5544.61,90,,1152,Percent of Total Billed Charges,90% of Total billed Charges,20.77,100,,,Fee Schedule,100% of CMS OPPS Rate,20.77,100,,,Fee Schedule,100% of CMS OPPS Rate,20.77,100,,,Fee Schedule,100% of CMS OPPS Rate,4045.98,65,,365.04,Percent of total Billed Charges,65% of Total Billed Charges,2716.86,44.1,,605.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,5852.65,95,,1216,Percent of Total Billed Charges,95% of Total Billed Charges,15.57,75,,,Fee Schedule,75% of CMS OPPS Rate,5421.4,88,,994.752,Percent of Total Billed Charges,88% of Total Billed Charges,5544.61,90,,1152,Percent of Total Billed charges,90% of Total Billed Charges,15.57,5852.65,
Cefazolin Sodium Inj,6360000432,CDM,636,RC,J0690,HCPCS,Outpatient,,,6.53,4.24,,6.53,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.96,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.56,350,,,Fee Schedule,350% of BCBS fee schedule,0.56,350,,,Fee Schedule,350% of BCBS fee schedule,6.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.56,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.16,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5.88,90,,251.632,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,5.88,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,6.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.24,65,,365.04,Percent of total Billed Charges,65% of Total Billed Charges,2.88,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,6.2,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,6.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.75,88,,1208.504,Percent of Total Billed Charges,88% of Total Billed Charges,5.88,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,0.16,6.53,
Benlysta 120mg inj,6360000433,CDM,636,RC,J0490,HCPCS,Outpatient,120,GM,191.18,124.27,,68.63,125,,,Fee Schedule,125% of CMS OPPS Rate,145.3,76,,369.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,143.22,350,,,Fee Schedule,350% of BCBS fee schedule,143.22,350,,,Fee Schedule,350% of BCBS fee schedule,54.91,100,,,Fee Schedule,100% of CMS OPPS Rate,143.22,350,,,Fee Schedule,350% of BCBS PPO fee schedule,40.92,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,172.06,90,,415.952,Percent of Total Billed Charges,90% of Total Billed Charges,86.03,45,,956.16,Percent of Total Billed Charges,45% of Total Billed Charges,172.06,90,,437.04,Percent of Total Billed Charges,90% of Total billed Charges,54.91,100,,,Fee Schedule,100% of CMS OPPS Rate,54.91,100,,,Fee Schedule,100% of CMS OPPS Rate,54.91,100,,,Fee Schedule,100% of CMS OPPS Rate,234.09,65,,496.08,Percent of total Billed Charges,65% of Total Billed Charges,84.31,44.1,,937.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,181.62,95,,461.32,Percent of Total Billed Charges,95% of Total Billed Charges,41.18,75,,,Fee Schedule,75% of CMS OPPS Rate,168.24,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,172.06,90,,437.04,Percent of Total Billed charges,90% of Total Billed Charges,40.92,234.09,
Synvisc 2ml,6360000434,CDM,636,RC,J7322,HCPCS,Outpatient,2,ML,79.18,51.47,,21.77,125,,,Fee Schedule,125% of CMS OPPS Rate,60.18,76,,213.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.6,350,,,Fee Schedule,350% of BCBS fee schedule,63.6,350,,,Fee Schedule,350% of BCBS fee schedule,17.42,100,,,Fee Schedule,100% of CMS OPPS Rate,63.6,350,,,Fee Schedule,350% of BCBS PPO fee schedule,18.17,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,71.26,90,,4519.904,Percent of Total Billed Charges,90% of Total Billed Charges,35.63,45,,956.16,Percent of Total Billed Charges,45% of Total Billed Charges,71.26,90,,252.432,Percent of Total Billed Charges,90% of Total billed Charges,17.42,100,,,Fee Schedule,100% of CMS OPPS Rate,17.42,100,,,Fee Schedule,100% of CMS OPPS Rate,17.42,100,,,Fee Schedule,100% of CMS OPPS Rate,86.31,65,,332.8,Percent of total Billed Charges,65% of Total Billed Charges,34.92,44.1,,937.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,75.22,95,,266.456,Percent of Total Billed Charges,95% of Total Billed Charges,13.06,75,,,Fee Schedule,75% of CMS OPPS Rate,69.68,88,,1869.816,Percent of Total Billed Charges,88% of Total Billed Charges,71.26,90,,252.432,Percent of Total Billed charges,90% of Total Billed Charges,13.06,86.31,
Daptomycin 500mg inj,6360000435,CDM,636,RC,J0878,HCPCS,Outpatient,500,GM,0.47,0.31,,0.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.36,76,,213.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.34,72,,0.272,Percent of Total Billed Charges,72% of Total Billed Charges,0.35,75,,0.28,Percent of Total Billed charges,75% of Total Billed Charges,0.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.34,72,,0.272,Percent of Total Billed Charges,72% of Total Billed Charges,0.28,60,,0.224,Percent of Total Billed Charges,60% of Total Billed Charges,0.42,90,,199.912,Percent of Total Billed Charges,90% of Total Billed Charges,0.47,100,,818.008,Fee Schedule,Pays based on 100% of TX Medicaid rate,0.42,90,,252.432,Percent of Total Billed Charges,90% of Total billed Charges,0.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.31,65,,183.56,Percent of total Billed Charges,65% of Total Billed Charges,0.47,100,,801.648,Fee Schedule,Pays based on 100% of TX Medicaid rate,0.45,95,,266.456,Percent of Total Billed Charges,95% of Total Billed Charges,0.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.41,88,,1869.816,Percent of Total Billed Charges,88% of Total Billed Charges,0.42,90,,252.432,Percent of Total Billed charges,90% of Total Billed Charges,0.28,0.47,
Retacrit Inj 3000u/ml Non ESRD,6360000436,CDM,636,RC,Q5106,HCPCS,Outpatient,1,ML,43.57,28.32,,9.33,125,,,Fee Schedule,125% of CMS OPPS Rate,33.11,76,,859.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.57,350,,,Fee Schedule,350% of BCBS fee schedule,45.57,350,,,Fee Schedule,350% of BCBS fee schedule,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,45.57,350,,,Fee Schedule,350% of BCBS PPO fee schedule,13.02,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,39.21,90,,327.4,Percent of Total Billed Charges,90% of Total Billed Charges,19.61,45,,1011.96,Percent of Total Billed Charges,45% of Total Billed Charges,39.21,90,,1017.36,Percent of Total Billed Charges,90% of Total billed Charges,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,43.26,65,,347.992,Percent of total Billed Charges,65% of Total Billed Charges,19.21,44.1,,991.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.39,95,,1073.88,Percent of Total Billed Charges,95% of Total Billed Charges,5.6,75,,,Fee Schedule,75% of CMS OPPS Rate,38.34,88,,1599.664,Percent of Total Billed Charges,88% of Total Billed Charges,39.21,90,,1017.36,Percent of Total Billed charges,90% of Total Billed Charges,5.6,45.57,
"Procrit 20,000u/ml Non ESRD",6360000437,CDM,636,RC,J0885,HCPCS,Outpatient,1,ML,1336.25,868.56,,8.07,125,,,Fee Schedule,125% of CMS OPPS Rate,1015.55,76,,1043.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.39,350,,,Fee Schedule,350% of BCBS fee schedule,56.39,350,,,Fee Schedule,350% of BCBS fee schedule,6.46,100,,,Fee Schedule,100% of CMS OPPS Rate,56.39,350,,,Fee Schedule,350% of BCBS PPO fee schedule,16.11,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,1202.63,90,,1158.48,Percent of Total Billed Charges,90% of Total Billed Charges,601.31,45,,125.816,Percent of Total Billed Charges,45% of Total Billed Charges,1202.63,90,,1235.976,Percent of Total Billed Charges,90% of Total billed Charges,6.46,100,,,Fee Schedule,100% of CMS OPPS Rate,6.46,100,,,Fee Schedule,100% of CMS OPPS Rate,6.46,100,,,Fee Schedule,100% of CMS OPPS Rate,881.48,65,,498.68,Percent of total Billed Charges,65% of Total Billed Charges,589.29,44.1,,123.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,1269.44,95,,1304.64,Percent of Total Billed Charges,95% of Total Billed Charges,4.84,75,,,Fee Schedule,75% of CMS OPPS Rate,1175.9,88,,1978.944,Percent of Total Billed Charges,88% of Total Billed Charges,1202.63,90,,1235.976,Percent of Total Billed charges,90% of Total Billed Charges,4.84,1269.44,
"Procrit 10,000u/ml Non ESRD",6360000438,CDM,636,RC,J0885,HCPCS,Outpatient,1,ML,668.13,434.28,,8.07,125,,,Fee Schedule,125% of CMS OPPS Rate,507.78,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.39,350,,,Fee Schedule,350% of BCBS fee schedule,56.39,350,,,Fee Schedule,350% of BCBS fee schedule,6.46,100,,,Fee Schedule,100% of CMS OPPS Rate,56.39,350,,,Fee Schedule,350% of BCBS PPO fee schedule,16.11,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,601.32,90,,1109.416,Percent of Total Billed Charges,90% of Total Billed Charges,300.66,45,,207.976,Percent of Total Billed Charges,45% of Total Billed Charges,601.32,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,6.46,100,,,Fee Schedule,100% of CMS OPPS Rate,6.46,100,,,Fee Schedule,100% of CMS OPPS Rate,6.46,100,,,Fee Schedule,100% of CMS OPPS Rate,447.2,65,,365.04,Percent of total Billed Charges,65% of Total Billed Charges,294.65,44.1,,203.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,634.72,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,4.84,75,,,Fee Schedule,75% of CMS OPPS Rate,587.95,88,,246.04,Percent of Total Billed Charges,88% of Total Billed Charges,601.32,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,4.84,634.72,
"Procrit 2,000u/ml Non ESRD",6360000439,CDM,636,RC,J0885,HCPCS,Outpatient,1,ML,133.65,86.87,,8.07,125,,,Fee Schedule,125% of CMS OPPS Rate,101.57,76,,1614.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.39,350,,,Fee Schedule,350% of BCBS fee schedule,56.39,350,,,Fee Schedule,350% of BCBS fee schedule,6.46,100,,,Fee Schedule,100% of CMS OPPS Rate,56.39,350,,,Fee Schedule,350% of BCBS PPO fee schedule,16.11,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,120.29,90,,1083.6,Percent of Total Billed Charges,90% of Total Billed Charges,60.14,45,,2259.952,Percent of Total Billed Charges,45% of Total Billed Charges,120.29,90,,1912.312,Percent of Total Billed Charges,90% of Total billed Charges,6.46,100,,,Fee Schedule,100% of CMS OPPS Rate,6.46,100,,,Fee Schedule,100% of CMS OPPS Rate,6.46,100,,,Fee Schedule,100% of CMS OPPS Rate,99.79,65,,498.68,Percent of total Billed Charges,65% of Total Billed Charges,58.94,44.1,,2214.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,126.97,95,,2018.552,Percent of Total Billed Charges,95% of Total Billed Charges,4.84,75,,,Fee Schedule,75% of CMS OPPS Rate,117.61,88,,406.704,Percent of Total Billed Charges,88% of Total Billed Charges,120.29,90,,1912.312,Percent of Total Billed charges,90% of Total Billed Charges,4.84,126.97,
"Procrit 3,000u/ml Non ESRD",6360000440,CDM,636,RC,J0885,HCPCS,Outpatient,1,ML,200.45,130.29,,8.07,125,,,Fee Schedule,125% of CMS OPPS Rate,152.34,76,,1614.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.39,350,,,Fee Schedule,350% of BCBS fee schedule,56.39,350,,,Fee Schedule,350% of BCBS fee schedule,6.46,100,,,Fee Schedule,100% of CMS OPPS Rate,56.39,350,,,Fee Schedule,350% of BCBS PPO fee schedule,16.11,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,180.41,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,90.2,45,,99.952,Percent of Total Billed Charges,45% of Total Billed Charges,180.41,90,,1912.312,Percent of Total Billed Charges,90% of Total billed Charges,6.46,100,,,Fee Schedule,100% of CMS OPPS Rate,6.46,100,,,Fee Schedule,100% of CMS OPPS Rate,6.46,100,,,Fee Schedule,100% of CMS OPPS Rate,143.21,65,,282.88,Percent of total Billed Charges,65% of Total Billed Charges,88.4,44.1,,97.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,190.43,95,,2018.552,Percent of Total Billed Charges,95% of Total Billed Charges,4.84,75,,,Fee Schedule,75% of CMS OPPS Rate,176.4,88,,4419.456,Percent of Total Billed Charges,88% of Total Billed Charges,180.41,90,,1912.312,Percent of Total Billed charges,90% of Total Billed Charges,4.84,190.43,
Leqvio 284mg/ml (1.5ml)Syringe,6360000441,CDM,636,RC,J1306,HCPCS,Outpatient,284,GM,29.48,19.16,,15.35,125,,,Fee Schedule,125% of CMS OPPS Rate,22.4,76,,1381.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,21.23,72,,16.984,Percent of Total Billed Charges,72% of Total Billed Charges,22.11,75,,17.688,Percent of Total Billed charges,75% of Total Billed Charges,12.28,100,,,Fee Schedule,100% of CMS OPPS Rate,21.23,72,,16.984,Percent of Total Billed Charges,72% of Total Billed Charges,17.69,60,,14.152,Percent of Total Billed Charges,60% of Total Billed Charges,26.53,90,,1555.2,Percent of Total Billed Charges,90% of Total Billed Charges,13.27,45,,163.696,Percent of Total Billed Charges,45% of Total Billed Charges,26.53,90,,1636.024,Percent of Total Billed Charges,90% of Total billed Charges,12.28,100,,,Fee Schedule,100% of CMS OPPS Rate,12.28,100,,,Fee Schedule,100% of CMS OPPS Rate,12.28,100,,,Fee Schedule,100% of CMS OPPS Rate,43.72,65,,628.68,Percent of total Billed Charges,65% of Total Billed Charges,13,44.1,,160.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.01,95,,1726.912,Percent of Total Billed Charges,95% of Total Billed Charges,9.21,75,,,Fee Schedule,75% of CMS OPPS Rate,25.94,88,,195.464,Percent of Total Billed Charges,88% of Total Billed Charges,26.53,90,,1636.024,Percent of Total Billed charges,90% of Total Billed Charges,9.21,43.72,
Fasenra 30mg/ml syringe,6360000442,CDM,636,RC,J0517,HCPCS,Outpatient,30,GM,704.53,457.94,,207.36,125,,,Fee Schedule,125% of CMS OPPS Rate,535.44,76,,1709.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,650.79,350,,,Fee Schedule,350% of BCBS fee schedule,650.79,350,,,Fee Schedule,350% of BCBS fee schedule,165.89,100,,,Fee Schedule,100% of CMS OPPS Rate,650.79,350,,,Fee Schedule,350% of BCBS PPO fee schedule,185.94,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,634.08,90,,1505.52,Percent of Total Billed Charges,90% of Total Billed Charges,317.04,45,,579.24,Percent of Total Billed Charges,45% of Total Billed Charges,634.08,90,,2023.92,Percent of Total Billed Charges,90% of Total billed Charges,165.89,100,,,Fee Schedule,100% of CMS OPPS Rate,165.89,100,,,Fee Schedule,100% of CMS OPPS Rate,165.89,100,,,Fee Schedule,100% of CMS OPPS Rate,789.72,65,,294.68,Percent of total Billed Charges,65% of Total Billed Charges,310.7,44.1,,567.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,669.3,95,,2136.36,Percent of Total Billed Charges,95% of Total Billed Charges,124.41,75,,,Fee Schedule,75% of CMS OPPS Rate,619.99,88,,320.12,Percent of Total Billed Charges,88% of Total Billed Charges,634.08,90,,2023.92,Percent of Total Billed charges,90% of Total Billed Charges,124.41,789.72,
"Retacrit 40,000u/ml inj NESRD",6360000443,CDM,636,RC,Q5106,HCPCS,Outpatient,1,ML,43.57,28.32,,9.33,125,,,Fee Schedule,125% of CMS OPPS Rate,33.11,76,,212.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.57,350,,,Fee Schedule,350% of BCBS fee schedule,45.57,350,,,Fee Schedule,350% of BCBS fee schedule,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,45.57,350,,,Fee Schedule,350% of BCBS PPO fee schedule,13.02,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,39.21,90,,2791.592,Percent of Total Billed Charges,90% of Total Billed Charges,19.61,45,,554.704,Percent of Total Billed Charges,45% of Total Billed Charges,39.21,90,,251.632,Percent of Total Billed Charges,90% of Total billed Charges,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,43.26,65,,991.64,Percent of total Billed Charges,65% of Total Billed Charges,19.21,44.1,,543.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.39,95,,265.616,Percent of Total Billed Charges,95% of Total Billed Charges,5.6,75,,,Fee Schedule,75% of CMS OPPS Rate,38.34,88,,1132.736,Percent of Total Billed Charges,88% of Total Billed Charges,39.21,90,,251.632,Percent of Total Billed charges,90% of Total Billed Charges,5.6,45.57,
"Retacrit 40,000u/ml inj (ERSD)",6360000444,CDM,634,RC,Q5105,HCPCS,Outpatient,1,ML,20.33,13.21,,0.93,125,,,Fee Schedule,125% of CMS OPPS Rate,15.45,76,,351.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.55,350,,,Fee Schedule,350% of BCBS fee schedule,4.55,350,,,Fee Schedule,350% of BCBS fee schedule,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.55,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.3,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,18.3,90,,2372.24,Percent of Total Billed Charges,90% of Total Billed Charges,9.15,45,,541.8,Percent of Total Billed Charges,45% of Total Billed Charges,18.3,90,,415.952,Percent of Total Billed Charges,90% of Total billed Charges,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,1.5,200,,546.52,Fee Schedule,200% of CMS OPPS Rate,8.97,44.1,,530.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.31,95,,439.056,Percent of Total Billed Charges,95% of Total Billed Charges,0.56,75,,,Fee Schedule,75% of CMS OPPS Rate,17.89,88,,1084.76,Percent of Total Billed Charges,88% of Total Billed Charges,18.3,90,,415.952,Percent of Total Billed charges,90% of Total Billed Charges,0.56,19.31,
"Retacrit 10,000u/ml inj NESRD",6360000445,CDM,636,RC,Q5106,HCPCS,Outpatient,1,ML,43.57,28.32,,9.33,125,,,Fee Schedule,125% of CMS OPPS Rate,33.11,76,,3816.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.57,350,,,Fee Schedule,350% of BCBS fee schedule,45.57,350,,,Fee Schedule,350% of BCBS fee schedule,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,45.57,350,,,Fee Schedule,350% of BCBS PPO fee schedule,13.02,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,39.21,90,,1213.92,Percent of Total Billed Charges,90% of Total Billed Charges,19.61,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,39.21,90,,4519.904,Percent of Total Billed Charges,90% of Total billed Charges,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,43.26,65,,1093.04,Percent of total Billed Charges,65% of Total Billed Charges,19.21,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.39,95,,4771.008,Percent of Total Billed Charges,95% of Total Billed Charges,5.6,75,,,Fee Schedule,75% of CMS OPPS Rate,38.34,88,,1059.52,Percent of Total Billed Charges,88% of Total Billed Charges,39.21,90,,4519.904,Percent of Total Billed charges,90% of Total Billed Charges,5.6,45.57,
"Retacrit 10,000u/ml inj ERSD",6360000446,CDM,634,RC,Q5105,HCPCS,Outpatient,1,ML,20.33,13.21,,0.93,125,,,Fee Schedule,125% of CMS OPPS Rate,15.45,76,,168.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4.55,350,,,Fee Schedule,350% of BCBS fee schedule,4.55,350,,,Fee Schedule,350% of BCBS fee schedule,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.55,350,,,Fee Schedule,350% of BCBS PPO fee schedule,1.3,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,18.3,90,,401.04,Percent of Total Billed Charges,90% of Total Billed Charges,9.15,45,,777.6,Percent of Total Billed Charges,45% of Total Billed Charges,18.3,90,,199.912,Percent of Total Billed Charges,90% of Total billed Charges,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.75,100,,,Fee Schedule,100% of CMS OPPS Rate,1.5,200,,651.04,Fee Schedule,200% of CMS OPPS Rate,8.97,44.1,,762.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.31,95,,211.016,Percent of Total Billed Charges,95% of Total Billed Charges,0.56,75,,,Fee Schedule,75% of CMS OPPS Rate,17.89,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,18.3,90,,199.912,Percent of Total Billed charges,90% of Total Billed Charges,0.56,19.31,
Kedrab 150u/ml (10ml) inj,6360000447,CDM,636,RC,90377,HCPCS,Outpatient,10,ML,589.15,382.95,,313.14,125,,,Fee Schedule,125% of CMS OPPS Rate,447.75,76,,276.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,424.19,72,,339.352,Percent of Total Billed Charges,72% of Total Billed Charges,441.86,75,,353.488,Percent of Total Billed charges,75% of Total Billed Charges,250.52,100,,,Fee Schedule,100% of CMS OPPS Rate,424.19,72,,339.352,Percent of Total Billed Charges,72% of Total Billed Charges,353.49,60,,282.792,Percent of Total Billed Charges,60% of Total Billed Charges,530.24,90,,401.04,Percent of Total Billed Charges,90% of Total Billed Charges,265.12,45,,752.76,Percent of Total Billed Charges,45% of Total Billed Charges,530.24,90,,327.4,Percent of Total Billed Charges,90% of Total billed Charges,250.52,100,,,Fee Schedule,100% of CMS OPPS Rate,250.52,100,,,Fee Schedule,100% of CMS OPPS Rate,250.52,100,,,Fee Schedule,100% of CMS OPPS Rate,883.99,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,259.82,44.1,,737.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,559.69,95,,345.584,Percent of Total Billed Charges,95% of Total Billed Charges,187.89,75,,,Fee Schedule,75% of CMS OPPS Rate,518.45,88,,1520.64,Percent of Total Billed Charges,88% of Total Billed Charges,530.24,90,,327.4,Percent of Total Billed charges,90% of Total Billed Charges,187.89,883.99,
Gelsyn-3   16.8MG/2ML syrg,6360000448,CDM,636,RC,J7328,HCPCS,Outpatient,16.8,GM,2.95,1.92,,2.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2.24,76,,978.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.18,350,,,Fee Schedule,350% of BCBS fee schedule,7.18,350,,,Fee Schedule,350% of BCBS fee schedule,2.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.18,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.05,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,2.66,90,,136.8,Percent of Total Billed Charges,90% of Total Billed Charges,1.33,45,,1395.792,Percent of Total Billed Charges,45% of Total Billed Charges,2.66,90,,1158.48,Percent of Total Billed Charges,90% of Total billed Charges,2.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.92,65,,133.64,Percent of total Billed Charges,65% of Total Billed Charges,1.3,44.1,,1367.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,2.8,95,,1222.84,Percent of Total Billed Charges,95% of Total Billed Charges,2.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.6,88,,1472.064,Percent of Total Billed Charges,88% of Total Billed Charges,2.66,90,,1158.48,Percent of Total Billed charges,90% of Total Billed Charges,1.3,7.18,
Evenity 210mg/2.34ml (2 syrg),6360000449,CDM,636,RC,J3111,HCPCS,Outpatient,210,GM,79.31,51.55,,14.36,125,,,Fee Schedule,125% of CMS OPPS Rate,60.28,76,,936.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,41.13,350,,,Fee Schedule,350% of BCBS fee schedule,41.13,350,,,Fee Schedule,350% of BCBS fee schedule,11.49,100,,,Fee Schedule,100% of CMS OPPS Rate,41.13,350,,,Fee Schedule,350% of BCBS PPO fee schedule,11.75,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,71.38,90,,81.36,Percent of Total Billed Charges,90% of Total Billed Charges,35.69,45,,1186.12,Percent of Total Billed Charges,45% of Total Billed Charges,71.38,90,,1109.416,Percent of Total Billed Charges,90% of Total billed Charges,11.49,100,,,Fee Schedule,100% of CMS OPPS Rate,11.49,100,,,Fee Schedule,100% of CMS OPPS Rate,11.49,100,,,Fee Schedule,100% of CMS OPPS Rate,74.53,65,,196.64,Percent of total Billed Charges,65% of Total Billed Charges,34.98,44.1,,1162.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,75.34,95,,1171.048,Percent of Total Billed Charges,95% of Total Billed Charges,8.61,75,,,Fee Schedule,75% of CMS OPPS Rate,69.79,88,,2729.552,Percent of Total Billed Charges,88% of Total Billed Charges,71.38,90,,1109.416,Percent of Total Billed charges,90% of Total Billed Charges,8.61,75.34,
Durolane 60mg/3ml inj,6360000450,CDM,636,RC,J7318,HCPCS,Outpatient,60,GM,23.17,15.06,,8.36,125,,,Fee Schedule,125% of CMS OPPS Rate,17.61,76,,915.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,56.67,350,,,Fee Schedule,350% of BCBS fee schedule,56.67,350,,,Fee Schedule,350% of BCBS fee schedule,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,56.67,350,,,Fee Schedule,350% of BCBS PPO fee schedule,16.19,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,20.85,90,,99.36,Percent of Total Billed Charges,90% of Total Billed Charges,10.43,45,,606.96,Percent of Total Billed Charges,45% of Total Billed Charges,20.85,90,,1083.6,Percent of Total Billed Charges,90% of Total billed Charges,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,28.46,65,,82.68,Percent of total Billed Charges,65% of Total Billed Charges,10.22,44.1,,594.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,22.01,95,,1143.8,Percent of Total Billed Charges,95% of Total Billed Charges,5.01,75,,,Fee Schedule,75% of CMS OPPS Rate,20.39,88,,2319.528,Percent of Total Billed Charges,88% of Total Billed Charges,20.85,90,,1083.6,Percent of Total Billed charges,90% of Total Billed Charges,5.01,56.67,
Euflexxa 20mg/2ml inj,6360000451,CDM,636,RC,J7323,HCPCS,Outpatient,20,GM,327.22,212.69,,150.85,125,,,Fee Schedule,125% of CMS OPPS Rate,248.69,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,640.68,350,,,Fee Schedule,350% of BCBS fee schedule,640.68,350,,,Fee Schedule,350% of BCBS fee schedule,120.68,100,,,Fee Schedule,100% of CMS OPPS Rate,640.68,350,,,Fee Schedule,350% of BCBS PPO fee schedule,183.05,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,294.5,90,,957.6,Percent of Total Billed Charges,90% of Total Billed Charges,147.25,45,,200.52,Percent of Total Billed Charges,45% of Total Billed Charges,294.5,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,120.68,100,,,Fee Schedule,100% of CMS OPPS Rate,120.68,100,,,Fee Schedule,100% of CMS OPPS Rate,120.68,100,,,Fee Schedule,100% of CMS OPPS Rate,454.05,65,,115.96,Percent of total Billed Charges,65% of Total Billed Charges,144.3,44.1,,196.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,310.86,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,90.51,75,,,Fee Schedule,75% of CMS OPPS Rate,287.95,88,,1186.944,Percent of Total Billed Charges,88% of Total Billed Charges,294.5,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,90.51,640.68,
Supartz 25mg/2.5ml,6360000452,CDM,636,RC,J7321,HCPCS,Outpatient,25,GM,725.00,471.25,,725,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,551,76,,1313.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,318.33,350,,,Fee Schedule,350% of BCBS fee schedule,318.33,350,,,Fee Schedule,350% of BCBS fee schedule,725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.33,350,,,Fee Schedule,350% of BCBS PPO fee schedule,90.95,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,652.5,90,,631.864,Percent of Total Billed Charges,90% of Total Billed Charges,326.25,45,,200.52,Percent of Total Billed Charges,45% of Total Billed Charges,652.5,90,,1555.2,Percent of Total Billed Charges,90% of Total billed Charges,725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.25,65,,196.64,Percent of total Billed Charges,65% of Total Billed Charges,319.73,44.1,,196.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,688.75,95,,1641.6,Percent of Total Billed Charges,95% of Total Billed Charges,725,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,638,88,,392.128,Percent of Total Billed Charges,88% of Total Billed Charges,652.5,90,,1555.2,Percent of Total Billed charges,90% of Total Billed Charges,90.95,725,
Synagis 50mg/0.5ml inj,6360000453,CDM,636,RC,,,Outpatient,50,GM,6881.93,4473.25,,6881.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5230.27,76,,1271.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4954.99,72,,3963.992,Percent of Total Billed Charges,72% of Total Billed Charges,5161.45,75,,4129.16,Percent of Total Billed charges,75% of Total Billed Charges,6881.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4954.99,72,,3963.992,Percent of Total Billed Charges,72% of Total Billed Charges,4129.16,60,,3303.328,Percent of Total Billed Charges,60% of Total Billed Charges,6193.74,90,,191.304,Percent of Total Billed Charges,90% of Total Billed Charges,3096.87,45,,68.4,Percent of Total Billed Charges,45% of Total Billed Charges,6193.74,90,,1505.52,Percent of Total Billed Charges,90% of Total billed Charges,6881.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6881.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6881.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4473.25,65,,196.64,Percent of total Billed Charges,65% of Total Billed Charges,3034.93,44.1,,67.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,6537.83,95,,1589.16,Percent of Total Billed Charges,95% of Total Billed Charges,6881.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6056.1,88,,392.128,Percent of Total Billed Charges,88% of Total Billed Charges,6193.74,90,,1505.52,Percent of Total Billed charges,90% of Total Billed Charges,3034.93,6881.93,
Synagis 100mg/ml inj,6360000454,CDM,636,RC,,,Outpatient,100,GM,6497.52,4223.39,,6497.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4938.12,76,,2357.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4678.21,72,,3742.568,Percent of Total Billed Charges,72% of Total Billed Charges,4873.14,75,,3898.512,Percent of Total Billed charges,75% of Total Billed Charges,6497.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4678.21,72,,3742.568,Percent of Total Billed Charges,72% of Total Billed Charges,3898.51,60,,3118.808,Percent of Total Billed Charges,60% of Total Billed Charges,5847.77,90,,193.688,Percent of Total Billed Charges,90% of Total Billed Charges,2923.88,45,,40.68,Percent of Total Billed Charges,45% of Total Billed Charges,5847.77,90,,2791.592,Percent of Total Billed Charges,90% of Total billed Charges,6497.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6497.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6497.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4223.39,65,,23.288,Percent of total Billed Charges,65% of Total Billed Charges,2865.41,44.1,,39.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,6172.64,95,,2946.68,Percent of Total Billed Charges,95% of Total Billed Charges,6497.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5717.82,88,,133.76,Percent of Total Billed Charges,88% of Total Billed Charges,5847.77,90,,2791.592,Percent of Total Billed charges,90% of Total Billed Charges,2865.41,6497.52,
Retacrit 2000u/ml  Non ESRD,6360000455,CDM,636,RC,Q5106,HCPCS,Outpatient,1,ML,20.32,13.21,,9.33,125,,,Fee Schedule,125% of CMS OPPS Rate,15.44,76,,2003.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.57,350,,,Fee Schedule,350% of BCBS fee schedule,45.57,350,,,Fee Schedule,350% of BCBS fee schedule,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,45.57,350,,,Fee Schedule,350% of BCBS PPO fee schedule,13.02,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,18.29,90,,1263.456,Percent of Total Billed Charges,90% of Total Billed Charges,9.14,45,,49.68,Percent of Total Billed Charges,45% of Total Billed Charges,18.29,90,,2372.24,Percent of Total Billed Charges,90% of Total billed Charges,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,28.15,65,,42.232,Percent of total Billed Charges,65% of Total Billed Charges,8.96,44.1,,48.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.3,95,,2504.032,Percent of Total Billed Charges,95% of Total Billed Charges,5.6,75,,,Fee Schedule,75% of CMS OPPS Rate,17.88,88,,79.552,Percent of Total Billed Charges,88% of Total Billed Charges,18.29,90,,2372.24,Percent of Total Billed charges,90% of Total Billed Charges,5.6,45.57,
Retacrit 4000u/ml Non ESRD,6360000456,CDM,636,RC,Q5106,HCPCS,Outpatient,1,ML,20.32,13.21,,9.33,125,,,Fee Schedule,125% of CMS OPPS Rate,15.44,76,,1025.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.57,350,,,Fee Schedule,350% of BCBS fee schedule,45.57,350,,,Fee Schedule,350% of BCBS fee schedule,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,45.57,350,,,Fee Schedule,350% of BCBS PPO fee schedule,13.02,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,18.29,90,,1263.456,Percent of Total Billed Charges,90% of Total Billed Charges,9.14,45,,478.8,Percent of Total Billed Charges,45% of Total Billed Charges,18.29,90,,1213.92,Percent of Total Billed Charges,90% of Total billed Charges,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,28.15,65,,49.84,Percent of total Billed Charges,65% of Total Billed Charges,8.96,44.1,,469.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.3,95,,1281.36,Percent of Total Billed Charges,95% of Total Billed Charges,5.6,75,,,Fee Schedule,75% of CMS OPPS Rate,17.88,88,,97.152,Percent of Total Billed Charges,88% of Total Billed Charges,18.29,90,,1213.92,Percent of Total Billed charges,90% of Total Billed Charges,5.6,45.57,
Retacrit 20000u/ml Non ESRD,6360000457,CDM,636,RC,Q5106,HCPCS,Outpatient,1,ML,43.57,28.32,,9.33,125,,,Fee Schedule,125% of CMS OPPS Rate,33.11,76,,338.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45.57,350,,,Fee Schedule,350% of BCBS fee schedule,45.57,350,,,Fee Schedule,350% of BCBS fee schedule,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,45.57,350,,,Fee Schedule,350% of BCBS PPO fee schedule,13.02,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,39.21,90,,1963.224,Percent of Total Billed Charges,90% of Total Billed Charges,19.61,45,,315.936,Percent of Total Billed Charges,45% of Total Billed Charges,39.21,90,,401.04,Percent of Total Billed Charges,90% of Total billed Charges,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,43.26,65,,159.48,Percent of total Billed Charges,65% of Total Billed Charges,19.21,44.1,,309.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,41.39,95,,423.32,Percent of Total Billed Charges,95% of Total Billed Charges,5.6,75,,,Fee Schedule,75% of CMS OPPS Rate,38.34,88,,936.32,Percent of Total Billed Charges,88% of Total Billed Charges,39.21,90,,401.04,Percent of Total Billed charges,90% of Total Billed Charges,5.6,45.57,
Prevnar 20 0.5ml Inj,6360000458,CDM,636,RC,90677,HCPCS,Outpatient,0.5,ML,575.55,374.11,,575.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,437.42,76,,338.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,414.4,72,,331.52,Percent of Total Billed Charges,72% of Total Billed Charges,431.66,75,,345.328,Percent of Total Billed charges,75% of Total Billed Charges,575.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.4,72,,331.52,Percent of Total Billed Charges,72% of Total Billed Charges,345.33,60,,276.264,Percent of Total Billed Charges,60% of Total Billed Charges,518,90,,4185.528,Percent of Total Billed Charges,90% of Total Billed Charges,259,45,,95.656,Percent of Total Billed Charges,45% of Total Billed Charges,518,90,,401.04,Percent of Total Billed Charges,90% of Total billed Charges,575.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.11,65,,151.84,Percent of total Billed Charges,65% of Total Billed Charges,253.82,44.1,,93.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,546.77,95,,423.32,Percent of Total Billed Charges,95% of Total Billed Charges,575.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.48,88,,617.824,Percent of Total Billed Charges,88% of Total Billed Charges,518,90,,401.04,Percent of Total Billed charges,90% of Total Billed Charges,253.82,575.55,
Rituximab 500mg/50ml Inj,6360000459,CDM,636,RC,J9312,HCPCS,Outpatient,10,GM,371.10,241.22,,95.91,125,,,Fee Schedule,125% of CMS OPPS Rate,282.04,76,,115.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,371.7,350,,,Fee Schedule,350% of BCBS fee schedule,371.7,350,,,Fee Schedule,350% of BCBS fee schedule,76.73,100,,,Fee Schedule,100% of CMS OPPS Rate,371.7,350,,,Fee Schedule,350% of BCBS PPO fee schedule,106.2,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,333.99,90,,1197.36,Percent of Total Billed Charges,90% of Total Billed Charges,167,45,,96.84,Percent of Total Billed Charges,45% of Total Billed Charges,333.99,90,,136.8,Percent of Total Billed Charges,90% of Total billed Charges,76.73,100,,,Fee Schedule,100% of CMS OPPS Rate,76.73,100,,,Fee Schedule,100% of CMS OPPS Rate,76.73,100,,,Fee Schedule,100% of CMS OPPS Rate,394.68,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,163.66,44.1,,94.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,352.55,95,,144.4,Percent of Total Billed Charges,95% of Total Billed Charges,57.54,75,,,Fee Schedule,75% of CMS OPPS Rate,326.57,88,,187.056,Percent of Total Billed Charges,88% of Total Billed Charges,333.99,90,,136.8,Percent of Total Billed charges,90% of Total Billed Charges,57.54,394.68,
Briumvi 150mg/6 ml inj,6360000460,CDM,636,RC,J2329,HCPCS,Outpatient,150,GM,18866.77,12263.40,,86.28,125,,,Fee Schedule,125% of CMS OPPS Rate,14338.75,76,,68.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13584.07,72,,10867.256,Percent of Total Billed Charges,72% of Total Billed Charges,14150.08,75,,11320.064,Percent of Total Billed charges,75% of Total Billed Charges,69.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13584.07,72,,10867.256,Percent of Total Billed Charges,72% of Total Billed Charges,11320.06,60,,9056.048,Percent of Total Billed Charges,60% of Total Billed Charges,16980.09,90,,776.16,Percent of Total Billed Charges,90% of Total Billed Charges,8490.05,45,,631.728,Percent of Total Billed Charges,45% of Total Billed Charges,16980.09,90,,81.36,Percent of Total Billed Charges,90% of Total billed Charges,69.03,100,,,Fee Schedule,100% of CMS OPPS Rate,69.03,100,,,Fee Schedule,100% of CMS OPPS Rate,69.03,100,,,Fee Schedule,100% of CMS OPPS Rate,12401.46,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,8320.25,44.1,,619.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,17923.43,95,,85.88,Percent of Total Billed Charges,95% of Total Billed Charges,51.77,75,,,Fee Schedule,75% of CMS OPPS Rate,16602.76,88,,189.384,Percent of Total Billed Charges,88% of Total Billed Charges,16980.09,90,,81.36,Percent of Total Billed charges,90% of Total Billed Charges,51.77,17923.43,
Radicava 30mg/100ml inj,6360000461,CDM,636,RC,J1301,HCPCS,Outpatient,30,GM,1528.77,993.70,,27.1,125,,,Fee Schedule,125% of CMS OPPS Rate,1161.87,76,,83.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.33,350,,,Fee Schedule,350% of BCBS fee schedule,64.33,350,,,Fee Schedule,350% of BCBS fee schedule,21.68,100,,,Fee Schedule,100% of CMS OPPS Rate,64.33,350,,,Fee Schedule,350% of BCBS PPO fee schedule,18.38,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,1375.89,90,,823.576,Percent of Total Billed Charges,90% of Total Billed Charges,687.95,45,,631.728,Percent of Total Billed Charges,45% of Total Billed Charges,1375.89,90,,99.36,Percent of Total Billed Charges,90% of Total billed Charges,21.68,100,,,Fee Schedule,100% of CMS OPPS Rate,21.68,100,,,Fee Schedule,100% of CMS OPPS Rate,21.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1037.06,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,674.19,44.1,,619.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,1452.33,95,,104.88,Percent of Total Billed Charges,95% of Total Billed Charges,16.26,75,,,Fee Schedule,75% of CMS OPPS Rate,1345.32,88,,1235.376,Percent of Total Billed Charges,88% of Total Billed Charges,1375.89,90,,99.36,Percent of Total Billed charges,90% of Total Billed Charges,16.26,1452.33,
MagnSulfate In Water 4gm/100ml,6360000462,CDM,636,RC,J3475,HCPCS,Outpatient,4,gm,555.10,360.82,,555.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,421.88,76,,808.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,0.25,350,,,Fee Schedule,350% of BCBS fee schedule,555.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.25,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.07,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,499.59,90,,776.16,Percent of Total Billed Charges,90% of Total Billed Charges,249.8,45,,981.616,Percent of Total Billed Charges,45% of Total Billed Charges,499.59,90,,957.6,Percent of Total Billed Charges,90% of Total billed Charges,555.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360.82,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,244.8,44.1,,961.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,527.35,95,,1010.8,Percent of Total Billed Charges,95% of Total Billed Charges,555.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.49,88,,1235.376,Percent of Total Billed Charges,88% of Total Billed Charges,499.59,90,,957.6,Percent of Total Billed charges,90% of Total Billed Charges,0.07,555.1,
Keytruda 100mg/4ml inj,6360000463,CDM,636,RC,J9271,HCPCS,Outpatient,100,GM,20016.33,13010.61,,72,125,,,Fee Schedule,125% of CMS OPPS Rate,15212.41,76,,533.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,155.93,350,,,Fee Schedule,350% of BCBS fee schedule,155.93,350,,,Fee Schedule,350% of BCBS fee schedule,57.6,100,,,Fee Schedule,100% of CMS OPPS Rate,155.93,350,,,Fee Schedule,350% of BCBS PPO fee schedule,44.55,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,18014.7,90,,1566.72,Percent of Total Billed Charges,90% of Total Billed Charges,9007.35,45,,2092.76,Percent of Total Billed Charges,45% of Total Billed Charges,18014.7,90,,631.864,Percent of Total Billed Charges,90% of Total billed Charges,57.6,100,,,Fee Schedule,100% of CMS OPPS Rate,57.6,100,,,Fee Schedule,100% of CMS OPPS Rate,57.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13125.81,65,,13,Percent of total Billed Charges,65% of Total Billed Charges,8827.2,44.1,,2050.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,19015.51,95,,666.968,Percent of Total Billed Charges,95% of Total Billed Charges,43.2,75,,,Fee Schedule,75% of CMS OPPS Rate,17614.37,88,,1919.6,Percent of Total Billed Charges,88% of Total Billed Charges,18014.7,90,,631.864,Percent of Total Billed charges,90% of Total Billed Charges,43.2,19015.51,
Epifix Skinsub 14mm 2units,6360000464,CDM,636,RC,Q4186,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,161.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,765.77,350,,,Fee Schedule,350% of BCBS fee schedule,765.77,350,,,Fee Schedule,350% of BCBS fee schedule,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,765.77,350,,,Fee Schedule,350% of BCBS PPO fee schedule,218.79,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,1800,90,,2591.392,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,598.68,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,191.304,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,47.568,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,586.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,201.936,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,4092.512,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,191.304,Percent of Total Billed charges,90% of Total Billed Charges,218.79,2000,
Epifix Skinsub 18mm 3units,6360000465,CDM,636,RC,Q4186,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,163.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,765.77,350,,,Fee Schedule,350% of BCBS fee schedule,765.77,350,,,Fee Schedule,350% of BCBS fee schedule,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,765.77,350,,,Fee Schedule,350% of BCBS PPO fee schedule,218.79,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,1800,90,,504,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,388.08,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,193.688,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,2238.016,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,380.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,204.448,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1170.752,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,193.688,Percent of Total Billed charges,90% of Total Billed Charges,218.79,2000,
Epifix Skinsub 2x2 4units,6360000466,CDM,636,RC,Q4186,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1066.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,765.77,350,,,Fee Schedule,350% of BCBS fee schedule,765.77,350,,,Fee Schedule,350% of BCBS fee schedule,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,765.77,350,,,Fee Schedule,350% of BCBS PPO fee schedule,218.79,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,1800,90,,719.28,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,411.784,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1263.456,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,47.568,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,403.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1333.648,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,758.912,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1263.456,Percent of Total Billed charges,90% of Total Billed Charges,218.79,2000,
Epifix Skinsub 2x3 6units,6360000467,CDM,636,RC,Q4186,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1066.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,765.77,350,,,Fee Schedule,350% of BCBS fee schedule,765.77,350,,,Fee Schedule,350% of BCBS fee schedule,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,765.77,350,,,Fee Schedule,350% of BCBS PPO fee schedule,218.79,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,1800,90,,2000.728,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,388.08,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1263.456,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,13,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,380.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1333.648,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,805.272,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1263.456,Percent of Total Billed charges,90% of Total Billed Charges,218.79,2000,
Epifix Skinsub Mesh 2x3 6units,6360000468,CDM,636,RC,Q4186,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1657.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,765.77,350,,,Fee Schedule,350% of BCBS fee schedule,765.77,350,,,Fee Schedule,350% of BCBS fee schedule,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,765.77,350,,,Fee Schedule,350% of BCBS PPO fee schedule,218.79,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,1800,90,,1111.632,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,783.36,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1963.224,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,47.568,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,767.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,2072.296,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,758.912,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1963.224,Percent of Total Billed charges,90% of Total Billed Charges,218.79,2000,
Epifix Skinsub Mesh 3.5x3.5 8u,6360000469,CDM,636,RC,Q4186,HCPCS,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,3534.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,765.77,350,,,Fee Schedule,350% of BCBS fee schedule,765.77,350,,,Fee Schedule,350% of BCBS fee schedule,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,765.77,350,,,Fee Schedule,350% of BCBS PPO fee schedule,218.79,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,1800,90,,1111.632,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,1295.696,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,4185.528,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,47.568,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,1269.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,4418.056,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1531.904,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,4185.528,Percent of Total Billed charges,90% of Total Billed Charges,218.79,2000,
Dalbavancin 500mg,6360000470,CDM,636,RC,J0875,HCPCS,Outpatient,500,GM,85.50,55.58,,19.5,125,,,Fee Schedule,125% of CMS OPPS Rate,64.98,76,,1011.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,53.73,350,,,Fee Schedule,350% of BCBS fee schedule,53.73,350,,,Fee Schedule,350% of BCBS fee schedule,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,53.73,350,,,Fee Schedule,350% of BCBS PPO fee schedule,15.35,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,76.95,90,,965.264,Percent of Total Billed Charges,90% of Total Billed Charges,38.48,45,,252,Percent of Total Billed Charges,45% of Total Billed Charges,76.95,90,,1197.36,Percent of Total Billed Charges,90% of Total billed Charges,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,86.78,65,,69.424,Percent of total Billed Charges,65% of Total Billed Charges,37.71,44.1,,246.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,81.23,95,,1263.88,Percent of Total Billed Charges,95% of Total Billed Charges,11.7,75,,,Fee Schedule,75% of CMS OPPS Rate,75.24,88,,2533.8,Percent of Total Billed Charges,88% of Total Billed Charges,76.95,90,,1197.36,Percent of Total Billed charges,90% of Total Billed Charges,11.7,86.78,
Octagam 10% 10g/100ml Injection,6360000471,CDM,636,RC,J1568,HCPCS,Outpatient,100,ML,83.17,54.06,,61.62,125,,,Fee Schedule,125% of CMS OPPS Rate,63.21,76,,655.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,217.14,350,,,Fee Schedule,350% of BCBS fee schedule,217.14,350,,,Fee Schedule,350% of BCBS fee schedule,49.3,100,,,Fee Schedule,100% of CMS OPPS Rate,217.14,350,,,Fee Schedule,350% of BCBS PPO fee schedule,62.04,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,74.85,90,,211.944,Percent of Total Billed Charges,90% of Total Billed Charges,37.43,45,,359.64,Percent of Total Billed Charges,45% of Total Billed Charges,74.85,90,,776.16,Percent of Total Billed Charges,90% of Total billed Charges,49.3,100,,,Fee Schedule,100% of CMS OPPS Rate,49.3,100,,,Fee Schedule,100% of CMS OPPS Rate,49.3,100,,,Fee Schedule,100% of CMS OPPS Rate,152.66,65,,122.128,Percent of total Billed Charges,65% of Total Billed Charges,36.68,44.1,,352.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,79.01,95,,819.28,Percent of Total Billed Charges,95% of Total Billed Charges,36.97,75,,,Fee Schedule,75% of CMS OPPS Rate,73.19,88,,492.8,Percent of Total Billed Charges,88% of Total Billed Charges,74.85,90,,776.16,Percent of Total Billed charges,90% of Total Billed Charges,36.68,217.14,
Octagam 10% 20g/200ml,6360000472,CDM,636,RC,J1568,HCPCS,Outpatient,200,ML,186.62,121.30,,61.62,125,,,Fee Schedule,125% of CMS OPPS Rate,141.83,76,,695.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,217.14,350,,,Fee Schedule,350% of BCBS fee schedule,217.14,350,,,Fee Schedule,350% of BCBS fee schedule,49.3,100,,,Fee Schedule,100% of CMS OPPS Rate,217.14,350,,,Fee Schedule,350% of BCBS PPO fee schedule,62.04,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,167.96,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,83.98,45,,1000.368,Percent of Total Billed Charges,45% of Total Billed Charges,167.96,90,,823.576,Percent of Total Billed Charges,90% of Total billed Charges,49.3,100,,,Fee Schedule,100% of CMS OPPS Rate,49.3,100,,,Fee Schedule,100% of CMS OPPS Rate,49.3,100,,,Fee Schedule,100% of CMS OPPS Rate,219.9,65,,175.92,Percent of total Billed Charges,65% of Total Billed Charges,82.3,44.1,,980.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,177.29,95,,869.328,Percent of Total Billed Charges,95% of Total Billed Charges,36.97,75,,,Fee Schedule,75% of CMS OPPS Rate,164.23,88,,703.296,Percent of Total Billed Charges,88% of Total Billed Charges,167.96,90,,823.576,Percent of Total Billed charges,90% of Total Billed Charges,36.97,219.9,
Gentamicin 120mg/100ml  premix,6360000473,CDM,636,RC,J1580,HCPCS,Outpatient,,,10.20,6.63,,10.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7.75,76,,655.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.87,350,,,Fee Schedule,350% of BCBS fee schedule,2.87,350,,,Fee Schedule,350% of BCBS fee schedule,10.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.87,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.82,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,9.18,90,,493.888,Percent of Total Billed Charges,90% of Total Billed Charges,4.59,45,,555.816,Percent of Total Billed Charges,45% of Total Billed Charges,9.18,90,,776.16,Percent of Total Billed Charges,90% of Total billed Charges,10.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.63,65,,5.304,Percent of total Billed Charges,65% of Total Billed Charges,4.5,44.1,,544.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,9.69,95,,819.28,Percent of Total Billed Charges,95% of Total Billed Charges,10.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.98,88,,1956.272,Percent of Total Billed Charges,88% of Total Billed Charges,9.18,90,,776.16,Percent of Total Billed charges,90% of Total Billed Charges,0.82,10.2,
Iohexol 350mg/ml 200ml bottle,6360000474,CDM,636,RC,Q9967,HCPCS,Outpatient,,,481.40,312.91,,481.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,365.86,76,,1323.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.37,350,,,Fee Schedule,350% of BCBS fee schedule,1.37,350,,,Fee Schedule,350% of BCBS fee schedule,481.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.37,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.39,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,433.26,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,216.63,45,,555.816,Percent of Total Billed Charges,45% of Total Billed Charges,433.26,90,,1566.72,Percent of Total Billed Charges,90% of Total billed Charges,481.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,481.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,481.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.91,65,,250.328,Percent of total Billed Charges,65% of Total Billed Charges,212.3,44.1,,544.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,457.33,95,,1653.76,Percent of Total Billed Charges,95% of Total Billed Charges,481.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,423.63,88,,1086.928,Percent of Total Billed Charges,88% of Total Billed Charges,433.26,90,,1566.72,Percent of Total Billed charges,90% of Total Billed Charges,0.39,481.4,
Cefoxitin 2g inj,6360000475,CDM,636,RC,J0694,HCPCS,Outpatient,,,15.07,9.80,,15.07,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,11.45,76,,2188.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.48,350,,,Fee Schedule,350% of BCBS fee schedule,13.48,350,,,Fee Schedule,350% of BCBS fee schedule,15.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.48,350,,,Fee Schedule,350% of BCBS PPO fee schedule,3.85,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,13.56,90,,687.432,Percent of Total Billed Charges,90% of Total Billed Charges,6.78,45,,482.632,Percent of Total Billed Charges,45% of Total Billed Charges,13.56,90,,2591.392,Percent of Total Billed Charges,90% of Total billed Charges,15.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.8,65,,7.84,Percent of total Billed Charges,65% of Total Billed Charges,6.65,44.1,,472.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,14.32,95,,2735.352,Percent of Total Billed Charges,95% of Total Billed Charges,15.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.26,88,,1086.928,Percent of Total Billed Charges,88% of Total Billed Charges,13.56,90,,2591.392,Percent of Total Billed charges,90% of Total Billed Charges,3.85,15.07,
Cefoxitin 1g inj,6360000476,CDM,636,RC,J0694,HCPCS,Outpatient,,,8.50,5.53,,8.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6.46,76,,425.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,13.48,350,,,Fee Schedule,350% of BCBS fee schedule,13.48,350,,,Fee Schedule,350% of BCBS fee schedule,8.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.48,350,,,Fee Schedule,350% of BCBS PPO fee schedule,3.85,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,7.65,90,,1010.592,Percent of Total Billed Charges,90% of Total Billed Charges,3.83,45,,105.976,Percent of Total Billed Charges,45% of Total Billed Charges,7.65,90,,504,Percent of Total Billed Charges,90% of Total billed Charges,8.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.53,65,,4.424,Percent of total Billed Charges,65% of Total Billed Charges,3.75,44.1,,103.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,8.08,95,,532,Percent of Total Billed Charges,95% of Total Billed Charges,8.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.48,88,,943.808,Percent of Total Billed Charges,88% of Total Billed Charges,7.65,90,,504,Percent of Total Billed charges,90% of Total Billed Charges,3.75,13.48,
Ruxience 500mg/50ml inj,6360000477,CDM,636,RC,Q5119,HCPCS,Outpatient,,,27.85,18.10,,29.48,125,,,Fee Schedule,125% of CMS OPPS Rate,21.17,76,,607.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,287.67,350,,,Fee Schedule,350% of BCBS fee schedule,287.67,350,,,Fee Schedule,350% of BCBS fee schedule,23.59,100,,,Fee Schedule,100% of CMS OPPS Rate,287.67,350,,,Fee Schedule,350% of BCBS PPO fee schedule,82.19,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,25.07,90,,615.992,Percent of Total Billed Charges,90% of Total Billed Charges,12.53,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,25.07,90,,719.28,Percent of Total Billed Charges,90% of Total billed Charges,23.59,100,,,Fee Schedule,100% of CMS OPPS Rate,23.59,100,,,Fee Schedule,100% of CMS OPPS Rate,23.59,100,,,Fee Schedule,100% of CMS OPPS Rate,65.28,65,,52.224,Percent of total Billed Charges,65% of Total Billed Charges,12.28,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,26.46,95,,759.24,Percent of Total Billed Charges,95% of Total Billed Charges,17.69,75,,,Fee Schedule,75% of CMS OPPS Rate,24.51,88,,207.24,Percent of Total Billed Charges,88% of Total Billed Charges,25.07,90,,719.28,Percent of Total Billed charges,90% of Total Billed Charges,12.28,287.67,
Zoledronic Acd/0.9NS 4mg/100ml,6360000478,CDM,636,RC,J3489,HCPCS,Outpatient,,,19.95,12.97,,19.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.16,76,,1689.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,28.35,350,,,Fee Schedule,350% of BCBS fee schedule,28.35,350,,,Fee Schedule,350% of BCBS fee schedule,19.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.35,350,,,Fee Schedule,350% of BCBS PPO fee schedule,8.1,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,17.96,90,,1875.976,Percent of Total Billed Charges,90% of Total Billed Charges,8.98,45,,246.944,Percent of Total Billed Charges,45% of Total Billed Charges,17.96,90,,2000.728,Percent of Total Billed Charges,90% of Total billed Charges,19.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.97,65,,10.376,Percent of total Billed Charges,65% of Total Billed Charges,8.8,44.1,,242.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,18.95,95,,2111.88,Percent of Total Billed Charges,95% of Total Billed Charges,19.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.56,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,17.96,90,,2000.728,Percent of Total Billed charges,90% of Total Billed Charges,8.1,28.35,
DARBEPOETIN ALFA 40mcg/ml NON,6360000480,CDM,636,RC,J0881,HCPCS,Outpatient,,,3057.30,1987.25,,3.71,125,,,Fee Schedule,125% of CMS OPPS Rate,2323.55,76,,938.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.08,350,,,Fee Schedule,350% of BCBS fee schedule,26.08,350,,,Fee Schedule,350% of BCBS fee schedule,2.97,100,,,Fee Schedule,100% of CMS OPPS Rate,26.08,350,,,Fee Schedule,350% of BCBS PPO fee schedule,7.45,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,2751.57,90,,532.08,Percent of Total Billed Charges,90% of Total Billed Charges,1375.79,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,2751.57,90,,1111.632,Percent of Total Billed Charges,90% of Total billed Charges,2.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1993.19,65,,1594.552,Percent of total Billed Charges,65% of Total Billed Charges,1348.27,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,2904.44,95,,1173.384,Percent of Total Billed Charges,95% of Total Billed Charges,2.22,75,,,Fee Schedule,75% of CMS OPPS Rate,2690.42,88,,482.912,Percent of Total Billed Charges,88% of Total Billed Charges,2751.57,90,,1111.632,Percent of Total Billed charges,90% of Total Billed Charges,2.22,2904.44,
DARBEPOETIN ALFA 40mcg ESRD,6360000481,CDM,636,RC,J0881,HCPCS,Outpatient,,,3057.30,1987.25,,3.71,125,,,Fee Schedule,125% of CMS OPPS Rate,2323.55,76,,938.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.08,350,,,Fee Schedule,350% of BCBS fee schedule,26.08,350,,,Fee Schedule,350% of BCBS fee schedule,2.97,100,,,Fee Schedule,100% of CMS OPPS Rate,26.08,350,,,Fee Schedule,350% of BCBS PPO fee schedule,7.45,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,2751.57,90,,194.4,Percent of Total Billed Charges,90% of Total Billed Charges,1375.79,45,,343.72,Percent of Total Billed Charges,45% of Total Billed Charges,2751.57,90,,1111.632,Percent of Total Billed Charges,90% of Total billed Charges,2.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1993.19,65,,1594.552,Percent of total Billed Charges,65% of Total Billed Charges,1348.27,44.1,,336.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,2904.44,95,,1173.384,Percent of Total Billed Charges,95% of Total Billed Charges,2.22,75,,,Fee Schedule,75% of CMS OPPS Rate,2690.42,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,2751.57,90,,1111.632,Percent of Total Billed charges,90% of Total Billed Charges,2.22,2904.44,
Belimumab 400mg inj,6360000482,CDM,636,RC,J0490,HCPCS,Outpatient,,,20180.25,13117.16,,68.63,125,,,Fee Schedule,125% of CMS OPPS Rate,15336.99,76,,815.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,143.22,350,,,Fee Schedule,350% of BCBS fee schedule,143.22,350,,,Fee Schedule,350% of BCBS fee schedule,54.91,100,,,Fee Schedule,100% of CMS OPPS Rate,143.22,350,,,Fee Schedule,350% of BCBS PPO fee schedule,40.92,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,18162.23,90,,315.136,Percent of Total Billed Charges,90% of Total Billed Charges,9081.11,45,,505.296,Percent of Total Billed Charges,45% of Total Billed Charges,18162.23,90,,965.264,Percent of Total Billed Charges,90% of Total billed Charges,54.91,100,,,Fee Schedule,100% of CMS OPPS Rate,54.91,100,,,Fee Schedule,100% of CMS OPPS Rate,54.91,100,,,Fee Schedule,100% of CMS OPPS Rate,13226.98,65,,10581.584,Percent of total Billed Charges,65% of Total Billed Charges,8899.49,44.1,,495.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,19171.24,95,,1018.888,Percent of Total Billed Charges,95% of Total Billed Charges,41.18,75,,,Fee Schedule,75% of CMS OPPS Rate,17758.62,88,,672.16,Percent of Total Billed Charges,88% of Total Billed Charges,18162.23,90,,965.264,Percent of Total Billed charges,90% of Total Billed Charges,40.92,19171.24,
Ganciclovir 500mg inj,6360000483,CDM,636,RC,J1570,HCPCS,Outpatient,,,885.82,575.78,,885.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,673.22,76,,178.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,174.2,350,,,Fee Schedule,350% of BCBS fee schedule,174.2,350,,,Fee Schedule,350% of BCBS fee schedule,885.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.2,350,,,Fee Schedule,350% of BCBS PPO fee schedule,49.77,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,797.24,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,398.62,45,,307.992,Percent of Total Billed Charges,45% of Total Billed Charges,797.24,90,,211.944,Percent of Total Billed Charges,90% of Total billed Charges,885.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,885.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,885.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.78,65,,460.624,Percent of total Billed Charges,65% of Total Billed Charges,390.65,44.1,,301.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,841.53,95,,223.72,Percent of Total Billed Charges,95% of Total Billed Charges,885.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,779.52,88,,988.136,Percent of Total Billed Charges,88% of Total Billed Charges,797.24,90,,211.944,Percent of Total Billed charges,90% of Total Billed Charges,49.77,885.82,
Vyepti 100mg/ml inj,6360000484,CDM,636,RC,J3032,HCPCS,Outpatient,,,17456.32,11346.61,,24.15,125,,,Fee Schedule,125% of CMS OPPS Rate,13266.8,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,12568.55,72,,10054.84,Percent of Total Billed Charges,72% of Total Billed Charges,13092.24,75,,10473.792,Percent of Total Billed charges,75% of Total Billed Charges,19.32,100,,,Fee Schedule,100% of CMS OPPS Rate,12568.55,72,,10054.84,Percent of Total Billed Charges,72% of Total Billed Charges,10473.79,60,,8379.032,Percent of Total Billed Charges,60% of Total Billed Charges,15710.69,90,,659.864,Percent of Total Billed Charges,90% of Total Billed Charges,7855.34,45,,937.984,Percent of Total Billed Charges,45% of Total Billed Charges,15710.69,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,19.32,100,,,Fee Schedule,100% of CMS OPPS Rate,19.32,100,,,Fee Schedule,100% of CMS OPPS Rate,19.32,100,,,Fee Schedule,100% of CMS OPPS Rate,11385.25,65,,9108.2,Percent of total Billed Charges,65% of Total Billed Charges,7698.24,44.1,,919.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,16583.5,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,14.49,75,,,Fee Schedule,75% of CMS OPPS Rate,15361.56,88,,602.304,Percent of Total Billed Charges,88% of Total Billed Charges,15710.69,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,14.49,16583.5,
Saphnelo 300mg/2ml inj,6360000485,CDM,636,RC,J0491,HCPCS,Outpatient,,,62946.12,40914.98,,4377.53,125,,,Fee Schedule,125% of CMS OPPS Rate,47839.05,76,,417.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,45321.21,72,,36256.968,Percent of Total Billed Charges,72% of Total Billed Charges,47209.59,75,,37767.672,Percent of Total Billed charges,75% of Total Billed Charges,4376.98,100,,,Fee Schedule,100% of CMS OPPS Rate,45321.21,72,,36256.968,Percent of Total Billed Charges,72% of Total Billed Charges,37767.67,60,,30214.136,Percent of Total Billed Charges,60% of Total Billed Charges,56651.51,90,,659.864,Percent of Total Billed Charges,90% of Total Billed Charges,28325.75,45,,266.04,Percent of Total Billed Charges,45% of Total Billed Charges,56651.51,90,,493.888,Percent of Total Billed Charges,90% of Total billed Charges,4376.98,100,,,Fee Schedule,100% of CMS OPPS Rate,4376.98,100,,,Fee Schedule,100% of CMS OPPS Rate,4376.98,100,,,Fee Schedule,100% of CMS OPPS Rate,45294.18,65,,36235.344,Percent of total Billed Charges,65% of Total Billed Charges,27759.24,44.1,,260.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,59798.81,95,,521.328,Percent of Total Billed Charges,95% of Total Billed Charges,4376.42,75,,,Fee Schedule,75% of CMS OPPS Rate,55392.59,88,,1834.288,Percent of Total Billed Charges,88% of Total Billed Charges,56651.51,90,,493.888,Percent of Total Billed charges,90% of Total Billed Charges,4376.42,59798.81,
Tezepelumab-ekko 210mg/1.91ml,6360000486,CDM,636,RC,J2356,HCPCS,Outpatient,,,42688.15,27747.30,,2969.66,125,,,Fee Schedule,125% of CMS OPPS Rate,32442.99,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,30735.47,72,,24588.376,Percent of Total Billed Charges,72% of Total Billed Charges,32016.11,75,,25612.888,Percent of Total Billed charges,75% of Total Billed Charges,2969.1,100,,,Fee Schedule,100% of CMS OPPS Rate,30735.47,72,,24588.376,Percent of Total Billed Charges,72% of Total Billed Charges,25612.89,60,,20490.312,Percent of Total Billed Charges,60% of Total Billed Charges,38419.34,90,,659.864,Percent of Total Billed Charges,90% of Total Billed Charges,19209.67,45,,97.2,Percent of Total Billed Charges,45% of Total Billed Charges,38419.34,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,2969.1,100,,,Fee Schedule,100% of CMS OPPS Rate,2969.1,100,,,Fee Schedule,100% of CMS OPPS Rate,2969.1,100,,,Fee Schedule,100% of CMS OPPS Rate,30718.67,65,,24574.936,Percent of total Billed Charges,65% of Total Billed Charges,18825.47,44.1,,95.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,40553.74,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,2968.53,75,,,Fee Schedule,75% of CMS OPPS Rate,37565.57,88,,520.256,Percent of Total Billed Charges,88% of Total Billed Charges,38419.34,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,2968.53,40553.74,
KedRab 300u/2ml inj,6360000487,CDM,636,RC,90377,HCPCS,Outpatient,,,3681.50,2392.98,,313.14,125,,,Fee Schedule,125% of CMS OPPS Rate,2797.94,76,,580.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2650.68,72,,2120.544,Percent of Total Billed Charges,72% of Total Billed Charges,2761.13,75,,2208.904,Percent of Total Billed charges,75% of Total Billed Charges,250.52,100,,,Fee Schedule,100% of CMS OPPS Rate,2650.68,72,,2120.544,Percent of Total Billed Charges,72% of Total Billed Charges,2208.9,60,,1767.12,Percent of Total Billed Charges,60% of Total Billed Charges,3313.35,90,,659.864,Percent of Total Billed Charges,90% of Total Billed Charges,1656.68,45,,157.568,Percent of Total Billed Charges,45% of Total Billed Charges,3313.35,90,,687.432,Percent of Total Billed Charges,90% of Total billed Charges,250.52,100,,,Fee Schedule,100% of CMS OPPS Rate,250.52,100,,,Fee Schedule,100% of CMS OPPS Rate,250.52,100,,,Fee Schedule,100% of CMS OPPS Rate,2894.02,65,,2315.216,Percent of total Billed Charges,65% of Total Billed Charges,1623.54,44.1,,154.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,3497.43,95,,725.624,Percent of Total Billed Charges,95% of Total Billed Charges,187.89,75,,,Fee Schedule,75% of CMS OPPS Rate,3239.72,88,,190.08,Percent of Total Billed Charges,88% of Total Billed Charges,3313.35,90,,687.432,Percent of Total Billed charges,90% of Total Billed Charges,187.89,3497.43,
Darbepoetin 25 mcg inj,6360000488,CDM,636,RC,J0881,HCPCS,Outpatient,,,1910.83,1242.04,,3.71,125,,,Fee Schedule,125% of CMS OPPS Rate,1452.23,76,,853.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.08,350,,,Fee Schedule,350% of BCBS fee schedule,26.08,350,,,Fee Schedule,350% of BCBS fee schedule,2.97,100,,,Fee Schedule,100% of CMS OPPS Rate,26.08,350,,,Fee Schedule,350% of BCBS PPO fee schedule,7.45,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,1719.75,90,,659.864,Percent of Total Billed Charges,90% of Total Billed Charges,859.87,45,,329.936,Percent of Total Billed Charges,45% of Total Billed Charges,1719.75,90,,1010.592,Percent of Total Billed Charges,90% of Total billed Charges,2.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1247.98,65,,998.384,Percent of total Billed Charges,65% of Total Billed Charges,842.68,44.1,,323.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,1815.29,95,,1066.736,Percent of Total Billed Charges,95% of Total Billed Charges,2.22,75,,,Fee Schedule,75% of CMS OPPS Rate,1681.53,88,,308.136,Percent of Total Billed Charges,88% of Total Billed Charges,1719.75,90,,1010.592,Percent of Total Billed charges,90% of Total Billed Charges,2.22,1815.29,
Darbepoetin 25 mcg inj,6360000489,CDM,636,RC,J0881,HCPCS,Outpatient,,,1910.83,1242.04,,3.71,125,,,Fee Schedule,125% of CMS OPPS Rate,1452.23,76,,520.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,26.08,350,,,Fee Schedule,350% of BCBS fee schedule,26.08,350,,,Fee Schedule,350% of BCBS fee schedule,2.97,100,,,Fee Schedule,100% of CMS OPPS Rate,26.08,350,,,Fee Schedule,350% of BCBS PPO fee schedule,7.45,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,1719.75,90,,659.864,Percent of Total Billed Charges,90% of Total Billed Charges,859.87,45,,329.936,Percent of Total Billed Charges,45% of Total Billed Charges,1719.75,90,,615.992,Percent of Total Billed Charges,90% of Total billed Charges,2.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1247.98,65,,998.384,Percent of total Billed Charges,65% of Total Billed Charges,842.68,44.1,,323.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,1815.29,95,,650.208,Percent of Total Billed Charges,95% of Total Billed Charges,2.22,75,,,Fee Schedule,75% of CMS OPPS Rate,1681.53,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,1719.75,90,,615.992,Percent of Total Billed charges,90% of Total Billed Charges,2.22,1815.29,
Leqembi 200mg/2ml inj,6360000490,CDM,636,RC,J0174,HCPCS,Outpatient,,,3270.78,2126.01,,1.66,125,,,Fee Schedule,125% of CMS OPPS Rate,2485.79,76,,1584.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2354.96,72,,1883.968,Percent of Total Billed Charges,72% of Total Billed Charges,2453.09,75,,1962.472,Percent of Total Billed charges,75% of Total Billed Charges,1.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2354.96,72,,1883.968,Percent of Total Billed Charges,72% of Total Billed Charges,1962.47,60,,1569.976,Percent of Total Billed Charges,60% of Total Billed Charges,2943.7,90,,1176.504,Percent of Total Billed Charges,90% of Total Billed Charges,1471.85,45,,329.936,Percent of Total Billed Charges,45% of Total Billed Charges,2943.7,90,,1875.976,Percent of Total Billed Charges,90% of Total billed Charges,1.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2128.67,65,,1702.936,Percent of total Billed Charges,65% of Total Billed Charges,1442.41,44.1,,323.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,3107.24,95,,1980.192,Percent of Total Billed Charges,95% of Total Billed Charges,0.99,75,,,Fee Schedule,75% of CMS OPPS Rate,2878.29,88,,645.2,Percent of Total Billed Charges,88% of Total Billed Charges,2943.7,90,,1875.976,Percent of Total Billed charges,90% of Total Billed Charges,0.99,3107.24,
Leqembi 500mg/5ml inj,6360000491,CDM,636,RC,J0174,HCPCS,Outpatient,,,8000.63,5200.41,,1.66,125,,,Fee Schedule,125% of CMS OPPS Rate,6080.48,76,,449.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5760.45,72,,4608.36,Percent of Total Billed Charges,72% of Total Billed Charges,6000.47,75,,4800.376,Percent of Total Billed charges,75% of Total Billed Charges,1.33,100,,,Fee Schedule,100% of CMS OPPS Rate,5760.45,72,,4608.36,Percent of Total Billed Charges,72% of Total Billed Charges,4800.38,60,,3840.304,Percent of Total Billed Charges,60% of Total Billed Charges,7200.57,90,,5216.28,Percent of Total Billed Charges,90% of Total Billed Charges,3600.28,45,,329.936,Percent of Total Billed Charges,45% of Total Billed Charges,7200.57,90,,532.08,Percent of Total Billed Charges,90% of Total billed Charges,1.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1.33,100,,,Fee Schedule,100% of CMS OPPS Rate,5203.07,65,,4162.456,Percent of total Billed Charges,65% of Total Billed Charges,3528.28,44.1,,323.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,7600.6,95,,561.64,Percent of Total Billed Charges,95% of Total Billed Charges,0.99,75,,,Fee Schedule,75% of CMS OPPS Rate,7040.55,88,,645.2,Percent of Total Billed Charges,88% of Total Billed Charges,7200.57,90,,532.08,Percent of Total Billed charges,90% of Total Billed Charges,0.99,7600.6,
Omnipaque 350 (75ml),6360000492,CDM,636,RC,Q9967,HCPCS,Outpatient,,,30.00,19.50,,30,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,22.8,76,,164.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1.37,350,,,Fee Schedule,350% of BCBS fee schedule,1.37,350,,,Fee Schedule,350% of BCBS fee schedule,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.37,350,,,Fee Schedule,350% of BCBS PPO fee schedule,0.39,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,27,90,,961.744,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,45,,329.936,Percent of Total Billed Charges,45% of Total Billed Charges,27,90,,194.4,Percent of Total Billed Charges,90% of Total billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.5,65,,15.6,Percent of total Billed Charges,65% of Total Billed Charges,13.23,44.1,,323.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,28.5,95,,205.2,Percent of Total Billed Charges,95% of Total Billed Charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.4,88,,645.2,Percent of Total Billed Charges,88% of Total Billed Charges,27,90,,194.4,Percent of Total Billed charges,90% of Total Billed Charges,0.39,30,
Fondapar 2.5mg/0.5ml,6360000493,CDM,636,RC,J1652,HCPCS,Outpatient,,,355.50,231.08,,355.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,270.18,76,,266.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.25,350,,,Fee Schedule,350% of BCBS fee schedule,7.25,350,,,Fee Schedule,350% of BCBS fee schedule,355.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.25,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.07,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,319.95,90,,1735.368,Percent of Total Billed Charges,90% of Total Billed Charges,159.98,45,,329.936,Percent of Total Billed Charges,45% of Total Billed Charges,319.95,90,,315.136,Percent of Total Billed Charges,90% of Total billed Charges,355.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.08,65,,184.864,Percent of total Billed Charges,65% of Total Billed Charges,156.78,44.1,,323.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,337.73,95,,332.648,Percent of Total Billed Charges,95% of Total Billed Charges,355.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.84,88,,645.2,Percent of Total Billed Charges,88% of Total Billed Charges,319.95,90,,315.136,Percent of Total Billed charges,90% of Total Billed Charges,2.07,355.5,
Fondapar 10mg/0.8ml,6360000494,CDM,636,RC,J1652,HCPCS,Outpatient,,,1341.03,871.67,,1341.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1019.18,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.25,350,,,Fee Schedule,350% of BCBS fee schedule,7.25,350,,,Fee Schedule,350% of BCBS fee schedule,1341.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.25,350,,,Fee Schedule,350% of BCBS PPO fee schedule,2.07,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,1206.93,90,,572.8,Percent of Total Billed Charges,90% of Total Billed Charges,603.46,45,,588.248,Percent of Total Billed Charges,45% of Total Billed Charges,1206.93,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,1341.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1341.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1341.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,871.67,65,,697.336,Percent of total Billed Charges,65% of Total Billed Charges,591.39,44.1,,576.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,1273.98,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,1341.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1180.11,88,,645.2,Percent of Total Billed Charges,88% of Total Billed Charges,1206.93,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,2.07,1341.03,
Sodium Chloride 1000ml Irrg Ba,6360000495,CDM,636,RC,,,Outpatient,,,117.50,76.38,,117.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,89.3,76,,557.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.6,72,,67.68,Percent of Total Billed Charges,72% of Total Billed Charges,88.13,75,,70.504,Percent of Total Billed charges,75% of Total Billed Charges,117.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.6,72,,67.68,Percent of Total Billed Charges,72% of Total Billed Charges,70.5,60,,56.4,Percent of Total Billed Charges,60% of Total Billed Charges,105.75,90,,2692.944,Percent of Total Billed Charges,90% of Total Billed Charges,52.88,45,,2608.136,Percent of Total Billed Charges,45% of Total Billed Charges,105.75,90,,659.864,Percent of Total Billed Charges,90% of Total billed Charges,117.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.38,65,,61.104,Percent of total Billed Charges,65% of Total Billed Charges,51.82,44.1,,2555.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,111.63,95,,696.528,Percent of Total Billed Charges,95% of Total Billed Charges,117.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.4,88,,645.2,Percent of Total Billed Charges,88% of Total Billed Charges,105.75,90,,659.864,Percent of Total Billed charges,90% of Total Billed Charges,51.82,117.5,
Aredia 30MG/10ML INJ,6360000496,CDM,636,RC,J2430,HCPCS,Outpatient,,,292.75,190.29,,292.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,222.49,76,,557.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,33.92,350,,,Fee Schedule,350% of BCBS fee schedule,33.92,350,,,Fee Schedule,350% of BCBS fee schedule,292.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.92,350,,,Fee Schedule,350% of BCBS PPO fee schedule,9.69,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,263.48,90,,511.2,Percent of Total Billed Charges,90% of Total Billed Charges,131.74,45,,480.872,Percent of Total Billed Charges,45% of Total Billed Charges,263.48,90,,659.864,Percent of Total Billed Charges,90% of Total billed Charges,292.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.29,65,,152.232,Percent of total Billed Charges,65% of Total Billed Charges,129.1,44.1,,471.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,278.11,95,,696.528,Percent of Total Billed Charges,95% of Total Billed Charges,292.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.62,88,,1150.36,Percent of Total Billed Charges,88% of Total Billed Charges,263.48,90,,659.864,Percent of Total Billed charges,90% of Total Billed Charges,9.69,292.75,
Luspatercept-AAMT 75mg,6360000497,CDM,636,RC,J0896,HCPCS,Outpatient,,,117119.68,76127.79,,8146.27,125,,,Fee Schedule,125% of CMS OPPS Rate,89010.96,76,,557.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,119.95,350,,,Fee Schedule,350% of BCBS fee schedule,119.95,350,,,Fee Schedule,350% of BCBS fee schedule,8144.98,100,,,Fee Schedule,100% of CMS OPPS Rate,119.95,350,,,Fee Schedule,350% of BCBS PPO fee schedule,34.27,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,105407.71,90,,1627.296,Percent of Total Billed Charges,90% of Total Billed Charges,52703.86,45,,867.68,Percent of Total Billed Charges,45% of Total Billed Charges,105407.71,90,,659.864,Percent of Total Billed Charges,90% of Total billed Charges,8144.98,100,,,Fee Schedule,100% of CMS OPPS Rate,8144.98,100,,,Fee Schedule,100% of CMS OPPS Rate,8144.98,100,,,Fee Schedule,100% of CMS OPPS Rate,84277.93,65,,67422.344,Percent of total Billed Charges,65% of Total Billed Charges,51649.78,44.1,,850.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,111263.7,95,,696.528,Percent of Total Billed Charges,95% of Total Billed Charges,8143.69,75,,,Fee Schedule,75% of CMS OPPS Rate,103065.32,88,,5100.36,Percent of Total Billed Charges,88% of Total Billed Charges,105407.71,90,,659.864,Percent of Total Billed charges,90% of Total Billed Charges,34.27,111263.7,
Mvasi 100mg/4ml inj,6360000498,CDM,636,RC,Q5107,HCPCS,Outpatient,,,8751.78,5688.66,,35.9,125,,,Fee Schedule,125% of CMS OPPS Rate,6651.35,76,,557.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,276.99,350,,,Fee Schedule,350% of BCBS fee schedule,276.99,350,,,Fee Schedule,350% of BCBS fee schedule,28.73,100,,,Fee Schedule,100% of CMS OPPS Rate,276.99,350,,,Fee Schedule,350% of BCBS PPO fee schedule,79.14,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,7876.6,90,,1521.712,Percent of Total Billed Charges,90% of Total Billed Charges,3938.3,45,,286.4,Percent of Total Billed Charges,45% of Total Billed Charges,7876.6,90,,659.864,Percent of Total Billed Charges,90% of Total billed Charges,28.73,100,,,Fee Schedule,100% of CMS OPPS Rate,28.73,100,,,Fee Schedule,100% of CMS OPPS Rate,28.73,100,,,Fee Schedule,100% of CMS OPPS Rate,5746.12,65,,4596.896,Percent of total Billed Charges,65% of Total Billed Charges,3859.53,44.1,,280.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,8314.19,95,,696.528,Percent of Total Billed Charges,95% of Total Billed Charges,21.54,75,,,Fee Schedule,75% of CMS OPPS Rate,7701.57,88,,940.368,Percent of Total Billed Charges,88% of Total Billed Charges,7876.6,90,,659.864,Percent of Total Billed charges,90% of Total Billed Charges,21.54,8314.19,
Mvasi 400mg/16ml inj,6360000499,CDM,636,RC,Q5107,HCPCS,Outpatient,,,34654.65,22525.52,,35.9,125,,,Fee Schedule,125% of CMS OPPS Rate,26337.53,76,,557.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,276.99,350,,,Fee Schedule,350% of BCBS fee schedule,276.99,350,,,Fee Schedule,350% of BCBS fee schedule,28.73,100,,,Fee Schedule,100% of CMS OPPS Rate,276.99,350,,,Fee Schedule,350% of BCBS PPO fee schedule,79.14,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,31189.19,90,,2196.72,Percent of Total Billed Charges,90% of Total Billed Charges,15594.59,45,,1346.472,Percent of Total Billed Charges,45% of Total Billed Charges,31189.19,90,,659.864,Percent of Total Billed Charges,90% of Total billed Charges,28.73,100,,,Fee Schedule,100% of CMS OPPS Rate,28.73,100,,,Fee Schedule,100% of CMS OPPS Rate,28.73,100,,,Fee Schedule,100% of CMS OPPS Rate,22582.98,65,,18066.384,Percent of total Billed Charges,65% of Total Billed Charges,15282.7,44.1,,1319.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,32921.92,95,,696.528,Percent of Total Billed Charges,95% of Total Billed Charges,21.54,75,,,Fee Schedule,75% of CMS OPPS Rate,30496.09,88,,1696.8,Percent of Total Billed Charges,88% of Total Billed Charges,31189.19,90,,659.864,Percent of Total Billed charges,90% of Total Billed Charges,21.54,32921.92,
Marcaine 0.25% 25mg/10ml inj,6360000500,CDM,636,RC,Q5107,HCPCS,Outpatient,,,52.20,33.93,,35.9,125,,,Fee Schedule,125% of CMS OPPS Rate,39.67,76,,557.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,276.99,350,,,Fee Schedule,350% of BCBS fee schedule,276.99,350,,,Fee Schedule,350% of BCBS fee schedule,28.73,100,,,Fee Schedule,100% of CMS OPPS Rate,276.99,350,,,Fee Schedule,350% of BCBS PPO fee schedule,79.14,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,46.98,90,,1358.28,Percent of Total Billed Charges,90% of Total Billed Charges,23.49,45,,255.6,Percent of Total Billed Charges,45% of Total Billed Charges,46.98,90,,659.864,Percent of Total Billed Charges,90% of Total billed Charges,28.73,100,,,Fee Schedule,100% of CMS OPPS Rate,28.73,100,,,Fee Schedule,100% of CMS OPPS Rate,28.73,100,,,Fee Schedule,100% of CMS OPPS Rate,91.39,65,,73.112,Percent of total Billed Charges,65% of Total Billed Charges,23.02,44.1,,250.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,49.59,95,,696.528,Percent of Total Billed Charges,95% of Total Billed Charges,21.54,75,,,Fee Schedule,75% of CMS OPPS Rate,45.94,88,,560.064,Percent of Total Billed Charges,88% of Total Billed Charges,46.98,90,,659.864,Percent of Total Billed charges,90% of Total Billed Charges,21.54,276.99,
Lamivudine 50mg/5ml sol,6360000501,CDM,636,RC,,,Outpatient,,,16.48,10.71,,16.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,12.52,76,,993.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.87,72,,9.496,Percent of Total Billed Charges,72% of Total Billed Charges,12.36,75,,9.888,Percent of Total Billed charges,75% of Total Billed Charges,16.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.87,72,,9.496,Percent of Total Billed Charges,72% of Total Billed Charges,9.89,60,,7.912,Percent of Total Billed Charges,60% of Total Billed Charges,14.83,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,7.42,45,,813.648,Percent of Total Billed Charges,45% of Total Billed Charges,14.83,90,,1176.504,Percent of Total Billed Charges,90% of Total billed Charges,16.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.71,65,,8.568,Percent of total Billed Charges,65% of Total Billed Charges,7.27,44.1,,797.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,15.66,95,,1241.864,Percent of Total Billed Charges,95% of Total Billed Charges,16.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.5,88,,2633.104,Percent of Total Billed Charges,88% of Total Billed Charges,14.83,90,,1176.504,Percent of Total Billed charges,90% of Total Billed Charges,7.27,16.48,
Lamivudine 1200mg/120ml sol,6360000502,CDM,636,RC,,,Outpatient,,,306.90,199.49,,306.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,233.24,76,,4404.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,220.97,72,,176.776,Percent of Total Billed Charges,72% of Total Billed Charges,230.18,75,,184.144,Percent of Total Billed charges,75% of Total Billed Charges,306.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.97,72,,176.776,Percent of Total Billed Charges,72% of Total Billed Charges,184.14,60,,147.312,Percent of Total Billed Charges,60% of Total Billed Charges,276.21,90,,239.76,Percent of Total Billed Charges,90% of Total Billed Charges,138.11,45,,760.856,Percent of Total Billed Charges,45% of Total Billed Charges,276.21,90,,5216.28,Percent of Total Billed Charges,90% of Total billed Charges,306.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.49,65,,159.592,Percent of total Billed Charges,65% of Total Billed Charges,135.34,44.1,,745.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,291.56,95,,5506.072,Percent of Total Billed Charges,95% of Total Billed Charges,306.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.07,88,,499.84,Percent of Total Billed Charges,88% of Total Billed Charges,276.21,90,,5216.28,Percent of Total Billed charges,90% of Total Billed Charges,135.34,306.9,
Nevirapine 50mg/5ml sol,6360000503,CDM,636,RC,,,Outpatient,,,34.48,22.41,,34.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.2,76,,812.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,24.83,72,,19.864,Percent of Total Billed Charges,72% of Total Billed Charges,25.86,75,,20.688,Percent of Total Billed charges,75% of Total Billed Charges,34.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.83,72,,19.864,Percent of Total Billed Charges,72% of Total Billed Charges,20.69,60,,16.552,Percent of Total Billed Charges,60% of Total Billed Charges,31.03,90,,914.4,Percent of Total Billed Charges,90% of Total Billed Charges,15.52,45,,1098.36,Percent of Total Billed Charges,45% of Total Billed Charges,31.03,90,,961.744,Percent of Total Billed Charges,90% of Total billed Charges,34.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.41,65,,17.928,Percent of total Billed Charges,65% of Total Billed Charges,15.21,44.1,,1076.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,32.76,95,,1015.168,Percent of Total Billed Charges,95% of Total Billed Charges,34.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.34,88,,1591.128,Percent of Total Billed Charges,88% of Total Billed Charges,31.03,90,,961.744,Percent of Total Billed charges,90% of Total Billed Charges,15.21,34.48,
Nevirapine 1200mg/120 ml sol,6360000504,CDM,636,RC,,,Outpatient,,,620.40,403.26,,620.4,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,471.5,76,,1465.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,446.69,72,,357.352,Percent of Total Billed Charges,72% of Total Billed Charges,465.3,75,,372.24,Percent of Total Billed charges,75% of Total Billed Charges,620.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.69,72,,357.352,Percent of Total Billed Charges,72% of Total Billed Charges,372.24,60,,297.792,Percent of Total Billed Charges,60% of Total Billed Charges,558.36,90,,2372.24,Percent of Total Billed Charges,90% of Total Billed Charges,279.18,45,,679.144,Percent of Total Billed Charges,45% of Total Billed Charges,558.36,90,,1735.368,Percent of Total Billed Charges,90% of Total billed Charges,620.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,620.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,620.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,403.26,65,,322.608,Percent of total Billed Charges,65% of Total Billed Charges,273.6,44.1,,665.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,589.38,95,,1831.776,Percent of Total Billed Charges,95% of Total Billed Charges,620.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,545.95,88,,1487.896,Percent of Total Billed Charges,88% of Total Billed Charges,558.36,90,,1735.368,Percent of Total Billed charges,90% of Total Billed Charges,273.6,620.4,
Zidovudine 1200mg/120ml sol,6360000505,CDM,636,RC,,,Outpatient,,,195.03,126.77,,195.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,148.22,76,,483.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,140.42,72,,112.336,Percent of Total Billed Charges,72% of Total Billed Charges,146.27,75,,117.016,Percent of Total Billed charges,75% of Total Billed Charges,195.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.42,72,,112.336,Percent of Total Billed Charges,72% of Total Billed Charges,117.02,60,,93.616,Percent of Total Billed Charges,60% of Total Billed Charges,175.53,90,,2430.184,Percent of Total Billed Charges,90% of Total Billed Charges,87.76,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,175.53,90,,572.8,Percent of Total Billed Charges,90% of Total billed Charges,195.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.77,65,,101.416,Percent of total Billed Charges,65% of Total Billed Charges,86.01,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,185.28,95,,604.616,Percent of Total Billed Charges,95% of Total Billed Charges,195.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.63,88,,2147.904,Percent of Total Billed Charges,88% of Total Billed Charges,175.53,90,,572.8,Percent of Total Billed charges,90% of Total Billed Charges,86.01,195.03,
Vasopressin in Ns 20u/100ml,6360000506,CDM,636,RC,J2601,HCPCS,Outpatient,,,778.13,505.78,,4.53,125,,,Fee Schedule,125% of CMS OPPS Rate,591.38,76,,2274.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,560.25,72,,448.2,Percent of Total Billed Charges,72% of Total Billed Charges,583.6,75,,466.88,Percent of Total Billed charges,75% of Total Billed Charges,3.63,100,,,Fee Schedule,100% of CMS OPPS Rate,560.25,72,,448.2,Percent of Total Billed Charges,72% of Total Billed Charges,466.88,60,,373.504,Percent of Total Billed Charges,60% of Total Billed Charges,700.32,90,,207.36,Percent of Total Billed Charges,90% of Total Billed Charges,350.16,45,,119.88,Percent of Total Billed Charges,45% of Total Billed Charges,700.32,90,,2692.944,Percent of Total Billed Charges,90% of Total billed Charges,3.63,100,,,Fee Schedule,100% of CMS OPPS Rate,3.63,100,,,Fee Schedule,100% of CMS OPPS Rate,3.63,100,,,Fee Schedule,100% of CMS OPPS Rate,513.04,65,,410.432,Percent of total Billed Charges,65% of Total Billed Charges,343.16,44.1,,117.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,739.22,95,,2842.552,Percent of Total Billed Charges,95% of Total Billed Charges,2.72,75,,,Fee Schedule,75% of CMS OPPS Rate,684.75,88,,1328.096,Percent of Total Billed Charges,88% of Total Billed Charges,700.32,90,,2692.944,Percent of Total Billed charges,90% of Total Billed Charges,2.72,739.22,
Levetiracetam in Ns 500mg/100m,6360000507,CDM,636,RC,,,Outpatient,,,117.50,76.38,,117.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,89.3,76,,431.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.6,72,,67.68,Percent of Total Billed Charges,72% of Total Billed Charges,88.13,75,,70.504,Percent of Total Billed charges,75% of Total Billed Charges,117.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.6,72,,67.68,Percent of Total Billed Charges,72% of Total Billed Charges,70.5,60,,56.4,Percent of Total Billed Charges,60% of Total Billed Charges,105.75,90,,1399.216,Percent of Total Billed Charges,90% of Total Billed Charges,52.88,45,,457.2,Percent of Total Billed Charges,45% of Total Billed Charges,105.75,90,,511.2,Percent of Total Billed Charges,90% of Total billed Charges,117.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.38,65,,61.104,Percent of total Billed Charges,65% of Total Billed Charges,51.82,44.1,,448.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,111.63,95,,539.6,Percent of Total Billed Charges,95% of Total Billed Charges,117.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.4,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,105.75,90,,511.2,Percent of Total Billed charges,90% of Total Billed Charges,51.82,117.5,
Levetiracetam in Ns 1000mg/100,6360000508,CDM,250,RC,,,Outpatient,,,117.50,76.38,,117.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,89.3,76,,1374.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,84.6,72,,67.68,Percent of Total Billed Charges,72% of Total Billed Charges,88.13,75,,70.504,Percent of Total Billed charges,75% of Total Billed Charges,117.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.6,72,,67.68,Percent of Total Billed Charges,72% of Total Billed Charges,70.5,60,,56.4,Percent of Total Billed Charges,60% of Total Billed Charges,105.75,90,,8745.808,Percent of Total Billed Charges,90% of Total Billed Charges,52.88,45,,1186.12,Percent of Total Billed Charges,45% of Total Billed Charges,105.75,90,,1627.296,Percent of Total Billed Charges,90% of Total billed Charges,117.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.38,65,,61.104,Percent of total Billed Charges,65% of Total Billed Charges,51.82,44.1,,1162.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,111.63,95,,1717.696,Percent of Total Billed Charges,95% of Total Billed Charges,117.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.4,88,,234.432,Percent of Total Billed Charges,88% of Total Billed Charges,105.75,90,,1627.296,Percent of Total Billed charges,90% of Total Billed Charges,51.82,117.5,
Capvaxive 0.5ml syrg,6360000509,CDM,636,RC,,,Outpatient,,,2834.13,1842.18,,2834.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2153.94,76,,1285,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2040.57,72,,1632.456,Percent of Total Billed Charges,72% of Total Billed Charges,2125.6,75,,1700.48,Percent of Total Billed charges,75% of Total Billed Charges,2834.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2040.57,72,,1632.456,Percent of Total Billed Charges,72% of Total Billed Charges,1700.48,60,,1360.384,Percent of Total Billed Charges,60% of Total Billed Charges,2550.72,90,,5574.96,Percent of Total Billed Charges,90% of Total Billed Charges,1275.36,45,,1215.088,Percent of Total Billed Charges,45% of Total Billed Charges,2550.72,90,,1521.712,Percent of Total Billed Charges,90% of Total billed Charges,2834.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2834.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2834.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1842.18,65,,1473.744,Percent of total Billed Charges,65% of Total Billed Charges,1249.85,44.1,,1190.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,2692.42,95,,1606.256,Percent of Total Billed Charges,95% of Total Billed Charges,2834.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2494.03,88,,894.08,Percent of Total Billed Charges,88% of Total Billed Charges,2550.72,90,,1521.712,Percent of Total Billed charges,90% of Total Billed Charges,1249.85,2834.13,
n NS W/Pit 1002ml bg,6360000510,CDM,636,RC,,,Outpatient,,,212.35,138.03,,212.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,161.39,76,,1855.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,152.89,72,,122.312,Percent of Total Billed Charges,72% of Total Billed Charges,159.26,75,,127.408,Percent of Total Billed charges,75% of Total Billed Charges,212.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.89,72,,122.312,Percent of Total Billed Charges,72% of Total Billed Charges,127.41,60,,101.928,Percent of Total Billed Charges,60% of Total Billed Charges,191.12,90,,8745.808,Percent of Total Billed Charges,90% of Total Billed Charges,95.56,45,,103.68,Percent of Total Billed Charges,45% of Total Billed Charges,191.12,90,,2196.72,Percent of Total Billed Charges,90% of Total billed Charges,212.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.03,65,,110.424,Percent of total Billed Charges,65% of Total Billed Charges,93.65,44.1,,101.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,201.73,95,,2318.76,Percent of Total Billed Charges,95% of Total Billed Charges,212.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.87,88,,2319.528,Percent of Total Billed Charges,88% of Total Billed Charges,191.12,90,,2196.72,Percent of Total Billed charges,90% of Total Billed Charges,93.65,212.35,
Hepatitis B immune Globulin 11,6360000511,CDM,636,RC,,,Outpatient,,,873.45,567.74,,873.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,663.82,76,,1146.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,628.88,72,,503.104,Percent of Total Billed Charges,72% of Total Billed Charges,655.09,75,,524.072,Percent of Total Billed charges,75% of Total Billed Charges,873.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,628.88,72,,503.104,Percent of Total Billed Charges,72% of Total Billed Charges,524.07,60,,419.256,Percent of Total Billed Charges,60% of Total Billed Charges,786.11,90,,1042.56,Percent of Total Billed Charges,90% of Total Billed Charges,393.05,45,,699.608,Percent of Total Billed Charges,45% of Total Billed Charges,786.11,90,,1358.28,Percent of Total Billed Charges,90% of Total billed Charges,873.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,873.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,873.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,567.74,65,,454.192,Percent of total Billed Charges,65% of Total Billed Charges,385.19,44.1,,685.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,829.78,95,,1433.744,Percent of Total Billed Charges,95% of Total Billed Charges,873.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,768.64,88,,2376.176,Percent of Total Billed Charges,88% of Total Billed Charges,786.11,90,,1358.28,Percent of Total Billed charges,90% of Total Billed Charges,385.19,873.45,
Lidocaine 1% 1:2 10ml,6360000512,CDM,636,RC,J2004,HCPCS,Outpatient,,,102.85,66.85,,102.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,78.17,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,74.05,72,,59.24,Percent of Total Billed Charges,72% of Total Billed Charges,77.14,75,,61.712,Percent of Total Billed charges,75% of Total Billed Charges,102.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.05,72,,59.24,Percent of Total Billed Charges,72% of Total Billed Charges,61.71,60,,49.368,Percent of Total Billed Charges,60% of Total Billed Charges,92.57,90,,4706.64,Percent of Total Billed Charges,90% of Total Billed Charges,46.28,45,,4372.904,Percent of Total Billed Charges,45% of Total Billed Charges,92.57,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,102.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.85,65,,53.48,Percent of total Billed Charges,65% of Total Billed Charges,45.36,44.1,,4285.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,97.71,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,102.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.51,88,,202.752,Percent of Total Billed Charges,88% of Total Billed Charges,92.57,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,45.36,102.85,
Simponi Aria 50mg/4ml inj,6360000513,CDM,636,RC,J1602,HCPCS,Outpatient,,,24857.48,16157.36,,13.17,125,,,Fee Schedule,125% of CMS OPPS Rate,18891.68,76,,202.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.1,350,,,Fee Schedule,350% of BCBS fee schedule,114.1,350,,,Fee Schedule,350% of BCBS fee schedule,10.54,100,,,Fee Schedule,100% of CMS OPPS Rate,114.1,350,,,Fee Schedule,350% of BCBS PPO fee schedule,32.6,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,22371.73,90,,907.416,Percent of Total Billed Charges,90% of Total Billed Charges,11185.87,45,,2787.48,Percent of Total Billed Charges,45% of Total Billed Charges,22371.73,90,,239.76,Percent of Total Billed Charges,90% of Total billed Charges,10.54,100,,,Fee Schedule,100% of CMS OPPS Rate,10.54,100,,,Fee Schedule,100% of CMS OPPS Rate,10.54,100,,,Fee Schedule,100% of CMS OPPS Rate,16178.44,65,,12942.752,Percent of total Billed Charges,65% of Total Billed Charges,10962.15,44.1,,2731.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,23614.61,95,,253.08,Percent of Total Billed Charges,95% of Total Billed Charges,7.9,75,,,Fee Schedule,75% of CMS OPPS Rate,21874.58,88,,1368.12,Percent of Total Billed Charges,88% of Total Billed Charges,22371.73,90,,239.76,Percent of Total Billed charges,90% of Total Billed Charges,7.9,23614.61,
TRAUMA ACTIVATION,6840000001,CDM,684,RC,G0390,HCPCS,Outpatient,,,6313.00,4103.45,,1663.29,125,,,Fee Schedule,125% of CMS OPPS Rate,4797.88,76,,772.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2738.65,350,,,Fee Schedule,350% of BCBS fee schedule,2738.65,350,,,Fee Schedule,350% of BCBS fee schedule,1330.64,100,,,Fee Schedule,100% of CMS OPPS Rate,2738.65,286,,,Fee Schedule,286% of BCBS PPO fee schedule,957.57,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,5681.7,90,,907.416,Percent of Total Billed Charges,90% of Total Billed Charges,2840.85,45,,4372.904,Percent of Total Billed Charges,45% of Total Billed Charges,5681.7,90,,914.4,Percent of Total Billed Charges,90% of Total billed Charges,1330.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1330.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1330.64,100,,,Fee Schedule,100% of CMS OPPS Rate,2484.86,200,,,Fee Schedule,200% of CMS OPPS Rate,2784.03,44.1,,4285.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,5997.35,95,,965.2,Percent of Total Billed Charges,95% of Total Billed Charges,997.96,75,,,Fee Schedule,75% of CMS OPPS Rate,5555.44,88,,8551.456,Percent of Total Billed Charges,88% of Total Billed Charges,5681.7,90,,914.4,Percent of Total Billed charges,90% of Total Billed Charges,957.57,5997.35,
PEDS EXTENDED 60 MIN RECO,7100000001,CDM,710,RC,,,Outpatient,,,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,2003.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,1347.592,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,521.28,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,2372.24,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,510.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,2504.032,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,5451.072,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,2372.24,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
EXTENDED 60 MIN RECO,7100000002,CDM,710,RC,,,Outpatient,,,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,2052.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,2435.76,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,2353.32,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,2430.184,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,2306.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,2565.192,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,8551.456,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,2430.184,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
EXT RECOVERY EA 30MI,7100000003,CDM,710,RC,,,Outpatient,,,94.82,61.63,,94.82,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.06,76,,175.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,68.27,72,,54.616,Percent of Total Billed Charges,72% of Total Billed Charges,71.12,75,,56.896,Percent of Total Billed charges,75% of Total Billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.27,72,,54.616,Percent of Total Billed Charges,72% of Total Billed Charges,56.89,60,,45.512,Percent of Total Billed Charges,60% of Total Billed Charges,85.34,90,,5511.008,Percent of Total Billed Charges,90% of Total Billed Charges,42.67,45,,453.712,Percent of Total Billed Charges,45% of Total Billed Charges,85.34,90,,207.36,Percent of Total Billed Charges,90% of Total billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.63,65,,49.304,Percent of total Billed Charges,65% of Total Billed Charges,41.82,44.1,,444.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,90.08,95,,218.88,Percent of Total Billed Charges,95% of Total Billed Charges,94.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.44,88,,1019.392,Percent of Total Billed Charges,88% of Total Billed Charges,85.34,90,,207.36,Percent of Total Billed charges,90% of Total Billed Charges,41.82,94.82,
RECOVERY RM USE/HR,7100000004,CDM,710,RC,,,Outpatient,,,1564.45,1016.89,,1564.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1188.98,76,,1181.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1126.4,72,,901.12,Percent of Total Billed Charges,72% of Total Billed Charges,1173.34,75,,938.672,Percent of Total Billed charges,75% of Total Billed Charges,1564.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1126.4,72,,901.12,Percent of Total Billed Charges,72% of Total Billed Charges,938.67,60,,750.936,Percent of Total Billed Charges,60% of Total Billed Charges,1408.01,90,,2532.6,Percent of Total Billed Charges,90% of Total Billed Charges,704,45,,453.712,Percent of Total Billed Charges,45% of Total Billed Charges,1408.01,90,,1399.216,Percent of Total Billed Charges,90% of Total billed Charges,1564.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1564.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1564.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1016.89,65,,813.512,Percent of total Billed Charges,65% of Total Billed Charges,689.92,44.1,,444.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,1486.23,95,,1476.944,Percent of Total Billed Charges,95% of Total Billed Charges,1564.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1376.72,88,,4602.048,Percent of Total Billed Charges,88% of Total Billed Charges,1408.01,90,,1399.216,Percent of Total Billed charges,90% of Total Billed Charges,689.92,1564.45,
RECOVERY RM EA ADDL,7100000005,CDM,710,RC,,,Outpatient,,,20.09,13.06,,20.09,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,15.27,76,,7385.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.46,72,,11.568,Percent of Total Billed Charges,72% of Total Billed Charges,15.07,75,,12.056,Percent of Total Billed charges,75% of Total Billed Charges,20.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.46,72,,11.568,Percent of Total Billed Charges,72% of Total Billed Charges,12.05,60,,9.64,Percent of Total Billed Charges,60% of Total Billed Charges,18.08,90,,1101.456,Percent of Total Billed Charges,90% of Total Billed Charges,9.04,45,,673.792,Percent of Total Billed Charges,45% of Total Billed Charges,18.08,90,,8745.808,Percent of Total Billed Charges,90% of Total billed Charges,20.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.06,65,,10.448,Percent of total Billed Charges,65% of Total Billed Charges,8.86,44.1,,660.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,19.09,95,,9231.68,Percent of Total Billed Charges,95% of Total Billed Charges,20.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.68,88,,887.248,Percent of Total Billed Charges,88% of Total Billed Charges,18.08,90,,8745.808,Percent of Total Billed charges,90% of Total Billed Charges,8.86,20.09,
EXTENDED 60 MIN RECO,7100000006,CDM,710,RC,,,Outpatient,,,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,4707.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,1101.456,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,1217.88,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,5574.96,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,1193.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,5884.68,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,887.248,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,5574.96,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
SP PROC RECOVERY R,7100000007,CDM,710,RC,,,Outpatient,,,1672.49,1087.12,,1672.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1271.09,76,,7385.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1204.19,72,,963.352,Percent of Total Billed Charges,72% of Total Billed Charges,1254.37,75,,1003.496,Percent of Total Billed charges,75% of Total Billed Charges,1672.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1204.19,72,,963.352,Percent of Total Billed Charges,72% of Total Billed Charges,1003.49,60,,802.792,Percent of Total Billed Charges,60% of Total Billed Charges,1505.24,90,,8791.168,Percent of Total Billed Charges,90% of Total Billed Charges,752.62,45,,2755.504,Percent of Total Billed Charges,45% of Total Billed Charges,1505.24,90,,8745.808,Percent of Total Billed Charges,90% of Total billed Charges,1672.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1672.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1672.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1087.12,65,,869.696,Percent of total Billed Charges,65% of Total Billed Charges,737.57,44.1,,2700.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1588.87,95,,9231.68,Percent of Total Billed Charges,95% of Total Billed Charges,1672.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1471.79,88,,1317.64,Percent of Total Billed Charges,88% of Total Billed Charges,1505.24,90,,8745.808,Percent of Total Billed charges,90% of Total Billed Charges,737.57,1672.49,
PHASE 1 RECOVERY INTERM 90MIN,7100000008,CDM,710,RC,,,Outpatient,,,2535.00,1647.75,,2535,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1926.6,76,,880.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1825.2,72,,1460.16,Percent of Total Billed Charges,72% of Total Billed Charges,1901.25,75,,1521,Percent of Total Billed charges,75% of Total Billed Charges,2535,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1825.2,72,,1460.16,Percent of Total Billed Charges,72% of Total Billed Charges,1521,60,,1216.8,Percent of Total Billed Charges,60% of Total Billed Charges,2281.5,90,,449.208,Percent of Total Billed Charges,90% of Total Billed Charges,1140.75,45,,1266.304,Percent of Total Billed Charges,45% of Total Billed Charges,2281.5,90,,1042.56,Percent of Total Billed Charges,90% of Total billed Charges,2535,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2535,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2535,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1647.75,65,,1318.2,Percent of total Billed Charges,65% of Total Billed Charges,1117.94,44.1,,1240.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,2408.25,95,,1100.48,Percent of Total Billed Charges,95% of Total Billed Charges,2535,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2230.8,88,,2381.632,Percent of Total Billed Charges,88% of Total Billed Charges,2281.5,90,,1042.56,Percent of Total Billed charges,90% of Total Billed Charges,1117.94,2535,
PHASE 1 RECOVERY MINOR 60MIN,7100000009,CDM,710,RC,,,Outpatient,,,1690.00,1098.50,,1690,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1284.4,76,,3974.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1216.8,72,,973.44,Percent of Total Billed Charges,72% of Total Billed Charges,1267.5,75,,1014,Percent of Total Billed charges,75% of Total Billed Charges,1690,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1216.8,72,,973.44,Percent of Total Billed Charges,72% of Total Billed Charges,1014,60,,811.2,Percent of Total Billed Charges,60% of Total Billed Charges,1521,90,,2477.488,Percent of Total Billed Charges,90% of Total Billed Charges,760.5,45,,550.728,Percent of Total Billed Charges,45% of Total Billed Charges,1521,90,,4706.64,Percent of Total Billed Charges,90% of Total billed Charges,1690,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1690,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1690,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1098.5,65,,878.8,Percent of total Billed Charges,65% of Total Billed Charges,745.29,44.1,,539.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1605.5,95,,4968.12,Percent of Total Billed Charges,95% of Total Billed Charges,1690,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1487.2,88,,5388.544,Percent of Total Billed Charges,88% of Total Billed Charges,1521,90,,4706.64,Percent of Total Billed charges,90% of Total Billed Charges,745.29,1690,
OR RECOVERY ROOM FLAT FEE,7100000010,CDM,710,RC,,,Outpatient,,,1600.00,1040.00,,1600,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1216,76,,766.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1152,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,1200,75,,960,Percent of Total Billed charges,75% of Total Billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1152,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,960,60,,768,Percent of Total Billed Charges,60% of Total Billed Charges,1440,90,,4830.304,Percent of Total Billed Charges,90% of Total Billed Charges,720,45,,550.728,Percent of Total Billed Charges,45% of Total Billed Charges,1440,90,,907.416,Percent of Total Billed Charges,90% of Total billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1040,65,,832,Percent of total Billed Charges,65% of Total Billed Charges,705.6,44.1,,539.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1520,95,,957.832,Percent of Total Billed Charges,95% of Total Billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1408,88,,2476.32,Percent of Total Billed Charges,88% of Total Billed Charges,1440,90,,907.416,Percent of Total Billed charges,90% of Total Billed Charges,705.6,1600,
CATH LAB RECOVERY ROOM LEVEL 1,7100000011,CDM,710,RC,,,Outpatient,,,1500.00,975.00,,1500,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1140,76,,766.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1080,72,,864,Percent of Total Billed Charges,72% of Total Billed Charges,1125,75,,900,Percent of Total Billed charges,75% of Total Billed Charges,1500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1080,72,,864,Percent of Total Billed Charges,72% of Total Billed Charges,900,60,,720,Percent of Total Billed Charges,60% of Total Billed Charges,1350,90,,88.56,Percent of Total Billed Charges,90% of Total Billed Charges,675,45,,4395.584,Percent of Total Billed Charges,45% of Total Billed Charges,1350,90,,907.416,Percent of Total Billed Charges,90% of Total billed Charges,1500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,975,65,,780,Percent of total Billed Charges,65% of Total Billed Charges,661.5,44.1,,4307.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,1425,95,,957.832,Percent of Total Billed Charges,95% of Total Billed Charges,1500,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1320,88,,1076.976,Percent of Total Billed Charges,88% of Total Billed Charges,1350,90,,907.416,Percent of Total Billed charges,90% of Total Billed Charges,661.5,1500,
CATH LAB RECOVERY ROOM LEVEL 2,7100000012,CDM,710,RC,,,Outpatient,,,1600.00,1040.00,,1600,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1216,76,,1137.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1152,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,1200,75,,960,Percent of Total Billed charges,75% of Total Billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1152,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,960,60,,768,Percent of Total Billed Charges,60% of Total Billed Charges,1440,90,,88.56,Percent of Total Billed Charges,90% of Total Billed Charges,720,45,,224.608,Percent of Total Billed Charges,45% of Total Billed Charges,1440,90,,1347.592,Percent of Total Billed Charges,90% of Total billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1040,65,,832,Percent of total Billed Charges,65% of Total Billed Charges,705.6,44.1,,220.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,1520,95,,1422.456,Percent of Total Billed Charges,95% of Total Billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1408,88,,1076.976,Percent of Total Billed Charges,88% of Total Billed Charges,1440,90,,1347.592,Percent of Total Billed charges,90% of Total Billed Charges,705.6,1600,
CATH LAB RECOVERY RM FLAT FEE,7100000013,CDM,710,RC,,,Outpatient,,,1600.00,1040.00,,1600,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1216,76,,2056.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1152,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,1200,75,,960,Percent of Total Billed charges,75% of Total Billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1152,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,960,60,,768,Percent of Total Billed Charges,60% of Total Billed Charges,1440,90,,58.32,Percent of Total Billed Charges,90% of Total Billed Charges,720,45,,1238.744,Percent of Total Billed Charges,45% of Total Billed Charges,1440,90,,2435.76,Percent of Total Billed Charges,90% of Total billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1040,65,,832,Percent of total Billed Charges,65% of Total Billed Charges,705.6,44.1,,1213.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,1520,95,,2571.08,Percent of Total Billed Charges,95% of Total Billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1408,88,,8595.808,Percent of Total Billed Charges,88% of Total Billed Charges,1440,90,,2435.76,Percent of Total Billed charges,90% of Total Billed Charges,705.6,1600,
PHASEII OR RECOVERY RM LEVEL 1,7100000014,CDM,710,RC,,,Outpatient,,,1520.00,988.00,,1520,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1155.2,76,,4653.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1094.4,72,,875.52,Percent of Total Billed Charges,72% of Total Billed Charges,1140,75,,912,Percent of Total Billed charges,75% of Total Billed Charges,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1094.4,72,,875.52,Percent of Total Billed Charges,72% of Total Billed Charges,912,60,,729.6,Percent of Total Billed Charges,60% of Total Billed Charges,1368,90,,58.32,Percent of Total Billed Charges,90% of Total Billed Charges,684,45,,2415.152,Percent of Total Billed Charges,45% of Total Billed Charges,1368,90,,5511.008,Percent of Total Billed Charges,90% of Total billed Charges,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,988,65,,790.4,Percent of total Billed Charges,65% of Total Billed Charges,670.32,44.1,,2366.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,1444,95,,5817.176,Percent of Total Billed Charges,95% of Total Billed Charges,1520,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1337.6,88,,439.224,Percent of Total Billed Charges,88% of Total Billed Charges,1368,90,,5511.008,Percent of Total Billed charges,90% of Total Billed Charges,670.32,1520,
PHASEII OR RECOVERY RM LEVEL 2,7100000015,CDM,710,RC,,,Outpatient,,,1728.00,1123.20,,1728,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1313.28,76,,2138.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1244.16,72,,995.328,Percent of Total Billed Charges,72% of Total Billed Charges,1296,75,,1036.8,Percent of Total Billed charges,75% of Total Billed Charges,1728,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1244.16,72,,995.328,Percent of Total Billed Charges,72% of Total Billed Charges,1036.8,60,,829.44,Percent of Total Billed Charges,60% of Total Billed Charges,1555.2,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,777.6,45,,44.28,Percent of Total Billed Charges,45% of Total Billed Charges,1555.2,90,,2532.6,Percent of Total Billed Charges,90% of Total billed Charges,1728,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1728,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1728,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.2,65,,898.56,Percent of total Billed Charges,65% of Total Billed Charges,762.05,44.1,,43.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1641.6,95,,2673.304,Percent of Total Billed Charges,95% of Total Billed Charges,1728,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1520.64,88,,2422.432,Percent of Total Billed Charges,88% of Total Billed Charges,1555.2,90,,2532.6,Percent of Total Billed charges,90% of Total Billed Charges,762.05,1728,
PHASEII OR RECOV RM FLAT FEE,7100000016,CDM,710,RC,,,Outpatient,,,1600.00,1040.00,,1600,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1216,76,,930.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1152,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,1200,75,,960,Percent of Total Billed charges,75% of Total Billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1152,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,960,60,,768,Percent of Total Billed Charges,60% of Total Billed Charges,1440,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,720,45,,44.28,Percent of Total Billed Charges,45% of Total Billed Charges,1440,90,,1101.456,Percent of Total Billed Charges,90% of Total billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1040,65,,832,Percent of total Billed Charges,65% of Total Billed Charges,705.6,44.1,,43.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1520,95,,1162.648,Percent of Total Billed Charges,95% of Total Billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1408,88,,4722.96,Percent of Total Billed Charges,88% of Total Billed Charges,1440,90,,1101.456,Percent of Total Billed charges,90% of Total Billed Charges,705.6,1600,
PHASEII CATH LAB REC RM LEV 1,7100000017,CDM,710,RC,,,Outpatient,,,1728.00,1123.20,,1728,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1313.28,76,,930.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1244.16,72,,995.328,Percent of Total Billed Charges,72% of Total Billed Charges,1296,75,,1036.8,Percent of Total Billed charges,75% of Total Billed Charges,1728,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1244.16,72,,995.328,Percent of Total Billed Charges,72% of Total Billed Charges,1036.8,60,,829.44,Percent of Total Billed Charges,60% of Total Billed Charges,1555.2,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,777.6,45,,29.16,Percent of Total Billed Charges,45% of Total Billed Charges,1555.2,90,,1101.456,Percent of Total Billed Charges,90% of Total billed Charges,1728,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1728,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1728,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.2,65,,898.56,Percent of total Billed Charges,65% of Total Billed Charges,762.05,44.1,,28.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,1641.6,95,,1162.648,Percent of Total Billed Charges,95% of Total Billed Charges,1728,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1520.64,88,,86.592,Percent of Total Billed Charges,88% of Total Billed Charges,1555.2,90,,1101.456,Percent of Total Billed charges,90% of Total Billed Charges,762.05,1728,
PHASEII CATH LAB REC RM LEV 2,7100000018,CDM,710,RC,,,Outpatient,,,1600.00,1040.00,,1600,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1216,76,,7423.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1152,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,1200,75,,960,Percent of Total Billed charges,75% of Total Billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1152,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,960,60,,768,Percent of Total Billed Charges,60% of Total Billed Charges,1440,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,720,45,,29.16,Percent of Total Billed Charges,45% of Total Billed Charges,1440,90,,8791.168,Percent of Total Billed Charges,90% of Total billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1040,65,,832,Percent of total Billed Charges,65% of Total Billed Charges,705.6,44.1,,28.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,1520,95,,9279.56,Percent of Total Billed Charges,95% of Total Billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1408,88,,86.592,Percent of Total Billed Charges,88% of Total Billed Charges,1440,90,,8791.168,Percent of Total Billed charges,90% of Total Billed Charges,705.6,1600,
PHASEII CATHLAB REC RM FLT FEE,7100000019,CDM,710,RC,,,Outpatient,,,1600.00,1040.00,,1600,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1216,76,,379.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1152,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,1200,75,,960,Percent of Total Billed charges,75% of Total Billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1152,72,,921.6,Percent of Total Billed Charges,72% of Total Billed Charges,960,60,,768,Percent of Total Billed Charges,60% of Total Billed Charges,1440,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,720,45,,12.6,Percent of Total Billed Charges,45% of Total Billed Charges,1440,90,,449.208,Percent of Total Billed Charges,90% of Total billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1040,65,,832,Percent of total Billed Charges,65% of Total Billed Charges,705.6,44.1,,12.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,1520,95,,474.168,Percent of Total Billed Charges,95% of Total Billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1408,88,,1062.56,Percent of Total Billed Charges,88% of Total Billed Charges,1440,90,,449.208,Percent of Total Billed charges,90% of Total Billed Charges,705.6,1600,
EXTENDED 60MIN RECO,7100000020,CDM,710,RC,,,Outpatient,,,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,2092.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,63.5,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,66.15,75,,52.92,Percent of Total Billed charges,75% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.5,72,,50.8,Percent of Total Billed Charges,72% of Total Billed Charges,52.92,60,,42.336,Percent of Total Billed Charges,60% of Total Billed Charges,79.38,90,,1086.712,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,2477.488,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,2615.12,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,1113.728,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,2477.488,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
OR RECOVERY MAJOR 120MIN,7100000021,CDM,710,RC,,,Outpatient,,,3128.90,2033.79,,3128.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2377.96,76,,4078.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2252.81,72,,1802.248,Percent of Total Billed Charges,72% of Total Billed Charges,2346.68,75,,1877.344,Percent of Total Billed charges,75% of Total Billed Charges,3128.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2252.81,72,,1802.248,Percent of Total Billed Charges,72% of Total Billed Charges,1877.34,60,,1501.872,Percent of Total Billed Charges,60% of Total Billed Charges,2816.01,90,,1139.04,Percent of Total Billed Charges,90% of Total Billed Charges,1408.01,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,2816.01,90,,4830.304,Percent of Total Billed Charges,90% of Total billed Charges,3128.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3128.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3128.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2033.79,65,,1627.032,Percent of total Billed Charges,65% of Total Billed Charges,1379.84,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,2972.46,95,,5098.648,Percent of Total Billed Charges,95% of Total Billed Charges,3128.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2753.43,88,,1057.408,Percent of Total Billed Charges,88% of Total Billed Charges,2816.01,90,,4830.304,Percent of Total Billed charges,90% of Total Billed Charges,1379.84,3128.9,
FETAL NONSTRESS TEST,7200000001,CDM,720,RC,,,Outpatient,,,428.00,278.20,,428,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,325.28,76,,74.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,308.16,72,,246.528,Percent of Total Billed Charges,72% of Total Billed Charges,321,75,,256.8,Percent of Total Billed charges,75% of Total Billed Charges,428,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.16,72,,246.528,Percent of Total Billed Charges,72% of Total Billed Charges,256.8,60,,205.44,Percent of Total Billed Charges,60% of Total Billed Charges,385.2,90,,1081.44,Percent of Total Billed Charges,90% of Total Billed Charges,192.6,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,385.2,90,,88.56,Percent of Total Billed Charges,90% of Total billed Charges,428,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,428,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,428,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.2,65,,222.56,Percent of total Billed Charges,65% of Total Billed Charges,188.75,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,406.6,95,,93.48,Percent of Total Billed Charges,95% of Total Billed Charges,428,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.64,88,,615.704,Percent of Total Billed Charges,88% of Total Billed Charges,385.2,90,,88.56,Percent of Total Billed charges,90% of Total Billed Charges,188.75,428,
DELV. OF PLACENTA SE,7200000002,CDM,720,RC,,,Outpatient,,,5813.23,3778.60,,5813.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4418.05,76,,74.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,4185.53,72,,3348.424,Percent of Total Billed Charges,72% of Total Billed Charges,4359.92,75,,3487.936,Percent of Total Billed charges,75% of Total Billed Charges,5813.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4185.53,72,,3348.424,Percent of Total Billed Charges,72% of Total Billed Charges,3487.94,60,,2790.352,Percent of Total Billed Charges,60% of Total Billed Charges,5231.91,90,,629.696,Percent of Total Billed Charges,90% of Total Billed Charges,2615.95,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,5231.91,90,,88.56,Percent of Total Billed Charges,90% of Total billed Charges,5813.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5813.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5813.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3778.6,65,,3022.88,Percent of total Billed Charges,65% of Total Billed Charges,2563.63,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,5522.57,95,,93.48,Percent of Total Billed Charges,95% of Total Billed Charges,5813.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5115.64,88,,1201.728,Percent of Total Billed Charges,88% of Total Billed Charges,5231.91,90,,88.56,Percent of Total Billed charges,90% of Total Billed Charges,2563.63,5813.23,
NEWBORN RESUSCITATIO,7200000003,CDM,720,RC,,,Outpatient,,,1481.51,962.98,,1481.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1125.95,76,,49.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1066.69,72,,853.352,Percent of Total Billed Charges,72% of Total Billed Charges,1111.13,75,,888.904,Percent of Total Billed charges,75% of Total Billed Charges,1481.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1066.69,72,,853.352,Percent of Total Billed Charges,72% of Total Billed Charges,888.91,60,,711.128,Percent of Total Billed Charges,60% of Total Billed Charges,1333.36,90,,1229.04,Percent of Total Billed Charges,90% of Total Billed Charges,666.68,45,,543.352,Percent of Total Billed Charges,45% of Total Billed Charges,1333.36,90,,58.32,Percent of Total Billed Charges,90% of Total billed Charges,1481.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1481.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1481.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,962.98,65,,770.384,Percent of total Billed Charges,65% of Total Billed Charges,653.35,44.1,,532.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,1407.43,95,,61.56,Percent of Total Billed Charges,95% of Total Billed Charges,1481.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1303.73,88,,204.128,Percent of Total Billed Charges,88% of Total Billed Charges,1333.36,90,,58.32,Percent of Total Billed charges,90% of Total Billed Charges,653.35,1481.51,
VAG. DELIVERY & PP C,7220000001,CDM,722,RC,,,Outpatient,,,9550.00,6207.50,,9550,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,7258,76,,49.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6876,72,,5500.8,Percent of Total Billed Charges,72% of Total Billed Charges,7162.5,75,,5730,Percent of Total Billed charges,75% of Total Billed Charges,9550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6876,72,,5500.8,Percent of Total Billed Charges,72% of Total Billed Charges,5730,60,,4584,Percent of Total Billed Charges,60% of Total Billed Charges,8595,90,,208.768,Percent of Total Billed Charges,90% of Total Billed Charges,4297.5,45,,569.52,Percent of Total Billed Charges,45% of Total Billed Charges,8595,90,,58.32,Percent of Total Billed Charges,90% of Total billed Charges,9550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6207.5,65,,4966,Percent of total Billed Charges,65% of Total Billed Charges,4211.55,44.1,,558.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,9072.5,95,,61.56,Percent of Total Billed Charges,95% of Total Billed Charges,9550,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8404,88,,208.008,Percent of Total Billed Charges,88% of Total Billed Charges,8595,90,,58.32,Percent of Total Billed charges,90% of Total Billed Charges,4211.55,9550,
"EKG, tracing only",7300000001,CDM,730,RC,,,Outpatient,,,284.45,184.89,,284.45,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,216.18,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,204.8,72,,163.84,Percent of Total Billed Charges,72% of Total Billed Charges,213.34,75,,170.672,Percent of Total Billed charges,75% of Total Billed Charges,284.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.8,72,,163.84,Percent of Total Billed Charges,72% of Total Billed Charges,170.67,60,,136.536,Percent of Total Billed Charges,60% of Total Billed Charges,256.01,90,,212.736,Percent of Total Billed Charges,90% of Total Billed Charges,128,45,,540.72,Percent of Total Billed Charges,45% of Total Billed Charges,256.01,90,,25.2,Percent of Total Billed Charges,90% of Total billed Charges,284.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.89,65,,147.912,Percent of total Billed Charges,65% of Total Billed Charges,125.44,44.1,,529.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,270.23,95,,26.6,Percent of Total Billed Charges,95% of Total Billed Charges,284.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.32,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,256.01,90,,25.2,Percent of Total Billed charges,90% of Total Billed Charges,125.44,284.45,
HOLTER HOOK UP,7310000001,CDM,731,RC,,,Outpatient,,,261.73,170.12,,261.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,198.91,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,188.45,72,,150.76,Percent of Total Billed Charges,72% of Total Billed Charges,196.3,75,,157.04,Percent of Total Billed charges,75% of Total Billed Charges,261.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.45,72,,150.76,Percent of Total Billed Charges,72% of Total Billed Charges,157.04,60,,125.632,Percent of Total Billed Charges,60% of Total Billed Charges,235.56,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,117.78,45,,314.848,Percent of Total Billed Charges,45% of Total Billed Charges,235.56,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,261.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.12,65,,136.096,Percent of total Billed Charges,65% of Total Billed Charges,115.42,44.1,,308.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,248.64,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,261.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.32,88,,391.96,Percent of Total Billed Charges,88% of Total Billed Charges,235.56,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,115.42,261.73,
CARDIAC EVENT MONITO,7310000002,CDM,731,RC,,,Outpatient,,,940.43,611.28,,940.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,714.73,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,677.11,72,,541.688,Percent of Total Billed Charges,72% of Total Billed Charges,705.32,75,,564.256,Percent of Total Billed charges,75% of Total Billed Charges,940.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.11,72,,541.688,Percent of Total Billed Charges,72% of Total Billed Charges,564.26,60,,451.408,Percent of Total Billed Charges,60% of Total Billed Charges,846.39,90,,400.864,Percent of Total Billed Charges,90% of Total Billed Charges,423.19,45,,614.52,Percent of Total Billed Charges,45% of Total Billed Charges,846.39,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,940.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,940.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,940.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.28,65,,489.024,Percent of total Billed Charges,65% of Total Billed Charges,414.73,44.1,,602.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,893.41,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,940.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,827.58,88,,67662.848,Percent of Total Billed Charges,88% of Total Billed Charges,846.39,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,414.73,940.43,
ECG UP TO 48 HRS SCANNING ANAL,7310000003,CDM,731,RC,,,Outpatient,,,261.73,170.12,,261.73,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,198.91,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,188.45,72,,150.76,Percent of Total Billed Charges,72% of Total Billed Charges,196.3,75,,157.04,Percent of Total Billed charges,75% of Total Billed Charges,261.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.45,72,,150.76,Percent of Total Billed Charges,72% of Total Billed Charges,157.04,60,,125.632,Percent of Total Billed Charges,60% of Total Billed Charges,235.56,90,,69200.64,Percent of Total Billed Charges,90% of Total Billed Charges,117.78,45,,104.384,Percent of Total Billed Charges,45% of Total Billed Charges,235.56,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,261.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.12,65,,136.096,Percent of total Billed Charges,65% of Total Billed Charges,115.42,44.1,,102.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,248.64,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,261.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.32,88,,277.088,Percent of Total Billed Charges,88% of Total Billed Charges,235.56,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,115.42,261.73,
EEG,7400000001,CDM,740,RC,,,Outpatient,,,643.86,418.51,,643.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,489.33,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,463.58,72,,370.864,Percent of Total Billed Charges,72% of Total Billed Charges,482.9,75,,386.32,Percent of Total Billed charges,75% of Total Billed Charges,643.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,463.58,72,,370.864,Percent of Total Billed Charges,72% of Total Billed Charges,386.32,60,,309.056,Percent of Total Billed Charges,60% of Total Billed Charges,579.47,90,,283.384,Percent of Total Billed Charges,90% of Total Billed Charges,289.74,45,,106.368,Percent of Total Billed Charges,45% of Total Billed Charges,579.47,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,643.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,643.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,643.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,418.51,65,,334.808,Percent of total Billed Charges,65% of Total Billed Charges,283.94,44.1,,104.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,611.67,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,643.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.6,88,,239.832,Percent of Total Billed Charges,88% of Total Billed Charges,579.47,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,283.94,643.86,
EEG  GREATER THAN 1 HOUR,7400000002,CDM,740,RC,,,Outpatient,,,1287.72,837.02,,1287.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,978.67,76,,917.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,927.16,72,,741.728,Percent of Total Billed Charges,72% of Total Billed Charges,965.79,75,,772.632,Percent of Total Billed charges,75% of Total Billed Charges,1287.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,927.16,72,,741.728,Percent of Total Billed Charges,72% of Total Billed Charges,772.63,60,,618.104,Percent of Total Billed Charges,60% of Total Billed Charges,1158.95,90,,245.28,Percent of Total Billed Charges,90% of Total Billed Charges,579.47,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,1158.95,90,,1086.712,Percent of Total Billed Charges,90% of Total billed Charges,1287.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1287.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1287.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,837.02,65,,669.616,Percent of total Billed Charges,65% of Total Billed Charges,567.88,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,1223.33,95,,1147.08,Percent of Total Billed Charges,95% of Total Billed Charges,1287.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1133.19,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,1158.95,90,,1086.712,Percent of Total Billed charges,90% of Total Billed Charges,567.88,1287.72,
EEG AWAKE DROWSY,7400000003,CDM,740,RC,,,Outpatient,,,776.16,504.50,,776.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,589.88,76,,961.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,558.84,72,,447.072,Percent of Total Billed Charges,72% of Total Billed Charges,582.12,75,,465.696,Percent of Total Billed charges,75% of Total Billed Charges,776.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.84,72,,447.072,Percent of Total Billed Charges,72% of Total Billed Charges,465.7,60,,372.56,Percent of Total Billed Charges,60% of Total Billed Charges,698.54,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,349.27,45,,200.432,Percent of Total Billed Charges,45% of Total Billed Charges,698.54,90,,1139.04,Percent of Total Billed Charges,90% of Total billed Charges,776.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,776.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,776.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,504.5,65,,403.6,Percent of total Billed Charges,65% of Total Billed Charges,342.29,44.1,,196.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,737.35,95,,1202.32,Percent of Total Billed Charges,95% of Total Billed Charges,776.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,683.02,88,,795.52,Percent of Total Billed Charges,88% of Total Billed Charges,698.54,90,,1139.04,Percent of Total Billed charges,90% of Total Billed Charges,342.29,776.16,
"ARTHROC ASP/INJ,MAJ JNT W/US",7610000001,CDM,761,RC,,,Outpatient,,,702.00,456.30,,702,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,533.52,76,,913.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,631.8,90,,813.6,Percent of Total Billed Charges,90% of Total Billed Charges,315.9,45,,34600.32,Percent of Total Billed Charges,45% of Total Billed Charges,631.8,90,,1081.44,Percent of Total Billed Charges,90% of Total billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.3,65,,365.04,Percent of total Billed Charges,65% of Total Billed Charges,309.58,44.1,,33908.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,666.9,95,,1141.52,Percent of Total Billed Charges,95% of Total Billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,617.76,88,,624.032,Percent of Total Billed Charges,88% of Total Billed Charges,631.8,90,,1081.44,Percent of Total Billed charges,90% of Total Billed Charges,50,702,
"ARTHROCEN ASP/INJ,MA JNT W/US",7610000003,CDM,761,RC,,,Outpatient,,,702.00,456.30,,702,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,533.52,76,,531.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,631.8,90,,638.216,Percent of Total Billed Charges,90% of Total Billed Charges,315.9,45,,141.696,Percent of Total Billed Charges,45% of Total Billed Charges,631.8,90,,629.696,Percent of Total Billed Charges,90% of Total billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.3,65,,365.04,Percent of total Billed Charges,65% of Total Billed Charges,309.58,44.1,,138.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,666.9,95,,664.68,Percent of Total Billed Charges,95% of Total Billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,617.76,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,631.8,90,,629.696,Percent of Total Billed charges,90% of Total Billed Charges,50,702,
BIOPSY SALIVARY GLAND INCIS,7610000004,CDM,761,RC,,,Outpatient,,,2037.29,1324.24,,2037.29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1548.34,76,,1037.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2037.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1833.56,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,916.78,45,,122.64,Percent of Total Billed Charges,45% of Total Billed Charges,1833.56,90,,1229.04,Percent of Total Billed Charges,90% of Total billed Charges,2037.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2037.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2037.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1324.24,65,,1059.392,Percent of total Billed Charges,65% of Total Billed Charges,898.44,44.1,,120.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,1935.43,95,,1297.32,Percent of Total Billed Charges,95% of Total Billed Charges,2037.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1792.82,88,,895.696,Percent of Total Billed Charges,88% of Total Billed Charges,1833.56,90,,1229.04,Percent of Total Billed charges,90% of Total Billed Charges,50,2037.29,
BIOPSY/ EXCISION OF LYMPH NODE,7610000005,CDM,761,RC,,,Outpatient,,,2535.75,1648.24,,2535.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1927.17,76,,176.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2282.18,90,,916.048,Percent of Total Billed Charges,90% of Total Billed Charges,1141.09,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,2282.18,90,,208.768,Percent of Total Billed Charges,90% of Total billed Charges,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1648.24,65,,1318.592,Percent of total Billed Charges,65% of Total Billed Charges,1118.27,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,2408.96,95,,220.368,Percent of Total Billed Charges,95% of Total Billed Charges,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2231.46,88,,398.952,Percent of Total Billed Charges,88% of Total Billed Charges,2282.18,90,,208.768,Percent of Total Billed charges,90% of Total Billed Charges,50,2535.75,
BONE MAR BIOPSY NDLE OR TROCAR,7610000006,CDM,761,RC,,,Outpatient,,,2007.25,1304.71,,2007.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1525.51,76,,179.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2007.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1806.53,90,,408.016,Percent of Total Billed Charges,90% of Total Billed Charges,903.26,45,,406.8,Percent of Total Billed Charges,45% of Total Billed Charges,1806.53,90,,212.736,Percent of Total Billed Charges,90% of Total billed Charges,2007.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2007.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2007.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1304.71,65,,1043.768,Percent of total Billed Charges,65% of Total Billed Charges,885.2,44.1,,398.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,1906.89,95,,224.56,Percent of Total Billed Charges,95% of Total Billed Charges,2007.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1766.38,88,,913.088,Percent of Total Billed Charges,88% of Total Billed Charges,1806.53,90,,212.736,Percent of Total Billed charges,90% of Total Billed Charges,50,2007.25,
BONE MARR ASP W/BIOPSYSAM DAY,7610000007,CDM,761,RC,,,Outpatient,,,454.72,295.57,,454.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,345.59,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,454.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,409.25,90,,933.84,Percent of Total Billed Charges,90% of Total Billed Charges,204.62,45,,319.104,Percent of Total Billed Charges,45% of Total Billed Charges,409.25,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,454.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,454.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,454.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.57,65,,236.456,Percent of total Billed Charges,65% of Total Billed Charges,200.53,44.1,,312.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,431.98,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,454.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.15,88,,1412.608,Percent of Total Billed Charges,88% of Total Billed Charges,409.25,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,50,454.72,
CT  BIOP / EXCIS OF LYMPH NODE,7610000008,CDM,761,RC,,,Outpatient,,,2535.75,1648.24,,2535.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1927.17,76,,338.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2282.18,90,,1444.72,Percent of Total Billed Charges,90% of Total Billed Charges,1141.09,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,2282.18,90,,400.864,Percent of Total Billed Charges,90% of Total billed Charges,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1648.24,65,,1318.592,Percent of total Billed Charges,65% of Total Billed Charges,1118.27,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,2408.96,95,,423.136,Percent of Total Billed Charges,95% of Total Billed Charges,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2231.46,88,,675.136,Percent of Total Billed Charges,88% of Total Billed Charges,2282.18,90,,400.864,Percent of Total Billed charges,90% of Total Billed Charges,50,2535.75,
CT FINE NDLE ASPIR W/OUT IMAGE,7610000009,CDM,761,RC,,,Outpatient,,,640.55,416.36,,640.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,486.82,76,,58436.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,640.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,576.5,90,,690.48,Percent of Total Billed Charges,90% of Total Billed Charges,288.25,45,,458.024,Percent of Total Billed Charges,45% of Total Billed Charges,576.5,90,,69200.64,Percent of Total Billed Charges,90% of Total billed Charges,640.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,640.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,640.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,416.36,65,,333.088,Percent of total Billed Charges,65% of Total Billed Charges,282.48,44.1,,448.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,608.52,95,,73045.12,Percent of Total Billed Charges,95% of Total Billed Charges,640.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.68,88,,494.208,Percent of Total Billed Charges,88% of Total Billed Charges,576.5,90,,69200.64,Percent of Total Billed charges,90% of Total Billed Charges,50,640.55,
CYSTOSTOMY TUBE CHANGE COMPL,7610000010,CDM,761,RC,,,Outpatient,,,2660.00,1729.00,,2660,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2021.6,76,,239.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2660,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2394,90,,505.44,Percent of Total Billed Charges,90% of Total Billed Charges,1197,45,,204.008,Percent of Total Billed Charges,45% of Total Billed Charges,2394,90,,283.384,Percent of Total Billed Charges,90% of Total billed Charges,2660,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2660,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2660,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1729,65,,1383.2,Percent of total Billed Charges,65% of Total Billed Charges,1173.06,44.1,,199.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,2527,95,,299.128,Percent of Total Billed Charges,95% of Total Billed Charges,2660,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2340.8,88,,494.208,Percent of Total Billed Charges,88% of Total Billed Charges,2394,90,,283.384,Percent of Total Billed charges,90% of Total Billed Charges,50,2660,
EPID INJ LUMB OR SACRALW/IMAGE,7610000012,CDM,361,RC,,,Outpatient,,,2019.00,1312.35,,2019,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1534.44,76,,207.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1453.68,72,,1162.944,Percent of Total Billed Charges,72% of Total Billed Charges,1514.25,75,,1211.4,Percent of Total Billed charges,75% of Total Billed Charges,2019,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1453.68,72,,1162.944,Percent of Total Billed Charges,72% of Total Billed Charges,1211.4,60,,969.12,Percent of Total Billed Charges,60% of Total Billed Charges,1817.1,90,,505.44,Percent of Total Billed Charges,90% of Total Billed Charges,908.55,45,,466.92,Percent of Total Billed Charges,45% of Total Billed Charges,1817.1,90,,245.28,Percent of Total Billed Charges,90% of Total billed Charges,2019,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2019,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2019,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.35,65,,1049.88,Percent of total Billed Charges,65% of Total Billed Charges,890.38,44.1,,457.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,1918.05,95,,258.912,Percent of Total Billed Charges,95% of Total Billed Charges,2019,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1776.72,88,,671.616,Percent of Total Billed Charges,88% of Total Billed Charges,1817.1,90,,245.28,Percent of Total Billed charges,90% of Total Billed Charges,890.38,2019,
EPID INJ LUMB OR SACRALW/IMAGE,7610000013,CDM,761,RC,,,Outpatient,,,2113.49,1373.77,,2113.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1606.25,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2113.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1902.14,90,,686.88,Percent of Total Billed Charges,90% of Total Billed Charges,951.07,45,,722.36,Percent of Total Billed Charges,45% of Total Billed Charges,1902.14,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,2113.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2113.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2113.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1373.77,65,,1099.016,Percent of total Billed Charges,65% of Total Billed Charges,932.05,44.1,,707.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,2007.82,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,2113.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1859.87,88,,450.56,Percent of Total Billed Charges,88% of Total Billed Charges,1902.14,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,50,2113.49,
EPIDUR INJ CERV/ THORAC W/IMAG,7610000014,CDM,761,RC,,,Outpatient,,,2368.00,1539.20,,2368,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1799.68,76,,687.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2368,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2131.2,90,,460.8,Percent of Total Billed Charges,90% of Total Billed Charges,1065.6,45,,345.24,Percent of Total Billed Charges,45% of Total Billed Charges,2131.2,90,,813.6,Percent of Total Billed Charges,90% of Total billed Charges,2368,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2368,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2368,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1539.2,65,,1231.36,Percent of total Billed Charges,65% of Total Billed Charges,1044.29,44.1,,338.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,2249.6,95,,858.8,Percent of Total Billed Charges,95% of Total Billed Charges,2368,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2083.84,88,,248.512,Percent of Total Billed Charges,88% of Total Billed Charges,2131.2,90,,813.6,Percent of Total Billed charges,90% of Total Billed Charges,50,2368,
EPIDUR INJ CERV/THORAC W/IMAG,7610000015,CDM,761,RC,,,Outpatient,,,2260.13,1469.08,,2260.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1717.7,76,,538.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2260.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2034.12,90,,254.16,Percent of Total Billed Charges,90% of Total Billed Charges,1017.06,45,,252.72,Percent of Total Billed Charges,45% of Total Billed Charges,2034.12,90,,638.216,Percent of Total Billed Charges,90% of Total billed Charges,2260.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2260.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2260.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1469.08,65,,1175.264,Percent of total Billed Charges,65% of Total Billed Charges,996.72,44.1,,247.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,2147.12,95,,673.672,Percent of Total Billed Charges,95% of Total Billed Charges,2260.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1988.91,88,,471.128,Percent of Total Billed Charges,88% of Total Billed Charges,2034.12,90,,638.216,Percent of Total Billed charges,90% of Total Billed Charges,50,2260.13,
EPIDURAL INJ FORAMEN ADD ON,7610000016,CDM,761,RC,,,Outpatient,,,1467.00,953.55,,1467,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1114.92,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1467,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1320.3,90,,481.84,Percent of Total Billed Charges,90% of Total Billed Charges,660.15,45,,252.72,Percent of Total Billed Charges,45% of Total Billed Charges,1320.3,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,1467,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1467,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1467,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,953.55,65,,762.84,Percent of total Billed Charges,65% of Total Billed Charges,646.95,44.1,,247.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,1393.65,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,1467,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1290.96,88,,675.136,Percent of Total Billed Charges,88% of Total Billed Charges,1320.3,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,50,1467,
EPIDURAL INJ FORAMEN L/S 1 LEV,7610000017,CDM,761,RC,,,Outpatient,,,1951.00,1268.15,,1951,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1482.76,76,,773.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1951,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1755.9,90,,690.48,Percent of Total Billed Charges,90% of Total Billed Charges,877.95,45,,343.44,Percent of Total Billed Charges,45% of Total Billed Charges,1755.9,90,,916.048,Percent of Total Billed Charges,90% of Total billed Charges,1951,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1951,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1951,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1268.15,65,,1014.52,Percent of total Billed Charges,65% of Total Billed Charges,860.39,44.1,,336.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,1853.45,95,,966.944,Percent of Total Billed Charges,95% of Total Billed Charges,1951,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1716.88,88,,494.208,Percent of Total Billed Charges,88% of Total Billed Charges,1755.9,90,,916.048,Percent of Total Billed charges,90% of Total Billed Charges,50,1951,
FACET INJ CERV/THOR 3RD LEV,7610000018,CDM,761,RC,,,Outpatient,,,1808.63,1175.61,,1808.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1374.56,76,,344.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1808.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1627.77,90,,505.44,Percent of Total Billed Charges,90% of Total Billed Charges,813.88,45,,230.4,Percent of Total Billed Charges,45% of Total Billed Charges,1627.77,90,,408.016,Percent of Total Billed Charges,90% of Total billed Charges,1808.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1808.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1808.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1175.61,65,,940.488,Percent of total Billed Charges,65% of Total Billed Charges,797.61,44.1,,225.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,1718.2,95,,430.688,Percent of Total Billed Charges,95% of Total Billed Charges,1808.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1591.59,88,,675.136,Percent of Total Billed Charges,88% of Total Billed Charges,1627.77,90,,408.016,Percent of Total Billed charges,90% of Total Billed Charges,50,1808.63,
FACET INJ CERV/THOR 3RD LEV,7610000019,CDM,761,RC,,,Outpatient,,,1808.63,1175.61,,1808.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1374.56,76,,788.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1808.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1627.77,90,,690.48,Percent of Total Billed Charges,90% of Total Billed Charges,813.88,45,,127.08,Percent of Total Billed Charges,45% of Total Billed Charges,1627.77,90,,933.84,Percent of Total Billed Charges,90% of Total billed Charges,1808.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1808.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1808.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1175.61,65,,940.488,Percent of total Billed Charges,65% of Total Billed Charges,797.61,44.1,,124.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,1718.2,95,,985.72,Percent of Total Billed Charges,95% of Total Billed Charges,1808.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1591.59,88,,382.976,Percent of Total Billed Charges,88% of Total Billed Charges,1627.77,90,,933.84,Percent of Total Billed charges,90% of Total Billed Charges,50,1808.63,
FACET INJ CERV/THOR SING LEV,7610000020,CDM,761,RC,,,Outpatient,,,2135.63,1388.16,,2135.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1623.08,76,,1219.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2135.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1922.07,90,,391.68,Percent of Total Billed Charges,90% of Total Billed Charges,961.03,45,,240.92,Percent of Total Billed Charges,45% of Total Billed Charges,1922.07,90,,1444.72,Percent of Total Billed Charges,90% of Total billed Charges,2135.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2135.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2135.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1388.16,65,,1110.528,Percent of total Billed Charges,65% of Total Billed Charges,941.81,44.1,,236.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,2028.85,95,,1524.976,Percent of Total Billed Charges,95% of Total Billed Charges,2135.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1879.35,88,,851.136,Percent of Total Billed Charges,88% of Total Billed Charges,1922.07,90,,1444.72,Percent of Total Billed charges,90% of Total Billed Charges,50,2135.63,
FACET INJ CERV/THOR SING LEV,7610000021,CDM,761,RC,,,Outpatient,,,2135.63,1388.16,,2135.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1623.08,76,,583.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2135.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1922.07,90,,870.48,Percent of Total Billed Charges,90% of Total Billed Charges,961.03,45,,345.24,Percent of Total Billed Charges,45% of Total Billed Charges,1922.07,90,,690.48,Percent of Total Billed Charges,90% of Total billed Charges,2135.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2135.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2135.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1388.16,65,,1110.528,Percent of total Billed Charges,65% of Total Billed Charges,941.81,44.1,,338.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,2028.85,95,,728.84,Percent of Total Billed Charges,95% of Total Billed Charges,2135.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1879.35,88,,398.952,Percent of Total Billed Charges,88% of Total Billed Charges,1922.07,90,,690.48,Percent of Total Billed charges,90% of Total Billed Charges,50,2135.63,
"INC/DRGE HEMATOMA,SEROMA FLD",7610000025,CDM,761,RC,,,Outpatient,,,2605.52,1693.59,,2605.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1980.2,76,,426.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2605.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2344.97,90,,408.016,Percent of Total Billed Charges,90% of Total Billed Charges,1172.48,45,,252.72,Percent of Total Billed Charges,45% of Total Billed Charges,2344.97,90,,505.44,Percent of Total Billed Charges,90% of Total billed Charges,2605.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1693.59,65,,1354.872,Percent of total Billed Charges,65% of Total Billed Charges,1149.03,44.1,,247.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,2475.24,95,,533.52,Percent of Total Billed Charges,95% of Total Billed Charges,2605.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2292.86,88,,1342.528,Percent of Total Billed Charges,88% of Total Billed Charges,2344.97,90,,505.44,Percent of Total Billed charges,90% of Total Billed Charges,50,2605.52,
INCIS& DRAIN OF ABSCESS SNGLE,7610000027,CDM,761,RC,,,Outpatient,,,400.21,260.14,,400.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,304.16,76,,426.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,400.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,360.19,90,,1373.04,Percent of Total Billed Charges,90% of Total Billed Charges,180.09,45,,345.24,Percent of Total Billed Charges,45% of Total Billed Charges,360.19,90,,505.44,Percent of Total Billed Charges,90% of Total billed Charges,400.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.14,65,,208.112,Percent of total Billed Charges,65% of Total Billed Charges,176.49,44.1,,338.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,380.2,95,,533.52,Percent of Total Billed Charges,95% of Total Billed Charges,400.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.18,88,,739.904,Percent of Total Billed Charges,88% of Total Billed Charges,360.19,90,,505.44,Percent of Total Billed charges,90% of Total Billed Charges,50,400.21,
INJ ANES SCIATIC NRV W/IMAGING,7610000028,CDM,761,RC,,,Outpatient,,,1951.00,1268.15,,1951,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1482.76,76,,580.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1951,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1755.9,90,,756.72,Percent of Total Billed Charges,90% of Total Billed Charges,877.95,45,,195.84,Percent of Total Billed Charges,45% of Total Billed Charges,1755.9,90,,686.88,Percent of Total Billed Charges,90% of Total billed Charges,1951,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1951,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1951,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1268.15,65,,1014.52,Percent of total Billed Charges,65% of Total Billed Charges,860.39,44.1,,191.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,1853.45,95,,725.04,Percent of Total Billed Charges,95% of Total Billed Charges,1951,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1716.88,88,,1479.808,Percent of Total Billed Charges,88% of Total Billed Charges,1755.9,90,,686.88,Percent of Total Billed charges,90% of Total Billed Charges,50,1951,
INJ ANST AGNT GRT OCCIPIT NRVE,7610000029,CDM,761,RC,,,Outpatient,,,795.55,517.11,,795.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,604.62,76,,389.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,795.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,716,90,,1513.44,Percent of Total Billed Charges,90% of Total Billed Charges,358,45,,435.24,Percent of Total Billed Charges,45% of Total Billed Charges,716,90,,460.8,Percent of Total Billed Charges,90% of Total billed Charges,795.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,795.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,795.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,517.11,65,,413.688,Percent of total Billed Charges,65% of Total Billed Charges,350.84,44.1,,426.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,755.77,95,,486.4,Percent of Total Billed Charges,95% of Total Billed Charges,795.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,700.08,88,,881.408,Percent of Total Billed Charges,88% of Total Billed Charges,716,90,,460.8,Percent of Total Billed charges,90% of Total Billed Charges,50,795.55,
INJ ANSTHTC AGNT TRIGEMIN NRVE,7610000030,CDM,761,RC,,,Outpatient,,,562.66,365.73,,562.66,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,427.62,76,,214.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,562.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,506.39,90,,901.44,Percent of Total Billed Charges,90% of Total Billed Charges,253.2,45,,204.008,Percent of Total Billed Charges,45% of Total Billed Charges,506.39,90,,254.16,Percent of Total Billed Charges,90% of Total billed Charges,562.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365.73,65,,292.584,Percent of total Billed Charges,65% of Total Billed Charges,248.13,44.1,,199.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,534.53,95,,268.28,Percent of Total Billed Charges,95% of Total Billed Charges,562.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495.14,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,506.39,90,,254.16,Percent of Total Billed charges,90% of Total Billed Charges,50,562.66,
INJ CYSTOGRAPHY /URETHROCYSTO,7610000031,CDM,761,RC,,,Outpatient,,,1029.74,669.33,,1029.74,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,782.6,76,,406.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1029.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,926.77,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,463.38,45,,686.52,Percent of Total Billed Charges,45% of Total Billed Charges,926.77,90,,481.84,Percent of Total Billed Charges,90% of Total billed Charges,1029.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1029.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1029.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,669.33,65,,535.464,Percent of total Billed Charges,65% of Total Billed Charges,454.12,44.1,,672.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,978.25,95,,508.608,Percent of Total Billed Charges,95% of Total Billed Charges,1029.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,906.17,88,,180.928,Percent of Total Billed Charges,88% of Total Billed Charges,926.77,90,,481.84,Percent of Total Billed charges,90% of Total Billed Charges,50,1029.74,
INJ EPID W/GD CERVIC/THOR SGLE,7610000032,CDM,761,RC,,,Outpatient,,,3689.00,2397.85,,3689,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2803.64,76,,583.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3689,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3320.1,90,,185.04,Percent of Total Billed Charges,90% of Total Billed Charges,1660.05,45,,378.36,Percent of Total Billed Charges,45% of Total Billed Charges,3320.1,90,,690.48,Percent of Total Billed Charges,90% of Total billed Charges,3689,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3689,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3689,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2397.85,65,,1918.28,Percent of total Billed Charges,65% of Total Billed Charges,1626.85,44.1,,370.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,3504.55,95,,728.84,Percent of Total Billed Charges,95% of Total Billed Charges,3689,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3246.32,88,,266.224,Percent of Total Billed Charges,88% of Total Billed Charges,3320.1,90,,690.48,Percent of Total Billed charges,90% of Total Billed Charges,50,3689,
INJ FACET LUMB SAC SEC LEV,7610000034,CDM,761,RC,,,Outpatient,,,671.00,436.15,,671,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,509.96,76,,426.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,671,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,603.9,90,,272.272,Percent of Total Billed Charges,90% of Total Billed Charges,301.95,45,,756.72,Percent of Total Billed Charges,45% of Total Billed Charges,603.9,90,,505.44,Percent of Total Billed Charges,90% of Total billed Charges,671,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,671,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,671,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,436.15,65,,348.92,Percent of total Billed Charges,65% of Total Billed Charges,295.91,44.1,,741.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,637.45,95,,533.52,Percent of Total Billed Charges,95% of Total Billed Charges,671,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,590.48,88,,111.936,Percent of Total Billed Charges,88% of Total Billed Charges,603.9,90,,505.44,Percent of Total Billed charges,90% of Total Billed Charges,50,671,
INJ FACET LUMB SACRAL SING LEV,7610000036,CDM,761,RC,,,Outpatient,,,1144.00,743.60,,1144,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,869.44,76,,583.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1144,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1029.6,90,,114.48,Percent of Total Billed Charges,90% of Total Billed Charges,514.8,45,,450.72,Percent of Total Billed Charges,45% of Total Billed Charges,1029.6,90,,690.48,Percent of Total Billed Charges,90% of Total billed Charges,1144,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1144,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1144,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,743.6,65,,594.88,Percent of total Billed Charges,65% of Total Billed Charges,504.5,44.1,,441.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,1086.8,95,,728.84,Percent of Total Billed Charges,95% of Total Billed Charges,1144,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1006.72,88,,156.992,Percent of Total Billed Charges,88% of Total Billed Charges,1029.6,90,,690.48,Percent of Total Billed charges,90% of Total Billed Charges,50,1144,
INJ. LUMB THORACIC PARAVERTEBR,7610000037,CDM,761,RC,,,Outpatient,,,2446.65,1590.32,,2446.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1859.45,76,,330.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2446.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2201.99,90,,160.56,Percent of Total Billed Charges,90% of Total Billed Charges,1100.99,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,2201.99,90,,391.68,Percent of Total Billed Charges,90% of Total billed Charges,2446.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2446.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2446.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1590.32,65,,1272.256,Percent of total Billed Charges,65% of Total Billed Charges,1078.97,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,2324.32,95,,413.44,Percent of Total Billed Charges,95% of Total Billed Charges,2446.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2153.05,88,,266.224,Percent of Total Billed Charges,88% of Total Billed Charges,2201.99,90,,391.68,Percent of Total Billed charges,90% of Total Billed Charges,50,2446.65,
INTERCOSTAL NERVE INJ EA ADD,7610000038,CDM,761,RC,,,Outpatient,,,1702.00,1106.30,,1702,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1293.52,76,,735.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1531.8,90,,272.272,Percent of Total Billed Charges,90% of Total Billed Charges,765.9,45,,92.52,Percent of Total Billed Charges,45% of Total Billed Charges,1531.8,90,,870.48,Percent of Total Billed Charges,90% of Total billed Charges,1702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1106.3,65,,885.04,Percent of total Billed Charges,65% of Total Billed Charges,750.58,44.1,,90.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,1616.9,95,,918.84,Percent of Total Billed Charges,95% of Total Billed Charges,1702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1497.76,88,,266.224,Percent of Total Billed Charges,88% of Total Billed Charges,1531.8,90,,870.48,Percent of Total Billed charges,90% of Total Billed Charges,50,1702,
INJ ANES INTERCOS NERVE MULTI,7610000039,CDM,761,RC,,,Outpatient,,,1791.56,1164.51,,1791.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1361.59,76,,344.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1791.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1612.4,90,,272.272,Percent of Total Billed Charges,90% of Total Billed Charges,806.2,45,,136.136,Percent of Total Billed Charges,45% of Total Billed Charges,1612.4,90,,408.016,Percent of Total Billed Charges,90% of Total billed Charges,1791.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1791.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1791.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1164.51,65,,931.608,Percent of total Billed Charges,65% of Total Billed Charges,790.08,44.1,,133.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,1701.98,95,,430.688,Percent of Total Billed Charges,95% of Total Billed Charges,1791.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1576.57,88,,147.84,Percent of Total Billed Charges,88% of Total Billed Charges,1612.4,90,,408.016,Percent of Total Billed charges,90% of Total Billed Charges,50,1791.56,
INJ ANES INTERCOS NERVE SINGL,7610000040,CDM,761,RC,,,Outpatient,,,900.00,585.00,,900,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,684,76,,1159.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,810,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,405,45,,57.24,Percent of Total Billed Charges,45% of Total Billed Charges,810,90,,1373.04,Percent of Total Billed Charges,90% of Total billed Charges,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,585,65,,468,Percent of total Billed Charges,65% of Total Billed Charges,396.9,44.1,,56.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,855,95,,1449.32,Percent of Total Billed Charges,95% of Total Billed Charges,900,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,792,88,,31.536,Percent of Total Billed Charges,88% of Total Billed Charges,810,90,,1373.04,Percent of Total Billed charges,90% of Total Billed Charges,50,900,
INJ ANES INTERCOS NERVE SINGL,7610000041,CDM,761,RC,,,Outpatient,,,947.05,615.58,,947.05,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,719.76,76,,639.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,947.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,852.35,90,,32.248,Percent of Total Billed Charges,90% of Total Billed Charges,426.17,45,,80.28,Percent of Total Billed Charges,45% of Total Billed Charges,852.35,90,,756.72,Percent of Total Billed Charges,90% of Total billed Charges,947.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,947.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,947.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,615.58,65,,492.464,Percent of total Billed Charges,65% of Total Billed Charges,417.65,44.1,,78.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,899.7,95,,798.76,Percent of Total Billed Charges,95% of Total Billed Charges,947.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,833.4,88,,57.168,Percent of Total Billed Charges,88% of Total Billed Charges,852.35,90,,756.72,Percent of Total Billed charges,90% of Total Billed Charges,50,947.05,
INJ ANSTHTC AGNT FACIAL NERVE,7610000042,CDM,761,RC,,,Outpatient,,,491.32,319.36,,491.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,373.4,76,,1278.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,491.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,442.19,90,,58.472,Percent of Total Billed Charges,90% of Total Billed Charges,221.09,45,,136.136,Percent of Total Billed Charges,45% of Total Billed Charges,442.19,90,,1513.44,Percent of Total Billed Charges,90% of Total billed Charges,491.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,491.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319.36,65,,255.488,Percent of total Billed Charges,65% of Total Billed Charges,216.67,44.1,,133.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,466.75,95,,1597.52,Percent of Total Billed Charges,95% of Total Billed Charges,491.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,432.36,88,,67.48,Percent of Total Billed Charges,88% of Total Billed Charges,442.19,90,,1513.44,Percent of Total Billed charges,90% of Total Billed Charges,50,491.32,
INJFAC LUMB SACRAL THIRD LEV,7610000043,CDM,761,RC,,,Outpatient,,,772.49,502.12,,772.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,587.09,76,,761.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,772.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,695.24,90,,69.016,Percent of Total Billed Charges,90% of Total Billed Charges,347.62,45,,136.136,Percent of Total Billed Charges,45% of Total Billed Charges,695.24,90,,901.44,Percent of Total Billed Charges,90% of Total billed Charges,772.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,772.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,772.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.12,65,,401.696,Percent of total Billed Charges,65% of Total Billed Charges,340.67,44.1,,133.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,733.87,95,,951.52,Percent of Total Billed Charges,95% of Total Billed Charges,772.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,679.79,88,,119.68,Percent of Total Billed Charges,88% of Total Billed Charges,695.24,90,,901.44,Percent of Total Billed charges,90% of Total Billed Charges,50,772.49,
INJFAC LUMB SACRAL THIRD LEVL,7610000044,CDM,761,RC,,,Outpatient,,,772.49,502.12,,772.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,587.09,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,772.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,695.24,90,,122.4,Percent of Total Billed Charges,90% of Total Billed Charges,347.62,45,,75.6,Percent of Total Billed Charges,45% of Total Billed Charges,695.24,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,772.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,772.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,772.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.12,65,,401.696,Percent of total Billed Charges,65% of Total Billed Charges,340.67,44.1,,74.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,733.87,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,772.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,679.79,88,,77.44,Percent of Total Billed Charges,88% of Total Billed Charges,695.24,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,50,772.49,
INJFACET CERV THORAC SECD LEV,7610000045,CDM,761,RC,,,Outpatient,,,1629.79,1059.36,,1629.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1238.64,76,,156.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1629.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1466.81,90,,79.2,Percent of Total Billed Charges,90% of Total Billed Charges,733.41,45,,16.128,Percent of Total Billed Charges,45% of Total Billed Charges,1466.81,90,,185.04,Percent of Total Billed Charges,90% of Total billed Charges,1629.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1629.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1629.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1059.36,65,,847.488,Percent of total Billed Charges,65% of Total Billed Charges,718.74,44.1,,15.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,1548.3,95,,195.32,Percent of Total Billed Charges,95% of Total Billed Charges,1629.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1434.22,88,,215.912,Percent of Total Billed Charges,88% of Total Billed Charges,1466.81,90,,185.04,Percent of Total Billed charges,90% of Total Billed Charges,50,1629.79,
INJFACET CERV THORAC SECD LEV,7610000046,CDM,761,RC,,,Outpatient,,,1629.79,1059.36,,1629.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1238.64,76,,229.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1629.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1466.81,90,,220.816,Percent of Total Billed Charges,90% of Total Billed Charges,733.41,45,,29.232,Percent of Total Billed Charges,45% of Total Billed Charges,1466.81,90,,272.272,Percent of Total Billed Charges,90% of Total billed Charges,1629.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1629.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1629.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1059.36,65,,847.488,Percent of total Billed Charges,65% of Total Billed Charges,718.74,44.1,,28.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,1548.3,95,,287.4,Percent of Total Billed Charges,95% of Total Billed Charges,1629.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1434.22,88,,205.568,Percent of Total Billed Charges,88% of Total Billed Charges,1466.81,90,,272.272,Percent of Total Billed charges,90% of Total Billed Charges,50,1629.79,
INJEC FOR SHOULDER ARTHROGRAM,7610000048,CDM,761,RC,,,Outpatient,,,437.69,284.50,,437.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,332.64,76,,96.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,393.92,90,,210.24,Percent of Total Billed Charges,90% of Total Billed Charges,196.96,45,,34.504,Percent of Total Billed Charges,45% of Total Billed Charges,393.92,90,,114.48,Percent of Total Billed Charges,90% of Total billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.5,65,,227.6,Percent of total Billed Charges,65% of Total Billed Charges,193.02,44.1,,33.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,415.81,95,,120.84,Percent of Total Billed Charges,95% of Total Billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.17,88,,215.912,Percent of Total Billed Charges,88% of Total Billed Charges,393.92,90,,114.48,Percent of Total Billed charges,90% of Total Billed Charges,50,437.69,
INS NONTUNN CVCYOUNGER 5 YRS,7610000051,CDM,761,RC,,,Outpatient,,,2537.92,1649.65,,2537.92,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1928.82,76,,135.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2537.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2284.13,90,,220.816,Percent of Total Billed Charges,90% of Total Billed Charges,1142.06,45,,61.2,Percent of Total Billed Charges,45% of Total Billed Charges,2284.13,90,,160.56,Percent of Total Billed Charges,90% of Total billed Charges,2537.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2537.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2537.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1649.65,65,,1319.72,Percent of total Billed Charges,65% of Total Billed Charges,1119.22,44.1,,59.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,2411.02,95,,169.48,Percent of Total Billed Charges,95% of Total Billed Charges,2537.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2233.37,88,,215.912,Percent of Total Billed Charges,88% of Total Billed Charges,2284.13,90,,160.56,Percent of Total Billed charges,90% of Total Billed Charges,50,2537.92,
INSER  OF TUNN CVC W/OUT PORT,7610000052,CDM,761,RC,,,Outpatient,,,5158.00,3352.70,,5158,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3920.08,76,,229.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,5158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4642.2,90,,220.816,Percent of Total Billed Charges,90% of Total Billed Charges,2321.1,45,,39.6,Percent of Total Billed Charges,45% of Total Billed Charges,4642.2,90,,272.272,Percent of Total Billed Charges,90% of Total billed Charges,5158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3352.7,65,,2682.16,Percent of total Billed Charges,65% of Total Billed Charges,2274.68,44.1,,38.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,4900.1,95,,287.4,Percent of Total Billed Charges,95% of Total Billed Charges,5158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4539.04,88,,3029.928,Percent of Total Billed Charges,88% of Total Billed Charges,4642.2,90,,272.272,Percent of Total Billed charges,90% of Total Billed Charges,50,5158,
INSER OF CENTRAL VENOUS CATH,7610000053,CDM,761,RC,,,Outpatient,,,2811.00,1827.15,,2811,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2136.36,76,,229.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2529.9,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,1264.95,45,,110.408,Percent of Total Billed Charges,45% of Total Billed Charges,2529.9,90,,272.272,Percent of Total Billed Charges,90% of Total billed Charges,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1827.15,65,,1461.72,Percent of total Billed Charges,65% of Total Billed Charges,1239.65,44.1,,108.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,2670.45,95,,287.4,Percent of Total Billed Charges,95% of Total Billed Charges,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2473.68,88,,1978.944,Percent of Total Billed Charges,88% of Total Billed Charges,2529.9,90,,272.272,Percent of Total Billed charges,90% of Total Billed Charges,50,2811,
INSER OF CENTRAL VENOUS CATH,7610000054,CDM,761,RC,,,Outpatient,,,2272.25,1476.96,,2272.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1726.91,76,,127.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2272.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2045.03,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,1022.51,45,,105.12,Percent of Total Billed Charges,45% of Total Billed Charges,2045.03,90,,151.2,Percent of Total Billed Charges,90% of Total billed Charges,2272.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2272.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2272.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1476.96,65,,1181.568,Percent of total Billed Charges,65% of Total Billed Charges,1002.06,44.1,,103.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,2158.64,95,,159.6,Percent of Total Billed Charges,95% of Total Billed Charges,2272.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1999.58,88,,1599.664,Percent of Total Billed Charges,88% of Total Billed Charges,2045.03,90,,151.2,Percent of Total Billed charges,90% of Total Billed Charges,50,2272.25,
DIALYSIS CVC TNNL CATH INSERT,7610000055,CDM,761,RC,,,Outpatient,,,5158.00,3352.70,,5158,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3920.08,76,,27.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,5158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4642.2,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,2321.1,45,,110.408,Percent of Total Billed Charges,45% of Total Billed Charges,4642.2,90,,32.248,Percent of Total Billed Charges,90% of Total billed Charges,5158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3352.7,65,,2682.16,Percent of total Billed Charges,65% of Total Billed Charges,2274.68,44.1,,108.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,4900.1,95,,34.04,Percent of Total Billed Charges,95% of Total Billed Charges,5158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4539.04,88,,3631.232,Percent of Total Billed Charges,88% of Total Billed Charges,4642.2,90,,32.248,Percent of Total Billed charges,90% of Total Billed Charges,50,5158,
INSER OF TUNN CVC W/OUT PRT,7610000056,CDM,761,RC,,,Outpatient,,,5158.00,3352.70,,5158,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3920.08,76,,49.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,5158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4642.2,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,2321.1,45,,110.408,Percent of Total Billed Charges,45% of Total Billed Charges,4642.2,90,,58.472,Percent of Total Billed Charges,90% of Total billed Charges,5158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3352.7,65,,2682.16,Percent of total Billed Charges,65% of Total Billed Charges,2274.68,44.1,,108.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,4900.1,95,,61.72,Percent of Total Billed Charges,95% of Total Billed Charges,5158,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4539.04,88,,3631.232,Percent of Total Billed Charges,88% of Total Billed Charges,4642.2,90,,58.472,Percent of Total Billed charges,90% of Total Billed Charges,50,5158,
INSERT INTRAV VENA CAVA FILTER,7610000057,CDM,761,RC,,,Outpatient,,,11618.15,7551.80,,11618.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8829.79,76,,58.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,11618.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,10456.34,90,,35.28,Percent of Total Billed Charges,90% of Total Billed Charges,5228.17,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,10456.34,90,,69.016,Percent of Total Billed Charges,90% of Total billed Charges,11618.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11618.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11618.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7551.8,65,,6041.44,Percent of total Billed Charges,65% of Total Billed Charges,5123.6,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,11037.24,95,,72.848,Percent of Total Billed Charges,95% of Total Billed Charges,11618.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10223.97,88,,8179.176,Percent of Total Billed Charges,88% of Total Billed Charges,10456.34,90,,69.016,Percent of Total Billed charges,90% of Total Billed Charges,50,11618.15,
INSERT TUNLED CVC W/SUB Q PORT,7610000058,CDM,761,RC,,,Outpatient,,,6456.24,4196.56,,6456.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4906.74,76,,103.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,6456.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,5810.62,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,2905.31,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,5810.62,90,,122.4,Percent of Total Billed Charges,90% of Total billed Charges,6456.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6456.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6456.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4196.56,65,,3357.248,Percent of total Billed Charges,65% of Total Billed Charges,2847.2,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,6133.43,95,,129.2,Percent of Total Billed Charges,95% of Total Billed Charges,6456.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5681.49,88,,4545.192,Percent of Total Billed Charges,88% of Total Billed Charges,5810.62,90,,122.4,Percent of Total Billed charges,90% of Total Billed Charges,50,6456.24,
INSR OF PIC LN W/OUT SUB Q PRT,7610000059,CDM,761,RC,,,Outpatient,,,1953.00,1269.45,,1953,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1484.28,76,,66.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1953,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1757.7,90,,65.864,Percent of Total Billed Charges,90% of Total Billed Charges,878.85,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,1757.7,90,,79.2,Percent of Total Billed Charges,90% of Total billed Charges,1953,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1953,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1953,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1269.45,65,,1015.56,Percent of total Billed Charges,65% of Total Billed Charges,861.27,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,1855.35,95,,83.6,Percent of Total Billed Charges,95% of Total Billed Charges,1953,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1718.64,88,,1374.912,Percent of Total Billed Charges,88% of Total Billed Charges,1757.7,90,,79.2,Percent of Total Billed charges,90% of Total Billed Charges,50,1953,
INSR OF TNLED CVC W/SUB Q PRT,7610000061,CDM,761,RC,,,Outpatient,,,6456.24,4196.56,,6456.24,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4906.74,76,,186.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,6456.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,5810.62,90,,3098.792,Percent of Total Billed Charges,90% of Total Billed Charges,2905.31,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,5810.62,90,,220.816,Percent of Total Billed Charges,90% of Total billed Charges,6456.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6456.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6456.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4196.56,65,,3357.248,Percent of total Billed Charges,65% of Total Billed Charges,2847.2,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,6133.43,95,,233.088,Percent of Total Billed Charges,95% of Total Billed Charges,6456.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5681.49,88,,4545.192,Percent of Total Billed Charges,88% of Total Billed Charges,5810.62,90,,220.816,Percent of Total Billed charges,90% of Total Billed Charges,50,6456.24,
INST GTUBE PERC W/GUDE & CONTR,7610000062,CDM,761,RC,,,Outpatient,,,2091.00,1359.15,,2091,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1589.16,76,,177.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2091,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1881.9,90,,65.864,Percent of Total Billed Charges,90% of Total Billed Charges,940.95,45,,17.64,Percent of Total Billed Charges,45% of Total Billed Charges,1881.9,90,,210.24,Percent of Total Billed Charges,90% of Total billed Charges,2091,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2091,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2091,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1359.15,65,,1087.32,Percent of total Billed Charges,65% of Total Billed Charges,922.13,44.1,,17.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,1986.45,95,,221.92,Percent of Total Billed Charges,95% of Total Billed Charges,2091,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1840.08,88,,1472.064,Percent of Total Billed Charges,88% of Total Billed Charges,1881.9,90,,210.24,Percent of Total Billed charges,90% of Total Billed Charges,50,2091,
INST TUN IP CAT PERC W/IMAG GD,7610000063,CDM,761,RC,,,Outpatient,,,2655.21,1725.89,,2655.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2017.96,76,,186.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2655.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2389.69,90,,35.28,Percent of Total Billed Charges,90% of Total Billed Charges,1194.84,45,,9,Percent of Total Billed Charges,45% of Total Billed Charges,2389.69,90,,220.816,Percent of Total Billed Charges,90% of Total billed Charges,2655.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2655.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2655.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1725.89,65,,1380.712,Percent of total Billed Charges,65% of Total Billed Charges,1170.95,44.1,,8.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,2522.45,95,,233.088,Percent of Total Billed Charges,95% of Total Billed Charges,2655.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2336.58,88,,1869.264,Percent of Total Billed Charges,88% of Total Billed Charges,2389.69,90,,220.816,Percent of Total Billed charges,90% of Total Billed Charges,50,2655.21,
JEJU DUODE PERC INSERT W/FLUOR,7610000064,CDM,761,RC,,,Outpatient,,,4225.00,2746.25,,4225,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3211,76,,186.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3802.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,1901.25,45,,32.936,Percent of Total Billed Charges,45% of Total Billed Charges,3802.5,90,,220.816,Percent of Total Billed Charges,90% of Total billed Charges,4225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2746.25,65,,2197,Percent of total Billed Charges,65% of Total Billed Charges,1863.23,44.1,,32.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,4013.75,95,,233.088,Percent of Total Billed Charges,95% of Total Billed Charges,4225,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3718,88,,2974.4,Percent of Total Billed Charges,88% of Total Billed Charges,3802.5,90,,220.816,Percent of Total Billed charges,90% of Total Billed Charges,50,4225,
MECH THROMBECTOMY VEIN REP TX,7610000065,CDM,761,RC,,,Outpatient,,,7536.69,4898.85,,7536.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5727.88,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,7536.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,6783.02,90,,65.864,Percent of Total Billed Charges,90% of Total Billed Charges,3391.51,45,,1549.4,Percent of Total Billed Charges,45% of Total Billed Charges,6783.02,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,7536.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7536.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7536.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4898.85,65,,3919.08,Percent of total Billed Charges,65% of Total Billed Charges,3323.68,44.1,,1518.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,7159.86,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,7536.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6632.29,88,,5305.832,Percent of Total Billed Charges,88% of Total Billed Charges,6783.02,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,50,7536.69,
MECHAN THROMB PRIM ART INIT,7610000066,CDM,481,RC,,,Outpatient,,,10919.37,7097.59,,10919.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,8298.72,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7861.95,72,,6289.56,Percent of Total Billed Charges,72% of Total Billed Charges,8189.53,75,,6551.624,Percent of Total Billed charges,75% of Total Billed Charges,10919.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7861.95,72,,6289.56,Percent of Total Billed Charges,72% of Total Billed Charges,6551.62,60,,5241.296,Percent of Total Billed Charges,60% of Total Billed Charges,9827.43,90,,65.864,Percent of Total Billed Charges,90% of Total Billed Charges,4913.72,45,,32.936,Percent of Total Billed Charges,45% of Total Billed Charges,9827.43,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,10919.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10919.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10919.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7097.59,65,,5678.072,Percent of total Billed Charges,65% of Total Billed Charges,4815.44,44.1,,32.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,10373.4,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,10919.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9609.05,88,,7687.24,Percent of Total Billed Charges,88% of Total Billed Charges,9827.43,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,4815.44,10919.37,
MECHAN THROMB PRIM ART SUB VES,7610000067,CDM,481,RC,,,Outpatient,,,1594.02,1036.11,,1594.02,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1211.46,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1147.69,72,,918.152,Percent of Total Billed Charges,72% of Total Billed Charges,1195.52,75,,956.416,Percent of Total Billed charges,75% of Total Billed Charges,1594.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1147.69,72,,918.152,Percent of Total Billed Charges,72% of Total Billed Charges,956.41,60,,765.128,Percent of Total Billed Charges,60% of Total Billed Charges,1434.62,90,,1147.696,Percent of Total Billed Charges,90% of Total Billed Charges,717.31,45,,17.64,Percent of Total Billed Charges,45% of Total Billed Charges,1434.62,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,1594.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1594.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1594.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1036.11,65,,828.888,Percent of total Billed Charges,65% of Total Billed Charges,702.96,44.1,,17.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,1514.32,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,1594.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1402.74,88,,1122.192,Percent of Total Billed Charges,88% of Total Billed Charges,1434.62,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,702.96,1594.02,
MECHAN THROMBECT VEIN REP,7610000068,CDM,761,RC,,,Outpatient,,,7536.69,4898.85,,7536.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5727.88,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,7536.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,6783.02,90,,5426.416,Percent of Total Billed Charges,90% of Total Billed Charges,3391.51,45,,9,Percent of Total Billed Charges,45% of Total Billed Charges,6783.02,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,7536.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7536.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7536.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4898.85,65,,3919.08,Percent of total Billed Charges,65% of Total Billed Charges,3323.68,44.1,,8.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,7159.86,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,7536.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6632.29,88,,5305.832,Percent of Total Billed Charges,88% of Total Billed Charges,6783.02,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,50,7536.69,
MECHAN THROMBECTOMY VEIN INIT,7610000069,CDM,761,RC,,,Outpatient,,,8039.43,5225.63,,8039.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6109.97,76,,29.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,8039.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,7235.49,90,,5788.392,Percent of Total Billed Charges,90% of Total Billed Charges,3617.74,45,,32.936,Percent of Total Billed Charges,45% of Total Billed Charges,7235.49,90,,35.28,Percent of Total Billed Charges,90% of Total billed Charges,8039.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8039.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8039.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5225.63,65,,4180.504,Percent of total Billed Charges,65% of Total Billed Charges,3545.39,44.1,,32.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,7637.46,95,,37.24,Percent of Total Billed Charges,95% of Total Billed Charges,8039.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7074.7,88,,5659.76,Percent of Total Billed Charges,88% of Total Billed Charges,7235.49,90,,35.28,Percent of Total Billed charges,90% of Total Billed Charges,50,8039.43,
MECHAN THROMBECTOMY VEIN INIT,7610000070,CDM,761,RC,,,Outpatient,,,8039.43,5225.63,,8039.43,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,6109.97,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,8039.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,7235.49,90,,5788.392,Percent of Total Billed Charges,90% of Total Billed Charges,3617.74,45,,32.936,Percent of Total Billed Charges,45% of Total Billed Charges,7235.49,90,,18,Percent of Total Billed Charges,90% of Total billed Charges,8039.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8039.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8039.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5225.63,65,,4180.504,Percent of total Billed Charges,65% of Total Billed Charges,3545.39,44.1,,32.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,7637.46,95,,19,Percent of Total Billed Charges,95% of Total Billed Charges,8039.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7074.7,88,,5659.76,Percent of Total Billed Charges,88% of Total Billed Charges,7235.49,90,,18,Percent of Total Billed charges,90% of Total Billed Charges,50,8039.43,
MRI  BIOPSY  EXCIS OF LYM NODE,7610000071,CDM,761,RC,,,Outpatient,,,2535.75,1648.24,,2535.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1927.17,76,,55.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2282.18,90,,1825.744,Percent of Total Billed Charges,90% of Total Billed Charges,1141.09,45,,912.872,Percent of Total Billed Charges,45% of Total Billed Charges,2282.18,90,,65.864,Percent of Total Billed Charges,90% of Total billed Charges,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1648.24,65,,1318.592,Percent of total Billed Charges,65% of Total Billed Charges,1118.27,44.1,,894.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,2408.96,95,,69.528,Percent of Total Billed Charges,95% of Total Billed Charges,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2231.46,88,,1785.168,Percent of Total Billed Charges,88% of Total Billed Charges,2282.18,90,,65.864,Percent of Total Billed charges,90% of Total Billed Charges,50,2535.75,
MYELOGR VIA LUMB INJ 2 OR MORE,7610000072,CDM,761,RC,,,Outpatient,,,4113.30,2673.65,,4113.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3126.11,76,,2616.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4113.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3701.97,90,,2961.576,Percent of Total Billed Charges,90% of Total Billed Charges,1850.99,45,,1480.792,Percent of Total Billed Charges,45% of Total Billed Charges,3701.97,90,,3098.792,Percent of Total Billed Charges,90% of Total billed Charges,4113.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4113.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4113.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2673.65,65,,2138.92,Percent of total Billed Charges,65% of Total Billed Charges,1813.97,44.1,,1451.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,3907.64,95,,3270.952,Percent of Total Billed Charges,95% of Total Billed Charges,4113.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3619.7,88,,2895.76,Percent of Total Billed Charges,88% of Total Billed Charges,3701.97,90,,3098.792,Percent of Total Billed charges,90% of Total Billed Charges,50,4113.3,
MYELOGRAPHY LUMB INJ 2 MRE REG,7610000073,CDM,761,RC,,,Outpatient,,,4113.30,2673.65,,4113.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3126.11,76,,55.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4113.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3701.97,90,,2961.576,Percent of Total Billed Charges,90% of Total Billed Charges,1850.99,45,,1480.792,Percent of Total Billed Charges,45% of Total Billed Charges,3701.97,90,,65.864,Percent of Total Billed Charges,90% of Total billed Charges,4113.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4113.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4113.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2673.65,65,,2138.92,Percent of total Billed Charges,65% of Total Billed Charges,1813.97,44.1,,1451.176,Percent of Total Billed Charges,44.1% of Total Billed Charges,3907.64,95,,69.528,Percent of Total Billed Charges,95% of Total Billed Charges,4113.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3619.7,88,,2895.76,Percent of Total Billed Charges,88% of Total Billed Charges,3701.97,90,,65.864,Percent of Total Billed charges,90% of Total Billed Charges,50,4113.3,
MYELOGRAPHY LUMBAR INJ LUMBOSA,7610000074,CDM,761,RC,,,Outpatient,,,3420.00,2223.00,,3420,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2599.2,76,,29.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3420,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3078,90,,2462.4,Percent of Total Billed Charges,90% of Total Billed Charges,1539,45,,1231.2,Percent of Total Billed Charges,45% of Total Billed Charges,3078,90,,35.28,Percent of Total Billed Charges,90% of Total billed Charges,3420,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3420,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3420,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2223,65,,1778.4,Percent of total Billed Charges,65% of Total Billed Charges,1508.22,44.1,,1206.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,3249,95,,37.24,Percent of Total Billed Charges,95% of Total Billed Charges,3420,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3009.6,88,,2407.68,Percent of Total Billed Charges,88% of Total Billed Charges,3078,90,,35.28,Percent of Total Billed charges,90% of Total Billed Charges,50,3420,
MYELOGRAPHY VIA LUM INJ THOR,7610000075,CDM,761,RC,,,Outpatient,,,2931.00,1905.15,,2931,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2227.56,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2931,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2637.9,90,,2110.32,Percent of Total Billed Charges,90% of Total Billed Charges,1318.95,45,,1055.16,Percent of Total Billed Charges,45% of Total Billed Charges,2637.9,90,,18,Percent of Total Billed Charges,90% of Total billed Charges,2931,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2931,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2931,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1905.15,65,,1524.12,Percent of total Billed Charges,65% of Total Billed Charges,1292.57,44.1,,1034.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,2784.45,95,,19,Percent of Total Billed Charges,95% of Total Billed Charges,2931,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2579.28,88,,2063.424,Percent of Total Billed Charges,88% of Total Billed Charges,2637.9,90,,18,Percent of Total Billed charges,90% of Total Billed Charges,50,2931,
MYELOGRM VIA LUMB INJ CERVICAL,7610000076,CDM,761,RC,,,Outpatient,,,2075.30,1348.95,,2075.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1577.23,76,,55.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2075.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1867.77,90,,1494.216,Percent of Total Billed Charges,90% of Total Billed Charges,933.89,45,,747.112,Percent of Total Billed Charges,45% of Total Billed Charges,1867.77,90,,65.864,Percent of Total Billed Charges,90% of Total billed Charges,2075.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2075.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2075.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1348.95,65,,1079.16,Percent of total Billed Charges,65% of Total Billed Charges,915.21,44.1,,732.168,Percent of Total Billed Charges,44.1% of Total Billed Charges,1971.54,95,,69.528,Percent of Total Billed Charges,95% of Total Billed Charges,2075.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1826.26,88,,1461.008,Percent of Total Billed Charges,88% of Total Billed Charges,1867.77,90,,65.864,Percent of Total Billed charges,90% of Total Billed Charges,50,2075.3,
MYELOGRM VIA LUMB INJ THORACIC,7610000077,CDM,761,RC,,,Outpatient,,,3085.00,2005.25,,3085,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2344.6,76,,55.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3085,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2776.5,90,,2221.2,Percent of Total Billed Charges,90% of Total Billed Charges,1388.25,45,,1110.6,Percent of Total Billed Charges,45% of Total Billed Charges,2776.5,90,,65.864,Percent of Total Billed Charges,90% of Total billed Charges,3085,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3085,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3085,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2005.25,65,,1604.2,Percent of total Billed Charges,65% of Total Billed Charges,1360.49,44.1,,1088.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,2930.75,95,,69.528,Percent of Total Billed Charges,95% of Total Billed Charges,3085,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2714.8,88,,2171.84,Percent of Total Billed Charges,88% of Total Billed Charges,2776.5,90,,65.864,Percent of Total Billed charges,90% of Total Billed Charges,50,3085,
NONCORONARY IVUS EACH ADDL,7610000078,CDM,761,RC,,,Outpatient,,,223.80,145.47,,223.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,170.09,76,,136.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,223.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,201.42,90,,161.136,Percent of Total Billed Charges,90% of Total Billed Charges,100.71,45,,80.568,Percent of Total Billed Charges,45% of Total Billed Charges,201.42,90,,161.136,Percent of Total Billed Charges,90% of Total billed Charges,223.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,223.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,223.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.47,65,,116.376,Percent of total Billed Charges,65% of Total Billed Charges,98.7,44.1,,78.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,212.61,95,,170.088,Percent of Total Billed Charges,95% of Total Billed Charges,223.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.94,88,,157.552,Percent of Total Billed Charges,88% of Total Billed Charges,201.42,90,,161.136,Percent of Total Billed charges,90% of Total Billed Charges,50,223.8,
PERCU CONT INJ EXIS TUB W IMAG,7610000079,CDM,761,RC,,,Outpatient,,,547.00,355.55,,547,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,415.72,76,,332.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,547,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,492.3,90,,393.84,Percent of Total Billed Charges,90% of Total Billed Charges,246.15,45,,196.92,Percent of Total Billed Charges,45% of Total Billed Charges,492.3,90,,393.84,Percent of Total Billed Charges,90% of Total billed Charges,547,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,547,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.55,65,,284.44,Percent of total Billed Charges,65% of Total Billed Charges,241.23,44.1,,192.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,519.65,95,,415.72,Percent of Total Billed Charges,95% of Total Billed Charges,547,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,481.36,88,,385.088,Percent of Total Billed Charges,88% of Total Billed Charges,492.3,90,,393.84,Percent of Total Billed charges,90% of Total Billed Charges,50,547,
PLMT URETERAL STNT PRQ,7610000081,CDM,761,RC,,,Outpatient,,,4954.60,3220.49,,4954.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3765.5,76,,3012.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4459.14,90,,3567.312,Percent of Total Billed Charges,90% of Total Billed Charges,2229.57,45,,1783.656,Percent of Total Billed Charges,45% of Total Billed Charges,4459.14,90,,3567.312,Percent of Total Billed Charges,90% of Total billed Charges,4954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3220.49,65,,2576.392,Percent of total Billed Charges,65% of Total Billed Charges,2184.98,44.1,,1747.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,4706.87,95,,3765.496,Percent of Total Billed Charges,95% of Total Billed Charges,4954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4360.05,88,,3488.04,Percent of Total Billed Charges,88% of Total Billed Charges,4459.14,90,,3567.312,Percent of Total Billed charges,90% of Total Billed Charges,50,4954.6,
PREVIOUS DRNGE CATH EXCHANGE,7610000082,CDM,761,RC,,,Outpatient,,,3878.60,2521.09,,3878.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2947.74,76,,2358.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3878.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3490.74,90,,2792.592,Percent of Total Billed Charges,90% of Total Billed Charges,1745.37,45,,1396.296,Percent of Total Billed Charges,45% of Total Billed Charges,3490.74,90,,2792.592,Percent of Total Billed Charges,90% of Total billed Charges,3878.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3878.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3878.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.09,65,,2016.872,Percent of total Billed Charges,65% of Total Billed Charges,1710.46,44.1,,1368.368,Percent of Total Billed Charges,44.1% of Total Billed Charges,3684.67,95,,2947.736,Percent of Total Billed Charges,95% of Total Billed Charges,3878.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3413.17,88,,2730.536,Percent of Total Billed Charges,88% of Total Billed Charges,3490.74,90,,2792.592,Percent of Total Billed charges,90% of Total Billed Charges,50,3878.6,
PUNC ASPIR ABSCESS AND /OR CYS,7610000083,CDM,761,RC,,,Outpatient,,,486.00,315.90,,486,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,369.36,76,,295.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,486,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,437.4,90,,349.92,Percent of Total Billed Charges,90% of Total Billed Charges,218.7,45,,174.96,Percent of Total Billed Charges,45% of Total Billed Charges,437.4,90,,349.92,Percent of Total Billed Charges,90% of Total billed Charges,486,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,486,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,486,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.9,65,,252.72,Percent of total Billed Charges,65% of Total Billed Charges,214.33,44.1,,171.464,Percent of Total Billed Charges,44.1% of Total Billed Charges,461.7,95,,369.36,Percent of Total Billed Charges,95% of Total Billed Charges,486,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.68,88,,342.144,Percent of Total Billed Charges,88% of Total Billed Charges,437.4,90,,349.92,Percent of Total Billed charges,90% of Total Billed Charges,50,486,
RAD  FNE NDLE ASP W/OUT IMAGE,7610000084,CDM,761,RC,,,Outpatient,,,640.55,416.36,,640.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,486.82,76,,389.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,640.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,576.5,90,,461.2,Percent of Total Billed Charges,90% of Total Billed Charges,288.25,45,,230.6,Percent of Total Billed Charges,45% of Total Billed Charges,576.5,90,,461.2,Percent of Total Billed Charges,90% of Total billed Charges,640.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,640.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,640.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,416.36,65,,333.088,Percent of total Billed Charges,65% of Total Billed Charges,282.48,44.1,,225.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,608.52,95,,486.816,Percent of Total Billed Charges,95% of Total Billed Charges,640.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.68,88,,450.944,Percent of Total Billed Charges,88% of Total Billed Charges,576.5,90,,461.2,Percent of Total Billed charges,90% of Total Billed Charges,50,640.55,
RAD  PLEUR DRNGE PERC W/ IMAG,7610000085,CDM,761,RC,,,Outpatient,,,1340.64,871.42,,1340.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1018.89,76,,815.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1340.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1206.58,90,,965.264,Percent of Total Billed Charges,90% of Total Billed Charges,603.29,45,,482.632,Percent of Total Billed Charges,45% of Total Billed Charges,1206.58,90,,965.264,Percent of Total Billed Charges,90% of Total billed Charges,1340.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1340.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1340.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,871.42,65,,697.136,Percent of total Billed Charges,65% of Total Billed Charges,591.22,44.1,,472.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,1273.61,95,,1018.888,Percent of Total Billed Charges,95% of Total Billed Charges,1340.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1179.76,88,,943.808,Percent of Total Billed Charges,88% of Total Billed Charges,1206.58,90,,965.264,Percent of Total Billed charges,90% of Total Billed Charges,50,1340.64,
RAD BIOPSY EXCIS OF LYMPH NODE,7610000086,CDM,761,RC,,,Outpatient,,,2535.75,1648.24,,2535.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1927.17,76,,1541.736,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2282.18,90,,1825.744,Percent of Total Billed Charges,90% of Total Billed Charges,1141.09,45,,912.872,Percent of Total Billed Charges,45% of Total Billed Charges,2282.18,90,,1825.744,Percent of Total Billed Charges,90% of Total billed Charges,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1648.24,65,,1318.592,Percent of total Billed Charges,65% of Total Billed Charges,1118.27,44.1,,894.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,2408.96,95,,1927.168,Percent of Total Billed Charges,95% of Total Billed Charges,2535.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2231.46,88,,1785.168,Percent of Total Billed Charges,88% of Total Billed Charges,2282.18,90,,1825.744,Percent of Total Billed charges,90% of Total Billed Charges,50,2535.75,
RAD EVAL OF CENT VEN ACC DEV,7610000087,CDM,761,RC,,,Outpatient,,,490.61,318.90,,490.61,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,372.86,76,,298.288,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,441.55,90,,353.24,Percent of Total Billed Charges,90% of Total Billed Charges,220.77,45,,176.616,Percent of Total Billed Charges,45% of Total Billed Charges,441.55,90,,353.24,Percent of Total Billed Charges,90% of Total billed Charges,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.9,65,,255.12,Percent of total Billed Charges,65% of Total Billed Charges,216.36,44.1,,173.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,466.08,95,,372.864,Percent of Total Billed Charges,95% of Total Billed Charges,490.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,431.74,88,,345.392,Percent of Total Billed Charges,88% of Total Billed Charges,441.55,90,,353.24,Percent of Total Billed charges,90% of Total Billed Charges,50,490.61,
RAD INJECSINUS TRACT THERAP,7610000088,CDM,761,RC,,,Outpatient,,,1601.93,1041.25,,1601.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1217.47,76,,973.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1601.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1441.74,90,,1153.392,Percent of Total Billed Charges,90% of Total Billed Charges,720.87,45,,576.696,Percent of Total Billed Charges,45% of Total Billed Charges,1441.74,90,,1153.392,Percent of Total Billed Charges,90% of Total billed Charges,1601.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1601.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1601.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1041.25,65,,833,Percent of total Billed Charges,65% of Total Billed Charges,706.45,44.1,,565.16,Percent of Total Billed Charges,44.1% of Total Billed Charges,1521.83,95,,1217.464,Percent of Total Billed Charges,95% of Total Billed Charges,1601.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1409.7,88,,1127.76,Percent of Total Billed Charges,88% of Total Billed Charges,1441.74,90,,1153.392,Percent of Total Billed charges,90% of Total Billed Charges,50,1601.93,
REM FO TUNNELED CVC WITH PORT,7610000089,CDM,761,RC,,,Outpatient,,,2273.36,1477.68,,2273.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1727.75,76,,1382.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2273.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2046.02,90,,1636.816,Percent of Total Billed Charges,90% of Total Billed Charges,1023.01,45,,818.408,Percent of Total Billed Charges,45% of Total Billed Charges,2046.02,90,,1636.816,Percent of Total Billed Charges,90% of Total billed Charges,2273.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2273.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2273.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1477.68,65,,1182.144,Percent of total Billed Charges,65% of Total Billed Charges,1002.55,44.1,,802.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,2159.69,95,,1727.752,Percent of Total Billed Charges,95% of Total Billed Charges,2273.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000.56,88,,1600.448,Percent of Total Billed Charges,88% of Total Billed Charges,2046.02,90,,1636.816,Percent of Total Billed charges,90% of Total Billed Charges,50,2273.36,
REM OF INTRAVASC VENA CAVA FIL,7610000091,CDM,761,RC,,,Outpatient,,,6277.64,4080.47,,6277.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4771.01,76,,3816.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,5649.88,90,,4519.904,Percent of Total Billed Charges,90% of Total Billed Charges,2824.94,45,,2259.952,Percent of Total Billed Charges,45% of Total Billed Charges,5649.88,90,,4519.904,Percent of Total Billed Charges,90% of Total billed Charges,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4080.47,65,,3264.376,Percent of total Billed Charges,65% of Total Billed Charges,2768.44,44.1,,2214.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,5963.76,95,,4771.008,Percent of Total Billed Charges,95% of Total Billed Charges,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5524.32,88,,4419.456,Percent of Total Billed Charges,88% of Total Billed Charges,5649.88,90,,4519.904,Percent of Total Billed charges,90% of Total Billed Charges,50,6277.64,
REM OF TUNLED INTRAPERITON CAT,7610000092,CDM,761,RC,,,Outpatient,,,3303.56,2147.31,,3303.56,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2510.71,76,,2008.568,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3303.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2973.2,90,,2378.56,Percent of Total Billed Charges,90% of Total Billed Charges,1486.6,45,,1189.28,Percent of Total Billed Charges,45% of Total Billed Charges,2973.2,90,,2378.56,Percent of Total Billed Charges,90% of Total billed Charges,3303.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3303.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3303.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2147.31,65,,1717.848,Percent of total Billed Charges,65% of Total Billed Charges,1456.87,44.1,,1165.496,Percent of Total Billed Charges,44.1% of Total Billed Charges,3138.38,95,,2510.704,Percent of Total Billed Charges,95% of Total Billed Charges,3303.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2907.13,88,,2325.704,Percent of Total Billed Charges,88% of Total Billed Charges,2973.2,90,,2378.56,Percent of Total Billed charges,90% of Total Billed Charges,50,3303.56,
REM OF TUNN CENTR VENOUS CATH,7610000093,CDM,761,RC,,,Outpatient,,,1703.36,1107.18,,1703.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1294.55,76,,1035.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1703.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1533.02,90,,1226.416,Percent of Total Billed Charges,90% of Total Billed Charges,766.51,45,,613.208,Percent of Total Billed Charges,45% of Total Billed Charges,1533.02,90,,1226.416,Percent of Total Billed Charges,90% of Total billed Charges,1703.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1703.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1703.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1107.18,65,,885.744,Percent of total Billed Charges,65% of Total Billed Charges,751.18,44.1,,600.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,1618.19,95,,1294.552,Percent of Total Billed Charges,95% of Total Billed Charges,1703.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1498.96,88,,1199.168,Percent of Total Billed Charges,88% of Total Billed Charges,1533.02,90,,1226.416,Percent of Total Billed charges,90% of Total Billed Charges,50,1703.36,
REM CONTRACEPTIVE IMPLANTABLE,7610000094,CDM,761,RC,,,Outpatient,,,888.62,577.60,,888.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,675.35,76,,540.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,888.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,799.76,90,,639.808,Percent of Total Billed Charges,90% of Total Billed Charges,399.88,45,,319.904,Percent of Total Billed Charges,45% of Total Billed Charges,799.76,90,,639.808,Percent of Total Billed Charges,90% of Total billed Charges,888.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,888.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,888.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.6,65,,462.08,Percent of total Billed Charges,65% of Total Billed Charges,391.88,44.1,,313.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,844.19,95,,675.352,Percent of Total Billed Charges,95% of Total Billed Charges,888.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,781.99,88,,625.592,Percent of Total Billed Charges,88% of Total Billed Charges,799.76,90,,639.808,Percent of Total Billed charges,90% of Total Billed Charges,50,888.62,
REP GASTROSTOMY TBE W/FLUO GDE,7610000097,CDM,761,RC,,,Outpatient,,,1825.00,1186.25,,1825,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1387,76,,1109.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1825,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1642.5,90,,1314,Percent of Total Billed Charges,90% of Total Billed Charges,821.25,45,,657,Percent of Total Billed Charges,45% of Total Billed Charges,1642.5,90,,1314,Percent of Total Billed Charges,90% of Total billed Charges,1825,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1825,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1825,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1186.25,65,,949,Percent of total Billed Charges,65% of Total Billed Charges,804.83,44.1,,643.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,1733.75,95,,1387,Percent of Total Billed Charges,95% of Total Billed Charges,1825,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1606,88,,1284.8,Percent of Total Billed Charges,88% of Total Billed Charges,1642.5,90,,1314,Percent of Total Billed charges,90% of Total Billed Charges,50,1825,
REP JEJUNOSTOMYDUEDONSTOM TUB,7610000098,CDM,761,RC,,,Outpatient,,,1295.44,842.04,,1295.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,984.53,76,,787.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1295.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1165.9,90,,932.72,Percent of Total Billed Charges,90% of Total Billed Charges,582.95,45,,466.36,Percent of Total Billed Charges,45% of Total Billed Charges,1165.9,90,,932.72,Percent of Total Billed Charges,90% of Total billed Charges,1295.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1295.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1295.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,842.04,65,,673.632,Percent of total Billed Charges,65% of Total Billed Charges,571.29,44.1,,457.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,1230.67,95,,984.536,Percent of Total Billed Charges,95% of Total Billed Charges,1295.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1139.99,88,,911.992,Percent of Total Billed Charges,88% of Total Billed Charges,1165.9,90,,932.72,Percent of Total Billed charges,90% of Total Billed Charges,50,1295.44,
REP JEJUNOSTOMYDUEDONSTOM TUB,7610000099,CDM,761,RC,,,Outpatient,,,1295.44,842.04,,1295.44,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,984.53,76,,787.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1295.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1165.9,90,,932.72,Percent of Total Billed Charges,90% of Total Billed Charges,582.95,45,,466.36,Percent of Total Billed Charges,45% of Total Billed Charges,1165.9,90,,932.72,Percent of Total Billed Charges,90% of Total billed Charges,1295.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1295.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1295.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,842.04,65,,673.632,Percent of total Billed Charges,65% of Total Billed Charges,571.29,44.1,,457.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,1230.67,95,,984.536,Percent of Total Billed Charges,95% of Total Billed Charges,1295.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1139.99,88,,911.992,Percent of Total Billed Charges,88% of Total Billed Charges,1165.9,90,,932.72,Percent of Total Billed charges,90% of Total Billed Charges,50,1295.44,
REPOS CVC UNDER FLUORO GUIDE,7610000101,CDM,761,RC,,,Outpatient,,,2273.36,1477.68,,2273.36,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1727.75,76,,1382.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2273.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2046.02,90,,1636.816,Percent of Total Billed Charges,90% of Total Billed Charges,1023.01,45,,818.408,Percent of Total Billed Charges,45% of Total Billed Charges,2046.02,90,,1636.816,Percent of Total Billed Charges,90% of Total billed Charges,2273.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2273.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2273.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1477.68,65,,1182.144,Percent of total Billed Charges,65% of Total Billed Charges,1002.55,44.1,,802.04,Percent of Total Billed Charges,44.1% of Total Billed Charges,2159.69,95,,1727.752,Percent of Total Billed Charges,95% of Total Billed Charges,2273.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000.56,88,,1600.448,Percent of Total Billed Charges,88% of Total Billed Charges,2046.02,90,,1636.816,Percent of Total Billed charges,90% of Total Billed Charges,50,2273.36,
REPOS INTRAVASC VENA CAVA FIL,7610000102,CDM,761,RC,,,Outpatient,,,6277.64,4080.47,,6277.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4771.01,76,,3816.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,5649.88,90,,4519.904,Percent of Total Billed Charges,90% of Total Billed Charges,2824.94,45,,2259.952,Percent of Total Billed Charges,45% of Total Billed Charges,5649.88,90,,4519.904,Percent of Total Billed Charges,90% of Total billed Charges,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4080.47,65,,3264.376,Percent of total Billed Charges,65% of Total Billed Charges,2768.44,44.1,,2214.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,5963.76,95,,4771.008,Percent of Total Billed Charges,95% of Total Billed Charges,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5524.32,88,,4419.456,Percent of Total Billed Charges,88% of Total Billed Charges,5649.88,90,,4519.904,Percent of Total Billed charges,90% of Total Billed Charges,50,6277.64,
RMV/RPLC INTERN DWEL URET STNT,7610000103,CDM,761,RC,,,Outpatient,,,4800.00,3120.00,,4800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3648,76,,2918.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4320,90,,3456,Percent of Total Billed Charges,90% of Total Billed Charges,2160,45,,1728,Percent of Total Billed Charges,45% of Total Billed Charges,4320,90,,3456,Percent of Total Billed Charges,90% of Total billed Charges,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3120,65,,2496,Percent of total Billed Charges,65% of Total Billed Charges,2116.8,44.1,,1693.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,4560,95,,3648,Percent of Total Billed Charges,95% of Total Billed Charges,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4224,88,,3379.2,Percent of Total Billed Charges,88% of Total Billed Charges,4320,90,,3456,Percent of Total Billed charges,90% of Total Billed Charges,50,4800,
SEL CAT PLCE ART AD 2ND OR 3RD,7610000104,CDM,761,RC,,,Outpatient,,,1385.84,900.80,,1385.84,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1053.24,76,,842.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1385.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1247.26,90,,997.808,Percent of Total Billed Charges,90% of Total Billed Charges,623.63,45,,498.904,Percent of Total Billed Charges,45% of Total Billed Charges,1247.26,90,,997.808,Percent of Total Billed Charges,90% of Total billed Charges,1385.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1385.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1385.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,900.8,65,,720.64,Percent of total Billed Charges,65% of Total Billed Charges,611.16,44.1,,488.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,1316.55,95,,1053.24,Percent of Total Billed Charges,95% of Total Billed Charges,1385.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1219.54,88,,975.632,Percent of Total Billed Charges,88% of Total Billed Charges,1247.26,90,,997.808,Percent of Total Billed charges,90% of Total Billed Charges,50,1385.84,
SEL CATH PLACEMNT  ART 1ST ORD,7610000105,CDM,761,RC,,,Outpatient,,,2098.06,1363.74,,2098.06,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1594.53,76,,1275.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2098.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1888.25,90,,1510.6,Percent of Total Billed Charges,90% of Total Billed Charges,944.13,45,,755.304,Percent of Total Billed Charges,45% of Total Billed Charges,1888.25,90,,1510.6,Percent of Total Billed Charges,90% of Total billed Charges,2098.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2098.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2098.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1363.74,65,,1090.992,Percent of total Billed Charges,65% of Total Billed Charges,925.24,44.1,,740.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,1993.16,95,,1594.528,Percent of Total Billed Charges,95% of Total Billed Charges,2098.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1846.29,88,,1477.032,Percent of Total Billed Charges,88% of Total Billed Charges,1888.25,90,,1510.6,Percent of Total Billed charges,90% of Total Billed Charges,50,2098.06,
SEL CATH PMNT ARTERY 2ND ORDER,7610000107,CDM,761,RC,,,Outpatient,,,1315.28,854.93,,1315.28,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,999.61,76,,799.688,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1315.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1183.75,90,,947,Percent of Total Billed Charges,90% of Total Billed Charges,591.88,45,,473.504,Percent of Total Billed Charges,45% of Total Billed Charges,1183.75,90,,947,Percent of Total Billed Charges,90% of Total billed Charges,1315.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1315.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1315.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,854.93,65,,683.944,Percent of total Billed Charges,65% of Total Billed Charges,580.04,44.1,,464.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,1249.52,95,,999.616,Percent of Total Billed Charges,95% of Total Billed Charges,1315.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1157.45,88,,925.96,Percent of Total Billed Charges,88% of Total Billed Charges,1183.75,90,,947,Percent of Total Billed charges,90% of Total Billed Charges,50,1315.28,
SEL CATH PMNT ARTERY 3RD ORDER,7610000108,CDM,761,RC,,,Outpatient,,,1469.63,955.26,,1469.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1116.92,76,,893.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1469.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1322.67,90,,1058.136,Percent of Total Billed Charges,90% of Total Billed Charges,661.33,45,,529.064,Percent of Total Billed Charges,45% of Total Billed Charges,1322.67,90,,1058.136,Percent of Total Billed Charges,90% of Total billed Charges,1469.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1469.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1469.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,955.26,65,,764.208,Percent of total Billed Charges,65% of Total Billed Charges,648.11,44.1,,518.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,1396.15,95,,1116.92,Percent of Total Billed Charges,95% of Total Billed Charges,1469.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1293.27,88,,1034.616,Percent of Total Billed Charges,88% of Total Billed Charges,1322.67,90,,1058.136,Percent of Total Billed charges,90% of Total Billed Charges,50,1469.63,
SPIN PUNC DRN CEREB FLUID THER,7610000109,CDM,761,RC,,,Outpatient,,,1120.14,728.09,,1120.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,851.31,76,,681.048,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1120.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1008.13,90,,806.504,Percent of Total Billed Charges,90% of Total Billed Charges,504.06,45,,403.248,Percent of Total Billed Charges,45% of Total Billed Charges,1008.13,90,,806.504,Percent of Total Billed Charges,90% of Total billed Charges,1120.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1120.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1120.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,728.09,65,,582.472,Percent of total Billed Charges,65% of Total Billed Charges,493.98,44.1,,395.184,Percent of Total Billed Charges,44.1% of Total Billed Charges,1064.13,95,,851.304,Percent of Total Billed Charges,95% of Total Billed Charges,1120.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,985.72,88,,788.576,Percent of Total Billed Charges,88% of Total Billed Charges,1008.13,90,,806.504,Percent of Total Billed charges,90% of Total Billed Charges,50,1120.14,
"SPINAL PUNCTURE, LUMBAR, DIAGN",7610000110,CDM,761,RC,,,Outpatient,,,1078.00,700.70,,1078,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,819.28,76,,655.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,970.2,90,,776.16,Percent of Total Billed Charges,90% of Total Billed Charges,485.1,45,,388.08,Percent of Total Billed Charges,45% of Total Billed Charges,970.2,90,,776.16,Percent of Total Billed Charges,90% of Total billed Charges,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,700.7,65,,560.56,Percent of total Billed Charges,65% of Total Billed Charges,475.4,44.1,,380.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,1024.1,95,,819.28,Percent of Total Billed Charges,95% of Total Billed Charges,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,948.64,88,,758.912,Percent of Total Billed Charges,88% of Total Billed Charges,970.2,90,,776.16,Percent of Total Billed charges,90% of Total Billed Charges,50,1078,
THORACENTESIS W/OUT IMAG GUID,7610000111,CDM,761,RC,,,Outpatient,,,1583.19,1029.07,,1583.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1203.22,76,,962.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1424.87,90,,1139.896,Percent of Total Billed Charges,90% of Total Billed Charges,712.44,45,,569.952,Percent of Total Billed Charges,45% of Total Billed Charges,1424.87,90,,1139.896,Percent of Total Billed Charges,90% of Total billed Charges,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1029.07,65,,823.256,Percent of total Billed Charges,65% of Total Billed Charges,698.19,44.1,,558.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,1504.03,95,,1203.224,Percent of Total Billed Charges,95% of Total Billed Charges,1583.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1393.21,88,,1114.568,Percent of Total Billed Charges,88% of Total Billed Charges,1424.87,90,,1139.896,Percent of Total Billed charges,90% of Total Billed Charges,50,1583.19,
TRANSC ART/VEN THROM TX LST DY,7610000112,CDM,761,RC,,,Outpatient,,,5537.86,3599.61,,5537.86,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4208.77,76,,3367.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,5537.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4984.07,90,,3987.256,Percent of Total Billed Charges,90% of Total Billed Charges,2492.04,45,,1993.632,Percent of Total Billed Charges,45% of Total Billed Charges,4984.07,90,,3987.256,Percent of Total Billed Charges,90% of Total billed Charges,5537.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5537.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5537.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3599.61,65,,2879.688,Percent of total Billed Charges,65% of Total Billed Charges,2442.2,44.1,,1953.76,Percent of Total Billed Charges,44.1% of Total Billed Charges,5260.97,95,,4208.776,Percent of Total Billed Charges,95% of Total Billed Charges,5537.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4873.32,88,,3898.656,Percent of Total Billed Charges,88% of Total Billed Charges,4984.07,90,,3987.256,Percent of Total Billed charges,90% of Total Billed Charges,50,5537.86,
TRANSC ARTER THROMBOLY INIT,7610000113,CDM,320,RC,,,Outpatient,,,2088.14,1357.29,,2088.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1586.99,76,,1269.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1503.46,72,,1202.768,Percent of Total Billed Charges,72% of Total Billed Charges,1566.11,75,,1252.888,Percent of Total Billed charges,75% of Total Billed Charges,2088.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1503.46,72,,1202.768,Percent of Total Billed Charges,72% of Total Billed Charges,1252.88,60,,1002.304,Percent of Total Billed Charges,60% of Total Billed Charges,1879.33,90,,1503.464,Percent of Total Billed Charges,90% of Total Billed Charges,939.66,45,,751.728,Percent of Total Billed Charges,45% of Total Billed Charges,1879.33,90,,1503.464,Percent of Total Billed Charges,90% of Total billed Charges,2088.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2088.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2088.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1357.29,65,,1085.832,Percent of total Billed Charges,65% of Total Billed Charges,920.87,44.1,,736.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,1983.73,95,,1586.984,Percent of Total Billed Charges,95% of Total Billed Charges,2088.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1837.56,88,,1470.048,Percent of Total Billed Charges,88% of Total Billed Charges,1879.33,90,,1503.464,Percent of Total Billed charges,90% of Total Billed Charges,920.87,2088.14,
TRANSCATH VENOUS THROMB INIT,7610000114,CDM,320,RC,,,Outpatient,,,2088.14,1357.29,,2088.14,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1586.99,76,,1269.592,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1503.46,72,,1202.768,Percent of Total Billed Charges,72% of Total Billed Charges,1566.11,75,,1252.888,Percent of Total Billed charges,75% of Total Billed Charges,2088.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1503.46,72,,1202.768,Percent of Total Billed Charges,72% of Total Billed Charges,1252.88,60,,1002.304,Percent of Total Billed Charges,60% of Total Billed Charges,1879.33,90,,1503.464,Percent of Total Billed Charges,90% of Total Billed Charges,939.66,45,,751.728,Percent of Total Billed Charges,45% of Total Billed Charges,1879.33,90,,1503.464,Percent of Total Billed Charges,90% of Total billed Charges,2088.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2088.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2088.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1357.29,65,,1085.832,Percent of total Billed Charges,65% of Total Billed Charges,920.87,44.1,,736.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,1983.73,95,,1586.984,Percent of Total Billed Charges,95% of Total Billed Charges,2088.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1837.56,88,,1470.048,Percent of Total Billed Charges,88% of Total Billed Charges,1879.33,90,,1503.464,Percent of Total Billed charges,90% of Total Billed Charges,920.87,2088.14,
TRANSFORAMINAL C/T SINGLE LEV,7610000115,CDM,761,RC,,,Outpatient,,,3882.62,2523.70,,3882.62,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2950.79,76,,2360.632,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3882.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3494.36,90,,2795.488,Percent of Total Billed Charges,90% of Total Billed Charges,1747.18,45,,1397.744,Percent of Total Billed Charges,45% of Total Billed Charges,3494.36,90,,2795.488,Percent of Total Billed Charges,90% of Total billed Charges,3882.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3882.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3882.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2523.7,65,,2018.96,Percent of total Billed Charges,65% of Total Billed Charges,1712.24,44.1,,1369.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,3688.49,95,,2950.792,Percent of Total Billed Charges,95% of Total Billed Charges,3882.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3416.71,88,,2733.368,Percent of Total Billed Charges,88% of Total Billed Charges,3494.36,90,,2795.488,Percent of Total Billed charges,90% of Total Billed Charges,50,3882.62,
TRANSFORAMINAL L/S EACH ADD,7610000116,CDM,761,RC,,,Outpatient,,,1467.00,953.55,,1467,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1114.92,76,,891.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1467,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1320.3,90,,1056.24,Percent of Total Billed Charges,90% of Total Billed Charges,660.15,45,,528.12,Percent of Total Billed Charges,45% of Total Billed Charges,1320.3,90,,1056.24,Percent of Total Billed Charges,90% of Total billed Charges,1467,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1467,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1467,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,953.55,65,,762.84,Percent of total Billed Charges,65% of Total Billed Charges,646.95,44.1,,517.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,1393.65,95,,1114.92,Percent of Total Billed Charges,95% of Total Billed Charges,1467,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1290.96,88,,1032.768,Percent of Total Billed Charges,88% of Total Billed Charges,1320.3,90,,1056.24,Percent of Total Billed charges,90% of Total Billed Charges,50,1467,
TRANSFORAMIN L/S SINGLE LEV,7610000117,CDM,761,RC,,,Outpatient,,,1951.00,1268.15,,1951,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1482.76,76,,1186.208,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1951,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1755.9,90,,1404.72,Percent of Total Billed Charges,90% of Total Billed Charges,877.95,45,,702.36,Percent of Total Billed Charges,45% of Total Billed Charges,1755.9,90,,1404.72,Percent of Total Billed Charges,90% of Total billed Charges,1951,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1951,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1951,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1268.15,65,,1014.52,Percent of total Billed Charges,65% of Total Billed Charges,860.39,44.1,,688.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,1853.45,95,,1482.76,Percent of Total Billed Charges,95% of Total Billed Charges,1951,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1716.88,88,,1373.504,Percent of Total Billed Charges,88% of Total Billed Charges,1755.9,90,,1404.72,Percent of Total Billed charges,90% of Total Billed Charges,50,1951,
URETAL STENT INS W NEPHRO TUBE,7610000118,CDM,761,RC,,,Outpatient,,,7016.00,4560.40,,7016,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5332.16,76,,4265.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,7016,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,6314.4,90,,5051.52,Percent of Total Billed Charges,90% of Total Billed Charges,3157.2,45,,2525.76,Percent of Total Billed Charges,45% of Total Billed Charges,6314.4,90,,5051.52,Percent of Total Billed Charges,90% of Total billed Charges,7016,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7016,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7016,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4560.4,65,,3648.32,Percent of total Billed Charges,65% of Total Billed Charges,3094.06,44.1,,2475.248,Percent of Total Billed Charges,44.1% of Total Billed Charges,6665.2,95,,5332.16,Percent of Total Billed Charges,95% of Total Billed Charges,7016,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6174.08,88,,4939.264,Percent of Total Billed Charges,88% of Total Billed Charges,6314.4,90,,5051.52,Percent of Total Billed charges,90% of Total Billed Charges,50,7016,
URETAL STNT REM PERCUT,7610000119,CDM,761,RC,,,Outpatient,,,4800.00,3120.00,,4800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3648,76,,2918.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4320,90,,3456,Percent of Total Billed Charges,90% of Total Billed Charges,2160,45,,1728,Percent of Total Billed Charges,45% of Total Billed Charges,4320,90,,3456,Percent of Total Billed Charges,90% of Total billed Charges,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3120,65,,2496,Percent of total Billed Charges,65% of Total Billed Charges,2116.8,44.1,,1693.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,4560,95,,3648,Percent of Total Billed Charges,95% of Total Billed Charges,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4224,88,,3379.2,Percent of Total Billed Charges,88% of Total Billed Charges,4320,90,,3456,Percent of Total Billed charges,90% of Total Billed Charges,50,4800,
URETAL STNT REM VIA  URETHRAL,7610000120,CDM,761,RC,,,Outpatient,,,4800.00,3120.00,,4800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3648,76,,2918.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4320,90,,3456,Percent of Total Billed Charges,90% of Total Billed Charges,2160,45,,1728,Percent of Total Billed Charges,45% of Total Billed Charges,4320,90,,3456,Percent of Total Billed Charges,90% of Total billed Charges,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3120,65,,2496,Percent of total Billed Charges,65% of Total Billed Charges,2116.8,44.1,,1693.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,4560,95,,3648,Percent of Total Billed Charges,95% of Total Billed Charges,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4224,88,,3379.2,Percent of Total Billed Charges,88% of Total Billed Charges,4320,90,,3456,Percent of Total Billed charges,90% of Total Billed Charges,50,4800,
URETAL STNT REM/REP PERC,7610000121,CDM,761,RC,,,Outpatient,,,4800.00,3120.00,,4800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3648,76,,2918.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4320,90,,3456,Percent of Total Billed Charges,90% of Total Billed Charges,2160,45,,1728,Percent of Total Billed Charges,45% of Total Billed Charges,4320,90,,3456,Percent of Total Billed Charges,90% of Total billed Charges,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3120,65,,2496,Percent of total Billed Charges,65% of Total Billed Charges,2116.8,44.1,,1693.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,4560,95,,3648,Percent of Total Billed Charges,95% of Total Billed Charges,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4224,88,,3379.2,Percent of Total Billed Charges,88% of Total Billed Charges,4320,90,,3456,Percent of Total Billed charges,90% of Total Billed Charges,50,4800,
URETAL STNT REP VIA URETHRA,7610000122,CDM,761,RC,,,Outpatient,,,4800.00,3120.00,,4800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3648,76,,2918.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4320,90,,3456,Percent of Total Billed Charges,90% of Total Billed Charges,2160,45,,1728,Percent of Total Billed Charges,45% of Total Billed Charges,4320,90,,3456,Percent of Total Billed Charges,90% of Total billed Charges,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3120,65,,2496,Percent of total Billed Charges,65% of Total Billed Charges,2116.8,44.1,,1693.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,4560,95,,3648,Percent of Total Billed Charges,95% of Total Billed Charges,4800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4224,88,,3379.2,Percent of Total Billed Charges,88% of Total Billed Charges,4320,90,,3456,Percent of Total Billed charges,90% of Total Billed Charges,50,4800,
US  INSER PIC LN W/OUT SUB PRT,7610000123,CDM,761,RC,,,Outpatient,,,1953.00,1269.45,,1953,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1484.28,76,,1187.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1953,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1757.7,90,,1406.16,Percent of Total Billed Charges,90% of Total Billed Charges,878.85,45,,703.08,Percent of Total Billed Charges,45% of Total Billed Charges,1757.7,90,,1406.16,Percent of Total Billed Charges,90% of Total billed Charges,1953,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1953,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1953,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1269.45,65,,1015.56,Percent of total Billed Charges,65% of Total Billed Charges,861.27,44.1,,689.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,1855.35,95,,1484.28,Percent of Total Billed Charges,95% of Total Billed Charges,1953,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1718.64,88,,1374.912,Percent of Total Billed Charges,88% of Total Billed Charges,1757.7,90,,1406.16,Percent of Total Billed charges,90% of Total Billed Charges,50,1953,
US BIOP / EXCIS OF LYMPH NODE,7610000124,CDM,761,RC,,,Outpatient,,,2657.00,1727.05,,2657,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2019.32,76,,1615.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2657,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2391.3,90,,1913.04,Percent of Total Billed Charges,90% of Total Billed Charges,1195.65,45,,956.52,Percent of Total Billed Charges,45% of Total Billed Charges,2391.3,90,,1913.04,Percent of Total Billed Charges,90% of Total billed Charges,2657,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2657,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2657,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1727.05,65,,1381.64,Percent of total Billed Charges,65% of Total Billed Charges,1171.74,44.1,,937.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,2524.15,95,,2019.32,Percent of Total Billed Charges,95% of Total Billed Charges,2657,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2338.16,88,,1870.528,Percent of Total Billed Charges,88% of Total Billed Charges,2391.3,90,,1913.04,Percent of Total Billed charges,90% of Total Billed Charges,50,2657,
US BIOP SKIN LES SHAVE <0.5 CM,7610000125,CDM,761,RC,,,Outpatient,,,474.00,308.10,,474,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,360.24,76,,288.192,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,474,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,426.6,90,,341.28,Percent of Total Billed Charges,90% of Total Billed Charges,213.3,45,,170.64,Percent of Total Billed Charges,45% of Total Billed Charges,426.6,90,,341.28,Percent of Total Billed Charges,90% of Total billed Charges,474,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.1,65,,246.48,Percent of total Billed Charges,65% of Total Billed Charges,209.03,44.1,,167.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,450.3,95,,360.24,Percent of Total Billed Charges,95% of Total Billed Charges,474,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.12,88,,333.696,Percent of Total Billed Charges,88% of Total Billed Charges,426.6,90,,341.28,Percent of Total Billed charges,90% of Total Billed Charges,50,474,
US FINE NDLE ASPIR W/OUT IMGE,7610000126,CDM,761,RC,,,Outpatient,,,640.55,416.36,,640.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,486.82,76,,389.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,640.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,576.5,90,,461.2,Percent of Total Billed Charges,90% of Total Billed Charges,288.25,45,,230.6,Percent of Total Billed Charges,45% of Total Billed Charges,576.5,90,,461.2,Percent of Total Billed Charges,90% of Total billed Charges,640.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,640.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,640.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,416.36,65,,333.088,Percent of total Billed Charges,65% of Total Billed Charges,282.48,44.1,,225.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,608.52,95,,486.816,Percent of Total Billed Charges,95% of Total Billed Charges,640.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.68,88,,450.944,Percent of Total Billed Charges,88% of Total Billed Charges,576.5,90,,461.2,Percent of Total Billed charges,90% of Total Billed Charges,50,640.55,
US PERITONE PLEURAL CATH DRNGE,7610000127,CDM,761,RC,,,Outpatient,,,5430.00,3529.50,,5430,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4126.8,76,,3301.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,5430,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4887,90,,3909.6,Percent of Total Billed Charges,90% of Total Billed Charges,2443.5,45,,1954.8,Percent of Total Billed Charges,45% of Total Billed Charges,4887,90,,3909.6,Percent of Total Billed Charges,90% of Total billed Charges,5430,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5430,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5430,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3529.5,65,,2823.6,Percent of total Billed Charges,65% of Total Billed Charges,2394.63,44.1,,1915.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,5158.5,95,,4126.8,Percent of Total Billed Charges,95% of Total Billed Charges,5430,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4778.4,88,,3822.72,Percent of Total Billed Charges,88% of Total Billed Charges,4887,90,,3909.6,Percent of Total Billed charges,90% of Total Billed Charges,50,5430,
XR  PERC ASP /INJ REN /PELV CY,7610000128,CDM,761,RC,,,Outpatient,,,2607.41,1694.82,,2607.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1981.63,76,,1585.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2607.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2346.67,90,,1877.336,Percent of Total Billed Charges,90% of Total Billed Charges,1173.33,45,,938.664,Percent of Total Billed Charges,45% of Total Billed Charges,2346.67,90,,1877.336,Percent of Total Billed Charges,90% of Total billed Charges,2607.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2607.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2607.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1694.82,65,,1355.856,Percent of total Billed Charges,65% of Total Billed Charges,1149.87,44.1,,919.896,Percent of Total Billed Charges,44.1% of Total Billed Charges,2477.04,95,,1981.632,Percent of Total Billed Charges,95% of Total Billed Charges,2607.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2294.52,88,,1835.616,Percent of Total Billed Charges,88% of Total Billed Charges,2346.67,90,,1877.336,Percent of Total Billed charges,90% of Total Billed Charges,50,2607.41,
XR CONVER GTBE/JEJUNOSTOMY PER,7610000129,CDM,761,RC,,,Outpatient,,,3877.21,2520.19,,3877.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2946.68,76,,2357.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3877.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3489.49,90,,2791.592,Percent of Total Billed Charges,90% of Total Billed Charges,1744.74,45,,1395.792,Percent of Total Billed Charges,45% of Total Billed Charges,3489.49,90,,2791.592,Percent of Total Billed Charges,90% of Total billed Charges,3877.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3877.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3877.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2520.19,65,,2016.152,Percent of total Billed Charges,65% of Total Billed Charges,1709.85,44.1,,1367.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,3683.35,95,,2946.68,Percent of Total Billed Charges,95% of Total Billed Charges,3877.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3411.94,88,,2729.552,Percent of Total Billed Charges,88% of Total Billed Charges,3489.49,90,,2791.592,Percent of Total Billed charges,90% of Total Billed Charges,50,3877.21,
XR CYSTOSTOMY TUBE EXCHNGE SIM,7610000130,CDM,761,RC,,,Outpatient,,,1400.00,910.00,,1400,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1064,76,,851.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1260,90,,1008,Percent of Total Billed Charges,90% of Total Billed Charges,630,45,,504,Percent of Total Billed Charges,45% of Total Billed Charges,1260,90,,1008,Percent of Total Billed Charges,90% of Total billed Charges,1400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,910,65,,728,Percent of total Billed Charges,65% of Total Billed Charges,617.4,44.1,,493.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,1330,95,,1064,Percent of Total Billed Charges,95% of Total Billed Charges,1400,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1232,88,,985.6,Percent of Total Billed Charges,88% of Total Billed Charges,1260,90,,1008,Percent of Total Billed charges,90% of Total Billed Charges,50,1400,
XR INJ TRIGGER POINT >3 MUSC,7610000132,CDM,761,RC,,,Outpatient,,,641.00,416.65,,641,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,487.16,76,,389.728,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,641,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,576.9,90,,461.52,Percent of Total Billed Charges,90% of Total Billed Charges,288.45,45,,230.76,Percent of Total Billed Charges,45% of Total Billed Charges,576.9,90,,461.52,Percent of Total Billed Charges,90% of Total billed Charges,641,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,641,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,641,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,416.65,65,,333.32,Percent of total Billed Charges,65% of Total Billed Charges,282.68,44.1,,226.144,Percent of Total Billed Charges,44.1% of Total Billed Charges,608.95,95,,487.16,Percent of Total Billed Charges,95% of Total Billed Charges,641,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,564.08,88,,451.264,Percent of Total Billed Charges,88% of Total Billed Charges,576.9,90,,461.52,Percent of Total Billed charges,90% of Total Billed Charges,50,641,
XR INJ TRIGGER POINT 12 MUSC,7610000134,CDM,761,RC,,,Outpatient,,,528.00,343.20,,528,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,401.28,76,,321.024,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,528,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,475.2,90,,380.16,Percent of Total Billed Charges,90% of Total Billed Charges,237.6,45,,190.08,Percent of Total Billed Charges,45% of Total Billed Charges,475.2,90,,380.16,Percent of Total Billed Charges,90% of Total billed Charges,528,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,528,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,528,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.2,65,,274.56,Percent of total Billed Charges,65% of Total Billed Charges,232.85,44.1,,186.28,Percent of Total Billed Charges,44.1% of Total Billed Charges,501.6,95,,401.28,Percent of Total Billed Charges,95% of Total Billed Charges,528,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,464.64,88,,371.712,Percent of Total Billed Charges,88% of Total Billed Charges,475.2,90,,380.16,Percent of Total Billed charges,90% of Total Billed Charges,50,528,
XR PERC TRANSPH URET STEN REP,7610000135,CDM,761,RC,,,Outpatient,,,1797.00,1168.05,,1797,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1365.72,76,,1092.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1797,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1617.3,90,,1293.84,Percent of Total Billed Charges,90% of Total Billed Charges,808.65,45,,646.92,Percent of Total Billed Charges,45% of Total Billed Charges,1617.3,90,,1293.84,Percent of Total Billed Charges,90% of Total billed Charges,1797,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1797,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1797,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1168.05,65,,934.44,Percent of total Billed Charges,65% of Total Billed Charges,792.48,44.1,,633.984,Percent of Total Billed Charges,44.1% of Total Billed Charges,1707.15,95,,1365.72,Percent of Total Billed Charges,95% of Total Billed Charges,1797,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1581.36,88,,1265.088,Percent of Total Billed Charges,88% of Total Billed Charges,1617.3,90,,1293.84,Percent of Total Billed charges,90% of Total Billed Charges,50,1797,
XR RMV TUNN PLEURAL CATH W/CUF,7610000136,CDM,761,RC,,,Outpatient,,,2394.46,1556.40,,2394.46,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1819.79,76,,1455.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2394.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2155.01,90,,1724.008,Percent of Total Billed Charges,90% of Total Billed Charges,1077.51,45,,862.008,Percent of Total Billed Charges,45% of Total Billed Charges,2155.01,90,,1724.008,Percent of Total Billed Charges,90% of Total billed Charges,2394.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2394.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2394.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1556.4,65,,1245.12,Percent of total Billed Charges,65% of Total Billed Charges,1055.96,44.1,,844.768,Percent of Total Billed Charges,44.1% of Total Billed Charges,2274.74,95,,1819.792,Percent of Total Billed Charges,95% of Total Billed Charges,2394.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2107.12,88,,1685.696,Percent of Total Billed Charges,88% of Total Billed Charges,2155.01,90,,1724.008,Percent of Total Billed charges,90% of Total Billed Charges,50,2394.46,
XR Sel Cath Plcmt Ven Sys1st O,7610000137,CDM,481,RC,,,Outpatient,,,2136.19,1388.52,,2136.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1623.5,76,,1298.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1538.06,72,,1230.448,Percent of Total Billed Charges,72% of Total Billed Charges,1602.14,75,,1281.712,Percent of Total Billed charges,75% of Total Billed Charges,2136.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1538.06,72,,1230.448,Percent of Total Billed Charges,72% of Total Billed Charges,1281.71,60,,1025.368,Percent of Total Billed Charges,60% of Total Billed Charges,1922.57,90,,1538.056,Percent of Total Billed Charges,90% of Total Billed Charges,961.29,45,,769.032,Percent of Total Billed Charges,45% of Total Billed Charges,1922.57,90,,1538.056,Percent of Total Billed Charges,90% of Total billed Charges,2136.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2136.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2136.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1388.52,65,,1110.816,Percent of total Billed Charges,65% of Total Billed Charges,942.06,44.1,,753.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,2029.38,95,,1623.504,Percent of Total Billed Charges,95% of Total Billed Charges,2136.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1879.85,88,,1503.88,Percent of Total Billed Charges,88% of Total Billed Charges,1922.57,90,,1538.056,Percent of Total Billed charges,90% of Total Billed Charges,942.06,2136.19,
XR SEL Cath Plcmt Ven Sys1st O,7610000138,CDM,761,RC,,,Outpatient,,,2136.19,1388.52,,2136.19,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1623.5,76,,1298.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2136.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1922.57,90,,1538.056,Percent of Total Billed Charges,90% of Total Billed Charges,961.29,45,,769.032,Percent of Total Billed Charges,45% of Total Billed Charges,1922.57,90,,1538.056,Percent of Total Billed Charges,90% of Total billed Charges,2136.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2136.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2136.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1388.52,65,,1110.816,Percent of total Billed Charges,65% of Total Billed Charges,942.06,44.1,,753.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,2029.38,95,,1623.504,Percent of Total Billed Charges,95% of Total Billed Charges,2136.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1879.85,88,,1503.88,Percent of Total Billed Charges,88% of Total Billed Charges,1922.57,90,,1538.056,Percent of Total Billed charges,90% of Total Billed Charges,50,2136.19,
XR THROMBIN INJ PSEUDO ANEURYS,7610000139,CDM,761,RC,,,Outpatient,,,771.23,501.30,,771.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,586.13,76,,468.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,771.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,694.11,90,,555.288,Percent of Total Billed Charges,90% of Total Billed Charges,347.05,45,,277.64,Percent of Total Billed Charges,45% of Total Billed Charges,694.11,90,,555.288,Percent of Total Billed Charges,90% of Total billed Charges,771.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.3,65,,401.04,Percent of total Billed Charges,65% of Total Billed Charges,340.11,44.1,,272.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,732.67,95,,586.136,Percent of Total Billed Charges,95% of Total Billed Charges,771.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678.68,88,,542.944,Percent of Total Billed Charges,88% of Total Billed Charges,694.11,90,,555.288,Percent of Total Billed charges,90% of Total Billed Charges,50,771.23,
XR THROMBIN INJ PSEUDO ANEURYS,7610000140,CDM,761,RC,,,Outpatient,,,771.23,501.30,,771.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,586.13,76,,468.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,771.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,694.11,90,,555.288,Percent of Total Billed Charges,90% of Total Billed Charges,347.05,45,,277.64,Percent of Total Billed Charges,45% of Total Billed Charges,694.11,90,,555.288,Percent of Total Billed Charges,90% of Total billed Charges,771.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.3,65,,401.04,Percent of total Billed Charges,65% of Total Billed Charges,340.11,44.1,,272.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,732.67,95,,586.136,Percent of Total Billed Charges,95% of Total Billed Charges,771.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678.68,88,,542.944,Percent of Total Billed Charges,88% of Total Billed Charges,694.11,90,,555.288,Percent of Total Billed charges,90% of Total Billed Charges,50,771.23,
FNA BX W FL GDN  1ST LESION,7610000143,CDM,761,RC,,,Outpatient,,,1600.00,1040.00,,1600,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1216,76,,972.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1440,90,,1152,Percent of Total Billed Charges,90% of Total Billed Charges,720,45,,576,Percent of Total Billed Charges,45% of Total Billed Charges,1440,90,,1152,Percent of Total Billed Charges,90% of Total billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1040,65,,832,Percent of total Billed Charges,65% of Total Billed Charges,705.6,44.1,,564.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,1520,95,,1216,Percent of Total Billed Charges,95% of Total Billed Charges,1600,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1408,88,,1126.4,Percent of Total Billed Charges,88% of Total Billed Charges,1440,90,,1152,Percent of Total Billed charges,90% of Total Billed Charges,50,1600,
RAD  SINOGRAM DIAGNOSTIC,7610000148,CDM,761,RC,,,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,720,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,50,800,
INJECTION(S) SINGLE TENDON,7610000149,CDM,361,RC,,,Outpatient,,,607.00,394.55,,607,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,461.32,76,,369.056,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,437.04,72,,349.632,Percent of Total Billed Charges,72% of Total Billed Charges,455.25,75,,364.2,Percent of Total Billed charges,75% of Total Billed Charges,607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.04,72,,349.632,Percent of Total Billed Charges,72% of Total Billed Charges,364.2,60,,291.36,Percent of Total Billed Charges,60% of Total Billed Charges,546.3,90,,437.04,Percent of Total Billed Charges,90% of Total Billed Charges,273.15,45,,218.52,Percent of Total Billed Charges,45% of Total Billed Charges,546.3,90,,437.04,Percent of Total Billed Charges,90% of Total billed Charges,607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.55,65,,315.64,Percent of total Billed Charges,65% of Total Billed Charges,267.69,44.1,,214.152,Percent of Total Billed Charges,44.1% of Total Billed Charges,576.65,95,,461.32,Percent of Total Billed Charges,95% of Total Billed Charges,607,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,534.16,88,,427.328,Percent of Total Billed Charges,88% of Total Billed Charges,546.3,90,,437.04,Percent of Total Billed charges,90% of Total Billed Charges,267.69,607,
PEDS INTUBATION,7610000153,CDM,761,RC,,,Outpatient,,,350.60,227.89,,350.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,266.46,76,,213.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,350.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,315.54,90,,252.432,Percent of Total Billed Charges,90% of Total Billed Charges,157.77,45,,126.216,Percent of Total Billed Charges,45% of Total Billed Charges,315.54,90,,252.432,Percent of Total Billed Charges,90% of Total billed Charges,350.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.89,65,,182.312,Percent of total Billed Charges,65% of Total Billed Charges,154.61,44.1,,123.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,333.07,95,,266.456,Percent of Total Billed Charges,95% of Total Billed Charges,350.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.53,88,,246.824,Percent of Total Billed Charges,88% of Total Billed Charges,315.54,90,,252.432,Percent of Total Billed charges,90% of Total Billed Charges,50,350.6,
INTUBATION,7610000154,CDM,761,RC,,,Outpatient,,,350.60,227.89,,350.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,266.46,76,,213.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,350.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,315.54,90,,252.432,Percent of Total Billed Charges,90% of Total Billed Charges,157.77,45,,126.216,Percent of Total Billed Charges,45% of Total Billed Charges,315.54,90,,252.432,Percent of Total Billed Charges,90% of Total billed Charges,350.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.89,65,,182.312,Percent of total Billed Charges,65% of Total Billed Charges,154.61,44.1,,123.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,333.07,95,,266.456,Percent of Total Billed Charges,95% of Total Billed Charges,350.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.53,88,,246.824,Percent of Total Billed Charges,88% of Total Billed Charges,315.54,90,,252.432,Percent of Total Billed charges,90% of Total Billed Charges,50,350.6,
INSERTION OF CHEST TUBE,7610000156,CDM,761,RC,,,Outpatient,,,1413.00,918.45,,1413,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1073.88,76,,859.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1271.7,90,,1017.36,Percent of Total Billed Charges,90% of Total Billed Charges,635.85,45,,508.68,Percent of Total Billed Charges,45% of Total Billed Charges,1271.7,90,,1017.36,Percent of Total Billed Charges,90% of Total billed Charges,1413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,918.45,65,,734.76,Percent of total Billed Charges,65% of Total Billed Charges,623.13,44.1,,498.504,Percent of Total Billed Charges,44.1% of Total Billed Charges,1342.35,95,,1073.88,Percent of Total Billed Charges,95% of Total Billed Charges,1413,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1243.44,88,,994.752,Percent of Total Billed Charges,88% of Total Billed Charges,1271.7,90,,1017.36,Percent of Total Billed charges,90% of Total Billed Charges,50,1413,
THORACENTESIS WITH IMAGING,7610000158,CDM,761,RC,,,Outpatient,,,1716.63,1115.81,,1716.63,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1304.64,76,,1043.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1716.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1544.97,90,,1235.976,Percent of Total Billed Charges,90% of Total Billed Charges,772.48,45,,617.984,Percent of Total Billed Charges,45% of Total Billed Charges,1544.97,90,,1235.976,Percent of Total Billed Charges,90% of Total billed Charges,1716.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1716.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1716.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1115.81,65,,892.648,Percent of total Billed Charges,65% of Total Billed Charges,757.03,44.1,,605.624,Percent of Total Billed Charges,44.1% of Total Billed Charges,1630.8,95,,1304.64,Percent of Total Billed Charges,95% of Total Billed Charges,1716.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1510.63,88,,1208.504,Percent of Total Billed Charges,88% of Total Billed Charges,1544.97,90,,1235.976,Percent of Total Billed charges,90% of Total Billed Charges,50,1716.63,
SCALP VEIN,7610000160,CDM,761,RC,,,Outpatient,,,88.20,57.33,,88.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,67.03,76,,53.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,79.38,90,,63.504,Percent of Total Billed Charges,90% of Total Billed Charges,39.69,45,,31.752,Percent of Total Billed Charges,45% of Total Billed Charges,79.38,90,,63.504,Percent of Total Billed Charges,90% of Total billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.33,65,,45.864,Percent of total Billed Charges,65% of Total Billed Charges,38.9,44.1,,31.12,Percent of Total Billed Charges,44.1% of Total Billed Charges,83.79,95,,67.032,Percent of Total Billed Charges,95% of Total Billed Charges,88.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,88,,62.096,Percent of Total Billed Charges,88% of Total Billed Charges,79.38,90,,63.504,Percent of Total Billed charges,90% of Total Billed Charges,38.9,88.2,
PERCUTANEOUS CENTRAL,7610000161,CDM,761,RC,,,Outpatient,,,2655.99,1726.39,,2655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2018.55,76,,1614.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2390.39,90,,1912.312,Percent of Total Billed Charges,90% of Total Billed Charges,1195.2,45,,956.16,Percent of Total Billed Charges,45% of Total Billed Charges,2390.39,90,,1912.312,Percent of Total Billed Charges,90% of Total billed Charges,2655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1726.39,65,,1381.112,Percent of total Billed Charges,65% of Total Billed Charges,1171.29,44.1,,937.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,2523.19,95,,2018.552,Percent of Total Billed Charges,95% of Total Billed Charges,2655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2337.27,88,,1869.816,Percent of Total Billed Charges,88% of Total Billed Charges,2390.39,90,,1912.312,Percent of Total Billed charges,90% of Total Billed Charges,50,2655.99,
PERCUTANEOUS VENOUS,7610000162,CDM,761,RC,,,Outpatient,,,2655.99,1726.39,,2655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2018.55,76,,1614.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2390.39,90,,1912.312,Percent of Total Billed Charges,90% of Total Billed Charges,1195.2,45,,956.16,Percent of Total Billed Charges,45% of Total Billed Charges,2390.39,90,,1912.312,Percent of Total Billed Charges,90% of Total billed Charges,2655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1726.39,65,,1381.112,Percent of total Billed Charges,65% of Total Billed Charges,1171.29,44.1,,937.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,2523.19,95,,2018.552,Percent of Total Billed Charges,95% of Total Billed Charges,2655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2337.27,88,,1869.816,Percent of Total Billed Charges,88% of Total Billed Charges,2390.39,90,,1912.312,Percent of Total Billed charges,90% of Total Billed Charges,50,2655.99,
INSERTION ON NONTUNNELED CVC,7610000163,CDM,761,RC,,,Outpatient,,,2272.25,1476.96,,2272.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1726.91,76,,1381.528,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2272.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2045.03,90,,1636.024,Percent of Total Billed Charges,90% of Total Billed Charges,1022.51,45,,818.008,Percent of Total Billed Charges,45% of Total Billed Charges,2045.03,90,,1636.024,Percent of Total Billed Charges,90% of Total billed Charges,2272.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2272.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2272.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1476.96,65,,1181.568,Percent of total Billed Charges,65% of Total Billed Charges,1002.06,44.1,,801.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,2158.64,95,,1726.912,Percent of Total Billed Charges,95% of Total Billed Charges,2272.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1999.58,88,,1599.664,Percent of Total Billed Charges,88% of Total Billed Charges,2045.03,90,,1636.024,Percent of Total Billed charges,90% of Total Billed Charges,50,2272.25,
US CVC NON TUNNELED,7610000164,CDM,761,RC,,,Outpatient,,,2811.00,1827.15,,2811,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2136.36,76,,1709.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2529.9,90,,2023.92,Percent of Total Billed Charges,90% of Total Billed Charges,1264.95,45,,1011.96,Percent of Total Billed Charges,45% of Total Billed Charges,2529.9,90,,2023.92,Percent of Total Billed Charges,90% of Total billed Charges,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1827.15,65,,1461.72,Percent of total Billed Charges,65% of Total Billed Charges,1239.65,44.1,,991.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,2670.45,95,,2136.36,Percent of Total Billed Charges,95% of Total Billed Charges,2811,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2473.68,88,,1978.944,Percent of Total Billed Charges,88% of Total Billed Charges,2529.9,90,,2023.92,Percent of Total Billed charges,90% of Total Billed Charges,50,2811,
ARTERIAL LINE,7610000168,CDM,761,RC,,,Outpatient,,,349.49,227.17,,349.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,265.61,76,,212.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,349.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,314.54,90,,251.632,Percent of Total Billed Charges,90% of Total Billed Charges,157.27,45,,125.816,Percent of Total Billed Charges,45% of Total Billed Charges,314.54,90,,251.632,Percent of Total Billed Charges,90% of Total billed Charges,349.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.17,65,,181.736,Percent of total Billed Charges,65% of Total Billed Charges,154.13,44.1,,123.304,Percent of Total Billed Charges,44.1% of Total Billed Charges,332.02,95,,265.616,Percent of Total Billed Charges,95% of Total Billed Charges,349.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.55,88,,246.04,Percent of Total Billed Charges,88% of Total Billed Charges,314.54,90,,251.632,Percent of Total Billed charges,90% of Total Billed Charges,50,349.49,
INSERTION OF UAC,7610000169,CDM,761,RC,,,Outpatient,,,577.71,375.51,,577.71,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,439.06,76,,351.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,519.94,90,,415.952,Percent of Total Billed Charges,90% of Total Billed Charges,259.97,45,,207.976,Percent of Total Billed Charges,45% of Total Billed Charges,519.94,90,,415.952,Percent of Total Billed Charges,90% of Total billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.51,65,,300.408,Percent of total Billed Charges,65% of Total Billed Charges,254.77,44.1,,203.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,548.82,95,,439.056,Percent of Total Billed Charges,95% of Total Billed Charges,577.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.38,88,,406.704,Percent of Total Billed Charges,88% of Total Billed Charges,519.94,90,,415.952,Percent of Total Billed charges,90% of Total Billed Charges,50,577.71,
TRANSCATHETER BIOPSY,7610000172,CDM,761,RC,,,Outpatient,,,6277.64,4080.47,,6277.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4771.01,76,,3816.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,5649.88,90,,4519.904,Percent of Total Billed Charges,90% of Total Billed Charges,2824.94,45,,2259.952,Percent of Total Billed Charges,45% of Total Billed Charges,5649.88,90,,4519.904,Percent of Total Billed Charges,90% of Total billed Charges,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4080.47,65,,3264.376,Percent of total Billed Charges,65% of Total Billed Charges,2768.44,44.1,,2214.752,Percent of Total Billed Charges,44.1% of Total Billed Charges,5963.76,95,,4771.008,Percent of Total Billed Charges,95% of Total Billed Charges,6277.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5524.32,88,,4419.456,Percent of Total Billed Charges,88% of Total Billed Charges,5649.88,90,,4519.904,Percent of Total Billed charges,90% of Total Billed Charges,50,6277.64,
NONCORONARY IVUS INITIAL,7610000173,CDM,761,RC,,,Outpatient,,,277.65,180.47,,277.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,211.01,76,,168.808,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,277.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,249.89,90,,199.912,Percent of Total Billed Charges,90% of Total Billed Charges,124.94,45,,99.952,Percent of Total Billed Charges,45% of Total Billed Charges,249.89,90,,199.912,Percent of Total Billed Charges,90% of Total billed Charges,277.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.47,65,,144.376,Percent of total Billed Charges,65% of Total Billed Charges,122.44,44.1,,97.952,Percent of Total Billed Charges,44.1% of Total Billed Charges,263.77,95,,211.016,Percent of Total Billed Charges,95% of Total Billed Charges,277.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.33,88,,195.464,Percent of Total Billed Charges,88% of Total Billed Charges,249.89,90,,199.912,Percent of Total Billed charges,90% of Total Billed Charges,50,277.65,
BONE MARROW ASPIRATION ONLY,7610000174,CDM,761,RC,,,Outpatient,,,454.72,295.57,,454.72,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,345.59,76,,276.472,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,454.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,409.25,90,,327.4,Percent of Total Billed Charges,90% of Total Billed Charges,204.62,45,,163.696,Percent of Total Billed Charges,45% of Total Billed Charges,409.25,90,,327.4,Percent of Total Billed Charges,90% of Total billed Charges,454.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,454.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,454.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.57,65,,236.456,Percent of total Billed Charges,65% of Total Billed Charges,200.53,44.1,,160.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,431.98,95,,345.584,Percent of Total Billed Charges,95% of Total Billed Charges,454.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.15,88,,320.12,Percent of Total Billed Charges,88% of Total Billed Charges,409.25,90,,327.4,Percent of Total Billed charges,90% of Total Billed Charges,50,454.72,
BIOPSY SALIVARY GLAND NEEDLE,7610000175,CDM,761,RC,,,Outpatient,,,1609.00,1045.85,,1609,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1222.84,76,,978.272,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1448.1,90,,1158.48,Percent of Total Billed Charges,90% of Total Billed Charges,724.05,45,,579.24,Percent of Total Billed Charges,45% of Total Billed Charges,1448.1,90,,1158.48,Percent of Total Billed Charges,90% of Total billed Charges,1609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1045.85,65,,836.68,Percent of total Billed Charges,65% of Total Billed Charges,709.57,44.1,,567.656,Percent of Total Billed Charges,44.1% of Total Billed Charges,1528.55,95,,1222.84,Percent of Total Billed Charges,95% of Total Billed Charges,1609,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1415.92,88,,1132.736,Percent of Total Billed Charges,88% of Total Billed Charges,1448.1,90,,1158.48,Percent of Total Billed charges,90% of Total Billed Charges,50,1609,
PARACENTESIS,7610000176,CDM,761,RC,,,Outpatient,,,1540.85,1001.55,,1540.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1171.05,76,,936.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1540.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1386.77,90,,1109.416,Percent of Total Billed Charges,90% of Total Billed Charges,693.38,45,,554.704,Percent of Total Billed Charges,45% of Total Billed Charges,1386.77,90,,1109.416,Percent of Total Billed Charges,90% of Total billed Charges,1540.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1540.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1540.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1001.55,65,,801.24,Percent of total Billed Charges,65% of Total Billed Charges,679.51,44.1,,543.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,1463.81,95,,1171.048,Percent of Total Billed Charges,95% of Total Billed Charges,1540.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1355.95,88,,1084.76,Percent of Total Billed Charges,88% of Total Billed Charges,1386.77,90,,1109.416,Percent of Total Billed charges,90% of Total Billed Charges,50,1540.85,
ABD PARACENTESIS W/OUT IMAGING,7610000177,CDM,761,RC,,,Outpatient,,,1505.00,978.25,,1505,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1143.8,76,,915.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1505,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1354.5,90,,1083.6,Percent of Total Billed Charges,90% of Total Billed Charges,677.25,45,,541.8,Percent of Total Billed Charges,45% of Total Billed Charges,1354.5,90,,1083.6,Percent of Total Billed Charges,90% of Total billed Charges,1505,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1505,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1505,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,978.25,65,,782.6,Percent of total Billed Charges,65% of Total Billed Charges,663.71,44.1,,530.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,1429.75,95,,1143.8,Percent of Total Billed Charges,95% of Total Billed Charges,1505,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1324.4,88,,1059.52,Percent of Total Billed Charges,88% of Total Billed Charges,1354.5,90,,1083.6,Percent of Total Billed charges,90% of Total Billed Charges,50,1505,
PARACENTESIS WITH IMAGING,7610000178,CDM,761,RC,,,Outpatient,,,2000.00,1300.00,,2000,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1520,76,,1216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1800,90,,1440,Percent of Total Billed Charges,90% of Total Billed Charges,900,45,,720,Percent of Total Billed Charges,45% of Total Billed Charges,1800,90,,1440,Percent of Total Billed Charges,90% of Total billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300,65,,1040,Percent of total Billed Charges,65% of Total Billed Charges,882,44.1,,705.6,Percent of Total Billed Charges,44.1% of Total Billed Charges,1900,95,,1520,Percent of Total Billed Charges,95% of Total Billed Charges,2000,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1760,88,,1408,Percent of Total Billed Charges,88% of Total Billed Charges,1800,90,,1440,Percent of Total Billed charges,90% of Total Billed Charges,50,2000,
ABD PARACENTESIS W/ IMAGING,7610000179,CDM,761,RC,,,Outpatient,,,2160.00,1404.00,,2160,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1641.6,76,,1313.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1944,90,,1555.2,Percent of Total Billed Charges,90% of Total Billed Charges,972,45,,777.6,Percent of Total Billed Charges,45% of Total Billed Charges,1944,90,,1555.2,Percent of Total Billed Charges,90% of Total billed Charges,2160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1404,65,,1123.2,Percent of total Billed Charges,65% of Total Billed Charges,952.56,44.1,,762.048,Percent of Total Billed Charges,44.1% of Total Billed Charges,2052,95,,1641.6,Percent of Total Billed Charges,95% of Total Billed Charges,2160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1900.8,88,,1520.64,Percent of Total Billed Charges,88% of Total Billed Charges,1944,90,,1555.2,Percent of Total Billed charges,90% of Total Billed Charges,50,2160,
PLACEMENT GASTROSTOMY TUBE,7610000180,CDM,761,RC,,,Outpatient,,,2091.00,1359.15,,2091,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1589.16,76,,1271.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2091,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1881.9,90,,1505.52,Percent of Total Billed Charges,90% of Total Billed Charges,940.95,45,,752.76,Percent of Total Billed Charges,45% of Total Billed Charges,1881.9,90,,1505.52,Percent of Total Billed Charges,90% of Total billed Charges,2091,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2091,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2091,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1359.15,65,,1087.32,Percent of total Billed Charges,65% of Total Billed Charges,922.13,44.1,,737.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,1986.45,95,,1589.16,Percent of Total Billed Charges,95% of Total Billed Charges,2091,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1840.08,88,,1472.064,Percent of Total Billed Charges,88% of Total Billed Charges,1881.9,90,,1505.52,Percent of Total Billed charges,90% of Total Billed Charges,50,2091,
CONVERSION GTTUBE TO GJTUBE,7610000181,CDM,761,RC,,,Outpatient,,,3877.21,2520.19,,3877.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2946.68,76,,2357.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3877.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3489.49,90,,2791.592,Percent of Total Billed Charges,90% of Total Billed Charges,1744.74,45,,1395.792,Percent of Total Billed Charges,45% of Total Billed Charges,3489.49,90,,2791.592,Percent of Total Billed Charges,90% of Total billed Charges,3877.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3877.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3877.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2520.19,65,,2016.152,Percent of total Billed Charges,65% of Total Billed Charges,1709.85,44.1,,1367.88,Percent of Total Billed Charges,44.1% of Total Billed Charges,3683.35,95,,2946.68,Percent of Total Billed Charges,95% of Total Billed Charges,3877.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3411.94,88,,2729.552,Percent of Total Billed Charges,88% of Total Billed Charges,3489.49,90,,2791.592,Percent of Total Billed charges,90% of Total Billed Charges,50,3877.21,
KIDNEY BIOPSY,7610000182,CDM,761,RC,,,Outpatient,,,3294.78,2141.61,,3294.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2504.03,76,,2003.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3294.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2965.3,90,,2372.24,Percent of Total Billed Charges,90% of Total Billed Charges,1482.65,45,,1186.12,Percent of Total Billed Charges,45% of Total Billed Charges,2965.3,90,,2372.24,Percent of Total Billed Charges,90% of Total billed Charges,3294.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3294.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3294.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2141.61,65,,1713.288,Percent of total Billed Charges,65% of Total Billed Charges,1453,44.1,,1162.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,3130.04,95,,2504.032,Percent of Total Billed Charges,95% of Total Billed Charges,3294.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2899.41,88,,2319.528,Percent of Total Billed Charges,88% of Total Billed Charges,2965.3,90,,2372.24,Percent of Total Billed charges,90% of Total Billed Charges,50,3294.78,
REMOVE RENAL TUBE W/FLUORO,7610000183,CDM,761,RC,,,Outpatient,,,1686.00,1095.90,,1686,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1281.36,76,,1025.088,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1686,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1517.4,90,,1213.92,Percent of Total Billed Charges,90% of Total Billed Charges,758.7,45,,606.96,Percent of Total Billed Charges,45% of Total Billed Charges,1517.4,90,,1213.92,Percent of Total Billed Charges,90% of Total billed Charges,1686,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1686,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1686,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1095.9,65,,876.72,Percent of total Billed Charges,65% of Total Billed Charges,743.53,44.1,,594.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,1601.7,95,,1281.36,Percent of Total Billed Charges,95% of Total Billed Charges,1686,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1483.68,88,,1186.944,Percent of Total Billed Charges,88% of Total Billed Charges,1517.4,90,,1213.92,Percent of Total Billed charges,90% of Total Billed Charges,50,1686,
PEDS BLADDER IRRIGATION,7610000184,CDM,761,RC,,,Outpatient,,,557.00,362.05,,557,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,423.32,76,,338.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,557,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,501.3,90,,401.04,Percent of Total Billed Charges,90% of Total Billed Charges,250.65,45,,200.52,Percent of Total Billed Charges,45% of Total Billed Charges,501.3,90,,401.04,Percent of Total Billed Charges,90% of Total billed Charges,557,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,557,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,557,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,362.05,65,,289.64,Percent of total Billed Charges,65% of Total Billed Charges,245.64,44.1,,196.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,529.15,95,,423.32,Percent of Total Billed Charges,95% of Total Billed Charges,557,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.16,88,,392.128,Percent of Total Billed Charges,88% of Total Billed Charges,501.3,90,,401.04,Percent of Total Billed charges,90% of Total Billed Charges,50,557,
BLADDER IRRIGATION,7610000185,CDM,761,RC,,,Outpatient,,,557.00,362.05,,557,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,423.32,76,,338.656,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,557,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,501.3,90,,401.04,Percent of Total Billed Charges,90% of Total Billed Charges,250.65,45,,200.52,Percent of Total Billed Charges,45% of Total Billed Charges,501.3,90,,401.04,Percent of Total Billed Charges,90% of Total billed Charges,557,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,557,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,557,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,362.05,65,,289.64,Percent of total Billed Charges,65% of Total Billed Charges,245.64,44.1,,196.512,Percent of Total Billed Charges,44.1% of Total Billed Charges,529.15,95,,423.32,Percent of Total Billed Charges,95% of Total Billed Charges,557,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.16,88,,392.128,Percent of Total Billed Charges,88% of Total Billed Charges,501.3,90,,401.04,Percent of Total Billed charges,90% of Total Billed Charges,50,557,
STRAIGHT CATHETERIZA,7610000186,CDM,761,RC,,,Outpatient,,,190.00,123.50,,190,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,144.4,76,,115.52,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,171,90,,136.8,Percent of Total Billed Charges,90% of Total Billed Charges,85.5,45,,68.4,Percent of Total Billed Charges,45% of Total Billed Charges,171,90,,136.8,Percent of Total Billed Charges,90% of Total billed Charges,190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.5,65,,98.8,Percent of total Billed Charges,65% of Total Billed Charges,83.79,44.1,,67.032,Percent of Total Billed Charges,44.1% of Total Billed Charges,180.5,95,,144.4,Percent of Total Billed Charges,95% of Total Billed Charges,190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.2,88,,133.76,Percent of Total Billed Charges,88% of Total Billed Charges,171,90,,136.8,Percent of Total Billed charges,90% of Total Billed Charges,50,190,
FOLEY CATHETERIZATION SIMPLE,7610000187,CDM,761,RC,,,Outpatient,,,113.00,73.45,,113,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,85.88,76,,68.704,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,101.7,90,,81.36,Percent of Total Billed Charges,90% of Total Billed Charges,50.85,45,,40.68,Percent of Total Billed Charges,45% of Total Billed Charges,101.7,90,,81.36,Percent of Total Billed Charges,90% of Total billed Charges,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.45,65,,58.76,Percent of total Billed Charges,65% of Total Billed Charges,49.83,44.1,,39.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,107.35,95,,85.88,Percent of Total Billed Charges,95% of Total Billed Charges,113,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.44,88,,79.552,Percent of Total Billed Charges,88% of Total Billed Charges,101.7,90,,81.36,Percent of Total Billed charges,90% of Total Billed Charges,49.83,113,
FOLEY CATH COMPLICATED+F8828,7610000190,CDM,761,RC,,,Outpatient,,,138.00,89.70,,138,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,104.88,76,,83.904,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,138,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,124.2,90,,99.36,Percent of Total Billed Charges,90% of Total Billed Charges,62.1,45,,49.68,Percent of Total Billed Charges,45% of Total Billed Charges,124.2,90,,99.36,Percent of Total Billed Charges,90% of Total billed Charges,138,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.7,65,,71.76,Percent of total Billed Charges,65% of Total Billed Charges,60.86,44.1,,48.688,Percent of Total Billed Charges,44.1% of Total Billed Charges,131.1,95,,104.88,Percent of Total Billed Charges,95% of Total Billed Charges,138,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.44,88,,97.152,Percent of Total Billed Charges,88% of Total Billed Charges,124.2,90,,99.36,Percent of Total Billed charges,90% of Total Billed Charges,50,138,
CYSTOSTOMY TUBE CHANGE SIMPLE,7610000194,CDM,761,RC,,,Outpatient,,,1330.00,864.50,,1330,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1010.8,76,,808.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1330,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1197,90,,957.6,Percent of Total Billed Charges,90% of Total Billed Charges,598.5,45,,478.8,Percent of Total Billed Charges,45% of Total Billed Charges,1197,90,,957.6,Percent of Total Billed Charges,90% of Total billed Charges,1330,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1330,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1330,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,864.5,65,,691.6,Percent of total Billed Charges,65% of Total Billed Charges,586.53,44.1,,469.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,1263.5,95,,1010.8,Percent of Total Billed Charges,95% of Total Billed Charges,1330,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170.4,88,,936.32,Percent of Total Billed Charges,88% of Total Billed Charges,1197,90,,957.6,Percent of Total Billed charges,90% of Total Billed Charges,50,1330,
COMPLEX CMG WITH UPP / LPP,7610000195,CDM,761,RC,,,Outpatient,,,877.59,570.43,,877.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,666.97,76,,533.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,877.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,789.83,90,,631.864,Percent of Total Billed Charges,90% of Total Billed Charges,394.92,45,,315.936,Percent of Total Billed Charges,45% of Total Billed Charges,789.83,90,,631.864,Percent of Total Billed Charges,90% of Total billed Charges,877.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,877.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,877.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,570.43,65,,456.344,Percent of total Billed Charges,65% of Total Billed Charges,387.02,44.1,,309.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,833.71,95,,666.968,Percent of Total Billed Charges,95% of Total Billed Charges,877.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,772.28,88,,617.824,Percent of Total Billed Charges,88% of Total Billed Charges,789.83,90,,631.864,Percent of Total Billed charges,90% of Total Billed Charges,50,877.59,
COMPLEX UROFLOW,7610000196,CDM,761,RC,,,Outpatient,,,265.70,172.71,,265.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,201.93,76,,161.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,239.13,90,,191.304,Percent of Total Billed Charges,90% of Total Billed Charges,119.57,45,,95.656,Percent of Total Billed Charges,45% of Total Billed Charges,239.13,90,,191.304,Percent of Total Billed Charges,90% of Total billed Charges,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.71,65,,138.168,Percent of total Billed Charges,65% of Total Billed Charges,117.17,44.1,,93.736,Percent of Total Billed Charges,44.1% of Total Billed Charges,252.42,95,,201.936,Percent of Total Billed Charges,95% of Total Billed Charges,265.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.82,88,,187.056,Percent of Total Billed Charges,88% of Total Billed Charges,239.13,90,,191.304,Percent of Total Billed charges,90% of Total Billed Charges,50,265.7,
EMG ELECTROMYOGRAPHY,7610000197,CDM,761,RC,,,Outpatient,,,269.01,174.86,,269.01,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,204.45,76,,163.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,269.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,242.11,90,,193.688,Percent of Total Billed Charges,90% of Total Billed Charges,121.05,45,,96.84,Percent of Total Billed Charges,45% of Total Billed Charges,242.11,90,,193.688,Percent of Total Billed Charges,90% of Total billed Charges,269.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.86,65,,139.888,Percent of total Billed Charges,65% of Total Billed Charges,118.63,44.1,,94.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,255.56,95,,204.448,Percent of Total Billed Charges,95% of Total Billed Charges,269.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.73,88,,189.384,Percent of Total Billed Charges,88% of Total Billed Charges,242.11,90,,193.688,Percent of Total Billed charges,90% of Total Billed Charges,50,269.01,
PERC ASP HYROCELE OF TESTES,7610000202,CDM,761,RC,,,Outpatient,,,1754.80,1140.62,,1754.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1333.65,76,,1066.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1579.32,90,,1263.456,Percent of Total Billed Charges,90% of Total Billed Charges,789.66,45,,631.728,Percent of Total Billed Charges,45% of Total Billed Charges,1579.32,90,,1263.456,Percent of Total Billed Charges,90% of Total billed Charges,1754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1140.62,65,,912.496,Percent of total Billed Charges,65% of Total Billed Charges,773.87,44.1,,619.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,1667.06,95,,1333.648,Percent of Total Billed Charges,95% of Total Billed Charges,1754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1544.22,88,,1235.376,Percent of Total Billed Charges,88% of Total Billed Charges,1579.32,90,,1263.456,Percent of Total Billed charges,90% of Total Billed Charges,50,1754.8,
US PERC ASP HYROCELE OF TESTES,7610000203,CDM,761,RC,,,Outpatient,,,1754.80,1140.62,,1754.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1333.65,76,,1066.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1579.32,90,,1263.456,Percent of Total Billed Charges,90% of Total Billed Charges,789.66,45,,631.728,Percent of Total Billed Charges,45% of Total Billed Charges,1579.32,90,,1263.456,Percent of Total Billed Charges,90% of Total billed Charges,1754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1140.62,65,,912.496,Percent of total Billed Charges,65% of Total Billed Charges,773.87,44.1,,619.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,1667.06,95,,1333.648,Percent of Total Billed Charges,95% of Total Billed Charges,1754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1544.22,88,,1235.376,Percent of Total Billed Charges,88% of Total Billed Charges,1579.32,90,,1263.456,Percent of Total Billed charges,90% of Total Billed Charges,50,1754.8,
L&D VAG. HEMATOMA,7610000204,CDM,761,RC,,,Outpatient,,,2726.70,1772.36,,2726.7,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2072.29,76,,1657.832,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2726.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2454.03,90,,1963.224,Percent of Total Billed Charges,90% of Total Billed Charges,1227.02,45,,981.616,Percent of Total Billed Charges,45% of Total Billed Charges,2454.03,90,,1963.224,Percent of Total Billed Charges,90% of Total billed Charges,2726.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2726.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2726.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1772.36,65,,1417.888,Percent of total Billed Charges,65% of Total Billed Charges,1202.47,44.1,,961.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,2590.37,95,,2072.296,Percent of Total Billed Charges,95% of Total Billed Charges,2726.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2399.5,88,,1919.6,Percent of Total Billed Charges,88% of Total Billed Charges,2454.03,90,,1963.224,Percent of Total Billed charges,90% of Total Billed Charges,50,2726.7,
AMNIOCENT THERAPEUTC,7610000205,CDM,761,RC,,,Outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,50,50,
INS CERVICAL DILATOR,7610000206,CDM,761,RC,,,Outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,50,50,
CEPHALIA EXTERNAL VE,7610000207,CDM,761,RC,,,Outpatient,,,5813.23,3778.60,,5813.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4418.05,76,,3534.44,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,5813.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,5231.91,90,,4185.528,Percent of Total Billed Charges,90% of Total Billed Charges,2615.95,45,,2092.76,Percent of Total Billed Charges,45% of Total Billed Charges,5231.91,90,,4185.528,Percent of Total Billed Charges,90% of Total billed Charges,5813.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5813.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5813.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3778.6,65,,3022.88,Percent of total Billed Charges,65% of Total Billed Charges,2563.63,44.1,,2050.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,5522.57,95,,4418.056,Percent of Total Billed Charges,95% of Total Billed Charges,5813.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5115.64,88,,4092.512,Percent of Total Billed Charges,88% of Total Billed Charges,5231.91,90,,4185.528,Percent of Total Billed charges,90% of Total Billed Charges,50,5813.23,
US ASP / INJ THYROID CYST,7610000208,CDM,761,RC,,,Outpatient,,,1663.00,1080.95,,1663,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1263.88,76,,1011.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1663,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1496.7,90,,1197.36,Percent of Total Billed Charges,90% of Total Billed Charges,748.35,45,,598.68,Percent of Total Billed Charges,45% of Total Billed Charges,1496.7,90,,1197.36,Percent of Total Billed Charges,90% of Total billed Charges,1663,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1663,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1663,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1080.95,65,,864.76,Percent of total Billed Charges,65% of Total Billed Charges,733.38,44.1,,586.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,1579.85,95,,1263.88,Percent of Total Billed Charges,95% of Total Billed Charges,1663,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1463.44,88,,1170.752,Percent of Total Billed Charges,88% of Total Billed Charges,1496.7,90,,1197.36,Percent of Total Billed charges,90% of Total Billed Charges,50,1663,
LUMBAR PUNCTURE,7610000209,CDM,761,RC,,,Outpatient,,,1078.00,700.70,,1078,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,819.28,76,,655.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,970.2,90,,776.16,Percent of Total Billed Charges,90% of Total Billed Charges,485.1,45,,388.08,Percent of Total Billed Charges,45% of Total Billed Charges,970.2,90,,776.16,Percent of Total Billed Charges,90% of Total billed Charges,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,700.7,65,,560.56,Percent of total Billed Charges,65% of Total Billed Charges,475.4,44.1,,380.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,1024.1,95,,819.28,Percent of Total Billed Charges,95% of Total Billed Charges,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,948.64,88,,758.912,Percent of Total Billed Charges,88% of Total Billed Charges,970.2,90,,776.16,Percent of Total Billed charges,90% of Total Billed Charges,50,1078,
CT SPINAL PUNCTURE L,7610000210,CDM,761,RC,,,Outpatient,,,1143.85,743.50,,1143.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,869.33,76,,695.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1143.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1029.47,90,,823.576,Percent of Total Billed Charges,90% of Total Billed Charges,514.73,45,,411.784,Percent of Total Billed Charges,45% of Total Billed Charges,1029.47,90,,823.576,Percent of Total Billed Charges,90% of Total billed Charges,1143.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1143.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1143.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,743.5,65,,594.8,Percent of total Billed Charges,65% of Total Billed Charges,504.44,44.1,,403.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,1086.66,95,,869.328,Percent of Total Billed Charges,95% of Total Billed Charges,1143.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1006.59,88,,805.272,Percent of Total Billed Charges,88% of Total Billed Charges,1029.47,90,,823.576,Percent of Total Billed charges,90% of Total Billed Charges,50,1143.85,
LUMBAR PUNCTURE,7610000211,CDM,761,RC,,,Outpatient,,,1078.00,700.70,,1078,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,819.28,76,,655.424,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,970.2,90,,776.16,Percent of Total Billed Charges,90% of Total Billed Charges,485.1,45,,388.08,Percent of Total Billed Charges,45% of Total Billed Charges,970.2,90,,776.16,Percent of Total Billed Charges,90% of Total billed Charges,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,700.7,65,,560.56,Percent of total Billed Charges,65% of Total Billed Charges,475.4,44.1,,380.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,1024.1,95,,819.28,Percent of Total Billed Charges,95% of Total Billed Charges,1078,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,948.64,88,,758.912,Percent of Total Billed Charges,88% of Total Billed Charges,970.2,90,,776.16,Percent of Total Billed charges,90% of Total Billed Charges,50,1078,
BLOOD PATCH,7610000212,CDM,761,RC,,,Outpatient,,,2176.00,1414.40,,2176,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1653.76,76,,1323.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1958.4,90,,1566.72,Percent of Total Billed Charges,90% of Total Billed Charges,979.2,45,,783.36,Percent of Total Billed Charges,45% of Total Billed Charges,1958.4,90,,1566.72,Percent of Total Billed Charges,90% of Total billed Charges,2176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1414.4,65,,1131.52,Percent of total Billed Charges,65% of Total Billed Charges,959.62,44.1,,767.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,2067.2,95,,1653.76,Percent of Total Billed Charges,95% of Total Billed Charges,2176,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1914.88,88,,1531.904,Percent of Total Billed Charges,88% of Total Billed Charges,1958.4,90,,1566.72,Percent of Total Billed charges,90% of Total Billed Charges,50,2176,
MYELOGRAPHY LUMBAR INJ,7610000213,CDM,761,RC,,,Outpatient,,,3599.15,2339.45,,3599.15,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2735.35,76,,2188.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3599.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3239.24,90,,2591.392,Percent of Total Billed Charges,90% of Total Billed Charges,1619.62,45,,1295.696,Percent of Total Billed Charges,45% of Total Billed Charges,3239.24,90,,2591.392,Percent of Total Billed Charges,90% of Total billed Charges,3599.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3599.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3599.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2339.45,65,,1871.56,Percent of total Billed Charges,65% of Total Billed Charges,1587.23,44.1,,1269.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,3419.19,95,,2735.352,Percent of Total Billed Charges,95% of Total Billed Charges,3599.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3167.25,88,,2533.8,Percent of Total Billed Charges,88% of Total Billed Charges,3239.24,90,,2591.392,Percent of Total Billed charges,90% of Total Billed Charges,50,3599.15,
TRIGEMINAL NERVE INJECTION,7610000214,CDM,761,RC,,,Outpatient,,,700.00,455.00,,700,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,532,76,,425.6,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,700,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,630,90,,504,Percent of Total Billed Charges,90% of Total Billed Charges,315,45,,252,Percent of Total Billed Charges,45% of Total Billed Charges,630,90,,504,Percent of Total Billed Charges,90% of Total billed Charges,700,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,700,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,700,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,455,65,,364,Percent of total Billed Charges,65% of Total Billed Charges,308.7,44.1,,246.96,Percent of Total Billed Charges,44.1% of Total Billed Charges,665,95,,532,Percent of Total Billed Charges,95% of Total Billed Charges,700,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,616,88,,492.8,Percent of Total Billed Charges,88% of Total Billed Charges,630,90,,504,Percent of Total Billed charges,90% of Total Billed Charges,50,700,
XR INJECTION PERIPHERAL NERVE,7610000215,CDM,761,RC,,,Outpatient,,,999.00,649.35,,999,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,759.24,76,,607.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,999,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,899.1,90,,719.28,Percent of Total Billed Charges,90% of Total Billed Charges,449.55,45,,359.64,Percent of Total Billed Charges,45% of Total Billed Charges,899.1,90,,719.28,Percent of Total Billed Charges,90% of Total billed Charges,999,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,999,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,999,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649.35,65,,519.48,Percent of total Billed Charges,65% of Total Billed Charges,440.56,44.1,,352.448,Percent of Total Billed Charges,44.1% of Total Billed Charges,949.05,95,,759.24,Percent of Total Billed Charges,95% of Total Billed Charges,999,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,879.12,88,,703.296,Percent of Total Billed Charges,88% of Total Billed Charges,899.1,90,,719.28,Percent of Total Billed charges,90% of Total Billed Charges,50,999,
Transforaminal C/T each add,7610000216,CDM,761,RC,,,Outpatient,,,2778.79,1806.21,,2778.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2111.88,76,,1689.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2778.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2500.91,90,,2000.728,Percent of Total Billed Charges,90% of Total Billed Charges,1250.46,45,,1000.368,Percent of Total Billed Charges,45% of Total Billed Charges,2500.91,90,,2000.728,Percent of Total Billed Charges,90% of Total billed Charges,2778.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2778.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2778.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1806.21,65,,1444.968,Percent of total Billed Charges,65% of Total Billed Charges,1225.45,44.1,,980.36,Percent of Total Billed Charges,44.1% of Total Billed Charges,2639.85,95,,2111.88,Percent of Total Billed Charges,95% of Total Billed Charges,2778.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2445.34,88,,1956.272,Percent of Total Billed Charges,88% of Total Billed Charges,2500.91,90,,2000.728,Percent of Total Billed charges,90% of Total Billed Charges,50,2778.79,
INJ LMR SAC AD LV,7610000217,CDM,761,RC,,,Outpatient,,,1543.93,1003.55,,1543.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1173.39,76,,938.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1543.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1389.54,90,,1111.632,Percent of Total Billed Charges,90% of Total Billed Charges,694.77,45,,555.816,Percent of Total Billed Charges,45% of Total Billed Charges,1389.54,90,,1111.632,Percent of Total Billed Charges,90% of Total billed Charges,1543.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1543.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1543.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1003.55,65,,802.84,Percent of total Billed Charges,65% of Total Billed Charges,680.87,44.1,,544.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,1466.73,95,,1173.384,Percent of Total Billed Charges,95% of Total Billed Charges,1543.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1358.66,88,,1086.928,Percent of Total Billed Charges,88% of Total Billed Charges,1389.54,90,,1111.632,Percent of Total Billed charges,90% of Total Billed Charges,50,1543.93,
TESI  LUM/SAC UNI,7610000218,CDM,761,RC,,,Outpatient,,,1543.93,1003.55,,1543.93,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1173.39,76,,938.712,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1543.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1389.54,90,,1111.632,Percent of Total Billed Charges,90% of Total Billed Charges,694.77,45,,555.816,Percent of Total Billed Charges,45% of Total Billed Charges,1389.54,90,,1111.632,Percent of Total Billed Charges,90% of Total billed Charges,1543.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1543.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1543.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1003.55,65,,802.84,Percent of total Billed Charges,65% of Total Billed Charges,680.87,44.1,,544.696,Percent of Total Billed Charges,44.1% of Total Billed Charges,1466.73,95,,1173.384,Percent of Total Billed Charges,95% of Total Billed Charges,1543.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1358.66,88,,1086.928,Percent of Total Billed Charges,88% of Total Billed Charges,1389.54,90,,1111.632,Percent of Total Billed charges,90% of Total Billed Charges,50,1543.93,
TPA,7610000219,CDM,761,RC,,,Outpatient,,,1340.64,871.42,,1340.64,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1018.89,76,,815.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1340.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1206.58,90,,965.264,Percent of Total Billed Charges,90% of Total Billed Charges,603.29,45,,482.632,Percent of Total Billed Charges,45% of Total Billed Charges,1206.58,90,,965.264,Percent of Total Billed Charges,90% of Total billed Charges,1340.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1340.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1340.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,871.42,65,,697.136,Percent of total Billed Charges,65% of Total Billed Charges,591.22,44.1,,472.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,1273.61,95,,1018.888,Percent of Total Billed Charges,95% of Total Billed Charges,1340.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1179.76,88,,943.808,Percent of Total Billed Charges,88% of Total Billed Charges,1206.58,90,,965.264,Percent of Total Billed charges,90% of Total Billed Charges,50,1340.64,
DEBRIDEMENT NON-SELECTIVE,7610000221,CDM,761,RC,,,Outpatient,,,294.37,191.34,,294.37,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,223.72,76,,178.976,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,264.93,90,,211.944,Percent of Total Billed Charges,90% of Total Billed Charges,132.47,45,,105.976,Percent of Total Billed Charges,45% of Total Billed Charges,264.93,90,,211.944,Percent of Total Billed Charges,90% of Total billed Charges,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.34,65,,153.072,Percent of total Billed Charges,65% of Total Billed Charges,129.82,44.1,,103.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,279.65,95,,223.72,Percent of Total Billed Charges,95% of Total Billed Charges,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.05,88,,207.24,Percent of Total Billed Charges,88% of Total Billed Charges,264.93,90,,211.944,Percent of Total Billed charges,90% of Total Billed Charges,50,294.37,
APSKSUBALT <25CM HIGH COST,7610000232,CDM,761,RC,,,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4514.74,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,50,5016.38,
APSKSUBALT EA ADL 25 HIGH COST,7610000233,CDM,761,RC,,,Outpatient,,,685.96,445.87,,685.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,521.33,76,,417.064,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,685.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,617.36,90,,493.888,Percent of Total Billed Charges,90% of Total Billed Charges,308.68,45,,246.944,Percent of Total Billed Charges,45% of Total Billed Charges,617.36,90,,493.888,Percent of Total Billed Charges,90% of Total billed Charges,685.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,445.87,65,,356.696,Percent of total Billed Charges,65% of Total Billed Charges,302.51,44.1,,242.008,Percent of Total Billed Charges,44.1% of Total Billed Charges,651.66,95,,521.328,Percent of Total Billed Charges,95% of Total Billed Charges,685.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,603.64,88,,482.912,Percent of Total Billed Charges,88% of Total Billed Charges,617.36,90,,493.888,Percent of Total Billed charges,90% of Total Billed Charges,50,685.96,
APSKSUBFHFG <25CM HIGH COST,7610000234,CDM,761,RC,,,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,4514.74,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,2257.37,45,,1805.896,Percent of Total Billed Charges,45% of Total Billed Charges,4514.74,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,2212.22,44.1,,1769.776,Percent of Total Billed Charges,44.1% of Total Billed Charges,4765.56,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,50,5016.38,
APSKSUBFHFG EA ADL 2 HIGH COST,7610000235,CDM,761,RC,,,Outpatient,,,954.77,620.60,,954.77,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,725.63,76,,580.504,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,954.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,859.29,90,,687.432,Percent of Total Billed Charges,90% of Total Billed Charges,429.65,45,,343.72,Percent of Total Billed Charges,45% of Total Billed Charges,859.29,90,,687.432,Percent of Total Billed Charges,90% of Total billed Charges,954.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,954.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,954.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,620.6,65,,496.48,Percent of total Billed Charges,65% of Total Billed Charges,421.05,44.1,,336.84,Percent of Total Billed Charges,44.1% of Total Billed Charges,907.03,95,,725.624,Percent of Total Billed Charges,95% of Total Billed Charges,954.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,840.2,88,,672.16,Percent of Total Billed Charges,88% of Total Billed Charges,859.29,90,,687.432,Percent of Total Billed charges,90% of Total Billed Charges,50,954.77,
XR CLOSURE DEVICE,7610000236,CDM,761,RC,G0269,HCPCS,Outpatient,,,1403.60,912.34,,1403.6,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1066.74,76,,853.392,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1403.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1263.24,90,,1010.592,Percent of Total Billed Charges,90% of Total Billed Charges,631.62,45,,505.296,Percent of Total Billed Charges,45% of Total Billed Charges,1263.24,90,,1010.592,Percent of Total Billed Charges,90% of Total billed Charges,1403.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1403.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1403.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,912.34,65,,729.872,Percent of total Billed Charges,65% of Total Billed Charges,618.99,44.1,,495.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,1333.42,95,,1066.736,Percent of Total Billed Charges,95% of Total Billed Charges,1403.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1235.17,88,,988.136,Percent of Total Billed Charges,88% of Total Billed Charges,1263.24,90,,1010.592,Percent of Total Billed charges,90% of Total Billed Charges,618.99,1403.6,
SPECIAL PROCEDURE RO,7610000239,CDM,761,RC,,,Outpatient,,,855.54,556.10,,855.54,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,650.21,76,,520.168,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,855.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,769.99,90,,615.992,Percent of Total Billed Charges,90% of Total Billed Charges,384.99,45,,307.992,Percent of Total Billed Charges,45% of Total Billed Charges,769.99,90,,615.992,Percent of Total Billed Charges,90% of Total billed Charges,855.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,855.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,855.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,556.1,65,,444.88,Percent of total Billed Charges,65% of Total Billed Charges,377.29,44.1,,301.832,Percent of Total Billed Charges,44.1% of Total Billed Charges,812.76,95,,650.208,Percent of Total Billed Charges,95% of Total Billed Charges,855.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,752.88,88,,602.304,Percent of Total Billed Charges,88% of Total Billed Charges,769.99,90,,615.992,Percent of Total Billed charges,90% of Total Billed Charges,50,855.54,
INCIS DRAINAGE HEMATOMA SEROMA,7610000240,CDM,761,RC,,,Outpatient,,,2605.52,1693.59,,2605.52,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1980.2,76,,1584.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2605.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2344.97,90,,1875.976,Percent of Total Billed Charges,90% of Total Billed Charges,1172.48,45,,937.984,Percent of Total Billed Charges,45% of Total Billed Charges,2344.97,90,,1875.976,Percent of Total Billed Charges,90% of Total billed Charges,2605.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1693.59,65,,1354.872,Percent of total Billed Charges,65% of Total Billed Charges,1149.03,44.1,,919.224,Percent of Total Billed Charges,44.1% of Total Billed Charges,2475.24,95,,1980.192,Percent of Total Billed Charges,95% of Total Billed Charges,2605.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2292.86,88,,1834.288,Percent of Total Billed Charges,88% of Total Billed Charges,2344.97,90,,1875.976,Percent of Total Billed charges,90% of Total Billed Charges,50,2605.52,
DECLOT IMPLANT VENOUS DEVICE,7610000243,CDM,761,RC,,,Outpatient,,,739.00,480.35,,739,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,561.64,76,,449.312,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,739,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,665.1,90,,532.08,Percent of Total Billed Charges,90% of Total Billed Charges,332.55,45,,266.04,Percent of Total Billed Charges,45% of Total Billed Charges,665.1,90,,532.08,Percent of Total Billed Charges,90% of Total billed Charges,739,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,739,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,739,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.35,65,,384.28,Percent of total Billed Charges,65% of Total Billed Charges,325.9,44.1,,260.72,Percent of Total Billed Charges,44.1% of Total Billed Charges,702.05,95,,561.64,Percent of Total Billed Charges,95% of Total Billed Charges,739,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,650.32,88,,520.256,Percent of Total Billed Charges,88% of Total Billed Charges,665.1,90,,532.08,Percent of Total Billed charges,90% of Total Billed Charges,50,739,
FLUSH IMPLANTED VENOUS DEVICE,7610000244,CDM,761,RC,,,Outpatient,,,270.00,175.50,,270,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,205.2,76,,164.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,243,90,,194.4,Percent of Total Billed Charges,90% of Total Billed Charges,121.5,45,,97.2,Percent of Total Billed Charges,45% of Total Billed Charges,243,90,,194.4,Percent of Total Billed Charges,90% of Total billed Charges,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.5,65,,140.4,Percent of total Billed Charges,65% of Total Billed Charges,119.07,44.1,,95.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,256.5,95,,205.2,Percent of Total Billed Charges,95% of Total Billed Charges,270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.6,88,,190.08,Percent of Total Billed Charges,88% of Total Billed Charges,243,90,,194.4,Percent of Total Billed charges,90% of Total Billed Charges,50,270,
ARTHROGRAM HIP INJ WO ANESTH,7610000245,CDM,761,RC,,,Outpatient,,,437.69,284.50,,437.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,332.64,76,,266.112,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,393.92,90,,315.136,Percent of Total Billed Charges,90% of Total Billed Charges,196.96,45,,157.568,Percent of Total Billed Charges,45% of Total Billed Charges,393.92,90,,315.136,Percent of Total Billed Charges,90% of Total billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.5,65,,227.6,Percent of total Billed Charges,65% of Total Billed Charges,193.02,44.1,,154.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,415.81,95,,332.648,Percent of Total Billed Charges,95% of Total Billed Charges,437.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.17,88,,308.136,Percent of Total Billed Charges,88% of Total Billed Charges,393.92,90,,315.136,Percent of Total Billed charges,90% of Total Billed Charges,50,437.69,
APSKSUBALT <25CM,7610000246,CDM,510,RC,,,Outpatient,,,5016.38,3260.65,,5016.38,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3812.45,76,,3049.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3611.79,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,3762.29,75,,3009.832,Percent of Total Billed charges,75% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3611.79,72,,2889.432,Percent of Total Billed Charges,72% of Total Billed Charges,3009.83,60,,2407.864,Percent of Total Billed Charges,60% of Total Billed Charges,4514.74,90,,3611.792,Percent of Total Billed Charges,90% of Total Billed Charges,284.72,100,,,Case Rate,Pays based on per visit rate,4514.74,90,,3611.792,Percent of Total Billed Charges,90% of Total billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3260.65,65,,2608.52,Percent of total Billed Charges,65% of Total Billed Charges,279.03,100,,,Fee Schedule,Pays based on per visit rate,4765.56,95,,3812.448,Percent of Total Billed Charges,95% of Total Billed Charges,5016.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4414.41,88,,3531.528,Percent of Total Billed Charges,88% of Total Billed Charges,4514.74,90,,3611.792,Percent of Total Billed charges,90% of Total Billed Charges,279.03,5016.38,
ARTHROGRAM ANKLE LT,7610000247,CDM,761,RC,,,Outpatient,,,916.48,595.71,,916.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,696.52,76,,557.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,824.83,90,,659.864,Percent of Total Billed Charges,90% of Total Billed Charges,412.42,45,,329.936,Percent of Total Billed Charges,45% of Total Billed Charges,824.83,90,,659.864,Percent of Total Billed Charges,90% of Total billed Charges,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,595.71,65,,476.568,Percent of total Billed Charges,65% of Total Billed Charges,404.17,44.1,,323.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,870.66,95,,696.528,Percent of Total Billed Charges,95% of Total Billed Charges,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,806.5,88,,645.2,Percent of Total Billed Charges,88% of Total Billed Charges,824.83,90,,659.864,Percent of Total Billed charges,90% of Total Billed Charges,50,916.48,
ARTHROGRAM ANKLE RT,7610000248,CDM,761,RC,,,Outpatient,,,916.48,595.71,,916.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,696.52,76,,557.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,824.83,90,,659.864,Percent of Total Billed Charges,90% of Total Billed Charges,412.42,45,,329.936,Percent of Total Billed Charges,45% of Total Billed Charges,824.83,90,,659.864,Percent of Total Billed Charges,90% of Total billed Charges,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,595.71,65,,476.568,Percent of total Billed Charges,65% of Total Billed Charges,404.17,44.1,,323.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,870.66,95,,696.528,Percent of Total Billed Charges,95% of Total Billed Charges,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,806.5,88,,645.2,Percent of Total Billed Charges,88% of Total Billed Charges,824.83,90,,659.864,Percent of Total Billed charges,90% of Total Billed Charges,50,916.48,
ARTHROGRAM ELBOW LT,7610000249,CDM,761,RC,,,Outpatient,,,916.48,595.71,,916.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,696.52,76,,557.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,824.83,90,,659.864,Percent of Total Billed Charges,90% of Total Billed Charges,412.42,45,,329.936,Percent of Total Billed Charges,45% of Total Billed Charges,824.83,90,,659.864,Percent of Total Billed Charges,90% of Total billed Charges,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,595.71,65,,476.568,Percent of total Billed Charges,65% of Total Billed Charges,404.17,44.1,,323.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,870.66,95,,696.528,Percent of Total Billed Charges,95% of Total Billed Charges,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,806.5,88,,645.2,Percent of Total Billed Charges,88% of Total Billed Charges,824.83,90,,659.864,Percent of Total Billed charges,90% of Total Billed Charges,50,916.48,
ARTHROGRAM ELBOW RT,7610000250,CDM,761,RC,,,Outpatient,,,916.48,595.71,,916.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,696.52,76,,557.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,824.83,90,,659.864,Percent of Total Billed Charges,90% of Total Billed Charges,412.42,45,,329.936,Percent of Total Billed Charges,45% of Total Billed Charges,824.83,90,,659.864,Percent of Total Billed Charges,90% of Total billed Charges,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,595.71,65,,476.568,Percent of total Billed Charges,65% of Total Billed Charges,404.17,44.1,,323.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,870.66,95,,696.528,Percent of Total Billed Charges,95% of Total Billed Charges,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,806.5,88,,645.2,Percent of Total Billed Charges,88% of Total Billed Charges,824.83,90,,659.864,Percent of Total Billed charges,90% of Total Billed Charges,50,916.48,
ARTHROGRAM WRIST LT,7610000251,CDM,761,RC,,,Outpatient,,,916.48,595.71,,916.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,696.52,76,,557.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,824.83,90,,659.864,Percent of Total Billed Charges,90% of Total Billed Charges,412.42,45,,329.936,Percent of Total Billed Charges,45% of Total Billed Charges,824.83,90,,659.864,Percent of Total Billed Charges,90% of Total billed Charges,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,595.71,65,,476.568,Percent of total Billed Charges,65% of Total Billed Charges,404.17,44.1,,323.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,870.66,95,,696.528,Percent of Total Billed Charges,95% of Total Billed Charges,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,806.5,88,,645.2,Percent of Total Billed Charges,88% of Total Billed Charges,824.83,90,,659.864,Percent of Total Billed charges,90% of Total Billed Charges,50,916.48,
ARTHROGRAM WRIST RT,7610000252,CDM,761,RC,,,Outpatient,,,916.48,595.71,,916.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,696.52,76,,557.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,824.83,90,,659.864,Percent of Total Billed Charges,90% of Total Billed Charges,412.42,45,,329.936,Percent of Total Billed Charges,45% of Total Billed Charges,824.83,90,,659.864,Percent of Total Billed Charges,90% of Total billed Charges,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,595.71,65,,476.568,Percent of total Billed Charges,65% of Total Billed Charges,404.17,44.1,,323.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,870.66,95,,696.528,Percent of Total Billed Charges,95% of Total Billed Charges,916.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,806.5,88,,645.2,Percent of Total Billed Charges,88% of Total Billed Charges,824.83,90,,659.864,Percent of Total Billed charges,90% of Total Billed Charges,50,916.48,
MYELOGRAM SPINE TOTAL,7610000253,CDM,761,RC,,,Outpatient,,,1634.03,1062.12,,1634.03,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1241.86,76,,993.488,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1634.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1470.63,90,,1176.504,Percent of Total Billed Charges,90% of Total Billed Charges,735.31,45,,588.248,Percent of Total Billed Charges,45% of Total Billed Charges,1470.63,90,,1176.504,Percent of Total Billed Charges,90% of Total billed Charges,1634.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1634.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1634.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1062.12,65,,849.696,Percent of total Billed Charges,65% of Total Billed Charges,720.61,44.1,,576.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,1552.33,95,,1241.864,Percent of Total Billed Charges,95% of Total Billed Charges,1634.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1437.95,88,,1150.36,Percent of Total Billed Charges,88% of Total Billed Charges,1470.63,90,,1176.504,Percent of Total Billed charges,90% of Total Billed Charges,50,1634.03,
NEPHROSTOMY VIA CATH,7610000254,CDM,761,RC,,,Outpatient,,,7244.83,4709.14,,7244.83,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5506.07,76,,4404.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,7244.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,6520.35,90,,5216.28,Percent of Total Billed Charges,90% of Total Billed Charges,3260.17,45,,2608.136,Percent of Total Billed Charges,45% of Total Billed Charges,6520.35,90,,5216.28,Percent of Total Billed Charges,90% of Total billed Charges,7244.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7244.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7244.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4709.14,65,,3767.312,Percent of total Billed Charges,65% of Total Billed Charges,3194.97,44.1,,2555.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,6882.59,95,,5506.072,Percent of Total Billed Charges,95% of Total Billed Charges,7244.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6375.45,88,,5100.36,Percent of Total Billed Charges,88% of Total Billed Charges,6520.35,90,,5216.28,Percent of Total Billed charges,90% of Total Billed Charges,50,7244.83,
PYELOGRAM ANTEGRADE,7610000255,CDM,761,RC,,,Outpatient,,,1335.75,868.24,,1335.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1015.17,76,,812.136,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1335.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1202.18,90,,961.744,Percent of Total Billed Charges,90% of Total Billed Charges,601.09,45,,480.872,Percent of Total Billed Charges,45% of Total Billed Charges,1202.18,90,,961.744,Percent of Total Billed Charges,90% of Total billed Charges,1335.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1335.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1335.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,868.24,65,,694.592,Percent of total Billed Charges,65% of Total Billed Charges,589.07,44.1,,471.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,1268.96,95,,1015.168,Percent of Total Billed Charges,95% of Total Billed Charges,1335.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1175.46,88,,940.368,Percent of Total Billed Charges,88% of Total Billed Charges,1202.18,90,,961.744,Percent of Total Billed charges,90% of Total Billed Charges,50,1335.75,
"TUBE PL CECO,COLON,OTH PERC",7610000256,CDM,761,RC,,,Outpatient,,,2410.23,1566.65,,2410.23,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1831.77,76,,1465.416,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2410.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2169.21,90,,1735.368,Percent of Total Billed Charges,90% of Total Billed Charges,1084.6,45,,867.68,Percent of Total Billed Charges,45% of Total Billed Charges,2169.21,90,,1735.368,Percent of Total Billed Charges,90% of Total billed Charges,2410.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2410.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2410.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1566.65,65,,1253.32,Percent of total Billed Charges,65% of Total Billed Charges,1062.91,44.1,,850.328,Percent of Total Billed Charges,44.1% of Total Billed Charges,2289.72,95,,1831.776,Percent of Total Billed Charges,95% of Total Billed Charges,2410.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2121,88,,1696.8,Percent of Total Billed Charges,88% of Total Billed Charges,2169.21,90,,1735.368,Percent of Total Billed charges,90% of Total Billed Charges,50,2410.23,
INJ ANST AGNT GRT OCCPTL NRV,7610000260,CDM,761,RC,,,Outpatient,,,795.55,517.11,,795.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,604.62,76,,483.696,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,795.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,716,90,,572.8,Percent of Total Billed Charges,90% of Total Billed Charges,358,45,,286.4,Percent of Total Billed Charges,45% of Total Billed Charges,716,90,,572.8,Percent of Total Billed Charges,90% of Total billed Charges,795.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,795.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,795.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,517.11,65,,413.688,Percent of total Billed Charges,65% of Total Billed Charges,350.84,44.1,,280.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,755.77,95,,604.616,Percent of Total Billed Charges,95% of Total Billed Charges,795.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,700.08,88,,560.064,Percent of Total Billed Charges,88% of Total Billed Charges,716,90,,572.8,Percent of Total Billed charges,90% of Total Billed Charges,50,795.55,
REMOVAL EXT FIX SYSTEM (ANESTH,7610000261,CDM,761,RC,,,Outpatient,,,3740.20,2431.13,,3740.2,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2842.55,76,,2274.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3740.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3366.18,90,,2692.944,Percent of Total Billed Charges,90% of Total Billed Charges,1683.09,45,,1346.472,Percent of Total Billed Charges,45% of Total Billed Charges,3366.18,90,,2692.944,Percent of Total Billed Charges,90% of Total billed Charges,3740.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3740.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3740.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2431.13,65,,1944.904,Percent of total Billed Charges,65% of Total Billed Charges,1649.43,44.1,,1319.544,Percent of Total Billed Charges,44.1% of Total Billed Charges,3553.19,95,,2842.552,Percent of Total Billed Charges,95% of Total Billed Charges,3740.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3291.38,88,,2633.104,Percent of Total Billed Charges,88% of Total Billed Charges,3366.18,90,,2692.944,Percent of Total Billed charges,90% of Total Billed Charges,50,3740.2,
ARTHROGRAM ELBOW INJECTION,7610000300,CDM,361,RC,,,Outpatient,,,710.00,461.50,,710,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,539.6,76,,431.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,511.2,72,,408.96,Percent of Total Billed Charges,72% of Total Billed Charges,532.5,75,,426,Percent of Total Billed charges,75% of Total Billed Charges,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511.2,72,,408.96,Percent of Total Billed Charges,72% of Total Billed Charges,426,60,,340.8,Percent of Total Billed Charges,60% of Total Billed Charges,639,90,,511.2,Percent of Total Billed Charges,90% of Total Billed Charges,319.5,45,,255.6,Percent of Total Billed Charges,45% of Total Billed Charges,639,90,,511.2,Percent of Total Billed Charges,90% of Total billed Charges,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,461.5,65,,369.2,Percent of total Billed Charges,65% of Total Billed Charges,313.11,44.1,,250.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,674.5,95,,539.6,Percent of Total Billed Charges,95% of Total Billed Charges,710,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,624.8,88,,499.84,Percent of Total Billed Charges,88% of Total Billed Charges,639,90,,511.2,Percent of Total Billed charges,90% of Total Billed Charges,313.11,710,
INTERLAMINAR EPIDURAL INJ C/T,7610000301,CDM,761,RC,,,Outpatient,,,2260.13,1469.08,,2260.13,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1717.7,76,,1374.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2260.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2034.12,90,,1627.296,Percent of Total Billed Charges,90% of Total Billed Charges,1017.06,45,,813.648,Percent of Total Billed Charges,45% of Total Billed Charges,2034.12,90,,1627.296,Percent of Total Billed Charges,90% of Total billed Charges,2260.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2260.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2260.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1469.08,65,,1175.264,Percent of total Billed Charges,65% of Total Billed Charges,996.72,44.1,,797.376,Percent of Total Billed Charges,44.1% of Total Billed Charges,2147.12,95,,1717.696,Percent of Total Billed Charges,95% of Total Billed Charges,2260.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1988.91,88,,1591.128,Percent of Total Billed Charges,88% of Total Billed Charges,2034.12,90,,1627.296,Percent of Total Billed charges,90% of Total Billed Charges,50,2260.13,
INTERLAMINAR EPIDURAL INJ L/S,7610000302,CDM,361,RC,,,Outpatient,,,2113.49,1373.77,,2113.49,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1606.25,76,,1285,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1521.71,72,,1217.368,Percent of Total Billed Charges,72% of Total Billed Charges,1585.12,75,,1268.096,Percent of Total Billed charges,75% of Total Billed Charges,2113.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1521.71,72,,1217.368,Percent of Total Billed Charges,72% of Total Billed Charges,1268.09,60,,1014.472,Percent of Total Billed Charges,60% of Total Billed Charges,1902.14,90,,1521.712,Percent of Total Billed Charges,90% of Total Billed Charges,951.07,45,,760.856,Percent of Total Billed Charges,45% of Total Billed Charges,1902.14,90,,1521.712,Percent of Total Billed Charges,90% of Total billed Charges,2113.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2113.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2113.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1373.77,65,,1099.016,Percent of total Billed Charges,65% of Total Billed Charges,932.05,44.1,,745.64,Percent of Total Billed Charges,44.1% of Total Billed Charges,2007.82,95,,1606.256,Percent of Total Billed Charges,95% of Total Billed Charges,2113.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1859.87,88,,1487.896,Percent of Total Billed Charges,88% of Total Billed Charges,1902.14,90,,1521.712,Percent of Total Billed charges,90% of Total Billed Charges,932.05,2113.49,
INSERT TUN IP CATH PERC W/IMAG,7610000303,CDM,761,RC,,,Outpatient,,,3051.00,1983.15,,3051,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2318.76,76,,1855.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3051,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2745.9,90,,2196.72,Percent of Total Billed Charges,90% of Total Billed Charges,1372.95,45,,1098.36,Percent of Total Billed Charges,45% of Total Billed Charges,2745.9,90,,2196.72,Percent of Total Billed Charges,90% of Total billed Charges,3051,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3051,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3051,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1983.15,65,,1586.52,Percent of total Billed Charges,65% of Total Billed Charges,1345.49,44.1,,1076.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,2898.45,95,,2318.76,Percent of Total Billed Charges,95% of Total Billed Charges,3051,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2684.88,88,,2147.904,Percent of Total Billed Charges,88% of Total Billed Charges,2745.9,90,,2196.72,Percent of Total Billed charges,90% of Total Billed Charges,50,3051,
IR REMOVAL BILIARY DRAIN CATH,7610000304,CDM,761,RC,,,Outpatient,,,1886.50,1226.23,,1886.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1433.74,76,,1146.992,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1886.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1697.85,90,,1358.28,Percent of Total Billed Charges,90% of Total Billed Charges,848.93,45,,679.144,Percent of Total Billed Charges,45% of Total Billed Charges,1697.85,90,,1358.28,Percent of Total Billed Charges,90% of Total billed Charges,1886.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1886.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1886.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1226.23,65,,980.984,Percent of total Billed Charges,65% of Total Billed Charges,831.95,44.1,,665.56,Percent of Total Billed Charges,44.1% of Total Billed Charges,1792.18,95,,1433.744,Percent of Total Billed Charges,95% of Total Billed Charges,1886.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1660.12,88,,1328.096,Percent of Total Billed Charges,88% of Total Billed Charges,1697.85,90,,1358.28,Percent of Total Billed charges,90% of Total Billed Charges,50,1886.5,
SINUS TRACT INJ (SINOGRAM),7610000305,CDM,761,RC,,,Outpatient,,,800.00,520.00,,800,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,608,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,720,90,,576,Percent of Total Billed Charges,90% of Total Billed Charges,360,45,,288,Percent of Total Billed Charges,45% of Total Billed Charges,720,90,,576,Percent of Total Billed Charges,90% of Total billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,520,65,,416,Percent of total Billed Charges,65% of Total Billed Charges,352.8,44.1,,282.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,760,95,,608,Percent of Total Billed Charges,95% of Total Billed Charges,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,704,88,,563.2,Percent of Total Billed Charges,88% of Total Billed Charges,720,90,,576,Percent of Total Billed charges,90% of Total Billed Charges,50,800,
ARTERIAL CATH-MONITOR PERC,7610000306,CDM,761,RC,,,Outpatient,,,333.00,216.45,,333,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,253.08,76,,202.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,333,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,299.7,90,,239.76,Percent of Total Billed Charges,90% of Total Billed Charges,149.85,45,,119.88,Percent of Total Billed Charges,45% of Total Billed Charges,299.7,90,,239.76,Percent of Total Billed Charges,90% of Total billed Charges,333,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.45,65,,173.16,Percent of total Billed Charges,65% of Total Billed Charges,146.85,44.1,,117.48,Percent of Total Billed Charges,44.1% of Total Billed Charges,316.35,95,,253.08,Percent of Total Billed Charges,95% of Total Billed Charges,333,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.04,88,,234.432,Percent of Total Billed Charges,88% of Total Billed Charges,299.7,90,,239.76,Percent of Total Billed charges,90% of Total Billed Charges,50,333,
IR ANTE NEPHROSTOGM ING EXISTG,7610000307,CDM,761,RC,,,Outpatient,,,1270.00,825.50,,1270,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,965.2,76,,772.16,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1143,90,,914.4,Percent of Total Billed Charges,90% of Total Billed Charges,571.5,45,,457.2,Percent of Total Billed Charges,45% of Total Billed Charges,1143,90,,914.4,Percent of Total Billed Charges,90% of Total billed Charges,1270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,825.5,65,,660.4,Percent of total Billed Charges,65% of Total Billed Charges,560.07,44.1,,448.056,Percent of Total Billed Charges,44.1% of Total Billed Charges,1206.5,95,,965.2,Percent of Total Billed Charges,95% of Total Billed Charges,1270,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1117.6,88,,894.08,Percent of Total Billed Charges,88% of Total Billed Charges,1143,90,,914.4,Percent of Total Billed charges,90% of Total Billed Charges,50,1270,
Liver Biopsy Percutaneous,7610000308,CDM,761,RC,,,Outpatient,,,3294.78,2141.61,,3294.78,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2504.03,76,,2003.224,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3294.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,2965.3,90,,2372.24,Percent of Total Billed Charges,90% of Total Billed Charges,1482.65,45,,1186.12,Percent of Total Billed Charges,45% of Total Billed Charges,2965.3,90,,2372.24,Percent of Total Billed Charges,90% of Total billed Charges,3294.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3294.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3294.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2141.61,65,,1713.288,Percent of total Billed Charges,65% of Total Billed Charges,1453,44.1,,1162.4,Percent of Total Billed Charges,44.1% of Total Billed Charges,3130.04,95,,2504.032,Percent of Total Billed Charges,95% of Total Billed Charges,3294.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2899.41,88,,2319.528,Percent of Total Billed Charges,88% of Total Billed Charges,2965.3,90,,2372.24,Percent of Total Billed charges,90% of Total Billed Charges,50,3294.78,
MECH RMVL INTRA OBSTRUC CV DEV,7610000309,CDM,761,RC,,,Outpatient,,,3375.25,2193.91,,3375.25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2565.19,76,,2052.152,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3037.73,90,,2430.184,Percent of Total Billed Charges,90% of Total Billed Charges,1518.86,45,,1215.088,Percent of Total Billed Charges,45% of Total Billed Charges,3037.73,90,,2430.184,Percent of Total Billed Charges,90% of Total billed Charges,3375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2193.91,65,,1755.128,Percent of total Billed Charges,65% of Total Billed Charges,1488.49,44.1,,1190.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,3206.49,95,,2565.192,Percent of Total Billed Charges,95% of Total Billed Charges,3375.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2970.22,88,,2376.176,Percent of Total Billed Charges,88% of Total Billed Charges,3037.73,90,,2430.184,Percent of Total Billed charges,90% of Total Billed Charges,50,3375.25,
BLN DILAT BILIARY DUCT ADD RSI,7610000311,CDM,761,RC,,,Outpatient,,,288.00,187.20,,288,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,218.88,76,,175.104,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,288,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,259.2,90,,207.36,Percent of Total Billed Charges,90% of Total Billed Charges,129.6,45,,103.68,Percent of Total Billed Charges,45% of Total Billed Charges,259.2,90,,207.36,Percent of Total Billed Charges,90% of Total billed Charges,288,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.2,65,,149.76,Percent of total Billed Charges,65% of Total Billed Charges,127.01,44.1,,101.608,Percent of Total Billed Charges,44.1% of Total Billed Charges,273.6,95,,218.88,Percent of Total Billed Charges,95% of Total Billed Charges,288,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,253.44,88,,202.752,Percent of Total Billed Charges,88% of Total Billed Charges,259.2,90,,207.36,Percent of Total Billed charges,90% of Total Billed Charges,50,288,
BILIARY DRG CATH REMOVAL RSI,7610000312,CDM,761,RC,,,Outpatient,,,1943.35,1263.18,,1943.35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1476.95,76,,1181.56,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1943.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1749.02,90,,1399.216,Percent of Total Billed Charges,90% of Total Billed Charges,874.51,45,,699.608,Percent of Total Billed Charges,45% of Total Billed Charges,1749.02,90,,1399.216,Percent of Total Billed Charges,90% of Total billed Charges,1943.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1943.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1943.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1263.18,65,,1010.544,Percent of total Billed Charges,65% of Total Billed Charges,857.02,44.1,,685.616,Percent of Total Billed Charges,44.1% of Total Billed Charges,1846.18,95,,1476.944,Percent of Total Billed Charges,95% of Total Billed Charges,1943.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1710.15,88,,1368.12,Percent of Total Billed Charges,88% of Total Billed Charges,1749.02,90,,1399.216,Percent of Total Billed charges,90% of Total Billed Charges,50,1943.35,
BILE DUCT STNT INS NEW ACCES,7610000313,CDM,761,RC,,,Outpatient,,,12146.95,7895.52,,12146.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9231.68,76,,7385.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,12146.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,10932.26,90,,8745.808,Percent of Total Billed Charges,90% of Total Billed Charges,5466.13,45,,4372.904,Percent of Total Billed Charges,45% of Total Billed Charges,10932.26,90,,8745.808,Percent of Total Billed Charges,90% of Total billed Charges,12146.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12146.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12146.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7895.52,65,,6316.416,Percent of total Billed Charges,65% of Total Billed Charges,5356.8,44.1,,4285.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,11539.6,95,,9231.68,Percent of Total Billed Charges,95% of Total Billed Charges,12146.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10689.32,88,,8551.456,Percent of Total Billed Charges,88% of Total Billed Charges,10932.26,90,,8745.808,Percent of Total Billed charges,90% of Total Billed Charges,50,12146.95,
BILIARY DRG CATH INS RSI EXT,7610000314,CDM,761,RC,,,Outpatient,,,7743.00,5032.95,,7743,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5884.68,76,,4707.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,7743,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,6968.7,90,,5574.96,Percent of Total Billed Charges,90% of Total Billed Charges,3484.35,45,,2787.48,Percent of Total Billed Charges,45% of Total Billed Charges,6968.7,90,,5574.96,Percent of Total Billed Charges,90% of Total billed Charges,7743,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7743,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7743,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5032.95,65,,4026.36,Percent of total Billed Charges,65% of Total Billed Charges,3414.66,44.1,,2731.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,7355.85,95,,5884.68,Percent of Total Billed Charges,95% of Total Billed Charges,7743,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6813.84,88,,5451.072,Percent of Total Billed Charges,88% of Total Billed Charges,6968.7,90,,5574.96,Percent of Total Billed charges,90% of Total Billed Charges,50,7743,
BILE DUCT STNT INS SAME ACCESS,7610000315,CDM,761,RC,,,Outpatient,,,12146.95,7895.52,,12146.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9231.68,76,,7385.344,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,12146.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,10932.26,90,,8745.808,Percent of Total Billed Charges,90% of Total Billed Charges,5466.13,45,,4372.904,Percent of Total Billed Charges,45% of Total Billed Charges,10932.26,90,,8745.808,Percent of Total Billed Charges,90% of Total billed Charges,12146.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12146.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12146.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7895.52,65,,6316.416,Percent of total Billed Charges,65% of Total Billed Charges,5356.8,44.1,,4285.44,Percent of Total Billed Charges,44.1% of Total Billed Charges,11539.6,95,,9231.68,Percent of Total Billed Charges,95% of Total Billed Charges,12146.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10689.32,88,,8551.456,Percent of Total Billed Charges,88% of Total Billed Charges,10932.26,90,,8745.808,Percent of Total Billed charges,90% of Total Billed Charges,50,12146.95,
Lumbar Puncture w/imaging,7610000316,CDM,761,RC,,,Outpatient,,,1448.00,941.20,,1448,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1100.48,76,,880.384,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1448,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1303.2,90,,1042.56,Percent of Total Billed Charges,90% of Total Billed Charges,651.6,45,,521.28,Percent of Total Billed Charges,45% of Total Billed Charges,1303.2,90,,1042.56,Percent of Total Billed Charges,90% of Total billed Charges,1448,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1448,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1448,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,941.2,65,,752.96,Percent of total Billed Charges,65% of Total Billed Charges,638.57,44.1,,510.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,1375.6,95,,1100.48,Percent of Total Billed Charges,95% of Total Billed Charges,1448,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1274.24,88,,1019.392,Percent of Total Billed Charges,88% of Total Billed Charges,1303.2,90,,1042.56,Percent of Total Billed charges,90% of Total Billed Charges,50,1448,
Tunnel PICC/Peripheral Insert,7610000317,CDM,761,RC,,,Outpatient,,,6537.00,4249.05,,6537,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4968.12,76,,3974.496,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,6537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,5883.3,90,,4706.64,Percent of Total Billed Charges,90% of Total Billed Charges,2941.65,45,,2353.32,Percent of Total Billed Charges,45% of Total Billed Charges,5883.3,90,,4706.64,Percent of Total Billed Charges,90% of Total billed Charges,6537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4249.05,65,,3399.24,Percent of total Billed Charges,65% of Total Billed Charges,2882.82,44.1,,2306.256,Percent of Total Billed Charges,44.1% of Total Billed Charges,6210.15,95,,4968.12,Percent of Total Billed Charges,95% of Total Billed Charges,6537,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5752.56,88,,4602.048,Percent of Total Billed Charges,88% of Total Billed Charges,5883.3,90,,4706.64,Percent of Total Billed charges,90% of Total Billed Charges,50,6537,
Skin Biopsy Single Lesion,7610000318,CDM,761,RC,,,Outpatient,,,1260.30,819.20,,1260.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,957.83,76,,766.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1260.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1134.27,90,,907.416,Percent of Total Billed Charges,90% of Total Billed Charges,567.14,45,,453.712,Percent of Total Billed Charges,45% of Total Billed Charges,1134.27,90,,907.416,Percent of Total Billed Charges,90% of Total billed Charges,1260.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1260.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1260.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,819.2,65,,655.36,Percent of total Billed Charges,65% of Total Billed Charges,555.79,44.1,,444.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,1197.29,95,,957.832,Percent of Total Billed Charges,95% of Total Billed Charges,1260.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1109.06,88,,887.248,Percent of Total Billed Charges,88% of Total Billed Charges,1134.27,90,,907.416,Percent of Total Billed charges,90% of Total Billed Charges,50,1260.3,
Skin Biopsy Addl Lesions,7610000319,CDM,761,RC,,,Outpatient,,,1260.30,819.20,,1260.3,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,957.83,76,,766.264,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1260.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1134.27,90,,907.416,Percent of Total Billed Charges,90% of Total Billed Charges,567.14,45,,453.712,Percent of Total Billed Charges,45% of Total Billed Charges,1134.27,90,,907.416,Percent of Total Billed Charges,90% of Total billed Charges,1260.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1260.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1260.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,819.2,65,,655.36,Percent of total Billed Charges,65% of Total Billed Charges,555.79,44.1,,444.632,Percent of Total Billed Charges,44.1% of Total Billed Charges,1197.29,95,,957.832,Percent of Total Billed Charges,95% of Total Billed Charges,1260.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1109.06,88,,887.248,Percent of Total Billed Charges,88% of Total Billed Charges,1134.27,90,,907.416,Percent of Total Billed charges,90% of Total Billed Charges,50,1260.3,
Transvers Abdomin plane block,7610000320,CDM,761,RC,,,Outpatient,,,1871.65,1216.57,,1871.65,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1422.45,76,,1137.96,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1871.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1684.49,90,,1347.592,Percent of Total Billed Charges,90% of Total Billed Charges,842.24,45,,673.792,Percent of Total Billed Charges,45% of Total Billed Charges,1684.49,90,,1347.592,Percent of Total Billed Charges,90% of Total billed Charges,1871.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1871.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1871.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1216.57,65,,973.256,Percent of total Billed Charges,65% of Total Billed Charges,825.4,44.1,,660.32,Percent of Total Billed Charges,44.1% of Total Billed Charges,1778.07,95,,1422.456,Percent of Total Billed Charges,95% of Total Billed Charges,1871.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1647.05,88,,1317.64,Percent of Total Billed Charges,88% of Total Billed Charges,1684.49,90,,1347.592,Percent of Total Billed charges,90% of Total Billed Charges,50,1871.65,
Incision/Remv FB SQ Complicatd,7610000321,CDM,761,RC,,,Outpatient,,,3383.00,2198.95,,3383,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2571.08,76,,2056.864,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3383,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3044.7,90,,2435.76,Percent of Total Billed Charges,90% of Total Billed Charges,1522.35,45,,1217.88,Percent of Total Billed Charges,45% of Total Billed Charges,3044.7,90,,2435.76,Percent of Total Billed Charges,90% of Total billed Charges,3383,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3383,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3383,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2198.95,65,,1759.16,Percent of total Billed Charges,65% of Total Billed Charges,1491.9,44.1,,1193.52,Percent of Total Billed Charges,44.1% of Total Billed Charges,3213.85,95,,2571.08,Percent of Total Billed Charges,95% of Total Billed Charges,3383,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2977.04,88,,2381.632,Percent of Total Billed Charges,88% of Total Billed Charges,3044.7,90,,2435.76,Percent of Total Billed charges,90% of Total Billed Charges,50,3383,
Cholangiogram inj w/imaging NA,7610000322,CDM,761,RC,,,Outpatient,,,7654.18,4975.22,,7654.18,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5817.18,76,,4653.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,7654.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,6888.76,90,,5511.008,Percent of Total Billed Charges,90% of Total Billed Charges,3444.38,45,,2755.504,Percent of Total Billed Charges,45% of Total Billed Charges,6888.76,90,,5511.008,Percent of Total Billed Charges,90% of Total billed Charges,7654.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7654.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7654.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4975.22,65,,3980.176,Percent of total Billed Charges,65% of Total Billed Charges,3375.49,44.1,,2700.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,7271.47,95,,5817.176,Percent of Total Billed Charges,95% of Total Billed Charges,7654.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6735.68,88,,5388.544,Percent of Total Billed Charges,88% of Total Billed Charges,6888.76,90,,5511.008,Percent of Total Billed charges,90% of Total Billed Charges,50,7654.18,
Breast Cyst Drainage,7610000323,CDM,761,RC,,,Outpatient,,,3517.50,2286.38,,3517.5,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2673.3,76,,2138.64,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3517.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3165.75,90,,2532.6,Percent of Total Billed Charges,90% of Total Billed Charges,1582.88,45,,1266.304,Percent of Total Billed Charges,45% of Total Billed Charges,3165.75,90,,2532.6,Percent of Total Billed Charges,90% of Total billed Charges,3517.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3517.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3517.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2286.38,65,,1829.104,Percent of total Billed Charges,65% of Total Billed Charges,1551.22,44.1,,1240.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,3341.63,95,,2673.304,Percent of Total Billed Charges,95% of Total Billed Charges,3517.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3095.4,88,,2476.32,Percent of Total Billed Charges,88% of Total Billed Charges,3165.75,90,,2532.6,Percent of Total Billed charges,90% of Total Billed Charges,50,3517.5,
BIOPSY VULVA OR PERINEUM 1 LS,7610000324,CDM,761,RC,,,Outpatient,,,1529.80,994.37,,1529.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1162.65,76,,930.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1529.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1376.82,90,,1101.456,Percent of Total Billed Charges,90% of Total Billed Charges,688.41,45,,550.728,Percent of Total Billed Charges,45% of Total Billed Charges,1376.82,90,,1101.456,Percent of Total Billed Charges,90% of Total billed Charges,1529.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1529.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1529.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.37,65,,795.496,Percent of total Billed Charges,65% of Total Billed Charges,674.64,44.1,,539.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1453.31,95,,1162.648,Percent of Total Billed Charges,95% of Total Billed Charges,1529.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1346.22,88,,1076.976,Percent of Total Billed Charges,88% of Total Billed Charges,1376.82,90,,1101.456,Percent of Total Billed charges,90% of Total Billed Charges,50,1529.8,
BIOPSY VULVA OR PERINUEM EA AD,7610000325,CDM,761,RC,,,Outpatient,,,1529.80,994.37,,1529.8,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1162.65,76,,930.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1529.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,1376.82,90,,1101.456,Percent of Total Billed Charges,90% of Total Billed Charges,688.41,45,,550.728,Percent of Total Billed Charges,45% of Total Billed Charges,1376.82,90,,1101.456,Percent of Total Billed Charges,90% of Total billed Charges,1529.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1529.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1529.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.37,65,,795.496,Percent of total Billed Charges,65% of Total Billed Charges,674.64,44.1,,539.712,Percent of Total Billed Charges,44.1% of Total Billed Charges,1453.31,95,,1162.648,Percent of Total Billed Charges,95% of Total Billed Charges,1529.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1346.22,88,,1076.976,Percent of Total Billed Charges,88% of Total Billed Charges,1376.82,90,,1101.456,Percent of Total Billed charges,90% of Total Billed Charges,50,1529.8,
PERC RF ABLATE RENAL TUMOR,7610000326,CDM,761,RC,,,Outpatient,,,12209.95,7936.47,,12209.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,9279.56,76,,7423.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,12209.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,10988.96,90,,8791.168,Percent of Total Billed Charges,90% of Total Billed Charges,5494.48,45,,4395.584,Percent of Total Billed Charges,45% of Total Billed Charges,10988.96,90,,8791.168,Percent of Total Billed Charges,90% of Total billed Charges,12209.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12209.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12209.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7936.47,65,,6349.176,Percent of total Billed Charges,65% of Total Billed Charges,5384.59,44.1,,4307.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,11599.45,95,,9279.56,Percent of Total Billed Charges,95% of Total Billed Charges,12209.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10744.76,88,,8595.808,Percent of Total Billed Charges,88% of Total Billed Charges,10988.96,90,,8791.168,Percent of Total Billed charges,90% of Total Billed Charges,50,12209.95,
Inj Therapeutic Carpal Tunnel,7610000327,CDM,761,RC,,,Outpatient,,,623.90,405.54,,623.9,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,474.16,76,,379.328,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,623.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,561.51,90,,449.208,Percent of Total Billed Charges,90% of Total Billed Charges,280.76,45,,224.608,Percent of Total Billed Charges,45% of Total Billed Charges,561.51,90,,449.208,Percent of Total Billed Charges,90% of Total billed Charges,623.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,623.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,623.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.54,65,,324.432,Percent of total Billed Charges,65% of Total Billed Charges,275.14,44.1,,220.112,Percent of Total Billed Charges,44.1% of Total Billed Charges,592.71,95,,474.168,Percent of Total Billed Charges,95% of Total Billed Charges,623.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.03,88,,439.224,Percent of Total Billed Charges,88% of Total Billed Charges,561.51,90,,449.208,Percent of Total Billed charges,90% of Total Billed Charges,50,623.9,
Carpal Tunnel Inj w guidance,7610000328,CDM,761,RC,,,Outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,50,50,
Bx SFT TIS PELVIS&HIP;SUPERFIC,7610000329,CDM,761,RC,,,Outpatient,,,3440.95,2236.62,,3440.95,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,2615.12,76,,2092.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3440.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,3096.86,90,,2477.488,Percent of Total Billed Charges,90% of Total Billed Charges,1548.43,45,,1238.744,Percent of Total Billed Charges,45% of Total Billed Charges,3096.86,90,,2477.488,Percent of Total Billed Charges,90% of Total billed Charges,3440.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3440.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3440.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2236.62,65,,1789.296,Percent of total Billed Charges,65% of Total Billed Charges,1517.46,44.1,,1213.968,Percent of Total Billed Charges,44.1% of Total Billed Charges,3268.9,95,,2615.12,Percent of Total Billed Charges,95% of Total Billed Charges,3440.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3028.04,88,,2422.432,Percent of Total Billed Charges,88% of Total Billed Charges,3096.86,90,,2477.488,Percent of Total Billed charges,90% of Total Billed Charges,50,3440.95,
"Bx, soft tis upper arm or elbw",7610000330,CDM,761,RC,,,Outpatient,,,6708.75,4360.69,,6708.75,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,5098.65,76,,4078.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50,100,,,Case Rate,Pays Based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,6708.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50,100,,,Case Rate,Pays based on per visit rate,50,100,,,Case Rate,Pays based on per visit rate,6037.88,90,,4830.304,Percent of Total Billed Charges,90% of Total Billed Charges,3018.94,45,,2415.152,Percent of Total Billed Charges,45% of Total Billed Charges,6037.88,90,,4830.304,Percent of Total Billed Charges,90% of Total billed Charges,6708.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6708.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6708.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4360.69,65,,3488.552,Percent of total Billed Charges,65% of Total Billed Charges,2958.56,44.1,,2366.848,Percent of Total Billed Charges,44.1% of Total Billed Charges,6373.31,95,,5098.648,Percent of Total Billed Charges,95% of Total Billed Charges,6708.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5903.7,88,,4722.96,Percent of Total Billed Charges,88% of Total Billed Charges,6037.88,90,,4830.304,Percent of Total Billed charges,90% of Total Billed Charges,50,6708.75,
OBSERVATION  TELE,7620000001,CDM,762,RC,G0378,HCPCS,Outpatient,,,123.00,79.95,,123,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.48,76,,74.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,362.33,350,,,Fee Schedule,350% of BCBS fee schedule,362.33,350,,,Fee Schedule,350% of BCBS fee schedule,123,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,362.33,286,,,Fee Schedule,286% of BCBS PPO fee schedule,126.69,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,110.7,90,,88.56,Percent of Total Billed Charges,90% of Total Billed Charges,55.35,45,,44.28,Percent of Total Billed Charges,45% of Total Billed Charges,110.7,90,,88.56,Percent of Total Billed Charges,90% of Total billed Charges,123,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.95,65,,63.96,Percent of total Billed Charges,65% of Total Billed Charges,54.24,44.1,,43.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.85,95,,93.48,Percent of Total Billed Charges,95% of Total Billed Charges,123,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.24,88,,86.592,Percent of Total Billed Charges,88% of Total Billed Charges,110.7,90,,88.56,Percent of Total Billed charges,90% of Total Billed Charges,54.24,362.33,
OBSERVATION PER HOUR,7620000002,CDM,762,RC,G0378,HCPCS,Outpatient,,,123.00,79.95,,123,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,93.48,76,,74.784,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,362.33,350,,,Fee Schedule,350% of BCBS fee schedule,362.33,350,,,Fee Schedule,350% of BCBS fee schedule,123,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,362.33,286,,,Fee Schedule,286% of BCBS PPO fee schedule,126.69,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,110.7,90,,88.56,Percent of Total Billed Charges,90% of Total Billed Charges,55.35,45,,44.28,Percent of Total Billed Charges,45% of Total Billed Charges,110.7,90,,88.56,Percent of Total Billed Charges,90% of Total billed Charges,123,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.95,65,,63.96,Percent of total Billed Charges,65% of Total Billed Charges,54.24,44.1,,43.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,116.85,95,,93.48,Percent of Total Billed Charges,95% of Total Billed Charges,123,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.24,88,,86.592,Percent of Total Billed Charges,88% of Total Billed Charges,110.7,90,,88.56,Percent of Total Billed charges,90% of Total Billed Charges,54.24,362.33,
ADMIN IMMUN INITIAL,7710000001,CDM,771,RC,,,Outpatient,,,81.00,52.65,,81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,61.56,76,,49.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,58.32,72,,46.656,Percent of Total Billed Charges,72% of Total Billed Charges,60.75,75,,48.6,Percent of Total Billed charges,75% of Total Billed Charges,81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.32,72,,46.656,Percent of Total Billed Charges,72% of Total Billed Charges,48.6,60,,38.88,Percent of Total Billed Charges,60% of Total Billed Charges,72.9,90,,58.32,Percent of Total Billed Charges,90% of Total Billed Charges,36.45,45,,29.16,Percent of Total Billed Charges,45% of Total Billed Charges,72.9,90,,58.32,Percent of Total Billed Charges,90% of Total billed Charges,81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.65,65,,42.12,Percent of total Billed Charges,65% of Total Billed Charges,35.72,44.1,,28.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,76.95,95,,61.56,Percent of Total Billed Charges,95% of Total Billed Charges,81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,72.9,90,,58.32,Percent of Total Billed charges,90% of Total Billed Charges,35.72,81,
ADMIN IMMUN INTITAL,7710000002,CDM,771,RC,,,Outpatient,,,81.00,52.65,,81,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,61.56,76,,49.248,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,58.32,72,,46.656,Percent of Total Billed Charges,72% of Total Billed Charges,60.75,75,,48.6,Percent of Total Billed charges,75% of Total Billed Charges,81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.32,72,,46.656,Percent of Total Billed Charges,72% of Total Billed Charges,48.6,60,,38.88,Percent of Total Billed Charges,60% of Total Billed Charges,72.9,90,,58.32,Percent of Total Billed Charges,90% of Total Billed Charges,36.45,45,,29.16,Percent of Total Billed Charges,45% of Total Billed Charges,72.9,90,,58.32,Percent of Total Billed Charges,90% of Total billed Charges,81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.65,65,,42.12,Percent of total Billed Charges,65% of Total Billed Charges,35.72,44.1,,28.576,Percent of Total Billed Charges,44.1% of Total Billed Charges,76.95,95,,61.56,Percent of Total Billed Charges,95% of Total Billed Charges,81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,72.9,90,,58.32,Percent of Total Billed charges,90% of Total Billed Charges,35.72,81,
IMMUN ADMIN EA ADDL,7710000003,CDM,771,RC,,,Outpatient,,,35.00,22.75,,35,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,26.6,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,25.2,72,,20.16,Percent of Total Billed Charges,72% of Total Billed Charges,26.25,75,,21,Percent of Total Billed charges,75% of Total Billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.2,72,,20.16,Percent of Total Billed Charges,72% of Total Billed Charges,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,31.5,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,15.75,45,,12.6,Percent of Total Billed Charges,45% of Total Billed Charges,31.5,90,,25.2,Percent of Total Billed Charges,90% of Total billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.75,65,,18.2,Percent of total Billed Charges,65% of Total Billed Charges,15.44,44.1,,12.352,Percent of Total Billed Charges,44.1% of Total Billed Charges,33.25,95,,26.6,Percent of Total Billed Charges,95% of Total Billed Charges,35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,31.5,90,,25.2,Percent of Total Billed charges,90% of Total Billed Charges,15.44,35,
ADMIN OF FLU VACCINE,7710000004,CDM,771,RC,G0008,HCPCS,Outpatient,,,141.12,91.73,,57.99,125,,,Fee Schedule,125% of CMS OPPS Rate,107.25,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,67.75,350,,,Fee Schedule,350% of BCBS fee schedule,67.75,350,,,Fee Schedule,350% of BCBS fee schedule,46.39,100,,,Fee Schedule,100% of CMS OPPS Rate,67.75,286,,,Fee Schedule,286% of BCBS PPO fee schedule,23.69,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,127.01,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,46.39,100,,,Fee Schedule,100% of CMS OPPS Rate,46.39,100,,,Fee Schedule,100% of CMS OPPS Rate,46.39,100,,,Fee Schedule,100% of CMS OPPS Rate,86.64,200,,,Fee Schedule,200% of CMS OPPS Rate,62.23,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,34.78,75,,,Fee Schedule,75% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,127.01,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,23.69,134.06,
PEDS ADMIN PNEUMONIA VACCINE,7710000005,CDM,771,RC,G0009,HCPCS,Outpatient,,,141.12,91.73,,57.99,125,,,Fee Schedule,125% of CMS OPPS Rate,107.25,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,136.51,350,,,Fee Schedule,350% of BCBS fee schedule,136.51,350,,,Fee Schedule,350% of BCBS fee schedule,46.39,100,,,Fee Schedule,100% of CMS OPPS Rate,136.51,286,,,Fee Schedule,286% of BCBS PPO fee schedule,47.73,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,127.01,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,46.39,100,,,Fee Schedule,100% of CMS OPPS Rate,46.39,100,,,Fee Schedule,100% of CMS OPPS Rate,46.39,100,,,Fee Schedule,100% of CMS OPPS Rate,86.64,200,,,Fee Schedule,200% of CMS OPPS Rate,62.23,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,34.78,75,,,Fee Schedule,75% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,127.01,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,34.78,136.51,
ADMIN OF PNEUMONIA VACCINE,7710000006,CDM,771,RC,G0009,HCPCS,Outpatient,,,141.12,91.73,,57.99,125,,,Fee Schedule,125% of CMS OPPS Rate,107.25,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,136.51,350,,,Fee Schedule,350% of BCBS fee schedule,136.51,350,,,Fee Schedule,350% of BCBS fee schedule,46.39,100,,,Fee Schedule,100% of CMS OPPS Rate,136.51,286,,,Fee Schedule,286% of BCBS PPO fee schedule,47.73,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,127.01,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,46.39,100,,,Fee Schedule,100% of CMS OPPS Rate,46.39,100,,,Fee Schedule,100% of CMS OPPS Rate,46.39,100,,,Fee Schedule,100% of CMS OPPS Rate,86.64,200,,,Fee Schedule,200% of CMS OPPS Rate,62.23,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,34.78,75,,,Fee Schedule,75% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,127.01,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,34.78,136.51,
ADMIN OF HEPATITIS B VACCINE,7710000008,CDM,771,RC,G0010,HCPCS,Outpatient,,,141.12,91.73,,57.99,125,,,Fee Schedule,125% of CMS OPPS Rate,107.25,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,147.8,350,,,Fee Schedule,350% of BCBS fee schedule,147.8,350,,,Fee Schedule,350% of BCBS fee schedule,46.39,100,,,Fee Schedule,100% of CMS OPPS Rate,147.8,286,,,Fee Schedule,286% of BCBS PPO fee schedule,51.68,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,127.01,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,46.39,100,,,Fee Schedule,100% of CMS OPPS Rate,46.39,100,,,Fee Schedule,100% of CMS OPPS Rate,46.39,100,,,Fee Schedule,100% of CMS OPPS Rate,86.64,200,,,Fee Schedule,200% of CMS OPPS Rate,62.23,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,34.78,75,,,Fee Schedule,75% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,127.01,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,34.78,147.8,
PEDS HEMODIALYSIS,8010000001,CDM,801,RC,,,Outpatient,,,1509.32,981.06,,1509.32,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1147.08,76,,917.664,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1086.71,72,,869.368,Percent of Total Billed Charges,72% of Total Billed Charges,1131.99,75,,905.592,Percent of Total Billed charges,75% of Total Billed Charges,1509.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1086.71,72,,869.368,Percent of Total Billed Charges,72% of Total Billed Charges,905.59,60,,724.472,Percent of Total Billed Charges,60% of Total Billed Charges,1358.39,90,,1086.712,Percent of Total Billed Charges,90% of Total Billed Charges,679.19,45,,543.352,Percent of Total Billed Charges,45% of Total Billed Charges,1358.39,90,,1086.712,Percent of Total Billed Charges,90% of Total billed Charges,1509.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,981.06,65,,784.848,Percent of total Billed Charges,65% of Total Billed Charges,665.61,44.1,,532.488,Percent of Total Billed Charges,44.1% of Total Billed Charges,1433.85,95,,1147.08,Percent of Total Billed Charges,95% of Total Billed Charges,1509.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1328.2,88,,1062.56,Percent of Total Billed Charges,88% of Total Billed Charges,1358.39,90,,1086.712,Percent of Total Billed charges,90% of Total Billed Charges,665.61,1509.32,
HEMODIALYSIS INPATIENT,8010000002,CDM,801,RC,,,Outpatient,,,1582.00,1028.30,,1582,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1202.32,76,,961.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1139.04,72,,911.232,Percent of Total Billed Charges,72% of Total Billed Charges,1186.5,75,,949.2,Percent of Total Billed charges,75% of Total Billed Charges,1582,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1139.04,72,,911.232,Percent of Total Billed Charges,72% of Total Billed Charges,949.2,60,,759.36,Percent of Total Billed Charges,60% of Total Billed Charges,1423.8,90,,1139.04,Percent of Total Billed Charges,90% of Total Billed Charges,711.9,45,,569.52,Percent of Total Billed Charges,45% of Total Billed Charges,1423.8,90,,1139.04,Percent of Total Billed Charges,90% of Total billed Charges,1582,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1582,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1582,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1028.3,65,,822.64,Percent of total Billed Charges,65% of Total Billed Charges,697.66,44.1,,558.128,Percent of Total Billed Charges,44.1% of Total Billed Charges,1502.9,95,,1202.32,Percent of Total Billed Charges,95% of Total Billed Charges,1582,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1392.16,88,,1113.728,Percent of Total Billed Charges,88% of Total Billed Charges,1423.8,90,,1139.04,Percent of Total Billed charges,90% of Total Billed Charges,697.66,1582,
Hemodialysis Proc w phys eval,8010000003,CDM,801,RC,,,Outpatient,,,1502.00,976.30,,1502,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1141.52,76,,913.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1081.44,72,,865.152,Percent of Total Billed Charges,72% of Total Billed Charges,1126.5,75,,901.2,Percent of Total Billed charges,75% of Total Billed Charges,1502,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1081.44,72,,865.152,Percent of Total Billed Charges,72% of Total Billed Charges,901.2,60,,720.96,Percent of Total Billed Charges,60% of Total Billed Charges,1351.8,90,,1081.44,Percent of Total Billed Charges,90% of Total Billed Charges,675.9,45,,540.72,Percent of Total Billed Charges,45% of Total Billed Charges,1351.8,90,,1081.44,Percent of Total Billed Charges,90% of Total billed Charges,1502,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1502,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1502,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,976.3,65,,781.04,Percent of total Billed Charges,65% of Total Billed Charges,662.38,44.1,,529.904,Percent of Total Billed Charges,44.1% of Total Billed Charges,1426.9,95,,1141.52,Percent of Total Billed Charges,95% of Total Billed Charges,1502,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.76,88,,1057.408,Percent of Total Billed Charges,88% of Total Billed Charges,1351.8,90,,1081.44,Percent of Total Billed charges,90% of Total Billed Charges,662.38,1502,
dialysis other than hemo evalu,8020000001,CDM,802,RC,,,Outpatient,,,874.58,568.48,,874.58,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,664.68,76,,531.744,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,629.7,72,,503.76,Percent of Total Billed Charges,72% of Total Billed Charges,655.94,75,,524.752,Percent of Total Billed charges,75% of Total Billed Charges,874.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,629.7,72,,503.76,Percent of Total Billed Charges,72% of Total Billed Charges,524.75,60,,419.8,Percent of Total Billed Charges,60% of Total Billed Charges,787.12,90,,629.696,Percent of Total Billed Charges,90% of Total Billed Charges,393.56,45,,314.848,Percent of Total Billed Charges,45% of Total Billed Charges,787.12,90,,629.696,Percent of Total Billed Charges,90% of Total billed Charges,874.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,874.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,874.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.48,65,,454.784,Percent of total Billed Charges,65% of Total Billed Charges,385.69,44.1,,308.552,Percent of Total Billed Charges,44.1% of Total Billed Charges,830.85,95,,664.68,Percent of Total Billed Charges,95% of Total Billed Charges,874.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,769.63,88,,615.704,Percent of Total Billed Charges,88% of Total Billed Charges,787.12,90,,629.696,Percent of Total Billed charges,90% of Total Billed Charges,385.69,874.58,
DIALYSIS TREATMENT UNSCHEDULED,8290000001,CDM,829,RC,G0257,HCPCS,Outpatient,,,1707.00,1109.55,,879.58,125,,,Fee Schedule,125% of CMS OPPS Rate,1297.32,76,,1037.856,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1710.37,350,,,Fee Schedule,350% of BCBS fee schedule,1710.37,350,,,Fee Schedule,350% of BCBS fee schedule,703.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1710.37,286,,,Fee Schedule,286% of BCBS PPO fee schedule,598.03,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,1536.3,90,,1229.04,Percent of Total Billed Charges,90% of Total Billed Charges,768.15,45,,614.52,Percent of Total Billed Charges,45% of Total Billed Charges,1536.3,90,,1229.04,Percent of Total Billed Charges,90% of Total billed Charges,703.66,100,,,Fee Schedule,100% of CMS OPPS Rate,703.66,100,,,Fee Schedule,100% of CMS OPPS Rate,703.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1314.04,200,,,Fee Schedule,200% of CMS OPPS Rate,752.79,44.1,,602.232,Percent of Total Billed Charges,44.1% of Total Billed Charges,1621.65,95,,1297.32,Percent of Total Billed Charges,95% of Total Billed Charges,527.74,75,,,Fee Schedule,75% of CMS OPPS Rate,1502.16,88,,1201.728,Percent of Total Billed Charges,88% of Total Billed Charges,1536.3,90,,1229.04,Percent of Total Billed charges,90% of Total Billed Charges,527.74,1710.37,
INDIVIDUAL PSYCHOTHE,9140000001,CDM,914,RC,,,Outpatient,,,289.96,188.47,,289.96,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,220.37,76,,176.296,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,208.77,72,,167.016,Percent of Total Billed Charges,72% of Total Billed Charges,217.47,75,,173.976,Percent of Total Billed charges,75% of Total Billed Charges,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.77,72,,167.016,Percent of Total Billed Charges,72% of Total Billed Charges,173.98,60,,139.184,Percent of Total Billed Charges,60% of Total Billed Charges,260.96,90,,208.768,Percent of Total Billed Charges,90% of Total Billed Charges,130.48,45,,104.384,Percent of Total Billed Charges,45% of Total Billed Charges,260.96,90,,208.768,Percent of Total Billed Charges,90% of Total billed Charges,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.47,65,,150.776,Percent of total Billed Charges,65% of Total Billed Charges,127.87,44.1,,102.296,Percent of Total Billed Charges,44.1% of Total Billed Charges,275.46,95,,220.368,Percent of Total Billed Charges,95% of Total Billed Charges,,,,,Other,Not separately Reimbursable,255.16,88,,204.128,Percent of Total Billed Charges,88% of Total Billed Charges,260.96,90,,208.768,Percent of Total Billed charges,90% of Total Billed Charges,127.87,289.96,
INTERACTIVE COMPLEXITY,9150000001,CDM,900,RC,,,Outpatient,,,295.47,192.06,,295.47,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,224.56,76,,179.648,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,212.74,72,,170.192,Percent of Total Billed Charges,72% of Total Billed Charges,221.6,75,,177.28,Percent of Total Billed charges,75% of Total Billed Charges,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.74,72,,170.192,Percent of Total Billed Charges,72% of Total Billed Charges,177.28,60,,141.824,Percent of Total Billed Charges,60% of Total Billed Charges,265.92,90,,212.736,Percent of Total Billed Charges,90% of Total Billed Charges,132.96,45,,106.368,Percent of Total Billed Charges,45% of Total Billed Charges,265.92,90,,212.736,Percent of Total Billed Charges,90% of Total billed Charges,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.06,65,,153.648,Percent of total Billed Charges,65% of Total Billed Charges,130.3,44.1,,104.24,Percent of Total Billed Charges,44.1% of Total Billed Charges,280.7,95,,224.56,Percent of Total Billed Charges,95% of Total Billed Charges,295.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.01,88,,208.008,Percent of Total Billed Charges,88% of Total Billed Charges,265.92,90,,212.736,Percent of Total Billed charges,90% of Total Billed Charges,130.3,295.47,
IOP PRO. GRP THPY,9150000002,CDM,915,RC,,,Outpatient,,,655.99,426.39,,655.99,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,498.55,76,,398.84,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,472.31,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,491.99,75,,393.592,Percent of Total Billed charges,75% of Total Billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.31,72,,377.848,Percent of Total Billed Charges,72% of Total Billed Charges,393.59,60,,314.872,Percent of Total Billed Charges,60% of Total Billed Charges,590.39,90,,472.312,Percent of Total Billed Charges,90% of Total Billed Charges,295.2,45,,236.16,Percent of Total Billed Charges,45% of Total Billed Charges,590.39,90,,472.312,Percent of Total Billed Charges,90% of Total billed Charges,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.39,65,,341.112,Percent of total Billed Charges,65% of Total Billed Charges,289.29,44.1,,231.432,Percent of Total Billed Charges,44.1% of Total Billed Charges,623.19,95,,498.552,Percent of Total Billed Charges,95% of Total Billed Charges,,,,,Other,Not separately Reimbursable,577.27,88,,461.816,Percent of Total Billed Charges,88% of Total Billed Charges,590.39,90,,472.312,Percent of Total Billed charges,90% of Total Billed Charges,289.29,655.99,
FAMILY THERAPY,9160000001,CDM,916,RC,,,Outpatient,,,556.76,361.89,,556.76,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,423.14,76,,338.512,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,400.87,72,,320.696,Percent of Total Billed Charges,72% of Total Billed Charges,417.57,75,,334.056,Percent of Total Billed charges,75% of Total Billed Charges,556.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.87,72,,320.696,Percent of Total Billed Charges,72% of Total Billed Charges,334.06,60,,267.248,Percent of Total Billed Charges,60% of Total Billed Charges,501.08,90,,400.864,Percent of Total Billed Charges,90% of Total Billed Charges,250.54,45,,200.432,Percent of Total Billed Charges,45% of Total Billed Charges,501.08,90,,400.864,Percent of Total Billed Charges,90% of Total billed Charges,556.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,556.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,556.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.89,65,,289.512,Percent of total Billed Charges,65% of Total Billed Charges,245.53,44.1,,196.424,Percent of Total Billed Charges,44.1% of Total Billed Charges,528.92,95,,423.136,Percent of Total Billed Charges,95% of Total Billed Charges,,,,,Other,Not separately Reimbursable,489.95,88,,391.96,Percent of Total Billed Charges,88% of Total Billed Charges,501.08,90,,400.864,Percent of Total Billed charges,90% of Total Billed Charges,245.53,556.76,
DEVELOPMENT TEST ADMIN 1ST HR,9180000000,CDM,918,RC,,,Outpatient,,,96112.00,62472.80,,96112,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,73045.12,76,,58436.096,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69200.64,72,,55360.512,Percent of Total Billed Charges,72% of Total Billed Charges,72084,75,,57667.2,Percent of Total Billed charges,75% of Total Billed Charges,96112,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69200.64,72,,55360.512,Percent of Total Billed Charges,72% of Total Billed Charges,57667.2,60,,46133.76,Percent of Total Billed Charges,60% of Total Billed Charges,86500.8,90,,69200.64,Percent of Total Billed Charges,90% of Total Billed Charges,43250.4,45,,34600.32,Percent of Total Billed Charges,45% of Total Billed Charges,86500.8,90,,69200.64,Percent of Total Billed Charges,90% of Total billed Charges,96112,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96112,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96112,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62472.8,65,,49978.24,Percent of total Billed Charges,65% of Total Billed Charges,42385.39,44.1,,33908.312,Percent of Total Billed Charges,44.1% of Total Billed Charges,91306.4,95,,73045.12,Percent of Total Billed Charges,95% of Total Billed Charges,96112,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84578.56,88,,67662.848,Percent of Total Billed Charges,88% of Total Billed Charges,86500.8,90,,69200.64,Percent of Total Billed charges,90% of Total Billed Charges,42385.39,96112,
DVLPMT TST ADMIN EA ADDL 30MIN,9180000001,CDM,918,RC,,,Outpatient,,,393.59,255.83,,393.59,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,299.13,76,,239.304,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,283.38,72,,226.704,Percent of Total Billed Charges,72% of Total Billed Charges,295.19,75,,236.152,Percent of Total Billed charges,75% of Total Billed Charges,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.38,72,,226.704,Percent of Total Billed Charges,72% of Total Billed Charges,236.15,60,,188.92,Percent of Total Billed Charges,60% of Total Billed Charges,354.23,90,,283.384,Percent of Total Billed Charges,90% of Total Billed Charges,177.12,45,,141.696,Percent of Total Billed Charges,45% of Total Billed Charges,354.23,90,,283.384,Percent of Total Billed Charges,90% of Total billed Charges,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.83,65,,204.664,Percent of total Billed Charges,65% of Total Billed Charges,173.57,44.1,,138.856,Percent of Total Billed Charges,44.1% of Total Billed Charges,373.91,95,,299.128,Percent of Total Billed Charges,95% of Total Billed Charges,393.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.36,88,,277.088,Percent of Total Billed Charges,88% of Total Billed Charges,354.23,90,,283.384,Percent of Total Billed charges,90% of Total Billed Charges,173.57,393.59,
ELEC ANYLS OF IMPLNT NEUROSTIM,9200000001,CDM,920,RC,,,Outpatient,,,340.67,221.44,,340.67,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,258.91,76,,207.128,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,245.28,72,,196.224,Percent of Total Billed Charges,72% of Total Billed Charges,255.5,75,,204.4,Percent of Total Billed charges,75% of Total Billed Charges,340.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.28,72,,196.224,Percent of Total Billed Charges,72% of Total Billed Charges,204.4,60,,163.52,Percent of Total Billed Charges,60% of Total Billed Charges,306.6,90,,245.28,Percent of Total Billed Charges,90% of Total Billed Charges,153.3,45,,122.64,Percent of Total Billed Charges,45% of Total Billed Charges,306.6,90,,245.28,Percent of Total Billed Charges,90% of Total billed Charges,340.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.44,65,,177.152,Percent of total Billed Charges,65% of Total Billed Charges,150.24,44.1,,120.192,Percent of Total Billed Charges,44.1% of Total Billed Charges,323.64,95,,258.912,Percent of Total Billed Charges,95% of Total Billed Charges,340.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,299.79,88,,239.832,Percent of Total Billed Charges,88% of Total Billed Charges,306.6,90,,245.28,Percent of Total Billed charges,90% of Total Billed Charges,150.24,340.67,
ANOGENITAL (CHILDREN),9200000002,CDM,920,RC,,,Outpatient,,,141.12,91.73,,141.12,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,107.25,76,,85.8,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,101.61,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,105.84,75,,84.672,Percent of Total Billed charges,75% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.61,72,,81.288,Percent of Total Billed Charges,72% of Total Billed Charges,84.67,60,,67.736,Percent of Total Billed Charges,60% of Total Billed Charges,127.01,90,,101.608,Percent of Total Billed Charges,90% of Total Billed Charges,63.5,45,,50.8,Percent of Total Billed Charges,45% of Total Billed Charges,127.01,90,,101.608,Percent of Total Billed Charges,90% of Total billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.73,65,,73.384,Percent of total Billed Charges,65% of Total Billed Charges,62.23,44.1,,49.784,Percent of Total Billed Charges,44.1% of Total Billed Charges,134.06,95,,107.248,Percent of Total Billed Charges,95% of Total Billed Charges,141.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,88,,99.352,Percent of Total Billed Charges,88% of Total Billed Charges,127.01,90,,101.608,Percent of Total Billed charges,90% of Total Billed Charges,62.23,141.12,
CAROTID DOPPLER BIL,9210000001,CDM,921,RC,,,Outpatient,,,1130.00,734.50,,1130,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,858.8,76,,687.04,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,813.6,72,,650.88,Percent of Total Billed Charges,72% of Total Billed Charges,847.5,75,,678,Percent of Total Billed charges,75% of Total Billed Charges,1130,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,813.6,72,,650.88,Percent of Total Billed Charges,72% of Total Billed Charges,678,60,,542.4,Percent of Total Billed Charges,60% of Total Billed Charges,1017,90,,813.6,Percent of Total Billed Charges,90% of Total Billed Charges,508.5,45,,406.8,Percent of Total Billed Charges,45% of Total Billed Charges,1017,90,,813.6,Percent of Total Billed Charges,90% of Total billed Charges,1130,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1130,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1130,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,734.5,65,,587.6,Percent of total Billed Charges,65% of Total Billed Charges,498.33,44.1,,398.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,1073.5,95,,858.8,Percent of Total Billed Charges,95% of Total Billed Charges,1130,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.4,88,,795.52,Percent of Total Billed Charges,88% of Total Billed Charges,1017,90,,813.6,Percent of Total Billed charges,90% of Total Billed Charges,498.33,1130,
CAROTID DOPPLER LIMITED,9210000002,CDM,921,RC,,,Outpatient,,,886.41,576.17,,886.41,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,673.67,76,,538.936,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,638.22,72,,510.576,Percent of Total Billed Charges,72% of Total Billed Charges,664.81,75,,531.848,Percent of Total Billed charges,75% of Total Billed Charges,886.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,638.22,72,,510.576,Percent of Total Billed Charges,72% of Total Billed Charges,531.85,60,,425.48,Percent of Total Billed Charges,60% of Total Billed Charges,797.77,90,,638.216,Percent of Total Billed Charges,90% of Total Billed Charges,398.88,45,,319.104,Percent of Total Billed Charges,45% of Total Billed Charges,797.77,90,,638.216,Percent of Total Billed Charges,90% of Total billed Charges,886.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,886.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,886.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,576.17,65,,460.936,Percent of total Billed Charges,65% of Total Billed Charges,390.91,44.1,,312.728,Percent of Total Billed Charges,44.1% of Total Billed Charges,842.09,95,,673.672,Percent of Total Billed Charges,95% of Total Billed Charges,886.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.04,88,,624.032,Percent of Total Billed Charges,88% of Total Billed Charges,797.77,90,,638.216,Percent of Total Billed charges,90% of Total Billed Charges,390.91,886.41,
IMEX SINGLE LEVEL,9210000003,CDM,921,RC,,,Outpatient,,,568.89,369.78,,568.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.36,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,409.6,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,426.67,75,,341.336,Percent of Total Billed charges,75% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.6,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,341.33,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,512,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,256,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,512,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.78,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,250.88,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,540.45,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.62,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,512,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,250.88,568.89,
IMEX SEG. PRESS,9210000004,CDM,921,RC,,,Outpatient,,,1272.29,826.99,,1272.29,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,966.94,76,,773.552,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,916.05,72,,732.84,Percent of Total Billed Charges,72% of Total Billed Charges,954.22,75,,763.376,Percent of Total Billed charges,75% of Total Billed Charges,1272.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.05,72,,732.84,Percent of Total Billed Charges,72% of Total Billed Charges,763.37,60,,610.696,Percent of Total Billed Charges,60% of Total Billed Charges,1145.06,90,,916.048,Percent of Total Billed Charges,90% of Total Billed Charges,572.53,45,,458.024,Percent of Total Billed Charges,45% of Total Billed Charges,1145.06,90,,916.048,Percent of Total Billed Charges,90% of Total billed Charges,1272.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1272.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1272.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,65,,661.592,Percent of total Billed Charges,65% of Total Billed Charges,561.08,44.1,,448.864,Percent of Total Billed Charges,44.1% of Total Billed Charges,1208.68,95,,966.944,Percent of Total Billed Charges,95% of Total Billed Charges,1272.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1119.62,88,,895.696,Percent of Total Billed Charges,88% of Total Billed Charges,1145.06,90,,916.048,Percent of Total Billed charges,90% of Total Billed Charges,561.08,1272.29,
IMEX POST TREADMILL,9210000005,CDM,921,RC,,,Outpatient,,,566.69,368.35,,566.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.68,76,,344.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,408.02,72,,326.416,Percent of Total Billed Charges,72% of Total Billed Charges,425.02,75,,340.016,Percent of Total Billed charges,75% of Total Billed Charges,566.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,408.02,72,,326.416,Percent of Total Billed Charges,72% of Total Billed Charges,340.01,60,,272.008,Percent of Total Billed Charges,60% of Total Billed Charges,510.02,90,,408.016,Percent of Total Billed Charges,90% of Total Billed Charges,255.01,45,,204.008,Percent of Total Billed Charges,45% of Total Billed Charges,510.02,90,,408.016,Percent of Total Billed Charges,90% of Total billed Charges,566.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.35,65,,294.68,Percent of total Billed Charges,65% of Total Billed Charges,249.91,44.1,,199.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.36,95,,430.688,Percent of Total Billed Charges,95% of Total Billed Charges,566.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.69,88,,398.952,Percent of Total Billed Charges,88% of Total Billed Charges,510.02,90,,408.016,Percent of Total Billed charges,90% of Total Billed Charges,249.91,566.69,
ART DUPLEX LOWER EXT,9210000006,CDM,921,RC,,,Outpatient,,,1297.00,843.05,,1297,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,985.72,76,,788.576,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,933.84,72,,747.072,Percent of Total Billed Charges,72% of Total Billed Charges,972.75,75,,778.2,Percent of Total Billed charges,75% of Total Billed Charges,1297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,933.84,72,,747.072,Percent of Total Billed Charges,72% of Total Billed Charges,778.2,60,,622.56,Percent of Total Billed Charges,60% of Total Billed Charges,1167.3,90,,933.84,Percent of Total Billed Charges,90% of Total Billed Charges,583.65,45,,466.92,Percent of Total Billed Charges,45% of Total Billed Charges,1167.3,90,,933.84,Percent of Total Billed Charges,90% of Total billed Charges,1297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,843.05,65,,674.44,Percent of total Billed Charges,65% of Total Billed Charges,571.98,44.1,,457.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,1232.15,95,,985.72,Percent of Total Billed Charges,95% of Total Billed Charges,1297,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1141.36,88,,913.088,Percent of Total Billed Charges,88% of Total Billed Charges,1167.3,90,,933.84,Percent of Total Billed charges,90% of Total Billed Charges,571.98,1297,
ART DUPLEX UPPER EXT COMP,9210000007,CDM,921,RC,,,Outpatient,,,2006.55,1304.26,,2006.55,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1524.98,76,,1219.984,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1444.72,72,,1155.776,Percent of Total Billed Charges,72% of Total Billed Charges,1504.91,75,,1203.928,Percent of Total Billed charges,75% of Total Billed Charges,2006.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1444.72,72,,1155.776,Percent of Total Billed Charges,72% of Total Billed Charges,1203.93,60,,963.144,Percent of Total Billed Charges,60% of Total Billed Charges,1805.9,90,,1444.72,Percent of Total Billed Charges,90% of Total Billed Charges,902.95,45,,722.36,Percent of Total Billed Charges,45% of Total Billed Charges,1805.9,90,,1444.72,Percent of Total Billed Charges,90% of Total billed Charges,2006.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2006.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2006.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1304.26,65,,1043.408,Percent of total Billed Charges,65% of Total Billed Charges,884.89,44.1,,707.912,Percent of Total Billed Charges,44.1% of Total Billed Charges,1906.22,95,,1524.976,Percent of Total Billed Charges,95% of Total Billed Charges,2006.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1765.76,88,,1412.608,Percent of Total Billed Charges,88% of Total Billed Charges,1805.9,90,,1444.72,Percent of Total Billed charges,90% of Total Billed Charges,884.89,2006.55,
US DUPLEX COMPLETE,9210000008,CDM,921,RC,,,Outpatient,,,959.00,623.35,,959,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,728.84,76,,583.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,690.48,72,,552.384,Percent of Total Billed Charges,72% of Total Billed Charges,719.25,75,,575.4,Percent of Total Billed charges,75% of Total Billed Charges,959,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,690.48,72,,552.384,Percent of Total Billed Charges,72% of Total Billed Charges,575.4,60,,460.32,Percent of Total Billed Charges,60% of Total Billed Charges,863.1,90,,690.48,Percent of Total Billed Charges,90% of Total Billed Charges,431.55,45,,345.24,Percent of Total Billed Charges,45% of Total Billed Charges,863.1,90,,690.48,Percent of Total Billed Charges,90% of Total billed Charges,959,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,959,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,959,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,623.35,65,,498.68,Percent of total Billed Charges,65% of Total Billed Charges,422.92,44.1,,338.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,911.05,95,,728.84,Percent of Total Billed Charges,95% of Total Billed Charges,959,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,843.92,88,,675.136,Percent of Total Billed Charges,88% of Total Billed Charges,863.1,90,,690.48,Percent of Total Billed charges,90% of Total Billed Charges,422.92,959,
US DUPLEX RENAL LIM,9210000009,CDM,921,RC,,,Outpatient,,,702.00,456.30,,702,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,533.52,76,,426.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,505.44,72,,404.352,Percent of Total Billed Charges,72% of Total Billed Charges,526.5,75,,421.2,Percent of Total Billed charges,75% of Total Billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,505.44,72,,404.352,Percent of Total Billed Charges,72% of Total Billed Charges,421.2,60,,336.96,Percent of Total Billed Charges,60% of Total Billed Charges,631.8,90,,505.44,Percent of Total Billed Charges,90% of Total Billed Charges,315.9,45,,252.72,Percent of Total Billed Charges,45% of Total Billed Charges,631.8,90,,505.44,Percent of Total Billed Charges,90% of Total billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.3,65,,365.04,Percent of total Billed Charges,65% of Total Billed Charges,309.58,44.1,,247.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,666.9,95,,533.52,Percent of Total Billed Charges,95% of Total Billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,617.76,88,,494.208,Percent of Total Billed Charges,88% of Total Billed Charges,631.8,90,,505.44,Percent of Total Billed charges,90% of Total Billed Charges,309.58,702,
US DUPLEX LIMITED,9210000010,CDM,921,RC,,,Outpatient,,,702.00,456.30,,702,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,533.52,76,,426.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,505.44,72,,404.352,Percent of Total Billed Charges,72% of Total Billed Charges,526.5,75,,421.2,Percent of Total Billed charges,75% of Total Billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,505.44,72,,404.352,Percent of Total Billed Charges,72% of Total Billed Charges,421.2,60,,336.96,Percent of Total Billed Charges,60% of Total Billed Charges,631.8,90,,505.44,Percent of Total Billed Charges,90% of Total Billed Charges,315.9,45,,252.72,Percent of Total Billed Charges,45% of Total Billed Charges,631.8,90,,505.44,Percent of Total Billed Charges,90% of Total billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.3,65,,365.04,Percent of total Billed Charges,65% of Total Billed Charges,309.58,44.1,,247.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,666.9,95,,533.52,Percent of Total Billed Charges,95% of Total Billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,617.76,88,,494.208,Percent of Total Billed Charges,88% of Total Billed Charges,631.8,90,,505.44,Percent of Total Billed charges,90% of Total Billed Charges,309.58,702,
USDUPLEXAORTAIV COMPLETE,9210000011,CDM,921,RC,,,Outpatient,,,954.00,620.10,,954,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,725.04,76,,580.032,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,686.88,72,,549.504,Percent of Total Billed Charges,72% of Total Billed Charges,715.5,75,,572.4,Percent of Total Billed charges,75% of Total Billed Charges,954,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,686.88,72,,549.504,Percent of Total Billed Charges,72% of Total Billed Charges,572.4,60,,457.92,Percent of Total Billed Charges,60% of Total Billed Charges,858.6,90,,686.88,Percent of Total Billed Charges,90% of Total Billed Charges,429.3,45,,343.44,Percent of Total Billed Charges,45% of Total Billed Charges,858.6,90,,686.88,Percent of Total Billed Charges,90% of Total billed Charges,954,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,954,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,954,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,620.1,65,,496.08,Percent of total Billed Charges,65% of Total Billed Charges,420.71,44.1,,336.568,Percent of Total Billed Charges,44.1% of Total Billed Charges,906.3,95,,725.04,Percent of Total Billed Charges,95% of Total Billed Charges,954,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,839.52,88,,671.616,Percent of Total Billed Charges,88% of Total Billed Charges,858.6,90,,686.88,Percent of Total Billed charges,90% of Total Billed Charges,420.71,954,
USDUPLEXAORTAIVC,9210000012,CDM,921,RC,,,Outpatient,,,640.00,416.00,,640,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,486.4,76,,389.12,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,460.8,72,,368.64,Percent of Total Billed Charges,72% of Total Billed Charges,480,75,,384,Percent of Total Billed charges,75% of Total Billed Charges,640,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,460.8,72,,368.64,Percent of Total Billed Charges,72% of Total Billed Charges,384,60,,307.2,Percent of Total Billed Charges,60% of Total Billed Charges,576,90,,460.8,Percent of Total Billed Charges,90% of Total Billed Charges,288,45,,230.4,Percent of Total Billed Charges,45% of Total Billed Charges,576,90,,460.8,Percent of Total Billed Charges,90% of Total billed Charges,640,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,640,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,640,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,416,65,,332.8,Percent of total Billed Charges,65% of Total Billed Charges,282.24,44.1,,225.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,608,95,,486.4,Percent of Total Billed Charges,95% of Total Billed Charges,640,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.2,88,,450.56,Percent of Total Billed Charges,88% of Total Billed Charges,576,90,,460.8,Percent of Total Billed charges,90% of Total Billed Charges,282.24,640,
DUP SCAN HEMGRAFT,9210000013,CDM,921,RC,,,Outpatient,,,353.00,229.45,,353,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,268.28,76,,214.624,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,254.16,72,,203.328,Percent of Total Billed Charges,72% of Total Billed Charges,264.75,75,,211.8,Percent of Total Billed charges,75% of Total Billed Charges,353,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,254.16,72,,203.328,Percent of Total Billed Charges,72% of Total Billed Charges,211.8,60,,169.44,Percent of Total Billed Charges,60% of Total Billed Charges,317.7,90,,254.16,Percent of Total Billed Charges,90% of Total Billed Charges,158.85,45,,127.08,Percent of Total Billed Charges,45% of Total Billed Charges,317.7,90,,254.16,Percent of Total Billed Charges,90% of Total billed Charges,353,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.45,65,,183.56,Percent of total Billed Charges,65% of Total Billed Charges,155.67,44.1,,124.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,335.35,95,,268.28,Percent of Total Billed Charges,95% of Total Billed Charges,353,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,310.64,88,,248.512,Percent of Total Billed Charges,88% of Total Billed Charges,317.7,90,,254.16,Percent of Total Billed charges,90% of Total Billed Charges,155.67,353,
US-DUPLEX-AORTA-IVC,9210000014,CDM,921,RC,,,Outpatient,,,669.22,434.99,,669.22,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,508.61,76,,406.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,481.84,72,,385.472,Percent of Total Billed Charges,72% of Total Billed Charges,501.92,75,,401.536,Percent of Total Billed charges,75% of Total Billed Charges,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,481.84,72,,385.472,Percent of Total Billed Charges,72% of Total Billed Charges,401.53,60,,321.224,Percent of Total Billed Charges,60% of Total Billed Charges,602.3,90,,481.84,Percent of Total Billed Charges,90% of Total Billed Charges,301.15,45,,240.92,Percent of Total Billed Charges,45% of Total Billed Charges,602.3,90,,481.84,Percent of Total Billed Charges,90% of Total billed Charges,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,434.99,65,,347.992,Percent of total Billed Charges,65% of Total Billed Charges,295.13,44.1,,236.104,Percent of Total Billed Charges,44.1% of Total Billed Charges,635.76,95,,508.608,Percent of Total Billed Charges,95% of Total Billed Charges,669.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,588.91,88,,471.128,Percent of Total Billed Charges,88% of Total Billed Charges,602.3,90,,481.84,Percent of Total Billed charges,90% of Total Billed Charges,295.13,669.22,
US DUPLEX ABD/PELV COMPLETE,9210000015,CDM,921,RC,,,Outpatient,,,959.00,623.35,,959,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,728.84,76,,583.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,690.48,72,,552.384,Percent of Total Billed Charges,72% of Total Billed Charges,719.25,75,,575.4,Percent of Total Billed charges,75% of Total Billed Charges,959,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,690.48,72,,552.384,Percent of Total Billed Charges,72% of Total Billed Charges,575.4,60,,460.32,Percent of Total Billed Charges,60% of Total Billed Charges,863.1,90,,690.48,Percent of Total Billed Charges,90% of Total Billed Charges,431.55,45,,345.24,Percent of Total Billed Charges,45% of Total Billed Charges,863.1,90,,690.48,Percent of Total Billed Charges,90% of Total billed Charges,959,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,959,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,959,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,623.35,65,,498.68,Percent of total Billed Charges,65% of Total Billed Charges,422.92,44.1,,338.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,911.05,95,,728.84,Percent of Total Billed Charges,95% of Total Billed Charges,959,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,843.92,88,,675.136,Percent of Total Billed Charges,88% of Total Billed Charges,863.1,90,,690.48,Percent of Total Billed charges,90% of Total Billed Charges,422.92,959,
US DUPLX ABD/PEL LTD,9210000016,CDM,921,RC,,,Outpatient,,,702.00,456.30,,702,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,533.52,76,,426.816,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,505.44,72,,404.352,Percent of Total Billed Charges,72% of Total Billed Charges,526.5,75,,421.2,Percent of Total Billed charges,75% of Total Billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,505.44,72,,404.352,Percent of Total Billed Charges,72% of Total Billed Charges,421.2,60,,336.96,Percent of Total Billed Charges,60% of Total Billed Charges,631.8,90,,505.44,Percent of Total Billed Charges,90% of Total Billed Charges,315.9,45,,252.72,Percent of Total Billed Charges,45% of Total Billed Charges,631.8,90,,505.44,Percent of Total Billed Charges,90% of Total billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,456.3,65,,365.04,Percent of total Billed Charges,65% of Total Billed Charges,309.58,44.1,,247.664,Percent of Total Billed Charges,44.1% of Total Billed Charges,666.9,95,,533.52,Percent of Total Billed Charges,95% of Total Billed Charges,702,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,617.76,88,,494.208,Percent of Total Billed Charges,88% of Total Billed Charges,631.8,90,,505.44,Percent of Total Billed charges,90% of Total Billed Charges,309.58,702,
US LIVER DUPLEX COMP,9210000017,CDM,921,RC,,,Outpatient,,,959.00,623.35,,959,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,728.84,76,,583.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,690.48,72,,552.384,Percent of Total Billed Charges,72% of Total Billed Charges,719.25,75,,575.4,Percent of Total Billed charges,75% of Total Billed Charges,959,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,690.48,72,,552.384,Percent of Total Billed Charges,72% of Total Billed Charges,575.4,60,,460.32,Percent of Total Billed Charges,60% of Total Billed Charges,863.1,90,,690.48,Percent of Total Billed Charges,90% of Total Billed Charges,431.55,45,,345.24,Percent of Total Billed Charges,45% of Total Billed Charges,863.1,90,,690.48,Percent of Total Billed Charges,90% of Total billed Charges,959,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,959,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,959,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,623.35,65,,498.68,Percent of total Billed Charges,65% of Total Billed Charges,422.92,44.1,,338.336,Percent of Total Billed Charges,44.1% of Total Billed Charges,911.05,95,,728.84,Percent of Total Billed Charges,95% of Total Billed Charges,959,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,843.92,88,,675.136,Percent of Total Billed Charges,88% of Total Billed Charges,863.1,90,,690.48,Percent of Total Billed charges,90% of Total Billed Charges,422.92,959,
US IMEX SINGLE LEVEL (ABI),9290000001,CDM,921,RC,,,Outpatient,,,544.00,353.60,,544,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,413.44,76,,330.752,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,391.68,72,,313.344,Percent of Total Billed Charges,72% of Total Billed Charges,408,75,,326.4,Percent of Total Billed charges,75% of Total Billed Charges,544,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,391.68,72,,313.344,Percent of Total Billed Charges,72% of Total Billed Charges,326.4,60,,261.12,Percent of Total Billed Charges,60% of Total Billed Charges,489.6,90,,391.68,Percent of Total Billed Charges,90% of Total Billed Charges,244.8,45,,195.84,Percent of Total Billed Charges,45% of Total Billed Charges,489.6,90,,391.68,Percent of Total Billed Charges,90% of Total billed Charges,544,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,544,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,544,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.6,65,,282.88,Percent of total Billed Charges,65% of Total Billed Charges,239.9,44.1,,191.92,Percent of Total Billed Charges,44.1% of Total Billed Charges,516.8,95,,413.44,Percent of Total Billed Charges,95% of Total Billed Charges,544,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,478.72,88,,382.976,Percent of Total Billed Charges,88% of Total Billed Charges,489.6,90,,391.68,Percent of Total Billed charges,90% of Total Billed Charges,239.9,544,
US IMEX MULTILEVEL,9290000002,CDM,929,RC,,,Outpatient,,,1209.00,785.85,,1209,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,918.84,76,,735.072,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,870.48,72,,696.384,Percent of Total Billed Charges,72% of Total Billed Charges,906.75,75,,725.4,Percent of Total Billed charges,75% of Total Billed Charges,1209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,870.48,72,,696.384,Percent of Total Billed Charges,72% of Total Billed Charges,725.4,60,,580.32,Percent of Total Billed Charges,60% of Total Billed Charges,1088.1,90,,870.48,Percent of Total Billed Charges,90% of Total Billed Charges,544.05,45,,435.24,Percent of Total Billed Charges,45% of Total Billed Charges,1088.1,90,,870.48,Percent of Total Billed Charges,90% of Total billed Charges,1209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,785.85,65,,628.68,Percent of total Billed Charges,65% of Total Billed Charges,533.17,44.1,,426.536,Percent of Total Billed Charges,44.1% of Total Billed Charges,1148.55,95,,918.84,Percent of Total Billed Charges,95% of Total Billed Charges,1209,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1063.92,88,,851.136,Percent of Total Billed Charges,88% of Total Billed Charges,1088.1,90,,870.48,Percent of Total Billed charges,90% of Total Billed Charges,533.17,1209,
US IMEX POST TREADMILL,9290000003,CDM,929,RC,,,Outpatient,,,566.69,368.35,,566.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,430.68,76,,344.544,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,408.02,72,,326.416,Percent of Total Billed Charges,72% of Total Billed Charges,425.02,75,,340.016,Percent of Total Billed charges,75% of Total Billed Charges,566.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,408.02,72,,326.416,Percent of Total Billed Charges,72% of Total Billed Charges,340.01,60,,272.008,Percent of Total Billed Charges,60% of Total Billed Charges,510.02,90,,408.016,Percent of Total Billed Charges,90% of Total Billed Charges,255.01,45,,204.008,Percent of Total Billed Charges,45% of Total Billed Charges,510.02,90,,408.016,Percent of Total Billed Charges,90% of Total billed Charges,566.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,566.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.35,65,,294.68,Percent of total Billed Charges,65% of Total Billed Charges,249.91,44.1,,199.928,Percent of Total Billed Charges,44.1% of Total Billed Charges,538.36,95,,430.688,Percent of Total Billed Charges,95% of Total Billed Charges,566.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.69,88,,398.952,Percent of Total Billed Charges,88% of Total Billed Charges,510.02,90,,408.016,Percent of Total Billed charges,90% of Total Billed Charges,249.91,566.69,
ART DUPLEX LOWER EXT,9290000004,CDM,921,RC,,,Outpatient,,,1907.00,1239.55,,1907,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1449.32,76,,1159.456,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1373.04,72,,1098.432,Percent of Total Billed Charges,72% of Total Billed Charges,1430.25,75,,1144.2,Percent of Total Billed charges,75% of Total Billed Charges,1907,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1373.04,72,,1098.432,Percent of Total Billed Charges,72% of Total Billed Charges,1144.2,60,,915.36,Percent of Total Billed Charges,60% of Total Billed Charges,1716.3,90,,1373.04,Percent of Total Billed Charges,90% of Total Billed Charges,858.15,45,,686.52,Percent of Total Billed Charges,45% of Total Billed Charges,1716.3,90,,1373.04,Percent of Total Billed Charges,90% of Total billed Charges,1907,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1907,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1907,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1239.55,65,,991.64,Percent of total Billed Charges,65% of Total Billed Charges,840.99,44.1,,672.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,1811.65,95,,1449.32,Percent of Total Billed Charges,95% of Total Billed Charges,1907,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1678.16,88,,1342.528,Percent of Total Billed Charges,88% of Total Billed Charges,1716.3,90,,1373.04,Percent of Total Billed charges,90% of Total Billed Charges,840.99,1907,
ART DUPLEX UPPER EXT LMTD,9290000005,CDM,929,RC,,,Outpatient,,,1051.00,683.15,,1051,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,798.76,76,,639.008,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,756.72,72,,605.376,Percent of Total Billed Charges,72% of Total Billed Charges,788.25,75,,630.6,Percent of Total Billed charges,75% of Total Billed Charges,1051,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.72,72,,605.376,Percent of Total Billed Charges,72% of Total Billed Charges,630.6,60,,504.48,Percent of Total Billed Charges,60% of Total Billed Charges,945.9,90,,756.72,Percent of Total Billed Charges,90% of Total Billed Charges,472.95,45,,378.36,Percent of Total Billed Charges,45% of Total Billed Charges,945.9,90,,756.72,Percent of Total Billed Charges,90% of Total billed Charges,1051,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1051,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1051,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,683.15,65,,546.52,Percent of total Billed Charges,65% of Total Billed Charges,463.49,44.1,,370.792,Percent of Total Billed Charges,44.1% of Total Billed Charges,998.45,95,,798.76,Percent of Total Billed Charges,95% of Total Billed Charges,1051,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,924.88,88,,739.904,Percent of Total Billed Charges,88% of Total Billed Charges,945.9,90,,756.72,Percent of Total Billed charges,90% of Total Billed Charges,463.49,1051,
BILATERAL VENOUS DOP,9290000006,CDM,921,RC,,,Outpatient,,,2102.00,1366.30,,2102,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,1597.52,76,,1278.016,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1513.44,72,,1210.752,Percent of Total Billed Charges,72% of Total Billed Charges,1576.5,75,,1261.2,Percent of Total Billed charges,75% of Total Billed Charges,2102,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1513.44,72,,1210.752,Percent of Total Billed Charges,72% of Total Billed Charges,1261.2,60,,1008.96,Percent of Total Billed Charges,60% of Total Billed Charges,1891.8,90,,1513.44,Percent of Total Billed Charges,90% of Total Billed Charges,945.9,45,,756.72,Percent of Total Billed Charges,45% of Total Billed Charges,1891.8,90,,1513.44,Percent of Total Billed Charges,90% of Total billed Charges,2102,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2102,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2102,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1366.3,65,,1093.04,Percent of total Billed Charges,65% of Total Billed Charges,926.98,44.1,,741.584,Percent of Total Billed Charges,44.1% of Total Billed Charges,1996.9,95,,1597.52,Percent of Total Billed Charges,95% of Total Billed Charges,2102,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1849.76,88,,1479.808,Percent of Total Billed Charges,88% of Total Billed Charges,1891.8,90,,1513.44,Percent of Total Billed charges,90% of Total Billed Charges,926.98,2102,
UNILATERAL VENOUS DO,9290000007,CDM,929,RC,,,Outpatient,,,1252.00,813.80,,1252,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,951.52,76,,761.216,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,901.44,72,,721.152,Percent of Total Billed Charges,72% of Total Billed Charges,939,75,,751.2,Percent of Total Billed charges,75% of Total Billed Charges,1252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,901.44,72,,721.152,Percent of Total Billed Charges,72% of Total Billed Charges,751.2,60,,600.96,Percent of Total Billed Charges,60% of Total Billed Charges,1126.8,90,,901.44,Percent of Total Billed Charges,90% of Total Billed Charges,563.4,45,,450.72,Percent of Total Billed Charges,45% of Total Billed Charges,1126.8,90,,901.44,Percent of Total Billed Charges,90% of Total billed Charges,1252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,813.8,65,,651.04,Percent of total Billed Charges,65% of Total Billed Charges,552.13,44.1,,441.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,1189.4,95,,951.52,Percent of Total Billed Charges,95% of Total Billed Charges,1252,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1101.76,88,,881.408,Percent of Total Billed Charges,88% of Total Billed Charges,1126.8,90,,901.44,Percent of Total Billed charges,90% of Total Billed Charges,552.13,1252,
US IMEX SINGLE LEVEL (ABI),9290000008,CDM,929,RC,,,Outpatient,,,568.89,369.78,,568.89,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,432.36,76,,345.888,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,409.6,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,426.67,75,,341.336,Percent of Total Billed charges,75% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.6,72,,327.68,Percent of Total Billed Charges,72% of Total Billed Charges,341.33,60,,273.064,Percent of Total Billed Charges,60% of Total Billed Charges,512,90,,409.6,Percent of Total Billed Charges,90% of Total Billed Charges,256,45,,204.8,Percent of Total Billed Charges,45% of Total Billed Charges,512,90,,409.6,Percent of Total Billed Charges,90% of Total billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.78,65,,295.824,Percent of total Billed Charges,65% of Total Billed Charges,250.88,44.1,,200.704,Percent of Total Billed Charges,44.1% of Total Billed Charges,540.45,95,,432.36,Percent of Total Billed Charges,95% of Total Billed Charges,568.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.62,88,,400.496,Percent of Total Billed Charges,88% of Total Billed Charges,512,90,,409.6,Percent of Total Billed charges,90% of Total Billed Charges,250.88,568.89,
INJ IM SQ AB,9400000001,CDM,940,RC,,,Outpatient,,,257.00,167.05,,257,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,195.32,76,,156.256,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,185.04,72,,148.032,Percent of Total Billed Charges,72% of Total Billed Charges,192.75,75,,154.2,Percent of Total Billed charges,75% of Total Billed Charges,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.04,72,,148.032,Percent of Total Billed Charges,72% of Total Billed Charges,154.2,60,,123.36,Percent of Total Billed Charges,60% of Total Billed Charges,231.3,90,,185.04,Percent of Total Billed Charges,90% of Total Billed Charges,115.65,45,,92.52,Percent of Total Billed Charges,45% of Total Billed Charges,231.3,90,,185.04,Percent of Total Billed Charges,90% of Total billed Charges,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.05,65,,133.64,Percent of total Billed Charges,65% of Total Billed Charges,113.34,44.1,,90.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,244.15,95,,195.32,Percent of Total Billed Charges,95% of Total Billed Charges,257,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.16,88,,180.928,Percent of Total Billed Charges,88% of Total Billed Charges,231.3,90,,185.04,Percent of Total Billed charges,90% of Total Billed Charges,113.34,257,
INJECTION IV PUSH,9400000002,CDM,940,RC,,,Outpatient,,,378.16,245.80,,378.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,287.4,76,,229.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,272.28,72,,217.824,Percent of Total Billed Charges,72% of Total Billed Charges,283.62,75,,226.896,Percent of Total Billed charges,75% of Total Billed Charges,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.28,72,,217.824,Percent of Total Billed Charges,72% of Total Billed Charges,226.9,60,,181.52,Percent of Total Billed Charges,60% of Total Billed Charges,340.34,90,,272.272,Percent of Total Billed Charges,90% of Total Billed Charges,170.17,45,,136.136,Percent of Total Billed Charges,45% of Total Billed Charges,340.34,90,,272.272,Percent of Total Billed Charges,90% of Total billed Charges,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.8,65,,196.64,Percent of total Billed Charges,65% of Total Billed Charges,166.77,44.1,,133.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,359.25,95,,287.4,Percent of Total Billed Charges,95% of Total Billed Charges,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.78,88,,266.224,Percent of Total Billed Charges,88% of Total Billed Charges,340.34,90,,272.272,Percent of Total Billed charges,90% of Total Billed Charges,166.77,378.16,
IV PUSH ADDL SEQ NEW,9400000003,CDM,940,RC,,,Outpatient,,,159.00,103.35,,159,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,120.84,76,,96.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,114.48,72,,91.584,Percent of Total Billed Charges,72% of Total Billed Charges,119.25,75,,95.4,Percent of Total Billed charges,75% of Total Billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.48,72,,91.584,Percent of Total Billed Charges,72% of Total Billed Charges,95.4,60,,76.32,Percent of Total Billed Charges,60% of Total Billed Charges,143.1,90,,114.48,Percent of Total Billed Charges,90% of Total Billed Charges,71.55,45,,57.24,Percent of Total Billed Charges,45% of Total Billed Charges,143.1,90,,114.48,Percent of Total Billed Charges,90% of Total billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.35,65,,82.68,Percent of total Billed Charges,65% of Total Billed Charges,70.12,44.1,,56.096,Percent of Total Billed Charges,44.1% of Total Billed Charges,151.05,95,,120.84,Percent of Total Billed Charges,95% of Total Billed Charges,159,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.92,88,,111.936,Percent of Total Billed Charges,88% of Total Billed Charges,143.1,90,,114.48,Percent of Total Billed charges,90% of Total Billed Charges,70.12,159,
THERAPEUTIC PHLEBOTOMY,9400000004,CDM,940,RC,,,Outpatient,,,223.00,144.95,,223,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,169.48,76,,135.584,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,160.56,72,,128.448,Percent of Total Billed Charges,72% of Total Billed Charges,167.25,75,,133.8,Percent of Total Billed charges,75% of Total Billed Charges,223,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.56,72,,128.448,Percent of Total Billed Charges,72% of Total Billed Charges,133.8,60,,107.04,Percent of Total Billed Charges,60% of Total Billed Charges,200.7,90,,160.56,Percent of Total Billed Charges,90% of Total Billed Charges,100.35,45,,80.28,Percent of Total Billed Charges,45% of Total Billed Charges,200.7,90,,160.56,Percent of Total Billed Charges,90% of Total billed Charges,223,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,223,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,223,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.95,65,,115.96,Percent of total Billed Charges,65% of Total Billed Charges,98.34,44.1,,78.672,Percent of Total Billed Charges,44.1% of Total Billed Charges,211.85,95,,169.48,Percent of Total Billed Charges,95% of Total Billed Charges,223,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.24,88,,156.992,Percent of Total Billed Charges,88% of Total Billed Charges,200.7,90,,160.56,Percent of Total Billed charges,90% of Total Billed Charges,98.34,223,
INJECTION IV PUSH ADDL,9400000006,CDM,940,RC,,,Outpatient,,,378.16,245.80,,378.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,287.4,76,,229.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,272.28,72,,217.824,Percent of Total Billed Charges,72% of Total Billed Charges,283.62,75,,226.896,Percent of Total Billed charges,75% of Total Billed Charges,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.28,72,,217.824,Percent of Total Billed Charges,72% of Total Billed Charges,226.9,60,,181.52,Percent of Total Billed Charges,60% of Total Billed Charges,340.34,90,,272.272,Percent of Total Billed Charges,90% of Total Billed Charges,170.17,45,,136.136,Percent of Total Billed Charges,45% of Total Billed Charges,340.34,90,,272.272,Percent of Total Billed Charges,90% of Total billed Charges,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.8,65,,196.64,Percent of total Billed Charges,65% of Total Billed Charges,166.77,44.1,,133.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,359.25,95,,287.4,Percent of Total Billed Charges,95% of Total Billed Charges,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.78,88,,266.224,Percent of Total Billed Charges,88% of Total Billed Charges,340.34,90,,272.272,Percent of Total Billed charges,90% of Total Billed Charges,166.77,378.16,
INJECTION IV PUSH,9400000007,CDM,940,RC,,,Outpatient,,,378.16,245.80,,378.16,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,287.4,76,,229.92,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,272.28,72,,217.824,Percent of Total Billed Charges,72% of Total Billed Charges,283.62,75,,226.896,Percent of Total Billed charges,75% of Total Billed Charges,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.28,72,,217.824,Percent of Total Billed Charges,72% of Total Billed Charges,226.9,60,,181.52,Percent of Total Billed Charges,60% of Total Billed Charges,340.34,90,,272.272,Percent of Total Billed Charges,90% of Total Billed Charges,170.17,45,,136.136,Percent of Total Billed Charges,45% of Total Billed Charges,340.34,90,,272.272,Percent of Total Billed Charges,90% of Total billed Charges,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.8,65,,196.64,Percent of total Billed Charges,65% of Total Billed Charges,166.77,44.1,,133.416,Percent of Total Billed Charges,44.1% of Total Billed Charges,359.25,95,,287.4,Percent of Total Billed Charges,95% of Total Billed Charges,378.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.78,88,,266.224,Percent of Total Billed Charges,88% of Total Billed Charges,340.34,90,,272.272,Percent of Total Billed charges,90% of Total Billed Charges,166.77,378.16,
IND MNT EA 15MIN AFTER 2ND REF,9420000001,CDM,942,RC,G0270,HCPCS,Outpatient,,,210.00,136.50,,37.68,125,,,Fee Schedule,125% of CMS OPPS Rate,159.6,76,,127.68,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,80.05,350,,,Fee Schedule,350% of BCBS fee schedule,80.05,350,,,Fee Schedule,350% of BCBS fee schedule,30.14,100,,,Fee Schedule,100% of CMS OPPS Rate,80.05,286,,,Fee Schedule,286% of BCBS PPO fee schedule,27.99,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,189,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,94.5,45,,75.6,Percent of Total Billed Charges,45% of Total Billed Charges,189,90,,151.2,Percent of Total Billed Charges,90% of Total billed Charges,30.14,100,,,Fee Schedule,100% of CMS OPPS Rate,30.14,100,,,Fee Schedule,100% of CMS OPPS Rate,30.14,100,,,Fee Schedule,100% of CMS OPPS Rate,60.28,200,,,Fee Schedule,200% of CMS OPPS Rate,92.61,44.1,,74.088,Percent of Total Billed Charges,44.1% of Total Billed Charges,199.5,95,,159.6,Percent of Total Billed Charges,95% of Total Billed Charges,22.61,75,,,Fee Schedule,75% of CMS OPPS Rate,184.8,88,,147.84,Percent of Total Billed Charges,88% of Total Billed Charges,189,90,,151.2,Percent of Total Billed charges,90% of Total Billed Charges,22.61,199.5,
MED NUT EDU GRP (>2) EA 30 MIN,9420000002,CDM,942,RC,,,Outpatient,,,44.79,29.11,,44.79,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,34.04,76,,27.232,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,32.25,72,,25.8,Percent of Total Billed Charges,72% of Total Billed Charges,33.59,75,,26.872,Percent of Total Billed charges,75% of Total Billed Charges,44.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.25,72,,25.8,Percent of Total Billed Charges,72% of Total Billed Charges,26.87,60,,21.496,Percent of Total Billed Charges,60% of Total Billed Charges,40.31,90,,32.248,Percent of Total Billed Charges,90% of Total Billed Charges,20.16,45,,16.128,Percent of Total Billed Charges,45% of Total Billed Charges,40.31,90,,32.248,Percent of Total Billed Charges,90% of Total billed Charges,44.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.11,65,,23.288,Percent of total Billed Charges,65% of Total Billed Charges,19.75,44.1,,15.8,Percent of Total Billed Charges,44.1% of Total Billed Charges,42.55,95,,34.04,Percent of Total Billed Charges,95% of Total Billed Charges,44.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.42,88,,31.536,Percent of Total Billed Charges,88% of Total Billed Charges,40.31,90,,32.248,Percent of Total Billed charges,90% of Total Billed Charges,19.75,44.79,
MED NUTR THER RE ASSE EA 15 MN,9420000003,CDM,942,RC,,,Outpatient,,,81.21,52.79,,81.21,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,61.72,76,,49.376,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,58.47,72,,46.776,Percent of Total Billed Charges,72% of Total Billed Charges,60.91,75,,48.728,Percent of Total Billed charges,75% of Total Billed Charges,81.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.47,72,,46.776,Percent of Total Billed Charges,72% of Total Billed Charges,48.73,60,,38.984,Percent of Total Billed Charges,60% of Total Billed Charges,73.09,90,,58.472,Percent of Total Billed Charges,90% of Total Billed Charges,36.54,45,,29.232,Percent of Total Billed Charges,45% of Total Billed Charges,73.09,90,,58.472,Percent of Total Billed Charges,90% of Total billed Charges,81.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.79,65,,42.232,Percent of total Billed Charges,65% of Total Billed Charges,35.81,44.1,,28.648,Percent of Total Billed Charges,44.1% of Total Billed Charges,77.15,95,,61.72,Percent of Total Billed Charges,95% of Total Billed Charges,81.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.46,88,,57.168,Percent of Total Billed Charges,88% of Total Billed Charges,73.09,90,,58.472,Percent of Total Billed charges,90% of Total Billed Charges,35.81,81.21,
MED NUTRI THER INIT EA 15 MIN,9420000004,CDM,942,RC,,,Outpatient,,,95.85,62.30,,95.85,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,72.85,76,,58.28,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,69.01,72,,55.208,Percent of Total Billed Charges,72% of Total Billed Charges,71.89,75,,57.512,Percent of Total Billed charges,75% of Total Billed Charges,95.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.01,72,,55.208,Percent of Total Billed Charges,72% of Total Billed Charges,57.51,60,,46.008,Percent of Total Billed Charges,60% of Total Billed Charges,86.27,90,,69.016,Percent of Total Billed Charges,90% of Total Billed Charges,43.13,45,,34.504,Percent of Total Billed Charges,45% of Total Billed Charges,86.27,90,,69.016,Percent of Total Billed Charges,90% of Total billed Charges,95.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.3,65,,49.84,Percent of total Billed Charges,65% of Total Billed Charges,42.27,44.1,,33.816,Percent of Total Billed Charges,44.1% of Total Billed Charges,91.06,95,,72.848,Percent of Total Billed Charges,95% of Total Billed Charges,95.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.35,88,,67.48,Percent of Total Billed Charges,88% of Total Billed Charges,86.27,90,,69.016,Percent of Total Billed charges,90% of Total Billed Charges,42.27,95.85,
INDIVIDUAL OUTPT DSMT 30MIN,9420000005,CDM,942,RC,G0108,HCPCS,Outpatient,,,170.00,110.50,,64.64,125,,,Fee Schedule,125% of CMS OPPS Rate,129.2,76,,103.36,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,154.98,350,,,Fee Schedule,350% of BCBS fee schedule,154.98,350,,,Fee Schedule,350% of BCBS fee schedule,51.71,100,,,Fee Schedule,100% of CMS OPPS Rate,154.98,286,,,Fee Schedule,286% of BCBS PPO fee schedule,54.19,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,153,90,,122.4,Percent of Total Billed Charges,90% of Total Billed Charges,76.5,45,,61.2,Percent of Total Billed Charges,45% of Total Billed Charges,153,90,,122.4,Percent of Total Billed Charges,90% of Total billed Charges,51.71,100,,,Fee Schedule,100% of CMS OPPS Rate,51.71,100,,,Fee Schedule,100% of CMS OPPS Rate,51.71,100,,,Fee Schedule,100% of CMS OPPS Rate,103.42,200,,,Fee Schedule,200% of CMS OPPS Rate,74.97,44.1,,59.976,Percent of Total Billed Charges,44.1% of Total Billed Charges,161.5,95,,129.2,Percent of Total Billed Charges,95% of Total Billed Charges,38.78,75,,,Fee Schedule,75% of CMS OPPS Rate,149.6,88,,119.68,Percent of Total Billed Charges,88% of Total Billed Charges,153,90,,122.4,Percent of Total Billed charges,90% of Total Billed Charges,38.78,161.5,
GROUP OUTPT DSMT PER 30MIN,9420000006,CDM,942,RC,G0109,HCPCS,Outpatient,,,110.00,71.50,,18.5,125,,,Fee Schedule,125% of CMS OPPS Rate,83.6,76,,66.88,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,42.07,350,,,Fee Schedule,350% of BCBS fee schedule,42.07,350,,,Fee Schedule,350% of BCBS fee schedule,14.8,100,,,Fee Schedule,100% of CMS OPPS Rate,42.07,286,,,Fee Schedule,286% of BCBS PPO fee schedule,14.71,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,99,90,,79.2,Percent of Total Billed Charges,90% of Total Billed Charges,49.5,45,,39.6,Percent of Total Billed Charges,45% of Total Billed Charges,99,90,,79.2,Percent of Total Billed Charges,90% of Total billed Charges,14.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14.8,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,200,,,Fee Schedule,200% of CMS OPPS Rate,48.51,44.1,,38.808,Percent of Total Billed Charges,44.1% of Total Billed Charges,104.5,95,,83.6,Percent of Total Billed Charges,95% of Total Billed Charges,11.1,75,,,Fee Schedule,75% of CMS OPPS Rate,96.8,88,,77.44,Percent of Total Billed Charges,88% of Total Billed Charges,99,90,,79.2,Percent of Total Billed charges,90% of Total Billed Charges,11.1,104.5,
CARD REHAB wo continuous ECGmonitoring,9430000001,CDM,943,RC,,,Outpatient,,,306.69,199.35,,306.69,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,233.08,76,,186.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,220.82,72,,176.656,Percent of Total Billed Charges,72% of Total Billed Charges,230.02,75,,184.016,Percent of Total Billed charges,75% of Total Billed Charges,306.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.82,72,,176.656,Percent of Total Billed Charges,72% of Total Billed Charges,184.01,60,,147.208,Percent of Total Billed Charges,60% of Total Billed Charges,276.02,90,,220.816,Percent of Total Billed Charges,90% of Total Billed Charges,138.01,45,,110.408,Percent of Total Billed Charges,45% of Total Billed Charges,276.02,90,,220.816,Percent of Total Billed Charges,90% of Total billed Charges,306.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.35,65,,159.48,Percent of total Billed Charges,65% of Total Billed Charges,135.25,44.1,,108.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,291.36,95,,233.088,Percent of Total Billed Charges,95% of Total Billed Charges,306.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.89,88,,215.912,Percent of Total Billed Charges,88% of Total Billed Charges,276.02,90,,220.816,Percent of Total Billed charges,90% of Total Billed Charges,135.25,306.69,
CARDIAC REHAB/MONITOR,9430000002,CDM,943,RC,,,Outpatient,,,292.00,189.80,,292,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,221.92,76,,177.536,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,210.24,72,,168.192,Percent of Total Billed Charges,72% of Total Billed Charges,219,75,,175.2,Percent of Total Billed charges,75% of Total Billed Charges,292,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.24,72,,168.192,Percent of Total Billed Charges,72% of Total Billed Charges,175.2,60,,140.16,Percent of Total Billed Charges,60% of Total Billed Charges,262.8,90,,210.24,Percent of Total Billed Charges,90% of Total Billed Charges,131.4,45,,105.12,Percent of Total Billed Charges,45% of Total Billed Charges,262.8,90,,210.24,Percent of Total Billed Charges,90% of Total billed Charges,292,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.8,65,,151.84,Percent of total Billed Charges,65% of Total Billed Charges,128.77,44.1,,103.016,Percent of Total Billed Charges,44.1% of Total Billed Charges,277.4,95,,221.92,Percent of Total Billed Charges,95% of Total Billed Charges,292,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.96,88,,205.568,Percent of Total Billed Charges,88% of Total Billed Charges,262.8,90,,210.24,Percent of Total Billed charges,90% of Total Billed Charges,128.77,292,
INTENS CARDIAC REHAB W/EXERC,9430000003,CDM,943,RC,G0422,HCPCS,Outpatient,,,306.69,199.35,,158.26,125,,,Fee Schedule,125% of CMS OPPS Rate,233.08,76,,186.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,332.56,350,,,Fee Schedule,350% of BCBS fee schedule,332.56,350,,,Fee Schedule,350% of BCBS fee schedule,126.61,100,,,Fee Schedule,100% of CMS OPPS Rate,332.56,286,,,Fee Schedule,286% of BCBS PPO fee schedule,116.28,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,276.02,90,,220.816,Percent of Total Billed Charges,90% of Total Billed Charges,138.01,45,,110.408,Percent of Total Billed Charges,45% of Total Billed Charges,276.02,90,,220.816,Percent of Total Billed Charges,90% of Total billed Charges,126.61,100,,,Fee Schedule,100% of CMS OPPS Rate,126.61,100,,,Fee Schedule,100% of CMS OPPS Rate,126.61,100,,,Fee Schedule,100% of CMS OPPS Rate,236.45,200,,,Fee Schedule,200% of CMS OPPS Rate,135.25,44.1,,108.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,291.36,95,,233.088,Percent of Total Billed Charges,95% of Total Billed Charges,94.95,75,,,Fee Schedule,75% of CMS OPPS Rate,269.89,88,,215.912,Percent of Total Billed Charges,88% of Total Billed Charges,276.02,90,,220.816,Percent of Total Billed charges,90% of Total Billed Charges,94.95,332.56,
INTENS CARDIAC REHAB NO EXER,9430000004,CDM,943,RC,G0423,HCPCS,Outpatient,,,306.69,199.35,,158.26,125,,,Fee Schedule,125% of CMS OPPS Rate,233.08,76,,186.464,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,332.56,350,,,Fee Schedule,350% of BCBS fee schedule,332.56,350,,,Fee Schedule,350% of BCBS fee schedule,126.61,100,,,Fee Schedule,100% of CMS OPPS Rate,332.56,286,,,Fee Schedule,286% of BCBS PPO fee schedule,116.28,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,276.02,90,,220.816,Percent of Total Billed Charges,90% of Total Billed Charges,138.01,45,,110.408,Percent of Total Billed Charges,45% of Total Billed Charges,276.02,90,,220.816,Percent of Total Billed Charges,90% of Total billed Charges,126.61,100,,,Fee Schedule,100% of CMS OPPS Rate,126.61,100,,,Fee Schedule,100% of CMS OPPS Rate,126.61,100,,,Fee Schedule,100% of CMS OPPS Rate,236.45,200,,,Fee Schedule,200% of CMS OPPS Rate,135.25,44.1,,108.2,Percent of Total Billed Charges,44.1% of Total Billed Charges,291.36,95,,233.088,Percent of Total Billed Charges,95% of Total Billed Charges,94.95,75,,,Fee Schedule,75% of CMS OPPS Rate,269.89,88,,215.912,Percent of Total Billed Charges,88% of Total Billed Charges,276.02,90,,220.816,Percent of Total Billed charges,90% of Total Billed Charges,94.95,332.56,
REFRIGERATOR KEY,9990000001,CDM,999,RC,,,Outpatient,,,1.10,0.72,,1.1,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,0.84,76,,0.672,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.83,75,,0.664,Percent of Total Billed charges,75% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.79,72,,0.632,Percent of Total Billed Charges,72% of Total Billed Charges,0.66,60,,0.528,Percent of Total Billed Charges,60% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total Billed Charges,0.5,45,,0.4,Percent of Total Billed Charges,45% of Total Billed Charges,0.99,90,,0.792,Percent of Total Billed Charges,90% of Total billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.72,65,,0.576,Percent of total Billed Charges,65% of Total Billed Charges,0.49,44.1,,0.392,Percent of Total Billed Charges,44.1% of Total Billed Charges,1.05,95,,0.84,Percent of Total Billed Charges,95% of Total Billed Charges,1.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,0.99,90,,0.792,Percent of Total Billed charges,90% of Total Billed Charges,0.49,1.1,
PCA KEY,9990000002,CDM,999,RC,,,Outpatient,,,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,4.96,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
LATEX CART KEY,9990000003,CDM,999,RC,,,Outpatient,,,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,4.96,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
L&D MEDICATION KEY,9990000004,CDM,999,RC,,,Outpatient,,,5.51,3.58,,5.51,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,4.19,76,,3.352,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.97,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,4.13,75,,3.304,Percent of Total Billed charges,75% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.97,72,,3.176,Percent of Total Billed Charges,72% of Total Billed Charges,3.31,60,,2.648,Percent of Total Billed Charges,60% of Total Billed Charges,4.96,90,,3.968,Percent of Total Billed Charges,90% of Total Billed Charges,2.48,45,,1.984,Percent of Total Billed Charges,45% of Total Billed Charges,4.96,90,,3.968,Percent of Total Billed Charges,90% of Total billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.58,65,,2.864,Percent of total Billed Charges,65% of Total Billed Charges,2.43,44.1,,1.944,Percent of Total Billed Charges,44.1% of Total Billed Charges,5.23,95,,4.184,Percent of Total Billed Charges,95% of Total Billed Charges,5.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,4.96,90,,3.968,Percent of Total Billed charges,90% of Total Billed Charges,2.43,5.51,
INCISION OF TOE TENDON,P960003212,CDM,960,RC,28010,HCPCS,Outpatient,,,510.38,331.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,202.95,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,202.95,202.95,
Excn Pilondial Cyst/Sinus cmpl,P960001968,CDM,960,RC,11772,HCPCS,Outpatient,,,1416.80,920.92,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,656.49,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,656.49,656.49,
80 Partial Hysterectomy,P960001973,CDM,960,RC,58180,HCPCS,Outpatient,,,2234.63,1452.51,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,823.33,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,823.33,823.33,
"Multiplex Test(Covid,RSV,Flu)",P960003162,CDM,960,RC,87637,HCPCS,Outpatient,,,356.57,231.77,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,121.24,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,121.24,121.24,
REMOVE VAGINA GLAND  LESION,P960003219,CDM,960,RC,56740,HCPCS,Outpatient,,,770.25,500.66,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,263.44,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,263.44,263.44,
LAP COLECTOMY PART W/ILEUM,P960003107,CDM,960,RC,44205,HCPCS,Outpatient,,,3209.70,2086.31,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1466.7,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1466.7,1466.7,
REVISION OF SCROTUM,P960003209,CDM,960,RC,55175,HCPCS,Outpatient,,,891.25,579.31,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,311.21,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,311.21,311.21,
BEHAV CHNG SMOKING<10MIN,P960000724,CDM,960,RC,99407,HCPCS,Outpatient,,,55.00,35.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20.36,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,20.36,20.36,
LONG LEG CAST,P960000222,CDM,960,RC,29345,HCPCS,Outpatient,,,265.00,172.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,115.35,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,115.35,115.35,
INCISION OF ANAL ABSCESS,P960000289,CDM,960,RC,46050,HCPCS,Outpatient,,,388.00,252.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,236.84,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,236.84,236.84,
REP SUPERFICIAL WND(S) 2.6-7.5,P960000080,CDM,960,RC,12002,HCPCS,Outpatient,,,210.00,136.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,99.27,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,99.27,99.27,
"CYSTOSCOPY, REMOVAL OF CLOTS",P960000335,CDM,960,RC,52001,HCPCS,Outpatient,,,733.00,476.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,345.87,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,345.87,345.87,
SKIN SUB GRAFT TRNK/ARM/LEG,P960000098,CDM,960,RC,15271,HCPCS,Outpatient,,,271.00,176.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,135.27,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,135.27,135.27,
DESTROY VULVA LESION/S COMPL,P960000391,CDM,960,RC,56515,HCPCS,Outpatient,,,442.00,287.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,213.95,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,213.95,213.95,
REPAIR FISTULA W/COLOSTOMY,P960000287,CDM,960,RC,45805,HCPCS,Outpatient,,,2845.00,1849.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1608.12,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1608.12,1608.12,
CYSTO AND TREAT 0.5-2.0,P960000340,CDM,960,RC,52234,HCPCS,Outpatient,,,495.00,321.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,206.92,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,206.92,206.92,
CRYOTHERAPY OF SKIN,P960000111,CDM,960,RC,17340,HCPCS,Outpatient,,,101.00,65.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,47.65,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,47.65,47.65,
TREAT FINGER FRAC CLOSED,P960000160,CDM,960,RC,26720,HCPCS,Outpatient,,,381.00,247.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,169.7,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,169.7,169.7,
AMPUTATE LEG AT THIGH,P960000182,CDM,960,RC,27590,HCPCS,Outpatient,,,1590.00,1033.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,686.19,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,686.19,686.19,
ASSAY TEST FOR BLOOD FECAL,P960000466,CDM,960,RC,82274,HCPCS,Outpatient,,,44.00,28.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,10.29,10.29,
EXC FACE-MM B9 MARG 0.6-1 CM,P960000048,CDM,960,RC,11441,HCPCS,Outpatient,,,323.00,209.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,154.17,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,154.17,154.17,
ANTEPARTUM CARE ONLY 4-6 VISIT,P960000438,CDM,960,RC,59425,HCPCS,Outpatient,,,892.00,579.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,312.38,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,312.38,312.38,
"FLU VACCINE, 6-35 MO, IM",P960000490,CDM,960,RC,90655,HCPCS,Outpatient,,,66.00,42.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17.32,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,17.32,17.32,
"INJECT, PROGESTERONE, 50 MG",P960000697,CDM,960,RC,J2675,HCPCS,Outpatient,,,4.00,2.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1.25,1.25,
80 COLOSTOMY,P960000919,CDM,960,RC,44320,HCPCS,Outpatient,,,2385.00,1550.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1316.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1316.1,1316.1,
ADM/DC SAME DAY-MOD CPLX,P960000621,CDM,960,RC,99235,HCPCS,Outpatient,,,333.00,216.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,119.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,119.3,119.3,
DRESS CHG OR DEBRID,P960000103,CDM,960,RC,16020,HCPCS,Outpatient,,,158.00,102.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,74.04,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,74.04,74.04,
I & D OF VULVA/PERINEUM,P960000387,CDM,960,RC,56405,HCPCS,Outpatient,,,213.00,138.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,108.65,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,108.65,108.65,
HEMOGLOBIN,P960000468,CDM,960,RC,85018,HCPCS,Outpatient,,,55.65,36.17,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.53,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1.53,1.53,
INCISION OF WINDPIPE,P960000238,CDM,960,RC,31605,HCPCS,Outpatient,,,367.00,238.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,302.28,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,302.28,302.28,
TOTAL HYSTERECTOMY,P960000410,CDM,960,RC,58150,HCPCS,Outpatient,,,2000.00,1300.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,864.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,864.82,864.82,
"CYSTO/URETERO, STONE REMOVE",P960000352,CDM,960,RC,52344,HCPCS,Outpatient,,,743.00,482.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,310.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,310.9,310.9,
EXC FACE-MM MALIG MARG 2.1-3,P960000063,CDM,960,RC,11643,HCPCS,Outpatient,,,620.00,403.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,286.51,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,286.51,286.51,
SHAVE TRUNK 1.1-2 CM,P960000026,CDM,960,RC,11302,HCPCS,Outpatient,,,273.00,177.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,126.09,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,126.09,126.09,
APPENDECTOMY ADD-ON,P960000274,CDM,960,RC,44955,HCPCS,Outpatient,,,168.00,109.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,91.72,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,91.72,91.72,
KNEE ARTHR/SURG ARTICULAR,P960000233,CDM,960,RC,29877,HCPCS,Outpatient,,,1220.00,793.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,536.72,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,536.72,536.72,
20 PARTIAL REMOVAL OF COLON,P960000872,CDM,960,RC,44140,HCPCS,Outpatient,,,2664.00,1731.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1470.97,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1470.97,1470.97,
Sigmoidoscopy w lesion remv,P960000965,CDM,960,RC,45338,HCPCS,Outpatient,,,757.43,492.33,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,306.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,306.43,306.43,
ANN WELL VST; PPS SUBSQT VST,P960000686,CDM,960,RC,G0439,HCPCS,Outpatient,,,226.00,146.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,84.61,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,84.61,84.61,
20 REMOVAL OF GALLBLADDER,P960000877,CDM,960,RC,47600,HCPCS,Outpatient,,,2114.00,1374.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1171.77,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1171.77,1171.77,
80 REMOVAL OF OVARY/TUBE(S),P960000935,CDM,960,RC,58720,HCPCS,Outpatient,,,1450.00,942.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,636.92,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,636.92,636.92,
INS CATH REN ART 1ST BILAT,P960000967,CDM,960,RC,36252,HCPCS,Outpatient,,,890.48,578.81,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,890.48,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,890.48,890.48,
INIT HOSP-MOD CPLX,P960000612,CDM,960,RC,99222,HCPCS,Outpatient,,,270.00,175.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,97.04,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,97.04,97.04,
80 LIGATE OVI DUCT(S) ADD ON,P960000934,CDM,960,RC,58611,HCPCS,Outpatient,,,152.00,98.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,66.19,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,66.19,66.19,
RIV4 VACC RECOMBINANT DNA IM,P960000838,CDM,960,RC,90682,HCPCS,Outpatient,,,149.60,97.24,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,54.56,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,54.56,54.56,
CL EV FISTULA W INT RESECT,P960000910,CDM,960,RC,44661,HCPCS,Outpatient,,,3853.20,2504.58,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1703.11,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1703.11,1703.11,
80 INCISION OF GALLBLADDER,P960000921,CDM,960,RC,47480,HCPCS,Outpatient,,,2180.50,1417.33,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,963.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,963.78,963.78,
80 LAPOROSCOPIC CHOLECYSTECTOM,P960000922,CDM,960,RC,47562,HCPCS,Outpatient,,,1301.00,845.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,721.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,721.23,721.23,
DEPO-PROVERA,P960000691,CDM,960,RC,J1050,HCPCS,Outpatient,,,120.00,78.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.5,0.5,
"80 MAST, MOD RAD",P960000912,CDM,960,RC,19307,HCPCS,Outpatient,,,2847.08,1850.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1092.28,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1092.28,1092.28,
IRRIGATION TRAY,P960000844,CDM,960,RC,,,Outpatient,,,7.87,5.12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7.87,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,7.87,7.87,
INTERMIT URIN CATH; STRAIT TIP,P960000670,CDM,960,RC,A4351,HCPCS,Outpatient,,,8.00,5.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.79,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1.79,1.79,
PREVENT CARE NEW PT. AGE 12-17,P960000645,CDM,960,RC,99384,HCPCS,Outpatient,,,502.00,326.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,96.11,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,96.11,96.11,
80 INTRA-ABD OMENTAL FLAP,P960000932,CDM,960,RC,49905,HCPCS,Outpatient,,,878.63,571.11,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,388.36,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,388.36,388.36,
UNLISTED E/M R/S AND CX'S,P960000903,CDM,960,RC,99499,HCPCS,Outpatient,,,276.00,179.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,276,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,276,276,
COLO CNCR SCR;COLNS NO HI RSK,P960000680,CDM,960,RC,G0121,HCPCS,Outpatient,,,612.00,397.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,242.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,242.82,242.82,
80 EXPLORATION OF ABDOMEN,P960000925,CDM,960,RC,49000,HCPCS,Outpatient,,,1526.00,991.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,842.69,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,842.69,842.69,
PREV CARE NEW PT. AGE <1 YR,P960000642,CDM,960,RC,99381,HCPCS,Outpatient,,,410.00,266.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,77.7,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,77.7,77.7,
IRRIGATION TRAY,P960000844,CDM,960,RC,,,Outpatient,,,7.87,5.12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7.87,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,7.87,7.87,
INPT/TELE FOLLOW UP 15,P960000804,CDM,960,RC,,,Outpatient,,,97.00,63.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,97,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,97,97,
PSYTX PT&/FAMILY 60 MINUTES,P960000547,CDM,960,RC,90837,HCPCS,Outpatient,,,369.07,239.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,117.89,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,117.89,117.89,
PROL CARE 1ST HR W/O CONTACT,P960000641,CDM,960,RC,99358,HCPCS,Outpatient,,,220.00,143.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,78.87,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,78.87,78.87,
20 FREEING OF BOWEL ADHESION,P960000870,CDM,960,RC,44005,HCPCS,Outpatient,,,2173.00,1412.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1198.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1198.29,1198.29,
INTERROG DEV EVAL SCRMS IP,P960000960,CDM,960,RC,93291,HCPCS,Outpatient,,,46.83,30.44,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,34.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,34.45,34.45,
ROTAVIRUS,P960000502,CDM,960,RC,90680,HCPCS,Outpatient,,,450.00,292.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,89.51,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,89.51,89.51,
NEB/MDI DEMO,P960000585,CDM,960,RC,94664,HCPCS,Outpatient,,,33.00,21.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18.87,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,18.87,18.87,
IIV4 VAC SPLT 0.5 ML IM STATE,P960000759,CDM,960,RC,90688,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IC INF PBW 2501-5000 G SUBSQ,P960000668,CDM,960,RC,99480,HCPCS,Outpatient,,,238.00,154.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,84.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,84.76,84.76,
EX ARM/ELBOW TUM DEEP 5 CM/>,P960000948,CDM,960,RC,24073,HCPCS,Outpatient,,,1717.45,1116.34,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,601.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,601.45,601.45,
REM PHYSIOL MNTR EA ADDL 20,P960000954,CDM,960,RC,99458,HCPCS,Outpatient,,,105.55,68.61,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,29.05,29.05,
EXC NECK TUM DEEP 5 CM>,P960000766,CDM,960,RC,21554,HCPCS,Outpatient,,,1447.00,940.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,632.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,632.05,632.05,
INJ DIPHENHYDRA HCL UP 50 MG,P960000693,CDM,960,RC,J1200,HCPCS,Outpatient,,,6.00,3.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.91,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.91,0.91,
SINGLE LENS SPECTACLE MOUNT,P960000863,CDM,960,RC,,,Outpatient,,,275.00,178.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,275,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,275,275,
"Lt Compres band >=3""<5/yd",P960000999,CDM,960,RC,,,Outpatient,,,68.35,44.43,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,68.35,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,68.35,68.35,
Exision Malig lesion level 2,P960002010,CDM,960,RC,11620,HCPCS,Outpatient,,,297.88,193.62,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,177.96,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,177.96,177.96,
80 Gastrostomy Rep w Img guidn,P960000990,CDM,960,RC,49450,HCPCS,Outpatient,,,160.25,104.16,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,160.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,160.25,160.25,
80 D & C diagnostic,P960001948,CDM,960,RC,58120,HCPCS,Outpatient,,,570.60,370.89,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,238.51,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,238.51,238.51,
REMOVE THYROID DUCT LESION,P960000447,CDM,960,RC,60280,HCPCS,Outpatient,,,869.00,564.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,373.31,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,373.31,373.31,
PROLONG CLINCL STAFF SVC ADD,P960000658,CDM,960,RC,99416,HCPCS,Outpatient,,,9.00,5.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.93,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2.93,2.93,
Intra Abd Omental Flap,P960000985,CDM,960,RC,49905,HCPCS,Outpatient,,,777.45,505.34,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,388.36,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,388.36,388.36,
CARDIOVASCULAR STRESS TEST,P960002063,CDM,960,RC,93016,HCPCS,Outpatient,,,53.15,34.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18.12,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,18.12,18.12,
LSH Uterus 250gm or less,P960001934,CDM,960,RC,58541,HCPCS,Outpatient,,,1781.48,1157.96,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,623.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,623.29,623.29,
Bx/exc lymph nd Open deep axil,P960002035,CDM,960,RC,38525,HCPCS,Outpatient,,,1060.48,689.31,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,367.41,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,367.41,367.41,
20 RPR AA HERNIA 1ST>10CM NCRC,P960003065,CDM,960,RC,49596,HCPCS,Outpatient,,,2402.37,1561.54,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2402.37,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2402.37,2402.37,
Aortic Balloon plcmt Percutan,P960001988,CDM,960,RC,33967,HCPCS,Outpatient,,,620.20,403.13,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,217.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,217.76,217.76,
Endometr Ablate Thermal,P960002005,CDM,960,RC,58353,HCPCS,Outpatient,,,561.03,364.67,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,561.03,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,561.03,561.03,
Zilretta Inj 1mg,P960001970,CDM,960,RC,,,Outpatient,,,44.73,29.07,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,44.73,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,44.73,44.73,
REMOVAL SWEAT GLAND LESION,P960000740,CDM,960,RC,11451,HCPCS,Outpatient,,,935.00,607.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,456.21,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,456.21,456.21,
RPR AA HERNIA 1ST 3-10CM REDUC,P960003039,CDM,960,RC,49593,HCPCS,Outpatient,,,1344.52,873.94,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1344.52,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1344.52,1344.52,
80 LSH Uterus 250gm or less,P960001935,CDM,960,RC,58541,HCPCS,Outpatient,,,1781.48,1157.96,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,623.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,623.29,623.29,
TETRACAINE 0.5% OPHTH SOLN,P960003187,CDM,960,RC,,,Outpatient,,,59.49,38.67,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,59.49,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,59.49,59.49,
Total Contact Leg Cast,P960001971,CDM,960,RC,29445,HCPCS,Outpatient,,,244.28,158.78,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,112.51,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,112.51,112.51,
80 RPR AA HERNIA RECR >10CM NC,P960003076,CDM,960,RC,49618,HCPCS,Outpatient,,,2910.67,1891.94,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2910.67,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2910.67,2910.67,
20 RPR AA HERNIA 1ST>10CM RED,P960003059,CDM,960,RC,49595,HCPCS,Outpatient,,,1808.62,1175.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1808.62,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1808.62,1808.62,
Exc Foot Cyst/ Ganglion,P960001972,CDM,960,RC,28090,HCPCS,Outpatient,,,748.90,486.79,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,407.15,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,407.15,407.15,
INFLU FLU PEDS 6-35MO,P960000757,CDM,960,RC,90687,HCPCS,Outpatient,,,25.00,16.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,8.58,8.58,
80 Rep Inguinal Hernia,P960000975,CDM,960,RC,49507,HCPCS,Outpatient,,,1310.20,851.63,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,641.63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,641.63,641.63,
EXC HAND TUM DEEP 1.5 CM/>,P960003112,CDM,960,RC,26113,HCPCS,Outpatient,,,1339.75,870.84,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,473.2,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,473.2,473.2,
HEPATITIS A (PEDIATRICS),P960000747,CDM,960,RC,90633,HCPCS,Outpatient,,,104.00,67.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,35.16,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,35.16,35.16,
Tracheobronchoscopy est trach,P960002026,CDM,960,RC,31615,HCPCS,Outpatient,,,425.48,276.56,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,152.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,152.78,152.78,
20Wound expl pen abd/flnk/back,P960001930,CDM,960,RC,20102,HCPCS,Outpatient,,,612.98,398.44,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,440.4,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,440.4,440.4,
Coronary Art Angiogram S & I,P960001991,CDM,960,RC,93454,HCPCS,Outpatient,,,571.30,371.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,571.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,571.3,571.3,
Repair of Corporeal Tear,P960003078,CDM,960,RC,54437,HCPCS,Outpatient,,,1640.37,1066.24,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,579.72,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,579.72,579.72,
"Tenolysis,flx tnd plm/finger",P960001917,CDM,960,RC,26440,HCPCS,Outpatient,,,1620.30,1053.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,541.12,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,541.12,541.12,
Initial I/P pedi Critical Care,P960002031,CDM,960,RC,99471,HCPCS,Outpatient,,,1923.55,1250.31,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,563.81,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,563.81,563.81,
TREAT ECTOPIC PREGNANCY,P960003116,CDM,960,RC,59150,HCPCS,Outpatient,,,1915.55,1245.11,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,524.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,524.25,524.25,
CREP F/G/H/F 2.6-7.5 cm,P960001960,CDM,960,RC,13132,HCPCS,Outpatient,,,735.18,477.87,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,430.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,430.43,430.43,
Vag Hysterectomy,P960003024,CDM,960,RC,58260,HCPCS,Outpatient,,,2047.15,1330.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,715.77,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,715.77,715.77,
80RPR AA HERNIA 1ST>10 CM NCRC,P960003064,CDM,960,RC,49596,HCPCS,Outpatient,,,2402.37,1561.54,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2402.37,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2402.37,2402.37,
EXC TR-EXT MLG MARG 0.5<CM,P960000745,CDM,960,RC,11600,HCPCS,Outpatient,,,370.00,240.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,177.08,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,177.08,177.08,
PRQ CARDIAC ANGIOPLAST 1 ART,P960001986,CDM,960,RC,92920,HCPCS,Outpatient,,,1255.53,816.09,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,620.85,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,620.85,620.85,
RMVL FB UPPER ARM/ELBW SUBQ,P960003240,CDM,960,RC,24200,HCPCS,Outpatient,,,24200.00,15730.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,186.03,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,186.03,186.03,
repair stomach lesion,P960000982,CDM,960,RC,43840,HCPCS,Outpatient,,,3019.15,1962.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1491.16,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1491.16,1491.16,
Repr Foot Extensor Tendon Each,P960001976,CDM,960,RC,28208,HCPCS,Outpatient,,,775.63,504.16,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,419.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,419.25,419.25,
20wound expl penetr wound neck,P960001924,CDM,960,RC,20100,HCPCS,Outpatient,,,1450.93,943.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,523.39,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,523.39,523.39,
Destruction Benign les 15>,P960001964,CDM,960,RC,17111,HCPCS,Outpatient,,,196.68,127.84,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,117.65,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,117.65,117.65,
Vag Hysterectomy Uterus >250gm,P960003118,CDM,960,RC,58290,HCPCS,Outpatient,,,2811.20,1827.28,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,989.71,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,989.71,989.71,
SPLENECTOMY TOTAL SEPAR. PROCD,P960003109,CDM,960,RC,38100,HCPCS,Outpatient,,,2770.35,1800.73,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,971.8,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,971.8,971.8,
AUDIT/DAST 15-30 MIN,P960000726,CDM,960,RC,99409,HCPCS,Outpatient,,,144.23,93.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,49.36,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,49.36,49.36,
PPD SKIN TEST INJ,P960000716,CDM,960,RC,86580,HCPCS,Outpatient,,,15.44,10.04,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,5.68,5.68,
INTERPROF PHONE/ONLINE 31/>,P960000733,CDM,960,RC,99449,HCPCS,Outpatient,,,179.30,116.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,45.72,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,45.72,45.72,
ACNE SURGERY,P960000734,CDM,960,RC,10040,HCPCS,Outpatient,,,197.00,128.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,98.4,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,98.4,98.4,
Wound expl pen abd/flnk/back,P960001928,CDM,960,RC,20102,HCPCS,Outpatient,,,612.98,398.44,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,440.4,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,440.4,440.4,
Wound Pref F/N/HF/G 100Sq CM1%,P960001975,CDM,960,RC,15004,HCPCS,Outpatient,,,635.40,413.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,361.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,361.68,361.68,
TREAT METACARPAL FRACTURE,P960003228,CDM,960,RC,26600,HCPCS,Outpatient,,,720.80,468.52,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,254.8,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,254.8,254.8,
EXC TR-EXT MLG MARG 0.5<CM,P960000745,CDM,960,RC,11600,HCPCS,Outpatient,,,370.00,240.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,177.08,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,177.08,177.08,
Open tx radial shaft fracture,P960002001,CDM,960,RC,25515,HCPCS,Outpatient,,,1628.50,1058.53,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,578.59,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,578.59,578.59,
AUDIT/DAST 15-30 MIN,P960000725,CDM,960,RC,99408,HCPCS,Outpatient,,,164.00,106.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,25.45,25.45,
CMG; Patient prov sensor plcmt,P960003115,CDM,960,RC,95249,HCPCS,Outpatient,,,145.82,94.78,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,61.85,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,61.85,61.85,
80RPR AA HERNIA 1ST 3-10CM RED,P960003056,CDM,960,RC,49593,HCPCS,Outpatient,,,1344.52,873.94,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1344.52,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1344.52,1344.52,
"P/M COUNSEL,INDIV 60MIN",P960000723,CDM,960,RC,99404,HCPCS,Outpatient,,,257.15,167.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,80.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,80.73,80.73,
HEPATITIS A (PEDIATRICS),P960000747,CDM,960,RC,90633,HCPCS,Outpatient,,,104.00,67.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,35.16,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,35.16,35.16,
Incision of Gallbladder,P960001956,CDM,960,RC,47480,HCPCS,Outpatient,,,2126.00,1381.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,963.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,963.78,963.78,
EGD GUIDE WIRE INSERTION,P960002038,CDM,960,RC,43248,HCPCS,Outpatient,,,1050.88,683.07,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,420.94,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,420.94,420.94,
Partial removal of foot fascia,P960002083,CDM,960,RC,28060,HCPCS,Outpatient,,,1274.15,828.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,455.34,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,455.34,455.34,
IMPL ABSRB MSH/PRSTH DLY CLS,P960003050,CDM,960,RC,15778,HCPCS,Outpatient,,,902.77,586.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,902.77,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,902.77,902.77,
20RPR AA HERNIA 1ST 3-10CM RED,P960003057,CDM,960,RC,49593,HCPCS,Outpatient,,,1344.52,873.94,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1344.52,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1344.52,1344.52,
MUSCLE-SKIN GRAFT TRUNK,P960003190,CDM,960,RC,15734,HCPCS,Outpatient,,,3640.37,2366.24,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1368.52,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1368.52,1368.52,
Neg Press Wound Tx >50 cm,P960000998,CDM,960,RC,97606,HCPCS,Outpatient,,,68.35,44.43,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,60.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,60.1,60.1,
Strapping of toes,P960001003,CDM,960,RC,29550,HCPCS,Outpatient,,,27.83,18.09,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16.41,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,16.41,16.41,
REMOVAL SWEAT GLAND LESION,P960000740,CDM,960,RC,11451,HCPCS,Outpatient,,,935.00,607.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,456.21,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,456.21,456.21,
Excn Pilondial Cyst/sinus Extn,P960001967,CDM,960,RC,11771,HCPCS,Outpatient,,,1072.55,697.16,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,541.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,541.58,541.58,
RPR AA HERN 1ST 3CM NCRC8/STRN,P960003041,CDM,960,RC,49592,HCPCS,Outpatient,,,1116.32,725.61,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1116.32,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1116.32,1116.32,
Treatment of Tibia Fracture,P960002077,CDM,960,RC,27752,HCPCS,Outpatient,,,1310.25,851.66,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,461.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,461.82,461.82,
TRIM SKIN LESIONS OVER 4,P960000735,CDM,960,RC,11057,HCPCS,Outpatient,,,126.00,81.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,73.19,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,73.19,73.19,
Hysterectomy after c section,P960002009,CDM,960,RC,59525,HCPCS,Outpatient,,,1135.90,738.34,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,323.96,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,323.96,323.96,
Exploration of Hip jnt rmv fb,P960002028,CDM,960,RC,27033,HCPCS,Outpatient,,,2346.98,1525.54,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,842.46,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,842.46,842.46,
FEM/POPL REVAS W/TLA,P960003084,CDM,960,RC,37224,HCPCS,Outpatient,,,1045.68,679.69,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1045.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1045.68,1045.68,
20 LSH UTERUS ABOVE 250 GM,P960001942,CDM,960,RC,58543,HCPCS,Outpatient,,,2055.38,1336.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,720.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,720.3,720.3,
Durolane Inj 1 mg,P960003034,CDM,960,RC,,,Outpatient,,,23.15,15.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23.15,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,23.15,23.15,
Lap Hyst 250g or less r T/O,P960001007,CDM,960,RC,58571,HCPCS,Outpatient,,,2198.48,1429.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,766.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,766.73,766.73,
Trans Care Mgmt w Mod med dec,P960001000,CDM,960,RC,99495,HCPCS,Outpatient,,,351.98,228.79,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,129.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,129.25,129.25,
"Destruction, Malignant Lesion",P960003123,CDM,960,RC,17272,HCPCS,Outpatient,,,293.58,190.83,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,168.57,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,168.57,168.57,
80Wound expl pen abd/flnk/back,P960001929,CDM,960,RC,20102,HCPCS,Outpatient,,,612.98,398.44,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,440.4,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,440.4,440.4,
INTERPROF PHONE/ONLINE 31/>,P960000733,CDM,960,RC,99449,HCPCS,Outpatient,,,179.30,116.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,45.72,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,45.72,45.72,
POST OP FOLLOW UP VISIT,P960000756,CDM,960,RC,99024,HCPCS,Outpatient,,,43.50,28.28,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.88,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2.88,2.88,
20 RPR AA HERNIA RECR>10CM NCR,P960003077,CDM,960,RC,49618,HCPCS,Outpatient,,,2910.67,1891.94,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2910.67,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2910.67,2910.67,
INTERPROF PHONE/ONLINE 21-30,P960000732,CDM,960,RC,99448,HCPCS,Outpatient,,,134.53,87.44,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,34.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,34.3,34.3,
20 Partial hysterectomy,P960001974,CDM,960,RC,58180,HCPCS,Outpatient,,,2334.63,1517.51,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,823.33,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,823.33,823.33,
Mobile cardiac Telemetry,P960002006,CDM,960,RC,93228,HCPCS,Outpatient,,,63.23,41.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21.63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,21.63,21.63,
"INJ,ONDANSETRON HCL PER 1MG",P960000753,CDM,960,RC,,,Outpatient,,,1.12,0.73,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.12,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1.12,1.12,
Right Heart Cath,P960001979,CDM,960,RC,93451,HCPCS,Outpatient,,,312.85,203.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,312.85,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,312.85,312.85,
Office consultation,P960001953,CDM,960,RC,99245,HCPCS,Outpatient,,,535.75,348.24,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,141.61,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,141.61,141.61,
Rmvl foreign body deep thigh,P960003006,CDM,960,RC,27372,HCPCS,Outpatient,,,1460.75,949.49,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,516.51,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,516.51,516.51,
Wound Expl penetr wound neck,P960001922,CDM,960,RC,20100,HCPCS,Outpatient,,,1450.93,943.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,523.39,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,523.39,523.39,
REPAIR OF RUPTURED TENDON,P960003239,CDM,960,RC,24342,HCPCS,Outpatient,,,24342.00,15822.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,671.65,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,671.65,671.65,
"COVID19 VAC,NOVAVAX,5mcg/0.5ml",P960003155,CDM,960,RC,91304,HCPCS,Outpatient,,,370.50,240.83,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SIGMOIDOSCOPY W/PLCMT STENT,P960003111,CDM,960,RC,45347,HCPCS,Outpatient,,,369.47,240.16,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,170.36,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,170.36,170.36,
REMOVAL SWEAT GLAND LESION,P960000742,CDM,960,RC,11463,HCPCS,Outpatient,,,948.00,616.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,463.97,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,463.97,463.97,
80 LSH UTERUS ABOVE 250 GM,P960001941,CDM,960,RC,58543,HCPCS,Outpatient,,,2055.38,1336.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,720.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,720.3,720.3,
Removal of Anal Tags,P960003002,CDM,960,RC,46230,HCPCS,Outpatient,,,418.93,272.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,319.18,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,319.18,319.18,
20RPR AA HERNIA RECR 3-10CM NC,P960003075,CDM,960,RC,49616,HCPCS,Outpatient,,,2015.47,1310.06,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2015.47,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2015.47,2015.47,
EXC RECT TUM TRANSANAL FULL,P960002065,CDM,960,RC,45172,HCPCS,Outpatient,,,2007.75,1305.04,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,892.8,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,892.8,892.8,
Arthroscopy Knee w/ Menisc Rpr,P960003010,CDM,960,RC,29882,HCPCS,Outpatient,,,1668.63,1084.61,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,598.97,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,598.97,598.97,
TRIM SKIN LESIONS OVER 4,P960000735,CDM,960,RC,11057,HCPCS,Outpatient,,,126.00,81.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,73.19,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,73.19,73.19,
INFLU FLU PEDS 6-35MO,P960000757,CDM,960,RC,90687,HCPCS,Outpatient,,,25.00,16.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,8.58,8.58,
Exc leg/ankle les sc 3cm/>,P960002058,CDM,960,RC,27632,HCPCS,Outpatient,,,996.20,647.53,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,357.26,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,357.26,357.26,
20 Decompression of lower leg,P960003098,CDM,960,RC,27602,HCPCS,Outpatient,,,1149.10,746.92,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,418.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,418.45,418.45,
REMOVAL SWEAT GLAND LESION,P960000743,CDM,960,RC,11470,HCPCS,Outpatient,,,793.00,515.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,388.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,388.76,388.76,
Psy Tx Crisis initial 60 min,P960001997,CDM,960,RC,90839,HCPCS,Outpatient,,,313.83,203.99,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,143.41,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,143.41,143.41,
Mastectomy Gynecomastia,P960003120,CDM,960,RC,19300,HCPCS,Outpatient,,,1051.93,683.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,495.93,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,495.93,495.93,
ADDL 30MIN-W/O CONT,P960000719,CDM,960,RC,99359,HCPCS,Outpatient,,,106.00,68.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,38.41,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,38.41,38.41,
TIS TRNFR S/A/L 10 SQ CM/<,P960003130,CDM,960,RC,14020,HCPCS,Outpatient,,,1370.20,890.63,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,625.97,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,625.97,625.97,
Cholecystectomy w cholangriogr,P960000984,CDM,960,RC,47605,HCPCS,Outpatient,,,2506.85,1629.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1232.77,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1232.77,1232.77,
I&D BELW FASCIA FT 1 BURSA SPC,P960003124,CDM,960,RC,28002,HCPCS,Outpatient,,,341.77,222.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,341.77,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,341.77,341.77,
PART REMOVAL OF METATARSAL,P960003242,CDM,960,RC,28110,HCPCS,Outpatient,,,1112.03,722.82,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,403.33,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,403.33,403.33,
REMOVAL OF STOMACH PARTIAL,P960003032,CDM,960,RC,43633,HCPCS,Outpatient,,,4596.05,2987.43,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2109.16,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2109.16,2109.16,
"ONDANSETRON, ORAL, 4MG",P960003185,CDM,960,RC,,,Outpatient,,,6.50,4.23,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.5,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,6.5,6.5,
HIB PRP-OMP Vaccine,P960001995,CDM,960,RC,90647,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CPRIT CA Screen; Pelvic/breast,P960003053,CDM,960,RC,,,Outpatient,,,98.18,63.82,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,98.18,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,98.18,98.18,
COLONOSCOPY W/BAND LIGATION,P960002045,CDM,960,RC,45398,HCPCS,Outpatient,,,2123.80,1380.47,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,847.33,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,847.33,847.33,
DRAIN HAND TENDON SHEATH,P960002072,CDM,960,RC,26020,HCPCS,Outpatient,,,1355.60,881.14,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,478.86,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,478.86,478.86,
Repair webbed toe(s),P960002084,CDM,960,RC,28345,HCPCS,Outpatient,,,1768.48,1149.51,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,454.83,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,454.83,454.83,
Beyfortus Vaccine 1.0 mL/State,P960003142,CDM,960,RC,90381,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EXC THIGH/KNEE LES SC 3 CM/>,P960003026,CDM,960,RC,27337,HCPCS,Outpatient,,,1013.47,658.76,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,361.53,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,361.53,361.53,
REPAIR RECTUM & VAGINA,P960003233,CDM,960,RC,57250,HCPCS,Outpatient,,,1506.60,979.29,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,520.85,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,520.85,520.85,
MENB-4C VACC 2 DOSE IM,P960000750,CDM,960,RC,,,Outpatient,,,760.67,494.44,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,760.67,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,760.67,760.67,
Trans care Mgmt w High med dec,P960001001,CDM,960,RC,99496,HCPCS,Outpatient,,,478.95,311.32,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,170.62,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,170.62,170.62,
80 Removal of Ovary(s),P960000978,CDM,960,RC,58940,HCPCS,Outpatient,,,1258.90,818.29,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,460.98,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,460.98,460.98,
EXC ABDL TUM DEEP 5 CM/>,P960003113,CDM,960,RC,22901,HCPCS,Outpatient,,,1612.35,1048.03,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,577,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,577,577,
Secondary closure Surg wound,P960001955,CDM,960,RC,13160,HCPCS,Outpatient,,,1929.65,1254.27,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,724.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,724.9,724.9,
LSH UTERUS ABOVE 250 G,P960001940,CDM,960,RC,58543,HCPCS,Outpatient,,,2055.38,1336.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,720.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,720.3,720.3,
Induced Abortion by Dil & Evac,P960001951,CDM,960,RC,59841,HCPCS,Outpatient,,,2969.45,1930.14,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,271.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,271.05,271.05,
RHO D IMMUNE GLOBULIN INJ,P960000751,CDM,960,RC,,,Outpatient,,,234.00,152.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,234,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,234,234,
KNEE ARTHROSCOPY/SURGERY,P960003229,CDM,960,RC,29876,HCPCS,Outpatient,,,1600.03,1040.02,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,565.08,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,565.08,565.08,
EXC TUMR SFT TIS FACE/SCLP 2CM,P960002014,CDM,960,RC,21012,HCPCS,Outpatient,,,817.38,531.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,291.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,291.23,291.23,
20 Removal of Ovary(s),P960000979,CDM,960,RC,58940,HCPCS,Outpatient,,,1258.90,818.29,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,460.98,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,460.98,460.98,
20 Repair Bladder Wound,P960001947,CDM,960,RC,51860,HCPCS,Outpatient,,,1807.68,1174.99,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,625.54,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,625.54,625.54,
"P/M COUNSEL,INDIV 45MIN",P960000722,CDM,960,RC,99403,HCPCS,Outpatient,,,217.75,141.54,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,63,63,
Ed Level 2 Low/Mod,P960002047,CDM,960,RC,99282,HCPCS,Outpatient,,,102.88,66.87,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30.69,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,30.69,30.69,
BEHAV CHNG SMOKING<10MIN,P960000724,CDM,960,RC,99407,HCPCS,Outpatient,,,55.00,35.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20.36,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,20.36,20.36,
"Laparoscopy, surg w Lysis adh",P960000987,CDM,960,RC,58660,HCPCS,Outpatient,,,1650.10,1072.57,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,579.81,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,579.81,579.81,
Aneurysm Abd Aorta Rupture,P960000981,CDM,960,RC,35082,HCPCS,Outpatient,,,4735.93,3078.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1834.32,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1834.32,1834.32,
Excn Pilondial Cyst/sinus smpl,P960001966,CDM,960,RC,11770,HCPCS,Outpatient,,,448.70,291.66,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,279.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,279.76,279.76,
Angriography extremity unilat,P960002004,CDM,960,RC,75710,HCPCS,Outpatient,,,385.98,250.89,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,109.79,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,109.79,109.79,
Breast Biopsy w plcmt of devic,P960000996,CDM,960,RC,19081,HCPCS,Outpatient,,,402.43,261.58,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,402.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,402.43,402.43,
Exc Shldr Tumor Deep < 5cm,P960002076,CDM,960,RC,23076,HCPCS,Outpatient,,,1314.70,854.56,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,467.42,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,467.42,467.42,
RMOVL PERM PM PULSE GEN ONLY,P960002021,CDM,960,RC,33233,HCPCS,Outpatient,,,560.83,364.54,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,193.8,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,193.8,193.8,
"Ultrasonic guidnce, intraoper",P960003114,CDM,960,RC,76998,HCPCS,Outpatient,,,147.52,95.89,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,42.59,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,42.59,42.59,
Insertion of Cannula,P960002025,CDM,960,RC,36800,HCPCS,Outpatient,,,296.93,193.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,104.64,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,104.64,104.64,
ED Level 3 Moderate,P960002048,CDM,960,RC,99283,HCPCS,Outpatient,,,174.78,113.61,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,45.98,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,45.98,45.98,
Incision drain pil cyst compl,P960002036,CDM,960,RC,10081,HCPCS,Outpatient,,,861.63,560.06,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,273.09,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,273.09,273.09,
Prevnar 20 IM,P960003108,CDM,960,RC,90677,HCPCS,Outpatient,,,721.65,469.07,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,721.65,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,721.65,721.65,
RPR AA HERNIA RECR >10CM REDUC,P960003046,CDM,960,RC,49617,HCPCS,Outpatient,,,2077.90,1350.64,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2077.9,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2077.9,2077.9,
ADMN SARSCOV2 VACC 1 DOSE,P960003154,CDM,960,RC,90480,HCPCS,Outpatient,,,100.00,65.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,100,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,100,100,
RCNSTJ POLYDACTYLOUS Dgt Sof,P960003008,CDM,960,RC,26587,HCPCS,Outpatient,,,2524.75,1641.09,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,900.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,900.05,900.05,
DX BONE MARROW ASPIRATIONS,P960003238,CDM,960,RC,38220,HCPCS,Outpatient,,,376.60,244.79,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,139.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,139.1,139.1,
Exc Malig Lsn F/E/E/N/L 0.5cm<,P960001950,CDM,960,RC,11640,HCPCS,Outpatient,,,305.50,198.58,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,182.17,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,182.17,182.17,
REMOVE VAGINA WALL PARTIAL,P960003232,CDM,960,RC,57106,HCPCS,Outpatient,,,1313.50,853.78,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,440.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,440.05,440.05,
Induced abort vag supp,P960002030,CDM,960,RC,59855,HCPCS,Outpatient,,,1011.15,657.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,281.37,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,281.37,281.37,
"PROMETHAZINE HCL INJ,UPTO 50MG",P960000752,CDM,960,RC,,,Outpatient,,,6.00,3.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,6,6,
Destr of Penis Lesion extensiv,P960001969,CDM,960,RC,54065,HCPCS,Outpatient,,,413.98,269.09,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,185.95,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,185.95,185.95,
Psy Tx Crisis ea addtl 30 min,P960001998,CDM,960,RC,90840,HCPCS,Outpatient,,,149.90,97.44,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,71.7,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,71.7,71.7,
POST OP FOLLOW UP VISIT,P960000756,CDM,960,RC,99024,HCPCS,Outpatient,,,43.50,28.28,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.88,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2.88,2.88,
Skin Full Graft Trunk,P960003030,CDM,960,RC,15200,HCPCS,Outpatient,,,1617.57,1051.42,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,754.26,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,754.26,754.26,
Dis site telehealth RHC,P960000995,CDM,960,RC,,,Outpatient,,,164.83,107.14,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,164.83,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,164.83,164.83,
80 RPR AA HERNIA 1ST>10CM RED,P960003058,CDM,960,RC,49595,HCPCS,Outpatient,,,1808.62,1175.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1808.62,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1808.62,1808.62,
DRAIN NECK/CHEST LESION,P960002055,CDM,960,RC,21501,HCPCS,Outpatient,,,808.10,525.27,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,402.18,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,402.18,402.18,
80 RPR AA HERNIA 1ST<3CM NCRC8,P960003060,CDM,960,RC,49592,HCPCS,Outpatient,,,1116.32,725.61,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1116.32,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1116.32,1116.32,
N H Visit Initial High Compex,P960000971,CDM,960,RC,99306,HCPCS,Outpatient,,,374.33,243.31,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,117.85,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,117.85,117.85,
ARTHRT EXPL DRG/RMVL LOOSE/FB,P960003099,CDM,960,RC,26080,HCPCS,Outpatient,,,981.10,637.72,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,339.49,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,339.49,339.49,
"P/M COUNSEL,INDIV 15MIN",P960000720,CDM,960,RC,99401,HCPCS,Outpatient,,,175.00,113.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27.66,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,27.66,27.66,
EXC S/N/H/F/G MAL+MRG 3.1-4,P960002061,CDM,960,RC,11624,HCPCS,Outpatient,,,825.10,536.32,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,304.95,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,304.95,304.95,
"P/M COUNSEL,INDIV 45MIN",P960000722,CDM,960,RC,99403,HCPCS,Outpatient,,,217.75,141.54,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,63,63,
REMOVAL SWEAT GLAND LESION,P960000739,CDM,960,RC,11450,HCPCS,Outpatient,,,733.00,476.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,365.83,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,365.83,365.83,
TREAT FX RAD INTRA-ARTICUL,P960002074,CDM,960,RC,25608,HCPCS,Outpatient,,,2005.95,1303.87,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,713.19,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,713.19,713.19,
Subsq I/P Pedi Critical Care,P960002032,CDM,960,RC,99472,HCPCS,Outpatient,,,978.53,636.04,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,284.79,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,284.79,284.79,
80wound expl extremities,P960001932,CDM,960,RC,20103,HCPCS,Outpatient,,,835.45,543.04,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,496.95,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,496.95,496.95,
REMOVE SKIN TAGS ADD-ON,P960000736,CDM,960,RC,11201,HCPCS,Outpatient,,,37.00,24.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16.88,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,16.88,16.88,
LAPAR COLECTOMY PART W/ANASTOM,P960003101,CDM,960,RC,44204,HCPCS,Outpatient,,,3692.72,2400.27,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1687.28,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1687.28,1687.28,
20 RPR AA HERNIA 1ST<3 CM NCRC,P960003061,CDM,960,RC,49592,HCPCS,Outpatient,,,1116.32,725.61,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1116.32,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1116.32,1116.32,
N H Visit initial Moderate,P960000970,CDM,960,RC,99305,HCPCS,Outpatient,,,290.48,188.81,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,91.42,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,91.42,91.42,
Correction Hallux Valgus,P960001962,CDM,960,RC,28292,HCPCS,Outpatient,,,1175.03,763.77,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,631.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,631.68,631.68,
INCISION OF ACHILLES TENDON,P960003225,CDM,960,RC,27606,HCPCS,Outpatient,,,658.70,428.16,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,240.88,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,240.88,240.88,
PARTIAL REMOVAL OF COLON,P960002022,CDM,960,RC,44146,HCPCS,Outpatient,,,5065.98,3292.89,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2314.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2314.3,2314.3,
80 Decompression of lower leg,P960003097,CDM,960,RC,27602,HCPCS,Outpatient,,,1149.10,746.92,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,418.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,418.45,418.45,
TREAT METACARPAL FRACTURE,P960003215,CDM,960,RC,26605,HCPCS,Outpatient,,,722.98,469.94,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,279.7,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,279.7,279.7,
"INJ,ONDANSETRON HCL PER 1MG",P960000753,CDM,960,RC,,,Outpatient,,,1.12,0.73,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.12,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1.12,1.12,
FUSION OF BIG TOE JOINT,P960003211,CDM,960,RC,28750,HCPCS,Outpatient,,,1408.88,915.77,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,692.92,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,692.92,692.92,
INT HRHC LIG 2+HROID W/O IMG,P960002066,CDM,960,RC,46946,HCPCS,Outpatient,,,940.13,611.08,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,412.06,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,412.06,412.06,
Biopsy of nail,P960000988,CDM,960,RC,11755,HCPCS,Outpatient,,,149.95,97.47,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,87.83,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,87.83,87.83,
Insertion of Catheter Artery,P960002024,CDM,960,RC,36620,HCPCS,Outpatient,,,108.48,70.51,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,38.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,38.1,38.1,
MENB Vaccine 2/3 dose,P960001989,CDM,960,RC,90621,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
Insert Non Tunnel CV Cath,P960001994,CDM,960,RC,36556,HCPCS,Outpatient,,,205.00,133.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,177.74,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,177.74,177.74,
"Multiplex Test(Covid,RSV,Flu)",P960003162,CDM,960,RC,87637,HCPCS,Outpatient,,,356.57,231.77,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,121.24,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,121.24,121.24,
Debrdmnt open wnd ea addt 20sq,P960002015,CDM,960,RC,97598,HCPCS,Outpatient,,,111.98,72.79,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,53.37,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,53.37,53.37,
N H Visit initial detail,P960000969,CDM,960,RC,99304,HCPCS,Outpatient,,,201.10,130.72,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,63.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,63.73,63.73,
Frenulotomy of penis,P960000997,CDM,960,RC,54164,HCPCS,Outpatient,,,468.58,304.58,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,164.63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,164.63,164.63,
"P/M COUNSEL,INDIV 30MIN",P960000721,CDM,960,RC,99402,HCPCS,Outpatient,,,257.00,167.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,45.88,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,45.88,45.88,
80RPR AA HERNIA 1ST 3-10CM NCR,P960003062,CDM,960,RC,49594,HCPCS,Outpatient,,,1750.75,1137.99,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1750.75,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1750.75,1750.75,
SIGMOIDOSCOPY & POLYPECTOMY,P960003182,CDM,960,RC,45333,HCPCS,Outpatient,,,1111.52,722.49,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,337.89,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,337.89,337.89,
REMOVAL OF RECTAL MARKER,P960003189,CDM,960,RC,46030,HCPCS,Outpatient,,,210.25,136.66,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,156.38,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,156.38,156.38,
ACNE SURGERY,P960000734,CDM,960,RC,10040,HCPCS,Outpatient,,,197.00,128.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,98.4,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,98.4,98.4,
Lap Hysterectomy 250g or less,P960001006,CDM,960,RC,58570,HCPCS,Outpatient,,,1951.55,1268.51,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,679.92,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,679.92,679.92,
INSERT/PLACE HEART CATHETER,P960002023,CDM,960,RC,93503,HCPCS,Outpatient,,,214.78,139.61,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,72.87,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,72.87,72.87,
80wound expl penetr wound neck,P960001923,CDM,960,RC,20100,HCPCS,Outpatient,,,1450.93,943.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,523.39,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,523.39,523.39,
PPD SKIN TEST INJ,P960000716,CDM,960,RC,86580,HCPCS,Outpatient,,,15.44,10.04,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,5.68,5.68,
REMOVAL SWEAT GLAND LESION,P960000744,CDM,960,RC,11471,HCPCS,Outpatient,,,985.00,640.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,473.96,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,473.96,473.96,
TREAT METATARSAL FRACTURE,P960003241,CDM,960,RC,28476,HCPCS,Outpatient,,,947.88,616.12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,317.37,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,317.37,317.37,
"SHAVE S,N,H>2CM",P960000737,CDM,960,RC,11308,HCPCS,Outpatient,,,292.00,189.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,138.65,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,138.65,138.65,
"P/M COUNSEL,INDIV 15MIN",P960000720,CDM,960,RC,99401,HCPCS,Outpatient,,,175.00,113.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27.66,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,27.66,27.66,
AUDIT/DAST 15-30 MIN,P960000725,CDM,960,RC,99408,HCPCS,Outpatient,,,164.00,106.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,25.45,25.45,
GLYCOSYLATED HB HOME DEVICE,P960000754,CDM,960,RC,83037,HCPCS,Outpatient,,,24.28,15.78,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.27,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,6.27,6.27,
Corp Cavernosa-Saph vein shunt,P960001982,CDM,960,RC,54420,HCPCS,Outpatient,,,1713.18,1113.57,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,605.54,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,605.54,605.54,
Beyfortus Vaccine 0.5 mL/State,P960003141,CDM,960,RC,90380,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VAGINAL DELIVERY AFTER CESAREA,P960003231,CDM,960,RC,59612,HCPCS,Outpatient,,,2208.98,1435.84,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,610.95,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,610.95,610.95,
LAP MOBIL SPLENIC FL ADD-ON,P960003102,CDM,960,RC,44213,HCPCS,Outpatient,,,445.50,289.58,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,205.6,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,205.6,205.6,
20LSH W/T/O UT 250 G OR LESS,P960001939,CDM,960,RC,58542,HCPCS,Outpatient,,,2026.25,1317.06,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,709.27,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,709.27,709.27,
CYSTECTOMY COMPLETE SEPARATE P,P960002073,CDM,960,RC,51570,HCPCS,Outpatient,,,3545.03,2304.27,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1244.21,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1244.21,1244.21,
LAP PART COLECTOMY W/STOMA,P960003177,CDM,960,RC,44206,HCPCS,Outpatient,,,4141.57,2692.02,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1917.22,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1917.22,1917.22,
Inj Corporo cavernosa w/ pharm,P960001977,CDM,960,RC,54235,HCPCS,Outpatient,,,175.25,113.91,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,75.15,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,75.15,75.15,
INSERT TUNNELED CV CATH,P960003234,CDM,960,RC,36558,HCPCS,Outpatient,,,620.45,403.29,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,620.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,620.45,620.45,
"80 VBAC,delv proc p prev Csect",P960001919,CDM,960,RC,59610,HCPCS,Outpatient,,,5925.20,3851.38,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1487.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1487.5,1487.5,
LAP FULGURATION OVIDUCTS,P960003121,CDM,960,RC,58670,HCPCS,Outpatient,,,909.13,590.93,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,315.95,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,315.95,315.95,
80RPR AA HERNIA RECR<3CM NCRC8,P960003072,CDM,960,RC,49614,HCPCS,Outpatient,,,1341.32,871.86,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1341.32,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1341.32,1341.32,
CHRNC CARE MGMT PHYS 1ST 30,P960003088,CDM,960,RC,99491,HCPCS,Outpatient,,,206.75,134.39,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,58.24,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,58.24,58.24,
Rep Elblow Med.Ligament,P960001980,CDM,960,RC,24345,HCPCS,Outpatient,,,1725.58,1121.63,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,607.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,607.23,607.23,
REMOVAL SWEAT GLAND LESION,P960000742,CDM,960,RC,11463,HCPCS,Outpatient,,,948.00,616.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,463.97,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,463.97,463.97,
CREP H/A/G/Ext Each Addtl 5cm<,P960001961,CDM,960,RC,13133,HCPCS,Outpatient,,,305.93,198.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,157.79,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,157.79,157.79,
AUDIT/DAST 15-30 MIN,P960000726,CDM,960,RC,99409,HCPCS,Outpatient,,,144.23,93.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,49.36,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,49.36,49.36,
Transesophageal Tee,P960002018,CDM,960,RC,93355,HCPCS,Outpatient,,,558.60,363.09,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,188.36,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,188.36,188.36,
TD VACC NO PRSRV >/= 7 IM ST,P960000523,CDM,960,RC,90714,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INIT HOSP-LOW CPLX,P960000611,CDM,960,RC,99221,HCPCS,Outpatient,,,396.00,257.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,71.65,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,71.65,71.65,
80 COLOSTOMY,P960000919,CDM,960,RC,44320,HCPCS,Outpatient,,,2385.00,1550.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1316.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1316.1,1316.1,
ADM/DC DAME DAY-LOW CPLX,P960000620,CDM,960,RC,99234,HCPCS,Outpatient,,,263.00,170.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,94.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,94.1,94.1,
EXC NECK TUM DEEP 5 CM>,P960000766,CDM,960,RC,21554,HCPCS,Outpatient,,,1447.00,940.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,632.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,632.05,632.05,
ANKLE CONTROL ORTHO PRE OTS,P960000860,CDM,960,RC,,,Outpatient,,,115.00,74.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,115,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,115,115,
20 REPAIR STOMACH LESION,P960000869,CDM,960,RC,43840,HCPCS,Outpatient,,,3373.68,2192.89,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1491.16,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1491.16,1491.16,
CHOLEDOCHOTOMY; WO TD SPHINCTE,P960000789,CDM,960,RC,47420,HCPCS,Outpatient,,,3326.02,2161.91,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1470.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1470.1,1470.1,
80Cholecystectomy w cholangio,P960000924,CDM,960,RC,47605,HCPCS,Outpatient,,,2789.00,1812.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1232.77,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1232.77,1232.77,
INCISION THROMBOSED HEMORR EXT,P960000768,CDM,960,RC,46083,HCPCS,Outpatient,,,341.00,221.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,208.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,208.76,208.76,
ALBUTEROL SULFATE .083%/ML,P960000709,CDM,960,RC,J7620,HCPCS,Outpatient,,,4.00,2.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.1,0.1,
INPT/TELE FOLLOW UP 25,P960000805,CDM,960,RC,,,Outpatient,,,178.25,115.86,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,178.25,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,178.25,178.25,
OL DIG E/M SVC 11-20 MIN,P960000810,CDM,960,RC,99422,HCPCS,Outpatient,,,66.18,43.02,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21.34,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,21.34,21.34,
"OFFICE VISIT, EST PT., LEVEL 1",P960000602,CDM,960,RC,99211,HCPCS,Outpatient,,,39.00,25.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16.04,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,16.04,16.04,
80Cholecystectomy w cholangio,P960000924,CDM,960,RC,47605,HCPCS,Outpatient,,,2789.00,1812.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1232.77,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1232.77,1232.77,
AUTONOMIC FUNCTION TEST VASOM,P960000760,CDM,960,RC,95922,HCPCS,Outpatient,,,193.00,125.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,114.06,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,114.06,114.06,
OL DIG E/M SVC 21+ MIN,P960000811,CDM,960,RC,99423,HCPCS,Outpatient,,,105.35,68.48,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,34.48,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,34.48,34.48,
HOSP SUB DAY-LOW CPLX,P960000617,CDM,960,RC,99231,HCPCS,Outpatient,,,77.00,50.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,27.73,27.73,
CERV CANCR SCR;PELV BRST EX,P960000676,CDM,960,RC,G0101,HCPCS,Outpatient,,,75.00,48.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28.98,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,28.98,28.98,
80 REPAIR STOMACH LESION,P960000915,CDM,960,RC,43840,HCPCS,Outpatient,,,3373.68,2192.89,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1491.16,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1491.16,1491.16,
DRAIN FINGER ABSC; SIMPLE,P960000940,CDM,960,RC,26010,HCPCS,Outpatient,,,340.55,221.36,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,258.4,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,258.4,258.4,
INDWLL CATH; 2WAY LATEX W/COAT,P960000669,CDM,960,RC,A4338,HCPCS,Outpatient,,,54.00,35.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12.11,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,12.11,12.11,
20 EXPL LAPAROTOMY EXPL CELIOT,P960000879,CDM,960,RC,49000,HCPCS,Outpatient,,,1526.00,991.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,842.69,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,842.69,842.69,
REM PHYSIOL MNTR 1ST 20 MIN,P960000953,CDM,960,RC,99457,HCPCS,Outpatient,,,129.03,83.87,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,35.39,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,35.39,35.39,
BUDESONIDE INHALATION SOL,P960000710,CDM,960,RC,J7626,HCPCS,Outpatient,,,22.00,14.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1.29,1.29,
OB US>=14 WKS SNGL FETUS,P960000780,CDM,960,RC,76805,HCPCS,Outpatient,,,124.05,80.63,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,93.87,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,93.87,93.87,
80 PART REM COLON W/ANATOMOSIS,P960000918,CDM,960,RC,44140,HCPCS,Outpatient,,,2664.00,1731.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1470.97,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1470.97,1470.97,
INDWLL CATH; 2WAY LATEX W/COAT,P960000669,CDM,960,RC,A4338,HCPCS,Outpatient,,,54.00,35.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12.11,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,12.11,12.11,
ALBUTEROL SULFATE .083%/ML,P960000709,CDM,960,RC,J7620,HCPCS,Outpatient,,,4.00,2.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.1,0.1,
20Cholecystectomy w cholangio,P960000878,CDM,960,RC,47605,HCPCS,Outpatient,,,2789.00,1812.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1232.77,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1232.77,1232.77,
HEPB VACC PED/ADOL 3 DOSE IM,P960000538,CDM,960,RC,90744,HCPCS,Outpatient,,,116.00,75.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,25.25,25.25,
RHOPHYLAC INJECTION,P960000698,CDM,960,RC,J2791,HCPCS,Outpatient,,,288.00,187.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.2,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,4.2,4.2,
PREVENT CARE EST. PT. AGE 1-4,P960000650,CDM,960,RC,99392,HCPCS,Outpatient,,,392.00,254.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,74.77,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,74.77,74.77,
PROLONG CLINCL STAFF SVC,P960000657,CDM,960,RC,99415,HCPCS,Outpatient,,,17.00,11.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.77,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,6.77,6.77,
"SURG TX ECT PREG,TUB/OVAR WO",P960000762,CDM,960,RC,59121,HCPCS,Outpatient,,,1567.00,1018.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,541.04,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,541.04,541.04,
NURSING FAC SUBSEQ MOD COMP,P960000638,CDM,960,RC,99309,HCPCS,Outpatient,,,179.00,116.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,64.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,64.23,64.23,
PROMAZINE HCL INJECTION 25 MG,P960000701,CDM,960,RC,J2950,HCPCS,Outpatient,,,5.00,3.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.72,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.72,0.72,
ANN WELL VST; PERSNL PPS INIT,P960000685,CDM,960,RC,G0438,HCPCS,Outpatient,,,334.00,217.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,125.03,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,125.03,125.03,
80 INCISION OF GALLBLADDER,P960000921,CDM,960,RC,47480,HCPCS,Outpatient,,,2180.50,1417.33,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,963.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,963.78,963.78,
PREVENT CARE EST. PT. AGE 5-11,P960000651,CDM,960,RC,99393,HCPCS,Outpatient,,,390.00,253.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,74.53,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,74.53,74.53,
DM OP SLF-MGMT TRN SRVC 30 MIN,P960000679,CDM,960,RC,G0108,HCPCS,Outpatient,,,105.00,68.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,41.34,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,41.34,41.34,
INIT HOSP-HI CPLX,P960000613,CDM,960,RC,99223,HCPCS,Outpatient,,,399.00,259.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,142.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,142.76,142.76,
APPLY CLUBFOOT CAST LONG OR SH,P960000803,CDM,960,RC,29450,HCPCS,Outpatient,,,283.40,184.21,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,124.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,124.68,124.68,
FLU VAC 3 YRS & > IM FLUZONE,P960000712,CDM,960,RC,Q2038,HCPCS,Outpatient,,,36.00,23.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,10.78,10.78,
INJ GARAMYCIN GENTAMICIN TO 80,P960000853,CDM,960,RC,,,Outpatient,,,50.00,32.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,50,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,50,50,
"SBSQ NB EM PER DAY, HOSP",P960000660,CDM,960,RC,99462,HCPCS,Outpatient,,,88.00,57.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29.79,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,29.79,29.79,
80 FREEZING OF BOWEL ADHESION,P960000916,CDM,960,RC,44005,HCPCS,Outpatient,,,2173.00,1412.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1198.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1198.29,1198.29,
PUNCH BX SKIN SINGLE LESION,P960000763,CDM,960,RC,11104,HCPCS,Outpatient,,,307.00,199.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,112.7,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,112.7,112.7,
20COLECTOMY PART; W SL CECOSTO,P960000905,CDM,960,RC,44141,HCPCS,Outpatient,,,4518.35,2936.93,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1997.12,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1997.12,1997.12,
REP RECURENT ING HERNIA ANY AG,P960000956,CDM,960,RC,49521,HCPCS,Outpatient,,,1776.25,1154.56,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,785.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,785.1,785.1,
EXCISION PREPATELLAR BURSA,P960000908,CDM,960,RC,27340,HCPCS,Outpatient,,,915.18,594.87,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,320.49,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,320.49,320.49,
DUPLEX EXT VEINS BILAT,P960000773,CDM,960,RC,93970,HCPCS,Outpatient,,,375.00,243.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,223.2,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,223.2,223.2,
PUNCH BX SKIN EA SEP/ADDL,P960000779,CDM,960,RC,11105,HCPCS,Outpatient,,,147.80,96.07,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,54.33,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,54.33,54.33,
20 REP RECURENT ING HERNIA AN,P960000957,CDM,960,RC,49521,HCPCS,Outpatient,,,1776.25,1154.56,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,785.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,785.1,785.1,
CLOSE ENTEROVES FIST; WO INT/B,P960000909,CDM,960,RC,44660,HCPCS,Outpatient,,,3327.13,2162.63,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1470.59,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1470.59,1470.59,
LEVALBUTEROL INHAL DOSE 0.5 MG,P960000708,CDM,960,RC,J7614,HCPCS,Outpatient,,,12.00,7.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.05,0.05,
TRIMMING DYSTROPHIC NAILS,P960000681,CDM,960,RC,G0127,HCPCS,Outpatient,,,44.00,28.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17.31,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,17.31,17.31,
SCR PAP SMER; PREP&CONVY-LAB,P960000711,CDM,960,RC,Q0091,HCPCS,Outpatient,,,86.00,55.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,34.81,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,34.81,34.81,
UNLISTED EXC PRESSURE ULCER,P960000827,CDM,960,RC,15999,HCPCS,Outpatient,,,1464.25,951.76,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1464.25,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1464.25,1464.25,
20 REMOVAL OF SMALL INTESTINE,P960000871,CDM,960,RC,44120,HCPCS,Outpatient,,,2430.00,1579.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1340.59,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1340.59,1340.59,
CRITICAL CARE 1ST HR,P960000634,CDM,960,RC,99291,HCPCS,Outpatient,,,536.00,348.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,196.03,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,196.03,196.03,
RHOPHYLAC INJECTION,P960000698,CDM,960,RC,J2791,HCPCS,Outpatient,,,288.00,187.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.2,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,4.2,4.2,
INPT/ED TELECONSULT50,P960000785,CDM,960,RC,,,Outpatient,,,336.03,218.42,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,336.03,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,336.03,336.03,
INCISION OF FIBULA,P960000796,CDM,960,RC,27707,HCPCS,Outpatient,,,984.87,640.17,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,344.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,344.9,344.9,
PUNCH BX SKIN EA SEP/ADDL,P960000779,CDM,960,RC,11105,HCPCS,Outpatient,,,147.80,96.07,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,54.33,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,54.33,54.33,
INIT DAY HOSP NEONATE CARE,P960000665,CDM,960,RC,99477,HCPCS,Outpatient,,,699.00,454.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,247.37,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,247.37,247.37,
20 REPAIR BOWEL OPENING,P960000874,CDM,960,RC,44620,HCPCS,Outpatient,,,1725.00,1121.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,949.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,949.82,949.82,
80 FREEZING OF BOWEL ADHESION,P960000916,CDM,960,RC,44005,HCPCS,Outpatient,,,2173.00,1412.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1198.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1198.29,1198.29,
DIAGNOSTIC ANOSCOPY SPX,P960000947,CDM,960,RC,46600,HCPCS,Outpatient,,,100.50,65.33,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,100.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,100.5,100.5,
"95 OFFICE VISIT, NEW PT,LEVEL2",P960000894,CDM,960,RC,99202,HCPCS,Outpatient,,,145.00,94.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,52.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,52.9,52.9,
PROLONG CLINCL STAFF SVC,P960000657,CDM,960,RC,99415,HCPCS,Outpatient,,,17.00,11.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.77,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,6.77,6.77,
PESSARY NON RUBBER ANY TYPE,P960000672,CDM,960,RC,A4562,HCPCS,Outpatient,,,222.00,144.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,50.55,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,50.55,50.55,
"INIT NB EM PER DAY, HOSP",P960000659,CDM,960,RC,99460,HCPCS,Outpatient,,,197.00,128.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,67.71,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,67.71,67.71,
"IC, LBW INF < 1500 GM SUBSQ",P960000666,CDM,960,RC,99478,HCPCS,Outpatient,,,277.00,180.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,97.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,97.25,97.25,
IC LBW INF 1500-2500 G SUBSQ,P960000667,CDM,960,RC,99479,HCPCS,Outpatient,,,247.00,160.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,88.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,88.25,88.25,
"95 OFFICE VISIT, EST PT,LEVEL3",P960000899,CDM,960,RC,99213,HCPCS,Outpatient,,,144.92,94.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,52.28,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,52.28,52.28,
OL DIG E/M SVC 5-10 MIN,P960000809,CDM,960,RC,99421,HCPCS,Outpatient,,,32.35,21.03,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.7,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,10.7,10.7,
REMOVE INT/EXT HEM 1 GROUP,P960000765,CDM,960,RC,46255,HCPCS,Outpatient,,,983.00,638.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,562.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,562.9,562.9,
WOUND(S) CARE NON-SELECTIVE,P960000843,CDM,960,RC,97602,HCPCS,Outpatient,,,419.43,272.63,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,95.63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,95.63,95.63,
20 INCISION OF GALLBLADDER,P960000875,CDM,960,RC,47480,HCPCS,Outpatient,,,2180.50,1417.33,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,963.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,963.78,963.78,
PREVENT CARE NEW PT. AGE 18-39,P960000646,CDM,960,RC,99385,HCPCS,Outpatient,,,490.00,318.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,93.13,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,93.13,93.13,
APPLY CLUBFOOT CAST LONG OR SH,P960000803,CDM,960,RC,29450,HCPCS,Outpatient,,,283.40,184.21,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,124.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,124.68,124.68,
PREV VISIT EST AGE 40-64,P960000654,CDM,960,RC,99396,HCPCS,Outpatient,,,466.00,302.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,89.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,89.45,89.45,
ADMN FLU VAC SCHED SAME DAY,P960000674,CDM,960,RC,G0008,HCPCS,Outpatient,,,94.00,61.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7.32,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,7.32,7.32,
20Cholecystectomy w cholangio,P960000878,CDM,960,RC,47605,HCPCS,Outpatient,,,2789.00,1812.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1232.77,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1232.77,1232.77,
INPT/ED TELECONSULT70,P960000786,CDM,960,RC,,,Outpatient,,,497.98,323.69,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,497.98,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,497.98,497.98,
CC EACH ADD 30 MIN,P960000635,CDM,960,RC,99292,HCPCS,Outpatient,,,241.00,156.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,86.84,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,86.84,86.84,
COMM SVCS BY RHC/FQHC 5 MIN,P960000821,CDM,960,RC,,,Outpatient,,,61.90,40.24,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,61.9,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,61.9,61.9,
IC INF PBW 2501-5000 G SUBSQ,P960000668,CDM,960,RC,99480,HCPCS,Outpatient,,,238.00,154.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,84.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,84.76,84.76,
CPR,P960000772,CDM,960,RC,92950,HCPCS,Outpatient,,,591.00,384.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,258.75,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,258.75,258.75,
BUDESONIDE INHALATION SOL,P960000710,CDM,960,RC,J7626,HCPCS,Outpatient,,,22.00,14.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1.29,1.29,
URINARY LEG OR ABDOMEN BAG,P960000671,CDM,960,RC,A4358,HCPCS,Outpatient,,,8.00,5.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.57,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,5.57,5.57,
"95 OFFICE VISIT,NEWPT,LEVEL5",P960000897,CDM,960,RC,99205,HCPCS,Outpatient,,,402.00,261.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,145.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,145.23,145.23,
TRIMMING DYSTROPHIC NAILS,P960000681,CDM,960,RC,G0127,HCPCS,Outpatient,,,44.00,28.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17.31,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,17.31,17.31,
REM SUTURES BY MD,P960000802,CDM,960,RC,,,Outpatient,,,156.25,101.56,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,156.25,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,156.25,156.25,
COLO CANCER SCREENING; FLEXSIG,P960000677,CDM,960,RC,G0104,HCPCS,Outpatient,,,319.00,207.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,127.75,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,127.75,127.75,
PREVENT CARE NEW PT AGE 1-4,P960000643,CDM,960,RC,99382,HCPCS,Outpatient,,,428.00,278.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,81.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,81.43,81.43,
"95 OFFICE VISIT,NEWPT,LEVEL5",P960000897,CDM,960,RC,99205,HCPCS,Outpatient,,,402.00,261.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,145.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,145.23,145.23,
80 REP RECURENT ING HERNIA AN,P960000958,CDM,960,RC,49521,HCPCS,Outpatient,,,1776.25,1154.56,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,785.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,785.1,785.1,
PREV CARE EST. PT. AGE <1 YR,P960000649,CDM,960,RC,99391,HCPCS,Outpatient,,,366.00,237.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,70.2,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,70.2,70.2,
80 CESAREAN DELIVERY ONLY,P960000938,CDM,960,RC,59514,HCPCS,Outpatient,,,1820.00,1183.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,611.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,611.82,611.82,
ROTARIX STATE,P960000504,CDM,960,RC,90681,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MANIP SHLDR JOINT UNDER ANESTH,P960000949,CDM,960,RC,23700,HCPCS,Outpatient,,,482.00,313.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,168.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,168.78,168.78,
80 INTRA-ABD OMENTAL FLAP,P960000932,CDM,960,RC,49905,HCPCS,Outpatient,,,878.63,571.11,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,388.36,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,388.36,388.36,
"95OFFICE VISIT, NEW PT, LEVEL4",P960000896,CDM,960,RC,99204,HCPCS,Outpatient,,,407.28,264.73,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,114.84,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,114.84,114.84,
INJ TRIAMCIN ACETONIDE 10 MG,P960000702,CDM,960,RC,J3301,HCPCS,Outpatient,,,50.00,32.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.14,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1.14,1.14,
ALBUTEROL INHAL UNIT DOSE 1 MG,P960000707,CDM,960,RC,J7613,HCPCS,Outpatient,,,4.00,2.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.03,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.03,0.03,
REM GAUNTLET BOOT OR BODY CAST,P960000798,CDM,960,RC,29700,HCPCS,Outpatient,,,82.67,53.74,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,53.48,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,53.48,53.48,
SINGLE LENS SPECTACLE MOUNT,P960000863,CDM,960,RC,,,Outpatient,,,275.00,178.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,275,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,275,275,
BONE BIOPSY OPEN SUPERFICIAL,P960000946,CDM,960,RC,20240,HCPCS,Outpatient,,,365.00,237.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,127.75,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,127.75,127.75,
OB US>=14 WKS SNGL FETUS,P960000780,CDM,960,RC,76805,HCPCS,Outpatient,,,124.05,80.63,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,93.87,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,93.87,93.87,
PREVENT CARE EST PT. AGE 18-39,P960000653,CDM,960,RC,99395,HCPCS,Outpatient,,,436.00,283.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,84.01,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,84.01,84.01,
"OFFICE VISIT, EST PT., LEVEL 1",P960000602,CDM,960,RC,99211,HCPCS,Outpatient,,,39.00,25.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16.04,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,16.04,16.04,
SURGICAL SUPPLIES,P960000848,CDM,960,RC,,,Outpatient,,,225.00,146.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,225,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,225,225,
Exc Rect Tum Transanal part,P960000966,CDM,960,RC,45171,HCPCS,Outpatient,,,1499.10,974.42,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,662.6,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,662.6,662.6,
BRAND NAME RX DRUG,P960000817,CDM,960,RC,,,Outpatient,,,50.23,32.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,50.23,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,50.23,50.23,
20 PARTIAL REMOVAL OF COLON,P960000872,CDM,960,RC,44140,HCPCS,Outpatient,,,2664.00,1731.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1470.97,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1470.97,1470.97,
Excision of lesion sperm cord,P960000968,CDM,960,RC,55520,HCPCS,Outpatient,,,1124.68,731.04,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,386.21,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,386.21,386.21,
DIL URETHR STRICT FILIF/FOLLOW,P960000950,CDM,960,RC,53620,HCPCS,Outpatient,,,218.03,141.72,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,122.57,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,122.57,122.57,
PESSARY NON RUBBER ANY TYPE,P960000672,CDM,960,RC,A4562,HCPCS,Outpatient,,,222.00,144.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,50.55,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,50.55,50.55,
SURGICAL SUPPLIES,P960000848,CDM,960,RC,,,Outpatient,,,225.00,146.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,225,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,225,225,
PREVENT CARE NEW PT AGE 1-4,P960000643,CDM,960,RC,99382,HCPCS,Outpatient,,,428.00,278.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,81.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,81.43,81.43,
INJ KETO TROMETHAMINE 15 MG,P960000694,CDM,960,RC,J1885,HCPCS,Outpatient,,,20.00,13.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.57,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.57,0.57,
PREV CARE NEW PT. AGE <1 YR,P960000642,CDM,960,RC,99381,HCPCS,Outpatient,,,410.00,266.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,77.7,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,77.7,77.7,
EXTREMITY STUDY,P960000580,CDM,960,RC,93923,HCPCS,Outpatient,,,262.00,170.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,151.27,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,151.27,151.27,
REM PHYSIOL MNTR EA ADDL 20,P960000954,CDM,960,RC,99458,HCPCS,Outpatient,,,105.55,68.61,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,29.05,29.05,
80 LAPOROSCOPIC CHOLECYSTECTOM,P960000922,CDM,960,RC,47562,HCPCS,Outpatient,,,1301.00,845.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,721.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,721.23,721.23,
WINDOWING OF CAST,P960000791,CDM,960,RC,29730,HCPCS,Outpatient,,,107.85,70.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,53.02,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,53.02,53.02,
NURSING FAC SUBSEQ FOCUS,P960000637,CDM,960,RC,99308,HCPCS,Outpatient,,,135.00,87.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,48.64,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,48.64,48.64,
BONE BIOPSY OPEN SUPERFICIAL,P960000946,CDM,960,RC,20240,HCPCS,Outpatient,,,365.00,237.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,127.75,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,127.75,127.75,
20 CESAREAN DELIVERY ONLY;,P960000892,CDM,960,RC,59514,HCPCS,Outpatient,,,1820.00,1183.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,611.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,611.82,611.82,
LAP; CHOLECYSTECTOMY W CHOLANG,P960000941,CDM,960,RC,47563,HCPCS,Outpatient,,,1776.20,1154.53,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,785.08,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,785.08,785.08,
INTERROG DEV EVAL SCRMS IP,P960000960,CDM,960,RC,93291,HCPCS,Outpatient,,,46.83,30.44,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,34.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,34.45,34.45,
SAME DAY NB DISCHARGE,P960000661,CDM,960,RC,99463,HCPCS,Outpatient,,,235.00,152.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,78.18,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,78.18,78.18,
"95 OFFICE VISIT, EST PT,LEVEL1",P960000898,CDM,960,RC,99211,HCPCS,Outpatient,,,39.00,25.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16.04,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,16.04,16.04,
80 REPAIR BOWEL OPENING,P960000920,CDM,960,RC,44620,HCPCS,Outpatient,,,1725.00,1121.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,949.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,949.82,949.82,
IC LBW INF 1500-2500 G SUBSQ,P960000667,CDM,960,RC,99479,HCPCS,Outpatient,,,247.00,160.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,88.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,88.25,88.25,
80 REMOVAL OF SMALL INTESTINE,P960000917,CDM,960,RC,44120,HCPCS,Outpatient,,,2430.00,1579.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1340.59,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1340.59,1340.59,
20COLECTOMY PART; W SL CECOSTO,P960000905,CDM,960,RC,44141,HCPCS,Outpatient,,,4518.35,2936.93,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1997.12,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1997.12,1997.12,
REM GAUNTLET BOOT OR BODY CAST,P960000798,CDM,960,RC,29700,HCPCS,Outpatient,,,82.67,53.74,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,53.48,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,53.48,53.48,
20 LAPAROSCOPY; CHOLECYSTECOMY,P960000876,CDM,960,RC,47562,HCPCS,Outpatient,,,1301.00,845.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,721.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,721.23,721.23,
20 REMOVAL OF OVARY/ TUBE(S),P960000889,CDM,960,RC,58720,HCPCS,Outpatient,,,1450.00,942.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,636.92,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,636.92,636.92,
ANN WELL VST; PPS SUBSQT VST,P960000686,CDM,960,RC,G0439,HCPCS,Outpatient,,,226.00,146.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,84.61,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,84.61,84.61,
NURSING FAC SUBSEQ FOCUS,P960000637,CDM,960,RC,99308,HCPCS,Outpatient,,,135.00,87.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,48.64,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,48.64,48.64,
PREV VISIT EST AGE 40-64,P960000654,CDM,960,RC,99396,HCPCS,Outpatient,,,466.00,302.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,89.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,89.45,89.45,
"NEONATE CRIT CARE, INITIAL",P960000664,CDM,960,RC,99468,HCPCS,Outpatient,,,1952.00,1268.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,651.36,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,651.36,651.36,
IM ADULT HEPA-HEPB,P960000836,CDM,960,RC,90636,HCPCS,Outpatient,,,440.70,286.46,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,114.35,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,114.35,114.35,
20 COLOSTOMY,P960000873,CDM,960,RC,44320,HCPCS,Outpatient,,,2385.00,1550.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1316.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1316.1,1316.1,
TOTAL VITAL CAPACITY,P960000840,CDM,960,RC,94150,HCPCS,Outpatient,,,332.10,215.87,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28.61,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,28.61,28.61,
"ARTHROSC KNEE, FR INF/LAVAGE",P960000774,CDM,960,RC,29871,HCPCS,Outpatient,,,1009.00,655.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,443.79,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,443.79,443.79,
PROGESTERONE PER 50 MG,P960000696,CDM,960,RC,J2675,HCPCS,Outpatient,,,5.00,3.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1.25,1.25,
HOSP SUB CARE-MOD CPLX,P960000618,CDM,960,RC,99232,HCPCS,Outpatient,,,142.00,92.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,51.09,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,51.09,51.09,
"95 OFFICE VISIT,EST PT,LEVEL4",P960000901,CDM,960,RC,99214,HCPCS,Outpatient,,,212.56,138.16,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,75.99,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,75.99,75.99,
INCISION OF FIBULA,P960000796,CDM,960,RC,27707,HCPCS,Outpatient,,,984.87,640.17,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,344.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,344.9,344.9,
OP TX ACLAV DISLOC ACUTE/CHRON,P960000792,CDM,960,RC,23550,HCPCS,Outpatient,,,1414.87,919.67,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,495.49,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,495.49,495.49,
"REPAIR ""MALLET FINGER""; WO GRA",P960000795,CDM,960,RC,26433,HCPCS,Outpatient,,,1337.37,869.29,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,468.35,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,468.35,468.35,
"OFFICE VISIT, NEW PT., LEVEL 3",P960000599,CDM,960,RC,99203,HCPCS,Outpatient,,,209.00,135.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,75.02,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,75.02,75.02,
80 REMOVAL OF OVARY/TUBE(S),P960000935,CDM,960,RC,58720,HCPCS,Outpatient,,,1450.00,942.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,636.92,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,636.92,636.92,
COUDE URINARY CATH,P960000846,CDM,960,RC,,,Outpatient,,,23.17,15.06,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23.17,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,23.17,23.17,
20 COLOSTOMY,P960000873,CDM,960,RC,44320,HCPCS,Outpatient,,,2385.00,1550.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1316.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1316.1,1316.1,
INPT/TELE FOLLOW UP 35,P960000806,CDM,960,RC,,,Outpatient,,,256.50,166.73,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,256.5,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,256.5,256.5,
HOSP DISC >30MIN,P960000624,CDM,960,RC,99239,HCPCS,Outpatient,,,211.00,137.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,75.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,75.5,75.5,
ECHO EXAM OF HEART,P960000570,CDM,960,RC,93308,HCPCS,Outpatient,,,238.00,154.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,78.41,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,78.41,78.41,
NB RESUSCITATION,P960000663,CDM,960,RC,99465,HCPCS,Outpatient,,,301.00,195.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,103.52,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,103.52,103.52,
RUBBER PESSARY ANY TYPE,P960000847,CDM,960,RC,,,Outpatient,,,211.00,137.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,211,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,211,211,
PREV CARE EST. PT. AGE <1 YR,P960000649,CDM,960,RC,99391,HCPCS,Outpatient,,,366.00,237.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,70.2,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,70.2,70.2,
PREVENT CARE NEW PT. AGE 5-11,P960000644,CDM,960,RC,99383,HCPCS,Outpatient,,,444.00,288.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,84.92,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,84.92,84.92,
ETONOGESTREL IMPLANT SYSTEM,P960000705,CDM,960,RC,J7307,HCPCS,Outpatient,,,2690.00,1748.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,834.33,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,834.33,834.33,
NEONATE CRIT CARE SUBSQ<=28DAY,P960000778,CDM,960,RC,99469,HCPCS,Outpatient,,,984.73,640.07,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,282.06,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,282.06,282.06,
UNLISTED ULTRASOUND,P960000904,CDM,960,RC,76999,HCPCS,Outpatient,,,191.58,124.53,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,191.58,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,191.58,191.58,
COLO CANCR SCR; COLON HI RISK,P960000678,CDM,960,RC,G0105,HCPCS,Outpatient,,,611.00,397.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,242.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,242.45,242.45,
SURG TX MISSED ABORT:2NDTRIMST,P960000783,CDM,960,RC,59821,HCPCS,Outpatient,,,902.45,586.59,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,272.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,272.43,272.43,
SURG TX MISSED ABORT:2NDTRIMST,P960000783,CDM,960,RC,59821,HCPCS,Outpatient,,,902.45,586.59,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,272.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,272.43,272.43,
"DTAP VACCINE, IM VFC/SL",P960000514,CDM,960,RC,90700,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
80 REP RECURENT ING HERNIA AN,P960000958,CDM,960,RC,49521,HCPCS,Outpatient,,,1776.25,1154.56,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,785.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,785.1,785.1,
PREV CARE NEW PT. AGE  >64,P960000648,CDM,960,RC,99387,HCPCS,Outpatient,,,616.00,400.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,117.21,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,117.21,117.21,
FASCIECTOMY PALM ONLY,P960000794,CDM,960,RC,26121,HCPCS,Outpatient,,,1476.90,959.99,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,517.21,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,517.21,517.21,
PREVENT CARE NEW PT. AGE 5-11,P960000644,CDM,960,RC,99383,HCPCS,Outpatient,,,444.00,288.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,84.92,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,84.92,84.92,
REMOT IMAGE SUBMIT BY PT,P960000808,CDM,960,RC,,,Outpatient,,,22.85,14.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22.85,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,22.85,22.85,
INIT DAY HOSP NEONATE CARE,P960000665,CDM,960,RC,99477,HCPCS,Outpatient,,,699.00,454.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,247.37,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,247.37,247.37,
20 TOTAL ABDOMINAL HYSTERECTOM,P960000887,CDM,960,RC,58150,HCPCS,Outpatient,,,2000.00,1300.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,864.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,864.82,864.82,
EXCISION PREPATELLAR BURSA,P960000908,CDM,960,RC,27340,HCPCS,Outpatient,,,915.18,594.87,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,320.49,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,320.49,320.49,
20 INTRA-ABD OMENTAL FLAP,P960000886,CDM,960,RC,49905,HCPCS,Outpatient,,,878.63,571.11,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,388.36,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,388.36,388.36,
"SURG TX ECT PREG,TUB/OVAR WO",P960000762,CDM,960,RC,59121,HCPCS,Outpatient,,,1567.00,1018.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,541.04,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,541.04,541.04,
SCR PAP SMER; PREP&CONVY-LAB,P960000711,CDM,960,RC,Q0091,HCPCS,Outpatient,,,86.00,55.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,34.81,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,34.81,34.81,
ANKLE CONTROL ORTHO PRE OTS,P960000860,CDM,960,RC,,,Outpatient,,,115.00,74.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,115,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,115,115,
OB US<14 WKS SINGLE FETUS,P960000781,CDM,960,RC,76801,HCPCS,Outpatient,,,124.05,80.63,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,82.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,82.1,82.1,
80 COLECTOMY PART; W SL CECOST,P960000906,CDM,960,RC,44141,HCPCS,Outpatient,,,4518.35,2936.93,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1997.12,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1997.12,1997.12,
BEHAV CHNG SMOKING 3-10 MIN,P960000656,CDM,960,RC,99406,HCPCS,Outpatient,,,28.00,18.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,10.68,10.68,
INIT HOSP-HI CPLX,P960000613,CDM,960,RC,99223,HCPCS,Outpatient,,,399.00,259.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,142.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,142.76,142.76,
80 CESAREAN DELIVERY ONLY,P960000938,CDM,960,RC,59514,HCPCS,Outpatient,,,1820.00,1183.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,611.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,611.82,611.82,
OL DIG E/M SVC 21+ MIN,P960000811,CDM,960,RC,99423,HCPCS,Outpatient,,,105.35,68.48,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,34.48,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,34.48,34.48,
CEFTRIAXONE (ROCEPHIN) IM / IV,P960000688,CDM,960,RC,J0696,HCPCS,Outpatient,,,10.00,6.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.48,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.48,0.48,
INPT/TELE FOLLOW UP 15,P960000804,CDM,960,RC,,,Outpatient,,,97.00,63.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,97,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,97,97,
PER PM REEVAL EST PAT 65+ YR,P960000655,CDM,960,RC,99397,HCPCS,Outpatient,,,504.00,327.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,96.11,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,96.11,96.11,
REP RECURENT ING HERNIA ANY AG,P960000956,CDM,960,RC,49521,HCPCS,Outpatient,,,1776.25,1154.56,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,785.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,785.1,785.1,
EX ARM/ELBOW TUM DEEP 5 CM/>,P960000948,CDM,960,RC,24073,HCPCS,Outpatient,,,1717.45,1116.34,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,601.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,601.45,601.45,
REMOT IMAGE SUBMIT BY PT,P960000808,CDM,960,RC,,,Outpatient,,,22.85,14.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22.85,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,22.85,22.85,
PLASTAZOTE SANDAL EACH,P960000859,CDM,960,RC,,,Outpatient,,,21.00,13.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,21,21,
2VHPV VACCINE 3 DOSE IM,P960000837,CDM,960,RC,90650,HCPCS,Outpatient,,,226.86,147.46,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,150.08,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,150.08,150.08,
20 REMOVAL OF SMALL INTESTINE,P960000871,CDM,960,RC,44120,HCPCS,Outpatient,,,2430.00,1579.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1340.59,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1340.59,1340.59,
INJ KETO TROMETHAMINE 15 MG,P960000694,CDM,960,RC,J1885,HCPCS,Outpatient,,,20.00,13.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.57,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.57,0.57,
ARTHROSCOPY KNEE; ABRAS ARTHRO,P960000800,CDM,960,RC,29879,HCPCS,Outpatient,,,1633.70,1061.91,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,572.14,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,572.14,572.14,
DESTR CUT VASC LES 10SQ CM<,P960000769,CDM,960,RC,17106,HCPCS,Outpatient,,,664.01,431.61,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,308.03,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,308.03,308.03,
DRAINAGE ABDOM ABSCESS OPEN,P960000945,CDM,960,RC,49020,HCPCS,Outpatient,,,3950.00,2567.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1746.2,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1746.2,1746.2,
DEXAMETH SODIUM PHOSPH 1 MG,P960000692,CDM,960,RC,J1100,HCPCS,Outpatient,,,5.00,3.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.14,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.14,0.14,
INJ TRIAMCIN ACETONIDE 10 MG,P960000702,CDM,960,RC,J3301,HCPCS,Outpatient,,,50.00,32.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.14,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1.14,1.14,
CHOLEDOCHOTOMY; WO TD SPHINCTE,P960000789,CDM,960,RC,47420,HCPCS,Outpatient,,,3326.02,2161.91,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1470.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1470.1,1470.1,
RIV4 VACC RECOMBINANT DNA IM,P960000838,CDM,960,RC,90682,HCPCS,Outpatient,,,149.60,97.24,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,54.56,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,54.56,54.56,
DM OP SLF-MGMT TRN SRVC 30 MIN,P960000679,CDM,960,RC,G0108,HCPCS,Outpatient,,,105.00,68.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,41.34,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,41.34,41.34,
20 REPAIR STOMACH LESION,P960000869,CDM,960,RC,43840,HCPCS,Outpatient,,,3373.68,2192.89,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1491.16,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1491.16,1491.16,
ATTENDANCE AT DELIVERY,P960000662,CDM,960,RC,99464,HCPCS,Outpatient,,,152.00,98.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,52.94,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,52.94,52.94,
NON-OB TRANSVAG US,P960000816,CDM,960,RC,76830,HCPCS,Outpatient,,,86.33,56.11,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,82.31,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,82.31,82.31,
CL TX RADIAL & ULNA FX W MANIP,P960000790,CDM,960,RC,25565,HCPCS,Outpatient,,,1145.00,744.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,444.96,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,444.96,444.96,
80 REMOVAL OF GALLBLADDER,P960000923,CDM,960,RC,47600,HCPCS,Outpatient,,,2114.00,1374.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1171.77,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1171.77,1171.77,
BETAMETHASONE ACET&SOD PHOSP 3,P960000851,CDM,960,RC,,,Outpatient,,,59.33,38.56,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,59.33,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,59.33,59.33,
OB US<14 WKS SINGLE FETUS,P960000781,CDM,960,RC,76801,HCPCS,Outpatient,,,124.05,80.63,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,82.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,82.1,82.1,
ANS PARASYMP & SYMP W/TILT,P960000761,CDM,960,RC,95924,HCPCS,Outpatient,,,179.00,116.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,174.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,174.73,174.73,
FREEING OF BOWEL ADHESION,P960000262,CDM,960,RC,44005,HCPCS,Outpatient,,,2173.00,1412.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1198.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1198.29,1198.29,
EGD BALLOON DIL ESOPH30 MM/>,P960000256,CDM,960,RC,43233,HCPCS,Outpatient,,,462.00,300.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,252.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,252.76,252.76,
INFLU FLUZONE 6-35MO VFC/SL,P960000492,CDM,960,RC,90657,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BIOPSY OF CERVIX,P960000404,CDM,960,RC,57500,HCPCS,Outpatient,,,246.00,159.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,121.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,121.05,121.05,
TREAT ULNAR FRACTURE,P960000141,CDM,960,RC,24685,HCPCS,Outpatient,,,1279.00,831.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,564.67,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,564.67,564.67,
EXC TR-EXT B9 MARG 0.5 < CM,P960000035,CDM,960,RC,11400,HCPCS,Outpatient,,,238.00,154.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,112.65,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,112.65,112.65,
INFLUENZA ASSAY W/OPTIC,P960000471,CDM,960,RC,87804,HCPCS,Outpatient,,,25.00,16.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.69,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,10.69,10.69,
SIGMOIDOSCOPY W/FB REMOVAL,P960000283,CDM,960,RC,45332,HCPCS,Outpatient,,,482.00,313.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,286.01,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,286.01,286.01,
DRAINAGE OF RECTAL ABSCESS,P960000277,CDM,960,RC,45005,HCPCS,Outpatient,,,531.00,345.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,316.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,316.23,316.23,
FNA BX W/US GDN 1ST LES,P960000001,CDM,960,RC,10005,HCPCS,Outpatient,,,272.00,176.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,116.6,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,116.6,116.6,
INCISE & DRAIN BLADDER,P960000323,CDM,960,RC,51040,HCPCS,Outpatient,,,575.00,373.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,243.02,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,243.02,243.02,
AMPUTATION TOE & METATARSAL,P960000211,CDM,960,RC,28810,HCPCS,Outpatient,,,855.00,555.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,372.48,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,372.48,372.48,
"BIO/REM, LYMPH NODE OPEN SUPER",P960000251,CDM,960,RC,38500,HCPCS,Outpatient,,,645.00,419.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,280.59,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,280.59,280.59,
DILATION OF URETHRA,P960000363,CDM,960,RC,53660,HCPCS,Outpatient,,,137.00,89.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,58.53,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,58.53,58.53,
LYSIS PENIL CIRCUMIC LESION,P960000371,CDM,960,RC,54162,HCPCS,Outpatient,,,504.00,327.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,219.17,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,219.17,219.17,
EXC SHOULDER LES SC > 3 CM,P960000132,CDM,960,RC,23071,HCPCS,Outpatient,,,824.00,535.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,362.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,362.73,362.73,
LESION REMOVAL COLONOSCOPY,P960000286,CDM,960,RC,45385,HCPCS,Outpatient,,,824.00,535.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,482.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,482.82,482.82,
INS HEART PCEMAKER ATRIAL&VENT,P960000244,CDM,960,RC,33208,HCPCS,Outpatient,,,1036.00,673.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,438.48,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,438.48,438.48,
DIAGNOSTIC SIGMOIDOSCOPY,P960000281,CDM,960,RC,45330,HCPCS,Outpatient,,,319.00,207.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,188.72,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,188.72,188.72,
INFLUENZA 6-35MS,P960000493,CDM,960,RC,90657,HCPCS,Outpatient,,,56.00,36.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,10.1,10.1,
"REREPAIR ING HERNIA, REDUCE",P960000307,CDM,960,RC,49520,HCPCS,Outpatient,,,1249.00,811.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,691.7,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,691.7,691.7,
TREAT KNEECAP DISLOCATION,P960000181,CDM,960,RC,27562,HCPCS,Outpatient,,,928.00,603.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,419.64,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,419.64,419.64,
APPLY FOREARM SPLINT,P960000218,CDM,960,RC,29125,HCPCS,Outpatient,,,125.00,81.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,54.56,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,54.56,54.56,
TREATMENT OF TIBIA FRACTURE,P960000188,CDM,960,RC,27756,HCPCS,Outpatient,,,1129.00,733.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,496.75,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,496.75,496.75,
INSERT PESSARY/OTHER DEVICE,P960000396,CDM,960,RC,57160,HCPCS,Outpatient,,,148.00,96.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,57.94,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,57.94,57.94,
APPENDECTOMY RUPTURED,P960000275,CDM,960,RC,44960,HCPCS,Outpatient,,,1733.00,1126.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,960.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,960.68,960.68,
DRAINAGE OF GLAND ABSCESS,P960000388,CDM,960,RC,56420,HCPCS,Outpatient,,,235.00,152.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,131.53,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,131.53,131.53,
INFLUENZA VACCINE,P960000494,CDM,960,RC,90658,HCPCS,Outpatient,,,72.00,46.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16.32,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,16.32,16.32,
CYSTOSCOPY WITH BIOPSY,P960000337,CDM,960,RC,52204,HCPCS,Outpatient,,,711.00,462.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,317.32,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,317.32,317.32,
LAYER CLOSURE OF WND 7.6-12.5,P960000088,CDM,960,RC,12044,HCPCS,Outpatient,,,692.00,449.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,334.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,334.25,334.25,
REMOVE LIMB NERVE LESION,P960000452,CDM,960,RC,64782,HCPCS,Outpatient,,,899.00,584.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,389.18,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,389.18,389.18,
REMOVAL OF ELBOW BURSA,P960000138,CDM,960,RC,24105,HCPCS,Outpatient,,,681.00,442.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,305.01,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,305.01,305.01,
REPAIR BOWEL OPENING/CLOSURE,P960000270,CDM,960,RC,44620,HCPCS,Outpatient,,,1725.00,1121.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,949.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,949.82,949.82,
TREAT ECTOPIC PREGNANCY,P960000431,CDM,960,RC,59151,HCPCS,Outpatient,,,1477.00,960.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,511.79,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,511.79,511.79,
DEB SUBQ TISSUE ADD-ON,P960000017,CDM,960,RC,11045,HCPCS,Outpatient,,,162.00,105.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,37.45,37.45,
APPENDECTOMY,P960000273,CDM,960,RC,44950,HCPCS,Outpatient,,,1272.00,826.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,704.34,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,704.34,704.34,
RELEASE PALM CONTRACTURE,P960000154,CDM,960,RC,26040,HCPCS,Outpatient,,,606.00,393.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,270.22,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,270.22,270.22,
"MAST, SIMPLE, COMPLETE",P960000118,CDM,960,RC,19303,HCPCS,Outpatient,,,1988.00,1292.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,869.32,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,869.32,869.32,
TREAT FRACTURE OF ULNA OPEN,P960000146,CDM,960,RC,25545,HCPCS,Outpatient,,,1219.00,792.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,537.91,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,537.91,537.91,
"DRAIN/INJECT, SM JOINT/BURSA",P960000123,CDM,960,RC,20600,HCPCS,Outpatient,,,93.00,60.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,43.46,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,43.46,43.46,
OCCLUDE FALLOPIAN TUBE(S),P960000423,CDM,960,RC,58615,HCPCS,Outpatient,,,487.00,316.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,213.96,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,213.96,213.96,
HUMAN PAPILLO(HPV) STATE,P960000486,CDM,960,RC,90649,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"SHAVE S,N,H <0.5 CM",P960000028,CDM,960,RC,11305,HCPCS,Outpatient,,,191.00,124.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,94.54,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,94.54,94.54,
CESAREAN DELIVERY,P960000441,CDM,960,RC,59510,HCPCS,Outpatient,,,6263.33,4071.16,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1487.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1487.5,1487.5,
TREAT VAGINA INFECTION,P960000395,CDM,960,RC,57150,HCPCS,Outpatient,,,88.00,57.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,45.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,45.29,45.29,
TREAT FX RAD EXTRA-ARTICUL,P960000151,CDM,960,RC,25607,HCPCS,Outpatient,,,1439.00,935.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,635.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,635.73,635.73,
REMOVAL OF OVARY/TUBE(S),P960000427,CDM,960,RC,58720,HCPCS,Outpatient,,,1450.00,942.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,636.92,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,636.92,636.92,
EXCISION OF ANAL LESION(S),P960000296,CDM,960,RC,46922,HCPCS,Outpatient,,,515.00,334.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,317.31,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,317.31,317.31,
REM SUPPORT IMPLANT DEEP,P960000127,CDM,960,RC,20680,HCPCS,Outpatient,,,1197.00,778.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,528.18,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,528.18,528.18,
TREAT ELBOW DISLOCATION,P960000140,CDM,960,RC,24605,HCPCS,Outpatient,,,914.00,594.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,408.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,408.73,408.73,
TREAT HUMERUS FRACTURE,P960000139,CDM,960,RC,24575,HCPCS,Outpatient,,,1438.00,934.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,633.4,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,633.4,633.4,
DIVIS FALLOPIAN TUBE ABD/VAG,P960000420,CDM,960,RC,58600,HCPCS,Outpatient,,,712.00,462.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,315.15,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,315.15,315.15,
REMV&REPLC PM GEN DUAL LEAD,P960000246,CDM,960,RC,33228,HCPCS,Outpatient,,,700.00,455.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,297.84,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,297.84,297.84,
"HYSTEROSCOPY, BIOPSY",P960000416,CDM,960,RC,58558,HCPCS,Outpatient,,,2585.00,1680.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1163.94,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1163.94,1163.94,
SUSPENSION OF TESTIS,P960000376,CDM,960,RC,54620,HCPCS,Outpatient,,,599.00,389.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,257.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,257.29,257.29,
EXC TR-EXT MLG LES MARG > 4 CM,P960000056,CDM,960,RC,11606,HCPCS,Outpatient,,,873.00,567.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,404,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,404,404,
CYSTO/TREAT W ORW/OUT BIO<0.5,P960000339,CDM,960,RC,52224,HCPCS,Outpatient,,,1328.00,863.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,628.09,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,628.09,628.09,
EXC BACK TUM DEEP < 5 CM,P960000131,CDM,960,RC,21932,HCPCS,Outpatient,,,1304.00,847.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,572.72,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,572.72,572.72,
INFLUENZA LIVE INTRANASAL,P960000497,CDM,960,RC,90660,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FOREIGN BODY-NOSE,P960000236,CDM,960,RC,30300,HCPCS,Outpatient,,,340.00,221.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,168.65,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,168.65,168.65,
CONIZATION OF CERVIX,P960000406,CDM,960,RC,57522,HCPCS,Outpatient,,,513.00,333.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,243.55,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,243.55,243.55,
"SHAVE F,E,E,N,L,M 0.6-1 CM",P960000032,CDM,960,RC,11311,HCPCS,Outpatient,,,214.00,139.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,123.35,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,123.35,123.35,
"DESTROY, VULVA LESIONS, SIM",P960000390,CDM,960,RC,56501,HCPCS,Outpatient,,,254.00,165.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,138.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,138.3,138.3,
INADM ANY ROUTE ADDL VAC/TOX,P960000476,CDM,960,RC,90461,HCPCS,Outpatient,,,25.00,16.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,4.25,4.25,
"INSERT BLADDER CATH, COMPLEX",P960000328,CDM,960,RC,51703,HCPCS,Outpatient,,,244.00,158.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,115.42,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,115.42,115.42,
REMOVE DRUG IMPLANT DEVICE,P960000077,CDM,960,RC,11982,HCPCS,Outpatient,,,310.00,201.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,105.64,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,105.64,105.64,
HEMORRHOIDOPEXY BY STAPLING,P960000297,CDM,960,RC,46947,HCPCS,Outpatient,,,753.00,489.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,420.97,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,420.97,420.97,
BIOPSY OF CERVIX W/SCOPE,P960000402,CDM,960,RC,57455,HCPCS,Outpatient,,,278.00,180.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,131.07,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,131.07,131.07,
SHAVE TRUNK <0.5 CM,P960000024,CDM,960,RC,11300,HCPCS,Outpatient,,,188.00,122.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,89.65,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,89.65,89.65,
OP UP GI END W/REM TU/POLY/LES,P960000261,CDM,960,RC,43251,HCPCS,Outpatient,,,847.00,550.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,516.09,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,516.09,516.09,
PNEUMOCOCCAL VACC 13 VAL IM,P960000500,CDM,960,RC,90670,HCPCS,Outpatient,,,404.00,262.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,215.98,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,215.98,215.98,
LAYER CLOSURE OF WND 12.6-20,P960000089,CDM,960,RC,12051,HCPCS,Outpatient,,,497.00,323.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,244.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,244.23,244.23,
DEB SUBQ TISSUE 20 SQ CM/<,P960000014,CDM,960,RC,11042,HCPCS,Outpatient,,,474.00,308.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,112.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,112.76,112.76,
INCISION OF URETHRA,P960000360,CDM,960,RC,53020,HCPCS,Outpatient,,,195.00,126.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,81.74,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,81.74,81.74,
"HYSTEROSCOPY, STERILIZATION",P960000418,CDM,960,RC,58565,HCPCS,Outpatient,,,3574.00,2323.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1518.15,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1518.15,1518.15,
REMOVE TONSILS AND ADENOIDS,P960000254,CDM,960,RC,42820,HCPCS,Outpatient,,,571.00,371.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,315.02,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,315.02,315.02,
HEMORRHOIDECTOMY 2 OR MORE,P960000294,CDM,960,RC,46260,HCPCS,Outpatient,,,937.00,609.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,524.91,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,524.91,524.91,
MRI NECK SPINE WO DYE,P960000456,CDM,960,RC,72141,HCPCS,Outpatient,,,148.00,96.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,148,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,148,148,
PART REM COLON W/COLOSTOMY,P960000265,CDM,960,RC,44143,HCPCS,Outpatient,,,3306.00,2148.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1822.8,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1822.8,1822.8,
REPAIR DEFORMITY OF TOE,P960000205,CDM,960,RC,28313,HCPCS,Outpatient,,,1036.00,673.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,456.31,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,456.31,456.31,
TOTAL KNEE ARTHROPLASTY,P960000176,CDM,960,RC,27447,HCPCS,Outpatient,,,3085.93,2005.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1173.22,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1173.22,1173.22,
REPAIR WOUND/LESION ADD-ON,P960000093,CDM,960,RC,13122,HCPCS,Outpatient,,,258.00,167.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,118.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,118.25,118.25,
INCISE FINGER TENDON SHEATH,P960000155,CDM,960,RC,26055,HCPCS,Outpatient,,,1068.00,694.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,468.04,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,468.04,468.04,
FNA BX W/O IMG GDN 1ST LES,P960000002,CDM,960,RC,10021,HCPCS,Outpatient,,,382.00,248.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,88.55,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,88.55,88.55,
TREAT METACARPAL FRAC OPEN,P960000159,CDM,960,RC,26615,HCPCS,Outpatient,,,1124.00,730.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,496.57,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,496.57,496.57,
EXC FACE-MM MALIG MARG 0.6-1,P960000061,CDM,960,RC,11641,HCPCS,Outpatient,,,459.00,298.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,214.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,214.23,214.23,
INSERTION OF CHEST TUBE,P960000240,CDM,960,RC,32551,HCPCS,Outpatient,,,315.00,204.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,142.56,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,142.56,142.56,
EPISIOTOMY OR VAGINAL REPAIR,P960000433,CDM,960,RC,59300,HCPCS,Outpatient,,,376.00,244.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,142.03,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,142.03,142.03,
IMMUNIZATION ADMIN,P960000477,CDM,771,RC,90471,HCPCS,Outpatient,,,49.00,31.85,,89.46,125,,,Fee Schedule,125% of CMS OPPS Rate,37.24,76,,29.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,166.45,350,,,Fee Schedule,350% of BCBS fee schedule,166.45,350,,,Fee Schedule,350% of BCBS fee schedule,71.56,100,,,Fee Schedule,100% of CMS OPPS Rate,166.45,286,,,Fee Schedule,286% of BCBS PPO fee schedule,58.2,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,44.1,90,,35.28,Percent of Total Billed Charges,90% of Total Billed Charges,22.05,45,,17.64,Percent of Total Billed Charges,45% of Total Billed Charges,44.1,90,,35.28,Percent of Total Billed Charges,90% of Total billed Charges,71.56,100,,,Fee Schedule,100% of CMS OPPS Rate,71.56,100,,,Fee Schedule,100% of CMS OPPS Rate,71.56,100,,,Fee Schedule,100% of CMS OPPS Rate,133.65,200,,,Fee Schedule,200% of CMS OPPS Rate,21.61,44.1,,17.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.55,95,,37.24,Percent of Total Billed Charges,95% of Total Billed Charges,53.67,75,,,Fee Schedule,75% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,44.1,90,,35.28,Percent of Total Billed charges,90% of Total Billed Charges,21.61,166.45,
TREAT OF ANKLE FRAN OPEN MEDIA,P960000190,CDM,960,RC,27766,HCPCS,Outpatient,,,1193.00,775.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,522.46,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,522.46,522.46,
TREAT KNEE FRACTURE OPEN,P960000179,CDM,960,RC,27535,HCPCS,Outpatient,,,1769.00,1149.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,777.95,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,777.95,777.95,
EXC FACE-MM B9 MARG 3.1-4 CM,P960000051,CDM,960,RC,11444,HCPCS,Outpatient,,,545.00,354.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,255.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,255.5,255.5,
NO CALL NO SHOW,P960000473,CDM,960,RC,,,Outpatient,,,50.00,32.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,50,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,50,50,
PARTIAL AMPUTATION OF TOE,P960000213,CDM,960,RC,28825,HCPCS,Outpatient,,,1059.00,688.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,464.59,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,464.59,464.59,
REM OF FT FOREIGN BODY SUBCU,P960000198,CDM,960,RC,28190,HCPCS,Outpatient,,,503.00,326.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,219.19,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,219.19,219.19,
DRAINAGE OF ARM BURSA,P960000137,CDM,960,RC,23931,HCPCS,Outpatient,,,551.00,358.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,248.53,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,248.53,248.53,
REPAIR OF WOUND/LESION COMPLEX,P960000094,CDM,960,RC,13131,HCPCS,Outpatient,,,744.00,483.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,351.46,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,351.46,351.46,
REPAIR HALLUX RIGIDUS,P960000202,CDM,960,RC,28289,HCPCS,Outpatient,,,1468.00,954.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,621.31,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,621.31,621.31,
TREAT OF ANKLE FRAC W/MANIPULA,P960000189,CDM,960,RC,27762,HCPCS,Outpatient,,,914.00,594.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,412.44,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,412.44,412.44,
REMOVAL OF GALLBLADDER,P960000300,CDM,960,RC,47600,HCPCS,Outpatient,,,2114.00,1374.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1171.77,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1171.77,1171.77,
TANGNTL BX SKIN SINGLE LES,P960000022,CDM,960,RC,11102,HCPCS,Outpatient,,,199.00,129.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,89.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,89.58,89.58,
PARTIAL REMOVAL OF FOOT BONE,P960000201,CDM,960,RC,28288,HCPCS,Outpatient,,,1188.00,772.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,530.61,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,530.61,530.61,
"BIOPSY OF BREAST, OPEN",P960000114,CDM,960,RC,19101,HCPCS,Outpatient,,,657.00,427.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,301.19,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,301.19,301.19,
ELTRD/INSERT PACE-DEFIB,P960000247,CDM,960,RC,33249,HCPCS,Outpatient,,,1821.00,1183.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,771.64,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,771.64,771.64,
ELECTROUROFLOWMETRY FIRST,P960000331,CDM,960,RC,51741,HCPCS,Outpatient,,,17.00,11.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.83,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,11.83,11.83,
REMOVAL OF SMALL INTESTINE,P960000263,CDM,960,RC,44120,HCPCS,Outpatient,,,2430.00,1579.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1340.59,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1340.59,1340.59,
DILATE URETHRA STRICTURE,P960000362,CDM,960,RC,53600,HCPCS,Outpatient,,,164.00,106.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,70.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,70.82,70.82,
REMOVAL OF HEMORRHOID CLOT,P960000295,CDM,960,RC,46320,HCPCS,Outpatient,,,356.00,231.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,213.97,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,213.97,213.97,
REPAIR FOOT DISLOCATION,P960000208,CDM,960,RC,28555,HCPCS,Outpatient,,,1724.00,1120.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,740.71,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,740.71,740.71,
REPAIR TOE DISLOCATION,P960000209,CDM,960,RC,28645,HCPCS,Outpatient,,,1294.00,841.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,572.06,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,572.06,572.06,
HPV9 STATE,P960000489,CDM,960,RC,90651,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DRAIN LOWER LEG LESION,P960000184,CDM,960,RC,27603,HCPCS,Outpatient,,,1025.00,666.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,459.59,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,459.59,459.59,
TREATMENT OF PENIS LESION,P960000367,CDM,960,RC,54115,HCPCS,Outpatient,,,902.00,586.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,388.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,388.9,388.9,
EXC NECK LES SC 3+ CM,P960000129,CDM,960,RC,21552,HCPCS,Outpatient,,,878.00,570.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,384.95,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,384.95,384.95,
TREAT OF ANKLE FRAC OPEN DISTA,P960000191,CDM,960,RC,27792,HCPCS,Outpatient,,,1280.00,832.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,560.08,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,560.08,560.08,
TREAT METATARSAL FRACTURE,P960000207,CDM,960,RC,28485,HCPCS,Outpatient,,,1068.00,694.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,480.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,480.45,480.45,
SKIN SUB GRAFT T/A/L ADD-ON,P960000099,CDM,960,RC,15272,HCPCS,Outpatient,,,53.00,34.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23.6,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,23.6,23.6,
REMOVAL OF ANAL FISSURE,P960000291,CDM,960,RC,46200,HCPCS,Outpatient,,,863.00,560.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,501.63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,501.63,501.63,
REMOVE TENDON SHEATH LESION,P960000156,CDM,960,RC,26160,HCPCS,Outpatient,,,1099.00,714.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,489.79,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,489.79,489.79,
LIGATION OF HEMORRHOID(S),P960000292,CDM,960,RC,46221,HCPCS,Outpatient,,,520.00,338.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,297.79,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,297.79,297.79,
EXC FACE-MM B9 MARG 0.5 < CM,P960000047,CDM,960,RC,11440,HCPCS,Outpatient,,,258.00,167.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,125.46,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,125.46,125.46,
AMPUTATION OF LOWER LEG,P960000197,CDM,960,RC,27880,HCPCS,Outpatient,,,1823.00,1184.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,785.84,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,785.84,785.84,
SHORT LEG CAST,P960000224,CDM,960,RC,29405,HCPCS,Outpatient,,,159.00,103.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,67.99,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,67.99,67.99,
US EXAM OF HEAD AND NECK,P960000458,CDM,960,RC,76536,HCPCS,Outpatient,,,223.00,144.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,77.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,77.43,77.43,
REM TUNNELED CV CATH W/OUT SUB,P960000249,CDM,960,RC,36589,HCPCS,Outpatient,,,322.00,209.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,139.46,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,139.46,139.46,
EXC TR-EXT B9 MARG 0.6-1 CM,P960000036,CDM,960,RC,11401,HCPCS,Outpatient,,,287.00,186.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,137.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,137.45,137.45,
LAYER CLOSURE OF WND 2.6-7.5,P960000087,CDM,960,RC,12042,HCPCS,Outpatient,,,558.00,362.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,270.2,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,270.2,270.2,
FRAGMENTING OF KIDNEY STONE,P960000321,CDM,960,RC,50590,HCPCS,Outpatient,,,1417.00,921.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,615.75,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,615.75,615.75,
SHLDER ARTHROSCOPY/SURG LIMIT,P960000229,CDM,960,RC,29822,HCPCS,Outpatient,,,1114.00,724.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,498.47,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,498.47,498.47,
TX THIGH FRAC W OR W/OUT SCREW,P960000171,CDM,960,RC,27245,HCPCS,Outpatient,,,2428.00,1578.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1063.84,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1063.84,1063.84,
PROSTATECTOMY (TURP),P960000357,CDM,960,RC,52601,HCPCS,Outpatient,,,1692.00,1099.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,614.87,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,614.87,614.87,
INFLUENZA SPLIT>3YRS IM VFC/SL,P960000495,CDM,960,RC,90658,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GATED HEART PLANAR SINGLE,P960000462,CDM,960,RC,78472,HCPCS,Outpatient,,,96.00,62.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,96,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,96,96,
"UPPER GI ENDOSCOPY, BIOPSY",P960000258,CDM,960,RC,43239,HCPCS,Outpatient,,,658.00,427.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,403.63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,403.63,403.63,
RPAIR ANKL LIGAMNT COLLAT-BOTH,P960000187,CDM,960,RC,27696,HCPCS,Outpatient,,,1093.00,710.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,486.72,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,486.72,486.72,
REMOVAL OF TESTIS SIMPLE,P960000373,CDM,960,RC,54520,HCPCS,Outpatient,,,649.00,421.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,279.33,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,279.33,279.33,
TX HIP DISLOC REG./GEN ANESTH,P960000173,CDM,960,RC,27266,HCPCS,Outpatient,,,1138.00,739.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,503.46,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,503.46,503.46,
TREAT FRACTURE OF ULNA W/MANI,P960000145,CDM,960,RC,25535,HCPCS,Outpatient,,,946.00,614.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,422.37,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,422.37,422.37,
REMOVAL OF SUTR/STAP REQ ANEST,P960000101,CDM,960,RC,15851,HCPCS,Outpatient,,,190.00,123.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,92.67,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,92.67,92.67,
LAPARO-ASST VAG HYSTERECTOMY,P960000414,CDM,960,RC,58550,HCPCS,Outpatient,,,1732.00,1125.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,756.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,756.76,756.76,
TREAT SHOULDER DISLOCATION,P960000135,CDM,960,RC,23655,HCPCS,Outpatient,,,781.00,507.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,348.87,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,348.87,348.87,
ENDOCERV CURETTAGE W/SCOPE,P960000403,CDM,960,RC,57456,HCPCS,Outpatient,,,262.00,170.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,123.16,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,123.16,123.16,
CHANGE OF BLADDER TUBE SIMPLE,P960000329,CDM,960,RC,51705,HCPCS,Outpatient,,,176.00,114.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,78.53,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,78.53,78.53,
"SHAVE S,N,H 1.1-2 CM",P960000030,CDM,960,RC,11307,HCPCS,Outpatient,,,278.00,180.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,129.49,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,129.49,129.49,
EXC H-F-NK-SP B9 MARG 0.5 <,P960000041,CDM,960,RC,11420,HCPCS,Outpatient,,,236.00,153.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,113.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,113.82,113.82,
APPLICATION OF FINGER SPLINT,P960000219,CDM,960,RC,29130,HCPCS,Outpatient,,,80.00,52.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,35.41,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,35.41,35.41,
EXC H-F-NK-SP MLG MARG 1.1-2,P960000058,CDM,960,RC,11622,HCPCS,Outpatient,,,495.00,321.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,229.4,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,229.4,229.4,
SURGERY FOR VULVA LESION,P960000389,CDM,960,RC,56440,HCPCS,Outpatient,,,358.00,232.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,155.04,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,155.04,155.04,
PROCTOSIGMOIDOSCOPY REMOVAL,P960000280,CDM,960,RC,45309,HCPCS,Outpatient,,,320.00,208.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,204.54,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,204.54,204.54,
"LAPAROSCOPY, REMOVE ADNEXA",P960000424,CDM,960,RC,58661,HCPCS,Outpatient,,,1279.00,831.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,557.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,557.68,557.68,
TRIM NAIL(S),P960000066,CDM,960,RC,11719,HCPCS,Outpatient,,,27.00,17.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.17,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,10.17,10.17,
TREAT UTERUS INFECTION,P960000445,CDM,960,RC,59830,HCPCS,Outpatient,,,861.00,559.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,302.06,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,302.06,302.06,
REMOVE CERCLAGE SUTURE,P960000446,CDM,960,RC,59871,HCPCS,Outpatient,,,266.00,172.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,88.59,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,88.59,88.59,
DESTRUCT SKIN LESIONS 1.1-2.0,P960000110,CDM,960,RC,17282,HCPCS,Outpatient,,,395.00,256.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,184.48,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,184.48,184.48,
APPLY BONE FIXATION DEVICE,P960000128,CDM,960,RC,20690,HCPCS,Outpatient,,,1172.00,761.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,516.56,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,516.56,516.56,
"MAST, MOD RAD",P960000119,CDM,960,RC,19307,HCPCS,Outpatient,,,2847.08,1850.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1092.28,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1092.28,1092.28,
REPAIR BOWEL OPENING/RESECTION,P960000271,CDM,960,RC,44626,HCPCS,Outpatient,,,3190.00,2073.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1754.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1754.29,1754.29,
PARTIAL HYSTERECTOMY,P960000411,CDM,960,RC,58180,HCPCS,Outpatient,,,1894.00,1231.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,823.33,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,823.33,823.33,
BX BREAST PERCUT W/O IMAGE,P960000113,CDM,960,RC,19100,HCPCS,Outpatient,,,289.00,187.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,137.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,137.73,137.73,
CARPAL TUNNEL SURGERY,P960000451,CDM,960,RC,64721,HCPCS,Outpatient,,,837.00,544.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,368.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,368.45,368.45,
REM TUNNELED CV CATH WITH SUB,P960000250,CDM,960,RC,36590,HCPCS,Outpatient,,,434.00,282.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,186.7,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,186.7,186.7,
TREAT OF ANKLE FRAC BIMALLEOLA,P960000192,CDM,960,RC,27814,HCPCS,Outpatient,,,1515.00,984.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,663.88,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,663.88,663.88,
REMOVAL PILONIDAL LESION COMP,P960000075,CDM,960,RC,11772,HCPCS,Outpatient,,,1340.00,871.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,656.49,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,656.49,656.49,
EXCISE LESION TESTIS,P960000372,CDM,960,RC,54512,HCPCS,Outpatient,,,1078.00,700.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,463.03,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,463.03,463.03,
DEBRIDE GENITALIA & PERINEUM,P960000012,CDM,960,RC,11004,HCPCS,Outpatient,,,2313.00,1503.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,525.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,525.43,525.43,
DRAINAGE OF SCROTUM,P960000377,CDM,960,RC,54700,HCPCS,Outpatient,,,425.00,276.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,183.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,183.29,183.29,
"BIO/REM, LYMPH NODE DEEP CERV",P960000252,CDM,960,RC,38510,HCPCS,Outpatient,,,1015.00,659.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,439.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,439.76,439.76,
"EXCISION, ADDL BREAST LESION",P960000117,CDM,960,RC,19126,HCPCS,Outpatient,,,321.00,208.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,146.18,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,146.18,146.18,
REMOVE EPIDIDYMIS LESION,P960000378,CDM,960,RC,54830,HCPCS,Outpatient,,,742.00,482.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,318.99,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,318.99,318.99,
TREAT OF ANKLE FRAC TRIMALLEOL,P960000193,CDM,960,RC,27822,HCPCS,Outpatient,,,1684.00,1094.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,749.33,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,749.33,749.33,
DRAINAGE OF BREAST LESION,P960000112,CDM,960,RC,19000,HCPCS,Outpatient,,,217.00,141.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,98.12,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,98.12,98.12,
PROCTOSIGMOIDOSCOPY DX,P960000278,CDM,960,RC,45300,HCPCS,Outpatient,,,237.00,154.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,133.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,133.5,133.5,
"RPR REM HERNIA, INIT, REDUCE",P960000309,CDM,960,RC,49550,HCPCS,Outpatient,,,1137.00,739.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,630.88,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,630.88,630.88,
EXC H-F-NK-SP B9 MARG 0.6-1,P960000042,CDM,960,RC,11421,HCPCS,Outpatient,,,302.00,196.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,143.49,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,143.49,143.49,
"PIN FINGER FRACTURE, EACH",P960000164,CDM,960,RC,26756,HCPCS,Outpatient,,,810.00,526.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,363.66,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,363.66,363.66,
EXC TR-EXT MLG MARG 1.1-2 CM,P960000053,CDM,960,RC,11602,HCPCS,Outpatient,,,479.00,311.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,222.11,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,222.11,222.11,
SHLDER ARTHROSCOPY/SURG EXT,P960000230,CDM,960,RC,29823,HCPCS,Outpatient,,,1216.00,790.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,542.51,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,542.51,542.51,
APPLICATION LOWER LEG SPLINT,P960000226,CDM,960,RC,29515,HCPCS,Outpatient,,,140.00,91.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,60.47,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,60.47,60.47,
"NEEDLE BIOPSY, LIVER ADD-ON",P960000298,CDM,960,RC,47001,HCPCS,Outpatient,,,208.00,135.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,114.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,114.1,114.1,
FOREIGN BODY/EAR,P960000453,CDM,960,RC,69200,HCPCS,Outpatient,,,160.00,104.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,74.92,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,74.92,74.92,
COLOSTOMY,P960000266,CDM,960,RC,44320,HCPCS,Outpatient,,,2385.00,1550.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1316.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1316.1,1316.1,
"REPAIR ROTATOR CUFF, CHRONIC",P960000133,CDM,960,RC,23412,HCPCS,Outpatient,,,1673.00,1087.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,737.66,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,737.66,737.66,
EXC FACE-MM B9 MARG 2.1-3 CM,P960000050,CDM,960,RC,11443,HCPCS,Outpatient,,,433.00,281.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,203.75,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,203.75,203.75,
IMMUNE ADMIN ORAL/NASAL ADDL,P960000480,CDM,960,RC,90474,HCPCS,Outpatient,,,25.00,16.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,4.25,4.25,
"SHAVE S,N,H 0.6-1 CM",P960000029,CDM,960,RC,11306,HCPCS,Outpatient,,,236.00,153.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,110.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,110.73,110.73,
"CYSTO/TREAT TRIG,NECK,PROFO,UR",P960000338,CDM,960,RC,52214,HCPCS,Outpatient,,,1266.00,822.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,600.92,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,600.92,600.92,
ENDOCERVICAL CURETTAGE,P960000405,CDM,960,RC,57505,HCPCS,Outpatient,,,198.00,128.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,108.79,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,108.79,108.79,
"DRESSING CHANGE,NOT FOR BURN",P960000102,CDM,960,RC,15852,HCPCS,Outpatient,,,93.00,60.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,42.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,42.45,42.45,
CARE OF MISCARRIAGE,P960000444,CDM,960,RC,59820,HCPCS,Outpatient,,,742.00,482.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,273.6,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,273.6,273.6,
SHAVE TRUNK 0.6-1 CM,P960000025,CDM,960,RC,11301,HCPCS,Outpatient,,,232.00,150.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,109.06,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,109.06,109.06,
FITTING OF DIAPHRAGM/CAP,P960000397,CDM,960,RC,57170,HCPCS,Outpatient,,,119.00,77.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,59.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,59.73,59.73,
REMOVE BLADDER STONE SIMPLE,P960000348,CDM,960,RC,52317,HCPCS,Outpatient,,,1555.00,1010.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,722.85,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,722.85,722.85,
CYSTO AND TREAT LG TUMOR,P960000342,CDM,960,RC,52240,HCPCS,Outpatient,,,788.00,512.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,330.63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,330.63,330.63,
INCISION OF RECTAL ABSCESS,P960000288,CDM,960,RC,46040,HCPCS,Outpatient,,,1040.00,676.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,593.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,593.82,593.82,
LAYER CLOSURE OF WND 20.1-30,P960000086,CDM,960,RC,12036,HCPCS,Outpatient,,,812.00,527.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,387.44,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,387.44,387.44,
CYSTOURETERO & OR PYELOSCOPE,P960000353,CDM,960,RC,52351,HCPCS,Outpatient,,,609.00,395.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,254.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,254.76,254.76,
CYSTO AND TREAT DIAL BLAD CYST,P960000343,CDM,960,RC,52260,HCPCS,Outpatient,,,422.00,274.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,177.4,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,177.4,177.4,
APPLICATION OF LONG LEG CAST,P960000221,CDM,960,RC,29345,HCPCS,Outpatient,,,265.00,172.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,115.35,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,115.35,115.35,
INCISION OF ANAL SPHINCTER,P960000290,CDM,960,RC,46080,HCPCS,Outpatient,,,482.00,313.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,292.4,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,292.4,292.4,
SHAVE TRUNK >2 CM,P960000027,CDM,960,RC,11303,HCPCS,Outpatient,,,302.00,196.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,138.91,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,138.91,138.91,
CHANGE OF BLADDER TUBE COMP,P960000330,CDM,960,RC,51710,HCPCS,Outpatient,,,250.00,162.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,109.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,109.43,109.43,
DEB BONE 20 SQ CM/<,P960000016,CDM,960,RC,11044,HCPCS,Outpatient,,,1231.00,800.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,282.86,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,282.86,282.86,
BIOPSY OF PENIS,P960000366,CDM,960,RC,54100,HCPCS,Outpatient,,,385.00,250.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,167.97,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,167.97,167.97,
APPLY SHORT LEG CAST,P960000223,CDM,960,RC,29405,HCPCS,Outpatient,,,159.00,103.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,67.99,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,67.99,67.99,
AMPUTATION OF FINGER/THUMB,P960000166,CDM,960,RC,26951,HCPCS,Outpatient,,,1248.00,811.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,573.86,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,573.86,573.86,
LAYER CLOSE OF WND 12.6-20 INT,P960000085,CDM,960,RC,12035,HCPCS,Outpatient,,,734.00,477.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,346.93,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,346.93,346.93,
REM LES WORW/OUT EPIDIDYMECTOM,P960000379,CDM,960,RC,54840,HCPCS,Outpatient,,,640.00,416.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,275.87,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,275.87,275.87,
MYOMECTOMY ABDOM METHOD,P960000409,CDM,960,RC,58140,HCPCS,Outpatient,,,1807.00,1174.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,795.08,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,795.08,795.08,
STREP A ASSAY W/OPTIC,P960000472,CDM,960,RC,87880,HCPCS,Outpatient,,,50.00,32.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,10.68,10.68,
URINE PREGNANCY TEST,P960000465,CDM,960,RC,81025,HCPCS,Outpatient,,,25.00,16.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.56,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,5.56,5.56,
INJECTION FOR URETER X-RAY,P960000322,CDM,960,RC,50690,HCPCS,Outpatient,,,193.00,125.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,89.88,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,89.88,89.88,
PRP I/HERN INIT BLOCK>5 YR,P960000306,CDM,960,RC,49507,HCPCS,Outpatient,,,1156.00,751.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,641.63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,641.63,641.63,
SLING,P960000398,CDM,960,RC,57288,HCPCS,Outpatient,,,1412.00,917.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,628.19,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,628.19,628.19,
INSERT BLADDER CATHETER,P960000326,CDM,960,RC,51701,HCPCS,Outpatient,,,92.00,59.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,36.99,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,36.99,36.99,
REM FOREIGN BODY SUB TIS COMP,P960000008,CDM,960,RC,10121,HCPCS,Outpatient,,,1068.00,694.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,244.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,244.78,244.78,
ANTEPARTUM CARE ONLY 7+VISITS,P960000439,CDM,960,RC,59426,HCPCS,Outpatient,,,1597.00,1038.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,556.39,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,556.39,556.39,
SKIN SUB GRAFT FACE/NK/HF/G,P960000100,CDM,960,RC,15275,HCPCS,Outpatient,,,290.00,188.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,142.15,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,142.15,142.15,
CYSTO AND TREAT 2.0-5.0,P960000341,CDM,960,RC,52235,HCPCS,Outpatient,,,580.00,377.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,242.91,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,242.91,242.91,
EXC FACE-MM MLG MARG > 4 CM,P960000065,CDM,960,RC,11646,HCPCS,Outpatient,,,1001.00,650.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,460.37,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,460.37,460.37,
REMOVAL OF FOREARM LESION,P960000144,CDM,960,RC,25120,HCPCS,Outpatient,,,972.00,631.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,432.63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,432.63,432.63,
REMOVAL PILONIDAL LESION EXT,P960000074,CDM,960,RC,11771,HCPCS,Outpatient,,,1106.00,718.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,541.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,541.58,541.58,
ABD PARACENTESIS W/IMAGING,P960000303,CDM,960,RC,49083,HCPCS,Outpatient,,,566.00,367.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,325.65,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,325.65,325.65,
OBSTETRICAL CARE INCL ANTE CAR,P960000435,CDM,960,RC,59400,HCPCS,Outpatient,,,4117.00,2676.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1487.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1487.5,1487.5,
FLU VACCINE NO PRESERV 3 AND >,P960000491,CDM,960,RC,90656,HCPCS,Outpatient,,,50.00,32.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17.69,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,17.69,17.69,
"SUTURE, SMALL INTESTINE",P960000269,CDM,960,RC,44602,HCPCS,Outpatient,,,2807.00,1824.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1546.74,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1546.74,1546.74,
DRAINAGE OF SCROTUM ABSCESS,P960000383,CDM,960,RC,55100,HCPCS,Outpatient,,,421.00,273.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,189.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,189.9,189.9,
"HYSTEROSCOPY, ABLATION",P960000417,CDM,960,RC,58563,HCPCS,Outpatient,,,3017.00,1961.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1633.57,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1633.57,1633.57,
"EXCISION OF NAIL FOLD, TOE",P960000073,CDM,960,RC,11765,HCPCS,Outpatient,,,322.00,209.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,121.01,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,121.01,121.01,
EXC H-F-NK-SP B9 MARG > 4 CM,P960000046,CDM,960,RC,11426,HCPCS,Outpatient,,,647.00,420.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,303.53,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,303.53,303.53,
COLONOSCOPY AND BIOPSY,P960000285,CDM,960,RC,45380,HCPCS,Outpatient,,,781.00,507.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,461.41,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,461.41,461.41,
CIRCUMCISION EXCISION,P960000369,CDM,960,RC,54160,HCPCS,Outpatient,,,429.00,278.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,186.48,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,186.48,186.48,
TREATMENT OF THIGH FRACTURE,P960000177,CDM,960,RC,27506,HCPCS,Outpatient,,,2637.00,1714.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1157.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1157.82,1157.82,
TREAT FRACTURE RADIUS & ULNA,P960000147,CDM,960,RC,25574,HCPCS,Outpatient,,,1320.00,858.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,582.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,582.1,582.1,
EXC H-F-NK-SP B9 MARG 3.1-4,P960000045,CDM,960,RC,11424,HCPCS,Outpatient,,,452.00,293.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,211.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,211.73,211.73,
NJX INTERLAMINAR LMBR/SAC,P960000449,CDM,960,RC,62322,HCPCS,Outpatient,,,302.00,196.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,126.63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,126.63,126.63,
REM IMPACTED CERUMEN,P960000455,CDM,960,RC,69210,HCPCS,Outpatient,,,95.00,61.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,44.17,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,44.17,44.17,
CYSTO/TREAT REM FOR BODY COMPL,P960000347,CDM,960,RC,52315,HCPCS,Outpatient,,,808.00,525.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,385.62,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,385.62,385.62,
TREAT KNEECAP FRACTURE,P960000178,CDM,960,RC,27524,HCPCS,Outpatient,,,1476.00,959.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,651.17,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,651.17,651.17,
IMMUNIZATION ADMIN EACH ADD,P960000478,CDM,771,RC,90472,HCPCS,Outpatient,,,25.00,16.25,,25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36.95,350,,,Fee Schedule,350% of BCBS fee schedule,36.95,350,,,Fee Schedule,350% of BCBS fee schedule,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.95,286,,,Fee Schedule,286% of BCBS PPO fee schedule,12.92,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,11.25,45,,9,Percent of Total Billed Charges,45% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.25,65,,13,Percent of total Billed Charges,65% of Total Billed Charges,11.03,44.1,,8.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.75,95,,19,Percent of Total Billed Charges,95% of Total Billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,22.5,90,,18,Percent of Total Billed charges,90% of Total Billed Charges,11.03,36.95,
TREAT FX RADIAL 3+ FRAG,P960000153,CDM,960,RC,25609,HCPCS,Outpatient,,,2056.00,1336.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,907.67,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,907.67,907.67,
"SHAVE F,E,E,N,L,M <0.5 CM",P960000031,CDM,960,RC,11310,HCPCS,Outpatient,,,219.00,142.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,103.86,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,103.86,103.86,
ATTENDANCE AT DELIVERY,P960000662,CDM,960,RC,99464,HCPCS,Outpatient,,,152.00,98.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,52.94,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,52.94,52.94,
PREVENT CARE NEW PT. AGE 12-17,P960000645,CDM,960,RC,99384,HCPCS,Outpatient,,,502.00,326.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,96.11,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,96.11,96.11,
PROMAZINE HCL INJECTION 25 MG,P960000701,CDM,960,RC,J2950,HCPCS,Outpatient,,,5.00,3.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.72,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.72,0.72,
LAP; CHOLECYSTECTOMY W CHOLANG,P960000941,CDM,960,RC,47563,HCPCS,Outpatient,,,1776.20,1154.53,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,785.08,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,785.08,785.08,
ORAL AZITHROMYCIN DIHYDRATE 1,P960000861,CDM,960,RC,,,Outpatient,,,21.20,13.78,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21.2,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,21.2,21.2,
20 FREEING OF BOWEL ADHESION,P960000870,CDM,960,RC,44005,HCPCS,Outpatient,,,2173.00,1412.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1198.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1198.29,1198.29,
PREVENT CARE NEW PT. AGE 40-64,P960000647,CDM,960,RC,99386,HCPCS,Outpatient,,,568.00,369.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,107.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,107.9,107.9,
DEVELOPMENTAL SCREEN W/SCORE,P960000841,CDM,960,RC,96110,HCPCS,Outpatient,,,219.00,142.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.19,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,11.19,11.19,
RUBBER PESSARY ANY TYPE,P960000847,CDM,960,RC,,,Outpatient,,,211.00,137.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,211,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,211,211,
REM MNTR PHYSIOL PARAM DEV,P960000952,CDM,960,RC,99454,HCPCS,Outpatient,,,156.10,101.47,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,42.15,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,42.15,42.15,
CC EACH ADD 30 MIN,P960000635,CDM,960,RC,99292,HCPCS,Outpatient,,,241.00,156.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,86.84,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,86.84,86.84,
INJECT PCN G BENZ 100000 UNITS,P960000687,CDM,960,RC,J0561,HCPCS,Outpatient,,,20.00,13.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13.46,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,13.46,13.46,
TREATMENT OF TIBIA FRACTURE,P960000819,CDM,960,RC,,,Outpatient,,,2209.90,1436.44,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2209.9,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2209.9,2209.9,
HOSP SUB CARE-MOD CPLX,P960000618,CDM,960,RC,99232,HCPCS,Outpatient,,,142.00,92.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,51.09,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,51.09,51.09,
DEVELOPMENTAL SCREEN W/SCORE,P960000841,CDM,960,RC,96110,HCPCS,Outpatient,,,219.00,142.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.19,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,11.19,11.19,
NEONATE CRIT CARE SUBSQ<=28DAY,P960000778,CDM,960,RC,99469,HCPCS,Outpatient,,,984.73,640.07,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,282.06,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,282.06,282.06,
INPT/ED TELECONSULT70,P960000786,CDM,960,RC,,,Outpatient,,,497.98,323.69,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,497.98,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,497.98,497.98,
ALLERGY IMMUNOLOGY SERVICES,P960000588,CDM,960,RC,95199,HCPCS,Outpatient,,,34.00,22.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,34,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,34,34,
ARTHROSCOPY KNEE; ABRAS ARTHRO,P960000800,CDM,960,RC,29879,HCPCS,Outpatient,,,1633.70,1061.91,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,572.14,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,572.14,572.14,
SAME DAY NB DISCHARGE,P960000661,CDM,960,RC,99463,HCPCS,Outpatient,,,235.00,152.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,78.18,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,78.18,78.18,
"INJECT, PROGESTERONE, 50 MG",P960000697,CDM,960,RC,J2675,HCPCS,Outpatient,,,4.00,2.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1.25,1.25,
REMOVE FULL ARM OR LEG CAST,P960000799,CDM,960,RC,29705,HCPCS,Outpatient,,,113.00,73.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,54.83,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,54.83,54.83,
UNLISTED ULTRASOUND,P960000904,CDM,960,RC,76999,HCPCS,Outpatient,,,191.58,124.53,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,191.58,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,191.58,191.58,
REM MNTR PHYSIOL PARAM SETUP,P960000951,CDM,960,RC,99453,HCPCS,Outpatient,,,46.93,30.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12.62,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,12.62,12.62,
NB RESUSCITATION,P960000663,CDM,960,RC,99465,HCPCS,Outpatient,,,301.00,195.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,103.52,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,103.52,103.52,
ORAL AZITHROMYCIN DIHYDRATE 1,P960000861,CDM,960,RC,,,Outpatient,,,21.20,13.78,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21.2,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,21.2,21.2,
COLO CANCER SCREENING; FLEXSIG,P960000677,CDM,960,RC,G0104,HCPCS,Outpatient,,,319.00,207.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,127.75,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,127.75,127.75,
20 REPAIR BOWEL OPENING,P960000874,CDM,960,RC,44620,HCPCS,Outpatient,,,1725.00,1121.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,949.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,949.82,949.82,
UNLISTED EXC PRESSURE ULCER,P960000827,CDM,960,RC,15999,HCPCS,Outpatient,,,1464.25,951.76,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1464.25,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1464.25,1464.25,
80 DR OVARIAN ABSCESS;ABDOMIN,P960000936,CDM,960,RC,58822,HCPCS,Outpatient,,,1722.00,1119.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,608.41,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,608.41,608.41,
EXC ARM/ELBOW LES SC 3 CM/>,P960003243,CDM,960,RC,24071,HCPCS,Outpatient,,,993.78,645.96,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,350.38,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,350.38,350.38,
Hosp IP/OBS care same date Mod,P960003079,CDM,960,RC,99235,HCPCS,Outpatient,,,389.07,252.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,119.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,119.3,119.3,
HEART FLOW RESERVE MEASURE,P960003087,CDM,960,RC,93572,HCPCS,Outpatient,,,124.30,80.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,90.43,90.43,
CCM RHC Clinical Staff 20min,P960003090,CDM,960,RC,,,Outpatient,,,194.85,126.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,194.85,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,194.85,194.85,
HEART FLOW RESERVE MEASURE,P960003087,CDM,960,RC,93572,HCPCS,Outpatient,,,124.30,80.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,90.43,90.43,
MECH REMOV TUNNELED CV CATH,P960003085,CDM,960,RC,36595,HCPCS,Outpatient,,,434.15,282.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,434.15,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,434.15,434.15,
Hosp IP/OBS care same date Mod,P960003079,CDM,960,RC,99235,HCPCS,Outpatient,,,389.07,252.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,119.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,119.3,119.3,
SARSCV2 VAC 30MCG TRS-SUC IM,P960003158,CDM,960,RC,91320,HCPCS,Outpatient,,,327.75,213.04,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,327.75,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,327.75,327.75,
R&L HRT ART/VENTRICLE ANGIO,P960003086,CDM,960,RC,93461,HCPCS,Outpatient,,,975.58,634.13,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,975.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,975.58,975.58,
HEART FLOW RESERVE MEASURE,P960003087,CDM,960,RC,93572,HCPCS,Outpatient,,,124.30,80.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,90.43,90.43,
INTRO NDL ICATH UPR/LXTR ART,P960003083,CDM,960,RC,36140,HCPCS,Outpatient,,,211.05,137.18,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,211.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,211.05,211.05,
MECH REMOV TUNNELED CV CATH,P960003085,CDM,960,RC,36595,HCPCS,Outpatient,,,434.15,282.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,434.15,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,434.15,434.15,
Hosp IP/OBS care same date Mod,P960003079,CDM,960,RC,99235,HCPCS,Outpatient,,,389.07,252.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,119.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,119.3,119.3,
CCM Staff Each addtl 20 min,P960003089,CDM,960,RC,99439,HCPCS,Outpatient,,,115.00,74.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25.93,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,25.93,25.93,
INTRO NDL ICATH UPR/LXTR ART,P960003083,CDM,960,RC,36140,HCPCS,Outpatient,,,211.05,137.18,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,211.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,211.05,211.05,
MECH REMOV TUNNELED CV CATH,P960003085,CDM,960,RC,36595,HCPCS,Outpatient,,,434.15,282.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,434.15,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,434.15,434.15,
MECH REMOV TUNNELED CV CATH,P960003085,CDM,960,RC,36595,HCPCS,Outpatient,,,434.15,282.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,434.15,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,434.15,434.15,
HEART FLOW RESERVE MEASURE,P960003087,CDM,960,RC,93572,HCPCS,Outpatient,,,124.30,80.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,90.43,90.43,
VAGOTOMY PFRMD W/PRTL DSTL GST,P960003081,CDM,960,RC,43635,HCPCS,Outpatient,,,269.27,175.03,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,123.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,123.58,123.58,
SARSCOV2 VAC 3MCG TRS-SUC IM,P960003156,CDM,960,RC,91318,HCPCS,Outpatient,,,163.40,106.21,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,163.4,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,163.4,163.4,
INTRO NDL ICATH UPR/LXTR ART,P960003083,CDM,960,RC,36140,HCPCS,Outpatient,,,211.05,137.18,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,211.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,211.05,211.05,
HEART FLOW RESERVE MEASURE,P960003087,CDM,960,RC,93572,HCPCS,Outpatient,,,124.30,80.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,90.43,90.43,
CCM Staff Each addtl 20 min,P960003089,CDM,960,RC,99439,HCPCS,Outpatient,,,115.00,74.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25.93,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,25.93,25.93,
R&L HRT ART/VENTRICLE ANGIO,P960003086,CDM,960,RC,93461,HCPCS,Outpatient,,,975.58,634.13,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,975.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,975.58,975.58,
INTRO NDL ICATH UPR/LXTR ART,P960003083,CDM,960,RC,36140,HCPCS,Outpatient,,,211.05,137.18,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,211.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,211.05,211.05,
CCM Staff Each addtl 20 min,P960003089,CDM,960,RC,99439,HCPCS,Outpatient,,,115.00,74.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25.93,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,25.93,25.93,
REM PHYSIOL MNTR 1ST 20 MIN,P960000953,CDM,960,RC,99457,HCPCS,Outpatient,,,129.03,83.87,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,35.39,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,35.39,35.39,
AMPUTATION OF TOE,P960000212,CDM,960,RC,28820,HCPCS,Outpatient,,,1109.00,720.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,485.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,485.78,485.78,
NURSING FAC SUBSEQ,P960000636,CDM,960,RC,99307,HCPCS,Outpatient,,,87.00,56.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30.97,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,30.97,30.97,
UNLISTED OB PROCEDURE,P960000788,CDM,960,RC,59899,HCPCS,Outpatient,,,398.58,259.08,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,332.35,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,332.35,332.35,
HPV VIRUS VACCINE 9 VAL IM,P960000488,CDM,960,RC,90651,HCPCS,Outpatient,,,436.00,283.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,243.95,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,243.95,243.95,
MENB-FHBP VACC 2/3 DOSE IM,P960000481,CDM,960,RC,90621,HCPCS,Outpatient,,,346.00,224.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,160.37,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,160.37,160.37,
"MMR VACCINE, SC VFC/SL",P960000518,CDM,960,RC,90707,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LSH W/T/O UT 250 G OR LESS,P960001937,CDM,960,RC,58542,HCPCS,Outpatient,,,2026.25,1317.06,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,709.27,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,709.27,709.27,
80 RPR AA HERNIA 1ST<3VM REDUC,P960003054,CDM,960,RC,49591,HCPCS,Outpatient,,,802.62,521.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,802.62,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,802.62,802.62,
PART EXC BONE FEMUR PROX TIBIA,P960001983,CDM,960,RC,27360,HCPCS,Outpatient,,,2182.83,1418.84,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,758.84,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,758.84,758.84,
Colectomy part w sl cecosto,P960000983,CDM,960,RC,44141,HCPCS,Outpatient,,,4052.13,2633.88,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1997.12,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1997.12,1997.12,
Prevnar 20 IM(pediatrics)State,P960003139,CDM,960,RC,90677,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
80 REP ANEURYSM;ABD AORTA RUPT,P960000914,CDM,960,RC,35082,HCPCS,Outpatient,,,5395.00,3506.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1834.32,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1834.32,1834.32,
INJECTION FOR BLADDER X-RAY,P960000324,CDM,960,RC,51600,HCPCS,Outpatient,,,352.00,228.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,169.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,169.82,169.82,
"LAPAROSCOPY, EXCISE LESIONS",P960000425,CDM,960,RC,58662,HCPCS,Outpatient,,,1397.00,908.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,609.65,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,609.65,609.65,
REM SUTURES BY MD,P960000802,CDM,960,RC,,,Outpatient,,,156.25,101.56,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,156.25,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,156.25,156.25,
REVISION OF CERVIX,P960000434,CDM,960,RC,59320,HCPCS,Outpatient,,,303.00,196.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,100.85,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,100.85,100.85,
EXC TR-EXT B9 MARG 3.1-4 CM,P960000039,CDM,960,RC,11404,HCPCS,Outpatient,,,420.00,273.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,199.64,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,199.64,199.64,
"DRAIN APP ABSCESS, OPEN",P960000272,CDM,960,RC,44900,HCPCS,Outpatient,,,1521.00,988.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,857.28,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,857.28,857.28,
REPAIR HAND JOINT,P960000157,CDM,960,RC,26540,HCPCS,Outpatient,,,1259.00,818.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,579.48,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,579.48,579.48,
DELIVER PLACENTA,P960000437,CDM,960,RC,59414,HCPCS,Outpatient,,,215.03,139.77,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,61.14,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,61.14,61.14,
REMOVAL OF KNEE CYST,P960000175,CDM,960,RC,27345,HCPCS,Outpatient,,,938.00,609.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,417.65,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,417.65,417.65,
ANN WELL VST; PERSNL PPS INIT,P960000685,CDM,960,RC,G0438,HCPCS,Outpatient,,,334.00,217.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,125.03,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,125.03,125.03,
80 LIGATE OVI DUCT(S) ADD ON,P960000934,CDM,960,RC,58611,HCPCS,Outpatient,,,152.00,98.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,66.19,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,66.19,66.19,
REMOVE SKIN TAGS ADD-ON,P960000736,CDM,960,RC,11201,HCPCS,Outpatient,,,37.00,24.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16.88,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,16.88,16.88,
TX THIGH FRACTURE PERCUTANEOUS,P960000168,CDM,960,RC,27235,HCPCS,Outpatient,,,1790.00,1163.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,785.83,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,785.83,785.83,
DESTRUCT SKIN LESIONS 0.6-1.0,P960000109,CDM,960,RC,17281,HCPCS,Outpatient,,,344.00,223.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,160.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,160.5,160.5,
CLOSE ENTEROVES FIST; WO INT/B,P960000909,CDM,960,RC,44660,HCPCS,Outpatient,,,3327.13,2162.63,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1470.59,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1470.59,1470.59,
20 D & C diagnostic,P960001949,CDM,960,RC,58120,HCPCS,Outpatient,,,570.60,370.89,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,238.51,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,238.51,238.51,
NEB/MDI RX INITIAL,P960000584,CDM,960,RC,94640,HCPCS,Outpatient,,,35.00,22.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20.08,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,20.08,20.08,
20 LIGATE FALLOPIAN TUBE W CES,P960000888,CDM,960,RC,58611,HCPCS,Outpatient,,,152.00,98.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,66.19,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,66.19,66.19,
CYSTO/TREAT URETERAL STENT,P960000350,CDM,960,RC,52332,HCPCS,Outpatient,,,940.00,611.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,374.48,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,374.48,374.48,
20REP ANEURYSM; ABD AORTA RUPT,P960000868,CDM,960,RC,35082,HCPCS,Outpatient,,,5395.00,3506.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1834.32,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1834.32,1834.32,
"REPAIR ING HERNIA, SLIDING",P960000308,CDM,960,RC,49525,HCPCS,Outpatient,,,1132.00,735.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,628.11,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,628.11,628.11,
"MANIPULATE,HIP JNT W ANEST",P960000776,CDM,960,RC,,,Outpatient,,,449.95,292.47,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,449.95,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,449.95,449.95,
CORRECTION OF BUNION,P960000203,CDM,960,RC,28296,HCPCS,Outpatient,,,1792.00,1164.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,791,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,791,791,
INPT/TELE FOLLOW UP 35,P960000806,CDM,960,RC,,,Outpatient,,,256.50,166.73,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,256.5,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,256.5,256.5,
"Gastrectomy,partial,distal",P960003080,CDM,960,RC,43632,HCPCS,Outpatient,,,4890.12,3178.58,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2230.27,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2230.27,2230.27,
PREVENT CARE NEW PT. AGE 40-64,P960000647,CDM,960,RC,99386,HCPCS,Outpatient,,,568.00,369.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,107.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,107.9,107.9,
"ICD DEVICE PROG EVAL, 1 SNGL",P960000563,CDM,960,RC,93282,HCPCS,Outpatient,,,123.00,79.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,59.03,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,59.03,59.03,
Repair Incompl Circumcision,P960000973,CDM,960,RC,54163,HCPCS,Outpatient,,,528.05,343.23,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,186.31,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,186.31,186.31,
Flu Vaccine S/dose State Charg,P960003218,CDM,960,RC,90656,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIAGNOSTIC COLONOSCOPY,P960000284,CDM,960,RC,45378,HCPCS,Outpatient,,,307.00,199.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,307,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,307,307,
EXPLORATION OF ABDOMEN,P960000301,CDM,960,RC,49000,HCPCS,Outpatient,,,1526.00,991.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,842.69,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,842.69,842.69,
APPLY LONG ARM SPLINT,P960000217,CDM,960,RC,29105,HCPCS,Outpatient,,,171.00,111.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,69.4,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,69.4,69.4,
LUMBAR PUNCTURE,P960000448,CDM,960,RC,62270,HCPCS,Outpatient,,,306.00,198.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,117.22,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,117.22,117.22,
SHOLDR SLING ABD RSTRN PREFAB,P960000673,CDM,960,RC,A4566,HCPCS,Outpatient,,,40.00,26.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18.39,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,18.39,18.39,
AMPUTATION THRU METATARSAL,P960000210,CDM,960,RC,28805,HCPCS,Outpatient,,,1458.00,947.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,631.41,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,631.41,631.41,
Exc Forearm lesion sc <3cm,P960001916,CDM,960,RC,25075,HCPCS,Outpatient,,,767.03,498.57,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,434.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,434.68,434.68,
"Tenolysis,flx tnd plm/finger ea",P960001917,CDM,960,RC,26440,HCPCS,Outpatient,,,1620.30,1053.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,541.12,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,541.12,541.12,
OB Visit New Level 3,P960003016,CDM,960,RC,99203,HCPCS,Outpatient,,,272.60,177.19,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,75.02,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,75.02,75.02,
MECH REMOV TUNNELED CV CATH,P960003085,CDM,960,RC,36595,HCPCS,Outpatient,,,434.15,282.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,434.15,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,434.15,434.15,
"HIB VACCINE, PRP-T, IM",P960000484,CDM,960,RC,90648,HCPCS,Outpatient,,,220.00,143.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.67,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,11.67,11.67,
PRQ CARD REVASC CHRONIC 1VSL,P960003161,CDM,960,RC,92943,HCPCS,Outpatient,,,1558.70,1013.16,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,776.14,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,776.14,776.14,
LAP ING HERNIA REPAIR RECUR,P960003163,CDM,960,RC,49651,HCPCS,Outpatient,,,1368.42,889.47,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,612.24,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,612.24,612.24,
CCM RHC Clinical Staff 20min,P960003090,CDM,960,RC,,,Outpatient,,,194.85,126.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,194.85,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,194.85,194.85,
Tis Trnfr Trunk 10sq cm <,P960001990,CDM,960,RC,14000,HCPCS,Outpatient,,,1204.63,783.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,563.7,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,563.7,563.7,
Cardiovascular Stress test,P960001984,CDM,960,RC,93015,HCPCS,Outpatient,,,172.95,112.42,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,56.64,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,56.64,56.64,
Hosp IP/OBS care same date Mod,P960003079,CDM,960,RC,99235,HCPCS,Outpatient,,,389.07,252.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,119.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,119.3,119.3,
MECH REMOV TUNNELED CV CATH,P960003085,CDM,960,RC,36595,HCPCS,Outpatient,,,434.15,282.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,434.15,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,434.15,434.15,
VAGOTOMY PFRMD W/PRTL DSTL GST,P960003081,CDM,960,RC,43635,HCPCS,Outpatient,,,269.27,175.03,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,123.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,123.58,123.58,
ENDOLUMINL IVUS OCT C EA ADDTL,P960003094,CDM,960,RC,92979,HCPCS,Outpatient,,,178.95,116.32,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,133.08,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,133.08,133.08,
US Pelvic Non OB Complete,P960000974,CDM,960,RC,76856,HCPCS,Outpatient,,,76.18,49.52,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,73.36,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,73.36,73.36,
VAGOTOMY PFRMD W/PRTL DSTL GST,P960003081,CDM,960,RC,43635,HCPCS,Outpatient,,,269.27,175.03,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,123.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,123.58,123.58,
CCM RHC Clinical Staff 20min,P960003090,CDM,960,RC,,,Outpatient,,,194.85,126.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,194.85,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,194.85,194.85,
OB Visit Estab Level 2,P960003019,CDM,960,RC,99212,HCPCS,Outpatient,,,137.63,89.46,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31.56,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,31.56,31.56,
R&L HRT ART/VENTRICLE ANGIO,P960003086,CDM,960,RC,93461,HCPCS,Outpatient,,,975.58,634.13,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,975.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,975.58,975.58,
SARSCV2 VAC 30MCG TRS-SUC IM,P960003158,CDM,960,RC,91320,HCPCS,Outpatient,,,327.75,213.04,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,327.75,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,327.75,327.75,
CCM RHC Clinical Staff 20min,P960003090,CDM,960,RC,,,Outpatient,,,194.85,126.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,194.85,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,194.85,194.85,
80Wound expl pentr chest wound,P960001926,CDM,960,RC,20101,HCPCS,Outpatient,,,504.78,328.11,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,409.22,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,409.22,409.22,
Penis straightening chordee,P960002029,CDM,960,RC,54300,HCPCS,Outpatient,,,1566.48,1018.21,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,554.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,554.45,554.45,
LAPAROSCOPY ASPIRATION,P960003131,CDM,960,RC,49322,HCPCS,Outpatient,,,907.25,589.71,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,409.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,409.23,409.23,
Colposcopy Leep W Bx,P960001981,CDM,960,RC,57460,HCPCS,Outpatient,,,388.10,252.27,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,258.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,258.76,258.76,
U S Guide vascular access,P960001985,CDM,960,RC,76937,HCPCS,Outpatient,,,33.85,22.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24.51,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,24.51,24.51,
HEART FLOW RESERVE MEASURE,P960003087,CDM,960,RC,93572,HCPCS,Outpatient,,,124.30,80.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,90.43,90.43,
ENDOLUMINL IVUS OCT C EA ADDTL,P960003094,CDM,960,RC,92979,HCPCS,Outpatient,,,178.95,116.32,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,133.08,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,133.08,133.08,
GEL ONE,P960000706,CDM,960,RC,,,Outpatient,,,3047.50,1980.88,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3047.5,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,3047.5,3047.5,
"95OFFICE VISIT, NEW PT, LEVEL4",P960000896,CDM,960,RC,99204,HCPCS,Outpatient,,,319.00,207.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,114.84,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,114.84,114.84,
"APPLICATION, LONG LEG SPLINT",P960000225,CDM,960,RC,29505,HCPCS,Outpatient,,,162.00,105.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,72.38,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,72.38,72.38,
CARDIOVASCULAR STRESS TEST,P960000556,CDM,960,RC,93018,HCPCS,Outpatient,,,29.00,18.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,12.1,12.1,
PLACE GASTROSTOMY TUBE,P960000259,CDM,960,RC,43246,HCPCS,Outpatient,,,406.00,263.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,221.34,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,221.34,221.34,
US URINE CAPACITY MEASURE,P960000332,CDM,960,RC,51798,HCPCS,Outpatient,,,37.00,24.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8.26,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,8.26,8.26,
TREAT LOWER LEG JOINT,P960000195,CDM,960,RC,27829,HCPCS,Outpatient,,,1363.00,885.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,606.08,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,606.08,606.08,
"95 OFFICE VISIT, EST PT,LEVEL1",P960000898,CDM,960,RC,99211,HCPCS,Outpatient,,,39.00,25.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16.04,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,16.04,16.04,
TREAT ANKLE DISLOCATION,P960000196,CDM,960,RC,27842,HCPCS,Outpatient,,,965.00,627.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,425.88,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,425.88,425.88,
OBSTETRICAL CARE DELIVERY ONLY,P960000436,CDM,960,RC,59409,HCPCS,Outpatient,,,3228.00,2098.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,542.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,542.9,542.9,
"EXCISION, BREAST LESION",P960000116,CDM,960,RC,19125,HCPCS,Outpatient,,,1062.00,690.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,501.59,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,501.59,501.59,
REMOVAL OF BREAST LESION,P960000115,CDM,960,RC,19120,HCPCS,Outpatient,,,958.00,622.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,454.11,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,454.11,454.11,
ADRENALIN EPINEPHRINE INJ 0.1,P960000850,CDM,960,RC,,,Outpatient,,,11.25,7.31,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.25,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,11.25,11.25,
REP SUPERFICIAL WND(S)7.6-12.5,P960000081,CDM,960,RC,12004,HCPCS,Outpatient,,,247.00,160.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,116,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,116,116,
EXCISION OF PENIS LESION(S),P960000365,CDM,960,RC,54060,HCPCS,Outpatient,,,350.00,227.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,158.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,158.9,158.9,
REM FORGN BODY SUB TIS SIMPLE,P960000007,CDM,960,RC,10120,HCPCS,Outpatient,,,592.00,384.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,136.26,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,136.26,136.26,
CHRON CARE MGMT SRVC 20 MIN,P960000955,CDM,960,RC,99490,HCPCS,Outpatient,,,79.50,51.68,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,29.05,29.05,
TREAT HEEL FRACTURE,P960000206,CDM,960,RC,28415,HCPCS,Outpatient,,,2214.00,1439.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,971.71,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,971.71,971.71,
REMOVAL OF TONSILS,P960000255,CDM,960,RC,42826,HCPCS,Outpatient,,,497.00,323.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,274.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,274.29,274.29,
INJECT PCN G BENZ 100000 UNITS,P960000687,CDM,960,RC,J0561,HCPCS,Outpatient,,,20.00,13.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13.46,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,13.46,13.46,
LACERATION <2.5CM,P960000079,CDM,960,RC,12001,HCPCS,Outpatient,,,173.00,112.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,81.14,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,81.14,81.14,
PREVENT CARE EST PT. AGE 12-17,P960000652,CDM,960,RC,99394,HCPCS,Outpatient,,,428.00,278.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,81.99,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,81.99,81.99,
EXCISION OF TONGUE LESION,P960000253,CDM,960,RC,41110,HCPCS,Outpatient,,,414.00,269.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,238.69,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,238.69,238.69,
REMOVE FULL ARM OR LEG CAST,P960000799,CDM,960,RC,29705,HCPCS,Outpatient,,,113.00,73.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,54.83,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,54.83,54.83,
DEBRIDE INFECTED SKIN,P960000011,CDM,960,RC,11000,HCPCS,Outpatient,,,217.00,141.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,51.06,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,51.06,51.06,
SHLDER ARTHROSCOPY/SUR DECOMP,P960000231,CDM,960,RC,29826,HCPCS,Outpatient,,,414.57,269.47,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,151.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,151.5,151.5,
PROCTOSIGMOIDOSCOPY W/BX,P960000279,CDM,960,RC,45305,HCPCS,Outpatient,,,275.00,178.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,175.34,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,175.34,175.34,
TOTAL VITAL CAPACITY,P960000840,CDM,960,RC,94150,HCPCS,Outpatient,,,332.10,215.87,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28.61,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,28.61,28.61,
FETAL NON-STRESS TEST,P960000430,CDM,960,RC,59025,HCPCS,Outpatient,,,94.00,61.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31.77,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,31.77,31.77,
"DESTROY LESIONS, 2-14",P960000105,CDM,960,RC,17003,HCPCS,Outpatient,,,11.00,7.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.41,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,5.41,5.41,
DESTROY BENIGN/PREMLG LESION,P960000104,CDM,960,RC,17000,HCPCS,Outpatient,,,128.00,83.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,58.6,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,58.6,58.6,
CPR,P960000772,CDM,960,RC,92950,HCPCS,Outpatient,,,591.00,384.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,258.75,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,258.75,258.75,
DRAINAGE OF ARM LESION,P960000136,CDM,960,RC,23930,HCPCS,Outpatient,,,685.00,445.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,306.48,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,306.48,306.48,
TLH W/T/O 250 G OR LESS,P960000419,CDM,960,RC,58571,HCPCS,Outpatient,,,1764.00,1146.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,766.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,766.73,766.73,
"OFFICE VISIT, EST PT., LEVEL 2",P960000603,CDM,960,RC,99212,HCPCS,Outpatient,,,137.63,89.46,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31.56,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,31.56,31.56,
IMMUNE ADMIN ORAL/NASAL,P960000479,CDM,960,RC,90473,HCPCS,Outpatient,,,49.00,31.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,4.25,4.25,
INCISION OF METATARSAL,P960000204,CDM,960,RC,28308,HCPCS,Outpatient,,,1116.00,725.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,495.75,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,495.75,495.75,
REMOVE VAGINA LESION,P960000394,CDM,960,RC,57135,HCPCS,Outpatient,,,375.00,243.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,188.28,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,188.28,188.28,
20 INTRA-ABD OMENTAL FLAP,P960000886,CDM,960,RC,49905,HCPCS,Outpatient,,,878.63,571.11,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,388.36,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,388.36,388.36,
"HEP A VACCINE, ADULT IM",P960000482,CDM,960,RC,90632,HCPCS,Outpatient,,,208.00,135.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,73.65,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,73.65,73.65,
ARTERY XRAYS ARMSLEGS,P960000457,CDM,960,RC,75716,HCPCS,Outpatient,,,127.00,82.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,117.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,117.5,117.5,
BX/CURETT OF CERVIX W/SCOPE,P960000401,CDM,960,RC,57454,HCPCS,Outpatient,,,299.00,194.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,139.08,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,139.08,139.08,
PREV CARE NEW PT. AGE  >64,P960000648,CDM,960,RC,99387,HCPCS,Outpatient,,,616.00,400.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,117.21,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,117.21,117.21,
IM ADULT HEPA-HEPB,P960000836,CDM,960,RC,90636,HCPCS,Outpatient,,,440.70,286.46,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,114.35,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,114.35,114.35,
INSERT TUNNELED CV CATH,P960000248,CDM,960,RC,36561,HCPCS,Outpatient,,,2083.00,1353.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,891.31,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,891.31,891.31,
"FLU VACCINE, NASAL",P960000496,CDM,960,RC,90660,HCPCS,Outpatient,,,94.00,61.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEBRIDE SKIN MUSC AT FX SITE,P960000013,CDM,960,RC,11011,HCPCS,Outpatient,,,2088.00,1357.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,474.33,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,474.33,474.33,
REPAIR ACHILLES TENDON,P960000185,CDM,960,RC,27650,HCPCS,Outpatient,,,1295.00,841.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,571,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,571,571,
Event Monitor Rep & Interp,P960002008,CDM,960,RC,93272,HCPCS,Outpatient,,,61.38,39.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20.74,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,20.74,20.74,
Hosp IP/OBS care same date Mod,P960003079,CDM,960,RC,99235,HCPCS,Outpatient,,,389.07,252.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,119.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,119.3,119.3,
CCM RHC Clinical Staff 20min,P960003090,CDM,960,RC,,,Outpatient,,,194.85,126.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,194.85,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,194.85,194.85,
EXPLORE SMALL INTESTINE,P960003192,CDM,960,RC,44020,HCPCS,Outpatient,,,2366.95,1538.52,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1067.12,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1067.12,1067.12,
VAGOTOMY PFRMD W/PRTL DSTL GST,P960003081,CDM,960,RC,43635,HCPCS,Outpatient,,,269.27,175.03,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,123.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,123.58,123.58,
SARSCOV2 VAC 25 MCG/.25ML IM,P960003159,CDM,960,RC,91321,HCPCS,Outpatient,,,364.80,237.12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,364.8,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,364.8,364.8,
Pt Focused Hlth Risk Assmt,P960003147,CDM,960,RC,96160,HCPCS,Outpatient,,,6.45,4.19,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.83,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2.83,2.83,
PRQ CARD REVASC CHRONIC 1VSL,P960003161,CDM,960,RC,92943,HCPCS,Outpatient,,,1558.70,1013.16,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,776.14,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,776.14,776.14,
hysteroscopy endomet ablation,P960001952,CDM,960,RC,58563,HCPCS,Outpatient,,,597.73,388.52,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,597.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,597.73,597.73,
PARTIAL REMOVAL OF FOOT BONE,P960003210,CDM,960,RC,28122,HCPCS,Outpatient,,,1076.20,699.53,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,519.39,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,519.39,519.39,
80RPR AA HERNIA RECR>10 CM RED,P960003070,CDM,960,RC,49617,HCPCS,Outpatient,,,2077.90,1350.64,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2077.9,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2077.9,2077.9,
80LSH W/T/O UTERUS ABOVE 250G,P960001944,CDM,960,RC,58544,HCPCS,Outpatient,,,2213.88,1439.02,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,775.88,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,775.88,775.88,
ORCHIOPEXY INGUN/SCROT APPR,P960002054,CDM,960,RC,54640,HCPCS,Outpatient,,,1045.65,679.67,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,373.28,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,373.28,373.28,
INCISION OF ACHILLES TENDON,P960002041,CDM,960,RC,27605,HCPCS,Outpatient,,,819.83,532.89,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,296.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,296.58,296.58,
REMOVE SHOULDER  FOREIGN BODY,P960003206,CDM,960,RC,23330,HCPCS,Outpatient,,,723.98,470.59,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,248.15,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,248.15,248.15,
HIB PRP-T Vacine 4 dose IM,P960001996,CDM,960,RC,90648,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LAP ENTERECTOMY,P960003100,CDM,960,RC,44202,HCPCS,Outpatient,,,3337.55,2169.41,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1518.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1518.78,1518.78,
SARSCOV2 VAC 50 MCG/0.5ML IM,P960003160,CDM,960,RC,91322,HCPCS,Outpatient,,,364.80,237.12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,364.8,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,364.8,364.8,
Brief Emotional/Behvrl Assmt,P960003149,CDM,960,RC,96127,HCPCS,Outpatient,,,11.10,7.22,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.54,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,5.54,5.54,
"Cath of umbilical vein,newborn",P960003125,CDM,960,RC,36510,HCPCS,Outpatient,,,129.67,84.29,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,69.7,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,69.7,69.7,
20 Gastrostomy rep w Img guidn,P960000991,CDM,960,RC,49450,HCPCS,Outpatient,,,160.25,104.16,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,160.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,160.25,160.25,
SUTR LG INTEST 1/MULT PRF WO C,P960003110,CDM,960,RC,44604,HCPCS,Outpatient,,,2538.05,1649.73,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1159.6,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1159.6,1159.6,
TREAT FRACTURE RADIUS/ULNA,P960002071,CDM,960,RC,25600,HCPCS,Outpatient,,,798.73,519.17,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,284.99,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,284.99,284.99,
EXC FOOT/TOE TUM SC 1.5 CM/>,P960002040,CDM,960,RC,28039,HCPCS,Outpatient,,,1197.40,778.31,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,431.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,431.76,431.76,
"DEBRIDE NAIL, 1-5",P960000067,CDM,960,RC,11720,HCPCS,Outpatient,,,62.00,40.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23.48,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,23.48,23.48,
OL DIG E/M SVC 11-20 MIN,P960000810,CDM,960,RC,99422,HCPCS,Outpatient,,,66.18,43.02,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21.34,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,21.34,21.34,
20 TOTAL ABDOMINAL HYSTERECTOM,P960000887,CDM,960,RC,58150,HCPCS,Outpatient,,,2000.00,1300.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,864.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,864.82,864.82,
LAYER CLOSE WND 2.6-7.5 SCALP,P960000083,CDM,960,RC,12032,HCPCS,Outpatient,,,584.00,379.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,271.63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,271.63,271.63,
STRAPPING OF HAND OR FINGER,P960000220,CDM,960,RC,29280,HCPCS,Outpatient,,,56.00,36.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,26.58,26.58,
LAYER CLOSE WND 7.6-12.5 SCALP,P960000084,CDM,960,RC,12034,HCPCS,Outpatient,,,602.00,391.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,291.63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,291.63,291.63,
IRRIGATION OF BLADDER,P960000325,CDM,960,RC,51700,HCPCS,Outpatient,,,141.00,91.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,61.81,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,61.81,61.81,
"95 OFFICE VISIT,EST PT, LEVEL2",P960000900,CDM,960,RC,99212,HCPCS,Outpatient,,,84.00,54.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31.56,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,31.56,31.56,
TX HUMERUS SH FX W IMLANT,P960000793,CDM,960,RC,24516,HCPCS,Outpatient,,,2122.30,1379.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,743.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,743.23,743.23,
LAYER CLOSURE OF WND 2.6-5.0,P960000090,CDM,960,RC,12052,HCPCS,Outpatient,,,568.00,369.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,274.33,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,274.33,274.33,
BUDESONIDE NON-COMP CON PER 0.,P960000857,CDM,960,RC,,,Outpatient,,,30.39,19.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30.39,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,30.39,30.39,
PRP I/HERN INIT REDUC>5 YR,P960000305,CDM,960,RC,49505,HCPCS,Outpatient,,,1027.00,667.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,570.36,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,570.36,570.36,
EXAM/BIOPSY OF VAG W/SCOPE,P960000399,CDM,960,RC,57421,HCPCS,Outpatient,,,307.00,199.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,143.42,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,143.42,143.42,
TREATMENT OF URETHRA LESION,P960000361,CDM,960,RC,53265,HCPCS,Outpatient,,,430.00,279.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,187.4,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,187.4,187.4,
DRAIN OF SKIN ABSCESS COMPLICA,P960000005,CDM,960,RC,10061,HCPCS,Outpatient,,,809.00,525.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,188.88,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,188.88,188.88,
REMOVAL OF TESTIS RADICAL,P960000374,CDM,960,RC,54530,HCPCS,Outpatient,,,1007.00,654.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,435.18,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,435.18,435.18,
DEPO-PROVERA,P960000691,CDM,960,RC,J1050,HCPCS,Outpatient,,,120.00,78.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.5,0.5,
PSYCH DIAG EVAL W/MED SRVCS,P960000542,CDM,960,RC,90792,HCPCS,Outpatient,,,291.00,189.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,143.41,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,143.41,143.41,
80 REPAIR STOMACH LESION,P960000915,CDM,960,RC,43840,HCPCS,Outpatient,,,3373.68,2192.89,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1491.16,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1491.16,1491.16,
PRQ CARDIAC ANGIO ADDL ART,P960003093,CDM,960,RC,92921,HCPCS,Outpatient,,,622.70,404.76,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,255.59,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,255.59,255.59,
GLYCOSYLATED HB HOME DEVICE,P960000754,CDM,960,RC,83037,HCPCS,Outpatient,,,24.28,15.78,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.27,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,6.27,6.27,
Gastrostomy repl w image guid,P960000989,CDM,960,RC,49450,HCPCS,Outpatient,,,160.25,104.16,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,160.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,160.25,160.25,
REMOVAL SWEAT GLAND LESION,P960000744,CDM,960,RC,11471,HCPCS,Outpatient,,,985.00,640.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,473.96,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,473.96,473.96,
20Wound expl extremities,P960001933,CDM,960,RC,20103,HCPCS,Outpatient,,,835.45,543.04,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,496.95,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,496.95,496.95,
Orphenadrine Inj 30mg,P960003170,CDM,960,RC,,,Outpatient,,,24.25,15.76,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24.25,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,24.25,24.25,
MTP Jnt Capsulotomy ea sngl jn,P960001963,CDM,960,RC,28270,HCPCS,Outpatient,,,816.08,530.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,429.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,429.3,429.3,
20 RPR AA HERNIA RECR <3CM RED,P960003067,CDM,960,RC,49613,HCPCS,Outpatient,,,989.70,643.31,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,989.7,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,989.7,989.7,
80RPR AA HERNIA RECR 3-10CM NC,P960003074,CDM,960,RC,49616,HCPCS,Outpatient,,,2015.47,1310.06,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2015.47,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2015.47,2015.47,
Triamcinolone Acetonide 1mg,P960001999,CDM,960,RC,,,Outpatient,,,13.23,8.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13.23,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,13.23,13.23,
REMOVAL SWEAT GLAND LESION,P960000743,CDM,960,RC,11470,HCPCS,Outpatient,,,793.00,515.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,388.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,388.76,388.76,
RELEASE OF BIG TOE,P960003202,CDM,960,RC,28240,HCPCS,Outpatient,,,1066.05,692.93,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,390.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,390.82,390.82,
MENB-4C VACC 2 DOSE IM,P960000750,CDM,960,RC,,,Outpatient,,,760.67,494.44,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,760.67,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,760.67,760.67,
INTRO NDL ICATH UPR/LXTR ART,P960003083,CDM,960,RC,36140,HCPCS,Outpatient,,,211.05,137.18,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,211.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,211.05,211.05,
TRIM SKIN LESION,P960000020,CDM,960,RC,11055,HCPCS,Outpatient,,,92.00,59.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,56.2,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,56.2,56.2,
RHO D IMMUNE GLOBULIN INJ,P960000751,CDM,960,RC,,,Outpatient,,,234.00,152.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,234,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,234,234,
TREAT LOWER LEG FRACTURE,P960002069,CDM,960,RC,27825,HCPCS,Outpatient,,,1196.25,777.56,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,471.27,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,471.27,471.27,
ED Lvl 5 High Sevrty & Threat,P960002052,CDM,960,RC,99285,HCPCS,Outpatient,,,429.25,279.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,122.36,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,122.36,122.36,
REMOVAL SWEAT GLAND LESION,P960000741,CDM,960,RC,11462,HCPCS,Outpatient,,,716.00,465.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,356.32,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,356.32,356.32,
Lap Hyst >250g w rem T/O,P960001009,CDM,960,RC,58573,HCPCS,Outpatient,,,2954.53,1920.44,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1035.99,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1035.99,1035.99,
RPR AA HERN RECR 3-10CM NCRC8,P960003048,CDM,960,RC,49616,HCPCS,Outpatient,,,2015.47,1310.06,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2015.47,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2015.47,2015.47,
LHC w Ventriculography,P960003009,CDM,960,RC,93452,HCPCS,Outpatient,,,562.50,365.63,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,562.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,562.5,562.5,
TTE W/O DOPPLER COMPLETE,P960002062,CDM,960,RC,93307,HCPCS,Outpatient,,,108.88,70.77,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,108.88,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,108.88,108.88,
20LSH W/T/O UTERUS ABOVE 250 G,P960001945,CDM,960,RC,58544,HCPCS,Outpatient,,,2213.88,1439.02,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,775.88,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,775.88,775.88,
ANTICOAG MGMT PT WARFARIN,P960000578,CDM,960,RC,93793,HCPCS,Outpatient,,,23.68,15.39,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13.63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,13.63,13.63,
"HIB VACCINE, PRP-T, IM VFC/SL",P960000485,CDM,960,RC,90648,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"ECG MONITOR/REPORT, 24 HRS",P960000558,CDM,960,RC,93224,HCPCS,Outpatient,,,174.00,113.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,69.96,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,69.96,69.96,
ICD DEVICE INTERROGATE,P960000567,CDM,960,RC,93289,HCPCS,Outpatient,,,128.00,83.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,53.02,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,53.02,53.02,
"IMMUNOTHERAPY, ONE INJECTION",P960000586,CDM,960,RC,95115,HCPCS,Outpatient,,,17.00,11.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,7.25,7.25,
REMOVE INTRAUTERINE DEVICE,P960000413,CDM,960,RC,58301,HCPCS,Outpatient,,,185.00,120.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,85.95,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,85.95,85.95,
DECOMPRESSION OF LOWER LEG,P960000183,CDM,960,RC,27602,HCPCS,Outpatient,,,966.00,627.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,418.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,418.45,418.45,
DRAINAGE OF PILONIDAL CYST,P960000006,CDM,960,RC,10080,HCPCS,Outpatient,,,715.00,464.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,188.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,188.45,188.45,
TREAT KNEE FRACTURE BICONDYLAR,P960000180,CDM,960,RC,27536,HCPCS,Outpatient,,,2344.00,1523.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1028.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1028.78,1028.78,
IMADM ANY ROUTE 1ST VAC,P960000475,CDM,960,RC,90460,HCPCS,Outpatient,,,49.00,31.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,8.5,8.5,
ADMN PNEUMCOC VAC SCHED DAY,P960000675,CDM,960,RC,G0009,HCPCS,Outpatient,,,46.00,29.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7.32,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,7.32,7.32,
DX BRONCHOSCOPE/BRUSH,P960000239,CDM,960,RC,31623,HCPCS,Outpatient,,,525.00,341.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,240.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,240.82,240.82,
EXC FACE-MM MALIG MARG 1.1-2,P960000062,CDM,960,RC,11642,HCPCS,Outpatient,,,525.00,341.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,243.14,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,243.14,243.14,
REMOVAL HYDROCELES BILATERAL,P960000382,CDM,960,RC,55041,HCPCS,Outpatient,,,1017.00,661.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,438.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,438.68,438.68,
ECHO TRANSESOPHA INTERP/REPORT,P960000572,CDM,960,RC,93317,HCPCS,Outpatient,,,368.00,239.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,146.63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,146.63,146.63,
PSYTX PT&/FAMILY 30 MINUTES,P960000543,CDM,960,RC,90832,HCPCS,Outpatient,,,127.00,82.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,59.19,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,59.19,59.19,
EXC TR-EXT B9 MARG 2.1-3 CM,P960000038,CDM,960,RC,11403,HCPCS,Outpatient,,,370.00,240.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,175.92,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,175.92,175.92,
TDAP STATE,P960000525,CDM,960,RC,90715,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INSERT DRUG IMPLANT DEVICE,P960000076,CDM,960,RC,11981,HCPCS,Outpatient,,,273.00,177.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,93,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,93,93,
CIRCUMCISION OLDER 28 DAYS OLD,P960000370,CDM,960,RC,54161,HCPCS,Outpatient,,,392.00,254.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,169.01,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,169.01,169.01,
DRAIN THIGH/KNEE LESION,P960000174,CDM,960,RC,27301,HCPCS,Outpatient,,,1302.00,846.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,581.53,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,581.53,581.53,
"REMOVE FOREIGN BODY, LARYNX",P960000237,CDM,960,RC,31577,HCPCS,Outpatient,,,529.00,343.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,247.61,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,247.61,247.61,
EXC TR-EXT MLG MARG 0.6-1 CM,P960000052,CDM,960,RC,11601,HCPCS,Outpatient,,,441.00,286.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,206.07,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,206.07,206.07,
PREVENT CARE EST PT. AGE 12-17,P960000652,CDM,960,RC,99394,HCPCS,Outpatient,,,428.00,278.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,81.99,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,81.99,81.99,
DRAIN FINGER ABSC; SIMPLE,P960000940,CDM,960,RC,26010,HCPCS,Outpatient,,,340.55,221.36,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,258.4,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,258.4,258.4,
EXC FACE-MM B9 MARG 1.1-2 CM,P960000049,CDM,960,RC,11442,HCPCS,Outpatient,,,362.00,235.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,171.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,171.43,171.43,
HOSP SUB DAY-LOW CPLX,P960000617,CDM,960,RC,99231,HCPCS,Outpatient,,,77.00,50.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,27.73,27.73,
EXC H-F-NK-SP MLG MAR > 4 CM,P960000060,CDM,960,RC,11626,HCPCS,Outpatient,,,791.00,514.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,367.62,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,367.62,367.62,
"TTE W/DOPPLER, COMPLETE",P960000569,CDM,960,RC,93306,HCPCS,Outpatient,,,436.00,283.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,165.24,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,165.24,165.24,
NURSING FAC SUBSEQ MOD COMP,P960000638,CDM,960,RC,99309,HCPCS,Outpatient,,,179.00,116.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,64.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,64.23,64.23,
80 CESAREAN DELIVERY,P960000937,CDM,960,RC,59510,HCPCS,Outpatient,,,4565.00,2967.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1487.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1487.5,1487.5,
CARE AFTER DELIVERY,P960000440,CDM,960,RC,59430,HCPCS,Outpatient,,,362.00,235.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,137.81,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,137.81,137.81,
"ARTHROSC KNEE, FR INF/LAVAGE",P960000774,CDM,960,RC,29871,HCPCS,Outpatient,,,1009.00,655.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,443.79,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,443.79,443.79,
REMOVAL OF NAIL PLATE,P960000069,CDM,960,RC,11730,HCPCS,Outpatient,,,203.00,131.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,79.31,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,79.31,79.31,
"SHAVE F,E,E,N,L,M >2 CM",P960000034,CDM,960,RC,11313,HCPCS,Outpatient,,,360.00,234.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,166.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,166.76,166.76,
"URINALYSIS, AUTO, W/O SCOPE",P960000464,CDM,960,RC,81003,HCPCS,Outpatient,,,36.75,23.89,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1.45,1.45,
INFLU FLU PEDS STATE 6-35MO,P960000507,CDM,960,RC,90687,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PUNCH BX SKIN SINGLE LESION,P960000763,CDM,960,RC,11104,HCPCS,Outpatient,,,307.00,199.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,112.7,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,112.7,112.7,
EXC TR-EXT MLG MARG 2.1-3 CM,P960000054,CDM,960,RC,11603,HCPCS,Outpatient,,,548.00,356.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,253.22,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,253.22,253.22,
TREAT METACARPAL FRAC PERCUTAN,P960000158,CDM,960,RC,26608,HCPCS,Outpatient,,,926.00,601.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,413.93,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,413.93,413.93,
DRAINAGE OF FOREARM LESION,P960000142,CDM,960,RC,25028,HCPCS,Outpatient,,,1016.00,660.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,511.34,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,511.34,511.34,
DR OVARIAN ABSCESS,P960000939,CDM,960,RC,,,Outpatient,,,1722.00,1119.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1722,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1722,1722,
BUDESONIDE COMP CON PER 0.25 M,P960000858,CDM,960,RC,,,Outpatient,,,51.12,33.23,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,51.12,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,51.12,51.12,
APPLICATION OF LONG ARM CAST,P960000214,CDM,960,RC,29065,HCPCS,Outpatient,,,186.00,120.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,80.95,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,80.95,80.95,
"SC THER INFUSION, ADDL HR",P960000591,CDM,960,RC,96370,HCPCS,Outpatient,,,30.00,19.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17.66,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,17.66,17.66,
"UPPR GI ENDOSCOPY, DIAGNOSIS",P960000257,CDM,960,RC,43235,HCPCS,Outpatient,,,494.00,321.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,303.12,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,303.12,303.12,
PSYTX PT&/FAMILY 45 MINUTES,P960000545,CDM,960,RC,90834,HCPCS,Outpatient,,,250.75,162.99,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,86.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,86.05,86.05,
INFLUENZA FLUZONE HIGH DOSE+65,P960000498,CDM,960,RC,90662,HCPCS,Outpatient,,,128.00,83.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,54.56,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,54.56,54.56,
80 CESAREAN DELIVERY,P960000937,CDM,960,RC,59510,HCPCS,Outpatient,,,6263.33,4071.16,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1487.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1487.5,1487.5,
"OFFICE VISIT, EST PT., LEVEL 5",P960000606,CDM,960,RC,99215,HCPCS,Outpatient,,,441.23,286.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,102.18,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,102.18,102.18,
80 REMOVAL OF GALLBLADDER,P960000923,CDM,960,RC,47600,HCPCS,Outpatient,,,2114.00,1374.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1171.77,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1171.77,1171.77,
DILATION AND CURETTAGE,P960000408,CDM,960,RC,58120,HCPCS,Outpatient,,,563.48,366.26,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,238.51,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,238.51,238.51,
CYSTOURETERO W/LITHOTRIPSY,P960000354,CDM,960,RC,52353,HCPCS,Outpatient,,,788.00,512.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,330.63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,330.63,330.63,
KNEE ARTHR/SURG DEBRIDEMENT,P960000235,CDM,960,RC,29881,HCPCS,Outpatient,,,1062.00,690.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,467.51,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,467.51,467.51,
"LAPAROSCOPY, TUBAL BLOCK",P960000426,CDM,960,RC,58671,HCPCS,Outpatient,,,712.00,462.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,315.44,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,315.44,315.44,
REMOVE/INSERT DRUG IMPLANT,P960000078,CDM,960,RC,11983,HCPCS,Outpatient,,,441.00,286.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,130.92,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,130.92,130.92,
"TETANUS VACCINE, IM",P960000474,CDM,960,RC,90389,HCPCS,Outpatient,,,128.00,83.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,128,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,128,128,
LAPAROSCOPIC CHOLECYSTECTOMY,P960000299,CDM,960,RC,47562,HCPCS,Outpatient,,,1301.00,845.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,721.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,721.23,721.23,
DEB MUSC/FASCIA ADD-ON,P960000018,CDM,960,RC,11046,HCPCS,Outpatient,,,288.00,187.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,66.71,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,66.71,66.71,
EXC BACK LES SC 3+ CM,P960000130,CDM,960,RC,21931,HCPCS,Outpatient,,,925.00,601.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,406.31,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,406.31,406.31,
CCM Staff Each addtl 20 min,P960003089,CDM,960,RC,99439,HCPCS,Outpatient,,,115.00,74.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25.93,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,25.93,25.93,
DIVI FALLOP TUBE ABD/VAG POSTP,P960000421,CDM,960,RC,58605,HCPCS,Outpatient,,,644.00,418.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,285.28,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,285.28,285.28,
"ELECTROCARDIOGRAM, TRACING",P960000555,CDM,960,RC,93005,HCPCS,Outpatient,,,16.00,10.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.62,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,6.62,6.62,
"THER/PROPH/DIAG INJ, SC/IM",P960000592,CDM,960,RC,96372,HCPCS,Outpatient,,,48.00,31.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,16.43,16.43,
"POLIOVIRUS, IPV, SC IM VFC/SL",P960000522,CDM,960,RC,90713,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
80RPR AA HERNIA RECR 3-10CM RE,P960003068,CDM,960,RC,49615,HCPCS,Outpatient,,,1501.00,975.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1501,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1501,1501,
INTERPROF PHONE/ONLINE 21-30,P960000732,CDM,960,RC,99448,HCPCS,Outpatient,,,134.53,87.44,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,34.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,34.3,34.3,
Lysis labial adhesions,P960002016,CDM,960,RC,56441,HCPCS,Outpatient,,,371.43,241.43,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,139.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,139.58,139.58,
Drain Open Retroperi Abscess,P960002094,CDM,960,RC,49060,HCPCS,Outpatient,,,2638.90,1715.29,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1207.11,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1207.11,1207.11,
Wound expl penetr extremities,P960001931,CDM,960,RC,20103,HCPCS,Outpatient,,,835.45,543.04,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,496.95,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,496.95,496.95,
Rev Foreign Body simple,P960003122,CDM,960,RC,20520,HCPCS,Outpatient,,,357.80,232.57,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,181.34,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,181.34,181.34,
Omentectomy epiploectomy,P960000977,CDM,960,RC,49255,HCPCS,Outpatient,,,1771.35,1151.38,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,863.42,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,863.42,863.42,
REVISION OF CALF TENDON,P960003226,CDM,960,RC,27687,HCPCS,Outpatient,,,1114.50,724.43,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,394.94,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,394.94,394.94,
Drainage of mouth lesion,P960002003,CDM,960,RC,41017,HCPCS,Outpatient,,,848.10,551.27,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,493.99,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,493.99,493.99,
ADMIN HEP B VAC FEE SCHED DAY,P960000749,CDM,771,RC,,,Outpatient,,,91.48,59.46,,91.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,69.52,76,,55.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.87,72,,52.696,Percent of Total Billed Charges,72% of Total Billed Charges,68.61,75,,54.888,Percent of Total Billed charges,75% of Total Billed Charges,91.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.87,72,,52.696,Percent of Total Billed Charges,72% of Total Billed Charges,54.89,60,,43.912,Percent of Total Billed Charges,60% of Total Billed Charges,82.33,90,,65.864,Percent of Total Billed Charges,90% of Total Billed Charges,41.17,45,,32.936,Percent of Total Billed Charges,45% of Total Billed Charges,82.33,90,,65.864,Percent of Total Billed Charges,90% of Total billed Charges,91.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.46,65,,47.568,Percent of total Billed Charges,65% of Total Billed Charges,40.34,44.1,,32.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,86.91,95,,69.528,Percent of Total Billed Charges,95% of Total Billed Charges,91.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,82.33,90,,65.864,Percent of Total Billed charges,90% of Total Billed Charges,40.34,91.48,
Lap Hysterectomy over 250g,P960001008,CDM,960,RC,58572,HCPCS,Outpatient,,,2520.28,1638.18,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,883.35,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,883.35,883.35,
Coronary Art/Graft Angio,P960002089,CDM,960,RC,93455,HCPCS,Outpatient,,,660.73,429.47,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,660.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,660.73,660.73,
"20 VBAC,delv proc p prev Csect",P960001920,CDM,960,RC,59610,HCPCS,Outpatient,,,5925.20,3851.38,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1487.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1487.5,1487.5,
Arexvy(RSV)vacc; 0.5 mL,P960003152,CDM,960,RC,90679,HCPCS,Outpatient,,,659.75,428.84,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,659.75,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,659.75,659.75,
Part. Excision Phalanx of toe,P960003103,CDM,960,RC,28124,HCPCS,Outpatient,,,813.25,528.61,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,417.72,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,417.72,417.72,
CESAREAN DELIVERY ONLY,P960000442,CDM,960,RC,59514,HCPCS,Outpatient,,,1820.00,1183.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,611.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,611.82,611.82,
HEPATITIS A (PEDIATRICS) STATE,P960000483,CDM,960,RC,90633,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEB BONE ADD-ON,P960000019,CDM,960,RC,11047,HCPCS,Outpatient,,,243.00,157.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,110.93,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,110.93,110.93,
ABD PARACENTESIS,P960000302,CDM,960,RC,49082,HCPCS,Outpatient,,,370.00,240.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,220.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,220.58,220.58,
EXAM OF CERVIX W/SCOPE,P960000400,CDM,960,RC,57452,HCPCS,Outpatient,,,213.00,138.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,101.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,101.78,101.78,
DRAINAGE OF PELVIS LESION,P960000167,CDM,960,RC,26990,HCPCS,Outpatient,,,1225.00,796.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,564.87,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,564.87,564.87,
"HYSTEROSCOPY, DX, SEP PROC",P960000415,CDM,960,RC,58555,HCPCS,Outpatient,,,518.00,336.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,272.71,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,272.71,272.71,
DRAIN BLOOD FROM UNDER NAIL,P960000071,CDM,960,RC,11740,HCPCS,Outpatient,,,95.00,61.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,38.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,38.29,38.29,
"I & D VAGINAL HEMATOMA, PP",P960000393,CDM,960,RC,57022,HCPCS,Outpatient,,,336.00,218.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,150.62,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,150.62,150.62,
APPLICATION OF PASTE BOOT,P960000227,CDM,960,RC,29580,HCPCS,Outpatient,,,102.00,66.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,54.13,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,54.13,54.13,
REM OF FT FOREIGN BODY DEEP,P960000199,CDM,960,RC,28192,HCPCS,Outpatient,,,923.00,599.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,408.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,408.05,408.05,
DEBRIDE TISSUE/MUSCLE,P960000015,CDM,960,RC,11043,HCPCS,Outpatient,,,905.00,588.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,209.49,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,209.49,209.49,
CYSTOSCOPY,P960000334,CDM,960,RC,52000,HCPCS,Outpatient,,,318.00,206.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,173.33,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,173.33,173.33,
LAYER CLOSURE OF WND <2.5CM,P960000082,CDM,960,RC,12031,HCPCS,Outpatient,,,457.00,297.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,226.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,226.25,226.25,
SKIN TISSUE REARRANGEMENT,P960000095,CDM,960,RC,14040,HCPCS,Outpatient,,,1479.00,961.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,682.93,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,682.93,682.93,
KNEE ARTHR/SURG MENISECTOMY,P960000234,CDM,960,RC,29880,HCPCS,Outpatient,,,1104.00,717.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,485.28,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,485.28,485.28,
I&D ABSCESS,P960000003,CDM,960,RC,10030,HCPCS,Outpatient,,,2219.00,1442.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,552.61,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,552.61,552.61,
REM MNTR PHYSIOL PARAM DEV,P960000952,CDM,960,RC,99454,HCPCS,Outpatient,,,156.10,101.47,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,42.15,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,42.15,42.15,
CL EV FISTULA W INT RESECT,P960000910,CDM,960,RC,44661,HCPCS,Outpatient,,,3853.20,2504.58,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1703.11,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1703.11,1703.11,
"OFFICE VISIT, NEW PT., LEVEL 2",P960000598,CDM,960,RC,99202,HCPCS,Outpatient,,,177.55,115.41,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,52.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,52.9,52.9,
ADMN FLU VAC SCHED SAME DAY,P960000674,CDM,960,RC,G0008,HCPCS,Outpatient,,,94.00,61.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7.32,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,7.32,7.32,
80 PART REM COLON W/ANATOMOSIS,P960000918,CDM,960,RC,44140,HCPCS,Outpatient,,,2664.00,1731.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1470.97,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1470.97,1470.97,
ADM/DC SAME DAY-MOD CPLX,P960000621,CDM,960,RC,99235,HCPCS,Outpatient,,,333.00,216.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,119.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,119.3,119.3,
URINARY LEG OR ABDOMEN BAG,P960000671,CDM,960,RC,A4358,HCPCS,Outpatient,,,8.00,5.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.57,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,5.57,5.57,
"80 MAST, MOD RAD",P960000912,CDM,960,RC,,,Outpatient,,,2352.00,1528.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2352,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2352,2352,
CATH INDW FOLEY 2 WAY SILICONE,P960000845,CDM,960,RC,,,Outpatient,,,70.00,45.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,70,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,70,70,
ADMN PNEUMCOC VAC SCHED DAY,P960000675,CDM,960,RC,G0009,HCPCS,Outpatient,,,46.00,29.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7.32,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,7.32,7.32,
PREVENT CARE NEW PT. AGE 18-39,P960000646,CDM,960,RC,99385,HCPCS,Outpatient,,,490.00,318.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,93.13,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,93.13,93.13,
PREVENT CARE EST PT. AGE 18-39,P960000653,CDM,960,RC,99395,HCPCS,Outpatient,,,436.00,283.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,84.01,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,84.01,84.01,
20 REMOVAL OF OVARY/ TUBE(S),P960000889,CDM,960,RC,58720,HCPCS,Outpatient,,,1450.00,942.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,636.92,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,636.92,636.92,
HOSP SUB CARE-HI CPLX,P960000619,CDM,960,RC,99233,HCPCS,Outpatient,,,206.00,133.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,73.61,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,73.61,73.61,
INPT/TELE FOLLOW UP 25,P960000805,CDM,960,RC,,,Outpatient,,,178.25,115.86,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,178.25,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,178.25,178.25,
Scrotal Exploration,P960000962,CDM,960,RC,55110,HCPCS,Outpatient,,,968.28,629.38,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,332.51,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,332.51,332.51,
INIT HOSP-MOD CPLX,P960000612,CDM,960,RC,99222,HCPCS,Outpatient,,,270.00,175.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,97.04,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,97.04,97.04,
REMOVE INT/EXT HEM 1 GROUP,P960000765,CDM,960,RC,46255,HCPCS,Outpatient,,,983.00,638.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,562.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,562.9,562.9,
"OFFICE VISIT, EST PT., LEVEL 3",P960000604,CDM,960,RC,99213,HCPCS,Outpatient,,,221.63,144.06,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,52.28,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,52.28,52.28,
ALBUTEROL INHAL UNIT DOSE 1 MG,P960000707,CDM,960,RC,J7613,HCPCS,Outpatient,,,4.00,2.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.03,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.03,0.03,
INPT/ED TELECONSULT 30,P960000784,CDM,960,RC,,,Outpatient,,,247.13,160.63,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,247.13,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,247.13,247.13,
CHRON CARE MGMT SRVC 20 MIN,P960000955,CDM,960,RC,99490,HCPCS,Outpatient,,,79.50,51.68,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,29.05,29.05,
20 LIGATE FALLOPIAN TUBE W CES,P960000888,CDM,960,RC,58611,HCPCS,Outpatient,,,152.00,98.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,66.19,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,66.19,66.19,
"95 OFFICE VISIT, EST PT,LEVEL3",P960000899,CDM,960,RC,99213,HCPCS,Outpatient,,,221.63,144.06,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,52.28,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,52.28,52.28,
INPT/ED TELECONSULT50,P960000785,CDM,960,RC,,,Outpatient,,,336.03,218.42,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,336.03,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,336.03,336.03,
DEBRIDE NAIL 6 OR MORE,P960000068,CDM,960,RC,11721,HCPCS,Outpatient,,,87.00,56.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,32.65,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,32.65,32.65,
"LAPAROSCOPY, APPENDECTOMY",P960000276,CDM,960,RC,44970,HCPCS,Outpatient,,,1188.00,772.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,657.74,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,657.74,657.74,
LAP ENTERECTOMY,P960003100,CDM,960,RC,44202,HCPCS,Outpatient,,,3337.55,2169.41,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1518.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1518.78,1518.78,
VAGOTOMY PFRMD W/PRTL DSTL GST,P960003081,CDM,960,RC,43635,HCPCS,Outpatient,,,269.27,175.03,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,123.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,123.58,123.58,
PNEUMO POLYSACCHARIDE,P960000532,CDM,960,RC,90732,HCPCS,Outpatient,,,208.00,135.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,112.67,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,112.67,112.67,
REMOVAL SWEAT GLAND LESION,P960000741,CDM,960,RC,11462,HCPCS,Outpatient,,,716.00,465.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,356.32,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,356.32,356.32,
EXC FOREARM TUM DEEP < 3 CM,P96000243,CDM,960,RC,25076,HCPCS,Outpatient,,,1257.23,817.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,447.27,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,447.27,447.27,
Repair ankle ligament,P960001992,CDM,960,RC,27698,HCPCS,Outpatient,,,1555.83,1011.29,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,554.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,554.82,554.82,
20 LSH Uterus 250gm or less,P960001936,CDM,960,RC,58541,HCPCS,Outpatient,,,1781.48,1157.96,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,623.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,623.29,623.29,
80Gastrostomy rep w/o Im guidn,P960000993,CDM,960,RC,43762,HCPCS,Outpatient,,,91.20,59.28,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,91.2,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,91.2,91.2,
Mastotomy w/ exploration,P960001954,CDM,960,RC,19020,HCPCS,Outpatient,,,752.80,489.32,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,424.21,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,424.21,424.21,
PART REMOVAL OF METATARSA,P960003230,CDM,960,RC,28112,HCPCS,Outpatient,,,767.05,498.58,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,424.61,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,424.61,424.61,
REMOVL PACEMAKR ELECTRODE DUAL,P960002020,CDM,960,RC,33235,HCPCS,Outpatient,,,1531.53,995.49,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,536.27,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,536.27,536.27,
20RPR AA HERNIA RECR<3CM NCRC8,P960003073,CDM,960,RC,49614,HCPCS,Outpatient,,,1341.32,871.86,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1341.32,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1341.32,1341.32,
Conization of cervix,P960003117,CDM,960,RC,57520,HCPCS,Outpatient,,,864.50,561.93,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,283.11,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,283.11,283.11,
HT MUSCLE IMAGE SPECT SING,P960000460,CDM,960,RC,78451,HCPCS,Outpatient,,,668.00,434.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,227.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,227.78,227.78,
SIGMOIDOSCOPY AND BIOPSY,P960000282,CDM,960,RC,45331,HCPCS,Outpatient,,,489.00,317.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,296.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,296.78,296.78,
CYSTOURETERO W/BIOPSY,P960000355,CDM,960,RC,52354,HCPCS,Outpatient,,,839.00,545.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,351.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,351.76,351.76,
TREAT CLAVICLE FRACTURE,P960000134,CDM,960,RC,23515,HCPCS,Outpatient,,,1413.00,918.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,622.44,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,622.44,622.44,
PART REM COLON W/ANASTOMOSIS,P960000264,CDM,960,RC,44140,HCPCS,Outpatient,,,2664.00,1731.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1470.97,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1470.97,1470.97,
"SHAVE F,E,E,N,L,M 1-2 CM",P960000033,CDM,960,RC,11312,HCPCS,Outpatient,,,310.00,201.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,142.67,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,142.67,142.67,
REMOVAL HYDROCELES UNILATERAL,P960000381,CDM,960,RC,55040,HCPCS,Outpatient,,,673.00,437.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,289.04,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,289.04,289.04,
REPAIR OF BLADDER WOUND,P960000333,CDM,960,RC,51860,HCPCS,Outpatient,,,1484.00,964.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,625.54,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,625.54,625.54,
REMOVE BLADDER STONE COMPLX/LG,P960000349,CDM,960,RC,52318,HCPCS,Outpatient,,,952.00,618.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,399.44,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,399.44,399.44,
REMOVE PROSTATE REGROWTH,P960000358,CDM,960,RC,52630,HCPCS,Outpatient,,,797.00,518.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,338.22,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,338.22,338.22,
TREAT FX DISTAL RADIAL,P960000150,CDM,960,RC,25606,HCPCS,Outpatient,,,1295.00,841.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,572.65,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,572.65,572.65,
BIOPSY OF PROSTATE INCISIONAL,P960000386,CDM,960,RC,55705,HCPCS,Outpatient,,,532.00,345.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,228.4,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,228.4,228.4,
EXC TR-EXT MLG MARG 3.1-4 CM,P960000055,CDM,960,RC,11604,HCPCS,Outpatient,,,609.00,395.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,282.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,282.25,282.25,
TREATMENT OF MISCARRIAGE,P960000443,CDM,960,RC,59812,HCPCS,Outpatient,,,624.00,405.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,227.93,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,227.93,227.93,
"N BLOCK INJ,  PLANTAR DIGIT",P960000450,CDM,960,RC,64455,HCPCS,Outpatient,,,94.00,61.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,41.24,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,41.24,41.24,
FINGER FRAC CLOSED ARTICULAR,P960000163,CDM,960,RC,26740,HCPCS,Outpatient,,,443.00,287.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,197.86,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,197.86,197.86,
INJECT TENDON ORIGIN/INSERT,P960000121,CDM,960,RC,20551,HCPCS,Outpatient,,,118.00,76.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,48.4,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,48.4,48.4,
APPLICATION OF FOREARM CAST,P960000215,CDM,960,RC,29075,HCPCS,Outpatient,,,168.00,109.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,72.95,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,72.95,72.95,
DIAG LAPARO SEPARATE PROC,P960000304,CDM,960,RC,49320,HCPCS,Outpatient,,,645.00,419.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,359.47,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,359.47,359.47,
TREAT FX RAD INTRA-ARTICUL,P960000152,CDM,960,RC,25608,HCPCS,Outpatient,,,1615.00,1049.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,713.19,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,713.19,713.19,
HEMORRHOIDECTOMY EXTERNAL,P960000293,CDM,960,RC,46250,HCPCS,Outpatient,,,897.00,583.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,515.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,515.25,515.25,
CYSTO W/URETER STRICTURE TX,P960000351,CDM,960,RC,52341,HCPCS,Outpatient,,,571.00,371.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,239.32,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,239.32,239.32,
ETONOGESTREL IMPLANT SYSTEM,P960000705,CDM,960,RC,J7307,HCPCS,Outpatient,,,2690.00,1748.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,834.33,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,834.33,834.33,
INJ VIT B12 CYNOCO 1000 MCG,P960000703,CDM,960,RC,J3420,HCPCS,Outpatient,,,6.00,3.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1.76,1.76,
ANS PARASYMP & SYMP W/TILT,P960000761,CDM,960,RC,95924,HCPCS,Outpatient,,,179.00,116.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,174.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,174.73,174.73,
20 EXPL LAPAROTOMY EXPL CELIOT,P960000879,CDM,960,RC,49000,HCPCS,Outpatient,,,1526.00,991.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,842.69,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,842.69,842.69,
ADM/DC DAME DAY-LOW CPLX,P960000620,CDM,960,RC,99234,HCPCS,Outpatient,,,263.00,170.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,94.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,94.1,94.1,
UNLISTED PROCEDURE ABD PERITON,P960000834,CDM,960,RC,49999,HCPCS,Outpatient,,,1886.50,1226.23,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1886.5,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1886.5,1886.5,
SHOLDR SLING ABD RSTRN PREFAB,P960000673,CDM,960,RC,A4566,HCPCS,Outpatient,,,40.00,26.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18.39,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,18.39,18.39,
20REP ANEURYSM; ABD AORTA RUPT,P960000868,CDM,960,RC,35082,HCPCS,Outpatient,,,5395.00,3506.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1834.32,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1834.32,1834.32,
INPT/ED TELECONSULT 30,P960000784,CDM,960,RC,,,Outpatient,,,247.13,160.63,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,247.13,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,247.13,247.13,
EXT COUNTERPULSATION-TX SESS,P960000682,CDM,960,RC,G0166,HCPCS,Outpatient,,,261.00,169.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,73.67,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,73.67,73.67,
80 P-MASTECTOMY W/LN REMOVAL,P960000911,CDM,960,RC,19302,HCPCS,Outpatient,,,2227.50,1447.88,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,817.96,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,817.96,817.96,
BRAND NAME RX DRUG,P960000817,CDM,960,RC,,,Outpatient,,,50.23,32.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,50.23,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,50.23,50.23,
DIAGNOSTIC ANOSCOPY SPX,P960000947,CDM,960,RC,46600,HCPCS,Outpatient,,,100.50,65.33,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,100.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,100.5,100.5,
PER PM REEVAL EST PAT 65+ YR,P960000655,CDM,960,RC,99397,HCPCS,Outpatient,,,504.00,327.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,96.11,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,96.11,96.11,
20 REP RECURENT ING HERNIA AN,P960000957,CDM,960,RC,49521,HCPCS,Outpatient,,,1776.25,1154.56,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,785.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,785.1,785.1,
80 REPAIR BOWEL OPENING,P960000920,CDM,960,RC,44620,HCPCS,Outpatient,,,1725.00,1121.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,949.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,949.82,949.82,
REM MNTR PHYSIOL PARAM SETUP,P960000951,CDM,960,RC,99453,HCPCS,Outpatient,,,46.93,30.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12.62,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,12.62,12.62,
WOUND(S) CARE NON-SELECTIVE,P960000843,CDM,960,RC,97602,HCPCS,Outpatient,,,419.43,272.63,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,95.63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,95.63,95.63,
COUDE URINARY CATH,P960000846,CDM,960,RC,,,Outpatient,,,23.17,15.06,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23.17,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,23.17,23.17,
CATH INDW FOLEY 2 WAY SILICONE,P960000845,CDM,960,RC,,,Outpatient,,,70.00,45.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,70,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,70,70,
"CARDIOASSIST, EXTERNAL",P960000553,CDM,960,RC,92971,HCPCS,Outpatient,,,201.00,130.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,81.04,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,81.04,81.04,
TRIAMCINOLONE ACET INJ NOS 10,P960000855,CDM,960,RC,,,Outpatient,,,50.00,32.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,50,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,50,50,
HEARING SCREENING,P960000864,CDM,960,RC,,,Outpatient,,,56.00,36.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,56,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,56,56,
ADM/DC SAME DAY-HI CPLX,P960000622,CDM,960,RC,99236,HCPCS,Outpatient,,,430.00,279.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,153.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,153.58,153.58,
PSYTX PT&/FAM W/E&M 30 MIN,P960000544,CDM,960,RC,90833,HCPCS,Outpatient,,,131.00,85.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,62.14,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,62.14,62.14,
80 REP ANEURYSM;ABD AORTA RUPT,P960000914,CDM,960,RC,35082,HCPCS,Outpatient,,,5395.00,3506.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1834.32,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1834.32,1834.32,
VARICELLA IMMUNIZATION VFC/SL,P960000528,CDM,960,RC,90716,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"P/M COUNSEL,INDIV 60MIN",P960000723,CDM,960,RC,99404,HCPCS,Outpatient,,,257.15,167.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,80.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,80.73,80.73,
SARSCV2 VAC 10MCG TRS-SUC IM,P960003157,CDM,960,RC,91319,HCPCS,Outpatient,,,219.45,142.64,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,219.45,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,219.45,219.45,
LSH W/T/O UTERUS ABOVE 250 G,P960001943,CDM,960,RC,58544,HCPCS,Outpatient,,,2213.88,1439.02,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,775.88,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,775.88,775.88,
20RPR AA HERNIA RECR 3-10CM RE,P960003069,CDM,960,RC,49615,HCPCS,Outpatient,,,1501.00,975.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1501,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1501,1501,
SARSCOV2 VAC 50 MCG/0.5ML IM,P960003160,CDM,960,RC,91322,HCPCS,Outpatient,,,364.80,237.12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,364.8,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,364.8,364.8,
R&L HRT ART/VENTRICLE ANGIO,P960003086,CDM,960,RC,93461,HCPCS,Outpatient,,,975.58,634.13,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,975.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,975.58,975.58,
Suprapubic Cath Ins/Asp Bladde,P761000310,CDM,761,RC,51102,HCPCS,Outpatient,,,4303.88,2797.52,,4303.88,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,3270.95,76,,2616.76,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3098.79,72,,2479.032,Percent of Total Billed Charges,72% of Total Billed Charges,3227.91,75,,2582.328,Percent of Total Billed charges,75% of Total Billed Charges,4303.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3098.79,72,,2479.032,Percent of Total Billed Charges,72% of Total Billed Charges,2582.33,60,,2065.864,Percent of Total Billed Charges,60% of Total Billed Charges,3873.49,90,,3098.792,Percent of Total Billed Charges,90% of Total Billed Charges,1936.75,45,,1549.4,Percent of Total Billed Charges,45% of Total Billed Charges,3873.49,90,,3098.792,Percent of Total Billed Charges,90% of Total billed Charges,4303.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4303.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4303.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2797.52,65,,2238.016,Percent of total Billed Charges,65% of Total Billed Charges,1898.01,44.1,,1518.408,Percent of Total Billed Charges,44.1% of Total Billed Charges,4088.69,95,,3270.952,Percent of Total Billed Charges,95% of Total Billed Charges,4303.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3787.41,88,,3029.928,Percent of Total Billed Charges,88% of Total Billed Charges,3873.49,90,,3098.792,Percent of Total Billed charges,90% of Total Billed Charges,1898.01,4303.88,
"INJ, BUPIVACAINE, NOS, 0.5MG",P960003200,CDM,960,RC,,,Outpatient,,,12.00,7.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,12,12,
20 Repair Inguinal Hernia,P960000976,CDM,960,RC,49507,HCPCS,Outpatient,,,1310.20,851.63,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,641.63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,641.63,641.63,
R&L HRT ART/VENTRICLE ANGIO,P960003086,CDM,960,RC,93461,HCPCS,Outpatient,,,975.58,634.13,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,975.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,975.58,975.58,
"PROMETHAZINE HCL INJ,UPTO 50MG",P960000752,CDM,960,RC,,,Outpatient,,,6.00,3.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,6,6,
ADDL 30MIN-W/O CONT,P960000719,CDM,960,RC,99359,HCPCS,Outpatient,,,106.00,68.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,38.41,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,38.41,38.41,
R&L HRT ART/VENTRICLE ANGIO,P960003086,CDM,960,RC,93461,HCPCS,Outpatient,,,975.58,634.13,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,975.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,975.58,975.58,
ADMIN HEP B VAC FEE SCHED DAY,P960000749,CDM,771,RC,,,Outpatient,,,91.48,59.46,,91.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,69.52,76,,55.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.87,72,,52.696,Percent of Total Billed Charges,72% of Total Billed Charges,68.61,75,,54.888,Percent of Total Billed charges,75% of Total Billed Charges,91.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.87,72,,52.696,Percent of Total Billed Charges,72% of Total Billed Charges,54.89,60,,43.912,Percent of Total Billed Charges,60% of Total Billed Charges,82.33,90,,65.864,Percent of Total Billed Charges,90% of Total Billed Charges,41.17,45,,32.936,Percent of Total Billed Charges,45% of Total Billed Charges,82.33,90,,65.864,Percent of Total Billed Charges,90% of Total billed Charges,91.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.46,65,,47.568,Percent of total Billed Charges,65% of Total Billed Charges,40.34,44.1,,32.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,86.91,95,,69.528,Percent of Total Billed Charges,95% of Total Billed Charges,91.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,82.33,90,,65.864,Percent of Total Billed charges,90% of Total Billed Charges,40.34,91.48,
PPD SKIN TEST INJ,P960000717,CDM,960,RC,86580,HCPCS,Outpatient,,,32.00,20.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,5.68,5.68,
INTERPROF PHONE/ONLINE 5-10,P960000730,CDM,960,RC,99446,HCPCS,Outpatient,,,44.55,28.96,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.36,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,11.36,11.36,
"P/M COUNSEL,INDIV 30MIN",P960000721,CDM,960,RC,99402,HCPCS,Outpatient,,,257.00,167.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,45.88,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,45.88,45.88,
20 RPR AA HERNIA RECR>10CM RED,P960003071,CDM,960,RC,49617,HCPCS,Outpatient,,,2077.90,1350.64,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2077.9,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2077.9,2077.9,
Arthroscopy knee; rem loose FB,P960001004,CDM,960,RC,29874,HCPCS,Outpatient,,,1307.18,849.67,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,464.84,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,464.84,464.84,
REMOVAL SWEAT GLAND LESION,P960000739,CDM,960,RC,11450,HCPCS,Outpatient,,,733.00,476.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,365.83,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,365.83,365.83,
20RPR AA HERNIA 1ST3-10CM NCRC,P960003063,CDM,960,RC,49594,HCPCS,Outpatient,,,1750.75,1137.99,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1750.75,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1750.75,1750.75,
INTRO NDL ICATH UPR/LXTR ART,P960003083,CDM,960,RC,36140,HCPCS,Outpatient,,,211.05,137.18,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,211.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,211.05,211.05,
HEART FLOW RESERVE MEASURE,P960003087,CDM,960,RC,93572,HCPCS,Outpatient,,,124.30,80.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,90.43,90.43,
Induced abortion by D & C,P960003091,CDM,960,RC,59840,HCPCS,Outpatient,,,606.62,394.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,157.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,157.58,157.58,
20RPR AA HERNIA 1ST <3CM REDUC,P960003055,CDM,960,RC,49591,HCPCS,Outpatient,,,802.62,521.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,802.62,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,802.62,802.62,
REMOVE RENAL TUBE W/FLUORO,P960002042,CDM,960,RC,50389,HCPCS,Outpatient,,,1073.50,697.78,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,308.51,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,308.51,308.51,
SARSCOV2 VAC 3MCG TRS-SUC IM,P960003156,CDM,960,RC,91318,HCPCS,Outpatient,,,163.40,106.21,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,163.4,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,163.4,163.4,
Dicyclomine 20 mg Inj,P960003197,CDM,960,RC,,,Outpatient,,,50.82,33.03,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,50.82,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,50.82,50.82,
Routine foot care- PT LOS,P960000986,CDM,960,RC,,,Outpatient,,,53.80,34.97,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,53.8,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,53.8,53.8,
OB Visit Est Level 3,P960003020,CDM,960,RC,99213,HCPCS,Outpatient,,,221.63,144.06,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,52.28,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,52.28,52.28,
Removal of sutures or staples,P960003133,CDM,960,RC,15853,HCPCS,Outpatient,,,27.20,17.68,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27.2,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,27.2,27.2,
PTCA during acute MI,P960002034,CDM,960,RC,92941,HCPCS,Outpatient,,,1561.63,1015.06,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,776.14,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,776.14,776.14,
REMOVAL OF SPERM DUCT(S),P960000384,CDM,960,RC,55250,HCPCS,Outpatient,,,555.43,361.03,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,305.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,305.23,305.23,
"OFFICE VISIT, NEW PT., LEVEL 5",P960000601,CDM,960,RC,99205,HCPCS,Outpatient,,,538.75,350.19,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,145.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,145.23,145.23,
CYSTO AND TREAT CYSTOGRAPHY,P960000345,CDM,960,RC,52281,HCPCS,Outpatient,,,530.00,344.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,265.37,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,265.37,265.37,
AUTONOMIC FUNCTION TEST VASOM,P960000760,CDM,960,RC,95922,HCPCS,Outpatient,,,193.00,125.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,114.06,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,114.06,114.06,
INSERT INTRAUTERINE DEVICE,P960000412,CDM,960,RC,58300,HCPCS,Outpatient,,,266.00,172.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,77.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,77.23,77.23,
"OFFICE VISIT, NEW PT., LEVEL 4",P960000600,CDM,960,RC,99204,HCPCS,Outpatient,,,407.28,264.73,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,114.84,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,114.84,114.84,
BIOPSY OF PROSTATE SINGL/MULTI,P960000385,CDM,960,RC,55700,HCPCS,Outpatient,,,481.00,312.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,209.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,209.9,209.9,
CERV CANCR SCR;PELV BRST EX,P960000676,CDM,960,RC,G0101,HCPCS,Outpatient,,,75.00,48.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28.98,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,28.98,28.98,
HUMAN PAPILLOMAVIRUS (HPV),P960000487,CDM,960,RC,90649,HCPCS,Outpatient,,,404.00,262.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,173.44,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,173.44,173.44,
EXC H-F-NK-SP MLG MARG 2.1-3,P960000059,CDM,960,RC,11623,HCPCS,Outpatient,,,582.00,378.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,269.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,269.45,269.45,
80 TX THIGH FRACTURE OPEN,P960000913,CDM,960,RC,27236,HCPCS,Outpatient,,,2359.00,1533.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1034.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1034.68,1034.68,
DRAIN PENIS LESION,P960000364,CDM,960,RC,54015,HCPCS,Outpatient,,,615.00,399.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,262.95,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,262.95,262.95,
D & C AFTER DELIVERY,P960000432,CDM,960,RC,59160,HCPCS,Outpatient,,,398.00,258.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,159.75,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,159.75,159.75,
REMOVAL OF SKIN TAGS,P960000023,CDM,960,RC,11200,HCPCS,Outpatient,,,171.00,111.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,79.74,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,79.74,79.74,
MMR,P960000517,CDM,960,RC,90707,HCPCS,Outpatient,,,189.46,123.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,83.77,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,83.77,83.77,
CCM Staff Each addtl 20 min,P960003089,CDM,960,RC,99439,HCPCS,Outpatient,,,115.00,74.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25.93,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,25.93,25.93,
"DTAP-HIB-IP VACCINE, IM VFC/SL",P960000512,CDM,960,RC,90698,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EXC H-F-NK-SP B9 MARG 1.1-2,P960000043,CDM,960,RC,11422,HCPCS,Outpatient,,,338.00,219.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,161.31,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,161.31,161.31,
DTAP,P960000513,CDM,960,RC,90700,HCPCS,Outpatient,,,92.00,59.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,26.45,26.45,
INJ VIT B12 CYNOCO 1000 MCG,P960000703,CDM,960,RC,J3420,HCPCS,Outpatient,,,6.00,3.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1.76,1.76,
PSYCH DIAGNOSTIC EVALUATION,P960000541,CDM,960,RC,90791,HCPCS,Outpatient,,,260.00,169.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,143.41,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,143.41,143.41,
VARICELLA IMMUNIZATION,P960000527,CDM,960,RC,90716,HCPCS,Outpatient,,,300.00,195.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,145.2,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,145.2,145.2,
HETEROPHILE ANTIBODIES,P960000470,CDM,960,RC,86308,HCPCS,Outpatient,,,142.80,92.82,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.35,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,3.35,3.35,
APPLY MULTLAY COMPRS LWR LEG,P960000228,CDM,960,RC,29581,HCPCS,Outpatient,,,119.00,77.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,76.84,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,76.84,76.84,
"MMRV VACCINE, SC",P960000519,CDM,960,RC,90710,HCPCS,Outpatient,,,460.00,299.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,240.24,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,240.24,240.24,
DTAP-IPV VACC 4-6 YR IM VFC/SL,P960000510,CDM,960,RC,90696,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ECHO GUIDE FOR BIOPSY,P960000459,CDM,960,RC,76942,HCPCS,Outpatient,,,66.00,42.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,38.74,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,38.74,38.74,
HEPATITIS B PEDI STATE,P960000537,CDM,960,RC,90744,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IMMUNIZATION ADMIN,P960000477,CDM,771,RC,90471,HCPCS,Outpatient,,,49.00,31.85,,89.46,125,,,Fee Schedule,125% of CMS OPPS Rate,37.24,76,,29.792,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,166.45,350,,,Fee Schedule,350% of BCBS fee schedule,166.45,350,,,Fee Schedule,350% of BCBS fee schedule,71.56,100,,,Fee Schedule,100% of CMS OPPS Rate,166.45,286,,,Fee Schedule,286% of BCBS PPO fee schedule,58.2,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,44.1,90,,35.28,Percent of Total Billed Charges,90% of Total Billed Charges,22.05,45,,17.64,Percent of Total Billed Charges,45% of Total Billed Charges,44.1,90,,35.28,Percent of Total Billed Charges,90% of Total billed Charges,71.56,100,,,Fee Schedule,100% of CMS OPPS Rate,71.56,100,,,Fee Schedule,100% of CMS OPPS Rate,71.56,100,,,Fee Schedule,100% of CMS OPPS Rate,133.65,200,,,Fee Schedule,200% of CMS OPPS Rate,21.61,44.1,,17.288,Percent of Total Billed Charges,44.1% of Total Billed Charges,46.55,95,,37.24,Percent of Total Billed Charges,95% of Total Billed Charges,53.67,75,,,Fee Schedule,75% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,44.1,90,,35.28,Percent of Total Billed charges,90% of Total Billed Charges,21.61,166.45,
PLACE GASTROSTOMY TUBE PERC,P960002019,CDM,960,RC,49440,HCPCS,Outpatient,,,494.13,321.18,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,494.13,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,494.13,494.13,
"DESTRUCT LESION, 1-14",P960000106,CDM,960,RC,17110,HCPCS,Outpatient,,,212.00,137.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,100,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,100,100,
IMMUNIZATION ADMIN EACH ADD,P960000478,CDM,771,RC,90472,HCPCS,Outpatient,,,25.00,16.25,,25,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,19,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,36.95,350,,,Fee Schedule,350% of BCBS fee schedule,36.95,350,,,Fee Schedule,350% of BCBS fee schedule,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.95,286,,,Fee Schedule,286% of BCBS PPO fee schedule,12.92,100,,,Fee Schedule,100% of Blue ADV HMO fee schedule,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,11.25,45,,9,Percent of Total Billed Charges,45% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.25,65,,13,Percent of total Billed Charges,65% of Total Billed Charges,11.03,44.1,,8.824,Percent of Total Billed Charges,44.1% of Total Billed Charges,23.75,95,,19,Percent of Total Billed Charges,95% of Total Billed Charges,25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,22.5,90,,18,Percent of Total Billed charges,90% of Total Billed Charges,11.03,36.95,
LASER SURGERY OF PROSTATE,P960000359,CDM,960,RC,52648,HCPCS,Outpatient,,,3528.00,2293.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1384,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1384,1384,
PRQ CARD STENT W/ANGIO 1 VSL,P960000551,CDM,960,RC,92928,HCPCS,Outpatient,,,1184.00,769.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,690.47,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,690.47,690.47,
INSERT TEMP BLADDER CATH,P960000327,CDM,960,RC,51702,HCPCS,Outpatient,,,121.00,78.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,50.38,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,50.38,50.38,
MCV4 (PEDI) STATE,P960000534,CDM,960,RC,90734,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PUNCTURE DRAINAGE OF LESION,P960000010,CDM,960,RC,10160,HCPCS,Outpatient,,,508.00,330.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,117.32,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,117.32,117.32,
"REMOVE NAIL PLATE, ADD-ON",P960000070,CDM,960,RC,11732,HCPCS,Outpatient,,,62.00,40.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24.06,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,24.06,24.06,
CYSTO/URETERO W/LITHOTRIPSY,P960000356,CDM,960,RC,52356,HCPCS,Outpatient,,,836.00,543.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,350.4,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,350.4,350.4,
REMOVE WRIST TENDON LESION,P960000143,CDM,960,RC,25111,HCPCS,Outpatient,,,623.00,404.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,277.19,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,277.19,277.19,
EXC FACE-MM MALIG MARG 3.1-4,P960000064,CDM,960,RC,11644,HCPCS,Outpatient,,,764.00,496.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,353.28,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,353.28,353.28,
Wound expl pentr chest wound,P960001925,CDM,960,RC,20101,HCPCS,Outpatient,,,504.78,328.11,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,409.22,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,409.22,409.22,
INTRAUTERINE COPPER CONTRA,P960000704,CDM,960,RC,,,Outpatient,,,1220.00,793.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1220,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1220,1220,
"ELECTROCARDIOGRAM, COMPLETE",P960000554,CDM,960,RC,93000,HCPCS,Outpatient,,,33.00,21.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,13.5,13.5,
SHINGRIX,P960000540,CDM,960,RC,90750,HCPCS,Outpatient,,,242.00,157.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,165.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,165.25,165.25,
20 REMOVAL OF GALLBLADDER,P960000877,CDM,960,RC,47600,HCPCS,Outpatient,,,2114.00,1374.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1171.77,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1171.77,1171.77,
GENERIC RX DRUG,P960000818,CDM,960,RC,,,Outpatient,,,25.41,16.52,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25.41,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,25.41,25.41,
ADM/DC SAME DAY-HI CPLX,P960000622,CDM,960,RC,99236,HCPCS,Outpatient,,,430.00,279.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,153.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,153.58,153.58,
"NEONATE CRIT CARE, INITIAL",P960000664,CDM,960,RC,99468,HCPCS,Outpatient,,,1952.00,1268.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,651.36,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,651.36,651.36,
80 COLECTOMY PART; W SL CECOST,P960000906,CDM,960,RC,44141,HCPCS,Outpatient,,,4518.35,2936.93,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1997.12,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1997.12,1997.12,
Correct Malrotation of Bowel,P960003014,CDM,960,RC,44055,HCPCS,Outpatient,,,3561.78,2315.16,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1633.55,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1633.55,1633.55,
20 CESAREAN DELIVERY ONLY;,P960000892,CDM,960,RC,59514,HCPCS,Outpatient,,,1820.00,1183.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,611.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,611.82,611.82,
COLO CNCR SCR;COLNS NO HI RSK,P960000680,CDM,960,RC,G0121,HCPCS,Outpatient,,,612.00,397.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,242.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,242.82,242.82,
DIL URETHR STRICT FILIF/FOLLOW,P960000950,CDM,960,RC,53620,HCPCS,Outpatient,,,218.03,141.72,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,122.57,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,122.57,122.57,
NS CATH ABD/L-EXT ART 3RD,P960003025,CDM,960,RC,36247,HCPCS,Outpatient,,,3633.60,2361.84,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1257.63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1257.63,1257.63,
RPR S/N/A/GEN/TRK12.6-20.0CM,P960003052,CDM,960,RC,12005,HCPCS,Outpatient,,,419.22,272.49,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,153.33,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,153.33,153.33,
Cardiac Event monitor hook-up,P960002007,CDM,960,RC,93270,HCPCS,Outpatient,,,21.33,13.86,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.89,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,6.89,6.89,
Removal of sutures and staples,P960003134,CDM,960,RC,15854,HCPCS,Outpatient,,,35.30,22.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,35.3,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,35.3,35.3,
SARSCV2 VAC 10MCG TRS-SUC IM,P960003157,CDM,960,RC,91319,HCPCS,Outpatient,,,219.45,142.64,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,219.45,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,219.45,219.45,
TREATMENT OF FOOT INFECTION,P960003128,CDM,960,RC,28003,HCPCS,Outpatient,,,926.12,601.98,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,611.44,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,611.44,611.44,
Unlisted Procedure intestine,P960003173,CDM,960,RC,44238,HCPCS,Outpatient,,,1500.00,975.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1500,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1500,1500,
Methylprednisolone 40 mg,P960003179,CDM,960,RC,,,Outpatient,,,2.50,1.63,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.5,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2.5,2.5,
"Cardiovascular Proc, unlisted",P960003011,CDM,960,RC,93799,HCPCS,Outpatient,,,336.90,218.99,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,336.9,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,336.9,336.9,
SURG ARTHROSCPY SHLDR DSTL CLV,P960003140,CDM,960,RC,29824,HCPCS,Outpatient,,,1653.32,1074.66,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,583.52,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,583.52,583.52,
"SHAVE S,N,H>2CM",P960000737,CDM,960,RC,11308,HCPCS,Outpatient,,,292.00,189.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,138.65,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,138.65,138.65,
INT HRHC LIG 1 HROID W/O IMG,P960003104,CDM,960,RC,46945,HCPCS,Outpatient,,,826.20,537.03,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,365.02,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,365.02,365.02,
REMOVE ANAL FIST COMPLEX,P960003106,CDM,960,RC,46280,HCPCS,Outpatient,,,1172.07,761.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,520.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,520.3,520.3,
RPR AA HERNIA 1ST<3cM REDUCIBL,P960003038,CDM,960,RC,49591,HCPCS,Outpatient,,,802.62,521.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,802.62,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,802.62,802.62,
Removal of sutures or staples,P960003135,CDM,960,RC,15851,HCPCS,Outpatient,,,138.72,90.17,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,92.67,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,92.67,92.67,
EXC SHOULDER LES SC < 3 CM,P960003151,CDM,960,RC,23075,HCPCS,Outpatient,,,1255.90,816.34,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,430.48,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,430.48,430.48,
DESTROY INTERNAL HEMORRHOIDS,P960003168,CDM,960,RC,46930,HCPCS,Outpatient,,,361.35,234.88,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,232.27,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,232.27,232.27,
LARYNGOSCOPY W/FB REMOVAL,P960002059,CDM,960,RC,31530,HCPCS,Outpatient,,,479.30,311.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,179.01,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,179.01,179.01,
PARTIAL REMOVAL OF TOE,P960003221,CDM,960,RC,28160,HCPCS,Outpatient,,,654.43,425.38,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,361.96,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,361.96,361.96,
PERC BX OR EXC LN; SUPERFICIAL,P960001911,CDM,960,RC,38505,HCPCS,Outpatient,,,169.20,109.98,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,104.12,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,104.12,104.12,
Hosp IP/OBS care same date Mod,P960003079,CDM,960,RC,99235,HCPCS,Outpatient,,,389.07,252.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,119.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,119.3,119.3,
Biopsy of Liver Wedge,P960003150,CDM,960,RC,47100,HCPCS,Outpatient,,,2049.43,1332.13,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,926.87,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,926.87,926.87,
DECOMPRESS FOREARM 1 SPACE,P960002067,CDM,960,RC,25020,HCPCS,Outpatient,,,1849.45,1202.14,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,550.66,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,550.66,550.66,
RPR AA HERNIA RECR <3CM NCRC8,P960003047,CDM,960,RC,49614,HCPCS,Outpatient,,,1341.32,871.86,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1341.32,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1341.32,1341.32,
INTERPROF PHONE/ONLINE 5-10,P960000730,CDM,960,RC,99446,HCPCS,Outpatient,,,44.55,28.96,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.36,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,11.36,11.36,
OB Visit New Level 2,P960003015,CDM,960,RC,99202,HCPCS,Outpatient,,,177.55,115.41,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,52.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,52.9,52.9,
Drain Neck/Chest Lesion,P960002051,CDM,960,RC,21501,HCPCS,Outpatient,,,808.10,525.27,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,402.18,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,402.18,402.18,
INITIAL PREVENTIVE EXAM,P960003037,CDM,960,RC,,,Outpatient,,,312.55,203.16,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,312.55,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,312.55,312.55,
20 Mastectomy Partial,P960001914,CDM,960,RC,19301,HCPCS,Outpatient,,,1585.10,1030.32,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,595.18,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,595.18,595.18,
FUSION OF BIG TOE JOINT,P960003036,CDM,960,RC,28755,HCPCS,Outpatient,,,1241.70,807.11,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,443.64,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,443.64,443.64,
"Inc Drn,cmplx, post op wound",P960002017,CDM,960,RC,10180,HCPCS,Outpatient,,,428.35,278.43,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,228.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,228.9,228.9,
Treatment of ankle fracture,P960002057,CDM,960,RC,27823,HCPCS,Outpatient,,,2397.98,1558.69,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,847.57,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,847.57,847.57,
COLPORRHAPHY SUTURE INJ VAGINA,P960003136,CDM,960,RC,57200,HCPCS,Outpatient,,,3348.00,2176.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,270.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,270.9,270.9,
80 Mastectomy Partial,P960001913,CDM,960,RC,19301,HCPCS,Outpatient,,,1585.10,1030.32,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,595.18,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,595.18,595.18,
OB Visit Est Level 4,P960003021,CDM,960,RC,99214,HCPCS,Outpatient,,,313.45,203.74,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,75.99,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,75.99,75.99,
LAP ING HERNIA REPAIR INIT,P960003029,CDM,960,RC,49650,HCPCS,Outpatient,,,1044.33,678.81,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,470.03,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,470.03,470.03,
SURG DX EXAM ANORECTAL,P960003031,CDM,960,RC,45990,HCPCS,Outpatient,,,253.17,164.56,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,116.57,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,116.57,116.57,
REMOVAL OF SESAMOID  BONE,P960003220,CDM,960,RC,28315,HCPCS,Outpatient,,,798.60,519.09,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,420.15,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,420.15,420.15,
RPR AA HERNIA 1ST>10 CM NCRC8,P960003043,CDM,960,RC,49596,HCPCS,Outpatient,,,2402.37,1561.54,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2402.37,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2402.37,2402.37,
"Skin Biopsy, single lesion",P960002081,CDM,960,RC,11106,HCPCS,Outpatient,,,387.90,252.14,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,136.54,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,136.54,136.54,
LAYER CLOSUR WND SCALP 12.6-20,P960000091,CDM,960,RC,12055,HCPCS,Outpatient,,,900.00,585.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,437.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,437.9,437.9,
Hepatitis B Adult State,P960002096,CDM,960,RC,90746,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LYSIS OF ADHESIONS SALPINX/OVA,P960002039,CDM,960,RC,58740,HCPCS,Outpatient,,,2189.58,1423.23,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,765.61,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,765.61,765.61,
Correction Hallux Valgus,P960002080,CDM,960,RC,28297,HCPCS,Outpatient,,,2545.35,1654.48,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,912.74,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,912.74,912.74,
80LSH W/T/O UT 250 G OR LESS,P960001938,CDM,960,RC,58542,HCPCS,Outpatient,,,2026.25,1317.06,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,709.27,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,709.27,709.27,
NEG PRESS WOUND TX >50 CM,P960003129,CDM,960,RC,97608,HCPCS,Outpatient,,,885.62,575.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,384.87,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,384.87,384.87,
REMOVE ANAL FIST INTER,P960003199,CDM,960,RC,46275,HCPCS,Outpatient,,,1029.75,669.34,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,601.37,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,601.37,601.37,
OB Visit New Level 5,P960003018,CDM,960,RC,99205,HCPCS,Outpatient,,,538.75,350.19,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,145.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,145.23,145.23,
TAP BLOCK BILATERAL BY INJECT,P960003095,CDM,960,RC,64488,HCPCS,Outpatient,,,167.40,108.81,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,115.8,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,115.8,115.8,
Gastrostomy rep w/o Im guidnce,P960000992,CDM,960,RC,43762,HCPCS,Outpatient,,,91.20,59.28,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,91.2,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,91.2,91.2,
EXC FOOT/TOE TUM SC < 1.5 CM,P960002000,CDM,960,RC,28043,HCPCS,Outpatient,,,635.55,413.11,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,342.56,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,342.56,342.56,
FTH/GFT FREE W/DIR CLOS S/A/L,P960003007,CDM,960,RC,15220,HCPCS,Outpatient,,,1872.23,1216.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,694.37,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,694.37,694.37,
Caregiver Health Risk Assmt,P960003148,CDM,960,RC,96161,HCPCS,Outpatient,,,6.45,4.19,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.83,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2.83,2.83,
HIB Vaccine,P960003146,CDM,960,RC,90647,HCPCS,Outpatient,,,64.65,42.02,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27.67,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,27.67,27.67,
PED CRIT CARE AGE 2-5 SUBSQ,P960003165,CDM,960,RC,99476,HCPCS,Outpatient,,,818.87,532.27,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,245.11,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,245.11,245.11,
ECG 12 lead Interp/Report only,P960001987,CDM,960,RC,93010,HCPCS,Outpatient,,,20.33,13.21,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.89,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,6.89,6.89,
Remove Aortic Assist Device,P960002050,CDM,960,RC,33968,HCPCS,Outpatient,,,78.77,51.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28.48,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,28.48,28.48,
EGD Control Bleeding Any,P960003198,CDM,960,RC,43255,HCPCS,Outpatient,,,479.90,311.94,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,479.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,479.9,479.9,
OB Visit New Level 4,P960003017,CDM,960,RC,99204,HCPCS,Outpatient,,,407.28,264.73,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,114.84,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,114.84,114.84,
RPR AA HERN 1ST 3-10CM NCRC8,P960003042,CDM,960,RC,49594,HCPCS,Outpatient,,,1750.75,1137.99,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1750.75,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1750.75,1750.75,
ED Level 1 Ltd/Minor,P960002046,CDM,960,RC,99281,HCPCS,Outpatient,,,53.15,34.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15.95,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,15.95,15.95,
LAP ING HERNIA REPAIR RECUR,P960003163,CDM,960,RC,49651,HCPCS,Outpatient,,,1368.42,889.47,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,612.24,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,612.24,612.24,
REMOVE FOREIGN BODY ABDOMEN,P960003183,CDM,960,RC,49402,HCPCS,Outpatient,,,2080.87,1352.57,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,938.27,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,938.27,938.27,
EXPLORE ABDOMINAL VESSELS,P960002078,CDM,960,RC,35840,HCPCS,Outpatient,,,2876.30,1869.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1009.14,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1009.14,1009.14,
NTUBATION ENDOTRACHEAL EMERGEN,P960003119,CDM,960,RC,31500,HCPCS,Outpatient,,,341.38,221.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,130.28,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,130.28,130.28,
INTERPROF PHONE/ONLINE 11-20,P960000731,CDM,960,RC,99447,HCPCS,Outpatient,,,89.95,58.47,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22.94,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,22.94,22.94,
SURG ARTHROSCOPY SHOULDER PRT,P960003096,CDM,960,RC,29820,HCPCS,Outpatient,,,1303.50,847.28,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,464.14,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,464.14,464.14,
Wedging cast,P960003023,CDM,960,RC,29740,HCPCS,Outpatient,,,236.58,153.78,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,84.39,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,84.39,84.39,
Placement Seton,P960002044,CDM,960,RC,46020,HCPCS,Outpatient,,,278.90,181.29,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,278.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,278.9,278.9,
DILATION OF ANAL SPHINCTER,P960003171,CDM,960,RC,45905,HCPCS,Outpatient,,,1435.32,932.96,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,184.31,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,184.31,184.31,
ARTHRSCPY KNEE W/MENISC REPAIR,P960003027,CDM,960,RC,29883,HCPCS,Outpatient,,,2032.50,1321.13,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,727.62,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,727.62,727.62,
Rem & Repl PM Gen Single,P960001958,CDM,960,RC,33227,HCPCS,Outpatient,,,814.15,529.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,284.59,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,284.59,284.59,
COLPOSCOPY VAGINA W/CERVIX,P960003143,CDM,960,RC,57420,HCPCS,Outpatient,,,216.82,140.93,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,106.48,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,106.48,106.48,
INS ENDOVAS VENA CAVA FILTR,P960002056,CDM,960,RC,37191,HCPCS,Outpatient,,,529.05,343.88,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,529.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,529.05,529.05,
CAPILLARY BLOOD DRAW,P960002060,CDM,960,RC,36416,HCPCS,Outpatient,,,25.00,16.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.77,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1.77,1.77,
CL Tx Post Hip Arthr Dislc w/o,P960001965,CDM,960,RC,27265,HCPCS,Outpatient,,,260.48,169.31,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,260.48,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,260.48,260.48,
Relocation of PM Pocket,P960001959,CDM,960,RC,33222,HCPCS,Outpatient,,,823.18,535.07,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,285.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,285.3,285.3,
"Colostomy, partial, ileocolost",P960002093,CDM,960,RC,44160,HCPCS,Outpatient,,,2977.83,1935.59,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1361.54,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1361.54,1361.54,
REMOVAL OF URETHRA LESION,P960003167,CDM,960,RC,53230,HCPCS,Outpatient,,,1461.37,949.89,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,512.41,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,512.41,512.41,
Bronchoscopy w FB removal,P960002027,CDM,960,RC,31635,HCPCS,Outpatient,,,729.15,473.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,254.55,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,254.55,254.55,
Pro Fee UMC Moore,P960003000,CDM,960,RC,55250,HCPCS,Outpatient,,,346.41,225.17,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,305.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,305.23,305.23,
Anterior Colporrhaphy,P960003145,CDM,960,RC,57240,HCPCS,Outpatient,,,1499.45,974.64,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,518.18,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,518.18,518.18,
ATTEMPTED VBAC DELIVERY ONLY,P960002079,CDM,960,RC,59620,HCPCS,Outpatient,,,2203.38,1432.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,632.86,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,632.86,632.86,
Remote 30 day ECG,P960002086,CDM,960,RC,93229,HCPCS,Outpatient,,,2173.90,1413.04,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,552.42,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,552.42,552.42,
Inject Skin lesions up to 7,P960002075,CDM,960,RC,11900,HCPCS,Outpatient,,,139.23,90.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,49.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,49.43,49.43,
Bx Vaginal mucosa simple,P960003005,CDM,960,RC,57100,HCPCS,Outpatient,,,254.38,165.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,81.52,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,81.52,81.52,
EGD VARICES LIGATION,P960003195,CDM,960,RC,43244,HCPCS,Outpatient,,,587.47,381.86,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,271.86,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,271.86,271.86,
"VBAC,delv proc after prev Csec",P960001918,CDM,960,RC,59610,HCPCS,Outpatient,,,5925.20,3851.38,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1487.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1487.5,1487.5,
RPR AA HERN RECR 3-10CM REDUCB,P960003045,CDM,960,RC,49615,HCPCS,Outpatient,,,1501.00,975.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1501,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1501,1501,
EXPLORE LIMB VESSELS,P960002068,CDM,960,RC,35860,HCPCS,Outpatient,,,1977.63,1285.46,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,702.7,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,702.7,702.7,
CL TX SHLDR DISLOC & FX GT; W,P960000822,CDM,960,RC,23665,HCPCS,Outpatient,,,976.30,634.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,369.44,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,369.44,369.44,
PED CRIT CARE AGE 2-5 INIT,P960003164,CDM,960,RC,99475,HCPCS,Outpatient,,,1358.62,883.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,396.88,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,396.88,396.88,
I&D ISCHIORCT/INTRAMURAL ABSC,P960003176,CDM,960,RC,46060,HCPCS,Outpatient,,,1166.32,758.11,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,526.99,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,526.99,526.99,
Metatarsectomy,P960003201,CDM,960,RC,28140,HCPCS,Outpatient,,,1041.58,677.03,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,512.64,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,512.64,512.64,
DSTR MAL LES S/N/H/F/G 0.6-1,P960003181,CDM,960,RC,17271,HCPCS,Outpatient,,,243.47,158.26,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,147.49,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,147.49,147.49,
Alcohol/Sub Interv 15-30 min,P960003001,CDM,960,RC,,,Outpatient,,,86.85,56.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,86.85,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,86.85,86.85,
NURSING FAC CARE SUBSEQ 45 min,P960003051,CDM,960,RC,99310,HCPCS,Outpatient,,,364.27,236.78,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,94.83,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,94.83,94.83,
"RPR FEM HERNIA, INIT BLOCKED",P960000310,CDM,960,RC,49553,HCPCS,Outpatient,,,1246.00,809.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,691.01,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,691.01,691.01,
ILEOSTOMY/JEJUNOSTOMY,P960003186,CDM,960,RC,44310,HCPCS,Outpatient,,,2522.77,1639.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1142.66,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1142.66,1142.66,
"Skin Biopsy, addtl lesions",P960002082,CDM,960,RC,11107,HCPCS,Outpatient,,,176.68,114.84,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,64.52,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,64.52,64.52,
PROCTOSIGMOIDOSCOPY ABLATE,P960003153,CDM,960,RC,45320,HCPCS,Outpatient,,,250.62,162.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,217.63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,217.63,217.63,
LAPAROSCOPY LYMPH NODE BIOP,P960003196,CDM,960,RC,38570,HCPCS,Outpatient,,,1258.80,818.22,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,432.26,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,432.26,432.26,
Vaxelis Vaccine State,P960002092,CDM,960,RC,90697,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
Treatment of toe fracture,P960002085,CDM,960,RC,28515,HCPCS,Outpatient,,,401.03,260.67,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,140.89,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,140.89,140.89,
V-Excision Lip w linear closur,P960003126,CDM,960,RC,40520,HCPCS,Outpatient,,,873.82,567.98,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,540.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,540.29,540.29,
TREAT FINGER FRACTURE EACH,P960002070,CDM,960,RC,26746,HCPCS,Outpatient,,,1804.88,1173.17,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,641.85,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,641.85,641.85,
Skin Full graft Face/Genit/HF,P960002033,CDM,960,RC,15240,HCPCS,Outpatient,,,1916.38,1245.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,839.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,839.23,839.23,
RPR AA HERNIA RECR <3CM REDUCB,P960003044,CDM,960,RC,49613,HCPCS,Outpatient,,,989.70,643.31,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,989.7,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,989.7,989.7,
PPD SKIN TEST INJ,P960000717,CDM,960,RC,86580,HCPCS,Outpatient,,,32.00,20.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,5.68,5.68,
REMOVAL OF TOE LESIONS,P960003035,CDM,960,RC,28092,HCPCS,Outpatient,,,1024.22,665.74,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,368.59,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,368.59,368.59,
"Phalangectomy, toe, each toe",P960003203,CDM,960,RC,28150,HCPCS,Outpatient,,,1006.73,654.37,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,367.14,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,367.14,367.14,
DTAP-IPV-HIB-HEPB VACCINE IM,P960002088,CDM,960,RC,90697,HCPCS,Outpatient,,,165.00,107.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,147.85,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,147.85,147.85,
"Reconstruction, toe",P960003012,CDM,960,RC,28344,HCPCS,Outpatient,,,1026.60,667.29,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,371.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,371.45,371.45,
DRAINAGE OF PALMAR BURSA SINGL,P960003028,CDM,960,RC,26025,HCPCS,Outpatient,,,1025.73,666.72,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,363.44,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,363.44,363.44,
REPAIR BLOOD VESSEL LESION,P960003180,CDM,960,RC,35221,HCPCS,Outpatient,,,3537.57,2299.42,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1232.95,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1232.95,1232.95,
"Arthroscopy, knee, diagnostic",P960003013,CDM,960,RC,29870,HCPCS,Outpatient,,,1352.53,879.14,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,492.13,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,492.13,492.13,
CYSTOURETERO W/RENAL STRICT,P960003137,CDM,960,RC,52346,HCPCS,Outpatient,,,5271.22,3426.29,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,376.17,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,376.17,376.17,
DBRDMT SKN SUBQ T/M/F ABD WALL,P960002013,CDM,960,RC,11005,HCPCS,Outpatient,,,1853.45,1204.74,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,710.24,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,710.24,710.24,
REMOVAL OF FALLOPIAN  TUBE,P960003213,CDM,960,RC,58700,HCPCS,Outpatient,,,1958.63,1273.11,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,675.26,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,675.26,675.26,
Mastectomy w LN removal,P960000980,CDM,960,RC,19302,HCPCS,Outpatient,,,2019.35,1312.58,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,817.96,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,817.96,817.96,
Pericardiocentesis w imaging,P960003003,CDM,960,RC,33016,HCPCS,Outpatient,,,556.40,361.66,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,198.89,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,198.89,198.89,
PREPUTIAL STRETCHING,P960003144,CDM,960,RC,54450,HCPCS,Outpatient,,,137.70,89.51,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,58.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,58.9,58.9,
Abd. Aorta w Runoffs,P960001978,CDM,960,RC,75630,HCPCS,Outpatient,,,232.65,151.22,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,114.54,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,114.54,114.54,
ECHO TRANSESOPHAG R-T 2D W/PRB,P960001993,CDM,960,RC,93312,HCPCS,Outpatient,,,266.88,173.47,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,196.86,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,196.86,196.86,
BONE BX TR/NDL; SUPERF,P960001915,CDM,960,RC,20220,HCPCS,Outpatient,,,214.05,139.13,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,212.36,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,212.36,212.36,
EXC FACE-MM B9+MARG >4 CM,P960003105,CDM,960,RC,11446,HCPCS,Outpatient,,,767.15,498.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,352.15,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,352.15,352.15,
Mastectomy Partial,P960001912,CDM,960,RC,19301,HCPCS,Outpatient,,,1585.10,1030.32,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,595.18,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,595.18,595.18,
PROSTATE LASER ENUCLEATION,P960003208,CDM,960,RC,52649,HCPCS,Outpatient,,,2002.75,1301.79,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,695.67,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,695.67,695.67,
EGD DILATE STRICTURE,P960003127,CDM,960,RC,43245,HCPCS,Outpatient,,,421.37,273.89,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,421.37,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,421.37,421.37,
COLONOSCOPY SUBMUCOUS NJX,P960002002,CDM,960,RC,45381,HCPCS,Outpatient,,,487.73,317.02,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,458.01,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,458.01,458.01,
EXC H-F-NK-SP MLG MARG 0.6-1,P960000057,CDM,960,RC,11621,HCPCS,Outpatient,,,444.00,288.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,206.94,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,206.94,206.94,
INS HEART PCEMAKER VENTRICULAR,P960000243,CDM,960,RC,33207,HCPCS,Outpatient,,,954.00,620.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,403.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,403.5,403.5,
BIOPSY OF UTERUS LINING,P960000407,CDM,960,RC,58100,HCPCS,Outpatient,,,213.00,138.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,82.63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,82.63,82.63,
"INJECT TRIGGER POINT, 1 OR 2",P960000122,CDM,960,RC,20552,HCPCS,Outpatient,,,107.00,69.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,47.95,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,47.95,47.95,
EXC H-F-NK-SP B9+MARG 2.1-3,P960000044,CDM,960,RC,11423,HCPCS,Outpatient,,,389.00,252.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,183.52,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,183.52,183.52,
TREAT FINGER FRAC OPEN,P960000162,CDM,960,RC,26735,HCPCS,Outpatient,,,1165.00,757.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,513.51,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,513.51,513.51,
"TRIM SKIN LESIONS, 2 TO 4",P960000021,CDM,960,RC,11056,HCPCS,Outpatient,,,112.00,72.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,66.34,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,66.34,66.34,
REMOVAL OF OVARIAN CYST(S),P960000428,CDM,960,RC,58925,HCPCS,Outpatient,,,1467.00,953.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,648.04,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,648.04,648.04,
ISTAT METABOLIC PANEL ION CA,P960000463,CDM,960,RC,80047,HCPCS,Outpatient,,,166.48,108.21,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8.87,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,8.87,8.87,
SKIN SPLIT GRAFT,P960000096,CDM,960,RC,15120,HCPCS,Outpatient,,,1653.00,1074.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,768.39,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,768.39,768.39,
PROTHROMBIN TIME,P960000469,CDM,960,RC,85610,HCPCS,Outpatient,,,11.00,7.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.77,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2.77,2.77,
RPAIR ANKL LIGAMNT COLLAT-SNGL,P960000186,CDM,960,RC,27695,HCPCS,Outpatient,,,939.00,610.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,412.24,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,412.24,412.24,
TX THIGH FRACTURE OPEN,P960000169,CDM,960,RC,27236,HCPCS,Outpatient,,,2359.00,1533.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1034.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1034.68,1034.68,
SMALL BOWEL ENDOSCOPY,P960000267,CDM,960,RC,44380,HCPCS,Outpatient,,,322.00,209.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,197.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,197.29,197.29,
DRAINAGE OF HEMATOMA/FLUID,P960000009,CDM,960,RC,10140,HCPCS,Outpatient,,,655.00,425.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,153.07,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,153.07,153.07,
CYSTO AND TREAT REM FOR BODY,P960000346,CDM,960,RC,52310,HCPCS,Outpatient,,,475.00,308.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,239.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,239.58,239.58,
REMOVAL OF EPIDIDYMIS,P960000380,CDM,960,RC,54860,HCPCS,Outpatient,,,835.00,542.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,359.27,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,359.27,359.27,
REPAIR OF WOUND/LESION 2.6-7.5,P960000092,CDM,960,RC,13121,HCPCS,Outpatient,,,824.00,535.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,387.39,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,387.39,387.39,
DESTRUCT SKIN LESION,P960000108,CDM,960,RC,17280,HCPCS,Outpatient,,,271.00,176.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,124.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,124.82,124.82,
EXC TR-EXT B9 MARG 1.1-2 CM,P960000037,CDM,960,RC,11402,HCPCS,Outpatient,,,319.00,207.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,152.46,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,152.46,152.46,
REDUCE TESTIS TORSION,P960000375,CDM,960,RC,54600,HCPCS,Outpatient,,,908.00,590.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,389.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,389.1,389.1,
EXC TR-EXT B9 MARG > 4.0 CM,P960000040,CDM,960,RC,11406,HCPCS,Outpatient,,,607.00,394.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,285.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,285.29,285.29,
TREAT FRAC RADIUS/ULNA W/MANIP,P960000149,CDM,960,RC,25605,HCPCS,Outpatient,,,1054.00,685.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,466.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,466.58,466.58,
CYSTOSCOPY & URETER CATHETER,P960000336,CDM,960,RC,52005,HCPCS,Outpatient,,,515.00,334.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,242.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,242.43,242.43,
REMOVAL OF OVARY(S),P960000429,CDM,960,RC,58940,HCPCS,Outpatient,,,1032.00,670.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,460.98,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,460.98,460.98,
ASPIRATE PLEURA W/O IMAGING,P960000241,CDM,960,RC,32554,HCPCS,Outpatient,,,390.00,253.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,198.32,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,198.32,198.32,
APPLY HAND/WRIST CAST LOWER,P960000216,CDM,960,RC,29085,HCPCS,Outpatient,,,185.00,120.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,80.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,80.43,80.43,
CYSTO AND TREAT URETHROTOMY,P960000344,CDM,960,RC,52276,HCPCS,Outpatient,,,532.00,345.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,222.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,222.73,222.73,
REPAIR OF HAMMERTOE,P960000200,CDM,960,RC,28285,HCPCS,Outpatient,,,1055.00,685.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,468.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,468.05,468.05,
REMOVAL OF NAIL BED,P960000072,CDM,960,RC,11750,HCPCS,Outpatient,,,296.00,192.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,112.57,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,112.57,112.57,
ARTHROSCOP ROTATOR CUFF REPR,P960000232,CDM,960,RC,29827,HCPCS,Outpatient,,,2082.00,1353.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,926.79,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,926.79,926.79,
DRAIN/INJ JOINT/BURSA W/O US,P960000125,CDM,960,RC,20610,HCPCS,Outpatient,,,118.00,76.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,53.31,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,53.31,53.31,
TREAT LOWER LEG FRACTURE,P960000194,CDM,960,RC,27827,HCPCS,Outpatient,,,2158.00,1402.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,960.7,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,960.7,960.7,
TX THIGH FRACTURE WITH PLATE,P960000170,CDM,960,RC,27244,HCPCS,Outpatient,,,2428.00,1578.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1064.8,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1064.8,1064.8,
REMOVE IMPACTED EAR WAX UNI,P960000454,CDM,960,RC,69209,HCPCS,Outpatient,,,37.75,24.54,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12.81,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,12.81,12.81,
TREAT FINGER FRAC PERCUTANEOUS,P960000161,CDM,960,RC,26727,HCPCS,Outpatient,,,913.00,593.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,406.94,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,406.94,406.94,
BIOPSY OF VULVA/PERINEUM,P960000392,CDM,960,RC,56605,HCPCS,Outpatient,,,160.00,104.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,76.66,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,76.66,76.66,
TREAT FINGER FRAC OPEN INTERN,P960000165,CDM,960,RC,26765,HCPCS,Outpatient,,,976.00,634.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,432.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,432.76,432.76,
INSERTION OF HEART ELECTRODE,P960000245,CDM,960,RC,33210,HCPCS,Outpatient,,,331.00,215.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,137.77,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,137.77,137.77,
LIGATE OVIDUCT(S) ADD-ON,P960000422,CDM,960,RC,58611,HCPCS,Outpatient,,,152.00,98.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,66.19,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,66.19,66.19,
OP UP GI ENDO WI REM FRGN BODY,P960000260,CDM,960,RC,43247,HCPCS,Outpatient,,,675.00,438.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,401.86,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,401.86,401.86,
COLON ENDOSCOPY,P960000268,CDM,960,RC,44388,HCPCS,Outpatient,,,558.00,362.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,329.83,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,329.83,329.83,
REM SUPPORT IMPLANT SUPERFICIA,P960000126,CDM,960,RC,20670,HCPCS,Outpatient,,,726.00,471.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,315.8,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,315.8,315.8,
INCISION THROMBOSED HEMORR EXT,P960000768,CDM,960,RC,46083,HCPCS,Outpatient,,,341.00,221.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,208.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,208.76,208.76,
PNEUMOVAX VFC/SL,P960000533,CDM,960,RC,90732,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ECHO TRANSTHORACIC,P960000573,CDM,960,RC,93350,HCPCS,Outpatient,,,460.00,299.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,151.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,151.23,151.23,
"POLIOVIRUS, IPV, SC",P960000521,CDM,960,RC,90713,HCPCS,Outpatient,,,116.00,75.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37.49,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,37.49,37.49,
"ICD DEVICE PROGR EVAL, DUAL",P960000564,CDM,960,RC,93283,HCPCS,Outpatient,,,159.00,103.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,73.85,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,73.85,73.85,
"ICD DEVICE PROGR EVAL, MULT",P960000565,CDM,960,RC,93284,HCPCS,Outpatient,,,177.00,115.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,79.87,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,79.87,79.87,
"DT VACCINE < 7, IM",P960000515,CDM,960,RC,90702,HCPCS,Outpatient,,,140.00,91.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,60.98,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,60.98,60.98,
TD VACC NO PRSRV >/= 7 IM,P960000524,CDM,960,RC,90714,HCPCS,Outpatient,,,78.00,50.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26.4,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,26.4,26.4,
EXTRACRANIAL STUDY,P960000579,CDM,960,RC,93880,HCPCS,Outpatient,,,385.00,250.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,228.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,228.68,228.68,
"TD VACCINE > 7, IM",P960000529,CDM,960,RC,90714,HCPCS,Outpatient,,,122.00,79.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26.4,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,26.4,26.4,
OPEN TX INTERCONDYLAR SPINE/TU,P960000907,CDM,960,RC,27540,HCPCS,Outpatient,,,2001.53,1300.99,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,700.93,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,700.93,700.93,
RHYTHM ECG WITH REPORT,P960000557,CDM,960,RC,93040,HCPCS,Outpatient,,,25.00,16.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.12,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,10.12,10.12,
"REPAIR ""MALLET FINGER""; WO GRA",P960000795,CDM,960,RC,26433,HCPCS,Outpatient,,,1337.37,869.29,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,468.35,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,468.35,468.35,
IMMUNOTHERAPY INJECTIONS,P960000587,CDM,960,RC,95117,HCPCS,Outpatient,,,19.00,12.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8.38,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,8.38,8.38,
"OFFICE VISIT, EST PT., LEVEL 4",P960000605,CDM,960,RC,99214,HCPCS,Outpatient,,,313.45,203.74,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,75.99,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,75.99,75.99,
HOSP DISC <30MIN,P960000623,CDM,960,RC,99238,HCPCS,Outpatient,,,143.00,92.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,51.43,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,51.43,51.43,
"DTAP-HEP B-IPV VACCINE, IM",P960000530,CDM,960,RC,90723,HCPCS,Outpatient,,,230.00,149.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,91.21,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,91.21,91.21,
DESTR CUT VASC LES 10SQ CM<,P960000769,CDM,960,RC,17106,HCPCS,Outpatient,,,664.01,431.61,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,308.03,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,308.03,308.03,
DRAIN BL W/CATH INSERTION,P960000959,CDM,960,RC,51102,HCPCS,Outpatient,,,364.80,237.12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,197,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,197,197,
INFLU 4 VALENT NASAL VFC/SL,P960000501,CDM,960,RC,90672,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
20 BIPOLAR HIP REPLACEMENT,P960000867,CDM,960,RC,27236,HCPCS,Outpatient,,,2359.00,1533.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1034.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1034.68,1034.68,
DTAP-IPV VACC 4-6 YR IM,P960000509,CDM,960,RC,90696,HCPCS,Outpatient,,,162.00,105.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,56.24,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,56.24,56.24,
"NEG PRESS WOUND TX, < 50 CM",P960000595,CDM,960,RC,97605,HCPCS,Outpatient,,,81.00,52.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,51.09,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,51.09,51.09,
"PM DEVICE PROGR EVAL,  DUAL",P960000562,CDM,960,RC,93280,HCPCS,Outpatient,,,114.00,74.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,57.51,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,57.51,57.51,
COMM SVCS BY RHC/FQHC 5 MIN,P960000821,CDM,960,RC,,,Outpatient,,,61.90,40.24,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,61.9,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,61.9,61.9,
"ARTHROSC KNEE, FR INF/LAVAGE",P96000771,CDM,960,RC,29871,HCPCS,Outpatient,,,1009.00,655.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,443.79,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,443.79,443.79,
NURSING FAC SUBSEQ,P960000636,CDM,960,RC,99307,HCPCS,Outpatient,,,87.00,56.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30.97,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,30.97,30.97,
INTERMIT URIN CATH; STRAIT TIP,P960000670,CDM,960,RC,A4351,HCPCS,Outpatient,,,8.00,5.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.79,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1.79,1.79,
MD CERTIFICATION HHA PATIENT,P960000684,CDM,960,RC,G0180,HCPCS,Outpatient,,,104.00,67.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,38.96,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,38.96,38.96,
FLU VAC NO PRSV 4 VAL 3 YRS+,P960000506,CDM,960,RC,90686,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
80 TOTAL HYSTERECTOMY,P960000933,CDM,960,RC,58150,HCPCS,Outpatient,,,2000.00,1300.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,864.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,864.82,864.82,
HEARING SCREENING,P960000864,CDM,960,RC,,,Outpatient,,,56.00,36.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,56,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,56,56,
"IC, LBW INF < 1500 GM SUBSQ",P960000666,CDM,960,RC,99478,HCPCS,Outpatient,,,277.00,180.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,97.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,97.25,97.25,
DRAINAGE ABDOM ABSCESS OPEN,P960000945,CDM,960,RC,49020,HCPCS,Outpatient,,,3950.00,2567.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1746.2,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1746.2,1746.2,
80 REMOVAL OF SMALL INTESTINE,P960000917,CDM,960,RC,44120,HCPCS,Outpatient,,,2430.00,1579.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1340.59,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1340.59,1340.59,
ACTIVE WOUND CARE/20 CM OR <,P960000594,CDM,960,RC,97597,HCPCS,Outpatient,,,144.00,93.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,111.72,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,111.72,111.72,
80 EXPLORATION OF ABDOMEN,P960000925,CDM,960,RC,49000,HCPCS,Outpatient,,,1526.00,991.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,842.69,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,842.69,842.69,
"CARDIOVERSION ELECTRIC, EXT",P960000552,CDM,960,RC,92960,HCPCS,Outpatient,,,308.00,200.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,127.92,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,127.92,127.92,
OL DIG E/M SVC 5-10 MIN,P960000809,CDM,960,RC,99421,HCPCS,Outpatient,,,32.35,21.03,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.7,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,10.7,10.7,
VISUAL ACUITY SCREEN,P960000596,CDM,960,RC,99173,HCPCS,Outpatient,,,12.00,7.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.12,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,3.12,3.12,
20 MAST MOD RAD,P960000866,CDM,960,RC,19307,HCPCS,Outpatient,,,2847.08,1850.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1092.28,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1092.28,1092.28,
VITAMIN K INJ PER 1 MG,P960000856,CDM,960,RC,,,Outpatient,,,39.45,25.64,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,39.45,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,39.45,39.45,
IIV4 VACCINE SPLT 0.5 ML IM,P960000508,CDM,960,RC,90688,HCPCS,Outpatient,,,60.00,39.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17.15,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,17.15,17.15,
"THER/PROPH/DIAG INJ, IA",P960000593,CDM,960,RC,96373,HCPCS,Outpatient,,,37.00,24.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21.28,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,21.28,21.28,
AUTO NERV FUNC TST SUDOMOTOR,P960000590,CDM,960,RC,95923,HCPCS,Outpatient,,,270.00,175.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,148.36,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,148.36,148.36,
AUDIOMETRY SCREEN,P960000550,CDM,960,RC,92551,HCPCS,Outpatient,,,100.00,65.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13.22,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,13.22,13.22,
FASCIECTOMY PALM ONLY,P960000794,CDM,960,RC,26121,HCPCS,Outpatient,,,1476.90,959.99,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,517.21,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,517.21,517.21,
LOWER EXTREMITY STUDY UNILATER,P960000582,CDM,960,RC,93926,HCPCS,Outpatient,,,289.00,187.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,153.81,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,153.81,153.81,
GLYCOSYLATED HEMOGLOBIN TEST,P960000815,CDM,960,RC,83036,HCPCS,Outpatient,,,24.28,15.78,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.27,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,6.27,6.27,
APPLY WLKR LG LEG CAST,P960000797,CDM,960,RC,29355,HCPCS,Outpatient,,,263.12,171.03,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,120.87,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,120.87,120.87,
ASPIRATE/INJ GANGLION CYST,P960000820,CDM,960,RC,20612,HCPCS,Outpatient,,,102.93,66.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,53.11,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,53.11,53.11,
PROL CARE 1ST HR W/O CONTACT,P960000641,CDM,960,RC,99358,HCPCS,Outpatient,,,220.00,143.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,78.87,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,78.87,78.87,
UPPER EXTREMITY STUDY,P960000583,CDM,960,RC,93930,HCPCS,Outpatient,,,396.00,257.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,236.02,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,236.02,236.02,
"ECG MONITOR/REVIEW, 24 HRS",P960000560,CDM,960,RC,93227,HCPCS,Outpatient,,,53.00,34.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21.57,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,21.57,21.57,
DX BRONCHOSCOPE/WASH,P960000961,CDM,960,RC,31622,HCPCS,Outpatient,,,330.00,214.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,216.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,216.29,216.29,
ROTAVIRUS VACC 2 DOSE ORAL,P960000505,CDM,960,RC,90681,HCPCS,Outpatient,,,450.00,292.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,129.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,129.45,129.45,
ECHO TRANSESOPHA NOT W/93355,P960000571,CDM,960,RC,93314,HCPCS,Outpatient,,,454.00,295.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,187.89,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,187.89,187.89,
SKIN SPLT GRFT TRNK/ARM/LEG 10,P960000942,CDM,960,RC,15100,HCPCS,Outpatient,,,1763.00,1145.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,780.72,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,780.72,780.72,
ECHO TRANSTHORACIC COMPLETE,P960000568,CDM,960,RC,93303,HCPCS,Outpatient,,,452.00,293.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,185,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,185,185,
PREVENT CARE EST. PT. AGE 1-4,P960000650,CDM,960,RC,99392,HCPCS,Outpatient,,,392.00,254.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,74.77,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,74.77,74.77,
"ZOSTER VACC, SC",P960000536,CDM,960,RC,90736,HCPCS,Outpatient,,,570.00,370.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,216.92,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,216.92,216.92,
"HEP B VACCINE, ADULT, IM",P960000539,CDM,960,RC,90746,HCPCS,Outpatient,,,240.00,156.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,62.31,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,62.31,62.31,
20 INCISION OF GALLBLADDER,P960000875,CDM,960,RC,47480,HCPCS,Outpatient,,,2180.50,1417.33,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,963.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,963.78,963.78,
DOPPLER COLOR FLOW,P960000767,CDM,960,RC,93325,HCPCS,Outpatient,,,48.00,31.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19.64,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,19.64,19.64,
INTERNAL NERVE REVISION,P960000801,CDM,960,RC,64727,HCPCS,Outpatient,,,450.70,292.96,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,154.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,154.78,154.78,
CEFTRIAXONE (ROCEPHIN) IM / IV,P960000688,CDM,960,RC,J0696,HCPCS,Outpatient,,,10.00,6.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.48,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.48,0.48,
FAMILY PSYTX W/PATIENT,P960000549,CDM,960,RC,90847,HCPCS,Outpatient,,,211.00,137.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,95.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,95.73,95.73,
80 TOTAL HYSTERECTOMY,P960000933,CDM,960,RC,58150,HCPCS,Outpatient,,,2000.00,1300.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,864.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,864.82,864.82,
"ECG MONITOR/RECORD, 24 HRS",P960000559,CDM,960,RC,93225,HCPCS,Outpatient,,,50.00,32.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,20,20,
TREAT FRACTURE RADIUS/ULNA,P960000148,CDM,960,RC,25575,HCPCS,Outpatient,,,1768.00,1149.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,779.47,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,779.47,779.47,
Commercial Beyfortus 0.5 mL,P960003222,CDM,960,RC,90380,HCPCS,Outpatient,,,1296.00,842.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1296,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1296,1296,
Commercial Beyfortus 1 mL,P960003223,CDM,960,RC,90381,HCPCS,Outpatient,,,1296.00,842.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1296,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1296,1296,
DESTRUCTION; MALIGNANT LESION,P960003132,CDM,960,RC,17261,HCPCS,Outpatient,,,210.07,136.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,130.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,130.78,130.78,
Perq Device Breast 1st,P960001002,CDM,960,RC,19281,HCPCS,Outpatient,,,242.60,157.69,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,220.83,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,220.83,220.83,
INTRO NDL ICATH UPR/LXTR ART,P960003083,CDM,960,RC,36140,HCPCS,Outpatient,,,211.05,137.18,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,211.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,211.05,211.05,
EXC SHOULDER TUM DEEP 5 CM/>,P960003178,CDM,960,RC,23073,HCPCS,Outpatient,,,1675.82,1089.28,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,601.37,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,601.37,601.37,
OB Visit Est Level 5,P960003022,CDM,960,RC,99215,HCPCS,Outpatient,,,441.23,286.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,102.18,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,102.18,102.18,
20Wound expl pentr chest wound,P960001927,CDM,960,RC,20101,HCPCS,Outpatient,,,504.78,328.11,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,409.22,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,409.22,409.22,
Dilate Esophagus 1/multipass,P960003004,CDM,960,RC,43450,HCPCS,Outpatient,,,472.28,306.98,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,185.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,185.29,185.29,
Tx Contour Defect 5.1-10cc,P960002087,CDM,960,RC,11952,HCPCS,Outpatient,,,347.78,226.06,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,129.99,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,129.99,129.99,
Exc Back Tum Deep 5CM/>,P960003172,CDM,960,RC,21933,HCPCS,Outpatient,,,2713.20,1763.58,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,638.15,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,638.15,638.15,
REMOVE ANAL FIST SUBQ,P960003138,CDM,960,RC,46270,HCPCS,Outpatient,,,2875.47,1869.06,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,569.41,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,569.41,569.41,
RPR AA HERNIA 1ST >10CM REDUCB,P960003040,CDM,960,RC,49595,HCPCS,Outpatient,,,1808.62,1175.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1808.62,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1808.62,1808.62,
SARSCOV2 VAC 25 MCG/.25ML IM,P960003159,CDM,960,RC,91321,HCPCS,Outpatient,,,364.80,237.12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,364.8,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,364.8,364.8,
LAPARO-VAG HYST INCL T/O,P960003033,CDM,960,RC,58552,HCPCS,Outpatient,,,2384.02,1549.61,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,843.31,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,843.31,843.31,
RPR AA HERN RECR >10CM NCRC8,P960003049,CDM,960,RC,49618,HCPCS,Outpatient,,,2910.67,1891.94,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2910.67,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2910.67,2910.67,
INTERPROF PHONE/ONLINE 11-20,P960000731,CDM,960,RC,99447,HCPCS,Outpatient,,,89.95,58.47,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22.94,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,22.94,22.94,
REAGENT STRIP/BLOOD GLUCOSE,P960000467,CDM,960,RC,82948,HCPCS,Outpatient,,,15.00,9.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.26,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,3.26,3.26,
"95 OFFICE VISIT, NEW PT,LEVEL2",P960000894,CDM,960,RC,99202,HCPCS,Outpatient,,,145.00,94.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,52.9,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,52.9,52.9,
"95 OFFICE VISIT,ESTPT,LEVEL5",P960000902,CDM,960,RC,99215,HCPCS,Outpatient,,,282.00,183.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,102.18,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,102.18,102.18,
"OFFICE VISIT, NEW PT., LEVEL 3",P960000599,CDM,960,RC,99203,HCPCS,Outpatient,,,272.60,177.19,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,75.02,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,75.02,75.02,
AUTO NERV FUNC TST CARDIOVAGAL,P960000589,CDM,960,RC,95921,HCPCS,Outpatient,,,165.00,107.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,99.72,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,99.72,99.72,
"95OFFICE VISIT, NEW PT, LEVEL3",P960000895,CDM,960,RC,99203,HCPCS,Outpatient,,,272.60,177.19,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,75.02,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,75.02,75.02,
"SBSQ NB EM PER DAY, HOSP",P960000660,CDM,960,RC,99462,HCPCS,Outpatient,,,88.00,57.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29.79,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,29.79,29.79,
"95 OFFICE VISIT,ESTPT,LEVEL5",P960000902,CDM,960,RC,99215,HCPCS,Outpatient,,,282.00,183.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,102.18,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,102.18,102.18,
L HRT ART/GRFT ANGIO,P960000575,CDM,960,RC,93459,HCPCS,Outpatient,,,2133.00,1386.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,923.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,923.78,923.78,
PLASTAZOTE SANDAL EACH,P960000859,CDM,960,RC,,,Outpatient,,,21.00,13.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,21,21,
IIV4 VAC SPLT 0.5 ML IM STATE,P960000759,CDM,960,RC,90688,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BEHAV CHNG SMOKING 3-10 MIN,P960000656,CDM,960,RC,99406,HCPCS,Outpatient,,,28.00,18.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,10.68,10.68,
PROGESTERONE PER 50 MG,P960000696,CDM,960,RC,J2675,HCPCS,Outpatient,,,5.00,3.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.25,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1.25,1.25,
FLU VAC 3 YRS & > IM FLUZONE,P960000712,CDM,960,RC,Q2038,HCPCS,Outpatient,,,36.00,23.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,10.78,10.78,
WINDOWING OF CAST,P960000791,CDM,960,RC,29730,HCPCS,Outpatient,,,107.85,70.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,53.02,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,53.02,53.02,
EXT COUNTERPULSATION-TX SESS,P960000682,CDM,960,RC,G0166,HCPCS,Outpatient,,,261.00,169.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,73.67,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,73.67,73.67,
ROTAVIRUS VFC/SL,P960000503,CDM,960,RC,90680,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
COLO CANCR SCR; COLON HI RISK,P960000678,CDM,960,RC,G0105,HCPCS,Outpatient,,,611.00,397.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,242.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,242.45,242.45,
LEVALBUTEROL INHAL DOSE 0.5 MG,P960000708,CDM,960,RC,J7614,HCPCS,Outpatient,,,12.00,7.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.05,0.05,
"DTAP-HIB-IP VACCINE, IM",P960000511,CDM,960,RC,90698,HCPCS,Outpatient,,,280.00,182.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,105.11,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,105.11,105.11,
"MENINGOCOCCAL VACCINE, IM",P960000535,CDM,960,RC,90734,HCPCS,Outpatient,,,346.00,224.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,137.33,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,137.33,137.33,
"95 OFFICE VISIT,EST PT, LEVEL2",P960000900,CDM,960,RC,99212,HCPCS,Outpatient,,,84.00,54.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31.56,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,31.56,31.56,
CRITICAL CARE 1ST HR,P960000634,CDM,960,RC,99291,HCPCS,Outpatient,,,536.00,348.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,196.03,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,196.03,196.03,
DTAP-HEP B-IPV VAC IM STATE,P960000531,CDM,960,RC,90723,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"DT VACCINE < 7, IM VFC/SL",P960000516,CDM,960,RC,90702,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MD RECERTIFICATION HHA PT,P960000683,CDM,960,RC,G0179,HCPCS,Outpatient,,,80.00,52.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29.84,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,29.84,29.84,
"CHEMICAL CAUTERY, TISSUE",P960000107,CDM,960,RC,17250,HCPCS,Outpatient,,,151.00,98.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,76.04,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,76.04,76.04,
DUPLEX EXT VEINS BILAT,P960000773,CDM,960,RC,93970,HCPCS,Outpatient,,,375.00,243.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,223.2,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,223.2,223.2,
80 RPR AA HERNIA RECR<3 CM RED,P960003066,CDM,960,RC,49613,HCPCS,Outpatient,,,989.70,643.31,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,989.7,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,989.7,989.7,
"MMRV VACCINE, SC VFC/SL",P960000520,CDM,960,RC,90710,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
20 LAPAROSCOPY; CHOLECYSTECOMY,P960000876,CDM,960,RC,47562,HCPCS,Outpatient,,,1301.00,845.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,721.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,721.23,721.23,
CCM Staff Each addtl 20 min,P960003089,CDM,960,RC,99439,HCPCS,Outpatient,,,115.00,74.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25.93,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,25.93,25.93,
R&L HRT ART/VENTRICLE ANGIO,P960000576,CDM,960,RC,93460,HCPCS,Outpatient,,,2299.00,1494.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1022.41,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1022.41,1022.41,
DEXAMETH SODIUM PHOSPH 1 MG,P960000692,CDM,960,RC,J1100,HCPCS,Outpatient,,,5.00,3.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.14,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.14,0.14,
"95 OFFICE VISIT,EST PT,LEVEL4",P960000901,CDM,960,RC,99214,HCPCS,Outpatient,,,313.45,203.74,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,75.99,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,75.99,75.99,
LOWER EXTREMITY STUDY BILATERA,P960000581,CDM,960,RC,93925,HCPCS,Outpatient,,,492.00,319.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,290.34,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,290.34,290.34,
L HRT ARTERY/VENTRICLE ANGIO,P960000574,CDM,960,RC,93458,HCPCS,Outpatient,,,1924.00,1250.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,848.65,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,848.65,848.65,
THER SPI PNXR DRG CSF,P960000782,CDM,960,RC,62272,HCPCS,Outpatient,,,217.15,141.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,153.2,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,153.2,153.2,
PM DEVICE EVAL IN PERSON,P960000566,CDM,960,RC,93288,HCPCS,Outpatient,,,73.00,47.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,39.29,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,39.29,39.29,
INSJ SUBQ CAR RHYTHM MNTR,P960003092,CDM,960,RC,33285,HCPCS,Outpatient,,,209.71,136.31,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,209.71,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,209.71,209.71,
CIRCUMCISION CLAMP,P960000368,CDM,960,RC,54150,HCPCS,Outpatient,,,302.00,196.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,130.23,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,130.23,130.23,
PNEUMO VACC 13 VAL IM STATE,P960000499,CDM,960,RC,90670,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DRAIN/INJECT INTER JOINT/BURSA,P960000124,CDM,960,RC,20605,HCPCS,Outpatient,,,98.00,63.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,44.99,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,44.99,44.99,
ASPIRATE PLEURA W/ IMAGING,P960000242,CDM,960,RC,32555,HCPCS,Outpatient,,,559.00,363.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,277.44,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,277.44,277.44,
DRAIN OF SKIN ABSCESS SIMPLE,P960000004,CDM,960,RC,10060,HCPCS,Outpatient,,,464.00,301.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,108.96,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,108.96,108.96,
TDAP VACCINE >7 IM VFC/SL,P960000526,CDM,960,RC,90715,HCPCS,Outpatient,,,70.00,45.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,44.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,44.05,44.05,
SKIN FULL GRAFT,P960000097,CDM,960,RC,15260,HCPCS,Outpatient,,,1970.00,1280.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,903.97,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,903.97,903.97,
PROLONG CLINCL STAFF SVC ADD,P960000658,CDM,960,RC,99416,HCPCS,Outpatient,,,9.00,5.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.93,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2.93,2.93,
DENOSUMAB INJECTION 1 MG,P960000852,CDM,960,RC,,,Outpatient,,,98.65,64.12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,98.65,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,98.65,98.65,
20Gastrostomy rep w/o Im guidn,P960000994,CDM,960,RC,43762,HCPCS,Outpatient,,,91.20,59.28,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,91.2,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,91.2,91.2,
"MAKENA, 10 MG",P960000854,CDM,960,RC,,,Outpatient,,,64.54,41.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,64.54,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,64.54,64.54,
ED Level 4 High/Urgent,P960002049,CDM,960,RC,99284,HCPCS,Outpatient,,,295.83,192.29,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,84.24,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,84.24,84.24,
Hosp IP/OBS care same date Mod,P960003079,CDM,960,RC,99235,HCPCS,Outpatient,,,389.07,252.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,119.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,119.3,119.3,
Hosp IP/OBS care same date Mod,P960003079,CDM,960,RC,99235,HCPCS,Outpatient,,,389.07,252.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,119.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,119.3,119.3,
20 P-MASTECTOMY W/LN REMOVAL,P960000865,CDM,960,RC,19302,HCPCS,Outpatient,,,2227.50,1447.88,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,817.96,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,817.96,817.96,
Colonoscopy w lesion removal,P960002011,CDM,960,RC,45384,HCPCS,Outpatient,,,551.03,358.17,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,513.83,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,513.83,513.83,
TX/PRO/DX INJ SAME DRUG ADDON,P960000842,CDM,960,RC,96376,HCPCS,Outpatient,,,341.00,221.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.4,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,11.4,11.4,
OP/PERC TX TIB SHAFT FX BY IM,P960000777,CDM,960,RC,27759,HCPCS,Outpatient,,,2463.03,1600.97,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,864.38,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,864.38,864.38,
INJ TENDON SHEATH/LIGAMENT,P960000120,CDM,960,RC,20550,HCPCS,Outpatient,,,103.00,66.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,47.2,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,47.2,47.2,
Hosp IP/OBS care same date Mod,P960003079,CDM,960,RC,99235,HCPCS,Outpatient,,,389.07,252.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,119.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,119.3,119.3,
TX HIP DISLOC W/ANESTH,P960000172,CDM,960,RC,27252,HCPCS,Outpatient,,,1490.00,968.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,653.74,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,653.74,653.74,
PRCRD DRG 6YR+ W/O CGEN CAR,P960003082,CDM,960,RC,33017,HCPCS,Outpatient,,,583.18,379.07,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,206.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,206.68,206.68,
HT MUSCLE IMAGE SPECT MULT,P960000461,CDM,960,RC,78452,HCPCS,Outpatient,,,157.00,102.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,157,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,157,157,
CYSTO W STONE MANIP OR REM,P960000787,CDM,960,RC,52352,HCPCS,Outpatient,,,888.03,577.22,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,298.91,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,298.91,298.91,
VAGOTOMY PFRMD W/PRTL DSTL GST,P960003081,CDM,960,RC,43635,HCPCS,Outpatient,,,269.27,175.03,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,123.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,123.58,123.58,
VAGOTOMY PFRMD W/PRTL DSTL GST,P960003081,CDM,960,RC,43635,HCPCS,Outpatient,,,269.27,175.03,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,123.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,123.58,123.58,
20 DR OVARIAN ABSCESS; ABDOMIN,P960000890,CDM,960,RC,58822,HCPCS,Outpatient,,,1772.00,1151.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,608.41,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,608.41,608.41,
80 Repair Bladder Wound,P960001946,CDM,960,RC,51860,HCPCS,Outpatient,,,1807.68,1174.99,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,625.54,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,625.54,625.54,
VAGOTOMY PFRMD W/PRTL DSTL GST,P960003081,CDM,960,RC,43635,HCPCS,Outpatient,,,269.27,175.03,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,123.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,123.58,123.58,
FRAC/DIS PROC FOREARM/WRIST,P960000972,CDM,960,RC,25660,HCPCS,Outpatient,,,1021.98,664.29,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,357.89,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,357.89,357.89,
Endometrial Cryoablation W/US,P960001921,CDM,960,RC,58356,HCPCS,Outpatient,,,864.38,561.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,864.38,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,864.38,864.38,
MECH REMOV TUNNELED CV CATH,P960003085,CDM,960,RC,36595,HCPCS,Outpatient,,,434.15,282.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,434.15,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,434.15,434.15,
R&L HRT ART/VENTRICLE ANGIO,P960003086,CDM,960,RC,93461,HCPCS,Outpatient,,,975.58,634.13,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,975.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,975.58,975.58,
LAP ENTEROLYSIS,P960001910,CDM,960,RC,44180,HCPCS,Outpatient,,,2208.50,1435.53,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1007.93,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1007.93,1007.93,
VAGOTOMY PFRMD W/PRTL DSTL GST,P960003081,CDM,960,RC,43635,HCPCS,Outpatient,,,269.27,175.03,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,123.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,123.58,123.58,
Orthovisc,P960001005,CDM,960,RC,,,Outpatient,,,321.38,208.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,321.38,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,321.38,321.38,
MUGA multi w W/M & EF,P960001957,CDM,960,RC,78473,HCPCS,Outpatient,,,171.63,111.56,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,171.63,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,171.63,171.63,
20 ROUTINE OB CARE INCL AP C-S,P960000891,CDM,960,RC,59510,HCPCS,Outpatient,,,6263.33,4071.16,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1487.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1487.5,1487.5,
SHO ARTHRS SRG COMPL SYNVCT,P960003227,CDM,960,RC,29821,HCPCS,Outpatient,,,1452.60,944.19,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,512.62,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,512.62,512.62,
OFFICE CONSULTATION LEVEL 5,P960000629,CDM,960,RC,99245,HCPCS,Outpatient,,,878.00,570.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,141.61,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,141.61,141.61,
COLONOSCOPY W/CONTROL BLEED,P960003204,CDM,960,RC,45382,HCPCS,Outpatient,,,1582.65,1028.72,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,760.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,760.68,760.68,
OFFICE CONSULTATION LEVEL 4,P960000628,CDM,960,RC,99244,HCPCS,Outpatient,,,678.00,440.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,116.15,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,116.15,116.15,
OFFICE CONSULTATION LEVEL 2,P960000626,CDM,960,RC,99242,HCPCS,Outpatient,,,334.00,217.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,56.54,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,56.54,56.54,
INITIAL INPAT CONSULT LEVEL 4,P960000633,CDM,960,RC,99254,HCPCS,Outpatient,,,620.00,403.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,106.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,106.78,106.78,
OFFICE CONSULTATION LEVEL 3,P960000627,CDM,960,RC,99243,HCPCS,Outpatient,,,458.00,297.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,77.44,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,77.44,77.44,
INITIAL INPAT CONSULT LEVEL 2,P960000631,CDM,960,RC,99252,HCPCS,Outpatient,,,254.00,165.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,47.58,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,47.58,47.58,
INITIAL INPAT CONSULT LEVEL 3,P960000632,CDM,960,RC,99253,HCPCS,Outpatient,,,430.00,279.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,73.39,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,73.39,73.39,
LAP VENT/ABD HERNIA REPAIR,P960000320,CDM,960,RC,49652,HCPCS,Outpatient,,,1471.00,956.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,815.22,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,815.22,815.22,
BRIEF CHECK IN BY MD/QHP,P960000807,CDM,960,RC,,,Outpatient,,,32.35,21.03,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,32.35,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,32.35,32.35,
ANNUAL NURSING FAC ASSESSMNT,P960000639,CDM,960,RC,99318,HCPCS,Outpatient,,,189.00,122.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,67.74,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,67.74,67.74,
INJ METHYLPRDN ACTAT 40 MG,P960000689,CDM,960,RC,J1030,HCPCS,Outpatient,,,20.00,13.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.07,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,5.07,5.07,
Methotrexate Sodium Injections,P960003237,CDM,960,RC,,,Outpatient,,,25.36,16.48,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25.36,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,25.36,25.36,
RPR Epigastric Hern reduce,P960002095,CDM,960,RC,49570,HCPCS,Outpatient,,,1014.30,659.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,455.85,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,455.85,455.85,
PHONE E/M BY PHYS 21-30 MIN,P960000729,CDM,960,RC,99443,HCPCS,Outpatient,,,266.08,172.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,75.99,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,75.99,75.99,
METHYLPREDNISOLONE ACETAT 20MG,P960000748,CDM,960,RC,,,Outpatient,,,14.00,9.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,14,14,
METHYLPREDNISOLONE ACETAT 20MG,P960000748,CDM,960,RC,,,Outpatient,,,14.00,9.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,14,14,
INJ METHYLPRDN SODIM 40 MG,P960000699,CDM,960,RC,J2920,HCPCS,Outpatient,,,10.00,6.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,3.78,3.78,
INJ METHYLPRDN SODIM 40 MG,P960000699,CDM,960,RC,J2920,HCPCS,Outpatient,,,10.00,6.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,3.78,3.78,
SOL-MEDROL 125 MG,P960000700,CDM,960,RC,J2930,HCPCS,Outpatient,,,20.00,13.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.12,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,5.12,5.12,
"80 RPR VENTRAL HERN INIT,REDUC",P960000926,CDM,960,RC,49560,HCPCS,Outpatient,,,1460.00,949.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,808.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,808.45,808.45,
OFFICE CONSULTATION LEVEL 1,P960000625,CDM,960,RC,99241,HCPCS,Outpatient,,,228.00,148.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29.89,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,29.89,29.89,
SOL-MEDROL 125 MG,P960000700,CDM,960,RC,J2930,HCPCS,Outpatient,,,20.00,13.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.12,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,5.12,5.12,
QUAL NONMD EST PT 5-10M,P960000812,CDM,960,RC,,,Outpatient,,,30.03,19.52,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30.03,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,30.03,30.03,
20 RPR UMBIL HERN BLOCK>5YR,P960000943,CDM,960,RC,49587,HCPCS,Outpatient,,,937.00,609.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,521.18,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,521.18,521.18,
"RPR VENTRAL HERN INIT, REDUC",P960000311,CDM,960,RC,49560,HCPCS,Outpatient,,,1460.00,949.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,808.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,808.45,808.45,
"RPR VENTRAL HERN INIT, BLOCK",P960000312,CDM,960,RC,49561,HCPCS,Outpatient,,,1842.00,1197.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1018.27,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1018.27,1018.27,
INJ METHYLPRDN ACTAT 80 MG,P960000690,CDM,960,RC,J1040,HCPCS,Outpatient,,,44.00,28.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9.49,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,9.49,9.49,
ADDL 30M OPD W/CONTACT,P960000718,CDM,960,RC,99355,HCPCS,Outpatient,,,192.00,124.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,69.53,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,69.53,69.53,
PHONE E/M BY PHYS 5-10 MIN,P960000835,CDM,960,RC,99441,HCPCS,Outpatient,,,64.00,41.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31.56,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,31.56,31.56,
"RPR UMBIL HERN, REDUC > 5 YR",P960000318,CDM,960,RC,49585,HCPCS,Outpatient,,,877.00,570.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,487.48,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,487.48,487.48,
20 REP RECURRENT INCISI HERNIA,P960000883,CDM,960,RC,49566,HCPCS,Outpatient,,,1858.00,1207.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1027.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1027.82,1027.82,
PHONE E/M BY PHYS 5-10 MIN,P960000835,CDM,960,RC,99441,HCPCS,Outpatient,,,64.00,41.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31.56,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,31.56,31.56,
"RPR EPIGASTRIC HERN, BLOCKED",P960000316,CDM,960,RC,49572,HCPCS,Outpatient,,,1018.00,661.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,566.01,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,566.01,566.01,
ADDL 30M OPD W/CONTACT,P960000718,CDM,960,RC,99355,HCPCS,Outpatient,,,192.00,124.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,69.53,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,69.53,69.53,
LIDO HCI 1% 10 ML MULTI VIAL,P960000695,CDM,960,RC,J2001,HCPCS,Outpatient,,,20.00,13.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.03,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.03,0.03,
"REREPAIR VENTRL HERN, BLOCK",P960000314,CDM,960,RC,49566,HCPCS,Outpatient,,,1858.00,1207.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1027.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1027.82,1027.82,
"80 RPR VENTRAL HERN INIT,BLOCK",P960000927,CDM,960,RC,49561,HCPCS,Outpatient,,,1842.00,1197.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1018.27,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1018.27,1018.27,
SUBS OBS CARE PROB FOCUSED,P960000614,CDM,960,RC,99224,HCPCS,Outpatient,,,79.00,51.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27.97,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,27.97,27.97,
INJ METHYLPRDN ACTAT 40 MG,P960000689,CDM,960,RC,J1030,HCPCS,Outpatient,,,20.00,13.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.07,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,5.07,5.07,
INJ METHYLPRDN ACTAT 80 MG,P960000690,CDM,960,RC,J1040,HCPCS,Outpatient,,,44.00,28.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9.49,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,9.49,9.49,
SUBS OBS CARE DETAILED,P960000616,CDM,960,RC,99226,HCPCS,Outpatient,,,207.00,134.55,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,73.86,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,73.86,73.86,
PHONE E/M BY PHYS 11-20 MIN,P960000728,CDM,960,RC,99442,HCPCS,Outpatient,,,126.68,82.34,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,52.28,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,52.28,52.28,
"RPR UMBIL HERN, BLOCK > 5 YR",P960000319,CDM,960,RC,49587,HCPCS,Outpatient,,,937.00,609.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,521.18,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,521.18,521.18,
PHONE E/M BY PHYS 21-30 MIN,P960000729,CDM,960,RC,99443,HCPCS,Outpatient,,,266.08,172.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,75.99,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,75.99,75.99,
EXC ABD TUM 5 CM OR LESS,P960002064,CDM,960,RC,49203,HCPCS,Outpatient,,,2871.75,1866.64,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1309.51,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1309.51,1309.51,
"RPR UMBIL HERN, BLOCK < 5 YR",P960000317,CDM,960,RC,49582,HCPCS,Outpatient,,,916.00,595.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,528.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,528.05,528.05,
"REREPAIR VENTRL HERN, REDUCE",P960000313,CDM,960,RC,49565,HCPCS,Outpatient,,,1520.00,988.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,841.71,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,841.71,841.71,
"OFFICE VISIT, NEW PT., LEVEL 1",P960000597,CDM,960,RC,99201,HCPCS,Outpatient,,,85.00,55.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,85,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,85,85,
80 Hernia Repair w Mesh,P960000964,CDM,960,RC,49568,HCPCS,Outpatient,,,533.00,346.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,293.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,293.1,293.1,
20REP INIT INCI/ VENTRAL HERNI,P960000880,CDM,960,RC,49560,HCPCS,Outpatient,,,1460.00,949.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,808.45,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,808.45,808.45,
INITIAL INPT CONSULT LEVEL 1,P960000630,CDM,960,RC,99251,HCPCS,Outpatient,,,184.00,119.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31.41,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,31.41,31.41,
"80 RPR EPIGASTRIC HERN,BLOCKED",P960000930,CDM,960,RC,49572,HCPCS,Outpatient,,,1018.00,661.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,566.01,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,566.01,566.01,
20REPAIR RECURRENT INC HERNIA;,P960000882,CDM,960,RC,49565,HCPCS,Outpatient,,,1520.00,988.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,841.71,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,841.71,841.71,
20 REPAIR EPIGASTRIC HERNIA; I,P960000884,CDM,960,RC,49572,HCPCS,Outpatient,,,1018.00,661.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,566.01,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,566.01,566.01,
HERNIA REPAIR W/MESH,P960000315,CDM,960,RC,49568,HCPCS,Outpatient,,,533.00,346.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,293.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,293.1,293.1,
LIDO HCI 1% 10 ML MULTI VIAL,P960000695,CDM,960,RC,J2001,HCPCS,Outpatient,,,20.00,13.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.03,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,0.03,0.03,
"80 REREPAIR VENTRL,HERN,BLOCK",P960000929,CDM,960,RC,49566,HCPCS,Outpatient,,,1858.00,1207.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1027.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1027.82,1027.82,
QUAL NONMD EST PT 11-20M,P960000813,CDM,960,RC,,,Outpatient,,,52.90,34.39,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,52.9,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,52.9,52.9,
INIT OBS-LOW COMPLEX,P960000608,CDM,960,RC,99218,HCPCS,Outpatient,,,197.00,128.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,70.38,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,70.38,70.38,
PHONE E/M BY PHYS 11-20 MIN,P960000728,CDM,960,RC,99442,HCPCS,Outpatient,,,126.68,82.34,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,52.28,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,52.28,52.28,
"80 REREPAIR VENTRL HERN,REDUCE",P960000928,CDM,960,RC,49565,HCPCS,Outpatient,,,1520.00,988.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,841.71,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,841.71,841.71,
80 RPR UMBIL HERN BLOCK>5YR,P960000944,CDM,960,RC,49587,HCPCS,Outpatient,,,937.00,609.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,521.18,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,521.18,521.18,
"95OFFICE VISIT, NEW PT, LEVEL1",P960000893,CDM,960,RC,99201,HCPCS,Outpatient,,,85.00,55.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,85,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,85,85,
QUAL NONMD EST PT 21>MIN,P960000814,CDM,960,RC,,,Outpatient,,,82.08,53.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,82.08,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,82.08,82.08,
OPD PRO C W/CON 1ST HR,P960000640,CDM,960,RC,99354,HCPCS,Outpatient,,,255.00,165.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,91.5,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,91.5,91.5,
INIT OBS-HI CPLX,P960000610,CDM,960,RC,99220,HCPCS,Outpatient,,,366.00,237.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,130.52,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,130.52,130.52,
20 REPAIR INITIAL INCISIONAL H,P960000881,CDM,960,RC,49561,HCPCS,Outpatient,,,1842.00,1197.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1018.27,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1018.27,1018.27,
OBS-DISC DAY,P960000607,CDM,960,RC,99217,HCPCS,Outpatient,,,143.00,92.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,51.18,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,51.18,51.18,
INIT OBS-MOD COMPLEX,P960000609,CDM,960,RC,99219,HCPCS,Outpatient,,,268.00,174.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,95.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,95.82,95.82,
20 Hernia Repair w Mesh,P960000963,CDM,960,RC,49568,HCPCS,Outpatient,,,533.00,346.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,293.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,293.1,293.1,
SUBS OBS CARE EXP PROB FOCUSED,P960000615,CDM,960,RC,99225,HCPCS,Outpatient,,,144.00,93.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,51.32,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,51.32,51.32,
Fecal Occult Blood Test,P960003214,CDM,960,RC,82272,HCPCS,Outpatient,,,10.58,6.88,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2.73,2.73,
PRQ CARD REVASC CHRONIC ADDL,P960003224,CDM,960,RC,92944,HCPCS,Outpatient,,,1558.70,1013.16,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,513.54,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,513.54,513.54,
TREATMENT OF ANKLE FRACTURE,P960003216,CDM,960,RC,27788,HCPCS,Outpatient,,,960.18,624.12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,366.05,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,366.05,366.05,
PRQ CORONARY MECH THROMBECT,P960003166,CDM,960,RC,92973,HCPCS,Outpatient,,,412.50,268.13,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,142.46,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,142.46,142.46,
COLONOSCOPY W/FB  REMOVAL,P960003205,CDM,960,RC,45379,HCPCS,Outpatient,,,1042.25,677.46,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,462.67,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,462.67,462.67,
CYSTO W/RENAL STRICTURE TX,P960003191,CDM,960,RC,52343,HCPCS,Outpatient,,,825.90,536.84,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,290.2,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,290.2,290.2,
Prolong OP E/M Each 15 min,P960002091,CDM,960,RC,99417,HCPCS,Outpatient,,,77.60,50.44,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23.3,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,23.3,23.3,
Prolong OP/Off visit Medicare,P960002090,CDM,960,RC,,,Outpatient,,,77.60,50.44,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,77.6,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,77.6,77.6,
CYSTOSCOPY AND TREATMENT,P960003193,CDM,960,RC,52320,HCPCS,Outpatient,,,591.10,384.22,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,207.82,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,207.82,207.82,
LAP PARAESOPHAG HERN REPAIR,P960003217,CDM,960,RC,43281,HCPCS,Outpatient,,,3728.40,2423.46,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1691.44,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1691.44,1691.44,
STRAPPING; ANKLE AND/OR FOOT,P960003207,CDM,960,RC,29540,HCPCS,Outpatient,,,67.83,44.09,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24.65,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,24.65,24.65,
NJX CAR CTH SPRVLV AORTGRPHY,P960003169,CDM,960,RC,93567,HCPCS,Outpatient,,,88.10,57.27,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,88.1,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,88.1,88.1,
LAP ILEO/JEJUNO-STOMY,P960003188,CDM,960,RC,44187,HCPCS,Outpatient,,,2638.70,1715.16,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1204.78,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1204.78,1204.78,
"ECG/REVIEW, INTERPRET ONLY",P960000561,CDM,960,RC,93272,HCPCS,Outpatient,,,50.00,32.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20.74,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,20.74,20.74,
Mobilization of colon,P960003175,CDM,960,RC,44139,HCPCS,Outpatient,,,285.00,185.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,132.73,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,132.73,132.73,
PERQ TRLUML CORONRY LITHOTRP,P960003174,CDM,960,RC,92972,HCPCS,Outpatient,,,343.25,223.11,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,343.25,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,343.25,343.25,
CYSTOSCOPY STONE REMOVAL,P960003194,CDM,960,RC,52325,HCPCS,Outpatient,,,768.27,499.38,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,269.76,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,269.76,269.76,
PSYTX PT&/FAM W/E&M 60 MIN,P960000548,CDM,960,RC,90838,HCPCS,Outpatient,,,219.00,142.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,109.94,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,109.94,109.94,
Endoluminal Coron ivus oct 1st,P960002012,CDM,960,RC,92978,HCPCS,Outpatient,,,226.83,147.44,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,216.86,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,216.86,216.86,
PSYTX PT&/FAM W/E&M 45 MIN,P960000546,CDM,960,RC,90836,HCPCS,Outpatient,,,166.00,107.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,95.61,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,95.61,95.61,
HEART FLOW RESERVE MEASURE,P960000577,CDM,960,RC,93571,HCPCS,Outpatient,,,354.00,230.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,167.68,85,,,Fee Schedule,85% of Aetna fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,167.68,167.68,
IRRIGATION TRAY,P960000844,CDM,960,RC,,,Outpatient,,,7.87,5.12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7.87,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,7.87,7.87,
IRRIGATION TRAY,P960000844,CDM,960,RC,,,Outpatient,,,7.87,5.12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7.87,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,7.87,7.87,
INPT/TELE FOLLOW UP 15,P960000804,CDM,960,RC,,,Outpatient,,,97.00,63.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,97,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,97,97,
SINGLE LENS SPECTACLE MOUNT,P960000863,CDM,960,RC,,,Outpatient,,,275.00,178.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,275,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,275,275,
"Lt Compres band >=3""<5/yd",P960000999,CDM,960,RC,,,Outpatient,,,68.35,44.43,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,68.35,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,68.35,68.35,
Zilretta Inj 1mg,P960001970,CDM,960,RC,,,Outpatient,,,44.73,29.07,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,44.73,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,44.73,44.73,
TETRACAINE 0.5% OPHTH SOLN,P960003187,CDM,960,RC,,,Outpatient,,,59.49,38.67,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,59.49,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,59.49,59.49,
Durolane Inj 1 mg,P960003034,CDM,960,RC,,,Outpatient,,,23.15,15.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23.15,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,23.15,23.15,
"INJ,ONDANSETRON HCL PER 1MG",P960000753,CDM,960,RC,,,Outpatient,,,1.12,0.73,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.12,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1.12,1.12,
"ONDANSETRON, ORAL, 4MG",P960003185,CDM,960,RC,,,Outpatient,,,6.50,4.23,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.5,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,6.5,6.5,
CPRIT CA Screen; Pelvic/breast,P960003053,CDM,960,RC,,,Outpatient,,,98.18,63.82,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,98.18,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,98.18,98.18,
MENB-4C VACC 2 DOSE IM,P960000750,CDM,960,RC,,,Outpatient,,,760.67,494.44,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,760.67,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,760.67,760.67,
RHO D IMMUNE GLOBULIN INJ,P960000751,CDM,960,RC,,,Outpatient,,,234.00,152.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,234,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,234,234,
"PROMETHAZINE HCL INJ,UPTO 50MG",P960000752,CDM,960,RC,,,Outpatient,,,6.00,3.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,6,6,
Dis site telehealth RHC,P960000995,CDM,960,RC,,,Outpatient,,,164.83,107.14,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,164.83,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,164.83,164.83,
"INJ,ONDANSETRON HCL PER 1MG",P960000753,CDM,960,RC,,,Outpatient,,,1.12,0.73,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.12,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1.12,1.12,
ANKLE CONTROL ORTHO PRE OTS,P960000860,CDM,960,RC,,,Outpatient,,,115.00,74.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,115,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,115,115,
INPT/TELE FOLLOW UP 25,P960000805,CDM,960,RC,,,Outpatient,,,178.25,115.86,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,178.25,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,178.25,178.25,
INJ GARAMYCIN GENTAMICIN TO 80,P960000853,CDM,960,RC,,,Outpatient,,,50.00,32.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,50,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,50,50,
INPT/ED TELECONSULT50,P960000785,CDM,960,RC,,,Outpatient,,,336.03,218.42,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,336.03,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,336.03,336.03,
INPT/ED TELECONSULT70,P960000786,CDM,960,RC,,,Outpatient,,,497.98,323.69,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,497.98,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,497.98,497.98,
COMM SVCS BY RHC/FQHC 5 MIN,P960000821,CDM,960,RC,,,Outpatient,,,61.90,40.24,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,61.9,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,61.9,61.9,
REM SUTURES BY MD,P960000802,CDM,960,RC,,,Outpatient,,,156.25,101.56,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,156.25,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,156.25,156.25,
SINGLE LENS SPECTACLE MOUNT,P960000863,CDM,960,RC,,,Outpatient,,,275.00,178.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,275,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,275,275,
SURGICAL SUPPLIES,P960000848,CDM,960,RC,,,Outpatient,,,225.00,146.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,225,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,225,225,
BRAND NAME RX DRUG,P960000817,CDM,960,RC,,,Outpatient,,,50.23,32.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,50.23,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,50.23,50.23,
SURGICAL SUPPLIES,P960000848,CDM,960,RC,,,Outpatient,,,225.00,146.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,225,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,225,225,
COUDE URINARY CATH,P960000846,CDM,960,RC,,,Outpatient,,,23.17,15.06,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23.17,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,23.17,23.17,
INPT/TELE FOLLOW UP 35,P960000806,CDM,960,RC,,,Outpatient,,,256.50,166.73,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,256.5,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,256.5,256.5,
RUBBER PESSARY ANY TYPE,P960000847,CDM,960,RC,,,Outpatient,,,211.00,137.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,211,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,211,211,
REMOT IMAGE SUBMIT BY PT,P960000808,CDM,960,RC,,,Outpatient,,,22.85,14.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22.85,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,22.85,22.85,
ANKLE CONTROL ORTHO PRE OTS,P960000860,CDM,960,RC,,,Outpatient,,,115.00,74.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,115,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,115,115,
INPT/TELE FOLLOW UP 15,P960000804,CDM,960,RC,,,Outpatient,,,97.00,63.05,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,97,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,97,97,
REMOT IMAGE SUBMIT BY PT,P960000808,CDM,960,RC,,,Outpatient,,,22.85,14.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22.85,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,22.85,22.85,
PLASTAZOTE SANDAL EACH,P960000859,CDM,960,RC,,,Outpatient,,,21.00,13.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,21,21,
BETAMETHASONE ACET&SOD PHOSP 3,P960000851,CDM,960,RC,,,Outpatient,,,59.33,38.56,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,59.33,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,59.33,59.33,
ORAL AZITHROMYCIN DIHYDRATE 1,P960000861,CDM,960,RC,,,Outpatient,,,21.20,13.78,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21.2,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,21.2,21.2,
RUBBER PESSARY ANY TYPE,P960000847,CDM,960,RC,,,Outpatient,,,211.00,137.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,211,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,211,211,
INPT/ED TELECONSULT70,P960000786,CDM,960,RC,,,Outpatient,,,497.98,323.69,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,497.98,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,497.98,497.98,
ORAL AZITHROMYCIN DIHYDRATE 1,P960000861,CDM,960,RC,,,Outpatient,,,21.20,13.78,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21.2,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,21.2,21.2,
CCM RHC Clinical Staff 20min,P960003090,CDM,960,RC,,,Outpatient,,,194.85,126.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,194.85,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,194.85,194.85,
REM SUTURES BY MD,P960000802,CDM,960,RC,,,Outpatient,,,156.25,101.56,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,156.25,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,156.25,156.25,
INPT/TELE FOLLOW UP 35,P960000806,CDM,960,RC,,,Outpatient,,,256.50,166.73,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,256.5,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,256.5,256.5,
CCM RHC Clinical Staff 20min,P960003090,CDM,960,RC,,,Outpatient,,,194.85,126.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,194.85,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,194.85,194.85,
CCM RHC Clinical Staff 20min,P960003090,CDM,960,RC,,,Outpatient,,,194.85,126.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,194.85,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,194.85,194.85,
CCM RHC Clinical Staff 20min,P960003090,CDM,960,RC,,,Outpatient,,,194.85,126.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,194.85,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,194.85,194.85,
GEL ONE,P960000706,CDM,960,RC,,,Outpatient,,,3047.50,1980.88,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3047.5,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,3047.5,3047.5,
ADRENALIN EPINEPHRINE INJ 0.1,P960000850,CDM,960,RC,,,Outpatient,,,11.25,7.31,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.25,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,11.25,11.25,
CCM RHC Clinical Staff 20min,P960003090,CDM,960,RC,,,Outpatient,,,194.85,126.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,194.85,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,194.85,194.85,
BUDESONIDE NON-COMP CON PER 0.,P960000857,CDM,960,RC,,,Outpatient,,,30.39,19.75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30.39,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,30.39,30.39,
Orphenadrine Inj 30mg,P960003170,CDM,960,RC,,,Outpatient,,,24.25,15.76,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24.25,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,24.25,24.25,
Triamcinolone Acetonide 1mg,P960001999,CDM,960,RC,,,Outpatient,,,13.23,8.60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13.23,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,13.23,13.23,
MENB-4C VACC 2 DOSE IM,P960000750,CDM,960,RC,,,Outpatient,,,760.67,494.44,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,760.67,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,760.67,760.67,
RHO D IMMUNE GLOBULIN INJ,P960000751,CDM,960,RC,,,Outpatient,,,234.00,152.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,234,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,234,234,
BUDESONIDE COMP CON PER 0.25 M,P960000858,CDM,960,RC,,,Outpatient,,,51.12,33.23,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,51.12,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,51.12,51.12,
ADMIN HEP B VAC FEE SCHED DAY,P960000749,CDM,771,RC,,,Outpatient,,,91.48,59.46,,91.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,69.52,76,,55.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.87,72,,52.696,Percent of Total Billed Charges,72% of Total Billed Charges,68.61,75,,54.888,Percent of Total Billed charges,75% of Total Billed Charges,91.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.87,72,,52.696,Percent of Total Billed Charges,72% of Total Billed Charges,54.89,60,,43.912,Percent of Total Billed Charges,60% of Total Billed Charges,82.33,90,,65.864,Percent of Total Billed Charges,90% of Total Billed Charges,41.17,45,,32.936,Percent of Total Billed Charges,45% of Total Billed Charges,82.33,90,,65.864,Percent of Total Billed Charges,90% of Total billed Charges,91.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.46,65,,47.568,Percent of total Billed Charges,65% of Total Billed Charges,40.34,44.1,,32.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,86.91,95,,69.528,Percent of Total Billed Charges,95% of Total Billed Charges,91.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,82.33,90,,65.864,Percent of Total Billed charges,90% of Total Billed Charges,40.34,91.48,
CATH INDW FOLEY 2 WAY SILICONE,P960000845,CDM,960,RC,,,Outpatient,,,70.00,45.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,70,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,70,70,
INPT/TELE FOLLOW UP 25,P960000805,CDM,960,RC,,,Outpatient,,,178.25,115.86,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,178.25,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,178.25,178.25,
INPT/ED TELECONSULT 30,P960000784,CDM,960,RC,,,Outpatient,,,247.13,160.63,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,247.13,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,247.13,247.13,
INPT/ED TELECONSULT50,P960000785,CDM,960,RC,,,Outpatient,,,336.03,218.42,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,336.03,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,336.03,336.03,
BRAND NAME RX DRUG,P960000817,CDM,960,RC,,,Outpatient,,,50.23,32.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,50.23,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,50.23,50.23,
COUDE URINARY CATH,P960000846,CDM,960,RC,,,Outpatient,,,23.17,15.06,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23.17,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,23.17,23.17,
CATH INDW FOLEY 2 WAY SILICONE,P960000845,CDM,960,RC,,,Outpatient,,,70.00,45.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,70,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,70,70,
TRIAMCINOLONE ACET INJ NOS 10,P960000855,CDM,960,RC,,,Outpatient,,,50.00,32.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,50,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,50,50,
HEARING SCREENING,P960000864,CDM,960,RC,,,Outpatient,,,56.00,36.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,56,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,56,56,
"INJ, BUPIVACAINE, NOS, 0.5MG",P960003200,CDM,960,RC,,,Outpatient,,,12.00,7.80,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,12,12,
"PROMETHAZINE HCL INJ,UPTO 50MG",P960000752,CDM,960,RC,,,Outpatient,,,6.00,3.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,6,6,
ADMIN HEP B VAC FEE SCHED DAY,P960000749,CDM,771,RC,,,Outpatient,,,91.48,59.46,,91.48,125,,,Fee Schedule,Pays based on 125% of OPPS Rate,69.52,76,,55.616,Percent of Total Billed Charges,76% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,65.87,72,,52.696,Percent of Total Billed Charges,72% of Total Billed Charges,68.61,75,,54.888,Percent of Total Billed charges,75% of Total Billed Charges,91.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.87,72,,52.696,Percent of Total Billed Charges,72% of Total Billed Charges,54.89,60,,43.912,Percent of Total Billed Charges,60% of Total Billed Charges,82.33,90,,65.864,Percent of Total Billed Charges,90% of Total Billed Charges,41.17,45,,32.936,Percent of Total Billed Charges,45% of Total Billed Charges,82.33,90,,65.864,Percent of Total Billed Charges,90% of Total billed Charges,91.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.46,65,,47.568,Percent of total Billed Charges,65% of Total Billed Charges,40.34,44.1,,32.272,Percent of Total Billed Charges,44.1% of Total Billed Charges,86.91,95,,69.528,Percent of Total Billed Charges,95% of Total Billed Charges,91.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not separately Reimbursable,82.33,90,,65.864,Percent of Total Billed charges,90% of Total Billed Charges,40.34,91.48,
Dicyclomine 20 mg Inj,P960003197,CDM,960,RC,,,Outpatient,,,50.82,33.03,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,50.82,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,50.82,50.82,
Routine foot care- PT LOS,P960000986,CDM,960,RC,,,Outpatient,,,53.80,34.97,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,53.8,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,53.8,53.8,
INTRAUTERINE COPPER CONTRA,P960000704,CDM,960,RC,,,Outpatient,,,1220.00,793.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1220,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,1220,1220,
GENERIC RX DRUG,P960000818,CDM,960,RC,,,Outpatient,,,25.41,16.52,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25.41,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,25.41,25.41,
Methylprednisolone 40 mg,P960003179,CDM,960,RC,,,Outpatient,,,2.50,1.63,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.5,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,2.5,2.5,
INITIAL PREVENTIVE EXAM,P960003037,CDM,960,RC,,,Outpatient,,,312.55,203.16,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,312.55,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,312.55,312.55,
Alcohol/Sub Interv 15-30 min,P960003001,CDM,960,RC,,,Outpatient,,,86.85,56.45,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,86.85,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,86.85,86.85,
COMM SVCS BY RHC/FQHC 5 MIN,P960000821,CDM,960,RC,,,Outpatient,,,61.90,40.24,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,61.9,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,61.9,61.9,
HEARING SCREENING,P960000864,CDM,960,RC,,,Outpatient,,,56.00,36.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,56,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,56,56,
VITAMIN K INJ PER 1 MG,P960000856,CDM,960,RC,,,Outpatient,,,39.45,25.64,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,39.45,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,39.45,39.45,
PLASTAZOTE SANDAL EACH,P960000859,CDM,960,RC,,,Outpatient,,,21.00,13.65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,21,21,
DENOSUMAB INJECTION 1 MG,P960000852,CDM,960,RC,,,Outpatient,,,98.65,64.12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,98.65,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,98.65,98.65,
"MAKENA, 10 MG",P960000854,CDM,960,RC,,,Outpatient,,,64.54,41.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,64.54,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,64.54,64.54,
Orthovisc,P960001005,CDM,960,RC,,,Outpatient,,,321.38,208.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,321.38,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,321.38,321.38,
BRIEF CHECK IN BY MD/QHP,P960000807,CDM,960,RC,,,Outpatient,,,32.35,21.03,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,32.35,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,32.35,32.35,
Methotrexate Sodium Injections,P960003237,CDM,960,RC,,,Outpatient,,,25.36,16.48,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25.36,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,25.36,25.36,
METHYLPREDNISOLONE ACETAT 20MG,P960000748,CDM,960,RC,,,Outpatient,,,14.00,9.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,14,14,
METHYLPREDNISOLONE ACETAT 20MG,P960000748,CDM,960,RC,,,Outpatient,,,14.00,9.10,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,14,14,
QUAL NONMD EST PT 5-10M,P960000812,CDM,960,RC,,,Outpatient,,,30.03,19.52,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30.03,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,30.03,30.03,
QUAL NONMD EST PT 11-20M,P960000813,CDM,960,RC,,,Outpatient,,,52.90,34.39,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,52.9,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,52.9,52.9,
QUAL NONMD EST PT 21>MIN,P960000814,CDM,960,RC,,,Outpatient,,,82.08,53.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,82.08,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,82.08,82.08,
Prolong OP/Off visit Medicare,P960002090,CDM,960,RC,,,Outpatient,,,77.60,50.44,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,77.6,100,,,Fee Schedule,Pays based on 100% of Aetna Market fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not separately Reimbursable,,,,,Other,Not Separately reimbursable,77.6,77.6,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,1,CDM,100,RC,,,Inpatient,,,,,,468242.14,125,MS-DRG,374593.712,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374593.71,100,MS-DRG,299674.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,195169.7,100,,,Case Rate,100% of CMS IPPS Rate,374593.71,100,MS-DRG,299674.968,Case Rate,100% of CMS IPPS Rate,172863.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,172863.8,468242.1,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,2,CDM,100,RC,,,Inpatient,,,,,,187866.81,125,MS-DRG,150293.448,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150293.45,100,MS-DRG,120234.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,65160.96,100,,,Case Rate,100% of CMS IPPS Rate,150293.45,100,MS-DRG,120234.76,Case Rate,100% of CMS IPPS Rate,57713.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,57713.72,187866.8,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",3,CDM,100,RC,,,Inpatient,,,,,,358098.79,125,MS-DRG,286479.032,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286479.03,100,MS-DRG,229183.224,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,148493.13,100,,,Case Rate,100% of CMS IPPS Rate,286479.03,100,MS-DRG,229183.224,Case Rate,100% of CMS IPPS Rate,131521.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,131521.9,358098.8,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",4,CDM,100,RC,,,Inpatient,,,,,,238719.45,125,MS-DRG,190975.56,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190975.56,100,MS-DRG,152780.448,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,97902.53,100,,,Case Rate,100% of CMS IPPS Rate,190975.56,100,MS-DRG,152780.448,Case Rate,100% of CMS IPPS Rate,86713.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,86713.27,238719.5,
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,5,CDM,100,RC,,,Inpatient,,,,,,181812.5,125,MS-DRG,145450,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145450,100,MS-DRG,116360,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,73786.5,100,,,Case Rate,100% of CMS IPPS Rate,145450,100,MS-DRG,116360,Case Rate,100% of CMS IPPS Rate,65353.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,65353.45,181812.5,
LIVER TRANSPLANT WITHOUT MCC,6,CDM,100,RC,,,Inpatient,,,,,,86980.68,125,MS-DRG,69584.544,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69584.54,100,MS-DRG,55667.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,33598.65,100,,,Case Rate,100% of CMS IPPS Rate,69584.54,100,MS-DRG,55667.632,Case Rate,100% of CMS IPPS Rate,29758.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29758.67,86980.68,
LUNG TRANSPLANT,7,CDM,100,RC,,,Inpatient,,,,,,221369.09,125,MS-DRG,177095.272,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177095.27,100,MS-DRG,141676.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90549.79,100,,,Case Rate,100% of CMS IPPS Rate,177095.27,100,MS-DRG,141676.216,Case Rate,100% of CMS IPPS Rate,80200.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,80200.87,221369.1,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,8,CDM,100,RC,,,Inpatient,,,,,,96658.09,125,MS-DRG,77326.472,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77326.47,100,MS-DRG,61861.176,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37699.75,100,,,Case Rate,100% of CMS IPPS Rate,77326.47,100,MS-DRG,61861.176,Case Rate,100% of CMS IPPS Rate,33391.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,33391.05,96658.09,
PANCREAS TRANSPLANT,10,CDM,100,RC,,,Inpatient,,,,,,138054.03,125,MS-DRG,110443.224,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110443.22,100,MS-DRG,88354.576,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,55242.53,100,,,Case Rate,100% of CMS IPPS Rate,110443.22,100,MS-DRG,88354.576,Case Rate,100% of CMS IPPS Rate,48928.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,48928.87,138054,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",11,CDM,100,RC,,,Inpatient,,,,,,95919.08,125,MS-DRG,76735.264,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76735.26,100,MS-DRG,61388.208,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37386.57,100,,,Case Rate,100% of CMS IPPS Rate,76735.26,100,MS-DRG,61388.208,Case Rate,100% of CMS IPPS Rate,33113.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,33113.67,95919.08,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",12,CDM,100,RC,,,Inpatient,,,,,,74791.94,125,MS-DRG,59833.552,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59833.55,100,MS-DRG,47866.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28433.31,100,,,Case Rate,100% of CMS IPPS Rate,59833.55,100,MS-DRG,47866.84,Case Rate,100% of CMS IPPS Rate,25183.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25183.67,74791.94,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",13,CDM,100,RC,,,Inpatient,,,,,,51024.3,125,MS-DRG,40819.44,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40819.44,100,MS-DRG,32655.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18361.06,100,,,Case Rate,100% of CMS IPPS Rate,40819.44,100,MS-DRG,32655.552,Case Rate,100% of CMS IPPS Rate,16262.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16262.57,51024.3,
ALLOGENEIC BONE MARROW TRANSPLANT,14,CDM,100,RC,,,Inpatient,,,,,,221908.63,125,MS-DRG,177526.904,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177526.9,100,MS-DRG,142021.52,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90778.44,100,,,Case Rate,100% of CMS IPPS Rate,177526.9,100,MS-DRG,142021.52,Case Rate,100% of CMS IPPS Rate,80403.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,80403.39,221908.6,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,16,CDM,100,RC,,,Inpatient,,,,,,106382.93,125,MS-DRG,85106.344,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85106.34,100,MS-DRG,68085.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,41820.94,100,,,Case Rate,100% of CMS IPPS Rate,85106.34,100,MS-DRG,68085.072,Case Rate,100% of CMS IPPS Rate,37041.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37041.23,106382.9,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,17,CDM,100,RC,,,Inpatient,,,,,,106382.93,125,MS-DRG,85106.344,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85106.34,100,MS-DRG,68085.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,41820.94,100,,,Case Rate,100% of CMS IPPS Rate,85106.34,100,MS-DRG,68085.072,Case Rate,100% of CMS IPPS Rate,37041.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37041.23,106382.9,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,18,CDM,100,RC,,,Inpatient,,,,,,624292.35,125,MS-DRG,499433.88,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499433.88,100,MS-DRG,399547.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,261300.68,100,,,Case Rate,100% of CMS IPPS Rate,499433.88,100,MS-DRG,399547.104,Case Rate,100% of CMS IPPS Rate,231436.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,231436.7,624292.4,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,19,CDM,100,RC,,,Inpatient,,,,,,137306.84,125,MS-DRG,109845.472,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109845.47,100,MS-DRG,87876.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,54925.88,100,,,Case Rate,100% of CMS IPPS Rate,109845.47,100,MS-DRG,87876.376,Case Rate,100% of CMS IPPS Rate,48648.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,48648.41,137306.8,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,20,CDM,100,RC,,,Inpatient,,,,,,139494.45,125,MS-DRG,111595.56,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111595.56,100,MS-DRG,89276.448,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,55852.94,100,,,Case Rate,100% of CMS IPPS Rate,111595.56,100,MS-DRG,89276.448,Case Rate,100% of CMS IPPS Rate,49469.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,49469.52,139494.5,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,21,CDM,100,RC,,,Inpatient,,,,,,98067.44,125,MS-DRG,78453.952,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78453.95,100,MS-DRG,62763.16,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37005.49,100,,,Case Rate,100% of CMS IPPS Rate,78453.95,100,MS-DRG,62763.16,Case Rate,100% of CMS IPPS Rate,32776.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,32776.14,98067.44,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,22,CDM,100,RC,,,Inpatient,,,,,,65418.61,125,MS-DRG,52334.888,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52334.89,100,MS-DRG,41867.912,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19137.07,100,,,Case Rate,100% of CMS IPPS Rate,52334.89,100,MS-DRG,41867.912,Case Rate,100% of CMS IPPS Rate,16949.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16949.9,65418.61,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,23,CDM,100,RC,,,Inpatient,,,,,,100974.43,125,MS-DRG,80779.544,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80779.54,100,MS-DRG,64623.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,39528.93,100,,,Case Rate,100% of CMS IPPS Rate,80779.54,100,MS-DRG,64623.632,Case Rate,100% of CMS IPPS Rate,35011.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,35011.17,100974.4,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,24,CDM,100,RC,,,Inpatient,,,,,,69854.31,125,MS-DRG,55883.448,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55883.45,100,MS-DRG,44706.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26340.84,100,,,Case Rate,100% of CMS IPPS Rate,55883.45,100,MS-DRG,44706.76,Case Rate,100% of CMS IPPS Rate,23330.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23330.35,69854.31,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,25,CDM,100,RC,,,Inpatient,,,,,,80818.45,125,MS-DRG,64654.76,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64654.76,100,MS-DRG,51723.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30987.23,100,,,Case Rate,100% of CMS IPPS Rate,64654.76,100,MS-DRG,51723.808,Case Rate,100% of CMS IPPS Rate,27445.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27445.7,80818.45,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,26,CDM,100,RC,,,Inpatient,,,,,,57704.81,125,MS-DRG,46163.848,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46163.85,100,MS-DRG,36931.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21192.12,100,,,Case Rate,100% of CMS IPPS Rate,46163.85,100,MS-DRG,36931.08,Case Rate,100% of CMS IPPS Rate,18770.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18770.08,57704.81,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,27,CDM,100,RC,,,Inpatient,,,,,,48045.39,125,MS-DRG,38436.312,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38436.31,100,MS-DRG,30749.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17098.65,100,,,Case Rate,100% of CMS IPPS Rate,38436.31,100,MS-DRG,30749.048,Case Rate,100% of CMS IPPS Rate,15144.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15144.44,48045.39,
SPINAL PROCEDURES WITH MCC,28,CDM,100,RC,,,Inpatient,,,,,,107095.78,125,MS-DRG,85676.624,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85676.62,100,MS-DRG,68541.296,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,42123.03,100,,,Case Rate,100% of CMS IPPS Rate,85676.62,100,MS-DRG,68541.296,Case Rate,100% of CMS IPPS Rate,37308.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37308.8,107095.8,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,29,CDM,100,RC,,,Inpatient,,,,,,62578.68,125,MS-DRG,50062.944,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50062.94,100,MS-DRG,40050.352,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23257.57,100,,,Case Rate,100% of CMS IPPS Rate,50062.94,100,MS-DRG,40050.352,Case Rate,100% of CMS IPPS Rate,20599.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20599.46,62578.68,
SPINAL PROCEDURES WITHOUT CC/MCC,30,CDM,100,RC,,,Inpatient,,,,,,44082.21,125,MS-DRG,35265.768,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35265.77,100,MS-DRG,28212.616,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15419.13,100,,,Case Rate,100% of CMS IPPS Rate,35265.77,100,MS-DRG,28212.616,Case Rate,100% of CMS IPPS Rate,13656.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13656.88,44082.21,
VENTRICULAR SHUNT PROCEDURES WITH MCC,31,CDM,100,RC,,,Inpatient,,,,,,76212.74,125,MS-DRG,60970.192,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60970.19,100,MS-DRG,48776.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29035.41,100,,,Case Rate,100% of CMS IPPS Rate,60970.19,100,MS-DRG,48776.152,Case Rate,100% of CMS IPPS Rate,25716.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25716.96,76212.74,
VENTRICULAR SHUNT PROCEDURES WITH CC,32,CDM,100,RC,,,Inpatient,,,,,,42613.99,125,MS-DRG,34091.192,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34091.19,100,MS-DRG,27272.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14796.93,100,,,Case Rate,100% of CMS IPPS Rate,34091.19,100,MS-DRG,27272.952,Case Rate,100% of CMS IPPS Rate,13105.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13105.79,42613.99,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,33,CDM,100,RC,,,Inpatient,,,,,,33783.49,125,MS-DRG,27026.792,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27026.79,100,MS-DRG,21621.432,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11054.74,100,,,Case Rate,100% of CMS IPPS Rate,27026.79,100,MS-DRG,21621.432,Case Rate,100% of CMS IPPS Rate,9791.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9791.3,33783.49,
CAROTID ARTERY STENT PROCEDURES WITH MCC,34,CDM,100,RC,,,Inpatient,,,,,,71276.74,125,MS-DRG,57021.392,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57021.39,100,MS-DRG,45617.112,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26943.64,100,,,Case Rate,100% of CMS IPPS Rate,57021.39,100,MS-DRG,45617.112,Case Rate,100% of CMS IPPS Rate,23864.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23864.25,71276.74,
CAROTID ARTERY STENT PROCEDURES WITH CC,35,CDM,100,RC,,,Inpatient,,,,,,44889.88,125,MS-DRG,35911.904,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35911.9,100,MS-DRG,28729.52,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15761.41,100,,,Case Rate,100% of CMS IPPS Rate,35911.9,100,MS-DRG,28729.52,Case Rate,100% of CMS IPPS Rate,13960.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13960.04,44889.88,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,36,CDM,100,RC,,,Inpatient,,,,,,37668.2,125,MS-DRG,30134.56,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30134.56,100,MS-DRG,24107.648,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12701,100,,,Case Rate,100% of CMS IPPS Rate,30134.56,100,MS-DRG,24107.648,Case Rate,100% of CMS IPPS Rate,11249.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11249.4,37668.2,
EXTRACRANIAL PROCEDURES WITH MCC,37,CDM,100,RC,,,Inpatient,,,,,,61993.35,125,MS-DRG,49594.68,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49594.68,100,MS-DRG,39675.744,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23009.52,100,,,Case Rate,100% of CMS IPPS Rate,49594.68,100,MS-DRG,39675.744,Case Rate,100% of CMS IPPS Rate,20379.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20379.77,61993.35,
EXTRACRANIAL PROCEDURES WITH CC,38,CDM,100,RC,,,Inpatient,,,,,,34041.83,125,MS-DRG,27233.464,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27233.46,100,MS-DRG,21786.768,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11164.21,100,,,Case Rate,100% of CMS IPPS Rate,27233.46,100,MS-DRG,21786.768,Case Rate,100% of CMS IPPS Rate,9888.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9888.26,34041.83,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,39,CDM,100,RC,,,Inpatient,,,,,,26306.76,125,MS-DRG,21045.408,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21045.41,100,MS-DRG,16836.328,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7886.25,100,,,Case Rate,100% of CMS IPPS Rate,21045.41,100,MS-DRG,16836.328,Case Rate,100% of CMS IPPS Rate,6984.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6984.93,26306.76,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",40,CDM,100,RC,,,Inpatient,,,,,,69370.36,125,MS-DRG,55496.288,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55496.29,100,MS-DRG,44397.032,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26135.75,100,,,Case Rate,100% of CMS IPPS Rate,55496.29,100,MS-DRG,44397.032,Case Rate,100% of CMS IPPS Rate,23148.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23148.7,69370.36,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",41,CDM,100,RC,,,Inpatient,,,,,,44618.48,125,MS-DRG,35694.784,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35694.78,100,MS-DRG,28555.824,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15646.39,100,,,Case Rate,100% of CMS IPPS Rate,35694.78,100,MS-DRG,28555.824,Case Rate,100% of CMS IPPS Rate,13858.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13858.17,44618.48,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",42,CDM,100,RC,,,Inpatient,,,,,,36433.79,125,MS-DRG,29147.032,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29147.03,100,MS-DRG,23317.624,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12177.88,100,,,Case Rate,100% of CMS IPPS Rate,29147.03,100,MS-DRG,23317.624,Case Rate,100% of CMS IPPS Rate,10786.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10786.07,36433.79,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,52,CDM,100,RC,,,Inpatient,,,,,,40601.34,125,MS-DRG,32481.072,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32481.07,100,MS-DRG,25984.856,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13944.01,100,,,Case Rate,100% of CMS IPPS Rate,32481.07,100,MS-DRG,25984.856,Case Rate,100% of CMS IPPS Rate,12350.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12350.35,40601.34,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,53,CDM,100,RC,,,Inpatient,,,,,,22762.13,125,MS-DRG,18209.704,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18209.7,100,MS-DRG,14567.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6384.1,100,,,Case Rate,100% of CMS IPPS Rate,18209.7,100,MS-DRG,14567.76,Case Rate,100% of CMS IPPS Rate,5654.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5654.47,22762.13,
NERVOUS SYSTEM NEOPLASMS WITH MCC,54,CDM,100,RC,,,Inpatient,,,,,,32207.36,125,MS-DRG,25765.888,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25765.89,100,MS-DRG,20612.712,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10386.81,100,,,Case Rate,100% of CMS IPPS Rate,25765.89,100,MS-DRG,20612.712,Case Rate,100% of CMS IPPS Rate,9199.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9199.71,32207.36,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,55,CDM,100,RC,,,Inpatient,,,,,,25535.03,125,MS-DRG,20428.024,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20428.02,100,MS-DRG,16342.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7559.21,100,,,Case Rate,100% of CMS IPPS Rate,20428.02,100,MS-DRG,16342.416,Case Rate,100% of CMS IPPS Rate,6695.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6695.27,25535.03,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,56,CDM,100,RC,,,Inpatient,,,,,,48638.89,125,MS-DRG,38911.112,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38911.11,100,MS-DRG,31128.888,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17350.16,100,,,Case Rate,100% of CMS IPPS Rate,38911.11,100,MS-DRG,31128.888,Case Rate,100% of CMS IPPS Rate,15367.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15367.21,48638.89,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,57,CDM,100,RC,,,Inpatient,,,,,,29514.56,125,MS-DRG,23611.648,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23611.65,100,MS-DRG,18889.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9245.66,100,,,Case Rate,100% of CMS IPPS Rate,23611.65,100,MS-DRG,18889.32,Case Rate,100% of CMS IPPS Rate,8188.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8188.97,29514.56,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,58,CDM,100,RC,,,Inpatient,,,,,,37877.48,125,MS-DRG,30301.984,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30301.98,100,MS-DRG,24241.584,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12789.69,100,,,Case Rate,100% of CMS IPPS Rate,30301.98,100,MS-DRG,24241.584,Case Rate,100% of CMS IPPS Rate,11327.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11327.96,37877.48,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,59,CDM,100,RC,,,Inpatient,,,,,,27703.03,125,MS-DRG,22162.424,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22162.42,100,MS-DRG,17729.936,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8477.96,100,,,Case Rate,100% of CMS IPPS Rate,22162.42,100,MS-DRG,17729.936,Case Rate,100% of CMS IPPS Rate,7509.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7509.01,27703.03,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,60,CDM,100,RC,,,Inpatient,,,,,,22287.99,125,MS-DRG,17830.392,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17830.39,100,MS-DRG,14264.312,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6183.17,100,,,Case Rate,100% of CMS IPPS Rate,17830.39,100,MS-DRG,14264.312,Case Rate,100% of CMS IPPS Rate,5476.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5476.5,22287.99,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",61,CDM,100,RC,,,Inpatient,,,,,,51897.38,125,MS-DRG,41517.904,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41517.9,100,MS-DRG,33214.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18731.05,100,,,Case Rate,100% of CMS IPPS Rate,41517.9,100,MS-DRG,33214.32,Case Rate,100% of CMS IPPS Rate,16590.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16590.28,51897.38,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",62,CDM,100,RC,,,Inpatient,,,,,,36814.73,125,MS-DRG,29451.784,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29451.78,100,MS-DRG,23561.424,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12339.32,100,,,Case Rate,100% of CMS IPPS Rate,29451.78,100,MS-DRG,23561.424,Case Rate,100% of CMS IPPS Rate,10929.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10929.06,36814.73,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",63,CDM,100,RC,,,Inpatient,,,,,,30665.59,125,MS-DRG,24532.472,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24532.47,100,MS-DRG,19625.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9733.44,100,,,Case Rate,100% of CMS IPPS Rate,24532.47,100,MS-DRG,19625.976,Case Rate,100% of CMS IPPS Rate,8621,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8621,30665.59,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,64,CDM,100,RC,,,Inpatient,,,,,,40220.39,125,MS-DRG,32176.312,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32176.31,100,MS-DRG,25741.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13782.57,100,,,Case Rate,100% of CMS IPPS Rate,32176.31,100,MS-DRG,25741.048,Case Rate,100% of CMS IPPS Rate,12207.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12207.36,40220.39,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,65,CDM,100,RC,,,Inpatient,,,,,,24323.53,125,MS-DRG,19458.824,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19458.82,100,MS-DRG,15567.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7045.8,100,,,Case Rate,100% of CMS IPPS Rate,19458.82,100,MS-DRG,15567.056,Case Rate,100% of CMS IPPS Rate,6240.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6240.53,24323.53,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,66,CDM,100,RC,,,Inpatient,,,,,,18951,125,MS-DRG,15160.8,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15160.8,100,MS-DRG,12128.64,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4769.02,100,,,Case Rate,100% of CMS IPPS Rate,15160.8,100,MS-DRG,12128.64,Case Rate,100% of CMS IPPS Rate,4223.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4223.97,18951,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,67,CDM,100,RC,,,Inpatient,,,,,,31484.71,125,MS-DRG,25187.768,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25187.77,100,MS-DRG,20150.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10080.57,100,,,Case Rate,100% of CMS IPPS Rate,25187.77,100,MS-DRG,20150.216,Case Rate,100% of CMS IPPS Rate,8928.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8928.46,31484.71,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,68,CDM,100,RC,,,Inpatient,,,,,,22109.76,125,MS-DRG,17687.808,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17687.81,100,MS-DRG,14150.248,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6107.65,100,,,Case Rate,100% of CMS IPPS Rate,17687.81,100,MS-DRG,14150.248,Case Rate,100% of CMS IPPS Rate,5409.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5409.61,22109.76,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,69,CDM,100,RC,,,Inpatient,,,,,,20778.9,125,MS-DRG,16623.12,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16623.12,100,MS-DRG,13298.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5543.65,100,,,Case Rate,100% of CMS IPPS Rate,16623.12,100,MS-DRG,13298.496,Case Rate,100% of CMS IPPS Rate,4910.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4910.07,20778.9,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,70,CDM,100,RC,,,Inpatient,,,,,,36126.4,125,MS-DRG,28901.12,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28901.12,100,MS-DRG,23120.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12047.62,100,,,Case Rate,100% of CMS IPPS Rate,28901.12,100,MS-DRG,23120.896,Case Rate,100% of CMS IPPS Rate,10670.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10670.7,36126.4,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,71,CDM,100,RC,,,Inpatient,,,,,,24928.45,125,MS-DRG,19942.76,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19942.76,100,MS-DRG,15954.208,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7302.16,100,,,Case Rate,100% of CMS IPPS Rate,19942.76,100,MS-DRG,15954.208,Case Rate,100% of CMS IPPS Rate,6467.59,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6467.59,24928.45,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,72,CDM,100,RC,,,Inpatient,,,,,,19963.05,125,MS-DRG,15970.44,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15970.44,100,MS-DRG,12776.352,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5197.91,100,,,Case Rate,100% of CMS IPPS Rate,15970.44,100,MS-DRG,12776.352,Case Rate,100% of CMS IPPS Rate,4603.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4603.84,19963.05,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,73,CDM,100,RC,,,Inpatient,,,,,,32967.64,125,MS-DRG,26374.112,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26374.11,100,MS-DRG,21099.288,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10709,100,,,Case Rate,100% of CMS IPPS Rate,26374.11,100,MS-DRG,21099.288,Case Rate,100% of CMS IPPS Rate,9485.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9485.07,32967.64,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,74,CDM,100,RC,,,Inpatient,,,,,,24740.44,125,MS-DRG,19792.352,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19792.35,100,MS-DRG,15833.88,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7222.48,100,,,Case Rate,100% of CMS IPPS Rate,19792.35,100,MS-DRG,15833.88,Case Rate,100% of CMS IPPS Rate,6397.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6397.02,24740.44,
VIRAL MENINGITIS WITH CC/MCC,75,CDM,100,RC,,,Inpatient,,,,,,35858.26,125,MS-DRG,28686.608,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28686.61,100,MS-DRG,22949.288,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11516.89,100,,,Case Rate,100% of CMS IPPS Rate,28686.61,100,MS-DRG,22949.288,Case Rate,100% of CMS IPPS Rate,10200.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10200.62,35858.26,
VIRAL MENINGITIS WITHOUT CC/MCC,76,CDM,100,RC,,,Inpatient,,,,,,22688.54,125,MS-DRG,18150.832,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18150.83,100,MS-DRG,14520.664,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6352.93,100,,,Case Rate,100% of CMS IPPS Rate,18150.83,100,MS-DRG,14520.664,Case Rate,100% of CMS IPPS Rate,5626.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5626.85,22688.54,
HYPERTENSIVE ENCEPHALOPATHY WITH MCC,77,CDM,100,RC,,,Inpatient,,,,,,32979.09,125,MS-DRG,26383.272,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26383.27,100,MS-DRG,21106.616,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10713.85,100,,,Case Rate,100% of CMS IPPS Rate,26383.27,100,MS-DRG,21106.616,Case Rate,100% of CMS IPPS Rate,9489.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9489.36,32979.09,
HYPERTENSIVE ENCEPHALOPATHY WITH CC,78,CDM,100,RC,,,Inpatient,,,,,,24012.89,125,MS-DRG,19210.312,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19210.31,100,MS-DRG,15368.248,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6914.15,100,,,Case Rate,100% of CMS IPPS Rate,19210.31,100,MS-DRG,15368.248,Case Rate,100% of CMS IPPS Rate,6123.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6123.93,24012.89,
HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,79,CDM,100,RC,,,Inpatient,,,,,,18597.84,125,MS-DRG,14878.272,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14878.27,100,MS-DRG,11902.616,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4584.03,100,,,Case Rate,100% of CMS IPPS Rate,14878.27,100,MS-DRG,11902.616,Case Rate,100% of CMS IPPS Rate,4060.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4060.12,18597.84,
NONTRAUMATIC STUPOR AND COMA WITH MCC,80,CDM,100,RC,,,Inpatient,,,,,,40197.5,125,MS-DRG,32158,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32158,100,MS-DRG,25726.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13642.61,100,,,Case Rate,100% of CMS IPPS Rate,32158,100,MS-DRG,25726.4,Case Rate,100% of CMS IPPS Rate,12083.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12083.4,40197.5,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,81,CDM,100,RC,,,Inpatient,,,,,,22490.73,125,MS-DRG,17992.584,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17992.58,100,MS-DRG,14394.064,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6269.09,100,,,Case Rate,100% of CMS IPPS Rate,17992.58,100,MS-DRG,14394.064,Case Rate,100% of CMS IPPS Rate,5552.59,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5552.59,22490.73,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,82,CDM,100,RC,,,Inpatient,,,,,,45632.16,125,MS-DRG,36505.728,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36505.73,100,MS-DRG,29204.584,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16075.97,100,,,Case Rate,100% of CMS IPPS Rate,36505.73,100,MS-DRG,29204.584,Case Rate,100% of CMS IPPS Rate,14238.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14238.65,45632.16,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,83,CDM,100,RC,,,Inpatient,,,,,,30430.16,125,MS-DRG,24344.128,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24344.13,100,MS-DRG,19475.304,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9633.66,100,,,Case Rate,100% of CMS IPPS Rate,24344.13,100,MS-DRG,19475.304,Case Rate,100% of CMS IPPS Rate,8532.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8532.63,30430.16,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,84,CDM,100,RC,,,Inpatient,,,,,,23329.45,125,MS-DRG,18663.56,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18663.56,100,MS-DRG,14930.848,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6624.53,100,,,Case Rate,100% of CMS IPPS Rate,18663.56,100,MS-DRG,14930.848,Case Rate,100% of CMS IPPS Rate,5867.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5867.41,23329.45,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,85,CDM,100,RC,,,Inpatient,,,,,,44746,125,MS-DRG,35796.8,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35796.8,100,MS-DRG,28637.44,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15700.43,100,,,Case Rate,100% of CMS IPPS Rate,35796.8,100,MS-DRG,28637.44,Case Rate,100% of CMS IPPS Rate,13906.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13906.03,44746,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,86,CDM,100,RC,,,Inpatient,,,,,,29141.8,125,MS-DRG,23313.44,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23313.44,100,MS-DRG,18650.752,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9087.68,100,,,Case Rate,100% of CMS IPPS Rate,23313.44,100,MS-DRG,18650.752,Case Rate,100% of CMS IPPS Rate,8049.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8049.05,29141.8,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,87,CDM,100,RC,,,Inpatient,,,,,,22150.65,125,MS-DRG,17720.52,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17720.52,100,MS-DRG,14176.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6124.97,100,,,Case Rate,100% of CMS IPPS Rate,17720.52,100,MS-DRG,14176.416,Case Rate,100% of CMS IPPS Rate,5424.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5424.95,22150.65,
CONCUSSION WITH MCC,88,CDM,100,RC,,,Inpatient,,,,,,30762.04,125,MS-DRG,24609.632,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24609.63,100,MS-DRG,19687.704,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9774.32,100,,,Case Rate,100% of CMS IPPS Rate,24609.63,100,MS-DRG,19687.704,Case Rate,100% of CMS IPPS Rate,8657.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8657.21,30762.04,
CONCUSSION WITH CC,89,CDM,100,RC,,,Inpatient,,,,,,25226.03,125,MS-DRG,20180.824,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20180.82,100,MS-DRG,16144.656,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7428.26,100,,,Case Rate,100% of CMS IPPS Rate,20180.82,100,MS-DRG,16144.656,Case Rate,100% of CMS IPPS Rate,6579.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6579.28,25226.03,
CONCUSSION WITHOUT CC/MCC,90,CDM,100,RC,,,Inpatient,,,,,,21714.1,125,MS-DRG,17371.28,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17371.28,100,MS-DRG,13897.024,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5939.97,100,,,Case Rate,100% of CMS IPPS Rate,17371.28,100,MS-DRG,13897.024,Case Rate,100% of CMS IPPS Rate,5261.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5261.1,21714.1,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,91,CDM,100,RC,,,Inpatient,,,,,,37501.43,125,MS-DRG,30001.144,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30001.14,100,MS-DRG,24000.912,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12630.33,100,,,Case Rate,100% of CMS IPPS Rate,30001.14,100,MS-DRG,24000.912,Case Rate,100% of CMS IPPS Rate,11186.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11186.81,37501.43,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,92,CDM,100,RC,,,Inpatient,,,,,,25006.94,125,MS-DRG,20005.552,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20005.55,100,MS-DRG,16004.44,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7335.41,100,,,Case Rate,100% of CMS IPPS Rate,20005.55,100,MS-DRG,16004.44,Case Rate,100% of CMS IPPS Rate,6497.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6497.05,25006.94,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,93,CDM,100,RC,,,Inpatient,,,,,,20602.33,125,MS-DRG,16481.864,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16481.86,100,MS-DRG,13185.488,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5468.82,100,,,Case Rate,100% of CMS IPPS Rate,16481.86,100,MS-DRG,13185.488,Case Rate,100% of CMS IPPS Rate,4843.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4843.79,20602.33,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,94,CDM,100,RC,,,Inpatient,,,,,,67352.8,125,MS-DRG,53882.24,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53882.24,100,MS-DRG,43105.792,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25280.75,100,,,Case Rate,100% of CMS IPPS Rate,53882.24,100,MS-DRG,43105.792,Case Rate,100% of CMS IPPS Rate,22391.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22391.42,67352.8,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,95,CDM,100,RC,,,Inpatient,,,,,,46891.1,125,MS-DRG,37512.88,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37512.88,100,MS-DRG,30010.304,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16609.48,100,,,Case Rate,100% of CMS IPPS Rate,37512.88,100,MS-DRG,30010.304,Case Rate,100% of CMS IPPS Rate,14711.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14711.18,46891.1,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,96,CDM,100,RC,,,Inpatient,,,,,,46891.1,125,MS-DRG,37512.88,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37512.88,100,MS-DRG,30010.304,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16609.48,100,,,Case Rate,100% of CMS IPPS Rate,37512.88,100,MS-DRG,30010.304,Case Rate,100% of CMS IPPS Rate,14711.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14711.18,46891.1,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,97,CDM,100,RC,,,Inpatient,,,,,,66304.78,125,MS-DRG,53043.824,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53043.82,100,MS-DRG,42435.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24836.62,100,,,Case Rate,100% of CMS IPPS Rate,53043.82,100,MS-DRG,42435.056,Case Rate,100% of CMS IPPS Rate,21998.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21998.04,66304.78,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,98,CDM,100,RC,,,Inpatient,,,,,,43164.98,125,MS-DRG,34531.984,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34531.98,100,MS-DRG,27625.584,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15030.43,100,,,Case Rate,100% of CMS IPPS Rate,34531.98,100,MS-DRG,27625.584,Case Rate,100% of CMS IPPS Rate,13312.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13312.6,43164.98,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,99,CDM,100,RC,,,Inpatient,,,,,,30477.58,125,MS-DRG,24382.064,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24382.06,100,MS-DRG,19505.648,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9653.76,100,,,Case Rate,100% of CMS IPPS Rate,24382.06,100,MS-DRG,19505.648,Case Rate,100% of CMS IPPS Rate,8550.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8550.43,30477.58,
SEIZURES WITH MCC,100,CDM,100,RC,,,Inpatient,,,,,,40156.61,125,MS-DRG,32125.288,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32125.29,100,MS-DRG,25700.232,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13755.55,100,,,Case Rate,100% of CMS IPPS Rate,32125.29,100,MS-DRG,25700.232,Case Rate,100% of CMS IPPS Rate,12183.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12183.43,40156.61,
SEIZURES WITHOUT MCC,101,CDM,100,RC,,,Inpatient,,,,,,22767.03,125,MS-DRG,18213.624,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18213.62,100,MS-DRG,14570.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6386.18,100,,,Case Rate,100% of CMS IPPS Rate,18213.62,100,MS-DRG,14570.896,Case Rate,100% of CMS IPPS Rate,5656.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5656.31,22767.03,
HEADACHES WITH MCC,102,CDM,100,RC,,,Inpatient,,,,,,26655.01,125,MS-DRG,21324.008,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21324.01,100,MS-DRG,17059.208,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8033.83,100,,,Case Rate,100% of CMS IPPS Rate,21324.01,100,MS-DRG,17059.208,Case Rate,100% of CMS IPPS Rate,7115.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7115.64,26655.01,
HEADACHES WITHOUT MCC,103,CDM,100,RC,,,Inpatient,,,,,,21598.03,125,MS-DRG,17278.424,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17278.42,100,MS-DRG,13822.736,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5890.78,100,,,Case Rate,100% of CMS IPPS Rate,17278.42,100,MS-DRG,13822.736,Case Rate,100% of CMS IPPS Rate,5217.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5217.52,21598.03,
ORBITAL PROCEDURES WITH CC/MCC,113,CDM,100,RC,,,Inpatient,,,,,,44592.31,125,MS-DRG,35673.848,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35673.85,100,MS-DRG,28539.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15500.89,100,,,Case Rate,100% of CMS IPPS Rate,35673.85,100,MS-DRG,28539.08,Case Rate,100% of CMS IPPS Rate,13729.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13729.29,44592.31,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,CDM,100,RC,,,Inpatient,,,,,,27024.5,125,MS-DRG,21619.6,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21619.6,100,MS-DRG,17295.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8190.42,100,,,Case Rate,100% of CMS IPPS Rate,21619.6,100,MS-DRG,17295.68,Case Rate,100% of CMS IPPS Rate,7254.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7254.33,27024.5,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,CDM,100,RC,,,Inpatient,,,,,,32728.93,125,MS-DRG,26183.144,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26183.14,100,MS-DRG,20946.512,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10607.84,100,,,Case Rate,100% of CMS IPPS Rate,26183.14,100,MS-DRG,20946.512,Case Rate,100% of CMS IPPS Rate,9395.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9395.47,32728.93,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,CDM,100,RC,,,Inpatient,,,,,,34978.65,125,MS-DRG,27982.92,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27982.92,100,MS-DRG,22386.336,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11561.23,100,,,Case Rate,100% of CMS IPPS Rate,27982.92,100,MS-DRG,22386.336,Case Rate,100% of CMS IPPS Rate,10239.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10239.9,34978.65,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,CDM,100,RC,,,Inpatient,,,,,,25332.33,125,MS-DRG,20265.864,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20265.86,100,MS-DRG,16212.688,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7013.23,100,,,Case Rate,100% of CMS IPPS Rate,20265.86,100,MS-DRG,16212.688,Case Rate,100% of CMS IPPS Rate,6211.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6211.69,25332.33,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,CDM,100,RC,,,Inpatient,,,,,,26715.49,125,MS-DRG,21372.392,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21372.39,100,MS-DRG,17097.912,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8059.46,100,,,Case Rate,100% of CMS IPPS Rate,21372.39,100,MS-DRG,17097.912,Case Rate,100% of CMS IPPS Rate,7138.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7138.35,26715.49,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,CDM,100,RC,,,Inpatient,,,,,,18787.5,125,MS-DRG,15030,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15030,100,MS-DRG,12024,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4699.74,100,,,Case Rate,100% of CMS IPPS Rate,15030,100,MS-DRG,12024,Case Rate,100% of CMS IPPS Rate,4162.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4162.61,18787.5,
NEUROLOGICAL EYE DISORDERS,123,CDM,100,RC,,,Inpatient,,,,,,20829.59,125,MS-DRG,16663.672,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16663.67,100,MS-DRG,13330.936,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5565.13,100,,,Case Rate,100% of CMS IPPS Rate,16663.67,100,MS-DRG,13330.936,Case Rate,100% of CMS IPPS Rate,4929.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4929.09,20829.59,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,CDM,100,RC,,,Inpatient,,,,,,29015.9,125,MS-DRG,23212.72,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23212.72,100,MS-DRG,18570.176,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9034.33,100,,,Case Rate,100% of CMS IPPS Rate,23212.72,100,MS-DRG,18570.176,Case Rate,100% of CMS IPPS Rate,8001.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8001.8,29015.9,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,CDM,100,RC,,,Inpatient,,,,,,21197.44,125,MS-DRG,16957.952,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16957.95,100,MS-DRG,13566.36,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5721.03,100,,,Case Rate,100% of CMS IPPS Rate,16957.95,100,MS-DRG,13566.36,Case Rate,100% of CMS IPPS Rate,5067.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5067.17,21197.44,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,CDM,100,RC,,,Inpatient,,,,,,47118.35,125,MS-DRG,37694.68,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37694.68,100,MS-DRG,30155.744,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16705.79,100,,,Case Rate,100% of CMS IPPS Rate,37694.68,100,MS-DRG,30155.744,Case Rate,100% of CMS IPPS Rate,14796.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14796.49,47118.35,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,CDM,100,RC,,,Inpatient,,,,,,23690.78,125,MS-DRG,18952.624,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18952.62,100,MS-DRG,15162.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6777.65,100,,,Case Rate,100% of CMS IPPS Rate,18952.62,100,MS-DRG,15162.096,Case Rate,100% of CMS IPPS Rate,6003.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6003.04,23690.78,
MOUTH PROCEDURES WITH CC/MCC,137,CDM,100,RC,,,Inpatient,,,,,,30564.23,125,MS-DRG,24451.384,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24451.38,100,MS-DRG,19561.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9690.48,100,,,Case Rate,100% of CMS IPPS Rate,24451.38,100,MS-DRG,19561.104,Case Rate,100% of CMS IPPS Rate,8582.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8582.96,30564.23,
MOUTH PROCEDURES WITHOUT CC/MCC,138,CDM,100,RC,,,Inpatient,,,,,,20997.99,125,MS-DRG,16798.392,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16798.39,100,MS-DRG,13438.712,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5636.5,100,,,Case Rate,100% of CMS IPPS Rate,16798.39,100,MS-DRG,13438.712,Case Rate,100% of CMS IPPS Rate,4992.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4992.3,20997.99,
SALIVARY GLAND PROCEDURES,139,CDM,100,RC,,,Inpatient,,,,,,30145.68,125,MS-DRG,24116.544,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24116.54,100,MS-DRG,19293.232,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9513.11,100,,,Case Rate,100% of CMS IPPS Rate,24116.54,100,MS-DRG,19293.232,Case Rate,100% of CMS IPPS Rate,8425.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8425.85,30145.68,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,CDM,100,RC,,,Inpatient,,,,,,76843.83,125,MS-DRG,61475.064,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61475.06,100,MS-DRG,49180.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29302.86,100,,,Case Rate,100% of CMS IPPS Rate,61475.06,100,MS-DRG,49180.048,Case Rate,100% of CMS IPPS Rate,25953.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25953.84,76843.83,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,CDM,100,RC,,,Inpatient,,,,,,42824.91,125,MS-DRG,34259.928,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34259.93,100,MS-DRG,27407.944,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14886.31,100,,,Case Rate,100% of CMS IPPS Rate,34259.93,100,MS-DRG,27407.944,Case Rate,100% of CMS IPPS Rate,13184.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13184.96,42824.91,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,CDM,100,RC,,,Inpatient,,,,,,33405.81,125,MS-DRG,26724.648,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26724.65,100,MS-DRG,21379.72,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10894.69,100,,,Case Rate,100% of CMS IPPS Rate,26724.65,100,MS-DRG,21379.72,Case Rate,100% of CMS IPPS Rate,9649.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9649.54,33405.81,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,CDM,100,RC,,,Inpatient,,,,,,61682.71,125,MS-DRG,49346.168,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49346.17,100,MS-DRG,39476.936,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22877.87,100,,,Case Rate,100% of CMS IPPS Rate,49346.17,100,MS-DRG,39476.936,Case Rate,100% of CMS IPPS Rate,20263.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20263.17,61682.71,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,CDM,100,RC,,,Inpatient,,,,,,36419.06,125,MS-DRG,29135.248,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29135.25,100,MS-DRG,23308.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12171.65,100,,,Case Rate,100% of CMS IPPS Rate,29135.25,100,MS-DRG,23308.2,Case Rate,100% of CMS IPPS Rate,10780.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10780.55,36419.06,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,CDM,100,RC,,,Inpatient,,,,,,27068.64,125,MS-DRG,21654.912,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21654.91,100,MS-DRG,17323.928,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8209.12,100,,,Case Rate,100% of CMS IPPS Rate,21654.91,100,MS-DRG,17323.928,Case Rate,100% of CMS IPPS Rate,7270.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7270.9,27068.64,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,CDM,100,RC,,,Inpatient,,,,,,45205.44,125,MS-DRG,36164.352,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36164.35,100,MS-DRG,28931.48,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15895.13,100,,,Case Rate,100% of CMS IPPS Rate,36164.35,100,MS-DRG,28931.48,Case Rate,100% of CMS IPPS Rate,14078.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14078.48,45205.44,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,CDM,100,RC,,,Inpatient,,,,,,28049.64,125,MS-DRG,22439.712,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22439.71,100,MS-DRG,17951.768,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8624.85,100,,,Case Rate,100% of CMS IPPS Rate,22439.71,100,MS-DRG,17951.768,Case Rate,100% of CMS IPPS Rate,7639.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7639.11,28049.64,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,CDM,100,RC,,,Inpatient,,,,,,20788.71,125,MS-DRG,16630.968,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16630.97,100,MS-DRG,13304.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5288.68,100,,,Case Rate,100% of CMS IPPS Rate,16630.97,100,MS-DRG,13304.776,Case Rate,100% of CMS IPPS Rate,4684.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4684.23,20788.71,
DYSEQUILIBRIUM,149,CDM,100,RC,,,Inpatient,,,,,,19918.9,125,MS-DRG,15935.12,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15935.12,100,MS-DRG,12748.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5179.2,100,,,Case Rate,100% of CMS IPPS Rate,15935.12,100,MS-DRG,12748.096,Case Rate,100% of CMS IPPS Rate,4587.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4587.27,19918.9,
EPISTAXIS WITH MCC,150,CDM,100,RC,,,Inpatient,,,,,,30296.1,125,MS-DRG,24236.88,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24236.88,100,MS-DRG,19389.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9576.85,100,,,Case Rate,100% of CMS IPPS Rate,24236.88,100,MS-DRG,19389.504,Case Rate,100% of CMS IPPS Rate,8482.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8482.31,30296.1,
EPISTAXIS WITHOUT MCC,151,CDM,100,RC,,,Inpatient,,,,,,20090.59,125,MS-DRG,16072.472,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16072.47,100,MS-DRG,12857.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5251.95,100,,,Case Rate,100% of CMS IPPS Rate,16072.47,100,MS-DRG,12857.976,Case Rate,100% of CMS IPPS Rate,4651.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4651.71,20090.59,
OTITIS MEDIA AND URI WITH MCC,152,CDM,100,RC,,,Inpatient,,,,,,26251.16,125,MS-DRG,21000.928,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21000.93,100,MS-DRG,16800.744,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7862.69,100,,,Case Rate,100% of CMS IPPS Rate,21000.93,100,MS-DRG,16800.744,Case Rate,100% of CMS IPPS Rate,6964.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6964.06,26251.16,
OTITIS MEDIA AND URI WITHOUT MCC,153,CDM,100,RC,,,Inpatient,,,,,,19333.58,125,MS-DRG,15466.864,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15466.86,100,MS-DRG,12373.488,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4931.16,100,,,Case Rate,100% of CMS IPPS Rate,15466.86,100,MS-DRG,12373.488,Case Rate,100% of CMS IPPS Rate,4367.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4367.57,19333.58,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,CDM,100,RC,,,Inpatient,,,,,,34287.06,125,MS-DRG,27429.648,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27429.65,100,MS-DRG,21943.72,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11268.14,100,,,Case Rate,100% of CMS IPPS Rate,27429.65,100,MS-DRG,21943.72,Case Rate,100% of CMS IPPS Rate,9980.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9980.31,34287.06,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,CDM,100,RC,,,Inpatient,,,,,,22961.58,125,MS-DRG,18369.264,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18369.26,100,MS-DRG,14695.408,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6468.63,100,,,Case Rate,100% of CMS IPPS Rate,18369.26,100,MS-DRG,14695.408,Case Rate,100% of CMS IPPS Rate,5729.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5729.34,22961.58,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,CDM,100,RC,,,Inpatient,,,,,,18691.04,125,MS-DRG,14952.832,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14952.83,100,MS-DRG,11962.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4658.86,100,,,Case Rate,100% of CMS IPPS Rate,14952.83,100,MS-DRG,11962.264,Case Rate,100% of CMS IPPS Rate,4126.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4126.4,18691.04,
DENTAL AND ORAL DISEASES WITH MCC,157,CDM,100,RC,,,Inpatient,,,,,,34470.19,125,MS-DRG,27576.152,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27576.15,100,MS-DRG,22060.92,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11345.75,100,,,Case Rate,100% of CMS IPPS Rate,27576.15,100,MS-DRG,22060.92,Case Rate,100% of CMS IPPS Rate,10049.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10049.04,34470.19,
DENTAL AND ORAL DISEASES WITH CC,158,CDM,100,RC,,,Inpatient,,,,,,23076.04,125,MS-DRG,18460.832,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18460.83,100,MS-DRG,14768.664,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6517.14,100,,,Case Rate,100% of CMS IPPS Rate,18460.83,100,MS-DRG,14768.664,Case Rate,100% of CMS IPPS Rate,5772.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5772.29,23076.04,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,CDM,100,RC,,,Inpatient,,,,,,18481.76,125,MS-DRG,14785.408,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14785.41,100,MS-DRG,11828.328,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4570.17,100,,,Case Rate,100% of CMS IPPS Rate,14785.41,100,MS-DRG,11828.328,Case Rate,100% of CMS IPPS Rate,4047.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4047.85,18481.76,
MAJOR CHEST PROCEDURES WITH MCC,163,CDM,100,RC,,,Inpatient,,,,,,83056.73,125,MS-DRG,66445.384,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66445.38,100,MS-DRG,53156.304,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31935.76,100,,,Case Rate,100% of CMS IPPS Rate,66445.38,100,MS-DRG,53156.304,Case Rate,100% of CMS IPPS Rate,28285.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28285.83,83056.73,
MAJOR CHEST PROCEDURES WITH CC,164,CDM,100,RC,,,Inpatient,,,,,,48849.79,125,MS-DRG,39079.832,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39079.83,100,MS-DRG,31263.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17439.54,100,,,Case Rate,100% of CMS IPPS Rate,39079.83,100,MS-DRG,31263.864,Case Rate,100% of CMS IPPS Rate,15446.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15446.38,48849.79,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,CDM,100,RC,,,Inpatient,,,,,,38173.4,125,MS-DRG,30538.72,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30538.72,100,MS-DRG,24430.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12915.1,100,,,Case Rate,100% of CMS IPPS Rate,30538.72,100,MS-DRG,24430.976,Case Rate,100% of CMS IPPS Rate,11439.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11439.03,38173.4,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,CDM,100,RC,,,Inpatient,,,,,,70648.91,125,MS-DRG,56519.128,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56519.13,100,MS-DRG,45215.304,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26677.57,100,,,Case Rate,100% of CMS IPPS Rate,56519.13,100,MS-DRG,45215.304,Case Rate,100% of CMS IPPS Rate,23628.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23628.6,70648.91,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,CDM,100,RC,,,Inpatient,,,,,,37571.73,125,MS-DRG,30057.384,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30057.38,100,MS-DRG,24045.904,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12660.12,100,,,Case Rate,100% of CMS IPPS Rate,30057.38,100,MS-DRG,24045.904,Case Rate,100% of CMS IPPS Rate,11213.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11213.2,37571.73,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,CDM,100,RC,,,Inpatient,,,,,,29833.4,125,MS-DRG,23866.72,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23866.72,100,MS-DRG,19093.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9380.77,100,,,Case Rate,100% of CMS IPPS Rate,23866.72,100,MS-DRG,19093.376,Case Rate,100% of CMS IPPS Rate,8308.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8308.64,29833.4,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,CDM,100,RC,,,Inpatient,,,,,,57868.3,125,MS-DRG,46294.64,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46294.64,100,MS-DRG,37035.712,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21261.41,100,,,Case Rate,100% of CMS IPPS Rate,46294.64,100,MS-DRG,37035.712,Case Rate,100% of CMS IPPS Rate,18831.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18831.45,57868.3,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,CDM,100,RC,,,Inpatient,,,,,,30735.89,125,MS-DRG,24588.712,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24588.71,100,MS-DRG,19670.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9763.23,100,,,Case Rate,100% of CMS IPPS Rate,24588.71,100,MS-DRG,19670.968,Case Rate,100% of CMS IPPS Rate,8647.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8647.39,30735.89,
PULMONARY EMBOLISM WITHOUT MCC,176,CDM,100,RC,,,Inpatient,,,,,,21014.34,125,MS-DRG,16811.472,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16811.47,100,MS-DRG,13449.176,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5643.43,100,,,Case Rate,100% of CMS IPPS Rate,16811.47,100,MS-DRG,13449.176,Case Rate,100% of CMS IPPS Rate,4998.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4998.44,21014.34,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,CDM,100,RC,,,Inpatient,,,,,,34126.84,125,MS-DRG,27301.472,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27301.47,100,MS-DRG,21841.176,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11200.24,100,,,Case Rate,100% of CMS IPPS Rate,27301.47,100,MS-DRG,21841.176,Case Rate,100% of CMS IPPS Rate,9920.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9920.17,34126.84,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,CDM,100,RC,,,Inpatient,,,,,,23918.05,125,MS-DRG,19134.44,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19134.44,100,MS-DRG,15307.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6873.96,100,,,Case Rate,100% of CMS IPPS Rate,19134.44,100,MS-DRG,15307.552,Case Rate,100% of CMS IPPS Rate,6088.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6088.34,23918.05,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,CDM,100,RC,,,Inpatient,,,,,,20281.88,125,MS-DRG,16225.504,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16225.5,100,MS-DRG,12980.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5333.02,100,,,Case Rate,100% of CMS IPPS Rate,16225.5,100,MS-DRG,12980.4,Case Rate,100% of CMS IPPS Rate,4723.51,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4723.51,20281.88,
RESPIRATORY NEOPLASMS WITH MCC,180,CDM,100,RC,,,Inpatient,,,,,,36273.55,125,MS-DRG,29018.84,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29018.84,100,MS-DRG,23215.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12109.98,100,,,Case Rate,100% of CMS IPPS Rate,29018.84,100,MS-DRG,23215.072,Case Rate,100% of CMS IPPS Rate,10725.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10725.93,36273.55,
RESPIRATORY NEOPLASMS WITH CC,181,CDM,100,RC,,,Inpatient,,,,,,25850.59,125,MS-DRG,20680.472,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20680.47,100,MS-DRG,16544.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7692.94,100,,,Case Rate,100% of CMS IPPS Rate,20680.47,100,MS-DRG,16544.376,Case Rate,100% of CMS IPPS Rate,6813.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6813.71,25850.59,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,CDM,100,RC,,,Inpatient,,,,,,21390.38,125,MS-DRG,17112.304,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17112.3,100,MS-DRG,13689.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5802.79,100,,,Case Rate,100% of CMS IPPS Rate,17112.3,100,MS-DRG,13689.84,Case Rate,100% of CMS IPPS Rate,5139.59,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5139.59,21390.38,
MAJOR CHEST TRAUMA WITH MCC,183,CDM,100,RC,,,Inpatient,,,,,,33649.43,125,MS-DRG,26919.544,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26919.54,100,MS-DRG,21535.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10997.93,100,,,Case Rate,100% of CMS IPPS Rate,26919.54,100,MS-DRG,21535.632,Case Rate,100% of CMS IPPS Rate,9740.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9740.97,33649.43,
MAJOR CHEST TRAUMA WITH CC,184,CDM,100,RC,,,Inpatient,,,,,,25160.64,125,MS-DRG,20128.512,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20128.51,100,MS-DRG,16102.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7400.54,100,,,Case Rate,100% of CMS IPPS Rate,20128.51,100,MS-DRG,16102.808,Case Rate,100% of CMS IPPS Rate,6554.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6554.74,25160.64,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,CDM,100,RC,,,Inpatient,,,,,,20412.66,125,MS-DRG,16330.128,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16330.13,100,MS-DRG,13064.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5388.45,100,,,Case Rate,100% of CMS IPPS Rate,16330.13,100,MS-DRG,13064.104,Case Rate,100% of CMS IPPS Rate,4772.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4772.6,20412.66,
PLEURAL EFFUSION WITH MCC,186,CDM,100,RC,,,Inpatient,,,,,,33530.08,125,MS-DRG,26824.064,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26824.06,100,MS-DRG,21459.248,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10947.35,100,,,Case Rate,100% of CMS IPPS Rate,26824.06,100,MS-DRG,21459.248,Case Rate,100% of CMS IPPS Rate,9696.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9696.18,33530.08,
PLEURAL EFFUSION WITH CC,187,CDM,100,RC,,,Inpatient,,,,,,24112.63,125,MS-DRG,19290.104,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19290.1,100,MS-DRG,15432.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6956.41,100,,,Case Rate,100% of CMS IPPS Rate,19290.1,100,MS-DRG,15432.08,Case Rate,100% of CMS IPPS Rate,6161.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6161.37,24112.63,
PLEURAL EFFUSION WITHOUT CC/MCC,188,CDM,100,RC,,,Inpatient,,,,,,19701.45,125,MS-DRG,15761.16,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15761.16,100,MS-DRG,12608.928,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5087.05,100,,,Case Rate,100% of CMS IPPS Rate,15761.16,100,MS-DRG,12608.928,Case Rate,100% of CMS IPPS Rate,4505.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4505.65,19701.45,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,CDM,100,RC,,,Inpatient,,,,,,27928.64,125,MS-DRG,22342.912,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22342.91,100,MS-DRG,17874.328,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8573.57,100,,,Case Rate,100% of CMS IPPS Rate,22342.91,100,MS-DRG,17874.328,Case Rate,100% of CMS IPPS Rate,7593.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7593.7,27928.64,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,CDM,100,RC,,,Inpatient,,,,,,26058.24,125,MS-DRG,20846.592,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20846.59,100,MS-DRG,16677.272,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7780.93,100,,,Case Rate,100% of CMS IPPS Rate,20846.59,100,MS-DRG,16677.272,Case Rate,100% of CMS IPPS Rate,6891.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6891.65,26058.24,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,CDM,100,RC,,,Inpatient,,,,,,21743.53,125,MS-DRG,17394.824,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17394.82,100,MS-DRG,13915.856,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5952.45,100,,,Case Rate,100% of CMS IPPS Rate,17394.82,100,MS-DRG,13915.856,Case Rate,100% of CMS IPPS Rate,5272.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5272.14,21743.53,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,CDM,100,RC,,,Inpatient,,,,,,18279.01,125,MS-DRG,14623.208,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14623.21,100,MS-DRG,11698.568,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4484.25,100,,,Case Rate,100% of CMS IPPS Rate,14623.21,100,MS-DRG,11698.568,Case Rate,100% of CMS IPPS Rate,3971.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3971.75,18279.01,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,CDM,100,RC,,,Inpatient,,,,,,29241.54,125,MS-DRG,23393.232,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23393.23,100,MS-DRG,18714.584,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9129.95,100,,,Case Rate,100% of CMS IPPS Rate,23393.23,100,MS-DRG,18714.584,Case Rate,100% of CMS IPPS Rate,8086.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8086.49,29241.54,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,CDM,100,RC,,,Inpatient,,,,,,21104.26,125,MS-DRG,16883.408,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16883.41,100,MS-DRG,13506.728,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5681.53,100,,,Case Rate,100% of CMS IPPS Rate,16883.41,100,MS-DRG,13506.728,Case Rate,100% of CMS IPPS Rate,5032.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5032.19,21104.26,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,CDM,100,RC,,,Inpatient,,,,,,17878.45,125,MS-DRG,14302.76,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14302.76,100,MS-DRG,11442.208,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4314.5,100,,,Case Rate,100% of CMS IPPS Rate,14302.76,100,MS-DRG,11442.208,Case Rate,100% of CMS IPPS Rate,3821.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3821.4,17878.45,
INTERSTITIAL LUNG DISEASE WITH MCC,196,CDM,100,RC,,,Inpatient,,,,,,38502.01,125,MS-DRG,30801.608,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30801.61,100,MS-DRG,24641.288,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13054.36,100,,,Case Rate,100% of CMS IPPS Rate,30801.61,100,MS-DRG,24641.288,Case Rate,100% of CMS IPPS Rate,11562.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11562.38,38502.01,
INTERSTITIAL LUNG DISEASE WITH CC,197,CDM,100,RC,,,Inpatient,,,,,,23883.73,125,MS-DRG,19106.984,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19106.98,100,MS-DRG,15285.584,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6859.41,100,,,Case Rate,100% of CMS IPPS Rate,19106.98,100,MS-DRG,15285.584,Case Rate,100% of CMS IPPS Rate,6075.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6075.45,23883.73,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,CDM,100,RC,,,Inpatient,,,,,,19148.84,125,MS-DRG,15319.072,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15319.07,100,MS-DRG,12255.256,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4663.02,100,,,Case Rate,100% of CMS IPPS Rate,15319.07,100,MS-DRG,12255.256,Case Rate,100% of CMS IPPS Rate,4130.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4130.08,19148.84,
PNEUMOTHORAX WITH MCC,199,CDM,100,RC,,,Inpatient,,,,,,36559.66,125,MS-DRG,29247.728,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29247.73,100,MS-DRG,23398.184,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12231.23,100,,,Case Rate,100% of CMS IPPS Rate,29247.73,100,MS-DRG,23398.184,Case Rate,100% of CMS IPPS Rate,10833.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10833.33,36559.66,
PNEUMOTHORAX WITH CC,200,CDM,100,RC,,,Inpatient,,,,,,25804.81,125,MS-DRG,20643.848,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20643.85,100,MS-DRG,16515.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7673.54,100,,,Case Rate,100% of CMS IPPS Rate,20643.85,100,MS-DRG,16515.08,Case Rate,100% of CMS IPPS Rate,6796.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6796.53,25804.81,
PNEUMOTHORAX WITHOUT CC/MCC,201,CDM,100,RC,,,Inpatient,,,,,,18767.88,125,MS-DRG,15014.304,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15014.3,100,MS-DRG,12011.44,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4691.42,100,,,Case Rate,100% of CMS IPPS Rate,15014.3,100,MS-DRG,12011.44,Case Rate,100% of CMS IPPS Rate,4155.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4155.24,18767.88,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,CDM,100,RC,,,Inpatient,,,,,,23502.76,125,MS-DRG,18802.208,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18802.21,100,MS-DRG,15041.768,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6697.97,100,,,Case Rate,100% of CMS IPPS Rate,18802.21,100,MS-DRG,15041.768,Case Rate,100% of CMS IPPS Rate,5932.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5932.46,23502.76,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,CDM,100,RC,,,Inpatient,,,,,,19086.69,125,MS-DRG,15269.352,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15269.35,100,MS-DRG,12215.48,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4826.53,100,,,Case Rate,100% of CMS IPPS Rate,15269.35,100,MS-DRG,12215.48,Case Rate,100% of CMS IPPS Rate,4274.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4274.91,19086.69,
RESPIRATORY SIGNS AND SYMPTOMS,204,CDM,100,RC,,,Inpatient,,,,,,20957.11,125,MS-DRG,16765.688,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16765.69,100,MS-DRG,13412.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5619.18,100,,,Case Rate,100% of CMS IPPS Rate,16765.69,100,MS-DRG,13412.552,Case Rate,100% of CMS IPPS Rate,4976.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4976.96,20957.11,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,CDM,100,RC,,,Inpatient,,,,,,38562.54,125,MS-DRG,30850.032,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30850.03,100,MS-DRG,24680.024,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13080,100,,,Case Rate,100% of CMS IPPS Rate,30850.03,100,MS-DRG,24680.024,Case Rate,100% of CMS IPPS Rate,11585.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11585.09,38562.54,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,CDM,100,RC,,,Inpatient,,,,,,22507.06,125,MS-DRG,18005.648,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18005.65,100,MS-DRG,14404.52,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6276.02,100,,,Case Rate,100% of CMS IPPS Rate,18005.65,100,MS-DRG,14404.52,Case Rate,100% of CMS IPPS Rate,5558.73,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5558.73,22507.06,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,CDM,100,RC,,,Inpatient,,,,,,113434.58,125,MS-DRG,90747.664,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90747.66,100,MS-DRG,72598.128,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,44809.29,100,,,Case Rate,100% of CMS IPPS Rate,90747.66,100,MS-DRG,72598.128,Case Rate,100% of CMS IPPS Rate,39688.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,39688.04,113434.6,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,CDM,100,RC,,,Inpatient,,,,,,51576.93,125,MS-DRG,41261.544,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41261.54,100,MS-DRG,33009.232,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18595.25,100,,,Case Rate,100% of CMS IPPS Rate,41261.54,100,MS-DRG,33009.232,Case Rate,100% of CMS IPPS Rate,16470,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16470,51576.93,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,CDM,100,RC,,,Inpatient,,,,,,185810.01,125,MS-DRG,148648.008,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148648.01,100,MS-DRG,118918.408,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,75480.56,100,,,Case Rate,100% of CMS IPPS Rate,148648.01,100,MS-DRG,118918.408,Case Rate,100% of CMS IPPS Rate,66853.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,66853.9,185810,
OTHER HEART ASSIST SYSTEM IMPLANT,215,CDM,100,RC,,,Inpatient,,,,,,180919.81,125,MS-DRG,144735.848,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144735.85,100,MS-DRG,115788.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,73408.19,100,,,Case Rate,100% of CMS IPPS Rate,144735.85,100,MS-DRG,115788.68,Case Rate,100% of CMS IPPS Rate,65018.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,65018.38,180919.8,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,CDM,100,RC,,,Inpatient,,,,,,165490.54,125,MS-DRG,132392.432,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132392.43,100,MS-DRG,105913.944,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,66869.58,100,,,Case Rate,100% of CMS IPPS Rate,132392.43,100,MS-DRG,105913.944,Case Rate,100% of CMS IPPS Rate,59227.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,59227.06,165490.5,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,CDM,100,RC,,,Inpatient,,,,,,113282.51,125,MS-DRG,90626.008,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90626.01,100,MS-DRG,72500.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,44744.85,100,,,Case Rate,100% of CMS IPPS Rate,90626.01,100,MS-DRG,72500.808,Case Rate,100% of CMS IPPS Rate,39630.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,39630.97,113282.5,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,CDM,100,RC,,,Inpatient,,,,,,104967.05,125,MS-DRG,83973.64,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83973.64,100,MS-DRG,67178.912,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,41220.91,100,,,Case Rate,100% of CMS IPPS Rate,83973.64,100,MS-DRG,67178.912,Case Rate,100% of CMS IPPS Rate,36509.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,36509.78,104967.1,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,CDM,100,RC,,,Inpatient,,,,,,134203.66,125,MS-DRG,107362.928,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107362.93,100,MS-DRG,85890.344,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,53610.82,100,,,Case Rate,100% of CMS IPPS Rate,107362.93,100,MS-DRG,85890.344,Case Rate,100% of CMS IPPS Rate,47483.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,47483.64,134203.7,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,CDM,100,RC,,,Inpatient,,,,,,94297.19,125,MS-DRG,75437.752,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75437.75,100,MS-DRG,60350.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,36699.25,100,,,Case Rate,100% of CMS IPPS Rate,75437.75,100,MS-DRG,60350.2,Case Rate,100% of CMS IPPS Rate,32504.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,32504.89,94297.19,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,CDM,100,RC,,,Inpatient,,,,,,82785.33,125,MS-DRG,66228.264,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66228.26,100,MS-DRG,52982.608,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31820.75,100,,,Case Rate,100% of CMS IPPS Rate,66228.26,100,MS-DRG,52982.608,Case Rate,100% of CMS IPPS Rate,28183.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28183.96,82785.33,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,CDM,100,RC,,,Inpatient,,,,,,89173.19,125,MS-DRG,71338.552,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71338.55,100,MS-DRG,57070.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,34527.79,100,,,Case Rate,100% of CMS IPPS Rate,71338.55,100,MS-DRG,57070.84,Case Rate,100% of CMS IPPS Rate,30581.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30581.62,89173.19,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,CDM,100,RC,,,Inpatient,,,,,,58484.7,125,MS-DRG,46787.76,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46787.76,100,MS-DRG,37430.208,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21522.62,100,,,Case Rate,100% of CMS IPPS Rate,46787.76,100,MS-DRG,37430.208,Case Rate,100% of CMS IPPS Rate,19062.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19062.8,58484.7,
CORONARY BYPASS WITH PTCA WITH MCC,231,CDM,100,RC,,,Inpatient,,,,,,146243.61,125,MS-DRG,116994.888,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116994.89,100,MS-DRG,93595.912,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,58713.11,100,,,Case Rate,100% of CMS IPPS Rate,116994.89,100,MS-DRG,93595.912,Case Rate,100% of CMS IPPS Rate,52002.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,52002.8,146243.6,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,CDM,100,RC,,,Inpatient,,,,,,107573.19,125,MS-DRG,86058.552,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86058.55,100,MS-DRG,68846.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,42325.35,100,,,Case Rate,100% of CMS IPPS Rate,86058.55,100,MS-DRG,68846.84,Case Rate,100% of CMS IPPS Rate,37487.99,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37487.99,107573.2,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,CDM,100,RC,,,Inpatient,,,,,,135493.66,125,MS-DRG,108394.928,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108394.93,100,MS-DRG,86715.944,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,54157.49,100,,,Case Rate,100% of CMS IPPS Rate,108394.93,100,MS-DRG,86715.944,Case Rate,100% of CMS IPPS Rate,47967.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,47967.84,135493.7,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,CDM,100,RC,,,Inpatient,,,,,,94681.4,125,MS-DRG,75745.12,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75745.12,100,MS-DRG,60596.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,36862.07,100,,,Case Rate,100% of CMS IPPS Rate,75745.12,100,MS-DRG,60596.096,Case Rate,100% of CMS IPPS Rate,32649.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,32649.11,94681.4,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,CDM,100,RC,,,Inpatient,,,,,,103902.66,125,MS-DRG,83122.128,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83122.13,100,MS-DRG,66497.704,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,40769.86,100,,,Case Rate,100% of CMS IPPS Rate,83122.13,100,MS-DRG,66497.704,Case Rate,100% of CMS IPPS Rate,36110.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,36110.28,103902.7,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,CDM,100,RC,,,Inpatient,,,,,,74929.28,125,MS-DRG,59943.424,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59943.42,100,MS-DRG,47954.736,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28491.51,100,,,Case Rate,100% of CMS IPPS Rate,59943.42,100,MS-DRG,47954.736,Case Rate,100% of CMS IPPS Rate,25235.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25235.22,74929.28,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,CDM,100,RC,,,Inpatient,,,,,,90049.53,125,MS-DRG,72039.624,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72039.62,100,MS-DRG,57631.696,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,34899.17,100,,,Case Rate,100% of CMS IPPS Rate,72039.62,100,MS-DRG,57631.696,Case Rate,100% of CMS IPPS Rate,30910.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30910.55,90049.53,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,CDM,100,RC,,,Inpatient,,,,,,55311.21,125,MS-DRG,44248.968,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44248.97,100,MS-DRG,35399.176,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20177.76,100,,,Case Rate,100% of CMS IPPS Rate,44248.97,100,MS-DRG,35399.176,Case Rate,100% of CMS IPPS Rate,17871.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17871.65,55311.21,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,CDM,100,RC,,,Inpatient,,,,,,32383.95,125,MS-DRG,25907.16,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25907.16,100,MS-DRG,20725.728,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10461.64,100,,,Case Rate,100% of CMS IPPS Rate,25907.16,100,MS-DRG,20725.728,Case Rate,100% of CMS IPPS Rate,9265.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9265.98,32383.95,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,CDM,100,RC,,,Inpatient,,,,,,63155.83,125,MS-DRG,50524.664,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50524.66,100,MS-DRG,40419.728,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23502.15,100,,,Case Rate,100% of CMS IPPS Rate,50524.66,100,MS-DRG,40419.728,Case Rate,100% of CMS IPPS Rate,20816.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20816.09,63155.83,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,CDM,100,RC,,,Inpatient,,,,,,44530.19,125,MS-DRG,35624.152,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35624.15,100,MS-DRG,28499.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15608.98,100,,,Case Rate,100% of CMS IPPS Rate,35624.15,100,MS-DRG,28499.32,Case Rate,100% of CMS IPPS Rate,13825.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13825.03,44530.19,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,CDM,100,RC,,,Inpatient,,,,,,37203.86,125,MS-DRG,29763.088,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29763.09,100,MS-DRG,23810.472,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12504.22,100,,,Case Rate,100% of CMS IPPS Rate,29763.09,100,MS-DRG,23810.472,Case Rate,100% of CMS IPPS Rate,11075.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11075.12,37203.86,
AICD GENERATOR PROCEDURES,245,CDM,100,RC,,,Inpatient,,,,,,87595.43,125,MS-DRG,70076.344,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70076.34,100,MS-DRG,56061.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,33859.17,100,,,Case Rate,100% of CMS IPPS Rate,70076.34,100,MS-DRG,56061.072,Case Rate,100% of CMS IPPS Rate,29989.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29989.41,87595.43,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,CDM,100,RC,,,Inpatient,,,,,,45507.9,125,MS-DRG,36406.32,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36406.32,100,MS-DRG,29125.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16023.31,100,,,Case Rate,100% of CMS IPPS Rate,36406.32,100,MS-DRG,29125.056,Case Rate,100% of CMS IPPS Rate,14192.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14192.01,45507.9,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,CDM,100,RC,,,Inpatient,,,,,,33245.58,125,MS-DRG,26596.464,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26596.46,100,MS-DRG,21277.168,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10826.79,100,,,Case Rate,100% of CMS IPPS Rate,26596.46,100,MS-DRG,21277.168,Case Rate,100% of CMS IPPS Rate,9589.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9589.39,33245.58,
OTHER VASCULAR PROCEDURES WITH MCC,252,CDM,100,RC,,,Inpatient,,,,,,63783.64,125,MS-DRG,51026.912,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51026.91,100,MS-DRG,40821.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23768.21,100,,,Case Rate,100% of CMS IPPS Rate,51026.91,100,MS-DRG,40821.528,Case Rate,100% of CMS IPPS Rate,21051.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21051.75,63783.64,
OTHER VASCULAR PROCEDURES WITH CC,253,CDM,100,RC,,,Inpatient,,,,,,49438.39,125,MS-DRG,39550.712,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39550.71,100,MS-DRG,31640.568,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17688.97,100,,,Case Rate,100% of CMS IPPS Rate,39550.71,100,MS-DRG,31640.568,Case Rate,100% of CMS IPPS Rate,15667.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15667.3,49438.39,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,CDM,100,RC,,,Inpatient,,,,,,36299.71,125,MS-DRG,29039.768,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29039.77,100,MS-DRG,23231.816,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12121.07,100,,,Case Rate,100% of CMS IPPS Rate,29039.77,100,MS-DRG,23231.816,Case Rate,100% of CMS IPPS Rate,10735.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10735.75,36299.71,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,CDM,100,RC,,,Inpatient,,,,,,50476.6,125,MS-DRG,40381.28,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40381.28,100,MS-DRG,32305.024,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18128.94,100,,,Case Rate,100% of CMS IPPS Rate,40381.28,100,MS-DRG,32305.024,Case Rate,100% of CMS IPPS Rate,16056.99,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16056.99,50476.6,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,CDM,100,RC,,,Inpatient,,,,,,35389.04,125,MS-DRG,28311.232,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28311.23,100,MS-DRG,22648.984,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11735.14,100,,,Case Rate,100% of CMS IPPS Rate,28311.23,100,MS-DRG,22648.984,Case Rate,100% of CMS IPPS Rate,10393.93,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10393.93,35389.04,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,CDM,100,RC,,,Inpatient,,,,,,22279.8,125,MS-DRG,17823.84,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17823.84,100,MS-DRG,14259.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5491.69,100,,,Case Rate,100% of CMS IPPS Rate,17823.84,100,MS-DRG,14259.072,Case Rate,100% of CMS IPPS Rate,4864.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4864.04,22279.8,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,CDM,100,RC,,,Inpatient,,,,,,53566.69,125,MS-DRG,42853.352,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42853.35,100,MS-DRG,34282.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19438.47,100,,,Case Rate,100% of CMS IPPS Rate,42853.35,100,MS-DRG,34282.68,Case Rate,100% of CMS IPPS Rate,17216.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17216.85,53566.69,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,CDM,100,RC,,,Inpatient,,,,,,36435.4,125,MS-DRG,29148.32,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29148.32,100,MS-DRG,23318.656,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12178.58,100,,,Case Rate,100% of CMS IPPS Rate,29148.32,100,MS-DRG,23318.656,Case Rate,100% of CMS IPPS Rate,10786.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10786.69,36435.4,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,CDM,100,RC,,,Inpatient,,,,,,63387.98,125,MS-DRG,50710.384,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50710.38,100,MS-DRG,40568.304,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23600.54,100,,,Case Rate,100% of CMS IPPS Rate,50710.38,100,MS-DRG,40568.304,Case Rate,100% of CMS IPPS Rate,20903.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20903.24,63387.98,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,CDM,100,RC,,,Inpatient,,,,,,38722.75,125,MS-DRG,30978.2,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30978.2,100,MS-DRG,24782.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13147.9,100,,,Case Rate,100% of CMS IPPS Rate,30978.2,100,MS-DRG,24782.56,Case Rate,100% of CMS IPPS Rate,11645.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11645.23,38722.75,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,CDM,100,RC,,,Inpatient,,,,,,32513.1,125,MS-DRG,26010.48,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26010.48,100,MS-DRG,20808.384,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10516.38,100,,,Case Rate,100% of CMS IPPS Rate,26010.48,100,MS-DRG,20808.384,Case Rate,100% of CMS IPPS Rate,9314.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9314.47,32513.1,
VEIN LIGATION AND STRIPPING,263,CDM,100,RC,,,Inpatient,,,,,,51549.14,125,MS-DRG,41239.312,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41239.31,100,MS-DRG,32991.448,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18583.47,100,,,Case Rate,100% of CMS IPPS Rate,41239.31,100,MS-DRG,32991.448,Case Rate,100% of CMS IPPS Rate,16459.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16459.56,51549.14,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,CDM,100,RC,,,Inpatient,,,,,,64841.48,125,MS-DRG,51873.184,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51873.18,100,MS-DRG,41498.544,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24216.5,100,,,Case Rate,100% of CMS IPPS Rate,51873.18,100,MS-DRG,41498.544,Case Rate,100% of CMS IPPS Rate,21448.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21448.8,64841.48,
AICD LEAD PROCEDURES,265,CDM,100,RC,,,Inpatient,,,,,,66020.3,125,MS-DRG,52816.24,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52816.24,100,MS-DRG,42252.992,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24716.06,100,,,Case Rate,100% of CMS IPPS Rate,52816.24,100,MS-DRG,42252.992,Case Rate,100% of CMS IPPS Rate,21891.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21891.26,66020.3,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,CDM,100,RC,,,Inpatient,,,,,,105645.55,125,MS-DRG,84516.44,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84516.44,100,MS-DRG,67613.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,41508.46,100,,,Case Rate,100% of CMS IPPS Rate,84516.44,100,MS-DRG,67613.152,Case Rate,100% of CMS IPPS Rate,36764.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,36764.46,105645.6,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,CDM,100,RC,,,Inpatient,,,,,,84618.15,125,MS-DRG,67694.52,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67694.52,100,MS-DRG,54155.616,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,32597.45,100,,,Case Rate,100% of CMS IPPS Rate,67694.52,100,MS-DRG,54155.616,Case Rate,100% of CMS IPPS Rate,28871.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28871.9,84618.15,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,CDM,100,RC,,,Inpatient,,,,,,116711.05,125,MS-DRG,93368.84,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93368.84,100,MS-DRG,74695.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,46197.8,100,,,Case Rate,100% of CMS IPPS Rate,93368.84,100,MS-DRG,74695.072,Case Rate,100% of CMS IPPS Rate,40917.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,40917.86,116711.1,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,CDM,100,RC,,,Inpatient,,,,,,75723.86,125,MS-DRG,60579.088,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60579.09,100,MS-DRG,48463.272,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28828.24,100,,,Case Rate,100% of CMS IPPS Rate,60579.09,100,MS-DRG,48463.272,Case Rate,100% of CMS IPPS Rate,25533.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25533.47,75723.86,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,CDM,100,RC,,,Inpatient,,,,,,91620.73,125,MS-DRG,73296.584,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73296.58,100,MS-DRG,58637.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,35565.02,100,,,Case Rate,100% of CMS IPPS Rate,73296.58,100,MS-DRG,58637.264,Case Rate,100% of CMS IPPS Rate,31500.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31500.3,91620.73,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,CDM,100,RC,,,Inpatient,,,,,,64012.54,125,MS-DRG,51210.032,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51210.03,100,MS-DRG,40968.024,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23865.21,100,,,Case Rate,100% of CMS IPPS Rate,51210.03,100,MS-DRG,40968.024,Case Rate,100% of CMS IPPS Rate,21137.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21137.66,64012.54,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,CDM,100,RC,,,Inpatient,,,,,,48607.8,125,MS-DRG,38886.24,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38886.24,100,MS-DRG,31108.992,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17336.99,100,,,Case Rate,100% of CMS IPPS Rate,38886.24,100,MS-DRG,31108.992,Case Rate,100% of CMS IPPS Rate,15355.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15355.55,48607.8,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,CDM,100,RC,,,Inpatient,,,,,,71629.89,125,MS-DRG,57303.912,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57303.91,100,MS-DRG,45843.128,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27093.3,100,,,Case Rate,100% of CMS IPPS Rate,57303.91,100,MS-DRG,45843.128,Case Rate,100% of CMS IPPS Rate,23996.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23996.81,71629.89,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,CDM,100,RC,,,Inpatient,,,,,,58725.04,125,MS-DRG,46980.032,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46980.03,100,MS-DRG,37584.024,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21624.47,100,,,Case Rate,100% of CMS IPPS Rate,46980.03,100,MS-DRG,37584.024,Case Rate,100% of CMS IPPS Rate,19153.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19153.02,58725.04,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,CDM,100,RC,,,Inpatient,,,,,,123241.15,125,MS-DRG,98592.92,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98592.92,100,MS-DRG,78874.336,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,48965.12,100,,,Case Rate,100% of CMS IPPS Rate,98592.92,100,MS-DRG,78874.336,Case Rate,100% of CMS IPPS Rate,43368.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,43368.91,123241.2,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,CDM,100,RC,,,Inpatient,,,,,,108974.36,125,MS-DRG,87179.488,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87179.49,100,MS-DRG,69743.592,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,42919.14,100,,,Case Rate,100% of CMS IPPS Rate,87179.49,100,MS-DRG,69743.592,Case Rate,100% of CMS IPPS Rate,38013.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,38013.92,108974.4,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,CDM,100,RC,,,Inpatient,,,,,,83754.86,125,MS-DRG,67003.888,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67003.89,100,MS-DRG,53603.112,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,32231.62,100,,,Case Rate,100% of CMS IPPS Rate,67003.89,100,MS-DRG,53603.112,Case Rate,100% of CMS IPPS Rate,28547.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28547.87,83754.86,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,CDM,100,RC,,,Inpatient,,,,,,89500.16,125,MS-DRG,71600.128,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71600.13,100,MS-DRG,57280.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,34666.36,100,,,Case Rate,100% of CMS IPPS Rate,71600.13,100,MS-DRG,57280.104,Case Rate,100% of CMS IPPS Rate,30704.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30704.35,89500.16,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,CDM,100,RC,,,Inpatient,,,,,,60088.59,125,MS-DRG,48070.872,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48070.87,100,MS-DRG,38456.696,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22202.33,100,,,Case Rate,100% of CMS IPPS Rate,48070.87,100,MS-DRG,38456.696,Case Rate,100% of CMS IPPS Rate,19664.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19664.83,60088.59,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,CDM,100,RC,,,Inpatient,,,,,,34533.95,125,MS-DRG,27627.16,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27627.16,100,MS-DRG,22101.728,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11372.77,100,,,Case Rate,100% of CMS IPPS Rate,27627.16,100,MS-DRG,22101.728,Case Rate,100% of CMS IPPS Rate,10072.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10072.98,34533.95,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,CDM,100,RC,,,Inpatient,,,,,,22768.66,125,MS-DRG,18214.928,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18214.93,100,MS-DRG,14571.944,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6386.88,100,,,Case Rate,100% of CMS IPPS Rate,18214.93,100,MS-DRG,14571.944,Case Rate,100% of CMS IPPS Rate,5656.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5656.92,22768.66,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,CDM,100,RC,,,Inpatient,,,,,,19552.66,125,MS-DRG,15642.128,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15642.13,100,MS-DRG,12513.704,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5024,100,,,Case Rate,100% of CMS IPPS Rate,15642.13,100,MS-DRG,12513.704,Case Rate,100% of CMS IPPS Rate,4449.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4449.81,19552.66,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,CDM,100,RC,,,Inpatient,,,,,,39667.75,125,MS-DRG,31734.2,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31734.2,100,MS-DRG,25387.36,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13548.38,100,,,Case Rate,100% of CMS IPPS Rate,31734.2,100,MS-DRG,25387.36,Case Rate,100% of CMS IPPS Rate,11999.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11999.94,39667.75,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,CDM,100,RC,,,Inpatient,,,,,,19812.64,125,MS-DRG,15850.112,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15850.11,100,MS-DRG,12680.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5134.17,100,,,Case Rate,100% of CMS IPPS Rate,15850.11,100,MS-DRG,12680.088,Case Rate,100% of CMS IPPS Rate,4547.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4547.38,19812.64,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,CDM,100,RC,,,Inpatient,,,,,,16876.21,125,MS-DRG,13500.968,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13500.97,100,MS-DRG,10800.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3889.77,100,,,Case Rate,100% of CMS IPPS Rate,13500.97,100,MS-DRG,10800.776,Case Rate,100% of CMS IPPS Rate,3445.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3445.21,16876.21,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,CDM,100,RC,,,Inpatient,,,,,,43884.36,125,MS-DRG,35107.488,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35107.49,100,MS-DRG,28085.992,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15335.29,100,,,Case Rate,100% of CMS IPPS Rate,35107.49,100,MS-DRG,28085.992,Case Rate,100% of CMS IPPS Rate,13582.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13582.62,43884.36,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,CDM,100,RC,,,Inpatient,,,,,,25513.79,125,MS-DRG,20411.032,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20411.03,100,MS-DRG,16328.824,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7550.2,100,,,Case Rate,100% of CMS IPPS Rate,20411.03,100,MS-DRG,16328.824,Case Rate,100% of CMS IPPS Rate,6687.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6687.29,25513.79,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,CDM,100,RC,,,Inpatient,,,,,,52356.8,125,MS-DRG,41885.44,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41885.44,100,MS-DRG,33508.352,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18925.74,100,,,Case Rate,100% of CMS IPPS Rate,41885.44,100,MS-DRG,33508.352,Case Rate,100% of CMS IPPS Rate,16762.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16762.72,52356.8,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,CDM,100,RC,,,Inpatient,,,,,,33476.13,125,MS-DRG,26780.904,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26780.9,100,MS-DRG,21424.72,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10924.48,100,,,Case Rate,100% of CMS IPPS Rate,26780.9,100,MS-DRG,21424.72,Case Rate,100% of CMS IPPS Rate,9675.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9675.92,33476.13,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,CDM,100,RC,,,Inpatient,,,,,,23703.86,125,MS-DRG,18963.088,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18963.09,100,MS-DRG,15170.472,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6783.2,100,,,Case Rate,100% of CMS IPPS Rate,18963.09,100,MS-DRG,15170.472,Case Rate,100% of CMS IPPS Rate,6007.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6007.95,23703.86,
HEART FAILURE AND SHOCK WITH MCC,291,CDM,100,RC,,,Inpatient,,,,,,29030.61,125,MS-DRG,23224.488,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23224.49,100,MS-DRG,18579.592,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9040.57,100,,,Case Rate,100% of CMS IPPS Rate,23224.49,100,MS-DRG,18579.592,Case Rate,100% of CMS IPPS Rate,8007.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8007.32,29030.61,
HEART FAILURE AND SHOCK WITH CC,292,CDM,100,RC,,,Inpatient,,,,,,21777.86,125,MS-DRG,17422.288,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17422.29,100,MS-DRG,13937.832,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5967,100,,,Case Rate,100% of CMS IPPS Rate,17422.29,100,MS-DRG,13937.832,Case Rate,100% of CMS IPPS Rate,5285.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5285.03,21777.86,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,CDM,100,RC,,,Inpatient,,,,,,16668.58,125,MS-DRG,13334.864,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13334.86,100,MS-DRG,10667.888,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3801.78,100,,,Case Rate,100% of CMS IPPS Rate,13334.86,100,MS-DRG,10667.888,Case Rate,100% of CMS IPPS Rate,3367.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3367.27,16668.58,
DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,294,CDM,100,RC,,,Inpatient,,,,,,27774.96,125,MS-DRG,22219.968,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22219.97,100,MS-DRG,17775.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8508.44,100,,,Case Rate,100% of CMS IPPS Rate,22219.97,100,MS-DRG,17775.976,Case Rate,100% of CMS IPPS Rate,7536.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7536.01,27774.96,
DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC,295,CDM,100,RC,,,Inpatient,,,,,,20610.49,125,MS-DRG,16488.392,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16488.39,100,MS-DRG,13190.712,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5472.29,100,,,Case Rate,100% of CMS IPPS Rate,16488.39,100,MS-DRG,13190.712,Case Rate,100% of CMS IPPS Rate,4846.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4846.86,20610.49,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,CDM,100,RC,,,Inpatient,,,,,,34484.9,125,MS-DRG,27587.92,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27587.92,100,MS-DRG,22070.336,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11351.98,100,,,Case Rate,100% of CMS IPPS Rate,27587.92,100,MS-DRG,22070.336,Case Rate,100% of CMS IPPS Rate,10054.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10054.57,34484.9,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,CDM,100,RC,,,Inpatient,,,,,,19214.23,125,MS-DRG,15371.384,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15371.38,100,MS-DRG,12297.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4880.58,100,,,Case Rate,100% of CMS IPPS Rate,15371.38,100,MS-DRG,12297.104,Case Rate,100% of CMS IPPS Rate,4322.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4322.78,19214.23,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,CDM,100,RC,,,Inpatient,,,,,,14919.15,125,MS-DRG,11935.32,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11935.32,100,MS-DRG,9548.256,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3060.41,100,,,Case Rate,100% of CMS IPPS Rate,11935.32,100,MS-DRG,9548.256,Case Rate,100% of CMS IPPS Rate,2710.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2710.63,14919.15,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,CDM,100,RC,,,Inpatient,,,,,,34144.81,125,MS-DRG,27315.848,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27315.85,100,MS-DRG,21852.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11207.87,100,,,Case Rate,100% of CMS IPPS Rate,27315.85,100,MS-DRG,21852.68,Case Rate,100% of CMS IPPS Rate,9926.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9926.92,34144.81,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,CDM,100,RC,,,Inpatient,,,,,,25201.51,125,MS-DRG,20161.208,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20161.21,100,MS-DRG,16128.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7417.87,100,,,Case Rate,100% of CMS IPPS Rate,20161.21,100,MS-DRG,16128.968,Case Rate,100% of CMS IPPS Rate,6570.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6570.08,25201.51,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,CDM,100,RC,,,Inpatient,,,,,,19361.39,125,MS-DRG,15489.112,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15489.11,100,MS-DRG,12391.288,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4942.93,100,,,Case Rate,100% of CMS IPPS Rate,15489.11,100,MS-DRG,12391.288,Case Rate,100% of CMS IPPS Rate,4378.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4378.01,19361.39,
ATHEROSCLEROSIS WITH MCC,302,CDM,100,RC,,,Inpatient,,,,,,26717.13,125,MS-DRG,21373.704,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21373.7,100,MS-DRG,17098.96,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8060.16,100,,,Case Rate,100% of CMS IPPS Rate,21373.7,100,MS-DRG,17098.96,Case Rate,100% of CMS IPPS Rate,7138.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7138.96,26717.13,
ATHEROSCLEROSIS WITHOUT MCC,303,CDM,100,RC,,,Inpatient,,,,,,18691.04,125,MS-DRG,14952.832,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14952.83,100,MS-DRG,11962.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4658.86,100,,,Case Rate,100% of CMS IPPS Rate,14952.83,100,MS-DRG,11962.264,Case Rate,100% of CMS IPPS Rate,4126.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4126.4,18691.04,
HYPERTENSION WITH MCC,304,CDM,100,RC,,,Inpatient,,,,,,26905.14,125,MS-DRG,21524.112,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21524.11,100,MS-DRG,17219.288,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8139.84,100,,,Case Rate,100% of CMS IPPS Rate,21524.11,100,MS-DRG,17219.288,Case Rate,100% of CMS IPPS Rate,7209.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7209.54,26905.14,
HYPERTENSION WITHOUT MCC,305,CDM,100,RC,,,Inpatient,,,,,,19971.21,125,MS-DRG,15976.968,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15976.97,100,MS-DRG,12781.576,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5201.38,100,,,Case Rate,100% of CMS IPPS Rate,15976.97,100,MS-DRG,12781.576,Case Rate,100% of CMS IPPS Rate,4606.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4606.91,19971.21,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,CDM,100,RC,,,Inpatient,,,,,,32179.59,125,MS-DRG,25743.672,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25743.67,100,MS-DRG,20594.936,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10375.04,100,,,Case Rate,100% of CMS IPPS Rate,25743.67,100,MS-DRG,20594.936,Case Rate,100% of CMS IPPS Rate,9189.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9189.27,32179.59,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,CDM,100,RC,,,Inpatient,,,,,,22843.88,125,MS-DRG,18275.104,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18275.1,100,MS-DRG,14620.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6418.75,100,,,Case Rate,100% of CMS IPPS Rate,18275.1,100,MS-DRG,14620.08,Case Rate,100% of CMS IPPS Rate,5685.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5685.15,22843.88,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,CDM,100,RC,,,Inpatient,,,,,,27413.64,125,MS-DRG,21930.912,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21930.91,100,MS-DRG,17544.728,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8355.32,100,,,Case Rate,100% of CMS IPPS Rate,21930.91,100,MS-DRG,17544.728,Case Rate,100% of CMS IPPS Rate,7400.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7400.39,27413.64,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,CDM,100,RC,,,Inpatient,,,,,,19784.84,125,MS-DRG,15827.872,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15827.87,100,MS-DRG,12662.296,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5122.39,100,,,Case Rate,100% of CMS IPPS Rate,15827.87,100,MS-DRG,12662.296,Case Rate,100% of CMS IPPS Rate,4536.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4536.95,19784.84,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,CDM,100,RC,,,Inpatient,,,,,,16845.14,125,MS-DRG,13476.112,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13476.11,100,MS-DRG,10780.888,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3876.61,100,,,Case Rate,100% of CMS IPPS Rate,13476.11,100,MS-DRG,10780.888,Case Rate,100% of CMS IPPS Rate,3433.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3433.55,16845.14,
ANGINA PECTORIS,311,CDM,100,RC,,,Inpatient,,,,,,19114.5,125,MS-DRG,15291.6,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15291.6,100,MS-DRG,12233.28,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4838.31,100,,,Case Rate,100% of CMS IPPS Rate,15291.6,100,MS-DRG,12233.28,Case Rate,100% of CMS IPPS Rate,4285.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4285.34,19114.5,
SYNCOPE AND COLLAPSE,312,CDM,100,RC,,,Inpatient,,,,,,21943,125,MS-DRG,17554.4,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17554.4,100,MS-DRG,14043.52,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6036.98,100,,,Case Rate,100% of CMS IPPS Rate,17554.4,100,MS-DRG,14043.52,Case Rate,100% of CMS IPPS Rate,5347.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5347.01,21943,
CHEST PAIN,313,CDM,100,RC,,,Inpatient,,,,,,19361.39,125,MS-DRG,15489.112,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15489.11,100,MS-DRG,12391.288,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4942.93,100,,,Case Rate,100% of CMS IPPS Rate,15489.11,100,MS-DRG,12391.288,Case Rate,100% of CMS IPPS Rate,4378.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4378.01,19361.39,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,CDM,100,RC,,,Inpatient,,,,,,42906.65,125,MS-DRG,34325.32,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34325.32,100,MS-DRG,27460.256,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14920.96,100,,,Case Rate,100% of CMS IPPS Rate,34325.32,100,MS-DRG,27460.256,Case Rate,100% of CMS IPPS Rate,13215.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13215.64,42906.65,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,CDM,100,RC,,,Inpatient,,,,,,23430.83,125,MS-DRG,18744.664,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18744.66,100,MS-DRG,14995.728,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6667.49,100,,,Case Rate,100% of CMS IPPS Rate,18744.66,100,MS-DRG,14995.728,Case Rate,100% of CMS IPPS Rate,5905.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5905.46,23430.83,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,CDM,100,RC,,,Inpatient,,,,,,18859.44,125,MS-DRG,15087.552,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15087.55,100,MS-DRG,12070.04,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4730.22,100,,,Case Rate,100% of CMS IPPS Rate,15087.55,100,MS-DRG,12070.04,Case Rate,100% of CMS IPPS Rate,4189.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4189.61,18859.44,
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,CDM,100,RC,,,Inpatient,,,,,,108843.56,125,MS-DRG,87074.848,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87074.85,100,MS-DRG,69659.88,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,42863.71,100,,,Case Rate,100% of CMS IPPS Rate,87074.85,100,MS-DRG,69659.88,Case Rate,100% of CMS IPPS Rate,37964.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37964.82,108843.6,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,CDM,100,RC,,,Inpatient,,,,,,79518.64,125,MS-DRG,63614.912,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63614.91,100,MS-DRG,50891.928,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30436.39,100,,,Case Rate,100% of CMS IPPS Rate,63614.91,100,MS-DRG,50891.928,Case Rate,100% of CMS IPPS Rate,26957.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26957.82,79518.64,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,CDM,100,RC,,,Inpatient,,,,,,45543.88,125,MS-DRG,36435.104,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36435.1,100,MS-DRG,29148.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16038.55,100,,,Case Rate,100% of CMS IPPS Rate,36435.1,100,MS-DRG,29148.08,Case Rate,100% of CMS IPPS Rate,14205.51,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14205.51,45543.88,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,CDM,100,RC,,,Inpatient,,,,,,54241.95,125,MS-DRG,43393.56,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43393.56,100,MS-DRG,34714.848,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19724.62,100,,,Case Rate,100% of CMS IPPS Rate,43393.56,100,MS-DRG,34714.848,Case Rate,100% of CMS IPPS Rate,17470.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17470.3,54241.95,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,CDM,100,RC,,,Inpatient,,,,,,37277.43,125,MS-DRG,29821.944,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29821.94,100,MS-DRG,23857.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12535.4,100,,,Case Rate,100% of CMS IPPS Rate,29821.94,100,MS-DRG,23857.552,Case Rate,100% of CMS IPPS Rate,11102.73,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11102.73,37277.43,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,CDM,100,RC,,,Inpatient,,,,,,77337.59,125,MS-DRG,61870.072,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61870.07,100,MS-DRG,49496.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29512.1,100,,,Case Rate,100% of CMS IPPS Rate,61870.07,100,MS-DRG,49496.056,Case Rate,100% of CMS IPPS Rate,26139.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26139.17,77337.59,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,CDM,100,RC,,,Inpatient,,,,,,59936.55,125,MS-DRG,47949.24,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47949.24,100,MS-DRG,38359.392,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22137.89,100,,,Case Rate,100% of CMS IPPS Rate,47949.24,100,MS-DRG,38359.392,Case Rate,100% of CMS IPPS Rate,19607.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19607.75,59936.55,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,CDM,100,RC,,,Inpatient,,,,,,54492.09,125,MS-DRG,43593.672,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43593.67,100,MS-DRG,34874.936,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19830.63,100,,,Case Rate,100% of CMS IPPS Rate,43593.67,100,MS-DRG,34874.936,Case Rate,100% of CMS IPPS Rate,17564.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17564.19,54492.09,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,CDM,100,RC,,,Inpatient,,,,,,90737.85,125,MS-DRG,72590.28,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72590.28,100,MS-DRG,58072.224,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,35190.87,100,,,Case Rate,100% of CMS IPPS Rate,72590.28,100,MS-DRG,58072.224,Case Rate,100% of CMS IPPS Rate,31168.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31168.91,90737.85,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,CDM,100,RC,,,Inpatient,,,,,,47396.3,125,MS-DRG,37917.04,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37917.04,100,MS-DRG,30333.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16823.58,100,,,Case Rate,100% of CMS IPPS Rate,37917.04,100,MS-DRG,30333.632,Case Rate,100% of CMS IPPS Rate,14900.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14900.81,47396.3,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,CDM,100,RC,,,Inpatient,,,,,,33750.78,125,MS-DRG,27000.624,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27000.62,100,MS-DRG,21600.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11040.88,100,,,Case Rate,100% of CMS IPPS Rate,27000.62,100,MS-DRG,21600.496,Case Rate,100% of CMS IPPS Rate,9779.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9779.02,33750.78,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,CDM,100,RC,,,Inpatient,,,,,,82773.9,125,MS-DRG,66219.12,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66219.12,100,MS-DRG,52975.296,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31815.9,100,,,Case Rate,100% of CMS IPPS Rate,66219.12,100,MS-DRG,52975.296,Case Rate,100% of CMS IPPS Rate,28179.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28179.66,82773.9,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,CDM,100,RC,,,Inpatient,,,,,,46343.38,125,MS-DRG,37074.704,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37074.7,100,MS-DRG,29659.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16377.37,100,,,Case Rate,100% of CMS IPPS Rate,37074.7,100,MS-DRG,29659.76,Case Rate,100% of CMS IPPS Rate,14505.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14505.6,46343.38,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,CDM,100,RC,,,Inpatient,,,,,,34690.89,125,MS-DRG,27752.712,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27752.71,100,MS-DRG,22202.168,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11439.28,100,,,Case Rate,100% of CMS IPPS Rate,27752.71,100,MS-DRG,22202.168,Case Rate,100% of CMS IPPS Rate,10131.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10131.89,34690.89,
RECTAL RESECTION WITH MCC,332,CDM,100,RC,,,Inpatient,,,,,,64409.84,125,MS-DRG,51527.872,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51527.87,100,MS-DRG,41222.296,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24033.58,100,,,Case Rate,100% of CMS IPPS Rate,51527.87,100,MS-DRG,41222.296,Case Rate,100% of CMS IPPS Rate,21286.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21286.79,64409.84,
RECTAL RESECTION WITH CC,333,CDM,100,RC,,,Inpatient,,,,,,42445.59,125,MS-DRG,33956.472,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33956.47,100,MS-DRG,27165.176,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14725.57,100,,,Case Rate,100% of CMS IPPS Rate,33956.47,100,MS-DRG,27165.176,Case Rate,100% of CMS IPPS Rate,13042.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13042.58,42445.59,
RECTAL RESECTION WITHOUT CC/MCC,334,CDM,100,RC,,,Inpatient,,,,,,34815.16,125,MS-DRG,27852.128,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27852.13,100,MS-DRG,22281.704,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11491.94,100,,,Case Rate,100% of CMS IPPS Rate,27852.13,100,MS-DRG,22281.704,Case Rate,100% of CMS IPPS Rate,10178.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10178.53,34815.16,
PERITONEAL ADHESIOLYSIS WITH MCC,335,CDM,100,RC,,,Inpatient,,,,,,66939.15,125,MS-DRG,53551.32,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53551.32,100,MS-DRG,42841.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25105.45,100,,,Case Rate,100% of CMS IPPS Rate,53551.32,100,MS-DRG,42841.056,Case Rate,100% of CMS IPPS Rate,22236.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22236.15,66939.15,
PERITONEAL ADHESIOLYSIS WITH CC,336,CDM,100,RC,,,Inpatient,,,,,,42233.04,125,MS-DRG,33786.432,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33786.43,100,MS-DRG,27029.144,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14635.49,100,,,Case Rate,100% of CMS IPPS Rate,33786.43,100,MS-DRG,27029.144,Case Rate,100% of CMS IPPS Rate,12962.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12962.8,42233.04,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,CDM,100,RC,,,Inpatient,,,,,,32795.96,125,MS-DRG,26236.768,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26236.77,100,MS-DRG,20989.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10636.25,100,,,Case Rate,100% of CMS IPPS Rate,26236.77,100,MS-DRG,20989.416,Case Rate,100% of CMS IPPS Rate,9420.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9420.63,32795.96,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,CDM,100,RC,,,Inpatient,,,,,,51751.86,125,MS-DRG,41401.488,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41401.49,100,MS-DRG,33121.192,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18669.38,100,,,Case Rate,100% of CMS IPPS Rate,41401.49,100,MS-DRG,33121.192,Case Rate,100% of CMS IPPS Rate,16535.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16535.66,51751.86,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,CDM,100,RC,,,Inpatient,,,,,,32037.33,125,MS-DRG,25629.864,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25629.86,100,MS-DRG,20503.888,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10314.76,100,,,Case Rate,100% of CMS IPPS Rate,25629.86,100,MS-DRG,20503.888,Case Rate,100% of CMS IPPS Rate,9135.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9135.88,32037.33,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,CDM,100,RC,,,Inpatient,,,,,,28057.8,125,MS-DRG,22446.24,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22446.24,100,MS-DRG,17956.992,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8628.31,100,,,Case Rate,100% of CMS IPPS Rate,22446.24,100,MS-DRG,17956.992,Case Rate,100% of CMS IPPS Rate,7642.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7642.18,28057.8,
ANAL AND STOMAL PROCEDURES WITH MCC,347,CDM,100,RC,,,Inpatient,,,,,,46394.06,125,MS-DRG,37115.248,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37115.25,100,MS-DRG,29692.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16398.85,100,,,Case Rate,100% of CMS IPPS Rate,37115.25,100,MS-DRG,29692.2,Case Rate,100% of CMS IPPS Rate,14524.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14524.63,46394.06,
ANAL AND STOMAL PROCEDURES WITH CC,348,CDM,100,RC,,,Inpatient,,,,,,28280.16,125,MS-DRG,22624.128,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22624.13,100,MS-DRG,18099.304,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8722.54,100,,,Case Rate,100% of CMS IPPS Rate,22624.13,100,MS-DRG,18099.304,Case Rate,100% of CMS IPPS Rate,7725.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7725.64,28280.16,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,CDM,100,RC,,,Inpatient,,,,,,22099.96,125,MS-DRG,17679.968,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17679.97,100,MS-DRG,14143.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6103.49,100,,,Case Rate,100% of CMS IPPS Rate,17679.97,100,MS-DRG,14143.976,Case Rate,100% of CMS IPPS Rate,5405.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5405.92,22099.96,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,CDM,100,RC,,,Inpatient,,,,,,47242.61,125,MS-DRG,37794.088,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37794.09,100,MS-DRG,30235.272,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16758.45,100,,,Case Rate,100% of CMS IPPS Rate,37794.09,100,MS-DRG,30235.272,Case Rate,100% of CMS IPPS Rate,14843.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14843.13,47242.61,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,CDM,100,RC,,,Inpatient,,,,,,32295.66,125,MS-DRG,25836.528,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25836.53,100,MS-DRG,20669.224,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10424.23,100,,,Case Rate,100% of CMS IPPS Rate,25836.53,100,MS-DRG,20669.224,Case Rate,100% of CMS IPPS Rate,9232.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9232.85,32295.66,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,CDM,100,RC,,,Inpatient,,,,,,25724.7,125,MS-DRG,20579.76,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20579.76,100,MS-DRG,16463.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7639.58,100,,,Case Rate,100% of CMS IPPS Rate,20579.76,100,MS-DRG,16463.808,Case Rate,100% of CMS IPPS Rate,6766.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6766.46,25724.7,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,CDM,100,RC,,,Inpatient,,,,,,55651.28,125,MS-DRG,44521.024,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44521.02,100,MS-DRG,35616.816,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20321.88,100,,,Case Rate,100% of CMS IPPS Rate,44521.02,100,MS-DRG,35616.816,Case Rate,100% of CMS IPPS Rate,17999.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17999.29,55651.28,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,CDM,100,RC,,,Inpatient,,,,,,35510.04,125,MS-DRG,28408.032,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28408.03,100,MS-DRG,22726.424,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11786.41,100,,,Case Rate,100% of CMS IPPS Rate,28408.03,100,MS-DRG,22726.424,Case Rate,100% of CMS IPPS Rate,10439.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10439.34,35510.04,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,CDM,100,RC,,,Inpatient,,,,,,29494.95,125,MS-DRG,23595.96,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23595.96,100,MS-DRG,18876.768,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9237.34,100,,,Case Rate,100% of CMS IPPS Rate,23595.96,100,MS-DRG,18876.768,Case Rate,100% of CMS IPPS Rate,8181.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8181.61,29494.95,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,CDM,100,RC,,,Inpatient,,,,,,77440.59,125,MS-DRG,61952.472,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61952.47,100,MS-DRG,49561.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29555.76,100,,,Case Rate,100% of CMS IPPS Rate,61952.47,100,MS-DRG,49561.976,Case Rate,100% of CMS IPPS Rate,26177.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26177.83,77440.59,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,CDM,100,RC,,,Inpatient,,,,,,44517.09,125,MS-DRG,35613.672,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35613.67,100,MS-DRG,28490.936,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15603.43,100,,,Case Rate,100% of CMS IPPS Rate,35613.67,100,MS-DRG,28490.936,Case Rate,100% of CMS IPPS Rate,13820.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13820.12,44517.09,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,CDM,100,RC,,,Inpatient,,,,,,29853.03,125,MS-DRG,23882.424,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23882.42,100,MS-DRG,19105.936,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9389.08,100,,,Case Rate,100% of CMS IPPS Rate,23882.42,100,MS-DRG,19105.936,Case Rate,100% of CMS IPPS Rate,8316,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8316,29853.03,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,CDM,100,RC,,,Inpatient,,,,,,35001.55,125,MS-DRG,28001.24,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28001.24,100,MS-DRG,22400.992,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11570.93,100,,,Case Rate,100% of CMS IPPS Rate,28001.24,100,MS-DRG,22400.992,Case Rate,100% of CMS IPPS Rate,10248.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10248.49,35001.55,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,CDM,100,RC,,,Inpatient,,,,,,24334.98,125,MS-DRG,19467.984,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19467.98,100,MS-DRG,15574.384,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7050.65,100,,,Case Rate,100% of CMS IPPS Rate,19467.98,100,MS-DRG,15574.384,Case Rate,100% of CMS IPPS Rate,6244.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6244.83,24334.98,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,CDM,100,RC,,,Inpatient,,,,,,19109.59,125,MS-DRG,15287.672,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15287.67,100,MS-DRG,12230.136,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4836.23,100,,,Case Rate,100% of CMS IPPS Rate,15287.67,100,MS-DRG,12230.136,Case Rate,100% of CMS IPPS Rate,4283.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4283.5,19109.59,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,CDM,100,RC,,,Inpatient,,,,,,36276.84,125,MS-DRG,29021.472,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29021.47,100,MS-DRG,23217.176,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12111.37,100,,,Case Rate,100% of CMS IPPS Rate,29021.47,100,MS-DRG,23217.176,Case Rate,100% of CMS IPPS Rate,10727.16,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10727.16,36276.84,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,CDM,100,RC,,,Inpatient,,,,,,24526.26,125,MS-DRG,19621.008,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19621.01,100,MS-DRG,15696.808,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7131.71,100,,,Case Rate,100% of CMS IPPS Rate,19621.01,100,MS-DRG,15696.808,Case Rate,100% of CMS IPPS Rate,6316.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6316.63,24526.26,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,CDM,100,RC,,,Inpatient,,,,,,19557.58,125,MS-DRG,15646.064,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15646.06,100,MS-DRG,12516.848,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5026.08,100,,,Case Rate,100% of CMS IPPS Rate,15646.06,100,MS-DRG,12516.848,Case Rate,100% of CMS IPPS Rate,4451.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4451.65,19557.58,
DIGESTIVE MALIGNANCY WITH MCC,374,CDM,100,RC,,,Inpatient,,,,,,42218.33,125,MS-DRG,33774.664,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33774.66,100,MS-DRG,27019.728,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14629.26,100,,,Case Rate,100% of CMS IPPS Rate,33774.66,100,MS-DRG,27019.728,Case Rate,100% of CMS IPPS Rate,12957.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12957.28,42218.33,
DIGESTIVE MALIGNANCY WITH CC,375,CDM,100,RC,,,Inpatient,,,,,,27786.41,125,MS-DRG,22229.128,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22229.13,100,MS-DRG,17783.304,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8513.29,100,,,Case Rate,100% of CMS IPPS Rate,22229.13,100,MS-DRG,17783.304,Case Rate,100% of CMS IPPS Rate,7540.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7540.31,27786.41,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,CDM,100,RC,,,Inpatient,,,,,,22134.3,125,MS-DRG,17707.44,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17707.44,100,MS-DRG,14165.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6118.04,100,,,Case Rate,100% of CMS IPPS Rate,17707.44,100,MS-DRG,14165.952,Case Rate,100% of CMS IPPS Rate,5418.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5418.81,22134.3,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,CDM,100,RC,,,Inpatient,,,,,,37424.6,125,MS-DRG,29939.68,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29939.68,100,MS-DRG,23951.744,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12597.76,100,,,Case Rate,100% of CMS IPPS Rate,29939.68,100,MS-DRG,23951.744,Case Rate,100% of CMS IPPS Rate,11157.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11157.97,37424.6,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,CDM,100,RC,,,Inpatient,,,,,,23816.69,125,MS-DRG,19053.352,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19053.35,100,MS-DRG,15242.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6831.01,100,,,Case Rate,100% of CMS IPPS Rate,19053.35,100,MS-DRG,15242.68,Case Rate,100% of CMS IPPS Rate,6050.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6050.29,23816.69,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,CDM,100,RC,,,Inpatient,,,,,,18107.34,125,MS-DRG,14485.872,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14485.87,100,MS-DRG,11588.696,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4411.5,100,,,Case Rate,100% of CMS IPPS Rate,14485.87,100,MS-DRG,11588.696,Case Rate,100% of CMS IPPS Rate,3907.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3907.31,18107.34,
COMPLICATED PEPTIC ULCER WITH MCC,380,CDM,100,RC,,,Inpatient,,,,,,39159.29,125,MS-DRG,31327.432,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31327.43,100,MS-DRG,25061.944,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13332.9,100,,,Case Rate,100% of CMS IPPS Rate,31327.43,100,MS-DRG,25061.944,Case Rate,100% of CMS IPPS Rate,11809.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11809.08,39159.29,
COMPLICATED PEPTIC ULCER WITH CC,381,CDM,100,RC,,,Inpatient,,,,,,25503.98,125,MS-DRG,20403.184,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20403.18,100,MS-DRG,16322.544,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7546.05,100,,,Case Rate,100% of CMS IPPS Rate,20403.18,100,MS-DRG,16322.544,Case Rate,100% of CMS IPPS Rate,6683.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6683.61,25503.98,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,CDM,100,RC,,,Inpatient,,,,,,19948.34,125,MS-DRG,15958.672,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15958.67,100,MS-DRG,12766.936,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5191.67,100,,,Case Rate,100% of CMS IPPS Rate,15958.67,100,MS-DRG,12766.936,Case Rate,100% of CMS IPPS Rate,4598.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4598.32,19948.34,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,CDM,100,RC,,,Inpatient,,,,,,28366.83,125,MS-DRG,22693.464,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22693.46,100,MS-DRG,18154.768,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8759.26,100,,,Case Rate,100% of CMS IPPS Rate,22693.46,100,MS-DRG,18154.768,Case Rate,100% of CMS IPPS Rate,7758.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7758.17,28366.83,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,CDM,100,RC,,,Inpatient,,,,,,21915.21,125,MS-DRG,17532.168,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17532.17,100,MS-DRG,14025.736,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6025.2,100,,,Case Rate,100% of CMS IPPS Rate,17532.17,100,MS-DRG,14025.736,Case Rate,100% of CMS IPPS Rate,5336.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5336.58,21915.21,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,CDM,100,RC,,,Inpatient,,,,,,34262.54,125,MS-DRG,27410.032,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27410.03,100,MS-DRG,21928.024,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11257.75,100,,,Case Rate,100% of CMS IPPS Rate,27410.03,100,MS-DRG,21928.024,Case Rate,100% of CMS IPPS Rate,9971.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9971.11,34262.54,
INFLAMMATORY BOWEL DISEASE WITH CC,386,CDM,100,RC,,,Inpatient,,,,,,23924.59,125,MS-DRG,19139.672,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19139.67,100,MS-DRG,15311.736,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6876.73,100,,,Case Rate,100% of CMS IPPS Rate,19139.67,100,MS-DRG,15311.736,Case Rate,100% of CMS IPPS Rate,6090.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6090.79,23924.59,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,CDM,100,RC,,,Inpatient,,,,,,18656.7,125,MS-DRG,14925.36,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14925.36,100,MS-DRG,11940.288,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4644.31,100,,,Case Rate,100% of CMS IPPS Rate,14925.36,100,MS-DRG,11940.288,Case Rate,100% of CMS IPPS Rate,4113.51,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4113.51,18656.7,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,CDM,100,RC,,,Inpatient,,,,,,31729.96,125,MS-DRG,25383.968,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25383.97,100,MS-DRG,20307.176,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10184.5,100,,,Case Rate,100% of CMS IPPS Rate,25383.97,100,MS-DRG,20307.176,Case Rate,100% of CMS IPPS Rate,9020.51,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9020.51,31729.96,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,CDM,100,RC,,,Inpatient,,,,,,20803.43,125,MS-DRG,16642.744,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16642.74,100,MS-DRG,13314.192,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5554.05,100,,,Case Rate,100% of CMS IPPS Rate,16642.74,100,MS-DRG,13314.192,Case Rate,100% of CMS IPPS Rate,4919.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4919.27,20803.43,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,CDM,100,RC,,,Inpatient,,,,,,16644.05,125,MS-DRG,13315.24,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13315.24,100,MS-DRG,10652.192,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3791.38,100,,,Case Rate,100% of CMS IPPS Rate,13315.24,100,MS-DRG,10652.192,Case Rate,100% of CMS IPPS Rate,3358.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3358.07,16644.05,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,CDM,100,RC,,,Inpatient,,,,,,28698.73,125,MS-DRG,22958.984,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22958.98,100,MS-DRG,18367.184,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8899.92,100,,,Case Rate,100% of CMS IPPS Rate,22958.98,100,MS-DRG,18367.184,Case Rate,100% of CMS IPPS Rate,7882.75,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7882.75,28698.73,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,CDM,100,RC,,,Inpatient,,,,,,20455.16,125,MS-DRG,16364.128,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16364.13,100,MS-DRG,13091.304,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5406.46,100,,,Case Rate,100% of CMS IPPS Rate,16364.13,100,MS-DRG,13091.304,Case Rate,100% of CMS IPPS Rate,4788.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4788.56,20455.16,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,CDM,100,RC,,,Inpatient,,,,,,34772.65,125,MS-DRG,27818.12,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27818.12,100,MS-DRG,22254.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11473.93,100,,,Case Rate,100% of CMS IPPS Rate,27818.12,100,MS-DRG,22254.496,Case Rate,100% of CMS IPPS Rate,10162.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10162.57,34772.65,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,CDM,100,RC,,,Inpatient,,,,,,23087.49,125,MS-DRG,18469.992,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18469.99,100,MS-DRG,14775.992,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6521.99,100,,,Case Rate,100% of CMS IPPS Rate,18469.99,100,MS-DRG,14775.992,Case Rate,100% of CMS IPPS Rate,5776.59,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5776.59,23087.49,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,CDM,100,RC,,,Inpatient,,,,,,18102.44,125,MS-DRG,14481.952,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14481.95,100,MS-DRG,11585.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4409.42,100,,,Case Rate,100% of CMS IPPS Rate,14481.95,100,MS-DRG,11585.56,Case Rate,100% of CMS IPPS Rate,3905.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3905.47,18102.44,
APPENDIX PROCEDURES WITH MCC,397,CDM,100,RC,,,Inpatient,,,,,,48208.89,125,MS-DRG,38567.112,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38567.11,100,MS-DRG,30853.688,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17167.93,100,,,Case Rate,100% of CMS IPPS Rate,38567.11,100,MS-DRG,30853.688,Case Rate,100% of CMS IPPS Rate,15205.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15205.81,48208.89,
APPENDIX PROCEDURES WITH CC,398,CDM,100,RC,,,Inpatient,,,,,,32437.91,125,MS-DRG,25950.328,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25950.33,100,MS-DRG,20760.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10484.51,100,,,Case Rate,100% of CMS IPPS Rate,25950.33,100,MS-DRG,20760.264,Case Rate,100% of CMS IPPS Rate,9286.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9286.24,32437.91,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,CDM,100,RC,,,Inpatient,,,,,,26071.31,125,MS-DRG,20857.048,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20857.05,100,MS-DRG,16685.64,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7786.47,100,,,Case Rate,100% of CMS IPPS Rate,20857.05,100,MS-DRG,16685.64,Case Rate,100% of CMS IPPS Rate,6896.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6896.56,26071.31,
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,CDM,100,RC,,,Inpatient,,,,,,71660.96,125,MS-DRG,57328.768,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57328.77,100,MS-DRG,45863.016,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27106.46,100,,,Case Rate,100% of CMS IPPS Rate,57328.77,100,MS-DRG,45863.016,Case Rate,100% of CMS IPPS Rate,24008.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24008.47,71660.96,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,CDM,100,RC,,,Inpatient,,,,,,96455.35,125,MS-DRG,77164.28,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77164.28,100,MS-DRG,61731.424,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37613.83,100,,,Case Rate,100% of CMS IPPS Rate,77164.28,100,MS-DRG,61731.424,Case Rate,100% of CMS IPPS Rate,33314.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,33314.95,96455.35,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,CDM,100,RC,,,Inpatient,,,,,,53614.1,125,MS-DRG,42891.28,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42891.28,100,MS-DRG,34313.024,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19458.56,100,,,Case Rate,100% of CMS IPPS Rate,42891.28,100,MS-DRG,34313.024,Case Rate,100% of CMS IPPS Rate,17234.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17234.65,53614.1,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,CDM,100,RC,,,Inpatient,,,,,,42617.28,125,MS-DRG,34093.824,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34093.82,100,MS-DRG,27275.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14798.32,100,,,Case Rate,100% of CMS IPPS Rate,34093.82,100,MS-DRG,27275.056,Case Rate,100% of CMS IPPS Rate,13107.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13107.02,42617.28,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,CDM,100,RC,,,Inpatient,,,,,,64942.84,125,MS-DRG,51954.272,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51954.27,100,MS-DRG,41563.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24259.46,100,,,Case Rate,100% of CMS IPPS Rate,51954.27,100,MS-DRG,41563.416,Case Rate,100% of CMS IPPS Rate,21486.85,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21486.85,64942.84,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,CDM,100,RC,,,Inpatient,,,,,,41974.71,125,MS-DRG,33579.768,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33579.77,100,MS-DRG,26863.816,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14526.02,100,,,Case Rate,100% of CMS IPPS Rate,33579.77,100,MS-DRG,26863.816,Case Rate,100% of CMS IPPS Rate,12865.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12865.84,41974.71,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,CDM,100,RC,,,Inpatient,,,,,,33057.56,125,MS-DRG,26446.048,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26446.05,100,MS-DRG,21156.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10747.11,100,,,Case Rate,100% of CMS IPPS Rate,26446.05,100,MS-DRG,21156.84,Case Rate,100% of CMS IPPS Rate,9518.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9518.82,33057.56,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,CDM,100,RC,,,Inpatient,,,,,,52436.93,125,MS-DRG,41949.544,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41949.54,100,MS-DRG,33559.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18800.33,100,,,Case Rate,100% of CMS IPPS Rate,41949.54,100,MS-DRG,33559.632,Case Rate,100% of CMS IPPS Rate,16651.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16651.65,52436.93,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,CDM,100,RC,,,Inpatient,,,,,,42548.59,125,MS-DRG,34038.872,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34038.87,100,MS-DRG,27231.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14769.22,100,,,Case Rate,100% of CMS IPPS Rate,34038.87,100,MS-DRG,27231.096,Case Rate,100% of CMS IPPS Rate,13081.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13081.25,42548.59,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,CDM,100,RC,,,Inpatient,,,,,,34878.93,125,MS-DRG,27903.144,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27903.14,100,MS-DRG,22322.512,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11518.96,100,,,Case Rate,100% of CMS IPPS Rate,27903.14,100,MS-DRG,22322.512,Case Rate,100% of CMS IPPS Rate,10202.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10202.46,34878.93,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,CDM,100,RC,,,Inpatient,,,,,,64983.71,125,MS-DRG,51986.968,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51986.97,100,MS-DRG,41589.576,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24276.78,100,,,Case Rate,100% of CMS IPPS Rate,51986.97,100,MS-DRG,41589.576,Case Rate,100% of CMS IPPS Rate,21502.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21502.19,64983.71,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,CDM,100,RC,,,Inpatient,,,,,,40038.9,125,MS-DRG,32031.12,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32031.12,100,MS-DRG,25624.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13705.66,100,,,Case Rate,100% of CMS IPPS Rate,32031.12,100,MS-DRG,25624.896,Case Rate,100% of CMS IPPS Rate,12139.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12139.24,40038.9,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,CDM,100,RC,,,Inpatient,,,,,,30099.9,125,MS-DRG,24079.92,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24079.92,100,MS-DRG,19263.936,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9493.7,100,,,Case Rate,100% of CMS IPPS Rate,24079.92,100,MS-DRG,19263.936,Case Rate,100% of CMS IPPS Rate,8408.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8408.67,30099.9,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,CDM,100,RC,,,Inpatient,,,,,,46552.65,125,MS-DRG,37242.12,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37242.12,100,MS-DRG,29793.696,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16466.06,100,,,Case Rate,100% of CMS IPPS Rate,37242.12,100,MS-DRG,29793.696,Case Rate,100% of CMS IPPS Rate,14584.15,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14584.15,46552.65,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,CDM,100,RC,,,Inpatient,,,,,,34811.9,125,MS-DRG,27849.52,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27849.52,100,MS-DRG,22279.616,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11490.56,100,,,Case Rate,100% of CMS IPPS Rate,27849.52,100,MS-DRG,22279.616,Case Rate,100% of CMS IPPS Rate,10177.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10177.3,34811.9,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,CDM,100,RC,,,Inpatient,,,,,,29239.9,125,MS-DRG,23391.92,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23391.92,100,MS-DRG,18713.536,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9129.26,100,,,Case Rate,100% of CMS IPPS Rate,23391.92,100,MS-DRG,18713.536,Case Rate,100% of CMS IPPS Rate,8085.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8085.87,29239.9,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,CDM,100,RC,,,Inpatient,,,,,,65403.91,125,MS-DRG,52323.128,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52323.13,100,MS-DRG,41858.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24454.85,100,,,Case Rate,100% of CMS IPPS Rate,52323.13,100,MS-DRG,41858.504,Case Rate,100% of CMS IPPS Rate,21659.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21659.91,65403.91,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,CDM,100,RC,,,Inpatient,,,,,,34471.83,125,MS-DRG,27577.464,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27577.46,100,MS-DRG,22061.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11346.44,100,,,Case Rate,100% of CMS IPPS Rate,27577.46,100,MS-DRG,22061.968,Case Rate,100% of CMS IPPS Rate,10049.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10049.66,34471.83,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,CDM,100,RC,,,Inpatient,,,,,,31721.79,125,MS-DRG,25377.432,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25377.43,100,MS-DRG,20301.944,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10181.03,100,,,Case Rate,100% of CMS IPPS Rate,25377.43,100,MS-DRG,20301.944,Case Rate,100% of CMS IPPS Rate,9017.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9017.44,31721.79,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,CDM,100,RC,,,Inpatient,,,,,,74198.44,125,MS-DRG,59358.752,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59358.75,100,MS-DRG,47487,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28181.79,100,,,Case Rate,100% of CMS IPPS Rate,59358.75,100,MS-DRG,47487,Case Rate,100% of CMS IPPS Rate,24960.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24960.9,74198.44,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,CDM,100,RC,,,Inpatient,,,,,,45028.85,125,MS-DRG,36023.08,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36023.08,100,MS-DRG,28818.464,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15820.3,100,,,Case Rate,100% of CMS IPPS Rate,36023.08,100,MS-DRG,28818.464,Case Rate,100% of CMS IPPS Rate,14012.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14012.2,45028.85,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,CDM,100,RC,,,Inpatient,,,,,,32970.91,125,MS-DRG,26376.728,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26376.73,100,MS-DRG,21101.384,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10710.38,100,,,Case Rate,100% of CMS IPPS Rate,26376.73,100,MS-DRG,21101.384,Case Rate,100% of CMS IPPS Rate,9486.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9486.3,32970.91,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,CDM,100,RC,,,Inpatient,,,,,,178967.65,125,MS-DRG,143174.12,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143174.12,100,MS-DRG,114539.296,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,72580.9,100,,,Case Rate,100% of CMS IPPS Rate,143174.12,100,MS-DRG,114539.296,Case Rate,100% of CMS IPPS Rate,64285.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,64285.64,178967.7,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,CDM,100,RC,,,Inpatient,,,,,,123824.84,125,MS-DRG,99059.872,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99059.87,100,MS-DRG,79247.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,49212.48,100,,,Case Rate,100% of CMS IPPS Rate,99059.87,100,MS-DRG,79247.896,Case Rate,100% of CMS IPPS Rate,43587.99,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,43587.99,123824.8,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,CDM,100,RC,,,Inpatient,,,,,,97688.11,125,MS-DRG,78150.488,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78150.49,100,MS-DRG,62520.392,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,38136.26,100,,,Case Rate,100% of CMS IPPS Rate,78150.49,100,MS-DRG,62520.392,Case Rate,100% of CMS IPPS Rate,33777.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,33777.67,97688.11,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,CDM,100,RC,,,Inpatient,,,,,,144064.19,125,MS-DRG,115251.352,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115251.35,100,MS-DRG,92201.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,57789.52,100,,,Case Rate,100% of CMS IPPS Rate,115251.35,100,MS-DRG,92201.08,Case Rate,100% of CMS IPPS Rate,51184.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,51184.76,144064.2,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,CDM,100,RC,,,Inpatient,,,,,,97138.78,125,MS-DRG,77711.024,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77711.02,100,MS-DRG,62168.816,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37903.45,100,,,Case Rate,100% of CMS IPPS Rate,77711.02,100,MS-DRG,62168.816,Case Rate,100% of CMS IPPS Rate,33571.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,33571.47,97138.78,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,CDM,100,RC,,,Inpatient,,,,,,39728.26,125,MS-DRG,31782.608,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31782.61,100,MS-DRG,25426.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13574.02,100,,,Case Rate,100% of CMS IPPS Rate,31782.61,100,MS-DRG,25426.088,Case Rate,100% of CMS IPPS Rate,12022.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12022.64,39728.26,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,CDM,100,RC,,,Inpatient,,,,,,25188.43,125,MS-DRG,20150.744,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20150.74,100,MS-DRG,16120.592,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7412.32,100,,,Case Rate,100% of CMS IPPS Rate,20150.74,100,MS-DRG,16120.592,Case Rate,100% of CMS IPPS Rate,6565.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6565.17,25188.43,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,CDM,100,RC,,,Inpatient,,,,,,19085.06,125,MS-DRG,15268.048,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15268.05,100,MS-DRG,12214.44,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4825.84,100,,,Case Rate,100% of CMS IPPS Rate,15268.05,100,MS-DRG,12214.44,Case Rate,100% of CMS IPPS Rate,4274.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4274.3,19085.06,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,CDM,100,RC,,,Inpatient,,,,,,37529.23,125,MS-DRG,30023.384,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30023.38,100,MS-DRG,24018.704,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12642.11,100,,,Case Rate,100% of CMS IPPS Rate,30023.38,100,MS-DRG,24018.704,Case Rate,100% of CMS IPPS Rate,11197.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11197.24,37529.23,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,CDM,100,RC,,,Inpatient,,,,,,26135.08,125,MS-DRG,20908.064,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20908.06,100,MS-DRG,16726.448,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7813.49,100,,,Case Rate,100% of CMS IPPS Rate,20908.06,100,MS-DRG,16726.448,Case Rate,100% of CMS IPPS Rate,6920.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6920.49,26135.08,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,CDM,100,RC,,,Inpatient,,,,,,20535.3,125,MS-DRG,16428.24,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16428.24,100,MS-DRG,13142.592,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5440.42,100,,,Case Rate,100% of CMS IPPS Rate,16428.24,100,MS-DRG,13142.592,Case Rate,100% of CMS IPPS Rate,4818.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4818.63,20535.3,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,CDM,100,RC,,,Inpatient,,,,,,34898.54,125,MS-DRG,27918.832,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27918.83,100,MS-DRG,22335.064,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11527.28,100,,,Case Rate,100% of CMS IPPS Rate,27918.83,100,MS-DRG,22335.064,Case Rate,100% of CMS IPPS Rate,10209.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10209.83,34898.54,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,CDM,100,RC,,,Inpatient,,,,,,21761.53,125,MS-DRG,17409.224,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17409.22,100,MS-DRG,13927.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5960.07,100,,,Case Rate,100% of CMS IPPS Rate,17409.22,100,MS-DRG,13927.376,Case Rate,100% of CMS IPPS Rate,5278.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5278.89,21761.53,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,CDM,100,RC,,,Inpatient,,,,,,17754.2,125,MS-DRG,14203.36,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14203.36,100,MS-DRG,11362.688,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4261.84,100,,,Case Rate,100% of CMS IPPS Rate,14203.36,100,MS-DRG,11362.688,Case Rate,100% of CMS IPPS Rate,3774.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3774.76,17754.2,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,CDM,100,RC,,,Inpatient,,,,,,38605.03,125,MS-DRG,30884.024,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30884.02,100,MS-DRG,24707.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13098.01,100,,,Case Rate,100% of CMS IPPS Rate,30884.02,100,MS-DRG,24707.216,Case Rate,100% of CMS IPPS Rate,11601.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11601.04,38605.03,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,CDM,100,RC,,,Inpatient,,,,,,23494.6,125,MS-DRG,18795.68,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18795.68,100,MS-DRG,15036.544,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6694.51,100,,,Case Rate,100% of CMS IPPS Rate,18795.68,100,MS-DRG,15036.544,Case Rate,100% of CMS IPPS Rate,5929.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5929.4,23494.6,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,CDM,100,RC,,,Inpatient,,,,,,19186.44,125,MS-DRG,15349.152,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15349.15,100,MS-DRG,12279.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4868.8,100,,,Case Rate,100% of CMS IPPS Rate,15349.15,100,MS-DRG,12279.32,Case Rate,100% of CMS IPPS Rate,4312.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4312.34,19186.44,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,CDM,100,RC,,,Inpatient,,,,,,35236.98,125,MS-DRG,28189.584,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28189.58,100,MS-DRG,22551.664,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11670.7,100,,,Case Rate,100% of CMS IPPS Rate,28189.58,100,MS-DRG,22551.664,Case Rate,100% of CMS IPPS Rate,10336.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10336.86,35236.98,
DISORDERS OF THE BILIARY TRACT WITH CC,445,CDM,100,RC,,,Inpatient,,,,,,25428.78,125,MS-DRG,20343.024,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20343.02,100,MS-DRG,16274.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7514.18,100,,,Case Rate,100% of CMS IPPS Rate,20343.02,100,MS-DRG,16274.416,Case Rate,100% of CMS IPPS Rate,6655.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6655.38,25428.78,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,CDM,100,RC,,,Inpatient,,,,,,20733.13,125,MS-DRG,16586.504,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16586.5,100,MS-DRG,13269.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5524.25,100,,,Case Rate,100% of CMS IPPS Rate,16586.5,100,MS-DRG,13269.2,Case Rate,100% of CMS IPPS Rate,4892.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4892.89,20733.13,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,CDM,100,RC,,,Inpatient,,,,,,117317.64,125,MS-DRG,93854.112,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93854.11,100,MS-DRG,75083.288,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,46454.85,100,,,Case Rate,100% of CMS IPPS Rate,93854.11,100,MS-DRG,75083.288,Case Rate,100% of CMS IPPS Rate,41145.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,41145.54,117317.6,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,CDM,100,RC,,,Inpatient,,,,,,74461.66,125,MS-DRG,59569.328,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59569.33,100,MS-DRG,47655.464,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28293.35,100,,,Case Rate,100% of CMS IPPS Rate,59569.33,100,MS-DRG,47655.464,Case Rate,100% of CMS IPPS Rate,25059.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25059.7,74461.66,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,CDM,100,RC,,,Inpatient,,,,,,91900.31,125,MS-DRG,73520.248,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73520.25,100,MS-DRG,58816.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,35683.5,100,,,Case Rate,100% of CMS IPPS Rate,73520.25,100,MS-DRG,58816.2,Case Rate,100% of CMS IPPS Rate,31605.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31605.24,91900.31,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,CDM,100,RC,,,Inpatient,,,,,,58152.8,125,MS-DRG,46522.24,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46522.24,100,MS-DRG,37217.792,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21381.97,100,,,Case Rate,100% of CMS IPPS Rate,46522.24,100,MS-DRG,37217.792,Case Rate,100% of CMS IPPS Rate,18938.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18938.23,58152.8,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,CDM,100,RC,,,Inpatient,,,,,,146166.78,125,MS-DRG,116933.424,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116933.42,100,MS-DRG,93546.736,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,58680.55,100,,,Case Rate,100% of CMS IPPS Rate,116933.42,100,MS-DRG,93546.736,Case Rate,100% of CMS IPPS Rate,51973.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,51973.96,146166.8,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,CDM,100,RC,,,Inpatient,,,,,,101535.21,125,MS-DRG,81228.168,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81228.17,100,MS-DRG,64982.536,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,39766.58,100,,,Case Rate,100% of CMS IPPS Rate,81228.17,100,MS-DRG,64982.536,Case Rate,100% of CMS IPPS Rate,35221.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,35221.66,101535.2,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,CDM,100,RC,,,Inpatient,,,,,,78295.69,125,MS-DRG,62636.552,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62636.55,100,MS-DRG,50109.24,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29918.13,100,,,Case Rate,100% of CMS IPPS Rate,62636.55,100,MS-DRG,50109.24,Case Rate,100% of CMS IPPS Rate,26498.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26498.79,78295.69,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,CDM,100,RC,,,Inpatient,,,,,,108030.96,125,MS-DRG,86424.768,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86424.77,100,MS-DRG,69139.816,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,41508.46,100,,,Case Rate,100% of CMS IPPS Rate,86424.77,100,MS-DRG,69139.816,Case Rate,100% of CMS IPPS Rate,36764.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,36764.46,108031,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,CDM,100,RC,,,Inpatient,,,,,,54519.89,125,MS-DRG,43615.912,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43615.91,100,MS-DRG,34892.728,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19842.41,100,,,Case Rate,100% of CMS IPPS Rate,43615.91,100,MS-DRG,34892.728,Case Rate,100% of CMS IPPS Rate,17574.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17574.63,54519.89,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,CDM,100,RC,,,Inpatient,,,,,,96002.46,125,MS-DRG,76801.968,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76801.97,100,MS-DRG,61441.576,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37421.91,100,,,Case Rate,100% of CMS IPPS Rate,76801.97,100,MS-DRG,61441.576,Case Rate,100% of CMS IPPS Rate,33144.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,33144.96,96002.46,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,CDM,100,RC,,,Inpatient,,,,,,55906.34,125,MS-DRG,44725.072,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44725.07,100,MS-DRG,35780.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20429.96,100,,,Case Rate,100% of CMS IPPS Rate,44725.07,100,MS-DRG,35780.056,Case Rate,100% of CMS IPPS Rate,18095.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18095.03,55906.34,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,CDM,100,RC,,,Inpatient,,,,,,36082.26,125,MS-DRG,28865.808,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28865.81,100,MS-DRG,23092.648,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12028.92,100,,,Case Rate,100% of CMS IPPS Rate,28865.81,100,MS-DRG,23092.648,Case Rate,100% of CMS IPPS Rate,10654.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10654.13,36082.26,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,CDM,100,RC,,,Inpatient,,,,,,90992.9,125,MS-DRG,72794.32,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72794.32,100,MS-DRG,58235.456,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,35298.96,100,,,Case Rate,100% of CMS IPPS Rate,72794.32,100,MS-DRG,58235.456,Case Rate,100% of CMS IPPS Rate,31264.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31264.64,90992.9,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,CDM,100,RC,,,Inpatient,,,,,,63698.63,125,MS-DRG,50958.904,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50958.9,100,MS-DRG,40767.12,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23732.18,100,,,Case Rate,100% of CMS IPPS Rate,50958.9,100,MS-DRG,40767.12,Case Rate,100% of CMS IPPS Rate,21019.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21019.84,63698.63,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,CDM,100,RC,,,Inpatient,,,,,,50587.75,125,MS-DRG,40470.2,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40470.2,100,MS-DRG,32376.16,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18176.06,100,,,Case Rate,100% of CMS IPPS Rate,40470.2,100,MS-DRG,32376.16,Case Rate,100% of CMS IPPS Rate,16098.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16098.72,50587.75,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,CDM,100,RC,,,Inpatient,,,,,,61139.9,125,MS-DRG,48911.92,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48911.92,100,MS-DRG,39129.536,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22647.84,100,,,Case Rate,100% of CMS IPPS Rate,48911.92,100,MS-DRG,39129.536,Case Rate,100% of CMS IPPS Rate,20059.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20059.42,61139.9,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,CDM,100,RC,,,Inpatient,,,,,,38524.93,125,MS-DRG,30819.944,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30819.94,100,MS-DRG,24655.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13064.06,100,,,Case Rate,100% of CMS IPPS Rate,30819.94,100,MS-DRG,24655.952,Case Rate,100% of CMS IPPS Rate,11570.97,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11570.97,38524.93,
CERVICAL SPINAL FUSION WITH MCC,471,CDM,100,RC,,,Inpatient,,,,,,87113.11,125,MS-DRG,69690.488,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69690.49,100,MS-DRG,55752.392,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,33654.77,100,,,Case Rate,100% of CMS IPPS Rate,69690.49,100,MS-DRG,55752.392,Case Rate,100% of CMS IPPS Rate,29808.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29808.38,87113.11,
CERVICAL SPINAL FUSION WITH CC,472,CDM,100,RC,,,Inpatient,,,,,,55065.95,125,MS-DRG,44052.76,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44052.76,100,MS-DRG,35242.208,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20073.83,100,,,Case Rate,100% of CMS IPPS Rate,44052.76,100,MS-DRG,35242.208,Case Rate,100% of CMS IPPS Rate,17779.59,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17779.59,55065.95,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,CDM,100,RC,,,Inpatient,,,,,,46403.88,125,MS-DRG,37123.104,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37123.1,100,MS-DRG,29698.48,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16403,100,,,Case Rate,100% of CMS IPPS Rate,37123.1,100,MS-DRG,29698.48,Case Rate,100% of CMS IPPS Rate,14528.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14528.31,46403.88,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,CDM,100,RC,,,Inpatient,,,,,,81021.2,125,MS-DRG,64816.96,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64816.96,100,MS-DRG,51853.568,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31073.14,100,,,Case Rate,100% of CMS IPPS Rate,64816.96,100,MS-DRG,51853.568,Case Rate,100% of CMS IPPS Rate,27521.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27521.8,81021.2,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,CDM,100,RC,,,Inpatient,,,,,,42968.78,125,MS-DRG,34375.024,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34375.02,100,MS-DRG,27500.016,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14947.28,100,,,Case Rate,100% of CMS IPPS Rate,34375.02,100,MS-DRG,27500.016,Case Rate,100% of CMS IPPS Rate,13238.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13238.96,42968.78,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,CDM,100,RC,,,Inpatient,,,,,,26713.86,125,MS-DRG,21371.088,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21371.09,100,MS-DRG,17096.872,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8058.77,100,,,Case Rate,100% of CMS IPPS Rate,21371.09,100,MS-DRG,17096.872,Case Rate,100% of CMS IPPS Rate,7137.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7137.74,26713.86,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,CDM,100,RC,,,Inpatient,,,,,,63924.26,125,MS-DRG,51139.408,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51139.41,100,MS-DRG,40911.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23827.8,100,,,Case Rate,100% of CMS IPPS Rate,51139.41,100,MS-DRG,40911.528,Case Rate,100% of CMS IPPS Rate,21104.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21104.52,63924.26,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,CDM,100,RC,,,Inpatient,,,,,,45933,125,MS-DRG,36746.4,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36746.4,100,MS-DRG,29397.12,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16203.46,100,,,Case Rate,100% of CMS IPPS Rate,36746.4,100,MS-DRG,29397.12,Case Rate,100% of CMS IPPS Rate,14351.57,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14351.57,45933,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,CDM,100,RC,,,Inpatient,,,,,,36731.35,125,MS-DRG,29385.08,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29385.08,100,MS-DRG,23508.064,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12303.99,100,,,Case Rate,100% of CMS IPPS Rate,29385.08,100,MS-DRG,23508.064,Case Rate,100% of CMS IPPS Rate,10897.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10897.76,36731.35,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,CDM,100,RC,,,Inpatient,,,,,,55782.08,125,MS-DRG,44625.664,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44625.66,100,MS-DRG,35700.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20377.31,100,,,Case Rate,100% of CMS IPPS Rate,44625.66,100,MS-DRG,35700.528,Case Rate,100% of CMS IPPS Rate,18048.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18048.39,55782.08,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,CDM,100,RC,,,Inpatient,,,,,,41621.56,125,MS-DRG,33297.248,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33297.25,100,MS-DRG,26637.8,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14376.36,100,,,Case Rate,100% of CMS IPPS Rate,33297.25,100,MS-DRG,26637.8,Case Rate,100% of CMS IPPS Rate,12733.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12733.29,41621.56,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,CDM,100,RC,,,Inpatient,,,,,,33634.7,125,MS-DRG,26907.76,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26907.76,100,MS-DRG,21526.208,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10991.69,100,,,Case Rate,100% of CMS IPPS Rate,26907.76,100,MS-DRG,21526.208,Case Rate,100% of CMS IPPS Rate,9735.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9735.45,33634.7,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,CDM,100,RC,,,Inpatient,,,,,,49359.9,125,MS-DRG,39487.92,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39487.92,100,MS-DRG,31590.336,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17655.71,100,,,Case Rate,100% of CMS IPPS Rate,39487.92,100,MS-DRG,31590.336,Case Rate,100% of CMS IPPS Rate,15637.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15637.84,49359.9,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,CDM,100,RC,,,Inpatient,,,,,,60332.21,125,MS-DRG,48265.768,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48265.77,100,MS-DRG,38612.616,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22305.56,100,,,Case Rate,100% of CMS IPPS Rate,48265.77,100,MS-DRG,38612.616,Case Rate,100% of CMS IPPS Rate,19756.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19756.26,60332.21,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,CDM,100,RC,,,Inpatient,,,,,,42373.65,125,MS-DRG,33898.92,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33898.92,100,MS-DRG,27119.136,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14695.08,100,,,Case Rate,100% of CMS IPPS Rate,33898.92,100,MS-DRG,27119.136,Case Rate,100% of CMS IPPS Rate,13015.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13015.58,42373.65,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,CDM,100,RC,,,Inpatient,,,,,,33533.34,125,MS-DRG,26826.672,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26826.67,100,MS-DRG,21461.336,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10948.73,100,,,Case Rate,100% of CMS IPPS Rate,26826.67,100,MS-DRG,21461.336,Case Rate,100% of CMS IPPS Rate,9697.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9697.4,33533.34,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,CDM,100,RC,,,Inpatient,,,,,,39831.26,125,MS-DRG,31865.008,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31865.01,100,MS-DRG,25492.008,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13617.67,100,,,Case Rate,100% of CMS IPPS Rate,31865.01,100,MS-DRG,25492.008,Case Rate,100% of CMS IPPS Rate,12061.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12061.31,39831.26,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,CDM,100,RC,,,Inpatient,,,,,,27944.99,125,MS-DRG,22355.992,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22355.99,100,MS-DRG,17884.792,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8580.5,100,,,Case Rate,100% of CMS IPPS Rate,22355.99,100,MS-DRG,17884.792,Case Rate,100% of CMS IPPS Rate,7599.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7599.84,27944.99,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,CDM,100,RC,,,Inpatient,,,,,,65758.7,125,MS-DRG,52606.96,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52606.96,100,MS-DRG,42085.568,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24605.2,100,,,Case Rate,100% of CMS IPPS Rate,52606.96,100,MS-DRG,42085.568,Case Rate,100% of CMS IPPS Rate,21793.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21793.08,65758.7,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,CDM,100,RC,,,Inpatient,,,,,,46953.21,125,MS-DRG,37562.568,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37562.57,100,MS-DRG,30050.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16635.81,100,,,Case Rate,100% of CMS IPPS Rate,37562.57,100,MS-DRG,30050.056,Case Rate,100% of CMS IPPS Rate,14734.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14734.5,46953.21,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,CDM,100,RC,,,Inpatient,,,,,,38523.29,125,MS-DRG,30818.632,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30818.63,100,MS-DRG,24654.904,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13063.37,100,,,Case Rate,100% of CMS IPPS Rate,30818.63,100,MS-DRG,24654.904,Case Rate,100% of CMS IPPS Rate,11570.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11570.36,38523.29,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,CDM,100,RC,,,Inpatient,,,,,,65258.4,125,MS-DRG,52206.72,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52206.72,100,MS-DRG,41765.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24393.18,100,,,Case Rate,100% of CMS IPPS Rate,52206.72,100,MS-DRG,41765.376,Case Rate,100% of CMS IPPS Rate,21605.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21605.29,65258.4,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,CDM,100,RC,,,Inpatient,,,,,,39955.51,125,MS-DRG,31964.408,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31964.41,100,MS-DRG,25571.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13670.33,100,,,Case Rate,100% of CMS IPPS Rate,31964.41,100,MS-DRG,25571.528,Case Rate,100% of CMS IPPS Rate,12107.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12107.95,39955.51,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,CDM,100,RC,,,Inpatient,,,,,,29648.64,125,MS-DRG,23718.912,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23718.91,100,MS-DRG,18975.128,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9302.47,100,,,Case Rate,100% of CMS IPPS Rate,23718.91,100,MS-DRG,18975.128,Case Rate,100% of CMS IPPS Rate,8239.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8239.29,29648.64,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,CDM,100,RC,,,Inpatient,,,,,,48978.94,125,MS-DRG,39183.152,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39183.15,100,MS-DRG,31346.52,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17494.27,100,,,Case Rate,100% of CMS IPPS Rate,39183.15,100,MS-DRG,31346.52,Case Rate,100% of CMS IPPS Rate,15494.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15494.86,48978.94,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,CDM,100,RC,,,Inpatient,,,,,,26676.25,125,MS-DRG,21341,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21341,100,MS-DRG,17072.8,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7612.56,100,,,Case Rate,100% of CMS IPPS Rate,21341,100,MS-DRG,17072.8,Case Rate,100% of CMS IPPS Rate,6742.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6742.52,26676.25,
SOFT TISSUE PROCEDURES WITH MCC,500,CDM,100,RC,,,Inpatient,,,,,,59504.93,125,MS-DRG,47603.944,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47603.94,100,MS-DRG,38083.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21954.97,100,,,Case Rate,100% of CMS IPPS Rate,47603.94,100,MS-DRG,38083.152,Case Rate,100% of CMS IPPS Rate,19445.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19445.74,59504.93,
SOFT TISSUE PROCEDURES WITH CC,501,CDM,100,RC,,,Inpatient,,,,,,36876.86,125,MS-DRG,29501.488,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29501.49,100,MS-DRG,23601.192,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12365.65,100,,,Case Rate,100% of CMS IPPS Rate,29501.49,100,MS-DRG,23601.192,Case Rate,100% of CMS IPPS Rate,10952.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10952.38,36876.86,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,CDM,100,RC,,,Inpatient,,,,,,30541.34,125,MS-DRG,24433.072,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24433.07,100,MS-DRG,19546.456,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9680.78,100,,,Case Rate,100% of CMS IPPS Rate,24433.07,100,MS-DRG,19546.456,Case Rate,100% of CMS IPPS Rate,8574.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8574.36,30541.34,
FOOT PROCEDURES WITH MCC,503,CDM,100,RC,,,Inpatient,,,,,,50968.71,125,MS-DRG,40774.968,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40774.97,100,MS-DRG,32619.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18337.5,100,,,Case Rate,100% of CMS IPPS Rate,40774.97,100,MS-DRG,32619.976,Case Rate,100% of CMS IPPS Rate,16241.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16241.71,50968.71,
FOOT PROCEDURES WITH CC,504,CDM,100,RC,,,Inpatient,,,,,,36391.28,125,MS-DRG,29113.024,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29113.02,100,MS-DRG,23290.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12159.87,100,,,Case Rate,100% of CMS IPPS Rate,29113.02,100,MS-DRG,23290.416,Case Rate,100% of CMS IPPS Rate,10770.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10770.12,36391.28,
FOOT PROCEDURES WITHOUT CC/MCC,505,CDM,100,RC,,,Inpatient,,,,,,36391.28,125,MS-DRG,29113.024,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29113.02,100,MS-DRG,23290.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12159.87,100,,,Case Rate,100% of CMS IPPS Rate,29113.02,100,MS-DRG,23290.416,Case Rate,100% of CMS IPPS Rate,10770.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10770.12,36391.28,
MAJOR THUMB OR JOINT PROCEDURES,506,CDM,100,RC,,,Inpatient,,,,,,32207.36,125,MS-DRG,25765.888,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25765.89,100,MS-DRG,20612.712,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10386.81,100,,,Case Rate,100% of CMS IPPS Rate,25765.89,100,MS-DRG,20612.712,Case Rate,100% of CMS IPPS Rate,9199.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9199.71,32207.36,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,CDM,100,RC,,,Inpatient,,,,,,39386.55,125,MS-DRG,31509.24,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31509.24,100,MS-DRG,25207.392,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13429.21,100,,,Case Rate,100% of CMS IPPS Rate,31509.24,100,MS-DRG,25207.392,Case Rate,100% of CMS IPPS Rate,11894.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11894.38,39386.55,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,CDM,100,RC,,,Inpatient,,,,,,28798.46,125,MS-DRG,23038.768,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23038.77,100,MS-DRG,18431.016,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8601.98,100,,,Case Rate,100% of CMS IPPS Rate,23038.77,100,MS-DRG,18431.016,Case Rate,100% of CMS IPPS Rate,7618.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7618.86,28798.46,
ARTHROSCOPY,509,CDM,100,RC,,,Inpatient,,,,,,36419.06,125,MS-DRG,29135.248,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29135.25,100,MS-DRG,23308.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12171.65,100,,,Case Rate,100% of CMS IPPS Rate,29135.25,100,MS-DRG,23308.2,Case Rate,100% of CMS IPPS Rate,10780.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10780.55,36419.06,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,CDM,100,RC,,,Inpatient,,,,,,54426.69,125,MS-DRG,43541.352,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43541.35,100,MS-DRG,34833.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19802.92,100,,,Case Rate,100% of CMS IPPS Rate,43541.35,100,MS-DRG,34833.08,Case Rate,100% of CMS IPPS Rate,17539.65,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17539.65,54426.69,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,CDM,100,RC,,,Inpatient,,,,,,39762.6,125,MS-DRG,31810.08,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31810.08,100,MS-DRG,25448.064,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13588.57,100,,,Case Rate,100% of CMS IPPS Rate,31810.08,100,MS-DRG,25448.064,Case Rate,100% of CMS IPPS Rate,12035.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12035.53,39762.6,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,CDM,100,RC,,,Inpatient,,,,,,33984.6,125,MS-DRG,27187.68,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27187.68,100,MS-DRG,21750.144,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11139.96,100,,,Case Rate,100% of CMS IPPS Rate,27187.68,100,MS-DRG,21750.144,Case Rate,100% of CMS IPPS Rate,9866.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9866.78,33984.6,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,CDM,100,RC,,,Inpatient,,,,,,32313.65,125,MS-DRG,25850.92,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25850.92,100,MS-DRG,20680.736,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10431.85,100,,,Case Rate,100% of CMS IPPS Rate,25850.92,100,MS-DRG,20680.736,Case Rate,100% of CMS IPPS Rate,9239.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9239.6,32313.65,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,CDM,100,RC,,,Inpatient,,,,,,24367.66,125,MS-DRG,19494.128,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19494.13,100,MS-DRG,15595.304,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7064.5,100,,,Case Rate,100% of CMS IPPS Rate,19494.13,100,MS-DRG,15595.304,Case Rate,100% of CMS IPPS Rate,6257.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6257.1,24367.66,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,CDM,100,RC,,,Inpatient,,,,,,58257.43,125,MS-DRG,46605.944,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46605.94,100,MS-DRG,37284.752,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21426.31,100,,,Case Rate,100% of CMS IPPS Rate,46605.94,100,MS-DRG,37284.752,Case Rate,100% of CMS IPPS Rate,18977.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18977.5,58257.43,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,CDM,100,RC,,,Inpatient,,,,,,40588.25,125,MS-DRG,32470.6,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32470.6,100,MS-DRG,25976.48,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13938.47,100,,,Case Rate,100% of CMS IPPS Rate,32470.6,100,MS-DRG,25976.48,Case Rate,100% of CMS IPPS Rate,12345.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12345.44,40588.25,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,CDM,100,RC,,,Inpatient,,,,,,32102.73,125,MS-DRG,25682.184,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25682.18,100,MS-DRG,20545.744,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10342.47,100,,,Case Rate,100% of CMS IPPS Rate,25682.18,100,MS-DRG,20545.744,Case Rate,100% of CMS IPPS Rate,9160.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9160.43,32102.73,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,CDM,100,RC,,,Inpatient,,,,,,66294.98,125,MS-DRG,53035.984,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53035.98,100,MS-DRG,42428.784,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24832.46,100,,,Case Rate,100% of CMS IPPS Rate,53035.98,100,MS-DRG,42428.784,Case Rate,100% of CMS IPPS Rate,21994.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21994.36,66294.98,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,CDM,100,RC,,,Inpatient,,,,,,39937.53,125,MS-DRG,31950.024,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31950.02,100,MS-DRG,25560.016,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13662.7,100,,,Case Rate,100% of CMS IPPS Rate,31950.02,100,MS-DRG,25560.016,Case Rate,100% of CMS IPPS Rate,12101.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12101.2,39937.53,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,CDM,100,RC,,,Inpatient,,,,,,31129.94,125,MS-DRG,24903.952,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24903.95,100,MS-DRG,19923.16,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9930.21,100,,,Case Rate,100% of CMS IPPS Rate,24903.95,100,MS-DRG,19923.16,Case Rate,100% of CMS IPPS Rate,8795.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8795.29,31129.94,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,CDM,100,RC,,,Inpatient,,,,,,55352.08,125,MS-DRG,44281.664,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44281.66,100,MS-DRG,35425.328,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20195.08,100,,,Case Rate,100% of CMS IPPS Rate,44281.66,100,MS-DRG,35425.328,Case Rate,100% of CMS IPPS Rate,17886.99,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17886.99,55352.08,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,CDM,100,RC,,,Inpatient,,,,,,42164.38,125,MS-DRG,33731.504,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33731.5,100,MS-DRG,26985.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14606.39,100,,,Case Rate,100% of CMS IPPS Rate,33731.5,100,MS-DRG,26985.2,Case Rate,100% of CMS IPPS Rate,12937.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12937.03,42164.38,
FRACTURES OF FEMUR WITH MCC,533,CDM,100,RC,,,Inpatient,,,,,,32629.2,125,MS-DRG,26103.36,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26103.36,100,MS-DRG,20882.688,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10565.57,100,,,Case Rate,100% of CMS IPPS Rate,26103.36,100,MS-DRG,20882.688,Case Rate,100% of CMS IPPS Rate,9358.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9358.04,32629.2,
FRACTURES OF FEMUR WITHOUT MCC,534,CDM,100,RC,,,Inpatient,,,,,,21006.15,125,MS-DRG,16804.92,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16804.92,100,MS-DRG,13443.936,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5639.96,100,,,Case Rate,100% of CMS IPPS Rate,16804.92,100,MS-DRG,13443.936,Case Rate,100% of CMS IPPS Rate,4995.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4995.37,21006.15,
FRACTURES OF HIP AND PELVIS WITH MCC,535,CDM,100,RC,,,Inpatient,,,,,,29441.01,125,MS-DRG,23552.808,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23552.81,100,MS-DRG,18842.248,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9214.48,100,,,Case Rate,100% of CMS IPPS Rate,23552.81,100,MS-DRG,18842.248,Case Rate,100% of CMS IPPS Rate,8161.36,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8161.36,29441.01,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,CDM,100,RC,,,Inpatient,,,,,,20955.48,125,MS-DRG,16764.384,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16764.38,100,MS-DRG,13411.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5618.48,100,,,Case Rate,100% of CMS IPPS Rate,16764.38,100,MS-DRG,13411.504,Case Rate,100% of CMS IPPS Rate,4976.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4976.35,20955.48,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,CDM,100,RC,,,Inpatient,,,,,,22722.88,125,MS-DRG,18178.304,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18178.3,100,MS-DRG,14542.64,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6367.48,100,,,Case Rate,100% of CMS IPPS Rate,18178.3,100,MS-DRG,14542.64,Case Rate,100% of CMS IPPS Rate,5639.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5639.74,22722.88,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,CDM,100,RC,,,Inpatient,,,,,,18676.31,125,MS-DRG,14941.048,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14941.05,100,MS-DRG,11952.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4652.62,100,,,Case Rate,100% of CMS IPPS Rate,14941.05,100,MS-DRG,11952.84,Case Rate,100% of CMS IPPS Rate,4120.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4120.87,18676.31,
OSTEOMYELITIS WITH MCC,539,CDM,100,RC,,,Inpatient,,,,,,40763.2,125,MS-DRG,32610.56,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32610.56,100,MS-DRG,26088.448,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14012.6,100,,,Case Rate,100% of CMS IPPS Rate,32610.56,100,MS-DRG,26088.448,Case Rate,100% of CMS IPPS Rate,12411.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12411.1,40763.2,
OSTEOMYELITIS WITH CC,540,CDM,100,RC,,,Inpatient,,,,,,28855.68,125,MS-DRG,23084.544,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23084.54,100,MS-DRG,18467.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8966.43,100,,,Case Rate,100% of CMS IPPS Rate,23084.54,100,MS-DRG,18467.632,Case Rate,100% of CMS IPPS Rate,7941.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7941.66,28855.68,
OSTEOMYELITIS WITHOUT CC/MCC,541,CDM,100,RC,,,Inpatient,,,,,,22001.86,125,MS-DRG,17601.488,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17601.49,100,MS-DRG,14081.192,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6061.92,100,,,Case Rate,100% of CMS IPPS Rate,17601.49,100,MS-DRG,14081.192,Case Rate,100% of CMS IPPS Rate,5369.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5369.1,22001.86,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,CDM,100,RC,,,Inpatient,,,,,,38191.39,125,MS-DRG,30553.112,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30553.11,100,MS-DRG,24442.488,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12922.72,100,,,Case Rate,100% of CMS IPPS Rate,30553.11,100,MS-DRG,24442.488,Case Rate,100% of CMS IPPS Rate,11445.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11445.78,38191.39,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,CDM,100,RC,,,Inpatient,,,,,,25042.91,125,MS-DRG,20034.328,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20034.33,100,MS-DRG,16027.464,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7350.66,100,,,Case Rate,100% of CMS IPPS Rate,20034.33,100,MS-DRG,16027.464,Case Rate,100% of CMS IPPS Rate,6510.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6510.55,25042.91,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,CDM,100,RC,,,Inpatient,,,,,,20052.98,125,MS-DRG,16042.384,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16042.38,100,MS-DRG,12833.904,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5236.02,100,,,Case Rate,100% of CMS IPPS Rate,16042.38,100,MS-DRG,12833.904,Case Rate,100% of CMS IPPS Rate,4637.59,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4637.59,20052.98,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,CDM,100,RC,,,Inpatient,,,,,,49011.65,125,MS-DRG,39209.32,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39209.32,100,MS-DRG,31367.456,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17508.13,100,,,Case Rate,100% of CMS IPPS Rate,39209.32,100,MS-DRG,31367.456,Case Rate,100% of CMS IPPS Rate,15507.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15507.13,49011.65,
CONNECTIVE TISSUE DISORDERS WITH CC,546,CDM,100,RC,,,Inpatient,,,,,,26625.56,125,MS-DRG,21300.448,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21300.45,100,MS-DRG,17040.36,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8021.36,100,,,Case Rate,100% of CMS IPPS Rate,21300.45,100,MS-DRG,17040.36,Case Rate,100% of CMS IPPS Rate,7104.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7104.6,26625.56,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,CDM,100,RC,,,Inpatient,,,,,,19897.65,125,MS-DRG,15918.12,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15918.12,100,MS-DRG,12734.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5170.2,100,,,Case Rate,100% of CMS IPPS Rate,15918.12,100,MS-DRG,12734.496,Case Rate,100% of CMS IPPS Rate,4579.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4579.3,19897.65,
SEPTIC ARTHRITIS WITH MCC,548,CDM,100,RC,,,Inpatient,,,,,,40635.68,125,MS-DRG,32508.544,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32508.54,100,MS-DRG,26006.832,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13958.56,100,,,Case Rate,100% of CMS IPPS Rate,32508.54,100,MS-DRG,26006.832,Case Rate,100% of CMS IPPS Rate,12363.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12363.24,40635.68,
SEPTIC ARTHRITIS WITH CC,549,CDM,100,RC,,,Inpatient,,,,,,27400.55,125,MS-DRG,21920.44,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21920.44,100,MS-DRG,17536.352,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8349.78,100,,,Case Rate,100% of CMS IPPS Rate,21920.44,100,MS-DRG,17536.352,Case Rate,100% of CMS IPPS Rate,7395.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7395.48,27400.55,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,CDM,100,RC,,,Inpatient,,,,,,21792.58,125,MS-DRG,17434.064,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17434.06,100,MS-DRG,13947.248,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5973.23,100,,,Case Rate,100% of CMS IPPS Rate,17434.06,100,MS-DRG,13947.248,Case Rate,100% of CMS IPPS Rate,5290.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5290.55,21792.58,
MEDICAL BACK PROBLEMS WITH MCC,551,CDM,100,RC,,,Inpatient,,,,,,35596.68,125,MS-DRG,28477.344,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28477.34,100,MS-DRG,22781.872,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11823.13,100,,,Case Rate,100% of CMS IPPS Rate,28477.34,100,MS-DRG,22781.872,Case Rate,100% of CMS IPPS Rate,10471.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10471.87,35596.68,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,CDM,100,RC,,,Inpatient,,,,,,23455.36,125,MS-DRG,18764.288,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18764.29,100,MS-DRG,15011.432,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6677.88,100,,,Case Rate,100% of CMS IPPS Rate,18764.29,100,MS-DRG,15011.432,Case Rate,100% of CMS IPPS Rate,5914.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5914.67,23455.36,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,CDM,100,RC,,,Inpatient,,,,,,29050.24,125,MS-DRG,23240.192,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23240.19,100,MS-DRG,18592.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9048.88,100,,,Case Rate,100% of CMS IPPS Rate,23240.19,100,MS-DRG,18592.152,Case Rate,100% of CMS IPPS Rate,8014.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8014.69,29050.24,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,CDM,100,RC,,,Inpatient,,,,,,21342.98,125,MS-DRG,17074.384,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17074.38,100,MS-DRG,13659.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5782.69,100,,,Case Rate,100% of CMS IPPS Rate,17074.38,100,MS-DRG,13659.504,Case Rate,100% of CMS IPPS Rate,5121.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5121.79,21342.98,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,CDM,100,RC,,,Inpatient,,,,,,29714.04,125,MS-DRG,23771.232,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23771.23,100,MS-DRG,19016.984,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9330.19,100,,,Case Rate,100% of CMS IPPS Rate,23771.23,100,MS-DRG,19016.984,Case Rate,100% of CMS IPPS Rate,8263.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8263.84,29714.04,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,CDM,100,RC,,,Inpatient,,,,,,21047.04,125,MS-DRG,16837.632,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16837.63,100,MS-DRG,13470.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5657.28,100,,,Case Rate,100% of CMS IPPS Rate,16837.63,100,MS-DRG,13470.104,Case Rate,100% of CMS IPPS Rate,5010.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5010.71,21047.04,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,CDM,100,RC,,,Inpatient,,,,,,33034.68,125,MS-DRG,26427.744,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26427.74,100,MS-DRG,21142.192,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10737.41,100,,,Case Rate,100% of CMS IPPS Rate,26427.74,100,MS-DRG,21142.192,Case Rate,100% of CMS IPPS Rate,9510.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9510.23,33034.68,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,CDM,100,RC,,,Inpatient,,,,,,21820.39,125,MS-DRG,17456.312,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17456.31,100,MS-DRG,13965.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5985.01,100,,,Case Rate,100% of CMS IPPS Rate,17456.31,100,MS-DRG,13965.048,Case Rate,100% of CMS IPPS Rate,5300.99,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5300.99,21820.39,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,CDM,100,RC,,,Inpatient,,,,,,38047.51,125,MS-DRG,30438.008,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30438.01,100,MS-DRG,24350.408,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12861.75,100,,,Case Rate,100% of CMS IPPS Rate,30438.01,100,MS-DRG,24350.408,Case Rate,100% of CMS IPPS Rate,11391.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11391.78,38047.51,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,CDM,100,RC,,,Inpatient,,,,,,26314.93,125,MS-DRG,21051.944,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21051.94,100,MS-DRG,16841.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7889.71,100,,,Case Rate,100% of CMS IPPS Rate,21051.94,100,MS-DRG,16841.552,Case Rate,100% of CMS IPPS Rate,6988,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6988,26314.93,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,CDM,100,RC,,,Inpatient,,,,,,21065.01,125,MS-DRG,16852.008,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16852.01,100,MS-DRG,13481.608,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5664.91,100,,,Case Rate,100% of CMS IPPS Rate,16852.01,100,MS-DRG,13481.608,Case Rate,100% of CMS IPPS Rate,5017.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5017.46,21065.01,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,CDM,100,RC,,,Inpatient,,,,,,31625.33,125,MS-DRG,25300.264,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25300.26,100,MS-DRG,20240.208,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10140.15,100,,,Case Rate,100% of CMS IPPS Rate,25300.26,100,MS-DRG,20240.208,Case Rate,100% of CMS IPPS Rate,8981.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8981.24,31625.33,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,CDM,100,RC,,,Inpatient,,,,,,22310.86,125,MS-DRG,17848.688,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17848.69,100,MS-DRG,14278.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6192.87,100,,,Case Rate,100% of CMS IPPS Rate,17848.69,100,MS-DRG,14278.952,Case Rate,100% of CMS IPPS Rate,5485.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5485.09,22310.86,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,CDM,100,RC,,,Inpatient,,,,,,33353.48,125,MS-DRG,26682.784,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26682.78,100,MS-DRG,21346.224,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10872.52,100,,,Case Rate,100% of CMS IPPS Rate,26682.78,100,MS-DRG,21346.224,Case Rate,100% of CMS IPPS Rate,9629.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9629.9,33353.48,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,CDM,100,RC,,,Inpatient,,,,,,24369.3,125,MS-DRG,19495.44,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19495.44,100,MS-DRG,15596.352,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7065.2,100,,,Case Rate,100% of CMS IPPS Rate,19495.44,100,MS-DRG,15596.352,Case Rate,100% of CMS IPPS Rate,6257.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6257.72,24369.3,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,CDM,100,RC,,,Inpatient,,,,,,19928.71,125,MS-DRG,15942.968,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15942.97,100,MS-DRG,12754.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5183.36,100,,,Case Rate,100% of CMS IPPS Rate,15942.97,100,MS-DRG,12754.376,Case Rate,100% of CMS IPPS Rate,4590.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4590.96,19928.71,
SKIN DEBRIDEMENT WITH MCC,570,CDM,100,RC,,,Inpatient,,,,,,56913.49,125,MS-DRG,45530.792,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45530.79,100,MS-DRG,36424.632,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20856.77,100,,,Case Rate,100% of CMS IPPS Rate,45530.79,100,MS-DRG,36424.632,Case Rate,100% of CMS IPPS Rate,18473.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18473.06,56913.49,
SKIN DEBRIDEMENT WITH CC,571,CDM,100,RC,,,Inpatient,,,,,,35071.85,125,MS-DRG,28057.48,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28057.48,100,MS-DRG,22445.984,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11600.72,100,,,Case Rate,100% of CMS IPPS Rate,28057.48,100,MS-DRG,22445.984,Case Rate,100% of CMS IPPS Rate,10274.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10274.88,35071.85,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,CDM,100,RC,,,Inpatient,,,,,,26375.41,125,MS-DRG,21100.328,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21100.33,100,MS-DRG,16880.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7915.35,100,,,Case Rate,100% of CMS IPPS Rate,21100.33,100,MS-DRG,16880.264,Case Rate,100% of CMS IPPS Rate,7010.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7010.7,26375.41,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,CDM,100,RC,,,Inpatient,,,,,,108382.49,125,MS-DRG,86705.992,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86705.99,100,MS-DRG,69364.792,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,42668.32,100,,,Case Rate,100% of CMS IPPS Rate,86705.99,100,MS-DRG,69364.792,Case Rate,100% of CMS IPPS Rate,37791.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37791.76,108382.5,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,CDM,100,RC,,,Inpatient,,,,,,64347.73,125,MS-DRG,51478.184,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51478.18,100,MS-DRG,41182.544,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24007.25,100,,,Case Rate,100% of CMS IPPS Rate,51478.18,100,MS-DRG,41182.544,Case Rate,100% of CMS IPPS Rate,21263.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21263.47,64347.73,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,CDM,100,RC,,,Inpatient,,,,,,40343.03,125,MS-DRG,32274.424,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32274.42,100,MS-DRG,25819.536,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13834.54,100,,,Case Rate,100% of CMS IPPS Rate,32274.42,100,MS-DRG,25819.536,Case Rate,100% of CMS IPPS Rate,12253.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12253.39,40343.03,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,CDM,100,RC,,,Inpatient,,,,,,95909.26,125,MS-DRG,76727.408,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76727.41,100,MS-DRG,61381.928,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37382.42,100,,,Case Rate,100% of CMS IPPS Rate,76727.41,100,MS-DRG,61381.928,Case Rate,100% of CMS IPPS Rate,33109.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,33109.98,95909.26,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,CDM,100,RC,,,Inpatient,,,,,,51233.58,125,MS-DRG,40986.864,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40986.86,100,MS-DRG,32789.488,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18449.74,100,,,Case Rate,100% of CMS IPPS Rate,40986.86,100,MS-DRG,32789.488,Case Rate,100% of CMS IPPS Rate,16341.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16341.12,51233.58,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,CDM,100,RC,,,Inpatient,,,,,,35335.08,125,MS-DRG,28268.064,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28268.06,100,MS-DRG,22614.448,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11712.27,100,,,Case Rate,100% of CMS IPPS Rate,28268.06,100,MS-DRG,22614.448,Case Rate,100% of CMS IPPS Rate,10373.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10373.68,35335.08,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,CDM,100,RC,,,Inpatient,,,,,,60987.84,125,MS-DRG,48790.272,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48790.27,100,MS-DRG,39032.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22583.4,100,,,Case Rate,100% of CMS IPPS Rate,48790.27,100,MS-DRG,39032.216,Case Rate,100% of CMS IPPS Rate,20002.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20002.35,60987.84,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,CDM,100,RC,,,Inpatient,,,,,,36685.56,125,MS-DRG,29348.448,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29348.45,100,MS-DRG,23478.76,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12284.59,100,,,Case Rate,100% of CMS IPPS Rate,29348.45,100,MS-DRG,23478.76,Case Rate,100% of CMS IPPS Rate,10880.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10880.58,36685.56,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,CDM,100,RC,,,Inpatient,,,,,,31228.03,125,MS-DRG,24982.424,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24982.42,100,MS-DRG,19985.936,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9971.79,100,,,Case Rate,100% of CMS IPPS Rate,24982.42,100,MS-DRG,19985.936,Case Rate,100% of CMS IPPS Rate,8832.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8832.11,31228.03,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,CDM,100,RC,,,Inpatient,,,,,,36329.15,125,MS-DRG,29063.32,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29063.32,100,MS-DRG,23250.656,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12133.54,100,,,Case Rate,100% of CMS IPPS Rate,29063.32,100,MS-DRG,23250.656,Case Rate,100% of CMS IPPS Rate,10746.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10746.8,36329.15,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,CDM,100,RC,,,Inpatient,,,,,,34555.19,125,MS-DRG,27644.152,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27644.15,100,MS-DRG,22115.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11381.78,100,,,Case Rate,100% of CMS IPPS Rate,27644.15,100,MS-DRG,22115.32,Case Rate,100% of CMS IPPS Rate,10080.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10080.95,34555.19,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,CDM,100,RC,,,Inpatient,,,,,,41171.95,125,MS-DRG,32937.56,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32937.56,100,MS-DRG,26350.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14185.82,100,,,Case Rate,100% of CMS IPPS Rate,32937.56,100,MS-DRG,26350.048,Case Rate,100% of CMS IPPS Rate,12564.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12564.53,41171.95,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,CDM,100,RC,,,Inpatient,,,,,,40153.36,125,MS-DRG,32122.688,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32122.69,100,MS-DRG,25698.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13754.16,100,,,Case Rate,100% of CMS IPPS Rate,32122.69,100,MS-DRG,25698.152,Case Rate,100% of CMS IPPS Rate,12182.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12182.2,40153.36,
SKIN ULCERS WITH MCC,592,CDM,100,RC,,,Inpatient,,,,,,41317.45,125,MS-DRG,33053.96,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33053.96,100,MS-DRG,26443.168,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14247.49,100,,,Case Rate,100% of CMS IPPS Rate,33053.96,100,MS-DRG,26443.168,Case Rate,100% of CMS IPPS Rate,12619.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12619.14,41317.45,
SKIN ULCERS WITH CC,593,CDM,100,RC,,,Inpatient,,,,,,27688.31,125,MS-DRG,22150.648,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22150.65,100,MS-DRG,17720.52,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8471.72,100,,,Case Rate,100% of CMS IPPS Rate,22150.65,100,MS-DRG,17720.52,Case Rate,100% of CMS IPPS Rate,7503.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7503.49,27688.31,
SKIN ULCERS WITHOUT CC/MCC,594,CDM,100,RC,,,Inpatient,,,,,,21573.5,125,MS-DRG,17258.8,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17258.8,100,MS-DRG,13807.04,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5880.39,100,,,Case Rate,100% of CMS IPPS Rate,17258.8,100,MS-DRG,13807.04,Case Rate,100% of CMS IPPS Rate,5208.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5208.32,21573.5,
MAJOR SKIN DISORDERS WITH MCC,595,CDM,100,RC,,,Inpatient,,,,,,42278.83,125,MS-DRG,33823.064,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33823.06,100,MS-DRG,27058.448,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14654.89,100,,,Case Rate,100% of CMS IPPS Rate,33823.06,100,MS-DRG,27058.448,Case Rate,100% of CMS IPPS Rate,12979.99,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12979.99,42278.83,
MAJOR SKIN DISORDERS WITHOUT MCC,596,CDM,100,RC,,,Inpatient,,,,,,25373.18,125,MS-DRG,20298.544,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20298.54,100,MS-DRG,16238.832,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7490.62,100,,,Case Rate,100% of CMS IPPS Rate,20298.54,100,MS-DRG,16238.832,Case Rate,100% of CMS IPPS Rate,6634.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6634.52,25373.18,
MALIGNANT BREAST DISORDERS WITH MCC,597,CDM,100,RC,,,Inpatient,,,,,,36419.06,125,MS-DRG,29135.248,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29135.25,100,MS-DRG,23308.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12171.65,100,,,Case Rate,100% of CMS IPPS Rate,29135.25,100,MS-DRG,23308.2,Case Rate,100% of CMS IPPS Rate,10780.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10780.55,36419.06,
MALIGNANT BREAST DISORDERS WITH CC,598,CDM,100,RC,,,Inpatient,,,,,,25337.21,125,MS-DRG,20269.768,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20269.77,100,MS-DRG,16215.816,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7349.96,100,,,Case Rate,100% of CMS IPPS Rate,20269.77,100,MS-DRG,16215.816,Case Rate,100% of CMS IPPS Rate,6509.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6509.94,25337.21,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,CDM,100,RC,,,Inpatient,,,,,,21674.85,125,MS-DRG,17339.88,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17339.88,100,MS-DRG,13871.904,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5923.35,100,,,Case Rate,100% of CMS IPPS Rate,17339.88,100,MS-DRG,13871.904,Case Rate,100% of CMS IPPS Rate,5246.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5246.37,21674.85,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,CDM,100,RC,,,Inpatient,,,,,,23337.64,125,MS-DRG,18670.112,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18670.11,100,MS-DRG,14936.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6627.99,100,,,Case Rate,100% of CMS IPPS Rate,18670.11,100,MS-DRG,14936.088,Case Rate,100% of CMS IPPS Rate,5870.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5870.48,23337.64,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,CDM,100,RC,,,Inpatient,,,,,,17499.15,125,MS-DRG,13999.32,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13999.32,100,MS-DRG,11199.456,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4153.76,100,,,Case Rate,100% of CMS IPPS Rate,13999.32,100,MS-DRG,11199.456,Case Rate,100% of CMS IPPS Rate,3679.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3679.02,17499.15,
CELLULITIS WITH MCC,602,CDM,100,RC,,,Inpatient,,,,,,31718.5,125,MS-DRG,25374.8,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25374.8,100,MS-DRG,20299.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10179.65,100,,,Case Rate,100% of CMS IPPS Rate,25374.8,100,MS-DRG,20299.84,Case Rate,100% of CMS IPPS Rate,9016.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9016.22,31718.5,
CELLULITIS WITHOUT MCC,603,CDM,100,RC,,,Inpatient,,,,,,22098.34,125,MS-DRG,17678.672,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17678.67,100,MS-DRG,14142.936,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6102.8,100,,,Case Rate,100% of CMS IPPS Rate,17678.67,100,MS-DRG,14142.936,Case Rate,100% of CMS IPPS Rate,5405.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5405.31,22098.34,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,CDM,100,RC,,,Inpatient,,,,,,31988.29,125,MS-DRG,25590.632,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25590.63,100,MS-DRG,20472.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10293.97,100,,,Case Rate,100% of CMS IPPS Rate,25590.63,100,MS-DRG,20472.504,Case Rate,100% of CMS IPPS Rate,9117.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9117.47,31988.29,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,CDM,100,RC,,,Inpatient,,,,,,22799.73,125,MS-DRG,18239.784,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18239.78,100,MS-DRG,14591.824,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6400.04,100,,,Case Rate,100% of CMS IPPS Rate,18239.78,100,MS-DRG,14591.824,Case Rate,100% of CMS IPPS Rate,5668.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5668.58,22799.73,
MINOR SKIN DISORDERS WITH MCC,606,CDM,100,RC,,,Inpatient,,,,,,34025.46,125,MS-DRG,27220.368,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27220.37,100,MS-DRG,21776.296,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11157.29,100,,,Case Rate,100% of CMS IPPS Rate,27220.37,100,MS-DRG,21776.296,Case Rate,100% of CMS IPPS Rate,9882.12,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9882.12,34025.46,
MINOR SKIN DISORDERS WITHOUT MCC,607,CDM,100,RC,,,Inpatient,,,,,,21826.91,125,MS-DRG,17461.528,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17461.53,100,MS-DRG,13969.224,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5987.78,100,,,Case Rate,100% of CMS IPPS Rate,17461.53,100,MS-DRG,13969.224,Case Rate,100% of CMS IPPS Rate,5303.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5303.44,21826.91,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,CDM,100,RC,,,Inpatient,,,,,,44958.55,125,MS-DRG,35966.84,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35966.84,100,MS-DRG,28773.472,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15790.51,100,,,Case Rate,100% of CMS IPPS Rate,35966.84,100,MS-DRG,28773.472,Case Rate,100% of CMS IPPS Rate,13985.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13985.81,44958.55,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,CDM,100,RC,,,Inpatient,,,,,,31126.65,125,MS-DRG,24901.32,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24901.32,100,MS-DRG,19921.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9928.83,100,,,Case Rate,100% of CMS IPPS Rate,24901.32,100,MS-DRG,19921.056,Case Rate,100% of CMS IPPS Rate,8794.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8794.06,31126.65,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,CDM,100,RC,,,Inpatient,,,,,,70889.25,125,MS-DRG,56711.4,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56711.4,100,MS-DRG,45369.12,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26779.43,100,,,Case Rate,100% of CMS IPPS Rate,56711.4,100,MS-DRG,45369.12,Case Rate,100% of CMS IPPS Rate,23718.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23718.81,70889.25,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,CDM,100,RC,,,Inpatient,,,,,,39278.64,125,MS-DRG,31422.912,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31422.91,100,MS-DRG,25138.328,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13383.48,100,,,Case Rate,100% of CMS IPPS Rate,31422.91,100,MS-DRG,25138.328,Case Rate,100% of CMS IPPS Rate,11853.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11853.88,39278.64,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,CDM,100,RC,,,Inpatient,,,,,,28054.55,125,MS-DRG,22443.64,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22443.64,100,MS-DRG,17954.912,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8626.92,100,,,Case Rate,100% of CMS IPPS Rate,22443.64,100,MS-DRG,17954.912,Case Rate,100% of CMS IPPS Rate,7640.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7640.95,28054.55,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,CDM,100,RC,,,Inpatient,,,,,,52275.06,125,MS-DRG,41820.048,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41820.05,100,MS-DRG,33456.04,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18891.1,100,,,Case Rate,100% of CMS IPPS Rate,41820.05,100,MS-DRG,33456.04,Case Rate,100% of CMS IPPS Rate,16732.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16732.04,52275.06,
O.R. PROCEDURES FOR OBESITY WITH CC,620,CDM,100,RC,,,Inpatient,,,,,,33808.03,125,MS-DRG,27046.424,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27046.42,100,MS-DRG,21637.136,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11065.13,100,,,Case Rate,100% of CMS IPPS Rate,27046.42,100,MS-DRG,21637.136,Case Rate,100% of CMS IPPS Rate,9800.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9800.5,33808.03,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,CDM,100,RC,,,Inpatient,,,,,,31597.54,125,MS-DRG,25278.032,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25278.03,100,MS-DRG,20222.424,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10128.37,100,,,Case Rate,100% of CMS IPPS Rate,25278.03,100,MS-DRG,20222.424,Case Rate,100% of CMS IPPS Rate,8970.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8970.8,31597.54,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,CDM,100,RC,,,Inpatient,,,,,,68878.23,125,MS-DRG,55102.584,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55102.58,100,MS-DRG,44082.064,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25927.2,100,,,Case Rate,100% of CMS IPPS Rate,55102.58,100,MS-DRG,44082.064,Case Rate,100% of CMS IPPS Rate,22963.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22963.98,68878.23,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,CDM,100,RC,,,Inpatient,,,,,,38971.26,125,MS-DRG,31177.008,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31177.01,100,MS-DRG,24941.608,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13253.22,100,,,Case Rate,100% of CMS IPPS Rate,31177.01,100,MS-DRG,24941.608,Case Rate,100% of CMS IPPS Rate,11738.51,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11738.51,38971.26,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,CDM,100,RC,,,Inpatient,,,,,,24097.9,125,MS-DRG,19278.32,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19278.32,100,MS-DRG,15422.656,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6900.29,100,,,Case Rate,100% of CMS IPPS Rate,19278.32,100,MS-DRG,15422.656,Case Rate,100% of CMS IPPS Rate,6111.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6111.66,24097.9,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,CDM,100,RC,,,Inpatient,,,,,,54573.84,125,MS-DRG,43659.072,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43659.07,100,MS-DRG,34927.256,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19865.28,100,,,Case Rate,100% of CMS IPPS Rate,43659.07,100,MS-DRG,34927.256,Case Rate,100% of CMS IPPS Rate,17594.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17594.88,54573.84,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,CDM,100,RC,,,Inpatient,,,,,,32374.15,125,MS-DRG,25899.32,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25899.32,100,MS-DRG,20719.456,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10457.49,100,,,Case Rate,100% of CMS IPPS Rate,25899.32,100,MS-DRG,20719.456,Case Rate,100% of CMS IPPS Rate,9262.3,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9262.3,32374.15,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,CDM,100,RC,,,Inpatient,,,,,,28410.96,125,MS-DRG,22728.768,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22728.77,100,MS-DRG,18183.016,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8777.97,100,,,Case Rate,100% of CMS IPPS Rate,22728.77,100,MS-DRG,18183.016,Case Rate,100% of CMS IPPS Rate,7774.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7774.74,28410.96,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,CDM,100,RC,,,Inpatient,,,,,,72208.66,125,MS-DRG,57766.928,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57766.93,100,MS-DRG,46213.544,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27338.57,100,,,Case Rate,100% of CMS IPPS Rate,57766.93,100,MS-DRG,46213.544,Case Rate,100% of CMS IPPS Rate,24214.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24214.05,72208.66,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,CDM,100,RC,,,Inpatient,,,,,,44469.69,125,MS-DRG,35575.752,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35575.75,100,MS-DRG,28460.6,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15583.34,100,,,Case Rate,100% of CMS IPPS Rate,35575.75,100,MS-DRG,28460.6,Case Rate,100% of CMS IPPS Rate,13802.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13802.32,44469.69,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,CDM,100,RC,,,Inpatient,,,,,,30608.38,125,MS-DRG,24486.704,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24486.7,100,MS-DRG,19589.36,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9709.19,100,,,Case Rate,100% of CMS IPPS Rate,24486.7,100,MS-DRG,19589.36,Case Rate,100% of CMS IPPS Rate,8599.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8599.53,30608.38,
DIABETES WITH MCC,637,CDM,100,RC,,,Inpatient,,,,,,31507.61,125,MS-DRG,25206.088,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25206.09,100,MS-DRG,20164.872,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10090.27,100,,,Case Rate,100% of CMS IPPS Rate,25206.09,100,MS-DRG,20164.872,Case Rate,100% of CMS IPPS Rate,8937.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8937.05,31507.61,
DIABETES WITH CC,638,CDM,100,RC,,,Inpatient,,,,,,22693.46,125,MS-DRG,18154.768,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18154.77,100,MS-DRG,14523.816,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6355,100,,,Case Rate,100% of CMS IPPS Rate,18154.77,100,MS-DRG,14523.816,Case Rate,100% of CMS IPPS Rate,5628.69,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5628.69,22693.46,
DIABETES WITHOUT CC/MCC,639,CDM,100,RC,,,Inpatient,,,,,,17942.23,125,MS-DRG,14353.784,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14353.78,100,MS-DRG,11483.024,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4341.52,100,,,Case Rate,100% of CMS IPPS Rate,14353.78,100,MS-DRG,11483.024,Case Rate,100% of CMS IPPS Rate,3845.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3845.33,17942.23,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,CDM,100,RC,,,Inpatient,,,,,,29409.93,125,MS-DRG,23527.944,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23527.94,100,MS-DRG,18822.352,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9201.31,100,,,Case Rate,100% of CMS IPPS Rate,23527.94,100,MS-DRG,18822.352,Case Rate,100% of CMS IPPS Rate,8149.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8149.7,29409.93,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,CDM,100,RC,,,Inpatient,,,,,,20473.16,125,MS-DRG,16378.528,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16378.53,100,MS-DRG,13102.824,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5414.09,100,,,Case Rate,100% of CMS IPPS Rate,16378.53,100,MS-DRG,13102.824,Case Rate,100% of CMS IPPS Rate,4795.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4795.31,20473.16,
INBORN AND OTHER DISORDERS OF METABOLISM,642,CDM,100,RC,,,Inpatient,,,,,,27989.14,125,MS-DRG,22391.312,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22391.31,100,MS-DRG,17913.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8599.21,100,,,Case Rate,100% of CMS IPPS Rate,22391.31,100,MS-DRG,17913.048,Case Rate,100% of CMS IPPS Rate,7616.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7616.41,27989.14,
ENDOCRINE DISORDERS WITH MCC,643,CDM,100,RC,,,Inpatient,,,,,,34793.9,125,MS-DRG,27835.12,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27835.12,100,MS-DRG,22268.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11482.93,100,,,Case Rate,100% of CMS IPPS Rate,27835.12,100,MS-DRG,22268.096,Case Rate,100% of CMS IPPS Rate,10170.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10170.55,34793.9,
ENDOCRINE DISORDERS WITH CC,644,CDM,100,RC,,,Inpatient,,,,,,24593.3,125,MS-DRG,19674.64,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19674.64,100,MS-DRG,15739.712,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7160.12,100,,,Case Rate,100% of CMS IPPS Rate,19674.64,100,MS-DRG,15739.712,Case Rate,100% of CMS IPPS Rate,6341.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6341.79,24593.3,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,CDM,100,RC,,,Inpatient,,,,,,20429.01,125,MS-DRG,16343.208,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16343.21,100,MS-DRG,13074.568,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5395.38,100,,,Case Rate,100% of CMS IPPS Rate,16343.21,100,MS-DRG,13074.568,Case Rate,100% of CMS IPPS Rate,4778.74,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4778.74,20429.01,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,CDM,100,RC,,,Inpatient,,,,,,83025.66,125,MS-DRG,66420.528,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66420.53,100,MS-DRG,53136.424,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31922.6,100,,,Case Rate,100% of CMS IPPS Rate,66420.53,100,MS-DRG,53136.424,Case Rate,100% of CMS IPPS Rate,28274.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28274.17,83025.66,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,CDM,100,RC,,,Inpatient,,,,,,64471.98,125,MS-DRG,51577.584,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51577.58,100,MS-DRG,41262.064,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24059.91,100,,,Case Rate,100% of CMS IPPS Rate,51577.58,100,MS-DRG,41262.064,Case Rate,100% of CMS IPPS Rate,21310.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21310.11,64471.98,
KIDNEY TRANSPLANT,652,CDM,100,RC,,,Inpatient,,,,,,57914.09,125,MS-DRG,46331.272,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46331.27,100,MS-DRG,37065.016,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21280.81,100,,,Case Rate,100% of CMS IPPS Rate,46331.27,100,MS-DRG,37065.016,Case Rate,100% of CMS IPPS Rate,18848.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18848.63,57914.09,
MAJOR BLADDER PROCEDURES WITH MCC,653,CDM,100,RC,,,Inpatient,,,,,,98840.8,125,MS-DRG,79072.64,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79072.64,100,MS-DRG,63258.112,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,38624.73,100,,,Case Rate,100% of CMS IPPS Rate,79072.64,100,MS-DRG,63258.112,Case Rate,100% of CMS IPPS Rate,34210.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,34210.32,98840.8,
MAJOR BLADDER PROCEDURES WITH CC,654,CDM,100,RC,,,Inpatient,,,,,,53838.09,125,MS-DRG,43070.472,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43070.47,100,MS-DRG,34456.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19553.48,100,,,Case Rate,100% of CMS IPPS Rate,43070.47,100,MS-DRG,34456.376,Case Rate,100% of CMS IPPS Rate,17318.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17318.72,53838.09,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,CDM,100,RC,,,Inpatient,,,,,,41660.81,125,MS-DRG,33328.648,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33328.65,100,MS-DRG,26662.92,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14392.99,100,,,Case Rate,100% of CMS IPPS Rate,33328.65,100,MS-DRG,26662.92,Case Rate,100% of CMS IPPS Rate,12748.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12748.02,41660.81,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,CDM,100,RC,,,Inpatient,,,,,,60964.95,125,MS-DRG,48771.96,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48771.96,100,MS-DRG,39017.568,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22573.7,100,,,Case Rate,100% of CMS IPPS Rate,48771.96,100,MS-DRG,39017.568,Case Rate,100% of CMS IPPS Rate,19993.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19993.76,60964.95,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,CDM,100,RC,,,Inpatient,,,,,,37586.45,125,MS-DRG,30069.16,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30069.16,100,MS-DRG,24055.328,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12666.36,100,,,Case Rate,100% of CMS IPPS Rate,30069.16,100,MS-DRG,24055.328,Case Rate,100% of CMS IPPS Rate,11218.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11218.72,37586.45,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,CDM,100,RC,,,Inpatient,,,,,,32287.49,125,MS-DRG,25829.992,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25829.99,100,MS-DRG,20663.992,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10420.76,100,,,Case Rate,100% of CMS IPPS Rate,25829.99,100,MS-DRG,20663.992,Case Rate,100% of CMS IPPS Rate,9229.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9229.78,32287.49,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,CDM,100,RC,,,Inpatient,,,,,,49950.13,125,MS-DRG,39960.104,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39960.1,100,MS-DRG,31968.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17905.84,100,,,Case Rate,100% of CMS IPPS Rate,39960.1,100,MS-DRG,31968.08,Case Rate,100% of CMS IPPS Rate,15859.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15859.38,49950.13,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,CDM,100,RC,,,Inpatient,,,,,,29606.14,125,MS-DRG,23684.912,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23684.91,100,MS-DRG,18947.928,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9284.46,100,,,Case Rate,100% of CMS IPPS Rate,23684.91,100,MS-DRG,18947.928,Case Rate,100% of CMS IPPS Rate,8223.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8223.34,29606.14,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,CDM,100,RC,,,Inpatient,,,,,,24482.11,125,MS-DRG,19585.688,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19585.69,100,MS-DRG,15668.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7113,100,,,Case Rate,100% of CMS IPPS Rate,19585.69,100,MS-DRG,15668.552,Case Rate,100% of CMS IPPS Rate,6300.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6300.06,24482.11,
MINOR BLADDER PROCEDURES WITH MCC,662,CDM,100,RC,,,Inpatient,,,,,,58702.14,125,MS-DRG,46961.712,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46961.71,100,MS-DRG,37569.368,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21614.77,100,,,Case Rate,100% of CMS IPPS Rate,46961.71,100,MS-DRG,37569.368,Case Rate,100% of CMS IPPS Rate,19144.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19144.42,58702.14,
MINOR BLADDER PROCEDURES WITH CC,663,CDM,100,RC,,,Inpatient,,,,,,32670.08,125,MS-DRG,26136.064,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26136.06,100,MS-DRG,20908.848,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10582.9,100,,,Case Rate,100% of CMS IPPS Rate,26136.06,100,MS-DRG,20908.848,Case Rate,100% of CMS IPPS Rate,9373.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9373.38,32670.08,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,CDM,100,RC,,,Inpatient,,,,,,25351.94,125,MS-DRG,20281.552,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20281.55,100,MS-DRG,16225.24,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7481.61,100,,,Case Rate,100% of CMS IPPS Rate,20281.55,100,MS-DRG,16225.24,Case Rate,100% of CMS IPPS Rate,6626.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6626.54,25351.94,
PROSTATECTOMY WITH MCC,665,CDM,100,RC,,,Inpatient,,,,,,63835.96,125,MS-DRG,51068.768,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51068.77,100,MS-DRG,40855.016,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23790.38,100,,,Case Rate,100% of CMS IPPS Rate,51068.77,100,MS-DRG,40855.016,Case Rate,100% of CMS IPPS Rate,21071.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21071.39,63835.96,
PROSTATECTOMY WITH CC,666,CDM,100,RC,,,Inpatient,,,,,,34630.4,125,MS-DRG,27704.32,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27704.32,100,MS-DRG,22163.456,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11413.65,100,,,Case Rate,100% of CMS IPPS Rate,27704.32,100,MS-DRG,22163.456,Case Rate,100% of CMS IPPS Rate,10109.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10109.18,34630.4,
PROSTATECTOMY WITHOUT CC/MCC,667,CDM,100,RC,,,Inpatient,,,,,,24501.73,125,MS-DRG,19601.384,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19601.38,100,MS-DRG,15681.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7121.32,100,,,Case Rate,100% of CMS IPPS Rate,19601.38,100,MS-DRG,15681.104,Case Rate,100% of CMS IPPS Rate,6307.42,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6307.42,24501.73,
TRANSURETHRAL PROCEDURES WITH MCC,668,CDM,100,RC,,,Inpatient,,,,,,55378.24,125,MS-DRG,44302.592,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44302.59,100,MS-DRG,35442.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20206.17,100,,,Case Rate,100% of CMS IPPS Rate,44302.59,100,MS-DRG,35442.072,Case Rate,100% of CMS IPPS Rate,17896.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17896.81,55378.24,
TRANSURETHRAL PROCEDURES WITH CC,669,CDM,100,RC,,,Inpatient,,,,,,32998.71,125,MS-DRG,26398.968,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26398.97,100,MS-DRG,21119.176,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10722.16,100,,,Case Rate,100% of CMS IPPS Rate,26398.97,100,MS-DRG,21119.176,Case Rate,100% of CMS IPPS Rate,9496.73,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9496.73,32998.71,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,CDM,100,RC,,,Inpatient,,,,,,23322.93,125,MS-DRG,18658.344,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18658.34,100,MS-DRG,14926.672,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6621.76,100,,,Case Rate,100% of CMS IPPS Rate,18658.34,100,MS-DRG,14926.672,Case Rate,100% of CMS IPPS Rate,5864.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5864.96,23322.93,
URETHRAL PROCEDURES WITH CC/MCC,671,CDM,100,RC,,,Inpatient,,,,,,35879.54,125,MS-DRG,28703.632,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28703.63,100,MS-DRG,22962.904,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11943,100,,,Case Rate,100% of CMS IPPS Rate,28703.63,100,MS-DRG,22962.904,Case Rate,100% of CMS IPPS Rate,10578.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10578.04,35879.54,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,CDM,100,RC,,,Inpatient,,,,,,25590.64,125,MS-DRG,20472.512,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20472.51,100,MS-DRG,16378.008,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7582.77,100,,,Case Rate,100% of CMS IPPS Rate,20472.51,100,MS-DRG,16378.008,Case Rate,100% of CMS IPPS Rate,6716.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6716.14,25590.64,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,CDM,100,RC,,,Inpatient,,,,,,76196.39,125,MS-DRG,60957.112,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60957.11,100,MS-DRG,48765.688,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29028.48,100,,,Case Rate,100% of CMS IPPS Rate,60957.11,100,MS-DRG,48765.688,Case Rate,100% of CMS IPPS Rate,25710.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25710.82,76196.39,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,CDM,100,RC,,,Inpatient,,,,,,45439.24,125,MS-DRG,36351.392,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36351.39,100,MS-DRG,29081.112,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15994.21,100,,,Case Rate,100% of CMS IPPS Rate,36351.39,100,MS-DRG,29081.112,Case Rate,100% of CMS IPPS Rate,14166.24,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14166.24,45439.24,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,CDM,100,RC,,,Inpatient,,,,,,33289.71,125,MS-DRG,26631.768,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26631.77,100,MS-DRG,21305.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10845.49,100,,,Case Rate,100% of CMS IPPS Rate,26631.77,100,MS-DRG,21305.416,Case Rate,100% of CMS IPPS Rate,9605.96,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9605.96,33289.71,
RENAL FAILURE WITH MCC,682,CDM,100,RC,,,Inpatient,,,,,,32253.15,125,MS-DRG,25802.52,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25802.52,100,MS-DRG,20642.016,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10406.21,100,,,Case Rate,100% of CMS IPPS Rate,25802.52,100,MS-DRG,20642.016,Case Rate,100% of CMS IPPS Rate,9216.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9216.89,32253.15,
RENAL FAILURE WITH CC,683,CDM,100,RC,,,Inpatient,,,,,,22230.76,125,MS-DRG,17784.608,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17784.61,100,MS-DRG,14227.688,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6158.92,100,,,Case Rate,100% of CMS IPPS Rate,17784.61,100,MS-DRG,14227.688,Case Rate,100% of CMS IPPS Rate,5455.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5455.02,22230.76,
RENAL FAILURE WITHOUT CC/MCC,684,CDM,100,RC,,,Inpatient,,,,,,17628.3,125,MS-DRG,14102.64,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14102.64,100,MS-DRG,11282.112,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4208.49,100,,,Case Rate,100% of CMS IPPS Rate,14102.64,100,MS-DRG,11282.112,Case Rate,100% of CMS IPPS Rate,3727.5,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3727.5,17628.3,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,CDM,100,RC,,,Inpatient,,,,,,38528.19,125,MS-DRG,30822.552,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30822.55,100,MS-DRG,24658.04,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13065.45,100,,,Case Rate,100% of CMS IPPS Rate,30822.55,100,MS-DRG,24658.04,Case Rate,100% of CMS IPPS Rate,11572.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11572.2,38528.19,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,CDM,100,RC,,,Inpatient,,,,,,24908.84,125,MS-DRG,19927.072,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19927.07,100,MS-DRG,15941.656,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7293.84,100,,,Case Rate,100% of CMS IPPS Rate,19927.07,100,MS-DRG,15941.656,Case Rate,100% of CMS IPPS Rate,6460.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6460.23,24908.84,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,CDM,100,RC,,,Inpatient,,,,,,19537.95,125,MS-DRG,15630.36,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15630.36,100,MS-DRG,12504.288,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5017.76,100,,,Case Rate,100% of CMS IPPS Rate,15630.36,100,MS-DRG,12504.288,Case Rate,100% of CMS IPPS Rate,4444.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4444.29,19537.95,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,CDM,100,RC,,,Inpatient,,,,,,26831.58,125,MS-DRG,21465.264,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21465.26,100,MS-DRG,17172.208,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8108.66,100,,,Case Rate,100% of CMS IPPS Rate,21465.26,100,MS-DRG,17172.208,Case Rate,100% of CMS IPPS Rate,7181.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7181.92,26831.58,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,CDM,100,RC,,,Inpatient,,,,,,20819.76,125,MS-DRG,16655.808,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16655.81,100,MS-DRG,13324.648,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5560.97,100,,,Case Rate,100% of CMS IPPS Rate,16655.81,100,MS-DRG,13324.648,Case Rate,100% of CMS IPPS Rate,4925.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4925.41,20819.76,
URINARY STONES WITH MCC,693,CDM,100,RC,,,Inpatient,,,,,,31738.13,125,MS-DRG,25390.504,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25390.5,100,MS-DRG,20312.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10187.96,100,,,Case Rate,100% of CMS IPPS Rate,25390.5,100,MS-DRG,20312.4,Case Rate,100% of CMS IPPS Rate,9023.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9023.58,31738.13,
URINARY STONES WITHOUT MCC,694,CDM,100,RC,,,Inpatient,,,,,,20473.16,125,MS-DRG,16378.528,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16378.53,100,MS-DRG,13102.824,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5414.09,100,,,Case Rate,100% of CMS IPPS Rate,16378.53,100,MS-DRG,13102.824,Case Rate,100% of CMS IPPS Rate,4795.31,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4795.31,20473.16,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,CDM,100,RC,,,Inpatient,,,,,,26136.7,125,MS-DRG,20909.36,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20909.36,100,MS-DRG,16727.488,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7814.19,100,,,Case Rate,100% of CMS IPPS Rate,20909.36,100,MS-DRG,16727.488,Case Rate,100% of CMS IPPS Rate,6921.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6921.11,26136.7,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,CDM,100,RC,,,Inpatient,,,,,,19008.23,125,MS-DRG,15206.584,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15206.58,100,MS-DRG,12165.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4793.27,100,,,Case Rate,100% of CMS IPPS Rate,15206.58,100,MS-DRG,12165.264,Case Rate,100% of CMS IPPS Rate,4245.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4245.45,19008.23,
URETHRAL STRICTURE,697,CDM,100,RC,,,Inpatient,,,,,,24076.65,125,MS-DRG,19261.32,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19261.32,100,MS-DRG,15409.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6740.24,100,,,Case Rate,100% of CMS IPPS Rate,19261.32,100,MS-DRG,15409.056,Case Rate,100% of CMS IPPS Rate,5969.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5969.9,24076.65,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,CDM,100,RC,,,Inpatient,,,,,,35179.76,125,MS-DRG,28143.808,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28143.81,100,MS-DRG,22515.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11646.45,100,,,Case Rate,100% of CMS IPPS Rate,28143.81,100,MS-DRG,22515.048,Case Rate,100% of CMS IPPS Rate,10315.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10315.38,35179.76,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,CDM,100,RC,,,Inpatient,,,,,,24372.58,125,MS-DRG,19498.064,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19498.06,100,MS-DRG,15598.448,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7066.58,100,,,Case Rate,100% of CMS IPPS Rate,19498.06,100,MS-DRG,15598.448,Case Rate,100% of CMS IPPS Rate,6258.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6258.94,24372.58,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,CDM,100,RC,,,Inpatient,,,,,,19047.46,125,MS-DRG,15237.968,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15237.97,100,MS-DRG,12190.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4809.9,100,,,Case Rate,100% of CMS IPPS Rate,15237.97,100,MS-DRG,12190.376,Case Rate,100% of CMS IPPS Rate,4260.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4260.18,19047.46,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,CDM,100,RC,,,Inpatient,,,,,,39425.79,125,MS-DRG,31540.632,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31540.63,100,MS-DRG,25232.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13445.84,100,,,Case Rate,100% of CMS IPPS Rate,31540.63,100,MS-DRG,25232.504,Case Rate,100% of CMS IPPS Rate,11909.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11909.11,39425.79,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,CDM,100,RC,,,Inpatient,,,,,,31935.96,125,MS-DRG,25548.768,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25548.77,100,MS-DRG,20439.016,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10271.8,100,,,Case Rate,100% of CMS IPPS Rate,25548.77,100,MS-DRG,20439.016,Case Rate,100% of CMS IPPS Rate,9097.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9097.84,31935.96,
PENIS PROCEDURES WITH CC/MCC,709,CDM,100,RC,,,Inpatient,,,,,,44436.98,125,MS-DRG,35549.584,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35549.58,100,MS-DRG,28439.664,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15569.48,100,,,Case Rate,100% of CMS IPPS Rate,35549.58,100,MS-DRG,28439.664,Case Rate,100% of CMS IPPS Rate,13790.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13790.05,44436.98,
PENIS PROCEDURES WITHOUT CC/MCC,710,CDM,100,RC,,,Inpatient,,,,,,32244.99,125,MS-DRG,25795.992,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25795.99,100,MS-DRG,20636.792,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10402.75,100,,,Case Rate,100% of CMS IPPS Rate,25795.99,100,MS-DRG,20636.792,Case Rate,100% of CMS IPPS Rate,9213.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9213.82,32244.99,
TESTES PROCEDURES WITH CC/MCC,711,CDM,100,RC,,,Inpatient,,,,,,38935.3,125,MS-DRG,31148.24,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31148.24,100,MS-DRG,24918.592,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13217.19,100,,,Case Rate,100% of CMS IPPS Rate,31148.24,100,MS-DRG,24918.592,Case Rate,100% of CMS IPPS Rate,11706.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11706.6,38935.3,
TESTES PROCEDURES WITHOUT CC/MCC,712,CDM,100,RC,,,Inpatient,,,,,,25185.16,125,MS-DRG,20148.128,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20148.13,100,MS-DRG,16118.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6139.52,100,,,Case Rate,100% of CMS IPPS Rate,20148.13,100,MS-DRG,16118.504,Case Rate,100% of CMS IPPS Rate,5437.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5437.84,25185.16,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,CDM,100,RC,,,Inpatient,,,,,,31339.2,125,MS-DRG,25071.36,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25071.36,100,MS-DRG,20057.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10018.9,100,,,Case Rate,100% of CMS IPPS Rate,25071.36,100,MS-DRG,20057.088,Case Rate,100% of CMS IPPS Rate,8873.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8873.84,31339.2,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,CDM,100,RC,,,Inpatient,,,,,,23061.31,125,MS-DRG,18449.048,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18449.05,100,MS-DRG,14759.24,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6510.9,100,,,Case Rate,100% of CMS IPPS Rate,18449.05,100,MS-DRG,14759.24,Case Rate,100% of CMS IPPS Rate,5766.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5766.77,23061.31,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,CDM,100,RC,,,Inpatient,,,,,,44620.1,125,MS-DRG,35696.08,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35696.08,100,MS-DRG,28556.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15647.08,100,,,Case Rate,100% of CMS IPPS Rate,35696.08,100,MS-DRG,28556.864,Case Rate,100% of CMS IPPS Rate,13858.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13858.78,44620.1,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,CDM,100,RC,,,Inpatient,,,,,,30902.68,125,MS-DRG,24722.144,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24722.14,100,MS-DRG,19777.712,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9833.9,100,,,Case Rate,100% of CMS IPPS Rate,24722.14,100,MS-DRG,19777.712,Case Rate,100% of CMS IPPS Rate,8709.99,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8709.99,30902.68,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,CDM,100,RC,,,Inpatient,,,,,,38034.43,125,MS-DRG,30427.544,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30427.54,100,MS-DRG,24342.032,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12856.2,100,,,Case Rate,100% of CMS IPPS Rate,30427.54,100,MS-DRG,24342.032,Case Rate,100% of CMS IPPS Rate,11386.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11386.87,38034.43,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,CDM,100,RC,,,Inpatient,,,,,,27838.73,125,MS-DRG,22270.984,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22270.98,100,MS-DRG,17816.784,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8535.47,100,,,Case Rate,100% of CMS IPPS Rate,22270.98,100,MS-DRG,17816.784,Case Rate,100% of CMS IPPS Rate,7559.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7559.95,27838.73,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,CDM,100,RC,,,Inpatient,,,,,,35964.55,125,MS-DRG,28771.64,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28771.64,100,MS-DRG,23017.312,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11979.03,100,,,Case Rate,100% of CMS IPPS Rate,28771.64,100,MS-DRG,23017.312,Case Rate,100% of CMS IPPS Rate,10609.95,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10609.95,35964.55,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,CDM,100,RC,,,Inpatient,,,,,,26056.59,125,MS-DRG,20845.272,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20845.27,100,MS-DRG,16676.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7780.24,100,,,Case Rate,100% of CMS IPPS Rate,20845.27,100,MS-DRG,16676.216,Case Rate,100% of CMS IPPS Rate,6891.04,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6891.04,26056.59,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,CDM,100,RC,,,Inpatient,,,,,,19609.9,125,MS-DRG,15687.92,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15687.92,100,MS-DRG,12550.336,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4551.46,100,,,Case Rate,100% of CMS IPPS Rate,15687.92,100,MS-DRG,12550.336,Case Rate,100% of CMS IPPS Rate,4031.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4031.28,19609.9,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,CDM,100,RC,,,Inpatient,,,,,,28340.65,125,MS-DRG,22672.52,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22672.52,100,MS-DRG,18138.016,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8748.18,100,,,Case Rate,100% of CMS IPPS Rate,22672.52,100,MS-DRG,18138.016,Case Rate,100% of CMS IPPS Rate,7748.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7748.35,28340.65,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,CDM,100,RC,,,Inpatient,,,,,,19868.21,125,MS-DRG,15894.568,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15894.57,100,MS-DRG,12715.656,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5157.72,100,,,Case Rate,100% of CMS IPPS Rate,15894.57,100,MS-DRG,12715.656,Case Rate,100% of CMS IPPS Rate,4568.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4568.25,19868.21,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,CDM,100,RC,,,Inpatient,,,,,,31721.79,125,MS-DRG,25377.432,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25377.43,100,MS-DRG,20301.944,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10181.03,100,,,Case Rate,100% of CMS IPPS Rate,25377.43,100,MS-DRG,20301.944,Case Rate,100% of CMS IPPS Rate,9017.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9017.44,31721.79,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,CDM,100,RC,,,Inpatient,,,,,,21056.85,125,MS-DRG,16845.48,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16845.48,100,MS-DRG,13476.384,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5661.44,100,,,Case Rate,100% of CMS IPPS Rate,16845.48,100,MS-DRG,13476.384,Case Rate,100% of CMS IPPS Rate,5014.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5014.4,21056.85,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,CDM,100,RC,,,Inpatient,,,,,,25696.91,125,MS-DRG,20557.528,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20557.53,100,MS-DRG,16446.024,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7627.81,100,,,Case Rate,100% of CMS IPPS Rate,20557.53,100,MS-DRG,16446.024,Case Rate,100% of CMS IPPS Rate,6756.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6756.03,25696.91,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,CDM,100,RC,,,Inpatient,,,,,,17620.11,125,MS-DRG,14096.088,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14096.09,100,MS-DRG,11276.872,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4205.03,100,,,Case Rate,100% of CMS IPPS Rate,14096.09,100,MS-DRG,11276.872,Case Rate,100% of CMS IPPS Rate,3724.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3724.44,17620.11,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,CDM,100,RC,,,Inpatient,,,,,,42077.71,125,MS-DRG,33662.168,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33662.17,100,MS-DRG,26929.736,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14569.67,100,,,Case Rate,100% of CMS IPPS Rate,33662.17,100,MS-DRG,26929.736,Case Rate,100% of CMS IPPS Rate,12904.51,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12904.51,42077.71,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,CDM,100,RC,,,Inpatient,,,,,,27544.44,125,MS-DRG,22035.552,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22035.55,100,MS-DRG,17628.44,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8410.75,100,,,Case Rate,100% of CMS IPPS Rate,22035.55,100,MS-DRG,17628.44,Case Rate,100% of CMS IPPS Rate,7449.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7449.49,27544.44,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,CDM,100,RC,,,Inpatient,,,,,,72076.24,125,MS-DRG,57660.992,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57660.99,100,MS-DRG,46128.792,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27282.45,100,,,Case Rate,100% of CMS IPPS Rate,57660.99,100,MS-DRG,46128.792,Case Rate,100% of CMS IPPS Rate,24164.34,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24164.34,72076.24,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,CDM,100,RC,,,Inpatient,,,,,,40370.8,125,MS-DRG,32296.64,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32296.64,100,MS-DRG,25837.312,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13846.31,100,,,Case Rate,100% of CMS IPPS Rate,32296.64,100,MS-DRG,25837.312,Case Rate,100% of CMS IPPS Rate,12263.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12263.82,40370.8,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,CDM,100,RC,,,Inpatient,,,,,,32498.4,125,MS-DRG,25998.72,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25998.72,100,MS-DRG,20798.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10510.15,100,,,Case Rate,100% of CMS IPPS Rate,25998.72,100,MS-DRG,20798.976,Case Rate,100% of CMS IPPS Rate,9308.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9308.94,32498.4,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,CDM,100,RC,,,Inpatient,,,,,,72784.19,125,MS-DRG,58227.352,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58227.35,100,MS-DRG,46581.88,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27582.46,100,,,Case Rate,100% of CMS IPPS Rate,58227.35,100,MS-DRG,46581.88,Case Rate,100% of CMS IPPS Rate,24430.07,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24430.07,72784.19,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,CDM,100,RC,,,Inpatient,,,,,,37426.2,125,MS-DRG,29940.96,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29940.96,100,MS-DRG,23952.768,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12598.46,100,,,Case Rate,100% of CMS IPPS Rate,29940.96,100,MS-DRG,23952.768,Case Rate,100% of CMS IPPS Rate,11158.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11158.58,37426.2,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,CDM,100,RC,,,Inpatient,,,,,,30155.46,125,MS-DRG,24124.368,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24124.37,100,MS-DRG,19299.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9517.26,100,,,Case Rate,100% of CMS IPPS Rate,24124.37,100,MS-DRG,19299.496,Case Rate,100% of CMS IPPS Rate,8429.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8429.54,30155.46,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,CDM,100,RC,,,Inpatient,,,,,,37563.55,125,MS-DRG,30050.84,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30050.84,100,MS-DRG,24040.672,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12656.66,100,,,Case Rate,100% of CMS IPPS Rate,30050.84,100,MS-DRG,24040.672,Case Rate,100% of CMS IPPS Rate,11210.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11210.13,37563.55,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,CDM,100,RC,,,Inpatient,,,,,,27295.91,125,MS-DRG,21836.728,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21836.73,100,MS-DRG,17469.384,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8305.43,100,,,Case Rate,100% of CMS IPPS Rate,21836.73,100,MS-DRG,17469.384,Case Rate,100% of CMS IPPS Rate,7356.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7356.21,27295.91,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,CDM,100,RC,,,Inpatient,,,,,,39644.88,125,MS-DRG,31715.904,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31715.9,100,MS-DRG,25372.72,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13538.68,100,,,Case Rate,100% of CMS IPPS Rate,31715.9,100,MS-DRG,25372.72,Case Rate,100% of CMS IPPS Rate,11991.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11991.35,39644.88,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,CDM,100,RC,,,Inpatient,,,,,,24452.7,125,MS-DRG,19562.16,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19562.16,100,MS-DRG,15649.728,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7100.53,100,,,Case Rate,100% of CMS IPPS Rate,19562.16,100,MS-DRG,15649.728,Case Rate,100% of CMS IPPS Rate,6289.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6289.01,24452.7,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,CDM,100,RC,,,Inpatient,,,,,,35076.76,125,MS-DRG,28061.408,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28061.41,100,MS-DRG,22449.128,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11602.8,100,,,Case Rate,100% of CMS IPPS Rate,28061.41,100,MS-DRG,22449.128,Case Rate,100% of CMS IPPS Rate,10276.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10276.72,35076.76,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,CDM,100,RC,,,Inpatient,,,,,,23314.74,125,MS-DRG,18651.792,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18651.79,100,MS-DRG,14921.432,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6618.29,100,,,Case Rate,100% of CMS IPPS Rate,18651.79,100,MS-DRG,14921.432,Case Rate,100% of CMS IPPS Rate,5861.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5861.89,23314.74,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,CDM,100,RC,,,Inpatient,,,,,,29970.73,125,MS-DRG,23976.584,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23976.58,100,MS-DRG,19181.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9438.97,100,,,Case Rate,100% of CMS IPPS Rate,23976.58,100,MS-DRG,19181.264,Case Rate,100% of CMS IPPS Rate,8360.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8360.19,29970.73,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,CDM,100,RC,,,Inpatient,,,,,,50020.44,125,MS-DRG,40016.352,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40016.35,100,MS-DRG,32013.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17935.63,100,,,Case Rate,100% of CMS IPPS Rate,40016.35,100,MS-DRG,32013.08,Case Rate,100% of CMS IPPS Rate,15885.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15885.77,50020.44,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,CDM,100,RC,,,Inpatient,,,,,,28780.48,125,MS-DRG,23024.384,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23024.38,100,MS-DRG,18419.504,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8934.56,100,,,Case Rate,100% of CMS IPPS Rate,23024.38,100,MS-DRG,18419.504,Case Rate,100% of CMS IPPS Rate,7913.43,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7913.43,28780.48,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,CDM,100,RC,,,Inpatient,,,,,,37279.06,125,MS-DRG,29823.248,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29823.25,100,MS-DRG,23858.6,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12536.1,100,,,Case Rate,100% of CMS IPPS Rate,29823.25,100,MS-DRG,23858.6,Case Rate,100% of CMS IPPS Rate,11103.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11103.35,37279.06,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,CDM,100,RC,,,Inpatient,,,,,,25847.3,125,MS-DRG,20677.84,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20677.84,100,MS-DRG,16542.272,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7691.55,100,,,Case Rate,100% of CMS IPPS Rate,20677.84,100,MS-DRG,16542.272,Case Rate,100% of CMS IPPS Rate,6812.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6812.48,25847.3,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,CDM,100,RC,,,Inpatient,,,,,,23311.48,125,MS-DRG,18649.184,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18649.18,100,MS-DRG,14919.344,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6616.91,100,,,Case Rate,100% of CMS IPPS Rate,18649.18,100,MS-DRG,14919.344,Case Rate,100% of CMS IPPS Rate,5860.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5860.66,23311.48,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,CDM,100,RC,,,Inpatient,,,,,,30837.28,125,MS-DRG,24669.824,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24669.82,100,MS-DRG,19735.856,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9806.19,100,,,Case Rate,100% of CMS IPPS Rate,24669.82,100,MS-DRG,19735.856,Case Rate,100% of CMS IPPS Rate,8685.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8685.44,30837.28,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,CDM,100,RC,,,Inpatient,,,,,,24362.76,125,MS-DRG,19490.208,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19490.21,100,MS-DRG,15592.168,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7062.42,100,,,Case Rate,100% of CMS IPPS Rate,19490.21,100,MS-DRG,15592.168,Case Rate,100% of CMS IPPS Rate,6255.26,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6255.26,24362.76,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,CDM,100,RC,,,Inpatient,,,,,,18161.3,125,MS-DRG,14529.04,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14529.04,100,MS-DRG,11623.232,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4434.37,100,,,Case Rate,100% of CMS IPPS Rate,14529.04,100,MS-DRG,11623.232,Case Rate,100% of CMS IPPS Rate,3927.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3927.56,18161.3,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,CDM,100,RC,,,Inpatient,,,,,,23811.79,125,MS-DRG,19049.432,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19049.43,100,MS-DRG,15239.544,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6828.93,100,,,Case Rate,100% of CMS IPPS Rate,19049.43,100,MS-DRG,15239.544,Case Rate,100% of CMS IPPS Rate,6048.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6048.45,23811.79,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,CDM,100,RC,,,Inpatient,,,,,,18061.58,125,MS-DRG,14449.264,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14449.26,100,MS-DRG,11559.408,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4392.1,100,,,Case Rate,100% of CMS IPPS Rate,14449.26,100,MS-DRG,11559.408,Case Rate,100% of CMS IPPS Rate,3890.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3890.13,18061.58,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,CDM,100,RC,,,Inpatient,,,,,,25621.69,125,MS-DRG,20497.352,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20497.35,100,MS-DRG,16397.88,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7006.3,100,,,Case Rate,100% of CMS IPPS Rate,20497.35,100,MS-DRG,16397.88,Case Rate,100% of CMS IPPS Rate,6205.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6205.55,25621.69,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,CDM,100,RC,,,Inpatient,,,,,,30415.45,125,MS-DRG,24332.36,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24332.36,100,MS-DRG,19465.888,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9535.97,100,,,Case Rate,100% of CMS IPPS Rate,24332.36,100,MS-DRG,19465.888,Case Rate,100% of CMS IPPS Rate,8446.11,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8446.11,30415.45,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,CDM,100,RC,,,Inpatient,,,,,,25289.79,125,MS-DRG,20231.832,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20231.83,100,MS-DRG,16185.464,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7455.28,100,,,Case Rate,100% of CMS IPPS Rate,20231.83,100,MS-DRG,16185.464,Case Rate,100% of CMS IPPS Rate,6603.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6603.22,25289.79,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,CDM,100,RC,,,Inpatient,,,,,,19363.01,125,MS-DRG,15490.408,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15490.41,100,MS-DRG,12392.328,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4943.63,100,,,Case Rate,100% of CMS IPPS Rate,15490.41,100,MS-DRG,12392.328,Case Rate,100% of CMS IPPS Rate,4378.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4378.62,19363.01,
ABORTION WITHOUT D&C,779,CDM,100,RC,,,Inpatient,,,,,,22981.2,125,MS-DRG,18384.96,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18384.96,100,MS-DRG,14707.968,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6476.95,100,,,Case Rate,100% of CMS IPPS Rate,18384.96,100,MS-DRG,14707.968,Case Rate,100% of CMS IPPS Rate,5736.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5736.7,22981.2,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,CDM,100,RC,,,Inpatient,,,,,,37815.34,125,MS-DRG,30252.272,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30252.27,100,MS-DRG,24201.816,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12763.36,100,,,Case Rate,100% of CMS IPPS Rate,30252.27,100,MS-DRG,24201.816,Case Rate,100% of CMS IPPS Rate,11304.64,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11304.64,37815.34,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,CDM,100,RC,,,Inpatient,,,,,,25404.24,125,MS-DRG,20323.392,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20323.39,100,MS-DRG,16258.712,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7503.78,100,,,Case Rate,100% of CMS IPPS Rate,20323.39,100,MS-DRG,16258.712,Case Rate,100% of CMS IPPS Rate,6646.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6646.18,25404.24,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,CDM,100,RC,,,Inpatient,,,,,,21978.98,125,MS-DRG,17583.184,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17583.18,100,MS-DRG,14066.544,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6052.22,100,,,Case Rate,100% of CMS IPPS Rate,17583.18,100,MS-DRG,14066.544,Case Rate,100% of CMS IPPS Rate,5360.51,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5360.51,21978.98,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,CDM,100,RC,,,Inpatient,,,,,,34117.03,125,MS-DRG,27293.624,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27293.62,100,MS-DRG,21834.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11196.09,100,,,Case Rate,100% of CMS IPPS Rate,27293.62,100,MS-DRG,21834.896,Case Rate,100% of CMS IPPS Rate,9916.49,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9916.49,34117.03,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,CDM,100,RC,,,Inpatient,,,,,,25057.63,125,MS-DRG,20046.104,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20046.1,100,MS-DRG,16036.88,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7356.89,100,,,Case Rate,100% of CMS IPPS Rate,20046.1,100,MS-DRG,16036.88,Case Rate,100% of CMS IPPS Rate,6516.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6516.08,25057.63,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,CDM,100,RC,,,Inpatient,,,,,,22489.08,125,MS-DRG,17991.264,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17991.26,100,MS-DRG,14393.008,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6268.39,100,,,Case Rate,100% of CMS IPPS Rate,17991.26,100,MS-DRG,14393.008,Case Rate,100% of CMS IPPS Rate,5551.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5551.98,22489.08,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,CDM,100,RC,,,Inpatient,,,,,,37169.53,125,MS-DRG,29735.624,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29735.62,100,MS-DRG,23788.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12489.67,100,,,Case Rate,100% of CMS IPPS Rate,29735.62,100,MS-DRG,23788.496,Case Rate,100% of CMS IPPS Rate,11062.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11062.23,37169.53,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,CDM,100,RC,,,Inpatient,,,,,,104893.48,125,MS-DRG,83914.784,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83914.78,100,MS-DRG,67131.824,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,41189.74,100,,,Case Rate,100% of CMS IPPS Rate,83914.78,100,MS-DRG,67131.824,Case Rate,100% of CMS IPPS Rate,36482.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,36482.17,104893.5,
PREMATURITY WITH MAJOR PROBLEMS,791,CDM,100,RC,,,Inpatient,,,,,,74075.83,125,MS-DRG,59260.664,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59260.66,100,MS-DRG,47408.528,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28129.83,100,,,Case Rate,100% of CMS IPPS Rate,59260.66,100,MS-DRG,47408.528,Case Rate,100% of CMS IPPS Rate,24914.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24914.88,74075.83,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,CDM,100,RC,,,Inpatient,,,,,,47749.45,125,MS-DRG,38199.56,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38199.56,100,MS-DRG,30559.648,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16973.24,100,,,Case Rate,100% of CMS IPPS Rate,38199.56,100,MS-DRG,30559.648,Case Rate,100% of CMS IPPS Rate,15033.37,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15033.37,47749.45,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,CDM,100,RC,,,Inpatient,,,,,,75884.11,125,MS-DRG,60707.288,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60707.29,100,MS-DRG,48565.832,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28896.14,100,,,Case Rate,100% of CMS IPPS Rate,60707.29,100,MS-DRG,48565.832,Case Rate,100% of CMS IPPS Rate,25593.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25593.61,75884.11,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,CDM,100,RC,,,Inpatient,,,,,,31832.98,125,MS-DRG,25466.384,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25466.38,100,MS-DRG,20373.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10228.15,100,,,Case Rate,100% of CMS IPPS Rate,25466.38,100,MS-DRG,20373.104,Case Rate,100% of CMS IPPS Rate,9059.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9059.17,31832.98,
NORMAL NEWBORN,795,CDM,100,RC,,,Inpatient,,,,,,10964.15,125,MS-DRG,8771.32,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8771.32,100,MS-DRG,7017.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1384.35,100,,,Case Rate,100% of CMS IPPS Rate,8771.32,100,MS-DRG,7017.056,Case Rate,100% of CMS IPPS Rate,1226.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1226.14,10964.15,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,CDM,100,RC,,,Inpatient,,,,,,28569.55,125,MS-DRG,22855.64,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22855.64,100,MS-DRG,18284.512,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7351.35,100,,,Case Rate,100% of CMS IPPS Rate,22855.64,100,MS-DRG,18284.512,Case Rate,100% of CMS IPPS Rate,6511.17,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6511.17,28569.55,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,CDM,100,RC,,,Inpatient,,,,,,23527.29,125,MS-DRG,18821.832,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18821.83,100,MS-DRG,15057.464,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6708.37,100,,,Case Rate,100% of CMS IPPS Rate,18821.83,100,MS-DRG,15057.464,Case Rate,100% of CMS IPPS Rate,5941.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5941.67,23527.29,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,CDM,100,RC,,,Inpatient,,,,,,23527.29,125,MS-DRG,18821.832,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18821.83,100,MS-DRG,15057.464,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6708.37,100,,,Case Rate,100% of CMS IPPS Rate,18821.83,100,MS-DRG,15057.464,Case Rate,100% of CMS IPPS Rate,5941.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5941.67,23527.29,
SPLENIC PROCEDURES WITH MCC,799,CDM,100,RC,,,Inpatient,,,,,,85437.26,125,MS-DRG,68349.808,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68349.81,100,MS-DRG,54679.848,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,32944.58,100,,,Case Rate,100% of CMS IPPS Rate,68349.81,100,MS-DRG,54679.848,Case Rate,100% of CMS IPPS Rate,29179.35,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29179.35,85437.26,
SPLENIC PROCEDURES WITH CC,800,CDM,100,RC,,,Inpatient,,,,,,55337.36,125,MS-DRG,44269.888,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44269.89,100,MS-DRG,35415.912,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20188.85,100,,,Case Rate,100% of CMS IPPS Rate,44269.89,100,MS-DRG,35415.912,Case Rate,100% of CMS IPPS Rate,17881.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17881.47,55337.36,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,CDM,100,RC,,,Inpatient,,,,,,34538.85,125,MS-DRG,27631.08,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27631.08,100,MS-DRG,22104.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11374.85,100,,,Case Rate,100% of CMS IPPS Rate,27631.08,100,MS-DRG,22104.864,Case Rate,100% of CMS IPPS Rate,10074.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10074.82,34538.85,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,CDM,100,RC,,,Inpatient,,,,,,66308.05,125,MS-DRG,53046.44,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53046.44,100,MS-DRG,42437.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24838,100,,,Case Rate,100% of CMS IPPS Rate,53046.44,100,MS-DRG,42437.152,Case Rate,100% of CMS IPPS Rate,21999.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21999.27,66308.05,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,CDM,100,RC,,,Inpatient,,,,,,36800.03,125,MS-DRG,29440.024,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29440.02,100,MS-DRG,23552.016,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12333.09,100,,,Case Rate,100% of CMS IPPS Rate,29440.02,100,MS-DRG,23552.016,Case Rate,100% of CMS IPPS Rate,10923.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10923.54,36800.03,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,CDM,100,RC,,,Inpatient,,,,,,25773.75,125,MS-DRG,20619,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20619,100,MS-DRG,16495.2,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7660.37,100,,,Case Rate,100% of CMS IPPS Rate,20619,100,MS-DRG,16495.2,Case Rate,100% of CMS IPPS Rate,6784.87,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6784.87,25773.75,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,CDM,100,RC,,,Inpatient,,,,,,24014.51,125,MS-DRG,19211.608,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19211.61,100,MS-DRG,15369.288,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6914.84,100,,,Case Rate,100% of CMS IPPS Rate,19211.61,100,MS-DRG,15369.288,Case Rate,100% of CMS IPPS Rate,6124.55,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6124.55,24014.51,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,CDM,100,RC,,,Inpatient,,,,,,19528.14,125,MS-DRG,15622.512,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15622.51,100,MS-DRG,12498.008,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5013.61,100,,,Case Rate,100% of CMS IPPS Rate,15622.51,100,MS-DRG,12498.008,Case Rate,100% of CMS IPPS Rate,4440.6,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4440.6,19528.14,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,CDM,100,RC,,,Inpatient,,,,,,18117.15,125,MS-DRG,14493.72,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14493.72,100,MS-DRG,11594.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4415.66,100,,,Case Rate,100% of CMS IPPS Rate,14493.72,100,MS-DRG,11594.976,Case Rate,100% of CMS IPPS Rate,3911,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3911,18117.15,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,CDM,100,RC,,,Inpatient,,,,,,45143.29,125,MS-DRG,36114.632,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36114.63,100,MS-DRG,28891.704,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15868.8,100,,,Case Rate,100% of CMS IPPS Rate,36114.63,100,MS-DRG,28891.704,Case Rate,100% of CMS IPPS Rate,14055.16,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14055.16,45143.29,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,CDM,100,RC,,,Inpatient,,,,,,27946.63,125,MS-DRG,22357.304,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22357.3,100,MS-DRG,17885.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8581.19,100,,,Case Rate,100% of CMS IPPS Rate,22357.3,100,MS-DRG,17885.84,Case Rate,100% of CMS IPPS Rate,7600.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7600.45,27946.63,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,CDM,100,RC,,,Inpatient,,,,,,23259.15,125,MS-DRG,18607.32,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18607.32,100,MS-DRG,14885.856,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6594.74,100,,,Case Rate,100% of CMS IPPS Rate,18607.32,100,MS-DRG,14885.856,Case Rate,100% of CMS IPPS Rate,5841.03,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5841.03,23259.15,
RED BLOOD CELL DISORDERS WITH MCC,811,CDM,100,RC,,,Inpatient,,,,,,30699.93,125,MS-DRG,24559.944,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24559.94,100,MS-DRG,19647.952,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9747.99,100,,,Case Rate,100% of CMS IPPS Rate,24559.94,100,MS-DRG,19647.952,Case Rate,100% of CMS IPPS Rate,8633.89,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8633.89,30699.93,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,CDM,100,RC,,,Inpatient,,,,,,22786.64,125,MS-DRG,18229.312,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18229.31,100,MS-DRG,14583.448,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6394.5,100,,,Case Rate,100% of CMS IPPS Rate,18229.31,100,MS-DRG,14583.448,Case Rate,100% of CMS IPPS Rate,5663.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5663.67,22786.64,
COAGULATION DISORDERS,813,CDM,100,RC,,,Inpatient,,,,,,33006.88,125,MS-DRG,26405.504,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26405.5,100,MS-DRG,21124.4,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10725.63,100,,,Case Rate,100% of CMS IPPS Rate,26405.5,100,MS-DRG,21124.4,Case Rate,100% of CMS IPPS Rate,9499.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9499.8,33006.88,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,CDM,100,RC,,,Inpatient,,,,,,41876.63,125,MS-DRG,33501.304,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33501.3,100,MS-DRG,26801.04,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14484.45,100,,,Case Rate,100% of CMS IPPS Rate,33501.3,100,MS-DRG,26801.04,Case Rate,100% of CMS IPPS Rate,12829.02,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12829.02,41876.63,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,CDM,100,RC,,,Inpatient,,,,,,24310.45,125,MS-DRG,19448.36,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19448.36,100,MS-DRG,15558.688,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7040.25,100,,,Case Rate,100% of CMS IPPS Rate,19448.36,100,MS-DRG,15558.688,Case Rate,100% of CMS IPPS Rate,6235.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6235.62,24310.45,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,CDM,100,RC,,,Inpatient,,,,,,18478.48,125,MS-DRG,14782.784,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14782.78,100,MS-DRG,11826.224,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4568.78,100,,,Case Rate,100% of CMS IPPS Rate,14782.78,100,MS-DRG,11826.224,Case Rate,100% of CMS IPPS Rate,4046.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4046.62,18478.48,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,CDM,100,RC,,,Inpatient,,,,,,49145.73,125,MS-DRG,39316.584,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39316.58,100,MS-DRG,31453.264,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15145.45,100,,,Case Rate,100% of CMS IPPS Rate,39316.58,100,MS-DRG,31453.264,Case Rate,100% of CMS IPPS Rate,13414.47,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13414.47,49145.73,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,CDM,100,RC,,,Inpatient,,,,,,28755.94,125,MS-DRG,23004.752,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23004.75,100,MS-DRG,18403.8,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6855.26,100,,,Case Rate,100% of CMS IPPS Rate,23004.75,100,MS-DRG,18403.8,Case Rate,100% of CMS IPPS Rate,6071.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6071.77,28755.94,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,CDM,100,RC,,,Inpatient,,,,,,21047.04,125,MS-DRG,16837.632,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16837.63,100,MS-DRG,13470.104,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4679.64,100,,,Case Rate,100% of CMS IPPS Rate,16837.63,100,MS-DRG,13470.104,Case Rate,100% of CMS IPPS Rate,4144.81,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4144.81,21047.04,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,CDM,100,RC,,,Inpatient,,,,,,102890.61,125,MS-DRG,82312.488,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82312.49,100,MS-DRG,65849.992,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,40340.97,100,,,Case Rate,100% of CMS IPPS Rate,82312.49,100,MS-DRG,65849.992,Case Rate,100% of CMS IPPS Rate,35730.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,35730.41,102890.6,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,CDM,100,RC,,,Inpatient,,,,,,44196.65,125,MS-DRG,35357.32,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35357.32,100,MS-DRG,28285.856,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15467.63,100,,,Case Rate,100% of CMS IPPS Rate,35357.32,100,MS-DRG,28285.856,Case Rate,100% of CMS IPPS Rate,13699.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13699.84,44196.65,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,CDM,100,RC,,,Inpatient,,,,,,26396.68,125,MS-DRG,21117.344,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21117.34,100,MS-DRG,16893.872,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7924.35,100,,,Case Rate,100% of CMS IPPS Rate,21117.34,100,MS-DRG,16893.872,Case Rate,100% of CMS IPPS Rate,7018.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7018.68,26396.68,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,CDM,100,RC,,,Inpatient,,,,,,84206.13,125,MS-DRG,67364.904,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67364.9,100,MS-DRG,53891.92,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,32422.85,100,,,Case Rate,100% of CMS IPPS Rate,67364.9,100,MS-DRG,53891.92,Case Rate,100% of CMS IPPS Rate,28717.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28717.25,84206.13,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,CDM,100,RC,,,Inpatient,,,,,,43657.11,125,MS-DRG,34925.688,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34925.69,100,MS-DRG,27940.552,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15238.98,100,,,Case Rate,100% of CMS IPPS Rate,34925.69,100,MS-DRG,27940.552,Case Rate,100% of CMS IPPS Rate,13497.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13497.32,43657.11,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,CDM,100,RC,,,Inpatient,,,,,,27820.74,125,MS-DRG,22256.592,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22256.59,100,MS-DRG,17805.272,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8527.84,100,,,Case Rate,100% of CMS IPPS Rate,22256.59,100,MS-DRG,17805.272,Case Rate,100% of CMS IPPS Rate,7553.2,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7553.2,27820.74,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,CDM,100,RC,,,Inpatient,,,,,,85775.7,125,MS-DRG,68620.56,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68620.56,100,MS-DRG,54896.448,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,33088.01,100,,,Case Rate,100% of CMS IPPS Rate,68620.56,100,MS-DRG,54896.448,Case Rate,100% of CMS IPPS Rate,29306.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29306.38,85775.7,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,CDM,100,RC,,,Inpatient,,,,,,46281.23,125,MS-DRG,37024.984,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37024.98,100,MS-DRG,29619.984,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16351.04,100,,,Case Rate,100% of CMS IPPS Rate,37024.98,100,MS-DRG,29619.984,Case Rate,100% of CMS IPPS Rate,14482.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14482.28,46281.23,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,CDM,100,RC,,,Inpatient,,,,,,33904.48,125,MS-DRG,27123.584,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27123.58,100,MS-DRG,21698.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11106.01,100,,,Case Rate,100% of CMS IPPS Rate,27123.58,100,MS-DRG,21698.864,Case Rate,100% of CMS IPPS Rate,9836.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9836.71,33904.48,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,CDM,100,RC,,,Inpatient,,,,,,58116.84,125,MS-DRG,46493.472,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46493.47,100,MS-DRG,37194.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21366.73,100,,,Case Rate,100% of CMS IPPS Rate,46493.47,100,MS-DRG,37194.776,Case Rate,100% of CMS IPPS Rate,18924.73,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18924.73,58116.84,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,CDM,100,RC,,,Inpatient,,,,,,31608.98,125,MS-DRG,25287.184,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25287.18,100,MS-DRG,20229.744,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10133.22,100,,,Case Rate,100% of CMS IPPS Rate,25287.18,100,MS-DRG,20229.744,Case Rate,100% of CMS IPPS Rate,8975.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8975.1,31608.98,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,CDM,100,RC,,,Inpatient,,,,,,26516.03,125,MS-DRG,21212.824,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21212.82,100,MS-DRG,16970.256,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7974.93,100,,,Case Rate,100% of CMS IPPS Rate,21212.82,100,MS-DRG,16970.256,Case Rate,100% of CMS IPPS Rate,7063.48,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7063.48,26516.03,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,CDM,100,RC,,,Inpatient,,,,,,19917.28,125,MS-DRG,15933.824,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15933.82,100,MS-DRG,12747.056,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5178.51,100,,,Case Rate,100% of CMS IPPS Rate,15933.82,100,MS-DRG,12747.056,Case Rate,100% of CMS IPPS Rate,4586.66,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4586.66,19917.28,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,CDM,100,RC,,,Inpatient,,,,,,16196.08,125,MS-DRG,12956.864,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12956.86,100,MS-DRG,10365.488,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3601.54,100,,,Case Rate,100% of CMS IPPS Rate,12956.86,100,MS-DRG,10365.488,Case Rate,100% of CMS IPPS Rate,3189.92,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3189.92,16196.08,
ACUTE LEUKEMIA WITH MCC,834,CDM,100,RC,,,Inpatient,,,,,,98067.44,125,MS-DRG,78453.952,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78453.95,100,MS-DRG,62763.16,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,38297,100,,,Case Rate,100% of CMS IPPS Rate,78453.95,100,MS-DRG,62763.16,Case Rate,100% of CMS IPPS Rate,33920.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,33920.05,98067.44,
ACUTE LEUKEMIA WITH CC,835,CDM,100,RC,,,Inpatient,,,,,,42618.9,125,MS-DRG,34095.12,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34095.12,100,MS-DRG,27276.096,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14799.01,100,,,Case Rate,100% of CMS IPPS Rate,34095.12,100,MS-DRG,27276.096,Case Rate,100% of CMS IPPS Rate,13107.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13107.63,42618.9,
ACUTE LEUKEMIA WITHOUT CC/MCC,836,CDM,100,RC,,,Inpatient,,,,,,28473.09,125,MS-DRG,22778.472,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22778.47,100,MS-DRG,18222.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8608.22,100,,,Case Rate,100% of CMS IPPS Rate,22778.47,100,MS-DRG,18222.776,Case Rate,100% of CMS IPPS Rate,7624.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7624.39,28473.09,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,CDM,100,RC,,,Inpatient,,,,,,89563.94,125,MS-DRG,71651.152,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71651.15,100,MS-DRG,57320.92,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,34693.39,100,,,Case Rate,100% of CMS IPPS Rate,71651.15,100,MS-DRG,57320.92,Case Rate,100% of CMS IPPS Rate,30728.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30728.29,89563.94,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,CDM,100,RC,,,Inpatient,,,,,,40858.04,125,MS-DRG,32686.432,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32686.43,100,MS-DRG,26149.144,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14052.79,100,,,Case Rate,100% of CMS IPPS Rate,32686.43,100,MS-DRG,26149.144,Case Rate,100% of CMS IPPS Rate,12446.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12446.7,40858.04,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,CDM,100,RC,,,Inpatient,,,,,,30103.15,125,MS-DRG,24082.52,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24082.52,100,MS-DRG,19266.016,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9495.09,100,,,Case Rate,100% of CMS IPPS Rate,24082.52,100,MS-DRG,19266.016,Case Rate,100% of CMS IPPS Rate,8409.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8409.9,30103.15,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,CDM,100,RC,,,Inpatient,,,,,,59836.83,125,MS-DRG,47869.464,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47869.46,100,MS-DRG,38295.568,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22095.62,100,,,Case Rate,100% of CMS IPPS Rate,47869.46,100,MS-DRG,38295.568,Case Rate,100% of CMS IPPS Rate,19570.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19570.32,59836.83,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,CDM,100,RC,,,Inpatient,,,,,,33333.88,125,MS-DRG,26667.104,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26667.1,100,MS-DRG,21333.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10864.2,100,,,Case Rate,100% of CMS IPPS Rate,26667.1,100,MS-DRG,21333.68,Case Rate,100% of CMS IPPS Rate,9622.53,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9622.53,33333.88,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,CDM,100,RC,,,Inpatient,,,,,,24895.78,125,MS-DRG,19916.624,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19916.62,100,MS-DRG,15933.296,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7288.3,100,,,Case Rate,100% of CMS IPPS Rate,19916.62,100,MS-DRG,15933.296,Case Rate,100% of CMS IPPS Rate,6455.32,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6455.32,24895.78,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,CDM,100,RC,,,Inpatient,,,,,,38652.45,125,MS-DRG,30921.96,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30921.96,100,MS-DRG,24737.568,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13118.11,100,,,Case Rate,100% of CMS IPPS Rate,30921.96,100,MS-DRG,24737.568,Case Rate,100% of CMS IPPS Rate,11618.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11618.84,38652.45,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,CDM,100,RC,,,Inpatient,,,,,,27238.68,125,MS-DRG,21790.944,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21790.94,100,MS-DRG,17432.752,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8281.18,100,,,Case Rate,100% of CMS IPPS Rate,21790.94,100,MS-DRG,17432.752,Case Rate,100% of CMS IPPS Rate,7334.73,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7334.73,27238.68,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,CDM,100,RC,,,Inpatient,,,,,,21378.93,125,MS-DRG,17103.144,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17103.14,100,MS-DRG,13682.512,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5797.94,100,,,Case Rate,100% of CMS IPPS Rate,17103.14,100,MS-DRG,13682.512,Case Rate,100% of CMS IPPS Rate,5135.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5135.29,21378.93,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,CDM,100,RC,,,Inpatient,,,,,,49451.45,125,MS-DRG,39561.16,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39561.16,100,MS-DRG,31648.928,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17694.51,100,,,Case Rate,100% of CMS IPPS Rate,39561.16,100,MS-DRG,31648.928,Case Rate,100% of CMS IPPS Rate,15672.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15672.21,49451.45,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,CDM,100,RC,,,Inpatient,,,,,,28473.09,125,MS-DRG,22778.472,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22778.47,100,MS-DRG,18222.776,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8804.3,100,,,Case Rate,100% of CMS IPPS Rate,22778.47,100,MS-DRG,18222.776,Case Rate,100% of CMS IPPS Rate,7798.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7798.06,28473.09,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,CDM,100,RC,,,Inpatient,,,,,,21086.28,125,MS-DRG,16869.024,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16869.02,100,MS-DRG,13495.216,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5673.91,100,,,Case Rate,100% of CMS IPPS Rate,16869.02,100,MS-DRG,13495.216,Case Rate,100% of CMS IPPS Rate,5025.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5025.44,21086.28,
RADIOTHERAPY,849,CDM,100,RC,,,Inpatient,,,,,,51369.29,125,MS-DRG,41095.432,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41095.43,100,MS-DRG,32876.344,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18507.25,100,,,Case Rate,100% of CMS IPPS Rate,41095.43,100,MS-DRG,32876.344,Case Rate,100% of CMS IPPS Rate,16392.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16392.06,51369.29,
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,CDM,100,RC,,,Inpatient,,,,,,158309.75,125,MS-DRG,126647.8,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126647.8,100,MS-DRG,101318.24,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,63826.49,100,,,Case Rate,100% of CMS IPPS Rate,126647.8,100,MS-DRG,101318.24,Case Rate,100% of CMS IPPS Rate,56531.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,56531.77,158309.8,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,CDM,100,RC,,,Inpatient,,,,,,89467.48,125,MS-DRG,71573.984,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71573.98,100,MS-DRG,57259.184,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,34652.51,100,,,Case Rate,100% of CMS IPPS Rate,71573.98,100,MS-DRG,57259.184,Case Rate,100% of CMS IPPS Rate,30692.08,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30692.08,89467.48,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,CDM,100,RC,,,Inpatient,,,,,,40365.9,125,MS-DRG,32292.72,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32292.72,100,MS-DRG,25834.176,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13844.24,100,,,Case Rate,100% of CMS IPPS Rate,32292.72,100,MS-DRG,25834.176,Case Rate,100% of CMS IPPS Rate,12261.98,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12261.98,40365.9,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,CDM,100,RC,,,Inpatient,,,,,,34275.61,125,MS-DRG,27420.488,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27420.49,100,MS-DRG,21936.392,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11263.29,100,,,Case Rate,100% of CMS IPPS Rate,27420.49,100,MS-DRG,21936.392,Case Rate,100% of CMS IPPS Rate,9976.01,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9976.01,34275.61,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,CDM,100,RC,,,Inpatient,,,,,,81460.99,125,MS-DRG,65168.792,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65168.79,100,MS-DRG,52135.032,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31259.52,100,,,Case Rate,100% of CMS IPPS Rate,65168.79,100,MS-DRG,52135.032,Case Rate,100% of CMS IPPS Rate,27686.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27686.88,81460.99,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,CDM,100,RC,,,Inpatient,,,,,,43321.95,125,MS-DRG,34657.56,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34657.56,100,MS-DRG,27726.048,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15096.94,100,,,Case Rate,100% of CMS IPPS Rate,34657.56,100,MS-DRG,27726.048,Case Rate,100% of CMS IPPS Rate,13371.52,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13371.52,43321.95,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,CDM,100,RC,,,Inpatient,,,,,,28762.49,125,MS-DRG,23009.992,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23009.99,100,MS-DRG,18407.992,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8926.94,100,,,Case Rate,100% of CMS IPPS Rate,23009.99,100,MS-DRG,18407.992,Case Rate,100% of CMS IPPS Rate,7906.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7906.68,28762.49,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,CDM,100,RC,,,Inpatient,,,,,,37759.75,125,MS-DRG,30207.8,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30207.8,100,MS-DRG,24166.24,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12739.8,100,,,Case Rate,100% of CMS IPPS Rate,30207.8,100,MS-DRG,24166.24,Case Rate,100% of CMS IPPS Rate,11283.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11283.77,37759.75,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,CDM,100,RC,,,Inpatient,,,,,,24045.59,125,MS-DRG,19236.472,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19236.47,100,MS-DRG,15389.176,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6928.01,100,,,Case Rate,100% of CMS IPPS Rate,19236.47,100,MS-DRG,15389.176,Case Rate,100% of CMS IPPS Rate,6136.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6136.21,24045.59,
FEVER AND INFLAMMATORY CONDITIONS,864,CDM,100,RC,,,Inpatient,,,,,,22379.54,125,MS-DRG,17903.632,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17903.63,100,MS-DRG,14322.904,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6221.97,100,,,Case Rate,100% of CMS IPPS Rate,17903.63,100,MS-DRG,14322.904,Case Rate,100% of CMS IPPS Rate,5510.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5510.86,22379.54,
VIRAL ILLNESS WITH MCC,865,CDM,100,RC,,,Inpatient,,,,,,31828.06,125,MS-DRG,25462.448,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25462.45,100,MS-DRG,20369.96,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10050.08,100,,,Case Rate,100% of CMS IPPS Rate,25462.45,100,MS-DRG,20369.96,Case Rate,100% of CMS IPPS Rate,8901.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8901.46,31828.06,
VIRAL ILLNESS WITHOUT MCC,866,CDM,100,RC,,,Inpatient,,,,,,22163.73,125,MS-DRG,17730.984,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17730.98,100,MS-DRG,14184.784,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6130.51,100,,,Case Rate,100% of CMS IPPS Rate,17730.98,100,MS-DRG,14184.784,Case Rate,100% of CMS IPPS Rate,5429.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5429.86,22163.73,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,CDM,100,RC,,,Inpatient,,,,,,42756.23,125,MS-DRG,34204.984,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34204.98,100,MS-DRG,27363.984,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14857.21,100,,,Case Rate,100% of CMS IPPS Rate,34204.98,100,MS-DRG,27363.984,Case Rate,100% of CMS IPPS Rate,13159.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13159.18,42756.23,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,CDM,100,RC,,,Inpatient,,,,,,24866.34,125,MS-DRG,19893.072,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19893.07,100,MS-DRG,15914.456,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7275.83,100,,,Case Rate,100% of CMS IPPS Rate,19893.07,100,MS-DRG,15914.456,Case Rate,100% of CMS IPPS Rate,6444.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6444.27,24866.34,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,CDM,100,RC,,,Inpatient,,,,,,19462.74,125,MS-DRG,15570.192,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15570.19,100,MS-DRG,12456.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4985.89,100,,,Case Rate,100% of CMS IPPS Rate,15570.19,100,MS-DRG,12456.152,Case Rate,100% of CMS IPPS Rate,4416.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4416.06,19462.74,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,CDM,100,RC,,,Inpatient,,,,,,121434.5,125,MS-DRG,97147.6,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97147.6,100,MS-DRG,77718.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,48199.5,100,,,Case Rate,100% of CMS IPPS Rate,97147.6,100,MS-DRG,77718.08,Case Rate,100% of CMS IPPS Rate,42690.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,42690.79,121434.5,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,CDM,100,RC,,,Inpatient,,,,,,39777.31,125,MS-DRG,31821.848,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31821.85,100,MS-DRG,25457.48,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13594.8,100,,,Case Rate,100% of CMS IPPS Rate,31821.85,100,MS-DRG,25457.48,Case Rate,100% of CMS IPPS Rate,12041.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12041.05,39777.31,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,CDM,100,RC,,,Inpatient,,,,,,24554.06,125,MS-DRG,19643.248,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19643.25,100,MS-DRG,15714.6,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7143.49,100,,,Case Rate,100% of CMS IPPS Rate,19643.25,100,MS-DRG,15714.6,Case Rate,100% of CMS IPPS Rate,6327.06,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6327.06,24554.06,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,CDM,100,RC,,,Inpatient,,,,,,71945.45,125,MS-DRG,57556.36,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57556.36,100,MS-DRG,46045.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27227.02,100,,,Case Rate,100% of CMS IPPS Rate,57556.36,100,MS-DRG,46045.088,Case Rate,100% of CMS IPPS Rate,24115.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24115.25,71945.45,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,CDM,100,RC,,,Inpatient,,,,,,23370.35,125,MS-DRG,18696.28,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18696.28,100,MS-DRG,14957.024,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6641.85,100,,,Case Rate,100% of CMS IPPS Rate,18696.28,100,MS-DRG,14957.024,Case Rate,100% of CMS IPPS Rate,5882.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5882.76,23370.35,
DEPRESSIVE NEUROSES,881,CDM,100,RC,,,Inpatient,,,,,,22642.76,125,MS-DRG,18114.208,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18114.21,100,MS-DRG,14491.368,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6333.52,100,,,Case Rate,100% of CMS IPPS Rate,18114.21,100,MS-DRG,14491.368,Case Rate,100% of CMS IPPS Rate,5609.67,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5609.67,22642.76,
NEUROSES EXCEPT DEPRESSIVE,882,CDM,100,RC,,,Inpatient,,,,,,23425.93,125,MS-DRG,18740.744,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18740.74,100,MS-DRG,14992.592,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6665.41,100,,,Case Rate,100% of CMS IPPS Rate,18740.74,100,MS-DRG,14992.592,Case Rate,100% of CMS IPPS Rate,5903.62,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5903.62,23425.93,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,CDM,100,RC,,,Inpatient,,,,,,38008.26,125,MS-DRG,30406.608,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30406.61,100,MS-DRG,24325.288,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12845.12,100,,,Case Rate,100% of CMS IPPS Rate,30406.61,100,MS-DRG,24325.288,Case Rate,100% of CMS IPPS Rate,11377.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11377.05,38008.26,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,CDM,100,RC,,,Inpatient,,,,,,35004.81,125,MS-DRG,28003.848,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28003.85,100,MS-DRG,22403.08,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11572.31,100,,,Case Rate,100% of CMS IPPS Rate,28003.85,100,MS-DRG,22403.08,Case Rate,100% of CMS IPPS Rate,10249.72,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10249.72,35004.81,
PSYCHOSES,885,CDM,100,RC,,,Inpatient,,,,,,30744.08,125,MS-DRG,24595.264,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24595.26,100,MS-DRG,19676.208,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9766.7,100,,,Case Rate,100% of CMS IPPS Rate,24595.26,100,MS-DRG,19676.208,Case Rate,100% of CMS IPPS Rate,8650.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8650.46,30744.08,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,CDM,100,RC,,,Inpatient,,,,,,37069.79,125,MS-DRG,29655.832,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29655.83,100,MS-DRG,23724.664,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12447.41,100,,,Case Rate,100% of CMS IPPS Rate,29655.83,100,MS-DRG,23724.664,Case Rate,100% of CMS IPPS Rate,11024.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11024.8,37069.79,
OTHER MENTAL DISORDER DIAGNOSES,887,CDM,100,RC,,,Inpatient,,,,,,27143.85,125,MS-DRG,21715.08,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21715.08,100,MS-DRG,17372.064,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8241,100,,,Case Rate,100% of CMS IPPS Rate,21715.08,100,MS-DRG,17372.064,Case Rate,100% of CMS IPPS Rate,7299.13,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7299.13,27143.85,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,CDM,100,RC,,,Inpatient,,,,,,17901.34,125,MS-DRG,14321.072,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14321.07,100,MS-DRG,11456.856,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4324.2,100,,,Case Rate,100% of CMS IPPS Rate,14321.07,100,MS-DRG,11456.856,Case Rate,100% of CMS IPPS Rate,3829.99,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3829.99,17901.34,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,CDM,100,RC,,,Inpatient,,,,,,31370.28,125,MS-DRG,25096.224,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25096.22,100,MS-DRG,20076.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9723.04,100,,,Case Rate,100% of CMS IPPS Rate,25096.22,100,MS-DRG,20076.976,Case Rate,100% of CMS IPPS Rate,8611.8,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8611.8,31370.28,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,CDM,100,RC,,,Inpatient,,,,,,36813.1,125,MS-DRG,29450.48,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29450.48,100,MS-DRG,23560.384,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12338.63,100,,,Case Rate,100% of CMS IPPS Rate,29450.48,100,MS-DRG,23560.384,Case Rate,100% of CMS IPPS Rate,10928.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10928.45,36813.1,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,CDM,100,RC,,,Inpatient,,,,,,22121.2,125,MS-DRG,17696.96,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17696.96,100,MS-DRG,14157.568,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6112.5,100,,,Case Rate,100% of CMS IPPS Rate,17696.96,100,MS-DRG,14157.568,Case Rate,100% of CMS IPPS Rate,5413.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5413.9,22121.2,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,CDM,100,RC,,,Inpatient,,,,,,80135.04,125,MS-DRG,64108.032,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64108.03,100,MS-DRG,51286.424,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30697.61,100,,,Case Rate,100% of CMS IPPS Rate,64108.03,100,MS-DRG,51286.424,Case Rate,100% of CMS IPPS Rate,27189.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27189.18,80135.04,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,CDM,100,RC,,,Inpatient,,,,,,38722.75,125,MS-DRG,30978.2,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30978.2,100,MS-DRG,24782.56,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13147.9,100,,,Case Rate,100% of CMS IPPS Rate,30978.2,100,MS-DRG,24782.56,Case Rate,100% of CMS IPPS Rate,11645.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11645.23,38722.75,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,CDM,100,RC,,,Inpatient,,,,,,27629.44,125,MS-DRG,22103.552,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22103.55,100,MS-DRG,17682.84,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8446.78,100,,,Case Rate,100% of CMS IPPS Rate,22103.55,100,MS-DRG,17682.84,Case Rate,100% of CMS IPPS Rate,7481.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7481.4,27629.44,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,CDM,100,RC,,,Inpatient,,,,,,70825.5,125,MS-DRG,56660.4,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56660.4,100,MS-DRG,45328.32,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26752.4,100,,,Case Rate,100% of CMS IPPS Rate,56660.4,100,MS-DRG,45328.32,Case Rate,100% of CMS IPPS Rate,23694.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23694.88,70825.5,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,CDM,100,RC,,,Inpatient,,,,,,34645.11,125,MS-DRG,27716.088,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27716.09,100,MS-DRG,22172.872,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11419.88,100,,,Case Rate,100% of CMS IPPS Rate,27716.09,100,MS-DRG,22172.872,Case Rate,100% of CMS IPPS Rate,10114.71,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10114.71,34645.11,
HAND PROCEDURES FOR INJURIES,906,CDM,100,RC,,,Inpatient,,,,,,43380.79,125,MS-DRG,34704.632,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34704.63,100,MS-DRG,27763.704,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15121.89,100,,,Case Rate,100% of CMS IPPS Rate,34704.63,100,MS-DRG,27763.704,Case Rate,100% of CMS IPPS Rate,13393.61,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13393.61,43380.79,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,CDM,100,RC,,,Inpatient,,,,,,72829.98,125,MS-DRG,58263.984,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58263.98,100,MS-DRG,46611.184,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27601.86,100,,,Case Rate,100% of CMS IPPS Rate,58263.98,100,MS-DRG,46611.184,Case Rate,100% of CMS IPPS Rate,24447.25,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24447.25,72829.98,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,CDM,100,RC,,,Inpatient,,,,,,40676.55,125,MS-DRG,32541.24,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32541.24,100,MS-DRG,26032.992,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13975.88,100,,,Case Rate,100% of CMS IPPS Rate,32541.24,100,MS-DRG,26032.992,Case Rate,100% of CMS IPPS Rate,12378.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12378.58,40676.55,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,CDM,100,RC,,,Inpatient,,,,,,28433.86,125,MS-DRG,22747.088,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22747.09,100,MS-DRG,18197.672,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8787.67,100,,,Case Rate,100% of CMS IPPS Rate,22747.09,100,MS-DRG,18197.672,Case Rate,100% of CMS IPPS Rate,7783.33,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7783.33,28433.86,
TRAUMATIC INJURY WITH MCC,913,CDM,100,RC,,,Inpatient,,,,,,34156.28,125,MS-DRG,27325.024,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27325.02,100,MS-DRG,21860.016,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11212.72,100,,,Case Rate,100% of CMS IPPS Rate,27325.02,100,MS-DRG,21860.016,Case Rate,100% of CMS IPPS Rate,9931.22,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9931.22,34156.28,
TRAUMATIC INJURY WITHOUT MCC,914,CDM,100,RC,,,Inpatient,,,,,,22680.39,125,MS-DRG,18144.312,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18144.31,100,MS-DRG,14515.448,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6349.46,100,,,Case Rate,100% of CMS IPPS Rate,18144.31,100,MS-DRG,14515.448,Case Rate,100% of CMS IPPS Rate,5623.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5623.78,22680.39,
ALLERGIC REACTIONS WITH MCC,915,CDM,100,RC,,,Inpatient,,,,,,36111.69,125,MS-DRG,28889.352,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28889.35,100,MS-DRG,23111.48,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12041.39,100,,,Case Rate,100% of CMS IPPS Rate,28889.35,100,MS-DRG,23111.48,Case Rate,100% of CMS IPPS Rate,10665.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10665.18,36111.69,
ALLERGIC REACTIONS WITHOUT MCC,916,CDM,100,RC,,,Inpatient,,,,,,18555.34,125,MS-DRG,14844.272,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14844.27,100,MS-DRG,11875.416,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4601.35,100,,,Case Rate,100% of CMS IPPS Rate,14844.27,100,MS-DRG,11875.416,Case Rate,100% of CMS IPPS Rate,4075.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4075.46,18555.34,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,CDM,100,RC,,,Inpatient,,,,,,34506.15,125,MS-DRG,27604.92,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27604.92,100,MS-DRG,22083.936,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11360.99,100,,,Case Rate,100% of CMS IPPS Rate,27604.92,100,MS-DRG,22083.936,Case Rate,100% of CMS IPPS Rate,10062.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10062.54,34506.15,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,CDM,100,RC,,,Inpatient,,,,,,22160.45,125,MS-DRG,17728.36,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17728.36,100,MS-DRG,14182.688,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6129.13,100,,,Case Rate,100% of CMS IPPS Rate,17728.36,100,MS-DRG,14182.688,Case Rate,100% of CMS IPPS Rate,5428.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5428.63,22160.45,
COMPLICATIONS OF TREATMENT WITH MCC,919,CDM,100,RC,,,Inpatient,,,,,,37512.86,125,MS-DRG,30010.288,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30010.29,100,MS-DRG,24008.232,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12635.18,100,,,Case Rate,100% of CMS IPPS Rate,30010.29,100,MS-DRG,24008.232,Case Rate,100% of CMS IPPS Rate,11191.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11191.1,37512.86,
COMPLICATIONS OF TREATMENT WITH CC,920,CDM,100,RC,,,Inpatient,,,,,,24307.18,125,MS-DRG,19445.744,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19445.74,100,MS-DRG,15556.592,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7038.87,100,,,Case Rate,100% of CMS IPPS Rate,19445.74,100,MS-DRG,15556.592,Case Rate,100% of CMS IPPS Rate,6234.4,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6234.4,24307.18,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,CDM,100,RC,,,Inpatient,,,,,,18941.18,125,MS-DRG,15152.944,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15152.94,100,MS-DRG,12122.352,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4764.87,100,,,Case Rate,100% of CMS IPPS Rate,15152.94,100,MS-DRG,12122.352,Case Rate,100% of CMS IPPS Rate,4220.29,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4220.29,18941.18,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,CDM,100,RC,,,Inpatient,,,,,,35318.74,125,MS-DRG,28254.992,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28254.99,100,MS-DRG,22603.992,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11705.35,100,,,Case Rate,100% of CMS IPPS Rate,28254.99,100,MS-DRG,22603.992,Case Rate,100% of CMS IPPS Rate,10367.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10367.54,35318.74,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,CDM,100,RC,,,Inpatient,,,,,,24372.58,125,MS-DRG,19498.064,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19498.06,100,MS-DRG,15598.448,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7066.58,100,,,Case Rate,100% of CMS IPPS Rate,19498.06,100,MS-DRG,15598.448,Case Rate,100% of CMS IPPS Rate,6258.94,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6258.94,24372.58,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,CDM,100,RC,,,Inpatient,,,,,,395559.34,125,MS-DRG,316447.472,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,316447.47,100,MS-DRG,253157.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,139352.09,100,,,Case Rate,100% of CMS IPPS Rate,316447.47,100,MS-DRG,253157.976,Case Rate,100% of CMS IPPS Rate,123425.56,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,123425.6,395559.3,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,CDM,100,RC,,,Inpatient,,,,,,116895.83,125,MS-DRG,93516.664,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93516.66,100,MS-DRG,74813.328,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,46276.09,100,,,Case Rate,100% of CMS IPPS Rate,93516.66,100,MS-DRG,74813.328,Case Rate,100% of CMS IPPS Rate,40987.21,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,40987.21,116895.8,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,CDM,100,RC,,,Inpatient,,,,,,59696.21,125,MS-DRG,47756.968,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47756.97,100,MS-DRG,38205.576,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22036.04,100,,,Case Rate,100% of CMS IPPS Rate,47756.97,100,MS-DRG,38205.576,Case Rate,100% of CMS IPPS Rate,19517.54,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19517.54,59696.21,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,CDM,100,RC,,,Inpatient,,,,,,78441.19,125,MS-DRG,62752.952,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62752.95,100,MS-DRG,50202.36,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29979.79,100,,,Case Rate,100% of CMS IPPS Rate,62752.95,100,MS-DRG,50202.36,Case Rate,100% of CMS IPPS Rate,26553.41,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26553.41,78441.19,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,CDM,100,RC,,,Inpatient,,,,,,42780.78,125,MS-DRG,34224.624,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34224.62,100,MS-DRG,27379.696,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14867.6,100,,,Case Rate,100% of CMS IPPS Rate,34224.62,100,MS-DRG,27379.696,Case Rate,100% of CMS IPPS Rate,13168.39,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13168.39,42780.78,
NON-EXTENSIVE BURNS,935,CDM,100,RC,,,Inpatient,,,,,,43608.06,125,MS-DRG,34886.448,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34886.45,100,MS-DRG,27909.16,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15218.2,100,,,Case Rate,100% of CMS IPPS Rate,34886.45,100,MS-DRG,27909.16,Case Rate,100% of CMS IPPS Rate,13478.91,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13478.91,43608.06,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,CDM,100,RC,,,Inpatient,,,,,,59591.56,125,MS-DRG,47673.248,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47673.25,100,MS-DRG,38138.6,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21991.69,100,,,Case Rate,100% of CMS IPPS Rate,47673.25,100,MS-DRG,38138.6,Case Rate,100% of CMS IPPS Rate,19478.27,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19478.27,59591.56,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,CDM,100,RC,,,Inpatient,,,,,,42218.33,125,MS-DRG,33774.664,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33774.66,100,MS-DRG,27019.728,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14629.26,100,,,Case Rate,100% of CMS IPPS Rate,33774.66,100,MS-DRG,27019.728,Case Rate,100% of CMS IPPS Rate,12957.28,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12957.28,42218.33,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,CDM,100,RC,,,Inpatient,,,,,,39649.78,125,MS-DRG,31719.824,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31719.82,100,MS-DRG,25375.856,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13540.76,100,,,Case Rate,100% of CMS IPPS Rate,31719.82,100,MS-DRG,25375.856,Case Rate,100% of CMS IPPS Rate,11993.19,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11993.19,39649.78,
REHABILITATION WITH CC/MCC,945,CDM,100,RC,,,Inpatient,,,,,,32655.38,125,MS-DRG,26124.304,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26124.3,100,MS-DRG,20899.44,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10576.66,100,,,Case Rate,100% of CMS IPPS Rate,26124.3,100,MS-DRG,20899.44,Case Rate,100% of CMS IPPS Rate,9367.86,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9367.86,32655.38,
REHABILITATION WITHOUT CC/MCC,946,CDM,100,RC,,,Inpatient,,,,,,25951.95,125,MS-DRG,20761.56,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20761.56,100,MS-DRG,16609.248,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7735.89,100,,,Case Rate,100% of CMS IPPS Rate,20761.56,100,MS-DRG,16609.248,Case Rate,100% of CMS IPPS Rate,6851.76,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6851.76,25951.95,
SIGNS AND SYMPTOMS WITH MCC,947,CDM,100,RC,,,Inpatient,,,,,,28726.53,125,MS-DRG,22981.224,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22981.22,100,MS-DRG,18384.976,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8911.69,100,,,Case Rate,100% of CMS IPPS Rate,22981.22,100,MS-DRG,18384.976,Case Rate,100% of CMS IPPS Rate,7893.18,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7893.18,28726.53,
SIGNS AND SYMPTOMS WITHOUT MCC,948,CDM,100,RC,,,Inpatient,,,,,,20687.34,125,MS-DRG,16549.872,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16549.87,100,MS-DRG,13239.896,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5504.85,100,,,Case Rate,100% of CMS IPPS Rate,16549.87,100,MS-DRG,13239.896,Case Rate,100% of CMS IPPS Rate,4875.7,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4875.7,20687.34,
AFTERCARE WITH CC/MCC,949,CDM,100,RC,,,Inpatient,,,,,,25338.85,125,MS-DRG,20271.08,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20271.08,100,MS-DRG,16216.864,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7476.07,100,,,Case Rate,100% of CMS IPPS Rate,20271.08,100,MS-DRG,16216.864,Case Rate,100% of CMS IPPS Rate,6621.63,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6621.63,25338.85,
AFTERCARE WITHOUT CC/MCC,950,CDM,100,RC,,,Inpatient,,,,,,17280.05,125,MS-DRG,13824.04,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13824.04,100,MS-DRG,11059.232,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4060.91,100,,,Case Rate,100% of CMS IPPS Rate,13824.04,100,MS-DRG,11059.232,Case Rate,100% of CMS IPPS Rate,3596.79,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3596.79,17280.05,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,CDM,100,RC,,,Inpatient,,,,,,16967.78,125,MS-DRG,13574.224,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13574.22,100,MS-DRG,10859.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3928.57,100,,,Case Rate,100% of CMS IPPS Rate,13574.22,100,MS-DRG,10859.376,Case Rate,100% of CMS IPPS Rate,3479.58,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3479.58,16967.78,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,CDM,100,RC,,,Inpatient,,,,,,119338.46,125,MS-DRG,95470.768,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95470.77,100,MS-DRG,76376.616,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,47311.24,100,,,Case Rate,100% of CMS IPPS Rate,95470.77,100,MS-DRG,76376.616,Case Rate,100% of CMS IPPS Rate,41904.05,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,41904.05,119338.5,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,CDM,100,RC,,,Inpatient,,,,,,70192.76,125,MS-DRG,56154.208,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56154.21,100,MS-DRG,44923.368,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26484.26,100,,,Case Rate,100% of CMS IPPS Rate,56154.21,100,MS-DRG,44923.368,Case Rate,100% of CMS IPPS Rate,23457.38,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23457.38,70192.76,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,CDM,100,RC,,,Inpatient,,,,,,129735.26,125,MS-DRG,103788.208,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103788.21,100,MS-DRG,83030.568,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,51717.2,100,,,Case Rate,100% of CMS IPPS Rate,103788.21,100,MS-DRG,83030.568,Case Rate,100% of CMS IPPS Rate,45806.45,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,45806.45,129735.3,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,CDM,100,RC,,,Inpatient,,,,,,74891.66,125,MS-DRG,59913.328,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59913.33,100,MS-DRG,47930.664,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28475.57,100,,,Case Rate,100% of CMS IPPS Rate,59913.33,100,MS-DRG,47930.664,Case Rate,100% of CMS IPPS Rate,25221.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25221.1,74891.66,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,CDM,100,RC,,,Inpatient,,,,,,50924.58,125,MS-DRG,40739.664,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40739.66,100,MS-DRG,32591.728,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18318.79,100,,,Case Rate,100% of CMS IPPS Rate,40739.66,100,MS-DRG,32591.728,Case Rate,100% of CMS IPPS Rate,16225.14,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16225.14,50924.58,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,CDM,100,RC,,,Inpatient,,,,,,52114.83,125,MS-DRG,41691.864,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41691.86,100,MS-DRG,33353.488,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18823.2,100,,,Case Rate,100% of CMS IPPS Rate,41691.86,100,MS-DRG,33353.488,Case Rate,100% of CMS IPPS Rate,16671.9,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16671.9,52114.83,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,CDM,100,RC,,,Inpatient,,,,,,32223.74,125,MS-DRG,25778.992,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25778.99,100,MS-DRG,20623.192,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10393.74,100,,,Case Rate,100% of CMS IPPS Rate,25778.99,100,MS-DRG,20623.192,Case Rate,100% of CMS IPPS Rate,9205.84,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9205.84,32223.74,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,CDM,100,RC,,,Inpatient,,,,,,22618.24,125,MS-DRG,18094.592,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18094.59,100,MS-DRG,14475.672,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6323.13,100,,,Case Rate,100% of CMS IPPS Rate,18094.59,100,MS-DRG,14475.672,Case Rate,100% of CMS IPPS Rate,5600.46,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5600.46,22618.24,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,CDM,100,RC,,,Inpatient,,,,,,111098.2,125,MS-DRG,88878.56,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88878.56,100,MS-DRG,71102.848,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,43819.18,100,,,Case Rate,100% of CMS IPPS Rate,88878.56,100,MS-DRG,71102.848,Case Rate,100% of CMS IPPS Rate,38811.09,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,38811.09,111098.2,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,CDM,100,RC,,,Inpatient,,,,,,51078.26,125,MS-DRG,40862.608,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40862.61,100,MS-DRG,32690.088,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18383.92,100,,,Case Rate,100% of CMS IPPS Rate,40862.61,100,MS-DRG,32690.088,Case Rate,100% of CMS IPPS Rate,16282.82,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16282.82,51078.26,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,CDM,100,RC,,,Inpatient,,,,,,56521.09,125,MS-DRG,45216.872,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45216.87,100,MS-DRG,36173.496,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20690.48,100,,,Case Rate,100% of CMS IPPS Rate,45216.87,100,MS-DRG,36173.496,Case Rate,100% of CMS IPPS Rate,18325.77,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18325.77,56521.09,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,CDM,100,RC,,,Inpatient,,,,,,30937,125,MS-DRG,24749.6,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24749.6,100,MS-DRG,19799.68,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9848.45,100,,,Case Rate,100% of CMS IPPS Rate,24749.6,100,MS-DRG,19799.68,Case Rate,100% of CMS IPPS Rate,8722.88,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8722.88,30937,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,CDM,100,RC,,,Inpatient,,,,,,24096.26,125,MS-DRG,19277.008,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19277.01,100,MS-DRG,15421.608,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6949.49,100,,,Case Rate,100% of CMS IPPS Rate,19277.01,100,MS-DRG,15421.608,Case Rate,100% of CMS IPPS Rate,6155.23,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6155.23,24096.26,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,CDM,100,RC,,,Inpatient,,,,,,31272.18,125,MS-DRG,25017.744,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25017.74,100,MS-DRG,20014.192,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9990.49,100,,,Case Rate,100% of CMS IPPS Rate,25017.74,100,MS-DRG,20014.192,Case Rate,100% of CMS IPPS Rate,8848.68,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8848.68,31272.18,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,CDM,100,RC,,,Inpatient,,,,,,85422.54,125,MS-DRG,68338.032,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68338.03,100,MS-DRG,54670.424,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,32938.35,100,,,Case Rate,100% of CMS IPPS Rate,68338.03,100,MS-DRG,54670.424,Case Rate,100% of CMS IPPS Rate,29173.83,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29173.83,85422.54,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,CDM,100,RC,,,Inpatient,,,,,,47726.56,125,MS-DRG,38181.248,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38181.25,100,MS-DRG,30545,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16963.54,100,,,Case Rate,100% of CMS IPPS Rate,38181.25,100,MS-DRG,30545,Case Rate,100% of CMS IPPS Rate,15024.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15024.78,47726.56,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,CDM,100,RC,,,Inpatient,,,,,,34972.11,125,MS-DRG,27977.688,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27977.69,100,MS-DRG,22382.152,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11558.46,100,,,Case Rate,100% of CMS IPPS Rate,27977.69,100,MS-DRG,22382.152,Case Rate,100% of CMS IPPS Rate,10237.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10237.44,34972.11,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,CDM,100,RC,,,Inpatient,,,,,,64965.74,125,MS-DRG,51972.592,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51972.59,100,MS-DRG,41578.072,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24269.16,100,,,Case Rate,100% of CMS IPPS Rate,51972.59,100,MS-DRG,41578.072,Case Rate,100% of CMS IPPS Rate,21495.44,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21495.44,64965.74,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,CDM,100,RC,,,Inpatient,,,,,,35753.64,125,MS-DRG,28602.912,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28602.91,100,MS-DRG,22882.328,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11889.65,100,,,Case Rate,100% of CMS IPPS Rate,28602.91,100,MS-DRG,22882.328,Case Rate,100% of CMS IPPS Rate,10530.78,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10530.78,35753.64,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,CDM,100,RC,,,Inpatient,,,,,,26589.6,125,MS-DRG,21271.68,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21271.68,100,MS-DRG,17017.344,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8006.11,100,,,Case Rate,100% of CMS IPPS Rate,21271.68,100,MS-DRG,17017.344,Case Rate,100% of CMS IPPS Rate,7091.1,100,,,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7091.1,26589.6,
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,998,CDM,100,RC,,,Inpatient,,,,,,7697.46,125,MS-DRG,6157.968,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6157.97,100,MS-DRG,4926.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,6157.97,100,MS-DRG,4926.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6157.97,7697.46,
UNGROUPABLE,999,CDM,100,RC,,,Inpatient,,,,,,7697.46,125,MS-DRG,6157.968,Case Rate,125% of CMS IPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6157.97,100,MS-DRG,4926.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,6157.97,100,MS-DRG,4926.376,Case Rate,100% of CMS IPPS Rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6157.97,7697.46,